To keep a working space, an external retractor is inserted through the skin incision in the axilla and is raised using a lifting device. A second skin incision (0.8cm in length) is made on the medial side of the anterior chest wall for the insertion of the fourth robot arm; apart 2cm superiorly, and 6~8cm medially from the nipple.
Four robotic arms are used for the operation. Three arms are inserted through the axillary incision, the dual channel endoscope is placed on the central arm, and the Harmonic curved shears along with the Maryland dissector is placed on both lateral side arms of the scope. The prograsp forceps is inserted through the anterior chest arm.
Despite these advantages, there are still many drawbacks to a conventional laparoscopy. The surgeon operates looking at a monitor that only shows a two dimensional image. The rigid instruments the surgeon works with are controlled from a distance; they have no wrists, which decreases precision, dexterity and control. As a result, the surgeon will also tire more quickly. Due to the small incision, the participation of the assistant is limited. This makes complex gynecologic operations very difficult, resulting in a higher likelihood that you will receive larger incision.
* 07/16/96 * ##
* 07/16/96 * ##
Laparoscopy: The impact on the future
Danny Yakoub MD
George S Ferzli MD FACS
Professor of Surgery - State University of New York (Downstate)
Chairman of Surgery - Lutheran Medical Center, New York, USA
1920: Zollikofer discovered the benefit of CO 2 gas for insufflation
1938: Janos Veress developed a spring loaded needle for the induction of pneumoperitoneum.
After World War II, the development of fiberoptics represented an important step forward for endoscopy
1966: Hopkins rod lens scope & cold light
1974: Dr Harrith M Hasson, MD working in Chicago, proposed a blunt mini-laparotomy which permitted direct visualization of the trocar entrance into the peritoneal cavity. It is popularly known today as Hasson‘s technique.
Once, while making a slide presentation on ovarian cysts; suddenly the projector was unplugged - with the explanation that “such unethical surgery should not be presented”
In 1970, after becoming the chairman of Ob/Gyn at the University of Kiel, his co-workers demanded that he undergo a brain scan because, they said, “only a person with brain damage would perform laparoscopic surgery”
German Engineer and Gynecologist. Introduced automatic insufflator, thermocoagulation ,loop knots, irrigation device in 1983, performed endoscopic appendectomy as part of A gynecologic procedure.
Journal of Reproductive Medicine 1977. Volume 18; No. 5: 235- 240
1985: Dr. Muhe (Prof Dr Med - Böblingen, Germany) performed the first successful laparoscopic cholecystectomy in a human. However, this was not well publicized until years later. The German Surgical Society rejected Mühe in 1986 after he reported that he had performed the first laparoscopic cholecystectomy.
These cables are made up of a bundle of optical fibers glass thread swaged at both ends.
The fiber size used is usually between 10 to 25 mm in diameter.
They have a very high quality of optical transmission, but are fragile.
tro-car - [Fr., troisis , three + carre, side] noun a sharp-pointed surgical instrument fitted with a cannula and used especially to insert the cannula into a body cavity cannula - [L., dim of canna, reed] noun a tube that is inserted into a cavity by means of a trocar filling it’s lumen
Correct trocar placement should provide direct access to the target organs, an optimal view of the operative field and minimize mental and muscular fatigue.
Avoid competing for the same space: Working against the camera and ‘blind spots’ “ Dueling swords” phenomenon (scissoring effect)
Avoid the epigastric vessels Saber et al. Safety zones for anterior abdominal wall entry during laparoscopy. Ann Surg 2004; 239:182
(adapted from) Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisions James L. Whiteside, MD, Matthew D. Barber, MD, MHS, Mark D. Walters, MD, and Tommaso Falcone, MD (Am J Obstet Gynecol 2003;189:1574-8.) Anatomic distribution of nerves across anterior abdominal wall Iliohypogastric nerve Ilioinguinal nerve
(adapted from) Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisions James L. Whiteside, MD, Matthew D. Barber, MD, MHS, Mark D. Walters, MD, and Tommaso Falcone, MD (Am J Obstet Gynecol 2003;189:1574-8.) Iliohypogastric n. Ilioinguinal n. Incision line/trocar sites vs. nerve distribution Epigastric a. Trocar site Pfannenstiel incision
Trocar distance from the target organ depends upon the size of the patient. Individual trocars can be moved closer to the target along an axis line. Additional trocars can be added along the semicircular line.
* 600,000 cholecystectomies annually in the U.S., 8%-20% have CBD stones, no consensus on optimal management. ** “No single clinical indicator is completely accurate in predicting CBD stones prior to cholecystectomy.” * Liu, TH et al. Ann Surg 234(1), July, 2001. **Abboud, et al. Gastrointestinal Endoscopy, 44(4), October 1996
Laparoscopic US as a good alternative to intraoperative cholangiography (IOC) during laparoscopic cholecystectomy: results of prospective study.
685 IOC (35 cannot canulate cystic duct)
269 LUS (2 steatosis)
IOC detected 4.5% common bile duct stones; LUS 6%
IOC sensitivity 96.9%, specificity 99.2%
LUS sensitivity 100%, specificity 99.6%
In this prospective study, LUS has been certainly as effective as IOC as
a primary imaging technique for bile duct. It permitted to detect CBDS
with a high specificity and sensitivity , and was not followed by an
increase in CBDI.
Hublet A et al Laparoscopic US as a good alternative to intraoperative cholangiography during lap chole: results of prospective study Acta Chir Belg . 2009 May-Jun Belgique.
National Hospital Discharge Survey database 1979 to 2001:
Frequency of ERCP vs CBDE
Beginning of study: 47,000 CBDE’s per year
End of study: 7,000 CBDE vs 43,000 ERCP
Complication rates from CBDE
3.4% at beginning of study
17.4% at end of study
“ ERCP has replaced the need for most but not all CBDE”
“ Both choledocholithiasis treatment algorithms and clinical training paradigms need to account for the rarity of CBDE and high complication rates associated with it, by incorporation of training modules in surgical residencies and advocating referral to centers having expertise in biliary tract operations from surgeons with little CBDE experience”
Livingston EH, Rege RV. Technical Complications are Rising as Common Duct Exploration is Becoming Rare. JACS 2005;201(3):426-433
Public Health Problem #1: Laparoscopy in Bariatric Surgery OBESITY
Derived from Center for Disease Control and Prevention website www.cdc.gov Percent of Obese (BMI ≥ 30) in US Adults
Derived from Center for Disease Control and Prevention website www.cdc.gov Percent of Obese (BMI ≥ 30) in US Adults
County-level Estimates of Obesity among Adults aged ≥ 20 years: United States
a Relative contraindications Contraindications for Laparoscopic Adrenalectomy Local tumor invasiveness Regional lymph node involvement Large tumor size larger than 10 to 12 cm a Prior nephrectomy, splenectomy, or liver resection on the side of the adrenal lesion a
Conclusion: Computed tomography-guided percutaneous RFA is a safe and efficacious alternative to laparoscopic adrenalectomy in treating patients with PA due to small APA. Ann Surg. Dec 2010;252:1058-1064
Rudolph Nissen, MD INFLUENTIAL PEOPLE: Lortat-Jacob, MD AndreToupet, MD Jacques Dor, MD Ernst Heller, MD Rudolph Nissen MD Ivor Lewis, MD J. Leigh Collis, MD K. Alvin Merendino, MD Lucius Hill, MD Ronald Belsey, MD Alan Thal, MD
Laparoscopic Sphincter Augmentation Device Eliminates Reflux Symptoms and Normalizes Esophageal Acid Exposure: One- and 2-Year Results of a Feasibility Trial
44 patients. At baseline, all patients had abnormal esophageal acid exposure on 24-hour pH monitoring and improved, but persistent, typical GERD symptoms while on acid suppression therapy with proton pump inhibitors (PPIs).
Patients were evaluated after surgery by GERD Health-Related Quality of Life symptom score, PPI usage, endoscopy, esophageal manometry, and 24-hour esophageal pH monitoring.
Results: The total mean GERD Health-Related Quality of Life symptom scores improved from a mean baseline value of 25.7 to 3.8 and 2.4 at 1- and 2-year follow-up, representing an 85% and 90% reduction, respectively ( P < 0.0001). Complete cessation of PPI use was reported by 90% of patients at 1 year and by 86% of patients at 2 years. Early dysphagia occurred in 43% of the patients and self-resolved by 90 days. One device was laparoscopically explanted for persistent dysphagia without disruption of the anatomy or function of the cardia. There were no device migrations, erosions, or induced mucosal injuries. At 1 and 2 years, 77% and 90% of patients had a normal esophageal acid exposure. The mean percentage time pH was less than 4 decreased from a baseline of 11.9% to 3.1% ( P < 0.0001) at 1 year and to 2.4% ( P < 0.0001) at 2 years. Patient satisfaction was 87% at 1 year and 86% at 2 years.
Conclusions: The new laparoscopically implanted sphincter augmentation device eliminates GERD symptoms without creating undue side effects and is effective at 1 and 2 years of follow-up.
Bonavina et al. Annals of Surgery. 252(5):857-862, Nov. 2010.
The Ebers Papyrus 1550 BC, Entitled “Beginning of the Secret of the Physician”
Heat application was one of the methods to reduce a strangulated hernia.
The mummy of Meren-Ptah (19th dynasty) shows a sign of an open wound resulting from surgical interference.
If thou examinst a swelling of the covering of his belly’s horns above his pudenda (sex organs) then thou shalt place thy finger on it and examine his belly and knock on the fingers (percuss) if thou examinst his that has come out and has arisen by his cough. Then thou shalt say concerning it: it is a swelling of the covering of his belly. It is a disease which I will treat”.
Material reduced meshes have some advantages with respect to longterm discomfort and foreign body sensation in open hernia repair (when only considering chronic pain).
Prophylactic resection of the ilioinguinal nerve does not reduce the risk of chronic pain after hernia surgery.
Identification of all inguinal nerves during open hernia surgery may reduce the risk of nerve damage and postoperative chronic groin pain.
Treatment of chronic pain
A multidisciplinary approach at a pain clinic is an option for the treatment of chronic post herniorrhaphy pain.
Surgical treatment of specific causes of chronic post herniorrhapy pain can be beneficial, such as resection of entrapped nerves, mesh removal in mesh-related pain, removal of endoscopic staples or fixating sutures.
European Hernia Society Guidelines: Treatment of Inguinal Hernia in Adult Patients
Laparoscopic Ventral Hernia: Is the Abdomen a Weakness in the Human Race ?
The most important functions of the abdominal wall are protection,
compression and retention of the abdominal contents, flexion and rotation
of the trunk and forced expiration.
Endogen Exogene Others
Age > 45 Sutures Emergency
BMI > 25 Length of incision Intra-abdominal
Previous operation Contamination pressure
Shock Type of incision
Significant predictors of surgical site infection and incisional hernia a Effect of Stitch Length on Wound Complications After Closure of Midline Incisions; A Randomized Controlled Study, Millbourn, D MD; Cengiz, Y MD, PhD; Israelsson, L MD, PhD Arch Surg/vol 144 (No. 11), Nov 2009 www.archsurg.com Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); CI, confidence interval; OR odds ratio; SL, suture length; WL wound length A Results of logistic regression analysis. All recorded variables were included in the model and removed by a backward reduction strategy if nonsignificant. Predictor Regression Coefficient (SE) OR (95%CI) Surgical site infection Wound contamination 1.03 (0.48) 2.81 (1.09-7.25) Being diabetic 1.01 (0.38) 2.73 (1.30-5.72) Long stitch length 0.77 (0.31) 2.15 (1.17-3.96) Incisional hernia Male sex 0.76 (0.34) 2.14 (1.10-4.15) Higher BMI 0.05 (0.02) 1.05 (1.01-1.10) Longer operation time 0.005 (0.002) 1.01 (1.002-1.01) Surgical site infection 1.16 (0.40) 3.18 (1.44-7.02) SL to WL ratio <4 1.32 (0.52) 3.73 (1.36-10.26) Long stitch length 1.44 (0.34) 4.24 (2.19-8.23)
Level of Complexity Grade 1 Low risk of infection Low risk of complications Grade 2 Smoker Immunosuppressed Obese Diabetic Grade 4 Active infection Infected mesh Grade 3 Contamination risk Stoma present Violation of bowel wall Previous Wound infection Grade 5 Traumatic fascia loss Extensive fascia loss Percent Performed Open Patients with co-morbid conditions have up to 4x increase in wound-infection rates Open incisional hernias are 10x more likely to have infection than a clean surgical case Infected mesh commonly results in a 2 nd procedure for removal Synthetic Biologic
Comparison of laparoscopic and open repair with mesh for the treatment of ventral incisional hernia: a randomized trial in 4 VA centres
162 patients with ventral incisional hernias.
Complications were less common in the laparoscopic group (23 patients [31.5%]) compared with the open repair group (35 patients [47.9%]
Surgical site infection through 8 weeks was less common in the laparoscopic group (5.6% vs 23.3%; AOR, 0.2; 95% CI, 0.1-0.6).
The mean worst pain score in the laparoscopic group was 15.2 mm lower on a visual analog scale at 52 weeks (95% CI, 1.0-29.3; P = .04).
Time to resume work activities was shorter for the laparoscopic group than for the open repair group (median, 23.0 days vs 28.5 days), with an adjusted hazard ratio of 0.54 (95% CI, 0.28-1.04; P = .06).
Overall recurrence at 2 years was 12.5% in the laparoscopic group and 8.2% in the open repair group (AOR, 1.6; 95% CI, 0.5-4.7; adjusted P = .44).
CONCLUSIONS: Laparoscopic repair was associated with fewer, albeit more severe, complications and improved some patient-centered outcomes
Itani et al. Arch Surg. 2010 Apr;145(4):322-8; discussion 328
Grevious MA. Cohen M. Shah SR. Rodriguez P. Structural and functional anatomy of the abdominal wall. Clinics in Plastic Surgery. 33(2):169-79, v, 2006 Apr. External oblique Internal oblique Transversus abdominis Rectus abdominis Components Separation
CONCLUSIONS: In those clinical settings where surgical expertise and equipment are available and affordable, diagnostic laparoscopy and LA (either in combination or separately) seem to have various advantages over OA. Some of the clinical effects of LA, however, are small and of limited clinical relevance. In spite of the mediocre quality of the available research data, we would generally recommend to use laparoscopy and LA in patients with suspected appendicitis unless laparoscopy itself is contraindicated or not feasible. Especially young female, obese, and employed patients seem to benefit from LA.
Meta-analysis by Aziz et al. Ann Surg 2006
Conclusion: Laparoscopy was associated with decreased risk of incisional infection but with an increased risk of OSI. The degree of this increased risk varies depending on the clinical profile of a surgical patient. Recognition of these differences in risk may aid clinicians in the choice of operative approach for appendectomy. Ann Surg. Dec 2010; 252:895-900
LAPAROSCOPIC PROCEDURES WITH CLEAR ADVANTAGES.
Laparoscopic left hemihepatectomy (resection of segments 2, 3, and 4). (A) Intraoperative view showing ischemic delineation of the left liver. Note the vascular endoscopic stapler encircling the left Glissonian pedicle. (B) Schematic view. The stapler is closed, and ischemic delineation of the left liver is obtained. (C) Intraoperative view. The stapler is fired, and the left main Glissonian pedicle is transected (arrows). (D) Schematic view. The stapler is fired
Pulitan ò C and Aldrighetti L Nat Clin Pract Gastroenterol Hepatol (2008) Outcomes of laparoscopic hepatectomy
Conclusion: Laparoscopic resection is a favorable alternative to open liver resection for patients with colorectal liver metastasis. The observed actuarial survival values after laparoscopic resection surpass the values expected by major scoring systems
PROSTATECTOMY A B C Trocars – added as needed along semicircular line. i.e., during a prostatectomy, another trocar is added between A and B. Another trocar may be added between B and C allowing the surgeon and assistant surgeon on the opposite side to each use both hands.
MIVAT and MIVAP yield equivalent endocrine results as open procedure
Oncologic result is equivalent in selected patients
Equivalent safety profile as open procedures
Postop pain is decreased
Patient satisfaction with procedure and cosmetic result is significantly increased
(Miccoli et al., RCT, Surgery. 2001)
What about large masses?!
It is not a ‘niche surgery’!
Robotic Parathyroidectomy Arm 1 Camera Arm 2 Arm 3 This approach was developed in South Korea by Dr. Woong Chung at Yonsei University College of Medicine in Seoul. He reported his experience with 338 patients
A. Schematic representation of prototype paddle-type retractor fully deployed.
B. Internal view of prototype elevating porcine spleen.
Conclusion: With gastric bypass, type 2 diabetes can be improved and even rapidly put into the state of remission irrespective of weight loss. Improved insulin resistance within the first week after surgery remains unexplained, but increased insulin production in the first week after surgery may be explained by the enhanced postprandial GLP-1 responses Ann Surg. Dec 2010; 252:966-971
And it ought to be remembered that there is nothing more difficult than to take the lead in the introduction of a new order of things, because the innovator has for enemies, all those who have done well under the old conditions.
From 1980 through 2006, the number of Americans with diabetes tripled (from 5.6 million to 16.8 million).
~24 million in 2009.
CDC. National Diabetes Fact Sheet, 2007. Source: 2003 –2006 National Health and Nutrition Examination Survey estimates of total prevalence (both diagnosed and undiagnosed) were projected to year 2007.
Slides taken from: DIABETES IS NO LONGER A HOPELESS DISEASE The Guilty Gut Walter Pories, MD, FACS, Chief, Metabolic Institute East Carolina University Greenville, North Carolina 2006:
2004: “ Results of our study support the hypothesis that the bypass of duodenum and jejunum can directly control type 2 diabetes and not secondarily to weight loss or treatment of obesity.” Effect of Duodenal-Jejunal Exclusion in a Non-obese Animal Model of Type 2 Diabetes: A New Perspective for an Old Disease. Rubino, Francesco, MD; Marescaux, Jacques MD, FRCS Annals of Surgery; 239 (1): 1-11, January 2004
Double blind study: 16 patients assigned to LRYGBP and 16 Pts to LSG
Patients reevaluated on the 1st, 3rd, 6th, and 12th mos
No change in ghrelin levels after LRYGBP Significant decrease in ghrelin after LSG ( P < 0.0001)
Fasting PYY levels increased after either surgical procedure ( P <= 0.001)
Appetite decreased in both groups but to a greater extend after LSG
Weight loss, appetite suppression, and changes in fasting and postprandial ghrelin and peptide-YY levels after Roux-en-Y gastric bypass and sleeve gastrectomy: a prospective, double blind study. Karamanakos et al Ann Surg . 2008 Mar; 247(3): 401-7.
A ll subjects consistently felt relief from fatigue, pain and/or numbness in the extremities, polyuria, and polydypsia.
Clinical resolution was obtained for one patient, and the preoperative diabetic medication requirements decreased for most of the other patients.
The subjects demonstrated an overall improved HbA1c (from 9.4% to 8.5%) and fasting blood glucose level (from 209 to 154 mg/dl).
The Diabetes Surgery Summit Consensus Conference Rubino et al. Annals of Surgery. Vol 251, Number3,300-405, March 2010 45% of type 2 patients with diabetes world-wide demonstrate a BMI less than 30 ADA : “ Bariatric Surgery should be considered for adults with BMI > 35Kg/m2 And type 2 diabetes ,especially if the diabetes is difficult to control with lifestyle And pharmacologic therapy
Clinical Evaluation of the Effect of Duodenal-Jejunal Bypass on Type 2 Diabetes (June 2007) Patient Duration of Type 2 Diabetes Pre-Operative Medication 1 Year Medication Requirement #1 19 Metformin 850mg One tablet daily Metformin 850 mg half tablet daily #2 10 30/10 Units Insulin 30/10 Units Insulin #3 12 40/20/20/20 Units Insulin 30 Units occasionally at night #4 12 2 Metformin 850mg daily; 40/20 Units Insulin 1 Metformin 850mg daily; 5 Units n occasionally #5 12 40/20 Units Insulin 5 Units Insulin three times per week #6 * 6 20/12 Units Insulin No Medication #7 4 Clormin 1000mg daily; 30/20 Units Insulin Diaformin 500mg daily; 30/20 Units Insulin
Clinical Evaluation of the Effect of Duodenal-Jejunal Bypass on Type 2 Diabetes (June 2007)
The mean HBA1c at pre-op and 1 year was 9.371 and 8.500 respectively
FBG at pre-op and 1 year were 208 and 154 respectively for the seven patients (p=0.057)
Lipid profiles improved with lower total cholesterol levels and triglycerides 1 year
Mean (SEM) Pre vs post op Correlation P value* HBA1C Pre-op 9.371 (0.85) -0.040 0.933 HBA1C 1yr 8.500 (0.67) FBG Pre-op 208.86 (22.50 0.74 0.057 FBG 1YR 154.86 (39.9) Cholesterol preop 183.71 (11.5) 0.632 0.128 Cholesterol 1yr 186.00 (19.9) TG pre-op 112.43 (27.7) -0.245 0.596 TG 1yr 127.29 (25.3) Cpep pre-op 1.343 (0.29) -0.245 0.205 Cpep 3 months 1.200 (0.32)