Principiile chirurgiei laparoscopice

Dr. Vasile Bintintan Cl. Chirurgie 1 Cluj Napoca vbintintan@gmail.com

Chirurgia laparoscopic

acces minim-invaziv mrire cmp operator disecie precis pierdere sangvin minim necesar redus analgetice recuperare postoperatorie rapid evit riscul eventraiilor

Principiul chirurgiei laparoscopice

Cavitatea virtual meninut deschis Introducerea n cavitatea abdominal a unei surse de lumin i o camer de luat vederi Manopere chirurgicale efectuate prin intermediul penselor

Materiale necesare

Turn laparoscopic

insuflator CO2
sursa de lumin cablu fibre optice

laparoscop
monitor electrocauter

videorecorder

Turnul laparoscopic

Materiale necesare Trocare

5 mm 10 mm 12 mm 15 mm

Materiale necesare Instrumente de lucru

Electrocauter

Monopolar / bipolar

Portac, foarfec Pens disectoare Pens prehensoare

autostatic / ne-autosatic, pens Babcock

Pens de extragere crocodil Pens aspirare/lavaj Aplicator clipuri Deprttoare

Structur fix / mobil

Materiale necesare Instrumente de lucru

Instrumentar laparoscopic

Instrumentar laparoscopic

Firele de sutur

Fire cu ac montat

monofilament: PDS, polipropilen

aluneca uor sutura continu risc redus infecie necesit multe noduri au memorie plastic

multifilament: vicryl, poliester

rmn nnodate nu au memorie plastic mai susceptibile la infecie alunec greu trauma tisular

Materiale accesorii

Pense de sutur mecanic

Endo GIA Staplere ciculare: ILS, EEA Ligasure Ultrascision

Hemostatice avansate

Transductori ecografie laparoscopic

Set clipuri (10-20 buc.) Ace de puncie laparoscopic mpingtor noduri Endo-loops Endo-sleeve pentru operaii hand-assised Sonde Fogharty, Dormia Endo-catch, saci de extracie

Materiale accesorii

Protezele chirurgicale

Montate intraperitoneal

Parietex Composite

poliester nglobare solid n esut Film exterior de colagen reduce aderenele la viscerele abdominale

Fixare proteze

ProTack 5 mm

30 clipuri titan helicoidale

Glue Instrumentar resterilizabil

Staplere n chirurgia laparoscopic

Staplere n chirurgia laparoscopic

Staplere liniare endo GIA

Staplere n chirurgia laparoscopic

Staplere liniare endo GIA

Clipuri de dimensiuni variabile

2 mm - gri 2.5 mm alb 3.5 mm albastru 4.8 mm verde

trocar 12mm trocar 15 mm

Lungimi varite, articulate/drepte

30 mm 45 mm 60 mm

Aplicabilitate clinic
Standard-ul

de aur

Chirurgia colecistului Chirurgia bolii de reflux esofagian Chirurgia ulcerului duodenal perforat Chirurgia bariatric Splenectomia pt ITP (Idiopatic Trhrombocitopenic Purpura) Stadializare tumoral invaziv

Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy

Golden standard for chronic and acute cholecystitis faster recovery, shorter hospital stay, better postoperatice

quality of life and cosmesis

2 RCT lap surgery was superior to open

Acute cholecystitis: early vs delayed surgery

recent RCT suggested early is better a recent meta-analysis of RCT (Lau) reported reduced conversion-

to-open rates (16% vs. 23%), blood loss, cost and length of hospital
stay in the early group

Conclusion
patients with acute cholecystitis should be offered a laparoscopic cholecystectomy within 72 hours of the initial diagnosis

EAES Guideliness
1.

Patients with acute cholecystitis should undergo laparoscopic cholecystectomy as early as possible after admission (GoR A)

2.

In patients unsuitable for early surgery, conservative treatment

or percutaneous cholecystostomy should be considered (GoR A)

Neugebauer et al. EAES Guideliness for Endoscopic Surgery 2006

Operative technique

Placement

supine

American position French position

pneumoperitoneum 12-15 mmHg

Verres needle open - trocar Hasson

Operative technique

Placement of trocars

Operative technique

Operative technique

Operative technique

Operative technique

video

Laparoscopic Nissen fundoplication

The golden standard in surgical treatment of GERD

good postoperative results

no. of patients

few complications quick recovery

Good results in 80-90% of cases

treated has raised significantly

RCT open vs laparoscopic Nissen

A 10-years outcome study

open approach associated with second surgery mainly to correct incsional hernia

otherwise similar concerning GERD symptoms, PPI use, quality of life, and objective reflux control
. Ten-year outcome of laparoscopic and conventional Nissen fundoplication: randomized clinical trial. Broeders JA, Ann Surg. 2009 Nov;250(5):698-706

Operative technique

placement

French position anti-Trendelenburg

pneumoperitoneum 12-15 mmHg

Verres needle open - trocar Hasson

Operative technique
Placement of trocars

Operative technique

Operative technique

Operative technique

Dissection of the greater curvature and left pillar of the diaphragm

Disection completed

Calibration of esophageal hiatus

Operative technique

Gastric wrap

50F 60F bougie 2 cm length 2.0 non-resorbable

Creation of the posterior wrap

Partial fundoplication - variants

Posterior - Toupet

Partial fundoplication - variants

Anterior - DOR

Aplicabilitate clinic
Rezulatate

comparabile statistic cu chirurgia deschis insa fara a fi dovedit ca abordul laparoscopic produce rezultate superioare

Chirurgia apendicelui Chirurgia herniei inghinale Chirurgia colorectal

Laparoscopic Appendectomy

although it is feasible and used often, there are still authors who

question its benefits

Negative appendectomies are still common

potential

role for laparoscopy: diagnostic and therapeutic tool

Laparoscopic vs open appendectomy

over 50 RCT in the literature, and numerous systematic reviews have been undertaken

the most recent systematic review examined 54 randomized studies with a total population of 5000 patients

reduction with 1 day of postop stay

50% reduction of would infection

Laparoscopic vs open appendectomy

female patients of fertile age

laparoscopy - significant reductions in the numbers of negative appendectomies and rate of un-established diagnoses

reduces risk of wound infection

helps planning incisions if other pathology is discovered (that can not be treated laparoscopically)

Cochrane review
Laparoscopic appendectomy offers certain
advantages, although the difference from

open appendectomy is not large

Sauerland, Neugebauer et al. 2004

EAES Guideliness
1.

patients with symptoms and signs of acute appendicitis should

undergo a diagnostic laparoscopy and appendectomy

2.

when a separate pathology is found - a normal appendix should be left in-situ

Neugebauer et al. EAES Guideliness for Endoscopic Surgery 2006

Operative technique

placement

supine position Trendelenburg

pneumoperitoneum 12-15 mmHg

Verres needle open Hasson trocar

Operative technique

Placement of trocars

Operative technique

Operative technique

Double stapling technique

Operative technique

video

Chirurgia colorectala laparoscopica

Chirurgia colorectala laparoscopica

Fezabil?

DA

1991 Jacobs, Cooperman, Fowler (USA) - prima hemicolectomie laparoscopica

Sigura oncologic?

Dubii anii 1990

Metastaze orificii trocar Rolul negativ al pneumoperitoneului Durata mare a intervetiei chirurgicale

Chirurgia colorectala laparoscopica

Sigura oncologic?

Demonstrata anii 2000

Trei trialuri clinice randomizate

COLOR EUROPA CLASSIC UK COST - USA

Pentru cancer abordul laparoscopic este o altenativa sigura la chirurgia colorectala clasica - 2004 American Society of Colon and Rectal Surgeons - UK Guideliness National Institute for Health and Clinical Excellence

Chirurgia colorectala laparoscopica

Indicaii

Polipoza familial de elecie Rectocolita ulcerohemoragic, B. Crohn colica Diverticuloza, diverticulita dupa puseu acut Cancer colorectal

Prevenia metastazelor pe orificiile de trocar

Exuflare lenta a gazului Protectoare de plaga Tehnica no touch

Chirurgia colorectala laparoscopica

Contraindicaii

Comorbiditti cardiopulmonare semnificative

Reactii adverse ale CO2, timp operator crescut

Obezitate CI relativa Tumori T4 (relativa) Localizarea tumorii (relativa)

Tumorile localizate pe transvers sunt dificil de disecat radical (+ limfadenectomie)

Chirurgia colorectala laparoscopica

Tehnica chirurgicala
Hemicolectomia dreapt Hemicolectomie stng

Hemicolectomi a dreapt
poziia echipei operatorii

Hemicolectomia dreapt
planurile de disecie medial lateral lateral - medial

Hemicolectomia stng
poziia echipei operatorii

Hemicolectomia stng
- planul de disecie - disecia AMI, VMI

Hemicolectomia stng
disecia rectului posterior i anterior

Hemicolectomia stng
secionarea rectului extragerea bontului colic proximal

Hemicolectomia stng
inseria nicovalei efectuarea anastomozei

Hemicolectomia stng
verificarea etanseittii anastomozei

Chirurgia colorectala laparoscopica

Evoluie postoperatorie

Durata de spitalizare mai scurt Durere postop de intensitate mai redusa Necesar mai redus de antialgice Reluarea motilitii gastrointestinale e mai rapid Funcia pulmonara este mai puin afectat de intervenia chirurgical

ESES Guideliness for Endoscopic Surgery Laparoscopic colorectal surgery

Chirurgia colorectala laparoscopica

Supravieuirea pe termen lung

RCT study

219 pacieni, 111 laparoscopic, 108 open Supravieuire 3 ani: 91% lap vs 79% open n special pt std .III
Nu sunt diferente semnificative lap vs open

Alte RCT, cu mai puini pacieni

Concluzie: supravietuirea pe termen lung e cel puin egal cu grupul open. ESES Guideliness for Endoscopic Surgery Laparoscopic colorectal surgery

Chirurgia colorectala laparoscopica

Laparoscopic

Timp operator

Acuratele excelent a diseciei

Aceleai limitele de exerez

Evoluie postoperatorie mai rapid, mai uoar

Recuperare rapid Iniiere rapid a tratamentului adjuvant Supravieuire pe termen lung cel puin comparabil

Aplicabilitate clinic
Chirurgie

laparoscopica avansata aflata inca intr-un stadiu incipient, abordul recomandat ramane in continuare cel clasic

Rezeciile esofagiene minim-invazive Rezeciile pancreatice caudale, duodenopancretectomia Gastrectomiile subtotale, totale Rezeciile hepatice

Chirurgia robotic

Robotul operator da Vinci

SiSTEMUL Chirurgical Robotic da Vinci

Partea efectoare

Consola de comand

Robotul operator da Vinci

Robotul operator da Vinci

Alte tendinte in chirurgia miniminvaziva

NOTES

Alte tendinte in chirurgia miniminvaziva NOTES

NOTES

Alte tendinte in chirurgia miniminvaziva

SILS, LESS

SILS, LESS

Chirurgia laparoscopic

un domeniu incitant, in continua schimbare

intens dependent de tehnologie

scopul final este ameliorarea calitii vieii n condiiil pstrrii extensiei rezeciei

viitorul e surprinzator si sun bine