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L Wiley Nifong

Publications and source records attributed to L Wiley Nifong.

32 records · Page 2Linked to original sources
PubMed2003

Robotic mitral valve repair: experience with the da Vinci system.

BACKGROUND: As part of a Food and Drug Administration trial, mitral repairs were performed in 38 patients using the robotic da Vinci surgical system (Intuitive Surgical, Inc, Mountain View, CA). Prospectively, we evaluated safety and efficacy in performing both simple and complex mitral repairs. METHODS: Eligible patients had nonischemic moderate to severe mitral insufficiency. Operative techniques included peripheral cardiopulmonary perfusion, a 4- to 5-cm mini-thoracotomy, transthoracic aortic occlusion, and antegrade blood cardioplegia. Transesophageal echocardiograms were done intraoperatively with three-dimensional reconstructions. Successful repairs were defined as mild or less residual regurgitation. RESULTS: Enhanced three-dimensional visualization of mitral leaflets and the subvalvar apparatus allowed safe, dexterous intracardiac tissue manipulation. All patients had successful valve repairs including quadrangular resections, sliding plasties, and edge-to-edge approximations, as well as both chordal transfers and replacements. There were no operative deaths, strokes, or device-related complications. One patient required valve replacement for hemolysis and 1 was reexplored for bleeding. There were no incisional conversions. Both robotic repair and total operating times decreased significantly from 1.9 +/- 0.1 and 5.1 +/- 0.1 hours (mean +/- standard error of the mean) for the first 19 patients to 1.5 +/- 0.1 (p = 0.002) and 4.4 +/- 0.1 hours (p = 0.04) for the last 19 operations, respectively. Total hospital length of stay for patients was 3.8 +/- 0.6 days. Of all patients, 31 (82%) had a 4-day or less length of stay. Seven patients (18%) had stays between 5 and 9 days (6.4 +/- 1.0). CONCLUSIONS: This study shows that the da Vinci surgical system (Intuitive Surgical, Inc) has few limitations in performing complex valve repairs. Articulated wrist-like instruments and three-dimensional visualization enabled precise tissue telemanipulation. Future robotic design advances and adjunctive suture technologies may promote continuing evolution of robotic cardiac operations.

Cardiac Surgical Procedures↗
PubMed2003

Outcomes and perioperative hyperglycemia in patients with or without diabetes mellitus undergoing coronary artery bypass grafting.

BACKGROUND: The association between perioperative hyperglycemia and outcomes in patients with and without diabetes mellitus undergoing coronary artery bypass grafting is not well defined. We measured the association between perioperative hyperglycemia and outcomes among patients undergoing coronary artery bypass grafting. METHODS: We report a historic cohort study of 1574 patients who had undergone coronary artery bypass grafting between 1998 and 1999, 545 (34.6%) with diabetes. Perioperative blood glucose level was defined as the average of all blood glucose tests obtained on the day of and the day after surgery. Outcomes were 30-day mortality, infection rates (sternum, harvest site, sepsis, pneumonia, urinary tract), and resource utilization. RESULTS: After adjusting for diabetes status and calculated preoperative mortality or mediastinitis risk scores, each 50 mg/dL (2.78 mmol/L) blood glucose increase was not statistically associated with higher mortality (odds ratio 1.37; 95% confidence interval, 0.98 to 1.92; p = 0.07), or higher infection rate (odds ratio 1.23, 95% confidence interval 0.94 to 1.60; p = 0.14). Each 50 mg/dL blood glucose increase was associated with longer postoperative days by 0.76 days (95% confidence interval 0.36 to 1.17 days; p < 0.001), increased hospitalization charges by 2824 dollars (95% confidence interval 1599 dollars to 4049 dollars; p < 0.001), and increased hospitalization cost by 1769 dollars (95% confidence interval 928 dollars to 2610 dollars; p < 0.001). In the unadjusted analysis, infections occurred more frequently in patients with diabetes (6.6% vs 4.1%, p = 0.03). CONCLUSIONS: Perioperative hyperglycemia is associated with increased resource utilization in patients undergoing coronary artery bypass grafting with and without diabetes.

Blood Glucose↗
PubMed2003

Robotic mitral valve surgery.

A renaissance in cardiac surgery has begun. The early clinical experience with computer-enhanced telemanipulation systems outlines the limitations of this approach despite some procedural success. Technologic advancements, such as the use of nitinol U-clips (Coalescent Surgical Inc., Sunnyvale, CA) instead of sutures requiring manual knot tying, have been shown to decrease operative times significantly. It is expected that with further refinements and development of adjunct technologies, the technique of computer-enhanced endoscopic cardiac surgery will evolve and may prove to be beneficial for many patients. Robotic technology has provided benefits to cardiac surgery. With improved optics and instrumentation, incisions are smaller. The ergometric movements and simulated three-dimensional optics project hand-eye coordination for the surgeon. The placement of the wristlike articulations at the end of the instruments moves the pivoting action to the plane of the mitral annulus. This improves dexterity in tight spaces and allows for ambidextrous suture placement. Sutures can be placed more accurately because of tremor filtration and high-resolution video magnification. Furthermore, the robotic system may have potential as an educational tool. In the near future, surgical vision and training systems might be able to model most surgical procedures through immersive technology. Thus, a "flight simulator" concept emerges where surgeons may be able to practice and perform the operation without a patient. Already, effective curricula for training teams in robotic surgery exist. Nevertheless, certain constraints continue to limit the advancement to a totally endoscopic computer-enhanced mitral valve operation. The current size of the instruments, intrathoracic instrument collisions, and extrathoracic "elbow" conflicts still can limit dexterity. When smaller instruments are developed, these restraints may be resolved. Furthermore, a working port incision is still required for placement of an atrial retractor, as well as needle, tissue, and suture retrieval. With the development of specialized retractors and a delivery/retrieval port, a truly endoscopic approach will be consistently reproducible. New navigation systems and image guided surgery portend an improving future for robotic cardiac surgery. Recently, we have combined robotically guided microwave catheters for ablation of atrial fibrillation with robotic mitral valve repairs (Fig. 8). Thus, we are beginning to achieve the ideal operation, with a native valve repair and a return to normal sinus rhythm. Robotic cardiac surgery is an evolutionary process, and even the greatest skeptics must concede that progress has been made toward endoscopic cardiac valve operations. Surgical scientists must continue to critically evaluate this technology in this new era of cardiac surgery. Despite enthusiasm, caution cannot be overemphasized. Surgeons must be careful because indices of operative safety, speed of recovery, level of discomfort, procedural cost, and long-term operative quality have yet to be defined. Traditional valve operations still enjoy long-term success with ever-decreasing morbidity and mortality, and remain our measure for comparison. Surgeons must remember that we are seeking the most durable operation with the least human trauma and quickest return to normalcy, all done at the lowest cost with the least risks. Although we have moved more asymptotically to these goals, surgeons alone must map the path for the final ascent.

Cardiac Surgical Procedures↗
PubMed2003

Robotic mitral valve surgery: a technologic and economic revolution for heart centers.

A renaissance in cardiac surgery is occurring. Cardiac operations are being performed through smaller incisions with enhanced technologic assistance. Specifically, minimally invasive mitral valve surgery has become standard for many surgeons. At our institution, we have developed a robotic mitral surgery program with the da Vinci telemanipulation system, which has recently gained Food and Drug Administration approval. This system allows the surgeon to perform complex mitral valve operations through small port sites rather than a traditional median sternotomy. Our techniques and initial results are reported. Despite procedural success, these devices are not inexpensive and hospitals will have to justify their purchase. The implementation of robotic surgery has forced us to compare costs and benefits compared with conventional cardiac surgery. Nevertheless, our desire for improved and less traumatic patient care will drive this new technology, which will serve as a good model for us to study over the next several years.

Aged↗
PubMed2003

Robotic cardiac surgery.

Traditionally, cardiac surgery has been performed by median sternotomy. However, a renaissance is occurring. Cardiac operations are being performed through smaller and alternative incisions with enhanced technological assistance. Both coronary artery bypass grafting and valve surgery can be accomplished with this novel methodology. Specifically, minimally invasive mitral valve surgery has become standard for many surgeons. At our institution, we have developed a robotic mitral surgery program with the da VinciTM telemanipulation system. This system allows the surgeon to perform complex mitral valve operations through small port sites rather than a traditional median sternotomy. Our techniques and initial results are reported, as is a brief overview of the evolution of robotic cardiac surgery.

Cardiac Surgical Procedures↗
PubMed2003

Robotic mitral valve surgery.

Traditionally mitral valve surgery has been performed via median sternotomy. However, a renaissance in cardiac surgery is occurring. Cardiac operations are being performed through smaller and alternative incisions with enhanced technological assistance. Specifically, minimally invasive mitral valve surgery has become standard for many surgeons. At our institution, we have developed a robotic mitral surgery program with the da Vinci(TM) telemanipulation system. This system allows the surgeon to perform complex mitral valve operations through small port sites rather than a traditional median sternotomy. Our techniques and initial results are reported as is a brief overview of the evolution of robotic cardiac surgery.

Cardiac Surgical Procedures↗
PubMed2003

Sutureless robot-assisted mitral valve repair: an animal model.

BACKGROUND: Robotic mitral valve repair with the da Vinci robotic surgical system has been performed in more than 70 patients at our institution. This procedure reduces the need for blood transfusions, shortens hospital stay, and hastens return to normal activities. However, the robot-assisted repair also requires longer cardiopulmonary bypass and arrested-heart times than conventional open repairs. Because of increased risk of myocardial damage, arrhythmia, and other significant morbidities associated with longer arrested-heart time, a more efficient tissue approximation and adherence technique was evaluated to reduce operating time. METHODS: Twelve Dorset sheep were divided equally into 2 groups. In the control group Cosgrove-Edwards annuloplasty bands were secured to the posterior annulus with conventional 2-0 Ticron mattress sutures placed with robotic assistance. In the experimental group, the band was secured with double-armed nitinol U-clips placed with robotic assistance. Postoperative echocardiography was used to assess mitral valve function, and the animals were sacrificed at 3 or 6 months for histological evaluation. RESULTS: Total U-clip placement time was significantly decreased at 2.6 +/- 0.2 (mean +/- SEM) minutes versus total suture placement time at 4.9 +/- 0.4 minutes (P =.001). The main difference in time occurred between clip deployment at 0.75 +/- 0.1 minutes and suture tying at 2.78 +/- 0.2 minutes (P =.000003). Pathologic review showed excellent band incorporation at 3 and 6 months. Echocardiographic imaging showed no discernible mitral valve stenosis or regurgitation. CONCLUSIONS: With more cardiac procedures progressing toward minimally invasive approaches, novel technology to improve existing techniques must be evaluated. Nitinol U-clips help to reduce arrested-heart time and may improve outcome by decreasing morbidity. U-clip placement is intuitive, easily learned, and effective in securing the annuloplasty band to the mitral annulus.

Animals↗
PubMed2002

Early experience with telemanipulative robot-assisted laparoscopic cholecystectomy using da Vinci.

In the past decade, robot-assisted surgery has become increasingly used to assist in minimally invasive surgical procedures. In this article we review the evolution of robotic devices, from the first use of an industrial robot for stereotactic biopsies to pioneering work with robots used for hip and prostate surgery, to the development of robotic guidance systems that enabled solo endoscopic surgery, to telemanipulative surgery with master-servant computer-enhanced robotic devices. In addition, we review our early experience with da Vinci Robotic Surgical Systems (Intuitive Surgical, Inc., Mountain View, CA, U.S.A.), which we used to perform robot-assisted laparoscopic cholecystectomies.

Adult↗
PubMed2002

The evolution of and early experience with robot-assisted mitral valve surgery.

Cardiac surgeons have embraced minimally invasive surgery with warranted enthusiasm. The acceleration of technological advances in optics, instrumentation, and cardiopulmonary bypass has allowed safe, effective, efficient minimally invasive cardiac procedures. In this article we review the evolution of and early experience with robot-assisted mitral valve surgery. Articles by leaders in the field of minimally invasive cardiac surgery, both American and European, are reviewed to describe the development of cardiac robotic surgery. The current state of robotic mitral surgery is described.

Humans↗
PubMed2002

Robotic-assisted adrenalectomy for adrenal incidentaloma: case and review of the technique.

An incidental left adrenal mass was found in a patient during an evaluation for mediastinal widening. The patient had no symptoms attributable to adrenal excess. Preoperative biochemical screening was negative for a functioning medullary or cortical adrenal tumor. Surgical resection was successfully completed with the assistance of the da Vinci robotic system. Pathology demonstrated a rare adrenal oncocytoma.

Adenoma, Oxyphilic↗
PubMed2002

Totally endoscopic atrial septal defect repair with robotic assistance.

BACKGROUND: The development of minimally invasive cardiac surgery has been characterized by the performance of increasingly complex operations through progressively smaller incisions. Computer (robotic) enhancement has emerged as a potential facilitator of these procedures, initially by providing enhanced endoscopic camera control and, more recently, by allowing the manipulation of surgical instruments through limited thoracic incisions. This report describes the next step in this progression, namely the performance of an atrial septal defect (ASD) repair entirely through thoracoscopic port incisions. This represents the first U.S. application of robotic technology for totally endoscopic open-heart surgery. MATERIALS AND METHODS: A 33-year-old woman with a secundum atrial septal defect underwent totally endoscopic repair through four port incisions by means of the Da Vinci (Intuitive Surgical, Mountain View, CA) robotic surgical system. Cardiopulmonary bypass was achieved peripherally (femoral Estech endoaortic balloon cannula; femoral and right internal jugular venous Bio-medicus cannulae). The myocardium was protected with antegrade cold blood cardioplegia delivered through the distal port of the arterial cannula. After port insertion, the entire operation, including pericardiotomy, bicaval occlusion, atriotomy, atrial septopexy, and atrial closure, was performed by computer-aided control of a camera and two instrument arms manipulated by a surgeon seated 15 feet away. The fourth port was used for suction and suture passage by the patient-side assistant. The aortic cross-clamp time was 43 minutes, and the postoperative transesophageal echocardiogram demonstrated normal ventricular function and the absence of interatrial shunting. The patient was extubated on the night of surgery, was ambulatory within 15 hours, and was discharged on the morning of postoperative day 3, 63 hours after the procedure. At 30-day follow-up, the patient was well and without complaints, and transthoracic echocardiogram confirmed the continued absence of interatrial shunting. CONCLUSIONS: Computer-aided robotic surgical technology can be used to perform open-heart procedures with a totally endoscopic approach. The benefits of this approach may include decreased perioperative pain, decreased recovery times, and improved cosmesis and patient acceptance. Clinical trials currently in progress will demonstrate whether this technology will be of reproducible value in the management of patients with intracardiac disease on a larger scale.

Adult↗
PubMedDate not supplied

Effect of Vacuum Assisted Closure Therapy on early systemic cytokine levels in a swine model.

Vacuum Assisted Closure (V.A.C.) Therapy has previously been shown to facilitate healing of wounds. However, the physiological mechanism(s) of this treatment modality and its systemic effects require further investigations. The goal of this porcine study was to investigate the effect of V.A.C. Therapy on the systemic distribution of the inflammatory cytokines interleukin (IL)-6, IL-8, IL-10, and transforming growth factor-beta1. Twelve pigs were each given one full-thickness excisional wound, using electrocautery. Six of the pigs were treated with V.A.C. Therapy and six with saline-moistened gauze. Serum samples were collected immediately after wound creation, and hourly for 4 hours. Samples were analyzed using commercially available enzyme-linked immunosorbent assay kits. During the initial 4 hours of treatment, V.A.C. Therapy resulted in earlier and greater peaking of IL-10 and maintenance of IL-6 levels compared with saline-moistened gauze controls, which showed decreased IL-6 values over the first hour (both at p<0.05). No other treatment-based differences were detected.

Animals↗