Laparoscopy & its Ergonomics by Dr.Mohammad Zarin
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Laparoscopic surgery poses unique ergonomic and physiological challenges compared to open surgery. Ergonomically, the laparoscopic surgeon must maintain straight line principles, triangulation, and proper instrument and body positioning to work efficiently in the confined space. Physiologically, the increased abdominal pressure from insufflation can temporarily decrease cardiac output and organ perfusion while increasing respiratory and renal stresses on the body. Proper patient positioning and understanding of these impacts are vital for the laparoscopic surgeon.
Laparoscopy & its Ergonomics by Dr.Mohammad Zarin
- 2. Ergonomics & Physiology In Laparoscopic Surgery Dr.Mohammad Zarin MBBS, FCPS, MRCS, FMAS Associate Professor, SEW Khyber Teaching Hospital
- 4. Outline of Presentation Ergonomics Physiology Instruments
- 6. 2 D Image No depth Perception No tactile feedback Counter-intuitive Limited movements Magnification
- 7. Open Surgeon Vs Lap Surgeon How do they differ?! Open Surgeon Fast Hand is as good as eyes Dissection precedes Ergonomics: Optional Laparoscopic Surgeon Slow and steady Stop when you dont see Haemostasis precedes Ergonomics: Vital
- 8. To be an efficient Surgeon Equipments Environment Concentrate on
- 9. PATIENT POSITION Produce gravitational displacement of viscera away from surgical site. Trendelenberg Rev Trendelenberg 15-20 head down 20-30 head up Endobronchial intubation Predisposition to DVT
- 11. Ergonomics Straight Line principle Triangulation Manipulation angle Elevation angle Low lying table Gaze down view
- 13. Visual Axis and Motor Axis
- 15. Base Ball Diamond Concept & TriangulationMonitor S C R L P
- 16. Manipulation angle Azimuth Angle Manipulation Angle 30-45 degree 60-90 degree
- 17. Elevation angle
- 18. Ideal angles! 1. Manipulatation angle: 60 degree 2. Azimuth angle: Equal/30 degree each 3. Elevation angle: 60 degree
- 19. Ergonomics of Hand Instruments Tip Range of movements Conventional Vs Robotic instrument: 4: 7
- 20. Ergonomics of Hand Instruments Tip Range of movements Conventional Vs Robotic instrument Length of the shaft
- 21. Fulcrum Effect of Hand Instruments 1: 1
- 23. Ergonomics of Port Placement
- 24. Ergonomics of Hand Instruments Tip Range of movements Conventional Vs Robotic instrument Force transmission Length of the shaft Handle design
- 26. Surgeons Stance Ideal relaxed stature Tiring
- 27. Ideal Relaxed Position -straight head, in the axis of the trunk, without rotation or extension of the cervical spine; - shoulders in a relaxed and neutral position; - arms alongside the body - elbows bent to 70 to 90 degrees - forearms in an horizontal or slightly descending axis- -hands pronated (physiological resting position); - hands and fingers lightly grip the handles/handpiece Waist line table Gaze down view of monitor Straight line principle Triangulation
- 28. PHYSIOLOGICAL EFFECTS OF LAPAROSCOPY Can be: Mechanical Metabolic On Cardiovascular Pulmonary Gastrointestinal Renal Peripheral vascular
- 29. Cardiovascular Effects: IAP CO VR SV Afterload MAP HRx = Vasopressin & Catecholamines CO2 CVP PCWP SVR VR LVEDV
- 30. Cardiovascular Effects: Cardiac Output Variation between studies < 30% decrease when observed On insufflation; in I.A.P; transient generally noted in: ASA Class III/IV hypovolemic patients PP > 15 mm Hg reverse Trendellenberg position
- 31. Respiratory Effects: IAP cephalad shift diaphragm paradoxic diaphragm motion ITP FRC RR CO2 Ve & work of breathing chest wall compliance Hypercapnia PAWP + Alveolar Collapse TV
- 32. Respiratory Complications: Pneumothorax / Pneumomediastinum / Pneumopericardium 2属 to diffusion of gas from pneumoperitoneum Accidental diaphragm injury / pre-existing diaphragmatic defect 2属 to rupture of blebs with PAWP Gas Embolism 2属 to vascular injury trocar / needle insertion on insufflation / intra-op vessel injury
- 33. Gastrointestinal effects: I.A.P. Mesenteric & celiac flow hepatic artery flow hepatic perfusion perfusion intestines & stomach Portal flow LFTs intestinal & gastric pH
- 34. Renal Effects: I.A.P. GFRERPF U/O RAAS CO2
- 35. Renal Effects: U/O return to baseline within hours No long-term change in GFR No change in Cr, BUN
- 36. Peripheral Vascular Effects: I.A.P. Reverse Trendellenberg Venous stasis VR Risk DVT?
- 37. Peripheral Vascular Effects: Incidence of DVT, PE generally lower post laparoscopic procedures Secondary to improved prophylaxis? Risk increased with longer procedures and reverse Trendellenberg
- 38. Laparoscopic Instruments Hand instruments
Editor's Notes
- #11: Trendelenburg position (head down) usually for gynaecological procedures or Reverse trendelenburg (head up) for upper GI surgery. Trendelenburg: Greater respiratory effects including further reduction in FRC, more V/Q mismatch and greater risk of atelactasis. Initial increase in VR may not be tolerated in patients with compromised myocardial compliance. Reverse Trendelenburg: More marked effects on CV system due to decreased VR and CO therefore low BP. 3 most common patient positions: supine for majority of procedures including cholecystectomy, appendectomy, gastric small bowel, colonic and vascular proceures. Modified lithotomy position used for procedures in pelvis. Allen stirrups used to hold leg in position. Lateral decubitus position most often used for splenectomy, adrenalectomy and thoracoscopic procedures.