Publications of Robotic Colon Surgery with at least 30 patients
\r\n\tNotably, the book encourages academic scholars and researchers to contribute to the modern concepts of CSR. Fundamentally, it speaks for well-developed literature for entrepreneurs and managers, thus assisting them in the decision-making process.
\r\n\tFurthermore, this book is of great value to policymakers, practitioners, and corporations, thus contributing to various disciplines (e.g., social science and management).
\r\n\tThese proposed themes encourage future researchers and professionals to share their ideas, concepts and work concerning these subject domains. All these suggested topics had recommended under the rubrics of CSR. Perhaps, all the professionals, researchers, and scholars are welcome to submit their piece of work, in particular to the suggested topics.
\r\n\tIndeed, the recommended topics include the following but are not limited to these only.
\r\n\t• Corporate Governance and Sustainability
\r\n\t• Green Innovation and CSR
\r\n\t• Social Entrepreneurship
\r\n\t• Green Economy and Social and Environmental Sustainability
\r\n\t• Sustainable Development and Industrialization
The application of robotics in surgery has expanded since its introduction not so long ago. Robotic surgery is promoted by hospitals and sought out by patients. Residency programs are including training in robotics and the next generation of surgeons is becoming more facile with robotic procedures. Use of robotics in surgery has been applied to general surgical, gynecologic, urologic, and cardiac procedures.
\n\t\t\tAs this technology expands, many questions arise. Cost is a major concern, as are the resources and staffing necessary for robotic procedures. Although these debates are ongoing, it is clear that the technology is expanding and robotics will continue to be promoted and applied. Here we present our experience with robotic colectomy and discuss some of the pertinent issues related to this topic.
\n\t\tRobotic surgery developed as a project of the Department of Defense with the goal of enabling a surgeon to operate remotely from a patient. Although its application in this aspect has not been realized, robotic systems have advanced, and it is now the private sector which has taken on this technology. The Automated Endoscopic System for Optimal Position (AESOP) was the first robotic system approved for intraabdominal surgery by the Food and Drug Administration (FDA) in 1993 (Computer Motion, Goleta, California) (Oddsdottir et al., 2004). This computerized robotic camera assistant is used in laparoscopic surgery. The voice-activated system allows a surgeon to control the visual field while keeping his/her hands free for operating.
\n\t\t\tThe da Vinci system (Intuitive Surgical, Inc., Sunnyvale, California) was introduced in 1997 and approved by the FDA in 2000. This system allows for direct manipulation and dissection capabilities and has become the only available “robotic” system. The first robotic procedure using the da Vinci system was a cholecystectomy performed in Brussels in 1997 (Kelley, 2002).
\n\t\t\tThe da Vinci system includes a surgeon’s console, a surgical cart, and the vision tower. Although newer generations are available, the basic concepts are similar. The surgeon’s console includes binocular monitors, foot pedals, and hand-held masters for manipulation of the surgical instruments and camera. The robot is draped into the field and includes up to four surgical arms, one for the camera, two for the operating surgeon’s hands, and a fourth as an assistant arm. The vision tower includes similar equipment to a laparoscopic tower: an insufflator, light source, camera, and printer, as well as the 3-D image synchronizing hardware.
\n\t\t\tParticipating as a university-affiliated, community training program at the University of Illinois College of Medicine at Peoria, The Peoria Surgical Group became the first private practice owner of the da Vinci system in 2002. The system has since been purchased by the local hospital, and a second hospital in our community also has a da Vinci system. More recently, one of our hospitals has purchased a recent generation da Vinci Si HD system. Robotic procedures are performed by general and cardiac surgeons, urologists, and gynecologists. A wide variety of general surgical procedures have been performed, including foregut and colon operations. We will focus our discussion on a single-surgeon (DLC) experience with robotic colectomy.
\n\t\t\tRight colectomy was the first laparoscopic procedure performed on the colon by Moises Jacobs in 1990 in Miami (Jacobs et al., 1991). Robotic-assisted colectomy was reported eleven years later in 2001 (Ballantyne et al., 2001). Multiple reports have since been published on robotic colectomy, including our own results. The benefits of cosmesis and recovery translate similarly to both techniques. Robotic surgery can be applied in both benign and malignant disease as long as appropriate principles are adhered to. Although controversy still exists as to the application of minimally invasive techniques in the treatment of rectal malignancies, multiple reports in the recent literature describe the use of the robot in performing pelvic dissection. It seems the benefits of using the robot in colorectal surgery are most appreciated in performing a total mesorectal excision, where the constraints of the pelvis limit maneuverability with common laparoscopic instruments. Although this area will likely receive more attention in the near future, it is not part of the senior author’s practice currently.
\n\t\tThe decision to proceed with a robotic colectomy is made after discussion between the operating surgeon and the patient. Of the three hospitals in our community, two have a da Vinci system available. If the patient is a candidate for minimally invasive surgery and has been scheduled at one of these two hospitals, they are offered the option of robotic surgery. These cases are typically scheduled as the first case of the day to allow for adequate staffing and preparation. Indications for surgery are similar to those for laparscopic colectomy. Procedures performed include Robotic Right Colectomy and Robotic Sigmoid Colectomy.
\n\t\t\tRobotic Right Colectomy is performed with the patient in the supine position. The patient is placed on a bean bag and the bag wraps the left arm. The chest and legs are secured to the table with conventional straps on the legs and heavy tape at the level of the clavicles (Fig 1). These measures are essential given the degree and variation of positioning necessary to carry out the procedure. Once pneumoperitoneum is established, trocars are placed as depicted in Figure 2. The camera is placed through the 12mm periumbilical trocar. With the omentum retracted cranially, the planned point of division of the transverse colon and mesocolon are marked with endoclips based on the right branch of the middle colic artery. The terminal ileum is also run for 20-30cm to ensure it is not fixed in the pelvis, as it must reach the transverse colon for anastomosis. The table is then tilted to the left and slightly head down to allow the small bowel to retract out of the visual field and to encourage the omentum to stay above the transverse colon. The robot is positioned over the right upper quadrant and the camera and instruments are docked. The robot’s right/green arm is placed through the 5mm epigastric trocar and the left/yellow arm is placed through the 5mm right lower quadrant trocar. A five millimeter trocar is inserted in the left lower quadrant for use by an assistant in retracting and exposing the ileocolic vascular pedicle. A grasper placed through the 12mm left lateral abdominal wall port can be used to hold the transverse mesocolon up and out of the way.
\n\t\t\t\tPatient Positioning
We proceed with a medial to lateral dissection by dividing the ileocolic vascular pedicle with a vascular load laparoscopic stapler at the level of the duodenum. The right mesocolon is then mobilized from Gerota’s fascia. After identification of the ureter, the ileal mesentery is divided using a harmonic energy device to a point ten centimeters proximal to the ileocecal valve. Once the entire right colon is mobilized out to the abdominal wall and around to the duodenal sweep, attention is directed to the transverse mesocolon. The previously incised or clipped line on the mesocolon is found and the right branch of the middle colic artery is identified. Clips and vascular staplers are used as needed to control this at its base. The mesocolon is then divided with a harmonic device up to the colon. The transverse colon and ileum are then divided intracorporeally with a laparoscopic stapler, however the right colon remains attached to its lateral peritoneal attachments to keep it retracted laterally. Once the transverse colon is divided, we improve the view in the area of the final attachments of the colon to the head of the pancreas as well as the distal stomach and duodenum. These final attachments are taken down with harmonic energy or clips until the specimen is free.
\n\t\t\t\tAn intracorporeal anastomosis is then created in an isoperistaltic side-to-side fashion between the ileum and transverse colon. The ileum is adjoined to the transverse colon 6cm from the end of the ileum using a 30cm 2-0 silk suture on a Keith needle. This needle is then externalized in the right upper quadrant and clamped externally for retraction (Fig 3). A harmonic energy device is then used to create enterotomies, through which the ends of an
\n\t\t\t\tTrocar Placement for Robotic Right Colectomy.
Bowel Alignment for Intracorporeal Ileocolic Anastomosis
endoscopic linear cutting stapler are inserted through the left lateral 12mm trocar and the stapler is fired. The defect is closed with a running 2-0 absorbable braided suture. The mesenteric defect is then closed with absorbable suture. The retracting 2-0 silk suture is divided and the lateral attachments of the right colon are taken down with a harmonic device or cautery. The specimen is extracted through the left lateral 12mm trocar site, which is extended to approximately four centimeters to accommodate extraction. The wound is protected with a bag to prevent contact with the specimen. Standard closure techniques are then followed.
\n\t\t\tRobotic Sigmoid Colectomy is performed with the patient in a supine modified lithotomy position, in which the anterior thighs are in the same plane as the abdominal wall. The patient is placed on a bean bag so that the bag can wrap the right arm and the chest is secured to the table with heavy tape at the clavicles. Trocars are placed as seen in Figure 4 after pneumoperitoneum is obtained. The procedure is begun with the patient in a steep right sided tilt and reverse Trendelenburg position. The robot is brought in from the left side of the patient (see arrow a, Figure4). The right/green arm and its trocar are slipped through the suprapubic 12mm port or the arm can be docked to the left lateral abdominal wall 5mm robot port. The left/yellow arm is docked to the epigastric port. A harmonic energy device is used in the left arm and a grasper in the right. The splenic flexure is taken down by dividing the gastrocolic ligament then elevating the mesocolon off of Gerota’s fascia. Downward and medial retraction by the assistant from the right sided trocars is invaluable. Electrocautery can be used for the latter portion of this mobilization over Gerota’s fascia but harmonic energy is particularly helpful with the thick and often vascular gastrocolic ligament. Visualization of the ligament of Treitz through the mesentery marks the medial extent of proximal mobilization. The inferior mesenteric vein is selectively taken for benign diagnoses and routinely taken for malignant. Because left ureter visualization medially is
\n\t\t\t\tTrocar Placement for Robotic Sigmoid Colectomy.
the goal all the way to the pelvic brim, changing table position is required. The robot is disengaged and drawn back from the table. The patient is placed in Trendelenberg position and the robot is brought in from the left hip (see arrow b, Figure 4). The right/green arm and its trocar are slipped through the right lower quadrant 12mm port and cautery or harmonic energy device is attached. The left/yellow arm is connected to the left lateral abdominal wall robot trocar and a grasper is inserted. The sigmoid colon is elevated and the inferior mesenteric vascular pedicle is demonstrated. The peritoneum on the right side of the rectosigomid colon is scored at its base and the inferior mesenteric artery is isolated. The rectosigmoid colon is then mobilized circumferentially down to the desired level on the rectum while visualizing both ureters.
\n\t\t\t\tAt this point the robot is disengaged and endoscopic staplers are used to divide the inferior mesenteric artery and the rectum. The suprapubic port is extended to accommodate externalization of the specimen through a protecting bag. After proximal division of the colon and resection of the specimen, the anvil of an end-to-end anastomotic stapler is secured into the end of the colon. The colon is returned to the abdomen and the fascia is closed to allow for reestablishment of the pneumoperitoneum. The stapler is then inserted transanally through the rectum and attached to the anvil and fired. We routinely test our anastomoses with insufflation. Standard closure techniques are then followed.
\n\t\t\t\tPost operative care is similar to that in patients undergoing laparoscopic colectomy, with an emphasis on quicker recovery times. Clear liquids are offered the day of surgery and early ambulation is encouraged. Patient controlled analgesia is employed until patients are tolerating diet and oral medicines. Epidurals are not used. Criteria for discharge include tolerance of liquids, ability to void, adequate pain control with oral analgesics and evidence of bowel function. Follow up visits are scheduled within one to two weeks from the day of discharge.
\n\t\t\tInstitutional Review Board (IRB) approval was obtained. From 2002 to 2009 a total of 102 consecutive robotic colectomies were performed by a single surgeon (DLC) at two institutions with varying amounts of resident participation. Data was recorded in a Statistical Package for the Social Services (SPSS) database prospectively and a retrospective review of this data was performed.
\n\t\tOne-hundred and two robotic colectomies were performed. Procedures included 59 right colectomies and 43 sigmoid colectomies. For all colectomies, average patient age was 63.5 years (22-86). Forty-nine patients were male and 53 were female. Preoperative indications included polyps in 53 patients, diverticular disease in 27 patients, cancer in 19 patients, and carcinoid in 3 patients.
\n\t\t\tTotal operative time for all cases averaged 219.6 minutes
Average blood loss was 66.6 milliliters. Four procedures were converted to laparoscopy and five to an open approach, with an overall conversion rate of 8.8%. Complications occurred in 19 patients with an overall complication rate of 18.6%. Anastomotic leak occurred in one patient (0.98%). Median length of stay for all patients was 3 days with a range of 2 to 27 days.
\n\t\tThe advance of technology in the recent era of surgery has outpaced the ability of the medical community to adequately interrogate the true utility of certain techniques prior to their widespread adoption. Often hospitals and patients within a community seeking the latest technology become a driving force for surgeons to adopt new techniques. Ideally, the benefit of these measures are examined and discussed within the surgical community prior to their establishment as “common practice.” Many surgeons would argue that the true role for robotics in surgery is yet to be properly defined. Certainly there is an appeal for hospitals in marketing themselves as centers offering robotic surgery, and for surgeons to be promoted as regional experts in robotics and minimally invasive surgery. Although they may not know why, patients request robotic surgery in the hopes that they are receiving the most advanced care possible. We as surgeons, however, must decide when the application of robotics is truly advantageous.
\n\t\t\tThere is no doubt that the robot enhances the technical ability of the surgeon in ways that common laparoscopic techniques currently do not. The wristed instruments increase the maneuverability of the operating instruments with two more degrees of freedom than traditional laparoscopic instruments. The robot adds internal pitch and yaw to the pitch, yaw, grasp, rotation, and in-and-out motions of the laparoscopic instruments. The end result is that the instruments mimic the motion of a surgeon’s hands with the added benefits of tremor reduction and motion scaling. Confined spaces such as the pelvis and mediastinum provide arenas where these benefits are best realized.
\n\t\t\tThe visualization offered by the da Vinci system also serves as an enhancement to traditional laparoscopy. A stereoscopic camera allows for representation in both two-dimensional and three-dimensional views. The three-dimensional view provides a clarity and depth of field which further improves the surgeon’s ability to discriminate among tissue planes. Furthermore, the surgeon has the added benefit of control over the camera with one of the robot arms. This eliminates the frustration that can be met with inexperienced or fatigued camera operators and enhances the ability of the surgeon to complete difficult maneuvers in an efficient fashion.
\n\t\t\tAnother benefit of robotics not to be overlooked is the reduction of surgeon fatigue. The long term toll of laparoscopy on an individual surgeon may still not be fully realized given the fairly recent adoption of laparoscopy into the every day practice of many surgeons. Over the course of a twenty to thirty year career, the stresses of awkward positioning and maneuvering may prove to be detrimental to the health of many operating surgeons. During a robotic procedure, the surgeon is sitting comfortably with arms and head resting against padded surfaces. Recentering of hand controls eliminates the cumbersome task of maintaining positions beyond the normal range of comfort and convenience. Control of the visual field with the head comfortably supported reduces the neck strain often encountered during many laparoscopic procedures. Although the immediate benefit to any given patient is difficult to demonstrate, the pending dilemma of physician shortage reminds us that physician longevity is perhaps more important than previously thought. The robotic model presents an opportunity to minimize surgeon fatigue that may warrant further investigation.
\n\t\t\tThese advantages must be weighed against the disadvantages of using the robot for any given procedure. System-based considerations include staffing and accessibility. Staff must be properly educated on setup and troubleshooting to ensure that robotic procedures can be completed without undue delay. Often, an increased number of skilled staff is required to execute a robotic procedure. Operative suites must be of adequate size to accommodate the robot while at the same time ensure procedures not requiring the robot be unhindered by its presence. Rooms must be fashioned in a way that allows for effective surgeon to staff communication, as the traditional prominence of the surgeon standing over the patient is altered in robotic surgery.
\n\t\t\tTechnically, the loss of tactile sensation and the ability to accurately gauge “strength” presents a challenge to the operating surgeon. The risk of patient injury is increased if the surgeon is unfamiliar with these limitations and visual clues become very important to the surgeon when handling tissue. Also limiting is the difficulty in operating in the far lateral extensions of the operative field, where robot arms are restricted from operating beyond a certain distance. Robot arms can interfere with each other outside the patient as well, creating an added challenge not encountered in traditional laparoscopy. Port placement, experience, and planning are critical in minimizing the incidence of this problem. Unlike traditional laparoscopy, instruments and camera are not conveniently interchanged to accommodate the various fields encountered in a given procedure. The robot must be moved in and out of the docked position to accomplish significant alterations in port, camera, and instrument positions. This is often timely and cumbersome. An important goal with any robotic procedure is to minimize time wasted with repositioning of the robot. Positioning of the patient too is important. Laparoscopy often requires frequent and exaggerated position changes to assist in retraction and accessibility of tissues. This must be anticipated in any robotic case, as most patient position changes require repositioning of the robot as well.
\n\t\t\tThe largest concern, of course, is cost. The system itself is expensive to acquire, as are instruments and the disposable equipment required for robotic cases. Often, increased time and staffing are required to accommodate robotic procedures. No specific reimbursement pattern exists to recuperate these costs. Whether private or nationally supported, a payer source must be able to justify the cost of the technology for it to survive in modern health care. This is an ongoing debate, and the outcome of this debate may determine what role robotics plays in the future.
\n\t\t\tIn our previous review, adjusted to 2005 US dollars, robotic colectomy carried a 15% greater total hospital cost compared to laparoscopic colectomy, although there was not statistical significance. In 17 robotic right colectomy cases, average total hospital cost was $9,255 compared to $8,073 for laparoscopic cases (Rawlings et al., 2007). Little else has been published regarding cost data, despite the fact that this is often a matter of debate. Delaney et al. also showed a higher total hospital cost for robotic procedures, with a $350 difference in operating room and equipment costs (Delaney et al., 2003). These costs have to be taken on by the operating institution. Interestingly, it is often these same institutions pushing surgeons to utilize the technology, despite the lack of avenues to directly regain the difference in cost. This cost, in some ways, can be considered a “marketing” expense that institutions assume when purchasing the da Vinci system. Any surgeon considering performing robotic surgery must also consider the local financial and institutional environment and should have support from their institution prior to employing robotics within their practice. Surgeons should be open about cost issues with both their patients and their institutions to avoid misconceptions about this significant matter.
\n\t\t\tTaking the above issues into consideration, one must ask “why robotics?” Certainly there are advantages and disadvantages, as there are many proponents and perhaps even more opponents to robotic surgery. When looking at the literature, we find that it is difficult to show a clear outcomes benefit to patients when comparing laparoscopy to robotic surgery of the colon. Multiple authors have reported their experiences and common points of discussion typically include operative time, cost, length of stay and complications. From 2004, we have identified five papers reporting experience with robotic surgery of at least 30 patients, as well as our own (Table 1). Here we discuss these papers.
\n\t\t\tAuthor | \n\t\t\t\t\t\tYear | \n\t\t\t\t\t\tn | \n\t\t\t\t\t\tTotal Case Time | \n\t\t\t\t\t\tConversion | \n\t\t\t\t\t\tComplication | \n\t\t\t\t\t
\n\t\t\t\t\t\t | \n\t\t\t\t\t\t | \n\t\t\t\t\t\t | (min) | \n\t\t\t\t\t\t\n\t\t\t\t\t\t | \n\t\t\t\t\t |
Luca | \n\t\t\t\t\t\t2009 | \n\t\t\t\t\t\t55 | \n\t\t\t\t\t\t290 | \n\t\t\t\t\t\t0 | \n\t\t\t\t\t\t12 | \n\t\t\t\t\t
Baik | \n\t\t\t\t\t\t2009 | \n\t\t\t\t\t\t56 | \n\t\t\t\t\t\t190.1 | \n\t\t\t\t\t\t0 | \n\t\t\t\t\t\t6 | \n\t\t\t\t\t
Spinoglio | \n\t\t\t\t\t\t2008 | \n\t\t\t\t\t\t50 | \n\t\t\t\t\t\t383.8 | \n\t\t\t\t\t\t2 | \n\t\t\t\t\t\t7 | \n\t\t\t\t\t
Crawford | \n\t\t\t\t\t\t2008 | \n\t\t\t\t\t\t70 | \n\t\t\t\t\t\t225 | \n\t\t\t\t\t\t8 | \n\t\t\t\t\t\t8 | \n\t\t\t\t\t
Hellan | \n\t\t\t\t\t\t2007 | \n\t\t\t\t\t\t39 | \n\t\t\t\t\t\t285 | \n\t\t\t\t\t\t1 | \n\t\t\t\t\t\t5 | \n\t\t\t\t\t
Crawford | \n\t\t\t\t\t\t2006 | \n\t\t\t\t\t\t30 | \n\t\t\t\t\t\t226 | \n\t\t\t\t\t\t2 | \n\t\t\t\t\t\t6 | \n\t\t\t\t\t
D\'Annibale | \n\t\t\t\t\t\t2004 | \n\t\t\t\t\t\t53 | \n\t\t\t\t\t\t240 | \n\t\t\t\t\t\t6 | \n\t\t\t\t\t\t4 | \n\t\t\t\t\t
Publications of Robotic Colon Surgery with at least 30 patients
When looking at the literature, operative time for robotic surgery of the colon typically ranges from 200 to 300 minutes, however some reach almost 400 minutes. In the papers we have focused on, average reported total procedure time is 262.8 minutes in 353 robotic colon cases. This includes all types of cases, from right colectomy to intersphincteric resection and APR. Conversion occurred in 19 (5.4%) cases with 9 to laparoscopic and 9 to open. Outcomes from robotic colectomy reflect those of laparoscopic colectomy. Complications were reported in 48 (13.6%) of the 353 patients with 14 (4.0%) representing anastomotic leak. Our low anastomotic leak rate and operative time compare favorably to these results. Our conversion rate was slightly higher, but similar to these results.
\n\t\t\tIn considering available series discussing robotic surgery of the colon, we find a good deal of inconsistency in the data collected. Conversion tends to be a rather infrequent occurrence, with conversion to both conventional laparoscopy and laparotomy (Table 2). Operative times vary, and no clear trend can be identified between operative experience and total case time. Outcomes also vary, but here too it seems results are comparable to those in conventional laparoscopic surgery. Certainly it can be argued that robotic surgery is safe and feasible for surgery of the colon when considering patient outcomes. The increase in operative time may be a concern when dealing with patients of increased preoperative morbidity, and we advocate surgeon discretion in these scenarios.
\n\t\t\tSeries of Robotic Surgery of the Colon
Also deserving mention is the role robotic technology plays in surgical training programs. Graduating surgeons must be familiar with modern techniques in order to remain relevant to contemporary practice. Although robotic surgery is not considered mainstream at the current time, being familiar with the technology and the opportunities it presents are important assets to have. Resident involvement in robotic surgery plays an important role at our institution. The residents participate in robotic cases starting their first year of training.
\n\t\t\tDuring the first and second years of training the residents attend a half day course that includes didactic lectures on the history and development of robotic surgery. They also receive hands on instruction with the device regarding setup, instrument exchanges, robot positioning and troubleshooting. They then receive individual instruction while sitting at the surgeon’s console with dexterity exercises and suturing. During this early stage the resident assists the surgeon while standing at the operating table. Over time, according to training level, interest, and operative talent, the residents become more involved in performing more integral portions of the procedure from the surgeon’s console. Senior residents often do more than 90% of the case, while the attending surgeon remains as assistant and instructor at the operating table.
\n\t\t\tWhen looking at our data, we find that resident involvement in robotic cases increases throughout training (Table 3). The exception to this is the fourth year of training due to the increased time spent on trauma and night float rotations. As the resident advances, we also see that the number of cases in which he or she performs >90% of the procedure also increases, along with the total cases participated in. It has been the senior author’s observation that the formal incorporation of robotic training in the curriculum has allowed residents to learn robotic techniques in an effective manner. Most residents are able to adapt to the technology quickly, often with less difficulty than in traditional laparoscopic surgery. This involvement has an added benefit in the recruitment of future residents. Allowing significant resident involvement in robotic surgery reassures applicants that they are pursuing a program which will not only expose them to, but train them in cutting edge techniques with cutting edge technology. We see this technology, therefore, advancing within academic training centers, where new applications and adaptations to robotics can be developed and applied.
\n\t\t\tResident involvement by training level
\n\t\t\tResident Involvement in Robotic Cases According to Training Level
Robotic technology has presented many opportunities and controversies for surgeons. Many are quick to adopt new technology, while others remain skeptical of the true benefits of robotics in abdominal surgery. We have presented our experience with robotic surgery in order to further the discussion of this matter in regards to surgery of the colon. How robotics will continue to be employed in colonic procedures remains to be settled. Certainly, the technology will continue to evolve, and perhaps be adapted to take on different forms and purposes. As attention turns to natural orifice surgery and single incision laparoscopic procedures, robotic technology may provide solutions for limitations in these areas. Regardless of outcome, it is essential as surgeons and academicians, that we continue this debate for the purpose of enhancement of our profession and improvement in patient outcomes.
\n\t\t\t\tIllustrations by Steven Henriques, M.D.
\n\t\t\tPectin is a structural heteropolysaccharide present in the primary cell walls of terrestrial plants. It can be obtained from renewable agriculture by-products and food processing industry wastes. These natural sources of pectin make it one of the most abundant biopolymers. It consists of D-galacturonic acid residues which possess carboxylic acid groups, some of which are methyl-esterified. The degree of esterification determines the solubility of pectin and its gelling and film-forming properties. Depending on the origin of pectin, the degree of esterification can vary from high methyl (HMP, up to 50 wt. % of carboxylic acid units are esterified) to low methyl (LMP, lower than 50 wt. % of carboxylic acid units are esterified) [1]. Pectin extracted from criolla orange (
On the contrary, low methyl pectin at pH 7 or higher can turn into more coiled chain conformations in the presence of counterions. Furthermore, the addition of salt to pectin solutions allows the formation of complexes between positively charged ions and negatively charged carboxylic acids, which is facilitated at pH 7 or higher because of deprotonation of carboxylic acid groups. These observations explain the cross-linking effect of positively charged ions on pectin structure and gel formation at higher pH and ion concentration [4].
On the other hand, it is well known that pectin films are obtained from aqueous solutions after slow solvent evaporation [1]. High molecular weight and low pH are required to facilitate the formation of coil entanglements responsible for film formation. The chain entanglements are supported by H-bonding interactions that give strength and physical resistance to the film. Kontogiorgos et al. [5] found that the strength of interactions and conformational changes on pectin during the transition from a liquid to a glassy state are the main factors influencing the physical properties of the solid-state system. However, in contact with aqueous environments, pectin films can absorb water, first swelling the polymer matrix and then dissolving it. Several authors have probed different methods of preparing water-resistant films. Cruces et al. [6] prepared multilayer films of pectin-beeswax/colophony-pectin varying the ratio between beeswax and colophony. This method reached water vapor permeation values (56 × 10−13 g m m−2 s−1 Pa−1) almost ten times higher than the WVP value of polyethylene films (LDPE 5.8 × 10−13 g m m−2 s−1 Pa−1). Gharsallaoui et al. [7] prepared composite films of pectin/sodium caseinate to improve the mechanical and water barrier properties of protein-free pectin. These authors found that pectin and protein are negatively charged at neutral pH (pH higher than the isoelectric point of a protein), which favors the formation of macroscopic segregated phases. However, even at high turbidity conditions, which demonstrated phase segregation, some positively charged residues on protein might interact with negatively charged groups on pectin, improving the mechanical and water barrier properties. Other authors have prepared insoluble films by cross-linking the pectin matrix using divalent or trivalent cations [4, 8]. Besides, there exist methods of cross-linking a polymer matrix by reacting it with bifunctional molecules such as glutaraldehyde to perform covalent cross-linking [9]. Usually, cross-linking of the polymer matrix causes chain stiffness and, consequently, detriment of mechanical properties.
Nevertheless, cross-linking might improve solvent resistance, water vapor, and gas barriers. So, it is interesting to study the proper film formation conditions in the presence of a cross-linking agent to overcome the challenge of obtaining a robust film, easy to manipulate with improved mechanical and barrier properties. In this work, pectin from criolla orange (
Pectin (Pec) from criolla orange was dissolved in distilled water at ambient temperature under mechanical stirring at a concentration of 2 wt.% of solid with 1 vol.% of glycerin (GLY, Biopack Argentina). The pH of the pectin solution measured with a pH meter (Melter Toledo) was 3.2. After the pectin solution was homogeneous, it was spread on a leveled Petri dish and placed in an oven at 40°C for 24 h for slow solvent evaporation. Once a pectin film was formed, it was peeled off and submerged in a 0.1 wt.% CaCl2 (Merck) solution at 40°C without stirring (stagnant conditions). Diffusion of calcium ions occurred by a driving force of concentration gradient, allowing a moderate cross-linking effect in the polymer matrix. A contact time of 24 h was probed to obtain cross-linked pectin films. After cross-linking time, the pectin film was washed with a hydroalcoholic solution several times to remove excess calcium salt on the film surface. Cross-linked pectin with calcium was named Pec-Ca, and it resulted in a transparent and handling film used for mechanical and barrier characterizations. The same procedure and salt concentration were used in the case of FeCl3 salt (Merck), and the cross-linked film was called Pec-Fe. This last film was light brown and retained transparency and easy handling. Commercial pectin from citrus peel was supplied by Sigma Aldrich (galacturonic acid ≥74.0%, methoxy groups ≤6.7%), and it was used to prepare uncross-linked films. The same procedure as pectin from criolla orange was used to obtain the commercial pectin film, and it was called Com-Pec.
CT3 Brookfield texture analyzer with a load cell of 50 kg and a resolution of 5 g was used to perform tensile strength assays at a speed of 5 mm·min−1 according to the ASTM D 882 requirements. For an experiment, samples were cut into rectangular pieces of 40 mm in length and 10 mm wide. Thickness was measured using a Köfer micrometer (precision ±1 μm). To ensure complete relaxation of the polymeric structure once the films were peeled off, they were placed in a humidity chamber for 24 h at a relative humidity of 40% and room temperature (25°C) before they were measured. Then, the experimental procedure was carried out under the same humidity and temperature conditions. Typical curves of tension (
where:
where:
Polysaccharides in general and pectin are hydrophilic polymers able to absorb water from the environment to the detriment of the films’ physical integrity. It is a matter of science to find ways to prevent water absorption for expanding the field of biopolymers application. Even reducing water uptake under acceptable values would represent a contribution to broadening polysaccharide film applications, for example, for food packaging. In this study, water uptake (WU) was determined gravimetrically. Weights of completely dried samples were measured directly. Film specimens were introduced into bottles containing 20 mL of distilled water and shaken at ambient temperature (25°C). At intervals of 24 h, films were removed from the medium, dried to remove excess water, and immediately weighed. The water uptake of the cross-linked films was calculated according to the following Equation [11]:
where:
Water vapor transmission rate (WVTR) was determined gravimetrically using a modified ASTM Method E 96–95. The film specimen was mounted on an acrylic permeation cell comprised of two chambers. The upper chamber was in contact with water vapor pressure, while the bottom chamber was filled with an adsorbent material. The film specimen was in between both chambers, acting as a barrier. Therefore, the driving force of the global process was the difference in water vapor pressure at both sides of the film specimen. Once the permeation cell was assembled, all systems were placed into a chamber with temperature and relative humidity control. The operational conditions are fixed at 37 ± 2°C and 98% relative humidity (RH). Water vapor permeability (WVP) (ng·m·m−2·s−1·Pa−1) was calculated from [11]:
where:
Flexible packaging materials must fulfill some specific characteristics according to the food they will pack. Fruits and vegetables are a particular type of food because they continue breathing after harvesting. Fruits and vegetables need oxygen to breathe, converting carbohydrates into carbon dioxide and water vapor. Post-harvest respiration uses stored starch or sugar and will stop when these reserves are exhausted. Therefore, designing a film that can retard fruits and vegetable respiration by controlling oxygen permeability and nitrogen and carbon dioxide exchange is desired. This condition might modify the atmosphere around the fruits and vegetables, altering oxygen levels inside the packaging, retarding the production of ethylene, and, thus, limiting the physiological decay of the product [12, 13]. This modification also reduces ripening-induced quality degradation in texture or loss of bioactive compounds during storage.
On the other hand, a minimal amount of oxygen might let anaerobic fermentation process, leading to spoilage [14]. For that reason, studying gas permeation through pectin and cross-linked pectin films is necessary to define the applicability of these films to the packaging of fruits and vegetables. In this study, N2, O2, and CO2 permeability were measured at 30°C and 1 bar using a classical time lag apparatus. The effective membrane area was 11.34 cm2, and permeate constant volume was 35.37 cm3. After the membrane degassing procedure, gas permeation measurements were carried out under high vacuum (
where: the cell constant
Theoretical separation factors (
Mechanical properties of pectin and cross-linked pectin films were evaluated through strength-strain curves of each sample. Besides, commercial pectin was also analyzed. Table 1 shows values of young’s modulus (
Film | ||||
---|---|---|---|---|
Pec | 614 ± 8.9 | 12.6 ± 0.5 | 2.7 ± 0.3 | 15 ± 4 |
Pec-Ca | 989 ± 10.1 | 21.3 ± 4.0 | 2.4 ± 1.0 | 265 ± 8 |
Pec-Fe | 876 ± 9.8 | 22.0 ± 5.0 | 4.3 ± 1.0 | 511 ± 10 |
Com-Pec | 176 ± 3.2 | 17.2 ± 1.7 | 30.3 ± 2.4 | 3330 ± 7 |
Mechanical properties of films.
Calcium “egg-box” model for pectin, based on [
Furthermore, water molecules might also interact with ions, competing with carboxylic acid units to stabilize them. The calcium egg-box model is formed in a two-fold conformation of pectin chains. Remnant water molecules within the pectin matrix might provoke a polymorphic transition from two-fold to three-fold chain conformation, disrupting the egg-box configuration. This fact might explain results obtained by Pec-Fe, which showed lower young’s modulus and higher elongations at break correlated with a more hydrated configuration. Regarding the structural possibilities of pectin-Fe, it could be like xanthan gum-Fe studied by Vazquez et al. [17].
The hydrophilic nature of polysaccharides is a known characteristic that prevents some of these biopolymers’ applications. Some strategies to reduce water uptake in films are cross-linking, blending, and mixing with other materials such as hydrophobic polymers [18], waxes [19], inorganic components [20], among others. In this study, cross-linking of the pectin matrix with calcium and iron ions was used to reduce the water uptake ability of film samples. Table 2 shows WU results. A reduction in absorption capacity was observed in the presence of cross-linking concerning criolla orange pectin. Even when all values were significantly high, they depicted a weak cross-linking effect on water uptake. This result might be a consequence of the method used to cross-link the samples, which was ion diffusion from slightly concentrated solutions toward the matrix of the submerged film. Furthermore, this result might be evidence of superficial instead of full matrix cross-linking. It is well known that diffusion is a mass transport mechanism driven by concentration gradients and facilitated by temperature and stirring. The cross-linking procedure was performed under ambient temperature in stagnant conditions. Besides, Pec-Ca showed lower water absorption than Pec-Fe following its tighter egg-box cross-linking conformation mentioned in the previous section. On the other hand, Com-Pec showed complete solubility in water after a contact time of 24 h. This result might be explained considering the low methoxyl content of commercial pectin (galacturonic acid ≥74.0%, methoxy groups ≤6.7%) compared to criolla orange pectin [2]. Methoxy groups confer hydrophobic characteristics to the pectin backbone, which explains Pec’s lower solubility in the water regarding Com-Pec.
Film | |
---|---|
Pec | 372 ± 38 |
Pec-Ca | 326 ± 20 |
Pec-Fe | 338 ± 25 |
Com-Pec | — |
Water uptake values.
Permeability depends on the solubility and diffusivity of water vapor molecules within the polymeric matrix [11]. When the polymer is hydrophilic, water molecules find many interacting sites and hopping by the polymer matrix through the formation of hydrogen bonds [21]. Hence, water vapor permeation is facilitated within hydrophilic polymers such as pectin. Despite this disadvantage, cross-linking reduces these interactions by blocking polar groups on pectin such as carboxylate and hydroxyl groups through interactions with divalent and trivalent ions such as Ca2+ and Fe3+. In order to study the effect of cross-linking on water vapor permeation, measurements were made gravimetrically using a modified ASTM Method E 96–95 (ASTM 96). Results are shown in Figure 2. A slight decrease in WVP of Pec-Ca concerning Pec was observed.
Water vapor permeation of pectin films.
On the contrary, Pec-Fe showed an increase regarding orange pectin. This last result might be explained by an increased solubility of water vapor molecules through the polymer matrix favored by interactions with trivalent iron ions in the three folded chain conformation. Com-Pec showed the highest permeation value according to the hopping mechanism of water vapor molecules proposed by Cruces et al. [21].
As mentioned before, Com-Pec has ≥74.0% of de-esterified carboxylic acid groups; hence the polymeric matrix is full of polar groups able to interact with water vapor molecules to hop through. WVP result of commercial pectin agreed with that reported by Cruces et al. (0.0361 ng·m·m−2·s−1·Pa−1) [21]. Other authors have studied water vapor permeation properties in polysaccharides and cross-linked polysaccharides. Values in the range from 1.5 to 0.6 ng·m·m−2·s−1·Pa−1 were reported for alginate-calcium cross-linked films [22], starch-based biopolymer with rye flour, cellulose, and citric acid as additives showed a WVP value of 0.87·ng·m·m−2·s−1·Pa−1 [23], xylan-alginate films containing bentonite, or halloysite clays showed a reduction in WVP from 0.394 for control film to 0.210 for 5 wt% for either clay [24]. Considering the reported WVP values for a variety of biopolymers, it is concluded that sensitivity to water vapor of hydrophilic polymers is still a matter of study.
Gas permeation was measured in pectin films to analyze their ability to control gas exchange between internal and external sides of the packaging. According to our knowledge, O2 and CO2 are among the most important gases that take part in fruits and vegetable respiration. N2 is an inert gas representing about 78% of atmosphere content, and it might show preservation effects [25]. The three main gases used in modified atmosphere packaging (MAP) are N2, O2, and CO2. Decreasing the respiratory rate of fruits and vegetables in food packaging retards their deterioration. This effect occurs by reducing at least 5% of O2 permeability, heightening CO2 concentration, and regulating N2 exchange inside the packaging. Oxygen promotes several deteriorative reactions in food, such as fat oxidation, browning reactions, and pigment oxidation. Besides, oxygen is necessary for bacteria and fungi growth. Carbon dioxide dissolves readily in water, increasing the acidity of food surroundings which can cause pack collapse due to the reduction of headspace volume. Nitrogen does not support the growth of aerobic microbes, and it is used to balance the volume decrease caused by CO2 solubilization in water [26]. Gas permeation results and gas selectivity are shown in Tables 3 and 4, respectively.
Film | Thickness (μm) | PN2 | PO2 | PCO2 |
---|---|---|---|---|
Pec | 152 | 3.87 | 1.44 | 0.33 |
Pec-Ca | 90 | 3.34 | 2.84 | 0.40 |
Pec-Fe | 258 | 5.16 | 1.45 | 0.59 |
Com-Pec | 254 | 3.06 | 0.49 | 2.04 |
Gas permeation in pectin films.
Film | |||
---|---|---|---|
Pec | 2.68 | 4.40 | 11.78 |
Pec-Ca | 1.17 | 7.09 | 8.33 |
Pec-Fe | 3.56 | 2.46 | 8.73 |
Com-Pec | 6.21 | 0.24 | 1.50 |
Gas selectivity.
Results shown in Table 3 depict a modified atmosphere by pectin and cross-linked pectin films. Considering fruit or vegetable packed in these films, it would be possible to see that normal atmosphere content (78% N2, 21% O2, and 0.01% CO2) and its gas ratios have been modified. These results are better observed from Table 4, which we analyzed forwards. From Table 3, a reduction in N2 permeability can be observed in the case of Pec-Ca and Com-Pec regarding orange pectin. On the contrary, an increase in PN2 was observed for Pec-Fe. Oxygen permeability increased for Pec-Ca, demonstrating a detriment in its ability to reduce oxygen content inside the packaging.
On the other hand, PCO2 was lower in the case of Pec, Pec-Ca, and Pec-Fe than Com-Pec. The barrier to CO2 might represent a promising property for MAP. Differences in gas permeability between calcium and iron cross-linked films might be related to the polarity of ions concerning gases. Besides, the availability of ions within the less hydrated two-folded chains in the case of Ca2+ or more hydrated three-folded chains conformation in Fe3+ could also influence the interactions with permeate gases. These molecular conformations can also explain the increment in PCO2 for Pec-Fe. Table 4 shows gas selectivity for selected gas pairs taking into account their abundance and gas ratio in the usual atmosphere. N2/O2 ratio in a usual atmosphere is around 3.71. From Table 4, it is observed that Pec-Fe has the closest value to that of the familiar atmosphere, while Pec and Pec-Ca have lower ratios and Com-Pec has the highest one. These results indicate that all films act as selective gas barriers favoring the permeance of N2 more than O2, except for Pec-Ca, in which N2/O2 selectivity is almost 1, i.e., no selectivity for N2 nor O2.
On the other hand, selectivity to O2 against CO2 was pronounced in the Pec-Ca film, followed by Pec and Pec-Fe. These results prove that an excellent barrier to CO2 is reached in cross-linked films. Furthermore, Com-Pec showed an opposite behavior concerning O2/CO2 selectivity being more permeable to CO2. Finally, N2/CO2 selectivity was excellent for Pec, and it was similar in the case of Pec-Ca and Pec-Fe. Values shown in Table 4 indicate that N2 permeability can balance the volume decrease caused by CO2 solubilization in water as respiration and transpiration occur in fruits and vegetables. Commercial pectin showed less selective films for N2/CO2 gas pair according to its lower barrier to CO2.
According to Sandhya [26], there has been much commercial interest in developing films with high gas transmission rates. High gas transmission films are obtained by modifying the film manufacturing process so that gases such as O2, CO2, and water vapor exit or enter the package in a controlled manner such that aerobic respiration needs are met, and desirable CO2 and moisture levels are maintained. This work successfully controlled gas permeation and selectivity to obtain a modifying atmosphere inside packaging were achieved.
An exhaustive analysis of the effect of cross-linking of the pectin matrix with calcium and iron ions was carried out. Mechanical and permeation properties were studied and discussed to find new insights about structure–property relationships of modified films. Mechanical stiffness was observed when pectin was cross-linked with Ca2+ and Fe3+ showing higher Young’s modulus and tension at break than orange and commercial pectin. Reduced water uptake was observed for Pec-Ca and Pec-Fe. However, values still being high concerning synthetic polymers. Similar results were obtained for water vapor permeation being Pec-Ca which depicted the lowest value. Finally, gas permeation assays were performed, demonstrating a good ability of cross-linked films to modify the atmosphere inside a packaging destined for fruits and vegetables packaging.
As a general conclusion, the conformation of two-folded chains in Pec-Ca concerning the three-folded chains in Pec-Fe was responsible for obtaining stronger mechanical properties, lower water uptake and water vapor permeation, and promising O2/CO2 selectivity in this cross-linked film.
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All published Book Chapters are licensed under a Creative Commons Attribution 3.0 Unported License. Monographs are licensed under the Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0) license granted to all others. Our Copyright Policy aims to guarantee that original material is published while at the same time giving significant freedom to our Authors. IntechOpen upholds a flexible Copyright Policy meaning that there is no copyright transfer to the publisher and Authors hold exclusive copyright to their work.
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Pal is Professor of Physics at Mahindra École\nCentrale Hyderabad India since July 1st 2014 after retirement\nas Professor of Physics from IIT Delhi; Ph.D.’1975 from IIT\nDelhi; Fellow of OSA and SPIE; Senior Member IEEE;\nHonorary Foreign Member Royal Norwegian Society for\nScience and Arts; Member OSA Board of Directors (2009-\n11); Distinguished Lecturer IEEE Photonics Society (2005-\n07).",institutionString:null,institution:{name:"Indian Institute of Technology Delhi",country:{name:"India"}}},{id:"69653",title:"Dr.",name:"Chusak",middleName:null,surname:"Limsakul",slug:"chusak-limsakul",fullName:"Chusak Limsakul",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Prince of Songkla University",country:{name:"Thailand"}}},{id:"23804",title:"Dr.",name:"Hamzah",middleName:null,surname:"Arof",slug:"hamzah-arof",fullName:"Hamzah Arof",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/23804/images/5492_n.jpg",biography:"Hamzah Arof received his BSc from Michigan State University, and PhD from the University of Wales. 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Thus the world is expecting a great recession once again. The rapid spread of COVID-19 has had far-reaching consequences for people’s daily lives in almost all parts of the world. Climate change and biodiversity depletion have now reached global boundaries; thus, human activity has surpassed Earth’s capacities. Earth capacities can be explained in terms of extreme climate change. This chapter is intended to investigate the link between the outbreak of Covid-19 and its effect on environmental and society. The discussion reveals that environmental pollution is minimized as a result of global lockdown. 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Similarly, carefully planned vegetation around the building helps in reducing the urban heat island effect and electricity consumption. Methodology adopted for presenting this study as book chapter, first by understanding the concept of landscape with respect to typologies and components. 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The purpose of this research is to establish Low Carbon Transportation in developing countries and we choose one of major city in India, where it is Ahmedabad city of Gujarat state—west cost of India. In order to approach the target, we need to understand the current situation of traffic condition in the city. The current traffic condition in India is some chaotic because of their different driving behavior compared with the advanced countries. It is becoming the chaotic traffic condition in India by not only diving behavior during investigation of this research. The main reason of the traffic congestion comes from the unbalance between growing transportation demand and its insufficient infrastructure preparation. In this chapter, it introduces the current traffic condition based on four years monitoring of the traffic by the traffic monitoring cameras and comparison by the traffic flow theory at first. Then it introduces the new traffic analysis method especially for its traffic congestion analysis and its parameters. After the traffic congestion analysis, it summarizes conclusion and our next step from the experience.",book:{id:"9838",slug:"design-of-cities-and-buildings-sustainability-and-resilience-in-the-built-environment",title:"Design of Cities and Buildings",fullTitle:"Design of Cities and Buildings - Sustainability and Resilience in the Built Environment"},signatures:"Tsutomu Tsuboi",authors:[{id:"327074",title:"Ph.D.",name:"Tsutomu",middleName:null,surname:"Tsuboi",slug:"tsutomu-tsuboi",fullName:"Tsutomu Tsuboi"}]},{id:"76112",title:"Introductory Chapter: Intelligence, Sustainable and Post-COVID-19 Resilience Built Environment: An Agenda for Future",slug:"introductory-chapter-intelligence-sustainable-and-post-covid-19-resilience-built-environment-an-agen",totalDownloads:364,totalCrossrefCites:0,totalDimensionsCites:0,abstract:null,book:{id:"9838",slug:"design-of-cities-and-buildings-sustainability-and-resilience-in-the-built-environment",title:"Design of Cities and Buildings",fullTitle:"Design of Cities and Buildings - Sustainability and Resilience in the Built Environment"},signatures:"Samad Sepasgozar, José David Bienvenido-Huertas, Sara Shirowzhan and Sharifeh Sargolzae",authors:[{id:"221172",title:"Dr.",name:"Samad M.E.",middleName:null,surname:"Sepasgozar",slug:"samad-m.e.-sepasgozar",fullName:"Samad M.E. 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