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Surgical Technology International XXVII contains 41 peer-reviewed articles featuring the latest advances in surgical techniques and technologies.
Nov, 2015 - ISSN:1090-3941
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General Surgery.
Continuous Intraoperative Neuromonitoring in Thyroid Surgery
Flavia Angeletti, MD, Senior house officer, Clinic of General, Visceral and , Transplantation Surgery, University Medical Center , Gutenberg University Mainz, Mainz, Germany, Petra B. Musholt, MD, Clinical Research Director, Translational Medicine and Early Clinical, R&D Diabetes Division, Sanofi-Aventis, Industrial Park Hoechst, Frankfurt, Germany, Thomas J. Musholt, MD, Professor of Endocrine Surgery, Section of Endocrine Surgery, Clinic of General, Visceral and Transplantation Surgery, University Medical Center, Gutenberg University Mainz, Mainz, Germany
668
Intermittent intraoperative neuromonitoring (I-IONM) has been introduced to thyroid surgery during the past two decades. The neuromonitoring devices (hardware and software) were significantly improved with the development of the second and third device generations. Needle electrodes, which were widely used 10 years ago, are almost completely substituted by less invasive, optimized endotracheal tube electrodes that ensure signal stability. In addition, recommendations of surgical societies for the standardized application of IONM have been established and incorporated into guidelines. However, due to the already very low frequency of (permanent) recurrent laryngeal nerve (RLN) paralysis following primary thyroid resections, a significant benefit of IONM compared to the “gold standard�? of visual identification of the RLN alone has not been demonstrated so far. Moreover, the idea to enable surgeons to recognize impending nerve damage during (not after) dissection cannot be implemented with I-IONM techniques. The main benefit of I-IONM, therefore, remains the possible change of resection strategy in case of a “loss of signal (LOS)�? after resection of one thyroid lobe in patients with planned bilateral resection. The recent introduction of continuous neuromonitoring (C-IONM) represents a significant step forward, potentially enabling the surgeon to react before irreversible damage to the RLN occurs. Preliminary data are supporting this methodological advantage.
Current Developments and Unusual Aspects in Gastrointestinal Surgical Stapling
Francesco Frattini, MD, General Surgeon, Insubria University, Department of Surgery, Varese, Italy, Francesco Amico, MD, General Surgery Registrar, Insubria University, Department of Surgery, Varese, Italy, Research Fellow, University of Melbourne, Department of Medicine, Melbourne, Australia, Stefano Rausei, MD, PhD, Associate Professor of Surgery, Insubria University, Department of Surgery, Varese, Italy, Luigi Boni MD, FACS, Professor of Surgery , Insubria University, Department of Surgery, Varese, Italy, Francesca Rovera, MD, Professor of Surgery, Insubria University, Department of Surgery, Varese, Italy, Gianlorenzo Dionigi, MD, FACS, Director 1st Division of Surgery, Professor of Surgery, Insubria University, Department of Surgery, Varese, Italy
555
Stapling devices are used in gastrointestinal, gynecologic, thoracic, and many other surgeries to resect organs, transect tissues, and anastomose different structures. These devices became widely accepted standard practice in many gastrointestinal operations, especially since the successful advent of minimally invasive surgery. Despite the relevant advantages related to the use of a surgical stapler, we must also consider that these instruments may be at risk of failure. When any component fails, the patient is at risk of operative morbidity. Gastrointestinal surgical stapling technique still needs refinement in order to increase its reliability. Staple line reinforcement has been widely used and seems to effectively reduce anastomotic complications. Literature provides us with examples of studies supporting both bleeding and leakage reduction after staple line reinforcement, but high-quality evidence is not available to date. Semi-absorbable and nonabsorbable materials have been the earliest available. The use of bioabsorbable staple line reinforcement materials has recently become more widespread, and these materials are more widely used these days. Powered staplers were made available to the market some time ago and represent a rather unheard of aspect of endosurgical stapling. Despite powered staples being supposedly convenient compared with manual ones only one relevant article was found when searching the U.S. National Library of Medicine for “powered stapler.�? New surgical stapling devices are constantly developed and introduced on the market. Results with such devices depend on the stapler features but also surely vary according to the surgeon experience.
LigaSure Vessel Sealing System in Altemeier’s Procedure for Geriatric Patients
Sandra Maria Moreira Paim, MD, FBCS, FBSCRS, Researcher, Colon and Rectal Surgeon, Department of Colon and Rectal Surgery, St. Mark’s Hospital, Salt Lake City, Utah, Eric Changchien, MD, Colon and Rectal Surgeon, Department of Colon and Rectal Surgery, St. Mark’s Hospital, Salt Lake City, Utah, John A Griffin, MD, FACS, FASCRS, Chair and Colon and Rectal Surgeon, Department of Colon and Rectal Surgery, St. Mark’s Hospital, Salt Lake City, Utah, Program Director, Colon and Rectal Fellowship , St. Mark’s Healthcare Foundation Program , Salt Lake City, Utah
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The aim of this study is to describe the feasibility, safety, and efficiency of LigaSure™ Vessel Sealing System (LSVSS) in Altemeier’s procedure for full-thickness rectal prolapse in a geriatric group of octogenarians and older. To the best of our knowledge, this is the first time a study on this procedure looks specifically at a very old patient group and LigaSure. A review of the literature was conducted on Pubmed Database. From April 2008 to October 2013, seven female patients (median age, 89 years) underwent Altemeier’s procedure for prolapse using the LSVSS. Preoperative, intraoperative, and postoperative data were collected and analyzed for all patients. Five out of seven patients were ASA class III and had previous history of pelvic surgery. All had preexisting medical conditions other than the full-thickness rectal prolapse. Stapled anastomoses were performed in 6/7 cases with a circular stapling device. The median surgical time was 74 min. and intraoperative blood loss was minimal for all 7 patients. The median length of the resected specimen was 9 cm. There was no surgery-related mortality or recurrence. All patients had at least a 2-year follow-up. The use of the LSVSS in Altemeier’s procedure is feasible, safe, and time-saving.
Tsunekazu Hanai, MD, PhD, Associate Professor, Koutarou Maeda, MD, PhD, Professor, Koji Masumori, MD, PhD, Associate Professor, Hidetoshi Katsuno, MD, PhD, Associate Professor, Hiroshi Matsuoka, MD, PhD, Assistant Professor , Gastrointestinal Surgery , Department of Surgery, Fujita Health University School of Medicine, Aichi, Japan
670
Robotic surgery offers advantages for operating in a narrow space such as inside the pelvis. We report on the technique of robotic-assisted laparoscopic total proctocolectomy with lymphadenectomy and ileal pouch-anal anastomosis for ulcerative colitis with transverse colitic cancer, using the single cart position. A 46-year-old female patient was diagnosed with colitic cancer of the transverse colon during the surveillance of ulcerative colitis. Six port sites were used. Mobilization of the left-sided colon through to the rectum and mobilization of the transverse colon with lymphadenectomy around the middle colic artery were performed using the robotic surgical system. After rectal mobilization was conducted near the anus, the right side of the colon was mobilized and the ileum resected laparoscopically. Thereafter, a mucosectomy of the proctorectum was carried out through a trans-anal approach, and a hand-sewn J-pouch was performed. Finally, a diverting ileostomy was constructed through the right lower abdomen. The operative time was 460 minutes, including the console time of 361 minutes. The amount of blood loss was 76 g. The patient was discharged on postoperative day nine. Pathological results demonstrated that the depth of the lesion was T3, and the positive lymph node was 1 of 115 retrieved lymph nodes. There were no complications or mortality. Robotic-assisted total proctocolectomy and lymphadenectomy with ileal pouch-anal anastomosis for transverse colitic cancer of ulcerative colitis was performed safely using the single cart position.
Development of an Ultra-rapid, Small Tissue-collecting Device for, Endoscopic Surgery — the Lymph Node Carrier: Useful in Protecting the Air-sealing Valves of the Trocar for Endoscopic Surgery and in Preventing Port Site Recurrence
Tokihisa Yamasaki, MS, Technical staff, Kyushu University, Center for Advanced Medical Initiatives, Fukuoka-ken, Japan, Takeshi Ohdaira, MD, PhD, Professor, Kyushu University, Center for Advanced Medical Initiatives, Fukuoka-ken, Japan
679
In laparoscopic and thoracoscopic surgery for malignant tumors, it is often necessary to recognize intraoperative rapid diagnosis by sampling a small section of tissue that is suspected of the lymphatic or disseminated metastasis of malignant tumor cells, or of the direct invasion. However, sampling of the target tissue has to be carried out without dropping a section into the peritoneal or thoracic cavity and port-site tumor recurrence. We developed a device named the “lymph node carrier (LNC)�? that is capable of instantaneously carrying a small piece of tissue out of the body after its insertion into the trocar for conventional laparoscopic surgery. LNC is composed of the following three parts: 1) the carrier container; 2) the external sheath that re-encloses the tissue, which protruded from the container, into the container; and 3) the air-sealing cap. In the in vivo study three sows were used to remove the sigmoid colon and to carry adipose tissue containing the dissected lymph nodes out of the body. Sliding of the external sheath and the LNC container allowed the re-enclosure of adipose tissue protruding from the container. Carriage time of the dissected lymph nodes out of three sows was 37.7±1.5 seconds in mean±SD. LNC was suggested to be a surgical device capable of allowing, in a very efficient manner and a very short period of time, the repeated collection of removed specimens out of the body without damaging the air-sealing valves of the trocar for endoscopic surgery.
Self-Retaining Retractor Widox® for Thyroid Surgeries: Technical Note
Davide Inversini, MD, Trainee Surgeon, Francesco Frattini, MD , Consultant Surgeon, Matteo Annoni, MD , Consultant Surgeon, Vincenzo Pappalardo, MD , Trainee Surgeon, Andrea Leotta, MD, Consultant Surgeon, Matteo Lavazza, MD , Trainee Surgeon, Stefano Rausei, MD, PhD, Consultant Surgeon, Gianlorenzo Dionigi, MD, FACS, Professor of Surgery, Department Chief, Circolo Hospital in Varese , Insubria University , Varese, Italy
680
During a thyroidectomy, perfect exposure of the vascular nerve structures, parathyroid gland, trachea, larynx, esophagus, and lymphnodes is crucial to facilitate the surgeon in the meticulous dissection. WIDOX® (MOSS Spa, Lesa, Italy) is an atraumatic self-retaining thyroidectomy retractor specifically designed for thyroid surgeries with an octagonal shape and six retractors (Fig. 1). It is a sterile, single-use device which keeps the surgical wound and the neck muscles retracted allowing the proper exposure of the operatory field. The device substitutes the manual retractors held by the surgeon’s assistants. In our institute, we started using the self-retaining retractor WIDOX® from May 2015 for a total of 50 patients. From our preliminary experience, the self-retaining retractor WIDOX® is simple and practical and can be adapted to each patient. The use of energy-based devices and the neuromonitoring is not prevented by the presence of this retractor.
