y Minimally invasive surgery : an area of surgery that crosses all

traditional disciplines, from general surgery to neurosurgery.

y It is not a discipline unto itself, but more a philosophy of surgery, a

way of thinking.
y A means of performing major operations through small incisions,

often using miniaturized, high-tech imaging systems, to minimize the trauma of surgical exposure.

y Robotic surgery today is practiced using a single platform and

termed computer enhanced surgery as the term robotics assumes autonomous action that is not a feature of the da Vinci robotic system.
y The da Vinci robot couples an ergonomic workstation that features

stereoptic video imaging and intuitive micromanipulators (surgeon side) with a set of arms delivering specialized laparoscopic instruments enhanced with more degrees of freedom than is allowed by laparoscopic surgery alone (patient side).
y A computer between the surgeon side and patient side removes

surgical tremor and scales motion to allow precise microsurgery, helpful for microdissection and difficult anastomoses.

y Natural orifice transluminal endoscopic surgery (NOTES): a recent

extension of interventional endoscopy.

y Using the mouth, the anus, the vagina, and the urethra (natural

orifices), flexible endoscopes are passed through the wall of the esophagus, stomach, colon, bladder, or vagina entering the mediastinum, the pleural space, or the peritoneal cavity.
y The advantage of this method of minimal access is principally the

elimination of the scar associated with laparoscopy or thoracoscopy.

Historical Background
y Minimally invasive surgery is relatively recent, the history of its

component parts is nearly 100 years old.

y Kelling in 1901: Primitive laparoscopy, placing a cystoscope within

an inflated abdomen.
y Late 1950s: Hopkins described the rod lens, a method of

transmitting light through a solid quartz rod with no heat and little light loss.

y 1970s: the application of flexible endoscopy grew faster than that of

rigid endoscopy except in a few fields such as gynecology and orthopedics.

y By the mid-1970s, rigid and flexible endoscopes made a rapid

transition from diagnostic instruments to therapeutic ones.

y The explosion of video-assisted surgery in the past 20 years was a

result of the development of compact, high-resolution, chargecoupled devices (CCDs) that could be mounted on the internal end of flexible endoscopes or on the external end of a Hopkins telescope.

y Flexible endoscopic imaging started in the 1960s with the first

bundling of many quartz fibers into bundles, one for illumination and one for imaging.
y Shinya and Wolfe: first endoscopic surgical procedure was the

colonoscopic polypectomy.
y 1981: percutaneous endoscopic gastrostomy (PEG) invented by

Gauderer and Ponsky may have been the first NOTES procedure.

y The first computer-assisted robot, the "RoboDoc" was designed to

accurately drill femoral shaft bone for wobble-free placement of hip prostheses.
y The robot proved no better than a skilled orthopedic surgeon and

was a good deal slower.

Physiology and Pathophysiology of Minimally Invasive Surgery

y Even with the least invasive of the MIS procedures, physiologic

changes occur.
y Many minimally invasive procedures require minimal or no

sedation, and there are few adverse consequences to the cardiovascular, endocrinologic, or immunologic systems.
y The least invasive of such procedures include stereotactic biopsy of

breast lesions and flexible GI endoscopy.

y Minimally invasive procedures that require general anesthesia have

a greater physiologic impact because of the anesthetic agent, the incision (even if small), and the induced pneumoperitoneum.

Laparoscopy
y The unique feature of laparoscopic surgery is the need to lift the abdominal

wall from the abdominal organs.

y Two methods : The first, used by most surgeons, is a pneumoperitoneum.

Intraperitoneal visualization was achieved by inflating the abdominal cavity with air, using a sphygmomanometer bulb.

y The problem with using air insufflation is that nitrogen is poorly soluble in

blood and is slowly absorbed across the peritoneal surfaces.

y Air pneumoperitoneum was believed to be more painful than nitrous oxide

(N2O) pneumoperitoneum, but less painful than carbon dioxide (CO2) pneumoperitoneum.

y N2O had the advantage of being physiologically inert and rapidly absorbed. It

also provided better analgesia for laparoscopy performed under local anesthesia when compared with CO2 or air.

y The physiologic effects of CO2

pneumoperitoneum can be divided into two areas: y gas-specific effects y pressure-specific effects CO2 is rapidly absorbed across the peritoneal membrane into the circulation.
y In the circulation, CO2 creates a

respiratory acidosis by the generation of carbonic acid.

y Body buffers, the largest reserve

of which lies in bone, absorb CO2 (up to 120 L) and minimize the development of hypercarbia or respiratory acidosis during brief endoscopic procedures.

y If the respiratory rate required exceeds 20 breaths per minute, there

may be less efficient gas exchange and increasing hypercarbia.

y If vital capacity is increased substantially, there is a greater opportunity

for barotrauma and greater respiratory motion-induced disruption of the upper abdominal operative field.

y It is advisable to evacuate the pneumoperitoneum or reduce the intra-

abdominal pressure to allow time for the anesthesiologist to adjust for hypercarbia. resistance, which elevates blood pressure and increases myocardial oxygen demand.

y Hypercarbia also causes tachycardia and increased systemic vascular

y The pressure effects of the pneumoperitoneum on cardiovascular

physiology:

y In the hypovolemic individual, excessive pressure on the inferior vena

cava and a reverse Trendelenburg position with loss of lower extremity muscle tone may cause decreased venous return and decreased cardiac output.

y The most common arrhythmia created by laparoscopy is bradycardia. y A rapid stretch of the peritoneal membrane often causes a vagovagal

response with bradycardia and, occasionally, hypotension.

y The appropriate management of this event is desufflation of the

abdomen, administration of vagolytic agents (e.g., atropine), and adequate volume replacement.

y The increased intra-abdominal pressure compressing the inferior

vena cava, there is diminished venous return from the lower extremities.
y In short-duration laparoscopic procedures, such as appendectomy,

hernia repair, or cholecystectomy, the risk of DVT may not be sufficient to warrant extensive DVT prophylaxis.

y The increased pressure of the pneumoperitoneum is transmitted

directly across the paralyzed diaphragm to the thoracic cavity, creating increased central venous pressure and increased filling pressures of the right and left sides of the heart.

y If the intra-abdominal pressures are kept under 20 mmHg, the cardiac

output usually is well maintained. The direct effect of the pneumoperitoneum on increasing intrathoracic pressure increases peak inspiratory pressure, pressure across the chest wall, and also, the likelihood of barotrauma.

y Increased intra-abdominal pressure decreases renal blood flow,

glomerular filtration rate, and urine output. These effects may be mediated by direct pressure on the kidney and the renal vein. The secondary effect of decreased renal blood flow is to increase plasma renin release, thereby increasing sodium retention.

y Intraoperative oliguria is common during laparoscopy, but the urine

output is not a reflection of intravascular volume status; IV fluid administration during an uncomplicated laparoscopic procedure should not be linked to urine output.
y Insensible fluid losses through the open abdomen are eliminated

with laparoscopy, the need for supplemental fluid during a laparoscopic surgical procedure should only keep up with venous pooling in the lower limbs, third-space losses into the bowel, and blood loss, which is generally less than occurs with an equivalent open operation.

y Endocrine responses to laparoscopic surgery are not always intuitive.

Serum cortisol levels after laparoscopic operations are often higher than after the equivalent operation performed through an open incision.
y The greatest difference between the endocrine response of open and

laparoscopic surgery is the more rapid equilibration of most stressmediated hormone levels after laparoscopic surgery.
y Immune suppression also is less after laparoscopy than after open

surgery. There is a trend toward more rapid normalization of cytokine levels after a laparoscopic procedure than after the equivalent procedure performed by celiotomy.

y Transhiatal mobilization of the distal esophagus is commonly

performed as a component of many laparoscopic upper abdominal procedures.

y If there is compromise of the mediastinal pleura with resultant CO2

pneumothorax, the defect should be enlarged so as to prevent a tension pneumothorax.

y A thoracostomy tube (chest tube) should be placed across the breach

into the abdomen with intra-abdominal pressures reduced below 8 mmHg, or a standard chest tube may be placed.

Thoracoscopy
y The physiology of thoracic MIS (thoracoscopy) is different from that of

laparoscopy.
y The bony confines of the thorax, it is unnecessary to use positive

pressure when working in the thorax.

y The disadvantages of positive pressure in the chest include:
y decreased venous return, mediastinal shift, and the need to keep a

firm seal at all trocar sites.

Extracavitary Minimally Invasive Surgery

y Many MIS procedures create working spaces in extrathoracic and

extraperitoneal locations.
y Laparoscopic inguinal hernia repair usually is performed in the

anterior extraperitoneal Retzius space.

y Laparoscopic nephrectomy often is performed with retroperitoneal

laparoscopy. Endoscopic retroperitoneal approaches to pancreatic necrosectomy have seen some limited use.

y Lower extremity vascular procedures and plastic surgical

endoscopic procedures require the development of working space in unconventional planes, often at the level of the fascia, sometimes below the fascia, and occasionally in nonanatomic regions.

y Some of these techniques use insufflation of gas, but many use

balloon inflation to develop the space, followed by low-pressure gas insufflation or lift devices to maintain the space. physiologic consequences than does the pneumoperitoneum, but the insufflation of carbon dioxide into extraperitoneal locations can spread widely, causing subcutaneous emphysema and metabolic acidosis.

y These techniques produce fewer and less severe adverse

Balloons are used to create extra-anatomic working spaces. In this example (A through C), a balloon is introduced into the space between the posterior rectus sheath and the rectus abdominal muscle. The balloon is inflated in the preperitoneal space to create working room for extraperitoneal endoscopic hernia repair

The Minimally Invasive Team

y Minimally invasive procedures require complicated and fragile

equipment that demands constant maintenance

y Multiple intraoperative adjustments to the equipment, camera,

insufflator, monitors, and patient/surgeon position are made during these procedures. excellent outcomes. More and more, flexible endoscopes are used to guide or provide quality control for laparoscopic procedures.

y A coordinated team approach is mandated to ensure patient safety and

y As NOTES evolves, hybrid procedures (laparoscopy and endoscopy)

and sophisticated NOTES technology will require a nursing staff capable of maintaining flexible endoscopes and understanding the operation of sophisticated endoscopic technology.

Room Setup and the Minimally Invasive Suite

y Nearly all MIS, whether using fluoroscopic, ultrasound, or

optical imaging, incorporates a video monitor as a guide.

y Occasionally, two images are necessary to adequately guide the

operation, as in procedures such as endoscopic retrograde cholangiopancreatography, laparoscopic common bile duct exploration, and laparoscopic ultrasonography.

y The video monitor(s) should be set across the operating table

from the surgeon. The patient should be interposed between the surgeon and the video monitor; ideally, the operative field also lies between the surgeon and the monitor.

y The development of the

minimally invasive surgical suite has been a tremendous contribution to the field of laparoscopy.
y The core equipment:
y monitors, insufflators and

imaging equipment

y The specifically designed minimally invasive surgical suite serves to:

y decrease equipment and cable disorganization y ease the movements of operative personnel around the room y improve ergonomics y facilitate the use of advanced imaging equipment such as

laparoscopic ultrasound.

Patient Positioning
y Patients usually are placed in the supine position for laparoscopic

surgery.
y When the operative field is the gastroesophageal junction or the left

lobe of the liver, it is easiest to operate from between the legs. y The legs may be elevated in Allen stirrups or abducted on leg boards to achieve this position.
y When pelvic procedures are performed, it usually is necessary to place

the legs in Allen stirrups to gain access to the perineum.

y Nephrectomy or adrenalectomy:
y A lateral decubitus position with

the table flexed provides the best access to the retroperitoneum.

y Laparoscopic splenectomy:
y a 45-tilt of the patient provides

excellent access to the lesser sac and the lateral peritoneal attachments to the spleen.
y Thoracoscopic surgery:
y The patient is placed in the

lateral position with table flexion to open the intercostal spaces and the distance between the iliac crest and costal margin.

General Principles of Access

y The most natural ports of access for MIS and NOTES are the anatomic

portals of entry and exit. y The nares, mouth, urethra, and anus are used to access the respiratory, GI, and urinary systems.
y The advantage of using these points of access is that no incision is

required.

y The disadvantages lie in the long distances between the orifice and

the region of interest.

y For NOTES procedures, the vagina may serve as another point of

access, entering the abdomen via the posterior cul de-sac of the pelvis. Similarly, the peritoneal cavity may be reached through the side wall of the stomach or colon.

y Access to the vascular system may be accomplished under local

anesthesia by cutting down and exposing the desired vessel, usually in the groin.
y Vascular access is obtained with percutaneous techniques using a small

incision, a needle, and a guidewire, over which are passed a variety of different sized access devices.
y Seldinger technique, is most frequently used by general surgeons for

placement of Hickman catheters, but also is used to gain access to the arterial and venous system for performance of minimally invasive procedures.

y Thoracoscopic surgery, the access technique is similar to that used

for placement of a chest tube.

y In these procedures general anesthesia and single lung ventilation

are essential.
y A small incision is made over the top of a rib and, under direct

vision, carried down through the pleura.

y The lung is collapsed, and a trocar is inserted across the chest wall

to allow access with a telescope. Once the lung is completely collapsed, subsequent access may be obtained with direct puncture, viewing all entry sites through the videoendoscope.

Laparoscopic Access
y The requirements for laparoscopy are more involved, because the

creation of a pneumoperitoneum requires that instruments of access (trocars) contain valves to maintain abdominal inflation.

y Two methods are used for establishing abdominal access during

laparoscopic procedures.

y The first, direct puncture laparoscopy, begins with the elevation of the

relaxed abdominal wall with two towel clips or a well-placed hand.

y A small incision is made in the umbilicus, and a specialized spring-

loaded (Veress) needle is placed in the abdominal cavity. y With the Veress needle, two distinct pops are felt as the surgeon passes the needle through the abdominal wall fascia and the peritoneum.

A. Insufflation of the abdomen is accomplished with a Veress needle held at its serrated collar with a thumb and forefinger. B. Because linea alba is fused to the umbilicus, the abdominal wall is grasped with fingers or penetrating towel clip to elevate the abdominal wall away from the underlying structures.

y The umbilicus usually is selected as the preferred point of access

because, in this location, the abdominal wall is quite thin, even in obese patients.
y The abdomen is inflated with a pressure-limited insufflator. y CO2 gas usually is used, with maximal pressures in the range of 14 to 15

mmHg.
y During the process of insufflation, it is essential that the surgeon

observe the pressure and flow readings on the monitor to confirm an intraperitoneal location of the Veress needle tip.

y After peritoneal insufflation, direct access to the abdomen is

obtained with a 5- or 10-mm trocar.

y The critical issues for safe direct-puncture laparoscopy include the

use of a vented stylet for the trocar, or a trocar with a safety shield or dilating tip.
y The trocar must be pointed away from the sacral promontory and

the great vessels.

y Patient position should be surveyed before trocar placement to

ensure a proper trajectory. y For performance of laparoscopic cholecystectomy, the trocar is angled toward the right upper quadrant.

y Two Kocher clamps are placed

on the fascia, and with curved Mayo scissors, a small incision is made through the fascia and underlying peritoneum.

y A finger is placed into the

abdomen to make sure that there is no adherent bowel.

y A sturdy suture is placed on

each side of the fascia and secured to the wings of a specialized trocar, which is then passed directly into the abdominal cavity.

y Rapid insufflation can make up for some of the time lost with the

initial dissection.
y This technique is preferable for the abdomen of patients who have

undergone previous operations in which small bowel may be adherent to the undersurface of the abdominal wound.
y The difficulties in visualizing the abdominal region immediately

adjacent to the primary trocar, it is recommended that the telescope be passed through a secondary trocar to inspect the site of initial abdominal access.
y Secondary punctures are made with 5- and 10-mm trocars. For safe

access to the abdominal cavity, it is critical to visualize all sites of trocar entry.

y At the completion of the operation, all trocars are removed under

direct vision, and the insertion sites are inspected for bleeding.
y If bleeding occurs, direct pressure with an instrument from another

trocar site or balloon tamponade with a Foley catheter placed through the trocar site generally stops the bleeding within 3 to 5 minutes.
y When this is not successful, a full-thickness abdominal wall suture

has been used successfully to tamponade trocar site bleeding.

Access for Subcutaneous and Extraperitoneal Surgery

y For retroperitoneal locations, balloon dissection is effective. y This access technique is appropriate for the extraperitoneal repair of

inguinal hernias and for retroperitoneal surgery for adrenalectomy, nephrectomy, lumbar discectomy, pancreatic necrosectomy, or paraaortic lymph node dissection. similar to direct puncture laparoscopy, except that the last layer (the peritoneum) is not traversed. with a balloon on the end is introduced.

y The initial access to the extraperitoneal space is performed in a way

y Once the transversalis fascia has been punctured, a specialized trocar y The balloon is inflated in the extraperitoneal space to create a working

chamber. The balloon then is deflated and a Hasson trocar is placed.

y An insufflation pressure of 10 mmHg usually is adequate to keep

the extraperitoneal space open for dissection and will limit subcutaneous emphysema.
y Higher gas pressures force CO2 into the soft tissues and may

contribute to hypercarbia.
y Extraperitoneal endosurgery provides less working space than

laparoscopy but eliminates the possibility of intestinal injury, intestinal adhesion, herniation at the trocar sites, and ileus.

y Subcutaneous surgery has been most widely used in cardiac, vascular,

and plastic surgery.

y In cardiac surgery, subcutaneous access has been used for saphenous

vein harvesting, and in vascular surgery for ligation of subfascial perforating veins (Linton procedure). the knee may be harvested through a single incision.

y With minimally invasive techniques, the entire saphenous vein above y Once the saphenous vein is located, a long retractor that holds a 5-mm

laparoscope allows the coaxial dissection of the vein and coagulation or clipping of each side branch. veins in the lower leg.

y A small incision above the knee also can be used to ligate perforating

A. With two small incisions, virtually the entire saphenous vein can be harvested for bypass grafting. B. The lighted retractor in the subcutaneous space during saphenous vein harvest is seen illuminating the skin.

Hand-Assisted Laparoscopic Access

y Thought to combine the tactile advantages of open surgery with the

minimal access of laparoscopy and thoracoscopy.

y This approach commonly is used to assist with difficult cases before

conversion to celiotomy is necessary. y Used to help surgeons negotiate the steep learning curve associated with advanced laparoscopic procedures.
y This technology uses a "port" for the hand that preserves the

pneumoperitoneum and enables endoscopic visualization in combination with the use of minimally invasive instruments .

This is an example of hand-assisted laparoscopic surgery during left colectomy. The surgeon uses a hand to provide retraction and counter tension during mobilization of the colon from its retroperitoneal attachments, as well as during division of the mesocolon. This technique is particularly useful in the region of the transverse colon.

Port Placement
y Trocars for the surgeon's left and

right hand should be placed at least 10 cm apart.

y 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.
y If one imagines the target of the
y The surgeon stands behind the

operation (e.g., the gallbladder or gastroesophageal junction) oriented at the apex of a second equilateral triangle built on the first, these four points of reference create a diamond

telescope, which provides optimal ergonomic orientation but frequently requires that a camera operator (or mechanical camera holder) reach between the surgeon's hands to guide the telescope.

Imaging Systems
y Two methods of videoendoscopic imaging are widely used. y Both methods use a camera with a CCD, which is an array of

photosensitive sensor elements (pixels) that convert the incoming light intensity to an electric charge. y The electric charge is subsequently converted into a black-and-white image.
y Videoendoscopy, the CCD chip is placed on the internal end of a long,

flexible endoscope.
y Most standard GI endoscopes have the CCD chip at the distal end, but

small, delicate choledochoscopes and nephroscopes are equipped with fiber-optic bundles.

y Priorities in a video imaging system for MIS are

y illumination y resolution y color third

y Without the first two attributes, video surgery is unsafe. y Illumination and resolution are as dependent on the telescope, light

source, and light cable as on the video camera used. Imaging for laparoscopy, thoracoscopy, and subcutaneous surgery uses a rigid metal telescope, usually 30 cm in length.
y Little illumination is needed in highly reflective, small spaces such as

the knee, and a very small telescope will suffice. y When working in the abdominal cavity, especially if blood is present, the full illumination of a 10-mm telescope usually is necessary.

y Rigid telescopes may have a flat or angled

end. y Flat end provides a straight view (0), y Angled end provides an oblique view (30 or 45) y Angled telescopes allow greater flexibility in viewing a wider operative field through a single trocar site rotating an angled telescope changes the field of view.
y The use of an angled telescope has

distinct advantages for most videoendoscopic procedures, particularly in visualizing the common bile duct during laparoscopic cholecystectomy or visualizing the posterior esophagus or the tip of the spleen during laparoscopic fundoplication.

y The quality of the

videoendoscopic image is only as good as the weakest component in the imaging chain .
y It is important to use a video

monitor that has a resolution equal to or greater than the camera being used.
y Resolution is the ability of the

The Hopkins rod lens telescope includes a series of optical rods that effectively transmit light to the eyepiece. The video camera is placed on the eyepiece to provide the working image. The image is only as clear as the weakest link in the image chain. CCD = charge-coupled device.

optical system to distinguish between line pairs. The larger the number of line pairs per millimeter, the sharper and more detailed the image.

Energy Sources for Endoscopic and Endoluminal Surgery

y Many MIS procedures use conventional energy sources, but the

benefits of bloodless surgery to maintain optimal visualization has spawned new ways of applying energy.
y The most common energy source is RF electrosurgery using an

alternating current with a frequency of 500,000 cycles/s (Hz).

y Tissue heating progresses through the well-known phases of

coagulation [60C (140F)], vaporization and desiccation [100C (212F)], and carbonization [>200C (392F)].

y The two most common methods of delivering RF electrosurgery are

with monopolar and bipolar electrodes.

y Monopolar electrosurgery, a remote ground plate on the patient's leg or

back receives the flow of electrons that originate at a point source, the surgical electrode. y A fine-tipped electrode causes a high current density at the site of application and rapid tissue heating.
y A short-duration, high-voltage discharge of current (coagulation

current) provides extremely rapid tissue heating. y Lower-voltage, higher-wattage current (cutting current) is better for tissue desiccation and vaporization. y When the surgeon desires tissue division with the least amount of thermal injury and least coagulation necrosis, a cutting current is used.

y Bipolar electrosurgery, the electrons

flow between two adjacent electrodes.

y The tissue between the two

electrodes is heated and desiccated.

y There is little opportunity for tissue

cutting when bipolar current is used, but the ability to coapt the electrodes across a vessel provides the best method of small-vessel coagulation without thermal injury to adjacent tissues.

A. Capacitive coupling occurs as a result of high current density bleeding from a port sleeve or laparoscope into adjacent bowel. B. Direct coupling occurs when current is transmitted directly from the electrode to a metal instrument or laparoscope, and then into adjacent tissue.

Instrumentation
y Hand instruments for MIS usually are duplications of conventional

surgical instruments made longer, thinner, and smaller at the tip.

y It is important to remember that when grasping tissue with

laparoscopic instruments, a greater force is applied over a smaller surface area, which increases the risk for perforation or injury.

y Certain conventional instruments such as scissors are easy to reproduce

with a diameter of 3 to 5 mm and a length of 20 to 45 cm, but other instruments such as forceps and clamps cannot provide remote access. various configurations of surgical forceps and clamps.

y Different configurations of graspers were developed to replace the y Standard hand instruments are 5 mm in diameter and 30 cm in length,

but smaller and shorter hand instruments are now available for pediatric surgery, for microlaparoscopic surgery, and for arthroscopic procedures.

y A unique laparoscopic hand instrument is the monopolar electrical

hook. Configured with a suction and irrigation apparatus to eliminate smoke and blood from the operative field. y Allows tenting of tissue over a bare metal wire with subsequent coagulation and division of the tissue.

Robotic Surgery
y Robot defines a device that has been

programmed to perform specific tasks in place of those usually performed by people.

y The devices that have earned the title

"surgical robots" would be more aptly termed computer-enhanced surgical devices, as they are controlled entirely by the surgeon for the purpose of improving performance.
y The first computer-assisted surgical device

was the laparoscopic camera holder, which enabled the surgeon to maneuver the laparoscope either with a hand control, foot control, or voice activation.

y The surgeon is physically

separated from the operating table, and the working arms of the device are placed over the patient.
y An assistant remains at the

bedside and changes the instruments as needed, providing retraction as needed to facilitate the procedure.

Natural Orifice Transluminal Endoscopic Surgery

y The "latest rage" in MIS is NOTES, the use of the flexible endoscope to

enter the GI, urinary, or reproductive tracts, then traverse the wall of the structure to enter the peritoneal cavity, the mediastinum, or the chest.
y The catalyzing event for NOTES was the demonstration that a porcine

gallbladder could be removed with a flexible endoscope passed through the wall of the stomach, then removed through the mouth, and the demonstration in a series of 10 human cases from India of the ability to perform transgastric appendectomy.
y Since that time, a great deal of money has been invested by endoscopic

and MIS companies to help surgeons and gastroenterologists explore this new territory.

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.

Pediatric Laparoscopy
y MIS in the adolescent is little different from that in the adult, and

standard instrumentation and trocar positions usually can be used. y The instruments are shorter (15 to 20 cm), and many are 3 mm in diameter rather than 5 mm.
y The abdomen of the child is much smaller than that of the adult, a 5-

mm telescope provides sufficient illumination for most operations.

y The development of 5-mm clippers and bipolar devices has obviated

the need for 10-mm trocars in pediatric laparoscopy.

y Abdominal wall is much thinner in infants, a pneumoperitoneum

pressure of 8 mmHg can provide adequate exposure. DVT is rare in children, so prophylaxis against thrombosis probably is unnecessary.

Laparoscopy during Pregnancy

y Concerns about the safety of laparoscopic cholecystectomy or appendectomy in

the pregnant patient have been thoroughly investigated and are readily managed.
y Access to the abdomen in the pregnant patient should take into consideration

the height of the uterine fundus, which reaches the umbilicus at 20 weeks.
y The patient should be positioned slightly on the left side to avoid compression

of the vena cava by the uterus. Pregnancy poses a risk for thromboembolism, sequential compression devices are essential for all procedures.
y Fetal acidosis induced by maternal hypercarbia also has been raised as a

concern. The arterial pH of the fetus follows the pH of the mother linearly; and therefore, fetal acidosis may be prevented by avoiding a respiratory acidosis in the mother.

Minimally Invasive Surgery and Cancer Treatment

y MIS techniques have been used for many decades to provide palliation

for the patient with an obstructive cancer.

y Laser treatment, intracavitary radiation, stenting, and dilation are

outpatient techniques that can be used to re-establish the continuity of an obstructed esophagus, bile duct, ureter, or airway.
y Used in the staging of cancer. y Laparoscopy also is used to assess the liver in patients being evaluated

for pancreatic, gastric, or hepatic resection.

Cirrhosis and Portal Hypertension

y Patients with hepatic insufficiency pose a significant challenge for any

type of surgical intervention. y The ultimate surgical outcome in this population relates directly to the degree of underlying hepatic dysfunction.
y Often, this group of patients has minimal reserve, and the stress of an

operation will trigger complete hepatic failure or hepatorenal syndrome. These patients are at risk for major hemorrhage at all levels, including trocar insertion, operative dissection in a field of dilated veins, and secondary to an underlying coagulopathy. Therefore, a watertight port site closure should be carried out in all patients.

y Ascitic leak from a port site may occur, leading to bacterial peritonitis.

y The presence of portal hypertension is a relative contraindication to

laparoscopic surgery until the portal pressures are reduced with portal decompression.

Economics of Minimally Invasive Surgery

y Minimally invasive surgical procedures reduce the costs of surgery most

when length of hospital stay can be shortened and return to work is quickened.
y Shorter hospital stays can be demonstrated in laparoscopic

cholecystectomy, Nissen fundoplication, splenectomy, and adrenalectomy. Procedures such as inguinal herniorrhaphy that are already performed as outpatient procedures are less likely to provide cost savings.
y Procedures that still require a 4- to 7-day hospitalization, such as

laparoscopy-assisted colectomy, are less likely to deliver a lower bottom line than their open surgery counterparts.