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MIS MASTERS Course January 14, 2020 Loews Sapphire Falls Resort MIS MASTERS Course January 14, 2020 Loews Sapphire Falls Resort Orlando, Florida 8:00 am-5:00 pm Grand Caribbean Ballrooms 3-5 MIS Multisociety Advanced Skills Training in EmeRgency Surgery (MASTERS) Course TUESDAY, JANUARY 14, 2020 8:00 am-5:00 pm This Course is Co-Sponsored by: SAGES, ASCRS, AAST, and EAST 8:00 am-8:05 am Introduction: Addressing the Education Gap in Acute Care Surgery and the Increasing Use of MIS Techniques 8:05 am-9:15 am - MIS Techniques in Trauma - Moderators: Robert Lim, MD (SAGES) & David Spain, MD (AAST) 8:05 am-8:20 am Exploration for Penetrating Abdominal Trauma – Matthew Martin, MD (EAST) 8:20 am-8:35 am Diaphragm Injury-Laparoscopy – Steve Eubanks, MD (SAGES) 8:35 am-8:50 am Retained Hemothorax-Percutaneous & Thoracoscopy – Clay Cothren Burlew, MD (AAST) 8:50 am-9:00 am Pro/Con Debate: MIS for Penetrating Trauma – Ruby Skinner, MD (EAST) vs. David Spain, MD (AAST) 9:00 am-9:15 am Panel Discussion – All Faculty 9:15 am-10:30 am - Foregut and Small Bowel - Moderator: Steve Eubanks, MD (SAGES) & Andrea Pakula, MD (EAST) 9:15 am-9:30 am Parasophageal/Diaphragmatic Hernias – Sharona Ross, MD (SAGES) 9:30 am-9:45 am Peptic Ulcer Disease – Michael Cripps, MD (SAGES) 9:45 am-10:00 am ACS Emergencies in the Post Bariatric Surgery Patient – Robert Lim, MD (SAGES) 10:00 am-10:10 am Pro/Con Debate – Lap SBO Exploration – Andrew Bernard, MD (EAST) vs. Robert Lim, MD, MD (SAGES) 10:10 am-10:30 am Panel Discussion – All Faculty 10:30 am-10:45 am Break 10:45 am-12:00 pm - Hepatobiliary/Pancreatic - Moderators: Sharona Ross, MD (SAGES) & Ruby Skinner, MD (EAST) 10:45 am-11:00 am The Disaster Gallbladder – David Spain, MD (AAST) 11:00 am-11:15 am Common Duct Exploration – Sara Hennessey, MD (SAGES) 11:15 am-11:30 am Necrotizing Pancreatitis & VARD – Andrew Bernard, MD (EAST) 11:30 am-11:40 am Debate: Subtotal Chole vs. Convert to Open – Matthew Martin, MD (EAST) vs. Ruby Skinner, MD (EAST) 11:50 am-12:05 pm Panel Discussion – All Faculty Lunch Break 12:00 pm -1:00 pm 1:00 pm-2:15 pm - Colorectal Emergencies - Moderators: Neil Hyman, MD (ASCRS) & Najjia Mahmoud, MD (ASCRS) 1:00 pm-1:15 pm Complicated Diverticular Disease – Jason Hall, MD (ASCRS) 1:15 pm-1:30 pm Colorectal Cancer-Obstructing and Near-Obstructing – Larissa Temple, MD (ASCRS) 1:30 pm-1:45 pm Iatrogenic Colon Perforation – Timothy Geiger, MD, MMHC (ASCRS) 1:45 pm-2:00 pm The Difficult Stoma – Eric Johnson, MD (ASCRS) 2:00 pm-2:10 pm Pro/Con Debate: Hartmann’s is Obsolete – Neil Hyman, MD (ASCRS) vs. Najjia Mahmoud, MD (ASCRS) 2:10 pm-2:30 pm Panel Discussion – Faculty 2:30 pm-3:45 pm - Hernia/Abd Wall - Moderators: Kimberly Davis, MD (AAST) & Eric Johnson, MD (ASCRS) 2:30 pm-2:45 pm Incarcerated /Strangulated Inguinal/Femoral Hernias – Sara Hennessey, MD (SAGES) 2:45 pm-3:00 pm Incarcerated/Strangulated Ventral Hernias – Patrick Reilly, MD (AAST) 3:00 pm-3:15 pm Approaches to Abd Wall Reconstruction – Andrea Pakula, MD, MPH (EAST) 3:15 pm-3:25 pm Pro/Con Debate: Mesh Use in Contaminated Hernia Cases – Michael Cripps, MD (SAGES) vs. Kimberly Davis, MD, MBA (AAST) 3:25 pm-3:45 pm Panel Discussion – All Faculty 3:45 pm-4:00 pm Break 4:00 pm-5:00 pm - Robotics in Acute Care Surgery - Moderators: Robert Lim, MD (SAGES) & Matthew Martin, MD (EAST) 4:00 pm-4:10 pm Robotic Surgery Platforms – Ruby Skinner, MD (EAST) 4:10 pm-4:20 pm Fluorescence Imaging-Overview & How to Use It – Sharona Ross, MD (SAGES) 4:20 pm-4:30 pm Integrating Robotics into Your ACS Practice – Andrea Pakula, MD, MPH (EAST) 4:30 pm-5:00 pm Panel: Integrating Robotics into Your Acute Care Surgery Practice – All Faculty MIS for Penetrating Abdominal Trauma Matthew Martin, MD, FACS, FASMBS Scripps Mercy Hospital San Diego, CA 1 Disclaimers/Disclosures No financial conflicts to disclose These are my opinions and do not represent EAST, Scripps, or any other organization MD, FACS, FASMBS? 2 3 Elective Emerg Trauma Gen Gen Surg Surg Surg We have some catching up to do! 4 51 studies, 2569 patients 44% were positive 1497 (58%) avoided a NTL 3% complications 5 Sensitivity: 66% to 100% Specificity: 33% to 100% 23 of the studies had 100% 6 Trocar Placement? 7 Evaluation for Peritoneal Penetration 8 Bad Bowel Handling Habits 9 Good bowel handling technique 10 The “Mesentery Handle” 11 The Diaphragm Evaluation Left subcostal stab wound Stable and benign abdominal exam Mild intoxication No indication for urgent laparotomy Taken to OR for DL to eval diaphragm Small diaphragm lac repaired POD 1 has free air and peritonitis?? 12 Left Subcostal Stab Wound 13 Avoiding Suboptimal MIS? 1.Going to OR too early Admit Serial exams for 8-24 hrs Then do focused laparoscopy 14 Avoiding Suboptimal MIS? 1.Going to OR too early 2.Inadequate visualization 15 Diaphragm/spleen Liver Stomach/duo Cecum/Sigmoid Bladder/Uterus Pelvis 16 Gravity as your first assistant 17 Avoiding Suboptimal MIS? 1.Going to OR too early 2.Inadequate visualization 3.Inadequate exploration 18 Int J Crit Illn Inj Sci. 2015 Jul-Sep; 5(3): 196–205. PMCID: PMC4613419 doi: 10.4103/2229-5151.165004 Laparoscopy in trauma: An overview of complications and related topics INADEQUATE“Hypothesize INJURY VISUALIZATION high rateAND MISSED of missed INJURY injuries In diagnosing hollow viscus injuries, TL has been known to be less diagnostically reliable, with sensitivity of only 18%, negativedue predictive to using value of 83%, 2 and ports specificity/positive instead predictive value of of 3”100%.[17] Consequently, the use of TL for diagnosing hollow viscous injury detection remains controversial and is believed to be very dependent on operator skills.[13] Zantut and colleagues recommend that if bowel perforation cannot be confidently ruled out on TL, laparotomy should be performed.[3] In one study, there were seven missed injuries in the TL group, all of which involved hollow viscus.[17] Of additional importance, although the sensitivity of laparoscopy was 97% in the thoracoabdominal area, it was only 43% in the epigastric, flank, and lower quadrants.[17] In another series, out of eight diaphragm injuries, TL missed one (12.5%), which occurred in a patient who sustained a gunshot wound with injury and hemoperitoneum preventing adequate visualization.[14] In a study by Kawahara et al.,[16] the only missed injury on TL was a pancreatic lesion that required a laparotomy. The authors hypothesized that the high rate of missed bowel injury in the past was secondary to using two laparoscopic port sites instead of three, and recommended that a standardized approach to TL not only reduces unnecessary laparotomies but can also more reliably rule out small bowel injury if the above three-port approach is utilized.[16] 19 Avoiding Suboptimal MIS? 1. Going to OR too early 2. Inadequate visualization 3. Inadequate exploration 4. Converting to open for any positive findings 20 Laparoscopic Suturing 21 Laparoscopic Knot-Tying 22 Laparoscopic Stapling 23 The Positive Exploration 24 Bowel Resection 25 Standard Stapled Anastomosis 26 “Triple-Stapled” Anastomosis 27 Anastomosis 28 Mesenteric Defect Closure 29 Extracorporeal Repair 30 31 Thank You! 32 1/8/2020 Retained Hemothorax No conflicts. Retained Hemothorax ● Tips and Tricks Diagnosis How to avoid it How to approach it 1 1/8/2020 Retained Hemothorax ● Tips and Tricks Diagnosis How to avoid it How to approach it Retained Hemothorax ● May need to confirm the diagnosis a.k.a. avoid sabotage Retained Hemothorax ● May need to confirm the diagnosis 2 1/8/2020 Retained Hemothorax ● CXR can have many different findings: Retained Hemothorax ● CXR can have very subtle findings: Retained Hemothorax ● Classic film and CT scan 3 1/8/2020 Retained Hemothorax ● Tips and Tricks Diagnosis How to avoid it How to approach it Retained Hemothorax ● How to avoid it (i.e. the film we all hate…): Retained Hemothorax ● Tube thoracostomy technique #1 – the “YATS” 4 1/8/2020 The “YATS” The “YATS” ● Sterile tubing ● Yankhauer suction ● Sweeping motion along posterior chest wall ● Importance of conscious sedation! The “YATS” ● Before and after…. 5 1/8/2020 Retained Hemothorax ● Tube thoracostomy technique #2 – pleural irrigation Pleural Irrigation ● Take time with local anesthetic ● Numb over top of the rib/pleura Pleural Irrigation ● Toomey syringe with plunger out ● 28 Fr chest tube ● YATS items 6 1/8/2020 Pleural Irrigation ● YATS first to evacuate the liquid blood and “easy clot” Pleural Irrigation ● Chest tube into pleural space ● Toomey into end of tube ● Warm irrigation Pleural Irrigation ● Evacuate irrigant and clot ● Ideally like… 7 1/8/2020 Pleural Irrigation ● More often like… Pleural Irrigation Trouble shooting: Irrigant exiting the chest tube hole Faster to use 2 tubes…irrigant in one, suction on other Pleural Irrigation - Results Before After 8 1/8/2020 Retained Hemothorax ● Tips and Tricks Diagnosis How to avoid it How to approach it (thoracoscopically) Surgery for Retained Hemothorax ● Be in the OR within 48-72 hours ● Plan for both a VATS and thoracotomy VS. 9 1/8/2020 When To Say “No” ● Hemodynamic instability ● Inability to achieve lung isolation ● Lack of equipment availability/familiarity ● Failure to make progress or failure of prior VATS Positioning ● Coordinate with other services ● Pelvic fx? ● Cspine cleared? Port Sites ● Wide prep and drape ● Plan potential incisions Start with posterior X Then 1 or 2 chest tube X sites as ports… X 10 1/8/2020 Questions?? 11 MIS FOR PENETRATING ABDOMINAL TRAUMA (PRO) Ruby A.
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