← All decks
General Surgery
Fundamentals of Laparoscopic Surgery
Built from Maingot's Abdominal Operations
What’s inside
8 sections · 143 slides
Foundations of minimally invasive surgery
What keyhole surgery buys, and what it costs the surgeon
- Growth of minimally invasive surgery
- Operations that gain most from laparoscopy
- Skills required of the laparoscopic surgeon
- Scope of the fundamentals
Patient considerations
Selection, positioning and preparation before the first incision
- Anaesthetic requirement for laparoscopy
- Carbon dioxide retention
- Nitrous oxide as an alternative gas
- Operative time as a selection factor
- Previous abdominal surgery
- Severe obesity
- Inadequate working space
- Factors for and against a laparoscopic approach
- Patient positioning and exposure
- Compression nerve injuries
- Arm position on the table
- Brachial plexus protection
- Venous thrombosis after laparoscopy
- Pathway from pneumoperitoneum to venous stasis
- Thromboprophylaxis
- Postoperative nausea and vomiting
- Further measures against nausea
Port placement and abdominal access
Where the ports go, how the first one gets in, and what can go wrong
- Purpose of planned port placement
- The diamond of success
- Diamond arrangement of laparoscopic ports
- Instrument length and the 1:1 rule
- Angle between the working instruments
- Avoiding abdominal wall vessels
- Sequence for placing a secondary port
- Bladed and nonbladed trocars
- Classification of trocar tips
- Safety shields
- Types of nonbladed trocar
- Bladed and nonbladed trocar tips
- Advantages of a nonbladed port
- Other features to weigh when choosing a port
- Techniques for placing the first port
- Veress needle technique
- Umbilical incisions for Veress entry
- Advantages claimed for the Veress technique
- Checks before inserting a Veress needle
- Safe Veress needle insertion
- Veress needle insertion in the left upper quadrant
- Aspiration test after Veress placement
- Drop test and a blocked needle
- Opening insufflation pressure
- Causes of a high insufflation pressure
- Interpreting a high insufflation pressure
- Direct trocar insertion without pneumoperitoneum
- Open (Hasson) access
- Securing and insufflating a Hasson port
- Optical trocars
- Optical trocar and the view through it
- Comparison of the two access families
- Command of several access techniques
- Difficult access in obesity
- Identifying the fascia in obesity
- Vakili and Knight modified technique
- Access after a previous midline incision
- Left upper quadrant entry
- Port-site hernia
- Which fascial defects to close
- Reducing the risk of port-site hernia
- Port-site closure devices
- Steps of device-assisted fascial closure
- Port-site closure device, panels a and b
- Port-site closure device, panels c and d
- Risk of trocar injury
- Structures injured during trocar insertion
- 13%
- Managing a major vascular injury
- Delayed recognition of bowel injury
Equipment
Telescope, camera, light, insufflator and monitor
- The laparoscope
- Angle of view
- Angled and straight-viewing telescopes
- Telescope diameters
- Video camera
- Camera iris and gain
- Light sources
- Insufflators
- Video monitors
- Components of the laparoscopic stack
Instruments and energy devices
Graspers, dissectors and the four ways to stop bleeding
- Design of laparoscopic instruments
- Laparoscopic instrument handles and tips
- Bowel graspers
- Atraumatic bowel grasper
- Glassman and toothed graspers
- “
- Maryland dissector
- Tip of the Maryland dissector
- Limits of the Maryland dissector
- Achieving haemostasis
- Controlling a bleeding vessel
- Monopolar electrosurgery
- The monopolar circuit
- Direct coupling
- Insulation failure and midair activation
- Ultrasonic shears
- How ultrasonic shears work
- Bipolar electrosurgery
- Strengths and limits of the LigaSure device
- Energy devices compared
Intracorporeal suturing
Placing a stitch and tying a knot inside the abdomen
- Importance of laparoscopic suturing
- Mechanical suture aids
- Extracorporeal and intracorporeal knots
- Sliding square knot, all six steps
- Sliding square knot, first three steps
- Sliding square knot, final three steps
- Sequence of the sliding square knot
Physiologic effects of pneumoperitoneum
What the pressure does, and what the carbon dioxide does
- Two sources of physiologic effect
- Pressure and venous return
- Cardiovascular chain of events
- Pressure as a pump in the well-filled patient
- Catecholamine response to carbon dioxide
- Who tolerates the response
- Minimising the cardiovascular effects
- Persistence after desufflation
- Effects on the lungs
- Bardoczky study of ventilatory effects
- +50%
- Effects on the kidneys
- Interpreting low urine output
- Hypercapnia during pneumoperitoneum
- Time course of arterial carbon dioxide
- Managing difficult hypercapnia
- Carbon dioxide embolism
- Recognising carbon dioxide embolism
- Treatment of carbon dioxide embolism
- Rationale for the Durant position
- Capnothorax and pneumothorax
- Signs of gas in the chest
- Treatment of capnothorax
- Draining a capnothorax at the end of the case
Summary
What to carry away from the fundamentals
- Key points on patients and access
- Key points on ports and instruments
- Key points on pneumoperitoneum physiology
- Conclusions
- References
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- Maingot's Abdominal Operations, 12th Edition