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Surgical Technology International

32nd Edition

 

Contains 45 peer-reviewed articles featuring the latest advances in surgical techniques and technologies.

 

May-2018- ISSN:1090-3941

 

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General Surgery

The Problem of Seroma After Ventral Hernia Repair
Nathaniel Stoikes, MD, Associate Professor, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, Esra Roan, PhD , CEO/President, SOMAVAC Medical Solutions, Inc., Memphis, Tennessee, David Webb, MD, Assistant Professor, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, Guy R. Voeller, MD, Professor, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee

1022

 

Abstract


Seroma is a common postoperative finding after ventral hernia repair with an incidence of 20%. Often, it can be managed conservatively, but in the case of persistent or chronic seroma, reinterventions may be required. Closed drain suction has been the mainstay of seroma management for the last 40 years. Other alternative technologies have been evaluated to improve outcomes with mixed results. Because seroma is common, it is often an accepted outcome. Patient morbidity and costs to the healthcare system are underestimated, which begs for a re-evaluation of the current state of seroma management that is nearly a half-century old.

 

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Indocyanine Green (Icg)-Enhanced Fluorescence for Intraoperative Assessment of Bowel Microperfusion During Laparoscopic and Robotic Colorectal Surgery: The Quest for Evidence-Based Results

Alberto Mangano, MD, Robotic Surgery Research Specialist, Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, Chicago, IL,  Federico Gheza, MD, Robotic Surgery Research Specialist, Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, Chicago, IL, Liaohai Leo Chen, PhD, Visiting Research Professor, Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, Chicago, IL, Eleonora Maddalena Minerva, MD, Medical Doctor, Istituto Clinico Humanitas IRCCS, Milan, Italy, Pier Cristoforo Giulianotti, MD, FACS, Vice Head Department of Surgery, Professor of Surgery: Distinguished Lloyd M. Nyhus Chair in Surgery, Chief, Division of General, Minimally, Invasive and Robotic Surgery, University of Illinois at Chicago, Chicago, IL

966

 

Abstract


Anastomotic leakage is a severe complication after colonic/rectal surgery. One of the most important causes of anastomotic leakage is poor vascular supply. However, microvascular impairment at the anastomotic site is very often not detected intraoperatively by observation under white light. Indocyanine green (ICG)-enhanced fluorescence is a technology that may be useful for detecting microvascular alterations and potentially preventing anastomotic leakage. The aim of this Editorial-Minireview is to briefly and critically assess the literature evidence regarding the feasibility of using an ICG fluorescent tracer for detecting microvascular changes in the perianastomotic tissue and its potential role in preventing anastomotic leakage. We focused on minimally invasive (robotic and laparoscopic) colorectal surgery. Intraoperative ICG angiography and the quantification of ICG kinetics can be used to intraoperatively reveal the tissue-perfusion status during colorectal surgery. This may be useful for intraoperatively changing a previously planned resection/anastomotic level, and conceivably decreasing the degree of anastomotic leakage. At this stage, even though ICG technology appears to be very promising and some preliminary clinical studies have suggested that certain ICG pharmacokinetic parameters may be used to predict leakage, more reliable scoring and grading tools are needed. Furthermore, in minimally invasive colorectal surgery, more randomized prospective well-powered trials are needed to properly standardize this surgical technology.

 

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  • Lumisque Lumisque

Video-Assisted Subcutaneous Destruction of the Sinus Tract with Vessel-Loop Drainage as Minimally-Invasive Surgical Treatment for Pilonidal Sinus Disease
Michael Korenkov, MD, Head of Department, Department of General and Visceral Surgery, Klinikum Werra-Meissner, Eschwege, Germany

964

 

Abstract


The video-assisted subcutaneous destruction of the sinus tract (VADST) is a novel, minimally-invasive technique for the treatment of pilonidal sinus disease (PSD). This is an advancement of the previously described subcutaneous destruction of the sinus tract and the removal of hairs as well as the long-term vessel-loop drainage of the wound channel (DST).
Although the first results of this operation seemed to be promising, some of my colleagues felt that the blind approach to this procedure could be its potential “weak point”. As a result of this critique, the procedure was enhanced with the subcutaneous video-assisted inspection of the natal cleft.
Throughout most steps of VADST, like the widening of pilonidal pits with mosquito and/or Pean clamps, the subcutaneous destroying of the sinus tract, lifting the skin in a natal cleft with a curette, removing the hair with a Pean clamp and a subcutaneous vessel-loop drainage, were found to be similar to DST. The new steps involve the possibility of the video-assisted control of hair vestiges and bleedings as well as the removal of hair and debris under visual control. A rigid choledochoscope from Berci (Firma Richard Wolf GmbH, Knittlingen, Germany) was used for the subcutaneous endoscopic examination of the natal cleft area. Neither gas application nor water perfusion were necessary for this step.
Three patients with simple forms of PSD, and one patient with an acute abscess formation, underwent the VADST procedure. The patients with simple forms of PSD had no adverse events during the first eight weeks postoperatively. The patient with an acute abscess formation developed a purulent inflammation that required a wide local excision with an open-wound healing.
Due to the very small number of patients in this report, we were not able to asses this technique properly. Contrary to DST, we intend to use VADST, not only for the treatment of patients with simple forms (primary pilonidal sinus without abscessed inflammation with maximal three orifices, all of them inside the navicular area), but also for the treatment of complex PSD forms.

 

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D3 Extended Mesenterectomy in Right Colectomy for Cancer: A Cadaver Simulation Model
Karen You, BS, Research assistant, Mahir Gachabayov, MD, PhD, Research fellow, Jela Bandovic, MD, Associate Professor of Pathology, Roberto Bergamaschi, MD, PhD, FRCS, Professor and Chief, Division of Colon and Rectal Surgery, State University of New York, Stony Brook, New York, Dejan Ignjatovic, MD, PhD, Professor of Surgery, Akershus Hospital, University of Oslo, Norway, Jens Marius Nesgaard, MD, Attending surgeon, Toensberg Hospital, University of Oslo, Norway

1009

Abstract


Background: D3 extended mesenterectomy (D3EM) for right colon cancer has received increased attention owing to suggested improvement of oncological outcomes. The aim of this study was to evaluate the proficiency-based progression of content-valid metrics in a cadaveric model for right colectomy with D3EM.
Materials and Methods: Three expert surgeons were enrolled. Surgeon one performed the procedure robotically and surgeons two and three performed open D3EM. Proficiency-based progression was recorded for eight content-valid outcomes. The superior mesenteric vein (SMV) and artery were cannulated by independent observers to evaluate vascular tears. The specimens were analyzed for lymph node harvest by a pathologist blinded to surgical access and to the surgeon.
Results: Operating times did not differ among surgeons (50.2, 32.4 and 43.7 min). SMV tears occurred in procedures A and B only. There was no significant progression in lymph node harvest for D2 (p=0.913) and D3EM (p=0.264).
Conclusions: Cadaveric training in D3EM was associated with progression in avoidance of vascular tears with no significant changes in operating time and lymph node harvest.

 

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Intracorporeal Ileocolic Anastomosis in Laparoscopic Right Colectomy: A New Way to Make it Simple?

Giorgio Lisi, MD, Resident, Department of General and Pancreatic Surgery, University Hospital of Verona, Verona, Italy, Irene Gentile, MD, Medical Staff, Giuliano Barugola, MD, Medical Staff, Giacomo Ruffo, MD, Head of Department of Surgery, Roberto Rossini, MD, Medical Staff, Department of General Surgery, Sacro Cuore – Don Calabria Hospital, Negrar, Italy

969

 

Abstract


Although there has been a recent increase in the use of laparoscopy in colorectal surgery, the percentage of patients who undergo surgery using entirely minimally invasive techniques is still quite low, and there are substantial differences among centers. It has been argued that the limiting factor in the use of laparoscopic procedures is not the tumor or patient characteristics, but rather the number of surgeons with adequate skills to perform an entirely laparoscopic colectomy. To address this issue, we report here our totally laparoscopic right colectomy technique, with particular focus on a new way to perform the enterotomy closure, which may simplify ileocolic anastomosis.

 

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Current Strategies to Prevent Iatrogenic Ureteral Injury During Colorectal Surgery
Jonathan Douissard, MD, Surgical Resident, Frederic Ris, MD, PD, Colorectal Surgery Consultant, Philippe Morel, MD, PhD, Head of the Surgery Department, Nicolas Christian Buchs, MD, PD, Colorectal Surgery Consultant, Department of Visceral Surgery, University Hospitals of Geneva, Geneva, Switzerland

970

Abstract


Iatrogenic ureteral injuries are a source of major concern among surgeons performing colorectal procedures. Although they are uncommon, these lesions lead to severe morbidity and long-term functional disabilities, as well as an increase in mortality, hospital stay, and cost. The laparoscopic approach has gained popularity in the field of colorectal surgery and is associated with improved global postoperative outcomes. However, it is also considered to increase the risk of ureteral injury when compared to open surgery, especially during left colonic and rectal resections.
To overcome these difficulties, surgical techniques have been improved over time through standardization of both open and laparoscopic procedures. However, these techniques are not infallible, and, in difficult cases, instrumental aids such as preoperative ureteral stenting may be used. To substitute the reduced haptic feedback in laparoscopic surgery, lighted stents have been developed. Unfortunately, prophylactic stenting, whether standard or lighted, is also associated with its own morbidity and its benefit-risk ratio remains highly controversial.
To enhance the surgeon’s visualization capabilities, augmented reality technologies have been developed. Near-infrared fluorescence and hyperspectral imaging are two promising techniques, which have been tested both in the preclinical and clinical settings. Early results show that these technologies could improve our ability to identify and protect the ureters, although technical limitations remain to be solved.
Reviewing the current literature, this article aims to evaluate pre- and intraoperative techniques to identify the ureters and potentially to avoid iatrogenic injury. In addition, future trends are explored.

 

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