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wishesmsg · 1 year ago
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Robotic Surgery in Lung Cancer
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Lung cancer, which is the most life-threatening type of cancer all over the world, causes approximately 1.6 million people to lose their lives every year. Surgery has an important place in the treatment of lung cancer, especially in the early stages. Robotic surgery, whose usage area has expanded with technological developments, can also be applied in lung cancer. After the operations performed with “da Vinci” robotic surgery, which is among the closed methods, patients experience a comfortable recovery period and can return to their daily lives in a shorter time. Robotic surgery, which has advantages such as less pain and bleeding, can be applied to all patients who are planned for lung resection with the closed method.
What is robotic surgery in lung cancer?
Robotic surgery is a minimally invasive surgical technique that uses robotic arms to perform surgery on a patient. In the case of lung cancer, robotic surgery can be used to remove cancerous tissue from the lungs. During the procedure, the surgeon sits at a console and uses hand and foot controls to manipulate the robotic arms, which hold surgical instruments and a camera. The camera provides a high-definition, 3D view of the inside of the patient's chest, which allows the surgeon to see the tumor and surrounding tissues in great detail. The robotic arms have a greater range of motion than human hands, which allows for more precise movements and greater dexterity in tight spaces. This can be particularly useful in lung cancer surgery, where the tumors may be located in hard-to-reach areas of the lungs. Robotic surgery in lung cancer has several potential benefits over traditional open surgery, including smaller incisions, less pain, reduced blood loss, and shorter hospital stays. However, it is important to note that robotic surgery may not be suitable for all patients, and the decision to use this technique should be made on a case-by-case basis by a team of experienced healthcare professionals.
In which diseases is robotic surgery applied in lung cancer?
Robotic surgery is a treatment option for lung cancer, regardless of the type or stage of the disease. It can be used to remove cancerous tumors from the lungs, as well as nearby lymph nodes if necessary. Robotic surgery may be particularly useful in cases where the tumor is located in a hard-to-reach area of the lung, or if the patient has other medical conditions that make open surgery more risky. In addition, robotic surgery can be used for patients who prefer a minimally invasive surgical approach, which can result in smaller incisions, less pain, and shorter hospital stays. It is important to note that robotic surgery may not be appropriate for all patients with lung cancer, and the decision to use this technique should be made on a case-by-case basis by a team of experienced healthcare professionals.
How is robotic surgery applied in lung cancer?
Robotic surgery is a minimally invasive surgical technique that is applied to lung cancer in the following way: Anesthesia: The patient is given general anesthesia, which means they are completely asleep and do not feel any pain during the procedure. Incisions: The surgeon makes small incisions in the patient's chest, typically between the ribs. These incisions are usually about 1-2 cm in size. Trocars: Trocars, which are thin tubes, are inserted through the incisions. These trocars allow the robotic arms and surgical instruments to be inserted into the chest. Robot placement: The surgeon sits at a console and controls the robotic arms using hand and foot controls. The camera and surgical instruments are attached to the robotic arms and are inserted through the trocars. Surgery: The surgeon uses the robotic arms to remove the cancerous tissue from the lung. The camera provides a high-definition, 3D view of the inside of the patient's chest, allowing the surgeon to see the tumor and surrounding tissues in great detail. The robotic arms have a greater range of motion than human hands, which allows for more precise movements and greater dexterity in tight spaces. Closure: Once the cancerous tissue has been removed, the robotic arms and trocars are removed, and the incisions are closed with sutures or surgical staples. After the surgery, the patient will be monitored in a recovery room until they wake up from the anesthesia. They will typically spend a few days in the hospital and will be given pain medication to manage any discomfort. Most patients can resume normal activities within a few weeks, although the recovery time may vary depending on the extent of the surgery and the individual patient's health.
What are the advantages of robotic surgery in lung cancer surgeries?
Robotic surgery offers several potential advantages over traditional open surgery for lung cancer, including: Minimally invasive: Robotic surgery is a minimally invasive surgical technique, which means it uses smaller incisions than traditional open surgery. Smaller incisions can lead to less pain, less scarring, and a shorter recovery time for patients. Precise movements: The robotic arms used in robotic surgery are very precise and can make very small, controlled movements. This can be particularly important in lung cancer surgery, where the surgeon needs to be very careful when removing cancerous tissue from the lungs. 3D visualization: The camera used in robotic surgery provides a high-definition, 3D view of the inside of the patient's chest. This allows the surgeon to see the tumor and surrounding tissues in great detail, which can help them make more accurate and precise movements during the surgery. Reduced blood loss: Robotic surgery can lead to less blood loss than traditional open surgery. This can be important for patients with lung cancer, who may already have a weakened immune system due to the cancer. Shorter hospital stays: Because robotic surgery is minimally invasive, patients may be able to go home from the hospital sooner than if they had traditional open surgery. This can reduce the risk of infection and other complications associated with a longer hospital stay. It is important to note that not all patients are candidates for robotic surgery, and the decision to use this technique should be made on a case-by-case basis by a team of experienced healthcare professionals. Frequently asked questions about robotic surgery in lung cancer
What is the recovery process like after lung cancer surgeries performed with robotic surgery?
The recovery process after a robotic surgery for lung cancer can vary depending on the individual patient and the extent of the surgery. However, here are some general guidelines for the recovery process: Hospital stay: Most patients will spend 1-3 days in the hospital after the surgery. During this time, they will be closely monitored for any complications and will receive pain medication as needed. Activity restrictions: After the surgery, patients will need to avoid heavy lifting and other strenuous activities for several weeks. The surgeon will provide specific instructions for activity restrictions based on the individual patient's situation. Pain management: Pain management is an important part of the recovery process. The surgeon may prescribe pain medication, and patients are encouraged to take the medication as directed. Follow-up appointments: Patients will need to schedule follow-up appointments with the surgeon to monitor their recovery and ensure that the cancer has not returned. Rehabilitation: In some cases, patients may need rehabilitation after the surgery to help them regain strength and mobility. This may include physical therapy or other types of rehabilitation. Lifestyle changes: After the surgery, patients may need to make lifestyle changes to help prevent the cancer from returning. This may include quitting smoking, eating a healthy diet, and getting regular exercise. It is important to follow the surgeon's instructions for postoperative care carefully to ensure a smooth recovery and reduce the risk of complications.
Is chemotherapy or radiotherapy required after robotic surgery in lung cancer?
Whether chemotherapy or radiation therapy is required after robotic surgery for lung cancer depends on several factors, including the stage of the cancer and whether any cancer cells were found in the lymph nodes. In some cases, chemotherapy or radiation therapy may be recommended after surgery to help destroy any remaining cancer cells and reduce the risk of the cancer returning. This is known as adjuvant therapy. In other cases, chemotherapy or radiation therapy may be used before surgery to shrink the tumor and make it easier to remove. This is known as neoadjuvant therapy. The decision to use chemotherapy or radiation therapy, and when to use it, should be made by a team of experienced healthcare professionals based on the individual patient's situation. Factors such as the patient's age, overall health, and the type and stage of the cancer will be taken into account when making this decision. It's important to note that while robotic surgery can remove the cancerous tissue, it does not guarantee that all of the cancer has been eliminated. Adjuvant therapy may be necessary to ensure that all of the cancer cells have been destroyed.
What is the difference between robotic surgery and open and closed surgeries in lung cancer?
The main difference between robotic surgery and open and closed surgeries in lung cancer is the approach used to access the lungs and perform the surgery. Open surgery, also known as thoracotomy, involves making a large incision in the chest to access the lungs. This approach provides the surgeon with a clear view of the lungs and allows them to manipulate the tissue directly. However, it is a more invasive procedure and may require a longer hospital stay and recovery time. Closed surgery, also known as video-assisted thoracoscopic surgery (VATS), is a minimally invasive technique that involves making small incisions in the chest and using a video camera and special instruments to access and manipulate the lungs. This approach can lead to less pain and a shorter recovery time than open surgery, but it may not provide the surgeon with the same level of precision and control as open surgery. Robotic surgery is a type of minimally invasive surgery that uses a robotic system to perform the surgery. The surgeon uses a console to control the robotic arms, which are equipped with small instruments and a camera. The camera provides a high-definition, 3D view of the inside of the patient's chest, and the robotic arms allow the surgeon to make precise movements with the instruments. Robotic surgery can offer several potential advantages over open and closed surgeries, including smaller incisions, less pain, shorter hospital stays, and more precise movements. The choice of surgical approach for lung cancer will depend on several factors, including the stage of the cancer, the patient's overall health, and the experience and preferences of the surgeon. The decision to use robotic surgery should be made on a case-by-case basis by a team of experienced healthcare professionals.
Are there risks of robotic surgery in lung cancer?
As with any surgical procedure, there are risks associated with robotic surgery for lung cancer. However, the risks of robotic surgery are generally similar to those of other types of lung cancer surgery, such as open or closed surgery. Some potential risks of robotic surgery for lung cancer may include: Infection: Any type of surgery can increase the risk of infection, which can be particularly dangerous in patients with lung cancer. Bleeding: Robotic surgery can cause bleeding, which may require transfusions or additional surgery to address. Pneumothorax: This is a condition in which air leaks into the space between the lung and the chest wall, which can cause chest pain and shortness of breath. Nerve damage: Robotic surgery can cause damage to nerves near the surgical site, which can result in temporary or permanent loss of sensation or movement. Anesthesia complications: General anesthesia, which is used during robotic surgery, can cause complications such as allergic reactions or breathing problems. Conversion to open surgery: In some cases, the surgeon may need to switch to an open surgery if there are complications during the robotic surgery. Blood clots: Robotic surgery can increase the risk of blood clots forming in the legs, which can be a serious complication if they travel to the lungs. It's important to note that the risks of robotic surgery are generally low, and most patients experience a smooth recovery with no serious complications. The decision to undergo robotic surgery for lung cancer should be made on a case-by-case basis by a team of experienced healthcare professionals, who can help the patient understand the risks and benefits of the procedure.
Can robotic surgery be applied to every patient in lung cancer?
Robotic surgery for lung cancer may not be suitable for every patient. The decision to undergo robotic surgery should be made on a case-by-case basis by a team of experienced healthcare professionals, who can evaluate the patient's individual situation and determine whether robotic surgery is the best option. Some factors that may affect whether a patient is a good candidate for robotic surgery for lung cancer may include: Size and location of the tumor: Robotic surgery may not be suitable for larger tumors or tumors located in certain areas of the lung. Stage of the cancer: Robotic surgery may not be recommended for advanced-stage lung cancer or cancer that has spread to other parts of the body. Overall health: Patients who have other medical conditions that could affect their ability to tolerate surgery, such as heart or lung disease, may not be good candidates for robotic surgery. Surgical experience: Robotic surgery for lung cancer requires a high level of surgical expertise and experience. Patients should seek out surgeons who are experienced in performing robotic surgery for lung cancer. Patient preference: Some patients may prefer a different surgical approach, such as open surgery or closed surgery, for personal or medical reasons. In summary, robotic surgery for lung cancer is not suitable for every patient. The decision to undergo robotic surgery should be made on an individual basis by a team of experienced healthcare professionals, who can evaluate the patient's individual situation and determine whether robotic surgery is the best option.
How many days stay in the hospital after the operation?
The length of hospital stay after robotic surgery for lung cancer can vary depending on several factors, such as the extent of the surgery, the patient's overall health, and their response to the procedure. In general, patients who undergo robotic surgery for lung cancer may stay in the hospital for two to five days. However, some patients may be able to go home sooner, while others may need to stay in the hospital longer. After the surgery, patients will be closely monitored by their healthcare team to ensure that they are recovering well and to manage any pain or discomfort. They may also receive breathing exercises or physical therapy to help improve their lung function and speed up their recovery. It's important to note that the length of hospital stay is just one aspect of the recovery process after robotic surgery for lung cancer. Patients may need several weeks or even months to fully recover and return to their normal activities, depending on the extent of the surgery and their overall health. Your healthcare team can provide you with more information about what to expect during the recovery process.
Will there be pain after the surgery?
It is common to experience some pain and discomfort after any type of surgery, including robotic surgery for lung cancer. However, the level and duration of pain can vary depending on several factors, such as the extent of the surgery and the patient's individual pain tolerance. Most patients who undergo robotic surgery for lung cancer will experience some pain or discomfort in the chest and incision area, which can be managed with pain medications prescribed by their healthcare team. Patients may also experience sore throat or hoarseness if a breathing tube was used during the surgery, but these symptoms typically improve within a few days. It's important to follow your healthcare team's instructions for managing pain after surgery and to report any severe or unexpected pain to your healthcare provider. They may be able to adjust your pain medications or recommend other strategies to help manage your pain. In some cases, patients may also experience other side effects after robotic surgery for lung cancer, such as fatigue, nausea, or constipation. Your healthcare team can provide you with more information about what to expect after the surgery and how to manage any side effects that may occur.
Is it necessary to stay in the intensive care unit after the operation?
Not all patients who undergo robotic surgery for lung cancer will require admission to the intensive care unit (ICU) after the operation. The need for ICU admission may depend on several factors, such as the extent of the surgery, the patient's overall health, and their response to the procedure. In some cases, patients may be transferred to the ICU after the surgery for close monitoring and management of any potential complications, such as bleeding or breathing problems. Patients who have preexisting medical conditions that could affect their recovery, such as heart or lung disease, may also be more likely to require admission to the ICU. However, many patients who undergo robotic surgery for lung cancer are able to recover in a regular hospital room under the care of their healthcare team. Your healthcare provider can provide you with more information about what to expect after the surgery and whether ICU admission may be necessary based on your individual situation. Read the full article
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medicuptodate · 4 years ago
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AN ARTIFICIAL SURGEON
By Gabriel Alfredo Garcia Gomez
 The future is now, science and technological advances arrive all the time, these advances make our life greater specifically in medicine. When we talk about a robot that can perform surgeries, it sounds weird. We can probably imagine an artificially intelligent robot that can perform a surgery by itself. This is a little fictional but not too far from reality; the Da Vinci Surgical Systems enable surgeons to perform delicate and complex operations through a few small incisions with robotically assisted surgery.
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The Da Vinci Surgical Systems is not an autonomous robot; it needs a qualified professional surgeon to make decisions and control it. It is extremely useful because they can operate with more precision and ease with a three dimensional view of the patient's interior. Through a computer console the surgeon controls the robot, providing him some advantages such as more precise incisions, lower loss of blood, transfusions, fewer infections or complications during the surgery, smaller and less noticeable scars, and a shorter recovery time for the patient.
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The name is an homage to Leonardo Da Vinci, the first inventor of this robot; this machine was developed by the North American company “Intuitive Surgical” and actually there are many Da Vinci Surgical Systems instruments that are used to improve the quality and efficacy of different aspects during the surgery. This technology is still improving and has shown satisfactory results; at the same time this looks attractive and beneficial to both surgeons and patients. It is hoped that this device will become more efficient and hopefully, in the future, it might be able to operate on its own.
 To read more about the Da Vinci Surgical Systems visit the following websites:
·         https://www.davincisurgery.com/
·         https://holosurgical.com/
·         https://www.intuitive.com/en-us/products-and-services/da-vinci/systems
·         https://www.uchealth.com/services/robotic-surgery/patient-information/davinci-surgical-system/
·         https://www.nbcnews.com/health/health-news/da-vinci-surgical-robot-medical-breakthrough-risks-patients-n949341
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suazo-san · 2 years ago
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Sin tener una puta idea de que hacer... ayudante laparoscopico del Da Vinci 🎨 Faroleando millones de dólares . . Manifestanding que sea yo luego quien lo maneje ✨ . . #surgeon #surgery #oncogine #oncology #davinci #davincisurgicalsystem #gyo #residentlife💊💉🏥 https://www.instagram.com/p/Cej0zgDJ2_-/?igshid=NGJjMDIxMWI=
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passionwoody-blog · 6 years ago
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Customized wooden bookmark, wooden tag, wooden embellishment. Da Vinci surgical system. #woodenbookmark #woodentag #woodengift #woodensouvenir #davincisurgery #davincisurgicalsystem #robotic #surgical #woodencrafted #surgicalsystem #woodbookmark #woodtag #woodenembellishments #roboticsurgery #davincisystem (at United States) https://www.instagram.com/p/BoNvw8JFDWe/?utm_source=ig_tumblr_share&igshid=cmzjonds3xkl
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sexydeathparty · 3 years ago
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First Dates' Merlin Griffiths Thanks NHS For 'Saving My Life' After Cancer Operation
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Merlin Griffiths
First Dates star Merlin Griffiths has thanked the NHS for after having surgery to remove a tumour.
The barman from the hit Channel 4 dating show shared that he had been diagnosed with bowel cancer last September. 
The 46-year-old has now returned home after undergoing the procedure to remove the tumour nearly a week ago. 
On Wednesday, Merlin took to Instagram and Twitter to share a smiling selfie and update fans about his robotic surgery.
He wrote: “And breathe. 6 days, start to finish. Now for real #cancer recovery. I’ve had open laparotomies before and the recovery was 6 weeks in hospital before robotic surgery!! Amazing.”
He later shared more details of his surgery on Twitter, and thanked the NHS for the “excellent” cancer care he had received.
And home again. 6 days from surgery. #NHS#davincisurgicalsystem is quite something. It's taken weeks off hospitalisation time! Road to recovery next. #cancer#bowelcancer#stomapic.twitter.com/v2SK85x16l
— Merlin 🌞 Griffiths (@MerlinFDC4) April 20, 2022
Now I'm home I'd also like to share that the excellent #cancer care has been jointly provided by MDT's at @OUHospitals & @nhsuhcw . Both treating patients with latest gold std pathways for best outcomes. Highly recommended if you need to refer your case. #NHS
— Merlin 🌞 Griffiths (@MerlinFDC4) April 21, 2022
Initial treatment plan (neoadjuvant) and chemotherapy at Oxford @OUHospitals . Final radiochemotherapy, assessments and Da Vinci operation with @nhsuhcw Coventry. Both have state of the art facilities & staff where it matters. Eternal thx to both. ♥️💙♥️
— Merlin 🌞 Griffiths (@MerlinFDC4) April 21, 2022
Journey is far from over yet. But the path is now clearer than it has been for quite some time. #nhs#BowelCancerAwarenessMonth
— Merlin 🌞 Griffiths (@MerlinFDC4) April 21, 2022
Merlin wrote: “Now I’m home I’d also like to share that the excellent #cancer care has been jointly provided by MDT’s at @OUHospitals & @nhsuhcw.
“Both treating patients with latest gold (standard) pathways for best outcomes. Highly recommended if you need to refer your case.
“Journey is far from over yet. But the path is now clearer than it has been for quite some time. #nhs #BowelCancerAwarenessMonth.”
He had previously thanked the NHS for “literally saving my life”.  
Thank you #NHS for literally saving my life.#BowelCancerAwarenessMonthpic.twitter.com/rAHQAhG6XC
— Merlin 🌞 Griffiths (@MerlinFDC4) April 15, 2022
Upon revealing his diagnosis last year, Merlin said he faced a year of treatment after doctors found a 4.5cm Stage 3 tumour.
In an interview with The Mirror, he said at the time: “I thought, as most people must when they get a diagnosis, ‘Oh fuck, I’ve got cancer’,” he told the newspaper.
“I also wanted to know, what are my chances of surviving? It’s terrifying – of course I want to live.
“I’ve shed a tear in private. But you can choose ‘to do’ or ‘not to do’. I chose to lead my life as normal, to stick to the facts about it, and to keep putting one step in front of the other.”
He added: “I won’t let it get the better of me.”
Merlin made his first appearance on First Dates when the series launched in 2013, and has been a mixologist and bartender for more than 20 years.
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ginecologiapanama · 3 years ago
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Con estas dos curiosas estudiantes de medicina @andreacarol22 y @kerima_lirieth10 realizando demostraciones ópticas de la visión monocular y la binocular (estereoscópica). Esta última fundamental, para la integración de la visión en tres dimensiones (3D), de realidad inmersiva de la consola del Robot #DaVinci. Esta capacidad le brinda ventajas al cirujano sobre la visión en dos dimensiones que se tiene en la laparoscopia convencional: pudiendo apreciar distancias entre estructuras en el plano de profundidad (eje “Z” o “tercera dimensión) 👍🏻💪🏼👌… . . #mujer #ginecologia #panama #pty #saludintima #prevencion #salud #panamacity #obstetricia #embarazo #oncologia #cancer #fertilidad #menstruacion #papnicolaou #vph #colposcopia #irregularidadmenstrual #minimainvasion #laparoscopia #controldeembarazo #ultrasonido #parto #cesarea #nacimientos #bebes #cirugiarobotica #davincisurgery #davincisurgicalsystem (at The Panama Clinic) https://www.instagram.com/p/CZjvAXbgH2A/?utm_medium=tumblr
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dheerajbojwaniconsultant · 6 years ago
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Surgical robotics is a new technology that holds significant promise. Robotic surgery is often heralded as the new revolution, and it is one of the most talked about subjects in surgery today.
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drvidali · 9 years ago
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classic #endometriosis example for #endometriosisawarenessmonth . #endometriosi #endometriose #davincisurgicalsystem #endofacts #endostrong #endowarrior #endometrioma #endometriosisawareness #endome
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drvidali · 9 years ago
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Shout Out to #endometriosisawarenessmonth . Bloopers included 😀. #endofacts #adenomyosis #endometriosis #fertility #ivf #endowarrior #endometriosis #endometriosisawareness #miscarriage #miscarriages #davincisurgicalsystem (at Andrea Vidali MD Endometriosis , Miscarriage , Infertility)
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drvidali · 9 years ago
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Here is an example of stage 4 #endometriosis for #endometriosisawarenessmonth . #davincisurgicalsystem #adenomyosis #endometrioma #ivf #fertility (at Andrea Vidali MD Endometriosis , Miscarriage , Infertility)
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drvidali · 9 years ago
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What does #excision of #endometriosis actually mean? For #endometriosisawarenessmonth i am presenting an example of a relatively simple excision. The tissue being pulled by the clamp is peritoneum containing #endometriosis being pulled away and excised. As the camera zooms in you can see the left ureter vermiculating. I think we have pretty much beaten into the groud the concept that excision is the appropriate treatment for #endometriosis . For most capable surgeons excision is pretty easy to carry out. I think the area where we really need to create awareness is proper preoperative evaluation, including wellperformed imaging studies. We need doctors to set clear goals especially when it pertains to fertility preservation. We need proper immunological, and endocrinological evaluations. I will be addressing many of these points in future posts . I also wanted to point out the amazing detail that the Davinci robot allows us to see. I know this operation can be executed well with regular laparoscpy, but lets just agree that robotic surgery is the future. #davincisurgicalsystem #endometriosisawarenessmonth #adenomyosis #endofacts (at Andrea Vidali MD Endometriosis , Miscarriage , Infertility)
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drvidali · 9 years ago
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#adenomyosis is often associated with #endometriosis .Typically #adenomyosis causes severe menstrual cramping and heavy menstrual bleeding. I blelieve that presence of #adenomyosis is a majour cause of #endometriosis surgery failure. #adenomyosis can be identified by ultrasound, but the ideal diagnostic test is an MRI . For decades adenomyosis has been treated by hysterectomy, but more recently the #osadasurgery has been proposed as an alternative to hysterectomy. I will post more info soon. #endometriosis #davincisurgicalsystem #endometriosisawarenessmonth
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drvidali · 9 years ago
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Shout out to #endometriosisawarenessmonth #selfie #adenomyosis #infertility #endometriosis #endoawareness #surgery #davincisurgicalsystem (at Hackensack University Medical Center)
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drvidali · 9 years ago
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Example of severe #adenomyosis in patient with #endometriosis . This is crazy stuff. You can see that as I squeeze the uterus black #endometriosis type blood seeps out of the incisions in the uterus. Even if the #endometriosis is treated , if seevere #adenomyosis is present , you will continue to have excruciating menstrual cramps. Most doctors treat #adenomyosis with a hysterectomy. In most cases this can be avoided and possibly preserve your #fertility. I am one of the few surgeons who is also a reproductive endocrinologist and I perform the #osadasurgery that consists in removing all the adenomyosis from the uterus. It can be performed utilizing the #davincisurgicalsystem or with a laparotomy. In this case i opted for a laparotomy because of the size of the uterus. if you have very severe menstrual cramps you may have #adenomyosis . feel free to email with questions, link in the profile. I apologize for the graphic image, but i feel that people need to be made aware of how severe this condition can be! #endoawareness #endometriosis #endometriosisawarenessmonth #endowarrior #infertility #ivf (at Andrea Vidali MD Endometriosis , Miscarriage , Infertility)
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drvidali · 9 years ago
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#selfie with the ne #davincisurgicalsystem davinci XI robot. With this new device, robotic is so superior to regular laparoscopy in terms of precision and magnification of detail! This is particularly true for the surgical excision of #endometriosis . If you are experiencing #miscarriage or #infertility or failing #ivf you may have. #endometriosis . #endometriosisawarenessmonth (at Andrea Vidali MD Endometriosis , Miscarriage , Infertility)
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