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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_605_Библиотеки_им_академика_М_И_Перельмана.pdf
Classical (Open) Surgery
Figure 6.42 The use of a linear cutting device for open abdominal surgery.
Resection of an intestinal segment: (A) The device is closed at the resection line and
fired; (B) the bowel is severed. Both edges are closed with stapler lines. Courtesy: PD
Dr. D. Wilhelm, Klinikum rechts der Isar.
261
Figure 6.43 Circular stapler: Note the slightly curved shape which facilitates the
insertion into the rectum. From MITI.
Figure 6.44 The head of the circular stapler in the “open” state. The anvil is at
a distance to the shaft but still connected to it. From MITI.
By squeezing the handle, the staples are pressed out of the cartridge
and formed against the anvil. In the same moment, the circular knife
is moved forward as well and pushed against the plastic r ing of the anvil,
thus cutting the tissue which protrudes into the lumen (
Fig. 6.45).
262
Biomedical Engineering in Gastrointestinal Surgery
Figure 6.45 (A) The anvil is removed and will now be positioned into the contralateral stump of the colon using a purse string suture. (B) A spearhead-like plastic tip is
attached to the central rod of the stapler. It helps to perforate the blindly occluded
distal stump. (C) Immediately before the stapler can be fired: The central rod of the
stapler is visible. The sharp plastic tip is already removed. The shaft of the anvil will
now be reunited. From (A,B) MITI and (B) M. Scholle.
The rigid design of today’s staplers limits their application to the
rectosigmoid area. Attempts have been made to create flexible circular
staplers to reach higher segments of the colon or—inserted through the
mouth—for esophageal or gastric anastomoses. Despite considerable
R&D efforts, flexible staplers are still lacking on the market. The gap is
still waiting to be closed.
6.6 BIOMATERIALS
Visceral surgery requires not only instruments and devices but, additionally, biomaterials as well. A well-known example is surgical sutures. Less
known is the widespread use of surgical meshes.
6.6.1 Surgical Suture Materials
Ancient surgery was performed with natural organic materials, such
as cotton, flax, hairs, silk, or catgut, the latter being collagen from sheep
263Classical (Open) Surgery
or goat intestines. Today, synthetic threads have almost completely replaced
the suture material of former times.
In order to classify the very broad range of suture materials on the
market, two different categories should be used: absorbability and
internal structure.
6.6.1.1 Absorbability
Absorbable sutures keep their tensile strength as long as it is required over
the healing process. Parallel to the increasing strength of the tissue, they
are degraded by the tissue metabolism (proteolytic enzymatic degradation)
until they are completely dissolved.
Table 6.1 gives an overview of the
most commonly used suture materials.
Nonabsorbable sutures remain in place forever, as long as they are
not removed. In general and visceral surgery they are still used for skin
closure. It is assumed that the cosmetic result is superior since immune
response is lower. At any rate, they are cheaper and easier to remove.
More evidence-based is the use of nonabsorbable sutures in highly
dynamic anatomical regions. Hernia repair (groin, scar, hiatal hernia)
is a classic example.
6.6.1.2 Internal Structure
The threads either may be produced as one homogenous fiber (monofilament) or consist of multiple cords, which are often braided (
Fig. 6.46).
Monofilament threads pass smoothly through the tissue, but are less
easy to knot than braided ones.
The strength of the thread has to be adapted to the anatomical
structure and the local force. Most remarkably, the diameter of surg ical
threads is not defined metrically (mm) but according to the Unites States
Pharmocopeia (USP) standard.
Table 6.2 gives an overview about
diameters which are commonly in use in visceral surgery.
Table 6.1 Suture materials
Absorbable Nonabsorbable
Polyglycolic acid Polypropylene
Polylactic acid Polyester
Polydioxanon Nylon
Caprolactone
264 Biomedical Engineering in Gastrointestinal Surgery
Figure 6.46 (A) Monofilament thread (nylon); (B) multifilament thread, braided
(polyglycolic acid). From MITI.
Table 6.2 USP codes and diameter
USP designation Diameter (mm)
5-0 0.1
4-0 0.15
3-01 0.2
2-0 0.3
0 0.35
1 0.4
2 0.5
In other surgical subdisciplines, thinner (ophthalmology) or thicker
threads are used, ranging from 0.01 mm (USP 11-0) to 0.7 mm (USP 5).
In the past, suture materials were delivered on coils. The suture was
threaded at the OR table with reusable, eyed needles. Today, practically
all suture materials are delivered as a fixed combination of threads and
needles (swaged needle or atraumatic suture) (
Fig. 6.47).
Reusable needles are becoming less popular, since the eye of the needle dilates the suture channel inadequately and the handling of the sutures
is more time-consuming.
6.6.2 Surgical Mesh
Certain pathologies, such as hernia, require a reinforcement of the anatomical structures. For this purpose, surgical meshes were developed
about 60 years ago. The first meshes (Marlex) were heavyweight, rather
rig id sheets made of polypropylene. They induced significant scar formation which was mechanically stable but often irritating.
Classical (Open) Surgery
Figure 6.47 (A) Prepacked swaged sutures: The prepacked needlesuture combina-
tion is delivered in a transparent cover. (B) The running nurse peels it open and
throws the sterile content onto the Mayo stand. (C) The needle can now be fixed
with the needle holder. All from MITI.
265
Figure 6.48 (A) Strip of a VYPRO II mesh (Ethicon). The meshes are available
in different sizes, the smallest being 103 15 cm; (B) microstructure of the mesh;
(C) magnified (1003) view of a strand: Note the multifilament structure. All: Courtesy:
G. Babaryka, Klinikum rechts der Isar.
Beyond excessive scar formation, erosion of surrounding tissue,
migration of the implant due to inadequate elasticity, or perforations
into bowels or bladder were observed. Surg ical site infection with
a mesh in situ is a catastrophe since biofilm for ming bacter ia cannot be
eliminated as long as the implant is still in place. Nonetheless, textile
prosthetic devices became a promising market. According to Sanders,
about 20 millions of them are used worldwide per year
[28].Avast
amount of R&D effort s was invested by the manufacturers to develop
the “ ideal mesh.” Currently, more than 200 different designs are on
the market.
Contemporary meshes are lightweight and loosely woven, being either
absorbable, nonabsorbable, or partly absorbable (
A more sophisticated classification was developed by Klinge et al.
Fig. 6.48).
[29]
(Table 6.3).
266 Biomedical Engineering in Gastrointestinal Surgery
Table 6.3 Classification of mesh materials based on porosity
Class I: Large-pore meshes with a low risk for bridging, defined by textile
porosity .50% and effective porosity .0%
(1a) monofilament
(1b) multifilament
(1c) mixed structure or polymer
Class II: Small-pore meshes with a high risk for bridging, defined by textile
porosity ,50% and effective porosity of 0%
(2a) monofilament
(2b) multifilament
(2c) mixed structure or polymer
Class III: Porous mesh with special features in addition to the pure textile
construction, e.g., to prevent adhesions
Class IV: Film-like mesh without porosity, submicron pore size or secondarily
excised pores
Class V: Complex textiles difficult to uniformly characterize, either preshaped,
preformed, or three-dimensional
Class VI: Tissue-derived biologicals
(6a) noncross-linked
(6b) cross-linked
(6c) special features
Up to now, meshes are still a matter of debate in surgery, since the
continuous development of new types has impaired a systematic evaluation of those in use (
Fig. 6.48).
REFERENCES
[1] Surgical Instruments: images & names, ,http://www.medword.com/surgical/.;
[accessed 17.09.16].
[2]
Wiss J and Sons. A story of shears and scissors. Newark, NJ: Wiss J and Sons; 1948.
[3] Ibbotson S, Dettmer T, Kara S, Herrmann C. Eco-efficiency of disposable and
reusable surgical instruments—a scissors case. Int J Life Cycle Assess 2013;18:1137.
[4] Carlander J, Koch C, Brudin L, Nordborg C, Gimm O, Johansson K. Heat
production, nerve function, and morphology following nerve close dissection with
surgical instruments. World J Surg 2012;36:13617.
[5] Karaki W, Akyildiz A, De S, Borca Tasciuc DA. Energy dissipation in ex-vivo porcine
liver during electrosurgery. IEEE Trans Biomed Eng 2016; [Epub ahead of pr int].
[6] Martin KE, Moore CM, Tucker R, Fuchshuber P, Robinson T. Quantifying inadvertent
thermal bowel injury from the monopolar instrument. Surg Endosc 2016;30(11):
477684.
[7] TaheriA,MansooriP,SandovalLF,FeldmanSR,PearceD,WillifordPM.
Electrosurgery: Part I. Basics and principles. J Am Acad Dermatol 2014;70(4), 591.e114.
267Classical (Open) Surgery
[8] Zhang H, Zhai Y, Yang X, Zhai G. Breaking the skin barrier: achievements and
future directions. Curr Pharm Des 2015;21(20):271324.
[9] Chan CL. Boundary element method analysis for the bioheat transfer equation.
J Biomech Eng 1992;114(3):35865.
[10] Kengne E, Lakhssassi A. Bioheat transfer problem for one-dimensional spherical
biological tissues. Math Biosci 2015;269:19.
[11] Demir E, O’Dey DM, Pallua N. Accidental burns during surgery. J Burn Care Res
2006;27(6):895900.
[12] Vancaillie TG. Active electrode monitoring. How to prevent unintentional thermal
injury associated with monopolar electrosurgery at laparoscopy. Surg Endosc
1998;12(8):100912.
[13] Heniford BT, Matthews BD, Sing RF, Backus C, Pratt B, Greene FL. Initial results
with an electrothermal bipolar vessel sealer. Surg Endosc 2001;15(8):799801.
[14] Farin G, Grund KE. Technology of argon plasma coagulation with particular regard
to endoscopic applications. Endosc Surg Allied Technol 1994;2(1):717.
[15] Postema RR, Plaisier PW, ten Kate FJW, Terpstra OT. Haemostasis after partial hep-
atectomy using argon beam coagulation. Br J Surg 1993;80(12):15635.
[16] Herrera S, Bordas JM, Llach J, Gine`s A, Pellise´M, Ferna´ndez-Esparrach G, et al.
The beneficial effects of argon plasma coagulation in the management of different
types of gastric vascular ectasia lesions in patients admitted for GI hemorrhage.
Gastrointest Endosc 2008;68(3):4406.
[17] Vilos GA, Rajakumar C. Electrosurgical generators and monopolar and bipolar elec-
trosurgery. J Minim Invasive Gynecol 2013;20(3):27987.
[18] Tixier F, Garc¸on M, Rochefort F, Corvaisier S. Insulation failure in electrosurgery
instrumentation: a prospective evaluation. Surg Endosc 2016;30(11):49955001.
[19] Feldman LS, Fuchshuber P, Jones DB, Mischna J, Schwaitzberg SD. FUSE
(Fundamental Use of Surgical Energyt) Task Force. Surgeons don’t know what they
don’t know about the safe use of energy in surgery. Surg Endosc 2012;26(10):27359.
[20] Robinson TN, Olasky J, Young P, Feldman LS, Fuchshuber PR, Jones SB, et al.
Fundamental Use of Surgical Energy (FUSE) certification: validation and predictors
of success. Surg Endosc 2016;30(3):91624.
[21] Riegler M, Cosentini E, Bischof G. Update and economic aspects of the harmonic
scalpel in general surgery. Eur Surg 2004;36(3):1729.
[22] Wilhelm D, Szabo M, Glass F, Schuhmacher C, Friess H, Feussner H. Randomized
controlled trial of ultrasonic dissection versus standard surgical technique in open left
hemicolectomy or total gastrectomy. Br J Surg 2011;98(2):2207.
[23] Schneider A, Doundoulakis E, Can S, Fiolka A, Wilhelm D, Feussner H. Evaluation
of mist production and tissue dissection efficiency using different types of ultrasound
shears. Surg Endosc 2009;23(12):28226.
[24] Rau HG, Duessel AP, Wurzbacher S. The use of water-jet dissection in open and
laparoscopic liver resection. HPB (Oxford) 2008;10(4):27580.
[25] Contini E, Whiffen J, Bronson D. Comparison of endostapler perfor mance in chal-
lenging tissue applications. Surg Obes Relat Dis 2013;9(3):41721.
[26] McGuire J, Wright C, Leverment JN. Surgical staplers: a review. J R Coll Surg
Edinb 1997;42(1):19.
[27] Giaccaglia V, Antonelli MS, Chieco PA, Cocorullo G, Cavallini M, Gulotta G.
Technical characteristics can make the difference in a surgical linear stapler. Or not?
J Surg Res 2015;97(1):1016.
[28] Sanders DL, Kingsnorth AN. Prosthetic mesh materials used in hernia surgery.
Expert Rev Med Devices 2012;9(2):15979.
[29] Klinge U, Park JK, Klosterhalfen B. The ideal mesh? Pathobiology 2013;80(4):16975.
CHAPTER 7
Operative (Surgical) Laparoscopy
Laparoscopy is a technique to look into the abdominal cavity via a tiny
incision using a (r igid) telescope, allowing a visual exploration of the
internal organs. The history of diagnostic laparoscopy is comparatively
long, since it was performed first in 1901. Georg Kelling in Germany
examined the peritoneal space in dogs using a cystoscope, but did not
dare yet to use this new approach in humans. This was done in Sweden
some 10 years later by Hans Christian Jacobaeus, who published the first
series of clinical cases. To reduce the risk of injury to intestinal organs
when inserting “blindly” the trocar, he selected patients only with
ascites (fluid collection in the abdomen). At any rate, he could prove that
laparoscopy permitted an excellent diagnostic approach to the liver, the
peritoneum, and partly of the intestine. Up to that time, any other imaging procedures of the viscerum were not yet available which explains why
diagnostic laparoscopy soon became extremely popular, in particular for
the diagnostic workup of liver diseases.
In 1927, the first monography upon laparoscopy was published by
Robert Kortsch. The technical equipment was continuously improved
and the range of indications was widened. Laparoscopy did not only
become a valuable diagnostic tool but also become a means of therapeutic
intervention. Conrad Fervers first dissected adhesions in 1930 and four
years later, Theodor Stolze even argued that laparoscopy could potentially
replace laparotomy in the future. Despite these visionary concepts, laparoscopy remained at that time merely a diagnostic procedure. However,
the technique was continuously refined. Being rather primitive in the
beginning (
by pioneers like Heinz Kalk and others. Simultaneously, the safety of this
rather invasive procedure could be proven by systematic studies.
The diagnostic impact could even be multiplied as soon as Kalk demonstrated the feasibility of taking biopsies (1942).
The early development of (diagnostic) laparoscopy is briefly reported
in
Table 7.1. For about 40 years laparoscopy was an important element of
diagnostic workup in gastroenterology.
Fig. 7.1), more advanced modifications followed soon, driven
Biomedical Engineering in Gastrointestinal Surgery. © 2017 Elsevier Inc.
All rights reserved.
269
270 Biomedical Engineering in Gastrointestinal Surgery
Figure 7.1 The beginnings of diagnostic laparoscopy (ca. 1930): (A) Via a large bore
puncture needle, air is pumped into the peritoneal cavity using a bladder syringe.
The patient is awake. (B) While the patient is summoned up to press the abdominal
musculature as firmly as possible, the trocar is inserted into the abdominal cavity
through the abdominal wall. (C) Direct visual exploration of the internal organs. Note
the low standard of asepsis. Courtesy: Dr. Hanfried Kalk, Bad Kissingen.
Table 7.1 The history of laparoscopic surgery
1901 Kelling Celioscopy (animal studies)
1910 Jacobaeus Laparoscopy
1913 Renon Laparoscopy
1924 Steiner Abdominoscopy
1927 Kortsch Textbook of laparoscopy
1929 Kalk Technical improvements, standardization
1930 Fervers Adhesiolysis
1934 Stolze Laparoscopy instead of laparotomy
1942 Kalk Laparoscopic liver biopsy
Later on, the clinical importance of diagnostic laparoscopy declined.
Gastrointestinal physicians could increasingly use more sophisticated laboratory tests and new imaging procedures such as ultrasonography and
computed tomography to establish an accurate diagnosis of abdominal
diseases. Laparoscopy appeared to be too invasive and too limited in its
diagnostic value as compared to more recent imaging modalities.
Maybe, laparoscopy would have become completely obsolete at that
time, if some surgeons had not detected the huge therapeutic potential of
laparoscopy. Kurt Semm, a gynecologist, demonstrated that even “real”
surgical operations were feasible through small trocar openings, like the
removal of an appendix in case of appendicitis.
The pioneers of laparoscopic surgery recognized some technical
innovations which have brought laparoscopy almost to perfection. Three
milestones deserve special mention:
The Hopkins optic. In the beginnings of the 1960s, Karl Storz, one of
the technical pioneers of modern instrument design and production,
271Operative (Surgical) Laparoscopy
became interested in the scientific activities of a young British physicist,
John Hopkins. Hopkins strongly recommended a new principle of image
transmission through the telescope (see below). Storz soon detected the
dramatic improvement of image quality and made it commercially available. The benefit was enormous.
Flexible fiber bundles for light transmission. Before a camera can take
images out of a large cavity, the latter has to be illuminated. Due to the
lack of flexible light transmission devices, laparoscopic telescopes usually
had a small light bulb at the tip. This solution was not only impractical
but even dangerous, since severe burning of the tissue occurred if it was
touched by the bulbs, and in some cases, the bulbs even exploded.
As soon as glass fiber cables became available, the light source could be
situated apart and illumination could be provided as so-called “cold light”
from a distance.
Real-time image transmission. An objective documentation of the
actual state of diseases is always crucial, in particular in chronic morbidity. In the early 1940s, photographic documentation was introduced
into laparoscopy. Thirty ye ars later, small and comparatively cheap
video cameras appeared on the market. Video camera mounted on a
laparoscopic telescope now enabled not only the surgeons but also the
whole team to obser ve the inter ior making active assistance possible if
required.
The sum of these innovations made surgical laparoscopy feasible and
opened the door for “minimally invasive surgery.”
The theoretical (and practical, as we know today) advantages were
significant: Whenever an incision is used to penetrate the abdomen, it is
unavoidable to cut anatomical structures like nerves, muscles, and fascia.
Even after subtle suturing at the end of the surgery, the original integrity
cannot be restored. Dissection of sensitive nerves and muscles leads to
severe postoperative pain and temporary physical impairment. Scars of the
fascia are less force resistant which raises the incidence of scar hernias.
This does not happen if the abdominal wall is only perforated by a trocar
(
Fig. 7.2).
Nonetheless, laparoscopic approaches were considered extremely
skeptically by the majority of surgeons at the beginning. Despite massive resistance, laparoscopic surgery soon became the gold standard
for numerous operations and is today an integ ral part of surgery
(
Tab le 7 . 2).