Emerging Technologies in Surgery

162 Pages·2007·32.69 MB·English

by  Achille Lucio Gaspari MD

Richard M. Satava · Achille Gaspari · Nicola Di Lorenzo (Eds.)
Emerging Technologies in Surgery
Richard M. Satava · Achille Gaspari
Nicola Di Lorenzo
Emerging
Technologies
in Surgery
With 90 Figures and 2 Tables
123
Richard M. Satava, MD
Professor of Surgery
Department of Surgery
University of Washington Medical Center
1959 NE Pacific St Rm BB487
Seattle, WA 98195
USA
Achille Gaspari, MD
Tor Vergata University of Rome
Department of General Surgery
Viale Oxford, 81
00133 Rome, Italy
Nicola Di Lorenzo, MD
Tor Vergata University of Rome
Department of General Surgery
Viale Oxford, 81
00133 Rome, Italy
Supported by:
Library of Congress Control Number: 2006934463
ISBN 978-3-540-39599-7 Springer Berlin Heidelberg New York
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Dedication
To our devoted wives,
Judith Satava, Franca Gaspari, and Fabiola di Lorenzo,
without whose encouragement and patience this would not have been possible.
During times of worry and frustration, you were there to console,
advise, and help us.
But most of all, you were our Muses, and gave us that unique inspiration
that lifts the mundane to the sublime.

For us, it was having you there to add that special sense of the aesthetic
that has made this monograph a true labor of love.
Foreword

We live in a technological age, and the practice of sur- a shaky start, have in the last few years progressed to a
gery is not exempt from this. Furthermore, predic- stage where no surgical training program can afford to
tions are that the inevitable trend in surgical practice overlook their importance; the apprenticeship system
is toward increasing dependence on high-technology of training is no longer sufficient, especially with the
equipment. Thus, Emerging Technologies in Surgery ed- curtailment of the training period. The World Wide
ited by Richard Satava, Achille Gaspari, and Nicola Di Web and progress in medical informatics in general
Lorenzo, is timely and appropriate. My experience with (disruptive technologies in the extreme) have removed
use of medical technologies together with my involve- all possible excuses for all healthcare providers—let
ment in related research and development work over alone surgeons—to be misinformed or be lacking in
many years has led me to classify these technologies in medical up-to-date information, because the technol-
four categories all expertly covered in this book: (1) fa- ogy brings accurate information to the shop floor of
cilitative—improve the efficiency of performance and medical practice. There is, however, one issue directly
reduce the degree of difficulty of execution of specific related to the increasing dependence of surgical care
tasks; (2) additive—bring technical sophistication and on high technology that I feel has been overlooked in
accuracy to surgical manipulations/interventions that all training programs and which needs emphasis: Sur-
are not considered essential to existing practice; (3) geons and other interventionalists increasingly use so-
enabling—make possible certain surgical interventions phisticated energized equipment often and regrettably,
or open new therapeutic approaches; and (4) disrup- without an adequate understanding of the physical and
tive—technologies that, by breaking new ground, un- engineering principles involved. This cognitive deficit
derpin real progress. The term “disruptive technologies” of current training program needs correction.
was first coined by Clayton M. Christensen in 1997 in It seems to me that the approaches covered in the
his book The Innovator’s Dilemma (Harvard Business various sections of Emerging Technologies in Surgery are
School Press), to refer to technologies that, as they ma- breaking down turf barriers between disciplines, such
ture, alter the way humans live and work. that patient management is slowly changing from iso-
Wisely, the three editors of this book, rather than lated, single-discipline treatment to multidisciplinary
pigeonholing the technologies covered in this ex- treatment by disease-related treatment groups, which
cellent monograph, have adopted a different layout surgeons must buy into. The spate of integrations, wit-
more suited—from a practical and educational stand- nessed on both sides of the Atlantic between vascular
point—to the current and future practice of surgery; surgeons and interventional vascular radiologists over
however, examples of all these categories are included the past 5 years, is a pertinent example.
in the various sections. The contributions to all these The editors are to be congratulated for an immensely
sections are by leading-edge experts in the respec- readable and informative monograph. It deserves to
tive fields, and after reading all the chapters, I have no be read and will, I am sure, be well received. I suspect,
doubts that the editors chose their contributors wisely. however, that we shall witness several future editions
Emerging Technologies in Surgery should be of interest since one thing is sure: Medical technology does not
to both the surgical trainees and their trainers, because stand still … for long.
it contains a wealth of useful and practical informa-
tion on the subject. It is appropriate in my view that Sir Alfred Cuschieri, FRS
emphasis has been made on education and training, as Professor of Surgery
they are axiomatic to quality care in surgical practice. Pisa
The advances in virtual surgical simulation that, after
Preface

Tremendous acceleration and changes in our daily vices that seem to belong to the future but in reality are
medical practice are occurring. Both as doctors and being implemented now. Because time and resources
ordinary citizens, we are aware of living in a world are not infinite for the surgeon, both in everyday life
more and more influenced by information technology. and in their busy practice, we hope this monograph
In surgery, this revolution has brought about a dra- will contribute to their ability to select those innova-
matic acceleration of the introduction of new devices, tions that will positively impact on his or her practice.
techniques, and procedures that are changing patients’ To that end, we have invited eminent surgeons who
treatment and destiny. In the last 30 years, innova- are experts on emerging procedures and significant
tion has developed exponentially, forcing both current advances in their respective fields to participate. We
and future generations to deal with new technologies have been fortunate to assemble authors who are ac-
such as microsurgery or laparoscopy, and informatics. knowledged authorities in these areas, both in clinical
Meanwhile, the old surgical approach still needs to be practice as well as in surgical education. We are grate-
learned and mastered for patients’ safety. ful to them for their essential contributions, to bring
Therefore, we decided to offer this book to illustrate together, outline, and illustrate the future trends. We
to the practicing surgeon, who has precious little time are especially indebted to Dr. Manzelli for his invalu-
to keep up with these rapid changes, what the impor- able support during the preparation of this work. We
tant emerging technologies are that could affect his or are proud to have the privilege to stand on the shoul-
her practice in the next 10–20 years. We approached ders of these giants.
this effort with the expectation that this book will serve
as a useful reference to introduce surgeons of every Richard M. Satava, Seattle
generation to the principles of new technologies, and Achille L. Gaspari, Roma
to familiarize them with those new procedures and de- Nicola Di Lorenzo, Roma
Contents

Part I Introduction 5.3 Metrics for Objective Assessment .... 29
5.4 Education and Training ............. 30
1 Overview of Emerging Technologies ....... 3 5.5 Simulation Fidelity:
Are Graphics Enough? .............. 31
2 Economics of New Surgical Technologies ... 7 5.6 Simulation as Part
2.1 Technology: A Definition of Terms ... 7 of the Curriculum ................. 31
2.2 A Brief History 5.7 Training to Proficiency
of Medical Technology .............. 7 on a VR Simulator ................. 32
2.3 The Economic Burden 5.8 Conclusion ........................ 32
of Health Care ...................... 8
2.4 A Technological Solution 6 Organizing Surgical Simulation Centers
to Health Care Cost ................. 8 in Response to Disruptive Technologies ... 35
6.1 Making the Case for Simulation
3 The Scientific, Social, and Ethical for Medical Education .............. 35
Implications of Disruptive Technologies ... 11 6.2 Simulation and Simulators
3.1 Introduction ....................... 11 for Medical Education:
3.2 Intelligent Computers and Robots ... 13 Past, Present, and Future ............ 36
3.3 Human Cloning ................... 13 6.2.1 Bench Models ..................... 37
3.4 Genetic Engineering ............... 13 6.2.2 Laparoscopic Skills ................. 37
3.5 Longevity ......................... 14 6.2.3 Gastrointestinal Endoscopy ......... 38
3.6 Human–Machine Communication .. 14 6.2.4 Endonasal Surgery ................. 38
3.7 Artificial Organs and Prostheses .... 14 6.2.5 Urology ........................... 38
3.8 Suspended Animation .............. 15 6.2.6 Bronchoscopy ..................... 38
3.9 Summary ......................... 15 6.2.7 Anesthesiology .................... 38
6.2.8 Case Study: The National Capital
Area Medical Simulation Center ..... 39
Part II Education and Training 6.3 Conclusion ........................ 44
4 The World Virtual University and 7 Ideal VR systems: Is There a „Holy Grail“
the Internet: http://www.websurg.com ..... 19 in Simulation System Land? ............... 47
4.1 Surgical Operative Techniques ...... 21 7.1 Curriculum ........................ 50
4.2 Video Footage ..................... 21
4.3 The Voices and Opinions 8 The Medical Informatics Challenge
of the Experts ...................... 22 in Surgery ................................ 57
4.4 New Improvements for Access 8.1 The Perioperative Environment ..... 57
to Surgical Education ............... 22 8.1.1 Why Adapt Solutions
4.5 Other Educational Services ......... 22 from Other Industries? ............. 58
8.2 Radical Improvement
5 Virtual Reality: Objective Assessment, in Quality of Patient Care is Possible 58
Education, and Training .................. 27 8.3 Toward a Solution:
5.1 Simulation Development: Adaptive Process Control ........... 59
Lessons Learned ................... 28 8.4 Context-Aware Workflow
5.2 Simulation Training: as Autopilot ....................... 60
Evidence-Based Adoption? .......... 28
XII Contents
8.5 Stealth Mode: 9.8 Adrenalectomy .................... 80
Automated Data Collection ......... 60 9.9 Donor Nephrectomy ............... 81
8.6 A RECIPE for Incremental Systems 9.10 Conclusion ........................ 82
Evolution and Process Improvement 61
8.7 Applying the RECIPE 10 Evolving Endoluminal Therapies .......... 85
to Perioperative Systems Design ..... 63 10.1 Endoluminal Surgery ............... 85
8.8 Perioperative Systems Acceleration 10.2 Transvisceral Surgery ............... 86
Tool in the Preoperative Period ...... 63
8.9 PSPAT in the Intraoperative Period .. 65
8.10 PSPAT in the Postoperative Period ... 65 Part IV Innovations in Surgical
8.11 PSPAT at the University of Instruments
Maryland Medical Center ........... 65
8.12 PSPAT Components ................ 66 11 Microtechnology in Surgical Devices ...... 89
8.12.1 A Workflow Engine ................ 66 11.1 Introduction ....................... 89
8.12.2 Adapters to Gather Information 11.2 MST in Medical Devices:
from any Human or Machine Source 67 Challenges and Opportunities ....... 89
8.12.3 MER: Virtual Information 11.3 Areas of MST Applications
Repository in Medical Devices ................. 90
for the Workflow Engine Access ..... 67 11.3.1 Extracorporeal
8.12.4 A Rules Engine to Provide MST-Enhanced Devices ............ 92
Intelligent Agent Support 11.3.2 Intracorporeal
for the Workflow Engine ............ 67 MST-Enhanced Devices ............ 92
8.12.5 An Alerting System to Ensure 11.3.3 Implantable MST Devices ........... 93
Timely Completion of Clinical Events 68 11.3.4 MST in Endoscopy ................. 95
8.12.6 A Reporting System to Access 11.4 Discussion ......................... 96
Outcomes Data in Real Time ........ 68
8.12.7 A Logistics Subsystem to Manage 12 Innovative Instruments
Inventory ......................... 69 in Endoscopic Surgery .................... 99
8.12.8 Web-Based Telemedicine View ...... 69 12.1 Introduction ....................... 99
8.13 Research Directions ................ 69 12.2 Innovative Instruments
8.14 Web Services ...................... 69 for Laparoscopic Surgery ........... 99
8.15 Conclusion ........................ 70 12.2.1 Curved Instruments ................ 99
12.2.2 Instruments with All Degrees
of Freedom for Suturing:
Part III Robotics and Novel Surgical the Radius Surgical System ......... 101
Approaches 12.2.3 The Endofreeze System ............ 102
12.2.4 Combination Instruments
9 Robotics in General Surgery: for Endoscopic Surgery ............ 103
Today and Tomorrow .................... 75 12.3 Endoluminal Surgery
9.1 Introduction ....................... 75 of Rectum and Colon .............. 103
9.2 Cholecystectomy ................... 75 12.4 Full-Thickness Resection Device,
9.3 Bariatric Surgery ................... 75 the Concept of a New Device
9.3.1 Robotic-Assisted for Removal of Polyps from
Roux-en-Y Gastric Bypass .......... 76 the Rectum and Descending Colon 105
9.3.2 Robotic-Assisted 12.5 Conclusion ....................... 106
Adjustable Gastric Banding ......... 77
9.3.3 Robotic-Assisted Biliary Pancreatic 13 New Hemostatic Dissecting Forceps
Diversion with Duodenal Switch .... 77 with a Metal Membrane Heating Element 107
9.4 Esophageal Surgery ................ 78 13.1 Introduction ...................... 107
9.4.1 Heller Myotomy ................... 78 13.2 Materials and Methods ............ 107
9.4.2 Resection of Epiphrenic 13.3 Results ........................... 109
Diverticulum ...................... 79 13.4 Discussion ........................ 110
9.4.3 Total Esophagectomy ............... 79 Acknowledgment ................. 112
9.4.4 Esophageal Leiomyoma ............. 79
9.5 Pancreatic Surgery ................. 80 14 Radiofrequency and Hepatic Tumors ..... 113
9.6 Gastric Surgery .................... 80 14.1 Introduction ...................... 113
9.7 Colorectal Surgery ................. 80 14.2 Conclusions ...................... 119
Contents XIII
15 Technological Innovations in Kidney Part V Bioengineering
and Liver Living-Donor–Related
Transplantation ............................... 123 16 Tissue Engineering ...................... 133
15.1 Introduction ..................... 123 16.1 Introduction ...................... 133
15.2 Robotic Technology in Laparoscopic 16.2 Overview ......................... 135
Living-Donor Nephrectomy ....... 123 16.2.1 Skin .............................. 135
15.3 Surgical Technique ............... 125 16.2.2 Cartilage ......................... 136
15.4 Liver Transplantation .............. 126 16.2.3 Bone ............................. 137
15.4.1 Technological Innovations in 16.2.4 Intestine .......................... 139
Transplant Surgery: from “Crash 16.2.5 Cardiovascular Tissue ............. 140
Clamp Technique” to Modern 16.2.6 Liver ............................. 143
Instruments of “Intelligent” 16.3 Future Prospects .................. 144
Dissection, Hemostasis ............ 126 16.4 Relevance
15.5 Transection Systems .............. 127 for the Practicing Surgeon ......... 146
15.5.1 Ultrasonic Dissector ............... 127
15.5.2 Water-Jet Dissector ................ 127
15.6 Hemostasis Systems ............... 127 Part VI Beyond the Future
15.6.1 Staplers .......................... 127
15.6.2 Floating Ball ...................... 127 17 Adapting to Future Technologies ......... 155
15.7 Simultaneous Hemostasis and 17.1 Introduction ...................... 155
Transection ....................... 128 17.2 The Scientific Method ............. 155
15.7.1 Thermal Methods ................ 128 17.3 Interdisciplinary Medicine ......... 156
15.7.2 Harmonic Scalpel ................. 128 17.4 Multiaccess Surgery ............... 156
15.7.3 Laparoscopic Donor Hepatectomy 17.5 Information Technologies .......... 157
for Living-Related Transplantation 128 17.6 Surgical Education and Certification 157
17.7 Surgical Simulation ............... 158
17.8 Artificial Organs
and Transplantation ............... 158
17.9 Surgical Systems and Robotics ..... 159
17.10 Unconventional Surgery ........... 159
17.11 Conclusion ....................... 160
Subject Index ............................ 163
List of Contributors

Enrico Benedetti Timothy Ganous, MPA
University of Illinois at Chicago University of Maryland School of Medicine
College of Medicine 351 West Camden, CY-211
840 S. Wood Street Baltimore, MD 21201
Suite 402, CSB (M/C 958) USA
Chicago, IL 60612
USA Achille Lucio Gaspari, MD
Division of General Surgery
Mark W. Bowyer MD, FACS Department of Surgery
Uniformed Services University Tor Vergata University of Rome
of the Health Sciences Viale Oxford, 81
4301 Jones Bridge Road 00133 Rome
Bethesda, MD 20814-4799 Italy
USA
Santiago Horgan, MD
Gerhard F. Bueß, MD Minimally Invasive Surgery
Section for Minimally Invasive Surgery University of Illinois
University of Tübingen 840 South Wood Street
72072 Tübingen Room 435 E
Germany Chicago, Il 60612
USA
Adriano De Majo
Division of General Surgery Eiji Kanehira
Department of Surgery Endosurgery Laboratory Kanehira (ELK)
Tor Vergata University of Rome Kanazawa
Viale Oxford, 81 Japan
00133 Rome
Italy Michael S. Kavic, MD
Director of Education, General Surgery
Nicola Di Lorenzo, MD St. Elizabeth Health Center
Division of General Surgery Professor of Clinical Surgery and Vice Chair,
Department of Surgery Department of Surgery
Tor Vergata University of Rome Northeastern Ohio Universities College of Medicine
Viale Oxford, 81 1044 Belmont Avenue, P.O. Box 1790
00133 Rome Youngstown, OH 44501-1790
Italy USA
Anthony G. Gallagher, PhD Antonio Manzelli, MD
Department of Surgery Division of General Surgery
Emory University Hospital Department of Surgery
Room B206 Tor Vergata University of Rome
1364 Clifton Road, NE Viale Oxford, 81
Atlanta, GA 30322 00133 Rome
USA Italy