Minimally invasive surgery

Minimally invasive/accessed surgery comprises of robotic and non robotic surgery. Non robotic surgery includes laparoscopy, endoscopy, arthroscopy and etc.

1. NUR FADZLINA ZABRI 082013100006 Minimally invasive surgery

2. Introduction A means of performing major operations through small incisions, often using miniaturized, high-tech imaging systems, to minimize the trauma of surgical exposure

3. Types of MIS

4. Further developments that made MIS even less invasive Single incision laparoscopic surgery (SILS) Natural orifice translumenal endoscopic surgery (NOTES)

5. Laparoscopy Surgical procedure that allows a surgeon to access the inside of the abdomen (tummy) and pelvis without having to make large incisions in the skin . Also known as keyhole surgery

6. Thoracoscopy Rigid endoscope is introduced through an incision in the chest to gain access to the thoracic contents No gas insufflation is required

7. Arthroscopy Surgical procedure in which a orthopedics inspects a joint through a tiny camera Helpful to diagnose joint conditions, or treat an already diagnosed problem

8. Perivisceral endoscopy Body planes can be assessed even in the absence of a natural cavity Eg : mediastinoscopy , retroperitonoscopy , retroperitoneal approaches Commonly done for hernial repair

9. Procedure that involves inserting a small wire with a balloon into blocked blood vessel. Inflation of balloon opens up the blockage Angioplasty

10. Advantages of MIS Decrease in wound size Reduction in infection, dehiscence, bleeding, herniation , and nerve entrapment Decrease in wound pain Improved mobility Decreased wound trauma Decreased heat loss Improved vision

11. Whole new anatomical landscape Haemostasis can be difficult to achieve Insufflants can cause locoregional hypoxia or change in the pH Limitations of MIS

12. Benefits to the surgeon It improves surgical precision and hand–eye coordination enhance the skills of a good surgeon shorten the learning curve of a novice surgeon shortening the surgical time thereby reducing cost, exposure to anaesthetic agents and morbidity improving the quality of care dispensed to the patient .

13. Preoperative evaluation

14. Preparation of the patient History : fit for GA and open procedures Examination Premedication Prophylaxis against thromboembolism DVT may developed from the reverse Tredelenburg position SC LMW heparin and antithromboembolic stockings should be used *Coagulation disorder *IHD *COPD

15. Theatre set up and tools Equipment needed Video imaging system (light source, video camera, camera control unit, HD LCD monitor, digital recording ) Laparoscopic kit ( Insufflator , Trocars and insufflator needles) Surgical instruments

16. Laparoscopes Trocars Veress Needle Insufflator

17. Basic principles of laparoscopy Patient preparation Usually performed under general anesthesia Positioning : Laparoscopic - supine position Gynaecologic cases – low lithotomy position Nephrectomy / adrenalectomy – lateral decubitus position Thoracoscopic – lateral position with table flexion Obese/pt with COPD – steep tredelenburg position

18. Technique Obtaining pneumoperitoneum Most common sites to place the initial trocar are: at the umbilicus , above the umbilicus in the midline, or in the left upper quadrant (Palmer’s point).

19. Two general approaches: open or closed entry Closed entry Blind puncture using Verres needle Used for entry at the umbilicus or at Palmer’s point The anterior abdominal wall is then grasped and elevated anteriorly to pull the abdominal wall away from the major vessels and bowel Fast and safe, however risk of getting intestinal or vascular injury

20. Open entry 1cm vertical incision at the level of umbilicus Dissect the subcutaneous fat, expose the fascia Free penetration into abdomen cavity is confirmed by introduction of finger Hasson trocar is inserted Avoids morbidity related to a blind puncture

21. The abdomen is inflated with a pressure-limited insufflator . CO2 gas usually is used, with maximal pressures in the range of 14 to 15 mmHg.

22. P ort placement Trocars for the surgeon's left and right hand should be placed at least 10 cm apart Four ports are used: optical (10mm), one 5mm and one 10mm operating, and one 5.0mm assisting port. The optical port is at or near the umbilicus

23. Preoperative problems In obese patient : increase thickness in subcutaneous fat

24. Operative problems Intra operative perforation of gall bladder If perforation is small  closed with endoloops or endoclip Stone spillage  collect and extract, with ultrasound to assess remain collection left

25. Bleeding From major vessel From gall bladder bed From trocar site Blood clots

26. Principles of electro surgery during laparoscopic surgery

27. Post operative care Nausea  antiemetics Shoulder tip pain  settles within 2-3 days, relieved with paracetamol Abdominal pain  increasing pain after 2-3days can be sign of infection, hence antibiotic is required

28. Suppository analgesia for postoperative pain relief Oral fluid and feeding – can be started 4-6 hours after surgery Urinary catheter – removed before patien t regains consciousness Drains – removed when problem has resolved

29. Discharge from hospital Comfortable, passed urine, eating and drinking satisfactorily Non absorbable sutures or skin staples can be removed after 7 days Encourage movement and mobility

30. References Bailey and Loves short practice of surgery, 26 th Edition Schwartz principles of surgery 9 th Edition http://emedicine.medscape.com/article/1848486-overview#showall http :// www.nhs.uk/conditions/Laparoscopy/Pages/Introduction.aspx