1. Innovations in Minimally
Invasive GI Surgery
Florida Gastroenterologic Society
Annual Meeting
September 25, 2010
Lake Buena Vista, Florida
C. Daniel Smith, MD
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2. Innovations in Minimally Invasive GI Surgery
• Natural Orifice Translumenal
Endoscopic Surgery (NOTES)
• Single Incision Laparoscopic
Surgery (SILS)
• Minimally Invasive Esophagectomy
• Antireflux Surgery
Innovations in MIS. FGS Annual Meeting.
Lake Buena Vista. Sept 25, 2010
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3. NOTES
• Natural
• Orifice
• Translumenal
• Endoscopic
• Surgery
Innovations in MIS. FGS Annual Meeting.
Lake Buena Vista. Sept 25, 2010
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4. NOTES
Laparoscopic Surgery
NOTES
Advanced Interventional
Imaging & Endoscopy
Guidance
Innovations in MIS. FGS Annual Meeting.
Lake Buena Vista. Sept 25, 2010
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5. NOTES
Innovations in MIS. FGS Annual Meeting.
Lake Buena Vista. Sept 25, 2010
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6. NOTES - U.S. Adoption
Innovations in MIS. FGS Annual Meeting.
Lake Buena Vista. Sept 25, 2010
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7. NOTES - U.S. Adoption
NOTES Surgery - Elsewhere
Dr. Christine Ren, an associate professor of
surgery at New York University’s school of
medicine, called the vaginal procedure
“repulsive” and said: “As a woman I find it very
invasive, physically and emotionally. To me it’s
quite distasteful. You will really have to prove to
me that there is a benefit.”
Innovations in MIS. FGS Annual Meeting.
Lake Buena Vista. Sept 25, 2010
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8. NOTES - Future ?
Innovations in MIS. FGS Annual Meeting.
Lake Buena Vista. Sept 25, 2010
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9. New Treatment Success – Key Elements
Carotid Lap
Lap Chole Lap Nissen
Stenting Colectomy
Clinical Results - +++ ++ +++
Ease of Use - +/- - -
Patient Demand +++++ +++ ++++++ +++
Cost - +/- - +
Reimbursement +/- + +/- ++
Other Rx Options - +++++ - +
WIDELY ADOPTED YES NO YES NO
Innovations in MIS. FGS Annual Meeting.
Lake Buena Vista. Sept 25, 2010
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10. New Treatment Success – Key Elements
Lap
Lap Chole Lap Nissen NOTES
Colectomy
Clinical Results - +++ +++
Ease of Use - +/- - ---
Patient Demand +++++ +++ +++ ++
Cost - +/- +/- ---
Reimbursement +/- + ++
Other Rx Options - +++++ +/- +++++
WIDELY ADOPTED YES NO NO NO
Innovations in MIS. FGS Annual Meeting.
Lake Buena Vista. Sept 25, 2010
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Sunday, November 25, 12

11. NOTES - Future ?
Which would you rather have:
A lap chole by a skilled surgeon
OR
A transgastric/vaginal cholecystectomy
Innovations in MIS. FGS Annual Meeting.
September 24-26, 2010
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12. Closing Comments
MIS vs. NOTES. SAGES Best of NOTES
April 10, 2008
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13. NOTES – Impact?
Innovations in MIS. FGS Annual Meeting.
Lake Buena Vista. Sept 25, 2010
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14. NOTES – Impact?
Natural Orifice Surgery Single Incision
Laparoscopic Surgery
Innovations in MIS. FGS Annual Meeting.
Lake Buena Vista. Sept 25, 2010
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Sunday, November 25, 12

15. Single Incision Laparoscopic Surgery
• Less pain • Earlier return
to work
• Faster
recovery • Superior
cosmesis
Innovations in MIS. FGS Annual Meeting.
Lake Buena Vista. Sept 25, 2010
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16. Single Incision Laparoscopic Surgery
Innovations in MIS. FGS Annual Meeting.
Lake Buena Vista. Sept 25, 2010
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17. Single Incision Laparoscopic Surgery
“The Next Lap Chole”
Natural Orifice Surgery
Over 100,000 hits
with Google Search
Laparocopic colectomy -
58,000 hits
Innovations in MIS. FGS Annual Meeting.
Lake Buena Vista. Sept 25, 2010
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18. Single Incision Laparoscopic Surgery
Laparoscopic surgery performed through a single incision: a
systematic review of the literature. JACS, Jan 2011, In Press
2007-2010 Procedure No. Publications
Cholecystectomy 52
219 publications
Nephrectomy 34
4,585 operations
Appendectomy 28
GYN 19
6 institutions - 57 cits Colectomy 15
1 institution - 26 cits
Inguinal Hernia 11
Innovations in MIS. FGS Annual Meeting.
Lake Buena Vista. Sept 25, 2010
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Sunday, November 25, 12

19. Single Incision Laparoscopic Surgery
Laparoscopic surgery performed through a single incision: a
systematic review of the literature. JACS, Jan 2011, In Press
2007-2010 OUTCOMES
219 publications 48% perioperative outcomes only
4,585 operations 12% compared outcomes to another technique
1 PRCT - Lap chole v. Single incision chole
6 institutions - 57 cits Improved pain scores
1 institution - 26 cits
Longer OR time
Innovations in MIS. FGS Annual Meeting.
Lake Buena Vista. Sept 25, 2010
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Sunday, November 25, 12

20. New Treatment Success – Key Elements
Lap
Lap Chole Lap Nissen SILS
Colectomy
Clinical Results - +++ +++ -
Ease of Use - +/- - -
Patient Demand +++++ +++ +++ ++
Cost - +/- +/- -
Reimbursement +/- + ++ +/-
Other Rx Options - +++++ +/- +++++
WIDELY ADOPTED YES NO NO NO
Innovations in MIS. FGS Annual Meeting.
Lake Buena Vista. Sept 25, 2010
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Sunday, November 25, 12

21. Single Incision Lap Surgery – Impact?
Single Incision
Laparoscopic Surgery
“The Next Lap Chole”
????
Innovations in MIS. FGS Annual Meeting.
Lake Buena Vista. Sept 25, 2010
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22. Single Incision Lap Surgery – Impact?
Single Incision Two Field MIE
Laparoscopic Surgery
Innovations in MIS. FGS Annual Meeting.
Lake Buena Vista. Sept 25, 2010
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23. Esophagectomy Outcomes
Transthoracic Transhiatal
Operative mortality (%) 4 2
Blood loss 1402 847
LOS 19 15
Respiratory complications (%) 57 27
Cardiac complications (%) 26 16
Anastomotic leak (%) 15 14
Innovations in MIS. FGS Annual Meeting.
Lake Buena Vista. Sept 25, 2010
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24. Minimally Invasive Esophagectomy (MIE)
Innovations in MIS. FGS Annual Meeting.
Lake Buena Vista. Sept 25, 2010
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25. Minimally Invasive Esophagectomy (MIE)
2-Field Technique
No. patients 8 (3 low risk, 5 high risk)
EBL (cc) 63 (25-400)
Operative time (min) 292 (194-375)
Lymph nodes harvested 23 (13-29)
LOS in ICU (days) 1 (1-5)
LOS overall (days) 7 (5-16)
Use of chest tubes 0
Reoperation 0
Mortality 0
Innovations in MIS. FGS Annual Meeting.
Lake Buena Vista. Sept 25, 2010
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Sunday, November 25, 12

26. Two-Field MIE - Impact?
Two Field MIE
No. patients 8 (3 low risk, 5 high risk)
EBL (cc) 63 (25-400)
Operative time (min) 292 (194-375)
Lymph nodes harvested 23 (13-29)
LOS in ICU (days) 1 (1-5)
LOS overall (days) 7 (5-16)
Use of chest tubes 0
Reoperation 0
Mortality 0
Innovations in MIS. FGS Annual Meeting.
Lake Buena Vista. Sept 25, 2010
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Sunday, November 25, 12

27. GERD
• Most common GI condition
• $ 10 billion healthcare
expenditure
• Mechanical defect in valve
• Surgery effective treatment
• Nissen (3600) fundoplication
is gold standard
Innovations in MIS. FGS Annual Meeting.
Lake Buena Vista. Sept 25, 2010
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28. Antireflux Surgery - Failure
No. patients 300 1127 1690
Mortality (%) 0.4 0.2 0.1
Conversion (%) 1.3 0.7 0.4
Intraoperative comp (%) 8 4 4
Early postop comp (%) 17 (transient) 30 (transient) 35 (transient)
Late postop comp (%) 4 5 5
Reoperation (%) - 3.5 2.8
Symptom free 12 months (%) 93 92 90
Continued medical Rx (%) 3 11 18
Satisfied with results (%) 97 95 94
Innovations in MIS. FGS Annual Meeting.
Lake Buena Vista. Sept 25, 2010
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Sunday, November 25, 12

29. Antireflux Surgery - Failure
No. patients 166
Follow-up (yrs) 11±1.2
Reoperation 26 (16%)
Failure* 43 (26%)
* Reoperation, patient dissatisfaction,
severe GERD symptoms
Surg Endosc (2007) 21:1978–1984 When Fundoplications Fails: Redo? Ann
Surg (2005) 241: 861-871
Innovations in MIS. FGS Annual Meeting.
Lake Buena Vista. Sept 25, 2010
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30. Antireflux Surgery – New Device
Innovations in MIS. FGS Annual Meeting.
Lake Buena Vista. Sept 25, 2010
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31. Antireflux Surgery – New Device
Innovations in MIS. FGS Annual Meeting.
Lake Buena Vista. Sept 25, 2010
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32. Antireflux Surgery – New Device
50.0
Baseline ! Pilot Trial
• 44 patients, 4-centers, US and
Total GERD HRQL Score
Follow-up
37.5 Europe
• Published J of Gastro 2008
25.0 • To be published Annals of
Surgery, November 2010
12.5
0
Pre-Implant 3 months 12 month 24 months
100
Normalized (Total pH < 5.3)
Percent of Patients
75
! Over 160 pts. implanted
to date under clinical 50
protocol
25
Innovations in MIS. FGS Annual Meeting. 0
Lake Buena Vista. Sept 25, 2010
3 months 12 months 24 months
Sunday, November 25, 12

33. Antireflux Surgery – New Device
! FDA Pivotal Trial
• 100 pt, 15-center, USA and Europe
• Jan 09 – Sept 09 (data pending completion of follow-up Sept 10)
University of Southern California
Ohio State University
Policlinico San Donat
University of Washington
Academic Medical Center, Amsterdam
University of Pittsburgh Medical Center
Abbott Northwestern
Knox Community, Ohio
University of California San Diego
Washington University
University of Rochester Medical Center
Phoebe Putney Medical Center
Legacy Health, Portland
Gunderson Lutheran, Wisconsin
Mayo Clinic - Jacksonville
Innovations in MIS. FGS Annual Meeting.
Lake Buena Vista. Sept 25, 2010
Sunday, November 25, 12

34. Antireflux Surgery – New Device - Impact?
100
Normalized (Total pH < 5.3)
Percent of Patients
75
50
25
0
3 months 12 months 24 months
Innovations in MIS. FGS Annual Meeting.
Lake Buena Vista. Sept 25, 2010
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35. Innovations in Minimally Invasive
Surgery
C. Daniel Smith, MD
smith.c.daniel@mayo.edu
404-323-4615
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