innovations in minimally invasive surgery 2011

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Innovations in Minimally Invasive GI Surgery

C. Daniel Smith, MD

Florida Gastroenterologic SocietyAnnual Meeting

September 25, 2010Lake Buena Vista, Florida

Sunday, November 25, 12

Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010

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Innovations in Minimally Invasive GI Surgery

• Natural Orifice Translumenal Endoscopic Surgery (NOTES)

• Single Incision Laparoscopic Surgery (SILS)

• Minimally Invasive Esophagectomy

• Antireflux Surgery



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NOTES

• Natural

• Orifice

• Translumenal

• Endoscopic

• Surgery



7

Laparoscopic Surgery

Advanced Imaging & Guidance

Interventional Endoscopy

NOTES

NOTES



6

NOTES



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NOTES - U.S. Adoption



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NOTES Surgery - Elsewhere

Dr. Christine Ren, an associate professor of surgery at New York University’s school of medicine, called the vaginal procedure “repulsive” and said: “As a woman I find it very invasive, physically and emotionally. To me it’s quite distasteful. You will really have to prove to me that there is a benefit.”

NOTES - U.S. Adoption


Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 11

NOTES - Future ?



New Treatment Success – Key Elements

Clinical Results

Ease of Use

Patient Demand

Cost

Reimbursement

Other Rx Options

WIDELY ADOPTED

Lap Chole

-

-

+++++

-

+/-

-

YES

Lap Nissen

+++

+/-

+++

+/-

+

+++++

NO

Carotid Stenting

++

-

++++++

-

+/-

-

YES

Lap Colectomy

+++

-

+++

+

++

+

NO



Clinical Results

Ease of Use

Patient Demand

Cost

Reimbursement

Other Rx Options

WIDELY ADOPTED

Lap Chole

-

-

+++++

-

+/-

-

YES

Lap Nissen

+++

+/-

+++

+/-

+

+++++

NO

Lap Colectomy

+++-

+++

+/-

++

+/-

NO

NOTES

- - -

++

- - -

+++++

NO


Lap Colectomy

+++-

+++

+/-

++

+/-

NO


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Which would you rather have:

A lap chole by a skilled surgeon

OR

A transgastric/vaginal cholecystectomy

Innovations in MIS. FGS Annual Meeting. September 24-26, 2010

NOTES - Future ?


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Closing Comments

MIS vs. NOTES. SAGES Best of NOTES April 10, 2008



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NOTES – Impact?



14

NOTES – Impact?

Single Incision Laparoscopic Surgery

Natural Orifice Surgery



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• Less pain

• Faster recovery

• Earlier return to work

• Superior cosmesis



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“The Next Lap Chole”

Over 100,000 hits with Google Search

Laparocopic colectomy - 58,000 hits

Natural Orifice Surgery



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Laparoscopic surgery performed through a single incision: a systematic review of the literature. JACS, Jan 2011, In Press

2007-2010

219 publications4,585 operations

Procedure No. Publications

Cholecystectomy 52

Nephrectomy 34

Appendectomy 28

GYN 19

Colectomy 15

Inguinal Hernia 11

6 institutions - 57 cits1 institution - 26 cits



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Laparoscopic surgery performed through a single incision: a systematic review of the literature. JACS, Jan 2011, In Press

2007-2010

219 publications4,585 operations

OUTCOMES

48% perioperative outcomes only

12% compared outcomes to another technique

1 PRCT - Lap chole v. Single incision chole

Improved pain scores

Longer OR time

6 institutions - 57 cits1 institution - 26 cits



Clinical Results

Ease of Use

Patient Demand

Cost

Reimbursement

Other Rx Options

WIDELY ADOPTED

Lap Chole

-

-

+++++

-

+/-

-

YES

Lap Nissen

+++

+/-

+++

+/-

+

+++++

NO

Lap Colectomy

+++-

+++

+/-

++

+/-

NO

SILS

--

++

-

+/-+++++

NO


Lap Colectomy

+++-

+++

+/-

++

+/-

NO



14

Single Incision Lap Surgery – Impact?


“The Next Lap Chole”

????



14

Single Incision Lap Surgery – Impact?


Two Field MIE



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Esophagectomy Outcomes

Transthoracic Transhiatal

Operative mortality (%) 4 2

Blood loss 1402 847

LOS 19 15

Respiratory complications (%) 57 27

Cardiac complications (%) 26 16

Anastomotic leak (%) 15 14



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Minimally Invasive Esophagectomy (MIE)



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Minimally Invasive Esophagectomy (MIE)

2-Field Technique

No. patients 8 (3 low risk, 5 high risk)EBL (cc) 63 (25-400)Operative time (min) 292 (194-375)Lymph nodes harvested 23 (13-29)LOS in ICU (days) 1 (1-5)LOS overall (days) 7 (5-16)Use of chest tubes 0Reoperation 0Mortality 0



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Two-Field MIE - Impact?

Two Field MIE

No. patients 8 (3 low risk, 5 high risk)EBL (cc) 63 (25-400)Operative time (min) 292 (194-375)Lymph nodes harvested 23 (13-29)LOS in ICU (days) 1 (1-5)LOS overall (days) 7 (5-16)Use of chest tubes 0Reoperation 0Mortality 0



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GERD

• Most common GI condition

• $ 10 billion healthcare expenditure

• Mechanical defect in valve

• Surgery effective treatment

• Nissen (3600) fundoplication is gold standard



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Antireflux Surgery - Failure

No. patients

Mortality (%)

Conversion (%)

Intraoperative comp (%)

Early postop comp (%)

Late postop comp (%)

Reoperation (%)

Symptom free 12 months (%)

Continued medical Rx (%)

Satisfied with results (%)

300

0.4

1.3

8

17 (transient)

4

-

93

3

97

1127

0.2

0.7

4

30 (transient)

5

3.5

92

11

95

1690

0.1

0.4

4

35 (transient)

5

2.8

90

18

94



4

Antireflux Surgery - Failure

No. patients

Follow-up (yrs)

Reoperation

Failure** Reoperation, patient dissatisfaction,

severe GERD symptoms

166

11±1.2

26 (16%)

43 (26%)

Surg Endosc (2007) 21:1978–1984 When Fundoplications Fails: Redo? Ann Surg (2005) 241: 861-871



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Antireflux Surgery – New Device



0

12.5

25.0

37.5

50.0

Pre-Implant 3 months 12 month 24 months

Tota

l GER

D H

RQ

L S

core

Baseline

Follow-up


0

25

50

75

100

3 months 12 months 24 months

Per

cen

t of

Pat

ien

ts Normalized (Total pH < 5.3)

! Pilot Trial • 44 patients, 4-centers, US and Europe

• Published J of Gastro 2008• To be published Annals of Surgery, November 2010

! Over 160 pts. implanted to date under clinical protocol




! FDA Pivotal Trial

• 100 pt, 15-center, USA and Europe• Jan 09 – Sept 09 (data pending completion of follow-up Sept 10)

University of Southern California

Policlinico San Donat

Academic Medical Center, Amsterdam

Abbott Northwestern

University of California San Diego

University of Rochester Medical Center

Legacy Health, Portland

Mayo Clinic - Jacksonville

Ohio State University

University of Washington

University of Pittsburgh Medical Center

Knox Community, Ohio

Washington University

Phoebe Putney Medical Center

Gunderson Lutheran, Wisconsin



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Antireflux Surgery – New Device - Impact?

0

25

50

75

100

3 months 12 months 24 months

Per

cen

t of

Pat

ien

ts

Normalized (Total pH < 5.3)


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Innovations in Minimally Invasive Surgery

C. Daniel Smith, MD

[email protected]


mailto:[email protected]




innovations in minimally invasive surgery 2011

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