SPIRAL COMPUTED TOMOGRAPHY IN EVALUATION OF LAPAROTOMY ACCESS IN OPERATIONS FOR THE UPPER ABDOMINAL ORGANS

Danilchenko I.Yu., Razvozzhaev Yu.B., Baranov A.I., Alontsev A.V., Akhmetzyanov R.G., Savostyanov I.V.

 Novokuznetsk State Institute of Postgraduate Medical Education, the branch of Russian Medical Academy of Continuous Professional Education,
Novokuznetsk City Clinical Hospital No.1, Novokuznetsk, Russia

SPIRAL COMPUTED TOMOGRAPHY IN EVALUATION OF LAPAROTOMY ACCESS IN OPERATIONS FOR THE UPPER ABDOMINAL ORGANS

The problem of optimization of surgical approaches exists the same time as surgery. The issue of traumatic potential of surgical approaches was firstly mentioned in 1884 by O.E. Gagen-Torn and later was reviewed by many authors. According to a figural expression by T. Kokher, a surgical approach can be as big as it is needed, and as small as possible.
Theory and practice of surgical incisions of abdominal wall assume that an incision with low traumatic potential may give a possibility for maximal exposure of organs. Traumatic potential and availability are two main factors influencing on selection of a surgical approach.
Also it is necessary to consider the fact that position of internal organs varies significantly and highly depends on individual characteristics of the body. Therefore, a surgeon often selects a surgical approach randomly, and this approach is the most universal and extensive, with exposure of the highest amount of organs.
There is a way for estimation of quality of a surgical approach on the basis of criteria by A.Yu. Sozon-Yaroshevich [1]. This way means the following: pronometer, protractor or line are used for measurement of wound depth and operation action pitch during making a surgical approach in anatomical experiment or in real surgical intervention. Quantitative estimation of conditions of a surgical approach to a targeted organ is conducted on the basis of received data.
The disadvantages of this method are absence of a possibility for estimation of parameters of a surgical approach at the presurgical stage, and realization of measurement is always associated with invasive intervention.
The new round of medicine development gave the possibility for using the above mentioned technique with modern radial methods at the presurgical stage. Particularly, magnetic resonance imaging and spiral tomography became wide spread in neurosurgical practice for neuronavigation for brain surgery [2-4]. Also there are some studies where spiral computer tomography and magnetic resonance imaging are used for planning of endoscopic surgeries and surgical interventions from mini-approach for abdominal organs and retroperitoneal space [5-13]. Also there are single studies of ultrasonic diagnosis for presurgical planning [14].
Currently, there are not any studies of non-invasive estimation of conditions of surgery for abdominal organs during laparotomy. Magnetic resonance imaging is less acceptable for determination of parameters of approaches owing to long duration of examination. Also there are some contraindications for MRI in patients with electric cardiostimulator and/or a metal construct.
Objective – to develop a universal, non-invasive method for evaluating the parameters of laparotomy access in operations for the upper abdominal organs at the pre-operative stage. 

MATERIALS AND METHODS

This study analyzes the spiral computer images of abdominal organs of 55 patients including 32 women and 23 men at the age of 25-81.
Computer tomography of abdominal cavity was performed in supine position with scanning region from the diaphragm to pubic symphysis with use of multispiral computer tomography. The use of multiplanar reformatting was realized in three main and mutually perpendicular planes: axial, frontal and sagittal, as well as oblique-axial and oblique-sagittal ones. The analysis of the data is possible to conduct with use of the operational station of the tomography and with any diagnostic software for view and preparation of medical images.
A location of a surgical approach on the anterior abdominal wall was determined with use of tomographic images (Fig. 1):

Figure 1. 3D reconstruction of abdominal cavity: А-АI – length of superior middle laparotomy according to Ellison modification, С-СI – length of superior transverse laparotomy.

- for superior median laparotomy (modification by Ellison), the approach is located along the middle line from the xyphoid process and downwards, 5 cm below the omphalus.
- for superior transverse laparotomy, the approach is located at the level of the border of inferior and middle one-thirds of distance from the omphalus to the xyphoid process; it goes to point of transection with costal arches; if the approach is below the level of the chest level, then the limit is the lines going vertically downwards from the lowest points of 10 ribs.

The parameters of spatial conditions of approaches were determined in relation to the most remote anatomic benchmarks, which can present the interest in extensive surgeries:
- right cupula of diaphragm;
- left cupula of diaphragm;
- esophageal opening.

Making the sagittal section was performed for measurement of length of the approach of superior middle laparotomy by Ellison. Making the axial section through end points of the approach was conducted for measurement of the length of the approach of superior transverse laparotomy (Fig. 2, 3). The linear vector connecting the end points of the approach was constructed. The distance between end points of the approach was measured along the vector.
Measurement of surgical action angle longwise (SAAL) was performed by means of construction of the oblique-axial section for superior transverse and oblique-sagittal sections for superior middle laparotomy by Ellison with end points of the approach and the application point (Fig. 2, 3). Linear vectors were constructed from each end point of the approach on the skin to the application points. The angle of these vectors which is opened ventrally in each approach was measured. The surgical action angle longwise was estimated in each approach in each application point.
For measurement of wound depth and inclination angle of surgical action axis (IASAA), the construction of the oblique-sagittal section was performed. It included the middle of the laparotomy approach and the application point (Fig. 2). Construction of the linear vector going through the middle of the laparotomy approach on the skin and through the application point was performed. The distance from skin surface in the middle of laparotomy approach to the application point along the constructed vector was measured; the wound depth in each approach to each application point was estimated in such manner. The inclination angle of the vector through the middle of the laparotomy approach in relation to the line of horizontal plane was measured; estimation of inclination angle of surgical action axis in each approach in each application point was conducted in this manner.

Figure 2. Oblique sagittal section of abdominal cavity through the end points of superior middle laparotomy according to Ellison modification and through the application point: 1 – the middle of laparotomy approach on the skin, 2 – application point, Y – the horizontal plane line, 1-2 – wound depth, А-АI – length of superior middle laparotomy according to Ellison modification, α -angle – angle of surgical action along the length, γ-angle – angle of inclination of surgical action axis.



Figure 3. Oblique axial section of abdominal cavity through end points of superior transverse laparotomy and through application point: 3 – application point, С-СI – length of superior transverse laparotomy, α -angle – angle of surgical action along the length.

Also the comparative estimation of parameters of laparotomy approaches was conducted using spiral computer images with the anatomical examination data from the study by V.A. Virvich and K.S. Radivilko – Substantiation of clinical use of superior transverse laparotomy in the experiment [15]. They studied the spatial conditions of laparotomy in 102 cadavers (age of 17-84, 39 women, 63 men). Comparative estimation was conducted with data of measurements of superior transverse laparotomy and superior middle laparotomy by Ellison to diaphragmatic surface of the spleen and to the abdominal segment of esophagus; it gives anatomical correspondence to the left cupula of diaphragm and to esophageal orifice of diaphragm correspondingly.
In their anatomical experiment, V.A. Virvich and K.S. Radivilko received the following data for superior transverse laparotomy (М ± m): wound depth to superior splenic pole = 19 ± 0.8 cm, IASAA = 48.7 ± 0.8°, SAAL = 25 ± 1°; wound depth to abdominal segment of esophagus = 18.6 ± 0.3 cm, IASAA = 43 ± 1.1°, SAAL = 28 ± 1°. The following results were received for superior middle laparotomy by Ellison (М ± m): wound depth to superior splenic pole = 20.7 ± 0.3 cm, IASAA = 46 ± 1°, SAAL = 18 ± 0.7°; wound depth to abdominal segment of esophagus = 14.5 ± 0.3 cm, IASAA = 54 ± 0.9°, SAAL = 26 ± 0.9°.
The statistical analysis was conducted with IBM SPSS Statistics v.22.0 (IBM, USA). Mann-Whitney’s non-parametric test was used for comparative estimation of parameters of laparotomy approaches. The critical level of p value was 0.05.
The study was approved by the local ethical committee of Novokuznetsk State Institute of Postgraduate Medical Education (the protocol No.83, 17 April 2017) and corresponded to the ethical norms and regulations of the Russian Federation and Helsinki Declare of Human Protection in Biomedical Studies. 

RESULTS

The tables 1 and 2 show the data of our study.

Table 1. Spatial characteristics of upper transverse laparotomy

 

Upper transverse laparotomy (М ± m, n = 55)

Angle of operation by length

Angle of slope of axis of operation

Wound depth, cm

Right cupula of diaphragm

73.1 ± 7.9

51.6 ± 6.5

18.3 ± 3.3

Left cupula of diaphragm

75.4 ± 9.7

54.4 ± 6.8

18.2 ± 3.5

Esophageal orifice of diaphragm

92.1 ± 11.3

46.5 ± 7.7

14.8 ± 3

Table 2. Spatial characteristics of upper median laparotomy in Ellison modification

 

Upper median laparotomy in Ellison modification (М ± m, n = 55)

Angle of operation by length

Angle of slope of axis of operation

Wound depth, cm

Right cupula of diaphragm

63.1 ± 9.3

52.6 ± 6.4

17.9 ± 2.8

Left cupula of diaphragm

65 ± 9.9

55 ± 7.3

17.6 ± 2.7

Esophageal orifice of diaphragm

77.6 ± 13.2

47.3 ± 7.8

14.3 ± 2.6

The statistically significant advantage was found for superior transverse laparotomy with parameter surgical action angle longwise to all application points: left cupula of diaphragm (p < 0.0001), right cupula of diaphragm (p < 0.0001), esophageal orifice of diaphragm (p < 0.0001).
There were not any statistically significant differences for parameter wound depth: right cupula of diaphragm to the application point (p = 0.644), left cupula of diaphragm to the application point (p = 0.489), esophageal orifice of diaphragm to the application point (p = 0.439).
There were not any statistically significant differences for the parameter inclination angle of surgical action axis: right cupula of diaphragm to the application point (p = 0.515), left cupula of diaphragm to the application point (p = 0.625), esophageal orifice of diaphragm to the application point (p = 0.45).
The result of spiral computer tomography for the parameters wound depth and inclination angle of surgical action axis were identical to the results of the anatomical experiment. But the results of measurements for the parameter surgical action angle longwise between the identical approaches to the application points left cupula of diaphragm and esophageal orifice of diaphragm were different significantly. 

DISCUSSION

The use of spiral computer tomography in estimation of parameters of laparotomy approaches will allow extending the range of surgical tools in prediction of surgical intervention course.
In comparison of the received data with data of the anatomical study, one can see that the results of the parameter wound depth and inclination angle of surgical action axis were comparable. It allows receiving the data of topographic and anatomical relationships at the presurgical stage.
The differences in the data of the parameter inclination angle of surgical action axis were conditioned by the fact that static spiral tomographic images cannot estimate movement of organs and tissues which are located directly along the surgical action.
However spiral computer tomography allows the comparative estimation between parameters of various laparotomy approaches, and, on the basis of results, estimating the advantages and disadvantages during interventions for specific organs.

CONCLUSION

Spiral computer tomography gives the objective presurgical estimation of parameters laparotomy approaches.

Information on financing and conflict of interests

The study was conducted without sponsorship.
The authors declare the absence of any clear or potential conflicts of interests relating to publication of this article.

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