Minimally Invasive Surgery, Robotics,

Natural Orifice Transluminal

Endoscopic Surgery, and Single-
Incision Laparoscopic Surgery

Leonard K Saleh
Perceptor : dr.M Iqbal Rivai SpB KBD
Minimally invasive surgery is a
• means of performing major operations
through small incisions,
• often using miniaturized,
• high-tech imaging systems,
• to minimize the trauma of surgical
exposure

John Wickham’s
→minimally invasive surgery(MIS)
HISTORICAL BACKGROUND
• MIS is relatively recent, the history nearly 100 years
• laparoscopy → the oldest →Kelling in 1901→ hot and dangerous
• Hopkins 1950 no heat and little light loss

• Flexible endoscopic imaging 1960 with the first bundling of many

quartz fibers into bundles, one for illumination and one for imaging
 diagnosis
 treatment
 early detection

• The first endoscopic surgical procedure was the colonoscopic

polypectomy ,Shinya and Wolfe
Laparoscopy
• laparoscopic surgery is the need to lift the abdominal wall from the
abdominal organs.
• Air pneumoperitoneum more painful than nitrous oxide (N2O) but
less painful than carbon dioxide (CO2)
Thoracoscopy
• different of laparoscopy
• no positive pressure
• necessary to place a double lumen endotracheal tube
Extracavitary Minimally Invasive Surgery
• Many MIS procedures create working spaces in extrathoracic and
extraperitoneal locations
• Laparoscopic inguinal hernia→anterior extraperitoneal Retzius
space.
• Laparoscopic nephrectomy →retroperitoneal laparoscopy
Anesthesia
• knowledge of the pathophysiology of he CO2 pneumoperitoneum.
• factors that require hospitalization after laparoscopic procedures
include
-the management of nausea,
-pain,
-urinary retention,

the anesthesiologist should

• minimize the use of agents that provoke these conditions and
• maximize the use of medications that prevent such problems
The Minimally Invasive Team
• A typical MIS team may consist of a laparoscopic surgeon
• and an operating room (OR) nurse with an interest in laparoscopic
and endoscopic surgery
• assistants and with an intimate knowledge of the equipment
Room Setup and the
Minimally Invasive Suite
• two images are necessary to
adequately guide the operation
• the minimally invasive surgical
suite has facilitated the
performance of advanced
procedures and techniques
• monitors, insufflators, and
imaging equipment
Patient Positioning
• supine position for
laparoscopic surgery
• operate from between the legs
→ Allen stirrups
lateral decubitus position
with the table flexed
General Principles of Access
• natural ports of access
-The nares,
-mouth,
- urethra,
-and anus are used to access the respiratory, GI, and urinary
systems→ no incision
Laparoscopic Access
• direct puncture laparoscopy
• A small incision is made in the
umbilicus
• The umbilicus usually is
selected as the preferred point
of access,
why?
Hand-Assisted
Laparoscopic Access
• combine the tactile advantages
of open surgery with the
minimal access of laparoscopy
and thoracoscopy
• for difficult cases
Natural Orifice
Transluminal
Endoscopic Surgery
Access
• safety in the performance
• The ease of decontamination,
entry, and closure of these
structures
Single-Incision
Laparoscopic Surgery
Access
• The advantage of this
technique is that conventional
laparoscopic tools can be
employed
-faster access,
- improved safety,
-minimization of air leaks
-platform-derived
instrument triangulation.

The major disadvantage is cost

Multiple trocars
through single
skin incision
Port Placement
• The ideal trocar orientation
creates an equilateral triangle
• between the surgeon’s right
hand, left hand, and the
telescope,with 10 to 15 cm on
each leg
 Robotic Surgery
• The first computerassisted
surgical device was the
laparoscopic camera holder
• master-slave surgical platform
that returned the wrist to
laparoscopic surgery and
improved manual dexterity by
developing an ergonomically
comfortable work station, with
• 3-D imaging, tremor
elimination, and scaling of
movement
Room setup and position of surgeon and assistant for
robotic surgery. (©2013 Intuitive Surgical, Inc. Reprinted
with permission.)
• The robotic platform (da Vinci) was initially greeted with some
skepticism by expert laparoscopists
– difficult to prove additional value for operations
– operations longer
– equipment more expensive

but additional quality could not be demonstrated

Two randomized controlled trials compared robotic and conventional
laparoscopic
-time was longer for robotic surgery,
- no difference in ultimate outcome
Natural Orifice
Transluminal
• Endoscopic Surgerythe flexible
endoscopeto patients wishing
to avoid scars and pain caused
by abdominal wall trauma
• Concerns about the safety of
transluminal access and
limitations in equipment remain
the greatest barriers to
expansion

Transgastric cholecystectomy using natural orifice transluminal

endoscopic surgery technology and one to three laparoscopic
ports has been performed occasionally in several locations around
the world
Single-Incision Laparoscopic Surgery
As surgeons sought to reduce the number and size of abdominal wall
trocars
-preexisting scar,
-is thought to be less painful,
-have fewer wound complications
- lead to quicker return to activity
-have a better cosmetic
Pediatric Laparoscopy
• advantages of MIS in children may be more significant than in the
adult population
• laparoscopy in the infant and young child requires specialized
instrumentation, instruments are shorter

Laparoscopy during Pregnancy

• safety of laparoscopic cholecystectomy or appendectomy in the
pregnant patient
• uterine fundus →umbilicus at 20 weeks
Minimally Invasive Surgery and Cancer Treatment
• palliation for the patient with an obstructive cancer
• Laparoscopy also is used to assess the liver in patients being
evaluated for pancreatic,gastric, or hepatic resection
• New technology and greater surgical skills allow for accurate
minimally invasive staging of cancer

Considerations in the Elderly and Infirm

The advantage of MIS lies in what happens after the operation
Much of the morbidity of surgery in the elderly is a result of impaired
mobility