Laparoscopic Surgery

Diagnostic and operative laparoscopy

Laparoscopy의 적응증
1. diagnostic ? acute or chronic pelvic pain, ectopic pregnancy, PID, ES,
torsion, other intraperitoneal pathology.
2. operative

laparoscopy의 금기증
1. 금기증 : bowel obstruction, ileus, peritonitis, intraperitoneal hemorrhage, diaphragmatic hernia, severe cardiorespiratiory disease.
2. 상대적인 금기증(relative contraindication) : extremes of body weight, inflammatory bowel disease, presence of a large abd mass, advanced intrauterine pregnancy,
3. 수술의 과거력은 금기증이 아님.

Equipment for laparoscopy

1. laparoscopes
A. different angles of view : straightforward or foreoblique
2. Pneumoperitoneal needle
Two needle type : Tuohy needle, veress needle ( reduce the chances of accidental puncture)
3. Trocars : Two basic models : flapper valve, trumpet valve
4. Gas insufflator : most insuffulators on low flow produce about 0.5 to 1.0 L/min
High flow setting must be used that will produce up to 10-15 L/min.
5. Light sources : Xenon or halogen light sources.
6. Camera Two component : camera head with its cable and the camera control unit.

Ancillary instruments
1. probe : simplest and most commonly used instrument is the blunt probe
2. Forceps: atraumatic grasping forceps을 많이 사용.
more delicate graspers는 control bleeding 혹은coagulation, suturing할 때 사용. Punch biopsy forceps
3. Scissors and scalpels : scissors are commoly used and come in many designs, including toothed, serrated, micro, and hooked.
4. Aspirators and irrigators.
5. Morcellators.

Positioning of the patient
환자의 팔은 펼쳐서 위치하는 것 보다 몸과 평행하게 위치하는게 더좋다. -> surgeon의 움직임이 더 자유로와짐.
The lithotomy position : uterus를 manipulation하기가 용이하고 vaginal approach가 더 용이함.
환자의 엉덩이는 table에서 약간 튀어나올정도로 위치 -> uterine manipulation이 용이함.

Pneumoperitoneum
1. Insufflation and trocar insertion 은 환자의 위와 방광이 비어있는지 확인후 삽입한다.
2. Carbon dioxide -> 혈액으로 흡수가 빠름, embolism의 위험성이 nitrous oxide보다 적다.
3. the veress or Tuohy needle을 umbilicus를 잡고서 삽입한다.
4. 복벽을 잡아 당겨서 들어올린 상태에서 hollow the sacrum쪽으로 needle을 삽입한다.
5. 과거 수술을 했거나, 혹이 있거나 장기가 커져있는 경우 다른곳에서 needle을 삽입한다. (lower quadrant puncture sites, above the umbilicus in the midline, left upper quadrant beneath the costal margin(ninth intercostals space) at the edge of the lateral rectus or ant axillary line
6. needle 삽입시 복압은 10mmHg를 넘어서면은 않된다.
7. 올바른 삽입의 여부를 syninge test로 확인할수 있다.(1L정도 gas삽입후 Liver dullness가 소실)
8. A small, thin patient with strong abd musches will require less volume(1-2L) than an obese , parous patient with lax abd muscle(3-6L)
9. 복압은 20-25mmHg를 넘지 않도록 한다. (higher pressure는 diaphragmatic excursion or with central venous return 을 방해할수 있다.)

Insertion of the primary trocar
lower abd wall을 잡아서 들어 올린후 scarum or uterus를 향해서 trocar를 삽입한다. Trocar가 fascia and peritoneum을 통과하면 ,sleeve of the trocar를 좀더 advanced시킨다.

Ancillary trocar placement
보통 1-2개의 정도가 필요하다.
적당한 기구의 사용을 위해서 수술 위치보다 약간 위쪽과 바깥쪽(lateral)에 위치하게 된다.
삽입할 자리를 먼저 손가락으로 확인하고 복벽의 다른 구조물이 있는지 여부를(inferior epigastric vessels) laparoscope으로 확인후 혈관을 피해서 puncture한다.
Puncture는 항상 직접 laparoscope으로 보면서 다른 장기나 혈관등의 손상이 없도록 한다.

Diagnostic examination of the pelvis
Scope을 삽입 후 abdominal cavity를 확인하여 다른 병변이나 needle, trocar로 인한 손상이 있는지 확인하여야 한다.

Assistance
Surgeon may have both hands occupied with ancillary instruments or the operating channel.
With a video camera, an experienced assistant can actively assit the operator

Operative laparoscopic procedures
1. Blunt dissection : Traction placed on an adhesion during stabilization of the involved structures can cause separation
사용하는 기구 : suction-irrigator, blunt probe,forceps, closed pair of scissors
2. Sharp dissection
3. Aquadissection
4. Electrodissection : unipolar and bipolar electrosurgery are used
unipolar needle near ureter or bowel should be limited to adhesions at least 1 to 2cm away
5. laser dissection
6. salpingoovariolysis
7. salpingectomy
Mesosalpinx를 electrocoagulation하고 cutting함(scissors or a knife)
coagulation and cutting은 proximal or fimbriated end or the fallopian tube에서부터 시작하고 fallopian tube에 가깝게 시행하여 난소로 가는 혈관의 손상을 피하도록 한다.
8. ovarian cystectomy
난소표면의 ES(<1cm) : coagulated or vaporized
3-5cm in size: laparotomy와 같은 방법으로 절제
>5cm difficult to handle at laparoscopy
cyst is drained and lavaged.
The lining is inspected and a relaxing incision is made. The plane of the pseudocapsule is identified. Atraumatic grasping forceps are used th hold the ovary and provide countertraction. The cyst wall lining is grasped and dissection is performed with laser scissors, or blunt probe.
Incompletedly resected areas can be further coagulated or vaporized
8. Oophorectomy and sampingoophorectomy
three loop ligatures(around the ovary or adnexa)를 시행한다.
Loop ligature하기 전에 adhesion이 없어야 한다.
Incision in the mesosalpinx are sometimes necessary to facilitate placement.
ovary or adnexa 는 loop에서 distal쪽으로 cutting한다.
Small bleeding points can be coagulated the suture.

Complication of laparoscopy
1. Pneumoperitoneum
Extraperitoneal insufflation-emphysema -> resolves spontaneously
Mediastinal emphysema, emphysema of the omentum
Pnemothorax-드물다.
Rarely penetrating injury to blood vessel is not recognized at the time of insufflation and may lead to gas embolism and death
2. Vessel injury
Veress needle or trocar 가 omental or mesenteric blood vessel or any of the major abdominal or pelvic arteries or veins을 손상시킬 수 있따.
Major vessel injury시는 즉시 개복을 해야 하고 수혈을 시행하셔야 한다.
Mesenteric vessel의 손상시는 segment of bowel and bowel resection이 필요할 수 있다
Superficial epigastric vessel의 손상은 transillumination으로 피할수있다.
Direct laparoscopic visulization of the inf epigastric vessels and insertion of trocars lateral th the edge of the rectus muscle will decrease the risk of vessel laceration.
3. Bowel injury
Gastric injury는 드물다.
Injury 은 과거 수술 받은 사람이나 유착이 있을 경우 생길수있다.
4. Bladder injury
More common in previous pelvic surgery
Laceration smaller than 5mm may heal spontaneously if the bladder is drained continuosly for 4-5 days postoperatively.
5. Trocar hernias
Z track method can lessen the risk of herniation.
Trocar larger than 7mm create an increased risk, and the use of these larger ports often mandates closure of the fascia with sutures.