future of laparoscopy

Laparoscopy: History, Laparoscopy: History,

Present and Emerging Present and Emerging

TrendsTrends

Dr. Sreejoy PatnaikDr. Sreejoy Patnaik

History of LaparoscopyHistory of Laparoscopy

A three bladed speculum was found in the ruins A three bladed speculum was found in the ruins

of Pompeii*. of Pompeii*.

*A *A roman town buried by a volcano eruption roman town buried by a volcano eruption

near modern Naples, Italy - 79 AD).near modern Naples, Italy - 79 AD).

The first description dates to Hippocrates in The first description dates to Hippocrates in Greece, for use of a speculum to visualize Greece, for use of a speculum to visualize the rectum (460–375 BC).the rectum (460–375 BC).


1806: Philip Bozzini developed an 1806: Philip Bozzini developed an

instrument called a instrument called a LichtleiterLichtleiter

(light-guiding instrument)(light-guiding instrument)

1853: Antoine Jean Desormeaux 1853: Antoine Jean Desormeaux

used Bozziniused Bozzini’’s Lichtleiters Lichtleiter

1867: Desormeaux used an open 1867: Desormeaux used an open

tube to examine the genitourinary tube to examine the genitourinary

tracttract


Maximilian Nitze (1848 – 1906) Maximilian Nitze (1848 – 1906)

invented the first cystoscope invented the first cystoscope

((Nitze-Leiter cystoscope) using an Nitze-Leiter cystoscope) using an

electrically heated platinum wire electrically heated platinum wire

for illuminationfor illumination..

In 1887, he modified Edison`s light In 1887, he modified Edison`s light

bulb and created the first electrical bulb and created the first electrical

light bulb for use during urological light bulb for use during urological

procedures.procedures.Original carbon-filament bulb- Thomas Edison


1901: George Kelling, Dresden, 1901: George Kelling, Dresden,

SaxonySaxony (Germany) (Germany) performed the performed the

1st experimental laparoscopy, 1st experimental laparoscopy,

calling it ‘Celioscopy’. calling it ‘Celioscopy’.

Kelling insufflated the abdomen of Kelling insufflated the abdomen of

a dog with filtered air and used a a dog with filtered air and used a

Nitze cystoscope to look inside.Nitze cystoscope to look inside.

Hans Christian Jacobaeus Hans Christian Jacobaeus (1879 – 1937) (1879 – 1937)

1910: Swedish internist; first 1910: Swedish internist; first

thoracoscopic diagnosis with a thoracoscopic diagnosis with a

cystoscope in a human subject.cystoscope in a human subject.

Treatment of a patient with tubercular Treatment of a patient with tubercular

intra-thoracic adhesions.intra-thoracic adhesions.

The Possibilities for Performing Cystoscopy in The Possibilities for Performing Cystoscopy in Examinations of Serous Cavities. Examinations of Serous Cavities. Münchner Medizinischen Münchner Medizinischen Wochenschrift,Wochenschrift, 1911 1911

Bertram BernheimBertram Bernheim

1911 : First laparoscopy at Johns Hopkins

12mm proctoscope into epigastric incision on one of Halstead’s patients to stage pancreatic cancer

Bernheim called his procedure ‘organoscopy’

Findings confirmed on laparotomy


1920: Zollikofer discovered the benefit of CO1920: Zollikofer discovered the benefit of CO22 gas for insufflation gas for insufflation

1938: Janos Veress developed a spring loaded needle for the 1938: Janos Veress developed a spring loaded needle for the induction of pneumoperitoneum.induction of pneumoperitoneum.

After World War II, the development of fiberoptics represented an After World War II, the development of fiberoptics represented an important step forward for endoscopyimportant step forward for endoscopy

1966: Hopkins rod lens scope & cold light1966: Hopkins rod lens scope & cold light

1974: Dr Harrith M Hasson, MD working in Chicago, 1974: Dr Harrith M Hasson, MD working in Chicago, proposed a blunt proposed a blunt mini-laparotomy which permitted direct visualization of the trocar mini-laparotomy which permitted direct visualization of the trocar entrance into the peritoneal cavity. It is popularly known today as entrance into the peritoneal cavity. It is popularly known today as Hasson‘s technique.Hasson‘s technique.

Kurt Semm (1927-2003)Kurt Semm (1927-2003) Once, while making a slide Once, while making a slide

presentation on ovarian cysts; presentation on ovarian cysts;

suddenly the projector was suddenly the projector was

unplugged - with the unplugged - with the

explanation that explanation that ““such such

unethical surgery should not unethical surgery should not

be presentedbe presented”” In 1970, after becoming the In 1970, after becoming the

chairman of Ob/Gyn at the chairman of Ob/Gyn at the

University of Kiel, his co-workers University of Kiel, his co-workers

demanded that he undergo a demanded that he undergo a

brain scan because, they said, brain scan because, they said,

““only a person with brain damage only a person with brain damage

would perform laparoscopic would perform laparoscopic

surgerysurgery””

German Engineer and Gynecologist.Introduced automatic insufflator,thermocoagulation ,loop knots,irrigation device in 1983, performedendoscopic appendectomy as part ofA gynecologic procedure.


1985: Dr. Muhe (Prof Dr Med - Böblingen, Germany)1985: Dr. Muhe (Prof Dr Med - Böblingen, Germany) performed performed

the first successful laparoscopic cholecystectomy in a human. the first successful laparoscopic cholecystectomy in a human.

However, this was not well publicized until years later. The However, this was not well publicized until years later. The

German Surgical Society rejected Mühe in 1986 after he reported German Surgical Society rejected Mühe in 1986 after he reported

that he had performed the first laparoscopic cholecystectomy.that he had performed the first laparoscopic cholecystectomy.

Laparoscopy Takes OffLaparoscopy Takes Off 1988: 1st Lap cholecystectomy in the USA, Surgiport 1st 1988: 1st Lap cholecystectomy in the USA, Surgiport 1st

availableavailable

1989: US TV picks up on “Key Hole” surgery EndoClip™ 1989: US TV picks up on “Key Hole” surgery EndoClip™ releasedreleased

1990: Cuschieri (Aberdeen) warns on the explosion of 1990: Cuschieri (Aberdeen) warns on the explosion of endoscopyendoscopy

1991: ‘Lap Chole’ is accepted and routine procedure1991: ‘Lap Chole’ is accepted and routine procedure

1992: The National Institutes of Health Consensus 1992: The National Institutes of Health Consensus Conference concludes that laparoscopic cholecystectomy is Conference concludes that laparoscopic cholecystectomy is now the preferred alternative to open cholecystectomynow the preferred alternative to open cholecystectomy

DefinitionDefinition

Minimal access surgery is a Minimal access surgery is a

marriage of modern technology marriage of modern technology

and surgical innovation that aims and surgical innovation that aims

to accomplish surgical to accomplish surgical

therapeutic goals with minimal therapeutic goals with minimal

somatic and psychological traumasomatic and psychological trauma

Extent of minimal access Extent of minimal access surgerysurgery

LaparoscopyLaparoscopy

ThoracoscopyThoracoscopy

Endoluminal endoscopyEndoluminal endoscopy

Perivisiceral endoscopyPerivisiceral endoscopy

Arthroscopy and intra-articular Arthroscopy and intra-articular

joint surgeryjoint surgery

Combined approachCombined approach

What operations can we do What operations can we do LaparoscopicallyLaparoscopically

DiagnosisDiagnosis

GallstoneGallstone

AppendicitisAppendicitis

HerniaHernia

AdhesionsAdhesions

Perforated ulcerPerforated ulcer

Hiatus HerniaHiatus Hernia

OperationOperation

CholecystectomyCholecystectomy

AppendicectomyAppendicectomy

Hernia repairHernia repair

Division of adhesionsDivision of adhesions

Closure of perforationClosure of perforation

Hiatus hernia repair.Hiatus hernia repair.

What operations can we do What operations can we do LaparoscopicallyLaparoscopically

DiagnosisDiagnosis

Colorectal carcinomaColorectal carcinoma

Caecal carcinomaCaecal carcinoma

Colonic carcinomaColonic carcinoma

Gastric carcinomaGastric carcinoma

Oesophageal carcinomaOesophageal carcinoma

The list is endless!!!The list is endless!!!

OperationOperation

Anterior resection/ APRAnterior resection/ APR

Right HemicolectomyRight Hemicolectomy

Left/Sigmoid ColectomyLeft/Sigmoid Colectomy

GastrectomyGastrectomy

OesophagogastrectomyOesophagogastrectomy

What operations can we do What operations can we do laparoscopically?laparoscopically?

DiagnosisDiagnosis

CrohnCrohn’’s Diseases Disease

DiverticulitisDiverticulitis

Rectal ProlapseRectal Prolapse

Benign renal diseaseBenign renal disease

Gastric ObstructionGastric Obstruction

Some Splenic disordersSome Splenic disorders

OperationOperation

Bowel resectionBowel resection

Bowel resectionBowel resection

Repair of ProlapseRepair of Prolapse

NephrectomyNephrectomy

BypassBypass

SpleenectomySpleenectomy

Principle Differences between Principle Differences between Laparoscopic and Open Laparoscopic and Open

SurgerySurgeryFOR THE PATIENTFOR THE PATIENT

Post operative pain related to size of incision- Post operative pain related to size of incision- smaller incisions =less pain.smaller incisions =less pain.

Less Handling of intestines results in little or no Less Handling of intestines results in little or no disturbance of normal function.disturbance of normal function.

Avoidance of the trauma of abdominal wall injury Avoidance of the trauma of abdominal wall injury by the incision allows rapid return to normal by the incision allows rapid return to normal activityactivity

No incision allows early return to more strenuous No incision allows early return to more strenuous activities: driving, lifting, sport etc.activities: driving, lifting, sport etc.

Principle Differences between Principle Differences between laparoscopic and open surgerylaparoscopic and open surgery

FOR THE HOSPITALFOR THE HOSPITAL Initial capital costs to establish laparoscopic surgery in Initial capital costs to establish laparoscopic surgery in

the order of Rs 10 - 20 lacsthe order of Rs 10 - 20 lacs

Reduced overall costs by shortening of hospital stay e.g. Reduced overall costs by shortening of hospital stay e.g. cholecystectomy reduced from 5 to 1 day, hiatus hernia cholecystectomy reduced from 5 to 1 day, hiatus hernia repair reduced from 7 to 3 days.repair reduced from 7 to 3 days.

Principle Differences between Principle Differences between laparoscopic and open surgerylaparoscopic and open surgery

For the SurgeonFor the Surgeon Magnified view often better than obtained via an Magnified view often better than obtained via an

incision allows precise dissection.incision allows precise dissection. Altered (but not absent) tactile responseAltered (but not absent) tactile response Two dimensional (flat screen) view.Two dimensional (flat screen) view. Usually (but not always) longer operating timeUsually (but not always) longer operating time Need to develop entirely different operating Need to develop entirely different operating

techniquetechnique Adaptation of principles of open surgery to Adaptation of principles of open surgery to

laparoscopic surgery.laparoscopic surgery.

InstrumentsInstruments

Redesign of instruments for laparoscopic use.Redesign of instruments for laparoscopic use. Instruments for open surgery in general 6 – 10Instruments for open surgery in general 6 – 10”” in length in length

built around a box joint.built around a box joint. Laparoscopic instruments in general 15 – 18Laparoscopic instruments in general 15 – 18”” in length in length

with an articulated connecting rod between handles and with an articulated connecting rod between handles and scissor blades, jaws etc.scissor blades, jaws etc.

Equipment Necessary for MASEquipment Necessary for MAS

CameraCamera

Light SourceLight Source

InsufflatorInsufflator

TV MonitorTV Monitor

TelescopesTelescopes

Light Guide CableLight Guide Cable

Apart from the Apart from the

insufflator the system insufflator the system

will work better if all will work better if all

the components are the components are

from the same from the same

company as one company as one

piece talks to another piece talks to another

CAMERACAMERA

These can be single chip or 3 chip.These can be single chip or 3 chip.

CHIP: thois is also called a charged coupled device in short, CHIP: thois is also called a charged coupled device in short,

CCD.CCD.

These are flat silicone wafers with a matrix, a grid of minute These are flat silicone wafers with a matrix, a grid of minute

image sensors called pixels.image sensors called pixels.

White balance and sometimes black balanceWhite balance and sometimes black balance

Sleeve it donSleeve it don’’t soak it!!!t soak it!!!

Light SourceLight Source

Halogen or Xenon, cold light but beware can still Halogen or Xenon, cold light but beware can still burn holes in drapes esp. disposable and burn burn holes in drapes esp. disposable and burn patientpatient’’s skin if left on the abdomen.s skin if left on the abdomen.

Brightest to darkest measured in units of decibels.Brightest to darkest measured in units of decibels. Automatic illumination, does it talk to the camera Automatic illumination, does it talk to the camera

and are the necessary leads plugged in.and are the necessary leads plugged in. Lamp life meter, look at it. Is it nearly out? EBME Lamp life meter, look at it. Is it nearly out? EBME

keep the spares and they change it.keep the spares and they change it. White balance by making sure white is correct then White balance by making sure white is correct then

all the colours through the spectrum are correct. all the colours through the spectrum are correct.

InsufflatorInsufflator CO2 because this has the same refractive CO2 because this has the same refractive

index as air, so doesnindex as air, so doesn’’t distort the image and t distort the image and is non combustible.is non combustible.

Intraabdominal pressure run between 10 and Intraabdominal pressure run between 10 and 13 mmhg.13 mmhg.

Use disposable filter and tubing for each Use disposable filter and tubing for each patient.patient.

High flow insufflators (35 litres) output High flow insufflators (35 litres) output determined by size of outlet.determined by size of outlet.

Ensure you know how to change a cylinder Ensure you know how to change a cylinder and were they are stored.and were they are stored.

TV MonitorsTV Monitors

Usually a 20Usually a 20”” screen. screen. HD is better.HD is better. You can use a standard TV but it must be run You can use a standard TV but it must be run

through an isolated transformer.through an isolated transformer. Horizontal resolution is the number of vertical Horizontal resolution is the number of vertical

lines.lines. Vertical resolution is the number of horizontal Vertical resolution is the number of horizontal

lineslines More lines of resolution, better detail of picture.More lines of resolution, better detail of picture.

TelescopesTelescopes Come in varying sizes, laparoscopes usually 5mm Come in varying sizes, laparoscopes usually 5mm

or 10mm.or 10mm. Diagnostic 3mm scope available.Diagnostic 3mm scope available. Made up of a rod and lens system.Made up of a rod and lens system. Bundles of fibres, incoherent carry light and Bundles of fibres, incoherent carry light and

coherent carry image.coherent carry image. Wide range of angles available 0, 30, 45 degree are Wide range of angles available 0, 30, 45 degree are

fairly standard.fairly standard. All laparoscopes are autoclavable and can go All laparoscopes are autoclavable and can go

through sterilisation, no ultrasonic bath required.through sterilisation, no ultrasonic bath required. Endo- chameleon- extra long for Bariatric patients.Endo- chameleon- extra long for Bariatric patients.

Light guide CablesLight guide Cables

Different diametersDifferent diameters

Fibre light cableFibre light cable

Buy auroclavableBuy auroclavable

DonDon’’t bend to acutely as will break fibres.t bend to acutely as will break fibres.

Check when you plug them in are all the fibres are okay.Check when you plug them in are all the fibres are okay.

CondensersCondensers

InstrumentationInstrumentation

SINGLE USE: breaking the Law if you reuse it SINGLE USE: breaking the Law if you reuse it on another patient.on another patient.

Reusable take apart.Reusable take apart. Need an ultrasonic washer to effectively clean Need an ultrasonic washer to effectively clean

them, not for telescopes.them, not for telescopes. DonDon’’t put 5mm cannulated instruments into a t put 5mm cannulated instruments into a

bench top autoclave that does not have a bench top autoclave that does not have a vacuum: vacuum is required to remove all air vacuum: vacuum is required to remove all air form lumen of instrument.form lumen of instrument.

Ports 5 and 10mm are the most common, make Ports 5 and 10mm are the most common, make sure the right trocar is in port and is it sharp.sure the right trocar is in port and is it sharp.

ElectrosurgeryElectrosurgeryYou should be aware of the You should be aware of the

following potential situations:following potential situations:

Insulation failureInsulation failure of the active electrode. of the active electrode.

Direct coupling of current Direct coupling of current to other instrumentation to other instrumentation by direct contact.by direct contact.

CapacitanceCapacitance which may be created by two electrical which may be created by two electrical conductors separated by an insulatorconductors separated by an insulator

Ultrascision or the Harmonic Ultrascision or the Harmonic ScalpelScalpel

Electrical generator (the box)Electrical generator (the box)

This adjusts the amount of electrical energy being This adjusts the amount of electrical energy being

delivered and monitors performance.delivered and monitors performance.

TransducerTransducer

This is where electrical energy is converted to the This is where electrical energy is converted to the

ultrasonic waves. The frequency is fixed however ultrasonic waves. The frequency is fixed however

the amplitude alters with the power input. the the amplitude alters with the power input. the

transducer is located in the hand piece and is transducer is located in the hand piece and is

connected to the generator by an electrical cable. connected to the generator by an electrical cable.

Dissection Instrument (peripheral hand piece)Dissection Instrument (peripheral hand piece)

A metallic rod is coupled to the transducer and A metallic rod is coupled to the transducer and

vibrates at the prescribed frequency (i.e. 55kHz). vibrates at the prescribed frequency (i.e. 55kHz).

The tip of the rod contacts with the surface tissue.The tip of the rod contacts with the surface tissue.

Principles of Piezo ElectronicsPrinciples of Piezo Electronics

The ultrasound waves are created by electrical The ultrasound waves are created by electrical

energy hitting a negatively charged crystal that energy hitting a negatively charged crystal that

vibrates (expands and contracts) at a particular vibrates (expands and contracts) at a particular

frequency. These crystals are disc shaped and frequency. These crystals are disc shaped and

made of ferroelectric ceramics. A pair of discs made of ferroelectric ceramics. A pair of discs

““coupledcoupled”” together produce a sinusoidal wave together produce a sinusoidal wave

form. This coupling results in a harmonic form. This coupling results in a harmonic

waveform that is of high electroacoustic waveform that is of high electroacoustic

efficiency.efficiency.

VERESS NEEDLEVERESS NEEDLE

1938 - 1938 - Janos VeressJanos Veress, of Hungary, developed the spring-, of Hungary, developed the spring-loaded needle. to perform therapeutic pneumothorax loaded needle. to perform therapeutic pneumothorax (TB).(TB).

Made of surgical stainless steel with a single trap valve. Made of surgical stainless steel with a single trap valve. 2mm diameter x 80mm length 2mm diameter x 80mm length

It consists of an outer cannula with a bevelled needle It consists of an outer cannula with a bevelled needle point for cutting through tissues. point for cutting through tissues.

GAS INSUFFLATIONGAS INSUFFLATION

Controlled pressure insufflation of the peritoneal Controlled pressure insufflation of the peritoneal cavity is used to achieve the necessary work cavity is used to achieve the necessary work space for laparoscopic surgery. space for laparoscopic surgery.

Automatic insufflators allow the surgeon to Automatic insufflators allow the surgeon to preset the insufflating pressure, and the device preset the insufflating pressure, and the device supplies gas until the required intra-abdominal supplies gas until the required intra-abdominal pressure is reached. pressure is reached.

TrocarTrocar

The trocar has a blade with The trocar has a blade with

a shaft and body.a shaft and body.

The body includes a The body includes a

pointed tip which makes pointed tip which makes

the initial incision in the the initial incision in the

abdominal wall of the abdominal wall of the

patient. patient.

(Trocar diameters range from (Trocar diameters range from

2mm-30 mm)2mm-30 mm)

TrocarsTrocars

Types:Types: CuttingCutting

Pyramidal tippedPyramidal tipped

Flat bladeFlat blade

NoncuttingNoncutting Pointed conicalPointed conical

Blunt conicalBlunt conical

OpticalOptical

TelescopeTelescope There are three important There are three important

structural differences in structural differences in

telescope available telescope available

1. 6 to 18 rod lens system 1. 6 to 18 rod lens system

telescopes are availabletelescopes are available

2. 0 to 120 degree telescopes 2. 0 to 120 degree telescopes

are availableare available

3. 1.5 mm to 15 mm of 3. 1.5 mm to 15 mm of

telescopes are availabletelescopes are available

Optic cablesOptic cables

These cables are These cables are made up of a bundle of made up of a bundle of optical fibers glass optical fibers glass thread swaged at both thread swaged at both ends. ends.

The fiber size used is The fiber size used is usually between 10 to usually between 10 to 25 mm in diameter.25 mm in diameter.

They have a very high They have a very high quality of optical quality of optical transmission, but are transmission, but are fragile.fragile.

Dissecting & Grasping Dissecting & Grasping Forceps Forceps

AtraumaticAtraumatic

KELLY atraumaticKELLY atraumatic

Atraumatic, with hollow Atraumatic, with hollow jawsjaws

MANGESHKAR Grasping MANGESHKAR Grasping Forceps, serratedForceps, serrated

General General instrumentsinstruments

Reusable three-piece designReusable three-piece design

Available in 2 mm, 3 mm, Available in 2 mm, 3 mm, 3.5mm, 5 mm and 10 mm 3.5mm, 5 mm and 10 mm sizes, with lengths of 20 cm, sizes, with lengths of 20 cm, 30 cm, 36 cm and 43 cm.30 cm, 36 cm and 43 cm.

Choice of handle styles.Choice of handle styles. Fully rotating 360° sheath.Fully rotating 360° sheath.

No hidden spaces that can No hidden spaces that can trap operative blood and trap operative blood and tissue debris. tissue debris.

Scissors Scissors

HOOK SCISSORS, single HOOK SCISSORS, single action jawsaction jaws

METZENBAUM SCISSORS, METZENBAUM SCISSORS, curved, length of blades 12-17 curved, length of blades 12-17 mm, widely used as an mm, widely used as an instrument for mechanical instrument for mechanical dissection in laparoscopic dissection in laparoscopic surgery. surgery.

STRAIGHT SCISSOR STRAIGHT SCISSOR can give can give controlled depth of cutting controlled depth of cutting because it has only one moving because it has only one moving jaw. jaw.

TROCAR PLACEMENT TROCAR PLACEMENT BY QUADRANTBY QUADRANT

Thoracic triangle

Pelvic triangle

1 2

34

TROCAR PLACEMENT TROCAR PLACEMENT BY QUADRANTBY QUADRANT

Each quadrant must be addressed from frontal as well as lateral positions.

yz

x

Correct trocar placement should Correct trocar placement should provide direct access to the provide direct access to the

target organs, target organs, an optimal view of the operative an optimal view of the operative

field field and minimize mental and and minimize mental and

muscular fatigue.muscular fatigue.

tro-car - [Fr., troisis, three +carre,

side] noun

a sharp-pointed surgical instrument

fitted with a cannula and used

especially to insert the cannula into

a body cavity

cannula - [L., dim of canna,reed] noun

a tube that is inserted into a cavity

by means of a trocar filling it’s lumen

Working against the camera and ‘blind spots’

“Dueling swords” phenomenon (scissoring effect)

Avoid Avoid competing competing

for the same for the same space:space:

No obstacle between trocar entry No obstacle between trocar entry and targetand target

To avoid iatrogenic injuries.

Avoid the epigastric vesselsAvoid the epigastric vessels

Saber et al. Safety zones for anterior abdominal wall entry during laparoscopy. Ann Surg 2004; 239:182

(adapted from) Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisions James L. Whiteside, MD, Matthew D. Barber, MD, MHS, Mark D. Walters, MD, and Tommaso Falcone, MD (Am J Obstet Gynecol 2003;189:1574-8.)

Anatomic distribution of nerves across anterior abdominal wall

Iliohypogastric nerveIlioinguinal nerve

(adapted from) Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisions James L. Whiteside, MD, Matthew D. Barber, MD, MHS, Mark D. Walters, MD, and Tommaso Falcone, MD (Am J Obstet Gynecol 2003;189:1574-8.)

Iliohypogastric n.

Ilioinguinal n.

Incision line/trocar sites vs. nerve distribution

Epigastric a.

Trocar site

Pfannenstiel incision

Be aware of bladder location Be aware of bladder location for suprapubic trocarfor suprapubic trocar

Avoid areas of prior surgeryAvoid areas of prior surgery

Trocar distance from the target organ depends upon the size of the patient.

Individual trocars can be moved closer to the target along an

axis line.

Additional trocars can

be added along

thesemicircular

line.

Gold Standard Laparoscopic Gold Standard Laparoscopic Procedures TodayProcedures Today

Laparoscopic cholecystectomyLaparoscopic cholecystectomy

Laparoscopic RYGB for obesityLaparoscopic RYGB for obesity

Laparoscopic adrenalectomyLaparoscopic adrenalectomy

Laparoscopic splenectomyLaparoscopic splenectomy

Huge DifferenceHuge Difference

Public Health Problem #1:

Laparoscopy in Bariatric Laparoscopy in Bariatric SurgerySurgery

OBESITY

Trocars - placed high, close Trocars - placed high, close to to

the costal margin.the costal margin.Trocar A - liver retraction. Trocar A - liver retraction. Trocar D - can be enlarged to Trocar D - can be enlarged to allow for placement of a port.allow for placement of a port.Trocar C - placed left of the Trocar C - placed left of the midline for correct view ofmidline for correct view ofAngle of His.Angle of His.

LAP-BANDLAP-BAND

C D

EB

A

Laparoscopic RYGBLaparoscopic RYGB

Multicenter, prospective, risk-adjusted Multicenter, prospective, risk-adjusted data show that laparoscopic gastric data show that laparoscopic gastric bypass is safer than open gastric bypass is safer than open gastric bypass, with respect to 30-day bypass, with respect to 30-day complication rate.complication rate.

LRYGB has become the standard of LRYGB has become the standard of carecare

Hutter et al. Ann Surg. May 2006Hutter et al. Ann Surg. May 2006 Massachusetts General Hospital, BostonMassachusetts General Hospital, Boston..

Current ProceduresCurrent Procedures

The first case of laparoscopic adrenalectomy was reported by Gagner The first case of laparoscopic adrenalectomy was reported by Gagner

in 1992.in 1992.

Laparoscopic Adrenalectomy

Less blood lossLess blood loss

LessLess operative time!! operative time!!

Less hospital stay Less hospital stay

Less post operative painLess post operative pain

Tiberio et al.Tiberio et al.

Prospective RCTProspective RCT

Surg Endosc. Jun 2008Surg Endosc. Jun 2008

Laparoscopic adrenalectomy

Unilateral adrenalectomy Bilateral adrenalectomy

Hyperfunctioning tumors Aldosteronoma

Cortisol-producing adenoma

Virilizing tumors

Pheochromocytoma

Failed treatment of ACTH-dependent

Cushing’s syndrome

Nonfunctioning cortical adenomaa Cushing’s syndrome from primary

adrenal hyperplasia

Malignant tumors Adrenocortical carcinoma

Malignant pheochromocytoma

Adrenal metastasis (solitary without

other metastatic

disease)

Bilateral pheochromocytoma

symptomatic or enlarging adrenal

myelolipomas, ganglioneuroma

ACTH: adrenocorticotrophic hormone

Indications for AdrenalectomyIndications for Adrenalectomy

Laparoscopic Splenectomy-Laparoscopic Splenectomy-IndicationsIndications

Idiopathic thrombocytopenic purpura

ITP/HIV +

Thrombotic thrombocytopenic purpura

Hereditary spherocytosis

Auto-immune hemolytic anemia

Splenic cysts

Evan’s syndrome

Felty’s syndrome

Hypersplenism (portal hypertension)

Non Hodgkin’s lymphoma

Hodgkin’s lymphoma

Lymphocytic leukemia

Myelocytic leukemia

Tricholeukocytic leukemia

Myelocytic splenomegaly

Splenic tumor

SPLENECTOMYSPLENECTOMY

Laparoscopic splenectomyLaparoscopic splenectomy

Significantly less pulmonary, wound, and infectious complications.Significantly less pulmonary, wound, and infectious complications. Longer operative times Longer operative times Winslow (meta-analysis). Surgery. 2003 Oct;134(4):647-Winslow (meta-analysis). Surgery. 2003 Oct;134(4):647-

5353

Laparoscopic ProceduresLaparoscopic Procedureswith equivalencewith equivalence

Laparoscopic hernia repairLaparoscopic hernia repair

Laparoscopic appendectomyLaparoscopic appendectomy

Laparoscopic fundoplicationLaparoscopic fundoplication

Laparoscopic Inguinal Laparoscopic Inguinal Hernia RepairHernia Repair

Hernia - Historic PerspectiveHernia - Historic Perspective

Galen of Pergamum (AC 129-179) who was a Galen of Pergamum (AC 129-179) who was a

surgeon to the gladiators practiced ligation of the sac surgeon to the gladiators practiced ligation of the sac

and cord with amputation of the testicle. and cord with amputation of the testicle.

Guy de Chauliac (AC 1300-1368) in his book Guy de Chauliac (AC 1300-1368) in his book

Chirurgia Magna: laxatives, hang patient from his Chirurgia Magna: laxatives, hang patient from his

legs, bed rest for 50 days.legs, bed rest for 50 days.

Trocar placementTrocar placement::

TransabdominalTransabdominal

Pre peritoneal (TAPP)Pre peritoneal (TAPP)

Totally

Extra Peritoneal (TEP)

Additional

trocar

INGUINAL INGUINAL HERNIA REPAIRHERNIA REPAIR

Inguinal Hernia RepairInguinal Hernia Repair

What are indications for What are indications for laparoscopic inguinal hernia laparoscopic inguinal hernia

repair?repair?Recurrent herniaRecurrent hernia

• Avoids scar tissueAvoids scar tissue

• Visualizes occult hernia Visualizes occult hernia

Bilateral herniaBilateral hernia

• Decreased pain Decreased pain

• Earlier return to workEarlier return to work

• No difference in recurrence or complicationNo difference in recurrence or complication

Obese / Athletic patientsObese / Athletic patients

• Definitive diagnosisDefinitive diagnosis

• Reduced infection in susceptible populationReduced infection in susceptible population

• GilmoreGilmore’’s groins groin

Patients with contralateral injury to vas deferensPatients with contralateral injury to vas deferens

• Less chance to injure other vasLess chance to injure other vas

Are there contraindications to Are there contraindications to lap. inguinal hernia repair?lap. inguinal hernia repair?

ContraindicationsContraindications• Patients for whom general anesthesia and Patients for whom general anesthesia and

pneumoperitoneum are risks (cardiac, pulmonary pneumoperitoneum are risks (cardiac, pulmonary disease)disease)

Relative ContraindicationsRelative Contraindications• Prior pre-peritoneal surgery (prostate, hernia, vascular, Prior pre-peritoneal surgery (prostate, hernia, vascular,

kidney transplant)kidney transplant)• Prior laparotomyPrior laparotomy• AscitesAscites• Strangulated herniaStrangulated hernia• Giant scrotal herniaGiant scrotal hernia• Anticipated bleeding (patients on anti-coagulation)Anticipated bleeding (patients on anti-coagulation)

2. Do we have an answer for

groin pain after hernia repair?

Nerves prone to injury Nerves prone to injury anterior and posterioranterior and posterior

Laparoscopic Ventral Hernia:Is the Abdomen a Laparoscopic Ventral Hernia:Is the Abdomen a Weakness in the Human Race ?Weakness in the Human Race ?

Laparoscopic Ventral Hernia:Is the Abdomen a Laparoscopic Ventral Hernia:Is the Abdomen a Weakness in the Human Race ?Weakness in the Human Race ?

Laparoscopic Repair of Laparoscopic Repair of Incisional HerniasIncisional Hernias

wound complicationswound complications

recurrence raterecurrence rate

LOSLOS

painpain

coverage of coverage of ““Swiss cheeseSwiss cheese”” abdomenabdomen

Ventral Hernia Defect

Mesh used to patch defect

Secure periphery Secure periphery

of mesh with tackerof mesh with tacker

Approximately 1cm Approximately 1cm

apartapart

Completed repair

Massive Incisional HerniasMassive Incisional Hernias

Laparoscopic AppendectomyLaparoscopic Appendectomy

Laparoscopic Appendectomy

Endo-loop

APPENDECTOMYAPPENDECTOMY

Alternatively, an appendectomy can be performed through a Alternatively, an appendectomy can be performed through a trocar in the umbilicus and two trocars in the suprapubic area trocar in the umbilicus and two trocars in the suprapubic area medial to the epigastric vessels for a superb cosmetic result (if medial to the epigastric vessels for a superb cosmetic result (if an extended right hemicolectomy is to be performed, the an extended right hemicolectomy is to be performed, the hepatic flexure positioning is preferred.)hepatic flexure positioning is preferred.)

Laparoscopic Appendectomy Laparoscopic Appendectomy Evidence-based MedicineEvidence-based Medicine

Clear advantage in children*Clear advantage in children*

- Less wound infection, LOS, ileus- Less wound infection, LOS, ileus

- More OR time, intra-abdominal abscess- More OR time, intra-abdominal abscess

Controversies in adultsControversies in adults

- Cost, obese patients, severe appendicitis- Cost, obese patients, severe appendicitis

*Aziz et al. *Aziz et al. Ann SurgAnn Surg 2006 2006

- Prelude to NOTES

LAPAROSCOPIC PROCEDURES

WITH CLEAR ADVANTAGES.

Laparoscopic HellerLaparoscopic Heller’’s s CardiomyotomyCardiomyotomy

Technically feasible

Short recovery time

Less overall complication

rates

Anti-reflux surgeryAnti-reflux surgery

1945 to present1945 to presentMultiple methods and techniques:Multiple methods and techniques:

Nissen fundoplicationNissen fundoplicationDor wrapDor wrapHill gastropexy ….Hill gastropexy ….

Different approaches:Different approaches:Laparotomy vs laparoscopyLaparotomy vs laparoscopyThoracotomy vs thoracoscopyThoracotomy vs thoracoscopy

Rudolph Nissen, MD

INFLUENTIAL PEOPLE:

Lortat-Jacob, MD

AndreToupet, MD

Jacques Dor, MD

Ernst Heller, MD

Rudolph Nissen MD

Ivor Lewis, MD

J. Leigh Collis, MD

K. Alvin Merendino, MD

Lucius Hill, MD

Ronald Belsey, MD

Alan Thal, MD

NissenNissen’’s Fundoplications Fundoplication

Technique

Nissen FundoplicationNissen Fundoplication

Esophageal HiatusEsophageal Hiatus

LiverLiver

EsophagusEsophagus

Left crusLeft crus

Right crusRight crus

AortaAorta

Hiatal DefectHiatal Defect

Chest cavityChest cavity

StomachStomach

Left crusLeft crus

Mesh RepairMesh Repair

Polypropylene mesh

Esophagus

• Do not use metal tacks

• Biologic mesh? dual mesh?

• No mesh at all? (remember original Toupet repair)

Mesh

Wrap

Circular mesh

Fundoplication

Laparoscopic Surgery Laparoscopic Surgery in Colorectal Diseasesin Colorectal Diseases

Port Site RecurrencePort Site Recurrence

NOTENOTE::

If proximal divided end of colon can reach through If proximal divided end of colon can reach through the skin there has been sufficient dissection of the skin there has been sufficient dissection of splenic flexure providing a tension-free anastomosis.splenic flexure providing a tension-free anastomosis.

HEPATIC HEPATIC FLEXURE FLEXURE COLON COLON

RESECTION RESECTION

ABTension-free anastomosis

The ileum is more mobile than the The ileum is more mobile than the transverse colon, which can still be transverse colon, which can still be delivered adequately at this level.delivered adequately at this level.

Trocar C is used for GIA divisionof distal ileum and midtransverse colon (site is enlarged to retrieve specimen and for extracorporeal anastomosis).

C

LAPAROSCOPIC LAPAROSCOPIC SIGMOID RESECTIONSIGMOID RESECTION

(lateral decubiti (lateral decubiti position)position)

LateralSupine

Laparoscopic colorectal Laparoscopic colorectal surgerysurgery

Cochrane Systematic review of short term outcomes in 25 RCTs showed that Cochrane Systematic review of short term outcomes in 25 RCTs showed that laparoscopic colorectal surgery had:laparoscopic colorectal surgery had:

Longer operative time Longer operative time Less intraoperative blood lossLess intraoperative blood loss Less postoperative painLess postoperative pain less postoperative ileusless postoperative ileus Better postoperative pulmonary functionBetter postoperative pulmonary function Less total and local morbidityLess total and local morbidity Less postoperative hospital stay Less postoperative hospital stay Similar general morbidity and mortalitySimilar general morbidity and mortality Better quality of life (within 30 days) Better quality of life (within 30 days)

Schwenk et al. 2005 Jul 20;(3):Cochrane Database 003145Schwenk et al. 2005 Jul 20;(3):Cochrane Database 003145

Cochrane Systematic review of long term outcomes showed:Cochrane Systematic review of long term outcomes showed: Similar port-site metastases and wound recurrencesSimilar port-site metastases and wound recurrences Similar cancer-related mortality at maximum follow-upSimilar cancer-related mortality at maximum follow-up Similar tumor recurrenceSimilar tumor recurrence Similar overall mortality Similar overall mortality

Kuhry et al. Cancer Treat Rev. Oct 2008Kuhry et al. Cancer Treat Rev. Oct 2008

Laparoscopic hepatectomyLaparoscopic hepatectomy

First performed 1994 First performed 1994 by Huscher et alby Huscher et al

A safe procedure in A safe procedure in experienced handsexperienced hands

Resection devices:Resection devices: StaplersStaplers Bipolar vessel sealing Bipolar vessel sealing

(Ligasure)(Ligasure) Radiofrequency Radiofrequency U/S dissectorU/S dissector Nd-YAG laserNd-YAG laser

Laparoscopic left hemihepatectomy (resection of segments 2, 3, and 4). (A) Intraoperative view showing ischemic delineation of the left liver. Note the vascular endoscopic stapler encircling the left Glissonian pedicle. (B) Schematic view. The stapler is closed, and ischemic delineation of the left liver is obtained. (C) Intraoperative view. The stapler is fired, and the left main Glissonian pedicle is transected (arrows). (D) Schematic view. The stapler is fired

Laparoscopic pancreatectomyLaparoscopic pancreatectomy

Pancreaticoduodenectomy Pancreaticoduodenectomy Total splenopancreatectomyTotal splenopancreatectomy Spleen-preserving total Spleen-preserving total

pancreatectomypancreatectomy Distal splenopancreatectomyDistal splenopancreatectomy Spleen-preserving distal Spleen-preserving distal

pancreatectomypancreatectomy Central pancreatectomyCentral pancreatectomy Enucleation Enucleation

Procedures are technically Procedures are technically challengingchallenging

Long learning curveLong learning curve High volume center improves High volume center improves

clinical outcomeclinical outcome

DISTAL PANCREATECTOMYDISTAL PANCREATECTOMY

DE

C

B

A

• Trocars “A ” and “B” divide gastrocolic ligament• GIA is introduced through “D”

Laparoscopic pancreatectomy Laparoscopic pancreatectomy Vs. openVs. open

Finan et al. Am Surg. Aug 2009 Finan et al. Am Surg. Aug 2009 Laparoscopic and open distal Laparoscopic and open distal pancreatectomy: a comparison of pancreatectomy: a comparison of outcomes.outcomes.

There was no significant difference in the There was no significant difference in the incidence of postoperative morbidity or incidence of postoperative morbidity or mortalitymortality

There was no significant difference in the rate There was no significant difference in the rate

of all pancreatic fistula formation or clinically of all pancreatic fistula formation or clinically significant leaks significant leaks

Lparoscopic technique had decreased: Lparoscopic technique had decreased: operative timeoperative time blood lossblood loss length of stay in the lap group. length of stay in the lap group.

ConclusionConclusion Lap and open distal pancreatectomy are Lap and open distal pancreatectomy are

performed safely at high-volume performed safely at high-volume pancreatic surgery centers. pancreatic surgery centers.

Laparoscopic Urologic Laparoscopic Urologic proceduresprocedures

Undescended testisUndescended testis

VaricocelectomyVaricocelectomy

Retroperitoneal fibrosisRetroperitoneal fibrosis

Lymph node dissectionLymph node dissection

Bladder neck suspensionBladder neck suspension

Bladder diverticulumBladder diverticulum

Patent urachusPatent urachus

NephrectomyNephrectomy

ProstatectomyProstatectomy

RT. KIDNEY RESECTIONRT. KIDNEY RESECTION• Subxiphoid port (D) - liver retraction

• Trocar A - parallel to vena cava (perpendicular approach to rt. renal vessels and rt. adrenal vein –additional trocar E may be placed more laterally and posterior to trocar A if needed.)

B

C

D

AE

PROSTATECTOMPROSTATECTOMYY

AB

C

Trocars – added as needed along semicircular line. i.e., during a prostatectomy, another trocar is added between A and B.Another trocar may be added between B and C allowing the surgeon and assistant surgeonon the opposite side to each use both hands.

Minimally invasive neck surgery

Minimally invasive neck surgery

Endoscopic

Central

Lateral

“Other” (transaxillary, transpectoral, transoral)

Minimally invasive MIVAT (min. invasive video assisted thyroidectomy)

MIVAP (min. invasive video assisted parathyroidectomy)

Robotic assisted

Inferior parathyroid release in Minimally invasive thyroidectomy

Cosmetic resultsCosmetic results

Open surgery scar Minimally invasive / endoscopic scars

ConclusionsConclusions

MIVAT and MIVAP yield equivalent endocrine results as

open procedure

Oncologic result is equivalent in selected patients

Equivalent safety profile as open procedures

Postop pain is decreased

Patient satisfaction with procedure and cosmetic result

is significantly increased

(Miccoli et al., RCT, Surgery. 2001)

Yet:

What about large masses?!

It is not a ‘niche surgery’!

Emerging TechnologiesEmerging Technologies

RoboticsRobotics

SILSSILS

NOTESNOTES

Trocarless laparoscopyTrocarless laparoscopy

ENDOBARRIERENDOBARRIER

History of RoboticsHistory of Robotics

Leonardo da Vinci Leonardo da Vinci

developed one of the developed one of the

first robots in 1495 – an first robots in 1495 – an

armored knight for the armored knight for the

purposes of purposes of

entertaining royalty.entertaining royalty.

What Robotics Aimed to Improve in Laparoscopy

Surgeon operates from a 2D imageSurgeon operates from a 2D image

Straight, rigid instruments (limited range of motion)Straight, rigid instruments (limited range of motion)

Instrument tips controlled at a distance Instrument tips controlled at a distance

Reduced dexterity, precision & controlReduced dexterity, precision & control

Unsteady camera controlled by assistantUnsteady camera controlled by assistant

Dependent on assistant for surgical support through Dependent on assistant for surgical support through

accessory portaccessory port

Greater surgeon fatigueGreater surgeon fatigue

Makes complex operations more difficultMakes complex operations more difficult

Surgical RobotsSurgical Robots

AESOPAESOP (Automated Endoscopic System for Optimal (Automated Endoscopic System for Optimal

Positioning)Positioning)

- Voice activated mechanical arm- Voice activated mechanical arm

- Steadier than human, never tires- Steadier than human, never tires

da Vincida Vinci®®

- FDA approval in 2002- FDA approval in 2002

- Laparoscopic instrumentation controlled by the - Laparoscopic instrumentation controlled by the

surgeon, positioned remotely at a consolesurgeon, positioned remotely at a console

Development of Development of da Vincida Vinci®®

Defense Advanced Research Projects Agency (DARPA) Defense Advanced Research Projects Agency (DARPA)

for military research of remote battlefield surgeryfor military research of remote battlefield surgery

Cholecystectomy performed remotely via telesurgery from 300 miles Cholecystectomy performed remotely via telesurgery from 300 miles

awayaway

Intuitive surgical created in 1999 after acquiring patent rights from Intuitive surgical created in 1999 after acquiring patent rights from

militarymilitary

First robotic prostatectomy performed in 2001First robotic prostatectomy performed in 2001

What is the What is the da Vincida Vinci®® Surgical Surgical System?System?

State-of-the-art robotic State-of-the-art robotic technologytechnology

Surgeon in controlSurgeon in control

Assistant has direct accessAssistant has direct access

Surgeon directs precise Surgeon directs precise

movements of instruments in movements of instruments in

the slave unit using console the slave unit using console

controls.controls.

What is the What is the da Vincida Vinci®® Surgical System?Surgical System?

Robotic Scrub NurseRobotic Scrub Nurse““PenelopePenelope””

Laparoscopic instruments Laparoscopic instruments

are rigid with no wristsare rigid with no wrists

EndoWristEndoWrist®® Instrument tips Instrument tips

move like a human wrist move like a human wrist

Allows surgeon to operate Allows surgeon to operate

with increased dexterity & with increased dexterity &

precision. No tremorprecision. No tremor

Wrist and Finger MovementWrist and Finger Movement

Disadvantages of Disadvantages of da Vincida Vinci®® RobotRobot

ExpensiveExpensive

- $1.4 million cost for machine- $1.4 million cost for machine

- $120,000 annual maintenance contract- $120,000 annual maintenance contract

- Disposable instruments $2000/case- Disposable instruments $2000/case

Steep surgical learning curveSteep surgical learning curve

Loss of tactile feedbackLoss of tactile feedback

Increased staff training/competenceIncreased staff training/competence

Increased OR set-up/turnover time!!Increased OR set-up/turnover time!!

Past Present

SILSSILSSingle Incision Laparoscopic SurgerySingle Incision Laparoscopic Surgery

SILS – Single Incision Laparoscopic Surgery

SSA – Single Site Access

SPA – Single Port Access

SAS – Single Access Site

SPL – Single Port Laparoscopy

LESS – Laparo Endoscopic Single Site Surgery

TUES – Trans Umbilical Endoscopic Surgery

What does that stand for ?

SILSSILS

UrologyUrology

Renal transplantRenal transplant

CholecystectomyCholecystectomy

Gastric band surgeryGastric band surgery

ColectomyColectomy

TechniqueTechnique

SILSSILS

SILSSILS

Ergonomically difficult ?!

Training !

Port Site Hernia !!Port Site Hernia !!

N.O.T.E.S.

Natural Orifice Transluminal Endoscopic Surgery

NOTES - instrumentNOTES - instrument

A Recent History of“New Minimal Access” Surgery

2000 Flexible endoscopic endoluminal therapy for GERD

2003 Kalloo et al transgastric peritoneoscopy with flexible

endoscope

2004 Rao and Reddy reported on transgastric

cholecystectomy and appendectomy in patients

2006 summit meeting: NOSCAR (Natural Orifice Surgery

Consortium for Assessment and Research) formed

Alleged NOTES Benefits

No surface incision

Reduced surgical site infection

Reduced visible scarring

Reduction in pain analgesics

Quicker recovery time

Reduction in hernias, adhesions

Advantages in the morbidly obese

Scarless surgery!Scarless surgery!

Notes- TransvaginalNotes- Transvaginal

Video-endoscope entering through the posterior vaginal fornix

NOTES - Transgastric

Courtesy of N Reddy, Hyperbad India 2005

NOTES - AppendectomyNOTES - Appendectomy

NOTES – Obesity SurgeryNOTES – Obesity Surgery

Surgery for DiabetesSurgery for Diabetes

DiabetesDiabetes

Considered major public health problem – emerging as a world Considered major public health problem – emerging as a world

wide pandemic. In 1995 ~ 135 million people worldwidewide pandemic. In 1995 ~ 135 million people worldwide

Currently 240 million, expected to rise to close to 380 million by Currently 240 million, expected to rise to close to 380 million by

2025 2025

ComplicationsComplications Peripheral vascular disease (PVD) accounts for 20-30% Peripheral vascular disease (PVD) accounts for 20-30%

10% of cerebral vascular accident 10% of cerebral vascular accident

Cardiovascular disease accounts for 50% of total mortality Cardiovascular disease accounts for 50% of total mortality 1. Venkat et al Diabetes–a common, growing, serious, costly, and potentially preventable public health

problem. Diabetes ResClin Pract. 2000; 5 (Suppl2): S77–S784.2. H. King et Global burden of diabetes, 1995-2025: prevalence, numerical estimates and projections.

Diabetes Care 21 (1998)1414-1431.3. Annals of Surgery. Volume 251, Number 3, March 2010

Metabolic Syndrome

Also Known as:1. Syndrome “X”

2. Insulin Resistance Syndrome

3. Reaven’s Syndrome

4. Deadly Quartet

5. CHAOSCoronary Artery DiseaseHypertensionAdult Onset DiabetesObesityStroke

Obesity Associated Conditions

Diabetes

Hypertension

Sleep apnea

Congestive heart failure

Hyperlipidemia

Stroke

Coronary artery disease

Osteoarthritis

Gastroesophageal reflux disease

Non-alcoholic fatty liver

Psychological disturbances

MorbidityMorbidity

Studies Type and Size Effect on Weight Effect on Comorbidities

Buchwald et al.Meta-analysisn = 22,094 pts

Mean excess weight loss: 61%

Resolution of: n Diabetes: 70% HTN: 62% Sleep apnea: 86%

Swedish Obese Subject trial (SOS)

Prospective matched cohortn = 4,047 pts

At 10 years: Med: 1.6% gainSurg: 16% loss

Improved by surgery: Diabetes Lipid profile HTN Hyperuricemia

1. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004; 292: 1724-37.

2. Sjostrom L, Lindros AK, Peltonem M, Torgerson J, Bouchard C, Carlsson B, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004; 351: 2683-93.

Long-term Weight Control Analysis

Schauer et al.Effect of laparoscopic Roux-en Y gastric bypass on

type 2 diabetes mellitus. Ann Surg. 2003 Oct; 238 (4): 467-84

1160 patients underwent LRYGBP 5-year period

LRYGBP resulted in significant weight loss (60% percent of excess body weight loss) and resolution (83%) of T2DM

Fasting plasma glucose and HBA1C normalized (83%) or markedly improved (17%) in all patients

Patients with the shortest duration and mildest form of T2DM had a higher rate of T2DM resolution after surgery suggesting that early surgical intervention

is warranted to increase the likelihood of rendering patients euglycemic

Rates of Remission of Diabetes

AdjustableGastric Banding

Roux-en-YGastric Bypass

BiliopancreaticDiversion

>95%(Immediate)

48%(Slow)

84%(Immediate)

“Gastric bypass and biliopancreatic diversion seem to achieve control of diabetes as a primary and

independent effect, not secondary to the treatment of overweight.”

Potential of Surgery for Curing Type 2 Diabetes Mellitus. Rubino, Francesco, MD; Gagner, Michel MD, FACS, FRCSC Annals of Surgery; 236 (5): 554-559, November 2002

2002: Antidiabetic Effect of 2002: Antidiabetic Effect of Bariatric Surgery: Direct or Indirect? Bariatric Surgery: Direct or Indirect?

2004:2004:

“Results of our study support the hypothesis that the bypass of duodenum and jejunum can

directly control type 2 diabetes and not secondarily to weight loss or treatment of obesity.”

Effect of Duodenal-Jejunal Exclusion in a Non-obese Animal Model of Type 2 Diabetes: A New Perspective for an Old Disease. Rubino, Francesco, MD; Marescaux, Jacques MD, FRCS Annals of Surgery; 239 (1): 1-11, January 2004

The Surgeon and the Diabetologists

THE FUTURETHE FUTURE It has not changed the nature of diseaseIt has not changed the nature of disease

The basic principles of good surgery still The basic principles of good surgery still

apply,including appropriate case selection, apply,including appropriate case selection,

excellent exposure,adequate retraction and excellent exposure,adequate retraction and

a high level technical expertisea high level technical expertise

If a procedure makes no sense with If a procedure makes no sense with

conventional access, it will make no sense conventional access, it will make no sense

with a minimal access approachwith a minimal access approach

THE FUTURETHE FUTURE

The cleaner and gentler the act of The cleaner and gentler the act of

operation, the less the patientoperation, the less the patient

suffers, the smoother and quicker suffers, the smoother and quicker

his convalescence,the more his convalescence,the more

exquisite his healed wound.exquisite his healed wound.

Berkeley GeorgeBerkeley George Andrew MoynihanAndrew Moynihan

THANK YOU ALL FOR A THANK YOU ALL FOR A PATIENT HEARINGPATIENT HEARING

future of laparoscopy

Health & Medicine