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LAPAROSCOPIC SURGERY- PAST, PRESENT AND FUTURE

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What is MIS? …

What is MIS?
A minimally invasive medical procedure is defined as one that is carried out by entering the body through the skin or through a body cavity or anatomical opening, but with the smallest damage possible to these structuresIncludes laparoscopic, endoscopic, and other approaches.
Why MIS?
Decreased patient pain
Decreased patient recovery period
Possible decrease in inflammatory response in the patient which may prove to have a better outcome in oncologic operations.
Distant future
In the distant future, there will be a para- digm shift with the development of non-inva- sive surgical techniques in combination with nanotechnologies and a new era in the devel- opment of surgery, and subsequently in surgi- cal techniques, will be opened.
Nanotechnology is an umbrella term for materials and devices that operate at the nanoskill (1 billionth of a meter). In terms of scale, a nanometer is approximately one 1/8000 of a human hair or 10 times the diam- eter of a hydrogen atom. The size of the device can vary but starts from a ten thou- sand-logic element system that will occupy a cube of no more than one hundred nanome- ters. This is a volume slightly larger than 0.001 cubic microns. This would be sufficient to hold a small computer. For example, if red blood cells are approximately eight microns in diameter, the 100 nanomicroprocessor will be 80 times smaller than a red blood cell. Devices this size could easily fit into the circulatory system and could even conceivably enter indi- vidual cells.

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  • Need a better picture
  • 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.
  • The da Vinci System was designed to overcome the limitations of the traditional open and conventional laparoscopic (minimally invasive) approaches.
    da Vinci is a state-of-the-art surgical robotic system that provides the extended capabilities necessary to complete your procedure using only a few small incisions.
    With da Vinci Surgery, the surgeon is seated at a nearby console and always in full control of the robotic instruments.
    Since the assistant is next to the patient and has direct access to the surgical site, he or she can assist during complex steps of the procedure.
  • Using master controls the System directly translates the surgeon’s hand movements into precise micro-movements of the instrument tips.
    Specialized instruments increase dexterity, and help the surgeon to perform a more precise surgery.
    The da Vinci System cannot be programmed to act on its own, and therefore requires the continuous, direct input of your surgeon.
  • If you remember from before, conventional minimally invasive instruments are rigid and have no wrists.
    The EndoWrist instruments of the da Vinci System move like a human wrist.
    This allows the surgeon to control the instruments with the precision necessary to perform complex procedures like lymph node dissection using only a few tiny incisions.
  • Transcript

    • 1. Laparoscopy: History, Present and Emerging Trends Dr. Sreejoy Patnaik
    • 2. History of Laparoscopy The first description dates to Hippocrates in Greece, for use of a speculum to visualize the rectum (460–375 BC). A three bladed speculum was found in the ruins of Pompeii*. *A roman town buried by a volcano eruption near modern Naples, Italy - 79 AD).
    • 3. History of Laparoscopy  1806: Philip Bozzini developed an instrument called a Lichtleiter (light-guiding instrument)  1853: Antoine Jean Desormeaux used Bozzini’s Lichtleiter  1867: Desormeaux used an open tube to examine the genitourinary tract
    • 4. History of Laparoscopy Maximilian Nitze (1848 – 1906) invented the first cystoscope (Nitze-Leiter cystoscope) using an electrically heated platinum wire for illumination. In 1887, he modified Edison`s light bulb and created the first electrical light bulb for use during urological procedures. Original carbonfilament bulbThomas Edison
    • 5. History of Laparoscopy  1901: George Kelling, Dresden, Saxony (Germany) performed the 1st experimental laparoscopy, calling it ‘Celioscopy’.  Kelling insufflated the abdomen of a dog with filtered air and used a Nitze cystoscope to look inside.
    • 6. Hans Christian Jacobaeus (1879 – 1937)  1910: Swedish internist; first thoracoscopic diagnosis with a cystoscope in a human subject.  Treatment of a patient with tubercular intra-thoracic adhesions. The Possibilities for Performing Cystoscopy in Examinations of Serous Cavities. Münchner Medizinischen Wochenschrift, 1911
    • 7. Bertram Bernheim  1911 : First laparoscopy at Johns Hopkins  12mm proctoscope into epigastric incision on one of Halstead’s patients to stage pancreatic cancer  Bernheim called his procedure ‘organoscopy’  Findings confirmed on laparotomy
    • 8. History of Laparoscopy  1920: Zollikofer discovered the benefit of CO2 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.
    • 9. Kurt Semm (1927-2003)  Once, while making a slide German Engineer and Gynecologist. Introduced automatic insufflator, thermocoagulation ,loop knots, irrigation device in 1983, performed endoscopic appendectomy as part of A gynecologic procedure. 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”
    • 10. History of Laparoscopy  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.
    • 11. Laparoscopy Takes Off  1988: 1st Lap cholecystectomy in the USA, Surgiport 1st available  1989: US TV picks up on “Key Hole” surgery EndoClip™ released  1990: Cuschieri (Aberdeen) warns on the explosion of endoscopy  1991: ‘Lap Chole’ is accepted and routine procedure  1992: The National Institutes of Health Consensus Conference concludes that laparoscopic cholecystectomy is now the preferred alternative to open cholecystectomy
    • 12. Definition  Minimal access surgery is a marriage of modern technology and surgical innovation that aims to accomplish surgical therapeutic goals with minimal somatic and psychological trauma
    • 13. Extent of minimal access surgery  Laparoscopy  Thoracoscopy  Endoluminal endoscopy  Perivisiceral endoscopy  Arthroscopy and intra-articular joint surgery  Combined approach
    • 14. What operations can we do Laparoscopically Diagnosis Operation Gallstone Cholecystectomy Appendicitis Appendicectomy Hernia Hernia repair Adhesions Division of adhesions Perforated ulcer Closure of perforation Hiatus Hernia Hiatus hernia repair.
    • 15. What operations can we do Laparoscopically Diagnosis Operation Colorectal carcinoma Anterior resection/ APR Caecal carcinoma Right Hemicolectomy Colonic carcinoma Left/Sigmoid Colectomy Gastric carcinoma Gastrectomy Oesophageal carcinoma Oesophagogastrectomy The list is endless!!!
    • 16. What operations can we do laparoscopically? Diagnosis Operation Crohn’s Disease Bowel resection Diverticulitis Bowel resection Rectal Prolapse Repair of Prolapse Benign renal disease Nephrectomy Gastric Obstruction Bypass Some Splenic disorders Spleenectomy
    • 17. Principle Differences between Laparoscopic and Open Surgery     FOR THE PATIENT Post operative pain related to size of incisionsmaller incisions =less pain. Less Handling of intestines results in little or no disturbance of normal function. Avoidance of the trauma of abdominal wall injury by the incision allows rapid return to normal activity No incision allows early return to more strenuous activities: driving, lifting, sport etc.
    • 18. Principle Differences between laparoscopic and open surgery  FOR THE HOSPITAL Initial capital costs to establish laparoscopic surgery in the order of Rs 10 - 20 lacs  Reduced overall costs by shortening of hospital stay e.g. cholecystectomy reduced from 5 to 1 day, hiatus hernia repair reduced from 7 to 3 days.
    • 19. Principle Differences between laparoscopic and open surgery       For the Surgeon Magnified view often better than obtained via an incision allows precise dissection. Altered (but not absent) tactile response Two dimensional (flat screen) view. Usually (but not always) longer operating time Need to develop entirely different operating technique Adaptation of principles of open surgery to laparoscopic surgery.
    • 20. Instruments  Redesign of instruments for laparoscopic use.  Instruments for open surgery in general 6 – 10” in length  built around a box joint. Laparoscopic instruments in general 15 – 18” in length with an articulated connecting rod between handles and scissor blades, jaws etc.
    • 21. Equipment Necessary for MAS Camera Light Source Insufflator TV Monitor Telescopes Light Guide Cable Apart from the insufflator the system will work better if all the components are from the same company as one piece talks to another
    • 22. CAMERA  These can be single chip or 3 chip.  CHIP: thois is also called a charged coupled device in short, CCD.  These are flat silicone wafers with a matrix, a grid of minute image sensors called pixels.  White balance and sometimes black balance  Sleeve it don’t soak it!!! 
    • 23. Light Source  Halogen or Xenon, cold light but beware can still     burn holes in drapes esp. disposable and burn patient’s skin if left on the abdomen. Brightest to darkest measured in units of decibels. Automatic illumination, does it talk to the camera and are the necessary leads plugged in. Lamp life meter, look at it. Is it nearly out? EBME keep the spares and they change it. White balance by making sure white is correct then all the colours through the spectrum are correct.
    • 24. Insufflator  CO2 because this has the same refractive     index as air, so doesn’t distort the image and is non combustible. Intraabdominal pressure run between 10 and 13 mmhg. Use disposable filter and tubing for each patient. High flow insufflators (35 litres) output determined by size of outlet. Ensure you know how to change a cylinder and were they are stored.
    • 25. TV Monitors       Usually a 20” screen. HD is better. You can use a standard TV but it must be run through an isolated transformer. Horizontal resolution is the number of vertical lines. Vertical resolution is the number of horizontal lines More lines of resolution, better detail of picture.
    • 26. Telescopes  Come in varying sizes, laparoscopes usually       5mm or 10mm. Diagnostic 3mm scope available. Made up of a rod and lens system. Bundles of fibres, incoherent carry light and coherent carry image. Wide range of angles available 0, 30, 45 degree are fairly standard. All laparoscopes are autoclavable and can go through sterilisation, no ultrasonic bath required. Endo- chameleon- extra long for Bariatric patients.
    • 27. Light guide Cables       Different diameters Fibre light cable Buy auroclavable Don’t bend to acutely as will break fibres. Check when you plug them in are all the fibres are okay. Condensers
    • 28. Instrumentation  SINGLE USE: breaking the Law if you reuse it     on another patient. Reusable take apart. Need an ultrasonic washer to effectively clean them, not for telescopes. Don’t put 5mm cannulated instruments into a bench top autoclave that does not have a vacuum: vacuum is required to remove all air form lumen of instrument. Ports 5 and 10mm are the most common, make sure the right trocar is in port and is it sharp.
    • 29. Electrosurgery You should be aware of the following potential situations:  Insulation failure of the active electrode.  Direct coupling of current to other instrumentation by direct contact.  Capacitance which may be created by two electrical conductors separated by an insulator
    • 30. Ultrascision or the Harmonic Scalpel Electrical generator (the box) This adjusts the amount of electrical energy being delivered and monitors performance. Transducer This is where electrical energy is converted to the ultrasonic waves. The frequency is fixed however the amplitude alters with the power input. the transducer is located in the hand piece and is connected to the generator by an electrical cable. Dissection Instrument (peripheral hand piece) A metallic rod is coupled to the transducer and vibrates at the prescribed frequency (i.e. 55kHz). The tip of the rod contacts with the surface tissue.
    • 31. Principles of Piezo Electronics  The ultrasound waves are created by electrical energy hitting a negatively charged crystal that vibrates (expands and contracts) at a particular frequency. These crystals are disc shaped and made of ferroelectric ceramics. A pair of discs “coupled” together produce a sinusoidal wave form. This coupling results in a harmonic waveform that is of high electroacoustic efficiency.
    • 32. VERESS NEEDLE  1938 - Janos Veress, of Hungary, developed the springloaded needle. to perform therapeutic pneumothorax (TB).  Made of surgical stainless steel with a single trap valve. 2mm diameter x 80mm length  It consists of an outer cannula with a bevelled needle point for cutting through tissues.
    • 33. GAS INSUFFLATION  Controlled pressure insufflation of the peritoneal cavity is used to achieve the necessary work space for laparoscopic surgery.  Automatic insufflators allow the surgeon to preset the insufflating pressure, and the device supplies gas until the required intra-abdominal pressure is reached.
    • 34. Trocar  The trocar has a blade with a shaft and body.  The body includes a pointed tip which makes the initial incision in the abdominal wall of the patient. (Trocar diameters range from 2mm-30 mm)
    • 35. Trocars  Types:  Cutting  Pyramidal tipped  Flat blade  Noncutting  Pointed conical  Blunt conical
    • 36. Telescope  There are three important structural differences in telescope available 1. 6 to 18 rod lens system telescopes are available 2. 0 to 120 degree telescopes are available 3. 1.5 mm to 15 mm of telescopes are available
    • 37. Optic cables  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.
    • 38. Dissecting & Grasping Forceps  Atraumatic  KELLY atraumatic  Atraumatic, with hollow jaws  MANGESHKAR Grasping Forceps, serrated
    • 39. General instruments  Reusable three-piece design  Available in 2 mm, 3 mm, 3.5mm, 5 mm and 10 mm sizes, with lengths of 20 cm, 30 cm, 36 cm and 43 cm.  Choice of handle styles.  Fully rotating 360° sheath.  No hidden spaces that can trap operative blood and tissue debris.
    • 40. Scissors  HOOK SCISSORS, single action jaws  METZENBAUM SCISSORS, curved, length of blades 12-17 mm, widely used as an instrument for mechanical dissection in laparoscopic surgery.     STRAIGHT SCISSOR can give controlled depth of cutting because it has only one moving jaw.
    • 41. TROCAR PLACEMENT BY QUADRANT Thoracic triangle 1 2 4 3 Pelvic triangle
    • 42. TROCAR PLACEMENT BY QUADRANT Each quadrant must be addressed from frontal as well as lateral positions. z y x
    • 43. Correct trocar placement should provide direct access to the target organs, an optimal view of the operative field and minimize mental and muscular fatigue.
    • 44. 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
    • 45. Avoid competing for the same space: “Dueling swords” phenomenon (scissoring effect) Working against the camera and ‘blind spots’
    • 46. No obstacle between trocar entry and target To avoid iatrogenic injuries.
    • 47. Avoid the epigastric vessels Saber et al. Safety zones for anterior abdominal wall entry during laparoscopy. Ann Surg 2004; 239:182
    • 48. Anatomic distribution of nerves across anterior abdominal wall Ilioinguinal nerve Iliohypogastric 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.)
    • 49. Incision line/trocar sites vs. nerve distribution Epigastric a. Iliohypogastric n. Ilioinguinal n. Trocar site Pfannenstiel incision (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.)
    • 50. Be aware of bladder location for suprapubic trocar
    • 51. Avoid areas of prior surgery
    • 52. Additional trocars can be added along the semicircular line. 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.
    • 53. Gold Standard Laparoscopic Procedures Today  Laparoscopic cholecystectomy  Laparoscopic RYGB for obesity  Laparoscopic adrenalectomy  Laparoscopic splenectomy
    • 54. Huge Difference
    • 55. Laparoscopy in Bariatric Surgery Public Health Problem #1: OBESITY
    • 56. LAP-BAND Trocars - placed high, close to the costal margin. Trocar A - liver retraction. Trocar D - can be enlarged to allow for placement of a port. Trocar C - placed left of the midline for correct view of Angle of His. A B E C D
    • 57. Laparoscopic RYGB  Multicenter, prospective, risk-adjusted data show that laparoscopic gastric bypass is safer than open gastric bypass, with respect to 30-day complication rate.  LRYGB has become the standard of care Hutter et al. Ann Surg. May 2006 Massachusetts General Hospital, Boston.
    • 58. Current Procedures
    • 59. Laparoscopic Adrenalectomy The first case of laparoscopic adrenalectomy was reported by Gagner in 1992.
    • 60. Laparoscopic adrenalectomy  Less blood loss  Less operative time!!  Less hospital stay  Less post operative pain Tiberio et al. Prospective RCT Surg Endosc. Jun 2008
    • 61. Indications for Adrenalectomy Unilateral adrenalectomy Bilateral adrenalectomy Hyperfunctioning tumors Aldosteronoma Cortisol-producing adenoma Virilizing tumors Pheochromocytoma Nonfunctioning cortical adenomaa Failed treatment of ACTH-dependent Cushing’s syndrome Cushing’s syndrome from primary adrenal hyperplasia Malignant tumors Adrenocortical carcinoma Malignant pheochromocytoma Adrenal metastasis (solitary without other metastatic disease) symptomatic or enlarging adrenal myelolipomas, ganglioneuroma ACTH: adrenocorticotrophic hormone Bilateral pheochromocytoma
    • 62. Laparoscopic Splenectomy-Indications Idiopathic thrombocytopenic purpura ITP/HIV + Thrombotic thrombocytopenic purpura Hereditary spherocytosis Auto-immune hemolytic anemia Splenic cysts Evan’s syndrome Felty’s syndrome Hypersplenism (portal hypertension) Non Hodgkin’s lymphoma Hodgkin’s lymphoma Lymphocytic leukemia Myelocytic leukemia Tricholeukocytic leukemia Myelocytic splenomegaly Splenic tumor
    • 63. SPLENECTOMY
    • 64. Laparoscopic splenectomy  Significantly less pulmonary, wound, and infectious complications.  Longer operative times 53 Winslow (meta-analysis). Surgery. 2003 Oct;134(4):647-
    • 65. Laparoscopic Procedures with equivalence  Laparoscopic hernia repair  Laparoscopic appendectomy  Laparoscopic fundoplication
    • 66. Laparoscopic Inguinal Hernia Repair
    • 67. Hernia - Historic Perspective  Galen of Pergamum (AC 129-179) who was a surgeon to the gladiators practiced ligation of the sac and cord with amputation of the testicle.  Guy de Chauliac (AC 1300-1368) in his book Chirurgia Magna: laxatives, hang patient from his legs, bed rest for 50 days.
    • 68. Trocar placement: Additional trocar Transabdominal Totally Pre peritoneal (TAPP) Extra Peritoneal (TEP)
    • 69. INGUINAL HERNIA REPAIR
    • 70. Inguinal Hernia Repair
    • 71. What are indications for laparoscopic inguinal hernia repair? Recurrent hernia • Avoids scar tissue • Visualizes occult hernia Bilateral hernia • Decreased pain • Earlier return to work • No difference in recurrence or complication Obese / Athletic patients • Definitive diagnosis • Reduced infection in susceptible population • Gilmore’s groin Patients with contralateral injury to vas deferens • Less chance to injure other vas
    • 72. Are there contraindications to lap. inguinal hernia repair? Contraindications • Patients for whom general anesthesia and pneumoperitoneum are risks (cardiac, pulmonary disease) Relative Contraindications • Prior pre-peritoneal surgery (prostate, hernia, vascular, kidney transplant) • Prior laparotomy • Ascites • Strangulated hernia • Giant scrotal hernia • Anticipated bleeding (patients on anti-coagulation)
    • 73. 2. Do we have an answer for groin pain after hernia repair?
    • 74. Nerves prone to injury anterior and posterior
    • 75. Laparoscopic Ventral Hernia:Is the Abdomen a Weakness in the Human Race ?
    • 76. Laparoscopic Repair of Incisional Hernias  ↓ wound complications  ↓ recurrence rate  ↓ LOS  ↓ pain  coverage of “Swiss cheese” abdomen
    • 77. Ventral Hernia Defect
    • 78. Mesh used to patch defect
    • 79.  Secure periphery of mesh with tacker  Approximately 1cm apart
    • 80. Completed repair
    • 81. Massive Incisional Hernias
    • 82. Laparoscopic Appendectomy
    • 83. Laparoscopic Appendectomy Endo-loop
    • 84. APPENDECTOMY Alternatively, an appendectomy can be performed through a trocar in the umbilicus and two trocars in the suprapubic area medial to the epigastric vessels for a superb cosmetic result (if an extended right hemicolectomy is to be performed, the hepatic flexure positioning is preferred.)
    • 85. Laparoscopic Appendectomy Evidence-based Medicine Clear advantage in children* - Less wound infection, LOS, ileus - More OR time, intra-abdominal abscess Controversies in adults - Cost, obese patients, severe appendicitis - Prelude to NOTES *Aziz et al. Ann Surg 2006
    • 86. LAPAROSCOPIC PROCEDURES WITH CLEAR ADVANTAGES.
    • 87. Laparoscopic Heller’s Cardiomyotomy  Technically feasible  Short recovery time  Less overall complication rates
    • 88. Anti-reflux surgery  1945 to present Multiple methods and techniques: Nissen fundoplication Dor wrap Hill gastropexy …. Different approaches: Laparotomy vs laparoscopy Thoracotomy vs thoracoscopy 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
    • 89. Nissen’s Fundoplication Technique
    • 90. Nissen Fundoplication
    • 91. Esophageal Hiatus Esophagus Liver Aorta Right crus Left crus
    • 92. Hiatal Defect Left crus Chest cavity Stomach
    • 93. Mesh Repair
    • 94. • Do not use metal tacks • Biologic mesh? dual mesh? Esophagus • No mesh at all? (remember original Toupet repair) Polypropylene mesh Mesh Circular mesh Wrap Fundoplication
    • 95. Laparoscopic Surgery in Colorectal Diseases
    • 96. Port Site Recurrence
    • 97. NOTE: If proximal divided end of colon can reach through the skin there has been sufficient dissection of splenic flexure providing a tension-free anastomosis.
    • 98. HEPATIC FLEXURE COLON RESECTION C Tension-free anastomosis B A Trocar C is used for GIA division of distal ileum and midtransverse colon (site is enlarged to retrieve specimen and for extracorporeal anastomosis). The ileum is more mobile than the transverse colon, which can still be delivered adequately at this level.
    • 99. LAPAROSCOPIC SIGMOID RESECTION (lateral decubiti position)
    • 100. Supine Lateral
    • 101. Laparoscopic colorectal surgery Cochrane Systematic review of short term outcomes in 25 RCTs showed that laparoscopic colorectal surgery had:  Longer operative time  Less intraoperative blood loss  Less postoperative pain  less postoperative ileus  Better postoperative pulmonary function  Less total and local morbidity  Less postoperative hospital stay  Similar general morbidity and mortality  Better quality of life (within 30 days) Schwenk et al. 2005 Jul 20;(3):Cochrane Database 003145 Cochrane Systematic review of long term outcomes showed:  Similar port-site metastases and wound recurrences  Similar cancer-related mortality at maximum follow-up  Similar tumor recurrence  Similar overall mortality Kuhry et al. Cancer Treat Rev. Oct 2008
    • 102. Laparoscopic hepatectomy  First performed 1994  by Huscher et al A safe procedure in experienced hands  Resection devices:  Staplers  Bipolar vessel sealing (Ligasure)  Radiofrequency  U/S dissector  Nd-YAG laser 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
    • 103. Laparoscopic pancreatectomy  Pancreaticoduodenectomy  Total splenopancreatectomy  Spleen-preserving total     pancreatectomy Distal splenopancreatectomy Spleen-preserving distal pancreatectomy Central pancreatectomy Enucleation  Procedures are technically challenging  Long learning curve  High volume center improves clinical outcome
    • 104. DISTAL PANCREATECTOMY • Trocars “A” and “B” divide gastrocolic ligament • GIA is introduced through “D” A B C E D
    • 105. Laparoscopic pancreatectomy Vs. open Finan et al. Am Surg. Aug 2009 Laparoscopic and open distal pancreatectomy: a comparison of outcomes.  There was no significant difference in the incidence of postoperative morbidity or mortality  There was no significant difference in the rate of all pancreatic fistula formation or clinically significant leaks  Lparoscopic technique had decreased:  operative time  blood loss  length of stay in the lap group.  Conclusion  Lap and open distal pancreatectomy are performed safely at high-volume pancreatic surgery centers.
    • 106. Laparoscopic Urologic procedures        Undescended testis Varicocelectomy Retroperitoneal fibrosis Lymph node dissection Bladder neck suspension Bladder diverticulum Patent urachus  Nephrectomy  Prostatectomy
    • 107. RT. KIDNEY RESECTION • Subxiphoid port (D) - liver retraction Trocar A - parallel to vena cava (perpendicular approach to rt. renal vessels and rt. adrenal vein – additional trocar E may be placed more laterally and posterior to trocar A if needed.) • D C E A B
    • 108. PROSTATECTOMY 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. A B C
    • 109. Minimally invasive neck surgery
    • 110. Minimally invasive neck surgery  Endoscopic  Central  Lateral  “Other” (transaxillary, transpectoral, transoral)  Minimally invasive  MIVAT (min. invasive video assisted thyroidectomy)  MIVAP (min. invasive video assisted parathyroidectomy)  Robotic assisted Inferior parathyroid release in Minimally invasive thyroidectomy
    • 111. Cosmetic results Open surgery scar Minimally invasive / endoscopic scars
    • 112. Conclusions  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)  Yet:  What about large masses?!
    • 113. Emerging Technologies      Robotics SILS NOTES Trocarless laparoscopy ENDOBARRIER
    • 114. History of Robotics Leonardo da Vinci developed one of the first robots in 1495 – an armored knight for the purposes of entertaining royalty.
    • 115. What Robotics Aimed to Improve in Laparoscopy  Surgeon operates from a 2D image  Straight, rigid instruments (limited range of motion)  Instrument tips controlled at a distance  Reduced dexterity, precision & control  Unsteady camera controlled by assistant
    • 116. Surgical Robots AESOP (Automated Endoscopic System for Optimal Positioning) - Voice activated mechanical arm - Steadier than human, never tires da Vinci® - FDA approval in 2002 - Laparoscopic instrumentation controlled by the surgeon, positioned remotely at a console
    • 117. Development of da Vinci® Defense Advanced Research Projects Agency (DARPA) for military research of remote battlefield surgery  Cholecystectomy performed remotely via telesurgery from 300 miles away  Intuitive surgical created in 1999 after acquiring patent rights from military  First robotic prostatectomy performed in 2001
    • 118. What is the da Vinci® Surgical System?  State-of-the-art robotic technology   Surgeon in control Assistant has direct access
    • 119. What is the da Vinci® Surgical System? Surgeon directs precise movements of instruments in the slave unit using console controls.
    • 120. Robotic Scrub Nurse “Penelope”
    • 121. Wrist and Finger Movement  Laparoscopic instruments are rigid with no wrists  EndoWrist® Instrument tips move like a human wrist  Allows surgeon to operate with increased dexterity & precision. No tremor
    • 122. Disadvantages of da Vinci® Robot  Expensive - $1.4 million cost for machine - $120,000 annual maintenance contract - Disposable instruments $2000/case     Steep surgical learning curve Loss of tactile feedback Increased staff training/competence Increased OR set-up/turnover time!!
    • 123. Past Present
    • 124. SILS Single Incision Laparoscopic Surgery
    • 125. What does that stand for ?        SILS – Single Incision Laparoscopic Surgery SSA – Single Site Access SPA – Single Port Access SAS – Single Access Site SPL – Single Port Laparoscopy LESS – Laparo Endoscopic Single Site Surgery TUES – Trans Umbilical Endoscopic Surgery
    • 126. SILS      Urology Renal transplant Cholecystectomy Gastric band surgery Colectomy
    • 127. Technique
    • 128. SILS
    • 129. SILS  Ergonomically difficult ?!  Training !
    • 130. Port Site Hernia !!
    • 131. N.O.T.E.S. Natural Orifice Transluminal Endoscopic Surgery
    • 132. NOTES - instrument
    • 133. A Recent History of “New Minimal Access” Surgery  2000 Flexible endoscopic endoluminal therapy for GERD  2003 Kalloo et al transgastric peritoneoscopy with flexible endoscope  2004 Rao and Reddy reported on transgastric cholecystectomy and appendectomy in patients  2006 summit meeting: NOSCAR (Natural Orifice Surgery Consortium for Assessment and Research) formed
    • 134. Alleged NOTES Benefits        No surface incision Reduced surgical site infection Reduced visible scarring Reduction in pain analgesics Quicker recovery time Reduction in hernias, adhesions Advantages in the morbidly obese
    • 135. Scarless surgery!
    • 136. Notes- Transvaginal Video-endoscope entering through the posterior vaginal fornix
    • 137. NOTES - Transgastric Courtesy of N Reddy, Hyperbad India 2005
    • 138. NOTES - Appendectomy
    • 139. NOTES – Obesity Surgery
    • 140. Surgery for Diabetes
    • 141. Diabetes  Considered major public health problem – emerging as a world wide pandemic. In 1995 ~ 135 million people worldwide  Currently 240 million, expected to rise to close to 380 million by 2025  Complications  Peripheral vascular disease (PVD) accounts for 20-30%  10% of cerebral vascular accident  Cardiovascular disease accounts for 50% of total mortality 1. Venkat et al Diabetes–a common, growing, serious, costly, and potentially preventable public health problem. Diabetes Res Clin Pract. 2000; 5 (Suppl2): S77–S784. 2. H. King et Global burden of diabetes, 1995-2025: prevalence, numerical estimates and projections. Diabetes Care 21 (1998) 1414-1431. 3. Annals of Surgery. Volume 251, Number 3, March 2010
    • 142. Metabolic Syndrome Also Known as: 1. Syndrome “X” 2. Insulin Resistance Syndrome 3. Reaven’s Syndrome 4. Deadly Quartet 5. CHAOS Coronary Artery Disease Hypertension Adult Onset Diabetes Obesity Stroke
    • 143. Morbidity Obesity Associated Conditions Diabetes Hypertension Sleep apnea Congestive heart failure Hyperlipidemia Stroke Coronary artery disease Osteoarthritis Gastroesophageal reflux disease Non-alcoholic fatty liver Psychological disturbances
    • 144. Long-term Weight Control Analysis Studies Type and Size Effect on Weight Effect on Comorbidities Resolution of: Buchwald et al. Meta-analysis n = 22,094 pts Mean excess weight loss: 61% n   Swedish Obese Subject trial (SOS) Prospective matched cohort n = 4,047 pts At 10 years:  Med: 1.6% gain Surg: 16% loss Diabetes: 70% HTN: 62% Sleep apnea: 86% Improved by surgery:  Diabetes  Lipid profile  HTN  Hyperuricemia 1. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004; 292: 1724-37. 2. Sjostrom L, Lindros AK, Peltonem M, Torgerson J, Bouchard C, Carlsson B, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004; 351: 2683-93.
    • 145. Schauer et al. Effect of laparoscopic Roux-en Y gastric bypass on type 2 diabetes mellitus. Ann Surg. 2003 Oct; 238 (4): 467-84  1160 patients underwent LRYGBP 5-year  period LRYGBP resulted in significant weight loss (60% percent of excess body weight loss) and resolution (83%) of T2DM  Fasting plasma glucose and HBA1C normalized (83%) or markedly improved (17%) in all patients  Patients with the shortest duration and mildest form of T2DM had a higher rate of T2DM resolution after surgery  suggesting that early surgical intervention is warranted to increase the likelihood of rendering patients euglycemic
    • 146. Rates of Remission of Diabetes Adjustable Gastric Banding Roux-en-Y Gastric Bypass Biliopancreatic Diversion 48% 84% >95% (Slow) (Immediate) (Immediate)
    • 147. 2002: Antidiabetic Effect of Bariatric Surgery: Direct or Indirect? “Gastric bypass and biliopancreatic diversion seem to achieve control of diabetes as a primary and independent effect, not secondary to the treatment of overweight.” Potential of Surgery for Curing Type 2 Diabetes Mellitus. Rubino, Francesco, MD; Gagner, Michel MD, FACS, FRCSC Annals of Surgery; 236 (5): 554-559, November 2002
    • 148. 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
    • 149. The Surgeon and the Diabetologists
    • 150. THE FUTURE  It has not changed the nature of disease  The basic principles of good surgery still apply,including appropriate case selection, excellent exposure,adequate retraction and a high level technical expertise  If a procedure makes no sense with conventional access, it will make no sense with a minimal access approach
    • 151. THE FUTURE  The cleaner and gentler the act of operation, the less the patient suffers, the smoother and quicker his convalescence,the more exquisite his healed wound. Berkeley George Andrew Moynihan
    • 152. THANK YOU ALL FOR A PATIENT HEARING

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