Scott J. Belsley

Robotically assisted left ventricular epicardial lead implantation for biventricular pacing

OBJECTIVES Ventricular resynchronization might be achieved in a minimally invasive fashion using a robotically assisted, direct left ventricular (LV) epicardial approach. BACKGROUND Approximately 10% of patients undergoing biventricular pacemaker insertion have a failure of coronary sinus (CS) cannulation. Rescue therapy for these patients currently is limited to standard open surgical techniques. METHODS Ten patients with congestive heart failure (New York Heart Association class 3.4 +/- 0.5) and a widened QRS complex (184 +/- 31 ms) underwent robotic LV lead placement after failed CS cannulation. Mean patient age was 71 +/- 12 years, LV ejection fraction (EF) was 12 +/- 6%, and LV end-diastolic diameter was 7.1 +/- 1.3 cm. Three patients had previous cardiac surgery, and five patients had a prior device implanted. RESULTS Nineteen epicardial leads were successfully placed on the posterobasal surface of the LV. Intraoperative lead threshold was 1.0 +/- 0.5 V at 0.5 ms, R-wave was 18.6 +/- 8.6 mV, and impedance was 1,143 +/- 261 ohms at 0.5 V. Complications included an intraoperative LV injury and a postoperative pneumonia. Improvements in exercise tolerance (8 of 10 patients), EF (19 +/- 13%, p = 0.04), and QRS duration (152 +/- 21 ms, p = 0.006) have been noted at three to six months follow-up. Lead thresholds have remained unchanged (2.1 +/- 1.4 V at 0.5 ms, p = NS), and a significant drop in impedance (310 +/- 59 ohms, p < 0.001) has been measured. CONCLUSIONS Robotic LV lead placement is an effective and novel technique which can be used for ventricular resynchronization therapy in patients with no other minimally invasive options for biventricular pacing.

Timely Airway Stenting Improves Survival in Patients With Malignant Central Airway Obstruction

BACKGROUND The survival of patients with malignant central airway obstruction is very limited. Although airway stenting results in significant palliation of symptoms, data regarding improved survival after stenting for advanced thoracic cancer with central airway obstruction are lacking. METHODS Fifty patients received a total of 72 airway stents for malignant central airway obstruction over a two-year period at a single institution. The Medical Research Council (MRC) dyspnea scale and Eastern Cooperative Oncology Group (ECOG) performance status were used to divide patients into a poor performance group (MRC = 5, ECOG = 4) and an intermediate performance group (MRC ≤ 4, ECOG ≤ 3). The SPSS version 16.0 (SPSS Inc, Chicago, IL) and Microsoft Excel (Microsoft, Redmond, WA) were used to analyze the data. Survival curves were constructed using the Kaplan-Meier survival analysis method and a log-rank test was used to compare the survival distributions among different groups. RESULTS Successful patency of the airway was achieved in all patients with no procedure-related mortality. Stenting resulted in significant improvement in MRC and ECOG performance scores (p < 0.01). Significantly improved survival was observed only in patients in the intermediate performance group compared with patients in the poor performance group (p < 0.05). CONCLUSIONS Airway stenting resulted in significant palliation of symptoms in both groups as evaluated by MRC dyspnea scale and ECOG performance status. Compared with historic controls, a significant survival advantage was seen only in the intermediate performance group. We postulate that timely stenting of the airway, before the morbid complications of malignant central airway obstruction have set in, results in improved survival.

Robotically assisted left ventricular epicardial lead implantation for biventricular pacing: the posterior approach.

Patients with congestive heart failure and altered interventricular conduction enjoy improvements in quality of life and ventricular function after successful resynchronization therapy with biventricular pacing. Technical limitations owing to individual coronary sinus and coronary venous anatomy result in a 10% to 15% failure rate of left ventricular (LV) lead placement through percutaneous approaches. To provide a minimally invasive option for these patients with LV lead failures, we developed a technique of endoscopic, epicardial LV lead implantation with the use of the da Vinci robotic system. The surgical approach targets the posterolateral wall through a novel posterior approach.

Single-Incision Laparoscopic Cholecystectomy Using a Flexible Endoscope

OBJECTIVE To describe our experience with a single-incision laparoscopic cholecystectomy (SILC) performed using a flexible endoscope as the means of visualization and surgical dissection. The use of flexible endoscopy in intra-abdominal surgery has never been described. DESIGN Prospective observational case series. PATIENTS Eleven patients with symptomatic cholelithiasis were selected based on age, clinical presentation, body habitus, and history of previous abdominal surgery. Patients with acute or chronic cholecystitis were excluded. RESULTS All procedures were completed laparoscopically via the single umbilical incision without the need to convert to an open operation and without introduction of any additional laparoscopic instruments or trocars. The mean operative time was 149.5 minutes (range, 99-240 minutes). The mean length of hospital stay was 0.36 days. There were no associated intraoperative or postoperative complications. CONCLUSIONS In our experience, SILC performed with a flexible endoscope is feasible and safe. Further studies are needed to determine its advantages in reference to postoperative pain and complication rate in juxtaposition with the current standard laparoscopic cholecystectomy.

Gastrointestinal changes after bariatric surgery

Severe obesity is a preeminent health care problem that impacts overall health and survival. The most effective treatment for severe obesity is bariatric surgery, an intervention that not only maintains long-term weight loss but also is associated with improvement or remission of several comorbidies including type 2 diabetes mellitus. Some weight loss surgeries modify the gastrointestinal anatomy and physiology, including the secretions and actions of gut peptides. This review describes how bariatric surgery alters the patterns of gastrointestinal motility, nutrient digestion and absorption, gut peptide release, bile acids and the gut microflora, and how these changes alter energy homeostasis and glucose metabolism.

Robotic intercostal nerve graft for reversal of thoracic sympathectomy: a large animal feasibility model

A subset of patients who undergo video‐assisted thoracoscopic sympathectomy for hyperhydrosis develop post‐procedure compensatory sweating that is perceived as more debilitating than their initial complaints. We propose a novel treatment to reverse sympathectomy by implantation of an intercostal nerve graft using the da Vinci robot.

Dietary Flaxseed Protects Against Lung Ischemia Reperfusion Injury Via Inhibition of Apoptosis and Inflammation in a Murine Model

BACKGROUND The hallmark of lung ischemia-reperfusion injury (IRI) is the production of reactive oxygen species (ROS), and the resultant oxidant stress has been implicated in apoptotic cell death as well as subsequent development of inflammation. Dietary flaxseed (FS) is a rich source of naturally occurring antioxidants and has been shown to reduce lung IRI in mice. However, the mechanisms underlying the protective effects of FS in IRI remain to be determined. METHODS We used a mouse model of IRI with 60 min of ischemia followed by 180 min of reperfusion and evaluated the anti-apoptotic and anti-inflammatory effects of 10% FS dietary supplementation. RESULTS Mice fed 10% FS undergoing lung IRI had significantly lower levels of caspases and decreased apoptotic activity compared with mice fed 0% FS. Lung homogenates and bronchoalveolar lavage fluid analysis demonstrated significantly reduced inflammatory infiltrate in mice fed with 10% FS diet. Additionally, 10% FS treated mice showed significantly increased expression of antioxidant enzymes and decreased markers of lung injury. CONCLUSIONS We conclude that dietary FS is protective against lung IRI in a clinically relevant murine model, and this protective effect may in part be mediated by the inhibition of apoptosis and inflammation.

Robotic Brachytherapy and Sublobar Resection for T1 Non-Small Cell Lung Cancer in High-Risk Patients

BACKGROUND Sublobar lung resection and brachytherapy seed placement is gaining acceptance for T1 non-small cell lung cancer (NSCLC) in select patients with comorbidities precluding lobectomy. Our institution first reported utilization of the da Vinci system for robotic brachytherapy developed experimentally in swine and applied to high-risk patients 5 years ago. We now report seed dosimetrics and midterm follow-up. METHODS Eleven high-risk patients with stage IA NSCLC who were not candidates for conventional lobectomy underwent limited resection of 12 primary tumors. To reduce locoregional recurrence, (125)I brachytherapy seeds were robotically sutured intracorporeally over resection margins to deliver 14,400 cGy 1 cm from the implant plane. Patients were followed with dosimetric computed tomography scans at 30 +/- 16 days. Survival and sites of recurrence were documented. RESULTS Resected tumor size averaged 1.48 +/- 0.38 cm (range, 1.1 to 2.1 cm). Perioperative mortality was 0% and recurrence was 9% (1 of 11 [margin recurrence at 6 months with resultant mortality at 1 year]). Follow-up duration was 31.82 +/- 17.35 months. Dosimetrics confirmed 14,400 cGy delivery using 24.21 +/- 4.6 (125)I seeds (range, 17 to 30 seeds) over a planning target volume of 10.29 +/- 2.39 cc(3). Overall, 84.1% of the planning target volume was covered by 100% of the prescription dose (V100), and 88.2% was covered by 87% of the prescription dose (V87), comparable to open dosimetric data at our institution. Follow-up imaging confirmed seed stability in all patients. CONCLUSIONS Robotic (125)I brachytherapy seed placement is a feasible adjuvant procedure to reduce the incidence of recurrence after sublobar resection in medically compromised patients. Tailored robotic seed placement delivers an exact dosing regimen in a minimally invasive fashion with equivalent precision to open surgery.

What technical barriers exist for real-time fluoroscopic and video image overlay in robotic surgery?†

A hypothetical advantage of the da Vinci® console is its ability to integrate multiple visual data sources. Current platforms for augmented reality surgery fuse pre‐operative radiographic studies but are limited with their ability to update with intra‐operative imaging. The aim of our study was to evaluate the feasibility of real‐time radiographic image overlay with current technology.

Hybrid TAPP/TEP Repair of Bilateral Obturator and Inguinal Hernias

Introduction: Obturator hernias represent a rare cause of small-bowel obstruction. When diagnosed on computed tomographic (CT) scan in a stable patient, timely surgical repair is indicated. Because of the absence of large-scale studies, the ideal operative approach has yet to be defined. Case Description: A 75-year-old woman presented to the emergency department with an incarcerated left-side obturator hernia manifesting as a small-bowel obstruction. The hernia was diagnosed on CT scan, and the patient was taken to the operating room for laparoscopic reduction and repair. During surgery, a contralateral obturator hernia and bilateral indirect inguinal hernias were discovered. Hybrid transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP) approaches were used to reduce and demonstrate the viability of the incarcerated bowel and then to repair all 4 defects with mesh. The procedure was well tolerated, and the patient was discharged uneventfully after the return of bowel function. Discussion: This case provides an example of how a hybrid TAPP/TEP laparoscopic approach can be effective for visualizing and repairing an obturator hernia as well as an incidentally discovered inguinal hernia.