Robotic-assisted laparoscopic dissection of the infrarenal aorta and iliac artery: a technical description and early results

We report our initial experience with a novel robotic-assisted dissection of the infrarenal aorta and iliac arteries for the treatment of aortoiliac occlusive disease and abdominal aortoiliac aneurysm. Seven patients underwent the procedure using the da Vinci Surgical System. Transabdominal, retroperitonal dissection of the aorta and iliac arteries was completed using the robotic system; then, a mini-laparotomy and hand-sewn aorta-to-graft anastomosis were performed. There was no mortality in this series of patients. This novel technique may overcome the difficulty of aortic dissection in a purely laparoscopic aortic surgery and serves as a bridging step toward totally robotic-assisted aortic surgery.     

Undergraduate orthopedic education: Is it adequate?

Background:

Basic musculoskeletal knowledge is essential to the practice of medicine. The purpose of this study was to assess the adequacy of musculoskeletal knowledge of medical students.

Materials and Methods:

The validated basic competency examination in musculoskeletal medicine devised by Freidman and Bernstein was administered to final year medical students just prior to their final professional examination. Participants were also required to assess their confidence at making a musculoskeletal physical examination and diagnosis as well as comment on the adequacy of time in the curriculum devoted to Orthopedics.

Results:

The response rate was 83% (40/48). The average cognitive examination score was 48.3%. Two participants (5%) obtained a score of ≥ 73.1%, the recommended mean passing score. Seventeen students (42.5%) felt orthopedic clinical cases were the most difficult to perform a physical examination and diagnose. Thirteen students (32.5%) felt that the time devoted to orthopedics in the medical curriculum was inadequate.

Conclusions:

Ninety-five percent of the students failed to show basic musculoskeletal competency. A change in medical curriculum and teaching methods is required to address this problem.     

Vattikuti Institute Prostatectomy: Technical Modifications in 2009

Background

Since we last published our technique of robotic prostatectomy, we have introduced three technical refinements: superveil nerve sparing, bladder drainage with a percutaneous suprapubic tube (PST), and limited node dissection of the obturator and internal iliac nodes in preference to the external iliac nodes in selected patients.

Objective

To describe selection criteria, to explain the three techniques, and to evaluate functional and oncologic results.

Design, setting, and participants

Single-institution study of 1151 radical prostatectomies performed from 2006 to 2008 by one surgeon.

Surgical procedure

The superveil nerve-sparing technique spares nerves from the 11-o’clock position to the 1-o’clock position. The bladder is drained with a PST rather than a urethral catheter. For low- or intermediate-risk disease, limited lymphadenectomy concentrates on the internal iliac and obturator nodes, excluding the external iliac lymph nodes.

Measurements

Erectile function and patient comfort were evaluated using questionnaires administered by a third party. Lymph node yield was quantified by a qualified uropathologist.

Results and limitations

At 6–18 months after surgery, 94% of men who attempted sexual intercourse were successful with a median Sexual Health Inventory For Men (SHIM) score of 18 out of 25. PST bladder drainage resulted in less patient discomfort; visual analog scores were 2 at 2 days after prostatectomy and 0 at 6 days after prostatectomy. The modified lymphadenectomy harvested few overall nodes, but it increased the yield of positive nodes >13-fold in patients with low-risk stratification (6.7% compared with 0.5%).

Conclusion

In this single-institution, single-surgeon study, these modifications improved erectile function outcomes, decreased catheter-associated discomfort, and enhanced the detection of positive nodes.     

Early recovery of left ventricle following coronary artery bypass grafting and mitral valve repair in a case of anomalous origin of left coronary artery from pulmonary artery

Anomalous origin of Left Coronary Artery from Pulmonary Artery (ALCAPA) is a rare congenital malformation, which can result in myocardial infarction, congestive heart failure and sudden death if left untreated. Reports of myocardial revascularization and Mitral Valve (MV) repair following ALCAPA repair in infants are uncommon. We report a critically ill infant with ALCAPA needing myocardial revascularization and MV repair after which there was early recovery of Left Ventricular (LV) function. At two years follow up, the child is clinically well; the postoperative cardiac catheterization shows good flow in the Left Internal Mammary Artery (LIMA) and Left Anterior Descending artery (LAD), good LV function and competent mitral valve.     

Mounier-Kuhn syndrome: report of 8 cases of tracheobronchomegaly with associated complications

Mounier-Kuhn syndrome is a rare congenital abnormality characterized by atrophy or absence of elastic fibers and thinning of smooth muscle layer in the trachea and main bronchi. These airways are thus flaccid and markedly dilated on inspiration and collapsed on expiration. First- to fourth-order bronchi are affected. There is an increase in dead space, tidal volume and diminished clearing of secretions. The usual presentation is recurrent respiratory tract infections with a broad spectrum of functional impairment ranging from minimal disease with preservation of lung function to severe disease in the form of bronchiectasis, emphysema and pulmonary fibrosis, ultimately culminating in respiratory failure and death. A congenital connective tissue weakness, in combination with inhalation of irritants like cigarette smoke and air pollution, are raised as possible factors in the development of this syndrome. Eight cases of tracheobronchomegaly with its associated complications are reported. Computed tomography scan of the chest was used for the diagnosis of tracheobronchomegaly. Treatment is mainly supportive with chest physiotherapy and antibiotics; however, there are a few reported cases where insertion of a tracheal stent resulted in some success.     

Potential heating caused by intraparenchymal intracranial pressure transducers in a 3-tesla magnetic resonance imaging system using a body radiofrequency resonator: assessment of the Codman MicroSensor Transducer

Magnetic resonance imaging and spectroscopy may provide important clinical information in the acute stages of brain injury. For this to occur it must be ensured that intracranial pressure (ICP) monitoring devices are safe to bring into the MR imaging suite. The authors tested a Codman MicroSensor ICP Transducer (Codman & Shurtleff, Inc.) within a 3-T MR imaging system using the transmit body coil and receive-only coils and the transmit-and-receive head coil. Extreme and rapid heating of 64 degrees C was noted with the transducer wire in certain positions when using the transmit body coil and receive-only head coil. This is consistent with the phenomenon of resonance, and the probe was shown to have a distinct resonant response when coupled to HP 4195A Network Analyzer (Hewlett Packard). Coiling some of the transducer wire outside of the receive-only head coil reduced the generated current and so stopped the thermogenesis. This may be due to the introduction of a radiofrequency choke. The ICP transducer performed within clinically acceptable limits in both the static magnetic field and during imaging with high radiofrequency power when the excess wire was in this configuration. No heating was observed when a transmit-and-receive head coil was used. This study has shown when using a high-field magnet, the Codman ICP probe is MR conditional. That is, in the authors' system, it can be safely used with the transmit-and-receive head coil, but when using the transmit body coil the transducer wire must be coiled into concentric loops outside of the receive-only head coil.     

Residency training in pyloromyotomy: a survey of 331 pediatric surgeons

Purpose

Both pediatric and general surgeons perform pyloromyotomy. Laparoscopic pyloromyotomy (LAP), and changes in referral patterns have affected the training of pediatric surgery fellows and general surgery residents. We surveyed pediatric surgeons regarding these issues.

Methods

We mailed an Institutional Review Board of New Hanover Regional Medical Center-approved survey to 701 members of the American Pediatric Surgical Association within the United States to determine each surgeon's preferred technique for pyloromyotomy (LAP vs Ramstedt or transumbilical procedures [OPEN]), practice setting, involvement with trainees, and opinions regarding pyloromyotomy. Significance was determined using χ² analyses.

Results

A total of 331 (48%) surgeons responded: 197 (60%) performed most or all OPEN, and 85 (26%), most or all LAP. Laparoscopic pyloromyotomy was more likely in academic practices and children's hospitals (P < .05). Residents under surgeons performing LAP were less likely to participate (58% vs 91%; P < .05) or gain competence (22% vs 42%; P < .5). Only 34% of surgeons performing LAP believed that general surgery residents should learn pyloromyotomy, whereas 67% of surgeons performing OPEN believed that residents should learn the procedure (P < .05). A total of 307 (93%) surgeons believed at least 4 OPEN were necessary to become competent, but 126 (44%) reported that their residents performed fewer than 4. Only 104 (31%) surgeons believed that their residents were competent in pyloromyotomy. There were 303 (92%) surgeons who believed that pyloromyotomy should be performed only by pediatric surgeons when possible.

Conclusions

Most general surgical residents are not learning pyloromyotomy, in part because of the adoption of laparoscopic technique, limited operative experience, and the opinion of most pediatric surgeons that the procedure should be performed only by pediatric surgeons.     

The role of (99m)technetium-labelled hepato imino diacetic acid (HIDA) scan in the management of biliary pain

Objective. To assess the outcome of laparoscopic cholecystectomy on the basis of an abnormal provocative ^99mtechnetium-labelled hepato imino diacetic acid (HIDA) scan for patients with typical biliary pain and normal trans-abdominal ultrasound (TUS) scan. Patients and methods. Prospective data were collected for 1201 consecutive patients with typical biliary symptoms. Patients who were found to have a normal TUS and upper GI endoscopy subsequently underwent cholescintigraphy (HIDA scan). Patients with an abnormal HIDA scan, i.e.<40% ejection fraction with Sincalide® (cholecystokinin octapeptide) – were offered cholecystectomy. Symptoms and histology were reviewed postoperatively. Results. In all, 48/1201 (4%) patients with typical biliary symptoms had a normal ultrasound and endoscopy; 35/48 patients had an abnormal provocative HIDA scan and all underwent laparoscopic cholecystectomy. Histology in all cases revealed chronic cholecystitis and 18 patients had sludge or microlithiasis within the gallbladder. At 6-week follow-up, 31 of the 35 patients were completely asymptomatic or improved. Furthermore, 79% of patients remained symptom-free or improved at a median follow-up of 28.5 months (range 4–70). Conclusions. HIDA scan is a useful clinical tool as an adjunct to the diagnosis and management of patients who present with typical biliary pain and a normal TUS scan.