腹腔鏡外科學(xué)英文版課件

LAPAROSCOPICSURGERY

JanePBradleyHendricks

RGN,BSE(hons),MCS,IndependentNursePrescriber

SurgicalCarePractitioner,LaparoscopicSurgery.

ColchesterGeneralHospitalSHORTHISTORY?1982SemmperformedfirstLaparoscopicAppendicectomy.?1987MouretperformedfirstLaparoscopicCholecystectomy.?1992FirstUKLaparoscopicTrainingcentreestablished.LAPAROSCOPICSURGERY

“KEYHOLESURGERY”

MINIMALLYINVASIVESURGERY

MINIMALACCESSSURGERYWhatoperationscanwedolaparoscopically?DiagnosisCrohn'sDisease

DiverticulitisRectalProlapseBenignrenaldiseaseGastricObstructionSomeSplenicdisordersOperationBowelresectionBowelresectionRepairofProlapseNephrectomyBypassSpleenectomy

WhatoperationscanwedoLaparoscopicallyDiagnosisGallstoneAppendicitisHerniaAdhesionsPerforatedulcerHiatusHerniaOperationCholecystectomyAppendicectomyHerniarepairDivisionofadhesionsClosureofperforationHiatusherniarepair.

WhatoperationscanwedoLaparoscopicallyDiagnosisColorectalcarcinomaCaecalcarcinomaColoniccarcinomaGastriccarcinomaOesophagealcarcinoma

Thelistisendless!!!OperationAnteriorresection/APRRightHemicolectomyLeft/SigmoidColectomyGastrectomyOesophagogastrectomyPrincipleDifferencesbetweenLaparoscopicandOpenSurgeryFORTHEPATIENT?Postoperativepainrelatedtosizeofincision-smallerincisions=lesspain.?LessHandlingofintestinesresultsinlittleornodisturbanceofnormalfunction.?Avoidanceofthetraumaofabdominalwallinjurybytheincisionallowsrapidreturntonormalactivity?Noincisionallowsearlyreturntomorestrenuousactivities:driving,lifting,sportetc.

PrincipleDifferencesbetweenlaparoscopicandopensurgeryFORTHEHOSPITAL?Initialcapitalcoststoestablishlaparoscopicsurgeryintheorderof￡30,000-￡40,000

?Reducedoverallcostsbyshorteningofhospitalstaye.g.cholecystectomyreducedfrom5to1day,hiatusherniarepairreducedfrom7to3days.PrincipleDifferencesbetweenlaparoscopicandopensurgeryFortheSurgeon?Magnifiedviewoftenbetterthanobtainedviaanincisionallowsprecisedissection.?Altered(butnotabsent)tactileresponse?Twodimensional(flatscreen)view.?Usually(butnotalways)longeroperatingtime?Needtodevelopentirelydifferentoperatingtechnique?Adaptationofprinciplesofopensurgerytolaparoscopicsurgery.

Instruments?Redesignofinstrumentsforlaparoscopicuse.?Instrumentsforopensurgeryingeneral6–

10”inlengthbuiltaroundaboxjoint.

?Laparoscopicinstrumentsingeneral15–

18”inlengthwithanarticulatedconnectingrodbetweenhandlesandscissorblades,jawsetc.

EquipmentNecessaryforMASCameraLightSourceInsufflatorTVMonitorTelescopesLightGuideCable

ApartfromtheinsufflatorthesystemwillworkbetterifallthecomponentsarefromthesamecompanyasonepiecetalkstoanotherCAMERA?Thesecanbesinglechipor3chip.?CHIP:thoisisalsocalledachargedcoupleddeviceinshort,CCD.?Theseareflatsiliconewaferswithamatrix,agridofminuteimagesensorscalledpixels.?Whitebalanceandsometimesblackbalance?Sleeveitdon'tsoakit!!!

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LightSource?HalogenorXenon,coldlightbutbewarecanstillburnholesindrapesesp.disposableandburnpatient'sskinifleftontheabdomen.

?Brightesttodarkestmeasuredinunitsofdecibels.?Automaticillumination,doesittalktothecameraandarethenecessaryleadspluggedin.?Lamplifemeter,lookatit.Isitnearlyout?EBMEkeepthesparesandtheychangeit.?Whitebalancebymakingsurewhiteiscorrectthenallthecoloursthroughthespectrumarecorrect.Insufflator?CO2becausethishasthesamerefractiveindexasair,sodoesn'tdistorttheimageandisnoncombustible.?Intraabdominalpressurerunbetween10and13mmhg.?Usedisposablefilterandtubingforeachpatient.?Highflowinsufflators(35litres)outputdeterminedbysizeofoutlet.?Ensureyouknowhowtochangeacylinderandweretheyarestored.TVMonitors?Usuallya20”screen.

?IfyourmonitorhasMDinthespec.theyarecompliantwiththlines.ehospitalelectricalsafetysystemsforexampleSon1343-MD.?YoucanuseastandardTVbutitmustberunthroughanisolatedtransformer.?Horizontalresolutionisthenumberofverticallines.?Verticalresolutionisthenumberofhorizontallines?Morelinesofresolution,betterdetailofpicture.Telescopes?Comeinvaryingsizes,laparoscopesusually5mmor10mm.?Diagnostic3mmscopeavailablebutnotingeneraluseinthishospital.?Madeupofarodandlenssystem.?Bundlesoffibres,incoherentcarrylightandcoherentcarryimage.?Widerangeofanglesavailable0and30degreearefairlystandard.?Alllaparoscopesareautoclavableandcangothrusteris,noultrasonicbath.LightguideCables?Differentdiameters?Fibrelightcable?Buyauroclavable?Don'tbendtoacutelyaswillbreakfibres.

?Checkwhenyouplugtheminareallthefibresareokay.?CondensersInstrumentation?SINGLEUSE:breakingtheLawifyoureuseitonanotherpatient.?Reusabletakeapart.?Needanultrasonicwashertoeffectivelycleanthem,notfortelescopes.?Don'tput5mmcannulatedinstrumentsintoabenchtopautoclavethatdoesnothaveavacuum:vacuumisrequiredtoremoveallairformlumenofinstrument.?Ports5and10mmarethemostcommon,makesuretherighttrocarisinportandisitsharp.ElectrosurgeryYoushouldbeawareofthefollowingpotentialsituations:?Insulationfailureoftheactiveelectrode.?Directcouplingofcurrenttootherinstrumentationbydirectcontact.?Capacitancewhichmaybecreatedbytwoelectricalconductorsseparatedbyaninsulator

Appropriatesafetystandardscanbemaintainedifsurgeonsadheretothefollowingguidelines?Usealowvoltagewaveform(cutinsteadofcoagulation)wheneverpossible.?Usethelowestpossiblepowersettingthatwilldeliverthedesiredtissueeffect.?Ensurethatinsulationonreusableanddisposableinstrumentationisintactanduncompromisedbeforeactivating.?Donotactivatetheelectrodeinairspace(opencircuitactivation).Activatethegeneratoronlywhentheactiveelectrodeisindirectcontactwithtargettissue.?Donotactivateelectrodewhenincontactwithotherinstruments.?Usebipolarelectrosurgerywereappropriate,goodforcoag.Butnotforcuttingtissue.

andmostimportantly………

?Donotusehybridtrocarsthatarecomprisedofmetalandplasticcomponents.Fortheoperativechanneluseallmetalorallplasticsystems.Electrosurgicalenergyshouldnotbepassedthroughhybridsystems.?Useavailabletechnologysuchasanactiveeletrodemonitor(AEM)tohelpeliminateconcernwithinsulationfailureandcapacitivecoupling.

ElectrosurgeryLaser?Insulationfailure?Directcoupling?Capacitivecoupling?Currentpasesthroughthebody-effectonpacemakers.?Returnelectrodeburns?Toxicsmoke?Charringofinstruments?Toxicsmoke?Expensive?Specialisedtheatresrequired.?VariablepenetrationWATERJET?Excessivemist?Poordepthcontrol

UltrascisionElectricalgenerator(thebox)Thisadjuststheamountofelectricalenergybeingdeliveredandmonitorsperformance.TransducerThisiswhereelectricalenergyisconvertedtotheultrasonicwaves.Thefrequencyisfixedhowevertheamplitudealterswiththepowerinput.thetransducerislocatedinthehandpieceandisconnectedtothegeneratorbyanelectricalcable.DissectionInstrument(peripheralhandpiece)Ametallicrodiscoupledtothetransducerandvibratesattheprescribedfrequency(i.e.55kHz).Thetipoftherodcontactswiththesurfacetissue.PrinciplesofPiezoElectronics?Theultrasoundwavesarecreatedbyelectricalenergyhittinganegativelychargedcrystalthatvibrates(expandsandcontracts)ataparticularfrequency.Thesecrystalsarediscshapedandmadeofferroelectricceramics.Apairofdiscs“coupled”togetherproduceasinusoidalwaveform.Thiscouplingresultsinaharmonicwaveformthatisofhighelectroacousticefficiency.LateralThermalDamage?Ultrasonicdissectorsaredesignedtooperateat60-80Celsiusandnotdestroycellsbyrapidlyheatingintracellularwatertostream.Theprocessofvaporisationoccursatveryhightemperatureswithcuttingmodeelectrosurgery.Theprocessofcoagulationbeginsatveryhightemperatureswithcuttingmodeelectrosurgery.Theprocessofcoagulationbeginsattemperaturesabove70Celsiuswhereproteinsaredenaturedandcollagenisconvertedtoglucose.Occasionallythetemperatureatthetipoftheultrasounddissectormayreachupto120Celsiushoweverthisiswellbelowthe200Celsiusrequiredtocarbonisetissuewithelectrosurgicalenergy(fulguration).Hopefullybydividingtissueatlowertemperaturestheamountoflateralthermaldamageisminimal.IsitSafe??ColorectalCancer-COSTtrialandCLASSIC.?Reoperationrate?Readmissionrate.?Mortality?Morbidity.EnhancedRecoveryprogramme?HenrikKeh