Minimally Invasive Surgery, Robotics, Natural

Orifice Transluminal Endoscopic Surgery, and

Single Incision Laparoscopic Surgery

GABRIEL KLEMENS WIENANDA, MD

ILMU BEDAH DASAR
 Journey

Rigid and flexible

Placing a cystoscope within The percutaneous
endoscopes made a rapid
an inflated abdomen,was endoscopic gastrostomy
transition from diagnostic
first performed by Kelling (PEG) invented by Gauderer
instruments to therapeutic
in 1901. and Ponsky ( 1981s)
ones. ( 1970s)
Prosedur dari MIS

USG For MIS

CT Guaided Percutaneous

MRI for MIS

Laparoscopy
Venca Cava
Pressure

Pneumoperitone CO2
um N2O  Gas Emboli
( If there is
( Inflating using Analgetik, Direct acsess
Sphygmomanomet Rapidly absorb. to Venous
er) System)

DVT

Decrease
Renal blood
flow, GFR and
urin output
Decreasing
Thoracoscopy

No need positive Pressure ETT  deflated ipsilateral lung

MIS

Dangreous area  Vonous

Return, Mediastenal Shift, Diffrent With Laparoscopy
respiration
Anasthesia

cardiovascular performance by
reducing or removing the CO2
pneumoperitoneum

IV fluid administration should

not exceed that necessary to
maintain circulating volume

Short-acting anesthetic agents are

preferable
The Minimally Invasive Team

OR Nurse Specially for Laparoscopic

Complete Equipment

Laparoscopic Surgeon

Circulating Staff with Knowladge

Room Setup and the Minimally Invasive Suite

The video monitor(s) should be set across the operating table

from the surgeon

The patient should be interposed between the surgeon and the video
monitor

the monitor is placed at the 10 o’clock position from patient

the surgeon stands on the patient’s left at the 4 o’clock position

Patient Positioning

Lateral Decubitus Supine

( Retroperitoneum )

Position

45° tilt of the Patient

lateral position with table flexion to open the
Lesser Sac and The Lateral Peritoneal intercostal spaces and the distance between
attachment to the spleen the iliac crest and costal margin
( Splenectomy Laparoscopic) ( Thoracoscopic)
Laparoscopic Access
 The requirements for laparoscopy are more involved, because the creation of a
pneumoperitoneum requires that instruments of access (trocars) contain valves to
maintain abdominal inflation.

Direct Special
Puncture Technique
 The trocar must be pointed away from the sacral
promontory and the great vessels.
 CO2 gas usually is used, with maximal pressures in the
range of 14 to 15 mmHg
 N2O ( 2 L of gas is insufflated or a pressure of 10 mmHg)
 Prefer with General Anasthesia
 direct access to the abdomen is obtained with a 5- or 10-
mm trocar.
Access for Subcutaneous and
Extraperitoneal Surgery

An insufflation pressure of 10 mmHg usually is adequate to

keep the extraperitoneal space open for dissection and will limit
subcutaneous emphysema.

Higher gas pressures force CO 2 into the soft tissues and may
contribute to hypercarbia
Natural Orifice Transluminal Endoscopic
Surgery Access
 Transvaginal
 Trasvesicle
 Transanal
 Transcolon
 Transgastric

Multiple studies have shown safety in the

performance of NOTES procedures.
Hand Asist Laparoscopic
Energy Sources for Endoscopic
and Endoluminal Surgery
ROBOTIC
Remote laparoscopic cholecystectomy has been performed
when a team of surgeons located in New York performed a
cholecystectomy on a patient located in France
Endoluminal and
Endovascular Surgery
1. To much ballon expantion make necrotic around the vascular
2. Titanium Stanting
Natural Orifice Transluminal
Endoscopic Surgery
Single-Incision Laparoscopic Surgery
As surgeons sought
to reduce the number and size of abdominal wall trocars and
NOTES procedures necessitated laparoscopic surveillance

Using the anus as the portal of entry,

transanal endo scopic microsurgery
(TEMS) employs a specialized multichan
nel trocar to reach lesions located 8 to 18
cm away from the anal verge
Special Concideration

During Pregnancy
Children 1. Uterin Fundus 20 weeeks at umbilicus
1. Instrument more Shorter ( 15-20 cm) 2. Position avoid compression vena cava
Minimal Surgery in Cancer Treatment
2. Abdominal wall thiner (Presure need 8 3. Abdominal wall thicker (Presure need 15
mmhg) mmhg)
4. Hipercarbi  fetal acidosis

Eldery Cirrhosis and portal hypertension

1. High risk of anasthesia 1. Stress operation triger Hepatic failure/
2. Impaired Mobility ( High Complication) – hepatorenal syndrom
DVT, UTI, Pulmonary emboly / comp;ication 2. Hemmorage disorder  easy bleeding
Thank
You