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  • Intuitive Surgical is currently working on a single port solution that works on the da Vinci Si platform. These instruments are currently in development and have not been cleared by the FDA. As you can see, there are two curved cannulae and an endoscope that all cross at the same remote center enable access through a single incision (remote center signified by red circle). This allows for triangulation at the target anatomy while allowing the instrument arms sufficient range of motion without collisions (range of motion signified by yellow arrows). The instruments being developed have semi-rigid shafts that allow them to be inserted through the curved cannulae to reach the surgical site and are controlled by the surgeon via the surgeon console. The da Vinci Si system allows the masters to be swapped to accommodate the crossing of the cannulae. In other words, in the surgeon console viewer right appears right and left appears left, even though the instruments are crossed. This brings intuitiveness as well as the many benefits of da Vinci Surgery to single site surgery.
  • Single Port: The premise of advanced single port surgery is to take single port surgery to the next level from the da Vinci Single Site platform. This is a single port trocar with a “chip on a stick” vision system….in other words, the camera and light source is flexible instead of rigid and the head can be manipulated and controlled…essentially an endoscope with a snake like head. In order to maneuver these single port instruments, you need a whole new patient cart that can manipulate and control them, this is the picture in the lower left corner of the slide. With this advanced architecture, single port surgery could be done transumbilical, transvaginal, transoral, or even transanal. Flexible Systems: With a completely flexible system, such as the snake like rendering you see in the upper right depiction, a surgeon could run this system through the intestines to target specific anatomy. This is the premise of NOTES surgery (Natural Orifice Transluminal Endoscopic Surgery) that we may see in the future. Because the da Vinci system is intelligent and knows where it’s instrument tips are in 3D space, if we can determine where the entire snake body is in 3D space, then we can accurately direct this snake like structure through the digestive system with no need to enter a patient through an exterior incision.
  • Here is an initial prototype of a single port surgial system with completely wristed instrumentation. As you can see, there are wrists and even elbows in this architecture. Likewise, in the upper right of the screen you can see the endoscope that also came through that single port. As we continue to advance MIS robotic surgery, the opportunities and advancements like we see in this video offer new challenges….but most importantly, new opportunities to increase the effectiveness of surgery while reducing the invasiveness.
  • Rotary voloyiannis

    1. 1. New Surgical Modalities in the Management of the Colon and Rectal Cancer Ted Voloyiannis, M.D., F.A.C.S., F.A.S.C.R.STed Voloyiannis, M.D., F.A.C.S., F.A.S.C.R.S Clinical Assistant Professor in SurgeryClinical Assistant Professor in Surgery University of Texas Houston, Health Sciences CenterUniversity of Texas Houston, Health Sciences Center Houston, TexasHouston, Texas Colon and Rectal SurgeryColon and Rectal Surgery Memorial Hermann Medical GroupMemorial Hermann Medical Group Chairman of SurgeryChairman of Surgery Memorial Hermann Hospital SEMemorial Hermann Hospital SE
    2. 2. What is a Colorectal Surgeon ? • Specialist for the Diagnosis and Treatment of diseases involving the Colon, Rectum, and Anus. (surgeon and proctologist) • Board certified in General Surgery and Colorectal Surgery • American Society of Colon and Rectal Surgery • •
    3. 3. Common Colon and Rectal Surgery Diseases and Conditions • Colon Cancer • Rectal Cancer • Anal Cancer • Diverticulitis • Colitis – Crohn’s disease – Ulcerative colitis • Constipation • Colonoscopy Hemorrhoids Fissures Fistulas Anal Warts Rectal Bleeding Incontinence
    4. 4. Every March in the USA is the Colon and Rectal Cancer Awareness Month
    5. 5. Colon and Rectal Cancer: Why Surgery? • Early Colon and Rectal Cancer can be cured with surgery only. If localized, 80-90% survival. • Surgery as part of the multi treatment modality for advanced Colon and Rectal Cancer. • Palliative Surgery for Colon and Rectal Cancer.
    6. 6. When Do I Need Surgery? • Colon or Rectal cancer • A polyp with cancer within it • A large polyp (greater than 2 cm) • A polyp that cannot be removed safely with a colonoscopy
    7. 7. Anatomy
    8. 8. Colon and Rectal Surgical Options • Open Abdominal Surgery • Combined approach (abdominal and perineal) • Laparoscopic Abdominal via a Hand port or via a Single Port • (Robotic) DaVinci Laparoscopic Assisted • Anorectal -local surgery or via a Single Laparoscopic Port
    9. 9. Open or Laparoscopic Abdominal Procedures ž Right Colectomy ž Extended Right Colectomy (Right and Transverse) ž Transverse Colectomy ž Left Colectomy ž Extended Left Colectomy (Transverse and Descending) ž Sigmoid Colectomy
    10. 10. Open or Laparoscopic Procedures on the Rectum • LAR – Low Anterior Resection – With or without ileostomy • APR- Abdomino-Perineal Resection – Permanent colostomy
    11. 11. LAR APR
    12. 12. Type of anastomosis • Anastomosis: (Connecting two ends of bowel together) – Hand sewn – Stapled – end to end – side to side – others
    13. 13. End to End Anastomosis
    14. 14. Side to side anastomosis
    15. 15. Side to side anastomosis
    16. 16. Side to side anastomosis
    17. 17. Ostomies • End Colostomy • End Ileostomy • Loop Ileostomy
    18. 18. Loop ileostomy
    19. 19. Innovative Techniques • Laparoscopic Surgery via a Single Port • Robotic – DaVinci Assisted Surgery • Transanal Surgery via a Single Port
    20. 20. Laparoscopic Surgery • Innovative method of operating and performing surgery through very small incisions • Also called “minimally invasive surgery” • “Laparoscope” is a lens and video camera • Laparoscope placed through “port” (small incision), surgical instruments through 2 or 3 other “ports” to allow surgeon to work inside the abdomen
    21. 21. 21 slide 21 Laparoscopy v. “open” surgery Laparoscopic SurgeryOpen Surgery
    22. 22. Laparoscopic Surgery ž Smaller incisions ž Less postop pain ž Less hospital stay ž Faster return of GI function ž Faster return to full activity ž May take longer ž More expensive ž Often more challenging technique
    23. 23. Robotic – “DaVinci” Assisted Laparoscopic Surgery • The same advantages as in laparoscopic surgery plus: • Promises unsurpassed visualization, precision, dexterity and control for rectal / pelvic surgery • Equivalent outcomes to the Laparoscopic Surgery
    24. 24. Robotic Colon and Rectal Surgery
    25. 25. Robotic Surgical Platform
    26. 26. Robotic Surgery
    27. 27. Transanal Surgery for Mid or Low Early Rectal Cancer
    28. 28. Anorectal Surgery • Mostly outpatient or 23 hour admission for observation
    29. 29. Role of genetic testing in Colon and Rectal Cancer • 5-6% of colorectal cancers have a known genetic mutation • Hereditary Non Ponpolyposis Coli Syndrome, Familial Adenomatous Polyposis and other syndromes • Young-age-of-onset colorectal cancer and other organs • Genetic counseling and testing useful when prophylactic surgery is considered
    30. 30. Single Incision-Single Port Laparoscopic Colon Surgery
    31. 31. Single Incision Surgery • New tools and platforms • Keep the procedure simple and safe • Cost effective
    32. 32. SILS strategy • Easily reproducible by surgeons with advanced laparoscopic skills • Eliminate use of single use items • Use equipment that hospital already has available • Eliminate additional training for OR personnel, surgical assistant
    33. 33. Colon Resection • Still <25% of colon surgery is performed laparoscopically across the nation • Majority of laparoscopic colon surgery is performed via the HALS technique • Most laparoscopic colon surgery is performed for right colectomy • Multiport laparoscopy for colon surgery is performed still by the minority of laparoscopists. • Single incision port laparoscopy is “raising the bar” in colon and rectal surgery
    34. 34. Less is More • Technologic advances have allowed more surgical diseases to be treated laparoscopically and have prompted us to refine our techniques • Smaller and fewer incisions and less trauma to benefit our patients • Natural orifice surgery has given birth to many areas of surgical research • New Surgical instruments • Single incision surgery: a refinement of laparoscopic surgery, introducing a multichannel port site with a 25-50mm total incision
    35. 35. New surgical instruments • Wristed instruments • Deflectable tip laparoscopes • New endoscopic instruments for cutting, retrieving, and closing devices • New platforms for single incision surgery
    36. 36. SIL Devices • SILS port (Covidien, Norwalk, CT, USA) • GELPOINT access platform (Applied Medical, Rancho Santa Margarita, CA, USA) • GELPORT access platform (Applied Medical) • TriPort system (Advanced Surgical Concepts, Wicklow, Ireland) • Single Site Laparoscopy (SSL) Access Systems (Ethicon Endo- Surgery Inc., Cincinnati, OH, USA) • Quadport access system (Olympus AMerica, Center Valley, PA, USA) • Spider Surgical system (Transenterix, Durham, NC) • R-Port System (Advanced Surgical Concepts) • Uni-X Single Port Access Laparoscopic System (Pnavel Systems, Morganville, New Jersey, USA)
    37. 37. Single incision ~ 2.5-3.5cm
    38. 38. Single incision for laparoscopic colectomy! SILS incision Prostatectomy Scar
    39. 39. Single incision scar 4 weeks postop sigmoid colectomy
    40. 40. Single incision scar 4 weeks postop sigmoid colectomy
    41. 41. Stretching the incision
    42. 42. Extraction of the specimen
    43. 43. Laparoscopic Single Port “INCISION- LESS” Low Anterior Resection/Loop Ileostomy
    44. 44. SIL Colon and rectal surgery: Applications • Ileocecal resection • Right colectomy • Extended right colectomy • Transverse colectomy • Left colectomy • Sigmoidectomy • Low anterior resection w/wo ileostomy • Restorative proctocolectomy with IPAA • Colostomy • Ileostomy • Benign: polyp, diverticulitis, colo-vesical/vaginal fistula, IBD • Colorectal malignancy
    45. 45. SILS is applicable to colorectal surgery Advantages • Improved cosmesis-shorter skin incision • Less pain compared to multiport and hand assisted laparoscopy • Option for convertion to multiport or hand assisted laparoscopy • No difference in conversion to open laparotomy • Similar morbidity • Similar operation time • Similar oncologic outcomes for colorectal cancer surgery • Safe compared to conventional laparoscopy • Shorter hospital stay compared to conventional laparoscopy? • Less total hospital cost compared to multiport laparoscopy and laparotomy
    46. 46. SILS is applicable to colorectal surgery Disadvantages • Instrument conflict: Reduced excursion-cluster effect around hands and camera • Difficulty with exposure, ergonomics • Cost for technology • New and high learning curve that can complicate an already challenging operation • SILS is inherently a one-operating surgeon technique-potential impact on resident education
    47. 47. Conclusion • Single incision laparoscopic colectomy is a safe and viable improvement on conventional multiport laparoscopic colectomy. • Shorter hospital stay, less pain, improved cosmesis, faster recovery, similar oncologic safety. • Future Randomized prospective trial between MLPS and SILS. • SILS ASCRS databank
    48. 48. India Ink Injection
    49. 49. The setupThe setup The roomThe room The ideal roomThe ideal room Life in the real worldLife in the real world
    50. 50. The setupThe setup The bedThe bed
    51. 51. Ports, Camera, Cables
    52. 52. Bariatric camera, additional ports
    53. 53. Right angle for light source, extra grasper
    54. 54. The InstrumentsThe Instruments Vascular Ligation Bowel divisionVascular Ligation Bowel division • Stapler – Cost $250/$90 per reload – Safe for large vessels – Can divide bowel – Easy and efficient
    55. 55. The InstrumentsThe Instruments Vascular LigationVascular Ligation • Energy devices – High energy coagulators, – Vessels up to 7mm in size – Infinite applications – 5mm and 10mm units – Easy to use – Has difficulty with calcified vessels
    56. 56. Single Port Laparoscopic Colon Surgery in action!
    57. 57. Other applications of single port in advanced laparoscopic colorectal surgery • Splenic flexure mobilization, then LAR via Pfannenstiel incision. • Ileostomy/colostomy reversal with ileorectal/colorectal anastomosis • LAR with loop ileostomy for rectal CA/other (incision-less single port!) • Lap APR • Lap LAR with Coloanal anastomosis • Lap TPC with IPAA, loop ileostomy • Lap Total colectomy • Lap Right colectomy, extended Right. • Transverse colectomy: laparoscopic resection with hand sewn anastomosis? • Takedown of colo-vesical/vaginal fistula
    58. 58. da Vinci Single Site  Using da Vinci Si system with 8.5mm 3D HD endoscope  Curved Instrument Cannulae  5mm, non-wristed, semi-rigid instruments Instruments and accessories shown have not been cleared by the FDA (da Vinci Single Site prototype) scope
    59. 59. Advanced Single Port or NOTES Flexible Systems Single Port  ~20mm diameter  da Vinci-like capability  Large range-of-motion (multi-quadrant capability)
    60. 60. Robotic Systems – Single Port Surgery Instruments and Accessories shown are currently under product development and have not been cleared by the Food and Drug Administration (FDA).
    61. 61. Summary • Surgery in early Colon and Rectal Cancer can cure! • Numerous surgical options and minimally invasive techniques. • Your surgeon will advocate the most suitable option. • Genetic testing may be recommended.
    62. 62. 29 slide 29 Which surgery is best for me? • There are many factors involved in determining the best operative approach • This question needs to be answered on an individual basis between the patient and surgeon