New Laparoscopic Devices from Ethicon
On August 26th 2014 Ethicon released several new laparoscopic devices with a Bariatric focus. These devices included:
- ECHELON FLEX™ GST SYSTEM – A new powered laparoscopic stapling system that grips the tissues to prevent slipping and allowing better formed staples, and may result in fewer staple loads used in a case. I suspect most likely to use less staple loads in a gastric sleeve resection.
- ENSEAL® G2 Articulating Tissue Sealer – a 5mm – 45cm articulating energy device. Giving extra length for dividing tissues plus the ability to come across vessels at a 90 degree angle. They tout that 90 degree angle is 28% stronger than coming across a vessel at a 45 degree angle.
- HARMONIC ACE®+7 Shears – the only purely ultrasonic device with a 7mm vessel indication. “Provides advanced hemostasis and precision dissection, while generating less heat.”
Check out the press release here.
Fighting Post Operative Ileus
Whether or not you believe pain is the fifth vital sign, a new objective measurement of “intestinal rate is being tested out called “Abstat”. The device is essentially an electronic stethoscope that is placed on the patients lower abdomen. The sound is then analyzed by a computer to detect bowel function and more specifically to identify the lack of intestinal function in conditions such as Post Operative Ileus(POI).
I can see this being most useful to avoid the immediate re-admission of the post-surgical patient who begins to manifest his ileus on the car ride home. Post operative ileus is the enemy of ERAS(Enhanced Recovery After Surgery) protocols, and I don’t believe it will be two long before this integrated into these programs. Objective measurements of bowel function will go a long way in helping us figure out how to prevent and maybe even solve many of our post operative ileus problems.
Check out the Medgadget article.
Check out the Data published in Journal of Gastrointestinal Surgery.
Check out the UCLA press release.
Ultra High Def Laparoscopy
How many pixels do we need to safely perform surgery? The standard definition televions used when laparoscopy first became standard had a resolution of about 640×480 and were viewed on CRT monitors. More recently we have seen high definition laparoscopy systems of 1920×1080 despite some of them using model numbers like 1288 that made me think they were higher than 1080p camera’s until I recently looked it up.
I recently read a few news articles about the testing of an 8K Ultra High Def Laparoscope. It was tested on animal and a cholecystectomy was actually performed. While the researchers interviewed in these articles rant and rave about the level of detail they could now see with this technology I doubt this detail influenced how the procedure was performed or any clinical impact. So what is the advantage of having such high resolution to laparoscopy:
Digital Zoom. An 8K camera has the resolution of 16 1080p(1920×1080 cameras). This may allow the camera to better stay out of the way of the instruments.
Digital Zoom w/ Pan capabilities. You may be able to require less of your camera driver if the surgeon has the ability to digital zoom and pan the camera to view the working field. This will require a wider angle lens and much better lighting system through the camera but could definately save the surgeon some frustration.
3d 4k laparoscopy. While 8k is obviously too much, our next step would be to 4k, and if we can do 8k resolutions, then 4k 3d is within the realm of our possibility.
Some interesting facts about resolutions of Laparoscopy:
Original davinci robot is 1280×720, the HD version is 1920×1080.
A single 8k Image is the equivalent of a 33 megapixel camera image.
If the detail you can see with images of resolution are compared to the 20/20 optometrist model. 1920×1080 is the equivalent of 20/20.4 whereas 8k is 20/4.68
Residents and Fellowships
General Surgery News had an article in the January edition about how residents are pursuing fellowships despite the job market not requiring fellowship training. The article can be found here. Clearly there appears to be a multitude of problems when 70% of surgery residents are entering fellowship and only 1/3rd of the job postings require a fellowship. While a lot has changed in general surgery, general surgery training, and the culture of the medical field resulting in residents wanting to specialize, I don’t think that analysis of job postings is the right way to look at it. Here are my thoughts:
- Fellowship trained physicians enter a much smaller community where job postings may not need to be as frequently utilized. Job postings are likely to be for more difficult to fill positions.
- Likely the organizations care less about your fellowship and more about how you fit into the call pool, and they want you in the general surgery call pool.
- Surgery has been in a specialization phase to keep up with the rapid advancement of minimally invasive techniques. This created a over-inflated demand for the young specialist who could do these procedures. Supply will overturn demand eventually.
- The real study should be surveying graduated fellows how completion of the training program affected their job, with a follow up survey at 3 years about the utility of their fellowship in their daily practice.
- The societies of the specialties should be the ones monitoring the utility of their fellowship and figuring out how to create maximum benefit to the graduates even if this means winding down lower tier fellowships ultimately reducing the number of members of their society. They have a duty to maintain the integrity of the specialty.
Ultimately with the proper training, good bedside manner, and excellent interactions with referring physicians you can find your niche and practice your specialty but it may become increasingly difficult to keep yourself in a specialist only practice and call pool and to fend off the wave of incoming newly minted specialists.
Great strides have been made in moving treatments into the less expensive outpatient setting. Diverticulitis is one disease process that we have become more and more aggressive in our outpatient management and a newly published randomized controlled trial shines high level evidence on this trend.
Article in Annals of Surgery, should be a free PDF too.
In a multicenter randomized controlled trial, researchers randomized uncomplicated diverticulitis patients in to two groups. Group 1 was hospitalized for minimum of 36h and given IV antibiotics and then discharged on PO antibiotics, Group 2 was given IV antibiotics in the ER and sent home on PO antibiotics.
While there were many worthwhile exclusion criteria included one, in particular bothered me “absence of symptom relief (maintenance of tenderness, fever, or/and persistence or worsening of acute pain after analgesic and first doses of antibiotics)” as this seems to subjectively select for the milder forms of diverticulitis. Which also plays out in the analysis of the patient populations as the mean WBC count was 11.1 for the two groups.
Ultimately their analysis demonstrated no difference between the inpatient and outpatient groups. So what does this mean… Unfortunately the most that I can take away from this evidence is that mild diverticulitis should be treated as an outpatient. Most physicians know this and their practice patterns reflect this.
I would have liked to have seen the study without the above mentioned exclusion criteria, to see whether or not the more severe diverticulitis patient’s benefited from hospitalization.