Minimally Invasive Surgery OR Consortium Paige klem

Definitions: Endoscopy: Lapar-: Arthr-: Hyster-: Examination of hollow body organs or cavities to permit visual inspection Lapar-: Abdomen, loin Laparoscopy: Endoscopic examination of the peritoneal body cavity Arthr-: Joint Arthroscopy: To look within the joint Hyster-: Uterus Hysteroscopy: Examination of the cervix and interior of the uterus

MIS: Minimally Invasive Surgery Broad Term Surgery utilizing minimal surgical incision to reduce trauma to the body Laparoscopic Procedures 3-5 puncture sites Robotics 1 puncture site Single site hernia risk

Equipment needed for MIS Procedures: Camera/Light Source Includes: Tower Camera control unit Printer Insufflator CO2 Tanks Trocars Scopes

Insufflation with Gas Pneumoperitoneum Use of Fluid Media Most Common: CO2 Keep pressures less than 15 mmHg; 8-15 is the suggested range Postoperative pain from insufflation Gas embolism risk Use of Fluid Media

Subcutaneous Emphysema Crepitus Rare Complication At risk after laparoscopic procedures with Gas Insufflation Factors: Using 4 or more trocars Using trocars that are not tight fitting Increased operating time Increased volume of gas

Insufflation with Fluid Fluid Media: Ex. Hysteroscopy Insufflation You want low viscosity or isotonic solution Glycine historically used for urological procedures Managing measuring of lost fluid Automated fluid management systems

Positioning Trendelenburg Issues with Positioning? Aides in moving the surgical area into view Issues with Positioning?

The transition from laparoscopic to robotic surgery ? Common question: Is the robot doing the surgery or is the surgeon doing the surgery? Why transition? Ability to do more complex surgeries 3-D vision Angulation of the robotic arms Frequent concerns: Cost Surgical and Equipment Costs Recovery and hospital inpatient costs

What is Robotics Surgery? Surgeon sits at surgeon console 3D HD vision Multiple wristed tools Filters human tremor Small openings to conduct complex procedures 1,300 Safety checks per second Less blood loss, faster recovery, less pain for patients

The 3 components of the da Vinci System

DA VINCI SURGICAL SYSTEMS CORE TECHNOLOGIES A natural extension of the surgeon’s eyes and hands into the patient The da Vinci Xi Surgical System is built on the core technologies of da Vinci Surgery, which has always served as a natural extension of the surgeons eyes and hands while providing: Magnified 3D HD Vision Highly-magnified 3D HD ensures the surgeon can see the surgical site with true depth perception and clear vision. EndoWrist Instrumentation Wristed instruments bend and rotate far beyond the abilities of the human hand. Tremor filtration and Intuitive® motion technologies allow the surgeon to operate with steady, natural motion. Enhanced Ergonomics Whether it is the first or last case of the day, the ergonomically-adjustable surgeon console makes performing surgery more comfortable. MAGNIFIED 3D HD VISION ENDOWRIST INSTRUMENTATION WITH INTUITIVE® MOTION ENHANCED ERGONOMICS PN 1006780 Rev A 3/14

Wristed Instruments: More freedom than the human hand Wristed Instruments: More freedom than the human hand. 5mm, 8mm, 12mm sizes.

How does the surgeon know/decide where to put ports and how many?

Example: Sigmoid colon

Example: hysterectomy

Advanced technology- single site

How does a surgeon become a da Vinci surgeon? Adequate volume Appropriate background On-line modules, hands-on practice, complete commitment 8 hour “basic training” with pig/cadaver lab Credentialing** hospital determines credentialing requirements and volume requirements for re-appointment First 3-4 cases proctored Advanced course/ continuing education More difficult cases

Robotics in Alaska 6 Robots in AK (2 Xi, 4 Si) Prov AK (2), ARH (2), Mat Su (1), Fairbanks (1) >1200 da Vinci cases completed in 2017 with 35% growth expected for 2018 Fastest areas of growth/adoption: General surgery: inguinal and ventral hernia Thoracic: minimally invasive pulmonary lobectomy Colorectal: intracorporeal anastomosis for colectomy

Questions?