Principles of Laparoscopic and

Robotic Surgery
Pembimbing
dr. M Iqbal Rivai, SpB KBD

I. ARNIF

Definition
Modern technology and surgical innovation
Minimal somatic and psychological trauma
Shorten operating time, shorten hospitality, faster

recuperation

Extent of minimal access surgery

Laparoscopy
Thoracoscopy
Endoluminal endoscopy
Perivisceral endoscopy
Arthroscopy and intraarticular joint surgery
Combined approach

Surgical trauma in open, laparoscopic and robotic surgery

Mechanical and human retractor additional

trauma
Exposure to atmoshere evaporation
Adhesion
Handling intestines adynamic ileus

Limitation of minimal access surgery

Operate remote
Two dimensional view
Hand-eye coordination problems (technically

demanding)
No tactile feedback (laparoscopic USG)
convert to an open operation isnt a complication
Arterial bleeding
Large pieces of resected tissue

Improvement
Hand assisted laparoscopic surgery
Ultrasonic dissection, tissue fusion device, tissue

removal have been utilised

Current units combine three or four functions
Three dimensional imaging
Knot tying

Robotic surgery
Mechanical device
Automatic physical tasks
Direct human supervision
Redefined program/general guidelines
Artificial intelligence techniques

Laparoscopic limitation robotic surgery

Better visualisation
elimination hand tremor, improved manoeuver

(robotic wrist)
Large external movement limited internal
movement (robotic hand)
Ergonomic place, less stress, higher concentration

preoperative evaluation
History
Examination
Premedication
Prohylaxis against thromboembolism
Urinary catheters and nasogastric tubes
Informed consent

Theatre set up and tools

Key to surgerys smooth running
New theatre designed with moveable tools come

down from ceiling

Image quality is vital
Disposable equiments more available
Simple designs are now being studied

General intraoperative principles

Creating a pneumoeritoneum (closed, open)

Preoperative problems
Previous abdominal surgery
obesity

Operative problems
Intraoperative perforation, bleding (operative)

*extra ports may be required

Handle bleeding prevent it from happening
Bleeding from major vessel : use fine tip grasper
(electrocautery/clip)
Good suction and irrigation

Bleeding from gallbladder perform dissection in

correct plane
Bleeding from trocar site upwards and lateral
pressure with the trocar
pressure (folley balloon catheter), and sutures
Blood clots avoid by careful dissection,
identification of artery
Routine 5000-7000 units heparin per litre of
irrigation fluids, small pool irrigation fluid, suction

principles of electrosurgery during laparoscopic surgery

Electrosurgical injuries are potentially serious, occur

by using monopolar diathermy (1-2 per 1000

operations)
Usually delayed recognised as a fever and
abdominal pain 3-7 days after surgery
Bipolar diathermy is safer

Postoperative care
Complaints: upper abdominal pain (dull), nausea,

pain around the shoulder

Suggestions: local anaesthetic, leave 1 litre saline,
Investigation: blood count, liver function, ultrasound

No problems discharge within 24 hours with instruction to return

if no satisfactry progress

Nausea. Avoid opioid analgesia

Shoulder tip pain
Abdominal pain
Analgesia
Orogastric tube
Oral fluids
Oral feeding 4-6 hours after surgery
Urinary catheter
drains

Discharge from hospital

On the day of surgery/following morning
Abdominal pain/severe symptoms return to

hospital
Sutures non absorbable in 7 days
Mobility and convalescence. move A.S.A.p

Common laparoscopic procedures

Certain emergency (stable patient) : diagnostic,

perforated duodenal ulcer repair, appendicectomy,

intestinal obstruction by adhesions, strangulated
hernia repair

Robotic disadvantages
Increased cost
Increased set up of the system and operating time
Sosioeconomic implications
Significant risk of conversion to convensional

techniques
Prolonged learning curve
Multiple repositioning of the arms can cause trauma
Haemostasis
Collision of the robotic arms in extreme positions

Further developments
Natural Orifice Translumenal endoscopic surgery

(NOTES)
Single Incision Laparoscopic surgery (SILS),
Laparoendoscopic singlesite surgery (LESS), Single
port Access (SA)

NOTES

SILS

The future
No change in nature of disease
Training is a key to progress
Robotic surgery now available not only for assisting,

but also for aiding in the perioerative management

Terima Kasih