Week 4: Alessandra Coogan

     Alessandra Coogan | Clinical Mentor: Dr. Scott Rodeo

    I shadowed Dr. Thomas Fahey during a robotic-assisted cholecystectomy (gallbladder removal) for a patient with symptomatic gallstones and biliary colic. One of the first steps of the procedure was insufflating the abdomen with carbon dioxide gas, creating a working space between the abdominal wall and internal organs. Once the camera was inserted, it was surprisingly easy to identify the gallbladder nestled beneath the liver, which stands out prominently within the abdominal cavity.

    One of the highlights was seeing the Da Vinci Xi surgical robot in action (Figure 1). Despite being an enormous machine, it is designed to perform incredibly delicate movements. The robot even announces its actions aloud and projects lasers onto the patient's abdomen to help align its arms before docking. The setup itself requires a coordinated team effort. While the surgeon operates from the console, assistants at the bedside continuously exchange robotic instruments (graspers, scissors, electrocautery devices, and clip appliers) as needed throughout the procedure.

    The gallbladder was grasped and manipulated to expose the cystic duct and cystic artery, which were clipped before being divided. The gallbladder was then carefully dissected from the liver bed using electrocautery. Watching this step made me wonder how the liver heals after separation from the gallbladder, since the attachment site remains exposed following removal. 



Figure 1. The Da Vinci Xi robotic surgical system used for robotic-assisted laparoscopic procedures

    I also observed a revision spinal fusion, followed by closure performed by Dr. Jason Spectre and his team. Going into the OR, I imagined spine surgery as an exceptionally delicate and quiet procedure. Instead, the operating room was filled with the sounds of drilling, hammering, ratcheting, and grinding... noises I never would have associated with spinal surgery. Although initially surprising, these instruments are essential for preparing bone and securing implants during orthopedic procedures.

    One aspect I found particularly impressive was the iterative workflow. Throughout the surgery, the team repeatedly obtained X-ray images and intraoperative CT scans, using computer-assisted navigation to verify the trajectory and placement of each pedicle screw before advancing to the next step. The combination of imaging, navigation software, and surgical expertise greatly increased the precision of implant placement.

    Another interesting technique involved the use of Gelfoam soaked in thrombin (Figure 2) to promote hemostasis during the procedure. 

Figure 2. Gelfoam saturated with thrombin, used intraoperatively to promote local hemostasis

    Before closing, the surgical team also applied vancomycin powder directly into the wound to reduce the risk of postoperative infection while limiting systemic antibiotic exposure. Finally, Dr. Spectre's team meticulously closed each tissue layer, using electrocautery to achieve hemostasis before completing the closure.

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