We're, we're back. I know for some of you it's breakfast time, dinner time, uh, we're, we, I'm really excited about this next session, um, which was one of the things I learned when I came to Cincinnati from, from these people about the concept of better collaboration really raises the boats for everybody, um, on specifically interventional radiology and surgery and how combining together is so powerful and there's so many other institutions in the country doing this now. Um, and so I want to turn this over. Uh, so we have Tim Lotz from Luri Children's. We have John Ricardo, who is IR at Cincinnati Children's, Amanda Wallingford who works with John, and Dan von Almen, who is our surgeon in Chief. So this is the team that's gonna talk about it. Thanks. We've heard multiple times today about the importance of collaborating and the the efficacy and the efficiency and the impact on, on kids' lives. And so this session is really about combining the expertise of surgeons with the expertise of our interventional radiologists and ultimately impacting the patient. So you keep the focus on what's right for the patient and put the egos aside, and you can do really great things. So, John, amen. All right, so we'll go to the first slide. Go ahead. All right, so let's just start with a quick poll of the audience here. How often do you perform cases in collaboration with interventional radiology? This is directed at the surgeons. I'm really interested to see online from an international perspective how cases, the actual cases, yes. We can go ahead and as we move through the results here. And, you know, happy to see that it's an occasional occurrence for most, but as you can see, there's a significant minority where it's an almost never or um even a lack of access to IR which hopefully you'll leave today, um, recognizing the value of this these collaborations. We're really talking today about image-guided surgery and what we mean by that is using real-time image guidance, uh, in order to enhance the care of our patients. And, and as Dan emphasized, this is really a collaborative effort and so we're gonna be emphasizing that over and over in our talks. Go on. Yeah, next slide. Um, and even when we talk about image guidance, I think sometimes surgeon and interventional radiologists may be speaking different languages. I think, you know, some surgeons may not know all that's possible with, uh, image guidance, so they don't know what to ask for. And, you know, interventional radiologists may not know what the surgeons need, so that they might not even know what to offer. So it's important to understand that you don't have to have a hybrid OR to be able to do this type of collaboration, right? So this can occur in multiple settings. It can occur in your regular OR by bringing in an ultra ultrasound machine. It can occur in a hybrid OR if you're lucky enough to have that, or it can occur in sort of dual settings where you go to interventional radiology, maybe go to the CT scanner for a coil or a wire localization and then roll the patient up to the OR. So talking about a cone beam CT, I'm not sure how many of you actually know what that is. So it's a CT scan that's performed on a CA fluoroscopy unit. That can be whether it's a mobile C arm in an OR, in a hybrid OR, or in an interventional suite. Basically, it's positioned over the patient's point of interest and it rotates around the patient, collecting multiple images which are then stacked together to create a CT. And I think this is technology that many people have and don't realize that they have available at their institutions even if they're not doing it within a hybrid OR space. This is something that your spine surgeons are probably using, and you can use it in a number of, uh, kind of situations that might otherwise be challenging. So we can move on, yeah, and, uh, the next, uh, audience poll question. Uh, where do you perform, uh, collaborations with IR? Is it in the standard operating room? Is it either OR or intervention radiology, uh, hybrid operating room, or we don't? So as we wait for the Results to come up. I think it's important, you know, you, you, you know, we happen to have a hybrid operating room, but um it's really that those relationships between IR and surgery that are so important. And you don't need a specialized room. Yeah, absolutely. I mean, just talking about our two institutions, you guys are doing it in a hybrid OR. We are having our colleagues from interventional radiology come up to the OR with ultrasound all the time and when we need to use the CT, we're generally just transporting the patients between the two locations and both work great. So let's see the results of um this poll. And so can you hover over the green? I'm curious how many people have, so about 13% have a hybridor, which is great. I think we'll probably see that number go up over the years. OK, so we can move on. Yeah, as I mentioned, at, at Cincinnati we are fortunate, I think, you know, many institutions, I think also predominantly adult institutions, uh, you, you can have adversarial relationships you've got guarded skill sets, you know, there's financial competition in, uh, 2002 at Cincinnati we moved our interventional department from Maine radiology, which is a different floor, different building to the peri-op area. So you know we're very collaborative with the surgeons, uh, we share know-how we still have cooperative boundaries, um, you know what, what we're kind of moving towards a little bit in, in, uh, in, in Cincinnati and those relationships is working together in our hybrid OR, uh, which we've had open for about 7 years now, uh, you know, there's some cross training we help train some of the pediatric, uh, surgery fellows with ultrasound guidance for vascular access. Um, you know, programmatically united, we, you know, we, we, we're working towards that, um, in fact, um, you know, I'm on the surgical faculty, uh, you know, so Dan funds, uh, one day a week of my salary, so that's the kind of thing that we're, we're doing in Cincinnati and in the hybrid OR. Next slide. Um, a big, uh, a big, uh, important part of the program is, um, having someone that can really, uh, uh, champion the efforts of the, of the surgeons and the interventional radiologists and kind of combine everyone working together. So next slide. So I'm the program manager at Cincinnati over image guided surgery and my job is really to help be the liaison between the surgeons and the interventional radiologists. So I stand in the, um, collaborative cases, make sure things go smoothly because we all know nobody's going to want to try something new if it's going to be more complicated and take a longer time than their normal practice. So I'm. Kind of the person who goes and makes sure the room is set up for the procedure. I'm thinking of the things prior to it happening. Are we gonna be able to get the CRM in when they need the, the CT scan? Are we going to be able to do these things and just making sure everything runs smoothly. And also a huge help is just having our leadership engaged in the program. Um, Doctor Von Almen is a huge supporter of the collaborations and so. I, um, the chief of radiology and that has really helped. I also um help train the surgeons and when I say train I'm not teaching them how to run the interventional equipment. It's more about building the relationships and letting them know that what we can do in the room and meeting them in person, telling them what our capabilities are because at that point they're starting to think how can I use these to help me. And procedures. Um, you can go to the next slide. So, um, our hybrid OR was built, um, so that any division can come in and use the room. It's not just sitting idle. We're doing collaborative cases with urology, neurosurgery, pulmonary, everybody's gynecology, they're coming in and and using the room, um, and we're doing multiple procedures on these patients when they're in there. Go ahead. So let's talk about what the barriers are. So what do you consider are the most significant factors as a surgeon that limit your collaboration with IR? So is it the scheduling and billing complexity or different financial kind of entities? Is it a physical separation, financial disincentives, um, or is it really an uncertainty about the benefit of the collaborative effort, effort? Let's see the results in real time. I think this is the important one for me is understanding, like having an imagination for what cases IR can really come in and add value. What I mean, that would be if, if that was an option, I would have chosen that one. Sometimes not knowing, oh, this is something that is a potentially tricky. IR has that skill set or this is their day to day, they can come in and, and add a lot of value. So having the imagination for what's possible, that would be the answer I would choose. Yeah, no, I think that's so key. I, and I think that's where the importance of actually having those communications. And when Amanda was talking about training the surgeons, um, initially, what this was was. Uh, you know, before a surgeon would, would, uh, you do a case in the hybrid OR, we would go over, um, the, you know, capabilities, all that kind of thing. But really the most valuable part of that is just what you're saying. Um, the surgeon will say, oh, you think you could, this would help in this specific case? I'm like, oh yeah, this is something we always do in, you know, in an IR case. So it's having those communications and, and that dialogue that really, I think. Yeah, one of the things that we've talked about is, you know, having a venue where the surgeons and the IR docs regularly meet and regularly discuss cases allows you to do that. So we have a weekly radiology conference that's always the surgeons and the IR docs, and we look at cases and the IR docs will chime in and say, hey, we could do this, and the surgeons say we could do that together and then suddenly we have a case. So let's see the results. So physical separation is a big component and then scheduling complexity. So glad to see that financial disincentives is not too big of, of, uh, a factor, and I'm also glad to see that people recognize that there's a potential benefit. So let's move on and actually we created this slide before we knew about the green, blue, and black diamond and so we actually kind of we, we kind of natively created our own system here where we're kind of talking about the spectrum of image guided surgery and, and we'll, we'll. Reframe it now in green, blue, and, and black. So moving on, let's talk about some green stuff. So, um, routine and widely available stuff, right? So, simple things, lymph node localization. You've got that supraclavicular lymph node that you can't really feel very well, you know, it needs to come out. It needs more than just a core bi. See, you work together. And so let's talk about working together. Yeah, I mean, this is a case we had, uh, uh, you know, there's a lymph node kind of hidden behind the clavicle sitting on, on, um, right next to the subclavian vein. Actually, it wasn't palpable. Uh, so with ultrasound guidance, we'll just localize that with the Copan's needle wire. Um, and then, you know, next slide. And you guys, you know, even if you don't have a hybrid, the ultrasound machine rolls up to the OR, it's one prep and drape, put the copan wire in, and then as the surgeon, you have your breadcrumb trail, you follow it down, you find that lymph node easily, and, uh, you know, it takes what could be a big dissection and turns it into a nice, uh, nice easy case. So let's go on. Let's talk about just real simple things. Sometimes there's a foreign body that's hard to feel. Sometimes it's a piece of glass, like in this case, sometimes it's a, you know, er insertion that is broken in half and you're trying to find the second half of the implant to get it out. Ultrasound right there in the OR, um, can be a great tool, and oftentimes surgeons will do this themselves, but sometimes when it's a more challenging tool and you've got a friendly, you know. radiology colleague you bring them in and you can, you know, turn a slog a case into a nice, nice easy procedure. Um, I think you had some points about sort of when and where to get the ultrasound, I think I, you know, when, when I'm you know, asked to come in and and help out a surgeon that's been rooting around in there for a while, you know, you you you get you, I mean, I mean, you know, very skillfully rooting um. You know, he's not speaking from experience. Um, you know, you, you actually introduced some air in the around the around that foreign body. So when you're ultrasounding, you know, it's really hard to see it. So, you know, if you know that something might be challenging beforehand, you know, maybe give your IR colleague a call and, you know, go, you know, we'll go ahead and localize it before there's an introduction of some of that air, which makes things virtually invisible. And Quick comment, um, and I've used ultrasound on ones that you can see, and then you can actually use your hemostat or that sort of thing. See that advancing under ultrasound guidance. Put a little water in there to be able to see your hemostat going in to see the piece of glass, and then you can see the two ends of the hemostat go around the piece of glass and then pull it back out for the really deep ones. So then you have a small opening. Yeah, we'll do that. We'll, we'll go down and we'll hydro dissect around the foreign body. So we'll hydro dissect with some saline and just like you're saying, you know, um, get a forceps down in there and, and, and remove it. Yeah, and then I think there's all sorts of ways that people use intraoperative ultrasound. We could probably do a 30 minute talk just about this and, you know, again, this is something that depending on the circumstance is, is something that the surgeons will do on their own or to, you know, bring in a, a colleague when it's, you know, something that's a little bit more, uh, involved, right? And so you can use it for looking at margins and the partial nephrectomy we talked about that earlier, mapping out your, your resection, um, with the ultrasound for sarcoma excision, there's lots of data about using it to, um, sort of define your margin. During those and likewise in hepatic resections. You can also use it for identifying and protecting critical structures during surgery. So we all know during those terrible neuroblastoma excisions when you're creeping up the aorta and you're trying to see where the celiac takeoff is, you know, I'm looking with the ultrasound every 5 minutes during that case and reorienting myself with the ultrasound. I know the liver surgeons also, you know, we use it all the time as they're looking at when the middle hepatic vein is sneaking up during a, during a complex resection. And then you can use it at the end of the case to confirm vessel patency. So, you know, the transplant surgeons have been doing this forever, whether it's, you know, looking at the flow in a kidney transplant at the end of a case or looking at portal flow after a Mesorex bypass, but also again on that hard neuroblastoma excision where you've really skeletonized the renal hylum, just reassuring yourself that the um renal flow looks good at the end of the case is, is an easy, um, and great use of these tools. So we're gonna talk about kind of two different ways. There's all sorts of different ways to do pulmonary nodule localization, and many of them involve collaboration between surgery and IR. You can do it with a wire, you can do it with a coil, you can do it with dye, do it with whatever you're most comfortable with at your institution. The way we do it at Laurie is we actually make use of us, you know, two different locations. So we go to the pre-op CT. Our IR colleagues will, um, go in under CT guidance and leave a coil right next to the nodule, and then in the OR we'll use fluoroscopy under two different orthogonal planes. So you gotta look at one angle and then move it 90 degrees to make sure you really have the nodule and remove it. I like this approach, um, sometimes combined with a dye because you're not at risk for wire, um, displacement. Now I think the people who use the wires, which John will talk about, yeah, um, in Cincinnati, we, we use a combination of methylene blue blood patch as we're going in. Um, so we'll basically be, um, we'll do acom beam CT, um, ideally with the patient in thoracoscopy position already, so it's one draping and one prepping. This will be in the hybrid OR. Um, we'll do, uh, methylene blue blood patch tattooing of the, um, visceral pleura as we're going through it with the Copan's needle, and then, um, we'll deploy the, you know, the Copan's wire. Um, I remember when we first, uh, started, started doing the methylene blue actually dates back to, uh, um, Fred Reichman. I don't know if you know this, this story, Dan. Uh, we were doing it down in CT and you know, we didn't really know how much to put in and, um, uh, so we went in and, you know, put in just methylene blue, like, you know, 0.5 of an mL and you know, then we sent the patient to the OR so Fred calls, calls back and says, yeah, uh, thanks for letting me know which was the blue lobe. The entire, the entire lobe was blue, so the, the blood patch is a key component of the methylene blue we found. What, what are you guys using to localize your pulmonary nodules? Um, and you can answer if it's none of these above, but something else. So I know some people are using ehodiol and some different things. I'd be curious to see. Bargo, yeah, yeah, it, it does in our institution, uh, I've sort of gone away from wires mostly because we have to travel from CT up dislodging all kinds of stuff, right? So basically we're doing intraparenchymal ICG injection if it is superficial enough. Just the 20 times the dilution, so 0.125 mg per mL. Just a very 0.1 cc's is all you need and just kind of lights up. But if it's beyond 2 centimeters or deeper, you really can't see them. And then we leave the coils and use the C arm uh to find it. And remember, don't forget about your cone beamMCT. If you do the coil and you have trouble finding it, you can bring that mobile CR to the OR and do a spin to find that coil and get it out. So it looks like people are not learning to use IR. They're just doing fluorescence guided surgery and giving ICG or, you know, if you're really on the cutting edge cytolux, which. We can have a whole another talk about, um, people are doing wires and coils and, uh, and then none of the above, which I assume either means anatomic localization, thoracotomies with palpation, or maybe some of the other localization techniques. I know we only have another minute or two. People are doing all these different, um, approaches so we can move on. And let's talk about some of the blue, uh, blue things. So, vascular malformations, these things are often managed in a multidisciplinary VLC clinic. The IR folks can offer sclerotherapy, we can offer resection, and sometimes a combination is the best. So if you have something where It's not really amenable to sclerotherapy, they can still do, uh, angiogram essentially and directly inject it and get a contrast study and then put glue in it so that if you have these little out pouchings, these little legs, you can make sure that you're getting those fully resected at the time. Um, and these are just collaborations with our interventional pulmonologists, uh, where, we'll help them with transbronchial biopsies, uh, and we'll do acom beam CT. We'll segment out the 3D anatomy. It takes about one minute, and then our live fluoro next slide. The live fluoroscopy will be, there should be a movie there on the right. The live fluoroscopy will be superimposed over the, this nodule. So in AP and a lateral view, they always know um where they're gonna be uh um performing the transbronchial biopsy. Yeah. What, what's the glue you're using for that vascular case? At the dial thing, right, yeah, for the um for the vascular case, yeah, it can be um um it's, I know we've used onyx we've used just, um, you know, um, uh reg regular standard glue for all of our embolizations that we, we typically use for a vascular so what is ital beetle, um, uh. I just asked for glue and they gave it to me. Yeah. It might be Elmer. I don't even know. All right, next slide. Um, I know we got to wrap up here. Uh. Yeah, next slide. You know, I'm really excited about robotic bronchoscopy. We're doing some research on this right now, but you know, uh, the thoracic folks are using intuitive, right? You're just using the preoperative CT instead of a real-time CT to map out your route and do biopsies, and I think this is iatrics. I think this is finally the diamonds we'll do 30 seconds of diamond. Yeah, this is really just, uh, yeah, you can click on this you know. Um, virtual reality, augmented reality, that's, that's, I think gonna be part of the future for sure. Try to figure out what is sexy, um, and what is sexy and actually clinically useful are another couple of things. But here's, uh, on our, on our IR research lab which kind of mirrors our clinical hybrid OR if this movie plays, uh. Oh, basically, um, it's just a holographic display, uh, superimposed over your patient on the table. So you take either pre-procedure, uh, CT MRI imaging, um, segment that out and actually co-register it to your patient, um, and then you, you know, the, the technology can track instruments, you know, kind of like Brain lab does for the neurosurgeons, um, but that's definitely coming along and, uh, I think when they're able to track movement. I don't know if it's playing that one there, oh, there, this is in the uh uh hydrocephalic sheep, uh, model like one day old that we did a, uh, MRI and then they're superimposing, um, that holographic image, you know, over the anatomy and there's fucial so you can match everything up and then actually slice through, uh, virtually, uh, with hand gestures, um, the anatomy to see that those dilated ventricles for EVD drain placement. And then we'll just end by asking you to put into the chat um box any other innovative things that you all are doing to combine IR and OR resources. Thank you. That was awesome. Thank you guys. And, um, I mean, this is, I can't wait to watch this every few years to see how collaborating, you know, it's, it's interesting at, um, my brother's a urologist and about 15 years ago, he called a meeting with all the surgical specialties to come together and share toys. And since then I've been doing operations with a hysteroscope, with a neuroscope, with a uro with a what is a ureteroscope. I mean, so it's great to start sharing tools and techniques together and we're all gonna get much better. Thank you. scope is just your ureter ureteroscope, right, yeah.
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