minimal invasive surger
TRANSCRIPT
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Minimal invasive surgery
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History of minimal invasive
surgery Hippocrates - rectum examination with
a speculum
1806,Philip Bozzini - built aninstrument that could be introduced in
the human body to visualize the internal
organs. He called this instrument"LICHTLEITER"
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History of minimal invasive
surgery 1868, Kussmaul performed the first
esophagogastroscopy on a professional
sword swallower, initiating efforts atinstrumentation of the gastrointestinal tract.
1901, The first experimental laparoscopy was
performed in Berlin in 1901 by this German
surgeon Georg Kelling, who used acystoscope to peer into the abdomen of a dog
after first insufflating it with air.
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History of minimal invasive
surgery 1929, Kalk, a German physician,
introduced the forward oblique (135
degree) view lens systems. He
advocated the use of a separate
puncture site for pneumoperitoneum.
Goetze of Germany first developed aneedle for insufflations.
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History of minimal invasive
surgery 1938, Janos Veress of Hungary
developed a specially designed spring-
loaded needle. Interestingly, Veress did
not promote the use of his Veress
needle for laparoscopy purposes. He
used veress needle for the induction ofpneumothorax.
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History of minimal invasive
surgery 1983,Semm, a German gynaecologist,
performed the first laparoscopicappendicectomy.
1985, The first documented laparoscopiccholecystectomy was performed by ErichMhe in Germany in 1985.
1987,Phillipe Mouret, has got the credit toperformed the first laparoscopiccholecystectomy in Lyons, France usingvideo technique.
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History of minimal invasive
surgery 1994,A robotic arm was designed to
hold the telescope with the goal of
improving safety and reducing the needof skilled camera operator.
1996,First live telecast of laparoscopic
surgery performed remotely via theInternet. (Robotic telesurgery)
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Equipment and instrumantation
Imaging System
- Laparoscopes- Cold light source
- Cameras
- Monitor
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Equipment and instrumantation
Dissectors
Hooks and spatulas
Clip appliers and endolinear cutter
Insuufflation/ Veress needle
Suctiom and irrigating apparatus Trocars
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Advantages of minimal invasive
surgery Safe
Reduced postopertive morbitity (pain,
fatigue, pulmonary embarrassement)
Faster return of bowel function
Shorter lenght of hospital stay
Rapid return to normal activity
Cost-effective
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Avoiding complications during
laparoscopy Training
Patient selection
Room setup
Port placement (site/technique)
Visualisation (equiepment/blood or debris)
Familiarity with anatomical landmarks
Early consultation
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Laparoscopy Today
Diagnostic laparoscopy
- gynecology/acut-chronic abdominal pain
- cancer staging/diagnosis
Emergency laparoscopy
- Appendectomy
- Surgical managment of perforated peptic ulcer- Surgical managment of diverticular diseases
- Intestinal obstruction
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Minimal invasive general surgery
Esophago-gastric surgery
Liver, pancreas surgery
Colorectal surgery
Endocrine surgery
Surgery of the abdominal wall
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Minimal invasive surgery
Thoracoscopic surgery (lung, esophageal
surgery) Cardio-vascular surgery
Gynecology
Urology
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Minimally Invasive
Techniques in the Surgery ofthe Esophagus
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Surgical approaches
of the esophagus
LAPAROTOMY
THORACOTOMY
TRANSCERVICAL
LAPAROSCOPY
THORACOSCOPY
MEDIASTINOSCOPY
ENDOLUMINAL
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MINIMALLY INVASIVE
TECHNIQUE IN ESOPHAGEAL
SURGERY
GERD, HIATAL HERNIAS,
ESOPHAGEAL DIVERTICULA ACHALASIA, OTHER MOTILITY
DISORDERS
ESOPHAGEAL PERFORATIONS
BENIGN TUMOURS
MALIGNANT TUMOURS ?
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MINIMALLY INVASIVE
SURGERY OF THE ESOPHAGUS
Department of Surgery, University ofSzeged, 1994 - 2001
LAPAROSCOPIC
NISSENFUNDOPLICATION
HELLER MYOTOMY
THORACOSCOPIC
ENUCLEATION OFBENIGN TUMOURS
ENDOSCOPIC
STAPLING
DIVERTICULOSTOMY
81
12
3
3
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LAPAROSCOPIC NISSEN
FUNDOPLICATION
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Characteristics of patients subjected
to laparoscopic Nissen
fundoplication1997. 01. 01. - 2001. 12. 31.
Sex M 38
F 43
Age (years/range) 43 (20-72)
Risk ASA 1-2 60
ASA 3 21
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Endoscopy
24 hour esophageal pH monitoring
Esophageal body and sphinctermanometry
Radiography 24 hour bile exposure monitoring
(Bilitec, 2000)
METHODS
/Preoperative assessment/
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Persistent or recurrent symptoms/
complications, in spite of optimal
medical treatment with proton-
pump inhibitors.
Indication for Surgery
METHODS Surgical technique
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Short, floppy fundoplication
Mobilization of the fundus with division ofshort gastric vessels
Dissection of the crura
Identification of vagal branches
Mobilization of the distal esophagus Closure the hiatal opening
Calibration by Bougie
Short wrap
METHODS Surgical technique
The standard 3600 Laparoscopic
Nissen fundoplication
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Laparoscopic Nissen fundoplication
Results
Mean operative time 140 min 60 min
Complications severe bleeding 1
neck co2 emphysema 4
Conversion 1
Hospital stay /days/ 5 /3-7/
Mortality 0
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Laparoscopic Nissen fundoplication
Results
Morbidity
Dysphagia Transitional Persistent
( > 3 month)
24 1
Diarrhea 8 -
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Laparoscopic Nissen fundoplication
Results24 hour pH monitoring - DeMeester score (
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Laparoscopic Nissen fundoplication
Results24 hour pH monitoring - reflux index (< 4 %)
0
2
4
6
8
10
12
14
16
Before
operation
3 month after
operation
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Laparoscopic Nissen fundoplication
ResultsManometry - LES pressure (24.213.2 mmHg)
0
2
46
8
10
12
14
16
Before
operation
3 month after
operation
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Laparoscopic Nissen fundoplication
ResultsSphincter length (cm)
0
0,5
1
1,5
2
2,5
3
3,5
4
4,5
Before
operation
3 month after
operation
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Conclusion
The laparoscopic Nissen
fundoplication with a standardizedsurgical technique results in a
proper reflux control as confirmed
by early functional tests.
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Transhiatal resection of
epiphrenic esophageal
diverticulum
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Barium swallow
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VIDEO-THORACOSCOPIC
TREATMENT OF BENIGN
TUMOURS OF THEESOPHAGUS
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Benign tumours of the esophagus
I. Leiomyoma
II. Cyst /enterogenic, bronchogenic/
III. Polyp
0,51 %
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Patients with benign esophageal
tumours
Age (years) sex1. Esophageal cyst 25 F
2. Leiomyoma 40 M
3. Leiomyoma 38 F
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Diagnostic tests
Barium swallow
Esophagoscopy
Endoscopic UH Chest CT
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Diagnostic tests
Barium swallow
Esophagoscopy
Endoscopic UH
Chest CT
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Diagnostic tests
Barium swallow
Oesophagoscopy
Endoscopic UH Chest CT
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Diagnostic tests
Barium swallow
Esophagoscopy
Endoscopic UH
Chest CT
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Surgical treatment of benign
esophageal tumours
Traditional surgical
technique
Thoracotomy
Minimal invasiv surgical
technique
Videothoracoscopy
EXCISION
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Surgical technique I.
Lateral decubitus position
Selective intubation
Endoluminal endoscopic control
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Surgical technique
II.
Port sites
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Viodeothoracoscopic treatment
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Viodeothoracoscopic treatment
of benign tumours of the
esophagus - results
Operative time
Blood loss
Complications
Hospital stay
70, 120, 180 minutes
Minimal (50100 ml)
None
7 days
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Videothoracoscopic treatment of
midesophageal diverticulum
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Preoperative Barium swallow
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Postoperative Barium swallow
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Conclusions
The videothoracoscopic technique is safe, involves
minimal pain and permits a rapid return to normal
activity.
It should be the method of choice for removing
benign lesions of the oesophagus.
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MINIMALLY INVASIVE
SURGERY FOR ZENKER
DIVERTICULUM
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Surgical treatment for Zenker
diverticulum
Conventional surgery: crycopharyngeal myotomy +
diverticulectomy or diverticulum suspensionEndoscopic approach (Mosher, 1917)
diathermic/laser dissection (Dohlman, Mattsson 1960)
Endoscopic stapling diverticulostomy (Collard, 1993)
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Light and short general anaesthesia
Short operation time and hospital stay Low risk of perforation of diverticular pouch
No injury of reccurent nerve
Early resumption of oral feeding Complete relief of dysphagia
No scar in neck
Advantages of endoscopic stapling
diverticulostomy
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Age/Sex 66 M, 82 F
Symptoms dysphagiaregurgitation
Diagnostic barium swallow,
assessment esophagoscopy
Diverticulum 4 and 5 cmSize
Characteristics of patients with
Zenker diverticulum
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Endoscopic stapling
diverticulostomy
Operative technique
General anaesthesia
Surgical equipments:Rigid, fixable, doublelipped laryngoscope
(Weerda, Karl Stortz)
Endostapler (Endopath ETS, Ethicon)5 mm rigid telescope
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Endoscopic stapling
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Endoscopic stapling
diverticulostomy
Results
Operative time: 15/25 min
No intra- or postoperative complications
Complete relief of dysphagia 18/6 months
after the operation
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Conclusion
The stapling diverticulostomy is atherapeutic alternative in the
surgical treatment for Zenker
diverticulum.
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Minimal invasive technique in
the surgery of the spleen
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Surgery/Patients
Laparoscopic splenectomies N: 20
Laparoscopic unroofings N: 5 Mean age (years) 43 (19-72)
Female/male 24 /1
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Indications for surgery
ITP 17
Metastatic melanoma 1
Non-Hodgkin lymphoma 1
Hereditary sphaerocytosis 1
Non-parasitic splenic cyst 5
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Preoperative assessment
Haematological / gastroenterological
check-up
Abdominal US/CT
Polyvalent pneumococcal vaccination
Antibiotic prophylaxis
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Surgical technique
Supine position
General anaesthesia
3 or 4 operating ports
Ultrasonic dissection
Linear cutting stapler
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Mtti technika
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Laparoscopic splenectomy -
results
Surgical time
Est. blood loss
Spleen weight
Conversions
Complications
Lenght of hospital
stay
130 (90-180) min.
150 (50-250) ml
310 g (200-2100)
N: 2 (10 %)
none
5 (4-7) days
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Laparoscopic unroofings -
results
Surgical time
Est. blood loss
Conversions
Complications
Lenght of hospitalstay
50 (40-90) min.
100 (50-200) ml
None
None
4 (3-6) days
Preoperative clinical parameters
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Open vs. laparoscopic splenectomy
OpenN:10
LaparoscopicN:15
Indication for surgery ITP ITP
Meanage/range(years)
45 (30-67) 49 (28-72)
Body weight ( kg) 63 (50-110) 60 (48-105)
ASA score 1.9 (1-3) 1.8 (1-3)
PrePLT (T/L) 41 (20-100) 39 (10-90)
Preop. htkr (L/L) 38 (25-40) 35 (20-38)
Open/ laparoscopic splenetomies
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Open/ laparoscopic splenetomies
Outcomes
Open
N:10
LaparoscopicN:15
Operating time (min) 80 (50-120) 90 (60-180)
Est. blood loss (ml) 150 (50-300) 150 (50-250)
Weight of the spleen
(g)
190 180
Liquid diet (days) 3 (2-4) 2 (1-3)
Post.op. bowel
paralysis (days)
3,5 (3-4) 2 (1-3)
Hospital stay (days) 7 (6-12) 5 (4-7)
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Conclusions
Laparoscopic splenectomy or unroofing
is feasible and safe,
resulting brief hospitalization, minimalrecovery time.
LS can be safely performed even for
enlarged spleens.
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Minimal invasive surgical
treatment of nonparasitic liver
cyst
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C l i
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Conclusion
Minimally
invasive surgical
technique
Conventional
surgical
technique
CO C S O
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CONCLUSION
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CONCLUSION
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FUTURE
Sooner and later you will see great changes.
Nostradamus (1503-1566) Centurie I, verse 56