This lecture will come out on Saturday night at my school at my school and get some

1. Minimal invasive
surgery
DR. KHALID K. HUSSEIN

2.  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 structures

3.  1901-Dimitri Ott, George Kelling, and H.C.
Jacobaeus first demonstrated on animals
that laparoscopy was possible
 1938 - Janos Veress of Hungary
developed a specially designed spring-
loaded needle. Interestingly, Veress did
not promote the use of his Veress needle
for laparoscopy purposes. He used the
veress needle for the induction of
pneumothorax.

4.  1953 - The rigid rod lens system and fiber optics was
introduced by Professor Harold H. Hopkins. The
credit of videoscopic surgery goes to this surgeon
who has revolutionized the concept by making this
instrument.

5. Content
 Laparoscopic/Minimally Invasive
Surgery
 Single Port Access Surgery (SILSTM)
 Robotic-assisted surgery (da Vinci
Robot)
 Natural Orifice Translumenal
Endoscopic Surgery (NOTES)
 endoscopy

6. Laparoscopic/Minimally
Invasive Surgery
 First lap cholecystectomy in: 1985
 Now, almost every organ is accessible
 >90% of cholecystectomies are done
laparoscopically

7. Equipment Necessary for
MIS
Camera
Light Source
Insufflator
TV Monitor
Telescopes
Light Guide Cable

8. CAMERA
 These can be single chip or 3 chip.
 CHIP: this 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

9. 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.

10. Telescope
 Come in varying sizes, laparoscopes
usually 5mm or 10mm.
 Made up of a rod and lens system.
 Bundles of fibres, incoherent carry light
and coherent carry image.
 Wide range of angles available 0 and 30
degree are fairly standard.
 All laparoscopes are autoclavable .

11. Light cable
 Different diameters
 Fibre light cable

12. 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.

13. TV Monitor
 Usually a 20” screen.
 Horizontal resolution is the number of
vertical lines.
 Vertical resolution is the number of
horizontal lines
 More lines of resolution, better detail of
picture.

14. Laparoscopic Instruments
 Graspers
 Sheers
 Cautery
 Harmonic (ultrasound)
 LigaSure
 Staplers
 Suturing devices

15. Benefits of Laparoscopic
Surgery
 Cosmetic
 Less pain
 Speedier recovery/shorter hospital stay
 Fewer adhesions (scar tissue)
 Fewer wound infections
 Fewer post-operative complications
 Photographs/video/magnified view

16. General Surgery MIS
Procedures
 Diagnostic laparoscopy (chronic pain)
 Lap cholecystectomy (gallbladder)
 Lap appendectomy (appendix)
 Lap inguinal hernia repair (groin hernia)
 Lap ventral/incisional hernia repair

17. General Surgery MIS
Procedures
 Lap gastric surgery (stomach)
 Lap colon surgery (benign or malignant)
 Lap small bowel surgery
 Lap splenectomy (spleen removal)
 Lap adrenalectomy (adrenal removal)
 Lap distal pancreatectomy (pancreas)

18. General Surgery MIS
Procedures
 Lap Nissen fundoplication (anti-reflux)
 Lap esophageal myotomy (achalasia)
 Lap paraesophageal hernia repair
 Lap cancer staging/lymph node biopsy
 Lap emergency surgery (bowel obstruction, ulcer,
trauma)

19. YES!
BUT, CAN THIS TYPE OF SURGERY BE
DONE WITH ONLY ONE INCISION?

20. Single Port Access Surgery

21. Single Port Access Surgery
 Instruments: articulate

22. Single Port Access Surgery
 Advantages
 Cosmetic: one incision! Basically scarless
 Less pain
 Quicker recovery
 Disadvantages
 Takes longer
 Higher cost
 Restricted degree of movement (tough on surgeon)

23. Robotic Surgery

24. The Evolution of Robotic
Surgery
 World’s first surgical robot, 1983
 1st robotic cholecystectomy using PUMA,
1987
 da Vinci Surgical Robot clears FDA, 1999-
2000
 1st robotic-assisted heart bypass in USA, 1999
 Remote robotic chole USA to France, 2001
 Robotic-assisted kidney transplant, 2009
 da Vinci Single-Site Platform FDA-approved,
2011

25. The Evolution of Robotic
Surgery

26. Robotic Surgery
 Benefits
 More precise/range of motion
 3D vision/magnified
 Less bleeding
 More comfortable for surgeon
 Can be done remotely
 Disadvantages
 Lack of haptics
 Cost?
 Long set-up/procedure time
 Higher learning curve

27. Robotic Surgery
 Commonly used for
 Urology (prostatectomy)
 Cardiac (heart surgery)
 Gynecology (hysterectomy)

28. Single-Site Robotic Surgery
Added benefits: virtually scarless & high patient
satisfaction

29. Single-Site Robotic Surgery
 Approved for
 Cholecystectomy, 2011
 Hysterectomy, 2013

30. Single-Site Robotic Surgery
Compared to robotic multi-port surgery…
 Advantages
 Cosmetic (scarless!)
 Less pain, quicker recovery
 Disadvantages
 Non-wristed instruments (not for long…)

31. Other Advantages of
Robotic Surgery
Firefly Fluorescence Imaging

32. Future of Robotic Surgery

33. NOTES Surgery:
Natural Orifice Translumenal
Endoscopic Surgery
 Orifice can be
 Mouth (to stomach)
 Vagina
 Rectum

34. NOTES
 What has been done with NOTES so far?
 Transgastric appendectomy
 Transgastric cholecystectomy
 Transvaginal cholecystectomy
 Transrectal colectomy

35. NOTES Surgery
 Benefits
 Cosmetic (No scars! Really no scars!)
 Less pain
 Faster recovery
 Less risk of would infections and hernias
 Disadvantages
 Learning curve
 Longer procedure time
 Problems with closing enterotomies

36. Conclusion
 There continues to be a push for more and more
minimally invasive surgery.
 Many patients (and healthcare professionals) are
still not aware of the availability and benefits of
MIS and robotic surgery.
 The future of surgery will continue to see a move
toward scarless surgery, advanced robotics.

37. Endoscopy

38.  Endoscopy, is the examination of internal body cavities using
a specialized medical instrument called an endoscope.
 Physicians use endoscopy to diagnose, monitor, and
surgically treat various medical problems.

39. An endoscope is a slender,
flexible tube equipped with
lenses and a light source.
Illumination is done by the
help of a number of optical
fibres.
Reflected light rays are
collected by CCD( Charge
coupled device) and
electrical signals are
produced, which are fed to
the video monitor to get
image.
Thorough one channel of
endoscope water and air is
conducted to wash and dry
the surgical site.

40. The endoscope also has a
channel through which
surgeons can manipulate
tiny instruments, such as
forceps, surgical scissors, and
suction devices.
A variety of instruments can
be fitted to the endoscope
for different purposes.
A surgeon introduces the
endoscope into the body
either through a body
opening, such as the mouth
or the anus, or through a
small incision in the skin.

41. THANK YOU