Principles Of Surgery (Transplantation & Minimal Access Surgery) PDF

Principles of Surgery (Transplantation and Principles of minimal access surgery) Prepared by Dr Ibrahim Mousa Maaroof Higher Diploma student M.B.Ch.B. Dr Sarmad Nadhem Ismael Higher Diploma student M.B.Ch.B. Supervised by Assist. Prof. Dr Baderkhan Saeed Ahmed Assist. Prof. Dr Azhy Muhammed Dewana 2...

Principles of Surgery (Transplantation and Principles of minimal access surgery) Prepared by Dr Ibrahim Mousa Maaroof Higher Diploma student M.B.Ch.B. Dr Sarmad Nadhem Ismael Higher Diploma student M.B.Ch.B. Supervised by Assist. Prof. Dr Baderkhan Saeed Ahmed Assist. Prof. Dr Azhy Muhammed Dewana 2 January 2024 1 TRANSPLANTATION TERMINOLOGY Types of grafts • Autograft (isograft) : transplantation of tissue from an individual to itself, usually a different site requires no immunosuppression. • Allograft: transplantation of tissue between genetically nonidentical individuals of the same species, requires immunosuppression. • Xenograft: transplantation of tissue between members of different species. B CELLS • These lymphocytes arise and partially mature in bone marrow • They respond by directly binding antigen to immunoglobulin (Ig) on the surface of the cell. To form antibody (Ab) producing plasma cells • Antibodies are glycoproteins secreted by plasma cells . • Antibodies are constructed from two light polypeptide chains and two heavy polypeptide chains to form IgM , IgG , IgE, IgA, and IgD T CELLS • These lymphocytes arise in the bone marrow and mature in the thymus • They are responsible for cell-mediated immunity as well as facilitating B-cell response. They are broadly classified as CD4 + or CD8 + • CD4 + cells have been termed helper cells • CD8 + cells affect the T-cell response. This frequently involves direct cytotoxicity MAJOR HISTOCOMPATIBILITY COMPLEX (MHC), • Group of genes that code for proteins found on the surfaces of cells that help the immune system recognize foreign substances. MHC proteins are found in all higher vertebrates. In human beings the complex is also called the human leukocyte antigen (HLA) system. • MHC molecules are important components of the immune system because they allow T lymphocytes to detect cells, In uninfected healthy cells, the MHC molecule presents peptides from its own cell (self peptides), to which T cells do not normally react. REJECTION AND IT’S TYPES • Transplant rejection is the host response (antibody-mediated, cellmediated, or both) directed against non-self antigens (transplanted tissue). Hyperacute rejection • This type of rejection is mediated by preformed antibodies against donor antigen • Hyperacute rejection occurs within minutes to hours after organ reperfusion. • There are no effective treatments for hyperacute rejection ACCELERATED ACUTE REJECTION • Is also antibody mediated • present clinically at 2 to 5 days after transplantation • This type of rejection is due to an anamnestic response from prior exposure • Can be successfully treated with plasmapheresis or rituximab to manipulate further antibody production. ACUTE REJECTION • Most acute rejections are cell mediated • This type of rejection occurs days to months following transplantation. • Acute rejection may present with fever, chills, arthralgias, and systemic toxicity. • Treated with immunosuppression protocols. Chronic rejection • Weeks to years • T -cell –dependent immunity • Chronic rejection likely encompasses both immunologic as well as nonimmunologic • May require re-transplantation. IMMUNOSUPPRESSION • Except in the case of transplantation between monozygotic twins , allografts between individuals will elicit an immune response. • The therapeutic window between lack of efficacy and toxicity/side effects is very narrow for most immunosuppressive medications. • Immunosuppressive agents are divided into two groups-agents used for induction therapy immediately after transplantation and drugs used for maintenance therapy. FIVE BASIC CATEGORIES OF IMMUNOSUPPRESSIVE AGENTS ARE USED : • Corticosteroids, • Calcineurin inhibitors, • Antiproliferative agents , • Monoclonal antilymphocyte antibodies, • Polyclonal antilymphocyte antibodies. CORTICOSTEROIDS • A corticosteroid is a glucocorticoid-based medication that works principally to block T cell and cytokine-receptor expression. • Side effects observed with corticosteroid use include hypertension, hyperlipidemia, osteoporosis , weight gain, glaucoma, ulcer formation. • Corticosteroids can be used to prevent as well as to treat Acute rejection. • High dose of IV methylprednisolone as induction, and maintenance doses consist of orally administered prednisone. CALCINEURIN INHIBITORS • Inhibits the production and secretion of IL-2 which is crucial in the activation and differentiation of B and T cells • Cyclosporine is a highly effective immunosuppressant. • Side effects observed with cyclosporine use include nephrotoxicity hypertension, tremor, coronary artery disease hirsutism • Tacrolimus is a macrolide antibiotic that works in a mechanism similar to that of cyclosporine to prevent allograft rejection • Side effects observed with tacrolimus use are similar to Cyclosporine. ANTIPROLIFERATIVE AGENTS • Are used in maintenance immunosuppression and treatment of rejection. • Antiproliferative agents are drugs that work to block the proliferative phase of acute cellular rejection • Azathioprine, it incorporates into the DNA, inhibiting nucleotide synthesis by causing feedback inhibition. • Azathioprine has little effect on established immune responses and is therefore effective only in the prevention. • Side effects observed with azathioprine use include: bone marrow depletion, suppression thrombocytopenia, anemia pancreatitis, hepatoxicity. MONOCLONAL ANTIBODIES • Monoclonal antibodies are antigen-specific immunosuppressants that will reduce immune response to antigens of the graft while preserving the response to unrelated antigens. • Muromonab-CD3 is the first type of murine monoclonal antibody • The recommended dose for muromonab-CD3 is 5 mg IV push once a day for 7 to 14 days. POLYCLONAL ANTIBODIES • Polyclonal antibodies are directed against lymphocyte antigens , but instead of the single-specificity of the monoclonal antibodies, these antilymphocyte anti bodies are directed against multiple epitopes • Used for early rejection prophylaxis and treatment of rejection. • Antithymocyte globulin is a polyclonal antibody derived from either horses or rabbits . • The agents contain antibodies specific for many common T-cell antigens • Side effects include leukopenia, serum sickness, thrombocytopenia , pruritus, fever, arthralgias. LIVER TRANSPLANTATION General principles • Indications for liver transplantation include acute hepatic failure and chronic liver failure. • Before the advent of surgery, the 1 -year mortality for patients with decompensated liver failure reached more than 50%. Since transplantation has been available, the survival reaches 85% at 1 year and 70% at 5 years. • Priority on the waiting list is determined by the Model for End - Stage Liver Disease (MELD) score . This involves a complex mathematical equation that places patients with greatest metabolic disturbance higher on the list • Selection for liver transplantation involves identification of contraindications (HIV, advanced age, disseminated cancer) , degree of liver disease, availability of psychosocial support group (to assist in postoperative care) , and financial ability. POSTOPERATIVE COMPLICATIONS • Bleeding • Primary nonfunction of the liver • Reperfusion injury • Vascular complications • Biliary tract stricture • Rejection • Infection • Recurrence o f native disease OUTCOME • Since the advent of transplantation, approximately 1 0 ,000 liver transplants have been performed. • This population has a 1 -year patient survival rate of 90% , and a 5year patient survival rate of 75%. • More importantly, these patients have a dramatic improvement in their quality of life Small Bowel • Patients who are offered this operation are usually dependenton total parenteral nutrition for life • Indications for this operation involve cases of short gut, intestinal disorders, or malabsorption syndromes • The procedure involves the removal of the donor bowel, maintaining the superior mesenteric artery (SMA) and celiac axis . The transplant is conducted by anastomosis of the SMA to the aorta, with venous drainage into the IVC or the portal vein. • Complications are failure of graft, infection, and rejection. MINIMAL ACCESS SURGERY 2 January 2024 23 DEFINITION • Minimal access surgery is a product of modern technology and surgical innovation that aims to accomplish surgical therapeutic goals with minimal somatic and psychological trauma. • This type of surgery has reduced wound access trauma and is less disfiguring than conventional techniques. • It can offer cost-effectiveness to both health services and employers by shortening operating times, shortening hospital stays, improving operative precision compared with open surgery in some (but not all) cases and allowing faster recuperation. 2 January 2024 24 PRINCIPLES OF MINIMAL ACCESS SURGERY Core principles of minimal access surgery (I-VITROS)  Insufflate/create space – to allow surgery to take place in the minimal access setting  Visualise – the tissues, anatomical landmarks and the environment for the surgery to take place  Identify – the specific structures for surgery  Triangulate – surgical tools (such as port placement) to optimise the efficiency of their action, and ergonomics by minimising overlap and clashing of instruments  Retract – and manipulate local tissues to improve access and gain entry into the correct tissue planes  Operate – incise, suture, anastomose, fuse  Seal/haemostasis. 2 January 2024 25 2 January 2024 26 MINIMAL ACCESS APPROACHES 1. 2. 3. 4. LAPAROSCOPY THORACOSCOPY SINGLE-INCISION MINIMAL ACCESS SURGERY ENDOLUMINAL ENDOSCOPY AND NATURAL ORIFICE SURGERY 5. PERIVISCERAL ENDOSCOPY 6. ARTHROSCOPY AND INTRA-ARTICULAR JOINT SURGERY 7. COMBINED APPROACH 2 January 2024 27 ADVANTAGES OF MINIMAL ACCESS SURGERY 1. Decrease in wound size 2. Reduction in wound infection, dehiscence, bleeding, herniation and nerve entrapment 3. Decrease in wound pain 4. Improved mobility 5. Decreased wound trauma 6. Decreased heat loss 7. Improved visualisation 2 January 2024 28 LIMITATIONS OF MINIMAL ACCESS SURGERY 1. 2. 3. 4. 5. 6. 7. Lack of 3D vision Loss of tactile feedback Haemostasis Extraction of large specimens Learning curve and increased operative time Cost Reliance on new technologies 2 January 2024 29 PERIOPERATIVE PLANNING FOR MINIMAL ACCESS SURGERY • Preparation of the patient and careful preoperative management is essential to minimise morbidity • History • Examination • Prophylaxis against thrombosis • Urinary catheter and nasogastric tubes • Informed consent 2 January 2024 30 PREPARATION FOR MINIMAL ACCESS SURGERY  Overall fitness: cardiac arrhythmia, lung function, medications, allergies  Previous surgery or oncological intervention: scars, adhesions  Body habitus: obesity, skeletal deformity  Normal coagulation  Thromboprophylaxis  Informed consent  Operative difficulty is predicted when possible with appropriate risk model  Appropriate theatre time and facilities are available (especially important for robotic cases) 2 January 2024 31 CONTRAINDICAIONS - RELATIVE • Previous abdominal surgeries • Morbid obesity • Peritonitis • Bleeding disorders • Severe chronic obstructive airways disease and ischaemic heart disease • 3rd trimester pregnancy • Portal hypertension 2 January 2024 32 OPERATIVE PROBLEMS • Intraoperative perforation of a viscus or vascular injury • Bleeding 1. Bleeding from a major vessel 2. Bleeding from an organ encountered during surgery 3. Bleeding from trocar site • Blood clots • Infection and septicaemia 2 January 2024 33 POSTOPERATIVE COMPLICATIONS 1. Nausea 2. Shoulder tip pain 3. Port site pain and numbness 2 January 2024 34 POSTOPERATIVE CARE Analgesia Orogastric or nasogastric tube Oral fluids Oral feeding Urinary catheter Drains 2 January 2024 35 DISCHARGE FROM HOSPITAL The discharge of patients is based on clinical indicators One of the core drivers for the application of minimally invasive surgery is an earlier recovery and therefore discharge from hospital. Patients should not be discharged until they are comfortable, have passed urine and are eating and drinking satisfactorily. They should be told that if they develop worsening pain or other severe symptoms they should return to the hospital 2 January 2024 36 Patients can get out of bed to go to the toilet as soon as they have recovered from the anaesthetic and they should be encouraged to do so. Such movements are remarkably pain free when compared with the mobility achieved after an open operation. Similarly, patients can cough actively and clear bronchial secretions, and this helps to diminish the incidence of chest infections. 2 January 2024 37 GENERAL INTRAOPERATIVE PRINCIPLES ● Meticulous care in the creation of a pneumoperitoneum ● Controlled dissection of adhesions ● Adequate exposure of operative field ● Avoidance and control of bleeding ● Avoidance of organ injury ● Avoidance of diathermy damage ● Vigilance in the postoperative period 2 January 2024 38 THERE ARE TWO FUNDAMENTAL WAYS TO ACCESS THE ABDOMEN LAPAROSCOPICALLY 1. The open technique (Hasson’s or modifed Hasson’s) 2. The closed technique (Veress needle and/or visual entry trocar) 2 January 2024 39 OPEN HASSON’S TECHNIQUE FOR LAPAROSCOPIC PRIMARY TROCAR INSERTION (a) Umbilicus everted, revealing the stalk of the umbilicus. (b) Periumbilical incision. 2 January 2024 skin 40 (c) The junction of the umbilicus and linea alba is identifed and opened longitudinally. (d) A curved haemostat used to break the peritoneum, which is then stretched open. (e) A blunt-tipped primary trocar is inserted. 2 January 2024 41 THE CLOSED TECHNIQUE (VERESS NEEDLE AND/OR VISUAL ENTRY TROCAR) 2 January 2024 42 BASIC LAPAROSCOPIC INSTRUMENTS • Laparoscope • Light source and fiberoptics • Trocars • Devices for dissection and grasping • Devices for haemostais • Surgical staplers • Tissue removal devices 2 January 2024 43 THE BENEFTS OF LAPAROSCOPIC SURGERY ● Less postoperative pain ● Better cosmesis ● Earlier return to normal physiology ● Shorter hospital stays ● Fewer intraoperative adhesions created ● Better perception of anatomy as image is often magnifed 2 January 2024 44 ROBOTIC SURGERY • TWO MAIN CATEGORIES OF ROBOTIC SURGICAL SYSTEMS 1. Teleoperated (master–slave) systems: human operators control remote robots through a communication network that is through televisual computerised platform, either via onsite connections or remotely through the internet or other digital channels – hence the publicity of ‘operating on a patient from another country’ 2. Active or semiactive systems: these are typically image-guided or preprogrammed: surgical robot completes a preprogramed surgical task which is guided by preoperative imaging and real-time anatomical constraints and cues through the application of inbuilt navigation systems. 2 January 2024 45 2 January 2024 46 Benefits: • Manoeuvrability, motion scaling and tremor suppression (as a result of the robotic wrist) • 3D Vision/magnified • More comfortable for Surgeon • Can be done remotely • Motion compensation (e.g.; on a moving target like beating heart) Disadvantages: • Lack of haptics • Expensive • increased operating time and overall learning curve requirement • Mechanical failure • Accidental burn injuries • Commonly used for: -Urology (prostatectomy)-Cardiac (heart surgery) –Gynecology (hysterectomy)-Less useful in general surgery 2 January 2024 47 REFERENCES • O'Connell, P.R., McCaskie, A.W., & Sayers, R.D. (Eds.). (2023). Bailey & Love's Short Practice of Surgery - 28th Edition • Brunicardi F, & Andersen D.K., & Billiar T.R., & Dunn D.L., & Kao L.S., & Hunter J.G., & Matthews J.B., & Pollock R.E.(Eds.), (2019). Schwartz's Principles of Surgery, 11e. 2 January 2024 48 Thank You 2 January 2024 49