What’s New in Minimally Invasive Surgery? David Renton MD Assistant Professor The Ohio State University Department of Surgery

Minimally Invasive Surgery Past, Present and Future What is MIS? A minimally invasive medical procedure is defined as one that is carried out by entering the body through the skin or through a body cavity or anatomical opening, but with the smallest damage possible to these structures.

Minimally Invasive Surgery Past, Present and Future Includes laparoscopic, endoscopic, and other approaches. Why MIS? Decreased patient pain Decreased patient recovery period Possible decrease in inflammatory response in the patient which may prove to have a better outcome in ocologic operations

Minimally Invasive Surgery Past, Present and Future 1901-Dimitri Ott, George Kelling, and H.C. Jacobaeus first demonstrated on animals that laparoscopy was possible 1938 - Janos Veress of Hungary developed a specially designed spring-loaded needle. Interestingly, Veress did not promote the use of his Veress needle for laparoscopy purposes. He used the veress needle for the induction of pneumothorax.

Minimally Invasive Surgery Past, Present and Future 1953 - The rigid rod lens system and fiber optics was introduced by Professor Harold H. Hopkins. The credit of videoscopic surgery goes to this surgeon who has revolutionized the concept by making this instrument.

Minimally Invasive Surgery Past, Present and Future 1985 - The first documented laparoscopic cholecystectomy was performed by Erich Mühe in Germany in 1985.  Fascinated by Semm's technique Idea of laparoscopic removal of gallstones 1984: designed an operative "Galloscope” September 12, 1985, first lap chole 1986: Published his technique at the Congress of the German Surgical Society 1987: Total of 97 endoscopic cholecystectomies. His concept, however, was ignored

Minimally Invasive Surgery Past, Present and Future Gave impetus to Eddie Joe Reddick & Barry McKernan of Marietta, GA June 22, 1988: 1st lap chole in U.S.

Current Practices in MIS Procedures currently performed using MIS techniques: Cholecystectomy Appendectomy Hernia Repair Inguinal Ventral Incisional Colectomy Splenectomy Adrenalectomy Heller Myotomy Nissen Fundoplication Esophagectomy Gastrectomy Pancreatectomy Bile Duct Exploration Bariatrics Roux en Y Gastric Bypass Lap Band Lymph Node Biopsy Almost Anything

Current Practices in MIS

Where to go next? Three Directions MIS is headed: Endo-luminal Technique NOTES – Natural Orifice Transluminal Endoscopic Surgery SILS – Single Incision Laparoscopic Surgery

The Future

The Future Endoluminal treatment for reflux Endoluminal sleeve gastrectomy for bariatrics Deployable absorption barriers for malabsorptive weight loss Gastric Ballons

The Future

The Future

NOTES NOTES Natural Orifice Transluminal Endoscopic Surgery

NOTES What is it? Using natural orifices as portals into the abdominal cavity to perform procedures using a flexible endoscope Transgastric Transrectal Transvaginal

NOTES The NOSCAR group was created by SAGES to help funnel research into this developing field Funded through a $500,00 grant by the Covidien Corporation Natural Orifice Surgery Consortium for Assessment and Research

NOTES First NOTES procedure preformed in Hyderabad, India by Drs Reddy and Rao Performed on prisoners without consent No IRB panel Data has never been published

NOTES NOTES crossed the ocean three years ago when the first IRB approved Transluminal procedure was performed outside of India on a human subject. We performed diagnostic peritonoscopy on patients with pancreatic cancer here at OSU Laparoscopic assistance was used

NOTES March 20th 2007 – a hybrid trans-vaginal cholecystectomy performed in New York. Used three additional trocars in the upper abdomen, no supraumbilical port All visualization and dissection done through endoscope

NOTES April 2, 2007 Strasbourg France the first “completely” transvaginal cholecystectomy performed Used a 2mm stab incision for insertion of a veress needle to insufflate and retract gallbladder

NOTES What has been done with NOTES so far? Transgastric appendectomy Transgastric cholecystectomy Transvaginal cholecystectomy Transrectal colectomy

NOTES A great deal of research is going into NOTES right now, some of it being done here at OSU Questions about safety, cost, and the ability for the practicing surgeon to learn these techniques abound

SILS Single Incision Laparoscopic Surgery Instead of making several small incision for the insertion of multiple trocars and instruments, make one incision and use this to deploy a multiport system

Traditional incisions for Lap Chole

SILS Incisons for Lap Chole 2.5 cm

Incision For SILS Lap Chole

SILS Colectomy Scar 5 cm

SILS Colectomy Scar

SILS What has been done with SILS so far? Cholecystectomy Appendectomy Lap Band Colectomy Nissen Splenectomy Adrenalectomy Nephrectomy

SILS We have begun SILS surgery at OSU East SILS Cholecystectomy SILS Colectomy SILS Appendectomy SILS Inguinal Hernia

Where Are We Going Next?