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ASSOC.PROF. UTHAM MURALI. M.S ; M.B.A.
Principles of Minimal Invasive Surgery
Anesthesia
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Monitor
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Surgeon
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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.
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Other Names
“ KEYHOLE SURGERY ”
“ LAPAROSCOPIC SURGERY ”
“ MINIMAL ACCESS SURGERY ”
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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. 1992 – “MAS” – Cuschieri.
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Extent of MIS
Laparoscopy. Thoracoscopy. Endoluminal endoscopy. Perivisceral endoscopy. Arthroscopy and Intra-articular Surgery. Combined Approach.
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Advantages of MIS
Decrease in wound size / wound pain Improved mobility Improved vision Good Instrument access Reduction in wound infection, dehiscence, bleeding,
herniation, nerve entrapment & adhesions
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Limitations of MIS Reliance on remote vision and operating Loss of tactile feedback Dependence on hand–eye coordination Difficulty with haemostasis Reliance on new techniques Extraction of large specimens
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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
Monitor positioning
[front / bel.eye level - 25°]
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Triangulation - Principle
P
R
L C
S
Monitor
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Ideal Angles
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Tools / Instruments
- 0°/30° Laparoscope- Light source –
Halogen lamp- Camera- Video-monitor- CO 2 insufflator- Veress needle- Trocars- Suction-irrigation apparatus- Working instruments
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General Pre-operative Principles
Technique
CO2 - Common
- Creating Pneumo.15 mm Hg
- Laparoscope inserted –
umbilical port
- Abdomen evaluated
- Organs – visualized
- Additional ports placed
- Cheaper
- Readily available
- Easily absorbed
- Released via respiration
- Highly diffusion coefficient
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Electro-surgery Principles
Inadvertent touching and grasping.
Direct coupling between the tissue & the instrument.
Break in insulation.
Direct sparking to bowel from the diathermy probe.
Passage of current to the bowel from recently coagulated tissue.
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Surgery Principles
Meticulous care – creation of a pneumo.
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
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Preparation for MIS
Overall fitness: card.arrh. / emph.
Previous surgery: scars,
adhesions
Body habitus: obesity, skeletal
deformity
Normal coagulation
Thrombo-prophylaxis
Informed consent
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Pneumoperitoneum - Changes
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Operative problems
Perforation of hollow
viscus
Bladder Injury
Bleeding From Major Vessel
From Gall bladder bed
From Trocar site
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Post – operative Care
Nausea
Shoulder Pain
Abdominal Pain
Analgesia
Oral fluids
Oral feeding
Drains
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Contraindications – Relative Compromised cardiac status
Peritonitis
Multiple Abdominal Surgeries
Bleeding disorders
Morbid obesity
III rd Trimester pregnancy
Portal hypertension
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Common - Surgeries Diagnostic laparoscopy
Cholecystectomy
Appendicectomy
Repair of all types of Hernia
Hysterectomy
Tubectomies
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References
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Future is Minimal Access Surgery
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