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minimally invasive surgery.doc

  1. 1. New Hope for Animals Needing SurgeryMore than 20 million people have chosen minimally invasive surgery (MIS) overconventional surgery because it allows them to feel better faster and involves less painand scarring. MIS is now being performed in animal patients at the Veterinary TeachingHospital of the Purdue University School of Veterinary Medicine.How Minimally Invasive Procedures Help PatientsVeterinarians employ the same technology used in human surgery to perform minimallyinvasive procedures on animals such as abdominal exploratory, biopsy,ovariohysterectomy (spay), removal of bladder stones, and gastropexy (sewing thestomach to the body wall to prevent twisting of the stomach). These procedures involveinserting two or three access ports (called “trocars”) through half-inch incisions in theabdomen. The abdomen is filled with carbon dioxide to create a working space betweenthe internal organs and the surface of the skin. Then a laparoscope (camera) is placedthrough one of the access ports so that the surgical team can watch the procedure on avideo monitor. The image on the monitor is magnified, which provides better visibility forthe operating room staff. Biopsy forceps and other devices are placed through the otheraccess ports to perform the operation. In some cases, a smaller scope is then insertedinto a hollow organ, such as the bladder, to retrieve bladder stones.Another and perhaps better known minimally invasive technique is arthroscopy, which is aused to examine the joints. This procedure involves inserting a small needle into the jointto inject fluid and create an underwater working space. Additional access ports are madeto insert a scope and camera and instruments to examine and treat the joint disease.Controlled studies have demonstrated that animals experience less postoperative painand less stress when undergoing MIS rather than conventional surgery.
  2. 2. The following images show some of the procedures that can be performed using MIS.
  3. 3. Laparoscopic Ovariohysterectomy An excellent view of abdominal structures is obtained during laparoscopic surgery. Here, a “Harmonic Scalpel” is used to prevent bleeding and cut tissues to remove the ovaries and uterus.
  4. 4. Laparoscopic-assisted Gastropexy To perform a gastropexy, the stomach is grasped and pulled to the body wall and sutured there. The adhesion between the stomach and the body wall prevents the stomach from rotating when it becomes dilated. This procedure is effective in preventing Bloat (Gastric Dilatation Volvulous).
  5. 5. Laparoscopic-assisted Bladder Surgery During laparoscopic assisted bladder surgery, a cystoscope is inserted into the bladder. These images show a view of bladder stones being grasped by forceps and retrieved from the bladder. This is a view of a mass inside the bladder seen with a cystoscope inserted into the bladder during laparoscopic- assisted surgery.
  6. 6. Current Research StudiesResearch in Minimally Invasive surgery Research In Progress  Clinical Research in Minimally Invasive Surgery Laparoscopy • OHE • Gastropexy • Exploratory • Liver Biopsy Thoracoscopy ArthroscopyMinimally Invasive Brain Biopsy – Targeted Radiation Therapy MIBB-TRT  Technique appears to be feasible  May have application to other disease states  Study is on-going *Funded by SVM
  7. 7. Natural Orifice Translumenal Endoscopic SurgerySurgery Meets Gastroenterology. Take NOTES!!Faculty members at Purdue University and Indiana University are undertaking a study ofalternative surgical procedures that could lead to changes in the way surgery is performedin people. Dr. Lynetta Freeman, Associate Professor of Small Animal Surgery at theSchool of Veterinary Medicine, and Dr. Emad Rahmani, a gastroenterologist and AssociateProfessor of Clinical Medicine at IU School of Medicine were recently awarded a grantfrom NOSCARTM (Natural Orifice Surgery Consortium for Assessment and ResearchTM) toinvestigate the feasibility of performing surgery via a flexible endoscope in dogs. TheNOSCAR group is a cooperative group founded by surgeons and gastroenterologists andtheir respective organizations, SAGES (The Society of American Gastrointestinal andEndoscopic Surgeons) and ASGE (American Society for Gastrointestinal Endoscopy) tostudy this next evolutionary step in how surgery is performed.The new surgical approach is termed NOTES (Natural Orifice Translumenal EndoscopicSurgery). NOTES was first described as peritoneoscopy by Kalloo, et al. in 1994.2 He andhis co-investigators used a flexible endoscope to create an opening in the gastric wallwhich allowed the endoscope to be introduced into the abdominal cavity. Much likelaparoscopy, the abdomen was insufflated with air through the endoscope to create aworking space. By manipulating the endoscope the authors were able to perform minorsurgical procedures such as full abdominal exploratory and liver biopsy in swine. Sincethen others have performed other experimental techniques in porcine models, using thestomach, colon, bladder and vagina as portals, including tubal ligation, entericanastomosis, lymphadenectomy, cholecystectomy, and splenectomy. Immediate clinicalapplications have been explored, applying the potential for NOTES approach in ICUpatients. Investigators have reported inserting a pacemaker on the diaphragm, performingan exploratory to discover potential sources for sepsis, and repositioning of a dislodgedPEG tube. Though the technique is still considered experimental, the first report of acholecystectomy being performed via a transvaginal approach in a woman was describedin the September issue of Archives of Surgery. It is anticipated that other ‘firsts’ will bepublished this year.NOTES is considered experimental because there are a number of unanswered questionsand remaining challenges related to performing surgery in this manner. The stomach,colon, bladder and vagina are considered contaminated environments. The best methodof achieving “surgical prep” must be determined. In addition a flexible endoscope instillsroom air into the abdominal cavity without pressure regulation, whereas standardlaparoscopic procedures utilize automatic insufflators to deliver pre-set pressures ofcarbon dioxide. Another difficulty is that the image obtained with the flexible endoscopemay project on the monitor as upside down and backwards, depending on the scopeorientation, so navigation is much more difficult than with laparoscopy which uses rigidtelescopes. Another critical difference from laparoscopy is that with the NOTESprocedures, all of the instrumentation is delivered down the 2.8 and 3.5 mm workingchannels of the endoscope; as a result the orientation of the instruments is coaxial to thecamera, which prohibits triangulation, the foundation of port placement for laparoscopicprocedures. In addition, current instruments are limited to very small biopsy forceps,scissors, snares, guide wires, and needle knife devices that are currently used inendoscopic procedures. None of these instruments are as robust as laparoscopicinstrumentation. Finally, there is no evidence that currently supports that the NOTESprocedure is less invasive – that is, that it causes less tissue trauma or less immunologicimpairment to an individual undergoing this procedure, as compared to laparoscopic oropen surgery.
  8. 8. The Purdue University/ Indiana University collaboration is a cross functional team ofphysician surgeons, gastroenterologists, and veterinary surgeons who are interested inevaluating the safety, feasibility, and the practicality of these new techniques. Byperforming ovariectomy via a flexible endoscope passed into the abdominal cavitythrough the stomach, Dr. Freeman and Dr. Rahmani have established a NOTES model.The team is researching the intra-operative complications, postoperative pain, andsurgical stress of the NOTES approach and comparing it to traditional and laparoscopicprocedures.While many patients are attracted to the idea of surgery without scars, considerableevidence must be obtained to show that these techniques are not only safe, but trulybetter. And who knows, perhaps they may be better for animals also?A flexible endoscope is used to perform surgical procedures through the gastric wall. Inthis step, a guide wire is inserted percutaneously to assist in identifying the site for thegastric incision.
  9. 9. Like laparoscopy, the camera in the endoscope provides visualization and the procedureis viewed on a video monitor.The ovarian tissue is examined to ensure complete excision.References:Rattner, DW, Hawes R. What is NOSCAR? Surg Endosc 2007:21:1045-1046.Kalloo AN, Singh VK, Jagannath SB, et al. Flexible transgastric peritoneoscopy: a novelapproach to diagnostic and therapeutic interventions in the peritoneal cavity. GastrointestEndosc 2004;60:114-117.
  10. 10. Jagannath SB, Kantesevoy SV, Vaughn CA, et al. Peroral transgastric endoscopic ligationof fallopian tubes with long-term survival in a porcine model. Gastrointest Endosc2005:61:449-453.Kantsevoy SV, Jagannath SB, Niiyama H, et al. Endoscopic gastrojejunostomy withsurvival in a porcine model. Gastrointest Endosc 2005:62:287-292.Fritscher-Ravens A, Mosse CA, Ikeda K, Swain P. Endoscopic transgastriclymphadenectomy by using EUS for selection and guidance. Gastrointest Endosc2006:63:307-312.Pai RD, Fong DG, Bundga ME, et al. Transcolonic endoscopic cyolecystectomy : aNOTES survival study in a porcine model [with video]. Gastrointest Endosc2006:64:428-434.Rolanda C, Lima E, Pego JM, et al. Third-generation cholecystectomy by natural orifices:transgastric and transvesical combined approach [with video]. Gastrointest Endosc2007:65:111-117.Kantsevoy SV, Hu B, Jagannath SB, et al. Transgastric endoscopic splenectomy: is itpossible? Surg Endosc 2006:20-522-525.Onders R, McGee MF, Marks J, et al. Diaphragm pacing with natural orifice transluminalendoscopic surgery: potential for difficult-to-wean intensive care unit patients. SurgEndosc 2007:21:475-479.Onders RP, McGee MF, Marks J, et al. Natural orifice transluminal endoscopic surgery(NOTES) as a diagnostic tool in the intensive care unit. Surg Endosc 2007:21:681-683.Marks JM, Ponsky JL, Pearl JP, McGee MF. PEG “Rescue”: a practical NOTES technique.Surg Endosc 2007:21:816-819.Marescaux J, Dallemagne B, Perretta S, et al. Surgery without scars: report oftransluminal cholecystectomy in a human being. Arch Surg 2007:142:823-826.
  11. 11. VIRTUAL REALITY TRAINING IN VETERINARY SURGERYOur project goal is to develop virtual reality simulation that can be used to developtechnical skills for basic surgical procedures without the use of live animals. We believethat virtual reality environments will allow for more accurate assessment of veterinarystudent and operative team performance in surgical settings than methods used today.We will capture digital pressure measurements using pressure sensors engaged on thesurgeon’s hands underneath sterile surgical gloves during the targeted tasks. Throughcollaboration by veterinary surgeons and members of the department of electrical andcomputer engineering the pressure measurements can then be integrated with the createdgraphics to create the haptic portion of the virtual simulation.We envision a computer workstation that allows students to use Wi sticks and 3D gogglesto interact with streaming video models to practice their surgical skills. The students willuse the computer to click on an instrument and then use the instrument to interact withthe video environment to handle tissue and perform simple tasks such as incising,suturing, and knot tying. Once these techniques are simulated sufficiently for the studentto learn, the tasks will be sequenced to simulate a surgical procedure. In the future,students will be evaluated by objective criteria such as elapsed time, force measurements,errors in technique, and ability to accomplish the assigned task.