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Surgical Technology International XXVIII contains peer-reviewed articles featuring the latest advances in surgical techniques and technologies.

 

April, 2016- ISSN:1090-3941

 

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General Surgery

 

A New Reusable Platform for TransAnal Minimally Invasive Surgery: First Experience
Giovanni Dapri MD, PhD, FACS, Professor of Surgery, Daniel Guta, MD, Fellow, Luca Cardinali, MD, Fellow, Claudia Mazzetti, MD, Fellow, Anny Cadenas Febres, MD, Fellow, Konstantin Grozdev, MD, Fellow, Sixte-Henry Sondji, MD, Assistant, Ion Surdeanu, MD, Assistant, Guy-Bernard Cadière, MD, PhD , Professor of Surgery & Director, Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, Brussels, Belgium

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Introduction: TransAnal Minimally Invasive Surgery (TAMIS) has generated interest and attracted research in the last decade. This approach is used to treat primary benign and malignant diseases, but it can also be adopted to resolve colorectal complications, such as leak and fistula, bleeding and stenosis. A new reusable transanal platform formed by a new port and monocurved instruments has been invented and here presented.
Materials and Methods: The first experience included 13 patients submitted to TAMIS for rectal adenocarcinoma (8), immediate colorectal leak (1), early rectovaginal fistula (1), late colorectal fistula (1), immediate colorectal bleeding (1), and benign stenosis (1). Mean age was 62.3 years (38-74), and mean BMI was 25.2 kg/m2 (20.5-32.1).
Results: Mean operative time for transanal total mesorectal excision (TME) was 149.2 minutes (96-193) and for the other procedures 80.6 minutes (15-163). Mean operative bleeding was 51.1 cc (0-450). Mean hospital stay was 5.0 days (2-8). The 3 patients with coloanal anastomosis presented diarrhea postoperatively. No other early postoperative complications were registered. Pathologic report in the oncologic diseases showed that a mean number of 14.7 nodes (16-20) were removed. After a mean follow-up of 8 months (1-14), there were no late complications in any of the 13 patients treated.
Conclusion: TAMIS is a feasible alternative approach to treat rectal cancer and a completely new technique to manage colorectal complications. Moreover, this new transanal platform offers surgeons a satisfactory working ergonomy, with no increase in cost of the procedures, because entirely reusable materials are adopted.

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Subcutaneous Destruction of Sinus Tract with Long-term Vessel Loop Drainage as a Minimally Invasive Surgical Treatment for Primary Pilonidal Sinus
Michael Korenkov, MD, Head of Department, General and Visceral Surgery, Klinikum Werra-Meissner, Teaching Hospital Eschwege, University of Goettingen, Eschwege, Germany

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The surgical management of pilonidal disease ranges from minimally invasive techniques to wide excision with secondary Advanced Wound Healing. Hypothetical counterarguments for using the minimally invasive techniques are that these techniques only incompletely remove the sinus tract and that they allow the formation of subcutaneous cavities as a result of rapid closure of small skin incisions. In order to avoid these problems we used a vessel loop drainage after subcutaneous destruction of the sinus tract. In this technique we combined two procedures: a narrow excision of pilonidal orifices with the subcutaneous destruction of the sinus tract and the removal of hair as well as the long-term vessel loop drainage of the wound channel with repeated revisions of the wound channel for removing hair remnants. In order to assess the efficacy and morbidity of this method 5 patients with primary symptomatic pilonidal sinus underwent an operation as a pilot study. Up to the removal of the vessel loop the wound channel had been regularly inspected using a mosquito clamp. If during two successive inspections no hair from the wound was found the vessel loop was removed. No adverse events occurred such as abscess or recurrent pilonidal sinus. One female patient with a history of long-term use of morphine derivatives and psychotropic substances experienced persistent coccygeal pain that persisted longer than 6 weeks. The complete Advanced Wound Healing with the formation of a qualitative scar took place on the 21st postoperative day (for 3 patients) and on the 28th postoperative day (for 2 patients). Initial results suggest that this operation is an effective procedure for the treatment of primary simple pilonidal sinus disease and we will continue to systematically test it.

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Reducing Opioid Adverse Events: A Safe Way to Improve Outcomes
Jay A. Redan, MD, FACS, Director of Minimally Invasive General Surgery, Florida Hospital-Celebration Health, Professor of Surgery, University of Central Florida College of Medicine, Orlando, Florida, Tina Wells, MSN, ARNP, Clinical Nurse Manager, Florida Hospital-Celebration Health, Celebration, Florida, Sandra Reeder, MSN, ARNP, Director of Nursing, Florida Hospital-Celebration Health, Celebration, Florida, Steven D. McCarus, MD, FACOG, Director of Minimally Invasive Gynecology, Florida Hospital-Celebration Health, Celebration, Florida

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Introduction: Opioids are commonly used in the postoperative period to manage postsurgical pain. However, adverse side effects of opioids include respiratory depression, urinary retention, pruritus, vomiting, nausea, constipation, and increased risk of falls. Surgical site infiltration with extended release liposomal bupivacaine is effective in the multimodal care plan of managing postsurgical patients. The purpose of the present study was to examine the possible effects of liposomal bupivacaine on postoperative opioid adverse events following open hernia repair and laparoscopic colon resection surgery.
Materials and Methods: The study population comprised 82 patients who had undergone open hernia repair or a laparoscopic colon resection. Forty-five of the 82 patients were treated with liposomal bupivacaine. Data were examined retrospectively from January 1, 2012 to August 31, 2012 in comparison with historical controls. Adverse opioid events measured included constipation, pruritus, vomiting, nausea, urinary retention, respiratory depression and fall risk. Statistical tools used were the Mann-Whitney U test, Pearson’s chi-squared test, and Fisher’s exact test.
Results: The addition of liposomal bupivacaine did significantly (p< 0.05) reduce urinary retention and respiratory depression. Additionally, from the perspective of hospital safety there was a significant reduction in patients at high risk of falls, from 16% to 8.4% as well as an increase in patients at low risk of falls, from 37.6% to 48.7%.
Conclusion: The findings of this study demonstrate that using liposomal bupivacaine can significantly reduce high-risk fall patients, increase low-risk fall patients as well as decrease urinary retention and respiratory depression in the postoperative setting. Given heightened consideration of the impact of sentinel events on hospital reimbursement since health care reforms in 2014, these results are important because they can mitigate complications associated with opioids in postsurgical pain management, and thereby reduce the costs of hospitalization.

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A Comparative Study of Performance in Ultrasonic Tissue Dissection for Sleeve Gastrectomy: Wired versus Cordless
Pim W. J. van Rutte, MD, Surgeon in training, Catharina Hospital , Eindhoven, The Netherlands, Sandra L. Lup, MSc, Researcher, Technical University of Delft, Delft, The Netherlands, Misha D. Luyer, MD, PhD, Gastrointestinal Surgeon, Catharina Hospital, Eindhoven, The Netherlands, Jack J. Jakimowicz, MD, PhD, FRCS(ED), Professor of Safety in Health Care, Technical University of Delft, Delft, The Netherlands, Richard H. M. Goossens, IR, Professor, Head of Industrial Design Department, Healthcare Program Coordinator, Technical University of Delft, Delft, The Netherlands, Simon W. Nienhuijs, MD, PhD, Gastrointestinal Surgeon, Catharina Hospital, Eindhoven, The Netherlands

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Background: The sleeve gastrectomy is being performed increasingly as a primary procedure for the treatment of morbid obesity. A minimally invasive approach is currently applied to the procedure. The two major steps are dissection and stapling. For dissection, several tools have been developed. The goal of this study was to compare the efficiency and the ergonomics of two ultrasonic devices during the sleeve gastrectomy.
Materials and Methods: Thirty patients were randomised for the use of a cordless Sonicision™ (Covidien, Mansfield, MA) or a cord-containing HARMONIC ACE®+ (Ethicon Endo-Surgery Inc., Cincinnati, OH) during dissection. Both devices were assessed for objective and subjective measures.
Results: There was no significant difference in duration of the procedures. The assembly and installation time of the Sonicision™ were significantly shorter; however, the dismantle time was not. No difference in plume formation or dissection failures was found between the devices. Scrub nurses scored the Sonicision™ significantly clearer and easier in use and more reliable. The surgeons, however, did not find one of the devices easier in use, more reliable or precise, but they did report better manoeuvrability of the Sonicision™.
Conclusion: In comparison to the wired HARMONIC ACE®+, during sleeve gastrectomy, the cordless Sonicision™ was considered easier to use, faster during assembling and installation, and more reliable with better manoeuvrability. Surgeons scored both devices equally effective. Both ultrasonic devices can be used easily and safely for a sleeve gastrectomy.

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Is There An Ideal Stump Closure Technique In Laparoscopic Appendectomy?
Ihsan Yıldız, MD, Assistant Professor, Department of General Surgery, Suleyman Demirel University Medical School, Isparta, Turkey

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Background: There is no standard routine closure technique in the management of appendiceal stump. Therefore, the ideal method should be determined based on the condition of the radix of the appendix. Aim: The aim of this study was to evaluate appendiceal stump closure methods in patients undergoing laparoscopic appendectomy due to acute appendicitis.
Materials and Methods: The retrospective study included 196 patients who underwent laparoscopic appendectomy due to the diagnosis of acute appendicitis at Gazipasa State Hospital, Golhisar State Hospital, and Isparta State Hospital between 2009 and 2013. The methods performed for the closure of the appendiceal stump included stapler closure technique (Group I), ENDOLOOP® (Johnson & Johnson Inc., New Brunswick, New Jersey) technique (Group II), Hem-o-lok® (Teleflex®, Limerick, Pennsylvania) clip (Group III), and handmade endo-loop technique (Group IV). The groups were compared in terms of duration of surgery, length of hospital stay, postoperative pain, complication rates, and cost of treatment.
Results: No significant difference was observed among the groups in terms of patient characteristics. In eight patients, laparoscopic appendectomy was converted to open surgery due to various reasons. Mean length of hospital stay was two days in all of the groups that underwent laparoscopic appendectomy. No significant difference was found among the groups in terms of duration of surgery, complications, and postoperative analgesic requirement, but a significant difference was observed in terms of the cost of treatment.
Conclusions: We suggest that the handmade endo-loop technique is a safe, applicable, and cost-effective method to be used in the closure of appendiceal stump.

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Karl Storz
Pacira Pharma
Medtronic