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LAPAROSCOPIC SURGERY AGUS SUPRIADI INTRODUCTION SYNONYM • KEY HOLE SURGERY • BUTTON HOLE SURGERY • MINIMALLY INVASIVE SURGERY • MINIMAL ACES SURGERY HISTORY • 1983 : First laparoscopic appendicectomy by Kurt Semm , German gynecologist • 1985 : First laparoscopic cholecystectomy by Erich Muhe, German surgeon • 1987 : first laparoscopic repair of inguinal hernia by Ger • 1991 : Ibrahim Ahmadsyah,first laparoscopic in Jakarta FREQUENTLY DONE PROCEDURE ABDOMEN: • Cholecystectomy incld Exploring CBD • Appendicectomy • Hernia Repair • Adhesiolysis • Diagnostic • Bariatric/Sleeve Gastrectomy • Colorectal tumour • Fundoplication • Achalasia CHOLECYSTECTOMY Indications: • Cholelithiasis • Mucocele gallbladder • Empyema gallbladder • Thypoid carrier • Porcelain gallbladder • Acute cholecystitis CHOLECYSTECTOMY Contraindications: • Hemodynamic instability • Uncorrected coagulopathy • Generalized Peritonitis • Severe cardiopulmonary disease • Abdominal wall infection • Multiple previous upper abdominal procedures • Late pregnancy CHOLECYSTECTOMY Advantage : • Cosmetically better outcome • Less tissue disection • Less pain postoperatively • Low intraoperative and postoperative complications • Early return to work APPENDICECTOMY Indications for laparoscopic : • Female of reproductive age group • Female of premenopausal group • Suspected appendicitis • High working class • Previous lower abdominal surgery • Obese patients • Disease conditions like cirrhosis • Immune compromised patients APPENDICECTOMY Indications for Open Surgery • Complicated appendicitis • COPD or Cardiac disease • Generalized peritonitis • Stump appendicitis after previous incomplete appendicectomy RISK FACTOR IN LAPAROSCOPIC APPENDICECTOMY • • • • • • • • Missed Diagnosis Bleeding Visceral Injury Wound Infection Incomplete Appendicectomy Leakage of Purulent Exudates Intra Abdominal Abscess Hernia INGUINAL HERNIA REPAIR Indications : • Bilateral Inguinal Hernias • Recurrent Inguinal Hernias Contraindications : • Non reducible,incarcerated inguinal hernia • Prior laparoscopic hernioraphy • Massive scrotal hernia • Prior pelvic lymph node disection • Prior groin irradiation INGUINAL HERNIA REPAIR Advantages of laparoscopic repair: • Tension free repair that reinforces myopectoneal orrifice • Less tissue disection • Less pain postoperatively • Low intraoperatively and postoperatively complication • Early return to work Types of Laparoscopic Hernia Repair 1. 2. 3. 4. Simple closure of the internal rings Plug and patch repair Intraperitoneal onlay mesh repair Transabdominal pre peritoneal mesh repair (TAPP) 5. Total Extra peritoneal repair (TEP) COMPLICATIONS OF LAPAROSCOPIC HERNIA REPAIR • • • • • • Recurrence Neurovascular injury Urinary tract injury Iinjury to vas Testicular complications Problem due to mesh LAPAROSCOPIC ADHESIOLYSIS Peritoneal adhesion is a common cause of bowel obstruction,pelvic and infertility Normal fibrinolytic activity prevents fibrinous attachments for 72 to 96 hours after surgery and mesothelial repair occurs within 5 days of trauma The most important factors which suppress fibrinolytic activity and promote adhesion formation are : • Port wound just above the target of dissection • Tissue ischemia • Drying of serosal surfaces • Excessive suturing omental patches • Traction of peritoneum • Blood clots, stones or dead tissue retained inside • • • • • Prolonged operation Visceral injury Infection Delayed postoperative mobilization of patient Postoperative pain due to inadequate analgesia DIAGNOSTIC LAPAROSCOPY 1.Non traumatic,Non gynecologycal,Acute Abdomen like : • Appendicitis • Diverticulitis • Mesenteric Adenitis • Intestinal Adhesion • Omental Necrosis • Intestinal Infarction • Complicated Meckel’s diverticulum • Torsion of intra abdominal testis 2.Gynecological Abdominal Emergencies like : • Ovarian cyst • PID • Acute salpingitis • Ectopic pregnancy • Endometriosis • Perforated uterus due to criminal abortion CONTRAINDICATIONS • • • • • • • Hemodynamic instability Mechanical or paralytic ileus Uncorrected coagulopathy Generalized peritonitis Severe cardiopulmonary disease Abdominal wall infection Multiple previous abdominal procedures LAPAROSCOPIC FUNDOPLICATION Gastroesophageal reflux disease (GERD) is defined as the failure of the anti reflux barrier, allowing abnormal reflux of gastric content into the esophagus. Symptoms : • Heartburn (retosternal burning ) 5-45% of adult in western countries • Regurgitation • Pain • Respiratory symptoms Diagnostic Test : • Endoscopy • Barium swallow • Esophageal manometry • pH monitoring TREATMENT OF GERD 1. Medical Therapy Esophagitis will heal approx 90% with intensive medical theraphy Symptoms recur more than 80% within one year of drug withdrawal Chronic condition , medical theraphy involving acid suppresion and pro motility agents may be required for the rest of patient’s life 2.Surgical Therapy Should be considered in individuals : • Refractory to medical management • Associated with hiatus hernia • Intolerance to PPH or H2 receptors • Not compliant to medical therapy • Have complications of GERD , e.g Barrett’s esophagus,stricture, grade 3 or 4 esophagitis • Atypical symptoms like : asthma,hoarseness,cough,chest pain and aspiration METHODS OF FUNDOPLICATION • The classical open methods • The modern Laparoscopic techniques Types of Laparoscopic Fundoplication 1. Nissen Fundoplication 2. Toupet Fundoplication 3. Dor Fundoplication THANK YOU
