This document provides a history of laparoscopy and key developments in the field. It discusses early developments in the 1800s and 1900s using cystoscopes and insufflation. The first laparoscopy was performed in 1901 by George Kelling. Developments continued through the 1900s including the introduction of trocars and telescopes. Laparoscopic cholecystectomy was first performed in 1985 but was not widely adopted until the late 1980s. The document also discusses current standard laparoscopic procedures and emerging technologies like fluorescent cholangiography and natural orifice transluminal endoscopic surgery (NOTES).

10. Journal of Reproductive Medicine 1977. Volume 18; No. 5: 235- 240

18. tro-car - [Fr., troisis , three + carre, side] noun a sharp-pointed surgical instrument fitted with a cannula and used especially to insert the cannula into a body cavity cannula - [L., dim of canna, reed] noun a tube that is inserted into a cavity by means of a trocar filling it’s lumen

19. Correct trocar placement should provide direct access to the target organs, an optimal view of the operative field and minimize mental and muscular fatigue.

20. Avoid competing for the same space: Working against the camera and ‘blind spots’ “ Dueling swords” phenomenon (scissoring effect)

21. Avoid the epigastric vessels Saber et al. Safety zones for anterior abdominal wall entry during laparoscopy. Ann Surg 2004; 239:182

22. (adapted from) Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisions James L. Whiteside, MD, Matthew D. Barber, MD, MHS, Mark D. Walters, MD, and Tommaso Falcone, MD (Am J Obstet Gynecol 2003;189:1574-8.) Anatomic distribution of nerves across anterior abdominal wall Iliohypogastric nerve Ilioinguinal nerve

23. (adapted from) Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisions James L. Whiteside, MD, Matthew D. Barber, MD, MHS, Mark D. Walters, MD, and Tommaso Falcone, MD (Am J Obstet Gynecol 2003;189:1574-8.) Iliohypogastric n. Ilioinguinal n. Incision line/trocar sites vs. nerve distribution Epigastric a. Trocar site Pfannenstiel incision

24. Trocar distance from the target organ depends upon the size of the patient. Individual trocars can be moved closer to the target along an axis line. Additional trocars can be added along the semicircular line.

26. Huge Difference

27. * 600,000 cholecystectomies annually in the U.S., 8%-20% have CBD stones, no consensus on optimal management. ** “No single clinical indicator is completely accurate in predicting CBD stones prior to cholecystectomy.” * Liu, TH et al. Ann Surg 234(1), July, 2001. **Abboud, et al. Gastrointestinal Endoscopy, 44(4), October 1996

33. Public Health Problem #1: Laparoscopy in Bariatric Surgery OBESITY

34. Derived from Center for Disease Control and Prevention website www.cdc.gov Percent of Obese (BMI ≥ 30) in US Adults

35. Derived from Center for Disease Control and Prevention website www.cdc.gov Percent of Obese (BMI ≥ 30) in US Adults

36. County-level Estimates of Obesity among Adults aged ≥ 20 years: United States

38. Current Procedures

41. a Relative contraindications Contraindications for Laparoscopic Adrenalectomy Local tumor invasiveness Regional lymph node involvement Large tumor size larger than 10 to 12 cm a Prior nephrectomy, splenectomy, or liver resection on the side of the adrenal lesion a

42. Conclusion: Computed tomography-guided percutaneous RFA is a safe and efficacious alternative to laparoscopic adrenalectomy in treating patients with PA due to small APA. Ann Surg. Dec 2010;252:1058-1064

43. Laparoscopic Splenectomy-Indications Idiopathic thrombocytopenic purpura ITP/HIV + Thrombotic thrombocytopenic purpura Hereditary spherocytosis Auto-immune hemolytic anemia Splenic cysts Evan’s syndrome Felty’s syndrome Hypersplenism (portal hypertension) Non Hodgkin’s lymphoma Hodgkin’s lymphoma Lymphocytic leukemia Myelocytic leukemia Tricholeukocytic leukemia Myelocytic splenomegaly Splenic tumor

44. SPLENECTOMY

48. Nissen’s Fundoplication Technique

49. Nissen Fundoplication

50. Esophageal Hiatus Liver Esophagus Left crus Right crus Aorta

51. Hiatal Defect Chest cavity Stomach Left crus

52. Mesh Repair

54. Emerging technologies in hiatal hernia repair

57. ESOPHYX

62. Linx ® Antireflux system

63. Magnetic Sphincter Augmentation How does it work? Yet, still in clinical trials

64. Is it feasible

67. Laparoscopic Inguinal Hernia Repair

71. INGUINAL HERNIA REPAIR

72. Inguinal Hernia Repair

76. Nerves prone to injury anterior and posterior

78. Laparoscopic Ventral Hernia: Is the Abdomen a Weakness in the Human Race ?

80. Significant predictors of surgical site infection and incisional hernia a Effect of Stitch Length on Wound Complications After Closure of Midline Incisions; A Randomized Controlled Study, Millbourn, D MD; Cengiz, Y MD, PhD; Israelsson, L MD, PhD Arch Surg/vol 144 (No. 11), Nov 2009 www.archsurg.com Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); CI, confidence interval; OR odds ratio; SL, suture length; WL wound length A Results of logistic regression analysis. All recorded variables were included in the model and removed by a backward reduction strategy if nonsignificant. Predictor Regression Coefficient (SE) OR (95%CI) Surgical site infection Wound contamination 1.03 (0.48) 2.81 (1.09-7.25) Being diabetic 1.01 (0.38) 2.73 (1.30-5.72) Long stitch length 0.77 (0.31) 2.15 (1.17-3.96) Incisional hernia Male sex 0.76 (0.34) 2.14 (1.10-4.15) Higher BMI 0.05 (0.02) 1.05 (1.01-1.10) Longer operation time 0.005 (0.002) 1.01 (1.002-1.01) Surgical site infection 1.16 (0.40) 3.18 (1.44-7.02) SL to WL ratio <4 1.32 (0.52) 3.73 (1.36-10.26) Long stitch length 1.44 (0.34) 4.24 (2.19-8.23)

83. Ventral Hernia Defect

84. Mesh used to patch defect

86. Completed repair

88. Competition Evaluation Covidien Pariextex Composite Bard Composix E/X Bard Ventralex Ethicon Proceed Atrium C-Qur Gore Dualmesh Genzyme Sepramesh IP Adhesion prevention +++ + + + ? + ++ Tissue integration ++ + + + + - ++ Shrinkage + + + + + - + Elasticity ++ - - + ? - + Ease of fixation ++ + ++ + + - + Protected edge Y Y Y N N N N

89. Biomeshes

90. Level of Complexity Grade 1 Low risk of infection Low risk of complications Grade 2 Smoker Immunosuppressed Obese Diabetic Grade 4 Active infection Infected mesh Grade 3 Contamination risk Stoma present Violation of bowel wall Previous Wound infection Grade 5 Traumatic fascia loss Extensive fascia loss Percent Performed Open Patients with co-morbid conditions have up to 4x increase in wound-infection rates Open incisional hernias are 10x more likely to have infection than a clean surgical case Infected mesh commonly results in a 2 nd procedure for removal Synthetic Biologic

95. Massive Incisional Hernias

99. Components Separation

100. Grevious MA. Cohen M. Shah SR. Rodriguez P. Structural and functional anatomy of the abdominal wall. Clinics in Plastic Surgery. 33(2):169-79, v, 2006 Apr. External oblique Internal oblique Transversus abdominis Rectus abdominis Components Separation

102. Case Report

103. Laparoscopic Appendectomy

104. Laparoscopic Appendectomy Endo-loop

107. Conclusion: Laparoscopy was associated with decreased risk of incisional infection but with an increased risk of OSI. The degree of this increased risk varies depending on the clinical profile of a surgical patient. Recognition of these differences in risk may aid clinicians in the choice of operative approach for appendectomy. Ann Surg. Dec 2010; 252:895-900

108. LAPAROSCOPIC PROCEDURES WITH CLEAR ADVANTAGES.

109. Laparoscopic Surgery in Colorectal Diseases

110. Port Site Recurrence

113. LAPAROSCOPIC SIGMOID RESECTION (lateral decubiti position)

114. Lateral Supine

118. Pulitan ò C and Aldrighetti L Nat Clin Pract Gastroenterol Hepatol (2008) Outcomes of laparoscopic hepatectomy

125. PROSTATECTOMY A B C Trocars – added as needed along semicircular line. i.e., during a prostatectomy, another trocar is added between A and B. Another trocar may be added between B and C allowing the surgeon and assistant surgeon on the opposite side to each use both hands.

126. Minimally invasive neck surgery

128. Cosmetic results Open surgery scar Minimally invasive / endoscopic scars

130. Robotic Parathyroidectomy Arm 1 Camera Arm 2 Arm 3 This approach was developed in South Korea by Dr. Woong Chung at Yonsei University College of Medicine in Seoul. He reported his experience with 338 patients

131. Confidential

133. Confidential

134. Confidential

135. Fourth arm trocar External retractor Connected with continuous suction system

136. Maryland dissector Harmonic curved shears

137. Confidential

142. Past Present

147. Technique

148. SILS

150. Port Site Hernia !!

151. N.O.T.E.S. Natural Orifice Transluminal Endoscopic Surgery

152. NOTES - instrument

155. Scarless surgery!

156. Notes- Transvaginal Video-endoscope entering through the posterior vaginal fornix

157. NOTES - Transgastric Courtesy of N Reddy, Hyperbad India 2005

158. NOTES - Appendectomy

159. NOTES – Obesity Surgery

166. Conclusion: With gastric bypass, type 2 diabetes can be improved and even rapidly put into the state of remission irrespective of weight loss. Improved insulin resistance within the first week after surgery remains unexplained, but increased insulin production in the first week after surgery may be explained by the enhanced postprandial GLP-1 responses Ann Surg. Dec 2010; 252:966-971

168. Endobarrier

175. Surgery for Diabetes

178. CDC. National Diabetes Fact Sheet, 2007. Source: 2003 –2006 National Health and Nutrition Examination Survey estimates of total prevalence (both diagnosed and undiagnosed) were projected to year 2007.

180. Morbidity Obesity Associated Conditions Diabetes Hypertension Sleep apnea Congestive heart failure Hyperlipidemia Stroke Coronary artery disease Osteoarthritis Gastroesophageal reflux disease Non-alcoholic fatty liver Psychological disturbances

183. Rates of Remission of Diabetes Adjustable Gastric Banding Roux-en-Y Gastric Bypass Biliopancreatic Diversion >95% (Immediate) 48% (Slow) 84% (Immediate)

185. 2004: Duodenal-Jejunal Exclusion - Foregut

186. Slides taken from: DIABETES IS NO LONGER A HOPELESS DISEASE The Guilty Gut Walter Pories, MD, FACS, Chief, Metabolic Institute East Carolina University Greenville, North Carolina 2006:

187. 2004: “ Results of our study support the hypothesis that the bypass of duodenum and jejunum can directly control type 2 diabetes and not secondarily to weight loss or treatment of obesity.” Effect of Duodenal-Jejunal Exclusion in a Non-obese Animal Model of Type 2 Diabetes: A New Perspective for an Old Disease. Rubino, Francesco, MD; Marescaux, Jacques MD, FRCS Annals of Surgery; 239 (1): 1-11, January 2004

191. 2009: Ferzli et al

192. 2009: Ferzli et al

194. The Diabetes Surgery Summit Consensus Conference Rubino et al. Annals of Surgery. Vol 251, Number3,300-405, March 2010 45% of type 2 patients with diabetes world-wide demonstrate a BMI less than 30 ADA : “ Bariatric Surgery should be considered for adults with BMI > 35Kg/m2 And type 2 diabetes ,especially if the diabetes is difficult to control with lifestyle And pharmacologic therapy

195. The Surgeon and the Diabetologists

196. Clinical Evaluation of the Effect of Duodenal-Jejunal Bypass on Type 2 Diabetes (June 2007) Patient Duration of Type 2 Diabetes Pre-Operative Medication 1 Year Medication Requirement #1 19 Metformin 850mg One tablet daily Metformin 850 mg half tablet daily #2 10 30/10 Units Insulin 30/10 Units Insulin #3 12 40/20/20/20 Units Insulin 30 Units occasionally at night #4 12 2 Metformin 850mg daily; 40/20 Units Insulin 1 Metformin 850mg daily; 5 Units n occasionally #5 12 40/20 Units Insulin 5 Units Insulin three times per week #6 * 6 20/12 Units Insulin No Medication #7 4 Clormin 1000mg daily; 30/20 Units Insulin Diaformin 500mg daily; 30/20 Units Insulin