BEYOND THE PULSE: Thursday, April 25, 2024 at 7:30 PM EDT
Mark K. Wax, MD, FACS, FRCS(C)
Professor Otolaryngology – Head & Neck
Surgery and Oral MaxilloFacial Surgery
Oregon Health & Science University (OHSU)
Alexandra E. Kejner, MD, FACS
Associate Professor Otolaryngology –
Head & Neck Surgery
Medical University of South Carolina (MUSC)
OBJECTIVES
Hi, my name's Shanna Deng, and I'm the vice president of marketing here for the medical device division at Cooper Surgical. We at Cooper Surgical are excited to add the implantable Doppler to our specialty surgery portfolio. We already have very many well-known and well utilized products in this space with the Lone Star retractor and stays, the Inzorb. Particular skin stapler and the Carter Thompson Port site closure systems. The Doppler, along with these legacy products, complement each other really well, as we support plastic, head and neck, colorectal, and other surgeons like yourself in treating patients during critical surgical procedures. We're excited to bring this programming to you today and thank you for being a partner of Cooper Surgical. Welcome and thank you for participating in tonight's event. My name is Troy Wingler, product manager for Cooper Surgical, and I will be the moderator for this evening's program. A couple of notes on how the program will run. First, we will have a 45 minute session with detailed clinical case reviews with Doctor Wax and Dr. Keckner. At the end of the presentation, they will participate in a dedicated 15 minute Q&A session. Our program is entitled Beyond the Pulse Techniques and Case Insights with the Implantable Doppler Monitor and Head and Neck Microvascular Surgery. Our distinguished presenters are Doctor Mark Wax and Doctor Alexandra Keckner. Doctor Wax is a professor of otolaryngology head and neck surgery at Oregon Health and Science University. Doctor Koechner is an associate professor of otolaryngology head and neck surgery at the Medical University of South Carolina. Welcome, Doctor Wax and Doctor Koechner. Hello, welcome, and we're really glad to be here and we're so thankful to be invited to um this discussion, uh, to go over some tips, tricks and troubleshooting for the use of the implantable Doppler. Thanks to everybody for coming. So free tissue transfer allows for us to replace uh composite tissue in the head and neck with a similar composite tissue, and by that I mean we're able to take someone on the top left here where you've removed some of their. And their musculature and then replace that uh soft tissue with living viable uh tissue and and it's been found to be the best way to rehabilitate and be able to get people back to a quality and standard of life that they had before as well as to aid in healing. When we do free tissue transfer, the success rate is uh phenomenally good. Our ability to get the tissue from one place to another, have it live and have it do sort of what we would like it to do, um, is excellent, um, but every now and then it doesn't work for a variety of reasons, and when it doesn't work, um, the morbidity and the impact on the system is huge. If the tissue is sort of an an all or nothing phenomenon, the tissue either lives or it doesn't. And if it doesn't live, then you now have to go back and and find tissue from another site and if it's the arm or taking a bone out of the leg, you have to go back to the operating room for another 4 or 5 hours. Uh, patient's length of stays uh have been increased dramatically when you have to do that second flap, uh, and then there's the patient and the family, and then there's also the effect on, uh, the surgeon, you know, when you lose a flap, it has tremendous impact on all of those issues. Getting a patient back to the operating room on an urgent or a semi-urgent basis, uh, can be quite time consuming, uh, uses a lot of resources, and then can really fatigue the team, uh, both, uh, for what they need to do next and for what your generalized outcomes are gonna be. We know from a number of uh various studies that if you, if the tissue, uh, it's an it's an input and outflow problem so blood has to get in and blood has to get out and if you have a problem with either one of those, then um you're gonna lose your uh you're gonna lose the tissue. Uh, and so how can we identify that? Um, how do we identify it in the operating room? Because sometimes when you hook up the blood vessels, uh, it doesn't work while you're still in the operating room. And more importantly, how can we affect it uh and uh find out uh and identify it in the postoperative setting, because there is some good data that has demonstrated that if you find that the tissue is going bad, so the vascular supply either in. Or out has been compromised and you can get them back in a timely fashion into the operating room, then um the chance of being able to save that flap, get rid of the clots, reestablish flow is very, very high. OK, so let's um chat a little bit about uh what current monitoring techniques are in use uh at this moment in time. There's a lot of research going on in this field. Um, if there was one perfect technique, then we would all use it, but there's a variety of other techniques that people use, uh, mainly because of familiarity and what's good in their hands. The most common method that people use is a clinical exam. It's getting in the room, it's looking at the patient, it's looking at the flap, and I think that that does multiple things. It lets you look to see if there's any uh hematomas, collections of blood. It gets you in to examine the patient, uh, and then you can look at um what the actual flap looks like. And I think we're pretty good when the flap is doing great and we're really good when the flap is doing terrible, uh, but there is that point in the middle there where you look and you go, I'm not really sure it's, it's something's off but. I can't really pinpoint it and in those instances, many of us will resort to saying what is the blood in the flap doing uh and that's where I use a pinprick. um, my partners and I think uh Doctor Kesner uses a scratch test, you know, which which. Every one that you like to do and that's just I use an 18 gauge needle. I poke the flap and I look and see what happens and either there's that's so big. I just use a 25 gauge. Well, you have, you have better eyes than I do and and I hate to have to wait. I want it to bleed, um, so we'll, we'll poke it or we'll scratch it and we'll look and see what the blood does and if it comes out, if there's no blood, then maybe the artery isn't working if it's. Dark or black blood, then maybe the vein isn't working. That works pretty well, but many of us don't like to do this on a routine basis, and many of us like to do this only when we're unsure or we want to confirm. And so if we're following these flaps and looking at them every hour, we used to use a handheld external Doppler and we're all pretty familiar with that. And with the issues that arise from those is they, they can be a little bit unreliable. You have to take the Doppler and uh put it over where your flap is and if it's in the oral cavity or if it's you know if it's on the patient, oftentimes they get contaminated. There's a whole number of issues with those and they're very operator dependent. You have to know where to put it in our institution we monitor them hourly. Uh, we have the nurse monitor them and if I tell the nurse that you have to spend 15 minutes every hour finding the Doppler probe with this device, um. I get a page, uh, usually within about an hour or two by the charge nurse to say that's crazy, you know, our nurses are not, you know, they're not gonna sit at the bedside and monitor it, they just can't do that. There's a whole bunch of other stuff going on, so. And one thing I think to point out too is oftentimes when they're, uh, depending on where the pedicle is, if it's something going through the face, the other adjacent vessels can sometimes be picked up inadvertently with this handheld and so people can feel reassured by something that might not be the real deal, and I think that really does come to play with that operator dependent thing, um, even if you were to draw out the whole thing, you still may have, well I can hear this thing that's over here. Um, and so certainly you know that that definitely fits into the monitoring piece. So, uh, we're gonna touch on the Cook Swartz Doppler flow probe and monitor and so what this consists of is basically 3 components for single vessel monitoring. You've got a a Doppler box as well as an extension cord and a probe and so what you can see here is fairly simple um buttons which makes it easy to use. Interface is fairly straightforward and very um. Sturdy, so the extension cable is plugged directly into the box and the blue monitor probe is then placed onto the vessel of interest. And so you can see here on the right hand side of the screen, the letter A for anastomosis. You can see that the silicon cuff letter B is wrapped around the vessel of interest in order to monitor this and then secured in place with small clips letter C, which is the braid. Wire and what the braided wire does is this is the portion that actually then as you can see on the blue monitor probe then connects to this wire, then the blue connects to the green, connects to the box. What this does is it provides a continuous monitoring sound which is all audible, which can be raised and lowered. In addition to that, there is a panel of blue lights which can also detect flow which go up and down while monitoring. And then we can talk about how we buy donuts if we accidentally cut the wire. So what are the advantages of implantable Doppler over clinical monitoring paradigms? You know, it looks at continuous versus periodic monitoring. Um, there is special equipment, but there's a decreased learning curve, so you know it's a very binary thing is it on or is it off compared to visual inspection which takes lots of clinical acumen as well as prior experience with free flaps. Handheld Dopplers, as we discussed are very user dependent and I do listen to the vein with the Doppler, but I think sometimes you know the the residents don't believe that that it's possible. I believe, uh, but you know it is it's nice to have something that is easily um accessible for pretty much anywhere and so this can be used, you know, in a in a setting where there's maybe not intensive care unit coverage and things like that. Um, it's nice because it can be used intraoperatively and postoperatively, and I don't know, Mark, if you've had this happen before where you're closing up the skin and you've got a pedicle that's draped over the mandible and as you're closing the skin, the signal is like, nope, don't like it, not happy here, um, and so it actually can help um impact decision making in the operating room as to where political placement is if there's something that's compressing our vessel. And it really is freedom to monitor. You can monitor the artery, you can monitor the vein, you can do both. Um, it's can be used end to end or end to side and osmosis, and you can do proximal or distal. Um, and it really depends on kind of, you know, what kind of flap you're using, where you feel comfortable, and a lot of times, um, you know, it, it's, as one of my fellows likes to tell me it's all voodoo, but it's the voodoo that you do that counts and what helps us to be able to take the best care of these patients. So the other advantages of the implantable Doppler is it really can help in these challenging situations where there's not something visual that you can look, scratch, feel, or push on. Um, and this can be in places that, you know, free flaps, uh, live that we just really can't see them. So this can include berry flaps, gold-based flaps, intranasal flaps, or pharyngeal flaps or pharyngeal flaps, and, and also in patients with darker skin. Um, there's actually some really good data showing that clinical exam for patients with um darker skin tones often can have decreased ability to monitor these because, uh, the people monitoring may be unfamiliar with discoloration or changes in turger as well, um, and so you know this is something that can sort of overcome a lot of our um abilities to clinically examine these patients. Um, also it's nice in patients who are for patients in units without specialized nursing who may be less comfortable with monitoring, um, especially now in the era of post-COVID life where we've had a huge turnover, um, and retirement kind of wave of nurses leaving the field and a big influx of traveling nurses and nursing turnover, this is also. Another thing that's really helpful to help mitigate some of that need for um specialized nursing when we when you know, especially if they're stretched thin and and patients um just need someone to monitor them um in addition to this, you know, as we see more work hour restrictions for trainees this can be really important because what we're looking at are you know um. A turnover handover handouts, things where we're trying to keep consistent monitoring for these patients and then physician burnout if you're having someone come in once an hour to scratch your flap and they also have to monitor for. Nose bleeds in the emergency department or foreign bodies and ears that that really does contribute to physician burnout. So anything we can do to kind of help keep this specialized workforce working is always going to be a good thing. So how has the use of this um um technology altered um. How we manage um our patients that have uh flaps that are uh not doing well and require a return to the operating room, so it's not common. I think we'll go over a little data a little bit later, but in the in the past, the residents, so we have an in-house residence still the the nurse or the resident would go that flap doesn't quite look right. There's something funny, maybe it's blue. I can't really tell and so they would then be able to phone they would then phone uh either the senior resident. The fellow or myself and someone would need to come in and take a look at the flap. What has happened uh with the use of the Doppler devices we now go it is so accurate and we're, you know, we believe in it that when the audible when the signal. Changes the resident gets called, the nurse or maybe the residents come by to check on it, and they go, the signal has disappeared, and they will do some troubleshooting for about 5, 1015 minutes and then they make the call. They call the fellow, they call the operating room. They don't call me because I hate being woken up until we're ready to go to the operating room, but they initiate the process and on average when our hospital is not going crazy with trauma or anything else from the time that someone detects there's something wrong with the flap, it takes us anywhere from 1 to 2 hours. And almost always under 3 hours to get to the operating room and have the patient to sleep on the table prepped, draped, and have the neck opened and be ready to do something. We know in in our series and then in my hands that if I use the Doppler about 10% of the time it tells me there's something funny with the blood vessel, uh, so we go in and we fix it. Um, and that means about 6% of the time it happens in the recovery room or it happens, you know, post-op day one on the floor. In patients where we weren't using the Doppler, nobody really records, and I've never done it either how many times you revise the vessel. It's just not something that's reported, but we know that about 10 to 12% of the time you ended up revising the vessels in the postoperative setting. And so what the Doppler did was it took vessels that were going badly. And it allowed us to fix it at the same time of the initial operation, so we're, we're only having to take half as many patients back to the operating room, uh, in order to fix it. When I just updated our series, we just looked at, you know, um, um, the the number of flaps over I think a 2025 year period, um, when you look at it, uh, and, and you compare those patients whose Doppler has gone back. That in the operating room, so you're operating away and the Doppler goes funny and immediately you then start to inspect the vessels and maybe you don't feel a pulse. It just isn't right to revise the vessel when you're in the operating room. You've got all the equipment you've got the microscope is 15-20 minutes and so we'll almost always if the if the Doppler doesn't sound right or things aren't good, then we will revise it. Uh, and what the data here shows is that if you have to revise it, then your overall survival rate is a little bit less than if you don't have to revise it. So those patients that get revised in the operating room, we know we have to follow them and be more cogent of uh what's going on with them. So how do you get started using and implementing this type of technology in your practice? So first things first is to remember there are no perfect monitoring techniques. Um, really clinical judgment should always be the first line when there's concern, as there is no perfect monitor, right? Um and implantable monitors are a useful adjunct, but really education and training of staff is the key for success, and it's all about the team. Speaking of the team, this is one of the most beautiful teams ever, you know, looking at what we do with our residents and how we, we work with trainees, um, we really wanna make sure that we are optimizing them from a learning standpoint as well as a patient care standpoint and so you know, looking at the historical monitoring techniques and what we've done in the past, um, actually Doctor Patel and and his team kind of looked back at at how we do it. The frequency of monitoring and how do you do it when we have restricted resident work hours because there's only so much time in the day. Um, in addition to that though, you know, we have to look now there are a lot more, uh, providers who are going out into community settings, so academic centers, there are trainees, nurses, nurse trainees, um, there are many people available when out in the community setting this can oftentimes change and can really affect what our ability is to do really intensive monitoring so we have to think about safety for patients and staff so for there for. Some systems there are surgeons who like to use pinprick test Q 1 hour, um, and which can be, you know, from a, um, trainee or from a resident standpoint that's a lot of sharps to be encountering, especially if there's more than one flap that needs to be monitored and there's also monitor fatigue. So you know when they're someone doing an hourly check and they go to look at 4 or 5 different flaps after a while, a lot of them start to look the same. So and as we talked about before, clinical monitoring it really is dependent on the ability to recognize subtleties in color, trigger needle scratch. So training the residents on the sound and the clinical examination can really be a useful adjunct to help decrease burnout, to help with accuracy of monitoring as well. When you want to institute the program, um, it turns out to be relatively easy, um, the institution. Once you've done an analysis that that tells the institution that you are gonna cut your your return to the operating room rate by 50%, so less people are going back to the operating room in the middle of the night, um, and by using this relatively simple monitoring technique, you can uh affect patient outcomes, length of stay, you know, if you have to go back and get your flap revised, your length of stay goes up dramatically. Uh, and so selling the institution on this is relatively easy. Nursing staff, the ability to walk in the room, flick a switch, listen, or if there are some patients love to have that uh monitor going full time just to be able to monitor it that way. Versus having to uh get the uh Doppler probe um and find the pulse and then listen and sometimes it's not that easy so nursing staff again it's very easy to sell this with uh residents, physicians, fellow once um. Um, you have convinced them that you are gonna believe them when they and they've learned how to troubleshoot, uh, when the signal goes away. Again, it's very easy for them because the signals there or is not there, whereas monitoring a flap that's in that stage of going from perfect to very bad. Can be very difficult. Uh, when we look again at data, I don't know if you're gonna try and sell your hospital on, um, uh, being able to institute this type of uh system, uh, it's always good to be able to have some data, and I think, uh, you know, we might have mentioned this, but the number of patients that end up being returned to the operating room drops almost in half. Um, you are able to get to the operating room faster because it. Doesn't depend on marching up the ladder with 4 people making decisions. Our junior resident calls it the operating room says the Doppler has gone down and everybody starts moving to get that patient, uh, back to the uh to the operating room. There's no hand wringing. There's no, well, what if it's OK, what if it's not OK? So the efficiency goes, uh, much higher, um, and the faster you can get them back to the operating room, um, the more likely you are to be able to save that flap and the. are just really low, so it's hard to say statistically what exactly that data is. Here's just showing you what happens with our salvage rates if you operate on patients and everything goes smoothly and it's great and you take them out to the recovery room about 6% of the time you're gonna have someone whose flap is not going to do well. And if you take those back to the operating room, you save 4 out of 5 of those, so your failure rate is about 22%. Uh, on the 6.1% uh of the ones that you've taken back. Whereas if you have a patient where you've detected a problem in the operating room, it's usually indicative of there is an underlying problem with the vasculature, your technique, the anatomy. Something and that those patients are gonna have a higher probability that they're gonna have an issue in the postoperative setting so in those patients maybe uh you heparinize them or you do some form of intervention that may help you to uh maintain a good uh flap uh survival rate. And to really just underline the um the the discussion regarding nursing care and um you know the ability to really teach anyone how to utilize this monitoring technique you know uh as I mentioned before, there's really been a huge rise in burnout with regards to our nursing staff. They are overworked, oftentimes underpaid, uh, overburdened with multiple patients at a time. And so really things that we can do to decrease their work burden and their workload to make things easier to make it so that they can concentrate on other aspects of patient care um really is an important aspect of what we can do um from the physician side so while while still maintaining excellent patient care at the same time. Now we're gonna talk about cases. You always have to put up a, uh, you know, some good slides with some good outcomes. Uh, gracillus is another type of buried free flaps, so all of our facial reanimations get monitored cause they're all buried flaps. This is uh the typical uh gracillus flap with the vascular pedicle uh and the uh neural supply coming into the gracillus muscle. Here's what it looks like, uh, both sitting outside the patient, then as we're gonna implant it uh inside the patient. Here it's been implanted uh sutured up to the temporal fossa down towards the uh nasolabbial fold and the uh moteolus and the vascular structures are going to the facial vessels. You can see the vascular anastomosis and then the wire uh for uh monitoring of the uh arterial pulse so. Another example of a buried flap is in the post laryngectomy patients. So, um, many of our patients get chemo radiation, uh, and in the small numbers that fail and end up having a laryngectomy, it's been well documented in the literature that having a free tissue transfer to reconstruct these patients helps with their rehabilitation. And it decreases the uh length of stay. So, uh, many of these patients, they'll still get a salivary leak, but they'll heal uh quicker and they'll heal without any other surgery, um, so you can see on the left, uh, you've got your pharyngeal wall uh feeding. Tube and you've got that anterior defect and you could argue that you could close that defect primarily um but then you run into problems in terms of speech and uh swallowing and this is a radial forearm flap on the right hand side we're gonna use it as a patch to reconstruct the larynx. Here we've got the radial forearm flap is patched uh and we're gonna sew it in as a uh patch graft uh to uh reconstruct the larynx. The vascular anastomosis is circled in teal with uh the Doppler wire, so we're monitoring arterial pulse, and I think that when you're inserting this flap, and then when you're putting your skin flaps down and you're closing the wound, oftentimes what looks like a perfectly great orientation. Everything's lined up, uh, and then the signal will go away and you lift up the neck flap and for whatever reason the drain shifted and now the drain is sucking up the pedicle or the pedicle has twisted, uh, and so having this intraoperative monitoring allows you to detect those problems um now rarely in, in my early career I routinely, well not routinely but you know we were taking patients from recovery room back to the operating room because the flap would go bad. Never happens to me now. Um, usually it's a day or two later, and I think it's because all of those flaps that went bad in the recovery room, they were going bad in the operating room. We just didn't have a way to detect them and using the intraoperative, using this as an inoperative monitoring technique allows us to detect them and so we don't have to go back to the operating room immediately we fix it immediately. It's always good to be able to publish a paper that says you're perfect and everything is, you know, 100% and so this is, uh, we looked at our buried free flaps and found that the Doppler picked up about 5% of them. There was a problem, so we would not have detected it until everything had fallen apart and in all of those. Cases we were able to salvage it and we had no incidences of flat failure and I'll tell you that that is great data and it all went to pot, you know, like within a year or two where we would, you know, lost, you know, 3 or 4 flaps so um we do not get 100% but the Doppler does allow us to detect when it's going bad versus the whole neck falling apart. So sometimes um one of the things that we're looking at are pretty extensive defects and as Mark mentioned failure in this area is catastrophic and so anything we can do to really prevent that is. It's, it's absolutely necessary. So you can see here, um, the entire larynopharynx complex as well as a portion of the oropharynx is missing in this patient. So really it's an oropharyngoingopharngectomy defect. Um, this is a patient who presented with a T17 tumor. And as you can see, the proximity of the carotid vessels to where our reconstruction site are um it's it's right next door and so really one of the most important things is being able to monitor this because we're using all of the skin of the the free flap to uh reline this area because this goes from nasopharynx to esophageal inlet so to have. That an external monitor paddle would be taking away from our reconstruction. So, um, to reconstruct this area, um, utilizing an anterolateral uh thigh free flap, including a little cuff of vasti laterals to reinforce the closure. And so, um, with these, one of the, uh, one of the things that I like to do is to buy the suture line, um, away from the vasculature, especially from our little tiny baby anastomosis, and then to reign everything with the vastus musculature. In order to protect everything, so with that additional muscle covering things that really can decrease the ability to get a handheld Doppler in the right spot to listen and monitor with the free flap and so having um on on these I usually will do an artery and a vein monitor and these are end to end on the superior thyroid artery and facial vein and I typically do put it on the free flap side of the um vasculature. And so then that could be monitored more easily and then as you can see on the closure everything is inside the wires coming out of the side and we'll talk about how we secure those as well, making sure to keep the drains away from the actual wires themselves and in this case the cuff was placed in the donor artery and the inside with no monitor paddle. You know those laryngectomy defects, so many of our flaps when they go bad if we lose the. Lap, you know, we can always come back and reconstruct it with doing some other technique. It just means that we've delayed their care, so I have a scalp flap. It went bad, so but I know it's bad and I know over the next 34 days, and it really it's a big impact on the patient, but we're gonna be able to solve the problem when one of those laryngectomy. Effects go bad. So when Dr. Kesner's androlateral thigh flap is one of the, you know, 5 out of 100 that goes bad, you don't know about it till day 10, day 12, when suddenly everything starts to stink, everything falls apart. Now you've got this gross smelly infected wound and so the impact is huge. Um, and being able to detect that early, even if the Doppler tells you the flaps, you know, has gone down and you get in and the flap is dead, you can at least fix it before you hit all of those other milestones, so. It really saves a great deal on those aspects. Sorry. And, and, and going to that too the back to your intraoperative monitoring, a lot of times when we have a bigger bulkier flap, this is one where you bring down that skin to close and you may have that change or uh alteration and signal and that's something that could be caught. Um, this here is a skull based reconstruction, so this is an HPV positive squamous cell carcinoma that invaded naso into the nasopharynx as well as up onto the skull base, then was actually going into a portion of the anterior skull base in Dura that had failed chemo radiation and so um the resection actually was via this um trans nasal approach. Um, the nasal bones were resected with this as well, and so you can see here we've lifted everything up. There is a the chimeric anterolateral thigh flap with the vasti muscle up against the skull base over a PDS plate, and then the um fascia and fat creating the new inner lining of the nose over a latticework of calvareal bone. So as you can imagine this is a fairly complex area to try and monitor because there is no monitor paddle and we've got, as you can see we're trying to maintain and stent open the nose as well as to provide alimentation by the other nest so with these there's really not a great way to monitor it as again this is one. Where if we have failure at the skull base, that's where nasal cavity bacteria can enter into the brain so incredibly important to have these free flaps do well. So in this case there's a facial artery and facial vein end to end with probe on the donor artery and on the donor vein um to uh monitor for flow and so this allowed us to have a really nice and tight clean reconstruction without having to have excess bulk, um, but with enough bulk to protect the brain. This is a patient who had medication related osteonecrosis of the jaw, and in her case she had failed conservative management, was having significant pain and was also requesting dental rehabilitation. So for her, we proceeded with the adipofascial fibula for osteonecrosis, using her native mucosa to close the intraoral portion and then laying the adipofascial tissue over the plate to help prevent any extrusion of her hardware. So no skin panel on this and again this is a three segment fibula on a woman who has a um chronically fractured contralateral fibula with bad runoff and who has had breast cancer with metastasis to her uh thorax. So really not a lot of other candidates for bony grafting in this patient and so it's kind of almost like a one shot with this fibula. So uh as all all free flaps are precious, but certainly when there's a limited um availability they become even more so. Um, and so in this patient we put the probe on a facial artery and the donor facial vein and and anastomosis and you can see here the subal gland retraced to the side so we left all of her as many native components of her anatomy intact because we wanted to really optimize as this was, um, sometimes referred to as a lifestyle flap one to help her lifestyle be better and it's not really related directly to a cancer operation. And if you see here on the bottom right hand slide, um, these two where the little arrow is pointing this teal arrow, um, so these are actually Lone Star retractors um that's what's holding our submandibular gland and our um skin panel back in order to be able to visualize. I also commonly refer to these as our medical student replacement devices because they can be in places where my medical student might not be paying as much attention, but they're very handy to use. OK, let's get on to uh. Some troubleshooting and uh if you place your drains first, then you don't pull out your wires. If you uh hook up your vessels and you have the wire there and then you go to place the drains, oftentimes you have to place the drains um and manipulate them around the wire and then as you're moving your hands you can catch the wire and pull it. So placing the drains first I think is uh works works pretty well. I'm an arterial guy. There are people that hook it up with the vein. There are people that use it on both the vein and the artery, whatever, you know, um, has worked well in your hands if it lets you sleep at night and if you think that it's uh it's helping with your success rate, then, uh, you know, then that's what you should do. It goes distal to the anastomosis, which seems like a no brainer, but there's a lot of things that we do in medicine that we only learned. As you know, through experience, so it's just something to point out. I usually have to point it out once to, you know, the resident or the fellow that's never seen one, but the, uh, proximal part of the anastomosis can be pounding away when there's a clot right at the anastomosis and so you'll think your vessels are good, but in fact they are clotted so distal to the anastomosis. I personally have not had a lot of success with um end to side. Uh, venous anastomosis just because of back flow but again some of my partners, uh, swear by it and and it seems to work pretty well. Um, it works well if you're doing an end to side for the artery, then it works very well. Uh, on vein grafts, um, I usually like to place it at the distal end of the second anastomosis, so it goes on the, um, flap artery. So you got facial artery. Um, or facial vessel, vein graft, flap artery, and I will put it on the flap artery. So it tells me how the vein graft and my other anastomosis are doing. Um, sometimes it's hard to get a good signal if you're on a vein graft for some reason, so we just place it as far distal as we can. There are different ways of securing the cuff, um, and again, you know, whatever works for you, um, sometimes you'll be able to put the cuff so that it runs parallel to the blood vessel, you know, to the vessel if you have a good assistant, then putting it on, you know. One I use small um hema clips um if you use one small clip uh and you can run it parallel to the vessel, it is better to be too loose than too tight because you can always add another clip to make it a little tighter uh or um if you're by yourself, um, or. Uh, if you're operating with the medical student or um even if I'm sometimes I'll be doing this with the uh scrub nurse, um, then I'll place one that's perpendicular on the cuff to the blasil and it just stabilizes it and then I can adjust where I wanna put the uh clip on the cuff. So this just demonstrates, uh, you know, where you wanna place the uh cuff um you want the cuff to be placed distal to the anastomosis, but you also want the wire to be oriented so that when you pull the wire you are not pulling the anastomosis uh you're not putting tension on the anastomosis. The left, uh, if you pull that wire you could put some traction on the anastomosis on the right you pull the wire, you're not putting any traction on that anastomosis, you know how are you gonna secure the wire, uh, on the left? This is how we secure the wire when I'm the last guy that bought donuts because I'm waiting for someone to take, you know, so that they can say don't do the whack. They can go to the Kesner and because that's the last person that pulled the wire um but on the right is how we uh fixate the wire so that you will stop the inadvertent pulling by the patient, the nurse, the resident, the fellow. So what about intraoperative troubleshooting, you know, what do you do during uh surgery? So um. I put the uh if you have the uh cuff on and the clip and it's held at just the right amount of tension up against the vessel, then you get this really great sound. Um, this would be the two loose sound where the device is not fitting appropriately. When we look at things then we're not getting as good a signal as we want, then I go through all of these things on the left side here, you know, inspect the clip, see how well it's being held up against the uh blood vessel um if you're palpating the vessel, does that improve? Um, if you irrigate with saline, you know, does that make it better? Does that make it worse? It may tell you that you have a particular cuff problem. And I'll say for um for people who like to use it on the vein and I say like in a very quotation marks so I I like it but sometimes it gives me you know a little bit of reflex because it is a slightly less um it takes a little bit more troubleshooting I think to get it right in the operating room because it's one that you don't want to squeeze too tightly. Um, but one of the things I've found is by really cleaning off the vein a lot more than I normally do to get the cuff to sit just right if I'm using a vein as a monitor, um, because that is where, um, sometimes intervening fat can really change the ability to monitor it well and so, uh, getting that right on there so I because I tend to try to not manipulate the overlying fascia too much between the arteries and veins and things like that, but in the if monitoring on the vein does help to have it a little bit closer to that. Um, outer table. Sometimes if you put it on too tight, um, you can again, if we uh if we hit the trigger here, you'll see this is what the uh the uh ideal uh sound is like. And in this instance, the cuff has been clipped uh too tightly, so it's impeding the flow through the artery. Uh, but if you put the, uh, clip on and it's too tight, sometimes it's obvious because it really looks like you've pinched it. And in that case we just take the clip off and we put a new one on, uh, vasospasm. Here we have uh the ideal sound where you've got uh excellent flow and the cuff is placed, uh, perfectly. And in this instance, the cuff is fitting and everything looks good, but because there's vasospasm distal to the anastomosis, you have this abnormal signal. I don't know about you, but vasospasm is uh is is my nemesis. So you've done your anastomosis, your vessel looks great. You've put the uh the the Dopper on, you're measuring it and you got terrible sound, but you're looking at the anastomosis and you're going, this looks great um and then you're feeling it and you're going, this looks great. You can feel the pulse, but. Not hearing anything and then you're back doing another flap so if it's not sounding good, even when you have a great anastomosis and you've got a great pressure that you can feel there's probably something going on distally and most of the time that's vasospasm um or you know if you have a really long pedicle then it could be because you've got your your vessels have kinked or twisted. Um, and then you have to address that, and that is a whole topic in itself. Um, and again, just another example, you've got uh your perfect sound, uh, and this is what you want to hear. And then you've got where the vessel is compromised, something's going on and you need to inspect both the anastomosis as well as the distal outflow. Yeah But And it is surprising to me that uh sometimes you will get the sound and sometimes the sound you have to turn the volume down because it is so loud that the whole operating room is shaking and sometimes you've got the volume cranked up all the way and it is quiet, you know, you hear a pulse but it isn't as loud as your last patient and then when you see them the next day it's it's much louder so the sound and the level uh can be quite different. So with regards to cuff placement as Doctor Wax mentioned, you know, placing it distal to the anastomosis um is typically the best way to look at it there it's really interesting looking at um kind of also the discussion with you know who gets which monitor and who monitors for what reason and really at the end of the day, um, some data supports it, uh, monitoring artery alone, some of it supports vein alone, some of it supports both. Um, so really it, it ends up being the, the many ways to skin a cat at the end of the day, and you know, the, that's kind of surgeon preference so whatever again makes you sleep well at night. So with regards to the wire, so leaving slack in the braided wire is very important to avoid it if you don't want donuts in your life, but what this can do is it allows um optimal cuff placement so when it does get pulled, as Doctor Wax mentioned, um, you want to pull it in a direction that's not going to a the cuff or avols the anastomosis. I will say that it does affect the handheld Doppler because there is noise when it encounters the wire if you're using a handheld in addition to that. Um, but typically also we'll secure these with either a Steri-Strip or a Tegaderm, and then the um the suture pads, which are the kind of the uh place where these are fixed over the shoulder, um, I typically will staple them. And then actually staple the blue portion of the cord as well and then cover that with uh another piece of tape um sometimes I like to put a little bow on it just so people know not to actually pull on that area um but things just sort of signify that this is an important area of the neck. This is uh an anastomotic cushion so um this is something that a lot of um a lot of. Surgeons actually used to help sort of optimize where the vessels are placed so that they have adequate cushion to one improve the contact of the Doppler probe with the vessel of of uh interest and then in addition to that to reduce kinking um and also to um fill dead spaces often times after pretty comprehensive neck dissection. There's a lot of space in that area and what this can actually do is um the fat sort of gives it a nice cover cushion um and can also help kind of plugging any small bleeders as well um so this is actually I, I picked this up courtesy of uh Doctor Judy Schooner who who introduced me to the um the fat mattress as we sometimes we'll call it. Um, and, uh, so some people use gel foam, muscle, other things can be used as well. Um, it can also support the probe to reduce migration. So in conclusion, as we discussed today, so really the standardization of monitoring helps in multiple ways improving patient outcomes, improving our ability to monitor freely, um, really any portion of the flap, um, helps with our workforce. Um, there's a potential to increase difficult monitoring for residents, nurses, and surgeons and helps us to monitor flaps without easily visualized skin paddles or um uh free flaps that are in difficult to monitor areas. And that concludes this portion of our presentation. Thank you, Doctor Wax and Doctor Keckner. That was a fascinating session and a really compelling program by our expert panel. We're now going to turn to the Q&A portion of the program. All right. Well, we got some really great questions that have come in from the audience. So, uh, we'll go ahead and get started. Uh, from the presentation, it was discussed that Doctor Wax monitors the artery and Doctor Kockner monitors the artery and the vein. Doctor Wax, is there a reason why you only monitor the, the artery? You know, um, in, in, in our hands, um, technically, it has been, um, a little difficult to monitor the vein. It's just, uh, not, it hasn't, uh, worked as well as monitoring the artery. Um, it's been more fussy in terms of being able to generate a signal and to get a consistent signal. Uh, and then I guess over time, our results have really demonstrated that monitoring the artery has been, uh, exceedingly efficient. Um, and our, uh, outcomes have been pretty good with it, so we're quite happy with, um, just monitoring of the artery. Uh, Doctor Kogner, what's the reason that you monitor both artery and vein? You're neuroticism? No, I'm just kidding. Um, so really a lot of it has come down to, um, depending on where it is. So especially for buried flaps, um, for those in particular, I like having that information, um, because sometimes the artery will be the thing that goes first if you can't see it, you can't really to, to adjust what's going on with the, the end organ. And so there are some subtleties in the findings on the artery when the vein goes down, but not everyone is particularly trained in it. And so this one is just one extra layer of protection because of, um, we don't have like a specific flat monitoring unit. And so I think we have a flat monitoring unit where people are more comfortable with like certain sounds. I think that can be um a little easier to do, but uh that's one of the things that we've had, we, we kind of have used sort of as a, as a result of that. So we, we did monitor both the artery and the vein, uh, for a period of time, and when we looked back at our data, we, we, um, showed that uh about 2 out of about 200 flaps, um, we detected the vein going down before the artery went down. Um, so I don't know if the, uh, the, the artery would have, uh, still have gone down and detected it, or if the clinical resident or the nurse would have detected it, but the, uh, venous Doppler uh went down first. Uh, and the major discussion when we presented the data to our group was a sort of like a cost-benefit analysis. Now, obviously, if you're the patient and your flap goes bad, That's 100% for you, but do you monitor 200 flaps to pick up 2 flaps that you may have picked up, but maybe you picked them up a little bit later. Um, and so we elected to not um continue with uh the venous monitoring if we were doing the arterial monitoring, um, cause we weren't sure what the efficacy would be, and when you looked at the overall total costs. Thank you. Uh, uh, Doctor Kegner, you mentioned buried flaps and, and that was a lot what was in the uh, the presentation. Uh, do you, do you monitor all free flaps or only buried flaps and why? Um, I monitor all of them unless it's one where, um, so for instance, like if we're doing a parotidectomy defect where we're doing like a, a vascularized fat graft, because that one is one where if it doesn't have vascular supply, it will eventually get a vascular supply. So those are some I'll, I'll set it and forget it. But a lot of our buried flaps are really in anatomically important areas. For instance, the skull base where you're reconstructing the covering over the brain, um, or in patients where We've got, you know, a defect running from the oropharynx down to the esophageal inlet and where breakdown could result in carotid blowout and things like that. So, um, the bar flops for sure are ones that, that I, that I like to have monitoring. If they're an exposed flap, meaning like it's out in the open and you can see it, and then those I feel more comfortable being able to do like a single monitor, either the, um, and typically that's gonna Be the artery. Cause I do agree that the vein can give you a lot more, um, heart palpitations because it is a little bit softer, especially right at the beginning of the hospital course. Um, but, uh, for the most part, yeah, I would say 97% of the flaps, or 98% of the flaps we monitor, and there are very few who are like, yeah, no, it's totally fine. It'll, you know, heal eventually. Um, because, as Mark mentioned at the beginning of the talk, you know, the, uh, the results of a flap loss are pretty devastating, not only for the, you know, the wound itself but for the patient's mental status too, um, because that could be really disheartening when you've gone through a big operation and say, yeah, actually we gotta go back and do. Another one or something like that. Doctor Wax, do you, uh, monitor buried and just uh and service labs? Right So we've, uh, we monitor all flops, um, I, I mean. You know, if, if, if a flap goes down and you can get it back to the operating room, so we monitor all of our flaps, uh, and then it's just a question of how do you want to monitor them. Originally we were using that, uh, an external Doppler probe, um. We use the internal Doppler on all flaps because it's just so much easier for a nurse to walk in the room and turn the machine on, or turn the machine off, uh, for the resident to come in, and it gets, uh, it gets someone in the room if something is going wrong. So, um, yeah, we, we use it on all of our flops. Thank you. Uh, how's the, how's the Doppler facilitated getting patients back into the operating room when there's uh concern over flaps viability? So it really does. We, we do a continuous monitor and so it's kind of a, often times a binary thing if it's off or sounding kind of funky or really on and off is, is the thing. And so a lot of times the, the uh that macro circulation will tell us before you get changes in the actual color of the, the flap itself. So it definitely shortens the time from problem to um to solution. So, um, Uh, you know, I, I look at it as, um, you know, we have a patient that has a lymph node, and you look at the lymph node and you go, this is 100%, I'm convinced this is benign. We don't need to do anything. Um, some patients need hard copy. They need a piece of paper that says it's benign. Some people need more than just a clinical, uh, judgment, no matter how expert it is. The operating room. Accepts our clinical judgment, but if you tell them technologically, um, the machine says this flap is no good, they are 100% behind you. When we call and we say the Dopper went down, they go, we'll get you in a room within 2 hours. If I call and say, hey, the flap's no good, they go, oh, you know, we got trauma coming in. We got all these other cases, uh, you know, uh, plastic's cold, their flap may not look good, uh, you know, what's going on? But you tell them the Doppler is no good and it's, they, they go, OK, good enough for us. Amen is, uh, how often do you have takebacks to the OR for false positives and or false negatives? Um, I would say for false, uh, a part of it too, like we talked about kind of the monitoring thing is that you always have a backup as well. So it's an, the Doppler makes a sound, someone comes to evaluate that person then gives their evaluation to like the next step up, and then that decision making happens there. So I think the rate of false positives is um pretty low. Um, it, it, it can be fairly accurate to confirm like, OK, the Doppler is out. Let me get a handheld Doppler. Handheld Doppler also is not working. Do a scratch test. Scratch test tells us what's happening. So I think that that does reduce a lot of that because it's a combination of, of clinical judgment in addition to the actual Doppler. I think Mark actually has some good numbers on that as well, specifically. So, um, I, I'm more my policy is a little bit different. I go, if the Doppler goes out, um, if, if the junior resident gets called, cause we have a resident in-house and the Doppler goes out, and they've confirmed that it's not pulled out of the patient, the box isn't broken, it's not. I mean, they troubleshoot it for, you know, like 1015 minutes, then we go back to the operating room. If you have to call the senior resident or you call the fellow who then, you know, whiffle waffles, then they call me, then it adds 1 hour, 2 hours on. So if the Doppler goes down, I take him back to the operating room, and I'll tell my fellow that um Once or twice every couple of years. So we do about 200, 220 flaps here. So, once or twice every couple of years, I'll get into the operating room and we'll look and I'll go, you know, the Doppler's out because, you know, it got pulled out. Or, you know, maybe if you cut the drain and the Doppler comes back. Some happens and maybe that patient gets their neck explored unnecessarily. But it's exceedingly rare. Um, and I'm willing to live with that, um, because it gets, everybody else gets back to the operating room, and we're back in the operating room within 2 or 3 hours when the Doppler goes down. Um, in terms of the, and I get the false negative, you know, however you want to define those. When is the Doppler pounding away and the flap is dying? Um, I'm gonna say it happens once or twice a year. Um, we have flaps that are dead. And the Doppler is pounding away and you go in, and the artery is patent, um, and it's just blood's going up and down the artery. Um, and the vein is thrombos and, and sometimes that happens. Uh, and those we pick up on physical exam, cause the nurse comes in or the resident comes in, flips the switch, and hopefully, not only do they listen, but they look at the flap and they go, boy, it looks blue. Um, so it does happen. Um, it's unusual though. Yeah, pretty rare. All right, so the next question, uh, since you talked about the pulling the probe early, there was a lot of talk around accidentally removing the probe and donuts. But how often, how often does that actually happen? What do you do to minimize the occurrence of this and how does it change your management going forward? Um, mainly guilt tripping for the most part, um, no, uh, but one of the things that you know we kind of talked a little bit about that was the kind of the pushing a little bit extra of the wire into the wound itself. Um, and what that does is it kind of decrease. So if there's a pull, it pulls it very gently. It doesn't go pull directly off, off of the, um, the cuff itself. And, um, we also will do Steri-Strips to kind of hold the wire in place, um, to kind of also prevent that from happening. Um, but, you know, accidents happen, um, and so, you know, mainly just having everyone be aware like, hey, these are the Doppler wires, see the shiny thing, don't cut it, don't pull it. Um, but if it does, let someone know. OK. Yeah, it's, it's like under 1%. It happens once or twice a year with us. Uh, we track who it happened to, uh, so that, you know, when we're putting the, uh, when we're, when we're uh securing the wire, or when we're looking at it, we can say don't, and Uh, you know, I'm really unhappy that you asked the question today because, uh, now, right now it's don't cut the wire like Doctor Wax did 3 months ago. So right now I'm the guilty party for having cut it or pulled it. Um, if it happens when the patient is in the operating room, then we replace it. So if the wire gets pulled. and they're still in the operating room, then we'll put them back to sleep as long as they're in, so our hospital goes by, if you're in the operating room, it's still the same surgery. So even if they're awake and they have to, you know, put them back to sleep, reintubate, we open the neck, put a new Doppler on, it's still considered the same surgery. Once they leave the operating room, Now you're, it's a second surgery and now it's M&M and it's all sorts of, you know, paperwork and they have to break down the, so it becomes a major issue. Um, so if the Doppler gets pulled in the recovery room or whatever, then, you know, they don't get monitored again. If it gets pulled or cut in the operating room, then we'll replace it. And that's another reason sometimes I have the two different monitors, uh, wires. I'm just kidding. We don't pull it that often either. I, I actually just, I, I was the most recent donut purchaser too, so. Yeah. Um, next question that came in is how difficult is it to train and get buy-in from nursing staff to use the Doppler? Right, you know, it depends on how you're monitoring your flaps now. Um, when we used, we used to monitor it with a handheld Doppler, so they'd have to come in, they'd have to, you know, put some lube on, put the handheld hunt around, look for it, um, and then you just show them this box where you say you flick this switch and it either makes a noise or it doesn't make a noise, they're like, Why didn't you do this 10 years ago? So the buy-in is uh tremendous, um, and the buy-in from the nursing staff is immediate, um, and I think there was probably uh an in-service where we had to teach them originally, uh, when we first got it. And now, you know, the turnover and nursing staff on the floor is tremendous, uh, but we are never asked to teach anyone about the Doppler box. It is internally taught by the nurses. That are on the floor to the new nurses, um, and it's, it's not a problem. All right. We got a couple more questions and we're coming towards the end of our time, but, uh, uh, are there times when the sound of the Doppler and the lights don't match? And if so, what do you instruct your nurses to do? Um, pretty much. Um, pretty unusual for that to happen. I would say that oftentimes the, the lights will be, for especially for the vein, the lights will show up more than the sound, um, right out of the operating room. So when the maps kind of fall below like 60 or so, um, uh, sometimes the vein will get very, very quiet, but you can still see the lights going up and down because it's still detecting the flow as they breathe. So, um, Usually, uh, for those, uh, we tell the nurses like, OK, can you see the lights or can you hear the sound? Which one do you do? And then, and then that's usually when we'll come and evaluate to make sure that, that uh what they're seeing, what they're hearing, and, and kind of figure out what's actually happening. If it's just a blood pressure issue, is it an actual flow issue? Um, I guess, uh, I guess I'm off the consultant staff, uh, after this, but, uh, it's either making noise or it's not. Um, I, I don't care what the lights do, uh, you either hear a sound or you don't hear a sound. And sometimes, you know, we'll be sticking our ear right next to the box, and sometimes we'll have a discussion, uh, how my younger residents, they can hear it. I can't hear it. Um, but it, it's, I, I go by a sound. If you can hear it, you're good. If you don't hear it, and the lights are still bopping up and down, then to me, that's not good enough. And I say for the artery for sure, yeah. But for, for the vein, because sometimes you'll get this like scary ghost squirrel noise is what I'll sometimes get from there, but then like that nice ocean sound. Um, so the, the, that would be the only one, yeah, for artery, it's gotta make a sound. That's a, that's a 0 or a 1. How long do you typically monitor the flap before removing the probe? I usually will monitor them until it's time to go home cause I'm also neurotic, but, um, and so when I, I usually will leave the drains on that ipsilateral side too. So when I'm getting all the drains out, we get the drains out, we get the wires out and everything comes out at one time. Um. And then, um, and then I comment on your side. Um, so we leave, uh, we leave it in for 5 days, um, and I leave it in for 5 days because there's, uh, uh, nobody gets sent home if the Doppler is in. My partners won't send people home. The nurses, nobody asks, and everybody says the Doppler's in, patient needs to be in the hospital. You know, the hospital can be 180% full, and nobody wants to send patients home if the Doppler's there. So I keep it in for 5 days because it assures that my patients are in hospital for 5 days and nobody wants to send them home earlier. Um, and that's the only reason I keep it for 5 days. All right. Well, thank you so much, Doctor Wax and Doctor Keckner for uh your presentations and, and your time answering questions from, from the audience. Thank you, audience, for joining us. Uh thank you all for your participation. And have a good evening.
