Laparoscopy: The impact on the future

Laparoscopy: The impact Laparoscopy: The impact

on the futureon the future

Danny Yakoub MDDanny Yakoub MD

George S Ferzli MD FACSGeorge S Ferzli MD FACSProfessor of Surgery - State University of New York Professor of Surgery - State University of New York

(Downstate)(Downstate)

Chairman of Surgery - Lutheran Medical Center, New York, Chairman of Surgery - Lutheran Medical Center, New York, USAUSA

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).


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


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


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


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 presented” be 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

surgery”surgery”

German Engineer and Gynecologist.Introduced automatic insufflator,thermocoagulation ,loop knots,irrigation device in 1983, performedendoscopic appendectomy as part ofA gynecologic procedure.

Journal of Reproductive Medicine 1977. Volume 18; No. 5: 235- 240


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

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 beveled needle It consists of an outer cannula with a beveled needle point for cutting through tissues. point for cutting through tissues.

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.

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

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.

Working against the camera and ‘blind spots’

“Dueling swords” phenomenon (scissoring effect)

Avoid Avoid competing competing

for the same for the same space:space:

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

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

Laparoscopic hiatal hernia repairLaparoscopic hiatal hernia repair

Huge DifferenceHuge Difference

* 600,000 cholecystectomies annually in the U.S.,8%-20% have CBD stones, no consensus on optimal management.

** “No single clinical indicator is completely accurate

in predicting CBD stones prior to cholecystectomy.”

* Liu, TH et al. Ann Surg 234(1), July, 2001.

**Abboud, et al. Gastrointestinal Endoscopy, 44(4), October 1996

Laparoscopic US as a good alternative to Laparoscopic US as a good alternative to intraoperative cholangiography (IOC) during intraoperative cholangiography (IOC) during laparoscopic cholecystectomy: results of laparoscopic cholecystectomy: results of prospective study.prospective study.

685 IOC (35 cannot canulate cystic duct) 269 LUS (2 steatosis)IOC detected 4.5% common bile duct stones; LUS 6%IOC sensitivity 96.9%, specificity 99.2%LUS sensitivity 100%, specificity 99.6%

Results:In this prospective study, LUS has been certainly as effective as IOC as a primary imaging technique for bile duct. It permitted to detect CBDS with a high specificity and sensitivity, and was not followed by an increase in CBDI.

Hublet A et al Laparoscopic US as a good alternative to intraoperative cholangiography during lap chole: results of prospective study Acta Chir Belg. 2009 May-Jun Belgique.

Indocyanine Green (ICG) Indocyanine Green (ICG) Injection:Injection:Shows the confluence between right and left hepatic

ducts during hepatectomy.

Enables identification of the cystic duct and CBD

before dissection of Calot’s triangle during

Cholecystectomy.

Ishizawa T, et al. Intraoperative Fluorescent Cholangiography Using Indocyanine Green: A Biliary Road Map for Safe Surgery. JACS 2009; 208(1):e1-e4

Indocyanine Green Injection (ICG)Indocyanine Green Injection (ICG) AdvantagesAdvantages

No need for dissection of Calot’s triangle

No need for insertion of trans-cystic tube

No exposure to radiation

No space-occupying C-arm machine required

Simple and convenient procedure

Allergic reactions

Ishizawa T, et al. Intraoperative Fluorescent Cholangiography Using Indocyanine Green: A Biliary Road Map for Safe Surgery. JACS 2009;208(1): e1-e4

Combined Laparoscopy Combined Laparoscopy and ERCP: Single Step – and ERCP: Single Step – TreatmentTreatment 45 pts underwent lap chole with intra-op cholangiogram

33 pts had succesful intra-op ERCP with extraction of common bile duct stones

No post-op complications related to procedure (i.e. pancreatitis, bleeding, perforation)

Mean hospital stay: 2.55+0.89 days

No pts with signs or symptoms of retained CBD stones during mean post-op follow-up of 9+4.07 months

Ghazal AH, Sorour MA, El-Riwini M, El-Bahrawy H. Single-step treatment of gallbladder and bile duct stones: a combined endoscopic-laparoscopic technique. Int J Surg 2009;7(4):338-46

Current TrendsCurrent Trends

National Hospital Discharge Survey database 1979 to 2001: Frequency of ERCP vs CBDE Beginning of study: 47,000 CBDE’s per year End of study: 7,000 CBDE vs 43,000 ERCP Complication rates from CBDE

3.4% at beginning of study 17.4% at end of study

“ERCP has replaced the need for most but not all CBDE”

“Both choledocholithiasis treatment algorithms and clinical training paradigms need to account for the rarity of CBDE and high complication rates associated with it, by incorporation of training modules in surgical residencies and advocating referral to centers having expertise in biliary tract operations from surgeons with little CBDE experience”

Livingston EH, Rege RV. Technical Complications are Rising as Common Duct Exploration is Becoming Rare. JACS 2005;201(3):426-433

Public Health Problem #1:

Laparoscopy in Bariatric Laparoscopy in Bariatric SurgerySurgery

OBESITY

Derived from Center for Disease Control and Prevention website www.cdc.gov

Percent of Obese (BMI ≥ 30) in US AdultsPercent of Obese (BMI ≥ 30) in US Adults

Derived from Center for Disease Control and Prevention website www.cdc.gov

Percent of Obese (BMI ≥ 30) in US AdultsPercent of Obese (BMI ≥ 30) in US Adults

County-level Estimates of Obesity among Adults County-level Estimates of Obesity among Adults aged ≥ 20 years: United States aged ≥ 20 years: United States

Period or Decades Incidence of Surgery Reason for Change

Late 1970’s Early 1980’s

25,000 procedures per year

Innovative procedures• gastroplasty• loop GBP• jejuno-ileal bypass

Late 1980’s1990’s

5,000 procedures per year

Multifactorial:• High M&M• Ineffective long-term• Perceived failure• Surgeon experience

2000’s80,000 to 110,000 procedures per year

Multifactorial:• Laparoscopy• Long-term data• Centers of Excellence

1.National Hospital Discharge Survey Public-use data file and documentation. Multi-year data CD-ROM. National Center for Health Statistics, 1979-1996.

2.Nguyen et al. Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery. Arch Surg 2005; 140: 1198-202.

3.Griffen et al. The decline and fall of the jejunoileal bypass. Surg Gynecol Obstet 1983; 157: 301-8.4.Shirmer et al. Bariatric Surgery Training: Getting Your Ticket Punched. J Gastrointest Surg 2007;11: 807-12.

Popularity of Surgical Management

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

Local tumor invasiveness

Regional lymph node involvement

Large tumor size larger than 10 to 12 cma

Prior nephrectomy, splenectomy, or liver resection on the side of the adrenal lesiona

a Relative contraindications

Contraindications for Contraindications for Laparoscopic AdrenalectomyLaparoscopic Adrenalectomy

Conclusion: Computed tomography-guided percutaneous RFA is a safe and efficacious alternative to laparoscopic adrenalectomy in treating patients with PA due to small APA. Ann Surg. Dec 2010;252:1058-1064

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 Heller’s Laparoscopic Heller’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

Nissen’s FundoplicationNissen’s 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

Emerging technologies in hiatal hernia repair

TIF: Transoral Incisionless Fundoplication

Esophyx/Stomaphyx

EsophyX TIF

TIF (Transoral Incisionless Fundoplication)

No incisions• No scarring• No incisional herniation• Less potential for infection -

nosocomial infection minimized

Patient friendly • Rapid return to work and

normal activities

ESOPHYX

EsophyX Experience

Reconstructs the natural primary barrier to reflux by creating a robust valve

45 - 60 minute procedure

8 - 14 fasteners “SerosaFuse fasteners”

(3.0 non-absorbable propylene sutures)

Overnight stay (general anesthesia)

Post-op discomfort minimal

Rapid recovery – Most patients are back to work and most

activities in a couple of days

Multi Center Trial (1 year) N=79

85% of Patients OFF daily PPIs

• Minimal risk of adverse events

• Excellent QOL improvement 73%

• Elimination of PPI use 85%

• Esophagitis resolution 59%

• Hiatal hernia reduction 71%

• pH normalization 49% (Hill grade

one)

Multi Center Trial (2 years) N=79

• Minimal risk of adverse events

• Patients satisfied with treatment 86%

• Patients can consume reflux causing 60-80% foods without symptoms

EsophyX-TIF was shown to be effective in treating chronic

GERD as indicated by the significantly improved quality of

life and reduced dependency on daily PPIs.

The results at 12 and 24 mo supported a long-term

maintenance of the anatomical integrity of TIF valves.

Effectiveness - Conclusions

Linx®Antireflux system

Magnetic Sphincter Augmentation How does it work?

Yet, still in clinical trials

Is it feasible

Laparoscopic Sphincter Augmentation Device Eliminates Reflux Symptoms and Normalizes Esophageal Acid Exposure: One- and 2-Year Results of a Feasibility Trial

44 patients. At baseline, all patients had abnormal esophageal acid exposure on 24-hour pH monitoring and improved, but persistent, typical GERD symptoms while on acid suppression therapy with proton pump inhibitors (PPIs).

Patients were evaluated after surgery by GERD Health-Related Quality of Life symptom score, PPI usage, endoscopy, esophageal manometry, and 24-hour esophageal pH monitoring.

Results: The total mean GERD Health-Related Quality of Life symptom scores improved from a mean baseline value of 25.7 to 3.8 and 2.4 at 1- and 2-year follow-up, representing an 85% and 90% reduction, respectively (P < 0.0001). Complete cessation of PPI use was reported by 90% of patients at 1 year and by 86% of patients at 2 years. Early dysphagia occurred in 43% of the patients and self-resolved by 90 days. One device was laparoscopically explanted for persistent dysphagia without disruption of the anatomy or function of the cardia. There were no device migrations, erosions, or induced mucosal injuries. At 1 and 2 years, 77% and 90% of patients had a normal esophageal acid exposure. The mean percentage time pH was less than 4 decreased from a baseline of 11.9% to 3.1% (P < 0.0001) at 1 year and to 2.4% (P < 0.0001) at 2 years. Patient satisfaction was 87% at 1 year and 86% at 2 years.

Conclusions: The new laparoscopically implanted sphincter augmentation device eliminates GERD symptoms without creating undue side effects and is effective at 1 and 2 years of follow-up.

Bonavina et al. Annals of Surgery. 252(5):857-862, Nov. 2010.

Laparoscopic ProceduresLaparoscopic Procedureswith equivalencewith equivalence

Laparoscopic hernia repairLaparoscopic hernia repair

Laparoscopic appendectomyLaparoscopic appendectomy

Laparoscopic Inguinal Laparoscopic Inguinal Hernia RepairHernia Repair

The Ebers Papyrus 1550 BC, Entitled The Ebers Papyrus 1550 BC, Entitled “Beginning of the Secret of the “Beginning of the Secret of the

Physician” Physician”

Heat application was one of the methods to reduce a strangulated Heat application was one of the methods to reduce a strangulated hernia. hernia.

The mummy of Meren-Ptah (19th dynasty) shows a sign of an open The mummy of Meren-Ptah (19th dynasty) shows a sign of an open wound resulting from surgical interference.wound resulting from surgical interference.

If thou examinst a swelling of the covering If thou examinst a swelling of the covering of his belly’s horns above his pudenda (sex of his belly’s horns above his pudenda (sex organs) then thou shalt place thy finger on organs) then thou shalt place thy finger on it and examine his belly and knock on the it and examine his belly and knock on the fingers (percuss) if thou examinst his that fingers (percuss) if thou examinst his that has come out and has arisen by his cough. has come out and has arisen by his cough. Then thou shalt say concerning it: it is a Then thou shalt say concerning it: it is a swelling of the covering of his belly. It is a swelling of the covering of his belly. It is a disease which I will treat”.disease which I will treat”.

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 placement:Trocar placement:

TransabdominalTransabdominal

Preperitoneal (TAPP)Preperitoneal (TAPP)

TotallyExtraperitoneal

(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

• Gilmore’s groinGilmore’s 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

Management of recurrent Management of recurrent inguinal herniasinguinal hernias

Itani K, Fitzhibbons R, Awad S, Duh QY, Ferzli GS.

Management of recurrent inguinal hernias. JACS, Vol. 209,

No. 5, 653-658, Nov. 2009.

Are there contraindications to Are there contraindications to lap. inguinal hernia repair?lap. inguinal hernia repair?

ContraindicationsContraindications• Patients for whom general anesthesia and pneumoperitoneum Patients for whom general anesthesia and pneumoperitoneum

are risks (cardiac, pulmonary disease)are risks (cardiac, pulmonary disease)

Relative ContraindicationsRelative Contraindications• Prior pre-peritoneal surgery (prostate, hernia, vascular, kidney Prior pre-peritoneal surgery (prostate, hernia, vascular, kidney

transplant)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)

Itani K, Fitzhibbons R, Awad S, Duh QY, Ferzli GS. Management of recurrent inguinal hernias. JACS, Vol. 209, No. 5, 653-658, Nov. 2009.

Nerves prone to injury Nerves prone to injury anterior and posterioranterior and posterior

What are recommendations for prevention of chronic pain?

ConclusionsLevel 1B• Material reduced meshes have some advantages with respect to longterm discomfort and foreign body sensation in open hernia repair (when only considering chronic pain).Level 2A• Prophylactic resection of the ilioinguinal nerve does not reduce the risk of chronic pain after hernia surgery.Level 2B• Identification of all inguinal nerves during open hernia surgery may reduce the risk of nerve damage and postoperative chronic groin pain.

Treatment of chronic painLevel 3• A multidisciplinary approach at a pain clinic is an option for the treatment of chronic post herniorrhaphy pain.• Surgical treatment of specific causes of chronic post herniorrhapy pain can be beneficial, such as resection of entrapped nerves, mesh removal in mesh-related pain, removal of endoscopic staples or fixating sutures.

European Hernia Society Guidelines: Treatment of Inguinal Hernia in Adult Patients

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 ?

Factors Influencing Ventral Hernia Occurrence

The most important functions of the abdominal wall are protection, compression and retention of the abdominal contents, flexion and rotation of the trunk and forced expiration.

Endogen Exogene Others

Age > 45 Sutures Emergency BMI > 25 Length of incision Intra-abdominal Previous operation Contamination pressure Anemia Medication Shock Type of incision Smoker Corticoïds Aneurysm/Marfan (+30% risks)

Significant predictors of surgical site infection and incisional herniaa

Effect of Stitch Length on Wound Complications After Closure of Midline Incisions; A Randomized Controlled Study, Millbourn, D MD; Cengiz, Y MD, PhD; Israelsson, L MD, PhD Arch Surg/vol 144 (No. 11), Nov 2009 www.archsurg.com

Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); CI, confidence interval; OR odds ratio; SL, suture length; WL wound length

A Results of logistic regression analysis. All recorded variables were included in the model and removed by a backward reduction strategy if nonsignificant.

Predictor Regression Coefficient

(SE)

OR (95%CI)

Surgical site infection

Wound

contamination

1.03 (0.48) 2.81 (1.09-7.25)

Being diabetic 1.01 (0.38) 2.73 (1.30-5.72)

Long stitch length 0.77 (0.31) 2.15 (1.17-3.96)

Incisional hernia

Male sex 0.76 (0.34) 2.14 (1.10-4.15)

Higher BMI 0.05 (0.02) 1.05 (1.01-1.10)

Longer operation

time

0.005 (0.002) 1.01 (1.002-1.01)

Surgical site infection 1.16 (0.40) 3.18 (1.44-7.02)

SL to WL ratio <4 1.32 (0.52) 3.73 (1.36-10.26)

Long stitch length 1.44 (0.34) 4.24 (2.19-8.23)

Incidence of Ventral HerniasIncidence of Ventral HerniasIncidence of Ventral HerniasIncidence of Ventral Hernias

Around 10% of all laparotomies will generate incisional hernias. Around 10% of all laparotomies will generate incisional hernias.

The bigger the incision, the higher the risk.The bigger the incision, the higher the risk.~77% are median hernias~77% are median hernias~17% are lateral hernias~17% are lateral hernias~6% are iliac hernias~6% are iliac hernias

Direct closure have a high recurrences incidence (50%). The rateDirect closure have a high recurrences incidence (50%). The rate increases (58%) with repair of recurrent hernias.increases (58%) with repair of recurrent hernias.

Significant reduction in recurrences is achieved when meshes are used.Significant reduction in recurrences is achieved when meshes are used.

LuijendijkLuijendijk RW, et al. A Comparison of Suture Repair with Mesh Repair for Incisional RW, et al. A Comparison of Suture Repair with Mesh Repair for Incisional HerniaHernia.NEJM .NEJM 2000; 343:392-398 2000; 343:392-398

Laparoscopic Repair of Laparoscopic Repair of Incisional HerniasIncisional Hernias

wound complicationswound complications

recurrence raterecurrence rate

LOSLOS

painpain

coverage of “Swiss cheese” coverage of “Swiss 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

Potential Mesh-Related Potential Mesh-Related Complications:Complications:

InfectionInfection

Intestinal adhesionsIntestinal adhesions

Bowel obstructionsBowel obstructions

Erosion of the prosthesis into the adjacent hollow Erosion of the prosthesis into the adjacent hollow viscousviscous

Contraction of prosthesisContraction of prosthesis

Competition EvaluationCompetition Evaluation

CovidienPariextex Composite

BardComposix E/X

BardVentralex

EthiconProceed

Atrium C-Qur

GoreDualmesh

GenzymeSepramesh IP

Adhesion prevention

+++ + + + ? + ++

Tissue integration

++ + + + + - ++

Shrinkage + + + + + - +Elasticity

++ - - + ? - +Ease of fixation ++ + ++ + + - +

Protected edge Y Y Y N N N N

BiomeshesBiomeshes

Biomesh Type Products, Manufacturers

Human acellular dermis AlloDerm®, LifeCell

Flex HDTM, J&J

AlloMaxTM, Davol

Xenogenic acellular dermis PermacolTM (porcine), Tissue Science Laboratories

SurgiMendTM (bovine,calf), TEI Biosciences

CollaMendTM, (porcine) Davol

XenMatriX® (porcine), Brennen Medical LLC;Brennenmed.com

StratticeTM, LifeCell

Porcine small intestinesubmucosa

Surgisis®, Cook Medical

FortaGen®, Organogenesis

Leve

l of C

ompl

exity

Grade 1Low risk of infection

Low risk of complications

Grade 2Smoker

Immunosuppressed

Obese

Diabetic

Grade 4Active infection

Infected meshGrade 3

Contamination risk

Stoma present

Violation of bowel wall

Previous Wound infection

Grade 5Traumatic fascia loss

Extensive fascia loss

Percent Performed Open

Patients with co-morbid conditions have up to 4x increase in wound-infection rates

Open incisional hernias are 10x more likely to have infection than a clean surgical case

Infected mesh commonly results in a 2nd procedure for removal

Synthetic

Biologic

Comparison of laparoscopic and open repair with mesh for the treatment of

ventral incisional hernia: a randomized trial in 4 VA centres 162 patients with ventral incisional hernias.

RESULTS: Complications were less common in the laparoscopic group (23 patients [31.5%])

compared with the open repair group (35 patients [47.9%] Surgical site infection through 8 weeks was less common in the laparoscopic group

(5.6% vs 23.3%; AOR, 0.2; 95% CI, 0.1-0.6). The mean worst pain score in the laparoscopic group was 15.2 mm lower on a visual

analog scale at 52 weeks (95% CI, 1.0-29.3; P = .04). Time to resume work activities was shorter for the laparoscopic group than for the

open repair group (median, 23.0 days vs 28.5 days), with an adjusted hazard ratio of 0.54 (95% CI, 0.28-1.04; P = .06).

Overall recurrence at 2 years was 12.5% in the laparoscopic group and 8.2% in the open repair group (AOR, 1.6; 95% CI, 0.5-4.7; adjusted P = .44).

CONCLUSIONS: Laparoscopic repair was associated with fewer, albeit more severe, complications and improved some patient-centered outcomes

Itani et al. Arch Surg. 2010 Apr;145(4):322-8; discussion 328

Massive Incisional HerniasMassive Incisional Hernias

Components SeparationComponents SeparationComponents SeparationComponents Separation

Developed by Dr. Ramirez in the late 80’sDeveloped by Dr. Ramirez in the late 80’s

Employs the use of autologous myofascial tissue to effect abdominal Employs the use of autologous myofascial tissue to effect abdominal wall closurewall closure

Bilateral relaxation incisions 2cm lateral to the external oblique from Bilateral relaxation incisions 2cm lateral to the external oblique from costal margin to level of symphasis pubiscostal margin to level of symphasis pubis

Blunt separation of external oblique layer from underlying internal Blunt separation of external oblique layer from underlying internal oblique layer taking care not to interrupt vascular/nerve supplyoblique layer taking care not to interrupt vascular/nerve supply

May employ undermining of one or both posterior rectus sheaths to May employ undermining of one or both posterior rectus sheaths to achieve further medial advancementachieve further medial advancement

**Provides dynamic support of the abdominal girdle****Provides dynamic support of the abdominal girdle**

Components SeparationComponents Separation

Grevious MA. Cohen M. Shah SR. Rodriguez P. Structural and functional anatomy of the abdominal wall. Clinics in Plastic Surgery. 33(2):169-79, v, 2006 Apr.

External oblique

Internal oblique

Transversus abdominis

Rectus abdominis

Components SeparationComponents Separation

Case ReportCase Report

Laparoscopic AppendectomyLaparoscopic Appendectomy

Laparoscopic Appendectomy

Endo-loop

APPENDECTOMYAPPENDECTOMYAlternatively, an appendectomy can be Alternatively, an appendectomy can be performed through a trocar in the performed through a trocar in the umbilicus and two trocars in the umbilicus and two trocars in the suprapubic area medial to the epigastric suprapubic area medial to the epigastric

vesselsvesselsfor a superb cosmetic result (if an extended for a superb cosmetic result (if an extended right hemicolectomy is to be performed, the 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 childrenClear 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

In adultsIn adults Sauerland S, Jaschinski T, Neugebauer EA. Sauerland S, Jaschinski T, Neugebauer EA. Cochrane Database Syst Cochrane Database Syst

RevRev. 2010 Oct 6;10:CD001546.. 2010 Oct 6;10:CD001546.

CONCLUSIONS: In those clinical settings where surgical expertise and equipment CONCLUSIONS: In those clinical settings where surgical expertise and equipment

are available and affordable, diagnostic laparoscopy and LA (either in combination or are available and affordable, diagnostic laparoscopy and LA (either in combination or

separately) seem to have various advantages over OA. Some of the clinical effects of separately) seem to have various advantages over OA. Some of the clinical effects of

LA, however, are small and of limited clinical relevance. In spite of the mediocre LA, however, are small and of limited clinical relevance. In spite of the mediocre

quality of the available research data, we would generally recommend to use quality of the available research data, we would generally recommend to use

laparoscopy and LA in patients with suspected appendicitis unless laparoscopy itself laparoscopy and LA in patients with suspected appendicitis unless laparoscopy itself

is contraindicated or not feasible. Especially young female, obese, and employed is contraindicated or not feasible. Especially young female, obese, and employed

patients seem to benefit from LA.patients seem to benefit from LA.

Meta-analysis by Aziz et al. Meta-analysis by Aziz et al. Ann SurgAnn Surg 2006 2006

Conclusion: Laparoscopy was associated with decreased risk of incisional infection but with an increased risk of OSI. The degree of this increased risk varies depending on the clinical profile of a surgical patient. Recognition of these differences in risk may aid clinicians in the choice of operative approach for appendectomy.

Ann Surg. Dec 2010; 252:895-900

LAPAROSCOPIC PROCEDURES

WITH CLEAR ADVANTAGES.

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

Consensus Review of Optimal Perioperative Care in Colorectal Consensus Review of Optimal Perioperative Care in Colorectal Surgery, Enhanced Recovery After Surgery (ERAS) Group Surgery, Enhanced Recovery After Surgery (ERAS) Group

RecommendationsRecommendations

Fast-track ProtocolFast-track Protocol No oral bowel preparationNo oral bowel preparation Pre operative fasting of 2 Pre operative fasting of 2

hours for liquids and 6 hours hours for liquids and 6 hours for solids. Carbohydrate for solids. Carbohydrate loadingloading

Single dose antibiotic Single dose antibiotic prophylaxis.prophylaxis.

No routine use of nasogastric No routine use of nasogastric tubes.tubes.

Use of drains not advisable.Use of drains not advisable. Oral diet at will after surgery.Oral diet at will after surgery.

Conventional ProtocolConventional Protocol

Oral bowel preparationOral bowel preparation

Pre operative fasting of 6 Pre operative fasting of 6

hourshours

Prolonged antibiotic use.Prolonged antibiotic use.

Nasogastric tubes used Nasogastric tubes used

routinely.routinely.

Drains routinely used.Drains routinely used.

Delayed oral intake.Delayed oral intake.

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

Pulitanò C and Aldrighetti L Nat Clin Pract Gastroenterol Hepatol (2008)

Outcomes of laparoscopic hepatectomy

Conclusion: Laparoscopic resection is a favorable alternative to open

liver resection for patients with colorectal liver metastasis. The

observed actuarial survival values after laparoscopic resection

surpass the values expected by major scoring systems

Ann Surg. Dec 2010;252:1005-1012

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’!

Robotic Parathyroidectomy

Arm 1

Camera

Arm 2Arm 3

This approach was developed in South Korea by Dr. Woong Chung at Yonsei University College of Medicine in Seoul. He reported his experience with 338 patients

Confidential

Confidential

Confidential

Fourth arm trocar

External retractor

Connected with continuous suction

system

Maryland dissector

Harmonic curved shears

Confidential

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.

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 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 accessory portDependent on assistant for surgical support through accessory port

Greater surgeon fatigueGreater surgeon fatigue

Makes complex operations more difficultMakes complex operations more difficult

Past Present

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

- Hospital reimbursement same DRG- Hospital reimbursement same DRG

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!!

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

Trocarless LaparoscopyTrocarless Laparoscopy

The development of magnetically controlled and anchored, The development of magnetically controlled and anchored, intracorporeal surgical instruments and camera introduced intracorporeal surgical instruments and camera introduced

through a single trocar.through a single trocar.

A. Schematic representation of conventional transabdominal trocar A. Schematic representation of conventional transabdominal trocar and instrument (left) and proposed magnetically anchored and and instrument (left) and proposed magnetically anchored and guided instrument/camera (right). guided instrument/camera (right).

B. Schematic representation of typical multitrocar laparoscopic B. Schematic representation of typical multitrocar laparoscopic surgery (left) and proposed single trocar surgery through which surgery (left) and proposed single trocar surgery through which multiple MAGS instruments are introduced and deployed. multiple MAGS instruments are introduced and deployed.

The novel use of The novel use of

‘Light’ trocar‘Light’ trocar

A. Schematic representation of A. Schematic representation of

prototype internal camera prototype internal camera

fully deployed. fully deployed.

B. Internal view of camera fully B. Internal view of camera fully

deployed. deployed.

A. Schematic representation A. Schematic representation

of prototype paddle-type of prototype paddle-type

retractor fully deployed. retractor fully deployed.

B. Internal view of prototype B. Internal view of prototype

elevating porcine spleen. elevating porcine spleen.

Conclusion: With gastric bypass, type 2 diabetes can be improved and even rapidly put into the state of remission irrespective of weight loss. Improved insulin resistance within the first week after surgery remains unexplained, but increased insulin production in the first week after surgery may be explained by the enhanced postprandial GLP-1 responses Ann Surg. Dec 2010; 252:966-971

Historical Perspective 1955- Friedman

3 patients with poorly control DM

3-4 days after subtotal gastrectomy all 3 pateints showed an improvement in their DM

Occurred sooner than associated weight loss

Patients later regained their weight without an associated loss of glucose control or

glycosuria

Mingrone 1977 : Case report Young, non obese woman with DM who underwent BPD for chylomicronemia

Plasma insulin and blood glucose levels normalized within 3 months

Bittner –1981- subtotal gastrectomy and gastrointestinal reconstructions that excluded duodenal passage (B2 and RYGB Lowered plasma glucose and insulin Conclusion: Plasma glucose and insulin fall rapidly post-operatively

antidiabetic medications can be reduced or stopped shortly after gastrointestinal bypass interventions

Rubino F. Bariatric Surgery:effects on glucose homeostasis. Curr. Opin. Clin. Nutr. Metab. Care 9: 497-507Bittner R. Homeostasis of glucose and gastric resection: the influence of food passage through the duodenum Z Gastroenterology 1981; 19: 698-707.Friedman NM et al. The amelioration of diabetes mellitus following subtotal gastrectomy. Surg. Gynecol. Obstetr. 1955; 100:201-204

EndobarrierEndobarrier

EndobarrierEndobarrier

The EndoBarrier The EndoBarrier

gastrointestinal liner works by gastrointestinal liner works by

creating a physical barrier creating a physical barrier

between ingested food and the between ingested food and the

intestinal wall. intestinal wall.

Food bypasses the duodenum Food bypasses the duodenum

and proximal jejunum as it does and proximal jejunum as it does

in a Roux-en-Y gastric bypass. in a Roux-en-Y gastric bypass.

Endo-BarrierEndo-Barrier

Benefits include:Benefits include:

Weight loss Weight loss

ADA: glycemic control in Type 2 diabetes ADA: glycemic control in Type 2 diabetes

Safe alternative to gastric bypass Safe alternative to gastric bypass

Non-invasive procedure Non-invasive procedure

Rapid recovery Rapid recovery

Lower costs Lower costs

Feb 2010: Feb 2010: SchoutenSchouten

Objective:Objective: To determine the safety and efficacy of To determine the safety and efficacy of

EndoBarrier Gastrointestinal Liner EndoBarrier Gastrointestinal Liner

Duodenal-jejunal bypass sleeveDuodenal-jejunal bypass sleeve

Designed to achieve weight loss in Designed to achieve weight loss in

morbidly obese patients. morbidly obese patients.

First European experience First European experience 41 patients included 41 patients included

30 underwent sleeve implantation.30 underwent sleeve implantation.

11 - diet control group. 11 - diet control group.

All followed the same low-calorie diet All followed the same low-calorie diet

during the study period.during the study period.

2010: Schouten et al. Role of 2010: Schouten et al. Role of EndoBarrierEndoBarrier

26 devices were successfully implanted 26 devices were successfully implanted

Mean procedure time -35 min (range: 12–102 Mean procedure time -35 min (range: 12–102

min) min)

No procedure related adverse events. No procedure related adverse events.

Mean excess weight loss after 3 monthsMean excess weight loss after 3 months

19.0% device vs 6.9% for control (19.0% device vs 6.9% for control (PP < 0.002) < 0.002)

Type 2 diabetes mellitusType 2 diabetes mellitus

8 pts with baseline Type 2 diabetes mellitus 8 pts with baseline Type 2 diabetes mellitus

Improvement in 7 patients during the study Improvement in 7 patients during the study

period period

Schouten et al. A multicenter, randomized efficacy study of the EndoBarrier Gastrointestinal Liner for presurgical weight loss prior to bariatric surgery. Ann Surg. 2010 Feb;251(2):236-43.

2010: Schouten et al. Role of 2010: Schouten et al. Role of EndoBarrier EndoBarrier

The EndoBarrier Gastrointestinal Liner The EndoBarrier Gastrointestinal Liner Feasible and safe noninvasive device Feasible and safe noninvasive device

Excellent short-term weight loss results. Excellent short-term weight loss results.

Type 2 DM Type 2 DM Significant positive effect Significant positive effect

Long-term randomized and sham studies Long-term randomized and sham studies

necessarynecessary

Schouten et al. A multicenter, randomized efficacy study of the EndoBarrier Gastrointestinal Liner for presurgical weight loss prior to bariatric surgery. Ann Surg. 2010 Feb;251(2):236-43.

And it ought to be remembered that there is nothing more And it ought to be remembered that there is nothing more

difficult than to take the lead in the introduction of a new difficult than to take the lead in the introduction of a new

order of things, because the innovator has for enemies, all order of things, because the innovator has for enemies, all

those who have done well under the old conditions.those who have done well under the old conditions.

Nicolo Machiavelli (1469-1527), Nicolo Machiavelli (1469-1527), The Prince,The Prince, 1513 1513

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

Prevalence of Diabetes

• From 1980 through 2006, the number of Americans with diabetes tripled (from 5.6 million to 16.8 million).

• ~24 million in 2009.

CDC. National Diabetes Fact Sheet, 2007.Source: 2003–2006 National Health and Nutrition Examination Survey estimates of total prevalence (both diagnosed and undiagnosed) were projected to year 2007.

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: Duodenal-Jejunal Exclusion - Foregut2004: Duodenal-Jejunal Exclusion - Foregut

Slides taken from:Slides taken from:

DIABETES IS NO LONGER DIABETES IS NO LONGER A HOPELESS DISEASEA HOPELESS DISEASE

The Guilty GutThe Guilty Gut

Walter Pories, MD, FACS, Walter Pories, MD, FACS,

Chief, Metabolic Institute Chief, Metabolic Institute

East Carolina University Greenville,East Carolina University Greenville,

North CarolinaNorth Carolina

2006:

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

Double blind study: 16 patients assigned to

LRYGBP and 16 Pts to LSG

Patients reevaluated on the 1st, 3rd, 6th,

and 12th mos

Results:

No change in ghrelin levels after LRYGBP

Significant decrease in ghrelin after

LSG (P < 0.0001)

Fasting PYY levels increased after

either surgical procedure (P <= 0.001)

Appetite decreased in both groups but to

a greater extend after LSG

Weight loss, appetite suppression, and changes in fasting and postprandial ghrelin and peptide-YY levels after Roux-en-Y gastric bypass and sleeve gastrectomy: a prospective, double blind study.

Karamanakos et al Ann Surg. 2008 Mar; 247(3): 401-7.

“PYY levels increased similarly after either procedure.

The markedly reduced ghrelin levels in addition to increased

PYY levels after LSG, are associated with greater appetite

suppression and excess weight loss compared with LRYGBP”

March 2008: Weight loss, appetite suppression, and changes in fasting and postprandial

ghrelin and peptide-YY levels after Roux-en-Y gastric bypass and sleeve gastrectomy: a

prospective, double blind study. Karamanakos et al Ann Surg. 2008 Mar; 247(3): 401-7.

March 2008:March 2008:

2009: Ferzli et al2009: Ferzli et al

2009: Ferzli et al2009: Ferzli et al

2009: Ferzli et al. Results at 2009: Ferzli et al. Results at 12 months12 months AAll subjects consistently felt relief from fatigue, pain ll subjects consistently felt relief from fatigue, pain

and/or numbness in the extremities, polyuria, and and/or numbness in the extremities, polyuria, and polydypsia.polydypsia.

Clinical resolution was obtained for one patient, and Clinical resolution was obtained for one patient, and the preoperative diabetic medication requirements the preoperative diabetic medication requirements decreased for most of the other patients.decreased for most of the other patients.

The subjects demonstrated an overall improved The subjects demonstrated an overall improved HbA1c (from 9.4% to 8.5%) and fasting blood HbA1c (from 9.4% to 8.5%) and fasting blood glucose level (from 209 to 154 mg/dl).glucose level (from 209 to 154 mg/dl).

The Diabetes Surgery Summit Consensus Conference

Rubino et al. Annals of Surgery. Vol 251, Number3,300-405, March 2010

45% of type 2 patients with diabetes world-wide demonstrate a BMI less than 30

ADA : “ Bariatric Surgery should be considered for adults with BMI > 35Kg/m2And type 2 diabetes ,especially if the diabetes is difficult to control with lifestyle And pharmacologic therapy

The Surgeon and the Diabetologists

Patient Duration of Type 2 Diabetes

Pre-Operative Medication

1 Year Medication Requirement

#1 19 Metformin 850mg One tablet daily

Metformin 850 mg half tablet daily

#2 10 30/10 Units Insulin 30/10 Units Insulin

#3 12 40/20/20/20 Units Insulin

30 Units occasionally at night

#4 12 2 Metformin 850mg daily; 40/20 Units

Insulin

1 Metformin 850mg daily; 5 Units n

occasionally#5 12 40/20 Units Insulin 5 Units Insulin three

times per week

#6 * 6 20/12 Units Insulin No Medication

#7 4 Clormin 1000mg daily; 30/20 Units

Insulin

Diaformin 500mg daily; 30/20 Units

Insulin

Clinical Evaluation of the Effect of Duodenal-Jejunal Bypass on Type 2 Diabetes (June 2007)

Clinical Evaluation of the Effect of Duodenal-Jejunal Bypass on Type 2 Diabetes (June 2007)

Mean (SEM)Pre vs post op

Correlation P value*

HBA1C Pre-op 9.371 (0.85)

-0.040 0.933HBA1C 1yr 8.500 (0.67)

FBG Pre-op 208.86 (22.50

0.74 0.057FBG 1YR 154.86 (39.9)

Cholesterol preop 183.71 (11.5)

0.632 0.128Cholesterol 1yr 186.00 (19.9)

TG pre-op 112.43 (27.7)

-0.245 0.596TG 1yr 127.29 (25.3)

Cpep pre-op 1.343 (0.29)

-0.245 0.205Cpep 3 months 1.200 (0.32)

• The mean HBA1c at pre-op and 1 year was 9.371 and 8.500 respectively• FBG at pre-op and 1 year were 208 and 154 respectively for the seven patients (p=0.057) • Lipid profiles improved with lower total cholesterol levels and triglycerides 1 year

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