Surgical Technology International
40th Anniversary Edition
May 2022 - ISSN:1090-3941
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User Evaluation of a Novel Smart Insufflator for Laparoscopic Surgery-The EVA-15
Niall McInerney, MB, BAO, BCh, Mohammad Faraz Khan, MB, BAO, BCh, Ronan Cahill, MD, Professor, UCD Centre for Precision Surgery, University College Dublin, Ireland , Kiaran O’Malley, MD, Associate Professor, Orla McCormack, MD, Tom Walsh, MD, John Conneely, MD, Mater Misericordiae University Hospital, Dublin, Ireland
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Introduction: There is resurging interest in the importance of effective, nuanced insufflation and personalised pneumoperitoneal pressure-management during laparoscopy. Here, we present user-evaluation data from a regulated, prospective, multispecialty study of a new insufflator (EVA-15, Palliare, Galway, Ireland) which provides high-frequency pressure-sensing, built-in smoke evacuation with pedal activation and highly responsive, high-flow gas provision.
Methods: With institutional ethics and regulatory body approval, a non-randomised, prospective clinical investigation was performed on 30 subjects undergoing laparoscopic surgery using an EVA-15 device. Cases were selected from a variety of specialties on a near-consecutive basis without specific exclusion criteria. Users (both surgeons and operating room nurses) completed a survey at case completion to capture ordinal categorical data on a 5-point Likert agreement scale (1 – Strongly disagree to 5 – Strongly agree) concerning (i) Settings and Setup Evaluations, (ii) Alarms and Displays Evaluations, (iii) Short Instruction Guide, and (iv) Insufflator Performance along with any additional feedback.
Results: Operations on 30 patients (mean age 54 y, 15 males) were studied with a questionnaire completed by operating room teams after individual consent. The procedures included general (n=13), upper (n=3) and lower (n=6) gastrointestinal surgery, bariatric (n=3), hepatobiliary (n=2) urology (n=2, both robotic prostatectomy) and gynaecology (n=1) operations. In all cases, the laparoscopic component was completed capably with the use of the EVA-15 device. The insufflator evaluation score across all categories was a median of 4, demonstrating satisfactory use and performance in all regards.
Conclusion: The EVA-15 is a smart insufflator system that is capable of satisfactory performance across a spectrum of cases among different specialties.
Role of Indocyanine Green (ICG)-Enhanced Fluorescence in Primary and Revisional Bariatric Surgery: Narrative Overview of Selected Literature and Intraoperative Surgical Videos
Alberto Mangano, MD, Valentina Valle, MD, Nicolas H Dreifuss, MD, Francisco Schlottmann, MD, MPH, Antonio Cubisino, MD, Carolina Baz, MD, Mario A Masrur, MD, Associate Professor, University of Illinois at Chicago, Chicago, IL, USA
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Laparoscopic sleeve gastrectomy is one of the most common bariatric surgical procedures. Despite being easier to perform than other bariatric procedures, it is not free of complications. Leaks are some of the most severe events, and are observed in around 0.5–6% of cases. Use of the near-infrared indocyanine green (ICG) perfusion test during sleeve gastrectomy seems to be promising. However, its application in sleeve gastrectomy is still in fieri. Similarly, ICG is not commonly used in Roux-en-Y gastric bypass. This report presents the main evidence from selected literature regarding the use of ICG during sleeve gastrectomy and Roux-en-Y gastric bypass, along with our remarks. It also provides intraoperative video clips and photographs showing the use of ICG in this surgical field.
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Effectiveness of the Fast Track Surgery Program for Patients with Planned Cholecystectomy
Vladimir Beloborodov, MD, PhD, DSs, Professor , Vladimir Vorobev, PhD, Assistant Professor, Andrey Sherbatykh, MD, PhD, DSs, Professor, Elena Kelchevskaya, MD, PhD, Associate Professor, Mihail Kozhevnikov, MD, PhD, Associate Professor, Igor Golub, MD, Professor, Irkutsk State Medical University, Irkutsk, Russian Federation Vladimir , Luchkevich, MD, PhD, DSs, Professor, North-Western State Medical University named after I.I. Mechnikov, St. Petersburg, Russian Federation
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Purpose: This study analyzed the effectiveness of minimizing surgical trauma, reducing the severity of the stress reaction, and restoring the normal functioning of the body after planned gallbladder operations under an enhanced recovery program.
Materials and Methods: This prospective comparison study included 30 patients from the surgical department of Irkutsk Clinical Hospital No. 1 who had been diagnosed with cholelithiasis in 2019-2020. All 30 patients completed the study and were randomly assigned to one of two groups: the FTS group (group I, n = 15) and the standard group (group II, n = 15). The comparison groups were statistically homogeneous in terms of preoperative parameters. All patients underwent prescribed surgeries. In the early and late postoperative period, there were no cases of mortality or significant complications.
Results: A comparison of the groups with respect to the effectiveness of treatment according to established criteria showed good treatment results for 13 (86.6%) patients in group I and 2 (13.3%) patients in group II (p = 0.016). The FTS treatment protocol was a significant predictor of treatment success (OR 3.1; 95% CI 0.2; 6.0; p = 0.033).
Conclusion: The fast track surgery protocol gave superior results for surgical treatment in comparison with the standard protocol in patients with cholelithiasis.
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The Viscoelastic Behavior of Soft Tissues Must be Accounted for in Stapler Design and Surgeon Technique
Jason L. Harris, PhD, Chad E. Eckert, PhD, Jeffrey W Clymer, PhD, William J Petraiuolo, MD, FACS, Ethicon, Inc., Cincinnati, OH
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Background: Since its adoption as a surgical technique over a half-century ago, stapling has continually undergone improvements, both in the devices used and in our understanding of tissue mechanics. To best design and use stapling devices, it is beneficial to have an intimate knowledge of the response of tissue to compression and stapling dynamics. This paper provides the relevant background in the field of biomechanics, and in particular addresses the viscoelastic behavior of soft tissues under compression.
Biomechanics of Stapling: The change in shape of a solid, or strain, is related to the load applied, or stress. Biological tissues are known to have non-linear relationships between stress and strain, and generally the relationships are anisotropic (dependent upon direction). Further complicating matters, there is typically a time-dependency to the relationship for compression and recovery, resulting in viscoelastic behavior. Hence both the amount and rate of compressive force applied can be expected to impact the outcome of stapling.
Discussion: The growth of the laparoscopic use of staples has increased the difficulty of device design, as precise control of compression is problematic in extended length staplers. Progressive firing along the cartridge and multi-stage compression have both been found to be beneficial in providing the uniform force needed to produce well-formed staples. Such technical advances can reduce stresses within the stapler, preventing deformation of the stapler arm and undesirable strain in the tissue. Current research includes understanding the effects of changing the rate of compression on staple formation with the hope that further improvements can be achieved in this ever-fruitful method of tissue apposition.
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The Risk of Mortality in Geriatric Patients with Emergent Gastroparesis is 7-fold Greater than that in Adult Patients: An Analysis of 27,000 Patients
Rahim Hirani, MS, Abbas Smiley, MD, PhD, Assistant Professor, New York Medical College, School of Medicine and Westchester Medical Center, Valhalla, NY, Lulejeta Latifi, Rifat Latifi, MD, FACS, FICS, FKCS, Adjunct Professor of Surgery, University of Arizona, Tucson, AZ
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Background: Gastroparesis, a chronic disorder distinguished by delays in gastric emptying, has been a concern for both health providers and hospitals due to several of its characteristics. Gastroparesis is heterogeneous in nature and is associated with several comorbidities and increasing mortality rates. It can often be caused by underlying conditions, most of which are not well understood. This lack of knowledge regarding its underlying mechanisms creates a need to better understand the risk factors involved in this patient population. This study was undertaken to understand the risk factors involved in the mortality of patients who present with gastroparesis.
Methods: This retrospective study considered data from the National Inpatient Sample for patients who were admitted with a primary diagnosis of gastroparesis from 2005 to 2014. The data were stratified according to various factors of interest to identify risk factors involved in mortality using statistical tools, including a multivariable logistic regression model with backward elimination.
Results: A total of 27,000 patients were admitted emergently with a primary diagnosis of gastroparesis. The mortality rate in adult patients (0.18%, N=39) was much lower than that in elderly patients (1.27%, N=71). Females accounted for the majority of patients in both the adult (73.7%) and elderly (71%) populations. The mean age of patients in the adult and elderly groups was 43 and 75 years, respectively. The association between mortality and age was significant in both adults (OR=1.04, 95%CI=1.005-1.08, p<0.025) and the elderly (OR=1.08, 95%CI=1.04-1.12, p<0.001). The hospital length of stay (HLOS, days) in adult females (5.08, SD=5.04) was significantly longer than that in adult males (4.41, SD=5.10) (p<0.001). The association between mortality and HLOS was significant in both adults (OR=1.12, 95%CI=1.09-1.15, p<0.001) and elderly patients (OR=1.10, 95%CI=1.06-1.14, p<0.001). A lower percentage of adults (6.6%, N=1,402) underwent an operation compared to the elderly (9.6%, N=538). The mean time to operation was 4.76 days for adult patients who survived and 17.50 days for adult patients who did not survive (SD=5.37 and 9.37, respectively, p=0.006). On the other hand, this value was 5.57 and 9.10 days for elderly patients (SD=6.50 and 7.15, respectively, p=0.037). Among patients who underwent an operation, the association between mortality and time to operation was significant for both adults (OR=1.17, 95%CI=1.094-1.247, p<0.001) and elderly patients (OR=1.05, 95%CI=1.005-1.124, p<0.001).
Conclusion: The risk of mortality in elderly patients with emergent gastroparesis was 7-fold greater than that in adult patients. The odds of mortality increased by 8% for every year increase in age in elderly patients and by 4% in adults.
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Conventional Total Thyroidectomy Using a Novel Single Retractor: Technical Note for Apollo®
Antonella Pino, MD, Alessandro Matarese, MD, Viola Villardita, MD, Gianlorenzo Dionigi, MD, PhD, FACS, FEBS-ES, Full Professor of Surgery, Division of General Surgery, Endocrine Surgery Section, Istituto Auxologico Italiano IRCCS, Milan, Italy, Francesco Frattini, MD, Division of General Surgery, ASST Settelaghi, Tradate, Varese, Italy, Hoon Yub Kim, MD, PhD, Department of Surgery, KUMC Thyroid Center, Korea University Hospital, Gianluca Donatini, MD, PhD, Department of Visceral and Endocrine Surgery, CHU Poitiers-University of Poitiers, Poitiers, France, Che Wei Wu, MD, PhD, Department of Otolaryngology-Head and Neck Surgery, Faculty of Medicine, Kaohsiung Medical, Young Jun Chai, MD, PhD, Department of Surgery, Seoul National University Boramae Medical Center, Seoul, Korea
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Despite the increasingly innovative techniques developed in thyroid surgery to offer patients minimally invasive and scarless interventions, conventional open procedures still account for most of the interventions performed in this field. The surgical incision length has been significantly reduced, from 6-9 cm to 3 cm, and therefore patients perceive the scar to be highly acceptable.
In this technical note, we present the use of a new single retractor (APOLLO®; Terumo Cardiovascular, Ann Arbor, MI) for conventional open thyroidectomies with intraoperative neuromonitoring. This device offers several advantages: a) better exposure of the surgical field; b) less traction on skin flaps and neck muscles; and c) protection of the skin edges from the heat generated by energy-based devices/coagulating instruments, with consequent better healing.
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Intraoperative Use of Platelet-Rich Fibrin (PRF) Reduces the Postoperative Fistula Rate After Pancreas Surgery
Arndt von Kirchbach, MD, Ralf-Uwe Kuehnel, MD, Anne Juffa, MD, Filip Schroeter, PhD, Roya Ostovar, MD, Johannes M. Albes, MD, Professor, University Hospital Brandenburg Medical School “Theodor Fontane“, Faculty of Health Sciences Brandenburg, Bernau, Germany
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Background: Patients undergoing pancreatic surgery are predominately very ill and therefore have a high potential for postoperative complications, which often has a life-limiting effect. As leakage of aggressive pancreatic secretions into the abdomen is one of the main reasons for an adverse outcome, measures to reduce it can be beneficial. Platelet-Rich Fibrin (PRF) is often used to seal areas that are already leaking or are susceptible to leakage at the end of the procedure. We sought to determine whether this positive intraoperative effect is associated with a positive postoperative outcome with regard to a reduction of complications.
Methods: We investigated 85 patients who underwent pancreatic surgery in our surgical department. All patients were treated intraoperatively with PRF in the surgical field. The occurrence of fistulas (biochemical leakage, post-operatic pancreatic fistula (POPF) grade B and POPF grade C). We compared our clinical data with patient data from the literature.
Results: The production of PRF from the patient's own blood is simple, safe, and not stressful for the patient. Complications related to production or use were not observed. Our patient group showed a lower fistula rate compared to those patient groups in the literature (POPF grade B and C: <13% vs. 16-72%).
Conclusion: The results showed that use of PRF had a beneficial effect in patients undergoing pancreatic surgery, as reflected by a reduction in postsurgical fistula formation and better outcomes.
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The Use of Self-Assembling Peptides (PuraStat™) in Functional Endoscopic Sinus Surgery for Haemostasis and Reducing Adhesion Formation. A Case Series of 94 Patients
Yael Friedland, MD, Fiona Stanley Hospital, Perth, Australia, Maurice Bagot d’Arc, MD, BluePharm Consulting, Paris, France, Jennifer HA, MBBS, FRACS, Wexford Medical Center Murdoch, Australia, Claudia Delin, MASc, BluePharm Consulting, Paris, France
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Introduction: Functional endoscopic sinus surgery (FESS) is a treatment option for patients with chronic rhinosinusitis. Bleeding and adhesions are common complications postoperatively.
Objective: To assess the effectiveness of PuraStat™ (3-D Matrix Medical Technology Pty Ltd, Melbourne, Australia) for use in FESS to achieve haemostasis and reduce adhesion formation.
Materials and Methods: A retrospective chart review over four years was performed on 94 patients undergoing FESS by a single surgeon, using PuraStat™ in absence of nasal packing. Results: Twenty-eight patients underwent complete FESS and 66 cases limited FESS most often combined with nasal surgery. Six patients had bleeding postoperatively, of which only four required additional treatment (4.25%). Twenty-three patients (24.47%) required debridement during the follow up, simply performed by suction for 13 or by scissors for 10. No patient required revision surgery for adhesion.
Conclusion: PuraStat™ used for the first time in context of FESS seems to be effective in achieving haemostasis, reducing adhesion formation, and avoiding nasal packing in most patients.
Conversion From Open to Laparoscopic Surgery in Strangulated Hernia Repair: Toward a
Gold Option Proposal
Michela Zanatta, MD, Francesco Basile, MD, PhD, FACS, Full Professor, Marcello Donati, MD, PhD,
FACS, Associate Professor, University of Catania, Catania, Italy
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Introduction: Strangulation is a common presentation of acute abdominal wall hernias that usually requires emergency surgery. The aim of this report is to propose a “reverse strategy” combining an open mesh-based anterior approach followed by a “conversion” to laparoscopy for the treatment of strangulated hernias.
Materials and Methods: A 68-year-old male patient came to the emergency room of our university hospital with a non-reducible left groin hernia. The CT scan demonstrated a left groin strangulated hernia with doubtful viability of the involved bowel loop. We decided to perform a transversal inguinotomy followed by a laparoscopic approach through the inguinal ring.
Results: The patient was discharged after four days in perfect general condition, with normal bowel function and no postoperative pain.
Conclusion: We propose this unconventional conversion from open to laparoscopic surgery as a new indication for the laparoscopic approach in emergency hernia surgery. We hope it can be used as a gold option for the surgical treatment of strangulated hernia in selected cases.
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