Avoiding hemodialysis access-induced distal ischemia.

Timely creation and maintenance of a safe and reliable vascular access is essential for hemodialysis patients with end-stage renal disease. Hemodialysis access-induced distal ischemia (HAIDI) is a recognized complication of arteriovenous fistulas and grafts that may result in serious or even devastating consequences. Avoiding such complications is clearly preferred over treatment of HAIDI once established. Proper recognition of patients at increased risk of HAIDI includes careful pre-operative evaluation of the patient's medical and surgical history along with physical examination and imaging to determine a plan for creating a functional permanent access while minimizing the risk of distal ischemia. Our aim is to review identifying characteristics of individuals at risk of HAIDI and provide recommendations regarding pre-operative assessment. Vascular access options and techniques are suggested for establishing a functional vascular access without distal ischemia for such patients.

Robotic Transhiatal Esophagectomy in a Community Hospital: Evolution of Technique.

Esophageal cancer is an uncommon but highly lethal disease. Surgical resection is the gold standard of treatment for early-stage disease. Traditional surgical approach entailed significant convalescence, hospital stay, and morbidity and mortality. Transhiatal esophagectomy (THE) involves blind dissection of the esophagus with minimal mediastinal lymphadenectomy. Integration of robotic surgery is an alternate platform for minimally invasive approach while maintaining safety and following oncologic principles. We review our technique for minimally invasive THE using robotic technology, demonstrating the safety and efficacy of robotic technology surgery. We present a retrospective review of a single surgeon's data of patients treated with robotic-assisted THE, with a chart review to evaluate pathology, adequacy of surgical resection, nodal harvest, and perioperative course. Robotic THE (rTHE) shows promise as a valid option for esophageal resection, including premalignant and advanced stages of cancer. Adequate transhiatal mediastinal nodal resection can be performed with the robot.

Application of an Epicardial Left Atrial Appendage Occlusion Device by a Robotic-Assisted, Right Chest Approach.

Closure of the left atrial appendage (LAA) has become a standard part of any mitral valve operation because it is thought to reduce the potential for late thrombus development and for embolic events. To date, surgeons performing robotic mitral valve operations have been limited to an endocardial approach to LAA closure. However, oversewing the orifice of the LAA is time consuming and lengthens the cross-clamp time, and failures to obtain permanent closure have been reported. We describe our technique for an epicardial approach that is safe and efficient and that gives a secure closure of the LAA.