La chirurgia di precisione
Chirurgia robotica |
stampa 3d |
La chirurgia robotica rappresenta la nuova frontiera della chirurgia mini-invasiva ed è l’evoluzione della chirurgia laparoscopica. Con il robot “Da Vinci”, uno dei robot chirurgici più diffusi al mondo, che conferisce al gesto chirurgico una precisione non confrontabile con altre tecniche, si possono infatti superare i limiti legati alla difficoltà di trattare, con la laparoscopia, patologie in sedi anatomiche difficili da raggiungere, estendendo, ad interventi complessi, i benefici della mini-invasività: riduzione delle cicatrici chirurgiche, dolore postoperatorio ridotto, minor degenza postoperatoria. I vantaggi della chirurgia robotica sono l’utilizzo di bracci articolabili che permettono un range di movimenti e con degli angoli impensabili per la chirurgia laparoscopica e che mimano in un certo senso i movimenti degli arti superiori. Il chirurgo operatore comanda i bracci robotici da una console attraverso due joistick ed ha la visione del campo operatorio grazie a un visore che consente di apprezzare le immagini in alta definizione ed in maniera tridimensionale, recuperando, quindi, anche la terza dimensione, assente in laparoscopia.
Robotic Heller myotomy with Dor fundoplication for esophageal achalasia
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Achalasia is an esophageal motility disorder characterized by an incomplete or absent esophagogastric junction (EGJ) relaxation associated with loss of peristalsis or uncoordinated contractions of the esophageal body in response to swallowing. All available treatments for achalasia are palliative, directed towards the elimination of the outflow resistance caused by abnormal lower esophageal sphincter (LES) function and aiming to improve the symptoms related to esophageal stasis, such as dysphagia and regurgitation. Laparoscopic Heller myotomy with partial fundoplication is the current standard of care for the treatment of achalasia. It is associated with symptom improvement or relief in about 90% of patients. However, it is a challenging procedure with the potential risk of esophageal perforation reported in up to 10% of cases. Interestingly, laparoscopic myotomy has some limitations which depend on the laparoscopic technique (bidimensional vision, poor range of movement) and on the surgeon’s experience. Recently, the use of the robotic technology has been proposed claiming that it might reduce intraoperative esophageal perforation rates and improve postoperative quality of life after Heller myotomy, mainly due to the 3D view and enhanced dexterity of the surgeon. Despite significant improvements in surgical treatment, the length of myotomy is still a matter of debate to date. Substantially, although some authors proposed a limited myotomy on the lower esophagus preserving a small portion of the LES to prevent postoperative reflux, most authors recommended a myotomy extending 4 to 6cm on the esophagus and 1 to 2cm on the gastric side. In this video, we performed a 6cm long esophagogastric myotomy, with a 2.5cm proximal extension above the Z-line (endoscopically recognized) and a 3.5cm distal extension below the same landmark. In a previous experimental study with intraoperative computerized manometry, we observed that myotomy of the esophageal portion of the LES (without dissection of the gastric fibers) did not lead to any significant variation in sphincteric pressure. Instead, the dissection of the gastric fibers for at least 2 to 2.5cm on the anterior gastric wall created a significant modification of the LES pressure profile. This may be due to the interruption of the anterior portion of gastric semicircular clasp and sling fibers, with consequent loss of their hook properties on the LES pressure profile.
Guarda il video dell'intervento del dott. Marano selezionato per la pubblicazione sul sito dell'IRCAD per l'elevata qualità tecnica e didattica:
websurg.com/en/doi/vd01en5331/
websurg.com/en/doi/vd01en5331/
IRCAD - Websurg
WebSurg is IRCAD’s online university, completely free of charge. It was launched by Professor Jacques Marescaux and his team at the European Institute of TeleSurgery (EITS) in 2000 in Strasbourg. It is a charge-free website specialized in minimally invasive surgery and dedicated to the promotion of medical and surgical training skills. It was created by surgeons for surgeons, in order to help them with their training and allow them to communicate with surgeons and experts from all over the world. It quickly became the international online reference for surgical training in minimally invasive surgery.Online university for surgeonsMultimedia content is published on the website on a monthly basis, targeting 12 specialties and 5 technologies of minimally invasive surgery: general and digestive surgery, pediatric surgery, thoracic surgery, robotic surgery, gynecologic surgery etc.
Weekly meetings are organized with the scientific and editorial committee of WebSurg in order to select the media and sections that to be published on the website each month.
Most of the content published on WebSurg is produced directly by the IRCAD institute and its partners. Contributions sent by international surgeons are also published on the website.The values of WebSurg- To promote the science and art of surgery with the goal to improve public health.
- To update surgeons on new technologies and provide continuing education to support informed clinical decisions.
- To rigorously assess and provide reliable information that is consistent with the best available evidence-based studies.
- To provide surgeons with information and updates on health technology assessment.
- To disseminate the highest quality of patient care through information validated according to the strictest standards.
- To improve public health on an international level by elevating the quality of medical and surgical care, disease prevention and research.
- To foster responsible debate on controversial issues that affect surgery and health care.
- To promote integrity in science and surgery.
Weekly meetings are organized with the scientific and editorial committee of WebSurg in order to select the media and sections that to be published on the website each month.
Most of the content published on WebSurg is produced directly by the IRCAD institute and its partners. Contributions sent by international surgeons are also published on the website.The values of WebSurg- To promote the science and art of surgery with the goal to improve public health.
- To update surgeons on new technologies and provide continuing education to support informed clinical decisions.
- To rigorously assess and provide reliable information that is consistent with the best available evidence-based studies.
- To provide surgeons with information and updates on health technology assessment.
- To disseminate the highest quality of patient care through information validated according to the strictest standards.
- To improve public health on an international level by elevating the quality of medical and surgical care, disease prevention and research.
- To foster responsible debate on controversial issues that affect surgery and health care.
- To promote integrity in science and surgery.
L'importanza della sicurezza intraoperatoria sia per i pazienti che per i chirurghi e il concetto di "chirurgia su misura" sono diventati uno degli argomenti principali della ricerca chirurgica negli ultimi anni. È necessaria una pianificazione preoperatoria centrata sul paziente per ottenere una conoscenza accurata dell'anatomia target, aiutando così i chirurghi durante le fasi critiche e le potenziali complicanze. Negli ultimi anni, l'ascesa della chirurgia assistita da robot per una varietà di procedure chirurgiche ha notevolmente rimodellato la pratica chirurgica, sebbene la sicurezza del paziente rimanga essenziale. La piattaforma robotica consente ai chirurghi di operare in modo più accurato durante le procedure difficili rispetto alla laparoscopia convenzionale, che offre viste operative tridimensionali (3D) ad alta risoluzione e migliora la percezione della profondità, nonché una migliore gestione dello strumento. La stampa 3D, oltre all'imaging medico standard, può rappresentare uno strumento prezioso per consentire una buona rappresentazione dello scenario chirurgico, in particolare in casi difficili. Inoltre, i modelli 3D offrono al chirurgo l'opportunità di rivedere, pianificare e studiare la procedura in dettaglio anche giorni prima dell'intervento.
Il dottor Marano ha utilizzato un modello stampato 3D del distretto esofago-gastrico di una donna con una variazione dell’anatomia vascolare dell’aorta causante una rarissima "disfagia aortica", e si è servito del nuovo robot daVinci per operarla con successo.
È la prima volta che è successo, in Italia, con meno di dieci casi a livello mondiale registrati finora.
Il dottor Marano ha utilizzato un modello stampato 3D del distretto esofago-gastrico di una donna con una variazione dell’anatomia vascolare dell’aorta causante una rarissima "disfagia aortica", e si è servito del nuovo robot daVinci per operarla con successo.
È la prima volta che è successo, in Italia, con meno di dieci casi a livello mondiale registrati finora.
| 2018-10-21-corriere-dell-umbria-spoleto-ospedale-chirurgia-robotica.pdf |
3dific: LA STAMPA 3D AL SERVIZIO DELLA MEDICINA
Le tecnologie digitali 3D permettono un’esatta riproduzione della diagnostica per immagini tradizionale (TC e ConeBeamTC, RMN, Eco3D) in file digitali. Questi, attraverso i nostri software certificati sono utilizzabili da robot a manifattura additiva (Stampa 3D) per realizzare la realizzazione di repliche anatomiche esatte.
I medici e le strutture sanitarie evolute possono aggiungere alle proprie risorse la potenza della stampa 3D.
La manifattura additiva permette di replicare le strutture anatomiche raccolte con gli esami radiologici TC-RMN-ConebeamCT-Echo3D, generando immagini tridimensionali.
Oltre al modello tridimensionale è possibile realizzare molto di più: protesi personalizzate, tutori, guide chirurgiche di taglio, perforazione, posizionamento…
Con la stampa 3D il planning prechirurgico è più semplice, le operazioni sono più brevi, la comunicazione con il paziente e la comunicazione interdisciplinare sono più chiare.
I medici e le strutture sanitarie evolute possono aggiungere alle proprie risorse la potenza della stampa 3D.
La manifattura additiva permette di replicare le strutture anatomiche raccolte con gli esami radiologici TC-RMN-ConebeamCT-Echo3D, generando immagini tridimensionali.
Oltre al modello tridimensionale è possibile realizzare molto di più: protesi personalizzate, tutori, guide chirurgiche di taglio, perforazione, posizionamento…
Con la stampa 3D il planning prechirurgico è più semplice, le operazioni sono più brevi, la comunicazione con il paziente e la comunicazione interdisciplinare sono più chiare.
Dalla pratica chirurgica alla ricerca scientifica.....e viceversa....
From digital world to real life: a robotic approach to the esophagogastric junction with a 3D printed model
Luigi Marano et al, BMC Surgery volume 19, Article number: 153 (2019)
Abstract
Background: Three-dimensional (3D) printing may represent a useful tool to provide, in surgery, a good representation of surgical scenario before surgery, particularly in complex cases. Recently, such a technology has been utilized to plan operative interventions in spinal, neuronal, and cardiac surgeries, but few data are available in the literature about their role in the upper gastrointestinal surgery. The feasibility of this technology has been described in a single case of gastroesophageal reflux disease with complex anatomy due to a markedly tortuous descending aorta.
Methods: A 65-year-old Caucasian woman was referred to our Department complaining heartburn and pyrosis. A chest computed tomography evidenced a tortuous thoracic aorta and consequent compression of the esophagus between the vessel and left atrium. A “dysphagia aortica” has been diagnosed. Thus, surgical treatment of anti-reflux surgery with separation of the distal esophagus from the aorta was planned. To define the strict relationship between the esophagus and the mediastinal organs, a life-size 3D printed model of the esophagus including the proximal stomach, the thoracic aorta and diaphragmatic crus, based on the patient’s CT scan, was manufactured.
Results: The robotic procedure was performed with the da Vinci Surgical System and lasted 175 min. The surgeons had navigational guidance during the procedure since they could consult the 3D electronically superimposed processed images, in a “picture-in-picture” mode, over the surgical field displayed on the monitor as well as on the robotic headset. There was no injury to the surrounding organs and, most importantly, the patient had an uncomplicated postoperative course.
Conclusions: The present clinical report highlights the feasibility, utility and clinical effects of 3D printing technology for preoperative planning and intraoperative guidance in surgery, including the esophagogastric field. However, the lack of published data requires more evidence to assess the effectiveness and safety of this novel surgical-applied printing technology.
Background: Three-dimensional (3D) printing may represent a useful tool to provide, in surgery, a good representation of surgical scenario before surgery, particularly in complex cases. Recently, such a technology has been utilized to plan operative interventions in spinal, neuronal, and cardiac surgeries, but few data are available in the literature about their role in the upper gastrointestinal surgery. The feasibility of this technology has been described in a single case of gastroesophageal reflux disease with complex anatomy due to a markedly tortuous descending aorta.
Methods: A 65-year-old Caucasian woman was referred to our Department complaining heartburn and pyrosis. A chest computed tomography evidenced a tortuous thoracic aorta and consequent compression of the esophagus between the vessel and left atrium. A “dysphagia aortica” has been diagnosed. Thus, surgical treatment of anti-reflux surgery with separation of the distal esophagus from the aorta was planned. To define the strict relationship between the esophagus and the mediastinal organs, a life-size 3D printed model of the esophagus including the proximal stomach, the thoracic aorta and diaphragmatic crus, based on the patient’s CT scan, was manufactured.
Results: The robotic procedure was performed with the da Vinci Surgical System and lasted 175 min. The surgeons had navigational guidance during the procedure since they could consult the 3D electronically superimposed processed images, in a “picture-in-picture” mode, over the surgical field displayed on the monitor as well as on the robotic headset. There was no injury to the surrounding organs and, most importantly, the patient had an uncomplicated postoperative course.
Conclusions: The present clinical report highlights the feasibility, utility and clinical effects of 3D printing technology for preoperative planning and intraoperative guidance in surgery, including the esophagogastric field. However, the lack of published data requires more evidence to assess the effectiveness and safety of this novel surgical-applied printing technology.
