This document provides an overview of minimal invasive surgery (MIS), also known as laparoscopic surgery. It discusses the history and development of laparoscopic techniques, advantages like less pain and faster recovery compared to open surgery. Prerequisites for MIS include patient fitness, instruments used like laparoscopes and trocars. Risks include injuries from trocars and potential complications from carbon dioxide insufflation like gas embolism. The document outlines general principles of MIS including visualization, triangulation and sealing blood vessels. Both basic procedures like laparoscopic cholecystectomy and more advanced surgeries are discussed.

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?