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3-D vision technology applied to advanced minimally invasive surgery systems.

Current-generation vision for laparoscopic surgery involves flat two-dimensional display on a video monitor; this approach makes it difficult to accurately place the tip of a surgical instrument in the three-dimensional real space of the patient. The surgeon must rely on motion parallax, monocular cues, and other indirect evidence of depth to judge accurately the correct spatial relationship of objects in the field of view. Stereoscopic video can return accuracy to the surgeon. Critical elements in creating stereovision are the biophysical laws governing field of view, focal point, depth of field, accommodation, and convergence. In addition, engineering constraints must be followed, such as fitting a 10-mm port, which are compatible with current systems and economic feasibility. There are two methods for 3-D vision under development which are variations on the same theme of modifying standard laparoscopes by using lenses, mirrors and prisms, and optical shuttering. One method uses two video cameras to simultaneous capture two separate images from a paired optical system. Each image is alternately transmitted to the video monitor (field sequential video) and viewed with electronic or polarizing glasses for a 3-D image. Another method uses a standard laparoscope, optically splits this one image into alternating right/left images, and reconstructs the image as above. A major challenge for both systems is that the distance between the optical elements in the laparoscope is not greater than 10 mm apart and fixed, whereas the human interpupillary distance is greater than 650 mm and can accommodate.(ABSTRACT TRUNCATED AT 250 WORDS)

Computer Graphics↗

Bacteriological study of surgical knives: is the use of two blades necessary?

Scalpel blades used in 115 operations were studied bacteriologically. In each case the knife used for skin incision was discarded immediately after the incision and a fresh knife was used to complete the operation. The scalpel blades were cultured in enriched thioglycolate and incubated at 37 degrees C. Readings were taken at 24 and 48 h. From positive cultures, colonies were isolated directly in solid media, and the germ was identified using routine tests. Results showed that there was no bacteriological evidence to justify the use of different blades for skin incision and deep dissection.

Colony Count, Microbial↗

Comparative morphological investigation on the rabbit's auricle after exposure to CO2- and Nd:YAG-laser radiation.

By comparing the effects of CO2- and Nd:YAG-laser radiation (mainly differing in wave-length by a factor of 10), a surgical instrument suitable for Otorhinolaryngology had to be found. The studies were performed on the rabbit's auricle in order to examine the effect of the laser irradiation mainly on the cartilage. The CO2-laser was found to be more efficient in cutting and caused less extended tissue damage than the Nd:YAG-laser. The latter seems to be more suitable for soft tissue surgery.

Animals↗

Percutaneous cervical diskectomy: preliminary experience.

We assessed the feasibility of percutaneous treatment of a cervical herniated disc. In the lumbar region, the surgical instrument for percutaneous diskectomy passes only through the paravertebral muscles, while in the cervical region there is considerable risk of nervous, parenchymal and vascular lesions. Moreover, open surgery for cervical herniated nucleus pulposus is a well-established, low-risk procedure, with little risk of epidural fibrosis, the main complication of lumbar open surgery; a percutaneous procedure should therefore have a low morbidity rate. A safe percutaneous approach to cervical discs could be useful for biopsy and for treatment of high-risk patients for general anaesthesia. We treated 15 patients with cervical herniated nucleus pulposus; all gave informed consent and refused or were not eligible for open surgery. We used the Nucleotome described for treatment of lumbar herniated discs; except for the first three cases, we used colour Doppler sonography to detect hazardous structures in the path of the probe. We had one complication, a cervical haematoma due to damage to the inferior thyroid artery, prior to the use of ultrasound.

Cervical Vertebrae↗

Video thoracoscopic excision of an intercostal neurilemoma presenting as a lateral chest wall tumor.

Thoracoscopic surgery has expanded with advances in endoscopic surgical instrumentation. We report on a 21-year-old woman with a complete thoracoscopic resection of an intercostal neurilemoma, which occurred extrapleurally in the ninth intercostal space of the lateral thoracic wall. The tumor was 70 x 40 x 25 mm in size, but a thoracotomy with a rib resection was avoided. The patient had an uncomplicated postoperative course and was discharged on the fourth postoperative day. Thoracoscopic resection of an intercostal neurilemoma, presenting as a lateral chest wall tumor, may be a safe and useful approach with an improved cosmetic result.

Adult↗

A prospective randomized trial comparing pneumoperitoneum and U-shaped retractor elevation for laparoscopic cholecystectomy.

Between April and August 1991, 83 Japanese patients with symptomatic gallstones underwent laparoscopic cholecystectomy in our clinics. A prospective randomized trial was carried out to examine the safety, efficacy, and complications of the two techniques, pneumoperitoneum vs an elevating method using a U-shaped retractor. Forty-two patients were randomly allocated to the pneumoperitoneum (P) group and 41 to the U-shaped retractor (U) group. These two groups were well matched with respect to age, sex, etiology, and the severity of the chronic cholecystitis. Laparoscopic resection was successful for 88.1% (37/42) in the P group and 100% (41/41) in the U group. In patients with a severe fibrotic gallbladder, the rate of success was significantly higher (P < 0.05) in the U group (100%, 6/6) than in the P group (11.8%, 1/6). In the moderately inflamed group, the operation time (mean +/- SD) was significantly (P < 0.01) less in the U group (58.7 +/- 22.7) than in the P group (87.3 +/- 18.3). With the U-shaped retractor the usual surgical instruments can be used, and a rapid and safer laparoscopic cholecystectomy can be carried out. We prefer this approach to a pneumoperitoneum for patients with an inflamed gallbladder as hospital stay and pain are minimal.

Cholecystectomy, Laparoscopic↗

[Surgical treatment in coronary heart disease (author's transl)].

This paper describes the operative techniques appropriate to the treatment of coronary heart disease. The chapters deal with general preliminaries and indications for surgery, the selection of bypass material, surgical instruments for coronary opertaions, the methods of extracorporeal circulation, the distal coronary anastomosis, the proximal aortal anastomosis, intraoperative monitoring of results, intra- and postoperative myocardinal infarction, the fate of venous bypass grafts, operative treatment of the ruptured ventricular septum and papillary muscle, and ventricular aneurysmectomy.

Coronary Artery Bypass↗

[Experimental liver and kidney surgery with CO2, CO, holmium, and neodym lasers. Cutting effect, hemostasis, histopathology, and healing (author's transl)].

Various laser devices (CO2, CO, Nd: YAG, and holmium: YAG lasers) have been used on pig livers and on dog kidneys for comparison with conventional surgical instruments (electroscalpel, cryoscalpel, and scalpel). CO2 and CO lasers caused the least tissue damage, followed by the holmium laser; severe damage was caused by the Nd: YAG laser. The order was reverse for coagulative effect. The conventional reference instruments showed a weaker hemostatic effect. Surfaces cut by laser healed in four to eight weeks without complications. Remnants of charred tissue in various quantities could still be detected after eight weeks in all cases where CO2, CO, and Nd: YAG lasers had been used. This obviously did not affect scar formation.

Animals↗

[Laparoscopic hernia repair].

From January 1992 to February 1993 a total of 361 inguinal hernia repairs were performed in our unit. We routinely performed the Shouldice repair. In 60 patients, 46 men and 14 women, 19-82 year old, we closed the inguinal defect with a patch, performing a "tension-free" repair by a laparoscopic technique. In 26 patients we found a left-sided hernia, in 21 patients a right-sided, and in 13 bilateral hernias. We found 29 direct hernias, 26 indirect hernias and 18 combined hernias. There were no intraoperative complications. Postoperatively, 1 patient suffered from epididymitis, and 5 patients reported disturbed sensibility of the skin at the medial proximal thigh for some weeks. One patient had an inguinal seroma postoperatively. In this patient we had not removed the hernia sac. There was no recurrence. Long time results are not available until now.

Adult↗

Nontraumatic tubal occlusion as a new technique for female voluntary sterilization.

Female voluntary sterilization is the most popular method of contraception worldwide. It is estimated that around 138 million or 16% of fertile couples, have been sterilized by this method. Female sterilization has been widely employed in Bali since 1970, in accord with '100' formula. The acceptance rate of female sterilization as a family planning method is 7.8% in Bali, and 5.1% nationally in Indonesia. But late complications associated with psychosomatic, psychosexual and menstrual disturbances are not infrequently found, complications attributed to the damage of ovarian blood vessels during the operation. Over the years the female sterilization acceptance rate has kept increasing, especially among the younger age group (around 30 years). A nontraumatic tubal occlusion technique has been developed to preserve the ovarian blood vessel during surgery. With the new technique, late complications could be overcome so women could enter a normal menopausal period. This new technique described here needs further study.

Fallopian Tubes↗

Use of the optical urethrotome knife in the treatment of a benign low rectal anastomotic stricture.

Several methods of treatment for benign anastomotic strictures following anterior resection have been described. Surgical intervention in terms of re-exploration and excision of the stricture or the formation of a permanent colostomy will be accompanied by substantial morbidity. The dilatation of these strictures without direct vision may not be safe. We describe a simple method of treating benign rectal anastomotic stricture using an optical urethrotome knife under direct vision. This technique affords an accurate incision of the stricture to increase the size of the lumen, thereby relieving obstruction.

Anastomosis, Surgical↗

Management of postoperative peritonitis after anterior resection: experience from a referral intensive care unit.

PURPOSE: Anastomotic leakage is the main cause of death after anterior resection. If it causes a single abscess, it may be successfully cured by percutaneous drainage, but in case of extensive peritoneal infection (multiple abscesses and generalized peritonitis), it is associated with a 40 to 60 percent mortality. This study aimed at evaluating aggressive, one-stage surgical management in such cases. METHODS: All patients referred to our surgical intensive care unit during the past ten years with generalized, multilocular, intra-abdominal sepsis after anterior resection were reviewed. There were 32 patients, with a mean age of 65 years, among which 15 (47 percent) were referred from other institutions. The mean Acute Physiology and Chronic Health Evaluation II score on admission was 18. All patients underwent a laparotomy with complete peritoneal exploration, intraoperative lavage, fecal diversion, capillary drainage of the pelvis excluding the rectal stump or the leaking anastomosis from the peritoneal cavity, and primary closure of the abdomen. A Hartmann's operation was done in 22 cases, and conservation of the anastomosis with proximal colostomy was done in 10 cases. The choice was based on the size of the leak, the viability of the colon, and the site of the anastomosis. RESULTS: Four patients died (12 percent), and five patients (16 percent) had recurrent sepsis. When the anastomosis had been conserved, restoration of continuity was achieved in all cases. After Hartmann's operation 8 patients of 19 survivors kept a permanent stoma; 7 had undergone a low anterior resection. CONCLUSIONS: Extensive intra-abdominal infection after anterior resection may be efficiently controlled by a surgical approach combining peritoneal debridement, fecal diversion, and capillary drainage of the pelvis. Intestinal continuity may be restored after diversion stoma or Hartmann's procedure after high anterior resection. This is not the case after a Hartmann's operation after a low colorectal anastomosis, and this procedure should be avoided whenever possible.

Abdominal Abscess↗

Usefulness of bipolar scissors for total colectomy.

PURPOSE: Total colectomy is frequently used in colorectal surgery. We evaluated the usefulness of bipolar scissors in this operation. METHODS: Twenty patients with ulcerative colitis underwent total colectomy at Hyogo College Hospital. Bipolar scissors were used in ten randomly chosen colectomies. The resected major vessels of the colonic mesentery were stained by hematoxylin and eosin. The bursting pressure of the artery weld was measured with a water-filled, open-tip catheter. RESULTS: Both number of ligations and operating time were reduced by use of bipolar scissors. The cut edge of the major artery was occluded by the weld created, with a mean bursting pressure of 213 (range, 175-250) mmHg. CONCLUSION: Use of bipolar scissors was safe and had the advantage of shortening the operating time by decreasing the number of clamping and ligating procedures.

Adolescent↗

Hepatic resections 1964-1979: vignettes drawn from the Malaysian experience.

We present a study of 288 hepatic resections carried out in Malaysia for the past fifteen years. First, we describe our indications for hepatic resectins which are not limited to hepatic trauma and hepatomas, but also include hepatic abscesses, cysts, intrahepatic calculi and hemangiomas. Second, we give a simplified classification of hepatic resections using accurate terminology. Third, we describe the safety of hepatic resections in our hands which we believe is due to specially designed surgical instruments and the accurate decision making process at surgery. We have had minimum postoperative mortality and no intraoperative deaths so far. Finally, while analysing each indication we have drawn vignettes from our experience for the past fifteen years.

Calculi↗