Challenges of conversion from robotic surgery for vascular complications.

A 67-year-old woman with endometrial adenocarcinoma had sustained an aortic injury during robotically assisted retroperitoneal lymphadenectomy. Repair could not be performed laparoscopically; however, graspers were used to maintain hemostasis while conversion to open surgery was initiated. Safety mechanisms locked the graspers in place, preventing tissue release, but resulting in additional aortic injury. Forceful removal of the graspers was eventually successful, and definitive aortic repair was then performed. Vascular surgeons who are not familiar with robotic surgery techniques should be aware that removal of robotic hardware requires the use of stepwise algorithms, which, if performed out of order, can introduce significant challenges.

Building a Simulator with Life-like Realism for Teaching Abdominal Operations.

OBJECTIVE: The objective of this communication is to provide an evolutionary description of an attempt to replicate the success of the Rampahl Cardiac Simulator using perfused abdominal organ blocks the way that the Rampahl Simulator uses ex vivo porcine hearts. DESIGN: This descriptive paper makes no attempt to prove the effectiveness of the described educational tool, but rather, outlines the successes and failures in development. The proven value of a perfused organ teaching tool, as the Rampahl Simulator, suggests that others can build upon the work described in this paper so that, in the future, perfused abdominal organs will be available to students of general surgery as a routine part of their pre-operative preparation. SETTING: The Animal Resource Facility of the University of Utah, under the oversight of the University Institutional Animal Use and Care Committee (IACUC), provided the animals, operating suites and technical support. PARTICIPANTS: During each development phase, General Surgery Residents and Medical Students from all levels participated. In addition, operating room staff with an interest in either medical school or perfusion were invited to participate. RESULTS: The efforts described in this paper eventually resulted in a reliable teaching tool for abdominal procedures in that viability of the porcine abdominal organs for up to three hours after euthanasia was regularly achieved. CONCLUSIONS: General Surgery Teaching Programs of a size similar to the University of Utah may have access to the resources necessary to replicate this teaching tool in a cost-effective manner. However smaller teaching programs, such as those without a research facility, may not be able to adapt the procedures described in this paper.

A novel perfused porcine simulator for teaching aortic anastomosis increases resident interest in vascular surgery.

OBJECTIVE: This report describes a novel simulator, euthanized pigs on cardiopulmonary bypass, and validates this simulator with a controlled trial in general surgery residents learning aortic anastomosis. We evaluated this novel simulator with the following hypothesis: our porcine perfused simulator is as good as or better than the standard rubber tubing, low-fidelity models used for vascular anastomotic training. METHODS: Euthanized pigs were placed on cardiopulmonary bypass, creating a perfused, ex vivo model on which to perform surgical procedures. The participants in the study were postgraduate year 2, 3, and 4 general surgery residents. Residents were randomized to practice aortic anastomosis in the pig laboratory (PL) simulator or in a dry laboratory. The PL residents and control residents performed a first vascular anastomosis on the rubber tube model. Anastomosis creation was filmed. The anastomosis and video were stored for later grading. Next, all residents underwent an ungraded, one-on-one training session with the attending vascular surgeon. After the training session, all residents completed a second videotaped rubber tubing anastomosis. The grading scales used were validated by other authors: Global Assessment Score, Final Product Score, and Checklist Scoring Instrument. Survey data describing this experience were collected using a 13-question prelaboratory and 16-question postlaboratory questionnaires consisting of yes/no, multiple selection, and 5-point Likert-type scale questions. RESULTS: All residents had a statistically significant improvement in time to completion and in the Global Assessment Score with tutored practice. The PL residents showed statistically significant improvement in completion time between the first and second videotaped anastomosis; however, there was no statistically significant improvement in the scoring metrics. The control residents showed statistically significant improvement in all three scoring metrics, but no statistically significant difference was found in completion time. The survey data showed a statistically significant shift in considering vascular surgery as a career after the experience in the PL group (P = .05) compared with the control group, who had no change in interest (P = .91). CONCLUSIONS: Our prospective, randomized clinical trial shows that the porcine cardiopulmonary bypass model achieves similar results to a previously validated bench top model while improving general surgery resident interest in vascular surgery as a career.

Minimally invasive lymphatic mapping using fluorescently labeled vitamin B12.

BACKGROUND: We examined the usefulness of a new agent in the mapping and dissection of inguinal lymph nodes in the pig. Cy5-cobalamin bioconjugate is blue under visible light and fluoresces brilliant red with laser stimulation. The wavelength of the emitted red light is sufficiently long that it is visible through blood, subcutaneous fat, and fascia. Currently available surgical techniques of minimally invasive dissection are well suited for using fluorescent detection in a dark operating field with minimal modification of an existing Hopkins surgical telescope. MATERIALS AND METHODS: We tested this concept in the live post-adolescent, female, nonlactating pig (30 kg). We insufflated the subcutaneous tissue over the groin and inserted three ports (1 x 10 mm and 2 x 5 mm) for dissection. We injected the Cy5-cobalamin bioconjugate in a dermal location on the hind limb. A HeNe laser stimulated the CobalaFluor in the lymphatics and the emitted fluorescence passed through a holographic notch filter to a three-chip camera. RESULTS: Under white light, the lymphatic trunks and the sentinel node were visualized within minutes of injection. Both the lymphatic trunks and the node fluoresced bright red under stimulation with red laser light. CONCLUSIONS: These preliminary studies establish the potential usefulness of this new agent in lymphatic mapping. This novel technology might be useful in visualizing cancers that spread to regional lymph nodes. This technique has the potential to map the lymphatic drainage and to identify the presence of malignant cells in that drainage with currently available minimally invasive technology.