lap surgery and colectomy

7/30/2019 Lap Surgery and Colectomy

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Laparoscopy and Colon Surgery

K. Alapati


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When did we start getting crazy

How crazy are we now Are there limits for our crazyness


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History

Great Physician

Hippocrates of ancient

Greece (460-377)

made the original

reference of a

speculum to examine

the rectum.


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In the early 1800s, Philip Bozzini of Austriaexamined the urethra of a patient using a simple

tube and a candle light(basic design of a futureendoscope)

An improvised cystoscope was designed by Nitze in1855 where in light rays were gathered via mirrorsinto his instruments.

Edison invented light bulb in 1879

Eventually the light bulb was miniaturized andincorporated into the cystoscope.


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George Kelling of Germany

performed the first

laparoscopiccholecystectomy in a dog in

1901.

He went on to perform the

first Laparoscopy with

pneumoperitoneum usingroom air insufflation with

basic Nitze cystoscope.


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The first ever

documented evidence

of Laparoscopic

surgery by George

Kelling on a dog.


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Jacobeus of sweden

presented his first 100

cases of laparoscopy

and thoracoscopy in

1910.


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In 1911 Lap was introduced at JohnsHopkins by Bernheim and named by him asOrganoscopy.

Benefit of Co2 was discovered in 1920 asopposed to atmospheric air.

First laparoscopic tubal sterilisation in 1936 1938 Janos Veress of Hungary first

developed the spring loaded veress needle


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The infamous veress

needle is one of the

most importantinstruments today to

create

pneumoperitoneum


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The rigid rod lens

system was developed

by Professor Hopkinswho revolutionized the

concept of

Laparoscopic surgery


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Gynecologists first

embraced the technique of

laparoscopy and thoroughlyincorporated into their

practice.

1978 Hasson introduced an

alternative method of trocar

placement by proposing ablunt mini laparotomy.


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1985 first documented Laparoscopic

Cholecystectomy was performed by Eric Muhe.

1987 first video assisted Lap Chole by Phillip Mouret

1994 Robotic arm was designed to hold the camera

with the goal of improving safety

1996 first live telecast of laparoscopic surgery vai the

internet


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How crazy are we now


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Applications

In general Laparoscopy

is classified into

Basic Laparoscopic

Surgery

Mostly appendix, gall

bladder, diagnostic

Advanced Laparoscopic

Surgery

Takes us beyond our

limits


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Advanced Laparoscopy

Ranges from hernia

repair to the most

complex surgeries

Laparoscopic

transperitoneal

Abdominal Aortic

replacement with leftrenal artery direct

reimplantation in pigs


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Young science

Mile stones in Laparoscopic Colon and Rectal

Surgery

Procedure Surgeon Date

Rt colectomy Moises Jacobs June-90

Sigmoid resection Dennis Fowler Oct-90

LAR Patrick Leahy Nov-90

APR Robert Beart Apr-91

Total Colectomy Steven Wexner Aug-91

Transverse Colectomy Garth Ballantyne Feb-92


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Unique Features of Laparoscopic

Colectomy

Multiple quadrants

Major vascular division Specimen extraction

Reconstruction

Fecal spillage malignancy


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Challenges

Less than 10% of all colon resections areminimally invasive Steep learning curve

Concerns for cancer Data maturing/matured and its looking good!

Most US surgeons dont/cant/wont do it 30,000 general surgeons and 1500 colon and rectal

surgeons


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Laparoscopic Bowel resections

Laparoscopic Colectomy is different fromcholecystectomy Mobile organ

Larger organ means poorer visualisation

Penalty for tearing

Specimen must be removed intact

Anastomosis required

Ileus involved


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Learning curve

Steep (20-50 cases) Depth perception

Multiple quadrants

Reverse angles

Team coordination

Loss of tactile sensation

Lesser operating times

Chances of converting ???


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Laparoscopy for cancer

1990:

Increases port site recurrence ASCRS and German Surgical Society

Curative colon cancer surgery prohibited

Prospective studies: Laparoscopic colectomy for cancer is both safe

and oncologically sound.


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Myths

Port site recurrence

Increased OR time and cost CO2 pneumoperitoneum causes tumour cells

implantation

Reduced ability to explore abdomen and

localize tumor.


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Laparoscopy-Cancer research

Examined the incidence of free intraperitoneal cancer cells

15/103 (14.6%) cancers had positive cytology

Increased if More than 50% LN involvement

Poorly differentiated

Liver metastasis present

Solomon DCR, 1997


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Laparoscopy Tumor Growth

Rat experiment

Full incision promotes tumor growth morethan carbon dioxide

Tumor manipulation promotes tumor spread

more than carbon dioxide

pneumoperitoneum.

Gutt, Lorenz, Br J Surg, 1999


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CO2 influence on Cancer

Human cancer cells incubated with various

CO2 levels

No increase in growth

Takiguchi, Surg Endo, 2000


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Laparoscopic Registry PortsiteRecurrence

504 cancer patients

6 recurrences

1.3%


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COST trial summary

Cancer outcomes

No difference in Overall survival

Disease free survival

Wound recurrences


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Immunological benefits

Significant immunosuppression occurs after

Laparotomy

Does Laparoscopy alter immune function

Can this result in improve survival


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Hand assisted laparoscopic surgery

Using a surgeons most valuable tool the

hand

Benefits

Tactile sensation

Decreases learning curve

Decreases OR time

Same advantage as Lap assisted colectomy


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HALS

Provides surgeons with

the same tactile sense

as thay have in opensurgery

Retract, palpate and

dissect with their hand.

Recovery that parallelsstraight laparoscopic

procedure.

QuickTime and adecompressor

are needed to see this picture.


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HALS

Prevents conversion to total open procedure.

Hand placement depends on the targetorgan.

Why not open the wound couple more

centimeters and do the procedure open

Handoscopy wounds do not experience sametissue trauma as open procedure wounds.


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Learning Laparoscopy:

Skills lab for basic movements

Simulators

Animal lab

Decide if it is right for you

For vast majority, practice makes perfect


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SILS

Single Incision Laparoscopic Surgery

Use one port with multiple trocar openings Single scar

Significantly less pain

? Better recovery

MINIMALLY INVASIVE SURGERY-

MINIMIZED


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SILS

What can be done with SILS

Appendix

Gall Bladder

Kidney

Hysterectomy

Lap band

Adrenalectomy


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SILS

What does it look like

Usually multiple ports in

one trocar Slightly cumbersome


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What is the future


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Robotic Surgery


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Da Vinci


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NOTES


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Whaaaat!!!!Where did they remove the gallbladder from?


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NOTES stands for

Natural Orifice

TransluminalEndoscopic Surgery

What it means

is.just open your

mouth and say AAAAH!


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How is NOTES done

Pick a decent natural

orifice and figure out theprocedure


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2006, First ever video presentation of 6

Trans Gastric Appendectomies performed by

Rao & Reddy in Hyderabad, India.


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April 2nd, 2007 first

Trans Vaginal

Cholecystectomy wasdone on a 30yr old

female at the University

Hospital, Strasbourg,

France by Prof.Jacques Marescaux


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Will all these techniques survive?

Most likely not Can a combination of these techniques?

Most likely yes


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Key is to try and keep up with the advancing

technology

This way you will be ready when the time

comes so you dont have to start from

scratch


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What does this all mean to me?

Dexterity is the most important skill

You better be able to whistle and ride at thesame time

Dont be focused on just one point

lap surgery and colectomy

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