Lighting Innovations in Open Surgery of the Esophagus, Stomach and Diaphragm

Introduction. One of the main requirements for the successful implementation of any surgical intervention in thoracoabdominal surgery is a sufficient overview of the surgical field, which depends on the parameters of the surgical wound and its illumination. This requires not only to clinically evaluate diverse technical approaches, equipment and tools for lighting, but also to develop fundamentally new, qualitatively better ones with proven effectiveness.

The aim of the study was to develop lighting LED retractors for "open" surgical interventions on the esophagus, stomach and diaphragm, and to evaluate their effectiveness in a comparative aspect.

Material. Surgical access was evaluated using conventional (Fedorov, Kelly, Mikulich and mediastinal) and newly developed (renal mirror, wire, flexoelastic and mediastinal with LED illuminators) retractors on 97 human corpses. The level of illumination in the operating rooms was determined by a luxmeter. To comparatively assess the illumination of hard-to-reach places, conventional lighting tools were used (ceiling lamp, headlamp illuminator, endoscopic illuminator (optical tube) and a mediastinal retractor with a fixed light guide from the illuminator and the previously specified newly developed retractors. The measurements were carried out in the operating room of a surgical profile on a human analog, and in the dissecting room of the Bureau of forensic medical examination on 31 fresh, non-fixed corpses died at 42-67 of the conditions other than pathologies of the thoracic and abdominal cavities.

Methods. Measurements were carried out: in subdiaphragmatic spaces; in the posterior (right) costal-mediastinal sinus, posterior mediastinum through a transchiatal access. A comparative assessment of surgical approaches was carried out according to the A.Y. Sozon-Yaroshevich criteria. The illumination parameters of hard-to-reach places were determined in terms of the best illumination, and retreating 4-7 cm to the lateral boundaries of the anatomical area.

Results. The lowest illumination values of hard-to-reach places were obtained for ceiling-mounted lamps. The following average values are recorded for the headliner. The endoscopic illuminator (optical tube), a retractor with a fixed light guide had maximum average illumination values (p<0.01), and a significant decrease in parameters was noted in the lateral boundaries of the anatomical regions. The newly developed retractors provided an average illumination of hard-to-reach places, comparable to the best values of light guide instruments (p<0.01), not only directly under the instrument, but also at points of the extreme distance, where the decrease in average values turned out to be insignificant. The illumination values of the mediastinal retractor exceeded the best results of traditional illuminators and original retractors (p<0.01). When comparing the parameters of surgical wounds, the angles of inclination of the axis of surgical action did not differ significantly when using traditional and original retractors (p<0.01). Notably, in all cases, the value was more than 42°, therefore, sufficient conditions were created for direct visual control of these intervention zones. The angle of surgical action turned out to be greater when using conventional retractors in comparison with the newly developed ones in the posterior mediastinum, posterior (right) costo-mediastinal sinus, subhepatic space and left subdiaphragmatic space (p<0.01). In addition, the value of this parameter never reached the critical value of 25°. The angle of intersection of the axis tilt of the surgical action and the incidence of the luminous flux in all hard-to-reach places of the abdominal cavity for the newly developed retractors with LED elements was less than 50°, which eliminates the possibility of direct sunlight entering the surgeon's view. Conclusion. Newly developed retractors combine functionality and ergonomics, have an aesthetic appearance, allow performing surgical interventions on the esophagus and stomach from thoracotomy and transchiatal accesses on a functioning lung and a working heart, with a slight decrease in the angle of surgical action, provide uniform illumination not only under the instrument, but also at the lateral borders of the anatomical area, eliminate visual discomfort (glare).