Surgical Technology International
33rd edition
Contains 45 peer-reviewed articles featuring the latest advances in surgical techniques and technologies.
376 pages
October 2018 - ISSN:1090-3941
1 year Institutional Subscription
both electronic and print versions
Near-Infrared Indocyanine Green-Enhanced Fluorescence and Minimally Invasive Colorectal Surgery: Review of the Literature
Alberto Mangano, MD, Robotic Surgery Research Specialist, Mario A. Masrur, MD, F.A.C.S., Assistant Professor of Surgery, Roberto Bustos, MD, Robotic Surgery Research Specialist, Liaohai Leo Chen, PhD, Research Visiting Professor, Eduardo Fernandes, MD, FRCS, Chief Administrative Surgical Resident, Pier Cristoforo Giulianotti, MD, FACS, Distinguished Lloyd Nyhus Professor of Surgery, Chief Division of General Minimally Invasive & Robotic Surgery, Vice-Head Department of Surgery, Director Robotic Surgery Fellowship Program, Associate Director UIC Health Science Simulation Consortium, Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, Chicago, IL
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Background: Leakage of the anastomosis after colonic/rectal surgery is a serious complication. One of the most important causes of anastomotic leakage is impaired vascularization. A microvascular tissue deficit is very often not intraoperatively de visu detectable under white light. Near-infrared indocyanine green (ICG)-enhanced fluorescence is a cutting-edge technology that may be useful for detecting microvascular impairment and potentially preventing anastomotic leakage.
Aim: The aim of this narrative review was to evaluate the feasibility and the usefulness of intraoperative assessment of vascular anastomotic perfusion in colorectal surgery using an indocyanine green (ICG) fluorescent tracer.
Material and methods: A PubMed/MedLine, Embase, and Scopus narrative literature review was performed, in which “colorectal surgery” and “indocyanine green” were used as key words. The inclusion criteria were 1) manuscripts written in English; 2) full text is available; 3) topic related to the use of ICG fluorescence for the assessment of tissue perfusion during laparoscopic or robotic colorectal surgery; and 4) sample: adult patients, benign or malignant disease. Exclusion criteria included 1) case reports; 2) topic not related to the use of ICG fluorescence for the evaluation of tissue perfusion during laparoscopic or robotic colorectal surgery; 3) manuscripts that focused solely on other applications of ICG technology; and 4) any study type not showing original data.
Results and Critical Discussion: The intraoperative visual assessment of tissue viability under white light may lead to an underestimation of microvascular blood flow impairment. ICG can be safely used in cases of minimally invasive colonic surgery and also low anterior resections. This technology may be useful when deciding whether to intraoperatively change a previously planned resection/anastomotic level, which could decrease theoretically the occurrence of anastomotic leakage.
Conclusions: Near-infrared ICG technology is a very useful approach. Multiple preliminary studies suggest that this technique may be used to predict anastomotic leakage. However, evaluation of the ICG signal is still too subjective. Some reliable scoring/grading parameters related to the ICG signal need to be defined. Additionally, more prospective, randomized, and adequately powered studies are required to completely reveal the true potential of this surgical technological innovation.
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Technical Steps and Tips for Linear-Stapled Gastric Bypass Based on Personal Experience and the Classification of Intraoperative Complexity
Michael Korenkov, MD, Head of Department, Department of General and Visceral Surgery, Klinikum Werra-Meissner, Eschwege, Germany
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The most commonly performed Roux-en-Y gastric bypass (RYGB) procedure is difficult and has many technical variations. The individual patient’s anatomic characteristics, like an exceptionally large left liver lobe, fatty mesentery with limited mobile Roux limb, difficulty in positioning a stapler, etc., can greatly increase the technical difficulty of this procedure. Challenging situations in laparoscopic gastric bypass surgery can be classified according to the intraoperative complexity. According to this classification scheme, all patients in laparoscopic linear-stapled gastric bypass can be classified into one of four types: Type I - ideal. Surgery is straightforward, and every operative technique is relatively routine. Type II - less-than-ideal. Some minor technical difficulties may occur; some operative techniques can be more difficult than others. Type III - problematic. Difficult, with some operative techniques considerably more difficult than others. Type IV - very difficult. Every operative step is very difficult. The goal of this article is to analyze the steps of laparoscopic linear-stapled RYGB with regard to personal experience and the classification of intraoperative complexity.
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Mechanical Reinforced Terminolateral Ileo-Transverse Anastomosis: An Option After Right Hemicolectomy-A 452 Patients Study
Jordi Castellví Valls, PhD, MD, Chief of General Surgery Department, Javier Pérez Calvo, PhD, MD, Surgeon, Ana Centeno Álvarez, PhD, Resident, Verónica González Santín, PhD, Surgeon, Lorenzo Viso Pons, PhD, Head of Coloproctology Unit, Sergio Mompart García, PhD, Luis Ortiz de Zárate, PhD, Nuria Farreras Catasus, PhD, MD, Jordi Mas Jove, PhD, Vicente Fernández Trigo, PhD, MD, Domenico Sabia, PhD, Department of Colorectal Surgery, Department of Surgery, Moisés Broggi Hospital, Barcelona, Spain
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Introduction: Bowel reconstruction techniques after right hemicolectomy has currently been objective of review, due to the high rate of anastomotic leak. The aim of this study is to analyse our results of the mechanical reinforced terminolateral ileo-transverse anastomosis.
Materials and Methods: A prospective and descriptive study of a consecutive series of right colonic cancer cases that underwent right hemicolectomy. Mechanical reinforced terminolateral ileo-transverse anastomosis technique was carried out in all patients. Demographics, emergency or elective surgery, surgical management, postoperative complications, rate of anastomotic leak, need for surgical procedure after complication, average stay, and mortality were analysed.
Results: A total of 452 patients underwent surgery between 2010 and 2017. Of those, 40.6% were female and 59.4% were male. The average age and body mass index (BMI) was 72±11.3 years old, and 26±7.1, respectively. Elective surgery was carried out in 405 (89.6%) patients. Laparoscopic approach was used in 250 patients (61.7%) and 6% needed conversion. Only 41 patients (10.6%) had major complications (Clavien-Dindo III-IV). The rate of postoperative paralytic ileus reach was up to 13.9%. Reintervention was needed in five patients (1.1%) due to anastomotic leak and three (0.7%) of them from the elective surgery subgroup. There were 10 patients (2.2%) with postoperative gastrointestinal bleeding. The average stay was 8.2±2.8 days and late postoperative mortality in the first 30 days was 2%.
Conclusions: Mechanical reinforced terminolateral ileo-colic anastomosis is a safe technique with a low anastomotic leak rate. Although our results using this approach seem promising, postoperative paralytic ileus is still a high-rate complication.
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Special Use of Intraoperative Endoscopy in Sleeve Gastrectomy: A Case Report
Francesco Frattini, MD, Surgeon, Vincenzo Pappalardo, MD, Surgeon, Davide Inversini, MD, Surgeon, Matteo Lavazza, MD, Resident, Stefano Rausei, MD, PhD, Surgeon, Giulio Carcano, MD, Full Professor, Department of Surgery, Circolo Hospital and Macchi Foundation, Varese, Italy
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Sleeve gastrectomy is the most frequently performed operation for the treatment of morbid obesity. Even though sleeve gastrectomy is now widely standardized, it may still benefit from the use of certain devices and procedures such as intraoperative endoscopy. The use of an endoscope offers numerous advantages that can considerably reduce the morbidity and mortality of patients who undergo laparoscopic sleeve gastrectomy. This paper describes our experience with a case in which the information obtained by endoscopy allowed us to perform a real-time assessment of the location of two large gastric polyps to control the staple-line.
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A Surgical Case of Inferior Mesenteric Arteriovenous Malformation
Yusuke Otani, MD, Chief Resident , Takehiro Okabayashi, MD, Division Manager, Yuichi Shibuya, MD, Head Medical Director, Tatsuaki Sumiyoshi, MD, Chief Physician, Kenta Sui, MD, Chief Physician, Jun Iwata, MD, Head Medical Director, Sojiro Morita, MD, Vice President, Yasuhiro Shimada, MD , Director , Kochi Health Sciences Center, Kochi, Japan
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The treatment option for inferior mesenteric arteriovenous malformations is under debate because of the number of cases. We, herein, report about a 35-year-old man with congenital inferior mesenteric artery malformation (AVM) presenting with mucous stool and severe abdominal pain. The radical operation, after building the diverting stoma, minimized the extent of the resection. This is the first reported case where surgical management was used to control severe symptoms induced by inferior mesenteric AVM.
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Conservative Management of Chronic Anal Fissure. Results of a Case Series at 2-years Follow-up and Proposition of a New Classification
Antonio Canero, MD, PhD, Consultant General Surgeon, Carmela Rescigno, MD, General Surgeon, Francesco Giglio, MD, Consultant general surgeon, L'Azienda Ospedaliero Universitaria San Giovanni di Dio e Ruggi D'Aragona, Salerno, Italy, Vincenzo Consalvo, MD, Consultant general surgeon, Chirurgia Generale, Università degli Studi di Salerno, Salerno, Italy, Francesca D'Auria, MD, General Surgeon, Salsano Vincenzo, MD, Director of Bariatric Surgery Department, Clinique Clementvielle, Montpellier, France
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Background: Anal fissure is a common proctological condition that is usually defined as an anodermal ulcerative process starting from the posterior commissure to the dentate line. The objective of this study was to evaluate the resolution rate of anal fissure through the use of conservative management in patients grouped according to our newly proposed classification. A secondary purpose was to quantify the recurrence rates at 2-years follow-up in each group.
Methods: A retrospective analysis was carried out on patients in our general database. Diagnosis was based on symptoms, clinical observation, anal manometry and transanal ultrasounds. After application of inclusion and exclusion criteria, patients were assigned to different groups. Follow-up was carried out at 3, 6, 12 and 24 months.
Results: A total of 136 patients (54 female and 82 male) were included in the statistical analysis. At the end of the treatment period, all patients in groups 1 and 2 had a complete resolution of illness and a normal basal sphincterial tone, while those in groups 3 and 4 had a higher rate of recurrence at the 2-year follow-up.
Conclusion: Based on our series, we propose a definitive non-surgical management for all group 1 and 2 anal fissures according to our protocol. For groups 3 and 4, we recommend a primary non-surgical approach with follow-up. This was a retrospective study and further randomized controlled studies will be necessary to confirm our results.
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Management of Staple Line Leaks Following Laparoscopic Sleeve Gastrectomy for Morbid Obesity
Giuseppe Currò, MD, Associate Professor of Surgery, Department of Human Pathology in Adult and Evolutive Age ''G. Barresi'', University Hospital G. Martino, University of Messina, Messina, Italy, Iman Komaei, MD, Surgeon in Training, Claudio Lazzara, MD, Surgeon in Training, Federica Sarra, MD, Surgeon in Training, Andrea Cogliandolo, MD, Associate Professor of Surgery, Giuseppe Navarra, MD, Full Professor of Surgery, Department of Human Pathology in Adult, and Evolutive Age ''G. Barresi'', University Hospital G. Martino, University of Messina, Messina, Italy, Saverio Latteri, MD, Consulting Surgeon, Surgical Unit, Cannizzaro Hospital, Catania, Italy
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Purposes: Management of staple-line leaks following laparoscopic sleeve gastrectomy (LSG) is challenging and controversial. Guidelines for leak treatment are not standardized and often involve multidisciplinary management by surgical, medical and radiological methods. Herein we present our experience and proposed strategy for handling leaks after LSG.
Patients and methods: Retrospective data regarding LSG performed from April 2012 to October 2017 at the Surgical Oncology Division, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital "G. Martino", University of Messina, Italy, were reviewed. The management approaches and the surgical, endoscopic, and percutaneous procedures used were examined. Outcomes measured included the prevalence of gastric leaks, radiological features, related morbidities and mortalities, hospital stay and management.
Results: LSG was performed in 310 patients. Eight patients were managed for gastric leak within the 5-year period: 5 (1.6% overall prevalence) from our division, 3 referred from another hospital. All cases were successfully treated conservatively with combined CT/US-guided drainage using a locking pigtail catheter and endoscopic gastric stent positioning. Endoscopic therapy included the use of fully covered self-expanding esophageal metal stents (Hanarostent® 24 cm; M.I. Tech, Seoul, Korea) in addition to pigtail drains (Drainage Catheter Locking Pigtail 8F/21cm; Tru-Set® Ure-Sil, Skokie, IL, USA). Complete closure of the leak was achieved in all patients. The mean time from presentation to healing was 74 days ± 37.76 (SD). None of the patients underwent remedial surgery.
Conclusion: This study presents our management strategy for leak resolution in LSG patients. Based on our results, we strongly recommend the conservative and combined management of gastric leaks following LSG by endoscopic stenting and percutaneous drainage.
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Favorable Management of Low Colorectal Anastomotic Leakage with Transanal Conventional and Endoscopic Drainage (GelPOINT® Path Transanal Access Platform)
Claudio Lazzara, MD, Resident, Giuseppe Currò, MD, Associate Professor, Iman Komaei, MD, Resident, Adalberto Barbera, MD, Aggregate Professor, Giuseppe Navarra, MD, Full Professor, Surgical Oncology Division, Department of Human Pathology of Adult and Evolutive Age, University Hospital of Messina, Messina, Italy
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Objective: We describe our experience with transanal-laparoscopic treatment of anastomotic leakage.
Summary of Background Data: Anastomotic leakage leads to high mortality rates, morbidity, a complicated post-operative course and increased cost. The management of low anastomotic leakage after anterior resection of rectal cancer is not standardized.
Methods: This was a retrospective cohort study based on prospectively collected data. Among patients who underwent anterior resection for rectal cancer in our division between January 2014 and October 2017, 14 developed colorectal or colo-anal anastomotic leakage and underwent reoperation with a transanal approach. Data regarding patient demographics, reoperative outcomes, morbidity, length of hospital stay, mortality, leak closure and long-term outcomes are presented.
Results: In all patients, anastomotic healing was confirmed by radiology. No perioperative complications were detected. One patient presented anastomotic stricture after 20 months, which was successfully treated with dilatation.
Conclusions: There is little information available on the management of anastomotic leakage after anterior resection for rectal cancer. Although more studies are needed to standardize patient selection criteria and evaluate the long-term outcome of these procedures, minimally invasive transanal conventional and laparoscopic anastomotic leak repair is a feasible and safe surgical option that can often avoid the need for anastomotic takedown and stoma formation.
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Prevention of Parastomal Hernia
Ian T. MacQueen, MD, Chief Resident, David C. Chen, MD, Associate Professor of Clinical Surgery, Lichtenstein Amid Hernia Clinic, David Geffen School of Medicine at University of California, Los Angeles, Santa Monica, CA, Philipp Kirchhoff, MD, Senior Surgical Consultant, University Hospital Basel, Switzerland
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Parastomal hernia (PSH), defined as an incisional hernia at the abdominal wall defect resulting from stoma formation, is a frequent complication of enterostomy (ileostomy and jejunostomy), colostomy, and urostomy. A growing body of evidence supports the use of prophylactic mesh at the time of stoma creation to prevent the development of PSH. In particular, the use of permanent mesh has been supported in the creation of an end colostomy, and prophylactic mesh has been studied for use in other types of stoma. Permanent mesh materials used for PSH prophylaxis include polypropylene, polyester, polytetrafluoroethylene, and composite prosthetics. Despite the appeal of biologic and bioabsorbable materials in an operative field that poses a potentially higher risk of infection, there is insufficient evidence to support their use in primary PSH prevention. Two-dimensional meshes are usually cut to contain a keyhole through which the bowel passes, and may be placed in the sublay/retrorectus, intraperitoneal, or preperitoneal position. Alternative techniques include placement of a non-keyhole mesh in a position similar to that of a Sugarbaker PSH repair or use of a circular stapler fired through the abdominal wall fascia and mesh simultaneously, fixing both together. Three-dimensional mesh devices, including the Prolene® and Ultrapro® Hernia Systems (PHS/UHS) (Ethicon US, LLC, Somerville, NJ), have been studied for use in PSH prevention. Novel, specialized devices such as the Koring™ (Koring AG, Basel, Switzerland) stoma mesh have been designed specifically for primary PSH prevention. While the benefits of mesh prophylaxis have been established, further evidence is needed to identify the optimal materials and technique for PSH prevention in a variety of patients and settings. The purpose of this report is to provide an overview of the operative techniques and evidence supporting prophylaxis of parastomal hernias.
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Intracorporeal Anastomosis in Both Elective and Emergency Right Hemicolectomy: Our Experience
Simona Macina, MD, Resident, Mikaela Imperatore, MD, Surgeon, Cosimo Feleppa, MD, Surgeon, Francesco Sucameli, MD, Resident, Giuseppina Talamo, MD, Resident, Stefano Berti, MD, Head of Department, Department of General Surgery, Sant’Andrea Hospital, La Spezia, Italy
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Purpose: The aim of this study was to examine whether intracorporeal anastomosis (IA) after laparoscopic right hemicolectomy (LRH) is a safe procedure in both emergency and elective settings.
Methods: A retrospective review of all consecutive adult patients (age > 17 years) who underwent LRH from November 2014 to May 2018 at S. Andrea Hospital, La Spezia, was performed. The primary and secondary outcomes were the anastomotic leak rate and the operative time, respectively. Both IA and extracorporeal anastomosis (EA) were performed according to standardized techniques by the same team of experienced surgeons. Our findings were compared to literature data on recent studies comparing IA and EA during LRH.
Results: During the observation period, 167 patients underwent RH at our institution: IA was performed in 115. The mean age was 73.5 y. Thirty-three RH were performed in an emergency setting: 15 laparotomic procedures, 3 conversions from laparoscopic to open, 6 laparoscopic-assisted with EA, and 9 complete IA. The remaining 134 patients underwent elective RH: IA was performed in 106. The overall anastomotic leak rate in LHR IA was 2.6% (3/115), and no anastomotic leak was reported in the emergency group (0/9). The mean operative time was 180 min. In our experience, the operative time is related to the surgeon’s experience and confidence with the technique, and not to the anastomosis technique per se.
Conclusion: Consistent with the literature data, IA in LRH was associated with better outcomes than EA in both elective and emergency settings.
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