LAP SURGERY

1. Prof. Dr. Mohammad Abdul Quayyum MBBS, FCPS
Gynecological Endoscopic surgeon,
Professor , Parkview Medical College , sylhet
Chief Consultant, Feni Pvt. Hospital and laparoscopy institute .
Bangladesh
Born in 1959 and passed MBBS in 1983 from SOMC
and FCPS(Gyn) from Bangladesh College of Physicians
and Surgeon in January 1994 .
He started his career as a Consultant (Gynae)
at Noakhali General Hospital in July 1995 .
•Appointed as Asstt. Professor at Cumilla
medical college, Bangladesh in March 1999.
•Promoted as Assoc.Professor at Faridpur
medical college, Bangladesh in Feb 2005.
Professor(Gyne).Park veiw medical college , BangladeshFounder member of IMAGES .
Member of AAGL and ISGE .
Observer in the AAGL Observer ship program at Winthrop University Hospital .
St.Luke’s‐Roosevelt Hospital Center U.S.A under the supervision of
Dr. NezhatMAY-2012.
Attended and presented in morethan32 national andinternational laparoscopic conferences.

2. ACCSSES TECHNIQUE AND ITS COMPLICATIONS
IN
LAPAROSCOPY
Dr. Mohammad Abdul Quayyum , FCPS
Chief Consultant (Gynae)
Gynecological Endoscopic surgeon
Feni Pvt. Hospital & Laparoscopy Institute
Park View Medical college , Sylhet ,Bangladesh .
FENI PVT HOSPITAL & LAPAROSCOPY INSTITUTE

3. FENIPVT.HOSPITALANDLAPAROSCOPICINSTITUTE
* Hospital is equipped with the latest technology and
infrastructure, supported by an experienced team .
* Performing all minor and major gynecological laparoscopic or
minimally invasive surgeries.
* Facilities for laparoscopic workshop and training

4. INTRODUCTION
1. Laparoscopic surgeries are currently being
increasingly used for wider application.
2. More surgeons are adopting this form of
management
3. New techniques are being developed .
4. Initially used as a diagnostic procedure in female infertility
and for tubal sterilization, it now allows one to perform
almost any surgery previously performed by laparotomy.
5. Entering the abdomen is the most dangerous part .
6. The complication rate can be expected to rise

5. 6.It is necessary tohaveaknowledge of itsequipments, basic
procedures, limitations and indications & complications
7.The learning curveforlaparoscopic procedures islengthy
8.Riskofcomplicationsisgreatestearlyinthesurgeonsexperience.
9 .The risk is higher when a new instrumentation.
or technique is utilized.
INTRODUCTION

6. LAPAROSCOPIC COMPLICATIONS
• Most complications during laparoscopy
occur during the surgeon’s first 100 cases.
Soderstrom RM et al.
Operative Laparoscopy: The Master’s Technique.
1993

7. • What is the Incidence of Laparoscopic
Complications?
1. Minor procedures :- 1.1% to 5.2%
2. Major procedures 2.5% to 6%
(Kane & Krejs, 1984).
INTRODUCTION

8. To reduce the prevalence of complications:-
1. Supervision Training programmes at all levels of
development.
2. There must be a high degree of awareness of the
potential risks of complications during
laparoscopic surgery.
INTRODUCTION

9. 1. Prior surgeries
2. Intra-abdominal disease: (endometriosis, & PID)
3. Extensive bowel distention
4. Very large pelvic or abdominal masses
5. Extensive pelvic/abdominal adhesions
6. Cardiopulmonary disease
7. Diaphragmatic hernia
Risk Factors for Complications

10. 1. ACCSSES OR PORT INSTRUMENTS .
2 . HANDS OR OPERATIVE INSTRUMENTS –
2A – RESUBLE INSTRUMENST
2B- DISPOSABLE INSTRUMENTS.
3 OPTICAL INSTRUMENTS
4 LIGHT INSTRUMENTS
5 INSUFFALATION INTRUMENTS
6 ENERGY SOURSE INSTRUMENTS –
LAPAROSCOPIC INSTRUMENTS

11. ABDOMINAL ACCESS INSTRUMENTS
A. Closed Technique
Blind
Co2 - Insufflated Veress Needle Entry
Non- Co2 -insufflated Direct Trocar Entry
Visual
- Optical Trocar insertion ( Layer by layer)
B- Open access
- Hasson Technique

12. 1. VERESS NEEDLE
• 3 SIZE - 8 cm = PEAD< 5 YRS
10 – 12 cm = ADULT
20 cm = BARIATRIC PATIENTS
• PARTS - NEEDLE AND STYLET, WITH EYE AT TIP AND SPRING VALVE
• Use of instruments.-
• 1 Pneumoperitonum
• 2 Aspiration of cyst overian or gall bladder
• 3 Port closure
• 4 Trans fascial mesh fixtion
2 .TROCAR CANULLA :- A – REUSEBLE B - DISPOSABLE
ACCSSES /PORT INSTRUMENTS

13. 1. Undue Long Needle
2. Premature Trendelnburg
3. Improper insertion
4. Distention:- stomach, colon or bladder
5. Adhesion
Risk Factors of vesses neddle

14. VERESS NEEDLE &PNEUMOPERITONEUM
Sharp, with a good and tested spring action.
INSERTION
Insertion sites
Insertion technique
Safety tests
Disposable Reusable
ACCESS RELATED INJURIES

15. Usual circumstances the Veress needle is inserted:-
 In the umbilical area– Cosmatic area ,thinest part and
Central point location acceses of all quadantat
 In the mid-sagittal plane
Unusual circumstances /Alternative Entry: When?
Suspected or known umbilical adhesions
History or presence of umbilical hernia
After 3 failed insufflations attempts at the umbilicus
What are Alternative Entries?
Left upper quadrant (Palmer’s point) 3 cm below
the left subcostal border in the midclavicular line.
Transuterine or Trans cul-de-sac
What are the Entry Sites of Choice?
ACCESS RELATED INJURIES

16. LEFT UPPER QUADRANT (PALMER’S ENTRY)
Elevation Of The Anterior Abdominal Wall- Veress Needle Insertion
Indication :-
Suspected or known periumbilical adhesions
History or presence of umbilical hernia
After three failed insufflation attempts at the umbilicus
obese as well as the very thin patient.
Prerequisites: -
Emptying of the stomach by nasogastric suction
No previous spleen or gastric surgery
No significant hepatosplenomegaly
ACCESS RELATED INJURIES

17. The veress needle can be inserted at 45°- in non-obese toward anus
90°- in very obese toward anus obese
Lift the abdominal wall maximum.and lax abdomen by muscle rextant .
Doule skin thikness plus 4cm
should be pushed in just sufficiently to penetrate the fascia and the peritoneum.
Two audible clicks are usually heard as these layers are penetrated.
INSERTION TECHNIQUE
ACCESS RELATED INJURIES

18. ACCORDING TO THE BMI OF THE PATIENT
THE UMBILICUS IS CAUDALLY TO THE AORTIC BIFURCATION .
(due to low shift of umbilicus)
ACCESS RELATED INJURIES

19. SAFETY TESTS:-
For determining the correct intra-peritoneal placement
1) Double click sound
2) Aspiration test
3) Hanging Drop of Saline test
4) “Hiss” sound test
5) Syringe test
What is the Most Reliable Safety Test?
The Veress intraperitoneal (VIP) Pressure Test:- ≤ 10 mm Hg is a
reliable indicator of correct intraperitoneal placement of the
Veress needle. ( single digite pressure ).
ACCESS RELATED INJURIES

20. ACCESS TECHNIQUE AND PORT PLACEMENT
1 All port are at and below umbilicus
2 Port Position depen upon pathology,H/o of surgeries,natureofoperation
Suturing techniques, hight of surgeon and surgeon comportness
3 Umbilicus port (primary) 10 or 5 mm - for telescope
4 Lateral Port (secondary) 5 or 3mm - for working instruments
-Bet. two instruments tips make 60 degree
5Difficult or extraperitoneal pneumoperitoneum-thenthrough Palmar’spoint
wrong port position cause of stressful surgery

21. .
ACCESS TECHNIQUE AND PORT PLACEMENT
Contraindications Of Umbilical Entry
Previous midline incision
Portal hypertension with recanalised umbilical artery
Umbilical abnormalities viz. Urachal cyst, sinus, hernia

22. Access technique and Port Placement
Pneumoperitoneum In Special Conditions
Obese Patients-Transumbilical perpendicular to abdominal wall
.
Assistant’shandinobesepatientscanhelpinintroductionoftrocar
Patient With Prior Abdominal Procedure - Choose site distant to
abdominal scar

23. Trocar Insertion
The first trocar is inserted blindly,
usage of safety trocars is mandatory!

24. COMPLICATIONS OF VERESSNEEDLE&PNEUMOPERITONEUM
1- Extra-peritoneal gas insufflation ( Common).
2- Pneumo-omentum
3- Pneumothorax
4- Mediastinal emphysema
5- Gas embolism
6- Blood vessel injury
7- Injury to gastro-intestinal tract
8- Bladder injury
9- Puncture of liver or spleen
10- Complications from the distension medium
ACCESS RELATED INJURIES

25. Management:-
Gas may be allowed to escape
Re-introduce through the same or another site.
Alternative :Open laparoscopy
Extra-peritoneal Gas Insufflation < 2%
Recognition:-
Typical telescopic appearance
Crepitus under the skin
ACCESS RELATED INJURIES

26. .
Usually occurs from laceration of the mesenteric vessels .
Small: Omental or mesenteric vessels. Major: Abdominal or pelvic large vessls
Recognition:
Blood returns up the open needle
Free blood in the peritoneal cavity or Hematoma
•Risk Groups: Adhesion Obese, thin or children
• Prevention
•Inserting only as much of the needle as necessary
Lifting the abdominal wall and Angling the needle towards the pelvis
Management
The needle should be left in place.
Minimal bleeding: - Controlled by bipolar coagulation or a laparoscopic suture
Severe bleeding: Laparotomy and compress the aorta - ( Call vascular surgery team)
ACCESS RELATED INJURIES
(Blood Vessel Injury )

27. ACCESS RELATED INJURIES
(Gastro-intestinal Tract Injury )
Predisposition:-
 Upper abdominal site of insertion
 Distension: (induction of anesthesia: Nasogastric T)
Adhesions of bowel to the abdominal
Recognition:-
 Aspiration through the needle: GIT fluid
Belching, passing of flatus or a fecal odor
Management:-
If No tear:- Broad spectrum antibiotic and observation
Tear is seen:- Surgical repair

28. Usually it is simple puncture
Prevention:- Routine catheterization
Proper sitting of the needle
Recognition:- Pneumo-maturia
Management: - Conservative with postoperative
bladder catheter
ACCESS RELATED INJURIES
(Urinary Badder Injury )

29. ComplicationsfromtheDistensionMedium
Co2:-
• Gas embolism
• Cardiac arrhythmia
• Chest pain
↑Intra-abdominal pressure + Anesthesia  ↓ Venous
return ↑ liability to DVT

30. They can cause the
most serious injuries
INTRODUCTION OF TROCARS & CANNULAE

31. Trocar- cannula
* Size – 3 mm , 5 mm 7 mm 10 mm & 12 mm
* Trocar with flap valve is better than trumpet valve
* Pyramidal tip is better than conical tip
* Introduction of primary trocar after
Pneumoperitoneum (20-22mm) Pressure is better .
*Introduction of Secondary trocar always under vision.

32. PRIMARY TROCAR INJURIES
 Primary entry is blind
 The injuries are similar to those of the Veress' needle.
But the magnitude of the injury is much greater.
• Risk Factors
 Inadequate pneumoperitoneum
 Peri-umbilical adhesions
 Poor technique
 What is the Adequate Pneumoperitoneum ?
 Adequate pneumoperitoneum should be determined by a
pressure of 20 to 25 mm Hg .

33. IS THIS HIGH PRESSURE ENTRY SAFE?
Shift from 15 mm Hg  ↓ pulmonary compliance by
20%
Transient high-pressure 20- 25 mm Hg causes minor
hemodynamic alterations of no clinical significance

34. THE HIGH INTRAPERITONEAL (15—20mm)
LAPAROSCOPIC ENTRY
The abdominal pressure may be increased
immediately prior to insertion of the first
secondary trocar with the patient flat.
The transient high intraperitoneal laparoscopic
entry technique does not adversely affect
cardiopulmonary function in healthy women.

35. ADEQUATEPNEUMOPERITONEUMPRESSURE ?
The distension pressure should be reduced to 12–15
mmHg once the insertion of the trocars is complete.
This gives adequate distension for operative
laparoscopy and allows the anesthetist to ventilate
the patient safely and effectively.
Once the laparoscope has been introduced through
the primary cannula.
It should be rotated through 360 degrees to check
visually for any adherent bowel and for any
evidence of hemorrhage, damage or
retroperitoneal hematoma

36. HOW SHOULD THE PRIMARY TROCAR BE INSERTED ?
(INSUSPECTED PERIUMBILICALADHESIONS)
)
Primary trocar site should be visualized from a
secondary 5 mm port
Bowel may be adherent under the umbilicus

37. A 5m Entry
Palmer site- Advocatedforpreviouslaparotomy .
Minilaparoscopy
Open laparoscopy (Hasson)
Optical trocar (Visual Entry Systems)
RISKFACTORSINSUSPECTED PERIUMBILICAL ADHESIONS

38. OPEN LAPAROSCOPIC ENTRY
A skin small incision at the umbilicus then the fascia,
then entering the peritoneal cavity under direct Vision.
The cannula is inserted with obturator with sutures on
either side of the cannula.
The laparoscope is then introduced and insufflation is
commenced.
At the end of the procedure the fascial defect and the
skin are closed.
(Hasson Technique71)

39. RISK FACTORS
(Poor Techniques)
Use of long trocar
Premature Trendelnburg
Uncontrolled sudden entry
Excessive force:
Improper Angle of Entry
 Small umbilical incision
 Scar tissue
 Dull trocar

40. PREMATURE TRENDELNBURG
Premature Trendelnburg
High liability to vascular injuries

41. WHERE SHOULD THE PRIMARY
TROCAR BE INSERTED?
1.Theprimarytrocar shouldbeinsertedin acontrolledmannerat90degreestotheskin..
2.Insertionshouldbestoppedimmediatelythe trocarisinsidetheabdominalcavity.
3.Oneusefultechniqueistogentlytwistthetrocar whileexertingfirmdownward
pressure.
4.Excessive pressure to overcome skin or fascial resistance can lead to
uncontrolled trocar entry, increasing the risk of injury to bowel or othe
abdominal or retroperitoneal structures.

42. Management of
Primary Trocar
Injuries

43. PRIMARY TROCAR INJURIES
•Trocar is left in place
•Laparoscopic management
•Immediate laparotomy if indicated

44. Secondary Ports

45. HOW SHOULD SECONDARY PORTS BE
INSERTED?
Secondary ports must be inserted under direct vision
perpendicular to the skin, with maintaining the
pneumoperitoneum at 20 mmHg
During insertion of secondary ports, the inferior
epigastric vessels should be visualized laparoscopically
to ensure the entry point is away from the vessels.
Any secondary punctures should be made medial or
lateral to the lateral edge of the rectus muscle

46. SUPERFICIAL EPIGASTRIC ARTERY INJURY
S.Circumflex Iliac
S Epigastric A
It arises from the femoral artery and
runs medially over the rectus muscle.
Prevention: Identified By
transillumination of the abdominal wall
Injury: subcutaneous haematoma
Management:
suture around the 5mm cannula

47. The inferior epigastric artery can
be identified at the junction of
the round ligament and the
umbilical ligament (obliterated
umbilical artery) at the inguinal
canal.
INFERIOR EPIGASTRIC ARTERY INJURY

48. Injury:
Retroperitoneal haematoma
Management:
- Suture around 5mm cannula or coagulation
- Foleys catheter technique.
- Open surgery
INFERIOR
EPIGASTRIC
ARTERY INJURY

49. Foleys catheter technique.
Bipolar Coagulation.
INFERIOR EPIGASTRIC ARTERY INJURY

50. HOW SHOULD SECONDARY PORTS
BE INSERTED?
Once the tip of the trocar has pierced the
peritoneum it should be angled towards
the anterior pelvis under careful visual
control until the sharp tip has been
removed.
RCOG Guideline No. 49 May 2008

51. SECONDARY PORTS REMOVAL
Secondary ports must be
removed under direct vision to ensure
that any hemorrhage can be observed
and treated, if present.

52. REMOVAL OF THE PRIMARY TROCAR
Primary port must be removed under direct vision to
ensure that bowel is not intraped

53. SMALL INTESTINE INJURY
Recognition
Early: (During operation)
Observation of lacerated area
Observation of the intestinal contents
Introduction of laparoscopy inside the
intestinal lumen
Late:
• 3rd, 4th post operative day fever, vomiting,
distension

54. Most common site is transverse colon
Diagnosis: -
• Direct observation
• Delayed: abdominal pain, distension,
fever, passage of fecal material from
abdominal wound
Treatment:-
• Exploration and repair, or colostomy
LARGE INTESTINE INJURIES

55. Omental and Richter's herniation
• May occur in 10 mm incisions and if cannula is withdrawn with its valve
closed, it is possible to draw a piece of omentum into the umbilical wound
by the negative pressure so produced.
• This is usually recognized immediately and the omentum is easily replaced.
Herniation may occur some hours after the operation.
• It is usually easy to replace it under local anesthesia and resuture the
wound.
• Herniation does not occur commonly with 5 mm skin incisions.
• Incisions greater than 7 mm should be sutured in layers to prevent
formation of a Richter's hernia.

56.  Wound hematoma:-
Delayed bleeding from trocar sites with significant
drops in Hb and large ecchymoses conservative
 Port site metastasis:-
If a patient with malignancy is explored after laparoscopy,
excision of port sites is a consideration if feasible.
 Shoulder pain:-
Due to irritation of the diaphragm - positive pressure
pulmonary inflation 5 times, with port valves open at
Trendelenburg position OR intraperitoneal irrigation with 50
ml of 0.5% percent lidocaine
OTHERS COMPLICATIONS

57. LAPAROSCOPIC SKILLS
It requires 5 to 7 years to gain
adequate laparoscopic skills by
doing several procedures each
week, with gradually increasing
levels of complexity.

58. PATIENT SELECTION
Select appropriate patients for laparoscopy.
Cases that may pose greater risks than usual for laparoscopy
= Weight > 100 kg
= Previous bowel obstruction or peritonitis.
= > 2 previous subumbilical vertical incisions

59. Patient Counseling
Discuss with all patients, in simple
language and with documents, the risks
benefits and alternatives to
laparoscopy.

60. Operative Difficulties
• Consider conversion to laparotomy if difficulties are
encountered, or abandon the procedure if no harm
has been done and surgery is elective.
• Report technical difficulty in the operative record and
discuss complications postoperatively with the
patient.

61. Complications
Consult an appropriate colleague if a
complication occurs.
Could be another gynecologist,
General surgeon,
Vascular surgeon
Urologist.

62. CONCLUSIONS
- Appropriate patient selection,
- Early recognition of complications
- Full disclosure to patients
Minimize the physical, emotional, and
economic consequences of
laparoscopic complications.

63. Thank U For A Patience Hearing