This document provides a history of laparoscopy and key developments in the field. It discusses early developments in the 1800s and 1900s using cystoscopes and insufflation. The first laparoscopy was performed in 1901 by George Kelling. Developments continued through the 1900s including the introduction of trocars and telescopes. Laparoscopic cholecystectomy was first performed in 1985 but was not widely adopted until the late 1980s. The document also discusses current standard laparoscopic procedures and emerging technologies like fluorescent cholangiography and natural orifice transluminal endoscopic surgery (NOTES).

1. 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

2. History of Laparoscopy 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). The first description dates to Hippocrates in Greece, for use of a speculum to visualize the rectum (460–375 BC).

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 carbon-filament bulb- Thomas 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 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.

9. Kurt Semm (1927-2003) 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.

10. Journal of Reproductive Medicine 1977. Volume 18; No. 5: 235- 240

11. 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.

12. 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

13. VERESS NEEDLE 1938 - Janos Veress , of Hungary, developed the spring-loaded 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 beveled needle point for cutting through tissues.

14. 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)

15. Trocars Types: Cutting Pyramidal tipped Flat blade Noncutting Pointed conical Blunt conical Optical

16. 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

17. 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.

18. 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

19. Correct trocar placement should provide direct access to the target organs, an optimal view of the operative field and minimize mental and muscular fatigue.

20. Avoid competing for the same space: Working against the camera and ‘blind spots’ “ Dueling swords” phenomenon (scissoring effect)

21. Avoid the epigastric vessels Saber et al. Safety zones for anterior abdominal wall entry during laparoscopy. Ann Surg 2004; 239:182

22. (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

23. (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

24. 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.

25. Gold Standard Laparoscopic Procedures Today Laparoscopic cholecystectomy Laparoscopic RYGB for obesity Laparoscopic adrenalectomy Laparoscopic splenectomy Laparoscopic hiatal hernia repair

26. Huge Difference

27. * 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

28. 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% Results: 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.

29. Indocyanine Green (ICG) Injection: Shows the confluence between right and left hepatic ducts during hepatectomy. Enables identification of the cystic duct and CBD before dissection of Calot’s triangle during Cholecystectomy. Ishizawa T, et al. Intraoperative Fluorescent Cholangiography Using Indocyanine Green: A Biliary Road Map for Safe Surgery. JACS 2009; 208(1):e1-e4

30. Indocyanine Green Injection (ICG) Advantages No need for dissection of Calot’s triangle No need for insertion of trans-cystic tube No exposure to radiation No space-occupying C-arm machine required Simple and convenient procedure Allergic reactions Ishizawa T, et al. Intraoperative Fluorescent Cholangiography Using Indocyanine Green: A Biliary Road Map for Safe Surgery. JACS 2009;208(1): e1-e4

31. Combined Laparoscopy and ERCP: Single Step – Treatment 45 pts underwent lap chole with intra-op cholangiogram 33 pts had succesful intra-op ERCP with extraction of common bile duct stones No post-op complications related to procedure (i.e. pancreatitis, bleeding, perforation) Mean hospital stay: 2.55+0.89 days No pts with signs or symptoms of retained CBD stones during mean post-op follow-up of 9+4.07 months Ghazal AH, Sorour MA, El-Riwini M, El-Bahrawy H. Single-step treatment of gallbladder and bile duct stones: a combined endoscopic-laparoscopic technique. Int J Surg 2009;7(4):338-46

32. Current Trends 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

33. Public Health Problem #1: Laparoscopy in Bariatric Surgery OBESITY

34. Derived from Center for Disease Control and Prevention website www.cdc.gov Percent of Obese (BMI ≥ 30) in US Adults

35. Derived from Center for Disease Control and Prevention website www.cdc.gov Percent of Obese (BMI ≥ 30) in US Adults

36. County-level Estimates of Obesity among Adults aged ≥ 20 years: United States

37. National Hospital Discharge Survey Public-use data file and documentation. Multi-year data CD-ROM. National Center for Health Statistics, 1979-1996. Nguyen et al. Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery. Arch Surg 2005; 140: 1198-202. Griffen et al. The decline and fall of the jejunoileal bypass. Surg Gynecol Obstet 1983; 157: 301-8. Shirmer et al. Bariatric Surgery Training: Getting Your Ticket Punched. J Gastrointest Surg 2007;11: 807-12. Popularity of Surgical Management Period or Decades Incidence of Surgery Reason for Change Late 1970’s Early 1980’s 25,000 procedures per year Innovative procedures gastroplasty loop GBP jejuno-ileal bypass Late 1980’s 1990’s 5,000 procedures per year Multifactorial: High M&M Ineffective long-term Perceived failure Surgeon experience 2000’s 80,000 to 110,000 procedures per year Multifactorial: Laparoscopy Long-term data Centers of Excellence

38. Current Procedures

39. The first case of laparoscopic adrenalectomy was reported by Gagner in 1992. Laparoscopic Adrenalectomy

40. Less blood loss Less operative time!! Less hospital stay Less post operative pain Tiberio et al. Prospective RCT Surg Endosc. Jun 2008 Laparoscopic adrenalectomy

41. 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

42. 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

43. 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

44. SPLENECTOMY

45. Laparoscopic splenectomy Significantly less pulmonary, wound, and infectious complications. Longer operative times Winslow (meta-analysis). Surgery. 2003 Oct;134(4):647-53

46. Laparoscopic Heller’s Cardiomyotomy Technically feasible Short recovery time Less overall complication rates

47. 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

48. Nissen’s Fundoplication Technique

49. Nissen Fundoplication

50. Esophageal Hiatus Liver Esophagus Left crus Right crus Aorta

51. Hiatal Defect Chest cavity Stomach Left crus

52. Mesh Repair

53. Polypropylene mesh Esophagus Do not use metal tacks Biologic mesh? dual mesh? No mesh at all? (remember original Toupet repair) Mesh Wrap Circular mesh Fundoplication

54. Emerging technologies in hiatal hernia repair

55. TIF: T ransoral I ncisionless F undoplication Esophyx/Stomaphyx

56. EsophyX TIF TIF ( T ransoral I ncisionless F undoplication) No incisions No scarring No incisional herniation Less potential for infection - nosocomial infection minimized Patient friendly Rapid return to work and normal activities

57. ESOPHYX

58. 45 - 60 minute procedure 8 - 14 fasteners “SerosaFuse fasteners” (3.0 non-absorbable propylene sutures) Overnight stay (general anesthesia) Post-op discomfort minimal Rapid recovery – Most patients are back to work and most activities in a couple of days EsophyX Experience Reconstructs the natural primary barrier to reflux by creating a robust valve

59. Multi Center Trial (1 year) N=79 85% of Patients OFF daily PPIs Minimal risk of adverse events Excellent QOL improvement 73% Elimination of PPI use 85% Esophagitis resolution 59% Hiatal hernia reduction 71% pH normalization 49% (Hill grade one)

60. Multi Center Trial (2 years) N=79 Minimal risk of adverse events Patients satisfied with treatment 86% Patients can consume reflux causing 60-80% foods without symptoms

61. EsophyX-TIF was shown to be effective in treating chronic GERD as indicated by the significantly improved quality of life and reduced dependency on daily PPIs . The results at 12 and 24 mo supported a long-term maintenance of the anatomical integrity of TIF valves. Effectiveness - Conclusions

62. Linx ® Antireflux system

63. Magnetic Sphincter Augmentation How does it work? Yet, still in clinical trials

64. Is it feasible

65. 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.

66. Laparoscopic Procedures with equivalence Laparoscopic hernia repair Laparoscopic appendectomy

67. Laparoscopic Inguinal Hernia Repair

68. 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”.

69. 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.

70. Trocar placement: Transabdominal Preperitoneal (TAPP) Totally Extraperitoneal (TEP) Additional trocar

71. INGUINAL HERNIA REPAIR

72. Inguinal Hernia Repair

73. 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

74. Management of recurrent inguinal hernias Itani K, Fitzhibbons R, Awad S, Duh QY, Ferzli GS. Management of recurrent inguinal hernias . JACS , Vol. 209, No. 5, 653-658, Nov. 2009.

75. 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) Itani K, Fitzhibbons R, Awad S, Duh QY, Ferzli GS. Management of recurrent inguinal hernias . JACS , Vol. 209, No. 5, 653-658, Nov. 2009.

76. Nerves prone to injury anterior and posterior

77. What are recommendations for prevention of chronic pain? Conclusions Level 1B Material reduced meshes have some advantages with respect to longterm discomfort and foreign body sensation in open hernia repair (when only considering chronic pain). Level 2A Prophylactic resection of the ilioinguinal nerve does not reduce the risk of chronic pain after hernia surgery. Level 2B 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 Level 3 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

78. Laparoscopic Ventral Hernia: Is the Abdomen a Weakness in the Human Race ?

79. Factors Influencing Ventral Hernia Occurrence 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 Anemia Medication Shock Type of incision Smoker Corticoïds Aneurysm/Marfan (+30% risks)

80. 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)

81. Incidence of Ventral Hernias Around 10% of all laparotomies will generate incisional hernias. The bigger the incision, the higher the risk. ~77% are median hernias ~17% are lateral hernias ~6% are iliac hernias Direct closure have a high recurrences incidence (50%). The rate increases (58%) with repair of recurrent hernias. Significant reduction in recurrences is achieved when meshes are used. Luijendijk RW, et al. A Comparison of Suture Repair with Mesh Repair for Incisional Hernia .NEJM 2000; 343:392-398

82. Laparoscopic Repair of Incisional Hernias  wound complications  recurrence rate  LOS  pain coverage of “Swiss cheese” abdomen

83. Ventral Hernia Defect

84. Mesh used to patch defect

85. Secure periphery of mesh with tacker Approximately 1cm apart

86. Completed repair

87. Potential Mesh-Related Complications: Infection Intestinal adhesions Bowel obstructions Erosion of the prosthesis into the adjacent hollow viscous Contraction of prosthesis

88. Competition Evaluation Covidien Pariextex Composite Bard Composix E/X Bard Ventralex Ethicon Proceed Atrium C-Qur Gore Dualmesh Genzyme Sepramesh IP Adhesion prevention +++ + + + ? + ++ Tissue integration ++ + + + + - ++ Shrinkage + + + + + - + Elasticity ++ - - + ? - + Ease of fixation ++ + ++ + + - + Protected edge Y Y Y N N N N

89. Biomeshes

90. 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

94. 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. RESULTS: 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

95. Massive Incisional Hernias

98. Components Separation Developed by Dr. Ramirez in the late 80’s Employs the use of autologous myofascial tissue to effect abdominal wall closure Bilateral relaxation incisions 2cm lateral to the external oblique from costal margin to level of symphasis pubis Blunt separation of external oblique layer from underlying internal oblique layer taking care not to interrupt vascular/nerve supply May employ undermining of one or both posterior rectus sheaths to achieve further medial advancement **Provides dynamic support of the abdominal girdle**

99. Components Separation

100. 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

102. Case Report

103. Laparoscopic Appendectomy

104. Laparoscopic Appendectomy Endo-loop

105. 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.)

106. Laparoscopic Appendectomy Evidence-based Medicine Clear advantage in children - Less wound infection, LOS, ileus - More OR time, intra-abdominal abscess In adults Sauerland S, Jaschinski T, Neugebauer EA. Cochrane Database Syst Rev . 2010 Oct 6;10:CD001546. 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

107. 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

108. LAPAROSCOPIC PROCEDURES WITH CLEAR ADVANTAGES.

109. Laparoscopic Surgery in Colorectal Diseases

110. Port Site Recurrence

111. 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.

112. HEPATIC FLEXURE COLON RESECTION The ileum is more mobile than the transverse colon, which can still be delivered adequately at this level. A B Tension-free anastomosis Trocar C is used for GIA division of distal ileum and midtransverse colon (site is enlarged to retrieve specimen and for extracorporeal anastomosis). C

113. LAPAROSCOPIC SIGMOID RESECTION (lateral decubiti position)

114. Lateral Supine

115. 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

116. Consensus Review of Optimal Perioperative Care in Colorectal Surgery, Enhanced Recovery After Surgery (ERAS) Group Recommendations Fast-track Protocol No oral bowel preparation Pre operative fasting of 2 hours for liquids and 6 hours for solids. Carbohydrate loading Single dose antibiotic prophylaxis. No routine use of nasogastric tubes. Use of drains not advisable. Oral diet at will after surgery. Conventional Protocol Oral bowel preparation Pre operative fasting of 6 hours Prolonged antibiotic use. Nasogastric tubes used routinely. Drains routinely used. Delayed oral intake.

117. 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

118. Pulitan ò C and Aldrighetti L Nat Clin Pract Gastroenterol Hepatol (2008) Outcomes of laparoscopic hepatectomy

119. 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 Ann Surg. Dec 2010;252:1005-1012

120. 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

121. DISTAL PANCREATECTOMY D E C B A Trocars “A” and “B” divide gastrocolic ligament GIA is introduced through “D”

122. 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.

123. Laparoscopic Urologic procedures Undescended testis Varicocelectomy Retroperitoneal fibrosis Lymph node dissection Bladder neck suspension Bladder diverticulum Patent urachus Nephrectomy Prostatectomy

124. 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.) B C D A E

125. 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.

126. Minimally invasive neck surgery

127. 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

128. Cosmetic results Open surgery scar Minimally invasive / endoscopic scars

129. 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?! It is not a ‘niche surgery’!

130. 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

131. Confidential

133. Confidential

134. Confidential

135. Fourth arm trocar External retractor Connected with continuous suction system

136. Maryland dissector Harmonic curved shears

137. Confidential

138. Emerging Technologies Robotics SILS NOTES Trocarless laparoscopy ENDOBARRIER

139. History of Robotics Leonardo da Vinci developed one of the first robots in 1495 – an armored knight for the purposes of entertaining royalty.

140. 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

141. 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 Dependent on assistant for surgical support through accessory port Greater surgeon fatigue Makes complex operations more difficult

142. Past Present

143. Disadvantages of da Vinci ® Robot Expensive - $1.4 million cost for machine - $120,000 annual maintenance contract - Disposable instruments $2000/case - Hospital reimbursement same DRG Steep surgical learning curve Loss of tactile feedback Increased staff training/competence Increased OR set-up/turnover time!!

144. SILS Single Incision Laparoscopic Surgery

145. 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 What does that stand for ?

146. SILS Urology Renal transplant Cholecystectomy Gastric band surgery Colectomy

147. Technique

148. SILS

149. SILS Ergonomically difficult ?! Training !

150. Port Site Hernia !!

151. N.O.T.E.S. Natural Orifice Transluminal Endoscopic Surgery

152. NOTES - instrument

153. 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

154. 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

155. Scarless surgery!

156. Notes- Transvaginal Video-endoscope entering through the posterior vaginal fornix

157. NOTES - Transgastric Courtesy of N Reddy, Hyperbad India 2005

158. NOTES - Appendectomy

159. NOTES – Obesity Surgery

161. Trocarless Laparoscopy The development of magnetically controlled and anchored, intracorporeal surgical instruments and camera introduced through a single trocar.

162. A. Schematic representation of conventional transabdominal trocar and instrument (left) and proposed magnetically anchored and guided instrument/camera (right). B. Schematic representation of typical multitrocar laparoscopic surgery (left) and proposed single trocar surgery through which multiple MAGS instruments are introduced and deployed.

163. The novel use of ‘Light’ trocar

164. A. Schematic representation of prototype internal camera fully deployed. B. Internal view of camera fully deployed.

165. A. Schematic representation of prototype paddle-type retractor fully deployed. B. Internal view of prototype elevating porcine spleen.

166. 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

167. Historical Perspective 1955- Friedman 3 patients with poorly control DM 3-4 days after subtotal gastrectomy all 3 pateints showed an improvement in their DM Occurred sooner than associated weight loss Patients later regained their weight without an associated loss of glucose control or glycosuria Mingrone 1977 : Case report Young, non obese woman with DM who underwent BPD for chylomicronemia Plasma insulin and blood glucose levels normalized within 3 months Bittner –1981- subtotal gastrectomy and gastrointestinal reconstructions that excluded duodenal passage (B2 and RYGB Lowered plasma glucose and insulin Conclusion: Plasma glucose and insulin fall rapidly post-operatively antidiabetic medications can be reduced or stopped shortly after gastrointestinal bypass interventions Rubino F. Bariatric Surgery:effects on glucose homeostasis. Curr. Opin. Clin. Nutr. Metab. Care 9: 497-507 Bittner R. Homeostasis of glucose and gastric resection: the influence of food passage through the duodenum Z Gastroenterology 1981; 19: 698-707. Friedman NM et al. The amelioration of diabetes mellitus following subtotal gastrectomy. Surg. Gynecol. Obstetr. 1955; 100:201-204

168. Endobarrier

169. Endobarrier The EndoBarrier gastrointestinal liner works by creating a physical barrier between ingested food and the intestinal wall. Food bypasses the duodenum and proximal jejunum as it does in a Roux-en-Y gastric bypass.

170. Endo-Barrier Benefits include: Weight loss ADA: glycemic control in Type 2 diabetes Safe alternative to gastric bypass Non-invasive procedure Rapid recovery Lower costs

171. Feb 2010: Schouten Objective: To determine the safety and efficacy of EndoBarrier Gastrointestinal Liner Duodenal-jejunal bypass sleeve Designed to achieve weight loss in morbidly obese patients. First European experience 41 patients included 30 underwent sleeve implantation. 11 - diet control group. All followed the same low-calorie diet during the study period.

172. 2010: Schouten et al. Role of EndoBarrier 26 devices were successfully implanted Mean procedure time -35 min (range: 12–102 min) No procedure related adverse events. Mean excess weight loss after 3 months 19.0% device vs 6.9% for control ( P < 0.002) Type 2 diabetes mellitus 8 pts with baseline Type 2 diabetes mellitus Improvement in 7 patients during the study period Schouten et al. A multicenter, randomized efficacy study of the EndoBarrier Gastrointestinal Liner for presurgical weight loss prior to bariatric surgery. Ann Surg. 2010 Feb;251(2):236-43.

173. 2010: Schouten et al. Role of EndoBarrier The EndoBarrier Gastrointestinal Liner Feasible and safe noninvasive device Excellent short-term weight loss results. Type 2 DM Significant positive effect Long-term randomized and sham studies necessary Schouten et al. A multicenter, randomized efficacy study of the EndoBarrier Gastrointestinal Liner for presurgical weight loss prior to bariatric surgery. Ann Surg. 2010 Feb;251(2):236-43.

174. 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. Nicolo Machiavelli (1469-1527), The Prince, 1513

175. Surgery for Diabetes

176. 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

177. Prevalence of Diabetes From 1980 through 2006, the number of Americans with diabetes tripled (from 5.6 million to 16.8 million). ~24 million in 2009.

178. 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.

179. Metabolic Syndrome Also Known as: 1. Syndrome “X” 2. Insulin Resistance Syndrome 3. Reaven’s Syndrome 4. Deadly Quartet 5. CHAOS C oronary Artery Disease H ypertension A dult Onset Diabetes O besity S troke

180. 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

181. 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. 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. Long-term Weight Control Analysis Studies Type and Size Effect on Weight Effect on Comorbidities Buchwald et al. Meta-analysis n = 22,094 pts Mean excess weight loss: 61% Resolution of: Diabetes: 70% HTN: 62% Sleep apnea: 86% Swedish Obese Subject trial (SOS) Prospective matched cohort n = 4,047 pts At 10 years: Med: 1.6% gain Surg: 16% loss Improved by surgery: Diabetes Lipid profile HTN Hyperuricemia

182. 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

183. Rates of Remission of Diabetes Adjustable Gastric Banding Roux-en-Y Gastric Bypass Biliopancreatic Diversion >95% (Immediate) 48% (Slow) 84% (Immediate)

184. “ 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 2002: Antidiabetic Effect of Bariatric Surgery: Direct or Indirect?

185. 2004: Duodenal-Jejunal Exclusion - Foregut

186. 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:

187. 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

188. Double blind study: 16 patients assigned to LRYGBP and 16 Pts to LSG Patients reevaluated on the 1st, 3rd, 6th, and 12th mos Results: 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.

189. “ PYY levels increased similarly after either procedure. The markedly reduced ghrelin levels in addition to increased PYY levels after LSG, are associated with greater appetite suppression and excess weight loss compared with LRYGBP” March 2008: 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. March 2008:

191. 2009: Ferzli et al

192. 2009: Ferzli et al

193. 2009: Ferzli et al. Results at 12 months 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).

194. 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

195. The Surgeon and the Diabetologists

196. 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

197. 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)