The subtotal laparoscopic pancreatic resection can safely be performed. The da Vinci robotic system allowed for technical refinements of laparoscopic pancreatic resection. Robotic assistance improved the dissection and control of major blood vessels due to three-dimensional visualization of the operative field and instruments with wrist-type end-effectors.
Progress in liver surgery has enabled hepatectomy with concomitant venous resection for liver malignancies involving the inferior vena cava (IVC). The authors describe an alternative technique for IVC reconstruction without the need of graft.
http://www.drmarcel.com.br
Laparoscopic intrahepatic Glissonian technique for liver surgery. Hepatectomi...Marcel Autran Machado
The main advantage of the intrahepatic Glissonian procedure over other techniques is the possibility of gaining a rapid and precise access to the left Glissonian sheaths facilitating left hemihepatectomy, bisegmentectomy 2-3, and individual resections of segments 2, 3, and 4. The authors believe that the intrahepatic Glissonian technique facilitates laparoscopic liver resection and may increase the development of segment-based laparoscopic liver resection.
Laparoscopic right trisectionectomy; Trisegmentectomia direita por video.Marcel Autran Machado
Totally laparoscopic right trisectionectomy is safe and feasible in selected patients and should be considered for patients with benign or malignant liver neoplasms. The described technique, with the use of the intrahepatic Glissonian approach and control of venous outflow, may facilitate laparoscopic
extended liver resections by reducing the technical difficulties in pedicle control and may diminish bleeding during liver transection.
Appleby operation for pancreatic cancer. Cancer de pancreas - tratamentoMarcel Autran Machado
We described a modified Appleby operation for locally advanced distal pancreatic cancer with compromised hepatic collateral flow that needed hepatic arterial revascularization, successfully accomplished by left external iliac-hepatic arterial bypass with Dacron prosthesis.
Brief description of hepatectomy with indications, procedure, pre operative, intra operative and post operative management of the patient. Also describes the various techniques and instrument available for liver resection.
Dr Pradeep Jain Fortis Hospital - Current Applications of Lap in GI SurgeryDr Pradeep Jain Reviews
Dr Pradeep Jain Fortis Hospital - Current Applications of Lap in GI Surgery. Dr. Pradeep Jain Fortis Hospital has over 20 years of experience in the Laparoscopic GI and GI Oncology Surgery.
Progress in liver surgery has enabled hepatectomy with concomitant venous resection for liver malignancies involving the inferior vena cava (IVC). The authors describe an alternative technique for IVC reconstruction without the need of graft.
http://www.drmarcel.com.br
Laparoscopic intrahepatic Glissonian technique for liver surgery. Hepatectomi...Marcel Autran Machado
The main advantage of the intrahepatic Glissonian procedure over other techniques is the possibility of gaining a rapid and precise access to the left Glissonian sheaths facilitating left hemihepatectomy, bisegmentectomy 2-3, and individual resections of segments 2, 3, and 4. The authors believe that the intrahepatic Glissonian technique facilitates laparoscopic liver resection and may increase the development of segment-based laparoscopic liver resection.
Laparoscopic right trisectionectomy; Trisegmentectomia direita por video.Marcel Autran Machado
Totally laparoscopic right trisectionectomy is safe and feasible in selected patients and should be considered for patients with benign or malignant liver neoplasms. The described technique, with the use of the intrahepatic Glissonian approach and control of venous outflow, may facilitate laparoscopic
extended liver resections by reducing the technical difficulties in pedicle control and may diminish bleeding during liver transection.
Appleby operation for pancreatic cancer. Cancer de pancreas - tratamentoMarcel Autran Machado
We described a modified Appleby operation for locally advanced distal pancreatic cancer with compromised hepatic collateral flow that needed hepatic arterial revascularization, successfully accomplished by left external iliac-hepatic arterial bypass with Dacron prosthesis.
Brief description of hepatectomy with indications, procedure, pre operative, intra operative and post operative management of the patient. Also describes the various techniques and instrument available for liver resection.
Dr Pradeep Jain Fortis Hospital - Current Applications of Lap in GI SurgeryDr Pradeep Jain Reviews
Dr Pradeep Jain Fortis Hospital - Current Applications of Lap in GI Surgery. Dr. Pradeep Jain Fortis Hospital has over 20 years of experience in the Laparoscopic GI and GI Oncology Surgery.
Η Λαπαροσκοπική Χειρουργική στον Καρκίνο του Παχέος Εντέρου και του ΟρθούDimitris P. Korkolis
One of the most common cancers in the world
US: 4th most common cancer
(after lung, prostate, and breast cancers)
2nd most common cause of cancer death
(after lung cancer)
2007: 130,000 new cases of CRC
56,500 deaths caused by CRC
Ureteral injury is one of the most serious complications of gynecologic surgery. Ureteral injury during laparoscopic surgery has become more common as a result of the increased number of laparoscopic hysterectomies and retroperitoneal procedures that are being performed.
The future laparoscopic technology includes threedimensional virtual reality and expands the scanning rate from 525 lines of resolution to 1,000 or 1,200 lines per frame and the quality of picture would be twice better than existing system.
Laparoscopic Partial Nephrectomy of Hilar Tumors with Cold Ischemiaguestd58ac53
Laparoscopic Partial Nephrectomy of Hilar Tumors with Cold Ischemia
Juza Chen and Avi Bery
Director of Sexual Dysfunction Clinic
Department of Urology
Tel-Aviv Sourasky Medical Center
Sackler Faculty of Medicine Tel-Aviv University
Moscow 2010
Hysteroscopy is a procedure used to view the inside of the uterus through a telescope-like device called a hysteroscope. Hysteroscopy offers a valuable extension to the gynecologist’s armamentarium.
Safe Laparoscopic Cholecystectomy Techniques that are discussed here are based on current literature and Evidence Based Medicine guidelines and reviews.
The indications and preparation for laparoscopic liver surgery remain the same as in open hepatic surgery. Visualization is excellent with the laparoscope, and the addition of laparoscopic ultrasound has been shown to help intraoperative plans in 66% of cases when compared to laparoscopic exploration alone.
Robotic assisted radical prostatectomy (RARP) has become the commonest minimally invasive surgical procedure for the treatment of localized prostate cancer. Despite limited data supporting the excellence of RARP over laparoscopic radical prostatectomy (LRP) or open radical prostatectomy (ORP), it has gained wide acceptance among the patients and surgeons.
Η Λαπαροσκοπική Χειρουργική στον Καρκίνο του Παχέος Εντέρου και του ΟρθούDimitris P. Korkolis
One of the most common cancers in the world
US: 4th most common cancer
(after lung, prostate, and breast cancers)
2nd most common cause of cancer death
(after lung cancer)
2007: 130,000 new cases of CRC
56,500 deaths caused by CRC
Ureteral injury is one of the most serious complications of gynecologic surgery. Ureteral injury during laparoscopic surgery has become more common as a result of the increased number of laparoscopic hysterectomies and retroperitoneal procedures that are being performed.
The future laparoscopic technology includes threedimensional virtual reality and expands the scanning rate from 525 lines of resolution to 1,000 or 1,200 lines per frame and the quality of picture would be twice better than existing system.
Laparoscopic Partial Nephrectomy of Hilar Tumors with Cold Ischemiaguestd58ac53
Laparoscopic Partial Nephrectomy of Hilar Tumors with Cold Ischemia
Juza Chen and Avi Bery
Director of Sexual Dysfunction Clinic
Department of Urology
Tel-Aviv Sourasky Medical Center
Sackler Faculty of Medicine Tel-Aviv University
Moscow 2010
Hysteroscopy is a procedure used to view the inside of the uterus through a telescope-like device called a hysteroscope. Hysteroscopy offers a valuable extension to the gynecologist’s armamentarium.
Safe Laparoscopic Cholecystectomy Techniques that are discussed here are based on current literature and Evidence Based Medicine guidelines and reviews.
The indications and preparation for laparoscopic liver surgery remain the same as in open hepatic surgery. Visualization is excellent with the laparoscope, and the addition of laparoscopic ultrasound has been shown to help intraoperative plans in 66% of cases when compared to laparoscopic exploration alone.
Robotic assisted radical prostatectomy (RARP) has become the commonest minimally invasive surgical procedure for the treatment of localized prostate cancer. Despite limited data supporting the excellence of RARP over laparoscopic radical prostatectomy (LRP) or open radical prostatectomy (ORP), it has gained wide acceptance among the patients and surgeons.
Laparoscopic colon resections are being performed with increasing frequency all over the world. However, the use of minimal access surgery in colorectal surgery has lagged behind its application in other surgical fields.
Laparoscopic Natural Orifice Specimen Extraction (NOSE) Total Colectomy with ...semualkaira
The benefit of laparoscopic surgery in terms of
reduced pain and fewer cosmetic problems is not always obvious,
and surgeons continue to seek the best ways to limit incision trauma and improve outcomes in laparoscopic colorectal surgery
Today, Laparoscopy is an alternative technique for carrying out many operations that have traditionally required an open approach. The benefits of minimal access surgery have been well recorded, including lower post-operative morbidity, shorter duration of hospital stay and a shorter return to work.
Analysis on the Treatment of Colorectal Cancerclinicsoncology
Over the past few years, Robotic surgery has been an emerging field in colorectal surgery. Over years there has been continuous shift towards minimally invasive procedures with enormous potential advantages but progress is impeded because of limited evidence,lack of technology and cost of expenditure...
Analysis on the Treatment of Colorectal Cancerpateldrona
Over the past few years, Robotic surgery has been an emerging field in colorectal surgery. Over years there has been continuous shift towards minimally invasive procedures with enormous potential advantages but progress is impeded because of limited evidence,lack of technology and cost of expenditure...
Analysis on the Treatment of Colorectal Cancergeorgemarini
Over the past few years, Robotic surgery has been an emerging field in colorectal surgery. Over years there has been continuous shift towards minimally invasive procedures with enormous potential advantages but progress is impeded because of limited evidence,lack of technology and cost of expenditure...
Over the past few years, Robotic surgery has been an emerging field in colorectal surgery. Over years there has been continuous shift towards minimally invasive procedures with enormous potential advantages but progress is impeded because of limited evidence
Analysis on the Treatment of Colorectal CancerSarkarRenon
Over the past few years, Robotic surgery has been an emerging field in colorectal surgery. Over years there has been continuous shift towards minimally invasive procedures with enormous potential advantages but progress is impeded because of limited evidence,lack of technology and cost of expenditure...
Analysis on the Treatment of Colorectal CancerAnonIshanvi
Over the past few years, Robotic surgery has been an emerging field in colorectal surgery. Over years there has been continuous shift towards minimally invasive procedures with enormous potential advantages but progress is impeded because of limited evidence,lack of technology and cost of expenditure...
Colorectal malignant growth is a disease that begins in the colon
or the rectum. These malignant growths can likewise be named
colon disease or rectal malignant growth, contingent upon where
they begin. Colon malignant growth and rectal disease are regularly gathered together collectively as they share same features.
CRC is the third most generally analysed malignant growth in
men and the second in women, with 1.8 million new cases and
very nearly 861,000 deaths in 2018 as indicated by the World
Health Organization [1-15]. Throughout the decade, open medical procedure was considered the far reaching and Objective standard for treatment and medical procedure of colorectal malignant
growth. The point of careful treatment is tumour size, lymphatic
waste, lymph node resection alongside clear careful edges [
Over the last two decades, laparoscopic cholecystectomy
has replaced open cholecystectomy as the standard surgical procedure for majority of patients of gall stone disease. Till 1999, laparoscopic Cholecystectomy was being performed using multiple ports usually 3 or 4 ports.
Intensive desire of surgeon to reduce the number of ports led invention of two port cholecystectomy and then finally
single incision laparoscopic cholecystectomy (SILC) .
Similar to Robotic pancreatectomy. Pancreatectomia robótica. (20)
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Evaluation of antidepressant activity of clitoris ternatea in animals
Robotic pancreatectomy. Pancreatectomia robótica.
1. LAP-2009-0164-Machado_1P.3D 08/01/09 3:05pm Page 1
LAP-2009-0164-Machado_1P
JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES
Volume &, Number &, 2009 Technical Report
ª Mary Ann Liebert, Inc.
DOI: 10.1089=lap.2009.0164
Robotic Resection of Intraductal
Neoplasm of the Pancreas
Marcel A.C. Machado, MD, Fabio F. Makdissi, MD,2
1,2
´
Rodrigo C. Surjan, MD, and Ricardo Z. Abdalla, MD1
2
Abstract
Background: Minimally invasive techniques have been revolutionary and provide clinical evidence of decreased
morbidity and comparable efficacy to traditional open surgery. Computer-assisted surgical devices have recently
been approved for general surgical use.
Aim: The aim of this study was to report the first known case of pancreatic resection with the use of a computer-
assisted, or robotic, surgical device in Latin America.
Patient and Method: A 37-year-old female with a previous history of radical mastectomy for bilateral breast
cancer due to a BRCA2 mutation presented with an acute pancreatitis episode. Radiologic investigation dis-
closed an intraductal pancreatic neoplasm located in the neck of the pancreas with atrophy of the body and tail.
The main pancreatic duct was enlarged. The surgical decision was to perform a laparoscopic subtotal pancre-
atectomy, using the da VinciÒ robotic system (Intuitive Surgical, Sunnyvale, CA). Five trocars were used.
Pancreatic transection was achieved with vascular endoscopic stapler. The surgical specimen was removed
without an additional incision.
Results: Operative time was 240 minutes. Blood loss was minimal, and the patient did not receive a transfusion.
The recovery was uneventful, and the patient was discharged on postoperative day 4.
Conclusions: The subtotal laparoscopic pancreatic resection can safely be performed. The da Vinci robotic
system allowed for technical refinements of laparoscopic pancreatic resection. Robotic assistance improved the
dissection and control of major blood vessels due to three-dimensional visualization of the operative field and
instruments with wrist-type end-effectors.
Introduction assisted surgery is a new acquisition to the armamentarium of
minimally invasive surgical techniques and remains in its
L aparoscopic and minimally invasive surgery devel-
opment has been one of the most important advances in
operative techniques. A variety of pancreatic lesions, such as
infancy but may be particularly useful in advanced laparo-
scopic procedures, such as pancreatic resections. Robotic
pancreatic resection is mentioned rarely in the English liter-
acinar-cell tumors, squamous-cell carcinomas, islet-cell tu- ature, with only four articles found dealing with this proce-
mors, cystic neoplasms, and adenocarcinomas, are most often dure.5–8 Among them, there are two case reports,5,6 two
treated by surgical resection.1 The rationale for minimally articles from the same group,5,7 and only two dealing directly
invasive pancreatic resections relies in evidences that lesser with this procedure and with a brief description of the tech-
perioperative trauma in laparoscopy is advantageous, when nique.5,6 There is a lack of technical description of this com-
compared to the open approach. This reduction results in plex procedure. The aim of this article was to describe the
decreased inflammatory response, preservation of the im- technique of a full robotic pancreatic resection in a patient
mune function, and perhaps even a reduction of malignant with intraductal neoplasm. To our knowledge, this is the first
recurrence.2–4 robotic pancreatic resection in Latin America and the first case
Computer-assisted surgical devices have recently been of intraductal neoplasm treated by this method, so far, in the
approved for general surgical use. Robotic or computer- English literature.
1
´ ˆ ˜
Research and Robotic Training Unit–IEP, Hospital Sırio Libanes, Sao Paulo, Brazil.
2
˜ ˜
Lim-37, Department of Gastroenterology, University of Sao Paulo, Sao Paulo, Brazil.
1
2. LAP-2009-0164-Machado_1P.3D 08/01/09 3:05pm Page 2
2 MACHADO ET AL.
FIG. 1. Robotic pancreatic resection. (A) Preoperative computed tomography scan shows an atrophic distal pancreas with
dilatation of the main pancreatic duct. (B) Preoperative magnetic resonance imaging suggests an intraductal neoplasm in the
neck of the pancreas with atrophy of the body and tail of the pancreas. (C) Five trocars were used: three 8-mm trocars, one
11-mm trocar, and one 12-mm trocar. (D) The patient was placed in a right semilateral decubitus position.
Patient and Method pancreas. The posterior aspect of the pancreas at the level of
the pancreatic neck was carefully dissected in order to disclose
A 37-year-old female with a previous history of radical the anterior surface of the portal and mesenteric veins. A ro-
mastectomy for bilateral breast cancer due to a BRCA2 mu- botic instrument was inserted behind the pancreatic neck, and
tation presented with an acute pancreatitis episode. Radi- the pancreas was encircled with a cardiac tape. This tape was
ologic investigation disclosed an intraductal pancreatic used during the whole procedure, allowing upward traction
neoplasm located in the neck of the pancreas with atrophy of of the pancreas (Fig. 2A). The next step was to transect the b F2
F1 c the body and tail (Fig. 1A–1B). The main pancreatic duct was pancreas by using a vascular endoscopic stapler (Fig. 2B).
enlarged. The surgical decision was to perform a laparoscopic Once this was accomplished, the splenic vein was divided
subtotal pancreatectomy, using the da VinciÒ robotic system with a vascular stapler and the distal pancreas was mobilized
(Intuitive Surgical, Sunnyvale, CA). The patient was initially from the retroperitoneum (Fig. 2C). Caution had to be taken to
placed in the supine position, and a cushion was placed below control the inferior mesenteric vein, which runs through the
the left flank, thus tilting the patient toward the right lateral inferior border of the pancreas. The lower pole of the spleen
decubitus position by approximately 30 degrees. An or- was mobilized through the partial division of the splenocolic
ogastric tube was inserted and removed at the completion of ligament (Fig. 2D). Dissection was completed with the mo-
the procedure. Using an open technique, an 11-mm trocar was bilization of the splenic upper pole through the division of the
placed in the supraumbilical position; through this port, the splenophrenic ligament (Fig. 3A). The surgical specimen b F3
robotic camera was introduced, and four additional ports containing the pancreas and spleen was lifted (Fig. 3B) and
were placed: three 8-mm and one 12-mm, as shown in Figure placed inside a plastic retrieval bag. This bag was brought
1C–1D. The gastroepiploic ligament and short gastric veins through the additional 12-mm port, where the spleen was
were divided with a Harmonic Scalpel (UltraCision; Ethicon morcellated without contamination of the abdominal cavity
Inc., Cincinatti,OH). This step permitted the location and li- with splenic cells. The pancreatic stump was revised for he-
gation of the splenic artery in the superior border of the mostasis (Fig. 3C). The pancreatic specimen was retrieved
3. LAP-2009-0164-Machado_1P.3D 08/01/09 3:05pm Page 3
PANCREATIC ROBOTIC RESECTION 3
4C c
FIG. 2. Robotic pancreatic resection surgical steps. (A) The pancreatic neck is dissected and encircled. (B) Upward trac-
tion of tape permits the insertion of a stapler. (C) The pancreas is already transected and upward traction allows full
mobilization of the pancreas from the retroperitoneum. (D) Division of the splenocolic ligament and mobilization of the lower
splenic pole.
intact for anatomopathologic examination (Fig. 3D). A round Himpens et al. reported the first laparoscopic cholecystec-
19-F Blake abdominal drain (Ethicon) was left in place, and tomy with using this robotic system.11 Three years later, in
the procedure was terminated. July 2000, the FDA approved the da Vinci system for use in
general surgical procedures. The da Vinci robotic system of-
Results fers a number of advantages over traditional laparoscopy,
including: 1) improvements in ergonomics—the surgeon sits
Operative time was 240 minutes. Blood loss was minimal,
in a console and manipulates hand controls in a comfortable,
and the patient did not receive a transfusion. The recovery
ergonomic fashion; 2) a fine-motion filter eliminates natural
was uneventful, and the patient was discharged on post-
tremors of the hands and allows motion to be scaled up to 5:1;
operative day 4. There was no pancreatic leakage, and the
3) significant increase in motion allowed by multiarticulated
drain was removed on postoperative day 7. The patient is well
robotic instruments; 4) three-dimensional (3D) visualization,
and asymptomatic 6 months after the procedure.
and 5) robotic control of the camera, allowing the operating
surgeon to control the visualization without movement or
Discussion
fatigue in a stable platform, as the camera cannot move unless
In 1996, Salky and Edye were the first researchers to when engaged by the surgeon.12
advocate the use of laparoscopic surgery to treat pancreatic However, robotic surgical systems have their limitations.
lesions.9 Minimally invasive surgery can reduce surgical As the initial step of a new technology, it is difficult to handle
trauma, increase safety, and accelerate recovery. Robotic and is quite large. It necessitates a large operating room, im-
surgery became a reality in 1994 when a camera holder for use poses limitations in patient positioning, and port placement
in laparoscopic surgery was approved by the U.S. Food and must be well planned to prevent interference between oper-
Drug Administration (FDA) and further evolved to a voice- ative and camera arms. Another important issue is that pro-
command system that enabled hands-off control of the lapa- prioception and tactile sensitivity is not yet available in the
roscope.10 The da Vinci robotic surgical system made the robotic system, making it dangerous to move instruments
remote control of laparoscopic instruments a reality. In 1997, outside the visual field. As experience with robotic technology
4. LAP-2009-0164-Machado_1P.3D 08/01/09 3:05pm Page 4
4 MACHADO ET AL.
4C c
FIG. 3. Robotic pancreatic resection technique. (A) Division of the splenophrenic ligament and mobilization of the upper
splenic pole. (B) Dissection was completed, and the surgical specimen was lifted to be placed in a retrieval bag. (C) The
pancreatic stump was revised (pancreas) for hemostasia. SA, splenic artery. (D) The pancreatic specimen was retrieved intact
for anatomopathologic examination.
has increased and its applications to advanced laparoscopic Disclosure Statement b AU1
procedures have become more understood, surgeons are
No competing financial conflicts exist.
carefully exploring the application of this innovative tech-
nology to the diseases of the pancreas. The first robotic pan-
References
creatic resection was reported by Melvin et al. in 2003.5 Since
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