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28 de Diciembre de 2006 |
| Original Text: Evolution of gynaecologic laparoscopic surgical technique |
How to make surgery easier. Introduction: We who had had the mission of beginning with this way of surgery in gynaecology, called endoscopic surgery, were in a great deal self didactic. There are multiple reasons for this. At first, at the beginning of the 90, this new way of surgery broke in with lots of new instruments, which differed from ones of classic laparotomic surgery; and lots of them were unknown patterns and pretended to have great variety of functions and promised success, which made them very attractive but very difficult to dominate. This pretended that the endoscopic access, since it was different, meant a complete different technique. This was why it was so difficult to learn and teach this new way of surgery in gynaecology by the endoscope, way that obliges the surgeon to use small holes for surgery, with different instruments to the ones that they were used to, and different techniques than those in conventional surgery. The result was immediate. Laparoscopy really didn’t have the expected diffusion during the 90. A French study, published in 1999 that Laparoscopic surgery is performed by the 10% of gynaecologic surgeons, and the 10% of these surgeons perform advanced laparoscopic procedures. (1) A great number of new pioneers joined in mid nineties when the European school, specially the French and German school, demonstrated that this new way of surgery could be applied with reusable instruments, identical to the classic ones, with systematic technique, that is to say easier to learn and teach. This remarkable change brought as consequence more surgery, lower costs and less complication. Laparoscopy has demonstrated with irrefutable evidence to be the choice for a great number of gynaecologic surgical pathology, due to the benefits is gives to the patients, its excellent and quick post operatory recovery. This new impulse of endoscopic surgery is built in a solid base thanks to modern ways of learning, training and certification. Teaching laparoscopic surgeries Nowadays the learning of the gynaecologic surgeons, since the beginning to the end of their technical surgery formation takes at least less than half the time than 20 years ago. Our curses of the European Institute of Endoscopic Sciences- IECE-, for Latin-American medical formation, we underline the practice shearing and teaching all the manoeuvres, tricks and gestures that conform the endoscopic surgery. This is so for laparoscopic and histeroscopic surgery. Especially in laparoscopic surgery, we have focused our effort in the teaching of the great column of the good surgical technique:
In successive opportunities, through our different “Newsletters” we will be discussing these themes. Instrumental Sources that promote a correct laparoscopic surgical technique With the objective of evaluate the use of these forceps and collaborate with the development of the surgical technique is that we create this “Newsletter” for the www.endogin.net users. Our experience has demonstrated the need of multi- function forceps. This prevents the continuous change of instruments and saves surgical time. A new multi-function laparoscopic forceps is called “ROBI” from STORZ®. Its name comes from “RO”: rotate and “BI”: bipolar, which describes two of its functions, i.e: rotation over its longitudinal axis and bipolar coagulation. Its “Kelly” name, describes the shape of tip, similar to the laparotomic Kelly forceps. It has also two jaws with symmetrical opening, without light in between. This design allows a delicate and firm grasp.
These multiple functions are used isolated depending of the progress of the surgical act, simplifying and making easier basic surgical gests as: separate, grasp, traction, dissect, and bipolar coagulation. If on the contra-lateral hand, the surgeon has a Metzelbaum scissor with a rounded point, he could use other important functions. And if this scissors is connected to a monopolar current it would be able to use the electric cut with the current set in pure cut, mechanical cold cut, coagulation by direct coupling and also separation and tissue dissection.
That is to say, in both hands the surgeon will able to use 10 functions. This is one of the principles of the use of a correct ergonomy in laparoscopic surgery.
The assistant could also use an aspirator that makes easier for the surgeon to make haemostasis. These instruments selection for gynaecologic laparoscopic surgery suggests the use of three accessory ports and the umbilical port. The surgeon’s position is by the left of the patient if he is right or by the right if he is left. These positions should be interchangeable with complete facility and it should be natural. The first assistant should be by the contra-lateral side of the surgeon and the second assistant between the patient’s legs that should be in gynaecological position giving comfort for the gynaecological laparoscopic surgery, but avoiding nervous compression or lesions of the extremities.
Nowadays it is proved that modern endoscopic surgery requires that the ability of the surgeon to perform endoscopic sutures. So it is necessary for him to be familiar with the needle holders, extra-corporeal knot pusher and with the technique of intra-corporeal sutures.
Each surgery may have also specific instruments as for example the morcellator for myomectomies (2-3-4-5), or the uterine manipulator for total hysterectomy, (1-6). When the uses of these instruments are unknown their purchase seems superficial and expensive. Their correct use makes the surgery easier and faster, and it seems reasonable to think that as soon as these instruments are used as a routine, it will be cost-effectiveness viable, and necessary in every endoscopic surgery department.
Concepts: 1.- Instruments, multi-function and technique: if the assistant is using a grasping forceps (assistant’s principal function), the surgeon should use in his lateral port the opposite grasping function and in the middle port he should use an instrument with cutting capacity. 3.-Avoid washing during surgery, which generates difficulties increasing surgery’s duration. It must be left for the end of the procedure in benign cases. 4.- Retraction restricts assistant’s functions. The assistant’s port should not be wasted just for retraction, for it should be useful during the surgery. We should consider an alternative way of intestinal retraction, traction and fixation of structures with sutures through the anterior abdominal wall. 5.- Always remember the display shows a virtual surgery field, so it selects and shapes the information displayed. We should use these virtual advantages for our own profit. For example the change of place of the central port when the uterus is big helps to improve the angles to achieve comfort during the surgery. So the decisions and action are not based on real data. 6.- The position of the trocars in relation to the type of surgery to be performed determines the angles which will make easier the laparoscopic surgical gestures. Laparoscopic surgery of 2000 has evolved allowing surgery in different degrees of complexity. This evolution has made real the original thoughts of the beginners of this method who saw a future in this type of surgery that was invented in the search of a benefit for the patient. References: 1-. Chapron C, Laforest L, Ansquer Y, Fauconnier A, Fernandez B, Breart G, Dubuisson JB. Hysterectomy techniques used for benign pathologies: results of a French multicentre study. Hum Reprod. 1999 Oct; 14(10):2464-70.
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