Robotic-Assisted Surgery

[Rabbit Hole]

Robotic Surgery: A Current Perspective

I think the future of robotic surgery will be particularly beneficial for NASA and the US Army (sounds really sci-fi). The article even mentions their early involvement in the development of telesurgery. Although these advancements are really fascinating, I personally think it's really important to be familiar with traditional "open" techniques before moving on to "the future".

From the article:

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[JackADeli]

...I think the future of robotic surgery will be particularly beneficial for...

Yes, I think robotics is primetime. It will continue to be refined and improved. I hear a single port.. spider arm type model is next in ~3yrs. Also, a plan to ceiling mount the system on rails so to eliminate any issues with operating bed movement.

As was noted earlier, what needs to be done for minimally invasive surgery (not just robotics) is remove some of the unusual un-reimbursed facets that discourage it. ideally, make some of these comparable approaches paid by patients a little more a la carte. Just as with name brand meds vs generics there is a different co-pay.

 

[SocialistMD]

I hear a single port.. spider arm type model is next in ~3yrs.

It already exists and is very creepy to watch.

 

[JackADeli]

It already exists and is very creepy to watch.

I have seen the animation demonstration. I have also heard a few universities are testing it.... but I don't think it is for sale yet. Intuitive just launched their ~3rd gen model the "Si" about 6-12 months ago.

 

[proman]

What do you guys think of robotic or hybrid lap/robotic Whipples? They've done very few in Europe, Cleveland Clinic did one in March, we're looking at doing it soon. I see major benefits for a patient avoiding the morbidity of the open procedure, if outcomes are equivalent or better.

 

[JackADeli]

What do you guys think of robotic or hybrid lap/robotic Whipples? They've done very few in Europe, Cleveland Clinic did one in March, we're looking at doing it soon. I see major benefits for a patient avoiding the morbidity of the open procedure, if outcomes are equivalent or better.

One of the big disadvantages to robotic & MIS-lap surgery is loss touch. You can not touch/palpate the liver. You can not touch/palpate numerous nodal areas. It may be more difficult to do intra-op, intra-abdominal hepatic ultrasound. So, with a disease like pancrease cancer, I have concerns you may proceed and complete whipple in the face of disease you might have otherwise identified during an open procedure. A whipple's morbidity is not primarily the incision.... So, as to MIS-lap or robotic or both whipples, I don't know. How long did Clevelands case take? was patient intubated post-op?

 

[JackADeli]

...I see major benefits for a patient avoiding the morbidity of the open procedure, if outcomes are equivalent or better.

I am not sure we will see "major benefits". Plenty of hard, large masses that are difficult to resect open. Patient selection will stear towards small, easily resected pancreatic heads. The outcomes on whipples for pancreatic cancer is crappy already. The "n" would have to be very large to even tease out equivalence and/or better.

 

[Rabbit Hole]

It already exists and is very creepy to watch.

Link? I love watching creepy stuff. Sorta.

 

[JackADeli]

Link? I love watching creepy stuff. Sorta.

This thread discusses some of the same things too:
http://forums.studentdoctor.net/showthread.php?t=720684
I think in the following video cut at the end there is an animation of the single port/spider type system:
http://www.ted.com/talks/lang/eng/catherine_mohr_surgery_s_past_present_and_robotic_future.html

I think the spider stuff is about 12.5 minutes into the vid.

 

[Rabbit Hole]

This thread discusses some of the same things too:
http://forums.studentdoctor.net/showthread.php?t=720684
I think in the following video cut at the end there is an animation of the single port/spider type system:
http://www.ted.com/talks/lang/eng/catherine_mohr_surgery_s_past_present_and_robotic_future.html

I think the spider stuff is about 12.5 minutes into the vid.

lol... I posted that. I didn't realize the spider robot thing was in there. Thanks.

 

[JackADeli]

lol... I posted that. I didn't realize the spider robot thing was in there. Thanks.

Yeh, you got to put up with DrMohr for 12+ minutes to get to the prototype images and such.

 

[proman]

I am not sure we will see "major benefits". Plenty of hard, large masses that are difficult to resect open. Patient selection will stear towards small, easily resected pancreatic heads. The outcomes on whipples for pancreatic cancer is crappy already. The "n" would have to be very large to even tease out equivalence and/or better.

Interesting to hear what you lose with a lap procedure. I don't know what percentage of our Whipples are aborted (I'd guess not many). Those that are tend to be classified non-resectable based on vascular involvement. Noninferiority vs open should be fairly easy to achieve. I only have experience with Whipples from an intraoperative and immediate postoperative (ICU) perspective. As for the morbidity, avoiding a large open procedure could have many benefits:

Less bowel manipulation/exposure to the air would likely decrease fluid requirements. Less fluid, better tissue oxygenation, maybe better outcomes? Lower postoperative pain decreases need for postop opioids. Better bowel function, earlier ambulation, less DVT/PE.

Our pathway Whipples leave the ICU on POD1, and the hospital by POD5. Avoiding a lot of the postop complications could add to the quality of life for patients with a dismal disease. I don't know what Cleveland had to do postop.

 

[SLUser11]

Interesting to hear what you lose with a lap procedure. I don't know what percentage of our Whipples are aborted (I'd guess not many). Those that are tend to be classified non-resectable based on vascular involvement. Noninferiority vs open should be fairly easy to achieve. I only have experience with Whipples from an intraoperative and immediate postoperative (ICU) perspective. As for the morbidity, avoiding a large open procedure could have many benefits:

Less bowel manipulation/exposure to the air would likely decrease fluid requirements. Less fluid, better tissue oxygenation, maybe better outcomes? Lower postoperative pain decreases need for postop opioids. Better bowel function, earlier ambulation, less DVT/PE.

Our pathway Whipples leave the ICU on POD1, and the hospital by POD5. Avoiding a lot of the postop complications could add to the quality of life for patients with a dismal disease. I don't know what Cleveland had to do postop.

I think that since the whipple is such an inherently morbid procedure that proving a benefit from laparoscopy would be very difficult and take a really long time to accumulate the numbers.

As far as non-inferiority, the number of surgeons that can perform a laparoscopic whipple, let alone a robotic whipple, is so small that I think it will be a pretty long time before this study happens. Look at the average operative time for some of those lap whipple studies.....

Still, I agree with you in theory. Once we're able to do all surgical procedures with a robot or a single incision, and our outcomes match the open equivalent, I'm sure the fluid requirements and postop pain issues will decrease.

 

[JackADeli]

Interesting to hear what you lose with a lap procedure. I don't know what percentage of our Whipples are aborted (I'd guess not many). Those that are tend to be classified non-resectable based on vascular involvement...

Probably a vascular issue. You may have some difficulties making that determination MIS Lap or robotic. you also may determine something unresectable MIS Lap or robotic that you may have actually proceded during open.

...A whipple's morbidity is not primarily the incision...

I am not sure we will see "major benefits"...The outcomes on whipples for pancreatic cancer is crappy already. The "n" would have to be very large to even tease out equivalence and/or better.

... Noninferiority vs open should be fairly easy to achieve...

I think that since the whipple is such an inherently morbid procedure that proving a benefit from laparoscopy would be very difficult and take a really long time to accumulate the numbers...

"...fairly easy to achieve..." No, not really. To achieve sufficient "n" would be difficult. You would have to have sufficient volume of very early pancrease head tumors to have multivariable comparisons between the open and MIS Lap or robotic cases. You would also need the patients to be willing to be randomized to the open option. It will not be "fairly easy to achieve". It never is when dealing with the ~elite pathologies.

...Less bowel manipulation/exposure to the air would likely decrease fluid requirements. Less fluid, better tissue oxygenation, maybe better outcomes? Lower postoperative pain decreases need for postop opioids. Better bowel function, earlier ambulation, less DVT/PE...

Maybe the lower pain component. The others you list are actually not likely.

Closed abdominal surgery leaves less room for the bowel. It has to be manipulated and held back with ~pincing graspers. It has not appeared to be "less" manipulation when I have watched lap bariatrics. The other issue is that in a cancer operation you are supposed to manipulate the bowel because you are doing a cancer exploration too.

Hopefully less fluid may be accurate as well. Although, there is some concern about what fluid amounts are lost during gas insufflation and smoke evacuation. A good open whipple surgeon and anesthesia team should get the case done fast with a good fluid balance. thus your protocol patients home by POD5.

Not likely to have better tissue oxygenation. I'm not sure where you arrived at that one. Positive pressure insufflation is known to have an impact on hemodynamics, abdominal perfusion, and cardiac venous return. Multiply that by longer operation for MIS lap or robotic procedure.

Not likely to have less DVTs. Again, I'm not sure how you arrived at that one. Greatest risk for DVT is at induction because of lower BP with decreased venous return resulting in venous stasis in legs and IVC. This is only exacerbated by intra-abdominal positive pressure insufflation and prolong operative case.

...the number of surgeons that can perform a laparoscopic whipple, let alone a robotic whipple, is so small that I think it will be a pretty long time before this study happens. Look at the average operative time for some of those lap whipple studies...

Actually... people keep using lap as a marker of complexity in comparison to robotic. I believe that to be deceptive. Folks can actually pick up robotics quicker then MIS lap. So, robotics may actually speed up the time frame of getting to MIS procedures from some of these very complex procedures.

...Still, I agree with you in theory. Once we're able to do all surgical procedures with a robot or a single incision, and our outcomes match the open equivalent, ...fluid requirements and postop pain issues will decrease.

Probably.

 

[BlondeDocteur]

I've found this thread very interesting, though don't have anything substantive to contribute. Instead I was wondering about the career option of one of the Columbia graduating chiefs, who'll spend the upcoming year doing a robotic surgery fellowship in Seoul (she's Korean-American and speaks fluent Korean). She fully plans on returning to the US to practice.

Knowing that at Columbia the Da Vinci is only used in the deep pelvis (urology and, on rare occasion, gyn-onc), and having learned from you fine folks how expensive the robots are and how general surgeons are not trained on them, how can she convince US hospitals to use her new skills? Realistically, what do you speculate she will be able to do when she gets back?

 

[JackADeli]

...I was wondering about the career option of one of the Columbia graduating chiefs, who'll spend the upcoming year doing a robotic surgery fellowship in Seoul... She fully plans on returning to the US to practice.

Knowing that at Columbia the Da Vinci is only used in the deep pelvis...

Not easily answered. She is apparently a USA grad and will be ABS certified? Yes, plenty of community hospitals look for and then market robotic trained or other special talent trained physicians. I am just not sure how well they will market Korean trained..... I just don't know if anybody can say if the overseas, Asian aspect will negatively impact the marketing. I suspect, hospitals will use it against her in contract negotiating but then turn around and market as "Columbia trained robotic surgeon..."

 

[BlondeDocteur]

US-trained, all the way. Moved here as a kid, I think. Just happens to speak Korean so this option is open to her.

 

[JackADeli]

US-trained, all the way. Moved here as a kid, I think. Just happens to speak Korean so this option is open to her.

Keep in mind... many state licensing boards don't even list your place of residency just your medical school. The same for some on-line doctor rating websites.... Guy may have trained in a closet but his profile lists Harvard cause that is where he went to medical school. In general though, there are numerous general surgery positions daily.

Good luck to her though.... not sure how much fun it will be!

 

[Winged Scapula]

I've found this thread very interesting, though don't have anything substantive to contribute. Instead I was wondering about the career option of one of the Columbia graduating chiefs, who'll spend the upcoming year doing a robotic surgery fellowship in Seoul (she's Korean-American and speaks fluent Korean). She fully plans on returning to the US to practice.

Knowing that at Columbia the Da Vinci is only used in the deep pelvis (urology and, on rare occasion, gyn-onc), and having learned from you fine folks how expensive the robots are and how general surgeons are not trained on them, how can she convince US hospitals to use her new skills? Realistically, what do you speculate she will be able to do when she gets back?

I suspect they'll have to create a new credentialing process for her, as the use of the Da Vinci in the credentialing process, requires documentation of a certain number of index cases. At my hospitals, all those cases are Uro or Gyn cases - probably because they've never heard of someone doing something else with the robot. Therefore, it will be up to her to present data on the types and number of cases she has done and to convince them that she is adequately trained to do operation x with the robot. The list of privileges will have to be changed which requires the Dept of Surgery to agree.

It certainly could be a great marketing tool for the hospital where she gets privileges at but I would expect a certain level of suspicion until she proves herself.

 

[JackADeli]

...it will be up to her to present data on the types and number of cases she has done and to convince them that she is adequately trained to do operation x with the robot...

...I would expect a certain level of suspicion until she proves herself.

I think this is important for general surgery residents that are longitudinally being trained in robotics too. You need to keep a close tally on cases that you have significant "drive time".

Currently, quite a few "super fellowships" in which folks take a year of supposed drive time. Current practicing attendings often have a on-site familiarization process, off-site pig or cadaver lab, off-site case observation and then on-site proctor cases (i.e. someone ?expert watches the surgeon now do their first case/s). This clinical pathway is what got the scathing Wall Street Journal criticism the other week. But, it is not unlike the clinical pathway used during the start of laparoscopy. thus, as in lap choles in the beginning, robotics has had unfortunate adverse events.

Keep in mind the some (?ethics) current "experts" with numerous case experience are sometimes in the background trying to block folks in-flux via clinical pathway. They are saying things about learning curve and number of cases required to be competant.... some go from 25 cases to as high as 200cases required!!!

This has resulted in some hospitals being leary to "clinical pathway" trained surgeons credentialing and more likely to require significant "fellowship" time from 3 months to a year. You might avoid that if your residency has integral and longitudinal training that does have you actually doing significant drive time.

They may question her choice to go overseas and the caliber of training she got at a facility/program outside US/Joint Commision jurisdiction. But, again, I don't know nor do I think anyone else knows.

 

[proman]

Not likely to have better tissue oxygenation. I'm not sure where you arrived at that one. Positive pressure insufflation is known to have an impact on hemodynamics, abdominal perfusion, and cardiac venous return. Multiply that by longer operation for MIS lap or robotic procedure.

The harm of excess fluid administration is recognized but not really well acknowledged. We're classically taught to add 2.5cc/kg/hr per exposed quadrant to the maintenance rate for open abdominal operations (the so-called insensible losses). This leads to much higher fluid administration than hemodynamics and renal perfusion would require. Peripheral edema is commonly seen as a consequence. What's not seen if the decrease in microvascular circulation and perfusion leading to poor tissue oxygenation, impaired wound healing and increased infection. There's also damage to the endothelial glycocalyx. Here's a nice review article on one approach to rational perioperative fluid management.

Not likely to have less DVTs. Again, I'm not sure how you arrived at that one. Greatest risk for DVT is at induction because of lower BP with decreased venous return resulting in venous stasis in legs and IVC. This is only exacerbated by intra-abdominal positive pressure insufflation and prolong operative case.

Do you have something I can read about this? This is the first I've heard of induction being the greatest risk. Obviously patients get hypercoagulable from an operation and stasis increases the risk of DVT. I was thinking that patients undergoing an lap or robotic procedure would ambulate earlier than those having undergone a laparotomy. Or, maybe it's a wash from the vascular effects of a pneumoperitoneum. I don't know if there's evidence that supports this.

We do about 300 Whipples a year and most are not highly invasive or highly vascular resections. Robotic Whipples will be an interesting development to watch.

 

[Rabbit Hole]

I've found this thread very interesting, though don't have anything substantive to contribute. Instead I was wondering about the career option of one of the Columbia graduating chiefs, who'll spend the upcoming year doing a robotic surgery fellowship in Seoul (she's Korean-American and speaks fluent Korean). She fully plans on returning to the US to practice.

Knowing that at Columbia the Da Vinci is only used in the deep pelvis (urology and, on rare occasion, gyn-onc), and having learned from you fine folks how expensive the robots are and how general surgeons are not trained on them, how can she convince US hospitals to use her new skills? Realistically, what do you speculate she will be able to do when she gets back?

She would only be able to do procedures that have been approved by the FDA using this system. As far as convincing US hospitals of her skills.. that's all in the numbers I suppose (and how she markets herself).

I did a quick search and I found some information on the company website. I don't know how reliable this is so she should definitely have look-see on the actual FDA website.

da Vinci Surgical System FDA Clearance
The U.S. Food and Drug Administration (FDA) has cleared the da Vinci® Surgical System for use in urological surgical procedures, general laparoscopic surgical procedures, gynecologic laparoscopic surgical procedures, transoral otolaryngology surgical procedures restricted to benign and malignant tumors classified as T1 and T2, general thoracoscopic surgical procedures, and thoracoscopically assisted cardiotomy procedures. The system can also be employed with adjunctive mediastinotomy to perform coronary anastomosis during cardiac revascularization. The system is indicated for adult and pediatric use (except for transoral otolaryngology surgical procedures). It is intended for us by trained physicians in an operating room environment in accordance with representative, specific procedures set forth in the Professional Instructions for Use.
Representative Uses: The da Vinci System has been successfully used in the following procedures, among others:

• Radical prostatectomy, pyeloplasty, cystectomy, nephrectomy, ureteral reimplantation
• Hysterectomy, myomectomy and sacrocolpopexy
• Cholecystectomy, Nissen fundoplication, Heller myotomy, gastric bypass, donor nephrectomy, adrenalectomy, splenectomy and bowel resection
• Internal mammary artery mobilization and cardiac tissue ablation
• Mitral valve repair, endoscopic atrial septal defect closure
• Mammary to left anterior descending coronary artery anastomosis for cardiac revascularization with adjunctive mediastinotomy
• Oropharyngeal, laryngeal and hypopharyngeal resections; floor of mouth and oral cavity resections

 

[JackADeli]

The harm of excess fluid administration is recognized but not really well acknowledged. We're classically taught to add 2.5cc/kg/hr per exposed quadrant to the maintenance rate for open abdominal operations (the so-called insensible losses). This leads to much higher fluid administration than hemodynamics and renal perfusion would require...

I am not saying fluid loss and such does not occur or is not taught and/or recognized. I am saying that if you go by cookbook you will have either overload or under resuscitation. A good surgical and anesthesia team will understand these parameters are just general guidelines and adjust accordingly. Prolonged procedures with warm insufflation and smoke evacuation will have substantial fluid loss. Prolonged intra-abdominal insufflation will decrease tissue perfusion and oxygenation.

RE: DVT
...This is the first I've heard of induction being the greatest risk. Obviously patients get hypercoagulable from an operation and stasis increases the risk of DVT. I was thinking that patients undergoing an lap or robotic procedure would ambulate earlier than those having undergone a laparotomy. Or, maybe it's a wash from the vascular effects of a pneumoperitoneum...

I will let you do the leg work on the research in these regards. A few points to keep in mind:
1. Why do you think it is regarded as standard of care to have leg squeezers on prior to induction?
2. Why do you think patients suffer the pain of sub-Q heparin injection prior to induction?
3. Why do you think so many surgeons in their operative dictation note that squeezers were applied and sub-Q heparin was administered prior to induction?
Yes, early ambulation is important. But, post-op patients, while maybe not ambulating can move in bed, flex their legs, etc... that can not be done while under general. The issues and risk of pneumoperitoneum, HD impacts, etc... are recognized and published. In fact, they used to show up on the basic knowledge for the written/computer exam of the FLS certification.

PS: check some of the anesthesia literature on induction and hemodynamic impact. Also watch the patients vitals sometime at induction.... and watch what anesthesia does with the syringe in their hand

http://lmgtfy.com/?q=anesthesia+induction+DVT
http://findarticles.com/p/articles/mi_m0FSL/is_4_79/ai_n6074246/

...Three primary factors affect coagulation in a blood vessel, which can lead to venous thrombosis. In 1846, these three conditions were identified as endothelial injury, stasis, or hypercoagulability. (1-3) Patients undergoing a surgical procedure may be exposed to all three of these conditions. Immobility is a primary factor in venous stasis, and patients are immobile during surgical procedures. Venous stasis during surgical procedures is caused by several mechanisms.
* Decreased actual linear velocity of blood due to the reclining position of the patient leads to venous congestion in the lower extremities, which consequently diminishes venous return.
* General anesthesia causes peripheral vessels to dilate by depressing the sympathetic nervous system. The resulting dilation can cause endothelial damage resulting in microtears in the vascular lining, which provide a site for thrombus formation...

 

[Winged Scapula]

I
1. Why do you think it is regarded as standard of care to have leg squeezers on prior to induction?
3. Why do you think so many surgeons in their operative dictation note that squeezers were applied and sub-Q heparin was administered prior to induction?

I have to wonder if, however, not every surgeon does this as I am asked before nearly every case if I want SCDs.

I am left thinking (after responding, "yes, every case, all the time") are there some surgeons who don't use them (lower extremity cases notwithstanding)?

 

[JackADeli]

I have to wonder if, however, not every surgeon does this as I am asked before nearly every case if I want SCDs.

I am left thinking (after responding, "yes, every case, all the time") are there some surgeons who don't use them (lower extremity cases notwithstanding)?

Plenty of hospitals have it as standard practice on routine check list. Some don't and OR staff go back and forth. I have unfortunately seen too many times when patient induced, 5 minutes later SCDs applied, then just prior to prep SQ heparin given. But, you would never know it by the op note. You should tell your OR staff to put it on "your card" to do it every time unless a known contraindication.

I might be mistaken, but I also think it is one of those quality of care markers for hospital scoring....

 

[Winged Scapula]

Plenty of hospitals have it as standard practice on routine check list. Some don't and OR staff go back and forth. I have unfortunately seen too many times when patient induced, 5 minutes later SCDs applied, then just prior to prep SQ heparin given. But, you would never know it by the op note. You should tell your OR staff to put it on "your card" to do it every time unless a known contraindication.

I might be mistaken, but I also think it is one of those quality of care markers for hospital scoring....

The cards. What an F'ing joke. Despite having completed the cards myself, if I had a mere dime for every time I was told "its on your card" or "its not on your card" or "we couldn't find your card so we substituted Dr. X's card for you" I'd be a gazillionaire.

One hospital had some sort of "ban" on updating the computerized cards. So every f'ing week, I'd have the same conversation because whatever baloney cards they had in their system couldn't be changed to reflect what I really use.

And that doesn't even begin to speak to the idea that perhaps the circulators should actually read the cards.

In case the above sounds like I've had some bad experiences lately, I have. Met with the OR supervisors at the hospital I operate at the most because of issues with mislabeling of pathology reports. I demanded that I have the same OR staff and examine the path request slips before they leave the room. So what happens? I have a specimen to be sent for imaging - PROCEDURE THAT IS ON MY CARDS (to verify obtaining the marking clip, entire localizing wire, nodule of interest, radiographic margins, etc)...about 25 minutes after I pass it off the circulator shows me the path slip and I'm reading it and suddenly it dawns on me (as patient is closed, dressings on, I'm just waiting for the image to come up on PACS) that the F'ing specimen is STILL IN THE ROOM. Gas has a fit, the scrub has a fit and I...I am good. I don't even utter one curse word.

So cards. Yeah. Bleh.

Sorry about the hijack...

 

[JackADeli]

...The cards. What an F'ing joke. Despite having completed the cards myself ...told "its on your card" or "its not on your card" or "we couldn't find your card so we substituted Dr. X's card for you" ...

...- PROCEDURE THAT IS ON MY CARDS ...about 25 minutes after I pass it off ...it dawns on me (as patient is closed, dressings on, I'm just waiting for the image to come up on PACS) that the F'ing specimen is STILL IN THE ROOM...

...So cards. Yeah. Bleh...

HeHe.... I was wondering if your experience was the same as mine

 

[proman]

http://lmgtfy.com/?q=anesthesia+induction+DVT
http://findarticles.com/p/articles/mi_m0FSL/is_4_79/ai_n6074246/
Originally Posted by WebLink
...Three primary factors affect coagulation in a blood vessel, which can lead to venous thrombosis. In 1846, these three conditions were identified as endothelial injury, stasis, or hypercoagulability. (1-3) Patients undergoing a surgical procedure may be exposed to all three of these conditions. Immobility is a primary factor in venous stasis, and patients are immobile during surgical procedures. Venous stasis during surgical procedures is caused by several mechanisms.
* Decreased actual linear velocity of blood due to the reclining position of the patient leads to venous congestion in the lower extremities, which consequently diminishes venous return.
* General anesthesia causes peripheral vessels to dilate by depressing the sympathetic nervous system. The resulting dilation can cause endothelial damage resulting in microtears in the vascular lining, which provide a site for thrombus formation...

Sorry, I'm not up to date on the April 2004 issue of the Association of PeriOperative Nurses Journal (which is what you quoted).

A better source for you to reference would be Prevention of Venous Thromboembolism The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy which has this to recommend:
Recommendation: Commencement of Prophylaxis
3.5.1. For major orthopedic surgical procedures, we recommend that a decision about the timing of the initiation of pharmacologic prophylaxis be based on the efficacy-to-bleeding tradeoffs for that particular agent (Grade 1A). For LMWH, there are only small differences between starting preoperatively or postopera- tively, and both options are acceptable (Grade 1A).

If, however, you find the reference that states that induction of anesthesia is "the greatest risk", please PM me. Otherwise the thread should go back to the robots.

 

[SLUser11]

Sorry, I'm not up to date on the April 2004 issue of the Association of PeriOperative Nurses Journal (which is what you quoted).

A better source for you to reference would be Prevention of Venous Thromboembolism The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy which has this to recommend:
Recommendation: Commencement of Prophylaxis
3.5.1. For major orthopedic surgical procedures, we recommend that a decision about the timing of the initiation of pharmacologic prophylaxis be based on the efficacy-to-bleeding tradeoffs for that particular agent (Grade 1A). For LMWH, there are only small differences between starting preoperatively or postopera- tively, and both options are acceptable (Grade 1A).

If, however, you find the reference that states that induction of anesthesia is "the greatest risk", please PM me. Otherwise the thread should go back to the robots.

I don't want you two to get too antagonistic with eachother since you are both excellent SDN contributors. You have to understand that things that seem simple and fundamental to us in surgery is different to anesthesia.

There are plenty of DVTs that develop on the table, as opposed to the postoperative recovery period. I'll do a lit search, but a lot of this is common sense. I think that our desire to prevent DVT will always be a little more vigilant than our anesthesia colleagues since we have to deal with the patient for a longer period of time....go back to our recent discussion on epidurals and foleys in the anesthesia forums.

I think JAD's point is that there are lots of hypothetical benefits to these minimally invasive procedures, but currently the skill set and evidence are not there, and the ability to do a laparoscopic whipple is currently more "gee whiz" than practice-changing technology.

As for excess fluid administration, nobody has more first-hand knowledge of that than the general surgeon. We just don't have a good solution, as the surgical patient is often intra-vascularly depleted despite their significant fluid overload. I think that anesthesia and surgery are fundamentally different fields with different goals, so our approach to this problem solving is fundamentally different.

 

[JackADeli]

Sorry, I'm not up to date on the April 2004 issue of the Association of PeriOperative Nurses Journal (which is what you quoted).

....3.5.1. For major orthopedic surgical procedures, we recommend that a decision about the timing of the initiation of pharmacologic prophylaxis be based on the efficacy-to-bleeding tradeoffs for that particular agent (Grade 1A). For LMWH, there are only small differences between starting preoperatively or postopera- tively, and both options are acceptable (Grade 1A).

If, however, you find the reference that states that induction of anesthesia is "the greatest risk", please PM me. Otherwise the thread should go back to the robots.

Wow. The obnoxious gothcha approach of your post is silly. I will refer you to SL for any further understanding.

...There are plenty of DVTs that develop on the table, as opposed to the postoperative recovery period. I'll do a lit search, but a lot of this is common sense..

...As for excess fluid administration, nobody has more first-hand knowledge of that than the general surgeon. We just don't have a good solution, as the surgical patient is often intra-vascularly depleted despite their significant fluid overload...

PMan, I aplaud your limited review of some literature. I encourage further review. I referred you to some of the anesthesia literature as a start not as the end all be all. However, to compare orthopedic surgery and their requirements to major abdominal surgery is fairly artificial. All general surgeons that have managed the ortho patients for ortho know of the remarkable blood loss associated with their procedures and high volumes of fluid and blood products required intra-op and post-op.... (though it oftened seemed like very little given intra-op and most waited for general surgery to order post-op).

Again, I will simply go back to discussing robots and leave you to gain more knowledge of the literature and surgery in general. My final comment will be, however, I do not have any evidence or reason to believe robotic whipples will decrease DVTs and/or increase tissue perfusion.

 

[filter07]

Sorry to raise this thread from the dead...

Are robotic CABG and hybrid PCI the exclusive realm of super-fellowships? I am curious whether there are fellowship programs in the US that will train robotic LIMA-LAD skills during the 2-year fellowship. Is UCSD one of them?

 

[JayDoc06]

To the premed, med student, young resident, chief resident:

Learn robotics if you can (and all new treatment modalities for that matter). Who knows what the data will show in years to come. If you don't learn it in training or early in your career you won't (exceptions exist of course.) Nobody here can predict the future. You don't want to be the one without a chair when the music stops.

Just like all technology, prices come down as technology improves. Most hospitals have already invested in the systems. Granted upkeep is also an issue. I think some smaller hospitals who shouldn't have bought them in the first place might abandon robotics.

There are many ridiculous applications for robotic technology- Gallbladders? really? There are clear advantages in the pelvis. LAR/TME is easier than open and laparoscopic in my opinion and should therefore be learned by colorectal surgeons rather than discounted as an unnecessary skill.

I'm not sure if I had a coherent point to make like sometimes and I honestly only browsed through most of the posts. Just gave a few thoughts.

However, the emergency undocking is an issue. In my opinion, it shouldn't have gotten to that point. It is no different than the decision to open from laparoscopy emergently. Removing robotic trocars emergently takes zero time. The only real difference is the time needed for the surgeon to scrub in- 20 seconds with waterless scrub??? Just like laparoscopy the real problem is when surgeons fail to recognize a problem and prolong the decision minutes or even hours.

 

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If it can be used quickly and with decreased morbidity to the patient, I'd love to use the robot. I love surgery, and I love video games. Hand me the daVinci 360 controller please.