Combined procedures in laparoscopic surgery

Introduction:

At the start of the era of laparoscopic surgery in the 1990s, surgeons were confronted by a series of problems closely comparable even in single procedure but slowly after better training available the new generation of laparoscopic surgeons are more skilled. Laparoscopic surgery is now a dynamic and integral component of surgical training for both surgeon and gynecologists. In many surgical programs, the surgeon-in-training gradually incorporates the minimal access surgical knowledge and skill-sets through a variable spectrum of "Hands On" training and instruction with different surgical mentors.

With advancements in minimal access surgery, and with increasing skill and experience of performing surgeon, combined laparoscopic procedures are performed for the treatment coexisting abdominal pathologies at the same surgery. In our center of Minimal Access Surgery at World Laparoscopy Hospital, we performed 101 combined surgeries from May 207 to August 2012. In the 145 procedures, 80 patients were combined laparoscopic procedures and 21 patients were open conventional surgical or gynecological procedures coupled with endoscopic procedures.

A combination included laparoscopic cholecystectomy, Hysterectomy, Appendicectomy, various hernia repairs, and other gynecological procedures like salpingectomy, ovarian cystectomy, tubal ligation. All of the combined surgical treatments were performed successfully. As long as the fundamental surgical principles of minimal access surgery and indications for combined procedures are adhered to, more patients with concomitant pathologies can enjoy the advantage of minimal access surgery. Laparoscopic surgical procedures are feasible and appears to possess several positive aspects in simultaneous management of two different coexisting pathologies in general surgical and gynecological speciality, without significant addition in postoperative morbidity and stay in hospital.

In recent year with widespread applications for minimally invasive techniques and advanced laparoscopic HD technology, and state of the art safe energy sources and contributions from skilled assistants are now increasingly more important for effective and safe operative conduct of combination laparoscopic procedure. Incorporating these challenges into a balanced educational process remains no easy matter.

Role of Surgeon in Combination Laparoscopic Procedures:

Role of Surgeon in Combination Laparoscopic Procedures is most important. The combination laparoscopic Surgery should be tried by only an experienced laparoscopic surgeon. Approximately 30 years after its introduction, the use of laparoscopy in gynecology and general surgery has expanded from diagnosis and tubal sterilization to cholecystectomy to appendicectomy to more sophisticated operations and is even being used for the management of combined pathologies in same sitting. Because levels of operative laparoscopy, study populations, surgeons skill and definitions of combined operation vary in different series, it is difficult to determine the exact incidence of complications and outcome if surgeon perform two laparoscopic procedure in same sitting but most important factor in this type of surgery is surgeon himself. "Skilled Surgeon - Safer Surgery".

The application of minimal access surgery to general surgical and gynecological practice has revolutionized the field of surgery. Since the first laparoscopic cholecystectomy performed more than a three decade ago, laparoscopic techniques have been applied to an increasing number and variety of general surgical, gynecological and urological procedures. The advanced laparoscopic approach provides the ability to access the entire abdominal cavity by appropriate port placement following base ball diamond concept of port position applied by a well trained surgeon.

Role of Good Assistant in Combination Procedure:

All laparoscopic surgeons know the benefits of having a good minimal access surgical assistant. No longer is the operating room just one or two nurses and an anaesthetist with a minimal access surgeon in charge, but a team of various specialists and support staff working closely together. The adverse effects of poor camera person have not been measured or discussed but are well known to every surgeon and gynecologists. In combination surgery it is particularly important to have a good camera person and assistant.

A newbie assistant requires their instruments applied from the surgeon per new step up the operation. This means the laparoscopic surgeon has got to let go of their particular instruments each time, which slows down the operation. As a possible expert assistant needs practice and understanding of what the surgeon is aiming to do, helped in the event the surgeon can explain this properly. Helping at lap surgical procedures are harder than helping at open surgery. There isn't any direct view in laparoscopic surgery plus you've got to think about the monitor screen and learn new co-ordination from the hand and eyes. For the reason that instrument passes through the port that is fixed in place, is provides for a lever with "paradoxical motion".

If the handle of laparoscopic instrument is moved, the running end with the instrument moves from the other way, which is confusing in the beginning. Specially in combination procedure the port position is compromised and so the role of a good assistant and camera person is enormous. Instruments used in laparoscopic surgery will be more dangerous than those in open surgery for their smaller size as well as the limited look at the operation. As an illustration, fan-like retractors are useful for retraction but when they are turned sideways as opposed to pressing flat, their thin edges can lacerate organs like the liver. Tips of instruments can perforate viscera if used blindly or forcefully, especially as feeling of touch is partly lost by friction of instruments moved in or out through a port.

Role of Ergonomics in Combination Laparoscopic Procedures:

Ergonomics in laparoscopic surgery is the scientific study of surgeon during surgery with the aims of improving accuracy, productivity, training, satisfaction, and safety. Its relevance to minimal access surgery seems more obvious, though it has been applied less often during laparoscopic surgery in a formal way than to other forms of work.

Throughout history of medicine the most effective surgeons, like the best engineers and best managers, are generally good in ergonomics. They gave the impression to understand the significance of designing equipment and details to accommodate their assistant surgeon and how to organize systems of fundamentals of laparoscopy from the best method. Because good ergonomics aims to boost productivity and the satisfaction of minimal access surgeon, it becomes typical in a combination laparoscopic procedures. Recent history shows that surgeons will need ergonomics in the design of their work and equipment, and as part of their skills.

CONCLUSION:

Surgeon variables play a significant role in speed of acquisition and performance of combination laparoscopic procedures. Further studies need to elucidate their role in quality of laparoscopic surgery performance if two procedure has to be combined together. Combined procedures by experienced surgeon can be a modality of choice for concomitant pathologies in the abdomen. Apart from financial benefit to the patient there are many other benefits of minimal access approach is there, namely lesser pain and morbidity, shorter hospital stay, and better anesthetic management, it is now possible to combine two laparoscopic surgical procedures done endoscopically in different parts of the body. This not only provides the patient all the advantages of minimally invasive surgery, but also gives the benefits of single time anesthesia for surgical intervention for multiple pathologies.

 

World Laparoscopy Hospital, Cyber City, DLF Phase II, Gurugram, NCR Delhi, 122 002, India
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