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We preferred to present the content comprehensively by only two
authors: A practicing surgeon and a biomedical engineer who are looking
back on more than 15 years on close, daily-based cooperation. Regarding
the wealth of existing knowledge in a broad range of medical, scientific,
and engineering specialties, this concept is not without risk, but we
expect it makes the book more easy to read.
We look forward to a positive echo of the readership. Hopefully, this
helps to promote the support of visceral surgery by biomedical
engineering.
Armin Schneider and Hubertus Feussner
xiForeword
ACKNOWLEDGMENTS
When we decided to mold our experiences and knowledge into a textbook as the publishing house asked us to do, it was quite obvious for us
that this ambitious undertaking was only conceivable at all with the help of
many coworkers, colleagues, and other experts in their fields and a highly
motivated team. Their essential contributions are acknowledged with gratitude. Ms. Sabrina Stoeppke is the first one who has to be mentioned here.
To call her the midwife of the book would be wrong. The midwife is
mainly responsible for the delivery, but Sabrina Stoeppke catalyzed every
single step of the way—so to say from the state of blastulation until the day
of delivery. The main support came from our Institute for Minimally
Invasive Interdisciplinary Therapeutic Intervention (MITI) with the scientific head Sebastian Koller and the surgical head Dr. Dirk Wilhelm. Daniel
Ostler has to be mentioned in particular, as he never failed to overcome so
many difficulties which presented during the making of this manuscript.
His outstanding expertise contributed much to the scientific substance.
Dr. Silvano Reiser provided lots of the historical background in the development of modern medicine. We are grateful for the support of Nils
Kohn and the graduate and undergraduate students. The assistance of
Tereza Baude is highly appreciated. Martina Scholle provided impressive
illustrations. Precious feedback came from Prof. Nassir Navab, Chair of
Computer Aided Medical Procedures and Augmented Reality, and Prof.
Tim Lu¨th, Chair of the Institute of Micro Technology and Medical Device
Technology, Technische Universita¨tMu¨nchen. We are much obliged to
Dr. Alexander Fingerle, Dr. Daniela Muenzel, and Dr. Konstantin
Holzapfel from the Department of Radiology and Profs. Stefan von Delius
and Monther Bajbouj as well as Dr. Jeannine Bachmann from the
Department of Gastroenterology of Klinikum rechts der Isar, Technische
Universita¨tMu¨nchen for their substantial contributions.
We have to thank all of the operating theater nurses in the surgical
OR, especially Barbara Detter, Annegret Luettges, and Stefanie Hallmann
for providing instruments and their support.
Last but not least, we have to thank our spouses Doris and Michela
and our children Roland and Robert and Sophia, Anna, and Elena for
the understanding and support when we spent so many additional hours
to write this textbook over the last few years.
xiii
CHAPTER 1
Surgery and Biomedical
Engineering
It goes without saying that surgery cannot be performed with bare hands.
Accordingly, surgeons were always compelled to use more or less dedicated instruments. Descriptions of specialized tools of the surgeons are
found early in the history of mankind. The papyri of ancient Egypt deal
in detail with surgical instruments, as do many manuscripts of Greek and
Roman antiquity. Often ignored, ancient India had also a profound
surgical legacy. In a classical Sanskrit text of Sushruta written in the 6th
century BC, more than 100 instruments are described, including saws,
needles, scalpels, etc. They certainly reflected the spearhead of contemporary technological innovation.
The obviously high level of surgical care as related to general development was not maintained in the following centuries.
Conservative medicine always remained the reserve of academics.
However, this only meant drug oriented noninvasive medicine. Diagnosis
and therapy were based upon the humoral pathology of Galenos.
Accordingly, the only “invasive” procedure was phlebotomy (bloodletting). Human diseases were treated with dr ugs, ointments, diets, or similar
conservative measures. Surgical tasks, such as the treatment of fractures,
open wounds, and hernia, were completely left over to the surgeons.
Surgeons at that time were looked down upon and avoided by physicians
since they were considered unlettered, lower class men, who learned their
graft by apprenticeship (
ticed as barbers as well. The situation improved only gradually. In
England and in France surgical guilds were created. A main impact came
again from the military since it was evident that contemporary warfare
needed qualified surgeons. In 1724 a collegium medico chirurgicum was
founded in Berlin (Charite´) to provide sufficiently educated surgeons
for the army. However, it took another century until it developed to
academic surgery with full integration into the medical studies at the
university. Famous names like Joseph Lister (18271912), Bernhard von
Fig. 1.1). In addition to surgery they often prac-
Biomedical Engineering in Gastrointestinal Surgery. © 2017 Elsevier Inc.
All rights reserved.
1
2
Biomedical Engineering in Gastrointestinal Surgery
Figure 1.1 Rural surgeon treating a lesion of the left arm. A variety of medical
equipment is visible but the rough scenario shows clearly the big differences between
academic medicine and the world of the “barber surgeon.” Etching by Cornelis Dusart
(16601704).
Langenbeck (181087), and Theodor Billroth (182994) are representatives of this historical progress. From then on surgery achieved one
triumph after another and is still considered today as the spearhead of
medicine. However, this formally unchanged position is currently heavily
in danger: Interventional medicine of today is characterized by the idea
of further trauma reduction. Increasingly, open surgical procedures are
replaced by minimally invasive interventions or even by interventional
gastroenterology and radiology. In this very competitive environment surgery is forced to improve continuously its own therapeutic armamentarium. Otherwise, surgery may not survive as a discipline of its own right.
Surgery and Biomedical Engineering
Figure 1.2 Three eras of interventional medicine: In the beginning, surgeons had to
conquer the various anatomical regions of the body: Abdomen, thorax, etc., and
finally the brain. As soon as this was achieved, the focus was laid upon reconstruction/substitutes. About 20 years ago, surgery entered the era of trauma reduction.
From MITI.
As shown in Fig. 1.1, scientific surgery has existed as an academic
discipline for only 150 years. Retrospectively, this comparatively short
period of time can be subdivided into three different eras (
Fig. 1.2).
In the beginning, surgeons learned to master the specific challenges
of the different anatomical regions—beginning with the abdomen and
ending with the brain. In the next phase, surgery was not any longer
confined to resection/amputation, etc. but the focus was now laid on
substituting deficits: Destroyed joints were replaced by artificial implants,
so-called pouches were developed to take over the role of the stomach,
the rectum after resection, etc. The final highlight of the era was the
transplantation of whole organs (heart, liver, kidney).
The trend of today is to further minimize the surgical trauma—collateral
damage to other organs, functional impairment, and pain. This third era
of surgery started with the introduction of laparoscopic surgery.
Laparoscopy was, however, only the beginning of a broad development
in many medical disciplines toward less trauma and lower invasiveness.
Many surgical operations are now substituted by new interventions that
do not need skin incisions, general anesthesia, etc. One of the classical
surgical emergency cases in former days was, e.g., gastroduodenal bleeding from peptic ulcers, forcing the surgeons frequently to spend another
few hours in the operating room (OR) during nighttime. This type of
surgery has almost vanished from the surgical departments, since upper
3
4
Biomedical Engineering in Gastrointestinal Surgery
gastrointestinal bleedings are now treated successfully by interventional
gastroenterologists who have learned to stop the bleeding from inside.
Another impressive example of how surgery became superseded by nonsurgical interventions is portal hypertension. Blood perfusion of the liver
is impaired in the case of liver cirrhosis. Prehepatic blood is deviated
and induces life-threatening bleeding into the esophagus. The surgical
answer was to create artificial shunts (portocaval shunts). Admittedly,
shunt surgery was highly demanding and complicated. If the patient
survived, the functional results usually were not particularly satisfying.
Today, shunt surgery is obsolete. It has been successfully replaced by
a radiological intervention called transjugular intraparenchymatous shunt.
Surgery of portal hypertension is no longer an issue in surgery. Many
similar examples exist.
This development will certainly continue and it is doubtful what will
be left for traditional surgery (
Fig. 1.3). One thing, however, is clear: In
order to achieve further progress in medicine, the surgeons and physicians
need more than ever the active support of basic sciences, engineers, and
computer scientists. Without innovative tools and methods—delivered by
biomedical engineering (BME)—the medical doctors will be unable to
further improve their armamentarium of interventional therapeutic
approaches. This is why an intensive continuous dialogue between
Figure 1.3 Developments in invasive medicine: Classical “open” surgery is rather
invasive, but remains to be the gold standard of all competitive less-invasive procedures. Step by step, alternative interventional options were developed. The latest
ones lost their connexion to conventional surgery. From MITI.
science, development, and medicine is today mandatory. It has been
shown that the translation of innovative surgical devices into the OR is
markedly improved by this interdisciplinary interaction
[1].
Fortunately, a corresponding response can be observed on the
technical/scientific side: The community of natural sciences developed the
concept of BME.
The definition of BME in brief:
“Application of engineering principles and design concepts to medicine for diag-
nostic or therapeutic purposes.”
Wikipedia
Admittedly, this definition is not very sharp and could include almost
everything. As a matter of fact, BME is the intersection of at least three
mighty disciplines: medicine, engineering, and basic science. Like surgery
or perhaps it would be better to say interventional medicine, many of the
natural sciences like chemistry, biology, and the engineering had a long
way to go in academic history to achieve the status of becoming their own
academic disciplines. Therefore, it is little wonder, that the overlap of these
three disciplines appears to be academically doubtful since it resembles
too much pure application rather than science for its own right.
It is the question now of whether BME has got the chance at all to
achieve in the long run an equal academic status to the other now wellacknowledged disciplines. In other words, whether BME can be released
of its ostensibly scientific interiority and gain a well-respected place in the
academic community (“academic emancipation”).
Disregard of natural science or even more of engineering is based
upon very old traditions. Greece was the cradle of the classical academy.
It is well known that only theoretical work like philosophy was considered as science. The reputation of productive physical work like producingfoodorbuildinghousesorshipswas considered low. This point of
view dominated academic reality in European u niversities for many
centuries. They mainly comprehended only four f acu lties: Theology,
law, medicine, and fine arts. Of course, the societies acquired in parallel
considerable technical knowledge in all fields—in par t icular in mining,
ship building, navigation, etc.—but the a cademic value of these impressive intellectual efforts was not recognized.
It took until the French revolution to come to the first educational
institution for practical/technical knowledge. The highly reputative E´cole
Polytechnique in Paris was originally founded in 1794 to provide the
5Surgery and Biomedical Engineering
6
Biomedical Engineering in Gastrointestinal Surgery
Figure 1.4 (A) The beginnings of systematical higher technical education: École
Polytechnique in Paris, founded in 1794. (B) Coat of arms of the École Polytechnique:
Besides of the military aspect, it also refers to civilian engineering. From MITI.
army with well-trained pioneers for the engineer units, but later on,
civilian professions were trained as well (
Fig. 1.4).
The idea found an overwhelming interest in other states and similar
“schools” for trade and industry were soon created in various European
countries (
Fig. 1.5).
Many of the famous pioneers of the industrial revolution started their
career at these places. The rapidly growing industry required more and
more competent young engineers. Accordingly, the number of institutions increased significantly in the following decades and they were
upgraded to “Technical high schools” beginning from 1879. This development was observed all over Europe, notwithstanding some differences
in different areas.
Surgery and Biomedical Engineering
7
Figure 1.5 Foundation of advanced technical education institutes. Modified by
Dr. A. Schneider.
The amazing flood of new scientific insights and the outbreak
of technical innovations augmented significantly the acceptance and
prestige of the technical and engineering disciplines in the society. The
German government under emperor Wilhelm II was the first one
which, accordingly, entitled Technical High Schools to offer diplomas
8 Biomedical Engineering in Gastrointestinal Surgery
and even a doctor’s degree to their students (1899). In real life, these
academic qualifications soon got broad acceptance and acknowledgment,
but in the “classical” academic world, esteem was low. Despite the impressive number of Nobel Prize winners, the new faculties were still scorned as
“grease oil faculties.”
Over the coming years, the impact of natural science, engineering,
and computer science was increasing so much that the differentiation
between technical high schools and real universities could no longer
be maintained. All over Europe, they were now—in between 1970 and
1980—denounced as Technical Universities. Two exceptions, however,
still exist in Europe. The “Eidgeno¨ssische Technische Hochschule
(ETH)” in Zurich and the “Rheinisch-Westfa¨lische Technische
Hochschule (RWTH)” decided to keep their original name, though
it is beyond doubt that they are full universities of outstanding position.
Self-evidently, the special problems in medical engineering had
always been a par t of disciplines like physics, electrical or mechanical
engineering, or computer science, but the idea to define its own scientific entity arose no earlier than 1990. Most probably, this was induced
by the end of the cold war, since research and development for military
purposes sharply declined, and new fields of activities had to be f ound
and these were found in medicine.
It is an optimistic statement that BME has emerged in the meantime
as a discipline of its own right rather than being a cross-disciplinary
hybrid specialization of other disciplines. In reality, many consider BME
still as a nonfertile hybrid, just like a mule. A mule is stronger, more resilient and more apt to achieve tasks than its father (donkey) and its mother
(horse), but it is unable to reproduce its own kind. This comparison
is impressive and plausible at first glance, but we are convinced that it is
not adequate to describe the situation of BME.
There is a real chance for BME to flourish as its own discipline:
Natural science/engineering and medicine have to cooperate as intensively as possible. This is not as easy as it seems to be: Actually, surgeons
and engineers are still living in different worlds, considering each other
from a different point of view (
Tables 1.1 and 1.2).
Engineers complain that physicians use a highly specific terminology
which is difficult to understand. Cooperation is often difficult since surgeons are considered to have only a limited awareness of the significance
of technical innovations, they are impatient and time management is often
chaotic. On the other hand, many surgeons are not really motivated to