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Thane A. Blinman, MD Division of General, Thoracic and Fetal Surgery Childrens Hospital of Philadelphia 34th and Civic Center Blvd Philadelphia, PA 19104 215.590.4510 blinman@email.chop.edu
Page 1 of 22
ABSTRACT
advantages
of
expert
technique
are
demonstrable,
but
moving
from
novice
to
expert
often
seems
more
the
product
of
fortune
than
intent.
Meanwhile,
the
modern
residency
is
being
driven
away
from
unlimited
hours
of
direct
experience
and
toward
formal
curricula,
more
didactics,
lessons
on
simulators,
and
learning
metrics.
Advocates
and
critics
of
these
changes
probably
can
agree:
We
need
to
teach
more
efEiciently.
That
is,
each
trainee
must
make
more
progress
toward
expertise
(however
deEined)
in
less
time.
In
pediatric
MIS,
that
need
seems
magniEied,
but
safe
surgical
methodology
hinges
less
on
contrived
core
competencies
than
on
sound
principles
and
heuristics.
This
essay
describes
teachable
principles
designed
to
improve
mechanical
advantage
in
any
MIS
procedure.
Pediatric
surgical
residents
who
learn
these
principles
exhibit
easier,
faster,
and
safer
minimally
invasive
technique.
KEY
WORDS:
laparoscopy,
thoracoscopy,
minimally
invasive
surgery,
surgical
education,
resident
training,
heuristics
Page 2 of 22
INTRODUCTION
As
to
methods
there
may
be
a
million
and
then
some,
but
principles
are
few.
The
man
who
grasps
principles
can
successfully
select
his
own
methods.
The
man
who
tries
methods,
ignoring
principles,
is
sure
to
have
trouble. Ralph
Waldo
Emerson
Minimally
invasive
surgery
(MIS)
is
hard
to
teach.
To
begin
with,
it
is
hard
to
learn(1).
The
skills
needed
for
successful
MIS
are
grounded
in
good
open
surgical
technique,
but
expert
ability
to
perform
a
given
operation
using
open
technique
is
only
the
First
prerequisite
to
endoscopic
expertise.
Successful
MIS
requires
a
superset
of
skills
to
perform
complex
procedures
in
small
spaces
with
long
tillers
via
remote
visualization.
MIS
is
not
a
replacement
for
good
surgical
habits
and
techniques,
but
is
a
very
powerful
extension
of
surgical
technique.
Despite
some
skepticism
of
MIS
in
pediatric
surgery
(2,
3),
the
potential
beneFits
to
patients
are
plain:
smaller
incisions
create
far
less
morbidity.
Nevertheless,
clumsy
laparoscopic
technique
is
not
minimally
invasive.
Ad
hoc
practices
and
imprecise
maneuvers
lead
to
long
operating
and
anesthetic
times,
poor
mechanical
results,
and
return
trips
to
the
operating
room.
These
risks
are
ampliFied
in
children: The
variety
of
cases
is
broader,
including
cases
in
the
chest,
abdomen,
and
pelvis
associated
with
a
very
wide
variety
of
malformations
and
other
problems.
The
scope
of
required
expertise
is
very
broad. The
patients
are
much
more
delicate,
and
have
much
smaller
structures.
Therefore,
precise
movement
of
instruments
within
body
cavities
is
essential
for
safe
tissue
manipulation
and
good
surgical
results. Scaling
effects
of
biomechanical
structures
and
essential
physiology
create
new
surgical
constraints.
For
example,
the
abdominal
wall
of
a
baby
is
relatively
similar
in
thickness
compared
to
that
of
a
lean
adult,
but
its
absolute
thickness
is
much
smaller,
dramatically
reducing
its
ability
to
hold
a
trocar
in
place.
Technique
must
be
speciFically
adapted
to
accommodate
the
thin
abdomen.
Similarly,
round
structures
(such
as
esophagus,
etc)
must
be
perfectly
approximated
during
repair,
lest
nonlinear
increases
in
resistance
at
small
diameters
lead
to
poor
outcomes.
The
patients
are
much
more
sensitive
to
hypothermia
than
adults
because
of
their
diminished
metabolic
capacity,
diminished
reserve,
and
physical
characteristics
allowing
greater
heat
loss.
Poor
endoscopic
technique
can
actually
Page 3 of 22
place small patients at increased risk of hypothermia compared to open technique, as long operating times and poor instrumentation choices force high insufFlation Flows to maintain visualization. The energy required to heat and humidify high-Flow insufFlation gas can easily be twice the basal metabolic rate of a baby. The instruments are shorter, narrower, and more delicate. Relatively few tools are specially adapted for pediatric use. The stakes from a misadventure can be much higher (e.g. In an adult, 90mL of blood loss is trivial; in a 3 kg child it is 1/3 of the total blood volume), and complications seem to be somehow more tragic in children than in adults. For all of these reasons, the margin for error in small patients is disproportionately small. The objective of this essay is to set out discrete principles of good pediatric minimally invasive surgical technique beyond simple exercises (4, 5). The heuristics listed here are intended to maximize the surgeons mechanical advantage at all times, in all cases. Maximum mechanical advantage fosters precision and spares the surgeon unnecessary fatigue, keeps him away from avoidable blunders, creates options for recovering from slips or unexpected anatomical challenges, increases, shortens operating time, and protects the patient.
Surgery is a physical art. Surgery is the art of applying mechanical solutions to medical problems. As such, surgical interventions lead to the best results when those medical problems have a mechanical basis. Some examples for which surgery is the best intervention include: repairing the damage from a stab incision; removing a tumor; relieving an intestinal blockage; reconnecting the esophagus; restoring the insertion of the ureter on the bladder; repairing a meniscal tear. These, and many other problems all have a mechanical problem as their source, and a mechanical solution is demanded. However, surgery sometimes is used for diseases that are not strictly mechanical, but more physiological, some disorder at the cellular level. For example, ulcerative colitis may be treated by colectomy, but this is more palliation than cure: the surgeon has not repaired a biomechanical problem, only removed an organ afFlicted with an inFlammatory disease that we dont really understand. The same may be said for obesity surgery. Observe that as a general rule, the results for mechanical interventions to mechanical problems are superior to those for physiological ones: repairing a
Page 4 of 22
duodenum damaged by a handle-bar is better than removing the antrum of the stomach to prevent ulcers in the duodenum. In this way, surgery is a kind of engineering. In order to achieve the best results, surgeons must know about their tools, their materials, the raw substrate they are manipulating, and what the mechanical objective is that they are trying to achieve. Try to state the purely mechanical objectives of: fundoplasty diaphragmatic plication appendectomy gunshot wound inguinal hernia repair
In diaphragmatic plication for example, there are two objectives: increase functional residual capacity of the ipsilateral lung, and provide a less compliant medial border to the contralateral hemidiaphragm so to increase its deFlection for the same muscular contraction. Compare mechanical objectives like this with palliative objectives in, for example, colectomy for ulcerative colitis, or pancreatectomy for hyperinsulinism. In each of these later cases, the basis of the treatment isnt biomechanical, but simply to remove the dysfunctional organ, trading a diseased physiology to some lesser dysfunction. In indirect inguinal hernia repair, the objective is to permanently close the internal ring (while avoiding damage to the spermatic cord structures). What approach most likely achieves this? Laparoscopic repairs allow the surgeon to visualize the ring at around 8x magniFication decreasing the probability of damaging the cord. But early results showed a disappointingly high recurrence rate. This problem vanished when permanent suture was used instead of the more traditional absorbable suture used in open technique. It appears that while the mechanical objective (permanently close the internal ring) of open and laparoscopic repairs is the same, the method may be different--one technique disconnects the sac, one does not--and so different materials must be used. Still, whatever the details of the method, the mechanical objective is the same, and must be achieved for a successful repair regardless of whether the approach is open or laparoscopic. The ten principles here increase the chances that the mechanical objectives of a given procedure will be achieved.
Page 5 of 22
the
tubing,
to
the
trocars,
to
the
instruments,
to
the
level
of
anesthesia.
The
expert
chooses
hook,
or
spatula,
or
hot
scissors,
or
Harmonic
Scalpel
(Ethicon,
Endosurgery,
Cincinnati,
OH),
or
Ligasure
(ValleyLab,
Boulder,
CO)
according
to
the
way
they
deliver
energy,
how
the
shape
of
the
business
end
Fits
his
surgical
Field,
and
what
problems
are
minimized
by
choosing
one
over
the
other.
The
novice
has
one
tool
and
tries
to
use
it
everywhere.
A
novice
blames
the
tools;
the
experts
tools
serve
his
technique.
In
other
words,
MIS
is
not
technology;
it
is
technique.
Surgeons
like
technology.
The
number
and
variety
of
instruments
and
devices
for
use
in
the
operating
room
runs
into
the
thousands.
With
the
spread
of
endoscopic
methods,
vendors
have
hugely
expanded
the
available
tools.
Certainly
technological
progress
in
charge-couple
devices,
electronics,
optics,
and
materials
has
helped
spur
the
broad
application
of
MIS
methods,
and
ongoing
advances
(especially
in
optics)
will
continue
to
aid
technique
and
help
patients.
But
a
large
number
of
these
are
mere
gadgets,
engineered
solutions
to
non-problems.
For
example,
suture
assist
devices
exist
in
order
to
bridge
a
deFicit
of
sewing
and
tying
skill.
Vendors
have
marketed
all
manner
of
devices
that
hold
in
common
only
that
they
are
complex,
expensive,
and
totally
unnecessary
to
the
expert
endoscopic
surgeon.
The
tools
never
do
the
operation.
For
example,
the
surgical
robot
is
really
a
telemanipulator
(or
a
waldo),
and
cannot
make
a
novice
endoscopic
surgeon
into
an
expert
one.
Even
suture
assist
devices
that
use
ski-needles
are
not
an
asset
but
a
liability
in
babies:
The
large
size
of
these
needles
makes
them
clumsy
instruments,
better
suited
to
inadvertently
damaging
the
liver
or
spleen
than
allowing
accurate
suture
placement.
In
any
case,
endoscopic
gadgets
are
rarely
designed
for
very
small
patients,
and
trying
to
force
these
devices
(e.g.
trying
to
squeeze
even
a
small
stapler
into
an
infants
chest)
is
no
route
to
better
outcomes.
The
wrong
tools
weaken
the
surgeon
and
endanger
the
patient.
On
the
other
hand,
the
expert
surgeon
has
attended
to
developing
robust
and
general
skills
with
basic
endoscopic
instruments.
He
exhibits
suture
technique
as
precise
as
open
technique.
He
understands
and
can
troubleshoot
the
equipment.
He
can
safely
and
rapidly
perform
a
very
wide
number
of
procedures
at
least
as
well
as
(and
in
many
cases
better
than)
using
open
technique.
Use
of
gadgets
fosters
shortcuts
and
poor
methods,
compromising
outcomes
and
lending
MIS
an
air
of
risk.
In
cases
of
trouble,
the
surgeon,
and
his
patient,
are
better
served
by
reliable
technique
than
by
technology.
One
problem
with
medical
and
surgical
devices
is
the
problem
of
implied
use,
the
cues
on
the
device
itself
that
imply
how
the
think
is
intended
to
be
used.
These
cues
are
sometimes
called
affordances.
Page 7 of 22
Rarely are surgeons given instruction on the elements of how devices are designed, and user manuals are an early casualty of a busy operating room, even if the surgeon was interested. Instead, surgeons during their training typically receive some lessons as memes or lore, often passed from a senior resident, a lesson they will pass to their own trainees. Often, those lessons are little more than someones workaround when trying to use the device for a certain purpose (e.g. a malecot drain repurposed as a gastrostomy tube, now virtually standard of care in pediatric surgery). Other times, the use is simply a misunderstanding of a design that implies, by its shape or structure, that it should be used a particular way (e.g. the suture holes on many gastrostomy tubes which are in fact merely ventilation holes, and not designed or intended for securing a tube). Sometimes, these hints for use are accurate, but often not, and the novice may have no basis on which to tell the difference. For example, novice operators very commonly pick up instruments and hold them in thumb and index Finger, a grip that puts the user at a disadvantage in terms of torque and precision. The surgeon must pay attention to how devices were actually engineered to be used, but hemust go further: he must understand when the design does not quite serve his need, and beware of how these shortcomings can increase risks. For example, it is common for surgical staplers to require a very strong grip in order to Fire. A surgeon with smaller hands may be at a mechanical disadvantage and struggle with the Firing, which can translate to jarring or shaking at the business end of the stapler. One way around this is to turn the handle upside down which acts to lengthen the moment arm, thereby decreasing the force required to exert the same torque on the Firing mechanism. Expert minimally invasive surgery is technology wielded according to proFicient technique.
The wrong hold. It can seem like the right way to grasp the instrument, but this hold destroys control at the tip and leaves the user unable to spin the shaft.
Stand up. No one can maintain precise technique if hunched over, twisted, or awkwardly positioned. The surgeon is the rst surgical instrument, and must be used properly like all the others.
some
paradoxical
motion
to
contend
with,
but
awkward
body
position
that
quickly
leads
to
fatigue.
If
you
are
shaking
and
sore
after
an
endoscopic
procedure,
your
set-up
was
probably
suboptimal.
Perfect
position
allows
the
surgeon
to
operate
with
little
effort.
The
most
important
principle
for
good
position
is
for
the
surgeon
to
face
the
organ
he
is
operating
on.
In
other
words,
the
surgeon
should
place
the
monitor
(ideally
mounted
on
the
ceiling,
but
the
practice
can
be
maintained
with
towers)
in
a
line
with
himself,
the
camera,
and
the
organ
of
interest.
A
good
mnemonic
that
some
surgeons
teach
is
S-C- O-P,
or
surgeoncameraorganpicture(6).
For
example,
with
appendectomy,
the
surgeon
stands
to
the
patients
left,
facing
the
right
lower
quadrant
with
the
screen
on
the
patients
right.
If
the
surgeon
is
operating
on
the
GE
junction,
he
should
stand
at
the
foot
of
the
bed
(with
babies
frog-legged
at
the
end
of
the
bed,
larger
patients
in
low
lithotomy
position)
facing
the
epigastrium,
with
the
monitor
hung
directly
over
the
patients
chest.
This
is
the
First
principle
that
allows
the
surgeon
to
use
all
available
degrees
of
freedom.
Implicit
in
this
rule
is
knowing
what
the
organ
is.
For
example,
when
performing
a
thoracoscopic
lobectomy,
the
organ
is
not
the
lung
or
the
lobe,
but
the
major
Fissure,
the
place
where
most
of
the
Fine
dissection
occurs
(see
Figure
1,
above),
and
the
surgeon
should
stand
in
line
with
it.
Similarly,
in
laparoscopic
pullthrough
for
Hirschprungs,
the
area
where
the
Fine
dissection
occurs
is
the
rectum,
and
the
surgeon
should
stand
at
the
babys
head.
One
mental
barrier
to
face
the
organ
is
the
implicit
rule
that
a
surgeon
and
his
assistant
must
operate
opposite
each
other.
In
nearly
every
open
procedure
surgeon
and
assistant
face
each
other,
and
any
other
arrangement
seems
wrong,
even
taboo.
But
what
brings
advantage
in
open
cases
may
bring
disadvantage
in
endoscopic
cases.
It
is
absurd
for
either
surgeon
or
assistant
to
struggle
with
paradoxical
motion,
but
this
foolish
practice
is
tolerated
because
of
the
belief
that
an
operator
must
stand
on
each
side
of
the
patient
regardless
of
the
surgical
objective.
Face
the
organ
goes
for
surgeon
and
assistant,
even
if
both
stand
on
the
same
side
of
a
patient
(as
they
often
should).
Only
when
facing
the
organ
can
the
other
aspect
of
good
positioning
be
employed,
the
Pianist
Position.
Virtuoso
pianists
hold
their
arms
loose
at
the
shoulder,
arms
bent
at
the
elbow,
wrists
loose
and
Fingers
on
the
keys.
Virtuoso
endoscopic
surgeons
operate
with
the
bed
at
a
level
that
allows
them
the
same
position:
head
upright
and
level
with
the
screen,
shoulders
relaxed,
elbows
bent
at
90 120degrees,
wrists
loose,
and
action
on
the
instruments
controlled
with
Fingertips.
The
novice
can
be
seen
with
back
bent,
arms
abducted,
elbows
askew,
wrists
stiff,
instruments
held
in
a
death
grip.
The
comfortable
surgeon
attends
to
surgical
detail;
the
uncomfortable
surgeon
thinks
about
his
sore
back.
Page 9 of 22
In lobectomy, the organ is not the lobe being removed, but the ssure. The surgeon gets best advantage by aligning tools and his body along its axis.
In general, trocars should be placed so that right and left hand instruments approach the organ of interest separated by approximately 90 degrees. Meanwhile, the camera port should (usually) be oset from the two main working ports such that the three ports form a triangle, not a line. These four pointsthe three main ports and the organform a kite shape, a conguration that generally allows the best view, comfort, and maneuverability.
Page 10 of 22
be working paradoxically. All moves would feel backwards, and unintuitive. No one can operate with precision this way. But rigidly keeping the camera in a center port is disadvantageous. Occasionally, operations are better performed (at least in part) by placing the camera to one side, as an outrigger camera. For example, in appendectomy, it may be easier to place the camera at the umbilicus and work through suprapubic and left-lower- quadrant ports. In thoracoscopic diaphragmatic hernia repair with the patient in decubitus position, it may be advantageous to have the camera (and the camera operator) in the port nearest the patients back and the operator using the ports in the mid and anterior axillary lines. In other cases, the peculiarities of the anatomy (e.g. some thoracic masses) may require the camera to occupy any of the ports as the procedure progresses. Observe that when using the outrigger camera technique, advantage can be gained by using an angled scope which allows the viewing angle to approach (if not perfectly achieve) a centered view. Triangulating the ports allows the freedom to move the camera whenever needed, without creating distortions in working mechanical advantage.
Page 11 of 22
laparoscopically. Alternatively, if you would never use a braided 2-0 on a ski needle for this anastomosis, dont use it laparoscopically simply because that is the only suture you can use with the scope. Do the same dissection. For example, if you carefully isolate and visualize the splenic vessels and clearly visualize the tail of the pancreas during splenectomy, you should do the same laparoscopically rather than Firing a stapler semi-blindly across the splenic hilum. Complete at least the same mechanical repair. If you stick- tie the appendiceal base during open appendectomy, you should do this (or a mechanical equivalent, like staples) in a laparoscopic appendectomy. If you would place a stitch in that serosal tear in an open case, put a suture in laparoscopically too. If you would mobilize the colon more to decrease tension during an open pull-through, you should mobilize it precisely the same amount when performing the procedure laparoscopically.
The idea is to perform at least as good an operation. In skilled hands of course, endoscopic procedures may produce superior results: a laparoscopic Nissen done well will have afforded a better view of the vagus nerves and a better, safer wrap; a laparoscopic pyloromyotomy is faster; a laparoscopic duodenoduodenostomy allows the anastomosis do be done largely in situ, decreasing the amount of dissection needed and possibly leading to faster resolution of gastric ileus; a thoracoscopic esophageal atresia repair allows less dissection of the distal segment and dissection under very high magniFication apparently leading to measurably lower stricture and leak rate(7). Better visualization can certainly allow the endoscopic expert to do a superior procedure. But the essential principle is a cognitive commitment to doing the same excellent operation one would do using open technique.
on
the
unusual
tiller-action-at-a-distance
that
is
laparoscopic
manipulation,
channeling
and
truncating
attention
into
narrow
tunnel
vision.
Novice
operators
struggle
to
manipulate
a
needle
or
cautery
one-handedly,
when
they
could
easily
help
themselves
with
their
non- dominant
hand.
Instead,
the
instrument
held
in
the
non-dominant
hand
drifts
out
of
view,
is
lost,
begins
grasping
with
a
white-knuckled
death
grip,
etc.
Nearby
organs
and
structures
are
at
great,
but
unrecognized,
risk
from
instrument
clutched
in
the
neglected
hand.
Good
teachers
will
stress
non-dominant
hand
awareness,
boring
their
students
with
the
refrain
What
is
your
other
hand
doing?
Only
by
repeatedly
redirecting
attention
to
both
hands
can
one
learn
to
use
both
hands
effectively,
and
automatically.
Even
seasoned
surgeon
need
to
explicitly
remind
themselves.
Non-dominant
hand
awareness
is
important
not
only
for
speed
and
efFiciency,
but
because
humans
are
more
coordinated
in
Fine
motor
tasks
when
both
hands
appear
in
their
visual
Field,
even
if
one
hand
is
not
participating
in
the
action(9).
You
can
verify
this
yourself;
try
cutting
suture
with
one
hand
on
your
chest
versus
with
both
hands
in
the
Field.
With
both
hands
in
view,
the
cutting
hand
will
be
smoother
and
more
precise.
The
same
effect
holds
in
MIS.
Endoscopic
methods
always
impose
constraints
on
manipulation,
since
the
number
of
hands
in
the
Field
are
always
one
fewer
than
the
number
of
trocars
(unless
one
has
an
experimental
camera/manipulator
combination
instrument).
So,
one
must
maximize
what
he
can
do
with
what
he
has.
Neglecting
the
non-dominant
hand
halves
an
already-restricted
dexterity
(by
removing
degrees
of
freedom
granted
by
that
hand).
Some
may
boast
that
they
can
operate
with
one
hand
tied
behind
their
back,
but
this
is
no
road
to
precision
and
accuracy
for
the
rest
of
us.
Precision
endoscopy
is
a
two-handed
proposition.
This
discussion
brings
up
one
common
but
very
poor
practice.
In
general
surgery,
training
cases
(like
cholecystectomy,
appendectomy,
or
even
splenectomy)
are
commonly
set
up
in
such
a
way
that
the
attending
manipulates
organs
with
one
instrument,
and
has
the
trainee
try
to
operate
with
the
dominant
while
the
non- dominant
hand
moves
the
camera.
There
are
natural
reasons
for
this:
Attending
surgeons
tire
of
(and
are
notoriously
unskilled
at)
running
the
camera
(see
#8,
below),
they
are
nervous
about
the
dexterity
of
the
trainee,
feel
the
need
to
have
a
hand
in
the
action
as
a
means
of
exerting
control,
and
they
worry
that
the
trainee
is
not
skillful
enough
to
use
both
hands.
However,
this
practice
always
puts
the
trainee
(and
thus
the
patient)
at
a
disadvantage
since
he
is
forced
to
divide
attention
between
two
very
different
tasks,
camera
work
and
Fine
dissection.
Meanwhile,
removing
the
non-dominant
hand
from
view
degrades
the
Page 13 of 22
coordination
of
the
operating
hand
as
described
above.
Finally,
no
degree
of
simpatico
between
teacher
and
student
will
allow
good
coordination
between
two
different
operators
single
hands.
This
attempted
coordination
almost
always
resembles
fencing
more
than
operating.
Instead,
the
teacher
is
always
better
having
the
learner
operate
with
two
hands
from
their
First
case,
just
as
we
teach
in
open
cases.
If
the
teacher
feels
he
needs
more
control,
the
solution
is
to
add
a
port
(see
#7
below)
and
an
instrument,
not
to
take
one
away
from
the
learning
operator.
But
there
is
more
to
the
skillful
use
of
two-handed
surgery
than
merely
remembering
to
use
two
hands.
The
skillful
operator
moves
his
instruments
the
way
a
geisha
walks,
with
small,
even
mincing,
but
highly-controlled
steps.
The
tips
of
the
instruments
remain
in
view
of
the
camera
(reducing
the
need
to
rely
on
#9,
below),
and
each
move
is
slow,
smooth,
controlled.
Furthermore,
the
skilled
endoscopic
surgeon
is
ambidextrous.
There
will
be
times
when
it
is
better
to
have
the
energy
source
enter
from
a
left-handed
port,
and
a
retractor
from
the
right.
One
should
be
able
to
readily
switch
instruments
from
hand
to
hand,
always
keeping
the
highest
possible
mechanical
advantage.
Those
Fine,
measured
movements
also
apply
to
the
use
of
energy
sources
like
monopolar
electrosurgery
(the
bovie).
Energy
sources
in
babies
not
only
require
lower
power
settings,
but
the
manner
of
applying
these
instruments
is
different.
In
particular,
when
using
the
hook
cautery,
energy
should
never
be
engaged
unless
in
contact
with
the
tissue
to
be
divided
or
fulgurated
(Swinging
the
activated
hook
around
like
a
lightsaber
risks
cautery
injury).
Also,
it
is
bad
practice
to
work
in
a
hole;
keeping
a
wide
working
front
maximizes
visualization
and
minimizes
collateral
damage.
All
energy
sources
certainly
perform
better
if
the
operator
avoids
getting
greedy,
e.g.
taking
large
bites
of
tissue
to
divide,
a
practice
that
leads
to
excess
char,
incomplete
hemostasis,
and
broad
collateral
burns.
Finally,
and
most
importantly,
precision
technique
beneFits
from
a
light
foot
on
the
pedal.
Most
division
and
coagulation
can
be
achieved
with
Fine
taps
of
the
pedal,
whereas
long
continuous
burns
produce
char
and
a
wide
penumbra
of
thermal
damage.
Of
course,
no
cutting
can
occur
without
proper
tension
on
the
tissue.
Perhaps
the
most
important
role
of
the
non-dominant
hand
is
creation
of
tension
on
whatever
area
is
to
be
cut.
Without
good
tension
applied
to
it,
the
tissue
will
merely
contract
and
char
when
energy
is
applied.
It
will
not
separate,
but
thermal
spread
will
take
over
as
the
operator
vainly
applies
more
electricity.
In
small
spaces,
unintended
tissue
damage
becomes
inevitable.
Novices
often
cannot
see
that
while
they
may
be
creating
tension
in
the
tissue,
the
focus
of
the
tension
is
away
from
where
it
is
that
they
want
to
be
cutting.
But
careful
Page 14 of 22
Put tension where you are cutting; cut where the tension is.
attention to tension lines combined with an unconstrained use of the non-dominant hand will allow the operator to recognize where the tissue tension lies within the tissue plain. Moreover, the non- dominant hand must continue to adjust to bring new tension to the working plane as attachments are cut and tension is released. In general, the principle is: Put tension where you are cutting, and cut where the tension is. This sounds hilariously obvious, but is notoriously difFicult to apply in practice without an explicit effort. Such dainty use of energy usually seems odd at First, but these habits lower energy settings, no lightsabers, no holes, no greediness, no Bovie pedal lead foot, and attention to tension translate into Fine, efFicient dissection with less smoke, less char, less bleeding, and less risk of unintentional damage. The surgeon who always operates with two hands has the fullest possible control over the surgical Field.
Page 15 of 22
operative target by gravity. Obviously, part of this set-up depends on Principle #2: Face the organ. Secure and pad the patient properly to restrain gravity. For example, one of the most common positions when operating on babies is to place them at the foot of the table, with legs frog-legged, and the monitor hanging above the patients head or chest (lower picture). This position is excellent for Nissen, Ladds, duodenal atresia repair, abdominal approach to CDH/eventration, Morgagni hernia repair, choledochal cyst excision, etc. But the same gravity that pulls the omentum down can pull the whole patient down as well. Indeed, in a baby, even a short slide down the table, say 1-2 cm, is enough to dislodge the endotracheal tube, creating unintended extubation. To avoid this kind of problem, careful padding and taping are essential. In addition, the use of a small bump under the abdomen acts as a kind of skid-stop to retard sliding. The pictures show two well-positioned patients, top, for laparoscopic right nephrectomy, and, bottom, for laparoscopic fundoplasty (or duodenal atresia, or choledochal cyst, or others). Observe that there is no stretch on the extremities that could produce nerve injuries, and that good padding is placed everywhere. No undercrossing lines or tubes snake beneath the body or limbs (these could quickly create pressure injuries in children). Also, note that tape with adequate tensile strength is used; it is a common blunder in pediatric surgery to rely on clear plastic or paper tape in an attempt to be gentle. But there is nothing gentle about falling off the operating table.
Using gravity well also means protecting from gravity. These patients are properly padded and secured.
#7 Add a Port
It
is
an
error
to
sacriFice
precision,
mechanical
advantage,
and
speed
in
the
name
of
making
fewer
port
incisions.
Occasionally,
a
perverse
sort
of
macho
ethic
sneaks
into
a
surgeons
mental
habits,
like
the
s u r g e o n
w h o
r a c e s
t h r o u g h
laparoscopic
cholecystectomies
aiming
for
personal
best
skin-to-skin
times.
Here
the
error
is
to
replace
effect
as
cause:
It
is
from
precision
and
efFiciency
that
a
speedy
operation
results.
Focusing
on
speed
will
not
improve
precision,
but
precision
always
brings
speed.
A
stitch
in
time
really
does
save
nine.
Similarly,
adding
Page 16 of 22
b b>>a
a port in a case where exposure or counter-tension is difFicult can dramatically improve the overall precision of the case, and allow its L = LENGTH 0 L T = NORMAL TENSION completion speedily. Regarding the addition of a trocar as some sort of failing, as a loss in some kind of Name That Tune type of numerical TO GET THE TOTAL TENSION, FIND THE contest (I can take out that spleen with only three trocars Well I can AREA UNDER THE CURVE (DOTTED LINE): do it with only two!) does not serve the patient. L/2 L = LENGTH L One of the worries about adding trocars is that the addition T= mL (dL) could add signiFicantly to the morbidity of the operation. However, a 2C 0 fourth or Fifth 3 or 5 mm trocar will not contribute substantially to a patients pain or scarring. Experience shows that the extra trocar site SOLVING, GIVES: THEN T(L) = NORMAL TENSION AT adds trivially to the patients pain. But if the operative time is EACH LENGTH POINT L2 shortened from 3 hours of struggle with grasping and regrasping the , Cm $ T 4 bowel to a smooth 1 hour case with the least amount of manipulation necessary, the patient is plainly well served. A TROCAR OF DIAMETER D... Consideration of trocar incision lengths brings us to one of the prime fallacies in endoscopic surgery. It is inevitable that one hears DEVELOPMENT OF TENSION D 250 the argument that ACROSS THE INCISION CAN surgical technique is not improved if an open BE APPROXIMATED BY A e done through a linear incision whose length is similar operation can b 200 LINEAR FUNCTION: length of all trocar site incisions. For example, it is argued ...REQUIRES AN INCISION to the sum OF LENGTH 150 that a 2.5 cm incision is no different than Five 5 mm incisions, with the L T (L) = CmLthat the endoscopic method is somehow a fancy waste. implication 100 D However, it is not true that the lengths of trocar incisions sum to L=r 2 50 similar open incision lengths in terms of pain, scar, disability, etc. For OR ONE HALF THE example, it is intuitively obvious that 00 incisions distributed around the 5 3 6 9 12 15 CIRCUMFERENCE! abdomen have a very low or zero risk of dehiscence, but a 2.5-3cm linear incision is vulnerable to this complication. Furthermore, the Good trocar placement requires making a precisely sized trocar incision. The outer mathematics of wound tension show that the total tension across an diameter of a 5mm trocar is usually just over incision varies as a function of the square of its length, so the total 7 mm, but the incision needs to be a little tension of a long incision is greater than the summed tensions across larger. This formula suggests an incision of several very small incisions of the same aggregate length (10). Pain 11mm for a 7mm OD trocar, but because the skin has a small amount of elasticity, the real and scarring plainly depend on tension(11). The smaller tensions value is the formula, minus a little bit, or across trocar incisions are the origin of the minimally invasive closer to 9mm. If it is too small, the trocar moniker, but there is no reason for the surgeon to endure a minimal will crush the skin edges, and the surgeon may damage underlying structures while he access disadvantage. struggles to insert it. Conversely, a trocar in Dont struggle. Add a port.
too large an incision will slide in and out with the instruments, easily falling out, etc.
seeing.
When
stern
orders
are
barked
(Look
left!
NO!
Left!
And
DOWN!)
the
result
is
a
dizzying
jumpy
picture
like
a
bad
1980s
music
video.
But
everyone
must
learn
camera
work
sometime.
Fortunately,
a
few
simple
ideas
can
vastly
help
the
learner
mentally
picture
what
it
is
he
needs
to
do.
First,
take
one
minute
to
show
(or
to
learn)
the
camera
controls,
lens
connection,
and
light
hook
up.
Explain
the
use
of
the
extra
degree
of
freedom
one
gains
with
an
angled
telescope,
and
how
to
use
it
to
advantage
(for
example,
twist
the
scope
so
the
objective
points
upward
when
placing
trocars,
etc.).
Demystify
it,
so
that
the
camera
operator
will
not
be
distracted
by
apprehension.
Next,
the
learner
must
understand
that
the
image
must
always
be
centered
on
the
action,
and
kept
upright.
Novices
tend
to
allow
the
camera
to
drift
away
from
center,
and
off
kilter.
If
you
Find
yourself
trying
to
look
around
the
corner
of
the
screen,
or
are
tilting
your
head,
check
your
cameraman.
Most
learners
need
to
be
reminded
of
this
multiple
times.
Even
seasoned
surgeons
can
be
pulled
into
this
tendency
to
look
around
corners
of
a
two-dimensional
image,
but
a
good
camera
operator
will
not
tempt
the
operator.
Not
only
should
the
camera
be
centered
on
the
action,
but
the
picture
must
be
kept
upright.
It
is
a
matter
of
simple
demonstration
that
task
precision
radically
degrades
if
the
image
tilts
relative
to
the
surgeons
sense
of
up
and
down.
It
is
possible
(although
not
optimal)
to
work
semi-paradoxically,
that
is
with
ones
body
oriented
up
to
nearly
90
degrees
off
the
line
between
camera
and
organ
of
interest
(that
is,
partially
violating
the
rule
to
face
the
organ
being
operate
on).
This
position
allows
an
assistant
to
work
well
from
the
patients
side
when
the
operator
is
at
the
foot,
for
example.
It
also
make
the
outrigger
camera
a
viable
strategy.
But
even
a
slight
change
in
tilt
destroys
the
surgeons
ability
to
move
because
of
human
reliance
on
an
absolute
z- axis.
For
both
surgeon
and
assistant,
the
up
and
down
must
remain
a
consistent
reference
frame
in
which
to
work.
Novices
also
tend
to
jerk
the
camera
around,
making
small,
brisk
movements
with
multiple
overcorrections.
Humans
are
known
to
perform
better
at
new
skills
if
they
can
mentally
link
the
new
action
to
an
imagined
action
or
image
that
they
know.
Martial
arts
teachers
have
known
this
for
centuries:
Bend
like
the
reed
in
the
wind
or
Stand
like
an
iron
horse.
The
images
do
not
need
to
be
an
action
that
the
novice
has
already
done
(although
that
is
helpful),
but
evocative
in
a
way
that
pre-Fires
the
cerebellum
in
a
particular
way.
In
this
spirit,
teach
the
new
camera
operator
to
move
the
camera
as
if
she
were
doing
Tai
Chi.
Everyone
can
picture
the
slow,
graceful,
highly
controlled
and
Fluid
motion
of
some
old
master
practicing
Tai
Chi.
Holding
this
image
in
mind
predisposes
the
novice
to
relax,
breathe,
and
move
the
camera
slowly,
precisely.
The
image
will
be
better
than
in
response
to
the
Page 18 of 22
order Move slower! The novice learns faster when primed than when bullied. The Tai Chi camera is always centered, upright, and deliberate.
Page 19 of 22
The second skill is the ability to ignore details. This skill is familiar to anyone who has learned the automatic, unconscious movements of driving a car. At First, every single move requires deliberate thought--clutch, signal, turn, gas, clutch, brake, gas....The new driver must pay so much attention to the mechanics of the car that he will not see that truck, that pedestrian, or that pothole. But with practice, the driver, and the surgeon, moves automatically, freeing the mind for other focus. In this way, practice is really a way of removing distractions. Somewhat paradoxically, being more mindful is the art of attending to less. Expertise is not the ability to attend to more things, but the ability to be more selective in attention. The expert automatically pays attention to the important stuff and neglects the unimportant. Being an expert means being able to tell the difference.
Page 20 of 22
Explicitly noting the reused movement objects (the small moves from which more complex actions are built) in different cases allows the surgeon to move up learning curves much more quickly. Every endoscopic case reinforces the others, even the easy onesif good principles are always followed. For example, safe trocar placement, non-dominant hand attention, camera movement, and use of gravity for retraction are used in every laparoscopic or thoracoscopic case, and the lessons and skills built here are actually more critical in harder cases. In this way, as cases are built from skill blocks (like classes in object-oriented computer programming), the learner discovers that there are no hard cases, only cases with a greater number of easy moves.
Conclusion
The
principles
described
here
can
be
applied
in
any
pediatric
MIS
case.
They
are
intended
to
help
maximize
the
surgeons
mechanical
advantage
anywhere
minimally
invasive
methods
are
used.
Each
of
these
is
intended
to
deal
with
the
scaling
problems
of
small
patients,
to
help
the
surgeon
wield
rather
than
simply
use
the
devices,
to
promote
precision
by
maximizing
available
degrees
of
freedom,
or
to
work
with
(or
overcome)
inherent
human
strengths
(and
weaknesses):
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Perfect tools are perfectly maintained...and understood Face the organ Triangulate the ports Do the same operation Operate with two hands Gravity is the third hand Add a port Tai Chi Camera Bifocals for Spatial and Situational Awareness Analogy builds versatility
The learning curve: prociency with any skill requires practice. But it is not true that each new operation starts the surgeon at the bottom of the curve. Instead, specic abilities--good set-up, two handed action, small moves, comfortable facility with electrosurgical devices, etc--are all objects that port easily to new procedures. But the surgeon must see the analogies to apply old methods to new circumstances!
Maximizing mechanical advantage aids precision, speed, and safety in MIS, a technological extension of surgery that, perhaps ironically, presents several mechanical disadvantages (and some advantages, of course) to the surgeon. Struggling with these disadvantages puts the patient at unnecessary risk, risk that is magniFied in babies and children. Fortunately, practiced application of the heuristics here can help the surgeon create the superset of skills needed to obviate common hazards. But principles can go too far. Regarding the principles presented here as rigid or exhaustive misses the principle behind principles: Principles are to be used, not blindly obeyed. TAB
Page 21 of 22
SELECTED CITATIONS
1. Morgenstern, L. Warning! Dangerous curve ahead: the learning curve. Surgical innovation 12: 101-103, 2005. 2. Rangel, S. J., Henry, M. C., Brindle, M., and Moss, R. L. Small evidence for small incisions: pediatric laparoscopy and the need for more rigorous evaluation of novel surgical therapies. Journal of pediatric surgery 38: 1429-1433, 2003. 3. Rogers, D. A., Lobe, T. E., and Schropp, K. P. Evolving uses of laparoscopy in children. The Surgical clinics of North America 72: 1299-1313, 1992. 4. Madan, A. K., and Frantzides, C. T. Prospective randomized controlled trial of laparoscopic trainers for basic laparoscopic skills acquisition. Surgical endoscopy 21: 209-213, 2007. 5. Van Sickle, K. R., Ritter, E. M., McClusky, D. A., 3rd, Lederman, A., Baghai, M., Gallagher, A. G., and Smith, C. D. Attempted establishment of prociency levels for laparoscopic performance on a national scale using simulation: the results from the 2004 SAGES Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR) learning center study. Surgical endoscopy 21: 5-10, 2007. 6. Najmaldin, A. (Ed.) Operative Endoscopy and Endoscopic Surgery in Infants and Children. New York: Oxford University Press, 2005. 7. Holcomb, G. W., 3rd, Rothenberg, S. S., Bax, K. M., MartinezFerro, M., Albanese, C. T., Ostlie, D. J., van Der Zee, D. C., and Yeung, C. K. Thoracoscopic repair of esophageal atresia and tracheoesophageal stula: a multi-institutional analysis. Annals of surgery 242: 422-428; discussion 428-430, 2005. 8. Desrosiers, J., Bourbonnais, D., Bravo, G., Roy, P. M., and Guay, M. Performance of the 'unaected' upper extremity of elderly stroke patients. Stroke; a journal of cerebral circulation 27: 1564-1570, 1996. 9. Georgopoulos, A. P., and Grillner, S. Visuomotor coordination in reaching and locomotion. Science (New York, N.Y 245: 1209-1210, 1989.
10. Blinman T Incisions do not simply sum. Surg Endosc. 2010 Jul;24(7): 1746-51. Epub 2010 Jan 7. 11. Burgess, L. P., Morin, G. V., Rand, M., Vossoughi, J., and Hollinger, J. O. Wound healing. Relationship of wound closing tension to scar width in rats. Archives of otolaryngology--head & neck surgery 116: 798-802, 1990.
Page 22 of 22