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Valley Surgical Clinics

Valley Surgical Clinics. Private Practice. Technology Advancement. Greene 1870 (3 cases) Kocher early 1900’s – report on 5000 cases with mortality of 0.11 ( Awarded Noble Prize in Medicine) Gagner 1996 – Endoscopic Parathyroidectomy Husher thyroid lobectomy using cervical approach.

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Valley Surgical Clinics

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  1. Valley Surgical Clinics Private Practice

  2. Technology Advancement • Greene 1870 (3 cases) • Kocher early 1900’s – report on 5000 cases with mortality of 0.11 ( Awarded Noble Prize in Medicine) • Gagner 1996 – Endoscopic Parathyroidectomy • Husher thyroid lobectomy using cervical approach

  3. Two major Technologic Innovations in Surgery • Laparoscopy • Robotic

  4. Laparoscopic and Robotic SurgeryTwo General Categories CO2 gas for insufflation or A Gasless Technique

  5. Today we focus on • Robotic gasless technique

  6. ROBOTIC THYROIDECTOMYEarly 2000 • MOST EXPERIENCE - South Korea • AXILLARY APPROACH “+” CHEST PORT • CHUNG et al. 2009: 100 CASES • LOBES AND TOTAL THYROIDECTOMY • LOW BMI’S • NO SERIOUS COMPLICATIONS

  7. VSC Robotic Experience July 2008 – VSC began Robotic Surgery Now Over 450 - DaVinci cases Whipple Procedure Bile Duct Exploration Distal Pancreatectomy Splenectomy Adrenalectomy Sarcoma Resection Colon resection Small Bowel Resection Antireflux procedures Cholecystectomy Thyroidectomy Gastrectomy Hernia Repairs Liver Resection

  8. VSC Robotic Thyroid EXPERIENCE • OCTOBER 2009 – PRESENT • Da VINCI GASLESS SINGLE INCISION AXILLARY APPROACH • NO CHEST PORT

  9. Concerns in Private Practice • First Patient • Legal Implications • Hospitals

  10. Co-existing

  11. Valley Surgical Technique 1. Position of the patient 2. Incision 3. Initial Dissection 4. VSC Retractor placement 5. Docking 6. Positioning of Robotic Arms 7. Dissection 8. Closure

  12. Valley Surgical Position of Patient

  13. Operative Positioning Supine Posterior Shoulder Roll Longitudinally Padded arm sled • Sniff position • Arm angle – no greater than 90*

  14. Valley Surgical Incisions

  15. Incision comparison Valley Surgical Clinics DaVinci® Surgery Traditional Open Method

  16. Incision

  17. VSC Initial Dissection

  18. Initial Dissection video clip

  19. Vsc Retractor Patent pending

  20. Components

  21. Retractor position Video

  22. Diagram for a Right thyroid Retractor ARM 2 CAMERA ARM 3 ARM 1 Axillary Incision

  23. Diagram for Left Approach Retractor Head ARM 2 CAMERA ARM 3 ARM 1 Axillary Incision

  24. Instrument placement Diagram for left approach Retractor ARM 2 CAMERA ARM3 ARM 1 Axillary Incision ARM 1 Harmonic Scalpel ARM2 Cobra Grasper ARM 3Single fenestrated or Cadiere grasper (usually Bipolar) The camera in the right thyroidectomy will be on the right side about 2 mm to the right of the retractor; for the left throidectomy the camera will be on the left side about 2mm to the left of the retractor

  25. placement

  26. Robot Arm Clip

  27. Instruments clip

  28. Video Clips- Thyroids

  29. Thyroid Video

  30. Thyroid Clip

  31. Thyroid Nerve Clip

  32. Closing

  33. ROBOTIC THYROIDECTOMYPUBLICATION

  34. ROBOTIC THYROIDECTOMYPUBLICATION “daVINCI GASLESS SINGLE INCISION AXILLARY APPROACH” Rodriguez et al. (On-line publication Jan 2011) • 35 PATIENTS • 3 OPEN CONVERSIONS • NO MAJOR COMPLICATIONS • ONE CHEST HEMATOMA

  35. Available online publication

  36. Current Data

  37. Current Data • 85 daVinci gasless single-incision axillary approach; thyroid and parathyroid • 80 Thyroids • 5 Parathyroids

  38. Indications for Surgery A. 1. FNA (cytology) – a. Follicular/Hurthle cell ‘OR’ inconclusive and CA (one patient) 2. Size of tumor (Mass) independent of Pathology 3. Multinodular (Goiter/Graves) 4. Histopathology (Path report) B. Primary Hyperparathyroidism

  39. 6 Patients were Converted to Open • 1 Patient had Large mass over 8 cm with BMI over 42 – Right lobe - open Left lobe daVinci • 1 Patient mass very large; invading capsule • 3 Patients large goiters Large Neck Circumference (football player) BMI OVER 30 - LARGE GOITER Hx of Polio – (left arm) • 1 Patient complication – Trachea puncture

  40. Total Thyroidectomy - 11 Lobectomy - 69

  41. 11 Total Thyroidectomy Initial operation; 10 were done for multinodular disease 1 done by choice of patient

  42. 80 Surgeries in 73 patients • FNA - only 4 patients had Diagnosis CA preoperatively - 3 patients were early CA • Two were less than 1 cm, resulted in lobectomy using da Vinci • One Total was Patient choice • One patient started robotic, tumor to large, converted to open, frozen section confirmed pathology

  43. 80 Thyroid surgeries; 73 Patients • 73 pts – 4 with preoperative CA = 69 no CA indication preoperatively • 69 patients had FNA (cytology) indicating Follicular/Hurthle or other indications

  44. Of the 69 patients 10 had Postoperative Pathology Cancer

  45. Of the 10 Postoperative Histopathology Diagnosis (path report) • 5 had completion thyroidectomy through opposite side using axillary approach. • Differentiated thyroid CA (less than 50 years old, tumor less than 1 cm, no capsulary invasion, no evidence of metastatic disease.

  46. Remaining patientsUnderwent Total thyroidectomy using the axillary approach ( FNA was done) dominate mass on the background; Multinodular disease

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