1. What’s New in Minimally Invasive Surgery?
David Renton MD
Assistant Professor
The Ohio State University
Department of Surgery

2. Minimally Invasive Surgery Past, Present and Future
What is MIS?
A minimally invasive medical procedure is defined as one that is carried out by entering the body through the skin or through a body cavity or anatomical opening, but with the smallest damage possible to these structures.

3. Minimally Invasive Surgery Past, Present and Future
Includes laparoscopic, endoscopic, and other approaches.
Why MIS?
Decreased patient pain
Decreased patient recovery period
Possible decrease in inflammatory response in the patient which may prove to have a better outcome in ocologic operations

4. Minimally Invasive Surgery Past, Present and Future
1901-Dimitri Ott, George Kelling, and H.C. Jacobaeus first demonstrated on animals that laparoscopy was possible
Janos Veress of Hungary developed a specially designed spring-loaded needle. Interestingly, Veress did not promote the use of his Veress needle for laparoscopy purposes. He used the veress needle for the induction of pneumothorax.

5. Minimally Invasive Surgery Past, Present and Future
The rigid rod lens system and fiber optics was introduced by Professor Harold H. Hopkins. The credit of videoscopic surgery goes to this surgeon who has revolutionized the concept by making this instrument.

6. Minimally Invasive Surgery Past, Present and Future
The first documented laparoscopic cholecystectomy was performed by Erich Mühe in Germany in 1985. 
Fascinated by Semm's technique
Idea of laparoscopic removal of gallstones
1984: designed an operative "Galloscope”
September 12, 1985, first lap chole
1986: Published his technique at the Congress of the German Surgical Society
1987: Total of 97 endoscopic cholecystectomies.
His concept, however, was ignored

7. Minimally Invasive Surgery Past, Present and Future
Gave impetus to Eddie Joe Reddick & Barry McKernan of Marietta, GA
June 22, 1988: 1st lap chole in U.S.

8. Current Practices in MIS
Procedures currently performed using MIS techniques:
Cholecystectomy
Appendectomy
Hernia Repair
Inguinal
Ventral
Incisional
Colectomy
Splenectomy
Adrenalectomy
Heller Myotomy
Nissen Fundoplication
Esophagectomy
Gastrectomy
Pancreatectomy
Bile Duct Exploration
Bariatrics
Roux en Y Gastric Bypass
Lap Band
Lymph Node Biopsy
Almost Anything

10. Current Practices in MIS

12. Where to go next? Three Directions MIS is headed:
Endo-luminal Technique
NOTES – Natural Orifice Transluminal Endoscopic Surgery
SILS – Single Incision Laparoscopic Surgery

13. The Future

14. The Future Endoluminal treatment for reflux
Endoluminal sleeve gastrectomy for bariatrics
Deployable absorption barriers for malabsorptive weight loss
Gastric Ballons

15. The Future

16. The Future

17. NOTES
NOTES
Natural
Orifice
Transluminal
Endoscopic
Surgery

18. NOTES
What is it?
Using natural orifices as portals into the abdominal cavity to perform procedures using a flexible endoscope
Transgastric
Transrectal
Transvaginal

19. NOTES
The NOSCAR group was created by SAGES to help funnel research into this developing field
Funded through a $500,00 grant by the Covidien Corporation
Natural
Orifice
Surgery
Consortium for
Assessment and
Research

20. NOTES
First NOTES procedure preformed in Hyderabad, India by Drs Reddy and Rao
Performed on prisoners without consent
No IRB panel
Data has never been published

22. NOTES
NOTES crossed the ocean three years ago when the first IRB approved Transluminal procedure was performed outside of India on a human subject.
We performed diagnostic peritonoscopy on patients with pancreatic cancer here at OSU
Laparoscopic assistance was used

24. NOTES
March 20th 2007 – a hybrid trans-vaginal cholecystectomy performed in New York.
Used three additional trocars in the upper abdomen, no supraumbilical port
All visualization and dissection done through endoscope

25. NOTES
April 2, 2007 Strasbourg France the first “completely” transvaginal cholecystectomy performed
Used a 2mm stab incision for insertion of a veress needle to insufflate and retract gallbladder

26. NOTES What has been done with NOTES so far? Transgastric appendectomy
Transgastric cholecystectomy
Transvaginal cholecystectomy
Transrectal colectomy

27. NOTES
A great deal of research is going into NOTES right now, some of it being done here at OSU
Questions about safety, cost, and the ability for the practicing surgeon to learn these techniques abound

28. SILS Single Incision Laparoscopic Surgery
Instead of making several small incision for the insertion of multiple trocars and instruments, make one incision and use this to deploy a multiport system

29. Traditional incisions for Lap Chole

30. SILS Incisons for Lap Chole
2.5 cm

31. Incision For SILS Lap Chole

32. SILS Colectomy Scar
5 cm

33. SILS Colectomy Scar

34. SILS What has been done with SILS so far? Cholecystectomy Appendectomy
Lap Band
Colectomy
Nissen
Splenectomy
Adrenalectomy
Nephrectomy

35. SILS We have begun SILS surgery at OSU East SILS Cholecystectomy
SILS Colectomy
SILS Appendectomy
SILS Inguinal Hernia

38. Where Are We Going Next?