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EM Targarona Servicio de Cirugía Hospital de Santpau. UAB Barcelona

Innovaciones en Cirugía Minimamente Invasiva

Sociedad Valenciana de Cirugia 28-29 de enero de 2016

27 años de Cirugia Laparoscópica“ Laparoscopic surgery represents a rare instance in surgical history where an advance has been so profound in patient benefit in so short a period of time”. Prof Sir A. Cuschieri

1929

1904

2011

CCD Couple Charge Device

1950➔ Open surgery HPB surgery Trasplantation

1987 ➔ Minimally invasive Surgery Wickham, J, CCD, Cirugía laparoscópica Robotic surgery, needlescopy 2004➔ N.O.T.E.S. Rao, 2005 / Apollo group (Tsin, DA 1991)

2007 ➔ Single Port Curcillo, PG (Navarra, G, 1997, Davila F. (Cirugía sin huella)

2011 ➔ Reduced Port Surgery Curcillo, PG

Medicina Basada en la Evidencia i MIS(Pubmed 26.2.12)

PRT Metananalisis C Consenso Recomendación •Apendicectomia 108 20 10 uso selectivo

• Hernia 276 41 6 uso selectivo • CxLap 801 59 20 GOLD STANDARD • Nissen 151 22 3 GOLD STANDARD • Adrenal 64 0 3 GOLD STANDARD • Acalasia 12 4 0 GOLD STANDARD •Esplenectomia 3 4 3 GOLD STANDARD •Bariátrica 142 19 10 GOLD STANDARD

•Colon 123 30 4 Recomendable

•Estomago 32 12 1 uso selectivo

•Páncreas 0 3 0 en desarrollo

•Hígado 5 10 7 en desenvolupament •

- Open surgery

- Hand assisted laparoscopc surgery

- Standard laparoscopy: (5-10 mm)

- Minilaparoscopy: (2-3,5 mm)

- Single port / Reduced port access

- N.O.T.E.S. / TEM

- Flexible endoscopy

- RF / HIFU

Avances en Cirugia Minímamente Invasiva

• Imagen • Consolidación indicaciones clinicas • La herencia del NOTES

• TaTME • Endoscopia intervencionista

• Big Data

Avances en Cirugía Minímamente Invasiva

• Imagen • Consolidación indicaciones clínicas • La herencia del NOTES

• POEM

• Endoscopia intervencionista

• Big Data

Consolidación de Indicaciones / técnicas avanzadas

• Gastrectomía • Pancreatectomía distal • Hepatectomía • Esofagectomía • Whipple

• Single port ??

• Peter Goh, 1992 • Técnica bien introducida en la práctica clínica en oriente • Técnicamente compleja

• Espécimen voluminoso • Cirugía oncológica

• Linfadenectomía D1-D2 • Múltiples pedículos vasculares

• Desarrollo en paralelo a la cirugía bariátrica • Anastomosis intracorpórea

• Medicina basada en la evidencia • Estudios PRT (KLASS, STOMACH)

Gastrectomía laparoscópica por cáncer

• Wakabayashi G1 Recommendations for laparoscopic liver resection: a report from the second international consensus conference held in Morioka. Ann Surg. 2015, 261:619-29.

2º International Consensus Conference on Laparoscopic Liver Resections (4-6/10/14 ) Benefits and risks of LLR. GRADE and Balliol Classification of IDEAL. - MINOR LLRs ➔ standard practice (IDEAL 3) - MAJOR LLRs ➔ still innovative procedures in the exploration phase (IDEAL 2b). - Cautious introduction of MAJOR LLRs - Need for a structured education because of the steep learning curve.

Moreno P

1

, Adrenalectomy for solid tumor metastases: results of a multicenter European study. Surgery. 2013, 154:1215-22

✓ N: 317 , 30 European centers. ✓ Non-small cell lung , Colorectal, Renal cell carcinoma.

• M1 synchronous (≤6 months) ➔ 73 (23%) • Isolated m1 ➔ 213 (67%). • Median disease-free interval ➔ 18.5 m. • Laparoscopic resection ➔ 46% • Surgery limited to the adrenal gland ➔ 73% • R0 ➔ 86% • Median overall survival ➔ 29 m. • Survival rates ➔ 3 yrs ➔ 42%

➔ 5 yrs ➔ 35%

Single Port

.Needle Endograb 2,3mm (Minilap, Stryker)

Liver endoretractor

Endoretractor (Endograb)

Single port• Factible • Incremento dificultad técnica • Potenciales ventajas estéticas • Definitivas ventajas clínicas? • Morbilidad incisión accesoria (ombligo)

Avances en Cirugia Mínimamente Invasiva

• Imagen • Consolidación indicaciones clinicas • La herencia del NOTES

• TaTME • Endoscopia intervencionista

• Big Data

•Cirugia del cáncer de recto:

•Avances en técnica quirurgica

•1900 Miles (APR) •1940 Dixon (RAB) •1979 Heald (TME) •2000 Abordaje laparoscópico •2012 TaTME ???

Original Article A Randomized Trial of Laparoscopic versus Open

Surgery for Rectal Cancer

the COLOR II Study Group

N Engl J Med Volume 372(14):1324-1332

2015 April 2, 2015

COLOR II Sites

Europe

Involved Circumferential Resection Margin and Locoregional Recurrence.

Bonjer HJ et al. N Engl J Med 2015;372:1324-1332

Open Lap

Succesful 89% 82% CRM - 97% 93% Distal Margin 99% 99% Quality mesorectum 92% 87%

Surgical technique

•Achilles talon of lap LAR •Avoid múltiple firings •LAR + ChT-RT + LAP ➔ Ileostomy

N: 1609 patients wits sphincter preservation LAR 11 Hospitals ➔ years 2006-2009 Leakage rate ➔ 6,3%

Multivariate analysis Factors related to anastomositc leakage

• Patients without ileostomy *1187 • Male sex HR 3.4 • Advanced tumour HR 2.5 • Lower tumour HR 2.4 • Preop RT HR 6.3 • Transfusion HR 10.7 • Multiple firings HR 6.2

Scarpinata R, Does robotic rectal cancer surgery offer improved early postoperative outcomes? Dis Colon Rectum. 2013, 56:253-62. The current evidence suggests that robotic rectal surgery could potentially offer better short-term outcomes especially when applied in selected patients. Obesity, male sex, preoperative radiotherapy, and tumors in the lower two-thirds of the rectum may represent selection criteria for robotic surgery to justify its increased cost.

ROLARR 2015 Estudio PRT lap vs Robot low rectal cancer NO ventajas para el robot

TaTME• Ventajas:

• Acceso amplio 1/3 inferior recto

• Inconvenientes: • Montaje y utillaje: 2 torres /equipos dedicados • Anastomosis ultrabaja / coloanal • Funcionalidad anorectal postop

• Aplicabilidad: • Pelvis estrechas • Lesiones por encima 5 cm

POEM

Acalasia ➔ El futuro

✓Pasricha PJ, et al. Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia. Endoscopy. 2007;39:761-4.

✓Mathew A, et al. . Heller-type cardiomyotomy using NOTES. Endoscopy. 2008;40:352.

✓Perretta S. Heller myotomy and intraluminal fundoplication: a NOTES technique., Surg Endosc. 2010 Apr 29

✓Inoue H, et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy. 2010, 42:265-71. N: 17 12 cm submucosal tunnel 8 cm endoscopic myotomy

Results: ➔ Dysphagia symptom score (10 to 1.3, p< .0003) ➔ Resting LES pressure (52 mmHg to 19.9 mmHg, p<.0001). ➔ No morbidity ➔ Follow-up (mean 5 m) : 1/17 IBP

S Peretta y J Marescaux, IRCAD EITS 2009

The use of over the scope clip (OTSC) device for sleeve gastrectomy leak.

Aly A, Lim HK. J Gastrointest Surg. 2013 Mar;17(3):606-8.

Mucosectomía como mecanismo antireflujo

Inspiración Espiración

Resección submucosa tumores benignos del esófago

Plicatura endoluminal

• Pose

• Apollo

Avances en Cirugía Minímamente Invasiva

• Imagen • Consolidación indicaciones clínicas • La herencia del NOTES

• TaTME • Endoscopia intervencionista

• Big Data

Kemp JA, Finlayson SR. Outcomes of laparoscopic and open colectomy: a national population-based comparison. Surg Innov. 2008, 15:277-83.

Nationwide Inpatient Sample USA 2000 to 2004 Adjusted for patient characteristics and co morbidities

Lap OPEN p

• In-hospital mortality 0.6% 1.7%, < .001 • Overall complication rate 32 % 38 % < .001 • Median hospital stay 5 7 days < .001 • Wound complications 0.8% 1.4 % < .001 • Cardiovascular 12 % 15 % < .001 • Pulmonary 6 % 9 % < .001 • Gastrointestinal 14 % 16 % < .001 • Reintervention rate 1.3 % 1.7 % = .02

Conclusions Outcome benefits of laparoscopic colectomy previously demonstrated in clinical

trials are observed on a population level.

Kiran RP1, Laparoscopic approach significantly reduces surgical site infections after colorectal surgery: data from national surgical quality improvement program. J Am Coll Surg. 2010 Aug;211(2):232-8.

STUDY DESIGN: NSQIP database from 2006 to 2007

10,979 patients - LAP 31.1% - Open 68.9%

SSI rate ➔ 14.0%

- Lap 9.5% - Open 6.1% (p < 0.001).

CONCLUSIONS: The LAP approach is independently associated with a reduced SSI when compared with open surgery and should, when feasible, be considered for colon and rectal conditions.

Mungo B1, Thirty-day outcomes of paraesophageal hernia repair using the NSQIP database: should laparoscopy be the standard of care? J Am Coll Surg. 2014 Aug;219(2):229-36.

2005 to 2011,

N: 8,186 78.4% ➔ lap 19.2% ➔ Open abdominal 2.4% ➔ Open thoracic TT

RESULTS:

Mortality: Stay: Transabdominal 2.6% 7.8 d Lap 0.5% (p < 0.001) 3.3 d TT 1.5% 6.5 d CONCLUSIONS: In the absence of published data indicating improved long-term outcomes after open TA or TT approach, our findings support the use of laparoscopy, whenever technically feasible, because it yields improved short-term outcomes.

N: 63950

Lap: 8.%

Open: 92%

The Balliol Colloquium a group of clinicians and methodologists who took part in three conferences at Balliol College, University of Oxford, UK, on the topic of surgical innovation and evaluation (organised by Jonathan L Meakins) between 2007 and 2009.

Conclusiones

• El abordaje laparoscópico se ha convertido en un procedimiento habitual en la mayoría de los hospitales para las indicaciones mejor establecidas.

• Todavía faltan años/experiencia par consolidar indicaciones avanzadas

• Los avances actuales en Cirugia Endoscópica se concretan en la evolución de la tecnología auxiliar y el refinamiento de técnicas seleccionadas

• Un área con especial posibilidad de desarrollo corresponde a la endoscopia flexible terapéutica

Hospital de la Santa Creu i Sant Pau