Surgical Technology International
35th Edition
Contains 55 peer-reviewed articles featuring the latest advances in surgical techniques and technologies.
456 pages
Nov 2019 - ISSN:1090-3941
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10-Year Experience with 1700
Single-Incision Laparoscopies
Giovanni Dapri, MD, PhD, FACS, Professor of Anatomy, University of Mons, Brussels, Belgium
1178
Background: Single-incision laparoscopy (SIL) was initially reported in the mid-1900’s, but remained unpopular until the arrival of Natural Orifice Transluminal Endoscopic Surgery. It was described not only for surgery involving the digestive system, but also for breast, thoracic, urologic, gynecologic and pediatric surgery. Various studies have proven its feasibility, safety and effectiveness. This report describes the 10-year experience with SIL of a single surgeon at a single institution.
Patients and Methods: From May 2009 to May 2019, 1700 abdominal SILs were performed, including: cholecystectomy (475), inguinal hernia repair (319), incisional/ventral hernia repair (293), appendectomy (226), colorectal surgery (158), fundoplication/diaphragmatic hernia repair (72), gastric surgery (54), diagnostic laparoscopy (42), liver surgery (18), small bowel resection (15), splenectomy (12), adrenalectomy (6), gynecologic surgery (6), pancreatic surgery (2), and urologic surgery (2). Three types of incision/access-site were adopted. Inclusion and exclusion criteria were considered. The following outcomes were evaluated: laparoscopic operative time, operative bleeding, supplementary scars or trocars for improved exposure of the operative field and/or control of perioperative complications, final incision length, hospital stay, postoperative pain during hospitalization and after discharge, early and late access-site complications and other early and late general complications.
Results: While there were no conversions to open surgery or conventional laparoscopy, a supplementary millimetric instrument or a 5-mm trocar was needed in 27.8% and 0.5% of cases, respectively. No operative or postoperative mortalities were registered. The mean final incision length was between 13.1 and 21.0 mm at the umbilicus, between 43.3 and 57.2 mm suprapubically, and between 21.4 and 36.3 mm in another abdominal quadrant. Postoperative pain decreased from the first hours until the end of hospitalization. The percentage of patients who required an analgesic drug for more than 5 days after discharge ranged between 0 and 16.6%. The early access-site complication rate was 7.5%, and the access-site incisional hernia rate was 1.3%. The other early general complication rate was 10.7%, and reoperation was required in 1.4%. The other late general complication rate was 0.7%, and reoperation was required in 0.5%.
Conclusion: SIL is a laparoscopic technique that can safely be offered to patients presenting abdominal diseases. The main advantages include enhanced cosmetic results and reduced abdominal trauma. The main disadvantages are patient selection, a longer operative time for some procedures, and a need to expose the operative field for some other procedures.
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Reduced Port Laparoscopic Cholecystectomy: An Innovative, Cost-Effective Technique with Superior Cosmetic Outcomes
Mori Krinalkumar, FRACS, General Surgeon, Department of Surgery, Northern Health, Epping, Victoria, Australia, Lecturer, University of Melbourne, Melbourne, Australia, Dhir Arun, FRACS, Upper GI, Bariatric and General Surgeon, Department of Surgery, Northern Health, Epping, Victoria, Australia, Director, Melbourne Gastro Surgery, Bundoora, Victoria, Australia
1174
Introduction: Patient demand for cosmetically superior surgical outcomes has driven minimally invasive technique development like single incision laparoscopic cholecystectomy (SILC). Implementation has been hindered by equipment factors, compromise of ergonomics, increased cost, and larger primary incision, leading to the associated risk of postoperative wound complications, incisional hernia, and fascial dehiscence. We present a method of reduced port laparoscopic cholecystectomy (RPLC), which utilises existing laparoscopic conventional equipment and an innovative MiniLap® grasper (Teleflex Incorporated, Wayne, Pennsylvania). The aim of the approach being enhanced cosmesis, cost equivalence with existing methods, and preservation of surgical ergonomics.
Materials and Methods: Twenty consecutive patients presenting to a single-surgeon practice with pathology requiring cholecystectomy and favourable body habitus were offered an RPLC procedure. Abdominal access was obtained via two laparoscopic working ports placed through a single incision within the umbilicus and with a 2.3mm port-less MiniLap® inserted via stab incision in the right upper quadrant utilised for retraction. Operative time, cost, cosmesis, postoperative pain, and patient demographics were compared with the standard four-port cholecystectomy.
Results: Twenty patients underwent RPLC with age ranging from 20 to 67 with a mean body mass index (BMI) of 31kg/m2. Mean operative time of 36.3 minutes was comparable to conventional multi-port laparoscopic cholecystectomy (LC). All operations were completed as RPLC, and no conversion to conventional four-port laparoscopic cholecystectomy was required. Gall bladder retraction with Teleflex grasper and an innovative swirling technique provides adequate exposure of the hepato-cystic triangle. Patient response regarding cosmetic outcome of the procedure was overwhelmingly positive. A single complication of the RPLC technique was documented—a superficial umbilical site wound infection, which was treated with oral antibiotics. Instrumental cost of the RPLC was $80 (AUD) greater than standard 4LP due to reduced port number but higher MiniLap® cost.
Conclusion: The RPLC method utilises an ergonomically attractive technique with outcomes and a safety profile equal to the standard multi-port LC whilst minimizing the complications and prohibitive economic penalties of traditional SILC. A well-designed prospective randomised trial can provide more insight into the pros and cons of this innovative technique.
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Venous Resection for Locally Advanced Pancreatic Cancer: Time-Trend and Outcome Analysis from 65 Consecutive Resections At A High-Hpb Volume Center
Caruso Riccardo, MD, PhD, Quijano Yolanda, MD, PhD, Ferri Valentina, MD, Duran Hipolito, PhD, MD, Diaz Eduardo, MD, Fabra Isabel, MD, Malave Luis, MD, Isernia Roberta, MD, Pinna Eva, MD, D’Ovidio Angelo, MD, Javier Nunez-Alfonsel, PhD, Plaza Carlos, MD, Ielpo Benedetto, MD, PhD, Vicente Vicente., MD, PhD, Sanchinarro University Hospital, San Pablo University, CEU, Madrid, Spain, Javier Núñez-Alfonsel, Fundación de Investigación HM Hospitales Madrid Spain
1191
Introduction: Locally advanced pancreatic cancer (LAPC) is a highly malignant carcinoma with an extremely poor prognosis. Vascular venous invasion is a frequent finding in patients with pancreatic cancer. The aim of this study was to investigate the morbidity, mortality, and survival of patients with advanced pancreatic cancer.
Methods: We retrospectively reviewed our experience of 65 consecutive pancreatic surgeries with venous resection for pancreatic cancer in three hospitals: Ramon y Cajal (Madrid, Spain) from 2002 to 2004, Monteprincipe University Hospital (Madrid, Spain) from 2005 to 2006 and Sanchinarro University Hospital (Madrid, Spain) from 2007 to December 2017. Prognostic factors were analyzed by the log-rank test and a multivariate proportional hazard regression analysis.
Results: Major venous reconstruction was performed by primary lateral venorrhaphy in 11 patients (17%), primary end-to-end anastomosis in 46 (70.7%) and reconstruction with a Gore-Tex® patch (W.L. Gore & Associates, Inc., Flagstaff, AZ) in 8 (12.3%). In 58% of the patients, the pathological examination showed infiltration of the vascular specimen. About 85% of the procedures performed were R0.
The perioperative morbidity rate with Dindo-Clavien classification ≥ III was 21.5%.
Tumor size and nodal status were the only prognostic variables, which significantly decreased survival by a multivariate analysis.
Conclusions: Major vascular resection to achieve macroscopic tumor clearance can be performed safely with acceptable operative morbidity and mortality. Nevertheless, it is justified only in carefully selected cases.
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How to Avoid and Manage Mental Nerve Injury in Transoral Thyroidectomy
Daqi Zhang, MD, PhD, Associate Professor of Surgery, Hui Sun, MD, PhD, Professor of Surgery, China-Japan Union Hospital of Jilin University, Jilin, China, Fausto Famà, MD, PhD, Associate Professor of Surgery, Ettore Caruso, MD, Giulia Pinto, MD, Alessandro Pontin, MD, Antonella Pino, MD, Gianlorenzo Dionigi, MD, FACS, Professor of Surgery, Tommaso Mandolfino, MD, Ettore Gagliano, MD, Enrico Nastro Siniscalchi, MD, Francesco Saverio De Ponte, MD, Professor of Maxillo-Facial Surgery, University of Messina, Messina, Italy
1209
Transoral endoscopic thyroidectomy by vestibular approach (TOETVA) represents an innovative and scarless technique for thyroid surgery. The procedure is conducted via a three-port technique at the oral vestibule using a 10mm port for the 30° endoscope and two additional 5mm ports for the dissecting and coagulating instruments. Patients meeting the following criteria can be considered as candidates for TOETVA: (a) an ultrasonographically (US) estimated thyroid diameter ≤10cm; (b) US-estimated gland volume ≤45mL; (c) nodule size ≤50mm; (d) presence of a benign tumor, such as a thyroid cyst or a single- or multinodular goiter; (e) Bethesda 3 and/or 4 categories, and (f) papillary microcar-cinoma without the evidence of metastasis. Beyond the classic complications of thyroid surgery, namely cervical hematoma, recurrent laryngeal nerve injury and hypoparathyroidism, novel consequences can occur as mental nerve (MN) injury. In this paper, leading experts in the field report on their current clinical experience with the TOETVA approach for thyroid gland surgery, with emphasis given to tips and tricks to avoid and manage MN injury.
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Laparoscopic Appendectomy: How Should we Deal with the Appendicular Stump?
Vincenzo Consalvo, MD, Francesca D'Auria, MD, PhD, Università degli Studi di Salerno (Italy), Salerno, Italy
1204
Background: The laparoscopic appendectomy approach (LAA) for acute appendicitis has fewer intra- and post-operative complications, less pain, and smaller scars compared to the traditional open appendectomy approach (OAA), but a higher frequency of intra-abdominal abscess (IAA). The relationship between this higher frequency of IAA and the omission of appendicular stump invagination is difficult to explain, even though such invagination of the appendicular stump is the only difference between standard LAA and OAA.
Methods: A randomized controlled trial was carried out to systematically evaluate our novel LAA with invagination of the appendicular stump.
Results: Age, gender, height, weight, post-operative surgical complications and operative time were comparable between our LAA and OAA.
Conclusion: Invagination of the appendicular stump in LAA appears to be safe and effective, and its routine use could be a starting point to achieve the reduction of IAA in LAA compared to OAA.
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Robotic-Assisted Nissen Fundoplication with the Senhance® Surgical System: Technical Aspects and Early Results
Robin Schmitz, MD , Duke University Medical Center, Durham, North Carolina, Frank Willeke, MD, PhD, Professor of Surgery, Chair, Ibrahim Darwich, MD, Stefan Marc Kloeckner-Lang, MD, Heike Saelzer, MD, St. Marienkrankenhaus, Siegen, Germany, Dietmar Stephan, MD, Chief, Division of Minimal Invasive Surgery and Robotics, St. Marienkrankenhaus , Siegen, Germany, Joachim Labenz, MD, PhD, Professor of Medicine, Daniela-Patricia Borkenstein, MD, Jung Stilling Hospital, Siegen, Germany, Sabino Zani, MD, Assistant Professor of Surgery, Duke University Medical Center, Durham, North Carolina
1207
Introduction: Robotic-assisted surgery continues to evolve. Technical advantages are reported for intracorporal suturing, a technique with a long learning curve in conventional laparoscopy. The success of laparoscopic fundoplication relies on precise suturing at the hiatus and of the fundal wrap. Therefore, robotic assistance can be a useful tool for this particular procedure. In March 2017, the Senhance® Surgical System (Transenterix, Inc., Morrisville, North Carolina) was introduced into robotic-assisted procedures at the St. Marien-Krankenhaus, Siegen, Germany.
Materials and Methods: Between March 2017 and July 2019, we performed 36 surgeries of the upper GI tract with the Senhance® Surgical System. Eighteen patients underwent the classic Nissen fundoplication and are the subject of this study. All patients gave informed consent for robotic assistance with prospective data acquisition and analysis.
Results: Seven male and 11 female patients were included in the study. The median age of the cohort was 58.5 years (range 30–81 years) and the median body mass index (BMI) was 30.4 kg/m2 (range 22.7–40.1 kg/m2). The median total operative time was 95.5 minutes (range 68–194 minutes) and, despite the small sample size, we observed a significant learning curve throughout the study period (p<0.05). Before the introduction of the Senhance® Ultrasonic energy device, conversion to laparoscopic fundoplication was necessary in two patients. We performed one re-do laparoscopy on the day of surgery due to pain without any significant intraoperative findings and one laparoscopic revision to Toupet fundoplication after seven months due to dysphagia.
Conclusion: This first report of robotic-assisted Nissen fundoplication with the Senhance® Surgical System demonstrates technical feasibility. After successful introduction of the Senhance® Ultrasonic, our conversion rate to standard laparoscopic surgery was significantly reduced.
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