Neil Mendoza, MD, FPALES, FPSGS

Early endoscopists
• lack of a satisfactory light source
• physicians relied on sunlight reflected by
mirrors or focused through flasks of water
• In the early 1800s
– candles or paraffin lamps for illumination the
idea of "a magic lantern into the human body"
• 1910: Swedish internist; first thoracoscopic
diagnosis with a cystoscope in a human subject
• 1911 : First laparoscopy at Johns Hopkins
• 12mm proctoscope into epigastric incision on one
of Halsted’s patients to stage pancreatic cancer
• Bernheim called his procedure ‘organoscopy’
• Findings confirmed on laparotomy
 HISTORY
• 1920: Zollikofer discovered the benefit of CO2 gas for
insufflation

• 1938: Janos Veress developed a spring loaded needle for the

induction of pneumoperitoneum
•
• After World War II, the development of fiberoptics
represented an important step forward for endoscopy

• 1966: Hopkins rod lens scope & cold light

• 1974: Dr Harrith Hasson proposed a blunt mini-laparotomy

which permitted direct visualization of the trocar entrance
into the peritoneal cavity- Hasson‘s technique
First experimental laparoscopy

• was performed in Berlin

in 1901
• German surgeon Georg
Kelling
• used a cystoscope to
peer into the abdomen
of a dog after first
insufflating it with air Georg Kelling
 First human laparoscopy
• performed in Sweden by Jacobeus in 1910
to investigate ascites

• coined the words "laparoscopie" and

"thoracoscopie“

• Jacobeus was first to publish a series of

abdominal and thoracic examination in
humans using minimally invasive
techniques
 “Father of modern laparoscopic
surgery"

• 1929, Kalk
• advocated a second puncture site
– pneumoperitoneum
• described several diagnostic and
therapeutic laparoscopic procedures
• devised a sophisticated lens system
• Fiberoptic technology and closed-circuit
videolaparoscopy evolved in the 1950s.
• This development enabled surgeons to
deliver more intense light with less heat,
and allowed the participation of an
assistant in the procedure
• The most important development was the
advent of the insufflator (Kurt Semm),
fiberoptics and the rod-lens system
(Harold Hopkins) 1982
  Mouret performed
the first human
laparoscopic
cholecystectomy
in France in 1987

Dr. Phillipe Mouret

• United States and the United Kingdom
followed in 1988 and 1989

• patients demand “Band-Aid” surgery

instead of traditional open techniques
 Minimally Invasive Surgery
• Band aid surgery
• Key hole surgery
• Button hole surgery
• Minimal access surgery
• Endoscopic surgery
• Pin hole surgery
 Definition:
Minimal access surgery is a marriage of
modern technology and surgical innovation
that aims to accomplish surgical
therapeutic goals with minimal somatic
and psychological trauma
 Advantages
• Improved diagnosis
• Less tissue disruption
– less wound infection
– less postoperative pain
– less chance of adhesions
• Early return to work
• Cosmetically better outcome
• Less surgery associated complications
– pneumonia, thromboembolism
 Minimal tissue injury

less
Permitting
tissue
Better dissection
the
cosmeticpatient
and
to
result
lower associated morbidities
Early return
disruption
to work
of tissue
and normal
planesactivity
 Infected cases

peritoneal cavity can be more

thoroughly irrigated

free fluid and purulent collections

aspirated under direct vision
Infertility problems in female patients

reduced because of
lesser intra-abdominal adhesions
 Post-operatively

do not require intravenous

narcotic medications in most
cases

allowed oral feeding when

hungry
 Surgical stress response in
laparoscopic surgery
• Endocrine balance • Rapid equilibration
of stress mediators
• Immune • Lesser
suppression
• More rapid
• Cytokine levels normalization
 Disadvantages
• A bit more expensive
• Potential for major complications in
inexperienced hands
• Loss of tactile feedback
• Difficult in complicated cases
– longer operative time
Today, virtually no abdominal organ
is exempt from laparoscopic
technique
 Extent of Minimal Access Surgery
• Laparoscopy
• Thoracoscopy
• Endoluminal endoscopy
• Arthroscopy and intra-articular joint surgery
• Combined approach
 Laparoscopic Procedures
Diagnosis Operation
Gallstone Cholecystectomy
Appendicitis Appendicectomy
Hernia Hernia repair
Adhesions Division of adhesions
Perforated ulcer Closure of perforation
Hiatal Hernia Hiatus hernia repair
 Open vs Lap…differences
Open Surgery Laparoscopic Surgery
• Fast • Slow and steady
• Hand is as good as eyes • Stop when you don’t
• Dissection is priority see
• Ergonomics: Optional • Hemostasis is priority
• Ergonomics: Vital
• Magnified view often better than obtained via an
incision allows precise dissection.
• Altered (but not absent) tactile response
• Two dimensional (flat screen) view
• Usually (but not always) longer operating time
• Need to develop entirely different operating
technique
• Adaptation of principles of open surgery to
laparoscopic surgery
• Redesign of instruments for laparoscopic use.

• Instruments for open surgery in general 6 –

10” in length built around a box joint

• Laparoscopic instruments in general 15 – 18”

in length with an articulated connecting rod
between handles and scissor blades, jaws etc.
 MIS: Basic equipment
• Camera
• Light Source
• Insufflator
• TV Monitor
• Telescopes
• Light Guide Cable
 CAMERA
• These can be single chip or 3 chip(red, green,
blue)

• CHIP: this is also called a charged coupled

device in short (CCD)

• White balance
 LIGHT SOURCE
• Halogen or Xenon, cold light

• White balance by making sure white is correct

then all the colors through the spectrum are
correct
 INSUFFLATOR
• Blows CO2 gas
• CO2 has the same refractive index as air, so
doesn’t distort the image; non-combustible.
• Intraabdominal pressure between 10 and 13
mmhg
• Filter and tubings for CO2 delivery
• High flow insufflators (35 litres)
 INSUFFLATOR
• Controlled pressure insufflation of the peritoneal
cavity is used to achieve the necessary work space
and exposure

• Automatic insufflators allow the surgeon to preset

the insufflating pressure & the machine supplies gas
until the pressure is reached

• Alarm sounds when IAP rises more than preset

pressure
 INSTRUMENTATION
• Single use
• Reusable
• 5 & 10mm PORTS are the most common
• Appropriate trocar is in port (blunt or sharp)
• TROCAR sharp - pointed surgical instrument fitted
with a cannula and used especially to insert the
cannula into a body cavity
• CANNULA - a tube that is inserted into a cavity by
means of a trocar within its lumen
 LAPAROSCOPE
• Come in varying sizes; usually 5mm or 10mm.
• Made up of a rod and lens system
• Bundles of fibres, incoherent carry light and
coherent carry image.
• Angles available 0, 30, 45 degree are fairly
standard.
• Autoclavable and can go through sterilisation
LAPAROSCOPE
 FIBEROPTIC CABLES
• made up of a bundle of optical fibers glass
thread swaged at both ends
• fiber size used is usually between 10 to 25
mm in diameter
• very high quality of optical transmission but
are fragile
FIBEROPTIC CABLES
 INSTRUMENTATION
• Reusable three-piece design
• Available in 2 mm, 3 mm, 3.5mm, 5 mm and
10 mm sizes, with lengths of 20 cm, 30 cm, 36
cm and 43 cm
• Choice of handle styles
• Fully rotating 360° sheath
• No hidden spaces that can trap operative
blood and tissue debris
 INSTRUMENTATION
Attachments
Base
INSTRUMENTATION
TROCAR PLACEMENT
TROCAR PLACEMENT
TROCAR PLACEMENT
 TROCAR PLACEMENT

Camera gets in the way

Proper spacing - min of 5cm
TROCAR PLACEMENT
TROCAR PLACEMENT
TROCAR PLACEMENT
ERGONOMICS
VISUAL-SPATIAL ORIENTATION
VISUAL-SPATIAL ORIENTATION
 VISUAL-SPATIAL ORIENTATION

30-45 degrees 60-90 degrees

VISUAL-SPATIAL ORIENTATION
VISUAL-SPATIAL ORIENTATION
ERGONOMICS
ERGONOMICS
ERGONOMICS & TROCAR POSITION
 COMPLICATIONS of MIS
1. Anaesthetics Complications
2. Complications due to pneumoperitonium
3. Surgical complications
4. Diathermy related injuries
5. Patients factors related complications
6. Post operative complications
SURGICAL COMPLICATIONS
DIATHERMY Related INJURIES
Patient Related Complications/Factors
POSTOPERATIVE Complications
CONTRAINDICATIONS
EMERGING TECHNOLOGIES
Robotic Surgery
ABC’s of MIS