Difficult Dissection during a Low Anterior Resection

Authors
Carol Li, MD1*, Apoorva T. Ramaswamy, MD1*, Sallie M. Long, MD 1 , Alexander Chern, MD 1 , Sei Chung, MD 1 , Brendon Stiles, MD 2 , Andrew B. Tassler, MD 1
1Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York, NY 2Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
*Co-First authors

Overview

The COVID-19 pandemic is an unprecedented global healthcare emergency. The need for prolonged invasive ventilation is common amid this outbreak. Despite initial data suggesting high mortality rates among those requiring intubation, United States data suggests better outcomes for those requiring invasive ventilation. Thus, many of these patients requiring prolonged ventilation have become candidates for tracheotomy. Considered aerosol generating procedures (AGP), tracheotomies performed on COVID-19 patients theoretically put health care workers at high risk for contracting the virus. In this video, we present our institution’s multidisciplinary team-based methodology for the safe performance of tracheotomies on COVID-19 patients. During the month of April 2020, 32 tracheotomies were performed in this manner with no documented cases of COVID-19 transmission with nasopharyngeal swab and antibody testing among the surgical and anesthesia team.

Procedure Details

The patient is positioned with a shoulder roll to place the neck in extension. The neck is prepped and draped in a sterile fashion with a clear plastic drape across the jawline extending superiorly to cover the head. An institutional timeout is performed. The patient is pre-oxygenated on 100% FiO2. A 2-cm vertical incision is made extending inferiorly from the lower border of the palpated cricoid cartilage. Subcutaneous tissues and strap muscles are divided in the midline. When the thyroid isthmus is encountered, it is either retracted out of the field or divided using electrocautery. The remaining fascia is then cleared off the anterior face of the trachea.

Prior to airway entry, the anesthesiologist pauses all ventilation and turns off oxygen flow. The endotracheal tube (ETT) is advanced distally past the planned tracheotomy incision, without deflating the cuff, if possible. If necessary, the endotracheal cuff is deflated partially to advance the tube, with immediate reinflation once in position. The surgical team then creates a tracheotomy using cold steel instruments. The cricoid hook is placed in the tracheotomy incision and retracted superiorly for exposure of the lumen. The tube is withdrawn under direct visual guidance, without deflating the endotracheal cuff if possible. The tracheotomy tube is placed, and to minimize aerosolization of respiratory secretions, the cuff is inflated prior to re-initiation of ventilation. The tracheotomy tube is then sewn to the skin using 2-0 prolene suture. A total of five simple stitches are placed around the tube to prevent accidental decannulation.

Indications/Contraindications

Candidacy for tracheotomy was determined on a case by case basis with consideration for progression of ventilator weaning, viral load, and overall prognosis. All patients who underwent tracheotomy were intubated prior to the surgery for a minimum of 14 days, able to tolerate a 90-second period of apnea without significant desaturation or hemodynamic instability, and expected to recover. Optimal ventilator settings included FiO2

As technique and technology have evolved in the modern age, surgical emphasis has shifted steadily towards minimally invasive alternatives. In colon surgery, laparoscopy has been shown to improve multiple outcome metrics, including reductions in post-operative morbidity, pain, and hospital length of stay, while maintaining surgical success rates. Unfortunately, despite the minimally invasive approach, elective laparoscopic sigmoidectomy typically requires an abdominal wall extraction site, leaving a large incision in addition to the laparoscopic port sites. It also utilizes three different types of intestinal staplers, leading to an anastomosis that may have multiple intersecting staple lines, thereby potentially influencing the anastomotic integrity, as well as increasing procedural costs substantially.
We present a case of a totally robotic sigmoidectomy utilizing a single stapler technique and natural orifice specimen extraction in a patient with multiple, severe, recurrent episodes of sigmoid diverticulitis over a 2-year period.

Authors:

First author: Dr. Thammineedi Subramanyeshwar Rao, M.S, MCh, FMAS

Corresponding author: Dr. R Rajagopalan Iyer, DNB,FSOG,MNAMS,FMAS

Third author: Dr. Srijan Shukla, M.S,FMAS

Affiliation of all authors: Basavatarakam Indo-American Cancer Institute and Research Centre,

Road no. 10, Banjara Hills, Hyderabad, Telangana, India; PIN: 500034

Corresponding author’s mailing address: Department of Surgical Oncology, 4th floor, Block 1, Basavatarakam Indo American Cancer Hospital, Road no. 10, Banjara Hills, Hyderabad, Telangana, India; PIN: 500034

Corresponding author’s email address: rajagopalan99@hotmail.com

Disclosure/ Conflict of interest: The authors whose names are listed above certify that they have NO affiliations with or involvement in any organisation or entity with any financial interest (such as honoraria; educational grants; participation in speakers ’bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

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