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Semelhante a Dr.Zarin Laparoscoopy FINAL.pptx
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Dr.Zarin Laparoscoopy FINAL.pptx
- 2. Dr.Mohammad Zarin MBBS, FCPS, MRCS, FMAS Associate Professor, SEW Khyber Teaching Hospital
- 4. Outline of Presentation • Ergonomics • Physiology • Instruments
- 5. ERGONOMICS
- 6. 2 D Image No depth Perception No tactile feedback Counter-intuitive Limited movements Magnification
- 7. Open Surgeon Vs Lap Surgeon How do they differ?! Open Surgeon • Fast • Hand is as good as eyes • Dissection precedes • Ergonomics: Optional Laparoscopic Surgeon • Slow and steady • Stop when you don’t see • Haemostasis precedes • Ergonomics: Vital
- 8. To be an efficient Surgeon… • Equipments • Environment Concentrate on
- 9. PATIENT POSITION Produce gravitational displacement of viscera away from surgical site. Trendelenberg Rev Trendelenberg 15-20˚ head down 20-30˚ head up Endobronchial intubation Predisposition to DVT
- 11. Ergonomics • Straight Line principle • Triangulation • Manipulation angle • Elevation angle • Low lying table • Gaze down view
- 13. Visual Axis and Motor Axis
- 15. Base Ball Diamond Concept & Triangulation Monitor S C R L P
- 16. Manipulation angle Azimuth Angle Manipulation Angle 30-45 degree 60-90 degree
- 17. Elevation angle
- 18. Ideal angles! 1. Manipulatation angle: 60 degree 2. Azimuth angle: Equal/30 degree each 3. Elevation angle: 60 degree
- 19. Ergonomics of Hand Instruments • Tip – Range of movements • Conventional Vs Robotic instrument: 4: 7
- 20. Ergonomics of Hand Instruments • Tip – Range of movements • Conventional Vs Robotic instrument • Length of the shaft
- 21. Fulcrum Effect of Hand Instruments 1: 1
- 23. Ergonomics of Port Placement
- 24. Ergonomics of Hand Instruments • Tip – Range of movements • Conventional Vs Robotic instrument – Force transmission • Length of the shaft • Handle design
- 26. Surgeon’s Stance Ideal relaxed stature Tiring
- 27. Ideal Relaxed Position -straight head, in the axis of the trunk, without rotation or extension of the cervical spine; - shoulders in a relaxed and neutral position; - arms alongside the body - elbows bent to 70 to 90 degrees - forearms in an horizontal or slightly descending axis- -hands pronated (physiological resting position); - hands and fingers lightly grip the handles/handpiece •Waist line table •Gaze down view of monitor •Straight line principle •Triangulation
- 28. PHYSIOLOGICAL EFFECTS OF LAPAROSCOPY Can be: Mechanical Metabolic On • Cardiovascular • Pulmonary • Gastrointestinal • Renal • Peripheral vascular
- 29. Cardiovascular Effects: ↑ IAP ↓ CO ↓ VR ↓ SV ↑ Afterload ↑ MAP HR x = ↑ Vasopressin & Catecholamines ↑ CO2 ↑ CVP ↑ PCWP ↑ SVR ↓ VR ↓ LVEDV
- 30. Cardiovascular Effects: • Cardiac Output – Variation between studies – < 30% decrease when observed – On insufflation; ∞ ↑ in I.A.P; transient • generally noted in: – ASA Class III/IV – hypovolemic patients – PP > 15 mm Hg – reverse Trendellenberg position
- 31. Respiratory Effects: ↑ IAP ↑ cephalad shift diaphragm paradoxic diaphragm motion ↑ ITP ↓ FRC ↑ RR ↑ CO2 ↑ Ve & work of breathing ↓chest wall compliance Hypercapnia ↑ PAWP + Alveolar Collapse ↓ TV
- 32. Respiratory Complications: • Pneumothorax / Pneumomediastinum / Pneumopericardium – 2° to diffusion of gas from pneumoperitoneum • Accidental diaphragm injury / pre-existing diaphragmatic defect – 2° to rupture of blebs with ↑ PAWP • Gas Embolism – 2° to vascular injury • trocar / needle insertion on insufflation / intra-op vessel injury
- 33. Gastrointestinal effects: ↑ I.A.P. ↓ Mesenteric & celiac flow ↓ hepatic artery flow ↓ hepatic perfusion ↓ perfusion intestines & stomach ↓ Portal flow ↑ LFTs ↓ intestinal & gastric pH
- 34. Renal Effects: ↑ I.A.P. ↓ GFR ↓ERPF ↓ U/O RAAS ↑ CO2
- 35. Renal Effects: • U/O return to baseline within hours • No long-term change in GFR • No change in Cr, BUN
- 36. Peripheral Vascular Effects: ↑ I.A.P. Reverse Trendellenberg Venous stasis ↓ VR ↑ Risk DVT?
- 37. Peripheral Vascular Effects: • Incidence of DVT, PE generally lower post laparoscopic procedures – Secondary to improved prophylaxis? – Risk increased with longer procedures and reverse Trendellenberg
- 38. Laparoscopic Instruments • Hand instruments
Notas do Editor
- Trendelenburg position (head down) usually for gynaecological procedures or Reverse trendelenburg (head up) for upper GI surgery. Trendelenburg: Greater respiratory effects including further reduction in FRC, more V/Q mismatch and greater risk of atelactasis. Initial increase in VR may not be tolerated in patients with compromised myocardial compliance. Reverse Trendelenburg: More marked effects on CV system due to decreased VR and CO therefore low BP. 3 most common patient positions: supine – for majority of procedures including cholecystectomy, appendectomy, gastric small bowel, colonic and vascular proceures. Modified lithotomy position used for procedures in pelvis. Allen stirrups used to hold leg in position. Lateral decubitus position most often used for splenectomy, adrenalectomy and thoracoscopic procedures.