Ultra-minimally invasive cardiac surgery: robotic surgery and awake CABG

Pain Management in Minimally Invasive Cardiac Surgery: A Review of Current Clinical Evidence

Compared with conventional sternotomy, minimally invasive cardiac surgery (MICS) is associated with significant advantages such as reduced tissue trauma, faster recovery, and shorter hospital stay. However, the management of postoperative pain caused by intercostal nerve injury, pleural irritation, and tissue retraction remains a major challenge. Despite the less invasive nature of MICS, patients often report experiencing pain similar to that experienced following conventional cardiac surgery, particularly during the acute postoperative period. Effective pain management is essential for optimizing recovery, reducing the consumption of opioids, and preventing the transition to chronic postsurgical pain. Regional anesthesia techniques play a key role in multimodal analgesia for MICS. Thoracic epidural analgesia exhibits strong analgesic efficacy; nevertheless, it remains underutilized owing to concerns regarding anticoagulation-related complications and hemodynamic instability. The thoracic paravertebral block is a safer alternative that provides comparable pain relief with fewer side effects. Similarly, ultrasound-guided fascial plane blocks, such as serratus anterior, parasternal intercostal, interpectoral + pectoserratus, and erector spinae plane blocks, have gained popularity owing to their safety and feasibility; however, the effectiveness of these blocks varies according to the surgical approach and type of incision. Systemic analgesia is an integral component of multimodal pain management in MICS. Despite the efficacy of opioids, a shift toward opioid-sparing strategies has been observed given the significant adverse effects associated with the use of opioids. Intravenous adjuncts such as dexmedetomidine, ketamine, and non-steroidal anti-inflammatory drugs can reduce opioid consumption and improve postoperative pain control. Despite advances in pain management, a single approach that can provide comprehensive analgesia for MICS remains to be established. A multimodal strategy that combines systemic and regional techniques must be developed to optimize pain management and long-term outcomes.

Improved robotic-assisted cardiac surgery outcomes with greater hospital volume: a national representative cohort analysis of 10,543 cardiac surgery surgeries

Robot-assisted surgical techniques have enhanced surgical precision, control, stability, and vision, particularly in cardiac interventions. However, the relationship between hospital volume and the clinical and readmission outcomes of robot-assisted cardiac surgery remains undefined. This retrospective cohort study analyzed Nationwide Readmissions Database (NRD) data from 2010 to 2020. Patients who underwent various cardiac procedures were categorized into three groups based on hospital volume of robot-assisted cardiac surgery: low-volume centers (LVCs), medium-volume centers (MVCs), and high-volume centers (HVCs). Our primary outcome variables of interest were the incidence of perioperative complications, 30-day readmission, and in-hospital mortality. 10,543 patients were included in the analysis. Compared with those treated in LVCs, the adjusted OR of 30-day readmission [OR, 0.70; (95% CI 0.53-0.92), P = 0.014] was lower in HVCs. However, higher perioperative bleeding rates were observed in MVCs (OR, 1.38; (95% CI 1.14-1.66), P = 0.001) and HVCs (OR, 1.84; (95% CI 1.52-2.21), P = 0.001). No significant differences were found in in-hospital mortality. Our research demonstrated that higher hospital surgical volume was associated with better outcomes in robot-assisted cardiac surgery, despite higher perioperative bleeding rates.

Awake robotic liver surgery: A case report

BACKGROUND

In recent years, minimally invasive liver resection has become a standard of care for liver tumors. Considering the need to treat increasingly fragile patients, general anesthesia is sometimes avoided due to respiratory complications. Therefore, surgical treatment with curative intent is abandoned in favor of a less invasive and less radical approach. Epidural anesthesia has been shown to reduce respiratory complications, especially in elderly patients with pre-existing lung disease.

CASE SUMMARY

A 77-year-old man with hepatitis-C-virus-related chronic liver disease underwent robotic liver resection for hepatocellular carcinoma. The patient was suffering from hypertension, diabetes and chronic obstructive pulmonary disease. The National Surgical Quality Improvement Program score for developing pneumonia was 9.2%. We planned a combined spinal-epidural anesthesia with conscious sedation to avoid general anesthesia. No modification of the standard surgical technique was necessary. Hemodynamics were stable and bleeding was minimal. The postoperative course was uneventful.

CONCLUSION

Robotic surgery in locoregional anesthesia with conscious sedation could be considered a safe and suitable approach in specialized centers and in selected patients.

The Current Status of Awake Endoscopic Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

To examine the use of local anesthesia and/or conscious sedation in endoscopic spine procedures within the past decade.

METHODS

This systematic review abided by PRISMA guidelines. Embase, PubMed, Google Scholar, and Cochrane databases were searched for post-2011 articles with patients >18 years old, lumbar/cervical percutaneous endoscopic spine procedures using local/awake anesthesia, and patient/surgical outcomes. Reviews, book chapters, single case reports, or small case series (n ≤15 patients) were excluded. Scoring systems of the National Institutes of Health quality assessment tool, Newcastle-Ottawa Scale, and Cochrane Risk of Bias evaluated interventional case series, comparative studies, and randomized control trials, respectively.

RESULTS

Twenty-six articles were included, with 4 studies comparing general and local anesthesia. Of 2113 total patients, 1873 patients received local anesthesia. Significant improvements were seen in pain and disability scores. Studies that included MacNab scores showed that 96% of patients rated their postoperative satisfaction as excellent to good. Subanalysis of comparative studies showed a reduced risk of surgical/major medical complications and a slight increased risk for minor medical complications among awake spine patients. Length of stay was shorter for patients receiving local anesthesia.

CONCLUSIONS

The current systematic review and meta-analysis shows that use of local anesthesia is a safe and effective alternative to general anesthesia among different endoscopic spinal procedures. Although awake spine surgery is associated with a decreased risk of severe complications, lower revision rates, and higher postoperative satisfaction, more robust studies involving larger cohorts of patients are needed to evaluate the true impact of awake spine surgery on outcomes.

Awake spine surgery: An eye-opening movement

Background:

Awake surgery is performed in multiple surgical specialties, but historically, awake surgery in the field of neurosurgery was limited to craniotomies. Over the past two decades, spinal surgeons have pushed for techniques that only require regional anesthesia as they may provide reduced financial burdens on patients, faster recovery times, and better outcomes. The list of awake spine surgeries that have been found in the literature include: laminectomies/discectomies, anterior cervical discectomy and fusions (ACDFs), lumbar fusions, and dorsal column (DC) stimulator placement.

Methods:

An extensive review of the published literature was conducted through PubMed database with articles containing the search term “awake spine surgery.” No date restrictions were used.

Results:

The search yielded 293 related articles. Cross-checking of articles was conducted to exclude of duplicate articles. The articles were screened for their full text and English language availability. We finalized those articles pertaining to the topic. Findings have shown that lumbar laminectomies performed with local anesthesia have shown shorter operating time, less postoperative nausea, lower incidence of urinary retention and spinal headache, and shorter hospital stays when compared to those performed under general anesthesia. Lumbar fusions with local anesthesia showed similar outcomes as patients reported better postoperative function and fewer side effects of general anesthesia. DC stimulator placement performed with local anesthesia is advantageous as it allows real time patient feedback for surgeons as they directly test affected nerves. However, spontaneous movement during the placement of DC stimulators is associated with higher failure rates when compared to general anesthesia (29.7% vs. 14.9%). Studies have shown that the use of local anesthesia during ACDFs has no significant differences when compared to general anesthesia, and patient’s report better tolerated pain with general anesthesia.

Conclusion:

The use of awake spine surgery is beneficial for those who cannot undergo general anesthesia. However, it is limited to patients who can tolerate prone positioning with no central airway (i.e., normal BMI with a healthy airway), have no pre-existing mental health conditions (e.g., anxiety), and require a minimally invasive procedure with a short operating time. Future studies should focus on long-term efficacies of these procedures that provide further insight on the indications and limitations of awake spine surgery.

Curative effect of Da Vinci robot assisted radical gastrectomy for gastric cancer

AIM

To assess the value of Da Vinci robot in radical gastrec-tomy for gastric cancer.

METHODS

The information of patients who underwent Da Vinci robot assisted radical gastrectomy for gastric cancer at the Department of General Surgery, Lanzhou General Hospital of the Chinese People's Liberation Army from December 2016 to April 2017 was collected. The information of patients who received laparoscopic radical gastrectomy for gastric cancer was also obtained. The information on surgical treatment, postoperative recovery, hospital expenses, and prognosis was statistically analyzed between the two groups.

RESULTS

Compared with the laparoscopic group, the Da Vinci group had less bleeding during operation (P < 0.05), more complete lymph node dissection (P < 0.05), and safer incision margin (P < 0.05), but the operative time was increased (P < 0.05). In the postoperative recovery of patients of the two groups, the time to first food intake, the time to the recovery of the digestive tract, and the incidence of complications were not significantly different between the two groups (P > 0.05), but surgical cost was significantly increased (P < 0.05). The hospital stay was significantly shorter in patients who received Da Vinci robot assisted radical gastrectomy than in the laparoscopy group (P < 0.05), but this difference was not found in patients who underwent distal radical gastrectomy (P > 0.05). There was no significant difference in long-term survival between the two groups (P > 0.05).

CONCLUSION

Da Vinci robot assisted radical gastrectomy has certain advantages over laparoscopic radical gastrectomy in the treatment of gastric cancer, but it is still necessary for practitioners to improve their skills and be cautious.

Figure 4 Knot: Simple Tying Technique for Robotic and Endoscopic Sutures

Various endoscopic suturing and tying methods have been reported, but these methods remain imperfect because knots are sometimes not tied completely and additional stitches are needed. To address this problem, we developed the "Figure 4" technique in which the knot can be easily slid to the suture point and tied by pulling suture tail-these knots will never come untied. This technique requires very simple technique and can be used in other surgical procedures such as conventional laparoscopic surgery.

Current status of robotic gastrectomy for gastric cancer

Although over 3000 da Vinci Surgical System (DVSS) devices have been installed worldwide, robotic surgery for gastric cancer has not yet become widely spread and is only available in several advanced institutions. This is because, at least in part, the advantages of robotic surgery for gastric cancer remain unclear. The safety and feasibility of robotic gastrectomy have been demonstrated in several retrospective studies. However, no sound evidence has been reported to support the superiority of a robotic approach for gastric cancer treatment. In addition, the long-term clinical outcomes following robotic gastrectomy have yet to be clarified. Nevertheless, a robotic approach can potentially overcome the disadvantages of conventional laparoscopic surgery if the advantageous functions of this technique are optimized, such as the use of wristed instruments, tremor filtering and high-resolution 3-D images. The potential advantages of robotic gastrectomy have been discussed in several retrospective studies, including the ability to achieve sufficient lymphadenectomy in the area of the splenic hilum, reductions in local complication rates and a shorter learning curve for the robotic approach compared to conventional laparoscopic gastrectomy. In this review, we present the current status and discuss issues regarding robotic gastrectomy for gastric cancer.