Surgical Technology International
34th edition
Contains 67 peer-reviewed articles featuring the latest advances in surgical techniques and technologies.
521 pages
May 2019 - ISSN:1090-3941
1 year Institutional Subscription
both electronic and print versions
New Paradigms for Neural Monitoring in Thyroid Surgery
Hui Sun, MD, Professor, Daqi Zhang, MD, Associate Professor of Surgery, Yishen Zhao, MD, Doctor, China-Japan Union, Hospital Of Jilin University, Jilin Provincial Key Laboratory Of Surgical, Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun, Jilin province, PR China, Paolo Carcofaro, MD, Professor of Surgery, S. Anna University Hospital, Ferrara, Italy, University of Ferrara, Ferrara, Italy, Hoon Yub Kim, MD, Associate Professor Of Surgery, Korea University College of Medicine, Seoul, Korea, Gianlorenzo Dionigi, MD, FACS, Professor of Surgery, Antonella Pino MD, Doctor, Ettore Caruso, MD, Doctor, Alessandro Pontin, MD, Doctor, University Hospital G. Martino, University of Messina, Messina, Italy, Vincenzo Pappalardo, MD, Doctor, Ospedale di Circolo di Varese, Varese, Italy, Özer Makay, MD, Professor of Surgery, Ege University Hospital, Ege University-Izmir, Turkey, Che-Wei Wu, MD, PhD, Professor of Surgery, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University Hospital, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Intraoperative neuromonitoring (IONM) in thyroid gland surgery provides real-time feedback to the endocrine surgeon regarding the electrophysiological consequences of surgical manipulation of the laryngeal nerves. The goal of monitoring modalities is to detect surgical or physiological insults to the recurrent laryngeal nerve (RLN) while they are still reversible or, in cases where prevention is not an option, to minimize the damage done to these structures during thyroidectomy. In recent decades, monitoring of the RLN has become a fundamental part of endocrine surgery. IONM is a feasible procedure in both open and endoscopic, robotic thyroidectomy. Experts in IONM have organized a working group of general, endocrine, head and neck ENT surgeons and endocrinologists (International Neural Monitoring Study Group; INMSG) to develop standards for practicing this technique in endoscopic and robotic thyroidectomy. This paper presents recent clinical and research experience with intraoperative neural monitoring for thyroid gland surgery.
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Benefits of Robotic Camera Assistance in Minimally Invasive Bariatric, Procedures: Prospective Clinical Trial Using a Joystick-Guided Camera-Holder
Sebastian W. Holländer, MD, Resident Physician, Hans Joachim Klingen, MD, Senior Physician, Visceral and Pediatric Surgery, University Hospital of the Saarland, Homburg, Germany, Sarah Hess, Diploma Ecotrophologist, Anna Merscher, MD, Assistant Physician, Hospital Bietigheim-Vaihingen, Bietigheim-Vaihingen, Germany, Dieter Birk, MD, Medical Director and Head of the Department, Matthias Glanemann, MD, Chief Physician and Head of the Department, Department of General Surgery, Vascular, Visceral and Pediatric Surgery, University Hospital of the Saarland, Homburg, Germany
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Background: While minimally invasive surgery is a growing sector in medicine, camera assistance remains a problem. Especially in bariatric surgery, the assistant holding the camera faces certain challenges. Furthermore, unless the surgeon controls the camera movement themselves, they will be challenged by an unstable image.
The aim of this study was to investigate the benefits of a robotic camera assistant (SoloAssist®, AKTORmed™ GmbH, Barbing, Germany) in bariatric surgery.
Patients and Methods: Three hundred thirty one consecutive laparoscopic bariatric procedures were performed with the assistance of a camera robot, including Roux-en-Y gastric bypass, laparoscopic gastric banding, sleeve gastrectomy, and gastroplication. Failures and aborts were documented and 6 surgeons were interviewed regarding their experiences using a questionnaire.
Results: In 18 of 331 procedures, robotic assistance was aborted and the procedure was continued manually, mostly because of a need for frequent changes of position in narrow spaces and adverse angles. Two short circuits, 4 joystick faliures and one malfunction of the control unit were reported. All of the surgeons preferred robotic to human assistance, mostly because of a steady image and the capacity for self-control. Discussion: The SoloAssist® is a reliable system for minimal invasive procedures, especially in bariatric surgery. It provides more comfortable conditions for the surgeon and their assistant by freeing one hand for other purposes. Even in narrow spaces (e.g., between a voluminous stomach and adipose liver), the robot guarantees a steady image. Slight movements of the camera can be precisely controlled, which leads to increased comfort for the surgeon.
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Near-Infrared Indocyanine Green-Enhanced Fluorescence and Evaluation of the Bowel Microperfusion During Robotic Colorectal Surgery: a Retrospective Original Paper
Alberto Mangano, MD, Robotic Surgery Research Specialist, Eduardo Fernandes, MD, PhD, FRCS, Chief Resident in General Surgery, Federico Gheza, MD, Robotic Surgery Research Specialist, Roberto Bustos, MD, Robotic Surgery Research Specialist, Liaohai Leo Chen, PhD, Visiting Research Professor, Mario Masrur, MD, FACS, Assistant Professor, Pier Cristoforo Giulianotti, MD, FACS, Lloyd Nyhus Professor of Surgery; Chief, Vice Head, Department of Surgery, University of Illinois at Chicago, Chicago, IL
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Background: Leakage of the anastomosis after colorectal surgery is a severe complication, and one of the most important causes is poor vascular supply. However, a microvascular deficit is often not detectable during surgery under white light. Near-infrared indocyanine green (ICG)-enhanced fluorescence may be useful for assessing microvascular deficits and conceivably preventing anastomotic leakage.
Objectives: This paper presents a preliminary retrospective case series on robotic colorectal surgery. The aim is to evaluate the feasibility, safety and role of near-infrared ICG-enhanced fluorescence for the intraoperative assessment of peri-anastomotic tissue vascular perfusion.
Materials and Methods: From among more than 164 robotic colorectal cases performed, we retrospectively analyzed 28 that were all performed by the same surgeon (PCG) using near-infrared ICG-enhanced fluorescence technology: 16 left colectomies (57.1%), 8 rectal resections (28.6%), 3 right colectomies (10.8%) and 1 pancolectomy (3.6%).
Results: The rates of conversion, intraoperative complications, dye allergic reaction and mortality were all 0%. In two cases (7.1%)—1 left and 1 right colectomy—the level of the anastomosis was changed intraoperatively after ICG showed ischemic tissues. Despite the application of ICG, one anastomotic leak (after left colectomy for a chronic recurrent sigmoid diverticulitis with pericolic abscess) was observed.
Conclusions: ICG technology may help to determine when to intraoperatively change the anastomotic level to a safer location. In our case series, ICG results led to a change in the level of the anastomosis in 7.1% of the cases. Despite the use of ICG, we observed one leak. This may have been related to vascularization-independent causes (e.g., infection in this case) or may reflect a need for better standardization of this ICG technology. In particular, we need a way to objectively assess the ICG signal and the related risk of leakage. More randomized, prospective, well-powered trials are needed to unveil the full potential of this innovative surgical technology.
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Clinicopathologic Features and Surgical Outcomes of Neuroendocrine Carcinoma of the Gallbladder
Nobuhisa Tanioka, MD, Chief Resident, Takehiro Okabayashi, MD, Division Manager, Kenta Sui, MD, Chief Physician, Takatsugu Matsumoto, MD, Chief Physician, Jun Iwata, MD, Head of Medical Pathology, Sojiro Morita, MD, Vice President, Yasuhiro Shimada, MD, Director, Department of Clinical Oncology, Kochi Health Sciences Center, Kochi, Japan
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Neuroendocrine carcinoma (NEC) of the gallbladder is highly aggressive and has a poor prognosis even after curative resection. The purpose of this study was to collate and analyze published data to clarify the surgical outcome of NEC of the gallbladder and the relationships between potential prognostic factors and survival after surgery. We surveyed worldwide literature from 1981 to 2018 and obtained clinicopathological data for 65 patients who had undergone surgical resection for NEC of the gallbladder. The relationships between potential prognostic factors and survival rates were examined by the Kaplan-Meier method and the log-rank test. The 1-, 3-, and 5-year disease-specific survival rates after surgery were 70.2%, 39.3%, and 29.5%, respectively. A multivariate analysis revealed that the factors that were independently associated with poor outcomes after surgery in patients with NEC of the gallbladder were older age, higher pathologic T stage, and positive lymph node metastasis. The major sites of recurrence were the liver, lung, lymph node, and local recurrence. The median time to the event for recurrence was 4.0 months. Even when curative resection was achieved, 36.9% of patients exhibited recurrence within 12 months after curative resection of gallbladder NEC. Although NEC of the gallbladder remains a rare disease worldwide, its poor prognosis, even after curative resection, demands further epidemiological and pathological studies that could lead to the development of new management strategies.
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Perioperative Use of Anti-TNFα Biological Agents in Open and Laparoscopic Surgery for Inflammatory Bowel Disease
Georgios D. Lianos, MD, MSc, PhD, Consultant General Surgeon, Konstantinos H. Katsanos, MD, PhD, Associate Professor of Gastroenterology, Georgios K. Glantzounis, MD, PhD, FEBS, Professor of Surgery, Dimitrios K. Christodoulou, MD, PhD, Professor of Gastroenterology, University of Ioannina School of Medicine, Ioannina, Greece, Maria Saridi, RN, BSc, MSc, PhD, Director of Nursing, University of Peloponnese, Corinth, Greece, Eleni Albani, MSc, PhD, Director of Nursing, TEI of Western Greece, Patras, Greece, Efstratios Koutroumpakis, MD, Gastroenterologist, University Hospital of Patras, Patras, Greece, Christos Zeglinas, MD, Gastroenterologist and Medical Advisor, AbbVie Pharmaceuticals S.A., Athens, Greece, Ioannis Papaconstantinou, MD, PhD, Professor of Surgery, University Hospital Aretaieion, Athens, Greece
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Inflammatory bowel disease (IBD) consists of two disorders: Crohn’s disease (CD) and ulcerative colitis (UC). Over the past few decades, a great body of knowledge has accumulated regarding the pathogenesis of IBD, and effective pharmaceutical agents, such as inhibitors of tumor necrosis factor (anti-TNF), have been introduced. Although these agents have dramatically improved the outcome of IBD, up to 70% of patients with CD and 10–30% of those with UC still undergo surgery within 10 years from diagnosis. Because of their young age and high recurrence rates, these patients are appropriate candidates for laparoscopic surgery as an alternative to laparotomy. Recently, considerable attention has been focused on perioperative outcomes of patients who are receiving anti-TNF agents and require surgery. The aim of this narrative review is to discuss the current evidence regarding the impact of perioperative anti-TNF treatment on post-operative complication rates with a special focus on laparoscopic surgery.
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Effects of Time to Application of Negative Pressure Therapy on Abdominal Infections After Colonic Perforation
Stefano Rausei, MD, PhD, General Surgeon, ASST Valle Olona, Gallarate, Italy, Vincenzo Pappalardo, MD, General Surgeon, Federica Galli, MD, Resident in General Surgery, Simone Giudici, MD, Resident in General Surgery, Antonio Colella, MS, Medical Student, Francesco Frattini, MD, General Surgeon, ASST Settelaghi, Varese, Italy, Luigi Boni, MD, FACS, General Surgeon, IRCCS Ca' Granda - Policlinico Hospital, University of Milan, Milan, Italy, Gianlorenzo Dionigi, MD, FACS, General Surgeon, University of Messina, Messina, Italy
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Background: Negative pressure therapy (NPT) seems to improve surgical outcomes in open abdomen (OA) management of severe intra-abdominal infections (IAIs). The aim of this study was to compare the effects of immediate vs. delayed application of NPT on outcomes in patients with IAIs after colonic perforation.
Materials and Methods: We analysed 38 patients who received NPT during OA management for IAI after colonic perforation. The endpoints were treatment duration, definitive fascial closure and in-hospital mortality. We subdivided patients according to the timing of NPT application: immediate (at the end of the first OA procedure) and delayed (at I-II revision, at III revision, and after III revision).
Results: NPT was applied immediately in 15 cases (39.5%) and was delayed in 23 (60.5%): 14 (36.8%) at I-II revision, 7 (18.4%) at III revision, and 2 (5.3%) after III revision. Immediate NPT application was associated with the best outcomes.
Conclusions: NPT should be used as soon as possible in OA management for IAIs due to colonic perforation.
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Long-term Results of Robotic Modified Belsey (Gastroesophageal Valvuloplasty) Fundoplication
Farid Gharagozloo, MD, FACS, FCCS, FACHE, Professor of Surgery, Surgeon-in-Chief, Director of Cardiothoracic Surgery, Basher Atiquzzaman, MD, Assistant Professor, Barbara Tempesta, CRNP, Nurse Practitioner, Global Robotics Institute, Florida Hospital Celebration Heath, University of Central Florida, Celebration, FL, RC Tolboom, MD, Resident in Surgery, Meanders Medical Center, Amersfoort, The Netherlands, Mark Meyer, MD, Resident in Thoracic Surgery, Stephan Gruessner, MD, Resident in Thoracic Surgery, University of Arizona Medical Center, Tucson, AZ
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Purpose: Nissen fundoplication is associated with poor long-term durability, as well as dysphasia and gas bloat. We report here the long-term results of modified Belsey fundoplication (Gastroesophageal Valvuloplasty; GEV) performed laparoscopically using a surgical robot.
Methods: Patients who underwent robotic GEV were reviewed retrospectively. Operations were performed by laparoscopy and included robotic dissection of the esophageal hiatus, primary closure of the hiatus, followed by intussusception of a 4 cm segment of the esophagus into the stomach for 270°, and suspension of the fundoplication on the hiatal closure. The results were assessed by postoperative endoscopy, contrast esophagography, a Subjective Symptom Questionnaire (SSQ), and objective Visick grading.
Results: There were 291 patients (156 male, 135 female, mean age 51±14 years). Indications were intractability (73%) and pulmonary symptoms (27%). Mean operative time was 130 minutes ± 52 minutes. Minor complications were seen in 21%. There was no mortality. Mean hospitalization was 2.8 days ± 1.7 days. Mean follow-up was 85 months ± 7 months. During this period, the mean SSQ score decreased from 8.3 ± 0.6 to 0.7± 0.2 (P < 0.05). There was no long-term dysphasia or gas bloat. Ninety-five percent of patients were Visick I and 5% were Visick II. Hiatal hernia recurred in 7 patients (2%).
Conclusions: Robotic laparoscopic modified Belsey fundoplication (GEV) is associated with excellent long-term durability, reflux control, and low rates of dysphasia and gas bloat. This procedure may represent an alternative to medical antireflux therapy and other surgical antireflux procedures such as Nissen fundoplication.
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Is Needlescopic Cholecystectomy a Safe Way to Improve Mininvasiveness and Cosmesis in Young Female Patients?
Giuseppina Talamo, MD, Resident, Francesco Sucameli, MD, Resident, Mikaela Imperatore, MD, Surgeon, Elisabetta Moggia, MD, Surgeon, Laura Dova, MD, Resident, Elisa Francone, MD, Surgeon, Costantino Eretta, MD, Surgeon, Stefano Berti, MD, Head of Department, Department of General Surgery, Sant’Andrea Hospital, La Spezia, Italy
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Introduction: Needlescopic cholecystectomy (NC) was introduced in the late 1990s. It uses a reduced trocar caliber in an otherwise standard four-port laparoscopic cholecystectomy (LC) and seeks to achieve “scarless” surgery without compromising patient safety.
Materials and Methods: Between May 2016 and November 2017, 29 patients underwent elective NC at the Department of General Surgery of Sant’Andrea Hospital (La Spezia, Italy). Inclusion criteria were female sex, age between 18 and 45 years, good performance status (ASA 1-2) and BMI lower than 25. Twenty-one patients underwent a standard 4-port technique: 12mm port in the supraumbilical area, 5mm port in the subxiphoid position, 3mm port in the mid-epigastric area and another 3 mm port in the right mid-clavicular position. In 8 patients, 3mm ports were replaced by 2mm angiocath. A Critical View of Safety (CVS) was achieved in all procedures. Intra-operative cholangiography (IOC) via the cystic duct before any transection of the structures was routinely performed in selected cases, such as those with an unclear biliary anatomy or risk factors for main-duct stones. In our institution, laparoscopic transcystic common bile duct (CBD) exploration is routinely performed in CBD lithiasis.
Results: The mean operative time was 66.79 min (range 25-120 min). IOC was performed in 12 patients (41.4%) with suspected choledocolythiasis. There was no conversion to conventional laparoscopic cholecystectomy or open cholecystectomy. The mean hospital stay was 1.48 days (1-7 days). A Clavien–Dindo IIIB complication occurred in one patient on the third postoperative day. The mean VAS pain score was 3 (0-7). Closure of the skin with primary intention was achieved in all patients. Mean return to work was 6.76 days (3-15 days) and the mean return to previous physical activity was 12.17 days (4-30 days). All of the patients completed the Scar Satisfaction Questionnaire: 26 (89.7% ) and 3 patients (10.3%) were very satisfied and satisfied, respectively.
Conclusion: Any effort to reduce invasiveness and improve cosmesis must not jeopardize safety. Our case series demonstrates that needlescopy can be safely associated with intraoperative cholangiography to recognize CBD stones. This technique offers the advantage of minor postoperative pain, better cosmesis results, early return to routine life activities and great satisfaction for the patient. Needlescopy is a valuable and safe alternative that is suitable for elective cholecystectomy in properly selected patients, such as young female patients.
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