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SURGICAL TECHNOLOGY INTERNATIONAL XII.

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$175.00

 

STI XII contains 33 articles with color illustrations.

 

Universal Medical Press, Inc.

San Francisco, 2004, ISBN: 1-890131-08-3

 

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General Surgery

 

Robot-Assisted Minimally Invasive Surgery: The Importance of Human Factors Analysis and Design
Caroline G.L. Cao, Ph.D. - Department of Mechanical Engineering, Tufts University School of Engineering, Medford, Massachusetts; Gary S. Rogers, M.D. Tufts University School of Medicine, Tufts University School of Engineering, Medford, Massachusetts

 

Abstract

Success in robotic minimally invasive surgery (MIS) has been limited despite the innovations in robotic technology for surgical applications. Human factors engineering approach to the design and implementation of this technology is major to improving system performance and patient safety. The engineering discipline of human factors involves the study of factors and development of tools that enable human interaction with systems in a safe and effective manner. Human factors contribution is important to the product design life cycle, as it supports the design of a product capable of supporting, extending, and transforming user work in a cost-effective and timely fashion. A framework for modelling the interaction between the surgeon and technology in MIS is presented. This approach allows for identification of requirements and constraints at the physical, functional, and cognitive levels, which in turn guides the design of the technology and its interface. The human factors approach is expected to increase the effectiveness of the technology when deployed.

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Hand-Assisted Laparoscopic (HAL) Gastric Partition With Roux-En-Y Intestinal Bypass
Dirk I. Rodriguez, M.D., F.A.C.S. - Texas Bariatric Center, Dallas, Texas; J. Don Jackson, Jr., M.D. - Advanced Surgery Group, Palestine, Texas; John B. Delcambre, M.D., F.A.C.S. - Advanced Surgery Group, Palestine, Texas; Karen Stiles, R.N. Texas Bariatric Center, Dallas, Texas; Karen Bauman, R.N. - Western Surgical Group, Reno, Nevada

 

Abstract

The surgical treatment of obesity with proximal gastric partition and Roux-en-Y intestinal bypass is recognized as effective in producing meaningful weight loss of excess body weight. Pure laparoscopic surgery has been perfected by a small number of surgeons in the United States. To acquire this new skill requires extensive training and supervision. In the hands of inexperienced operators, it is associated with prolonged surgery times and significant complications. Hand-assisted laparoscopic (HAL) surgery has been developed as an alternative method of minimally invasive surgery that can increase the number of surgeons who can offer laparoscopic surgery to their obese patients while decreasing the case load necessary to obtain expertise. The technique and approach of HAL surgery is presented in detail.

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Gastric Banding for Clinically Severe Obesity: Results With The Swedish Band
Wim P. Ceelen, M.D., Anne Cardon, M.D., Piet Pattyn, M.D., Ph.D. - Department of Surgery, Ghent University Hospital, Ghent, Belgium

 

Abstract

Parallel with the rise of the obesity pandemic, bariatric surgery is quickly becoming one of the most frequently performed GI procedures. In selected, well-informed patients, restrictive surgery offers a good alternative to more complex malabsorption-inducing procedures. Laparoscopic gastric banding is a reversible, technically straightforward procedure. Both early and late complications seen with the original models are less common with the Swedish adjustable gastric band SAGB (Ethicon Endosurgery, Johnson & Johnson, Dilbeek, Belgium) engineered as a low-pressure device. This chapter is a review of our experience with the SAGB and provides an overview of current controversies regarding its place in management of severe obesity.

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Laparoscopic Roux-En-Y Gastric Bypass VS. Laparoscopic Adjustable Gastric Banding for Treatment of Morbid Obesity
Ninh T. Nguyen, M.D., Dmitri V. Gelfand, M.D., Kambiz Zainabadi, M.D., - Department of Surgery, University of California, Irvine, Medical Center, Orange, California

 

Abstract

Bariatric surgery is a rapidly growing discipline in General Surgery. Roux-en-Y gastric bypass (GBP) is currently the most commonly performed bariatric surgical procedure for treatment of morbid obesity in the United States (U.S). The laparoscopic approach to (GBP) has led to a greater acceptance for surgical treatment of morbid obesity by the public and, in return, more surgeons are becoming interested in learning laparoscopic bariatric surgery to meet the high demand. Laparoscopic adjustable silicone gastric banding was approved in the U.S. by the Food and Drug Administration (FDA) for clinical use in 2001, and is emerging as an alternative laparoscopic option in management of morbid obesity. This chapter reviews the indications, techniques, and outcomes of laparoscopic GBP vs. laparoscopic adjustable gastric banding. The advantages and disadvantages of laparoscopic adjustable gastric banding compared to laparoscopic GBP is discussed.

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A New Technique for Laparoscopic Hernia Repair Using Fibrin Sealant
Namir Katkhouda, M.D., F.A.C.S. - Chief, Minimally Invasive Surgery, University of Southern California, Los Angeles, California

 

Abstract

The purpose of this study was to evaluate whether an adequate prosthetic mesh fixation in laparoscopic preperitoneal inguinal hernia repair can be achieved with fibrin sealant (FS) (Tisseel trade mark, Hyland/Immuno Div., Baxter Healthcare Corp., Deerfield, IL, USA), and compare it with stapled fixation. The use of staples for prosthetic mesh fixation in laparoscopic preperitoneal hernia repair is associated with a small but significant number of complications, mainly nerve injury and hematomas. An alternative method of fixation should be as efficient as staples in preventing graft migration. An experimental study was conducted using swine models to compare the efficacy of polypropylene mesh fixation with FS to that achieved with staples and to non-fixed mesh grafts in the preperitoneal groin area. Twenty-five female pigs were used in the study. In each pig, a prosthetic mesh was placed laparoscopically in the groin area bilaterally and fixed with either FS, staples, or left without fixation. The pigs were killed after 12 days. The following outcome measures were evaluated: macroscopic findings including graft alignment and motion, tensile strength between the grafts and surrounding tissues, and histologic findings (fibrous reaction and inflammatory response). The procedures were completed laparoscopically in 49 sites. FS was used to fix 18 grafts; 16 with staples, and 15 were not fixed. No significant difference was noted in graft motion between the FS and staple groups. The non-fixed grafts had a median motion of 5 mm (range: 0 to 10 mm), significantly more than the FS fixed (p < 0.01) and stapled grafts (p < 0.001). No significant difference was noted in median tensile strength between the FS and staples groups (0.955 Kg vs. 1.03 Kg, respectively) compared with 0.46 Kg in the non-fixed group (p < 0.01). FS triggered a significantly stronger fibrous reaction and inflammatory response than those observed in the staples and control groups. An adequate mesh fixation in the extraperitoneal inguinal area can be accomplished using FS, based on our experimental evidence. The FS is equivalent to fixation achieved by staples and superior to no fixation. Soft fixation with FS prevents graft migration and avoids complications associated with use of staples

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Rutkow Perfix®-Plug Repair for Primary and Recurrent Inguinal Hernias - A Prospective Study
F.E. Isemer, M.D., V. Dathe, M.D., B. Peschka, M.D., R. Heinze, M.D., A. Radke, M.D. - Department of Surgery, St. Josefs Hospital, Wiesbaden, Germany

 

Abstract

Surgery of the groin hernia has become more a question of the applied tension-free, mesh technique. Whereas studies on laparascopic versus open tension-free hernia repair or open-mesh versus open-nonmesh repair have been performed sufficiently, data regarding the open tension-free plug-and-patch technique are rather poor. During the period from January 2001 to October 2003, we followed and filed 766 hernia repairs in the plug-and-patch technique of Rutkow. Follow up was during the hospital stay, 4 weeks, and minimally 12 months after operation. The main follow-up variables were complications, recurrence rate, and pain. The mean operating time was 37.8 +/- 15.85 (12-135) minutes. In 141 (19.3%) patients (n=730), the ilioinguinal nerve was resected. The 1 intraoperative complication that occurred was a severed small intestine. Length of hospital stay was 2.09 +/- 1.35 (0-17) days, work leave lasted for 15.3 +/- 12.42 (0-60) days, and return to normal daily activities was possible within 6.54 +/- 6.86 (0-35) days. Twenty-two (2.9%) patients (n=766) developed a postoperative hematoma as the most common complication, and a reoperation was required 17 (2.2%) times during the hospital stay. Early complications included hematoma (3.7%), seroma (3.5%), infection (0.2%), necrosis of 1 testicle (0.2%), persisting scrotal swelling (1.5%), persisting pain (0.9%), and hypoesthesia (2.4%). Within 4 weeks, 4 (0.9%) patients were reoperated for 1 seroma, hematoma, infection, and testicle necrosis. After 605.4 +/- 154.5 (365-1018) days, the following 19 (5.7%) patient complaints were noted: persisting pain (2.1%), hypoesthesia (1.8%), foreign-body feeling (0.6%), scrotal swelling (0.6%), and 1 (0.3%) mesh dislocation. Six (1.8%) reoperations have been performed. The overall recurrence rate was 1.8% (n=6), for primary 1.5% (n=4), and 3.3% (n=2) for recurrent hernias; 96.3% of the patients would agree to undergo the same operation a second time. Tension-free repair of the inguinal hernia by the plug-and-patch technique is a quick and secure method that simplifies hernia surgery without compromising the high-quality standards such as a low recurrence rate and low pain load of the patient. Patients had a fast recovery with a subsequent short work leave. The method is a simple, effective, and economical operation, suitable as a standard performed in local anesthesia on an out-patient basis.

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Risk of Gas Embolism in Hand-Assisted Versus Total Laparoscopic Hepatic Resection
Thomas C. Schmandra, M.D. - Department of Surgery, Johann Wolfgang Goethe University Hospital, Frankfurt Ammain, Germany; Stefan Mierdl, M.D. - Department of Anaesthesiology, Johann Wolfgang Goethe-University Hospital, Frankfurt Ammain, Germany; Dirk Hollander, M.D. - Department of Surgery, Johann Wolfgang Goethe-University Hospital, Frankfurt am Main, Germany; Ernst Hanisch, M.D. - Department of Surgery, Johann Wolfgang Goethe-University Hospital, Frankfurt am Main, Germany; Carsten Gutt, M.D. - Department of Surgery, Ruprecht-Karls-University Hospital, Heidelberg, Germany

 

Abstract

Laparoscopic hepatic resection represents an alternative to open surgery in patients with advanced underlying hepatic disease. Management of haemorrhage and the risk of gas embolism are the major problems in laparoscopic liver surgery. In this study, safety and efficacy of liver dissection using ultrasonic energy was investigated in hand-assisted versus total laparoscopic surgery. The study had a special emphasis on evaluating the risk of gas embolism during both procedures. Female pigs were divided into two groups for A) total laparoscopic (n=7), and B) hand-assisted laparoscopic (n=7) hepatic resection. For tissue dissection, an ultrasound aspirator (CUSA) was used in both groups. Laparoscopic procedure was performed under a CO2 pneumoperitoneum (intraperitoneal pressure: 12 mmHg). Before dissection, a Pringle manoeuver was carried out. The anaesthetized pigs were monitored haemodynamically by an arterial line and Swan-Ganz catheter. Transoesophageal echocardiography (TEE) was performed with special attention to the right atrium and ventricle. Gas emboli were graded according to size and correlated with haemodynamic and blood-gas data. In both groups, the ultrasound-aspirator enabled an effective tissue dissection. In total laparoscopic hepatic resection, TEE monitoring disclosed gas embolism in 5/7 (71%) animals. In 3/7 (42%) animals, gas embolism was accompanied by a sequence of cardiac arrhythmia. No direct correlation was noted between episodes of embolism and blood-gas variables. None of the pigs died after episodes of embolization. In hand-assisted liver resection, no air embolism was noted. The internal hand impressively facilitated organ exposure and provided an immediate and efficient haemorrhage control. The use of an ultrasound aspirator system enables an effective laparoscopic hepatic dissection. Total laparoscopic liver dissection is at increased risk for gas embolism, whereas hand-assisted laparoscopic procedure appears to reduce this risk. Due to tactile response and facilitated retraction of the liver parenchyma, the hand-assisted procedure shows impressive advantages in laparoscopic liver surgery.

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Intraoperative Ultrasonography in Patients Who Undergo Liver Resection Or Transplantation for Hepatocellular Carcinoma
Gerd R. Silberhumer, M.D.- Department of Surgery, Medical University of Vienna, Vienna, Austria; Rudolf Steininger, M.D. - Department of Transplant Surgery, Medical University of Vienna, Vienna, Austria; Friedrich Laengle, M.D. - Department of Surgery, Medical University of Vienna, Vienna, Austria; Ferdinand Muehlbacher, M.D. - Department of Transplant Surgery, Medical University of Vienna, Vienna, Austria; Johannes Zacherl, M.D. - Department of Surgery, Medical University of Vienna, Vienna, Austria; Peter Pokieser, M.D. - Department of Radiology, Medical University of Vienna, Vienna, Austria

 

Abstract

Careful staging of hepatic tumors forms the basis of appropriate selection of, and is a precondition for, customized treatment. Advances in radiodiagnostic technology have increased the sensitivity of noninvasive liver staging by means of magnetic resonance imaging (MRI), computed tomography (CT), and helical CT (HCT). Nevertheless, surgical exploration and intraoperative ultrasonography (IOUS) are considered the "gold standard." The value of HCT and IOUS was investigated in patients who underwent orthotopic liver transplantation (OLT) (group A; n=23) or hepatic resection for hepatocellular carcinoma (HCC) (group B; n=52). In group A, the results of liver imaging (HCT performed immediately before OLT, IOUS) were compared with histopathological results after 3-mm slicing of the explanted liver. In group B, patients were evaluated by CT (n=8), HCT (n=43), MRI (n=18), or both, as indicated by the respective surgeon. The results were compared with those of surgical exploration and IOUS (n=52), as well as with the pathological examination of the resected liver specimen. In group A, 52 malignant lesions were detected by histopathology. By each of the preoperative examinations (IOUS, HCT), 54 lesions were suspected of being malignant. Thirteen HCCs were missed by HCT (for IOUS: n=4) and 15 lesions were false-positive (for IOUS: n=6). Thirty-nine of 52 lesions were verified to be true-positive by HCT in contrast to 48/52 by IOUS, which resulted in sensitivities of 75% (HCT) and 92% (IOUS, P=0.017), respectively. In group B, the sensitivity of CT was 77%, HCT 90%, MR 93%, and IOUS 99% (P < 0.01). In 10%, the strategy of surgical treatment was changed because of IOUS findings. IOUS offered relevant additional information in 6%. Even after sufficient preoperative evaluation, IOUS can provide additional information that frequently has a remarkable impact on surgical decision-making. Identification of HCC is commonly hampered by coexistent cirrhosis. Identification of lesions and orientation of borders to non-tumorous tissue are assessed reliably by IOUS. Thus, IOUS remains a mandatory tool in patients treated by locoregional surgical modalities such as resection, cryotherapy, and intraoperative ethanol instillation for HCC even after refinement of radiological technologies.

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Complications and Sequelae of Thyroidectomy and an Analysis of Surgeon Experience and Outcome

Elizabeth A. Mittendorf, M.D. - Uniformed Services University of The Health Sciences, Malcom Growmedical Center and Walter Reed Army Medical Center, Washington, D.C.; Christopher R. McHenry, M.D. - Case Western Reserve University, Department of Surgery, Division of General Surgery, Metrohealth Medical Center, Cleveland, Ohio

 

Abstract

Theodor Kocher is credited with refining the technique of thyroidectomy and reducing the incidence of postoperative hemorrhage. He also recognized the importance of preservation of the parathyroid glands. His accomplishments led to a reduction in surgical mortality, from 50% to less than 4.5%. Additional improvements in technique have reduced the mortality rate to near zero. Morbidity, however, remains a concern for surgeons who perform thyroid surgery. Complications and sequelae of thyroid surgery are reviewed, including recurrent and superior laryngeal nerve injury, temporary hypocalcemia, permanent hypoparathyroidism, thyroid storm, bleeding, wound infection, and hypothyroidism. The association between the volume of thyroidectomies performed by a surgeon and outcome is also discussed in this chapter.

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