Basic Principles of Laparoscopic Surgery - Part 1

Basic Training in Laparoscopic Surgery

Basic Training in Laparoscopic Surgery includes:-

• Understanding the fundamental principles of laparoscopy
• Mastering the art of Instrumentation
• Hands on Training
• Supervised practice on humans (Most important)
• To know one’s role as a Team work(Very important)

Fundamental principles of laparoscopy:-

Pneumoperitoneum is created using a distention medium like Carbon dioxide with the help of an Insufflator machine.

Since carbon dioxide is soluble in blood a capnograph is a must in monitoring the patient during anesthesia for laparoscopic surgeries.

Safe method of insufflation is by using a spring loaded Veress needle.

Insufflation is completed by the introduction of Primary Trocar and the Telescope. This is called the camera port.

The telescope is in turn connected to a light source, fiber optic cable and to a video monitor.

Other ancillary instruments like forceps, scissors, electro cautery, needle holder, clip applicator, suction irrigation device etc are also used. Almost all instruments used in open surgery are now available for laparoscopic surgery.

These instruments are introduced through different ports. The positions of primary port and the accessory ports are determined by the principles of Ergonomics for laparoscopic surgery. (Ergonomics means the norms of work)

Hands on training is a must for the proper hand eye coordination. Good coordination between right and left hands are also needed for laparoscopic procedures.

Supervised practice on humans is another important aspect of training. Each member of the team should know his or her role  for a particular procedure.

Obesity, Morbid Obesity, Super Obesity, Super Super Morbid Obesity

Obesity, Morbid Obesity, Super Obesity, Super Super Morbid Obesity:-

Bariatric Surgery for Morbid Obesity

Body Mass Index is the ratio of Body weight in Kg and the square of the Height in metres.

Normal Body Mass Index (BMI) 18.5-24.9 Kg/m²

Overweight is Body Mass Index  25-29.9 Kg/m²

Obesity is defined as a Body Mass Index > 30 Kg/m²

Morbid obesity is Body Mass Index > 40 Kg/m²

Super obesity is Body Mass Index > 50 Kg/m²

Super super obesity (body mass index (BMI)>60 Kg/m²

Bariatric Surgery means surgery done for the correction of Morbid Obesity, Super Obesity, Super Super Morbid Obesity.

Two most popular techniques of  Bariatric Surgery are:-

1.Laparoscopic Sleeve Gastrectomy ( LSG )

2.Roux-en-Y Gastric Bypass ( RYGB )

Bariatric Surgery surprisingly induces remission of the metabolic disorders associated with obesity like Hypertension, Diabetes, Obstructive Sleep Apnoea and Dislipidemia.

Hence if such bariatric surgical procedure is done for the correction of a metabolic condition like Diabetes mellitus with failed medical therapy in a non-obese person  is termed as Metabolic Surgery.

              

                                                  

Foreign Body Inside the Urinary Bladder

Foreign body inside the Urinary Bladder- A Case Report

Wooden Foreign body inside the Urinary Bladder

Case Capsule

70 year old male patient, presented to the emergency surgical  department with history of accidental fall  over a wooden piece .

 With complaints of pain in the lower abdomen and wound over the peri anal region.

 On admission patient was hemodynamicaly stable.

He did not pass urine since the event.

No associated  bleeding per meatus or fecal incontinence

Per Abdomen: showed diffused lower abdominal tenderness.

 No rigidity noted.

Bladder not palpable per abdomen.

Local Examination

  Lacerated wound over the perianal region at 7’o clock position measuring approx 4 x 2 cm extending to the anterior rectal wall.

Digital Rectal Examination

 Lax sphincter tone

Approx 5 cm linear defect palpated over the anterior rectal wall starting approx about 2cm from the anal verge, communicating with external perianal wound.

With fecal contamination of the perianal wound noted.

CT scan taken revealed :

Rectovesical fistula tract extending from the perianal external wound to the base of the bladder.

Linear tear involving the anterior rectal wall.

Tear involving the base of the bladder.

Foreign body inside the bladder.

Urology consulatation was taken and planned for cystostomy and evacuation of the vesical foreign body.

Patient was posted for the emergency surgery.

Intra op findings and the Procedure

A linear tear of the anterior rectal wall was noticed starting approximately  2cm from the anal verge.

 With a full thickness rectal rent noted in its most proximal portion of the tear just below the peritoneal reflection communicating with the base of the bladder.

Tear involving the base of the bladder measuring approx 1 x 0.5 cm just above the inter ureteric ridge noted.

Wooden piece noted with in the bladder cavity, which was extracted.

Bilateral ureteric orifice normal.

Bilateral  DJ stenting done.

Vesical tear closure done.

SPC  done.

Vertical cystostomy closure done.

Rectum mobilised and primary repair  of the rectal tear done.

Diversion clostomy done via sigmoid loop colostomy.

Perianal wound was kept open.

Post Operative Period 

Post op period was uneventful.

Was started on enteral feeds on the post operative day 2.

Was discharged onpost operative day 12 with insitu spc and uretheral catheter.

                                        Courtesy : Dr Mohammed Jashin

Paget Disease of Breast

Paget Disease of Breast

Paget Disease of Breast is an eczema like condition due to underlying carcinoma.

Differentiation between Eczema and Paget's Disease of Breast:-

Paget disease of the breast starts from the nipple and spreads towards the areola of the breast.

Whereas the normal eczema starts from the periphery and involve the areola and nipple.

In benign eczema patient can have evidence of eczema anywhere else in the body.

Nipple Destruction is very characteristic in Paget Disease of Breast.

Treatment of Paget Disease with a Breast Lump is Modified Radical Mastectomy.

Treatment of Paget Disease with no Lump is Total Mastectomy.

 

Post Auricular Dermoid Cyst

Post Auricular Dermoid Cyst

                            

Post Auricular Dermoid Cyst

Post Auricular Dermoid Cyst-Incision for Excision

Post Auricular Dermoid Cyst-Excision

Post Auricular Dermoid Cyst is type of Sequestration Dermoid,  in which the epidermal cells are sequestrated to deeper layers of tissues. Hence it is also called Epidermal Cyst.

Sequestration Dermoids are seen close to the mesodermal derivatives like bone. Hence it is possible to get indentation of  the underlying skull bone and even an intracranial extension.

Sequestration Dermoids are seen along the line of embryonic fusion. Other examples of Sequestration Dermoids are External Angular Dermoid and Submental Dermoid.

Age group:-

The second or third decades of life.

Clinical Features:-

Painless Swelling with a smooth surface and soft consistency. Indentation of the underlying bone may be appreciated.

Soft cosisitency of a dermoid cyst is due the tooth paste like pultaceous material composed of sebum and desquamated epithelial cells with or without hair.

Complications of Dermoid Cyst:-

• Infection
• Ulceration
• Mechanical compression to adjacent structures

Investigations-

Plain X Ray Skull- to assess bony erosions.

CT Scan Head- if  intracranial extension is suspected.

Treatment

Surgical Excision under appropriate anesthesia.

Peau d’ orange Appearance in Carcinoma Breast

Peau d’ orange Appearance in Carcinoma Breast

Dimpling of the skin over the breast is due to involvement of the Cooper’s ligaments.

Blockage of the dermal lymphatics of the breast due to malignancy results in oedema of the skin.

Skin dimpling along with odema of the skin is the cause of Peau d’ orange Appearance ( Orange peel ) in Carcinoma breast.

Significance of Peau d’ orange Appearance in Carcinoma breast:-

Peau d’ orange Appearance is considered as skin involvement in Carcinoma breast and hence affects the stage of the disease.

NB:  Mere dimpling of the skin over the breast will not affect the stage of the disease as it is not considered as skin involvement.

Skin involvement in Carcinoma breast means presence of any one of the following:-

1.     Peau d’ orange Appearance

2.     Skin Ulceration

3.     Skin nodules

Benign condtions producing Peau d’ orange Appearance:-

Mastistis

Radiation

Hematocele

Hematocele

Causes of Hematocele:- Trauma (Cricket ball injury, Road Traffic Accidents etc), Iatrogenic ( Aspiration of a Hydrocele-Not recommended), Testicular neoplasms.

Clinical Features:- Painful swelling of scrotum with history of Trauma.

Investigations:-Doppler Ultra Sound Scan to assess the vascularity and architecture of the testes.

Treatment:- Scrotal Exploration and evacuation of blood clots.

Important:- Viability  of the testes is confirmed. Small linear lacerations are sutured, severely shattered testis requires orchidectomy.

Complications:- Infection, Atrophy of testes due to pressure haematoma.