Day 4 - Lymphatic's/mapping/pinpoint/spyphi

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What are technical contributing factors to anastomotic leaks?

Surgical technique, insufficient blood supply, tension

Breast recon, colorectal, assessing tissue perfusion are ideal in overlay.

TRUE

Can litigation costs go up to millions of dollars for ureteral injuries?

TRUE

Can you see if cancer cells are present by examining lymph nodes?

TRUE

The Laparascope has 2 adapters in the same spot

TRUE

What is the idea behind the Sentinel Node Concept?

That cancer spreads in a particular order and the Sentinel node is the first node in a given region

What happens when you pres and hold green (illumination) button?

Turns illumination button off

What does the green button do?

Turns light on, first mode is overlay

What does the white balance button look like

Two triangle facing eachother with a rectangle in the middle

What is the enhanced pathology to find micrometastesis

UltraStaging

What cancers are approved for lymph node mapping?

Uteran and cervical cancer

What is the second step of a colorectal procedure

Vascular ID

What does VPI Stand for?

Video Processor/Illuminator

After injection it condenses in the parametria

What is ICG

When are there 4 windows on a Pinpoint?

When in fluorescent modes

What is lymphadema

When lymph doesn't drain and causes significant swelling (photo of patient with large leg)

What is an ischemic failure?

When tissue dies days after case

From top to bottom what is the order ALWAYS on Pinpoint (for the windows on the left of the screen)

White Light, Spy, Overlay (CSF NEVER shows up on left side)

What does a gyecologist do?

Works with disesases specific ot girls and women - especially the reproductive organs

Can surgeons maintain anatomical context while getting flourescent imaging in Overlay?

Yes

Does Blue Dye have white light visualization

Yes

What is the Mayo Criteria?

do hysterectomy first check margins around tumor instead of doing Radical

What is the function of the lymphatic system?

transport/drain/filter lymph - to keep us healthy

When would you use SPY Mode

when you need a high level of contrast and detail, Breast recon, colorectal, assessing skin perfusion

What is the cost without v with anastomotic leaks?

$26k to $66k

How often do ureteral injuries occur in lower pelvic procedures/

0.3%-1.8%

What was the overall leak rate?

1.40%

What percentage of cases result in leaks per the literature?

10%-15%

How many adapters and what ends does the light cord have adapters

2 (1 at each end)

How far should surgeon go with catheters and how can you tell when you're there?

20 cm and double black band

What percentage of patients develop Lymphadema?

23%

How many colorectal porcedures occur annually in the US?

250,000

What is the row of lymph nodes AFTER the sentinel node?

2nd echelon, 3rd, etc. etc...

What are the 3 ways that dyes are injected into the cervix?

3 (3,9 - 2, 4, 8, 10 - 12,3,6,9)

How long is the GynOnc fellowship?

3-4 years, learning about surgery and cancer therapies

What percentage of micrometasesis are identified with ultrastaging vs. routine patholgy?

4.50%

How long can ureter identifcation take?

45 minutes

How many colorectal porcedures are performed in the US yearly?

600,000

What percentage of cases did pinpoint make an impact and also resulted in 0% leak rate?

8%

What percentage of patients who have had total lymphadenectomies had 0 LN involvement?

80-85%

How do you change display mode AND/OR exit the menu?

A Button

What is Technetium 99/Tech99

A prob that detects radioactive colloids

What is another name for the "Mayo Approach"?

All-or-Nothing Criteria

What is the fifth step of a colorectal procedure

Anastomosis

What is the most devastating complication in colorectal surgery?

Anastomotic leak

What is CSF mode ideal for?

Anatomical margins (off label mapping, open lap choles)

What large blood vessel is in the middle of the Colon

Aorta

Colorectal Anatomy

Appendix, Cecum Ascending Colon, Hepatic Flexure, Transverse Colon, Splenic Flexure, Descending Colon, Sigmoid Colon, Rectum

How do you pull up button and select something when in the menu?

B Button

What flows faster, blood or lymph?

Blood - due to the heart pumping it

What is the gold standard?

Blue dye and radioactive colloids

What is the process of ICG for lymph node mapping

Cervix injection > Lymph node system > condenses in parametria

What do you need for a PinPoint case?

Check for allergy, VPI, Camera Tray, Pinpoin scope and light guide cable, Pinpoint Kit, DRSI (disposable rigid scope introducer) with insufflation bulb

What is another name for colon resection?

Colectomy

What is the surgrical removal of all or some of the colon?

Colectomy/Colon Resection

What are 3 examples of causes for colorectal surgery?

Colorectal cancer, polups, diverticulitis

What color is lymph?

Colorless/clear

Who makes an adapter to stop urine

Cook Medical and Applied Medical

What does an OB do?

Deliver Babies

Where is ICG injected for cervical cases?

Directly into cervix (Direct Injection) - NOT STERILE, Not into blood vessel

What does DRSI stand for?

Disposable Rigid Scope Introducer

What is the fourth step of a colorectal procedure

Division of Colon

Is the DRSI Sterile?

FALSE

Does IRIS emit heat?

FALSE - is negligible

Lymphatic vessels are never by arteries or veins

FALSE - they run "in parallel" per Robyn

Lymph runs in a bi-directional flow

False - Uni-directional, always going the same way "Drains"

What does FILM stand for?

Fluor. imaging and lymphatic mapping

What do the up and down arrows do?

Focus image

What two surgeons would be interested in IRIS?

GYN and Colorectal

For use of IRIS iwth L10 and L11 what scope must you use?

Green AIM - Purple is off label and "doesn't always work"

What does the logo for overlay mode in Spy Phi look like?

Green circle, red, blue, green dot (clockwise from 12)

Describe the data port

Green with a rectangular entrance, video port

What Dr. specializes in diagnosing and treating cancers of the female reproductive organs

Gynecologic Oncology

What are the components for a Pinpoint Tower?

HD-LED Medical Grade display, insufflator, pull out keyboard, VPI, HD Video Recorder, Printer

What is a main reason that Spy Agent Green is better than the Blue Dye?

Higher detection rate with obese patients

What is the first step of a colorectal procedure

ID Anatomy

List the six steps of a colorectal procedure in order

ID Anatomy, Vascular ID, Mobilization, Division of Colon, Anastomosis, Leak Check

Diverticulitis

Inflammation of a diverticulum especial in the colon, causing pain and disturbance of bowel fountion

What is lymph fluid?

Interstitial Fluid that is in a Lymph vessel

What are the steps for cancer that were shown?

Intial encounter (Exam) > Surgery (Lymphandenctomy/surgery) > Pathology

What is the sixth step of a colorectal procedure

Leak Check

Which side of the colon is much more challenging to operate on and why?

Left, it is a lot less space to work with

What is an LAR

Lower anterior resection, removes part of sigmoid and part of descending colon

What does the lymphatic system circulate?

Lymph

What is a lymphadenectomy?

Lymph node biopsy/surgical lymph node dissection

What is the surgical lymph node dissection?

Lymphadenectomy

What is the use of dye or radioactive substances to identify lymph nodes that may contain cancer cells?

Lymphatic Mapping

Where does lymph flow through?

Lymphatic Vessels/Channels

What are the different names for the Blue Dye

Lymphazurin (Isosulfan blue), Methylene Blue

What are 2 very important Facilities for GynOnc with regard to ICG?

MSK, MD Anderson

Who wrote the PILLAR II study?

Michael Stamos, Steve Wexner

What is the third step of a colorectal procedure

Mobilization

Is the DRSI reprocessible?

No - It is disposable

Does the Spy Phi work in a fixed working distance?

No, Variable (5-40 cm)

What equipment did Matt Smith present and how does it work

Obturator, Sheath, 4 30 Cystoscope, Double Horn Bridge

Decribe the light cable port?

Orange with circlular entrance

What is a lymphocyst?

Painful cyst

What is done at the initial encounter?

Pelvic exam, imaging, biopsy of tissue, initial diagnosis of early stage cancer

What type and size of scope needed for transanal views?

Pinpoint 10mm 0*

What is the approved FDA Indication?

Pinpoint using Spy Agent Green for lymphatic mapping in uterine and cervical cancer

What are 4 specialties for Spy Phi

Plastic micro recon GI

What does PHI stand for in Spy Phi?

Portable Handheld Imaging

What are the steps to image acquisition?

Position Image, Correct display mode, start recording on SDC3, administer ICG and flush with 10cc of saline, watch magic

Why is Sentinel node concept benefical?

Potentially reduce morbitity by taking out less nodes, and maintains quality of disease detection

How do you get to white light mode?

Press green button two times

What are patient contributing factors to anastomotic leaks?

Radiation, smoking obestity?

What are the ways to perform a lymphadenectomy from most invasive to least?

Radical, Regional, Select, Sentinel lymph node w/ Ultrastaging

What is the tool used to hear the lymph mapping

Radioactive Colloids

Which side of the colon has a more robust blood supply?

Right side

What does SLNB stand for?

Sentinel Lymph Node Biopsy

What is the concept that lymph node mapping is always done with?

Sentinel Node Concept

What does SGO stand for?

Society of Gynocology Oncologists

What is a technical failure that leads to anastomotic leaks?

Stapler misfire

What was Pillar 2?

Study of 139 patients who had LARs where ICG was used on each case

What supplies blood to the right side of the colon

Superior Mesenteric Artery (SMA)

Inferior Mesenteric Artery (IMA) does what?

Supplies blood to the left colon


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