Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1260_Библиотеки_им_академика_М_И_Перельмана
.pdf
Operating room set-up and equipment for laparoscopic hepatopancreatobiliary surgery 29
interfaces of laparoscopic imaging and longer instruments
makes the relationship between surgeon and equipment
an important factor in the surgeon’s operative performance. Moreover, the “remoteness” of laparoscopic surgery
is also an important factor in the surgeon’s mental and
physical well-being through the challenges related to
ergonomics and 2D imagery. Optimization of this surgeon–equipment interface depends on multiple factors,
including OR set-up, patient positioning, type of procedure performed, number of available monitors, and ability
to reposition monitors. The optimal OR set-up adjusts for
challenges specific to laparoscopic HPB surgery, such as
monitor positioning above the patient for inline working
during laparoscopic liver surgery, and picture-in-picture
mode for intraoperative laparoscopic ultrasound. The ultimate goal for advanced laparoscopic HPB surgery is the
creation of an optimal OR environment that enhances
effectiveness and efficacy in the interaction between team
members, equipment, and instruments while ergonomics
as well as patient and team safety are ensured.
3.2.1 Optimal equipment positioning in
the operating room
3.2.1.1 Monitor positioning
One of the key pi eces of equipment for the accurate and
effective completion of laparoscopic surgery is the monitor or bank of monitors that provide the visual field.
Often, the monitor is positioned outside the sterile
operating field, which may force the surgeon to work
in one di rec tion while viewing in another. Major deviations of working direction (hand–target axis) and view
direction (eye–monitor axis) can disrupt proper spatial
cognition and delicate control of instruments (Figure 3.1). In addition, such a suboptimal eye–hand–
target–monitor axis imposes an uncomfortable and
unnatural position of neck and spine, which impacts
negatively on ergonomics and ultimately on surgical
performance. Suboptimal ergonomics can lead to injuries and physical discomfort of neck, shoulders, and
upper extremities. Monitor position above eye level can
be particularly harmful. It may result in discomfort and
fatigue of the lower back, neck, and shoulders, as well
as extensive extraocular and ciliary muscle activity,
causing eyestrain. Additionally, a monitor distance
that is too close can cause excessive accommodation
of eyes and convergent gaze by the extraocular musculature. A distance too far may result in staring and
loss of resolution.
Figure 3.1 The angle between working direction (hand–target
axis) and direction of view (eye–monitor axis) should be less
than 15°.
The optimal angle between eye–monitor and hand–tar-
get axes for comfort, ergonomic safety, optimized procedural precision, and reduced operative time is less than 15°.
Ideally, multiple monitors should be set in front of each
surgeoninlinewiththehand–target axis and adjusted
before, during, and after the procedure [1]. The optimal
height of the monitor is just below eye level to allow a
moderately declined viewing angle (preferably a downward
direction of 15°) [1]. The optimal distance to the monitor
depends on screen size and image resolution and has been
reported to be between 80 cm and 120 cm for a 19-inch CRT
monitor [1] (Figure 3.2, left). With newer and larger highdefinition monitors, an optimal viewing distance would be
further away. In the future, greater availability of threedimensional (3D) cameras/monitors will facilitate the 3D
motor movement required in laparoscopic surgery. Nevertheless, even with these advanced devices that reduce the
fatigue from 2D image to 3D motor movement conversion,
aspects of ergonomics and avoidance of motion sickness to
optimize surgical performances apply.
3.2.1.2 Laparoscopic equipment
The equipment, cables, and tubing running from the
equipment to the patient should not disrupt the eye–
monitor or hand–target axis of the operating surgeon or
block the view of the operating team members.
3.2.1.3 Dedicated minimally invasive surgery suite
Much of the laparoscopic equipment such as monitors,
insufflators, light sources, video equipment, and
30 Chapter 3
Figure 3.2 An IMM integrated operating room (ENDOALPHA OR, Olympus, Tokyo, Japan) has multiple ceiling-suspended monitors
(left) and a centralized control system for equipment such as imaging system, insufflator, room light, and electrosurgery (right).
A ceiling-suspended monitor is set in front of the operating surgeon in line with the hand–target axis and just below the eye height.
ENDOBOY holds a laparoscopic retractor from the right side of the patient (left).
electrosurgery devices can be grouped together on one or
multiple trolleys. These heavy trolleys take up space and
clutter the floor with cables and tubing. This may pose a
possible threat to the safety of patients and OR personnel.
The room should be large enough to hold all the necessary
equipment and to permit unencumbered transfer of the
OR staff around tubing and equipment.
A number of ergonomic factors are different from open
surgery before, during, and after laparoscopic HPB surgery. The establishment of an optimal OR environment
for superior operating team performance depends on the
needed and available equipment, especially the degree of
freedom of the monitors. Unlike a monitor fixed on top of
a trolley, a ceiling-suspended monitor can be positioned
easily and independently from the rest of the laparoscopic
equipment. The suspension system allows intraoperative
repositioning, screen inclination for each monitor, and
placement above the patient to optimize the important
eye–hand–target–monitor axis for surgeon and assistant
(see Figure 3.2, left).
The modern minimally invasive OR is equipped with
centralized and simplified interfaces (see Figure 3.2, right)
and permanently installed laparoscopic equipment that is
operational on demand. The equipment, together with
multiple high-definition flat-screen monitors, is attached
to a ceiling-mounted suspension system to facilitate versatile positioning. Various cables (such as electric power
supply and video transmission cables) are kept off the
floor and within easy reach of the surgeon or OR staff.
Efficient design of such an OR improves overall operational efficiency and safety.
3.2.2 Patient positioning
Proper, stable positioning of the patient is a vital step in
successful laparoscopic HPB surgery and critical for target
organ exposure and optimal trocar placement. Arm and
leg position should not disrupt the movement of the
laparoscope or instruments, or the view of each surgeon
on the monitors, and limbs should be positioned to
prevent pressure injuries, such as ulnar or peroneal
neuropathy. All bony prominences are given extra padding, and all patients should have cushioned arm covers
as well as compression boots on their lower extremities to
prevent formation of deep venous thrombus. A safety trap
is placed on the chest to prevent the patient from sliding as
the surgical bed tilts.
In laparoscopic HPB surgery, patients are generally
placed in the low lithotomy or supine position with the
legs abducted on straight leg boards (so-called French
position) (Figure 3.3) and with both arms tucked alongside
the body. Tucking the armsmight minimize brachialplexus
stretch and subsequent injury in case the patient slides in
reversed Trendelenburg position. The operating surgeon
stands between the legs, allowing for a straight eye–hand–
target–monitor axis. Lumbar padding is added behind the
right back when performing right hepatectomy, and
patients are set in the left lateral position (Figure 3.4)
when accessing the posterosuperior segments of the liver.
Operating room set-up and equipment for laparoscopic hepatopancreatobiliary surgery 31
Figure 3.3 Low lithotomy position is often used in laparoscopic
HPB surgery with both arms tucked alongside the body.
3.2.3 Staff positioning and fixed
mounting devices
3.2.3.1 Operating surgeon
The operating surgeon should be positioned to work
directly in front of the target organ, having the most
direct access. The monitor for the operating surgeon is
positioned to optimize the eye–hand–target–monitor
axis. In many laparoscopic HPB procedures, the operating
surgeon stands between the patient’s legs, with some
exceptions (e.g. transdiaphragmatic liver surgery).
3.2.3.2 Assisting surgeon and scrub nurse
The position of the assisting surgeons and scrub nurses
should not disrupt the eye–hand– target–monitor axis of
the operating surgeon. In order to avoid motion sickness, reduce fatigue, and optimize visualization, the
assistant needs to pr ovide a pr ecise and s table laparoscopic image. To achieve this, the assistant surgeon
who han dles the laparoscope must be positioned in a
comfortable and neutral posture to provide a stable
image over a prolonged period of time. Constant small
movements of the image lead to surgeon fatigue and
motion sickness.
3.2.4 Laparoscope mounting devices
Several surgical robots ca pable of holding the laparoscope and altering its position in response to a surgeon’s
verbal command are available [2] ( Figure 3.5, left).
Such robotic devices consist of two mai n components:
the voice- or motion-controlled computer interf ace and
Figure 3.4 Patients are set in the left lateral position when
accessing the posterosuperior segments of the liver with/
without placing transdiaphragmatic trocars.
Figure 3.5 The Vision Kontrol endoscopY (VIKY) system (Endocontrol, Grenoble, France) consists of a display console, an
autoclavable robotic camera holder, and a foot pedal (left). A robotic holder places the laparoscope just in front of the operating
surgeon and between both instruments in the surgeon’s hands (right).
the motori zed laparoscopic mounting arm. Some
devices can store sev eral presets of laparoscope position, allowing the surgeon to rapidly return the image
32 Chapter 3
Figure 3.6 The angle between the laparoscope–target axis and
eye–monitor/hand–target axes should be minimized to avoid
losing spatial orientation.
to a previous position. This can be particularly helpful
during laparoscopic suturing: a first position i s a clo seup image, preferred when driving the needle through
tissue, and a second position is a zoom-out when the
knot is fashioned.
Ideally, a trocar for the laparoscope is placed
between two working trocars of the operating surgeon. This set-up overlays the laparoscope–target axis
to the eye–hand– target–monitor axes of the operating
surgeon and facilitates optimal efficiency of t he procedure. Extensive deviation of the laparoscope–target
axis from the eye– hand–target– monitor axes can negatively impact the surgeon’s spatial cognition – the socalled mirror image (see Figure 3.5, right; Figure 3.6).
A robotic camera holder can decrease interference
between the operating surgeon’s hands/instruments
as well as the assistant holding the camera, and it
provides a surgeon with a controlled and stationary
laparoscopic image.
3.2.5 Autostatic instrument stabilizer
Prolonged laparoscopic retraction in the same position
(e.g. retraction of the liver during portal dissection) can
effectively be accomplished by an autostatic instrument
stabilizer such as ENDOBOY (ASFS Medic’s, Niort,
France) (see Figure 3.2, left), which has benefits similar
to the robotic camera holder. Stationary holding of a
laparoscopic retractor is accomplished without interfering
with the operating surgeon’s movements. The autostatic retractor position can be manually altered with
ease during the procedure, while being strong enough
to retract large or heavy organs such as the liver over
a prolonged period of time without perforating the
liver capsule.
3.3 Imaging system
3.3.1 Standard laparoscope
Because the surgeon depends almost exclusively on the
visual information provided through the imaging system,
a high-quality image is vital in performing laparoscopic
HPB procedures safely.
The laparoscope transmits light fr om an external light
source through a bundle of glass fibers, illuminates the
abdominal cavity, gathers images, and transmits them
through a collection of rod lenses to digital imaging chips
in a camera head. A 10 mm laparoscope is commonly
used for its greater image quality and wider field of view
compared with smaller caliber laparoscopes. Various
diameters of laparoscope are available, ranging from 3
to 12 mm. Rigid, angled (0–120°)orflexible tip laparo-
scopes are cho sen based on the type of procedure and
surgeon preference. The laparoscope lens is prone to
frequent fogging, especially early in the procedure before
the lens warms up. This can significantly im pede effective visualization. Warming the laparoscope using hot
water, creating friction with a towel, and using anti-fog
solutions or an electric warming device helps to reduce
lens fogging.
A high-intensity light source and light cable are
required for a sufficiently bright laparoscopic image. Light
is transmitted from the light source, which is generally
located off the operating field and reaches the scope
through a fiber-optic light cable. The number of light
fibers is a determinant factor for efficient light transmission. This means that broken fibers lead to light loss and
persistently dark images. In those cases the cable should
be replaced.
The video monitor receives electrical signals to synthesize optic images for the presentation of intra-abdominal
images to the surgeon and OR staff. For a detailed image,
the monitor should be high resolution at the same level as
the charge-coupling device (CCD) tips and high
Operating room set-up and equipment for laparoscopic hepatopancreatobiliary surgery 33
Figure 3.7 Laparoscopic and ultrasonographic images are
simultaneously visualized in a single monitor using the picturein-picture function.
frequency (at least 100 MHz) to decrease sparkling artifacts. At least two monitors are required: one for the
operating surgeon and the other for the assistant surgeon
(see Figure 3.5). Ceiling-suspended multiple flat monitors
are preferred to achieve the best monitor set-up and
positioning. Some newer displaying systems have a picture-in-picture function, which enables the display of
images from two different imaging devices at the same
time: this is crucial when performing laparoscopic ultrasonography as it allows surgeons to visualize the laparoscopic and ultrasonographic images simultaneously in a
single monitor (Figure 3.7). Through availability of the
two images in the eye–hand–target–monitor axis, manipulation of the ultrasonic probe can be accomplished while
analyzing the parenchymal transection plane and guiding
a radiofrequency ablation probe or a biopsy needle. Further, equipment to record the procedure is important for
transparency, furthering research on surgical technique
or for self-assessment.
Figure 3.8 The portable C-arm system is used for fluoroscopic
study in a variety of positions.
X-ray generator, image intensifier, viewing monitors, and
workstation for image manipulation, and it is equipped
with mechanisms to allow a variety of movements for
maximum positional flexibility (Figure 3.8).
Once choledocholithiasis is suspected, the common bile
duct is explored via transcystic or transcholedochal choledochoscopy. Common bile duct stones are extracted
using a Dormia basket or Fogarty catheter. Newer choledochoscopes are flexible and equipped with irrigation,
suction, and a working channel through which a catheter
can be passed (Figure 3.9). The choledochoscope can be
introduced through a 10 mm trocar placed under the right
3.3.2 Imaging for bile duct stone
Intraoperative cholangiography is performed to detect
bile duct stones and, in some centers, to decrease the
risk of bile duct injury. Air cholangiograms can also be
performed to detect possible biliary leakage after liver
resection. The gallbladder or the cystic duct is cannulated
to inject the radiographic contrast agent, and an image is
obtained using a portable X-ray imaging system, referred
to as a C-arm. The portable C-arm system encompasses an
Figure 3.9 The choledochoscope is used to explore the
common bile duct and extract bile duct stones.
34 Chapter 3
costal margin, and images are transmitted to a monitor
outside the surgical bed.
3.3.3 Special imaging devices
Laparoscopic ultrasound (Figure 3.10) is an essential device
for HPB surgery to help surgeons understand patients’
anatomy, detect additional or confirm known lesions,
and ensure vascular flow. The mechanics and techniques
for this device are discussed in detail in Chapter 15.
Indocyanine green (ICG) fluorescence technique offers
real-time navigation for the localization of intrahepatic
lesions, evaluation of the biliary tree, detection of biliary
leakage, and visualization of the demarcation following
portal pedicle occlusion (Figure 3.11). The technique
necessitates a near-infrared probe and camera for providing light excitation and capturing of a luminescence
signal. It has been used mainly in open surgery [3]. A
laparoscopic probe for the ICG fluorescence technique is
commercially available today and could become a vital
tool for laparoscopic HPB surgeons.
Imaging systems (specialized laparoscope, camera
head, and monitor) offering 3D images have been developed to overcome the difficulties of 2D images. Threedimensional images allow depth perception and facilitate
spatial navigation. The use of 3D imaging systems is not
widespread yet, owing to their cost, the need for additional 3D glasses, head-up displays, 3D screens, and also
because of so-called visually induced motion sickness
caused by conflicting visual and physical motion and/or
Figure 3.11 The transection border between segment V and VI
is demonstrated using the ICG fluorescence technique. In the
inset window, the ICG fluorescence image shows that the liver
surface of segment VI is positively stained with ICG while that
of segment V is negative for staining. This staining border is
being incised using ultrasonic shears.
binocular stereopsis to fuse monocular vision into a single
“normal” vision. Additionally, a significant proportion of
surgeons lack the ability to see in 3D with the equipment
available today. In these surgeons, motion sickness obviates the need for 3D cameras and displaying equipment.
Overall, however, 3D vision for advanced laparoscopic
HPB surgery has been shown to reduce both surgeon
Figure 3.10 Laparoscopic ultrasound is an essential device to help surgeons understand the patient’s anatomy, detect an intrahepatic
lesion, and confirm vascular flow.
Operating room set-up and equipment for laparoscopic hepatopancreatobiliary surgery 35
Figure 3.12 The operating surgeon refers to a total of four screens which display a virtual liver (in the leftmost screen), augmented
reality (in the second left), laparoscopic view (in the second right), and centralized control system (in the rightmost).
fatigue and operative time. It is likely to become the
standard display in the future.
Augmented reality technology has been developed
using various modalities such as ultrasound, computed
tomography, and magnetic resonance imaging and represents the next step towards more advanced surgical
navigation (Figure 3.12). To date, however, no prototypes have provided the quality required for complex
procedures such as laparoscopic liver and pancreatic
resections, and there are several challenges. These
include real-time deformation of reconstructed organ
images (especially the liver) and precise image overlay
of the laparoscopic image with high spatial resolution.
3.4 Abdominal entry and closure
A laparoscopic procedure begins with the establishment
of pneumoperitoneum followed by the placement of
several trocars through which the laparoscope and instruments are passed. Choice of the first trocar depends on the
technique used to access the peritoneum. The closed
technique by blind insertion of a Veress needle has
been widely used to create laparoscopic entry and
pneumoperitoneum but the risk of major organ injury,
including vascular injury, is well documented. An optically guided closed technique using a specialized trocar
with a transparent tip (Figure 3.13) is often preferable for
inserting the first trocar because of the increased safety
afforded by direct visualization and quick entry to the
abdominal cavity. Each layer of the abdominal wall can be
seen with a 0° laparoscope in the optic trocar as it is being
traversed. The open technique (Hasson method) is
another choice with the benefit of a low risk for major
complications but with the disadvantages of longer time
and difficulty in obese patients.
Disposable and reusable trocars (Figure 3.14) are
used today. Ten millimeter and 5 mm balloon-tipped
blunt trocars (Figure 3.15) prevent accidental cannula
withdrawal, which can be important especially when
trocars are inserted through the diaphragm for operating on the pos terosupe rio r liver. A trocar i s preferably
equipped with a separate insufflation route for clearing
intra-abdominal smoke and steam produced by electrosurgical devices. Newer insufflation devices recirculate
the gas insufflated into the abdomen to c lear it of
smoke, warm the gas, and provide a constant insuffl ation pressure.
36 Chapter 3
Figure 3.13 Before creating a laparoscopic entry with the optically guided closed technique, an optic trocar (right) is attached to the
tip of a 0° laparoscope (left).
A wound protector (Figure 3.16, left) is used to decrease
the risk of surgical site infection and obtain circumferential
retraction during procedures via mini-laparotomy. Wound
protectors combined with special covers or lids offer the
additional benefit of giving access to a surgeon’shand
or laparoscopic instruments while maintaining intraabdominal pressure (see Figure 3.16, left, upper insets,
and Figure 3.16, right). These devices enable a combination
of pure laparoscopic with mini-laparotomy procedure
(hybrid technique) or hand-assisted procedure. They may
also decrease the need for conversion to conventional open
procedure, which allows maintenance of the benefits of the
minimally invasive surgery. Even in patients with significant
adhesions or bleeding that is challenging to control purely
laparoscopically, hand access ports can facilitate completion
of the procedure.
After removal of a 10 mm or greater trocar, the fascial
defect should be closed with a suture to reduce the risk of
Figure 3.14 Reusable trocars in diameter of 5.5 mm (left) and
10.5 mm (right).
Figure 3.15 10 mm (Covidien, Dublin, Ireland) (upper) and
5 mm (Applied Medical, Rancho Santa Margarita, USA) (lower)
balloon-tipped blunt trocars used to prevent an accidental
cannula withdrawal.
Operating room set-up and equipment for laparoscopic hepatopancreatobiliary surgery 37
Figure 3.16 The use of a wound protector (left) decreases the risk of surgical site infection and provides circumferential retraction
during a mini-laparotomic procedure. Alexis wound protector/retractor (left, right upper inset), Gelpoint advanced access platform
(left, left upper inset), and Gelport laparoscopic system (right) are combined with the wound protector to provide single, triple or
multiple laparoscopic and hand accesses (Applied Medical, Rancho Santa Margarita, USA).
3.5.1 Monopolar and bipolar
electrocautery
Conventional electrosurgery and monopolar and bipolar
cautery achieve tissue cutting and coagulating via the
passage of high-frequency electrical current produced by
an electrosurgical generator. During monopolar electrosurgery, electrical current passes through the tissue from
an active electrode to a broad electrically indifferent plate
which causes high current density and significant heat
(upto300°C) with the risk of deeper injury [4]. In
Figure 3.17 A Reverdin suture needle is used for a closing port
site fascial defect. The sharp, notched tip passes through the
fascia in one side of the trocar, holding a thread in its small
window, and pulls through the fascia in the other side of the
trocar, capturing the thread again.
developing a port site hernia. Fascial closure can be
difficult under direct vision, especially in obese patients,
and several specialized instruments for port site closure
are available (Figure 3.17).
3.5 Energy devices
Prevention of bleeding and adequate hemostasis are
essential during the laparoscopic procedure. Most devices
used in open surgery have been modified for laparoscopic
surgery.
contrast to monopolar electrosurgery, with bipolar
energy, the current flows back to a return electrode.
Conventional electrosurgery remains the main laparoscopic modality thanks to its low cost and general
availability.
Monopolar cautery can combine cutting and coagulating functions, and a wide variety of disposable and reusable laparoscopic instruments have a cautery attachment
for monopolar current, including scissors and dissectors.
In contrast, bipolar cautery has a higher hemostatic efficiency with no cutting ability and decreased risk of thermal injury to adjacent tissue. Modern electrosurgical
generators have new or improved modes for high hemostatic efficiency using voltage-controlling technology,
such as soft coagulation (e.g. ERBE, Tübingen, Germany)
(Figure 3.18). Such modes contribute to the excellent
usability of conventional electrosurgery, especially the
bipolar technique, in complex HPB procedures [5].
38 Chapter 3
Figure 3.18 One of the new electrosurgical generators,
VIO300D, has a soft coagulation mode with a high hemostatic
efficiency.
3.5.2 Advanced bipolar vessel
sealing devices
Advanced bipolar sealing devices (e.g. LigaSure, Enseal)
(Figure 3.19) combine bipolar current with optimized
tissue apposition and compression to provide better vessel
sealing capability while minimizing the risks associated
with conventional electrosurgery [5]. Bipolar sealing
technology has made laparoscopic suturing or clipping
of vascular pedicles of up to 7 mm unnecessary in some
cases. However, the need for an additional instrument for
transection as well as the generally large size of the tip can
potentially limit the use of bipolar sealing devices in tissue
dissection.
3.5.3 Ultrasonic devices
Ultrasonic devices (e.g. SonoSurg, Harmonic ACE) (Figure 3.20) produce cutting and coagulating effects through
Figure 3.19 The LigaSure is an advanced bipolar sealing device
and some types of LigaSure are equipped with scissors to
transect tissue after sealing.
Figure 3.20 Shears type of ultrasonic device.
vibration of a piezoelectric crystalmountedatthetip(active
blade) of the instrument. The Cavitron ultrasound surgical
aspirator (e.g. CUSA Excel, SonoSurg) is widely used for
liver parenchymal dissection through an open approach [6].
Liver parenchymal tissue is fragmented, irrigated, and aspirated away from the dissection field while preserving intrahepatic vessels and bile ducts. The shears-type ultrasonic
devices offer less hemostatic ability when compared with
bipolar sealing devices and are equipped with finer tips
suitable for tissue dissection. The ultrasonic shears enable
quick tissue transection concomitant with coagulation. Furthermore, the cavitation effect caused by an active blade can
be utilized for dissecting liver parenchyma, similar to the
CUSA device [7,8]. Nevertheless, inserting the active blade
blindly into liver parenchyma for parenchymal transection
carries the risk of inadvertent biliary or vascular injury and
must be avoided by using a refined technique of parenchymal transection.
3.5.4 Combined bipolar sealing and
ultrasonic devices
Today, devices have become available that allow for
integration of both advanced bipolar sealing and ultrasonic technologies, which are delivered simultaneously
through a single instrument (Thunderbeat, Olympus,
Tokyo, Japan) (Figure 3.21). This integration provides
the benefits of each individual energy device: the ability to
rapidly cut tissue with ultrasonic shears and to create
reliable vessel seals with bipolar sealing technology,
which allows surgeons more secure hemostasis and fewer
instrument exchanges [9]. When required, bipolar
energy can be applied to seal thetissue without the cutting
function being used.
Соседние файлы в папке Библиотека им академика М.И. Перельмана