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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_794_Библиотеки_им_академика_М_И_Перельмана.pdf
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Section I • General Principles
Advanced energy-based devices
Advanced bipolar devices
Advanced bipolar devices, such as Enseal (.
introduced in 1998, use pulsed bipolar energy and a feedback control of the energy output during
tissue coagulation. us, heat production is low compared with that of basic and other advanced
electric-based surgical devices, minimizing tissue sticking, smoke, and lateral thermal spread.
Enseal (Ethicon) utilizes a positive temperature coecient (PTC) polymer compound within
the jaw to modulate energy ow (.
ter-sized conductive particles organized in chains, which polymerize at temperatures approximating 100 °C, allowing energy ow through this bipolar device. Once the tissue temperature reaches
100 °C during the sealing process, the particles depolymerize owing to their physical properties and thus disrupt the energy ow. Aer the sealing step, an integrated cutting blade divides
mechanically the tissue (
designs of advanced bipolar devices contain energy ow within the jaw and decrease the lateral
thermal spread and the propensity for collateral or proximity thermal damage.
Advanced bipolar devices simultaneously seal and transect relatively thick vessels up to 7 mm
and large tissue bundles. Seal strengths are comparable with techniques of mechanical ligation,
such as ligatures and clips and are greater than other energy-based techniques such as standard
bipolar or ultrasonic coagulation.
. Fig. 6.3d). In addition to the low sealing temperatures, the electrode
Fig. 6.3c
Fig. 6.3; . Tab. 6.1
). is compound contains a large number of nanome-
) and LigaSure (Covidien), rst
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. Fig.6.3
Ultrasonic dissection systems
Ultrasonic dissection systems that cut and coagulate tissues were introduced in the early 1990s
and have been applied with great success in hepato-pancreato-biliary (HPB) and upper gastrointestinal surgery (see also
(.
Fig. 6.4; . Tab. 6.1
mately 55 kHz at the functional tip of the device over a 50- to 100-μm arc through piezoelectric
transducers that convert electrical into mechanical energy. is energy results from the ultrasonic
frequency shearing of the bottom against the upper tip of the functional end and creates frictional
heating as well as cell disruption during tissue compression between the blades (. Fig. 6.4c). is
process leads to the denaturation of proteins, such as collagen in the walls of hollow structures
(e. g., vessels), which in turn results in reliable sealing and cutting of the lumen of vessels up to
5 mm in diameter. Depending on the setting, this Harmonic device can increase the longitudinal
movement of the blades to deliver faster cutting and less hemostasis or decrease the longitudinal
movement and provide slower cutting but more hemostasis. Ultrasonic devices carry advantages
over high-frequency electrosurgery in that they transect tissue faster and do not generate smoke.
▶ Chap. 3). e most widely used systems, such as the Harmonic scalpel
), generate a high vibration frequency in the ultrasonic range of approxi-
Chapter • Surgical Energy Devices or Devices for Hemostasis
However, they lead to higher maximum temperatures of up to 200 °C at the tips and, therefore,
may disperse substantially greater amounts of energy to surrounding tissue during activation.
. Fig.6.4
Integrated bipolar and ultrasonic devices
Integrated bipolar and ultrasonic devices deliver the benets of both advanced bipolar and ultrasonic energy in a single tool. is integration of energy modalities combines the advantages
of safe hemostasis from advanced bipolar energy with the speed of ultrasonic dissection. In the
underbeat device (Olympus) (.
Fig. 6.5; . Tab. 6.1
), bipolar heat energy is applied laterally
while additional sealing and cutting is achieved by ultrasonic energy in the central part of the
device (.
Fig. 6.5c
). e energy device can achieve high burst pressures even in large vessels while
having the fastest cutting speed of all commonly used advanced energy-based devices. However,
similar to other ultrasonic devices, heat production and the dispersal of greater amounts of energy to surrounding tissue can lead to lateral thermal damage and potential injury to adjacent
organs.
a
b
bipolar electrodes
. Fig.6.5
Ultrasonic pad
Ultrasonic probe
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bc
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Section I • General Principles
Argon plasma coagulation (APC)
APC (ConMed) has been applied during surgical procedures since the 1970s and is a noncontact electrocoagulation device that delivers high-frequency monopolar current through a column of ionized argon gas to achieve hemostasis control (.
channel of gas from the probe electrode to the targeted tissue to cause coagulation. e thermal
coagulation of tissue results in a thin and supercial, electrically insulated zone of desiccation,
which produces an increased electrical resistance in the targeted area, prompting the current
to move to another point on the tissue surface where resistance is lower, which in turn limits
the depth of coagulation to only a few millimeters. Coagulation depth is dependent on the
generator power setting, ow rate of the argon gas, duration of application, and distance of the
probe tip to the target tissue. APC can be used in both open and laparoscopic surgery as well as
during endoscopic procedures. Potential complications caused by the use of APC include those
found with basic monopolar devices, such as unintended tissue damage due to factors such as
insulation failure as well as argon gas embolism, which is a very rare but potentially serious
complication.
Fig. 6.6
). Electrons ow through this
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HF Electrode
Argon (Ar)
Argon
Plasma
Beam
Tissue
HF
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. Fig.6.6
Topical hemostatic and sealant devices
Topical hemostatic agents are designed to provide a useful adjunct to assist in the control of
diuse oozing blood and minor bleeding. ey can be divided into three categories: the active
and passive hemostatics as well as the synthetic sealants (
consists of agents that are activated by mixing two components, human puried brinogen and
thrombin, that are involved at the end of the coagulation cascade (e. g., Evicel Fibrin sealant
[Ethicon], Tisseel Fibrin sealant [Baxter Healthcare Corporation]). rombin is the already active form of prothrombin that catalyses the conversion of brinogen to brin, one of the last
steps of the coagulation cascade that induces a clot at the site of bleeding. e passive hemostatic
agents, such as collagens, cellulose, and gelatins, act through physically restricting the ow of
blood, as well as the promotion of platelet aggregation and contact activation of the coagulation
cascade. Devices such as Tachosil Absorbable Fibrin sealant (Baxter Healthcare Corporation),
which consists of a collagen sponge coated on one side with thrombin and brinogen, and Floseal
Hemostatic Matrix (Baxter Healthcare Corporation), which is composed of a gelatin matrix
. Tab. 6.2). In principle, the rst group
Chapter • Surgical Energy Devices or Devices for Hemostasis
. Tab.6.2
Device Evicel, Tissel Tachosil Floseal Coseal
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Principle Active: brinogen and
Open surgery Yes Yes Yes Yes
Laparascopic surgery No Yes Yes Yes
Preparation and application
Maximum bleeding
intensity
Comment No bovine components:
thrombin, transexamic acid
Reconstitute components
immediately before use,
spray on target tissue
Oozing Oozing Oozing to minor pulsatile Oozing to minor pulsatile
minimal risk for allergetic
reaction
Active and passive: collagen sponge coated on one
side with thrombin and
brinogen
Ready-to-use sponge Reconstitute components
Easy preparation Conforms well to irregular
Active and passive: gelatin
matrix and thrombin
immediately before use,
apply gel on target tissue
tissue surfaces; contains
bovine components
Synthetic sealant: polyethylene glycol polymers
Reconstitute components
immediately before use,
spray on target tissue
Fast and realiable
haemostasis; no bovine
components
and thrombin, incorporate both active and passive hemostatic components to improve bleeding
control. Lastly, the synthetic sealants (also known as adhesives) such as CoSeal Surgical sealant
(Baxter Healthcare Corporation) are low-viscosity liquids that do not have any intrinsic hemostatic activity but polymerize in a few seconds, forming a solid lm that connects adjacent tissue
sur
faces, making them fast and eective hemostatic agents.
Clip applicators
As a mainstay of both laparoscopic and open surgery, clip applicators combine fast and costeective vessel and tissue sealing even in areas that are dicult to reach using traditional wound
closure equipment. Clips create a seal by mechanical compression and pose little risk to surrounding tissues when applied accurately. In principle, three categories of clips are in wide use:
titanium, plastic, and absorbable. All can achieve reliable seals with high, supraphysiologic
bursting pressures comparable with those of advanced bipolar devices and standard surgical
techniques. However, they carry the risk of dislodgment with tissue manipulation, which is
greatest with the titanium clips (.
toothed grasping surface and locking device (. Fig. 6.7b). In addition, metallic clips carry the
disadvantage of interfering with CT and MRI as well as of being electroconductive. Conversely,
metallic clips are cheaper and narrower than other types of clips and thus easier to place in narrow sites. A further disadvantage of nonabsorbable clips is the reported, albeit rare, migration
of t
he clip, for example, into the common bile duct, causing its obstruction and the induction
of stone formation. e surgeon can choose dierent clip applicators, including single-re and
multi-re applicators, varying sizes, 360°-rotating devices or applicators with an angled head,
depending on the intended use.
Fig. 6.7a
) and minimized in plastic clips designed with a
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Section I • General Principles
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. Fig.6.7
Tricks of the Senior Surgeon
1. Surgical devices facilitate hemostasis, tissue sealing, and dissection. However, there is no
substitute for placing stitches, tying knots, and using standard tissue dissection techniques,
key skills that every surgeon must possess.
2. For optimal use, be familiar with several surgical devices and have a good knowledge of their
individual advantages, biophysics, ranges of eectiveness, and application methods. Familiarity with the products facilitates their optimal use.
3. Lower power settings and short application times of all electrosurgery instruments is advised
in order to prevent thermal injury to nearby anatomic structures.
4. Topical hemostatic agents are envisioned to provide a useful adjunct to assist in the control
of diuse oozing blood and minor bleeding but not to supplant ligation or surgical repair of
major vascular disruption.
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Introduction to Robotic Surgery
Justin Ady, Vincent P. Laudone
Introduction
e history of robotic surgery started in the 1980s with the PUMA560 robot. It was used in 1985
to increase the precision of neurosurgical biopsies. at same robot was then used later to perform
a transurethral resection of the prostate. is lead to the development of PROBOT, a robot designed specically for transurethral resection of the prostate. Around the same time another robot
called ROBODOC was designed to machine the femur with greater precision in hip replacement
surgery and eventually went on to become the rst surgical robot approved by the FDA.
A number of medical robots are available currently in the United States. ese medical robots
include the Mako robotic system, which is a single-purpose robot currently used for orthopedic
prosthetic implantation. ey also include the Pernt Maxio Robot, which is used for imageguided biopsy and ablation procedures coupled to a CT scanner.
In the 1980s, both NASA and the U.S. Army began work on telesurgical systems. is work
resulted in two commercially available systems, the da Vinci surgical system (Intuitive Surgical)
and ZEUS (Computer Motion). In 2003, the two companies owning these products merged and
ZEUS was phased out in favor of the da Vinci surgical system. e da Vinci surgical system is
a master-slave surgical robot with multiple arms that are operated remotely from a console by
a surgeon. It is the only robot approved currently by the U.S. FDA for so tissue procedures. In
that capacity, over 1million surgical procedures have been performed using this surgical robotic
system worldwide. In this chapter, we outline the principles of use of this robot. In subsequent
chapters, we present the common upper gastrointestinal surgical applications of this robot, including cholecystectomy, splenectomy, distal pancreatectomy, gastrectomy, and hepatectomy.
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_7, © Springer-Verlag Berlin Heidelberg 2016
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Section I • General Principles
Room Setup
e setup of the general operative suite for upper gastrointestinal surgery is shown in . Fig. 7.1.
With the recent introduction of the Xi model, the patient side cart of the robotic system can be
brought in toward the patient from any angle. e overhanging arm design allows for equal access
to all quadrants. In contrast, with the Si or older models, it is very important to orient properly
the patient side cart to the patient for each operation. With these models, redirecting the robotic
components requires undocking and moving the cart and oen times the patient as well. is can
be both dicult and time consuming. In general, cholecystectomy and right liver operations will
require docking the patient side cart from the patient’s right (
pancreatectomies, and le liver operations can be approached by docking directly overhead or
from the le (
. Fig. 7.2b).
. Fig. 7.2a). Gastrectomies, central
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. Fig.7.1
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Chapter • Introduction to Robotic Surgery
. Fig.7.2
Section I • General Principles
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e general principles of room setup are:
Once docked, access to the patient’s arms will be limited. us all intravenous and intra-
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arterial access lines need to be placed before positioning and docking.
ere needs to be a stopcock on the intravenous line close to the patient to allow adminis-
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tration of emergency medications and blood products without going through a long length
of intravenous tubing.
e tubing for ventilation needs to be long.
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Standard table-attached retractors cannot be placed, because they will be obstacles for dock-
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ing.
Patient Positioning
For most upper gastrointestinal operations, the patient will be positioned in a supine position.
For a splenectomy, the patient may be positioned in a right lateral decubitus position. For right
posterior liver operations, a le lateral decubitus position may be chosen (
Cart
. Fig. 7.3)
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. Fig.7.3
e general principles of positioning are:
Most cases will require the patient to be in a supine position in reverse Trendelenburg posi-
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tion.
A foot board is helpful for limiting the sliding of the patient during the surgery.
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Some surgeons prefer a split leg position, although that is more helpful for pelvis proce-
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dures.
Pad all pressure points.
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Need to commit to choice of degree of rotation and Trendelenburg, because the patient can-
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not be moved with the robot docked.
In some cases such as splenectomy, the patient will need to be in right lateral decubitus
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position, similar to the laparoscopic approach.
For a right posterior liver operations, a le lateral decubitus position is helpful.
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Set a time limit for the case: the longer the case, the more likely a positioning/pressure
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injury.
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Chapter • Introduction to Robotic Surgery
Port Site Placement
Port placements for individual operations are described in individual chapters. One option for
port placement for distal pancreatectomy is shown in .
ports can be used.
Fig. 7.4
as an example. ree types of
Tower
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2
(A2)
. Fig.7.4
Dedicated robotic ports. ese are generally 8 mm in diameter and have a marked isocenter
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to minimize trauma to the abdominal wall. ese come in short and long (bariatric) lengths.
Standard laparoscopic ports.
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A gel port can also be used. is port can be used for extraction of large specimens and
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for palpation of intra-abdominal organs. e gel port will also allow rapid access for those
operations in which life-threatening hemorrhage is a possible complication. Laparoscopic
and robotic ports can be placed through the gel port.
e general principles of port placement are similar to laparoscopic port placement, with some
exceptions listed below:
Ports should be and could be further from the intended surgical eld than in laparoscopic
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surgery.
A 7-mm robotic port can be placed within a 12-mm laparoscopic port for use. is “port-
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in-port” conguration allows the exibility of using this port as a backup camera port, a
robotic port, and an assistant port.
An assistant port should be 12 mm if it is anticipated that staplers will be needed.
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5- and 8-mm port sites do not generally need to be closed.
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e patient side cart (tower), target organ, and camera port (black) should be roughly in
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line with each other.
Working ports (red) and assistant ports (white, blue) are placed around the target or set in a
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fashion so as to not conict in position.
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(A1)
Instrumentation
e wide range of instrumentation used for robotic surgery falls into four categories:
a) Articulated instruments designed specically for robotic surgery:
Graspers including ProGrasp, Cardiere, DeBakey, Tenaculum
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Forceps including right-angle, Maryland, fenestrated bipolar
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Dissectors including cautery hook, spatula
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Scissors
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Needle drivers
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