Laparoscopic Surgery - Science topic
Laparoscopic surgery, also called minimally invasive surgery (MIS), bandaid surgery, or keyhole surgery, is a modern surgical technique in which operations in the abdomen are performed through small incisions (usually 0.5–1.5 cm) as opposed to the larger incisions needed in laparotomy.
Questions related to Laparoscopic Surgery
As more number of major and lengthy surgeries are done laparoscopically. I'm looking for some clear-cut guidelines or recommendations in this regard especially degree of head down tilt allowed or duration of surgery allowed for steep Trendlenberg position etc especially considering the kind of devastating adverse effects such extreme position can cause.
In the case of a fit patient (ECOG 0/1), having a distal ureteric tumor, with a proven TCC high grade pT1- of the bladder, what would be the most apt management strategy?
Would the choice of management vary, depending on-
A) Age of the patient
B) Status of the Opposite kidney
C) Role of reimplantation of the ureter in a diseased bladder.
D) Need for surveillance of the upper tract.
Many believe that minilaparoscopy is attractive option that may replace conventional laparoscopy and might be an alternative to technically challenging LESS
In the past 15 years or so, there has been exponential growth of technology in surgery. This new era requires a specialized workforce. The 20th century was truly the age of surgeons; however, the 21st century will be the age of multidisciplinary patient care. One good example is the treatment of cancer patients
Are General Surgery trained personnel perform better in other specialties too?
How are their performance on other surgical specialties?
Any evidence to suggest their skill transferability to other disciplines?
As an aerosol generating procedures, laparoscopic surgery with pneumoperitoneum has got the potential to transmit COVID-19 virus to surgeons and other health care workers during surgery. Given a choice, should open surgery be done in COVID-19 positive patients? Apart from guidelines from professional bodies like SAGES, evidences are emerging regarding laparoscopic surgeries during COVID-19 pandemic. But there is still uncertainty regarding routine use of laparoscopic surgery in COVID-19 positive patients. Like what will be the preferred approach for acute appendicitis in a COVID-19 positive patient? Laparoscopy or open appendectomy?
In perforated appendicitis with pus and inflammation post laparoscopic appendicectomy. Obviously the duration of lap surgery is prolonged in such cases. Is there an increased chance of pelvic collection and post op morbidity?
- I am looking for statistical data on Endosopic, Laproscopic and minimal access surgery across globe and India
- What is the estimation to grow Endosopic, Laproscopic and minimal access surgery across glob and India
I have two sets, one contains 8 experts and the other contains 29 novices. Both evaluated their experience with 5 different questionnaires(e.g. 5-point, 10-point, and 21-points Likert style scales). The responses are non-normally distributed. Which type of non parametric test is applicable to compare the sum? And which is suite to reckon single item? Do I need a post hoc test?
Pts would ask for lap incisional hernia mesh repair in the same sitting along with Hysterectomy. The problem is the chances of mesh infection.
It is very important to eliminate them in LVHR in order to prevent their many intra- and postoperative complications (organs iatrogenic lesions, intraoperative bleeding, hematomas, postoperative abdominal-wall chronic pain (1.4-30%), mesh breakdown, suture site infections, thin skin scars, etc.), and to reduce operative time.
Here, i got a problem we didn't have the propriate disposable sterile protective sheath for laparoscopic ultrasound probe, we use the Arthroscopic sheath in replace. But it's difficult to restrain the bubble and handle the probe in this mean.
Theoretically, the probe can be sterilized before surgery, i am wondering if it bring incremental losses to the probe or not, and the better way to make sure the probe be sterillized?
The appendix is the picture of the laporascopic ultrasonograpic probe.
I have been using 3DMax Bard for over 100 cases of direct,indirect and femoral hernia in both Tapp and Tep, I found it easy,faster to deploy,easy to orient and spread the mesh.Fixation was done in most of the cases,one point fixation to cooper's ligament/pubic tubercle.One year followup ,no recurrences. Size of the defect is mostly 3 to 4cms. Downside is the cost. Mostly light weight mesh was used.
This can save rectum to be able to make anastomosis, instead of being forced to do ultra-low anterior resection.
A Beaurocrat 62 years on his annual checkup found to have a cystic leision in the pelvis reaching up to the Right Iliac fossa on U/S.Suspected as a case of Enteric duplication cyst, hence he was referred for further management.He is a Hypertnsive on medication.Clinical exam was normal , could not feel any mass.
Rest of the work up was normal except cect showed tubular cystic structure measuring 15cmsx6.2 cmsx6.3 cms extending from the Right iliac fossa .Endoscopic and colonoscopic assessmennt was not done.would a simlpe appendicetomy suffiecient !
A man of 49years presented with a history of constipation for over 5years, bleeding,feeling of mass per rectum on straining and used various methods to regulate his bowel habits with out success.He is not a diabetic or hypertensive.CBC(Hb dropped from 12Gr to 10 Gr) , LFT,TSH,PTH, Calcium,U/S scan are normal.Colonoscopy is normal except congested haemorroids. 2degree.
Anorectal manometry-normal squeeze pressure,50 mls balloon was expelled without difficulty and shicters are normal.Psychological assessment is not significant.
He says that his life style is getting affected.
66 year old who had Liver transplant in 2011 presented with a blow out at the left edge of the Bilateral subcoastal incision for 6 months. Immunosuppression has been titrated and antiplatlet drugs were stopped. His LFT are normal.He prefers to avoid open surgery.
This is for a patient with severe GERD with previous ischemic heart disease, so anti-reflux surgery needs to be done at the shortest time possible to avoid anesthesia complications
We have a a good choice of composite meshes for use.whenever i conduct a training programme,first question of participants is what mesh do you deploy /advice.As such there is no ideal mesh in my openion.However each brand has a one or more beneficial qualities.
Current evidence indicates that appendectomy puts patients at increased risk for recurrent clostridium difficile-associated colitis.
62 yrs old, no h/o HTN , DM underwent EMR for rectal polypoid lesion about 2 yrs ago, HPE was high grade dysplasia following which he underwent Anterior resection. 6-8 months later he developed difficulty in defecation predominantly frequency .
O/E there is an anastomotic stricture about 7-8 cm from the anal verge. serial endoscopic balloon dilatations were done , improvement f/b narrowing .
presently the stricture diameter is about 5-6 mm.
previous colonoscopy showed only benign looking stricture and scope could not be passed beyond.
Regarding technical aspects, "critical" view, indocyanine green cholangiography, infrared vision, etc.
Cold light sources are important for laparoscopy but are currently available sources actually cold light source? What is the effect of cold light on the problem of fogging apart from the chances of visceral injury?
I apologize if the question is a bit unclear, please allow me to elaborate using specifics.
In regards to a surgical intervention (lets say an appendectomy), my collaborators and I would like to compare the outcomes of manoeuvre A and B in laparoscopic appendectomy. Unfortunately, there have not been any clinical trials yet that compare the outcomes manoeuvre A and B in laparoscopic appendectomy.
What we have found, however, is RCTs that have compared the outcomes of open versus laparoscopic appendectomy. In certain RCTs, manoeuvre A is used for the laparoscopic appendectomy, and in other studies, manoeuvre B is used. Again, in each study we have found, either A or B is used (not both), as the studies are really comparing laparoscopic versus open appendectomy.
My question is: Is it possible to gather the outcomes from one limb of multiple RCTs (i.e. the laparoscopic appendectomy limb)--some of which use manoeuvre A and some of which use B--and compare them in any sort of systematic or meaningful way?
I have not seen a study that has done this before, which may be somewhat telling, but my knowledge of statistics is limited and I would love another opinion. If a direct comparison is not possible, would the presentation of the results be meaningful, or would the bias be too great?
Thank you very much for your time.
We know that laparoscopic systems with haptic feedback have more advantage than something else. so, Do they have mass production? In which countries?
I am doing quite some laparoscopic inguinal hernia surgery. Some patients with significant pulmonary morbidity prefer spinal anesthesia over general anesthesia. Others are afraid of the cerebral effects of general anesthesia.
Is it safe and feasible to perform TEP under spinal anesthesia or is the preperitoneal space to limited when patients are insufficiently relaxed?
Acute cholecystitis (AC) is frequently encountered in daily clinical practice. Since its publication in 2007 and the update in 2013, the Tokyo guidelines (TK 13) for the diagnosis and management of acute cholangitis and acute cholecystitis rapidly gained popularity. Besides defining diagnostic criteria, the TK 13 also enable a classification of acute cholecystitis in three severity grades. Grade I describes a mild form of inflammation, grade II describes a moderate gallbladder inflammation, while grade III corresponds to severe gallbladder inflammation in association with organ dysfunction. Laparoscopic cholecystectomy l (LC) is recommended for patients with grade I, a portion of patients with grade II should undergo LC in centers with expertise while all other patients (the rest of grade II and all grade III patients) should be managed via percutaneous cholecystostomy (PC).
A major problem with AC is the heterogeneity of clinical presentation! This makes it difficult to standardize treatment options. The treatment algorithm suggested in the TG13 cannot be universal! Besides, the benefit of PC in the management of severely ill patients with AC could not be established in a number of meta analyses.
The greatest weakness of the TK13 in my opinion is the failure to incorporate patient - dependent factors. Therefore my primary question is how do you choose candidates for PC? Second, do you adhere to the TG13? Third, how do you judge the current evidence on PC.
One of the commonly performed minimal access procedure is Lap mesh ventral hernia repair.we started with plain polypropylene grafts and now we are using composite mesh grafts.The market is flooded with variety of expensive grafts.Most of them are good. It is always a difficult task to choose.One such is symbotex which has been recently introduced in India.
In recent literature there have been many studies, with quite a few using ACS-NSQIP data, that have concluded that prolonged operative duration "leads" to more infective and "other" complications ... but I have been unable to find any article that can discuss and describe the patho-physiological mechanisms and basis of these findings. I will be grateful if someone can shed some light on this aspect of the notion that prolonged surgeries lead to more averse outcomes...
Direct trocar insertion through Palmer's point with 10 mm trocar OR Veress needle insufflation prior to trocar entry through Palmer's point? Which one is preferable or practiced?
What do you think, which method of four-port laparoscopic cholecystectomy (American or French) has advantages in terms of ergonomic conditions of access?
What are the methods to prevention of spillage gallstones you used in case of gallbladder perforation (in consequence traction or dissection) during laparoscopic cholecystectomy (on step of dissection of the gallbladder from its bed) in patients with acute cholecystitis and numerous small gallstones?
Patient may be male or female, 45 years old with no special alimentary habits. No previous operations, no GERD, no HP
The most common bariatric procedures are the Laparoscopic adjustable gastric banding, gastric bypass and sleeve gastrectomy, all with strong pros and cons. Other operations, such as biliopancreatic diversions are more rarely performed (for various reasons). Do you think that the "ordinary" operations would be efficient for such a patient?
I have been doing this procedure and found it to be a feasible and effective option in selected cases and in patients that are much conscious of an incision made over the breast. Below is the link of one of my video for reference and coments.
The evidence on laparoscopic vs. open left sided pancreatic resection is limited. Up to now no evidence from RCT can be used to evaluate the value of the laparoscopic technique.
Given the fact that the incidence of left sided resections is low even in centers for pancreatic surgery we postulate that it is necessary to perform an international trail. Would you be willing to participate?
Is there laparoscopic training box especially for laparoscopic Gynaecology now? and do you think that is it useful?
We found this to be very annoying probelm during TEP hernioplasty. Even no tear is seen in the peritoneum at the end of the procedure pneumoperitoneum is present. We've tried changing troacar positions, lowering the pressure of insuflator- no significant effect. Finally we found solition for this situation by placing a Veress needle lateral to the 10mm port for the camera. What is your experience with this problem?
Laparoscopic inguinal hernia is an excellent technique with a lower complication rate and incidence of postoperative pain compared to conventional open repair. A rare complication is accumulation of fluid collection in the dead space left after removing the hernia sack. Post-operatively it presents as a lump in the groin region sometimes accompanied with groin or testicle pain. This gives quite big concerns to the patient and surgeon. As far as I know, conservative treatment is recommended. But is there any indication for surgical intervention?
Different suture materials could be used during advanced laparoscopy. What is your favorite suture material and suturing technique for laparoscopic nissen fundoplication ?
How far one can proceed with aspiration? Is there another way to deal with Seromas following TEP repair? Inversion of the false sac and fixing it is one of the methods to reduce the seroma but what if happens postoperatively despite the above?
What about seromas following large incisional hernia repair?
49 yr old diabetic underwent Lap TV+GJ for Gatric outlet obstruction due to chronic DU.60 blue load was used for GJ.It was anterior, horizontal and stapler openings closed with 3 0vicryl single layer &continuous .Well for over one year and six months and started complaing of symtoms prior to surgery.Ba meal free flow through the stoma,upper Gi scopy: scope is easily entering in to afferent and efferent limbs and no comment was made about the stoma.But stomach appeared dilated with residual food.CECT showed markedly dilated stomach with food residue,duodenum is stenosed and the GJ stoma was 3.8 mm.
30 year old who under went an attempted lap chole converted to open,also underwent a diagnostic Lap 8months ago,presented with complaints of abdominal pain,feels full with small quantity ,no vomitings and no significant loss of weight.She was hospitalised twice after surgery for pain and was treated conservatively as per her hospital records.OGD in their hospital showed a gastric ulcer and a repeat was said to have the ulcer healed.Clinical exam is normal except Right subcoastal incision and multiple Lap port scars.OGD in our hospital showed the above suspected diagnosis and technically difficult to extract.CECT report is awaited.
Patient (54 years old) underwent laparoscopic cholecystectomy with Hasson technique and within 24 hours presented with acute abdomen. At operation, over 1 liter of succus entericus was aspirated and an enterotomy at the anti-mesenteric border of the distal ileum, measuring about 1 cm, was discovered.
Gone were the days that open cholecystectomy in this part of the Globe was not a common procedure. Now Lap chole is a household name and Gold standard technique for Gallstone disease. However complications are not common but if they occur the patient becomes a biliary cripple.
I just started with laparoscopic abdominoperineal resections for low rectal cancer. There was a patient with rectal cancer on 1 cm, without neoadjuvant therapy. It was a thin man, and operation went smoothly. I put some sutures on peritoneum to close the pelvis, like in open procedure. But after operation patient went in ileus and I had to operate him again (laparoscopicaly) on day 8 and found cca 30cm of terminal ileum in pelvis, which slipped between sutures. Bowel was vital but affected, no perforation, no peritonitis. I closed the pelvis with dual mesh. After two days patient became more and more septic and our team decided to make laparotomy and we found diffuse peritonitis with fibrin and pus everywhere. The mesh was in situ, there was no bowel perforation. We performed only lavage and treated the abdomen with negative pressure. After two sessions we managed to close the abdomen, and the patient is now OK.
How do you act in APR? Do you close the peritoneum over pelvis or leave it open?
Let’s imagine that there is only one available option regarding hands-on training in laparoscopic and/or robotic surgery for residents, besides assisting at surgical operations. The choices are as follows:
- surgery simulation using high-end virtual reality software or
- animal models as part of licensed live-tissue research protocols.
Which one would you choose and why?
It would be interesting to explore the perspective of professionals from different scientific fields (i.e. residents, board certified surgeons, professors, computer engineers, animal specialists or even financial analysts etc).
*Evidence-based answers with literature references will be appreciated.
Someone might be confused about the difference between the robot assisted surgery and the navigation system, which is helping a surgeon to direct the target. To answer this question, several experts' points of view is required.
There are several articles in the literature on this subject (including publications by many members of ResearchGate): some studies say it is beneficial while others differ. So definite conclusions have not been reached. But I found these studies (including RCTs) don't mention specific indications regarding which patients undergo HSV along with fundoplication.
Measuring 'quality' in surgery has become important, as its only with measuring 'quality' that we can begin to make improvements in care. Various measures have been suggested, such as
Length of stay
Intra-operative injury rate (for example CBD injury / ureteric injury)
Rate of laparoscopic surgery
Rates of conversion to open surgery
to be measured to compare quality in surgery specifically.
Lots of these factors can vary naturally, with a hospitals patient population (rich, poor, age group, comorbidities, hospital size, urban, rural, delays in presentation, access to healthcare etc) and other factors such as surgeon training / experience etc and many other reasons. So variability in these factors is to be expected.
What makes a good 'quality marker' in surgery?
Your thoughts would be appreciated.
All the best
Minimal access technique should be the gold standard and should be offered to patients when possible.One of the important issues in hernia surgery is Recti Diverication.Majority of patient are having advice of conservative measures like exercise,weight reduction,etc.Surgery is rarely suggested .
In the era of modern surgery,an acceptable and realistic solution is expected to be offered to these patients.
Case series here and there ,but no solid opinion is reflected in current literatures.
Is there still, a role for 2% gluteraldehyde, OPA or peracetic acid. Many surgeons have shifted to autoclavable reusable instruments. But how do you sterilize your light cables and scopes. How do you sterilize the instruments in between cases. I would like to know the opinions of surgeons who perform laparoscopy routinely.
Two pts were ref recently who had Lap Apx,one had emergency procedure and the other Elective.Both presented with acute Appendicitis.CECT showed 2cms appedicular stump with an abscess.one underwent open and the other Lap completion appendectomy.Both procedures were difficult.
I would love to design a simple questionnaire in which I Intend to find out if a surgeon would want to treat a condition "X" using procedure " A" or " B" and the reasons for the procedure (A or B) chosen.
I have a 25-year-old patient who underwent laparoscopic appendectomy for a ruptured appendix with peritonitis 9 days ago. He still has not opened bowels, has abdominal distension and one episode of vomiting. There is no fever/tachycardia/ hypotension. Bowel sounds are present. CECT revealed no collections, distended jejunum and large bowel, collapsed ileum and sigmoid colon. Sigmoidoscopy was normal, appendix HPE showed no TB or IBD.
He is now on TPN due to malnutrition, medications are erythromycin & mosapride, he is chewing gum daily.
According to the guidelines of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), elective surgery is expected to have an increased risk in patients with pulmonary hypertension. Epidural anaesthesia is thought to be better tolerated than general anaesthesia. (Eur Heart J. 2009; 2493-2537.)
Traditionally, we use a 11 x 6cm in open hernia repair. In laparoscopic repair, most surgeons use one of these sizes: 15 x 10cm, 15 x 12cm or 15 x 7.5cm. The recommendation is to adequately cover the myopectineal orifice of Fruchaud, so what size mesh will do this?
Is there a consensus?
Simultaneous pancreas and kidney transplantation is major surgery, involving quite big laparotomy and dissection. Generally, large laparotomy and major open surgery is considered to be relative (even absolute) contraindication to laparoscopy.
On the other side, laparoscopic surgery is associated with less incidence of postoperative complication compare to open approach. This benefit is even more significant in transplant patient. These patients, due to extensive co-morbidity and immunocompromised status are known to have higher incidence of postoperative complications.
Therefore, there is dilemma if in the case of need to remove gallbladder or any other elective surgery, laparoscopic option should be considered.
I'm sure this situation arises more often than not in all surgeon's practice. Typically, these burns leave a 'whitish' mark on the serosa. In my experience, I keep observing these injuries once every few minutes till I finish the procedure. Slowly, the 'whitish' mark diappears, and there is no problem postoperatively.
Do you prefer open or Laparoscopic repair for uncomplicated hernias. For open repair, do you go for the high or low approach. What should be the strategy for acute presentations of these hernias?
After disconnecting the uterus, I think suturing is faster and easier if its done transvaginally. Laparoscopy & CO2 insufflation times can be reduced as well. Is there any specific advantage of suturing intracorporeally?
The depth of neuromuscular block does reduce the values of pneumoperitoneum and its consequences.
With an increased incidence of APD, more and more patients are taking long-term PPIs. However, there is recent evidence that long-term PPIs can cause renal damage, more so in diabetics. Can surgeons offer laparoscopic highly selective vagotomy as an alternative to long-term medications? Surgery may offer permanent relief to most of these patients - especially the poorly (medically) compliant ones.
I need to find the rate of suppuration of laparotomy wounds in order to compare the rates in our country and worldwide.
I am currently conducting a systematic review on the subject.
Any recommendations especially from those with the relevant experience are very much welcomed.
The West Midlands Research Collaborative (http://www.wmresearch.org.uk) is preparing the largest, prospective audit of Cholecystectomies - called the 'CholeS study' in response to the recently published commissioning guidelines from the Royal College [http://www.rcseng.ac.uk/providers-commissioners/docs/rcs-eng-augis-commissioning-guide-on-gallstone-disease]
A brief synopsis is provided below and can be found at www.choles-study.org. You can register your interest via this website or email directly.
We would like 1-2 StRs (surgical registrars) with 2-3 CSTs (interns or resident level surgeons) in each hospital to help plus you will need to identify a supervising consultant. Medical students are welcome to be a part of a team.The audit will be for a 2 month period with an additional month for follow up. Only 28 data points on each patient will be needed.
As ever, ALL contributors to data collection will be citable authors on any subsequent publications. Individual centres can use this data to inform their local commissioning groups.
Let me know if you are interested and I will forward on protocols, audit standards, data collection forms and spreadsheets.
With best wishes
Ravi Vohra (On behalf of the WMRC)
Ewen Griffiths, Consultant Upper GI Surgeon
ABSTRACT: Clinical Variation in Practice of Laparoscopic Cholecystectomy and Surgical Outcomes: a multi-centre, prospective, population-based cohort study (CholeS Study)
Background: Cholecystectomy is one of the most common general surgical operations performed in the UK. Increasing proportions of patients have surgery in the acute setting for severe biliary colic, cholecystitis and following gallstone pancreatitis. Randomised clinical trials in acute cholecystitis and gallstone pancreatitis suggest early laparoscopic surgery performed in specialist units is safe. Despite this, management still differs between surgeons and centres across the UK. This has been highlighted in a recent commissioning guide produced jointly by the Royal College of Surgeons and the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland. The impact of these variations on outcomes is unclear.
Aim: To investigate surgical outcomes following acute, ‘delayed’ and elective cholecystectomies in a population-based cohort
Audit standard: All-cause 30-day readmission rate should be less than 10% following cholecystectomy (primary outcome measure). Secondary outcome measures are all highlighted variable within the commissioning guide: pre-operative (demographics, admission type, diagnostic tests) peri-operative (conversion rates of laparoscopy to open surgery, complications,) and post-operative (length of stay, in-hospital morbidity) factors.
Methods: The study will be performed over a two-month period in 2014. Participation from centres in the West Midlands alone is estimated to recruit 1,300 patients. Participation from centres across the UK is estimated to recruit 10,000 patients. The study will be performed using a standardised spreadsheet at each centre. Inclusion criteria will be: All patients undergoing cholecystectomy will be categorised into one of three groups: (1) Acute Chole