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Please wait loading VIdeo Lecture of Prof. R.K. Mishra about Safe Port Position in Minimal Access Surgery
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Operations completed using the minimal access approach ought to be of the same quality his or her conventional open counterpart. It should be emphasised that the difference between minimal access surgery and open surgery is the extent of the access as indicated by the name of the technique. Minimal access surgery mustn't compromise patient safety. There are several factors which influence using minimal access surgery: Safety of the access to body cavity With previous abdominal surgery, there's a risk of bowel injury because of adhesions. The technique and the site of induction of pneumoperitoneum needs to be modified in patients with previous surgery. Laparoscopy is contraindicated in patients having a good reputation for previous extensive abdominal surgery.
Adequacy of exposure Optimum assessment using the minimal access approach requires adequate space to reveal and handle different organs. With gross obesity, the laparoscopic approach is more difficult and technically demanding. In the presence of bowel obstruction or organomegaly, the intra- abdominal space is reduced and, therefore, experience and caution are required. In some cases, laparoscopy may not be practical. Task difficulty The mechanical and imaging constraints in minimal access surgery make laparoscopic task performance harder than its open counterpart. The individual surgeon has to balance their own laparoscopic experience against the operative task. While a surgeon might be competent in undertaking bowel anastomosis utilizing an open approach, he or she might not be in a position to perform laparoscopic bowel suturing.
Patient safety Some patients require effective and quick intervention as in the cases of uncontrolled shock or faecal peritonitis. These patients aren't suitable for lengthy laparoscopic procedures. The surgeon should be prepared to convert to a wide open approach should she or he encounter technical complications or experience a lack of progress using the procedure. This will 't be regarded as a sign of failure. All patients undergoing laparoscopic surgery should be warned of the risks of converting to an open procedure. For instance, the 'standard' conversion rate for elective cholecystectomy is all about 5% and all patients should be warned of this possibility. Constraints in minimal access surgery The minimal access approach creates a group of mechanical and visual restrictions on the execution of surgical tasks. A few of these are considered below. 1. Mechanical restrictions These are the restrictions encountered on handling the tissues by endoscopic instruments: - Limited degrees of freedom of instrument movement. - Diminished tactile feedback. - Small , long instruments. - Problems of organ retrieval.
Standard endoscopic instruments have four examples of freedom of movement. A diploma of freedom is the potential for movement in one independent direction, or a rotation around one axis. As opposed to the 4° of freedom in minimal access surgery, there are more than 36° of freedom of the body-arm-fingertips movement in open surgery. This limited number of degrees of freedom makes handling of tissues in laparoscopic procedures harder than during conventional open surgery.
In minimal access surgery, direct tactile feedback (hand to tissue) is lost and also the indirect tactile feedback (with the instrument) is markedly diminished because of along endoscopic instruments and also the friction between your instruments and also the ports. This degrades ale the surgeon to identify the character of component tissues and tissue planes. Additionally, it may result in tissue damage from excessive instrument grip, which may be poorly appreciated by the surgeon. The little size endoscopic ports dictates the size of endoscopic instruments. This causes several difficulties in the design of endoscopic instruments to do the same function as their open counterparts. Long thin instruments have a poor mechanical advantage. The length of endoscopic instruments exaggerates hand tremors, particularly in a magnified endoscopic field.
Another intrinsic problem in minimal access surgery is tissue retrieval after detachment from adjacent tissues. This problem has two aspects: (i) the tissue must be reduced towards the size access wounds with preservation of tissue architecture and (ii) the chance of contamination including spillage of cancer cells must be eliminated. .
However, the growth of laparoscopic cholecystectomy continues to be then equally rapid development and using minimal access procedures in just about any surgical specialty. This chapter considers the individual safety issues that arise with the diffusion of a new procedurally-based technology. It highlights the "learning curve" inherent in any new procedure, as competence invariably grows with more experience. Because it is so widely performed and has the largest literature describing its record, this chapter focuses on lessons learned in the introduction of laparoscopic cholecystectomy.