Robotically assisted minimally invasive biliary surgery in aporcine model

BACKGROUND: A robotic surgery system has the potential both to reduce the effects of tremor and fatigue and to enhance dexterity in the performance of complex, fine endosurgical tasks. We report a prospective study of robotically assisted minimally invasive biliary surgery in a porcine model using the Zeus robotic surgical system (Computer Motion, Goleta, Ca, USA). METHODS: For this study, 50-kg domestic swine were used. Minimally invasive robotically assisted cholecystectomy was performed in 16 animals, either longitudinal or transverse common bile duct incision, T-tube placement, and suture repair of the common bile duct. Retrieval of 12 simulated bile duct calculi was attempted. Eight animals were monitored for 6 weeks postoperatively. Liver function tests and cholangiography were performed 2 and 6 weeks after surgery. RESULTS: The median setup time for the robotic system was 45 min (range, 10-120 min). The median operative time was 40 min (range, 25-60 min) for cholecystectomy and 80 min (range, 40-165 min) for bile duct dissection, exploration, and repair. Of 12 bile duct calculi, 11 were retrieved successfully. Cholangiography demonstrated no leaks, and the anastomotic stenotic index (diameter of the proximal bile duct divided by the diameter of distal bile duct) at 6 weeks was 0.98. The results of the liver function tests remained normal in all animals. One postoperative death unrelated to operative technique occurred. Complications included one minor splenic laceration and two intraoperative gallbladder perforations. CONCLUSIONS: Robotically assisted minimally invasive biliary surgery in this animal model is both feasible and safe. The Zeus system provides enhanced dexterity, which facilitates precise laparoscopic suture repair of small bile ducts.     

微创手术治疗桡骨远端Barton骨折

目的 探讨采用闭合复位内固定术和有限切开复位可吸收螺钉内固定治疗桡骨远端Barton骨折的可行性。方法 1990年5月-2004年5月，对25例桡骨远端Barton骨折的患者，采用微创手术治疗。其中16例在X线机透视下，采用手法复位克氏针内固定术（闭合复位内固定组）；9例采用有限切开复位可吸收螺钉内固定术（有限切开内固定组）。结果 术后23例获得6个月～1．5年随访，2例失访。闭合复位内固定组术后4～6周骨折达到骨性愈合，有限切开内固定组6．8周达到骨性愈合，其中1例出现骨性关节炎。按Deoliveiva腕关节功能评定标准：闭合复位内固定组优11例，良3例，可1例，优良率达93％。有限切开内固定组优4例，良3例，差1例，优良率达87％。结论 微创手术治疗桡骨远端Barton骨折，操作简单，创伤小，功能恢复满意。     

髌骨骨折的微创治疗

[目的]探讨微创方法治疗髌骨骨折的疗效。[方法]采用闭合复位空心螺钉固定或空心螺钉加张力带钢丝固定。[结果]全部病例骨折均骨性愈合，膝关节功能综合评价：优15例；良1例。[结论]本方法符合髌骨骨折内固定的生物力学要求，手术创伤少，可早期下地活动，有利于膝关节功能的恢复。     

食管平滑肌瘤的微创手术治疗

目的探讨微创手术在食管平滑肌瘤治疗中的临床应用价值. 方法回顾性分析1996年9月～2002年10月26例食管平滑肌瘤采用微创手术治疗的临床资料. 结果电视胸腔镜食管平滑肌瘤摘除术23例,其中3例(2例胸膜腔紧密粘连,1例肿瘤无法定位)中转开胸(胸腔镜辅助小切口);经颈部食管平滑肌瘤摘除术2例;经食管镜食管平滑肌瘤切除1例.26例手术顺利,术后恢复平稳,无手术死亡及严重并发症,术后病理诊断均为平滑肌瘤.随访2～73个月,平均32.3个月,无复发. 结论电视胸腔镜肌瘤摘除术可作为食管固有肌层平滑肌瘤的首选治疗方法,对于食管粘膜肌层的平滑肌瘤,可考虑经食管镜切除.     

Training for minimally invasive surgery

Summary Controversy exists regarding the training of surgeons for the performance of minimally invasive surgical procedures. The use of live animals is essential, especially in teaching dissection techniques. Seventeen percent of animals experienced excessive operative hemorrhage, which contributed to premature mortality during training exercises, demonstrating the need for live animals in this component of the training. A number of abdominal procedures can be performed with minimally invasive techniques without suturing by utilizing a rapidly expanding array of devices. However, other procedures cannot be successfully accomplished without suturing skills. Laparoscopic suturing skills are particularly demanding; thus specific training and practice prior to hands-on exercises in animal models is recommended. Emphasis on acquisition of advanced laparoscopic surgical skills is a necessity.Presented at the Third World Congress of Endoscopic Surgery, June 20, 1992, Bordeaux, France     

Anaesthesia and minimally invasive surgery

Minimally invasive surgery is commonly performed because of various advantages such as reduced postoperative pain, faster recovery, and reduced postoperative pulmonary complications. However, anaesthesia for laparoscopy can be difficult and potentially hazardous in long, complex surgical procedures and in sick patients. Establishment of CO₂ pneumoperitoneum produces adverse pathophysiological changes due to increased intra-abdominal pressure and hypercapnia, and these are further altered by postural changes. Laparoscopy is also associated with potential complications such as extraperitoneal gas insufflation and pneumothorax. It is important for the anaesthetist to understand the advantages and potential risks. General anaesthesia with endotracheal intubation is the most common anaesthetic technique, but supraglottic airway devices can sometimes be used. Neuroaxial anaesthesia has been used in some laparoscopic procedures as the sole anaesthetic technique. This article will focus on the pathophysiological changes caused by CO₂ pneumoperitoneum, the anaesthetic management for patients undergoing laparoscopy, and potential complications.     

Anesthesia for minimally invasive surgery

Canadian Journal of Anesthesia/Journal canadien d'anesthésie -     

Anaesthesia and minimally invasive surgery

As with so many different forms of anaesthesia, anaesthesia for minimally invasive surgery is dependent on the type of surgery being performed and the impact of the surgical procedure itself on the human body. With an increase in the number of surgical specialties embracing laparoscopic procedures, anaesthetists must consider the risks and benefits to the patient. On the whole, laparoscopic procedures are well tolerated. The advantages of laparoscopic surgery compared with open procedures are associated with reduced morbidity and mortality. The reductions in acute pain and postoperative respiratory tract infections and ileus allow earlier mobilization and lead to earlier discharge. Laparoscopy also improves the cosmetic appearance. It improves the view of the operative field and enables alternative anatomical views to be seen. Anaesthesia per se is fairly standard in minimally invasive surgery, but it is the comprehension of the effects of the position of the patient and that of the pneumoperitoneum that can make the difference between a successful or less elegant outcome.     

Validation of a six-task simulation model in minimally invasive surgery

Background The content validity of currently available inanimate simulation models is questionable, because some tasks seem too far from clinical reality. The aim of this study was to validate a simulation model with six tasks commonly used in clinical practice (6-TSM) for the acquisition of psychomotor skills in minimally invasive surgery (MIS).Methods This was a prospective randomized trial comparing the 6-TSM to a previously described three-task training method (3-TTM). All first, second, and third postgraduate year surgical residents were eligible. The 6-TSM included clipping and dividing of a vessel, excision of lesion, appendectomy, mesh repair, suturing perforation, and hand-sewn anastomosis. The outcome measures of 6-TSM included accuracy error, tissue damage, sliding knot, leak, operating time, and dangerous movements. After completion of training, 6-TSM and 3-TTN residents were tested by the Minimally Invasive Surgical Trainer—Virtual Reality (MIST-VR). Criterion-related and construct validity, responsiveness, test–retest, and interrater reliability were assessed.Results During six months, 17 residents underwent training with the 6-TSM or the 3-TTM as allocated. The mean duration of training with 6-TSM and 3-TTM was similar (7.8 vs 8.1 h). The criterion-related validity of the 6-TSM was shown by significantly increased skill improvement in the 6-TSM residents, as compared with the 3-TTM residents at MIST-VR. Construct validity the of 6-TSM was shown by the finding that the experts baseline was superior to the residents baseline. The responsiveness of the 6-TSM was shown by the significantly increased skill improvement of the 6-TSM residents in sliding knot, leak, and operating time. The test–retest reliability of the 6-TSM was good (> 0.80), except for accuracy error and dangerous movements (Cronbachs intraclass correlation coefficient : 0.57, p < 0.0001; 0.62, p < 0.0001, respectively). The interrater reliability of the 6-TSM was good (>0.80) except for leak (Kendalls concordance coefficient tau_b:0.76, p = 0.06 for hand-sewn anastomosis) and dangerous movements (tau_b:0.72, p = 0.08 for suturing perforation and tau_b:0.68, p = 0.10 for hand-sewn anastomosis). The perresident cost for 6-TSM was $769.Conclusions The 6-TSM is a valid and reliable learning tool for surgical residents acquisition of laparoscopic motor skills.     

Anaesthesia and minimally invasive surgery

Minimally invasive surgery is commonly performed because of various advantages such as reduced postoperative pain, faster recovery, and reduced postoperative pulmonary complications. However, anaesthesia for laparoscopy can be difficult and potentially hazardous in long, complex surgical procedures and in those with significant co-morbidity. Establishment of carbon dioxide (CO₂) pneumoperitoneum produces adverse pathophysiological changes due to increased intraabdominal pressure and hypercapnia, and these are further altered by postural changes. Laparoscopy is also associated with potential complications such as extraperitoneal gas insufflation and pneumothorax. It is important for the anaesthetist to understand the advantages and potential risks. General anaesthesia is most commonly used but neuraxial anaesthesia is possible, although spontaneous ventilation may be difficult. Endotracheal intubation has been a popular technique but supraglottic airway devices are less traumatic, easier to insert and more modern versions provide a good airway seal as well as gastric drainage, should it be required. This article will focus on the pathophysiological changes caused by CO₂ pneumoperitoneum, the anaesthetic management for patients undergoing laparoscopy, and potential complications.     

Instruments for minimally invasive surgery

Although the advantages of minimally invasive surgery (MIS) have been clearly established for the patient, the surgeon must cope with disadvantages caused by unergonomic instrument handles. Pressure areas and persisting nerve lesions have been described in the literature. The shape of the instrument handles has been identified as the reason for these disorders. To prevent these, it is necessary to use ergonomically designed handles for MIS instruments. Anatomic, physiologic, and ergonomic facts as well as the results of the authors' own experiences and tests are presented. On this basis, an ideal ergonomic working posture for the laparoscopic surgeon and an optimal grasp for manipulating the instruments' functional elements are recommended. To enable the surgeon to evaluate ergonomic handles for MIS instruments according to his own needs, 14 criteria for genuine ``ergonomic handles' are established. On the basis of these criteria, deficiencies of handles currently available (ring and shank handles at an angle or with axial extension to the instrument shaft, and pistol handles) are discussed. Furthermore, new handles, developed by the authors according to the criteria for genuine ergonomic handles, are presented. Received: 12 September 1997/Accepted: 28 May 1998     

甲状腺微创外科进展

随着国内外腔镜技术及微创理念的不断推广,腔镜甲状腺手术出现了各种不同的手术方式和快速发展,笔者就常见的腔镜甲状腺手术径路、建腔方式及新技术、新理念作一综述。     

Imaging systems in minimally invasive surgery

The imaging system is the eye of the laparoscopic surgeon. The success or failure of a minimally invasive procedure depends on the quality and working order of the imaging system used. The components that work together to produce an image on the monitor is called the imaging chain. The image displayed will be good as the chain's weakest component. Understanding how the pieces of this process work together will allow the surgeon to troubleshoot basic system problems, leading to improved image displays and safer operating environments. Continuous refinement of laparoscopes, lighting systems, cameras, monitors, and displays lead to an ever-improving operating environment.     

Outcomes assessment and minimally invasive surgery

Background: Outcomes assessment is being used increasingly to shape practice patterns in all areas of medicine. Although outcomes assessment is not a new concept, the widespread application of outcomes measurement for modifying practice is novel. Instead of focusing on results of interventions in highly controlled environments, outcomes studies usually report results as they occur in uncontrolled, real-world environments. Recently, the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) has initiated a society-wide initiative to monitor outcomes in patients undergoing various laparoscopic operations. Methods: Pertinent literature is reviewed as it relates to outcomes assessment. The historical background underpinning the modern interest in outcomes is outlined. Definitions of terms useful for understanding outcomes research are given. The impact of outcomes assessment on minimally invasive surgery, both positive and negative, are examined. The SAGES outcome initiative is introduced. Conclusions: Although outcomes studies usually do not provide information on the causes of observations made, they have gained in popularity because they provide information about patient perceptions of disease, disability, and treatment. Minimally invasive surgical procedures often are reported in terms of outcomes assessment because a controlled clinical trial was rendered impossible by early and widespread application of laparoscopic surgery. The SAGES outcomes initiative will provide the necessary tools for the participation of surgeons in the process of practice profiling. Received: 17 December 1999/Accepted: 4 April 2000/Online publication: 29 August 2000     

Immunologic changes during minimally invasive surgery

Although recent experimental and clinical trials have documented that postoperative inflammation and changes in different immunologic parameters are less pronounced after laparoscopic approaches in comparison to open surgery, it still remains unclear what influence the pneumoperitoneum itself has on immunologic defense and function. This is mainly due to the endpoints of the different studies which investigate changes in the so-called immunologic parameters (cell subunits, C-reactive protein, cytokines, catecholamines or other stress hormones in plasma samples) rather than analyzing immunologic functions, such as cell activation, production of proteins, cell proliferation or in vivo immune defenses. So far, especially in clinical trials, no correlation has been demonstrated between the changes in immunologic parameters and relevant postoperative clinical endpoints, such as postoperative complications. Thus further clinical prospective randomized studies with relevant clinical endpoints and additional investigations of immunologic parameters are needed to prove the consequences of either minimally invasive surgery or open procedures on postoperative immune functions.     

Intraoperative enteroscopy in minimally invasive surgery

PURPOSE: The purpose of this study was to assess the efficacy and safety of intraoperative enteroscopy (IOE) in patients undergoing minimally invasive surgery. METHODS: Twelve patients underwent minimally invasive surgery and IOE at Miyazaki University Hospital. Patients included 11 men and 1 woman. After extraction of the intestine via minilaparotomy, enterotomy was performed, and a sterilized enteroscope was inserted. RESULTS: Length of the skin incision was 5.7+/-0.2 cm (mean+/-standard error). Length of the small intestine observed enteroscopically was 334+/-19 cm. Distance from the ligament of Treitz to the orally observed jejunum was 11.8+/-3.6 cm. In 5 of 9 patients with Crohn disease, additional lesions were found by IOE that were not found by preoperative examination. One additional tumor was found in 1 patient with ileal tumor. Postoperative complications occurred in 2 patients. CONCLUSION: IOE is efficacious in patients undergoing minimally invasive surgery.