21. TROCAR PLACEMENT BY QUADRANT Thoracic triangle Pelvic triangle 1 2 3 4

22. TROCAR PLACEMENT BY QUADRANT Each quadrant must be addressed from frontal as well as lateral positions. y z x

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

24. 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

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

26. No obstacle between trocar entry and target To avoid iatrogenic injuries.

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

28. (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

29. (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

30. Be aware of bladder location for suprapubic trocar

31. Avoid areas of prior surgery

32. 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.

34. Huge Difference

35. * 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

36. Liu TH et al: Patient evaluation and management with selective use of magnetic resonance cholangiography and endoscopic retrograde cholangiopancreatography before laparoscopic cholecystectomy. Ann Surg 234: 33-40, 2001

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

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

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

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

48. Current Procedures

52. ACTH: adrenocorticotrophic hormone Indications for Adrenalectomy Unilateral adrenalectomy Bilateral adrenalectomy Hyperfunctioning tumors Aldosteronoma Cortisol-producing adenoma Virilizing tumors Pheochromocytoma Failed treatment of ACTH-dependent Cushing’s syndrome Nonfunctioning cortical adenoma a Cushing’s syndrome from primary adrenal hyperplasia Malignant tumors Adrenocortical carcinoma Malignant pheochromocytoma Adrenal metastasis (solitary without other metastatic disease) Bilateral pheochromocytoma symptomatic or enlarging adrenal myelolipomas, ganglioneuroma

53. 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

54. 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

55. SPLENECTOMY

58. Laparoscopic Inguinal Hernia Repair

62. INGUINAL HERNIA REPAIR

63. Inguinal Hernia Repair

68. 2. Do we have an answer for groin pain after hernia repair?

69. Nerves prone to injury anterior and posterior

70. Groin Pain Incidence * Groin pain or discomfort lasting more than 3 months after groin hernia repair. Intern. Assn. for the Study of Pain. Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. Prepared by the International Association for the Study of Pain, Subcommittee on Taxonomy. Pain . 1986; 3 (suppl): 1–226. Author # of Pts Pain * Pain Severe Outcome of Pain A. S. Poobalan 2001 226 30% > 3 mo Morten Bay-Nielsen 2001 1166 28.7% > year 3% S. Kumar 2002 454 30% >21 mo C. A. Courtney 2002 4062 > 3 mo 3% > 2.5 yrs 71% have pain Severe in 22% Mild in 45% Marcello Picchio 2004 593 25% > 1 yr 6%>1 yr A. M. Grant 2004 928 9.7%>1 yr 1.8% > 5 yrs Jrg Kninger 2004 208 36% (Shouldice) 31% (Lichtenstein) 15% (TAPP) > 52 mo Ulf Fränneby 2006 2456 31% >24 to 36 mo Sergio Alfieri 2006 973 9.7% > 6 mo 2.1 %> 6 mo Mild 4.1% > 1yr Severe 0.5% > 1yr E. K. Aasvang 2006 210 34.3% >1year Less pain 75.8% Same pain 16.7% More severe 7.5% > 6.5 years

71. Quality of Life Author Pts Pain affects the quality of life Morten Bay-Nielsen 2001 1166 16.6% S Kumar 2002 454 18.1% Jrg Kninger 2004 208 14% (Shouldice) 13% (Lichtenstein) 2.4% (TAPP) Ulf Fränneby 2006 2456 6% EK Aasvang 2006 210 Nb 24.8% 6% after 6.5 years Sergio Alfieri 2006 973 11.3% to 14.2%

72. Causes and Risk Factors of Groin Pain Anatomical Variation Innervation symmetry - 40.6% Normal distribution - 20.3% “ Normal” anatomic pattern - 56.3% Mesh repair No clear correlation between use of mesh and chronic pain Age Studies disagree on correlation between older age and post-herniorrhaphy pain Pre-operative pain Pain associated with hernia before repair is associated with post-operative pain BMI No correlation found between elevated BMI and post-operative pain Post-operative complications Postoperative complications linked to an increased risk for long term pain Recurrent hernia Day case surgery Open versus laparoscopic Recurrence associated with recurrent pain The probability of developing chronic pain is 2.5 times higher in day-case patients, controlling for age Open repair strongly correlated with post-operative pain compared to laparoscopic repair

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

78. 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)

81. Ventral Hernia Defect

82. Mesh used to patch defect

84. Completed repair

86. Biomeshes

89. 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

90. Massive Incisional Hernias

95. Ventral Hernia: Anatomy

96. Components Separation

97. 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

99. Case Report

103. Laparoscopic Appendectomy

104. Laparoscopic Appendectomy Endo-loop

107. LAPAROSCOPIC PROCEDURES WITH CLEAR ADVANTAGES.

110. Nissen’s Fundoplication Technique

111. Nissen Fundoplication

112. Esophageal Hiatus Liver Esophagus Left crus Right crus Aorta

113. Hiatal Defect Chest cavity Stomach Left crus

114. Mesh Repair

116. Laparoscopic Surgery in Colorectal Diseases

117. Port Site Recurrence

120. LAPAROSCOPIC SIGMOID RESECTION (lateral decubiti position)

121. Lateral Supine

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

132. 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.

133. Minimally invasive neck surgery

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

145. da Vinci ® Surgical System U.S. Installed Base 1999 – 2006

148. Robotic Scrub Nurse “Penelope”

151. Past Present

155. Technique

156. SILS

158. Port Site Hernia !!

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

160. NOTES - instrument

163. Scarless surgery!

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

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

166. NOTES - Appendectomy

167. NOTES – Obesity Surgery

174. Endobarrier

180. Surgery for Diabetes

183. 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.

185. 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

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

191. 2004: Duodenal-Jejunal Exclusion - Foregut

192. 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:

193. 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

197. 2009: Ferzli et al

198. 2009: Ferzli et al

200. 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

201. The Surgeon and the Diabetologists

203. 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