Refaratminimally Invasive Surgery

7/28/2019 Refaratminimally Invasive Surgery

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MINIMALLY INVASIVE SURGERY (MIS)

Minimally invasive surgery is an innovative method of surgery that allows for smaller incisions with

minimal access. Smaller incisions mean less pain, shorter hospital stays, less scarring and faster healing

MIS is sometimes known as videoscopic surgery, "keyhole" surgery, laparoscopic surgery (laparoscopy),

thoracoscopic surgery, or surgical endoscopy because surgeons are now able to perform proceduresthrough incisions (or openings called ports) as small as 1/16 of an inch.

Advantages and disadvantages of minimally invasive surgery

Advantages Disadvantages

Less expensive Shorter duration of hospital stay Less trauma to patient Less pain Less blood loss Smaller skin scars Becoming more common for major surgical

procedures, e.g. cardiac surgery

Requires special equipment Specialist training required Equipment is more expensive Some procedures, especially latest

ones, may take longer

Some complications can be masked,e.g.biliary peritonitis

Patient suitability

Not all patients will be suitable for minimally invasive procedures. For example, raised body mass index,

previous abdominal surgery leading to adhesions or other underlying medical conditions may affect the

decision on whether to proceed towards more invasive surgery.

Types of procedures performed using minimally invasive surgery

Body system Procedures performed

Cardiac Closing atrial septal defects

Coronary artery bypass graft ('off pump')

Repairing patent foramen ovale

Valve surgery

Gastrointestinal AppendicectomyAdrenalectomy

Cholecystectomy

Lymph node biopsy

Splenectomy

Hiatus hernia, umbilical and inguinal hernia repairs

Colonic cancer
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Diverticular disease

Inflammatory bowel disease

Rectal prolapse

Dividing adhesions

Gynaecological Polypectomy

Sterilisation

Endometrial ablation

Fibroid removal

Neurological Removal of pituitary tumours

Treatment of intracranial aneurysms

Carotid angioplasty

Radiosurgery for brain tumours

Orthopaedic Arthroscopy of jointsCarpal tunnel release

Pelvic fracture repair

Rotator cuff repair

Otorhinolaryngology Removal of nasal/sinus tumours

Lymph node biopsy

Respiratory/Thoracic Lung surgery

Recurrent pleural effusions

Urology Biopsy

Remove kidney and ureteric calculi

Nephrectomy

Vascular Stenting carotid and renal arteries

Repair of thoracic and abdominal aneurysms

Varicose veins


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MINIMALLY INVASIVE SURGERY IN HEART

For drainage and puncture of pericardium (Pericardiocentesis)Procedures

1. Aseptic procedures are followed.2. Make a small incision in the skin and the intercostal muscles, particularly when using the

intrapleural drain set.

3. Attaching a sterile ECG extension lead to the needle and a precordial chest lead to the ECGmachine will allow monitoring for a marked deviation of the ST segment or iatrogenic ventricular

arrhythmias.

4. It is usually possible to appreciate when the catheter enters the pleural space.5. Direct the catheter craniodorsally to puncture the pericardium at a perpendicular angle.6. The needle/trocar tip can be felt to scrape on the pericardium. It is then punctured with a short

stabbing movement.

7. The needle/trocar is pushed forward to enter the pericardium.8. If the catheter touches the epicardium, ventricular premature complexes or ST segment

deviation are often evident on the ECG monitor.

9. After removing the needle/trocar, connect a 50 ml syringe and three-way tap to the catheter andremove as much effusion as possible.

10. Haemorrhagic effusion can be difficult to distinguish from blood obtained by puncturing aventricle. Pericardial haemorrhage does not clot and so can be distinguished from blood. In

addition, there will be a difference in the packed cell volume.


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Atrial septal defect (ASD) closure

An atrial septal defect is an abnormal opening in the wall (septum) that divides the two upper chambers

of the heart (atria). The atrial septal defect closure procedure corrects this abnormal opening.

Mini-ASD Repair

Currently, the most commonly employed minimally invasive approach to ASDs is a mini-thoracotomy

which consists of a 3 inch incision made through the right side of the chest between the ribs. Heart-lung

bypass is instituted with small tubes placed in the main artery and vein of the right leg through a 1 to 2

inch incision placed in the right groin crease. The heart is then stopped and the right atrium is opened to

expose the ASD. At this point, specialized hand-held chopstick like instruments are inserted through

this small incision by the surgeon to repair the defect. After the defect is repaired, the heart is then

closed and restarted. Finally, heart-lung bypass is discontinued and the incisions are closed.

Minimally Invasive Approach to ASD Closure


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Coronary artery bypass graft (CABG)The atherosclerotic process causes significant narrowing in one or more coronary arteries. When

coronary arteries narrow more than 50 to 70%, the blood supply beyond the plaque becomes

inadequate to meet the increased oxygen demand duringexercise. The heart muscle in the territory of

these arteries becomes starved of oxygen (ischemic). Patients often experience chest pain(angina)

when the blood oxygen supply cannot keep up with demand.

CABG is one treatment for CHD. During CABG, a healthy artery or vein from the body is connected, or

grafted, to the blocked coronary artery. The grafted artery or vein bypasses (that is, goes around) the

blocked portion of the coronary artery.This creates a new passage, and oxygen-rich blood is routed

around the blockage to the heart muscle.

Coronary Artery Bypass Grafting
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Angioplasty ( Percutaneous coronary intervention)The angioplasty procedure usually consists of most of the following steps and is performed by

physicians, physician assistants, nurse practitioners, nurses, radiological technologists and cardiac

invasive specialist; all whom have extensive and specialized training in these types of procedures.

1. Access into the femoral artery in the leg (or, less commonly, into the radial artery or brachialartery in the arm) is created by a device called an "introducer needle". This procedure is often

termed percutaneous access.

2. Once access into the artery is gained, a "sheath introducer" is placed in the opening to keep theartery open and control bleeding.

3. Through this sheath, a long, flexible, soft plastic tube called a "guiding catheter" is pushed. The tip ofthe guiding catheter is placed at the mouth of the coronary artery. The guiding catheter also allows

for radiopaque dyes (usually iodine based) to be injected into the coronary artery, so that the

disease state and location can be readily assessed using real time x-ray visualization.

4. During the x-ray visualization, the cardiologist estimates the size of the coronary artery and selectsthe type of balloon catheter and coronary guidewire that will be used during the case. Heparin (a

"blood thinner" or medicine used to prevent the formation of clots) is given to maintain blood flow.

5. The coronary guidewire, which is an extremely thin wire with a radio-opaque flexible tip, is insertedthrough the guiding catheter and into the coronary artery. While visualizing again by real-time x-ray

imaging, the cardiologist guides the wire through the coronary artery to the site of the stenosis or

blockage. The tip of the wire is then passed across the blockage. The cardiologist controls the

movement and direction of the guide wire by gently manipulating the end that sits outside the

patient through twisting of the guidewire.

6. While the guidewire is in place, it now acts as the pathway to the stenosis. The tip of the angioplastyor balloon catheter is hollow and is then inserted at the back of the guidewirethus the guidewire

is now inside of the angioplasty catheter. The angioplasty catheter is gently pushed forward, until

the deflated balloon is inside of the blockage.

7. The balloon is then inflated, and it compresses the atheromatous plaque and stretches the arterywall to expand.

8. If an expandable wire mesh tube (stent) was on the balloon, then the stent will be implanted (leftbehind) to support the new stretched open position of the artery from the inside.

(Left: RCA closed, right: RCA successfully

dilated)
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Coronary artery balloon angioplasty


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MINIMALLY INVASIVE SURGERY IN GASTROINTESTINAL SYSTEM

(a ) Transjugular Intrahepatic Portosystemic Shunts (TIPS)

A transjugular intrahepatic portosystemic shunt

(TIPS) is a small, tubular metal device commonly

called a stent that is placed in veins in the

middle of the liver to permit blood flow to

bypass the liver.

A TIPS is used to treat the complications of

portal hypertension, including:

variceal bleeding, bleeding from any of theveins that normally drain the stomach,

esophagus, or intestines into the liver.

portal gastropathy, an engorgement of theveins in the wall of the stomach, which can

cause severe bleeding.

severe ascites (the accumulation of fluid inthe abdomen) and/or hydrothorax (in the

chest).

Budd-Chiari syndrome, a blockage in oneor more veins that carry blood from the

liver back to the heart.

Fluoroscopic image of TIPS in progress. A

catheter has been passed into the hepatic vein

and after needle puncture, a guidewire was

passed into a portal vein branch. The tract was

dilated with a balloon, and contrast injected.

A self-expandable metallic stent has yet to be

placed over the wire.
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Percutaneous transhepatic cholangiographyPercutaneous transhepatic cholangiography (PTHC or PTC) is a radiologic technique used to visualize

the anatomy of the biliary tract. A contrast medium is injected into a bile duct in the liver, after which X-

rays are taken. It allows access to the biliary tree in cases where endoscopic retrograde

cholangiopancreatography (ERCP) has been unsuccessful.

If the biliary system is obstructed, PTC may be used to drain bile until a more permanent solution for

the obstruction is performed (e.g. surgery). Additionally, self expanding metal stents can be placed

across malignant biliary strictures to allow palliative drainage. Percutaneous placement of metal stents

can be utilised when therapeutic ERCP has been unsuccessful.

(c ) Endoscopic retrograde cholangiopancreatography (ERCP)

Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines the use

ofendoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic

ductal systems. Through the endoscope, the physician can see the inside of the stomach and duodenum,

and inject dyes into the ducts in the biliary tree and pancreas so they can be seen on x-rays.

ERCP is used primarily to diagnose and treat conditions of the bile ducts, including gallstones,

inflammatory strictures (scars), leaks (from trauma and surgery), and cancer.
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Laparoscopic splenectomyThe surgery begins with the administration ofanesthesia. Once the patient is unconscious, the surgery

begins, typically with the introduction of five small incisions approximately 2 to 3 centimeters in length

below the ribs on the left side. A tiny camera called a laparoscope is inserted into one of the incisions.

The other incisions are used for the insertion of surgical instruments and the actual performance of the

surgery. During the surgery, the surgeon views the space being operated on with the camera, as the

incisions are too small to allow the surgeon to view the surgery directly.

The spleen has many blood vessels, so the surgeon finds the blood vessels leading to and from the

spleen and places clips on them to permanently stop blood from flowing through to the spleen. The

spleen is then cut away from the other structures of the body. When it is free, the spleen is placed in a

sterile bag so it can be pulled out of the body through one of the incisions. If necessary, the incision can

be slightly enlarged to permit the bag to pass through. This is done so no pieces of the spleen are able to

break off and remain in the abdominal cavity, where they could cause serious infection.

Once the spleen has been removed and the surgeon has found no signs of continued bleeding, the

instruments are removed and the incisions are closed. The incisions may be closed with surgical glue,

steri-strips (small strips of adhesive bandage), or less frequently, staples or sutures.
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Trocar and instrument positions during laparoscopic splenectomy

CholecystectomyLaparoscopic cholecystectomy has now replaced open cholecystectomy as the first-choice of treatment

for gallstones and inflammation of the gallbladder unless there are contraindications to the laparoscopic

approach. This is because open surgery makes you more prone to infection. Sometimes, a laparoscopic

cholecystectomy will be converted to an open cholecystectomy for technical reasons or safety.

Laparoscopic cholecystectomy requires several small incisions in the abdomen to allow the insertion of

operating ports, small cylindrical tubes approximately 5-10 mm in diameter, through which surgicalinstruments and a video camera are placed into theabdominal cavity. The camera illuminates the

surgical field and sends a magnified image from inside the body to a video monitor, giving the surgeon a

close-up view of the organs and tissues. The surgeon watches the monitor and performs the operation

by manipulating the surgical instruments through the operating ports.

To begin the operation, the patient is anesthetized and placed in the supine position on the operating

table. A scalpel is used to make a small incision at the umbilicus. Using either a Veress needle or Hasson

technique the abdominal cavity is entered. The surgeon inflates the abdominal cavity withcarbon

dioxide to create a working space. The camera is placed through the umbilical port and the abdominal

cavity is inspected. Additional ports are placed inferior to the ribs at the epigastric, midclavicular,

andanterior axillary positions. The gallbladder fundus is identified, grasped, and retracted superiorly.

With a second grasper, the gallbladder infundibulum is retracted laterally to expose and open Calot's

Triangle (the area bound by the inferior border of the liver, cystic duct, and common hepatic duct). The

triangle is gently dissected to clear the peritoneal covering and obtain a view of the underlying

structures. The cystic duct and the cystic artery are identified, clipped with tiny titanium clips and cut.

Then the gallbladder is dissected away from the liver bed and removed through one of the ports. This

type of surgery requires meticulous surgical skill, but in straightforward cases can be done in about an

hour.
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MINIMALLY INVASIVE SURGERY IN VASCULAR SYSTEM

Endovascular aneurysm repairsEVAR which stands for Endovascular Aneurysm Repair (or Endovascular Aortic Repair), is a type

ofEndovascular surgery used to treat an abdominal aortic aneurysm (AAA) or Thoracic Aortic Aneurysm,the procedure then specifically termed TEVAR (Thoracic Endovascular Aortic/Aneurysm Repair).

The procedure is carried out in a sterile environment, usually a theatre, under x-ray fluoroscopic

guidance. It is carried out by an Interventional Radiologist. The patient is either given a full GA (general

anaestheic) or an epidural.

Vascular 'sheaths' are introduced into the patient's femoral arteries, through which the guidewires,

catheters and eventually, the Stent Graft is passed.

Diagnostic angiography images or 'runs' are captured of the aorta to determine the location on the

patient's renal arteries, so the stent graft can be deployed without blocking these. Failure to achieve this

will cause renal failure, thus the precision and control of the graft stent deployment is extremely

important. The main 'body' of the stent graftis placed first, follow by the 'limbs' which

join on to the main body and sit on the

Aortic Bifurcation for better support, and

extend to the Iliac arteries. The idea is that

the stent graft (covered stent), once in place

acts as a artificial lumen for blood to flow

down, and not into the surrounding

aneurysm sac. This therefore immediately

takes the pressure off the aneurysm wall,

which itself will thrombose in time.
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Varicose vein surgery ( Endovenous laser treatment)Varicose veins are veins that have become enlarged and tortuous. Veins have leaflet valves to prevent

blood from flowing backwards (retrograde). Leg muscles pump the veins to return blood to the heart,

against the effects of gravity. When veins become varicose, the leaflets of the valves no longer meet

properly, and the valves do not work. This allows blood to flow backwards and they enlarge even more.

Varicose veins are most common in the superficial veins of the legs, which are subject to high pressurewhen standing.

Endovenous laser treatment is a treatment for varicose veins in which an optical fiber is inserted into

the vein to be treated, and laser light, normally in the infrared portion of the spectrum, is shone into the

interior of the vein. This causes the vein to contract, and the optical fiber is slowly withdrawn.

During the procedure, a catheter bearing a laser fibre is inserted under ultrasound guidance into

the great saphenous vein (GSV) or small saphenous vein (SSV) through a small puncture. The catheter is

then advanced (also under ultrasound guidance) to the level of the groin or knee crease. Dilute local

anesthesia is injected around and along the vein (perivascular infiltration) using ultrasound imaging to

place the local anesthetic solution around the vein, mostly in a sub-facial location.

The laser is activated whilst the catheter or laser fibre is slowly withdrawn, resulting in obliteration ofthe saphenous vein along its entire length.
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HORACOSCOPY

Thoracoscopy is a minimally invasive procedure that allows visualization of the pleural space and

intrathoracic structures. Thoracoscopy is safely performed under general or local anesthesia, depending

on the indication and severity of illness of the patient, as well as on the experience of the physician and

institutional biases. A variety of rigid telescopes, a cold light source, electrocautery, 5-10 mm pleural

trocars and cannulas, and an assortment of disposable and reusable instruments may be used.

Procedures can be performed in an appropriately equipped endoscopy suite or the operating room.

Video equipment enhances direct endoscopic visualization, teaching, and documentation.

Procedures are performed by appropriately trained and experienced chest physicians and surgeons.

Diagnostic procedures allow thorough inspection of the parietal and visceral pleural surfaces, diaphragm

mediastinum, and lung. Thoracoscopic biopsies can be performed of pleural-based abnormalities (for

diagnosis of diseases such as metastatic cancer, tuberculosis, fungal and bacterial empyema, and

mesothelioma), lung parenchyma (for diagnosis of diseases such as aspergillosis, Pneumocystis carinii

and other infections, or interstitial lung disease and hypersensitivity pneumonitis), and mediastinal

lymph nodes.

Therapeutic procedures are performed to achieve pleurodesis in case of recurrent benign or malignant

pleural effusions or pneumothorax to close airleaks using electrocautery or endoscopic stapling devices,

to resect blebs or bullae, to drain complicated parapneumonic effusions or early stage empyema, and toperform sympathectomy for palmar hyperhidrosis. Thoracic surgeons are successfully using video

assisted thoracic surgery (VATS) techniques to perform nodule resections, pericardial windows,

segmentectomy, lobectomy, Nissan plications, esophageal myotomy, and esophagectomy as well as for

lung volume reduction surgery or bullectomy, pacemaker implantation, and mediastinal exploration.


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ROBOTIC SURGERY

Robotic surgery is a technique in which a surgeon performs surgery using a computer that remotely

controls very small instruments attached to a robot.

Description

This procedure is done under general anesthesia (you are asleep and pain-free). The surgeon sits at a

computer station nearby and directs the movements of a robot. Small instruments are attached to the

robot's arms.The surgeon first inserts these instruments into your body through small surgical cuts.

Under the surgeons direction, the robot matches the doctors hand movements to perform the

procedure using the tiny instruments.

A thin tube with a camera attached to the end of it (endoscope) allows the surgeon to view highly

magnified three-dimensional images of your body on a monitor in real time.
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Refaratminimally Invasive Surgery