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
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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
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Procedures currently performed using MIS techniques:
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Cholecystectomy
Appendectomy
Hernia Repair
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Colectomy
Splenectomy
Adrenalectomy
Heller Myotomy
Nissen Fundoplication
Esophagectomy
Gastrectomy
Pancreatectomy
Bile Duct Exploration
Bariatrics
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Inguinal
Ventral
Incisional
Roux en Y Gastric Bypass
Lap Band
Lymph Node Biopsy
Almost Anything
Current Practices in MIS
Where to go next?
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Three Directions MIS is headed:
1. Endo-luminal Technique
2. NOTES – Natural Orifice Transluminal
Endoscopic Surgery
3. 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
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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?