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Avances en Cirugía Mínimamente Invasiva

• Imagen • Consolidación indicaciones clínicas

• Cirugía esofagogástrica • Cirugía hepática

• La herencia del NOTES • TaTME • Endoscopia intervencionista

• Big Data

Image in Surgical Endoscopy• HD • 3D • 4K • Robotic surgery • Augmented reality • Beyond the image

• Indocyanine Green • Others

• Tissue markers (sentinel node) • Google glass • 3D printing

Image in Surgical Endoscopy

• Basic features and characteristics • Clinical indications • Pro’s • Con’s • Evidence Based Medicine

1.- HD

• SD ➔780 pixels • HDTV ➔ 1920x1080 píxeles • Better detail, shadows, ‘seudo 3D’

effect • Current standard in our OR • EBM:

• HD • increases surgical precision • reduces operative time

• Pierre SA, High definition laparoscopy: objective assessment of performance characteristics and comparison with standard laparoscopy. J Endourol. 2009 , 23:523-8.

• SD vs HD • HD:

• > resolution at 50 mm distance (2.4 line pairs/mm v 2.0 line pairs/mm) • Increased image brightness (129 lumens v 112 lumens) • Increased depth of field • Decreased distortion. • Color and grayscale reproduction ➔ similar for HD & SD

• CONCLUSION: • HD laparoscopy has superior objective performance characteristics compared

with standard laparoscopes. • These improved optics may lead to easier identification of anatomic

structures, finer dissection, and enhanced three-dimensional spatial positioning during HD laparoscopic procedures.

• . Hagiike M, Performance differences in laparoscopic surgical skills between true high-definition and three-chip CCD video systems. Surg Endosc. 2007, 21:1849-54

• Digital 3 chip CCD camera with a standard monitor (SD system) vs • HD camera (1,080 pixels) with a 16:9-ratio HD monitor (HD system) • N: 53

• (1) subjective visual evaluation during actual surgical cases • (2) subjective visual evaluation in a controlled laboratory surgical setting • (3) three laparoscopic surgical task

RESULTS: • HD superior to SD in the laboratory setting and during actual surgery. • Knot-tying time was significantly less with HD (mean, 173 +/- 84 s vs 214 +/- 107 s; p =

0.003). • Subjects with less skill improved significantly in the knot-tying task with the HD ( p =

0.005).

CONCLUSION: • All the participants preferred HD to SD. • HD significantly improved laparoscopic knot tying, which requires precise depth perception • HD is more than just a pretty picture.

2.- 3D

2.- 3D• Pro:

• Recovery of third dimension • Technical improvement • Reducing learning curve • Reducing operative time • Increasing efficiency

• Con: • Technical development • Cumbersome (lens) • Side effects (dizziness) • Increasing cost

• Jones DB1The influence of three-dimensional video systems on laparoscopic task performance.

Surg Laparosc Endosc. 1996 Jun;6(3):191-7.

• . Five different tasks performed using 2-D and 3-D technology • medical students (n = 10 • inexperienced surgical residents (n = 10) • laparoscopic attending surgeons (n = 10).

• There was no significant difference in task performance between 2-D and 3-D • Subjective assessment of the video systems

• 46% (p = 0.72) preferred working in three dimensions • 60% (p = 0.27) sensing more motor control in 3-D.

• Our results suggest that first-generation 3-D video systems offer no significant advantage to the novice or expert surgeon performing laparoscopic procedures.

2. 3D: EBM

• Author / yr n Task Outcome Comment • Feng/15 4 Pediatric < time Advant. small space • Wilhem/14 48 Knotting < 20% time Save time • Mashiach/14 30 Lab tasks < 18-31% time = exp & novices • Kinoshita/14 PRT Prostate = OpT, less fatigue > confort • Usta/14 24 Lab tasks < time & errors Better Learning Curve • Wagner/12 34 Lab tasks < 25-70% time Save time • Storz/12 30 Lab task < errors. < time > task efficiency

• Con: No PRT in clinical setting

3.- 4k

4K resolution ➔ • Display device or content having horizontal resolution on the order of 4,000 pixels. • (UHDTV), 3840 x 2160 (at a 16:9, or 1.78:1 aspect ratio)

• Con: • Big screen • Technical evolution

5.- Robotic surgery

6.- Robotic surgeryPro: Binocular / estereoscopic image Inmersion in the operating field Freedom of movements

Con: No tactile feedback Cumbersome docking Cost

7.- Augmented reality

• Marescaux JAugmented-reality-assisted laparoscopic adrenalectomy.JAMA. 2004, 10;292, :2214-5.

• Pessaux. Towards cybernetic surgery: robotic and augmented reality-assisted liver segmentectomy. Langenbecks Arch Surg. 2014 Nov 13

• D'Agostino J, Virtual neck exploration for parathyroid adenomas: a first step toward minimally invasive image-guided surgery. JAMA Surg. 2013, 148:232-8;

Fig. 2

Journal of Pediatric Surgery 2015 50, 30-36DOI: (10.1016/j.jpedsurg.2014.10.022) Copyright © 2015 Elsevier Inc. Terms and Conditions

Courtesy Dr. Andrea Pietrabissa (Pavía, I)

8.- Beyond the conventional view: Indocyanine Green & fluorescence

• Dye developed for near infra-red (NIR) photography (Kodak, 1955) • Tricarbocyanine molecule (mass of 776 Daltons). • sterile, anionic, water-soluble • IV injection ➔ bound to plasma proteins • NO known metabolites. • Rapidly extracted & excreted by the liver (in bile < 8 min after IV )

8.- Beyond the conventional view: • injected outside blood vessels ➔ draining lymph node in 15 min.

• ICG becomes fluorescent excited by a laser beam or near infra-red (NIR) light at about 820 nm

• Fluorescence released by ICG can be detected using specifically designated scopes and camera.

• Laparoscopic equipment: full HD camera system (IMAGE 1 SPIESTM, K STORZ) Pintpointm, Firefly (intuitive)

8.- Indocyanine Green : indications • Bile duct imaging (virtual cholangiography) • Liver tumor identification during liver resection • Sentinel node identification • Bowel perfusion

• Strangulated hernia • Bowel end viability:

• Colectomy • Esophagus graft • Strangulated hernia

• Watanabe J1, Evaluation of the intestinal blood flow near the rectosigmoid junction using the indocyanine green fluorescence method in a colorectal cancer surgery. Int J Colorectal Dis. 2015 Mar;30(3):329-35.

• Kumagai Y Hemodynamics of the reconstructed gastric tube during esophagectomy: assessment of outcomes with indocyanine green fluorescence. , World J Surg. 2014 Jan;38(1):138-43.

• Ris F, Near-infrared (NIR) perfusion angiography in minimally invasive colorectal surgery. Surg Endosc. 2014 Jul;28(7):2221-6

• Sherwinter DA Intra-operative transanal near infrared imaging of colorectal anastomotic perfusion: a feasibility study. , Colorectal Dis. 2013 Jan;15(1):91-6.

Courtesy of L Boni, Varese, Italy)

Next step in minimally invasive surgery: hybrid image-guided surgery

Jacques Marescaux, Michele Diana

Journal of Pediatric Surgery Volume 50, Issue 1, Pages 30-36 (January 2015)

DOI: 10.1016/j.jpedsurg.2014.10.022

Courtesy of L Boni, Varese, Italy)

ICG and sentinel node detection

Real-time navigation by fluorescence-based enhanced reality for precise estimation of future anastomotic site in digestive surgery. Diana M, Marescaux J. Surg Endosc. 2014 Nov;28(11):3108-18

The future of Surgical Image:

Robotic surgery. Diana M, Marescaux J. Br J Surg. 2015 Jan;102(2):e15-28.

Next step in minimally invasive surgery: hybrid image-guided surgery. Marescaux J, Diana M. J Pediatr Surg. 2015 Jan;50(1):30-6

9.- Google glass

•Integrating surgery •Checklist •Comunication •Teaching/training

•Bull ACS, July 1, 2014

10.- 3D printing

• Preoperative Planning • Preoperative moulding the new prothesis • ‘Physical’ simulation • ‘Physical Augmented Reality’ • To be explored.....

Conclusions• Image viewing is the most important feature of endoscòpic surgery, and

any technical improving facilitates the reduction of operative time and incresases safety.

• 3D seem that will play an interesting role in reducing the length of learning curve and increasing the efficacy of surgery in reduced spaces.

• There is a number of ancillary techniqyes that may help to see beyond the standard screen imatge

• Obviously, the cost is an issue