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 Set clipuri (10-20 buc.)

mecanic Ace de puncie
Endo GIA laparoscopic
Staplere ciculare: ILS,
EEA mpingtor noduri
Hemostatice avansate Endo-loops
Ligasure Endo-sleeve pentru
Ultrascision operaii hand-assised
Transductori ecografie Sonde Fogharty, Dormia
laparoscopic
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 trocar 12mm
3.5 mm albastru
4.8 mm verde 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 treated has raised

significantly

quick recovery

Good results in 80-90% of cases

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
Alte RCT, cu mai puini pacieni
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
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 minim-
invaziva

NOTES
Alte tendinte in chirurgia minim-
invaziva NOTES
NOTES
Alte tendinte in chirurgia minim-
invaziva

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