¼±Åà - È­»ìǥŰ/¿£ÅÍŰ ´Ý±â - ESC

 

Laparoscopic Surgery

Diagnostic and operative laparoscopy

LaparoscopyÀÇ ÀûÀÀÁõ
1. diagnostic ? acute or chronic pelvic pain, ectopic pregnancy, PID, ES,
torsion, other intraperitoneal pathology.
2. operative

laparoscopyÀÇ ±Ý±âÁõ
1. ±Ý±âÁõ : bowel obstruction, ileus, peritonitis, intraperitoneal hemorrhage, diaphragmatic hernia, severe cardiorespiratiory disease.
2. »ó´ëÀûÀÎ ±Ý±âÁõ(relative contraindication) : extremes of body weight, inflammatory bowel disease, presence of a large abd mass, advanced intrauterine pregnancy,
3. ¼ö¼úÀÇ °ú°Å·ÂÀº ±Ý±âÁõÀÌ ¾Æ´Ô.

Equipment for laparoscopy

1. laparoscopes
A. different angles of view : straightforward or foreoblique
2. Pneumoperitoneal needle
Two needle type : Tuohy needle, veress needle ( reduce the chances of accidental puncture)
3. Trocars : Two basic models : flapper valve, trumpet valve
4. Gas insufflator : most insuffulators on low flow produce about 0.5 to 1.0 L/min
High flow setting must be used that will produce up to 10-15 L/min.
5. Light sources : Xenon or halogen light sources.
6. Camera Two component : camera head with its cable and the camera control unit.

Ancillary instruments
1. probe : simplest and most commonly used instrument is the blunt probe
2. Forceps: atraumatic grasping forcepsÀ» ¸¹ÀÌ »ç¿ë.
more delicate graspers´Â control bleeding ȤÀºcoagulation, suturingÇÒ ¶§ »ç¿ë. Punch biopsy forceps
3. Scissors and scalpels : scissors are commoly used and come in many designs, including toothed, serrated, micro, and hooked.
4. Aspirators and irrigators.
5. Morcellators.

Positioning of the patient
ȯÀÚÀÇ ÆÈÀº ÆîÃļ­ À§Ä¡ÇÏ´Â °Í º¸´Ù ¸ö°ú ÆòÇàÇÏ°Ô À§Ä¡ÇÏ´Â°Ô ´õÁÁ´Ù. -> surgeonÀÇ ¿òÁ÷ÀÓÀÌ ´õ ÀÚÀ¯·Î¿ÍÁü.
The lithotomy position : uterus¸¦ manipulationÇϱⰡ ¿ëÀÌÇϰí vaginal approach°¡ ´õ ¿ëÀÌÇÔ.
ȯÀÚÀÇ ¾ûµ¢ÀÌ´Â table¿¡¼­ ¾à°£ Æ¢¾î³ª¿ÃÁ¤µµ·Î À§Ä¡ -> uterine manipulationÀÌ ¿ëÀÌÇÔ.

Pneumoperitoneum
1. Insufflation and trocar insertion Àº ȯÀÚÀÇ À§¿Í ¹æ±¤ÀÌ ºñ¾îÀÖ´ÂÁö È®ÀÎÈÄ »ðÀÔÇÑ´Ù.
2. Carbon dioxide -> Ç÷¾×À¸·Î Èí¼ö°¡ ºü¸§, embolismÀÇ À§Ç輺ÀÌ nitrous oxideº¸´Ù Àû´Ù.
3. the veress or Tuohy needleÀ» umbilicus¸¦ Àâ°í¼­ »ðÀÔÇÑ´Ù.
4. º¹º®À» Àâ¾Æ ´ç°Ü¼­ µé¾î¿Ã¸° »óÅ¿¡¼­ hollow the sacrumÂÊÀ¸·Î needleÀ» »ðÀÔÇÑ´Ù.
5. °ú°Å ¼ö¼úÀ» Ç߰ųª, ȤÀÌ Àְųª Àå±â°¡ Ä¿Á®ÀÖ´Â °æ¿ì ´Ù¸¥°÷¿¡¼­ needleÀ» »ðÀÔÇÑ´Ù. (lower quadrant puncture sites, above the umbilicus in the midline, left upper quadrant beneath the costal margin(ninth intercostals space) at the edge of the lateral rectus or ant axillary line
6. needle »ðÀԽà º¹¾ÐÀº 10mmHg¸¦ ³Ñ¾î¼­¸éÀº ¾ÊµÈ´Ù.
7. ¿Ã¹Ù¸¥ »ðÀÔÀÇ ¿©ºÎ¸¦ syninge test·Î È®ÀÎÇÒ¼ö ÀÖ´Ù.(1LÁ¤µµ gas»ðÀÔÈÄ Liver dullness°¡ ¼Ò½Ç)
8. A small, thin patient with strong abd musches will require less volume(1-2L) than an obese , parous patient with lax abd muscle(3-6L)
9. º¹¾ÐÀº 20-25mmHg¸¦ ³ÑÁö ¾Êµµ·Ï ÇÑ´Ù. (higher pressure´Â diaphragmatic excursion or with central venous return À» ¹æÇØÇÒ¼ö ÀÖ´Ù.)

Insertion of the primary trocar
lower abd wallÀ» Àâ¾Æ¼­ µé¾î ¿Ã¸°ÈÄ scarum or uterus¸¦ ÇâÇØ¼­ trocar¸¦ »ðÀÔÇÑ´Ù. Trocar°¡ fascia and peritoneumÀ» Åë°úÇϸé ,sleeve of the trocar¸¦ Á»´õ advanced½ÃŲ´Ù.

Ancillary trocar placement
º¸Åë 1-2°³ÀÇ Á¤µµ°¡ ÇÊ¿äÇÏ´Ù.
Àû´çÇÑ ±â±¸ÀÇ »ç¿ëÀ» À§Çؼ­ ¼ö¼ú À§Ä¡º¸´Ù ¾à°£ À§Âʰú ¹Ù±ùÂÊ(lateral)¿¡ À§Ä¡ÇÏ°Ô µÈ´Ù.
»ðÀÔÇÒ ÀÚ¸®¸¦ ¸ÕÀú ¼Õ°¡¶ôÀ¸·Î È®ÀÎÇÏ°í º¹º®ÀÇ ´Ù¸¥ ±¸Á¶¹°ÀÌ ÀÖ´ÂÁö ¿©ºÎ¸¦(inferior epigastric vessels) laparoscopeÀ¸·Î È®ÀÎÈÄ Ç÷°üÀ» ÇÇÇØ¼­ punctureÇÑ´Ù.
Puncture´Â Ç×»ó Á÷Á¢ laparoscopeÀ¸·Î º¸¸é¼­ ´Ù¸¥ Àå±â³ª Ç÷°üµîÀÇ ¼Õ»óÀÌ ¾øµµ·Ï ÇÑ´Ù.

Diagnostic examination of the pelvis
ScopeÀ» »ðÀÔ ÈÄ abdominal cavity¸¦ È®ÀÎÇÏ¿© ´Ù¸¥ º´º¯À̳ª needle, trocar·Î ÀÎÇÑ ¼Õ»óÀÌ ÀÖ´ÂÁö È®ÀÎÇÏ¿©¾ß ÇÑ´Ù.

Assistance
Surgeon may have both hands occupied with ancillary instruments or the operating channel.
With a video camera, an experienced assistant can actively assit the operator

Operative laparoscopic procedures
1. Blunt dissection : Traction placed on an adhesion during stabilization of the involved structures can cause separation
»ç¿ëÇÏ´Â ±â±¸ : suction-irrigator, blunt probe,forceps, closed pair of scissors
2. Sharp dissection
3. Aquadissection
4. Electrodissection : unipolar and bipolar electrosurgery are used
unipolar needle near ureter or bowel should be limited to adhesions at least 1 to 2cm away
5. laser dissection
6. salpingoovariolysis
7. salpingectomy
Mesosalpinx¸¦ electrocoagulationÇϰí cuttingÇÔ(scissors or a knife)
coagulation and cuttingÀº proximal or fimbriated end or the fallopian tube¿¡¼­ºÎÅÍ ½ÃÀÛÇϰí fallopian tube¿¡ °¡±õ°Ô ½ÃÇàÇÏ¿© ³­¼Ò·Î °¡´Â Ç÷°üÀÇ ¼Õ»óÀ» ÇÇÇϵµ·Ï ÇÑ´Ù.
8. ovarian cystectomy
³­¼ÒÇ¥¸éÀÇ ES(<1cm) : coagulated or vaporized
3-5cm in size: laparotomy¿Í °°Àº ¹æ¹ýÀ¸·Î ÀýÁ¦
>5cm difficult to handle at laparoscopy
cyst is drained and lavaged.
The lining is inspected and a relaxing incision is made. The plane of the pseudocapsule is identified. Atraumatic grasping forceps are used th hold the ovary and provide countertraction. The cyst wall lining is grasped and dissection is performed with laser scissors, or blunt probe.
Incompletedly resected areas can be further coagulated or vaporized
8. Oophorectomy and sampingoophorectomy
three loop ligatures(around the ovary or adnexa)¸¦ ½ÃÇàÇÑ´Ù.
Loop ligatureÇϱâ Àü¿¡ adhesionÀÌ ¾ø¾î¾ß ÇÑ´Ù.
Incision in the mesosalpinx are sometimes necessary to facilitate placement.
ovary or adnexa ´Â loop¿¡¼­ distalÂÊÀ¸·Î cuttingÇÑ´Ù.
Small bleeding points can be coagulated the suture.

Complication of laparoscopy
1. Pneumoperitoneum
Extraperitoneal insufflation-emphysema -> resolves spontaneously
Mediastinal emphysema, emphysema of the omentum
Pnemothorax-µå¹°´Ù.
Rarely penetrating injury to blood vessel is not recognized at the time of insufflation and may lead to gas embolism and death
2. Vessel injury
Veress needle or trocar °¡ omental or mesenteric blood vessel or any of the major abdominal or pelvic arteries or veinsÀ» ¼Õ»ó½Ãų ¼ö ÀÖµû.
Major vessel injury½Ã´Â Áï½Ã °³º¹À» ÇØ¾ß ÇÏ°í ¼öÇ÷À» ½ÃÇàÇÏ¼Å¾ß ÇÑ´Ù.
Mesenteric vesselÀÇ ¼Õ»ó½Ã´Â segment of bowel and bowel resectionÀÌ ÇÊ¿äÇÒ ¼ö ÀÖ´Ù
Superficial epigastric vesselÀÇ ¼Õ»óÀº transilluminationÀ¸·Î ÇÇÇÒ¼öÀÖ´Ù.
Direct laparoscopic visulization of the inf epigastric vessels and insertion of trocars lateral th the edge of the rectus muscle will decrease the risk of vessel laceration.
3. Bowel injury
Gastric injury´Â µå¹°´Ù.
Injury Àº °ú°Å ¼ö¼ú ¹ÞÀº »ç¶÷À̳ª À¯ÂøÀÌ ÀÖÀ» °æ¿ì »ý±æ¼öÀÖ´Ù.
4. Bladder injury
More common in previous pelvic surgery
Laceration smaller than 5mm may heal spontaneously if the bladder is drained continuosly for 4-5 days postoperatively.
5. Trocar hernias
Z track method can lessen the risk of herniation.
Trocar larger than 7mm create an increased risk, and the use of these larger ports often mandates closure of the fascia with sutures.