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SURGICAL TECHNOLOGY INTERNATIONAL II.

$245.00 - Online Edition

 

Surgical Technology International II contains 66 peer-reviewed articles featuring the latest advances in surgical techniques and technologies.

 

1993 - ISBN: 0-9638866-0-6

 

 

 

 

 

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Sections

Minimal Access Surgery

 

25 Years of Laparoscopic Surgery Personal Reflections Problems in Laparoscopy Past and Present  
Kurt Semm, Dr. Med., Kiel, Germany

 

 

Abstract

Laparoscopy was developed by Kalki of Germany in 1929 as a routine procedure in the University and Michaelis-Midwifery School, Kiel, Germany internal medicine for diagnosis of liver diseases. Air was insufflated to create the pneumoperitoneum, and an electric lamp was placed at the end of the laparoscope to provide illumination of the abdominal cavity. Entrance into the peritoneal cavity was in the upper abdomen two finger breadths under the ribs. The danger of damaging the bowel by burning, etc. was very low. Previously laparotomized patients were considered an absolute contraindication for Laparoscopy. In 1946 Palmer, France turned the laparoscope from the upper abdomen to look into the lower abdomen. He called this technique Coelioscopy. It was used as for a diagnostic procedure mainly for the sterility patient in Gynecology. For coelioscopy Palmer used the same instruments as were used for Laparoscopy. The danger of burning bowel increased enormously as the protector of the upper abdomen, the omentum, was missing in the lower abdomen.

 

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Horizons in Endoscopic Surgery
Toby D. Broussard, MD, Henry L. Laws, MD, Birmingham Alabama, J. Barry Mckernan, MD, PhD, Atlanta, Georgia

 

 

 

Abstract

Dramatic advances continue to occur with video-directed endoscopic operations. This commentary will follow the same format as the one in the previous edition two years ago. Most of the predictions anticipated in our last writing have been met or exceeded. Change will continue to accelerate, though the individual innovations will be of smaller magnitude.

 

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Avoiding Laparoscopic Complications
Eddie Joe Reddick, MD, Brentwood, Tennessee

 

 

 

Abstract

Two years after laparoscopic cholecystectomy was introduced, and new horizons in laparoscopic surgery were being developed, a noted academic surgeon told me that although he had initially doubted the viability of laparoscopic cholecystectomy, he had become an avid supporter. He cautioned, however, that many surgeons would perform the operation with minimal training and marginal laparoscopic skills and that the injury rate would be devastating. Unfortunately, that prophecy has come to pass. In this dissertation, I would like to discuss some of those complications and how to avoid them. I choose not to dwell on minor or peripheral complications such as wound infection, pneumonia, deep venous thrombosis, urinary tract infection and the like, but rather, concentrate on complications related directly to laparoscopy and laparoscopic surgery. Laparoscopic complications are either a direct result of poor laparoscopic technique or related to anatomic misidentification. Technical complications include major vascular or intestinal injury or insufflation injury. Anatomic injuries usually involve the bile ducts, ureter or sensory nerves due to poor dissection and identification.

 

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Laparoscopic Common Bile Duct Exploration
Morris E. Franklin, Jr., MD, James P. Dorman, MD, San Antonio, Texas

 

 

 

Abstract

As is pointed out in multiple publications, laparoscopic cholecystectomy has rapidly gained recognition an acceptance in the management of chronic cholecystitis and most cases of acute cholecystitis. A low incidence of complications accompanies laparoscopic cholecystectomy now that experience has been gained with this procedure by laparoscopically skilled surgeons. However, the management of stones found or suspected in the common bile duct continues to be controversial. The gold standard for treatment of choledocholisthiasis remains the open exploration of the bile ducts with a reported mortality of 0.3%-0.19% and a rate of retained stones of between 2-4%. Both surgeons and gastroenterologists skilled in endoscopy have espoused endoscopic retrograde cholangiopanreatography and sphincterotomy (ERCP/ES) preoperatively or postoperatively for the treatment of known common bile duct stones. This approach adds additional procedures and potentially compounds the complications of the separate operative interventions to deal with the diseased gallbladder and to clear the common bile duct of obstruction. In several series of patients the morbidity of endoscopic sphincterotomy has ranged from 9-16%, with bleeding, acute pancreatitis, acute cholangitis, residual stones, duodenal perforation, and common bile duct perforation the leading causes of complications. There continues to be an incidence of retained stones of 9.1-14.7% with ERCP/ES. Furthermore, as high as 86% of indiscriminate preoperative ERCP studies show no evidence of stones in the common bile duct, making this an unnecessary intervention in such cases. There has been no consistent reduction in subsequent mortality in complicated biliary cases by the use of ERCP/ES alone, even with the gallbladder left in situ.

 

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Laparoscopic Herniorrhaphy
Douglas O. Olsen, MD, Nashville, Tennessee

 

 

Abstract

With the introduction of laparoscopic cholecystectomy, the general surgery community was introduced to the world of minimally invasive surgery. In less than two years, just about every meeting, journal, and medical trade show demonstrated this "new" found technique. Surgeons have been very quick to pick up on the laparoscopic technique, and have actively sought other applications for the laparoscopic approach. With approximately 400,000 inguinal hernia repairs being performed in the United States annually, the laparoscopic repair of this common malady was very quickly embraced as a possible new application. The concept of a trans-abdominal repair of a hernia defect is not new, having been described as early as the original description of "the modern day" hernia repair by Marcey. A trans-abdominal laparoscopic repair has a potential advantage over a conventional groin approach by it's avoidance of the groin incision and the need to mobilize the cord structures. This not only minimizes post operative pain, but also the risk of long term morbidity related to mobilization of the cord. (neuroma formation secondary to injury of the cutaneous nerves, epididymitis and orchitis) There is also the possible advantage of an earlier return to normal activities. In contrast to laparoscopic cholecystectomy, there are technical differences between the laparoscopic and open hernia repairs. This difference raises the question as to whether or not the laparoscopic repair will yield results that will compare with an open technique. Open surgical techniques are considered a safe and effective means of treating inguinal hernias. The operation avoids the violation of the abdominal cavity, can be performed under local anesthesia, and is often performed on an outpatient basis. This raises the question "why via the laparoscope »? Despite reports from specialized hernia centers reporting a recurrence rate of 0 to 2 percent, large series from community based surgeons continue to report recurrence rates in the range of 5 to 10 percent. This recurrence rate has changed very little since Bassini reported a recurrence rate of 10 percent at the turn of the century. Although the overall morbidity of an open repair is only in the range of 2 percent, this morbidity consists almost entirely of complications related to the wound and mobilization of the cord structures. The standard open hernia repair is not a perfect operation, and any attempt at its improvement is warranted. Since the laparoscopic repairs approaches the defect from within avoiding a large surgical incision and mobilization of the cord structures, the repair logically makes sense. Despite the intuitive advantages of the laparoscopic repair, questions regarding recurrence rates and safety of the laparoscopic repair still need to be answered.

 

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Laparoscopic Colon Resection
Dennis G. Begos, MD, Garth H. Ballantyne, MD, New Haven, Connecticut

 

 

Abstract

Laparoscopic surgery has been in existence for nearly a century, yet its widespread acceptance and application in the field of general surgery is a relatively recent occurrence. With the rapid acceptance of laparoscopic cholecystectomy, surgeons have sought other procedures which would be amenable to laparoscopic approaches. This, combined with a technology boom in laparoscopic instrumentation has made possible the development of advanced laparoscopic procedures such as colectomy. It is important to emphasize that laparoscopic colon surgery is still in an evolutionary stage, and that the procedures described are being continually refined as more experience is gained, as newer instruments are developed, and as software and video applications continue to improve. Nevertheless, the goal of any surgeon performing a laparoscopic procedure should be to perform an operation identical to the one done through a large incision.

 

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Laparoscopic Fundoplication

Michael J. O'reilly, MD, Spencer G. Mullins, MD, Marietta, Georgia


 

 

 

Abstract

Gastroesophageal reflux disease (gerd) is a common disorder of the foregut. Over the past twenty-five years the developement of instrumentation and techniques to study GERD have revealed it to be a complex disorder. Increasingly effective pharmacotherapeutics have been developed over the same time frame. As such the great majority of patients are adequately treated by a medical regimen. Patients who are medically refractory or those requiring long term medications are potential candidates for anti-reflux surgery. Over the past decade decreasing numbers of anti-reflux surgical procedures have been performed. The two main reasons are improved pharmacology i.e. Prilosec and the complication rate associated with antireflux surgery. The laparoscopic performance of anti-reflux surgery offers dramatic benefits to the patient. As in the performance of laparoscopic cholecystectomies the decreased postoperative morbidity and rapid return to normal activities ensures overall cost savings. We present our experience with laparoscopic anti-reflux surgery to include the work up, technique, results, and a new laparoscopic anti-reflux procedure.

 

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Thoracoscopic Sympathicotomy

Goran Claes, MD, PhD, Christer Drott, MD, PhD, Boras, Sweden


 

 

 

Abstract

Thoracoscopy - looking into the thoracic cavity was first described in 1910 by the Swedish physician, Jacobeus. He used a cystoscope intrapleuraly in order to diagnose pleural diseases. He also used his method for cutting adhesions in order to achieve collapse of the lung in patients with tuberculosis of the lung. Thoracic sympathicotomy was first performed by Kotzareff in 1920. The operation was found to be effective for treatment of palmar hyperhidrosis. Different open techniques for sympathicotomy have since been described, the most common being the dorsal approach by Cloward in 1969. Sympathicotomy was found to be effective not only for palmar, but also axillar hyperhidrosis, vascular insufficiency of the arm and hand, causalgia and angina pectoris (Lindgren 1950). However, the operation using the open technique was difficult and, though effective, not many patients were prepared to meet the demands for problems such as hyperhidrosis. Therefore, the operation became rather common. In the middle of the 1940'S, several attempts were made to make the sympathicotomy through thoracoscopic approach and in 1951, Kux described a large number of patients treated in this way for many different diseases such as duodenal ulcer, diabetes mellitus, as well as the generally accepted indications. He published his experiences in a book; but for some obscure reason, his technique did not achieve general acceptance. In the late 1970'S and the 1980'S, the principle was again taken up by different centers (Byrnes, et. al.). I will describe here a technique which can be regarded as a simplification of previous methods. The technique was elaborated in our department and the first operation was performed in 1987 (Claes, et. al.). By June 1993, six hundred and seventy operations have been carried out.

 

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Upper Thoracic Sympathectomy

Eliahu Antebi, MD, Michael Nobel, MD, Tel Aviv, Israel

 

 

Abstract

In the extremities, the vascular response to sympathetic stimulation is vasoconstriction with blanching and cooling of skin and increased sweating, whereas, blocking of the sympathetic system results in increased blood flow through cutaneous arteriovenous fistulae and cessation of sweating, thereby, resulting in increased dryness, warmth and accentuation of pink color. In the past, sympathetic denervation of the upper extremity was suggested as a treatment of many disorders; bronchial asthma, essential hypertension, peptic ulcer disease, hyperthyroidism, hyperhidrosis, vasospastic syndromes (Raynaud's disease), thoracic outlet syndrome, causalgia, post-traumatic sympathetic dystrophy (Sudeck atrophy), and angina pectoris. The indications for upper thoracic sympathectomy are imited today to hyperhidrosis, causalgia, severe vasospastic disorders, and ischemic changes of the extremities (Buerger's disease).

 

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Thoracoscopic Treatment of Recurrent Pneumothorax By Pleura Brushing and Argon Beam Coagulation

Dr. B. Asfour, Dr. R. Forster, Dr. Aw. Geiger, Dr. S. Toth, Dr. B. Thullg, Dr. H.H. Scheld Munster, Germany



 

 

Abstract

There is no consensus in treating relapsing pneumothorax and pleural effusion. Various types of treatment exist. While open chest surgery with mechanical pleurodesis or pleurectomy is effective, with a recurrence rate close to zero, for patients in poor conditions this treatment may be disadvantageous because of its invasiveness. Therefore minimally invasive techniques using antibiotics, fibrin glue, talcum, kaolin, blood and silver nitrate have been described. Several side effects accompany these agents, and the recurrence rate is between 5-39%. New video-assisted thoracoscopic techniques have enabled surgeons to combine the effectiveness of pleurectomy with minimal invasiveness. Results using these techniques are encouraging. As with open pleurectomy, bleeding complications have been reported. Further disadvantages have to be considered, such as the effect of destroying the parietal layer of the pleura, which may complicate subsequent operations in the thoracic cavity. A technique for avoiding this pleural injury, while maintaining the same efficiency as open pleural abrasion and coagulation is described below.

 

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Thoracoscopic Surgery Spontaneous Pneumothorax and Nodules of the Lung

Martin Hurtgen Dr. Med., Jens-Peter Stahl Dr. Med., Jorg Buhr Dr. Med., Giessen, Germany

 

 

 

Abstract

Indications and principles of the surgical procedure should be the same for endoscopic and open surgery. Those performing endoscopic surgery should be familiar with the corresponding open procedure, thus being capable to manage complications. Unbiased decision for endoscopic or open procedure might be compromised by lack of experience in one of them. Keeping this in mind, the trauma of surgical access for treatment of some diseases may be diminished by the thoracoscopic approach. There are only few established or almost established indications for thoracoscopic surgery. Since January 1990, we have gained some experience with spontaneous pneumothorax and nodules of the lung. Our patients have been followed-upcarefully and the future results will have to be compared with those obtained by conventional surgery (thoracotomy). Our surgical technique and early results will be describedin the following.

 

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Laparoscopy in the Trauma Patient
Jonathan M. Sackier, MD, Nancyl.Furumoto, MD, San Diego, California

 

 

 

Abstract

The first laparoscopic exam of the abdominal viscera was done by kelling in 1902. Since that time, laparoscopy has been used more extensively in abdominal and pelvic disorders by gynecologists and gastroenterologists than general surgeons. However, since the introduction of laparoscopic cholecystectomy in the 1980s by Mouret in France and Muhe in Germany, laparoscopy has been embraced by the general surgeon and has exponentially increased in number and types of procedures being done. New technology, such as the enhancement of video image along with better instrumentation, has further accelerated the acceptance of "minimally invasive" surgery in all surgical specialties.

 

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Endoscopic Innovations
Warren S. Grundfest, MD, Los Angeles, California

 

 

Abstract

The goal of this chapter is to describe the evolution and implementation of several new interventional technologies which expand the capabilities for less invasive surgery. These technologies, including laparoscopic transcystic duct common bile duct exploration, fallopian tube endoscopy, and laser lithotripsy, are all based on the use of new fiberoptics and laser technology. While the application of these technologies may appear unrelated, each specialty has borrowed technology and techniques from other disciplines to develop less invasive forms of therapy. Until recently, transfer of new techniques between different medical specialities has been impeded by a lack of communication. This lack of communication has been a primary impediment to the transfer of enabling technologies from one discipline to another. The Laser Research and Technology Development Program at Cedars-Sinai Medical Center provides the physical setting and administrative support for collaborative research which emphasizes technology transfer. Focused, well defined research projects are developed to solve a particular problem. New technologies which might provide potential solutions to the problem are systematically examined for feasibility, cost, ease of implementation and application to medicine. Successful application of new technologies to medicine requires a well defined, goal-oriented program with the support of a broadly-based research team including physicists, chemists, engineers, biologists, and physicians.

 

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Laparoscopic Ultrasonography
Allan Siperstein, MD, San Francisco, California

 

 

Abstract

Laparoscopic surgery imposes limitations on the surgeon not present in open surgery, including restricted degrees of freedom of instrument movement, lack of binocular vision, and severely restricted tactile feedback from the tissues. An aggressive effort is being made to apply technology to overcome some of these limitations and the adaptation of ultrasound probes for laparoscopic use now allows the surgeon to not only examine the surface of structures but to look into them with ultrasonic imaging. Laparoscopic ultrasonography has been used to evaluate the biliary tree during laparoscopic cholecystectomy both to delineate the biliary anatomy and look for common duct stones. This technology may have its widest use in the future in examining the liver for metastatic disease in patients undergoing laparoscopic colon resection. It must be realized that this is a technology in its infancy and further studies need to be done to evaluate areas where laparoscopic ultrasonography will have its greatest clinical utility.

 

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Gasless Laparoscopic Surgery
Edmund K. M. Tsoi MD, R. Stephen Smith MD, Claude H. Organ, Jr., MD, Oakland, California

 

 

 

Abstract

Conventional laparoscopic surgery requires pneumoperitoneum to elevate THE abdominal wall for maintaining expansion in an operating field. A continuous insufflation of a noncombustible, soluble gas in a sealed environment is essential. At 15 mm Hg intra-abdominal pressure (the upper limit of intra-abdominal pressure used by most surgeons), significant cardiovascular changes have been observed. These changes are caused by diaphragm elevation and inferior vena cava compression. Elevation of the diaphragm also causes a decrease in tidal volume with resulting pulmonary dysfunction. In conventional practice where CO2 is used to create pneumoperitoneum, increased absorption of the gas causes metabolic acidosis and increased intracerebral pressure. Therefore, in patients with intracranial pathology, the use of CO2 pneumoperitoneum is not desirable. Compression of the vena cava by pneumoperitoneum results in venous stasis in the lower extremities. Deep venous thrombosis has not been a major problem for gynecologists because pelvic peritoneoscopy is performed in the Trendelenburg position where blood return is enhanced. More lower extremity thromboembolism would be expected when more upper abdominallaparoscopic procedures are performed with the patient positioned in a reversed Trendelenburg position.

 

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Endoscopic Suturing and Knotting
Zoltan Szabo, PhD, San Francisco, California

 

 

 

Abstract

As the minimally invasive approach to surgery has taken a firm foothold the new quest has been to find if there were any limits to procedures being done entirely "closed". The obvious patient and cost benefits had already been established, thus many a creative and adventurous surgeon busily explored these possibilities. It has already been demonstrated clinically that laparoscopic tubotubal reanastomosis is feasible and in the experimental setting laparoscopic vesico-urethral anastomosis (following laparoscopic radical prostatectomy) and fetoscopic repair of a cleft lip, all using fine sutures, are possible. The answer seemed to lie in the limitations: setup, skill, technique, visualization, and instrumentation. Problems with visualization have been addressed during the past decade and substantial gains have been made in optical and audio-visual technology. Instrumentation lagged behind, not only because of astronomical demand but also because of the lack of understanding of the exact needs of the laparoscopic surgeon. A good deal of borrowing or adaptation of conventional instruments has occurred which has been beneficial in the sense that these were familiar to surgeon (habit is stronger than logic). The problem was the that highly restricted operative field rendered many of them nearly useless. New instruments had to be developed and many innovative designs have since become available for almost everything but suturing and knot tying.

 

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Laparoscopic Electrosurgery: Complications and Prevention

Robert D. Tucker, PhD, MD, Iowa City, Iowa, C. Randle Voyles, MD, Jackson, Mississippi

 

 

Abstract

Even though monopolar electrosurgery has been utilized laparoscopically for over two decades, post procedural complications, including bowel burns, remain significant. Initially employed by gynecologists, electrosurgical cutting and coagulation is rapidly becoming popular with general surgeons and urologists. Electrosurgery in a closed environment presents a special set of problems and in order to prevent complications surgeons need to familiarize themselves with the basic science of electrosurgery and the potentiallaparoscopic complications. This chapter presents an overview of the physics of electrosurgery with special attention to laparoscopic use. Also discussed are two technologies, a shielding-monitoring system for monopolar electrodes and bipolar electrodes, which minimize and/or eliminate potential laparoscopic complications associated with the use of electrosurgery.

 

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