Lap Surgery and Colectomy
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Transcript of Lap Surgery and Colectomy
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Laparoscopy and Colon Surgery
K. Alapati
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When did we start getting crazy
How crazy are we now Are there limits for our crazyness
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History
Great Physician
Hippocrates of ancient
Greece (460-377)
made the original
reference of a
speculum to examine
the rectum.
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In the early 1800s, Philip Bozzini of Austriaexamined the urethra of a patient using a simple
tube and a candle light(basic design of a futureendoscope)
An improvised cystoscope was designed by Nitze in1855 where in light rays were gathered via mirrorsinto his instruments.
Edison invented light bulb in 1879
Eventually the light bulb was miniaturized andincorporated into the cystoscope.
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George Kelling of Germany
performed the first
laparoscopiccholecystectomy in a dog in
1901.
He went on to perform the
first Laparoscopy with
pneumoperitoneum usingroom air insufflation with
basic Nitze cystoscope.
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The first ever
documented evidence
of Laparoscopic
surgery by George
Kelling on a dog.
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Jacobeus of sweden
presented his first 100
cases of laparoscopy
and thoracoscopy in
1910.
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In 1911 Lap was introduced at JohnsHopkins by Bernheim and named by him asOrganoscopy.
Benefit of Co2 was discovered in 1920 asopposed to atmospheric air.
First laparoscopic tubal sterilisation in 1936 1938 Janos Veress of Hungary first
developed the spring loaded veress needle
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The infamous veress
needle is one of the
most importantinstruments today to
create
pneumoperitoneum
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The rigid rod lens
system was developed
by Professor Hopkinswho revolutionized the
concept of
Laparoscopic surgery
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Gynecologists first
embraced the technique of
laparoscopy and thoroughlyincorporated into their
practice.
1978 Hasson introduced an
alternative method of trocar
placement by proposing ablunt mini laparotomy.
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1985 first documented Laparoscopic
Cholecystectomy was performed by Eric Muhe.
1987 first video assisted Lap Chole by Phillip Mouret
1994 Robotic arm was designed to hold the camera
with the goal of improving safety
1996 first live telecast of laparoscopic surgery vai the
internet
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How crazy are we now
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Applications
In general Laparoscopy
is classified into
Basic Laparoscopic
Surgery
Mostly appendix, gall
bladder, diagnostic
Advanced Laparoscopic
Surgery
Takes us beyond our
limits
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Advanced Laparoscopy
Ranges from hernia
repair to the most
complex surgeries
Laparoscopic
transperitoneal
Abdominal Aortic
replacement with leftrenal artery direct
reimplantation in pigs
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Young science
Mile stones in Laparoscopic Colon and Rectal
Surgery
Procedure Surgeon Date
Rt colectomy Moises Jacobs June-90
Sigmoid resection Dennis Fowler Oct-90
LAR Patrick Leahy Nov-90
APR Robert Beart Apr-91
Total Colectomy Steven Wexner Aug-91
Transverse Colectomy Garth Ballantyne Feb-92
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Unique Features of Laparoscopic
Colectomy
Multiple quadrants
Major vascular division Specimen extraction
Reconstruction
Fecal spillage malignancy
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Challenges
Less than 10% of all colon resections areminimally invasive Steep learning curve
Concerns for cancer Data maturing/matured and its looking good!
Most US surgeons dont/cant/wont do it 30,000 general surgeons and 1500 colon and rectal
surgeons
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Laparoscopic Bowel resections
Laparoscopic Colectomy is different fromcholecystectomy Mobile organ
Larger organ means poorer visualisation
Penalty for tearing
Specimen must be removed intact
Anastomosis required
Ileus involved
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Learning curve
Steep (20-50 cases) Depth perception
Multiple quadrants
Reverse angles
Team coordination
Loss of tactile sensation
Lesser operating times
Chances of converting ???
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Laparoscopy for cancer
1990:
Increases port site recurrence ASCRS and German Surgical Society
Curative colon cancer surgery prohibited
Prospective studies: Laparoscopic colectomy for cancer is both safe
and oncologically sound.
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Myths
Port site recurrence
Increased OR time and cost CO2 pneumoperitoneum causes tumour cells
implantation
Reduced ability to explore abdomen and
localize tumor.
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Laparoscopy-Cancer research
Examined the incidence of free intraperitoneal cancer cells
15/103 (14.6%) cancers had positive cytology
Increased if More than 50% LN involvement
Poorly differentiated
Liver metastasis present
Solomon DCR, 1997
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Laparoscopy Tumor Growth
Rat experiment
Full incision promotes tumor growth morethan carbon dioxide
Tumor manipulation promotes tumor spread
more than carbon dioxide
pneumoperitoneum.
Gutt, Lorenz, Br J Surg, 1999
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CO2 influence on Cancer
Human cancer cells incubated with various
CO2 levels
No increase in growth
Takiguchi, Surg Endo, 2000
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Laparoscopic Registry PortsiteRecurrence
504 cancer patients
6 recurrences
1.3%
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COST trial summary
Cancer outcomes
No difference in Overall survival
Disease free survival
Wound recurrences
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Immunological benefits
Significant immunosuppression occurs after
Laparotomy
Does Laparoscopy alter immune function
Can this result in improve survival
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Hand assisted laparoscopic surgery
Using a surgeons most valuable tool the
hand
Benefits
Tactile sensation
Decreases learning curve
Decreases OR time
Same advantage as Lap assisted colectomy
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HALS
Provides surgeons with
the same tactile sense
as thay have in opensurgery
Retract, palpate and
dissect with their hand.
Recovery that parallelsstraight laparoscopic
procedure.
QuickTime and adecompressor
are needed to see this picture.
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HALS
Prevents conversion to total open procedure.
Hand placement depends on the targetorgan.
Why not open the wound couple more
centimeters and do the procedure open
Handoscopy wounds do not experience sametissue trauma as open procedure wounds.
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Learning Laparoscopy:
Skills lab for basic movements
Simulators
Animal lab
Decide if it is right for you
For vast majority, practice makes perfect
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SILS
Single Incision Laparoscopic Surgery
Use one port with multiple trocar openings Single scar
Significantly less pain
? Better recovery
MINIMALLY INVASIVE SURGERY-
MINIMIZED
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SILS
What can be done with SILS
Appendix
Gall Bladder
Kidney
Hysterectomy
Lap band
Adrenalectomy
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SILS
What does it look like
Usually multiple ports in
one trocar Slightly cumbersome
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What is the future
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Robotic Surgery
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Da Vinci
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NOTES
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Whaaaat!!!!Where did they remove the gallbladder from?
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NOTES stands for
Natural Orifice
TransluminalEndoscopic Surgery
What it means
is.just open your
mouth and say AAAAH!
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How is NOTES done
Pick a decent natural
orifice and figure out theprocedure
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2006, First ever video presentation of 6
Trans Gastric Appendectomies performed by
Rao & Reddy in Hyderabad, India.
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April 2nd, 2007 first
Trans Vaginal
Cholecystectomy wasdone on a 30yr old
female at the University
Hospital, Strasbourg,
France by Prof.Jacques Marescaux
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Will all these techniques survive?
Most likely not Can a combination of these techniques?
Most likely yes
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Key is to try and keep up with the advancing
technology
This way you will be ready when the time
comes so you dont have to start from
scratch
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What does this all mean to me?
Dexterity is the most important skill
You better be able to whistle and ride at thesame time
Dont be focused on just one point