Week 2: Eddie Wei

On June 8, the first operating room case involved a male patient with an ileal conduit undergoing cystoscopy. The cystoscopy was used to identify concerning tissue for a possible left ureteral biopsy, including cobblestone-like areas seen inside the left kidney region. During the procedure, the existing ostomy bag was removed and replaced. There were also two smaller procedures that day. One involved real-time ultrasound imaging to evaluate a hydrocele, which is a large collection of excess fluid around the left testicle. Another involved a smaller cystoscopy using alternating white and fluorescent light to assess a small tumor after the patient reported bleeding concerns. Overall, the day included cystoscopy-guided evaluation, ostomy management, ultrasound imaging, and tumor assessment using enhanced visualization techniques.

The next day, June 9, focused on patient meetings and smaller cystoscopy procedures rather than major surgery. During one cystoscopy, the bladder was visualized and showed changes from prior radiation treatment, including inflamed blood vessels. Another patient had bladder ultrasound imaging. There was also an ER case involving a patient with a kidney stone, showing the urgent-care side of urology. One major discussion involved a muscle-invasive bladder tumor with plasmacytoid features. Because of the aggressive nature of this cancer, surgery was needed, likely involving bladder removal and urinary reconstruction or diversion. Overall, the day highlighted cystoscopy, ultrasound imaging, emergency stone management, and surgical planning for advanced bladder cancer.

On June 10, I observed two multi-port robot-assisted surgeries. The first involved a female patient whose procedure focused on removing potentially cancerous portions of the left ureter and reconnecting the remaining ureter to the bladder. The robotic system was operated using two consoles controlled by two surgeons and four separate robotic arms. Arm 1 held the ProGrasp forceps, Arm 2 held the Maryland bipolar forceps, Arm 3 held the endoscope with a standard white-light camera, and Arm 4 held the monopolar curved scissors. The monopolar scissors generated heat to cut and cauterize tissue, helping the surgical team access the left ureter. During the procedure, Port 4 was changed to allow the use of a larger specialized instrument. The surgical team also removed lymph nodes from the left pelvic area. A suture fiber with a hook attached was used to support more controlled stitching during the ureter reconnection. During the surgery, the pathology team was called to examine tissue samples extracted during the surgery using histology to determine whether carcinoma was present at the ureter margins. The pathology assessment was performed on another floor of the building, and the results were reported back to the operating room by phone. This case strengthened my interest in my immersion project. It showed the importance of real-time tissue evaluation during urologic robotic surgery and highlighted the potential value of improving current endoscope models for real-time bladder and urinary tract diagnosis during surgery.

The second case I observed on June 10 was another robotic-assisted surgery, using a setup similar to the previous ureter case. This procedure involved removing part of a donor liver so it could be transplanted into another patient. Because the liver can regenerate, only a portion of the liver needed to be removed. The robotic system again used multiple robotic arms controlled by the surgical team from consoles. Different arms held specialized instruments, including forceps, monopolar curved scissors, an endoscope, and later an ultrasound probe. The endoscope provided real-time visualization of the surgical field, while the robotic instruments allowed the surgeons to carefully dissect, seal, and cut tissue. The surgical team first identified and cut the bile duct. Indocyanine green was injected intravenously and viewed through the endoscopic fluorescence imaging channel, producing green fluorescence that helped visualize bile duct anatomy and blood flow. After the bile duct was cut, a 7.5 MHz ultrasound probe was introduced and held by a robotic arm to guide where the liver should be divided. Using the ultrasound probe for guidance, another robotic arm used monopolar curved scissors to cut through the liver tissue. Blood vessels and arteries between the right and left liver sections were sealed, clipped, and cut. White clips were used to control blood flow, and cold water was applied to help protect the liver tissue by slowing metabolic activity. After the selected liver portion was removed, the vessels were prepared and the liver was flushed for transplant.

June 11, I observed three different procedures. The first was a single-port robotic surgery to remove a tumor near the right kidney area, where air insufflation expanded the surgical space and was deflated after removal. Hemostatic agents were used to control bleeding. The single-port approach was beneficial because multiple tools could be used through one incision, potentially reducing surgical trauma and scarring. More importantly, the area of incision was that of a rash from a bike. In the first operating room case today, I observed removal of a left testicular tumor. In the second case, I observed an augmented reality-guided procedure using multimodal CT and X-ray imaging to locate and remove excess fluid precisely without requiring a large open incision.

The first robotic surgery supports the motivation for my immersion project: developing a multimodal endoscopic imaging system with AI-assisted diagnostics for urology and potentially other domains. During the ureter surgery, tissue samples had to be sent to pathology on another floor, with results reported back by phone. This highlighted the need for real-time tissue evaluation during robotic procedures. My immersion project will focus on developing a single endoscope that combines OCT, and confocal microscopy, as well as a machine learning model for providing real time diagnostics based on data from past surgeries. OCT can delineate tissue-layer within bladder, while confocal microscopy can provide higher-resolution cellular information from using fluorescein, which is already FDA-approved and used in clinical procedures. The goal is to improve real-time diagnosis, guide more targeted biopsies, and potentially reduce unnecessary tissue sampling during surgery or cystoscopy.