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Laparoscopy

Historical Background

The term laparoscopy belongs to an area of surgery that crosses all traditional disciplines , from general surgery to neurosurgery. It is a minimally invasive surgery ( MIS ) . Minimally invasive surgery is a means of performing major operations through small incisions, often using miniaturized high – tech imaging systems , to minimize the trauma of surgical exposure .

The newest and most popular variety of MIS , laparoscopy , is infact the oldest . Primitive laparoscopy , placing a cystoscope within an inflated abdomen , was first performed by Kelling in 1901 . It was dangerous because of hot elements at the tip of the scope . In the late 1950s , Hopkins described the rod lens , a method of transmitting light through a solid quartz rod with no heat and little light loss . At the same time , thin quartz fibers were discovered to be capable of trapping light internally and conducting it around corners . This important discovery , opend the field of fiberoptics and allowed the rapid development of flexible endoscopes . By the mid 1970s , rigid and flexible endoscopes made a rapid transition from diagnostic instruments to therapeutic ones .

The Team of Laparoscopy

The team may consist of a laparoscopic surgeon and an operating room nurse with an interest in laparoscopic surgery . Adding laparoscopic assistants and circulating staff with an intimate knowledge of the equipment will add to and enhance the team nucleus . Having a good designated laparoscopic team reduces the conversion rate and overall operative time , and leads to a cost saving for patient and hospital .

Physiologic changes

There is occurance of physiologic changes even with the least invasive procedures .Many minimally invasive procedures require minimal or no sedation , so there are few alterations in cardiovascular , endocrine and immune systems function .

Those that require general anesthesia , have a greater physiologic impact , because of the anesthetic agent , the incision and the pneumoperitoneum .

Laparoscopy

Nitrous oxide and carbon dioxide are used for inflating the abdomen . N2O is physiologically inert and absorbs rapidly . It provides better analgesia for laparoscopic performance under local anesthesia , when compares with co2 or air . N2O would not suppress combustion , but controlled clinical trials have established its safety within the peritoneal cavity .

There are two types of the physiologic effects of co2 pneumoperitoneum : 1 – gas effects and 2 – pressure effects

CO2 is rapidly absorbed across the peritoneal membrane into the circulation and creats a respiratory acidosis ( generation of carbonic acid ) .

Te largest reserve of body buffers lies in bone . They absorb co2 ( up to 120 ) , and minimize the development of hypercarbia or respiratory acidosis during brief endoscopic procedures . With saturation of body buffers , respiratory acidosis developes rapidly . The respiratory system assumes the burden of keeping up with the absorption of co2 and its release from these buffers . In patients with normal respiratory function , this is not difficult . The anesthesiologist increases the ventilatory rate or vital capacity on the ventilator . In cases with respiratory rate more than 20 per minute , there may be less efficient gas exchange and increasing hypercarbia . * Hypercarbia causes tachycardia and increases systemic vascular resistance . Therefore elevates blood pressure and increases myocardial oxygen demands .

***Pressure effects of the Pneumoperitoneum : In the hypovolemic individual , excessive pressure on the inferior vena cava ( IVC ) and a reverse Trendelenburg position with loss of lower extremity muscle tone may cause decreased venous return and cardiac output .

*The most common arrhythmia created by laparoscopy is bradycardia . A rapid stretch of the peritoneal membrane often causes a vasovagal response with bradycardia and occasionally hypotension . Increased intra-abdominal pressure compresses the inferior vena cava ( IVC ) and therefore diminishes venous return from the lower extremities , more prominently in the patient placed in the reverse Trendelenburg position for upper abdominal operations . Venous engorgement and decreased venous return promote venous thrombosis . It is an avoidable complication with the use of sequential compression stockings , subcutaneous heparin or LMWH .

Increased intra-abdominal pressure decreases renal blood flow , glomerular filtration rate and urine output . These effects may be mediated by direct pressure on the kidney and the renal vein . Decreased renal blood flow causes increase of plasma renin release , thereby increasing sodium retention . Rise of ADH level during the pneumoperitoneum causes more free water reabsorption in the distal tubules .

*Intraoperative oliguria is common during laparoscopy . Serum cortisol levels after laparoscopic operations are often higher than after the equivalent operation performed through an open incision . The greatest difference between open and laparoscopic surgery is the more rapid equilibration of most stress – mediated hormone levels after laparoscopic surgery .

Immune suppression is less after laparoscopy than after open surgery .

To be continued ...

تاريخ بروز رساني : شنبه 12/05/87 ساعت 21:29

Mashhad University of Medical Sciences Contact Details:
Main address: University St., Ghoraishy Building 91375-345 Mashhad, Iran ,
Tel:( 98 511) 841 2081-5 , Fax:( 98 511) 8430249 , E-mail: Info(at)mums.ac.ir Members: - Schools and Hospitals School: Dentistry , School: Health , School: Medicine , School: Nursing & Midwifery , School: Paramedical , School: Pharmacy , School: Traditional Medicine , Hospital: Dr.Sheikh , Hospital: Dr.Shariati , Hospital: Emam Reza , Hospital: Ghaem , Hospital: Hashemi Nezhad , Hospital: Ibn-e-Sina , Hospital: Khatam-al-Anbia , Hospital: Montaserie , Hospital: Ommul-Banin , Hospital: Omid , Hospital: Shahid Kamyab , Hospital: Taleghani , History: Mashhad Faculty of Medicine was officially opened on Nov. 23, 1949 by Dr Zanganeh, the minister of culture. The school started out with 61 students, one associate professor and seven tutors. In 1956, when the school of Arts opened, the two schools merged to form the University of Mashhad. In 1989, the faculties offering Medical Sciences' degrees across the country separated from the Ministry of Culture and Higher Education. New emerging Medical Universities have gone under management of Ministry of Health, Treatment and Medical Education. Thus the original University of Mashhad was divided into two independent universities: "Ferdowsi University of Mashhad" and "Mashhad University of Medical Sciences'. Mashhad University of Medical Sciences operates at present with 8 faculties, 32 hospitals, 179 rural and 147 urban health centers. It covers an enormous area stretching from the north east to the central parts of the country, which makes it the largest university of Medical Sciences providing health care and treatment services. With 597 teaching staff, 1645 MDs with different specialties, 138 dentists, 123 pharmacists and 25, 402 employees, the university provides health care and medical services to the area's large population as well as to over 25 million tourists a year.

مشهد، خیابان احمدآباد، بیمارستان قائم(عج)، طبقه سوم، بخش جراحی 2، اتاق 29/3، دفتر مرکز تحقیقات جراحی آندوسکوپیک وروشهای کم تهاجمی. تلفن: 8012806 0511 نمابر: 8402972 0511 پست الکترونیک: emis@mums.ac.ir
تمام حقوق مادی و معنوی این سایت مربوط به دانشگاه علوم پزشکی مشهد می باشد و هرگونه کپی برداری از مطالب آن تنها با ذکر منبع بلامانع است.