clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer
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SECTION 1 |
General Principles |
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Laparoscopic Surgery |
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Establishing Pneumoperitoneum |
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Pneumoperitoneum can be established using a Veress needle or by an open approach. The open technique is generally preferred, as it minimizes the risks of inherent lesions to the small bowel. However, in obese patients, the Veress needle is used, as the thick subcutis does not allow visualization of the fascia through a 1–2cm incision.
Gaining Access with a Veress Needle
■Incision of the skin (generally infraumbilical in the midline) and blunt dissection of the subcutaneous tissue
■The fascia is grasped with a hook retractor or a Kocher clamp and is pulled anteriorly (A-1)
■Before inserting the Veress needle, its correct functioning must be checked
■Insertion of the needle at a 90° angle to the abdominal wall. As the needle’s springloaded safety mechanism crosses the abdominal fascia and then the peritoneum, two clicks are heard and are usually felt
■Verification of the needle’s intraperitoneal location by injecting 3ml of saline with no resistance (A-2) followed by the “hanging drop” test (A-3) (i.e., a drop of saline is placed on the top of the needle, which is sucked into the needle when the abdominal fascia is lifted up)
■Pneumoperitoneum. When a pressure of 13–15mmHg is reached, the Veress needle is withdrawn, and a sharp-tipped camera trocar is blindly inserted through the same incision
A-2
A-1
A-3
Positioning and Accesses |
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Gaining Access with the Open Technique
■Incision of the skin (generally infraumbilical in the midline) and blunt dissection of the subcutaneous tissue
■Incision of the fascia (1–2cm) and opening of the peritoneum with scissors (two sutures can be placed to lift up the abdominal wall and to later secure the port) (A-1)
■Entry into the abdominal cavity is easily confirmed by inserting a finger
■A blunt-tipped camera trocar is inserted and fixed with the two sutures if needed (A-2)
A-1
A-2
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A-1
SECTION 1 |
General Principles |
Placement of Accessory Ports
Selecting the insertion sites of working trocars is dependent on the procedure to be performed and also depends on the surgeon’s preference, the patient’s body habitus, and the presence or absence of previous scars or intra-abdominal adhesions.
The Steps
■The size of the skin incision must be planned carefully. If the incision is too small, friction will develop between the skin and the port, and greater force will be required for insertion, which will increase the risk of uncontrolled insertion. If the incision is too large, gas may leak and the port may dislocate more easily
■Transillumination of the skin can help to avoid cutting through major blood vessels (A-1)
■The trocar is optimally inserted by holding it between the index and the middle fingers. The shaft of the trocar should also be supported by the opposite hand as the body wall is traversed (A-2)
A-2
Positioning and Accesses |
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Closures
General
■the length of the suture material should be 4:1 to the length of the wound
■avoid excessive tension on the suture closure of the fascial edgestraction as it may compromise vascularization of the wound edges
■below the umbilicus, the posterior fascia (rostral to the smi-circular line caudal to which there is no posterior rectus fascia) and then the anterior fascia of the rectus abdominis muscle can bei closed as separate layers
■Grasp the needle with the tip of the instrument
Midline Laparotomy
■The fascia is closed with a running loop of monofilament, absorbable suture material (e.g., PDS II-1 loop or Maxon-1 loop) with or without inclusion of the peritoneum
■The subcutaneous fatty layer is not closed and subcutaneous drains are rarely needed
■The skin is preferably closed with a running intracutaneous absorbable monofilament suture (e.g., Maxon 5-0) or with staples
Subcostal Incision
■ In contrast to the midline laparotomy, the fascia should be closed in two layers
Trocar Wound Closure
■Ports are removed under direct vision with the camera and port sites should be routinely watched for 10s to exclude port site bleeding
■All fascial defects of trocars greater than 5mm are closed with absorbable sutures (e.g.,Vicryl 0)
■The skin is closed with interrupted mattress sutures (e.g., Dermalon 4-0) or with staples
Tricks of the Senior Surgeon
■The surgeon should personally check the correct positioning of the patient and the adequate protection of the extremities before draping.
■Marking the incision site before the beginning of the procedure is useful for teaching and prevents malpositioning.
■The incision should always be large enough to guarantee good visualization of the operative fields and to guarantee a safe and efficient operation
■Avoid extensive traction on the wound edges, as it may compromise healing.
■Place trocars carefully according to the operative need and according to the body habitus of the patient (eg. obesity).
■Visualize the port site for at least 10s after removal of the trocar to check for bleeding.
Retractors and Principles of Exposure
Tim Gessmann, Markus Schäfer
Principles of Surgical Exposure
Introduction
Adequate exposure of the target organ represents a laudable prerequisite of every successful operation. Therefore, it is worthwhile to be equipped with different retractors and to invest enough time intraoperatively to optimize exposure. Basic principles of exposure have recently been challenged by the advent of minimally invasive surgery. However, minimally invasive surgery has only changed the means of surgical access; the procedures performed at the target organs remain largely unchanged. In contrast to open surgery, exposure during laparoscopy is achieved predominantly by patient position and trocar placement. Retractor systems are less important.
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A
SECTION 1 |
General Principles |
Retractor Systems
In general, a retractor system needs to fulfill the following requirements for an ideal surgical exposure:
■Broad, unrestricted view into the abdominal cavity
■Wide access to the target organ
■Illumination provided or enabled
■Stable retraction of the abdominal wall and surrounding organs
■Careful tissue retraction, preventing local ischemia
■Freeing up the hands of the surgeon and assistants
■Adaptability in usage (different patients, different incisions, etc.)
■Various type of accessories to retract the abdominal wall and organs
Hand-held retractors have the main disadvantage of losing „free hands“ of the surgical team. Self-retaining retractors are most commonly used to keep open the abdominal and thoracic cavity.
Two types of self-retaining retractors are available:
1.Closed ring retractors:
Ring system retractors are self-stabilizing by the retaining force of the different retracting devices and do not necessarily need to be fixed to the operating table (e.g. Kirschner, A). The best exposure is achieved by placing one retracting device strictly opposite to the other. In some systems, stabilization and exposure can further be improved by attaching the ring to the operating table by a rail arm.
2.Arm retractors:
Arm retractors need to be fixed to the operating table. They allow for an asymmetric exposure (e.g. Thompson, B).
B
Retractors and Principles of Exposure |
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Overview of Different Self-Retaining Retractors
Thompson (previous page, see figure B)
The basic compounds of this very stable retracting system are the rail arm, the two rods, and the different retracting paddles that are attached to a retaining arm. The Thompson retractor is favored for uniand bilateral subcostal incisions, which are often used for hepatobiliary procedures, in which most of the retraction required is oriented cephalic and anteriorly. The exposure of the lower abdominal parts is limited. There is a wide range of blades and paddles available as accessories.
Bookwalter (C)
This system has a frame (closed ring) fixed by a rail arm attached to the operating table. Different retracting accessories, such as blades and paddles, are available that can be clamped to the frame. The Bookwalter retracting system is used for both longitudinal and transverse abdominal incisions. Although some training is necessary to achieve a safe installation, fine adjustment is possible in three dimensions. Cleaning and sterilization need substantial effort due to the rather complex single components.
C
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A-1
SECTION 1 |
General Principles |
Omnitract
Although this retractor system needs precise installation, it offers excellent access for most incisions. The open frame system can easily be completed to a closed ring. This retractor can be used widely for intraperitoneal and retroperitoneal operations. Maintenance and cleaning are not too elaborate. The figure shows longitudinal (A-1) and transverse (A-2) laparotomy using the Omnitract system.
A-2
Retractors and Principles of Exposure |
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Rochard
The Rochard retractor (not shown) is a single blade retractor that is mainly used for upper GI surgery. A large semicircular blade retracts the abdominal wall, and is attached to a fixed arm at the operating table. The main disadvantages are the unidirectional tension and the lack of lifting the abdominal wall.
Kirschner, Balfour, O’Sullivan-O’Conner (A, B)
The Kirschner frame (A) and the Balfour retractor (B) are good examples of systems that do not need any form of rail arm. However, retraction is not as stable and tension in the vertical dimension is not possible. They are rapidly usable, readily available, and are preferred when only lateral exposure is desired.
A
B
Recommendation
Many factors and aspects influence the choice of a specific retractor. Some commonly used retractors are compared in Table1. More than one type of retractor should be available to obtain the best possible exposure of the different parts of the abdominal cavity.
Table 1. Comparison of different retractor systems
System |
Construction |
Installation |
Adjustment |
Accessories |
Maintenance |
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Bookwalter |
Closing ring and fixation |
Complex |
Three dimensions |
+++ |
Elaborate |
Thompson |
Arm |
Complex |
Three dimensions |
+++ |
Elaborate |
Omnitract |
Arm |
Complex |
Three dimensions |
+++ |
Elaborate |
Rochard |
Arm |
Complex |
Tension only in one direction |
+ |
Elaborate |
Kirschner |
Closing ring |
Quick |
Limited |
++ |
Easy |
Balfour |
Closing ring |
Quick |
Limited |
+ |
Easy |
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26 SECTION 1 General Principles
Retractors in Laparoscopic Surgery
Whereas the abdominal wall is lifted by the pneumoperitoneum, intra-abdominal exposure is achieved primarily by patient positioning and trocar placement. There are several devices that may be used to retract the liver during upper GI operations, such as laparoscopic fundoplication, gastric bypass, or adrenalectomy.
Tricks of the Senior Surgeon
■For optimal use, be familiar with several retractors and have a good knowledge of their individual advantages.
■Slow, incremental retraction prevents rib fractures and postoperative pain.
■Intermittent release of the retraction during long duration operations prevents local ischemic complications.