References Vue
1. Caravati F, Ceriani F, Moroni M, et al. The learning curve in laparoscopic resections of the colon and rectum results and considerations. Chir Ital 2003 55 199-206. 2. Senagore AJ, Delaney CP, Madboulay K, et al. Laparoscopic colectomy in obese and nonobese patients. J Gastrointest Surg 2003 7 558-561. 3. Dunker MS, Bemelman WA, Slors JF, et al. Laparoscopic-assisted vs open colectomy for severe acute colitis in patients with inflammatory bowel disease IBD a retrospective study in 42...
Special Considerations Fui
The most common intraoperative complication associated with laparo-scopic total colectomy is bleeding from the vascular pedicles during intracorporeal ligation. Whether vascular clips, laparoscopic vascular staplers, or sealing devices such as LigaSure are used, all have the potential to cause minor or significant bleeding. The surgeon must be prepared for this. On the Mayo stand should be several laparoscopic grasping forceps which can be easily reached by the operating surgeon should bleeding...
scopy training
Didactic sessions videos textbooks Interactive sessions PC- web-based Live surgery observations telementoring Box trainers Mechanical Organ models Tissue labs of the essentials of laparoscopic surgery e.g., how to prepare video equipment, how to select sites for port placement. In addition, ergo-nomic principles of laparoscopic surgery e.g., optimal height of operating table, optimal working angle between two instruments have to be taught at this phase of training, so that the trainees can...
Technique Bai
The extent of exploration is somewhat dictated by the disease process. For example, in inflammatory bowel disease, it is critical to fully evaluate the entire intestine to confirm diagnosis and determine the extent of disease. Only after the small bowel has been thoroughly examined and cleared of disease can Crohn's disease be excluded and an ileal pouch fashioned for patients with presumed ulcerative colitis. Furthermore, in patients with Crohn's disease in whom skip lesions are not uncommon,...
Indications Edh
Indications for laparoscopic stoma formation do not differ from those of open surgery. Laparoscopic stoma formation can be performed independently for a variety of indications or as a part of more complex gastrointestinal surgery. A variety of intestinal sites can be chosen for stoma formation the terminal ileum, transverse colon, and sigmoid colon are the most common sites chosen for stoma formation. The choice for different sites depends on indications and subsequent procedures planned. A...
Cannula Positioning Ssm
Positioning and number of cannulae placed Figure 10.2.2, for the ileostomy formation largely depend on the extent of intraabdominal manipulations expected. Most patients with virgin abdomens, not requiring extensive adhesiolysis, can be performed using a more limited number of cannulae, whereas a thorough inspection of the entire small Figure 10.2.2. Positions of the cannulae for the laparoscopic ileostomy formation. Use of optional cannulae should be used with a low threshold if this makes the...
Outcomes After Laparoscopic Adhesiolysis
Adhesions are a common sequela after abdominal surgery and may also form after intraabdominal inflammatory diseases. Adhesions are an important etiology of acute or chronic intestinal obstruction or even chronic pain, and must be suspected as a leading cause of abdominal pain whenever the patient has undergone previous abdominal surgery. Ray et al.1 reported an estimated 303,836 hospitalizations for adhesiolysis-related procedures in the United States in 1994. Although this frequency may herald...
Outcomes Lrk
The following short-term outcome measures were analyzed duration of surgery, estimated intraoperative blood loss, functional data post operative pulmonary function, duration of postoperative ileus , postoperative hospital stay, morbidity, and mortality. Subcutaneous wound infection, anastomotic leakage, intraabdominal abscess, ileus, pulmonary, or cardiac complications were analyzed separately. Whenever available, the following long-term data for long-term outcomes were extracted from the...
Cannula and HandDevice Positioning
It is logical and expedient to place the hand device first, before establishing pneumoperitoneum and placing cannulae. The hand device is placed centrally in the suprapubic region via either a low transverse Pfannenstiel incision or a vertical midline incision Figure 9.1.2 . The latter is advised in situations in which conversion is deemed more likely obesity, multiple prior operations, etc. . The length of the handdevice incision will vary depending on the surgeon's hand size. Transverse...
Special Considerations Gpo
Conversion to laparotomy should not be considered a complication of the laparoscopic approach and in fact laparoscopic adhesiolysis has one of the highest risks of conversion to an open method. The main reasons for conversion to laparotomy include dense adhesions, nonviable intestine, suspected tumor, or iatrogenic perforation during laparoscopy. The presence of dense adhesions is the most common cause of conversion to laparotomy.11-13 Laparoscopic adhesiolysis with scissors may be inconvenient...
Discussion Ghb
Whereas the perineal approach perineal resection or the Delorme procedure is usually performed in elderly or high-risk patients, the abdominal approach is generally preferred in otherwise healthy patients because of the lower incidence of recurrence. Different abdominal procedures have been recommended to cure rectal prolapse. Madbouly et al.6 described good results after laparoscopic Wells procedure n 13 and sutured rectopexy with resection n 11 . The Wells procedure needed less operative time...
Crohn S Disease Indication To Total Abdominal Colectomy
Except for cancer, the indications for laparoscopic total abdominal colectomy are basically the same as in open surgery. For less experienced laparoscopic surgeons, however, further restrictions may apply such as previous operations with formation of intraabdominal adhesions, obesity, or fistula formation, because these conditions may make laparoscopic orientation and accessibility difficult.1,2 This is especially true for the anatomic regions of the omentum, transverse colon, and meso-colon...
Technique 1
The patient is placed in the Trendelenburg position, and three or four trocars are inserted. For establishment of pneumoperitoneum, CO2 is channeled through the infraumbilical trocar until the intraabdominal pressure reaches 10 mm Hg. Both the operating surgeon and camera holder stand on the patient's left side. After abdominal exploration, the operation table is rotated left side down so the small intestine falls toward the left upper quadrant. The ascending colon is thoroughly mobilized from...
Technique Esi
The procedure begins with the patient in Trendelenburg position. A Pfannenstiel or vertical suprapubic incision is created, usually 6-9 cm in size, just large enough to insert one's gloved hand. The general rule is to make the incision as large as the surgeon's glove size for example, size 7 glove 7-cm incision . Superior and inferior flaps are created of the anterior rectus fascia, and the rectus abdominus is split in the midline and the peritoneum opened. Before inserting the hand-assist...
HandAssisted Laparoscopic Anterior Resection
Although the safety and feasibility of laparoscopic-assisted segmental colectomy have been demonstrated in a number of studies, there are far less data available concerning sphincter-saving anterior rectal resections. Laparoscopic rectal mobilization and resection at the level of the mid or distal rectum is considerably more difficult than segmental colectomy and provides numerous technical challenges. Anatomic characteristics that conspire to make pelvic dissection difficult include a narrow...
Outcomes After Laparoscopic Colectomy for Diverticular Disease
The incidence of diverticulosis of the colon increases gradually with age so that by the eighth decade of life almost 80 of the elderly have some diverticula of the colon. Only a minority of these patients complain about acute or chronic diverticulitis and are candidates for surgery. The indications for emergent surgery are well established Acute abdomen with perforation and diffuse peritonitis. A more conservative approach may be chosen in patients with acute diverticulitis and local...
Telesurgery
This topic deserves a separate discussion, although it involves many different technologies, techniques, and educational concepts. From the earliest time of using the miniaturized cameras of the laparoscope, the transmittal of these images to remote locations telesurgery has been a fundamentally important part of the laparoscopic revolution Figure 13.1 . This permitted many individuals to see, witness, and learn about new methods of performing surgery. For the first time, many surgeons could...
Electrosurgery
Electrosurgery is universally accepted as an important tool in open surgery. Although we do not intend to describe the principles of elec-trosurgery in detail, some basic principles should be discussed to understand the relationship between different operating modes of the electrosurgical unit. For example, tissue heating during the desiccation is a function of the amount of current flowing through a given cross-sectional area of tissue. The electrons collide with the tissue molecules, and the...
The Right Lower Quadrant
By placing the patient in the Trendelenburg position with the right side up, the terminal ileum, its retroperitoneal attachments, the cecum, and the ligament of Treitz can be visualized Figure 7.12, see color plate . The vascular structures of the ileum and right colon may also be identified Figure 7.13, see color plate , and their relationship to the duodenum may be appreciated. With dissection of the ileum and right colon away from their retroperitoneal attachments, then the psoas major...
References Puw
1. Heah SM, Hartley JE, Hurley J, et al. Laparoscopic suture rectopexy without resection is effective treatment for full-thickness rectal prolapse. Dis Colon Rectum 2000 43 638-643. 2. Himpens J, Cadiere GB, Bruyns J, et al. Laparoscopic rectopexy according to Wells. Surg Endosc 1999 13 139-141. 3. van Dalen RM, Modi AK, Hershman MJ. How to do it in surgery laparoscopic rectopexy. Br J Hosp Med 1997 58 587-588. 4. Xynos E, Chrysos E, Tsiaoussis J, et al. Resection rectopexy for rectal prolapse....
Special Considerations Pgf
As described in the previous section, a clear understanding and definition of the anatomy of the pelvis at the time of dissection and exposure are mandatory to avoid intraoperative complications. Two major structures ought to be identified and avoided intraopera-tively The left ureter and the presacral veins. As in any sigmoid and rectal resection, the left ureter is at risk for injury if not properly visualized and retracted out of the operating field. The left ureter should be immediately...
Anesthetic Techniques Monitoring and Positioning
Most anesthesiologists prefer general anesthesia during laparoscopic colorectal surgery. Muscle relaxation allows controlled ventilation compensating for the various changes in respiratory mechanics. The majority of general anesthetics are delivered through a cuffed endotracheal tube. Anesthetic gases may also be delivered with the laryngeal mask airway. Positive pressure ventilation up to inspiratory pressure of 40 cm is possible with the Proseal laryngeal mask airway LMA . Use of the LMA in...
Laparoscopic Adhesiolysis
Intraabdominal adhesions are the inevitable result of abdominal operations.1 Postoperative adhesions are not always symptomatic, but a small percentage do become symptomatic as an acute or chronic small bowel obstruction. An adhesive small bowel obstruction is estimated to develop in 3 of all patients who have undergone laparotomy.2 Beck et al.3 reviewed 18,912 patients with open abdominal surgery and found 14.3 had obstruction within 2 years, with 2.6 requiring adhesiolysis. Moreover, the...
The Pelvis
In the Trendelenburg position, by displacing the small bowel contents into the upper abdomen, the pelvic contents may be inspected. Often it is surprising how well the pelvis may be seen as compared with open surgery, and part of this is attributable to the distension of the pelvis from the pneumoperitoneum. The relationship of the pelvic vessels to the organs is seen, and the inguinal areas are also visualized in a manner not often appreciated during conventional surgery Figure 7.16 . In...
The Left Upper Quadrant
By sweeping the laparoscope across the abdomen to the left side and tilting the left side of the body up, segments II and III of the liver can be easily inspected Figure 7.5, see color plate . The esophageal hiatus, the caudate lobe through the hepatogastric ligament, and the cardia of the stomach can be demonstrated by lifting up the left lobe with atrau-matic grasper Figure 7.6 . Also demonstrable is the undersurface of the left hemidiaphragm, and the spleen. The splenic flexure, the...
Virtual Reality Simulators
The term virtual reality VR refers to a computer-generated representation of an environment allowing sensory interaction sound, sight, and touch , thus giving the impression of true realism. Because of the nature of laparoscopy, it will likely benefit from developments in VR technology.15 In fact, elaborating on the successful paradigm of flight-simulator training for pilots, the potential of VR applications for lapa-roscopic surgical skills training was proposed almost a decade ago. Recent...
Laparoscopes
The majority of currently available rigid laparoscopes are derived from the Hopkins-type rod-shaped lens system developed in 1952.4 This lens system, which is contained in the core of the laparoscope, focuses and transmits the light from the abdomen to the camera. Modern versions consist of rod-shaped lenses, air-filled spaces between the lenses, and additional lenses that compensate for peripheral distortion. Optical fibers at the periphery of the scope transmit light from the light source...
Instruments 1
Specific instruments recommended for laparoscopic sigmoidectomy are listed in Table 8.4.1. Figure 8.4.1. Positions of the equipment and the surgical team for the laparo-scopic sigmoid colectomy. Table 8.4.1. Specific instruments recommended for laparoscopic sigmoidectomy Table 8.4.1. Specific instruments recommended for laparoscopic sigmoidectomy Dissecting device i.e., LigaSure VTM or Ultrasonic Shears or
Dissection of the Inferior Mesenteric Artery
The dissection commences as the first assistant, either from the left side of the abdomen or alternatively from between the legs, exposes the IMA for the surgeon. This is done by retracting the mesosigmoid in a ventro-lateral direction using bowel graspers from the left upper and lower quadrants. The surgeon incises the peritoneum to the right of the superior rectal artery starting at the sacral promontory Figure 8.6.3 . Under continuous traction, the peritoneum is incised cephalad toward the...
Insufflation Needles
The Veress needle, modified little since its invention by Janos Veress in 1938,13 continues to be the standard instrument used for creation of pneumoperitoneum by a closed method.8 Needles are commercially available in various lengths, all with an outside diameter of 1.8 mm. With its safety mechanism with blunt-tipped, spring-loaded inner stylet, the needle has remained the safest instrument for establishing pneumoperitoneum at laparoscopic surgery, when using an appropriate percutaneous...
The Right Upper Quadrant
To best see in the RUQ, the patient should lie in the reverse Trendelenburg position with the body tilted with the right side up. First, the liver should be assessed overall for its shape, size, and surface texture Figure 7.1 . Also demonstrable is the under surface of the right diaphragm Figure 7.2 . Generally, the umbilical port is best for doing this, with instruments in the other ports used for lifting up the edge of the liver and looking underneath at the porta hepatis, and the gallbladder...
Editors Comments Fad
Indications We believe that patients with rectal lesions below the peritoneal reflection requiring circumferential mobilization completely down to the pelvic floor are potentially not good indications for even a HAL resection. This relates to the need for complex dissection deep in the pelvis and the need for a distal rectal washout. Otherwise, we agree that the indications are not different from open surgery. Patient positioning We do not use a bean bag as described in this chapter. A gel-like...
IrrigationSuction
An excellent combination of irrigation and suction systems is necessary for any laparoscopic procedure. In cases of bleeding or spilled intestinal contents, irrigation systems with a minimal flow rate of 1 L min are essential. Adjustable suction with interchangeable 5- and 10-mm metallic suction tubes should be available to remove smoke, laser plume, fluid, clots, or other debris. Using suction tips with multiple side holes is important when irrigating and evacuating fluid or clots rapidly or...
Info Uwg
Figure 6.2. The Hasson cannula is introduced into the body wall using two fascial sutures which elevate the anterior rectus fascia. Later, these are used to secure the cannula and also to close the fascia at the conclusion of surgery. Figure 6.2. The Hasson cannula is introduced into the body wall using two fascial sutures which elevate the anterior rectus fascia. Later, these are used to secure the cannula and also to close the fascia at the conclusion of surgery. Figure 6.3. Optical access...
References Fbw
1. Hashizume M, Sugimachi K. Needle and trocar injury during laparoscopic surgery in Japan. Surg Endosc 1997 11 1198-1201. 2. Ternamian AM, Deitel M. Endoscopic threaded imaging port EndoTIP for laparoscopy experience with different body weights. Obes Surg 1999 9 44-47. 3. Lee DW, Chan AC, Kwok SP, et al. Ports, don't slip out Surg Endosc 1999 13 628. 4. Milsom JW, Okuda J, Kim S-H, et al. Atraumatic and expeditious laparoscopic bowel handling using a new endoscopic device. Dis Colon Rectum...
References Ens
1. Taylor E, Feinstein R, White PF, et al. Anesthesia for laparoscopic cholecystectomy. Is nitrous oxide contraindicated Anesthesiology 1992 76 541-543. 2. Yao FSF. Anesthesiology Problem Oriented Patient Management. Philadelphia Lippincott 2003. 3. Liu SY, Leighton T, Davis I, et al. Prospective analysis of cardiopulmonary responses to laparoscopic cholecystectomy. J Laparoendosc Surg 1991 1 241-246. 4. Wittgen CM, Andrus CH, Fitzgerald SD, et al. Analysis of the hemody-namic and ventilatory...
Biological Glues and Adhesives
The role of these agents in the treatment of surgical diseases is increasing. Glues such as Tisseel Baxter Healthcare Corp., Deerfield, IL and BioGlue Cryolife, Kennesaw, GA , which are derivatives of fibrin, are in common use in multiple disciplines such as vascular, cardiac, and neurosurgery. There they are used to stop bleeding from pinpoint areas. The companies manufacturing these products are exploring a wide array of clinical applications in the abdomen, and some areas, such as the cut...
Laparoscopic Anatomy of the Abdominal Cavity
Jeffrey W. Milsom, Bartholom us B hm, and Kiyokazu Nakajima In only the past one and a half decades, the surgeon has become capable of inspecting every recess of the abdomen with extremely high resolution and magnification through a tiny incision in the abdominal wall. By placing a laparoscopic videocamera into the abdominal cavity, not only the surgeon but the entire surgical team may achieve a visual perspective heretofore not possible, thus accelerating the learning of surgery and anatomy....
Grasping Instruments
Laparoscopic graspers are designed to hold the tissue firmly without exerting excessive pressure. The shaft on most of these instruments is 5 mm in diameter, 31 cm long, and isolated by a thin layer of plastic Teflon or polyvinylchloride that electrically insulates the instrument. The grasping blades are blunt and are about 2 cm long with a maximum jaw span of about 2 cm. Although the quantity of tissue that can be held with these graspers is limited, we use this type of grasper for almost all...
Patient Positioning and Operating Room Setup
The patient is placed supine in a modified lithotomy position using Dan Allen stirrups. Surgery is begun in the Trendelenburg position 20 head-down tilt and, after cannula insertion, the patient is tilted left side down for ileal surgery or the right side down for jejunal surgery. The surgeon and assistants stand in a half circle opening toward the area of interest. Figure 8.1.1A shows the positions for ileal surgery. After cannula insertion, the surgeon stands between the legs and both...
Cannula Positioning Ccb
A standardized approach to cannula size and placement for all colorec-tal resections has reduced operative times. Five cannulae are generally required with the camera port placed in the supraumbilical position utilizing an open technique. After a diagnostic laparoscopy to assess feasibility, right-sided cannulae are placed. A 12-mm cannula is placed two fingerbreadths above and medial 2 2 to the right anterior superior iliac spine Figure 8.8.2 . This should always be lateral to the rectus...
Inanimate Models
After the introductory session, the actual laparoscopic training begins using inanimate models e.g., bench models or training boxes . The inanimate models are totally risk-free, reproducible, readily available, inexpensive, offer unlimited practice, and basically require no intense supervision.4 The purposes of this training are 1 To become comfortable working with both hands using laparoscopic instruments 2 to become familiar with the video and laparoscopic equipment and 3 to begin learning...
Cannula Positioning Aci
The cannulae are positioned in the umbilical region above or below, depending on the size of the patient . If the patient is thin, just below the umbilicus is usually best. If the patient has a large and dependent pannus, somewhere above the umbilicus is better, usually about 23-25 cm above the symphysis pubis. Other cannulae are placed in the right and left upper and lower lateral abdominal wall. The proposed stoma site is not used for a cannula, because this is almost always located too far...
Patient Positioning and Operating Room Setup Kxc
We fix the body with the right side of the patient lower than the left about 15 using the magic bed bean bag moldable device and provide lateral support on the right side. We always use intermittent lower extremity compression stockings and adjustable leg stirrups. With regard to the head, we apply a foam pad to the forehead, and fix it there to the bed with adhesive tapes. The surgeon stands to the right side of the patient, the cameraman second assistant stands to the left side of the...
Cannula Positioning Oka
We make an arc-shaped incision immediately above the umbilicus, introducing the first cannula 12 mm by an open minilaparotomy method, performing a purse string suture of the peritoneum and fascia, f Figure 8.5.2. Positions of the cannulae for the laparoscopic anterior resection. Note that the surgeon works mainly through the right lower quadrant and the suprapubic cannulae. Figure 8.5.2. Positions of the cannulae for the laparoscopic anterior resection. Note that the surgeon works mainly...
Technique
Once the preoperative diagnosis is confirmed and the laparoscopic procedure appears feasible, the pathology is located by running the entire length of the small bowel and placing a suture just upstream of the pathology. Running the small bowel is accomplished from proximal to distal by placing the patient on the left side up, in slight reverse Trendelenburg position until the mid small bowel is reached, then adjusting the patient to the right side up with Trendelenburg position to run the...
Patient Positioning and Operating Room Setup Xil
After induction of general anesthesia, an orogastric tube and Foley catheter are inserted. The patient is placed in a modified lithotomy position using adjustable stirrups, with both arms tucked at the sides. Venous compression stockings are used in all cases. The patient is placed in Trendelenburg position 20 head-down tilt , and a handassist port is placed in the suprapubic position. For the first phase of the operation right colon mobilization , the surgeon and first assistant stand on the...
Trocar Wound Closure
At the conclusion of every laparoscopic procedure, cannulae should be removed one by one under direct laparoscopic control while the abdominal wall puncture sites are inspected for hemostasis. As each cannula is removed, an assistant should plug the puncture site with a finger to maintain the low-pressure pneumoperitoneum. After all can-nulae are removed except the one housing the laparoscope, the laparo-scope is withdrawn 4-5 cm into the cannula and this cannula then is slowly withdrawn from...
Contributors
Bartholom us B hm, MD, Chief of Surgery, HELIOS Klinifum Erfurt, Klinik f r Allgemeain-und Viszeralchirurgie, Erfurt, Germany Joseph Carter, MD, Assistant professor, New York University Medical Center, New York, NY, USA Panchali Dhar, MD, Assistant Professor of Anesthesiology, Weill Medical College of Cornell University, New York, NY, USA Alessandro Fichera, MD, FACS, FASCRS, Assistant Professor, Department of Surgery, University of Chicago, Chicago, IL, USA Margaret Henri, MD, Staff Surgeon, H...
Ilocolic Pedical
The laparoscopic portion of the procedure is broken into two segments, an extended right colectomy followed by left colectomy. Once the colon is fully mobilized and devascularized, it is brought over the small intestine to the right lower quadrant and all the small intestine is brought to the left of the midline in the left upper quadrant. A 6- to 8-cm muscle-splitting Pfannenstiel incision is created to mobilize and transect the distal rectum from the top of the anal canal, create the pouch,...