DE4212908A1 - Surgical simulation model, including methods for practicing training operations, performing success checks, or the like - Google Patents

Abstract

A surgical simulation model for operative training purposes, especially laparoscopic, thoracoscopic and endoscopic techniques, is to be constructed in such a way that training and operations may be performed in an artificial, anatomically correct body cavity on the open abdomen or with minimal invasive methods. This is achieved in that the shape and surface of the inside of at least a human or animal body cavity corresponding to the respective layers are reproduced at least in part or in zones in a faithfull anatomic and topographic manner. The outside of the model corresponds at least in part or in zones to the anatomical shape or structure; objects, artificial organs or organic implants may be inserted and/or implanted in the body cavity or cavities; parts of the digestive tract, blood circulatory system, bronchial system and leads for electric power, fluids, gas, light, or the like have external access; and the body cavity or cavities can be hermetically closed after the insertion or implantation of objects and organs.

Description

The invention relates to a surgical simulation model, including procedures for practicing training operations, Performance checks or the like, according to the Preambles of claims 1 and 25.

In the course of "Minimally Invasive Surgery" she is currently experiencing General surgery an incomparable "boom", now with the endoscopic surgical technique in body cavities (abdomen cave, chest cavity and small pelvis) directly the most common Operations (gallbladder removal, appendectomy, lei fracture surgery and operations on the colon) of the general surgery are affected.

It is primarily the postoperative benefits (less pain zen, significantly shorter lying and recovery times, lower Ar Disability duration, smaller scars, less adhesions bellies, fewer infections, less thrombosis, used earlier intestinal activity) and the potential transition to outpatient ter treatment, most likely the proportion of this minimally invasive surgical technique on general surgeons conventional interventions will continue to increase. Also for the numerous minimally invasive Opera enough surgeons in time in these training sessions intensive techniques are trained and available.

Particularly suitable for laparoscopic surgical techniques appears for example in the case of a tumor of the colon deep rectal resection (removal of a section of the large intestine with continence-preserving suture = anastomosis of the two free Large intestine in the depth of the small pelvis) and the Rectum amputation (removal of the rectum with artificial  Intestinal exit). Even with conventional surgery on open stomach, the small pelvis is extremely inaccessible, so that must be operated with long instruments. In addition, at Operate in the depth of the small pelvis and the viewing angle the illumination is severely restricted.

With this conventional surgical technique is the preparation of the rectum in the small pelvis difficult, especially when Man is very narrow and narrows down like a funnel, important structures such as bladder, urine in the small pelvis ladder, vessels, nerves, prostate, seminal vesicles, vas deferens in men - uterus and ovaries in women - dense lie side by side.

With exercise programs on the proposed simulation model the laparoscopic steps of the conventional surgical technique and the technique for the laparoscopic use can be optimized. The Wei Development of the surgical technique and the associated In instruments are in the foreground.

Of course, the simulation model can also be used for Training the conventional rectal resection on the open stomach be provided. But other operations can do the same or special surgical techniques, as well as the transplant be trained in surgery. The result is higher quality standard and greater security with the corresponding Operation on humans or animals. The Simula also offers the prerequisite for a clinical training, Research, development and test center related to surgery surgical techniques, especially training-intensive ones laparoscopic, thoracoscopic and endoscopic operati on techniques. The control, training task and quality securing the laparoscopic "boom" can thus be closer to the clinical area of responsibility.

The need for simulation models has already increased education and training courses for laparoscopic Gallbladder removal shown.  

The object of the present invention is a simulation engine dell for operational training purposes, especially the laparo scopic, thoracoscopic and endoscopic (corresponds minimally invasive surgery) surgical technique gene, by means of which in an artificial, anatomically correct Body cavity on the open stomach or minimally invasive trai can be operated on and operated on. The subject of the invention is also a procedure for practicing training operations a simulation model according to the invention.

These tasks are characterized by the distinctive features of the Claims 1 and 25 solved.

In the foreground are the resective and reconstructive operas cations on hollow intestinal organs. With the anatomical Replica of the transition from the abdominal cavity to the small one Pelvis, the small pelvis itself and the anal region, are right alistic training operations on the colon, sigmoid and rectum (Parts of the large intestine), and especially the anastomosing tech nik possible in this area.

The present invention advantageously enables the step wise adaptation to the reality desired for the training Expectations.

So in the simplest case in the empty body cavity of the Si mulationsmodelle, the top with an interchangeable body cave cover can be repeatedly sealed tight, yes with little effort on objects previously in the body have been placed using minimally invasive techniques be practiced.

In addition, organs or parts of organs can enter the body cavity be placed and it can be minimally invasively trained on them will.

The next step is topographic implantation of animal and / or artificial organs or parts of organs The step to reality is made by an animal "full Transplant "(heart, lung, abdominal cavity organs) or through a graft from individual animal organs or organ divide reached into one or more body cavities (abdomen  cave, chest cavity, small pelvis) of the artificial model for the training operations are implanted. According to procedure of transplant surgery these are according to the organ and the implantation in the simulation model via a "Heart-lung machine" or just "heart machine" with the tie donated blood. With the prepared Mo. dell are for learning the minimally invasive surgical technique also caused bleeding and complications realistically simu can be used.

With these steps you can also gain experience for the Trans collect plantation surgery, as well as conventional opera Exercise and improve your “open stomach” techniques. This is how important medical advances can be made on the Ge offers transplant surgery, intensive care medicine, interdis ziplinic surgery, laparoscopic surgery and drug Check and research the tel application.

Another advantage is that it's not just operational Standard situations, but also deliberately caused critical ones Situations can be trained.

Also, without endangering someone's life, Expe riments and new surgical methods explored, including Postoperative consequences examined and functional tests carried out will. For the numerous new ones, some of which are still little tested Instruments can be tested according to different test criteria their usability and reliability checked and with compared to other instruments. Training with the simulation model according to the invention is not a special one Locations tied.

Further advantageous embodiments of the invention are in the Subclaims placed under protection.

The following are exemplary embodiments of the invention surgical simulation model with conceivable variants described in detail by drawings.  

Show it:

Figure 1 is a semi-schematic view of the simulation model with an insight into the chest cavity, abdominal cavity and small pelvis. The abdominal wall and thoracic lid are removed

Fig. 2 shows a cross section through the abdomen in the navel with relaxed abdominal wall,

Fig. 2a shows a cross section through the abdomen in the navel with bloated abdomen,

FIG. 2b shows an enlarged detail with the abdominal wall frame and the sealing portion to the lower tray of the model,

Fig. 3 shows a cross section through the diaphragm plate, which separates the abdominal cavity from the chest cavity,

Fig. 3a shows a cross section through the upper seal portion of the diaphragm plate,

Fig. 4 is a semi-schematic longitudinal section through a femal ches model pool,

Fig. 5 is a semi-schematic longitudinal section through a male pendant ches model pool,

Fig. 6 shows a schematic overview of the top of a female model pool,

Fig. 7 the anal canal with a screw-in coupling for the connection intestines,

Fig. 8, the anal area with a needle ring and pressure ring for fixing the anus,

Fig. 9 schematic drawings of resective and reconstructive training operations on the colorectum.

In Fig. 1 the anatomical model of a human body is shown. In part, neck 1 , arms 2 and legs 3 are formed. Anatomical structures, such as the clavicles 4, are indicated. An anatomically correct thoracic cover, which can be removed separately or together with the abdominal wall, has been removed. One looks directly into the chest cavity A, into the abdominal cavity B and partly into the small pelvis C. On the inner wall of the chest cavity A, the ribs 8 and the elevation of the spine 5 a are visible. The diaphragm plate 9 can be inserted as a partition between the chest area A and abdominal cavity B from the ventrally into a corresponding groove 20 and supplements with the ventral surface the circumferential placement and sealing surface 10 for the thorax cover 22 and the abdominal cover 14 which can also be placed tightly . Alternatively, a bracket can also be inserted for this purpose without the two caves A and B being separated. The elevation of the spine 5 b in the abdominal cavity B is also designed as a continuation 5 c in the small pelvis. The hollow system of the kidneys 6 and the ureters 7 , which lie largely retroperitoneally under one layer, is shown in dashed lines. Connections 11 for example arteries, veins and the bronchial system are indicated in the neck area.

In Fig. 2 is a cross section through the empty abdominal cavity B approximately at the level of the navel. On the lower shell 12 of the trunk with the elevation of the spine 5 b there is an exchangeable, anatomically adapted frame 13 in which the layers of the abdominal wall 14 are edged. The abdominal wall 14 with the frame 13 can be exchanged for an undamaged cover if it has become unusable due to trocar punctures or cuts. After gas insufflation into the abdominal cavity B, the abdominal wall 14 expands to a desired degree, depending on the pressure ( FIG. 2a). This is made possible by the all-round placement and sealing surface 10 on the upper edge of the lower shell 12 of the fuselage, possibly with a continuation on the upper edge of the diaphragm plate - or the alternative bracket - if the thoracic lid and abdominal wall consist of two parts. On the underside of the frame 13 , as well as on the underside of the thoracic cover 22 , a wedge-shaped web 15 protrudes all around, which can be pressed into a corresponding, tapering groove 16 in the upper wall edge 10 or diaphragm plates or upper edge of the bow. The sides of the groove 16 are lined on both sides with an elastic, sealing material 17 . Handles 18 on the frame 13 provide attachment points for lifting or prying off the abdominal wall 14 . Using the same principle, the thoracic cover 22 can be removed from the thoracic cavity A and placed back on tightly. In contrast to the abdominal wall, the thoracic lid 22 is not constructed from comparable elastic layers and is therefore not expandable to the extent that gas is pumped into the closed chest cavity A. It therefore appears sufficient to rigidly design the thoracic lid. Structures such as the continuation of the clavicles 4 , the continuation of the ribs 8 , the sternum or the nipples are favorable for orientation. However, it is also within the scope of the invention to simulate the structure of the rib cage in the appropriate density and arrangement of the individual structures as a thorax cover.

Fig. 3 shows the top view of a part of the diaphragm plate 9 , which is tightly attached by the seal 19 in the groove 20 on the inner surface of the body wall. A part of the upper wall edge 10 with the groove 16 for the thorax cover 22 or the abdominal wall 14 is also shown . Passage openings 21 for, for example, arteries, veins and esophagus are preferably arranged in the central region of the diaphragm plate 9 . Fig. 3a shows a cross section through the upper part of the Zwerch furplatte 9th The thorax cover 22 and the frame 13 of the abdominal wall 14 are inserted with the respective wedge-shaped web 15 in a respective groove 16 on the upper edge of the diaphragm plate 9 .

FIGS. 4 and 5 show, in a sagittal section anato the mixing ratios in the pelvis C in a female model (Fig. 4) and a male model (FIG. 5). The elevation of the spine 5 c bends dorsally in the area of the promontory 5 d and runs out in an arc as a coccyx 5 e. Up to the anal canal 23 or anus 24 , the small pelvis narrows downwards in a funnel shape and becomes forward in the man ( FIG. 5) of the prostate 25 , seminal vesicles 26 , vas deferens 27 and the bladder 28 , which is followed by the anterior abdominal wall 29 . limited. The front boundary in the female model ( Fig. 4 is formed by vagina 30 , uterus 31 with adnexa 40 , the bladder 28 and the anterior abdominal wall 29. The abdominal cavity B with continuation in the small pelvis C and the organs in the small pelvis are of at least partially covered with a translucent layer 32 comparable to the peritoneum. In the preferred exemplary embodiment, the presacral cavity D is also covered with individual layers (comparable to the Waldeyer fascia 33 and the Denonvillier fascia 34 ). The simulations are in the corresponding layer of the two urethers (in FIG. 5, left urether 35 with crossover of the vas deferens 27 , right ter urether approach 36 ) and their crossover and undercrossing points with the vas deferens and the vasa iliaca communis or vasa iliaca externa and the larger vessels as closed, to fillable hollow systems part of the model For orientation it is useful if the pubic bone 37 and the B corner combs are indicated.

FIG. 6 shows a view from above into the small pelvis C of a female model and illustrates how it narrows in a funnel shape towards the anal canal 23 . By way of illustration, part of an implanted animal rectum 38 is shown which is held away by a hook 39 so that the uterus 31 and the adnexa 40 (part of the model) are visible. If the graft cannot be implanted with the anal canal and anus, whereby the intestinal lumen of the graft has to continue outwards through the model without the abdominal cavity becoming leaky in this area, the anal canal and anus must alternatively become part of the model.

Fig. 7 shows the artificial anus 24 and the tubular anal canal 23 , which is equipped with an internal thread 25 at its inner end. The animal rectum 38 is pulled onto a short piece of pipe 41 and tightened with a tobacco pouch suture 43 pierced into the intestinal wall. A bead-shaped edge 42 at the end of the pipe section 41 additionally prevents the casing 38 from sliding off the pipe section 41 . With the thus fixed intestine 38 that is threaded equipped kitchens ended pipe section 41 in the artificial anal canal 23 is screwed. A flange 45 presses when you screw a device ring 46 against the anal canal tube 23 and seals the connec tion. If the animal intestinal implant is implanted with an anal canal and a skin rosette, it is drawn outward through the artificial anal canal 23 - see FIG. 8. The skin rosette 47 is spread out flat and placed on the needles 48 , which extend in a ring shape around the anus 24 to the outside. To fi xation, a corresponding perforated plate 49 is finally pressed onto the needles 48 and thus the rosette 47 is pressed sealingly against a seal 50 on the needle base.

Fig. 9 schematically shows several examples of resective and reconstructive surgery on the intestines. In the figures arranged in pairs, the initial findings with the section of the intestine to be resected (hatched) that contains the tumor are always shown on the left and the condition after the operation with anastomosis or artificial outcome is shown on the right. The four bottom images show bypass surgery of the intestinal passage.

Is the use of animal organs or organ parts ge wishes, it is useful in the body cavity or in the preferred example in the body wall to integrate "cooling coils" ren that can be connected to a refrigerator, so that a desired cooling or freezing pe in the body cavity maturity can be achieved. By lowering the "Operating temperature" during training operations on biolo gisch active animal transplants, the metabolism slowing down. This reduces the need for "nutrient fen "and oxygen. Only on organs that have already died practiced, the cooling serves as a preservation during the introduction in the simulation model or storage in the same.

The natural outcome of the implant in the simulation model ten guts is also tested in an Anastomo sen tester needed. This consists of an air pump, egg a manometer and one of the outer shape of the anal region fit adapter with valve. It is favorable if this Adaptation piece with the valve from the pump system and / or to Line system is separable, and this isolates with the valve and possibly the manometer can be pressed onto the anus or tight to the anus via a holding device at the anal region can be held for the period of measurement or measurement line. To retrograde in the intestinal lumen with the anastomosis tester To be able to build up pressure must be proximal to the anastomosis  appropriate height of the intestine temporarily, d. H. for the period of Measuring time.

Claims (30)

1. Surgical simulation model for surgical training purposes - in particular the laparoscopic, thoracoscopic and endoscopic surgical technique, characterized in that the shape and area of the inside of at least one human or animal body cavity - preferably the abdominal cavity with continuation in the small pelvis - according to the respective Layers, at least partially or partially ana tomia-appropriate and topographically corresponding, is simulated that the model exterior corresponds at least partially or partially to the anatomical shape or structure, that objects, artificial organ replicas or organic implants can be inserted into the body cavity or body cavities and / or can be planted that parts of the digestive tract (e.g. esophagus, large intestine), parts of the bloodstream (e.g. arteries, veins), parts of the bronchial system and lines for electrical current, liquids, gas and light or Optics To have passage to the outside, and that the body cavity or body cavities can be locked gas or liquid-tight after insertion or implantation of objects or organs. 2. Simulation model according to claim 1, characterized in that that next to the abdominal cavity with continuation in the small pelvis including the chest cavity and this against the abdomen cave is delimited, either with an elastic Diaphragm as a replica of the diaphragm, or with a corresponding one shaped plate-shaped element, which corresponds to a suitable groove, possibly with an elastic, sealing lining from can slide in above, with the diaphragm simulation with Recesses for conduction pathways (e.g. aorta, vena cava, Esophagus) is provided.   3. Simulation model according to claim 1 or 2, characterized shows that ribs, collarbones and Sternum and the outer surface of the thorax Orientation for trocar punctures shaped anatomically and is provided with replica nipples, and that at least least in the areas between the ribs ver the wall is similar to the natural chest wall. 4. Simulation model according to claim 3, characterized in that that the thorax be made entirely or partially of homogeneous material stands, in which characteristic structures (ribs, keys legs, sternum, nipples) are modeled. 5. Simulation model according to one of claims 1 to 4, characterized characterized in that the abdominal wall is anatomically attached fit frame is stretched on the corresponding to place tightly on the lower half of the model is settable and removable, and thus also after the z. B. laparoscopic training surgery against an intact Abdominal wall (without the holes of the trocars) is interchangeable. 6. Simulation model according to claim 5, characterized in that that the abdominal wall in elasticity, tear resistance, strength, Layer structure or the like. Replicated the natural abdominal wall is so that, for example, the piercing of the trocars, the layer-by-layer sewing of an abdominal wound is trainable, or that Inflation of the abdominal wall by means of a gas insufflation which the laparoscopic intervention is necessary, if possible is of course simulable, and that for navel orientation is reproduced (at an anatomically correct location). 7. Simulation model according to one of claims 1 to 6, characterized characterized in that the upper part of the thorax acts as a lid from the The underside of the body is removable and can be put back on tightly.   8. Simulation model according to claim 7, characterized in that that a removable bracket that is on both inner sides of the Model in corresponding shapes at diaphragm height across to the longitudinal axis of the body can be inserted, the circumferential and sealing surface for the separately removable thorax cover and the separately removable abdominal wall is supplemented. 9. Simulation model according to claim 7, characterized in that that remove the abdominal wall and the thoracic lid as one part bar and can be put back on tightly. 10. Simulation model according to claim 7, characterized in that the removable abdominal wall and / or the thorax cover around running into the corresponding one with a wedge-shaped projection Indentation on the underside of the model, which has elasti schematic, sealing material is lined, tightly pressed is, and that attachment points on the lid for removing the same are provided, as well as safety devices, so the pressed-in lid on the inflated body is not can take off. 11. Simulation model according to one of claims 1 to 10, there characterized in that the material for the inner surface of the Body cavities is selected so that with a surgical thread The needle can be inserted and removed and the trailing one Thread holds enough, or that at least anatomically gave way positions for the fixation of objects, organs, banks and / or fascia (especially for the fixation of the Mes enterial root, colon, liver and diaphragm) a material is incorporated in which a thread stops or on a thread can be knotted. 12. Simulation model according to one of claims 1 to 11, there characterized in that on the one hand two kidneys, two urine lead and a bladder, on the other hand prostate, seminal vesicles, Vas deferens in the "male model" - in the "female model" Uterus and Adnexe -, as well as vessel sections as one each individual hollow systems can be filled with liquid.   13. Simulation model according to one of claims 1 to 12, there characterized in that nerves are simulated that originate from a material that conducts the electrical current and the component of a circuit with optical and / or acoustic warning function. 14. Simulation model according to one of claims 1 to 13, there characterized in that individual anatomical layers in the Abdominal area and individual layers and fascia leaves imitated in the small pelvis (e.g. peritoneum, peritoneal envelope fold, Gerota's fascia, Waldayer's Fascia, fascia pelvis visceralis, fascia pelvis parietalis, Denonvillier fascia, urogenital diaphragm, muscle levator ani, paraproctia), and that in the pelvic region for Orientation at least approximate structures of the pelvic ring (e.g. pelvic crests, pubis) and the spine re-flexed det. 15. Simulation model according to claim 14, characterized in that that a funnel-shaped insert in the area of the small pelvis from several cutable and preparable layers can be used interchangeably in this area the inner wall of the model. 16. Simulation model according to one of claims 1 to 15, there characterized by that the region around the anus from other Material exists and as interchangeable, sewable and cutable Material insert is formed in which the implanted artificial Natural or organic rosette of the anus can be sewn in, firmly can be clamped or clamped. 17. Simulation model according to claim 16, characterized in that that for the fixation of the skin rosette to be implanted Anus needles are attached in a ring around the anus to which the Skin rosette and a corresponding pressure plate inserted can be.   18. Simulation model according to one of claims 1 to 17, there characterized in that the anus or anal canal is artificial is reproduced and a thread at its inner end area, preferably has an internal thread into which a short Pipe piece with corresponding counter thread, on the other End of an intestinal end is drawn up and fixed, screwed in can be, so that the intestinal lumen continues to the outside. 19. Simulation model according to one of claims 1 to 18, there characterized in that comparable connections (for e.g. Esophagus, vessels, bronchial system) in the neck area of the Model are attached as through openings. 20. Simulation model according to one of claims 1 to 19, there characterized in that an anastomosis tester on the anus can be put on, consisting of an air pump, a Manometer, a feeding hose and a connector, that can be disconnected from the hose and with a valve is provided. 21. Simulation model according to one of claims 1 to 20, there characterized by that in the model or in the model wall cooling units, cooling coils with appropriate circuits for a cooling machine or for radiators are. 22. Simulation model according to claim 21, characterized in that that in the model there is a thermostat or a thermocouple associated line is installed to the outside. 23. Simulation model according to one of claims 1 to 22, there characterized in that the material used in the mecha African properties and / or the color as much as possible corresponds to natural conditions. 24. Simulation model according to one of claims 1 to 23, there characterized in that at least partially on the model the extremities and neck are formed.   25. Procedure for practicing training operations on one Simulation model according to one or more of claims 1 to 24, characterized in that in a simulation model counter positions or organs correspond anatomically and topographically implanted and on one or more circulating Liquid or gas circuits with one or more external lines can be connected. 26. The method according to claim 25, characterized in that for an extensive simulation of the human intestinal length two or more parts of one or more animal intestines ana be stomosed and with or without the associated supply implanted tissue, or that the intestine corresponds is shortened accordingly, and that beehive-like adhesions of an animal intestine intended for implantation, in particular Pig intestine to be solved. 27. Procedure for practicing and monitoring the success of operations techniques and operations according to claim 25, characterized records that on the simulation model surgical techniques and Operations performed, these recorded on videotape and be compared with the corresponding standard operations. 28. Procedure for anastomosing parts of the digestive system tractes in resective and / or reconstructive training options rations on a simulation model according to one or more of claims 1 to 24, characterized in that on Ab cut the digestive tract a resect is removed and the free ends with a seam or with a stapler are interconnected while maintaining the lumen, or that the free ends are closed butt, or that a or several stepped ends, closed or open, by the abdominal wall are directed outwards, or that in the sense a bypass operation parts of the digestive tract with a Seam or be connected with a stapler, that the lumen is still connected.   29. Procedure for testing the tightness of anastomosed Portions of the digestive tract according to claim 28, characterized characterized in that an anastomosis tester according to claim 20 at an opening of the digestive tract (e.g. anus, anus prae ter, esophagus) that the distal ab cut the digestive tract and that in the Area of the digestive tract with the anastomosis to be checked a certain overpressure is built up, its maintenance or Sinking over time is documented. 30. The method according to claim 25, characterized in that for Training operations on the simulation model cuts or Insertion sleeves (trocars) can be attached or inserted.