laparoscopy & its ergonomics by dr.mohammad zarin
TRANSCRIPT
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Ergonomics & Physiology In Laparoscopic Surgery
Dr.Mohammad ZarinMBBS, FCPS, MRCS, FMASAssociate Professor, SEWKhyber Teaching Hospital
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Outline of Presentation
• Ergonomics• Physiology• Instruments
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RAAS
ERGONOMICS
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2 D ImageNo depth PerceptionNo tactile feedback
Counter-intuitiveLimited movements
Magnification
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Open Surgeon Vs Lap SurgeonHow do they differ?!
Open Surgeon• Fast• Hand is as good as eyes• Dissection precedes• Ergonomics: Optional
Laparoscopic Surgeon• Slow and steady• Stop when you don’t see• Haemostasis precedes• Ergonomics: Vital
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To be an efficient Surgeon…
• Equipments• Environment
Concentrate on
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PATIENT POSITION
Produce gravitational displacement of viscera away from surgical site.
Trendelenberg Rev Trendelenberg 15-20˚ head down 20-30˚ head up Endobronchial intubation
Predisposition to DVT
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Patient positioning
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Ergonomics
• Straight Line principle• Triangulation• Manipulation angle• Elevation angle• Low lying table• Gaze down view
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Straight Line Principle
Surgeon
PathologyMonitor
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Visual Axis and Motor Axis
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Co Axial alignment
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Base Ball Diamond Concept& TriangulationMonitor
S
C
R
L
P
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Manipulation angle
Azimuth Angle Manipulation Angle
30-45 degree60-90 degree
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Elevation angle
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Ideal angles!
1. Manipulatation angle: 60 degree2. Azimuth angle: Equal/30 degree each3. Elevation angle: 60 degree
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Ergonomics of Hand Instruments
• Tip– Range of movements
• Conventional Vs Robotic instrument: 4: 7
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Ergonomics of Hand Instruments
• Tip– Range of movements
• Conventional Vs Robotic instrument
• Length of the shaft
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Fulcrum Effect of Hand Instruments
1: 1
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Ergonomics of Port Placement
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Ergonomics of Hand Instruments
• Tip– Range of movements
• Conventional Vs Robotic instrument– Force transmission
• Length of the shaft• Handle design
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Ergonomic handles…
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Surgeon’s Stance
Ideal relaxed stature Tiring
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Ideal Relaxed Position
-straight head, in the axis of the trunk, without rotation or extension of the cervical spine;- shoulders in a relaxed and neutral position;- arms alongside the body- elbows bent to 70 to 90 degrees- forearms in an horizontal or slightly descending axis- -hands pronated (physiological resting position);- hands and fingers lightly grip the handles/handpiece
•Waist line table•Gaze down view of monitor•Straight line principle•Triangulation
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PHYSIOLOGICAL EFFECTS OF LAPAROSCOPY
Can be: Mechanical Metabolic
On • Cardiovascular• Pulmonary• Gastrointestinal• Renal• Peripheral vascular
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Cardiovascular Effects:
↑ IAP
↓ CO
↓ VR
↓ SV
↑ Afterload
↑ MAP
HRx =
↑ Vasopressin & Catecholamines
↑ CO2
↑ CVP ↑ PCWP ↑ SVR
↓ VR ↓ LVEDV
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Cardiovascular Effects:
• Cardiac Output– Variation between studies– < 30% decrease when observed– On insufflation; ∞ ↑ in I.A.P; transient
• generally noted in:– ASA Class III/IV– hypovolemic patients– PP > 15 mm Hg– reverse Trendellenberg position
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Respiratory Effects:↑ IAP
↑ cephalad shift diaphragm
paradoxic diaphragm motion
↑ ITP
↓ FRC
↑ RR
↑ CO2
↑ Ve & work of breathing
↓chest wall compliance
Hypercapnia
↑ PAWP
+
Alveolar Collapse
↓ TV
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Respiratory Complications:• Pneumothorax / Pneumomediastinum /
Pneumopericardium– 2° to diffusion of gas from
pneumoperitoneum• Accidental diaphragm injury / pre-existing diaphragmatic
defect– 2° to rupture of blebs with ↑ PAWP
• Gas Embolism– 2° to vascular injury
• trocar / needle insertion on insufflation / intra-op vessel injury
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Gastrointestinal effects:
↑ I.A.P.
↓ Mesenteric & celiac flow↓ hepatic
artery flow
↓ hepatic perfusion
↓ perfusion intestines &
stomach
↓ Portal flow
↑ LFTs↓ intestinal & gastric pH
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Renal Effects:
↑ I.A.P.
↓ GFR↓ERPF
↓ U/O
RAAS
↑ CO2
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Renal Effects:
• U/O return to baseline within hours• No long-term change in GFR• No change in Cr, BUN
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Peripheral Vascular Effects:
↑ I.A.P.
Reverse Trendellenberg
Venous stasis
↓ VR
↑ Risk DVT?
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Peripheral Vascular Effects:
• Incidence of DVT, PE generally lower post laparoscopic procedures– Secondary to improved prophylaxis?– Risk increased with longer procedures and
reverse Trendellenberg
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Laparoscopic Instruments
• Hand instruments
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