LAPAROSCOPIC SURGERY- PAST, PRESENT AND FUTURE

Laparoscopy: History, Present
and Emerging Trends

Dr. Sreejoy Patnaik

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

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).

 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

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 carbonfilament bulbThomas Edison

 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.

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

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

 1920: Zollikofer discovered the benefit of CO2 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.

Kurt Semm (1927-2003)
 Once, while making a slide
German Engineer and Gynecologist.
Introduced automatic insufflator,
thermocoagulation ,loop knots,
irrigation device in 1983, performed
endoscopic appendectomy as part of
A gynecologic procedure.

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”

 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.

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

Definition
 Minimal access surgery is a marriage of
modern technology and surgical
innovation that aims to accomplish
surgical therapeutic goals with minimal
somatic and psychological trauma

Extent of minimal access surgery
 Laparoscopy
 Thoracoscopy
 Endoluminal endoscopy
 Perivisiceral endoscopy
 Arthroscopy and intra-articular joint surgery
 Combined approach

What operations can we do
Laparoscopically
Diagnosis

Operation

Gallstone

Cholecystectomy

Appendicitis

Appendicectomy

Hernia

Hernia repair

Adhesions

Division of adhesions

Perforated ulcer

Closure of perforation

Hiatus Hernia

Hiatus hernia repair.

Laparoscopically
Diagnosis

Operation

Colorectal carcinoma

Anterior resection/ APR

Caecal carcinoma

Right Hemicolectomy

Colonic carcinoma

Left/Sigmoid Colectomy

Gastric carcinoma

Gastrectomy

Oesophageal
carcinoma

Oesophagogastrectomy

The list is endless!!!

laparoscopically?
Diagnosis

Operation

Crohn’s Disease

Bowel resection

Diverticulitis

Bowel resection

Rectal Prolapse

Repair of Prolapse

Benign renal disease

Nephrectomy

Gastric Obstruction

Bypass

Some Splenic disorders

Spleenectomy

Principle Differences between
Laparoscopic and Open Surgery
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FOR THE PATIENT
Post operative pain related to size of incisionsmaller incisions =less pain.
Less Handling of intestines results in little or no
disturbance of normal function.
Avoidance of the trauma of abdominal wall injury
by the incision allows rapid return to normal
activity
No incision allows early return to more strenuous
activities: driving, lifting, sport etc.

laparoscopic and open surgery


FOR THE HOSPITAL
Initial capital costs to establish laparoscopic surgery in
the order of Rs 10 - 20 lacs

 Reduced overall costs by shortening of hospital stay e.g.
cholecystectomy reduced from 5 to 1 day, hiatus hernia
repair reduced from 7 to 3 days.

laparoscopic and open surgery
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For the Surgeon
Magnified view often better than obtained via an
incision allows precise dissection.
Altered (but not absent) tactile response
Two dimensional (flat screen) view.
Usually (but not always) longer operating time
Need to develop entirely different operating
technique
Adaptation of principles of open surgery to
laparoscopic surgery.

Instruments
 Redesign of instruments for laparoscopic use.
 Instruments for open surgery in general 6 – 10” in length


built around a box joint.
Laparoscopic instruments in general 15 – 18” in length
with an articulated connecting rod between handles and
scissor blades, jaws etc.

Equipment Necessary for MAS
Camera
Light Source
Insufflator
TV Monitor
Telescopes
Light Guide Cable

Apart from the
insufflator the system
will work better if all
the components are
from the same
company as one
piece talks to another

CAMERA
 These can be single chip or 3 chip.
 CHIP: thois 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
 Sleeve it don’t soak it!!!


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.
Automatic illumination, does it talk to the camera
and are the necessary leads plugged in.
Lamp life meter, look at it. Is it nearly out? EBME
keep the spares and they change it.
White balance by making sure white is correct
then all the colours through the spectrum are
correct.

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.
Ensure you know how to change a cylinder
and were they are stored.

TV Monitors
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

Usually a 20” screen.
HD is better.
You can use a standard TV but it must be run
through an isolated transformer.
Horizontal resolution is the number of vertical
lines.
Vertical resolution is the number of horizontal
lines
More lines of resolution, better detail of picture.

Telescopes

 Come in varying sizes, laparoscopes usually



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

5mm or 10mm.
Diagnostic 3mm scope available.
Made up of a rod and lens system.
Bundles of fibres, incoherent carry light and
coherent carry image.
Wide range of angles available 0, 30, 45 degree
are fairly standard.
All laparoscopes are autoclavable and can go
through sterilisation, no ultrasonic bath required.
Endo- chameleon- extra long for Bariatric
patients.

Light guide Cables

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Different diameters
Fibre light cable
Buy auroclavable
Don’t bend to acutely as will break fibres.
Check when you plug them in are all the fibres are okay.
Condensers

Instrumentation
 SINGLE USE: breaking the Law if you reuse it






on another patient.
Reusable take apart.
Need an ultrasonic washer to effectively clean
them, not for telescopes.
Don’t put 5mm cannulated instruments into a
bench top autoclave that does not have a
vacuum: vacuum is required to remove all air
form lumen of instrument.
Ports 5 and 10mm are the most common, make
sure the right trocar is in port and is it sharp.

Electrosurgery
You should be aware of the following
potential situations:
 Insulation failure of the active electrode.
 Direct coupling of current to other instrumentation
by direct contact.

 Capacitance which may be created by two electrical
conductors separated by an insulator

Ultrascision or the Harmonic Scalpel
Electrical generator (the box)
This adjusts the amount of electrical energy
being delivered and monitors performance.
Transducer
This is where electrical energy is converted to
the ultrasonic waves. The frequency is fixed
however the amplitude alters with the power
input. the transducer is located in the hand
piece and is connected to the generator by an
electrical cable.
Dissection Instrument (peripheral hand piece)
A metallic rod is coupled to the transducer and
vibrates at the prescribed frequency (i.e.
55kHz). The tip of the rod contacts with the
surface tissue.

Principles of Piezo Electronics
 The ultrasound waves are created by electrical
energy hitting a negatively charged crystal that
vibrates (expands and contracts) at a particular
frequency. These crystals are disc shaped and
made of ferroelectric ceramics. A pair of discs
“coupled” together produce a sinusoidal wave
form. This coupling results in a harmonic
waveform that is of high electroacoustic
efficiency.

VERESS NEEDLE

 1938 - Janos Veress, of Hungary, developed the springloaded 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 bevelled needle
point for cutting through tissues.

GAS INSUFFLATION


Controlled pressure insufflation of the peritoneal cavity
is used to achieve the necessary work space for



Automatic insufflators allow the surgeon to preset the
insufflating pressure, and the device supplies gas until
the required intra-abdominal pressure is reached.

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)

Trocars

 Types:
 Cutting
 Pyramidal
tipped
 Flat blade

 Noncutting
 Pointed conical
 Blunt conical

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

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.

Dissecting & Grasping Forceps
 Atraumatic

 KELLY atraumatic

 Atraumatic, with hollow jaws
 MANGESHKAR Grasping
Forceps, serrated

General instruments
 Reusable three-piece design
 Available in 2 mm, 3 mm,

3.5mm, 5 mm and 10 mm
sizes, with lengths of 20 cm,
30 cm, 36 cm and 43 cm.

 Choice of handle styles.
 Fully rotating 360° sheath.
 No hidden spaces that can
trap operative blood and
tissue debris.

Scissors


HOOK SCISSORS, single action
jaws



METZENBAUM SCISSORS,

curved, length of blades 12-17 mm,
widely used as an instrument for
mechanical dissection in


STRAIGHT SCISSOR can give

controlled depth of cutting because
it has only one moving jaw.

TROCAR PLACEMENT
BY QUADRANT
Thoracic triangle

1

2

4

3

Pelvic triangle

TROCAR PLACEMENT
BY QUADRANT
Each quadrant must be
addressed from frontal
as well as lateral positions.

z

y
x

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

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

Avoid competing
for the same space:
“Dueling

swords”
phenomenon
(scissoring effect)

Working against the camera
and ‘blind spots’

No obstacle between trocar entry and target

To avoid
iatrogenic
injuries.

Avoid the epigastric vessels

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

Anatomic distribution of nerves across
anterior abdominal wall
Ilioinguinal nerve

Iliohypogastric nerve

(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.)

Incision line/trocar sites vs. nerve distribution
Epigastric a.

Iliohypogastric n.

Ilioinguinal n.

Trocar site

Pfannenstiel incision

(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.)

Be aware of bladder location
for suprapubic trocar

Additional
trocars can be
added along the
semicircular line.
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.

Gold Standard Laparoscopic Procedures
Today
 Laparoscopic cholecystectomy
 Laparoscopic RYGB for obesity
 Laparoscopic adrenalectomy
 Laparoscopic splenectomy

Laparoscopy in Bariatric Surgery

Public Health Problem #1:

OBESITY

LAP-BAND
Trocars - placed high, close
to
the costal margin.
Trocar A - liver retraction.
Trocar D - can be enlarged to
allow for placement of a port.
Trocar C - placed left of the
midline for correct view of
Angle of His.

A
B

E
C

D

Laparoscopic RYGB
 Multicenter, prospective, risk-adjusted
data show that laparoscopic gastric
bypass is safer than open gastric
bypass, with respect to 30-day
complication rate.

 LRYGB has become the standard of
care

Hutter et al. Ann Surg. May 2006
Massachusetts General Hospital, Boston.

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

Laparoscopic adrenalectomy

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

Indications for Adrenalectomy
Unilateral adrenalectomy

Bilateral adrenalectomy

Hyperfunctioning tumors
Aldosteronoma
Cortisol-producing adenoma
Virilizing tumors
Pheochromocytoma

Nonfunctioning cortical adenomaa

Failed treatment of ACTH-dependent
Cushing’s syndrome

Cushing’s syndrome from primary
adrenal hyperplasia

Malignant tumors
Adrenocortical carcinoma
Malignant pheochromocytoma
Adrenal metastasis (solitary without
other metastatic
disease)

symptomatic or enlarging adrenal
myelolipomas, ganglioneuroma
ACTH: adrenocorticotrophic hormone

Bilateral pheochromocytoma

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

Laparoscopic splenectomy

 Significantly less pulmonary, wound, and infectious complications.
 Longer operative times
53

Winslow (meta-analysis). Surgery. 2003 Oct;134(4):647-

Laparoscopic Procedures
with equivalence
 Laparoscopic hernia repair
 Laparoscopic appendectomy
 Laparoscopic fundoplication

Laparoscopic Inguinal Hernia
Repair

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.

Trocar placement:

Additional
trocar

Transabdominal

Totally

Pre peritoneal (TAPP)

Extra Peritoneal (TEP)

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

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)

2. Do we have an answer for
groin pain after hernia repair?

Nerves prone to injury
anterior and posterior

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

Laparoscopic Repair of
Incisional Hernias
 ↓ wound complications
 ↓ recurrence rate
 ↓ LOS
 ↓ pain

 coverage of “Swiss cheese”
abdomen

 Secure periphery
of mesh with
tacker

 Approximately
1cm apart

Laparoscopic Appendectomy

Endo-loop

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.)

Laparoscopic Appendectomy
Evidence-based Medicine
Clear advantage in children*
- Less wound infection, LOS, ileus
- More OR time, intra-abdominal abscess

Controversies in adults
- Cost, obese patients, severe appendicitis

- Prelude to NOTES
*Aziz et al. Ann Surg 2006

LAPAROSCOPIC PROCEDURES
WITH CLEAR ADVANTAGES.

Laparoscopic Heller’s Cardiomyotomy

 Technically feasible
 Short recovery time
 Less overall complication rates

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

Nissen’s Fundoplication
Technique

Esophageal Hiatus
Esophagus

Liver

Aorta

Right crus

Left crus

Hiatal Defect

Left crus

Chest cavity

Stomach

• Do not use metal tacks
• Biologic mesh? dual mesh?
Esophagus

• No mesh at all?

(remember original Toupet repair)
Polypropylene mesh

Mesh
Circular mesh

Wrap

Fundoplication

Laparoscopic Surgery
in Colorectal Diseases

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.

HEPATIC FLEXURE
COLON
RESECTION

C

Tension-free anastomosis

B
A

Trocar C is used for GIA division
of distal ileum and midtransverse
colon (site is enlarged to retrieve
specimen and for extracorporeal
anastomosis).

The ileum is more mobile than the
transverse colon, which can still be
delivered adequately at this level.

LAPAROSCOPIC
SIGMOID RESECTION
(lateral decubiti position)

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

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

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

DISTAL PANCREATECTOMY
• Trocars “A” and “B” divide gastrocolic ligament
• GIA is introduced through “D”

A
B
C

E
D

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.

Laparoscopic Urologic
procedures








Undescended testis
Varicocelectomy
Retroperitoneal fibrosis
Lymph node dissection
Bladder neck suspension
Bladder diverticulum
Patent urachus

 Nephrectomy
 Prostatectomy

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.)
•

D

C

E

A

B

PROSTATECTOMY
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.

A

B

C

Minimally invasive neck surgery

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

Cosmetic results

Open surgery scar

Minimally invasive / endoscopic scars

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?!

Emerging Technologies

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


Robotics
SILS
NOTES
Trocarless laparoscopy
ENDOBARRIER

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

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

Surgical Robots
AESOP (Automated Endoscopic System for Optimal
Positioning)
- Voice activated mechanical arm
- Steadier than human, never tires

da Vinci®
- FDA approval in 2002
- Laparoscopic instrumentation controlled by the
surgeon, positioned remotely at a console

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

What is the da Vinci® Surgical System?

 State-of-the-art robotic
technology




Surgeon in control
Assistant has direct access

What is the da Vinci®
Surgical System?
Surgeon directs precise
movements of instruments in
the slave unit using console
controls.

Robotic Scrub Nurse
“Penelope”

Wrist and Finger Movement
 Laparoscopic instruments
are rigid with no wrists

 EndoWrist® Instrument tips
move like a human wrist

 Allows surgeon to operate
with increased dexterity &
precision. No tremor

Disadvantages of da Vinci® Robot
 Expensive
- $1.4 million cost for machine
- $120,000 annual maintenance contract
- Disposable instruments $2000/case

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

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Steep surgical learning curve
Loss of tactile feedback
Increased staff training/competence
Increased OR set-up/turnover time!!

SILS
Single Incision Laparoscopic Surgery

What does that stand for ?





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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

SILS






Urology
Renal transplant
Cholecystectomy
Gastric band surgery
Colectomy

SILS

 Ergonomically difficult ?!
 Training !

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

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

Alleged NOTES Benefits



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



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

Notes- Transvaginal

Video-endoscope entering through the
posterior vaginal fornix

NOTES - Transgastric

Courtesy of N Reddy, Hyperbad India 2005

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

Metabolic Syndrome
Also Known as:
1. Syndrome “X”
2. Insulin Resistance Syndrome
3. Reaven’s Syndrome
4. Deadly Quartet
5. CHAOS
Coronary Artery Disease
Hypertension
Adult Onset Diabetes
Obesity
Stroke

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

Long-term Weight Control Analysis
Studies

Type and Size

Effect on Weight

Effect on Comorbidities
Resolution of:

Buchwald et al.

Meta-analysis
n = 22,094 pts

Mean excess
weight loss: 61%

n



Swedish Obese
Subject trial (SOS)

Prospective matched
cohort
n = 4,047 pts

At 10 years:
 Med: 1.6% gain
Surg: 16% loss

Diabetes: 70%
HTN: 62%
Sleep apnea: 86%

Improved by surgery:
 Diabetes
 Lipid profile
 HTN
 Hyperuricemia

1. 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.
2. 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.

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

Rates of Remission of Diabetes

Adjustable
Gastric Banding

Roux-en-Y
Gastric Bypass

Biliopancreatic
Diversion

48%

84%

>95%

(Slow)

(Immediate)

(Immediate)

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

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

The Surgeon and the Diabetologists

THE FUTURE

It has not changed the nature of disease
 The basic principles of good surgery still

apply,including appropriate case selection, excellent
exposure,adequate retraction and a high level
technical expertise

 If a procedure makes no sense with conventional

access, it will make no sense with a minimal access
approach

THE FUTURE
 The cleaner and gentler the act of
operation, the less the patient
suffers, the smoother and quicker
his convalescence,the more
exquisite his healed wound.

Berkeley George Andrew Moynihan

THANK YOU ALL FOR A
PATIENT HEARING

LAPAROSCOPIC SURGERY- PAST, PRESENT AND FUTURE

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