MINIMALLY INVASIVE

SURGERIES
MODERATOR :Dr. A INDRAJIT
PRESENTED BY : SOWMIYA SREE S
SONIA NAYAK
B. S. SRI CHANDHINI
SRIMATHI G
Minimally invasive surgeries
 What is minimally invasive surgery ?
• A means of performing major operations through small incisions,often using miniatured ,high
tech imaging systems ,to minimise somatic and physiological trauma.
• ADVANTAGES-

Reduce wound access trauma

Cost effectiveness for both health
services and the patient
Less operative time and shortened
hospital stay
 PRINCIPLES OF MAS
๏ Insufflate
๏ Visualisation
๏ Inspection
๏ Triangulation
๏ Retraction of tissue
๏ Operations
๏ Seal
 Types of minimally invasive surgeries
Laparoscopy
Thoracoscopy
Arthroscopy
Angioplasty
Endoscopy
Endoluminal
Perivisceral NOTES
Robotic surgery
Endoscopic ultrasound
 Preparation of patient for MAS

‣ Routine investigation
‣ HbSAg,HCV
‣ Coagulation profile
‣ Other blood and serum tests according to ailment
‣ USG , CT scan , MRI
‣ cardiology fitness
‣ Informed consent
 Laparoscopic surgery

• Lapara - soft parts of body between rib margins and hip

• Skopein - to see or view or examine
๏ HISTORY -
• 1901 - primitive laparoscopy by G.Kelling
• 1985 - Muhe performed laparoscopic assisted cholecystectomies
• 1987 - Mouret and Dubious performed first video laparoscopy
 Indications of laparoscopy
• BASIC • LAPAROSCOPY ASSISTED
Appendicectomy PROCEDURE
Cholecystectomy Hepatectomy
Hernia repair
Hysterectomy
• ADVANCED
Pancreatectomy
•
Gastrectomy
•
Colectomy • DIAGNOSTIC
•
Splenectomy
Infertility
Ectopic pregnancy
Acute/ chronic pelvic pain
 Equipments
• Consists of imaging system , insufflating system and specialised surgical equipments.
• IMAGING SYSTEM -
LAPAROSCOPE

It may be a 10 mm or 5mm
laparoscope
Commonly used is a 0 degree angles
telescope but 30 degree allows better
visualisation and careful orientation.
LIGHT SOURCE -
Introduced through laparoscope with fibre optic cable powered by light source
High density light source like halogen or preferably xenon is used
CAMERA UNIT
Consists of camera head ,cable,camera control and TV monitor
Image seen through eye piece of laparoscope charge coupled device electric signals
processed by camera control TV monitor
• INSUFFLATING SYSTEM
Allows gas to fill abdominopelvic cavity for better visualisation and for bigger workspace
Commonly used gases are CO2 and N2O
 Principle of laparoscopic surgery
• To lift abdominal wall from abdominal organs by creating PNUEMOPERITONEUM
• Pressure achieved - 10-14 mmHg for abdominal surgeries and 5 - 8 mmHg for mediastinal
surgeries
๏ PHYSIOLOGICAL EFFECTS
Peritoneal stretching vagal stimulation sinus bradycardia
Metabolic acidosis
Pressure on arteries causes reduced RBF ,GFR and urine output
Decreased intra thoracic volume and increased intra thoracic pressure
 Creation of pneumoperitoneum
• Two ways - Veress needle and Hassan’s method
• Veress needle
12-15 cm length and 2mm diameter
Has beveled edge
Stop valve to regulate co2 flow
MC site of insertion - INFRA UMBILICAL
To check position- drop test and saline injection
• Hasson’s method or open method
Infra umbilical incision is made
Then Hasson’s trocar is inserted
Used in cases with previous abdominal surgeries
Procedure of laparoscopic surgery
• ADVANTAGES
Less postoperative pain
Earlier return to normal physiology
Shorter hospital stay
Better cosmesis
• DISADVANTAGES
•
Bleeding from trochar site
•
CO2 retention
•
Loss of tactile feedback
• CONTRAINDICATIONS
Absolute C/I
Peritonitis
Irreducible hernia
Abdominal obstruction
Relative C/I
Previous surgery
Abdominal sepsis
Morbid obesity
Pregnancy
Cardiopulmonary compromise
Aortic or iliac aneurysm
• COMPLICATIONS
Injury to bowel or bladder
Injury to major vessels
CO2 related complications such as
Hypercapnia
Carbon dioxide embolus
Capnothorax or pneumothorax
 ENDOSCOPY
• Endoscopy is a procedure that allows
a doctor to view the internal body
cavities and hollow internal organs
and perform scar free surgery via
natural body orifices ( mouth ,
rectum or vagina )by natural orifice
translumenal endoscopic surgery i.e
NOTES.
• Sites:
Esophagus ,thorax, stomach ,colon ,
heart, urinary tract ,
joints ,abdomen,pelvis .
Parts of an endoscope
• LIGHT SOURCE CONNECTOR

• CONTROL SECTION → controls endoscope function

• UMBILICAL CORD → attaches to :

 Processor - providing light
 Hookups- for air suction and water

• INSERTION TUBE→ part of endoscope that is inserted into the body cavity.

• BENDING PART
PRINCIPLE

Optical fibre present in endoscope travels smoothly through curved paths

Total internal reflection along the optical fibre

Light travels along the filament hitting at an angle to the filament walls

Viewing of places difficult to reach is possible

TYPES OF
ENDOSCOPES
PROCEDURE INSTRUMENT VIEWED AREA NATURAL BODY
ORIFICE

Bronchoscopy Bronchoscope Trachea, lungs Inserted through mouth

Arthroscopy Arthroscope joints Small incision through the

mouth

Colonoscopy Colonoscope Entire colon and large anus

intestine

Cystoscopy cystoscope Urinary bladder urethra

Anoscopy Anoscope Anus and rectum anus

Hysteroscopy Hysteroscope Uterus vagina

Colposcopy Colposcope Vagina and cervix vagina

NATURAL ORIFICE TRANSLUMENAL
ENDOSCOPIC SURGERY(NOTES)
It is a procedure that allows a doctor to view the internal body cavities
and hollow internal organs and perform scar free surgery via natural
body orifices ( mouth , rectum or vagina ) .
• Favourable routes includes:
Transvaginal access
Transgastric access
Transcolonic access
Transviceral access
Indications of NOTES
• Appendicitis
• Colonic polyps
• Tracheal pathology
• Abnormal uterine bleeding
• Detection of cancers of GI Tract
• Biopsies
• Balloon dilatation
• Endoscopic suturing
PERIVISCERAL ENDOSCOPY
• Access of body planes even in the absence of a natural body cavity.

• It includes :
Mediastinoscopy
Retroperitoneoscopy
Subfacial endoscopic perforator surgery in varicose vein surgery
Endoscopic harvesting of saphenous vein for coronary artery bypass
grafting
Hernia repair

• SITES : approach to kidney , aorta , lumbar sympathetic chain

ENDOSCOPIC ULTRASOUND (EUS)
• It’s a combination of endoscope and ultrasound probe to examine by
visualisation of layers of GIT and beyond.

• Helps visualise the :

complete thicknes of the wall of the organ
Adjacent lymph nodes
Adjacent structures
e.g bile duct , pancreas through duodenum or stomach EUS
• APPLICATIONS:
Staging of tumors
Biopsies
Assists in procedures of drainage of pancreatic pseudocytes
Gastrojejunal stenting to palliate obstructing pancreatic tumors
 ULTRASCOPIC PROBE

Radial echo endoscope Linear echo endoscope

Image produced is Image produced is

perpendicular to axis of parallel to axis of
insertion tube insertion of scope
ENDOSCOPIC MUCOSAL
RESECTION(EMR)
EMR is a minimally invasive , organ preserving technique to
endoscopically remove premalignancy or early stage cancer arising
from gastrointestinal epithelium as a mucosal- submucosal complex.

INDICATIONS
• Cancer related colonic indications
• Small carcinoid tumors
• Early stage esophageal cancers
• Barrett’s esophagus
CONTRAINDICATIONS
• Deep submucosal invasive
lesions
• Lesions in difficult anatomical
positions eg. Diverticulum
• Lesions >2cm in size
• EMR is done by any of the 2 procedures
1. SNARE POLYPECTOMY

2. STRIP BIOPSY METHOD

ENDOSCOPIC SUBMUCOSAL
DISSECTION(ESD)
• ESD is a minimally invasive procedure to dissect and remove the
tumours formed under the lining of GI Tract in submucosal layer

INDICATIONS
• Malignant tumors oof submucosal invasion
• Submucosal fibrotic lesions of<2cm
• Removal of early colorectal cancer
• Large polyp removal without transanal access
• Cases where snare tool cant be used to remove tumour
Procedure OF ESD
ADVANTAGES DISADVANTAGES

Less invasive or scarless Concern over closure of visceral

punctures site

Reduction in postoperative pain , Loss of tactile feedback

hospital stay duration,
Faster recuperation

Improves operative precision and Extraction of large specimens

visualization

Shortens operating time haemostasis

Reduced wound infection , hernia Reliance on new technologies

formations
 THORACOSCOPY
A rigid endoscope is introduced through an incision
placed between ribs to access the thorax.
In majority of cases a anaesthetic support is required to
ensure isolation of lung on side of surgery
patient is ventilated on non operative side by use of right
or left sided double lumen endotracheal tube (comp.
brochial & tracheal lumen)
 There is no requirement of gas insufflation usually
but in specific cases like mediastinal tumour
resection , diaphragmatic
surgery, gas insufflation
at low pressure 5-8mmHg
may be applied.
indications:
Diagnostic :
❑ Pleural effusions of unknown origin.
❑ Suspected tuberculous
effusions.
❑ Suspected malignancy with
inconclusive cytology.
❑Evaluating chest trauma.
❑Staging of lung cancer.
 Therapeutic:
 For pleurodesis in malignant or recurrent pleural effusion, recurrent
pneumothorax
 To divide adhesions in
recurrent/persistent
spontaneous pneumothorax
 To perform pleural toilet in
the fibrino-purulent stage
of empyema(drinage)

)
 Advantages
 Quick recovery time
 Less pain
 Higher diagnostic yield than percutaneous
procedures(thoracentesis)
 Fewer complications
 SINGLE INCISION MINIMAL ACCESS
SURGERY
 SILS involves insertion of all
instrumentation through a channel
port via a single incision at the
umbilicus(benefits - incision,
through a natural scar (the
umbilicus),
is virtually scarless and
that fewer port sites
potentially reduce
pain and
lessens the risks of
port site bleeding and
the potential for
port side hernia).
 SILS requires specially manufactured multichannel ports and
often roticulating instruments. And commonly been adopted in
gallbladder and hernia surgery, although more complex colon and
rectal surgery can be performed.

 DISADVANTAGES : The increased procedural difficulty, steep

learning curve and increased direct costs in terms of devices,
instruments and operating time can be offset by significant
clinical benefit.
 Uniportal thoracic surgery requires
less specialist equipment; many
minor thoracic procedures are
commonly performed using this
technique.

 Surgical approach for primary

spontaneous pneumothorax (PSP) in
single incision thoracoscopic surgery
(SITS).
 ARHTHROSCOPY
It is one of the endoscopic techniques used to diagnose and treat your
joints structural problem, using arthroscope which is a long ,thin tube
fitted with a video camera and light source.
Types :
elbow arthroscopy
hip arthroscopy
knee arthroscopy
shoulder arthroscopy
LIMITATIONS OF MINIMAL ACCESS
SURGERY
⮚LACK OF 3-D VISION:
To perform minimal access surgery with safety,
the surgeon operates using an imaging system that
provides a two-dimensional (2D) representation of the
operative site. which is different from the usual open
approach .
❖The instruments are longer and sometimes more
complex than those commonly used in open
surgery. This results in significant problems of
hand-eye coordination.
❖ Simulation training and monitoring are
required .
❖Three-dimensional (3D) imaging
systems are
available( expensive ,currently are not
commonplace) and it also causes
ergonomics problem (headache w/o
quantifiable benefit in accuracy and
time & reduced display brightness and
interfere with normal vision & need to
wear glasses )
❖It enhances potential in critical procedure like
knot tying ,dissection of closely overlaying
tissue
❖These factors currently limit stereoscopic
straight stick endoscopic surgery, which has
largely been super- seeded by the development
of robotic technology incorporating 3D vision.
⮚ INCREASED OPERATIVE TIME:

prolonged anaesthetic and

operative times may cause negate
no. of beneficial effects of MIS
Increase risk of
respiratory and wound
complications as well as
compression neuropathy and
venous thromboembolism.
 Ultrasonic dissection and tissue fusion devices continue
to evolve incremental technical improvement
 some devices combine all these function of sep
instruments ,reducing the need of instrument exchange
during procedure
 this flexibility ,combined with ability to provide
clean,smoke free field ,facilitates disection,improves
haemostasis and reduces operating times.
⮚ LOSS OF TACTILE
FEEDBACK:
Although it is less with
straight stick endoscopy than
robotic procedure
widely used examples
are appraisal of nodal disease
in cancer surgery and biliary
tract exploration.
TISSUE EXTRACTION :
By enlarging one incision ,so to facilitate removal without disruption
to specimen .
Ex – removal of lung via subxiphoid approach ( to reduce
intercostal neuropraxia)
Natural orifice extraction of abdominal resection specimen.
Complications – herniation, injury to str outside direct operative
field.
Surgery for malignancy- tumors are seperated by bagging ,irrigation and
protecting the extraction site.
COST :
Despite higher direct consumable
costs,improvements in outcomes, hospital stay and
general upscaling of procedural vol have resulted in
improved cost – effectiveness.
ROBOTIC SURGERY
• A robot is a mechanical device that performs automated physical tasks
according to direct human supervision , a predefined program or a set
of general guidelines , using artificial intelligence technology.

• In surgery , robots can be used to assist surgeons to perform operative

procedures, primarily in the form of automated camera systems and
telemanipulator.

• Results in the creation of human- machine interface.

 HISTORY
Dr. Frederick Moll Dr. Sudhir Srivastava
• The first documented clinical robotic
procedure was a computed
tomography CT guidedbrain biopsy
performed in 1985 utilising the
PUMA(Programmable Universal
Machine for Assembly )560 system.

• Followed by ROBODOC , a
preprogrammed active robot that
enabled precise preparation of the
femoral implant cavity during hip
replacement .
 TELEOPERATED(master –slave ) SYSTEMS

A surgeon performs an operation via a robot and its robotic instruments

through a televisual computerised platform where
Surgeon operator
Robot slave
 ACTIVE OR SEMIACTIVE SYSTEMS
typically image –guided or pre -programmed

• In active system , a surgical robot

completes a pre –programmed surgical
task
• This is guided by preoperative imaging
and real-time anatomical constraints
and cued through the application of
in-built navigation systems .
• In semiactive systems , the robotic
device may be in part pre-
programmed and in part surgeon
driven
 TYPES OF ROBOTIC SURGERY
SYSTEMS
1. Supervisory controlled robotic surgery system

2. Tele surgical system :3 types includes:

• Da Vinci robotic surgery systems
• ZEUS robotic surgery system
• AESOP robotic surgery system

3. Shared control robotic system

Da Vinci surgical AESOP robotic surgical ZEUS robotic surgical
system system system
 Common Procedures done by Da Vinci
surgical system
• Bladder cancer • Obesity
• Colorectal cancer • Prostate cancer
• Coronary artery • Throat cancer
disease
• Uterine fibroids
• Endometriosis
• Uterine prolapse
• Gynaecologic cancer
• Kidney cancer • Mitral valve prolapse
 ADVANTAGES
• Surgeons are able to perform more complex task, increased
precision ,physically easier ,less awkward positioning for surgeons.

• Risk of death complication and hospital stay reduced .

• Provides enhanced 3D high definition visualisation.

• Reduced trauma to body , less risk of infections

• Faster recovery
 DISADVANTAGES

• More expensive than traditional surgery

• Removal of physical contact with surgery surface

• Size of equipment can take up lot of space inside the operating room