Table Of ContentA. Cuschieri . G. Buess . J. Perissat (Eds.)
Operative
Manual
o f Endoscopic
Surgery
With 273 Figures in 432 Separate Illustrations, Mostly in Color
Springer-Verlag Berlin Heidelberg GmbH
A. CUSCHIERI, MD
Ninewells Hospital and Medical School, Dept. of Surgery
University of Dundee
Dundee DD1 9SY, Scotland, UK
G.BUESS, MD
Sektion fUr Minimal Invasive Chirurgie
Abt. fUr Allgemeinchirurgie
Klinikum Schnarrenberg, Eberhard-Karls-Universităt
Hoppe-Seyler-Str. 3, 72076 Tiibingen, FRG
J. PERISSAT, MD
Cliniques Chirurgicales, 311 Boulevard du President Wilson
33200 Bordeaux, France
Cover picture: Fig. 12.15 b, p. 233
Drawings created by M. Wosczyna, Rheinbreitbach, FRG
ISBN 978-3-662-01568-1 ISBN 978-3-662-01566-7 (eBook)
DOI 10.1007/978-3-662-01566-7
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Preface
The second volume of Operative Manual of Endoscopic Surgery covers some of
the operative endoscopic procedures which have been introduced into clinical
practice since the publication of VoI. 1. In the general section, we have included
an updated chapter on instrumentation and new chapters on anaesthetic manage
ment of patients undergoing endoscopic surgery and on video image and record
ing. Both topics are of importance to the practice of endoscopic surgery and have
not been adequately covered in the reported literature.
Volume 2 deals with endoscopic procedures)nthechest and abdomen. There
have been significant advances in thoracoscopic surgery duririg the past 2 years;
rs
particular reference made to anatomical pulmonary resections and oesophageal
resections. As far as the gastrointestinal trad is concerned, we have included
gastric and allied operations but have not covered the colorectal region as we
believe that more evaluation is needed before definitive accounts can be written
on endoscopic colorectal resections, especially for cancer. For this reason, we have
decided to defer this important topic to VoI. 3, which is in preparation. The same
applies to laparoscopic repair of abdominal hernias.
The same layout has been adopted as in VoI. 1 of the series, with heavy em
phasis on illustrative representation of the operative steps and techniques. In the
diagrams on sites of trocar/cannulae, we have indicated not only the site and size
but also the functional role of each port.
As on the previous occasion, we are very grateful to the contributing authors
for the high quality of their submissions and in this respect, our editorial task has
been a light one. We also would like to acknowledge the constant support and en
couragement from the staff at Springer-Verlag, especially Ms. B. Wehner, in the
preparation of this volume.
A. CUSCHIERI G. BUESS J. PERISSAT
Contents
1 Instrumentation and Allied Technology for Endoscopic Surgery
A. MELZER, G. BUESS, and A. CUSCHIERI ........................ 1
2 Videotechnology for Minimally Invasive Surgery
T. LANGE and G. BUESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
3 Anaesthetie Management in Endoscopic Surgery
B. M. KOTTLER and G. LENZ .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
4 Right Subtotal Thoracoscopie Oesophagectomy
with Lymphadenectomy
A. CUSCHIERI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
5 Thoracoscopie Pericardiectomy and Insertion
of Epieardial Pacemaker Lead
A. CUSCHIERI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 121
6 Endoscopie Procedures in the Mediastinum
K. MANNCKE, G. BUESS, and G. ROVIARO. . . . . . . . . . . . . . . . . . . . . . . . . 131
7 Videoendoscopie Pulmonary Resections
G. ROVIARO, C. REBUFFAT, F. VAROLI, C. VERGANI,
M. MACIOCCO, and S.M. SCALAMBRA............................ 139
8 Laparoscopie Liver Surgery
A. CUSCHIERI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
9 Laparoscopic Bilioenterie Bypass
A. CUSCHIERI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
10 Laparoscopie Treatment of Ductal Calculi
A. CUSCHIERI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 189
11 Laparoscopie Splenectomy
A. CUSCHIERI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 207
12 Laparoscopie Gastric Procedures
A. CUSCHIERI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 221
13 Laparoscopy and Laparoscopie Contact Ultrasound Scanning
in Disorders of the Liver, Biliary nact, and Pancreas
A. CUSCHIERI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 241
Subject Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 259
List of Contributors
G. BUESS, MD, FRCS Ed G. LENZ, MD
Sektion fur Minimal Invasive Abt. fur Anaesthesiologie
Chirurgie Klinikum Schnarrenberg
Abt. fUr Allgemeinchirurgie Eberhard-Karls-Universitat
Klinikum Schnarrenberg Hoppe-Seyler-Str. 3
Eberhard-Karls-Universitat 72076 Tubingen
Hoppe-Seyler-Str. 3 FRG
72076 Tubingen
M. MACIOCCO, MD
FRG
C. REBUFFAT, MD
A. CUSCHIERI, MD, ChM, FRCS Ed S. M. SCALAMBRA, MD
Ninewells Hospital F. VAROLI, MD
and Medical School C. VERGANI, MD
University of Dundee Universita di Milano
Department of Surgery Via S. Vittore 12
Dundee DD1 9SY 20100 Milano
Scotland, UK Italy
B. M. KOTTLER, MD K. MANNCKE, MD
Abt. fUr Anaesthesiologie Abt. fur Allgemeinchirurgie
Klinikum Schnarrenberg Klinikum Schnarrenberg
Eberhard-Karls-Universitat Eberhard-Karls-Universitat
Hoppe-Seyler-Str. 3 Hoppe-Seyler-Str. 3
72076 Tubingen 72076 Tubingen
FRG FRG
T. LANGE, MD A. MELZER
Sektion fur Minimal Invasive Sektion fur Minimal Invasive Chirurgie
Chirurgie Abt. fUr Allgemeinchirurgie
Abt. fUr Allgemeinchirurgie Klinikum Schnarrenberg
Klinikum Schnarrenberg Eberhard-Karls-Universitat
Eberhard-Karls-Universitat Hoppe-Seyler-Str. 3
Hoppe-Seyler-Str. 3 72076 Tubingen
72076 Tubingen FRG
FRG
G. ROVIARO, MD
Universita di Milano
Via S. Vittore 12
20100 Milano
Italy
1 Instrumentation and Allied Technology for Endoscopic Surgery
A. MELZER, G. BUESS, and A. CUSCHIERI
Introduction Developmental Principles
The instrumentation for endoscopic surgery has in Historically, physicians and technicians have
creased substantially since 1989 when the first worked closely to develop surgical instruments. Al
laparoscopic cholecystectomy was performed; how though these instruments were relatively primitive,
ever, the instruments and the technology have not they incorporated the necessary design features for
advanced significantly from the original devices de good function using the manufacturing processes
signed and developed by Jakobeus [1], Wittmoser available at that time. Over the past centuries nu
and Pfau [2], Semm [3] and our teams [4, 5]. Al merous instruments have been made [9]. Some were
though trocars, cannulae, needle holders, scissors, modified and then discarded, according to the pro
forceps, and clip and stapler systems have been re gress in surgical science and current knowledge
fined the basic technical problems of endoscopic [10]. The conventional instruments of open surgery
surgery have not been overcome [6]. Sutures, liga have obviously stood the test of time and over the
tures and difficult organ dissections have to be exe years have been perfectly adapted to their purpose.
cuted with rigid needle holders, external slip knots But this tradition of instrument development and
and unergonomic handles across a two-dimension processing amongst surgeons and technicians has
al operative field. Thus, complicated endoscopic been interrupted and in past years the initiative has
operations can only be conducted safely by experi been taken over by industry.
enced surgeons. These procedures will be facilitated
if the present disadvantages and limitations of en
doscopic surgery technology due to restricted han New Area of Surgery:
dling of tissue, lack of tactile sensation and force Old Principles of Development
control are resolved [7] and three-dimensional vi
sion is established routinely [8]. More complex and Endoscopic surgery reveals the limitations and fun
exacting procedures require even more intricate and damental problems of current instrumentation. In
delicate instrumentation. It is important that the this respect, the close co-operation between the en
surgeon become familiar with engineering and gineer and the surgeon is assuming more impor
technological principles because he is the one who tance, and so, as in the past, they must join effort
has to address the technical operative problems. to utilize all the available technological advances to
Aside from the need for instrument development, produce the instrumentation which is best suited
certain basic medical and surgical principles must for the operations. Endoscopic surgery requires
be followed. These include adequate operating new instrumentation, e.g. instruments which are
times, completely sterile equipment, minimum mal steerable, multifunctional, with automatic sutur
function and uncompromised patient safety. In this ing, etc. Our goal has been to create the required
respect it is important that we encourage the indus tools by appropriate design [11]. As in former
try and engineering departments to co-operate with times, the instruments are designed by both the sur
surgeons in order to produce the instrumentation geon and the technician. This interdisciplinary
which meets the needs of endoscopic surgery. linkage has revealed an important advantage; while
2 A. Melzer et al.
PROBLEMS IN SURGERY
O
SYSTEM SCIENCE
1. STEPWISE REALISATION
simple model -+Prototyp
II. TESTING ON ANIMAL TISSUE
in Training Phantoms
III. ANIMAL EXPERIMENTS
Definitive Prototyp
IV. CLiNICAL APPLlCATION
Industrial Production
IMPLEMENTATION OF TECHNOLOGY
o
SYSTEM SOLUTION
the surgeon is learning some important rules of de Fig. 1.1. Innovation level 1 in technology development for
sign and principles of construction, the technician endoscopic surgery.
The developmental process is subdivided in four phases:
is acquiring knowledge concerning basic surgical
first phase (1): theoretical solutions and simple models; sec
and medical principles [12, 13].
ond phase (II): practical approval of ideas in phantom ex
periments on animal tissue; third phase (III): animal experi
ments and professional manufacturing of prototypes; fourth
phase (IV): clinical tests and industrial production. AII sec
Interdisciplinary Co-operation
tions of the development are interconnected and thus influ
enced and controlled by each other, not necessarily proceed
We have established an interdisciplinary team con
ing from phase 1 to phase 4. Ideas can be realized in ali
cerned with the development of endoscopic surgi
phases depending on their technological complexity or the
cal technology. This team always operates with a medical approach
specific goal according to the principles of the co
operative model, which is divided into two levels:
- Level 1 entails the development of simple instru-
ments and devices in consideration of practical The development in level 1 is governed by the
surgical requirements for endoscopic opera surgical problem and consists of four phases
tions. (Fig. 1.1). These phases are interconnected and in
- Level 2 includes system research [14] of en fluenced by current technologies as well as system
doscopic surgery as the cornerstone of the devel analysis and techniques.
opment of advanced, intelligent instrumenta In phase one the surgeon and the technician
tion and operating systems. discuss and outline a number of theoretical solu-
Instrumentation and AUied Technology for Endoscopic Surgery 3
tions regarding the instrument with sketches, draw quire the whole spectrum of scientific engineering.
ings and simple wire or wooden models. Therefore we are collaborating with research teams
Phase two includes the crafting of simple proto from the Nuclear Research Centre, Karlsruhe (KfK)
types, for example by modifying conventional in Germany, the Fraunhofer Society, St. Ingbert, Ger
struments and creating test phantoms using animal many, and the German Aerospace (DASA), Mu
tissue. At this stage the options are reduced to those nich, Germany. The design and te sting may be en
which appear promising at the initial testing and hanced by simulating and modelling tools. In cur
only these are processed in the next phase. Whether rent microsystem engineering, computerized check
engineers are involved in the theoretical calculation of the design is indispensable [15]. The engineer
and design depends on the devices which are plann proves and tests his development repeatedly to
ed. The industry has to be involved early to consid eliminate instrument failures. Such quality assur
er processing, serial production and marketing. an ce and error analysis in endoscopic surgery will
In phase three the prototype is designed, manu provide more reliable instrumentation. Even so,
factured and tested, first in phantoms and then in there is still the need for final experimental and
animals. Further modifications can be made in a clinic al evaluation, because in surgical practice, in
workshop close to the animallab. The practical ex strument performance during actual operations is
perience gained by the use of the instrument in ani what ultimately determines its usefulness. It is im
mals oft en requires that an instrument be rede portant that the surgeon become more familiar
signed. with engineering principles and technological sci
In phase four a real prototype of the final in ence, because he is the one who has to address the
strument is manufactured by a medical instruments technical problems and to indicate the ways of re
manufacturer. Only a device which has been suc solving them. Hence, one of our most important
cessfully tested in human surgical procedures aims is to create useful interdisciplinary co-opera
should reach the market for routine clinical appli tion in the future which requires that both groups
cation. However, reliability and clinic al value of the be able to understand a certain basic language 1.
solution only becomes apparent after an instru
ment has been used routinely. Not seldom, medical
progress in other fields competes with or outmodes
Technological and Medical
the operation itself.
Considerations Governing Safe
This model is flexible; there are no fixed demar
cations between the phases. The very first proto Endoscopic Instrumentation
type of a simple instrument, for instance, can reach
the routine usage phase and, by contrast, more Reliability
complex developments such as manipulators or
multifunctional instruments [7] may require pro Spatial restrictions put limitations on the design
cessing through all the phases plus extensive testing and construction of reliable and safe endoscopic
and modification. instrumentation. Multifunctional devices are espe
Level2 entails systems research [14] and the de cially delicate and susceptible to breakage, and so
velopment of intelligent instrument systems. The cleaning and sterilization can damage instruments
next generation of instruments will be intelligent [18]. Besides the financial aspect, breakage and loss
steerable instruments equipped with microsensors, of a jaw, for instance, while clamping a vessel, is
actuators [7, 15] and complex electronic controlling unacceptable and can cause complications. The
systems. The development of such instrumentation paramount problem in technical design, though, is
is, indeed, difficult and specific research must be the narrow calibre and the length of the instru
conducted e.g. on qualification of tactile and pro ments. Critical constructions with hinges and small
prioceptive impulse transmis sion [16, 17] or
microsensor and actuator systems to achieve appro
1 A new journal, Endoscopic Surgery and Allied Technolo
priate remote handling under three-dimensional
gies, has been established to provide a forum for interdis
endoscopic vision. Such delicate developments re- ciplinary communication, for example.
