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50 Biomedical Engineering in Gastrointestinal Surgery
The most important aspect is the reliable closure of the fascia. Strong
sutures are required. Today, reabsorbable sutures are applied, either as
single stitch or as running sutures.
Two complications may occur: “burst” of the suture a few days after
the operation or incisional hernia later on.
In difficult cases or in the closure of incisional hernia, synthetic
meshes are often used to reinforce the abdominal wall.
3.3 STRUCTURE AND ORGANIZATION OF SURGICAL CARE
In former times, medical care was usually provided at the patient’s home
if he/she was unable to see the physician in his medical practice. A few
centuries ago, it became increasingly popular to establish specialized institutions to care for the sick, aged, or disabled. Later on, this type of institution specialized in delivering medical care. After treatment, the patients
were discharged and new patients were referred.
Gradually, the separation of ambulant (outpatient) and in-hospital
medical care took place.
3.3.1 Outpatient Surgical Care
Minor surgical diseases or lesions can be treated on an outpatient basis.
Outpatient treatment is advantageous both for the patient and the social
systems. The patient is not forced to stay in the foreign environment of
the hospital and this type of surgery is significantly less expensive.
Outpatient surgical care is continuously extended. Many surgical interventions which formerly required in-hospital treatment are now
performed without a hospital bed. Typical examples are herniotomies,
appendectomies, or even cholecystectomies. Considerable differences
exist all over the world, depending upon the medical care structure, the
gross national product, and surgical traditions.
3.3.2 In-Hospital Surgical Care
More complex surgical procedures can only be performed within the
comprehensive care environment of the hospital.
Stationary care in a hospital is, of course, more expensive which is
why in many countries of the world the governments are striving for a
further reduction of hospital beds.
Initially, there was no separation between conservative and medical treatment. With the growing significance of interventional therapy, the division
between internal medicine and operative surgery was gradually established.
51Principles of Gastrointestinal Surgery
Figure 3.4 The Klinikum rechts der Isar, Technische Universität München, Germany,
as an example of a modern university medical center.
Table 3.1 Departments, institutes, and additional facilities of a modern tertiary
care hospital
Anesthesiology Cardiology Dermatology
Ear-nose-throat
medicine
Human genetics Internal medicine Interventional radiology
Nephrology Neuroradiology Neurosurgery
Nuclear medicine Nutritional medicine Obstetrics
Ophthalmology Oral and maxillofacial surgery Orthopedics
Physiotherapy Plastic and cosmetic surgery Psychiatry
Psychosomatic Radiation therapy Radiology
Surgery Toxicology Urology
Vascular surgery
Gynecology Hemato-oncology
In the past, a hospital consisted of two departments only: internal
medicine and surgery. Today, these are still the core structures, but a medical center of today encompasses many more diagnostic (X-ray department, nuclear medicine, numerous clinical laboratories) and therapeutic
units (
Fig. 3.4). The traditional disciplines are subdivided into many fields
of specialization as shown in
Table 3.1.
The comprehensive spectrum is offered in university hospitals or tertiary level units. Smaller or particularly specialized institutions mostly offer
a selection.
52
Biomedical Engineering in Gastrointestinal Surgery
Patients are referred to the hospital either electively by their family
doctor or come as cases of emergency.
3.3.2.1 Emergencies in Visceral Surgery
Emergencies in visceral surgery are mostly less spectacular than in trauma
surgery. Typical examples are GI perforation or bleeding (stomach, duodenum, colon), acute inflammation (appendicitis, cholecystitis, pancreas,
etc.), ischemia, or GI obstruction (ileus).
Emergency patients are physically examined by the surgeon on-call in
the emergency department (
Fig. 3.5). A complete history is taken and
laboratory examinations are performed. In addition, sonography is carried
out by the surgeon for screening. In cases of doubt, this examination is
followed by a CT-scan (
Fig. 3.6). In mild cases, the patient is referred to
the clinical unit for further surveillance and/or conservative treatment. In
a few cases, an immediate referral to the surgical OR is indicated.
Figure 3.5 (A) First physical examination, history; (B) flow sheet of emergency
surgical care. All from MITI.
Figure 3.6 Preoperative diagnostic workup: (A) peripheral or central venous line to
take blood samples and for intravenous infusion of fluids and drugs; (B) ultrasonography; (C) emergency CT-scan. All from MITI.
Principles of Gastrointestinal Surgery
53
In the next step, the patient enters the surgical floor if conservative
treatment is considered or to wait for the surgery.
In a few cases, the patient has to be brought immediately to the OR,
but the majority of patients go to the surgical floor first.
On the surgical floor, nurses and the doctoral team take over further
care (
Fig. 3.7). The patients are registered and a treatment plan is estab-
lished. As soon as it is adequate and required, the patient is transported
into the OR (
Fig. 3.8).
Depending upon the severity of the procedure, the intraoperative
course, and the general state of the patient, a postoperative stay in the
intensive care unit (ICU) may be required. In this department, intensive
care medicine is delivered to critically ill patients by specially trained physicians and nurses with a significantly higher staff-to-patient ratio than in
normal wards (
Fig. 3.9).
Figure 3.7 Impressions of a surgical floor: (A) the corridor which gives access to the
patients rooms; (B) nurses point; (C) the doctor’s room. All from MITI.
Figure 3.8 Surgical OR: (A) contemporary surgical OR for abdominal/visceral surgery;
(B) typical scenario of a laparoscopic operation. Each surgical hospital should provide
at least one OR around the clock (including the surgical and anesthesiological team
and the logistic staff) for emergency and urgent cases. From (A) Courtesy TRUMPF
Medical, Puchheim, Germany, (B) MITI.
54
Biomedical Engineering in Gastrointestinal Surgery
Figure 3.9 (A) ICU; (B) fully equipped ICU bed for monitoring and continuous treatment. Artificial ventilation, extracorporal membrane oxygenization, and extracorporal
circulation support are provided, as well as renal dialysis, etc. All from MITI.
In many countries, hospitals have, in addition, so-called intermediate
care units or high dependency units for patients who require special
observation and intensive nur sing not available on a normal floor but
whose state is not so critical as to justify a treatment on an ICU.
As soon as the patient’s state is stable again, he/she can be brought
back to the regular surgical unit. Oral feeding is started again. The
patients are mobilized. Wound dressings are renewed and drainages are
removed. Nutritional recommendations are given. If necessary, patients
also learn to handle artificial body openings (“stoma”) or to cope with
other changes to the previous normal conditions.
After recovery, he/she is dismissed into ambulatory care or specialized
facilities for after-treatment.
3.3.2.2 Elective Surgery
This is a surgical intervention which should be performed/is necessary
but not urgent. The patient and the caregiver can decide when the operation should be done. To some extent, the interval between decision
making and the surgery also depends on the type of the disease. In the
case of a malignancy, the surgical treatment should be performed earlier
than, e.g., in the case of gastroesophageal reflux disease.
Nowadays, all over the world it is striven for doing the necessary
examinations, etc. on an outpatient base to reduce costs. On his/her first
Principles of Gastrointestinal Surgery
Figure 3.10 (A) The first contact between the patient and his/her surgeon. Taking
the history, a comprehensive physical examination and a thorough analysis of preoperative findings are essential. The next step is to get informed consent after detailed
information of the patient. (B) Sample Patient Information/Informed Consent Form. All
from MITI.
55
appointment with the surgeon, the patient should be able to deliver the
comprehensive information (
Fig. 3.10).
As soon as the relevant problem of the patient is identified, a careful
medical history of the patient and in particular his/her specific complaints
are taken. In the next step, all relevant documentation of medical findings
which already have been elaborated previously are checked.
Additional tests and examinations—if required—are performed.
Finally, it is decided whether a surgical intervention is indicated (should
be done) or not. If a surgery is considered, the patient has to be informed
in detail about what has to be done to get his/her informed consent. It is
of utmost importance to document precisely and reliably the content and
extent of this oral communication, since it may, later on, play a decisive
role in medicolegal issues.
Finally, the date of the surgery is scheduled. The patient is instructed
where to go on the morning of the respective day (building, floor, ward).
On the scheduled day, the patient is received at his surgical floor
(
Fig. 3.11). It is checked again whether all documents are at hand, and a
room and a bed-place are allocated using the hospital information system
(HIS; see Chapter 12: Health Informatics/Health Information
Technology).
The surgical unit is—from now on—the temporary and provisional
home of the patient. From here, he/she will be brought to the OR, and
he/she will return here afterward, potentially after a shorter or longer
56
Biomedical Engineering in Gastrointestinal Surgery
Figure 3.11 (A) Reception on the ward; (B) after a personal introduction, the responsible nurse checks the documents and provides a bed-place using the HIS (see
Chapter 12: Health Informatics/Health Information Technology). All from MITI.
stopover at the ICU. At the end of the procedure, he/she is dismissed
into outpatient care.
A surgical floor is more than a specialized hotel (
Fig. 3.12). BME
plays an essential role to provide the specific requirements of modern
health care delivery. Highly sophisticated surveillance and alert systems,
multifunctional beds and devices, as well as a highly efficient administration are hidden behind a warm, convenient hotel-like environment which
should offer an atmosphere of well-being.
Patient care on the floor needs special sur veillance. Each patient
should be able to alarm the staff in case he/she requires help (
Fig. 3.13).
Accordingly, each hospital bed is equipped with a so-called “nurse call
button” which often offers additional functionalities.
Fig. 3.14 shows a typical scenario in a patient’s room in a surgical
floor.
3.3.2.3 Hospital Beds
In former times, hospital beds were more or less identical to those used in
daily life at home.
Today, modern hospital beds are complex multifunctional systems to
provide as much comfort as possible to the patient and to warrant safe,
effective health care delivery. Much has also been done to improve the
convenience to the medical staff (
Fig. 3.15).
A modern hospital bed has to be mobile. The wheels must be firmly
locked as long as the bed is placed in its designated position. For
Principles of Gastrointestinal Surgery
57
Figure 3.12 Floor plan of a modern surgical unit. The two-bed patient rooms are
opposite to the functional area including the nurses point and the floor office.
transportation of the patient (e.g., into the OR), the bed should be easily
movable. To enable single persons to move the bed, the pair of wheels of
one axis can be locked making it better steerable.
58
Biomedical Engineering in Gastrointestinal Surgery
Figure 3.13 (A) Typical “nurse call button”; (B) additional functionalities like TV
control and intercom function. All from MITI.
Figure 3.14 Patient room with three beds in a typical surgical unit: patients in
various states of convalescence or a few hours before surgery. From MITI.
Figure 3.15 Hospital bed: (A) fully equipped with bed gallow; (B, C) different positions of the surface. All from MITI.
Principles of Gastrointestinal Surgery
Figure 3.16 (A) Typical decubital ulcer; (B) antidecubitus mattress; (C) pneumohydraulic antidecubitus system. All from MITI.
59
The bed is commonly divided into three differently adjustable segments
to provide optimal conditions according to the different needs. These functions, including the raising and lowering of the entire bed, are carried out
electronically, initiated by the patient or the staff.
For the patient’s safety, most beds have side rails which can be activated by raising them, which can be done manually or electronically as
well. For facilitating the patient’s mobility, bed gallows can be helpful.
Critically ill patients are particularly prone to develop a decubitus.
This is a more or less deep ulceration of the parts of the body which are
in direct contact with the surface due to pressure and reduced blood perfusion (
systems (
Fig. 3.16A). Antidecubitus mattresses (Fig. 3.16B) and technical
Fig. 3.16C) are available.
Although modern hospital beds are highly effective, a lot of room is
left for further improvement. The bed could contribute to a better
surveillance of the patients. Bed exit alarms are already available on the
market. Other parameters such as humidity or body weight control would
be helpful as well. Physical activity, vital signs, and mental state could be
valuable too, just to name a few.