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Chirurgia laparoscopic
acces minim-invaziv mrire cmp operator disecie precis pierdere sangvin minim necesar redus analgetice recuperare postoperatorie rapid evit riscul eventraiilor
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
Electrocauter
Monopolar / bipolar
Instrumentar laparoscopic
Instrumentar laparoscopic
Firele de sutur
Fire cu ac montat
rmn nnodate nu au memorie plastic mai susceptibile la infecie alunec greu trauma tisular
Materiale accesorii
Hemostatice avansate
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 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
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.
Operative technique
Placement
supine
Operative technique
Placement of trocars
Operative technique
Operative technique
Operative technique
Operative technique
video
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
Operative technique
Placement of trocars
Operative technique
Operative technique
Operative technique
Disection completed
Operative technique
Gastric wrap
Anterior - DOR
Aplicabilitate clinic
Rezulatate
comparabile statistic cu chirurgia deschis insa fara a fi dovedit ca abordul laparoscopic produce rezultate superioare
Laparoscopic Appendectomy
although it is feasible and used often, there are still authors who
potential
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
laparoscopy - significant reductions in the numbers of negative appendectomies and rate of un-established diagnoses
Cochrane review
Laparoscopic appendectomy offers certain
advantages, although the difference from
EAES Guideliness
1.
2.
Operative technique
placement
Operative technique
Placement of trocars
Operative technique
Operative technique
Operative technique
video
Fezabil?
DA
Sigura oncologic?
Metastaze orificii trocar Rolul negativ al pneumoperitoneului Durata mare a intervetiei chirurgicale
Sigura oncologic?
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
Indicaii
Polipoza familial de elecie Rectocolita ulcerohemoragic, B. Crohn colica Diverticuloza, diverticulita dupa puseu acut Cancer colorectal
Contraindicaii
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
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
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
Concluzie: supravietuirea pe termen lung e cel puin egal cu grupul open. ESES Guideliness for Endoscopic Surgery Laparoscopic colorectal surgery
Laparoscopic
Timp operator
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
Partea efectoare
Consola de comand
NOTES
SILS, LESS
SILS, LESS
Chirurgia laparoscopic