10 Principles of minimal access surgery

Analgesia
Analgesia
The type and extent of  analgesic requirement will depend on both the patient and procedural factors. Prior experience of  opiate analgesia may increase patient tolerance to similar agents, necessitating larger doses. There is also evidence to suggest that those patients struggling with chronic pain preoperatively often present a more complex postoperative analgesic problem. The extent and region of  surgery will also dictate the analgesic regimen. For example, even mini mal access thoracic surgical procedures commonly require patient-controlled opiate analgesia with or without local nerve blockade (intercostal or paravertebral) in the initial 48 hours after surgery . T his may be avoided for some abdominal surgery by careful use of  non-steroidal agents and paracetamol. Opiate analgesics cause nausea, impair gut motility and should be avoided unless the pain is very severe. When pain is dispropor tionate to the presenting problem, suspect a complication (see also Chapter 23 ). Analgesia
The type and extent of  analgesic requirement will depend on both the patient and procedural factors. Prior experience of  opiate analgesia may increase patient tolerance to similar agents, necessitating larger doses. There is also evidence to suggest that those patients struggling with chronic pain preoperatively often present a more complex postoperative analgesic problem. The extent and region of  surgery will also dictate the analgesic regimen. For example, even mini mal access thoracic surgical procedures commonly require patient-controlled opiate analgesia with or without local nerve blockade (intercostal or paravertebral) in the initial 48 hours after surgery . T his may be avoided for some abdominal surgery by careful use of  non-steroidal agents and paracetamol. Opiate analgesics cause nausea, impair gut motility and should be avoided unless the pain is very severe. When pain is dispropor tionate to the presenting problem, suspect a complication (see also Chapter 23 ). Analgesia
The type and extent of  analgesic requirement will depend on both the patient and procedural factors. Prior experience of  opiate analgesia may increase patient tolerance to similar agents, necessitating larger doses. There is also evidence to suggest that those patients struggling with chronic pain preoperatively often present a more complex postoperative analgesic problem. The extent and region of  surgery will also dictate the analgesic regimen. For example, even mini mal access thoracic surgical procedures commonly require patient-controlled opiate analgesia with or without local nerve blockade (intercostal or paravertebral) in the initial 48 hours after surgery . T his may be avoided for some abdominal surgery by careful use of  non-steroidal agents and paracetamol. Opiate analgesics cause nausea, impair gut motility and should be avoided unless the pain is very severe. When pain is dispropor tionate to the presenting problem, suspect a complication (see also Chapter 23 ).

DEFINITION
DEFINITION
Minimal access surgery is a product of  modern technology and surgical innovation that aims to accomplish surgical ther apeutic goals with minimal somatic and psychological trauma. This type of  surgery has reduced wound access trauma and is less disfiguring than conventional techniques. It can o ff er cost-e ff ectiveness to both health services and employ ers by shortening operating times, shortening hospital stays, improv ing operative precision compared with open surgery in some (but not all) cases and allowing faster recuperation. DEFINITION
Minimal access surgery is a product of  modern technology and surgical innovation that aims to accomplish surgical ther apeutic goals with minimal somatic and psychological trauma. This type of  surgery has reduced wound access trauma and is less disfiguring than conventional techniques. It can o ff er cost-e ff ectiveness to both health services and employ ers by shortening operating times, shortening hospital stays, improv ing operative precision compared with open surgery in some (but not all) cases and allowing faster recuperation. DEFINITION
Minimal access surgery is a product of  modern technology and surgical innovation that aims to accomplish surgical ther apeutic goals with minimal somatic and psychological trauma. This type of  surgery has reduced wound access trauma and is less disfiguring than conventional techniques. It can o ff er cost-e ff ectiveness to both health services and employ ers by shortening operating times, shortening hospital stays, improv ing operative precision compared with open surgery in some (but not all) cases and allowing faster recuperation.

DISCHARGE FROM HOSPITAL
DISCHARGE FROM HOSPITAL
The discharge of  patients is based on clinical indicators and the patient’s fitness for recuperating in a non-hospital environ - ment. One of  the core drivers for the application of minimally invasive surgery is an earlier recovery and therefore discharge from hospital. Pa tients should not be discharged until they are comfortable, have passed urine and are eating and drinking Principles of minimal access surgery /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF satisfactorily . They should be told that if  they develop worsen ing pain or other severe symptoms they should return to the hospital or to their general practitioner. Even for more major cases, some units have demonstrated safe and feasible protocols for a 23-hour stay .
Meticulous care in the creation of a pneumoperitoneum
Controlled dissection of adhesions
Adequate exposure of operative
/f_i
eld
Avoidance and control of bleeding
Avoidance of organ injury
Avoidance of diathermy damage
Vigilance in the postoperative period
DISCHARGE FROM HOSPITAL
The discharge of  patients is based on clinical indicators and the patient’s fitness for recuperating in a non-hospital environ - ment. One of  the core drivers for the application of minimally invasive surgery is an earlier recovery and therefore discharge from hospital. Pa tients should not be discharged until they are comfortable, have passed urine and are eating and drinking Principles of minimal access surgery /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF satisfactorily . They should be told that if  they develop worsen ing pain or other severe symptoms they should return to the hospital or to their general practitioner. Even for more major cases, some units have demonstrated safe and feasible protocols for a 23-hour stay .
Meticulous care in the creation of a pneumoperitoneum
Controlled dissection of adhesions
Adequate exposure of operative
/f_i
eld
Avoidance and control of bleeding
Avoidance of organ injury
Avoidance of diathermy damage
Vigilance in the postoperative period
DISCHARGE FROM HOSPITAL
The discharge of  patients is based on clinical indicators and the patient’s fitness for recuperating in a non-hospital environ - ment. One of  the core drivers for the application of minimally invasive surgery is an earlier recovery and therefore discharge from hospital. Pa tients should not be discharged until they are comfortable, have passed urine and are eating and drinking Principles of minimal access surgery /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF satisfactorily . They should be told that if  they develop worsen ing pain or other severe symptoms they should return to the hospital or to their general practitioner. Even for more major cases, some units have demonstrated safe and feasible protocols for a 23-hour stay .
Meticulous care in the creation of a pneumoperitoneum
Controlled dissection of adhesions
Adequate exposure of operative
/f_i
eld
Avoidance and control of bleeding
Avoidance of organ injury
Avoidance of diathermy damage
Vigilance in the postoperative period

Direct robotic systems and hybrid robotic surgery
Direct robotic systems and hybrid robotic surgery
In addition to the remote master–slave platform design, direct robot systems also exist. Each of these systems o ff ers di ff erent advantages to the operating surgeon, ranging from reducing the need for assistants and providing better ergonomic operating positions to providing experienced guidance from surgeons not physically present in the operating theatre. Examples include: /uni25CF tremor suppression robots; /uni25CF active guidance systems; /uni25CF articulated mechatronic devices; /uni25CF force control systems; /uni25CF haptic feedback devices. Direct robotic systems and hybrid robotic surgery
In addition to the remote master–slave platform design, direct robot systems also exist. Each of these systems o ff ers di ff erent advantages to the operating surgeon, ranging from reducing the need for assistants and providing better ergonomic operating positions to providing experienced guidance from surgeons not physically present in the operating theatre. Examples include: /uni25CF tremor suppression robots; /uni25CF active guidance systems; /uni25CF articulated mechatronic devices; /uni25CF force control systems; /uni25CF haptic feedback devices. Direct robotic systems and hybrid robotic surgery
In addition to the remote master–slave platform design, direct robot systems also exist. Each of these systems o ff ers di ff erent advantages to the operating surgeon, ranging from reducing the need for assistants and providing better ergonomic operating positions to providing experienced guidance from surgeons not physically present in the operating theatre. Examples include: /uni25CF tremor suppression robots; /uni25CF active guidance systems; /uni25CF articulated mechatronic devices; /uni25CF force control systems; /uni25CF haptic feedback devices.

Disadvantages of robotic surgery
Disadvantages of robotic surgery
Cost Robotic surgery remains more costly than minimally invasive alternatives. Through upscaling of  use between surgical specialties, the direct costs of  purchasing a novel robotic system can be partially o ff set; however, consumable costs remain high. When compared with open techniques, robotic surgical procedures can reduce hospital stay , thus in part o ff setting this expenditure; however, it remains di ffi cult to demonstrate significant improvement in length of  stay or clinical outcomes when compared with other minimally invasive alternatives. Another consideration is the increased operating time and overall learning curve requirement when establishing a robotic surgical programme. While some specialties have reported shorter learning curves than in the early days of  laparoscopic surgery , this is highly heterogeneous, across both specialties and practitioners. Furthermore, although shared interspecialty
Figure 10.3
Robotic theatre set-up demonstrating the da Vinci Xi sys
tem. The surgeon and trainee surgeon are positioned at joint consoles
remote from the operating table with the surgical assistant and scrub
nurse at the bedside (courtesy of Mr Tom Routledge, Guy’s and St
Thomas’ NHS Foundation Trust, London, UK).
quently reduces the access opportunities for each individual user, potentially prolonging the learning curve. Disadvantages of robotic surgery
Cost Robotic surgery remains more costly than minimally invasive alternatives. Through upscaling of  use between surgical specialties, the direct costs of  purchasing a novel robotic system can be partially o ff set; however, consumable costs remain high. When compared with open techniques, robotic surgical procedures can reduce hospital stay , thus in part o ff setting this expenditure; however, it remains di ffi cult to demonstrate significant improvement in length of  stay or clinical outcomes when compared with other minimally invasive alternatives. Another consideration is the increased operating time and overall learning curve requirement when establishing a robotic surgical programme. While some specialties have reported shorter learning curves than in the early days of  laparoscopic surgery , this is highly heterogeneous, across both specialties and practitioners. Furthermore, although shared interspecialty
Figure 10.3
Robotic theatre set-up demonstrating the da Vinci Xi sys
tem. The surgeon and trainee surgeon are positioned at joint consoles
remote from the operating table with the surgical assistant and scrub
nurse at the bedside (courtesy of Mr Tom Routledge, Guy’s and St
Thomas’ NHS Foundation Trust, London, UK).
quently reduces the access opportunities for each individual user, potentially prolonging the learning curve. Disadvantages of robotic surgery
Cost Robotic surgery remains more costly than minimally invasive alternatives. Through upscaling of  use between surgical specialties, the direct costs of  purchasing a novel robotic system can be partially o ff set; however, consumable costs remain high. When compared with open techniques, robotic surgical procedures can reduce hospital stay , thus in part o ff setting this expenditure; however, it remains di ffi cult to demonstrate significant improvement in length of  stay or clinical outcomes when compared with other minimally invasive alternatives. Another consideration is the increased operating time and overall learning curve requirement when establishing a robotic surgical programme. While some specialties have reported shorter learning curves than in the early days of  laparoscopic surgery , this is highly heterogeneous, across both specialties and practitioners. Furthermore, although shared interspecialty
Figure 10.3
Robotic theatre set-up demonstrating the da Vinci Xi sys
tem. The surgeon and trainee surgeon are positioned at joint consoles
remote from the operating table with the surgical assistant and scrub
nurse at the bedside (courtesy of Mr Tom Routledge, Guy’s and St
Thomas’ NHS Foundation Trust, London, UK).
quently reduces the access opportunities for each individual user, potentially prolonging the learning curve.

Drains
Drains
The use of postoperative drains depends on the operation performed. Drain output should initially be documented at least hourly or more regularly in the event of  concern regard - ing high drain output. Given the heterogeneity of drainage - systems available it is paramount that nursing sta ff are familiar with the system used. The exact loca tion and size of  any drains should be clearly documented in the operation notes and the tubing labelled accordingly . This avoids inadvertent removal of the wrong drain or confusion for the ward team. Continued blood loss from a drain is an indication for re-exploration and should be immediately highlighted to the operating surgeon. - Drains
The use of postoperative drains depends on the operation performed. Drain output should initially be documented at least hourly or more regularly in the event of  concern regard - ing high drain output. Given the heterogeneity of drainage - systems available it is paramount that nursing sta ff are familiar with the system used. The exact loca tion and size of  any drains should be clearly documented in the operation notes and the tubing labelled accordingly . This avoids inadvertent removal of the wrong drain or confusion for the ward team. Continued blood loss from a drain is an indication for re-exploration and should be immediately highlighted to the operating surgeon. - Drains
The use of postoperative drains depends on the operation performed. Drain output should initially be documented at least hourly or more regularly in the event of  concern regard - ing high drain output. Given the heterogeneity of drainage - systems available it is paramount that nursing sta ff are familiar with the system used. The exact loca tion and size of  any drains should be clearly documented in the operation notes and the tubing labelled accordingly . This avoids inadvertent removal of the wrong drain or confusion for the ward team. Continued blood loss from a drain is an indication for re-exploration and should be immediately highlighted to the operating surgeon. -

Endoluminal endoscopy and natural orifice surgery
Endoluminal endoscopy and natural orifice surgery
Flexible or rigid endoscopes are introduced into hollow organs or systems, such as the urinary tract, upper or lower gastrointestinal tract and the respiratory and vascular systems. Advances in endoluminal technology now enable more complex procedures to be completed endoscopically where previous transabdominal or transthoracic surgical resection would have been advocated. Examples include endoscopic submucosal resection of  complex colonic polyps, transanal endoscopic microsurgery and endobronchial laser resection of tracheal pathology . Natural orifice translumenal endoscopic surgery (NOTES) o ff ers the opportunity for ‘scar-free’ surgery by performing entire procedures via natural body orifices. While these tech niques have been applied in the pelvis, abdomen and thorax, technical limitations and safety concerns have limited adop tion. Concern over closure of  the visceral puncture site is the principal issue that has prevented widespr ead uptake, as trans gastric and transcolonic closure of  peritoneal entry sites in a safe manner remains problematic. In addition, there ar nificant cost and training implications that have limited more widespread adoption. Endoluminal endoscopy and natural orifice surgery
Flexible or rigid endoscopes are introduced into hollow organs or systems, such as the urinary tract, upper or lower gastrointestinal tract and the respiratory and vascular systems. Advances in endoluminal technology now enable more complex procedures to be completed endoscopically where previous transabdominal or transthoracic surgical resection would have been advocated. Examples include endoscopic submucosal resection of  complex colonic polyps, transanal endoscopic microsurgery and endobronchial laser resection of tracheal pathology . Natural orifice translumenal endoscopic surgery (NOTES) o ff ers the opportunity for ‘scar-free’ surgery by performing entire procedures via natural body orifices. While these tech niques have been applied in the pelvis, abdomen and thorax, technical limitations and safety concerns have limited adop tion. Concern over closure of  the visceral puncture site is the principal issue that has prevented widespr ead uptake, as trans gastric and transcolonic closure of  peritoneal entry sites in a safe manner remains problematic. In addition, there ar nificant cost and training implications that have limited more widespread adoption. Endoluminal endoscopy and natural orifice surgery
Flexible or rigid endoscopes are introduced into hollow organs or systems, such as the urinary tract, upper or lower gastrointestinal tract and the respiratory and vascular systems. Advances in endoluminal technology now enable more complex procedures to be completed endoscopically where previous transabdominal or transthoracic surgical resection would have been advocated. Examples include endoscopic submucosal resection of  complex colonic polyps, transanal endoscopic microsurgery and endobronchial laser resection of tracheal pathology . Natural orifice translumenal endoscopic surgery (NOTES) o ff ers the opportunity for ‘scar-free’ surgery by performing entire procedures via natural body orifices. While these tech niques have been applied in the pelvis, abdomen and thorax, technical limitations and safety concerns have limited adop tion. Concern over closure of  the visceral puncture site is the principal issue that has prevented widespr ead uptake, as trans gastric and transcolonic closure of  peritoneal entry sites in a safe manner remains problematic. In addition, there ar nificant cost and training implications that have limited more widespread adoption.

Endoscopic surgery
Endoscopic surgery
Lack of three-dimensional vision To perform minimal access surgery with safety , the surgeon must operate using an imaging system that provides a two-dimensional (2D) representation of  the operative site. The endoscope o ff ers a whole new anatomical landscape, which the surgeon must learn to navigate without the usual ‘open approach’ clues that make it easy to judge depth. The instruments are longer and sometimes more complex to use than those commonly used in open surgery . This results in the novice being faced with significant problems of  hand–eye coordination. There is a well-described learning curve for novice surgeons and experienced ‘open’ surgeons when adopt - ing the minimally invasive approach. Simulation training and mentoring are required to attain competence. Three-dimensional (3D) imaging systems are available b ut are expensive and currently are not commonplace. Many sur - geons feel that endoscopic 3D technology does not yet o ff er the technical enhancement necessary to improve safety . Indeed, - 3D technology has been associated with ergonomic problems - such as headache without quantifiable benefit in terms of  accu - racy and time to perform directed tasks. Future improvements in these systems carry the potential to enhance manipulative ability in critical procedures, such as knot tying and dissection of  closely overlapping tissues. There are , however, some draw - backs, such as reduced display brightness and interference with normal vision because of  the need to wear specially designed glasses for some systems. It is likely that brighter projection displays will be developed; however, the need to w ear glasses is not easily overcome. These factors currently limit stereoscopic straight stick endoscopic surgery , which has largely been super - seded by the development of robotic technology incorporating 3D vision. Minimal access surgery can be more technically demanding and slower to perform than conventional open surgery . On occasion, a minimally invasive operation is so technically demanding that both patient and surgeon would be better served by conversion to an open procedure. Prolonged anaesthetic and operative times may negate a number of the beneficial e ff ects of  minimal access surgery and increase the risk of  respiratory and wound complications as well as compression neuropathy and venous thromboembolism. It is vital for surgeons and patients to appreciate that the decision to convert to an open operation is not a complication but, instead, usually implies sound surgical judgement in favour of  patient safety . Control of bleeding and haemostasis Haemostasis may be di ffi cult to achieve endoscopically because blood may obscure the field of  vision with reduced image quality owing to light absorption. Experienced surgeons may be able to manage a degree of  bleeding via an endoscopic approach; however, this requires a significant degree of  experience and skill to be achieved safely . Such scenarios are also reliant on an experienced assistant able to reduce visual loss through optimal camera positioning. It should be remembered that a situation of  controlled conversion can easily become uncontrolled, negating any benefit a minimally access approach would have achieved. Advanced electrosurgery/diathermy and laser technology have improved dissection precision and haemostatic e ffi cacy in endoscopic surgery . Ultrasonic dissection and tissue devices continue to evolve with incremental technical improve ments and surgeons are increasingly familiar with their use. Some devices now combine the functions of three or four sep ara te instruments, reducing the need for instrument exchanges during a procedure. This flexibility , combined with the abil ity to provide a clean, smoke-free field, facilitates dissection, improves haemostasis and reduces operating times . Loss of tactile feedback Minimal access surgery is associated with some loss of tactile feedback, although this is less with straight stick endoscopy than with robotic procedures. This is an area of  ongoing research in haptics and biofeedback systems. Early work suggested that laparoscopic ultrasonography might be a substitute for the need to ‘feel’ in intraoperative decision-making. Rather than producing tactile feedback, endoscopic ultrasound provides a visual representation of  structures that in open surgery would rely on palpation for accurate localisation and appraisal. Widely used examples include appraisal of  nodal disease in cancer surgery and biliary tract exploration. Tissue extraction Large pieces of  tissue, such as the lung or colon, may have to be extracted from the body cavity following resection. In some circumstances this significantly increases the surgical trauma of  the procedure that could otherwise be carried out via two or three small port incisions. Although tissue ‘morcellators, mincers and liquidisers’ can be used in some circumstances, morphology and cannot be used in surgery for malignancy . Typically , extraction is performed by enlarging one incision so as to facilitate remov al without disruption to the specimen. Strategies to reduce surgical trauma have been considered. These include removal of lung via a subxiphoid approach so as to reduce intercostal neuropraxia or natural orifice extraction of abdominal resection specimens. However, such approaches are themselves associated with di ff erent complications such as herniation and injury to structures outside the direct operative field. While tumour implantation and localisation at port sites initially raised important questions about the future of  the laparoscopic treatment of malignancy , large-scale trials have shown concer ns to be minimised by appropriate tissue han - dling, separating any tumours by bagging, irrigation and pro - tecting the extraction site. Cost Initially high consumable costs and factors such as surgical learning curve and high conversion rates led to increased costs of  minimal access approaches compared with their open equivalents. This is now largely no longer the case for straight stick endoscopic surgery such as laparoscopy and thoracoscopy . Indeed, despite higher direct consumable costs, improvements in outcomes, hospital stay and general upscaling of  the proce - dural volume have resulted in improved cost-e ff ectiveness for many minimal access procedures. Future reductions in the costs of  image-processing technol - ogy will result in a wide range of  transformed presenta tions fusion becoming available. It should ultimately be possible for a sur - - geon to access any view of  the operative region accessible to a camera and present it stereoscopically in any siz e or orienta - - tion, superimposed on past images taken in other modalities. Such augmented reality systems continue to improve and are - discussed in more detail below . Summary box 10.2 Limitations of minimal access surgery /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF
Lack of 3D vision
Loss of tactile feedback
Haemostasis
Extraction of large specimens
Learning curve and increased operative time
Cost
Reliance on new technologies
Endoscopic surgery
Lack of three-dimensional vision To perform minimal access surgery with safety , the surgeon must operate using an imaging system that provides a two-dimensional (2D) representation of  the operative site. The endoscope o ff ers a whole new anatomical landscape, which the surgeon must learn to navigate without the usual ‘open approach’ clues that make it easy to judge depth. The instruments are longer and sometimes more complex to use than those commonly used in open surgery . This results in the novice being faced with significant problems of  hand–eye coordination. There is a well-described learning curve for novice surgeons and experienced ‘open’ surgeons when adopt - ing the minimally invasive approach. Simulation training and mentoring are required to attain competence. Three-dimensional (3D) imaging systems are available b ut are expensive and currently are not commonplace. Many sur - geons feel that endoscopic 3D technology does not yet o ff er the technical enhancement necessary to improve safety . Indeed, - 3D technology has been associated with ergonomic problems - such as headache without quantifiable benefit in terms of  accu - racy and time to perform directed tasks. Future improvements in these systems carry the potential to enhance manipulative ability in critical procedures, such as knot tying and dissection of  closely overlapping tissues. There are , however, some draw - backs, such as reduced display brightness and interference with normal vision because of  the need to wear specially designed glasses for some systems. It is likely that brighter projection displays will be developed; however, the need to w ear glasses is not easily overcome. These factors currently limit stereoscopic straight stick endoscopic surgery , which has largely been super - seded by the development of robotic technology incorporating 3D vision. Minimal access surgery can be more technically demanding and slower to perform than conventional open surgery . On occasion, a minimally invasive operation is so technically demanding that both patient and surgeon would be better served by conversion to an open procedure. Prolonged anaesthetic and operative times may negate a number of the beneficial e ff ects of  minimal access surgery and increase the risk of  respiratory and wound complications as well as compression neuropathy and venous thromboembolism. It is vital for surgeons and patients to appreciate that the decision to convert to an open operation is not a complication but, instead, usually implies sound surgical judgement in favour of  patient safety . Control of bleeding and haemostasis Haemostasis may be di ffi cult to achieve endoscopically because blood may obscure the field of  vision with reduced image quality owing to light absorption. Experienced surgeons may be able to manage a degree of  bleeding via an endoscopic approach; however, this requires a significant degree of  experience and skill to be achieved safely . Such scenarios are also reliant on an experienced assistant able to reduce visual loss through optimal camera positioning. It should be remembered that a situation of  controlled conversion can easily become uncontrolled, negating any benefit a minimally access approach would have achieved. Advanced electrosurgery/diathermy and laser technology have improved dissection precision and haemostatic e ffi cacy in endoscopic surgery . Ultrasonic dissection and tissue devices continue to evolve with incremental technical improve ments and surgeons are increasingly familiar with their use. Some devices now combine the functions of three or four sep ara te instruments, reducing the need for instrument exchanges during a procedure. This flexibility , combined with the abil ity to provide a clean, smoke-free field, facilitates dissection, improves haemostasis and reduces operating times . Loss of tactile feedback Minimal access surgery is associated with some loss of tactile feedback, although this is less with straight stick endoscopy than with robotic procedures. This is an area of  ongoing research in haptics and biofeedback systems. Early work suggested that laparoscopic ultrasonography might be a substitute for the need to ‘feel’ in intraoperative decision-making. Rather than producing tactile feedback, endoscopic ultrasound provides a visual representation of  structures that in open surgery would rely on palpation for accurate localisation and appraisal. Widely used examples include appraisal of  nodal disease in cancer surgery and biliary tract exploration. Tissue extraction Large pieces of  tissue, such as the lung or colon, may have to be extracted from the body cavity following resection. In some circumstances this significantly increases the surgical trauma of  the procedure that could otherwise be carried out via two or three small port incisions. Although tissue ‘morcellators, mincers and liquidisers’ can be used in some circumstances, morphology and cannot be used in surgery for malignancy . Typically , extraction is performed by enlarging one incision so as to facilitate remov al without disruption to the specimen. Strategies to reduce surgical trauma have been considered. These include removal of lung via a subxiphoid approach so as to reduce intercostal neuropraxia or natural orifice extraction of abdominal resection specimens. However, such approaches are themselves associated with di ff erent complications such as herniation and injury to structures outside the direct operative field. While tumour implantation and localisation at port sites initially raised important questions about the future of  the laparoscopic treatment of malignancy , large-scale trials have shown concer ns to be minimised by appropriate tissue han - dling, separating any tumours by bagging, irrigation and pro - tecting the extraction site. Cost Initially high consumable costs and factors such as surgical learning curve and high conversion rates led to increased costs of  minimal access approaches compared with their open equivalents. This is now largely no longer the case for straight stick endoscopic surgery such as laparoscopy and thoracoscopy . Indeed, despite higher direct consumable costs, improvements in outcomes, hospital stay and general upscaling of  the proce - dural volume have resulted in improved cost-e ff ectiveness for many minimal access procedures. Future reductions in the costs of  image-processing technol - ogy will result in a wide range of  transformed presenta tions fusion becoming available. It should ultimately be possible for a sur - - geon to access any view of  the operative region accessible to a camera and present it stereoscopically in any siz e or orienta - - tion, superimposed on past images taken in other modalities. Such augmented reality systems continue to improve and are - discussed in more detail below . Summary box 10.2 Limitations of minimal access surgery /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF
Lack of 3D vision
Loss of tactile feedback
Haemostasis
Extraction of large specimens
Learning curve and increased operative time
Cost
Reliance on new technologies
Endoscopic surgery
Lack of three-dimensional vision To perform minimal access surgery with safety , the surgeon must operate using an imaging system that provides a two-dimensional (2D) representation of  the operative site. The endoscope o ff ers a whole new anatomical landscape, which the surgeon must learn to navigate without the usual ‘open approach’ clues that make it easy to judge depth. The instruments are longer and sometimes more complex to use than those commonly used in open surgery . This results in the novice being faced with significant problems of  hand–eye coordination. There is a well-described learning curve for novice surgeons and experienced ‘open’ surgeons when adopt - ing the minimally invasive approach. Simulation training and mentoring are required to attain competence. Three-dimensional (3D) imaging systems are available b ut are expensive and currently are not commonplace. Many sur - geons feel that endoscopic 3D technology does not yet o ff er the technical enhancement necessary to improve safety . Indeed, - 3D technology has been associated with ergonomic problems - such as headache without quantifiable benefit in terms of  accu - racy and time to perform directed tasks. Future improvements in these systems carry the potential to enhance manipulative ability in critical procedures, such as knot tying and dissection of  closely overlapping tissues. There are , however, some draw - backs, such as reduced display brightness and interference with normal vision because of  the need to wear specially designed glasses for some systems. It is likely that brighter projection displays will be developed; however, the need to w ear glasses is not easily overcome. These factors currently limit stereoscopic straight stick endoscopic surgery , which has largely been super - seded by the development of robotic technology incorporating 3D vision. Minimal access surgery can be more technically demanding and slower to perform than conventional open surgery . On occasion, a minimally invasive operation is so technically demanding that both patient and surgeon would be better served by conversion to an open procedure. Prolonged anaesthetic and operative times may negate a number of the beneficial e ff ects of  minimal access surgery and increase the risk of  respiratory and wound complications as well as compression neuropathy and venous thromboembolism. It is vital for surgeons and patients to appreciate that the decision to convert to an open operation is not a complication but, instead, usually implies sound surgical judgement in favour of  patient safety . Control of bleeding and haemostasis Haemostasis may be di ffi cult to achieve endoscopically because blood may obscure the field of  vision with reduced image quality owing to light absorption. Experienced surgeons may be able to manage a degree of  bleeding via an endoscopic approach; however, this requires a significant degree of  experience and skill to be achieved safely . Such scenarios are also reliant on an experienced assistant able to reduce visual loss through optimal camera positioning. It should be remembered that a situation of  controlled conversion can easily become uncontrolled, negating any benefit a minimally access approach would have achieved. Advanced electrosurgery/diathermy and laser technology have improved dissection precision and haemostatic e ffi cacy in endoscopic surgery . Ultrasonic dissection and tissue devices continue to evolve with incremental technical improve ments and surgeons are increasingly familiar with their use. Some devices now combine the functions of three or four sep ara te instruments, reducing the need for instrument exchanges during a procedure. This flexibility , combined with the abil ity to provide a clean, smoke-free field, facilitates dissection, improves haemostasis and reduces operating times . Loss of tactile feedback Minimal access surgery is associated with some loss of tactile feedback, although this is less with straight stick endoscopy than with robotic procedures. This is an area of  ongoing research in haptics and biofeedback systems. Early work suggested that laparoscopic ultrasonography might be a substitute for the need to ‘feel’ in intraoperative decision-making. Rather than producing tactile feedback, endoscopic ultrasound provides a visual representation of  structures that in open surgery would rely on palpation for accurate localisation and appraisal. Widely used examples include appraisal of  nodal disease in cancer surgery and biliary tract exploration. Tissue extraction Large pieces of  tissue, such as the lung or colon, may have to be extracted from the body cavity following resection. In some circumstances this significantly increases the surgical trauma of  the procedure that could otherwise be carried out via two or three small port incisions. Although tissue ‘morcellators, mincers and liquidisers’ can be used in some circumstances, morphology and cannot be used in surgery for malignancy . Typically , extraction is performed by enlarging one incision so as to facilitate remov al without disruption to the specimen. Strategies to reduce surgical trauma have been considered. These include removal of lung via a subxiphoid approach so as to reduce intercostal neuropraxia or natural orifice extraction of abdominal resection specimens. However, such approaches are themselves associated with di ff erent complications such as herniation and injury to structures outside the direct operative field. While tumour implantation and localisation at port sites initially raised important questions about the future of  the laparoscopic treatment of malignancy , large-scale trials have shown concer ns to be minimised by appropriate tissue han - dling, separating any tumours by bagging, irrigation and pro - tecting the extraction site. Cost Initially high consumable costs and factors such as surgical learning curve and high conversion rates led to increased costs of  minimal access approaches compared with their open equivalents. This is now largely no longer the case for straight stick endoscopic surgery such as laparoscopy and thoracoscopy . Indeed, despite higher direct consumable costs, improvements in outcomes, hospital stay and general upscaling of  the proce - dural volume have resulted in improved cost-e ff ectiveness for many minimal access procedures. Future reductions in the costs of  image-processing technol - ogy will result in a wide range of  transformed presenta tions fusion becoming available. It should ultimately be possible for a sur - - geon to access any view of  the operative region accessible to a camera and present it stereoscopically in any siz e or orienta - - tion, superimposed on past images taken in other modalities. Such augmented reality systems continue to improve and are - discussed in more detail below . Summary box 10.2 Limitations of minimal access surgery /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF
Lack of 3D vision
Loss of tactile feedback
Haemostasis
Extraction of large specimens
Learning curve and increased operative time
Cost
Reliance on new technologies

FURTHER DEVELOPMENTS Augmented reality and minimal access surgical adjuncts
FURTHER DEVELOPMENTS Augmented reality and minimal access surgical adjuncts
The future of  minimal access surgery will almost certainly feature more advanced applications of  adjuncts to facilitate anatomical recognition and the localisation of  pathology . These are becoming commonplace in both video-assisted and robotic-assisted procedures. Augmented reality Augmented reality by definition comprises the fusion of projected computerised images with a real environment. In surgery , this involves the application of  real-time imaging or other data overlaid via computer processing software onto the surgical field. Such technology may be particularly beneficial in minimal access surgery where the localisation of  pathology and identification of  anatomy may be more di ffi cult than in open surgery because of  the lack of  digital palpation of  the relevant structures. At an elementary level, examples include the use of  indocyanine green for immunofluorescent localisation of tumours as well as vascular, bronchial or lymphatic structures. When bound to plasma proteins, indocyanine green emits light with near-infrared light. Through use of  a specifically designed HD camera and software system with imposed pseudo-colour, areas of  di ff er ential tissue density and vascular supply can be detected clearly without the need for digital palpation, thus facilitating complete resection and clear surgical margins. Its use is now well established in procedures such as minimal access liver, lung, renal and prostatic resections, and its role in other specialties such as colorectal surgery is also under investigation. The technology can be integrated into both video-assisted and robotic-assisted surgical procedures and is available within ® the da Vinci Xi and X robotic surgical systems as the Firefly mode, which can be turned on as required from the surgical console ( Figure 10.7 ) . - Another role for augmented reality in minimal access sur - gery is the overlay of  imaging beside or directly onto the surgi - cal field, ‘navigating’ the surgeon to the site of  interest without the need to look away from the patient to review imaging. Such navigational techniques originated in image-guided diagnos - tics, enabling identifica tion of  pathology in areas more di ffi cult to reach anatomically . Through increasing adoption of  hybrid theatre complexes, these approaches ma y be utilised for both diagnosis and treatment in a single setting. An example is the use of  navigational bronchoscopy to identify , diagnose and treat di ffi cult to reach or small lung nodules. Preoperative planning CT scan is reconstructed by specialist software. The result is a 3D ‘road map’ of  the bronchial tree and a side-by-side picture of real-time endobronchial images with those from the imag - ing system ( Figure 10.8 ). The surgeon is then guided directly along the airway to the lesion of interest that can be biopsied with on-site frozen section. Where the lesion is resectable but di ffi cult to localise, a fiducial marker may be placed to enable localisation under fluoroscopy guidance in a second-stage pro - cedur e performed in a hybrid theatre ( Figure 10.9 ). Where resection is not possible, ablation or other treatment may be o ff ered in the same setting, both reducing surgical in vasiveness and increasing the provision of  curative surgery to patients who may not otherwise be candidates for resection. An area of interest is the application of head-mounted dis - plays and eyeglasses to minimal access surgery . Although the majority of  applications remain in the realm of  simulation and training, the promise of  real-time image guidance by means of  multiplanar or imaging over lay of  the surgeon’s view is par - ticularly attractive. Head-mounted displays may also provide data display or communication tools, reducing the need for the surgeon to look away from the operative field and allow real-time guidance by a trainer or pr octor. To date, clinical application is limited owing to time lag, the need for high-speed wireless Internet or Bluetooth connection and device weight and battery life; application to minimal access surgery remains under development.

FURTHER DEVELOPMENTS Augmented reality and minimal
FURTHER DEVELOPMENTS Augmented reality and minimal access surgical adjuncts
The future of  minimal access surgery will almost certainly feature more advanced applications of  adjuncts to facilitate anatomical recognition and the localisation of  pathology . These are becoming commonplace in both video-assisted and robotic-assisted procedures. Augmented reality Augmented reality by definition comprises the fusion of projected computerised images with a real environment. In surgery , this involves the application of  real-time imaging or other data overlaid via computer processing software onto the surgical field. Such technology may be particularly beneficial in minimal access surgery where the localisation of  pathology and identification of  anatomy may be more di ffi cult than in open surgery because of  the lack of  digital palpation of  the relevant structures. At an elementary level, examples include the use of  indocyanine green for immunofluorescent localisation of tumours as well as vascular, bronchial or lymphatic structures. When bound to plasma proteins, indocyanine green emits light with near-infrared light. Through use of  a specifically designed HD camera and software system with imposed pseudo-colour, areas of  di ff er ential tissue density and vascular supply can be detected clearly without the need for digital palpation, thus facilitating complete resection and clear surgical margins. Its use is now well established in procedures such as minimal access liver, lung, renal and prostatic resections, and its role in other specialties such as colorectal surgery is also under investigation. The technology can be integrated into both video-assisted and robotic-assisted surgical procedures and is available within ® the da Vinci Xi and X robotic surgical systems as the Firefly mode, which can be turned on as required from the surgical console ( Figure 10.7 ) . - Another role for augmented reality in minimal access sur - gery is the overlay of  imaging beside or directly onto the surgi - cal field, ‘navigating’ the surgeon to the site of  interest without the need to look away from the patient to review imaging. Such navigational techniques originated in image-guided diagnos - tics, enabling identifica tion of  pathology in areas more di ffi cult to reach anatomically . Through increasing adoption of  hybrid theatre complexes, these approaches ma y be utilised for both diagnosis and treatment in a single setting. An example is the use of  navigational bronchoscopy to identify , diagnose and treat di ffi cult to reach or small lung nodules. Preoperative planning CT scan is reconstructed by specialist software. The result is a 3D ‘road map’ of  the bronchial tree and a side-by-side picture of real-time endobronchial images with those from the imag - ing system ( Figure 10.8 ). The surgeon is then guided directly along the airway to the lesion of interest that can be biopsied with on-site frozen section. Where the lesion is resectable but di ffi cult to localise, a fiducial marker may be placed to enable localisation under fluoroscopy guidance in a second-stage pro - cedur e performed in a hybrid theatre ( Figure 10.9 ). Where resection is not possible, ablation or other treatment may be o ff ered in the same setting, both reducing surgical in vasiveness and increasing the provision of  curative surgery to patients who may not otherwise be candidates for resection. An area of interest is the application of head-mounted dis - plays and eyeglasses to minimal access surgery . Although the majority of  applications remain in the realm of  simulation and training, the promise of  real-time image guidance by means of  multiplanar or imaging over lay of  the surgeon’s view is par - ticularly attractive. Head-mounted displays may also provide data display or communication tools, reducing the need for the surgeon to look away from the operative field and allow real-time guidance by a trainer or pr octor. To date, clinical application is limited owing to time lag, the need for high-speed wireless Internet or Bluetooth connection and device weight and battery life; application to minimal access surgery remains under development. FURTHER DEVELOPMENTS Augmented reality and minimal access surgical adjuncts
The future of  minimal access surgery will almost certainly feature more advanced applications of  adjuncts to facilitate anatomical recognition and the localisation of  pathology . These are becoming commonplace in both video-assisted and robotic-assisted procedures. Augmented reality Augmented reality by definition comprises the fusion of projected computerised images with a real environment. In surgery , this involves the application of  real-time imaging or other data overlaid via computer processing software onto the surgical field. Such technology may be particularly beneficial in minimal access surgery where the localisation of  pathology and identification of  anatomy may be more di ffi cult than in open surgery because of  the lack of  digital palpation of  the relevant structures. At an elementary level, examples include the use of  indocyanine green for immunofluorescent localisation of tumours as well as vascular, bronchial or lymphatic structures. When bound to plasma proteins, indocyanine green emits light with near-infrared light. Through use of  a specifically designed HD camera and software system with imposed pseudo-colour, areas of  di ff er ential tissue density and vascular supply can be detected clearly without the need for digital palpation, thus facilitating complete resection and clear surgical margins. Its use is now well established in procedures such as minimal access liver, lung, renal and prostatic resections, and its role in other specialties such as colorectal surgery is also under investigation. The technology can be integrated into both video-assisted and robotic-assisted surgical procedures and is available within ® the da Vinci Xi and X robotic surgical systems as the Firefly mode, which can be turned on as required from the surgical console ( Figure 10.7 ) . - Another role for augmented reality in minimal access sur - gery is the overlay of  imaging beside or directly onto the surgi - cal field, ‘navigating’ the surgeon to the site of  interest without the need to look away from the patient to review imaging. Such navigational techniques originated in image-guided diagnos - tics, enabling identifica tion of  pathology in areas more di ffi cult to reach anatomically . Through increasing adoption of  hybrid theatre complexes, these approaches ma y be utilised for both diagnosis and treatment in a single setting. An example is the use of  navigational bronchoscopy to identify , diagnose and treat di ffi cult to reach or small lung nodules. Preoperative planning CT scan is reconstructed by specialist software. The result is a 3D ‘road map’ of  the bronchial tree and a side-by-side picture of real-time endobronchial images with those from the imag - ing system ( Figure 10.8 ). The surgeon is then guided directly along the airway to the lesion of interest that can be biopsied with on-site frozen section. Where the lesion is resectable but di ffi cult to localise, a fiducial marker may be placed to enable localisation under fluoroscopy guidance in a second-stage pro - cedur e performed in a hybrid theatre ( Figure 10.9 ). Where resection is not possible, ablation or other treatment may be o ff ered in the same setting, both reducing surgical in vasiveness and increasing the provision of  curative surgery to patients who may not otherwise be candidates for resection. An area of interest is the application of head-mounted dis - plays and eyeglasses to minimal access surgery . Although the majority of  applications remain in the realm of  simulation and training, the promise of  real-time image guidance by means of  multiplanar or imaging over lay of  the surgeon’s view is par - ticularly attractive. Head-mounted displays may also provide data display or communication tools, reducing the need for the surgeon to look away from the operative field and allow real-time guidance by a trainer or pr octor. To date, clinical application is limited owing to time lag, the need for high-speed wireless Internet or Bluetooth connection and device weight and battery life; application to minimal access surgery remains under development.

GENERAL INTRAOPERATIVE PRINCIPLES
GENERAL INTRAOPERATIVE PRINCIPLES
Many minimal access procedures have a unique set of  proce - dural steps that may often be in a distinctly di ff erent sequence from those of  the open alternative. Methods for creating a pneumoperitoneum are described in Chapter 7 . Preoperativ e evaluation is necessary to assess the type and location of  surgical scars and potential for perivisceral adhesions. In the setting of  redo sur gery , trocar insertion may be complex and should be performed by an open approach with direct visualisation on entry to the body cavity (abdomen - gertip helps to ascertain penetration into the body cavity and allows adhesions to be gently removed from the entry site. The endoscopic camera may be used as a blunt dissector to tease adhesions gently awa y and form a tunnel towards the quad rant where the operation is to take place. With experience, the surgeon learns to di ff erentiate visually between thick adhesions that should be avoided and thin adhesions that would lead to a window into a free area. In obese patients the location of  some of  the ports ma need to be modified and, in some instances, larger and lon ger instruments may be necessary . It is important to recognise this preoperatively to ensure that adequate measures are put in place to ensure safe and e ffi cient surger y when the patient arrives. It is also important to consider the weight and dimen sion restrictions of  the operating table. In some cases, specialist operating tables will be required ( Chapter 68 ). GENERAL INTRAOPERATIVE PRINCIPLES
Many minimal access procedures have a unique set of  proce - dural steps that may often be in a distinctly di ff erent sequence from those of  the open alternative. Methods for creating a pneumoperitoneum are described in Chapter 7 . Preoperativ e evaluation is necessary to assess the type and location of  surgical scars and potential for perivisceral adhesions. In the setting of  redo sur gery , trocar insertion may be complex and should be performed by an open approach with direct visualisation on entry to the body cavity (abdomen - gertip helps to ascertain penetration into the body cavity and allows adhesions to be gently removed from the entry site. The endoscopic camera may be used as a blunt dissector to tease adhesions gently awa y and form a tunnel towards the quad rant where the operation is to take place. With experience, the surgeon learns to di ff erentiate visually between thick adhesions that should be avoided and thin adhesions that would lead to a window into a free area. In obese patients the location of  some of  the ports ma need to be modified and, in some instances, larger and lon ger instruments may be necessary . It is important to recognise this preoperatively to ensure that adequate measures are put in place to ensure safe and e ffi cient surger y when the patient arrives. It is also important to consider the weight and dimen sion restrictions of  the operating table. In some cases, specialist operating tables will be required ( Chapter 68 ). GENERAL INTRAOPERATIVE PRINCIPLES
Many minimal access procedures have a unique set of  proce - dural steps that may often be in a distinctly di ff erent sequence from those of  the open alternative. Methods for creating a pneumoperitoneum are described in Chapter 7 . Preoperativ e evaluation is necessary to assess the type and location of  surgical scars and potential for perivisceral adhesions. In the setting of  redo sur gery , trocar insertion may be complex and should be performed by an open approach with direct visualisation on entry to the body cavity (abdomen - gertip helps to ascertain penetration into the body cavity and allows adhesions to be gently removed from the entry site. The endoscopic camera may be used as a blunt dissector to tease adhesions gently awa y and form a tunnel towards the quad rant where the operation is to take place. With experience, the surgeon learns to di ff erentiate visually between thick adhesions that should be avoided and thin adhesions that would lead to a window into a free area. In obese patients the location of  some of  the ports ma need to be modified and, in some instances, larger and lon ger instruments may be necessary . It is important to recognise this preoperatively to ensure that adequate measures are put in place to ensure safe and e ffi cient surger y when the patient arrives. It is also important to consider the weight and dimen sion restrictions of  the operating table. In some cases, specialist operating tables will be required ( Chapter 68 ).

History of minimal access surgery
History of minimal access surgery
The first experimental laparoscopic procedure was performed by Kelling in 1901. Jacobaeus performed the first thoracoscopy in 1910, again using a cystoscope; however, it took another 70 years before Steptoe in the UK developed laparoscopy for treatment of  infertility and Mouret performed the first video-laparoscopic cholecystectomy in 1987. Since laparo scopic techniques became widely adopted in the mid-1990s, minimal access surgery has developed into a multidisciplinary approach that crosses all traditional specialty boundaries and serves the patient as a w hole and not specific organ systems. History of minimal access surgery
The first experimental laparoscopic procedure was performed by Kelling in 1901. Jacobaeus performed the first thoracoscopy in 1910, again using a cystoscope; however, it took another 70 years before Steptoe in the UK developed laparoscopy for treatment of  infertility and Mouret performed the first video-laparoscopic cholecystectomy in 1987. Since laparo scopic techniques became widely adopted in the mid-1990s, minimal access surgery has developed into a multidisciplinary approach that crosses all traditional specialty boundaries and serves the patient as a w hole and not specific organ systems. History of minimal access surgery
The first experimental laparoscopic procedure was performed by Kelling in 1901. Jacobaeus performed the first thoracoscopy in 1910, again using a cystoscope; however, it took another 70 years before Steptoe in the UK developed laparoscopy for treatment of  infertility and Mouret performed the first video-laparoscopic cholecystectomy in 1987. Since laparo scopic techniques became widely adopted in the mid-1990s, minimal access surgery has developed into a multidisciplinary approach that crosses all traditional specialty boundaries and serves the patient as a w hole and not specific organ systems.

History of robotic surgery
History of robotic surgery
The first documented clinical robotic procedure was a computed tomography (CT)-guided brain biopsy performed in 1985 utilising the PUMA (Programmable Universal Machine for Assembly) 560 system. This was followed by the ROBODOC, a pre-programmed active robot that enabled precise preparation of  the femoral implant cavity during hip replacement. The benefit of such a device was the ability to perform tasks to a high degree of  accuracy , thus minimising error and variation. While this and other active surgical robots demonstrated a number of  advantages, they were largely copy , which became increasingly commonplace across during the 1990s and 2000s. - In 1992, Computer Motion developed the AESOP (Auto - mated Endoscopic System for Optimal Positioning) system, which mounted the endoscopic camera on a single robotic arm, allowing the surgeon to control it r emotely via voice com - mand. The system was widely used in cholecystectomy and her nia surgery and for harvesting the mammary conduit in - coronary artery bypass. This was followed by the de velopment of  the ZEUS robot in 1996, a master–slave teleoperated system that provided three robotic arms, one for the voice-controlled endoscope and two further instrument arms. The surgeon was positioned at a remote console and the device was capable of motion scaling and tremor correction, facilitating its use for microsurgical procedures. ZEUS was used for the first fully endoscopic robotic surgical procedure, the reanastomosis of a Fallopian tube in 1998. The first remote surgical procedure - was performed in 2001, also utilising the ZEUS system. Here a cholecystectomy was performed on a patient in Paris by a surgeon in New Y ork, demonstrating the feasibility of  remote operating. ZEUS was discontinued in 2003 after the merger of Computer Motion with Intuitive Surgical. The current era of  surgical robots is dominated by the da ® Vinci surgical system, which was first approved for clinical use in 2000. The system o ff ers a number of  advantages, including ® 3D surgical vision, EndoWrist precision instruments, tremor reduction, motion scaling and improved ergonomics. The ini - tial system was released in 1999 and provided three robotic arms, one of  which held the endoscope. This was upgraded to the da Vinci S (2006), the da Vinci Si (2009) and subsequently the da Vinci Xi in 2014 ( Figure 10.2 ). With each itera tion came improvements in vision and instrumentation, along with which came integrated fluorescence imaging. More recently , nov el technologies include the development of a single port system (da Vinci SP), which combines multijointed wristed instrumentation with a wristed camera through a single port to further improve dexterity and minimise surgical trauma.
(a)
(b)
Figure 10.2
The da Vinci Xi system:
(a)
surgeon console;
(b)
da Vinci Xi robot;
(c)
(c)
vision cart (courtesy of Intuitive Surgical).
Surgical robots have been considered to o ff er many benefits, which have arisen as a result of  new technology in lenses, cameras and computer software. Just as laparoscopic surgery benefited from advances in light technology allowing the targeted transmission of  light down tubing, robotic surgery benefits from computer integration of  mechanical (surgical) arms that have paved the way for computer-integrated surgery . Vision Modern robotic camera systems o ff er 3D high-definition imag ing, providing stereoscopic vision with true depth perception that enhances the visualisation of  tissue planes and key struc tures. Multiport systems typically employ a rigid endoscope with or without angulation. As with conventional endoscopes, angulation to 30° allows for a wider range of  vision thr manipulation of  the camera position, which, in the case of robotic surgery , can be controlled by the surgeon at the console or, if  required, by the assistant at the bedside. A reference horizon is commonly provided to the surgeon at the console system so as to maintain orientation throughout the procedure. More recently , modern single-port systems such as the da Vinci SP employ a wristed camera system that, in combination with fully wristed instruments, may allow for operative triangulation while at the same time maintaining a small, single skin incision. Manoeuvrability, motion scaling and tremor suppression Improved manoeuvring as a result of the ‘robotic wrist’ in some systems allows for up to seven degrees of  freedom, thus improving dexterity for the surgeon. This has particular benefits in fields with significant space restraints such as transoral surgery , where conventional laparoscopy has limited applicability . Furthermore, the increased dexterity of  surgical robots may facilitate a minimal access approach to more complex procedures where the technical di ffi culty of  applying conventional laparoscopy may be prohibitive. As the motion of  the surgeon’s hand is translated to the ‘slave’ motion of  the robotic arm, modern surgical robots are able to scale down large external movements of  the surgical hands to limited internal movements. At the same time, the computer may filter out tremor in the surgeon’s hands, thus ensuring stability of  the instrument tips and enhancing surgical precision. Ergonomics Although the advent of straight stick laparoscopic surgery had many advantages for the patient, for the surgeon there was a trade-o ff in terms of operative ergonomics. Increased operative time in addition to unergonomic positioning can result in significant physical discomfort for the surgeon. This is particularly true in specialties such as bariatric surgery , where the patient’s body habitus and the use of  long, fulcrumed instruments puts further strain on the surgeon’s back, neck and upper arms. The advent of  robotic surgery vastly improves upon the ergonomic environment for the surgeon; in the case of  many of  the current master–slave systems, allowing for the surgeon to be seated at a console remote from the operating table ( Figure 10.3 ). The console positioning can be optimised ical stress and fatigue. The enclosed console system of  many robotic systems also provides the advantage of  surgical isolation from external distractions that may impact on the operator’s concentration. The disadv antage is reduced awareness of non-verbal communication, thus highlighting the importance of  team training and regular verbal cues. Motion compensation Although not commonplace in current clinical practice, robotic surgical systems may in future provide motion compensation - to facilitate surgery on a moving target. Examples where this may be beneficial are in beating heart cardiac surgery , such as - coronary artery bypass grafting and mitral valve repair. In this setting, the increased dexterity of robotic surgery combined with removing the need for cardioplegia and cross-clamping ough may be particularly beneficial in terms of  reducing the post - operative inflammatory response and improving its associated morbidity . History of robotic surgery
The first documented clinical robotic procedure was a computed tomography (CT)-guided brain biopsy performed in 1985 utilising the PUMA (Programmable Universal Machine for Assembly) 560 system. This was followed by the ROBODOC, a pre-programmed active robot that enabled precise preparation of  the femoral implant cavity during hip replacement. The benefit of such a device was the ability to perform tasks to a high degree of  accuracy , thus minimising error and variation. While this and other active surgical robots demonstrated a number of  advantages, they were largely copy , which became increasingly commonplace across during the 1990s and 2000s. - In 1992, Computer Motion developed the AESOP (Auto - mated Endoscopic System for Optimal Positioning) system, which mounted the endoscopic camera on a single robotic arm, allowing the surgeon to control it r emotely via voice com - mand. The system was widely used in cholecystectomy and her nia surgery and for harvesting the mammary conduit in - coronary artery bypass. This was followed by the de velopment of  the ZEUS robot in 1996, a master–slave teleoperated system that provided three robotic arms, one for the voice-controlled endoscope and two further instrument arms. The surgeon was positioned at a remote console and the device was capable of motion scaling and tremor correction, facilitating its use for microsurgical procedures. ZEUS was used for the first fully endoscopic robotic surgical procedure, the reanastomosis of a Fallopian tube in 1998. The first remote surgical procedure - was performed in 2001, also utilising the ZEUS system. Here a cholecystectomy was performed on a patient in Paris by a surgeon in New Y ork, demonstrating the feasibility of  remote operating. ZEUS was discontinued in 2003 after the merger of Computer Motion with Intuitive Surgical. The current era of  surgical robots is dominated by the da ® Vinci surgical system, which was first approved for clinical use in 2000. The system o ff ers a number of  advantages, including ® 3D surgical vision, EndoWrist precision instruments, tremor reduction, motion scaling and improved ergonomics. The ini - tial system was released in 1999 and provided three robotic arms, one of  which held the endoscope. This was upgraded to the da Vinci S (2006), the da Vinci Si (2009) and subsequently the da Vinci Xi in 2014 ( Figure 10.2 ). With each itera tion came improvements in vision and instrumentation, along with which came integrated fluorescence imaging. More recently , nov el technologies include the development of a single port system (da Vinci SP), which combines multijointed wristed instrumentation with a wristed camera through a single port to further improve dexterity and minimise surgical trauma.
(a)
(b)
Figure 10.2
The da Vinci Xi system:
(a)
surgeon console;
(b)
da Vinci Xi robot;
(c)
(c)
vision cart (courtesy of Intuitive Surgical).
Surgical robots have been considered to o ff er many benefits, which have arisen as a result of  new technology in lenses, cameras and computer software. Just as laparoscopic surgery benefited from advances in light technology allowing the targeted transmission of  light down tubing, robotic surgery benefits from computer integration of  mechanical (surgical) arms that have paved the way for computer-integrated surgery . Vision Modern robotic camera systems o ff er 3D high-definition imag ing, providing stereoscopic vision with true depth perception that enhances the visualisation of  tissue planes and key struc tures. Multiport systems typically employ a rigid endoscope with or without angulation. As with conventional endoscopes, angulation to 30° allows for a wider range of  vision thr manipulation of  the camera position, which, in the case of robotic surgery , can be controlled by the surgeon at the console or, if  required, by the assistant at the bedside. A reference horizon is commonly provided to the surgeon at the console system so as to maintain orientation throughout the procedure. More recently , modern single-port systems such as the da Vinci SP employ a wristed camera system that, in combination with fully wristed instruments, may allow for operative triangulation while at the same time maintaining a small, single skin incision. Manoeuvrability, motion scaling and tremor suppression Improved manoeuvring as a result of the ‘robotic wrist’ in some systems allows for up to seven degrees of  freedom, thus improving dexterity for the surgeon. This has particular benefits in fields with significant space restraints such as transoral surgery , where conventional laparoscopy has limited applicability . Furthermore, the increased dexterity of  surgical robots may facilitate a minimal access approach to more complex procedures where the technical di ffi culty of  applying conventional laparoscopy may be prohibitive. As the motion of  the surgeon’s hand is translated to the ‘slave’ motion of  the robotic arm, modern surgical robots are able to scale down large external movements of  the surgical hands to limited internal movements. At the same time, the computer may filter out tremor in the surgeon’s hands, thus ensuring stability of  the instrument tips and enhancing surgical precision. Ergonomics Although the advent of straight stick laparoscopic surgery had many advantages for the patient, for the surgeon there was a trade-o ff in terms of operative ergonomics. Increased operative time in addition to unergonomic positioning can result in significant physical discomfort for the surgeon. This is particularly true in specialties such as bariatric surgery , where the patient’s body habitus and the use of  long, fulcrumed instruments puts further strain on the surgeon’s back, neck and upper arms. The advent of  robotic surgery vastly improves upon the ergonomic environment for the surgeon; in the case of  many of  the current master–slave systems, allowing for the surgeon to be seated at a console remote from the operating table ( Figure 10.3 ). The console positioning can be optimised ical stress and fatigue. The enclosed console system of  many robotic systems also provides the advantage of  surgical isolation from external distractions that may impact on the operator’s concentration. The disadv antage is reduced awareness of non-verbal communication, thus highlighting the importance of  team training and regular verbal cues. Motion compensation Although not commonplace in current clinical practice, robotic surgical systems may in future provide motion compensation - to facilitate surgery on a moving target. Examples where this may be beneficial are in beating heart cardiac surgery , such as - coronary artery bypass grafting and mitral valve repair. In this setting, the increased dexterity of robotic surgery combined with removing the need for cardioplegia and cross-clamping ough may be particularly beneficial in terms of  reducing the post - operative inflammatory response and improving its associated morbidity . History of robotic surgery
The first documented clinical robotic procedure was a computed tomography (CT)-guided brain biopsy performed in 1985 utilising the PUMA (Programmable Universal Machine for Assembly) 560 system. This was followed by the ROBODOC, a pre-programmed active robot that enabled precise preparation of  the femoral implant cavity during hip replacement. The benefit of such a device was the ability to perform tasks to a high degree of  accuracy , thus minimising error and variation. While this and other active surgical robots demonstrated a number of  advantages, they were largely copy , which became increasingly commonplace across during the 1990s and 2000s. - In 1992, Computer Motion developed the AESOP (Auto - mated Endoscopic System for Optimal Positioning) system, which mounted the endoscopic camera on a single robotic arm, allowing the surgeon to control it r emotely via voice com - mand. The system was widely used in cholecystectomy and her nia surgery and for harvesting the mammary conduit in - coronary artery bypass. This was followed by the de velopment of  the ZEUS robot in 1996, a master–slave teleoperated system that provided three robotic arms, one for the voice-controlled endoscope and two further instrument arms. The surgeon was positioned at a remote console and the device was capable of motion scaling and tremor correction, facilitating its use for microsurgical procedures. ZEUS was used for the first fully endoscopic robotic surgical procedure, the reanastomosis of a Fallopian tube in 1998. The first remote surgical procedure - was performed in 2001, also utilising the ZEUS system. Here a cholecystectomy was performed on a patient in Paris by a surgeon in New Y ork, demonstrating the feasibility of  remote operating. ZEUS was discontinued in 2003 after the merger of Computer Motion with Intuitive Surgical. The current era of  surgical robots is dominated by the da ® Vinci surgical system, which was first approved for clinical use in 2000. The system o ff ers a number of  advantages, including ® 3D surgical vision, EndoWrist precision instruments, tremor reduction, motion scaling and improved ergonomics. The ini - tial system was released in 1999 and provided three robotic arms, one of  which held the endoscope. This was upgraded to the da Vinci S (2006), the da Vinci Si (2009) and subsequently the da Vinci Xi in 2014 ( Figure 10.2 ). With each itera tion came improvements in vision and instrumentation, along with which came integrated fluorescence imaging. More recently , nov el technologies include the development of a single port system (da Vinci SP), which combines multijointed wristed instrumentation with a wristed camera through a single port to further improve dexterity and minimise surgical trauma.
(a)
(b)
Figure 10.2
The da Vinci Xi system:
(a)
surgeon console;
(b)
da Vinci Xi robot;
(c)
(c)
vision cart (courtesy of Intuitive Surgical).
Surgical robots have been considered to o ff er many benefits, which have arisen as a result of  new technology in lenses, cameras and computer software. Just as laparoscopic surgery benefited from advances in light technology allowing the targeted transmission of  light down tubing, robotic surgery benefits from computer integration of  mechanical (surgical) arms that have paved the way for computer-integrated surgery . Vision Modern robotic camera systems o ff er 3D high-definition imag ing, providing stereoscopic vision with true depth perception that enhances the visualisation of  tissue planes and key struc tures. Multiport systems typically employ a rigid endoscope with or without angulation. As with conventional endoscopes, angulation to 30° allows for a wider range of  vision thr manipulation of  the camera position, which, in the case of robotic surgery , can be controlled by the surgeon at the console or, if  required, by the assistant at the bedside. A reference horizon is commonly provided to the surgeon at the console system so as to maintain orientation throughout the procedure. More recently , modern single-port systems such as the da Vinci SP employ a wristed camera system that, in combination with fully wristed instruments, may allow for operative triangulation while at the same time maintaining a small, single skin incision. Manoeuvrability, motion scaling and tremor suppression Improved manoeuvring as a result of the ‘robotic wrist’ in some systems allows for up to seven degrees of  freedom, thus improving dexterity for the surgeon. This has particular benefits in fields with significant space restraints such as transoral surgery , where conventional laparoscopy has limited applicability . Furthermore, the increased dexterity of  surgical robots may facilitate a minimal access approach to more complex procedures where the technical di ffi culty of  applying conventional laparoscopy may be prohibitive. As the motion of  the surgeon’s hand is translated to the ‘slave’ motion of  the robotic arm, modern surgical robots are able to scale down large external movements of  the surgical hands to limited internal movements. At the same time, the computer may filter out tremor in the surgeon’s hands, thus ensuring stability of  the instrument tips and enhancing surgical precision. Ergonomics Although the advent of straight stick laparoscopic surgery had many advantages for the patient, for the surgeon there was a trade-o ff in terms of operative ergonomics. Increased operative time in addition to unergonomic positioning can result in significant physical discomfort for the surgeon. This is particularly true in specialties such as bariatric surgery , where the patient’s body habitus and the use of  long, fulcrumed instruments puts further strain on the surgeon’s back, neck and upper arms. The advent of  robotic surgery vastly improves upon the ergonomic environment for the surgeon; in the case of  many of  the current master–slave systems, allowing for the surgeon to be seated at a console remote from the operating table ( Figure 10.3 ). The console positioning can be optimised ical stress and fatigue. The enclosed console system of  many robotic systems also provides the advantage of  surgical isolation from external distractions that may impact on the operator’s concentration. The disadv antage is reduced awareness of non-verbal communication, thus highlighting the importance of  team training and regular verbal cues. Motion compensation Although not commonplace in current clinical practice, robotic surgical systems may in future provide motion compensation - to facilitate surgery on a moving target. Examples where this may be beneficial are in beating heart cardiac surgery , such as - coronary artery bypass grafting and mitral valve repair. In this setting, the increased dexterity of robotic surgery combined with removing the need for cardioplegia and cross-clamping ough may be particularly beneficial in terms of  reducing the post - operative inflammatory response and improving its associated morbidity .

Hybrid minimal access surgery
Hybrid minimal access surgery
Hybrid surgery may utilise a combination of  flexible and straight stick endoscopic approaches or a combination of  open and endoscopic surgery . Totally endoscopic hybrid approach The diseased organ is visualised and treated by an assortment of  endoluminal and extraluminal endoscopes and other imaging devices. In the abdomen, examples include the combined laparo-endoscopic approach for the management of  biliary lithiasis, colonic polyp excision and several urological procedures, such as pyeloplasty and donor nephrectomy . In the thorax, navigational bronchoscopy with placement of fiducial markers has been employed as a means of  marking lung nodules that can then be resected via a minimal access video-assisted approach. Cardiovascular surgeons have - for some time employed hybrid technologies to facilitate catheter-based placement of  cardiac valves, atrial devices and - intravascular stents. Hybrid techniques o ff er improved visualisation, facilitating - the primary procedure to be carried out either via a smaller incision or a minimal access approach where otherwise open e sig - surgery would have been necessar y . Such approaches may necessitate the availability of  ‘hybrid’ theatre facilities, limit - ing this approach to tertiary centres where such technology is available ( Figure 10.1 ) . Open and endoscopic hybrid approach Hand-assisted laparoscopic surgery (HALS) is a well-developed technique. It involves the intra-abdominal placement of  a
Figure 10.1
Modern hybrid theatre set-up (courtesy of Mr Kelvin Lau,
Barts Thorax Centre, London, UK).
pneumoperitoneum is maintained. In this way , the surgeon’s hand can be used as in an open procedure. It can be used to palpate organs or tumours, reflect organs atraumatically , retract structures, identify vessels, dissect bluntly along a tissue plane and provide finger pressure to bleeding points, while proximal control is achieved. This approach has been suggested to o ff er technical and economic e ffi ciency when compared with a totally laparoscopic approach, in some instances reducing both the number of  laparoscopic ports and the number of  instru ments required. Indeed, some advocates argue that if  such an incision is necessary for extraction of  the final specimen then HALS does not significantly increase surgical trauma over totally laparoscopic approaches. Furthermore, for those trained in open surgery it may be easier to learn and perform than totally laparoscopic approaches, subsequently improving patient safety . With the new generation of  surgeons training in totally laparoscopic surgery it is likely that use of  HALS will diminish, although it should remain part of  the minimally invasive surgeon’s armamentarium. Hybrid minimal access surgery
Hybrid surgery may utilise a combination of  flexible and straight stick endoscopic approaches or a combination of  open and endoscopic surgery . Totally endoscopic hybrid approach The diseased organ is visualised and treated by an assortment of  endoluminal and extraluminal endoscopes and other imaging devices. In the abdomen, examples include the combined laparo-endoscopic approach for the management of  biliary lithiasis, colonic polyp excision and several urological procedures, such as pyeloplasty and donor nephrectomy . In the thorax, navigational bronchoscopy with placement of fiducial markers has been employed as a means of  marking lung nodules that can then be resected via a minimal access video-assisted approach. Cardiovascular surgeons have - for some time employed hybrid technologies to facilitate catheter-based placement of  cardiac valves, atrial devices and - intravascular stents. Hybrid techniques o ff er improved visualisation, facilitating - the primary procedure to be carried out either via a smaller incision or a minimal access approach where otherwise open e sig - surgery would have been necessar y . Such approaches may necessitate the availability of  ‘hybrid’ theatre facilities, limit - ing this approach to tertiary centres where such technology is available ( Figure 10.1 ) . Open and endoscopic hybrid approach Hand-assisted laparoscopic surgery (HALS) is a well-developed technique. It involves the intra-abdominal placement of  a
Figure 10.1
Modern hybrid theatre set-up (courtesy of Mr Kelvin Lau,
Barts Thorax Centre, London, UK).
pneumoperitoneum is maintained. In this way , the surgeon’s hand can be used as in an open procedure. It can be used to palpate organs or tumours, reflect organs atraumatically , retract structures, identify vessels, dissect bluntly along a tissue plane and provide finger pressure to bleeding points, while proximal control is achieved. This approach has been suggested to o ff er technical and economic e ffi ciency when compared with a totally laparoscopic approach, in some instances reducing both the number of  laparoscopic ports and the number of  instru ments required. Indeed, some advocates argue that if  such an incision is necessary for extraction of  the final specimen then HALS does not significantly increase surgical trauma over totally laparoscopic approaches. Furthermore, for those trained in open surgery it may be easier to learn and perform than totally laparoscopic approaches, subsequently improving patient safety . With the new generation of  surgeons training in totally laparoscopic surgery it is likely that use of  HALS will diminish, although it should remain part of  the minimally invasive surgeon’s armamentarium. Hybrid minimal access surgery
Hybrid surgery may utilise a combination of  flexible and straight stick endoscopic approaches or a combination of  open and endoscopic surgery . Totally endoscopic hybrid approach The diseased organ is visualised and treated by an assortment of  endoluminal and extraluminal endoscopes and other imaging devices. In the abdomen, examples include the combined laparo-endoscopic approach for the management of  biliary lithiasis, colonic polyp excision and several urological procedures, such as pyeloplasty and donor nephrectomy . In the thorax, navigational bronchoscopy with placement of fiducial markers has been employed as a means of  marking lung nodules that can then be resected via a minimal access video-assisted approach. Cardiovascular surgeons have - for some time employed hybrid technologies to facilitate catheter-based placement of  cardiac valves, atrial devices and - intravascular stents. Hybrid techniques o ff er improved visualisation, facilitating - the primary procedure to be carried out either via a smaller incision or a minimal access approach where otherwise open e sig - surgery would have been necessar y . Such approaches may necessitate the availability of  ‘hybrid’ theatre facilities, limit - ing this approach to tertiary centres where such technology is available ( Figure 10.1 ) . Open and endoscopic hybrid approach Hand-assisted laparoscopic surgery (HALS) is a well-developed technique. It involves the intra-abdominal placement of  a
Figure 10.1
Modern hybrid theatre set-up (courtesy of Mr Kelvin Lau,
Barts Thorax Centre, London, UK).
pneumoperitoneum is maintained. In this way , the surgeon’s hand can be used as in an open procedure. It can be used to palpate organs or tumours, reflect organs atraumatically , retract structures, identify vessels, dissect bluntly along a tissue plane and provide finger pressure to bleeding points, while proximal control is achieved. This approach has been suggested to o ff er technical and economic e ffi ciency when compared with a totally laparoscopic approach, in some instances reducing both the number of  laparoscopic ports and the number of  instru ments required. Indeed, some advocates argue that if  such an incision is necessary for extraction of  the final specimen then HALS does not significantly increase surgical trauma over totally laparoscopic approaches. Furthermore, for those trained in open surgery it may be easier to learn and perform than totally laparoscopic approaches, subsequently improving patient safety . With the new generation of  surgeons training in totally laparoscopic surgery it is likely that use of  HALS will diminish, although it should remain part of  the minimally invasive surgeon’s armamentarium.

Introduction
Introduction
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LIMITATIONS OF MINIMAL ACCESS SURGERY
LIMITATIONS OF MINIMAL ACCESS SURGERY
Minimal access surgery has limitations. A number of  these have been addressed with advances in instrumentation and endoscopic systems; however, the basic principles remain. Surgical robots further address a number of  these limitations but present novel challenges. LIMITATIONS OF MINIMAL ACCESS SURGERY
Minimal access surgery has limitations. A number of  these have been addressed with advances in instrumentation and endoscopic systems; however, the basic principles remain. Surgical robots further address a number of  these limitations but present novel challenges. LIMITATIONS OF MINIMAL ACCESS SURGERY
Minimal access surgery has limitations. A number of  these have been addressed with advances in instrumentation and endoscopic systems; however, the basic principles remain. Surgical robots further address a number of  these limitations but present novel challenges.

Learning objectives
Learning objectives
To understand: The principles of minimal access surgery • The advantages and disadvantages of minimal access • approaches The safety issues and indications for minimal access • surgery Learning objectives
To understand: The principles of minimal access surgery • The advantages and disadvantages of minimal access • approaches The safety issues and indications for minimal access • surgery Learning objectives
To understand: The principles of minimal access surgery • The advantages and disadvantages of minimal access • approaches The safety issues and indications for minimal access • surgery

MINIMAL ACCESS APPROACHES Laparoscopy
MINIMAL ACCESS APPROACHES Laparoscopy
A rigid endoscope is introduced through a port into the perito neal cavity . Full details of  laparoscopy including the principles of  pneumoperitoneum can be found in Chapter 7 . Georg Kelling , 1866–1945, surgeon, Dresden, Germany , performed the first ‘celioscopy’ on a dog in 1901 using air insu ffl ation and a Nitze-cystoscope. Hans Christian Jacobaeus , 1879–1937, physician, Karolinska Institutet, Sweden. Patrick Christopher Steptoe , 1913–1988 gynaecologist, Oldham, UK, a pioneer of Phillippe Mouret , 1938–2008, surgeon, Lyon, France.
The perioperative assessment of patients undergoing
•
minimal access surgery
Novel advances in minimal access surgery and its
•
adjuncts
The application of arti
/f_i
cial intelligence to minimal access
•
surgery
MINIMAL ACCESS APPROACHES Laparoscopy
A rigid endoscope is introduced through a port into the perito neal cavity . Full details of  laparoscopy including the principles of  pneumoperitoneum can be found in Chapter 7 . Georg Kelling , 1866–1945, surgeon, Dresden, Germany , performed the first ‘celioscopy’ on a dog in 1901 using air insu ffl ation and a Nitze-cystoscope. Hans Christian Jacobaeus , 1879–1937, physician, Karolinska Institutet, Sweden. Patrick Christopher Steptoe , 1913–1988 gynaecologist, Oldham, UK, a pioneer of Phillippe Mouret , 1938–2008, surgeon, Lyon, France.
The perioperative assessment of patients undergoing
•
minimal access surgery
Novel advances in minimal access surgery and its
•
adjuncts
The application of arti
/f_i
cial intelligence to minimal access
•
surgery
MINIMAL ACCESS APPROACHES Laparoscopy
A rigid endoscope is introduced through a port into the perito neal cavity . Full details of  laparoscopy including the principles of  pneumoperitoneum can be found in Chapter 7 . Georg Kelling , 1866–1945, surgeon, Dresden, Germany , performed the first ‘celioscopy’ on a dog in 1901 using air insu ffl ation and a Nitze-cystoscope. Hans Christian Jacobaeus , 1879–1937, physician, Karolinska Institutet, Sweden. Patrick Christopher Steptoe , 1913–1988 gynaecologist, Oldham, UK, a pioneer of Phillippe Mouret , 1938–2008, surgeon, Lyon, France.
The perioperative assessment of patients undergoing
•
minimal access surgery
Novel advances in minimal access surgery and its
•
adjuncts
The application of arti
/f_i
cial intelligence to minimal access
•
surgery

Mobility and convalescence
Mobility and convalescence
Patients can get out of  bed to go to the toilet as soon as they have recovered from the anaesthetic and they should be encouraged to do so. Such movements are remarkably pain free when compared with the mobility achieved after an open operation. Similarly , patients can cough actively and clear bronchial secretions, and this helps to diminish the incidence of  chest infections. Mobility and convalescence
Patients can get out of  bed to go to the toilet as soon as they have recovered from the anaesthetic and they should be encouraged to do so. Such movements are remarkably pain free when compared with the mobility achieved after an open operation. Similarly , patients can cough actively and clear bronchial secretions, and this helps to diminish the incidence of  chest infections. Mobility and convalescence
Patients can get out of  bed to go to the toilet as soon as they have recovered from the anaesthetic and they should be encouraged to do so. Such movements are remarkably pain free when compared with the mobility achieved after an open operation. Similarly , patients can cough actively and clear bronchial secretions, and this helps to diminish the incidence of  chest infections.

Operative problems
Operative problems
Intraoperative perforation of a viscus or vascular injury Perforation of  any viscus, such as bowel, is a potential hazard that may occur inadvertently and go unrecognised or be of  a severity that may require emergency conversion. The added time required for this to take place may result in increased blood loss and haemodynamic instability that would not have occurred should the same injury have occurred in an open setting. With surgical experience, education, preparation and patient selection many of  these emergencies and their resultant complications can be avoided. It is vital for the surgical team to both recognise its own limitations and continually reflect throughout the procedure on the surgical progress and oper ative di ffi culty . Bleeding Bleeding is the most common cause of  conversion to open surgery . The impact of  light absorption is particularly import ant in robotic surgery , and regular haemostasis is paramount to facilitate dissection and surgical progress. Risk factors that predispose to increased bleeding include: /uni25CF liver disease impacting on the production of  vitamin K-dependent clotting factors, e.g. cirrhosis, autoimmune liver disease; /uni25CF inflammatory conditions (acute cholecystitis, diverticulitis); /uni25CF patients on anticoagulants; /uni25CF coagulation defects: these may be contraindications to both open and minimal access surgery and require thorough dis cussion with haematology colleagues to determine, where possible, how to optimise the patient for surgery . Damage to a large vessel requires immediate assessment of the magnitude and type of  bleeding. It is paramount that as soon as b leeding is identified this is communicated clearly to all members of  the theatre and anaesthetic team. There should be a relatively lo w threshold for early conversion; however, this will depend on the expertise of  the operating team. It is per tinent to achieve early control by whatever means necessary . trol may be achieved by clipping, stapling or use of  an energy device, depending on vessel size. Occasionally suturing may be possible; however, this may be significantly more complex - via a minimal access approac h. When the vessel is not identi - fied, compression should be applied immediately with a blunt instrument, a cotton swab or with the adjacent organ. Good suction and irrigation are of  utmost importance. Once the area has been cleaned, pressure should be released gradually y to identify the site of  bleeding. Insertion of  an e xtra port may - be required. There should be no delay in converting to an open procedure when necessary . This is of  particular importance in robotic surgery as some or all of  the robotic arms may need to be urgently undocked to facilitate the surgeon gaining bedside - access to the patient. The bedside assistant should be confident to perform this process. It is sometimes appropriate for a single robotic arm to be left in place to help maintain pressure on the bleeding vessel while direct access is achieved. Alternatively , pressure may be maintained via an assistant port (if  present), allowing the robot to be undocked completely and removed from the surgical field. Bleeding from organs encountered during surgery Excessive retraction can tear a visceral surface, resulting in bleeding. This is particularly so in robotic surgery , where instrument graspers have a small surface area, increasing the potential for injury to retracted tissue. Here rolled swabs may be inserted into the surgical field and held within the grasper, producing a larger surface for retraction and reducing ® tissue injury . Surgicel (absorbable fibrillar oxidised cellulose polymer) or other clot-promoting strips, tissue glues or other haemostatic agents may also be used to aid haemostasis, e.g. from the gallbladder bed during cholecystectomy . - Bleeding from a trocar site Bleeding from the trocar sites is usually treated by localised diathermy or applying upwards and lateral pressure with the trocar itself. Considerable bleeding may occur if  a vessel - such as the inferior epigastric or intercostal artery is injured. Haemostasis can be accomplished either by pressure or by suturing the bleeding site. Devices such as the EndoClose™ may also be used to apply transabdominal sutures under direct laparoscopic view to close port sites that bleed. When a bleeding vessel cannot be easily identified, mass ligation of  the vessel around the port site can be performed. This manoeuvre is accomplished by extending the skin incision by 3 /uni00A0 mm at both ends of  the bleeding trocar site w ound. Two figure-of-eight sutures are placed in the path of  the vessel at both ends of the wound ( Figure 10.5 ). Alternatively , pressure - can be applied using a Foley balloon catheter. The catheter is introduced into the abdominal cavity through the bleeding trocar site wound, the balloon is inflated and traction is placed on the catheter, which is bolstered in place to keep it under ten - sion. T he catheter is left in situ for 24 hours and then removed. If  significant continuous bleeding from the falciform lig - ament occurs, haemostasis is achieved by percutaneously inserting a large, straight needle at one side of  the ligament. - A monofilament suture attached to the needle is passed into the abdominal cavity and the needle is exited at the other side compression is achieved. Maintaining compression throughout the procedure usually su ffi ces. After the procedure has been completed, the loop is removed under direct laparoscopic visu alisation to ensure complete haemostasis. Evacuation of blood clots Careful haemostasis is important as even small, localised pools of  blood or clot absorb light and can significantly impair the surgical view . Carefully directed suction is usually su ffi cient in open cases; however, suction may be problematic in laparo scopic and robotic procedures that are reliant on carbon diox ide insu ffl ation to maintain the surgical field. It is important that suction is applied below a fluid level, or, if  used in the operative field, only in short bursts as required. Should tissue be inadvertently sucked into the end of  the suction device, the tubing can be kinked to allow the tissue to dr op away before removing. Rolled swabs or sponges can be used to remove blood from the surgical field without need for suction ( Figure 10.6 These can also be used for gentle retraction, minimising tissue damage and thus further reducing blood loss. Such swabs may be inserted and removed via a 15-mm assistant port or in some cases a 12-mm robotic trocar with the port cap r emoved. Care should be taken to avoid carbon dioxide loss during extraction. Finally , the surgeon may choose to use a specially designed robotic sucker that integrates with the robotic system. Alterna tively , non-wristed suction can be provided via an assistant port if  included in the operative set-up. Operative problems
Intraoperative perforation of a viscus or vascular injury Perforation of  any viscus, such as bowel, is a potential hazard that may occur inadvertently and go unrecognised or be of  a severity that may require emergency conversion. The added time required for this to take place may result in increased blood loss and haemodynamic instability that would not have occurred should the same injury have occurred in an open setting. With surgical experience, education, preparation and patient selection many of  these emergencies and their resultant complications can be avoided. It is vital for the surgical team to both recognise its own limitations and continually reflect throughout the procedure on the surgical progress and oper ative di ffi culty . Bleeding Bleeding is the most common cause of  conversion to open surgery . The impact of  light absorption is particularly import ant in robotic surgery , and regular haemostasis is paramount to facilitate dissection and surgical progress. Risk factors that predispose to increased bleeding include: /uni25CF liver disease impacting on the production of  vitamin K-dependent clotting factors, e.g. cirrhosis, autoimmune liver disease; /uni25CF inflammatory conditions (acute cholecystitis, diverticulitis); /uni25CF patients on anticoagulants; /uni25CF coagulation defects: these may be contraindications to both open and minimal access surgery and require thorough dis cussion with haematology colleagues to determine, where possible, how to optimise the patient for surgery . Damage to a large vessel requires immediate assessment of the magnitude and type of  bleeding. It is paramount that as soon as b leeding is identified this is communicated clearly to all members of  the theatre and anaesthetic team. There should be a relatively lo w threshold for early conversion; however, this will depend on the expertise of  the operating team. It is per tinent to achieve early control by whatever means necessary . trol may be achieved by clipping, stapling or use of  an energy device, depending on vessel size. Occasionally suturing may be possible; however, this may be significantly more complex - via a minimal access approac h. When the vessel is not identi - fied, compression should be applied immediately with a blunt instrument, a cotton swab or with the adjacent organ. Good suction and irrigation are of  utmost importance. Once the area has been cleaned, pressure should be released gradually y to identify the site of  bleeding. Insertion of  an e xtra port may - be required. There should be no delay in converting to an open procedure when necessary . This is of  particular importance in robotic surgery as some or all of  the robotic arms may need to be urgently undocked to facilitate the surgeon gaining bedside - access to the patient. The bedside assistant should be confident to perform this process. It is sometimes appropriate for a single robotic arm to be left in place to help maintain pressure on the bleeding vessel while direct access is achieved. Alternatively , pressure may be maintained via an assistant port (if  present), allowing the robot to be undocked completely and removed from the surgical field. Bleeding from organs encountered during surgery Excessive retraction can tear a visceral surface, resulting in bleeding. This is particularly so in robotic surgery , where instrument graspers have a small surface area, increasing the potential for injury to retracted tissue. Here rolled swabs may be inserted into the surgical field and held within the grasper, producing a larger surface for retraction and reducing ® tissue injury . Surgicel (absorbable fibrillar oxidised cellulose polymer) or other clot-promoting strips, tissue glues or other haemostatic agents may also be used to aid haemostasis, e.g. from the gallbladder bed during cholecystectomy . - Bleeding from a trocar site Bleeding from the trocar sites is usually treated by localised diathermy or applying upwards and lateral pressure with the trocar itself. Considerable bleeding may occur if  a vessel - such as the inferior epigastric or intercostal artery is injured. Haemostasis can be accomplished either by pressure or by suturing the bleeding site. Devices such as the EndoClose™ may also be used to apply transabdominal sutures under direct laparoscopic view to close port sites that bleed. When a bleeding vessel cannot be easily identified, mass ligation of  the vessel around the port site can be performed. This manoeuvre is accomplished by extending the skin incision by 3 /uni00A0 mm at both ends of  the bleeding trocar site w ound. Two figure-of-eight sutures are placed in the path of  the vessel at both ends of the wound ( Figure 10.5 ). Alternatively , pressure - can be applied using a Foley balloon catheter. The catheter is introduced into the abdominal cavity through the bleeding trocar site wound, the balloon is inflated and traction is placed on the catheter, which is bolstered in place to keep it under ten - sion. T he catheter is left in situ for 24 hours and then removed. If  significant continuous bleeding from the falciform lig - ament occurs, haemostasis is achieved by percutaneously inserting a large, straight needle at one side of  the ligament. - A monofilament suture attached to the needle is passed into the abdominal cavity and the needle is exited at the other side compression is achieved. Maintaining compression throughout the procedure usually su ffi ces. After the procedure has been completed, the loop is removed under direct laparoscopic visu alisation to ensure complete haemostasis. Evacuation of blood clots Careful haemostasis is important as even small, localised pools of  blood or clot absorb light and can significantly impair the surgical view . Carefully directed suction is usually su ffi cient in open cases; however, suction may be problematic in laparo scopic and robotic procedures that are reliant on carbon diox ide insu ffl ation to maintain the surgical field. It is important that suction is applied below a fluid level, or, if  used in the operative field, only in short bursts as required. Should tissue be inadvertently sucked into the end of  the suction device, the tubing can be kinked to allow the tissue to dr op away before removing. Rolled swabs or sponges can be used to remove blood from the surgical field without need for suction ( Figure 10.6 These can also be used for gentle retraction, minimising tissue damage and thus further reducing blood loss. Such swabs may be inserted and removed via a 15-mm assistant port or in some cases a 12-mm robotic trocar with the port cap r emoved. Care should be taken to avoid carbon dioxide loss during extraction. Finally , the surgeon may choose to use a specially designed robotic sucker that integrates with the robotic system. Alterna tively , non-wristed suction can be provided via an assistant port if  included in the operative set-up. Operative problems
Intraoperative perforation of a viscus or vascular injury Perforation of  any viscus, such as bowel, is a potential hazard that may occur inadvertently and go unrecognised or be of  a severity that may require emergency conversion. The added time required for this to take place may result in increased blood loss and haemodynamic instability that would not have occurred should the same injury have occurred in an open setting. With surgical experience, education, preparation and patient selection many of  these emergencies and their resultant complications can be avoided. It is vital for the surgical team to both recognise its own limitations and continually reflect throughout the procedure on the surgical progress and oper ative di ffi culty . Bleeding Bleeding is the most common cause of  conversion to open surgery . The impact of  light absorption is particularly import ant in robotic surgery , and regular haemostasis is paramount to facilitate dissection and surgical progress. Risk factors that predispose to increased bleeding include: /uni25CF liver disease impacting on the production of  vitamin K-dependent clotting factors, e.g. cirrhosis, autoimmune liver disease; /uni25CF inflammatory conditions (acute cholecystitis, diverticulitis); /uni25CF patients on anticoagulants; /uni25CF coagulation defects: these may be contraindications to both open and minimal access surgery and require thorough dis cussion with haematology colleagues to determine, where possible, how to optimise the patient for surgery . Damage to a large vessel requires immediate assessment of the magnitude and type of  bleeding. It is paramount that as soon as b leeding is identified this is communicated clearly to all members of  the theatre and anaesthetic team. There should be a relatively lo w threshold for early conversion; however, this will depend on the expertise of  the operating team. It is per tinent to achieve early control by whatever means necessary . trol may be achieved by clipping, stapling or use of  an energy device, depending on vessel size. Occasionally suturing may be possible; however, this may be significantly more complex - via a minimal access approac h. When the vessel is not identi - fied, compression should be applied immediately with a blunt instrument, a cotton swab or with the adjacent organ. Good suction and irrigation are of  utmost importance. Once the area has been cleaned, pressure should be released gradually y to identify the site of  bleeding. Insertion of  an e xtra port may - be required. There should be no delay in converting to an open procedure when necessary . This is of  particular importance in robotic surgery as some or all of  the robotic arms may need to be urgently undocked to facilitate the surgeon gaining bedside - access to the patient. The bedside assistant should be confident to perform this process. It is sometimes appropriate for a single robotic arm to be left in place to help maintain pressure on the bleeding vessel while direct access is achieved. Alternatively , pressure may be maintained via an assistant port (if  present), allowing the robot to be undocked completely and removed from the surgical field. Bleeding from organs encountered during surgery Excessive retraction can tear a visceral surface, resulting in bleeding. This is particularly so in robotic surgery , where instrument graspers have a small surface area, increasing the potential for injury to retracted tissue. Here rolled swabs may be inserted into the surgical field and held within the grasper, producing a larger surface for retraction and reducing ® tissue injury . Surgicel (absorbable fibrillar oxidised cellulose polymer) or other clot-promoting strips, tissue glues or other haemostatic agents may also be used to aid haemostasis, e.g. from the gallbladder bed during cholecystectomy . - Bleeding from a trocar site Bleeding from the trocar sites is usually treated by localised diathermy or applying upwards and lateral pressure with the trocar itself. Considerable bleeding may occur if  a vessel - such as the inferior epigastric or intercostal artery is injured. Haemostasis can be accomplished either by pressure or by suturing the bleeding site. Devices such as the EndoClose™ may also be used to apply transabdominal sutures under direct laparoscopic view to close port sites that bleed. When a bleeding vessel cannot be easily identified, mass ligation of  the vessel around the port site can be performed. This manoeuvre is accomplished by extending the skin incision by 3 /uni00A0 mm at both ends of  the bleeding trocar site w ound. Two figure-of-eight sutures are placed in the path of  the vessel at both ends of the wound ( Figure 10.5 ). Alternatively , pressure - can be applied using a Foley balloon catheter. The catheter is introduced into the abdominal cavity through the bleeding trocar site wound, the balloon is inflated and traction is placed on the catheter, which is bolstered in place to keep it under ten - sion. T he catheter is left in situ for 24 hours and then removed. If  significant continuous bleeding from the falciform lig - ament occurs, haemostasis is achieved by percutaneously inserting a large, straight needle at one side of  the ligament. - A monofilament suture attached to the needle is passed into the abdominal cavity and the needle is exited at the other side compression is achieved. Maintaining compression throughout the procedure usually su ffi ces. After the procedure has been completed, the loop is removed under direct laparoscopic visu alisation to ensure complete haemostasis. Evacuation of blood clots Careful haemostasis is important as even small, localised pools of  blood or clot absorb light and can significantly impair the surgical view . Carefully directed suction is usually su ffi cient in open cases; however, suction may be problematic in laparo scopic and robotic procedures that are reliant on carbon diox ide insu ffl ation to maintain the surgical field. It is important that suction is applied below a fluid level, or, if  used in the operative field, only in short bursts as required. Should tissue be inadvertently sucked into the end of  the suction device, the tubing can be kinked to allow the tissue to dr op away before removing. Rolled swabs or sponges can be used to remove blood from the surgical field without need for suction ( Figure 10.6 These can also be used for gentle retraction, minimising tissue damage and thus further reducing blood loss. Such swabs may be inserted and removed via a 15-mm assistant port or in some cases a 12-mm robotic trocar with the port cap r emoved. Care should be taken to avoid carbon dioxide loss during extraction. Finally , the surgeon may choose to use a specially designed robotic sucker that integrates with the robotic system. Alterna tively , non-wristed suction can be provided via an assistant port if  included in the operative set-up.

Oral feeding
Oral feeding
Provided that the patient has an appetite, a light meal can be taken 4–6 hours after the operation. Some patients remain slightly nauseated at this stage, but almost all eat a normal breakfast on the morning after surgery . Subsequently a balanced diet is recommended in most cases and where specific procedural recommendations are needed these should be clearly communicated to both the patient and relatives with appropriate dietetic referral made. Oral feeding
Provided that the patient has an appetite, a light meal can be taken 4–6 hours after the operation. Some patients remain slightly nauseated at this stage, but almost all eat a normal breakfast on the morning after surgery . Subsequently a balanced diet is recommended in most cases and where specific procedural recommendations are needed these should be clearly communicated to both the patient and relatives with appropriate dietetic referral made. Oral feeding
Provided that the patient has an appetite, a light meal can be taken 4–6 hours after the operation. Some patients remain slightly nauseated at this stage, but almost all eat a normal breakfast on the morning after surgery . Subsequently a balanced diet is recommended in most cases and where specific procedural recommendations are needed these should be clearly communicated to both the patient and relatives with appropriate dietetic referral made.

Oral fluids
Oral fluids
There is no significant ileus after minimal access surgery , except in abdominal resectional procedures, such as colectomy or small bowel resection. Patients may resume oral fluids as soon as they are conscious; they usually do so 4–6 hours after the end of  the operation. Oral fluids
There is no significant ileus after minimal access surgery , except in abdominal resectional procedures, such as colectomy or small bowel resection. Patients may resume oral fluids as soon as they are conscious; they usually do so 4–6 hours after the end of  the operation. Oral fluids
There is no significant ileus after minimal access surgery , except in abdominal resectional procedures, such as colectomy or small bowel resection. Patients may resume oral fluids as soon as they are conscious; they usually do so 4–6 hours after the end of  the operation.

Orogastric or nasogastric tube
Orogastric or nasogastric tube
An orogastric or nasogastric tube may be placed for some abdominal surgery if  the stomach is distended and obscuring the view . It is not necessary in all cases and is very rarely used in other minimal access surgery . Where possible, it should be regains consciousness. This is most commonly used in bariatric and oesophagogastric surgery , where a larger (32F or 34F) tube is used. Orogastric or nasogastric tube
An orogastric or nasogastric tube may be placed for some abdominal surgery if  the stomach is distended and obscuring the view . It is not necessary in all cases and is very rarely used in other minimal access surgery . Where possible, it should be regains consciousness. This is most commonly used in bariatric and oesophagogastric surgery , where a larger (32F or 34F) tube is used. Orogastric or nasogastric tube
An orogastric or nasogastric tube may be placed for some abdominal surgery if  the stomach is distended and obscuring the view . It is not necessary in all cases and is very rarely used in other minimal access surgery . Where possible, it should be regains consciousness. This is most commonly used in bariatric and oesophagogastric surgery , where a larger (32F or 34F) tube is used.

PERIOPERATIVE PLANNING FOR MINIMAL ACCESS SURGERY
PERIOPERATIVE PLANNING FOR MINIMAL ACCESS SURGERY
PERIOPERATIVE PLANNING FOR MINIMAL ACCESS SURGERY
PERIOPERATIVE PLANNING FOR MINIMAL ACCESS SURGERY

POSTOPERATIVE CARE
POSTOPERATIVE CARE
The postoperative care of  patients after minimal access surgery - is generally straightforward, with a low incidence of  pain or other problems when compared with their open counterparts. It is a good general rule that if  the patient develops a fever or tachycardia, or complains of  severe pain at the operation site, something is wrong and close observation or intervention is necessary (see also Chapter 24 ). ). - -
(a)
(b)
Figure 10.6
Use of rolled swabs for retraction of the lung during
pulmonary lobectomy (courtesy of Mr Tom Routledge, Guy’s and St
Thomas’ NHS Foundation Trust, London, UK).
About half  of  patients experience some degree of  nausea after minimal access surgery . It usually responds to an antiemetic, such as ondansetron, and settles within 12–24 hours. It is made worse by opiate analgesics and these should be rationalised or avoided where at all possible. POSTOPERATIVE CARE
The postoperative care of  patients after minimal access surgery - is generally straightforward, with a low incidence of  pain or other problems when compared with their open counterparts. It is a good general rule that if  the patient develops a fever or tachycardia, or complains of  severe pain at the operation site, something is wrong and close observation or intervention is necessary (see also Chapter 24 ). ). - -
(a)
(b)
Figure 10.6
Use of rolled swabs for retraction of the lung during
pulmonary lobectomy (courtesy of Mr Tom Routledge, Guy’s and St
Thomas’ NHS Foundation Trust, London, UK).
About half  of  patients experience some degree of  nausea after minimal access surgery . It usually responds to an antiemetic, such as ondansetron, and settles within 12–24 hours. It is made worse by opiate analgesics and these should be rationalised or avoided where at all possible. POSTOPERATIVE CARE
The postoperative care of  patients after minimal access surgery - is generally straightforward, with a low incidence of  pain or other problems when compared with their open counterparts. It is a good general rule that if  the patient develops a fever or tachycardia, or complains of  severe pain at the operation site, something is wrong and close observation or intervention is necessary (see also Chapter 24 ). ). - -
(a)
(b)
Figure 10.6
Use of rolled swabs for retraction of the lung during
pulmonary lobectomy (courtesy of Mr Tom Routledge, Guy’s and St
Thomas’ NHS Foundation Trust, London, UK).
About half  of  patients experience some degree of  nausea after minimal access surgery . It usually responds to an antiemetic, such as ondansetron, and settles within 12–24 hours. It is made worse by opiate analgesics and these should be rationalised or avoided where at all possible.

Perivisceral endoscopy
Perivisceral endoscopy
Body planes can be accessed even in the absence of  a natural cavity . Examples are mediastinoscopy , retroperitoneoscopy and retroperitoneal approaches to the kidney , aorta and lumbar sympathetic chain. Some of  these approaches have been in place for many years (cervical mediastinoscopy was first performed in 1959); however, the availability of  novel videoscopes has enhanced visualisation, thus improving the safety and accuracy of  dissection. Extraperitoneal approaches to the retroperitoneal organs, as well as hernia repair, are now commonplace, further decreasing morbidity associated with manipulation of  the visceral peritoneum. Other examples include subfascial endoscopic perforator surgery for ligation of  incompetent perforating veins in varicose vein surgery and endoscopic harvesting of  the saphenous vein for use in coronary artery bypass grafting. Masaki Watanabe , 1911–1995, orthopaedic surgeon, Tokyo, Japan, known as the ‘founder of  modern arthroscopy’. - Perivisceral endoscopy
Body planes can be accessed even in the absence of  a natural cavity . Examples are mediastinoscopy , retroperitoneoscopy and retroperitoneal approaches to the kidney , aorta and lumbar sympathetic chain. Some of  these approaches have been in place for many years (cervical mediastinoscopy was first performed in 1959); however, the availability of  novel videoscopes has enhanced visualisation, thus improving the safety and accuracy of  dissection. Extraperitoneal approaches to the retroperitoneal organs, as well as hernia repair, are now commonplace, further decreasing morbidity associated with manipulation of  the visceral peritoneum. Other examples include subfascial endoscopic perforator surgery for ligation of  incompetent perforating veins in varicose vein surgery and endoscopic harvesting of  the saphenous vein for use in coronary artery bypass grafting. Masaki Watanabe , 1911–1995, orthopaedic surgeon, Tokyo, Japan, known as the ‘founder of  modern arthroscopy’. - Perivisceral endoscopy
Body planes can be accessed even in the absence of  a natural cavity . Examples are mediastinoscopy , retroperitoneoscopy and retroperitoneal approaches to the kidney , aorta and lumbar sympathetic chain. Some of  these approaches have been in place for many years (cervical mediastinoscopy was first performed in 1959); however, the availability of  novel videoscopes has enhanced visualisation, thus improving the safety and accuracy of  dissection. Extraperitoneal approaches to the retroperitoneal organs, as well as hernia repair, are now commonplace, further decreasing morbidity associated with manipulation of  the visceral peritoneum. Other examples include subfascial endoscopic perforator surgery for ligation of  incompetent perforating veins in varicose vein surgery and endoscopic harvesting of  the saphenous vein for use in coronary artery bypass grafting. Masaki Watanabe , 1911–1995, orthopaedic surgeon, Tokyo, Japan, known as the ‘founder of  modern arthroscopy’. -

Port site pain and numbness
Port site pain and numbness
Pain in one or other of  the port site wounds is not uncommon and is worse if  there is haematoma formation. It usually settles very rapidly . In the case of  thoracoscopy , intercostal nerve pain may be more common in those with smaller intercostal spaces. Nerve blockade by means of  directed local anaesthesia is e ff ective at reducing pain and the need for opiate medication in the immediate postoperative period. Increasing pain after 2–3 days may be a sign of  infection and, with concomitant signs, antibiotic therapy is occasionally required. Occasionally , herniation through a port may account for localised pain and should be considered, particularly if  occurring late with a relevant preceding history (e.g. coughing). Failure of  a patient to follow the expected recovery pathway should prompt senior review with appropriate imaging and relook surgery if  consid ered necessary . Port site pain and numbness
Pain in one or other of  the port site wounds is not uncommon and is worse if  there is haematoma formation. It usually settles very rapidly . In the case of  thoracoscopy , intercostal nerve pain may be more common in those with smaller intercostal spaces. Nerve blockade by means of  directed local anaesthesia is e ff ective at reducing pain and the need for opiate medication in the immediate postoperative period. Increasing pain after 2–3 days may be a sign of  infection and, with concomitant signs, antibiotic therapy is occasionally required. Occasionally , herniation through a port may account for localised pain and should be considered, particularly if  occurring late with a relevant preceding history (e.g. coughing). Failure of  a patient to follow the expected recovery pathway should prompt senior review with appropriate imaging and relook surgery if  consid ered necessary . Port site pain and numbness
Pain in one or other of  the port site wounds is not uncommon and is worse if  there is haematoma formation. It usually settles very rapidly . In the case of  thoracoscopy , intercostal nerve pain may be more common in those with smaller intercostal spaces. Nerve blockade by means of  directed local anaesthesia is e ff ective at reducing pain and the need for opiate medication in the immediate postoperative period. Increasing pain after 2–3 days may be a sign of  infection and, with concomitant signs, antibiotic therapy is occasionally required. Occasionally , herniation through a port may account for localised pain and should be considered, particularly if  occurring late with a relevant preceding history (e.g. coughing). Failure of  a patient to follow the expected recovery pathway should prompt senior review with appropriate imaging and relook surgery if  consid ered necessary .

Preparation of the patient
Preparation of the patient
Although the patient may be in hospital for a shorter period, - careful preoperative management is essential to minimise morbidity . Recognition of  patient- or procedure-related factors that may in turn complicate a minimal access approach is vital to optimise outcomes. History Patients must be fit for general anaesthesia and open operation if  necessary . Potential coagulation disorders are particularly dangerous in minimal access surgery where options for haemostasis may be more limited. A prior history of  surgical intervention in the same area is vitally important and should be carefully documented, so as to best predict factors such as adhesions that may preclude a minimal access approach. Previous oncological treatment can also create a more hostile surgical environment and an appropriate threshold for conver - sion to open access should be set prior to the procedure and communicated clearly with the patient. Preparation for minimal access surgery /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Examination Routine preoperative physical examination is required as for any major operation. Although, in general, minimal access surgery allows quicker recovery , it may involve longer operat ing times and carbon dioxide insu ffl ation in both the chest and abdomen may provoke cardiac arrhythmias. Severe chronic obstructive airways disease and ischaemic heart disease may be contraindica tions to a minimal access approach. Moderate obesity does not increase operative di ffi culty significantly , but morbid obesity may require specialist instrumentation and trocars. Patients with a particularly low body mass index and small body habitus may present separate challenges in terms of  port placement, particularly when adopting a robotic approach. Severe spinal deformity including kyphosis and scoliosis may present problems in terms of  positioning as well as impact on overall recovery if there are associated problems with sputum clearance and mobility . Prophylaxis against thromboembolism V enous stasis induced by the reverse Trendelenburg position during laparoscopic surgery coupled with prolonged duration of  operation are risk factors for deep vein thrombosis. Subcuta neous low-molecular-weight heparin and antithromboembolic stockings should be used routinely in addition to pneumatic calf compression during the operation. Patients already taking anticoagulation should have this stopped temporarily or appropriate, be converted to intravenous or subcutaneous heparin, depending on the underlying condition and local thromboprophylaxis protocols. In most cases patients can continue on aspirin when the benefits outweigh the slight increase in bleeding potential. Urinary catheters and nasogastric tubes In the early days of  minimal access surgery , routine bladder catheterisation and nasogastric intubation were advised. Most surgeons now omit these in favour of  enhanced recovery , which has demonstrated benefits in terms of  both length of stay and morbidity outcomes. It remains essential to check that Friedrich Trendelenburg , 1844–1924, Professor of  Surgery successively at Rostock (1875–1882), Bonn (1882–1895), Leipzig (1895–1911), Germany . The Tren delenburg position was first described in 1885. particularly before creating pneumoperitoneum for minimal access surgery approaches to the abdomen. Informed consent It is essential that the patient understands the nature of  the procedure, the risks involved and, when appropriate, the alternatives that are available. A locally prepared explanatory booklet concerning the minimal access procedure to be under - taken is extremely useful ( Chapter 14 ). The patient should understand that the procedure may be converted to an open operation. Common complications should be mentioned, such as shoulder tip pain and minor surgical emphysema, as well as rare but serious complications, suc h as inadvertent visceral injury from trocar insertion or diathermy . Patients may also have specific questions or requests in terms of  the application of  minimal access surgery . It is important to be considerate and address these. Some patients remain concerned about the application of  technology , particularly robotics, to their care and it is important to ensure they understand and agree with the proposed surgical approach. -
Overall
/f_i
tness: cardiac arrhythmia, lung function, medications,
allergies
Previous surgery or oncological intervention: scars, adhesions
Body habitus: obesity, skeletal deformity
Normal coagulation
Thromboprophylaxis
Informed consent
Operative dif
/f_i
culty is predicted when possible with appropriate
risk model
Appropriate theatre time and facilities are available (especially
important for robotic cases)
Preparation of the patient
Although the patient may be in hospital for a shorter period, - careful preoperative management is essential to minimise morbidity . Recognition of  patient- or procedure-related factors that may in turn complicate a minimal access approach is vital to optimise outcomes. History Patients must be fit for general anaesthesia and open operation if  necessary . Potential coagulation disorders are particularly dangerous in minimal access surgery where options for haemostasis may be more limited. A prior history of  surgical intervention in the same area is vitally important and should be carefully documented, so as to best predict factors such as adhesions that may preclude a minimal access approach. Previous oncological treatment can also create a more hostile surgical environment and an appropriate threshold for conver - sion to open access should be set prior to the procedure and communicated clearly with the patient. Preparation for minimal access surgery /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Examination Routine preoperative physical examination is required as for any major operation. Although, in general, minimal access surgery allows quicker recovery , it may involve longer operat ing times and carbon dioxide insu ffl ation in both the chest and abdomen may provoke cardiac arrhythmias. Severe chronic obstructive airways disease and ischaemic heart disease may be contraindica tions to a minimal access approach. Moderate obesity does not increase operative di ffi culty significantly , but morbid obesity may require specialist instrumentation and trocars. Patients with a particularly low body mass index and small body habitus may present separate challenges in terms of  port placement, particularly when adopting a robotic approach. Severe spinal deformity including kyphosis and scoliosis may present problems in terms of  positioning as well as impact on overall recovery if there are associated problems with sputum clearance and mobility . Prophylaxis against thromboembolism V enous stasis induced by the reverse Trendelenburg position during laparoscopic surgery coupled with prolonged duration of  operation are risk factors for deep vein thrombosis. Subcuta neous low-molecular-weight heparin and antithromboembolic stockings should be used routinely in addition to pneumatic calf compression during the operation. Patients already taking anticoagulation should have this stopped temporarily or appropriate, be converted to intravenous or subcutaneous heparin, depending on the underlying condition and local thromboprophylaxis protocols. In most cases patients can continue on aspirin when the benefits outweigh the slight increase in bleeding potential. Urinary catheters and nasogastric tubes In the early days of  minimal access surgery , routine bladder catheterisation and nasogastric intubation were advised. Most surgeons now omit these in favour of  enhanced recovery , which has demonstrated benefits in terms of  both length of stay and morbidity outcomes. It remains essential to check that Friedrich Trendelenburg , 1844–1924, Professor of  Surgery successively at Rostock (1875–1882), Bonn (1882–1895), Leipzig (1895–1911), Germany . The Tren delenburg position was first described in 1885. particularly before creating pneumoperitoneum for minimal access surgery approaches to the abdomen. Informed consent It is essential that the patient understands the nature of  the procedure, the risks involved and, when appropriate, the alternatives that are available. A locally prepared explanatory booklet concerning the minimal access procedure to be under - taken is extremely useful ( Chapter 14 ). The patient should understand that the procedure may be converted to an open operation. Common complications should be mentioned, such as shoulder tip pain and minor surgical emphysema, as well as rare but serious complications, suc h as inadvertent visceral injury from trocar insertion or diathermy . Patients may also have specific questions or requests in terms of  the application of  minimal access surgery . It is important to be considerate and address these. Some patients remain concerned about the application of  technology , particularly robotics, to their care and it is important to ensure they understand and agree with the proposed surgical approach. -
Overall
/f_i
tness: cardiac arrhythmia, lung function, medications,
allergies
Previous surgery or oncological intervention: scars, adhesions
Body habitus: obesity, skeletal deformity
Normal coagulation
Thromboprophylaxis
Informed consent
Operative dif
/f_i
culty is predicted when possible with appropriate
risk model
Appropriate theatre time and facilities are available (especially
important for robotic cases)
Preparation of the patient
Although the patient may be in hospital for a shorter period, - careful preoperative management is essential to minimise morbidity . Recognition of  patient- or procedure-related factors that may in turn complicate a minimal access approach is vital to optimise outcomes. History Patients must be fit for general anaesthesia and open operation if  necessary . Potential coagulation disorders are particularly dangerous in minimal access surgery where options for haemostasis may be more limited. A prior history of  surgical intervention in the same area is vitally important and should be carefully documented, so as to best predict factors such as adhesions that may preclude a minimal access approach. Previous oncological treatment can also create a more hostile surgical environment and an appropriate threshold for conver - sion to open access should be set prior to the procedure and communicated clearly with the patient. Preparation for minimal access surgery /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Examination Routine preoperative physical examination is required as for any major operation. Although, in general, minimal access surgery allows quicker recovery , it may involve longer operat ing times and carbon dioxide insu ffl ation in both the chest and abdomen may provoke cardiac arrhythmias. Severe chronic obstructive airways disease and ischaemic heart disease may be contraindica tions to a minimal access approach. Moderate obesity does not increase operative di ffi culty significantly , but morbid obesity may require specialist instrumentation and trocars. Patients with a particularly low body mass index and small body habitus may present separate challenges in terms of  port placement, particularly when adopting a robotic approach. Severe spinal deformity including kyphosis and scoliosis may present problems in terms of  positioning as well as impact on overall recovery if there are associated problems with sputum clearance and mobility . Prophylaxis against thromboembolism V enous stasis induced by the reverse Trendelenburg position during laparoscopic surgery coupled with prolonged duration of  operation are risk factors for deep vein thrombosis. Subcuta neous low-molecular-weight heparin and antithromboembolic stockings should be used routinely in addition to pneumatic calf compression during the operation. Patients already taking anticoagulation should have this stopped temporarily or appropriate, be converted to intravenous or subcutaneous heparin, depending on the underlying condition and local thromboprophylaxis protocols. In most cases patients can continue on aspirin when the benefits outweigh the slight increase in bleeding potential. Urinary catheters and nasogastric tubes In the early days of  minimal access surgery , routine bladder catheterisation and nasogastric intubation were advised. Most surgeons now omit these in favour of  enhanced recovery , which has demonstrated benefits in terms of  both length of stay and morbidity outcomes. It remains essential to check that Friedrich Trendelenburg , 1844–1924, Professor of  Surgery successively at Rostock (1875–1882), Bonn (1882–1895), Leipzig (1895–1911), Germany . The Tren delenburg position was first described in 1885. particularly before creating pneumoperitoneum for minimal access surgery approaches to the abdomen. Informed consent It is essential that the patient understands the nature of  the procedure, the risks involved and, when appropriate, the alternatives that are available. A locally prepared explanatory booklet concerning the minimal access procedure to be under - taken is extremely useful ( Chapter 14 ). The patient should understand that the procedure may be converted to an open operation. Common complications should be mentioned, such as shoulder tip pain and minor surgical emphysema, as well as rare but serious complications, suc h as inadvertent visceral injury from trocar insertion or diathermy . Patients may also have specific questions or requests in terms of  the application of  minimal access surgery . It is important to be considerate and address these. Some patients remain concerned about the application of  technology , particularly robotics, to their care and it is important to ensure they understand and agree with the proposed surgical approach. -
Overall
/f_i
tness: cardiac arrhythmia, lung function, medications,
allergies
Previous surgery or oncological intervention: scars, adhesions
Body habitus: obesity, skeletal deformity
Normal coagulation
Thromboprophylaxis
Informed consent
Operative dif
/f_i
culty is predicted when possible with appropriate
risk model
Appropriate theatre time and facilities are available (especially
important for robotic cases)

Principles of electrosurgery during laparoscopic s
Principles of electrosurgery during laparoscopic surgery
Inadvertent electrosurgical injuries during minimal access surgery are potentially serious and are often unrecognised at the time. The vast majority occur following the use of  monopolar diathermy . For conventional laparoscopy , the overall incidence is thought to be between one and two cases per 1000 operations. Injuries can occur through inadvertent touching or grasping of  tissue during current application; direct coupling between tissue and a metal instrument that is touching the activated probe; insulation breaks in the laparoscopic or robotic instru ments; direct sparking from the diathermy probe; or current Bipolar diathermy is safer and should be used in preference to monopolar diathermy , especially in anatomically crowded - areas. If  monopolar diathermy is to be used, important safety measures include attainment of  a perfect visual image, avoid - ing excessive current application and meticulous attention to insulation. Alternative methods of  performing dissection, such as the use of  ultrasonic devices, may improve safety .
Figure 10.5
Management of bleeding from a surgical trocar site.
Principles of electrosurgery during laparoscopic surgery
Inadvertent electrosurgical injuries during minimal access surgery are potentially serious and are often unrecognised at the time. The vast majority occur following the use of  monopolar diathermy . For conventional laparoscopy , the overall incidence is thought to be between one and two cases per 1000 operations. Injuries can occur through inadvertent touching or grasping of  tissue during current application; direct coupling between tissue and a metal instrument that is touching the activated probe; insulation breaks in the laparoscopic or robotic instru ments; direct sparking from the diathermy probe; or current Bipolar diathermy is safer and should be used in preference to monopolar diathermy , especially in anatomically crowded - areas. If  monopolar diathermy is to be used, important safety measures include attainment of  a perfect visual image, avoid - ing excessive current application and meticulous attention to insulation. Alternative methods of  performing dissection, such as the use of  ultrasonic devices, may improve safety .
Figure 10.5
Management of bleeding from a surgical trocar site.

Principles of electrosurgery during laparoscopic surgery
Principles of electrosurgery during laparoscopic surgery
Inadvertent electrosurgical injuries during minimal access surgery are potentially serious and are often unrecognised at the time. The vast majority occur following the use of  monopolar diathermy . For conventional laparoscopy , the overall incidence is thought to be between one and two cases per 1000 operations. Injuries can occur through inadvertent touching or grasping of  tissue during current application; direct coupling between tissue and a metal instrument that is touching the activated probe; insulation breaks in the laparoscopic or robotic instru ments; direct sparking from the diathermy probe; or current Bipolar diathermy is safer and should be used in preference to monopolar diathermy , especially in anatomically crowded - areas. If  monopolar diathermy is to be used, important safety measures include attainment of  a perfect visual image, avoid - ing excessive current application and meticulous attention to insulation. Alternative methods of  performing dissection, such as the use of  ultrasonic devices, may improve safety .
Figure 10.5
Management of bleeding from a surgical trocar site.

ROBOTIC SURGERY
ROBOTIC SURGERY
A robot is a mechanical device that performs automated phys - ical tasks according to direct human supervision, a predefined program or a set of  general guidelines, using artificial intel - ligence (AI) technology . In surgery , robots can be used to assist surgeons to perf orm operative procedures, primarily in the form of automated camera systems and telemanipulator interface. Reduced degrees of  freedom of movement and di ffi cult ergonomic positioning for the surgeon can limit the application of  straight stick endoscopy to a number of  special ties owing to a loss in surgical precision. This has driven the uptake of  robotic surgical systems, currently existing as two main categories: /uni25CF Teleoperated (master–slave) systems: a surgeon performs an operation via a robot and its robotic instru ments through a televisual computerised platform (where the surgeon is the master, i.e. the operator, and the robot is the slave). This may be via onsite connections or remotely through the internet or other digital channels – hence the publicity of  ‘operating on a patient from another country’ (such ‘remote’ operations are currently rarely performed but their existence is established). /uni25CF Active or semiactive systems: these are typically image-guided or pre-programmed. In active sys tems, a surgical robot completes a pre-programmed surgical task. This is guided by preoperative imaging and real-time anatomical constraints and cues through the application of in-built navigation systems. In semiactive systems, the robotic device may be in part pre-programmed and in part surgeon driven. ROBOTIC SURGERY
A robot is a mechanical device that performs automated phys - ical tasks according to direct human supervision, a predefined program or a set of  general guidelines, using artificial intel - ligence (AI) technology . In surgery , robots can be used to assist surgeons to perf orm operative procedures, primarily in the form of automated camera systems and telemanipulator interface. Reduced degrees of  freedom of movement and di ffi cult ergonomic positioning for the surgeon can limit the application of  straight stick endoscopy to a number of  special ties owing to a loss in surgical precision. This has driven the uptake of  robotic surgical systems, currently existing as two main categories: /uni25CF Teleoperated (master–slave) systems: a surgeon performs an operation via a robot and its robotic instru ments through a televisual computerised platform (where the surgeon is the master, i.e. the operator, and the robot is the slave). This may be via onsite connections or remotely through the internet or other digital channels – hence the publicity of  ‘operating on a patient from another country’ (such ‘remote’ operations are currently rarely performed but their existence is established). /uni25CF Active or semiactive systems: these are typically image-guided or pre-programmed. In active sys tems, a surgical robot completes a pre-programmed surgical task. This is guided by preoperative imaging and real-time anatomical constraints and cues through the application of in-built navigation systems. In semiactive systems, the robotic device may be in part pre-programmed and in part surgeon driven. ROBOTIC SURGERY
A robot is a mechanical device that performs automated phys - ical tasks according to direct human supervision, a predefined program or a set of  general guidelines, using artificial intel - ligence (AI) technology . In surgery , robots can be used to assist surgeons to perf orm operative procedures, primarily in the form of automated camera systems and telemanipulator interface. Reduced degrees of  freedom of movement and di ffi cult ergonomic positioning for the surgeon can limit the application of  straight stick endoscopy to a number of  special ties owing to a loss in surgical precision. This has driven the uptake of  robotic surgical systems, currently existing as two main categories: /uni25CF Teleoperated (master–slave) systems: a surgeon performs an operation via a robot and its robotic instru ments through a televisual computerised platform (where the surgeon is the master, i.e. the operator, and the robot is the slave). This may be via onsite connections or remotely through the internet or other digital channels – hence the publicity of  ‘operating on a patient from another country’ (such ‘remote’ operations are currently rarely performed but their existence is established). /uni25CF Active or semiactive systems: these are typically image-guided or pre-programmed. In active sys tems, a surgical robot completes a pre-programmed surgical task. This is guided by preoperative imaging and real-time anatomical constraints and cues through the application of in-built navigation systems. In semiactive systems, the robotic device may be in part pre-programmed and in part surgeon driven.

SURGICAL TRAUMA IN OPEN, MINIMALL Y INVASIVE AND R
SURGICAL TRAUMA IN OPEN, MINIMALL Y INVASIVE AND ROBOTIC SURGERY
Most of the trauma of an open procedure is inflicted because the surgeon must have a wound that is large enough to give adequate exposure for safe dissection at a target site. The wound is often the cause of  morbidity , including infection, dehiscence, bleeding, herniation and nerve entrapment. Wound pain prolongs recovery time and, by reducing mobility , contributes to an increased incidence of  pulmonary atelectasis, chest infection, paralytic ileus and deep venous thrombosis. Mechanical and human retractors cause additional trauma. Body wall retractors can inflict localised damage that may be as painful as the wound itself. In contrast, during laparoscopy , the retraction is provided by the low-pressur e pneumoperitoneum, giving a di ff use force applied gently and evenly over the whole body wall, causing minimal trauma. Exposure of  any body cavity to the atmosphere also causes morbidity through cooling and fluid loss by evaporation. The incidence of  postsurgical adhesions is reduced by use of mini mally invasive approaches because there is less damage to del icate serosal coverings. In the manual handling of  intestinal loops, the surgeon and assistant disturb the peristaltic activity of  the gut and provoke adynamic ileus. While minimal access methods were initially established in elective surgery , the advantages have led to increased uptake for a number of  emergency surgical procedures, including perf orated viscus repair, such as omental patch repair of  a peptic ulcer perforation, lavage of  localised perforation of diverticular disease, intrathoracic debridement of  empyema and pneumothorax and haemothorax surgery . More recently , some experienced surgeons have chosen to employ minimal access approaches to trauma situations for initial assessment and treatment in stable patients. Advantages of minimal access surgery /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF - /uni25CF /uni25CF
Decrease in wound size
Reduction in wound infection, dehiscence, bleeding, herniation
and nerve entrapment
Decrease in wound pain
Improved mobility
Decreased wound trauma
Decreased heat loss
Improved visualisation
SURGICAL TRAUMA IN OPEN, MINIMALL Y INVASIVE AND ROBOTIC SURGERY
Most of the trauma of an open procedure is inflicted because the surgeon must have a wound that is large enough to give adequate exposure for safe dissection at a target site. The wound is often the cause of  morbidity , including infection, dehiscence, bleeding, herniation and nerve entrapment. Wound pain prolongs recovery time and, by reducing mobility , contributes to an increased incidence of  pulmonary atelectasis, chest infection, paralytic ileus and deep venous thrombosis. Mechanical and human retractors cause additional trauma. Body wall retractors can inflict localised damage that may be as painful as the wound itself. In contrast, during laparoscopy , the retraction is provided by the low-pressur e pneumoperitoneum, giving a di ff use force applied gently and evenly over the whole body wall, causing minimal trauma. Exposure of  any body cavity to the atmosphere also causes morbidity through cooling and fluid loss by evaporation. The incidence of  postsurgical adhesions is reduced by use of mini mally invasive approaches because there is less damage to del icate serosal coverings. In the manual handling of  intestinal loops, the surgeon and assistant disturb the peristaltic activity of  the gut and provoke adynamic ileus. While minimal access methods were initially established in elective surgery , the advantages have led to increased uptake for a number of  emergency surgical procedures, including perf orated viscus repair, such as omental patch repair of  a peptic ulcer perforation, lavage of  localised perforation of diverticular disease, intrathoracic debridement of  empyema and pneumothorax and haemothorax surgery . More recently , some experienced surgeons have chosen to employ minimal access approaches to trauma situations for initial assessment and treatment in stable patients. Advantages of minimal access surgery /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF - /uni25CF /uni25CF
Decrease in wound size
Reduction in wound infection, dehiscence, bleeding, herniation
and nerve entrapment
Decrease in wound pain
Improved mobility
Decreased wound trauma
Decreased heat loss
Improved visualisation

SURGICAL TRAUMA IN OPEN, MINIMALL Y INVASIVE AND ROBOTIC SURGERY
SURGICAL TRAUMA IN OPEN, MINIMALL Y INVASIVE AND ROBOTIC SURGERY
Most of the trauma of an open procedure is inflicted because the surgeon must have a wound that is large enough to give adequate exposure for safe dissection at a target site. The wound is often the cause of  morbidity , including infection, dehiscence, bleeding, herniation and nerve entrapment. Wound pain prolongs recovery time and, by reducing mobility , contributes to an increased incidence of  pulmonary atelectasis, chest infection, paralytic ileus and deep venous thrombosis. Mechanical and human retractors cause additional trauma. Body wall retractors can inflict localised damage that may be as painful as the wound itself. In contrast, during laparoscopy , the retraction is provided by the low-pressur e pneumoperitoneum, giving a di ff use force applied gently and evenly over the whole body wall, causing minimal trauma. Exposure of  any body cavity to the atmosphere also causes morbidity through cooling and fluid loss by evaporation. The incidence of  postsurgical adhesions is reduced by use of mini mally invasive approaches because there is less damage to del icate serosal coverings. In the manual handling of  intestinal loops, the surgeon and assistant disturb the peristaltic activity of  the gut and provoke adynamic ileus. While minimal access methods were initially established in elective surgery , the advantages have led to increased uptake for a number of  emergency surgical procedures, including perf orated viscus repair, such as omental patch repair of  a peptic ulcer perforation, lavage of  localised perforation of diverticular disease, intrathoracic debridement of  empyema and pneumothorax and haemothorax surgery . More recently , some experienced surgeons have chosen to employ minimal access approaches to trauma situations for initial assessment and treatment in stable patients. Advantages of minimal access surgery /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF - /uni25CF /uni25CF
Decrease in wound size
Reduction in wound infection, dehiscence, bleeding, herniation
and nerve entrapment
Decrease in wound pain
Improved mobility
Decreased wound trauma
Decreased heat loss
Improved visualisation

Shoulder tip pain
Shoulder tip pain
Patients should be warned about this preoperatively and informed that the pain is referred from the diaphragm and that it is not due to a local problem in the shoulders. It can be at its worst 24 hours after the operation. It usually settles within 2–3 days and is relieved by simple analgesics, such as paracetamol. Shoulder tip pain
Patients should be warned about this preoperatively and informed that the pain is referred from the diaphragm and that it is not due to a local problem in the shoulders. It can be at its worst 24 hours after the operation. It usually settles within 2–3 days and is relieved by simple analgesics, such as paracetamol. Shoulder tip pain
Patients should be warned about this preoperatively and informed that the pain is referred from the diaphragm and that it is not due to a local problem in the shoulders. It can be at its worst 24 hours after the operation. It usually settles within 2–3 days and is relieved by simple analgesics, such as paracetamol.

Single-incision minimal access surgery
Single-incision minimal access surgery
Single-incision minimal access surgery has varied in popularity with both strong advocates and others who are sceptical of any advantages. Single-incision laparoscopic surgery (SILS) involves insertion of  all instrumentation through a multiple channel port via a single incision at the umbilicus. The benefits are that the incision, through a natural scar (the umbilicus), is virtually ‘scarless’ and that fewer port sites potentially reduces pain and lessens the risks of  port site bleeding and the potential for port site hernia. SILS requires specially manufactured multichannel ports - and often roticulating instruments. It has most commonly been adopted in gallbladder and hernia surgery , although more in vitro fertilisation. remains debate as to whether the increased procedural di ffi culty , steep learning curve and increased direct costs in terms of  devices, instruments and operating time can be o ff set by significant clinical benefit. Uniportal thoracic surgery requires less specialist equip ment; many minor thoracic procedures are commonly per formed using this technique. More complex resectional procedures are less commonly performed, largely because of technical complexity when compared with multiport niques, which are on the whole very well tolerated. Single-incision minimal access surgery
Single-incision minimal access surgery has varied in popularity with both strong advocates and others who are sceptical of any advantages. Single-incision laparoscopic surgery (SILS) involves insertion of  all instrumentation through a multiple channel port via a single incision at the umbilicus. The benefits are that the incision, through a natural scar (the umbilicus), is virtually ‘scarless’ and that fewer port sites potentially reduces pain and lessens the risks of  port site bleeding and the potential for port site hernia. SILS requires specially manufactured multichannel ports - and often roticulating instruments. It has most commonly been adopted in gallbladder and hernia surgery , although more in vitro fertilisation. remains debate as to whether the increased procedural di ffi culty , steep learning curve and increased direct costs in terms of  devices, instruments and operating time can be o ff set by significant clinical benefit. Uniportal thoracic surgery requires less specialist equip ment; many minor thoracic procedures are commonly per formed using this technique. More complex resectional procedures are less commonly performed, largely because of technical complexity when compared with multiport niques, which are on the whole very well tolerated. Single-incision minimal access surgery
Single-incision minimal access surgery has varied in popularity with both strong advocates and others who are sceptical of any advantages. Single-incision laparoscopic surgery (SILS) involves insertion of  all instrumentation through a multiple channel port via a single incision at the umbilicus. The benefits are that the incision, through a natural scar (the umbilicus), is virtually ‘scarless’ and that fewer port sites potentially reduces pain and lessens the risks of  port site bleeding and the potential for port site hernia. SILS requires specially manufactured multichannel ports - and often roticulating instruments. It has most commonly been adopted in gallbladder and hernia surgery , although more in vitro fertilisation. remains debate as to whether the increased procedural di ffi culty , steep learning curve and increased direct costs in terms of  devices, instruments and operating time can be o ff set by significant clinical benefit. Uniportal thoracic surgery requires less specialist equip ment; many minor thoracic procedures are commonly per formed using this technique. More complex resectional procedures are less commonly performed, largely because of technical complexity when compared with multiport niques, which are on the whole very well tolerated.

Skin sutures
Skin sutures
If  non-absorbable sutures or skin staples have been used, they can be removed from the port sites after 7–10 days. Skin sutures
If  non-absorbable sutures or skin staples have been used, they can be removed from the port sites after 7–10 days. Skin sutures
If  non-absorbable sutures or skin staples have been used, they can be removed from the port sites after 7–10 days.

THE FUTURE
THE FUTURE
Minimal access surgery has changed surgical practice; however, it has not changed the nature of  disease. The basic principles of good surgery still apply , including appropriate case selection, excellent exposure, adequate retraction and a high level of technical expertise. Endoscopic and robotic surgery training is key to allow the specialty to progress. The pioneers of  yesterday have to teach the surgeons of  tomorrow not only the technical and dexterous skills required but also the decision-making and innovative skills necessary for the field to continue to evolve. Training is often perceived as di ffi cult, as trainers have less control over the trainees at the time of  surgery and caseloads may be smaller, especially in centres where laparoscopic and robotic procedures are not common. However, trainees now rightly expect exposure to these procedures, and training systems should be adaptable for international exposure so that these techniques can be disseminated worldwide. The predominant video and digital component of  these new techniques opens the door for simulation approaches for training in these modalities , which have demonstrated benefits in reducing learning curves and in tur n are aimed at improv - ing patient outcomes. The ultimate goal for this educational approach is to develop expert surgeons through the ‘totally safe’ and ‘risk-free’ environment of  simulation before they
Figure 10.7
Robotic-assisted lung segmentectomy utilising indocyanine green administered endobronchially to highlight the segment for resec
tion.
(a)
Robotic dissection of the superior (S6) segment.
(b)
Indocyanine green immuno
/f_l
uorescence of the marked segment, enabling clear
identi
/f_i
cation of the area for resection.
Figure 10.8
Navigational bronchoscopy. Split screen image demonstrating real-time endobronchial imaging adjacent to a virtual bronchoscope
image and a three-dimensional map of the lesion and bronchial tree (courtesy of Mr Kelvin Lau, Barts Thorax Centre, London, UK).
actually have to operate on patients. Indeed, both videoscopic and robotic platforms now have established simulation pro grams that are a prerequisite for surgical trainees. Modern robotic simulation modules are able to create an environment that mirrors console use (face validity) and subsequently vide hierarchical training compatible with the user’s expertise. The combination of  simulation with proficiency-based ‘mas tery’ training may be the key to optimising the impact that sim ulation may have on the sur gical learning curve and remains the subject of  research in a range of  surgical specialties. With widespread uptake of  minimal access surgery , train ees are now facing a new pr oblem owing to lack of  experience in open surgery . Surgeons must have su ffi cient open surgical experience to feel comfortable converting cases in the ev of  di ffi culty or emergency . A minimal access approach to a particular procedure may di ff er significantly in the order of operative steps and dissection technique. It is therefore vital that the new generation of  surgeons continues to receive train ing in open surgery so that they can apply either technique as appropriate. Advances in robotic surgery lend themselves to further AI integration, with potential advantages such as providing enhanced clinical decision support, warning of  de from optimal workflow or detecting and over laying potentially at-risk structures. In this way , artificially intelligent systems may streamline procedural technique, reduce error and improve patient outcomes. Intelligent operating theatres may provide automated optimisation of  a wide range of  ergonomic features such as table positioning, lighting and temperature, further facilitating procedural e ffi ciency and e ff ectiveness. In turn, more advanced artificial systems may also develop a degree of supervised autonomy whereby basic surgical procedures can be independently performed by the robotic system. Indeed, Berkeley George Andrew Moynihan (Lord Moynihan) , 1865–1936, Professor of  Clinical Surgery , Leeds, UK. Moynihan felt that English surgeons knew little about the work of  their colleagues both at home and abroad. Therefore, in 1909, he established a small travelling club which in 1929 became the Moynihan Chirurgical Club. It still exists today . He took a leading part in founding the until his death. Robot) robotic system has demonstrated superiority over human surgeons in porcine bowel anastomosis. Translation of  such laboratory-based e xperiments to real- world surgery is not simple. Application requires detailed understanding of  surgical workflow and integra tion of  com - plex data. To provide a fully comprehensive, annotated train - ing data set on which deep learning may be established, all devices and systems in the dynamic operating environment must be integrated, including operating room set-up, tool and camera usage and the variab le patient and procedural factors. In addition there are complex questions in terms of  data pro - tection and confidentiality , not to mention the ethical consider - ations and accountability of  autonomous or semi-autonomous robotic surgeons. The most promising elements of  AI inte - gration into minimal access surgery remain enhanced object detection, speech recognition, video characterisation and integ ration with next-generation technologies. Real-time met - abolic pr ofiling and tissue-level diagnosis may di ff erentiate between cancerous and non-cancerous tissues on the basis of their metabolic signature. An example is the iKnife, w hich uses a rapid evaporative ionisation mass spectrometric (REIMS) technique to report tissue histology in real time by analysing - aerosolised tissue during electrosurgical dissection. Artificially intelligent systems also hold potential to dramat - ically improve the fidelity of  simulation training in minimal pro - access surgery , through the creation of  a ‘real-world’ training environment based on the vast data accrued in their develop - - ment. Such data may be used to create a dynamic simulation - environment for any procedure, much more akin to that of ‘real-life’ surgery . This holds potential f or a stepwise tutorial system similar to that of  bedside teaching, with objective feed - - back provided against standardised proficiency benchmarks that can be easily integrated into national training programmes. One major obstacle for minimally invasive technology ent remains the cost e ffi ciency and device financing in an increas - ingly rationed global healthcare environment; this is an issue that will require surgical liaison with hospital management and national policy pro viders. Surgeons need to continue to have - a dialogue, discussing their experiences and ideas in order to e ff ectiv ely progress minimal access surgery and continue to adopt novel technology . As technological advancements are adopted, carefully designed outcomes research is required to provide a clear evidence base to support changes to clinical viations practice. In this way the comparative e ff ectiveness of  novel minimal access technologies will be better understood in terms of  both clinical outcomes and cost-e ff ectiveness, allowing selection of  those with the greatest potential to provide lasting improvements in patient care. British Journal of  Surgery in 1913 and became the first chairman of  the editorial committee
Figure 10.9
Image-guided video-assisted thoracoscopic surgery with
the use of a navigationally placed
/f_i
ducial marker to guide tumour
resection (courtesy of Mr Kelvin Lau, Barts Thorax Centre, London,
UK).
The cleaner and gentler the act of operation, the less the
patient suffers, the smoother and quicker his convales
cence, the more exquisite his healed wound.
Berkeley George Andrew Moynihan (1920)
Athanasiou T , Ashrafian H, Rao C et al . The tipping point of robotic surgery in healthcare: from master–slave to flexible access bio-inspired platforms. Surg T echnol Int 2011; 21 : 28–34. Bhandari M, Ze ffi ro T , Reddiboina M. Artificial intelligence and ro botic surgery: current perspective and future directions. Curr Opin Urol 2020; 30 (1): 48–54. Bodenstedt S, Wagner M, Müller-Stich BP et al . Artificial intelli gence-assisted surgery: potential and challenges. Visc Med 36 (6): 450–5. Brodie A, Vasdev N. The future of  robotic surgery . Ann R Coll Surg Engl 2018; 100 (Suppl 7): 4–13. augmented reality in minimally invasive spine surgery . Global Spine J 2020; 10 (2 Suppl): 22S–33S. St John ER, Balog J, McKenzie JS et al . Rapid evaporative ionization mass spectrometry of  electrosurgical vapours for the identification - of  breast pathology: towards an intelligent knife for breast cancer surgery . Breast Cancer Res 2017; 19 (1): 59. Tan A, Ashrafian H, Scott AJ et al . Robotic surgery: disruptive innova - - tion or unfulfilled promise? A systematic review and meta-analysis 2020; of  the first 30 years. Surg Endosc 2016; 30 (10): 4330–52. THE FUTURE
Minimal access surgery has changed surgical practice; however, it has not changed the nature of  disease. The basic principles of good surgery still apply , including appropriate case selection, excellent exposure, adequate retraction and a high level of technical expertise. Endoscopic and robotic surgery training is key to allow the specialty to progress. The pioneers of  yesterday have to teach the surgeons of  tomorrow not only the technical and dexterous skills required but also the decision-making and innovative skills necessary for the field to continue to evolve. Training is often perceived as di ffi cult, as trainers have less control over the trainees at the time of  surgery and caseloads may be smaller, especially in centres where laparoscopic and robotic procedures are not common. However, trainees now rightly expect exposure to these procedures, and training systems should be adaptable for international exposure so that these techniques can be disseminated worldwide. The predominant video and digital component of  these new techniques opens the door for simulation approaches for training in these modalities , which have demonstrated benefits in reducing learning curves and in tur n are aimed at improv - ing patient outcomes. The ultimate goal for this educational approach is to develop expert surgeons through the ‘totally safe’ and ‘risk-free’ environment of  simulation before they
Figure 10.7
Robotic-assisted lung segmentectomy utilising indocyanine green administered endobronchially to highlight the segment for resec
tion.
(a)
Robotic dissection of the superior (S6) segment.
(b)
Indocyanine green immuno
/f_l
uorescence of the marked segment, enabling clear
identi
/f_i
cation of the area for resection.
Figure 10.8
Navigational bronchoscopy. Split screen image demonstrating real-time endobronchial imaging adjacent to a virtual bronchoscope
image and a three-dimensional map of the lesion and bronchial tree (courtesy of Mr Kelvin Lau, Barts Thorax Centre, London, UK).
actually have to operate on patients. Indeed, both videoscopic and robotic platforms now have established simulation pro grams that are a prerequisite for surgical trainees. Modern robotic simulation modules are able to create an environment that mirrors console use (face validity) and subsequently vide hierarchical training compatible with the user’s expertise. The combination of  simulation with proficiency-based ‘mas tery’ training may be the key to optimising the impact that sim ulation may have on the sur gical learning curve and remains the subject of  research in a range of  surgical specialties. With widespread uptake of  minimal access surgery , train ees are now facing a new pr oblem owing to lack of  experience in open surgery . Surgeons must have su ffi cient open surgical experience to feel comfortable converting cases in the ev of  di ffi culty or emergency . A minimal access approach to a particular procedure may di ff er significantly in the order of operative steps and dissection technique. It is therefore vital that the new generation of  surgeons continues to receive train ing in open surgery so that they can apply either technique as appropriate. Advances in robotic surgery lend themselves to further AI integration, with potential advantages such as providing enhanced clinical decision support, warning of  de from optimal workflow or detecting and over laying potentially at-risk structures. In this way , artificially intelligent systems may streamline procedural technique, reduce error and improve patient outcomes. Intelligent operating theatres may provide automated optimisation of  a wide range of  ergonomic features such as table positioning, lighting and temperature, further facilitating procedural e ffi ciency and e ff ectiveness. In turn, more advanced artificial systems may also develop a degree of supervised autonomy whereby basic surgical procedures can be independently performed by the robotic system. Indeed, Berkeley George Andrew Moynihan (Lord Moynihan) , 1865–1936, Professor of  Clinical Surgery , Leeds, UK. Moynihan felt that English surgeons knew little about the work of  their colleagues both at home and abroad. Therefore, in 1909, he established a small travelling club which in 1929 became the Moynihan Chirurgical Club. It still exists today . He took a leading part in founding the until his death. Robot) robotic system has demonstrated superiority over human surgeons in porcine bowel anastomosis. Translation of  such laboratory-based e xperiments to real- world surgery is not simple. Application requires detailed understanding of  surgical workflow and integra tion of  com - plex data. To provide a fully comprehensive, annotated train - ing data set on which deep learning may be established, all devices and systems in the dynamic operating environment must be integrated, including operating room set-up, tool and camera usage and the variab le patient and procedural factors. In addition there are complex questions in terms of  data pro - tection and confidentiality , not to mention the ethical consider - ations and accountability of  autonomous or semi-autonomous robotic surgeons. The most promising elements of  AI inte - gration into minimal access surgery remain enhanced object detection, speech recognition, video characterisation and integ ration with next-generation technologies. Real-time met - abolic pr ofiling and tissue-level diagnosis may di ff erentiate between cancerous and non-cancerous tissues on the basis of their metabolic signature. An example is the iKnife, w hich uses a rapid evaporative ionisation mass spectrometric (REIMS) technique to report tissue histology in real time by analysing - aerosolised tissue during electrosurgical dissection. Artificially intelligent systems also hold potential to dramat - ically improve the fidelity of  simulation training in minimal pro - access surgery , through the creation of  a ‘real-world’ training environment based on the vast data accrued in their develop - - ment. Such data may be used to create a dynamic simulation - environment for any procedure, much more akin to that of ‘real-life’ surgery . This holds potential f or a stepwise tutorial system similar to that of  bedside teaching, with objective feed - - back provided against standardised proficiency benchmarks that can be easily integrated into national training programmes. One major obstacle for minimally invasive technology ent remains the cost e ffi ciency and device financing in an increas - ingly rationed global healthcare environment; this is an issue that will require surgical liaison with hospital management and national policy pro viders. Surgeons need to continue to have - a dialogue, discussing their experiences and ideas in order to e ff ectiv ely progress minimal access surgery and continue to adopt novel technology . As technological advancements are adopted, carefully designed outcomes research is required to provide a clear evidence base to support changes to clinical viations practice. In this way the comparative e ff ectiveness of  novel minimal access technologies will be better understood in terms of  both clinical outcomes and cost-e ff ectiveness, allowing selection of  those with the greatest potential to provide lasting improvements in patient care. British Journal of  Surgery in 1913 and became the first chairman of  the editorial committee
Figure 10.9
Image-guided video-assisted thoracoscopic surgery with
the use of a navigationally placed
/f_i
ducial marker to guide tumour
resection (courtesy of Mr Kelvin Lau, Barts Thorax Centre, London,
UK).
The cleaner and gentler the act of operation, the less the
patient suffers, the smoother and quicker his convales
cence, the more exquisite his healed wound.
Berkeley George Andrew Moynihan (1920)
Athanasiou T , Ashrafian H, Rao C et al . The tipping point of robotic surgery in healthcare: from master–slave to flexible access bio-inspired platforms. Surg T echnol Int 2011; 21 : 28–34. Bhandari M, Ze ffi ro T , Reddiboina M. Artificial intelligence and ro botic surgery: current perspective and future directions. Curr Opin Urol 2020; 30 (1): 48–54. Bodenstedt S, Wagner M, Müller-Stich BP et al . Artificial intelli gence-assisted surgery: potential and challenges. Visc Med 36 (6): 450–5. Brodie A, Vasdev N. The future of  robotic surgery . Ann R Coll Surg Engl 2018; 100 (Suppl 7): 4–13. augmented reality in minimally invasive spine surgery . Global Spine J 2020; 10 (2 Suppl): 22S–33S. St John ER, Balog J, McKenzie JS et al . Rapid evaporative ionization mass spectrometry of  electrosurgical vapours for the identification - of  breast pathology: towards an intelligent knife for breast cancer surgery . Breast Cancer Res 2017; 19 (1): 59. Tan A, Ashrafian H, Scott AJ et al . Robotic surgery: disruptive innova - - tion or unfulfilled promise? A systematic review and meta-analysis 2020; of  the first 30 years. Surg Endosc 2016; 30 (10): 4330–52. THE FUTURE
Minimal access surgery has changed surgical practice; however, it has not changed the nature of  disease. The basic principles of good surgery still apply , including appropriate case selection, excellent exposure, adequate retraction and a high level of technical expertise. Endoscopic and robotic surgery training is key to allow the specialty to progress. The pioneers of  yesterday have to teach the surgeons of  tomorrow not only the technical and dexterous skills required but also the decision-making and innovative skills necessary for the field to continue to evolve. Training is often perceived as di ffi cult, as trainers have less control over the trainees at the time of  surgery and caseloads may be smaller, especially in centres where laparoscopic and robotic procedures are not common. However, trainees now rightly expect exposure to these procedures, and training systems should be adaptable for international exposure so that these techniques can be disseminated worldwide. The predominant video and digital component of  these new techniques opens the door for simulation approaches for training in these modalities , which have demonstrated benefits in reducing learning curves and in tur n are aimed at improv - ing patient outcomes. The ultimate goal for this educational approach is to develop expert surgeons through the ‘totally safe’ and ‘risk-free’ environment of  simulation before they
Figure 10.7
Robotic-assisted lung segmentectomy utilising indocyanine green administered endobronchially to highlight the segment for resec
tion.
(a)
Robotic dissection of the superior (S6) segment.
(b)
Indocyanine green immuno
/f_l
uorescence of the marked segment, enabling clear
identi
/f_i
cation of the area for resection.
Figure 10.8
Navigational bronchoscopy. Split screen image demonstrating real-time endobronchial imaging adjacent to a virtual bronchoscope
image and a three-dimensional map of the lesion and bronchial tree (courtesy of Mr Kelvin Lau, Barts Thorax Centre, London, UK).
actually have to operate on patients. Indeed, both videoscopic and robotic platforms now have established simulation pro grams that are a prerequisite for surgical trainees. Modern robotic simulation modules are able to create an environment that mirrors console use (face validity) and subsequently vide hierarchical training compatible with the user’s expertise. The combination of  simulation with proficiency-based ‘mas tery’ training may be the key to optimising the impact that sim ulation may have on the sur gical learning curve and remains the subject of  research in a range of  surgical specialties. With widespread uptake of  minimal access surgery , train ees are now facing a new pr oblem owing to lack of  experience in open surgery . Surgeons must have su ffi cient open surgical experience to feel comfortable converting cases in the ev of  di ffi culty or emergency . A minimal access approach to a particular procedure may di ff er significantly in the order of operative steps and dissection technique. It is therefore vital that the new generation of  surgeons continues to receive train ing in open surgery so that they can apply either technique as appropriate. Advances in robotic surgery lend themselves to further AI integration, with potential advantages such as providing enhanced clinical decision support, warning of  de from optimal workflow or detecting and over laying potentially at-risk structures. In this way , artificially intelligent systems may streamline procedural technique, reduce error and improve patient outcomes. Intelligent operating theatres may provide automated optimisation of  a wide range of  ergonomic features such as table positioning, lighting and temperature, further facilitating procedural e ffi ciency and e ff ectiveness. In turn, more advanced artificial systems may also develop a degree of supervised autonomy whereby basic surgical procedures can be independently performed by the robotic system. Indeed, Berkeley George Andrew Moynihan (Lord Moynihan) , 1865–1936, Professor of  Clinical Surgery , Leeds, UK. Moynihan felt that English surgeons knew little about the work of  their colleagues both at home and abroad. Therefore, in 1909, he established a small travelling club which in 1929 became the Moynihan Chirurgical Club. It still exists today . He took a leading part in founding the until his death. Robot) robotic system has demonstrated superiority over human surgeons in porcine bowel anastomosis. Translation of  such laboratory-based e xperiments to real- world surgery is not simple. Application requires detailed understanding of  surgical workflow and integra tion of  com - plex data. To provide a fully comprehensive, annotated train - ing data set on which deep learning may be established, all devices and systems in the dynamic operating environment must be integrated, including operating room set-up, tool and camera usage and the variab le patient and procedural factors. In addition there are complex questions in terms of  data pro - tection and confidentiality , not to mention the ethical consider - ations and accountability of  autonomous or semi-autonomous robotic surgeons. The most promising elements of  AI inte - gration into minimal access surgery remain enhanced object detection, speech recognition, video characterisation and integ ration with next-generation technologies. Real-time met - abolic pr ofiling and tissue-level diagnosis may di ff erentiate between cancerous and non-cancerous tissues on the basis of their metabolic signature. An example is the iKnife, w hich uses a rapid evaporative ionisation mass spectrometric (REIMS) technique to report tissue histology in real time by analysing - aerosolised tissue during electrosurgical dissection. Artificially intelligent systems also hold potential to dramat - ically improve the fidelity of  simulation training in minimal pro - access surgery , through the creation of  a ‘real-world’ training environment based on the vast data accrued in their develop - - ment. Such data may be used to create a dynamic simulation - environment for any procedure, much more akin to that of ‘real-life’ surgery . This holds potential f or a stepwise tutorial system similar to that of  bedside teaching, with objective feed - - back provided against standardised proficiency benchmarks that can be easily integrated into national training programmes. One major obstacle for minimally invasive technology ent remains the cost e ffi ciency and device financing in an increas - ingly rationed global healthcare environment; this is an issue that will require surgical liaison with hospital management and national policy pro viders. Surgeons need to continue to have - a dialogue, discussing their experiences and ideas in order to e ff ectiv ely progress minimal access surgery and continue to adopt novel technology . As technological advancements are adopted, carefully designed outcomes research is required to provide a clear evidence base to support changes to clinical viations practice. In this way the comparative e ff ectiveness of  novel minimal access technologies will be better understood in terms of  both clinical outcomes and cost-e ff ectiveness, allowing selection of  those with the greatest potential to provide lasting improvements in patient care. British Journal of  Surgery in 1913 and became the first chairman of  the editorial committee
Figure 10.9
Image-guided video-assisted thoracoscopic surgery with
the use of a navigationally placed
/f_i
ducial marker to guide tumour
resection (courtesy of Mr Kelvin Lau, Barts Thorax Centre, London,
UK).
The cleaner and gentler the act of operation, the less the
patient suffers, the smoother and quicker his convales
cence, the more exquisite his healed wound.
Berkeley George Andrew Moynihan (1920)
Athanasiou T , Ashrafian H, Rao C et al . The tipping point of robotic surgery in healthcare: from master–slave to flexible access bio-inspired platforms. Surg T echnol Int 2011; 21 : 28–34. Bhandari M, Ze ffi ro T , Reddiboina M. Artificial intelligence and ro botic surgery: current perspective and future directions. Curr Opin Urol 2020; 30 (1): 48–54. Bodenstedt S, Wagner M, Müller-Stich BP et al . Artificial intelli gence-assisted surgery: potential and challenges. Visc Med 36 (6): 450–5. Brodie A, Vasdev N. The future of  robotic surgery . Ann R Coll Surg Engl 2018; 100 (Suppl 7): 4–13. augmented reality in minimally invasive spine surgery . Global Spine J 2020; 10 (2 Suppl): 22S–33S. St John ER, Balog J, McKenzie JS et al . Rapid evaporative ionization mass spectrometry of  electrosurgical vapours for the identification - of  breast pathology: towards an intelligent knife for breast cancer surgery . Breast Cancer Res 2017; 19 (1): 59. Tan A, Ashrafian H, Scott AJ et al . Robotic surgery: disruptive innova - - tion or unfulfilled promise? A systematic review and meta-analysis 2020; of  the first 30 years. Surg Endosc 2016; 30 (10): 4330–52.

THEATRE SET-UP AND TOOLS
THEATRE SET-UP AND TOOLS
Operating theatre design is key to e ffi ciency . Modern theatres are designed with moveable booms for video, diathermy and laparoscopic equipment with at least two high-resolution, high-definition (HD) or ultra-high-definition (4K) monitors, a carbon dioxide supply and flow monitor and appropriate audiovisual kit ( Figure 10.1 ) . Image quality is vital to the success of  minimal access surgery . New camera and lens technology allows the use of smaller cameras while maintaining excellent resolution. Auto - matic focusing and charge-coupled devices (CCDs) ar e used to detect di ff erent levels of  brightness and adjust for the best image possible. E ffi cient teamwork is crucial for high-quality surger y and quick yet safe turnover. This is particularly important in robotic surgery , where verbal interaction between all team members is - paramount throughout the procedure. The robotic team must carefully rehearse protocols for both controlled and uncon - trolled conversion in the event of  emergency . , where THEATRE SET-UP AND TOOLS
Operating theatre design is key to e ffi ciency . Modern theatres are designed with moveable booms for video, diathermy and laparoscopic equipment with at least two high-resolution, high-definition (HD) or ultra-high-definition (4K) monitors, a carbon dioxide supply and flow monitor and appropriate audiovisual kit ( Figure 10.1 ) . Image quality is vital to the success of  minimal access surgery . New camera and lens technology allows the use of smaller cameras while maintaining excellent resolution. Auto - matic focusing and charge-coupled devices (CCDs) ar e used to detect di ff erent levels of  brightness and adjust for the best image possible. E ffi cient teamwork is crucial for high-quality surger y and quick yet safe turnover. This is particularly important in robotic surgery , where verbal interaction between all team members is - paramount throughout the procedure. The robotic team must carefully rehearse protocols for both controlled and uncon - trolled conversion in the event of  emergency . , where THEATRE SET-UP AND TOOLS
Operating theatre design is key to e ffi ciency . Modern theatres are designed with moveable booms for video, diathermy and laparoscopic equipment with at least two high-resolution, high-definition (HD) or ultra-high-definition (4K) monitors, a carbon dioxide supply and flow monitor and appropriate audiovisual kit ( Figure 10.1 ) . Image quality is vital to the success of  minimal access surgery . New camera and lens technology allows the use of smaller cameras while maintaining excellent resolution. Auto - matic focusing and charge-coupled devices (CCDs) ar e used to detect di ff erent levels of  brightness and adjust for the best image possible. E ffi cient teamwork is crucial for high-quality surger y and quick yet safe turnover. This is particularly important in robotic surgery , where verbal interaction between all team members is - paramount throughout the procedure. The robotic team must carefully rehearse protocols for both controlled and uncon - trolled conversion in the event of  emergency . , where

Thoracoscopy
Thoracoscopy
A rigid endoscope is introduced through an incision placed - between the ribs to gain access to the thorax. In the majority of  cases, specialist anaesthetic support is required to ensure isolation of  the lung on the side of  surgery , enabling the patient to be ventilated only on the non-operative side. This is achieved through the use of right- or left-sided double - lumen endotracheal tubes that comprise both a bronchial and a tracheal lumen. Usually there is no requirement for gas insu ffl ation as the operating space is held open by the rigidity of  the thoracic cavity . In specific cases, such as mediastinal tumour resection and diaphragmatic surgery , gas insu ffl ation at low pressure (5–8 /uni00A0 mmHg) may be applied. Further infor - mation on the general principles of  thoracoscopy are found in Chapter 60 . Thoracoscopy
A rigid endoscope is introduced through an incision placed - between the ribs to gain access to the thorax. In the majority of  cases, specialist anaesthetic support is required to ensure isolation of  the lung on the side of  surgery , enabling the patient to be ventilated only on the non-operative side. This is achieved through the use of right- or left-sided double - lumen endotracheal tubes that comprise both a bronchial and a tracheal lumen. Usually there is no requirement for gas insu ffl ation as the operating space is held open by the rigidity of  the thoracic cavity . In specific cases, such as mediastinal tumour resection and diaphragmatic surgery , gas insu ffl ation at low pressure (5–8 /uni00A0 mmHg) may be applied. Further infor - mation on the general principles of  thoracoscopy are found in Chapter 60 . Thoracoscopy
A rigid endoscope is introduced through an incision placed - between the ribs to gain access to the thorax. In the majority of  cases, specialist anaesthetic support is required to ensure isolation of  the lung on the side of  surgery , enabling the patient to be ventilated only on the non-operative side. This is achieved through the use of right- or left-sided double - lumen endotracheal tubes that comprise both a bronchial and a tracheal lumen. Usually there is no requirement for gas insu ffl ation as the operating space is held open by the rigidity of  the thoracic cavity . In specific cases, such as mediastinal tumour resection and diaphragmatic surgery , gas insu ffl ation at low pressure (5–8 /uni00A0 mmHg) may be applied. Further infor - mation on the general principles of  thoracoscopy are found in Chapter 60 .

Uptake of robotic surgery
Uptake of robotic surgery
Many surgical specialties have embraced robot-assisted techniques, including general surgery , cardiothoracic surgery , urology , orthopaedics, ear, nose and throat surgery , gynaecol ogy and paediatric surgery . Specialties that use microsurgical techniques also benefit from this technology . Current robotic systems were designed to o ff er multifunctionality , including multianatomy and specialty capability in both operating thea tre and remote environments. Currently , despite a small number of  reports of  remote surgical procedures, robotic surgery remains focused on in-house operating. New entrants In 2017, Intuitive Surgical released the da Vinci X, a low-cost entry point in its robotic surgical portfolio that includes features of  the Xi while sacrificing some flexibility in terms of  multi- quadrant surgery . In the same year, Korean company Meere gained a licence for the use of  its surgical robot, the REVO-I, by the local Ministry for Food and Drug Safety . Similar to the da Vinci, this four-arm robot is mounted on a single cart. The surgeon is seated at an open vision cart and, by use of  3D glasses, can achieve three-dimensional high-definition (3D-HD) vision. In March 2019, CMR Surgical received a European CE mark for its novel modular robot, the V ersius ( Figure 10.4 ). This system incorporates individual cart-mounted modular robotic arms that can be configured to fit the procedure and the operating room environment. The design di ff ers from other robotic arms in that it aims to more closely mimic a human ar m, improving freedom of  port placement. Its vision cart similarly allows for ergonomic operating with 3D-HD vision, through the use of  3D glasses. Bridging the gap between laparoscopic and robotic surgery ® the Senhance robotic system received its CE mark in 2016. In order to reduce cost and sustain familiarity with conven tional laparoscopy , the system uses independent robotic arms mounted on separate carts that can be placed in accordance with the procedure required. T he system utilises reusable non wristed instruments that can be inserted through standard system also creates familiarity with conventional laparoscopy and facilitates hybrid techniques where this may be beneficial. Surgery is enhanced though a 3D-HD system with the use of 3D glasses and eye-tracking camera control. As the field of  robotic surgery continues to expand and innovate, there also remain a number of  systems in devel - opment that are not yet approv ed for clinical use. Examples - similar to existing technologies include the Medtronic Hugo Robotic-Assisted Surgery (RAS) system, which was launched in late 2019. This modular system aims to provide a low er cost alternative by means of  a more readily upgradeable model that may be used flexibly across surgical specialties and procedures. Moving forward, companies such as V erb Surgical strive to build on the currently dominant master–slave model, incorpo - rating robotic autonomy and machine learning. While this may in time revolutionise robotic surgery , such technologies remain in the early phase of  development.
Figure 10.4
The Versius robotic system (courtesy of CMR Surgical).
Uptake of robotic surgery
Many surgical specialties have embraced robot-assisted techniques, including general surgery , cardiothoracic surgery , urology , orthopaedics, ear, nose and throat surgery , gynaecol ogy and paediatric surgery . Specialties that use microsurgical techniques also benefit from this technology . Current robotic systems were designed to o ff er multifunctionality , including multianatomy and specialty capability in both operating thea tre and remote environments. Currently , despite a small number of  reports of  remote surgical procedures, robotic surgery remains focused on in-house operating. New entrants In 2017, Intuitive Surgical released the da Vinci X, a low-cost entry point in its robotic surgical portfolio that includes features of  the Xi while sacrificing some flexibility in terms of  multi- quadrant surgery . In the same year, Korean company Meere gained a licence for the use of  its surgical robot, the REVO-I, by the local Ministry for Food and Drug Safety . Similar to the da Vinci, this four-arm robot is mounted on a single cart. The surgeon is seated at an open vision cart and, by use of  3D glasses, can achieve three-dimensional high-definition (3D-HD) vision. In March 2019, CMR Surgical received a European CE mark for its novel modular robot, the V ersius ( Figure 10.4 ). This system incorporates individual cart-mounted modular robotic arms that can be configured to fit the procedure and the operating room environment. The design di ff ers from other robotic arms in that it aims to more closely mimic a human ar m, improving freedom of  port placement. Its vision cart similarly allows for ergonomic operating with 3D-HD vision, through the use of  3D glasses. Bridging the gap between laparoscopic and robotic surgery ® the Senhance robotic system received its CE mark in 2016. In order to reduce cost and sustain familiarity with conven tional laparoscopy , the system uses independent robotic arms mounted on separate carts that can be placed in accordance with the procedure required. T he system utilises reusable non wristed instruments that can be inserted through standard system also creates familiarity with conventional laparoscopy and facilitates hybrid techniques where this may be beneficial. Surgery is enhanced though a 3D-HD system with the use of 3D glasses and eye-tracking camera control. As the field of  robotic surgery continues to expand and innovate, there also remain a number of  systems in devel - opment that are not yet approv ed for clinical use. Examples - similar to existing technologies include the Medtronic Hugo Robotic-Assisted Surgery (RAS) system, which was launched in late 2019. This modular system aims to provide a low er cost alternative by means of  a more readily upgradeable model that may be used flexibly across surgical specialties and procedures. Moving forward, companies such as V erb Surgical strive to build on the currently dominant master–slave model, incorpo - rating robotic autonomy and machine learning. While this may in time revolutionise robotic surgery , such technologies remain in the early phase of  development.
Figure 10.4
The Versius robotic system (courtesy of CMR Surgical).
Uptake of robotic surgery
Many surgical specialties have embraced robot-assisted techniques, including general surgery , cardiothoracic surgery , urology , orthopaedics, ear, nose and throat surgery , gynaecol ogy and paediatric surgery . Specialties that use microsurgical techniques also benefit from this technology . Current robotic systems were designed to o ff er multifunctionality , including multianatomy and specialty capability in both operating thea tre and remote environments. Currently , despite a small number of  reports of  remote surgical procedures, robotic surgery remains focused on in-house operating. New entrants In 2017, Intuitive Surgical released the da Vinci X, a low-cost entry point in its robotic surgical portfolio that includes features of  the Xi while sacrificing some flexibility in terms of  multi- quadrant surgery . In the same year, Korean company Meere gained a licence for the use of  its surgical robot, the REVO-I, by the local Ministry for Food and Drug Safety . Similar to the da Vinci, this four-arm robot is mounted on a single cart. The surgeon is seated at an open vision cart and, by use of  3D glasses, can achieve three-dimensional high-definition (3D-HD) vision. In March 2019, CMR Surgical received a European CE mark for its novel modular robot, the V ersius ( Figure 10.4 ). This system incorporates individual cart-mounted modular robotic arms that can be configured to fit the procedure and the operating room environment. The design di ff ers from other robotic arms in that it aims to more closely mimic a human ar m, improving freedom of  port placement. Its vision cart similarly allows for ergonomic operating with 3D-HD vision, through the use of  3D glasses. Bridging the gap between laparoscopic and robotic surgery ® the Senhance robotic system received its CE mark in 2016. In order to reduce cost and sustain familiarity with conven tional laparoscopy , the system uses independent robotic arms mounted on separate carts that can be placed in accordance with the procedure required. T he system utilises reusable non wristed instruments that can be inserted through standard system also creates familiarity with conventional laparoscopy and facilitates hybrid techniques where this may be beneficial. Surgery is enhanced though a 3D-HD system with the use of 3D glasses and eye-tracking camera control. As the field of  robotic surgery continues to expand and innovate, there also remain a number of  systems in devel - opment that are not yet approv ed for clinical use. Examples - similar to existing technologies include the Medtronic Hugo Robotic-Assisted Surgery (RAS) system, which was launched in late 2019. This modular system aims to provide a low er cost alternative by means of  a more readily upgradeable model that may be used flexibly across surgical specialties and procedures. Moving forward, companies such as V erb Surgical strive to build on the currently dominant master–slave model, incorpo - rating robotic autonomy and machine learning. While this may in time revolutionise robotic surgery , such technologies remain in the early phase of  development.
Figure 10.4
The Versius robotic system (courtesy of CMR Surgical).

Urinary catheter
Urinary catheter
The requirement for a urinary catheter depends on the opera - tion. In shorter (<4 hours) minimal access procedures a urinary catheter is not usually required. If  a urinary catheter has been placed in the bladder during an operation with likely short stay , it can be removed before the patient reg ains conscious - - ness if  the procedure has been uneventful. Postoperatively it is important to check that the patient has been able to pass urine and empty their bladder without di ffi culty . When there is uncertainty point-of-care bladder scanning can assess residual bladder volume. Urinary catheter
The requirement for a urinary catheter depends on the opera - tion. In shorter (<4 hours) minimal access procedures a urinary catheter is not usually required. If  a urinary catheter has been placed in the bladder during an operation with likely short stay , it can be removed before the patient reg ains conscious - - ness if  the procedure has been uneventful. Postoperatively it is important to check that the patient has been able to pass urine and empty their bladder without di ffi culty . When there is uncertainty point-of-care bladder scanning can assess residual bladder volume. Urinary catheter
The requirement for a urinary catheter depends on the opera - tion. In shorter (<4 hours) minimal access procedures a urinary catheter is not usually required. If  a urinary catheter has been placed in the bladder during an operation with likely short stay , it can be removed before the patient reg ains conscious - - ness if  the procedure has been uneventful. Postoperatively it is important to check that the patient has been able to pass urine and empty their bladder without di ffi culty . When there is uncertainty point-of-care bladder scanning can assess residual bladder volume.

surgery
surgery
Arthroscopy was one of  the earliest applications of  endoscopic techniques, first being applied in the knee as early as the 1930s. - In the 1950s Watanabe developed arthroscopic techniques that - have evolved such that shoulder, wrist, elbow and hip arthros - copy is now commonplace. Novel approaches to smaller joints such as the temporomandibular and metatarsal joints are being tech - developed. surgery
Arthroscopy was one of  the earliest applications of  endoscopic techniques, first being applied in the knee as early as the 1930s. - In the 1950s Watanabe developed arthroscopic techniques that - have evolved such that shoulder, wrist, elbow and hip arthros - copy is now commonplace. Novel approaches to smaller joints such as the temporomandibular and metatarsal joints are being tech - developed. surgery
Arthroscopy was one of  the earliest applications of  endoscopic techniques, first being applied in the knee as early as the 1930s. - In the 1950s Watanabe developed arthroscopic techniques that - have evolved such that shoulder, wrist, elbow and hip arthros - copy is now commonplace. Novel approaches to smaller joints such as the temporomandibular and metatarsal joints are being tech - developed.