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