38 MIS - ERAS.pdf

Surgery II MD 420 Coordinator: Dimitrios Ntourakis MD, PhD, FACS Minimally Invasive Surgery (MIS) & Enhanced Recovery After Surgery (ERAS) SURGERY II MD420 DIMITRIS NTOURAKIS MD, PHD, FACS Objectives  Analyze the concept of minimally invasive surgery (MIS)  Describe the different techniques that a...

Surgery II MD 420 Coordinator: Dimitrios Ntourakis MD, PhD, FACS Minimally Invasive Surgery (MIS) & Enhanced Recovery After Surgery (ERAS) SURGERY II MD420 DIMITRIS NTOURAKIS MD, PHD, FACS Objectives  Analyze the concept of minimally invasive surgery (MIS)  Describe the different techniques that are used for MIS  Identify the indications and limitations of MIS  Analyze the Enhanced Recovery After Surgery (ERAS) philosophy  Describe the main components of ERAS Introduction  Minimally invasive surgery  Not a discipline but a philosophy of surgery  Minimize surgical trauma but achieve the same results with conventional surgery  Use of technology, miniaturization, image guidance, computer assistance  For all surgeries and specializations  “Small holes, big operations” Definitions  Minimally Access Surgery = small incision for same operation  Minimally Invasive Surgery = small incision + less trauma during the surgery  Endoscopy = visualization of a normal cavity with a telescope   Laparoscopy = endoscopy of the peritoneal cavity  Thoracoscopy = endoscopy of the pleural cavity Pneumoperitoneum = inflating the peritoneal cavity with CO2 gas Definitions  Intralumenal Surgery = performing surgery inside the lumen of an organ  Normal Orifice Translumenal Surgery (NOTES) = operation performed through a natural orifice (rectum, vagina, etc)  Image guided surgery = surgery under the guidance of radiological image  Robotic assisted surgery = surgery with the use of telemanipulated mechanical arms  Hybrid surgery = combination of two or more different techniques Laparoscopy  Creation of pneumoperitoneum of 12 mmHg  Veress needle technique  Direct access (Hasson) technique  Lifting of abdominal wall away from organs  Introduction of working ports (trocars) Effects of pneumoperitoneum  Gas specific   CO2 absorption in circulation (hypercarbia)  Buffers (bone up to 120L CO2)  Respiratory function (RR or VC) Pressure specific  Excessive pressure on IVC  Rapid stretch of peritoneal membrane  Increase intrathoracic pressure Hunter JG: Bailliere’s Clinical Gastroenterology Laparoscopic Surgery. London/Philadelphia: Bailliere Tindall; 1993 Ergonomics of laparoscopic surgery  Port placement  Triangulation   Eyes – Hands – target organ Patient position  Gravity is our friend  Trendelemburg  Reverse-Trendelemburg  Tilt https://nurseslabs.com/patient-positioning/ Technical difficulties of laparoscopic surgery  2D vision => no depth perception  Long instruments   Fulcrum effect  Four degrees of freedom + grasping  Whole instrument shaft not visualized  No feeling with fingers Number and type of instruments limited by ports Robotics for Minimally Invasive Surgery: A Historical Review from the Perspective of Kinematics. January 2009. DOI: 10.1007/978-1-4020-9485-9_24. In book: International Symposium on History of Machines and Mechanisms; Chin-Hsing KuoJian S DaiJian S Dai Surgical education and skill training Demanding learning curve Surgical training & education  Skills labs  Fundamentals of Laparoscopic Surgery  Simulators  Video education  Tele-mentoring Cleveland Clinic Foundation Laparoscopic Colectomy CUSUM analysis Learning Curve: 62 cases for left-sided lap colon resections Tekkis, Paris P. MD, FRCS*†; Senagore, Antony J. MD, MS, FACS‡; Delaney, Conor P. MCh, PhD, FRCSI§; Fazio, Victor W. MD, MS*. Evaluation of the Learning Curve in Laparoscopic Colorectal Surgery: Comparison of Right-Sided and Left-Sided Resections. Annals of Surgery 242(1):p 83-91, July 2005. | Surgical technology    Imaging  HD → 4K → 3D  NIR Fluorescent imaging  Augmented Reality Instrument functionality  Specialized instruments  Articulated instruments  Robotic assisted surgery Energy sources  Electrocoagulation  Laser  Ultrasound  Radio frequency / microwave https://www.jnjmedtech.com/en-EMEA/product-family/surgical-stapling https://www.karlstorz.com/cps/rde/xbcr/karlstorz_assets/ASSETS/3331211.pdf Laparoscopic surgery Showcase of a laparoscopic procedure  Laparoscopic umbilical hernia repair  Pneumoperitoneum with Veress Needle  Insertion or optical trocar with camera  Two working trocars  Reduction of hernia sac and suturing of neck  Intraperitoneal mesh fixation Single Incision Laparoscopic Surgery (SILS)  Only one (bigger) incision  Specialized port with multiple channels  Curved instruments to avoid conflict  Crossing of instruments  Applications  SILS appendectomy  SILS cholecystectomy  SILS colectomy with stoma Endoscopic Surgery  Flexible endoscope  Rigid Surgical platform Mavrogenis G, Ntourakis D, Kritikos N, Kasapidis P, Kaklamanis L, Kouloulias V, Bazerbachi F. Salvage endoscopic wide-field full-thickness resection of T2 rectal cancer with endoscopic submucosal dissection instruments, without defect closure. Endoscopy. 2023 Dec;55(S 01):E751-E752. doi: 10.1055/a-2081-9081. Epub 2023 Jun 7. PMID: 37286179; PMCID: PMC10247307. Normal Orifice Translumenal Surgery (NOTES)  Endoscope introduced through normal orifice (mouth, anus, vagina)  Incision of the visceral wall to access the peritoneal cavity  Performance of the operation through the hole and retraction of specimen  Closure of visceral opening  Applications:  Cholecystectomy  Transanal Total Mesorectal Excision (TaTME) Robotic Assisted Surgery  Create by American army for tele-surgery  Trans-Atlantic operation in 2001 (Lindberg procedure)  Applied to urologic, gynecologic, colorectal surgery, and complex abdominal wall reconstruction  Increased procedure cost  Doubts about superiority in simple procedures https://www.ircad.fr/le-geste-chirurgical-a-traverse-latlantique/ https://www.youtube.com/watch?v=wWVgA19WRTo Kalata S, Thumma JR, Norton EC, Dimick JB, Sheetz KH. Comparative Safety of Robotic-Assisted vs Laparoscopic Cholecystectomy. JAMA Surg. 2023 Dec 1;158(12):1303-1310. Image Guided Surgery & Augmented Reality in Surgery  Multiple imaging modalities (US, CT, MRI)  Image processing (3D modeling, fusion)  Fluorescent imaging  Imaging during surgery Hybrid Surgery  Combination of different techniques  Laparoscopy  Endoscopy  Ultrasound imaging  X-ray imaging Enhanced Recovery After Surgery (ERAS)  Multimodal perioperative care pathway  Aims to achieve early recovery for patients undergoing major surgery  Paradigm shift in perioperative care  Re-examines traditional practices   Use of evidence-based best practices Comprehensive in its scope  covering all areas of the patient’s journey  Preoperative  Intraoperative  Postoperative https://erassociety.org/guidelines/ https://clinicalview.gehealthcare.com/article/eras-protocols-are-they-right-every-surgery Enhanced Recovery After Surgery (ERAS)  ERAS components  Preoperative (patient optimization)  Intraoperative (anesthesia and surgical technique)  Postoperative (early return to normal function) https://erassociety.org/guidelines/ https://clinicalview.gehealthcare.com/article/eras-protocols-are-they-right-every-surgery Enhanced Recovery After Surgery (ERAS) results  Systematic reviews & Meta-analyses   Colorectal surgery  Decreased hospitalization (MD - 2.49, 95% CI - 4.11 to 0.88)  + Lower morbidity (OR 0.38, 95% CI 0.25-0.59)  + Earlier return of bowel function Gastric surgery  + Lower cost (WMD-USD$ 4400, 95% CI - USD$ 5580 to - USD$ 3210)  + reduced stress response (CRP, IL-6, TNF-a)  - increased readmission rate (RR = 1.95, 95% CI 1.03-3.67) Zhou J, Du R, Wang L, Wang F, Li D, Tong G, Wang W, Ding X, Wang D. The Application of Enhanced Recovery After Surgery (ERAS) for Patients Undergoing Bariatric Surgery: a Systematic Review and Meta-analysis. Obes Surg. 2021 Mar;31(3):1321-1331. doi: 10.1007/s11695-020-05209-5. Epub 2021 Jan 9. PMID: 33420977. Tan JKH, Ang JJ, Chan DKH. Enhanced recovery program versus conventional care after colorectal surgery in the geriatric population: a systematic review and metaanalysis. Surg Endosc. 2021 Jun;35(6):3166-3174. doi: 10.1007/s00464-020-07673-7. Epub 2020 May 28. PMID: 32468264. Colorectal Surgery: Figure 2: Forest plot comparing post-operative morbidity rate between ERAS and Non-ERAS group. Figure 3 Forest plot comparing length of stay between ERAS and Non-ERAS group. Figure 4 Forest plot comparing time to flatus between ERAS and Non-ERAS group Questions? Conclusions  In minimally invasive surgery access trauma is minimized without compromising the quality of the surgical procedure.  CO2 is used for insufflation in laparoscopy resulting in unique pathophysiologic consequences.  Robotic surgery has been most valuable in the performance of minimally invasive urologic, gynecologic, colorectal, and complex abdominal wall reconstruction procedures but has a higher cost.  Single-incision laparoscopic surgery, Natural orifice translumenal surgery, and endoscopic surgery reduce or eliminate the amount of abdominal wall trauma but have unique challenges to ergonomics and surgical wound healing.  Image guided surgery and augmented reality can help the surgeon map the procedure and receive important information during surgery (surgical GPS).  Minimally invasive surgery requires practice and training in addition to conventional surgery. Simulation laboratories and structured exercise training are necessary.