Principles of Minimal Access Surgery PDF

Bailey & Love Bailey & Love Bailey & Love Bailey PART& Loveprinciples 1 | Basic Bailey & Love Bailey & Love CH A P T E R 10 Principles of minimal access surgery Learning objectives To understand: The principle...

Bailey & Love Bailey & Love Bailey & Love Bailey PART& Loveprinciples 1 | Basic Bailey & Love Bailey & Love CH A P T E R 10 Principles of minimal access surgery Learning objectives To understand: The principles of minimal access surgery The perioperative assessment of patients undergoing The advantages and disadvantages of minimal access minimal access surgery approaches Novel advances in minimal access surgery and its The safety issues and indications for minimal access adjuncts surgery The application of artifcial intelligence to minimal access surgery DEFINITION Thoracoscopy Minimal access surgery is a product of modern technology A rigid endoscope is introduced through an incision placed and surgical innovation that aims to accomplish surgical ther- between the ribs to gain access to the thorax. In the majority apeutic goals with minimal somatic and psychological trauma. of cases, specialist anaesthetic support is required to ensure This type of surgery has reduced wound access trauma and isolation of the lung on the side of surgery, enabling the is less disfguring than conventional techniques. It can ofer patient to be ventilated only on the non-operative side. This cost-efectiveness to both health services and employers by is achieved through the use of right- or left-sided double shortening operating times, shortening hospital stays, improv- lumen endotracheal tubes that comprise both a bronchial ing operative precision compared with open surgery in some and a tracheal lumen. Usually there is no requirement for gas (but not all) cases and allowing faster recuperation. insufation as the operating space is held open by the rigidity of the thoracic cavity. In specifc cases, such as mediastinal History of minimal access surgery tumour resection and diaphragmatic surgery, gas insufation at low pressure (5–8 mmHg) may be applied. Further infor- The frst experimental laparoscopic procedure was performed mation on the general principles of thoracoscopy are found by Kelling in 1901. Jacobaeus performed the frst thoracoscopy in Chapter 60. in 1910, again using a cystoscope; however, it took another 70 years before Steptoe in the UK developed laparoscopy for treatment of infertility and Mouret performed the frst Single-incision minimal access surgery video-laparoscopic cholecystectomy in 1987. Since laparo- scopic techniques became widely adopted in the mid-1990s, Single-incision minimal access surgery has varied in popularity minimal access surgery has developed into a multidisciplinary with both strong advocates and others who are sceptical of approach that crosses all traditional specialty boundaries and any advantages. Single-incision laparoscopic surgery (SILS) serves the patient as a whole and not specifc organ systems. involves insertion of all instrumentation through a multiple channel port via a single incision at the umbilicus. The benefts are that the incision, through a natural scar (the umbilicus), is MINIMAL ACCESS APPROACHES virtually ‘scarless’ and that fewer port sites potentially reduces pain and lessens the risks of port site bleeding and the potential Laparoscopy for port site hernia. A rigid endoscope is introduced through a port into the perito- SILS requires specially manufactured multichannel ports neal cavity. Full details of laparoscopy including the principles and often roticulating instruments. It has most commonly been of pneumoperitoneum can be found in Chapter 7. adopted in gallbladder and hernia surgery, although more Georg Kelling, 1866–1945, surgeon, Dresden, Germany, performed the frst ‘celioscopy’ on a dog in 1901 using air insufation and a Nitze-cystoscope. Hans Christian Jacobaeus, 1879–1937, physician, Karolinska Institutet, Sweden. Patrick Christopher Steptoe, 1913–1988 gynaecologist, Oldham, UK, a pioneer of in vitro fertilisation. Phillippe Mouret, 1938–2008, surgeon, Lyon, France. 01_10_B&L28_Pt1_Ch10_5th.indd 162 31/08/2022 10:31 ve PART 1 | BASIC PRINCIPLES Minimal access approaches 163 ve complex colon and rectal surgery can be performed. There remains debate as to whether the increased procedural dif- Arthroscopy and intra-articular joint culty, steep learning curve and increased direct costs in terms surgery of devices, instruments and operating time can be ofset by Arthroscopy was one of the earliest applications of endoscopic signifcant clinical beneft. techniques, frst being applied in the knee as early as the 1930s. Uniportal thoracic surgery requires less specialist equip- In the 1950s Watanabe developed arthroscopic techniques that ment; many minor thoracic procedures are commonly per- have evolved such that shoulder, wrist, elbow and hip arthros- formed using this technique. More complex resectional copy is now commonplace. Novel approaches to smaller joints procedures are less commonly performed, largely because of such as the temporomandibular and metatarsal joints are being technical complexity when compared with multiport tech- developed. niques, which are on the whole very well tolerated. Hybrid minimal access surgery Endoluminal endoscopy and natural Hybrid surgery may utilise a combination of fexible and orifce surgery straight stick endoscopic approaches or a combination of open and endoscopic surgery. Flexible or rigid endoscopes are introduced into hollow organs or systems, such as the urinary tract, upper or lower Totally endoscopic hybrid approach gastrointestinal tract and the respiratory and vascular systems. The diseased organ is visualised and treated by an assortment Advances in endoluminal technology now enable more of endoluminal and extraluminal endoscopes and other complex procedures to be completed endoscopically where imaging devices. In the abdomen, examples include the previous transabdominal or transthoracic surgical resection combined laparo-endoscopic approach for the management would have been advocated. Examples include endoscopic of biliary lithiasis, colonic polyp excision and several urological submucosal resection of complex colonic polyps, transanal procedures, such as pyeloplasty and donor nephrectomy. In endoscopic microsurgery and endobronchial laser resection of the thorax, navigational bronchoscopy with placement of tracheal pathology. fducial markers has been employed as a means of marking Natural orifce translumenal endoscopic surgery (NOTES) lung nodules that can then be resected via a minimal access ofers the opportunity for ‘scar-free’ surgery by performing video-assisted approach. Cardiovascular surgeons have entire procedures via natural body orifces. While these tech- for some time employed hybrid technologies to facilitate niques have been applied in the pelvis, abdomen and thorax, catheter-based placement of cardiac valves, atrial devices and technical limitations and safety concerns have limited adop- intravascular stents. tion. Concern over closure of the visceral puncture site is the Hybrid techniques ofer improved visualisation, facilitating principal issue that has prevented widespread uptake, as trans- the primary procedure to be carried out either via a smaller gastric and transcolonic closure of peritoneal entry sites in a incision or a minimal access approach where otherwise open safe manner remains problematic. In addition, there are sig- surgery would have been necessary. Such approaches may nifcant cost and training implications that have limited more necessitate the availability of ‘hybrid’ theatre facilities, limit- widespread adoption. ing this approach to tertiary centres where such technology is available (Figure 10.1). Perivisceral endoscopy Open and endoscopic hybrid approach Body planes can be accessed even in the absence of a natural Hand-assisted laparoscopic surgery (HALS) is a well-developed cavity. Examples are mediastinoscopy, retroperitoneoscopy technique. It involves the intra-abdominal placement of a and retroperitoneal approaches to the kidney, aorta and lumbar sympathetic chain. Some of these approaches have been in place for many years (cervical mediastinoscopy was frst performed in 1959); however, the availability of novel videoscopes has enhanced visualisation, thus improving the safety and accuracy of dissection. Extraperitoneal approaches to the retroperitoneal organs, as well as hernia repair, are now commonplace, further decreasing morbidity associated with manipulation of the visceral peritoneum. Other examples include subfascial endoscopic perforator surgery for ligation of incompetent perforating veins in varicose vein surgery and endoscopic harvesting of the saphenous vein for use in coronary artery Figure 10.1 Modern hybrid theatre set-up (courtesy of Mr Kelvin Lau, bypass grafting. Barts Thorax Centre, London, UK). Masaki Watanabe, 1911–1995, orthopaedic surgeon, Tokyo, Japan, known as the ‘founder of modern arthroscopy’. 01_10_B&L28_Pt1_Ch10_5th.indd 163 31/08/2022 10:31  PART 1 | BASIC PRINCIPLES 164 CHAPTER 10 Principles of minimal access surgery hand or forearm through a minilaparotomy incision, while pneumoperitoneum is maintained. In this way, the surgeon’s Summary box 10.1 hand can be used as in an open procedure. It can be used to Advantages of minimal access surgery palpate organs or tumours, refect organs atraumatically, retract Decrease in wound size structures, identify vessels, dissect bluntly along a tissue plane Reduction in wound infection, dehiscence, bleeding, herniation and provide fnger pressure to bleeding points, while proximal and nerve entrapment control is achieved. This approach has been suggested to ofer Decrease in wound pain technical and economic efciency when compared with a Improved mobility totally laparoscopic approach, in some instances reducing both Decreased wound trauma the number of laparoscopic ports and the number of instru- Decreased heat loss ments required. Indeed, some advocates argue that if such Improved visualisation an incision is necessary for extraction of the fnal specimen then HALS does not signifcantly increase surgical trauma over totally laparoscopic approaches. Furthermore, for those trained in open surgery it may be easier to learn and perform LIMITATIONS OF MINIMAL ACCESS than totally laparoscopic approaches, subsequently improving patient safety. With the new generation of surgeons training SURGERY in totally laparoscopic surgery it is likely that use of HALS Minimal access surgery has limitations. A number of these will diminish, although it should remain part of the minimally have been addressed with advances in instrumentation and invasive surgeon’s armamentarium. endoscopic systems; however, the basic principles remain. Surgical robots further address a number of these limitations but present novel challenges. SURGICAL TRAUMA IN OPEN, MINIMALLY INVASIVE AND Endoscopic surgery ROBOTIC SURGERY Lack of three-dimensional vision Most of the trauma of an open procedure is inficted because To perform minimal access surgery with safety, the surgeon the surgeon must have a wound that is large enough to give must operate using an imaging system that provides a adequate exposure for safe dissection at a target site. The two-dimensional (2D) representation of the operative site. wound is often the cause of morbidity, including infection, The endoscope ofers a whole new anatomical landscape, dehiscence, bleeding, herniation and nerve entrapment. which the surgeon must learn to navigate without the usual Wound pain prolongs recovery time and, by reducing mobility, ‘open approach’ clues that make it easy to judge depth. The contributes to an increased incidence of pulmonary atelectasis, instruments are longer and sometimes more complex to use chest infection, paralytic ileus and deep venous thrombosis. than those commonly used in open surgery. This results in Mechanical and human retractors cause additional trauma. the novice being faced with signifcant problems of hand–eye Body wall retractors can infict localised damage that may be as coordination. There is a well-described learning curve for painful as the wound itself. In contrast, during laparoscopy, the novice surgeons and experienced ‘open’ surgeons when adopt- retraction is provided by the low-pressure pneumoperitoneum, ing the minimally invasive approach. Simulation training and giving a difuse force applied gently and evenly over the whole mentoring are required to attain competence. body wall, causing minimal trauma. Three-dimensional (3D) imaging systems are available but Exposure of any body cavity to the atmosphere also causes are expensive and currently are not commonplace. Many sur- morbidity through cooling and fuid loss by evaporation. The geons feel that endoscopic 3D technology does not yet ofer the incidence of postsurgical adhesions is reduced by use of mini- technical enhancement necessary to improve safety. Indeed, mally invasive approaches because there is less damage to del- 3D technology has been associated with ergonomic problems icate serosal coverings. In the manual handling of intestinal such as headache without quantifable beneft in terms of accu- loops, the surgeon and assistant disturb the peristaltic activity racy and time to perform directed tasks. Future improvements of the gut and provoke adynamic ileus. in these systems carry the potential to enhance manipulative While minimal access methods were initially established in ability in critical procedures, such as knot tying and dissection elective surgery, the advantages have led to increased uptake of closely overlapping tissues. There are, however, some draw- for a number of emergency surgical procedures, including backs, such as reduced display brightness and interference with perforated viscus repair, such as omental patch repair of a normal vision because of the need to wear specially designed peptic ulcer perforation, lavage of localised perforation of glasses for some systems. It is likely that brighter projection diverticular disease, intrathoracic debridement of empyema displays will be developed; however, the need to wear glasses is and pneumothorax and haemothorax surgery. More recently, not easily overcome. These factors currently limit stereoscopic some experienced surgeons have chosen to employ minimal straight stick endoscopic surgery, which has largely been super- access approaches to trauma situations for initial assessment seded by the development of robotic technology incorporating and treatment in stable patients. 3D vision. 01_10_B&L28_Pt1_Ch10_5th.indd 164 31/08/2022 10:31  PART 1 | BASIC PRINCIPLES Robotic surgery 165 Increased operative time they have the disadvantage of disrupting gross specimen Minimal access surgery can be more technically demanding morphology and cannot be used in surgery for malignancy. and slower to perform than conventional open surgery. On Typically, extraction is performed by enlarging one incision occasion, a minimally invasive operation is so technically so as to facilitate removal without disruption to the specimen. demanding that both patient and surgeon would be better Strategies to reduce surgical trauma have been considered. served by conversion to an open procedure. Prolonged These include removal of lung via a subxiphoid approach so as anaesthetic and operative times may negate a number of to reduce intercostal neuropraxia or natural orifce extraction the benefcial efects of minimal access surgery and increase of abdominal resection specimens. However, such approaches the risk of respiratory and wound complications as well as are themselves associated with diferent complications such as compression neuropathy and venous thromboembolism. It is herniation and injury to structures outside the direct operative vital for surgeons and patients to appreciate that the decision to feld. convert to an open operation is not a complication but, instead, While tumour implantation and localisation at port sites usually implies sound surgical judgement in favour of patient initially raised important questions about the future of the safety. laparoscopic treatment of malignancy, large-scale trials have shown concerns to be minimised by appropriate tissue han- Control of bleeding and haemostasis dling, separating any tumours by bagging, irrigation and pro- Haemostasis may be difcult to achieve endoscopically because tecting the extraction site. blood may obscure the feld of vision with reduced image quality Cost owing to light absorption. Experienced surgeons may be able to manage a degree of bleeding via an endoscopic approach; Initially high consumable costs and factors such as surgical however, this requires a signifcant degree of experience and learning curve and high conversion rates led to increased skill to be achieved safely. Such scenarios are also reliant on an costs of minimal access approaches compared with their open experienced assistant able to reduce visual loss through optimal equivalents. This is now largely no longer the case for straight camera positioning. It should be remembered that a situation stick endoscopic surgery such as laparoscopy and thoracoscopy. of controlled conversion can easily become uncontrolled, Indeed, despite higher direct consumable costs, improvements negating any beneft a minimally access approach would have in outcomes, hospital stay and general upscaling of the proce- achieved. dural volume have resulted in improved cost-efectiveness for Advanced electrosurgery/diathermy and laser technology many minimal access procedures. have improved dissection precision and haemostatic efcacy Future reductions in the costs of image-processing technol- in endoscopic surgery. Ultrasonic dissection and tissue fusion ogy will result in a wide range of transformed presentations devices continue to evolve with incremental technical improve- becoming available. It should ultimately be possible for a sur- ments and surgeons are increasingly familiar with their use. geon to access any view of the operative region accessible to a Some devices now combine the functions of three or four sep- camera and present it stereoscopically in any size or orienta- arate instruments, reducing the need for instrument exchanges tion, superimposed on past images taken in other modalities. during a procedure. This fexibility, combined with the abil- Such augmented reality systems continue to improve and are ity to provide a clean, smoke-free feld, facilitates dissection, discussed in more detail below. improves haemostasis and reduces operating times. Loss of tactile feedback Summary box 10.2 Minimal access surgery is associated with some loss of tactile Limitations of minimal access surgery feedback, although this is less with straight stick endoscopy than Lack of 3D vision with robotic procedures. This is an area of ongoing research Loss of tactile feedback in haptics and biofeedback systems. Early work suggested that Haemostasis laparoscopic ultrasonography might be a substitute for the Extraction of large specimens need to ‘feel’ in intraoperative decision-making. Rather than Learning curve and increased operative time producing tactile feedback, endoscopic ultrasound provides a Cost visual representation of structures that in open surgery would Reliance on new technologies rely on palpation for accurate localisation and appraisal. Widely used examples include appraisal of nodal disease in cancer surgery and biliary tract exploration. Tissue extraction ROBOTIC SURGERY Large pieces of tissue, such as the lung or colon, may have to A robot is a mechanical device that performs automated phys- be extracted from the body cavity following resection. In some ical tasks according to direct human supervision, a predefned circumstances this signifcantly increases the surgical trauma program or a set of general guidelines, using artifcial intel- of the procedure that could otherwise be carried out via two ligence (AI) technology. In surgery, robots can be used to or three small port incisions. Although tissue ‘morcellators, assist surgeons to perform operative procedures, primarily in mincers and liquidisers’ can be used in some circumstances, the form of automated camera systems and telemanipulator 01_10_B&L28_Pt1_Ch10_5th.indd 165 31/08/2022 10:31  PART 1 | BASIC PRINCIPLES 166 CHAPTER 10 Principles of minimal access surgery systems, thus resulting in the creation of a human–machine superseded by the advent of wider laparoscopy and thoracos- interface. Reduced degrees of freedom of movement and copy, which became increasingly commonplace across during difcult ergonomic positioning for the surgeon can limit the the 1990s and 2000s. application of straight stick endoscopy to a number of special- In 1992, Computer Motion developed the AESOP (Auto- ties owing to a loss in surgical precision. This has driven the mated Endoscopic System for Optimal Positioning) system, uptake of robotic surgical systems, currently existing as two which mounted the endoscopic camera on a single robotic main categories: arm, allowing the surgeon to control it remotely via voice com- mand. The system was widely used in cholecystectomy and Teleoperated (master–slave) systems: a surgeon hernia surgery and for harvesting the mammary conduit in performs an operation via a robot and its robotic instru- coronary artery bypass. This was followed by the development ments through a televisual computerised platform (where of the ZEUS robot in 1996, a master–slave teleoperated system the surgeon is the master, i.e. the operator, and the robot is that provided three robotic arms, one for the voice-controlled the slave). This may be via onsite connections or remotely endoscope and two further instrument arms. The surgeon was through the internet or other digital channels – hence the positioned at a remote console and the device was capable of publicity of ‘operating on a patient from another country’ motion scaling and tremor correction, facilitating its use for (such ‘remote’ operations are currently rarely performed microsurgical procedures. ZEUS was used for the frst fully but their existence is established). endoscopic robotic surgical procedure, the reanastomosis of Active or semiactive systems: these are typically a Fallopian tube in 1998. The frst remote surgical procedure image-guided or pre-programmed. In active sys- was performed in 2001, also utilising the ZEUS system. Here tems, a surgical robot completes a pre-programmed surgical a cholecystectomy was performed on a patient in Paris by a task. This is guided by preoperative imaging and real-time surgeon in New York, demonstrating the feasibility of remote anatomical constraints and cues through the application operating. ZEUS was discontinued in 2003 after the merger of of in-built navigation systems. In semiactive systems, the Computer Motion with Intuitive Surgical. robotic device may be in part pre-programmed and in part The current era of surgical robots is dominated by the da surgeon driven. Vinci® surgical system, which was frst approved for clinical use in 2000. The system ofers a number of advantages, including 3D surgical vision, EndoWrist® precision instruments, tremor History of robotic surgery reduction, motion scaling and improved ergonomics. The ini- The frst documented clinical robotic procedure was a tial system was released in 1999 and provided three robotic computed tomography (CT)-guided brain biopsy performed arms, one of which held the endoscope. This was upgraded to in 1985 utilising the PUMA (Programmable Universal the da Vinci S (2006), the da Vinci Si (2009) and subsequently Machine for Assembly) 560 system. This was followed by the the da Vinci Xi in 2014 (Figure 10.2). With each iteration ROBODOC, a pre-programmed active robot that enabled came improvements in vision and instrumentation, along with precise preparation of the femoral implant cavity during hip which came integrated fuorescence imaging. More recently, replacement. The beneft of such a device was the ability to novel technologies include the development of a single port perform tasks to a high degree of accuracy, thus minimising system (da Vinci SP), which combines multijointed wristed error and variation. While this and other active surgical robots instrumentation with a wristed camera through a single port demonstrated a number of advantages, they were largely to further improve dexterity and minimise surgical trauma. (a) (b) (c) Figure 10.2 The da Vinci Xi system: (a) surgeon console; (b) da Vinci Xi robot; (c) vision cart (courtesy of Intuitive Surgical). 01_10_B&L28_Pt1_Ch10_5th.indd 166 31/08/2022 10:31  PART 1 | BASIC PRINCIPLES Robotic surgery 167 Advantages of robotic surgery to ft the individual profle of the operator, thus reducing phys- ical stress and fatigue. The enclosed console system of many Surgical robots have been considered to ofer many benefts, robotic systems also provides the advantage of surgical isolation which have arisen as a result of new technology in lenses, from external distractions that may impact on the operator’s cameras and computer software. Just as laparoscopic surgery concentration. The disadvantage is reduced awareness of benefted from advances in light technology allowing the non-verbal communication, thus highlighting the importance targeted transmission of light down tubing, robotic surgery of team training and regular verbal cues. benefts from computer integration of mechanical (surgical) arms that have paved the way for computer-integrated surgery. Motion compensation Although not commonplace in current clinical practice, robotic Vision surgical systems may in future provide motion compensation Modern robotic camera systems ofer 3D high-defnition imag- to facilitate surgery on a moving target. Examples where this ing, providing stereoscopic vision with true depth perception may be benefcial are in beating heart cardiac surgery, such as that enhances the visualisation of tissue planes and key struc- coronary artery bypass grafting and mitral valve repair. In this tures. Multiport systems typically employ a rigid endoscope setting, the increased dexterity of robotic surgery combined with or without angulation. As with conventional endoscopes, with removing the need for cardioplegia and cross-clamping angulation to 30° allows for a wider range of vision through may be particularly benefcial in terms of reducing the post- manipulation of the camera position, which, in the case of operative infammatory response and improving its associated robotic surgery, can be controlled by the surgeon at the console morbidity. or, if required, by the assistant at the bedside. A reference horizon is commonly provided to the surgeon at the console system so as to maintain orientation throughout the procedure. Disadvantages of robotic surgery More recently, modern single-port systems such as the da Vinci Cost SP employ a wristed camera system that, in combination with Robotic surgery remains more costly than minimally invasive fully wristed instruments, may allow for operative triangulation alternatives. Through upscaling of use between surgical while at the same time maintaining a small, single skin incision. specialties, the direct costs of purchasing a novel robotic system Manoeuvrability, motion scaling and tremor can be partially ofset; however, consumable costs remain high. When compared with open techniques, robotic surgical suppression procedures can reduce hospital stay, thus in part ofsetting Improved manoeuvring as a result of the ‘robotic wrist’ this expenditure; however, it remains difcult to demonstrate in some systems allows for up to seven degrees of freedom, signifcant improvement in length of stay or clinical outcomes thus improving dexterity for the surgeon. This has particular when compared with other minimally invasive alternatives. benefts in felds with signifcant space restraints such as Another consideration is the increased operating time and transoral surgery, where conventional laparoscopy has limited overall learning curve requirement when establishing a robotic applicability. Furthermore, the increased dexterity of surgical surgical programme. While some specialties have reported robots may facilitate a minimal access approach to more shorter learning curves than in the early days of laparoscopic complex procedures where the technical difculty of applying surgery, this is highly heterogeneous, across both specialties conventional laparoscopy may be prohibitive. As the motion and practitioners. Furthermore, although shared interspecialty of the surgeon’s hand is translated to the ‘slave’ motion of the robotic arm, modern surgical robots are able to scale down large external movements of the surgical hands to limited internal movements. At the same time, the computer may flter out tremor in the surgeon’s hands, thus ensuring stability of the instrument tips and enhancing surgical precision. Ergonomics Although the advent of straight stick laparoscopic surgery had many advantages for the patient, for the surgeon there was a trade-of in terms of operative ergonomics. Increased operative time in addition to unergonomic positioning can result in signifcant physical discomfort for the surgeon. This is particularly true in specialties such as bariatric surgery, where the patient’s body habitus and the use of long, fulcrumed instruments puts further strain on the surgeon’s back, neck and upper arms. The advent of robotic surgery vastly improves Figure 10.3 Robotic theatre set-up demonstrating the da Vinci Xi sys- upon the ergonomic environment for the surgeon; in the case tem. The surgeon and trainee surgeon are positioned at joint consoles of many of the current master–slave systems, allowing for the remote from the operating table with the surgical assistant and scrub surgeon to be seated at a console remote from the operating nurse at the bedside (courtesy of Mr Tom Routledge, Guy’s and St table (Figure 10.3). The console positioning can be optimised Thomas’ NHS Foundation Trust, London, UK). 01_10_B&L28_Pt1_Ch10_5th.indd 167 31/08/2022 10:31  PART 1 | BASIC PRINCIPLES 168 CHAPTER 10 Principles of minimal access surgery use increases cost-efectiveness for the institution, it also conse- laparoscopic trocars so as to reduce consumable cost. This quently reduces the access opportunities for each individual system also creates familiarity with conventional laparoscopy user, potentially prolonging the learning curve. and facilitates hybrid techniques where this may be benefcial. Surgery is enhanced though a 3D-HD system with the use of 3D glasses and eye-tracking camera control. Uptake of robotic surgery As the feld of robotic surgery continues to expand and Many surgical specialties have embraced robot-assisted innovate, there also remain a number of systems in devel- techniques, including general surgery, cardiothoracic surgery, opment that are not yet approved for clinical use. Examples urology, orthopaedics, ear, nose and throat surgery, gynaecol- similar to existing technologies include the Medtronic Hugo ogy and paediatric surgery. Specialties that use microsurgical Robotic-Assisted Surgery (RAS) system, which was launched techniques also beneft from this technology. Current robotic in late 2019. This modular system aims to provide a lower cost systems were designed to ofer multifunctionality, including alternative by means of a more readily upgradeable model that multianatomy and specialty capability in both operating may be used fexibly across surgical specialties and procedures. theatre and remote environments. Currently, despite a small Moving forward, companies such as Verb Surgical strive to number of reports of remote surgical procedures, robotic build on the currently dominant master–slave model, incorpo- surgery remains focused on in-house operating. rating robotic autonomy and machine learning. While this may in time revolutionise robotic surgery, such technologies remain New entrants in the early phase of development. In 2017, Intuitive Surgical released the da Vinci X, a low-cost entry point in its robotic surgical portfolio that includes features of the Xi while sacrifcing some fexibility in terms of multi- Direct robotic systems and hybrid quadrant surgery. In the same year, Korean company Meere robotic surgery gained a licence for the use of its surgical robot, the REVO-I, In addition to the remote master–slave platform design, direct by the local Ministry for Food and Drug Safety. Similar to the robot systems also exist. Each of these systems ofers diferent da Vinci, this four-arm robot is mounted on a single cart. The advantages to the operating surgeon, ranging from reducing the surgeon is seated at an open vision cart and, by use of 3D glasses, need for assistants and providing better ergonomic operating can achieve three-dimensional high-defnition (3D-HD) vision. positions to providing experienced guidance from surgeons not In March 2019, CMR Surgical received a European CE mark physically present in the operating theatre. Examples include: for its novel modular robot, the Versius (Figure 10.4). This system incorporates individual cart-mounted modular robotic tremor suppression robots; arms that can be confgured to ft the procedure and the active guidance systems; operating room environment. The design difers from other articulated mechatronic devices; robotic arms in that it aims to more closely mimic a human force control systems; arm, improving freedom of port placement. Its vision cart haptic feedback devices. similarly allows for ergonomic operating with 3D-HD vision, through the use of 3D glasses. PERIOPERATIVE PLANNING FOR Bridging the gap between laparoscopic and robotic surgery the Senhance® robotic system received its CE mark in 2016. MINIMAL ACCESS SURGERY In order to reduce cost and sustain familiarity with conven- tional laparoscopy, the system uses independent robotic arms Preparation of the patient mounted on separate carts that can be placed in accordance Although the patient may be in hospital for a shorter period, with the procedure required. The system utilises reusable non- careful preoperative management is essential to minimise wristed instruments that can be inserted through standard morbidity. Recognition of patient- or procedure-related factors that may in turn complicate a minimal access approach is vital to optimise outcomes. History Patients must be ft for general anaesthesia and open operation if necessary. Potential coagulation disorders are particularly dangerous in minimal access surgery where options for haemostasis may be more limited. A prior history of surgical intervention in the same area is vitally important and should be carefully documented, so as to best predict factors such as adhesions that may preclude a minimal access approach. Previous oncological treatment can also create a more hostile surgical environment and an appropriate threshold for conver- sion to open access should be set prior to the procedure and Figure 10.4 The Versius robotic system (courtesy of CMR Surgical). communicated clearly with the patient. 01_10_B&L28_Pt1_Ch10_5th.indd 168 31/08/2022 10:31  PART 1 | BASIC PRINCIPLES General intraoperative principles 169 the patient has fasted and has recently emptied their bladder, Summary box 10.3 particularly before creating pneumoperitoneum for minimal access surgery approaches to the abdomen. Preparation for minimal access surgery Overall ftness: cardiac arrhythmia, lung function, medications, Informed consent allergies Previous surgery or oncological intervention: scars, adhesions It is essential that the patient understands the nature of the Body habitus: obesity, skeletal deformity procedure, the risks involved and, when appropriate, the Normal coagulation alternatives that are available. A locally prepared explanatory Thromboprophylaxis booklet concerning the minimal access procedure to be under- Informed consent taken is extremely useful (Chapter 14). The patient should Operative diffculty is predicted when possible with appropriate understand that the procedure may be converted to an open risk model operation. Common complications should be mentioned, such Appropriate theatre time and facilities are available (especially as shoulder tip pain and minor surgical emphysema, as well important for robotic cases) as rare but serious complications, such as inadvertent visceral injury from trocar insertion or diathermy. Patients may also have specifc questions or requests in terms of the application of minimal access surgery. It is important to be considerate Examination and address these. Some patients remain concerned about the Routine preoperative physical examination is required as for application of technology, particularly robotics, to their care any major operation. Although, in general, minimal access and it is important to ensure they understand and agree with surgery allows quicker recovery, it may involve longer operat- the proposed surgical approach. ing times and carbon dioxide insufation in both the chest and abdomen may provoke cardiac arrhythmias. Severe chronic obstructive airways disease and ischaemic heart disease may THEATRE SET-UP AND TOOLS be contraindications to a minimal access approach. Moderate Operating theatre design is key to efciency. Modern theatres obesity does not increase operative difculty signifcantly, but are designed with moveable booms for video, diathermy and morbid obesity may require specialist instrumentation and laparoscopic equipment with at least two high-resolution, trocars. Patients with a particularly low body mass index and high-defnition (HD) or ultra-high-defnition (4K) monitors, small body habitus may present separate challenges in terms a carbon dioxide supply and fow monitor and appropriate of port placement, particularly when adopting a robotic audiovisual kit (Figure 10.1). approach. Severe spinal deformity including kyphosis and Image quality is vital to the success of minimal access scoliosis may present problems in terms of positioning as well surgery. New camera and lens technology allows the use of as impact on overall recovery if there are associated problems smaller cameras while maintaining excellent resolution. Auto- with sputum clearance and mobility. matic focusing and charge-coupled devices (CCDs) are used to detect diferent levels of brightness and adjust for the best Prophylaxis against thromboembolism image possible. Venous stasis induced by the reverse Trendelenburg position Efcient teamwork is crucial for high-quality surgery and during laparoscopic surgery coupled with prolonged duration quick yet safe turnover. This is particularly important in robotic of operation are risk factors for deep vein thrombosis. Subcuta- surgery, where verbal interaction between all team members is neous low-molecular-weight heparin and antithromboembolic paramount throughout the procedure. The robotic team must stockings should be used routinely in addition to pneumatic carefully rehearse protocols for both controlled and uncon- calf compression during the operation. Patients already taking trolled conversion in the event of emergency. anticoagulation should have this stopped temporarily or, where appropriate, be converted to intravenous or subcutaneous GENERAL INTRAOPERATIVE heparin, depending on the underlying condition and local thromboprophylaxis protocols. In most cases patients can PRINCIPLES continue on aspirin when the benefts outweigh the slight Many minimal access procedures have a unique set of proce- increase in bleeding potential. dural steps that may often be in a distinctly diferent sequence from those of the open alternative. Urinary catheters and nasogastric tubes Methods for creating a pneumoperitoneum are described In the early days of minimal access surgery, routine bladder in Chapter 7. Preoperative evaluation is necessary to assess the catheterisation and nasogastric intubation were advised. Most type and location of surgical scars and potential for perivisceral surgeons now omit these in favour of enhanced recovery, adhesions. In the setting of redo surgery, trocar insertion may which has demonstrated benefts in terms of both length of be complex and should be performed by an open approach stay and morbidity outcomes. It remains essential to check that with direct visualisation on entry to the body cavity (abdomen Friedrich Trendelenburg, 1844–1924, Professor of Surgery successively at Rostock (1875–1882), Bonn (1882–1895), Leipzig (1895–1911), Germany. The Tren- delenburg position was frst described in 1885. 01_10_B&L28_Pt1_Ch10_5th.indd 169 31/08/2022 10:31  PART 1 | BASIC PRINCIPLES 170 CHAPTER 10 Principles of minimal access surgery or thorax). Before trocar insertion, the introduction of a fn- When the bleeding vessel can be identifed and grasped, con- gertip helps to ascertain penetration into the body cavity and trol may be achieved by clipping, stapling or use of an energy allows adhesions to be gently removed from the entry site. The device, depending on vessel size. Occasionally suturing may endoscopic camera may be used as a blunt dissector to tease be possible; however, this may be signifcantly more complex adhesions gently away and form a tunnel towards the quad- via a minimal access approach. When the vessel is not identi- rant where the operation is to take place. With experience, the fed, compression should be applied immediately with a blunt surgeon learns to diferentiate visually between thick adhesions instrument, a cotton swab or with the adjacent organ. Good that should be avoided and thin adhesions that would lead to suction and irrigation are of utmost importance. Once the a window into a free area. area has been cleaned, pressure should be released gradually In obese patients the location of some of the ports may to identify the site of bleeding. Insertion of an extra port may need to be modifed and, in some instances, larger and lon- be required. There should be no delay in converting to an open ger instruments may be necessary. It is important to recognise procedure when necessary. This is of particular importance in this preoperatively to ensure that adequate measures are put robotic surgery as some or all of the robotic arms may need to in place to ensure safe and efcient surgery when the patient be urgently undocked to facilitate the surgeon gaining bedside arrives. It is also important to consider the weight and dimen- access to the patient. The bedside assistant should be confdent sion restrictions of the operating table. In some cases, specialist to perform this process. It is sometimes appropriate for a single operating tables will be required (Chapter 68). robotic arm to be left in place to help maintain pressure on the bleeding vessel while direct access is achieved. Alternatively, pressure may be maintained via an assistant port (if present), Operative problems allowing the robot to be undocked completely and removed from the surgical feld. Intraoperative perforation of a viscus or vascular injury Bleeding from organs encountered during surgery Perforation of any viscus, such as bowel, is a potential hazard Excessive retraction can tear a visceral surface, resulting that may occur inadvertently and go unrecognised or be of a in bleeding. This is particularly so in robotic surgery, where severity that may require emergency conversion. The added instrument graspers have a small surface area, increasing time required for this to take place may result in increased the potential for injury to retracted tissue. Here rolled swabs blood loss and haemodynamic instability that would not have may be inserted into the surgical feld and held within the occurred should the same injury have occurred in an open grasper, producing a larger surface for retraction and reducing setting. With surgical experience, education, preparation and tissue injury. Surgicel® (absorbable fbrillar oxidised cellulose patient selection many of these emergencies and their resultant polymer) or other clot-promoting strips, tissue glues or other complications can be avoided. It is vital for the surgical team haemostatic agents may also be used to aid haemostasis, e.g. to both recognise its own limitations and continually refect from the gallbladder bed during cholecystectomy. throughout the procedure on the surgical progress and oper- ative difculty. Bleeding from a trocar site Bleeding from the trocar sites is usually treated by localised Bleeding diathermy or applying upwards and lateral pressure with Bleeding is the most common cause of conversion to open the trocar itself. Considerable bleeding may occur if a vessel surgery. The impact of light absorption is particularly import- such as the inferior epigastric or intercostal artery is injured. ant in robotic surgery, and regular haemostasis is paramount Haemostasis can be accomplished either by pressure or by to facilitate dissection and surgical progress. Risk factors that suturing the bleeding site. Devices such as the EndoClose™ predispose to increased bleeding include: may also be used to apply transabdominal sutures under direct laparoscopic view to close port sites that bleed. liver disease impacting on the production of vitamin When a bleeding vessel cannot be easily identifed, mass K-dependent clotting factors, e.g. cirrhosis, autoimmune ligation of the vessel around the port site can be performed. liver disease; This manoeuvre is accomplished by extending the skin incision infammatory conditions (acute cholecystitis, diverticulitis); by 3 mm at both ends of the bleeding trocar site wound. Two patients on anticoagulants; fgure-of-eight sutures are placed in the path of the vessel at coagulation defects: these may be contraindications to both both ends of the wound (Figure 10.5). Alternatively, pressure open and minimal access surgery and require thorough dis- can be applied using a Foley balloon catheter. The catheter cussion with haematology colleagues to determine, where is introduced into the abdominal cavity through the bleeding possible, how to optimise the patient for surgery. trocar site wound, the balloon is infated and traction is placed Damage to a large vessel requires immediate assessment of on the catheter, which is bolstered in place to keep it under ten- the magnitude and type of bleeding. It is paramount that as sion. The catheter is left in situ for 24 hours and then removed. soon as bleeding is identifed this is communicated clearly to If signifcant continuous bleeding from the falciform lig- all members of the theatre and anaesthetic team. There should ament occurs, haemostasis is achieved by percutaneously be a relatively low threshold for early conversion; however, this inserting a large, straight needle at one side of the ligament. will depend on the expertise of the operating team. It is per- A monoflament suture attached to the needle is passed into tinent to achieve early control by whatever means necessary. the abdominal cavity and the needle is exited at the other side 01_10_B&L28_Pt1_Ch10_5th.indd 170 31/08/2022 10:31  PART 1 | BASIC PRINCIPLES Postoperative care 171 of the ligament using a grasper. The loop is suspended and passage from recently coagulated, electrically isolated tissue. compression is achieved. Maintaining compression throughout Bipolar diathermy is safer and should be used in preference the procedure usually sufces. After the procedure has been to monopolar diathermy, especially in anatomically crowded completed, the loop is removed under direct laparoscopic visu- areas. If monopolar diathermy is to be used, important safety alisation to ensure complete haemostasis. measures include attainment of a perfect visual image, avoid- ing excessive current application and meticulous attention to Evacuation of blood clots insulation. Alternative methods of performing dissection, such Careful haemostasis is important as even small, localised pools as the use of ultrasonic devices, may improve safety. of blood or clot absorb light and can signifcantly impair the surgical view. Carefully directed suction is usually sufcient in open cases; however, suction may be problematic in laparo- POSTOPERATIVE CARE scopic and robotic procedures that are reliant on carbon diox- The postoperative care of patients after minimal access surgery ide insufation to maintain the surgical feld. It is important is generally straightforward, with a low incidence of pain or that suction is applied below a fuid level, or, if used in the other problems when compared with their open counterparts. operative feld, only in short bursts as required. Should tissue It is a good general rule that if the patient develops a fever or be inadvertently sucked into the end of the suction device, the tachycardia, or complains of severe pain at the operation site, tubing can be kinked to allow the tissue to drop away before something is wrong and close observation or intervention is removing. Rolled swabs or sponges can be used to remove blood necessary (see also Chapter 24). from the surgical feld without need for suction (Figure 10.6). These can also be used for gentle retraction, minimising tissue damage and thus further reducing blood loss. Such swabs may be inserted and removed via a 15-mm assistant port or in some (a) cases a 12-mm robotic trocar with the port cap removed. Care should be taken to avoid carbon dioxide loss during extraction. Finally, the surgeon may choose to use a specially designed robotic sucker that integrates with the robotic system. Alterna- tively, non-wristed suction can be provided via an assistant port if included in the operative set-up. Principles of electrosurgery during laparoscopic surgery Inadvertent electrosurgical injuries during minimal access surgery are potentially serious and are often unrecognised at the time. The vast majority occur following the use of monopolar diathermy. For conventional laparoscopy, the overall incidence is thought to be between one and two cases per 1000 operations. Injuries can occur through inadvertent touching or grasping (b) of tissue during current application; direct coupling between tissue and a metal instrument that is touching the activated probe; insulation breaks in the laparoscopic or robotic instru- ments; direct sparking from the diathermy probe; or current Figure 10.6 Use of rolled swabs for retraction of the lung during pulmonary lobectomy (courtesy of Mr Tom Routledge, Guy’s and St Figure 10.5 Management of bleeding from a surgical trocar site. Thomas’ NHS Foundation Trust, London, UK). 01_10_B&L28_Pt1_Ch10_5th.indd 171 31/08/2022 10:31  PART 1 | BASIC PRINCIPLES 172 CHAPTER 10 Principles of minimal access surgery Nausea removed as soon as the operation is over and before the patient regains consciousness. This is most commonly used in bariatric About half of patients experience some degree of nausea after and oesophagogastric surgery, where a larger (32F or 34F) tube minimal access surgery. It usually responds to an antiemetic, is used. such as ondansetron, and settles within 12–24 hours. It is made worse by opiate analgesics and these should be rationalised or avoided where at all possible. Oral fuids There is no signifcant ileus after minimal access surgery, Shoulder tip pain except in abdominal resectional procedures, such as colectomy or small bowel resection. Patients may resume oral fuids as Patients should be warned about this preoperatively and soon as they are conscious; they usually do so 4–6 hours after informed that the pain is referred from the diaphragm and that the end of the operation. it is not due to a local problem in the shoulders. It can be at its worst 24 hours after the operation. It usually settles within 2–3 days and is relieved by simple analgesics, such as paracetamol. Oral feeding Provided that the patient has an appetite, a light meal can be Port site pain and numbness taken 4–6 hours after the operation. Some patients remain slightly nauseated at this stage, but almost all eat a normal Pain in one or other of the port site wounds is not uncommon breakfast on the morning after surgery. Subsequently a and is worse if there is haematoma formation. It usually settles balanced diet is recommended in most cases and where specifc very rapidly. In the case of thoracoscopy, intercostal nerve procedural recommendations are needed these should be pain may be more common in those with smaller intercostal clearly communicated to both the patient and relatives with spaces. Nerve blockade by means of directed local anaesthesia appropriate dietetic referral made. is efective at reducing pain and the need for opiate medication in the immediate postoperative period. Increasing pain after 2–3 days may be a sign of infection and, with concomitant Urinary catheter signs, antibiotic therapy is occasionally required. Occasionally, The requirement for a urinary catheter depends on the opera- herniation through a port may account for localised pain and tion. In shorter (2 seconds). Circulating blood volume = 70–80 mL/kg (90–100 mL/kg in preterms) Hyponatraemia (40 cm of small intes- tine usually adapt over a few months, but others may need prolonged admissions or home PN. Biliary atresia/choledochal Figure 18.11 Abdominal radiograph showing pneumatosis. malformation Congenital or acquired (e.g. cytomegalovirus) extrahepatic late, there may be malabsorption, growth failure and coagulop- biliary atresia is a progressive obliterative cholangiopathy with athy. Some associations appear in Table 18.1. The diagnosis absent or narrow bile ducts. Type I involves the common bile is confrmed with a radionucleotide hepatobiliary iminodia- duct, type II the common hepatic duct, and 80% have the most cetic acid (HIDA) scan. Early diagnosis and avoiding sepsis common type III, involving the proximal bile ducts. Biliary may prevent irreversible liver fbrosis and death. The Kasai atresia presents with conjugated hyperbilirubinaemia, pale hepatico-portoenterostomy using a jejunal Roux-en-Y loop stools and dark urine in the frst few weeks of life. If presenting anastomosed to the portal plate gives drainage for some years, Morio Kasai, 1922–2008, pioneering Japanese surgeon, trained by C Everett Koop. César Roux, 1857–1934, Swiss surgeon, assistant to Theodor Kocher. 02_18_B&L28_Pt2_Ch18_4th.indd 268 31/08/2022 11:06  PART 2 | GENERAL PAEDIATRICS Neonatal gastrointestinal surgery 269 B R Figure 18.12 Operative appearance of neonatal necrotising entero- colitis. Figure 18.14 A rectourethral fstula, visible on a contrast study per- formed via a sigmoid colostomy. The bladder is flled with contrast via but many need liver transplantation. Congenital choledochal the fstula and the radio-opaque dot has been placed on the infant’s malformations manifest as cystic dilatations of the biliary tree perineum over the normal site of the anus. B, bladder; R, rectum. and are also managed with resection and portoenterostomy. Anorectal malformations Hirschsprung’s disease In an anorectal malformation, there is usually no opening in Genetic defects (e.g. RET, EDNRB, EDN3) can afect the boys, and the rectum ends either blindly (notably in aneuploi- migration of neural crest-derived intestinal neurones (neuro- dies) or with a fstula to the bulbar urethra (Figure 18.13a), cristopathy), leading to aganglionosis and thickened nerve prostate or bladder neck. Occasionally, there is a rectoperineal trunks in the distal bowel. There may be a family history. Agan- fstula in a boy. In contrast, there is usually a rectovestibular glionic bowel fails to relax, causing a functional obstruction. (Figure 18.13b) or rectoperineal fstula in girls; meconium is Aganglionosis extends from the anus to the sigmoid colon in passed and therefore, many are missed on cursory newborn 75%, the proximal colon in 15%, and the terminal ileum in examinations. In girls, the rectum may join a common channel 10% of cases. A transition zone lies between dilated, proximal, with the vagina and urethra; this is referred to as a cloaca normal bowel and narrow, distal aganglionic bowel. Neonatal (Figure 18.13c). Hirschsprung’s disease presents with delayed passage of meco- In boys, a divided proximal sigmoid colostomy allows feed- nium, abdominal distension and bilious vomiting requiring ing. A contrast study is performed through the defunctioned resuscitation, gastric decompression, antibiotics and a bowel end (Figure 18.14). Repair of prostatic and bladder neck fstu- washout. The diagnosis is made on a cot-side suction rectal lae may be approached with a combined laparoscopic and per- biopsy. A contrast enema may show the narrow aganglionic ineal approach, whereas prostatic and bulbar urethral fstulae segment, a cone and dilated proximal bowel (Figure 18.15). can both be approached in a posterior sagittal anorectoplasty Daily rectal washouts may allow a period of growth at home (PSARP). The stoma is closed at a third stage. Most perineal before surgery. If decompression fails, a stoma is fashioned and some vestibular fstulae can be transposed into the muscle using frozen section histopathology to identify ganglionic complex without a stoma. bowel. Defnitive surgery removes the aganglionic segment (a) (b) (c) Figure 18.13 (a) Rectobulbar urethral fstula in a boy. (b) Rectovestibular fstula in a girl. (c) Cloaca in a girl. 02_18_B&L28_Pt2_Ch18_4th.indd 269 31/08/2022 11:06  PART 2 | GENERAL PAEDIATRICS 270 CHAPTER 18 Neonatal surgery Figure 18.15 Barium enema in an infant, showing a ‘transition zone’ in the proximal sigmoid colon between the dilated proximal normally innervated bowel and the contracted aganglionic rectum. Figure 18.16 Gastroschisis. and brings ganglionic bowel to the anus; Swenson, Duhamel, Yancey–Soave and transanal ‘pull-throughs’ are options. Most children achieve reasonable bowel control, but some have residual constipation, incontinence or episodes of enterocolitis. Gastroschisis In gastroschisis, an abdominal wall defect lies to the right- hand side of the umbilical cord and transmits the small and large intestine, stomach, bladder and sometimes the ovaries or undescended abdominal testes (Figure 18.16). Risk factors include teenage pregnancy, recreational drugs, smoking and genitourinary infection in pregnancy. It is easily diagnosed antenatally, allowing delivery near a surgical unit. Vaginal delivery is appropriate. After birth, twisting or kinking of the mesenteric blood supply must be avoided. The abdomen and viscera are wrapped using a transparent plastic food wrap Figure 18.17 Closing gastroschisis: the defect has narrowed and (e.g. cling flm, Saran wrap), a large-bore nasogastric tube is occluded the vessels to a few loops of intestine. Note the atresia placed, and fuid resuscitation is initiated. The bowel may found at laparotomy. have a thick wall and be matted together. Sometimes, the defect closes antenatally, causing an atresia and an external length of damaged intestine (Figure 18.17). A narrow defect Exomphalos may need to be widened and a sutured silo (silo: structure for Exomphalos describes a central abdominal wall defect in which storage) created using Silastic sheeting or an empty intravenous prolapsed viscera are covered in a thin, three-layered membrane fuid bag. Primary closure under general anaesthesia usually (peritoneum, Wharton’s jelly and amnion) in continuity with the requires NICU admission for postoperative ventilation. An umbilical cord. Exomphalos minor (