Minimally invasive surgery

Minimally invasive surgery

Minimally invasive surgery refers to the set of techniques that allow the performance of more or less complex surgical procedures without the need to make large incisions in the abdomen. In practice, the various procedures are carried out through small incisions in which cameras and surgical instruments are introduced.

These categories include laparoscopic surgery and the more recent robotic surgery. The first laparoscopic surgeries date back to the 1980's while robotic surgery has been developed since 1999. The technological evolution of minimally invasive instrumentation and the research of the pioneers of these techniques allow today to perform more and more complex interventions with minimally invasive technique.

General principles

Generally, minimally invasive approaches require general anesthesia for the patient. This allows the abdomen to be inflated with low-pressure carbon dioxide (10-15 mm Hg) in order to create the necessary space inside the abdominal cavity to perform surgery. Small incisions of 0.5-1.5 cm are made in the abdomen through which plastic or metal tubes (trocar or port) are introduced to serve as introducers for the camera and surgical instruments. Most surgeries require 3 to 6 trocars. For operations that require the removal of a large surgical piece, it is sometimes necessary to make larger incisions that are usually made above the pubis to be less visible.

Thanks to the latest technology available in the operating rooms of Fondazione Poliambulanza, the cameras have a very high resolution (up to 4K) and/or allow the viewing of three-dimensional images (3D) on large screens. This allows to obtain a much more detailed and "magnified" view of anatomical details compared to traditional open surgery.

Finally, the instruments introduced vary depending on whether the surgery is laparoscopic or robotic
. In both cases, the instruments are long and small so that they can be introduced through trocars and reach the anatomical target of the surgery.

Almost all interventions are carried out without substantial changes in what are the steps of the various surgical procedures, simply by performing these steps with minimally invasive instruments and camera instead of touching and under direct vision. This is important because it must always be considered that the primary objective is and must always be to complete the intervention safely and, when appropriate, respecting the principles of oncological surgery.

Minimally invasive surgery


During laparoscopic interventions, the team consisting of at least two surgeons and an instrument nurse operate directly at the patient's bedside. The surgical instruments and the camera are operated by the surgeons who, thanks to the oculo-manual coordination acquired with experience, can perform the steps of the intervention visualizing on the monitor the movements of the instruments introduced into the abdomen.

Minimally invasive surgery


Robotic surgeries as they are conceived today are surgeries in which the surgeon is seated at a console, (i.e. a control platform) from which he has the possibility to have a 3D "immersion" view of the operating field, as well as to control through two handpieces and a foot pedal the robotic surgical instruments and the robotic camera.

At the patient's bedside there will be the assistant surgeon, the nurse instrumentalist and the robotic cart, which in the form of the DaVinci® Xi (the most advanced model from Intuitive Surgical, Inc, world leader in the sector) consists of 4 robotic arms on which cameras and various instruments are mounted.

The robotic instruments, unlike laparoscopic instruments, are therefore not directly operated by the surgeon at the patient's bedside but are controlled remotely with the interposition of a robotic system that eliminates tremor. Another important difference of robotic instrumentation is the ability to have the ends of the instruments articulate with the degrees of freedom of the human so that the movements of open surgery can be reproduced through minimally invasive access.

Advantages of minimally invasive surgery

Faster return of bowel function

the abdomen is not open and the bowel is not handled so patients regain bowel function faster and can eat and drink sooner than after open surgery

Fewer respiratory complications

rapid mobilization and less pain after surgery reduce the risk of postoperative lung infections

Shorter hospital stay

smaller incisions and less pain mean that recovery is faster

Less post-operative pain

due to smaller incisions and less tissue trauma

Less bleeding and less need for transfusion

due to more precise visualization of anatomical structures

Better cosmetic result

smaller incisions heal less visible or disfiguring

Faster resumption of work activities

thanks to rapid recovery

Additional benefits of robotic surgery

Increased surgical skills

thanks to robotic joints that can perfectly reproduce the surgeon's hand movements

Elimination of tremors

thanks to movements filtered by the robotic platform

Ergonomics for the surgeon

the surgeon can complete the procedure from the comfort of the console

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Prof. Mohammad Abu Hilal is the Director of the Department of General Surgery and Head of the Hepatobiliopancreatic, Robotic and Minimally Invasive Surgery Unit at Fondazione Poliambulanza.

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