Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_605_Библиотеки_им_академика_М_И_Перельмана.pdf
312
Biomedical Engineering in Gastrointestinal Surgery
Figure 7.59 Image procession to eliminate surgical plume: (A) Filtering out pixels
which are shadowed by floating plume leads to an impressive improvement of
visibility; (B) original image. From MITI.
Figure 7.60 Vessel sealing generator. From MITI.
successfully, an acoustic signal indicates that the blade can be pushed
forward by activation of a mechanical handle (
Fig. 7.61).
The first devices were only available with a diameter of 10 mm.
Currently, 5-mm systems are the standard.
7.2.11 Comparison between ultrasound and impedanceguided dissection
There is plenty of literature comparing the two different dissecting principles with each other in laparoscopic surgery or conventional dissection or
clipping under various conditions
Many parameters were evaluated like time of performance, collateral
damage (thermal spread), burst pressure, and ergonomy.
In most of these studies, there are no significant differences in compli-
cation rates, operative time, pain medication, and cost.
[1520].
Operative (Surgical) Laparoscopy
Figure 7.61 (A) Handpiece of impedance-controlled vessel sealing system; (B) tips of
the hand instrument. All from MITI.
313
Both types of devices are valuable tools which contributed a lot to the
development of minimally invasive surgery.
7.3 MINILAPAROSCOPIC PROCEDURES
With the onset of laparoscopic surgery, surgeons soon thought about
ways to make minimally invasive surgery even less traumatic. One
approach was to further reduce the diameter of the trocars (instruments)
in use. Instead of 10- or 5-mm instruments, it was attempted early in
the history of laparoscopic surgery to replace them by instruments of
a diameter of 2 or 3 mm. Soon, instruments became available but
it became clear that they suffered from distinct mechanical limitations.
The small effector tips were suboptimal. Electrosurgical functionality was
poor and the instruments’ durability low. Most irritating, however, was
excessive instrument shaft flexibility. The required force could not
be exerted to the tissue. The so-called whiplash effect occurred.
Accordingly, minilaparoscopic procedures did not gain widespread
acceptance at the beginnings of laparoscopic surgery
Minilaparoscopy was further stigmatized as a complicated approach
that only could be applied in low BMI patients without major advantages
over conventional laparoscopy with the exception of esthetics.
The situation changed considerably over time. The manufacturers
now provide instruments with better designs, using more resilient
materials with better durability, and telescopes with a significantly better
visualization
[22,23] (Fig. 7.62).
Last but not least, the “Achilles heel” of minilaparoscopy, i.e., the
occlusion of cannalicular structures such as blood vessels or the cystic
duct, could be solved. To apply adequate clips using a 3-mm clip applier
is problematic. Instead, new suturing techniques are now available to
overcome this typical disadvantage of former minilaparoscopy.
A wide range of suitable instruments is now on the market (
[21].
Tab le 7 . 5 ).
314
Biomedical Engineering in Gastrointestinal Surgery
Figure 7.62 The spectrum of commercially available miniinstruments. From MITI.
The aim of minilaparoscopic procedures is to do the surgery with only
one conventional trocar site (currently 10 mm, but hopefully in future
times with 5 mm) which is placed within the umbilicus, but with the
additional help of two or three additional tiny incisions (23 mm), leaving
almost invisible scars. In contrast to mono-port surgery (see
Section 7.4:
Mono-Port (Single Port) Surgery), there is no need to insert all instruments through one single port. This avoids the enlargement of the singlesite incision and allows for the normal kinematics of instrument use.
The search for better technical solutions has already led to fascinating
new developments. Visualization is always a crucial aspect of laparoscopy.
Small bore telescopes are becoming increasingly more powerful. An
interesting alternative is the use of so-called satellite cameras (
Fig. 7.63).
The idea is to position an independent, remotely guided camera within
the abdominal cavity (attached to the abdominal wall) which saves the
trocar usually required for the laparoscope.
The small effector tips could cause trouble, since the grip is too weak
but, nevertheless, rather traumatic. The artificial enlargement by mounting separate larger tips was already evaluated.
Last but not least, the passive retractor function of some instruments could
be taken over by internal or external stay sutur es or anchors (
Fig. 7.64).
Beyond doubt, technical advancements are still conceivable which
certainly will make minilaparoscopic surgery to a most valuable tool in
the armamentarium of surgery.
Table 7.5 Current generation of minilaparoscopy hand instruments
Braun Gimmi
Product name Aesculap
AdTech
(CareFusion)
AlphaDur
MicroLap
Storz Storz Stryker SurgiQuest
(ABMedica)
Clickline Koh 3 mm Low
impact
Teleflex Teleflex Wolf Covidien
Percuvance MiniLap Eragon
MiniSite
Mini
Mini
Reusability Reusable Reusable Reusable Reusable Reusable Reusable Reusable
Disposable Reusable Disposable
handle
Shaft diameter
3.5 2.8, 3.4 2, 3, 3.5 3 3 3.1 2.9 2.32.4 3.5 2
(mm)
Shaft length
20, 29 16, 30 20, 30 30 20, 29 31, 35 29, 36 25 24, 33 19, 31, 45
(cm)
Handle
designs
Pistol grip Castro Viejo Pistol grip;
Straight
Pistol grip;
Straight
Pistol
grip
Pistol grip Pistol grip Thumb
handle;
7 designs Pistol grip
Pistol
grip
Effectors/tips 11 11 11 6 18 13 7 8 1821 1
Insulation Yes Yes Variable No Yes Yes Yes Yes Yes Yes
Rotation Yes Yes Yes No Yes Yes Yes Yes Yes Yes
Trocars Yes Yes Yes,
Yes Yes No No Yes Yes
including
low
friction
MiniShears
316
Biomedical Engineering in Gastrointestinal Surgery
Figure 7.63 Satellite camera: The “internal” camera is able to replace the classical
telescope which requires an own trocar. Experimental design with an outer diameter
of 10 mm. All from MITI.
Figure 7.64 (A) External stay sutures: A sling created by a transdermal thread
elevates the falciform ligament (arrow); (B) intraabdominal anchor. All from MITI.
7.4 MONO-PORT (SINGLE PORT) SURGERY
Even more visionary appears the idea to perform surgery using just one
single port instead of additional 35 trocars. Nevertheless, it is feasible,
as many working groups all over the world have been able to show.
Up to now, no clear terminology has been found.
overview upon the different denominations.
In order to avoid a too close proximity to specific manufacturers, we
recommend the neutral term of “mono-port surgery” as neutral denomination for this new surgical approach.
Mono-port surgery is technically considerably more challenging than
conventional laparoscopic surgery. All instruments have to be inserted
through one single port site which makes triangulation and the movement of instruments difficult. The instruments have to be handled against
normal intuition (see below). The trocar is the needle hole through
Table 7.6 gives an
Operative (Surgical) Laparoscopy
Table 7.6 Company specific denominations of mono-port surgery
OPUS One-port umbilical surgery
TUES Transumbilical endoscopic surgery
e-NOTES Embryonic NOTES
SLAPP Single laparoscopic port procedure
SPL Single port laparoscopy
SLIT Single laparoscopic incision tran sabdominal surgery
LESS Laparoendoscopic single site surgery
SILS Single incision laparoscopic surgery
317
Figure 7.65 Disposable single port trocars: Deformable soft plastic main bodies bear
a number of flexible ports with valves. From MITI.
which instruments and the telescope have to be inserted. The team
usually consists just of two surgeons. It has been pointed out that mono-port
surgery is also particularly apt for solo surgery
[24].
7.4.1 Trocars
The incision has to be kept as small as possible, but the trocar must,
nonetheless, provide flexible introduction channels for at least two instruments and, separately, the telescope. The industrial companies were very
creative in designing both disposable (
trocars.
Disposable Mono-Port Trocars
Single use mono-port trocars are mostly made of soft material for easy
insertion through the 12-25-mm incision in the abdominal wall and to
provide sufficient flexibility for the inserted instruments. Some designs
are made out of two flexible rings with a transparent plastic film between,
Fig. 7.65) and reusable mono-port
318
Biomedical Engineering in Gastrointestinal Surgery
making it possible to inspect the wound margins of the abdominal
incision. Mostly all disposable trocars are having several ports with a diameter
of 5 mm and an additional 10-mm instrument port for stapling devices or
other lager instruments. All of the ports are gas-tight closed with a valve.
Reusable Mono-Port Trocars
The design of a reusable trocar is, perhaps, even more of a challenge,
since the needs of reprocessing have to be considered. The use of plastics,
e.g., is therefore limited. However, some successful solutions could
already be found and are commercially available (
Fig. 7.66).
Trocars for mono-port surgery must allow an adequate angulation of
each single instrument. Each of it has to be sealed gas-tight.
7.4.2 Hand Instruments
If the instruments are inser ted through one common hole, collisions are
inevitable. A conflict between instruments and the scope is frequent. If
normal straight laparoscopic instruments are used, the surgeon is forced
to manipulate crosswise which is extremely difficult (
surgical technique becomes insecure and extremely time-consuming.
Surgeons and engineers, looking for better solutions, soon found some
improvement. Curved instruments (
Fig. 7.67B) allow for a better triangu-
lation, but the problem is still valid that the tips of the instruments are
“on the wrong side.”
Double-curved instruments (
Fig. 7.67C) make life easier, but,
nonetheless, considerable training is required.
Currently, all of the most renowned manufacturers provide instrument
sets dedicated to mono-port surgery. Producers of reusable instruments
offered quite a bunch of funny shaped instruments which never became
really popular (
Fig. 7.68).
Fig. 7.67A). The
Figure 7.66 X-cone (STORZ): (A) Functional state; (B) the first half of the device is
inserted through the miniincision; (C) the second cone half is introduced; (D) by
approximation of the two cones a funnel is shaped. The top with the sleeves can
now be mounted. All from KARL STORZ GmbH & Co. KG.
Operative (Surgical) Laparoscopy
Figure 7.67 Problems of single incision laparoscopy: (A) Standard laparoscopic instruments: triangulation is difficult. Due to the joint point of invariancy (fulcrum), an
inverse movement of the tip results. (B) Curved instruments: triangulation is better,
but the problem of “crosswise” manipulation remains. (C) Double-bent instruments:
the tip follows the movements of the surgeon’shandasheisaccustomedto.From MITI.
319
Figure 7.68 A set of double-bent instruments. Reusable tools. All from KARL STORZ
GmbH & Co. KG.
Companies dedicated to the production of disposable instr uments
offered even more sophisticated designs (
Fig. 7.69).
The search for even more functional hand instruments initiated the design
of some very tricky devices with multiple degrees of freedom (
Fig. 7.70).
320
Biomedical Engineering in Gastrointestinal Surgery
Figure 7.69 Disposable instruments with variable bending. The bending can be
scaled. From MITI.
Figure 7.70 The SILS hand instrument family. Bending of the tip, rotation of the shaft,
and a variable position of the handle provide high flexibility. From Medtronic GmbH.
Some surgeons may feel irritated by the additional degrees of freedom.
Accordingly, the various functionalities can be neutralized.
A radically new design of hand instruments is the Radius device
(Tu¨bingen Scientific Medical, Tu¨bingen, Germany). The aim is to create
a natural extension of the human hand. The handle is positioned in
Operative (Surgical) Laparoscopy
321
a rectangle. The tip is rotatable and deflectable. In addition, the shaft is
rotatable as well. Depending upon the actual task, the effector tips can
easily and rapidly be changed during the operation (
Fig. 7.71).
Last but not least, the Single-Site Instrumentation for the DaVinci
surgical system (Intuitive Surgical, Sunnyvale, CA, the United States) has
to be mentioned (see Chapter 10.1.2: Master-Slave Systems). It is not surprising that the manufacturers took the advantage of a remotely controlled slave system to perform mono-port surgery (
Fig. 7.72).
Though the instruments are crossed, the surgeon is able to use his
interfaces at the console as he is accustomed to. The system “translates”
the movement of his hands into the appropriate steering commandos.
7.4.2.1 The SPIDER Surgical System
The SPIDER surgical system (TransEnterix, Morrisville, NC, the United
States) was the first device specifically designed for mono-port surgery
Figure 7.71 The Radius T surgical system: The specially designed handles enable the
use of the multiple degrees of freedom. From Tuebingen Scientific Medical GmbH.
Figure 7.72 DaVinci EndoWrist single-site instrumentation. From Intuitive Surgical.