Boston Dynamics can Walk the Walk

It really doesn't get much cooler than this. Boston Dynamics has rocketed into the engineering stratosphere with their "Big Dog" robot shown last year, but now they are going orbital with this new you tube video release of PETMAN prototype.

I envision the future with amputees able to walk again. Now, that's cool!

Between a Rock and a Hard Place

Dr. Craig P. Fischer - Hepatobiliary Surgeon

(the screen shows the choledochoscopic view of a large stone in the common bile duct)

Life in general surgery is changing radically as we become more specialized. Fact is, it is simply impossible to be an expert across the wide breath of what is considered "general surgery". For those of you not in the business, the general surgeon is expected to have a command of surgical pathophysiology from the neck to the extremities and nearly everything in between (save for the heart and genitourinary system). However, as our understanding of surgical diseases has improved, our ability to intervene in meaningful and more sophisticated ways has increased in kind. Because of these increased capabilities, the general surgeon has been pushed into becoming  more specialized. For example, we have colorectal surgeons, bariatric surgeons, vascular surgeons, thoracic surgeons, minimally invasive surgeons, endocrine surgeons, breast surgeons, acute care surgeons, and in this case hepatobiliary surgeons. Many of those listed have been specialized for many decades, but each area is still certainly one in which the general surgeon is expected to have the ability to manage if they are to become certified by the American Board of Surgery. Enter the benefit of having specialized training and expertise.

Intraoperative Cholangiogram (IOC)

Every general surgeon is expected to have a strong command of biliary stone disease. But not every case of gallbladder disease is the same. As seen above, this IOC reveals a rather impressive stone burden that fills the entire biliary system. Although, any good general surgeon can technically handle this case, saying that this is just another "gallbladder surgery" would be quite the understatement. Add to it that this patient has a BMI of over 55 and you have yourself a rather challenging operation ahead. Fortunately, patients such as this are able to be transferred to our medical center due to the expertise we have available.

Above the ruler: The contracted gallbladder

Below the ruler: Stones removed from the hepatic ducts and common bile duct (CBD).

Preoperatively, we knew the complexity of this patient's biliary disease. Given the availability of expertise, we proceeded with an attempt at a minimally invasive approach. This went smoothly, identifying the anatomy by IOC and accessing the CBD with laparoscopic choledochoscopy. Despite these maneuvers, the stone burden exceeded the technical limitations of the laparoscopic approach, and conversion to an open approach was required. Ultimately, every amount of expertise was brought to bear, as the shear amount of disease necessitated performing a choledochoduodenostomy. This last portion of the procedure, when performed with an expert in hepatobiliary surgery is rather enjoyable (enjoyable like a kid running around at his first county fair). I can only imagine that as a young general surgeon, alone in practice, this might be otherwise unnerving. It simply isn't something that you do everyday as a general surgeon.

The best part. The patient had a fantastic outcome. No complications. Fast recovery. You just can't ask for more.

The Tiny Just Got Smaller - The GE Vscan

 GE VScan Portable Ultrasound

I was truly impressed with the SonoSite NanoMaxx. However, GE has really blown me away with the GE Vscan "pocket" ultrasound. This is truly cool technology. Its cool not for technologies sake alone, but because it helps to crystallize a vision that what was once science fiction is clearly becoming so common place as to almost make medical technology a commodity. A commodity? you say. Yes, medical technologies will become commodities.

Jeff Immelt introducing the Vscan at the Web 2.0 Summit

We are still stuck with this idea that doctors and hospitals will be the only ones that will control these technologies. I believe those days are ending (at least definitely changing). The Internet has given patients unfettered access to knowledge, allowing them to become more educated about their own health. It's only a matter of time before patients have access to cheap but sophisticated medical technologies enabling them to control their own care. 

This product is NOT being marketed to the general public, but I look at this and see Dr. "Bones" McCoy's medical tricorder. Just a wave over the body and poof! You've got your diagnosis. Give me 2 decades (and a stable economy), and I will give you a radical change in what patients will be able to do for themselves.

Story from GE Reports

Business of Innovation/Redefining Health Care - CNBC.com

I have been exploring the concept of using telemedicine to augment our multidisciplinary team approach to the care of critically ill surgical patients. My particular spin on this technology was featured this week on CNBC as part of a series by Maria Bartiromo entitled Business of Innovation/Redefining Health Care - CNBC.com. My part starts around the 13:40 mark. But, as is typical, they edited the content to such a degree as to not really get my point across. That's OK... that's just the way things work in the media. Unfortunately, the "experts" only viewed this edited material and made the expected negative comments based on the lack of the whole story. Therefore, I will present a short version of "the whole story" here.

First, it should be noted that this technology is very very early in its lifespan. We honestly don't know how much of an impact that this will have on healthcare. My opinion is that we will see huge advances in this area in another decade. These advances will show us that the technology will be invaluable, just as the Internet as a whole has been invaluable for patient and physician access to information.

My implementation of this technology utilizes something termed Robotic Telepresence (RTP). The robot part comes from the ability for a provider to control a mobile unit from anywhere there is an Internet connection. This mobile unit comes equipped with a two way audio AND visual communication platform that sits on the top of the robot and is shown below.

My team uses this tool in a unique way. We have a multidisciplinary ICU team that sees all the surgical ICU patients. This team is comprised of a surgical intensivist, nurse practitioners, clinical pharmacists, bedside ICU nurses, surgical residents, respiratory therapists, nutritionists and social workers. Not to mention that this is a teaching facility, thus the team is also comprised of students from medical school, pharmacy school and nurse practitioner school. Additionally, we have a top-tier liver transplant program and we round with the transplant team that comprises the transplant surgeon, hepatologist, transplant pharmacist, transplant resident and.... Do you get the point? The team I have is ginormous!

Now, just think about the immense size of my team standing at the bedside or outside the hallway. Well, why don't I just paint you a picture below.

This large team is put together for the sole purpose of optimizing patient care by enhancing communication amongst the team of providers responsible for said patient. The resources that we pour into patient care is meant to ensure that all details are checked, double-checked and checked again. But the downside that we experience is that this team creates a noise and traffic problem in the patient care area. It is also difficult for the team to communicate well if the noise level is elevated. Additionally, having this many people show up at your bedside can be scary to the patient and their family.

Thus, we implemented a solution to this problem. We implemented Robotic Telepresence. Our doctors personally see the patient early in the morning, examining the patient and collecting the details. We then meet as a team in a remote conference room where the patient clinical information and xrays are projected onto large screens. We then use the robot to "see" the patient and his/her nurse at the bedside. In this way, the entire team is figuratively inside the robot. Thus the teams footprint and noise level is reduced to that of a single person. Just as importantly, the team can communicate better because they are in an environment that is designed for communication (a conference room). They all see the patient and the clinical information as a team. This enhances the ability for any individual on the team to engage in the patient's care, no matter what role they serve.

Finally, the team designs a plan of care for that patient. Once the plan of care is set, the surgical intensivist team re-engages directly and personally with the patient and bedside nurse to enact the care plan. We believe that this model enhances patient safety and helps to optimize our patients outcomes.

I have performed an as yet unpublished, IRB approved study that surveyed the patients and their families requesting their perception of the robot. I have an overwhelmingly positive response. That is the whole story.
 
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Rectusbanding: a method for the repair of incisional hernias

M. Sahm Email: m.sahm@drk-kliniken-berlin.de

Received: 22 November 2008  Accepted: 3 May 2009  Published online: 3 June 2009

In this October release of Hernia, Vol. 13, Issue 5 we find another report from our inventive German surgical colleagues detailing their experience with a technique they have been pioneering for the past decade termed "Rectus Banding". Their intention was to develop an inexpensive, simple and safe technique for the repair of incisional hernia while preventing postoperative "stiff abdomen".

 

My take; I find the study to be performed very well. They did an excellent job at defining their patient population and did as good, or better than most at followup. They have excellent outcomes. However, I don't think that they met the intended goal of developing an improved simpler technique. In fact, this technique appears considerably more difficult than a more traditional wide-underlay technique. Additionally, creating multiple fascial defects for placement of the bands appears to be counter-intuitive and poses a risk of creating more problems with iatrogenic hernia formation. I would think that multiple bands would have to result in dennervation of the rectus musculature, but the authors report that this is not the case.

Finally, I can understand that decreasing the amount of mesh can be helpful in improving the dynamic compliance of the abdominal wall, but there are increasing reports that lightweight mesh can and should be used to achieve this goal. In my opinion, the use of lightweight mesh will be the lasting trend in hernia repair which will achieve the goal of decreasing the so-called "stiff abdomen".

Link: SpringerLink - Journal Article

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Knot Tying 101 With a Pulmonary Artery Catheter

I hear many outlandish stories in medicine and have come to accept that if it sounds unbelievable, then its probably true. During my training, I was taught to stop pulling on a pulmonary artery (PA) catheter if you meet resistance. The balloon might not have deflated, or it may have gotten caught in the chordae tendonae of the heart.

As you can see above, this PA catheter is literally tied in a knot. It is a rather unusual problem and in the 1980s this would have required a radical operation to get this catheter removed. Fortunately, in the 21st century with the technology used by interventional radiologists, this does not require an operation. In fact, this problem can be resolved via accessing the right internal jugular vein and manipulating the PA catheter with another catheter under flouroscopic guidance. The knot gets untied. The PA catheter is removed. No surgery. No anethesia. No adverse sequelae. No problem... Technology continues to advance.

Surgical Repair of Complex Abdominal Wall Defects

I specialize in the repair of complex abdominal wall defects such as that pictured above. Over the past 5 years I have learned a great deal about this problem. The intricacies posed by the anatomical void are abound. Repairing these abdominal wall problems is fraught with a myriad of complications. In fact, maybe as much as 20-60% of these patients will have a failed repair in the first three years. Just as many will have a surgical wound complication that may necessitate the removal of mesh. These two facts alone have spawned the search for surgical techniques and implantable mesh that reduce the risk of these occurrences.


Many of us have moved towards performing bilateral rectus advancement flaps (components separation) to achieve advancement of local autologous tissue to the midline. This alone has not been successful in decreasing the rate of hernia recurrence. Additionally, often in these cases there just isn't enough living tissue to achieve midline closure. Therefore, some type of mesh is needed to bridge the defect as shown below.

In cases where contamination or fear that there is high risk for wound complications, placing biologic mesh has become a standard practice. Its the biologic mesh that is the crux of this post. There are many of these products now on the market. They are derived from a variety of sources; human, pig (porcine), cow (bovine). Some come from dermis, others from gut mucosa, and finally as seen in the latest release from The American Journal of Surgery, pericardium. All are processed in a variety of patented ways such to remove the cellular and antigenic components, leaving an acellular matrix that is free from the issues of xenograft rejection.

ScienceDirect - The American Journal of Surgery : Repair of abdominal wall defects with bovine pericardium

While I applaud the authors for their good work and a respectable 20% recurrence rate, I hesitate to use this article as one to which I can say bovine pericardium is good or bad for the repair of complicated ventral hernias. In fact, this paper suffers from the same problem all others before it. That is, small patient group of 26 patients (underpowered), recurrence is determined by the surgeon who operated (bias), surgical technique is not controlled (inlay, overlay, components separation/no separation), etc.. Clearly the authors are experts in this topic. Their comments are basically the same ones that I espouse. Unfortunately, this paper adds nothing to the confusing landscape of biologic mesh implantation.

What we do know is that these biologic products appear to have a very good safety profile. What we don't know is the long-term outcome (except for that of human acellular dermal matrix) AND we don't know which product is better than the other. What I am seeing in the industry is a huge marketing campaign. They all claim that their product is better than the other. But there is no data to support their claims. Additionally, there is no long-term data that shows if the outcomes of these expensive products are better than the traditional synthetic meshes. We need a large prospective randomized controlled multi-center trial. Who is up for that challenge?

JFS

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I Guess It's Better Than Swallowing a Rock

 

From the original purveyors of imaging your small intestine (Given Imaging, Ltd, Yoqneam, Israel) comes the Agile patency capsule. GI endoscopy can only take you so far, and there are few people skilled in push and double-balloon enteroscopy. So, in 2000 the FDA cleared the way for Given Imaging's video capsule endoscopy (VCE) pill for identifying those obscure small bowel pathologies that just won't reveal themselves. We surgeon's joked often that you might as well give the patient a rock to swallow (it will get stuck in the place where the bad thing is happening). Of course, that's not completely true, but humor does usually have some basis in truth.

Nonetheless, the Agile patency system may make some sense. If the pill 'gets stuck' it will dissolve within 40-80 hours. However, in one study 1(noted at the bottom) 10% (2 patients) required emergency surgery due to symptoms of intestinal obstruction after ingesting this device. Subsequently the pill has been redesigned to allow for improved dissolution. This may have improved its safety profile.

I am not completely sold on the idea that you need a "patency capsule". If a patient needs to have their GI tract studied, then there likely is pathology that needs surgical intervention. If the PillCam SB becomes 'stuck' in the intestine, then you have your source of pathology and the surgeon has an area to focus his/her work. On the other hand, this forces you into a semi-urgent procedure.

I think what is more fascinating is the idea that in the future these devices will shed their diagnostic skin and become a therapeutic instrument through advances in nanotechnology. Some day, we may be able to send these devices through the bowel as vehicles for a small army of nanobots that will can deliver medications to the point of pathology, or laser seal bleeding mucosal vessels, thus terminating the need for surgeons to grotesquely enter the abdomen and resect large portions of intestine for otherwise small areas of disease.

1. Delvaux, M, Ben Soussan, E, Laurent, V, et al. Clinical Evaluation of the Use of the M2A Patency Capsule System Before a Capsule Endoscopy Procedure, in Patients with Known or Suspected Intestinal Stenosis. Endoscopy. 2005; 37:801

Improve Patient Care AND Reduce Costs With Better Technology

Just a decade ago you wouldn't catch me dead using an ultrasound for vascular access procedures. Just the thought made me recoil in a rage of machismo. I don't think that I was/am too different from most surgeons out there. The reality is that I performed thousands of central venous access procedures safely. But truth be told, I had two instances that resulted in early complications. Now, one could argue that my safety record is phenomenal. But let me tell you that I vividly recall both of these complications over a decade later. I never want to have this happen again.

 [SonoSite NanoMaxx]

Fast forward to the 21st century. For 5 years now I have performed every central venous access procedure with ultrasound guidance. This technique has been proven beyond a shadow of a doubt to reduce not only the immediate complications (carotid puncture, pneumothorax, etc.), but it reduces the more common near-term complications of catheter related blood-stream infection. Additionally, it increases the success rate of achieving access on the first attempt.

One aspect that I haven't personally seen in the literature, but have experienced first hand is that my surgical ICU residents have an astoundingly high success rate and incredibly only have two immediate complications in the last 3 years. That is unheard of in a busy tertiary care ICU where we are placing central venous catheters every day.

This all adds up to reduced complications, reduced hospital length of stay, improved patient outcomes and satisfaction. Featured above is the new SonoSite NanoMaxx. It is a testament to advancing technology. This type of unit is small and portable (6 lbs.) while still retaining incredible resolution and functionality. Bring on the technology!

SonoSite NanoMaxx Product Site