46 r

Surgicot Procedures lncluding Minimol Access Procedures

S4gi:d Procedures lncluding Minimol Access procedures disease,

47

tractors, clamps, sponges, and so on, until the surgical site is exposed. In each anatomic site different instruments may be employed, but this general principle is applicable. In specialized procedures, utilizing endo-

."op"., the operating microscope, electrosurgical equipment, lasers, a plasma scalpel, argon beam coagulator,

=etastatic !3 ertent o_f trauma, and so on. Biopsies or fluid sam_ f&s and cultures can be obtained. Continuation of the E itd _access procedure or conversion to a standard

infertility, dndometriosis,

sepsis,

tpoach
, .

may then be performed accordingly.

hydrodissector, intraoperative radiation therapy moaaLties, ultrasound modalities, and so on, the technique is altered accordingly. In procedures in which potential contamination is inherent (e.g., intestinal surgery), the wound is protected throughout. When clean closure of the incision is indicated, the operating team regowns and regloves, the field is redraped, attd the instruments, electrosurgical
pencil, and so on are replaced. Historically, procedures employing limrted incisions have been applied to sitrlations in which the underlying structures are immediately apparent with minimal dissection and manipulation oftissues. Ingenious recently introduced (embellished and reintroduced) techniques of performing lesser and greater procedures via limited access are now commonly utilized in most surgical specialties. Previously, the procedures included thoracoscopic, abdominal, and pelvic laparoscopic surgery, but curiently they have been extended to include orthopedic, neuiological, otolaryngological, and urological specialties. The basic tenet of limited access surgery is that the definitive portions of the procedure be accomplishedin identical fashion to that of an "open" procedure. If, for whatever reason, inability to safely expose and visualize structures due to uncontrolled hemorrhage, inflammation and sepsis, dense adhesions, obesity; or xcssive anesthesia time, or if consequent surgical injury ensues, or the urgency pfthe situation dictates, or there is equipment failure, the procedure must promptly be converied to the traditional approach. In certain instances a lesser formal incision may be employed wrth

]rcililtcAr

coNstDERATtONS

-eto the availability of intensl illumination', ;rC-h_ don, and capability to see ,,around" structuies. Most
L|eEd monitors with associaied recording u"d pfrot* graphic capabilities. A virtual deluge of instruments for limited access mgery has been introduced with continual tnodificafrn- Many are precision miniatures of standard in_ sftuments with attached pistol grip handles and with "! capabilities of locking, rota-tion, angulation, and dectrification. Also available is a great rTariety bf tro_ cans,,.electrosurgical devices, lasei adaptations, hy_ fraulic dissectors, extrudable retractors, and so on. There has been a trend to substitute reusable in_ qfuumerrts for single use items with the obvious exceptlms o{ staplers, cutting-edged instruments, and so on. Inrleed, novel technology has been introduced for ul_
&asonic_ cleaning

fudamental in limited acc-ess surgery is the ability to limalize the operative field. On oc"casion this may su_ pusede visualization in a comparable open procedure

rfrA! a video camera is incorporated into the specifiC s!rcand the image is displayed on two appropriatel5r

and sterilization of these instru_ Special training courses, books and visual aids nrr physrclans and nursing personnel, accreditation, and credentials have a"co-panied this new technology. Finally, clinical success, time, and economic limila_ tions rather than innovative scientific ua".rr."" ;ii-i;tablish which limited access procedures will be utilized.

the limited access technique as in "laparoscopic

sisted" surgery.

as-

An additional use for limited access surgery is in its diagnostic capabilities with respect to assessment of