Laparoscopic surgery, also known as minimally invasive surgery (MIS) or ‘keyhole’ surgery is a modern surgical technique for carrying out operations in the abdomen through cannulae (also known as ports) which are channels into the body through small incisions.

Using a video camera the surgeon is able to view the operative field without invasive surgery. The abdomen is usually insufflated with carbon dioxide gas.

By inflating the abdomen, the abdominal wall is elevated above the internal organs to create a working and viewing space for the surgeons.

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The Rise of Bariatric Surgery

One of the most common types of laparoscopic surgery is bariatric (obesity). Over the last decade there have been more advancements in bariatric surgery than there had been in the previous 50 years, fuelled largely by the growing obesity epidemic which began in the 1970s. The epidemic created the need for effective treatment of severe obesity and its co morbidities leading to the development of procedures such as gastric banding, gastric bypass and duodenal switch over the past decade. More recently, the advent of minimally invasive surgery in the mid-1990s accounted for the second wave of advances.

Before Laparoscopic Surgery

Before laparoscopy was practiced, surgeons operated using open/invasive surgery. This means cutting skin and tissues so that the surgeon has direct access to structures and organs. This involves more direct access than in minimally invasive procedures as the openings are bigger so the internal organs are openly exposed.

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Cholecystectomy, Appendectomy & Colectomy

Vagotomy

Hiatal, Inguinal & Diaphragmatic hernia repair

Urological- Nephrectomy, Adrenelectomy & Prostatectomy.

OBG-Tubal surgeries,cystectomies,hystrectomies & various ablations (endometriosis)

Thoracoscopies

Neurosurgeries

Lumbar discectomies

Diagnostic procedures

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AdvantagesMinimal pain & illeus

Improved cosmesis

Shorter hospital stay , faster recovery & rapid return to work

Non muscle splinting incision & less blood loss

Post op respiratory muscle function returns to normal more quickly

Wound complications i.e. infection & dehiscence are less

Lap surgery can be done as day care surgery

DisadvantagesLonger duration of surgery

Loss of 3D view, impaired touch sensation

poor dexterity, fulcrum effect, risk of visceral / vsl. Injury (may go unrecognised)

Long learning curve for surgeons

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Ideal insufflating gas of choice

Colorless, non toxic, nonflammable, easily available, inexpensive, inert, readily soluble in blood and easily ventilated out of lungs

Why CO2 is the gas of choice for laparoscopy?

Nonflammable & does not support combustion

Highly soluble in blood because of rapid buffering in blood so risk of embolisation is small

Rapidly diffusible through membranes so easily removed by lungs

CO2 levels in blood & expired air can be easily measured & its elimination is augmented by increasing ventilation

CO2 is readily available & is inexpensive

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Physiologic effects seen with CO2 insufflations are

transient and derive from the body's reaction to increases

in intra abdominal pressure and CO2 absorption as it tries

to achieve a new state of homeostasis. People who are

otherwise healthy will tolerate laparoscopy well, while

individuals with underlying cardiopulmonary or renal

diseases may not tolerate prolonged CO2 insufflations.

Additionally, patient positioning, for example steep

Trendelenburg in prostatectomy, can exacerbate

cardiovascular alterations in laparoscopy.

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Absorption of carbon dioxide (CO2) from the peritoneal cavity

VA/Q mismatch:

Increased physiologic dead space

Abdominal Distention

Position of the patient (e.g., steep tilt)

Controlled mechanical ventilation

Reduced cardiac output

These mechanisms are accentuated in sick patients

Increased metabolism (e.g., insufficient plane of anesthesia)

Depression of ventilation by anesthetics (e.g., spontaneous breathing)

Accidental events

CO2 emphysema (i.e., subcutaneous or body cavities)

Capnothorax

CO2 embolism (Selective bronchial intubation) www.dossindia.com

Cause

accidental extraperit insufflation (malpositioned verris needle)

deliberate extraperit insufflations- retroperit surg,TEPP,fundoplication, pelvic lymphadenectomy

Diagnosis

ETCO2 -cannot be corrected by adjusting ventilation even after plateau reached

ABG, Palpation

Treatment

Stop CO2 insufflation, interrupt lap temporarily

CMV continued till hypercapnia resolves

Resume lap at low insufflation P thereafter

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Risk factors

hysteroscopies, previous abd surg, needle/Trocar in vsl

Consequences-

GAS LOCK in vena cava ,RA → ↓ VR →© collapse - Ac RV HTN → opens foramen ovale →paradoxical gas embolism

Diagnosis

HR, ↓BP, CVP, hypoxia, cyanosis, ET CO2 biphasic change, Δa ETco2 ECG- Rt heart strain, TEE, pulm art. Aspiration of gas/ foamy bld from CVP line

Treatment

Release source (stop co2 + release pneumoperit)

position – steep head low + durant position

stop N2O + 100%O2

Hyperventilation

CVP/PA catheter to aspirate CO2

Cardiac massage may break embolus- rapid absorption

Hyperbaric o2 - cerebral embolism

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Due to cephalad movement of diaph with head down tilt and IAP

Diagnosis - Sp O2 ↓ airway P

Treatment – Repositioning of ETT

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Mendelson syndrome

At IAP>20 mmHg

Changes in LES due to IAP that maintain transsphincteric P gradient + head down position protect against entry of gastric content in airways

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Prevented by

avoid overextension of arms

padding at P points

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Indications-

appendicectomy

cholecystectomy

Risk – preterm labour, miscarriage, fetal acidosis

Timing – II trimester (< 23 wk)

Lap technique – HASSANS tech

Special considerations

prophylactic- antithrombolytic measures + tocolytics

operating time to be minimised

IAP as low as possible

Continous fetal monitoring (TVS)

Lead shield to protect foetus if intraop cholangiography needed

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Dr. Satish Pattanshetti

M.S ( Gen. Surg ) , F M A S

Fellowship in Bariatric and Metabolic Surgery (Taiwan)

Consulting Laparoscopic & General Surgeon

Bariatric & Metabolic Surgeon

Specialist in Single port Laparoscopic Surgery

Dr. Neeraj V RayateDirector and Principal Surgeon

Dr Neeraj Rayate is a GI and General surgeon with expertise is laparoscopic and robotic surgery for

gastro-intestinal diseases and bariatric surgery. After completing his medical education in India. He has

also completed a fellowship in Gynecological Endoscopy from the Giessen School of Endoscopic Surgery

in Germany. Dr. Rayate has special interest in Hepatopancreatobiliary surgery and gynecolological

oncology.