nishanth ppt[1].pptx management and symptoms

Recent advances in surgery

1. DEPARTMENT OF GENERAL SURGERY THE OXFORD MEDICAL COLLEGE, HOSPITAL AND RESEARCH CENTRE, BENGALURU Friday,feb 16,2024

2. Recent advances in surgery DATE : 16/2/2024 Presenter : Dr. Nishanth A L Chair Persons: Dr . Sushil Kumar B.V. (HOD, Department of GENERAL SURGERY) Moderator Dr manjunath Friday,December 1,2023 Department of General Surgery, TOMCH, Bengaluru 2

3. TOPICS – CHROMOENDOSCOPY ROBOTIC SURGERY NOTES

4. CHROMOENDOSCOPY TECHNIQUE OF topical application of stains or dyes at the time of endoscopy in an effort to enhance tissue characterization, differentiation or diagnosis.

5. INDICATIONS OF CHROMOENDOSCOPY Evaluation of barret’s esophagus Evaluation of esophageal adenocarcinoma Evaluation of gastric metaplasia/ adenocarcinoma Detection and charecterisation of colonic polyps Surveillence of IBD

6. IDEAL STAINS Inexpensive Readily available Applied by catheter GENERAL CONSIDERATIONS Require pre treatment by N acetyl cysteine to clear excess mucous Use of antispasmodic to decrease motility Spray catheter 2cm distal to tip Directing spray catheter tip toward mucosa and spraying the dye while rotating the shaft of the endoscope in repeated clockwise – counterclockwise fashion and simultaneously slowly withdrawing the endoscope

7. Friday,December 1,2023 Department of General Surgery, TOMCH, Bengaluru

8. Classification of stains ABSORPTIVE STAINS Lugol's solution Methylene blue Toluidine blue Crystal violet Contrast stains Indigo carmine Reactive stains Congo red Phenol red IDENTIFY SPECIFIC EPITHELIAL CELL TYPES BY PREFERENTIAL ABSORPTION OR DIFFUSION ACROSS CELL MEMBRANE SEEP THROUGH MUCOSAL CERVICES AND HIGHLIGHT SURFACE TOPOGRAPHY AND MUCOSAL IRREGULARITIES UNDERGO CHEMICAL REACTIONS WITH SPECIFIC CELLULAR CONSTITUENTS, RESULTING IN A COLOUR CHANGE SIMILAR TO Ph INDICATOR

9. Directing the spray catheter tip toward the mucosa and spraying the dye while rotating the shaft of the endoscope in a repeated clockwise- counterclockwise fashion and simultaneously slowly withdrawing the endoscope. Rinse with water from the same channel Endoscopic observation and interpretation Friday,December 1,2023 Department of General Surgery, TOMCH, Bengaluru

10. Some specific staining techniques Lugols iodine Has an affinity for glycogen in nonkeratinized squamous epithelium. 20 to 30 mL of 1.5% to 3% Lugol's solution is sprayed onto the esophageal mucosa. Normal esophagus promptly undergoes a dark green-brown to black discoloration Glycogen-depleted areas such as dysplasia squamous cell carcinoma, Barrett's epithelium and inflammation remain unstained or weakly stained S/E Can cause thyrotoxicosis Severe allergic reaction Mucosal irritation – retrosternal discomfort

11. Methylene blue Methylene blue stains intestinal metaplasia of the esophagus and stomach. Typically 0.5% methylene blue used Amount depend upon target surface area Positive staining for Barrett's intestinal metaplasia is defined as the presence of dark blue stained mucosa that persists despite vigorous irrigation S/E – Oxidative damage of epithelium Transient harmless blue discolouration of urine and stools

12. Toluidine blue Toluidine blue is a basic absorptive dye that stains cell nuclei and can identify malignant cells, in part because of their increased mitotic activity and nuclear/ cytoplasmic ratio The staining technique involves prewashing the mucosa with 1% acetic acid followed by the application of 10 to 20 mL of a 1% aqueous solution of toluidine blue Best results combined with lugols iodine Abnormal areas are stained royal blue

13. Crystal violet Crystal violet stains cell nuclei and has been applied recently in the oesophagus for the detection of Barrett's intestinal metaplasia and dysplasia 0.05% to 0.1% crystal violet solution is used Indigo carmine Indigo carmine is a deep-blue contrast stain that is used primarily in the colon for enhancing the detection or differentiation of colorectal neoplasms

14. Crystal Violet Indigo

15. Congo red Congo red is a reactive stain that changes colour from red to dark blue or black in the presence of acid ph less than 3 A dministering a secretagogue ( eg , pentagastrin 5 mg/kg) to stimulate acid production, rinsing the mucosa with 0.5% to 5% sodium bicarbonate solution to neutralize gastric juice at the surface, and spraying the mucosa with 0.3% to 0.5% congo red Acid-secreting areas become black within minutes USES used to detect ectopic site of acid production Used to evaluate post vagotomy patients Along with methylene blue used to detect intestinal metaplasia

16. PHENOL RED Phenol red is a reactive dye that changes colour from yellow to red . Phenol red has been used to detect and map the gastric distribution of Helicobacter pylori during endoscopy 0.1% phenol red solution containing 5% urea is then sprayed over the entire surface of the stomach. Positive staining from red, indicative of H pylori, occurs within 2 to 3 minutes after dye spraying and persists for at least 15 minutes Chromoendoscopic technique with red phenol at 0.1% over the gastric mucosa. Zone with red stain (positive staining) and zones with persisting yellow color (negative staining)

17. Phenol red

18. Acetic acid The use of acetic acid is not considered a chromoscopic technique per se because acetic acid is not a coloring agent, but the end result is similar to that achieved with a contrast I t whitens dysplastic squamous lesions 2 0 mL of 1.5% to 3% acetic acid when applied on esophageal mucosa stains lesion more white than normal epithelium USES Identification of colonoscopic mucosa Predict presence of specialized columnar epithelium in endoscope Dysplastic squamous epithelium in cervix

19. ROBOTIC SURGERY ROBOT: Mechanical device that performs automated physical tasks according to direct human supervision, a predefined programmes or a set general guidelines, using artificial intelligent techniques. Robotic assistant to surgeon can be in the form of automated camera systems and tele-manipulator systems TYPES OF ROBOTIC SURGERY - Supervisory controlled robotic surgery system Tele surgical system – Da vinci robotic surgery system -ZEUS robotic surgery system -AESOP robotic surgery system Shared control robotic system

20. SUPERVISORY CONTROLLED ROBOTIC SURGERY Follows specific set of instructions Surgeon should map body of patient in 3 different ways – planning, registration and navigation Precise in nature

21. TELE SURGERY SYSTEM Also called as remote surgery, is performed by surgeon at remote site Surgical tasks are directly performed by robotic system controlled by surgeon at remote site

22. SHARED CONTROLLED ROBOTIC SURGERY SYSTEM Surgeons does most of the work Surgeons must operate surgical instruments themselves Robots does not work unless surgeons give data to robot

23. PRINCIPLES OF ROBOTIC SURGERY Half instrument should be inside the abdomen and half should be outside Telescope should be in middle of working instruments Manipulation angle of working instruments should be 60-90 degree

24. DRAWBACKS: Higher cost. Applicability and benefits for particular surgery. Training requirements. Support. ADVANTAGES: To the patient: Decreased wound size, trauma, infection, dehiscence, bleeding herniation, nerve entrapment and pain. -Improved mobility. - Early return to work. To the surgeon: Better visualization ( 3D vision), higher magnification.(25X) Elimination of hand tremor, greater precision. Robotic wrist- greater maneuvering. Ability to perform complete tasks in limited space. Ergonomic environment with less stress. Less need of assistance.

25. Da Vinci Robot: Most commonly used worldwide. Based on master slave principle. Surgeon inserts hand into master which translates the motion of his hands into motions of robotic arm (Hand like instrument). INSTRUMENTS: Robotic arm Ports Surgeon console Patient cart Robotic endowrist instruments.

26. ROBOTIC SURGERIES: Three components: Surgeon console: Surgeon views 3D image of operating site Robot scales surgeons motions and translates into operating arms Instrument control masters has to multi joint master controls 2. The patient (robotic) cart: Has four arms all mounted on maneuverable wheelbase Colour coded cables are used Camera arm compatible with 12mm port Other three arms compatible with 8 mm metallic port 3. Vision card with inside binocular vision system with high resolution 3D endoscope provides 3D images of operative field . Images are enhanced refined and optimised

27. ROBOTICS IN VARIOUS FIELDS 1) Robotic radical prostatectomy . Most common robotic procedure in the world Standard of care for resectable prostate cancer .Advantage of lesser blood loss, lesser chances of impotence, lesser chances of urinary incontinence Useful for ureteral anastomosis in a narrow pelvic cavity 2) Robotic nephrectomy - partial nephrectomy and nephron sparing surgery 3)Robotic cystectomy . Comparable to open radical cystectomy Robotic surgery is superior in the field of intraoperative blood loss Better yield of lymph nodes Lesser requirement for analgesics Shorter hospital stay 4) GIT reconstructive procedures Robotic fundoplication, Nissen's fundoplication is the most common using robot robotic gastrectomy for malignancy

28. 5)Robotic colorectal surgeries Colectomy Abdominoperineal resection (APR) Low anterior resection Advantage of better approach and maneuverability in the depth of pelvis . Total mesorectal excision: Has proven advantages over open procedures

29. ROBOTICS IN HEPATOBILIARY AND PANCREATIC PROCEDURES ROBOTIC CHOLECYSTECTOMY Conventional laparoscopic cholecystectomy is still the preferred approach ROBOT ASSISTED PANCREATIC RESECTION Has clear advantages like fine movements, magnification, tremor stabilization, endo wrist technology

30. COMPLICATIONS OF ROBOTIC SURGERY Flawed design Malfunction of hardware and software components Misinterpretation and incorrect or inadequate specification Increase in cost and complexity

31. INTRODUCTION • Natural Orifice Transluminal Endoscopic Surgery (NOTES) is a surgical technique whereby a flexible endoscope passed through a natural orifice(mouth, vagina, urethra and anus) thus avoiding any external incisions or scars.

32. NOTES INTRODUCTION  NOTES was originally described in animals by researchers at Johns Hopkins University Dr . Anthony Kalloo The first NOTES transgastric appendectomy performed by Rao and Reddy in 2004 The first transvaginal appendectomy performed by Bernhardt in 2007. On June 25, 2007 Swanstrom and colleagues reported the first human transgastric cholecystectomy. • In late 2008 surgeons from Johns Hopkins School of Medicine removed a healthy kidney from a woman donor using NOTES.

33. ADVANTAGES OF NOTES Lack of skin incision, improving cosmesis Reduced post operative pain and wound complications Preferable approach for obese patients and for th ose with conditions that affect abdominal wall such as scars, burns, infections Diminished risk of post operative hernia Easier access for difficult to reach by open/ lap like esophagus and rectum Decreasing physiologic and immune response to surgery Earlier reco very, reduced adhesion development, shorter postoperative ileus .

34.   FAVOURED ROUTES FOR NOTES; 1. Transvaginal 2. Transgastric 3. Transcolonic 4. Transvesical ✓ All routes are under experimental usage. ✔ In clinical application Transvaginal access appears to be the safest, most feasible and potentially less complications but only possible in women.

35. COMMON PROCEDURES THAT CAN BE DONE USING "NOTES Transgastric cholecystectomy Transgastric appendectomy Transvaginal cholecystectomy Transrectal colectomy

36. COMPLICATIONS OF NOTES Visceral injury Vascular injury Infection Delayed anastomotic or entry site leaks Adhesion formation Dyspareunia Vascular and visceral injuries can both passed unrecognized and difficult to control due to the position and orientation of the endoscope

37. NOTES INSTRUMENTATION TECHNOLOGY The ultimate goal remains the design and production of a flexible endoscope or NOTES platform that is; ✓ Multichannelled , ✓ Can bend in more than two axes ✓ Can be stabilized once the correct operating position has been reached.

38. DISADVANTAGES OF NOTES Abdominal infection Leaks Technically challenging Prolonged operative time Learning curve Cost

39. CONCLUSION Bringing surgery into digital age True benefit over conventional therapy Advancing surgical technology

40. THANK YOU Friday, February 16, 2024 Department of General Surgery, TOMCH, Bengaluru