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What is Minimally Invasive Surgery ?
Minimally Invasive Surgery (MIS) is a new kind of surgery
which gets more and more common nowadays. Another
well-known expression is 'endoscopic surgery'. With this
method, a surgical operation is performed by the help of: a small endoscopic camera. several long, thin, rigid instruments.
through natural body openings or small artificial incisions ('keyholesurgery').
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Minimally Invasive Surgery:
Becoming the Standard of Care
Laparoscopy is currently the preferred
surgical modality for a variety of
procedures like:
95% of cholecystectomies
90% of fundoplications
70% of ectopic
pregnancies 50% of benign ovarian
cysts
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Minimally Invasive Surgery:
Becoming the Standard of Care
Better Visualization
Able to visualize/evaluate all abdominal structures
Pelvis: Adnexa, Posterior Cul-de-Sac, Uterus
Upper abdomen: Liver, Stomach, Bowel
Complete evaluation of adnexal pathology
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Early Physician Assumptions
When one looked into the
surgical future of gynecology,most felt they would look
through an endoscope
Franklin D. Loffer, M.D
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Early Assumptions
Franklin D. Loffer, M.D
The Gynecologic Endoscopists
everything will be done through the
scope
The Public - everything will be donewith a laser
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Indications for Surgery Have
Been Reduced
Better understanding of disease
process Better medical therapies
Economic considerations
Patient sophistication
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1805 Bozzini Urethroscopy
1865 Desormeaux Cystoscopy
1869 Pantaleoni Hysteroscopy
1894 Fritsch (not Asherman in1948)
Uterine Synechiae
1910 Jacobaeus Laparoscopy
1937 Bardenheuer (not Goldrath in1981)
Endometrial ablation
1940 Power & Barnes (not Loffer in1974)
Tubal coag
Endoscopy Just Turned
200 Years Old Is It Time For It To RIP?
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Medical Progress Frequently
Follows Technical Advances
1880 - Edison Incandescent light
1943 - Fourestiere Fiber optic light
1953 - Hopkins Rod lens
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Adoption of Endoscopy by
Specialty
Urologist 20th century
Gastroenterologist 1930sGynecologist late 1960s
General Surgeons late 1980s
Other Specialties 1990s
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At First Gynecologic Endoscopy
Was A Diagnostic Tool
Endometriosis
Ovarian cysts
Ectopic pregnancies
Endometrial polyp Submucosal myoma
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Early Modern Gynecologic
EndoscopyLaparoscopy - circa 1960s
Diagnostic
Tubal sterilization
Lysis of adhesions
Coagulation endometriosis
Hysteroscopy circa 1970s
Diagnostic
Tubal sterilization
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Advancing Modern Gynecologic
Endoscopy
Future Trends in Gynecologic Surgery
Laparoscopy - circa 1970s
Ectopic pregnancy Ovarian cystectomy
Salpingoopherectomy
Hysteroscopy circa 1980s
Septum
Adhesions
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Current Gynecologic
EndoscopyLaparoscopy - circa 1990
LAVH / TAH
Bladder suspension Pelvic floor reconstruction
Node dissection
Hysteroscopy circa 1990
Endometrial ablation/resection
Submucosal fibroid resection
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Challenges to Surgical
Endoscopy Hysteroscope vs LAVH in AUB
Global vs hysteroscopic EA
Vaginal hysterectomy vs LAVH UBT vs endometrial ablation
UAE / UAO / Ultrasound vs myomectomy
Sonohysterography vs hysteroscopy Transvaginal hydrolaparoscopy vs
diagnostic laparoscopy
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Gynecologic Surgery Before
Modern Endoscopy Was:
Hysterectomy
Oophorectomy
Pelvic repair vag & MMK
Tube sterilization & ectopic
D & C
Congenital anomalies
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Where does Endoscopy stand now ?
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What Has Happened to the
Hysterectomy? AUBAUB Endometriosis / Pelvic painEndometriosis / Pelvic pain
MyomasMyomas CIN - Leep
- Immunization?
Prolapse - Vaginal approach
Cancer - Still 10 approach
Franklin D. Loffer, M.D.
Will
discuss
later
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What Has Happened With the
Ovary?
Cystectomy - laparoscopy
Oophorectomy - laparoscopy
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What Has Happened With
Pelvic Repair and Incontinence?
Laparoscopic Burch
Slings
Meshes
Radio frequency
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What Has Happened With
the Fallopian Tubes?
Sterilization - Laparoscopic
- Hysteroscopic - IUD
Ectopics - Laparoscopic approach
- Medical approach
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What Has Happened With The
D&C?*
Hysteroscopy Sonohysteroscopy
Franklin D. Loffer, M.D.
*The D&C Has Died RIP Franklin D. Loffer
Presented at the AAGL 3rd World Congress on Hysteroscopy
Miami Florida 1987
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What Has Happened With
Infertility?
PID - Laparoscopy
Tubal factor - IVF
Synechiae - Hysteroscopy
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What Has Happened With
Congenital Anomalies?
Septum - Hysteroscopy
Uterine Horn - Laparoscopy
Vaginal agenesis - Laparoscopy
Franklin D. Loffer, M.D.
Wh t H H d With th
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What Has Happened With the
Management of Abnormal
Uterine Bleeding?
Endometrial ablation - Nd:yag
- Resectoscope
Progesterone - IUD
Submucosal myoma - Hysteroscopy
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What Has Happened to the
Management of Endometriosis /
Pelvic Pain?
GnRH agonists - current
SPRMs - future LUNAS - not effective
Presacral neurectomy - rare
Other - IC
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What Has Happened to the
Management of Myomas? UAE - Radiology UAO - Laparoscopic
- Vaginal Myolysis - Laparoscopic
- Focused ultrasound
Medical - Asoprisnil Resection - Hysteroscopic
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Obese patients
Ideal Robotic Case
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Obese
Case requiring extensivesuturing
- sacrocolpopexy
Ideal Robotic Case
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Obese patients
Extensive suturing
Complex gynecologic procedure
- invasive endometriosis
Ideal Robotic Case
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Obese patients
Extensive suturing
Complex gynecologic procedure
Complex oncologic procedure
- Aortic lymphadenectomy
Ideal Robotic CaseIdeal Robotic Case
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Compared to laparotomy there isdecreased:
- EBL- LOS
- Post-op transfusions
- Number of major post-opcomplications
pared
Giles, Magrina, Magtibay, Presented WAGO (June 2007)
Robotic Hysterectomy in theRobotic Hysterectomy in the
Treatment of Uterine CancerTreatment of Uterine Cancer
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Gynecologic Endoscopy
So where do we stand?
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Gynecologic Endoscopy
Trends
Franklin D. Loffer, M.D.
Increasing Decreasing NC
Ovary pelvic floor / incont Hyst
Ca Dx AUB Tube
Cong Anomal Endo / pain Dx
Myoma
Infertility
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Role of New Technology in Minimally
Invasive Gynecologic Surgery:
Robots, 3-D Vision, Simulators
Role of New Technology in Minimally
Invasive Gynecologic Surgery:
Robots, 3-D Vision, Simulators
Camran Nezhat, MD, FACOG,FACS.
www.nezhat.org
Camran Nezhat, MD, FACOG,FACS.
www.nezhat.org
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Its offspring is called
Minimally Invasive Gynecology
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Minimally Invasive Surgery: What
are the Limiting Factors?
Surgeons must progress beyond the traditionaltechniques of cutting and sewing . ,to a future in
which minimal access to the abdominal cavity areonly the beginning.
How can we overcome surgeon and equipmentlimitations?
Pappas, Jacobs, NEJM 2004