1. Minimally Invasive Surgical Techniques and Instruments David Ramsay

2. What is Minimally Invasive Surgery? • Minimally invasive surgery is a surgical procedure in which operations are performed through very small incisions using specially designed surgical instruments and endoscopes.

3. Endoscope • An endoscope is a small tube-like surgical instrument that is made up of three parts: • A light source • A Camera • A port through which surgical instruments can pass • May also be a wireless light and camera capsule

4. Endoscopy • An endoscopy is a surgical procedure that uses an endoscope. • In an endoscopy a surgeon starts by making a small incision, usually one centimeter to one inch in length then inserts the endoscope and proceeds with the steps of the operation • An endoscopy may also use natural anatomical openings in the body, such as the esophagus or nasal passageway.

5. Benefits of an Endoscopy over an open surgical procedure • Significantly less post-operation pain • Reduced scar tissue • Faster recovery time • Less time spent in the intensive care unit post-operation • Reduced chances of surgical infection

6. Heart Surgery • There are two main minimally invasive surgical procedures for a coronary artery bypass: • Port-Access Coronary Artery Bypass (PACAB) • Minimally Invasive Coronary Artery Bypass (MIDCAB)

7. Port-Access Coronary Artery Bypass • In a PACAB surgery the heart is stopped and blood is pumped through an oxygenator, in a cardiopulmonary bypass. • Then a surgeon makes small incisions in the chest. Using a special endoscope arteries or veins are taken from either the chest or the leg and are surgically grafted to the heart to bypass the blocked coronary artery. • The surgeon uses a small camera on the endoscope to perform the procedure instead of directly viewing it.

8. Minimally Invasive Coronary Artery Bypass • In a MIDCAB procedure the patient is not put on a cardiopulmonary bypass system. This procedure can only be done when one or two arteries need to be bypassed. • Small incisions are made and endoscopes are used, an incision is also made directly over the artery being bypassed so the surgeon can view it directly. • Then the grafts are sewn into place using endoscopes .

9. Benefits of MIDCAB Surgery • Lower risk of post-operation bleeding, stroke, and chest wound infections • Avg hospital stay for MIDCAB is 3 days • Avg hospital stay for PACAB is 6-8 days

10. Atherosclerosis • Atherosclerosis is when plaque from blood cholesterol builds up on the inside lining of blood vessels. • Over time the plaque build-up can become so severe that it will eventually cut off the blood flow to portions of the body which can lead to a lack of oxygen in tissues, leading to necrosis or tissue death. • Atherosclerosis also greatly increases the chance of the formation of blood clots in blood vessels.

11. Angioplasty • Angioplasty is an endoscopic procedure to restore blood flow through a blood vessel that has been effected from Atherosclerosis. • When a surgeon performs an Angioplasty procedure they inflate a surgical balloon on the end of an endoscope to stretch out the blood vessel and place a stent in it to effectively restore blood flow and trigger the healing response for the body. • Blood vessels have three major layers, the thin smooth inner layer, the muscular elastic middle layer and the external layer made up of connective tissue.

12. Angioplasty Procedure of the leg • The surgeon starts by making a very small incision in the upper thigh. • Then they feed an endoscope with an angioplasty balloon and a stent on the end of it down through the femoral artery. • When the endoscope reaches the plaque build up inside of the blood vessel the balloon is inflated which causes a controlled injury on the blood vessel, this triggers the body’s healing process as well as compresses and breaks apart the plaque build up. • The stent is also put into place with the inflation of the balloon and this keeps the blood vessel open and ensures a restored blood flow.

13. Benefits of a Minimally Invasive Angioplasty • Because there is no major incision made during the operation tissue damage is minimized, muscles and tendons do not get damaged during the operation. • Post-operation pain is dramatically reduced • Recovery time is greatly reduced as well as required hospital stay • Scarring is reduced significantly

14. Robot assisted Surgery • Robot and or computer assisted surgical procedures are operations where a very precise robot, or computer program, or both are utilized to help a surgeon perform a surgical procedure. • An example of a Surgical Robot: • The Da Vinci® Surgical System

15. Da Vinci® Surgical System • The Da Vinci® system is a four armed robotic surgical system that allows a surgeon to operate on the patient at a distance in a work station. • It only needs to make a one centimeter to one inch incision for each instrument. • It is comprised of four major parts: • The Surgeon’s Console • The Patient Side Cart • The Detachable Instruments • The 3-D Vision System

16. Da Vinci® Surgeon’s Console • Set up several feet away from the operating table. • Contains all of the controls the surgeon needs as well as the magnified 3-dimensional image of the surgical field. • The surgeon can operate in a one cubic foot area.

17. Da Vinci® Patient Side Cart • The part of the system that performs the surgical procedure. • It has four arms; One endoscopic arm with a special 3-d magnified camera. The endoscope is automatically self heated to prevent lens fogging. • The other three arms are instrument arms. • The system can monitor tool to tool contact to make sure that the surgeon can solely focus on the visual area while they perform the procedure.

18. Da Vinci® Detachable Instruments • The main Instrument is the EndoWrist®. • It is able to mimic the seven degrees of motion of the human hand, with the advantage of being able to rotate in a full 360 degree arc. • Each arm has a specific purpose for each procedure, which may include suturing or clamping. • The movement software is able to filter out hand tremors and scale movements for very precise pinpoint surgical procedures. • The surgeon is also able to control how much force is applied, from fractions of an ounce to several pounds of force if necessary. • Carbon dioxide can also be pumped into the body cavity to make more room for the arms to work.

19. Da Vinci® Imaging System • The Imaging system uses an enhanced endoscope with a special miniature 3-D camera. • The system magnifies the work space and provides over a thousand frames per second of imagery and filters out each individual frame to eliminate background noise • The endoscope is able to heat itself to prevent the camera lens from fogging up and blinding the surgeon during the procedure. • The surgeon is able to switch views by simply hitting a foot pedal in his station.

20. Da Vinci® Safety Protocols • The surgeon’s head must remain inside of the viewing console at all times, or the system will be put into a locked mode. • During the procedure the robotic arms cannot pivot or change position at or above the incision to prevent unintentional tearing • The system has a backup battery that allows the system to run for twenty minutes which gives the hospital enough time to restore power. • Each instrument contains a computer chip to determine when it needs to be replaced and to ensure only tools designed to work with the Da Vinci® system are used.

21. Da Vinci® Benefits • Each Da Vinci® System costs the hospital about $1 Million dollars, But the procedure is generally covered by Medicare for patients • The system reduces hospital stay by about half which in turn reduces the hospital costs by about 33% • Fewer days are required in the intensive care unit due to decreased pain and increased recovery time. • Leaves a very small surgical scar from the procedure. • Can be used for many different procedures. • In heart procedures: • Patients spend 4.5 less days in the hospital post-op • Save $9,000 per heart valve for every procedure • 3.5 days are spent in the ICU after open surgery, 1.2 days are spent in the ICU following a Da Vinci® surgery.

22. References • http://lessinvasive.com/ • http://lessinvasive.com/cardiology.html • http://www.kirkseyvascular.com/angioplastyandstenting.htm • http://biomed.brown.edu/Courses/BI108/BI108_2005_Groups/04/davinci.html • http://www.bing.com/health/article/mayo-119453/Endoscopy?q=endoscopy&FORM=K1RE5