Pneumoperitoneum. Laparoscopic instrumentation Access into the abdomen

Transcription

1 Basic Science in Laparoscopic Surgery

2 Contents Pneumoperitoneum Patient positioning Laparoscopic instrumentation Access into the abdomen

3 Laparoscopic Surgery Minimally Invasive Surgery (MIS) Keyhole Surgery Pinhole Surgery

4 Contraindication Uncorrected coagulopathy Inability to tolerate laparotomy Inability ti tolerate general anesthesia Hypovolemic shock Uncompensated cardiopulmonary disease

5 Pneumopeitoneum Mechanical effect (Primarily) 1. Upward displacement of diaphragm Intrathoracic pressure Diaphragmatic i motion Lung volume vital capacity, compliance Airway pressure peak, mean airway pressure Work of breathing

6 Pneumopeitoneum Metabolic effect 1. CO2 absorption Leads to hypercarbia and acidosis In healthy h individuals: id corrected by ventilation i and body buffering system In COPD:risk to develop hypercarbia Expired CO2 (ETCO2) levels are unreliable: arterial CO2 needed

7 Hypercarbia Moderate increase in PaCO mmhg produce a hyperdynamic state: SVR, CVP, HR and BP no effect on CO Marked increase in PaCO2> 30 mmhg:cardio depressive predominate, cardiovascular collapse, severe acidosis, fatal dysrhythmias y Minute ventilation must be increased 20 30%

8 Hypercarbia Lowering IAP to mmhg Alternative gas : Helium Gasless laparoscopy Converted to open surgery

9 Pneumoperitoneum $ Ventilation

10 ETCO2

11 Ventilation change 1. High inspiratory airway pressure 2. Decrease FRC 3. Increase V/Q mismatch

12 Cardiovascular change Initially: venous return due to the blood volume sequestrated in splanchnic vasculature Increase mean arterial pressure Later on: venous return, arterial resistance, CVP Resulted in compensatory HR Net effect = no change in CO IAP> 20 mmhg: IVC is compressed then venous return is impeded IAP> 40 mm Hg, venous return drop precipitously

13 Pneumoperitoneum $ Cardiovascular

14 Patient Positioning Head down d (Trendelenburg dl position) ii Central blood volume and pressure Cardiac output Chest wall resistance, dead space Head up Venous return & Cardiac output Femoral venous pressure risk of DVT or pulmonary embolism

15 Pneumoperitoneum $ Ventilation$ Positioning

16 Pneumoperitoneum $ Cardiovascular $ Positioning

17 Arrhythmia Vagal reflex because of sudden stretching peritoneum with rapid insufflation provoke AV dissociation, nodal rhythm, sinus bradycardia and asystole Raise PaCO2: sympathetic response Embolism Underlying cardiac disease

18 Renal 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 losses

19 Renal lblood Flow $ Pre load d$ Pneumoperitoneum

20 Lactic Acidosis Elevation in IAP produces lactic acidosis, probably by severely lowering CO and impairing hepatic clearance of blood lactic acid

21 Intracranial and Intraoccular change Increase cerebral blood flow from hypercarbia But increase intracranial pressure, intraocular pressure in the cases that have underlying diseases

22 Metabolic Effect of CO2 Increase in PaCO2 1. Absorption of CO2 fromthe peritoneal cavity 2. V/Q mismatch 3. Impaired dco 2 e x cretion capacity (e.g., COPD, cyanotic CHD)

23 CO2 Emboli Presenting signs Hypotension Jugular vein distension Tachycardia Mill Wheel Murmur

24 CO2 Emboli Early (< ml/kg of emboli): TEE CO 2 bubbling in right heart splashing sound with ihprecordial doppler millwheel murmur hypoxemia, high h increasing i PCO2 PaCO2, high ΔPaCO2 ETCO2 Late (2 (>2ml/kg of emboli): increase CVP, PAP hypotension, arrhythmia h cardiac arrest

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26 CO2 Emboli

27 CO2 Emboli Treatment Evacuate pneumoperitoneum p Left lateral decubitus, head down position Introduce central venous catheter

28 Laparoscopic Equipment Laparoscopes Video Tower Gas Supply Suction Device Equipment Table

29 Laparoscopes

30 Laparoscopes Deliver light from a light source Conduct image to eyepiece

31 Laparoscopes

32 Video Tower Light cable Light source

33 Imaging systems Camera Head Unit Camera Control Unit

34 Gas Supply Gas tank Gas CO2 Readily available Ine x pensive Not support combustion N2O Helium

35 Insufflator Control the flow of gas from the cylinder to the abdomen High flow insufflator can dl deliver 10 or more liters of gas per mintue and rate can adjust from low to high

36 Insufflator Control panel Indication system listing the preset abdominal pressure The current abdominal pressure The flow rate of the gas Amount of gas used

37 Gas Supply A sterile line takes gas from the sufflator to the patient (Luer lock or push on tube Some line have a filter in place

38 Suction Devices Multiple suction devices are needed Anesthesiologist Nasogastric tube Laparoscopic instruments

39 Video monitor Video Tower

40 FORMATS

41 Resolution

42 Definition

43 Full HD

44 Full HD

45 Full HD 16:9 ratio for natural vision 16:9 ratio provides lateral ex tension of field of vision Great color brilliance 1920 x 1080 offers 7 times the SD resolution at 480 lines Clear differentiation of tissue structures t

46 Impeded view Pressure Flow Cause Low High Leak Low High High Low Low High Empty Rela x ation/ Occlusion Multifactorial/ mulfunction

47 Energy Source Electrosurgery Monopolar cautery Bipolar cautery Ultrasonic

48 Injury from Energy Source Direct Coupling

49 Injury from Energy Source Indirect Coupling

50 Ultrasonic Coagulation Relies on mechanical energy to produce effects

51 Operating Room Set up Patient positioning Video endoscopic endoscopic equipment Ancillary equipment Personnel

52 Patient Positioning Supine Lateral Decubitus Lithotomy

53 Supine Arms out Upper abdomen Incisional hernia

54 Supine Tucking arms Pelvis and lower abdomen

55 Patient Positioning Tendelenberg Reverse Tendelenberg

56 DVT Prevention

57 Personnel

58 Personnel

59 Primary Access Open Hasson

60 Direct vision Primary Access

61 Veress Needle Primary Access

62 Direct vs Veress (RCT)

63 Current Laparoscopic Surgery LC Adrenalectomy CBD exploration Trauma Anti reflux surgery Large and small bowel Achalasia Appendectomy Hernia (inguinal, ventral) Gastric surgery Peptic ulcer operation Morbid obesity Splenectomy (endoscopic thyroid Sx)

64 Conclusion

65 Conclusion