Rawalpindi Medical college

1. Principal of
Laparoscopic Surgery
PROFESSOR HAMID HASSAN
PROFESSOR OF SURGERY
SURGICAL UNIT – I, RGH.

2. Minimal Access Surgery is the
marriage of the modern
technology and Surgical
Innovation.

3. Aims
 Minimal Somatic trauma
 Minimal Psychological Trauma
 lesser Hospital Stay
 Faster recuperation

4. Category
 Laparoscopy.
 Thoracoscopy.
 Endoluminal endoscopy.
 Perivisceral endoscopy.
 Arthroscopy and Intra-articular Surgery.
 Combined Approach.

5. Dimension of
Laparoscopic Surgery
 Diagnostic Laparoscopic Surgery




Non Specific Abdominal Pain
B.A.T
Staging of Intra abdominal Malignancy
Secondary Infertility in Females

6.  Therapeutic Laparoscopic Surgery






Lap. Cholecystectomy
Lap. Spleenectomy
Lap Thyroidectomy
Lap. Ligation of Varicose vein perforators
Lap. Cardiac bypass surgery
Lap. Biopsy taken from Lungs and Liver

7. Dif ferent
Instr ument
use
in Laparoscopic
Sur ger y

8. Blunt Tip Trocar
Trocar
sleeve
Blunt tip
Adjustable
olive
Desufflation
lever
Suture
tie point
Cam
Stopcock
Locking
button
Obturator
handle

9. Dilating Tip Surgical Trocar
*trademark

10. Curved Intraluminal Staplers
with Detachable Head

11. CONVENTIONAL LIGATION
LIGACLIP* Multiple Clip Appliers
ABSOLOK* EXTRA Absorbable Single Clip System
LIGACLIP* EXTRA Single Clip System

12. Skin Stapler

13. PROXIMATE* Linear Cutters

14. Preoperative Evaluation

15. Aims
 The patient is fit for surgery
 The patient is fully informed and
consented
 Operative difficulty is predicted where
possible
 Appropriate theater time and facilities
available

16.  History
 Examination
 Premedication

17.  Prophylaxis against Thromboembolism
 Informed consent
 Urinary catheter and NG tube if needed.

18. General Intraoperative
Principles

19. Assistant
Nurse
Scrub
Surgeon
Instrument Table
Anesthesia
Mayo
Stand
Operation Theater Setup
Monitor

20. Creating a
Pneumoperitonium

21. Preoperative Problems
 Previous Abdominal Surgery
 Obesity

22. Operative Problems
 Perforation of hollow viscus
 Bleeding
 From Major Vessel
 From Gall Bladder Bed
 From Trocar Site
How to Evacuate the Clot ?

23. Principal of Electrosurgery
during
Laparoscopic Surgery

24. ©19
95
Eth
ico
n
En
do
-S
urg
ery
, In
c..
 Monopolar diathermy
 Bipolar Diathermy
Electrosurgery
Electrical Injuries unrecognized at the time of operation patient
present after about 3 -7 days with abdominal pain and fever.

25. Causes of injury
 Inadvertent touching and grasping.
 Direct coupling between the tissue and
the instrument.
 Break in insulation.

26.  Direct sparking to bowel from the
diathermy probe.
 Passage of current to the bowel from
recently coagulated tissue.

27. Postoperative Care

28.  Nausea
 Shoulder Pain
 Abdominal Pain
 Analgesia

29.  Oral fluids
 Oral feeding
 Drains

30.  Mobility and Convalescence
 Discharge from the Hospital
 Skin Sutures.

31. Principal Of
Common
Laparoscopic Procedure

32. Laparoscopic
Cholecystectomy
Cystic duct
Hartmann’s pouch
(infundibulum)
Gallbladder
Liver margin
Hepatic ducts
Common hepatic duct
Sphincter of Oddi
Fundus
Duodenum
Duodenal wall
Ampulla of Vater
Common bile duct
Pancreatic duct
Duodenal papilla

33. Left hepatic artery
Portal vein
Proper hepatic artery
Liver
Common hepatic artery
Ligamentum teres
Left gastric artery
Common hepatic duct
Right hepatic artery
Celiac trunk
Splenic artery
Gallbladder
Cystic artery
Cystic duct
Pancreas
Common bile duct
Abdominal aorta
Gastroduodenal artery
Superior mesenteric vein
Superior mesenteric artery

34. Video monitor
Light source
Camera
VCR
Suction unit
CO2 insufflator
in CO
su
ff 2
la
to
r
Anesthesia
se
ur
N
Instrument
stand
Surgeon
Assistant
V
m id
on eo
ito
r
Electrocautery unit
Suction unit

35. 5mm trocar
midclavicular
5mm trocar
anterior axillary
5mm or
10/12mm trocar
subxiphoid
10/11mm or
10/12mm trocar
umbilicus
Port Placement

36. Laparoscopic
Cholecystectomy (Hook)
 Use the hook blade to
dissect cystic duct and
artery
 Ligate with clips
 Transect with hook blade

37.  Use side of hook for
coaptive coagulation
prior to transaction
Cavitationally
assisted dissection
off the liver bed

38.  Back or side of hook
blade for small
bleeders on the liver
bed

39. Laparoscopic Inguinal
Hernia
 Trans Abdominal Preperitoneal repair
 Extraperitoneal repair

40. Rectus
abdominis
Medial
umbilical
ligament
Hesselbach’s
triangle
Lacunar
(Gimbernat’s)
ligament
Urinary
bladder
Vas deferens
Ureter
Inferior
epigastric
vessels
Internal
inguinal
ring
Cooper’s
ligament
Iliopubic
tract
Testicular
vessels
External
iliac
vessels
Cecum
Sacral
promontory

41. Laparoscopic
Antireflux Surgery

42. Esophagus
Phrenoesophageal
ligament
(ascending or
upper limb)
Respiratory
diaphragm
Phrenoesophageal ligament
(ascending or upper limb)
Infradiaphragmatic
fascia
Phrenoesophageal
ligament
(descending limb)
Visceral
peritoneum
Subhiatal
fat ring
Phrenoesophageal
ligament
(descending limb)
Fundus
of stomach
Visceral
peritoneum
Ligaments of the Esophageal Hiatus
(anterior view)

43. Nissen Fundoplication
Anesthesia
Monitor
Assistant
First
Assistant
Instrument Table
Monitor
Surgeon

44. 5 or 10/12mm trocar
operating port
10/12mm trocar
operating port
5 or 10/12 mm trocar
liver retraction
10/12mm trocar
stomach retraction
umbilicus
10/12mm trocar
camera port
Port Placement

45. NISSEN FUNDOPLICATION
Fig. 1
Liver

46. Fig. 2
Crura

47. Fig. 3
Short gastric vessels
divided

48. Fig. 4
Wrap created

49. Fig. 5
Wrap fixated

50. Laparoscopic
Spleenectomy

51. Greater curvature
of vascular arcade
Stomach
(posterior surface)
Left gastric artery
Greater omentum
Splenic artery
Caudate lobe
of liver
Spleen
Left
gastroepiploic
artery
Proper hepatic artery
Inferior vena cava
Superior pole
of kidney
Gastroduodenal artery
Right gastroepiploic
artery
Duodenum
Pancreas
Celiac trunk
Common hepatic artery
Greater omentum
Anterior superior
pancreaticoduodenal
artery
Left suprarenal
gland

52. Spleenic Artery Anatomy

53. Division of short gastric
vessels

54. Division of short gastric
vessels

55. Division of short gastric
vessels

56. Dissection of Spleenic Vessels

57. Ligating Spleenic Artery

58. Divided splenic artery and vein

59. Exposure of Inferior Pole Ligaments

60. Direct Approach to Hilium

61. Division of Hilum with
Endoscopic Stapler

62. Completion of Spleenectomy

63. Spleen Placed in Bag

64. Bagged Spleen

65. Removed Spleen

66. Cannula Sites

67. Future Of
Laparoscopic
1.
2.
3.
4.
Gas less Laparoscopic Surgery
Hand assisted Laparoscopic Surgery
Natural Orifice Transluminal Endoscopic Surgery (NOTES)
is being investigated as an alternative to laparoscopy.
Laparoscopic surgery utilizing the computer robot system