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Minimally Invasive Abdominal Surgery
I
II
Minimally Inv asive
Abdominal Surgery
Edited by
III
Professor Emeritus of Surgery Director, Surgical University Clinic Düsseldorf, Germany
Hans Wilhelm Schreiber, M.D.
Professor Emeritus of Surgery Director of General Surgery Surgical University Clinic Hamburg, Germany
1088 illustrations by F.v. Aspern, P. Haller, R. Henkel, and R. Lazarus
Werner Platzer, M.D.
Professor Emeritus of Anatomy Director, Institute of Anatomy University of Innsbruck Innsbruck, Austria
Felicien M. Steichen, M.D.
Professor of Surgery St. Agnes Hospital Institute for Minimally Invasive Surgery
White Plains, N.Y., USA
Thieme Stuttgart · New York 2001
IV
Library of Congress Cataloging-in-Publication Data
is available from the publisher
Important Note: Medicine is an ever-changing science under­going continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest as­sured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the
state of knowledge at the time of production of the book.
Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in re­spect of any dosage instructions and forms of application stated in the book. Every user is requested to examine carefully the manufacturer’s leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the con­traindications stated by the manufacturers differ from the state­ments made in the present book. Such examination is particu­larly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or
every form of application used is entirely at the user’s own risk and responsibility. The authors and publishers request
every user to report to the publishers any discrepancies or inac­curacies noticed.
The bulk of this book is an authorized translation of the German edition Minimal-invasive Chirurgie, Vol. 7/2 of Chirurgische Operationslehre, edited by K. Kremer, W. Lierse, W. Platzer, H.W.Schreiber, S. Weller, published and copyrighted 1995 by Georg Thieme Verlag, Stuttgart, Germany.
Translated by John Grossman, Berlin Cover drawing by Reinhold Henkel, Heidelberg
Any reference to or mention of manufacturers or specific brand names should not be interpreted as an endorsement or adver­tisement for any company or product. Some of the product names, patents, and registered designs re­ferred to in this book are in fact registered trademarks or pro­prietary names, even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain. This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation, without the pub­lisher’s consent, is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeograph­ing or duplication of any kind, translating, preparation of micro­films, and electronic data processing and storage.
© 2001 Georg Thieme Verlag, Rüdigerstraße 14, D-70469 Stuttgart, Germany Thieme New York, 333 Seventh Avenue, New York, NY 10001, USA
Typesetting by primustype R. Hurler GmbH, D-73274 Notzingen Printed in Italy by G. Canale & C., Turin
ISBN 3-13-108191-0 (GTV) ISBN 0-86577-639-3 (TNY) 12345

Preface

V
“Primum Non Nocere − First and Foremost Do No Harm”, has
been a basic guide for our diagnostic and therapeutic endeavors ever since Hippocrates (460−361 B.C.) expressed this principle
as a major aphorism in the care of the sick and injured. Taken to its rational conclusion in modern healthcare, this means that a seemingly injurious and “radical” operative action, when indi-
cated, causes less harm than medication-based, “conservative” inaction. For example, the truly “conservative” treatment of ruptured appendicitis, a decisive incision, excision of the of­fending organ, and “laudable” drainage of pus is superior to the “radical” use of pills, potions, and various warm or cold com­presses. However, this approach does entail a violation of ana-
tomical integrity with all the real and potential, short and long-
term morbidity associated with a surgical wound, often regard­less of the urgent or elective nature of the procedure, especially if it is established to cure infection or neoplasia.
Advances in the technology of endoscopy, the ability to transmit
and project anatomical and pathological findings onto a televi­sion monitor and the progressive mastery of operative skills
within a closed space, guided by a two- or three-dimensional image, have greatly reduced and in some instances eliminated
the handicap of a conventional incision. Local and systemic
wound morbidity, so aptly called “maladie de l’incision” by Ph.
Mouret, has been largely remedied by this minimal invasion of endocavitary, endoluminal, endovascular, and endoarticular spaces!
While the injury of surgical access has been greatly reduced, if not eliminated, the indications, strategy, technique, and goals of any given internal operative procedure feasible through a mini­mal approach have not changed in their essential features. This
Atlas of Minimally Invasive Surgery does provide a comprehen­sive and didactic guide to this new art and craft of operative surgery within the abdomen.
We wish to thank our contributing authors for their enthusi­asm, expertise, and prompt responses. Mr. Gert Krueger and Dr. Clifford Bergman of Georg Thieme Verlag have earned our grati­tude for their masterful design and layouts, as well as their patience with last-minute changes. Last but not least, the artists Franziska von Aspern, Peter Haller, Reinhold Henkel, and Robin Lazarus, deserve special recognition for the way they were able to transform their own operating-room sketches and those of neophyte medical illustrators into true works of surgical art.
White Plains, N.Y. October 2000
Felicien M. Steichen
VI

Contributors

G. Abtahi
Chir. Klinik Otto-von-Guericke Universität Leipzig, Germany
M. E., Arregui, M.D., F.A.C.S.
Attending Surgeon St. Vincent’s Hospital Indianapolis, IN USA
G. Berci, M.D. FACS, FRCS Ed.
Director Endoscopic Research Cedars Sinai Medical Center Dept. of Surgery Los Angeles, LA USA
M. Berry, M.D.
Attending Surgeon Miguel Claro Santiago, Chile
K. M. Bhuta, M.D.
Assistant Professor of Surgery New York Medical College Dept. of Surgery Valhalla, NY USA
M. Birth, M.D.
Klinik für Chirurgie/ Chir. Intensivstation Universitätsklinikum Lübeck, Germany
R. Bittner, M.D.
Professor Director Surg. Clinic Marienhospital Stuttgart, Germany
C. Bloechle, M.D.
Professor General Surgery Chir. Univ. Klinik Hamburg Hamburg, Germany
E. Bodner, M.D.
Professor Chairman II Surg. Univ. Clinic Innsbruck, Austria
F.J. Borao, M.D.
Inst. for Minimally Invasive Surgery St. Agnes Hospital White Plains, NY USA
H.-P. Bruch, M.D.
Professor Director Surg. Clinic Medizinische Universität zu Lübeck Lübeck, Germany
Michael Butters, M.D.
Professor Director Clinic for General and Visceral Surgery Krankenhaus Bietigheim-Bissingen Bietigheim-Bissingen, Germany
L. R. M. Del Guercio, M.D.
Professor and Chairman Dept. of Surgery New York Medical College Valhalla, NY USA
T.R. DeMeester, M.D.
Professor and Chairman Dept. of Surgery University of Southern California Medical Center Los Angeles, C.A. USA
F. Dubois, M.D.
President Académie Nationale de Chirurgie “Les Cordeliers” Paris, France
D. B. Earle, M.D.
Director, Division of Min. Inv. Surgery Baystate Medical Center Springfield, MA USA
R. Eichen, M.D.
Director Surg. Dept. Marienkrankenhaus Düren, Germany
A. Emmermann, M.D.
Israelitisches Krankenhaus Chirurgische Klinik Hamburg, Germany
A. Encke, M.D.
Professor Director Chir. Univ. Klinik Frankfurt, Germany
H. Feussner, M.D.
Surg. Clinic and Polyclinic Techn. Univ. Klinikum rechts der Isar Munich, Germany
Robert J. Fitzgibbons Jr., M.D., F.A.C.S.,
Professor of Surgery Omaha, Nebraska USA
M. E. Franklin Jr., M.D., F.A.C.S.,
Clinical Professor of Surgery Baptist Medical Center San Antonio, TX USA
K. H. Fuchs, M.D.
Professor Chir. Univ. Klinik Würzburg, Germany
L. A. Galibert, M.D.
Assistant Director St. Agnes Hospital Inst. for Min. Inv. Surgery White Plains, N.Y. USA
Ingo Gastinger, M.D.
Professor Schwarza, Germany
M. F. Gioscia, M.D.
Attending Surgeon St. Agnes Hospital Inst. for Min. Inv. Surgery White Plains, NY USA
F. Götz, M.D.
Professor Linnich, Germany
E. J. Hagopian
Dept. of Hepato-Biliary Surgery Hôpital Paul Brousse Paris, France
B. L. Herz, M.D.
Director of Surgery Sound Shore Medical Center of Westchester Dept. of Surgery New Rochelle, NY USA
M. A. Hopkins, M.D.
Assistant Professor of Surgery NYU Medical School New York, NY USA
T.P. Hüttl, M.D.
Chir. Univ. Klinik Munich, Germany
Contributors
VII
J. C. Iraci, M.D.
Attending Surgeon Lenox Hill Hospital New York, NY USA
Jakob R. Izbicki, M.D.
Professor General Surgery Chir. Universitätsklinik Hamburg, Germany
J. Jacimowicz, M.D., Ph.D. FRCS (Ed)
Department of Surgery Catharina Hospital Eindhoven, Netherlands
W. Jonat, M.D.
Professor and Director Universitäts-Frauenklinik Kiel Kiel, Germany
L. U. Jung, M.D.
Staten Island Medical Group Staten Island, NY USA
R. G. Karanfilian, M.D.
Attending Surgeon Sound Shore Medical Center of Westchester New Rochelle, NY USA
Namir Katkhouda, M.D.
Associate Professor of Surgery Div. of Min. Inv. Surgery School of Medicine University of Southern California USC Healthcare Consultation Center Los Angeles, CA USA
D. Kettler, M.D.
Professor Director Center for Anesthesiology Klinikum der Universität Göttingen Göttingen, Germany
Ch. Klaiber, M.D.
Director Surg. Spital Aarberg Aarberg, Switzerland
F. Köckerling, M.D.
Professor Director Surg. Clinic Krankenhaus Siloah Hannover, Germany
Ernst Kraas, M.D.
Professor Director Surg. Clinic Krankenhaus Mohabit Berlin, Germany
Bernhard J. Leibl, M.D.
Supervising Physician Surg. Clinic Marienhospital Stuttgart, Germany
E. Löhde, M.D.
Medical Director Meoclinic Minimally Invasive Surgery Berlin, Germany
J. M. Loubeau, M.D.
Associate Director of Surgery Lenox Hill Hospital New York, NY USA
Bruce V. MacFayden, Jr., M.D.
Dept. of Surgery Medical School Houston, TX USA
L. Maffucci, M.D.
Attending Surgeon Sound Shore Medical Center of Westchester New Rochelle, NY USA
V. A. Marrero, M.D.
Director Emeritus Department of Surgery St. Agnes Hospital White Plains, NY USA
C. Mann, M.D.
Carolina Physicians Greenville, NC USA
S. Alejandro Metzger, M.D.
Surg. Clinic Bürgerspital Solothurn, Switzerland
G. Meyer, M.D.
Chir. Univ. Klinic Munich, Germany
Vittorio Paolucci, M.D.
Professor Ospedale Regionale di Bolzano Divisione di Chirurgia II Bolzano, Italy
J. H. Peters, M.D.
Associate Professor of Surgery Dept. of Surgery, School of Medicine, Univ. of Southern California Los Angeles, CA USA
A. Pier, M.D.
Aachen, Germany
H. P. Rajdeo, M.D.
Assistant Professor of Surgery New York Medical College Valhalla, NY USA
M. Rangraj, M.D.
Chief, Division of Laparoscopic Surgery Sound Shore Medical Center of Westchester New Rochelle, NY USA
Raul J. Rosenthal, M.D.
Beth Israel Medical Center New York New York, NY USA
A. E. Roth, M.D.
Coordinator, Surgical Intensive Care St. Agnes Hospital White Plains, NY USA
K. Rückert, M.D.
Professor Director Surg. Clinic Nord Heidberg Hamburg, Germany
Th. Schiedeck, M.D.
Chir. Univ. Klinik Lübeck, Germany
Fr. W. Schildberg, M.D.
Professor Director Chir. Univ. Klinik Klinikum Großhadern Munich, Germany
E. Schippers, M.D
Professor Julius Spital Surg. Clinic General and Visceral Surgery Würzburg, Germany
C. A. Schneider, M.D.
Millburn Surgical Associates Millburn, NJ USA
K. Schönleben, M.D.
Professor Director Surg. Clinic Klinikum der Stadt Ludwigshafen Ludwigshafen, Germany
V. Schumpelick, M.D.
Professor Surg. Clinic and Polyclinic Univ. Klinikum Rheinisch-Westf. Techn. Hochschule Aachen Aachen, Germany
N. Soehendra, M.D.
Professor Director Clinic for Interdisciplinary Endoscopy Hamburg, Germany
U. Kunath, M.D.
Professor Surgery, Visceral Surgery Meoclinic Berlin, Germany
S. D. Potter, M.D.
Attending Surgeon Chilton Memorial Hospital Pompton Plains, NJ USA
E. B. Sottile, M.D.
Chief of General Surgery St. Agnes Hospital White Plains, NY USA
VIII
Contributors
T. Strate, M.D.
General Surgery Chir. Univ. Klinik Hamburg, Germany
G. Stringel, M.D.
Prof. of Surgery and Pediatrics New York Medical College Valhalla, NY USA
J. Teixeira, M.D.
Assistant Professor of Surgery New York Medical College Valhalla, NY USA
T.A. Thomas, M.D.B24
St. Agnes Hospital Inst. Min. Inv. Surgery White Plains, NY USA
Greg Van Stiegmann, M.D.
Prof. of Surgery Head Gastrointestinal, Tumor, and Endocrine Surgery University of Colorado, School of Medicine Denver, CO USA
H. Troidl, M.D.
Professor Director Surg. Clinic Köln-Merheim Cologne, Germany
H. F. Weiser, M.D.
Professor Diakoniekrankenhaus Rotenburg, Germany
R. Welter, M.D.
President AECV, Telemediana Luxembourg
S. D. Wexner, M.D., F.A.C.S., FA.S.C.R.S.
Director Dept. of Colorectal Surgery Cleveland Clinic Florida Fort Lauderdale USA
H. K. Yang, M.D.
Attending Surgeon Sound Shore Medical Center of Westchester New Rochelle, NY USA
C. Zornig, M.D.
Professor Director Surg. Clinic Israelitisches Krankenhaus Hamburg, Germany

Contents

1. Introduction
IX
1.1 Introduction
H. W. Schreiber, F. M. Steichen, E. Kraas
..................................... 1
2. Instruments and Methods
2.1 Three-Dimensional Optics in Clinical Practice
H. P. Bruch, T. H. K. Schiedeck
Clinical Application ............................... 6
Advantages and Disadvantages of 3-D Optical Sys-
tem.............................................. 6
2.2 Access and Exposure Techniques in Laparoscopic Surgery
L. Galibert, D. B. Earle, F.M. Steichen, G. Stringel
Summary ........................................ 9
.......................................... 9
...... 6
3. Laparoscopic Exploration, Diagnosis, and Staging
3.1 Visual Exploration of the Peritoneal Cavity
F. Götz, A. Pier
3.2 Diagnostic Laparoscopy for Trauma
H. Feussner
3.3 Laparoscopy for the Acute Abdomen
A. Metzger, K. Schönleben, Ch. Klaiber
3.4 Laparoscopy for Peritonitis
E. Löhde, E. Kraas
3.5 Comments on Laparoscopy for the Acute Abdomen
M.−E. Arregui
........................ 71
................ 61
......... 59
............... 68
.74
1.2 Minimally Invasive Surgery and Videolaparoscopic Surgery
H. W. Schreiber, F. M. Steichen, E. Kraas
Surgical Strategy ................................. 2
2.3 Joining and Sealing Tissues and Hollow Organs
D. B. Earle, L. A. Galibert, M.A.. Hopkins, F. M. Steichen
2.4 Gasless Laparoscopy
V. Paolucci, A. Encke
2.5 Anesthesia in Videolaparoscopic Surgery
D. Kettler
3.6 Diagnostic Laparoscopy for Tumors
H. Feussner
3.7 Staging of Neoplastic Disease with Ultrasound
M. Birth, H.−F. Weiser
3.8 Comments on Laparoscopic Ultrasonography for Staging
G. Van Stiegmann
3.9 Visual Exploration of the Pelvic Organs in Women
W. Jonat
.......................................... 2
..... 24
.............................. 51
........... 54
................ 75
..... 76
.......................................... 81
.82
4. Laparoscopic Cholecystectomy
4.1 Retrograde Cholecystectomy
F. Götz, A. Pier
4.2 Anterograde Cholecystectomy
F. Köckerling
...................... 85
..................... 117
5. Extrahepatic Bile Ducts: Diagnosis and Treatment
5.1 Ultrasonography of the Bile Ducts
M. Birth, H.−F. Weiser
Ultrasound Technique ............................ 129
5.2 Intraoperative Cholangiography
A. Pier, F. Götz
5.3 Comments on Intraopertive Cholangiography
B. V. MacFadyen, Jr.
................. 128
................... 133
...... 136
4.3 Alternate Method of Gallbladder Retrieval
F. Köckerling
4.4 Comments on Laparoscopic Cholecystectomy
G. Berci
5.4 Intraluminal Endoscopic Common Bile Duct Ex­ploration and Stone Retrieval
N. Soehendra
5.5 Common Bile Duct Exploration and Stone Removal
F. Götz, A. Pier
5.6 Laparoscopic Cholecystojejunostomy
L. U. Jung, M. S. Rangraj, C.A. Schneider, V. Maffucci
5.7 Comments on Laparoscopic Biliary Operations
..................... 137
......... 119
...... 126
.............. 148
. 142
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