Minimal invasive surgery

History of minimal invasive surgery

Hippocrates - rectum examination with a speculum 1806, Philip Bozzini - built an instrument that could be introduced in the human body to visualize the internal organs. He called this instrument "LICHTLEITER"

History of minimal invasive surgery

1868, Kussmaul performed the first esophagogastroscopy on a professional sword swallower, initiating efforts at instrumentation of the gastrointestinal tract. 1901, The first experimental laparoscopy was performed in Berlin in 1901 by this German surgeon Georg Kelling, who used a cystoscope to peer into the abdomen of a dog after first insufflating it with air.

History of minimal invasive 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 a needle for insufflations.

History of minimal invasive surgery

1938, Janos Veress of Hungary developed a specially designed springloaded needle. Interestingly, Veress did not promote the use of his Veress needle for laparoscopy purposes. He used veress needle for the induction of pneumothorax.

History of minimal invasive surgery

1983, Semm, a German gynaecologist, performed the first laparoscopic appendicectomy. 1985, The first documented laparoscopic cholecystectomy was performed by Erich Mhe in Germany in 1985. 1987, Phillipe Mouret, has got the credit to performed the first laparoscopic cholecystectomy in Lyons, France using video technique.

History of minimal invasive surgery

1994, A robotic arm was designed to hold the telescope with the goal of improving safety and reducing the need of skilled camera operator. 1996, First live telecast of laparoscopic surgery performed remotely via the Internet. (Robotic telesurgery)

Equipment and instrumantation

Imaging System - Laparoscopes - Cold light source - Cameras - Monitor

Equipment and instrumantation

Dissectors Hooks and spatulas Clip appliers and endolinear cutter Insuufflation/ Veress needle Suctiom and irrigating apparatus Trocars

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

Avoiding complications during laparoscopy

Training Patient selection Room setup Port placement (site/technique) Visualisation (equiepment/blood or debris) Familiarity with anatomical landmarks Early consultation

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

Minimal invasive general surgery

Esophago-gastric surgery Liver, pancreas surgery Colorectal surgery Endocrine surgery Surgery of the abdominal wall

Minimal invasive surgery

Thoracoscopic surgery (lung, esophageal surgery) Cardio-vascular surgery Gynecology Urology

Minimally Invasive Techniques in the Surgery of the Esophagus

Surgical approaches of the esophagus

LAPAROTOMY THORACOTOMY TRANSCERVICAL

LAPAROSCOPY THORACOSCOPY MEDIASTINOSCOPY ENDOLUMINAL

MINIMALLY INVASIVE TECHNIQUE IN ESOPHAGEAL SURGERY

GERD, HIATAL HERNIAS, ESOPHAGEAL DIVERTICULA ACHALASIA, OTHER MOTILITY DISORDERS ESOPHAGEAL PERFORATIONS BENIGN TUMOURS MALIGNANT TUMOURS ?

MINIMALLY INVASIVE SURGERY OF THE ESOPHAGUS

Department of Surgery, University of Szeged, 1994 - 2001
LAPAROSCOPIC NISSEN FUNDOPLICATION HELLER MYOTOMY THORACOSCOPIC ENUCLEATION OF BENIGN TUMOURS ENDOSCOPIC STAPLING DIVERTICULOSTOMY 81

12 3

LAPAROSCOPIC NISSEN FUNDOPLICATION

Characteristics of patients subjected to laparoscopic Nissen fundoplication

1997. 01. 01. - 2001. 12. 31.

Sex

M F

38 43

Age (years/range)

43 (20-72)

Risk

ASA 1-2 ASA 3

60 21

METHODS /Preoperative assessment/

Endoscopy 24 hour esophageal pH monitoring Esophageal body and sphincter manometry Radiography 24 hour bile exposure monitoring (Bilitec, 2000)

Indication for Surgery

Persistent or recurrent symptoms/ complications, in spite of optimal medical treatment with protonpump inhibitors.

METHODS Surgical technique The standard 3600 Laparoscopic Nissen fundoplication

Short, floppy fundoplication Mobilization of the fundus with division of short gastric vessels Dissection of the crura Identification of vagal branches Mobilization of the distal esophagus Closure the hiatal opening Calibration by Bougie Short wrap

Laparoscopic Nissen fundoplication Results

Mean operative time
Complications

140 min

60 min
1

severe bleeding

neck co2 emphysema 4

Conversion 1

Hospital stay /days/

Mortality

5 /3-7/
0

Laparoscopic Nissen fundoplication Results

Morbidity

Dysphagia

Transitional 24

Persistent ( > 3 month) 1 -

Diarrhea

Laparoscopic Nissen fundoplication Results

24 hour pH monitoring - DeMeester score (<14.76)
45 40 35 30 25 20 15 10 5 0 Before operation 3 month after operation

Laparoscopic Nissen fundoplication Results

24 hour pH monitoring - reflux index (< 4 %)
16 14 12 10 8 6 4 2 0 Before operation 3 month after operation

Laparoscopic Nissen fundoplication Results

Manometry - LES pressure (24.213.2 mmHg)
16 14 12 10 8 6 4 2 0 Before operation 3 month after operation

Laparoscopic Nissen fundoplication Results

Sphincter length (cm)
4,5 4 3,5 3 2,5 2 1,5 1 0,5 0 Before operation 3 month after operation

Conclusion
The laparoscopic Nissen fundoplication with a standardized surgical technique results in a proper reflux control as confirmed by early functional tests.

Transhiatal resection of epiphrenic esophageal diverticulum

Barium swallow

VIDEO-THORACOSCOPIC TREATMENT OF BENIGN TUMOURS OF THE ESOPHAGUS

Benign tumours of the esophagus

0,5 1 %

I. Leiomyoma II. Cyst /enterogenic, bronchogenic/ III. Polyp

Patients with benign esophageal tumours

Age (years) 25 40 38 sex F M F

1. Esophageal cyst 2. Leiomyoma 3. Leiomyoma

Diagnostic tests
Barium swallow
Esophagoscopy Endoscopic UH Chest CT

Diagnostic tests
Barium swallow

Esophagoscopy
Endoscopic UH Chest CT

Diagnostic tests
Barium swallow Oesophagoscopy

Endoscopic UH
Chest CT

Diagnostic tests
Barium swallow Esophagoscopy Endoscopic UH

Chest CT

Surgical treatment of benign esophageal tumours

EXCISION
Traditional surgical technique Minimal invasiv surgical technique

Thoracotomy

Videothoracoscopy

Surgical technique I.

Lateral decubitus position Selective intubation Endoluminal endoscopic control

Surgical technique II. Port sites

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

Videothoracoscopic treatment of midesophageal diverticulum

Preoperative Barium swallow

Postoperative Barium swallow

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.

MINIMALLY INVASIVE SURGERY FOR ZENKER DIVERTICULUM

Surgical treatment for Zenker diverticulum

Conventional surgery: crycopharyngeal myotomy +

diverticulectomy or diverticulum suspension

Endoscopic approach (Mosher, 1917) diathermic/laser dissection (Dohlman, Mattsson 1960) Endoscopic stapling diverticulostomy (Collard, 1993)

Advantages of endoscopic stapling diverticulostomy

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

Characteristics of patients with Zenker diverticulum

Age/Sex Symptoms Diagnostic assessment Diverticulum Size 66 M, 82 F dysphagia regurgitation barium swallow, esophagoscopy 4 and 5 cm

Endoscopic stapling diverticulostomy Operative technique

General anaesthesia Surgical equipments:
Rigid, fixable, double lipped laryngoscope (Weerda, Karl Stortz) Endostapler (Endopath ETS, Ethicon) 5 mm rigid telescope

Endoscopic stapling diverticulostomy Results

Operative time: 15/25 min No intra- or postoperative complications Complete relief of dysphagia 18/6 months after the operation

Conclusion
The stapling diverticulostomy is a therapeutic alternative in the surgical treatment for Zenker diverticulum.

Minimal invasive technique in the surgery of the spleen

Surgery/Patients
Laparoscopic splenectomies Laparoscopic unroofings Mean age (years) Female/male N: 20 N: 5 43 (19-72) 24 /1

Indications for surgery

ITP Metastatic melanoma Non-Hodgkin lymphoma Hereditary sphaerocytosis Non-parasitic splenic cyst 17 1 1 1 5

Preoperative assessment
Haematological / gastroenterological check-up Abdominal US/CT Polyvalent pneumococcal vaccination Antibiotic prophylaxis

Surgical technique
Supine position General anaesthesia 3 or 4 operating ports Ultrasonic dissection Linear cutting stapler

Mtti technika

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

Laparoscopic unroofings results

Surgical time Est. blood loss Conversions Complications Lenght of hospital stay 50 (40-90) min. 100 (50-200) ml None None 4 (3-6) days

Preoperative clinical parameters Open vs. laparoscopic splenectomy

Open
N:10
Indication for surgery ITP Mean age/range(years) 45 (30-67)

Laparoscopic
N:15
ITP 49 (28-72)

Body weight ( kg)

ASA score PrePLT (T/L)

63 (50-110)
1.9 (1-3) 41 (20-100)

60 (48-105)
1.8 (1-3) 39 (10-90)

Preop. htkr (L/L)

38 (25-40)

35 (20-38)

Open/ laparoscopic splenetomies Outcomes

Open
N:10
Operating time (min) Est. blood loss (ml) Weight of the spleen (g) Liquid diet (days) Post.op. bowel paralysis (days) Hospital stay (days) 80 (50-120) 150 (50-300) 190 3 (2-4) 3,5 (3-4) 7 (6-12)

Laparoscopic
N:15
90 (60-180) 150 (50-250) 180 2 (1-3) 2 (1-3) 5 (4-7)

Conclusions
Laparoscopic splenectomy or unroofing is feasible and safe, resulting brief hospitalization, minimal recovery time. LS can be safely performed even for enlarged spleens.

Minimal invasive surgical treatment of nonparasitic liver cyst

Conclusion

Conventional surgical technique

Minimally invasive surgical technique

CONCLUSION

CONCLUSION

FUTURE
Sooner and later you will see great changes. Nostradamus (1503-1566) Centurie I, verse 56