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Main · Videos; Dinamo r1 yahoo dating eyepiece review pit falls of dating a surgeon eyepiece review pit falls of dating a surgeon lascelles stephens dating site. John C. Kucharczuk MD, in Surgical Pitfalls, It is helpful to review the planned procedure with the entire operating room team as well as to have a The right hand grasps the scope at the level of the eyepiece. . may not be accurate, potentially overestimating protection among those claiming up-to-date status and. Studies reviewed demonstrated 3D printing applications in surgical planning including of face-lift patients evaluated by the FACE-Q with the longest follow- up to date. .. an image retrieval system, a series of rods and lenses, and an eyepiece for are able to communicate with mentees, and can avoid potential pitfalls.
Abstract Mounting evidence suggests that a more extensive surgical resection is associated with an improved life expectancy for both low-grade and high-grade glioma patients.
However, radiographically complete resections are not often achieved in many cases due to the lack of sensitivity and specificity of current neurosurgical guidance techniques at the margins of diffuse infiltrative gliomas.
Intraoperative fluorescence imaging offers the potential to improve the extent of resection and to investigate the possible benefits of resecting beyond the radiographic margins.
Here, we provide a review of wide-field and high-resolution fluorescence-imaging strategies that are being developed for neurosurgical guidance, with a focus on emerging imaging technologies and clinically viable contrast agents. The strengths and weaknesses of these approaches will be discussed, as well as issues that are being addressed to translate these technologies into the standard of care.
In recent years, MR-based neuronavigation and intraoperative MRI, coupled with intraoperative mapping techniques and functional MRI, have enabled improved radiographic and functional outcomes, yet still present major drawbacks.
In particular, because the margins of gliomas are diffuse and ill-defined, the boundaries indicated by T1-weighted Gadolinium-enhanced MRI for high-grade gliomasor T2-weighted hyperintensity for low-grade gliomas are ambiguous and do not necessarily correspond to biological metrics such as histopathological grade or tumor-cell density.
In addition, brain shift is a major impediment for neuronavigation-based resections. While intraoperative MRI allows for periodic image acquisition during an operation to mitigate brain-shift artifacts, this technology is time-consuming, expensive, and does not circumvent the aforementioned limitations of conventional structural imaging. For the neurosurgical oncologist, the balance of maximal cytoreduction and functional preservation remain central challenges, as the process of determining an ideal resection margin suffers from insufficient and unreliable visual, tactile, and radiographic data.
Although considerable controversy persists regarding the clinical benefits of more extensive extent of resection for low- and high-grade gliomas, mounting literature continues to support this approach. For example, it may be possible to evaluate the benefits of resection margins that are beyond, or independent of, the radiographic margins i. Abstract Recently, demand for minimally invasive surgery has increased greatly.
As a result, robot-assisted techniques have gained in popularity, because they overcome several of the shortcomings of conventional laparoscopic techniques.
However, robotic surgery may require innovations with regard to patient positioning and the overall arrangement of operative equipment and personnel, which may go against the conservative nature of anesthesia care. Anesthesiologists should become familiar with these changes by learning the basic features of robotic surgical systems to offer better anesthetic care and promote patient safety.
General anesthesia, Remote operation Over the past decade, robot-assisted surgery has become widespread in a variety of operations. Basically, robotic surgery offers the benefits of laparoscopic surgery, such as improved cosmesis, reduced postoperative pain, and wound complications, and faster recoveries, with shorter hospital stays. Robotic surgery also overcomes some of the shortcomings of conservative laparoscopic or endoscopic techniques, such as the assistant-dependent unstable video camera platform, two-dimensional view, restricted ergonomics of the surgeon, and instruments with limited degrees of freedom and the absence of wrist gear.
Robotic systems now present three-dimensional views with magnification and tools with seven degrees of freedom that are capable of duplicating hand movements with high accuracy [ 1 ]. Several robotic systems have attempted to enter the field of robotic surgery. Presently, the da Vinci system of Intuitive Surgical is the only commercially available robotic system and is predominant in Korea.
Thus, this article will focus on the da Vinci system. According to Intuitive Surgical, Korea, robotic surgery was first started in Korea in with a single da Vinci system; 10 prostatectomies, 10 gastrectomies, and 5 cholecystectomies were performed that year.
The most commonly conducted surgery is the prostatectomy, followed by thyroidectomy, low anterior resection, and gastrectomy.
Each has now been performed in more than 1, cases. Nephrectomies and cholecystectomies have also gained in popularity; performance of gynecological and transoral robotic surgery TORS has also increased recently. The setting for robotic surgery requires specific considerations that differ from conservative surgical techniques.
The modern anesthesiologist should keep abreast of these changes, and consider the impact on the anesthetic plan and patient safety. These issues will be reviewed in this article. The surgical cart has four arms that can be manipulated by the surgeon in a console through real-time computer-assisted control. The first two arms represent the right and left arms of the surgeon, so they hold the instruments.
The third arm positions the endoscope. The optional fourth arm enables the surgeon to hold another instrument or perform additional tasks, such as holding countertraction and following running sutures, thus eliminating the need for a patient-side surgeon. The surgical cart is heavy and bulky. Because of the proximity of the cart to the patient, the patient must be guarded against inadvertent contact due to the motions of the robotic arms. Instruments that are installed in the surgical cart have seven degrees of freedom: This "EndoWrist" technology exceeds the capacity of a surgeon's hand in open surgery.
Additionally, more than 6 Hz of hand tremor can be filtered, and motion scaling also can be invoked, up to a ratio of 5: In most cases, two surgeons perform the operation.
Besides the surgeon at the console, the other skilled assistant at the tableside places the trocars and connects them with the robotic arms, changes the robotic instruments, and manipulates additional endoscopic instruments. The console is where the surgeon sits to view the operational field and controls the robotic arms performing the surgery [ 3 ]. In addition, there are three foot-pedals for disengaging robotic motion, alternating between the robotic arms, adjusting the camera, and controlling the energy of electric cauterization or ultrasonic instruments.
The system allows the surgeon to be physically remote from the patient and to control the surgery from the console. The optical tower contains the computer equipment needed to integrate the left and right optical channels to provide stereoscopic vision. It also runs the software to control the kinetics of the robotic arms. In summary, the benefits of the robotic surgical system are as follows: Second, the surgeon also regains three extra degrees of motion that are lost with conventional laparoscopy.
Finally, the surgeon benefits from tremor-filtering and motion-scaling [ 4 ]. Typical blood loss is ml, although more is not unusual. An experienced surgeon can perform an easy prostatectomy in 2. Several studies have shown that RALRP reduces hospital stay duration, blood loss, postoperative pain, and provided a more rapid return of urinary function and higher rate of potency recovery. Additionally, control of cancer by RALRP has been found to be comparable to open surgery [ 156 ]. Regarding radical nephrectomy, robot-assisted surgery failed to show any advantage compared with the laparoscopic method.
However, in partial nephrectomy, it is thought to have advantages over the laparoscopic method [ 7 ]. Robot-assisted partial nephrectomy RAPN was associated with a significant reduction in blood loss and surgical complications, and with a shorter duration of hospitalization [ 8 ]. Moreover, it has been used to reduce the risk of renal damage by shortening the "warm ischemic time" [ 7 ].
To reduce the warm ischemic time, early unclamping, no vascular clamping, selective renal parenchymal clamping, and selective arterial clamping have been attempted; these are difficult to perform in laparoscopic surgery [ 7 ]. Compared with RALRP, a wider surgical field is required, and clashes between the robotic arms can be problematic. Thus, RAPN requires three robotic arms, and the fourth arm is generally not used to minimize external collisions [ 9 ].A Day in the Life in the Johns Hopkins Emergency Medicine Residency Program
Robot-assisted radical cystectomy RARC is still in early development, but early studies have shown a reduction in complications with equivalent oncological results [ 10 ]. Like other robotic surgeries, RARC is expected to have the potential to reduce transfusion and to provide a more rapid return of bowel function. Although the comparison of major complications differs between studies, RARC is known to be at least not worse than the open procedure.
Cost, quality of life after surgery, and long-term oncological outcomes need further investigation [ 11 ]. Gynecological surgery While the introduction of robotic surgery in the field of gynecology was later than in other fields, there has also been a substantial increase in recent years [ 1 ]. It is difficult to perform complex tasks such as lymph node removal and intracorporeal knot tying within the female pelvic cavity [ 12 ]. Laparoscopic gynecological surgeries thus have a slow learning curve, with associated complications, and demand high surgical skills, especially when the surgical anatomical field is affected by advanced pathology [ 13 ].
A robotic surgical system may offer many advantages over laparoscopic surgery with regard to these difficulties. Hysterectomy, myomectomy, tubal re-anastomosis, radical hysterectomy, lymph node dissection, and sacrocolpopexy have been performed using robotic surgical systems [ 13 ]. Some case studies and retrospective cohort reviews have shown that robot-assisted gynecological surgeries resulted in reduced blood loss and shorter hospital stays than laparoscopic or open surgeries.
However, no randomized controlled study has been performed to date. Abdominal surgery Not only hollow viscus, but also solid abdominal organs, including the liver, pancreas, and adrenal glands are included within the indications for robotic surgery.
Among the many types of abdominal surgery, fundoplication, rectal resection, and gastric bypass have been particularly preferred for robotic surgery due to the difficulties in orientation and dexterity, especially in small spaces when suturing is needed or the instruments are at unergonomic angles [ 1 ]. During robot-assisted gastrectomy, the surgical cart is placed at the head side of the patient and the anesthetic workstation and anesthesiologist are on the far left side of the patient.
With an experienced laparoscopic surgeon, it is possible to achieve comparable clinical outcomes with robot-assisted gastrectomy to a skilled laparoscopic surgeon [ 14 ]. Robot-assisted colorectal dissection has been found to be feasible and can be performed safely. Several benefits of robotic surgery can facilitate certain steps in colorectal procedures, including splenic flexure takedown, dissection of the inferior mesenteric vessels, autonomic nerve preservation, rectal mobilization, ureter and gonadal vessel identification, dissection in the narrow pelvis, and suturing [ 4 ].
However, prolonged operation durations have been reported due to maneuvers that require repositioning of the robot and its arms, such as splenic flexure mobilization and high ligation of the inferior mesenteric artery and vein, which add significant time to the surgical procedure [ 215 ].
Similar clinical results between robotic and laparoscopic colorectal surgery with regard to operation time, perioperative Hb changes, conversion rates, and oncological radicality have been reported [ 16 ]. The duration of hospital stay showed mixed results, and none of the studies so far has clearly demonstrated enhanced recovery after surgery [ 4 ]. Although the concept of robotic colorectal surgery seems appealing based on these findings, firm evidence to support widespread implementation remains scarce.
Although pancreatic and hepatic malignancies have been resected via robotic surgery and have shown safe and feasible results when compared with open surgery, existing outcome data are unclear. Robotic cardiac surgery Various cardiac surgeries, including mitral valve surgery, coronary revascularization, arrhythmia operation, left ventricular lead implantation, congenital heart surgery, and aortic valve replacement, have been performed with robot-assisted techniques.
The list continues to grow [ 3 ]. Contraindications for robotic cardiac surgery are essentially identical to those for one-lung ventilation: Aortic occlusion methods include transthoracic aortic cross-clamp and endoaortic balloon occlusion. The latter method has the risk of aortic dissection, increased morbidity, and higher cost [ 17 ].
Robotic thoracic surgery Thoracic surgical procedures include thymectomy, mediastinal mass extirpation, fundoplication, esophageal dissection, esophagectomy, and pulmonary lobectomy. Few series of isolated case reports have been published to date. Because lung isolation is mandatory for thymectomy or mediastinal tumor resection, left-sided double lumen tubes are commonly used.
These operations require training for port placement, use of proper instruments and correct robotic arms, and proper positioning; the learning curve is steep. However, robot-assisted techniques can provide an ideal surgical approach for thymectomy and the resection of other mediastinal tumors [ 18 ].
Changes in patient positioning are required during robot assisted minimally invasive thoraco-laparoscopic esophagectomy, because it consists of three different phases. First is the thoracic phase, during which the patient is positioned in the left lateral decubitus position and the robotic system sits on the dorsocranial side of the patient.
At this stage, the esophagus is resected en bloc with the surrounding lymph nodes. Second is the abdominal phase, when the patient is turned to the supine position and the stomach is mobilized.
Then, a left-sided vertical incision along the sternocleidomastoid muscle is made and the cervical phase of the esophagectomy is performed.
Finally, the resected specimen is removed through the widened left para-umbilical trocar port, and the gastric conduit is anastomosed with the cervical esophagus [ 19 ].
Trends in Fluorescence Image-guided Surgery for Gliomas
Although the conventional open transthoracic method is the first choice, this technique has its own important limitations and significant morbidity. There are great expectations for robot-assisted surgery with regard to reduced blood loss and shorter intensive care unit stays, although at this stage evidence of its superiority is lacking [ 19 ]. The performance of robot-assisted pulmonary resection is limited to a few centers.
The advantages are not yet clearly defined.
Anesthetic considerations for robotic surgery
In one center, many cases of robotic pulmonary resection were converted to open thoracotomy due to prolongation of surgery and difficulty in the dissection of tenacious calcified lymph nodes [ 18 ].
Regarding cost, although robotic thoracic surgery is more expensive than endoscopic surgery, this is expected to be compensated for by decreased hospital stay durations [ 20 ]. Increased surgical times, requirements for increased numbers of skilled personnel, costs, and outcomes should be investigated and addressed [ 21 ]. Traditional ENT operations require wider surgical exposure than the actual surgical field. However, the robotic surgical system, with a three-dimensional surgical field, can provide adequate depth using various endoscopes, cameras, and dual eyepieces.
Thus, disfiguring mandibulotomies or tracheostomies can be avoided with TORS. Additionally, the risks of chemoradiation therapy may be reduced or avoided, and recovery of postoperative quality of life, such as speaking and eating, is known to better and more rapid [ 22 ]. Possible problems related to the insertion of the robotic arm into the intraoral space include facial skin lacerations, tooth injuries, mucosal lacerations, mandible fractures, cervical spine fractures, and ocular injuries.
However, according to a study using cadavers, even under intentionally reckless conditions, the forces generated by the da Vinci Surgical System and the application of these forces to the cadaver was not found to cause severe injury. Attempts to cause tooth injury resulted in either instrument failure or tripping alarms in the robot. Furthermore, attempts to lift the cadaver's head resulted in tripping alarms in the robot and it going into a safe mode, precluding further movement of the robotic arms against resistance [ 23 ].
Trends in Fluorescence Image-guided Surgery for Gliomas
Radical tonsillectomy, tongue base resection, supraglottic laryngectomy, and phonomicrosurgery have been performed using the da Vinci system. Current indications for TORS are benign lesions of the oral cavity, larynx, and pharynx, and all T1 and T2 malignancies.
Exclusion criteria are known to be pediatric diseases, lesions invading the mandible, and dental procedures. Three arms are needed: The surgeon places a mouth gag or retractor, and the three sterilely draped robotic arms are placed into their surgical positions.
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After completion of the surgery, hemostasis is achieved with confirmation of the bloodless surgical field by a Valsalva maneuver. After final assessment of the airway, PVC tube exchange is performed when significant laryngopharyngeal edema or airway compromise is suspected [ 22 ]. Surgical time depends on the experience of surgeon. The learning curve is known to be steep, and operation experience significantly shortens the preoperative set-up time.
Robotic surgery in pediatric patients Several robot-assisted surgeries have been performed safely in pediatric patients, including simple procedures, such as pyeloplasty, PDA closure, and nephrectomy, and more complex procedures, such as Bochdalek hernia repair, Kasai portoenterostomy, and choledochal cyst excision [ 2425 ].
Because the working space is limited and the abdominal wall is thinner than in adults, proper positioning of ports is important and inadvertent visceral injury during port introduction and instrument manipulation should always be kept in mind [ 25 ].
With respect to pyeloplasty, hospital stay duration and postoperative pain were reduced compared with open surgery, but comparable to laparoscopic surgery [ 25 ]. The relatively limited selection of instruments and the size of the robotic device port sites, which should be separated by a minimal distance of 46 cm, are emphasized as limitations for use in children [ 25 ]. Anesthetic Considerations for Robotic Surgery General aspects In robot-assisted operations, spatial restrictions due to the bulky equipment are a universal issue.
After the robot has been positioned and engaged, the anesthesiologist is unable to readily access the patient. Thus, any lines, monitors, and patient-protective devices must be placed beforehand and should be secured to ensure no kinking or displacement [ 26 ]. It is impossible to allow changes in patient position or any kind of access to the patient if the robot is not detached first.
Because this time delay in patient management may result in critical complications, especially in unhealthy patients or pediatric cases [ 24 ], early detection of any problems by the anesthesiologist and training of the surgical team for fast detachment of the robotic system in emergency situations is needed.
Additionally, no type of movement is allowed during an operation. Movement of the patient while robotic instruments are docked could lead to tearing or puncturing of internal organs and vasculature, with potentially devastating consequences [ 20 ].
According to the type of operation, robotic surgery may require surgical positioning that is relatively extreme and steeper than in other conventional or laparoscopic surgery. These extreme positions increase the risk of patients sliding off the OR table, making the use of restraints inevitable.
Some of these extreme positions may even cause physiological changes. Additionally, bulky robotic arms accompanied by extreme positioning and prolonged operation durations place patients at risk of positioning injuries [ 27 ]. The anesthesiologist should give attention to the robotic arms and the patient position to prevent pressure or crush injuries.
In one center, positioning injuries were documented in 6. Longer operation durations and worse patient conditions were found to be significant risk factors [ 27 ].
- Introduction to the da Vinci System
Some procedures, such as upper abdominal, thoracic, or head and neck surgeries, require the patient's airway to be situated away from the anesthesiologist and anesthesia workstation. During these procedures, access to the airway is almost impossible [ 2 ]. Robotic surgeries regarding intrathoracic or intra-abdominal pathologies require the use of CO2 pneumoperitoneum or capnothorax.
Many complications related to these conditions have been noted during laparoscopic surgery, such as subcutaneous emphysema, pneumothorax, pneumomediastium, and, in the worst case, gas embolism. Specific Anesthetic Considerations for Each Surgery Prostatectomy Two main concepts associated with robotic prostatectomy are the steep Trendelenburg position and CO2 pneumoperitoneum. Several issues regarding them have been noticed: Retroperitoneal dissection also increases the absorption of CO2 [ 28 ].
Interpreting the effect of the steep Trendelenburg position and that of CO2 pneumoperitoneum separately is impossible: The Trendelenburg position combined with pneumoperitoneum pushes the abdominal contents cephalad; hence, FRC and lung compliance are reduced.
However, the lung has a remarkable, though incompletely understood, capacity to withstand the effects of CO2 pneumoperitoneum and the steep Trendelenburg position during general anesthesia. While individual responses vary and should be monitored, effects on dead-space ventilation and venous admixture are typically small and should not be an obstacle to providing optimal surgical exposure during robot-assisted prostatectomy or hysterectomy [ 29 ].
Also, most of the lung is below the left atrium and thus in the pulmonary zone 3 or 4 condition. Patients are prone to ventilation-perfusion mismatch, atelectasis, and pulmonary interstitial edema [ 26 ].
Pressure-controlled ventilation was found to result in greater dynamic compliance and lower peak inspiratory airway pressure, compared with volume-controlled ventilation [ 30 ].
A prolonged inspiratory duration can be an alternative to producing better gaseous exchange conditions and respiratory mechanics [ 31 ].