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General Surgeon In Pune - Laparoscopy Surgeon In Pune


Dr. Sanjay Kolte, a general surgeon based in India who specializes in laparoscopic,Thoracoscopic,gastrointestinal, Emergency and General surgery. – PowerPoint PPT presentation

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Title: General Surgeon In Pune - Laparoscopy Surgeon In Pune

  • 1902 - Georg Kelling, of Dresden, Saxony,
    performed the first laparoscopic procedure on
  • 1910 - Hans Christian Jacobaeus of Sweden,
    reported the first laparoscopic operation on
  • 1980 - Patrick Steptoe from England, started to
    perform laparoscopic procedures in the operating
    room under sterile conditions.
  • 1982 - The first solid state camera was
    introduced and this was the start of
  • 1987 - Phillipe Mouret performed the first
    video-laparoscopic cholecystectomy in Lyons,
  • 1994 - A robotic arm was designed to hold the
    laparoscope camera and instruments.
  • 1996 - The first ever live broadcast of
    laparoscopic surgery via the Internet was
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What is Laparoscopic Surgery?
  • Laparoscopic surgery, also known as minimally
    invasive surgery (MIS) or keyhole surgery is a
    modern surgical technique for carrying out
    operations in the abdomen through cannulae (also
    known as ports) which are channels into the body
    through small incisions.
  • Using a video camera the surgeon is able to view
    the operative field without invasive surgery. The
    abdomen is usually insufflated with carbon
    dioxide gas.
  • By inflating the abdomen, the abdominal wall is
    elevated above the internal organs to create a
    working and viewing space for the surgeons.
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Why Laparoscopy?
  • There are a number of advantages to operating on
    the patient with laparoscopic surgery versus open
    surgery. Some of these are
  • Less post-operative scarring
  • Reduced pain
  • Shorter recovery time
  • Less time spent in hospital to recover
  • Reduced hemorrhaging
  • Reduced risk of exposing internal organs to
    external contaminants
  • Quicker return to normal activities
  • Quicker return to work

  • The Rise of Bariatric Surgery
  • One of the most common types of laparoscopic
    surgery is bariatric (obesity). Over the last
    decade there have been more advancements in
    bariatric surgery than there had been in the
    previous 50 years, fuelled largely by the growing
    obesity epidemic which began in the 1970s. The
    epidemic created the need for effective treatment
    of severe obesity and its co morbidities leading
    to the development of procedures such as gastric
    banding, gastric bypass and duodenal switch over
    the past decade. More recently, the advent of
    minimally invasive surgery in the mid-1990s
    accounted for the second wave of advances.
  • Before Laparoscopic Surgery
  • Before laparoscopy was practiced, surgeons
    operated using open/invasive surgery. This means
    cutting skin and tissues so that the surgeon has
    direct access to structures and organs. This
    involves more direct access than in minimally
    invasive procedures as the openings are bigger so
    the internal organs are openly exposed.
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Laparoscopic Surgery
  • Cholecystectomy, Appendectomy Colectomy
  • Vagotomy
  • Hiatal, Inguinal Diaphragmatic hernia
  • Urological- Nephrectomy, Adrenelectomy
  • OBG-Tubal surgeries,cystectomies,hystrectomie
    s various ablations (endometriosis)
  • Thoracoscopies
  • Neurosurgeries
  • Lumbar discectomies
  • Diagnostic procedures
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Advantages and Disadvantages
  • Advantages
  • Minimal pain illeus
  • Improved cosmesis
  • Shorter hospital stay , faster recovery rapid
    return to work
  • Non muscle splinting incision less blood loss
  • Post op respiratory muscle function returns to
    normal more quickly
  • Wound complications i.e. infection dehiscence
    are less
  • Lap surgery can be done as day care surgery
  • Disadvantages
  • Longer duration of surgery
  • Loss of 3D view, impaired touch sensation
  • poor dexterity, fulcrum effect, risk of visceral
    / vsl. Injury (may go unrecognised)
  • Long learning curve for surgeons
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Fig. Demonstarting surgical incision Sites in lap
  • Ideal insufflating gas of choice
  • Colorless, non toxic, nonflammable, easily
    available, inexpensive, inert, readily soluble in
    blood and easily ventilated out of lungs
  • Why CO2 is the gas of choice for laparoscopy?
  • Nonflammable does not support combustion
  • Highly soluble in blood because of rapid
    buffering in blood so risk of embolisation is
  • Rapidly diffusible through membranes so
    easily removed by lungs
  • CO2 levels in blood expired air can be
    easily measured its elimination is augmented by
    increasing ventilation
  • CO2 is readily available is inexpensive
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Gas Oswalds BG solubility coef. complications
Air 0.017 Supports combustion, Gas embolism
Oxygen 0.036 do
Nitrogen Gas embolism
N2O 0.042 Supports combustion (if mixed with methane from bowel), Bowel distension, PONV, Explosion with cautery
CO2 0.49 Hypercarbia, Pain abdomen ,Shoulder tip pain, Arrythmia, Promotion of port site tumour growth, peritoneal irritant
He 0.00098 Embolism, diffusible, expensive
Argon Embolism, expensive
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  • Physiologic effects seen with CO2 insufflations
    are transient and derive from the body's reaction
    to increases in intra abdominal pressure and CO2
    absorption as it tries to achieve a new state of
    homeostasis. People who are otherwise healthy
    will tolerate laparoscopy well, while individuals
    with underlying cardiopulmonary or renal diseases
    may not tolerate prolonged CO2 insufflations.
    Additionally, patient positioning, for example
    steep Trendelenburg in prostatectomy, can
    exacerbate cardiovascular alterations in
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  • Cardiovascular changes vary with intra abdominal
    pressure, with higher pressures associated with
    more significant changes than lower pressures. In
    any other case healthy patients undergoing
    laparoscopy, the threshold intra abdominal
    pressure that led to hemodynamic changes was 12
    mm Hg. Those with underlying cardiac disease will
    likely have a lower intra abdominal pressure
  • Heart rate may rise transiently in response to
    increases in SVR and arterial blood pressure
    level to maintain cardiac output, but most
    studies have reported no significant long-term
    changes in heartbeat with laparoscopy. In a tiny
    subset (0.5) of otherwise healthy patients,
    however, bradycardia and asystole can occur
    during CO2 insufflation and pneumoperitoneum.
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  • CO2 may be the gas of choice for laparoscopic
    surgeries because it is noncombustible, extremely
    soluble, and readily eliminated with the lungs.
  • Despite the proven effectiveness and protection
    of CO2 for insufflation in laparoscopy, the
    respiratory response to mechanical improves in
    intra abdominal pressure as well as hypercapnia
    from absorption should be considered.
  • With CO2 insufflation and increases in intra
    abdominal pressure, the dintra abdominal
    pressurehragm is pushed cephalad into the
    thoracic cavity, constraining downward dintra
    abdominal pressurehragmatic excursion with
    respiration. All round functional respiratory
    capacity, vital capacity, and pulmonary
    compliance drop with boosts in intra abdominal
    pressure, and peak airway and plateau pressures
    can enhance up to 50 and 81, respectively.
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  • Mechanistically, as intra abdominal pressure
    increases, its compressive effects on the renal
    vasculature, the renal parenchyma, and the IVC
    will reduce effective renal blood circulation
    (ERBF), cortical and medullary perfusion, and
    renal venous outflow.
  • The renal effects are mild to negligible once the
    intra abdominal pressure is under 10 mm Hg, but
    as intra abdominal pressure reaches and exceeds
    15 mm Hg, there's a pressure-dependent decrease
    in the glomerular filtration rate (GFR), ERBF,
    creatinine clearance, sodium excretion, and
    urinary output. In a typical intra abdominal
    pressure of 15 mm Hg, urinary output decreases by
    as much as 63 to 64, GFR by 21, and ERBF by
    26. Despite this drop, however, there are no
    long-term renal squeal, even in patients with
    pre-existing renal disease, and
    pneumoperitoneum-induced renal failure does not
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  • Metabolic acidosis from CO2 absorption is the
    primary derangement with laparoscopy. Systemic
    CO2 absorption and resultant metabolic
    consequences differ depending on the patient's
    underlying respiratory status since the lung
    eliminates absorbed CO2 buffered by the blood. In
    otherwise healthy patients, an increase in minute
    ventilation is enough, but for individuals with
    COPD, removal of CO2 is less capable, causing
    them to are afflicted by more major and extended
    derangements in acid-base balance. As stated
    earlier, desufflation might be necessary during a
    long laparoscopic procedure in patients with COPD
    or interstitial lung condition.
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Causes for Paco2 during Laparoscopy
  • Absorption of carbon dioxide (CO2) from the
    peritoneal cavity
  • VA/Q mismatch
  • Increased physiologic dead space
  • Abdominal Distention
  • Position of the patient (e.g., steep tilt)
  • Controlled mechanical ventilation
  • Reduced cardiac output
  • These mechanisms are accentuated in sick patients
  • Increased metabolism (e.g., insufficient plane of
  • Depression of ventilation by anesthetics (e.g.,
    spontaneous breathing)
  • Accidental events
  • CO2 emphysema (i.e., subcutaneous or body
  • Capnothorax
  • CO2 embolism (Selective bronchial intubation)

  • PAC
  • Done in usual manner with special attention to
    cardiac pulmonary system
  • Investigations
  • Complete hemogram
  • RBS
  • Na, K
  • BUN, Creatinine
  • Coagulation profile
  • CXR, ECG
  • BG, CM
  • Special investigations
  • ECHO
  • PFT
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  • NPO
  • Complete bowel preparation
  • Antibiotics as per surgical team
  • Awareness about post op shoulder tip pain
  • Written informed consent for laparotomy
  • Anxiolytics/antiemetics/H2 receptor
  • Antisialagogue (glyco-P) and vagolytic may be
    administered at induction of anaes.
  • DVT prophylaxis (rTn, pelvic Sx, long
    duration, malignancy, obesity)
  • Clonidine/ dexmetetomidine to decrease stress
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  • HR
  • NIBP
  • Continous ECG
  • Pulse oximetry
  • Capnography
  • Temperature
  • Airway pressure
  • IAP
  • If required, ABG, precordial doppler,TEE may
    be instituted.
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CO2 s/c emphysema
  • Cause
  • accidental extraperit insufflation
    (malpositioned verris needle)
  • deliberate extraperit insufflations-
    retroperit surg,TEPP,fundoplication, pelvic
  • Diagnosis
  • ETCO2 -cannot be corrected by adjusting
    ventilation even after plateau reached
  • ABG, Palpation
  • Treatment
  • Stop CO2 insufflation, interrupt lap
  • CMV continued till hypercapnia resolves
  • Resume lap at low insufflation P thereafter
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Pneumothorax / pneumomediastinum
  • Cause
  • pleuroperitoneal communications (RgtL)
  • Diaph defects( aortic, esophageal, GE jn surg)
  • Rupture of preexisting bullae
  • Perf falciform ligament
  • Diagnosis
  • airway P, sudden ?Sp O2 , sudden ?/ ? ETco2,
  • Abnormal motion of hemidiaph by laparoscopist

CAPNOTHORAX ? ET CO2 (may fall later) ? V CO2, ? PaCO2, AIR PNEUMOTHORAX ?ET CO2 (due to ?CO)
Stop N2O 100 O2 IAP PEEP Thoracocentesis not needed Inform surgeon Do not apply PEEP Mandatory
CO2 embolism (rare but potentially fatal)
  • Risk factors
  • hysteroscopies, previous abd surg, needle/Trocar
    in vsl
  • Consequences-
  • GAS LOCK in vena cava ,RA ? ? VR ? collapse -
    Ac RV HTN ? opens foramen ovale ? paradoxical gas
  • Diagnosis
  • HR, ?BP, ? CVP, hypoxia, cyanosis, ET CO2
    biphasic change, ?a ETco2 ECG- Rt heart strain,
    TEE, pulm art. Aspiration of gas/ foamy bld from
    CVP line
  • Treatment
  • Release source (stop co2 release pneumoperit)
  • position steep head low durant position
  • stop N2O 100O2
  • Hyperventilation
  • CVP/PA catheter to aspirate CO2
  • Cardiac massage may break embolus- rapid
  • Hyperbaric o2 - cerebral embolism
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Endobronchial intubation
  • Due to cephalad movement of diaph with head
    down tilt and ? IAP
  • Diagnosis - Sp O2 ? airway P
  • Treatment Repositioning of ETT
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  • Mendelson syndrome
  • At IAPgt20 mmHg
  • Changes in LES due to IAP that maintain
    transsphincteric P gradient head down position
    protect against entry of gastric content in
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Nerve injuries
  • Prevented by
  • avoid overextension of arms
  • padding at P points
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Laparoscopy in children 
  • Physiological changes adults
  • Paco2 ETco2 increase but ETco2 overestimates
  • Co2 abs more rapid and intense due to larger
    peritoneal SA / body wt.
  • More chances of trauma to liver during trocar
  • More chances of bradycardia , maintain IAP to as
    low as possible
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Laparoscopy in pregnancy
  • Indications-
  • appendicectomy
  • cholecystectomy
  • Risk preterm labour, miscarriage, fetal
  • Timing II trimester (lt 23 wk)
  • Lap technique HASSANS tech
  • Special considerations
  • prophylactic- antithrombolytic measures
  • operating time to be minimised
  • IAP as low as possible
  • Continous fetal monitoring (TVS)
  • Lead shield to protect foetus if intraop
    cholangiography needed
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