D. Luttman, RN

SYLLABUS NOT AVAILABLE

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2. The Anatomy of Video Imaging:
The Skills, Tools, Instruments and Equipment

E. Harper, RN

SYLLABUS NOT AVAILABLE

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3. Energy Based Vessel Ligation

Brenda C. Ulmer, RN, MN, CNOR

Senior Clinical Educator, Valleylab, Inc.

1758 East Gate Dr.; Stone Mountain, GA 30087

 

1) Current Methods of Achieving Hemostasis

     a) Mechanical occlusion devices:

     b) Engery based thermal coagulation devices:

          i) Laser Coagulation

          ii) Ultrasonic Coagulation

          iii) Electrosurgical Coagulation

               (1) Monopolar

               (2) Bipolar

2) Vessel Sealing System Offers an alternative form of electrosurgery to provide:

          i) Reliable, consistent, permanent vessel wall fusion

          ii) Minimal thermal spread

          iii) Reduced sticking and charring

          iv) Seal strengths higher than other energy based techniques

          v) Seal strengths comparable to existing mechanical based techniques

3) Vessel Sealing System

          i) Generator

          ii) Instruments

          iii) System Operation

               (1) Applies optimal pressure to vessel/tissue bundle

               (2) Energy delivery cycle:

4) Seal Characteristics

          i) Intimal layers of vessel walls fused

          ii) Plastic-like consistency due to collagen remodeling

          iii) Distinctive, possibly translucent seal zone

          iv) Permanent

          v) Does not rely on a proximal thrombus

          vi) Withstands >3 times normal systolic pressure

5) Tissue Selection Criteria

6) Analysis of Vessel Seal

     a) Results

          i) High burst strength seals exhibited the following properties:

               (1) thin, translucent, plastic-like seal site

               (2) seal zone significantly compressed

               (3) intimal layers of vessel walls fused

               (4) lateral thermal damage <2mm

     b) Camparison Burst Pressure Study Results

          i) Probability of seal failure below 400 mmHg:

               (1) Ulstrasonic coagulator 95.0%

               (2) Standard bipolar 28.0%

               (3) Clips 00.4%

               (4) Vessel sealer 00.2%

               (5) Ligatures 00.0%

 

Energy Based Vessel Ligation

 

Edison invented the light bulb and it revolutionized the way we see. Bovie and Cushing invented electrosurgery and it revolutionized the way surgeons achieve hemostasis during surgical procedures. Energy based vessel ligation takes the next step in the evolution of electrosurgery by providing surgeons with a new and unique form of electrosurgery that provides hemostasis by fusing the collagen in vessel walls to create a permanent seal.

 

Objectives:

• Identify current methods of vessel ligation for surgical procedures
• Describe high force, controlled radio frequency vessel ligation as an additional ligation method
• Discuss benefits and limitations of vessel ligation methods

 

Suggested Reading:

 

J. Kennedy, P. Stranahan, S. Buysse, T. Ryan, J. Pearce, S. Thomsen, ALarge Vessel Ligation Using Bipolar Energy: A Chronic Animal Study and Histologic Evaluation,: Valleylab, Boulder, CO: University of Colorado Health Sciences Center, Denver, CO; University of Texas, Austin, TX; University of Texas M. D. Anderson Cancer Center, Houston, TX;.

 

J. Kennedy, P. Stranahan, K. Taylor, J. Chandler, AHigh-burst-strength, feedback-controlled bipolar vessel sealing,@ Surgical Endoscopy, 1998(12), New York, Springer-Verlag, pages 876-878.

 

J. Kennedy, S. Buysse, J. Chandler, J. Eggleston, K. Taylor, S. Thomsen, AControlled Radio Frequency Vessel Sealing System for Surgical Applications,@ Proceedings of SPIE, 1998, 3249: pages 125-129.

 

E. Crawford, J. Kennedy, V. Sieve, AUse of Vessel Sealing System in Urologic Cancer Surgery,@ Grand Rounds in Urology, 1(4); 10-17.

 

A. Brill, J. Feste, T. Hamilton, A. Tsarouhas, S. Berglund, J. Petelin, P. Perantinides, APatient Safety During Laparsocopic Monopolar Electrosurgery B Principles and Guidelines,@ Journal of the Society of Laparoendoscopic Surgeons, 1998, 2: pages 221-225.

 

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4. Laparoscopic Common Bile Duct Exploration: Is your OR ready?

George Berci, MD

SYLLABUS NOT AVAILABLE

 

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5. Ultrasound 101: How to Operate and Interpret Ultrasound Images

J. Jakimowicz, MD

SYLLABUS NOT AVAILABLE

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David R. Urbach, MD, MSc

Assistant Professor of Surgery and Health Administration, University of Toronto

8th Floor Main Pavilion, Room 332, Toronto Western Hospital

399 Bathurst St., Toronto, Ontario, Canada M5T 2S8

 

Performing good research is not easy. It involves a large time commitment and a lot of hard work. However, planning, executing and presenting research projects adds variety and excitement to a career in clinical surgery. There is an excellent opportunity for OR personnel, whether physicians, nurses, physician assistants or operating room technologists, to become involved in research projects. Surgical techniques and technology are changing so quickly that there is plenty of room for evaluation and experimentation, and the individuals involved in the day-to-day process of clinical care are those most likely to recognize areas that require scrutiny. The type of research that I will focus on in this presentation is "clinical research." Clinical research means different things to different people, but I use it to mean any systematic study of the care that is provided to "patients." I will not discuss other important research disciplines such as qualitative research,(1) which has an especially strong tradition within academic nursing, nor will I discuss "basic science" or "laboratory" research. This presentation will discuss some of the "basics" of getting started in clinical research for people who don't necessarily have previous experience in planning and reporting research projects.

 

Types of research studies

Although there are several different types of research designs, most projects fall into one of a few specific categories. Research designs vary in terms of complexity and expense, and the very best studies (those that are published in top medical journals) are usually very expensive, take years to perform, and are carried out by people who devote a significant proportion of their career to doing research. The good news for the novice researcher is that the research designs used for most studies in surgery are fairly simple. The "hierarchy" of research designs, in order or increasing methodological "soundness," includes: case reports and case series, cross-sectional surveys, epidemiologic studies (such as case-control and cohort studies), and randomized controlled trials. More rigorous research designs are less likely to reach erroneous conclusions (see "Error and validity" below). Surgical journals also contain a miscellany of other types of reports, including reviews, surgical "technique" papers, letters and brief reports. The beginner researcher should start simple. Good starter projects include reporting a case series, conducting a survey, or comparing the cost or OR utilization measures for different surgical procedures. It is always helpful to conceptualize a project as a comparison that can be made, such as between two groups of patients, two different procedures, or two types of OR designs.

 

Think of a good question

Good research always involves planning ahead. Think of an upcoming meeting that you would want to present a project or a journal where you think your paper should be submitted, and work towards that goal. Interesting research questions may occur to you from a number of sources: problems you encounter during day-to-day work, questions people ask you that you don't know the answer to, or questions that occur to you while reading other papers in surgical or nursing journals. Reading papers in medical journals is an excellent way of keeping abreast of issues that other researchers are interested in, as well as becoming familiar with important research methods.

 

All projects should start with a good research question. The best research questions have several important attributes. They are interesting, they are important, they are specific, and they are answerable. The test of whether a question is interesting and important is that a good question can be easily defended when somebody asks "so what?" Asking an interesting and important question serves two purposes: first, you will be much more enthusiastic about your research project (this helps when you write it up), and second, the completed research will have a much greater chance of being published or accepted for presentation at a meeting. Once you have a good question, you should narrow it down into a single, very specific study hypothesis. A final criterion is that the question must be answerable. An answerable question represents a hypothesis that can be tested (and possibly rejected) using some form of experiment that would be feasible to perform. Hypotheses are expressed as "null" hypotheses. If your research question is whether it takes longer to suture a skin incision than to staple it, a null hypothesis might look like: "The time taken to close an elective inguinal hernia skin incision is the same whether continuous subcuticular suture or staple closure is used."

 

Write a protocol and consult with "experts"

The best research projects are completely spelled out in detail before the investigator even gets started. It is extremely helpful to draw up a detailed protocol (a document that describes the background, methods, and study personnel involved). Data collection forms are an integral part of the protocol. The protocol should be built around the study question, and should state the hypothesis, study subjects (how will they be selected, what are the eligibility and exclusion criteria), how the exposures and outcomes will be measured, how the resulting data will be managed, and how the data will be analyzed. There are excellent references that describe study design and methods in detail.(2,3)

 

A critical component is the "sample size" or "power" calculation. Early on, discuss your proposed project with a statistician (see below). He or she will tell you how many subjects you need to include or how many observations you need to have for your study, but you must be able to state exactly what it is you are trying to find. If you are trying to show that there is a difference between two different ways of doing something (e.g., using a harmonic scalpel instead of clips to divide blood vessels during a laparoscopic Nissen fundoplication), you must tell the statistician exactly what change you think is important (e.g., a ten minute or longer difference in operating time). The statistician may ask for some "pilot data," such as what the operating times have been for some recent procedures.

 

A good protocol makes performing the study much easier, and also helps when the time comes to write a manuscript. Early on, you should assemble a study team. Especially important for the novice researcher is to include at least one "expert" on the study team. My definition of an expert is someone with experience in designing, conducting, analyzing and writing up research. Most hospitals, and especially academic medical centers, are teeming with these types of people. A final caveat is to include a statistician in the study, and to get them involved early. This person should ideally be a "professional" statistician - with a Master's level degree or higher in a discipline involving biostatistics, and not simply a "motivated amateur."

 

Error and validity

A researcher's goal is to find the true answer to their question. Unfortunately, the answer that a researcher comes up with is not always the right one. The reason for this is the fact that there is always some degree of error involved in the process of research. The validity of a study (its ability to find the true answer as opposed to some false answer) is improved by minimizing error. There are two major categories of error: random error and systematic error. Random error occurs because of random variation in patient characteristics, measurement imprecision, or misclassification that does not occur preferentially in favor of one comparison group or the other. Random error is inevitable, but ensuring an adequate sample size and performing appropriate statistical tests can minimize the effect of random error.

 

Systematic error (also called "bias"), on the other hand, is a major problem. Like random error, systematic error also involves inaccurate observations, but in this case the error occurs preferentially in favor or against one of the comparison groups. The problem with systematic error is that it often cannot be minimized using large sample sizes or fancy statistical procedures. There are two major categories of bias: selection bias, and information bias. The most effective means of ensuring the validity of a research project is minimizing bias. Various methodological techniques such as random allocation of study subjects, control groups, intention-to treat analysis, accounting for all study subjects, blinded assessment of outcomes and complete follow-up can help reduce bias. The principles of research design comprise an entire area of study, and the novice should consult experienced researchers and textbooks on research methods.(2)

 

Writing style

The key to medical writing is to write as simply and clearly as possible. The goal is to explain what you did and what you found, and not to impress anybody with your literary talent (save this for your great novel). Sentences should be very short. When in doubt, break a long sentence into two or more short sentences. Papers that are written in the active voice are interesting to read and sound enthusiastic, and writing in the first person is perfectly acceptable. This means that you can use sentences like "We stratified patients into two groups" instead of "Patients were stratified into two groups." The "bible" of good writing technique is a very short book called "The elements of style" by Strunk and White,(4) which is available in most hospital libraries.

 

Format of a biomedical manuscript

A medical manuscript contains the following components: title page, abstract, introduction, methods, results, discussion, and references. Of course, the manuscript does not have to be written in this order, and many writers prefer to start with the methods and results sections, since they are usually the easiest to write (and the methods section may already exist in the protocol). My preference is to create an outline on a word processor, including titles and subtitles, and then to fill in the text. The British Journal of Surgery has published an excellent series of articles on writing a manuscript for a surgical journal.(5-8) Different journals have different specific requirements for manuscripts, and authors should carefully review the "Instructions to authors" pages published in each journal, as well as "Uniform requirements for manuscripts submitted to biomedical journals" (available at http://www.icmje.org). The guidelines below are just one approach to writing a paper, and different authors use different techniques equally effectively.

 

The abstract should be written only after the rest of the manuscript is completed, in order to ensure that its content exactly matches that of the body of the paper. The abstract is a short summary of the paper, and is usually structured into sub-headings (background, methods, results, and conclusions). The introduction should be short and to the point. This section should briefly explain the nature of the problem and the importance and rationale for doing the study - the introduction is not the place for a literature review. If the introduction is more than three short paragraphs, it should be shortened and rewritten. Excess material from the "introduction" can always be added to the discussion. The methods section may be broken into sub-headings (e.g., study subjects, operative procedures, measurement of outcomes, statistical analysis). This section should describe exactly how and why you did what you did, in as much detail as possible. The methods should always describe the statistical analyses that were done, and should also include details on the sample size calculation, including the study's power, and the size of the effect that it was trying to detect. The results section should contain only the actual findings of the study, presented in a logical pattern. All interpretation of the findings is left for the discussion. Typically, results are presented as text, tables or figures. Authors should strive to present data as tables or figures whenever possible. Data from tables and figures should not be repeated in the text except for brief emphasis of important findings. The discussion section should stress the important findings of the study, acknowledge the limitations of the methods, discuss the implications of the findings, and put the findings into perspective in the light of previous studies. Authors should be careful not to conclude more than allowed from the results of the study. A list of all references cited should follow the text of the manuscript. Every statement of fact used in the manuscript should be supported by a published reference, as should all references to statistical or experimental methods except for those that are universally used and understood (e.g., Student's t test).

Before you do anything with your manuscript, have somebody else read it! It is extremely difficult for the author of a paper to recognize flaws that will cause problems in peer review. Having one (or two or three) colleagues proofread your work will undoubtedly save time and aggravation later on.

 

 

 

Final advice

The most important task of a clinical researcher is to minimize bias, and to measure everything as accurately as possible. Unfortunately, this fact is frequently unrecognized by peer reviewers, who may be disproportionately impressed by large sample sizes or complex surgical procedures, and not appreciate the difficulty involved in collecting, maintaining and analyzing high-quality data. Nevertheless, diligent attention to the under-appreciated job of careful research procedure helps to generate work of the highest possible quality. Research is a team sport. The best studies and manuscripts include contributions from a number of different people, and trying to "do it on your own" is bound to cause grief. Much research that we do is done "on our own time" and without remuneration, so it helps to be self-motivated and interested in the research project. Despite the extra time and hard work that is involved, doing and presenting research is actually a lot of fun, and most people who do research appreciate the variety and excitement that their research activity adds to their day-to-day work.

 

References

 

1. Wright JG, McKeever P. Qualitative research: its role in clinical research. Annals of the Royal College of Physicians and Surgeons of Canada 2000;33(5):275-80.

2. Hulley SB, Cummings SR. Designing clinical research: An epidemiologic approach. Baltimore: Williams & Wilkins; 1988.

3. Riegelman RK. Studying a study and testing a test. 4th Ed. ed. Philadelphia: Lippincott Williams & Wilkins; 2000.

4. Strunk WJr; White EB. The elements of style. 4th Ed. ed. Boston: Allyn and Bacon; 2000.

5. Sarr MG. Generating an idea: will it be publishable? Br J Surg 2000;87:388-9.

6. Alderson D. On getting started. Br J Surg 2000;87:532-3.

7. Wells SrAJ. Writing the manuscript. Br J Surg 2000;87:691-2.

8. Murie JA. The final product. Br J Surg 2000;87:980-2.

 

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7. The Intelligent OR & the Emerging
Role of Robotics

T. Kenyon, RN

 

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8. Laparoscopic Fundoplication: Nissen vs. Toupet

W. Laycock, MD

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9. Colectomy: Essential Steps in Performing
Laparoscopic Colectomy

Jim Fleshmann, M.D., FACS, FASCRS

Washington University Medical Center

and

David Beck, M.D., FACS, FASCRS

Ochsner Medical Institutions

 

EQUIPMENT

 

Trocar/ports - 10/12 mm

30 or flexible scope

Endobabock

Electrocautery scissors or harmonic scalpel

 

POSITION

 

Lithotomy

Bean bag - Velcro to bed

Allen stirrups

Thromboguards (penumatic compression stockings)

Secure for airplanning/Trendelenburg

 

RIGHT COLON STEPS

 

1. Safe access and establishment of Pneumoperitoneum.

2. Exploration of abdomen.

3. Port placement (anchor shaped). See Figure 1.

4. Position in steep Trendelenburg, airplane to left.

5. Retract small intestine to patient's left and toward

the head (use LLQ Babcock).

6. Life cecum to anterior abdominal wall with a Babcock

through the SP or RLQ and incise peritoneum at

pelvic brim medially (Figure 2) to aortic bifurcation

with scissors through the suprapubic port. (Figure 3)

An avascular plan can be followed to the third portion

of the duodenum and protects all of the

retroperitoneal structures.

 

 

7. Retract the cecum to the left using the LLQ Babcock adn incise the right gutter peritoneum to the

hepatic flexure with the scissors throughout the suprapubic or LLQ port (Figure 4).

 

 

8. Divid the haptic flexure suspensory ligament beginning laterally (Figure 5) and working medially

(Figure 6). Occasionally an additional port in the LUQ (5mm) is needed to get the scissors closer to

the tissue. Tension is placed on the transverse colon.

9. The ileocolic artery is identified in the right colon mesentery with a window in the mesentery on

either side and the SMA running across the bottom of the mesentery. Traction is placed upward on

the vascular pedicle with a Babcock through the RLQ (Figure 7). The vessels are dissected,

clipped and transected (Figure 8). The right branch of the middle colic artery and the terminal

branch of the SMA can also be transected. (Figure 9).

 

 

10. The vertical umbilical decision is enlarged to 4 to 6 com, a ring drape placed, the right colon and

terminal iluem delivered and resected. The anastomosis is completed at the level of the skin.

11. All 10mm ports and the midline incision are closed.

Note: These are suggested steps only and may not be complete steps of the procedure. Individual surgeon preference and experience, as well as patient needs, should always dictate variation in procedural steps.

 

TRANSVERSE COLON STEPS

1. Save access and establishment of pneumoperitoneum.

2, Exploration of abdomen.

3. Port placement (anchor shaped). See Figure 1.

4. Position in Reverse Trendelenburg.

5. Elevate transverse colong omentum with Babcocks. Retract colon inferiorally and divide

avascular area between omentum and colon (Figure 10A).

6. Divide Middle Colic vessels (Figure 10B).

 

 

LEFT COLON STEPS

1. Safe access and establishment of pneumoperitoneum.

2. Exploration of abdomen.

3. Port placement (anchor shaped). See Figure 1.

4. Position in steep Trenelenburg airplaned to right.

5. Retract small intestine from pelvis to right upper quadrant with Babcock through RLQ. Retract

sigmoid to right with Babcock through RLQ and divide pertioneal attachments and begin

dissection along left gutter with scissors through suprapubic port. (Figure 11A & B). Push left

colon medially with a Babcock through the LLQ port. An avascular plane between the left

colon mesentery and retroperitoneum and its structures can be developed all the way to the

splenic flexure and medially to the aorta.

 

 

6. Identify and protect the left ureter from the pelvic brim to the kidney (Figure 12 A & B).

7. Free the splenic flexure from the omentum, spleen and pancreas. The patient is placed in

reverse Trenelenburg, the omentum is lifted with the Babcock through the RLQ port, the

transverse colon is pulled caudad with a Babcock through the suprapubic port and the adhesion

of the omentum to colon is divided beginning distally with a scissors through the LLQ (Figure

13). Dissection is carried medially. Retroperitoneal and splenic attachments are incised to enter

the lesser omental sac.

8. The plane behind the superior hemorrhoidal artery is incsed from the RLQ with the patient once

again in Trendelenburg and the sigmoid lifted by a Babcock through the LLQ. The window behind

the artery, anterior to the aorta is developed BROM the sacral promontory to the IMA. The left

gutter can be seen through the window and a Babcock from the LLQ passed through to lift the

sigmoid and left colon.

 

 

 

9. The IMA is cleaned of mesenteric fat with scissors through the RLQ, clipped through the

suprapubic port and divided. (Figure 14). The IMV is the next structure encountered cephalad.

This structure is cleaned, clipped and divided.

10. The mesentery of the left colon or transverse colon is divded by clipping vessels at the level of

the colon planned for transection.

11. The mesenter of the proximal rectum is divided with scissors and clip applier through the RLQ.

12. A 6-10cm inciscion is made in midline at the pubis, protected with a ring drape and the left

colon and sigmoid delivered through the wound. The distal resection line is transected with a

linear stapler through the wound.

13. The proximal pursestring is placed and an anastomosis is performed through the incision. The

wounds are closed from the internal aspects at the trocar sites.

Note: These are suggested steps only and may not be complete steps of the procedure. Individual surgeon preference and experience, as well as patient needs, should always dictate variation in procedural steps.

 

LAR STEPS

 

1. Safe access and establishment of pneumoperitoneum.

2. Exploration of the abdomen.

3. Port placement (anchor shape). See Figure 1.

4. Position in steep Trendelenburg airplaned to right.

5. Retract small intestine from pelvis to right upper quadrant with Babcock through RLQ. Retract

sigmoid to right with Babcock through RLQ and divide peritoneal attachments and begin dissection

along left gutter with scissors through suprapubic port. Push left colon medially with a Babcock

through the LLQ port. An avascular plane between the left colon mesentery and retroperitoneum

and its structures can be developed all the way to the splenic flexure and medially at the aorta.

6. Identify and protect the left ureter from the pelvic brim to the kidney. (Figure 15).

7. Free the splenic flexure from the omentum, spleen and pancreas. The patient is placed in reverse

Trendelenburg, the omentum is lifted with the Babcock through the RLQ port, the transverse

colon is pulled caudad with a Babcock through the suprapubic port and the adhesion of the

omentum to colon is divided beginning distally with a scissors through the LLQ. Dissection is

carried medially. Retroperitoneal and splenic attachments are incised to enter the lesser

omental sac.

8. The plane behind the superior hemorrhoidal artery is incised from the RLQ with the patient

once again in a Trendelenburg and the sigmoid lifted by a Babcock through the LLQ. The window

behind the artery, anterior to the aorta is developed from the sacral promontory to the IMA.

The left gutter can be seen through the window and a Babcock from the LLQ passed through

to lift the sigmoid and left colon.

9. The IMA is cleaned of mesenteric fat with scissors through the RLQ, clipped through the

suprapubic port and divided. The IMV is the next structure encountered. (Figure 16).

10. The mesentery of the left colon or transverse colon is divided by clipping vessels at the level of the

colon planned for transection.

11. An endocutter stapler is introduced through a trocar placed through the planned stoma site. The

colon is divided in the descending portion (Figure 17) and pulled through the enlarged trocar

site to make a colostomy (Figure 18).

 

 

12. The dissection of the rectum begins at the pelvis with the rectosigmoid pulled toward the pubis by

a Babcock through the LLQ while dissection is performed through the suprapubic port with the

scissors and traction placed on the mesorectum with a Babcock through the RLQ port. The

avascular plane of the areolar tissue between the fascia propria investing the mesorectum and the

presacral fascia can be developed all the way to the pelvic floor (Figure 19).

13. The anterior peritoneum and middle rectal vessels are divided with electrocautery scissors through

the suprapubic port (Figure 20).

14. Transection of the rectum at the appropriate level can be accomplished using and articulated linear

cutter stapler through the suprapubic port.

15. The anastomosis is made through a midline suprapubic incision with a double stapled technique

(Figure 18.). The wounds are closed through the suprapubic wound.

 

 

APR

If an APR is planned the remainder of the procedure is performed through the perineal incision. The colostomy is matured and wounds closed.

 

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10. Laparoscopic Solid Organ Removal

C. Daniel Smith, MD

 

 

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* Articles provided with print version of syllabus

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