Minimally Invasive Surgery (MIS) + NOTES + Technology + Global Surgery 🌎 💻🕹️

Question 1

What is Minimally Invasive Surgery?

Answer 1

Surgical techniques which minimal invasion to skin integrity either thro’ natural orifice or thro’ minimal skin incision

Question 2

What are the Advantages of minimally invasive surgery?

Answer 2

1. Patient
- Cosmetic
- Less morbidity
1. Less ileus from reduced handling
2. Less adhesion
3. Less skin trauma
4. Reduce surgical site infection
5. Less pain —> good breathing effort —> less respiratory complications
6. Early mobilisation —> reduce DVT
7. Early discharge /early ambulation
8. Fewer wound related complication
9. Reduced incisional hernia rate

2. Hospital
- Reduce hospital stay —> reduce cost
- Good turn over —> Provide more service to public
- Apply to day care surgery

3. Surgeon/staff
- Satisfaction
- Improve progression surgeon capability
- Magnified surgical field —>improved exposure/visualisation in obese patients or deep structure(eg pelvis during TME)
- Reduced contamination of theatre staff (Hepatitis and HIV)

Question 3

What are the disadvantages of minimally invasive surgery?

Answer 3

Hospital/ Facility :
- Cost – instrument with training
- need laparoscopic set and monitor

Patient:
- Increased costs due to equipment
- cant be done patient with chronic lung disease
- Not feasible for thin patient ( limited space)

Surgeon/ Staff
- Increased operating time

• Expertise —> certain procedure need long learning curve
  
  1. Adaptation to new technique
  2. Time consuming in the beginning
  3. Need practice —> prolong OT time —>Increased costs
• High risk of co-lateral injury —> Limiting view – injury to other organs
  
  1. CBD in lap cholecystectomy
  2. Bowel/bladder/vascular injury in hernia surgery
  3. Verres needle injury
  4. Diathermy may lead to organ damage eg late cbd stricture
• Tumor seeding-port site recurrence
• Loss of tactile sensation
• MO - Loss of training opportunity eg appendicitis and inguinal hernia
• Need more trained assistant to handle op, instrument
• Transferring image to other source – need coordination

Question 4

Talk about laparoscopic surgery

Answer 4

• Main Componend divided into:
  1) Insufflation Component ( Medium, Insufflator devices/setting)
  2) Imaging system ( laparoscopic camera)
  3) Aspiration system
• Setting:
  1. Pressure : 8-10 mmHg (max 12mmHg)
  2. Flow rate: 4-5L/min
  • Why CO2
    
    1. Non inflammable
    2. Readily absorb by system
    3. Readily excreted through the lung and kidneys
    4. Limited systemic absorption across the peritoneum
    5. Limited systemic effects when absorbed (Helium & argon —> risk of toxicity in blood is slightly higher compared to CO2)
    6. Incapable of supporting combustion (Nitrous oxide, Oxigen & air support combustion)
    7. Rapid excretion if absorbed
    8. High solubility in blood
    9. Cheap
    10. Limited physiological effect with intravascular systemic embolism

Besides carbon dioxide (CO₂), other gases that can be used for laparoscopy (insufflation) include:
- Nitrous Oxide (N₂O) – Similar to CO₂ but has mild anesthetic properties. However, it carries a risk of supporting combustion and has some concerns about potential air embolism.
- Helium (He) – Inert and non-combustible, but it has a lower solubility in blood, increasing the risk of gas embolism.
- Argon (Ar) – Rarely used due to cost and risk of embolism, but it is inert like helium.
- Room Air or Oxygen (O₂) – Generally not recommended due to the high risk of combustion in electrosurgical procedures

• Safety
  
  1. Ryle tube to decompress stomach
  2. Bladder catherization
  3. Trendelenburg‘s position
  4. Carefully positioning and padding of patients
  5. Open method for insertion camera port (aviod use of Varess needle)
  6. Remaining of port insertion under direct vision
• Complication
  
  1. Specific
     
     • Immediate
       
       1. Extra-peritoneal insufflations,
       2. Injury to intra-abdominal viscera or vessels
       3. Injury to blood vessel either of the anterior abdominal wall or in the retroperitoneum
     • Early :Pain in shoulder tip ( diaphragmatic overstretching under pressure in a pneumoperitoneum - affecting the phrenic nerve)
     • Late : Incisional hernia, metastases at port site

2. General
   
   1. Immediate
      -Inadequate oxygenation secondary to diaphragmatic splinting by excessive peritoneal insufflations or extreme head down position in an obese patient
      -Pneumothorax
      -Pneumomediastinum
      -Gas embolism
   2.Early
   1. DVT/Pulmonary embolism
   2. Hypothermia
   3. N/V

Question 5

Overview on NOTES

Answer 5

Question 6

Overview of Robotic surgery

Answer 6

Latest advances :
The hinotori™ Surgical Robot System is regulatory approved for use only in Japan.

Question 7

What is Global Surgery?

Answer 7

The World Health Organization (WHO) Global Surgery Indicators are six key metrics established under the Lancet Commission on Global Surgery (LCoGS) to assess and improve surgical care worldwide. These indicators help policymakers and healthcare providers evaluate surgical system performance, identify gaps, and implement necessary reforms.

The 6 WHO Global Surgery Indicators
1. Access to Timely Essential Surgery
Definition: The percentage of the population that can reach a surgical facility offering essential procedures within two hours.
Significance: This reflects the geographical availability of surgical services, which is crucial for conditions requiring urgent intervention (e.g., trauma, obstetric emergencies, acute abdomen).

2. Specialist Surgical Workforce Density
Definition: The number of specialist surgical providers (surgeons, anesthesiologists, and obstetricians) per 100,000 population.
Target: At least 20 per 100,000 people.
Significance: A low workforce density indicates a shortage of skilled professionals, leading to delays and poorer surgical outcomes.

3. Surgical Volume
Definition: The number of surgical procedures performed annually per 100,000 population.
Target: At least 5,000 surgeries per 100,000 population per year.
Significance: This represents the overall surgical capacity of a healthcare system. Low surgical volume often correlates with unmet surgical needs.

4. Perioperative Mortality Rate (POMR)
Definition: The percentage of patients who die within 30 days after undergoing a surgical procedure.
Significance: This is a key measure of surgical safety and quality. A high POMR suggests poor perioperative care, lack of resources, or inadequate postoperative monitoring.

5. Protection Against Catastrophic Expenditure for Surgical Care
Definition: The percentage of the population at risk of spending more than 10% of their household income on surgical care.
Significance: This assesses financial accessibility and affordability. High out-of-pocket costs can push families into poverty, discouraging them from seeking needed surgery.

6. Protection Against Impoverishing Expenditure for Surgical Care
Definition: The percentage of the population at risk of falling below the poverty line due to out-of-pocket surgical expenses.
Significance: This measures the financial burden of surgical care on economically vulnerable populations, highlighting the need for universal health coverage and financial protection mechanisms.

How to Prevent Catastrophic and Impoverishing Expenditure for Surgical Care (Indicators 5 & 6):
1. Strengthen Universal Health Coverage (UHC) & Health Insurance
🔹 Implement National Health Insurance – Expand public health insurance schemes that cover surgical and postoperative care (e.g., Malaysia’s MySalam, UK’s NHS, Thailand’s UCS).
🔹 Subsidize Surgery for Low-Income Groups – Offer free or subsidized surgical services for vulnerable populations.
🔹 Expand Private Health Insurance Participation – Encourage affordable private insurance that includes surgical coverage, with subsidies for lower-income individuals.

2. Reduce Out-of-Pocket (OOP) Payments for Surgery
🔹 Increase Government Healthcare Spending – Allocate more public funds to reduce OOP costs for surgical care.
🔹 Cap Patient Expenses – Set limits on co-payments, deductibles, or additional fees for surgeries in public hospitals.
🔹 Standardized Pricing – Regulate surgical procedure costs to prevent overcharging and price inflation.

3. Strengthen Surgical Infrastructure in Public Hospitals
🔹 Invest in Public Healthcare Facilities – Ensure regional and district hospitals have essential surgical services, reducing the need for expensive private care.
🔹 Equip Rural Hospitals – Provide necessary equipment, surgical staff, and anesthesia services to reduce patient travel costs.
🔹 Telemedicine & Referral Networks – Implement teleconsultation and structured referral systems to reduce unnecessary travel and costs.

4. Increase Availability of Essential Medicines & Surgical Supplies
🔹 Reduce the Cost of Surgical Equipment & Drugs – Governments should negotiate lower prices for essential surgical supplies, including anesthesia and sutures.
🔹 Promote Local Manufacturing – Develop local production of surgical instruments and pharmaceuticals to lower costs.
🔹 Implement Bulk Purchasing Agreements – Use collective bargaining for essential drugs and equipment (e.g., WHO’s Global Fund Procurement Mechanisms).

5. Expand Financial Assistance & Social Protection Programs
🔹 Surgical Care Assistance Funds – Set up government or donor-funded programs to support low-income and uninsured patients.
🔹 Microfinance & Loans for Health Care – Provide zero-interest or low-interest loans for surgical procedures.
🔹 Employer-Based Health Benefits – Encourage companies to provide surgical coverage in employee health benefits.

6. Strengthen Governance & Policy Reforms
🔹 Implement Surgical Price Regulations – Prevent unfair pricing by setting standard costs for common surgical procedures.
🔹 Improve Transparency in Billing – Ensure hospitals provide clear and upfront pricing for surgical procedures.
🔹 Monitor & Track Financial Protection Indicators – Governments should use data from Indicators 5 & 6 to adjust policies and improve access to affordable surgical care.

Question 8

Overview of Computer in Surgery

Answer 8

SOFIE, or Surgeon’s Operating Force-feedback Interface Eindhoven, is a surgical robot that was developed at Eindhoven University of Technology. It was the first surgical robot to incorporate force feedback.

Question 9

POMR death Category

Answer 9

Question 10

Advances or new technologies in endoscopy

Answer 10

Red dichromatic imaging (RDI) is a novel image-enhanced endoscopy technique that uses green, amber, and red wavelengths to enhance the visibility of deep blood vessels and bleeding points, aiding in quicker and safer hemostasis during endoscopic procedures.

Magnetic compression anastomosis (MCA) is a novel, minimally invasive surgical technique that uses magnetic attraction to create connections (anastomoses) between tubular structures, like the intestines, offering an alternative to traditional surgery for certain conditions