University of Illinois at Chicago
One issue I noticed in surgery was they were required to wait 3 minutes for a sterilizing liquid to dry because the liquid was sometimes flammable despite the resident saying that this particular sterilizing liquid was not flammable. Perhaps the biggest issue I continued to notice from the prior week was the room turnover was very time consuming. Along these same lines, one of the anesthesiologists was trying to coordinate what rooms would be available when for add on patients. Once again, the surgical team spent significant amount of time adapting the operating room to fit their needs for a given surgery. This no doubt contributed to the slower room turnover and caused operations to take longer than they may have otherwise.
Some of the surgeries also did not start on time for a multitude of reasons, which pushed all of the surgeries back. Electrical outlet placement relative to the operating area required many of the cords to be taped down on the floor. Furthermore, many of the cords had lengths that restricted the placement of the machine in the operating room.
Another issue that arose was during a ureteral stent placement. The wrong chair was used so the urologist was unable to get a good view of where the stent was. The chair prevented the imaging equipment from accessing the necessary views the urologist needed, as the area that was supporting the patient’s weight was under the patient’s lower back obstructing the view.
This rotation has come to an end and I can honestly say that I have learned a great deal. Me and Sam recently visited Dr. Niederberger’s clinic located at 900 N Michigan Avenue. This was a completely different realm in comparison to UIC OR. Upon entering the building we amazed at the types of procedures that were scheduled at this location. Most of the procedures pertained to male and female fertility or cosmetics. These high end procedures were consistent with the high end location of the surgery center. The surgery we was was a non-robotic reverse vasectomy. An interesting fact that Dr. Kathrins told us was that the procedure will take 3 hours while the vasectomy itself only took 45 minutes. A picture of a vasectomy is seen below:
One of the problem that is not apparent in this picture but nonetheless exists is the microscope. The microscope is used to analyze the texture of the tissue the doctors are operating on. A problem with this device is that the handles for adjustment and focusing of the lens is above the surgeons head. This is very inconvenient for the surgeon and simply kills time. The longer the surgeon takes to adjust the microscope the higher the chance of infection and the procedure going astray. This is something that needs to be addressed in order to reduce the time spent on focusing the microscope. A more user friendly automated microscope is necessary. This is something that is of interest to me.
One of the problems perceived include that of biocompatibility, which can be improved by adding a medicinal coating for scar tissue prevention. Scar tissue makes it very difficult for the intended device to function properly. In addition to that, scar tissue makes the removal of the device very difficult. The medicinal coating can also be utilized to help patient deal with the painful process of having an internal stent. There is an issue with placing stents because they often result in some degree of rejection resulting usually in excessive inflammation. Cytoscopic procedures such as the one seen below are used to place the stent into the patient. We saw particularly the surgeons struggle to remove a metallic stent due to its texture and excess scar tissue.
Bioresorbability is another aspect in which improvements, such as the creation of resorbable stents, can be made. A patient receiving removal of a stent removal would benefit if this stent was resorbable. The removal process is fairly invasive and forgoing the process would be ideal.
We saw an interesting procedures towards the end of this week. The interesting procedure we saw was a cysto transurethral prostate resection. We have seen this procedure before but what we had not seen previously was beginning of the procedure. In order to remove the bladder stones the doctors used red light lasers. They used this technology to obliterate the kidney stones. In a previous blog I described the green laser light that was used to destroy the tissue on the prostrate lobes. A different color of light was necessary because the stones had an entirely different composition. Therefore a different wavelength of light was necessary. In order to both these procedures, the green and red light laser, two large machines were necessary. This required personnel and space for operation. The doctors suggested that one machine handling both wavelengths would be ideal. This is a potential improvement that can potentially help improve the efficiency of the procedures.
More and more needs have become apparent during this second week in Urology. After completing my radiology rotation I believed that it was very technology heavy. However after this rotation, it is clear that there is far more technology used in this rotation. There is a very delicate nature associated with these procedures. For example most of the procedures that deal with the urethra require very meticulous work. A simple stent cannot be placed to counteract the closure of the urethra. Instead we saw a robotic procedure that was performed to mobilize the bladder and connect to the non-occluded part of the urethra. This seemingly simple procedure ended up needing heavy robotic machinery. The doctor informed us that a stent cannot be used to hold the occlusion open because it will tear the urethra. While they were performing the surgery, we noticed the tech was using markings on her table to measure her tools. This does not seem like a very efficient way to measure wire and tool length. An improvement is necessary to improve the archaic practices of surgeons.
The end of this week has been quite eventful. We got to see an endoscopic procedure with the assistance of the di vinci robot. This is seen below:
The procedure was intended to remove a tumor that was growing on the kidney. This was the longest procedure we had seen thus far. Roughly two hours were spent gaining access to the kidney. In order to do this, the surgeons had to create three incisions in the patients back. Then the robotic arms were placed into the individual. The surgeon operating the robot is seen below
The surgeon has fairly complex controls. He has two joysticks which control the movement of the arms and three pedals. One pedal activates the camera, the other pedal activates one arm while the final pedal activates the other arm. The doctor is using a three dimensional view to guide his arms. The doctor can also see the tumors before he begins to cut into the lesion with the help of ultrasound. The doctors struggled to remove the tissue to access the kidneys. A better approach is necessary to apply tension to the tissues.
The beginning of this week has been a transitioning period for radiology to urology. After spending three weeks in radiology, I became accustomed to very short procedures. Spending time in the Urology IR has given me a true understanding of how lengthy and meticulous surgeries are. The first procedure we saw was a cyto transurethral resection prostate. This surgery was performed to remove lobes on the patients prostrate. The procedure required and endoscope and what is known as a green light laser. The urethra was dilated in order to place the endoscope into the urinary tract. Once this was placed, the green light laser therapy was used to effectively vaporize tissues. It was very cool to see the tissue literally disintegrate in front of our eyes. This procedure was very extensive and eventually both lobes were removed. The neat thing about this procedure is that the tissue is vaporized and so there is no bleeding. It was really interesting to see how extensive some surgeries can be. During the procedure we had to wear special eyewear because of the nature of the lasers.
I am definitely having to adjust to this new rotation. The amount of standing on your feet is far more substantial than radiology. I am looking forward to seeing more of the Robotic procedures.
IR as we know is heavily dependent on technology. Since technology is being used to visualize and treat patients during procedures, there are ways to further optimize these technologies. Problems with visualization added to the difficulty of carrying out the procedures. Interventional radiologists use imaging techniques to assist them in the minimally invasive treatments of their patients. The minimally invasive aspect falls to the fact that the success of these procedures relies heavily on the quality of images obtained. A more radiopaque material or a three dimensional x-ray may be a potential step toward better visualization. The more x-rays used, result in more harm to the patient.
Other problems perceived include that of biocompatibility, which can be improved by adding a medicinal coating for scar tissue prevention. Scar tissue makes it very difficult for the intended device to function properly. In addition to that, scar tissue makes the removal of the device very difficult. Some devices, such as chest ports, remain in patients for years. Also, the microspheres that are used to administer chemotherapy can be improved. Only a few drugs are compatible with the microspheres. A better microsphere design will greatly improve the breadth of chemotherapy that is administered.
Thank you to Dr. Bui and the entire IR department for teaching us so much and allowing us this opportunity. The work these individuals do on a daily basis is truly amazing and being able to think innovatively while in this environment is an experience and a blessing.
This week has been fairly eventful thus far. To begin with, we saw our first pediatric patient. She was in for a ureteral stent placement. This is for patients who have a blockage in their ureter. This results in a pooling of urine in the kidneys because there is a urine back up. The stent collects the urine in the kidney and creates a pathway for flow to the bladder. There was considerable tension that was apparent before the procedure. The parents were very reluctant to leave their daughter for the procedure. Next, when the anesthesiologist came there was some difficulty administering the analgesics to the patient. In order to properly place the non-rebreather mask on the patient, the doctors had to flip over the girl. After the surgery was successful, we talked to Dr. Ray regarding the procedure. He told us that it was a fairly stressful procedure for the following reasons: its very hard to see the ureteral stent with the fluoroscopy X-Ray system. This is definitely something that needs to be improved because the hard the stent is to see, the more X-Ray radiation the doctors have to administer to the child to try to visualize the stent. Perhaps there is some coating that can be utilized to more effectively see the stent system.
We have also seen a large number of biopsy procedures. This has been the most common procedure that radiologists perform. Image guided biopsies range in difficulty. For example a kidney biopsy can be pretty simple and can be completed by simply using ultrasound and a biopsy gun. However, there is one drawback of these biopsy procedures. The procedures require a dual needle gun. This needle has to cut through the tissue and cut a core of tissue. the problem with this that the gun makes a very loud sound as it cuts the core. This is a very intimidating and frightening sound. I was definitely startled when I first heard. The mechanism must be improved to reduce this noise.
We saw three interesting procedures this week. The first procedure we saw was transjugular intrahepatic portal shunt (tips). This procedure is used to treat hepatic Hypertension. Due to cirrhosis of the liver there is a back up blood in the hepatic artery. This causes compromised function in the liver. It is by far the longest procedure we’ve seen. It took over two hours to perform the procedure. There was a great deal of time spent trying to find the hepatic vein. The visualization abilities of a x-ray system are limited. It is hard to see the vein without a three dimensional representation of the vascular system. Also we saw them using a balloon angioplasty system to burrow through the liver tissue. A pressure device was used to control the pressure in the balloon. Also the doctors were using a pressure transducer to figure out the pressure gradient between the two veins they were shunting. The transducer was very similar to the transducer we had seen in instrumentation class. The other procedure we saw was a bone biopsy. We saw the doctor drill through the sacrum. The patient didn’t feel any pain. The picture of this is seen above.
To start off the week we saw a inferior vena cava filter removal. This filter is seen above. The process is analogous to arcade claw machine. A lasso is fed through the catheter and is used to tie base of the filter. Then the flexible filter is fed through a sheath and the sheath is guided out of the jugular vein with the filter. While the doctor is doing this he is referring constantly to his live x-ray image of the IVC. The x-ray looks like the following:
The doctor must tighten his lasso when he sees that it is on top of the filter. This doesn’t always lead to proper hooking and instead often results in miss-hooks. A 2-D visualization of the lasso device and the filter does not adequately represent what the doctor needs to see to effectively hook on to the filter. There is a lot of trial and error that is necessary in order to hook on to the filter. This is not usually a problem but sometimes the filter can be pushed into the renal vein during the hooking trial and error process. This can be problematic. A more effective visualization technique will benefit the doctors in the filter removal process.
We have also begun to see several embolization procedures. This a process where an embolus is passed to a tumor to block of the tumors blood supply. This does effectively kill the tumor but it does take time, usually months. We have seen the doctors inject EMBOSPHERES as their choice of embolus. They are seen below:
You can see the tiny microspheres that create the embolus. They are roughly 400 microns in diameter. This is close to 6o times the diameter of the a red blood cell. The massive spheres can clog up the artery leading to the tumor. We have seen this procedure performed in the kidney, liver, and uterine. Uterine fybroid embolism has been the most interesting embolism procedure. This is because there were two different vessels supplying blood to the tumor and so two embolisms are made. To test that the embolisms have formed, the doctors inject contrast to the artery. If the is an impedance in flow, the embolism has successfully been created.
We have started to see more eventful procedures. The main procedure we are starting to see is known as ablations. Ablations procedures that remove a cancerous tumor mass by several means such as heating or chemical means. The two procedures that we’ve seen is ethanol ablation and radio frequency ablation. Ethanol ablation is less eventful and requires injection of ethanol to the tumor. RF ablation uses AC currents to generate heat to essentially cook the tumor. The picture seen above shows the RF ablation device inside the patient. He is receiving RF ablation to treat a tumor in his liver. The device is seen below:
This is the ablation device is inserted through a catheter system to the site of the tumor. Upon reaching the tumor, it has talon that are released. This is seen below:
Saline is released from the talons. This allows for equal conduction and heating of the tumor. The temperature is monitored using the following:
The machine maintains a temperature of 150 celsius. This is done for 8 minutes to adequately cook the tumor. The device is held in the liver as seen in the picture. The device is free to move externally but is anchored by the talons inside and so it will not move in the liver. As the device is pulled out it is very hot. We saw that as it was pulled out it burned the patients skin. This is definitely a limitation of the device, and I feel it can be improved. A smarter design must be used to reduce the burning the patients feel.
The first few days of the Clinical Immersion internship program have been very fulfilling. Radiology has been even more exciting than I anticipated. As soon as we got to the Interventional Radiology (IR) operation room (OR) we were greeted by Dr. Bui. He told us to go get scrubs on. As me and Ossama went to get our scrubs on we noticed that there were a lot of monitors. In fact, each doctor was in front of three monitors. There was one regular monitor and the other two monitors were vertically placed and were primarily being used to view x-rays. There was clearly emphasis on technology in this department.
The first procedure we witnessed was a kidney biopsy. We noticed that first the doctor would use an ultrasound to find a tumor of interest. When the doctor was dealing with soft tissue and the abdomen area he would utilize a ultrasound system. For me and Ossama it was very hard to see what the doctor was seeing. We were eventually able to see the tumor that aiming for. Once the doctor found the tumor mass, he used a biopsy gun to obtain the tissue sample. The biopsy gun mechanism is seen below:
The next procedure we say was an administration of a chemotherapeutic drug known as doxorubicin. The doctor used a lipid mixture as well as the concentrated dox to make a drug emulsification mixture. The lipid material was used so that the cells could take up the lipid/dox mixture since the favorable polarity. The drugs were mixed using a simple one way valve with two ports, one for each syringe. The drug was injected using a catheter. We were not able to go in the OR for this procedure because there was X-Rays being used. In order to be in the same room as X-Rays, a lead protection apron must be used.
My initial impression is that interventional radiologists are truly talented individual. From one day I was able to see that these doctors are experts on a vast array of treatments. This is made possible largely by the powerful ability of imaging modalities. Each imaging duality is used in each respective circumstance and procedure. At this point there is no specific need that is noticed but I anticipate that as we move forward a need will surface. The doctors seem to be very fond of us bioengineering students. They frequently encourage us by saying, “you’ll invent the next so and so, you just don’t know it yet”. The vast array of technologies being used such as the biopsy gun is a testament to this statement.