Minimally Invasive Surgery

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Minimally Invasive Surgery

• Juan Cendan
• Medical Student Lecture

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Background

• Cystoscopes early 1800s
• Laparoscopy early 20th century
• Laparoscope with video camera 1980s
• 1985 first lap chole (France)

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Physiology

• Increased intra-abdominal pressure
• Effects (similar to intra-abdominal compartment
  syndrome)
• Ventilation
• Decreases venous return
• Reduces renal perfusion
• Increases intracranial pressure
• Balance between cardiac function and volume
  status

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Physiology - Exposure

• Gas used is CO2
• Can be a problem for patients with COPD
• Alternates helium, air, NO, gasless
• Patient position
• Pressure points
• Obesity
• Securing patient

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Benefits

• Decreased pain
• Attenuated stress response
• Early return to ambulation

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Pulmonary Effects
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Circulatory Effects
?
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General Complications of Laparoscopy

• Injury to adjacent organs
• Bleeding solid organs
• Vascular injuries
• Bowel injury (puncture, cautery)
• Bladder/uterus injury
• Access site complications
• Port site hernia
• Wound infection

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Trocars
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General Complications, cont

• Specimen removal
• Port site cancer
• Splenosis
• Endometriosis
• Pneumoperitoneum
• Pneumothorax
• Pneumomediastinum
• Gas embolus
• Subcutaneous emphysema

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Specific cases

• Major vascular injury
• Rare 0.02 - 0.3 incidence but 15 mortality
• R Common Iliac is most common injury due to
  location beneath umbilicus
• Open vs Veress technique

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Specific operations

• Cholecystectomy
• Indications are same
• Technical concerns
• Bile duct injury
• 0.36
• 0.21 with cholangiogram
• 0.43 without
• Bile duct exploration
• Role of ERCP
• IO BDE

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Lap Chole
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Delivering the gallbladder
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Inguinal hernia
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Traditional inguinal approach with mesh
(Lichtenstein procedure)
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The view from behind the abdominal wall
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Inguinal Hernia
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Appendicitis
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Appendix locations benefit of laparoscopy
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Dissection of the mesoappendix
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Dividing the appendix
Looped
Stapled
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Nissen step-by-step

Step 1 The operating surgeon stands between the
patients legs while the camera operator stands
to the patients right and the second assistant
assumes a position on the patients left. Step
2 Circumferential blunt dissection of the
esophagus at the level of the hiatus will allow
for the anterior retraction of the esophagus
with the left hand dissector, allowing for
further posterior dissection of the esophagus.
The posterior window is then identified with
careful blunt dissection posterior to the
esophagus just anterior and lateral to the left
crus.
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Nissen step-by-step

• Step 3 A space just superior to the free edge
  of the left crus is dissected free to allow for
  closure of the hiatus. This space is often
  referred to as the cave.(Reprinted from Ferguson
  MK Atlas of Esophageal Surgery, in Digestive
  Tract Surgery A Text and Atlas, Bell RH et al,
  eds, 1996, Philadelphia, Lippincott William
  Wilkins, p 137, with permission.)
• Step 4 After the crura have been adequately
  identified and dissected free for a distance of 2
  to 3 centimeters, the hiatus is closed using from
  1 to 4 2-0 Prolene sutures.
• Step 5 Using the harmonic scalpel, the short
  gastric vessels are divided to mobilize the
  fundus. (Reprinted from Townsend et al Hiatal
  hernia and gastroesophageal reflux disease, in
  Sabiston Textbook of Surgery The Biological
  Basis of Modern Surgical Practice, 16th Edition,
  2000, Philadelphia, Saunders, p 761, with
  permission

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Nissen step-by-step

• Step 6 Graspers are used to identify a point on
  the fundus approximately 15 cm distal to the
  Angle of His. This point is then placed into the
  open Babcock clamp and slowly pulled behind the
  esophagus through the window.
• Step 7 The shoe-shine maneuver is used to ensure
  that the fundus slides freely posterior to the
  esophagus and is of appropriate length.
• Step 8 The wrap is sutured into place using a
  single U-stitch of 2-0 Prolene buttressed with
  Teflon pledgets tied in an extracorporeal manner.
  A 50-56 Fr Maloney bougie may be introduced prior
  to sizing the wrap and is removed before placing
  the sutures.
• Step 9 A 3-0 silk suture is used to further
  secure the wrap and is most easily tied
  intracorporeally.

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Reflux surgery
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Conclusions

• Laparoscopy is a TOOL
• Used properly allows us to do many operations
  that were once done open
• General Consensus is that return to activity is
  improved as is abdominal wall wounding
• Trade off is visualization and degree of surgeon
  comfort with exposure and instrumentation
• Risk/benefit should always favor opening if
  safety is enhanced