History

It is difficult to credit one individual with the pioneering of laparoscopic approach. In 1902 Georg Kelling, of Dresden, Saxony, performed the first laparoscopic procedure in dogs and in 1910 Hans Christian Jacobaeus of Sweden reported the first laparoscopic operation in humans. In the ensuing several decades, numerous individuals refined and popularized the approach further for laparoscopy. The introduction of computer chip television camera was a seminal event in the field of laparoscopy. This innovation in technology provided the means to project a magnified view of the operative field onto a monitor, and at the same time freed both the operating surgeon's hands, thereby facilitating performance of complex laparoscopic procedures. Prior to its conception, laparoscopy was a surgical approach with very limited application and used mainly for purposes of diagnosis and performance of simple procedures in gynecologic applications.

The introduction in 1990 of a laparoscopic clip applier with twenty automatically advancing clips (rather than a single load clip applier that would have to be taken out, reloaded and reintroduced for each clip application) made surgeons more comfortable with making the leap to laparoscopic cholecystectomies (gall bladder removal).

Procedures

Laparoscopic cholecystectomy is the most common laparoscopic procedure performed. In this procedure, 5-10mm diameter instruments (graspers, scissors, clip applier) can be introduced by the surgeon into the abdomen through trocars (hollow tubes with a seal to keep the CO2 from leaking). Rather than a minimum 20cm incision as in traditional cholecystectomy, four incisions of 0.5-1.0cm will be sufficient to perform a laparoscopic removal of a gallbladder. Since the gall bladder is similar to a small balloon that stores and releases bile, it can usually be removed from the abdomen by suctioning out the bile and then removing the deflated gallbladder through the 1cm incision at the patient's navel. The length of postoperative stay in the hospital is minimal, and same-day discharges are possible in cases of early morning procedures.

In certain advanced laparoscopic procedures where the size of the specimen being removed would be too large to pull out through a trocar site, as would be done with a gallbladder, an incision larger than 10mm must be made. The most common of these procedures are removal of all or part of the colon (colectomy), or removal of the kidney (nephrectomy). Some surgeons perform these procedures completely laparoscopically, making the larger incision toward the end of the procedure for specimen removal, or, in the case of a colectomy, to also prepare the remaining healthy bowel to be reconnected (create an anastomosis). Many other surgeons feel that since they will have to make a larger incision for specimen removal anyway, they might as well use this incision to have their hand in the operative field during the procedure to aid as a retractor, dissector, and to be able to feel differing tissue densities (palpate), as they would in open surgery. This technique is called hand-assist laparoscopy. Since they will still be working with scopes and other laparoscopic instruments, CO2 will have to be maintained in the patient's abdomen, so a device known as a hand access port (a sleeve with a seal that allows passage of the hand) must be used. Surgeons that choose this hand-assist technique feel it reduces operative time significantly vs. the straight laparoscopic approach, as well as providing them more options in dealing with unexpected adverse events (i.e. uncontrolled bleeding) that may otherwise require creating a much larger incision and converting to a fully open surgical procedure.

Conceptually, the laparoscopic approach is intended to minimise post-operative pain and speed up recovery times, while maintaining an enhanced visual field for surgeons. Due to improved patient outcomes, in the last two decades, laparoscopic surgery has been adopted by various surgical sub-specialties including gastrointestinal surgery (including bariatric procedures for morbid obesity), gynecologic surgery and urology. Based on numerous prospective randomized controlled trials, the approach has proven to be beneficial in reducing post-operative morbidities such as wound infections and incisional hernias (especially in morbidly obese patients), and is now deemed safe when applied to surgery for cancers such as cancer of colon.

The restricted vision, the difficulty in handling of the instruments (new hand-eye coordination skills are needed), the lack of tactile perception and the limited working area are factors which add to the technical complexity of this surgical approach. For these reasons, minimally invasive surgery has emerged as a highly competitive new sub-specialty within various fields of surgery. Surgical residents who wish to focus on this area of surgery gain additional training during one or two years of fellowship after completing their basic surgical residency.

The first transatlantic surgery (Lindbergh Operation) ever performed was a laparoscopic gallbladder removal.

Самостійна робота №6 до практичного заняття №11

Тема: Лікування серця дитини

Treatment of cardiac pathologies of babies.

In recent decades, the most important place in the treatment of cardiac pathologies have a heart operation and vessels. Invasive, that is, with penetration into the inner environment of the organism, the methods are used both for diagnosis and for treatment.

As is known, heart disease is the main cause of mortality in the world. On the first place in this category of disease is coronary heart disease (CHD). It should be noted that the mortality from myocardial infarction, the fatal manifestations of CHD, in Israel markedly lower than in other developed countries. It is 4.2%, which according to the who, by 4.4% lower than in France, by 4.6% lower than in Germany and by 0.4% lower than in the us. This is one of the indicators, clearly confirms the leading positions of cardiology and cardiac surgery of Israel.

Treatment of heart disease is one of the priority directions of medicine of Israel. The Israeli cardiosurgery is known for its achievements far beyond the country. Qualified specialists are not only excellent practical doctors, but also have a number of own scientific developments in this area. Israeli clinics (asuta, Шиба - tel-Hashomer, Ассута and others) are equipped with the latest technology, including robotics, that allows to carry out operations on the heart, on the most modern techniques. In addition, rehabilitation after heart diseases and heart surgery in Israel is organized according to the highest world standards. Israeli cardiac surgeons have a positive statistics in the operations in the heart of even the most severe patients, the treatment of which until recently was considered science fiction.

What are the heart operation?

Surgery may be used not only for treatment but also for diagnostic purposes. Catheterization of the large blood vessels is carried out with the purpose of introduction of drugs, contrasting substances and monitoring the condition of the patient during the operations on the heart and life events. Catheterization of the heart do to clarify the scope of the defeat, which is necessary before carrying out the operations on the heart. These procedures shall be made by means of a catheter (a long, narrow tube) under the control of the x-ray through a small incision in the area of the large blood vessels of the hands or feet.

The above manipulation of conduct and for therapeutic purposes. So, with acute myocardial infarction through the catheter may be submitted medicine, dissolving blood clots. The same minimally invasive technique can be conducted a number of operations on the heart.

For the treatment of ischemic heart disease are two main types of operations:

aorto-coronary bypass

coronary angioplasty.

The essence of the operation aorto-coronary bypass surgery is that the surgeon makes bypass (shunt) around tapering areas of the coronary arteries feeding the heart. For shunt is usually used a vein or artery of a patient, it connects the coronary artery to the aorta. This allows you to bypass the main cause of the disease, warning of the development of myocardial infarction. This method has long proved its safety and effectiveness. For decades, has gained a great experience and has achieved significant success in the implementation of these operations. Aorto-coronary bypass is now widespread and fairly simple operation.

The most well-known way of coronary ангиопластки is TRANS skin transluminal coronary angioplasty (ЧТКА). The essence of the intervention is to increase the problematic area of coronary artery with the help of a tiny spray, вводящегося with the help of a catheter and раздувающегося in the place of destruction.

When changes pump apparatus heart, become the reason of insufficiency of blood circulation, it is possible operation to replace them - prosthetic valve. Depending on the testimony of the affected valve is replaced by biological (e.g., pork valve) or mechanical prosthesis. This operation is also carried out through the vascular access, that is, with the help of catheters. Many congenital heart diseases are also successfully treated with surgery. In this case it is necessary to act quickly, because time is working against the patient.

Aorto-coronary bypass surgery in Israel

Aorto-coronary bypass surgery is a surgical intervention, as a result of which restores the blood flow of the heart below the narrowing of the vessel. In this surgical manipulations around the site of the narrowing of creating another way for the blood flow to that part of the heart, which is not supplied with blood.

Incision, which provides access to the heart, will be made at the middle of the chest, it will be held on the Central line of the sternum. The second cut or cuts is usually performed on the legs. This is where surgeons take a piece of Vienna, which will be used to bypass.

Leg veins use is not always the case. The fact that the veins of the legs are usually relatively “clean”, not slain with atherosclerosis.

In addition, these veins longer and bigger than other available for a capture veins of the human body. Finally, after taking the length of the vein from the leg, there is usually no any problems in the future. The circulation of the blood is not violated.

In the first weeks after the operation, the patient may have a leg ache a little, especially when walking or prolonged standing. Over time, this inconvenience is held, and the patient feels perfectly normal.

Most of all for the bypass is used inside the chest and the radial artery. This provides a more full-fledged functioning of a shunt (its functionality and durability).

One of these arteries is the radial artery hand, it is located on the inner surface of the forearm closer to the big finger.

In case of if you will use this artery, the doctor will conduct further studies, which preclude the occurrence of complications, connected with the fence of the arteries. So one of the incisions may be placed on the hand, usually on the left.

Internal thoracic artery is taken from under the sternum, usually the left, but in some cases, use the right and left CAA. Enough of its diameter and the lack of atherosclerosis lesions is defined in carrying out коронарографии.

Varieties of coronary bypass surgery:

With the use of artificial blood circulation

Without artificial circulation with the use of “stabilizer” for bypass

The implementation of minimum surgical interventions, including endoscopic operations.

The choice of the operative intervention is determined after the коронарографии and expert assessment of the extent of lesions of the coronary arteries of the heart.

At multifocal defeat of the coronary arteries of the heart, including in cases of combined pathology of the heart (the presence of постинфарктной aneurysm of the left ventricle of the heart, congenital or acquired heart disease requiring surgical correction), the operations are carried out by using artificial blood circulation.

Advantages perform coronary bypass through a small incision:

The patient easier to cough and deep breath after the operation.

Less blood loss

The patient feels less pain and discomfort after the operation

Reducing the likelihood of infection

Return to normal activity occurs much faster.

Aorto-coronary bypass surgery with artificial circulation

Traditional coronary artery grafting is performed through a median sternotomy (incision in the middle of the chest). During the operation the heart can be reversed.

For the implementation of an artificial circulation (stopping of cardiac activity) to the heart join the cannula, which are connected to the loop of the apparatus of artificial blood circulation.

For the period of the main phase of operation instead of the heart will work unit heart-lungs (the apparatus of artificial blood circulation), which provides circulation of the blood throughout the body. The blood of the patient arrives in the apparatus of artificial blood circulation, where gas exchange occurs, blood saturated with oxygen and then the pipes delivered to the patient.

In addition, blood when it is filtered, cooled or warmed to maintain the desired temperature of the patient.

In the period of artificial blood circulation surgeon creates анастамоз between Vienna and coronary artery below the stenosis. Then resumes the heart activity and the opposite end of the Vienna attached to the aorta.

After bypass all of the coronary arteries, gradually stop the artificial blood circulation. The operation of shunting of coronary artery usually lasts from 3 to 6 hours.

The duration of the operation depends on its complexity and individual features of the patient. Therefore it is impossible to say in advance exactly how much time will last for one or another operation. Naturally, the more arteries need to bypass an, the longer it will last for operation.

Aorto-coronary bypass surgery without artificial circulation

Good surgical technique and medical equipment allow the surgeon to perform aorto-coronary bypass surgery in Israel on a working heart. It is possible to do without the use of artificial blood circulation in the traditional surgery for coronary arteries.

To perform such an operation, special equipment, which allows to reduce fluctuations of the heart when coronary artery bypass surgery.

For анастамозов applies Vienna, or internal mammary artery.