Vice Chair, University of Puerto Rico School of Medicine
The composition of the dialysis fluid is similar to that of plasma and consists of approximately 130 mEq/L of sodium hiv infection rate morocco famciclovir 250mg with mastercard, 100 mEq/L of chloride side effects of antiviral drugs discount 250 mg famciclovir amex, 35 mEq/L of acetate or lactate as a buffer hiv infection prophylaxis generic famciclovir 250 mg on-line, 3 hiv infection from dentist generic famciclovir 250 mg without prescription. Respiratory compromise can occur with peritoneal dialysis because the increased abdominal pressure caused by the dialysate in the abdomen can prevent effective spontaneous ventilation. Severe dehydration, circulatory collapse, and metabolic derangements are other complications of peritoneal dialysis. The principles of hemodialysis are essentially the same as those of peritoneal dialysis, except the blood interfaces with a semipermeable membrane rather than with the peritoneum. Hemodialysis is more appropriate in the acute setting with life-threatening electrolyte disturbances, fluid overload, and toxic ingestions. An ultrafiltrate of plasma is created by hydrostatic pressure exerted across a highly permeable membrane, with simultaneous blood volume replacement with modified lactated Ringer solution. Hyperkalemia can lead to life-threatening cardiac arrhythmias and requires immediate treatment. Electrocardiographic presentation demonstrates a peak in the T wave at moderately elevated potassium levels. Treatment includes removal of exogenous potassium administration should be discontinued immediately, and calcium in the form of intravenous CaCl (10 to 20 mg/kg) or CaGluconate (30 to 60 mg/kg) to stabilize the cardiac cell membrane. Intravenous sodium bicarbonate (1 to 2 mEq/kg) will drive potassium into the intracellular fluid by increasing blood pH. It is important to note, that none of these efforts will remove potassium from the body. Prior to the initiation of dialysis, potassium removal may be attempted with the ion exchange resin Kayexalate, a sodium polystyrene sulfate, which can bind potassium. It is given orally or rectally in suspension, but does require excretion from the body. The dose is 1 g/kg orally, and it can be given every 6 hours; rectally it can be given every 2 to 6 hours. Severe hyponatremia and hypernatremia can be another electrolyte disturbance seen in the critically ill child. Hyponatremia can present with seizure activity, often when serum sodium is less than 120 mEq/L. In the presence of hyponatremic seizures, the initial treatment is the administration of 3% hypertonic saline with a goal to terminate seizure activity and raise serum sodium to greater than 124 mEq/L. However, in the absence of seizures, if a patient reached this low value slowly it has to be corrected slowly, to potentially avoid osmotic demyelination. Rapid correction of elevated serum sodium is likely more harmful than the value itself. Furthermore, technical challenges occur in smaller patients because of flow characteristics of smaller dialysis catheters. Hemodialysis can be performed with two separate 5-French single-lumen catheters, but typically a dual-lumen 7-French catheter at a minimum is required. Citrate can be given in a stopcock before the machine, which creates a regional area of hypocalcia in the circuit, leading to relative anticoagulation in the circuit, while intravenous calcium is given back to the patient via a central line. In general, children fare better than adults; in fact, children usually recover completely from a renal insult if the hypoxia or ischemia lasted only a short time and other organ systems are not involved. Children with chronic renal failure require long-term outpatient peritoneal dialysis or hemodialysis until they can undergo renal transplantation. This syndrome is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute renal injury. Infections can be spread by person-to-person contact in daycare centers, institutions, and the military. There is also a familial form of the disease that accounts for a small percentage of the total cases. In fact, some investigators consider the two disorders a continuum of the same disease. Toxin-induced damage to renal endothelial cells, the vasculature, and other organs is directly or indirectly associated with the activation of leukocytes. Patients usually have abdominal cramping, bloody diarrhea, tenesmus, and vomiting. Mildly affected patients exhibit anemia, thrombocytopenia, azotemia, and decreased urine output and have an uncomplicated course. In severely affected patients, anuria is common, hypertension and seizures can occur, and the duration of illness is prolonged. A small number of children exhibit progressive and permanent renal insufficiency, severe and recurrent hemolysis, thrombocytopenia, and neurologic impairment. Hemolysis often causes hyperbilirubinemia and, despite reticulocytosis, severe anemia with hemoglobin concentrations of 4 to 5 g/dL. Thrombocytopenia is the result of platelet destruction and sequestration in the liver and spleen. Acute renal failure with oliguria or anuria usually lasts less than 1 week but can linger for more than 10 weeks. Meticulous attention should be paid to volume status, electrolyte and acid-base balance, nutrition, antisepsis, and treatment of hypertension and coagulopathies. Accurate fluid intake and output measurements and frequent assessment of weight and volume status are important for management of these patients.
In addition to the intravenous and intramuscular routes hiv infection unaids quality famciclovir 250mg, ketamine may be administered rectally (10 mg/kg) hiv infection without symptoms order 250 mg famciclovir amex, orally (6 to 10 mg/kg) antiviral cream purchase discount famciclovir on-line, or intranasally (3 to 6 mg/kg) antiviral resistance purchase discount famciclovir online. Larger doses (up to 10 mg/kg intramuscularly) provide sufficient analgesia for the insertion of invasive monitoring devices before the induction of anesthesia (cardiac surgery) or in children with limited venous access. Patient-to-patient variability in response to this drug is relatively large, however. A major side effect, increased production of secretions, usually requires the administration of an antisialagogue agent. Other undesirable side effects include vomiting and postoperative "dreaming" or hallucinations; the incidence of dreaming may be reduced by the concomitant administration of a benzodiazepine. Although spontaneous respirations and a patent airway are usually maintained, apnea and laryngospasm may occur. Ketamine does not preserve the gag reflex and thus should not be used as the sole anesthetic for children with a full stomach or a hiatal hernia. Midazolam Midazolam is water soluble and therefore not generally painful on intravenous administration (also see Chapter 30). The clinician waits at least 3 minutes between intravenous doses to avoid stacking of effect. Food and Drug Administration for use in neonates; the half-life is significantly longer (6 to 12 hours) in this population. One important interaction is that erythromycin, calcium channel blockers, protease inhibitors, and even grapefruit juice produce a clinically important delay in midazolam metabolism because of inhibition of cytochrome P450. In this circumstance, either midazolam should be avoided or the dose reduced by 50%. Etomidate Etomidate is a steroid-based hypnotic drug used for induction of anesthesia (also see Chapter 30). As with propofol, the incidence of pain on intravenous administration is frequent. Concerns regarding anaphylactoid reactions and suppression of adrenal function have limited widespread use of this anesthetic. Etomidate is extremely useful in children with a head injury and those with an unstable cardiovascular status, such as children with a cardiomyopathy, because of the virtual absence of adverse effects on the cardiovascular system. Etomidate is often used to facilitate tracheal intubation in children who are critically ill. Because a high proportion of critically ill children, particularly those resistant to vasopressors, suffer from relative adrenal insufficiency, steroid supplementation may be indicated in such children in whom etomidate is deemed necessary for their safe airway management. The role of this drug for the care of children awaits further investigation to clarify its exact advantages and disadvantages. A pharmacokinetic trial involving 36 children, 2 to 12 years of age, revealed a terminal elimination half-life of approximately 110 minutes with both heart rate (15%) and systolic blood pressure (25%) decreasing over time as the dose is increased; these observations are similar to those in adults. Only one child initially demonstrated an increase in blood pressure, but it was unclear whether it was drug related. Transient sedation occurred in all children, and the authors recommend slow intravenous infusion to minimize possible adverse hemodynamic events that might occur with bolus administration. The use of dexmedetomidine as a sole drug or combined with other sedatives has been described in children undergoing cardiac catheterization and a variety of radiologic procedures. Intravenous administration is painful and not well tolerated; diazepam may also be rectally administered. Because the liver is the main site of degradation, this medication should be given with caution to any child with hepatic disease. Diazepam has an extremely long half-life in neonates (80 hours) and may not be indicated until the infant is 6 months of age or until hepatic metabolic pathways have matured. Chapter 93: Pediatric Anesthesia 2769 the incidence of emergence agitation,73,74 and facilitates withdrawal from opioids. Large dose dexmedetomidine (2 to 3 g/kg initial dose, followed by 1 to 2 g/kg/hr) infusion has been associated with severe bradycardia (heart rate, 40 beats/minute),77,78 but treatment with glycopyrrolate resulted in severe and persistent hypertension of unknown cause. This opioid is more lipophilic than meperidine; the potential effects of the blood-brain barrier are of no importance with fentanyl. Termination of the effect of low doses of fentanyl primarily results from redistribution, whereas termination of the effect of high doses depends on elimination. Fentanyl induces a very stable cardiovascular response while providing an anesthetic state. Impaired hepatic function may also play a role in the altered kinetics with increased intraabdominal pressure. These doses are safe in children whose ventilation will be controlled postoperatively; much smaller doses (2 to 10 g/kg) should be used with other anesthetics if ventilation is not to be controlled postoperatively. Because the cardiac output of neonates is determined by the heart rate, fentanyl-induced bradycardia may require the administration of a vagolytic drug, such as atropine or even pancuronium during long procedures. Its use in neonates (those younger than 10 days) remains controversial because it may cause more respiratory depression than meperidine. Higher brain levels of morphine were found in neonatal rats than in adult rats, thus implying that permeability of the blood-brain barrier may account, in part, for the apparent sensitivity of the human neonate to morphine. Newborns have slower clearance of morphine, and therefore a smaller dose will result in higher plasma values because of a longer elimination half-life. The issue of respiratory sensitivity and the age at which it decreases in humans has yet to be resolved; a difference between morphine and fentanyl may exist that may not relate to the transport of drug into the brain. Morphine should be administered with caution to neonates and preterm infants who are not in a monitored setting. Alfentanil Alfentanil is more rapidly eliminated than fentanyl; its pharmacokinetic effects are independent of dose (also see Chapter 31), which may provide a margin of safety because the greater the administered dose, the greater the elimination.
As many as 90% of patients with decompensated cirrhosis suffer weight loss hiv infection trends buy genuine famciclovir on line, muscle wasting secondary to anorexia over the counter antiviral discount famciclovir 250mg with amex, large protein loses into ascites hiv infection symptoms wikipedia buy 250mg famciclovir with amex, poor oral intake because of unpalatable low-salt and low-protein diets hiv infection from dentist discount 250 mg famciclovir amex, and hypermetabolism. However, these therapies result in the loss of amino acids (10 to 15 g/day) unrelated to amino acid intake but related to plasma amino acid concentrations, volume of dialysate effluent, and filter efficiency. Up to 35% to 45% of this glucose can be absorbed and is a source of carbohydrate calories. Similarly, glucose-containing solutions used as replacement solutions during hemofiltration can be a source of glucose calories, in one study providing 300 g/day of glucose. This glucose load must be considered when designing nutritional regimens and glucosecarbohydrate contents reduced accordingly. Additionally, glucose concentrations need to be monitored because of both the profound stress state and dialysis-associated glucose absorption. Calcium intake may need to be increased, whereas sodium content should be nearly isotonic because of an inability to regulate serum sodium concentrations. However, during dialysis, all the serum electrolytes must be closely monitored and deficiencies corrected as indicated. However, contemporary practice is to begin enteral nutrition early (within 48 to 72 hours) in the course of the disease. This dynamic situation requires tools that can rapidly assess the metabolic and immunologic milieu. These omic techniques, with their ability to profile many biomarkers rapidly, differ from the current approach of tracking only one or two biomarkers. For example, young girls with burns have less hypermetabolism and higher anabolic hormone concentrations than boys, whereas healthy adult women appear to have lower susceptibility to sepsis than men, possibly because of more pronounced proinflammatory innate immunity and a lesser decrease in norepinephrine sensitivity when exposed to endotoxin. In Fisher J, Reason J, editors: Handbook of life stress, cognition and health, New York, 1988, John Wiley & Sons, pp 629-649. A report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters, Anesthesiology 114:495, 2011. Intensive versus conventional glucose control in critically ill patients, N Engl J Med 360:1283, 2009. Complications and monitoring-guidelines on parenteral nutrition, Chapter 11, Ger Med Sci 7, 2009. An G, Faeder J, Vodovotz Y: Translational systems biology: introduction of an engineering approach to the pathophysiology of the burn patient, J Burn Care Res 29:277-285, 2008. Gogenur I, Ocak U, Altunpinar O, et al: Disturbances in melatonin, cortisol and core body temperature rhythms after major surgery, World J Surg 31:290-298, 2007. Siami S, Bailly-Salin J, Polito A, et al: Osmoregulation of vasopressin secretion is altered in the postacute phase of septic shock, Crit Care Med 38:1962-1969, 2010. Kazmierski J, Banys A, Latek J, et al: Cortisol levels and neuropsychiatric diagnosis as markers of postoperative delirium: a prospective cohort study, Crit Care 17:R38, 2013. Gjedsted J, Buhl M, Neilsen S, et al: Effects of adrenaline on lactate, glucose, lipid and protein metabolism in the placebo controlled bilaterally perfused human leg, Acta Physiol (Oxf) 202:641-648, 2011. Christ-Crain M, Jutla S, Widmer I, et al: Measurement of serum free cortisol shows discordant responsivity to stress and dynamic evaluation, J Clin Endocrinol Metab 92:1729-1735, 2007. Cohen J, Deans R, Dalley A, et al: Measurement of tissue cortisol levels in patients with severe burns: a reliminary investigation, Crit Care 13:R189, 2009. Witasp A, Nordfors L, Schalling M, et al: Expression of inflammatory and insulin signaling genes in adipose tissue in response to elective surgery, J Clin Endocrinol Metab 95:3460-3469, 2010. De Backer D, Orbegozo Cortes D, et al: Pathophysiology of microcirculatory dysfunction and the pathogenesis of septic shock, Virulence 5:73-79, 2014. Schneider C, von Aulock S, Zedler S, et al: Perioperative recombinant human granulocyte colony-stimulating factor (Filgastim) treatment prevents immunoinflammatory dysfunction associated with major surgery, Ann Surg 239:75-81, 2004. Ishiguro A, Suzuki Y, Mito M, et al: Elevation of serum thrombopoietin preceded thrombocytosis in acute infections, Br J Haematol 116:612-618, 2002. Lupia E, Bosco O, Mariano F, et al: Elevated thrombopoietin in plasma of burned patients without and with sepsis enhances platelet activation, J Thromb Haemost 7:1000-1008, 2009. Papi A: Investigating the steroids and long acting 2-agonists combination: why do we need more Mebis L, Van den Berghe G: Thyroid axis function and dysfunction in critical illness, Best Pract Res Clin Endocrinol Metab 25:745757, 2011. Tognini S, Marchini F, Dardano A, et al: Non-thyroidal illness syndrome and short-term survival in a hospitalized older population, Age Ageing 201 39:46-50, 2010. Strowig T, Heao-Mejia J, Elinav E, Flaveil R: Inflammasones in health and disease, Nature 481:278-286, 2012. Bakele M, Joos M, Burdi S, et al: Localization and functionality of the inflammasome in neutrophils, J Biol Chem 289:5320-5329, 2014. Narita S, Tsuchiya N, Kumazawa T, et al: Comparison of surgical stress in patients undergoing open versus laparoscopic radical prostatectomy by measuring perioperative serum cytokine levels, J Laparoendosc Adv Surg Tech A 23:33-37, 2013. Tsiminikakis N, Chouillard E, Tsigris C, et al: Fibrinolytic and coagulation pathways after laparoscopic and open surgery: a prospective randomized trial, Surg Endosc 23:2762-2769, 2009. Zauner A, Nimmerrichter P, Anderwald C, et al: Severity of insulin resistance in critically ill medical patients, Metabolism 56:1-5, 2007. Lass A, Zimmermann R, Oberer M, Zechner R: Lipolysis-a highly regulated multi-enzyme complex mediates the catabolism of cellular fat stores, Prog Lipid Res 50:14-27, 2011. Grisouard J, Bouillet E, Timper K, et al: Both inflammatory and classical lipolytic pathways are involved in lipopolysaccharideinduced lipolysis in human adipocytes, Innate Immunity 18:25-34, 2012.
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Elective procedures in patients with sustained stage 3 hypertension should be delayed until after 2 weeks of antihypertensive therapy antiviral birth control cheap 250mg famciclovir amex. If the patient cannot lie flat kleenex anti viral ingredients order famciclovir 250 mg on line, or if there is intractable cough hiv infection rates by county purchase on line famciclovir, a perioperative complication is more likely hiv infection natural history order online famciclovir. Preoperative risk reduction strategies include cessation of cigarette smoking, treatment of airflow obstruction with bronchodilators or steroids, and administration of antibiotics for respiratory infections. For some patients, treatment with a mild stimulant such as caffeine can be helpful in keeping them awake and cooperative during a procedure. Discomfort and anxiety are associated with many of these blocks, and so are rare but severe complications. Supplementation with intravenous sedation and continuous patient monitoring are frequently preferred. Most patients meet recovery discharge criteria at the end of surgery, and can bypass a stay in the postanesthesia care unit. Arterial blood pressure, electrocardiogram, and oxygen saturation monitors are placed. An air blower is often placed with the outlet on the chest to eliminate carbon dioxide and oxygen buildup under the drapes and to prevent claustrophobia. This author omits midazolam and fentanyl in patients with limited cognitive reserve resulting from stroke or mild dementia. Hyaluronidase can also be important in preventing anesthetic-related damage to the extraocular muscles. Insulin therapy should be used, if needed, to maintain blood glucose at 150 to 250 mg/dL. The potential for autonomic neuropathy needs to be considered, especially when elevating the patient from the supine position. Patients undergoing long-term steroid therapy generally do not require "stress-dose" steroid treatment for ophthalmic surgery. The physician should be alert to the occasional patient who might require additional glucocorticoid perioperatively. Unexpected hypotension, fatigue, and nausea may be signs of a patient who needs additional steroid. Perioperative management of anticoagulants involves weighing the relative risks of thrombotic against possible hemorrhagic complications. In a study of more than 19,000 cataract procedures, the incidence of hemorrhagic and thrombotic complications was infrequent. Serious complications from arterial thromboembolic disease, such as atrial fibrillation or valvular heart disease, are much more common than complications from venous disease, such as deep vein thrombosis. The risk factors for thromboembolism, especially if and when the patient had a previous episode of thromboembolism. Serious hemorrhagic complications are most probable in orbital and oculoplastic surgery; of intermediate probability in vitreoretinal, glaucoma, and corneal transplant surgery; and least likely in cataract surgery. A consensus is developing that cataract surgery can be performed safely while maintaining patients receiving warfarin. For intermediate-risk procedures, such as some glaucoma surgeries, stopping warfarin intake for 4 days preoperatively is indicated. Modified van Lint block: the needle is placed 1 cm lateral to the orbital rim, and 2 to 4 mL of anesthetic is injected deep on the periosteum just lateral to the superolateral and inferolateral orbital rim. The disadvantages of this block include discomfort, proximity to the eye, and common postoperative ecchymoses. The needle is inserted perpendicular to the skin approximately 1 cm to the periosteum. Nadbath-Rehman block: A 12-mm, 25-gauge needle is inserted perpendicular to the skin between the mastoid process and the posterior border of the mandible. The needle is advanced its full length, and after careful aspiration, 3 mL of anesthetic is injected as the needle is withdrawn. The patient should be told to expect a lower facial droop for several hours postoperatively. The major disadvantage to this block is the proximity of the injection to important structures, such as the carotid artery and the glossopharyngeal nerve. If no bulging is noted at the superior nasal lid area, a second injection of 2 to 3 mL is administered inferonasally. Disadvantages of the technique include a longer onset time (9 to 12 minutes) and lower incidence of complete akinesia. A 2- to 3-mm spot of cautery can be made 5 mm from the limbus in the inferonasal or inferolateral quadrant. A 2-mm snip is made in the conjunctiva with blunt dissection through the fascia of Tenon. A blunt cannula is directed under fascia of Tenon posteriorly, but not beyond the equator of the globe, with injection of 1 to 3 mL of local anesthetic. The needle is placed at the junction of the inferior and lateral walls of the orbit just above the inferior orbital rim. The needle is advanced until it enters between the extraocular muscles; 2 to 3 mL of anesthetic solution is injected. Some intorsion on downgaze is expected because the superior oblique muscle is outside the muscle cone and may not be blocked. Retrobulbar hemorrhage is the most common complication of this block; proptosis and subconjunctival ecchymosis also are seen. If the pressure becomes elevated, a lateral canthotomy is performed to decompress the orbit. Bleeding outside the muscle cone is seen as subconjunctival ecchymosis without proptosis. The total dose of local anesthetic used is small, and even if the total dose is given intravenously, no systemic effects would be likely.
Such haptic systems have a short learning curve and allow the surgeon to have greater precision hiv infection law purchase cheap famciclovir line. Robotic arthroplasty surgery has similar outcomes with significantly higher costs antiviral ganciclovir cheap famciclovir 250mg on-line. As surgeons gain expertise with robotically assisted surgery hiv infection with no symptoms buy 250mg famciclovir with mastercard, operative times decrease dramatically hiv infection without ejaculation generic 250mg famciclovir fast delivery. As the size and cost of robotic systems decrease and potentially improved outcome data become available, robotic systems are likely to become less of a marketing tool and more a technological innovation to improve patient care. Although robotic systems have improved a great deal in dexterity, technically, much needs to be done to realize the full potential of this surgery. Current areas of research include the development of sensory input, and the ability to relay touch sensation from the robotic instruments to the surgeon. Some laboratories are also working to develop instruments for surgical anastomosis that requires no sutures. The possibility of automating some of these tasks in the operating room is another exciting and controversial idea. In the future, robots will be regarded less as mechanical devices and more as information systems. Robotic systems may also make long-distance consultation and guidance possible by experienced surgeons. The latest innovation in robotics is that of image-guided surgery, in which a surgeon is able to see in real time the scanner images superimposed on the surgical field. The human anatomy will be rendered translucent, and the exact location of any vital structure will be clearly visible. Preoperative diagnostic imaging in combination with virtual reality simulators will allow the surgeon to rehearse complex procedures in advance and to program the robot to avoid any vital structures during surgery. Visualization systems are being developed that will improve surgery on mobile structures, such as the beating heart. Advances in motion gating technology will allow the heart to appear as if it were standing still. This will be done by properly timing a strobe light that is synchronized with the heart rate to achieve the proper virtual image of the heart standing still. Initially, robotically assisted procedures increased the Chapter 87: Anesthesia for Robotically Conducted Surgery 53. Advanced Robotic Telemanipulator for Minimally Invasive Surgery, Surg Endosc 14(4):375-381, 2000. Marescaux J, Leroy J, Gagner M, et al: Transatlantic robot-assisted telesurgery, Nature 413(6854):379-380, 2001. Marescaux J, Leroy J, Rubino F, et al: Transcontinental robotassisted remote telesurgery: feasibility and potential applications, Ann Surg 235(4):487-492, 2002. Anvari M: Remote telepresence surgery: the Canadian experience, Surg Endosc 21(4):537-541, 2007. Bonaros N, Schachner T, Oehlinger A, et al: Robotically assisted totally endoscopic atrial septal defect repair: insights from operative times, learning curves, and clinical outcome, Ann Thorac Surg 82(2):687-693, 2006. Argenziano M, Katz M, Bonatti J, et al: Results of the prospective multicenter trial of robotically assisted totally endoscopic coronary artery bypass grafting, Ann Thorac Surg 81(5):1666-1674, 2006. Chauhan S, Sukesan S: Anesthesia for robotic cardiac surgery: an amalgam of technology and skill, Ann Card Anaesth 13(2): 169-175, 2010. Colangelo N, Torracca L, Lapenna E, Moriggia S, Crescenzi G, Alfieri O: Vacuum-assisted venous drainage in extrathoracic cardiopulmonary bypass management during minimally invasive cardiac surgery, Perfusion 21(6):361-365, 2006. Carpentier A, Loulmet D, Le Bret E, Haugades B, Dassier P, Guibourt P: Open heart operation under videosurgery and minithoracotomy. Seco M, Cao C, Modi P, et al: Systematic review of robotic minimally invasive mitral valve surgery, Ann Cardiothorac Surg 2(6):704-716, 2013. Gerosa G, Bianco R, Buja G, di Marco F: Totally endoscopic robotic-guided pulmonary veins ablation: an alternative method for the treatment of atrial fibrillation, Eur J Cardiothorac Surg 26(2):450-452, 2004. Augustin F, Schmid T, Bodner J: the robotic approach for mediastinal lesions, Int J Med Robot 2(3):262-270, 2006. Xiong B, Ma L, Zhang C: Robotic versus laparoscopic gastrectomy for gastric cancer: a meta-analysis of short outcomes, Surg Oncol, 2012. Bodner J, Augustin F, Wykypiel H, et al: the da Vinci robotic system for general surgical applications: a critical interim appraisal, Swiss Med Wkly 135(45-46):674-678, 2005. Yang Y, Wang F, Zhang P, et al: Robot-assisted versus conventional laparoscopic surgery for colorectal disease, focusing on rectal cancer: a meta-analysis, Ann Surg Oncol 19(12):3727-3736, 2012. Talamini M, Campbell K, Stanfield C: Robotic gastrointestinal surgery: early experience and system description, J Laparoendosc Adv Surg Tech A 12(4):225-232, 2002. Lu D, Liu Z, Shi G, Liu D, Zhou X: Robotic assisted surgery for gynaecological cancer, Cochrane Database Syst Rev 1, 2012. Gupta K, Mehta Y, Sarin Jolly A, Khanna S: Anaesthesia for robotic gynaecological surgery, Anaesth Intensive Care 40(4):614-621, 2012. Cobb J, Henckel J, Gomes P, et al: Hands-on robotic unicompartmental knee replacement: a prospective, randomised controlled study of the acrobot system, J Bone Joint Surg Br 88(2):188-197, 2006. Gharagozloo F, Margolis M, Tempesta B: Robot-assisted thoracoscopic lobectomy for early-stage lung cancer, Ann Thorac Surg 85(6):1880-1885, 2008. Ficarra V, Cavalleri S, Novara G, Aragona M, Artibani W: Evidence from robot-assisted laparoscopic radical prostatectomy: a systematic review, Eur Urol 51(1):45-55, 2007.
