•Preoperative marking of the site (usually on the pts left side and just below the level of the umbilicus) so that it does not sit in a crease or belt line
•Preop shave and betadine prep
•Betadine prep and square drape
•Ioban
•Surgeon stands on pts right and the tower is at the pts feet.
•If the preop marking is on the pts right side then all the ports and surgeon positions is opposite.
•Most of the tubes/wires come from the feet and place the quiver at the pts left hip.
•First incision is left and caudal of the umbilicus, transverse incision just a bit off the midline to go through the left rectus sheaths.
•Local anaesthetic in skin and peritoneum
•Transverse incision and use S shaped retractors to retract tissue
•Hold up the ant sheath with a stay 3/0 dexon suture on each side of the planned longitudinal incision. Incise the rectus sheath longitudinally b/w the stay sutures.
•Part the rectus muscle with blunt parting dissection of the scissors and S retractors.
•Get down to the post sheath and place an artery forcep in the planned entry point of the port and hold it up, place a running dexon suture around the planned port site as a purse string stitch.
•Incise into the post sheath and place a 12mm port in. This will be the camera port.
•Hold the port in with the ant dexon stay sutures and tie it to the port and hold it anteriorly together with one artery clip.
•Place the other 5 mm port site on the pts right side, one at the level of the 12mm port and the other in the RIF.
•Before putting in the ports using the endoclose. To place a dexon tie in one angle and out another so that the peritoneum can be sealed appropriately at the end. The port is passed through the dexon tie.
•Place the suture through the end of the tenchoff catheter, flatten the needle so that it can come out a 5 mm port. Now pass the suture in through the 12 mm port, place a stitch into the dome of the bladder and bring out of the 5mm RIF port. On the other end of the catheter place a dexon tie.
Use the x2 5mm working ports to place a stitch into the dome of the bladder or the uterus (preferably), so that the catheter stays in the pelvis. Place the stitch first and once it has been passed out of the RIF port then pass the catheter into the 12mm port and adjust the position of the catheter accordingly and bring the other end of the stitch out the RIF port.
•Bring out the stitch through the RIF port and do an extra-corporeal knot and pass it down with a knot pusher, will need 5 throws on maxon or PDS sutures.
•Once secured then bring out the tail end of the catheter making sure that no loops of bowel are caught up in it.
•Make sure the cuff is just above the post sheath and place one throw. Test the catheter and irrigate peritoneal dialysis fluid into the peritoneum 20mls x3 at a time till the fluid out is clear or coming freely.
•Then put the trochar on the end of the catheter and pass it up behind the ant rectus sheath and down and around to the X mark on the skin. Making sure the second cuff on the tenchoff is at least an inch away from the skin.
•Then irrigate dialysis fluid in for 2 minutes and check the outflow. If the fluid coming out is still heavily blood stained then peritoneal irrigation will need to be started in recovery to prevent blockage of the catheter.
•Close the anterior sheath with running maxon suture. Then close the fat with maxon and then skin with a continuous dexon subcuticular stitch.
•Close the other port sites with the dexon ties on the peritoneum with the aid of a stitch pusher and then the skin.
Post op issues:
oIf the peritoneal fluid is blood stained than the peritoneum will need to be washed several times in the post op recovery to prevent clotting
oIf catheter is blocked than it can be mechanical or clot blocking the catheter
oTrial of urokinase can sometimes work to unblock it
oDialysis does not start up for roughly 3 weeks
Showing posts with label Laparoscopic. Show all posts
Showing posts with label Laparoscopic. Show all posts
Saturday, October 13, 2007
Thursday, October 4, 2007
Laparoscopic Hellers myotomy
Beanbag
Stirrups
20-30 Reverse Trendelenburg
Compression stockings
Stand between legs
Nathanson
Divide gastrohepatic ligament
Separate right crus from diaphragm with blunt dissection
transect peritoneum and phreno-oesophageal membrane
Separate left crus by blunt dissection
Continue into posterior mediastinum to expose 6-7cm of oesophagus
Identify and preserve anterior and posterior vagal divisions
Divide short gastrics all the way to the angle of His
Hook diathermy myotomy to submucosal plane 2cm down onto stomach to 5cm past GE junction
Avoid diathermy if bleeding encountered as can cause delayed perforation
If perforation suspected, intstil saline and blow air down orogastric, if found repair with 3-0 PDS
Combine with fundoplication
Ba swallow only if perforation suspected
Avoid meat or bread for 2 weeks
Stirrups
20-30 Reverse Trendelenburg
Compression stockings
Stand between legs
Nathanson
Divide gastrohepatic ligament
Separate right crus from diaphragm with blunt dissection
transect peritoneum and phreno-oesophageal membrane
Separate left crus by blunt dissection
Continue into posterior mediastinum to expose 6-7cm of oesophagus
Identify and preserve anterior and posterior vagal divisions
Divide short gastrics all the way to the angle of His
Hook diathermy myotomy to submucosal plane 2cm down onto stomach to 5cm past GE junction
Avoid diathermy if bleeding encountered as can cause delayed perforation
If perforation suspected, intstil saline and blow air down orogastric, if found repair with 3-0 PDS
Combine with fundoplication
Ba swallow only if perforation suspected
Avoid meat or bread for 2 weeks
Sunday, September 30, 2007
Laparoscpic Nissen fundoplication
Indications include oesophageal pH <4, recorded 5cm above a manometrically defined LOS, present for >4%/24hrs,
Complicated - oesophagitis/stricture/Barretts on endoscopy,
Uncomplicated - failure to respond to conservative measures, desire to discontinue lifelong medication.
1.Position the patient in low Lloyd -Davies, reverse Trendelenberg
2.There should be two monitors on either side of the head end of the table.
3.Camera port a third of the way above and to the left of umbilicus, xiphisternal Nathanson retractor on an Omnitract bar, 5mm ports in RUQ, two in LUQ.
4.If the greater omentum is obstructing the view it can be picked up in a suture and brought out through one of the left sided ports.
5.Commence by identifying and dissecting the left crus with the assistant retracting the fundus downwards, extending the incision to the left over the fundus of the stomach. At this point it is also convenient to divide the short gastric vessels to enable a mobile fundus if required.
6.Divide and open gastro-hepatic omentum. The hepatic vagal branch in the lesser omentum may have to be sacrificed; however a smaller window prevents the wrap from slipping caudally.
7.Dissect the right crus, while retracting the oesophagus.
8.There should now be an adequate posterior window created in the retro-oesophageal space. Bring a grasper through to the left of the oesophagus staying close to the posterior wall of the oesophagus.
9.Place a Penrose drain in the abdomen and bring it through around the oesophagus to be used as a retractor.
10.Complete the definition of the left crus.
11.Perform the crural repair with 1-3 sutures (3/0 prolene). A bougie (56 or 58F) in the oesophagus can be used as a guide but I don’t normally use this.
12.Bring the fundus around the back of the oesophagus and get the assistant to hold the fundus at the site of intended wrap.
13.Fix the right side of the wrap to the right crus with 1-2 sutures to prevent the wrap from falling back around.
14.Complete the wrap by suturing the right and left sides of the fundus across the front of the oesophagus with three sutures (posterior partial or 270 degree wrap also known as Toupet).
Complications PPPPDBV
1.Paraoesophageal hiatus hernia upto 5% (routine hiatal repair dramatically reduces)
2.PE
3.Pneumothorax in up to 2%
4.Perforation up to 1%
5.Dysphagia in nearly all
6.Bilobed stomach by using to distal stomach for wrap
7.Vascular injury rare.
Complicated - oesophagitis/stricture/Barretts on endoscopy,
Uncomplicated - failure to respond to conservative measures, desire to discontinue lifelong medication.
1.Position the patient in low Lloyd -Davies, reverse Trendelenberg
2.There should be two monitors on either side of the head end of the table.
3.Camera port a third of the way above and to the left of umbilicus, xiphisternal Nathanson retractor on an Omnitract bar, 5mm ports in RUQ, two in LUQ.
4.If the greater omentum is obstructing the view it can be picked up in a suture and brought out through one of the left sided ports.
5.Commence by identifying and dissecting the left crus with the assistant retracting the fundus downwards, extending the incision to the left over the fundus of the stomach. At this point it is also convenient to divide the short gastric vessels to enable a mobile fundus if required.
6.Divide and open gastro-hepatic omentum. The hepatic vagal branch in the lesser omentum may have to be sacrificed; however a smaller window prevents the wrap from slipping caudally.
7.Dissect the right crus, while retracting the oesophagus.
8.There should now be an adequate posterior window created in the retro-oesophageal space. Bring a grasper through to the left of the oesophagus staying close to the posterior wall of the oesophagus.
9.Place a Penrose drain in the abdomen and bring it through around the oesophagus to be used as a retractor.
10.Complete the definition of the left crus.
11.Perform the crural repair with 1-3 sutures (3/0 prolene). A bougie (56 or 58F) in the oesophagus can be used as a guide but I don’t normally use this.
12.Bring the fundus around the back of the oesophagus and get the assistant to hold the fundus at the site of intended wrap.
13.Fix the right side of the wrap to the right crus with 1-2 sutures to prevent the wrap from falling back around.
14.Complete the wrap by suturing the right and left sides of the fundus across the front of the oesophagus with three sutures (posterior partial or 270 degree wrap also known as Toupet).
Complications PPPPDBV
1.Paraoesophageal hiatus hernia upto 5% (routine hiatal repair dramatically reduces)
2.PE
3.Pneumothorax in up to 2%
4.Perforation up to 1%
5.Dysphagia in nearly all
6.Bilobed stomach by using to distal stomach for wrap
7.Vascular injury rare.
Laparoscpic Oesophago-myotomy
1.Position the patient in lithotomy, reverse Trendelenberg.
2.There should be two monitors on either side of the head end of the table.
3.Camera port a third of the way above and to the left of umbilicus, xiphisternal Nathanson retractor on an Omnitract bar, 5mm ports in RUQ, two in LUQ.
4.You will also need extra room at the head end of the table for a UGI endoscopy setup.
5.Begin by mobilizing the oesophagus as for Lap Nissen, however attempt this with minimal posterior dissection. It will decrease the incidence of post-operative reflux.
6.Pass a grasper under the oesophagus across to the left of the oesophagus and bring a Penrose drain around to be used as a retractor, lengthening the segment of intra-abdominal oesophagus.
7.Find a convenient point in the middle of the thickened segment of oesophagus and divide with diathermy scissors.
8.Atraumatic graspers can then be used to pull down on the longitudinal muscle to reveal the underlying thickened circular muscle layer.
9.Similarly divide the circular layer and watch the layer spring apart. Atraumatic graspers are adjusted to hold the divided circular fibre layer.
10.The epithelial tube can be protected by pushing it down with a right angled grasper. Extend the myotomy proximally and distally (should extend 1cm on to the stomach) until the muscle appears to thin out.
11.Irrigate with saline and fill the LUQ. Insufflate the oesophagus with the endoscope and watch for any leaks.
12.Perform an anterior partial wrap (Dor) if there is a leak once repaired with interrupted 3/0 PDS or a partial posterior wrap as it is supposed to help keep the edges of the myotomy apart.
13.Close in layers.
2.There should be two monitors on either side of the head end of the table.
3.Camera port a third of the way above and to the left of umbilicus, xiphisternal Nathanson retractor on an Omnitract bar, 5mm ports in RUQ, two in LUQ.
4.You will also need extra room at the head end of the table for a UGI endoscopy setup.
5.Begin by mobilizing the oesophagus as for Lap Nissen, however attempt this with minimal posterior dissection. It will decrease the incidence of post-operative reflux.
6.Pass a grasper under the oesophagus across to the left of the oesophagus and bring a Penrose drain around to be used as a retractor, lengthening the segment of intra-abdominal oesophagus.
7.Find a convenient point in the middle of the thickened segment of oesophagus and divide with diathermy scissors.
8.Atraumatic graspers can then be used to pull down on the longitudinal muscle to reveal the underlying thickened circular muscle layer.
9.Similarly divide the circular layer and watch the layer spring apart. Atraumatic graspers are adjusted to hold the divided circular fibre layer.
10.The epithelial tube can be protected by pushing it down with a right angled grasper. Extend the myotomy proximally and distally (should extend 1cm on to the stomach) until the muscle appears to thin out.
11.Irrigate with saline and fill the LUQ. Insufflate the oesophagus with the endoscope and watch for any leaks.
12.Perform an anterior partial wrap (Dor) if there is a leak once repaired with interrupted 3/0 PDS or a partial posterior wrap as it is supposed to help keep the edges of the myotomy apart.
13.Close in layers.
Common Bile Duct Exploration
Bile duct exploration
Lap trans-cystic exploration
Note there is available evidence suggesting that a watch and wait policy is appropriate when stones found on cholangiogram, other options including pre-op ERCP for clinical or imaging suspicion pre-operatively, lap exploration via cystic duct, open exploration via choledochotomy, post-op ERCP.
Available in Ballarat include Segura hemisphere stone retrieval basket (2.4F) that can be passed down the cholangiocatheter (4 or 5F). Once stone retrieved place a laparoscopic CBD stent (Cook, 7F, 4cm stent with below components included) loading barbed end of stent first onto included guide wire (0.89mm, 145cm). Use positioner (50cm) to place stent in appropriate position.
1.Prior to starting, attempt to flush the stones by administering buscopan 20mg IV, Glucagon 1mg IV, nitrolingual spray and flush the CBD with 200ml of saline.
2.Insert a slippery guidewire into D2 via the cystic duct stump through the cholangiogram catheter.
3.Remove the cholangiogram catheter, replace with Cook extraction kit components and then remove the guidewire.
4.Insert the wire basket into the cystic duct stump, pass it into the duodenum and then withdraw the wire with the basket open. Alternatively, pass the balloon catheter into D2 having blown up the balloon proximally in an attempt to push the stone into D2.
5.Examine the CBD and the IHD with the choledochoscope passed via a RUQ port with sleeve/constant lubrication and distention of CBD with saline to enable easy passage and viewing. This may require balloon dilatation of the cystic duct stump.
6.Alternatively, if a formal choledochotomy is required because of a narrow cystic duct convert to open. Place stay sutures on each side of the planned vertical incision of the CBD. Examine the duct with the scope as above after crossing the stay sutures to provide an adequate seal for distention of the CBD with saline.
7.If there is a suspicion of further stones needing ERCP or perhaps even routinely, re-insert slippery guidewire into D2 and push a Sherman stent (leading barb and trailing pigtail) Be sure of where the radio-opaque markers are as this can be misleading and can cause you to push the stent all the way into the duodenum) down into the ampulla.
8.Close the CBD incision using an interrupted 4/0 PDS. This can be tested by passing the cholangiogram catheter into the cystic duct stump and flushing with saline. You can also leave a biliary drain via the cystic duct stump (size 8 infant feeding tube) or a T-tube brought out through a separate incision which remains in situ for cholangiogram in 6/52.
9.Drain the GB fossa (14F) with a suction drain.
Salient facts about open exploration of CBD
•You will need to Kocherize the duodenum.
•Retrieve stone fragments following choledochotomy using Randall stone removing forceps or Pituitary scoop or Fogarty balloon catheter (4F).
•Options for draining the CBD include a Trans-cystic biliary drain as above, T-tube brought out through a separate incision in the bile duct.
Lap trans-cystic exploration
Note there is available evidence suggesting that a watch and wait policy is appropriate when stones found on cholangiogram, other options including pre-op ERCP for clinical or imaging suspicion pre-operatively, lap exploration via cystic duct, open exploration via choledochotomy, post-op ERCP.
Available in Ballarat include Segura hemisphere stone retrieval basket (2.4F) that can be passed down the cholangiocatheter (4 or 5F). Once stone retrieved place a laparoscopic CBD stent (Cook, 7F, 4cm stent with below components included) loading barbed end of stent first onto included guide wire (0.89mm, 145cm). Use positioner (50cm) to place stent in appropriate position.
1.Prior to starting, attempt to flush the stones by administering buscopan 20mg IV, Glucagon 1mg IV, nitrolingual spray and flush the CBD with 200ml of saline.
2.Insert a slippery guidewire into D2 via the cystic duct stump through the cholangiogram catheter.
3.Remove the cholangiogram catheter, replace with Cook extraction kit components and then remove the guidewire.
4.Insert the wire basket into the cystic duct stump, pass it into the duodenum and then withdraw the wire with the basket open. Alternatively, pass the balloon catheter into D2 having blown up the balloon proximally in an attempt to push the stone into D2.
5.Examine the CBD and the IHD with the choledochoscope passed via a RUQ port with sleeve/constant lubrication and distention of CBD with saline to enable easy passage and viewing. This may require balloon dilatation of the cystic duct stump.
6.Alternatively, if a formal choledochotomy is required because of a narrow cystic duct convert to open. Place stay sutures on each side of the planned vertical incision of the CBD. Examine the duct with the scope as above after crossing the stay sutures to provide an adequate seal for distention of the CBD with saline.
7.If there is a suspicion of further stones needing ERCP or perhaps even routinely, re-insert slippery guidewire into D2 and push a Sherman stent (leading barb and trailing pigtail) Be sure of where the radio-opaque markers are as this can be misleading and can cause you to push the stent all the way into the duodenum) down into the ampulla.
8.Close the CBD incision using an interrupted 4/0 PDS. This can be tested by passing the cholangiogram catheter into the cystic duct stump and flushing with saline. You can also leave a biliary drain via the cystic duct stump (size 8 infant feeding tube) or a T-tube brought out through a separate incision which remains in situ for cholangiogram in 6/52.
9.Drain the GB fossa (14F) with a suction drain.
Salient facts about open exploration of CBD
•You will need to Kocherize the duodenum.
•Retrieve stone fragments following choledochotomy using Randall stone removing forceps or Pituitary scoop or Fogarty balloon catheter (4F).
•Options for draining the CBD include a Trans-cystic biliary drain as above, T-tube brought out through a separate incision in the bile duct.
Laparoscopic cholecystectomy
Be mindful of any anatomical variations such as an aberrant right hepatic artery traversing along the right side of the CBD posteriorly. The RHA can also be adjacent to the cystic duct in 50%.
Aberrant biliary anatomy includes short cystic duct, long cystic duct (spiral or parallel). Rarely a right sectoral duct may join the junction of cystic and CHD or traverse across the liver substance and join the left sided ducts.
For GB bed bleeding: if arterial bleeding will respond to diathermy, if venous then need to apply pressure with gauze or surgicell
5mm epigastric port with 5mm clipper. Pass GB through umbilical port with medial port grasper
Problems
1.Avulsion of cystic duct
Keep the rest of the GB on the liver so that you can use it for retraction
Try to find cystic duct stump
Use 3-0 prolene suture on the edge of the remnant duct then bring up through the epigastric port
Use stay suture to help guide the cholangiogram catheter
Transfix the end using a 3-0 prolene suture
2. Large stones
Get extra large sucker that has side holes / scoop
3. Port site bleeding
? Endoclose
? suture intra corporealally
4.Acutely inflamed GB
10mm RUQ port
Always decompress GB
Mother in law grasper to grab GB
Sucker for blunt dissection
Wednesday, September 19, 2007
Laparoscopic Gastric Surgery
Indications
GIST, EGC, Benign pathology, palliative settings
For EGC: preoperative endoscopy and India ink tattoo: consider whether adequate Rx: some authors suggest subtotal and D1 dissection is minimum reqd as local recurrence rate is high
Laparoscopic partial gastrectomy
Small lesions at fundus of anterior wall: Endoscopic linear cutter stapler
If involves greater or lesser curve, divide vascular arcades with harmonic scalpel then several linear cutter staplers. Intra-operative gastroscopy to ensure lesion clearance.
Laparoscopic distal/subtotal gastrectomy
Billroth II recontruction with endoscopic linear staplers, close defect with intracorporeal suture. Be generous with margins in EGC.
Laparoscopic total
Oesophagojejunostomy with endoscopic linear and circular staplers reinforced by seromuscular sutures
If significant adhesion from previous surgery, divide gastrocolic omentum to enter lesser sac and virgin posterior wall of stomach. Then identify posterior and left gastric vessels before proceeding.
GIST, EGC, Benign pathology, palliative settings
For EGC: preoperative endoscopy and India ink tattoo: consider whether adequate Rx: some authors suggest subtotal and D1 dissection is minimum reqd as local recurrence rate is high
Laparoscopic partial gastrectomy
Small lesions at fundus of anterior wall: Endoscopic linear cutter stapler
If involves greater or lesser curve, divide vascular arcades with harmonic scalpel then several linear cutter staplers. Intra-operative gastroscopy to ensure lesion clearance.
Laparoscopic distal/subtotal gastrectomy
Billroth II recontruction with endoscopic linear staplers, close defect with intracorporeal suture. Be generous with margins in EGC.
Laparoscopic total
Oesophagojejunostomy with endoscopic linear and circular staplers reinforced by seromuscular sutures
If significant adhesion from previous surgery, divide gastrocolic omentum to enter lesser sac and virgin posterior wall of stomach. Then identify posterior and left gastric vessels before proceeding.
Tuesday, September 18, 2007
Laparoscopic Splenectomy
Anatomical clues
No two spleens have same anatomy
Size of spleen does not determine number of arteries
Notches and tubercles correlates with greater number of entering arteries
Splenic artery tends to be more tortuous with age and may arise from aorta, SMA, middle colic, left gastric and others
Arteries outside spleen are divided into first second and third terminal divisions, most spleens have 2-3 terminal branches entering hilum. The arteries are true terminal arteries, meaning there is an avascular plane between them in the spleen
Veins are usually posterior to arteries
Search for accessory spleens should occur at the start of the operation, most are found at the hilum and distal pancreas
Tail of pancreas is within 1cm of spleen in 70% patients
Tail of pancreas is in contact with spleen in 30%
Two arterial patterns (see photos) distributed 70% (short splenic trunk with long branches) and bundled 30%
Normal spleen <11cm, moderate splenomegaly 11-20cm
Therefore: a notched spleen with a wide hilum will have a complicated vascular anatomy
Ligaments
Gastrosplenic contains short gastrics and gastroepiploics
Lienorenal ligament contains hilar vessels and tail of pancreas
Other ligaments are avascular except in portal hypertension
Indication
Usually ITP with moderately enlarged spleens
1.Right lateral position with the table broken and bean bag
2.Surgeon stands to the patient’s right with the Tower to the patients left.
3.Hassan cutdown in subcostal position at the anterior axillary line with 10mm camera, one 10mm for endoGIA and remaining 5mm ports (i.e. may need an additional port for retraction (working, Hasson, working, retractor from anterior to posterior as for left adrenal)
Open the 'splenic tent' by opening lesser sac to identify anatomy (between gastrosplenic and lienorenal ligaments)
4.Using a Lap Ligasure or harmonic scalpel mobilize the splenic flexure.
5.Dissect medially by dividing the gastro-splenic ligament and ligating the left gastroepiploic and short gastric vessels to visualize the hilum. Identify the splenic artery, vein and tail of pancreas. Some authors suggest ligating the artery first to minimize risk of bleeding and diminish its size.
6.Divide the lienorenal ligament but not all attachments as they help secure the spleen.
7.Use an EndoGIA Roticulator stapler with white cartridges over the vessels completely, avoiding the tail of pancreas. You may need 2-3 cartridges
8.Once the hilum is secured, divide any remaining attachments to the diaphragm.
9.Deliver the spleen into an EndoCatch apparatus (10 or 15mm but will require removal of port if 15mm used and blunt insertion). Try and deliver the spleen intact if for malignancy by enlarging the most posterior/retracting port or it can be morcellated if for ITP.
10.Lavage and close in layers.
Morcellation and extract in bag, avoid spillage to avoid splenic rests
HALS if spleen more than 20cm in length
Complications
Portal vein thrombosis: suspect where unexplained fever or ongoing abdominal symptoms
Accessory spleens
10% patients
Around splenic hilum, greater omentum, mesentery, pelvis
CT and Nuclear med scan to localise
Friday, September 14, 2007
Laparoscopic Adrenalectomy
ANATOMY
Blood supply from 6-8 branches of inferior phrenic, middle adrenal from aorta near SMA origin, inferior from renal artery
Left drains into renal vein, right directly into IVC
PROCEDURE
If phaeochromocytoma, ligate veins first, be careful handling gland.
Lap left adrenalectomy
1.Position patient in right lateral with table broken.
2.One Hasson, one 10mm port for clip applicator and one 5mm, (possibly one additional for retracting the spleen and 2 working ports, in order – working, hasson, working, retractor from anterior to posterior) are inserted along the costal margin and pneumoperitoneum achieved.
3.Begin mobilization of the splenic flexure of colon.
4.Divide lienorenal ligament from lower pole of spleen to diaphragm. This will help the spleen and tail of pancreas fall medially.
5.Retract the spleen if required via the most posterior port. Start to mobilize the left adrenal starting laterally (leave the glands attachment to the kidney intact till last as it can be used to retract the gland inferiorly).
6.Follow the capsule of the gland infero-medially to identify the adrenal vein emanating from the postero-medial aspect and clip once defined.
7.Once freed, the gland is placed in an endocatch bag and removed through an enlarged port site.
Lap right adrenal
1.Position patient in left lateral with table broken.
2.One Hasson, one 10mm port for clip applicator and one 5mm, (possible one additional 10mm for retracting the liver and 2 working ports, in order – retractor, working, hasson, working from anterior to posterior) are inserted along the costal margin and pneumoperitoneum achieved.
3.Begin mobilization of the hepatic flexure of colon and divide any other sub-hepatic adhesions as necessary. The right triangular ligament may also have to be divided.
4.Retract the lower edge of the liver (via the most anterior port) and incise the posterior peritoneum just below the liver so as to open a curved space between the adrenal (located partly adjacent to the bare area of liver) and the liver superiorly (i.e. the inferior leaf of the coronary ligament).
5.Start to mobilize the right adrenal by deepening the incision medially to identify the right adrenal vein emanating from the antero-medial surface, entering the posterior aspect of the IVC (as the gland is in a plane posterior to the IVC). Beware of an adrenal artery coming from behind the IVC. Leave the attachment to the kidney intact till last as it can be used to retract the gland inferiorly.
6.Clip the adrenal vein using two ligaclips on the staying side.
7.Once freed, the gland is placed in an endocatch bag and removed through an enlarged port site.
Blood supply from 6-8 branches of inferior phrenic, middle adrenal from aorta near SMA origin, inferior from renal artery
Left drains into renal vein, right directly into IVC
PROCEDURE
If phaeochromocytoma, ligate veins first, be careful handling gland.
Lap left adrenalectomy
1.Position patient in right lateral with table broken.
2.One Hasson, one 10mm port for clip applicator and one 5mm, (possibly one additional for retracting the spleen and 2 working ports, in order – working, hasson, working, retractor from anterior to posterior) are inserted along the costal margin and pneumoperitoneum achieved.
3.Begin mobilization of the splenic flexure of colon.
4.Divide lienorenal ligament from lower pole of spleen to diaphragm. This will help the spleen and tail of pancreas fall medially.
5.Retract the spleen if required via the most posterior port. Start to mobilize the left adrenal starting laterally (leave the glands attachment to the kidney intact till last as it can be used to retract the gland inferiorly).
6.Follow the capsule of the gland infero-medially to identify the adrenal vein emanating from the postero-medial aspect and clip once defined.
7.Once freed, the gland is placed in an endocatch bag and removed through an enlarged port site.
Lap right adrenal
1.Position patient in left lateral with table broken.
2.One Hasson, one 10mm port for clip applicator and one 5mm, (possible one additional 10mm for retracting the liver and 2 working ports, in order – retractor, working, hasson, working from anterior to posterior) are inserted along the costal margin and pneumoperitoneum achieved.
3.Begin mobilization of the hepatic flexure of colon and divide any other sub-hepatic adhesions as necessary. The right triangular ligament may also have to be divided.
4.Retract the lower edge of the liver (via the most anterior port) and incise the posterior peritoneum just below the liver so as to open a curved space between the adrenal (located partly adjacent to the bare area of liver) and the liver superiorly (i.e. the inferior leaf of the coronary ligament).
5.Start to mobilize the right adrenal by deepening the incision medially to identify the right adrenal vein emanating from the antero-medial surface, entering the posterior aspect of the IVC (as the gland is in a plane posterior to the IVC). Beware of an adrenal artery coming from behind the IVC. Leave the attachment to the kidney intact till last as it can be used to retract the gland inferiorly.
6.Clip the adrenal vein using two ligaclips on the staying side.
7.Once freed, the gland is placed in an endocatch bag and removed through an enlarged port site.
Laparoscopic anterior resection
ANATOMY
Can to down to approx 8cm
Nerves
Ureters
PROCEDURE
RIF 10mm port
RUQ 5mm
2 more 5mm ?where on left side
Lithotomy position with legs low so instruments don’t clash
3 x lap DeBakeys
Harmonic scalpel (use diathermy/scissors of not available)
Always mobilise to splenic flexure, including
dissecting the greater omentum off the colon.
The line of dissection is always more on the colon side than you think! (the registrars mistake: this is where you will get bleeding and hit the ureter)
On table colonoscopy to confirm site of lesion
Make window in mesocolon after identifying ureter and gonadals
35mm endostaple IMA and IMV (may have to do separately in cancer operation.)
Care with nerves esp in male (these will be behind rectum)
May have to staple vessels lateral to rectum down low.
35mm endostaple with a few reloads to transect rectum
LIF appendicectomy incision with wound protector to mobilise colon and tie on anvill
Make sure you clear all fat from colon over staple line.
Purse string PDS continuous then second inner ring.
Maxon to 10mm RIF port.
Can to down to approx 8cm
Nerves
Ureters
PROCEDURE
RIF 10mm port
RUQ 5mm
2 more 5mm ?where on left side
Lithotomy position with legs low so instruments don’t clash
3 x lap DeBakeys
Harmonic scalpel (use diathermy/scissors of not available)
Always mobilise to splenic flexure, including
dissecting the greater omentum off the colon.
The line of dissection is always more on the colon side than you think! (the registrars mistake: this is where you will get bleeding and hit the ureter)
On table colonoscopy to confirm site of lesion
Make window in mesocolon after identifying ureter and gonadals
35mm endostaple IMA and IMV (may have to do separately in cancer operation.)
Care with nerves esp in male (these will be behind rectum)
May have to staple vessels lateral to rectum down low.
35mm endostaple with a few reloads to transect rectum
LIF appendicectomy incision with wound protector to mobilise colon and tie on anvill
Make sure you clear all fat from colon over staple line.
Purse string PDS continuous then second inner ring.
Maxon to 10mm RIF port.
Laparoscopic Right Hemicolectomy
Pre op CT scan
Cephazolin Flagyl
Low Lloyd Davies position
Laparoscpic Debakey to handle bowel
Harmonic scalpel preferably
Dissect caecum up to duodenum first (i.e inferomedial)
Use diathermy on maryland or mixter to dissect and diathermy at the same time if no harmonic
Plane is always closer to mesentery of colon than you think (i.e not in the areolar tissue. Avoid getting into retroperitoneal tissue)
Then roll colon medially to come across hepatic flexure
Middle colic vessels are the limitation of mobility
Pitfalls:
Duodenum
Ureter (if you see this you are way off)
Gonadal
Veins on front of pancreas
GB
Take ileocolic close to origin (the right colic is variable and not often present)
Test marginal blood supply
5cm margin from tumour
Betadine on bowel ends
Alexis wound retractor
Anastomosis based on luminal discrepancy
Minimal: hand sewn single layer interrupted PDS
Otherwise: Side-side stapled. Avoid T staple junction by anastomosing on rotated bowel
Cephazolin Flagyl
Low Lloyd Davies position
Laparoscpic Debakey to handle bowel
Harmonic scalpel preferably
Dissect caecum up to duodenum first (i.e inferomedial)
Use diathermy on maryland or mixter to dissect and diathermy at the same time if no harmonic
Plane is always closer to mesentery of colon than you think (i.e not in the areolar tissue. Avoid getting into retroperitoneal tissue)
Then roll colon medially to come across hepatic flexure
Middle colic vessels are the limitation of mobility
Pitfalls:
Duodenum
Ureter (if you see this you are way off)
Gonadal
Veins on front of pancreas
GB
Take ileocolic close to origin (the right colic is variable and not often present)
Test marginal blood supply
5cm margin from tumour
Betadine on bowel ends
Alexis wound retractor
Anastomosis based on luminal discrepancy
Minimal: hand sewn single layer interrupted PDS
Otherwise: Side-side stapled. Avoid T staple junction by anastomosing on rotated bowel
Laparoscopic Nissen fundoplication
Surgical history
Rudolf Nissen. German
First performed 1937 for bleeding chronic ulcer in sliding HH. Created to protect anastomosis
DeMeester introduced pH monitoring and bile reflux studies
Laparoscopic technique 1991
Modern principles
Long intra-abdominal segment
Posterior crural repair
Accentuation of angle of His
Fixation of intra-abdominal oesophagus to right crus
Loose, floppy wrap over large bougie (50Fr)
Types
Traditional Nissen: 360 deg post wrap
Partial
Besley Mark IV 270
Toupet 180 degree
Lithotomy
Hasson at mid point b/w umbilicus and xiphisternum
Nathanson retractor under left lobe liver
3 x 5mm ports (2 on Right side)
Harmonic scalpel
Reduce hiatal hernia
crural repair important
Division of short gastrics controversial: may lead to more gas bloat. Literature equivocal
Penrose drain around oesophagus for traction, held by assistant
Suture oesophageal hiatus over 50 Fr bougie (extracorporeal)
?temporary mesh over hiatus
Wrap fundus
Little role for Collis gastroplasty for shortened oesophagus as this is rare
Rudolf Nissen. German
First performed 1937 for bleeding chronic ulcer in sliding HH. Created to protect anastomosis
DeMeester introduced pH monitoring and bile reflux studies
Laparoscopic technique 1991
Modern principles
Long intra-abdominal segment
Posterior crural repair
Accentuation of angle of His
Fixation of intra-abdominal oesophagus to right crus
Loose, floppy wrap over large bougie (50Fr)
Types
Traditional Nissen: 360 deg post wrap
Partial
Besley Mark IV 270
Toupet 180 degree
Lithotomy
Hasson at mid point b/w umbilicus and xiphisternum
Nathanson retractor under left lobe liver
3 x 5mm ports (2 on Right side)
Harmonic scalpel
Reduce hiatal hernia
crural repair important
Division of short gastrics controversial: may lead to more gas bloat. Literature equivocal
Penrose drain around oesophagus for traction, held by assistant
Suture oesophageal hiatus over 50 Fr bougie (extracorporeal)
?temporary mesh over hiatus
Wrap fundus
Little role for Collis gastroplasty for shortened oesophagus as this is rare
TEPP inguinal hernia
PROCEDURE
Paramedian longitudinal umbilical incision
Incise anterior sheath
Push rectus muscle aside
Push inflation dissector into space between rectus and posterior sheath and inflate under vision
Put Hasson into space after holding plane open with Langenbeck
Dissect hernial sac away
Inferior epigastric vessels
Purple trash
Triangles of doom and pain
Beware of iliac vessels inferiorly
Dissect lateral peritoneum
Cut mesh into shape
Put maxon/PDS suture on posterolateral surface of mesh and roll
Place into space
Tack medially and be careful placing tacks laterally
Paramedian longitudinal umbilical incision
Incise anterior sheath
Push rectus muscle aside
Push inflation dissector into space between rectus and posterior sheath and inflate under vision
Put Hasson into space after holding plane open with Langenbeck
Dissect hernial sac away
Inferior epigastric vessels
Purple trash
Triangles of doom and pain
Beware of iliac vessels inferiorly
Dissect lateral peritoneum
Cut mesh into shape
Put maxon/PDS suture on posterolateral surface of mesh and roll
Place into space
Tack medially and be careful placing tacks laterally
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