1. Laparoscopic Surgery
Jon Gabrielsen MD, FACS

2. Objectives Understand the history of laparoscopic surgery
Understand the physiologic benefits of laparoscopic surgery
Awareness of the negative consequences of pneumoperitoneum
Awareness of the effects of patient positioning as it relates to laparoscopy

3. History of Laparoscopic Surgery
Phillip Bozzini 1805-examines urethra of living patient using a simple tube and candelight
1843-first effective endoscope developed
1880-incandescent light bulb invented by Thomas Edison
1883-incandescent bulb adapted for use with cystoscope
1901-George Kelling examines the peritoneal cavity of a living dog using room air insufflation

5. History of Laparoscopic Surgery
1911-Hans Christian Jacobaeus of Sweden reports on results of laparoscopy and thoracoscopy in over 110 patients
1920-BH Ordnoff (United States) introduces pyramidal-tipped trocar
1924-Richard Zollikofer promotes use of CO2 as insufflation gas (rapid absorption)
1927-First textbook on laparoscopy published

6. History of Laparoscopic Surgery
1970’s-Palmer, Steptoe, Neuwirth, liston report a large series of laparoscopic tubal ligations
Late 1970’s-laparoscpic oophorectomies, salpinectomies, and adnexectomies performed
Where was general surgery when all this was happening?

7. History of Laparoscopic Surgery
Eric Muhe performs cholecystectomy using the “galloscope” in 1985

8. History of Laparoscopic Surgery
Why didn’t this stuff take off?
Scopes were monocular
Assistants could not see what the surgeon was seeing

9. History of Laparoscopic Surgery
1986-Miniature solid –state camera introduced (laparoscopic image now up on monitors)
1987-Philippe Mouret (France) performed the first laparoscopic cholecystectomy
1988-First laparoscopic cholecystectomy performed in the US
From this point on the use of laparoscopy in general surgery rapidly expanded

10. Why is this such a big deal?

11. Major Milestones in Surgery
William Thomas Green Morton-1846
Birth of modern anesthesia
Joseph Lister-1860’s
Developer of Antiseptic Surgery

12. 120 Years of Nothing

13. A Quantum Leap SAGES Meeting 1988 Within 10 years
77% of elective cholecystectomies done laparoscopically
68% of urgent cholecystectomies
JACS 2008 Jan(1):28-32

14. Positive Effects of Laparoscopic Surgery
Pulmonary function maintained better (FEV1 and FVC)
Less acute phase stress response
Inflammatory response is dampened
Less immunosuppression
Decreased intra-abdominal adhesions
Quicker GI tract recovery
Decrease in wound complications

15. Negative Consequences of CO2 Pneumoperitoneum
Cardiovascular
Tachycardia
Decreased preload
Increased afterload (mechanical, vasocontriction)
Dysrhythmias
Hypercarbia (PVC, VT, VF)
Acidosis
Sympathetic stimulation from decreased venous return
Vagal stimulation

16. Summary-Cardiovascular Changes

17. Negative Consequences of CO2 Pneumoperitoneum
Pulmonary
Decreased Lung Volumes (FRC, TV, VC)
Decreased compliance
Increased peak inspiratory pressure
Atelectasis from diaphragm displacement
Impaired oxygenation and ventilation

18. Summary-Pulmonary Changes

19. Negative Consequences of CO2 Pneumoperitoneum
Renal-decreased renal blood flow, GFR, and urine output
Hepatic-decreased portal venous blood flow

20. Impact of Patient Positioning
Reverse Trendelenburg
Pooling of blood in lower extremities (DVT risk)
Decreased venous return, decreased preload
Improved pulmonary function, decreased pressure on diaphragm

21. Impact of Patient Positioning
Trendelenburg
Increased preload due to increased venous return
Detrimental pulmonary function changes associated with CO2 pneumoperitoneum are accentuated

22. Contraindications to Laparoscopic Surgery
Relative Anatomic Contraindications
Reoperative abdomen
Intraperitoneal mesh
Cirrhosis and portal hypertension
Mechanical bowel obstruction
Gravid Uterus
Locally invasive cancers

23. Contraindications to Laparoscopic Surgery
Physiologic Limitations
Pulmonary: CO2 retention/hypoventilation
Cardiac: patients in hemorrhagic shock
Neurologic: Acute brain injury (trendelenburg position increased ICP)
Coagulopathy: rarely a contraindication with improved surgical technique and recombinant anticoagulation factors. UNCORRECTED coagulopathy is considered a contraindication to laparoscopic surgery

24. Laparoscopy in Pregnancy-Concerns
Decreased Cardiac Output (IVC pressure)
Fetus depends upon maternal hemodynamic stability
Primary cause of fetal demise is maternal hypotension and hypoxia
Decreased uterine blood flow/increased intra-uterine pressure (Pneumoperitoneum)
Both could lead to fetal hypoxia
CO2 absorption leading to respiratory acidosis

25. Laparoscopic Surgery and Pregnancy
Laparoscopic surgery can be performed safely in the pregnant patient
Second trimester is best
Open access techniques safest
Use lowest pressure possible (12 mm Hg or less)
Greater pressures lead to fetal acidosis
Semi-left decubitus position to relieve pressure on IVC
Anti-embolic devices (higher DVT risk with pregnancy)
Remember increased risk of aspiration in pregnancy
Delayed gastric emptying
Decreased lower esophageal sphincter tone
Monitor maternal end tidal CO2
Continuous intra-operative fetal monitoring if the fetus is viable

26. New Frontiers in Minimally Invasive Surgery
SILS/SPA
Often no visible scar, cosmetically superior
Technically more difficult, longer OR times
+/- less pain
+/- more hernias?
NOTES
POEM (Per oral esophageal myotomy)
Endoscopic therapies for GERD

27. Energy Devices
Cautery (generator, application electrode, return electrode)
Bipolar vs. Monopolar
Cutting (continuous waveform) vs. Coag (intermittent waveform)
Temperature degrees Celsius
Significant lateral thermal spread causing tissue dehydration/vessel thrombosis
Doesn’t work underwater (in blood)

28. Energy Devices Harmonic Scalpel Ultrasonic level vibrations (55K/sec)
Denatures protein via vibratory heat rather than electrical current
Smaller lateral thermal spread
Less Heat ( degrees Celsius)
How it works depends on power, pressure of blades, tissue tension

29. Energy Devices Ligasure (tissue response generator)
Bipolar technology at heart but lower voltage/higher current
Changes the nature of vessel walls (collagen and elastin within the tissue melt then reform creating seal)
Vessels up to 7 mm
Very little lateral thermal spread
Not as versatile for dissection

30. Questions?