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SURGICAL TECHNOLOGY INTERNATIONAL III.
$175.00
STI III contains 60 articles with color illustrations.
Universal Medical Press, Inc.
San Francisco, 1994, ISBN: 0-9643425-1-0
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Minimal Access Surgery
Endoscopic Surgery - A Fascinating Idea Requires Responsibility in Evaluation and Handling
Prof. Dr Med Hans Troidi, University of Cologne, Cologne, Germany.
When we think of the pioneers of endoscopic surgery, we think of people like Wittmoser, Semm, Miihe, Wickham, Mouret, Perissat and Buess as well as industrialists like Karl Storz and Leon C. Hirsch (Figure 1). Despite differences in personalities, these pioneers had an impact on endoscopic surgery because of important, common denominators they shared, such as curiosity, eccentricity, and, according to De Bono and Bocher.v" "lateral thinking." Of course, these pioneers were ignored at the beginning and even called crazy. They saw controlled clinical trials as irrelevant to their work. They were open minded, innovative and recognized the revolutionary potential of seeing their ideas come to fr-uition," And it was from these risk-takers that endoscopic surgery-this fascinating alternative in general surgery-was born.
Credentialing, Privileging, Proctoring in the Era of Laparoscopic Surgery
Mohan C. Airan, M.S., F.A.C.S., F.A.C.M.Q., Sung-Tao Ko, M.D. F.A.C.S., F.R.C.S., Mount Sinai Hospital Medical Center, Chicago, IL
Laparoscopic surgery in the United States was revolutionized in 1989. Even though Semm had popularized laparoscopic surgery in the early nineteen eighties in Germany,' it was the advent of Laparoscopic Cholecystectomy in 1989that triggered the explosive training and eredentialing issues in laparoscopic surgery.2 In a letter to the editor of the American Journal of Surgery, in June 1990,the author had recommended the following for training courses: 1) the operators should have extensive hands-on experience in diagnostic laparoscopy prior to embarking on laparoscopic surgery; 2) hands-on training to develop hand-eye coordination using Berci-Sackier trainers; 3) extensive explanation on the use and abuse of video laparoscope and accessory instrumentation; 4) a minimum experience as prime operator in at least 3 pigs, each weighing 90- tOOlbs., with experience as an assistant operator and camera operator in 6 more pigs, making a total of9 pigs per par-ticipant," This letter was written with an intent that proper training of surgeons would take place. We advocated a surgeon/co-surgeon team approach," to avoid adverse outcomes. In those days, weekend courses proliferated and surgeons came back and started doing procedures with minimal experience. This explosive growth was driven by patient demands for this procedure. As anticipated, untoward outcomes were reported.
Training for Advanced Laproscopic Skills: Suturing, Knotting and Anastomosis Techniques
Zoltan Szabo, Ph.D., F.I.C.S., MOET Intitiute, San Francisco, Ca. John G. Hunter, M.D., Emory University, Atlanta GA, Demetrius E.M. Litwin, M.D., F.R.C.S., University of Toronto, Ontario, Canada, George Berci M.D., F.A.C.S., F.R.C.S., Ed. (Hon.), University of Southern California, Los Angeles, CA
If surgical art can be defined as the operative relationship between the surgeon and the living tissue then it is easy to conclude that this relationship has changed. On the one hand, changed for the better as far as the end result is concerned, but on the other hand, for the worse, as far as it relates to the surgeon's effort, that is, the method by which this improved result is obtained. In essence, the surgeon will have to work a great deal harder to provide the added benefit for the patient.
Advanced Endoscopic Imaging: 3D Laparoscopic Endoscopy
Asim F. Durrani, M.D., Glenn M. Preminger M.D., Duke University Medical Center, Durham, NC
Video imaging technology has significantly enhanced the performance of minimally InVaSIVesurgIcal procedures. However, a major limiting factor for the endoscopic surgeon is to work in a 3- dimensional field while viewing a two-dimensional video image. Advances in electronic video imaging have resulted in satisfactory image quality! yet the lack of depth perception with standard 2-dimensional video system results in the surgeon having to rely on indirect evidence to assess the third dimension. To gauge depth, one may have to rely on touching the tissues with endoscopic instruments or estimate the relative movement of the instruments in relation to the intra-abdominal organs. These maneuvers result in a reduction in the speed of surgery and may cause unnecessary tissue trauma. Recently a number of manufacturers have developed three-dimensional (3-D) video systems which significantly improve visualization and enhance the ability of the surgeon to perform delicate endoscopic dissection and suturing. These 3-D video systems may also improve the education of surgeons-in-training as they would have a better understanding of 3-dimensional anatomy during laparoscopic surgery.
Laparoscopic Fixation and Guiding Devices.
Zoltan Szabo, Ph.D., F.I.C.S., MOET Institute, San Francisco, CA Johnathan M. Sakier, M.D., University of California School of Medicine, San Diego, CA
Since the new advances in video technology in the mid 1980's and the couplmg of the video camera to the laparoscope the surgeon no longer needs to control the laparoscope with his own hands. The advantage of this new development in laparoscopic surgery is that (1) it is not as tiring to perform (i.e., he no longer had to bend over the patient to look through the laparoscope's ocular), (2) the whole operating team could follow the progress of the surgery (for better or worse), and (3) that the surgeon is then enabled to operate with two hands, a new skill which must be learned since it is one of the keys to being more effective and efficient under the laparoscope. One of these advanced skills, intracorporeal suturing, 1 is an especially demanding skill and requires a well-centered, and steady camera support for the technique to be performed efficiently. The disadvantage is that he must give oral commands to the individual who is now charged with guiding the laparoscope within the operative field and this disadvantage alone is sometimes thought the tip the balance in the wrong direction.
Ultrasonic Energy in Laparoscopic Surgery
Joseph F. Amaral, M.D., Brown University, Providence, RI
The ideal energy form for use in laparoscopic surgery should provide controlled, hemostatic cutting. A good dissection technique should be further characterized by minimal thermal injury to surrounding tissue, no smoke obscuring the visual field, cutting ability equal to or superior to a conventional scalpel, coagulative ability equal to or greater than electrosurgery, lack of danger to the patient such as from stray energy, no toxins from exposure to smoke in the pneumoperitoneum elevating patient levels of methemoglobin or carboxyhemoglobin, no need for special preparation of the patient (grounding pad) or surgeon (glasses), and no need for special training. For a technology to replace that which is the current standard, this should all be provided at a cost similar to the cost associated with electrosurgery.
Complications of Trocar Wounds and their Prophylaxis
Osvaldo Contarini, M.D., Jacksonville, FL
Laparotomy is vision of the abdominal content by direct eyesight through an abdominal incision. Laparoscopy achieves the same or better result with an optic device placed into the abdomen through special introducers. Exploration, part or complete procedures, can be performed with much less postoperative morbidity; this has instilled a new sense of optimism in both the community and surgical ranks. Suddenly it appeared that the old "sacred" rules of traditional surgery had been buried under a thick layer of dust.
Laparoscopic Surgery of the Liver
Namir Katkhouda, M.D., Sharrie Mills M.D., University of Southern California School of Medicine, Los Angeles, CA
The liver, with its multiple metabolic, detoxifying, and filtering functions plays a key role in the field of oncology, as it is the site of both metastatic and primary cancers. This phenomenon occurs because of two factors, namely the proximity of the liver to other intraabdominal organs as well as the extensive portal vein and lymphatic drainage systems. The lobular structure of the liver represents a barrier to cancer cells which ultimately flourish by producing either synchronous or metachronous hepatic lesions. The size of these metastasizes varies greatly and obeys the laws of expediential tumor growth, thus implying that some lesions will be too small to be detected by conventional methods.
Transcytic C-Tube Drainage Following Laparoscopic Common Bile Duct Exploration
Seigo Kitano M.D., Toshio Bandoh, M.D., Takanori Yoshida, M.D., Koichirou Shuto M.D., Oita Medical University, Oita, Japan.
At the beginning of laparoscopic surgery', common bile duct (CBD) stones were thought to be a contraindication for laparoscopic cholecystectomy (LC) in the treatment of gallstones. At present, well-trained surgeons remove these stones in relation to LC. CBD stones are often present during laparoscopic cholecystectomy and when these stones are removed choledochoscopically a T-tube has to be inserted. This approach to remove the CBD stones has been documented. 2,3,4 Insertion of a T-tube into the CBD is a subject open to discussion, because of one disadvantage when the T-tube is inserted into the CBD, patients stay in the hospital for more than 2 to 3 weeks postoperatively.
Laparoscopic Common Bile Duct Exploration and Hand-Sutured Closure of the Choledochotomy
Paul S. Strange M.D., St. Francis Hospital, Indianapolis, IN, Zoltan Szabo, Ph.D., F.I.C.S., MOET Intitute, San Francisco, CA
Inthe years since 1987,when Mouret introduced laparoscopic cholecystectomy in France, this approach has become the preferred method for management of symptomatic gallbladder disease. However, the treatment of calculous disease other than the gallbladder is not generally practiced by the laparoscopic approach. The treatment of common duct stones is largely managed by preoperative Endoscopic Retrograde Cholangio Pancreatography (ERCP)or choledochotomy and exploration through a laparotomy incision. The authors believe that this lack of acceptance of laparoscopic treatment of common duct stones is because of the ready availability of ERCP and sphincterotomy in most centers countenanced by the difficulty of laparoscopic treatment.
Laparoscopic Treatment of the Gastro-Esophageal Reflux Disease
Jacques J. Perissat M.D., Denis Collet M.D., University Hospital of Bordeaux, Bordeaux, France.
Gasrro-esophageal reflux d.isease (GERD), with or without hiatal hernia, is the consequence of a functional disturbance of the -lower sphincter of the esophagus. This dysfunction is more and more often seen in populations with Western eating habits. According to recent reports, 10 percent of the patients suffer from constant heartburn, 30 percent from discontinuous heartburn demanding active treatment. Finally, a great number of non-digestive symptoms, either pulmonary, E.N.T.,or cardiac, are also connected with GERD. In the early 1970s, medical treatment was not very effective, hence the popularity of open surgery. Although the results were satisfactory, postoperative sequelae, in particular parietal ones, could not be avoided. The reason is that a large laparotomy is necessary to gain access to the esophageal hiatus, which always involves potential risks of postoperative incisional hernia.
Laparoscopic Rossetti Fundoplication
Jean Mouiel M.D., University of Nice, France, Namir Katkhouda M.D., Sharrie Mills, M.D., University of Southern California School of Medicine, Los Angeles, CA
Afundal wrap of the abdominal segment of the esophagus, transposed from the Rossetti modification of the classic Nissen fundopfication, is the operation of choice for surgical treatment of gastroesophageal reflux refractory to medical therapy. Previously validated by open anti-reflux surgery, fundoplication has also proven reliable, effective, and reproducible when performed by laparoscopy, a technique the authors have used routinely since 1989 thanks to the experience gained in vagotomy by a trans hiatal approach.
Laparoscopic Treatment of Peptic Ulcer Disease and its Complications
Sharrie Mills, M.D., Namir Katkhouda, M.D., University of Southern California, Los Angeles, CA, Jean Mouiel M.D., University of Nice, Nice, France
Peptic ulcer disease will eventually affect more than 3-4% of the Occidental population. The medical management of this disease, including H2 Blockers, proton pump inhibitors and antihelicobacter therapy, has been well defined and has been very successful. However, the treatment of chronic duodenal ulcer disease has been less successful, thus subjecting these patients to long term disability. It is with chronic duodenal ulcer disease as well as with its complications, such as bleeding, obstruction or perforation, where the surgeon can impact, using laparoscopic surgical techniques as an added therapeutic option.
Laparoscopic Intra-Gastric Surgery for Early Gastric Cancer
Shuichi Ohashi, M.D., Takarazuka, Japan
Anew laparoscopic operation for the treatment of mucosal or submucosal gastric lesions has been designed and performed on 12 patients. In this procedure, all three trocars are placed in the gastric cavity, penetrating both the abdominal and gastric walls in order to perform a Iaparoscopic removal of gastric lesions. The operation is then carried out in the gastric cavity using currently available laparoscopic instruments and laparoscopic monitoring. The procedure is easy, safe and feasible for mucosal or submucosal lesion of the stomach that cannot be treated by gastrofiberscopic technique. In this series, we treated a total of 12 patients: 10 patients with early gastric cancer, 1 with a submucosal leiomyoma and 1 with giant polyps of the stomach- all of which were treated uneventfully. Since this technique is based on a new concept in laparoscopic surgery, the author has named this operation "Laparoscopic Intra-gastric Surgery" (L.I.G.S.).
Laparoscopic Billroth II Gastrectomy
Peter M.Y. Goh, M.D., F.R.C.S., David J. Alexander, M.D., National University Hospital, Singapore
The first successful totally intra-abdominal laparoscopic Billroth II gastrectomy was performed on February 10, 1992,by our group (4) in Singapore. The patient was a 76-year-old Chinese man with a 2- year history of gastric ulcer, which presented with bleeding. The operation took 4 hours and consumed 17 ENDO GIA* (Auto Suture, USSC, Norwalk, CT) staplers. The benefits of this minimally invasive approach were clearly evident. The patient was walking on the first postoperative day, taking liquids on the third, solids on the fourth, and was discharged on the fourth postoperative day. The operation was subsequently emulated by surgeons in about a dozen countries. The description in this chapter is a modification of the original technique, using the improved instrumentation that is now available.
Extraperitoneal Laparoscopic Hernia Repair: Experience in 178 Patients
Barry N. Gardner, M.D., University of California at Davis, Davis, CA, Albert K. Chin, M.D., Frederic H. Moll, M.D., Menlo Park, CA, Zoltan Szabo, Ph.D., F.I.C.S., MOET Institute, San Francisco, CA A. Johannes Coburg, M.D. City Hospital, Neuss, Germany
The evolution of a preferred technique for laparosco'pic inguinal hernia repair has been occurring over the past several years. The early work of Ger!:2 involved a stapled closure of the dilated internal ring using a specialized 12-mm. instrument, which combined the functions of tissue approximation and stapling. This was followed by a prosthetic mesh plug technique of Schultz! and Corbitt,' which consisted of a free mesh plug occlusion of the inguinal canal, combined with prosthetic patch coverage of the hernia defect.
Laparoscopic Management of Complete Rectal Prolapse
Ara Darzi, M.D., F.R.C.S.I., Central Middlesex Hospital, London, England
Laparoscopic surgery has been successfully employed for many years by gynecological surgeons. Following the widespread success of laparoscopic cholecystectomy, minimally invasive surgery has expanded to be adapted to all general surgical procedures including hernia repair,' oesophagectomy," appendicectomy.v' Meckel's diverticulectomy/ and Nissen fundop lication." Laparoscopic colonic surgery has not developed at the same rate as other procedures because of the requirement for advanced laparoscopic surgical skills, deficiencies in instrumentation and concerns about the potential risks oflaparoscopic surgery for neoplasia. However, laparoscopic procedures for treating rectal prolapse may constitute some of the best applications for co1- orectal laparoscopic techniques. A technique of laparoscopic rectopexy performed using the endoscopic stapler and intracorporal suturing of mesh is described.
An Innovative Thorascopic Surgery for Patent Ductus Arteriosus: A Japanese First Case Report
Tadaaki Maehara, M.D., Masahiro Ohgami, M.D., Kiyokazu Kokaji, M.D., Keio University School of Medicine, Tokyo, Japan. Yukio Yamashita, M.D., Go Wakabayashi, M.D., Katsuhiko Nohga, M.D., Kawasaki City Hospital, Kawasaki, Japan
A5-year-old girl with patent ductus arteriosus (PDA) was successfully treated by thoracoscopic surgery, which was the first successful case in Japan. The operation was carried out under general anesthesia with the usual endotracheal intubation. Short trocars were inserted through the left intercostal spaces to introduce a flexible video thoracoscope and adequate surgical instruments. After the ductus was carefully dissected and exposed, two titanium clips, 11 mm in length, were applied to interrupt the ductus completely. The continuous heart murmur of PDA disappeared, as confirmed by an esophageal stethoscope. Postoperative course was uneventful and the patient was discharged on the 6 postoperative day. Eighteen months after surgery, no residual PDA shunt was revealed by doppler echocardiogram. The advantages of thoracoscopic surgery for PDA are les's postoperative pain and discomfort, early recovery and short hospital stay, and cosmetic preservation. Availability of smaller sized surgical instruments should allow smaller children or newborns with PDA to be treated with this method.
Use of Endoluminal Illuminated Bougie During Laparoscopic and Thoracoscopic Surgery of the Esophagus
Younan Nowzaradan, M.D., Best Care Clinic, Houston TX, Peyton Barnes, M.D., Texas Medical School, Houston, TX
Newly developed endoscopic instruments and devices, along with advanced endoscopic surgical techniques, have made it possible to perform an increasing variety of endoscopic procedures. These procedures consist of the same steps employed in the open procedure that preceded them but avoid their large incisions. This in turn eliminates many of the disadvantages associated with laparotomy and thoracotomy incisions. Postoperative pain is greatly decreased, postoperative hospital stay is shortened, and return to normal activities is expedited. Postoperative complications as well as early and late morbidity related to the surgical wound (e.g. wound infection, incisional hernia, wound dehiscence) are minimized. The incidence of intraabdominal adhesions and both early and late postoperative intestinal obstruction are decreased. Cosmesis is dramatically enhanced.
Endoscopic Surgery in Rhinology and Opthamology.
Olof Kalm, M.D., Ph.D., University Hospital of Lund, Lund, Sweden
The rapid development of endoscopic methods in many fields of surgery has been possible by the fiberoptic technique in connection with high-quality video representation and computer-tomograhic imaging. In rhinology, there has been a worldwide adoption of the technique in diagnostics and treatment. In the beginning, the technique was founded on concepts developed after many years of endoscopic investigation and clinical observations by W. Messerklinger and coworkers in Graz, Austria, with later contributions from other European ENT clinicians, 1,2,3and it was subsequently made popular by Kennedy and colleagues in the United States.' Nasal and paranasal sinus endoscopy proved to be a valuable diagnostic contribution to rhinology. Endoscopic sinus surgery (ESS)has also proved suitable for treatment, not only of rhinologic disorders but also for some ophthalmologic and neurosurgical conditions. When properly used, ESScauses much less morbidity than does treatment with older "conventional" surgical methods. In the following discussion, I will briefly cover the pathophysiology of some of the disorders, the surgical indications and technique, as well as the results and complications of this kind of surgery.