Surgical Technology International
36th Edition
Contains 69 peer-reviewed articles featuring the latest advances in surgical techniques and technologies.
472 pages
May 2020 - ISSN:1090-3941
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both electronic and print versions
Evolution of Multimodality Imaging for Structural Heart Interventions: More than a Tool
EDITORIAL
Francesco Maisano, MD, Full Professor , Alberto Pozzoli, MD, Heart Surgeon, University Hospital Zürich, Zürich, Switzerland
1311
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External Stents for Vein Grafts in Coronary Artery Bypass Grafting: Targeting Intimal Hyperplasia
Luca Paolo Weltert, MD, Heart Surgeon and Professor of Statistics, Lorenzo Guerrieri Wolf, MD, Raffaele Scaffa, MD, Andrea Salica, MD, Alessandro Ricci, PhD, MD, Francesco Giosuè Irace, MD, Samuel Fusca, MD, Salvatore D’Aleo, MD, Alessandro Bellisario, MD, Ruggero de Paulis, MD, Head of Heart Surgery Unit, Heart Surgery Unit, European Hospital, Rome, Italy, Luigi Garufi, MD, San Camillus International University for Health Sciences, Rome, Italy, Ilaria Chirichilli MD, San Camillo Forlanini Hospital Rome, Italy
1236
Introduction: Progressive saphenous vein graft (SVG) failure remains a key limitation to the long-term success of coronary artery bypass grafting (CABG). SVG disease after the first year is dominated by intimal hyperplasia, which predisposes the SVG to thrombosis and accelerated atherosclerosis. The objective of this study was to review and summarize the latest experimental and clinical data on the use of mechanical external stents for vein grafts.
Methods: In January 2020, the PubMed database was searched using the terms “external stent”, “CABG”, “saphenous vein graft” and “intimal hyperplasia”. The results were reviewed and only randomized experimental and clinical studies that analyzed the effect of external stenting on venous intimal hyperplasia were included in the analysis, together with studies that investigated the clinical benefit of external stenting.
Results: Eight experimental and four clinical trials met the search criteria. Controlled trials in different large animal models concluded that external stenting significantly reduced intimal hyperplasia 3-6 months post implantation, and reduced both thrombosis rates and the development of lumen irregularities. Data from randomized controlled trials with a follow-up period of 1-4.5 years supported the pre-clinical findings and demonstrated that external stents significantly reduced vein graft disease.
Conclusion: Strong evidence indicates that supporting the vein with external stents is safe and leads to clear advantages at both the anatomical and cellular levels. With the further accumulation of consistent positive results, external stenting of SVG may become the standard of care in future CABG.
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New Hybrid Prosthesis for Acute Type A Aortic Dissection
Matteo Montagner, MD, Roland Heck, MD, Markus Kofler, MD, Semih Buz, MD, Christoph Starck, MD, PhD, Associate Professor, Simon Sündermann, MD, PhD, Volkmar Falk, MD, PhD, Jörg Kempfert, MD, PhD, Associate Professor, Deutsches Herzzentrum, Berlin, Germany, Stephan Kurz, MD, Charité- Universitätsmedizin Berlin, Berlin, Germany
1295
Background: Acute type A aortic dissection (ATAAD) is a surgical emergency with high rates of morbidity and mortality. The treatment of ATAAD is highly individualized and mainly depends on anatomical and technical factors. Great efforts to reduce the time to diagnosis and technological innovations have led to improved surgical results with a lower rate of dissection-related reoperations during long-term follow up. The aim of this article is to introduce a novel hybrid device for the treatment of DeBakey I acute aortic dissection.
Concept: A non-covered hybrid stent from Ascyrus Medical (Boca Raton, FL, USA) aims to improve the current standard of care, without increasing technical complexity or device-related complications. The AMDS (Ascyrus Medical Dissection Stent) prolongs the hemiarch operation by only a few minutes, does not need endovascular skills to be deployed, and provides an anatomical and “haemodynamic” correction. The device is intended to reduce perfusion of the false lumen by sealing the distal anastomosis, and to restore distal perfusion of the true lumen. Obliteration of the false lumen at the distal anastomosis is likely to reduce aortic enlargement and the need for reoperations, mainly driven by a low-flow state and pressure reduction, which promote thrombosis. Conclusions: The AMDS provides a new concept to treat acute aortic dissection by moving the focus from resecting the dissected tissue to restoring adequate true-lumen flow and sealing the false lumen at the distal anastomosis. With a high rate of procedural success, AMDS represents a safe, reproducible and promising solution to treat DeBakey I aortic dissections.
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Removal of Peripheral Arterial Occlusive Material with the Rotarex® S Device: Mechanical Atherothrombectomy
Miroslav Bulvas, MD, PhD, Associate Professor, Charles University Prague, Third School of Medicine, University Hospital Královské Vinohrady, Prague, Czech Republic
1276
Mechanical atherothrombectomy (MATH) with the Rotarex® S (Straub Medical AG, Wangs, Switzerland) catheter is an endovascular therapeutic technique for removing fragmentable occlusive material from the lumen of peripheral vessels. It can be used as a rapid, safe and efficacious initial modality for the treatment of acute or subacute ischemia of the lower limbs, even in patients with an immediately threatened extremity and those with a contraindication for surgical and/or thrombolytic therapy. Patient placement in an intensive care unit and routine embolic prevention with a filter are not necessary. In the literature, the technical success of MATH has varied from 92% to 100%, with lower rates in subgroups with occluded bypass grafts (78%) and a crossover approach (56%). The number of secondary surgical revascularization procedures has ranged from 0% to 5.3% and the mortality rate at 30 days has varied between 0% and 1%. The 30-day clinical success has varied from 68% to 98%, secondary patency from 68% to 97.6%, amputation-free survival from 94.4% to 100%, frequency of major complications from 0% to 6.9%, major hemorrhage from 0% to 2.6% and frequency of major debulking device-related complications from 0% to 0.4%.
Open Access
Role of Automated Suturing Technology in Minimally Invasive Aortic and Mitral Valve Surgery
Hossein Amirjamshidi, MD, MSc, University of Rochester Medical Center, Rochester, NY, Jude S. Sauer, MD, Clinical Assistant Professor of Surgery, Peter A. Knight, MD, Marjorie B. Morris Professor, of Cardiac Surgery, University of Rochester Medical Center, Rochester, NY
1223
Minimally invasive cardiac surgery continues to evolve and expand as technology and surgeon experience develops. Among the barriers to the adoption of non-sternotomy minimally invasive valve surgery are the challenges associated with suture placement. Automated technology enables ergonomic remote suture placement that allows for reproducible results while shortening the learning curve. The objective of this review is to describe the latest advancements in automated suturing technology for minimally invasive valve surgery.
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Deep Sternal Wound Infection (DSWI) and Mediastinitis After Cardiac Surgery: Current Approaches and Future Trends in Prevention and Management
Camilla Chello, MD, Università La Sapienza di Roma, Rome, Italy, Mario Lusini, MD, PhD, Associate Professor in Cardiac Surgery, Antonio Nenna, MD, Umberto Maria Satriano, MD, Francesco Cardetta, MD, Ciro Mastroianni, MD, PhD, Università Campus Bio-Medico di Roma, Rome, Italy, Massimo Chello, MD, Full Professor in Cardiac Surgery, Università Campus Bio-Medico di Roma, Rome, Italy, Francesco Nappi, MD, Centre Cardiologique du Nord, Saint Denis, Paris, France, Cristiano Spadaccio, MD, PhD, Golden Jubilee National Hospital, Glasgow, UK
1240
Median sternotomy is the most common access for cardiac surgery. Deep surgical wound infection (DSWI) and mediastinitis after median sternotomy remain significant clinical problems after cardiac surgery in terms of mortality, morbidity and healthcare-associated costs. Despite recent advances in medical management and consensus papers, their incidence ranges from 1% to 5%, and the associated mortality ranges from 20% to 50%. Recent studies in this field are providing excellent outcomes with promising results for the near future. The choice of sternal closure technique plays a crucial role in the prevention of DSWI and mediastinitis and should be tailored to the patient’s characteristics, as clinical judgement and experience play a pivotal role. Early aggressive surgical debridement, vacuum-assisted closure (VAC) therapy, muscle flap and newer technologies are revolutionizing the paradigm of treatment of DSWI. Also, recent advances in tissue engineering have been refining potential approaches to tissue regeneration or substitution for enhanced wound repair. This editorial aims to briefly summarize the current and future techniques in DSWI prevention and treatment after cardiac surgery.
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Transcatheter Tricuspid and Pulmonary Valve Repair and Replacement
Christopher M. Faries, BA , Division of Vascular Surgery , Aditya Sengupta, MD, Sophia L. Alexis, MD, Rami O. Tadros, MD, Associate Professor, David Octeau, BA, Hanna J. Barnes, BA, Gilbert H. L. Tang, MD, MSc, MBA, , Associate Professor, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, New York, New York
1190
Severe tricuspid regurgitation (TR) is associated with significant mortality and morbidities. Currently, surgical tricuspid repair with annuloplasty is the gold standard treatment. However, the prohibitive risks of open surgery and increasing evidence that severe TR should be intervened on early has led to an outburst in the development and evolution of transcatheter tricuspid valve interventions (TTVI). These technologies are broadly categorized into direct suture annuloplasty devices, minimally invasive annuloplasty, direct ring annuloplasty devices, coaptation-based strategies, edge-to-edge repair devices, and transcatheter valve replacement. Each has its own set of advantages and limitations and have been tried, to varying degrees of success, in a myriad of pathoanatomic scenarios. Challenges faced in TTVI device and trial designs include heterogeneous patient populations, the need for quality imaging, variations of imaging requirements and anatomic criteria by device, hard-to-define clinical endpoints, and the poor prognosis carried by significant residual TR. Similar to tricuspid valve disease, pulmonic valve (PV) disease can occur on its own or secondary to a congenital heart defect, most commonly tetralogy of Fallot. Many patients with pulmonic stenosis or insufficiency often require repeat surgical interventions for other cardiac problems, highlighting the importance of developing transcatheter approaches to reduce the number of repeat open-heart surgeries required. Transcatheter PV replacement (TPVR) is growing in use and is the procedure of choice in patients with failed bioprostheses via valve-in-valve implantation. The Melody™ (Medtronic Inc., Minneapolis, Minnesota) and SAPIEN XT (Edwards Lifesciences Inc., Irvine, California) devices are the currently available TPVR technologies. Current limitations here include device kinking, the risk of stent fracture, anatomic difficulties, such as asymmetric right ventricular outflow tracts leading to poor landing zones and procedural risks of coronary artery and aortic root compression.
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Main Risk Factor in Long-Term Postoperative Aortic Root Enlargement After Aortic Valve Surgery Associated with Ascending Aorta Replacement
Francesca D’Auria, MD, PhD, Massimo Chello, MD, Elvio Covino, MD, Medico University of Rome, Rome, Italy, Alberto Pilozzi Casado, MD, Santa Croce e Carle HospitalCuneo, Italy
1288
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Robotic First Rib Resection for Thoracic Outlet Syndrome
Farid Gharagozloo, MD, Professor of Surgery, Barbara Tempesta, CRNP, Scott Werden, MD, University of Central Florida, Celebration, FL, Mark Meyer, MD, Chief of Surgery, Wellington Regional Medical Center, Wellington, FL
1228
Purpose: First rib resection is a key component of the treatment of Thoracic Outlet Syndrome (TOS). We report our experience with, and technique for, robotic first rib resection.
Methods: Patients diagnosed with TOS underwent robotic first rib resection of the offending portion of the first rib with disarticulation of the costo-sternal joint. Definitive diagnosis of TOS was made by Magnetic Resonance Angiography (MRA) with maneuvers.
Results: A total of 67 patients underwent robotic first rib resection. Neurogenic TOS: 39 patients underwent robotic resection for Neurologic Symptoms of the upper extremity (Neurogenic TOS). There were 14 men and 25 women, with a mean age of 34 ± 9.5 years. Paget-Schroetter Syndrome (PSS) or Venous TOS: 28 patients underwent transthoracic robotic first rib resection for PSS. There were 16 men and 12 women, with a mean age of 24 ± 8.5 years. Operative time was 87.6 ± 10.8 minutes. There were no intraoperative complications. Hospital stay ranged from 2 to 4 days with a median hospitalization of 3 days. There were no neurovascular complications. There was no mortality. In patients with Neurogenic TOS, QuickDASH Scores (mean ± SEM) decreased from 60.3 ± 2.1 preoperatively to 5 ± 2.3 in the immediate postoperative period and to 3.5 ± 1.1 at 6 months (p<0001). Immediate relief of symptoms was seen in 35/39 patients (91%). Persistent paresthesia was seen in 4/39 (9%) immediately postop, and in 2/39 (2.5%) at 6 months. Thirty-seven of 39 (97.5%) patients reported complete relief of symptoms. Among patients with PSS or Venous TOS, 9/28 (32%) required endovascular venoplasty to completely open the subclavian vein after the relief of extrinsic compression. At a median follow-up of 24 months, all patients with PSS had an open subclavian vein, for a patency rate of 100%.
Conclusions: Robotic transthoracic first rib resection allows for minimally invasive resection of the first rib in patients with TOS, with excellent relief of symptoms and no neurovascular complications.
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Review of Procedures and Outcomes of Video-Assisted Thoracic Surgery for the Treatment of Non-Small Cell Lung Cancer in 45 Patients Undergoing Segmentectomy
Rachel Sier, BS, Osita Onugha, MD, MBA, Assistant Professor of Thoracic Oncology, John Wayne Cancer Institute, Santa Monica, CA
1227
Background: Lung cancer is the leading cause of death due to cancer in the United States and survival is heavily dependent upon the cancer stage at diagnosis. In the treatment of Stage I or Stage II non-small cell lung cancer (NSCLC), cancerous lung nodules are removed through lobectomy or segmentectomy. Lobectomy removes an entire lobe of the lung. Segmentectomy removes only a portion of the lobe, minimizing removal of functional lung parenchyma. Both procedures can be completed through video-assisted thoracic surgery (VATS). In this retrospective review of the outcomes of VATS segmentectomy, the locations of nodules in relation to segmentectomy and the selection of patients to undergo segmentectomy are discussed.
Methods: A retrospective analysis of 60 patients who underwent VATS segmentectomy from January 2016 to December 2017 was performed. Forty-five patients were selected based on a diagnosis of NSCLC and the availability of reported outcomes. Patients were reviewed over 18 to 42 months for evidence of disease recurrence or progression.
Results: The patients had an average age of 71.2 years, and 31 (69%) were former or current smokers. Most of the lung nodules removed were located in the left upper lobe (LUL) and removed by LUL trisegmentectomy. The median lung nodule size was 18 mm. Most of the cancers diagnosed were Stage I adenocarcinoma. The median length of stay in the hospital was 3 days. The median chest tube retention was 2 days. Six patients had nodule recurrence or progression of disease.
Conclusion: In decision-making between segmentectomy and lobectomy, adequate margins are required for the selection of segmentectomy, the most common of which is LUL trisegmentectomy. Technical challenges can be overcome with adequate training and simulation. Additional research could focus on the identification of factors associated with recurrence.
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Robotic Lobectomy: Experience with 638 Consecutive Cases
Farid Gharagozloo, MD, Professor of Surgery, Surgeon-in-Chief, Barbara Tempesta, Advent Health University of Central Florida Celebration, FL , Mark Meyer, MD, Wellington Regional Medical Center, Wellington, FL
1229
BACKGROUND: Robotic lobectomy has been evolving over the past decade and has been shown to be an oncologically acceptable procedure. We evaluated our experience with robotic lobectomy for the treatment of early-stage lung cancer.
METHODS: We performed a retrospective review of prospectively accrued patients at our institution who underwent robotic lobectomy for early-stage lung cancer from February 2004 to July 2019.
RESULTS: Of 3304 consecutive patients who underwent a robotic operation by a single surgeon, 638 underwent robotic lobectomy for early-stage primary non-small cell lung cancer (NSCLC; stages I and II). The 427 (67%) men and 211 (33%) women had a median age of 69 y (range 41-86), and 567 (89 %) were former or current smokers. The median operative time was 176 minutes (range 160-456), the median chest tube time was 3 days (2-8), the median air leak time was 0 days (0-3), and the median length of stay was 3 days (1-26). The median tumor size was 2.6 cm (range 06-3.4). The mean number of nodes recovered was 14 ± 3. Pathologic upstaging was noted in 121 patients (19%). Minor complications were observed in 133 patients (21%). Conversion to thoracotomy occurred in 11 (1.7%) patients. Mortality was 0.5%.
CONCLUSION: Robotic lobectomy is a safe, minimally invasive procedure that replicates the oncologic and technical principles of thoracotomy for the treatment of lung cancer.
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The Emerging Role of Percutaneous Thermal Ablation in the Treatment of Thoracic Malignancies: A Review
Jonathan Stone, MD, Zachary Hartley-Blossom, MD, MBA, Terrence Healey, MD, Associate Professor, Department of Diagnostic Imaging, The Warren Alpert School of Medicine at Brown University/Rhode Island Hospital, Providence, Rhode Island
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Thoracic malignancies pose a significant public health burden in the United States, with primary lung cancer accounting for nearly 25% of cancer deaths each year. Percutaneous thermal ablation (PTA) for the treatment of lung cancer has evolved from a novel oncologic strategy in the 1970s, to a limited therapeutic option in select patients through the early 2000s, into its current rapidly expanding role as an adjunct therapy, or even standalone treatment, for a diverse group of thoracic malignancies in patients with both localized and disseminated disease. Radiofrequency ablation (RFA) benefits from the largest clinical dataset and greater user experience, but its utility has been limited by a suboptimal heating mechanism in the setting of poor thermal conductive properties within the lung. As the limitations of RFA have come into sharper focus, microwave ablation (MWA) has emerged as a potentially superior ablation technique due to its ease of use and improved heating profile, allowing for larger ablation zones with reduced treatment times. Cryoablation shares many of the technical features of MWA, while targeting cancer cells via pressurized argon gas to induce cryodestruction of target tissue. In clinical practice, the need for at least two cryoprobes and prolonged freeze-thaw protocols adds to procedural time and complexity. To date, there is considerable evidence supporting the safety, tolerability, and efficacy of these minimally invasive modalities, which have been shown to be cost effective and can often be performed on an outpatient basis. Clinical outcomes continue to improve as more data is acquired for each modality, enabling clinicians to refine patient selection and tailor follow-up protocols to better reflect expected post-procedural imaging findings and potential complications. At present, combined multi-modality therapy is an exciting area of active investigation, particularly in cryoablation due to an apparent synergism with established immunotherapies. Recent data suggests PTA may also be useful in more aggressive malignancies, such as advanced NSCLC and small cell lung cancer. Looking forward, PTA remains well positioned to be a valuable therapeutic option in the treatment of patients with lung cancer.
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Robotic Staged Bilateral Selective Postganglionic Sympathectomy for Upper-Extremity Hyperhidrosis
Farid Gharagozloo, MD, Professor of Surgery, Surgeon-in-Chief, Barbara Tempesta, CRNP, Center for Advanced Thoracic Surgery, Global Robotics Institute, Advent Health, University of Central Florida, Celebration, FL, Mark Meyer, MD, Wellington Regional Medical Center, Wellington, FL
1230
Purpose: The prevalence of compensatory hyperhidrosis (CH) has been reported to be as high as 80% in patients following thoracic sympathectomy for upper-extremity hyperhidrosis. The CH rate is 7.2% with simultaneous bilateral robotic selective dorsal sympathectomy. We reviewed the results in patients who underwent staged bilateral robotic selective dorsal sympathectomy (SBRSS).
Methods: A case series analysis of patients who underwent SBRSS was performed. A surgical robot was used to divide the postganglionic sympathetic fibers and communicating rami to intercostal nerves 2, 3, and 4. The sympathetic chain was left intact. The operation was performed on the dominant side, and the same procedure was then performed on the contralateral side after 4 weeks. The success of the sympathectomy was determined by intraoperative temperature measurement, patient interviews, and the Hyperhidrosis Disease Severity Scale.
Results: There were 47 patients (22 men, 25 women), with a mean age of 22 ± 3 years. Minor complications were seen in 4% of patients. One patient had transient heart block. One patient had transient partial Horner’s syndrome. Forty percent of patients had transient CH after the first surgery, and 45% had transient CH after sympathectomy on the contralateral side. There were no deaths. The median hospitalization was 3 days. At a mean follow-up of 28 ± 6 months, 46/47 patients (98%) had sustained relief of hyperhidrosis. In one patient (1/47, 2%), hyperhidrosis recurred on the first operated side. One patient (2%) exhibited sustained CH. Conclusion: SBRSS is associated with a lower rate of CH than when the procedure is performed bilaterally in a simultaneous fashion. This procedure is associated with the lowest reported rate of CH.
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Stapled Diaphragmatic Plication: Is It Better Than Suture Plication?
Terra M Hill, MS, Medical Student, University of Kansas School of Medicine, Kansas City, KS, USA, Osita Onugha, MD, MBA, Assistant Professor , Providence St. John’s Health Center, John Wayne Cancer Institute, Santa Monica, CA, USA
1206
Diaphragm dysfunction, which can be due to eventration or an abnormally high-positioned diaphragm, can cause respiratory compromise. Eventration is most commonly due to unilateral diaphragm paralysis, which reduces ventilatory function in adults by about 25%. Since the 1920s, this condition has been treated with diaphragm plication, which itself has evolved to include the use of several different techniques and materials. This review explores the relevant literature on diaphragm plication using sutures or staples for the treatment of eventration to determine if either provides a clinical benefit over the other.
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