Minimal Invasive Surger

8/22/2019 Minimal Invasive Surger

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Minimal invasive surgery


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History of minimal invasive

surgery Hippocrates - rectum examination with

a speculum

1806,Philip Bozzini - built aninstrument that could be introduced in

the human body to visualize the internal

organs. He called this instrument"LICHTLEITER"


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surgery 1868, Kussmaul performed the first

esophagogastroscopy on a professional

sword swallower, initiating efforts atinstrumentation of the gastrointestinal tract.

1901, The first experimental laparoscopy was

performed in Berlin in 1901 by this German

surgeon Georg Kelling, who used acystoscope to peer into the abdomen of a dog

after first insufflating it with air.


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surgery 1929, Kalk, a German physician,

introduced the forward oblique (135

degree) view lens systems. He

advocated the use of a separate

puncture site for pneumoperitoneum.

Goetze of Germany first developed aneedle for insufflations.


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surgery 1938, Janos Veress of Hungary

developed a specially designed spring-

loaded needle. Interestingly, Veress did

not promote the use of his Veress

needle for laparoscopy purposes. He

used veress needle for the induction ofpneumothorax.


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surgery 1983,Semm, a German gynaecologist,

performed the first laparoscopicappendicectomy.

1985, The first documented laparoscopiccholecystectomy was performed by ErichMhe in Germany in 1985.

1987,Phillipe Mouret, has got the credit toperformed the first laparoscopiccholecystectomy in Lyons, France usingvideo technique.


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surgery 1994,A robotic arm was designed to

hold the telescope with the goal of

improving safety and reducing the needof skilled camera operator.

1996,First live telecast of laparoscopic

surgery performed remotely via theInternet. (Robotic telesurgery)


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Equipment and instrumantation

Imaging System

- Laparoscopes- Cold light source

- Cameras

- Monitor


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Equipment and instrumantation

Dissectors

Hooks and spatulas

Clip appliers and endolinear cutter

Insuufflation/ Veress needle

Suctiom and irrigating apparatus Trocars


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Advantages of minimal invasive

surgery Safe

Reduced postopertive morbitity (pain,

fatigue, pulmonary embarrassement)

Faster return of bowel function

Shorter lenght of hospital stay

Rapid return to normal activity

Cost-effective


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Avoiding complications during

laparoscopy Training

Patient selection

Room setup

Port placement (site/technique)

Visualisation (equiepment/blood or debris)

Familiarity with anatomical landmarks

Early consultation


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Laparoscopy Today

Diagnostic laparoscopy

- gynecology/acut-chronic abdominal pain

- cancer staging/diagnosis

Emergency laparoscopy

- Appendectomy

- Surgical managment of perforated peptic ulcer- Surgical managment of diverticular diseases

- Intestinal obstruction


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Minimal invasive general surgery

Esophago-gastric surgery

Liver, pancreas surgery

Colorectal surgery

Endocrine surgery

Surgery of the abdominal wall


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Minimal invasive surgery

Thoracoscopic surgery (lung, esophageal

surgery) Cardio-vascular surgery

Gynecology

Urology


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Minimally Invasive

Techniques in the Surgery ofthe Esophagus


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Surgical approaches

of the esophagus

LAPAROTOMY

THORACOTOMY

TRANSCERVICAL

LAPAROSCOPY

THORACOSCOPY

MEDIASTINOSCOPY

ENDOLUMINAL


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MINIMALLY INVASIVE

TECHNIQUE IN ESOPHAGEAL

SURGERY

GERD, HIATAL HERNIAS,

ESOPHAGEAL DIVERTICULA ACHALASIA, OTHER MOTILITY

DISORDERS

ESOPHAGEAL PERFORATIONS

BENIGN TUMOURS

MALIGNANT TUMOURS ?


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MINIMALLY INVASIVE

SURGERY OF THE ESOPHAGUS

Department of Surgery, University ofSzeged, 1994 - 2001

LAPAROSCOPIC

NISSENFUNDOPLICATION

HELLER MYOTOMY

THORACOSCOPIC

ENUCLEATION OFBENIGN TUMOURS

ENDOSCOPIC

STAPLING

DIVERTICULOSTOMY

81

12

3

3


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LAPAROSCOPIC NISSEN

FUNDOPLICATION


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Characteristics of patients subjected

to laparoscopic Nissen

fundoplication1997. 01. 01. - 2001. 12. 31.

Sex M 38

F 43

Age (years/range) 43 (20-72)

Risk ASA 1-2 60

ASA 3 21


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Endoscopy

24 hour esophageal pH monitoring

Esophageal body and sphinctermanometry

Radiography 24 hour bile exposure monitoring

(Bilitec, 2000)

METHODS

/Preoperative assessment/


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Persistent or recurrent symptoms/

complications, in spite of optimal

medical treatment with proton-

pump inhibitors.

Indication for Surgery

METHODS Surgical technique


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Short, floppy fundoplication

Mobilization of the fundus with division ofshort gastric vessels

Dissection of the crura

Identification of vagal branches

Mobilization of the distal esophagus Closure the hiatal opening

Calibration by Bougie

Short wrap

METHODS Surgical technique

The standard 3600 Laparoscopic

Nissen fundoplication


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Laparoscopic Nissen fundoplication

Results

Mean operative time 140 min 60 min

Complications severe bleeding 1

neck co2 emphysema 4

Conversion 1

Hospital stay /days/ 5 /3-7/

Mortality 0


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Results

Morbidity

Dysphagia Transitional Persistent

( > 3 month)

24 1

Diarrhea 8 -


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Results24 hour pH monitoring - DeMeester score (


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Results24 hour pH monitoring - reflux index (< 4 %)

0

2

4

6

8

10

12

14

16

Before

operation

3 month after

operation


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ResultsManometry - LES pressure (24.213.2 mmHg)

0

2

46

8

10

12

14

16

Before

operation

3 month after

operation


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ResultsSphincter length (cm)

0

0,5

1

1,5

2

2,5

3

3,5

4

4,5

Before

operation

3 month after

operation


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Conclusion

The laparoscopic Nissen

fundoplication with a standardizedsurgical technique results in a

proper reflux control as confirmed

by early functional tests.


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Transhiatal resection of

epiphrenic esophageal

diverticulum


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Barium swallow


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VIDEO-THORACOSCOPIC

TREATMENT OF BENIGN

TUMOURS OF THEESOPHAGUS


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Benign tumours of the esophagus

I. Leiomyoma

II. Cyst /enterogenic, bronchogenic/

III. Polyp

0,51 %


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Patients with benign esophageal

tumours

Age (years) sex1. Esophageal cyst 25 F

2. Leiomyoma 40 M

3. Leiomyoma 38 F


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Diagnostic tests

Barium swallow

Esophagoscopy

Endoscopic UH Chest CT


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Diagnostic tests

Barium swallow

Esophagoscopy

Endoscopic UH

Chest CT


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Diagnostic tests

Barium swallow

Oesophagoscopy

Endoscopic UH Chest CT


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Diagnostic tests

Barium swallow

Esophagoscopy

Endoscopic UH

Chest CT


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Surgical treatment of benign

esophageal tumours

Traditional surgical

technique

Thoracotomy

Minimal invasiv surgical

technique

Videothoracoscopy

EXCISION


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Surgical technique I.

Lateral decubitus position

Selective intubation

Endoluminal endoscopic control


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Surgical technique

II.

Port sites


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Viodeothoracoscopic treatment


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Viodeothoracoscopic treatment

of benign tumours of the

esophagus - results

Operative time

Blood loss

Complications

Hospital stay

70, 120, 180 minutes

Minimal (50100 ml)

None

7 days


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Videothoracoscopic treatment of

midesophageal diverticulum


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Preoperative Barium swallow


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Postoperative Barium swallow


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Conclusions

The videothoracoscopic technique is safe, involves

minimal pain and permits a rapid return to normal

activity.

It should be the method of choice for removing

benign lesions of the oesophagus.


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MINIMALLY INVASIVE

SURGERY FOR ZENKER

DIVERTICULUM


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Surgical treatment for Zenker

diverticulum

Conventional surgery: crycopharyngeal myotomy +

diverticulectomy or diverticulum suspensionEndoscopic approach (Mosher, 1917)

diathermic/laser dissection (Dohlman, Mattsson 1960)

Endoscopic stapling diverticulostomy (Collard, 1993)


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Light and short general anaesthesia

Short operation time and hospital stay Low risk of perforation of diverticular pouch

No injury of reccurent nerve

Early resumption of oral feeding Complete relief of dysphagia

No scar in neck

Advantages of endoscopic stapling

diverticulostomy


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Age/Sex 66 M, 82 F

Symptoms dysphagiaregurgitation

Diagnostic barium swallow,

assessment esophagoscopy

Diverticulum 4 and 5 cmSize

Characteristics of patients with

Zenker diverticulum


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Endoscopic stapling

diverticulostomy

Operative technique

General anaesthesia

Surgical equipments:Rigid, fixable, doublelipped laryngoscope

(Weerda, Karl Stortz)

Endostapler (Endopath ETS, Ethicon)5 mm rigid telescope


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Endoscopic stapling


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Endoscopic stapling

diverticulostomy

Results

Operative time: 15/25 min

No intra- or postoperative complications

Complete relief of dysphagia 18/6 months

after the operation


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Conclusion

The stapling diverticulostomy is atherapeutic alternative in the

surgical treatment for Zenker

diverticulum.


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Minimal invasive technique in

the surgery of the spleen


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Surgery/Patients

Laparoscopic splenectomies N: 20

Laparoscopic unroofings N: 5 Mean age (years) 43 (19-72)

Female/male 24 /1


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Indications for surgery

ITP 17

Metastatic melanoma 1

Non-Hodgkin lymphoma 1

Hereditary sphaerocytosis 1

Non-parasitic splenic cyst 5


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Preoperative assessment

Haematological / gastroenterological

check-up

Abdominal US/CT

Polyvalent pneumococcal vaccination

Antibiotic prophylaxis


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Surgical technique

Supine position

General anaesthesia

3 or 4 operating ports

Ultrasonic dissection

Linear cutting stapler


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Mtti technika


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Laparoscopic splenectomy -

results

Surgical time

Est. blood loss

Spleen weight

Conversions

Complications

Lenght of hospital

stay

130 (90-180) min.

150 (50-250) ml

310 g (200-2100)

N: 2 (10 %)

none

5 (4-7) days


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Laparoscopic unroofings -

results

Surgical time

Est. blood loss

Conversions

Complications

Lenght of hospitalstay

50 (40-90) min.

100 (50-200) ml

None

None

4 (3-6) days

Preoperative clinical parameters


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Open vs. laparoscopic splenectomy

OpenN:10

LaparoscopicN:15

Indication for surgery ITP ITP

Meanage/range(years)

45 (30-67) 49 (28-72)

Body weight ( kg) 63 (50-110) 60 (48-105)

ASA score 1.9 (1-3) 1.8 (1-3)

PrePLT (T/L) 41 (20-100) 39 (10-90)

Preop. htkr (L/L) 38 (25-40) 35 (20-38)

Open/ laparoscopic splenetomies


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Open/ laparoscopic splenetomies

Outcomes

Open

N:10

LaparoscopicN:15

Operating time (min) 80 (50-120) 90 (60-180)

Est. blood loss (ml) 150 (50-300) 150 (50-250)

Weight of the spleen

(g)

190 180

Liquid diet (days) 3 (2-4) 2 (1-3)

Post.op. bowel

paralysis (days)

3,5 (3-4) 2 (1-3)

Hospital stay (days) 7 (6-12) 5 (4-7)


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Conclusions

Laparoscopic splenectomy or unroofing

is feasible and safe,

resulting brief hospitalization, minimalrecovery time.

LS can be safely performed even for

enlarged spleens.


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Minimal invasive surgical

treatment of nonparasitic liver

cyst


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C l i


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Conclusion

Minimally

invasive surgical

technique

Conventional

surgical

technique

CO C S O


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CONCLUSION


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CONCLUSION


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FUTURE

Sooner and later you will see great changes.

Nostradamus (1503-1566) Centurie I, verse 56

Minimal Invasive Surger

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