MIS - Basic science for general surgical residents Facebook: Happy Friday Knight

1. Minimal Invasive Surgery
Facebook: Happy Friday Knight
Basic Science for General Surgical Residency Program
Thailand

2. • Small incision necessary to gain access to
surgical sites in high-tech surgery
• Small holes, big operation

3. • Robotic surgery
• Endovascular and endoluminal surgery
• SILS = single-incision laparoscopic surgery
• HALS = Hand-assisted laparoscopic surgery
• NOTES = Natural orifice transluminal endoscopic
surgery
• POEM = Peroral endoscopic myotomy

4. Robotic Surgery
• Computer-enhanced surgical devices
• Steadier image
• Fewer members
• Popular procedure: mitral valve surgery,
prostatectomy
• Telesurgery: surgeon is a great distance from
patient e.g. combat and space

6. • EGD, ERCP, colonoscope,
bronchoscope, cystoscope,
hysteroscope
• Stent placement
– Coronary angioplasty
– ERCP stent
Endoluminal and Endovascular Surgery

7. Natural Orifice Transluminal
Endoscopic Surgery (NOTES)
• Strong appeal to patients wishing to avoid scar
and pain
• Access: Transvaginal, transvesicle, transanal,
transcolonic, transgastric, transoral
• Contamination and closure the orifice are the
challenges
• High rate of major complication (3.4%)
• PEG, transgastric pseudocyst drainage,
appendectomy, cholecystectomy

9. Peroral Endoscopic Myotomy (POEM)
for Achalasia
• Surgical myotomy is still standard

10. Single-Incision Laparoscopic Surgery (SILS)

11. Hand-assisted Laparoscopic Surgery
(HALS)

12. Physiology
• Even with least invasive, physiologic changes
occur
• Pneumoperitoneum: N2O VS CO2

13. Pneumoperitoneum: N2O
• Inert
• Rapidly absorbed
• Reduce intra-op ETCO2
• Least painful
• Use in pregnancy, tumor biology and port site
metastasis are unknown

14. Pneumoperitoneum: CO2

15. • Inexpensive
• Low risk of gas embolism
• Safe with electrocautery
• Radidly absorbed to circulation: respiratory
acidosis
• Hypercarbia: causes tachycardia and increased
systemic vascular resistance
Pneumoperitoneum: CO2

16. Pneumoperitoneum: Pressure effect
• Excessive pressure on IVC and reverse
Trendelenburg position  decrease venous
return and cardiac output
• Venous engorgement  venous thrombosis
– Management: sequential compression stocking
• Transmitting to thoracic cavity: increased
filling pressure of both sides of heart
• Decreased renal blood flow, GFR, urine output

17. • Gas emboli
– Suspected when hypotension during insufflation
– Mill wheel murmur: A temporary loud,
machinery-like, splashing sound due to blood
mixing with air in the right ventricle
– Management: head down, left lateral decubitus
central vein insertion to aspirate the gas
Pneumoperitoneum

18. Basic laparoscopic instruments
• Laparoscope
• Light source and fiberoptics
• Trocars
• Devices for dissection and grasping
• Devices for hemostasis
• Surgical staplers
• Tissue removal devices

19. Laparoscope

20. Trocars

21. Dissection and grasping

22. Hemostasis

23. Suction and irrigation devices

24. Staplers

25. Tissue bag

26. Laparoscopic access
• Establishing abdominal access:
– Veress
– Hasson

29. Laparoscopic access
• Peritoneal insufflation (14-15 mmHg for CO2)
• Direct access to the abdomen with 5-to-10 mm
trocar (point away from sacral promontory and
great vessels)
• Secondary puncture via direct vision

30. Port Placement

31. Energy Sources
• Electrosurgical coagulation
– Monopolar VS bipolar
– Using radiofrequency energy to generate heat in
tissue resulting in cutting and coagulation
– Inexpensive
– Easy to use
– No foreign materials left behind
– Thermal spread

32. Monopolar Electrosurgery

33. • Cut
– Low voltage
– produce the greatest
amount of heat over
a very short period of time,
which results in
vaporization and
Explode of tissue
Monopolar Electrosurgery

34. Monopolar Electrosurgery
• Coag
– High voltage
– Creation of coagulum

35. • Fulguration
– Coagulate and char tissue over a wide area
• Desiccation
– occurs when the electrode is in direct contact with
the tissue.
– Achieved most efficiently with the cutting current
– Less heat is generated and no cutting action occurs
Monopolar Electrosurgery

36. Bipolar Electrosurgery

37. • Electrons flow between two adjacent
electrodes
• Tissue is heated and desiccated
• Small vessel coagulation
Bipolar Electrosurgery

38. Thermal Injury

39. Avoid Complications
• inspect insulation carefully
• Use lowest possible power setting
• Use a low voltage waveform (cut)
• Do not activate in close proximity or direct
contact with another instrument
• Use bipolar electrosurgery when appropriate

40. Special Consideration

41. Pediatric Laparoscopy
• Same as adult
• The instruments are 15-20 cm long and 3 mm in
diameter
• The telescope is 5 mm
• Pneumoperitoneum 8 mmHg is adequate for
infants
• DVT is rare
• E.g. pull-through procedure for Hirschsprung’s
disease, repair of congenital diaphragmatic hernia

42. Laparoscopy during Pregnancy
• Timing
– 1st trimester
• Risk of organogenesis
• Teratogenesis and miscarriage rate 12%
– 2nd trimester
• Favored period for elective surgery
• Risk of preterm labor 5-8%
– 3rd trimester
• Risk for preterm labor

43. • Techniques
– Minimize operative time
– Hasson entry above umbilicus
– Pneumoperitoneum pressure 10-12 mmHg
– Right side up
– Angled or flexible laparoscopes
– Maternal and fetal monitoring, ETCO2, ABG
– sequential compression devices
Laparoscopy during Pregnancy

44. MIS and Cancer
• Treatment for palliation obstructive cancer:
laser, intracavitary radiation, stenting, dilation
• Staging of cancer:
– Mediastinoscopy for evaluate lymph node
– Laparoscopy for assess liver
• Perform palliation measures: laparoscopic
gastrojejunostomy
• For curative treatment: segmental colectomy,
hepatectomy, distal pancreatectomy

45. Elderly and Infirm
• safe
• More likely to require conversion to
laparotomy due to disease chronicity
• Require close monitoring of anesthesia

46. Cirrhosis and Portal Hypertension
• Risk for hemorrhage at all levels
• Ascitic leak from port site leading to bacterial
peritonitis
• Portal hypertension is a relative
contraindication to laparoscopic surgery

47. Economics of MIS
• Reduce costs of surgery most when length of
hospital stay can be shortened and return to
work is quickened

48. References
Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed.
McGraw-Hill Education, 2015.
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