Common abdominal sites for gas delivery.
Table 1. U.S. Pharmacopeia National Standards for Carbon Dioxide
Table 2. Toxic chemical by-products resulting from pyrolysis of protein and lipids.
Figure 2. Direct Coupling.
Figure 3. Instrument/Hybrid Cannula Configuration
The waveforms associated with standard cut, coag and blend.
Figure 2. Defects in the insulation- too small to be visually perceptible- may deliver current outside the field of view.
Figure 3. The potential for recognition and injury of stray current depends on the zone of the defect. Zone four defects burn the surgeon; zone two burn the patients.
Figure 4. A "capacitance injury" may occur as a result of induced currents through intact insulation when a hybrid cannula (metal cannula with plastic gripper) is used.
Figure 5. Direct coupling can transfer 100% of the current to bowel outside the field of view when a plastic cannula is used around the laparoscope.
Figure 1. Wavelenghts of the various types of lasers.
Figure 2. Zones of tissue injury following laser use.
Figure 1. Test 1. Preoperatively, palpate the abdomen with attention paid to the location of the aorta.
Figure 10. Operating team positioning for laparoscopic appendectomy.
Figure 11. Mobilization of appendix.
Figure 12. Roeders Loop applied to tip of appendix.
Figure 13. Mobilization of cecum.
Figure 14. Mesoappendix secured with endoclips.
Figure 16. Base of the appendix secured with an endoloop of chromic catgut.
Figure 17. Base of appendix secured with endo-GIA.
Figure 18. Appendiceal stump.
Figure 19. "Bagged" appendix.
Figure 2. Test 2: Check needle patency and insufflation pressure through the Veress needle against open air prior to its passage into the abdominal cavity.
Figure 20. Irrigation of appendiceal fossa.
Figure 21. Appendiceal abscess.
Figure 22. Umbilical preparation for laparoscopy.
Figure 23. Omental emphysema.
Figure 24. Bleeding from trocar site.
Figure 25. Semm Emergency Needle.
Figure 26. Carter Thomason Closure System.
Figure 3. Test 3: Snap test: Observe the spring-loaded Veress needle indicator while the needle traverses the abdominal wall into the abdominal cavity.
Figure 4. Test 4: Hiss Test: Once the Veress needle has been positioned, listen for the ingress of air through the opened needle or check for aspiration of fluid while lifting the abdominal wall.
Figure 5. Test 5: Aspiration test: Aspirate the Veress needle with syringe after it has been inserted into the abdominal cavity, check for blood or GI content.
Figure 6. Test 6: Once the Veress needle has been connected to an insufflator, a "quadrotest" of insufflator parameters are checked to confirm needle placement.
Figure 7. "Z" trocar insertion for all abdominal trocar perforations to avoid later hernias.
Figure 8. Alternate access technique under visual control through normal laparoscope to avoid laceration of adherent bowel according to Semm.
Figure 9. Cannula position for laparoscopic appendectomy.
Figure 3. Picture demonstating the infundibulum of the gallblader emphasizing the need to dissect totally the transition between the gallblader and the cystic duct.
Figure 1. Pie Chart showing the relative make up of complications seen with laparoscopic cholecystectomy.
Figure 2. Picture demonstrating the cystic duct/ common bile duct junction. One of the "clasic" landmarks used to positively identify the anatomy.
Figure 4. Drawing demonstrating how distortion of the anatomy can cause the common bile duct to appear to be going into the gallbladder.
Figure 5. Picture of a cholangiogram showing how it clearly demonstrates the anatomy. In this particular case, an aberrant right hepatic duct is demonstrated.
Anatomic variations of the blood supply for the gallbladder. The cystic artery usually arises from the right hepatic artery (A). Variations to this unusual anatomy include dual cystic arteries, one arising from each of the hepatic arteries (B); cystic artery arising from the common hepatic artery (C); cystic artery arising from the gastroduodenal artery (D); cystic artery arising from an anterior right hepatic artery (E); a single cystic artery arising from the left hepatic artery (F).
Anatomic variations of the cystic duct. The cystic duct commonly joins the common hepatic duct, giving rise to the common bile duct before draining into the second portion of the duodenum (A). Variations to this usual anatomy include accessory duct (of Luschka) draining into the cystic duct distal to the common bile duct junction (B); low insertion of the cystic duct onto the common hepatic duct, just proximal to its entry into the duodenum (C); spiral cystic duct joining the common hepatic duct postero-medially (D); common wall for cystic duct and common hepatic duct (E); right hepatic duct insertion (F); absent cystic duct (G).
Identification and dissection of the cystic duct during laparoscopic cholecystectomy. The identification of the cystic duct may safely start with the incision of the peritoneal reflection on each side of Hartmann’s pouch onto the liver. This maneuver allows anterior and cephalad retraction of Hartmann’s pouch and consequent lengthening of the cystic duct, allowing its safe, distal ligation.
Intraoperative cholangiography provides safe identification of the extrahepatic and intrahepatic biliary ductal anatomy. In addition, cholangiography may facilitate detection of common bile duct stones, allowing operative management of choledocholithiasis.
Abnormal intraoperative cholangiogram. A very common bile duct, mistaken for the cystic duct, has been ligated proximally. The cholangiogram obtained through an incision in the common bile duct demonstrates no flow into the proximal common bile duct, alarming the surgeon of impending injury to the common bile duct.
The retroperitoneum and its contents including the aorta and the vena cava are potential targets for the Veress needle or the laparoscopic trocars. In slim patients, especially in the absence of pneumoperitoneum, the aorta and the vena cava often lie closer to the anterior abdominal wall than the posterior abdominal wall. Therefore, injuries to these retroperitoneal structures are a real concern.