2024 Update Course - Updates in Techniques from Mexico - Carlos Colunga & Todd Ponsky

One of the things um we wanted to do from now on going forward is to highlight different regions that have their own updates that are specific to that region so Carlos wanted to talk about some of the updates from Mexico from uh Monterrey Mexico Hospital. OK, so let's talk about different updates in Mexico and we'll start with the beautiful, amazing Monterrey Nuevo Leon, and we'll talk about CO2 laser for pediatric surgery. This has uh with my partner Cerri Sildo and Jorge Garcia in the private hospital in Texalud we've been working on this uh the use of the device. OK, so let's start with a clinical scenario a 3 year old male with chronic. Balanopostitis, uh, recurrent infections not responsive to medical treatment and it has a tight fimosis with painful urination reported. So which is your preferred weapon of surgical use to treat the circumcision? A scalpel, B electrocautery, C CO2 laser, or D, a specialized stapler. OK, uh how about anyone in the audience? Scalpel? Well, we don't, I mean, how many people in this room deal with fimosis? Alright. Yeah, what were you gonna say, Steve? Just every now and then. Yeah, OK, perfect. But bipolar diet, yeah, it, it'll, it would be a really, uh, good choice, but my friends, you've just been bamboozled because this was a rhetoric question and I wanted you to ignore CO2 laser, and I'll use this rhetoric question to convince you that CO2 laser is not a black diamond, it's really a blue square disguised as a black diamond. Why? Because it has the potential to outperform conventional circumcisions and other surgeries, but I'll use circumcision as a proof of concept. It can give you faster operative time, reduced pain, lower rates of of scarring, and an amazing cosmesis. Here we have some uh proof of concept and that this is the thing that when we hear about the use of CO2 lasers for surgery we think oh this is new, but this has been reported since 1970, since 1980, since 1990, the 2000s, etc. etc. it's just not well researched in pediatric surgery. So I know when we hear lasers we think oh the future we think Star Wars, but Star Wars is 50 years old, so there's a lot of proof that this could be a really viable tool. So next please. Next. OK, well, while we get the, the next one we've been getting over in, in Monterey by using CO2 lasers and JAG lasers, which is uh the the way it works is the laser emits infrared light. It is highly absorbed by water and biological tissues depending on the nanometer wavelength that you changed. It absorbs differently, but we're using it in the spectrum of 920 to 1400, which is really well absorbed by water and it's really, really, and I'll emphasize again, really effective for precise cutting and ablation which permits bloodless or very, very minimal blood in your surgery, so. It does reduce blood loss. We have great precision and control. We have great reduced pain and and and edema and shorter operative time. The disadvantages is it, it as an initial inversion, it is quite expensive. It's around $5000 around 100,000 Mexican pesos. It has an increased learning curve. Initially it has high initial cost barrier, but when you look at the papers. You can justify it because it diminishes by a great deal operating uh uh OR time. And lower complications which at the end gives you better uh cost savings for your patients. So you need ocular protection and you need specialized training required. So now let's go to a step one type of question which we all hate. Which type of tissue is most suitable for laser surgery, especially at this wavelength muscle tissue, mucosa, connective tissue, or bone tissue? Amazing, yes, and people all around the world are right. mucosa tissue is of course filled with mucus, which is 95% water, so it reacts really well to the laser. And if we think about it, how, what tissue or where in the body could we use this? Next, please. Well, we have a wide range of places where mu mucosa is present. So I'm gonna talk a little bit about where we've used it, uh, as a team over in Monterrey. We used it for circumcision 56 patients. We use the sleep technique with, uh, the dorsal slit. We use ciannual credit a asset, but we put points in the, uh, coordinates at the north, south, etc. And we've only had a 3% complication rate, but a partial wound basin that could be managed, uh, in a conservative manner. We've also had it. Well, here's an example of how we've used it, but I'm gonna go ahead because of, of time. Just look at the scarring profile. It's amazing low pain profile. We only use uh prorenata ibuprofen. Our surgical time is around 10 minutes plus minus 3 and amazing aesthetically results. Uh, next, just proof of concept papers we've used it for renellectomy. 47 patients, low pain profile, no, uh, suture required. Next. Perianal fistulas we've done it for 4 patients fistulotomy, a plannoidal cyst. 12 patients we do laser ablation and we, if there's a sinus tract, we also ablate it. It's great for searching for the necrotic tissue, lower labia fusion, and next, condylomatosis, great for ablation. And this is just papers that do proof of concept from 10 years, 5 years, etc. So just to convince you, it has less bleeding, lower pain profiles, shorter over time, high equipment costs, need for specialized training, and the lack of availability with a little special hyphen. Because if we're in contact with the dermatology department they have lasers and so we we actually uh the wife of Eric is a dermatologist and we, we started leasing it from them at the beginning next. So I'll, I'll jump the questions up up until the end. Let's go over to beautiful Guadalajara, not as beautiful as Monterrey, but it's also beautiful. Percutaneous track, the digestive endoscopy and airway team from my surgical alma mater. So clinical scenario 2 month old male, uh, 20 weeks of gestation, unsuccessful extubation attempts, and 1.6 kg, which is 3.5 pounds for the non-universal type of, of waiting. So which would be a contraindication for percutaneous tracheostomy age, no contraindication, the weight or pulmonary pathology. Yes, none. Well, there's multiple, uh, meta-analysis and systematic reviews that have found it to be really, really accessible in our all types of patients. Here we see the systematic review. It emphasizes on the Greeks and the Greek's technique, and I'm gonna tell you about the technique that we're using over in Guadalajara. Next please. Next, Next, OK, advantages MIS easy technique, fast and safe, nowhere needed. So the advantages that we know from PTrac in adults next. And here's our video of our adaptation of the Siagle Blue rhino technique. We do the, uh, incremental dilation. Can you put a play to the video, please? What we've done, uh, with the team in Guadalajara, they've adapted. No, it's, it's, it's just, no, they've adapted, it's, it's the same technique, but they've adapted with the use of, uh, percutaneous nephrostomy dilators, the alets dilators, so that you can use it on patients that cannot be fitted with the blue rhino. So the technique is is pretty standard with the blue rhino technique, but you'll see. The little alets dilator that's also been done. So they do the the access they dilate. You have your push dilator. You introduce the, the guide wire, and then on the table that we're gonna show in the next, uh, slides, we use the equivalent uh dilator for the track tube that our team personally searched for which would be the, the specific dilator that could be used with the specific cannula time. Uh, shout out to Doctor Roberto, Doctor Yanowski, and Doctor, uh, Trujillo because they did this by actually looking at which one fitted in, in what cannula. So next, disadvantages big learning curve, uh, you need the bronchoscopy equipment we use it with the flexible, uh, bronchoscope. You need a skilled bronchoscopist. Immetric cannulation is impossible, which I'll talk about it in a little later, and specific dilators are, are needed. OK, since 2017, more than 180 patients, low morbidity 1%, low mortality also 1%. Yes, uh, the, the main contraindication that I would say is you really, really need the specific team because I've, I've seen it being tried by people who are not skilled and it, it, it was the 1% mortality. How many here are doing pork tricks? anyone OK. This is awesome. Thank you. Appreciate it. We're on to our last session, um.