basic science in laparoscopic surgeryrcst.or.th/userfiles/mis.pdf · laparoscopic surgery •...
TRANSCRIPT
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Basic Science in Basic Science in Laparoscopic SurgeryLaparoscopic Surgery
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ContentsContents
• Pneumoperitoneum
• Patient positioningPatient positioning
• Laparoscopic instrumentation
• Access into the abdomen
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Laparoscopic SurgeryLaparoscopic Surgery
• Minimally Invasive Surgery (MIS)
• Keyhole SurgeryKeyhole Surgery
• Pinhole Surgery
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ContraindicationContraindication
• Uncorrected coagulopathy
• Inability to tolerate laparotomyInability to tolerate laparotomy
• Inability ti tolerate general anesthesia
• Hypovolemic shock
• Uncompensated cardiopulmonary diseaseUncompensated cardiopulmonary disease
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PneumopeitoneumPneumopeitoneum
Mechanical effect (Primarily)
• 1. Upward displacement of diaphragm1. Upward displacement of diaphragm– ↑ Intrathoracic pressure
↓ Di h i i– ↓ Diaphragmatic motion
– ↓ Lung volume “↓vital capacity,↓ compliance”
– ↑ Airway pressure“↑ peak ,↑mean airway pressure”
– ↑Work of breathing↑ Work of breathing
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PneumopeitoneumPneumopeitoneum
Metabolic effect
• 1. CO2 absorption1. CO2 absorption– Leads to hypercarbia and acidosis
“I h l h i di id l d b il i d“In healthy individuals: corrected by ventilation and body buffering system”
“In COPD:risk to develop hypercarbia
Expired CO2 (ETCO2) levels are unreliable:Expired CO2 (ETCO2) levels are unreliable:
arterial CO2 needed
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HypercarbiaHypercarbia
d i i• Moderate increase in PaCO2 15‐30 mmHg produce a hyperdynamic state: SVR, CVP, HR and BP “no effect on CO”
• Marked increase in PaCO2> 30 mmHg: cardio gdepressive predominate, cardiovascular collapse, severe acidosis, fatal dysrhythmiasp , , y y
• Minute ventilation must be increased 20‐30%
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HypercarbiaHypercarbia
• Lowering IAP to 10‐12 mmHg
• Alternative gas : HeliumAlternative gas : Helium
• Gasless laparoscopy
• Converted to open surgery
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Pneumoperitoneum $ VentilationPneumoperitoneum $ Ventilation
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ETCO2ETCO2
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Ventilation changeVentilation change
• 1. High inspiratory airway pressure
• 2. Decrease FRC2. Decrease FRC
• 3. Increase V/Q mismatch
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Cardiovascular changeCardiovascular change
I iti ll ↑ t d t th bl d• Initially: ↑ venous return due to the blood volume sequestrated in splanchnic vasculature
“Increase mean arterial pressure”“Increase mean arterial pressure”• Later on: ↓venous return, ↑arterial resistance , ↑ CVP↑ CVP
“ Resulted in compensatory ↑HR”“N t ff t h i CO”“Net effect = no change in CO”
• IAP> 20 mmHg: IVC is compressed then venous return is impededreturn is impeded
• IAP> 40 mm Hg, venous return drop precipitously
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Pneumoperitoneum $ CardiovascularPneumoperitoneum $ Cardiovascular
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Patient PositioningPatient Positioning
d d ( d l b i i )• Head‐down (Trendelenburg position)–↑Central blood volume and pressurep–↑Cardiac output↑Chest wall resistance ↑ dead space– ↑Chest wall resistance, ↑ dead space
• Head‐up–↓Venous return & Cardiac output–↑Femoral venous pressure↑Femoral venous pressure–↑risk of DVT or pulmonary embolism
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Pneumoperitoneum $ Ventilation$Pneumoperitoneum $ Ventilation$ Positioningg
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Pneumoperitoneum $ Cardiovascular $ p $ $Positioning
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ArrhythmiaArrhythmia
• Vagal reflex because of sudden stretching peritoneum with rapid insufflation p pprovoke AV dissociation, nodal rhythm, sinus bradycardia and asystolesinus bradycardia and asystole
• Raise PaCO2: sympathetic response
• Embolism
• Underlying cardiac disease• Underlying cardiac disease
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Renal Blood FlowRenal Blood Flow
• Decreased RBF and GFR Increase in renal vascular resistance, reduction in ,glomerular filtration gradient and decrease in CO
• Decreased urine output and insensible fluid losseslosses
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R l Bl d Fl $ P l d $Renal Blood Flow $ Pre‐load $ PneumoperitoneumPneumoperitoneum
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Lactic AcidosisLactic Acidosis
• Elevation in IAP produces lactic acidosis, probably by severely lowering CO and p y y y gimpairing hepatic clearance of blood lactic acidacid
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Intracranial and Intraoccular changeIntracranial and Intraoccular change
l l fl f • Increase cerebral blood flow from hypercarbiayp
• But increase intracranial pressure, intraocular pressure in the cases that intraocular pressure in the cases that have underlying diseases
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Metabolic Effect of CO2Metabolic Effect of CO2
Increase in PaCO2
1. Absorption of CO2 from the peritoneal cavity1. Absorption of CO2 from the peritoneal cavity2. V/Q mismatch3 I i d CO ti it ( COPD3. Impaired CO2 e x cretion capacity (e.g., COPD,
cyanotic CHD)
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CO2 EmboliCO2 Emboli
• Presenting signs– Hypotensionyp
– Jugular vein distension
– TachycardiaTachycardia
– Mill Wheel Murmur
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CO2 EmboliCO2 Emboli
E l ( 0 5 l/k f b li)• Early (< 0.5ml/kg of emboli):– TEE CO2 bubbling in right heart
l hi d i h di l d l– splashing sound with precordial doppler– millwheel murmur
h i hi h i i P CO2– hypoxemia, high increasing PaCO2, – high ΔPaCO2‐ETCO2L ( 2 l/k f b li)• Late (>2ml/kg of emboli):– increase CVP, PAP
h i h h i– hypotension, arrhythmia– cardiac arrest
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CO2 EmboliCO2 Emboli
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CO2 EmboliCO2 Emboli
• Treatment– Evacuate pneumoperitoneump p
– Left lateral decubitus , head down position
Introduce central venous catheter– Introduce central venous catheter
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Laparoscopic EquipmentLaparoscopic Equipment
• Laparoscopes
• Video TowerVideo Tower
• Gas Supply
• Suction Device
• Equipment TableEquipment Table
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LaparoscopesLaparoscopes
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LaparoscopesLaparoscopes
• Deliver light from a light source
• Conduct image to eyepieceConduct image to eyepiece
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LaparoscopesLaparoscopes
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Video TowerVideo Tower
Light source
Light cable
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Imaging systemsImaging systems
• Camera Head Unit
• Camera Control Unit
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Gas SupplyGas Supply
• Gas tank
• GasGas– CO2
R dil il bl• Readily available
• Ine x pensive
N b i• Not support combustion
– N2O
– Helium
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InsufflatorInsufflator
Control the flow of gas– Control the flow of gas from the cylinder to the abdomenthe abdomen
– High flow insufflatord lcan deliver 10 or more
liters of gas per mintued dand rate can adjust
from low to high
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InsufflatorInsufflator
• Control panel– Indication system listing y gthe preset abdominal pressurep
– The current abdominal pressurepressure
– The flow rate of the gas
A f d– Amount of gas used
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Gas SupplyGas Supply• A sterile line takes gas from the sufflatorA sterile line takes gas from the sufflatorto the patient (Luer lock or push on tube
S li h filt i l• Some line have a filter in place
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Suction DevicesSuction Devices
• Multiple suction devices are needed– Anesthesiologistg
– Nasogastric tube
Laparoscopic instruments– Laparoscopic instruments
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Video TowerVideo Tower
• Video monitor
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FORMATSFORMATS
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ResolutionResolution
640640
1280
1920
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DefinitionDefinition
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Full HDFull HD
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Full HDFull HD
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Full HDFull HD
• 16:9 ratio for natural vision
• 16:9 ratio provides lateral ex tension of field of16:9 ratio provides lateral ex tension of field of vision
G l b illi• Great color brilliance
• 1920 x 1080 offers 7 times the SD resolution at 480 lines
Cl diff ti ti f ti t t• Clear differentiation of tissue structures
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Impeded viewImpeded view
Pressure Flow Cause
Low High LeakLow High
Low Low
Leak
Empty
High Low
High High
Rela x ation/ Occlusion
Multifactorial/ mulfunction
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Energy SourceEnergy Source
• Electrosurgery– Monopolar cauteryp y
– Bipolar cautery
Ult i• Ultrasonic
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Injury from Energy SourceInjury from Energy Source
• Direct Coupling
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Injury from Energy SourceInjury from Energy Source
• Indirect Coupling
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Ultrasonic CoagulationUltrasonic Coagulation
• Relies on mechanical energy to produce effects
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Operating Room Set upOperating Room Set‐up
• Patient positioning
• Video‐endoscopic equipmentVideo endoscopic equipment
• Ancillary equipment
• Personnel
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Patient PositioningPatient Positioning
• Supine
• Lateral DecubitusLateral Decubitus
• Lithotomy
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SupineSupine
• Arms out– Upper abdomenpp
– Incisional hernia
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SupineSupine
• Tucking arms– Pelvis and lower abdomen
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Patient PositioningPatient Positioning
• Tendelenberg
• Reverse TendelenbergReverse Tendelenberg
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DVT PreventionDVT Prevention
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PersonnelPersonnel
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PersonnelPersonnel
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Primary AccessPrimary Access
• Open
“Hasson”Hasson
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Primary AccessPrimary Access
• Direct vision
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Primary AccessPrimary Access
• Veress Needle
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Direct vs Veress (RCT)Direct vs Veress (RCT)
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Current Laparoscopic SurgeryCurrent Laparoscopic Surgery
• LC
• CBD exploration• Adrenalectomy
• TraumaCBD exploration
• Anti‐reflux surgery• Trauma
• Large and small bowel• Achalasia
• Hernia (inguinal ventral)• Appendectomy
• Gastric surgeryHernia (inguinal, ventral)
• Peptic ulcer operation• Gastric surgery
• Morbid obesity• Splenectomy • (endoscopic thyroid Sx)
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ConclusionConclusion
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ConclusionConclusion