Seminars in laparoscopic surgery最新文献

Telemedicine is becoming a subset of information science and should benefit tremendously from the geometric growth of information architecture in hospitals. The use of telemedicine to break the isolation of the operating room is a highly achievable goal. An open operating room has information on demand for the personnel, fluid communication among operating room personnel, and broad interaction with the learner community and consultants. In an operating room with significant data capture, the patient is brought into the process not only as a real person, but also as a huge data set that acquires all the events of the surgery. The data include the visual, electrical, and mechanical events that define the surgical procedure. As part of a dynamic electronic medical record, they are available to those who are present and those who are asked to help from even a great distance away with real-time advice. The data are also available to those who seek to understand what happened to the patient afterwards for the purpose of root cause analysis, near miss analysis, instruction, or more accurate medical records.

The huge changes brought about by minimal access surgery in the last 15 years tell us much about the dynamic state of surgical technology and the need for sudden accommodation to a new item or concept that has captured the public eye. The minimal access technology invites us to extrapolate improvements in ergonomics and visualization and the combination of diagnostic and therapeutic motives in the operating room. The need for proper sensors to provide haptics to our instruments is high. Smart materials, smart catheters, wireless connectivity, and integrated technology for plug-and-play use are very attractive subjects that will draw many resources toward their successful application to operating room issues. Collaboration among institutions and industry will be useful to achieve efficiency, synergy, and the critical mass of talent to solve the significant problems ahead.

Colonoscopy, although increasingly used as a screening tool, has many surgical applications. As a tool for the abdominal surgeon, colonoscopy may be used not only to diagnose neoplasia, but also hemorrhage, and inflammatory and obstructive disorders. Therapeutically, endoscopic polypectomy has impacted the incidence of colorectal cancer, and further visualization techniques have augmented the ability of the endoscopist to discriminate between benign and neoplastic lesions. Colonoscopy remains a necessary implement to facilitate the diagnosis and therapy of those patients with disorders of the colon and rectum.

The use of intensive nutritional support to meet the metabolic nutrient requirements of critically ill patients has become standard medical treatment. It has been shown that enteral feeding provides significantly better metabolic support than long-term intravenous hyper-alimentation and therefore, endoscopic placement of enteral access has become common-place. As an extension of flexible endoscopy, the transoral or percutaneous placement of enteral access devices is appropriate for patients with gastrointestinal disease, post-trauma support, and oncologic processes. The main access route continues to be achieved through the use of nasoenteric feeding tubes that may be facilitated by endoscopic placement. Percutaneous endoscopic gastrostomy and jejunostomy have become reliable methods of achieving enteral access as videoendoscopy usage has increased. The placement of jejunal feeding tubes reduces the opportunity for reflux of gastric content and, in the long-term, has proven a reliable method for enteral support.

Advanced laparoscopic techniques have continued to grow in prevalence for the treatment of gastrointestinal surgical conditions. The field of flexible endoscopy has also continued to increase the boundaries of its capabilities with the advent of purely flexible endoscopic techniques, such as in the treatment of gastrointestinal reflux disease. This article illustrates how flexible endoscopy can be used in combination with laparoscopy in a diverse number of operations in the human foregut and hindgut, such as reflux operations, esophageal myotomies, gastric resections, peptic ulcer operations, colon resections, and pancreatic pseudocyst operations. These examples of the utility of flexible endoscopy during laparoscopy show the marriage of these two disciplines. To be able to adequately use flexible endoscopy during laparoscopy, the surgeon will need to be skilled in flexible endoscopy, and the best way to maintain those skills is to use the flexible endoscopy in one's daily practice.

Endoscopic retrograde cholangiopancreatography remains an important tool for the management of biliary and pancreatic disease. Endoscopic removal of common bile duct stones is the procedure of choice for retained stones and is a common option preoperatively with the gallbladder in place. Cholangitis is best treated by endoscopic sphincterotomy and stenting along with intravenous antibiotics initially with the possibility of definitive treatment with endoscopic stone removal and/or dilatation and stenting for strictures. Endoscopic sphincterotomy is also recommended in severe or rapidly worsening gallstone pancreatitis or in those with combined pancreatitis and rising bilirubin or cholangitis. Palliation with internal stents for malignant strictures has been possible with good outcome and very little difference in efficacy, complications, mortality, and long-term survival compared to surgical treatment. Biliary fistulae are easily treated by endoscopic stenting, particularly when the source is the cystic or an accessory duct. Benign biliary strictures can be dilated and stented for prolonged periods with good long-term success in selected cases. Pancreatic stenting is useful to treat pancreatic duct strictures and duct hypertension with considerable improvement of pain. Endoscopic drainage of pancreatic pseudocyst appears to be a safe, effective, and definitive treatment for patients in whom anatomic considerations allow its use. In summary, therapeutic uses of ERCP are of broad interest to the general surgeon and should be understood and utilized appropriately by the surgical community.

Over the past 20 years, flexible endoscopy has evolved from a primarily diagnostic endeavor to one of the most rapidly growing fields of therapeutic surgery. Multitudes of techniques and technologies have been developed to treat a wide spectrum of gastrointestinal diseases. Endoscopic suturing, radiofrequency energy delivery, mucosal resection, and thermal ablative techniques are among the most promising modalities in the field. Furthermore, the development of endoscopic transgastric surgery opens the door to a variety of novel intraluminal procedures. Though the ultimate role of these innovations is yet to be determined, the future of feasible surgical endoscopy holds great potential.

Training in flexible endoscopy is becoming increasingly complex. In an effort to improve the efficiency of endoscopic education, physicians are turning to simulation technology to provide a platform for training away from the endoscopy suite. The concept of medical simulation is not new, but the recent addition of powerful computer-generated virtual reality simulation has revolutionized the field. These compact computers are now able to generate a simulated environment that not only mimics the movement of the endoscope, but also recreates the sounds of the endoscopy suite, the feel of the movement of the scope, the reaction of intestinal tissue, and the response of a patient experiencing discomfort. Within this life-like simulated environment, a wide variety of diagnostic and therapeutic endoscopic procedures can be performed. This article reviews the history of flexible endoscopy simulators and details the most advanced models currently available. The literature supporting the use of these simulators is also presented, and issues involving the incorporation of simulation technology into endoscopic education and credentialing are discussed.