Minimally Invasive Surgery (MIS) Dr. Manalo (in lieu of Dr.

Ong-Cunanan)
Minimal Invasive Surgery (MIS) - a.k.a. Minimal Access Surgery - Alternative form of surgery; an alternative to open conventional surgery - One of the most significant advances in surgery - Because it is an alternative form of surgery you have to give patient a choice o Does the patient want MIS? o Does the patient want open surgery? - Can be divided broadly into 2 fields: a. Endoscopic surgery b. Laparoscopic surgery A. ENDOSCOPIC SURGERY - Derived from endoscopy o Endo inside o oscopy to peer into; to look into; to peep - Medical procedure by which internal organs (their lumens and parts) are directly visualized using a scope for diagnostic and therapeutic purposes - MEDICAL PROCEDURE o Requires sub-subspecialty training and done by MD Unlike X-ray and UTZ, you have the technician Endoscopy- by MDs not done by technician, nurses, etc. - INTERNAL ORGANS (THEIR LUMENS AND PARTS) ARE DIRECTLY VISUALIZED o Review the gross anatomy o Internal organs that can be viewed: Organs Procedure Esophagus Esophagoscopy Colon Colonoscopy Sigmoid Sigmoidoscopy Bronchus Bronchoscopy Jejunum None; too coiled and too far for you to visualize; the ileum and jejunum can now be visualized using a capsule Duodenum Duodenoscopy Stomach Gastroscopy Esophagus, EGD stomach, duodenum Urinary Bladder Cystoscopy Larynx Laryngoscopy Fallopian tube Salphingoscopy Liver Hepatoscopy Vagina Not need scope; use speculum Uterus Hysteroscopy Mediastinum Mediatinoscopy Pleura Pleuroscopy Rectum Proctoscopy Urethra Urethroscopy UB + Urethra Cystourethroscopy Intraperitoneal Laparoscopy or Peritoneoscopy organs *Laparoscopy where laparoscopic surgery was derived; visualization of intraperitoneal organs - surface of liver, gallbladder, omentum, mesentery and colon * cant place the scope at the joint

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USING A SCOPE Instrumentation 2 types of Scope: 1. Rigid - Simple tube that is inserted in a natural opening of the body - ADVANTAGES: o Simpler to use o No need extra training - DISADVANTAGES: o More traumatic because it can perforate viscera o More discomfort for the patient o Only one view- it can only view single field Examples: Arthroscopy Cystourethroscopy Laparoscopy 2. Flexible Fiber Optic Scope - Made up of fiber glass - Its tip is attached to a light source - Used in EGD, colonoscopy, etc - PARTS: - eye piece- old model o newer model- no more eyepiece; instead of eyepiece, you have a camera that is attached to a computer; the image come out to the screen or monitor, so you can store and recall material, etc; o what the examiner sees, the patient is able to see as well as the relatives and students - Body of the scope- with innumerable fiber glass; the light and image are transmitted to the fiber glass - Tip of the scope- the most sensitive part of the scope since the lens is found there and where you will attach to a light source - Side port- where you will put accessories like Punch Biopsy Forcep or Alligator Forcep; where you can do your therapeutic uses o Example: when a child swallowed a pin, instead of an open wound, you can grasp the pin through the forcep Scope has TWO BUTTONS: o Red- for suction of secretions like gastric juices and content of colon o Blue button- for flushing and air insufflating o DIAGNOSTIC AND THERAPEUTIC PURPOSES o Diagnostic o Therapeutic * Endoscopic surgery Surgical procedures: - Biopsy of lesions- can do with Punch Biopsy Forcep - Polypectomy - Extraction of foreign bodies - Control of bleeders- sclerotherapy - Debulking of tumor - Extraction of stones o Sphincterotomy- (Billiary tract) cutting the sphincter of Oddi to open the duodenal papilla so that stones will come out o Basket extraction- stones in Common Bile Duct o Endoscopic Mechanical Lithotropsy (EML)- use to crush large stones o Endoscopic Nasobiliary Drainage (ENBD)- temporary relief of biliary obstruction in compromised patient o Endoscopic Retrograde Biliary Drainage (ERBD)- a stent is inserted to relieve obstruction; permanent

Aiza, Damocs, Oninsky

Minimally Invasive Surgery (MIS) Dr. Manalo (in lieu of Dr. Ong-Cunanan)
o Endoscopic Retrograde Cholangiopancreatography (ERCP)- X-ray that you can do with scope o Gastrostomy- used for feeding patient when upper GIT is obstructed o Relief of EARLY intussusceptions- putting the scope into the anus, then you will be able to push the intussusceptions out o Derotation of Sigmoid volvulus- for EARLY volvulus - Significance: In Endoscopic surgery, there are no incisions because the scope is inserted in a normal portal of entry like mouth, nose, vagina, urethra, etc. - Endoscopy is done by surgeons o Insertion of scope-use of local anesthesia o Colonoscopy- done under sedation The therapeutic use is endoscopic surgery B. LAPAROSCOPIC SURGERY - a.k.a. keyhole surgery, band aid surgery, patient friendly surgery - alternative form of surgery - Laparoscopy or Peritoneoscopy o Visualization of intraperitoneal organs o Can do even outside Laparoscopic nephrectomy Laparoscopic thyroidectomy Laparoscopic mastectomy o Almost all open surgery can be done laparoscopically except Ceasarian Section - Endoscopic surgery- no incision - Laparoscopic surgery- small incision (band aid surgery) - Alternative form to open conventional surgery (OCS) offering the same safety and efficacy - ADVANTAGES over OCS: o Faster recovery period o Shorter convalescence period o Lesser pain or discomfort o Better cosmetic (small incision) o Decrease endocrine and metabolic response *but offers the same safety and efficacy as OCS - Prototype: LAPAROSCOPIC CHOLECYSTECTOMY Removable of gallbladder - Principal indication: Presence of stones in the GB which is medically term as Cholelithiasis or Chronic Calculus Cholecystitis Medical term Cholelithiasis Cholecystolithiasis Choledocholithiasis Choledolithiasis Location of stones Gallbladder Cystic Duct Common Bile Duct Common Hepatic duct

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patient exhales, GB goes down, where tenderness is present o Diagnostics: Ultrasound- single most important imaging procedure to confirm diagnosis UTZ of GB/liver/pancreas Can also visualize if CBD is dilated or not o <1cm normal diameter of CBD o >1cm choledocolithiasis or obstruction CBC Bleeding time Clotting time Chest X-ray Blood typing ECG o What type of patient? 4 Fs: Female- not necessary; Male also Fertile- not necessary Forty- not necessary. Can affect persons whose ages range from 18-70 Fat- not necessary. Thin individuals can also be affected STEPS in Cholecystectomy: A. Before performing the surgery, give patient a choice (Lap chole or open chole) o Get consent both (Lap or open) because there is 3-5% conversion rate from Lap to open in the sense of: o Bleeding hemorrhage o Perforation of GB o Stones falling into peritoneal cavity o Bile peritonitis o Difficult anatomy o Dense adhesions or fibrosis from inflammation B. Induction of General Anesthesia o The anesthesiologist can better control the cardiopulmonary function of the patient o Spinal anesthesia can also be done in uncomplicated cholecystectomy only C. Skin preparation o Asepsis and antisepsis D. Put drapes E. Insertion of Trocars o The conventional approach of trocars Advancement in the field of surgery 4 trochar approach: Trochar 1 o a.k.a. umbilical port/ primary camera angle port/ CO2 insufflation port o Primary angle port- where you insert the rigid scope o CO2 insufflation port- side port attached to CO2 tank Insufflate CO2 8-15 mmHg In SLU- 8 mmHg create pneumoperitoneum using CO2 Why CO2? Poorly absorbed by peritoneum o Insufflate once Not combustible Oxygen- flammable, electrocoagulation Rapidly absorbed by the peritoneum Insufflate O2 more often Nitrogen- when absorbed>not dissolved>nitrogen gas or bubbles> resulting to gas embolism and bends

o Clinical presentation: Most common chief complaint- RUQ pain Character: Colicky Pain (hollow organ) Radiating to the tip of Right scapula or Right shoulder Precipitated by fatty food intake Usually with or without fever Chronic cholecystitis- with fever Usually without jaundice o Physical Examination: Murphys sign- single most important PE finding Ask patient to inhale and exhale; when the patient inhales, the GB goes up; when the

Aiza, Damocs, Oninsky

Minimally Invasive Surgery (MIS) Dr. Manalo (in lieu of Dr. Ong-Cunanan)
Helium- too light. The patient will float o Length- 1 cm in dm o 1 cm incision passes through skin, subcutaneous tissue, anterior rectus sheath, posterior rectus sheath, peritoneum o In fat individual: 2 fingers above the umbilicus at midline> less vascular o In thin individuals: 2 fingers below In current practice, trochar 1 is placed in the umbilicus to reduce scar Trochar 2 o a.k.a. operating port/ cutting/ coagulation port o operating port- where the surgical instruments are inserted o length- 1 cm in dm o place 2 fingerbreadths below xiphoid process at the midline; while inserting the camera in trochar 1, it should be directed towards trochar 2 so not to perforate or injure viscera Trochar 3 o a.k.a. Dynamic Retraction port active retraction o Length- cm in dm o Inserted midway between Trochar 1 and Trochar 2 at midclavicular line Trochar 4 o a.k.a. Static Retraction port o can do surgery without Trochar 4 o inserted at the level of Trochar 1 at anterior axillary line TROCAR PLACEMENT IN CONVENTIONAL PRACTICE

September 13, 2012

TROCAR PLACEMENT IN CURRENT PRACTICE

Trocar 1 Umbilicus Trocar 2 2 fingerbreadths below xiphoid process Trocar 3 At the level of trocar 1 at MCL Trocar 4 At the level of trocar1 and trocar 3 at AAL - surgical instruments used in laparoscopic surgery are longer, thinner, smaller, and more slender - Once you are inside, the operating technique is the same. It is only the approach that is different COMPLICATIONS: Class I- Uneventful surgery o No untoward events, no effects, no complications o 80% Class II- There is an adverse event during the operation but does not affect the patient o Example: Bleeding that was controlled Adverse event- bleeding No effect- controlled Class III- No adverse event during the operation but there is an untoward effect to the patient o Example: Hematoma/ Post-op infection Class IV- There is an adverse event that affects the patient o Example: Injury to CBD, peritonitis Class V- Severe adverse events such as death o Example: Patient goes to cardiac arrest during the operation OPERATING TIME: Simple- 20 minutes Difficult- 2 - 3 hours AVERAGE HOSPITAL DAYS: 3 days SHORT TERM FOLLOW-UP 4-6 weeks

Trocar 1 Umbilicus Trocar 2 2 fingerbreadths below xiphoid process Trocar 3 Midway between trocar 1 and 2 at MCL Trocar 4 At the level of trocar 1 at AAL

Note: Dr. Manalo told us that it is still Dr. Ong-Cunanan who will give the quiz for this topic. Thank you.

Aiza, Damocs, Oninsky