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What is MIS? A minimally invasive medical procedure is defined as one that is carried out by entering the body through the skin or through a body cavity or anatomical opening, but with the smallest damage possible to these structuresIncludes laparoscopic, endoscopic, and other approaches. Why MIS? Decreased patient pain Decreased patient recovery period Possible decrease in inflammatory response in the patient which may prove to have a better outcome in oncologic operations. Distant future In the distant future, there will be a para- digm shift with the development of non-inva- sive surgical techniques in combination with nanotechnologies and a new era in the devel- opment of surgery, and subsequently in surgi- cal techniques, will be opened. Nanotechnology is an umbrella term for materials and devices that operate at the nanoskill (1 billionth of a meter). In terms of scale, a nanometer is approximately one 1/8000 of a human hair or 10 times the diam- eter of a hydrogen atom. The size of the device can vary but starts from a ten thou- sand-logic element system that will occupy a cube of no more than one hundred nanome- ters. This is a volume slightly larger than 0.001 cubic microns. This would be sufficient to hold a small computer. For example, if red blood cells are approximately eight microns in diameter, the 100 nanomicroprocessor will be 80 times smaller than a red blood cell. Devices this size could easily fit into the circulatory system and could even conceivably enter indi- vidual cells.
Citation preview
Laparoscopy: History, Laparoscopy: History,
Present and Emerging Present and Emerging
TrendsTrends
Dr. Sreejoy PatnaikDr. Sreejoy Patnaik
History of LaparoscopyHistory of Laparoscopy
A three bladed speculum was found in the ruins A three bladed speculum was found in the ruins
of Pompeii*. of Pompeii*.
*A *A roman town buried by a volcano eruption roman town buried by a volcano eruption
near modern Naples, Italy - 79 AD).near modern Naples, Italy - 79 AD).
The first description dates to Hippocrates in The first description dates to Hippocrates in Greece, for use of a speculum to visualize Greece, for use of a speculum to visualize the rectum (460–375 BC).the rectum (460–375 BC).
History of LaparoscopyHistory of Laparoscopy
1806: Philip Bozzini developed an 1806: Philip Bozzini developed an
instrument called a instrument called a LichtleiterLichtleiter
(light-guiding instrument)(light-guiding instrument)
1853: Antoine Jean Desormeaux 1853: Antoine Jean Desormeaux
used Bozziniused Bozzini’’s Lichtleiters Lichtleiter
1867: Desormeaux used an open 1867: Desormeaux used an open
tube to examine the genitourinary tube to examine the genitourinary
tracttract
History of LaparoscopyHistory of Laparoscopy
Maximilian Nitze (1848 – 1906) Maximilian Nitze (1848 – 1906)
invented the first cystoscope invented the first cystoscope
((Nitze-Leiter cystoscope) using an Nitze-Leiter cystoscope) using an
electrically heated platinum wire electrically heated platinum wire
for illuminationfor illumination..
In 1887, he modified Edison`s light In 1887, he modified Edison`s light
bulb and created the first electrical bulb and created the first electrical
light bulb for use during urological light bulb for use during urological
procedures.procedures.Original carbon-filament bulb- Thomas Edison
History of LaparoscopyHistory of Laparoscopy
1901: George Kelling, Dresden, 1901: George Kelling, Dresden,
SaxonySaxony (Germany) (Germany) performed the performed the
1st experimental laparoscopy, 1st experimental laparoscopy,
calling it ‘Celioscopy’. calling it ‘Celioscopy’.
Kelling insufflated the abdomen of Kelling insufflated the abdomen of
a dog with filtered air and used a a dog with filtered air and used a
Nitze cystoscope to look inside.Nitze cystoscope to look inside.
Hans Christian Jacobaeus Hans Christian Jacobaeus (1879 – 1937) (1879 – 1937)
1910: Swedish internist; first 1910: Swedish internist; first
thoracoscopic diagnosis with a thoracoscopic diagnosis with a
cystoscope in a human subject.cystoscope in a human subject.
Treatment of a patient with tubercular Treatment of a patient with tubercular
intra-thoracic adhesions.intra-thoracic adhesions.
The Possibilities for Performing Cystoscopy in The Possibilities for Performing Cystoscopy in Examinations of Serous Cavities. Examinations of Serous Cavities. Münchner Medizinischen Münchner Medizinischen Wochenschrift,Wochenschrift, 1911 1911
Bertram BernheimBertram 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
History of LaparoscopyHistory of Laparoscopy
1920: Zollikofer discovered the benefit of CO1920: Zollikofer discovered the benefit of CO22 gas for insufflation gas for insufflation
1938: Janos Veress developed a spring loaded needle for the 1938: Janos Veress developed a spring loaded needle for the induction of pneumoperitoneum.induction of pneumoperitoneum.
After World War II, the development of fiberoptics represented an After World War II, the development of fiberoptics represented an important step forward for endoscopyimportant step forward for endoscopy
1966: Hopkins rod lens scope & cold light1966: Hopkins rod lens scope & cold light
1974: Dr Harrith M Hasson, MD working in Chicago, 1974: Dr Harrith M Hasson, MD working in Chicago, proposed a blunt proposed a blunt mini-laparotomy which permitted direct visualization of the trocar mini-laparotomy which permitted direct visualization of the trocar entrance into the peritoneal cavity. It is popularly known today as entrance into the peritoneal cavity. It is popularly known today as Hasson‘s technique.Hasson‘s technique.
Kurt Semm (1927-2003)Kurt Semm (1927-2003) Once, while making a slide Once, while making a slide
presentation on ovarian cysts; presentation on ovarian cysts;
suddenly the projector was suddenly the projector was
unplugged - with the unplugged - with the
explanation that explanation that ““such such
unethical surgery should not unethical surgery should not
be presentedbe presented”” In 1970, after becoming the In 1970, after becoming the
chairman of Ob/Gyn at the chairman of Ob/Gyn at the
University of Kiel, his co-workers University of Kiel, his co-workers
demanded that he undergo a demanded that he undergo a
brain scan because, they said, brain scan because, they said,
““only a person with brain damage only a person with brain damage
would perform laparoscopic would perform laparoscopic
surgerysurgery””
German Engineer and Gynecologist.Introduced automatic insufflator,thermocoagulation ,loop knots,irrigation device in 1983, performedendoscopic appendectomy as part ofA gynecologic procedure.
History of LaparoscopyHistory of Laparoscopy
1985: Dr. Muhe (Prof Dr Med - Böblingen, Germany)1985: Dr. Muhe (Prof Dr Med - Böblingen, Germany) performed performed
the first successful laparoscopic cholecystectomy in a human. the first successful laparoscopic cholecystectomy in a human.
However, this was not well publicized until years later. The However, this was not well publicized until years later. The
German Surgical Society rejected Mühe in 1986 after he reported German Surgical Society rejected Mühe in 1986 after he reported
that he had performed the first laparoscopic cholecystectomy.that he had performed the first laparoscopic cholecystectomy.
Laparoscopy Takes OffLaparoscopy Takes Off 1988: 1st Lap cholecystectomy in the USA, Surgiport 1st 1988: 1st Lap cholecystectomy in the USA, Surgiport 1st
availableavailable
1989: US TV picks up on “Key Hole” surgery EndoClip™ 1989: US TV picks up on “Key Hole” surgery EndoClip™ releasedreleased
1990: Cuschieri (Aberdeen) warns on the explosion of 1990: Cuschieri (Aberdeen) warns on the explosion of endoscopyendoscopy
1991: ‘Lap Chole’ is accepted and routine procedure1991: ‘Lap Chole’ is accepted and routine procedure
1992: The National Institutes of Health Consensus 1992: The National Institutes of Health Consensus Conference concludes that laparoscopic cholecystectomy is Conference concludes that laparoscopic cholecystectomy is now the preferred alternative to open cholecystectomynow the preferred alternative to open cholecystectomy
DefinitionDefinition
Minimal access surgery is a Minimal access surgery is a
marriage of modern technology marriage of modern technology
and surgical innovation that aims and surgical innovation that aims
to accomplish surgical to accomplish surgical
therapeutic goals with minimal therapeutic goals with minimal
somatic and psychological traumasomatic and psychological trauma
Extent of minimal access Extent of minimal access surgerysurgery
LaparoscopyLaparoscopy
ThoracoscopyThoracoscopy
Endoluminal endoscopyEndoluminal endoscopy
Perivisiceral endoscopyPerivisiceral endoscopy
Arthroscopy and intra-articular Arthroscopy and intra-articular
joint surgeryjoint surgery
Combined approachCombined approach
What operations can we do What operations can we do LaparoscopicallyLaparoscopically
DiagnosisDiagnosis
GallstoneGallstone
AppendicitisAppendicitis
HerniaHernia
AdhesionsAdhesions
Perforated ulcerPerforated ulcer
Hiatus HerniaHiatus Hernia
OperationOperation
CholecystectomyCholecystectomy
AppendicectomyAppendicectomy
Hernia repairHernia repair
Division of adhesionsDivision of adhesions
Closure of perforationClosure of perforation
Hiatus hernia repair.Hiatus hernia repair.
What operations can we do What operations can we do LaparoscopicallyLaparoscopically
DiagnosisDiagnosis
Colorectal carcinomaColorectal carcinoma
Caecal carcinomaCaecal carcinoma
Colonic carcinomaColonic carcinoma
Gastric carcinomaGastric carcinoma
Oesophageal carcinomaOesophageal carcinoma
The list is endless!!!The list is endless!!!
OperationOperation
Anterior resection/ APRAnterior resection/ APR
Right HemicolectomyRight Hemicolectomy
Left/Sigmoid ColectomyLeft/Sigmoid Colectomy
GastrectomyGastrectomy
OesophagogastrectomyOesophagogastrectomy
What operations can we do What operations can we do laparoscopically?laparoscopically?
DiagnosisDiagnosis
CrohnCrohn’’s Diseases Disease
DiverticulitisDiverticulitis
Rectal ProlapseRectal Prolapse
Benign renal diseaseBenign renal disease
Gastric ObstructionGastric Obstruction
Some Splenic disordersSome Splenic disorders
OperationOperation
Bowel resectionBowel resection
Bowel resectionBowel resection
Repair of ProlapseRepair of Prolapse
NephrectomyNephrectomy
BypassBypass
SpleenectomySpleenectomy
Principle Differences between Principle Differences between Laparoscopic and Open Laparoscopic and Open
SurgerySurgeryFOR THE PATIENTFOR THE PATIENT
Post operative pain related to size of incision- Post operative pain related to size of incision- smaller incisions =less pain.smaller incisions =less pain.
Less Handling of intestines results in little or no Less Handling of intestines results in little or no disturbance of normal function.disturbance of normal function.
Avoidance of the trauma of abdominal wall injury Avoidance of the trauma of abdominal wall injury by the incision allows rapid return to normal by the incision allows rapid return to normal activityactivity
No incision allows early return to more strenuous No incision allows early return to more strenuous activities: driving, lifting, sport etc.activities: driving, lifting, sport etc.
Principle Differences between Principle Differences between laparoscopic and open surgerylaparoscopic and open surgery
FOR THE HOSPITALFOR THE HOSPITAL Initial capital costs to establish laparoscopic surgery in Initial capital costs to establish laparoscopic surgery in
the order of Rs 10 - 20 lacsthe order of Rs 10 - 20 lacs
Reduced overall costs by shortening of hospital stay e.g. Reduced overall costs by shortening of hospital stay e.g. cholecystectomy reduced from 5 to 1 day, hiatus hernia cholecystectomy reduced from 5 to 1 day, hiatus hernia repair reduced from 7 to 3 days.repair reduced from 7 to 3 days.
Principle Differences between Principle Differences between laparoscopic and open surgerylaparoscopic and open surgery
For the SurgeonFor the Surgeon Magnified view often better than obtained via an Magnified view often better than obtained via an
incision allows precise dissection.incision allows precise dissection. Altered (but not absent) tactile responseAltered (but not absent) tactile response Two dimensional (flat screen) view.Two dimensional (flat screen) view. Usually (but not always) longer operating timeUsually (but not always) longer operating time Need to develop entirely different operating Need to develop entirely different operating
techniquetechnique Adaptation of principles of open surgery to Adaptation of principles of open surgery to
laparoscopic surgery.laparoscopic surgery.
InstrumentsInstruments
Redesign of instruments for laparoscopic use.Redesign of instruments for laparoscopic use. Instruments for open surgery in general 6 – 10Instruments for open surgery in general 6 – 10”” in length in length
built around a box joint.built around a box joint. Laparoscopic instruments in general 15 – 18Laparoscopic instruments in general 15 – 18”” in length in length
with an articulated connecting rod between handles and with an articulated connecting rod between handles and scissor blades, jaws etc.scissor blades, jaws etc.
Equipment Necessary for MASEquipment Necessary for MAS
CameraCamera
Light SourceLight Source
InsufflatorInsufflator
TV MonitorTV Monitor
TelescopesTelescopes
Light Guide CableLight Guide Cable
Apart from the Apart from the
insufflator the system insufflator the system
will work better if all will work better if all
the components are the components are
from the same from the same
company as one company as one
piece talks to another piece talks to another
CAMERACAMERA
These can be single chip or 3 chip.These can be single chip or 3 chip.
CHIP: thois is also called a charged coupled device in short, CHIP: thois is also called a charged coupled device in short,
CCD.CCD.
These are flat silicone wafers with a matrix, a grid of minute These are flat silicone wafers with a matrix, a grid of minute
image sensors called pixels.image sensors called pixels.
White balance and sometimes black balanceWhite balance and sometimes black balance
Sleeve it donSleeve it don’’t soak it!!!t soak it!!!
Light SourceLight Source
Halogen or Xenon, cold light but beware can still Halogen or Xenon, cold light but beware can still burn holes in drapes esp. disposable and burn burn holes in drapes esp. disposable and burn patientpatient’’s skin if left on the abdomen.s skin if left on the abdomen.
Brightest to darkest measured in units of decibels.Brightest to darkest measured in units of decibels. Automatic illumination, does it talk to the camera Automatic illumination, does it talk to the camera
and are the necessary leads plugged in.and are the necessary leads plugged in. Lamp life meter, look at it. Is it nearly out? EBME Lamp life meter, look at it. Is it nearly out? EBME
keep the spares and they change it.keep the spares and they change it. White balance by making sure white is correct then White balance by making sure white is correct then
all the colours through the spectrum are correct. all the colours through the spectrum are correct.
InsufflatorInsufflator CO2 because this has the same refractive CO2 because this has the same refractive
index as air, so doesnindex as air, so doesn’’t distort the image and t distort the image and is non combustible.is non combustible.
Intraabdominal pressure run between 10 and Intraabdominal pressure run between 10 and 13 mmhg.13 mmhg.
Use disposable filter and tubing for each Use disposable filter and tubing for each patient.patient.
High flow insufflators (35 litres) output High flow insufflators (35 litres) output determined by size of outlet.determined by size of outlet.
Ensure you know how to change a cylinder Ensure you know how to change a cylinder and were they are stored.and were they are stored.
TV MonitorsTV Monitors
Usually a 20Usually a 20”” screen. screen. HD is better.HD is better. You can use a standard TV but it must be run You can use a standard TV but it must be run
through an isolated transformer.through an isolated transformer. Horizontal resolution is the number of vertical Horizontal resolution is the number of vertical
lines.lines. Vertical resolution is the number of horizontal Vertical resolution is the number of horizontal
lineslines More lines of resolution, better detail of picture.More lines of resolution, better detail of picture.
TelescopesTelescopes Come in varying sizes, laparoscopes usually 5mm Come in varying sizes, laparoscopes usually 5mm
or 10mm.or 10mm. Diagnostic 3mm scope available.Diagnostic 3mm scope available. Made up of a rod and lens system.Made up of a rod and lens system. Bundles of fibres, incoherent carry light and Bundles of fibres, incoherent carry light and
coherent carry image.coherent carry image. Wide range of angles available 0, 30, 45 degree are Wide range of angles available 0, 30, 45 degree are
fairly standard.fairly standard. All laparoscopes are autoclavable and can go All laparoscopes are autoclavable and can go
through sterilisation, no ultrasonic bath required.through sterilisation, no ultrasonic bath required. Endo- chameleon- extra long for Bariatric patients.Endo- chameleon- extra long for Bariatric patients.
Light guide CablesLight guide Cables
Different diametersDifferent diameters
Fibre light cableFibre light cable
Buy auroclavableBuy auroclavable
DonDon’’t bend to acutely as will break fibres.t bend to acutely as will break fibres.
Check when you plug them in are all the fibres are okay.Check when you plug them in are all the fibres are okay.
CondensersCondensers
InstrumentationInstrumentation
SINGLE USE: breaking the Law if you reuse it SINGLE USE: breaking the Law if you reuse it on another patient.on another patient.
Reusable take apart.Reusable take apart. Need an ultrasonic washer to effectively clean Need an ultrasonic washer to effectively clean
them, not for telescopes.them, not for telescopes. DonDon’’t put 5mm cannulated instruments into a t put 5mm cannulated instruments into a
bench top autoclave that does not have a bench top autoclave that does not have a vacuum: vacuum is required to remove all air vacuum: vacuum is required to remove all air form lumen of instrument.form lumen of instrument.
Ports 5 and 10mm are the most common, make Ports 5 and 10mm are the most common, make sure the right trocar is in port and is it sharp.sure the right trocar is in port and is it sharp.
ElectrosurgeryElectrosurgeryYou should be aware of the You should be aware of the
following potential situations:following potential situations:
Insulation failureInsulation failure of the active electrode. of the active electrode.
Direct coupling of current Direct coupling of current to other instrumentation to other instrumentation by direct contact.by direct contact.
CapacitanceCapacitance which may be created by two electrical which may be created by two electrical conductors separated by an insulatorconductors separated by an insulator
Ultrascision or the Harmonic Ultrascision or the Harmonic ScalpelScalpel
Electrical generator (the box)Electrical generator (the box)
This adjusts the amount of electrical energy being This adjusts the amount of electrical energy being
delivered and monitors performance.delivered and monitors performance.
TransducerTransducer
This is where electrical energy is converted to the This is where electrical energy is converted to the
ultrasonic waves. The frequency is fixed however ultrasonic waves. The frequency is fixed however
the amplitude alters with the power input. the the amplitude alters with the power input. the
transducer is located in the hand piece and is transducer is located in the hand piece and is
connected to the generator by an electrical cable. connected to the generator by an electrical cable.
Dissection Instrument (peripheral hand piece)Dissection Instrument (peripheral hand piece)
A metallic rod is coupled to the transducer and A metallic rod is coupled to the transducer and
vibrates at the prescribed frequency (i.e. 55kHz). vibrates at the prescribed frequency (i.e. 55kHz).
The tip of the rod contacts with the surface tissue.The tip of the rod contacts with the surface tissue.
Principles of Piezo ElectronicsPrinciples of Piezo Electronics
The ultrasound waves are created by electrical The ultrasound waves are created by electrical
energy hitting a negatively charged crystal that energy hitting a negatively charged crystal that
vibrates (expands and contracts) at a particular vibrates (expands and contracts) at a particular
frequency. These crystals are disc shaped and frequency. These crystals are disc shaped and
made of ferroelectric ceramics. A pair of discs made of ferroelectric ceramics. A pair of discs
““coupledcoupled”” together produce a sinusoidal wave together produce a sinusoidal wave
form. This coupling results in a harmonic form. This coupling results in a harmonic
waveform that is of high electroacoustic waveform that is of high electroacoustic
efficiency.efficiency.
VERESS NEEDLEVERESS NEEDLE
1938 - 1938 - Janos VeressJanos Veress, of Hungary, developed the spring-, of Hungary, developed the spring-loaded needle. to perform therapeutic pneumothorax loaded needle. to perform therapeutic pneumothorax (TB).(TB).
Made of surgical stainless steel with a single trap valve. Made of surgical stainless steel with a single trap valve. 2mm diameter x 80mm length 2mm diameter x 80mm length
It consists of an outer cannula with a bevelled needle It consists of an outer cannula with a bevelled needle point for cutting through tissues. point for cutting through tissues.
GAS INSUFFLATIONGAS INSUFFLATION
Controlled pressure insufflation of the peritoneal Controlled pressure insufflation of the peritoneal cavity is used to achieve the necessary work cavity is used to achieve the necessary work space for laparoscopic surgery. space for laparoscopic surgery.
Automatic insufflators allow the surgeon to Automatic insufflators allow the surgeon to preset the insufflating pressure, and the device preset the insufflating pressure, and the device supplies gas until the required intra-abdominal supplies gas until the required intra-abdominal pressure is reached. pressure is reached.
TrocarTrocar
The trocar has a blade with The trocar has a blade with
a shaft and body.a shaft and body.
The body includes a The body includes a
pointed tip which makes pointed tip which makes
the initial incision in the the initial incision in the
abdominal wall of the abdominal wall of the
patient. patient.
(Trocar diameters range from (Trocar diameters range from
2mm-30 mm)2mm-30 mm)
TrocarsTrocars
Types:Types: CuttingCutting
Pyramidal tippedPyramidal tipped
Flat bladeFlat blade
NoncuttingNoncutting Pointed conicalPointed conical
Blunt conicalBlunt conical
OpticalOptical
TelescopeTelescope There are three important There are three important
structural differences in structural differences in
telescope available telescope available
1. 6 to 18 rod lens system 1. 6 to 18 rod lens system
telescopes are availabletelescopes are available
2. 0 to 120 degree telescopes 2. 0 to 120 degree telescopes
are availableare available
3. 1.5 mm to 15 mm of 3. 1.5 mm to 15 mm of
telescopes are availabletelescopes are available
Optic cablesOptic cables
These cables are These cables are made up of a bundle of made up of a bundle of optical fibers glass optical fibers glass thread swaged at both thread swaged at both ends. ends.
The fiber size used is The fiber size used is usually between 10 to usually between 10 to 25 mm in diameter.25 mm in diameter.
They have a very high They have a very high quality of optical quality of optical transmission, but are transmission, but are fragile.fragile.
Dissecting & Grasping Dissecting & Grasping Forceps Forceps
AtraumaticAtraumatic
KELLY atraumaticKELLY atraumatic
Atraumatic, with hollow Atraumatic, with hollow jawsjaws
MANGESHKAR Grasping MANGESHKAR Grasping Forceps, serratedForceps, serrated
General General instrumentsinstruments
Reusable three-piece designReusable three-piece design
Available in 2 mm, 3 mm, Available in 2 mm, 3 mm, 3.5mm, 5 mm and 10 mm 3.5mm, 5 mm and 10 mm sizes, with lengths of 20 cm, sizes, with lengths of 20 cm, 30 cm, 36 cm and 43 cm.30 cm, 36 cm and 43 cm.
Choice of handle styles.Choice of handle styles. Fully rotating 360° sheath.Fully rotating 360° sheath.
No hidden spaces that can No hidden spaces that can trap operative blood and trap operative blood and tissue debris. tissue debris.
Scissors Scissors
HOOK SCISSORS, single HOOK SCISSORS, single action jawsaction jaws
METZENBAUM SCISSORS, METZENBAUM SCISSORS, curved, length of blades 12-17 curved, length of blades 12-17 mm, widely used as an mm, widely used as an instrument for mechanical instrument for mechanical dissection in laparoscopic dissection in laparoscopic surgery. surgery.
STRAIGHT SCISSOR STRAIGHT SCISSOR can give can give controlled depth of cutting controlled depth of cutting because it has only one moving because it has only one moving jaw. jaw.
TROCAR PLACEMENT TROCAR PLACEMENT BY QUADRANTBY QUADRANT
Thoracic triangle
Pelvic triangle
1 2
34
TROCAR PLACEMENT TROCAR PLACEMENT BY QUADRANTBY QUADRANT
Each quadrant must be addressed from frontal as well as lateral positions.
yz
x
Correct trocar placement should Correct trocar placement should provide direct access to the provide direct access to the
target organs, target organs, an optimal view of the operative an optimal view of the operative
field field and minimize mental and and minimize mental and
muscular fatigue.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
Working against the camera and ‘blind spots’
“Dueling swords” phenomenon (scissoring effect)
Avoid Avoid competing competing
for the same for the same space:space:
No obstacle between trocar entry No obstacle between trocar entry and targetand target
To avoid iatrogenic injuries.
Avoid the epigastric vesselsAvoid the epigastric vessels
Saber et al. Safety zones for anterior abdominal wall entry during laparoscopy. Ann Surg 2004; 239:182
(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.)
Anatomic distribution of nerves across anterior abdominal wall
Iliohypogastric nerveIlioinguinal 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.)
Iliohypogastric n.
Ilioinguinal n.
Incision line/trocar sites vs. nerve distribution
Epigastric a.
Trocar site
Pfannenstiel incision
Be aware of bladder location Be aware of bladder location for suprapubic trocarfor suprapubic trocar
Avoid areas of prior surgeryAvoid areas of prior surgery
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.
Additional trocars can
be added along
thesemicircular
line.
Gold Standard Laparoscopic Gold Standard Laparoscopic Procedures TodayProcedures Today
Laparoscopic cholecystectomyLaparoscopic cholecystectomy
Laparoscopic RYGB for obesityLaparoscopic RYGB for obesity
Laparoscopic adrenalectomyLaparoscopic adrenalectomy
Laparoscopic splenectomyLaparoscopic splenectomy
Huge DifferenceHuge Difference
Public Health Problem #1:
Laparoscopy in Bariatric Laparoscopy in Bariatric SurgerySurgery
OBESITY
Trocars - placed high, close Trocars - placed high, close to to
the costal margin.the costal margin.Trocar A - liver retraction. Trocar A - liver retraction. Trocar D - can be enlarged to Trocar D - can be enlarged to allow for placement of a port.allow for placement of a port.Trocar C - placed left of the Trocar C - placed left of the midline for correct view ofmidline for correct view ofAngle of His.Angle of His.
LAP-BANDLAP-BAND
C D
EB
A
Laparoscopic RYGBLaparoscopic RYGB
Multicenter, prospective, risk-adjusted Multicenter, prospective, risk-adjusted data show that laparoscopic gastric data show that laparoscopic gastric bypass is safer than open gastric bypass is safer than open gastric bypass, with respect to 30-day bypass, with respect to 30-day complication rate.complication rate.
LRYGB has become the standard of LRYGB has become the standard of carecare
Hutter et al. Ann Surg. May 2006Hutter et al. Ann Surg. May 2006 Massachusetts General Hospital, BostonMassachusetts General Hospital, Boston..
Current ProceduresCurrent Procedures
The first case of laparoscopic adrenalectomy was reported by Gagner The first case of laparoscopic adrenalectomy was reported by Gagner
in 1992.in 1992.
Laparoscopic Adrenalectomy
Less blood lossLess blood loss
LessLess operative time!! operative time!!
Less hospital stay Less hospital stay
Less post operative painLess post operative pain
Tiberio et al.Tiberio et al.
Prospective RCTProspective RCT
Surg Endosc. Jun 2008Surg Endosc. Jun 2008
Laparoscopic adrenalectomy
Unilateral adrenalectomy Bilateral adrenalectomy
Hyperfunctioning tumors Aldosteronoma
Cortisol-producing adenoma
Virilizing tumors
Pheochromocytoma
Failed treatment of ACTH-dependent
Cushing’s syndrome
Nonfunctioning cortical adenomaa Cushing’s syndrome from primary
adrenal hyperplasia
Malignant tumors Adrenocortical carcinoma
Malignant pheochromocytoma
Adrenal metastasis (solitary without
other metastatic
disease)
Bilateral pheochromocytoma
symptomatic or enlarging adrenal
myelolipomas, ganglioneuroma
ACTH: adrenocorticotrophic hormone
Indications for AdrenalectomyIndications for Adrenalectomy
Laparoscopic Splenectomy-Laparoscopic Splenectomy-IndicationsIndications
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
SPLENECTOMYSPLENECTOMY
Laparoscopic splenectomyLaparoscopic splenectomy
Significantly less pulmonary, wound, and infectious complications.Significantly less pulmonary, wound, and infectious complications. Longer operative times Longer operative times Winslow (meta-analysis). Surgery. 2003 Oct;134(4):647-Winslow (meta-analysis). Surgery. 2003 Oct;134(4):647-
5353
Laparoscopic ProceduresLaparoscopic Procedureswith equivalencewith equivalence
Laparoscopic hernia repairLaparoscopic hernia repair
Laparoscopic appendectomyLaparoscopic appendectomy
Laparoscopic fundoplicationLaparoscopic fundoplication
Laparoscopic Inguinal Laparoscopic Inguinal Hernia RepairHernia Repair
Hernia - Historic PerspectiveHernia - Historic Perspective
Galen of Pergamum (AC 129-179) who was a Galen of Pergamum (AC 129-179) who was a
surgeon to the gladiators practiced ligation of the sac surgeon to the gladiators practiced ligation of the sac
and cord with amputation of the testicle. and cord with amputation of the testicle.
Guy de Chauliac (AC 1300-1368) in his book Guy de Chauliac (AC 1300-1368) in his book
Chirurgia Magna: laxatives, hang patient from his Chirurgia Magna: laxatives, hang patient from his
legs, bed rest for 50 days.legs, bed rest for 50 days.
Trocar placementTrocar placement::
TransabdominalTransabdominal
Pre peritoneal (TAPP)Pre peritoneal (TAPP)
Totally
Extra Peritoneal (TEP)
Additional
trocar
INGUINAL INGUINAL HERNIA REPAIRHERNIA REPAIR
Inguinal Hernia RepairInguinal Hernia Repair
What are indications for What are indications for laparoscopic inguinal hernia laparoscopic inguinal hernia
repair?repair?Recurrent herniaRecurrent hernia
• Avoids scar tissueAvoids scar tissue
• Visualizes occult hernia Visualizes occult hernia
Bilateral herniaBilateral hernia
• Decreased pain Decreased pain
• Earlier return to workEarlier return to work
• No difference in recurrence or complicationNo difference in recurrence or complication
Obese / Athletic patientsObese / Athletic patients
• Definitive diagnosisDefinitive diagnosis
• Reduced infection in susceptible populationReduced infection in susceptible population
• GilmoreGilmore’’s groins groin
Patients with contralateral injury to vas deferensPatients with contralateral injury to vas deferens
• Less chance to injure other vasLess chance to injure other vas
Are there contraindications to Are there contraindications to lap. inguinal hernia repair?lap. inguinal hernia repair?
ContraindicationsContraindications• Patients for whom general anesthesia and Patients for whom general anesthesia and
pneumoperitoneum are risks (cardiac, pulmonary pneumoperitoneum are risks (cardiac, pulmonary disease)disease)
Relative ContraindicationsRelative Contraindications• Prior pre-peritoneal surgery (prostate, hernia, vascular, Prior pre-peritoneal surgery (prostate, hernia, vascular,
kidney transplant)kidney transplant)• Prior laparotomyPrior laparotomy• AscitesAscites• Strangulated herniaStrangulated hernia• Giant scrotal herniaGiant scrotal hernia• Anticipated bleeding (patients on anti-coagulation)Anticipated bleeding (patients on anti-coagulation)
2. Do we have an answer for
groin pain after hernia repair?
Nerves prone to injury Nerves prone to injury anterior and posterioranterior and posterior
Laparoscopic Ventral Hernia:Is the Abdomen a Laparoscopic Ventral Hernia:Is the Abdomen a Weakness in the Human Race ?Weakness in the Human Race ?
Laparoscopic Ventral Hernia:Is the Abdomen a Laparoscopic Ventral Hernia:Is the Abdomen a Weakness in the Human Race ?Weakness in the Human Race ?
Laparoscopic Repair of Laparoscopic Repair of Incisional HerniasIncisional Hernias
wound complicationswound complications
recurrence raterecurrence rate
LOSLOS
painpain
coverage of coverage of ““Swiss cheeseSwiss cheese”” abdomenabdomen
Ventral Hernia Defect
Mesh used to patch defect
Secure periphery Secure periphery
of mesh with tackerof mesh with tacker
Approximately 1cm Approximately 1cm
apartapart
Completed repair
Massive Incisional HerniasMassive Incisional Hernias
Laparoscopic AppendectomyLaparoscopic Appendectomy
Laparoscopic Appendectomy
Endo-loop
APPENDECTOMYAPPENDECTOMY
Alternatively, an appendectomy can be performed through a Alternatively, an appendectomy can be performed through a trocar in the umbilicus and two trocars in the suprapubic area trocar in the umbilicus and two trocars in the suprapubic area medial to the epigastric vessels for a superb cosmetic result (if medial to the epigastric vessels for a superb cosmetic result (if an extended right hemicolectomy is to be performed, the an extended right hemicolectomy is to be performed, the hepatic flexure positioning is preferred.)hepatic flexure positioning is preferred.)
Laparoscopic Appendectomy Laparoscopic Appendectomy Evidence-based MedicineEvidence-based Medicine
Clear advantage in children*Clear advantage in children*
- Less wound infection, LOS, ileus- Less wound infection, LOS, ileus
- More OR time, intra-abdominal abscess- More OR time, intra-abdominal abscess
Controversies in adultsControversies in adults
- Cost, obese patients, severe appendicitis- Cost, obese patients, severe appendicitis
*Aziz et al. *Aziz et al. Ann SurgAnn Surg 2006 2006
- Prelude to NOTES
LAPAROSCOPIC PROCEDURES
WITH CLEAR ADVANTAGES.
Laparoscopic HellerLaparoscopic Heller’’s s CardiomyotomyCardiomyotomy
Technically feasible
Short recovery time
Less overall complication
rates
Anti-reflux surgeryAnti-reflux surgery
1945 to present1945 to presentMultiple methods and techniques:Multiple methods and techniques:
Nissen fundoplicationNissen fundoplicationDor wrapDor wrapHill gastropexy ….Hill gastropexy ….
Different approaches:Different approaches:Laparotomy vs laparoscopyLaparotomy vs laparoscopyThoracotomy vs thoracoscopyThoracotomy 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
NissenNissen’’s Fundoplications Fundoplication
Technique
Nissen FundoplicationNissen Fundoplication
Esophageal HiatusEsophageal Hiatus
LiverLiver
EsophagusEsophagus
Left crusLeft crus
Right crusRight crus
AortaAorta
Hiatal DefectHiatal Defect
Chest cavityChest cavity
StomachStomach
Left crusLeft crus
Mesh RepairMesh Repair
Polypropylene mesh
Esophagus
• Do not use metal tacks
• Biologic mesh? dual mesh?
• No mesh at all? (remember original Toupet repair)
Mesh
Wrap
Circular mesh
Fundoplication
Laparoscopic Surgery Laparoscopic Surgery in Colorectal Diseasesin Colorectal Diseases
Port Site RecurrencePort Site Recurrence
NOTENOTE::
If proximal divided end of colon can reach through If proximal divided end of colon can reach through the skin there has been sufficient dissection of the skin there has been sufficient dissection of splenic flexure providing a tension-free anastomosis.splenic flexure providing a tension-free anastomosis.
HEPATIC HEPATIC FLEXURE FLEXURE COLON COLON
RESECTION RESECTION
ABTension-free anastomosis
The ileum is more mobile than the The ileum is more mobile than the transverse colon, which can still be transverse colon, which can still be delivered adequately at this level.delivered adequately at this level.
Trocar C is used for GIA divisionof distal ileum and midtransverse colon (site is enlarged to retrieve specimen and for extracorporeal anastomosis).
C
LAPAROSCOPIC LAPAROSCOPIC SIGMOID RESECTIONSIGMOID RESECTION
(lateral decubiti (lateral decubiti position)position)
LateralSupine
Laparoscopic colorectal Laparoscopic colorectal surgerysurgery
Cochrane Systematic review of short term outcomes in 25 RCTs showed that Cochrane Systematic review of short term outcomes in 25 RCTs showed that laparoscopic colorectal surgery had:laparoscopic colorectal surgery had:
Longer operative time Longer operative time Less intraoperative blood lossLess intraoperative blood loss Less postoperative painLess postoperative pain less postoperative ileusless postoperative ileus Better postoperative pulmonary functionBetter postoperative pulmonary function Less total and local morbidityLess total and local morbidity Less postoperative hospital stay Less postoperative hospital stay Similar general morbidity and mortalitySimilar general morbidity and mortality Better quality of life (within 30 days) Better quality of life (within 30 days)
Schwenk et al. 2005 Jul 20;(3):Cochrane Database 003145Schwenk et al. 2005 Jul 20;(3):Cochrane Database 003145
Cochrane Systematic review of long term outcomes showed:Cochrane Systematic review of long term outcomes showed: Similar port-site metastases and wound recurrencesSimilar port-site metastases and wound recurrences Similar cancer-related mortality at maximum follow-upSimilar cancer-related mortality at maximum follow-up Similar tumor recurrenceSimilar tumor recurrence Similar overall mortality Similar overall mortality
Kuhry et al. Cancer Treat Rev. Oct 2008Kuhry et al. Cancer Treat Rev. Oct 2008
Laparoscopic hepatectomyLaparoscopic hepatectomy
First performed 1994 First performed 1994 by Huscher et alby Huscher et al
A safe procedure in A safe procedure in experienced handsexperienced hands
Resection devices:Resection devices: StaplersStaplers Bipolar vessel sealing Bipolar vessel sealing
(Ligasure)(Ligasure) Radiofrequency Radiofrequency U/S dissectorU/S dissector Nd-YAG laserNd-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 pancreatectomyLaparoscopic pancreatectomy
Pancreaticoduodenectomy Pancreaticoduodenectomy Total splenopancreatectomyTotal splenopancreatectomy Spleen-preserving total Spleen-preserving total
pancreatectomypancreatectomy Distal splenopancreatectomyDistal splenopancreatectomy Spleen-preserving distal Spleen-preserving distal
pancreatectomypancreatectomy Central pancreatectomyCentral pancreatectomy Enucleation Enucleation
Procedures are technically Procedures are technically challengingchallenging
Long learning curveLong learning curve High volume center improves High volume center improves
clinical outcomeclinical outcome
DISTAL PANCREATECTOMYDISTAL PANCREATECTOMY
DE
C
B
A
• Trocars “A ” and “B” divide gastrocolic ligament• GIA is introduced through “D”
Laparoscopic pancreatectomy Laparoscopic pancreatectomy Vs. openVs. open
Finan et al. Am Surg. Aug 2009 Finan et al. Am Surg. Aug 2009 Laparoscopic and open distal Laparoscopic and open distal pancreatectomy: a comparison of pancreatectomy: a comparison of outcomes.outcomes.
There was no significant difference in the There was no significant difference in the incidence of postoperative morbidity or incidence of postoperative morbidity or mortalitymortality
There was no significant difference in the rate There was no significant difference in the rate
of all pancreatic fistula formation or clinically of all pancreatic fistula formation or clinically significant leaks significant leaks
Lparoscopic technique had decreased: Lparoscopic technique had decreased: operative timeoperative time blood lossblood loss length of stay in the lap group. length of stay in the lap group.
ConclusionConclusion Lap and open distal pancreatectomy are Lap and open distal pancreatectomy are
performed safely at high-volume performed safely at high-volume pancreatic surgery centers. pancreatic surgery centers.
Laparoscopic Urologic Laparoscopic Urologic proceduresprocedures
Undescended testisUndescended testis
VaricocelectomyVaricocelectomy
Retroperitoneal fibrosisRetroperitoneal fibrosis
Lymph node dissectionLymph node dissection
Bladder neck suspensionBladder neck suspension
Bladder diverticulumBladder diverticulum
Patent urachusPatent urachus
NephrectomyNephrectomy
ProstatectomyProstatectomy
RT. KIDNEY RESECTIONRT. 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.)
B
C
D
AE
PROSTATECTOMPROSTATECTOMYY
AB
C
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 surgeonon the opposite side to each use both hands.
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 resultsCosmetic results
Open surgery scar Minimally invasive / endoscopic scars
ConclusionsConclusions
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?!
It is not a ‘niche surgery’!
Emerging TechnologiesEmerging Technologies
RoboticsRobotics
SILSSILS
NOTESNOTES
Trocarless laparoscopyTrocarless laparoscopy
ENDOBARRIERENDOBARRIER
History of RoboticsHistory of Robotics
Leonardo da Vinci Leonardo da Vinci
developed one of the developed one of the
first robots in 1495 – an first robots in 1495 – an
armored knight for the armored knight for the
purposes of purposes of
entertaining royalty.entertaining royalty.
What Robotics Aimed to Improve in Laparoscopy
Surgeon operates from a 2D imageSurgeon operates from a 2D image
Straight, rigid instruments (limited range of motion)Straight, rigid instruments (limited range of motion)
Instrument tips controlled at a distance Instrument tips controlled at a distance
Reduced dexterity, precision & controlReduced dexterity, precision & control
Unsteady camera controlled by assistantUnsteady camera controlled by assistant
Dependent on assistant for surgical support through Dependent on assistant for surgical support through
accessory portaccessory port
Greater surgeon fatigueGreater surgeon fatigue
Makes complex operations more difficultMakes complex operations more difficult
Surgical RobotsSurgical Robots
AESOPAESOP (Automated Endoscopic System for Optimal (Automated Endoscopic System for Optimal
Positioning)Positioning)
- Voice activated mechanical arm- Voice activated mechanical arm
- Steadier than human, never tires- Steadier than human, never tires
da Vincida Vinci®®
- FDA approval in 2002- FDA approval in 2002
- Laparoscopic instrumentation controlled by the - Laparoscopic instrumentation controlled by the
surgeon, positioned remotely at a consolesurgeon, positioned remotely at a console
Development of Development of da Vincida Vinci®®
Defense Advanced Research Projects Agency (DARPA) Defense Advanced Research Projects Agency (DARPA)
for military research of remote battlefield surgeryfor military research of remote battlefield surgery
Cholecystectomy performed remotely via telesurgery from 300 miles Cholecystectomy performed remotely via telesurgery from 300 miles
awayaway
Intuitive surgical created in 1999 after acquiring patent rights from Intuitive surgical created in 1999 after acquiring patent rights from
militarymilitary
First robotic prostatectomy performed in 2001First robotic prostatectomy performed in 2001
What is the What is the da Vincida Vinci®® Surgical Surgical System?System?
State-of-the-art robotic State-of-the-art robotic technologytechnology
Surgeon in controlSurgeon in control
Assistant has direct accessAssistant has direct access
Surgeon directs precise Surgeon directs precise
movements of instruments in movements of instruments in
the slave unit using console the slave unit using console
controls.controls.
What is the What is the da Vincida Vinci®® Surgical System?Surgical System?
Robotic Scrub NurseRobotic Scrub Nurse““PenelopePenelope””
Laparoscopic instruments Laparoscopic instruments
are rigid with no wristsare rigid with no wrists
EndoWristEndoWrist®® Instrument tips Instrument tips
move like a human wrist move like a human wrist
Allows surgeon to operate Allows surgeon to operate
with increased dexterity & with increased dexterity &
precision. No tremorprecision. No tremor
Wrist and Finger MovementWrist and Finger Movement
Disadvantages of Disadvantages of da Vincida Vinci®® RobotRobot
ExpensiveExpensive
- $1.4 million cost for machine- $1.4 million cost for machine
- $120,000 annual maintenance contract- $120,000 annual maintenance contract
- Disposable instruments $2000/case- Disposable instruments $2000/case
Steep surgical learning curveSteep surgical learning curve
Loss of tactile feedbackLoss of tactile feedback
Increased staff training/competenceIncreased staff training/competence
Increased OR set-up/turnover time!!Increased OR set-up/turnover time!!
Past Present
SILSSILSSingle Incision Laparoscopic SurgerySingle Incision Laparoscopic Surgery
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
What does that stand for ?
SILSSILS
UrologyUrology
Renal transplantRenal transplant
CholecystectomyCholecystectomy
Gastric band surgeryGastric band surgery
ColectomyColectomy
TechniqueTechnique
SILSSILS
SILSSILS
Ergonomically difficult ?!
Training !
Port Site Hernia !!Port Site Hernia !!
N.O.T.E.S.
Natural Orifice Transluminal Endoscopic Surgery
NOTES - instrumentNOTES - instrument
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
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
Scarless surgery!Scarless surgery!
Notes- TransvaginalNotes- Transvaginal
Video-endoscope entering through the posterior vaginal fornix
NOTES - Transgastric
Courtesy of N Reddy, Hyperbad India 2005
NOTES - AppendectomyNOTES - Appendectomy
NOTES – Obesity SurgeryNOTES – Obesity Surgery
Surgery for DiabetesSurgery for Diabetes
DiabetesDiabetes
Considered major public health problem – emerging as a world Considered major public health problem – emerging as a world
wide pandemic. In 1995 ~ 135 million people worldwidewide pandemic. In 1995 ~ 135 million people worldwide
Currently 240 million, expected to rise to close to 380 million by Currently 240 million, expected to rise to close to 380 million by
2025 2025
ComplicationsComplications Peripheral vascular disease (PVD) accounts for 20-30% Peripheral vascular disease (PVD) accounts for 20-30%
10% of cerebral vascular accident 10% of cerebral vascular accident
Cardiovascular disease accounts for 50% of total mortality 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 ResClin 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. CHAOSCoronary Artery DiseaseHypertensionAdult Onset DiabetesObesityStroke
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
MorbidityMorbidity
Studies Type and Size Effect on Weight Effect on Comorbidities
Buchwald et al.Meta-analysisn = 22,094 pts
Mean excess weight loss: 61%
Resolution of: n Diabetes: 70% HTN: 62% Sleep apnea: 86%
Swedish Obese Subject trial (SOS)
Prospective matched cohortn = 4,047 pts
At 10 years: Med: 1.6% gainSurg: 16% loss
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.
Long-term Weight Control Analysis
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
AdjustableGastric Banding
Roux-en-YGastric Bypass
BiliopancreaticDiversion
>95%(Immediate)
48%(Slow)
84%(Immediate)
“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
2002: Antidiabetic Effect of 2002: Antidiabetic Effect of Bariatric Surgery: Direct or Indirect? Bariatric Surgery: Direct or Indirect?
2004:2004:
“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 FUTURETHE FUTURE It has not changed the nature of diseaseIt has not changed the nature of disease
The basic principles of good surgery still The basic principles of good surgery still
apply,including appropriate case selection, apply,including appropriate case selection,
excellent exposure,adequate retraction and excellent exposure,adequate retraction and
a high level technical expertisea high level technical expertise
If a procedure makes no sense with If a procedure makes no sense with
conventional access, it will make no sense conventional access, it will make no sense
with a minimal access approachwith a minimal access approach
THE FUTURETHE FUTURE
The cleaner and gentler the act of The cleaner and gentler the act of
operation, the less the patientoperation, the less the patient
suffers, the smoother and quicker suffers, the smoother and quicker
his convalescence,the more his convalescence,the more
exquisite his healed wound.exquisite his healed wound.
Berkeley GeorgeBerkeley George Andrew MoynihanAndrew Moynihan
THANK YOU ALL FOR A THANK YOU ALL FOR A PATIENT HEARINGPATIENT HEARING