no (visible) scar colectomy michael j stamos, md professor and chair department of surgery univ. of...
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No (Visible) Scar Colectomy
Michael J Stamos, MDProfessor and Chair
Department of SurgeryUniv. of California, Irvine
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PHILOSOPHY of PHILOSOPHY of SINGLE PORT/ACCESS SURGERYSINGLE PORT/ACCESS SURGERY
Perform interventional laparoscopy through the umbilicus (No Scar)Perform interventional laparoscopy through the umbilicus (No Scar)
Perform interventional laparoscopy with reduced number of Perform interventional laparoscopy with reduced number of laparoscopic incisions (goal of 1 incision)laparoscopic incisions (goal of 1 incision)- Without increasing the size of the incision- Without increasing the size of the incision
Appropriate for:Appropriate for:- Procedures requiring implantation of a device - Procedures requiring implantation of a device - Procedures requiring removal of a surgical specimen- Procedures requiring removal of a surgical specimen
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RevolutionRevolution
Transition from open surgery Transition from open surgery to multiport trans-abdominal to multiport trans-abdominal surgerysurgery
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EvolutionEvolution
Transition from open surgery to Transition from open surgery to multiport trans-abdominal surgerymultiport trans-abdominal surgery
Single site transabdominal surgerySingle site transabdominal surgery LESS (Laparo Endoscopic Single LESS (Laparo Endoscopic Single
Site Surgery)Site Surgery)
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Revolution?Revolution?
Transition from open surgery to Transition from open surgery to multiport trans-abdominal surgerymultiport trans-abdominal surgery
Single site transabdominal surgerySingle site transabdominal surgery LESS (Laparo Endoscopic Single Site LESS (Laparo Endoscopic Single Site
Surgery)Surgery) Single port transoral/visceral surgery Single port transoral/visceral surgery
(NOTES)(NOTES)
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Advantages of LESS vs. Advantages of LESS vs. NOTESNOTES
Able to use many conventional rigid Able to use many conventional rigid laparoscopic instrumentslaparoscopic instruments
Laparoscopic skill setLaparoscopic skill set
Able to work on same organs approached via Able to work on same organs approached via conventional laparoscopyconventional laparoscopy
Stepping stone for the next evolutionStepping stone for the next evolution
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Balanced Strategy leads to Balanced Strategy leads to Single Incision SurgerySingle Incision Surgery
Improved cosmesis
Technical difficulty &Compromising safety
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Tools availableTools available
Narrow-low profile Narrow-low profile trochars/multiport trochars/multiport devicesdevices
Articulated cameraArticulated camera Articulated grasperArticulated grasper Articulated dissectorArticulated dissector Articulated L-hookArticulated L-hook Articulated scissorsArticulated scissors Straight instrumentsStraight instruments
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Principles to followPrinciples to follow
Triangulation of view with adequate exposureTriangulation of view with adequate exposure
Open surgeryOpen surgery Single incision, angled arms, straight Single incision, angled arms, straight
instrumentsinstruments Laparoscopic surgeryLaparoscopic surgery
Multiple ports, straight camera and instrumentsMultiple ports, straight camera and instruments Single site laparoscopySingle site laparoscopy
Single site, Articulated camera +/- instrumentsSingle site, Articulated camera +/- instruments
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TriangulationTriangulation
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NOTES vs. Single Site SurgeryNOTES vs. Single Site Surgery
NOTESNOTES Require 1-portRequire 1-port All Flexible equipmentAll Flexible equipment Potential BenefitsPotential Benefits
- No abdominal scar- No abdominal scar
- Other ?- Other ? Almost all are hybridAlmost all are hybrid Endoscopic skillsEndoscopic skills
Single Site SurgerySingle Site Surgery Requires 1-port/siteRequires 1-port/site Flexible/rigid Flexible/rigid
equipmentequipment BenefitsBenefits
- Minimal scar- Minimal scar- Other ?Other ?
- Some hybridsSome hybrids Purely Laparoscopic Purely Laparoscopic
skillsskills
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AppendectomyAppendectomy
UmbilicusTarget organCameraInstrument
Single-Incision Appendix
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LESS AppendectomyLESS Appendectomy
Nguyen, Reavis , Hinojosa, Smith, Stamos, Surg Innov 2009
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LESS AppendectomyLESS Appendectomy
Nguyen, Reavis , Hinojosa, Smith, Stamos, Surg Innov 2009
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What about LESS Colectomy?What about LESS Colectomy?
Increased complexity w/trocars due to Increased complexity w/trocars due to multi quadrant operationmulti quadrant operation
Awkward/suboptimal location for Awkward/suboptimal location for “single site” at umbilicus“single site” at umbilicus
Unfavorable cosmesisUnfavorable cosmesis
Hernia riskHernia risk
Consider goal of single site (i.e. it’s all Consider goal of single site (i.e. it’s all about cosmesis)about cosmesis)
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What about LESS Colectomy?What about LESS Colectomy? No Visible Scar (NVIS) ColectomyNo Visible Scar (NVIS) Colectomy
Standard approachStandard approach
Applicable to right and left/sigmoid colonApplicable to right and left/sigmoid colon
2 sites utilized2 sites utilized
Suprapubic incision below hair line(3-5 cm)Suprapubic incision below hair line(3-5 cm)
2 trocars(5 + 12 mm) or2 trocars(5 + 12 mm) or
Multiport deviceMultiport device
Umbilicus is a “freebie”Umbilicus is a “freebie”
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NVIS vs. Single Site SurgeryNVIS vs. Single Site Surgery
NVISNVIS Allows 2 ports/sitesAllows 2 ports/sites Flexible/rigid equipmentFlexible/rigid equipment Potential BenefitsPotential Benefits
- Minimal/hidden scar- Minimal/hidden scar
- Other?- Other? Hybrid an optionHybrid an option Purely Laparoscopic skillsPurely Laparoscopic skills
Single Site SurgerySingle Site Surgery Requires 1-port/siteRequires 1-port/site Flexible/rigid Flexible/rigid
equipmentequipment BenefitsBenefits
- Minimal scar- Minimal scar- Other ?Other ?
- Some hybridsSome hybrids Purely Laparoscopic Purely Laparoscopic
skillsskills
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NVIS vs. Single Site SurgeryNVIS vs. Single Site Surgery
NVISNVIS No IRB issuesNo IRB issues Regain triangulationRegain triangulation Less expensive?Less expensive?
Shorter OR timeShorter OR time Less device Less device
dependentdependent
Single Site SurgerySingle Site Surgery IRB required?IRB required? Angled/articulated Angled/articulated
instruments/scope instruments/scope try to regain try to regain triangulationtriangulation
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Standard Lap Sigmoidectomy/LAR
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Standard Lap Right Colectomy
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NVIS Approach
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NVIS Sigmoid ColectomyNVIS Sigmoid Colectomy
Need long instruments(45 mm)Need long instruments(45 mm) Camera at umbilicus for medial lateral Camera at umbilicus for medial lateral
dissection and at suprapubic site for dissection and at suprapubic site for splenic flexure splenic flexure
Multiport device facilitates placement Multiport device facilitates placement of anvil and subsequent anastomosisof anvil and subsequent anastomosis
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NVIS Right ColectomyNVIS Right Colectomy
Need long instruments(45 mm)Need long instruments(45 mm) Camera at suprapubic site for Camera at suprapubic site for
operation operation Multiport device not neededMultiport device not needed Intracorporeal anastomotic technique Intracorporeal anastomotic technique
requiredrequired
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We’re Making ProgressWe’re Making Progress
Come on! It can‘t go
wrong every time...
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ConclusionsConclusions LESS or NVIS surgery can be used as a LESS or NVIS surgery can be used as a bridgebridge to to
NOTES procedures or NOTES procedures or instead ofinstead of NOTES NOTES
Enable surgeons to advance skill set while providing Enable surgeons to advance skill set while providing safety for our patientssafety for our patients
Unlike NOTES, there are no reimbursement issuesUnlike NOTES, there are no reimbursement issues
Can also be applied to advanced laparoscopic Can also be applied to advanced laparoscopic operations that are not amenable to NOTES techniqueoperations that are not amenable to NOTES technique
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What does the Future hold?What does the Future hold?
Technologic advances will drive Technologic advances will drive surgery toward less invasive optionssurgery toward less invasive options Robotic single portRobotic single port Newer/improved roboticsNewer/improved robotics Improved miniaturizationImproved miniaturization
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ConclusionsConclusions
Exciting time to be in surgeryExciting time to be in surgery
Evolution from open to minimally Evolution from open to minimally invasive surgery to “minimalist” invasive surgery to “minimalist” approachesapproaches
Dual site allows use of current skill set Dual site allows use of current skill set and instrumentation (with more to come)and instrumentation (with more to come)
Principles of surgical technique followedPrinciples of surgical technique followed
Surgical evolution is a journey…Surgical evolution is a journey…
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Minimize the footprint we leave
behind
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Thank youThank you