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https://www.youtube.com/watch?v=xApmbgXZPHAhttps://www.laparoscopyhospital.com/
Laparoscopic Mini Gastric Bypass (MGB) is one of the most commonly performed bariatric surgery and slowly getting popular all over world as obesity surgery. This video demonstrate step by step technique of performing mini gastric bypass surgery by Dr R K Mishra at World Laparoscopy Hospital for a female suffering from Morbid Obesity. Mini Gastric Bypass has Restrictive, Malabsorptive and Hormonal component.
Restrictive:
A small stomach pouch is created restricting the amount of food you can eat.
Malabsorptive:
A portion of the small intestine is bypassed. Since the small intestine is responsible for absorbing the calories from the food you eat, bypassing a portion of the small intestine results in fewer calories being absorbed, thus creating additional weight loss.
Hormonal:
The hormone ghrelin has been nicknamed the “Hunger Hormone” by researchers because of its significant effect on appetite. Gastric Bypass results in a fall in ghrelin levels resulting in a reduced appetite.-
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Dr. R. K. Mishra
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https://www.youtube.com/watch?v=2WgmVLu5wMQThis video demonstrate Total Laparoscopic Hysterectomy (TLH) with Infrared Ureteral Stent by Dr R K Mishra at World Laparoscopy Hospital. IRIS U-Kits of stryker has Lighted ureteral stents which can be used in gynecological procedures. This Visualization technology built into the L10 Light Source is designed to help identify the ureters in lower pelvic procedures and reduce the risk of ureteral injury.
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Dr. R. K. Mishra
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https://www.youtube.com/watch?v=T4x5D2dVJNo&feature=youtu.beThis video demonstrate Laparoscopic Cholecystectomy with Real-time Near-Infrared Fluorescent Cholangiography by Dr R K Mishra at World Laparoscopy Hospital. Indocyanine green (icg) fluorescent cholangiography also called Fluorescent cholangiography can be considered as a useful tool for intra-operative visualization of the biliary tree during laparoscopic cholecystectomies. Bile duct injury remains the most feared complication of laparoscopic cholecystectomy. Intraoperative cholangiography (IOC) is the current gold standard for biliary imaging and may reduce injury, but is not widely used. Near Infrared Fluorescence Cholangiography (NIRF-C) is a novel non-invasive method for real-time, radiation free, intra-operative biliary mapping. NIRF-C is a safe and effective alternative to IOC for imaging extrahepatic biliary structures during laparoscopic cholecystectomy. Significantly less time was required to perform NIRF-C than IOC and it is significantly cheaper to use compared to IOC. NIRF-C has the potential to decrease bile duct injury at a significantly lower cost than the use of routine IOC during laparoscopic cholecystectomy.
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Dr. R. K. Mishra
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Dr. Elsemani Widaa Mohammed Elamin Well done and nice perform it is very helpful specially in very difficult cases , it gives another distance to laparoscopic surgery .
Thank you very much indeed prof Mishra.
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This Video Demonstrate Sleeve Gastrectomy Fully Explained by Dr R K Mishra at World Laparoscopy Hospital. Sleeve gastrectomy is a surgical weight-loss procedure in which the stomach is reduced to about 15% of its original size, by surgical removal of a large portion of the stomach along the greater curvature. For more information https://www.laparoscopyhospital.com
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Dr. R. K. Mishra
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Published on 11 Jun 2017
Robotic assisted tubal reversal surgery is a surgical procedure in which the Fallopian tubes are repaired by a surgeon using a remotely controlled, robotic surgical system. The robotic system involves two components: a patient side-cart (also referred to as the robot) and a surgeon's console. The robot is placed adjacent to the patient and has several attached arms. Each arm has a unique surgical instrument and performs a specialized surgical function. The surgeon sits near the patient at the surgeon's console and visualizes the surgery through a monitor. The surgeon performs the entire reversal surgery using controllers located inside the surgeon's console.
Robotic tubal ligation reversal uses the same small incisions as a traditional laparotomy tubal reversal surgery. Smaller incisions generally result in less pain and quicker return to work when compared to traditional tubal ligation reversal using larger abdominal incisions. The robotic system offers a greater range of motion and more surgical dexterity than a surgeon can obtain during laparoscopic tubal ligation reversal, but not as much dexterity as with an open procedure using a 2 to 3 inch incision. The disadvantages to robotic surgery are longer operating times and much higher costs than even traditional laparoscopic surgery.
https://www.laparoscopyhospital.com-
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Dr. R. K. Mishra
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This video demonstrate laparoscopic myomectomy performed by Dr R K Mishra at World Laparoscopy Hospital. 80% of women between 30 and 50 years of age have uterine fibroids. Depending on their size and location, fibroids can be completely asymptomatic or can cause pelvic pain, dyspareunia, pressure, urinary problems, and recurrent menorrhagia. In general, the larger the fibroid, the more severe the symptoms. Abnormal bleeding is usually caused by fibroids adjacent to the uterine cavity. Patients who have smaller serosal fibroids may be completely asymptomatic or report only one symptom. Less than 1% of fibroids are malignant, and, unless they affect the patient's quality of life, there's no need for treatment.
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Dr. R. K. Mishra
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Abstract
Study Objective
To compare perioperative outcomes associated with the use of three techniques for tissue removal at the time of laparoscopic hysterectomy and myomectomy.
Design
Retrospective cohort study.
Design Classification
II-2
Setting
Academic hospital in Boston, MA
Patients
Women who underwent a laparoscopic or robot-assisted laparoscopic hysterectomy or myomectomy involving tissue morcellation in 2014.
Interventions
One of three morcellation techniques: electronic power morcellation (PM), manual morcellation via vagina (VM) or manual morcellation via minilaparotomy (ML).
Measurements and Main Results
Of the 297 cases included in this study (137 myomectomies, 62 total laparoscopic hysterectomies and 98 laparoscopic supracervical hysterectomies), 96% of the cases were performed by fellowship-trained surgeons using conventional laparoscopy. Containment bags were used at time of tissue extraction in 77% of the cases. Baseline characteristics and perioperative outcomes were similar in all groups. In hysterectomy cases, the average specimen size was largest in the ML group (591±419 grams in ML, compared with 368±293 grams in PM and 449±175 grams in VM group, P=0.0009). After multivariate regression, no significant difference was found in blood loss, length of stay or complications. The operative time was shorter in the PM group compared with ML by 16 minutes (mean 140 (95% CI (130, 149) compared to 156 (146, 167), P=0.02); this association remained significant once additionally adjusting for use or nonuse of containment bags (p=0.05).
Conclusion
We did not detect a significant difference between the three morcellation techniques when comparing the perioperative complications, though the longest operative times were noted for minilaparotomy approach. All three morcellation techniques represent viable options for tissue extraction at time of minimally invasive surgery.-
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Dr. R. K. Mishra
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The vision of Dr. R. K. Mishra for World Laparoscopy Hospital is to be the world leader in patient experience, clinical outcomes, research and education. We believe in diverse specialists working and thinking as a unit. This kind of cooperation, efficiency and shared vision has fostered excellence in patient care, research and education in laparoscopic, endoscopic and robotic surgery. These principles endure today at WLH, as a nonprofit super specialty institute involve in group practice.
Read More https://www.wlh.ae-
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Dr. R. K. Mishra
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Dr. Chinaka Ugochukwu Chinyere Congratulations Dr Mishra on WLH, Dubai. Another giant stride.
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This video demonstrate Laparoscopic meckel's diverticulectomy performed by Dr R K Mishra at World Laparoscopy Hospital. Meckel's diverticulum was first described about 400 years ago and continues to be a rare congenital disorder of small intestine. Laparoscopic surgery for Meckel's diverticulum has been described as a safe and effective procedure. We present our this video of patient with symptomatic Meckel's diverticulum. The incidence of Meckel's diverticulum at our institution is 0.3%. The majority of patients were male children. There were no staple-line leaks in any case.
Laparoscopy is useful in both diagnosis and treatment. Laparoscopic resection of Meckel's diverticulum is feasible and ideal, especially when performed in specialized centers.
For more videos https://www.laparoscopyhospital.com/DOWNLOADS.HTM-
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Dr. R. K. Mishra
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https://www.laparoscopyhospital.com/union.htm
World Congress of Laparoscopic Surgeons on 10th and 11th of February 2018
Register for WALS 2018
World Congress of Laparoscopic Surgeons on 10th and 11th of February 2018
India Habitat Center, New Delhi
Unite For 6th International Conference of World Association of Laparoscopic Surgeons. This conference of Minimal Access Surgery will convene hundreds of Surgeons, Gynecologists, Urologists and Pediatric Surgeon from every corner of the world. We look forward to getting to know you as, together, we lead the way in shaping the future of minimally invasive surgery.-
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Dr. R. K. Mishra
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This video demonstrate Pediatric Laparoscopic Cholecystectomy and Appendectomy in same patient by Two Port by Dr R K Mishra at World Laparoscopy Hospital. The laparoscopic appendicectomy can be performed using one to several ports. We present our experience of two port laparoscopic cholecystectomy and appendectomy in pediatric patient. The objective was to assess the results retrospectively in terms of complications and its limitations. From our experience, laparoscopic cholecystectomy and appendicectomy using two reusable ports had good visualization, decreased rate of misdiagnosis and a short hospital stay. Contrary to the general belief, the incidence of port site wound infection was minimal.
https://www.laparoscopyhospital.com/-
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Dr. R. K. Mishra
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https://www.youtube.com/watch?v=lwwPaZBC4e0&feature=youtu.beThis video demonstrate Bilateral Transabdominal Preperitonial Laparoscopic Inguinal Hernia Surgery Performed by Dr R K Mishra at World Laparoscopy Hospital. Laparoscopic inguinal hernia repair originated in the early 1990s as laparoscopy gained a foothold in general surgery. Inguinal hernias account for 75% of all abdominal wall hernias, and with a lifetime risk of 27% in men and 3% in women. Repair of these hernias is one of the most commonly performed surgical procedures in the world. In the United States, approximately 800,000 inguinal herniorrhaphies are performed annually. https://www.laparoscopyhospital.com
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Dr. R. K. Mishra
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http://www.einnews.com/pr_news/360683358/now-it-is-easy-to-earn-cme-credit-hour-online-for-laparoscopic-surgeons-and-gynaecologistsWorld Laparoscopy Hospital, Gurgaon is announcing a series of CME-certified webcasts that allow participants to view pre-recorded demonstrations and discussions
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Dr. R. K. Mishra
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WORLD LAPAROSCOPY HOSPITAL is proud to release a special focus of the event dedicated to robotic hepatobiliary surgery.
FALS HPB 2017, February 2-4, 2017 at Sir Ganga Ram Hospital, New Delhi and Hands On Robotic Surgery Training at World Laparoscopy Hospital Gurgaon,
For more Please log on to:
https://www.laparoscopyhospital.com/newsletter/preview.php?id=21&p=#ontitle-
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Dr. R. K. Mishra
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https://www.laparoscopyhospital.com/newsletter/preview.php?id=20&p=#ontitleSignup for the latest newsletter of World Laparoscopy Hospital Provide Latest News for all their surgeon and gynecologists of surgeon and gynecologists who come for training
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Dr. R. K. Mishra
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Laparoscopic inguinal hernia repair "IPOM" with Dual-Mesh is an ideal technique for small inguinal hernia. It is easy technique and in our experience has an excellent result. Intraperitoneal Onlay mesh repair is already Worldwide accepted technique foe ventral hernia but its use in direct and indirect inguinal hernia is limited. We have started this surgery first time in 2005. Previously we were performing it with fibrin glue. Bur recently Dr R K Mishra at World Laparoscopy Hospital has started performing IPOM inguinal hernia surgery with the help of tacker and suturing technique.
The IPOM technique focused on the placement of an intra-abdominal piece of a prosthetic biomaterial usually a polypropylene or expanded polytetrafluoroethylene fixed with some type of stapling device which may be tacker or suture; the repair did not involve any dissection of the peritoneum, triangle of DOOM or triangle of PAIN. The advantages of this intraperitoneal onlay mesh repair were the lack of significant dissection of the peritoneal space and the rapid placement of the prosthesis. The recurrence rate, however, was somewhat less than that of the more widely adopted repairs developed later. IPOM technique follow the principle Hydrostatic Pascal law.
The results of this study performed at World Laparoscopy Hospital as well as the meta-analysis of the series presented in the various literature from all over World, indicate that the IPOM (Intra Peritoneal Onlay Mesh) is a feasible, safe and effective procedure in the treatment of recurrent and bilateral hernias.
This an excellent option when a hernia repair is performed by laparoscopic procedures. Surgeon should have good suturing skill. The IPOM has in fact been shown to be faster and easier than the other more commonly performed laparoscopic hernioplasties (TAPP and TEP). It has less chances of faster recovery minimal hospital stay and much earlier return to work.
The preliminary data may also suggest to utilize IPOM laparoscopic inguinal hernia surgery technique in particular cases of inguinal hernia such as very active young males or heavy duty workers. However, the limited series and the short follow-up ask for randomized prospective long term studies to definitely ascertain the true incidence of recurrence and therefore the effectiveness of this attractive procedure.-
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This surgical video demostrate da Vinci Robotic surgery for severe intra abdominal adhesion in a patient who has undergone multiple laparostomies in the past. She was suffering from severe pain abdomen. The da Vinci Robotic Surgical System speaks to the most recent in surgical and apply autonomy in minimal access surgical advancements. Surgeon has 100% control of the da Vinci System at all circumstances and this is the surgeon who is actually doing the surgery. da Vinci innovation interprets surgeons hand developments into littler, exact developments of modest instruments inside patient body.
In case of severe abdominal adhesion it has great advantage and it can be used as an important tool to perform adhesiolysis. In da Vinci robotic surgery precision of the surgery is better but complication is also possible. Serious complications may occur in any minimal access surgery, including da Vinci robotic Surgery, up to and including death. Individual surgical results and outcome may vary. While doing da Vinci robotic surgery minimal access surgeon should review all available information on non-surgical and surgical options in order to make an informed decision.
Due to small incisions, 3D high definition viseon, less trauma to the body and greater surgeon precision, da Vinci robotic surgery in severe abdominal adhesion provides the following benefits over traditional open procedures including:
Shorter hospital stay
Less blood loss
Less pain
Fewer complications, including less risk of infection
Faster return to normal activities
For minimal access surgeons, da vinci robotic surgery is more precise then conventional laparoscopic surgery due to better visualization of the operative surgical field, correction for tremors in human hand movements and greater maneuverability of instruments because of wrist articulation.
In robotic surgery one arm is a camera, two to go about as the specialist's hands and a fourth arm might be utilized to move hindrances off the surgical path. Patients are encompassed by a total surgical group, while the specialist is situated at a close-by surgeons console. The specialist utilizes a viewfinder which gives a three dimensional picture of the surgical field, and the specialist's hands are set in extraordinary gadgets that direct the instruments. The automated arms sift through any tremors in the surgeon's hands and expands the surgeons's scope of movement. This improved accuracy is particularly useful to the specialist amid particularly sensitive bits of methods during the surgery of severe abdominal adhesion.-
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Dr. R. K. Mishra
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This multi specialty conference of World Association of Laparoscopic Surgeon, helps the delegates to increase knowledge of laparoscopic surgery, robotic surgery, endoscopic, and minimally invasive surgical techniques. This international Meeting of laparoscopic surgeon, gynecologist and urologist consists of Postgraduate Master’s Classes; Plenary Sessions; Laparoscopic da Vinci Robotic and Endoscopic Updates of multiple topics. Expert review and discussion of minimally invasive surgical videos will be showing accidents, mishaps, and surprises. Live surgery will be demonstrated by pioneer laparoscopic surgeons from all over World. Demonstration of live da Vinci robotic surgeries performed by master robotic surgeons. Exhibitions of laparoscopic instruments and books; Competitions for Best Papers and Case Presentation will be area of interest. Videos, and Posters from Professors to Fellows and Residents will be displayed. Future Surgical Technology Sessions will be very interesting. During this two days conference over 100 General Surgery, Gynecology, Urology, and Multi specialty Scientific Presentations will be observed by the delegates from all over the World. There will be grand cultural program and social gathering during this World Congress.
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Dr. R. K. Mishra
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Dr. R. K. Mishra Director at World Laparoscopy Hospital Please go here to see the detail https://www.laparoscopyhospital.com/union.htmXLaparoscopy Hospital is celeberating the alumni re-union every year hundreds of surgeon and gynecologists will participate in this re-union
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Dr. Elsemani Widaa Mohammed Elamin please if not mind give information about time and registration
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With advancement in laparoscopic surgery a number of surgical procedures can be performed combined with laparoscopic cholecystectomy in a single surgery. We evaluate the safety & efficacy of such surgeries. A retrospective review of all patients who had undergone combined procedures with laparoscopic cholecystectomy and hysterectomy. In addition to the benefits of minimal access, patient gets the additional advantage of single hospital stay and single anaesthesia exposure. Thus it is more convenient for the patient and also more cost effective to do cholecystectomy and hysterectomy together if required.
https://www.laparoscopyhospital.com/research/preview.php-
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https://www.laparoscopyhospital.com/union.htmLaparoscopy Hospital is celeberating the alumni re-union every year hundreds of surgeon and gynecologists will participate in this re-union
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Dr. R. K. Mishra
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https://www.laparoscopyhospital.com/hindi/preview.php
This video demonstrate laparoscopic salpingectomy for right sided ruptured ectopic pregnancy. A ruptured ectopic pregnancy is a medical emergency in which a fertilized egg implants itself outside the uterus where a normal pregnancy gestates. Usually, an ectopic pregnancy is situated in one of the fallopian tubes, and as it grows, it can cause the tube gets to tear or burst.-
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Dr. Cuauhtémoc Cano Dr How did You dilute the heparin?, I mean, how much heparin in how much saline water? Thank U!!
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Laparoscopy is endoscopic visualization of the peritoneal cavity usually assisted by a pneumoperitoneum that distends and separates the abdominal wall from its contents. Visual clarity, space to perform diagnostic and therapeutic procedures and maintenance of a normal physiologic state is required for safe effective surgery. To perform laparoscopic procedures the abdominal cavity is inflated with gas to create the pneumoperitoneum.
Factors that determine the most appropriate gas for pneumoperitoneum are type of anesthesia, physiologic compatibility, toxicity, ease of use, safety, delivery method, cost, and non-combustibility. Gases used for pneumoperitoneum include carbon dioxide (CO2), air, oxygen, nitrous oxide (N2O), argon, helium and mixtures of these gases.
CO2 gas insufflation is preferred by most laparoscopists because it has a high diffusion coefficient and is a normal metabolic end product rapidly cleared from the body. Also, CO2 is highly soluble in blood and tissues and does not support combustion. The risk of gas embolism is lowest with CO2. Cardiac arrhythmias can occur with CO2 pneumoperitoneum. Because of possible CO2 induced hypercarbia, N2O may be preferred in patients with cardiac disease. With prolonged procedures, CO2 retention is possible as evidenced by tachycardia and acidosis.
Pneumoperitoneum is usually initiated by use of a needle or trocar device to transverse the abdominal wall and distend the peritoneal cavity. Another method of access is with an open incision and entering by direct vision through the peritoneum. Caution is required with any method of abdominal entrance or distention. Abdominal penetration complications and incorrect gas placement may result in bleeding or gas dissection within the abdominal wall. Bowel injury, puncture of intra-abdominal vessels, dissection of the fascia or omentum can occur.
After peritoneal access, a gas delivery system is used to inflate and maintain the abdominal distention. Preset pressures of 15 mm Hg or less are safest to maintain pneumoperitoneum and allow performance of laparoscopic techniques. Intra-abdominal pressures in excess of 25 mm Hg are associated with increased airway pressure, increased intrathoracic pressure, increased femoral venous pressure and signs of cardiovascular stimulation with tachycardia and hypertension. Large patients and those who have had multiple abdominal surgeries present a challenge to establish a pneumoperitoneum. Patient selection for laparoscopic procedures and surgical judgment concerning the appropriateness of laparoscopic versus open surgery should be individualized for each circumstance.
Gas delivery systems are composed of a containment cylinder, insufflator (gas throttling down pressure regulating unit), tubing, filter and abdominal entry device or port. The gases used for medical purposes have their production regulated by the Food and Drug Administration. Acceptable limits of contamination are listed in The U.S. Pharmacopoeia. Gas cylinders are made of ferrous alloy that meets Department of Transportation specifications which ensure safe transport. The cylinders contain the gas as a liquid under pressure. Over time, the cylinders build up inorganic and organic contamination. This occurrence requires filtration of the gas prior to insufflation of a patient’s abdomen. The pressure change from the containment cylinder to insufflator and into the patient’s abdomen causes cooling by the Jewel-Thompson effect.
The temperature of carbon dioxide gas is about 20.1° C as it enters the abdomen. The cool gas causes hypothermia if the gas is not pre-conditioned. Gas flow also contributes to hypothermia by convection effects. There is enhanced evaporation from the bowel surface due to gas turbulence from pressurized delivery. Additionally, general anesthesia causes patients to be unable to maintain thermal stability. The net effect is a loss of 0.3 degree C per 60 liters of gas insufflated. In addition, hypothermia may cause decreased gastrointestinal motility and lead to increased potential for ileus.
When the laparoscope is first introduced into the abdominal cavity lens fogging often occurs. This phenomenon is due to the relatively cold dry lens being introduced into a warm moist environment causing the dew point to be reached. This results in condensation forming on the internal lens surface. When the insufflation gas is heated and hydrated or a surface wetting agent is used, no lens fogging occurs and the visual field is clear.
The gases used for pneumoperitoneum have low water content. CO2 has less than 200 parts per million of water. Dry insufflation gases cause drying of the peritoneum and result in intact mesothelial cells being lost or desiccated from the peritoneum surface. To preserve peritoneal surface integrity and decrease the tendency to adhesion formation continuous or intermittent moistening should be performed.
All mechanical systems have inherent weaknesses. Insufflators require proper calibration and maintenance. Insufflator pressure accuracy depends on the quality of the gauges used in the insufflator. Wide ranges of variation are seen due to gauge inaccuracy. Pressure testing should be done regularly to assure proper readings.
Over time, insufflators become contaminated on their internal and external surfaces. Germicidal cleaning of external ports is important. Gas filtration to 0.3 microns prior to abdominal entry assures reduction of quantitative exposure of the peritoneal cavity from these organic and inorganic materials.
Initial abdominal entry pressure readings should be low—less than 2-3 mm Hg. Elevated initial pressures indicate improper placement. Increased intra-abdominal pressures after proper access can impede venous return and result in potential anesthesia complications. Pressure on intra-abdominal surfaces due to the pneumoperitoneum can inhibit bleeding giving a false sense of security regarding hemostasis. Prior to concluding any procedure, surgical sites need to be observed with reduced pressure to assure appropriate hemostasis.
During laparoscopic procedures the abdominal cavity can become contaminated with smoke from the lasers or electrosurgical device used. On a toxicologic basis, tissue combustion within the closed abdomen at laparoscopy is an iatrogenic smoke poisoning incident. Toxic chemicals produced by pyrolysis of human tissue. These chemicals effect peritoneal cells and other cellular components (i.e. activation of macrophages and increased production of tumor necrosis factor). Absorption of these chemicals occurs via the peritoneum. Combustion processes that occur in low oxygen environments cause elevated CO emissions and are common in the laparoscopic situation. Peritoneal absorption of CO causes carboxyhemoglobin formation. Carbon monoxide has 200-240 times greater affinity for hemoglobin than oxygen. The half-life of CO is 5.33 hours in room air. Depending on the amount of smoke produced, anesthetic oxygen concentration and whether smoke evacuation was performed during the procedure, determines the postoperative effects of CO and how much time is required to return to preoperative levels. Carbon monoxide (CO) is known to cause cardiac arrhythmias and can initiate or exacerbate many intra- and postoperative complications. For these reasons smoke within the pneumoperitoneum should be continuously or intermittently evacuated.
Methemoglobinemia may occur during laparoscopic procedures when abdominal tissue combustion occurs. Methemoglobin is the oxidative product of hemoglobin causing the reduced ferrous (Fe2+) to be converted to the ferric (Fe3+) form. The difference between methemoglobin and oxyhemoglobin in the ferric state is that methemoglobin is formed from unoxygenated hemoglobin and is not capable of carrying oxygen or carbon dioxide. This property shifts the oxyhemoglobin dissociation curve to the left, inhibiting oxygen delivery to tissues, and may lead to anoxia. The eventual concentration of smoke and subsequent physiologic changes that occur depend on the amount tissue pyrolized, duration of smoke exposure and effectiveness of smoke evacuation. It must be noted that pulse oximetry does not give a proper evaluation of oxygen saturation in the presence of dyshemoglobinemias (carboxyhemoglobin and methemoglobinemia).
Peritoneal defenses are also effected by irrigation and suction. Irrigation serves to separate tissue surfaces and remove debris and clotted material. However, irrigation also causes dilution washout of resident peritoneal macrophages. Macrophages direct host defense mechanisms that result in recognition, phagocytosis and destruction of foreign substances.
As a result of irrigating the peritoneal cavity with 1 liter of fluid, 60-80% of the original number of macrophages are washed out. It has been shown in the murine model and in patients undergoing peritoneal dialysis that restoration of 90% of the original complement of macrophages requires 72-84 hours. Postoperatively, macrophages are intimately involved in protecting the peritoneum and abdominal cavity from foreign material, bacteria and foreign bodies. They are also involved with the initiation of reperitonealization.
Tissue combustion generates 284 mg of particulates from each gram of tissue pyrolized or 0.3-3.0 x 109 particles per gram of tissue vaporized. These particles range from 0.1-1.0 microns in size clustering between 0.2-0.5 microns. This material is phagocytosed by macrophages, chemically digested, and causes macrophage activation, alteration in chemotaxis and increased cytokine production.
The seemingly inactive invisible pneumoperitoneum is not a static condition and must not be ignored in laparoscopic surgery. The pneumoperitoneum is a dynamic space that affects the patient’s general well being, and specific physiologic cellular processes. The insufflation gas needs to be filtered to reduce contamination, heated to reduce hypothermia and hydrated to preserve cellular integrity and reduce adhesion formation. It is important to recognize the affects of intra-abdominal therapy and the consequences of surgical devices. This includes tissue particles, aerosol production, the by-products of combustion, and their effect on peritoneal tissues locally and the body chemistry and metabolism as a whole.
Conclusion
The pneumoperitoneum creates a complex dynamic set of changing conditions having pathophysiologic consequences during laparoscopy. The effects of unseen tissue touching due to gas flow, cellular stress and inflammation caused by lack of water in the gas combined with increased intra-abdominal pressure can be minimized and corrected. Maintaining intra-abdominal pressure below 12 mmHg, using humidified warmed gas, and adhering to microsurgical principles of tissue handling can be controlled and result in improved clinical outcomes.
https://www.laparoscopyhospital.com/worldlaparoscopyhospital/index.php?id=165&p=&search=-
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Dr. R. K. Mishra
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Chantip Tharanon, Kovit Khampitak
Department of Obstetrics and Gynecology, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand
Objectives: To compare the effect of peritoneal gas drain on postoperative pain in benign gynecologic laparoscopic surgery and the amount of postoperative analgesic dosage.
Methods: The trial included 45 females who had undergone operations during the period December 2014 to October 2015. The patients were block randomized based on operating time (<2 and ≥2 hours). The intervention group (n=23) was treated with postoperative intraperitoneal gas drain and the control group (n=22) was not. The mean difference in scores for shoulder, epigastric, suprapubic, and overall pain at 6, 24, 48 hours postoperatively were statistically evaluated using mixed-effect restricted maximum likelihood regression. The differences in the analgesic drug usage between the groups were also analyzed using a Student’s t-test. The data were divided and analyzed to two subgroups based on operating time (<2 hours, n=20; and ≥2 hours, n=25).
Results: The intervention had significantly lower overall pain than the control group, with a mean difference and 95% confidence interval at 6, 24, and 48 hours of 2.59 (1.49–3.69), 2.23 (1.13–3.34), and 1.48 (0.3–2.58), respectively. Correspondingly, analgesic drug dosage was significantly lower in the intervention group (3.52±1.47 mg vs 5.72±2.43 mg, P<0.001). The three largest mean differences in patients with operating times of ≥2 hours were in overall pain, suprapubic pain at 6 hours, and shoulder pain at 24 hours at 3.27 (1.14–5.39), 3.20 (1.11–5.26), and 3.13 (1.00–5.24), respectively. These were greater than the three largest mean differences in the group with operating times of <2 hours, which were 2.81 (1.31–4.29), 2.63 (0.51–4.73), and 2.02 (0.68–3.36). The greatest analgesic drug requirement was in the control group with a longer operative time.
Conclusion: The use of intraperitoneal gas drain was shown to reduce overall postoperative pain in benign gynecologic laparoscopic surgery. The effects were higher in patients who had experienced longer operating times.-
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Dr. R. K. Mishra
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http://mistic2016.com/12th International Congress of Minimally Invasive Surgery and Techniques
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Being a doctor is a well-paid profession, but the highest earning medical professionals are surgeons. Everybody who has had surgery knows just how much trepidation you feel when entering that room and realizing that someone is going to cut you open, root around a bit, and then sew you back up. Now if a robotic surgeon were to conduct the same operation, would you feel any better about it? What if robotic surgery gave you a 10X better success rate? Which would you choose it then?
It’s only a matter of time before the majority of skilled tasks are threatened by artificial intelligence and sophisticated automation techniques like robotics. Let’s take a look at 10 robotic surgery companies that may be operating on you sometime in your lifetime.
Intuitive Surgical
If you’ve heard mention of robots in surgery, it was probably referencing Intuitive Surgical (NASDAQ:ISRG) and their da Vinci surgical robot. The company raised $46 million in an initial public offering in 2000 and in the same year, became the first robotic surgical system cleared by the FDA for general laparoscopic surgery. Since then, da Vinci has been used for more than 3 million minimally invasive procedures in various surgical specialties. The robotic surgery device comes in two parts as see below:
Da Vinci Product
Surgeons shouldn’t feel threatened yet, as Da Vinci is “assisted robotic surgery” and is always controlled by a surgeon from a console. Retail investors who saw the potential of Da Vinci 16 years ago would be sitting on a return of +3,687%.
Verb Surgical
Verb Surgical was founded with technology, expertise, and funding from Verily (formerly Google Life Sciences) and Ethicon, a medical device company in the Johnson & Johnson family of companies. The company will leverage the medical instrumentation developed by Ethicon and the “big data” and machine learning expertise from Google to develop a “surgical platform” that will also include robotics as well. They refer to their surgical system as “digital surgery” and claim that it will cost much less than Intuitive Surgical’s da Vinci robot.
Auris
Founded in 2007, Silicon Valley based Auris Surgical Robotics has taken in $184 million and is the fourth startup founded by Dr. Fred Moll who was the co-founder of Intuitive Surgical (NASDAQ:ISRG). He just acquired one of his previous companies, Hansen Medical, for about $80 million. Hansen was working on intravascular robotics which involves technology that is used to position, monitor and control catheters and related products. Auris received FDA clearance this year for a teleoperated robotic endoscopy system called ARES (Auris Robotic Endoscopy System). A recent article by IEEE talks in detail about what this stealth-mode Company might be up to, including a focus on endolumenal surgery which involves introducing flexible robots via the body’s natural openings (the mouth in particular).
Medrobotics
Founded in 2005, Massachusetts-based Medrobotics has taken in $147.4 million so far to develop a medical robot built on exclusive worldwide licenses for robotics technology from Carnegie Mellon University and the University of Pittsburgh. Medrobotics received FDA clearance for their Flex Robotic System last year which is now used for ear, nose and throat surgeries.
Medrobotics Flex Robotics
The Flex Robotic System is based on a core flexible, steerable scope technology that surgeons can use to navigate around anatomy using integrated HD video. Once positioned, the scope becomes rigid and you can then deploy flexible instruments through the tube to perform procedures that would not be possible using a line-of-sight approach.
Restoration Robotics LogoFounded in 2002, Restoration Robotics has taken in $118 million to develop a robotic system that can be used to transplant hair and treat baldness. This is yet another company founded by Dr. Fred Moll who we mentioned before as being the co-founder of ISRG and the founder of Auris. Restoration has developed a robotic surgery device called ARTAS that takes hair follicles from the back and sides of the head and moves them to the top and front.
ARTAS Robotic Surgery Hair Transplant
According to a recent article in the L.A. Times, the robot costs $200,000 and the procedure can cost anywhere from $5,000 to $10,000. Before you get out your checkbook, note that ARTAS can only be used on patients with straight, dark hair, and is limited to follicle extraction from the back and sides of the head.
Virtual Incision
Founded in 2006, Nebraska startup Virtual Incision Corporation has taken in $19.6 million in funding to develop a miniaturized robot for general surgery abdominal procedures, such as colon resections. The device was first used on a human this year and is described by the Company as “a small, self-contained surgical device that is inserted through a single midline umbilical incision in the patient’s abdomen” as seen below:
Virtual Incision Product
With over 90 patents covering their technology and 40+ prototypes developed, Virtual Incision seems to be well on their way towards getting the FDA approvals needed to move this from an investigatory device to a commercially available robotic surgery device.
Think Surgical
THINK Surgical, Inc. develops, manufactures and markets the only active robotic surgical systems for orthopaedic surgery. The systems include two components: a 3D workstation for preoperative planning, and a robot used for precise cavity and surface preparation for hip and knee replacement surgeries.
Think Surgical has multiple FDA approved systems which have been used in thousands of joint replacements worldwide.
Medtech LogoFounded in 2002, Medtech S.A. (EPA:ROSA) is a French robotic surgery company which has a market cap of $133 million and trades on the Euronext Paris exchange. The Company has developed a robotic device called ROSA which was designed to increase the safety and reliability of various neurological procedures. To date, ROSA™ is the only robotic assistant approved for neurosurgical procedures in clinical use in Europe, the United States and Canada and has been used for over 100 spinal surgeries so far.
Rosa Robotic Surgery Device
This month Zimmer Biomet Holdings acquired 59 percent of MedTech in a private transaction causing the share price to jump by over 60%.
With a market cap of $160 million, TransEnterix (NYSEMKT:TRXC) is actually a publicly traded company that doesn’t trade on the over-the-counter (OTC) market. The Company is developing their robotic surgery device called Alf-X which “address the limitations of current robotic systems” and looks to be on about the same scale as the da Vinci.
Alf-X
The only problem is that TRXC has been burning through some serious cash over the years and isn’t showing any revenues yet. Just last year they lost $47 million leaving them with just $68 million in cash on hand. Alf-X is not yet for sale in any country, though the Company has been granted CE mark approval (European equivalent of FDA approval) to use the device for laparoscopic surgery in the abdomen and pelvis.
Titan Medical
Canada’s Titan Medical (TSE:TMD) is a publicly traded company on the TSE which is developing their Sport Surgical System, a versatile, single incision advanced robotic surgical system. As we would expect, their website talks all about the “size of the opportunity” and how their solution will transcend what we now call “robotic surgery”. They talk about targeting the European market first, then the U.S. market. They provide “updates” that contain tactical details, some of which are so mundane that you wonder why they included them. And all the while, they haven’t been treating investors well with the stock having lost over -60% since it began trading a few years ago giving the Company a present market cap of $98 million. While the technology may sound exciting, on the surface it looks and smells like an OTC company. You know what we think about OTC companies.
Medical robotic systems are expected to grown at an estimated CAGR of 12.7% from 2014 to 2020. Intuitive Surgical is the leader at the moment by size, but any one of these startups could have an IPO and address a completely new market. One firm that allows you to buy shares in startups before they IPO is Motif Investing. You can open a Motif Investing account for free with no deposit required so you are ready to buy shares of future IPOs before they begin trading.-
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Dr. R. K. Mishra
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https://www.laparoscopyhospital.com/mmas.htm
This video demonstrate Total Laparoscopic Hysterectomy with ligation of Uterine Artery by Dr R K Mishra at World Laparoscopy Hospital. In this surgery for ligation of uterine artery Mishra's knot is used and for the vault closure Weson knot is used. The patient was suffering from severe DUB and surgical removal of the uterus can be lifesaving for those suffering from gynecological cancers or the severe pain and heavy bleeding due to fibroids or endometriosis. Today, there are several surgical approaches that are far less invasive than a total abdominal hysterectomy, which is still widely performed.
The total laparoscopic hysterectomy (TLH) offers women an option that is far less invasive than other surgical approaches. The need for a hysterectomy is an important and difficult decision.-
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Dr. R. K. Mishra
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https://www.laparoscopyhospital.com/SERV01.HTM
This video demonstrate Laparoscopic Repair of Recurrent Incisional Hernia by Two Port by Dr R K Mishra at World Laparoscopy Hospital. In 1993, LeBlanc reported the first case of laparoscopic incisional hernia repair with the use of synthetic mesh. The procedure involves the placement of a mesh inside the abdomen without abdominal wall reconstruction. The mesh is fixed with sutures, staples, or tacker.-
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Dr. R. K. Mishra
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https://www.laparoscopyhospital.com/
This video demonstrate experimental Ipom Inguinal Hernia Surgery by Suturing - Personnel Technique of Dr R K Mishra. So far we have perform 36 cases of IPOM inguinal hernia surgery with two year followup and the results are encouraging. Any long term randomized control trial is required to see the feasibility of this technique. he IPOM repair has largely fallen from favor, and currently, the most commonly performed laparoscopic techniques are the TEP and TAPP repairs. Although many facets of laparoscopic inguinal hernia repair continue to be debated—such as the possible superiority of one laparoscopic approach to another but IPOM technique we are trying to redefine in our study..-
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Dr. R. K. Mishra
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https://www.laparoscopyhospital.com/g...
Laparoscopic myomectomy is an ideal procedure for fibroid uterus and it is safe in the hand of experienced surgeon with good suturing skill. During myomectomy, surgeons take extra steps to avoid excessive bleeding, including blocking flow from the uterine arteries and injecting medications around fibroids to cause blood vessels to clamp down. Nowadays an increasing number of patients with fibroids wish to retain their uterus without improving fertility. Laparoscopic myomectomy can be offered to all women as a safe procedure. Myoma in also called as Rasoli in Hindi language.-
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Dr. R. K. Mishra
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