Day 2 :
Johns Hopkins Bayview Medical Center, USA
Keynote: Awake craniotomy anesthesia: A comparison between the monitored anesthesia care (MAC) versus the asleep-awake-asleep (AAA) technique
Time : 09:30-10:00
Punita Tripathi was a practicing Cardiac Anesthesiologist at the All India Institute of Medical Sciences (AIIMS), New Delhi, before moving to USA in 1996. Thereafter, she completed her Residency in Anesthesiology from Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA in 2002. Since 2002, she is a Faculty at the Johns Hopkins University, Baltimore. For the past five years, she has been Director of Neurosurgical Anesthesia at Johns Hopkins Bayview Medical Center and has been actively involved in writing protocols for Awake Craniotomy and Anesthesia for neurosurgical cases. Her areas of research interests are as follows: Neurosurgical Anesthesia, Thoracic Anesthesia and Obstetric Anesthesia. She has authored papers in many reputed journals and has written book chapters.
Introduction: Awake craniotomy (AC) with intraoperative brain mapping, allows for maximum tumor resection while monitoring neurological function. It is used for lesions involving the eloquent areas of the brain, such as Broca's, Wernicke’s, or the primary motor area. Common techniques used are monitored anesthesia care (MAC), using an unprotected airway, or the asleep-awake-asleep (AAA) technique, using a partially or totally protected airway. Comparative analysis between the MAC and AAA technique in a consecutive series of patients undergoing the removal of an eloquent brain lesion is being presented.
Method: Approved by the appropriate Institutional Review Board (IRB), requirement for written informed consent was waived by the IRB. A prospective data collection and subsequent retrospective data analysis was conducted on 81 patients who underwent an awake craniotomy for an eloquent brain lesion over a nine year period. Fifty patients underwent anesthesia with the monitored anesthesia care (MAC) technique and 31 patients underwent the asleep-awake-asleep (AAA) technique by a single surgeon and a team of anesthesiologists. The monitored anesthesia care technique included, and was based on, no set protocol for sedation, different medications for MAC based on the comfort level of anesthesiologist, requirements of the patient and whether the scalp block is working well. Nose was sprayed with phenylephrine and the posterior pharynx was sprayed with lidocaine; the nasopharyngeal airway was coated with 5% lidocaine ointment which was then inserted into the more patent nostril, connected to the anesthesia circuit for oxygenation. For the AAA technique, propofol was used for induction, followed by laryngeal mask airway placement (LMA). An anesthesia circuit was attached to the LMA with the anesthesia being maintained with sevoflurane until the patient was spontaneously ventilating and asleep. A complete scalp block of the supraorbital, supratrochlear, auriculotemporal, zygomatico-temporal, greater occipital, lesser occipital and greater auricular nerves was performed by the neurosurgeon or anesthesiologist (Figure 1) in all patients. Infiltrative block was performed at the pinning site and also the incision site. After craniotomy, local anesthesia was infiltrated around the nerves supplying the dura mater by the surgeons.
Results: Similar preoperative patient characteristics were observed in the two groups (Table 1). Operative time was shorter in the MAC group (283.5 mins.) versus the AAA (313.3 mins, p=0.038), by about 30 minutes. Hypertension was the most common intraoperative complication (MAC: 8% vs. AAA: 9.7%, p=0.794). Intraoperative seizures incident were 4% in the MAC group and 3.2% in the AAA group (p=0.858). Awake cases conversion to general anesthesia occurred in none of the MAC groups and 3.2% of the AAA cohort (p=0.201). No cases were aborted in either of the cohorts (Table 2). Mean hospital stay was 3.98 and 3.84 days in the MAC and AAA group, respectively (p=0.833) (Table 3).
Conclusion: Successful awake craniotomy requires cooperation between the surgeon and anesthesiologists, a working scalp block and infiltrative block, a good understanding of airway management and sedation protocol, as well as the ability to manage adverse intraoperative issues. Both MAC and AAA provide safe and effective anesthetic management for awake craniotomy.
University of Saskatchewan, Canada
Time : 10:00-10:30
Samar Tabl is a Clinical Associate Professor at the University of Saskatchewan, Canada. She is a Graduate of the Faculty of Medicine, Ain Shams University, Cairo, Egypt, and has trained in both Egypt and Canada. She holds both Masters and PhD Degrees in Clinical Anaesthesia. She also did a Research Fellowship in Obstetric Anaesthesia at Mount Sinai Hospital, University of Toronto, Canada. Her areas of research interests include: Obstetric Anaesthesia, Ultrasound Guided Regional Techniques in Obstetric Anesthesia, Airway Management and Simulation Education.
Purpose: The purpose of the study was to compare the efficacy of two doses of carbetocin—20 mcg and 100 mcg—in women undergoing elective cesarean delivery.
Methods: The study was conducted as a randomized double-blinded, non-inferiority study in women undergoing elective cesarean delivery under spinal anesthesia. They were randomized into two groups to receive either 20 mcg or 100 mcg of carbetocin, intravenously upon delivery of the anterior shoulder of the baby. Uterine tone was assessed by obstetrician at two and five minutes after carbetocin administration, according to a numerical verbal scale of 0 to 10 (0=atonic uterus and 10=firm uterus). If the uterine tone was considered unsatisfactory by the obstetrician and additional uterotonic was deemed necessary, this was administered according to usual practice at our hospital (oxytocin and/or ergot and/or hemabate). The primary outcome was the uterine tone at two minutes after carbetocin administration. While, the secondary outcomes were uterine tone at five minutes, use of additional uterotonics within 24 hours, blood loss, hypo/hypertension, brady/tachycardia, nausea/vomiting, chest pain/shortness of breath, headache and flushing.
Results: There was no significant difference in the uterine tone [mean (SD)] at two minutes between 20 mcg [7.5 (1.9)] or 100 mcg [8.0 (1.5)] groups (p=0.06). Nine patients required additional uterotonics in the 20 mcg group, versus seven patients in the 100 mcg group (p=0.53). There was no significant difference in the uterine tone at five minutes in the two groups or the incidence of side effects. The mean (SD) estimated blood loss was 889.6 (536.2) mL in 20 mcg and 795.4 (428.8) mL in 100 mcg group (p=0.33).
Conclusion: Our study suggests carbetocin 20 mcg is not inferior to 100 mcg in producing adequate uterine tone in women undergoing elective cesarean delivery. Further studies are warranted in women at risk for postpartum hemorrhage.
Wake Forest University, USA
Keynote: The combined use of acellular urinary bladder matrix with negative pressure for treatment of complex lower extremity wound coverage
Time : 10:30-11:00
Claire Dillingham is a Board-Certified Plastic and Reconstructive Surgeon. She is currently, the Medical Director of Safety and Quality at her local hospital. She was the Medical Director of a wound care facility for five years. She teaches advanced techniques in wound care management to Surgery and Medicine residents. Her focus is on the patient as a whole for improving nutritional status, body dynamics, diabetic control, treatment of peripheral vascular disease, compression of lower extremities, and implementation of advanced wound care modalities.
Statement of the Problem: Patients with complex wounds can be a challenge to heal. The longer the wound is present the higher the complication rates which can lead to severe infections, loss of function, loss of a limb and even death. Traditional methods of wound healing have a place in initial wound care such as wet to dry saline gauze dressing changes. However, the implementation of this treatment requires an available and capable person to do the dressing change three times a day which is often not an option. The aging population also means higher rates of comorbid diseases which contribute to poor healing.
Purpose: The purpose of this study is to review the essentials in wound healing and describe the treatment modality of Acellular Urinary Bladder matrix (UBM) (MatriStem, ACell Inc. Columbia, MD, USA) with negative pressure therapy (KCI) for complex wounds.
Methodology & Theoretical Orientation: A retrospective review was performed of 4 patients with complex lower extremity wounds. All patients were treated with surgical debridement of the wound and placement of ACell (MiroMatrix powder and Multilayer Wound Matrix sheet) and negative pressure wound therapy. Two patients had traumatic wounds. One patient had diabetes and a previous contralateral below knee amputation. One patient had diabetes and pyoderma gangrenosum. The patients were evaluated weekly and the dressing changed weekly. Additional Acell was applied if there was a remaining deficit in the depth of the wound.
Findings: Closure was achieved in all four cases with the combined treatment of Acell and negative pressure therapy. Patients expressed pain relief and convenience with once a week dressing changes.
Conclusion & Significance: In the treatment of complex wounds, porcine urinary bladder matrix devices offer an option that has shown advantages to traditional modalities with successful closure and aesthetically acceptable results.
- Plastic Surgery | Robotic Surgery | Oncology and Surgery | Regional Anesthesia | Surgery Anesthesia | Critical Care | Sedation
Location: Lucan Suite
Wake Forest University Medical School, USA
Advanced Nucleus in Plastic Surgery, Brazil
Time : 11:15-11:35
Felipe Massignan is a plastic surgeon member of Sociedade Brasileira de Cirurgia Plástica (SBCP) and American Society of Plastic Surgeons (ASPS). He is an enthusiastic medical doctor in his expertise, adding current technical concepts with artistic skills that have been developed since the beginning of his career. He especially distinguishes himself in body contouring plastic surgeries. He has been seeking to improve his professional development in major centers around the world. Currently, he has virtually become a reference in his field by using ultrasound liposuction in high definition.
Statement of the Problem: Historically, many approaches have been used to remove adipose tissue during liposuction. Throughout the natural refinement process, improvements were achieved by refining various aspects of the procedure, such as surgical technique, cannulas and the use of adjuvant devices. In this aspect, it is a walk without a finish line. There are no definitive goals, only goals to overcome. Traditional liposuction still faces the problem of being often a strenuous procedure and considered by some surgeons with as a technique without much refinement. In this sense, any initiative capable of generating load reduction and mechanical stress is a potential optimizer of results. The third-generation ultrasonic device VASER (vibration amplification of sound energy at resonance), is intended to bring greater safety and satisfactory results, especially in the quest for higher definition and superficial liposuction.
Methodology & Theoretical Orientation: A retrospective study was performed by analyzing the medical records of patients who underwent liposuction procedure to improve body contour with the aid of VASER, from January 2015 to June 2017, at the Santa Mônica Hospital Center in Erechim , Rio Grande do Sul, Brazil. Surgical complications were evaluated and compared with the available medical literature.
Conclusion & Significance: The medical literature, as well as our analysis, seems to demonstrate that the use of VASER in liposuction procedures for improving body contouring presents as a safe approach with low rates of complications. The potential risks of using an ultrasonic device, such as overheating leading to tissue ischemia, are mostly believed as result of inappropriate device use.
University of Central Florida, USA
Time : 11:35-11:55
Sharona Ross, MD FACS served in the Israel Defense Forces. She moved to the US to attain her undergraduate degree and received her Medical Degree from the George Washington University School of Medicine. After General Surgery residency training at the University of South Florida, she completed two Fellowships, one in Advanced GI Minimally Invasive Foregut & HPB Surgery and the other in Gastroenterology and Endoscopy. She is a Professor of Surgery at the College of Medicine, University of Central Florida, USA. She is also the Director of the Advanced GI Foregut and HPB Surgery Fellowship at Florida Hospital Tampa, USA. As the Director of MIS and Surgical Endoscopy at Florida Hospital Tampa, she continues to develop new and innovative techniques to promote the safety and application of minimally invasive laparo-endoscopic single site (LESS) surgery and robotic surgery. She is one of the few surgeons to offer patients robotic complex abdominal operations for malignancies of the esophagus, stomach, pancreas, biliary system, gallbladder, liver and small bowel. She has numerous peer reviewed publications and book chapters to her credit. She is also the Founder and Chair of the International Women in Surgery Career Symposium.
Introduction: As minimally invasive surgery continues to progress; robotic surgery is finding its application for complex abdominal operations. This study was undertaken to document our continued development of proficiency with robotic pancreaticoduodenectomy (PD).
Methodology: With IRB (Institutional Review Board) approval, the first 128 patients undergoing attempted robotic PD (pancreaticoduodenectomy) at a single institution have been prospectively followed. Patient demographics and outcomes were analyzed. Clavien scores of I-IIIb are defined as minimal severity. Operative duration was defined as time from incision to dressing application. Data are presented as median (mean±SD).
Results: 61% of patients were men, of age 69 (68±10.9) years, BMI 26 (27±7.5) kg/m2, and ASA class 3 (3±0.6). 77% of patients were diagnosed with adenocarcinoma. 21% of attempted robotic PD were converted to ‘open’ operations; operations converted to 'open' decreased with time (p<0.05, Figure). Operative duration (424 (425±113.6) minutes) did not change over time. 62% of resections were R0 and 38% of resections were initially R1 that were converted to R0. EBL (estimated blood loss) decreased with time, was minimal in patients undergoing robotic PD, and was greater in patients converted to ‘open’ PD (p<0.05). LOS (Length of stay) was longer for operations converted to ‘open’ PD (8 (12±13.1) days] than those completed robotically (5 (8±8.7) days, p<0.05]. Postoperative complications and in-hospital mortality were lower in operations completed robotically (p<0.05). Overall, 49% of patients experienced postoperative complications (e.g., infection, urinary retention, respiratory insufficiency) the majority of which, 78%, were of minimal severity. Of the procedures completed robotically, 45% of patients experienced postoperative complications with 85% of minimal severity.
Conclusions: Experience with robotic PD led to fewer conversions to ‘open’ and less EBL, but not shorter operative times. Operations converted to ‘open’ had a greater EBL, more postoperative complications, and longer LOS. By 128 attempted robotic pancreaticoduodenectomy, there was notable progress in the standardization of operative conduct; however, there remains room for further improvement. Our experience indicates robotic pancreaticoduodenectomy is practical and efficacious, but with longer operative duration and a notable learning curve.
Kenan Yusif Zade holds an MD and PhD Degree from Azerbaijan Medical University, Azerbaijan. He is the Head of Military Hospital of State Border Service, Azerbaijan. His professional fields are general surgery, gastroenterology and invasive endoscopy. In 2007, he founded an Association of Turkish-Azerbaijani Endoscopic Surgeons. He is also the President-elect (2017-2019) of Ambroise Paré International Military Forum (APIMSF). His second education is business management. He holds an MBA Degree from Maastricht School of Management, The Netherlands and EMBA Degree from ADA University, Azerbaijan.
Introduction: In choledocholithiasis subject to the size of the stone and the anatomical structure of the papilla the size of the cross-section in sphincterotomy may vary. Sufficiently large incision in sphincterotomy leads to the increase in the incidence of complications after ERCP as perforation, cholangitis, and pancreatitis.
Materials & Methodology: We performed 77 ERCP (endoscopic retrograde cholangio-pancreatography) operations in patients with a diagnosis of "choledocholithiasis". In the first group (59 patients) we performed standard sphincterotomy incision in 11, 12 or 13 o’clock direction, in the second group (18 patients) - "radial" sphincterotomy. The technique of "radial" sphincterotomy we developed allows to make several lateral incisions in 11, 12 and 13 o’clock directions. Thus, the main incision can be made up to transverse fold, and other radial incisions shall be made below the transverse folds, without going beyond the boundaries of the assumed course of intramural choledoch. Thus, the complete cross section of the incision with additional insections at the radial sphincterotomy becomes 1.5 times larger than the main incision in standard sphincterotomy.
Results: In the first group periampullary diverticulum was 16.7%, while in the second group - 47.4%. Number of stones in the first group – 2.25±0.49, in the second – 2.22±0.32, sizes of the stones – 10.07±4.93 and 19.01±3.31 mm, respectively. In the first group, complications occurred in 3 (5.08%) patients: in 1 of them - post-ERCP pancreatitis, in 2 - bleeding during the session. In the second group, only 1 (5.5%) patient had pancreatitis and other early and late complications. In the first group with 3 patients - the common bile duct stone removal was achieved in two sessions with a few day interval, the remaining - in a single session. In the 2nd group, all patients required only one session. No cases of mortality occurred in any of the groups.
Conclusions: Radial sphincterotomy technique was substantiated from anatomical and mathematical aspects. The proposed technique is a safe way to increase the area of dissected papillae ensuring efficient removal of large stones through such incision.
University of Basrah, Iraq
Title: Efficacy of ultrasound guided popliteal sciatic-Saphenous adductor canal block versus ankle block in diabetic foot surgery
Time : 12:15-12:35
Nawfal Ali Almubarak is Assistant Professor of Anesthesiology, Department of Surgery, College of Medicine at the University of Basrah, Iraq. He is also the Head of Anesthesia and ICU Department at Alfayhaa General Hospital, Basrah, Iraq and a Sponsor of Iraq and Arab Board of Anesthesiology and Intensive Care. He completed his MB, ChB and Diploma in Anesthesiology and FICMS Anesthesiology under the Head of Department of Anesthesiology, Alfayhaa Teaching Hospital, Basrah.
Background: Foot is one of those parts of the body that faces so many problems such as trauma, strain, infection and other pathological conditions. Diabetes mellitus is a multi-systemic disease that affects most organs; the foot is the most vulnerable part of the body involved in the complications of diabetic syndrome. Therefore, the management of this problem is considered as a big dilemma for the anesthesiologist, orthopedic surgeons as well as the patient with regards to surgical treatment, controlling of blood sugar, foot hygiene and promoting the function of limb in the future.
Aim: This prospective study aimed to compare the effectiveness of five nerves ankle block versus popliteal sciatic with adductor canal saphenous block in diabetic foot surgery.
Results: All had full routine pre-operative investigations with Doppler ultrasound study for peripheral circulation. Patients were randomly allocated equally into two groups; group A, are those who had operation under ankle block regional anesthesia, while in group B, anesthesia was done by popliteal sciatic–saphenous adductor canal block. The outcome of this study showed significant difference between the two anesthetic techniques regarding the onset of action and efficiency of 0.75% ropivacaine in popliteal sciatic nerve block (PSNB) in comparison with five nerves ankle block. Almost all the patients and surgeons were satisfied by popliteal sciatic-saphenous adductor canal block in which there was minimal need of sedative and analgesic drugs such as midazolam or ketamine
Conclusion: The results of this study showed that popliteal sciatic–adductor canal saphenous block is more convenient and effective to provide the state of surgical anesthesia with minimal need to adjuvant sedative drugs. Best results could be obtained with the popliteal sciatic-saphenous block with only two injections instead of five; this will minimize the risk of infection as it is too far from the operative site. Also, it is faster in onset of action and provides good post-operative analgesia than ankle block.
University of Miami Miller School of Medicine, USA
Title: Effectiveness of a perioperative transthoracic ultrasound training program for students and residents
Time : 12:35-12:55
Objectives: Focused ultrasound (US) is being incorporated across all levels of medical education. While many comprehensive US courses exist, their scope is broad, requiring expert instructors, access to simulation, and extensive time commitment by the learner. We aim to compare learning across levels of training and specialties using a goal-directed, web-based course without live skills training.
Design: A prospective observational study of students and residents from medicine, surgery, and anesthesiology. Analysis compared pre- and post-tests assessing 3 competencies. Individual mean score improvement (MSI) was compared by paired-sample t-tests and MSI between cohorts by ANOVA (Analysis of Variance), with significance set at p≤0.05. McNemar’s test compared those who agreed or strongly agreed with survey items to those who did not before and after intervention.
Setting: The research study was set up at the Jackson Memorial Hospital, Miami. Florida, residency training programs in Medicine, Surgery, and Anesthesiology.
Results: 180 trainees participated. A significant MSI was noted in each of the three competencies in all three cohorts. Students’ (S) MSI was significantly higher than residents’ (R) & interns’ (I) in US “knobology” and window recognition [S=2.28±1.29/5 vs R=1.63±1.21/5 (p=0.014); vs I=1.59±1.12/5 (p=0.032)]; students’ total score MSI was significantly higher than residents [7.60±3.43/20 vs 5.78±3.08/20 (p<0.008)]. All cohorts reported improved comfort in using transthoracic US and improved ability to recognize indications for use. More than 81% of all participants reported improved confidence in performing transthoracic US; more than 91% reported interest in additional training; more than 88% believed course length was appropriate.
Conclusions: Learners across levels of medical training and specialties can benefit from a brief, goal-directed, web-based training with early incorporation producing maximal yield.
Walid Saad Alhabashy is an Anesthesia and Critical Care Egyptian Consultant with multiple certifications, including MSc, EDIC, EDAIC, Arab Board of Anesthesiology and FCAI. His main expertise is POCUS in critically ill patients particularly when complex hemodynamic management is the scenario. He finished Master’s Degree in Echocardiography from Austria, Vienna. He has conducted many national and international courses as course Instructor/Director in Egypt, Gulf area and Europe and worked under different societies, e.g. WINFOCUS and SCCM. He is the founder of YouTube Channel “US/ECHO in Anesthesia/ICU” concerned with POCUS teaching. He has built this own way after years of experience in POCUS teaching in both hospitals and education institutions.
Echocardiography is pivotal in the diagnosis and management of the complex hemodynamics of septic shock. Important characteristics are non-invasive, quick, differentiate hypodynamic from hyperdynamic sepsis and, not only, tailor management accordingly, but follow the trends as well to decide when to go up or down on each line of management. Following are three good examples of patients presented with sepsis and shock: Case1: Elderly male with presented with septic shock due to tertiary peritonitis that was previously healthy. Open laparotomy and resection anastomosis presented to ICU with refractory septic shock and severe lactic acidosis on high noradrenaline/adrenaline requirements and anuric. Echocardiography showed: Hyper dynamic left ventricle, Small right ventricle, good systolic functions, Diastolic dysfunction G II “Pseudo normal” , stroke volume variation (SVV) on left ventricular outflow tract (LVOT) showed positive fluid responsiveness. Adrenaline was replaced with vasopressin and IV fluids were delayed. Re-evaluation showed improving Diastolic dysfunction to GI, SVV on LVOT showed fluid responsiveness. one litre of CSL was infused. Eight hours later acid base status was normalized. Patient was stable enough to be extubated next day and discharged to the ward few days later. Post extubation Echocardiography showed normal ECHO study. Case2: 74-year-old man with a history of COPD presents with infective COPD exacerbation with atrial fibrillation. Intubated d.t. worsening shock, lactate/troponin rising With No ECG Ischemic changes. Bedside echocardiography showed AHFREF with RWMA, Hypodynamic left ventricle, full non-collapsing IVC, with low left ventricular end diastolic and systolic volumes with PAOP is 6 mmHg. Patient was treated with noradrenaline 2 mcg/min dobutamine 5 mcg/kg/min. and received a liter of CSL. Stable to be extubated next morning, Anti-failure measures were introduced and patient was discharged from the ICU 3 days later. Case 3: 63 years old lady presented to ED with CAP, previously healthy except for undiagnosed murmur. Fluids 3L failed to improve her hypoperfusion, Vasopressors added which failed to control the shock, she was intubated and mechanically ventilated with worsening shock. Echocardiography showed AHFREF with severe Aortic stenosis and Mitral regurgitation. Improved with Diuretics, Milrinone and weaning down of Noradrenaline. Sepsis with shock is not infrequently complex management with no clinically distinct clue which line to start with first.
Cairo University, Egypt
Title: Relationship between the resected stomach volume and early postoperative weight loss following laparoscopic sleeve gastrectomy
Time : 14:00-14:20
Mohammed Abdallah Salman, MD from Cairo University pursued Member of the Royal College Surgeons 4 years ago and MSc 6 years ago. He was a Lecturer from the Faculty of Medicine at the same university. He is an Associate FAC, consultant of general and laparoscopic surgery.
Purpose: The aim of the study was evaluation of the effect of the resected gastric volume (RGV) on weight loss after laparoscopic sleeve gastrectomy (LSG).
Patients & Methodology: This prospective study included 40 morbidly obese patients undergoing LSG. Multi Detector Computed Tomography (MDCT) was used to measure preoperative stomach volume and sleeve volume. The actual RGV was measured after surgery. The primary outcome measure was the relation between RGV and percentage of excess body weight loss (%EBWL) after 3 and 6 months respectively. The secondary outcome was early postoperative complications.
Results: The mean preoperative BMI was 43.5±4.3 kg/m2. The actual RGV was substantially correlated with that estimated by CT (r=0.996, p<0.001). The former was significantly larger with a mean deviation of 17.6 cc (95%CI: 12.2-23.0 kg). The actual and CT-estimated RGV were positively correlated with %EBWL after 3 months (r=0.361, p=0.022 and r=0.471, p<0.001, respectively) and after 6 months (r=0.466, p=0.002 and r=0.553, p<0.001, respectively). Percentage of volume reduction was positively correlated with weight reduction after 3 and 6 months (r=0. 0.525, p=0.001 and r=0.564, p<0.001, respectively).
Conclusions: The resected gastric volume during LSG was significantly correlated with weight reduction after 3 and 6 months of surgery. Sleeve volume was not correlated with early weight reduction. MDCT is a reliable method to measure gastric volume before and after surgery.
University Hospital Galway, Ireland
Title: Combined real time ultrasound scan and fiberoptic bronchoscopy for percutaneous dilatational tracheostomy: A safe technique
Time : 14:20-14:40
Ahmed Abdelaatti is currently working as an Anesthesia Registrar, University Hospital Galway (UCHG), Ireland. He has worked as an Anesthesia and Intensive Care Assistant Consultant at the King Abdullah Medical Complex (KAMCJ), Jeddah, KSA, Anesthesia and Intensive Care Registrar at the North West Armed Forces Hospital (NWAFH)), Tabuk, KSA and as an Anesthesia Specialist and Lecturer at the National Hepatology and Tropical Medicine Research Institute at Cairo, Egypt.
Introduction: This case report describes the successful use of combined ultrasound scan (USS) and fiberoptic bronchoscopy in two cases for insertion of a percutaneous dilatational tracheostomy (PDT).
Case Description: Two patients were scheduled for percutaneous dilatational tracheostomy. The first patient was a 56 year old female and the second patient was 63 year old male.
Methods: The patient’s neck was exposed and scanned in the neutral position to determine the need for an extended or regular tracheostomy tube. The neck was then extended, sterilized and draped. Higher frequency linear probe (7.5 MHZ) in a sterile sheath and fiberoptic bronchoscopy were used with two intensivists and a nurse in attendance. The midline structures and cricoid cartilage were identified in out of plane position. The probe was then rotated 90 degrees to obtain a longitudinal view of the cricothyroid cartilage, cricoid cartilage and tracheal rings. The needle was inserted between the 2nd and 3rd tracheal rings using in plane mode, with the goal of placing the puncture site between 11 and 1 o’clock on the bronchoscopy view as close as possible to the midline. The bronchoscope was used to visualize the needle insertion point and to avoid injury to the posterior wall of the trachea.
Discussion: USS of the upper airway can provide important anatomical information that would not be evident upon clinical examination alone. This includes information about the anatomy of the pre- and paratracheal regions and identification of vulnerable structures, such as blood vessels and the thyroid gland, thereby avoiding immediate vascular complications. It also enables the clear visualization of the tracheal rings, thereby facilitating positioning of the tracheal puncture and correct midline placement. Real-time US guidance makes it possible to follow the needle path during tracheal puncture and to determine the final position of the tracheostomy tube. However, intraluminal air prevents the visualization of structures such as the posterior pharynx and the posterior wall of the trachea with USS. Therefore, injury to the posterior wall of the trachea cannot be completely avoided. However, we believe that the combined use of fiberoptic bronchoscopy makes it safer by minimizing injury to the posterior tracheal wall, avoiding false passages and tracheal cartilage rupture.
Sharona Ross moved to the US to attain her undergraduate degree and received her Medical Degree from the George Washington University School of Medicine. She completed two fellowships (Advanced GI Minimally Invasive Foregut & HPB Surgery; Gastroenterology & Endoscopy). She is a Professor of Surgery at the College of Medicine University of Central Florida, USA. She is also the Director of the Advanced GI Foregut and HPB Surgery Fellowship, and Director of MIS and Surgical Endoscopy at Florida Hospital Tampa, USA. She has over 80 peer reviewed publications and numerous book chapters.
This video documents a robotic pancreaticoduodenectomy and cholecystectomy undertaken in a 70-year-old man. The patient presented upon transfer with painless jaundice and unintentional weight loss. Preoperative workup included a contrast enhanced CT scan, EGD (Esophagogastroduodenoscopy), Endoscopic ultrasound (EUS) and Fine needle aspiration (FNA) and Endoscopic retrograde cholangiopancreatography (ERCP) with stent placement. An 8 mm trocar was placed through the umbilicus for the robotic camera and two 8 mm robotic ports were placed at the right and left midclavicular lines on the same level as the umbilicus. A fourth 8 mm robotic port was placed at the left anterior axillary line halfway between the level of the umbilicus and the costal margin. Finally, an Advanced Access Gelport® was placed between the midclavicular line and the umbilicus and an AirSeal® Access Port at the right anterior axillary line. The gastrohepatic omentum was opened in a stellate fashion. The Kocher maneuver was undertaken, and the jejunum was transected using a robotic stapling device. The dissection continued along the gastrocolic omentum and the duodenum was transected just distal of the pylorus. The pancreatic neck was divided, and dissection continued along the uncinate process of the pancreas. A cholecystectomy was performed, and the distal common bile duct was transected. A laparoscopic EndoCatch bag was used to extract the specimen through the Advanced Access Gelport®. Reconstruction was initiated with a single-layer hepaticojejunostomy anastomosis followed by a two-layer pancreaticojejunostomy anastomosis. A single-layer duodenojejunostomy was constructed just distal to the pylorus. Finally, a Jackson Pratt drain was placed prior to closure. The patient tolerated the operation well and was discharged on day 3 following postoperation.