Question & Answer
June, 10 / 2009
From : Dr Cadri Muhamad (Israel)
my name is Mohamed Cadri. I am an MD with a specialization in Anesthesiology in the Tal-Hashomer hospital in Israel. First of all, we would like to make many compliments to the ideators of this new concession in the field of surgery that has fascinated me and my colleagues, both anesthetists and surgeons. We think that the latter represents a truly innovative and excellent surgical technique, which allow the maximum possible respect for the tissues, still guaranteeing an immediate resumption function to the whole organism with scars outcomes under the cosmetological side. In addition, we are convinced that the reduction in the length of hospitalization, the reduced use of drugs and therefore the lower costs associated with this technique make it a precious and unique opportunity in the field of surgery. We do really hope that the above-mentioned characteristics will make it possible to promote your technique all over the world, especially in those countries which would benefit more from a steep decrease of surgical costs. It would be a pleasure to us if you could send us some detailed information on a few technical aspects of your technique. Specifically, we would really appreciate it if you could clarify the phases of the incision of the single epidermis taking part the extra-corporeal via, as well as the type of suture you use. Please accept my congratulations for the results of your technique, and I really hope that we will have the chance to collaborate in the future.
I thank you very much for your letter. I would also like to thank you and all your colleagues from the Tel-Hashomer Hospital in Israel for the interest you have showed in our Minitraumatic Surgery. I particularly appreciate your letter, since it is written by a specialist in the field, who shares the same principles upon which our technique is based. In addition, your letter has also strengthened our commitment to diffuse knowledge about our technique, since we are strongly convinced that any acquaintance of public interest should be advertised and widespread as much as possible, and knowledge should circulate free of charge to benefit the whole humanity, not only a privileged group of people. In this view, your letter and wishes of a widespread diffusion of our technique are already a great contribution to achieve our primary goal.
We are fully persuaded that our technique will be of great interest for all surgeons, patients and administrators of health service providing structures all over the world. This is so, because of the very easy way in which the technique can be learnt and performed anywhere. In addition, our technique dramatically lowers costs in providing health services.
I also have to thank you for your sharp questions, which I believe got to the heart of crucial aspects of our Minitraumatic Surgery. Hence, I would like to address your suggestions in the following paragraphs.
Any medical procedure should be inspired by the Ippocratic aforism “Primum non Nocere” ( first of all, don’t cause any damage), which is fully justified under the biological point of view.
The epidermis is an epithelium and, as such, it does not show any vascularization.The perfusion of its structural and functional elements is guaranteed by the lamina basale, which allows all bidirectional exchanges between the Epidrmide and the Derma. The latter, on the contrary, has a significant vascularization (1).
Therefore, if the incision is only made on the epidermis, we will not cause any form any bleeding. The epidermal incision has to be done by means of a cold blade scalpel, with an tail inclination of 45 degrees.
Hence, it is sufficient that the adherent areas are maintained in such position, by means of some self-adhesive bandage, until a scar tissue appears.
Our technique makes it possible to avoid any classic suture material, which often ends up creating fistulous ways through the skin along which microorganisms can freely move, from the outside to the inside of the organism and viceversa. The latter phenomenon can be defined as a bidirectional-movement effect, and it is responsible for the majority of possible infectious complications.
Then, it is crucial that the functional area of the derma is totally respected (see image), since it is responsible for all the repairing processes and the overall defense of the cute. For all these reasons, all the under levels must be only modified by a small central perforation of the epidermal incision, which we get by means of an electrocoagulator, until we reach and pass over the central line of rectal muscles. Finally, we manually widen the access to the abdominal-pelvic cavity without any tissue incisions, through delicate and precise manual tensions.
We do not use any kind of instruments, and we follow the naturally existing cleavage plans.
In conclusion, the access is widened without any spilling of blood, through are concept of a “dynamic, 3D and therefore volumetric” surgery, instead of the classical bidimensional and a static one, which requires retractors to be implemented.
The internal components of the high abdominal cavity can be easily isolated from the pelvic region by means of a waterproof splint. Still, the abdominal cavity is easily monitored at any time. In addition, it is very easy to move organs and other structures which need to be treated to the exterior through the elastic access which has been opened in the front abdominal wall.
Hence, our technique makes it possible to operate with dramatically less risks than classical surgery. The surgical operation on internal organs and other pelvic (5-10) structures takes place outside the body and requires a continuous irrigation of the surgical area;
in addition, we follow organs’ natural cleavage planes with manual tension actions, as firstly suggested by the Wien School of Gynecology. Specifically, we have drawn on the teaching of two leading scholars in Wien, Prof. Kurt Richter (11)
and Prof. Manlio Luisi (12),
who I have had the pleasure to work with in person and who receive my greatest acknowledgements.
In order to make a good use of cleavage planes, it is crucial to have a deep knowledge of the connective tissue (see link), especially, in gynecological operations, its pre-internal organ section which lies between the peritoneum and the pelvis (see link). Most of the characteristics of those planes can only be fully appreciated if operating by hands, since the latter contain sensory structures, which enable the operator to constantly monitor any variation of density, retractility, temperature, lacerability and perfusion.
Exception made for the knot hemostatic sutures, all other sutures are monodirectional, planar and have a double greek key design.
Hence, a unique knot is made over the all length, exactly between the two end of the thread.
Sutures are isolated from superior plans,
still to avoid a bidirectional-movement effect; they are fixed to the two ends, as in a hammock.
Our suture makes it possible to keep adherent tissue margins, which then easily heal up due to the platelet-adherence factors, matzellen and fibroblast metabolic activity, neoangiogenesis and other phenomena which contribute to the healing up, with exceptional results even under the cosmetic point of view.
I do hope that this short description makes it clear what the crucial principles and ways to operate are for the Minitraumatic Surgery, and I wait for any other explanation which you might ask me in the future (13,14).
Thank you very much for your interest and patience.
Best regards, Antonio D'Acunto
To find out more:
1. RothmanS.: Physiology and Biochemestry of the Skin, 83-93,Univ.of Chicago Press. Chicago. Illinois, 1965
2. Guyton A.C., Hall J.E., Textbook of Medical Physiology, 11th ed. c 2005, W.B.Saunders Company, Philadelphia. ISBN: 0721602401
3. Monti M,:Chiusura in Bellezza, Corriere Salute 01.12.02-10.
4. D'Acunto A., Cortés-Prieto J.: Cirugia Diafanoscopica, VII Diploma Universitario Europeo de Endoscopia Operatoria en Ginecología, 23 a 27 de Abril, 2001 - Alcalá de Henares-Madrid(España)
5. D'Acunto A., Cortés-Prieto J,: La Biocirugia, VII Congreso Sociedad Iberoamericana de Endoscopía e Imagenología Ginecológicas, 9 al 12 de Marzo, 2002-Caracas (Venezuela)
6. D'Acunto A., Cortés-Prieto J,: Apertura y cierre abdominal, acta VIII Congreso Sociedad Iberoamericana de Endoscopía e Imagenología Ginecológicas, 23-27 de junio 2004- Quito (Ecuador)
7. D'Acunto A., Cortés-Prieto J,: Cirugía abdominal y casuística, VIII Congreso Sociedad Iberoamericana de Endoscopía e Imagenología Ginecológicas, 23-27 de junio 2004- Quito (Ecuador)
8. D'Acunto A.; Cortés-Prieto J.: Cirugia Minitraumatica, Diplome Universitaire Europeen D' Endoscopie Operatoire en Gynecologíe, du 23 ou 27 Janvier 2006, Clermont-Ferrand (France)
9. D'Acunto A. y Cortés-Prieto J: Cirugia Minitraumatica, bases teorico-practicas, acta X Congresso Norte-Nordeste de Reprodução Humana, 16-18 de agosto de 2007, João Pessoa-PB (Brasil)
10. D'Acunto A. ; Cortés-Prieto J.: Cirugia Vaginal y Minitraumatica, XIII Diploma Universitario Europeo de Endoscopia Operatoria en Ginecología, 23 a 27 de Abril 2007, Alcalá de Henares-Madrid (España)
11. Richter K, Heine F, Terruhn V. Gynäkologische Chirurgie des Beckenbodens. Thieme, Stuttgart-London. 1998
12. Luisi M. Anatomia Clinica Ginecológica. Casa Editrice Ambrosiana, Milano, 1978
13. Cortés-Prieto J. (coordinador),: Obstetricia General, Ed. Centro de Estudios R, Areces S.A. Madrid-2004, ISBN:84-8004-641-4. Web:www.cerasa.es
14. Website: www.c-m-m.eu