Techniques of liver resection. Comparison of suction knife, ultrasonic dissector, and contact neodymium-YAG laser

Liver resections were performed in 18 pigs with an inexpensive disposable plastic suction knife, an ultrasonic dissector, or a contact neodymium (Nd)-YAG laser. Technical aspects and intraoperative and postoperative data were compared. Intraoperative blood loss was less with the suction knife (112 +/- 28 mL) than with the ultrasonic dissector (149 +/- 45 mL) or Nd-YAG laser (174 +/- 25 mL). Operating time was similar in all groups. The number of ligatures used in the Nd-YAG laser group (12 +/- 1) was significantly less than in the ultrasonic dissector (27 +/- 2) or suction knife (32 +/- 2) groups. In the ultrasonic dissector group, there was an increase in postoperative white blood cell count and liver enzyme levels compared with the other two groups. Light microscopy revealed dilated bile ducts in the ultrasonic dissector resection group, which may reflect biliary stasis. There were no significant differences in mortality among the three experimental groups. Results indicated that the ultrasonic dissector and the contact laser method were not substantially better than an inexpensive, easily modified plastic suction catheter in performing a major nonanatomic liver resection in piglets.     

Proximity storage of surgical instruments in the operative field

A new microsurgical instrument, the surgical pocket, is described, and its value for storing instruments in the surgical field during operation is discussed. Specific procedures for using the pocket in the field with the bipolar coagulator, suction irrigator, dissector, and scissors are presented. Proximity storage of microsurgical instruments reduces the surgeon's reliance upon other surgical personnel by allowing instrument transfers to be made without assistance. In addition, it reduces stress and fatigue for the surgeon by shortening the length of the operation and reducing eye strain by reducing the need to shift vision from the eyepieces of the microscope to the operating room and back each time an instrument is exchanged.     

Transvaginal Cholecystectomy without Abdominal Ports

Background:

Pioneers in natural orifice transvaginal cholecystectomy are in search of an approach that uses less percutaneous assistance. The approach must be safe and affordable. The authors present a successful cholecystectomy using a technique of transvaginal operative laparoscopy with no abdominal ports.

Methods:

A 24-year-old female patient with gallbladder lithiasis underwent a natural orifice cholecystectomy with only one transvaginal 12-mm port, using a laparoscope with a working channel. We used laparoscopic instruments 5 mm in diameter by 43cm in length (including a needle holder, Maryland dissector clamp, spatula, hook, suction cannula, and clip applier) and assistance with percutaneous marionette leashes.

Results:

The patient stayed in the hospital for 24 hours and was discharged without pain and without scars.

Conclusion:

Transvaginal cholecystectomy performed using an operative laparoscope with a working channel is possible in select cases. This technique requires no abdominal ports and is an alternative to culdolaparoscopy or hybrid transvaginal procedures with flexible endoscopes.     

Intraoperative measurements of harvestable septal cartilage in rhinoplasty

The aim of this study was to assess the dimensions of the septal cartilage available for grafting in patients undergoing open rhinoplasty and analyze whether the size of the external nose might be a useful indicator of the size and amount of harvestable septal cartilage. A prospective study was conducted on 55 Korean rhinoplasties. Intraoperative measurement of the harvested septal cartilage with preservation of 10 mm width l-strut was performed. The correlation between the quantity and size of the septal cartilage in situ with anthropometric measurements were evaluated. The mean caudal length of the harvested septal cartilage was 15.1 mm, the mean dorsal length was 18.2 mm, and the mean area was 520.9 mm2. Only 5 patients (9.1%) had cartilage sufficient for full-length dorsal onlay grafts, whereas 10 patients (18.2%) had septal cartilages of length >25 mm that could be used as spreader grafts. Dimensions of the septal cartilage in situ did not correlate with preoperative external nose measurements. The amount of harvested septal cartilage is usually insufficient for simultaneous use for multiple grafts in Korean. External nose size may not be a useful indicator of the availability of adequate septal cartilage for rhinoplasty. The need to harvest additional graft material should be kept in mind during preoperative planning for rhinoplasty procedures.     

自体软骨与膨体聚四氟乙烯在鼻整形手术中的应用

目的：通过应用自体鼻中隔软骨和耳软骨及膨体聚四氟乙烯解决鼻部美容整形的问题,以形成较理想的鼻形。方法：以鼻小柱飞鸟形切口加鼻翼软骨缘切口,切开分离鼻背皮肤,显露两侧鼻翼软骨及侧鼻软骨,中线分离弓形取出深部鼻中隔软骨,鼻中隔软骨雕刻塑形后插入两鼻翼软骨之间,并贯穿缝合形成中隔软骨＋鼻翼软骨为新的鼻小柱。将取下的耳软骨雕刻成杏仁状固定缝合于鼻小柱前端,雕刻好的膨体聚四氟乙烯插入鼻背固定,缝合切口。结果：20例美容就医者鼻部整形术后效果良好,自然美观,手感良好,无不良并发症发生,术后恢复时间略长。结论：应用自体鼻中隔软骨和耳软骨及膨体聚四氟乙烯行鼻部美容整形,能从根本上改变外鼻形态,是较理想的手术方法。     

Technique for Harvesting of Conchal Cartilage Grafts

Conchal cartilage is an important source of cartilage for the rhinoplasty surgeon [Falces E, Gorney M: Plast Reconstr Surg 50:147, 1972; Hage J: Brit J Plast Surg 18:92, 1965; Juri J et al: Plast Reconstr Surg 63:377, 1979]. We describe a technique to harvest conchal cartilage which minimizes morbidity for the patient and produces an excellent scar.     

Sequence and task analysis of instrument use in common laparoscopic procedures

Background: In the area of instrument evaluation, one aspect that still requires objective assessment is the dynamics of instrument maneuver and exchange. If we could gain a better understanding of these phenomena, we could improve the design of the instruments themselves. Methods: A total of 29 laparoscopic procedures were videotaped and reviewed using time motion analysis. Instrument multifunctionality was determined using a standardized list of laparoscopic maneuvers. State transition diagrams were utilized to document the sequence of instrument exchanges. Results: The curved dissector, atraumatic grasper, and cautery scissors were identified as the most multifunctional instruments; each was able to perform five distinct maneuvers. Instrument sequences were found to consist of a three-part dissect ? clip ? cut cycle and a two-part dissect ? suction cycle of instrument exchange. Conclusion: This study demonstrated that laparoscopic instruments are often used to perform a variety of maneuvers in addition to their primary function. Furthermore, there are common patterns in instrument exchange that provide a potential source of design parameters for improved surgical efficiency.     

New instrumentation for video-assisted anterior spine release

Endoscopic surgery in the area of orthopedics has been evolving, particularly in spine surgery. We describe the clinical outcome of thoracoscopic anterior spine release using new instruments. A harmonic scalpel (HS) with a 5-mm hook dissector was used to dissect the spine and rib and to coagulate and transect the vascular bundles. A rib dissector and resector were used for excision of the rib to be implanted in the disk spaces. We treated scoliosis in four patients (three male, one female) with a mean age of 19.5 ± 4.5 years and thoracolumbar kyphosis in a 16-year-old male patient. A mean number of 6.5 ± 2.5 vertebrae with scoliosis and four vertebrae with kyphosis were released. In all cases, division of the vascular bundle and exposure of the spine were completed using only the HS, and excision of a rib segment was performed via a port incision using only the rib dissector and resector. The mean duration of thoracoscopic anterior release was 92 ± 28 min. Blood loss was minimal during and after surgery. Thoracoscopic anterior spine release can be facilitated by the new instruments described above. Received: 8 March 1999/Accepted: 24 September 1999/Online publication: 10 April 2000     

The ultrasonic dissector facilitates laparoscopic cholecystectomy.

The ultrasonic dissector disrupts tissues in proportion to their fluid content by ultrasonically induced cavitational forces. Since sturdy tissues are spared, the instrument tends to follow tissue planes and to dissect fat and other soft tissues selectively. We performed a prospective, randomized, controlled trial in 73 patients comparing the safety and efficacy of a prototype ultrasonic dissector with that of electrosurgery and laser during laparoscopic cholecystectomy. Randomization was as follows: ultrasonic dissector, 37 patients; electrosurgery, 21 patients; and laser, 15 patients. The results were not different with respect to patient characteristics, amount of blood loss, technical difficulties, length of hospital stay, or return to work. Subjectively, the ultrasonic dissector was thought to be of special value in isolating the hilar structures, particularly when they were edematous or embedded in fat. The ultrasonic dissector disintegrated the fat, which was rapidly cleared up the suction channel, allowing the cystic duct and artery to be bared with less risk of injury. We concluded that the ultrasonic dissector has unique attributes that contribute to the ease and safety of laparoscopic cholecystectomy.     

Sensitivity of laparoscopic dissectors

Background: Sensory feedback is reduced considerably in minimally invasive procedures by the interposition of instruments, causing loss of direct manual contact with the tissue. The purpose of this study was to evaluate the feedback quality of commercially available reusable and disposable laparoscopic dissectors. Methods: A total of 31 participants were asked to feel a simulated arterial pulse with their bare fingers and through laparoscopic dissectors, tweezers, an orthopedic forceps, and a laparoscopic low-friction prototype. The absolute sensory threshold was determined by the psychophysical method of limits. Results: The sensory feedback quality was significantly better for the reusable dissectors tested than for the disposable dissector (p < 0.001). Nevertheless, the reusable dissectors were at least eight times less sensitive than bare fingers. Furthermore, sensitivity qualities were highly variable, depending on the dissector tested. Conclusions: This study showed that the overall sensitivity loss through instruments could be accurately assessed, proving that the sensory feedback for commercially available instruments was low compared to bare fingers. The good sensory feedback results of the prototype indicated that careful design could decrease the overall sensitivity loss. Received: 30 June 1998/Accepted: 20 January 1999     

Aktueller Stand der Behandlungsmöglichkeiten von Knorpeldefekten

Even centuries ago, before much was known about the cell biology of cartilage, it was clear that trauma and degenerative disease affecting cartilage were not easily amenable to treatment. As neither operative nor conservative methods have so far been able to initiate the regeneration of cartilage, the methods used have been aimed at reducing mechanical stress on the damaged tissue or stimulating the overgrowth of defects by fibrous tissue . These efforts have never resulted in the restoration of a normal joint surface. Based on recent successful research in cell biology, many studies have now documented considerable progress in the transplantation of chondrocytes grown in vitro. Another boost for the transplantation of joint cartilage together with bony tissue came with the development of new surgical instruments. In particular, the extremely high-precision methods used in production of the new diamond-coated cutting instruments has made it possible to apply a press-fit technique allowing really accurate defect coverage. Nonetheless, the literature does not contain any classification of the different techniques by indication; nor is any such classification reflected in clinical practice.     

Variable curvature shape- memory spatula for laparoscopic surgery

Summary A curved spatula made from a pseudoelastic nickel-titanium alloy (Tinel) has been developed and evaluated in animal experiments prior to its use in humans. Its adjustable, curved functional end enables laparoscopic dissection around structures such as arteries, ducts, the oesophagus and the colon. The initial experience with this pseudoelastic instrument has been entirely favourable and indicates the need for the development of a new generation of laparoscopic instruments based on shape-memory alloys.     

POSSIBLE VENOUS AIR EMBOLISM WITH A NEW WATER JET DISSECTOR

An incident of apparent major venous air embolism occurred duringhepatic resection using a water jet dissector, an instrumentusing a high pressure, high velocity jet to disintegrate liverparenchyma. (Br. J. Anaesth. 1993; 70: 466–467)     

A newly designed single dissector useful for laparoscopic cholecystectomy

Summary We developed a modified dissector capable of carrying out a one-hand operation involving three fundamental functions: grasping, sharp or blunt dissection, and dividing the tissues. With this single dissector, laparoscopic cholecystectomy can be rapidly and safely performed without changing the forceps or instruments through the trocar.     

几种肝切开(断)术的比较

本文描述一种简易、安全的断肝法─—刮吸法，同时介绍一种高效率的器械─—彭氏多功能手术解剖器（ＰＭＯＤ）。文中还对刮吸法切肝和钳折法切肝二组病人进行了比较，每组各４６人。结果：平均出血量刮吸法为钳折法的一半（Ｐ＜０．０１），平均断肝时间也是刮吸法短于钳折法，约缩短４０％（Ｐ＜０．０１）。讨论了指折法、钳折法、微波刀、激光刀、水射和超声解剖器（ＣＵＳＡ）等方法的器械的优缺点。认为刮吸法的优点超过其它各种方法；ＰＭＯＤ较之ＣＵＳＡ经济、实用、安全和高效。     

Correction of the nasal tip and columella in Koreans by a complete septal extension graft using an extensive harvesting technique.

The nose of most Koreans is characterised by a low nasal dorsum, retracted columella, and an acute columella-labial angle. For the surgical correction of the tip and columella, a complete septal extension graft, along with augmentation rhinoplasty has been developed. However, the use of this type of graft is frequently problematic because the septal cartilage is not large enough. In a study involving 10 cadavers, a complete septal extension graft was achieved in two of them by using septal cartilage harvested according to standard techniques. Therefore, the septal cartilage was harvested, leaving a 5-mm L-shaped strut, and a complete septal extension graft was implanted. The present report describes the results obtained in 34 patients and offers an analysis of the results as judged by the columella-labial angle and three proportional indices (nose height index, nasal bridge length index, and nasal tip projection index), measured by photogrammetry. The postoperative values obtained in these four categories increased significantly compared to the preoperative ones, thus confirming that the projection of tip was augmented, the nose was lengthened, and the columella was advanced caudally. Moreover, these positive outcomes were maintained during long-term follow-up, and no side effects, such as saddle nose deformity, were reported.     

The suction knife in liver surgery

A simple, inexpensive alternative method of blunt dissection for dividing liver parenchyma utilizing a suction knife is presented. The device, made from an ordinary suction tube, has been used successfully in six patients. Details of the device and method are discussed herein.     

Brain spatula with transparent tip: Technical note

Summary A newly developed brain spatula with transparent tip for brain retraction is introduced. The high-molecular polymer plastic material is used only for the tip of the new spatula whilst rest of the spatula is made up of the ordinary malleable metal. The transparent nature of the spatula tip helps us in observing the retracted brain vessels and cranial nerves in continuity with the main operating area. The extent of distortion as a result of the retraction can be directly observed assisting in prevention of an inadvertent injury. The new brain spatula with transparent tip is helpful for microneurosurgery under high magnification. Various shapes and sizes of the spatula can be used.     

Intramedullary pressure increase and increase in cortical temperature during reaming of the femoral medullary cavity: the effect of draining the medullary contents before reaming

BACKGROUND:Reaming is regarded as the most adverse aspect of the intramedullary nailing procedure since it leads not only to impairment of the vessels but also to an increase in intramedullary pressure and cortical temperatures which may in turn lead to aseptic cortical necroses and pulmonary dysfunction. Intramedullary pressure increase is considered to be the most detrimental of these factors. METHODS: The aim of this study was to investigate the effect on intramedullary pressure and cortical temperature of removing the medullary fat before reaming. The fat was removed through a suction tube inserted proximally. The measurements were made on pairs of human femora whereby in one group the contents of the medulla were drained by suction before reaming. The pressure was measured in the mid diaphysis and in the metaphysis. The temperature was measured in the mid diaphysis. The femora were reamed in a water bath at 37 degrees C and at a constant insertion force. RESULTS: In comparison to the group which was not drained, the pressure for the 9.0 mm reamer in previously drained femora was reduced as follows: positive diaphyseal pressure by 88% (reamer insertion); positive metaphyseal pressure by 78% (reamer insertion); negative diaphyseal pressure by 84% (reamer withdrawal); negative metaphyseal pressure by 65% (reamer withdrawal). No significant difference was determined for temperature increase (median suction, 39.7 degrees C; median without suction, 39.4 degrees C). CONCLUSION: The removal of the medullary contents by suction before inserting reaming instruments leads to a considerable and statistically significant pressure reduction. If the medullary contents are not sucked out before reaming or insertion of unreamed nails, high intramedullary pressure and the risk of embolization is unaltered. Consequently new instruments should be developed to facilitate the removal of the medullary contents before commencing the reaming procedure or insertion of unreamed nails.     

The laparoscopic sponge

Purpose: Hemorrhage and spillage of enteric contents during laparoscopic surgery can be problematic and obscure the operative field. Although the suction device can often clear the field, we have found that use of a sponge is often more efficient and effective. Materials and methods: An unrolled 4 × 4 sponge can be introduced down a 10-mm port without difficulty. The addition of a suture tied to one corner of the sponge allows easy retrieval of the sponge and eliminates the possibility of leaving the sponge in the abdomen. Conclusions: The laparoscopic sponge is simply constructed and is easily introduced and retrieved through a trocar. It can be used to deal with a troublesome hemorrhage, either to put on direct pressure or to absorb blood. It can also be used as a blunt retractor and dissector. With the addition of the suture tail, it is quickly retrieved and cannot be forgotten within the abdomen.