Minimally Invasive Surgery PDF

BASIC SURGERY, ‘DI NAMAN BASIC LECTURER: DI KO ULIT KILALA HEHE HISTORICAL BACKGROUND Halos lahat daw ng subspecialty ginagamit tong minimally...

BASIC SURGERY, ‘DI NAMAN BASIC LECTURER: DI KO ULIT KILALA HEHE HISTORICAL BACKGROUND Halos lahat daw ng subspecialty ginagamit tong minimally invasive surgery from neurosurgery, to gynecology, to Performed in Berlin in 1901 thoracosurgery and so on. FIRST German surgeon: Georg Kelling Performing MAJOR operations through small incisions EXPERIMENTAL Used a cystoscope to peer into the Minimally invasive surgery describes a philosophical approach to LAPAROSCOPY abdomen of a dog after first insufflating it surgery in which access trauma is minimized without with air compromising the quality of the surgical procedure. Performed in Sweden by Hans Christian The Carbon Dioxide Pneumoperitoneum used for laparoscopy Jacobaeus in 1910 to investigate ascites induces some unique pathophysiologic consequences. Coined the word “laparoscopie” and Single-Incision Laparoscopic Surgery (SILS) ® reduces the amount FIRST HUMAN “thoracoscopie” of abdominal wall trauma but presents unique challenges to the LAPAROSCOPY Jacobeus was first to publish a series of traditional tenets of laparoscopic ergonomics. abdominal and thoracic examination in Wag malilito ang minimally invasive surgery ay tinatawag ding humans using minimally invasive techniques laparoscopic surgery. As to comparison with open surgery, less In 1910, merely used for diagnostic purposes ang trauma dito sa minimally invasive surgery or laparoscopic 1929, Kalk surgery kasi nga small incision lang ang ginagawa dito, kaya ang Advocated a second puncture site effect nito sa katawan is minimal lang. In 1929, now aims for therapeutic purposes FATHER OF PNEUMOPERITONEUM – to introduce air in the MODERN CHOLECYSTECTOMY peritoneal cavity; Kalk also used different LAPAROSCOPIC A study by Shyr-Ming Sheen-Chen, MD et al World J Surg 2002 types of lenses to make laparoscopy clearer SURGERY Taiwan; 70 patients Described several diagnostic and Laparoscopic approach shows decreased (better) immunologic therapeutic laparoscopic procedures and metabolic response Devised a sophisticated lens system Fiberoptic technology was introduced and SURGICAL STRESS RESPONSE IN LAPAROSCOPIC SURGERY closed-circuit video laparoscopy evolved Endocrine balance Rapid equilibration of stress mediators This development enabled surgeons to Immune suppression Lesser immune response 1950s deliver more intense light with less heat and Cytokine levels More rapid normalization of levels allowed participation of an assistant in the procedure Who was the first person to perform Phillipe Mouret Multi-puncture surgery was born laparoscopic cholecystectomy? PM – First The most important development: GK – Experiment A. Georg Kelling o Advent of the INSUFFLATOR (Kurt RJ – who u, I only know B. Phillipe Mouret Semm) Hanz C. Raymund Jacobeus Kalk – the Father of - a machine that pumps air (CO2) D. Andrew Kalk Modern Laproscopy 1982 into the peritoneal cavity When was the first laparoscopic 1987 - it creates a “working space” for cholecystectomy performed? PM-First-1987 the surgeon] PM me first nung 1987 (luh di pa A. 1987. B. 1981 C. 1965. D. 1991 ako buhay, pero anyways o Fiberoptics and the rod-lens system tandaan niyo nalang) (Harold Hopkins) What best describes minimally invasive Performs surgery Dr. Philippe Mouret - performed the First laparoscopic surgery? through small 1987 Human Laparoscopic Cholecystectomy in A. Performs only minor surgery through single incisions, minimizing France incision trauma of surgical Memorize niyo ung mga nakabold letters nasa samps ‘ung tsaka B. Performs surgery through small incisions, exposure binanggit din talaga ni Doc. minimizing trauma of surgical exposure A. Performs MAJOR C. Requires large doses of post – operative surgery, small WHAT IS MINIMALLY INVASIVE SURGERY? analgesia incision D. Patients stays longer in the hospital due to B. SMALL It uses high-tech imaging systems C. SHORTER STAY Miniaturized surgical instruments are smaller and longer delayed ambulation o Aims to minimize the trauma of surgical exposure Crosses all traditional disciplines a. General surgery to neurosurgery b. Gynecology KUMUNOY’S IMPROPERTY 1  BASIC SURGERY, ‘DI NAMAN BASIC LECTURER: DI KO ULIT KILALA HEHE The metabolic response of the host after a The elevated Extraperitoneal CO2 can widely spread causing subcutaneous major surgery is a well-documented cytokine levels emphysema and metabolic acidosis phenomenon. Which among the response recover faster Uses balloon/space maker to develop working space followed by is correct after a laparoscopic surgery? Less: Immune low-pressure gas insufflation or lift devices to maintain the space suppression, metabolic A. The elevated cytokine levels recover Examples: response, faster Cortisol, mabilis mabalik o TOTALLY EXTRAPERITONEAL (TEP) INGUINAL HERNIA REPAIR B. Greater immune suppression sa normal, o ENDOSCOPIC THYROID SURGERY C. Greater metabolic response Elevated Cytokine levels - This is the best example of EMIS, sa discussion sabi ni D. Cortisol level is higher for repair and faster doc ung thyroid problem nasa right side so siyempre recovery nasa right side din si surgeon. Para ma-access ung right thyroid gland pwedeng dumaan sa right axillary area, Which of the following is/are an endocrine then magcreate na ng space (separate ‘ung fats from response to laparoscopic surgery is/are? muscle) tapos kapag nagawa na ‘ung space meron A. Serum cortisol levels after laparoscopic ng transillumination outside ng skin. IT CREATES A SPACE operations are often higher than after the OVERRRRRRR THE THYROID GLAND. Tapos last na to equivalent operation performed through All of the above talaga, walang scar sa neck kapag ito ‘ung procedure an open incision - Insufflator: 6L / min B. There is more rapid equilibration of most Word by word sa - Pressure: 10-12 mmHg stress-mediated hormone levels after book. o ENDOSCOPIC MASTECTOMY laparoscopic surgery o ENDOSCOPIC RETROPERITONEAL NEPHRECTOMY C. Immune suppression also is less after o VIDEO ASSISTED RETROPERITONEAL DEBRIDEMENT (VARD) laparoscopy than after open surgery D. All of the above Which of the following is NOT an example Laparoscopic of extracavitary minimally invasive cholecystectomy THORACOSCOPY AKA surgery? Memorize the 5 examples of EMIS: TEP Inguinal Hernia Repair VIDEO ASSISTED THORACIC SURGERY (VATS) A. Totally extraperitoneal inguinal hernia (TEP-IHR), Endoscopic Thyroid The problem here is the rib cage, the boney confines of the repair Surgery (ETS), Endoscopic thorax, that space is fixed, it is unnecessary to use positive B. Endoscopic thyroid surgery Retroperitoneal Nephrectomy pressure when working in the thorax C. Endoscopic retroperitoneal (ERN), nephrectomy Endoscopic Mastectomy (EM) And because insufflation is unnecessary in thoracoscopic and Video assisted surgery, it can be beneficial to use standard equipment via D. Laparoscopic cholecystetomy Retroperitoneal Debridement extended port sites in conjunction with thoracoscopic (VARD) instruments Which of the following is NOT TRUE for High pressure gas Unnecessary to use positive pressure Extracavitary Minimally Invasive insufflation is used 1. Decreased venous return Surgery? Extracavitary – areas na limited 2. Mediastinal shift lang yung space, so usually ang A. High pressure gas insufflation is used need mo dito ay balloon 3. Keep a firm seal at all trocar sites B. Uses balloon to develop working inflation to make a space, and Without positive pressure, it is necessary to place or use a double space then low-pressure gas lumen endotracheal tube so that the ipsilateral lung can be C. Extraperitoneal CO2 can cause insufflation to maintain a deflated or collapsed when the operation starts to create a subcutaneous emphysema working space. Isipin mo nalang pag high pressure gas, puputok working space D. An example is a Transabdominal ung balloon, mas mawawala Dito ang gumagawa nito ay mga thoracic surgeon malamang. Preperitoneal Inguinal Hernia Repair yung working space mo Diba sa thorax andun ‘ung rib cage yan ‘ung problema dito kasi Which of the following is an example of fixed na ‘ung space sa part na yan so ang mangyayari ‘ung extracavitary minimally invasive lungs dapat magcollapse using of double lumen endotracheal Endoscopic surgery? tube para magkaroon ng working space. Thyroidectomy A. Laparoscopic cholecystectomy Endoscopic Thyroid B. Transabdominal preperitoneal repair Surgery din yan! EXTRACAVITARY MINIMALLY INVASIVE SURGERY (EMIS) of Indirect Inguinal Hernia You operate on areas that usually do not have a space just like C. Endoscopic Thyroidectomy the abdomen and the thoracic cavity D. Laparoscopic Low Anterior Resection A special procedure in which the surgeon makes or develops his working space Less physiologic consequences KUMUNOY’S IMPROPERTY 2  BASIC SURGERY, ‘DI NAMAN BASIC LECTURER: DI KO ULIT KILALA HEHE Which of the following is NOT an example magkaroon ng co2 retention. Para saan ba kasi tong CO2 na ‘to, of extracavitary minimally invasive insufflator siya ibig sabihin naccreate ng air para may working space surgery? sa loob ng katawan Laparoscopic A. Endoscopic thyroid surgery cholecystectomy B. Totally extraperitoneal inguinal hernia TEP-IHR, ETS, ERN, EM, MINIMALLY INVASIVE SURGERY (M.I.S.) TEAM repair 1. Laparoscopic surgeon: oversees execution of roles in preop VARD C. Endoscopic retroperitoneal 2. Camera man nephrectomy 3. First assist: supervises the prep of equipment and patient D. Laparoscopic cholecystectomy 4. Anesthesiologist Which of the following is an example of 5. OR nurse extracavitary minimally invasive 6. Laparoscopic/Endoscopic nurse Endoscopic thyroid surgery? o M.I.S. dedicated assistants surgery A. Transabdominal preperitoneal repair In general, the surgeon stands on the side of the table opposite ULIT ULIT TAYO, MEMORIZE B. Endoscopic thyroid surgery the pathological process. Whereas the assistant stands on the THE 5 TYPES UNDER EMIS C. Laparoscopic cholecystectomy ipsilateral side (eg. in laparoscopic cholecystectomy; the surgeon D. Pelvic laparoscopy usually stands on the left lower quadrant of the patient) How do you create a working space for Use of double The surgeon always stands opposite the organ to be removed thoracic surgery? endotracheal tube to Monitor placed in a direct line with the surgeon and the surgical A. Use of double endotracheal tube to collapse the ipsilateral field (coaxial setup) [GAZE DOWN VIEW = ERGONOMICS] collapse the ipsilateral lung lung B. Use of double-endotracheal tube to Sabi kasi, di ba may rib cage ka, so hindi pwede MINIMALLY INVASIVE SURGERY (M.I.S.) collapse the contralateral lung dito ung high insufflation, Initially termed as: Band aid surgery, Key hole surgery, Button hole C. Use of single endotracheal tube to kasi nga wala naman surgery, Minimal access surgery, Endoscopic surgery, Pin hole surgery collapse the ipsilateral lung pupuntahan ung air since ADVANTAGES DISADVANTAGES D. Use of single endotracheal tube to bones yan! instead, Improved diagnosis More expensive collapse the contralateral lung icollapse mo ung Less tissue disruption Potential for major IPSILATERAL lung, para Less wound infection complications in magkaroon ka ng working Less postoperative pain inexperienced hands space. Less chance of pelvic Loss of tactile feedback adhesions especially in Difficult in complicated cases female patients in their Longer operative time ANESTHESIA childbearing years The surgeon can influence the cardiovascular performance by Cosmetically better outcome reducing or removing the CO2 pneumoperitoneum; Early return to work CO2 will be dissolved in the blood and it will produce metabolic Less surgery associated acidosis in excess complications 1. Maintain the lungs’ good perfusion and ventilation Early ambulation, feeding function because CO2 is excreted by way of the lungs; and return to work 2. Poor pulmonary function, ventilation and perfusion = CO2 retention Most open surgery procedures would complicate with atelectasis Insensible fluid losses are negligible, and therefore, IV fluid or pneumonia because of prolonged bedridden state that can administration should not exceed that is necessary to maintain also cause DVT circulating volume Most common cause of fever in the first 24 hours after a MIS procedures are often outpatient procedures, so short acting laparoscopic procedure → Atelectasis anesthetic agents are preferable Critical to the anesthesia management of these patients is the use In Infected cases of MIS: of nonnarcotic analgesics (e.g., ketorolac) when hemostasis In open procedure you need to make a very long incision, but in allows it, and the liberal use of antiemetic agents including laparoscopy, only 5mm incision and at least enough for the ondansetron and steroids. camera to fit [1cm] Sabi ni doc ‘ung ginagamit daw na anesthesia sa MIS is almost the Peritoneal cavity can be more thoroughly irrigated without making same lang with open surgery pero kasi dito kailangan ng observation a big incision ng effects of absorbed CO2 kasi kapag excess ung CO2 pwedeng You do not touch the bowels; you do not inflict more inflammatory magkaroon ng acidosis kaya sa MIS laging binabantayan ng process in laparoscopy anesthesiologist ung acid base balance ni px. Tapos dapat may good Free fluid and purulent collections under direct vision lung perfussion kasi kapag poor ng function ni lungs pwedeng Patient ambulates/walks earlier [2nd or 3rd day] KUMUNOY’S IMPROPERTY 3  BASIC SURGERY, ‘DI NAMAN BASIC LECTURER: DI KO ULIT KILALA HEHE Which of the following is NOT an More surgery associated POST-OPERATIVELY advantage of minimally Invasive surgery? complications most patients do not require intravenous narcotic medications → A. Improved diagnosis Memorize/Familiarize Less nausea/vomiting & can initiate early feeding; patients can B. Less tissue disruption the table! Hanapin niyo ambulate a few hours after surgery without feeling any pain; in C. Cosmetically better outcome ung negative! open surgery you wait for 3-5 days until px would have flatus unlike D. More surgery associated complications in MIS less than 24 hrs only the px would have flatus Which of the following is a benefit of Today, virtually NO abdominal organ is exempted from Increased range of minimally invasive surgery? laparoscopic, meaning almost anything in the abdomen can be motion and faster return A. Higher cost performed or operated on laproscopically. to activity B. Increased pain Main purpose: MAJOR Meaning mas maganda talaga kapag laparoscopic surgery ang C. Increased range of motion and faster surgery, through small gagawin sa abdomen kesa open surgery basahin mo na lang ‘yung return to activity incision, remember? mga advantages na nabanggit naka highlight naman bhie. D. Slower healing times Which of the following is/are an advantage A 45 year old male 12 hours after a of minimally invasive surgery? All of the choices are Deep breathing laparoscopic cholecystectomy A. Improved diagnosis correct exercises developed fever of moderate grade. What B. Less tissue disruption Memorize/Familiarize Cause of fever within 24 treatment should be given? C. Cosmetically better outcome the table! hours is ATELACTASIS A. Hydrate and electrolyte replacement D. All of the choices are correct (collapsed part of a B. Early ambulation and passive body Which of the following statements is/are lung) so need mo mag conditioning correct regarding the minimally invasive deep breathing exercise C. Start antibiotics immediately surgery team? to re-expand the lung The surgeon always D. Deep breathing exercises A. The surgeon always stands opposite the stands opposite the Which of the following is NOT a organ to be removed organ to be removed disadvantage of minimally invasive Early return to work B. The camera man stands opposite the surgery? I believe common sense surgeon Surgeon: Opposite A. Difficult in complicated cases ‘to alin ba ung positive? C. The first assistant stands beside the surgeon Assistant: Ipsilateral B. More expensive D. A second assistant is necessary to retract Pero memorize the table during umbilical access using the open C. Early return to work J hasson technique D. Loss of tactile feedback Which of the following is NOT an Which of the following is a DISADVANTAGE Less tactile feedback advantage of minimally invasive surgery? of Minimally Invasive Surgery? Memorize/Familiarize Requires specialized A. Reduced scarring A. Less surgery associated complications the table! Pero dito less high-end medical B. Less trauma to tissues, nerves, organs B. Less Tissue disruption tactile feedback since equipment and muscles C. Less chance of infertility in women instead of open surgery Memorize/Familiarize C. Minimal bleeding D. Less tactile feedback na more on hands the table! D. Requires specialized high-end medical gamit, dito ung equipment laparoscope na Which of the following statements is correct regarding the minimally invasive surgery What is the most common cause of fever in team? the last 24 hours after a laparoscopic A. The cameraman stands opposite the procedure? _____________ ?! Atelectasis surgeon A. Atelectasis ALAM NIYO NA YAN, !!!!!!! B. A second assistant is necessary to retract B. Urinary tract infection during umbilical access using the open IF HINDI SCROLL UP, 2 boxes from here. C. Deep vein thrombosis C. The surgeon always stand opposite the D. Surgical site infection organ to be removed Which of the following is NOT a D. The first assistant stands beside the surgeon disadvantage of minimally invasive Which of the following is/are TRUE surgery? regarding minimally invasive surgery? Early return to work A. Early return to work A. Miniaturized surgical instruments All of the choices are Umulit na po B. More expensive B. Aims to minimize the trauma of surgical correct C. Loss of tactile feedback exposure J D. Difficult in complicated cases C. High-tech imaging systems D. All of the choices are correct KUMUNOY’S IMPROPERTY 4  BASIC SURGERY, ‘DI NAMAN BASIC LECTURER: DI KO ULIT KILALA HEHE PATIENT SELECTION Instrument of access: Primary trocars [Blunt/Hasson] – used to Same indications to open surgery, if the patient is a candidate for access the umbilicus open surgery, you can use laparoscopy as long as the expertise is o Sa FEU daw ito yung ginagamit as laparoscopic access there. yung Hasson, gamit ng trocars Goal: To perform procedures in a manner not significantly different Two methods are used for establishing abdominal access during from standard techniques but without opening the peritoneal laparoscopic procedures cavity 1. Direct puncture [Veress needle technique] Laparoscopy saves the patient from much pain, also from 2. Direct peritoneal [Open Hasson] access complications of infection and incisional hernias Laparotomy [open surgical exploration] has a higher chance of DIRECT PUNCTURE (VERESS NEEDLE TECHNIQUE) incisional hernias; In a usual exploratory laparotomy incision, you Inserting a [Veress] needle directly into the peritoneal cavity expect 30% of these patients will develop incisional hernia in the Closed technique, blind direct procedure future. 45-degree angle, 14-15 CO2 mmhg, 5-10mm trocar o Baka malito, kapag laparotomy open surgery yan mas If unskilled: possibly perforate/puncture the bowels and injure malaki incision ‘dyan kesa sa laparoscopic surgery kaya the great vessels over the puncture area since the procedure may 30% chance of incisional hernia si laparotomy has BLIND INSERTION OF TROCARS and has NO DIRECT The ONLY absolute contraindication for laparoscopy is the inability VISUALIZATION of the peritoneal cavity to tolerate general anesthesia. Preferred location: Still UMBILICUS o Because almost all patients who undergo laparotomy Abdominal wall is elevated away from abdominal contents by are under general anesthesia. grasping at umbilicus (linea alba is fused to the umbilicus) and Relative Contraindications: [Depends on the expertise of the lifting surgeon] With the Veress needle, two distinct pops are felt as the surgeon o Training of surgeon passes the needle first through the abdominal wall fascia and o Carcinomatosis second into the peritoneum. o Pregnancy, Previous surgery, Obesity (Increased difficulty) Basta kapag direct puncture, insert or tusok ung needle directly o Fitness for pneumoperitoneum sa peritoneal cavity, ito ay closed or blind procedure o Severe COPD and cardiac diseases o Portal hypertension, Coagulopathy DIRECT PERITONEAL (OPEN HASSON) ACCESS o Grade II, III shock Safest and preferred abdominal access technique to access the abdomen during laparoscopic surgery What is the absolute Preferable for patients who have undergone previous operations contraindication of laparoscopic as bowel adhesions are likely; bowel may be adherent to the Unable to tolerate general surgery? undersurface of the abdominal wound anesthesia A. Multiple reoperations Open technique, safer as it uses direct visualization General Anesthesia ang B. Obesity required for laparoscopic Laparoscope (camera) allows intra-abdominal visualization - C. Diabetes mellitus surgery, so alangan bawal Trocars are pointed away from the sacral promontory and great D. Unable to tolerate general sakanila!!! vessels anesthesia Procedure: [preferred location: still UMBILICUS] o A small incision is made just below (inferior border) of the umbilicus [thinnest part of the abdominal wall, SURGICAL TECHNIQUE concealed scar after surgery] Access of peritoneal cavity o Under direct vision the abdominal fascia is located Establishment of pneumoperitoneum o Two Kocher clamps are placed on the fascia, and with Do an initial diagnostic laparoscopy curved Mayo scissors, a small vertical incision is made Insertion of secondary trocars & instruments under direct through the fascia and underlying peritoneum. visualization o A finger is placed into the abdomen to make sure that Patient positioning there is no adherent bowel. Extended diagnostic laparoscopy o Suture is placed on each side of the fascia and secured Lahat tong mga binaggit na ‘to kailangan munang gawin bago to the wings of a specialized trocar, which is then passed magstart ng laparoscopic surgery, okay? Unlike sa open surgery, cut directly into the abdominal cavity mo lang daw ‘ung abdomen tas proceed kana sa surgery. o Insufflation is initiated LAPAROSCOPIC ACCESS Dito naman open hasson, may small incision below na umbilicus kasi Most important part of laparoscopic technique - ACCESS yun daw pinaka thin part ng abdominal wall and walang scar after. So It is during this time that more than 50% of injuries happen after macut dun sa ilalim ng umbilicus and next naman is separation KUMUNOY’S IMPROPERTY 5  BASIC SURGERY, ‘DI NAMAN BASIC LECTURER: DI KO ULIT KILALA HEHE from the fascia from their andon na yung peritoneum. Parang Why is it that the umbilicus is the gumawa lang ng butas sa umbilicus tas dun ipapasok ung trocar. best site for abdominal access? A. It is the strongest layer of the It is the thinnest layer and scars ADDITIONAL TROCAR SITES abdominal wall can be concealed PRIMARY BLUNT/HASSON’S Trocar – minimizes injury to the B. It is the thinnest layer and scars Specifically: BELOW umbilicus TROCAR bowel can be concealed o Conical or pyramidal type, pointy C. Can be used as a single access SECONDARY o Inserted after insufflation route TROCAR o Utilizes 5- and 10-mm working trocars D. It varies in size and location o Inserted under direct visualization with What is the preferred abdominal laparoscope at all time technique? Open Hasson A. Open Hasson SAFE KA KAY HASSON KASI DIRECT VISUALIZATION, KAY VESSER BASTA TROCARS PRODUCE DIFFERENT FASCIAL DEFECTS: (MEMORIZEEE!!) B. Veress needle TUSOK LANG (DIRECT PUNCTURE)/ BLIND NOT ALL fascial defects must be repaired; C. Blind direct puncture INSERTION, KAY HASSON TAYO