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WORLD LAPAROSCOPY HOSPITAL Cyberciti, DLF Phase II, NCR Delhi, Gurgaon, 122 002, India Phone: !

1"0#12$ %2&'1''' (obile: !1"0#!)11%1*)&), !)11!12+*), ,-ail: contact.la/arosco/yhos/ital0coThe Premier Laparoscopic Training Institute for Surgeon & Gynaecologist Click here for training detail

Diagnostic Laparoscopy

Diagnostic la/arosco/y is a -ini-ally in1asi1e surgical /rocedure that allo2s the 1isual e3a-ination o4 intra abdo-inal organs in order to detect /athology0 5he 1ideo i-age o4 the li1er, sto-ach, intestines, gallbladder, s/leen, /eritoneu-, and /el1ic organs can be 1ie2ed on a -onitor a4ter insertion o4 a telesco/e into the abdo-en0 (ani/ulation and bio/sy o4 the 1iscera is /ossible through additional /orts0

Diagnostic la/arosco/y 2as 4irst introduced in 1!01, 2hen 6elling, /er4or-ed a /eritoneosco/y in a dog and 2as called 7celiosco/y80 9 :2edish internist na-ed ;acobaeusc is credited 2ith /er4or-ing the 4irst diagnostic la/arosco/y on hu-an in 1!100 <e described its a//lication in /atients 2ith ascites and 4or the early diagnosis o4 -alignant lesions0 La/arosco/y has e1ol1ed as an in4or-ati1e, i-/ortant -ethod o4 diagnosing a 2ide s/ectru- o4 both benign and -alignant diseases0 ,lecti1e diagnostic la/arosco/y re4ers to the use o4 the /rocedure in chronic intra$abdo-inal disorders0 ,-ergency diagnostic la/arosco/y is /er4or-ed in /atients /resenting 2ith acute abdo-en0 The indications for diagnostic laparoscopy can be di ided into fo!r "ain gro!ps# $on%tra!"atic& non%gynaecological ac!te abdo"en li'e# o 9//endicitis o Di1erticulitis o Duodenal /er4oration o (esenteric adenitis0 o Intestinal adhesion

o =-ental necrosis0 o Intestinal in4arction0 o Co-/licated (ec>el?s di1erticulu-0 o @edside La/arosco/y in the ICA0 o 5orsion o4 intra$abdo-inal testis0 (ynaecological abdo"inal e"ergencies li'e# o =1arian cysts0 o Pel1ic in4la--atory diseases0 o 9cute sal/ingitis0 o ,cto/ic /regnancy0 o ,ndo-etriosis0 o Per4orated uterus due to cri-inal abortion o :al/ingitis Abdo"inal tra!"a# Ad antages# Diagnostic la/aroto-y 4or abo1e -entioned abdo-inal condition is /er4or-ed by general surgeon since long but la/arosco/ic diagnostic la/arosco/y has 4ollo2ing ad1antages: o Cos-etically better outco-e0 o Less tissue dissection and disru/tion o4 tissue /lanes o Less /ain /osto/erati1ely0 o Lo2 intra$o/erati1ely and /osto/erati1e co-/lications0 o ,arly return to 2or>0 o @etter 1isualiBation o4 Para$colic gutters and /el1ic ca1ity 2hich is not /ossible by diagnostic la/aroto-y OP)RATI*) T)CH$I+,) Patient Position o 5he /atient is /laced on the o/erating table 2ith the legs straight or lithoto-y /osition i4 4e-ale0 o 5he o/erating table is tilted head u/ or do2n by a//ro3i-ately 1' degree de/ends on the -ain area o4 e3a-ination0 o Co-/ression bandage -ay be used on leg during the thro-boe-bolis- es/ecially i4 /atient is in lithoto-y /osition0 o 5he surgeon stands on le4t side o4 the /atient0 o 5he 4irst assistant, 2hose -ain tas> is to /osition the 1ideo ca-era, is also on the /atient?s le4t side0 o 5he instru-ent trolley is /laced on the /atient?s le4t allo2ing the scrub nurse to assist 2ith /lacing the a//ro/riate instru-ents in the o/erating /orts0 o/eration to /re1ent

o 5ele1ision -onitors are /ositioned on either side o4 the to/ end o4 the o/erating table at a suitable height so surgeon, anesthetists, as 2ell as assistant can see the /rocedure0 Anaesthesia# Recently local anaesthesia "1C lidocaine# is 4a1ored by 4e2 surgeons0 <o2e1er, the -aDority uses general anaesthesia0 General endotracheal anaesthesia is used0 ,ach /atient is inDected in the /re$induction /hase 2ith *0-g I( Contra-ol, IE (etronidaBole or 5inidaBole and 2ith 2grs0 o4 Ce4iBo3 IE0 5he /ro/hylactic antibiotic is generally not indicated in diagnostic la/arosco/y but in tro/ical country li>e India it is ad1isable to use /ro/hylactic antibiotic Creation of Pne!"operitone!"Pneu-o/eritoneu-, on a1erage )$10--<g, is created using Eeress needle0 5rans$u-bilical insertion o4 the Eeress needle and o/tical /ort should be used0 9n e3trau-bilical /lace-ent -ay be used 2hene1er surgical /eri$u-bilical scars 2ere /resent or adhesions sus/ected0 o Chec> Eeress needle be4ore insertion0 o Chec> 1eress needle ti/ s/ring0 o Con4ir- that gas connection is 4unctioning0 o ,nsure 4lushing 2ith saline does not bloc> that needle0 o (a>e a s-all incision Dust abo1e the u-bilicus0 o Li4t u/ abdo-inal 2all and gently insert Eeress needle till a 4eeling o4 gi1ing 2ay0 o Con4ir- /osition o4 needle by saline dro/ -ethod0 o Connect C=2 tube to needle0 o :2itch o44 gas 2hen desired /neu-o/eritoneu- is created and re-o1e the Eeress needle 5he o/en techniFue 4or trocar insertion is reco--ended i4 /atient /resents 2ith se1ere abdo-inal distension0 Nitrous o3ide is used i4 diagnostic la/arosco/y is /er4or-ed in local anaesthesia because Nitrous o3ide has its o2n analgesic e44ect0 Carbon dio3ide is the /ro44ered gas i4 diagnostic la/arosco/y is /er4or-ed under general anaesthesia0 Insu44lation should be 1ery slo2 and 2ith care ta>en not to e3ceed 1200 --<g0 Port location#

(enerally one optical port in !"bilic!s and one ."" port in left iliac fossa are re/!ired

9 three$/ort a//roach should be used i4 there is any di44iculty in -ani/ulation0 o 10-- u-bilical "o/tical#, o ' -- su/ra/ubic and o ' -- right hy/ochondriu-0 9 &0G telesco/e is e-/loyed in -ost instances, as this 4acilitates easier ins/ection o4 the /eritoneal ca1ity and abdo-inal organs0 5he secondary /orts are inserted under la/arosco/ic 1ision0 5he selected site on the abdo-inal 2all is identi4ied by 4inger indentation o4 the /arietal /eritoneu-0 Inspection#

Syste"ic plan of inspection of !pper abdo"en


Patient in steep trendelenberg position
Hepatic flexure Right side of ascendin g colon

Start

Structure just below umbilicus

Caecum and Appendix

Syste"ic plan of inspection in "id abdo"en


Reverse the Trendelenberg tilt
Right lobe of the liver and gall bladder Telescope Transver Left lobe of should then be se colon the liver. withdrawn a little to cross Sple falciform en ligament !al" over to esc Small #ntestine endi ng colon Sigmoi d colon

Inspection of Pel is
Patient should again positioned in steep trendelenberg position The full length of fallopian tube %rom cornua to fimbriae The round ligament Anterior cul de sac $terus

Some snap shots of Diagnostic Laparoscopy:

Carcino"a li er

Hae"angio"a

Carcino"atosis

)ndo"etriosis

)ctopic pregnancy

0icorn!ate !ter!s

Polycystic o ary

1ibroid

Adhesion of Appendi2

Di ertic!l!"

I"palpable Testes

Perforation

o 9bdo-inal organs are ins/ected 4or any /athology o 9bdo-inal ca1ity is ins/ected 4or 4luids0 o :a-/les are ta>en i4 4ree 4luid is /resent 4or laboratory tests "che-istry, cytology or bacteriology#0 o Peritoneal la1age and adhesiolysis -ay need to be /er4or-ed to i-/ro1e 1isualisation o4 organs0 o 5hera/eutic la/arosco/y is then underta>en, i4 indicated and surgeon is e3/erienced enough0 )nding of the operationo ,3a-ine the abdo-en 4or any /ossible bo2el inDury or hae-orrhage0 o Re-o1e the Instru-ent and then /ort0 o Re-o1e telesco/e lea1ing gas 1al1e o4 u-bilical /ort o/en to let out all the gas0 o Close the 2ound 2ith :uture0 o Ase 1icryl 4or rectus and An$absorbable intra$der-al or :ta/ler 4or s>in0 o 9//ly adhesi1e sterile dressing o1er the 2ound0

5he usual site o4 insertion o4 the trocarHcannula 4or diagnostic la/arosco/y is belo2 or to the side o4 the u-bilicus0 5his /osition -ay reFuire to be altered in the /resence o4 abdo-inal scars0 5he use o4 a &0 degree 4or2ard obliFue telesco/e is /re4erable 4or 1ie2ing the sur4ace architecture o4 organs0 @y rotation o4 the telesco/e, di44erent angles o4 ins/ection can be achie1ed0 5he 4irst i-/ortant ste/ a4ter access to the abdo-en has been gained is to chec> 4or da-age caused by trocar insertion0 9 second ' -- /ort -ay then be inserted under 1ision in an a//ro/riate Fuadrant to ta>e a /al/ating rod0 9 syste-atic e3a-ination o4 the abdo-en -ust then be /er4or-ed Dust as in la/aroto-y0 Ie begin at the le4t lobe o4 the li1er but any sche-e can be used as long as it is consistent0 Ne3t, chec> around the 4alci4or- liga-ent to the right lobe o4 li1er, gallbladder and hiatus0 94ter chec>ing the sto-ach, -o1e on to the caecu- and a//endi3 and chec> the ter-inal ileu-0 Follo2 the colon round to the sig-oid colon, and then chec> the /el1is0 Jou should be con1ersant 2ith sa-/ling and bio/sy techniFues, and the use o4 /osition and -ani/ulation to aid 1ision0 5his is the 4irst /rocedure to be -astered 2hen learning la/arosco/ic surgery0 Ihen /er4or-ing a diagnostic la/arosco/y to con4ir- a//endicitis, a 4i1e -- /ort is /laced in the le4t iliac 4ossa to 4acilitate -ani/ulation0 5he /atient is /laced head do2n and rotated to the le4t to dis/lace the s-all bo2el 4ro- the /el1is and allo2 the uterus and o1aries to be chec>ed0 5his ho2e1er should be li-ited to a1oid conta-ination o4 sub/hrenic s/aces i4 this is not already /resent0 Patient -ay be discharged on the sa-e day a4ter o/eration i4 e1ery thing goes 2ell0 5he /atient -ay ha1e slight /ain initially but usually resol1es0 Diagnostic la/arosco/ic is a use4ul -ethod 4or reducing hos/ital stay, co-/lications and return to nor-al acti1ity i4 carried on in /ro/er -anner0 Iith better training in -ini-al access surgery and better ergono-ics no2 a1ailable the ti-e has arri1ed 4or it to ta>e its /lace in the surgeon?s re/ertoire0
For More Information Contact: Laparoscop& Hospital $nit of Shanti Hospital' ()*+ Tila" ,agar' ,ew -hone. /0*1+2**3 45*554+4 /0*1+20(**6*7(8(' 0(**0*497( :mail. contact;laparoscop&hospital.com elhi' **++*(. #ndia.

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