Minimally invasive thoracic surgery, when compared with open thoracotomy, has been shown to have improved perioperative outcomes as well as comparable long-term survival. Robotic surgery represents a powerful advancement of minimally invasive surgery, with vastly improved visualization and instrument maneuverability, and is increasingly popular for thoracic surgery. However, there remains debate over the best robotic approaches for lung resection, with several different techniques evidenced and described in the literature. We delineate our method for total port approach with four robotic arms and discuss how its advantages outweigh its disadvantages. We conclude that it is preferred to other robotic approaches, such as the robotic assisted approach, due to its enhanced visualization, improved instrument range of motion, and reduced potential for injury. Vinci Si or Xi robot. Our port positioning and placement is systematic and optimized for robotic arm maneuverability (8,14,15) ( Figure 1). For the da Vinci Si system, we use two 8 mm ports (left and right robotic arm ports), a 12 mm port (camera), and a 5 mm port (fourth robotic arm port-we use the smallest size port because it is all that is required for the fourth arm instrument, allowing us to minimize pain); for the Xi system, all the ports are 8 mm ports. We also utilize a 12 mm assistant port that can be used for stapling and exchange of items such as rolled-up sponges and vessel loops. The assistant port is also important in case sudden or catastrophic bleeding occurs. The following is a description of port placement for a right-sided resection.We place the ports in the seventh (upper or middle lobectomy) or eighth (lower lobectomy) intercostal space. The fourth robotic arm is located 2-3 cm from the spine, the left robotic arm port is located 10 cm away from that port, the camera port is located 9 cm from the left robotic arm port, and the right robotic arm is located 9 cm away from the camera port (Figure 1). The port locations are marked beforehand, although slight changes to these locations are often necessary once the intrathoracic anatomy is visualized. The first port to be placed is the camera port [C]. To verify pleural space entry, a camera is introduced into the port before insufflating the thoracic cavity with warmed, humidified carbon dioxide to inferiorly displace the diaphragm and maximize the cavity size. Next, in an effort to reduce postoperative pain, we administer a subpleural paravertebral block of ribs three to eleven using 0.25% bupivacaine with epinephrine via a 21-gauge needle. Then, the fourth robotic arm port (labeled "3" in Figure 1) is placed. This port is inserted two ribs beneath the oblique fissure (often over the top of the eighth rib for upper lobectomy and over the top of the ninth rib for lower lobectomy) at a maximally posterior location about 2 cm anterior to the spinous processes of the vertebral bodies; it will control the second left hand instrument. The camera is then placed through the fourth robotic arm ...
BACKGROUND: Little is known about the impact of multimorbidity on long-term outcomes for older emergency general surgery patients. STUDY DESIGN: Medicare beneficiaries, age 65 and older, who underwent operative management of an emergency general surgery condition were identified using Centers for Medicare & Medicaid claims data. Patients were classified as multimorbid based on the presence of a Qualifying Comorbidity Set (a specific combination of comorbid conditions known to be associated with increased risk of in-hospital mortality in the general surgery setting) and compared with those without multimorbidity. Risk-adjusted outcomes through 180 days after discharge from index hospitalization were calculated using linear and logistic regressions. RESULTS: Of 174,891 included patients, 45.5% were identified as multimorbid. Multimorbid patients had higher rates of mortality during index hospitalization (5.9% vs 0.7%, odds ratio [OR] 3.05, p < 0.001) and through 6 months (17.1% vs 3.4%, OR 2.33, p < 0.001) after discharge. Multimorbid patients experienced higher rates of readmission at 1 month (22.9% vs 11.4%, OR 1.48, p < 0.001) and 6 months (38.2% vs 21.2%, OR 1.48, p < 0.001) after discharge, lower rates of discharge to home (42.5% vs 74.2%, OR 0.52, p < 0.001), higher rates of discharge to rehabilitation/nursing facility (28.3% vs 11.3%, OR 1.62, p < 0.001), greater than double the use of home oxygen, walker, wheelchair, bedside commode, and hospital bed (p < 0.001), longer length of index hospitalization (1.33 additional in-patient days, p < 0.001), and higher costs through 6 months ($5,162 additional, p < 0.001). CONCLUSIONS: Older, multimorbid patients experience worse outcomes, including survival and independent function, after emergency general surgery than nonmultimorbid patients through 6 months after discharge from index hospitalization. This information is important for setting recovery expectations for high-risk patients to improve shared decision-making.
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