Transcript Document

Laparoscopic Surgery
Jon Gabrielsen MD, FACS
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Objectives
• Understand the history of laparoscopic
surgery
• Understand the physiologic benefits of
laparoscopic surgery
• Awareness of the negative consequences of
pneumoperitoneum
• Awareness of the effects of patient
positioning as it relates to laparoscopy
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History of Laparoscopic Surgery
• Phillip Bozzini 1805-examines urethra of living patient
using a simple tube and candelight
• 1843-first effective endoscope developed
• 1880-incandescent light bulb invented by Thomas
Edison
• 1883-incandescent bulb adapted for use with
cystoscope
• 1901-George Kelling examines the peritoneal cavity
of a living dog using room air insufflation
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History of Laparoscopic Surgery
• 1911-Hans Christian Jacobaeus of Sweden
reports on results of laparoscopy and
thoracoscopy in over 110 patients
• 1920-BH Ordnoff (United States) introduces
pyramidal-tipped trocar
• 1924-Richard Zollikofer promotes use of CO2
as insufflation gas (rapid absorption)
• 1927-First textbook on laparoscopy published
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History of Laparoscopic Surgery
• 1970’s-Palmer, Steptoe, Neuwirth, liston
report a large series of laparoscopic tubal
ligations
• Late 1970’s-laparoscpic oophorectomies,
salpinectomies, and adnexectomies
performed
• Where was general surgery when all this was
happening?
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History of Laparoscopic Surgery
• Eric Muhe performs cholecystectomy using
the “galloscope” in 1985
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History of Laparoscopic Surgery
• Why didn’t this stuff take off?
– Scopes were monocular
– Assistants could not see what the surgeon was
seeing
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History of Laparoscopic Surgery
• 1986-Miniature solid –state camera
introduced (laparoscopic image now up on
monitors)
• 1987-Philippe Mouret (France) performed the
first laparoscopic cholecystectomy
• 1988-First laparoscopic cholecystectomy
performed in the US
• From this point on the use of laparoscopy in
general surgery rapidly expanded
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Why is this such a big deal?
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Major Milestones in Surgery
• William Thomas Green Morton-1846
– Birth of modern anesthesia
• Joseph Lister-1860’s
– Developer of Antiseptic Surgery
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120 Years of Nothing
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A Quantum Leap
• SAGES Meeting 1988
• Within 10 years
– 77% of elective cholecystectomies done
laparoscopically
– 68% of urgent cholecystectomies
JACS 2008 Jan(1):28-32
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Positive Effects of Laparoscopic Surgery
• Pulmonary function maintained better (FEV1
and FVC)
• Less acute phase stress response
• Inflammatory response is dampened
• Less immunosuppression
• Decreased intra-abdominal adhesions
• Quicker GI tract recovery
• Decrease in wound complications
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Negative Consequences of CO2
Pneumoperitoneum
• Cardiovascular
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Tachycardia
Decreased preload
Increased afterload (mechanical, vasocontriction)
Dysrhythmias
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Hypercarbia (PVC, VT, VF)
Acidosis
Sympathetic stimulation from decreased venous return
Vagal stimulation
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Summary-Cardiovascular Changes
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Negative Consequences of CO2
Pneumoperitoneum
• Pulmonary
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Decreased Lung Volumes (FRC, TV, VC)
Decreased compliance
Increased peak inspiratory pressure
Atelectasis from diaphragm displacement
• Impaired oxygenation and ventilation
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Summary-Pulmonary Changes
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Negative Consequences of CO2
Pneumoperitoneum
• Renal-decreased renal blood flow, GFR, and
urine output
• Hepatic-decreased portal venous blood flow
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Impact of Patient Positioning
• Reverse Trendelenburg
– Pooling of blood in lower extremities (DVT risk)
– Decreased venous return, decreased preload
– Improved pulmonary function, decreased pressure
on diaphragm
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Impact of Patient Positioning
• Trendelenburg
– Increased preload due to increased venous return
– Detrimental pulmonary function changes
associated with CO2 pneumoperitoneum are
accentuated
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Contraindications to Laparoscopic
Surgery
• Relative Anatomic Contraindications
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Reoperative abdomen
Intraperitoneal mesh
Cirrhosis and portal hypertension
Mechanical bowel obstruction
Gravid Uterus
Locally invasive cancers
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Contraindications to Laparoscopic
Surgery
• Physiologic Limitations
– Pulmonary: CO2 retention/hypoventilation
– Cardiac: patients in hemorrhagic shock
– Neurologic: Acute brain injury (trendelenburg
position increased ICP)
– Coagulopathy: rarely a contraindication with
improved surgical technique and recombinant
anticoagulation factors. UNCORRECTED
coagulopathy is considered a contraindication to
laparoscopic surgery
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Laparoscopy in Pregnancy-Concerns
• Decreased Cardiac Output (IVC pressure)
– Fetus depends upon maternal hemodynamic
stability
– Primary cause of fetal demise is maternal
hypotension and hypoxia
• Decreased uterine blood flow/increased intrauterine pressure (Pneumoperitoneum)
– Both could lead to fetal hypoxia
• CO2 absorption leading to respiratory
acidosis
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Laparoscopic Surgery and Pregnancy
• Laparoscopic surgery can be performed safely in the pregnant
patient
• Second trimester is best
• Open access techniques safest
• Use lowest pressure possible (12 mm Hg or less)
– Greater pressures lead to fetal acidosis
– Semi-left decubitus position to relieve pressure on IVC
• Anti-embolic devices (higher DVT risk with pregnancy)
• Remember increased risk of aspiration in pregnancy
– Delayed gastric emptying
– Decreased lower esophageal sphincter tone
• Monitor maternal end tidal CO2
• Continuous intra-operative fetal monitoring if the fetus is viable
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New Frontiers in Minimally Invasive
Surgery
• SILS/SPA
– Often no visible scar, cosmetically superior
– Technically more difficult, longer OR times
– +/- less pain
– +/- more hernias?
• NOTES
• POEM (Per oral esophageal myotomy)
• Endoscopic therapies for GERD
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Energy Devices
• Cautery (generator, application electrode,
return electrode)
– Bipolar vs. Monopolar
– Cutting (continuous waveform) vs. Coag
(intermittent waveform)
– Temperature 200-300 degrees Celsius
– Significant lateral thermal spread causing tissue
dehydration/vessel thrombosis
– Doesn’t work underwater (in blood)
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Energy Devices
• Harmonic Scalpel
– Ultrasonic level vibrations (55K/sec)
– Denatures protein via vibratory heat rather than
electrical current
– Smaller lateral thermal spread
– Less Heat (80-100 degrees Celsius)
– How it works depends on power, pressure of
blades, tissue tension
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Energy Devices
• Ligasure (tissue response generator)
– Bipolar technology at heart but lower
voltage/higher current
– Changes the nature of vessel walls (collagen and
elastin within the tissue melt then reform creating
seal)
– Vessels up to 7 mm
– Very little lateral thermal spread
– Not as versatile for dissection
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Questions?
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