Minimally Invasive Surgery and Robotic Applications

Endoscopy

Visual examination of interior body structures using an endoscope.

Operative Endoscopy

Allows a surgeon to perform surgery while viewing inside a closed body cavity through small incisions or through a natural body orifice.

Diagnostic Endoscopy

Used to view internal organs or obtain a small biopsy of tissue.

Laparoscopy

A type of operative endoscopy that uses a rigid endoscope.

Cystoscopy

A type of operative endoscopy that uses a rigid endoscope.

Arthroscopy

A type of operative endoscopy that uses a rigid endoscope.

Thoracoscopy

A type of operative endoscopy that uses a rigid endoscope.

Pelviscopy

A type of diagnostic endoscopy that may use rigid, semi rigid, or flexible endoscopes.

Bronchoscopy

A type of diagnostic endoscopy that may use rigid, semi rigid, or flexible endoscopes.

Colonoscopy

A type of diagnostic endoscopy that may use rigid, semi rigid, or flexible endoscopes.

Mediastinoscopy

A type of diagnostic endoscopy that may use rigid, semi rigid, or flexible endoscopes.

Fiber Optic Light Cord

Attached to the endoscope on the sterile field, it sends light through the cord into the endoscope to illuminate the interior of the body cavity.

Rigid Endoscopes

Metal tubes with intricate lens systems used for diagnosis, biopsy, visualization, and repair.

0° Scope

A straight viewing scope with limited peripheral view.

Angled Rigid Endoscopes

Endoscopes with slanted distal ends used to visualize rounded structures and can be rotated.

Flexible Endoscopes

Valuable for diagnostic imaging of difficult to reach anatomical areas, can bend up to 180°.

Semi Rigid Endoscopes

Less common type of endoscope.

Camera Head

A sterile component of the operative endoscopy set that is connected to the endoscope.

White Balance

Necessary function that adjusts the color settings of the picture for proper anatomical identification.

FRED (Fog Reduction Elimination Device)

A small bottle of anti-fog solution with a sponge that adheres to the drape near the incision site.

Abdominal Cavity Temperature

Much warmer than room temperature, causing the lens of a laparoscope to fog quickly.

Biopsy Forceps

Instruments inserted through working channels of flexible endoscopes for obtaining tissue samples.

Snares

Instruments used in flexible endoscopes for tissue removal.

Ports of Entry

Natural body orifices - mouth, nares, vagina, urethra, or anus.

Transcutaneous access

Access through the skin and deep tissue layers. Performed through very small incisions or puncture sites.

Insufflation needles

Small diameter, cannulated needles may be used to establish separation of intraabdominal structures by a method called insufflation, which uses CO2 gas as a distention medium. The needles are known as Veress needles.

Trocars

Numerous styles of trocar design are available for MIS procedures. They may be sharp (bladed), blunt, dilating, or single site multiport; straight or pistol-shaped; disposable plastic or reusable metal; standard or long; and have cannula diameters from 2mm to 15mm.

Typical trocar design

Includes: a. Outer sheath or cannula (hollow tube), b. Inner obturator that either cuts through tissue layers or is blunt or dilating and provides atraumatic passage through deep tissue layers, c. Valve mechanism that allows insertion of operating instruments without loss of insufflation, d. Stopcock valve for attachment of tubing or closure if no tubing is attached.

Blunt Hasson trocars

May be used instead of Veress needles for establishment of pneumoperitoneum, which is a collection of air or gas within the peritoneal cavity of the abdomen.

Peritoneal Cavity Insufflation

Veress needles and trocars can be used to create access for instillation of CO2 gas for insufflation.

Insufflator

A device that controls the rate of flow, monitors the intraabdominal pressure, and may also warm the gas.

Typical rates of gas flow for insufflation

3 - 4 liters per minute.

Intraabdominal pneumoperitoneal pressure

For an average adult should be kept at 12 - 15 mm Hg.

Higher distention pressures

May result in pulmonary gas embolism, hypercapnia, cardiac compression or pulmonary decompensation due to excess pressure on the diaphragm from the distended abdominal cavity.

Post-operative shoulder pain

Patients may complain of shoulder pain due to irritation of the phrenic nerve, which is a temporary side effect that disappears once the residual CO2 is fully resorbed.

Mechanical Distention

Temporary distention of the abdominal cavity can be achieved simply by pinching and lifting the skin of the abdomen to avoid placing the Verres needle into the intestine.

Balloon dissection trocars

More commonly used for laparoscopic hernia repairs and endoscopic saphenous vein harvesting for coronary artery bypass grafting.

Fluid Distention

Hollow organs such as the bladder are somewhat flaccid if unfilled, similar to a balloon with no air.

Visualization of structures in tight spaces

These areas, which are normally fluid-filled, are distended with fluids to accommodate insertion of the scope and instruments necessary to perform the procedure without damage to adjacent structures.

Applications and Surgical Specialties

Many surgeries can be performed through endoscopic means.

Examples of surgical specialties routinely done endoscopically

Include: 1. Gastrointestinal surgery, 2. Gynecological surgery, 3. Urological surgery, 4. Diagnostic laparoscopy, 5. Orthopedic surgery, 6. Thoracic and Cardiac surgery.

Laparoscopic Supplies

The nature of laparoscopic procedures and equipment includes many specialty supplies.

Bovie cord

Connects a cattery post on laparoscopic instruments that can be used as a bovie tip.

Suction and irrigator

Devices used in surgery to remove fluids and provide irrigation to the surgical site.

Endo stitch or V lock suturing devices

Instruments designed for suturing in endoscopic procedures.

Endoclip applier

A device used to apply clips to tissues during endoscopic surgery.

Dissectors

Instruments used to separate tissues during surgical procedures.

Balloon dissectors

Devices that use inflatable balloons to create space in tissues during surgery.

Smoke evacuator

A device that removes smoke produced during laser or electrosurgical procedures.

Endo bag specimen retrieval devices

Instruments used to retrieve specimens from the body during laparoscopic surgery.

Trocar site closure devices

Instruments used to close the incisions made by trocars in laparoscopic surgery.

Laparoscopic instruments

Surgical tools with long, thin shafts designed for insertion through trocars.

Video tower

Equipment that includes a monitor, insufflator, camera control unit, light source, printer, and video recording device.

MIS robotic systems

Robotic systems used in minimally invasive surgery to enhance precision, flexibility, and control.

Da Vinci® Robotic System

The pioneering robotic system by Intuitive Surgical for robotic-assisted surgery.

Patient side cart

The component of the robotic system that positions the patient and supports the instrument and camera arms.

Manipulators

Devices categorized by their geometrical design, used to control surgical instruments.

Vision cart

The communication hub for advanced image and energy components in robotic systems.

Telesurgery

Performing a surgical procedure in real time at a distance.

Lag time

The delay between the surgeon's hand movements and the robotic arm's responses in telesurgery.

Remote Robotics Manipulation

The use of robotic systems to perform surgery, eliminating hand tremors and enhancing visualization.

Three-dimensional imaging

A visualization technique that enhances the surgeon's view of the operative site.

Telesurgery

Fosters increased utilization of telesurgery that is a benefit to isolated or small rural hospitals.

Risks of Remote Robotics Manipulation

Involves many of the same risks as conventional surgical procedures.

Unique Risks of Robotic Surgery

Robotic surgery presents unique risks, including the distance the surgeon is from the patient and the dependence on the quality of data connection between the robot and the console.

Intraoperative Risks

The potential for intraoperative mechanical, device, or software problems.

Hybrid OR

A typical hybrid OR and/or hybrid endovascular lab is a large room designed to accommodate advanced technology components that enable surgeons to perform highly complex minimally invasive procedures.

Endovascular abdominal aortic aneurysm (AAA) repair

Common procedure performed in a hybrid OR.

Endovascular thoracic aortic aneurysm repair

Common procedure performed in a hybrid OR.

Transcatheter aortic valve replacement

Common procedure performed in a hybrid OR.

Minimally invasive valve repair or replacement

Common procedure performed in a hybrid OR.

Coronary artery revascularization

Common procedure performed in a hybrid OR.

Atrial fibrillation ablation

Common procedure performed in a hybrid OR.

Pacemaker and ICD implantation

Common procedure performed in a hybrid OR.

Diagnostic and intraoperative cranial and spinal angiography

Common procedure performed in a hybrid OR.

Peripheral vascular and embolization procedures

Common procedure performed in a hybrid OR.

Surgical navigation

Uses computer assisted technology to allow surgeons to plan, guide, and optimally perform surgical tasks.

Preoperative Imaging

The patient typically undergoes a series of imaging that collects data and uploads to a computer on the day of surgery.

Registration

The images are calibrated, and positional data is created in a process called registration.

Image-based Navigation

Minimally invasive procedures that benefit from the use of navigation systems are image based.

Model-Based Navigation

Navigation is used in orthopedic surgery.

Common Imaging in Navigation

The most common imaging used with navigation are: Computer tomography CT, Magnetic resonance imaging MRI, Medtronic O arm, Ultrasound.

Navigation

A general term used to describe a process of patient scans, real time tracking, and often the use of computer aided planning.

Tracking

A vital component of surgical navigation that can estimate the orientation and position of specifically marked objects containing fiducial markers.

Fiducial markers

Small objects placed on or in the body to mark an area targeted for radiation treatment or surgery.

Computer aided planning

Software provides additional intraoperative guidance to the surgeon when integrated with a navigation system when there is a complex route to the target structure.

Needle placement

Needles are commonly used to obtain biopsy samples and electrode placement; navigational tracking can help the surgeon estimate the shortest route and view the needle in real time.

Interventional Radiology (IR)

A rapidly growing area that specializes in minimally invasive procedures using imaging guidance.

Purposes of Interventional Radiology

Diagnose and treat disease.

Common IR Procedures

Include balloon angioplasty, embolization, stent placement, and needle biopsy.

Fluoroscopy

Provides moving images of internal organs and structures.

Radiation Safety Principles

The three basic principles of radiation safety are time, distance, and shielding.

Adverse Effects of Radiation Overexposure

Include injury to the skin, hair loss, and cataracts.

Dosimeter

A device that measures the dose uptake of ionizing radiation.