Google Glass for Surgeons

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.

Absite changes for 2014

The ABS recently released their changes for the absite.  Here is a brief summary of the high points.

  • Junior and Senior exams will be combined, and their will only be one exam from now on.
  • This exam will continue to be 5 hours in length and given in an online format
  • The information covered on the exam will be from the score SCORE Curriculum Outline seen here in PDF format.
  • Made available to all ACGME residency programs.  If  you are not associated with an ACGME program you can take it if you can find a program director that will let you take it. Also offered to integrated vascular residencies.
  • There continues to be an interactive sample text here to learn the testing system.

 

Specific Warning Signs of Colorectal Complications

Just a few interesting facts from this press release by the FACS.  They cite that there are 600,000  colorectal operations performed per year and that 11.4% of colorectal patients are back in the hospital within 30 days, stay an average of 8 days, and cost the country 300 million dollars. These are some pretty impressive numbers and warrants investigation and intervention. They set out to define early warning signs to identify problems earlier and bring them to the attention of the surgeon.  The panel of 11 experts came up with the following:

  • wound drainage, opening, or redness (all three of these signs can indicate an infection)
  • no bowel movement or lack of gas/stool from any ostomy for more than 24 hours
  • increasing abdominal pain
  • vomiting
  • abdominal swelling
  • high ostomy output and/or dark urine or no urine
  • fever greater than 101.5
  • not being able to take anything by mouth for more than 24 hours

And also added medical symptoms warranting ER evaluation as:

  • chest pain
  • shortness of breath

I think it’s important to focus on the patient education aspect of addressing the re-admission problems. There is a window of opportunity to prevent minor complications from becoming major complications and the patients are the best one’s to monitor these symptoms and bring them to appropriate physican’s attention.

Behind the Scenes Robot in the OR

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.

Fluorescent Surgery

A surgical oncologists dream is to be able to see the extent of the tumor they are resecting while they are operating room. Experimental fluorescent molecules have the capability to make tumors light up in the operative field. Very similar to the Firefly system on the Da Vinci Robot, these molecules can be tagged to tumor cells which then glow when exposed to certain wavelengths of light.  While this may be huge for surgical oncologists, I am excited to see what happens when it becomes widely available and we find other uses for it.

Watch the TEDMED video below to see a possible future of surgical intervention:

Epidural as DVT prophylaxis

Cancer patients undergoing major oncologic surgery may decrease their risks of deep venous thrombosis(DVT) and Pulmonary Embolism(PE) by using an epidural for pain management. In a recent article published in JAMA Surgery(Previously Archives of Surgery) titled Thromboprophylaxis and Major Oncologic Surgery Performed With Epidural Anesthesia the surgical oncologists at Cedars Sinai note that in their retrospective analysis of their prospective database that their patients who underwent epidural anesthesia without chemical prophylaxis had similar rates of DVT to those that had chemical prohpylaxis.

epidural.

The author states that a previous review of 26 randomized controlled trials in surgical cancer patients yielded a DVT rate of 35.2% in those without any prophylaxis, 12.7% in those with chemical prophylaxis alone, and 5% with chemical and mechanical prophylaxis.  They then reviewed 119 patients of theirs that had an epidural and no chemoprophylaxis but did have mechanical prophylaxis and early ambulation, and noted that their asymptomatic screening ultrasounds had detected a 6.7% DVT rate and that only 0.8% had above knee thrombosis. Of note some of these patients did receive chemical prophylaxis after the epidural was discontinued.

I was previously unaware that spinal anesthetics had demonstrated decreased DVTs and would have expected these results only because of better pain control resulting in better and earlier ambulation.  The article cites several articles from orthopedic literature that demonstrate decreased thrombotic events with spinal anesthesia as well. Some of the theories of the mechanism for this include decreased sympathetic response with epidural anesthesia resulting in improved lower extremity blood flow and cite that sympathetic stimulation alters levels of coagulation factors resulting in increased Factor VIII, inhibited fibrinolysis, decreased antithrombin III, and increased platelet aggregation. Apparently the systemic absorption of local anesthetics can act as a anticoagulant.

Take away message for me: There may be some evidence that we can be less aggressive in chemical prophylaxis in patient with epidural anesthesia.

 

Surgical Simulator Nightmare

Once open surgery is dead and it’s all NOTES, and IR interventions, we will have this as our open surgery simulator! I want to get my FOS(Fundamentals of Open Surgery) pin to go along with my FLS(Fundamentals of Laparoscopic Surgery) pin.

You have to hand it to the creators of the game, apparently they made the simulator in less than 48 hours.

You can play the game here, but it requires a plugin install.

Literature Review: Anastomotic Leakage after Laparoscopic Rectal Cancer Operations

While the risk factors for anastomotic leakage have been well defined for open procedures, there is a paucity of data demonstrating the risk factors when the procedure is performed laparoscopically. The Korean Laparoscopic Colorectal Surgery Study group set out to generate this data and published it in the Annals of Surgery article Multicenter Analysis of Risk Factors for Anastomotic Leakage After Laparoscopic Rectal Cancer Excision.

This study utilized 11 hospitals and 12 surgeons between January 2006 and  March 2009 collecting data on 1734 patients who underwent laparoscopic surgery for rectal cancer. While there were many similarities in how these surgeons performed the surgery, the decision of whether or not to perform a protective ostomy varied widely among the surgeons and institutions with the low being 3.9% and the high 62.5%. They defined anastomotic leakage as passage of fecal materal from a drain, pelvic abscess, or peritonitis.

There were 101 leaks in the study giving a leak rate of 6.3% leak rate. On comparison between surgeons and institutions they found that surgeon prior experience did not affect the leak rate and neither did the caseload throughout the study. At institutions with the highest stoma rate, the leak rate was the lowest(4.6%) and 7.9% at the institution with the lowest rate.

Risk factors for leak were then analyzed using the whole data set and the non-diverted data set.

Diverted and Non-Diverted:

  • Male Gender(HR 1.943)
  • Advanced Tumor Stage(HR 2.842)
  • Perioperative Transfusion Requirement(HR 8.432)
  • Multiple Firings of the Linear Stapler(HR 7.849)

Non-diverted

  • Male Gender(HR 3.468)
  • Advanced Tumor Stage(HR 2.520)
  • Tumor Located Less than 7cm(HR 2.418)
  • Preoperative Chemoradation(HR 6.284)
  • Perioperative Transfusion Requirement(HR 10.705)
  • Multiple Firings of the Linear Staple(HR 6.181)

In addition to identifying the risk factors, they propose that any patient having 2 or more of these risk factors should undergo protective stoma formation secondary to the high risk of anastomotic dehiscience.

 

Additional Learning Points from the article:

  • Conventional open leak rates: 3.9 to 11
  • Open risk factors for leakage: Low Lying(below 7cm), Male sex, Advanced tumor stage, Multiple linear firings of the stapler, preoperative chemoradiation, and perioperative bleeding.
  • Increased risk of local recurrence, and reduced long term survival  after pelvic sepsis
  • Stoma closure morbidity rates 36.5%, Mortality rates 1.4%
  • Anastomotic leak rate traditionally has a 6% to 30% mortality rate.