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5 Advances and Diagnostics in Surgery

Dr. Samuel Vincent Yrastorza | March 13, 2014
I. Introduction
II. Diagnostic and Surgical
Advances
A. CT Scan
B. Non-Invasive Surgeries
C. Surgical Advances
D. Robootic Advances

OUTLINE
III. Education and Training
A. Telementoring
B. Telesurgery
IV. Stem Cell Therapy
V. Tissue Engineering

SURGERY
2nd

2013-2014

Has the most advanced and highest capability for high

detection rate and correct diagnosis.
Diagnostic modality of choice usually chosen for many
situations, especially for a majority of surgical cases, with the
advent of 3D reconstruction and CT angiography.
Has a high sensitivity and specificity, and a majority of cases
(about 70-90%) can be detected, identified, and diagnosed.

References:
Dr. Yrastorzas lecture recording and ppt

I. INTRODUCTION

How do Filipino physicians measure up to physicians in the first

world countries?
In symptomatic diseases, history and physical exam alone can
give a 80-90% chance of obtaining a correct diagnosis and lead
to the subsequent treatment of the patient. Ancillary
procedures are supposed to be there only to give additional
boosts to your primary diagnosis.
In asymptomatic diseases, screening procedures can help detect
diseases, such as cancer, much earlier.
Nowadays, however, especially in the first world countries,
screening exams have become the primary means of obtaining
diagnoses, and this approach is also now becoming more
prevalent in the Philippines.
Becoming more common in the metropolis and urban centers
like in Metro Manila.
The art of medicine might get lost in future, but may not be true
for the Philippines since many cannot afford healthcare.
Thus, our emphasis in the basic science of history taking and
physical exam boosts our clinical eye, and gives us an advantage
to healthcare of the first world.

Figure 1. (L to R) Prototype, EMI CT Scan, 256 Slice CT Scan.

Figure 2. New CT Scan Modalities. A 256 slice with 3D reconstruction. More

slices allows more structures to be detected, making the scan highly specific and
highly sensitive.

II. DIAGNOSTIC AND SURGICAL ADVANCES

Before, only patients presenting with signs and symptoms can

be diagnosed. Now, even asymptomatic patients who are simply
undergoing their annual diagnostic screening can be diagnosed.
There has been great leaps and bounds for diagnostic advances
in the past years, especially in the field of gastroenterology.
Modalities such as CT Scan have been fundamental in the
diagnosis and detection of many conditions such as the
presence tumors.

Figure 3. Compare old colonoscopy (L) with 3D technology (L).

A. CT Scan

With the advent of 3D-CT Scan/virtual colonoscopy, we are able

to see inside a human person using non-invasive means, thus
causing no need for anesthesia and no discomfort during patient
screening.
Some disadvantages, however, is that these non-invasive
procedures will not allow you to obtain a tissue
biopsy.Thus, you would still need to do a colonosopy
especially for those indicated for a biopsy, doubling the
amount of procedures the patient has to undertake and
pay for.
But how many of these patients undergoing screening
exams have tumors/polyps/etc and need tissue biopsy?
Very few. This is the beauty of using CT Scan, because if not
indicated, can provide non-invasive screening for those
patients who do not need it.

Figure 4. Conventional angiogram (L) CT Angiogram (R). With 3D

reconstruction, you can see the full anatomy of your organs, in this case, the
kidney. CT angiogram is less invasive, you only need to put in a dye on your
IV line. Compared to the conventional angiogram where you have to make
an incision on the femoral area, insert the catheter and then the contrast.

B. Non-Invasive Surgery
1. Brachytherapy
Greek: brachy meaning short
radioactive source placed inside or next to the area of
treatment administered via temporary or permanent delivery
of implants such as needles, seeds or catheters

affects a very localized area radiation is confined to the area of

the target organ
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Group 12: Cabuguason, Cabungcal (09228966531), Caldozo, Calingo, Calma, Calubayen

SURGERY3.5
less exposure to surrounding normal tissue less
complications
not just for adjunctive therapy or palliation
as first line treatment for various forms of cancer
o for cancer of the prostate, cervix, head and neck
Radioactive Sources:
o strontium plaque
o iridium wires
o iodine 125 seeds

seeds within a small area only less exposure to the rectum, bladder and to
the skin.

b. Transvaginal Brachytherapy
used as a treatment modality in endometrial cancer
radiotherapy is delivered internally using a vaginal cylinder
radiation is confined within the cervix or endometrium with
lesser exposure to the surrounding structures

Brachytherapy vs External Beam Radiotherapy

Brachytherapy
External Beam Radiotherapy
Radiation source is in contact
An external source of radiation
with the tissue being irradiated.
is pointed at a particular part of
the body.
Radiation source is inside the
body.
Both are localized forms of radiotherapy

Figure 8. Transvaginal Brachytherapy.Radiation is confined within the vagina,

hence limiting the radiation exposure to rectum and the bladder.

Figure 5. External Beam Radiotherapy

a. Prostate Brachytherapy
for early and localized cancer
NOT for locally advanced or metastatic prostate cancer
comparable result to radical prostatectomy(removal of
prostate gland)
lesser complications than radical prostatectomy
outpatient procedure
uses iodine 125 seeds

c. Breast Brachytherapy
Technique for delivering radiation treatment in women with
early stage breast cancer or recurrent breast cancers
Usually given after lumpectomy or surgical removal of breast
cancer
It is a short alternative to the more traditional method of using
seven weeks of external beam radiation
Mastectomy is still the gold standard for breast cancer
treatment

Figure 9. Breast Brachytherapy.

2. Cryotherapy
Used for
o benign and malignant skin conditions
o early and localized cancers
liver
prostate
o hemorrhoids
Figure 6. Radical Prostatectomy (surgical removal of the prostate gland)

Probes and needles

directed at organ or tissue

Freezing-thawing-freezing
cycle

doesnt pass through the skin

Figure 7. Prostate Brachytherapy. Iodine 125 seeds are delivered into the
prostate through a puncture in the perineum using a needle guided with an
ultrasound probe inserted into the rectum. Radiation is delivered around the

Cellular Disruption

Cell death

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Figure 10. Cryotherapy causes cellular disruption and cell death by freezing the
target organ.

P
Figure 14. Three ways of applying the radiofrquency ablation: Percutaneously,
Laparoscopically, and through Open approach.

3. High Intensity Focused Ultrasound (HIFU)

Used for:
o uterine fibroids
o solid tumor of the brain, bone, breast, liver, pancreas, rectum,
kidney, testes, prostate
o earliest and widest use: for prostate cancer
o atrial fibrillation, arrhythmia
Figure 11. Cryotherapy (arrows pointing at ice balls created by liquid nitrogen)

HIFU

2. Radiofrequency Ablation
There are not enough studies which show that radiofrequency
ablation is more beneficial in treating primary or early stage
cancers as compared to other standard modalilties like surgery.
Indications:
o tumors of the lung, liver, bone
o used for primary and metastatic tumors
o recurrent atrial fibrillation and supraventricular tachycardia
o varicose veins
o used for areas of the body that are hard to reach

Directed at tissue or tumor

(by ultrasound or MRI)

Increase in temperature at
target tissue or tumor

Tissue or tumor
destruction

RFA probe (needle) placed inside the tumor

(guided by CT scan or ultrasound or through open
procedures)

Figure 15. HIFU produces tissue or tumor necrosis by increasing the

temperature at the target tissue or tumor (opposite of cryotherapy).

Radiofrequency waves passed through

probe into tumor

Increased in temperature
within tumor

Tumor necrosis
Figure 12. Radiofrequency ablation causes tumor necrosis through exposure to
high frequency radiation.

Figure 16. HIFU as a primary treatment modality for early stage (resectable)
prostate cancer.

C. Surgical Procedures

Trend toward less invasive procedures

1. Laparoscopic Surgery

Figure 13. Radiofrequency Ablation

Part of a broader field of Endoscopy

Also called
o Minimally invasive surgery
o Minimal access surgery
o Key hole surgery
o Pinhole surgery
o Band-aid surgery
Indications
o For diagnostic purposes (any cavity of the body)
o Cancer surgery
o Donor organ harvest (donor nephrectomy)
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o Vascular surgeries
o Any abdominal surgery
Advantages
o Better visualization of abdominal structures: because of the
camera system (most important)
o Smaller incisions smaller scars (aesthetic reason)
o Fast recovery short hospital stay
Disadvantages
o More expensive
o Requires expertise
o Steep learning curve
see one, do one does not apply here, they say that
you have to do at least 100 procedures to be really
adept in laparoscopy
o Longer operating time (gap is slowly closing with that of
open surgery)
Instruments
o Trocars
o Lens or telescope/camera
o Hand instruments

Figure 19. Thorascopic Surgery

5. Transaxillary Thyroidectomy

2. Retroperitoneoscopy

Figure 20.
Transaxillary
Thyroidectomy

For Thyroidectomy: space is created just right under the skin

Done more fore aesthetic reasons
Open surgery is easier to do vs Transaxillary Thyroidectomy

Figure 17. Retroperitoneoscopy

Endoscopy in the retropertoneum (any area of the body

where theres space, you can do endoscopy!)
Dilate area with a balloon and then expand it with carbon
dioxide, so that you dont have to pass through the
abdominal cavity to take out masses

6. Neuroendoscopy
Not enough space in the cranial cavity
you cant compress on the brain because youll produce
herniations. Not for use on the brain parenchyma.
Can be used for lesions in the ventricles because the ventricles
have space (either tumors or CSF obstructions)

3. Anthroscopic Surgery

Cystoscopic surgery of the joints

Similar advantages and disadvantages as laparoscopy
Most often used in treating ACL tears
Recovery is faster, less scars

Figure 20. Neuroendoscopy

Figure 18. Three incision points are made through Arthroscopy, instead of long
a long incision in Open Surgery

4. Thoroscopic Surgery

Cystoscopic surgery of the thorax

Similar advantages and disadvantages as laparoscopy
Instruments basically the same

7. Microlaparoscopy
3mm port instead of the usual 5 and 10 mm ports
Smaller ports used in pediatrics are now being used in adults
Smaller, finer instruments but more difficult to control
Less pain and scar
8. Single Incision Laparoscopic Surgery
1 incision
1 port (omniport, single port system) then with 3 smaller ports
for the instruments
Lesser scar is apparently better now they want only 1 hole,
usually via the umbilicus
Problem: instruments may clash; thus bendable instruments are
made more expensive!
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Figure 21. Single incision laparoscopic surgery

9. Natural Orifice Surgery
Natural Orifice Transluminal Endoscopic Surgery (NOTES)
No incision
Use natural openings in the body (mouth, anus, vagina)
Cholecystectomy via mouth/vagina
Nephrectomy via vagina
Rectal surgery via anus

Figure23. Dr Yrsatoza with the latest Da Vinci 5 in St. Lukes Medical Center <3

III. EDUCATION AND TRAINING

A. Telementoring

Figure 22. No Incision Surgery

D. Robotic Surgery
Physicians came up with robotic surgery because laparoscopic
procedure was difficult
It was initially made for cardiologists to allow more precise
movements for their heart procedures. Apparently the
cardiologists didnt need the robots and it didnt help them that
much. Hence, urologists again took advantage of this new
technology.
In robotic surgery, the robot holds the instruments which is
inside the patient, but the surgeon who controls the robot is the
one who operates it.
Surgeon doesnt necessarily have to wear gown, perform
handwashing and be sterile. There is increase in comfort and
convenience.
Robotic hands allow 360 degrees range of motion, while
laparoscopic instruments can only afford 120 degrees
Tremors are also reduced by fine-tuning the settings, giving you
more precise movements
Suturing is easier with robotic surgery

Teaching from a distance

Surgical teaching/mentoring through the internet or other forms
of communication
Out of school students or out of school teachers
Open universities

B. Telesurgery
Operating from a distance
The surgeon is in another country. The robot is in the country
where the patient is. The surgeon connects though internet and
controls robot from where he is.
Problem is when something happens to the patient. Who will be
liable? Hence, there are legal and moral issues.

IV. STEM CELL THERAPY

Use of stem cells to treat certain diseases

To create new tissues/organs to replace/augment the existing
ones

A. Stem Cells

Unspecialized cells capable of renewing themselves through cell

division
Can be induced to become tissue or organ of specific cells
In gut and bone marrow: Stem cells regularly divide to repair
and replace worn out/damaged tissues
Pancreas and heart: Stem cells divide only under special
conditions
Has not prospered because of ethical issues, especially in the
US
GOAL: is for the stem cells to repair or replace damaged cell

B. Categories of Stem Cells

1) Non Embryonic somatic or adult stem cell
eg. Bone marrow transplant
For leukemia
Replacing the old marrow with new marrow
New marrow will produce new and normal blood cells
(leukocytes, macrophages, etc.)
2) Embryonic use of human embryo (fertilized ovum)

Figure 22. Example of a robotic surgery set-up

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5. Radiofrequency ablation of a liver mass may be done through the following:
a. Extracorporeal
b. Extraperitoneal
c. Laparoscopic
d. Intradermal
6. A 25-year-old basketball player sustains a complete anterior cruciate
ligament injury on the left knee. Best treatment would be:
a. Complete and vigorous physical rehabilitation
b. Ultrasound therapy of the knee
c. Open surgery
d. Arthroscopic surgery
7. True of laparoscopic surgery:
a. Longer hospital stay
b. More difficult to identify small vessels compared to open surgery
c. Cannot be used for diagnostic procedures
d. Practically any abdominal procedure can be performed
8. The following laparoscopic procedures can now be done, except:
a. Arthroscopy
b. Endoscopy
c. Cranioscopy
d. Hysteroscopy
Figure 24. Embryonic Stem Cell Therapy

C. The Promise of Stem Cells

Understanding the development of specialized cells and

eventually the evolution of diseases.
Possibility of renewable source of replacement cells and tissues
to treat diseases.

V. TISSUE ENGINEERING
Essentially, you are constructing the organ itself from the stem
cell tissues
Tissue is created using 3 items
1) Cells: autologous, allogenic, stem cells
2) Matrix (scaffolds): support for cells to grow into new tissues
3) Cell Communicators: protein or growth factors
Tissue engineering for erectile dysfunction is already available at
Wake Forest University.
rabbits

SAMPLE EXAM QUESTIONS (2012)

1. The following are advantages of virtual colonoscopy over conventional
colonoscopy, except:
a. Non-invasive
b. Visualization of other abdominal structures
c. High sensitivity for polyps and tumors
d. Biopsy may be done
2. Use of cryotherapy, except:
a. Continuous freezing of the target tissue leads to slowing cancer cell
proliferation
b. For benign and malignant skin lesions
c. Early and localized cancers
d. In hemorrhoids

9. Radiofrequency ablation causes cellular death of the target tissue by:

a. High intensity vibration of the tissue
b. Distorting the frequency levels of the tissue
c. Heating up the tissue
d. Mechanical disruption of the cellular wall

10. In prostate permanent brachytherapy, the radioactive source used is:

a. Strontium plaque
b. Iridium wires
c. Iodine 125 seeds
d. Uranium plates
11. Placement of radiation seeds within a tumor as a form of cancer treatment
is called:
a. Brachytherapy
b. Cobalt therapy
c. Teletherapy
d. 3D conformal radiotherapy
12. In robot-assisted laparoscopic procedure, the following is true?
a. The doctor can do the operation miles away from the patient
b. The robot acts on its own directed by pre programmed instructions that is
tailored to the specific type of surgeries
c. The doctor conducts the operation guided by the robot through a
preprogrammed instructions
d. OR assistants are no longer needed during the operation
13. Laparoscopic surgery is also known as:
a. Minimally invasive surgery
b. Key-hole surgery
c. Pinhole surgery
d. All of the above

3. The earliest and widest use of high intensity focus ultrasound (HIFU) is for
the treatment of:
a. Uterine fibrosis
b. Atrial fibrillation and arrhythmias
c. Liver cancer
d. Prostate cancer
4. Which of the following is also known as minimal access surgery?
a. Brachytherapy
b. Radiofrequency ablation
c. Laparoscopy
d. HIFU

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