Background: Reoperative neck surgery is technically more demanding because of the presence of scar tissue and distorted anatomy. We aimed to investigate the magnetic probe–guided excision of nonpalpable neck lesions in patients with previously operated neck compartments. Methods: This study included 9 patients with recurrent/persistent thyroid carcinoma, recurrent/persistent hyperparathyroidism with previously operated neck compartments. The pathologic lesions were localized by ultrasonography, and magnetic tracer (0.2 mL, iron oxide) was injected directly into the pathologic lesions. Careful dissection was carried out following the area of maximum magnetic activity until the nonpalpable lesions were identified and excised. Result: All neck lesions were removed in 9 patients. The median count from lesion was significantly higher than values from lesion bed (background activity; (9900/5 seconds vs 250/5 seconds, P < .001). During follow-up, all patients had negative ultrasonography. Conclusion: Magnetic probe–guided technique could provide access to nonpalpable lesion localization in centers without readily available access to nuclear medicine facilities.
Introduction: Anastomotic leak after pancreaticoduodenectomy is the most important cause of postoperative morbidity and mortality. Histological studies of bowel anastomoses have provided valuable insights regarding causes of anastomotic failure. However, this crucial information is lacking for pancreatico-enteric anastomoses. Methods: Pancreaticoduodenectomy was performed in a porcine model. Animals were survived up to 10 days and then the pancreatico-enteral anastomosis specimen was resected en bloc. Anastomotic bursting pressure was measured and histological sections of the anastomoses were examined. Results: Six out of 8 animals had excellent healing of the anastomoses. One animal developed a clinically significant leak at the pancreaticoduodenal anastomosis (12.5%) and one animal had a subclinical duodeno-duodenal leak discovered on necropsy (12.5%). Both anastomoses that failed had a collagen-to-tissue ratio less than 40%. In contrast, none of the anastomoses with a ratio greater than 40% showed any evidence of disruption. Conclusion: Our results indicate that quantitative measurement of collagen deposition at the pancreatic anastomosis provides objective assessment of healing of the pancreatic anastomosis. A survival porcine model of pancreaticoduodenectomy results in a similar leak rate to published data on pancreaticoduodenectomy in humans and will be useful for future studies assessing novel pharmacologic or technical interventions aimed at improving outcomes.
This present study examined the hemostatic efficacy of nanofibrous matrix in a rat liver model. The nanofibrous matrix comprising gelatin and polycaprolactone was prepared by electrospinning method. Twelve animals underwent surgery and were followed-up for a month. Time taken to cease bleeding, activated partial thromboplastin time, prothrombin time, and fibrinogen concentration were measured. Histopathological examination of liver was also done of treated and control animals. All test animals showed very rapid hemostasis after application of electrospun sheet. Histopathological study showed quick recovery of liver wound in the test group as compared to the control group. The nanofibrous matrix has proven to be not only safe and effective as hemostat but has also shown its potential for liver regeneration.
The aim of this study was to evaluate the short and medium-term effects of radiofrequency (RF) and potassium titanyl phosphate (KTP) and neodymium-yttrium-aluminum garnet (Nd:YAG) laser treatment on the inferior turbinate mucosa in a porcine model. Following randomization, the inferior turbinates were treated either with RF submucosally or with the KTP or the Nd:YAG laser on the surface under videoendoscopic control. Tissue samples were taken at the end of postoperative weeks 1 and 6, and were evaluated macroscopically and histopathologically. Scanning electron microscopy was implemented to demonstrate the morphological changes in the respiratory epithelium. Six weeks following the RF procedure, the mucosa was intact in all cases, and the volume of the inferior turbinates was reduced in the majority of the cases. Although a volume reduction occurred in both laser groups, more complications associated with the healing procedure were noted. With hematoxylin and eosin and periodic acid–Schiff staining, intact epithelium, and submucosal glands remained after the RF procedures at the end of postoperative week 6. Following the KTP-laser intervention, necrotizing sialometaplasia and cartilage destruction occurred, and squamous metaplasia was also apparent in the Nd:YAG group. In both laser groups, dilated glands with excess mucus were seen. The scanning electron microscopic findings demonstrated that cilia were present in all cases. In conclusion, the medium-term macroscopic results were similar in all 3 groups, but the postoperative complications were less following the RF procedure. RF procedure is minimally invasive due to the submucosal intervention that leads to a painless, function preserving recovery.
Introduction. Simulated laparoscopy training is limited by its low-quality image. A high-definition (HD) laparoscopic training box was developed under the present necessity of simulating advanced surgery. Objective. To describe and test a new HD laparoscopic training box for advanced simulation training. Methods. We describe the features and image quality of the new training box. The simulator was tested and then evaluated by a group of 76 expert surgeons using a 4-item questionnaire. To assess the effectiveness of training using this simulation box, 15 general surgery residents were trained to perform a laparoscopic jejuno-jejunostomy in a validated simulation program. They were assessed with objective rating scales before and after the training program, and their results were compared with that of experts. Results. The training box was assembled using high-density fiberglass shaped as an insufflated abdomen. It has an adapted full-HD camera with a LED-based illumination system. A manually self-regulated monopod attached to the camera enables training without assistance. Of the expert surgeons who answered the questionnaire, 91% said that the simulation box had a high-quality image and that it was very similar to real laparoscopy. All residents trained improved their rating scores significantly when comparing their initial versus final assessment (P < .001). Their performance after completing the training in the box was similar to that of experts (P > .2). Conclusions. This novel laparoscopic training box presents a high-resolution image and allows training different types of advanced laparoscopic procedures. The simulator box was positively assessed by experts and demonstrated to be effective for laparoscopy training in resident surgeons.
Objective. The study assesses user acceptance and effectiveness of a surgeon-authored virtual reality (VR) training module authored by surgeons using the Toolkit for Illustration of Procedures in Surgery (TIPS). Methods. Laparoscopic adrenalectomy was selected to test the TIPS framework on an unusual and complex procedure. No commercial simulation module exists to teach this procedure. A specialist surgeon authored the module, including force-feedback interactive simulation, and designed a quiz to test knowledge of the key procedural steps. Five practicing surgeons, with 15 to 24 years of experience, peer reviewed and tested the module. In all, 14 residents and 9 fellows trained with the module and answered the quiz, preuse and postuse. Participants received an overview during Surgical Grand Rounds session and a 20-minute one-on-one tutorial followed by 30 minutes of instruction in addition to a force-feedback interactive simulation session. Additionally, in answering questionnaires, the trainees reflected on their learning experience and their experience with the TIPS framework. Results. Correct quiz response rates on procedural steps improved significantly postuse over preuse. In the questionnaire, 96% of the respondents stated that the TIPS module prepares them well or very well for the adrenalectomy, and 87% indicated that the module successfully teaches the steps of the procedure. All participants indicated that they preferred the module compared to training using purely physical props, one-on-one teaching, medical atlases, and video recordings. Conclusions. Improved quiz scores and endorsement by the participants of the TIPS adrenalectomy module establish the viability of surgeons authoring VR training.
Introduction. Achieving primary fascial closure after damage control laparostomy can be challenging. A number of devices are in use, with none having yet emerged as best practice. In July 2013, at Westmead Hospital, we started using the abdominal reapproximation anchor (ABRA; Canica Design, Almonte, Ontario, Canada) device. We report on our experience. Methods. A retrospective review of medical records for patients who had open abdomens managed with the ABRA device between July to December 2013 was done. Data extracted included age, sex, body mass index (BMI), reason for the open abdomen, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, number of laparostomies prior to ABRA placement, duration of placement, device complications, length of hospital and intensive care unit (ICU) stay, and outcomes. Results. Four cases of open abdomens managed using the ABRA device were identified, with 3 a consequence of intra-abdominal sepsis and 1 a consequence of penetrating trauma. Mean BMI was 33.5 kg/m2, APACHE II score was 14.5, duration with open abdomen prior to ABRA placement was 11.75 days, duration with ABRA in situ was 9 days, duration of hospital stay was 64.25 days, and ICU stay was 37.75 days. Three patients (75%) achieved fascial closure, and 1 achieved skin closure. No incidences of enterocutaneous fistulae occurred. Conclusion. The ABRA is a unique emerging alternative to aid in achieving fascial closure in patients managed with open abdomens. Our case series demonstrates that it can be used effectively in selected patients. Studies are needed to compare its efficacy with more traditional methods.
The goal of this study was to establish face, content, and construct validity of NOViSE—the first force-feedback enabled virtual reality (VR) simulator for natural orifice transluminal endoscopic surgery (NOTES). Fourteen surgeons and surgical trainees performed 3 simulated hybrid transgastric cholecystectomies using a flexible endoscope on NOViSE. Four of them were classified as "NOTES experts" who had independently performed 10 or more simulated or human NOTES procedures. Seven participants were classified as "Novices" and 3 as "Gastroenterologists" with no or minimal NOTES experience. A standardized 5-point Likert-type scale questionnaire was administered to assess the face and content validity. NOViSE showed good overall face and content validity. In 14 out of 15 statements pertaining to face validity (graphical appearance, endoscope and tissue behavior, overall realism), ≥50% of responses were "agree" or "strongly agree." In terms of content validity, 85.7% of participants agreed or strongly agreed that NOViSE is a useful training tool for NOTES and 71.4% that they would recommend it to others. Construct validity was established by comparing a number of performance metrics such as task completion times, path lengths, applied forces, and so on. NOViSE demonstrated early signs of construct validity. Experts were faster and used a shorter endoscopic path length than novices in all but one task. The results indicate that NOViSE authentically recreates a transgastric hybrid cholecystectomy and sets promising foundations for the further development of a VR training curriculum for NOTES without compromising patient safety or requiring expensive animal facilities.
The study assessed the role of an activated carbon nanoparticle lymphatic tracer in reducing unintentional damage to the parathyroid glands during thyroidectomy for papillary thyroid non-microcarcinoma diagnosed intraoperatively by cryosections. A total of 103 patients with papillary thyroid non-microcarcinomas diagnosed by intraoperative cryosection were randomly assigned to receive routine radical thyroidectomy or radical thyroidectomy following administration of activated carbon nanoparticle lymphatic tracer to the contralateral thyroid, at the department of Thyroid Surgery, Sun Yat-sen Memorial Hospital (Guangzhou, China), between January 2012 and May 2013. The success of level VI lymphadenectomy and postoperative parathyroid function were compared. Administration of the activated carbon nanoparticle lymphatic tracer did not affect the frequency of recovered lymph nodes containing metastases; however, it did significantly reduce the incidence of permanent and transient hypoparathyroidism from 2 to 0 and 18 to 6, and reduced the mean recovery time for transient hypoparathyroidism from 57.0 days to 22.3 days. Administration of activated carbon nanoparticles to the contralateral thyroid after intraoperative cryosections did not contribute to lymphadenectomy for papillary thyroid non-microcarcinoma, but significantly protected parathyroid functions. This approach could decrease the morbidity of radical thyroidectomy and the occurrence of hypoparathyroidism.
Background: Mini-laparoscopy, or needlescopy, is an emerging minimally invasive technique that aims to improve on standard laparoscopy in the areas of tissue trauma, pain, and cosmesis. The objective of this study was to determine if there was a difference in functionality between 2 novel mini-laparoscopic instruments when compared to standard laparoscopic tools. Differences were assessed in a simulated surgical environment. Methods: Twenty participants (5 novices, 10 intermediate, 5 expert) were recruited for this institutional review board–approved study in a surgical simulation training center. Group A tools were assembled intracorporeally, and Group B tools were assembled extracorporeally. Using standard laparoscopic graspers, mini-laparoscopic graspers, or a combination of both, each participant performed 3 basic laparoscopic training tasks: a Peg Transfer, Rubber Band Stretch, and Tootsie Roll Unwrapping. Following each round of tasks, participants completed a survey evaluating the mini-laparoscopic graspers with respect to standard laparoscopic graspers. Data were analyzed using Kruskal-Wallis test with Dunn’s test for post hoc comparisons. Results: When comparing task times, both mini tools performed at the level of standard laparoscopic graspers in all participant groups. Group A tools were quicker to assemble and disassemble versus Group B tools. According to posttask surveys, all participant groups indicated that both sets of mini-laparoscopic graspers were comparable to the standard graspers. Conclusion: In a nonclinical setting, mini-laparoscopic instruments perform at the level of standard laparoscopic tools. Based on these results, clinical trials would be a reasonable next step in assessing feasibility and safety.
Background. Complex procedures often have numerous acceptable approaches; it is unclear how surgical fellows choose between techniques. We used pancreaticoduodenectomy as a model to catalogue variability between surgeons and investigate factors that affect fellows’ acquisition of techniques. Materials and methods. Semistructured interviews and operative note analysis were conducted to determine techniques of 5 attending surgeons, and these data were mapped to identify variations. Identical interviews and questioning were completed with 4 fellowship graduates whose practice includes pancreaticoduodenectomy. Results. All surgeons performed a different operation, both in order and techniques employed. Based on minor variations, there were 21 surgical step data points that differed. Of 5 surgeons, 4 were unable to identify colleagues’ techniques. Fellows reported adopting techniques from mentors who had regimented techniques, teaching styles they related to, and with whom they frequently operated. Residency training did not strongly influence their choice of technique; however, senior partners after fellowship did influence technique. Conclusions. The number of variants of pancreaticoduodenectomy based on granular, step-by-step differences is larger than previously described. Results hint that variation may be furthered by the fact that surgeons are not aware of the techniques used by colleagues. Fellows choose techniques based on factors not directly related to their own outcomes but rather mentor factors. Whether fellows adopt techniques that will be optimal given their abilities is worthy of further investigation, as are changes in technique over time. Better codification of variation is needed to facilitate these investigations as well as matching of technical variations to patient outcomes.
Background. Preoperative localization of the parathyroid gland prior to a minimally invasive parathyroidectomy (MIP) is important because of varying locations of the parathyroid gland. Several methods have been described to localize the affected gland. One novel technique is the use of an iodine 125 (I-125) seed as a marker. The aim of this study is to evaluate the feasibility of using an I-125 seed in localizing the diseased parathyroid gland prior to MIP. Materials and methods. This is a pilot study of 10 patients performed in the Amphia Hospital, the Netherlands. Patients in whom primary hyperparathyroidism (PHPT) was diagnosed in combination with 1 enlarged parathyroid gland on ultrasound (US) and scintigraphy and who were eligible for MIP were included in this study. These patients underwent a preoperative US-guided I-125 seed placement in the affected parathyroid gland. The main study parameters were the feasibility of the placement, intraoperative localization of the diseased gland and complications. Results. A total of 10 patients were included. The US-guided I-125 placement in the affected parathyroid gland was technically feasible in the majority of cases. Because of the anatomical location of the gland, the placement was difficult in 2 patients, resulting in suboptimal position and possible misplacement of the marker. MIP was uncomplicated in most cases. Complications during surgery were mainly intraoperative bleeding. Conclusions. The use of an I-125 seed for preoperative localization in PHPT is a relatively safe technique in parathyroid surgery. More research is needed to compare this technique with other preoperative localization techniques.
Background. Existing nonsurgical procedures for the treatment of grade I and II internal hemorrhoids are often painful, technically demanding, and often necessitate multiple applications. This study prospectively assessed the safety and efficacy of the HET Bipolar System, a novel minimally invasive device, in the treatment of symptomatic grade I and II internal hemorrhoids. Methods. Patients with symptomatic grade I or II internal hemorrhoids despite medical management underwent hemorrhoidal ligation with the HET Bipolar System. Endpoints included resolution or improvement of hemorrhoidal bleeding and/or prolapse from baseline, recurrent or refractory symptoms, and pain. Results. Twenty patients were treated with the HET Bipolar System. Two were lost to follow-up. Refractory or recurrent bleeding was present in 8 of 18 (44.4%), 4 of 11 (36.4%), and 4 of 8 (50.0%) patients, and prolapse was reported by 1 of 18 (5.6%), 4 of 11 (36.4%), and 1/7 (14.3%) of patients at 1, 3, and 6 months, respectively. Bleeding improved from baseline in 88.2%, 81.8%, and 87.5% of patients, and resolution of baseline prolapse was seen in 11 of 11 (100%), 4 of 7 (57.1%), and 5 of 5 (100%) patients at the same intervals. Thirteen of 18 (72.2%) patients did not require additional treatment for their symptoms. Conclusions. The HET Bipolar System is safe and easy to use with short-term effectiveness comparable to that of currently used techniques for the treatment of symptomatic grade I and II internal hemorrhoids. It may be an effective alternative to rubber band ligation in patients with larger internal hemorrhoids and those with hemorrhoids close to the dentate line in which banding may produce debilitating pain.
Purpose. The purpose of this study is to examine the activity of collagenase from cultures of Vibrio alginolyticus as in vitro as in biological samples and to evaluate clinical perspectives of this product about the treatment of fibroproliferative diseases like Dupuytren’s contracture. Methods. The experimental part of the study has been divided in 2 stages. In the first stage, the collagenase has been produced in laboratory, assessing its purity, verifying the in vitro degradation of collagen by the enzyme and measuring the size of the fragments; in the second part, an experimental injection into samples of fibrous cord typical of Dupuytren’s disease has been performed in vitro. For the injection we used only collagenase, or collagenase after having subjected them to 2 types of mechanical stress or a collagenase combined with ethylenediamine tetra-acetic acid. Considering that the human samples have been treated in vitro, our institution does not require a specific informed consent. Results. It appeared evident that the collagenase obtained from Vibrio alginolyticus (nonpathogenic bacterium) is highly pure (>98%) and does not contain nonspecific protease. The collagenase from Vibrio alginolyticus therefore has an excellent degradative capacity against the collagen and this activity takes on a dose- and time-dependent behavior. The collagenase from Vibrio alginolyticus does not act negatively on cell survival and collagen peptides obtained may provide a better proliferative stimulus compared to controls. Conclusions. The collagenase from Vibrio alginolyticus, given its obvious ability in vitro and biological samples, could be an option in the nonsurgical treatment of Dupuytren’s disease. Level of evidence. Level III, therapeutic.
Introduction. Our nation suffers from a shortage in surgeons. This deficiency must be addressed at the medical student level. Increasing faculty and resident interaction with junior students augments surgical interest. Our surgical interest group has recently redefined its role to address these concerns. Methods. A multifocal approach has been implemented to increase interest in the surgical specialties. Each academic year, senior students recruit first and second year students to our group to establish early exposure. Members receive didactic presentations from surgical faculty, addressing various topics, on a biweekly basis. In addition, scrubbing, knot-tying, and suturing workshops address technical skills throughout the semester. Membership and match data were collated and analyzed. Results. Over the past 5 years, the enrollment in the student interest group increased significantly from 112 to 150. Accordingly, we have observed a parallel increase in the number of students who have successfully matched into surgical residencies. A record number of students (37) from the class of 2013 matched into surgical specialties, representing an 85% increase over the last decade. After creating bylaws and electing societal officers, the group has been recognized by the school’s Student Council and given financial support. At present, the group is fiscally solvent with support from the institution, surgery department, and faculty. Conclusion. As the demand for surgeons increases so too does the need to increase student interest in surgery. Our school has been successful because of our surgical interest group, and we encourage other schools to adopt a similar approach.
Background. After initial enthusiasm in the use of a dedicated curved stapler (CCS-30 Contour Transtar) to perform stapled transanal rectal resection (STARR) for obstructed defecation syndrome (ODS), difficulties have emerged in this surgical technique. Objective. First, to compare surgeons’ perception of difficulties of STARR performed with only Transtar versus STARR performed with the combined use of linear staplers and Transtar to cure ODS associated with large internal prolapse and rectocele; second, to compare the postoperative incidence of the urge to defecate between the 2 STARR procedures. Design and Setting. An Italian multicenter randomized trial involving 25 centers of colorectal surgery. Patients. Patients with obstructed defecation syndrome and rectocele or rectal intussusception, treated between January and December 2012. Interventions. Participants were randomly assigned to undergo STARR with a curved alone stapler (CAS group) or with the combined use of linear and curved staplers (LCS group). Main Outcome Measures. Primary end-points were the evaluation of surgeons’ perception of difficulties score and the incidence of the "urge to defecate" at 3-month follow up. Secondary end-points included duration of hospital stay, rates of early and late complications, incidence of "urge to defecate" at 6 and 12 months, success of the procedures at 12 months of follow-up. Results. Of 771 patients evaluated, 270 patients (35%) satisfied the criteria. Follow-up data were available for 254 patients: 128 patients (114 women) in the CAS group (mean age, 52.1; range, 39-70 years) and 126 (116 women) in LCS group (mean age, 50.7 years; range, 41-75 years). The mean surgeons’ perception score, was 15.36 (SD, 3.93) in the CAS group and 12.26 (SD, 4.22) in the LCS group (P < .0001; 2-sample t test). At 3-month follow-up, urge to defecate was observed in 18 (14.6%) CAS group patients and in 13 (10.7%) LCS group patients (P = .34; Fisher’s exact test). These values drastically decrease at 6 months until no urge to defecate in all patients at 12 months was observed. At 12-month follow-up, a successful outcome was achieved in 100 (78.1%) CAS group patients and in 105 (83.3%) LCS group patients (P = .34; Fisher’s exact test). No significant differences between groups were observed in the hospital stay and rates of early or late complications occurring after STARR. Conclusions. STARR with Transtar associated with prior decomposition of prolapse, using linear staplers, seems to be less difficult than that without decomposition. Both procedures appear to be safe and effective in the treatment of obstructed defecation syndrome resulting in similar success rates and complications.
Purpose. To evaluate effectiveness of a novel hemostatic dissection tool in patients with congenital heart disease undergoing redo pericardiac dissections. Description. This dissection tool employs ferromagnetic energy to cut and coagulate. The unit passes no electric current through the patient, thus eliminating cautery-induced dysrhythmias and electrical interference. Ferromagnetic dissection is precise and reduces thermal injury spread by as much as 90%. Evaluation. We case matched 22 patients undergoing reoperation for congenital heart surgery by weight/operation. Group 1 used the ferromagnetic tool, and Group 2 used conventional monopolar cautery for pericardiac dissection. For groups 1 and 2, the mean weight was 27.7 and 28.4, respectively (P = .87). Time (minutes) from skin incision to cardiopulmonary bypass was 71 versus 72 (P = .44), cardiopulmonary bypass (minutes) was 75.6 versus 73.6 (P = .42), total operative time (minutes) was 193 versus 201 (P = .34). Chest tube output/kilogram in first 6 and first 24 hours was 0.4 versus 1.3 (P = .02) and 0.8 versus 2.4 (P = .01) for groups 1 and 2, respectively. Re-exploration for bleeding was 0% versus 9% (P = .07). There was no mortality. Conclusion. The ferromagnetic dissection system appears safe and efficacious. Bleeding was significantly decreased and the need for re-exploration reduced.
Background. Robotic-assisted radical cystectomy (RARC) is gaining traction as a surgical approach, but there are limited data on patient-reported outcomes for this technique compared to open radical cystectomy (ORC). Objective. To compare health-related quality of life (HRQoL) and short-term convalescence among bladder cancer patients who underwent ORC and RARC. Methods. Review of a single-institution bladder cancer database was conducted. Baseline and postoperative HRQoL was evaluated using the Bladder Cancer Index (BCI) for 324 patients who had ORC (n = 267) or RARC (n = 57) between 2008 and 2012. The BCI assesses function and bother in urinary, bowel, and sexual domains. Among 87 distinct patients (ORC n = 67, RARC n = 20), we also evaluated short-term postoperative convalescence using the Convalescence and Recovery Evaluation (CARE) questionnaire. Our primary outcomes were HRQoL within 12 months and short-term convalescence within 6 weeks following cystectomy. We fit generalized estimating equation regression models to estimate longitudinal changes in BCI scores within domains, and CARE domain score differences were tested with Wilcoxon rank-sum tests. Results. Clinical characteristics and baseline BCI/CARE scores were similar between the 2 groups (all P > .05). Within 1 year after surgery, recovery of HRQoL across all BCI domains was comparable, with scores nearly returning to baseline at 1 year for all patients. CARE scores at 4 weeks revealed that patients treated with ORC had better pain (29.1 vs 20.0, P = .02) domain scores compared to RARC. These differences abated by week 6. Conclusions. HRQoL recovery and short-term convalescence were similar in this cohort following ORC and RARC.
Background. Despite meticulous aseptic technique and systemic antibiotics, bacterial colonization of mesh remains a critical issue in hernia repair. A novel minocycline/rifampin tyrosine–coated, noncrosslinked porcine acellular dermal matrix (XenMatrix AB) was developed to protect the device from microbial colonization for up to 7 days. The objective of this study was to evaluate the in vitro and in vivo antimicrobial efficacy of this device against clinically isolated methicillin-resistant Staphylococcus aureus (MRSA) and Escherichia coli. Methods. XenMatrix AB was compared with 5 existing uncoated soft tissue repair devices using in vitro methods of zone of inhibition (ZOI) and scanning electron microscopy (SEM) at 24 hours following inoculation with MRSA or E coli. These devices were also evaluated at 7 days following dorsal implantation and inoculation with MRSA or E coli (60 male New Zealand white rabbits, n = 10 per group) for viable colony-forming units (CFU), abscess formation and histopathologic response, respectively. Results. In vitro studies demonstrated a median ZOI of 36 mm for MRSA and 16 mm for E coli for XenMatrix AB, while all uncoated devices showed no inhibition of bacterial growth (0 mm). SEM also demonstrated no visual evidence of MRSA or E coli colonization on the surface of XenMatrix AB compared with colonization of all other uncoated devices. In vivo XenMatrix AB demonstrated complete inhibition of bacterial colonization, no abscess formation, and a reduced inflammatory response compared with uncoated devices. Conclusion. We demonstrated that XenMatrix AB possesses potent in vitro and in vivo antimicrobial efficacy against clinically isolated MRSA and E coli compared with uncoated devices.
With advancements in imaging techniques, neurosurgical procedures are becoming highly precise and minimally invasive, thus demanding development of new ergonomically aesthetic instruments. Conventionally, neurosurgical instruments are manufactured using subtractive manufacturing methods. Such a process is complex, time-consuming, and impractical for prototype development and validation of new designs. Therefore, an alternative design process has been used utilizing blue light scanning, computer-aided designing, and additive manufacturing direct metal laser sintering (DMLS) for microsurgical instrument prototype development. Deviations of DMLS-fabricated instrument were studied by superimposing scan data of fabricated instrument with the computer-aided designing model. Content and concurrent validity of the fabricated prototypes was done by a group of 15 neurosurgeons by performing sciatic nerve anastomosis in small laboratory animals. Comparative scoring was obtained for the control and study instrument. T test was applied to the individual parameters and P values for force (P < .0001) and surface roughness (P < .01) were found to be statistically significant. These 2 parameters were further analyzed using objective measures. Results depicts that additive manufacturing by DMLS provides an effective method for prototype development. However, direct application of these additive-manufactured instruments in the operating room requires further validation.
Background. Google Glass has been used in a variety of medical settings with promising results. We explored the use and potential value of an asynchronous, near-real time protocol—which avoids transmission issues associated with real-time applications—for recording, uploading, and viewing of high-definition (HD) visual media in the emergency department (ED) to facilitate remote surgical consults. Study Design. First-responder physician assistants captured pertinent aspects of the physical examination and diagnostic imaging using Google Glass’ HD video or high-resolution photographs. This visual media were then securely uploaded to the study website. The surgical consultation then proceeded over the phone in the usual fashion and a clinical decision was made. The surgeon then accessed the study website to review the uploaded video. This was followed by a questionnaire regarding how the additional data impacted the consultation. Results. The management plan changed in 24% (11) of cases after surgeons viewed the video. Five of these plans involved decision making regarding operative intervention. Although surgeons were generally confident in their initial management plan, confidence scores increased further in 44% (20) of cases. In addition, we surveyed 276 ED patients on their opinions regarding concerning the practice of health care providers wearing and using recording devices in the ED. The survey results revealed that the majority of patients are amenable to the addition of wearable technology with video functionality to their care. Conclusions. This study demonstrates the potential value of a medically dedicated, hands-free, HD recording device with internet connectivity in facilitating remote surgical consultation.
Background. Robotic-assisted surgery has potential benefits over laparoscopy yet little has been published on the integration of this platform into complex surgical oncology. We describe the outcomes associated with integration of robotics into a large surgical oncology program, focusing on metrics of safety and efficiency. Methods. A retrospective review of a prospectively maintained database of robotic procedures from July 2009 to October 2014 identifying trends in volume, operative time, complications, conversion to open, and 90-day mortality. Results. Fourteen surgeons performed 1236 cases during the study period: thyroid (246), pancreas/duodenum (458), liver (157), stomach (56), colorectal (129), adrenal (38), cholecystectomy (102), and other (48). There were 38 conversions to open (3.1%), 230 complications (18.6%), and 13 mortalities (1.1%). From 2009 to 2014, operative volume increased (7 cases/month vs 24 cases/month; P < .001) and procedure time decreased (471 ± 166 vs 211 ± 140 minutes; P < .001) with statistically significant decreases for all years except 2014 when volume and time plateaued. Conversion to open decreased (12.1% vs 1.7%; P = .009) and complications decreased (48.5% vs 12.3%; P < .001) despite increasing complexity of cases performed. There were 13 deaths within 90 days (5/13 30-day mortality) and 2 (15.4%) were from palliative surgeries. Conclusions. Implementation of a diverse robotic surgical oncology program utilizing multiple surgeons is safe and feasible. As operative volume increased, operative time, complications, and conversions to open decreased and plateaued at approximately 3 years. No unanticipated adverse events attributable to the introduction of this platform were observed.
Introduction.The surgical treatment of the acute neonatal abdomen still poses a challenge in pediatric surgery. Various underlying etiologies require different surgical procedures. Until today the role of laparoscopy in the surgical treatment of the acute neonatal abdomen is controversial. The aim of this study was to analyze our experiences with laparoscopy and to perform a review of the literature. Methods. Retrospective, single-institution study including all term and preterm neonates initially undergoing laparoscopy due to an acute abdomen. Results. Altogether, 17 neonates presenting with an acute neonatal abdomen initially underwent laparoscopy. Unnecessary laparotomy could be avoided in 9 of 17 (53%) neonates. After diagnostic laparoscopy, 2 patients did not require any further surgical intervention. Eight neonates presented midgut atresia intraoperatively, 5 of them underwent laparoscopic-assisted correction. Successful laparoscopic derotation of an acute volvulus (n = 1) and laparoscopic appendectomy (n = 1) could be performed. Conversion to open surgery was necessary in 8 neonates (47%) due to creation of a stoma (n = 5), multiple intestinal bands causing poor visualization (n = 2), and bowel necrosis (n = 1). Conclusions. Laparoscopy is a useful diagnostic tool to evaluate the need for further surgical intervention in the acute neonatal abdomen and enables immediate surgical treatment of acute volvulus, appendicitis, or intestinal atresia. In case of conversion to laparotomy, precise localization of the incision is guaranteed. Minimization of the surgical trauma and avoidance of unnecessary laparotomy are the most important benefits of the minimal-invasive approach for the critically ill neonate.
Background. Abdominoplasty is considered an operation linked to a considerable rate of morbidity. The convenience of simultaneously performing an incisional hernia repair and an abdominoplasty remains controversial. Methods. A total of 111 patients were randomized prospectively to compare isolated incisional hernia repair and hernia repair when combined with abdominoplasty. Primary end points were in-hospital stay and early morbidity. Secondary end points were late morbidity, recurrences, and quality of life. Patients were followed-up for 24 months. Results. Duration of the surgical procedure differed significantly between both groups (39 vs 85 minutes, P < .001) and postoperative hospital stay (2.5 vs 3.5 days; P < .001). No statistically significant differences in early or late morbidity between both groups were detected. The perceived quality of life for patients was higher in the combined surgery group (P < .001) that in the isolated hernia repair group. Conclusions. Postoperative in-hospital stay and early and late morbidity do not differ significantly between isolated incisional hernia repair and simultaneous hernia repair with abdominoplasty, but associated abdominoplasty provides a higher quality of life when indicated.
Background. Sampling of submucosal lesions in the gastrointestinal tract through a flexible endoscope is a well-recognized clinical problem. One technique often used is endoscopic ultrasound-guided fine-needle aspiration, but it does not provide solid tissue biopsies with preserved architecture for histopathological evaluation. To obtain solid tissue biopsies from submucosal lesions, we have constructed a new endoscopic biopsy tool and compared it in a crossover study with the standard double cupped forceps. Methods. Ten patients with endoscopically verified submucosal lesions were sampled. The endoscopist selected the position for the biopsies and used the instrument selected by randomization. After a biopsy was harvested, the endoscopist chose the next site for a biopsy and again used the instrument picked by randomization. A total of 6 biopsies, 3 with the forceps and 3 with the drill instrument, were collected in every patient. Results. The drill instrument resulted in larger total size biopsies (mm2; Mann-Whitney U test, P = .048) and larger submucosal part (%) of the biopsies (Mann-Whitney U test, P = .003) than the forceps. Two patients were observed because of chest pain and suspicion of bleeding in 24 hours. No therapeutic measures were necessary to be taken. Conclusion. The new drill instrument for flexible endoscopy can safely deliver submucosal tissue samples from submucosal lesions in the upper gastrointestinal tract.
Introduction. Analysis of force application in laparoscopic surgery is critical to understanding the nature of the tool-tissue interaction. The aim of this study is to provide real-time data about manipulations to abdominal organs. Methods. An instrumented short fenestrated grasper was used in an in vivo porcine model, measuring force at the grasper handle. Grasping force and duration over 5 small bowel manipulation tasks were analyzed. Forces required to retract gallbladder, bladder, small bowel, large bowel, and rectum were measured over 30 seconds. Four parameters were calculated—T(hold), the grasp time; T(close), time taken for the jaws to close; F(max), maximum force reached; and F(rms), root mean square force (representing the average force across the grasp time). Results. Mean F(max) to manipulate the small bowel was 20.5 N (±7.2) and F(rms) was 13.7 N (±5.4). Mean T(close) was 0.52 seconds (±0.26) and T(hold) was 3.87 seconds (±1.5). In individual organs, mean F(max) was 49 N (±15) to manipulate the rectum and 59 N (±13.4) for the colon. The mean F(max) for bladder and gallbladder retraction was 28.8 N (±7.4) and 50.7 N (±3.8), respectively. All organs exhibited force relaxation, the F(rms) reduced to below 25 N for all organs except the small bowel, with a mean F(rms) of less than 10 N. Conclusion. This study has commenced the process of quantifying tool-tissue interaction. The static measurements discussed here should evolve to include dynamic measurements such as shear, torque, and retraction forces, and be correlated with evidence of histological damage to tissue.
Transanal, hybrid natural orifice translumenal endoscopic surgery (NOTES) and NOTES-assisted natural orifice specimen extraction techniques hold promise as leaders in the field of natural orifice surgery. We report the feasibility of a novel NOTES assisted technique for unlimited length, clean, endolumenal proctocolectomy in a porcine model. This technique is a modification of a transanal intussusception and pull-through procedure recently published by our group. Rectal mobilization was achieved laparoscopically; this was followed by a transanal recto-rectal intussusception and pull-through (IPT). IPT was established in a stepwise fashion. First, the proximal margin of resection was attached laparoscopically to the shaft of the anvil of an end-to-end circular stapler with a ligature around the rectum. Second, this complex was pulled transanally to produce IPT. To achieve an unlimited-length proctocolectomy, the IPT step was repeated several times prior to bowel resection. This was facilitated by removing the ligature applied in the first step of this procedure. Once sequential IPT established the desired length of bowel to be resected, a second ligature was placed around the rectum approximating the proximal and distal resection margins. The specimen was resected and extracted by making a full-thickness incision through the 2 bowel walls. The anastomosis was achieved by deploying the stapler. The technique was found to be feasible. Peritoneal samples, collected after transanal specimen extraction, did not demonstrate bacterial growth. The minimally invasive nature of this evolving technique as well as its aseptic bowel manipulation has the potential to limit the complications associated with abdominal wall incision and surgical site infection.
Recent evidence suggests surgical quality may be demonstrated and evaluated using video capture during surgery. Operative video documentation may also aid in quality improvement initiatives. We discuss how operative video has the potential to help improve patient outcomes and increase professional accountability, patient safety, and surgical quality.
Background. The use of sealing devices has been established in thyroid surgeries. Recently, LigaSure Small Jaw (LS), a new device that utilizes bipolar energy, was approved by the Food and Drug Administration for use in different head and neck procedures. The purpose of this study is to assess the efficiency and safety of LS use in thyroid surgery compared to Harmonic Focus Scalpel (HS), a well-established device. Methods. A prospective study was conducted to compare the efficacy of LS versus the HS. We evaluated 301 patients who underwent surgery at a North American academic institution. Patients were allocated into two groups according to LS or HS use. All patients underwent vocal cord assessment using direct laryngoscopy preoperatively and postoperatively. Analyses were performed to examine the difference in perioperative outcomes resulting from the utilization of either device. Results. No difference was seen in operative time between both groups (124.20 ± 68.44 minutes in HS vs 125.20 ± 72.13 minutes in LS, P = .99). Overall complications were similar between both groups (22.86% in HS vs 13.84% in LS, P = .05). However, LS use was also associated with a lower incidence of postoperative transient hypocalcemia as compared to the HS (P = .025). No significant difference was found between both groups regarding the incidence of recurrent laryngeal nerve injury (P = .52). Conclusion. The use of the LS is safe, feasible, and is associated with comparable outcomes to HS. Both intraoperative and postoperative variables were similar between both devices. Future larger studies are warranted to further investigate the effect on postoperative transient hypocalcemia.
Minimally invasive surgery (MIS) poses visual challenges to the surgeons. In MIS, binocular disparity is not freely available for surgeons, who are required to mentally rebuild the 3-dimensional (3D) patient anatomy from a limited number of monoscopic visual cues. The insufficient depth cues from the MIS environment could cause surgeons to misjudge spatial depth, which could lead to performance errors thus jeopardizing patient safety. In this article, we will first discuss the natural human depth perception by exploring the main depth cues available for surgeons in open procedures. Subsequently, we will reveal what depth cues are lost in MIS and how surgeons compensate for the incomplete depth presentation. Next, we will further expand our knowledge by exploring some of the available solutions for improving depth presentation to surgeons. Here we will review the innovative approaches (multiple 2D camera assembly, shadow introduction) and devices (3D monitors, head-mounted devices, and auto-stereoscopic monitors) for 3D image presentation from the past few years.
Background. Clinical effectiveness and safety of biological and synthetic adhesives in digestive closures have been evaluated. Their use is becoming more prevalent, as rigidity and inflexibility are its more remarkable weaknesses. However, little is known about their role in gastric and anastomotic closures. Moreover, usefulness of novel flexible types of synthetic adhesives as n-butyl-cyanoacrylate has not been assessed yet. Materials and Methods. One centimeter long gastrotomy was performed in 24 male Wistar rats, which were divided depending on the type of closure method employed: manual USP 5/0 silk interrupted suture versus sutureless closure with Histoacryl Flexible (n-butyl-cyanoacrylate with softener) or Histoacryl Double Component (n-butyl-cyanoacrylate with softener and hardener). Microscopic evaluation of the suture viability and integrity was performed, and adhesion formation during the cicatrization process were assessed. During an 8-week follow-up clinical and histopathological aspects as well as hematologic and inflammatory biomarkers were studied. Results. No differences among groups where found in any of the clinical, analytical, or histopathological issues assessed except for a higher incidence rate of adhesions in the Histoacryl Double Component group when compared with hand-sewn suture group (P = .04). Our results support experimental studies in large mammals (pigs) for further study of sutureless hollow viscera closure.
Introduction. Histological analysis of surgical specimen is the gold standard for cancer classification. In particular, frozen histological diagnosis of vague peritoneal spots or uncertain excision of tumors plays a crucial role for proceeding with or without change of the operation procedure. Confocal laser microscopy (CLM) enables in vivo and real-time high-resolution tissue analysis. To evaluate a novel technique of CLM without any fluorescent dye, this pilot ex vivo study demonstrates a CLM camera device for minimal invasive surgical approach. Methods. In 5 cases, a laparoscopic CLM camera was used for examining colon and rectum specimen. Images of nonmalignant and malignant intestinal mucosa were characterized in terms of specific signal-patterns. No fluorescent dye was used. Correlations to findings in conventional histology were systematically recorded and described. Results. Using this CLM camera device, it is possible to analyze colon specimen mucosa. Nonmalignant and malignant intestinal mucosa show specific signal patterns. Nonmalignant mucosa is defined by honeycomb structure. There is deregulated structure in colon and rectum carcinoma mucosa. The inside lumen is irregular. The radial border appears swollen with reduced contrast. Discussion. This pilot study shows that the assessment of colon mucosa with a prototype of CLM camera for minimally invasive surgical approach without any fluorescent dye is feasible. It is possible to differentiate between benign and malignant mucosa in colon specimen by easy to evaluate and reproducible parameters. These first steps of this pioneering achievement to establish CLM in minimal invasive surgical procedures show a great potential for a more reliable intraoperative evaluation of suspect foci.
Background. Patient-to-image registration is a core process of image-guided surgery (IGS) systems. We present a novel registration approach for application in laparoscopic liver surgery, which reconstructs in real time an intraoperative volume of the underlying intrahepatic vessels through an ultrasound (US) sweep process. Methods. An existing IGS system for an open liver procedure was adapted, with suitable instrument tracking for laparoscopic equipment. Registration accuracy was evaluated on a realistic phantom by computing the target registration error (TRE) for 5 intrahepatic tumors. The registration work flow was evaluated by computing the time required for performing the registration. Additionally, a scheme for intraoperative accuracy assessment by visual overlay of the US image with preoperative image data was evaluated. Results. The proposed registration method achieved an average TRE of 7.2 mm in the left lobe and 9.7 mm in the right lobe. The average time required for performing the registration was 12 minutes. A positive correlation was found between the intraoperative accuracy assessment and the obtained TREs. Conclusions. The registration accuracy of the proposed method is adequate for laparoscopic intrahepatic tumor targeting. The presented approach is feasible and fast and may, therefore, not be disruptive to the current surgical work flow.
Recent technological advances have enabled real-time near-infrared fluorescence cholangiography (NIRFC) with indocyanine green (ICG). Whereas several studies have shown its feasibility, dosing and timing for practical use have not been optimized. We undertook a prospective study with systematic variation of dosing and timing from injection of ICG to visualization. Adult patients undergoing laparoscopic biliary and hepatic operations were enrolled. Intravenous ICG (0.02-0.25 mg/kg) was administered at times ranging from 10 to 180 minutes prior to planned visualization. The porta hepatis was examined using a dedicated laparoscopic system equipped to detect NIRFC. Quantitative analysis of intraoperative fluorescence was performed using a scoring system to identify biliary structures. A total of 37 patients were enrolled. Visualization of the extrahepatic biliary tract improved with increasing doses of ICG, with qualitative scores improving from 1.9 ± 1.2 (out of 5) with a 0.02-mg/kg dose to 3.4 ± 1.3 with a 0.25-mg/kg dose (P < .05 for 0.02 vs 0.25 mg/kg). Visualization was also significantly better with increased time after ICG administration (1.1 ± 0.3 for 10 minutes vs 3.4 ± 1.1 for 45 minutes, P < .01). Similarly, quantitative measures also improved with both dose and time. There were no complications from the administration of ICG. These results suggest that a dose of 0.25 mg/kg administered at least 45 minutes prior to visualization facilitates intraoperative anatomical identification. The dosage and timing of administration of ICG prior to intraoperative visualization are within a range where it can be administered in a practical, safe, and effective manner to allow intraoperative identification of extrahepatic biliary anatomy using NIRFC.
Background. Chyle leakage following lateral neck dissection (LND) is rare, but can induce metabolic disturbances, delay wound healing, and prolong hospitalization. n-Butyl-2-cyanoacrylate (NBCA) has been used to achieve hemostasis and seal tissues in several surgical settings. We here assessed whether application of NBCA to the thoracic duct area is effective in sealing chyle leakage. Methods. The medical records of 163 patients who underwent total thyroidectomy with unilateral LND between March 2011 and September 2012 were reviewed. NBCA was applied to 84 patients and not applied to 79. Drainage volume, duration of hospital stay, and incidence of complications were compared between the 2 groups. Results. The 2 groups were not different with regard to age, body weight, gender, primary tumor histology, and number of lateral neck nodes harvested. Mean hospital stay was significantly shorter (4.3 ± 1.8 vs 5.7 ± 3.0 days, P < .001), median total drainage volume was significantly smaller (270 mL; range: 97–931 mL vs 328 mL; range: 113–2636 mL; P < .001), and rate of chyle leakage was significantly lower (0% vs 6.3%, P = .025) in the NBCA than in the non-NBCA group. Conclusion. NBCA application to the dissected area of the thoracic duct posterior to its angle of junction with the internal jugular and subclavian veins could be safe and effective in reducing surgical complications related to chyle leakage after LND.
Purpose. This study investigates the feasibility and potential utility of head-mounted displays for real-time wireless vital sign monitoring during surgical procedures. Methods. In this randomized controlled pilot study, surgery residents (n = 14) performed simulated bedside procedures with traditional vital sign monitors and were randomized to addition of vital sign streaming to Google Glass. Time to recognition of preprogrammed vital sign deterioration and frequency of traditional monitor use was recorded. User feedback was collected by electronic survey. Results. The experimental group spent 90% less time looking away from the procedural field to view traditional monitors during bronchoscopy (P = .003), and recognized critical desaturation 8.8 seconds earlier; the experimental group spent 71% (P = .01) less time looking away from the procedural field during thoracostomy, and recognized hypotension 10.5 seconds earlier. Trends toward earlier recognition of deterioration did not reach statistical significance. The majority of participants agreed that Google Glass increases situational awareness (64%), is helpful in monitoring vitals (86%), is easy to use (93%), and has potential to improve patient safety (85%). Conclusion. In this early feasibility study, use of streaming to Google Glass significantly decreased time looking away from procedural fields and resulted in a nonsignificant trend toward earlier recognition of vital sign deterioration. Vital sign streaming with Google Glass or similar platforms is feasible and may enhance procedural situational awareness.
Introduction. Tissue dissection and vessel sealing is performed using a variety of energy sources and surgical devices. We describe the postmarketing analysis of a cordless ultrasonic dissector and vessel sealer in a series of general and gynecological procedures. Methods. Patients were prospectively screened and consented for participation. Data collected included demographics, device activations/seals and failures, and patient complications. Surgeons were surveyed following each case. Data was analyzed using standard statistical methods. Results. A total of 110 patients were consented and participated in the study. The most frequently performed procedures were bilateral salpingo-oophorectomy (n = 48) and total laparoscopic hysterectomy (n = 36). Mean age was 54.2 years and 79.2% were female. The most frequent number of device activations per case was between 26 and 50 (36.6%). Five failed seals occurred out of 4858 total estimated seals (0.11%). Failed seals were felt to be due to thickened, scarred tissue not amenable to device compression. There were no patient intraoperative complications related to the device itself. Overall, surgeons felt the device was extremely easy to use (97.6%) and no visual obstruction due to steam from the device was encountered (95%). Ninety-five percent of surgeons felt the device was beneficial for soft tissue dissection and vessel sealing. Conclusion. Sonicision is safe and effective for use in dissection of soft tissues and vessel sealing in a variety of laparoscopic and open procedures. In this study, there were no complications related to the device itself. The remarkable cordless design of this device enhances its ease of use with overall excellent effectiveness.
Background. The amount of direct hand-tool-tissue interaction and feedback in minimally invasive surgery varies from being attenuated in laparoscopy to being completely absent in robotic minimally invasive surgery. The role of haptic feedback during surgical skill acquisition and its emphasis in training have been a constant source of controversy. This review discusses the major developments in haptic simulation as they relate to surgical performance and the current research questions that remain unanswered. Search Strategy. An in-depth review of the literature was performed using PubMed. Results. A total of 198 abstracts were returned based on our search criteria. Three major areas of research were identified, including advancements in 1 of the 4 components of haptic systems, evaluating the effectiveness of haptic integration in simulators, and improvements to haptic feedback in robotic surgery. Conclusions. Force feedback is the best method for tissue identification in minimally invasive surgery and haptic feedback provides the greatest benefit to surgical novices in the early stages of their training. New technology has improved our ability to capture, playback and enhance to utility of haptic cues in simulated surgery. Future research should focus on deciphering how haptic training in surgical education can increase performance, safety, and improve training efficiency.
Objectives. Increasing number of mechanical circulatory assist devices (MCADs) are being placed in heart failure patients. Morbidity from device placement is high and the outcome of patients who require noncardiac surgery after, is unclear. As laparoscopic interventions are associated with decreased morbidity, we examined the impact of such procedures in these patients. Methods. A retrospective review was conducted on 302 patients who underwent MCAD placement from 2005 to 2012. All laparoscopic abdominal surgeries were included and impact on postoperative morbidity and mortality studied. Results. Ten out of 16 procedures were laparoscopic with 1 conversion to open. Seven patients had a HeartMate II, 2 had Total Artificial Hearts, and 1 had CentriMag. Four patients had devices for ischemic cardiomyopathy and 6 cases were emergent. Surgeries included 6 laparoscopic cholecystectomies, 2 exploratory laparoscopies, 1 laparoscopic colostomy takedown, and 1 laparoscopic ventral hernia repair with mesh. Median age of the patients was 63 years (range, 29-79 years). Median operative time was 123 minutes (range, 30-380 minutes). Five of 10 patients were on preoperative anticoagulation with average intraoperative blood loss of 150 mL (range, 20-700 mL). There were 3 postoperative complications; acute respiratory failure, acute kidney injury and multisystem organ failure resulting in death not related to the surgical procedure. Conclusion. The need for noncardiac surgery in post-MCAD patients is increasing due to limited donors and due to more durable and longer support from newer generation assist devices. While surgery should be approached with caution in this high-risk group, laparoscopic surgery appears to be a safe and successful treatment option.
Suturing is one of the more tiresome and difficult tasks during laparoscopic surgeries. To cope with this problem, we aimed to develop a novel successive suturing device. A novel needle holding and locking mechanism is proposed to transfer the needle between the upper and bottom jaws. The device is straightforward to use with intuitive 2-trigger control, and it can perform successive suturing without the need of reload between stiches. Also, it is compact enough to be inserted through a 12-mm trocar. The feasibility of the device is verified through in vitro and in vivo experiments. It was found that the developed device was able to successfully close the wounds without any leakage. The developed successive suturing device offers an easy way of performing suture, and it will greatly help surgeons during laparoscopic surgeries.
Objective. We aim to evaluate the technique of identifying parathyroid glands with carbon nanoparticle suspension (CNPS) in thyroid surgeries from the perspectives of degrees of declining intact parathyroid hormone (iPTH), operation time, and time of postoperative stay. Methods. A total of 156 patients who underwent thyroid surgeries in General Surgical Department of Xiangya Hospital between May 2012 and May 2015 were involved in the study. A total of 78 patients were injected with CNPS during the surgery (CNPS group); the other 78 patients received normal saline (control group). Cases were classified into 3 surgical approaches: conventional partial thyroidectomy, conventional total thyroidectomy, and endoscopic partial thyroidectomy. Degrees of declining iPTH were tested to determine the severity of parathyroid injury. Operation time and postoperative hospital stay time were recorded. A P value of less than .05 was considered statistically significant. Results. For levels of declining iPTH, there was no statistically significant (ss) difference in conventional thyroid surgery. In endoscopic partial thyroidectomy, it was 23.37 ± 16.20 versus 11.94 ± 11.23 pg/mL (P = .02, ss). The operation time of conventional total thyroidectomy was 210.10 ± 83.75 versus 164.84 ± 69.22 minutes (P = .03, ss), while it was 193.04 ± 75.53 versus 127.67 ± 60.06 minutes (P = .007, ss) in endoscopic thyroidectomy. Conclusions. CNPS is not beneficial for protecting the function of parathyroid gland in thyroid surgery from the perspective of declining iPTH. Applying CNPS in conventional total thyroidectomy and endoscopic partial thyroidectomy will also lead to significantly prolonged operation time.
Background. Minimally invasive approach has gained interest in the treatment of patients with colorectal cancer. The purpose of this study is to analyze the differences between laparoscopy and robotics for colorectal cancer in terms of oncologic and clinical outcomes in an initial experience of a single center. Materials and Methods. Clinico-pathological data of 100 patients surgically treated for colorectal cancer from March 2008 to April 2014 with laparoscopy and robotics were analyzed. The procedures were right colonic, left colonic, and rectal resections. A comparison between the laparoscopic and robotic resections was made and an analysis of the first and the last procedures in the 2 groups was performed. Results. Forty-two patients underwent robotic resection and 58 underwent laparoscopic resection. The postoperative mortality was 1%. The number of harvested lymph nodes was higher in robotics. The conversion rate was 7.1% for robotics and 3.4% for laparoscopy. The operative time was lower in laparoscopy for all the procedures. No differences were found between the first and the last procedures in the 2 groups. Conclusions. This initial experience has shown that robotic surgery for the treatment of colorectal adenocarcinoma is a feasible and safe procedure in terms of oncologic and clinical outcomes, although an appropriate learning curve is necessary. Further investigation is needed to demonstrate real advantages of robotics over laparoscopy.
Background. The sentinel lymph node (SLN) concept might minimize surgical aggressiveness in cervical and endometrial malignancies. The aim of the study was to test the feasibility and reliability of minilaparoscopic extraperitoneal SLN excision after indocyanine green (ICG) cervical injection using a high-definition near infrared (NIR) imaging system in an in vivo porcine model. The same procedure was performed using conventional laparoscopic instruments and both outcomes were compared. Methods. Twenty-four animals were equally and randomly divided into a minilaparoscopic group (group A) and a 5-mm conventional laparoscopic group (group B). A high-definition NIR imaging system and a 30° ICG endoscope were used. First, ICG (0.5 mL) was injected in the paracervical region. The SLN coloring time was recorded. An extraperitoneal approach to the SLN was executed with the same CO2 retropneumoperitoneum pressures (10 mm Hg). In both groups, the times for SLN localization and excision, as well as complications, were registered. Finally, a laparotomy was then done to evaluate whether any stained SLN still remained. The same surgical team performed all experiments. Results. SLNs were identified and extraperitoneally excised in all animals without major complications. The SLN localization varied between animals from external iliac to preaortic regions. The surgical times were shorter with minilaparoscopy (39.3 ± 13 minutes) than with conventional 5-mm instruments (51.3 ± 14.17 minutes; P = .042). In group B, one stained SLN remained and was only detected by laparotomy. Conclusions. We confirmed the feasibility and reliability of extraperitoneal minilaparoscopic approach for identification, dissection, and excision of SLN using an NIR imaging system and ICG.
Objective. The aim of this study was to investigate the feasibility and future clinical applications of near-infrared (NIR) fluorescence imaging to guide liver resection surgery for metastatic cancer to improve resection margins. Summary Background Data. A subset of patients with metastatic hepatic tumors can be cured by surgery. The degree of long-term and disease-free survival is related to the quality of surgery, with the best resection defined as "R0" (complete removal of all tumor cells, as evidenced by microscopic examination of the margins). Although intraoperative ultrasonography can evaluate the surgical margins, surgeons need a new tool to perfect the surgical outcome. Methods. A preliminary study was performed on 3 patients. We used NIR imaging postoperatively "ex vivo" on the resected liver tissue. The liver tumors were preoperatively labelled by intravenously injecting the patient with indocyanine green (ICG), a NIR fluorescent agent (24 hours before surgery, 0.25 mg/kg). Fluorescent images were obtained using a miniaturized fluorescence imaging system (FluoStic, Fluoptics, Grenoble, France). Results. After liver resection, the surgical specimens from each patient were sliced into 10-mm sections in the operating room and analyzed with the FluoStic. All metastatic tumors presented rim-type fluorescence. Two specimens had incomplete rim fluorescence. The pathologist confirmed the presence of R1 margins (microscopic residual resection), even though the ultrasonographic analysis indicated that the result was R0. Conclusions. Surgical liver resection guided by NIR fluorescence can help detect potentially uncertain anatomical areas that may be missed by preoperative imaging and by ultrasonography during surgery. These preliminary results will need to be confirmed in a larger prospective patient series.
We performed an observational longitudinal cohort study on patients affected by stress urinary incontinence (SUI) and surgically treated with a transobturator adjustable tape sling (TOA) in order to evaluate this surgical procedure in terms of efficacy, safety, quality of life (QoL) improvement, and patient satisfaction. For all patients, we recorded: general features, preoperative SUI risk factors, obstetrics history, preoperative urodynamic tests, intraoperative/postoperative complications, number of postoperative sling regulations, postmicturition residue, and hospital stay. All patients were asked to complete the validated short version of the Urogenital Distress Inventory (UDI-6) questionnaire 18 months after discharge to evaluate the efficacy of the TOA system. We added 2 adjunctive items to the UDI-6 in order to evaluate patient satisfaction and QoL. All 77 surgical procedures were performed under locoregional anesthesia without complications. Postoperative TOA regulations were performed in 46.8% of patients immediately after the procedure and in 14.3% during hospitalization. Before discharge, postmicturition residue was negative in 67 cases and less than 50 cc in 10 cases. Mean hospital stay was 2.18 days. From the questionnaire evaluation, we found that after the procedure, 90.9% of patients showed a complete regression of urinary symptoms, 1.3% obtained considerable relief from preoperative symptoms, and 6.6% reported poor or absent symptom improvements; 75.3% of patients were totally satisfied and 5.2% totally disappointed. The possibility of modulating postoperative sling tension and reusing the surgical materials in association with short hospitalization as well as high patient satisfaction render TOA a safe, effective, and low-cost technique for the treatment of female SUI.
Background. Operative hemorrhoidectomy can result in pain and altered continence from excessive excision of anoderm or surrounding tissue.. We assessed a novel low-profile slotted anoscope to determine if the device would promote safe dissection, lessen trauma, and reduce operative times for hemorrhoidectomy. Methods. Patients requiring hemorrhoidectomy (June 2008 - January 2010) underwent a prospective phase-2 trial evaluating a new operating anoscope (CAD, Ethicon Endosurgery, Cincinnati, OH). Demographics and perioperative end points including bleeding, pain, fecal incontinence, stenosis, and symptom recurrence were analyzed at 4 weeks, 3 months, 6 months, and 1 year postoperatively. We compared these to patients undergoing hemorrhoidectomy (February 2010 - November 2012) with a traditional Hill-Ferguson anoscope (THF). Results. 40 patients (CAD, 20 vs THF, 20) were included. Presenting symptoms were similar, whereas mean duration of symptoms was longer for CAD (41.2 ± 8.4 vs 27 ± 9.5 months; P < .05). Estimated blood loss was lower for CAD [8.3 mL (range = 2-40 mL) vs 11.3 mL THF (range = 5-35 mL; P = .87)]. Mean operative times were lower for the CAD than the THF group (15.6 ± 3.4 vs 26.1 ± 4.1 minutes; P < .05). Visual analog pain scores were non-significantly increased in the THF group at 4 weeks (P = .23). At 3 months, 6 months, and 1 year, there was no difference in continence. Conclusion. The CAD anoscope reduced operative times for modified Ferguson (closed) hemorrhoidectomy when compared with traditional retractors. There was no difference in incontinence or pain between groups.
Background. We examined the impact of tool complexity on surgeons’ performance and evaluated the value of using a simulation-based program for reducing training cost. Methods. Three pairs of surgical graspers with increasing mechanical complexity, which were designed for open, laparoscopic, and endoscopic procedures, were used in performing a simple object transportation task. Task times and mental workload of 17 surgeons were compared using all 3 variations of the graspers to test the impact of tool complexity on surgical performance. Subsequently, 4 of these surgeons decided to enter a 3-week training phase and practiced with these 3 surgical instruments on a daily basis. Learning curves were plotted to examine the value of using simulation for proficiency training with these tools. Results. Task time was significantly prolonged as tool complexity increased. Practice in a simulated environment shortened the task time significantly and moderately reduced mental workloads. However, the difference in task time varied among the 3 types of tools. Between days 1 and 9, task times for each types of grasper were reduced by 55% (endoscopic), 42% (open), and 22% (laparoscopic). Conclusions. Tool complexity may degrade a surgeon’s performance. Extensive simulation training programs are important for surgeons to gain proficiency in handling a tool before they practice on patients.
Introduction. Peer-to-peer learning is a well-established learning modality, which has been shown to improve learning outcomes, with positive implications for clinical practice. The purpose of this pilot study was to explore the feasibility of linking students from North America and Europe with a peer-to-peer learning approach. Methods. Face and content validity studies were completed on the previously designed and validated online repository http://www.pilgrimshospital.com. Four medical students from the University of Toronto, Canada, were paired with four students from University College Cork, Ireland. Each student was invited to upload two pieces of information learned from a senior colleague that day. Each student was asked to review the information uploaded by their partner, editing with references if needed. Quantitative and qualitative evaluations of the e-peer system were conducted. Results. Over the study period, the system recorded a total of 10 079 individual page views. Questionnaires completed by participants demonstrated that 6/8 found the system either "very easy" or "easy" to use, whereas all found that the system promoted evidenced-based and self-directed learning. Structured interviews revealed 3 main themes: The Peer Connection, Trust in Data Veracity, and Aid to Clinical Learning. Conclusion. This pilot study demonstrates it is feasible to link students from separate continents in a community of peer-to-peer learning. This is viewed positively by students and enhances evidenced-based learning, and the aspect of peer connectivity was important to participating students. Such an approach encourages peer cooperation and has the potential to disseminate key clinical learning experiences widely.
Objective. The purposes of this study were to evaluate the feasibility, safety, and advantages of nonintubated video-assisted thoracoscopic surgery (VATS) under epidural anesthesia, by comparing with the performance of conventional approaches. Patients and methods. A total of 354 patients (245 men and 109 women) were recruited in this study. The surgical procedures included bullae resection, pulmonary wedge resection, and lobectomy. The anesthetic technique (epidural vs general) was selected randomly. Patients who underwent nonintubated VATS under epidural anesthesia comprised the intervention group, and patients who received VATS under general anesthesia with double lumen tube comprised the control group. Results. In total, 167 patients were included in the intervention group, and 180 patients were included in the control group. The 2 treatment groups of bullae resection showed significant differences in postoperative fasting time, duration of postoperative antibiotic use depending on the time when the white blood cells decreased to normal levels, and duration of postoperative hospital stay (P < .05). Nonintubated VATS is associated with a decreased level of inflammatory cytokines (P < .05). Conclusion. VATS under anesthesia with nontracheal intubation is safe and feasible, and has demonstrated advantages, including shorter postoperative fasting time, shorter duration of antibiotic use, and shorter hospital stay, compared with VATS under general anesthesia with double lumen tube.
Background. Surgical trauma elicits inflammatory responses, including the secretion of cytokines. Recent studies demonstrated that beta-blockers could reduce the expression of cytokines after injury. We therefore tested the effects of different doses of intraoperative esmolol on the inflammatory response after surgery. Methods. Patients undergoing laparoscopic gastrectomy were randomly separated into 1 of 3 groups: saline, clinical dose, and subclinical dose groups. The levels of interleukin (IL)-6, IL-4, and IL-10 were quantified by sandwich enzyme-linked immunoassay after the induction of anesthesia (T0), at the end of peritoneal closure (T1), and 60 minutes after surgery (T2). Levels of C-reactive protein (CRP) were measured on postoperative day 1. Results. At T2, the levels of IL-6 and IL-10 in the saline group were elevated significantly compared with at T0 or T1 (IL-6: 119.62 and 15.97 pg/mL at T2 and T0, respectively [P = .042]; IL-10: 27.27 and 7.03 pg/mL at T2 and T1, respectively [P = .037]). However, no changes were observed over time in the clinical dose group. In contrast, postoperative levels of IL-4 were decreased significantly in the clinical dose group compared with the saline group (2.14 vs 21.91 pg/mL, P = .022). In addition, the CRP levels on postoperative day 1 were lower in the esmolol-treated groups, in a dose-dependent manner. Conclusions. Serum IL-6 and IL-10 levels were increased over time, suggesting that laparoscopic surgery is a stressor, even though it causes minimal tissue injury. Treatment with esmolol decreased the inflammatory response and CRP production in a dose-dependent manner.
Background. Operating rooms have become increasingly complex environments and more prone to errors because of loss of situation awareness. Adding computer intelligence to the operating room may help overcome these limitations particularly if the system can automatically track which step of an operation a surgeon is performing. To develop such a platform, it is necessary to track which laparoscopic instruments are being used and in which port they are inserted. This article describes the development and validation of a "Smart Trocar" that can automatically perform this function. Methods. A Smart Trocar system prototype was developed that uses a wireless camera attached to a standard laparoscopic port and custom software algorithms. The system recognizes color wheels attached to the handle of a laparoscopic instrument and compares the unique color pattern to an instrument library for proper tool identification. The system was tested for reliability in a box trainer environment using a variety of tool positions and levels of room light illumination. Results. Correct color classification was achieved in 96.7% of trials. There were no errors in detection of the color wheel in space. In addition, the distance of the color wheel from the camera did not influence results and correct classifications were evenly distributed among the 12 laparoscopic tool positions tested. Conclusion. This work describes a Smart Trocar system that identifies which laparoscopic tool is being used and in which port and proves its reliability. The system is an important element of a more comprehensive program being developed to automatically understand what step of an operation a surgeon is performing and use these data to improve situation awareness in the operating room.
Background. Modulation of the enteric nervous system seems to be promising in several functional colorectal disorders for which targeted, causal treatment methods do not exist. However, sacral nerve stimulation can induce undesirable muscle contraction or paresthesia. Therefore, we have developed a laparoscopic technique for implanting a neural electrode, placed directly over the pelvic autonomic nerve plexus. The aim of this experimental study was to evaluate the effect of stimulating the hypogastric plexus and pelvic nerves on inducing distal colon contraction, defecation, and micturition. Method. A total of 10 white, male healthy pigs (25-30 kg) were subjected to the laparoscopic implantation of the electrode and the stimulator. In the third and fourth weeks postimplantation, the efficacy of the acute and chronic stimulation to induce defecation was evaluated. Results. The average operative time was 105 minutes (85-150 minutes). In all pigs, acute stimulation activated induced defecation, every second day, every time on demand, with an average delay of 139.7 s. Micturition was induced incidentally. Acute or chronic stimulation did not cause any harm, pain, or suffering to the animals. No adverse effects of the stimulation were observed, and no septic complications or macroscopic fibrosis around the electrodes were found on autopsy. Conclusion. Hypogastric plexus stimulation can be a useful and safe option of distal colon contraction, defecation, and micturition. However, the efficacy of the stimulation was observed for a relatively short period of time, and it is not known if it will be sustained for a longer duration.
Background. Incomplete control of troublesome regurgitation and extraesophageal manifestations of chronic gastroesophageal reflux disease (GERD) is a known limitation of proton pump inhibitor (PPI) therapy. This multicenter randomized study compared the efficacy of transoral incisionless fundoplication (TIF) against PPIs in controlling these symptoms in patients with small hiatal hernias. Methods. Between June and August 2012, 63 patients were randomized at 7 US community hospitals. Patients in the PPI group were placed on maximum standard dose (MSD). Patients in the TIF group underwent esophagogastric fundoplication using the EsophyX2 device. Primary outcome was elimination of daily troublesome regurgitation or extraesophageal symptoms. Secondary outcomes were normalization of esophageal acid exposure (EAE), PPI usage and healing of esophagitis. Results. Of 63 randomized patients (40 TIF and 23 PPI), 3 were lost to follow-up leaving 39 TIF and 21 PPI patients for analysis. At 6-month follow-up, troublesome regurgitation was eliminated in 97% of TIF patients versus 50% of PPI patients, relative risk (RR) = 1.9, 95% confidence interval (CI) = 1.2-3.11 (P = .006). Globally, 62% of TIF patients experienced elimination of regurgitation and extraesophageal symptoms versus 5% of PPI patients, RR = 12.9, 95% CI = 1.9-88.9 (P = .009). EAE was normalized in 54% of TIF patients (off PPIs) versus 52% of PPI patients (on MSD), RR = 1.0, 95% CI = 0.6-1.7 (P = .914). Ninety percent of TIF patients were off PPIs. Conclusion. At 6-month follow-up, TIF was more effective than MSD PPI therapy in eliminating troublesome regurgitation and extraesophageal symptoms of GERD.
Background. Creating a surgical specialty referral center requires a strong interest, expertise, and a market demand in that particular field, as well as some form of promotion. In 2004, we established a tertiary hernia referral center. Our goal in this study was to examine its impact on institutional volume and economics. Materials and methods. The database of all hernia repairs (2004-2011) was reviewed comparing hernia repair type and volume and center financial performance. The ventral hernia repair (VHR) patient subset was further analyzed with particular attention paid to previous repairs, comorbidities, referral patterns, and the concomitant involvement of plastic surgery. Results. From 2004 to 2011, 4927 hernia repairs were performed: 39.3% inguinal, 35.5% ventral or incisional, 16.2% umbilical, 5.8% diaphragmatic, 1.6% femoral, and 1.5% other. Annual billing increased yearly from 7% to 85% and averaged 37% per year. Comparing 2004 with 2011, procedural volume increased 234%, and billing increased 713%. During that period, there was a 2.5-fold increase in open VHRs, and plastic surgeon involvement increased almost 8-fold, (P = .004). In 2005, 51 VHR patients had a previous repair, 27.0% with mesh, versus 114 previous VHR in 2011, 58.3% with mesh (P < .0001). For VHR, in-state referrals from 2004 to 2011 increased 340% while out-of-state referrals jumped 580%. In 2011, 21% of all patients had more than 4 comorbidities, significantly increased from 2004 (P = .02). Conclusion. The establishment of a tertiary, regional referral center for hernia repair has led to a substantial increase in surgical volume, complexity, referral geography, and financial benefit to the institution.
Background. Single-access laparoscopic surgery is not used routinely for the treatment of colorectal disease. The aim of this retrospective cohort study is to compare the results of single-access laparoscopic rectal resection (SALR) versus multiaccess laparoscopic rectal resection with a mean follow-up of 24 months. Methods. This retrospective cohort study enrolled 42 patients. Between January 2010 and June 2012, 21 SALRs were performed. These patients were compared with a group of 21 other patients who had undergone multiport laparoscopic rectal resection. This control group had the same exclusion criteria and patient demographics. Short-term outcomes were reassessed with a mean follow-up of 2 years. Statistical analysis included the Student t test and Fisher’s exact test. Finally, we performed a differential cost analysis between the 2 procedures. Results. Exclusion criteria, patient demographics, and indication for surgery were similar in both groups. The conversion rate was 0% in both groups. There were no intraoperative complications or deaths. Bowel recovery was similar in both groups. No interventions, readmissions, or deaths were recorded at 30 days’ follow-up. At a mean follow-up of 24 months, all the patients with a preoperative diagnosis of cancer are still alive and disease free. Considering the selected 3 items, the mean cost per patient for single-access laparoscopic surgery and multiple-access laparoscopic surgery were estimated as 7213 and 7495 Euros, respectively. Conclusion. We think that SALR could be performed in selected patients by surgeons with high multiport laparoscopic skills. It is compulsory by law to evaluate outcomes and cost-effectiveness by using randomized controlled trials.
Introduction. There are a vast array of smartphone applications that could benefit both surgeons and their patients. To review and identify all relevant surgical smartphone applications available for the Apple iPhone iOS and Google Android platform based on their user group and subspecialty for which they were designed. Method. Both the literature using PubMed and Google Scholar were searched using the following terms: application$, smartphone$, app$, app*, surgery, surgical, surg*, general surgery, general surg*, bariatric$, urology and plastic surgery, ortho*, orthop(a)edic, cardiac surgery, cardiothoracic, neurosurgery, and ophthalmology. Results. The search yielded 38 articles of which 23 were eligible. Each of the key specialties was searched in the Apple iTunes App Store for iPhone iOS and the Google Play Android application store. In total, there were 621 surgical applications for Apple iPhone iOS and 97 identified on Android’s Google Play. There has been a 9-fold increase in the number of surgical applications available for the Apple iPhone iOS from 2009 to 2012. Of these applications there were 126 dedicated to plastic surgery, 79 to orthopedics, 41 to neurosurgical, 180 to general surgery, 36 to cardiac surgery, 121 to ophthalmology, and 44 to urology. There was a wide range of applications ranging from simple flashcards to be used for revision to virtual surgery applications that provided surgical exposure and familiarization with common operative procedures. Conclusions. Despite the plethora of surgical applications available for smartphones, there is no taxonomy for medical applications. Only 12% were affiliated with an academic institution or association, which highlights the need for greater regulation of surgical applications.
Introduction. Normothermic machine perfusion (NMP) is an emerging preservation modality that holds the potential to prevent the injury associated with low temperature and to promote organ repair that follows ischemic cell damage. While several animal studies have showed its superiority over cold storage (CS), minimal studies in the literature have focused on safety, feasibility, and reliability of this technology, which represent key factors in its implementation into clinical practice. The aim of the present study is to report safety and performance data on NMP of DCD porcine livers. Materials and Methods. After 60 minutes of warm ischemia time, 20 pig livers were preserved using either NMP (n = 15; physiologic perfusion temperature) or CS group (n = 5) for a preservation time of 10 hours. Livers were then tested on a transplant simulation model for 24 hours. Machine safety was assessed by measuring system failure events, the ability to monitor perfusion parameters, sterility, and vessel integrity. The ability of the machine to preserve injured organs was assessed by liver function tests, hemodynamic parameters, and histology. Results. No system failures were recorded. Target hemodynamic parameters were easily achieved and vascular complications were not encountered. Liver function parameters as well as histology showed significant differences between the 2 groups, with NMP livers showing preserved liver function and histological architecture, while CS livers presenting postreperfusion parameters consistent with unrecoverable cell injury. Conclusion. Our study shows that NMP is safe, reliable, and provides superior graft preservation compared to CS in our DCD porcine model.
Background. Intra-abdominal abscess is a common complication in Crohn’s disease (CD). Traditional percutaneous catheter drainage (PCD) and surgical intervention could not obtain satisfactory results in some cases. We herein demonstrate a novel management option and compare it with traditional strategies. Methods. A total of 77 patients were retrospectively collected into 3 groups. Postoperative complication, postoperative recurrence of abscess, subsequent surgery, ultimate stoma creation rate, and survival rate were analyzed. Results. Patients were divided into the trocar group (n = 21), PCD group (n = 25), and surgery group (n = 31). The incidences of postoperative complication as well as the incidence of recurrent abscess were lowest in trocar group, and ultimate stoma creation rate was highest in the surgery group. Subsequent surgery after initial intervention and survival rate during the follow-up period were similar among the 3 groups. Conclusions. Trocar puncture with sump drain had lower incidence of postoperative complication, postoperative recurrence of abscess, and ultimate stoma creation compared with conventional PCD and surgical interventions. This novel technique might be an optimal option in the management of intra-abdominal abscesses in CD.
In appropriate situations, extensive decompression with laminectomy often continues to be described as the method of choice for operations involving lumbar zygoapophyseal joint (z-joint) cysts. Tissue-sparing procedures are nevertheless becoming more common. Endoscopic techniques have become the standard procedures in many areas because of the advantages they offer in terms of surgical technique and in rehabilitation. One key aspect in spinal surgery was the development of instruments for sufficient bone resection carried out under continuous visual control. This enabled endoscopes to be used when operating on z-joint cysts. The objective of this prospective study was to examine the technical possibilities for the full-endoscopic interlaminar and transforaminal technique in lumbar z-joint cysts. A total of 74 patients were followed up for 2 years. The results show that 85% of the patients no longer have any leg pain or that the pain had been almost completely eliminated, and 11 % experience occasional pain. The complication rate was low. The full-endoscopic techniques brought advantages in the following areas: operation, complications, traumatization, and rehabilitation. The recorded results show that full-endoscopic resection of a z-joint cyst using an interlaminar and transforaminal approach provides an adequate and safe supplement, and is an alternative to conventional procedures when the indication criteria are fulfilled. It also offers the advantages of a minimally invasive intervention.
Background. Time-of-flight (TOF) cameras can guide surgical robots or provide soft tissue information for augmented reality in the medical field. In this study, a method to automatically track the soft tissue envelope of a minimally invasive hip approach in a cadaver study is described. Methods. An algorithm for the TOF camera was developed and 30 measurements on 8 surgical situs (direct anterior approach) were carried out. The results were compared to a manual measurement of the soft tissue envelope. Results. The TOF camera showed an overall recognition rate of the soft tissue envelope of 75%. On comparing the results from the algorithm with the manual measurements, a significant difference was found (P > .005). Conclusions. In this preliminary study, we have presented a method for automatically recognizing the soft tissue envelope of the surgical field in a real-time application. Further improvements could result in a robotic navigation device for minimally invasive hip surgery.
Introduction. An outpatient transoral endoscopic procedure for gastroesophageal reflux disease (GERD) and obesity would be appealing if safe, effective, and durable. We present the first in human experience with a new system. Methods. Eight patients with GERD (3) and obesity (5) were selected according to a preapproved study protocol. All GERD patients had preprocedure manometry and pH monitoring to document GERD as well as quality of life and symptom questionnaires. Obese patients (body mass index >35) underwent a psychological evaluation and tests for comorbidities. Under general anesthesia, a procedure was performed at the gastroesophageal junction including mucosal excision, suturing of the excision beds for apposition, and suture knotting. Results. One patient with micrognathia could not undergo the required preprocedural passage of a 60 F dilator and was excluded. The first 2 GERD patients had incomplete procedures due to instrument malfunction. The subsequent 5 subjects had a successfully completed procedure. Four patients were treated for obesity and had an average excess weight loss of 30.3% at 2-year follow-up. Of these patients, one had an 8-mm outlet at the end of the procedure recognized on video review—a correctable error—and another vomited multiple times postoperatively and loosened the gastroplasty sutures. The treated GERD patient had resolution of reflux-related symptoms and is off all antisecretory medications at 2-year follow-up. Her DeMeester score was 8.9 at 24 months. Conclusion. The initial human clinical experience showed promising results for effective and safe GERD and obesity therapy.
Background. Precise targeting has played a pivotal role in the success of surgery for recurrent differentiated thyroid cancers (DTCs). To improve on current targeting methods, we developed a novel technique using 99mTc-macroaggregated human serum albumin and indocyanine green (TIGMA), with which surgeons effectively target lesions in real time by radiofluorescence dual guidance. Methods. Seven patients with 10 recurrent DTC lesions were retrospectively enrolled in the study. Prior to the operation, we injected TIGMA into the target lesion under the guidance of ultrasonography. Resection was concurrently monitored using a gamma probe and a specially designed near infrared fluorescence camera. Outcomes were evaluated using imaging, surgical, and pathological records. Results. In all enrolled cases, both injection of TIGMA and radiofluorescence dual guidance were well tolerated and easy to implement. The technical success rates were 100%, confirmed by final pathological examination, postoperative ultrasonography, and I-131 scan clearance. Complications such as temporary postoperative neck pain (n = 2) were minimal. Conclusions. TIGMA using radiofluorescence dual guidance facilitated the precise targeting of recurrent lesions. The entire procedure was feasible, safe, and successful. This method would help enhance surgical outcomes for recurrent DTCs.
Background/Aim: Laparoscopic cholecystectomy is currently the gold standard treatment for gallstone disease. Bile duct injury is a rare and severe complication of this procedure, with a reported incidence of 0.4% to 0.8% and is mostly a result of misperception and misinterpretation of the biliary anatomy. Robotic cholecystectomy has proven to be a safe and feasible approach. One of the latest innovations in minimally invasive technology is fluorescent imaging using indocyanine green (ICG). The aim of this study is to evaluate the efficacy of ICG and the Da Vinci Fluorescence Imaging Vision System in real-time visualization of the biliary anatomy. Methods: A total of 184 robotic cholecystectomies with ICG fluorescence cholangiography were performed between July 2011 and February 2013. All patients received a dose of 2.5 mg of ICG 45 minutes prior to the beginning of the surgical procedure. The procedures were multiport or single port depending on the case. Results: No conversions to open or laparoscopic surgery occurred in this series. The overall postoperative complication rate was 3.2%. No biliary injuries occurred. ICG fluorescence allowed visualization of at least 1 biliary structure in 99% of cases. The cystic duct, the common bile duct, and the common hepatic duct were successfully visualized with ICG in 97.8%, 96.1%, and 94% of cases, respectively. Conclusions: ICG fluorescent cholangiography during robotic cholecystectomy is a safe and effective procedure that helps real-time visualization of the biliary tree anatomy.
Additive manufacturing technologies are widely used in industrial settings and now increasingly also in several areas of medicine. Various techniques and numerous types of materials are used for these applications. There is a clear need to unify and harmonize the patterns of their use worldwide. We present a 5-class system to aid planning of these applications and related scientific work as well as communication between various actors involved in this field. An online, matrix-based platform and a database were developed for planning and documentation of various solutions. This platform will help the medical community to structurally develop both research innovations and clinical applications of additive manufacturing. The online platform can be accessed through http://www.medicalam.info.
Objective. The advantages of single-incision surgery for the treatment of gallstone disease is debated. Previous meta-analyses comparing single-incision laparoscopic cholecystectomy (SILC) and standard laparoscopic multiport cholecystectomy (SLMC) included few and underpowered trials. To overcome this limitation, we performed a meta-analysis of randomized and nonrandomized studies. Methods. A MEDLINE, EMBASE, and Cochrane Library literature search of studies published in and comparing SILC with SLMC was performed. The primary outcome was safety of SILC as measured by the overall rate of postoperative complications and biliary spillage. Feasibility was another primary outcome as measured by the conversion and operative time. Postoperative pain, length of hospital stay, perioperative blood loss, time to return to normal activity, and cosmetic satisfaction were secondary outcomes. Results. We identified 43 studies of which 30 were observational reports and 13 experimental trials, for a total of 7489 patients (2090 SILC and 5389 SLMC). The overall rate of complications was comparable between groups (relative risk [RR] = 1.08; 95% CI = 0.87-1.35; P = .46), as were the rates of biliary spillage (RR = 1.16; 95% CI = 0.73-1.84; P = .53) and conversion rate (RR = 0.88; 95% CI = 0.53-1.46; P = .62). Operative time was in favor of SLMC (weighted mean difference = 0.73; 95% CI = 0.67-0.79; P < .0001). Secondary outcomes favored SILC, but with marginal advantages. Conclusions. SILC is a feasible technique but without any significant advantage over SLMC for relevant end points. Although secondary outcomes favored SILC, the small magnitude of the advantage and the low quality of assessment methods question the clinical significance of these benefits.
The decreasing availability of surgical physicians is a concern in most countries. In the past decade, total physician manpower in Taiwan increased by 12%, but the number of surgical physicians decreased by 11%. Medical students are not inclined to choose surgery as a career—this study examines the factors involved in students’ career choices. This study was conducted from January 2011 to April 2011. In total, 401 interns successfully completed questionnaires; this population makes up 34% of all interns in Taiwan. The structural questionnaire was designed to investigate factors affecting specialty decisions, with additional open-ended questions to investigate students’ preferences in career specialty. Based on the research findings, the 3 most relevant factors in decreasing order of priority are personal interest, career-oriented lifestyle, and specialty characteristics (including workload and stress). For students likely to become surgical physicians, concerns about the work environment include the balance between work and family, wages that are incompatible with the workload, and the shortage of manpower on duty. Addressing the following concerns would increase medical students’ likelihood of choosing a career in surgery: the need for a facilitator to help mitigate medical disputes and legal problems, decreased work hours, and decreased on-call duty hours. This study shows both motivating and discouraging factors affecting whether medical students choose surgery as a career. The purpose of this study is to strengthen the incentives for medical students to choose surgery as a career and to minimize the influence of factors that negatively affect such a choice.
Objective. Omnidirectional articulated instruments enhance dexterity. In neurosurgery, for example, the simultaneous use of 2 instruments through the same endoscopic shaft remains a difficult feat. It is, however, very challenging to manufacture steerable instruments of the requisite small diameter. We present a new technique to produce such instruments by means of laser cutting. Only 3 coaxial tubes are used. The middle tube has a cutting pattern that allows the steering forces to be transmitted from the proximal to the distal end. In this way the steering part is concealed in the wall of the tube. Large diameter articulated instruments such as for laparoscopy might benefit from the excellent tip stability provided by the same economical technology. Method. Coaxial nitinol tubes are laser-cut with a Rofin Stent Cutter in a specific pattern. The 3 tubes are assembled by sliding them over one another, forming a single composite tube. In a surgical simulator, the neurosurgical microinstruments and laparoscopic needle drivers were evaluated on surgical convenience. Results. Simultaneous use of 2 neurosurgical instruments (1.5 mm diameter) through the same endoscopic shaft proved to be very intuitive. The tip of the steerable laparoscopic instruments (10 mm diameter) could resist a lateral force of more than 20 N. The angle of motion for either instrument was at least 70° in any direction. Conclusions. A new design for steerable endoscopic instruments is presented. It allows the construction in a range from microinstruments to 10-mm laparoscopic devices with excellent tip stability.
Background. Laparoscopic splenectomy has become the gold-standard procedure for normal to moderately enlarged spleens. However, the safety of laparoscopic splenectomy for patients with portal hypertension remains controversial. We carried out this systematic review to identify the feasibility and safety of laparoscopic splenectomy in treating portal hypertension. Data sources. A systematic search for comparative studies that compared laparoscopic splenectomy with open splenectomy for portal hypertension was carried out. Studies were independently reviewed for quality, inclusion and exclusion criteria, demographic characteristics, and perioperative outcomes. Conclusion. Although laparoscopic splenectomy is associated with longer operating time, it offers advantages over the open procedure in terms of less blood loss, lower operative complications, earlier resumption of oral intake, and shorter posthospital stay. Therefore, laparoscopic splenectomy is a safe and feasible intervention for portal hypertension.
Background. Implantation of synthetic meshes for reinforcement of abdominal wall hernias can be complicated by mesh infection, which often requires mesh explantation. The risk of mesh infection is increased in a contaminated environment or in patients who have comorbidities such as diabetes or smoking. The use of biological prostheses has been advocated because of their ability to resist infection. Initial results, however, have shown high hernia recurrence rates and wound occurrences. The objective of the present study is to evaluate early and mid-term outcomes in the largest French series that included 43 consecutive complex abdominal hernias repaired with biological prostheses. Materials and methods. Retrospective observational study of a prospective collected data bank. Patient demographics, history of previous repairs, intraoperative findings and degree of contamination, associated procedures, postoperative prosthetic-related complications, and long-term results were retrospectively reviewed. Results. There were 25 (58%) incisional, 14 parastomal, and 4 midline hernia repairs. Hernias were considered "clean" (n = 5), "clean-contaminated" (n = 19), "contaminated" (n = 12), or "dirty" (n = 7). Wound-related morbidity occurred in 17 patients; 4 patients needed reoperation for cutaneous necrosis or abscess. Smoking was the only risk factor associated with wound complication (P = .022). No postoperative wound events required removal of the prosthesis. There were 4 hernia recurrences (9%). A previous attempt at repair (P = .018) and no complete fascia closure (P = .033) were associated with hernia recurrence. Conclusions. This study demonstrated that the use of bioprothesis in complex hernia repair allowed successful single-stage reconstruction. Wound-related complications were frequent. Cost-benefit analyses are important to establish the validity of these findings.
Background. Transesophageal natural-orifice transluminal endoscopic surgery (NOTES) mediastinoscopy has been described as a feasible, less-invasive alternative to video-assisted mediastinoscopy (VAM). We aimed to investigate hemodynamic and respiratory effects during transesophageal NOTES mediastinoscopy compared with VAM. Patients and methods. This was a short-survival experiment in 20 female pigs randomized to NOTES (n = 10) or VAM (n = 10) mediastinoscopy. In the NOTES group, an endoscopist accessed the mediastinum through a 5-cm submucosal tunnel in the esophageal wall, and CO2 was used to create the pneumomediastinum. Conventional VAM was carried out by thoracic surgeons. A 30-minute systematic exploration of the mediastinum was then performed, including invasive monitoring for hemodynamic and respiratory data. Blood samples were drawn for gas analyses. Results. All experiments except 2 in the NOTES group (one because of technical difficulties, the other because of thoracic lymphatic duct lesion) were completed as planned, and animals survived 24 hours. Also, 3 animals in the NOTES group presented a tension pneumothorax that was immediately recognized and percutaneously drained. VAM and NOTES animals showed similar pulmonary and systemic hemodynamic behavior during mediastinoscopy. Pulmonary gas exchange pattern was mildly impaired during the NOTES procedure, showing lower partial arterial oxygen pressure associated with higher airway pressures (more important in animals that presented with pneumothorax). Conclusions. NOTES mediastinoscopy induces minimal deleterious respiratory effects and hemodynamic changes similar to conventional cervical VAM and could be feasible when performed under strict hemodynamic and respiratory surveillance. Notably, serious complications caused by the injury of pleura are more frequent in NOTES, which mandates an improvement in technique and suitable equipment.
Introduction. Reducing the number of abdominal incisions in laparoscopic cholecystectomy introduces ergonomic challenges while establishing the critical view during dissection of the triangle of Calot (TC). This study investigates the use of a novel internal retracting device in performing cholecystectomy with a reduced number of ports. Methods. A 3-port laparoscopic cholecystectomy was attempted by 4 surgeons unfamiliar with the novel device. Exposure of the TC was obtained using the internal retractor, which comprises 2 clips, linked by an adjustable thread. One clip is fixed on the gallbladder and the other is fixed to the peritoneum. The endpoint was to evaluate the efficacy and reliability of the device in establishing the critical view of safety. Results. Thirteen patients with a mean body mass index of 25.29 kg/m2 (standard deviation = 6.24; range = 17.6-36.7 kg/m2) were included in the study. The critical view was obtained in 10 of 13 patients. Application of the device was completed in a median time of 2.25 minutes without injury of the gallbladder or bile leak. Failure occurred in 3 patients, related to wrong manipulation of the device (2 patients), and correct placement of the device but inadequate exposure (1 patient). A conventional 4-port technique was used in these patients. Operators rated their experience with the device as an "easy-to-operate" device with a good safety profile and without any interference with the operative process. Conclusions. Throughout the minimization process specific to minimal access surgery, internal retractors will certainly allow for a reduction in the number of trocars used in laparoscopic procedures.
Background. The morbidity linked to the use of sutures in inguinal hernioplasty is well known. Tissue adhesives may be an alternative, so as to be able to improve levels of postoperative comfort, but clinical experience using them is limited. The aim of this study is to evaluate the efficiency of cyanoacrylate as a substitute for sutures in the treatment of inguinal hernias. Patients. Randomized clinical trial in abdominal wall unit. A total of 208 patients were operated upon for inguinal hernias of which 102 were unilateral hernias via open surgery using the Lichtenstein technique, randomized to receive prolene sutures (n = 52) or n-hexyl-α-cyanoacrylate glue (n = 50) and 106 were patients with bilateral inguinal hernias operated upon via totally extraperitoneal laparoscopy and randomized to receive either tackers (n = 54) or glue (n = 52). Main Outcome Measures. The primary endpoints were pain and recurrence. Secondary endpoints were operating time, postoperative morbidity, pain, and analgesic consumption. Results. No morbidity associated with the use of the glue existed. The use of glue significantly reduced the mean of surgical time (12 minutes in open surgery, 13 minutes in laparoscopic surgery), pain, and analgesics consumption, both via the open and laparoscopic approaches (P < .001). After 1 year the adhesive did not change the recurrence rate in either of the approaches. The economic analysis shows potential yearly savings of 123 916.3 Euros. Conclusions. Substituting sutures with glue (n-hexyl-α-cyanoacrylate) in open or laparoscopic inguinal hernioplasty is safe with less postoperative pain and the same possibilities of recurrence.
Objective. Jugular bulb abnormalities can induce tinnitus, hearing loss, or vertigo. Vertigo can be very disabling and may need surgical treatments with risk of hearing loss, major bleeding or facial palsy. Hence, we have developed a new treatment for vertigo caused by jugular bulb anomalies, using an endovascular technique. Patients. Three patients presented with severe vertigos mostly induced by high venous pressure. One patient showed downbeat vertical nystagmus during the Valsalva maneuver. The temporal-bone computed tomography scan showed a high rising jugular bulb or a jugular bulb diverticulum with dehiscence and compression of the vestibular aqueduct in all cases. Intervention. We plugged the upper part of the bulb with coils, and we used a stent to maintain the coils and preserving the venous permeability. Results. After 12- to 24-month follow-up, those patients experienced no more vertigo, allowing return to work. The 3-month arteriographs showed good permeability of the sigmoid sinus and jugular bulb through the stent, with complete obstruction of the upper part of the bulb in all cases. Conclusion. Disabling vertigo induced by jugular bulb abnormalities can be effectively treated by an endovascular technique. This technique is minimally invasive with a probable greater benefit/risk ratio compare with surgery.
Background. Laparoendoscopic single-site sleeve gastrectomy is gaining acceptance. However, totally natural orifice translumenal endoscopic surgery (NOTES) in morbidly obese patients is still controversial due to safety and technical issues. To this end, we have developed a technique for sleeve gastrectomy in which the surgical field view is achieved through transgastric approach and the operating channel will eventually be through the vagina to form a dual lumen totally NOTES procedure for sleeve gastrectomy. As a step toward this approach, we performed a single abdominal incision in order to simulate the transvaginal route. This study is another step toward combined transvaginal and transgastric totally NOTES sleeve gastrectomy. Methods and Procedures. A combined NOTES and single trocar sleeve gastrectomy was performed on 8 porcine animal models. The endoscope was inserted through the gastric wall and served as the vision source for the procedure. A second endoscope was inserted via the transabdominal trocar together with the surgical instruments. Results. Sleeve gastrectomy was performed on 8 porcine models. The operative time for the first procedure was 5 hours, but after determining the technique, the time was reduced by half. Conclusion. Combined NOTES and single trocar sleeve gastrectomy is feasible in a porcine model. We achieved an excellent view of the surgical field through the transgastric approach. We believe that in the near future, combining the transgastric visualization of the surgical field together with a transvaginal approach may enable performing a total NOTES sleeve gastrectomy procedure. This hypothesis will be studied in further animal experiments before implementation in humans.
Background. The aim of this study was to introduce a novel technique of pancreaticojejunostomy, namely, mesh inner embedding and outer binding pancreaticojejunostomy, and to evaluate wound healing after this operation in piglets. Methods. Thirty-six domestic piglets were randomly divided into 2 groups after pancreaticoduodenectomy: the mesh inner embedding and outer binding pancreaticojejunostomy group (n = 18) and the conventional double-deck invaginated pancreaticojejunostomy group (n = 18). Bursting pressure and breaking strength were assessed on the operative day and on days 7 and 14 postoperatively. The pathologic findings and collagen content of the anastomotic site were evaluated on days 7 and 14 postoperatively. Results. Both the bursting pressure and breaking strength were significantly higher in the mesh inner embedding and outer binding pancreaticojejunostomy group than in the double-deck invaginated pancreaticojejunostomy group on days 0, 7, and 14 (P < .01). The collagen content of the anastomotic site was significantly higher in the mesh inner embedding and outer binding pancreaticojejunostomy group than in the double-deck invaginated pancreaticojejunostomy group on days 7 and 14 postoperatively (P < .01). The anastomotic site was more completely repaired by connective and granulation tissue in the mesh inner embedding and outer binding pancreaticojejunostomy group on day 7 than in the double-deck invaginated pancreaticojejunostomy group. Conclusion. Mesh inner embedding and outer binding pancreaticojejunostomy significantly enhanced the anastomotic firmness and sped up the wound healing process compared with conventional mesh inner embedding and outer binding pancreaticojejunostomy. Therefore, it may decrease the risk of pancreatic fistulas after pancreaticoduodenectomy.
Background. Laparoendoscopic single-site surgery has been presented in the past few years as an innovative minimally invasive approach, one which despite its advantages is also challenging and requires specific training. We propose to analyze the performance of attendants in a specific LESS training course. Methods. Following the LESSCAR 2010 guidelines, we focused on level 1 hands-on simulator tasks and level 2 hands-on training on animal model for skills acquisition during a LESS-specific training course. Each attendant completed coordination and cut tasks on simulator, followed by a cholecystectomy on an ex vivo porcine liver. Hands-on animal model each trainee performed 1 cholecystectomy and at least 2 nephrectomies (N1, N2). Performance was analyzed through video recording and reviewed by 3 independent observers. Each result was registered according to a modified objective structured assessment of technical skills. Total task or procedure completion time was also determined. Results. Regarding coordination and cut tasks, attendants improved on their performance from first to third attempts with an accompanying decrease in completion time. Surgeons completed the cholecystectomy on animal model significantly faster than on simulator, although with lower performance quality. Regarding N1 and N2, attendants showed improvement both in quality and total completion time. Conclusions. A gradual and positive evolution of attendants was observed throughout the training course. Thus, we believe a structured program for the acquisition of basic skills in new minimally invasive surgical approaches should be recommended. Considering that this is a small study, it would be advisable to increase the number of study subjects on future opportunities.
Background. The uptake of minimal access surgery (MAS) has by virtue of its clinical benefits become widespread across the surgical specialties. However, despite its advantages in reducing traumatic insult to the patient, it imposes significant ergonomic restriction on the operating surgeons who require training for the safe execution. Recent progress in manipulator technologies (robotic or mechanical) have certainly reduced the level of difficulty, however it requires information for a complete gesture analysis of surgical performance. This article reports on the development and evaluation of such a system capable of full biomechanical and machine learning. Methods. The system for gesture analysis comprises 5 principal modules, which permit synchronous acquisition of multimodal surgical gesture signals from different sources and settings. The acquired signals are used to perform a biomechanical analysis for investigation of kinematics, dynamics, and muscle parameters of surgical gestures and a machine learning model for segmentation and recognition of principal phases of surgical gesture. Results. The biomechanical system is able to estimate the level of expertise of subjects and the ergonomics in using different instruments. The machine learning approach is able to ascertain the level of expertise of subjects and has the potential for automatic recognition of surgical gesture for surgeon–robot interactions. Conclusions. Preliminary tests have confirmed the efficacy of the system for surgical gesture analysis, providing an objective evaluation of progress during training of surgeons in their acquisition of proficiency in MAS approach and highlighting useful information for the design and evaluation of master–slave manipulator systems.
Background. The objectives of this study were to report the surgical techniques and clinical outcome of thoracoscopic half carina resection and thoracoscopic bronchial sleeve resection for central lung cancer. Methods. Between January 2011 and November 2012, 675 patients with lung cancer underwent radical surgery by thoracoscopy, and 49 (7.3%) underwent bronchial sleeve resection. Among 49 patients, 20 (41%) received thoracoscopic bronchial sleeve lobectomy. Perioperative variables and postoperative outcomes of these cases were analyzed to evaluate the technical feasibility and safety of this operation. Results. In one patient, right upper lung sleeve resection was combined with half-carinal resection and reconstruction. In another, right medial lung sleeve resection was combined with lower right dorsal segment resection. The average time of surgery was 239 ± 51 minutes (range = 142-330 minutes), and the average time of airway reconstruction was 44 ± 17 minutes (range = 22-75 minutes). The intraoperative blood loss averaged 207 ± 96 mL (range = 80-550 mL). The median postoperative hospital stay was 10 days (interquartile range = 8-12 days). Postoperatively, extubation was achieved in the recovery room without further need for mechanical ventilation. None of the patients developed anastomotic leak. Perioperative mortality was not observed. Conclusion. Thoracoscopic bronchial sleeve resection can be considered a feasible and safe operation for selected patients with central lung cancer. The complicated anastomosis technique of half carina resection was feasible.
Background. Laparoendoscopic single-site surgery (LESS) is limited by loss of triangulation and internal instruments conflict. To overcome these difficulties, some concepts have been introduced, namely, articulating instruments and cross-handed manipulation, which causes the right hand to control the left instrument tip and vice versa. The aim of this study was to compare task performance with different approaches based on a mechanical evaluation platform. Methods. A LESS mechanical evaluation platform was set up to investigate the performance of 2 tasks (suture pass-through rings and clip-cut) with 3 different settings: uncrossed manipulation with straight instruments (group A, the control group), uncrossed manipulation with articulating instruments (group B), and cross-handed manipulation with articulating instruments (group C). The operation time and average load required for accomplishment of the standard tasks were measured. Results. Group A presented significantly better time scores than group B, and group C consumed the longest time to accomplish the 2 tasks (P < .05). Comparing of average load required to perform the suture pass-through rings task, it differed significantly between dominant and nondominant hand in all groups (P < .01) and was less in group A and group B than group C in dominant hand (P < .01), while it was almost the same in all groups in the nondominant hand. In terms of average load requirement to accomplish clip-cut task, it was almost equal not only between group A and B but also between dominant and nondominant hand while the increase reached statistical significance when comparing group C with other groups (P < .05). Conclusions. Compared with conventional devices and maneuvering techniques, articulating instruments and cross-handed manipulation are associated with longer operation time and higher workload. Instruments with better maneuverability should be developed in the future for LESS.
Introduction. Natural orifice transluminal endoscopic surgery (NOTES) could reduce procedure-associated morbidity and mortality. The aim of this study was to determine the feasibility of performing a simple model of gastrojejunal anastomosis in a living porcine model exclusively using NOTES. Methods. It was a prospective experimental animal study concerning pigs weighing between 25 and 30 kg. Endoscopies were performed using a double-channel gastroscope. A preliminary phase allowed for the development of the technique on 3 animals that were immediately euthanized. The experimental phase included the implementation of a gastrojejunal anastomosis in 9 animals. Antibiotic therapy was continued for 7 days with gradual feeding. Surviving animals were euthanized after 3 weeks. Anastomosis permeability in each animal was confirmed by opacification, endoscopy, and histopathological analysis. The main outcome measurements were the feasibility and animal survival at 3 weeks postsurgery. Results. The entire procedure was performed on 9 animals (4 males and 5 females). Anastomosis required 4.7 ± 1.2 stitches (range 4-7). The average total length of the procedure was 143 ± 50.8 minutes (range 87-225 minutes). One bleeding, 2 suture dehiscences, and a poor stomach incision were the immediate complications endoscopically resolved. At 3 weeks, 5 animals had survived. Three animals died as a result of anastomotic leakage confirmed at necropsy and histopathology. In the surviving animals, histology confirmed permeable anastomoses with collagen scar tissue and continuity of the mucosa and mucosa muscle layers. Conclusion. Successful gastrojejunal anastomosis by NOTES is technically feasible but is subject to a learning curve.
Introduction. Recently, the lymphatic vessels has been considered to play a key role in the pathophysiology and, consequently, in the treatment of Crohn’s disease (CD). The aim of this study is to show that the evaluation of lymphatic anomaly might be a useful tool in the recognition of the pathological involvement of the intestinal wall in CD. Material and methods. Fourteen patients with CD who underwent surgical treatment for distal ileum critical stenosis were prospectively evaluated. During surgery, 0.05 to 0.1 mL of Patent Blue V was injected into the subserosal layer of the antimesenteric edge of ileum and colon. The intestinal section was performed just beneath the outflow of the vital dye where it seemed to be normal (≤2 minutes), as a index of healthy intestinal wall. A comparison between the lymphatic alterations and the macroscopic aspects was performed. Results. Out of 14 patients, 13 were electively operated on, whereas 1 was treated in emergency. In 8 patients (57%), laparoscopic approach was chosen in the first instance. One patient needed laparotomic conversion. When comparing the Patent Blue V outflow time with the macroscopic and microscopic evidence of CD, we found an absolute integrity of the intestinal wall with an outflow ≤2 minutes. Mean follow-up was 110 months with a recurrence rate of 14%. Conclusion. We can conclude that this method may be of utility to distinguish between normal and diseased intestine in CD. The possible consequences in postsurgical recurrences of this evidence are critical.
Background. Laparoscopic splenectomy and azygoportal disconnection (LSD) using many different surgical techniques has become increasingly popular for treatment of cirrhotic patients with bleeding portal hypertension and secondary hypersplenism. Surgical procedures with the least possible impairment are consistently expected by both surgeons and patients. Here, we report a clinical cohort of 10 patients who underwent LSD with a new technique and present the advantages of less impairment during performance of this new technique. Methods. A cohort of 10 cirrhotic patients with bleeding portal hypertension and secondary hypersplenism treated with LSD were studied. During the procedure, an electromechanical morcellator allowed for easy extraction of the entire massive splenic tissue without a cumbersome intracorporeal bag, enlarged incision, or hand-assisted incision. Various perioperative data were recorded. Results. LSD was successful in all patients. There was no conversion to open operations or significant perioperative complications. The operative time was 288.0 ± 53.9 minutes, the spleen removal time was 39.3 ± 15.1 minutes, and blood loss was 240.0 ± 217.1 mL. Conclusions. This new technique involving the use of an electromechanical morcellator provides expedient recovery and minimal postoperative pain and scarring. LSD with this technique is a feasible, effective, and safe surgical procedure, and embodies all the benefits of minimally invasive surgery for cirrhotic patients with bleeding portal hypertension and hypersplenism.
Background. The Explorer Minimally Invasive Liver (MIL) system uses imaging to create a 3-dimensional model of the liver. Intraoperatively, the system displays the position of instruments relative to the virtual liver. A prospective clinical study compared it with intraoperative ultrasound (iUS) in laparoscopic liver ablations. Methods. Patients undergoing ablations were accrued from 2 clinical sites. During the procedures, probes were positioned in the standard fashion using iUS. The position was synchronously recorded using the Explorer system. The distances from the probe tip to the tumor boundary and center were measured on the ultrasound image and in the corresponding virtual image captured by the Explorer system. Results. Data were obtained on the placement of 47 ablation probes during 27 procedures. The absolute difference between iUS and the Explorer system for the probe tip to tumor boundary distance was 5.5 ± 5.6 mm, not a statistically significant difference. The absolute difference for probe tip to tumor center distance was 8.6 ± 7.0 mm, not statistically different from 5 mm. Discussion. The initial clinical experience with the Explorer MIL system shows a strong correlation with iUS for the positioning of ablation probes. The Explorer MIL system is a promising tool to provide supplemental guidance information during laparoscopic liver ablation procedures.
Introduction. The surgical management of anal fistulas is still a matter of discussion and no clear recommendations exist. The present study analyses the results of the ligation of the intersphincteric fistula tract (LIFT) technique in treating complex anal fistulas, in particular healing, fecal continence, and recurrence. Methods. Between October 2010 and February 2012, a total of 26 consecutive patients underwent LIFT. All patients had a primary complex anal fistula and preoperatively all underwent clinical examination, proctoscopy, transanal ultrasonography/magnetic resonance imaging, and were treated with the LIFT procedure. For the purpose of this study, fistulas were classified as complex if any of the following conditions were present: tract crossing more than 30% of the external sphincter, anterior fistula in a woman, recurrent fistula, or preexisting incontinence. Patient’s postoperative complications, healing time, recurrence rate, and postoperative continence were recorded during follow-up. Results. The minimum follow-up was 16 months. Five patients required delayed LIFT after previous seton. There were no surgical complications. Primary healing was achieved in 19 patients (73%). Seven patients (27%) had recurrence presenting between 4 and 8 weeks postoperatively and required further surgical treatment. Two of them (29%) had previous insertion of a seton. No patients reported any incontinence postoperatively and we did not observe postoperative continence worsening. Conclusion. In our experience, LIFT appears easy to perform, is safe with no surgical complication, has no risk of incontinence, and has a low recurrence rate. These results suggest that LIFT as a minimally invasive technique should be routinely considered for patients affected by complex anal fistula.
Obtaining a reliable distal margin during anterior colorectal resection can be difficult. In this study, endoscopic transmural tattoos were placed to mark the distal transection point in patients with distal colorectal neoplasms who undergo bowel resection. In the operating room, before surgery, sigmoidoscopy is performed with a 2-channel scope using CO2 insufflation. Through channel 1, a biopsy forceps, marked 5 cm from its end, is inserted to the tumor’s distal edge; in channel 2, a sclerotherapy catheter is placed. The scope is then withdrawn and forceps inserted at the same rate until the mark is seen, next, via the needle catheter, 4 tattoos are placed at that level circumferentially. After rectal mobilization, visible external tattoos guide stapler placement. If no tattoo is seen, sigmoidoscopy is done and the tattoos used to guide stapler placement. In all 27 patients, the tattoos guided stapler placement; tattoos were seen via the abdomen in 26 and the stapler placed as per tattoos in 25. In 2 patients, repeat endoscopy was done and tattoos used to guide or confirm stapler placement. The margin was ≤1 cm from target in 74% while in 22% the margin was 2 to 3.5 cm off target (mean deviation from target margin = 0.33 cm). In conclusion, this method facilitates stapler placement and provides more reliable margins.
Background. This is a prospective, randomized, controlled, single-blinded study to investigate peritoneal adhesion formation of standard argon plasma coagulation (APC) versus aerosol plasma coagulation in a rat model. Methods. Bilateral lesions were created on the abdominal wall of 16 female Wistar rats with standard and aerosol plasma coagulation APC energy in a standard fashion. After 10 days, the rats were killed humanely to evaluate the peritoneal trauma sites. Adhesion incidence, quantity, and quality were scored 10 days postoperatively and studied histopathologically. Results. Average energy intake was 97.7 ± 3.1 J for APC and 93.8 ± 4.2 J for aerosol plasma coagulation. Incidence of adhesion formation was 74.2% for standard APC and 16.1% for aerosol plasma coagulation (P < .0001). Standard APC mainly results in dense adhesions. Histological evaluation revealed no significant difference with regard to the average depth of lesions created by APC and aerosol plasma coagulation (P = 0.21) at day 10; both groups showed an identical morphology of necrosis and granulation tissue formation. Conclusions. This study compares adhesion formation of standard APC versus aerosol plasma coagulation in a rat model. Standard APC produced significantly more adhesions. Aerosol plasma coagulation creates fewer adhesions, which are of lower grade, which seems to be achieved mainly by improved peritoneal conditioning in this animal model.
Background. Modern endoscopy requires video display. Recent miniaturized, ultraportable projectors are affordable, durable, and offer quality image display. Objective. Explore feasibility of using ultraportable projectors in endoscopy. Methods. Prospective bench-top comparison; clinical feasibility study. Masked comparison study of images displayed via 2 Samsung ultraportable light-emitting diode projectors (pocket-sized SP-HO3; pico projector SP-P410M) and 1 Microvision Showwx-II Laser pico projector. Bench-top feasibility study: Prerecorded endoscopic video was streamed via computer. Clinical comparison study: Live high-definition endoscopy video was simultaneously displayed through each processor onto a standard liquid crystal display monitor and projected onto a portable, pull-down projection screen. Endoscopists, endoscopy nurses, and technicians rated video images; ratings were analyzed by linear mixed-effects regression models with random intercepts. Results. All projectors were easy to set up, adjust, focus, and operate, with no real-time lapse for any. Bench-top study outcomes: Samsung pico preferred to Laser pico, overall rating 1.5 units higher (95% confidence interval [CI] = 0.7-2.4), P < .001; Samsung pocket preferred to Laser pico, 3.3 units higher (95% CI = 2.4-4.1), P < .001; Samsung pocket preferred to Samsung pico, 1.7 units higher (95% CI = 0.9-2.5), P < .001. The clinical comparison study confirmed the Samsung pocket projector as best, with a higher overall rating of 2.3 units (95% CI = 1.6-3.0), P < .001, than Samsung pico. Conclusions. Low brightness currently limits pico projector use in clinical endoscopy. The pocket projector, with higher brightness levels (170 lumens), is clinically useful. Continued improvements to ultraportable projectors will supply a needed niche in endoscopy through portability, reduced cost, and equal or better image quality.
Background. Acute liver failure (ALF) is a severe and highly fatal complication arising after extended hepatobiliary surgery. The aim of this study was to investigate the primary management experience of portal vein arterialization (PVA) as a bridge procedure to reduce the risk of ALF for hilar cholangiocarcinoma (HCCA) after extended hepatectomy. Method. Between January 2010 and January 2012, 4 patients with HCCA with possible involvement of the right and/or left hepatic artery underwent resectional surgery with reconstruction of the right or left artery blood flow by arterializations of portal vein. Results. The arteries used for this surgical procedure included gastroduodenal artery (n = 2), common hepatic artery (n = 1), and right gastroepiploic artery (n = 1). PVA was verified as a key point during the course of the disorder between surgery and postoperative recovery. During follow-up, 1 patient suffered secondary portal hypertension and was subsequently cured by interventional artery coil embolization. Conclusion. PVA can be indicated where there is arterial involvement in HCCA patients who have undergone extended hepatectomy or trisectionectomy.
Background. Surgery for locally advanced and recurrent rectal carcinoma can be associated with major blood loss. Objective. We developed a promising technique using a hemostatic balloon to stop uncontrollable bleeding. Design. Models were developed using pelvic magnetic resonance imaging scans, and these models were tested in a cadaveric study. Eventually a model was tested in a clinical setting. The Hemostatic Balloon Device was placed in patients in whom during surgery uncontrollable bleeding from the venous presacral plexus occurred. Settings. A tertiary referral hospital for locally advanced and recurrent rectal cancer. Patients. Patients receiving multimodality treatment for primary or recurrent locally advanced rectal carcinomas. Main Outcome Measures. First the developed prototypes were tested in a cadaveric study where the developing pressure on the pelvic wall was measured. Second, the Hemostatic Balloon Device was placed in patients in whom during surgery uncontrollable bleeding from the venous presacral plexus occurred. Results. The balloon was used in 9 patients. Median volume of blood loss was 7500 mL. In 8 patients treatment with the hemostatic balloon was successful. In 1 patient the balloon was dislocated cranially and the pelvis was packed with surgical gauzes. Limitations. These first results are promising but further research is needed to evaluate how effective the balloon is in controlling massive bleeding during rectal cancer surgery. Future perspectives include a possibly thinner silicon rubber that can be stretched more easily with a lower inflated volume. Discussion. The hemostatic balloon is a new and promising technique for accomplishing hemostasis with controllable pressure on the pelvic cavity wall and can be removed without the need for a second laparotomy.
Pectus excavatum is the most common deformity of the thorax. A minimally invasive surgical correction is commonly carried out to remodel the anterior chest wall by using an intrathoracic convex prosthesis in the substernal position. The process of prosthesis modeling and bending still remains an area of improvement. The authors developed a new system, i3DExcavatum, which can automatically model and bend the bar preoperatively based on a thoracic CT scan. This article presents a comparison between automatic and manual bending. The i3DExcavatum was used to personalize prostheses for 41 patients who underwent pectus excavatum surgical correction between 2007 and 2012. Regarding the anatomical variations, the soft-tissue thicknesses external to the ribs show that both symmetric and asymmetric patients always have asymmetric variations, by comparing the patients’ sides. It highlighted that the prosthesis bar should be modeled according to each patient’s rib positions and dimensions. The average differences between the skin and costal line curvature lengths were 84 ± 4 mm and 96 ± 11 mm, for male and female patients, respectively. On the other hand, the i3DExcavatum ensured a smooth curvature of the surgical prosthesis and was capable of predicting and simulating a virtual shape and size of the bar for asymmetric and symmetric patients. In conclusion, the i3DExcavatum allows preoperative personalization according to the thoracic morphology of each patient. It reduces surgery time and minimizes the margin error introduced by the manually bent bar, which only uses a template that copies the chest wall curvature.
Background. Laparoscopic splenectomy has been used safely for patients with blunt splenic trauma and failed nonoperative management. Reports of using laparoscopic splenorraphy for spleen salvage were fewer and mainly limited to lower grades of injuries. No study has focused on the role of laparoscopic splenorraphy in the treatment of patients with high grades of splenic injuries. Methods. Medical records of 15 patients with high grades of splenic injuries that required an operation for failed nonoperative management were retrospectively reviewed. They underwent a new technique of sandwich repair laparoscopically for spleen salvage by 3 surgeons who had adequate training in laparoscopy for trauma. Preoperative parameters, sandwich repair technique, perioperative parameters, and postoperative outcomes were evaluated. Results. Fourteen of the 15 (93.3%) patients underwent the technique successfully with 1 patient converting to laparotomy. The median (interquartile range) time to reach hemostasis was 30.0 (26.0-40.0) minutes, and the median overall operation time was 135.0 (120.0-165.0) minutes. Median blood loss amount was 1300.0 (750.0-2300.0) mL. The median length of hospital stay was 8.0 (7.0-11.0) days, and the intensive care unit stay was 2.0 (0.0-4.0) days. No mortality was noted. No rebleeding, total splenic infarction, or intra-abdominal abscess was noted during 3-month follow-up after the operation. Conclusions. The preliminary results show that laparoscopic splenorraphy by the "sandwich repair technique" is feasible and safe for patients with high-grade splenic injuries.
Background. Radiofrequency ablation (RFA) is widely used for treating liver tumors; recurrence is common owing to proximity to blood vessels possibly due to the heat sink effect. We seek to investigate this phenomenon using unipolar and bipolar RFA on an egg white tumor tissue model and an animal liver model. Materials and methods. Temperature profiles during ablation (with and without vessel simulation) were studied, using both bipolar and unipolar RFA probes by 4 strategically placed temperature leads to monitor temperature profile during ablation. The volume of ablated tissue was also measured. Results. The volume ablated during vessel simulation confirmed the impact of the heat sink phenomenon. The heat sink effect of unipolar RFA was greater compared with bipolar RFA (ratio of volume affected 2:1) in both tissue and liver models. The volume ablated using unipolar RFA was less than the bipolar RFA (ratio of volume ablated = 1:4). Unipolar RFA achieved higher ablation temperatures (122°C vs 98°C). Unipolar RFA resulted in tissue damage beyond the vessel, which was not observed using bipolar RFA. Conclusion. Bipolar RFA ablates a larger tumor volume compared with unipolar RFA, with a single ablation. The impact of heat sink phenomenon in tumor ablation is less so with bipolar than unipolar RFA with sparing of adjacent vessel damage.
Background. Untrained laparoscopic camera assistants in minimally invasive surgery (MIS) may cause suboptimal view of the operating field, thereby increasing risk for errors. Camera navigation is often performed by the least experienced member of the operating team, such as inexperienced surgical residents, operating room nurses, and medical students. The operating room nurses and medical students are currently not included as key user groups in structured laparoscopic training programs. A new virtual reality laparoscopic camera navigation (LCN) module was specifically developed for these key user groups. Methods. This multicenter prospective cohort study assesses face validity and construct validity of the LCN module on the Simendo virtual reality simulator. Face validity was assessed through a questionnaire on resemblance to reality and perceived usability of the instrument among experts and trainees. Construct validity was assessed by comparing scores of groups with different levels of experience on outcome parameters of speed and movement proficiency. Results. The results obtained show uniform and positive evaluation of the LCN module among expert users and trainees, signifying face validity. Experts and intermediate experience groups performed significantly better in task time and camera stability during three repetitions, compared to the less experienced user groups (P < .007). Comparison of learning curves showed significant improvement of proficiency in time and camera stability for all groups during three repetitions (P < .007). Conclusion. The results of this study show face validity and construct validity of the LCN module. The module is suitable for use in training curricula for operating room nurses and novice surgical trainees, aimed at improving team performance in minimally invasive surgery.
Background. Stark law’s in-office ancillary services exception permits physicians to furnish designated health services in the office, including advanced imaging. Objectives. To determine whether arrangements tailored to fit this loophole spur utilization. Research design. Cross-sectional. Subjects. Procedure-based specialty clinics participating in the National Ambulatory Medical Care Survey. Measures. Using restricted data files (2006-2008), we identified specialty practices with on-site advanced imaging capabilities (ie, computed tomography, magnetic resonance imaging, and/or positron emission tomography). We then characterized these practices and the physicians who worked in them over a variety of factors. Finally, we performed multivariable regression to evaluate the association between imaging use and the availability of in-office imaging. Results. Fourteen percent of practices performed advanced imaging on site. While this proportion remained stable over the study period for most specialties, it rose significantly among orthopedic surgery clinics from 13.6% to 31.3% (P = .023 for the temporal trend). The availability of advanced imaging varied by practice organization and size. For instance, 32.6% of large single-specialty groups provided in-office imaging as compared to only 10.1% of solo/partnership practices. While less than a quarter of specialty visits were made to practices that offered advanced imaging, these locations generated a third of all advanced imaging studies. In fact, 1 in 11 visits (9.0%; 95% confidence interval = 6.8% to 11.6%; P = .030) to them resulted in advanced imaging. Conclusions. The availability of in-office advanced imaging is associated with increased imaging use.
Objective. Several studies show that stapled transanal rectal resection (STARR) significantly improves constipation in most patients, while others remain syntomatic for obstructed defecation syndrome (ODS). The aim of the study was to analyze clinical, manometric, and endoanal ultrasonography results in order to find any possible correlation between clinical and instrumental data, particularly in dissatisfied patients, both for those who remain symptomatic for ODS and for patients with new-onset fecal disorders. Patients and methods. All patients underwent a preoperative and postoperative assessment based on clinical evaluation, proctoscopy, defecography, anorectal manometry, and endoanal ultrasonography. Furthermore, we asked patients about a subjective satisfaction grading of outcome. Results. From January 2007 to December 2009, 103 patients were treated in our department with STARR for ODS. Postoperative endoanal ultrasound did not demonstrate any variations compared with the preoperative one. Postoperative scores showed statistically significant improvement, with respect to the preoperative value, with good and sufficient scores in 79.6% of patients, and an overall rate of satisfaction of 87.1%. Fecal disorders, including also the slightest alteration of continence, occurred in 24% of patients, in particular soiling 1.8%, urgency 7.4%, occasional gas leakage 5.5%, and liquid/solid leakage 9.3%. Anorectal manometry revealed a statistically significant reduction only in sensitivity threshold and maximum tolerated volume compared to patients with no disorders of continence. Conclusion. Results indicate good satisfaction grading and a statistically significant improvement in scores of constipation. There is no close correlation between satisfaction grading and scores. Besides, the assessment of patient’s satisfaction often does not match the objective functional outcome.
The knowledge of liver anatomy has led to a rapid evolution based on the intrahepatic distribution of the portal pedicle. One great advance in liver surgery was the used of segment-based liver resections. Techniques based with intrahepatic Glissonian access of portal pedicles were described to safely perform anatomical liver resections. We have earlier described a standardized intrahepatic access to right and left liver segments’ pedicles without hilar dissection for anatomical hepatectomies. To improve the intrahepatic Glissonian technique, we designed a new atraumatic instrument for liver pedicle retrieval based on the anatomical liver landmarks. This new instrument was successfully employed in seventeen consecutive liver resections with minimum blood loss and without any complications related to its use. This new instrument, atraumatic retriever, replaces the right angle dissector or Gray clamp. The new instrument can slide easily and smoothly around Glissonian pedicle with a simple movement. This new instrument is a useful adjunct for performing intrahepatic access for liver resections. It can also be used to compass delicate anatomical structures such as esophagus and major abdominal vessels. The retriever can further be used in other common situations, including access for Pringle maneuver, encircling proximal esophagus during total gastrectomies or esophagectomies, and access for total vascular exclusion of the liver. This instrument can also be adapted to be used for laparoscopic liver resections.
Objective. We questioned whether the position of the dynamic reference frame (DRF) influences the application accuracy in electromagnetically navigated cranial procedures. A carrier for an electromagnetic DRF was developed, which could be fixed at the posterior edge of the vomer near the center of the head. This nasopharyngeal DRF was compared with a standard DRF fixed to the surface of the forehead. Methods. Image coordinates and real-world coordinates were co-registered and the total target error (TTE) was measured in the frontal and the lateral skull base of formalin fixed human head. At each anatomical site, 10 targets served for TTE determinations and 5 different fiducial combinations were used for registration. Results. With the nasopharyngeal DRF, lower TTE values (2.8 ± 1.4 mm; mean ± SD) were observed when compared with the forehead DRF (3.7 ± 2.8 mm; P = .004). TTEs of both anatomical sites investigated were significantly lower when using the nasopharyngeal DRF (frontal skull base 3.4 vs 2.1 mm, P = .005 and lateral skull base 3.9 vs 3.5 mm, P = .013) than with the standard forehead mounted one. Conclusion. Positioning the DRF in the center of the head significantly improved the application accuracy of targets in the skull base with electromagnetic navigation by 25%.
Background. Sentinel lymph node biopsy (SLNB) is a standard staging procedure in breast cancer and skin melanoma patients. Radioactive colloid (RC) and blue dye are the routinely used markers for staining. The new dye used in this procedure, indocyanine green (ICG), seems to have true potential in near-infrared–guided SLNB. The aim of this study was to analyze 1-year morbidity after SLNB using RC and ICG or RC and ICG conjugated to human serum albumin (ICG:HSA) in breast cancer and skin melanoma patients. Methods. Forty-nine patients diagnosed with breast cancer and 10 patients with skin melanoma underwent SLNB using ICG with RC and ICG:HSA with RC. A total of 47 SLNB patients without the need for additional lymphadenectomy were evaluated approximately 1 year (11-13 months) for the presence of tattoo, extremity swelling, nerve dysfunction/pain, range of motion, and stiffness. Results. From the 47 patients examined, long-term morbidity was present in 3 (6.4%). In 1 patient, tattoo persisted for 11 months. Mild lymphedema was seen in 1 patient, and 1 patient exhibited minor functional deficit. Conclusions. Using ICG or ICG:HSA seems to be safe, and long-term morbidity in SLNB patients is low. However, skin discoloration may appear as it does after the use of blue dye, and an increased number of harvested nodes might be associated with an increased number of iatrogenic lymphedema.
Objective. We sought to evaluate the efficacy of incisional negative pressure therapy in decreasing postoperative wound complications when placed prophylactically over clean, closed incisions following cesarean section in obese patients. Study design. This was a retrospective cohort study comparing rates of wound complications following cesarean sections in morbidly obese women prior to and following the institution of standard use of prophylactic incisional negative pressure therapy. All women with a body mass index greater than 45 kg/m2 undergoing cesarean section in a 2-year period in a single institution were included. The exposure was incisional negative pressure therapy, which began in September 2009, versus standard wound dressing used in the previous year. The main outcome was wound complication identified by ICD-9 codes. Demographic and wound outcomes were compared with 2 and t tests. Stata version 11.0 was used for all analysis. Results. A total of 63 women met the inclusion criteria, 21 of whom received negative pressure wound therapy. The historical comparison and exposure groups were similar in all characteristics studied with the exceptions of length of surgery (64 vs 76 minutes, P = .03), length of labor (78 vs 261 minutes, P = .02), scheduled versus nonscheduled (77% vs 52%, P = .04), and mean age (29.5 vs 26.1 years, P = .04), respectively. There were 5 wound complications in the control group (10.4%) and none (0%) in the study group (P = .15). Conclusions. This pilot study suggests a decrease in wound complications in morbidly obese women receiving incisional negative pressure therapy following cesarean section.
Introduction. Laparoendoscopic single-site surgery (LESS) uses a multiple-entry portal in a single 3.0- to 4.0-cm incision in a natural scar, the umbilicus. The present study aimed to compare the inflammatory impact of classic video laparoscopic cholecystectomy (LC) versus LESS cholecystectomy. Methods. A prospective randomized controlled study was conducted from January to June 2011 at 2 university hospitals in Rio de Janeiro, Brazil. Fifty-seven patients (53 women, 4 men; mean age = 48.7 years) were randomly assigned to receive LC (n = 29) or LESS (n = 28) cholecystectomy. C-reactive protein (CRP) and interleukin 6 (IL-6) were measured from blood samples collected during induction of anesthesia and at 3 and 24 hours postoperatively. Results. Median IL-6 levels in the LESS and LC groups, respectively, were 2.96 and 4.5 pg/mL preoperatively, 11.6 and 28.05 pg/mL at 3 hours postoperatively (P = .029), and 13.18 and 15.1 pg/mL at 24 hours postoperatively (P = .52). Median CRP levels in the LESS and LC groups, respectively, were 0.33 and 0.44 mg/mL preoperatively, 0.40 and 0.45 mg/mL (P = .73) at 3 hours postoperatively, and 1.7 and 1.82 mg/mL (P = .84) at 24 hours postoperatively. We did not find a significant association between IL-6 (and CRP) and body mass index in the LESS group. Conclusions. LESS cholecystectomy requires a larger size incision than LC. We found a tendency of less postoperative pain following LESS cholecystectomy than LC. There was also a tendency toward lower early inflammatory impact following LESS cholecystectomy versus LC.
Background. The purpose of this study was to determine construct and face validities of an interactive Web-based module for pneumoperitoneum and insufflator. Methods. Participants were recruited from surgical departments in 2 academic hospitals and 1 large nonacademic teaching hospital. They were stratified into 3 groups based on their laparoscopic experience (A, no experience; B, experience as assistant; and C, experience as primary surgeon). Within each group the participants were randomized into a training subgroup and a control subgroup. All participants performed a theoretical and a practical test. The training participants first completed the module before they performed the tests. The control participants immediately performed the tests. Results were compared between the training and control participants. All training participants filled out a questionnaire on their opinion about the module. Results. In total, 40 participants were enrolled in the study: group A consisted of 20 participants and groups B and C both consisted of 10 participants. The trained participants answered significantly more theoretical questions correctly (8.3 vs 6.6; P < .001), correctly identified more alarm causes (91% vs 86%; P = .014) and made significantly less errors in the practical test (1.5 vs 3.6; P = .001). All 20 trained participants rated the module fairly good and indicated the module to be of additive value to surgical training programs. Conclusions. Training with the interactive web-based module on installation of a pneumoperitoneum and use of an insufflator has a positive effect on both theoretical and practical competence. Construct and face validities were established for this module.
Introduction. Endoscopic submucosal dissection (ESD) is a technically challenging procedure in which complications and operative times depend on the operator’s expertise as well as on the location and size of the lesion. Good visualization of the submucosal dissection plane is essential to perform a safe and effective ESD. Objectives. To evaluate the feasibility, efficacy, and safety of a novel traction method using an over-the-scope steerable grasper to improve the exposure of the dissection plane during gastric ESD. Results. A total of 24 ESDs were performed without any complications in various locations of porcine stomachs, including antrum, gastric body, and cardia. En bloc complete resections were achieved in all cases. The mean specimen size was 44.92 ± 8.30 mm, mean total procedure time was 29.17 ± 11.27 minutes, and mean dissection time was 15.08 ± 7.21 minutes. The optimal dissection plane could be obtained by controlling the grasper in all cases. Conclusions. Technical feasibility, efficacy, and safety of the over-the-scope steerable grasper technique were demonstrated in order to provide dynamic and controlled traction during ESD at different locations of porcine stomachs.
Objective. The cultural desire to avoid cervical incisions and increasing concern for cosmetic outcomes has motivated surgeons to develop alternative approaches to thyroid surgery. The Direct Drive Endoscopic System (DDES) platform combines a flexible endoscope with a pair of separately controlled articulating instruments through a single, flexible, access system. We hypothesized that the DDES platform would permit single-incision minimally invasive thyroid lobectomy without robotic assistance. Methods. This is a single-cadaver feasibility study. A single, 2.2-cm subxyphoid incision was used for access. The platform’s 55-cm flexible sheath was secured to the operating table rails and introduced into the subcutaneous space. A flexible pediatric endoscope was simultaneously introduced with 2 interchangeable 4-mm instruments. Blunt dissection and electrocautery were used to create the tunnel in the otherwise free central plane. The thyroid was dissected using a superior to inferior technique while maintaining the critical steps of traditional thyroid surgery. A Veress needle introduced through the lateral neck provided additional retraction. Results. The total operating time was 2.5 hours. The subcutaneous tunnel was safe and accommodated the DDES well. Visualization was adequate. Graspers, scissors, and hook cautery were used to complete the lobectomy. The ergonomics, articulation, and strength of the instrumentation were sufficient. Conclusions. Subxyphoid thyroidectomy is technically possible and avoids the difficulties inherent to a transaxillary approach while still avoiding cosmetically unappealing cervical scars. Continued technological refinement will only expand the therapeutic possibilities of flexible endoscopy while minimizing the physical insult to patients and maximizing aesthetics for patients.
Introduction. Transvaginal natural orifice transluminal endoscopic surgery procedures are at the forefront of minimally invasive innovation, remarkable for shorter recovery times and decreased postoperative pain. We aim to demonstrate a novel technique of pure transvaginal laparoscopic ventral hernia repair in a series of patients performed in our institution. Technique Description. The patient was placed in lithotomy position and steep Trendelenburg. A 2-cm transverse colpotomy incision was made and a SILS port was introduced. One 12-mm trocar and two 5-mm trocars were placed through the SILS port and standard straight laparoscopic instruments were used. An appropriately sized round mesh was deployed within a specimen retrieval bag into the peritoneal cavity. Complete anterior circumferential fixation of the mesh was achieved using an AbsorbaTack device. The colpotomy incision was closed. Results. There were a total of 6 pure transvaginal ventral hernia repair procedures performed in our institution between November 2010 and February 2012. The first case was converted to an open procedure after a rectal injury was recognized and repaired. Two patients had transient urinary retention that resolved after 24 hours. One patient had vaginal wound granulation noted at 2 months postoperatively. No long-term complications or recurrences were noted with a median follow-up of 9 months. The mean operative time was 107 minutes. Conclusion. Our initial experience with transvaginal ventral hernia repair in humans suggests that this procedure is feasible, safe, and associated with improved cosmetic results.
Background. New developments in intraoperative electrophysiological neuromonitoring for conventional surgery are providing further insights into functional neuroanatomy and nerve-sparing in the minor pelvis. The aim of this study was to open up potential scopes of application in laparoscopy. Methods. Ten patients with different indications for surgery (presacral tumor excision, n = 2; resection rectopexy. n = 2; low anterior rectal resection, n = 2; proctocolectomy. n = 2; abdomino-perineal excision of the rectum, n = 2) were investigated prospectively. The pelvic autonomic nerves were bilaterally mapped by laparoscopic electric stimulation under simultaneous electromyography of the internal anal sphincter and manometry of the bladder. Stimulation results were compared to patients’ anorectal and urogenital functional outcome. Results. In all the operations laparoscopic neuromapping (LNM) was technically feasible. Laparoscopy enabled excellent visibility of pelvic neural structures for simple and differentiated electric stimulation. In all cases LNM resulted in significantly evoked electromyographic potentials and intravesical pressure rises. The technique facilitated electrophysiological determination of functional neuroanatomical topography in the minor pelvis. The stimulation results were suitable to confirm laparoscopic nerve-sparing and compatible with patients’ anorectal and urogenital functional outcome. Conclusions. LNM is technically feasible and opens up a new dimension for verification of functional nerve integrity. Further developments and investigations are mandatory to evaluate its role for laparoscopic nerve-sparing procedures.
Introduction. Surgical site infections (SSIs) affect costs of care and prolong length of stay. Crohn’s disease (CD) represents an independent risk factor for SSI. The risk can be further increased by concomitant administration of immunosuppressive drugs and poor performance status at the time of surgery. Patients suffering from CD often need more than one surgical intervention during life, sometimes requiring fashioning of a stoma. The aim of this pilot study was to compare a portable device for negative pressure wound therapy (PICO, Smith & Nephew, London, UK) to conventional gauze dressings in patients undergoing surgery for stricturing CD. Methods. Between January 2010 and November 2011, this controlled trial enrolled 30 patients, who were assigned to treatment with either PICO (n = 13) or conventional dressings (n = 17). Each patient completed a 3-month follow-up. Results. Patients receiving PICO experienced significantly less postoperative wound complications (P = .001) and SSI (P = .017) compared with those who received conventional dressings. This resulted in shorter hospital stay (P = .0007). No significant differences in cosmetic results were found. Conclusion. These data suggest that PICO allows faster and safe discharge by reducing the incidence of SSI and wound-related complications in selected patients undergoing surgical intervention for stricturing CD. This could be particularly useful in patients receiving steroids.
Background and objectives. Autofluorescence imaging (AFI) is mainly used to detect (pre)cancerous colorectal and pulmonal lesions. This is the first report establishing the feasibility of AFI in patients with peritoneal carcinomatosis (PC). Methods. This is a prospective analysis of 10 patients undergoing conventional white-light laparoscopy (WL) and AFI for PC of different gastrointestinal tumors and 1 ovarian cancer. Before taking biopsies, suspicious peritoneal lesions were first detected by WL and then investigated by AFI. The intraoperative findings were photographed and then correlated with histological results. Results. Conventional WL and AFI evaluation was successful in all patients. A total of 38 biopsies were taken. The neoplasm detection rate under WL was 66% and increased to 86% when using AFI. The positive tumor detection rate was slightly higher in low AF lesions (83 vs 88%) and higher in tumor nodules (94%) than in flat peritoneal lesions (75%). For tumor nodules, the sensitivity was 94%, and the specificity was 100%. For flat lesions, the sensitivity was 75% and specificity 50%. Conclusions. We demonstrate the feasibility and effectiveness of AFI in patients with PC.
Introduction. Component separation (CS) has become a viable alternative to repair large ventral defects when the fascia cannot be reapproximated. However, the impact of transecting the external oblique to facilitate closure of the abdomen on quality of life (QOL) has yet to be investigated. The study goal was to investigate QOL and outcomes after standard open ventral hernia repair (OVHR) versus CS for large ventral hernias. Study design. Prospective data for all CSs were reviewed and compared with matched OVHR controls. All defects were 100 to 1000 cm2 in size and repaired with mesh. Comorbidities, complications, outcomes, and Carolinas Comfort Scale (CCS) scores, were reviewed. Results. Seventy-four CS patients were compared with 154 patients undergoing standard OVHR with similar defect sizes. Age (56.7±13.0 vs 54.7 ± 12.3 years, P = .26), defect sizes (299 ± 160 vs 304 ± 210cm2, P = .87), and BMI (32.7 ± 6.9 vs 34.2 ± 9.0 kg/m2, P = .26) were similar in both groups, respectively. There were no differences in major postoperative complications (P = .22), mesh infections (P = 1.00), wound infections (P = .07), or hernia recurrence (P = .09), but wound breakdown increased after CS (10% vs 1%, P < .001) as did seroma interventions (15% vs 4%, P = .005). Postoperative CCS scores were similar at 1 month (P = .82) and 1 year (P = .14). Conclusions. In the first comparative study of its kind, it is found that patient undergoing CS with mesh reinforcement had equal short- and long-term QOL outcomes compared with similar patients who underwent standard OVHR. Whereas wound breakdown and seroma formation are higher, the overall complication, mesh infection, and recurrence rates are similar.
Background. Hysterectomies are very common, and most of them are still performed abdominally. The minimally invasive alternatives are perceived as difficult by gynecologists. Robotic assistance is thought to facilitate laparoscopic surgery. The aim of this study was to compare the surgical outcomes of robotic-assisted and conventional total laparoscopic hysterectomy. Methods. Patients, candidate to hysterectomy for benign indications, were allocated to either robotic or conventional laparoscopy in a quasi-randomized fashion. Patients were operated following a standardized surgical protocol. Main outcome measures were total surgical time, conversions to laparotomy, blood loss, hospital stay, and complications. Results. Fifty-one patients underwent robotic hysterectomy (mean age = 46.59 years) and 54 conventional laparoscopy (mean age = 50.02 years). The groups were homogeneous in body mass index and uterine weight. Robotic-assisted hysterectomies were significantly shorter (154.63 ± 36.57 vs 185.65 ± 42.98 minutes in the control group; P = .0001). Patients in the robotic group also had a significantly smaller reduction in hemoglobin (9.69% ± 8.88% vs 15.29% ± 8.39% in controls; P = .0012) and hematocrit (10.56% ± 8.3% vs 14.89% ± 8.11%; P = .008). No intraoperative conversions to laparotomy were required. Complication rate was low and similar in both groups. All patients were fully recovered at 1-month follow-up outpatient visit. Conclusions. Significantly lower operative times and blood loss indicate that robotic assistance can facilitate surgery already during the learning curve period. Nevertheless, proficiency can be reached in conventional laparoscopy through training, and the cost-effectiveness of robotic hysterectomy for benign conditions is yet to be confirmed.
Background. Components separation has been proposed as a means to close large ventral hernia without undue tension. We report a modification on open components separation that allows for the incorporation of onlaid noncrosslinked porcine acellular dermal matrix (Strattice, LifeCell Corp, Branchburg, NJ) as a load-sharing structure. Methods. This was a retrospective case series including all cases using Strattice from July 2008 through December 2009. Data evaluated included patient demographics, comorbidities associated with risk of recurrence, hernia grade, and postoperative complications. The primary outcomes were hernia recurrence and surgical site occurrences. Results. There were 58 patients; 60.8% presented with a recurrent incisional hernia. Average length of follow-up was 384 days. There were 4 hernia recurrences (7.9%). Complications included surgical site infection (20.7%), seroma (15.5%), and hematoma (5%) requiring intervention. Four deaths occurred in the series due to causes unrelated to the hernia repair, only 1 within 30 days of operation. Conclusions. This series demonstrates that components separation reinforced with noncrosslinked porcine acellular dermal matrix onlay is an efficacious, single-stage repair with a low rate of recurrence and surgical site occurrences.
Background. Exposure to surgical smoke in the operation room has been a long-standing concern. Smoke generated by the interaction between lasers or electrocautery devices with biological tissue contains several toxic and carcinogenic substances, but only a few studies so far have provided quantitative data necessary for risk assessment. Methods. With laser and Fourier-transform infrared spectroscopy, we investigated the chemical composition of smoke produced with a vessel-sealing device in an anoxic environment during laparoscopic surgery. Results. Harmless concentrations of methane (<34 ppm), ethane (<2 ppm), and ethylene (<10 ppm) were detected. Traces of carbon monoxide (<3.2 ppm) and of the anesthetic sevoflurane (<450 ppm) were also found. Conclusions. Gas leaking or gas being released from the pneumoperitoneum could therefore increase pollution by waste anesthetic gas in the operating room. Most toxic compounds found in earlier studies remained undetected. Adverse health effects for operating room personnel due to some of those substances (eg, toluene, styrene, xylene) can be excluded, assuming no significant losses or changes in the chemical composition of the samples occurred between our sampling and measurements.
Idiopathic achalasia is a motor disorder of the esophagus of unknown etiology caused by loss of motor neurons determining an altered motility. It may determine severe symptoms such as progressive dysphagia, regurgitations, and pulmonary aspirations. Many therapeutic options may be offered to patients with achalasia, from surgery to endoscopic treatments such as pneumatic dilation, botulinum injection, peroral endoscopic myotomy, or endoscopic stenting. Recently, temporary placement of a stent was proposed by Cheng as therapy for achalasia disorders, whereas no Western authors have dealt with it up to date. The present study reports our preliminary experience in 7 patients with achalasia treated with a temporary stent. Partially covered self-expanding metallic stents (Micro-Tech, Nanjin, China) 80 mm long and 30 mm wide were placed under fluoroscopic control and removed after 6 days. Clinical follow-up was scheduled to check endoscopic success, symptoms release, and complications. The placement and the removal of the stents were obtained in all patients without complications. Mean clinical follow-up was 19 months. Five out of 7 patients referred total symptoms release and 2 experienced significant improvement of dysphagia. The procedure was not time consuming and was safe; no mild or severe complications were registered. In conclusion, our results may suggest a possible safe and effective endoscopic alternative treatment in patients with achalasia; however, further larger studies are necessary to confirm these promising, but very preliminary, data.
Surgical stapling instruments, a revolutionary concept in surgical technique, were introduced in the United States in 1967. Notably absent in the new family of American instruments was the circular stapler (EEA) for end-to-end intestinal anastomosis. This strange omission was corrected a decade later. The EEA is now one of the most widely used stapling instruments in the surgical armamentarium.
Laparoscopic instruments that are newly inserted into trocars are initially outside the surgeon’s endoscopic field of view. This can make it difficult to accurately position the instrument at the operative site and presents a potential risk to patients since the tip of the instrument could potentially perforate organs and blood vessels while it is advanced blindly. To solve this problem, I have designed a trocar that incorporates a laser pointer to guide laparoscopic instruments while they are outside the endoscopic field of view. The laser dot is projected along the long axis of the trocar. This allows the surgeon to instantly determine the direction and target of the introduced instrument. Furthermore, the projected laser dot serves as evidence of an unobstructed path from the trocar to the target. This modification improves safety in laparoscopic surgery.
Background. The purpose of the current study is to present the clinical and surgical results in patients who underwent hybrid video-assisted thoracic surgery with segmental–main bronchial sleeve resection. Methods. Thirty-one patients, 27 men and 4 women, underwent segmental–main bronchial sleeve anastomoses for non–small cell lung cancer between May 2004 and May 2011. Results. Twenty-six (83.9%) patients had squamous cell carcinoma, and 5 patients had adenocarcinoma. Six patients were at stage IIB, 24 patients at stage IIIA, and 1 patient at stage IIIB. Secondary sleeve anastomosis was performed in 18 patients, and Y-shaped multiple sleeve anastomosis was performed in 8 patients. Single segmental bronchiole anastomosis was performed in 5 cases. The average time for chest tube removal was 5.6 days. The average length of hospital stay was 11.8 days. No anastomosis fistula developed in any of the patients. The 1-, 2-, and 3-year survival rates were 83.9%, 71.0%, and 41.9%, respectively. Conclusion. Hybrid video-assisted thoracic surgery with segmental–main bronchial sleeve resection is a complex technique that requires training and experience, but it is an effective and safe operation for selected patients.
Background. Balancing donor safety and graft volume is difficult. We previously reported that intentional modulation of portal venous pressure (PVP) during living-donor liver transplantation (LDLT) is crucial to overcoming problems with small-for-size grafts; however, detailed studies of portal venous flow (PVF) and a reliable parameter are still required. Patients and Methods. The elimination rate (k) of indocyanine green (ICG) was measured in 49 adult LDLT recipients. PVP was controlled during LDLT, with a target of <20 mm Hg. ICG reflects hepatocyte volume and effective PVF. The kICG value is divided by the graft weight to calculate PVF. Recipients were divided into 2 groups: those with severe and/or fatal complications within 1 month after LDLT and those without. Results. Survival rates and postoperative profiles were significantly different between the 2 groups. Univariate analysis showed significant differences in ABO blood group, final PVP, final kICG, and the final kICG/graft weight value; however, multivariate analysis showed that only the kICG/graft weight value was significant. The cutoff level for the final kICG/graft weight value for predicting successful LDLT was 3.1175 x 10–4/g. Conclusion. Accurate evaluation and monitoring of optimal PVF during LDLT should overcome the use of small-for-size grafts and improve donor safety and recipient outcomes.
Background. Although the value of surgeon-performed neck ultrasound (SPUS) for thyroid nodules has been validated, the utility of intraoperative ultrasound (US) in modified radical neck dissection (MRND) has not been reported in the literature. The aim of this study was to analyze the utility of intraoperative SPUS in assessing the completeness of MRND for thyroid cancer. Methods. Between 2007 and 2011, a total of 25 patients underwent MRND by 1 surgeon for thyroid cancer. All patients underwent intraoperative SPUS, which was repeated at the end of the neck dissection (completion US) to look for missed lymph nodes (LNs). Results. There were 10 male and 15 female patients. Pathology included 23 papillary and 2 medullary carcinomas. The number of LNs removed per case was 23 ± 2, and the number of positive was LNs 5 ± 1. In 4 (16%) cases, intraoperative US detected 7 residual LNs, which would have been missed, if completion US were not done. These missed LNs were located in low-level IV (3 nodes), high-level II (2 nodes), and posterior level V (2 nodes) and measured 1.4 ± 0.2 cm. At follow-up, recurrence was seen in 2 (8%) patients, including a superior mediastinal recurrence in a patient with tall cell cancer and a jugular LN recurrence at level II in another patient with papillary thyroid cancer. Conclusion. This pilot study shows that intraoperative SPUS can help assess the completeness of MRND. According to our results, intraoperative completion US identifies LNs missed by palpation 16% of the time.
Background. Spatial orientation in natural orifice translumenal endoscopic surgery (NOTES) has been identified as a potential barrier to clinical application. We aim to evaluate a triaxial inertial sensor and software that automatically corrects any movements on the roll axis of the flexible endoscope, allowing for stabilization of the image horizon during NOTES operations in a randomized controlled trial. Methods. A total of 18 participants (11 surgeons/7 gastroenterologists) performed a transgastric task in the ELITE simulator, which included navigation to the appendix and gallbladder, diathermy of the appendix base and gallbladder fossa, and clipping of the cystic duct using a single-channel gastroscope. Each participant performed the task twice with randomization to horizon stabilization occurring at the second attempt. The primary end point was change in overall performance (time taken and errors made) between the first and second attempt, and secondary end points were absolute performances in the second attempt and subjective evaluation. Results. Without horizon stabilization, there was a median improvement of 42.4% in time taken and 38% in number of errors made from the first to the second attempt; however, with the software turned on, there was a statistically significant deterioration of 4.9% (P = .038) in time taken and an increase in errors made of 183% (P = ns). Conclusions. Although the software corrects the view to that preferred during surgery, the endoscopic control mechanism as well as the exit point of the instrument are altered in this process, leading to a deterioration of overall performance. Potential solutions include deploying intermittent horizon stabilization or using a robotic interface to achieve fully aligned perceptual-motor control.
Background. Deep pelvic endometriosis is a complex disorder that affects 6% to 12% of all women in childbearing age. The incidence of bowel endometriosis ranges between 5.3% and 12%, with rectum and sigma being the most frequently involved tracts, accounting for about 80% of cases. It has been reported that segmental colorectal resection is the best surgical option in terms of recurrence rate and improvement of symptoms. The aim of this study is to analyze indications, feasibility, limits, and short-term results of robotic (Da Vinci Surgical System)-assisted laparoscopic rectal sigmoidectomy for the treatment of deep pelvic endometriosis. Patients and Methods. Between January 2006 and December 2010, 19 women with bowel endometriosis underwent colorectal resection through the robotic-assisted laparoscopic approach. Intraoperative and postoperative data were collected. All procedures were performed in a single center and short-term complications were evaluated. Results. Nineteen robotic-assisted laparoscopic colorectal resections for infiltrating endometriosis were achieved. Additional procedures were performed in 7 patients (37%). No laparotomic conversion was performed. No intraoperative complications were observed. The mean operative time was 370 minutes (range = 250-720 minutes), and the estimated blood loss was 250 mL (range = 50-350 mL). The overall complication rate was 10% (2 rectovaginal fistulae). Conclusions. Deep pelvic endometriosis is a benign condition but may have substantial impact on quality of life due to severe pelvic symptoms. We believe that robotic-assisted laparoscopic colorectal resection is a feasible and relatively safe procedure in the context of close collaboration between gynecologists and surgeons for treatment of deep pelvic endometriosis with intestinal involvement, with low rates of complications and significant improvement of intestinal symptoms.
Objectives. To assess trends in the use of sacral neuromodulation and to measure the magnitude of variation in its use across geographic regions. Methods. We used the State Ambulatory Surgery Database (SASD) from 2002 to 2009 from Florida to identify patients implanted with a neuromodulator. Age- and gender-adjusted rates of implantation were calculated by year and by geographic region, defined by the Hospital Service Area. The coefficient of variation was estimated to quantify the magnitude of variation for different time periods. Results. Adjusted rates of sacral neuromodulation increased significantly from 1.1 per 100 000 population in 2002 to 10.4 per 100 000 population in 2009. The majority of cases were performed for overactive bladder. There was a very large amount of geographic variation in rates of these procedures as evidenced by the high coefficients of variation: 1.67 (2002 and 2003), 1.70 (2004 and 2005), 1.49 (2006 and 2007), and 1.05 (2008 and 2009). Conclusions. Rates of sacral neuromodulation have increased dramatically over the past decade. However, these rates of utilization are highly variable across regions, with some regions performing large numbers of these procedures and other regions performing few to no procedures. This range in practice patterns may reflect medical uncertainty surrounding the role of this procedure.
Aim. The concept of compression alimentary anastomosis is well established. Recently, magnetic axial alignment pressures have been encompassed within such device constructs. We quantify the magnetic compression force and pressure required to successfully achieve gastrointestinal and bilioenteric anastomosis by in-depth interrogation of the reported literature. Methods. Reports of successful deployment and proof of anastomotic patency on survival were scrutinized to quantify the necessary dimensions and strengths of magnetic devices in (a) gastroenteral anastomosis in live porcine models and (b) bilioenteric anastomosis in the clinical setting. Using a calculatory tool developed for this work (magnetic force determination algorithm, MAGDA), ideal magnetic force and compression pressure were quantified from successful reports with regard to their variance by intermagnet separation. Results. Optimized ranges for both compression force and pressure were determined for successful porcine gastroenteral and clinical bilioenteric anastomoses. For gastroenteral anastomoses (porcine investigations), an optimized compression force between 2.55 and 3.57 kg at 2-mm intermagnet separation is recommended. The associated compression pressure should not exceed 60 N/cm2. Successful bilioenteric anastomoses is best clinically achieved with intermagnet compression of 18 to 31 g and associated pressures between 1 and 3.5 N/mm2 (at 2-mm intermagnet separation). Conclusion. The creation of magnetic compression anastomoses using permanent magnets demonstrates a remarkable resilience to variations in magnetic force and pressure exertion. However, inappropriate selection of compression characteristics and magnet dimensions may incur difficulties. Recommendations of this work and the availability of the free online tool (http://magda.ucc.ie/) may facilitate a factor of robustness in the design and refinement of future devices.
Background. This study aimed to evaluate the safety and efficacy of a sutureless hemostatic control during laparoscopic nephron sparing surgery (LNSS) for the treatment of small renal masses. Methods. Between November 2007 and August 2010, 245 patients underwent nephron sparing surgery. Overall, 100 patients (41%) had LNSS. Hemostasis was controlled either by a knot-tying suture repair (standard-LNSS) or by a sutureless technique (s-LNSS). The s-LNSS was done using a bipolar cauterization of the resection bed, followed by Floseal apposition. Operative and warm ischemia time (WIT), intraoperative blood loss, hospital stay, blood tests, and perioperative complications were recorded. Results. In 32 cases (32%) hemostasis was controlled by the sutureless technique. The s-LNSS was the treatment of choice for small tumors ≤1.5 cm, and it was also used for the treatment of tumors between 1.6 and 2.5 cm, aside from their spatial extension. Indeed, the mean (range; interquartile range) clinical dimension of the tumors in the s-LNSS group was 1.9 (1-3.5; 1.5-2.1) cm. On the contrary, the vast majority of tumors >2.5 cm were treated with standard-LNSS. Mean (range; interquartile range) WIT in the s-LNSS group was 16 (8-22; 12-16) minutes. The mean (range) intraoperative blood loss in the s-LNSS group was 107 cc (25-205). No postoperative early and late bleeding were reported in the s-LNSS group, and the mean (range) time to drainage removal and time to discharge were 3 (2-5) and 4 (3-7) days, respectively. Conclusions. The sutureless technique with bipolar cauterization of the surgical bed and Floseal apposition is safe and effective for the hemostatic control in the treatment of small cortical masses. It can be always used for tumors ≤1.5 cm and can be a valid option also for tumors between 1.6 and 2.5 cm, aside from their spatial extension.
Background. To date there are no practical platforms for performing natural orifice transluminal endoscopic surgery in the thoracic cavity. This study evaluates the feasibility of transumbilical thoracosopy for lung biopsy and pericardial window creation. Methods. Eleven dogs (6 in the nonsurvival group and 5 in the survival group) were used for this study. A homemade metallic tube was advanced into the abdominal cavity via a 12-mm umbilical incision. The metallic tube was advanced into the thoracic cavity through a subxyphoid diaphragmatic incision under video guidance. Access to the thoracic cavity was achieved by a flexible bronchoscope via the metallic tube. Surgical lung biopsy and pericardial window creation were performed using an electrocautery loop and needle knife. The animals were euthanized 20 minutes after the surgery was complete (nonsurvival group) or 14 days postsurgery (survival group) for necropsy evaluation. Results. Eight pericardial window creations and 21 of 22 preplanned lung biopsies were completed in a median time of 72.18 minutes (range 50-105 minutes). One dog in the nonsurvival group died after tension pneumothorax due to postprocedure massive air leaks. In the survival group, the postoperative period was uneventful in all 5 dogs. Autopsies revealed no signs of vital organ injury and complete healing of the diaphragmatic incision occurred in all animals. Conclusions. The study demonstrated that transumbilical thoracoscopic surgical lung biopsy and pericardial window creation is feasible. The safety and efficacy of the transumbilical approach need to be verified by a more detailed survival study.
Laparoscopic cholecystectomy is associated with attenuated acute-phase response and hypercoagulable state compared with the open procedure. Single-incision laparoscopic cholecystectomy is a new technique aiming to minimize the invasiveness of the procedure. By comparing the degree of coagulation and fibrinolysis activation after conventional multiport (CLC) and single-incision (SILC) laparoscopic cholecystectomy, we aimed to determine whether the reduced incision size induces a lower thrombophilic tendency. Thirty-two adult patients with noncomplicated symptomatic cholelithiasis were nonrandomly assigned to CLC or SILC. Prothrombin fragment 1 + 2 (F1 + 2), thrombin–antithrombin complexes (TAT), D-dimers, fibrinogen, and von Willebrand factor levels were measured at baseline, at 1st, and 24th hour, postoperatively. Twenty-six patients were finally included in the study. Fifteen patients underwent CLC (male/female: 5/10) and 11 underwent SILC (male/female: 1/10). There were no perioperative complications. An almost similar postoperative pattern and degree of activation of coagulation and fibrinolysis pathways was noted in both groups. No statistically significant differences were found between SILC and CLC for F1 + 2, TAT, D-dimers, fibrinogen, and von Willebrand factor levels, duration of surgery, length of hospital stay, and postoperative morbidity. A similar pattern and extent of coagulation and fibrinolysis activation is present in SILC and CLC, and therefore there is no difference in tendency for thrombosis. Thromboembolic prophylaxis should be considered in SILC as recommended for CLC, pharmacologic or mechanical, considering the hemorrhagic risk and the presence of additional thromboembolism risk factors. SILC appears to be a safe, feasible technique that can be recommended for its potential advantages in cosmesis and reduced incisional pain.
Background: There are limited large animal models for the research of novel anastomotic technologies. Subtotal colectomy requires the anastomosis of relatively remote segments of the alimentary tract that are different anatomically, histologically, and pose significant physiological challenge. The quest for a foreign material–free anastomotic line reintroduced nitinol compression anastomosis into clinical use in the last decade. Objective: To evaluate the safety, histological, and physiological parameters of side-to-side ileocolic nitinol compression anastomosis in a newly developed large animal model, mimicking the human subtotal colectomy. Intervention: Resection of the entire spiral colon with an ileocolic side-to-side compression anastomosis in 12 animals, compared to resection of a short ileal segment in 6 animals. All anastomoses were constructed by using a novel nitinol-based compression device. The animals were followed up to 30 days postoperatively and were reoperated and sacrificed. Results: All 12 animals underwent successful subtotal colectomy with side-to-side nitinol compression anastomosis. No signs of abdominal infection were found. The increase in the colectomized animals’ bodyweight over the postoperative course was significantly lower and the animals presented with longer periods of diarrhea. The histopathology revealed minimal inflammation and foreign body reaction with good alignment of the bowel wall layers in both groups. The anastomotic line width was shown to be reduced during the healing course of the compression anastomoses. Conclusions: Side-to-side nitinol compression anastomosis is safe and demonstrates favorable functional and histopathological features. The porcine model of subtotal colectomy can be used for further research of novel anastomotic technologies.
Background: Providing augmented visual feedback is one way to enhance robot-assisted surgery (RAS) training. However, it is unclear whether task specificity should be considered when applying augmented visual feedback. Methods: Twenty-two novice users of the da Vinci Surgical System underwent testing and training in 3 tasks: simple task, bimanual carrying (BC); intermediate task, needle passing (NP); and complex task, suture tying (ST). Pretraining (PRE), training, and posttraining (POST) trials were performed during the first session. Retention trials were performed 2 weeks later (RET). Participants were randomly assigned to 1 of 4 feedback training groups: relative phase (RP), speed, grip force, and video feedback groups. Performance measures were time to task completion (TTC), total distance traveled (D), speed (S), curvature, relative phase, and grip force (F). Results: Significant interaction for TTC and curvature showed that the RP feedback training improved temporal measures of complex ST task compared to simple BC task. Speed feedback training significantly improved the performance in simple BC task in terms of TTC, D, S, curvature, and F even after retention. There was also a lesser long-term effect of speed feedback training on complex ST task. Grip force feedback training resulted in significantly greater improvements in TTC and curvature for complex ST task. For the video feedback training group, the improvements in most of the outcome measures were evident only after RET. Conclusions: Task-specific augmented feedback is beneficial to RAS skills learning. Particularly, the RP and grip force feedback could be useful for training complex tasks.
Background. The NOSCAR white paper lists training as an important step to the safe clinical application of natural orifice translumenal endoscopic surgery (NOTES). The aim of this randomized controlled trial was to evaluate whether training novices in either a laparoscopic or endoscopic simulator curriculum would affect performance in a NOTES simulator task. Methods. A total of 30 third-year medical undergraduates were recruited. They were randomized to 3 groups: no training (control; n = 10), endoscopy training on a validated colonoscopy simulator protocol (n = 10), and training on a validated laparoscopy simulator curriculum (n = 10). All participants subsequently completed a simulated NOTES task, consisting of 7 steps, on the ELITE (endoscopic-laparoscopic interdisciplinary training entity) model. Performance was assessed as time taken to complete individual steps, overall task time, and number of errors. Results. The endoscopy group was significantly faster than the control group at accessing the peritoneal cavity through the gastric incision (median 27 vs 78 s; P = .015), applying diathermy to the base of the appendix (median 103.5 vs 173 s; P = .014), and navigating to the gallbladder (median 76 vs 169.5 s; P = .049). Endoscopy participants completed the full NOTES procedure in a shorter time than the laparoscopy group (median 863 vs 2074 s; P < .001). Conclusion. This study highlights the importance of endoscopic training for a simulated NOTES task that involves both navigation and resection with operative maneuvers. Although laparoscopic training confers some benefit for operative steps such as applying diathermy to the gallbladder fossa, this was not as beneficial as training in endoscopy.
Aim. The purpose of this study is to investigate the effect of intraperitoneal (IP) bevacizumab on colonic anastomosis and evaluate the effects on early postoperative adhesion formation. Materials and Methods. A total of 24 mature female Sprague-Dawley rats were used for this study. Rats were randomly assigned to a control group that received saline (n = 8) or to experimental groups (n = 8 each) that received bevacizumab at a dose of 2.5 mg/kg (group 1) or 5 mg/kg (group 2). Animals were killed humanely on the seventh day after operation, and measurements of anastomotic strength and biochemical variables were performed. Results. The mean adhesion grade was 2.63 ± 0.92, and 1 ± 0.93 and 0.75 ± 0.71 for the control and test groups, respectively. Bevacizumab significantly reduced adhesion formation in both low-dose and high-dose IP applications (P < .05). When all groups were compared, it was found that VEGF levels decreased significantly only in the tissue (P = .001), whereas there was no significant difference in the blood and the IP fluid (P = .73 and .08, respectively). We evaluated hydroxyproline levels, anastomosis bursting pressure, and histopathological healing scores. When each of these parameters were examined, there was statistical difference between groups (P = .01, .004, and .01, respectively). It was found that these parameters significantly decreased depending on increasing drug dose. Conclusion. IP administration of bevacizumab effectively reduced the formation of adhesions and caused significant impairment of anastomotic wound healing when standard doses were administered (5 mg/kg), but the 2.5-mg/kg dosage did not affect the anastomotic wound healing and also effectively reduced the formation of adhesions.
Total hip replacements for older patients are usually cemented to ensure high postoperative primary stability. Curing temperatures vary with implant material and cement thickness (30°C to 70°C), whereas limits for the initiation of thermal bone damage are reported at 45°C to 55°C. Thus, optimizing surgical treatment and the implant material are possible approaches to lower the temperature. The aim of this study was to investigate the influence of water cooling on the temperature magnitude at the acetabulum cement interface during curing of a modular cobalt-chromium cup and a monoblock polyethylene acetabular cup. The curing temperature was measured for SAWBONE and human acetabuli at the cement–bone interface using thermocouples. Peak temperature for the uncooled condition reached 70°C for both cup materials but was reduced to below 50°C in the cooled condition for the cobalt-chromium cup (P = .027). Cooling is an effective method to reduce curing temperature with metal implants, thereby avoiding the risk of thermal bone damage.
Background/Purpose. Closure of large wounds is a difficult surgical challenge. This article reports on the effective closure of large surgical wounds using elastic rubber strips. Methods. One to 3 circular elastic rubber strips were sutured by applying moderate tension to the opposite edges of 30 large wounds in 28 patients. The strips were sutured in a successive "X" fashion by crossing one over the other. These rubber strips were replaced when they ruptured or after their tension had reduced because of the closure of the wounds. Results. Complete closure of the wounds was achieved with no further need for any surgical procedure or device. One patient with laparostomy and colostomy presented with difficulty on adapting the colostomic bag, and the rubber strips were removed. The rubber strip had little effect on a large wound of the skull. In the late postoperative follow-up, 3 of the 15 closed laparostomies developed incisional hernias, and all these patients were subjected to hernioplasties with good results. Conclusion. The use of circular elastic rubber strips maintained at moderate tension is a simple, effective, and inexpensive surgical option for healing large wounds. It is readily available at any hospital and requires no extensive surgical experience.
Background. Despite advances in many areas of therapeutic endoscopy, the development of an effective endoscopic suturing device has been elusive. The purpose of this trial was to evaluate the safety and effectiveness of a suturing device to place and secure sutures within normal, in vivo human colonic tissue prior to surgical resection. Methods. Patients undergoing elective colectomy were enrolled in this treat-and-resect model. The Overstitch endoscopic suturing device (Apollo Endosurgery, Austin, TX) was used to place sutures in healthy colonic tissue during a 15-minute, time-limited period. Following colectomy, the explanted tissue was evaluated to determine the depth of suture penetration and the effectiveness of the suture/cinch element. Clinical and operative data were recorded. Results. Four patients (50% female) were enrolled. Seven sutures were successfully placed, incorporating a total of 10 tissue bites in a mean of 13.5 minutes. On inspection of the explanted tissue, all sutures were found to be located subserosal (no full thickness bites were taken). The suture and cinch elements were judged to be effective in the majority of cases. One device-related issue did not inhibit the ability to oppose tissue or place the cinch. There were no intraoperative or postoperative complications. Conclusions. The Overstitch permitted safe and effective suturing in an in vivo human colon model. The sutures were placed at a consistent subserosal depth and at no point risked iatrogenic injury to adjacent structures. Technical issues with the device were infrequent and did not inhibit the ability to place sutures effectively.
Background. Totally implantable access ports (Port-A) can be inserted using 2 techniques: cut-down and percutaneous. The cut-down method is safer than the percutaneous method. However, the cut-down method has a higher failure rate. We report an alternative method to decrease the failure rate of the cut-down method. Patients and Methods. In all, 758 cases of Port-A implantation with cephalic vein cut-down were tried, and 56 cases failed. Of the 56 cases, 29 cases were converted to the percutaneous subclavian method (group A), and 27 cases were converted to the external jugular vein cut-down method (group B). The patient’s characteristics, causes of failure of cephalic vein cut-down, operating time, and complications were compared. Results. The failure rate of cephalic vein cut-down was 7.4%. The causes of failure of cephalic vein cut-down are described. There were 4 complications in group A, including one pneumothorax (1/29), one fracture of the catheter (1/29), one embolization of the catheter (1/29), and one hematoma formation in the port site (1/29); 2 complications occurred in group B, including one embolization of the catheter (1/27) and one hematoma in the port site (1/27). The total complications were 17.7%. Conclusion. Conversion to external jugular vein cut-down is safely and easily applied in cases of cephalic vein cut-down failure. This method did not take more time than the percutaneous subclavian method. However, placement of the port should be made more carefully to prevent angulation of the catheter. We provide an alternative method to deal with failure of cephalic vein cut-down.
Background. Orthognathic surgery leads to alteration of the spatial relationship of the mandible and maxilla resulting changes in the degree of facial projection. Traditional 2-dimensional cephalometry and photographic techniques do not provide data on facial depth. Though stereophotogrammetry can be used as a noninvasive method for evaluating facial depth, the unavailability of ethnicity-specific norms hinder its routine use in clinical practice. The objectives of this study were to (a) generate an analytic scheme suitable for evaluating facial depth using stereophotogrammetry and (b) create normative data for the facial depth measurements for young Hong Kong Chinese adults. Methods. Stereophotographic images from 41 male and 45 female ethnic Chinese young adults without facial deformities were analyzed. Facial depth measurements were performed based on standard anthropometric landmarks, with the aid of 3dMDVultus software. Results. All facial depth measurements were found in absolute terms to be significantly higher in males. In contrast, the upper face, maxillary, and sublabial depth indices were significantly higher in females, whereas no significant gender differences emerged for lower facial and maxillomandibular indices. Conclusions. A novel method of using stereophotographic images for quantifying facial depth was evaluated. Normative facial depth measurements for young Hong Kong Chinese adults were established. This gender-specific database can be used as a reference in the diagnosis, treatment planning, or evaluation of outcomes after surgical correction of facial deformities.
Background. Suture and staple-based endoluminal devices for gastroesophageal reflux disease (GERD) and obesity have failed to demonstrate long-term efficacy. Objective. To demonstrate the feasibility of mucosal excision and full-thickness suture apposition of the excision beds to create sufficient scar tissue formation at the gastroesophageal junction for the intraluminal treatment of GERD or obesity. Design. Survival animal experiments. Patients. Seven mongrel dogs. Interventions. Under general endotracheal anesthesia, a Barostat test was performed on 4 dogs. A mucosal excision device was introduced through the esophagus into the proximal stomach. Two to 4 mucosal excisions were performed on all dogs at or just below the gastroesophageal junction and the mucosal pieces were removed. After hemostasis, an intraluminal suturing instrument was introduced and either 2 or 4 sutures were placed through the excision beds to bring them into apposition. These were tied and the suture strands cut. All dogs were survived for 2 months. End-term endoscopies were performed, and a repeat Barostat procedure was performed on the animals undergoing an antireflux procedure. After euthanasia the stomachs were explanted, examined, photographed, and sectioned for histologic examination. Results. All dogs survived without complication. In the 4 GERD dogs, the Barostat studies demonstrated a significant decrease in gastroesophageal junction compliance. In the 3 dogs undergoing the obesity procedure, the gastric outlet apposition to a 6-mm endoscope was satisfactory with full insufflation and the desired scarring was seen on histologic examination. Conclusion. It is possible to create adequate gastroesophageal junction scarring for the treatment of GERD and obesity. A clinical pilot study will be initiated.
Adhesions are a formidable challenge in patients undergoing reoperative cardiac surgery, particularly in those supported by an intracorporeal left ventricular assist device (LVAD) and undergoing heart transplantation. This report describes the pathological findings following the clinical use of a surgical sealant (CoSeal, Baxter Healthcare, Fremont, CA), in a patient who underwent LVAD implantation. On the treated surfaces, a minimal amount of adhesions were observed, whereas in untreated surfaces adhesions were present.
Background. Sacral neuromodulation (SN) is an emerging treatment for constipation. This review evaluates the mechanism of action, techniques, efficacy, and adverse effects of SN in the management of constipation. Methods. Electronic searches for studies describing the use of SN were performed in PubMed, MEDLINE and Embase. Abstracts were reviewed and full text copies of all relevant articles obtained. Results. Fifty-nine results were obtained on the initial searches. Ten studies discussed the results of SN in patients with constipation. A total of 225 temporary neuromodulations and 125 permanent implants were performed. Bowel diaries showed improvement in assessment criteria in more than 50% of patients on temporary neuromodulation and the results were maintained in approximately 90% of patients who underwent permanent implantation over medium to long-term follow-up. The rate of adverse effects was high, but the majority of them were related to electrode position. Improvements in transit studies and anorectal physiology after neuromodulation were noted in some studies. The recognized limitations included a lack of randomized studies and an inability to perform meta-analysis. Conclusion. Sacral neuromodulation may be an effective treatment in selected patients with constipation and should be a part of the management repertoire. Improvement in defecatory frequency with temporary wire placement is a good predictor of subsequent response following permanent implant. Further research into predictive factors for success would improve patient selection.
Background. This study evaluated the use of laparoscopy in hemodynamically stable patients with blunt abdominal trauma. Methods. We retrospectively reviewed the medical records of hemodynamically stable blunt abdominal trauma patients. Patients admitted from July 1, 2003, to June 30, 2006 (prior to the adoption of laparoscopy for patients with blunt abdominal trauma) were categorized as group A. Patients admitted from July 1, 2007, to June 30, 2010, when laparoscopy was included in the algorithm for the management of blunt abdominal trauma, were categorized as group B. Results. There were 47 patients in group A and 57 patients in group B. There were no significant differences in demographic characteristics, injury severity score, and injuries requiring surgical intervention between the groups (all, P > .05). Patients in group B had a shorter hospital stay (11 days vs 21 days, P < .001) and shorter ICU stay (0 [0, 1] days vs 0 [0, 9] days, P = .029). In group A, 6 of 47 patients (12.8%) underwent a nontherapeutic laparotomy. In contrast, 9 of 57 patients (15.8%) in group B avoided a nontherapeutic laparotomy because no significant intra-abdominal findings warranting an intervention were disclosed by laparoscopy. The incidence of laparotomy for patients with significant injuries in group B was lower than in group A (4.2% vs 100.0%; P < .001). There was no difference in the complication rate between the groups. Conclusions. Laparoscopy is feasible and safe for the diagnosis and treatment of hemodynamically stable patients with blunt abdominal trauma and can reduce the laparotomy rate.
The aim of the study was to present a clinical use of compression anastomosis clip (CAC) implants made of shape memory materials—nickel titanium alloys (NiTi). The concept involved in the use of CAC was to compress 2 bowel walls together, cause necrosis, and detach the CAC from the tissue to be expelled with the stool. The CAC is a double-ring elliptical device with a diameter of 30 mm. The device has the ability to recover its original closed shape when it senses a change in ambient temperature. In all, 20 anastomoses using CACs were performed: 6 of the small with the large bowel and 14 between the small bowel and small bowel. Two patients experienced complications. Although the anastomosis is not difficult to perform, the rules on how to apply the CAC must be well known. Because only a small number of anastomoses have been performed by us to date, this procedure requires further study.
Aim. To present our preliminary experience with nerve-sparing minilaparoscopic radical hysterectomy plus pelvic lymphadenectomy for the surgical treatment of cervical cancer and to compare outcomes with those of the conventional laparoscopic approach. Methods. Data of 87 consecutive women who underwent minimally invasive surgery for early and locally advanced stage cervical cancer were prospectively collected. Ten women who underwent laparoscopic surgery using a nerve-sparing technique performed through 3-mm ancillary ports were compared with the 77 patients who had standard laparoscopic surgery previously with 3 sovrapubic 5-mm trocars. Results. Minilaparoscopic radical hysterectomy was successfully accomplished in every case with no conversion to standard laparoscopy or open surgery. Two (2.6%) conversions to open surgery occurred in the conventional laparoscopy group. Surgical characteristics (operative time, estimated blood loss, and length of stay) and complication rate were similar between the 2 groups. No differences in the amount of parametrial and vaginal tissue removed were observed. The number of lymph nodes retrieved through minilaparoscopy was higher than conventional laparoscopy (30 [range = 26-38] vs 22 [range = 8-49]; P = .002). However, no difference was observed when the analysis was restricted to the last 10 conventional procedures (30 [range = 26-38] vs 29 [range = 24-49]; P = .81). Conclusions. Our data show that minilaparoscopic radical hysterectomy with pelvic lymphadenectomy is a feasible procedure if performed by skilled surgeons.
Introduction. Longo’s technique (or PPH technique) is well known worldwide. Meta-analysis suggests that the failure due to persistence or recurrence is close to 7.7%. One of the reasons for the recurrence is the treatment of the advanced hemorrhoidal prolapse with a single stapling device, which is not enough to resect the appropriate amount of prolapse. Materials and methods. We describe the application of "Double PPH Technique" (D-PPH) to treat large hemorrhoidal prolapses. We performed a multicentric, prospective, and nonrandomized trial from July 2008 to July 2009, wherein 2 groups of patients with prolapse and hemorrhoids were treated with a single PPH or a D-PPH. Results were compared. The primary outcome was evaluation of safety and efficacy of the D-PPH procedure in selected patients with large hemorrhoidal prolapse. Results. In all, 281 consecutive patients suffering from hemorrhoidal prolapse underwent surgery, of whom 74 were assigned intraoperatively to D-PPH, whereas 207 underwent single PPH. Postoperative complications were 5% in both groups (P = .32), in particular: postoperative major bleeding 3.0% in PPH versus 4.1% D-PPH (P = .59); pain 37.9 % PPH versus 27.3% D-PPH (mean visual analog scale [VAS] = 2.5 vs 2.9, respectively; P = .72); and fecal urgency 2.1% PPH versus 5.7% D-PPH (P = .8). Persistence of hemorrhoidal prolapse at 12-month follow-up was 3.7% in the PPH group versus 5.9% in the D-PPH group (P = .5). Conclusions. Our data support the hypothesis that an accurate intraoperative patient selection for single (PPH) or double (D-PPH) stapled technique will lower in a significant way the incidence of recurrence after Longo’s procedure for hemorrhoidal prolapse.
Purpose. Mesh surgeries are counted among the most frequently applied surgical procedures. Despite global spread of mesh applying surgeries, there is no current systematic analysis of incidence and possible prevention of adverse events after mesh implantation. Materials and Methods. Based on the recommendations of IDEAL an in vitro test system for biocompatibility of surgical meshes has been generated (Innovation). Coating strategies for biocompatibility optimization have been developed (Development). The native and modified alloplastic materials have been tested in an animal model over 2 years (Exploration and Assessment and Long-term study). Results. In 3 meshes, implanted in sheep and explanted at 4 different time points (a, 3 months; b, 6 months; c, 12 months; and d, 24 months) over 24 months, thickness of inflammatory tissue (TVT a, 35 µm; b, 32 µm; c, 33 µm; d, 28 µm; UltraPro, a, 25 µm; b, 24 µm; c, 21 µm; d, 22 µm; PVDF a, 20 µm; b, 21 µm; c, 14 µm; d, 15µm), connective tissue (TVT a, 37 µm; b, 36 µm; c, 43 µm; d, 41 µm; UltraPro a, 33 µm; b, 32 µm; c, 40 µm; d, 38 µm; PVDF a, 25 µm; b, 22 µm; c, 22 µm; d, 24 µm), and macrophage infiltration (TVT a, 36%; b, 33%; c, 23%; d, 20%; UltraPro a, 34%; b, 28%; c, 25%; d, 22%; PVDF a, 24%; b, 18%; c, 18%; d, 16%) revealed comparable ranking characteristics at every time point after explantation. The in vivo performance of these meshes in a sheep model was predictable with a previously developed in vitro test system. Coating of meshes with autologous plasma prior to implantation seems to have a positive effect on the meshes biocompatibility. Conclusion. We have applied IDEAL criteria on a new innovation for surgical meshes. The results permit the generation of a ranking of currently available meshes with potential to optimize future meshes.
Aim. So far, not many clinical examples that follow the IDEAL (Idea, Development, Evaluation, Assessment, and Long-term study) recommendations for evaluating and reporting surgical innovation and adoption are available. Methods. In this article, all IDEAL stages will be described for a recent surgical innovation, the ileo neorectal anastomosis (INRA), a procedure restoring intestinal continuity after colectomy. Results. INRA showed that the technique of small-bowel transposition with a vascular pedicle is feasible, with good long-term results. From the patient’s point of view, no distinct advantage for INRA was found, with morbidity and functional results being in range with the gold standard ileal pouch anal anastomosis. Conclusion. The adoption of the IDEAL recommendations—that is, by performing evidence-based surgical studies—will improve surgical science, with the consequence that progress in surgical care continues and interventions become safer and more efficient and allow a better quality of life in surgical patients.
Background. Single-incision laparoscopy (SIL) has gained significance recently. The umbilicus has been the preferred access site for SIL. Suprapubic access site (SAS) can be an alternative, especially for a right hemicolectomy (RH). Methods. Between November 2011 and July 2012, 7 consecutive patients underwent suprapubic SIL RH (SSILRH). The median age was 53 years, and the median body mass index was 23.9 kg/m2. Indications for surgery included appendicular tumor (1) and adenocarcinoma of the right colon (6). Three reusable trocars were used, and the resection was performed through the SAS. An intracorporeal linear stapled anastomosis was performed, the mesenteric defect was closed, and the access site was used for specimen extraction. Results. No patient required additional trocars or conversion to an open surgery. The median laparoscopic time was 222 minutes, and the median final incision length was 50 mm. The median Visual Analogue Scale score (0-10) at 6, 18, 30, 42, 54, 66, and 78 postoperative hours was 6, 6, 2, 2, 2, 2, and 2, respectively. The median hospital stay was 4 days. Conclusions. SSILRH is useful because the SAS can be enlarged for extraction of the specimen without compromising the cosmetic outcome. The mesocolic and mesenteric dissections are on the same axis as the access site. The intracorporeal anastomosis can be performed without traction. Finally, positioning of the operative table improves exposure of the operative field and allows the surgeon to maneuver the colon and small bowel intracorporeally.
Ultrasonic thermal energy is commonly used for dissection and vessel ligation. This study compared HARMONIC ACE and Sonicision Cordless Ultrasonic Dissector (SCUD). The devices were used in an in vivo porcine model to coagulate 189 arteries up to 5 mm. Seal times were similar: SCUD, 5.2 ± 1.7 s; ACE, 4.9 ± 1.5 s (P = .20). Burst pressures for SCUD and AVE were 578 ± 284 and 605 ± 288 mm Hg, respectively (P = .48). Stratification by vessel diameter yielded similar results. In all, 17 applications resulted in seal failure on either the proximal or distal side, with no difference between SCUD (4.4%) and ACE (6.6%; P = .37). Histological examination of 48 specimens showed similar thermal spreads: 1.06 ± 0.05 versus 1.08 ± 0.05 mm for SCUD and ACE, respectively (P = .82). In 41 timed mesenteric transections, SCUD required 24.8 ± 4.9 s, which was significantly less than the 33.8 ± 5.4 s for ACE (P < .0001), with no bleeding in either group. SCUD and ACE showed similar vessel seal times, burst pressures, thermal spreads, and seal failure rates. SCUD was more efficient than ACE in mesenteric transection.
Background. Visualization of the lymphatic system is challenging. Lymphatic imaging is a crucial diagnostic tool for benign and malignant lymphatic pathologies. Fluorescence-guided imaging allows selective lymphatic mapping and sentinel lymph node (SLN) identification. There are a few fluorescence systems, but some drawbacks remain due to technical and ergonomic aspects. The aim of this study was to evaluate the feasibility of the new Fluobeam 800 imaging system. Methods. After approval by the ethics committee, the system was evaluated for lymphography and SLN biopsy in an animal model. Five pigs each with 4 lymph node (LN) stations (n = 20 LN stations) were subjected to lymphatic imaging using indocyanine green (ICG). Additionally, the use of ICG was compared with ICG adsorbed to human serum albumin (ICG–HSA). Lymphatic vessels and SLN identification rates were measured. Results. After injection, a clear fluorescence signal of the lymphatic vessels was visualized leading to the LN station. Overall, ICG fluorescence imaging identified a mean of 2.0 lymphatic vessels and 1.1 (range = 1-2) SLN in 20 of 20 LN stations. Reverse lymphography was feasible. A clinical difference in resolution was not detected between use of ICG–HSA and ICG. Conclusion. This is the first study analyzing the feasibility of the Fluobeam 800 imaging system allowing transcutaneous real-time imaging. It enables detection of the SLN by fluorescence retention with increased detection depth and resolution. After fixation to the ceiling, the ergonomics advanced for simultaneous field navigation and dissection. The new system can be applied for lymphatic imaging for lympatico-reconstructive surgery and SLN biopsy.
Background. The aim of this prospective study is to objectively assess the acquisition of skills of trainees attending laparoscopic surgery courses. Methods. Thirty-four junior surgical trainees had their laparoscopic skills assessed before and after attending 1 of 3 separate runs of 3-day core skills in laparoscopic surgery course. Nine control trainees were also included who did not attend the course. Three virtual tasks (camera navigation, hand–eye coordination, and 2-handed maneuver) were used from a virtual reality simulator (Simbionix) for assessment. Camera navigation was assessed by completion time and maintenance of horizontal view, whereas the other 2 tasks were assessed by completion time, path length (both hands), and the number of movements (both hands). A composite score of overall performance was calculated by combining all the 12 parameters. Results. The course significantly (P < 0.001) improved 91% of the junior trainees’ precourse laparoscopic skills. Around 70% to 85% of the participants had improvement in skills in all the parameters following the course. The significant improvements were seen in 10 out of 12 task-specific parameters (P ≤ .004) except path length of the left hand. No significant improvement in skills was seen in any 1 of the 12 parameters for the control participants except for a slight reduction in performance matrics. Foundation and core trainees had acquired significantly (P = .02) more skills (23% improvement) than the specialist trainees (8% improvement). Overall acquired skills did not differ significantly in terms of age, sex, or dominant hand of trainees. Conclusion. Objective validated methods can be used to demonstrate course efficacy in addition to providing participants with an insight into their skills. Junior trainees with little or no previous experience benefit the most from such courses irrespective of their age, sex, and dominant hand.
Background. The current articulating instruments used in laparoendoscopic single-site surgery do not appear to provide the joint forces required. Thus, we measured the joint forces of first-generation articulating laparoscopic instruments. To compare these forces with those necessary in the surgical context, we evaluated the forces sufficient to produce secure surgical ties in an animal model. Methods. The articulating instruments tested were Laparo-Angle (Cambridge Endoscopic Devices Inc, Framingham, MA), RealHand (Novare Surgical Systems Inc, Cupertino, CA), and Roticulator (Covidien Inc, Mansfield, MA). For each, we measured the angle between the end-effector and the shaft in proportion to the articulating force using a push–pull gauge. Two fixed-position configurations of the instruments were predetermined: the neutral and the fully articulated positions. The forces required to secure surgical ties for the ureter, renal artery, and renal vein were evaluated using kidneys harvested from a female pig. Results. The bending forces required to bend from the neutral position to 30° were 5.6 ± 1.2 and 4.7 ± 1.0 N with the Laparo-Angle and RealHand, respectively. Furthermore, the slippage forces in the fully articulated state were 1.8 ± 0.3, 1.6 ± 0.2, and 1.5 ± 0.2 N in the above order. In contrast, the mean forces to produce surgical ties of the ureter, renal artery, and renal vein were 14.5 ± 2.3, 11.5 ± 0.8, and 10.3 ± 2.3 N, respectively. Conclusion. The joint forces of first-generation articulating instruments for laparoendoscopic single-site surgery are not sufficient to meet the usual operative needs. Improved articulating instruments with greater articulating forces should be developed.
Background. Abdominal perineal resection (APR) with applied colostomy remains the standard treatment for low rectal cancer; however, to date, a very high morbidity rate has been reported. Aims. The aims of this study were to assess fecal continence, persistence of disease-related symptoms, and quality of life in patients with low rectal cancer after APR and pseudocontinent perineal colostomy and concomitant appendicostomy. Methods. We included 17 patients with low rectal cancer who underwent APR at our hospital in this cross-sectional study. Following APR, pseudocontinent perineal colostomy and concomitant appendicostomy were performed. Patients then underwent antegrade colonic enema with tap water. Patients’ symptoms, fecal continence, and quality of life were evaluated at regular time intervals. Results. After a median follow-up of 12 months, 15 of 17 patients completed the study period. All patients were able to perform an antegrade enema by themselves. Mean continence score was 7 (out of 20) based on the Wexner Scale scoring system. Mean global health status score was 78, physical function was 93, and emotional function was 88. Minor morbidity was observed in 6 patients (40%). Conclusion. Pseudocontinent perineal colostomy with appendicostomy provides an acceptable level of continence and functional and emotional improvement in patients with low rectal cancer undergoing APR. Hence, this combinative method could be considered as an alternative for abdominal colostomy in selected patients.
Background. Minimally invasive surgery has proved to be effective and efficient in the management of gastric submucosal tumors (SMT). However, confronting a SMT near the esophagogastric junction (EGJ) is still challenging because of the potentially devastating risks of stenosis or leakage. This study evaluated the safety, feasibility, and oncological efficacy of laparoscopic resection for SMTs located near the EGJ. Methods. From December 2008 to November 2011, we enrolled a total of 19 patients diagnosed with gastric SMTs located near the EGJ who underwent laparoscopic surgery. The clinicopathological characteristics and surgical outcomes of the 19 patients were recorded and reviewed retrospectively. Results. All 19 patients underwent laparoscopic resections of their gastric SMTs without complications during the study period. There were 9 men and 10 women, with a mean age of 63.3 ± 15.1 years (range 33-86 years). The operative duration was 187.8 ± 58.9 minutes (range 90-310 minutes). Intraoperative localization included endoscopy (n = 3), tattooing (n = 2), and combined modalities (n = 1). The exogastric (n = 12) and transgastric methods (n = 7) were used. The histopathology showed 10 gastrointestinal stromal tumors, 7 leiomyomas, 1 hyperplastic polyp, and 1 lipoma. The postoperative courses for all cases were uneventful. The mean follow-up period was 16.7 ± 9.4 months, with no recurrence noted. Conclusions: Laparoscopic resections for gastric SMTs near the EGJ are safe and feasible, with satisfactory oncological outcomes in the short term.
Minimally invasive surgery has been continuously evolving over the past 20 years. The use of natural orifice specimen extraction (NOSE) is one of the most recent contributions to minimally invasive methods. The anus has been widely used in NOSE procedures. However, an open rectal stump carries the highest risk of contamination compared with other translumenal approaches to the peritoneal cavity. In this study, the feasibility of a novel NOSE method was tested in a porcine model. This technique combined abdominal and transanal approaches. The abdominal approach was used in rectal mobilization; this was followed by a transanal recto-rectal intussusception and pull-through (IPT). IPT was established in a stepwise fashion. First, the proximal margin of resection was attached to the shaft of the anvil of an end-to-end circular stapler with a ligature around the rectum. Second, this complex was pulled transanally to produce IPT. Once IPT was established, a second ligature was placed around the rectum, approximating the proximal and distal resection margins. The specimen was resected and extracted by making a full-thickness incision through 2 bowel walls distal to the previously placed ligatures. Anastomosis was achieved by applying the stapler. The technique was found to be feasible. A substantial length of bowel was resected in all experiments. Peritoneal samples, collected after transanal specimen extraction, did not demonstrate bacterial growth. Although more investigation is warranted, this procedure has the potential to limit surgical site infections by using aseptic bowel manipulation during colorectal resection and transanal specimen extraction.
The Mozart Effect is a phenomenon whereby certain pieces of music induce temporary enhancement in "spatial temporal reasoning." To determine whether the Mozart Effect can improve surgical performance, 55 male volunteers (mean age = 20.6 years, range = 16-27), novice to surgery, were timed as they completed an activity course on a laparoscopic simulator. Subjects were then randomized for exposure to 1 of 2 musical pieces by Mozart (n = 21) and Dream Theater (n = 19), after which they repeated the course. Following a 15-minute exposure to a nonmusical piece, subjects were exposed to one of the pieces and performed the activity course a third time. An additional group (n = 15) that was not corandomized performed the tasks without any exposure to music. The percent improvements in completion time between 3 successive trials were calculated for each subject and group means compared. In 2 of the tasks, subjects exposed to the Dream Theater piece achieved approximately 30% more improvement (26.7 ± 8.3%) than those exposed to the Mozart piece (20.2 ± 7.8%, P = .021) or to no music (20.4 ± 9.1%, P = .049). Distinct patterns of covariance between baseline performance and subsequent improvement were observed for the different musical conditions and tasks. The data confirm the existence of a Mozart Effect and demonstrate for the first time its practical applicability. Prior exposure to certain pieces may enhance performance in practical skills requiring spatial temporal reasoning.
In this work, we compared accuracy, repeatability, and usability in breast surface imaging of 2 commercial surface scanning systems and a hand-held laser surface scanner prototype coupled with a patient’s motion acquisition and compensation methodology. The accuracy of the scanners was assessed on an anthropomorphic phantom, and to evaluate the usability of the scanners on humans, thorax surface images of 3 volunteers were acquired. Both the intrascanner repeatability and the interscanner comparative accuracy were assessed. The results showed surface-to-surface distance errors inferior to 1 mm and to 2 mm, respectively, for the 2 commercial scanners and for the prototypical one. Moreover, comparable performances of the 3 scanners were found when used for acquiring the breast surface. On the whole, this study demonstrated that handheld laser surface scanners coupled with subject motion compensation methods lend themselves as competitive technologies for human body surface modeling.
Background. Herein, we report our initial experience with laparoendoscopic single-site surgery for partial nephrectomy (LESSPN) using a microwave tissue coagulator (MTC). Methods. Two patients with small and exophytic renal tumors underwent LESSPN. A multichannel port was inserted into the peritoneal or retroperitoneal space through a 3-cm skin incision. After tumor exposure, the surgeon introduced a laparoscopic MTC instrument through a 5-mm port and the tumor margin was coagulated circumferentially. After coagulation, the tumor was resected without renal pedicle clamping. Results. These procedures were successfully performed without any conversions to standard laparoscopy or need for placement of additional trocars. The operative times were 183 and 160 minutes, respectively. The estimated blood loss was <150 mL in both cases. The final length of the LESS wound was 3 cm. Using the transumbilical approach, the operative scar receded into the umbilicus and was hardly visible. Conclusions. This novel surgical technique is feasible and enables the bloodless resection of a renal tumor without renal pedicle clamping. Further clinical experience and longer follow-up are needed to define the benefits of this new technique.
Purpose. A novel technique using the reversed iliac leg of a Zenith device has been reported. This study reports a complicated isolated iliac artery aneurysm (IIAA) using this novel technique and reviews the relative literature to discuss current treatment modalities. Case report. A 46-year-old man presented with a mass in the left lower quadrant accompanied by abdominal pain for 60 days. Computer tomography angiography (CTA) revealed a complicated IIAA and a massive retroperitoneal hematoma. Percutaneous puncture and drainage at the hematoma was done. Enterococcus faecium was isolated from the hematoma. The infection was controlled after 2 weeks of drainage and anti-infection treatment. The IIAAs were successfully excluded using the novel technique. The 12-month CTA follow-up was unremarkable. Conclusion. Using inverted Zenith device legs is safe and effective even in complicated IIAAs. Further studies are warranted before it can become a widely acceptable definitive treatment option.
Introduction. Morgagni hernia results from a rare congenital defect in the anterior diaphragm and can have symptomatic and/or asymptomatic presentation of abdominal viscera in the thorax. This is a case report of a Morgagni hernia repair done laparoscopically in the outpatient setting. Patient and technique. The patient was a 43-year-old man who had an evaluation for upper respiratory symptoms and was found to have a Morgagni hernia on subsequent workup. He underwent laparoscopic primary suture repair of the defect under general anesthesia and was discharged the same day without complications. He has not had a recurrence of his hernia in over a year of follow-up. Discussion. Laparoscopic repair of this patient’s Morgagni hernia could be safely performed in an outpatient setting with excellent outcome. This may be a feasible management option in future cases in a similar patient population.
Schwannomas are benign tumors that arise from neural sheath Schwann cells. Solitary benign schwannoma is generally located in the head and neck and is a rare neoplasm among the tumors of the retroperitoneal space. Reports of laparoscopic excision of retroperitoneal schwannomas have recently been on the increase. However, few cases of single-port laparoscopic excision of these tumors have been reported. Moreover, there are no reports of single-port excision of schwannomas attached to the body of pancreas and around the splenic vessels. This is the first report of a schwannoma lying adjacent to the body of the pancreas between the splenic artery and vein that was excised by single-port laparoscopic surgery. The most notable aspect of our procedure is the use of bipolar forceps. Single-port laparoscopic excision using bipolar forceps is a feasible and safe procedure for retroperitoneal solitary tumors, even when they are close to the splenic artery and vein.
Introduction. Appendectomy is performed on almost 700 000 patients per year in the European Community, rendering it the most common acute surgical procedure. Since the introduction of laparoscopic surgery, there has been increased interest in carrying out procedures with fewer incisions and less ports. Materials and methods. After the inception of single-port access, it is possible to insert into the abdominal cavity multiple instruments through a single device. A total of 15 patients—mean age 22 years and mean body mass index 27 kg/m2—with acute appendicitis were included in this study. Results. Mean operative time was 35 minutes with no conversions. Local suction drain was needed in 2 patients. Mean hospital stay was less than 24 hours with no complications. Conclusion. Single-port suprapubic appendectomy is feasible and safe, and can allow a more direct vision of the operating field depending on the position of the appendix and presents good cosmetic and postoperative outcomes.
Objective. Single-incision laparoscopy surgery (SILS) has rapidly developed as both a cosmetic advantage of natural orifice translumenal endoscopic surgery and a standard surgical procedure. In this article, the authors report on the new technique of SILS splenectomy plus pericaudial devascularization with conventional laparoscopic instruments. Methods. The technique of SILS splenectomy plus pericaudial devascularization in one patient with portal hypertension was introduced. Results. The procedure was feasible with conventional laparoscopic instruments. Operative time was 240 minutes, and blood loss was 350 mL. No intraoperative or postoperative complications, such as secondary hemorrhage or pancreatic leakage, were recorded. The patient was fully recovered, and the single umbilical scar was well healed. Conclusion. SILS splenectomy plus pericaudial devascularization is feasible when performed by experienced laparoscopic surgeons. It may have the same cosmetic advantage as natural orifice translumenal endoscopic surgery and may offer the safety of conventional laparoscopic operation. As far as the authors are aware, this is the first report.
This study presents a case report of parathyroid adenoma, which was managed by trans-areola single-site endoscopic parathyroidectomy. Two incisions were made along the right areola margin. The single subcutaneous narrow tunnel from the areola to neck was bluntly dissected in the right anterior chest. The authors successfully removed the adenoma through this channel. The intraoperative quick parathyroid hormone was decreased to a great extent. The operative time for the whole procedure was 110 minutes. The patient experienced transient postoperative hypocalcemia without recurrent laryngeal nerve palsy. She was very satisfied with the cosmetic results.
Management of complex abdominal defects remains a significant challenge for many surgeons, especially in contaminated fields. Currently, available biosynthetic grafts include human cadaveric dermis (AlloDerm), porcine dermal (Permacol and Strattice), and submucosal (Surgisis) sources. All these grafts are composed of an acellular collagen scaffold to provide a bridge for tissue incorporation and neovascularization. The authors describe a case report of a woman who required dual mesh explantation and successive reparative surgery using a porcine dermal matrix for a complex and infected abdominal wound. Twelve months postdischarge the patient remains well, she is pain free, and she returned home to full activities with complete wound closure and without any evidence of residual or recurrent hernia. The patient was satisfied with her cosmetic results. In conclusion, the authors’ experience shows that the use of Permacol, a porcine dermal matrix, has been successful in treating an infected abdomen and a vast abdominal wall defect.