MINIMALLY INVASIVE SURGERY

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1 DR YAN YANG WAI DEPARTMENT OF SURGERY HRPB IPOH My God, Jim, we can t leave him in the hands of 20th century medicine. Those butchers will use needles and knives and cut open his belly and chest. It is still the dark ages. You have no idea what those barbarians will do. Dr. 'Bones' McCoy Starship Enterprise Star Date HISTORY OF MIS HISTORY OF MIS PHILIP BOZZINI 1800 EXAMINED URETHRA USING METAL TUBE AND REFLECTED CANDLELIGHT - LICHTLEITER PROVIDED BASIC DESIGN FOR DEVELOPMENT OF FUTURE ENDOSCOPES KELLING CELIOSCOPY IN DOG 1901 USING CYSTOSCOPE AND TROCAR HISTORY OF MIS KURT SEMM JACOBEUS (SWEDEN) 1910 SERIES OF 100 LAPAROSCOPY AND THORACOSCOPY IN HUMAN PATIENTS FATHER OF LAPAROSCOPY CO2 INSUFFLATOR 1960 ENDOLOOP 1977 LAPAROSCOPIC APPENDICECTOMY

2 HISTORY OF LAPAROSCOPY LAPAROSCOPIC CHOLECYSTECTOMY 1985 ERIC MUHE GERMANY FIRST DOCUMENTED LAP CHOLE 1987 PHILLIPE MOURET CREDITED FOR PERFORMING FIRST LAP CHOLE LAPAROSCOPIC CHOLECYSTECTOMY l Started in late 1980s l Within 10 years, rapidly adopted approx 90% are done laparoscopically l Already adopted long before scientific data available l Rapid rise due to patient demand l Hugely popular due much less pain compared to traditional open approach LAPAROSCOPIC CHOLECYSTECTOMY l Started in late 1980s l Within 10 years, rapidly adopted approx 90% are done laparoscopically l Already adopted long before scientific data available l Rapid rise due to patient demand l Hugely popular due much less pain compared to traditional open approach ACCESS TRAUMA SURGERY WHERE THE SURGICAL PROCEDURE IS COMPLETED WITH MINIMAL ACCESS TRAUMA AND PROCEDURAL TRAUMA NOT ONLY WOUND SIZE AND WOUND RETRACTION BUT ALSO EXPOSURE OF VISCERA TO ATMOSPHERE 2

3 Trauma of access l l l Larger incision = more trauma Retraction = trauma Rate of trauma increase not proportionate to increase in wound length e.g. l 1 cm wound 3.14xrxr = 3.14x0.5x0.5 = l 2 cm wound 3.14xrxr = 3.14x1.0x1.0 = 3.14 Procedural trauma l Low hernia, lumps, appendicectomy, cholecystectomy l Moderate small bowel surgery, splenectomy, right hemicolectomy l High Whipples, oesophagectomy, anterior resection Criteria for MIS l low access trauma and low procedure trauma Criteria for DCS l low access trauma and low procedure trauma l Prolonged surgery will increase morbidity LEARNING CURVE OF MIS LEARNING CURVE IN MIS Open chole era rate of CBD injury 0.1 to 0.2% Initial period of lap chole introduction, rate of CBD injury rose dramatically Currently CBD injury between 0.2 to 0.4% Lap chole entirely different procedure with different skillsets Laparoscopic skills need to learnt 3

4 LAPAROSCOPIC SIMULATORS COMPUTERISED SIMULATORS BOX TRAINERS McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTILS) McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTILS) LEARNING MIS SKILLS Task Allowable errors Proficiency time (s) 1 Peg transfer No drops outside field of view No. of repetitions required 48 2 consecutive + 10 nonconsecutive 2 Pattern cut All cuts within 2 mm of line 98 2 consecutive + 10 nonconsecutive 3 Ligating loop Up to 1-mm accuracy error No knot insecurity 4 Extracorporeal suture Up to 1-mm accuracy or gap error No knot insecurity 53 2 consecutive consecutive MIS NOT RECOGNISED AS SUBSPECIALITY IN MALAYSIA RECOGNISED AS A SURGICAL TECHNIQUE TRAINING OF MIS AS PART OF THE SUBSPECIALITY TRAINING ITSELF 5 Intracorporeal suture No model avulsion consecutive + 10 nonconsecutive 4

5 ACQUIRING AND HONING SKILLS NO FORMAL TRAINING IN MALAYSIA Basic laparoscopic hands-on training College of Surgeons Malaysia UKM UM Ipoh ACQUIRING AND HONING SKILLS Overseas training centres India Singapore Vietnam SAGES LEARNING MIS SKILLS Attend basic and laparoscopic skills courses Training with simulators at hospital Preceptorship with accredited preceptors Performing MIS surgeries under preceptors supervision Performing advanced MIS procedures under subspeciality training Attending local and overseas workshops PROPOSED MIS POLICY IN KKM KKM HAVE REGULAR MIS SKILLS TRAINING WORKSHOPS BOTH BASIC AND ADVANCED SKILLS WORKSHOP TARGETED AT DIFFERENT LEVELS OF TRAINEES KKM SHOULD CREDENTIAL CENTRES OR HOSPITALS AS TRAINING CENTRE FOR MIS MAJOR SPECIALIST HOSPITAL SHOULD HAVE TRAINING SKILLS LAB WHERE CANDIDATES CAN PRACTISE THEIR MIS SKILLS AND ALSO TO FACILITATE TRAINING COURSES KKM SHOULD ACQUIRE ADEQUATE SIMULATORS FOR TRAINEES USE KKM SHOULD RECOGNISE AND CREDENTIAL PRECEPTORS/ TRAINERS WHO CAN ACCEPT TRAINEES FOR MIS SURGERIES PROMOTION OF MIS Currently MIS is only practised and promoted by those who are interested in MIS No budget or dedicated program for promotion and development of MIS USE PAIN FREE HOSPITAL INITIATIVE TO PROMOTE MINIMAL INVASIVE SURGERY 5

6 CONCLUSION MIS/LAPAROSCOPY IS A SURGICAL SKILL NEED TO MASTER BASIC AND ADVANCED MIS SKILLS BEFORE EMBARKING ON LAPAROSCOPIC SURGERY THE FUTURE NO FORMAL TEACHING OF MIS SKILLS IN MALAYSIA BY ADOPTING PAIN FREE HOSPITAL CONCEPT, MIS CAN BE PROMOTED AND DEVELOPED SPACE THE FINAL FRONTIER 6