Surgery Minimally Invasive Surgery

AY 2020-2021 Gilbert Oporto, MD

3rd Bimonthly 01/20/2020

OUTLINE ● Allows the surgeon to examine the abdominal organs on a video

Introduction monitor
Types of MIS ● Other small incisions are then made for instruments to perform
Laparoscopy procedures
● Instruments of laparoscopy:
INTRODUCTION → Laparoscopic tower
▪ Monitor, processor, light source, gas (CO2), recorder
● Minimally Invasive Surgery (MIS) ▪ Either “Stand-alone tower” or “Ceiling-Panel System”
→ Performing operations thru small incision (better ergonomy)
→ Minimal access surgery → Trocars
→ Not a discipline but more of a philosophy of surgery, a ▪ Used for access
way of thinking → Laparoscope/ Endoscope and Lap cord
→ Benefits of MIS of less post-op pain, early recovery, and → Cautery machine and cautery cord
better cosmesis must be weighed against overenthusiasm → Other Instruments:
of application and the problems created by a lack of ▪ Maryland dissector, Graspers, Scissors, Bobcock,
familiarity of instruments and new techniques. Retractors, Hook, Needle Holder

ADVANTAGES DISADVANTAGES
Smaller scar/ better cosmesis More costly
Less trauma to the patient Requires special skill/ training
Less post-op pain Required special equipment
Shorter hospital stay Steeper learning curve for
surgeons Stand-alone Laparoscopy Ceiling-panel system Laparoscopy
Less blood loss Not applicable in complicated
cases
Early return to work/ activity Peculiar risk of induced Gas Insufflation
pneumoperitoneum ● Controlled pressure insufflation of the peritoneal cavity is used to
achieve the necessary work space for laparoscopic surgery
TYPES OF MINIMALLY INVASIVE SURGERY ● Automatic insufflators: allow the surgeon to preset the insufflating
● Laparoscopy pressure, and the device supplies gas until the required intra-
● Thoracoscopy abdominal pressure is reached.
● SILS (Single Incision Laparoscopic Sx)
● NOTES (Natural Orifice Transluminal Endoscopic Sx)
● Robotic Surgery

LAPAROSCOPY
• A surgical procedure where a small incision is made, thru which
a viewing tube (laparoscope) with camera on the eyepiece is
inserted

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 Laparoscope
Abdominal Access ● Three important
structural differences in
Open Technique Closed Technique telescope available:
→ 6 – 18 rod lens
system telescopes
→ 0o – 120o
telescopes
→ 1.5 mm – 15 mm
telescopes

● Direct visualization in ● Blind insertion into

opening peritoneal cavity peritoneal cavity
● Uses Hasson’s Trocar ● Uses Veress Needle Optic Cables/ Lap Cord
● Cables are made up of a
bundle of optical fibers
glass thread swaged at
Endocrine Response both ends
● The greatest difference in Lap vs Open is: ● Have a very high quality
→ More rapid equilibration of most stress-mediated hormone of optical transmission,
levels but are fragile
● Immune suppression is also lesser
→ More rapid normalization of cytokine levels

Instruments Dissecting & Grasping

Forceps
Atraumatic
Trocars
● Has a blade with a shaft
and body
● The body includes a
pointed top which makes
the initial incision in the Kelly atraumatic
abdominal wall of the
patient.
● Diameter range:
2mm - 30mm
Atraumatic, with hollow
● Trocar distance from the jaws
target organ depends
upon the size of the
patient.

Mangeshikar grasping
forceps, serrated

● Additional trocars can be

added along the
semicircular line.

● Individual trocars can be

moved to the target
along an axis line.

Inguinal Hernia Repair

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 Types of Lap Hernia Repair
1. TEP (Total Extraperitoneal) Repair REFERENCES
2. TAPP (Trans-abdominal preperitoneal) Repair Dr. Oporto’s PPT

Nissen Fundoplication

Complications of Laparoscopy
● Complications of Trocar Access
→ Injury to intra and retroperitoneal organs and vessels,
abdominal wall hematoma
● Physiologic Complications of Pneumoperitoneum
→ Respiratory acidosis (CO2)
→ Decrease cardiac output (30%)
→ Increase SVR
→ DVT
→ Advantage: Decrease stress metabolic response and hepatic
catabolic response
● Specific procedure complication

Physiology & Pathophysiology of MIS

● Has effects to cardiovascular, endocrinologic, immunologic
systems
● Pneumoperitoneum (Gas used: CO2, N2O, Argon, Neon,
Helium)
● Physiologic effects of CO2 Pneumoperitoneum
→ Local effects:
▪ Peritoneal distension
▪ Vagal Reaction
▪ Elevated diaphragm
▪ Altered venous return
▪ Pain
→ Systemic effects:
▪ Hypercarbia
▪ Acidosis
▪ Increased afterload
▪ Increased catecholamines
▪ Myocardial stress

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 Surgery Minimally Invasive Surgery Day 2
AY 2020-2021 Gilbert Orporto, MD
3rd Bimonthly 01/21/2021

ROBOTICS
OUTLINE
Complications of Laparoscopy What Robotics Aimed to Improve in Laparoscopy
Physiology & Pathophysiology of MIS ● Surgeon operates from a 2D image
Robotics ● Straight, rigid instruments (limited range of motion)
Single Incision Laparoscopic Surgery (SILS) ● Instrument tips controlled at a distance
Natural Orifice Transluminal Endoscopic Surgery (NOTES) ● Reduced dexterity, precision, & control
→ the robot can filter the surgeons tremors
COMPLICATIONS OF LAPAROSCOPY ● Unsteady camera controlled in laparoscopy
● Dependent on assistant
Complications of Trocar Access ● Greater surgeon fatigue
● Injury to intra & retroperitoneal organs and vessels, abdominal ● Makes complex operations
wall hematoma
Surgical Robots
Physiologic Complications of Pneumoperitoneum ● AESOP - Automated Endoscopic System for Optimal Positioning
● Respiratory acidosis (CO2) → voice activated mechanical arm
● Decreased cardiac output (30%) → steadier than human, never tires
● Increase SVR, DVT ● da Vinci
● ADVANTAGE: → FDA approval in 2002
→ Decrease stress metabolic response and hepatic catabolic → laparoscopic instrumentation controlled by the surgeon
response → positioned remotely at a console

PHYSIOLOGY & PATHOPHYSIOLOGY OF MIS Development of da Vinci

● Has effects to cardiovascular, endocrinologic, immunologic ● Defense Advanced Research Projects Agency (DARPA) for
systems military research of remote battlefield surgery
● Pneumoperitoneum → Cholecystectomy performed remotely via telesurgery from
→ Gas used: 300 miles away
▪ CO2 - most commonly used → Intuitive surgical created in 1999 after acquiring patent
▪ N2O rights from military
▪ Argon → First robotic prostatectomy performed in 2001
▪ Neon
● What is the da Vinci Surgical System?
▪ Helium
→ State-of-the-art robotic technology
● Physiologic Effects of CO2 Pneumoperitoneum
→ Surgeon in control
→ Local Effects: where the gas is
▪ console - where the surgeon is operating
▪ Peritoneal distension
▪ Vagal reaction - sudden stretch of nerves
▪ Elevated diaphragm - due to increased intraabdominal
pressure and may have certain effects on the patient’s
breathing
▪ Altered venous return - veins decompressed by the
pressure that’s why the gas regulator is very important
because we don’t want the pressure in the intra abdominal
cavity to exceed the physiologic pressure
▪ Pain
→ Systemic Effects:
▪ Hypercarbia → Assistant has direct access
▪ Acidosis → Surgeon directs precise movements of instruments in the
▪ Increased afterload - due to increased intraabdominal slave unit using console controls
pressure
▪ Increased catecholamines
▪ Myocardial stress

frbm Excelsus 2023 1 of 3

 Wrist and Finger Movement
● Laparoscopic instruments are rigid with no wrists
● EndoWrist Instrument tips move like a human wrist ● Training needed
→ allows surgeons to operate with increased dexterity and ● Port Site Hernia
precision. No tremor → 2nd highest risk next to open surgery
→ laparoscopic or robotic surgery has the least risk but still
SINGLE INCISION LAPAROSCOPIC SURGERY (SILS) possible to develop
There’s only one trocar and in that trocar are some smaller trocars.
patient will have on but a bigger scar

NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC

SURGERY (NOTES)

● 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
→ utilizes the natural anatomic openings of the body usually
mouth, vagina, and the rectum
● Scarless surgery

NOTES - Transvaginal
● Video-endoscope entering through the posterior vaginal fornix
→ induce air/ induce pneumoperitoneum to have a larger
● Ergonomically difficult surgical field and then using the different manipulators at
→ instruments might overlap with each other the tip of the scope which has also slide source and
camera where they can do the cholecystectomy and other
procedures

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 NOTES - Transgastric
● can be done through the stomach

REFERENCES
Doc Gilbert’s PPT

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