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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_794_Библиотеки_им_академика_М_И_Перельмана.pdf
Section I • General Principles
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. Table5.1 Advantages and Disadvantages of Open and Closed-Suction Drains
Open drain Closed-suction drain
Advantages Generates pathways for bulky or viscous
Disadvantages Retrograde infection More vulnerable to obstruction by small
Closed Suction, Active Drains
Jackson-Pratt and Blake drains (.
for closed-suction systems. e Jackson-Pratt drain is oval-shaped with numerous orices and
intraluminal corrugations (inlay). e Blake drain has four channels along the sides with a solid
core center. In contrast to passive drains, active or suction drains maintain a negative pressure
gradient.
material
Lowers risk of mechanical erosion and
pressure necrosis
Fig. 5.2
) are commonly used radiopaque, silicone products
Lowers risk of retrograde infection
Accurate measurement of drainage
Facilitates radiographic studies Skin protection from irritating discharge
tissue fragments or ingrowth of surrounding tissue
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. Fig.5.2
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Chapter • Principles of Drainage
Sump Drains
Sump drains (.
inow “sump” lumen. e larger lumen is connected to a suction system and evacuates intraabdominal secretions. e smaller lumen serves as a venting tube, allowing air to enter the larger
lumen. is principle should help to break the vacuum in the large draining tube, maintaining
the drain in a productive patent state, without the surrounding tissues continually occluding the
drainage holes in the tube. Sump drains are oen used when large uid volumes or more particulate or thick collections have to be evacuated. e occlusion of the smaller venting tube by tissue
debris due to retrograde inow demonstrates a potential disadvantage of sump drains that occurs
especially when the suction is disconnected. Some sump drains have an additional third lumen
that allows the instillation of a lavage solution.
. Fig.5.3
Fig. 5.3
) are usually double-lumen tubes with a larger outow lumen and a smaller
Complete Drainage System
Collapsible devices connected to the drain tubes generate automatically a negative pressure gradient and keep the system “sealed”, which is believed to have resulted in a substantial decrease in
retrograde infections (
. Fig.5.4
. Fig. 5.4).
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Section I • General Principles
Prophylactic Drainage
Drain Orifice
e drain exit site through the skin is created by a penetrating cut with a scalpel (. Fig. 5.5a). A
Kelly clamp is inserted into the orice (
(.
Fig. 5.5c
). e underlying hand prevents bowel injury. is technique creates a tunnel that helps
to seal the abdominal cavity aer drain removal. Aer clamping the drain tip, the Kelly clamp and
drain are pulled through the abdominal wall from inside outwards (. Fig. 5.5d). Others prefer to
create the tunnel from inside out and pull the drain into the abdomen. Finally, the drain position
is secured by a non-reactive skin suture, and the drain tube is connected to the suction device.
. Fig. 5.5b) and penetrates the abdominal wall diagonally
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. Fig.5.5
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Chapter • Principles of Drainage
Prophylactic Drains
Prophylactic drainage aer upper abdominal operations is used to evacuate intra-abdominal uid
that may develop, such as ascites, blood, chyle, bile, pancreatic, or intestinal juice, that are either
harmful/toxic for adjacent tissue or might become infected. erefore, drains are placed in spaces
that tend to accumulate uid, such as the subhepatic (1), right subphrenic (2), le subphrenic (3),
and parapancreatic (4) spaces (. Fig. 5.6).
. Fig.5.6
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Section I • General Principles
Perianastomotic Drains
Another proposed function of prophylactic drainage is the early detection of anastomotic leakage. If drains are to be used near a high-risk anastomosis, they should not be placed in direct
contact with the anastomosis, but, rather, with a safety margin in between to prevent drain-related
erosions. is principle is illustrated for a biliodigestive anastomosis, where the drain is placed
posterior to the anastomosis (
Although routine use of prophylactic drainage was oen considered necessary to prevent
complications, there is growing evidence that this practice may be associated with adverse eects.
Retrograde drain infections or drain-related complications are known adverse eects. Several
randomized, controlled trials are available investigating the routine use of prophylactic drainage
for selected procedures (
. Fig. 5.7).
. Table 5.2).
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. Fig.5.7
. Table5.2 Evidence-based Recommendations for Prophylactic Drainage Practice
Gastrointestinal surgery Procedures Evidence-based
Hepato-pancreatico-biliary Hepatic resection without
biliodigestive anastomosis
Cholecystectomy (open,
laparoscopic)
Pancreatic resection Controversial
Biliodigestive anastomosis NA
Upper GI tract Esophageal resections Intrathoracic drain for any
Total gastrectomy Controversial
Distal gastrectomy No drain
Roux-en-Y gastric bypass No drain
Duodenotomy with omental No drain
patch for duodenal perforation
recommendation
No drain
a
No drain
b
approach
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NA, not assessed
a
Only one randomized controlled trial in pancreatic cancer
b
Controversial even in centers where a prospective randomized trial suggested no benet
Chapter • Principles of Drainage
Therapeutic Drainage
Predisposed Spaces for Collections
Infected collections, such as abscesses or infected bilomas, are known complications aer upper
abdominal surgery and require drainage by operative or radiologically guided drain placement.
e right subphrenic space (1), le subphrenic space (2), Morison’s pouch (3), le subhepatic space
(4), and omental sac (5) are anatomic spaces that predispose to abscess development (. Fig. 5.8).
. Fig.5.8
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Section I • General Principles
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Catheters
e majority of postoperative collections in the upper abdomen are manageable by means of
percutaneous drainage by interventional radiologic techniques using standard aseptic technique
and local anesthesia. ereby, collections are drained percutaneously under ultrasonographic or
CT guidance using the Seldinger or trocar techniques. is gure illustrates a typical percutaneous
drainage catheter, the MAC-LOC (. Fig. 5.9a) that can be inserted by the introduction cannula
(
. Fig. 5.9b) or the trocar stylet (. Fig. 5.9c). e catheter has large, oval side ports to increase
the drainage capability, as well as a radiopaque band that identies the proximal area of the loop.
is type of “self-locking” loop catheter has “memory” to prevent later displacement, i. e., the loop
at the end can be straightened during insertion by introducing a stylet intraluminally. Aer the
catheter is positioned in place, the stylet is removed, and the loop reforms.
Some uid collections may require surgical drainage with repeated abdominal lavage and
second-look procedures (. Table 5.3).
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. Fig.5.9
. Table5.3 Criteria for Percutaneous and Surgical Drainage of Infected Collections
Percutaneous drainage Surgical drainage
Unilocular collection/abscess Multilocular collections/abscesses
Low viscosity of drain uid Multiple, non-communicating collections
Drain route not traversing intra-abdominal organs
or thorax
Tricks of the Senior Surgeon
Whenever indicated, always use closed drain systems and keep drains as short as possible to
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minimize the risk of retrograde infections.
Place drains near but never in direct contact to the anastomotic sutures to prevent drain-
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induced erosions or drain-induced anastomotic leaks.
When drains are not productive, do not rely on them! Drains could be occluded or obstructed
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by tissue despite an adjacent uid collection.
Try to position intraperitoneal drains such that the drain does not rub against or lie in direct
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contact with blood vessels or hollow organs in an attempt to prevent drain erosions.
These drains often can be manipulated and positioned better under uoroscopic guidance
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by interventional radiologists.
Drains may not eectively evacuate bleeding, especially when there are thick or older blood
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clots.
High viscosity of drain uid Percutaneous drain route
traversing intra-abdominal organs or thorax
Surgical Energy Devices or Devices for Hemostasis
Lukasz Filip Grochola, René Vonlanthen
Surgical Devices: Hemostasis, Sealing, and Dissection
Surgical energy devices that provide adequate hemostasis and allow accurate dissection of tissue
are essential during surgical procedures. Unreliable tools can lead to bleeding, cause injury to
adjacent organs, and jeopardize visualization. Modern energy devices have seen a rapid development in the past few years, leading to a striking improvement in both the control of hemostasis
and the precision of tissue dissection, therefore minimizing operation time, collateral damage to
surrounding tissue, and blood loss, and resulting in strikingly improved outcomes in both laparoscopic and open surgical procedures.
Requirements for surgical energy devices
In general, an energy surgical device used for control of hemostasis, sealing, and tissue dissection
should fulll the following requirements in order to enable safe and ecient surgery:
Provide reliable hemostasis
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Minimize collateral damage to surrounding tissue
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Permit fast dissection of tissue to minimize operation time
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Provide exibility in usage allowing unrestricted access to the operating eld
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Be easy to handle by trained sta
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Be cost-eective
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ere are ve types of widely used general surgical devices:
1. Basic energy-based devices: Instruments that utilize high-frequency monopolar or bipolar
electric current to cut or coagulate biologic tissue. ey lack highly sophisticated additional
technical features designed to improve the control of dissection and hemostasis.
2. Advanced energy-based devices: Tools that utilize bipolar or ultrasonic energy combined with
sophisticated features, such as tissue sealing mechanisms, temperature feedback control, and
other features designed to control lateral thermal spread for simultaneous tissue dissection
and hemostasis control.
3. Argon plasma coagulator (APC): A noncontact monopolar electrocoagulation device designed
to deliver a high-frequency current through a jet of ionized argon gas for the purpose of hemostasis control.
4. Topical hemostatic/sealant devices: Assist in the control of diuse oozing and minor bleeding.
Provide hemostasis by contact activation of coagulation or induction of the last steps of the
coagulation cascade, mechanical tamponade, or synthetic sealing.
5. Clips: Provide fast and reliable vessel and tissue sealing by mechanical compression.
Overview of devices
Basic energy-based devices
Monopolar electrosurgery
Monopolar electrosurgery devices revolutionized surgery aer their development in the 1920s
and are the mainstay of surgical dissection techniques and control of hemostasis. ey generate a
high-frequency (HF) electrical current, which ows from the active electrode in the hand-piece
P.-A. Clavien, M. G. Sarr, Y. Fong, M. Miyazaki (Eds.), Atlas of Upper Gastrointestinal and Hepato-Pancreato-Biliary Surger y,
DOI 10.1007/978-3-662-46546-2_6, © Springer-Verlag Berlin Heidelberg 2016
Section I • General Principles
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to the target tissue and subsequently through the patient to the passive electrode, grounding pad
(
. Fig. 6.1, top; . Tab. 6.1). is ow heats the tissue and causes a small area of tissue to vaporize
through rapid tissue heating to temperatures reaching 400 °C (CUT mode) or coagulate through
a slower heating process to temperatures approximating 100 °C (COAG mode). ose two modes
are generated by distinct types of electrical current, which dier with regard to the wave form,
frequency, and voltage. Monopolar current can be applied to the target tissue using a wide variety
of surgical tips attached to a pencil-shaped hand-piece (
include the blade, eective in both the cutting and the coagulation of tissue; the Colorado needle
(an ultrasharp tip), used for precise tissue dissection; the ball electrode for coagulation of a larger
tissue area; and the monopolar forceps. In addition, the surgeon can choose dierent congurations of electrosurgical pencils, such as the rocker switch and push button congurations, as well
as foot control pencils. Although monopolar electrosurgery is highly useful and eective, the
surgeon should be aware of its potential safety hazards, such as unintended burns to the patient,
malfunction of implanted electronic devices (e. g., pacemakers, cardioversion devices, sacral/spinal
cord stimulators) or superheating of prosthetic conductive joints.
. Fig. 6.1, bottom, le to right). Such tips
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. Fig.6.1
Bipolar electrosurgery
Bipolar electrosurgery devices utilize an active and a return electrode, which are part of a single
instrument, most oen a surgical forceps (.
tool and only through the targeted tissue. is feature reduces lateral thermal spread and creates
less smoke compared with monopolar equipment. However, this technology leads to less penetration of current density, which can be a disadvantage for hemostasis in certain areas. e lateral
thermal spread as well as the sticking of tissue debris can be further decreased by a bipolar forceps,
which incorporates a water irrigation system that causes a cooling of the forceps tip as well as of
the targeted tissue. is feature, as described in more details in
useful in hemostasis control and dissection of liver parenchyma.
Fig. 6.2; . Tab. 6.1
). Current ows from one tip of the
▶ Chap. 3, makes it particularly
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. Fig.6.2
Chapter • Surgical Energy Devices or Devices for Hemostasis
Combined: ultrasonic,
pressure, bipolar
Pressure, bipolar,
integrated blade
Freq: 47 kHz Power: n.a.
Fastest dissection in class,
highest burst pressure,
relatively high prospen-
sity for collateral tissue
damage
Temperature is controlled
at tissue interface, low
lateral thermal spread;
optionally available with
additional monopolar tip
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integrated blade
Maxim. Power: 135 W Maxim. Power: 150 W Amp: 50–80 µm
Freq: 55 kHz
Maxim. Power 180 W Amp: 50–100 µm
Temperature is controlled
at tissue interface. Oset
electrode further reduces
lateral thermal spread
Fast dissection, high pros-
pensity for collateral tissue
damage
Cost-eective device,
optionally available with
integrated water irrigation
to cool down tip and
reduce lateral thermal
spread
. Tab.6.1
Yes Ye s Yes Ye s Ye s Yes
Yes Ye s Yes Ye s Ye s Yes
Device Monopolar pencil Bipolar forceps Harmonic ACE Enseal LigaSure Thunderbeat
Principle Monopolar Bipolar Ultrasonic Pressure, bipolar,
Sealing function Ye s Yes Yes Yes Ye s Yes
Transecting function Ye s Yes Ye s Yes Ye s Yes
Haemostasis
(w/o cutting)
Open + laprascopic
surgery
n.a. n.a. 450 mmHg 720 mmHg 615 mmHg 730 mmHg
(CUT) 200 W (COAG)
Burst pressure
Technical specications Maxim. Power: 300 W
(5–7 mm vessels)*
Lateral thermal spread ++++ ++ +++ + ++ +++
2–3 mm 2–3 mm 5 mm 7 mm 7 mm 7 mm
Maximum size
of vessel*
highest propensity for col-
lateral tissue damage
Tissue compression n.a. Not uniform Not uniform Uniform Not uniform Uniform
Comment Cost-eective device,
* approximate values