Minimal Invasive Surgery,

Robotic, Natural Orifice

transluminal Endoscopic
KR
• Minimal invasive surgey  performing
major operation throught small incisions,
often using miniaturized, high-tech
imaging system, to minimize the trauma of
surgical exposure
HISTORICAL BACKGROUND
Although the term minimally invasive
surgery is relatively recent, the history of its
component parts is nearly 100 years old.

What is considered the newest and most

popular variety Minimally invasive surgery
describes an area of surgery that crosses all
traditional disciplines, from general surgery
to neurosurgery
Flexible endoscopic imaging started in the
1960s  first bundling  quartz fibers into
bundles, one for illumination and one for
imaging
PHYSIOLOGY AND PATHOPHYSIOLOGY
OF MINIMALLY INVASIVE SURGERY
Minimally invasive procedure require
minimal or no sedation  consequenses to
cardiovascular, endocrinology, or
immunologic system.

Minimally invasive procedure that require

general anesthesia  have a greater impact
because of the anesthetic agent, the incision
(even if small), and the induce
pneumoperitoneum
Laparoscopy
Unique feature of laparoscopic  need to lift
the abdominal wall from the abdominal
organs  method
• Pneumoperitoneum  intraperitoneal
visualization achieved by inflating the
abdominal cavity with air, using
spigmomanometer bulb  CO2 and N2O
use for inflating abdomen
Thoracoscopy
• Physiology thoracic MIS (Thoracoscopy) is
different from that laparoscopy.
• Bony confines of the thorax 
unnecessary to use positive pressure
when working in thorax
• Disadvantages of positive pressure in the
chest include decreased venous return,
mediastinal shift and the need to keep firm
seal at all trocar site.
Extracavitary minimally invasive
• MIS procedure  create working spaces
in extrathoracic and extraperitoneal
location.
– Laparoscopic hernia  anterior
extraperitoneal Retzius space.
– Laparoscopy nefrectomy  perform with
retroperitoneal laparoscopy
– Endoscopic retroperitoneal  approaches to
pancreatic necrosectomy
Anesthesia
Laparoscopic  surgeon can influence
cardiovascular performance by reducing or
removing CO2 pneumoperitoneum
• Insensible fluid losses  negligible
• Iv fluid administration should not exceed
that necessary maintain circulation volume

Anasthesia must minimize the use of agents

that provoke these condition
 The Minimally Invasive Team
Many Laparoscopic procedure perform daily
range from basic to advanced complexity,
and require that the surgical team have an
intimate understanding of the operative
conduct
Room setup and minimally
invasive state
Nearly MIS, using fluoroscopic, ultrasound
or optical imaging, incorporates a video
monitor as a guide.

Two images ar necessary to adequately

guide the operation, as in prodedure such a
sendoscopic retrogate cholangio
pancretographym.
The core equipment (monitor, insufflators
and imaging equipment) located wirhin
mobile, ceiling mounted console, surgery
team is able to occumudate and make a
small adjustment rapidly and continuously
through the procedur
Patient Posisitioning
Patient are placed in supine position for
laparoscopic surgery.

When operative field is the gastroesophageal

junction or the left lobe of liver, it is easiest to
operate from between legs.

Leg may be elevated in allen stirrups or abducted

on leg board to achive this position.
General principal access
• The most natural port of access for MIS
and NOTES are the anatomic portals of
entry and exit.

• The nares, mouth, urethra, and anus are

used to access respiratory, GI and Urinary
system.
• Advantage of using this point of access is
that no tension required.

• Disadvantage lie in the long distances

between the orifice and the region of interest.

• For NOTES procedure, the vagina may

serveas another point access, entering
abdomen via posterion cul-de-sac of pelvis.
Laparoscopic Access
The requirement for laparoscopic are more involved, because the creation of a
pneumoperitoneum requires that instrument of access (trocars) contain valves to
maintain abdominal inflation.

Two methods are used for establishing abdominal access during laparoscopic
procedures.

The first, direct puncture laparoscopy, begin with elevation of the relaxed abdominal wall
with two towel clips or a well placed hand. Small incison made in umbilicus, and a
specialized spring-loaded (veress) needle, two distinct pop are felt as the surgeon passes
the needle through the abdominal wall fascia and peritoneum

Direct peritoneal access (Hasson) technique  advisable. With this technique surgeon
makes a small incision just below the umbilicus and under direct vision locates the
abdominal fascia. Two Kocher clamps are placed on the fascia, with curve mayor
scissors, a small incision made through the fascia and underlying peritoneum.
Access for Subcutaneus and
extraperitoneal surgery
There are two methods for gaining access to
nonatomic spaces. For retroperitoneal
locations, balloon dissection is effective.

This access technique is appropriate for

extraperitoneal repair of inguinal hernias and
retroperitoneal surgery for adrenectomy,
nephrectomy, lumbar discectomy, pancreatic
necrosectomy or para aortic lymph dissection.
Natural Orifice Transluminal
Endoscopic Surgery Access
Endoscopic surgical access

Multiple studies  safety performance NOTES

Transvaginal, transvesicle, transanal, transcolonic,

transgastric and transoral  varying success

Extracttion of the gallbladder, kidney, bladder, large bowel

and stomach can be perfom via vagina.

Oesofagus can be traversed to enter mediastinum

Single incision Laparoscopic Surgery Access

• No standardized for SILS, and access technique vary by

surgeon preference.

• Traditionally a single skin incision is made directly

through umbilical scar ranging from 1 to 3 cm.

• Through this single incision, multiple low profile brocars

can be placed separatcly into the fascia to allow
insuffilation, camera, and working instrument.
Port Placement
Trocars for the surgeons left hand should be
placed at least 10 cm apart. Most operations
 orient the telescope between these two
trocars and slightly back from them.

The ideal trocars orientation creates and

equilateral triangle between surgeon right
hand, left hand and the telescope with 10 to
15 cm on each leg
Imaging System
Two methods of videoendoscopic imaging 
widely used

Both methods use camera with CCD, which

is an array of photosensitive sensor
element (pixels) that convert the incoming
light intensity to an electric charge. The
electric charge is subsequently converted
into the black and white image
Energy Sources for Endoscopic
and Endoluminal Surgery
Many MIS procedures  conventional energy sources, but
the benefit of bloodless surgery to maintain optimal
visualization have spawner new ways of applying energy.

Common energy sources is RF electrosurgery using an

alternative current with a frequency of 500.000 cycles/s
(Hz)

Tissue heating progresses through the well known phases

of coagulation (60 C / 140 F), vapolarization and
desiccation (100 C / 212 F) and carbonization (>200 C /
392 F)
Robotic Surgery
The term robot defines a divice that has been
programed to perform specific task.

Surgical robot  computer enhanced surgical

devices, controlled entirely by surgeon for purpose
of improving performance. First computer assisted
surgical devices was the laparoscopic camera
holder (Aesop, computer motion, goleta, CA)
which enable surgeon to maneuver the
laparoscope either with a hand control foot control,
or voice activation
Endoluminal and Endovascular
Surgery
Field vascular surgery, intervational
radiology, neuroradiology, gastroenterology,
general surgery, pulmonology, and urology
all encounter clinical scenarios that require
the urgent restoration of luminal patency.

Base on need, fundamental techniques have

been pioneered that are applicable to all
specialities and virtuality every organ
system.
Natural Orifice Transluminal
Endoscopic Surgery
The use of the flexible endoscope to enter
the GI, Urinary, or reproductive tracts and
then tranverse the wall of the structure to
enter the peritoneal cavity, the mediastinum,
or the chest has strong appeal to patients
wishing to avoid scars and pain pain caused
by abdominal wall trauma.
Single Incision Laparoscopic
Surgery