Minimally Invasive Surgery, Robotics, Natural

Orifice Transluminal Endoscopic Surgery,

Single-Incision Laparoscopic Surgery

Anisa Z. Sadain, MD, FPSCRS, FPCS,

FPSCS, FPALES, DPBAMIS
July 25, 2024
Scope of Lecture

• Historical background
• Physiology &
pathophysiology of MIS
• Special Considerations
Terminology: Minimally invasive surgery

• major operations through small incisions, using miniaturized, high-tech

imaging systems, to minimize trauma of surgical exposure.
 Terminology: Robotic surgery or computer-
enhanced surgery
• couples an ergonomic work-station that
features stereoptic video imaging and
intuitive micromanipulators (surgeon
side) with a set of arms delivering
specialized laparoscopic instruments
enhanced with more degrees of freedom
than are allowed by laparoscopic surgery
alone (patient side).
 Terminology: Single-incision laparoscopic surgery (SILS), or
laparoendoscopic single-site surgery (LESS)

• multiple trocars within the fascia at the

umbilicus or through a single
multichannel trocar at the umbilicus.
• primary advantage: reduction to one
surgical scar.
• Robotic SILS
• enables computer reassignment of the
surgeon’s hands, thus eliminating the
difficult ergonomic challenges making the
technique far more accessible.
Terminology: Natural orifice transluminal
endoscopic surgery (NOTES)
• extension of interventional endoscopy.
• Using the mouth, anus, vagina, and
urethra (natural orifices), flexible
endoscopes are passed through the wall
of the esophagus, stomach, colon,
bladder, or vagina entering the
mediastinum, the pleural space, or the
peritoneal cavity.
• advantage: elimination of the scar
associated with laparoscopy or
thoracoscopy.
Historical Background
• 1901 (Kelling): Primitive laparoscopy, placing
a cystoscope within an inflated abdomen.
Illumination of the abdomen required hot
elements at the tip of the scope and was
dangerous.
Historical Background
• late 1950s: Hopkins described the rod
lens, a method of transmitting light
through a solid quartz rod with no heat
and little light loss. Then thin quartz
fibers were discovered to be capable of
trapping light internally and conducting
it around corners, opening the field of
fiber optics and allowing the rapid
development of flexible endoscopes.
 Historical Background
• 1970s: application of flexible endoscopy
grew faster than that of rigid endoscopy
except in a few fields such as gynecology
and orthopedics.
• mid-1970s: rigid and flexible endoscopes
made a rapid transition from diagnostic
instruments to therapeutic ones.
• Video-assisted surgery in the past 20
years was a result of the development of
compact, high-resolution, charge-
coupled devices (CCDs) that could be
mounted on the internal end of flexible
endoscopes or on the external end of a
Hopkins telescope.
 Historical Background
• 1960s: Flexible endoscopic imaging started,
with the first bundling of many quartz fibers
into bundles, one for illumination and one for
imaging.
• upper endoscopes for the diagnosis and
treatment of gastroesophageal reflux and
peptic ulcer disease and made possible early
detection of upper and lower gastrointestinal
(GI) cancer at a stage that could be cured.
• (Shinya and Wolfe) - first endoscopic surgical
procedure was the colonoscopic polypectomy
Historical Background
• 1981: percutaneous endoscopic gastrostomy (PEG)
invented by Gauderer and Ponsky may have been
the first NOTES procedure
• NOTES: transvaginal approach has been studied
the most extensively.
• Endoscopic mucosal resection (EMR) of early-stage
esophageal and gastric lesions has revolutionized
the management of these malignancies.
• Peroral endoscopic myotomy (POEM) procedure
for achalasia
Historical Background
• Single-incision laparoscopic surgery (SILS),
synonymously termed laparoendoscopic single-site
surgery (LESS) - used regularly across a wide variety
of surgical areas including general, urologic,
gynecologic, colorectal, and bariatric surgery.
• 1970s: Fluoroscopic imaging allowed the adoption
of percutaneous vascular procedures - balloon
angioplasty to open up clogged lumens with
minimal access.
• transvenous intrahepatic portosystemic shunt and
by the aortic stent graft, which has nearly replaced
open elective abdominal aortic aneurysm repair.
• MIS procedures using ultrasound imaging -
fragmenting kidney stones and freezing liver
tumors
Historical Background
• Newer, high-resolution ultrasound methods with
high-frequency crystals may act as a guide while
performing minimally invasive resections of
individual layers of the intestinal wall.
• computed tomography (CT): CT-guided drainage of
abdominal fluid collections and percutaneous
biopsy of abnormal tissues are minimally invasive
means of performing procedures that previously
required a celiotomy.
• CT-guided percutaneous radiofrequency (RF)
ablation has emerged as a useful treatment for
primary and metastatic liver tumors. This
procedure also is performed laparoscopically under
ultrasound guidance.
Historical Background
• magnetic resonance imaging (MRI): diagnostic tool, but it is only slowly coming
to be of therapeutic value. The advantage of MRI, in addition to the superb
images produced, is that there is no radiation exposure to patient or surgeon.
Some neurosurgeons are accumulating experience using MRI to perform
frameless stereotactic surgery.
• Robotic surgery: latest iteration of the da Vinci Xi platform released in 2014
features high-definition, three-dimensional vision and a dual-console capability
allowing greater visualization, assistance, and instruction capabilities.
Additionally, the new overhead boom design facilitates anatomical access from
virtually any position enabling complex multiquadrant surgeries.
Physiology and
Pathophysiology of MIS
 Laparoscopy: Pneumoperitoneum
• intraperitoneal visualization achieved by inflating the
abdominal cavity with air
• N2O
• Advantages:
• physiologically inert & rapidly absorbed.
• better analgesia for laparoscopy performed
under local anesthesia
• reduces intraoperative end-tidal CO2 and
minute ventilation required to maintain
homeostasis
• effect on tumor biology and development of port site
metastasis are unknown
• safety of N2O pneumoperitoneum in pregnancy has
yet to be elucidated
Laparoscopy: Pneumoperitoneum
• CO2
• physiologic effects: gas-specific effects &
pressure-specific effects
• rapidly absorbed across peritoneal membrane
into circulation  respiratory acidosis by
generation of carbonic acid.
• Body buffers, the largest reserve of which lies
in bone, absorb CO2 (up to 120 L) and
minimize development of hypercarbia or
respiratory acidosis during brief endoscopic
procedures.
• Once body buffers are saturated, respiratory
acidosis develops rapidly.
Laparoscopy: Pneumoperitoneum
Gas specific Effects:
• In patients with normal respiratory function, this is
not difficult; the anesthesiologist increases the
ventilatory rate or vital capacity on the ventilator.
• If respiratory rate required exceeds 20 breaths per
minute, there may be less efficient gas exchange and
increasing hypercarbia.
• Conversely, if vital capacity is increased substantially,
there is a greater opportunity for barotrauma and
greater respiratory motion–induced disruption of
the upper abdominal operative field.
• Mild respiratory acidosis probably is an insignificant
problem, but more severe respiratory acidosis
leading to cardiac arrhythmias has been reported.
• Hypercarbia  tachycardia and increased systemic
vascular resistance,  elevates blood pressure and
increases myocardial oxygen demand.
Laparoscopy: Pneumoperitoneum
Pressure effects: cardiovascular physiology
• In the hypovolemic individual, excessive pressure
on the inferior vena cava and a reverse
Trendelenburg position with loss of lower
extremity muscle tone may cause decreased
venous return and decreased cardiac output.
• This is not seen in the normovolemic patient.
• The most common arrhythmia created by
laparoscopy is bradycardia.
• A rapid stretch of the peritoneal membrane often
causes a vagovagal response with bradycardia and,
occasionally, hypotension. The appropriate
management of this event is desufflation of the
abdomen, administration of vagolytic agents (e.g.,
atropine), and adequate volume replacement.
Laparoscopy: Pneumoperitoneum
Increased intra-abdominal pressure compressing
inferior vena cava  diminished venous return from
the lower extremities
• patient placed in the reverse Trendelenburg
position for upper abdominal operations. Venous
engorgement and decreased venous return
promote venous thrombosis.
• If no deep venous thrombosis (DVT) prophylaxis
during advanced lap cases done  risk of
pulmonary embolus.
• use of sequential compression stockings,
subcutaneous heparin, or low molecular
weight heparin.
• In short-duration laparoscopic procedures
(appendectomy, hernia repair, or cholecystectomy)
the risk of DVT may not be sufficient to warrant
extensive DVT prophylaxis.
Laparoscopy: Pneumoperitoneum
increased pressure of the pneumoperitoneum is
transmitted directly across the paralyzed diaphragm
to the thoracic cavity
 increased central venous pressure
 increased filling pressures of the right and left
sides of the heart.
• If intra-abdominal pressures are kept under 20
mmHg, cardiac output usually is well
maintained.
 increasing intrathoracic pressure increases
peak inspiratory pressure, pressure across the
chest wall, and also, the likelihood of
barotrauma.
•  Pneumothoraces during laparoscopic
esophageal surgery may be very significant.
Laparoscopy: Pneumoperitoneum
Increased pressure of the pneumoperitoneum  Increased
intra-abdominal pressure
•  decreases renal blood flow, glomerular filtration rate, and
urine output (by direct pressure on kidney and renal vein)
•  secondary effect of decreased renal blood flow is to
increase plasma renin release  increasing sodium retention
•  increased circulating antidiuretic hormone levels 
increasing free water reabsorption in the distal tubules
• decreases urine output for up to 1 hour after the procedure
has ended.
• Intraoperative oliguria is common during laparoscopy, but
the urine output is not a reflection of intravascular volume
status
• intravenous (IV) fluid administration during an
uncomplicated laparoscopic procedure should not be linked
to urine output.
Laparoscopy: Pneumoperitoneum
hemodynamic & metabolic consequences in patient with
compromised cardiovascular function subjected to a long
laparoscopic procedure
• alternative approaches considered or insufflation pressure
reduced
• alternative gases (inert gases helium, neon, and argon)
cause no metabolic effects, but are poorly soluble in blood
(unlike CO2 and N2O) and are prone to create gas emboli if
gas has direct access to the venous system.
• Gas emboli are rare but serious complications of
laparoscopic surgery.
• if hypotension develops during insufflation;
characteristic “mill wheel” murmur.
• treatment: place patient in a left lateral decubitus
position with head down to trap the gas in apex of
right ventricle. A rapidly placed central venous
catheter then can be used to aspirate gas out of right
ventricle.
 Laparoscopy
In some situations, minimally invasive abdominal
surgery can be performed without insufflation.
• assistance of an abdominal lift device that can be
placed through a 10- to 12-mm trocar at the
umbilicus.
• Advantage: little physiologic derangement
• Disadvantage: bulky and intrusive, exposure and
working room are inferior, reduces space available
laterally and thereby displaces the bowel medially
and anteriorly into the operative field; cause more
postoperative pain
Laparoscopy
Endocrine responses
• Serum cortisol levels are often higher
• more rapid equilibration of most stress-mediated
hormone levels after laparoscopic surgery.
• Immune suppression also is less after laparoscopy
• more rapid normalization of cytokine levels after a
laparoscopic procedure than after the equivalent
procedure performed by celiotomy.
 Laparoscopy: Pneumothorax
• Transhiatal mobilization of the distal esophagus
• defect should be enlarged to prevent a
tension pneumothorax.
• thoracostomy tube should be placed across
the breach into the abdomen with intra-
abdominal pressures reduced below 8 mmHg,
or a standard chest tube may be placed.
• Nissen fundoplication or Heller myotomy
• preferable to place an 18-French red rubber
catheter with multiple side holes cut out of
the distal end across the defect.
• At end of procedure, the distal end of the
tube is pulled out a 10-mm port site (as the
port is removed), and pneumothorax is
evacuated to a primitive water seal using a
bowl of sterile water or saline.
• Laparoscopic esophagectomy
• preferable to leave a standard chest tube
 Thoracoscopy (Thoracic MIS)
• unnecessary to use positive pressure when
working in the thorax due to the bony confines of
the thorax
• disadvantages of positive pressure in the chest:
decreased venous return, mediastinal shift, and
the need to keep a firm seal at all trocar sites.
• Without positive pressure, place a double-lumen
endotracheal tube so that ipsilateral lung can be
deflated when operation starts.
• collapsing ipsilateral lung  working space within
the thorax is obtained.
• beneficial to use standard instruments via
extended port sites in conjunction with
thoracoscopic instruments.
 Extracavitary Minimally
Invasive Surgery
• Laparoscopic inguinal hernia repair: usually
performed in anterior extraperitoneal Retzius
space
• Laparoscopic nephrectomy: usually performed with
retroperitoneal laparoscopy.
• Endoscopic retroperitoneal approaches to
pancreatic necrosectomy
Extracavitary Minimally Invasive
Surgery
• Lower extremity vascular procedures and plastic
surgical endoscopic procedures: development of
working space in unconventional planes, often at
the level of the fascia/below the fascia or in
nonanatomic regions.
• insufflation of gas or balloon inflation to
develop the space, followed by low-pressure
gas insufflation or lift devices to maintain the
space.
• produce fewer and less severe adverse
physiologic consequences but insufflation of
carbon dioxide into extraperitoneal locations
can cause subcutaneous emphysema and
metabolic acidosis.
Anesthesia
• Insensible fluid losses are negligible, therefore, IV
fluid administration should not exceed that
necessary to maintain circulating volume.
• MIS procedures are often outpatient procedures,
so short-acting anesthetic agents are preferable.
• factors that require hospitalization after
laparoscopic procedures include management of
nausea, pain, and urinary retention  the
anesthesiologist should minimize the use of agents
that provoke these conditions and maximize the
use of medications that prevent such problems.
• use of nonnarcotic analgesics (e.g., ketorolac) and
the liberal use of antiemetic agents (ondansetron)
and steroids.
The Minimally Invasive Team
• require complicated and fragile equipment that
demands constant maintenance.
• multiple intraoperative adjustments to the
equipment, camera, insufflator, monitors, and
patient/surgeon position are made during these
procedures.
• A coordinated team approach is mandated to
ensure patient safety and excellent outcomes.
• hybrid procedures (laparoscopy and endoscopy):
flexible endoscopes are used to guide or provide
quality control for laparoscopic procedures; will
require a nursing staff capable of maintaining
flexible endoscopes and understanding the
operation of sophisticated technology.
The Minimally Invasive Team
• typical MIS team may consist of:
• a laparoscopic surgeon
• an operating room (OR) nurse with an interest
in laparoscopic and endoscopic surgery.
• assistants and circulating staff with an
intimate knowledge of the equipment
• having a designated laparoscopic team increases
the efficiency and safety of laparoscopic surgery,
which is translated into a benefit for the patient
and the hospital.
 Room Setup &
Minimally Invasive Suite
• Nearly all MIS incorporates a video monitor as a guide.
• Usually two images are necessary to adequately guide
operation; should be displayed on two adjacent video monitors
or projected on a single screen with a picture-in-picture effect.
• video monitor(s) should be set across the operating table from
the surgeon.
 Room Setup &
Minimally Invasive Suite
• patient should be interposed between the surgeon
and the video monitor; the operative field also lies
between the surgeon and the monitor.
• pelviscopic surgery - video monitor at patient’s
feet
• laparoscopic cholecystectomy - monitor is
placed at the 10 o’clock position (relative to
patient) while surgeon stands on patient’s left 4
o’clock position
• insufflating and patient-monitoring equipment
ideally also is placed across the table from the
surgeon so that the insufflating pressure and the
patient’s vital signs and end-tidal CO2 tension can be
monitored.
Room Setup & Minimally Invasive
Suite
• minimally invasive surgical suite
• core equipment (monitors, insufflators, and
imaging equipment) located within mobile, ceiling-
mounted consoles, the surgery team is able to
accommodate and make small adjustments rapidly
and continuously throughout the procedure.
• serves to decrease equipment and cable
disorganization, ease the movements of operative
personnel around the room, improve ergonomics,
and facilitate the use of advanced imaging
equipment such as laparoscopic ultrasound.
Patient Positioning
• Patients usually are placed in the supine
position for laparoscopic surgery.
 Patient Positioning
• operative field is the gastroesophageal junction or
the left lobe of the liver
• operate from between the legs; legs elevated
in Allen stirrups or abducted on leg boards to
achieve this position.
Patient Positioning
• Pelvic procedures
• usually is necessary to place
the legs in Allen stirrups to
gain access to the perineum.
Patient Positioning
• Nephrectomy or adrenalectomy
• lateral decubitus position with the table flexed
provides the best access to the
retroperitoneum
Patient Positioning
• laparoscopic splenectomy
• a 45° tilt of the patient provides
excellent access to the lesser sac and
the lateral peritoneal attachments to the
spleen.
Patient Positioning
• thoracoscopic surgery
• patient is placed in the lateral position with
table flexion to open the intercostal spaces
and the distance between the iliac crest and
costal margin.
 Patient Positioning
• Robotic operations
• clashing of the robotic arms with surrounding equipment or each other
can occur if not positioned correctly; once the robot is docked to the
patient the bed cannot be moved without undocking.
Patient Positioning
• When the patient’s knees are to be bent for
extended periods or the patient is going to be
placed in a reverse Trendelenburg position for
more than a few minutes, DVT prophylaxis
should be used.
• Sequential compression devices should be
placed on the lower extremities during
laparoscopic procedures to increase venous
return and provides inhibition of
thromboplastin activation.
General Principles of Access
• most natural ports of access for MIS and NOTES are the anatomic portals of entry and exit:
• nares, mouth, anus, vagina, and urethra are used to access the respiratory, GI, and urinary systems.
• Advantage: no incision is required.
• Disadvantages lie in the long distances between the orifice and the region of interest.
• For NOTES procedures, the vagina may serve as point of access, entering the abdomen via the posterior cul-de-sac
of the pelvis. Similarly, the peritoneal cavity may be reached through the side wall of the stomach or colon.
General Principles of Access
• Access to the vascular system may be
accomplished under local anesthesia by cutting
down and exposing the desired vessel, usually in
the groin.
• Increasingly, vascular access is obtained with
percutaneous techniques using a small incision, a
needle, and a guidewire, over which are passed a
variety of different-sized access devices.
• Guidewire-assisted, Seldinger-type techniques -
helpful for gaining access to the gut for procedures
such as PEG, for gaining access to the biliary system
through the liver, and for gaining access to the
upper urinary tract.
General Principles of Access
• In thoracoscopic surgery, the access technique is
similar to that used for placement of a chest tube.
• general anesthesia and single lung ventilation are
essential
• small incision is made over the top of a rib and,
under direct vision, carried down through the
pleura.
• The lung is collapsed, and a trocar is inserted
across the chest wall to allow access with a
telescope.
• Once the lung is completely collapsed, subsequent
access may be obtained with direct puncture,
viewing all entry sites through the
videoendoscope.
 Laparoscopic Access
• creation of a pneumoperitoneum requires
instruments of access (trocars) to contain valves to
maintain abdominal inflation.
• Two methods for abdominal access during
laparoscopic procedures.
Direct puncture laparoscopy
• elevation of relaxed abdominal wall with two towel
clips or a well-placed hand.
• small incision is made in umbilicus, and a specialized
spring-loaded (Veress) needle is placed in the
abdominal cavity
• With the Veress needle, two distinct pops are felt as
the surgeon passes the needle through the abdominal
wall fascia and the peritoneum.
• Umbilicus - preferred point of access because, in this
location, the abdominal wall is quite thin, even in
obese patients.
Laparoscopic Access
Direct puncture laparoscopy
• abdomen is inflated with a pressure-limited insufflator.
• CO2 gas: maximal pressures in the range of 14 to 15
mmHg.
• During process of insufflation, surgeon observes the
pressure and flow readings on the monitor to confirm an
intraperitoneal location of the Veress needle tip.
• Laparoscopic surgery can be performed under local
anesthesia, but general anesthesia is preferable.
• Under local anesthesia: N2O used as insufflating agent,
and insufflation is stopped after 2 L of gas is insufflated
or when a pressure of 10 mmHg is reached.
• After peritoneal insufflation, direct access to abdomen
is obtained with a 5- or 10-mm trocar (through a radially
dilating sheath placed over the Veress needle or an
optical viewing trocar).
Laparoscopic Access
• Optical viewing trocar: camera is placed inside of a
clear pyramidal trocar. Direct puncture entry is
observed as trocar is passed through abdominal wall;
can be used without prior insufflation; however, proper
recognition of abdominal wall layers is critical to avoid
entry into the mesentery or underlying structures
• critical issues for safe direct-puncture laparoscopy: use
of a vented stylet for the trocar, or a trocar with a safety
shield or dilating tip.
• In all direct puncture entry the trocar must be pointed
away from the sacral promontory and the great vessels.
• Patient position should be surveyed before trocar
placement to ensure a proper trajectory.
Laparoscopic Access
Direct peritoneal access (Hasson) technique
• small incision just below the umbilicus and under direct
vision locates the abdominal fascia.
• Two Kocher clamps are placed on fascia, and with curved
Mayo scissors, a small incision is made through the fascia
and underlying peritoneum.
• A finger is placed into the abdomen to make sure that
there is no adherent bowel.
• A sturdy suture is placed on each side of the fascia and
secured to the wings of a specialized trocar, which is then
passed directly into the abdominal cavity
• Rapid insufflation can make up for some of the time lost
with the initial dissection.
• preferable for the abdomen of patients who have
undergone previous operations in which small bowel may
be adherent to the undersurface of the abdominal
wound.
Laparoscopic Access
Direct peritoneal access (Hasson) technique
• recommended that the telescope be passed through a
secondary trocar to inspect the site of initial abdominal
access.
• Secondary punctures: 5- and 10-mm trocars.
• For safe access to the abdominal cavity, it is critical to
visualize all sites of trocar entry.
• At the completion of the operation, all trocars are
removed under direct vision, and the insertion sites are
inspected for bleeding.
• If bleeding occurs, direct pressure with an instrument
from another trocar site or balloon tamponade with a
Foley catheter placed through the trocar site generally
stops the bleeding within 3 to 5 minutes.
• When this is not successful, a full-thickness abdominal
wall suture has been used successfully to tamponade
trocar site bleeding.
Laparoscopic Access
• Generally, 5-mm trocars need no site suturing.
• Ten-millimeter trocars placed off the midline,
through a radially dilating sheath or above the
transverse mesocolon do not typically require
repair.
• Conversely, if the fascia has been dilated to allow
the passage of the gallbladder or other organ, it
should be repaired at the fascial level with
interrupted sutures.
• Failure to close lower abdominal trocar sites that
are 10 mm in diameter or larger can lead to an
incarcerated hernia.
 Access for Subcutaneous &
Extraperitoneal Surgery
• two methods for gaining access to
nonanatomic spaces.
Balloon dissection
• appropriate for extraperitoneal repair of
inguinal hernias and for retroperitoneal
surgery for adrenalectomy, nephrectomy,
lumbar discectomy, pancreatic necrosectomy,
or para-aortic lymph node dissection.
• similar to direct puncture laparoscopy
• Once transversalis fascia has been punctured,
a specialized trocar with a balloon on the end
is introduced  balloon is inflated in
extraperitoneal space to create a working
chamber  balloon then is deflated, and a
Hasson trocar is placed.
Access for Subcutaneous &
Extraperitoneal Surgery
• An insufflation pressure of 10 mmHg usually is
adequate to keep the extraperitoneal space open
for dissection and will limit subcutaneous
emphysema.
• Higher gas pressures force CO2 into the soft tissues
and may contribute to hypercarbia.
• Extraperitoneal endosurgery provides less working
space than laparoscopy but eliminates the
possibility of intestinal injury, intestinal adhesion,
herniation at the trocar sites, and ileus.
• These issues are important for laparoscopic hernia
repair because extraperitoneal approaches prevent
the small bowel from sticking to the prosthetic
mesh.
 Access for Subcutaneous &
Extraperitoneal Surgery
Subcutaneous access
• most widely used in cardiac, vascular, and plastic surgery.
• In cardiac surgery: saphenous vein harvesting, and in
vascular surgery for ligation of subfascial perforating veins
(Linton procedure).
• entire saphenous vein above the knee may be harvested
through a single incision
• saphenous vein is located, a long retractor that holds a 5-mm
laparoscope allows coaxial dissection of the vein and
coagulation or clipping of each side branch. A small incision
above the knee used to ligate perforating veins in lower leg.
• In cosmetic surgery: hide several 5-mm incisions than one
long incision.
• technique of blunt dissection along fascial planes combined
with lighted retractors and endoscope-holding retractors is
most successful for extensive subcutaneous surgery.
• Some prefer gas insufflation of these soft tissue planes, but
subcutaneous emphysema can be created.
Hand-Assisted Laparoscopic Access
Hand-assisted laparoscopic surgery
• combine the tactile advantages of open surgery with the
minimal access of laparoscopy and thoracoscopy
• commonly is used to assist with difficult cases before
• Also used to help surgeons negotiate the steep learning
curve associated with advanced laparoscopic procedures.
• This technology uses an entryway for the hand that
preserves the pneumoperitoneum and enables
laparoscopic visualization in combination with the use of
minimally invasive instruments
• Common in solid organ and colon surgery.
Robotic Surgery
• Intraperitoneal, intrathoracic, and retroperitoneal access
for robotic surgery adheres to the principles of
laparoscopic and thoracoscopic access; however, the port
size for primary puncture is 12 mm to allow placement of
the stereo laparoscope. Remaining trocars are 8 mm.
Natural Orifice Transluminal
Endoscopic Surgery Access
• Transvaginal, transvesicle, transanal, transcolonic,
transgastric, and transoral approaches
• ease of decontamination, entry, and closure of
these structures
• Transvaginal approach for resection of the uterus
• Extraction of gallbladder, kidney, bladder,
large bowel, and stomach can be performed
via the vagina.
• Esophagus can be traversed to enter the
mediastinum
• Leaving the orifice or organ of entry with an
endoscope requires the use of an endoscopic
needle knife followed by submucosal tunneling or
direct puncture and balloon dilation
• Closure has been performed using endoscopic clips
or sutures with advanced endoscopic platforms.
Single-Incision Laparoscopic Surgery
Access
• Traditionally, a single skin incision is made directly
through the umbilical scar ranging from 1 to 3 cm.
• Through this single incision, multiple low- profile
trocars can be placed separately into the fascia to
allow insufflation, camera, and working
instruments.
• Advantage: conventional laparoscopic tools
can be employed.
• Disadvantage becomes apparent when an
extraction site is needed.
• Specialized multilumen trocars
• Advantages: faster access, improved safety,
minimization of air leaks, and platform-
derived instrument triangulation.
• Disadvantage: cost
 Port Placement
• Trocars for the surgeon’s left and right hand should be
placed at least 10 cm apart.
• Ideal trocar orientation: creates an equilateral triangle
between the surgeon’s right hand, left hand, and the
telescope, with 10 to 15 cm on each leg.
• If one imagines the target of the operation oriented at
the apex of a second equilateral triangle built on the
first, these four points of reference create a diamond
• surgeon stands behind the telescope, which provides
optimal ergonomic orientation but frequently requires
that a camera operator reach between the surgeon’s
hands to guide the telescope.
 Port Placement
• SILS is challenging because it violates most of the
aforementioned ergonomic principles.
• surgeon must often work in a crossed hands
fashion
• axis of camera view is often in line with working
instruments, making visualization difficult
without a deflectable tip laparoscope.
• The position of the operating table should permit the
surgeon to work with both elbows in at the sides, with
arms bent 90° at the elbow.
 Imaging Systems
• Two methods of videoendoscopic imaging
• Both use a camera with a charge-coupled device (CCD),
which is an array of photosensitive sensor elements (pixels)
that convert incoming light intensity to an electric charge 
converted into a color image.
• With videoendoscopy, the CCD chip is placed on the
internal end of a long, flexible endoscope.
• older flexible endoscopes: thin quartz fibers are packed
together in a bundle, and the CCD camera is mounted on
the external end of the endoscope.
• Most standard GI endoscopes have the CCD chip at the
distal end, but small, delicate choledochoscopes and
nephroscopes are equipped with fiber-optic bundles.
• Digital enhancement detects edges, areas where there are
drastic color or light changes between two adjacent pixels.
By enhancing this difference, the image appears sharper
and surgical resolution is improved.
• laparoscopic cameras contain high-definition (HD) chip,
increasing the lines of resolution from 480 to 1080 lines.
• HD monitors also are necessary.
 Imaging Systems
• Priorities in a video imaging system for MIS:
• illumination first, resolution second, and color third.
• Illumination and resolution are as dependent on the
telescope, light source, and light cable as on the video
camera used.
• Imaging for laparoscopy, thoracoscopy, and subcutaneous
surgery uses a rigid metal telescope (~30 cm in length).
• Longer telescopes: for obese patients and for reaching
mediastinum and deep in the pelvis from a periumbilical
entry site.
• standard telescope contains a series of quartz optical rods
and focusing lenses.
• Telescopes vary in size from 2 to 12 mm in diameter.
• Little illumination is needed in highly reflective, small
spaces (ie. knee), and a very small telescope will suffice.
• When working in the abdominal cavity, especially if blood
is present, the full illumination of a 10-mm telescope
usually is necessary.
Imaging Systems
Rigid telescopes may have a flat or angled end.
• Flat end provides a straight view (0°)
• Angled end provides an oblique view (30° or 45°)
• allow greater flexibility in viewing a wider operative
field through a single trocar site, rotating an angled
telescope changes the field of view.
• advantages for most videoendoscopic procedures,
particularly in visualizing the common bile duct
during laparoscopic cholecystectomy or visualizing
the posterior esophagus or the tip of the spleen
during laparoscopic fundoplication.
• Flexible tip laparoscopes offer even greater optical
freedom.
• Light is delivered to the endoscope through a fiber-optic
light cable.
• light cables are highly inefficient, losing >90% of the light
delivered from the light source. Extremely bright light
sources (300 watts) are necessary to provide adequate
illumination for laparoscopic surgery.
 Imaging Systems
• important to use a video monitor that has a resolution equal to
or greater than the camera being used.
• Resolution is the ability of the optical system to distinguish
between line pairs. The larger the number of line pairs per
millimeter, the sharper and more detailed the image.
• Most high-resolution monitors have up to 700 horizontal lines.
• HD television can deliver up to eight times more resolution than
standard monitors; when combined with digital enhancement, a
very sharp and well-defined image can be achieved.
• A heads-up display is a high-resolution liquid crystal monitor
that is built into eyewear worn by the surgeon.
• allows the surgeon to view the endoscopic image and
operative field simultaneously.
• Advantages: high-resolution monocular image, which
affords the surgeon mobility and reduces vertigo and
eyestrain.
 Imaging Systems
3-D laparoscopy
• provides additional depth of field that is lost with two-
dimensional endosurgery and improves performance
of novice laparoscopists performing complex tasks of
dexterity, including suturing and knot tying.
• require the flickering of two similar images, which are
resolved with special glasses, the images’ edges
become fuzzy and resolution is lost.
The da Vinci robot
• uses a specialized laparoscope with two optical
bundles on opposite sides of the telescope.
• specialized binocular eyepiece receives input from two
CCD chips, each capturing the image from one of the
two quartz rod lens systems, thereby creating true 3-D
imaging without needing to employ active or passive
technologies
Imaging Systems
Single-incision laparoscopy
• presents challenges to visualization of the
operative field.
• bulky scope handle creates crowding in an already
limited space.
• an adequate perspective is often unobtainable
even with a 30° scope.
• The advent of increased length laparoscopes with
lighting coming from the end and a deflectable tip
now allows the surgeon to recreate a sense of
internal triangulation with little compromise
externally.
• ability to move the shaft of the scope off line while
maintaining the same image provides a greater
degree of freedom for the working ports.
Energy Sources for Endoscopic and
Endoluminal Surgery
• most common energy source is RF electrosurgery
using an alternating current with a frequency of
500,000 cycles/s (Hz).
• Tissue heating progresses through the well-
known phases of coagulation (60°C [140°F]),
vaporization and desiccation (100°C [212°F]),
and carbonization (>200°C [392°F]).
• two most common methods of delivering RF
electrosurgery: monopolar and bipolar electrodes.
Energy Sources for Endoscopic
and Endoluminal Surgery
Monopolar electrosurgery
• a remote ground plate on patient’s leg or back
receives the flow of electrons that originate at
a point source, the surgical electrode.
• A fine-tipped electrode causes a high current
density at the site of application and rapid
tissue heating.
• is inexpensive and easy to modulate to
achieve different tissue effects
• Coagulation current - short-duration, high-voltage
discharge of current provides extremely rapid
tissue heating.
• Cutting current - lower-voltage, higher-wattage
current is better for tissue desiccation and
vaporization.
• tissue division with the least amount of
thermal injury and least coagulation necrosis
Energy Sources for Endoscopic and
Endoluminal Surgery
Bipolar electrosurgery
• electrons flow between two adjacent electrodes.
• tissue between the two electrodes is heated and
desiccated.
• ability to coapt the electrodes across a vessel
provides the best method of small-vessel
coagulation without thermal injury to adjacent
tissues.
• use bipolar energy and combined it with
compressive force and a controllable blade to
create a number of highly functional dissection and
vessel-sealing tools.
 Energy Sources for Endoscopic and
Endoluminal Surgery
• To avoid thermal injury to adjacent structures,
the laparoscopic field of view must include all
uninsulated portions of the electrosurgical
electrode.
• the integrity of the insulation must be
maintained and assured.
• Capacitive coupling occurs when a plastic
trocar insulates the abdominal wall from the
current; in turn, the current is bled off of a
metal sleeve or laparoscope into the viscera 
thermal necrosis and a delayed fecal fistula.
• unrecognized visceral injury may occur with the
direct coupling of current to the laparoscope
and adjacent bowel
Energy Sources for Endoscopic and
Endoluminal Surgery
Argon beam coagulation
• Another method of delivering RF electrosurgery
• type of monopolar electrosurgery in which a
uniform field of electrons is distributed across a
tissue surface by the use of a jet of argon gas which
distributes electrons more evenly across the
surface than does spray electrofulguration.
• greatest application for coagulation of diffusely
bleeding surfaces such as the cut edge of liver or
spleen.
• It is of less value in laparoscopic procedures
because the increased intra-abdominal pressures
created by the argon gas jet can increase the
chances of a gas embolus.
• It is paramount to vent the ports and closely
monitor insufflation pressure when using this
source of energy within the context of laparoscopy.
 Energy Sources for Endoscopic and
Endoluminal Surgery
• With endoscopic endoluminal surgery, RF
alternating current in the form of a monopolar
circuit represents the mainstay for procedures
such as snare polypectomy, sphincterotomy,
lower esophageal sphincter ablation, and
biopsy.
• A grounding (return) electrode is necessary
for this form of energy.
• Bipolar electrocoagulation is used primarily
for thermal hemostasis.
• The electrosurgical generator is activated by a
foot pedal so the endoscopist may keep both
hands free during the endoscopic procedure.
 Energy Sources for Endoscopic
and Endoluminal Surgery
CO2 laser
• wavelength 10.6 μm
• most appropriately used for cutting and
superficial ablation of tissues.
• most helpful in locations unreachable
with a scalpel such as excision of vocal
cord granulomas.
 Energy Sources for Endoscopic and
Endoluminal Surgery
Neodymium yttrium-aluminum garnet (Nd:YAG)
laser
• 1.064 μm (1064 nm) in wavelength.
• in the near-infrared portion of the spectrum and is
invisible to the naked eye.
• poorly absorbed by most tissue pigments and
therefore travels deep into tissue  deep tissue
heating  capable of the greatest amount of tissue
destruction with a single application.
• ideal laser for destruction of large fungating
tumors of the rectosigmoid, tracheobronchial tree,
or esophagus.
• Disadvantage: deep tissue heating may cause
perforation of a hollow viscus.
Energy Sources for Endoscopic and
Endoluminal Surgery
KTP laser (potassium thionyl phosphate crysta)
• frequency-doubled Nd:YAG laser provides 532-nm
light.
• in the green portion of the spectrum
• selective absorption by red pigments in tissue
(such as hemangiomas and arteriovenous
malformations) is optimal.
• The depth of tissue heating is intermediate,
between those of the CO2 and the Nd:YAG lasers.
• Coagulation (without vaporization) of superficial
vascular lesions can be obtained without intestinal
perforation.
Energy Sources for Endoscopic and
Endoluminal Surgery
Heater probe
• In flexible GI endoscopy, the CO2 and Nd:YAG lasers have
largely been replaced by heater probes and endoluminal
stents.
• is a metal ball that is heated to a temperature (60–100°C
[140°–212°F]) that allows coagulation of bleeding lesions
without perforation.
Photodynamic therapy
• palliative treatment for obstructing cancers of the GI tract.
• Patients given an IV dose of porfimer sodium, which is a
photosensitizing agent that is taken up by malignant cells.
• Two days after administration, the drug is endoscopically
activated using a laser.
• The activated porfimer sodium generates oxygen free
radicals, which kill the tumor cells  tumor later
endoscopically debrided.
Energy Sources for Endoscopic and
Endoluminal Surgery
High-energy lasers: Pulse dye laser
• extremely rapid discharge (<10–6 s) of large amounts of
energy (>103 volts).
• allow the conversion of light energy to mechanical
disruptive energy in the form of a shock wave.
• delivered through a quartz fiber, and with rapid repetitive
discharges, can provide sufficient shock-wave energy to
fragment kidney stones and gallstones.
Shock waves
• may be created with miniature electric spark-plug
discharge systems known as electrohydraulic
lithotripters, inserted through thin probes for endoscopic
application.
• Lasers have the advantage of pigment selectivity, but
electrohydraulic lithotriptors are more popular because
they are substantially less expensive and are more
compact.
Energy Sources for Endoscopic and
Endoluminal Surgery
Extracorporeal shockwave lithotripsy
• creates focused shock waves that intensify as the focal point of
the discharge is approached.
• When focal point is within the body, large amounts of energy are
capable of fragmenting stones.
• can be used to provide noninvasive focused internal heating of
tissues to destroy tissue without an incision.
Laparoscopic coagulation shears device (Harmonic Scalpel)
• ultrasonic energy is to create rapidly oscillating instruments that
are capable of heating tissue with friction  coagulating and
dividing blood vessels by first occluding them and then providing
sufficient heat to weld blood vessel walls together and to divide
the vessel
• nonelectric method of coagulating and dividing tissue with a
minimal amount of collateral damage.
• useful in the control of bleeding from medium-sized vessels that
are too big to manage with monopolar electrocautery.
 Instrumentation
• Hand instruments for MIS:
• duplications of conventional surgical instruments
made longer, thinner, and smaller at the tip.
• when grasping tissue with laparoscopic instruments,
a greater force is applied over a smaller surface
area, which increases the risk for perforation or
injury.
• Certain instruments such as scissors are easy to
reproduce with a diameter of 3 to 5 mm and a
length of 20 to 45 cm, but other instruments such as
forceps and clamps cannot provide remote access.
• Standard hand instruments are 5 mm in diameter
and 30 cm in length
• Smaller and shorter hand instruments are now
available for pediatric surgery, for microlaparoscopic
surgery, and for arthroscopic procedures.
 Instrumentation
• Unique laparoscopic hand
instrument: monopolar electrical
hook
• usually is configured with a
suction and irrigation apparatus to
eliminate smoke and blood from
the operative field.
• allows tenting of tissue over a bare
metal wire with subsequent
coagulation and division of the
tissue.
 Instrumentation
• Instrumentation for NOTES:
• long micrograspers, microscissors, electrocautery
adapters, suturing devices, clip appliers, and visceral
closure devices - often require an entirely different
endoscopic platform.
• Instrumentation for SILS:
• seeks to restore surgeon’s ability to triangulate the
left and right hands through variation in length,
mechanical articulation, or curved design.
• a lower profile camera head helps reduce the
instrument crowding that occurs at the single point
of abdominal entry.
Robotic Surgery
• computer-enhanced surgical devices are controlled
entirely by the surgeon for the purpose of improving
performance.
• first computer-assisted surgical device was the
laparoscopic camera holder (Aesop, Computer Motion,
Goleta, CA), which enabled surgeon to maneuver the
laparoscope either with a hand control, foot control, or
voice activation.
• demonstrated a reduction in operative time, steadier
image, and a reduction in the number of required
laparoscope cleanings
• advantage of eliminating the need for a human
camera holder, which served to free valuable OR
personnel for other duties.
• improved manual dexterity by developing an
ergonomically comfortable work station, with 3-D imaging,
tremor elimination, and scaling of movement (e.g., large,
gross hand movements can be scaled down to allow
suturing with microsurgical precision)
Robotic Surgery
• second surgical console: surgeon is
physically separated from the operating
table, and the working arms of the
device are placed over the patient.
• An assistant remains at the bedside and
changes the instruments as needed,
providing retraction as needed to
facilitate the procedure.
• Studies: operative time was longer for
robotic surgery, and there was no
difference in ultimate outcome
• Almost any procedure performed
laparoscopically has been attempted
robotically, although true advantage is
demonstrated only very sparingly.
• Increased cost and operative time
challenge the notion of “better.”
Robotic Surgery
• minimally invasive urologists declared robotic prostatectomy to be preferable to laparoscopic and open
prostatectomy. The advantage of robotic prostatectomy is the ability to visualize and spare pelvic nerves
responsible for erectile function.
• the creation of the neocystourethrotomy, following prostatectomy, was greatly facilitated by needle
holders and graspers with a wrist in them.
• Female pelvic surgery with the da Vinci robot - magnified imaging ideal for microsurgical tasks such as
reanastomosis of the Fallopian tubes.
• Revisional bariatric surgery and complex abdominal wall reconstruction
• The final frontier for computer-enhanced surgery is telesurgery, in which the surgeon is a great distance from
the patient (e.g., combat or space).
• This application has rarely been used, as the safety provided by having the surgeon at bedside cannot
be sacrificed to prove the concept.
Endoluminal and Endovascular
Surgery
• clinical scenarios that require the urgent
restoration of luminal patency.
• involve the use of access devices, catheters,
guidewires, balloon dilators, stents, and other
devices (e.g., lasers, atherectomy catheters) that
are capable of opening up the occluded biologic
cylinder.
• Endoluminal balloon dilators may be inserted
through an endoscope, or they may be
fluoroscopically guided.
• Balloon dilators all have low compliance: balloons
do not stretch as the pressure within the balloon is
increased.
 Endoluminal and Endovascular
Surgery
• Once the dilation has been attained, it is
frequently beneficial to hold the lumen open
with a stent.
• Stenting
• treating malignant lesions and
atherosclerotic occlusions or aneurysmal
disease
• to seal leaky cylinders, including aortic
dissections, traumatic vascular injuries,
leaking GI anastomoses, and fistulas.
• not applicable for long-term management
of benign GI strictures except in patients
with limited life expectancy
 Endoluminal and Endovascular
Surgery
• Stents are divided into six basic categories:
• Plastic stents - came first and widely as endoprostheses for temporary
bypass of obstructions in the biliary or urinary systems.
• Metal stents - delivered over a balloon and expanded with the balloon
to the desired size; made of titanium or nitinol; still used in coronary
stenting.
• Drug-eluting stents - chemotherapeutic agent added to coronary stents
to decrease endothelial proliferation & fibrovascular hyperplasia;
provide greater long-term patency but require long-term
anticoagulation with antiplatelet agents to prevent thrombosis.
• Coated metal stents - used to prevent tissue ingrowth. Ingrowth may be
an advantage in preventing stent migration, but such tissue ingrowth
may occlude the lumen and cause obstruction anew.
• Covered metal stents - filling interstices with Silastic or other materials
to prevent tumor ingrowth but makes stent migration more likely.
• Anchored stent grafts - to minimize stent migration, stents have been
incorporated with hooks and barbs at the proximal end of the stent to
anchor it to the wall of the vessel.
• Self-expanding plastic stents - temporary devices to be used in the GI
tract to close internal fistulas and bridge leaking anastomoses.
Natural Orifice Transluminal
Endoscopic Surgery
• catalyzing events for NOTES: demonstration that a
porcine gallbladder could be removed with a flexible
endoscope passed through the wall of the stomach and
removed through the mouth; and the demonstration in
a series of 10 human cases from India of the ability to
perform transgastric appendectomy.
• Systemic inflammatory markers such as C-reactive
protein, tumor necrosis factor-α, interleukin (IL)-1β, and
IL-6 have been shown to be similar in transgastric and
transcolonic NOTES when compared to laparoscopy in
porcine models
Transvaginal and transgastric removal of the gallbladder
• To ensure safety, all human cases thus far have involved
laparoscopic assistance to aid in retraction and ensure
adequate closure of the stomach or vagina.
Natural Orifice Transluminal
Endoscopic Surgery
Peroral esophageal myotomy (POEM)
• NOTES treatment for esophageal achalasia.
• 1.5- to 2-cm mucosotomy is created within anterior
esophagus 10 cm proximal to the gastroesophageal
junction.
• submucosal tunnel is created using a combination of
electrocautery, hydrodissection, CO2 insufflation.
• scope is advanced beyond gastroesophageal junction, and
a circular myotomy is performed avoiding disruption of
the longitudinal fibers.
• mucosotomy is then closed using endoscopic clips
• avoids abdominal trauma and minimally disrupts normal
anatomic characteristics of the gastroesophageal junction
while providing significant relief of symptoms.
• NOTES procedures - associated with an increased mental
workload and significant learning curve for even
experienced surgical endoscopists.
Single-Incision Laparoscopic Surgery
• An incision in the umbilicus, a preexisting scar, is
thought to be less painful, have fewer wound
complications, lead to quicker return to activity,
and have a better cosmetic appearance than
conventional laparoscopy.
• one of the earliest examples of SILS: laparoscopic
instrumentation to resect lesions in the rectum or
sigmoid colon.
• Using the anus as the portal of entry, transanal
endoscopic microsurgery (TEMS) employs a
specialized multichannel trocar to reach lesions
located 8 to 18 cm away from the anal verge.
• More deformable versions of these complex
trocars have been developed with features to allow
insufflation and be amenable to maintaining a seal
within the natural orifice of the umbilicus
• Ports typically contain three or four channels.
Single-Incision Laparoscopic Surgery
• Challenges: crowded trocar placement, a lack of
triangulation of left- and right-hand instruments,
frequent crossing or clashing of instruments,
limited visualization, and limited retraction ability.
• development of specialized instruments:
Articulating or curved instruments of varying
lengths and an extended length can improve
working space.
• innovative strategies to retract structures away
from the operative field: use of percutaneous
needlescopic instruments to the application of
transfascial sutures.
Single-Incision Laparoscopic Surgery
 Single-Incision Laparoscopic Surgery
• When performing SILS procedures, it is imperative to follow proven tenets of operative conduct such as visualizing the
“critical view” of safety in a laparoscopic cholecystectomy.
• As safety should always be the paramount concern, the addition of extra trocars or conversion to traditional laparoscopy
should not be considered a failure.
Single-Incision Laparoscopic Surgery
• Contraindications include those true of traditional
laparoscopy.
• Relative contraindications include previous surgery
and high body mass index (BMI).
• high BMI or central obesity can pose a
challenge because the umbilicus may be
located far from operative target.
• equivalency to standard laparoscopic procedures
regarding intraoperative and postoperative
complications.
• Study: conversion rate from SILS to conventional
laparoscopy to be 0% to 24% for cholecystectomies,
0% to 41% for appendectomies, and 0% to 33% for
nephrectomies.
• The most common complications were
intrabdominal abscesses and wound infections.
Special Considerations
Pediatric Laparoscopy
• MIS in the adolescent is little different from that in
the adult, and standard instrumentation and trocar
positions usually can be used.
• laparoscopy in the infant and young child requires
specialized instrumentation.
• instruments are shorter (15–20 cm), and are 3
mm in diameter rather than 5 mm.
• a 5-mm telescope, 5-mm clippers and bipolar
devices
• abdominal wall is much thinner in infants:
pneumoperitoneum pressure of 8 mmHg
• DVT is rare in children, so prophylaxis against
thrombosis probably is unnecessary.
• Common pediatric surgical procedures performed
with MIS access: pullthrough procedures for
colonic aganglionosis (Hirschsprung’s disease),
repair of congenital diaphragmatic hernias
Laparoscopy during Pregnancy
• Access to the abdomen in the pregnant patient:
height of the uterine fundus reaches the umbilicus
at 20 weeks.
• to damage the uterus or its blood supply: do open
(Hasson) approach
• patient positioned slightly on left side to avoid
compression of the vena cava by the uterus.
• pregnancy poses a risk for thromboembolism:
sequential compression devices are essential
• Fetal acidosis induced by maternal hypercarbia is a
concern
• arterial pH of fetus follows the pH of the
mother
• prevented by avoiding a respiratory acidosis in
the mother.
Laparoscopy during Pregnancy
• pneumoperitoneum pressure induced by
laparoscopy is not a safety issue: mid-pregnancy
uterine contractions provide a much greater
pressure in utero than a pneumoperitoneum of 15
mmHg.
• laparoscopic cholecystectomy in pregnancy:
• should be performed during the second
trimester of pregnancy if possible.
• Protection of the fetus against intraoperative
X-rays is imperative.
• heart rate decelerations reversibly associated with
pneumoperitoneum creation might signal the need
to convert to open cholecystectomy or
appendectomy.
MIS techniques & Cancer Treatment
• used to provide palliation for the patient with an
• safe curative treatment of cancer is no different
obstructive cancer:
from the principles of open surgery.
• Laser treatment, intracavitary radiation,
stenting, and dilation are outpatient • All gross and microscopic tumor are removed (an
techniques to reestablish the continuity of an R0 resection), and an adequate lymphadenectomy
obstructed esophagus, bile duct, ureter, or performed to allow accurate staging.
airway. • Generally 10 to 15 lymph nodes
• also used in the staging of cancer. • major abdominal cancer operations performed
• Mediastinoscopy before thoracotomy to with laparoscopy
assess status of mediastinal lymph nodes. • Common resections of GI cancer: liver lobe,
• Laparoscopy to assess the liver in patients pancreatic head, and esophagus
being evaluated for pancreatic, gastric, or • Laparoscopic hepatectomy, distal pancreatectomy,
hepatic resection. laparoscopic-assisted gastrectomy
• appropriate to perform palliative measures at time • most common cancer operation performed
of diagnostic laparoscopy if diagnostic findings laparoscopically is segmental colectomy
preclude attempts at curative resection.
• laparoscopic gastrojejunostomy to bypass a
pancreatic cancer
Considerations in the Elderly and
Infirm
• Laparoscopic cholecystectomy - possible removal of a symptomatic gallbladder in many patients
previously thought to be too elderly or too ill to undergo a laparotomy.
• Older patients are more likely to require conversion to laparotomy because of disease chronicity.
• require close monitoring of anesthesia.
• intraoperative management may be more difficult BUT the advantage of MIS lies in what happens after
the operation.
• Much of the morbidity of surgery in the elderly is a result of impaired mobility.
• pulmonary complications, urinary tract sepsis, DVT, pulmonary embolism, congestive heart failure,
and myocardial infarction often are the result of improper fluid management and decreased
mobility.
• By allowing rapid and early mobilization, laparoscopic surgery has made possible the safe performance
of procedures in the elderly and infirm.
 Cirrhosis and Portal Hypertension
• hepatic insufficiency - patients has minimal reserve, stress of an operation will trigger complete
hepatic failure or hepatorenal syndrome.
• at risk for major hemorrhage at all levels: trocar insertion, operative dissection in a field of
dilated veins, and secondary to an underlying coagulopathy.
• ascitic leak from a port site may occur  bacterial peritonitis. Therefore, a watertight port site
closure should be carried out in all patients.
• severity of hepatic cirrhosis by a Model of End-Stage Liver Disease (MELD) score or Child’s
classification.
• presence of portal hypertension is a relative contraindication to laparoscopic surgery until
portal pressures are reduced with portal decompression.
• insufflation pressures should be reduced to prevent a decrease in cardiac output, and minimal
amounts of Na+-sparing IV fluids should be given, because these patients commonly are
intravascularly depleted
Economic of Minimally Invasive
Surgery
• Minimally invasive surgical procedures reduce the costs of surgery most when
length of hospital stay can be shortened and return to work is quickened.
• shorter hospital stays seen in laparoscopic cholecystectomy, Nissen
fundoplication, splenectomy, and adrenalectomy.
• Procedures such as inguinal herniorrhaphy that are already performed as
outpatient procedures are less likely to provide cost savings.
• Procedures that still require a 4- to 7-day hospitalization, such as laparoscopy-
assisted colectomy
• with responsible use of disposable instrumentation and a commitment to the
most effective use of the inpatient setting, most laparoscopic procedures can be
made less expensive than their conventional equivalents.
Education and Skill Acquisition
• Skills labs started at nearly every surgical training
center in the 1990s with low fidelity box-type
trainers.
• rudimentary simulated abdominal cavities
with a video camera, monitor, trocars,
laparoscopic instruments, and target models.
• pegboard and rubber rings, or a latex drain to
practice suturing and knot tying.
• Virtual reality training devices - improve and
enhance experiential learning in endoscopy and
laparoscopy
• advantage of enabling objective measurement
of psychomotor skills, which can be used to
determine progress in skill acquisition and,
ultimately, technical competency.
Telementoring
Teleconsultation or telementoring
• is a two-way audio and visual communication
between two geographically separated providers.
• communication can take place in the office setting
or directly in the OR when complex scenarios are
encountered.
Innovation and Introduction of New
Procedures
• The revolution in minimally invasive general surgery, which occurred in 1990, created
ethical challenges for the profession.
• Once the opportunity has been established, the next step involves a search through
other disciplines for technologies and techniques that might be applied
• The third step is in vivo studies in the most appropriate animal model.
• “Preclinical phase of procedure development”
• The procedure should be reproducible, provide the desired effect, and not have serious
side effects  human application  institutional support: involvement of the medical
board, the chief of the medical staff, and the institutional review board
Innovation and Introduction of New
Procedures
• PHASE I of procedure development: operative team: surgeon experienced with the
old technique, and assistants who have participated in the earlier animal work  full
competence with the procedure is attained (10-50 procedures).
• PHASE II: the efficacy of the procedure is tested in a nonrandomized fashion. Ideally,
the outcome of new techniques must be as good as or better than the procedure that
is being replaced.
• PHASE III: a randomized trial pits the new procedure against the old  competence
curve
• The second stage of learning occurs when the new procedure has proven its value
and a handful of experts exist, but the majority of surgeons have not been trained to
perform the new procedure: the experts should provide feedback to the learners as
to whether they feel the learners are equipped to forge ahead on their own.
Thank you!!