The Transition to Laparoscopic Surgery
Mastering the fundamentals of laparoscopy is crucial for surgeons to ensure patient safety, improve outcomes, and increase efficiency in the operating room. Laparoscopy is a whole new fascinating world giving amazing results, unbelievably quicker recovery, and great satisfaction. However, here are some key areas to focus on:
It is essential to know that, the approach to the abdomen is the first thing that is going to change as one moves on from an open surgical approach to the laparoscopic surgical approach.
The anatomy remains the same, but the way we have to view it and operate changes drastically when we switch from conventional open surgery to laparoscopy. It’s like relearning anatomy. This calls for urgent attention to understand and study in detail the endoscopic/laparoscopic anatomy of the abdomen. There are very prominent landmarks that help us perform safe surgery while studying laparoscopic anatomy.
The other important factor is that in conventional open surgery, hands were all that one needed to operate with tactile sensation i.e. touch and pressure sensation, feeling the tissues being the most important factor while operating and decision making.
Laparoscopy on the other hand is highly equipment and instrument-dependent, with absolutely no chance to feel the tissues, as it’s only the tip of the long laparoscopic instruments that get to touch the tissues. One needs to get used to this.
The Laparoscopic Operating Room
As laparoscopy involves the use of long thin instruments, there is a fulcrum effect at the abdominal wall through which the instruments enter into the tummy. This gives rise to paradoxical movements and this is the other important factor that one needs to get used to while changing from conventional surgery to open surgery. Endotrainers are available to bridge the gap and practicing on the endotrainer can help one acquire laparoscopic skills very soon with perfection.
Understanding the equipment tower that holds the cameras, light source, insufflator, and various laparoscopic equipment is important as lap surgery is equipment-dependent.
A high-definition camera is a valid investment as in laparoscopy, the camera is your eye and you can see only what the camera shows you.
Also handling lap instruments, dismantling, and re-fixing is essential for the surgeon and the staff should also be well-versed with the equipment and instruments.
The OT setup is very important as in laparoscopy unlike open surgery one has to get used to extra equipment in the OT, making sure that there are no loose cables running on the floor so that one may not drip and fall. All this equipment will have cables and wiring.
The OT table should be able to give the different tilts like the Trendelenberg, reverse Trendelenberg, side tilts, etc as laparoscopy involves and is successful due to the various tilts in order to get adequate exposure and access to the organs that need to be operated upon. Proper strapping of the patient to the table is necessary to ensure that the patient does not slip or fall.
Essential Laparoscopic Skills
Master the techniques, Veress needle technique or Hassans technique for safe insufflation of the abdominal cavity, understanding the physiology of pneumoperitoneum, the intra-abdominal pressure that needs to be maintained, knowledge of all this will be required.
1. Daithermy
As we don’t have our hands in the abdomen to hold a bleeder or give pressure in case there is bleeding, during laparoscopy, one is highly dependent on energy sources in order to maintain hemostasis. Diathermy ( monopolar/ bipolar), ultrasonic energy. Investing in a good energy source calls for safe laparoscopy.
2. Ergonomics
Port placement i.e. the conduit through which the lap instruments enter into the tummy in order to perform surgery, needs to be placed with diligence. The direction through which the ports enter is important making sure that there is full flexibility for the instrument to move freely for best results. Distance between the ports and the positioning on the abdominal wall is important in maintaining triangulation which is important for ergonomics so that the surgeon can operate in the proper posture to minimize fatigue and enhance precision.
3. Maintenance
Laparoscopy as we have discussed at the start, involves a substantial investment in terms of equipment and instrumentation, and hence maintenance of equipment and instruments is paramount to make sure that there is proper functioning, less wear and tear, and ensuring long-lasting service.
The Path to Laparoscopic Excellence
It is worthwhile to visit a high-volume laparoscopy hospital that offers training in laparoscopy. Here you will get all that is required to know about laparoscopy under one roof. Structured training courses are available wherein one gets individualized attention.
The training course should include
1) Lectures giving you detailed knowledge regarding safety precautions in laparoscopy, complications, peritoneal access, ergonomics, energy sources, OT setup,
maintenance of equipment and instruments, Sterilization, etc.
2) Live surgical demonstrations of different procedures imparting knowledge on insufflations, port placement, different dissection techniques, suturing, knotting,
clipping, ligating, specimen removal, etc.
3) Video demonstrations of a variety of surgical procedures, complications, how to manage the complications, etc.
4) Endotrainer. This is the backbone of a laparoscopic training course, wherein you will learn from scratch and get phenomenal confidence by practicing task-based exercises on a daily basis starting with very basic tasks initially and progressing to more specific tasks culminating in knotting and suturing which is the dream come true for a beginner in laparoscopy.
5) Cadaver training: Once you have gone through this rigorous training course, you can now be ready to perform a procedure on a cadaver and thus get maximum confidence.
You need to start sometime. Time to take the first step to training.