Minimally Invasive Surgery for Rural Surgeons

3/9/2016

Courses: Minimally Invasive Surgery for Rural Surgeons Lesson 22 | mdCurrent India

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Minimally Invasive Surgery for Rural Surgeons – Lesson 22 Gasless Laparoscopic Surgeries Gasless laparoscopies are one of the best things that can happen for rural surgeons interested in minimally invasive surgeries. For many years, large incisions were required to perform abdominal surgical procedures. Although effective, multiple morbidities were associated with this method, including postoperative pain, wound infection, incisional hernia, and prolonged hospitalization. Laparoscopy, prevalent in gynecologic surgery for many years, was widely introduced to the general surgical domain with laparoscopic cholecystectomy more than 20 years ago. By making much smaller incisions that were protected by a port, there was a great reduction in incisionrelated complications [1]. There was faster postoperative recovery, pain reduction, less need for narcotics, respiratory function improvement, decrease in infection and hernias, and better overall cosmesis. [2] However, with the introduction of a new technique came a price [46]. They were more expensive and had steep learning curves. DISADVANTAGES FOR PATIENTS with GAS LAPAROSCOPIC SURGERY High pressure in the abdomen and decrease in body temperature Pain in the shoulder and neck that can last many days Acidity or organs and overload of carbonic acid

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RARE COMPLICATIONS WITH GAS LAPAROSCOPIC SURGERY Injury and emergency situations due to insertion of trocars or needle for Gas laparoscopic surgeries causing injuries and bleeding Air embolism that can very rarely lead to death Handling the laparoscopic surgical instruments is difficult and hence the steep learning curve.

DISADVANTAGES OF GAS LAPAROSCOPY TO SURGEONS http://mdcurrent.in/courses/misforruralsurgeonslesson22/

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With long instruments with 2 joints the surgeon loses tactile sense Operations with long instruments are difficult to learn and hence only 10% of surgeons are doing laparoscopic surgeries THE ADVANTAGES OF GASLESS LAPAROSCOPIC SURGERY Has all the advantages of laparoscopic surgery without the disadvantages Faster, more precise surgery Less expensive as regional anesthesia could be used Less expensive as the disposables used are less Less painful and more cosmetic as the incisions are placed much lower in the abdomen for pelvic surgeries For gasless laparoscopic surgeries AbdoLift designed by Daniel Kruschinski as described in his Atlas for LiftLaparoscopy [3] is used to lift the anterior abdominal wall. The advantages of gasless laparoscopic surgeries are well established [4]. One of the first surgical procedures that could be carried out by gasless laparoscopic procedures is appendicectomies. GASLESS SINGLE INCISION APPENDICECTOMIES METHOD The patient was placed in Trendelenburg position with the body tilted so that the right side is elevated after sufficient time has elapsed after spinal anesthesia. A small infra umbilical incision extending onto the umbilicus was made and the AbdoLift designed by Daniel Kruschinski as described in his Atlas for LiftLaparoscopy [5] was used to lift the anterior abdominal wall. The umbilical opening was made large enough to pass the 10 mm telescope and extended to pass another 10 mm port. However there was no need to use the ports and a combination of laparoscopic and long open instruments were used for carrying out the Appendicectomy [Figure 1]. The final cosmetic result was very good [Figure 2].

FIGURE 1: Lift laparoscopy and the use of instruments without the need for ports

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FIGURE 2: Very small incision near the Umbilicus

GASLESS SILS FOR LESS: SINGLE INCISION LAPAROSCOPIC SURGERIES MADE LESS EXPENSIVE, SAFE AND SIMPLE Singleincision surgery has been given a panoply of acronyms and names, including singleincision laparoscopic surgery (SILS), singleport access (SPA) surgery, laparoscopic endoscopic singlesite surgery (LESSS), single laparoscopic incision transabdominal (SLIT) surgery, oneport umbilical surgery (OPUS), natural orifice trans umbilical surgery (NOTUS), and embryonic natural orifice trans umbilical endoscopic surgery (ENOTES). SILS has been described since the late 1990s, beginning with appendectomy and cholecystectomy [6]. Studies have shown that smaller incisions, including smaller port size, decrease morbidity in both appendectomy and cholecystectomy patients. In comparing patients undergoing needlescopic versus conventional laparoscopic appendectomy, the needlescopic group had a shorter hospital stay (1.3 days vs. 3.2 days), reduced narcotic requirements, and faster return to work (8 days vs. 17 days) than controls[7]. Based on the results of these studies, it seems logical that eliminating multiple incisions/port sites would further decrease associated morbidity. However, no prospective, randomized study demonstrating clear advantage over standard laparoscopy has been reported [8].The improved cosmetic result also may lead to improved patient satisfaction with surgery. Pneumoperitoneum, as a necessary precondition of laparoscopic procedures, represents a restriction of the surgeon's freedom of movement and can lead to rare but typical complications [8].Gasless laparoscopic surgery has all the advantages of laparoscopic surgery without the disadvantages and helps in faster, more precise surgery. It is also less expensive as regional anesthesia could be used and less disposable materials are necessary [9]. We describe our experience with gasless single incision laparoscopic surgeries. METHOD After regional anesthesia the patients are placed in the position appropriate for the surgery to be carried out after sufficient time has elapsed. Extended Trendelenburg position is used for pelvis surgeries while the right side is elevated in addition for appendicectomies. A small infra umbilical incision extending onto the umbilicus is made and the AbdoLift designed by Daniel Kruschinski as described in his Atlas for LiftLaparoscopy [10] is used to lift the anterior abdominal wall. The infra–umbilical incision is made after holding up the umbilicus with towel clips. The http://mdcurrent.in/courses/misforruralsurgeonslesson22/

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cosmetic result with such an incision is better than the curved “smile” incision or the incision right through the umbilicus. It is easier to pass the instruments for carrying out surgeries followed by the telescope rather than pass the instruments by the side of the telescope while operating. Figure 4 shows that the cosmetic result of the incision is very good.

FIGURE 3: Good cosmetic result with the incision

The following gives the list of single incision gasless laparoscopic surgeries carried out at the SEESHA Karunya Rural Community Hospital and Surgical Camp at Bethesda Hospital at Aizawl from March 16, 2012 to November 30, 2012.


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SILLS = Single Incision Lift Laparoscopic DISCUSSION Gasless laparoscopic surgeries have a small but definite advantage over the regular laparoscopic surgeries. While looking at the cost alone it has a far greater advantage. This is because of the following 1. The initial investment is for very sturdy equipment which is once a life time investment. 2. In rural areas the difficulty of getting and transporting carbon dioxide is not there 3. The cost of disposables needed is also not there. Single incision surgeries again are more convenient with gasless procedures. A. The size of the incision necessary is much smaller as no special ports are necessary for preventing air leak B. The instruments could be passed first and the telescope later making it easier and faster for surgical procedures C. It is easy to clean the blood stains in the port unlike the long trocars where blood in the tip is difficult to clean D. The regular long instruments could be used for grasping and suturing etc., and they are easier to use and more familiar. E. The tissue retrieval is also much easier F. There is no violation of natural orifices G. Patient acceptance is good While considering the disadvantages the following are the possible one A. There is violation of principles of ergonomics. However it is better than with the regular gas laparoscopic surgeries B. Consequent to the above fact the learning curve is steeper but again compared with regular ones since regular instruments could be used is better. C. The chances of hernia are not assessed but since it is easier to close than the stab http://mdcurrent.in/courses/misforruralsurgeonslesson22/

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incisions should be less. REFERENCES 1. Vitale GC, Davis BR, Tran TC. The advancing art and science of endoscopy. Am J Surg. 2005;190. 2. Sauerland S, Lefering R, Neugebauer EA. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev. 2004;CD001546. 3. Jenny Choi, Luca Milone, Marc Bessier. Emerging technologies – Single incision laparoscopic surgery: How and Why. Bariatric Times April 2009 [accessed on April 13, 2012; http://bariatrictimes.com/2009/04/17/emergingtechnologies%E2%80%94single incisionlaparoscopicsurgeryhowandwhy/] 4. Kruschinski Daniel Atlas of LiftLaparoscopy: The New Concept of Gasless Laparoscopy Publisher: Informa Healthcare, 4/2007 5. Daniel Kruschinski. http://endogyn.com/endogyn/whatmakesthedifference/gaslesslift laparoscopy/ 6. Jenny Choi, Luca Milone, Marc Bessier. Emerging technologies – Single incision laparoscopic surgery: How and Why. Bariatric Times April 2009 [accessed on April 13, 2012; http://bariatrictimes.com/2009/04/17/emergingtechnologies%E2%80%94single incisionlaparoscopicsurgeryhowandwhy/] 7. Mostafa G, Matthews BD, Sing RF, et al. Minilaparoscopic versus laparoscopic approach to appendectomy, BMC Surg. 2001;1:4. 8. Paolucci V, GuttCN, Schaeff B, Encke A. Gasless laparoscopy in abdominal surgery. SurgEndosc. 1995 May;9(5):497500. 9. The History of Minimally invasive surgery. Prof. Wolfgang Wayand. http://www.touchbriefings.com/pdf/952/Wayand.pdf [accessed on April 10, 2012] « Back to course page

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