Diagnostic Laproscopic

Laparoscopic surgery, also called minimally invasive surgery (MIS), bandaid surgery, or keyhole surgery, is a modern surgical technique in which operations in the abdomen are performed through small incisions (usually 0.5–1.5 cm) as opposed to the larger incisions needed in laparotomy.

Keyhole surgery makes use of images displayed on TV monitors to magnify the surgical elements. Laparoscopic surgery includes operations within the abdominal or pelvic cavities, whereas keyhole surgery performed on the thoracic or chest cavity is called thoracoscopic surgery. Laparoscopic and thoracoscopic surgery belong to the broader field of endoscopy.

There are a number of advantages to the patient with laparoscopic surgery versus an open procedure. These include reduced pain due to smaller incisions and hemorrhaging, and shorter recovery time.

The key element in laparoscopic surgery is the use of a laparoscope.

There are two types

• A telescopic rod lens system, that is usually connected to a video camera (single chip or three chip), or
• A digital laparoscope where the charge-coupled device is placed at the end of the laparoscope, eliminating the rod lens system. Also attached is a fiber optic cable system connected to a 'cold' light source (halogen or xenon), to illuminate the operative field, inserted through a 5 mm or 10 mmcannula or trocar to view the operative field. The abdomen is usually insufflated, or essentially blown up like a balloon, with carbon dioxide gas. This elevates the abdominal wall above the internal organs like a dome to create a working and viewing space. CO2 is used because it is common to the human body and can be absorbed by tissue and removed by the respiratory system. It is also non-flammable, which is important because electrosurgical devices are commonly used in laparoscopic procedures.

• Procedures

  Surgeons perform laparoscopic stomach surgery.

  Laparoscopic cholecystectomy is the most common laparoscopic procedure performed. In this procedure, 5–10 mm diameter instruments (graspers, scissors, clip applier) can be introduced by the surgeon into the abdomen through trocars (hollow tubes with a seal to keep theCO2 from leaking).

  There are two different formats for laparoscopic surgery. Multiple incisions are required for technology such as the da Vinci Surgical System, which uses a console located away from the patient, with the surgeon controlling a camera, vacuum pump, saline cleansing solution, cutting tools, etc. each located within its own incision site, but oriented toward the surgical objective. The surgeon's hands manipulate two haptic grippers which track hand movements and rotations while relaying haptic sensations back to the surgeon.

  Rather than a minimum 20 cm incision as in traditional (open) cholecystectomy, four incisions of 0.5–1.0 cm will be sufficient to perform a laparoscopic removal of a gallbladder. Since the gall bladder is similar to a small balloon that stores and releases bile, it can usually be removed from the abdomen by suctioning out the bile and then removing the deflated gallbladder through the 1 cm incision at the patient's navel. The length of postoperative stay in the hospital is minimal, and same-day discharges are possible in cases of early morning procedures.

  In certain advanced laparoscopic procedures, where the size of the specimen being removed would be too large to pull out through a trocar site (as would be done with a gallbladder), an incision larger than 10mm must be made. The most common of these procedures are removal of all or part of the colon (colectomy), or removal of the kidney (nephrectomy). Some surgeons perform these procedures completely laparoscopically, making the larger incision toward the end of the procedure for specimen removal, or, in the case of a colectomy, to also prepare the remaining healthy bowel to be reconnected (create an anastomosis). Many other surgeons feel that since they will have to make a larger incision for specimen removal anyway, they might as well use this incision to have their hand in the operative field during the procedure to aid as a retractor, dissector, and to be able to feel differing tissue densities (palpate), as they would in open surgery. This technique is called hand-assist laparoscopy. Since they will still be working with scopes and other laparoscopic instruments, CO2 will have to be maintained in the patient's abdomen, so a device known as a hand access port (a sleeve with a seal that allows passage of the hand) must be used. Surgeons who choose this hand-assist technique feel it reduces operative time significantly versus the straight laparoscopic approach. It also gives them more options in dealing with unexpected adverse events (i.e. uncontrolled bleeding) that may otherwise require creating a much larger incision and converting to a fully open surgical procedure.

  Conceptually, the laparoscopic approach is intended to minimise post-operative pain and speed up recovery times, while maintaining an enhanced visual field for surgeons. Due to improved patient outcomes, in the last two decades, laparoscopic surgery has been adopted by various surgical sub-specialties including gastrointestinal surgery (including bariatric procedures for morbid obesity), gynecologic surgery and urology. Based on numerous prospective randomized controlled trials, the approach has proven to be beneficial in reducing post-operative morbidities such as wound infections and incisional hernias (especially in morbidly obese patients), and is now deemed safe when applied to surgery for cancers such as cancer of colon.

  Laparoscopic instruments

  The restricted vision, the difficulty in handling of the instruments (new hand-eye coordination skills are needed), the lack of tactile perception and the limited working area are factors which add to the technical complexity of this surgical approach. For these reasons, minimally invasive surgery has emerged as a highly competitive new sub-specialty within various fields of surgery.

• Advantages

  There are a number of advantages to the patient with laparoscopic surgery versus an open procedure. These include:

  • Reduced hemorrhaging, which reduces the chance of needing a blood transfusion.
  • Smaller incision, which reduces pain and shortens recovery time, as well as resulting in less post-operative scarring.
  • Less pain, leading to less pain medication needed.
  • Although procedure times are usually slightly longer, hospital stay is less, and often with a same day discharge which leads to a faster return to everyday living.
  • Reduced exposure of internal organs to possible external contaminants thereby reduced risk of acquiring infections.

  Although laparoscopy in adult age group is widely accepted, its advantages in pediatric age group is questioned. Benefits of laparoscopy appears to recede with younger age. Efficacy of laparoscopy is inferior to open surgery in certain conditions such as pyloromyotomy for Infantile hypertrophic pyloric stenosis. Although laparoscopic appendectomy has lesser wound problems than open surgery, the former is associated with more intra-abdominal abscesses.

• Disadvantages

  While laparoscopic surgery is clearly advantageous in terms of patient outcomes, the procedure is more difficult from the surgeon's perspective when compared to traditional, open surgery

  • The surgeon has limited range of motion at the surgical site resulting in a loss of dexterity.
  • Poor depth perception.
  • Surgeons must use tools to interact with tissue rather than manipulate it directly with their hands. This results in an inability to accurately judge how much force is being applied to tissue as well as a risk of damaging tissue by applying more force than necessary. This limitation also reduces tactile sensation, making it more difficult for the surgeon to feel tissue (sometimes an important diagnostic tool, such as when palpating for tumors) and making delicate operations such as tying sutures more difficult.
  • The tool endpoints move in the opposite direction to the surgeon's hands due to the pivot point, making laparoscopic surgery a non-intuitive motor skill that is difficult to learn. This is called the Fulcrum effect
  • Some surgeries (carpal tunnel for instance) generally turn out better for the patient when the area can be opened up, allowing the surgeon to see "the whole picture" surrounding physiology, to better address the issue at hand. In this regard, keyhole surgery can be a disadvantage.

• Risks

  Some of the risks are briefly described below

  • The most significant risks are from trocar injuries during insertion into the abdominal cavity, as the trocar is typically inserted blindly. Injuries include abdominal wall hematoma, umbilical hernias, umbilical wound infection, and penetration of blood vessels or small or large bowel. The risk of such injuries is increased in patients who have a low body mass index or have a history of prior abdominal surgery. While these injuries are rare, significant complications can occur, and they are primarily related to the umbilical insertion site. Vascular injuries can result in hemorrhage that may be life threatening. Injuries to the bowel can cause a delayed peritonitis. It is very important that these injuries be recognized as early as possible.
  • Some patients have sustained electrical burns unseen by surgeons who are working with electrodes that leak current into surrounding tissue. The resulting injuries can result in perforated organs and can also lead to peritonitis. This risk is eliminated by utilizing active electrode monitoring.
  • There may be an increased risk of hypothermia and peritoneal trauma due to increased exposure to cold, dry gases during insufflation. The use of Surgical Humidificationtherapy, which is the use of heated and humidified CO2 for insufflation, has been shown to reduce this risk.
  • Many patients with existing pulmonary disorders may not tolerate pneumoperitoneum (gas in the abdominal cavity), resulting in a need for conversion to open surgery after the initial attempt at laparoscopic approach.
  • Not all of the CO2 introduced into the abdominal cavity is removed through the incisions during surgery. Gas tends to rise, and when a pocket of CO2 rises in the abdomen, it pushes against the diaphragm (the muscle that separates the abdominal from the thoracic cavities and facilitates breathing), and can exert pressure on the phrenic nerve. This produces a sensation of pain that may extend to the patient's shoulders. For an appendectomy, the right shoulder can be particularly painful. In some cases this can also cause considerable pain when breathing. In all cases, however, the pain is transient, as the body tissues will absorb the CO2 and eliminate it through respiration.
  • Coagulation disorders and dense adhesions (scar tissue) from previous abdominal surgery may pose added risk for laparoscopic surgery and are considered relative contra-indications for this approach.
  • Intra-abdominal adhesion formation is a risk associated with both laparoscopic and open surgery and remains a significant, unresolved problem. Adhesions are fibrous deposits that connect tissue to organ post surgery. Generally, they occur in 50-100% of all abdominal surgeries, with the risk of developing adhesions being the same for both procedures. Complications of adhesions include chronic pelvic pain, bowel obstruction, and female infertility. In particular, small bowel obstruction poses the most significant problem. The use of Surgical Humidification therapy during laparoscopic surgery may minimise the incidence of adhesion formation.

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