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Anesthesiology and Pain Medicine Jun 2022Robotic surgery is becoming the most common approach in minimally invasive urologic procedures. Robotic surgery offers less pain to patients because of smaller keyhole... (Review)
Review
CONTEXT
Robotic surgery is becoming the most common approach in minimally invasive urologic procedures. Robotic surgery offers less pain to patients because of smaller keyhole incisions and less tissue retraction and stretching of fascia and muscular fibers. Tailored pain regimens have also evolved and allowed patients to feel minimal to no discomfort after robotic urologic surgery, allowing in parallel better surgical outcomes. This study aims to analyze the most current pain regimens in robotic urologic surgery and to evaluate the most current pain protocols and corresponding outcomes.
EVIDENCE ACQUISITION
A literature review was performed of published manuscripts utilizing Pubmed and Google Scholar on pain protocols for patients undergoing robotic urologic surgery.
RESULTS
Multimodal analgesia is gaining ground in robotic urologic surgery. Regional analgesia includes four major modalities: Neuroaxial analgesia, intercostal blocks, tranvsersus abdominis plane blocks, and paravertebral blocks. Each approach has a different injection site, region of analgesia coverage, and duration of coverage depending upon local anesthesia and/or adjuvant utilized with advantages and disadvantages that make each modality unique and efficacious.
CONCLUSIONS
Robotic urologic surgery has offered the advantage of smaller incisions, faster recovery, less postoperative opioid consumption, and better surgical outcomes. Neuraxial, intercostal, transversus abdominis plane, and quadratus lumborum blocks are the best and most adopted approaches which offer optimal outcomes to patients.
PubMed: 36818482
DOI: 10.5812/aapm-127911 -
Journal of Vascular Surgery Mar 2015The supraclavicular approach to scalenectomy and first rib resection has been modified since the original description in 1985. The incision is 1 to 2 cm above the...
The supraclavicular approach to scalenectomy and first rib resection has been modified since the original description in 1985. The incision is 1 to 2 cm above the clavicle, 1 cm lateral to the midline, and 5 to 7 cm long. Subplatysmal skin flaps are created. The sternocleidomastoid muscle is mobilized on its lateral edge and retracted but not divided. The scalene fat pad is split vertically, the omohyoid muscle excised, and the C5 nerve root dissected free. The accessory phrenic nerve is identified, if present, arising medially from C5, and preserved. The rest of the plexus is dissected free, muscular and connective tissue removed from all nerve roots and trunks, and the subclavian artery identified. The phrenic nerve is identified on the medial edge of the anterior scalene muscle (ASM). The ASM is divided on the first rib. The ASM is elevated, freed, and divided as high as possible and free of C5. The middle scalene muscle is dissected. C5 and C6 branches of the long thoracic nerve are identified and protected as the portion of middle scalene muscle adjacent to the nerves of the plexus is excised. The decision on whether the first rib is to be removed is determined by whether the lower trunk of the plexus is touching the first rib. If the rib is removed, its posterior end is freed, divided, and 1 cm excised. The rest of the rib is freed from the intercostal muscles with a periosteal elevator or harmonic scalpel, the pleura is separated from the inner surface of the rib, and the anterior end divided with an infraclavicular rib cutter. The operation has been made safer by identifying and dissecting the C5 nerve root before looking for the phrenic nerve.
Topics: Anatomic Landmarks; Brachial Plexus; Clavicle; Decompression, Surgical; Dissection; Humans; Osteotomy; Patient Positioning; Radiography; Recurrence; Reoperation; Ribs; Surgical Flaps; Thoracic Outlet Syndrome; Treatment Outcome
PubMed: 25600336
DOI: 10.1016/j.jvs.2014.11.047 -
Frontiers in Surgery 2022The adoption of minimally invasive esophagectomy has been used for over a decade, and the chest part is evolving into a uniportal video-assisted thoracoscopic surgery...
The adoption of minimally invasive esophagectomy has been used for over a decade, and the chest part is evolving into a uniportal video-assisted thoracoscopic surgery (VATS) approach. Uniportal esophageal mobilization and anastomosis have many peculiar aspects, which include placement of the incision, alignment of instruments, and anastomosis. The incision is placed over the sixth intercostal space posterior axillary line. The esophagus is usually encircled at the level of the inferior pulmonary vein. The use of curved suction helps in the retraction of the esophagus and the exposure of the left main bronchus deep in the mediastinum. For intrathoracic anastomosis in Ivor Lewis esophagectomy, a completely side-to-side linear-stapled anastomosis is preferred. This anastomotic technique results in a long stapler line. The correct alignment of tissues and adequate anastomotic circumference are of utmost importance to prevent leaks or strictures. Perioperative and oncologic results in several series with uniportal VATS, esophageal mobilization, and anastomosis are comparable with open or other types of minimally invasive esophagectomy. Uniportal VATS for esophagectomy is feasible and fast with good results.
PubMed: 35402499
DOI: 10.3389/fsurg.2022.844796 -
Fujita Medical Journal Feb 2022Massive hemothorax due to multiple rib fractures and intercostal artery (ICA) injuries is one of the most lethal forms of chest trauma. Urgent thoracotomy is required;...
Extensive rib resection followed by thoracic wall reconstruction using polytetrafluoroethylene mesh and titanium plates for refractory intercostal artery bleeding induced by severe blunt thoracic injury: report of a case.
Massive hemothorax due to multiple rib fractures and intercostal artery (ICA) injuries is one of the most lethal forms of chest trauma. Urgent thoracotomy is required; however, suturing is sometimes difficult owing to the limited operative field in the thoracic cavity and because the transected ICA retracts between the surrounding intercostal muscles. We present a patient with refractory ICA bleeding induced by severe blunt thoracic injury successfully treated with extensive rib resection followed by thoracic wall reconstruction using GORE DUALMESH and titanium plates. A 66-year-old woman attempted suicide by diving into the path of a train. She incurred massive left hemothorax associated with multiple rib fractures and severe trauma to her extremities; both upper limbs and left leg at the thigh were nearly disconnected. Initially, she underwent urgent left anterolateral thoracotomy followed by partial lung resection and suture hemostasis of the thoracic wall. Subsequently, interventional radiology was performed for the ICA bleeding, and her extremities except her right leg were amputated. However, because hemothorax persisted, and because of the comminuted fractures, we removed the fifth to eighth ribs, and the ICA vascular sheath was ligated. Resecting multiple ribs caused deformities and lung herniations, although hemostasis was achieved. On the third postoperative day, thoracic reconstruction using Gore-Tex Dual Mesh and titanium plates was performed. Although a small empyema occurred, it was controlled with antibiotics and drainage. Paradoxical respiration and atelectasis did not occur, and the patient was moved to the hospital for continued care in a lucid state.
PubMed: 35233345
DOI: 10.20407/fmj.2020-026 -
Advances in Respiratory Medicine 2018Although NIV is a simple and useful method, considerable variation in its use across countries, regions and hospitals may be noted. The patient should be evaluated...
Although NIV is a simple and useful method, considerable variation in its use across countries, regions and hospitals may be noted. The patient should be evaluated according to subjective response (respiratory distress, consciousness, problems related to mask and airflow), physiological responses (respiration rate, respiratory effort, air leakage) and patient-ventilator compliance (gas exchange, pulse oximetry, arterial blood gases). Normalization in respiration rate within 1 or 2 hours after initiation of treatment is one of the most important markers for recovery. The goal is to maintain respiration rate between 20 and 30 breaths/minute. Reduction in intercostal and supraclavicular retractions, paradoxical respiration and sympathetic activity indicate success of treatment. Arterial blood gases are measured within first 2 hours in order to assess pH and CO2; and as needed thereafter. In general, NIV is assessed by arterial blood gases, hemodynamic parameters and several laboratory tests. There is limited number of studies in NIV. Here, we aimed to assess radiological implications of gas distribution within lung tissue during NIV therapy.
Topics: Blood Gas Analysis; Humans; Noninvasive Ventilation; Positive-Pressure Respiration; Pulmonary Disease, Chronic Obstructive; Respiratory Insufficiency; Respiratory Physiological Phenomena; Respiratory Rate
PubMed: 30378652
DOI: 10.5603/ARM.2018.0038 -
Current Health Sciences Journal 2022A male infant, one month old, weight 4000 g, breastfed only, no pathological history, was admitted to the 2 Pediatric Clinic, Clinical Emergency County Hospital in...
A male infant, one month old, weight 4000 g, breastfed only, no pathological history, was admitted to the 2 Pediatric Clinic, Clinical Emergency County Hospital in Craiova with fever and cough. Clinical findings when he was admitted: fever 38.7°C, perioral cyanosis, spastic cough, expiratory dyspnea, intercostal retraction, polypnea, subcrepitant rales in the right lung area. The chest x-ray revealed pneumonia aspect in the right middle perihilar region. He was administered antibiotic treatment, HHC, antithermics, with a favorable evolution. The control x-ray, when the infant was in a fair general state, with no disease symptomatology, pointed out a cystic formation at the level of the right middle lobe. The pulmonary CT revealed cavitary lesion, with a diameter of about 40mm in the right lung, and with the presence of septa to the interior and air content. The infant was urgently transferred to Marie Curie Hospital in Bucharest, where the cyst formation was removed through a surgical procedure. The anatomo-pathological examination revealed a bronchogenic cyst. The evolution was favorable after the surgical procedure.
PubMed: 35911936
DOI: 10.12865/CHSJ.48.01.20 -
Annals of Cardiothoracic Surgery Jan 2023The da Vinci single-port system (SPS) has been applied in several fields of surgery; however, only a few studies have reported its applications in general thoracic...
BACKGROUND
The da Vinci single-port system (SPS) has been applied in several fields of surgery; however, only a few studies have reported its applications in general thoracic surgery. This retrospective study aimed to investigate the multi-institutional experiences of applications of SPS in Korea.
METHODS
The surgical outcomes of three institutions in Korea were collected and retrospectively reviewed.
RESULTS
A total of 39 surgeries were performed using SPS without conversion to multiport surgery. The patients included 16 males, and the mean age was 54.2±12.4 years. The most common pathological diagnoses were thymoma (18 cases) and benign cystic lesions (10 cases). The approach used for SPS was subxiphoid, subcostal, and intercostal in 26, 10, and 3 cases, respectively. All patients underwent the surgeries without postoperative complications. The median operation time and peak pain score were 121.4±45.4 min and 3.1±1.1. The median duration of chest tube and hospital stay was 1.3±0.6 and 2.9±1.2 days, respectively.
CONCLUSIONS
The application of SPS for general thoracic surgery was safe and feasible, whereas its applications remain limited to simple cases. To enable the widespread use of SPS surgery, alleviation of cost-related problems and technical improvement of SPS for complex procedures are required.
PubMed: 36793990
DOI: 10.21037/acs-2022-urats-157 -
Journal of Visualized Surgery 2017Classical video-assisted thoracic surgery (VATS) approach to esophageal cancer uses four incisions. The rationale is to facilitate movement of the instruments and the...
Classical video-assisted thoracic surgery (VATS) approach to esophageal cancer uses four incisions. The rationale is to facilitate movement of the instruments and the esophagus and also suturing during placement of a purse-string suture for an intrathoracic anastomosis. Uniportal VATS (U-VATS) is challenge for surgeons, as you have to do an esophageal mobilization and anastomosis from a single 3-5 cm incision. The incision is placed either at the 5th or 6th intercostal space close to the posterior axillary line. Esophagus is mobilized en bloc with the subcarinal and periesophageal lymph nodes. The crucial parts are inclusion of subcarinal lymph node in the specimen, mobilization of the specimen from the left main bronchus and esophagogastric anastomosis. Esophagus is encircled with a thick penrose drain and retracted anterior and posteriorly during this dissection. Once the esophagus is completely mobilized, if an intrathoracic anastomosis is to be performed, gastric conduit is pulled inside the chest in correct orientation. A linear completely stapled side to side anastomosis is performed. A thick tissue endoscopic stapler is used for posterior and anterior wall. A single chest drain is placed and incision is closed. There are several intrathoracic anastomotic techniques. All of these techniques can be applied through a uniportal approach. Side to side completely stapled anastomosis is safe, fast and easy to perform. There is a single report on esophagectomy comparing uniportal and multiportal VATS approaches in esophageal cancer which showed comparable results in terms of duration of surgery, amount of bleeding, lymph node yield and leak rates. U-VATS for esophageal cancer is emerging as a new approach and the technique is feasible and certainly future studies will show if it is reproducible and provides a clinical advantage for the patient.
PubMed: 29302432
DOI: 10.21037/jovs.2017.09.14 -
Revista Da Sociedade Brasileira de... 2018The most frequent jellyfish in Southern Brazil causes mainly local pain and skin plaques. A 3-year-old female bather presented an erythematous, irregular plaque on the...
The most frequent jellyfish in Southern Brazil causes mainly local pain and skin plaques. A 3-year-old female bather presented an erythematous, irregular plaque on the left forearm after contact with a jellyfish and intense facial angioedema with facial flushing. The lungs had vesicular murmur, wheezes, and snorts, and pink and spumous secretion in the airways with intercostal retraction. She was administered subcutaneous adrenaline (0.1mg/kg) and hydrocortisone intravenous (10mg/kg) with total recovery in a few minutes. The manifestations of anaphylactic reactions are distinct from those of envenomations, and prompt and adequate care is fundamental in these situations.
Topics: Anaphylaxis; Angioedema; Animals; Bites and Stings; Child, Preschool; Cnidaria; Cnidarian Venoms; Female; Humans
PubMed: 29513832
DOI: 10.1590/0037-8682-0044-2017 -
Annals of Translational Medicine Nov 2021Effective traction and dissection of the esophagus are key steps during thoracoscopic esophagectomy. In traditional methods, a separate trocar for the traction...
BACKGROUND
Effective traction and dissection of the esophagus are key steps during thoracoscopic esophagectomy. In traditional methods, a separate trocar for the traction instruments or thoracic punctures are adopted to externally retract the esophageal loop. However, both methods bring about chest wall damage that is associated with increased morbidity and mortality. The magnetic anchoring and traction system can not only achieve exposure and pulling multi-directional flexible but also reduce the number of transthoracic ports and trocars used, and then avoid the chopstick effect in surgery. We aimed to verify the feasibility and safety of a self-designed magnetic anchoring and traction system in assisted thoracoscopic esophagectomy.
METHODS
Ten healthy pigs were used as the experimental objects. A magnetic anchoring and traction system composed of an external unit and internal unit was designed, then the requirements and stress characteristics of esophageal pulling and exposure during thoracoscopic esophagectomy were analyzed. The internal unit was introduced through the 5th intercostal space port and was secured to the right wall of the esophagus, the external unit was placed on the surface of the chest wall to allow pairing with the internal unit. The external unit was moved on the chest wall to help exposing operative field.
RESULTS
Ten pigs underwent a 3-port thoracoscopic esophagectomy using a magnetic anchoring and traction technique, and all operations were successful. The system provided adequate traction force to pull the esophagus. The external unit could move freely outside the chest wall, enabling suitable positioning of the esophagus for dissection.
CONCLUSIONS
The novel magnetic anchoring and traction system in thoracoscopic esophagectomy is safe and feasible, and has the potential for clinical application.
PubMed: 34988172
DOI: 10.21037/atm-21-5359