Overview
Laparoscopic surgery is a minimally invasive form of surgery (MIC: minimally invasive surgery) in which small skin incisions are made using narrow access points is operated on. In order to create sufficient space for the laparoscopic operation, the narrow intra-abdominal space is CO2 filled (so-called Capnoperitoneum). Advantages of laparoscopy include less postoperative pains, earlier mobilization and cosmetically more favorable results. Disadvantages are, for example, the greater technical complexity and the longer duration of the operation. Nowadays, more and more operations perform minimally invasively as standard.
Simulation of laparoscopy is significant choice with Ethicon Laparoscopic Trainer.
Indication
Abdominal Surgical Procedures
Visceral surgical operations: e.g. cholecystectomy, Herniated Operations (TEPP , TAPP , Hiatoplasty) , Colorectal Interventions
Gynecological operations: e.g. hysterectomy, oophorectomy, removal of endometriosis
Urological operations: e.g. nephrectomy, renal pelvis plastic,radical prostatectomy
Diagnostic Laparoscopies
Acute obscure abdominal pain
E.g. with VaAppendizitis
CAVE: Laparoscopy contraindicated in case of circulatory instability or shock
For more information on how to proceed in an emergency, see also: Diagnosis of the acute abdomen
Chronic abdominal complaints: e.g. in the case of possible adhesions or endometriosis
Acute abdominal trauma: e.g. knife stab wound
Laparoscopy right upper abdomen (liver and gallbladder) Laparoscopy right lower abdomen (appendix and cecum) Indirect inguinal hernia on the left (intraoperative laparoscopic finding) Laparoscopy of the lower abdomen (uterus and ovaries)Ulzerophlegmonöse AppendizitisKnife stab injury to the liver (intraoperative laparoscopic finding) Peritoneal carcinosis with ascites.
Advantages And Disadvantages
Advantages and disadvantages of laparoscopic surgery
benefits
disadvantage
Reduction of postoperative pain , thereby
Difficulty managing complications such as bleeding
Earlier mobilization ( thrombosis , embolism , pneumonia)
Inspection and touch reduced
Less analgesic consumption
Longer operation time
Shortening of the hospital stay
Higher cost
Shortening of postoperative intestinal atony
Technically high effort
Improving cosmetic results with smaller scars
More intra-abdominal abscesses
Less wound healing disorders
Longer learning curves
Fewer incisional hernias
Less adhesion formation
Better vision due to the magnifying effect of the optics
Contraindication
Whether a laparoscopy can perform depends, among other things, on patient-specific factors and internal hospital standards. Absolute contraindications increasingly put into perspective in recent years. For example, pregnancies in the 3rdTrimenon were long considered a contraindication for laparoscopy , but this has now been revised .
Absolute Contraindications
Decompensated heart failure
Decompensatedrespiratory failure
shock
Relative Contraindications
Multiple prior surgeries (high risk of bowel injuries due toadhesions )
Ileus
Increased intracranial pressure
Pregnancy is not a contraindication for laparoscopy if surgery indicates.
The main contraindications lists. No claim to completeness.
Preparation
Preoperative Management
As with all surgical procedures, various preoperative measures must carries out before laparoscopy. Depending on the urgency of the operation (elective vs. emergency), these can be more or less intensive. See also:
· Indication ( laparoscopy - indications )
· Perioperatives Management
· Preoperative diagnostics and laboratory tests
· Perioperative handling of premedication
· Surgical Education
· For intestinal surgery see esp.
· Preoperative management in intestinal surgery
· Surgical education: Special features in intestinal surgery
· Preoperative bowel preparation
· For information on surgical preparation on the ward and the procedure in the operating theatre, see
· Immediate perioperative management
· Surgical Safety Checklist
Material And Equipment
Non-Sterile
· Laparoscopy tower: screen, light source, camera control unit, gas insufflator
· electrosurgical device
· Saugsystem
Sterile
· Camera and fiber optic cable
· Trokare
· Possibly Veres needle
· instruments
· conventional instruments
· Laparoskopische Instrumente
· If necessary, teat/rinse
· Possibly monopolar/bipolar instruments
· gas hose
· Suture material for fascial and skin sutures
· OP cover
· compresses/swabs
· gloves and gowns
· TrokarVeres-Nadel
· Anesthesia in laparoscopic procedures
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Implementation of General Anesthesia
· Reduction of the risk ofAspiration risk through intubation and use of a nasogastric feeding tube
· Deep neuromuscular blockade
· Necessary for creating Capnoperitoneums
· neuromuskulärem MonitoringRelaxometry
Change In Physiological/Anaesthesiological Parameters
Peritoneal CO2Insufflationdiaphragm
Reduced functional residual capacity and compliance of the lungs higher ventilation pressures are necessary for the same volume
Decreased venous return Sufficient Volume necessary (CAVE in case of heart failure)
Change In Gas Exchange
Reduced O 2 uptake
CO2Diffusionperitoneal
Increase in Atemminuten volumens ventilation necessary to avoid hypercapnia
Increased CO 2 absorption with simultaneously reduced CO 2 release via the lungs leads to a difference between arterial and end-tidal CO 2 values
Measurement of the arterial CO 2 value via a BGA
More Changes
· Increase in gastroesophageal reflux
· Decrease in body temperature
· Decrease in urine output
Process/Execution
Access Routes
With regard to the first trocar placement, two different access routes have establish – an open procedure is according to Hasson and the closed procedure using Veres-Nadel. There is no evidence that either approach is superior in terms of complications. In gynecology, the access route using the Veres-Nadel establishes. As a rule, the first inserts above or below the navel, since that is where the abdominal wall is thinnest.
Open procedure according to Hasson (Hasson technique)
Execution
Skin incision with a trocar-sized scalpel (15–20 mm)
Dissection of the Subcutaneous down to the anterior fascial sheet
Sharp opening of the anterior sheet of fascia
Tighten the posterior fascia sheet by pulling up with a Kocher clamp or forceps and opening the posterior fascia sheet with scissors or a scalpel
Opening of the Peritoneums
Insertion of the first with a blunt inlay
TrokarsCO2InsufflationCapnoperitoneum
Immediate laparoscopy by inserting the camera through the firstTrokar to check the position
If necessary, reposition the Trokars in the event of an incorrect position
Closed approach using a Veres needle
Execution
Incision of the High with a trocar-sized scalpel (15–20 mm )
Dissection of the Subcutaneous down to the anterior fascial sheet
Grasping and lifting the fascia, e.g. with Kocher clamps
Place theVeres-Nadel perpendicular to the fascia and advance it into the abdominal cavity
Carrying out the position tests (see below)
Veres-NadelCO2InsufflationCapnoperitoneum
With sufficientCapnoperitoneum : removal of theVeres-Nadel
Insertion of the sharpTrokars through the same access
Immediate laparoscopy by inserting the camera through the firstTrokar to check the position
If necessary, reposition theTrokars in the event of an incorrect position
Lagekontrolle derVeres-Nadel
Aspiration test : placing a syringe on theVeres-Nadel → If the needle is in the correct position, noAspiration (of air or liquid) is possible
Slurping test : Application of a drop of NaCl to theVeres-Nadel → When theabdominal wall is lifted manually , the NaCl should be sucked in intra-abdominal (slurping noise)
Injection test : Injection of 2–3 mL NaCl through theVeres-Nadel → If the position is correct, this is possible without resistance and the liquid disappears intra-abdominal
CO2InsufflationVeres-Nadel
Trocar placement according to HassonTrocar placement using a Veres needleVeres-Nadel
Creation Of The Capnoperitoneum S
CO2Capnoperitoneum
Aim
Enlargement of the operating area
Better visibility and freer access to the surgical field
Reduced risk of injury to internal organs
Execution
CO2
Connection of the gas hoseto the valve of the firstTrokars
CO2Insufflation
Pressure maintained by continuous gas flow
Complications see: Complications of theCapnoperitoneums
Surgical Steps
Laparoscopy: Inspection of all 4 quadrants of the abdominal space with the camera
Exclusioniatrogener injuries by placing the trocar directly below the optical trocar
Creation of further working trocars
Skin incision in the area of the planned trocar placement according to the trocar size
Inserting theTrokare with a sharp inlay under view (camera) should avoide
Injury to the superficial epigastric artery and vein
Injury to intra-abdominal structures
Scenery phenomenon
Implementation of the necessary measures
Diagnostic laparoscopy: Inspection of all 4 quadrants using a probe and/or atraumatic grasping forceps
Therapeutic measures: treatment of pathologies detected during laparoscopy
Closure of the fascia: For fascial incisions >1 cm (prevention of trocar hernias)
Removal of theTrokare and drainage of theCapnoperitoneums
Closure of theHigh : By sutures or staples and protection by sterile bandage/plaster
Sign-out : Cross-team summary of the course of the operation with actions taken, any important post-treatments, pathology specimens present and confirmation of full count control
Postoperatives Management
Similar to conventional surgical operations – no special measures are required here with regard to laparoscopy. However, the need for painkillers is generally lower after laparoscopy than with conventional surgical techniques. For more information on the postoperative procedure see also:
Postoperatives Management
Postoperative management on the ward
For intestinal surgery see esp.
Postoperative management after intestinal surgery
Complications
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Intraoperative Complications
Complications from the capnoperitoneum
impairment of respiratory mechanics
Pneumothorax
impairment of hemodynamics
Increased gastric reflux (due to increased intra-abdominal pressure) → Increased risk of aspiration
Hautephysem
Rise in bye CO 2 (by 8–10 mmHg on average ) → Possible hypercapnia
reduction in body temperature
Injury to extraperitoneal and intraperitoneal structures
Postoperative Complications
Storage damage due to sometimes-extreme storage
See also: General Postoperative Complications and Postoperative Complications of Bowel Surgery
The most important complications mention to no claim to completeness.
Alternate Methods
A conventional, open surgical procedure always chooses as an alternative. In addition, the laparoscopic technique itself constantly further develops and supplements by the following newer technologies in recent years:
Alternative Types of Laparoscopy
Single Incision Laparoscopic Surgery (SILS)
Special feature: All the necessary instruments, including the camera, introduce via just one
Applications: Cholezystektomie , Appendektomie
, Fundoplicatio
Natural Orifice Transluminal Endoscopic Surgery (NOTES)
Special feature: A natural body opening serves as access route
Applications: Hybrid transvaginal cholecystectomy
3D Laparoscopy
Special feature: Creation of a three-dimensional image with depth perception with polarized glasses
Applications: inguinal hernia surgery, nephrectomy, cholecystectomy
Robot-Assisted Laparoscopy
Special feature: 3-4 robotic arms controls by surgeons via a console that does not necessarily to in the operating room
Possible uses: prostatectomy, hysterectomy, bowel resection
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