Basics of Minimal Access surgery

1. Minimal Invasive Surgery
(M.I.S.)
UG 4th Semester Batch
17/10/22
Dr. Ankita Singh
Assistant Professor
Department of Surgery

2. Learning Objectives
• What is M.I.S. ?
• History
• What are the indications?
• What are the advantages & disadvantages?
• Prerequisites & Principles
• Complications

3. Terminologies
• Minimal Access Surgery(MAS)
– surgical innovation that aims to accomplish surgical therapeutic goals with
minimal somatic and psychological trauma.
– reduced wound access trauma, as well
– less disfiguring than conventional techniques
• Minimal Invasive Surgery(MIS)
– Laparoscopic
– Endoscopic

4. Laparoscopy: History
• First laparoscopic cholecystectomy –
– done by Muhe of Germany in 1985 & by Mouret in Lyon in 1987
– in USA in 1988, by McKeran and Saye
– In India, by Professor TE Udwadia
• First laparoscopic appendicectomy –
– done by Semm as prophylaxis
– by Schreiber in 1987 for acute appendicitis

5. Laparoscopy: Advantages
• Relatively less painful
– Trauma of access is very less
• Shorter hospital stay and early return to work
• Faster postoperative recovery
• Better visualization of the anatomy,
– better approach for dissection and visualization of other parts of abdomen for
any other pathology
• Instrumental access to different locations is many times better
• Minimal scar

6. Laparoscopy: Limitations
• Relative contraindications:
– Compromised cardiac status
– Peritonitis
– Previous abdominal surgeries.
– Bleeding disorders.
– Morbid obesity.
– Third trimester pregnancy.
– Portal hypertension.

7. Laparoscopy: Limitations..
• Limitations of MIS:
– Reliance on remote vision and operating
– Loss of tactile feedback
– Dependence on hand–eye coordination
– Difficulty with hemostasis
– Reliance on new techniques
– Extraction of large specimens

8. Laparoscopy: Prerequisites
• Overall fitness: cardiac arrhythmia, emphysema, medications,
allergies
• Previous surgery: scars, adhesions
• Body habitus: obesity, skeletal deformity
• Normal coagulation
• Thromboprophylaxis
• Informed consent
• Instruments used

9. Laparoscopy: Prerequisites..
• Instruments used:
– Laparoscope
– Camera
– Cold light source
– Video monitor
– C02 insufflator
– Surgical instruments:
• Long fine dissectors
• Hooks & spatulas
• Clip applicators
• Needle holders
• Endostaplers
• Veress needle
• Suction-irrigation apparatus
• Trocars
• Reducers

13. Laparoscopy: Prerequisites..
• Preparation:
– General anesthesia
– Prevention of inadvertent injuries
– Pressure bandages/ cuffs
– Position of patient
• Strapping
• According to surgery
• Reverse Trendelenburg position

14. Laparoscopy: Technique
• Access:
– Open vs. closed method
• Creation of pneumoperitonium
• Visualization
• Additional ports
– Triangulation
– Ergonomics
• Sometimes additional incision required

15. Laparoscopy: Physiologic changes
• CO2 causes
– hypercarbia, acidosis and hypoxia.
• Pneumoperitoneum
– decreases the venous return
– increases the arterial pressure
• It compromises the respiratory function
– by compressing over the diaphragm

16. Laparoscopy: Complications
• CO2 narcosis and hypoxia
• Sepsis- subphrenic abscess, pelvic abscess, septicaemia
• IVC compression
• Bleeding
• Leak from the site, e.g. bile leak
• Organ injury during insertion of ports
• Subcutaneous emphysema and pneumomediastinum

17. Laparoscopy: Complications..
• Gas emboli, though is rare but fatal
• Postoperative shoulder pain due to irritation of diaphragm
• Cardiac dysfunction due to decreased venous return
• Injury to the abdominal wall vessels and nerves
• Cautery burn to abdominal structures
• Abdominal wall hernias
• Wound infection
• Mortality-0.5%

18. Laparoscopy: General principles
• Core principles of MAS summarized by acronym I VITROS
– Insufflate/create space
– Visualize – the tissues, anatomical landmarks and the
– environment for the surgery to take place
– Identify
– Triangulate – surgical tools (such as port placement) to optimize the efficiency
of their action, and ergonomics by minimizing overlap and clashing of
instruments
– Retract – and manipulate local tissues to improve access and gain entry into
the correct tissue planes
– Operate – incise, suture, anastomose, fuse
– Seal/haemostasis

19. Laparoscopy: Procedures
• Basic surgeries:
– Laparoscopic cholecystectomy
– Laparoscopic appendicectomy
• Advanced surgeries:
– Hernia repairs, splenectomy, fundoplication, vagotomy & GJ, Colectomy: APR,
LAR, hysterectomy, urologic procedures, thoracic/thyroid/paediatric surgeries
etc.

21. Thank you
Any questions?