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Long-term results of above the knee femoro-popliteal bypass depend on indication for surgery and graft-material

The first joint replacement surgery was performed in 1919. Since then, joint replacement surgery has undergone tremendous development in terms of surgical technique and anesthetic management. In this era of nuclear family and independent survival, physical mobility is of paramount importance. In recent years, with an increase in life expectancy, advances in geriatric medicine and better insurance coverage, the scenario of joint replacement surgery has changed significantly. Increasing number of young patients are undergoing joint replacement for pathologies like rheumatoid arthritis and ankylosing spondylitis. The diverse pathologies and wide range of patient population brings unique challenges for the anesthesiologist. This article deals with anesthetic issues in joint replacement surgery in patients with comorbidities.

Background: Minimally invasive techniques for non-oncologic lung resections especially fungal infections are not widely employed. Through this video we share our experience of one such case of a robotic resection of pulmonary aspergilloma. Methods:A 55-year-old male with recurrent hemoptysis underwent surgical resection of post tuberculosis aspergilloma of right upper lobe using a 4-arm DaVinci Robot.Results: He received antituberculous drugs for 6 weeks pre-operatively. Systemic antifungals were given 2 weeks prior and continued for 3 months postoperatively.The operative time was 188 minutes and blood loss was 560 mL. Postoperative Chest X-rays showed complete lung expansion. intubation was done in the lateral position and a Fogarty catheter was placed on the non-affected side to prevent spillage of fungus to the normal lung. Incisions and ports were placed as shown in Figures 1,2. ConclusionsFollowing the incisions and port placement a 4-arm DaVinci Robot was docked to the patient and adhesiolysis started (Figure 3). The superior pulmonary vein was first dissected and divided using an endoscopic stapler, which was followed by the division of upper lobe bronchus. All arterial branches to the affected lobe were carefully dissected & divided later. Dense adhesions of the apex to the upper lobe were then divided. They were purposely not taken down initially for two reasons. Firstly they act as a good retraction for the lobe and secondly as they are highly vascular, lysing them early on in the procedure leads to blood loss and obscured vision. The robot was then undocked and subsequently one of the incisions was extended to facilitate the removal of the specimen from the chest, which was extracted out in an endobag ( Figure 4).A number 28 intercostal chest drain was placed after ensuring hemostasis and connected to a digital suction device. CommentsTraditionally surgical approach for aspergilloma is through a liberal thoracotomy. However the last decade has seen a rise in the number of VATS pulmonary resections performed for aspergilloma.Gossot et al. have shared their experience of 15 patients with invasive pulmonary aspergillosis (IPA), and they showed that full thoracoscopic resection (including lobectomies) of these fungal infections is possible with less postoperative morbidity (2). Whitson et al. have described a successful thoracoscopic lingulectomy for IPA (3). A recent retrospective study (4) compared VATS in the treatment of simple mycetoma and complex mycetoma. They concluded that VATS can be safely applied to simple aspergilloma and complex aspergilloma without infiltration of the hilum and allows for an early postoperative recovery.With the advent of robotics in thoracic surgery, case volumes for robotic pulmonary resections has increased significantly during the last few years, and thoracic surgeons have been able to adopt the robotic approach safely.Multiple published articles have shown the efficacy and safety of robotic pulmonary resection including lobectomy, segmentectomy, and even several repo...

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