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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_605_Библиотеки_им_академика_М_И_Перельмана.pdf
Health Informatics/Health Information Technology
485
gastric cancer surgery, developed a new classification program for knowledge extraction already decades ago.
In each of his patients with gastric cancer, he documented prospectively any relevant detail (epidemiology, type, localization, grading, etc. of
the tumor), then performed surgery (with the opportunity to confirm or
modify the preoperative findings) and observed the further course
[11].
After about 800010,000 individual patients, he was not only able to
predict rather reliably the 5-year survival rate of an individual patient but
also to give reliable information upon the required extent of the surgical
resection. This offered surgery the chance to become individualized
(
Fig. 12.9).
Based upon the preoperative information of which lymph nodes were
inflicted and which ones were negative, lymph node resection could be
limited to the minimum. A considerable number of gastric cancer resections could be performed in a less invasive manner.
The value of the Maruyama classification was underestimated. Not
too many surgeons recognized it as a basis for “tailored surgery,” although
the validity, even in Europe, was confirmed
[12]. However, the basic idea
was excellent. About 30 years later, electronic health records would not
offer the chance to exploit the knowledge which is uselessly hidden in
the archives.
The rapidly expanding field of big data analysis provides now the tools
to accumulate, manage, analyze, and assimilate large volumes of disparate,
structured, and unstructured data produced by health information
technology
[13].
Figure 12.9 (A) The prospective evaluation of any kind of gastric tumor stage is the
basis for the prediction of true tumor extension and lymph node infliction. (B) Close
and distant lymph node groups in gastric cancer. Inflicted lymph nodes are marked
in red (dark gray box with white labeling). Lymph node groups in green (dark gray
box with black labeling) should be free of tumor cells
[11].
486 Biomedical Engineering in Gastrointestinal Surgery
It can certainly support in decision making, replacing perhaps, in the
future, costly and long-lasting clinical trials.
12.2 SURGICAL TELEMATICS/”TELESURGERY”
Surgery of the future will become increasingly more transparent and
open-label. Laparoscopic surgery is video based by nature, and in many
ORs lights for open surgery video cameras are integrated. Accordingly,
the surgical procedure becomes visible not only to the OR team but also
to—at least in theory—an unlimited number of spectators. This offers
new opportunities for quality control, education, training, etc., if the
view into the surgical OR can be shared with others even over great
distances.
12.2.1 Teleconsultation
In case of difficult intraoperative decision making, external consultants are
sometimes required—e.g., a senior expert or a specialist from other
disciplines.
This is time-consuming and tedious both for the OR team (waiting)
and the consultant who is forced to walk to the OR, change clothes, etc.
To avoid the physical presence of the consultant, teleconsultation could
be an answer. The first attempts to use teleconsultation in surgery were
made more than 20 years ago
priate equipment in their office or had to go to a room equipped with
telemedicine facilities. In daily routine, this was too impractical to make
teleconsultation popular
To overcome these limitations, and to allow spontaneous video communication during routine clinical activities, mobile video consultation
systems could be better. The first attempts were made about 10 years ago
[16] (Fig. 12.10).
It took another 10 years until it is now mature for routine clinical
use. Experts are now able to attend vir tually any operation. They
are able to communicate with the surgeon at the point of care, give
advice, etc.
[14]. However, consultants needed appro-
[15].
12.2.2 Telepresence
Telepresence is a more sophisticated version of teleconsultation. Whereas
the latter is merely based upon visual and oral information, in
Health Informatics/Health Information Technology
Figure 12.10 Mobile device with video at original size (left) and zoomed to full
screen (right): laparoscopic view of the liver
[16]. All from MITI.
487
telepresence the consultant is able to take an active part in the process at
the point of care.
If an active camera holder is used during a laparoscopic surgery, he/she
is able to control the camera. In case of open surgery, he/she can remotely
move the OR camera mounted in the OR lamp to get optimal insight into
the surgical field. In addition, he/she can clearly indicate at the surgical site
what he/she is speaking about, e.g., by using a cursor on the monitor in
video-based surgery or a “telestrator” in open surgery
[17].
The next step would be telesurgery, i.e., the surgery being performed
by the remote expert.
12.2.3 Telesurgery
The idea of teleoperation came up about 20 years ago, when the first two
masterslave units (DaVinci, ZEUS) appeared on the market (see
Section 10.1.2: Master-Slave Systems). In this type of surgical robot, the
surgeon in his/her “cockpit” is separated from the OR table and the
patient. Thus, the surgeon may be located in the United States, and the
operation could be going on in Europe—this has already been demonstrated in a pioneer application in 2001
However, telesurgery still is too expensive up to now to gain a role in
practical care. What weighs even more are the technical shortcomings
like the high end-to-end latency and the limited availability. However,
this pioneer phase will certainly be left soon
It is expected from the oncoming 5G program that the specific
requirements of telesurgery will be met: guaranteed and reliable
[18].
[19].
488
Biomedical Engineering in Gastrointestinal Surgery
Figure 12.11 Telesurgery is a complex process: Players, functionality, and technical
requirement of data streaming. From MITI.
availability of information from back and data bases and real-time data
streams from a large variety of sources (
Fig. 12.11).
However, telesurgery is not only meant to be performed over large
distances but even within an OR theater. Even today, the surgeon is
already separated from the patient by meters while the operation is
mechanically performed by a machine. In the future, the application of
uncoupled robots and microsystems will require the further development
of telesurgical systems that have to provide a comprehensive sensorial
input.
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Weissauer W, Feussner H. Telekonsultation in der Chirurgie Rahmenbedingungen
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German exper ience. Surg Endosc 1999;13(12):12545.
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http://dx.doi.org/10.1186/s12938-016-
CHAPTER 13
Training and Simulation
Simulation and training (S&T) in medicine is most often understood as a
synonym of surgical education. This is certainly the major field of application, but beyond it, additional fields have to be considered, such as
individualized therapy planning for the experienced surgeon or the evaluation of new instruments.
S&T becomes increasingly important in modern visceral surgery
because of multiple reasons:
• The rapid development of new surgical techniques requires that
surgeons continuously learn to master these new techniques.
• Patients become increasingly demanding in regards to safety. Surgical
failures are less accepted than ever.
• OR time becomes increasingly costly. Training at the OR table is
time-consuming
• Suitable cases for surgical training are rare. Accordingly, surgical education at the OR table is the “needle hole” of the surgical curriculum
(
Fig. 13.1).
[1].
13.1 TRAINING AND SIMULATION FOR SURGICAL
EDUCATION
Surgery needs talent and experience. The natural gift of being particularly
dexterous is attributed to outstanding surgeons (“golden hands”) to
explain their success, but manual skills are mostly overestimated. Beyond
personal features like stress resilience, surgical professionalism is coined by
additional factors (
have a clear concept of what has to be done and in which sequence the
actions have to be executed (“procedural knowledge”).
In other words, he should know the precise and detailed “model” of
the operation (see Chapter 14: Visceral Surgery of the Future: Prospects
and Needs).
The second factor or element of surgical e ducation is the acquisi-
tion of cognitive knowledge. The surgeon has to be able to recognize
Biomedical Engineering in Gastrointestinal Surgery. © 2017 Elsevier Inc.
Fig. 13.2). Before doing the surgery, the surgeon has to
All rights reserved.
491
492
Biomedical Engineering in Gastrointestinal Surgery
Figure 13.1 Real surgical education in the OR comes often late in the educational
curriculum. Courtesy: Dr. M. Maak, Universitätsklinikum Erlangen.
Figure 13.2 Three pillars of surgical success: Every surgeon has, self-evidently, to
acquire the necessary manual skills. In addition, he/she must possess the right cognitive abilities, understand the respective situation (knowledge of the visible and
invisible anatomy, critical sites, etc.). Last but not least, he/she must be able to
execute the task by an adapted surgical strategy. From MITI.
493Training and Simulation
Table 13.1 Currently available options for surgical education and training
Cadaver studies Fresh/preserved corpses
Animal studies Pigs; Sheep
Analog models Knot benches; Box trainers; Manikins
Hybrid models External artificial environment/organ packages
VR models Basics; Advanced procedures
the anatomy and to identify pathological conditions. The different tissue layers have to be detected. Similarly, dangerous areas have to be
respected, etc. Each individual situation has to be inter preted
correctly.
Last but not least, he/she should of course be able to carry out what
has to be done. Knowing about what has to be done still does not yet
mean that the individual is actually able to do it. Intensive manual exercise is required (manual training).
In the past, learning by doing under the surveillance of senior repre-
sentatives of the art of medical care was the main process to achieve a
professional level. This was complemented by theoretical lectures and
studies of the literature, but training in surgery remained a matter of
apprenticeship.
With the rise of modern academic surgery, additional options were looked
for to improve the effectiveness of surgical training/education (
Tab l e 13 . 1 ).
13.2 CADAVER STUDIES
They offer the opportunity to work under “normal” anatomical
conditions.
The surgeon can interact with the very structures he/she also has to
manipulate during the surgical operation.
However, getting access to human cadavers for undertaking therapeu-
tic studies is becoming increasingly difficult. Ideally, fresh corpses should
be used but they are seldom available in time. Accordingly, preservation is
required, which presents quite a number of practical problems. Various
methods of preservation are available (
• Quick-freezing
• Formalin preservation
Table 13.2):
Table 13.2 Comparison of different preservation methods for cadavers [3]
Method Formaldehyde
concentration
Costs Advantages Disadvantages
Fresh-frozen
cadaver
0% Very high initial
cost and
running cost
(cost per
cadaver
inestimable)
Formalin About 48% Initially low
(about US$15
per cadaver)
Thiel’s
method
0.6% High (about
US$300 per
cadaver)
Saturated salt
solution
method
0.75% Low (about
US$30 per
cadaver)
Flexible joints and tissues, realistic
color, minimal tissue change,
well studied
Longevity, minimal infection
risk, good histological quality,
very well studied
Flexible joints and tissues, almost
realistic color, good imaging
quality, ability to ventilate, well
studied
Natural color, comparatively low
deterioration throughout usage
period (on a monthly basis),
good imaging and histological
quality, ability to ventilate (not
well validated)
Infection risk, deterioration
throughout usage period (on
an hourly basis), mounting of
body parts when not using full
cadaver
Stiff joints and tissues, discolored,
unnatural texture, poor
imaging quality, not
suitable for insufflation or
ventilation, health hazards
including carcinogenic
property
Deterioration throughout usage
period (on a daily basis), poor
histological quality, technically
difficult and need time for
embalming process
Somewhat rigid joints and
tissues, edematous (particularly
subcutaneous tissue), change in
state during storage period, not
well studied
495Training and Simulation
• Thiel’s preservation
• Saturated salt preservation
Freshly frozen cadavers, as soon as they are thawed, come very close
to real conditions, but they are very costly and endangered by rapid
putrefaction.
Since many pathogens are not significantly harmed by deep freezing,
the risk of infection is significant.
Formalin preservation has been the most popular technique since it
was introduced in 1893. Formalin is cheap and effective, but it hardens
tissue leading to extreme rigidity even of soft tissue. The haptic properties
are no longer comparable to reality.
A superior technique (Thiel’s preservation) uses a composition of
ammonium nitrate, potassium nitrate, sodium sulfite with small amounts
of formaldehyde, ethylenglycol, boric acid, and p-chlorocresol
[2].
It leads to a significant improvement of the biomechanical properties.
The tissue remains soft and flexible, and the color comes closer to reality
than after formalin treatment. The corpses are suitable for open surgical
interventions, laparoscopic surgery, and flexible endoluminal endoscopy.
Nonetheless, the difference to living tissue is still striking.
A promising alternative to the latter approach is the saturated salt
method.
The latest innovation in cadaver training is the pulsated, revascular-
ized, and reventilated corpse
[4].
In general, training in human cadavers is expensive, difficult to orga-
nize, and even experienced surgeons often have to overcome some internal resistance to perform human cadaver experiments.
13.3 LIVE ANIMAL TRAINING
Animal studies are the only option if surgery has to be performed in living tissue. They offer important challenges, such as bleeding, perforation,
and ischemia, which every surgeon should be able to manage or, even
better, to avoid.
Various animal species are in use. Decades ago, monkeys were available
which offered excellent working conditions, but today this is inconceivable
for ethical reasons. In many parts of the world, pigs are the current standard in visceral surgery, whereas sheep are more popular in bone surgery.
In addition, rabbits, dogs, and even chicken may be suitable for training
purposes. However, animal studies are hampered by numerous problems.