Laparoscope - (Part 1)

KEYHOLE SURGERY:

Keyhole surgery or Bandaid surgery or Minimally invasive surgery or Laparoscopic surgery is a modern surgical technique used to access the interior of the body, where operations are performed through small incisions (0.5-1.5cm) as opposed to large incisions (open surgery).

IMAGE OF KEYHOLE SURGERY

• Keyhole surgery needs specialized skills and expertise, with the help of long fibre optic cable system known as a laparoscope.

• During keyhole surgery laparoscope (a thin rod, fitted with a telescopic lens, light source and a camera) is passed through a small incision in the skin, giving doctors a magnified view of the inside of the body.

• It is inserted to examine the abdomen and reproductive organ in order to examine the abnormality, health problems.

• Keyhole surgery helps to treat many health problems such as endometriosis, pelvic adhesions, fibroids, ovarian cysts and ectopic pregnancy.

• Based on the area keyhole surgery is named in different medical terms, for example; Keyhole surgery used to access the abdomen and the female pelvic organs in a procedure known as laparoscopy,  when keyhole surgery used to access the thorax, the medical name of the chest, the procedure is known as video-assisted thoracoscopic surgery, Keyhole surgery on a joint such as the knee is known as arthroscopy.

 LAPAROSCOPY:

Laparoscopy is a surgical diagnostic procedure used to examine the organs inside the abdomen mainly female reproductive organ, it is also known as keyhole surgery, minimally invasive surgery or minimal access surgery.

• Laparoscopic surgery is the process of surgical procedure in which a fibre-optic instrument known as a laparoscope is inserted through the abdominal wall to view the organs in the abdomen.

• A laparoscope is a long, thin tube with a high-intensity light and high-resolution camera at the front. 

• The laparoscope is inserted through a small incision in the abdominal wall, as it moves along the camera sends images to a video monitor.

• Laparoscopy allows your doctor to see inside your body in real-time without any open surgery.

HISTORY OF LAPAROSCOPE:

1. In 460-375 BC the first description dates to Hippocrates in Greece, for use of speculum to visualize the rectum.

2. In 1901, von ott, the first inspection of the abdominal cavity using a speculum and candlelight.

3. In 1902, George Kelling, of Dresden, Saxony, performed the first laparoscopic procedure on dogs.

IMAGE OF GEROGE KELLING LAPAROSCOPE

4. In 1910, Hans Christian Jacobaeus of Sweden reported the first laparoscopic operations on humans. (i.e) a first thoracoscopic diagnosis with a cystoscope in a human subject.

5. In 1911, Bertrambernhein invented 12mm proctoscope into an epigastric incision on one of Halstead's patients to stage pancreatic cancer. He named the procedure as ‘organoscopy’. Then later findings confirmed on laparotomy.

6. In 1920, Zollicoffer discovered the benefit of CO2 gas for insufflation.

7. In 1938, Janos Veres developed a spring-loaded needle for the induction of pneumoperitoneum.

IMAGE OF SPRING LOADED NEEDLE

8. In 1985, DR. Muhe performed the first successful laparoscopic cholecystectomy in a human. However, this was not well-publicized until years later.

IMAGE OF LAPAROSCOPE BY DR.MUHE

9. In 1991, ‘lap chole’ is accepted and routine procedure.

10. 1992, the national institute of health consensus conference concludes that laparoscopic cholecystectomy is now the preferred alternative to open cholecystectomy.

WHEN LAPAROSCOPY IS USED?

Laparoscopy is often used to examine and diagnose the source of pelvic or abdominal pain, it is usually needed when non-invasive methods are unable to help with diagnosis. Usually, non-invasive methods of abdominal problems can be diagnosed with imaging techniques such as ultrasound, MRI (magnetic resonance imaging technique) scan and CT (computed tomography) scan. Laparoscopy is used when this non-invasive test doesn’t provide enough information. Laparoscopes are now widely used to diagnose many different conditions and it may help to investigate some certain symptoms such as:

• Unexplained pelvic or abdominal pain.

• An ovarian cyst (it is a fluid-filled sac that develops on woman’s ovary)

• Female infertility

• Pelvic inflammatory disease (PID), it is the bacterial infection of the female upper genital tract, including the womb, fallopian tubes and ovaries.

• Ectopic pregnancy (a pregnancy that develops outside the womb).

• Endometriosis, the endometrium (where small pieces of the womb lining the womb) are found outside the womb.

• Fibroids, it is non-cancerous tumours that grow outside the womb.

• Appendicitis, it’s a painful swelling of the appendix.

• Undescended testicles, it’s a common childhood condition where a boy is born without one or both testicles in their scrotum.

• The laparoscope is also used to obtain a biopsy (tissue).

WHEN YOU NEED LAPAROSCOPY?

You will need laparoscopy if you have:

• Laparoscopic surgery is needed because it is a minimally invasive procedure and also small incisions are needed compared to the open surgery, in open surgery the long incisions are made to access the abdomen.

• Feel a lump in your abdomen

• The woman who needs a surgical form of birth control

• If you have severe acute or chronic pain in your abdomen or pelvis.

• If the women having heavy menstrual periods than normal.

• If the patient has abdominal cancer.

• Laparoscopy is used to check for the blockages that present in the fallopian tube and other conditions that can affect fertility. So the women who had trouble in getting pregnant need laparoscopy

IMAGE OF RIGID AND FLEXIBLE LAPAROSCOPE:

FLEXIBLE LAPAROSCOPE

RIGID LAPAROSCOPE

TYPES OF LAPAROSCOPIC SURGERY:

There are a number of operations that can be performed using laparoscopy they are:

• Laparoscopic cholecystectomy (removal of gall bladder)
• Laparoscopic hernia repair (removal of hernia)
• Laparoscopic splenectomy (removal of the spleen)
• Laparoscopic hepatectomy (removal of the part of the liver)
• Laparoscopic pancreatectomy ( removal of part of the pancreas)

LAPAROSCOPIC CHOLECYSTECTOMY: Cholecystectomy is the surgical removal of the gallbladder. Cholecystectomy is a common treatment of symptomatic gallstones and other gall bladders. 

IMAGE OF LAPAROSCOPIC CHOLECYSTECTOMY

LAPAROSCOPIC HERNIA REPAIR: In this surgery, the abdomen is inflated with a harmless gas. They make a small cut near the hernia. The laparoscope inserted into the abdomen to visualize the hernia defect on a monitor.

LAPAROSCOPIC SPLENECTOMY: Laparoscopic splenectomy is a standard procedure for elective removal of the spleen for most indications. With the help of laparoscope the spleen is removed. It takes 2 to 4 hours.

GYNECOLOGIC LAPAROSCOPY: Gynecologic laparoscopy is an alternative method to open surgery. It is used to view inside the pelvic area. It is used to treat a variety of female health problems. 

LAPAROSCOPIC HEPATECTOMY: Laparoscopic hepatectomy is the process of liver resection, it is performed using the laparoscope. It is used to remove the tumour in the surface of the liver.

LAPAROSCOPIC PANCREATECTOMY: Laparoscopic pancreatectomy is a procedure performed to remove benign or malignant tumours that present in the tail of the pancreas.

IS THERE ANY PREPARATION NEEDED FOR LAPAROSCOPY?

Depending on the type of laparoscopic procedure being performed, the preparation may get varied the most common preparations are:

• Before the procedure patients are asked not to eat or drink anything for 6 to 12 hours.

• The evening before the procedure your surgeon advised to bowel prep, this process usually includes a liquid diet.

• If the patients are taking any blood-thinning (anticoagulants)medication you have to tell to your doctor before the procedure, so that your doctor will tell you how they should be used before and after the procedure and also they may change the dosage level of the medications that could affect the outcome of laparoscopy. These drugs include:-

1. Non-steroidal anti-inflammatory drugs such as aspirin, ibuprofen etc.
2. warfarin 
3. any dietary supplements 
4. vitamin k

• Patient’ sare advised stopping smoking because it may delay your healing process after the surgery and leads to severe complications.

• If the patient were pregnant tell your doctor before the surgery this will reduce the risk of harm to your developing baby.

• Before the procedure, your doctor may ask to take some test such as blood test, electrocardiogram, chest X-ray, MRI, CT, and ultrasound. These test can help your doctor for better understanding about the abnormality of your abdomen before the procedure and also it increases the effectiveness of laparoscopy.

PROCEDURE DURING LAPAROSCOPY:

There are some common procedures are there during laparoscopy they are:

• Laparoscopy is an outpatient procedure which means it does not require days you can go to your home on the same day as your surgery.

• During this procedure, you will be given general anaesthesia, which means you will feel sleepy throughout the procedure and also you won’t feel any pain during the procedure.

• There are two ways of anaesthesia will be given one is a general anaesthesia an intravenous line (i.e) IV line is inserted in one of your veins. Through the IV your anesthesiologist can give you special medications as well as hydrating fluids, and another one is local anaesthesia in some situation this local anaesthesia is used instead of general anaesthesia, in local anaesthesia a local anaesthetic numbs the area, so even though the patient wake up they don’t feel any pain.

• During laparoscopy, a surgeon made a small incision or cut of about 0.5 to 1.5cm around 0.4 to 0.6 inches in your belly button which is known as a cannula.

• A tube is inserted into the cannula, and carbon dioxide gas(CO2 is used as insufflation gas because it is non-flammable, colourless and has higher blood solubility than air and thus reducing the risk of complications after venous embolism) is pumped through the tube to inflate your abdomen. By inflating the abdomen it allows the surgeon to view your organs more clearly and it gives a better understanding.

• A laparoscope is then inserted through the tube. The camera is attached to the laparoscope in which it relays images to the monitor in the operating theatre, it gives a surgeon for a better view of the whole area in a real-time.

• If the laparoscopy is used to carry out the surgical treatment, such as removing your appendix, further incisions will be made in your abdomen, generally, you may get one or four incisions that are each between 1 and 2 cm in length. These cannula or incisions allow the instruments to be inserted.

• With the help of this incision during a biopsy, they take a small sample of tissue from the organ to be analysed.

• The instruments and carbon dioxide are removed from the abdomen, once the procedure is over, the incisions made are then closed with stitches, clips or surgical tapes.

• You will be moved to the recovery room.

• The diagnostic procedure of laparoscopy usually needs 30-60 minutes and also It will take more time if the surgeon treating the condition.

RECOVERY AFTER LAPAROSCOPY:

After the laparoscopy the time needed to recover may get varied for everybody, the recovery time depends on the procedure whether it was therapeutic or diagnostic if your procedure is diagnostic then you have to take rest for 5 days, if your procedure is therapeutic then it depends on the treatment they undergone for example if you have appendix removal then you have to resume your normal activity for 3 weeks if you have undergone any major surgery such as removal of ovaries the recovery time may as long as 12 weeks. The doctor gives you clear information about when will you able to do your normal activities.

• After the procedure, the patient may feel drowsy and disoriented as you recover from the effects of the anaesthetic. Some patient may feel nausea, fatigue, moderate pain, throbbing in the areas where incisions made these are the normal problem that causes after anaesthetic and it will be recovered quickly. The timing needed may get varied based on the overall physical condition, your body reaction to the surgery, and the type of anaesthesia used.

• After the procedure, the patient will be monitored by the nurse for your vital signs such a heart rate, breathing and blood pressure.

• For a few days after procedure/surgery, the patient feels some discomfort in their surgical area where the incisions were made.

• The gas (co2) used for inflation may cause cramps, bloating, shoulder pain or back pain and also it causes some irritation in the diaphragm which shares nerves with our shoulder.

• Avoid tight-fitting clothes.

• Begin some light activity with the advice of your surgeon.

IMAGES TAKEN IN LAPAROSCOPY:

LAPAROSCOPIC SURGERY IN GALL BLADDER

IMAGE OF REPRODUCTIVE LAPAROSCOPY

IMAGE OF LAPAROSCOPIC HYSTERECTOMY

IMAGE OF LAPAROSCOPIC PANCREATECTOMY

IMAGE OF LAPAROSCOPIC SPLENECTOMY

COMPLICATIONS OF LAPAROSCOPY:

Sometimes local anaesthesia may cause some complications they are:

• Anxiety
• The vasovagal reaction may be associated with bradycardia and in more cases cardiac arrest, convulsion and shock. The treatment ma includes respiratory and cardiac resuscitation.
• Pain - it may be prevented to some extend by the administration of non- steroidal drugs.
• allergic reactions and anaphylaxis
• Injury to the gastrointestinal tract
• Bladder injury
• Blood vessel injury
• Gas embolism

Some complications may occur after the laparoscopic surgery the patient may have: 

• Heavy abdominal bleeding
• Heavy vaginal bleeding
• Severe or worse pain
• Nausea vomiting
• Heavy menstrual bleeding
• Signs of infection including fever, swelling, discharge at the site of incision, redness etc.
• Shortness of breath

INSTRUMENTS / TOOLS USED IN LAPAROSCOPY:

During laparoscopy, many instruments are used that fits through the cannula or small incisions in the abdomen instead of large incisions. These laparoscopic instruments/tools made of durable material generally the stainless steel. Usually, the laparoscopic instruments have very narrow shaft so that they can able to fit inside the laparoscopic ports. There are also many tips are available for different handling styles such as rotating, locking, grasping etc. These laparoscopic instruments are used along with the laparoscope. There are some common instruments used during laparoscopic surgery they are:

1. Laparoscope
2. Trocar and cannulas
3. Grasper and forceps
4. Hooks and probes
5. Needles and needle holders
6. Laparoscopic bipolar scissors
7. Needle driver

LAPAROSCOPE:

Laparoscopes are the surgical scopes used in laparoscopy, the size of the laparoscopy ranging from 2mm – 12mm. 10mm size is mostly used in gynaecology. Every laparoscope has an engraved number by the eyepiece that specifies the viewing angle.

TROCAR:

A trocar is a pen-like shape and has a sharp triangular point. Trocars are usually placed inside the hollow cannulas and introduced inside body cavities to assist the fluids. Trocars are referred to as initial entry device. trocars are used to create small passages through the abdominal wall and it is available in different textures disposable and reusable with varies sizes and the parts are:

• Sharp tips -trocars cut an entry path through the abdominal cavity.   
• Blunt tips -trocars stretch the tissue apart to gain access to the peritoneal cavity.
• Valve- in which different valve system prevents gas leaking from trocars and allow the insertion of instruments.
• Sleeve- trocar sleeves or collars can have textures on the outer surface that help it anchor to the abdominal wall.
• Side port- side port in the trocars allows for gas insufflation or smoke evacuation.

GRAPSERS AND SCISSORS:

Graspers and forceps are come along with trocars usually the have an insulated sheath, handle and a rotating capability at working end, the advantage of using laparoscopic graspers is that they enable the surgeon to grasp and manipulate abdomen tissue with precision without having to cut open the abdomen.

HOOKS AND PROBES:

Hooks and probes are used for lifting and retracting tissues. Usually, the flexible probe with a blunt end is used.

IMAGE OF HOOK

IMAGE OF PROBE

LAPAROSCOPIC BIPOLAR SCISSORS:

The handle is ergonomically designed to be comfortable for the surgeons and allow single finger, accurate control of the working end of the scissors which can be used for grasping, cutting, and coagulating tissue. 

LAPAROSCOPIC BIPOLAR SCISSORS

NEEDLE AND NEEDLE HOLDERS:

IMAGE OF VERESS NEEDLE

Veress needle is specially designed needle with a blunt-tipped, spring-loaded and sharp outer needle used to achieve pneumoperitoneum while performing closed laparoscopy. It is available in a disposable and reusable form.

IMAGE OF NEEDLE HOLDER

A needle holder or needle driver or needle forceps is used by laparoscopic surgeons to hold suturing needles when closing wounds. Needle holder has three parts jaws, joints and handles. A needle driver is classified as straight or curved depending upon the shape of the jaws.

COMPONENTS OF LAPAROSCOPE:

The components used in laparoscope are:-

1. VIDEO CAMERA
2. STAINLESS STEEL TUBE
3. TEFLON SLEEVE
4. SOFT IRON WIRE COMPRESSED OVER SPRING
5. HIGH STRENGTH INNER STEEL SPRING
6. NECK TUBE
7. HANDLE
8. ANALOGUE TO DIGITAL CONVERTER
9. USB MALE CONNECTOR

VIDEO CAMERA: Charge-coupled video camera is used in laparoscope, single-chip and three-chip CCD cameras are available. Single-chip produce 450 lines/inch resolution whereas three-chip have high fidelity thereby produce 750 lines/inch resolution.

ANALOGUE TO DIGITAL CONVERTER: It converts the analogue signal into digital signal performing image rotation or inversion or both.

USB MALE CONNECTOR: Camera is connected to the USB connector which is fitted outside of the scope.

DISADVANTAGE OF LAPAROSCOPIC SURGERY:

• The most important factor is that laparoscopy is extremely expensive, the instruments used in the laparoscopy are quite costly.

• Laparoscopic surgery is quite less accessible why because the affluent hospitals cannot able to afford the instruments.

• The video image created on the monitor is two dimensional (without depth)

• The 3-dimensional field of vision cannot be provided by laparoscopy so laparoscopic surgery may not be suitable for complicated surgeries.

• The surgeries where large chunks of tissues are to be removed, these minimally invasive surgeries are not required.

• Laparoscopy cannot always be performed on everyone. Some patients with many prior operations may have so scars tissue within the body that safe operation cannot be done. 

• The instruments restrict the sense of touch

• The body wall and laparoscopic ports act as fulcrum stopping free movement of the instrument

• The laparoscopy needed special skill set and every hospital is not equipped specialized person who knows how to operate the unit.

• Laparoscopic surgery may also need a second open surgery in case of any complication during the procedure, therefore they having a chance of risk of having two surgeries increases for patients who opt for laparoscopic surgery.

RISK OF LAPAROSCOPIC SURGERY:

• The risk of laparoscopy include
• Internal Bleeding and the potential need for a blood transfusion
• Nerve damage
• Hernia (a bulge caused by poor healing) at incision sites
• Infection
• Adverse reaction to anaesthesia
• Abdominal inflammation
• Acute kidney injury
• Cardio cerebral vascular insufficiency
• Abdominal blood vessel damage, stomach, bladder etc.,
• Blood clot

BENEFITS OF LAPAROSCOPY:

• The laparoscopic surgery has many benefits such as
• Smaller incisions
• The patient has small scars after surgery
• The patient may have less internal scarring
• Faster recovery
• Less risk of infection
• Less pain than an open procedure, the scars heal quickly
• In open surgery, the patient needs to take 4 to 8 weeks but if you have laparoscopic surgery it may take only 2 or 3 weeks to recover.

👉 Please Watch Our Laparoscope Videos (Part 1 & Part 2) from Our YouTube Channel Below:-

1. Part 1 Video:-

2. Part 2 Video:-

👉..... Click Here to Read Part 2 .....👈

Article Written By:-

👉 Surya@Kruthiga