Minimally invasive surgery

( MIS )

Roberto O. Domingo, M.D.,FPCS

 Types of procedure /surgery
• Non invasive- no break in skin ,no contact
mucosa e.g. ct scan , ultrasound, ESWL

• Minimally invasive surgery- less invasive

Laparoscopic, thoracoscopic

• Invasive / open surgery

Hippocrates 460-375 B.C.

rectal speculum
Philipp Bozzini “ light conductor”
George Kelling -1902

First cystoscope
Janos Veress – (1938) chest physician

Father of laparoscopy
 History MIS

Kurt Semm – ( 1983 ) German gynecologist

first lap appendectomy

Philippe Mouret ( 1987)- French surgeon

first lap cholecystectomy
• 1981 - Gauderer and Ponsky invented
percutaneous endoscopic gastrostomy (PEG)

considered as the first natural orifice

transluminal endoscopic surgery ( NOTES)
• CT guided drainage of abdominal fluid and
percutaneous biopsy of abnormal tissues- also
considered minimally invasive procedures
• Robotic surgery – computerized enhanced
surgery
• Developed in 2009 named Da Vinci Robot

• High definition three dimensional vision

• Provide mechanical assistance to surgeon

 Minimally invasive surgery
• Brain
• Cardiac
• Thoracic
• Vascular
• Abdominal ( laparoscopy)
 Benefits MIS
• Less operative trauma
• Less pain /scarring
• Shorter hospitalization
• Early recovery /return to work
• Operative procedure ( ± )

expensive
1982 –first videolaparoscope
 Laparoscopic surgeries
• Basic
 appendectomy
 cholecystectomy
 hernia repair
• Advanced
 gastrectomy splenectomy
 esophagectomy colectomy
 pancreatectomy adrenalectomy
 MIS team
• Lap surgeon
• Cameraman
• Assistant
• nurse
 Laparoscopic vs open surgery
stress response

• Endocrine balance -rapid equilibration

• Immune suppression- less
• Cytokine levels- rapid normalization
 anesthesia
• General

• Spinal – not recommended

 Laparoscopy- create space
• Abdominal lift
• Pneumoperitoneum
 air- N2 poorly absorbed –painful
 N20- rapidly absorbed pregnancy (?)
 C02- rapidly absorbed
 helium,argon- poorly absorbed,gas
embolism
 Thoracoscopic surgery
• no positive pressure needed

• Collapse ipsilateral lung to create a space

Gasless lap surgery
 Laparoscopic access
• 1. blind technique – veress needle

• 2. direct peritoneal access- Hasson’s technique

( preferred)
 Laparoscopic access port
gallbladder

Rt
hand
Lt hand

assistant

endoscope

Equilateral triangle; surgeons rt hand,left hand and telescope create a

diamond shape
 Effects C02 pneumoperitoneum
• Mechanical ( pressure )
 blood supply heart - ( > 20 mm Hg
pressure )
• stretch peritoneum- bradycardia

• Chemical -  C02 absorption ( > 35 )

respiratory acidosis
tachycardia
 BP
Lap tower

TV monitor

Image processor

Light source

insufflator

Cautery machine

recorder
Laparoscopic tower
insuflator
Endoscopy camera
World’s highest resolution HDTV surgical
camera
 endoscopes

10 mm
5 mm

3 mm

0 degree, 30 degree , 180 degree

Lap instruments
Setup lnstruments for lap chole
Energy sources
Capacitive coupling

Tissue injury undetected

Capacitive coupling effect
Direct coupling effect
Open surgery

Laparoscopic surgery

Single incision
laparoscopic
surgery ( SILS)
Needlescopic surgery
Single incision laparoscopic surgery
Natural orifice transluminal endoscopic
surgery (NOTES)
Robotic surgery
 considerations
• Pediatric
• Pregnancy
• Cancer
• Elderly
• Cirrhosis/portal hypertension
 MIS training
• Animal workshop
• Pelvic trainer
• Simulator
Concerns to develop/familiarize
• Magnified image
• Depth perception
• Can not hold tissues
Pelvic trainer
Laparoscopic virtual simulator training
Laparoscopic simulator
 What’s next?
• Technology
• Resources
• Painless and scarless surgery