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Laparoscopic Surgery Training Tips

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  • Stem cells are “non-specialized” cells that have the potential to form into other types of specific cells, such as blood, muscles or nerves. They are unlike 'differentiated' cells which have already become whatever organ or structure they are in the body. Stem cells are present throughout our body, but more abundant in a fetus.
    Medical researchers and scientists believe that stem cell therapy will, in the near future, advance medicine dramatically and change the course of disease treatment. This is because stem cells have the ability to grow into any kind of cell and, if transplanted into the body, will relocate to the damaged tissue, replacing it. For example, neural cells in the spinal cord, brain, optic nerves, or other parts of the central nervous system that have been injured can be replaced by injected stem cells. Various stem cell therapies are already practiced, a popular one being bone marrow transplants that are used to treat leukemia. In theory and in fact, lifeless cells anywhere in the body, no matter what the cause of the disease or injury, can be replaced with vigorous new cells because of the remarkable plasticity of stem cells. Biomed companies predict that with all of the research activity in stem cell therapy currently being directed toward the technology, a wider range of disease types including cancer, diabetes, spinal cord injury, and even multiple sclerosis will be effectively treated in the future. Recently announced trials are now underway to study both safety and efficacy of autologous stem cell transplantation in MS patients because of promising early results from previous trials.
    Research into stem cells grew out of the findings of two Canadian researchers, Dr’s James Till and Ernest McCulloch at the University of Toronto in 1961. They were the first to publish their experimental results into the existence of stem cells in a scientific journal. Till and McCulloch documented the way in which embryonic stem cells differentiate themselves to become mature cell tissue. Their discovery opened the door for others to develop the first medical use of stem cells in bone marrow transplantation for leukemia. Over the next 50 years their early work has led to our current state of medical practice where modern science believes that new treatments for chronic diseases including MS, diabetes, spinal cord injuries and many more disease conditions are just around the corner.
    There are a number of sources of stem cells, namely, adult cells generally extracted from bone marrow, cord cells, extracted during pregnancy and cryogenically stored, and embryonic cells, extracted from an embryo before the cells start to differentiate. As to source and method of acquiring stem cells, harvesting autologous adult cells entails the least risk and controversy.
    Autologous stem cells are obtained from the patient’s own body; and since they are the patient’s own, autologous cells are better than both cord and embryonic sources as they perfectly match the patient’s own DNA, meaning that they will never be rejected by the patient’s immune system. Autologous transplantation is now happening therapeutically at several major sites world-wide and more studies on both safety and efficacy are finally being announced. With so many unrealized expectations of stem cell therapy, results to date have been both significant and hopeful, if taking longer than anticipated.
    What’s been the Holdup?
    Up until recently, there have been intense ethical debates about stem cells and even the studies that researchers have been allowed to do. This is because research methodology was primarily concerned with embryonic stem cells, which until recently required an aborted fetus as a source of stem cells. The topic became very much a moral dilemma and research was held up for many years in the US and Canada while political debates turned into restrictive legislation. Other countries were not as inflexible and many important research studies have been taking place elsewhere. Thankfully embryonic stem cells no longer have to be used as much more advanced and preferred methods have superseded the older technologies. While the length of time that promising research has been on hold has led many to wonder if stem cell therapy will ever be a reality for many disease types, the disputes have led to a number of important improvements in the medical technology that in the end, have satisfied both sides of the ethical issue.
    CCSVI Clinic
    CCSVI Clinic has been on the leading edge of MS treatment for the past several years. We are the only group facilitating the treatment of MS patients requiring a 10-day patient aftercare protocol following neck venous angioplasty that includes daily ultrasonography and other significant therapeutic features for the period including follow-up surgeries if indicated. There is a strict safety protocol, the results of which are the subject of an approved IRB study. The goal is to derive best practice standards from the data. With the addition of ASC transplantation, our research group has now preparing application for member status in International Cellular Medicine Society (ICMS), the globally-active non-profit organization dedicated to the improvement of cell-based medical therapies through education of physicians and researchers, patient safety, and creating universal standards. For more information please visit http://www.neurosurgeonindia.org/
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  • After 6 months of offering stem cell therapy in combination with the venous angioplasty liberation procedure, patients of CCSVI Clinic have reported excellent health outcomes. Ms. Kasma Gianopoulos of Athens Greece, who was diagnosed with the Relapsing/Remitting form of MS in 1997 called the combination of treatments a “cure”. “I feel I am completely cured” says Ms. Gianopoulos, “my symptoms have disappeared and I have a recovery of many functions, notably my balance and my muscle strength is all coming (back). Even after six months, I feel like there are good changes happening almost every day. Before, my biggest fear was that the changes wouldn’t (hold). I don’t even worry about having a relapse anymore. I’m looking forward to a normal life with my family. I think I would call that a miracle.”
    Other recent MS patients who have had Autologous Stem Cell Transplantation (ASCT), or stem cell therapy have posted videos and comments on YouTube. www.youtube.com/watch?v=jFQr2eqm3Cg.
    Dr. Avneesh Gupte, the Neurosurgeon at Noble Hospital performing the procedure has been encouraged by results in Cerebral Palsy patients as well. “We are fortunate to be able to offer the treatment because not every hospital is able to perform these types of transplants. You must have the specialized medical equipment and specially trained doctors and nurses”. With regard to MS patients, “We are cautious, but nevertheless excited by what patients are telling us. Suffice to say that the few patients who have had the therapy through us are noticing recovery of neuro deficits beyond what the venous angioplasty only should account for”.
    Dr. Unmesh of Noble continues: “These are early days and certainly all evidence that the combination of liberation and stem cell therapies working together at this point is anecdotal. However I am not aware of other medical facilities in the world that offer the synthesis of both to MS patients on an approved basis and it is indeed a rare opportunity for MS patients to take advantage of a treatment that is quite possibly unique in the world”.
    Autologous stem cell transplantation is a procedure by which blood-forming stem cells are removed, and later injected back into the patient. All stem cells are taken from the patient themselves and cultured for later injection. In the case of a bone marrow transplant, the HSC are typically removed from the Pelvis through a large needle that can reach into the bone. The technique is referred to as a bone marrow harvest and is performed under a general anesthesia. The incidence of patients experiencing rejection is rare due to the donor and recipient being the same individual.This remains the only approved method of the SCT therapy.
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Laparoscopic Surgery Training Tips

  1. 1. Laparoscopic Surgery Training Tips How to start How to improve Adelaide South Australia
  2. 2. What is the Learning Curve? <ul><li>The number of cases to be deemed proficient in the technique. </li></ul><ul><li>20 cases to be eligible for the ALCCaS and CLASSIC studies. </li></ul><ul><li>More than this are probably necessary. </li></ul><ul><li>The number may vary for different procedures (RHC, LHC, Rectal resection) </li></ul>
  3. 3. What is an acceptable conversion rate? <ul><li>What is a conversion? </li></ul><ul><li>Alteration in the planned site or length of incision. This may still have a laparoscopic component. </li></ul><ul><li>Rate? </li></ul><ul><li>20% or less </li></ul><ul><li>May fall or increase with time (experience and case mix) </li></ul><ul><li>Northern Colorectal Unit rate for 32004 and 32024 20% </li></ul><ul><li>Reversal Hartmann’s 40+% </li></ul>
  4. 4. What are acceptable operating and surgical parameters? Should we set limits? <ul><li>Operating time. </li></ul><ul><li>Blood loss and transfusion rates </li></ul><ul><li>Ability to achieve a high tie?? </li></ul><ul><li>Complication rates </li></ul><ul><li>Pathological margins </li></ul><ul><li>Lymph node yields </li></ul>
  5. 5. Training – What is Available? <ul><li>Literature, video, internet </li></ul><ul><li>Computer simulation </li></ul><ul><li>Case observation </li></ul><ul><li>Laparoscopic courses </li></ul><ul><li>Surgeon mentoring </li></ul><ul><li>Surgical fellowship </li></ul>
  6. 6. How to start <ul><li>Understand the principles of OPEN colorectal surgery </li></ul><ul><li>Basic general training in laparoscopy (appendix, gallbladder) </li></ul><ul><li>Application of these principles to laparoscopic colorectal surgery </li></ul>
  7. 7. How to start <ul><li>Get the Hospital on side </li></ul><ul><li>Discuss the operation, instruments </li></ul><ul><li>Dedicated nursing staff in theatre </li></ul><ul><li>Post-operative care plan </li></ul><ul><li>Cost </li></ul><ul><li>Length of stay – Short vs Long stay </li></ul><ul><li>What will the health funds pay for? </li></ul>
  8. 8. How to start <ul><li>Choose a suitable case </li></ul><ul><li>Lap stoma </li></ul><ul><li>Benign vs Malignant </li></ul><ul><li>Right vs Left resection </li></ul><ul><li>Male vs Female </li></ul><ul><li>Size of pathology </li></ul><ul><li>BMI </li></ul><ul><li>ASA grade </li></ul><ul><li>Realistic patient expectations </li></ul>
  9. 9. How to start <ul><li>Allow plenty of time </li></ul><ul><li>Get it correct from the start </li></ul><ul><li>Anaesthetic </li></ul><ul><li>Patient set up </li></ul><ul><li>Scrub nurse </li></ul><ul><li>Assistant </li></ul><ul><li>Instruments </li></ul>
  10. 10. How to start <ul><li>Accurately locate the pathology </li></ul><ul><li>Spot, Barium enema, CT scan </li></ul><ul><li>Don’t accept the stated site from a colonoscopy report (unless you can see the ileo-caecal valve) </li></ul><ul><li>Set yourself achievable goals </li></ul><ul><li>Mobilisation and delineation anatomy (ureter) </li></ul><ul><li>Ligation vessels </li></ul><ul><li>Resection </li></ul><ul><li>Anastomosis </li></ul>
  11. 11. Tips <ul><li>Conversion </li></ul><ul><li>Early assessment of the pathology and feasibility </li></ul><ul><li>Open early if not going well </li></ul><ul><li>Use a midline incision </li></ul><ul><li>Don’t consider it a failure </li></ul><ul><li>Consider an extra port as an extension of the wound </li></ul><ul><li>Hand port ??? </li></ul>
  12. 12. Tips <ul><li>Mobilise more than you need (LHC) </li></ul><ul><li>Place your incision at point where mobilised bowel will reach easily (RHC) </li></ul>
  13. 13. Oncological Principles <ul><li>Suture port sites in position </li></ul><ul><li>Limited tumour manipulation </li></ul><ul><li>Adhere to standard tissue planes </li></ul><ul><li>Wound protector </li></ul><ul><li>Cytocidal washout abdominally and where appropriate rectally </li></ul>
  14. 14. Tips <ul><li>Approach </li></ul><ul><li>Medial vs Lateral </li></ul><ul><li>Do what you are used to (don’t change) </li></ul><ul><li>Achieve a goal (eg mobilise the left colon and splenic flexure then use a lower ML incision – the patient still benefits) </li></ul>
  15. 15. Tips <ul><li>Be versatile with port placement </li></ul><ul><li>Be versatile with incision placement </li></ul><ul><li>Midline vs Pfannensteil incision </li></ul>
  16. 16. How to Improve <ul><li>Operate with someone else who is interested (Collaborate) </li></ul><ul><li>Regionalise experience </li></ul><ul><li>Video and review each case </li></ul><ul><li>Keep a database </li></ul><ul><li>Do an audit </li></ul><ul><li>Know your results </li></ul>
  17. 17. Summary
  18. 18. Conclusions