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.”
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.
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
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.
If you were surfing anywhere techy or healthcare related today, you probably noticed Google’s announcement about their new contact lens that senses glucose levels and transmits it to a smart phone. They refer to it as their “Smart Contact Lens Project” but I like Google Glass Glucose edition better. This is a gigantic step forward in Google’s wearables, and possibly a huge pain killer for diabetics around the world.
I am curious how long it will be until my surgical patients come in wearing a glucose sensing contact lens and I have to answer a nurses phone call about whether or not to do Q6H or QACHS fingersticks or how often to get a reading from a contact lens. Will the anesthesiologists leave the contact in during general anesthesia and be expected to provide tight glycemic control during procedures on diabetics(likely some piece of code in the Google Cloud will control the drip for them). Maybe we can finally sort out the literature on tight glycemic control and surgical outcomes. If this solution works it will have huge ramifications on the treatment of our diabetic patients.
SICKO is a surgery related educational game designed to aid learners in applying didactic learning to clinical situations. I found the game to be both entertaining and educational. It broke free from the boredom of standard case presentation interactive software by having you manage multiple patients under time constraints, and giving you feedback as you correctly manage the patient rather than waiting till the simulation is over. The patients are represented by cards, and give you an idea of how they are doing by dropping to the bottom of the screen.
I did notice that I kept getting docked points for putting NG tubes in patients, I guess I was trained to aggressively put NG tubes in early on patients with vomitting or obstructive patterns on imaging.
While playing around with the software I was chatting online and let a patient sit too long who I ultimately diagnosed with appendicitis. Apparently as a result of my delay the patient perforated and developed an abscess there in the ER. I lost points for that.
After you make a decision to operate, you have to know enough of the diagnosis to pick out an operation to perform. You then answer multiple choice questions about different problems that you could encounter with intra-operatively and post-operatively.
Overall I thought the simulator was one of the better ones I have tried. I think that it would be a great tool for medical students and lower level residents and maybe even higher level residents working with more diagnosis.
Just came across this Single incision robotic platform the other day. I think the biggest factor for the success of robotic surgery will be competition to improve the function and utility of these systems while driving down the costs. So I watched the video found:
I think it looks like a good SILS platform, but they failed to demonstrate a solution to my main problem with the DaVinci system. In laparoscoyc or single incision laparoscopy you can aim your instruments with little effort in various quadrants of the abdomen. For example in rectal surgery you can work in the pelvis, and then mobilize the left colon, and even takedown the splenic flexure with minor adjustments. With the DaVinci system it takes a major repositioning of the operating platform. I was hoping that SILS systems would solve this problem and allow freedom of working throughout the abdomen. Maybe the Titan medical “SPORT” can they just didn’t demonstrate it in this 5 minute video.
I’ve been watching the Google Glass project for a while now thinking of possible applications in surgery. Clearly the video output could be used to stream views to monitors within the room to allow all team members to see what the surgeon with the best view can see, and it would make it extremely easy to video record rare cases for use in teaching.
Use of the viewer seems like a double edge sword, as it may be incredibly useful when you want to see the patients vitals, or to review imaging such as CT scans under your own control while in a case it could be incredibly distracting. I’ll just have to try it out and see.
A couple of less obvious thoughts that I’ve had for uses:
1) Intraoperative visual consults: Obviously you gain a lot in surgery by touch, but if you just want another visual opinion, this could be easily done, and could easily be done with surgeons who are operating simultaneously wearing the glass.
2)Pathologists could send their camera output to the surgeon to demonstrate where the positive margin is.on the resected tumor.
3)Pseudo-Autonomy for residents. The attending connects to the residents camera output to monitor the procedure progression and offer suggestions without actually having his hands in the field
4) Remote/Stealth Rounds – Have the intern or midlevel provider round with Glass on. Then document LGFG(Looks Good From Glass).
Anybody willing to spot me $1500 for a developer edition set of Glass would get a serious thank you.
GE is working on a robot that will run behind the scenes in the operating room. Their intent is to automate instrument transport and processing and hopefully will cut costs and demonstrate quality improvement effects unlike other robots in the operating room that still have controversy about their use. Part of this system will involve technology to identify surgical instruments via RFID during the collection process as well as building trays for future cases. I’m interested to see if the robot will participate in counting at the end of the case to standardize instrument counting and use the RFID as an extra layer of protection. The video is a little anti-climactic but explains the idea behind developing this technology for the OR.