Principles of Minimal Invasive Surgery

Anesthesia

Assistant
Instrument Table

Surgeon
Nurse
Scrub
Mayo
Stand

Monitor
 Definition

Minimal Invasive Surgery can be defined as the application of modern

technology to minimize the trauma of surgical access without

compromising the exposure of the surgical site, or the safety of the patient.
Other Names

KEYHOLE SURGERY

LAPAROSCOPIC SURGERY

MINIMAL ACCESS SURGERY

 Short History

1901 - Von Ott - First inspection of abd.cavity.

1983 - First lap.app. Semm, a Ger. gynae.

1985 - First lap.Chole Erich Muhe, a Ger. surg.

1987 - First lap.ing.hernia repair Ger.

1989 - First lap.hyst. Reich et al.

1990 MIS Wickman & Fitzpatrick.

Extent of MIS

Laparoscopy.

Thoracoscopy.

Endoluminal endoscopy.

Perivisceral endoscopy.

Arthroscopy and Intra-articular Surgery.

Combined Approach.
Advantages of MIS

Decrease in wound size / wound pain

Improved mobility

Improved vision

Reduction in wound infection, dehiscence, bleeding,

herniation & adhesions
 Limitations of MIS
Reliance on remote vision and operating

Loss of tactile feedback

Dependence on handeye coordination

Difficulty with haemostasis

Reliance on new techniques

Extraction of large specimens

 Theatre set -up
Straight Line Principle

Surgeon opposite to the

organ of interest

Assistant opposite to the

surgeon

Camera man same side

of the surgeon
Triangulation - Principle

Monitor

P
R

L C

S
Equipment Necessary for MAS

Camera Apart from the insufflator the system

will work better if all the components
Light Source
are from the same company as one
Insufflator piece talks to another
TV Monitor
Telescopes
Light Guide Cable
 GAS INSUFFLATION

Controlled pressure insufflation of the peritoneal cavity

is used to achieve the necessary work space for
laparoscopic surgery.

Automatic insufflators allow the surgeon to preset the

insufflating pressure, and the device supplies gas until
the required intra-abdominal pressure is reached.
 Trocar
The trocar has a blade with a
shaft and body.

The body includes a pointed tip

which makes the initial incision
in the abdominal wall of the
patient.
(Trocar diameters range from 2mm-
30 mm)
Trocars

Types:
Cutting
Pyramidal tipped
Flat blade

Noncutting
Pointed conical
Blunt conical
Optical
 Telescope
There are three important structural
differences in telescope available

1. 6 to 18 rod lens system telescopes

are available

2. 0 to 120 degree telescopes are

available

3. 1.5 mm to 15 mm of telescopes are

available
Dissecting & Grasping Forceps

Atraumatic

KELLY atraumatic

Atraumatic, with hollow jaws

MANGESHKAR Grasping
Forceps, serrated
General instruments
Reusable three-piece design

Available in 2 mm, 3 mm,

3.5mm, 5 mm and 10 mm
sizes, with lengths of 20 cm,
30 cm, 36 cm and 43 cm.

Fully rotating 360 sheath.

No hidden spaces that can

trap operative blood and
tissue debris.
 Scissors
HOOK SCISSORS, single action
jaws

METZENBAUM SCISSORS, curved,

length of blades 12-17 mm, widely
used as an instrument for
mechanical dissection in
laparoscopic surgery.

STRAIGHT SCISSOR can give

controlled depth of cutting because
it has only one moving jaw.
 General Pre-operative Principles
Technique CO2 - Common

- Creating Pneumo.15 mm Hg - Cheaper

- Laparoscope inserted - Readily available

umbilical port - Easily absorbed

- Released via
- Abdomen evaluated
respiration
- Organs visualized
- Highly diffusion

- Additional ports placed

Preparation for MIS

Overall fitness: card.arrh

Previous surgery: scars, adhesions

Body habitus: obesity, skeletal deformity

Normal coagulation

Thrombo-prophylaxis

Informed consent
 Operative problems

Perforation of hollow

viscus

Bladder Injury

Bleeding
From Major Vessel

From Gall bladder bed

From Trocar site

Post operative Care

Nausea

Abdominal Pain

Analgesia
Contraindications Relative

Compromised cardiac status

Peritonitis

Multiple Abdominal Surgeries

Bleeding disorders

Morbid obesity

III rd Trimester pregnancy

Portal hypertension
References
Laparoscopy and entry

RCOG BASIC PRACTICAL SKILLS COURSE

1. Position

Prone
Non slip mattress
Green-top Guideline. No. 49 May 2008

The operating table should be horizontal

(not in the Trendelenberg tilt) at the start
of the procedure

The abdomen should be palpated to

check for any masses before insertion of
the Veress needle
2. Primary port closed entry
Why intra umbilical entry?

Fixed peritoneum
Thin
Least vascular
Cosmetic
Green-top Guideline. No. 49 May 2008

The primary incision for laparoscopy should

be vertical from the base of the umbilicus
(not in the skin below the umbilicus)

Care should be taken not to incise so

deeply as to enter the peritoneal cavity.
2. Primary port closed entry
Insertion of Veress needle
Pencil grip
Vertical, then towards pelvis
Double click
Green-top Guideline. No. 49 May 2008

Two audible clicks are usually heard as the

layers of the umbilicus are penetrated.

Excessive lateral movement of the needle

should be avoided. This may convert a small
needle point injury in the wall of the bowel or
vessel into a complex tear
2. Primary port closed entry

Saline test
Withdraw
Instil
Withdraw

If no fluid, frank blood (or faeces) then

proceed with insufflation
2. Primary port closed entry

Insufflation
Set pressure cut off to at least 20-25mmHg
Start at low flow (1L/min)
Check gas entering at low pressure (<8mmHg)
After 0.5L flow rate can be increased
Insufflate to pressure cut off (20-25mmHg)
2. Primary port closed entry
The greater the gas bubble & abdominal wall
tension the less the risk of bowel injury

Abdominal pressure= 8mmHg Abdominal pressure=25mmHg

Green-top Guideline. No. 49 May 2008

An intra-abdominal pressure of 2025

mmHg should be achieved before
inserting the primary trocar

The distension pressure should be

reduced to 1215 mmHg once the
insertion of the trocars is complete
Green-top Guideline. No. 49 May 2008

The primary trocar should be inserted at 90

degrees to the skin, through the incision at
the base of the umbilicus

Once the laparoscope has been introduced it

should be rotated through 360 degrees to
check for any adherent bowel
2. Primary port closed entry

Closed entry can still cause bowel injury,

especially if adhesions are present
2. Primary port closed entry

Other injuries
Vascular injury
Retroperitoneal
haemorrhage
Bladder injury
Injury to over inflated
stomach
3. Secondary ports

Secondary ports are inserted under direct

vision - an inadvertent injury from a
secondary port could be considered
negligent

Principles
Avoid inferior epigastric vessels
Avoid bowel/vascular injury
Minimise hernia risk
Green-top Guideline. No. 49 May 2008

Secondary ports inserted under direct

vision at right angles to the skin at 2025
mmHg pneumoperitoneum

Inferior epigastric vessels should be

visualised laparoscopically prior to
secondary port placement

Once the trocar has pierced the

peritoneum it should be angled towards
the anterior pelvis
3. Secondary ports - Anatomy

Mid-line

Rectus muscles

Obliterated umbilical artery

Round ligament
3. Secondary ports - Anatomy

Inf epigastric artery

4. Primary port Alternatives
Alternatives to closed umbilical entry
considered:
If there is risk of umbilical adhesions - previous
(midline) laparotomy
In very slim or morbidly obese women
Failed saline test or Veress insertion x2
Unsatisfactory closed Veress insufflation

Alternatives include:
Palmers point closed entry
Green-top Guideline. No. 49 May 2008

When Hasson open laparoscopic entry is

employed, confirm that the peritoneum has
been opened by visualising bowel or
omentum

Palmers point is the preferred alternative

trocar insertion site, except in cases of
previous surgery in this area or
splenomegaly.
5. Exit techniques

Under direct view to identify:

Bleeding

Injury to omentum

Injury to bowel
- (partial/complete)
5. Exit techniques

Wound closure:
Proper closure of fascia within umbilical
port site to prevent wound dehiscence or
hernia
Avoid hernia risk by closing sheath:
- Midline port sites > 7mm
- Lateral port sites > 5 mm