LAPAROSCOPIC SURGERYLOOKING BEYOND EXISTING HORIZONS

Dr Pradeep Jain Director

Laparoscopic G I & GI Oncosurgery and Bariatric Surgery Fortis Hospital Shalimar Bagh

1901 George Kelling first laparoscopic procedure in animals 1910 Hans Christian Jacobaeus reported first laparoscopic

procedures in humans 1965 Berci introduces rode lens system 1982 video laparoscope introduced 1983 Semm performed first laparoscopic appendicectomy 1985 Muhe performed first laparoscopic cholecystectomy

( though Mouret is often credited for first lap chole ) 1992 NIH consensus conference lap chole as preferred

alternative to open chole Decade of 90s almost every GI surgery done laparoscopically 1st decade of 2000s safety and efficacy of GI cancers established 2005 Rao and Reddy first transgastric appendicectomy

( NOTES) 2007 First NOTES in USA ( trans vaginal cholecystectomy )

History line of Laparoscopy

Advancement of technology Awareness Benefit to patients Competitiveness among surgeons

Why this “KOLAVERI DI”

Cholecystectomy Appendicectomy Hernia repair Fundoplication Rectopexy Hellers myotomy Bariatric surgery

Gold standard

Laparoscopy for cancers Pancreatic necrosis surgery Bariatric surgery SILS (single incision laparoscopic surgery ) NOTES (natural orifice transluminal

endoscopic surgery ) Robotic Surgery

Demanding surgery Dissection near vessels Oncological clearance Lymphadenectomy Port site recurrences Local recurrences

Cancer concerns

Colorectal cancers Esophagectomy Gastrectomy Distal pancreatectomy Whippels Hepatic resections

Disease Free Survival: ◦ Comparative Randomised Studies

Barcelona (Lacy 2002) USA (COST 2004) Hong Kong RCT (Leung 2004) New Mexico (Curet 2000) Los Angeles (Kaiser 2004)

Evidence to Support Laparoscopic Colorectal Surgery

Clinical Effectiveness◦ Shorter length of stay◦ Fewer complications◦ Less blood loss & use of blood products◦ Less pain & analgesia◦ Quicker return to normal activities◦ Better cosmesis◦ Incidence of port site metastases is 1%

Equivalent to open surgery

Evidence to Support Laparoscopic Colorectal Surgery

Laparoscopic surgery is recommended as an alternative to open surgery for colorectal cancer…..

The surgeon has been trained in laparoscopic surgery for colorectal cancer and performs the operation often enough to keep his skills up to date

NICE guidelines laparoscopic colorectal cancer - August 2006

Laparoscopic APR

Laparoscopic Ant Resection

Laparoscopic Hemicolectomy

Enough evidence for safety, oncological clearances, comparable morbidity and mortality.

No RCTs like colorectum suggesting equivalence to open surgery

Lap esophagectomy, gastrectomy,distal pancreatectomy

Thoracolaparoscopic Esophagectomy

Morbidity, mortality and overall outcome not dependent on incision

Feasibility and safety has been documented

Still can not be recommended as a routine

Lap Whippels , Hepatic Resection

Laparoscopic liver resection

Lap. Pancreatic Necrosectomy

Substantial decrease in mortality and

morbidity Improved surgical techniques Increased media attention Increased profitability

Bariatric Surgery

Laparoscopic Bariatric Surgery

SILS (Single incision laparoscopic surgery )

NOTES ( natural orifice transluminal endoscopic surgery )

ROBOTICS

New kids on the block

Safe No pain No scar No post operative complication No loss of activity Out patient Any body can have it Inexpensive All surgeon can do it

Goals of minimally invasive surgery

SILS

Hernias Less safe Wound complications No decrease in pain

Concerns of sils

Standard laparoscopy and hernia 0.08 to 0.14 % port hernia >400 articles in print - no reported data on

port site hernia

Hussain et al :J soc of lap surg 2009

SILS and Hernia

Oral

Rectal Vaginal

Uretheral

Natural orifice transluminal endoscopic surgery ( NOTES )

NOTES

SILS NOTES

Safe +/- +/-

No pain - +/-

No scar +/- +

No complication +/- -

No loss of activity

- +/-

Out patient +/- +/-

Every body can have it

+ -

inexpensive - -

All surgeon can do it

- -

SILS VS NOTES

Best example of man machine combination Advantages - Precision - 3 D magnification - Articulation beyond normal manipulation - Miniaturization Disadvantages - Cost - Advantage over routine laparoscopy not

established except urological and cardiac procedures

Robotic surgery

Robotic Surgical Cart

Robotic Endowrist

OT schema

Robotic OT layout

The end of the beginning

Thanks