Medical Articles

The Future of Minimally Invasive Surgery 2008

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Overview

• History
• Evidence based support for current specttrum off procedures
• The future

The History of Endoscopy

• In Pompeii`s ruins they found a three bladed specullum dating from 936 AD

• 1806 Philip Bozzini developed an instrument called ‘Lichtleiter’

• 1867 - Desormeaux used Bozzinis “Lichtleiter” and an open tube to examine the genitourinary tract
• Maximilian Nitze (1848 – 1906) modified Edison`s light bulb and created the first electrical light bulb for using it for urological procedures

• 1901 George Kelling did the first experimental laparoscopy.. He insuffllated air into the abdomen of a dog and used pneumoperitoneum and a cyctoscope on a dog.
• 1918 Goettze developed an automatic pneumoperitoneum needle

• 1960’s Gynaecologists take up Endoscopy
• Kirt Semm initiates modern endoscopy
• Develops the automatic insufflator and introduces electro-thermo coagulation
• invents an irrigation device for lap conditions & electronic insufflator
• 1966 Kurt Semm performed an endoscopic appendectomy
• 1985 Phillipe Mouret performes the first laparoscopic cholecystectomy in Lyons France

Current evidence: Abdominal Laparoscopy

• Eviidence based advanttages over open surgery:
  • Cosmesis
  • Decreased hospital stay
  • Earlier return of bowel function
  • Faster recuperation
  • Decreased pain
  • Rapid return to work!
  • Higher bed turnover

Advantages – Laparoscopic Cholecystectomy

Current evidence: Abdominal Laparoscopy

• Disadvantages over open surgery::
  • Cost (total hospital cost sometimes lower)
  • Learning curve (Not all surgeons have the aptitude)
  • Length of procedure
  • Complication rate (specific complications)

Which procedure?

• The Hypothesis:
  Where the trauma due to surgical access > trauma of procedure itself
• Cholecystectomy
• Adrenalectomy
• Not true for:
  • Pancreaticoduodenectomy
  • Liver resection

The future

• These are Exciting times to be a Surgeon” Lord Lister more than 100 years ago
• The future will be marked by attempts to further decrease trauma caused by access and improve on current minimal access techniques
  • Needleoscopic surgery
  • 3D vision and digital enhancement
  • Robotic assistance
  • NOTES
  • SILS

Needleoscopic surgery

• In an attempt to further reduce the trauma of access instruments and access ports have been reduced from 10mm to 5mm (standard) to 3.5mm and now 2mm or less
• No scar visible
• Problems:
  • Cost
  • Delicate
  • Maintenance

3D and digital enhancement

• One off the main problems with minimal access surgery is lack off depth perception
• Devices now on trial with a steriovision camera and scope that gets reconstructed and viewed on a special screen usiing glasses allowing the surgeon 3D vision
• Superimpose imaging studies over the view inside the abdomen

Robotics

• Attempts to overcome lack off dexterity within the abdomen
• Removes shake ffor delliicatte procedures and for suturing
• Telesurgery
• Disadvantages
  • Cost
  • Set up time

Single Incision Laparoscopic Surgery

• Mulltiaxis (high dexterity) instrumentattion and a variable angle scope allows for a procedure to be performed via a single incision
• Single 8cm incision
• Problems:
  • Step learning curve
  • Experimental – No proven benefit as yet
  • Not suited to all procedures

Natural Orifice Translumenal Endoscopic Surgery
N.O.T.E.S

• Most promising development in minimal access surgery
• Dimitri von Ott from Stt.Petersburg examined the intrabdominal contents and the pelvis via an incision in the vaginal vault (1901)
• Technology eventually is catching up wiith the dream of operating without scars

NOTES

Developing natural orifice approaches and innovative devices that enable flexible endoscopists to perform intra- and translumenal procedures where the next alternative for the patient is a conventional surgical procedure.

• Questions of “can we” yielded to “should we” and are now yielding to questions of “how can we do this responsibly?”
• Applications are not clear and will be driven by clinical and economic evidence
  • Rao: Appendectomy, liver biopsy, tubal ligation
  • Brazil: Endoscopically-assisted laparoscopic cholecystectomy
  • New York: lap-assisted transvaginal chole (Stevens – GI, Besser – Bariatric surgeon)
  • Oregon and France: transvaginal cholecystecomies have been completed
  • Ohio State Univ.: NOTES approach to stagiing of pancreatic cancer (10+ cases completed)

How Will NOTES Be Investigated?

Case Study: Pancreatic Cancer Staging

Problem: Whipple surgeries require operating rooms to be booked for 4-6 hours. Lap staging (after initial EUS FNA staging) at the beginning of the procedure, however, could yield metastases, which then lead to canceling the Whipple, wasting OR time, and distressing the patient.

Conclusion

• Surgery will continue to focus on minimal access
• Patient demand will be a powerful stimulus
• Paradigm shift moving toward NOTES
• More out patient surgery envisaged
• Fiscal viability moulding approaches