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PHYSIOLOGY OF LAPAROSCOPY

CHRISTIAN REY CAYABYAB


SURGERY PRESENTATION
12.04.19
WHAT IS LAPAROSCOPY?

• Laparoscopy is from the ancient Greek “lapara” - flank and “skopeo” - to see.

• Also known as minimally invasive surgery or keyhole surgery.

• Uses several small incisions or ports to insert laparoscopic instruments with


peritoneal insufflation.

• George Kelling (1901) - first laparoscopic surgery was performed on a dog


WHAT IS IT USED FOR?

• Management
• Diagnosis
• Cholecystectomy and appendicectomy
• Assessment of liver disease

• Unknown cause of ascites • Fundoplication

• Acute abdomen, including acute appendicitis • Colonic resections

• Detailed diagnosis and staging of intra- • Splenectomy and retroperitoneal


abdominal malignancy and lymphoma procedures
• Pre-op assessment of blunt and penetrating
trauma
CONTRAINDICATIONS

• Relative • Absolute

• Cardiac failure • Haemodynamic instability/shock

• Pulmonary failure • Acute intestinal obstruction with


dilated bowel loops
• Pregnancy/large pelvic mass
• Increased intracranial pressure
• Soft tissue infection at port sites

• Extensive adhesions

• AAA
PROCEDURE OVERVIEW

• Patient is put under general anaesthetic

• Determine location for ports - depends on the type of surgery

• Sites include: midline abdomen, umbilicus, medial costal margin,


lateral abdomen/flank, ninth left ICS, hypogastrium

• After the initial trocar is inserted, the abdomen is insufflated with CO2.

• Primary and secondary ports are placed through 1-1.5 cm incisions

• Primary port normally the same site as insufflation

• Secondary port must have a good view of the operating field but with
adequate spacing between the hands

• After surgery, abdomen is desufflated and wounds are closed.


PERITONEAL ACCESS

• 50% of complications occur during the initial access

• Open (Hasson)

• An open incision (usually periumbilical) is made under direct vision

• Surgeon has direct view of all layers of the abdominal wall during entry all the
way through fascia, preperitoneal fat and peritoneum

• The underside of the peritoneum is palpated for any adhesions and the clear
the bowel and omentum

• A blunt ended trocar, i.e. Hasson, is placed through the incision and secured

• Needs to be sutured after the procedure

• Adds to the length of the procedure


PERITONEAL ACCESS

• Closed (Veress needle)

• Originally designed for iatrogenic pneumothorax for TB

• Has a needle and a springloaded protective obturator that prevents damage to


organs

• Typically inserted in the umbilicus - no fat or muscle between the skin and
peritoneum

• A 5-mm incision is made through the skin and subcutaneous tissue

• Needle is inserted and depth is noted - needle is held just above this line

• Fascia and abdominal wall are elevated using clamps and needle is inserted

• 2 “pops” - abdominal fascia and parietal peritoneum

https://www.youtube.com/watch?v=30nKa4_M_Dg
PHYSIOLOGICAL EFFECTS OF PNEUMOPERITONEUM

• Cardiovascular

• Increased intra-abdominal pressure (IAP) affect venous return (VR)

• Initial increase in VR and cardiac output (CO)

• Further increase in IAP → compression if IVC → ↓ VR and CO

• IAP and release of cathecolamines also ↑ systemic vascular resistance and ↑ HR

• Hypercapnia vasodilates and is a myocardial depressant; however ↑ in SVR is usually still


greater → ↑BP and cardiac workload → possible ischemia

• Hence, it is important to optimise the patient’s fluid volume and cardiac status
PHYSIOLOGICAL EFFECTS OF PNEUMOPERITONEUM

• Respiratory

• Reduced functional residual capacity (FRC) - general


anaesthesia, supine and Trendelenburg positions, and
pneumoperitoneum

• ↓ FRC can cause airway collapse, atelectasis and V/Q


mismatch → potential hypoxaemia and hypercapnia

• ↑ in airway resistance and ↓ lung compliance → ↑ risk of


barotrauma with positive pressure ventilation

• Renal

• ↑ IAP and ↓CO → ↓ renal blood flow → ↓GFR → ↓ renal


function → RAAS activation
PHYSIOLOGICAL EFFECTS OF PNEUMOPERITONEUM

• Gastrointestinal

• ↑ IAP may cause regurgitation of gastric contents → risk of aspiration

• Particularly significant in obese patients

• Neurological

• Rise in IAP increases intracranial pressure → may ↓ cerebral perfusion pressure especially with ↓
CO

• Remember: cerebral perfusion pressure = MAP - intracranial pressure

• Healthy patients usually able to maintain homeostasis. Other comorbidities may be significant,
e.g. carotid atherosclerosis and other cardiovascular disease
PHYSIOLOGICAL EFFECTS OF POSITIONING

• Trendelenburg

• Used in pelvic surgery

• Further ↓FRC, more V/Q mismatch and ↑ risk of atelectasis

• Cephalad movement of lungs and carina in relation to fixed


endotrachial tube

• ↑ VR initially - normal for healthy patients but may cause problems in


patients with compromised heart

• Reverse Trendelenburg

• ↓ VR → ↓CO → ↓BP

• Effect is more obvious in hypovolaemia and cardiac compromise


EFFECTS OF GAS INSUFFLATION AND
COMPLICATIONS

• Rapid absorption of CO2 plateaus after 1 hour.

• Arrhythmias: stretching of the peritoneum → vagal stimulation → possible sinus bradycardia and
asystole

• More pronounced initially due to rapid stretching of peritoneum

• Subcutaneous emphysema, penumomediastinum and pneumothorax

• May occur due to incorrect positioning of gas insufflation needle or trocars or anatomical
anomalies

• Venous gas embolism - rare especially CO2 since it readily dissolves

• Trauma - more likely in closed access


COMPLICATIONS CONTINUED…

• Complications associated with initial access occurs in <1% of patients

• Vascular damage

• Conversion to an open procedure

• Gastrointestinal puncture - 3rd leading cause of death after anaesthesia and major vascular damage

• Bladder puncture

• Nerve injury

• Hernia - port site and extraction site

• Surgical site infection


RECOVERY

• Monitor vitals, ECG, end-tidal CO2. Additional monitoring depending on


procedure.

• Post-op recovery is generally quicker compared to open surgeries

• Pulmonary function is better preserved with less atelectasis

• Smaller wounds → less pain

• Shoulder tip pain causes the most discomfort

• Quicker mobilisation and less post-op ileus


PROS AND CONS OF LAPAROSCOPY

ADVANTAGES DISADVANTAGES

• Minimally invasive

• Less analgaesia
• Instrumentation cost and availability
• Reduced post-operative pain
• Long learning curve
• Shorter recovery period and hospital stay
• Perceptual difficulties - two-dimensional and
limited view, no direct tactile contact with organs
• Lower risk of post-op complications

• The ports limit the movement of instruments


• Less risk of adhesions

• Better cosmesis
SUMMARY OF THE EFFECTS OF PNEUMOPERITONEUM

Cardiovascular Respiratory Renal

Lung volumes esp


IAP < 10 mm Hg ↑ VR ⟶ ↑ CO ↓ Renal function ↓
FRC
↑ IAP ⟶ ↓ VR ⟶ ↓
IAP 10–20 mm Hg Airway resistance ↑ Gastrointestinal
CO
Pulmonary
↑ IAP ⟶ ↑ SVR ↓ Risk of regurgitation ↑
compliance

BP = ↓ CO × ↑↑ SVR Airway pressure ↑ Neurological

↔↑ BP Risk of barotrauma ↑ ICP ↔↑

IAP > 20 mm Hg ↓↓ VR ⟶ ↓↓↓ CO V/Q mismatch ↑

↓ BP