Surgical Technology International
40th Anniversary Edition
New Online Studies
Online First -Feb 2022
ISSN:1090-3941
1 year Institutional Subscription
both electronic and print versions
Micro-Invasive 3D Endoscopic Mitral Valve Surgery
Daniele Maselli, MD, Saverio Nardella, MD,Gianluca Santise, MD, Annarita Iavazzo, MD, Luigi Chiariello, PhD, Professor, Mediterranea Cardiocentro, Napoli, Italy
1530
Since its introduction in 1995, minimally invasive mitral valve surgery (MIMVS) has been shown to be a valid alternative to conventional sternotomy and several studies have reported excellent clinical outcomes. While MIMVS is now a commonly performed procedure, it is still difficult to standardize. We proprose here a "road to safer surgery", and offer some tips and tricks that could be useful in its learning and performance, and may help surgeons minimize the risk of major complications. With the introduction of 3D vision with a 3D videothoracoscope for 4K stereoscopic acquisition, a medical LCD ultra-HD monitor and active 3D glasses, it is possible to obtain a very realistic view of the surgical field and the mitral valve anatomy, while significantly reducing the learning curve. We describe the procedure step-by-step, with details from the pre-operative phase to the end of the operation. The procedure is structured in consecutive stages: patient induction and positioning, thoracoscopic access and port placement, surgical field exposure, and operative technique.
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Topical Oxygen Therapy for Wound Healing: A Critical Evaluation
Nicole K. Cates, DPM, AACFAS, Hand & Microsurgery Medical Group, San Francisco, California, Paul J. Kim, DPM, MS, Professor, University of Texas Southwestern Medical Center, Dallas, Texas
1492
Oxygen is an undisputed key factor in wound healing. Adequate oxygen pressure in tissues allows for cell growth and proliferation, necessary for wound healing. In the case of peripheral arterial disease leading to hypoxemia, oxygen supplementation is beneficial. The roles and validity of topical and systemic oxygen therapy in wound healing is debated. Topical oxygen therapy (TOT) is delivered at 100% oxygen saturation and has been demonstrated to increase the pO2 levels within the wound base center, decrease the size of the wound, and decrease the time to wound healing compared to patients that did not undergo topical oxygen therapy. Alternatives to topical oxygen therapy are systemic oxygen therapy including hyperbaric oxygen therapy and inspired oxygen therapy. Systemic oxygen therapy carries the risk of oxygen organ toxicity as the result of an oxidative stress and genotoxicity state. Topical O2 therapy is a viable option for chronic wounds, with its demonstrated effects on decrease in wound size and time to healing. Adjunctive clinical wound debridement’s decrease the necrotic debris and therefore the topical oxygen diffusion distance optimizing the therapy effect.
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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
1533
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
1517
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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Optimizing Total Knee Arthroplasty With ROSA® Robotic Technology
Paul W. Knapp, DO, Giles R. Scuderi, MD, Northwell Health Orthopaedics, Lenox Hill Hospital, New York, New York, Michael P. Nett, MD, Northwell Health Orthopaedics, South Shore University Hospital, Bayshore, New York
1522
A new robotic platform (ROSA® Knee system, Zimmer Biomet, Warsaw, Indiana) for total knee arthroplasty (TKA) has been created to increase precision of bony resections and knee balancing while maintaining surgeon autonomy. Our aim is to discuss: (1) the background of robotic technology in orthopedics, (2) current literature and potential benefits of the ROSA® Knee system, and the (3) optimal surgical technique for this specific robotic TKA platform. Early literature regarding this robotic system is promising as studies have shown precision of its bony resections, accuracy of overall limb alignment, and low early revision rates. There is a need for continued research on clinical outcomes using this platform, and the intention is to provide a review with insight into the potential advantages of robotics and the ideal surgical technique for successful use of this system.
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Latest Advances in Transcatheter Aortic Valve Implantation (2022)
Vedat Tiyerili, MD, Dagmar Sötemann, MD, Christina Grothusen, MD, Johannes Blumenstein, MD, Helge Möllmann, MD, Clemens Eckel, MD, Department of Cardiology, St. Johannes-Hospital Dortmund, Dortmund, Germany, Marc Ulrich Becher, MD, Department of Cardiology, University of Bonn, Bonn, Germany, Holger Nef, MD, Department of Cardiology, University of Giessen, Giessen, Germany
1478
Since the last decade, transcatheter aortic valve implantation (TAVI) has become the treatment of choice in patients with symptomatic severe aortic stenosis (AS) who are ineligible or at higher risk for surgery. Due to the high safety profile of current device generation, TAVI has emerged as a qualified alternative to surgical aortic valve replacement (SAVR) in patients with classic aortic stenosis and intermediate surgical risk, severe bicuspid aortic valve stenosis, and isolated pure aortic regurgitation. Moderate aortic stenosis, with and without concomitant heart failure with reduced ejection fraction, are under investigation in randomized controlled clinical trials from which we will gain exciting insights on the best timing of TAVI to protect the left ventricle from further functional deterioration due to increasing AS. In these cases, a meticulous diagnostic approach including advanced imaging is becoming more and more important. Current evidence on antithrombotic strategies after TAVI is weak, contributing to poor levels of standardization and high variability in daily clinical practice. This review will provide a short overview of recent clinical trials including best timing for TAVI with moderate AS and antithrombotic strategies after TAVI with current and future TAVI generations.
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Thoracic Endovascular Aortic Repair Using the C-TAG® Device with ACTIVE CONTROL System
Michele Antonello, MD, PhD, Associate Professor, Francesco Squizzato, MD, Elda Chiara Colacchio, MD, Andrea Spertino, MD, Franco Grego, MD, PhD, Full Professor, Michele Piazza, MD, PhD, Associate Professor, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Vascular and Endovascular Surgery Clinic, Padova University, School of Medicine, Padova, Italy
1509
Objective: To describe our experience with the Gore® C-TAG® endograft with ACTIVE CONTROL System (ACS) (W.L. Gore & Associates, Inc., Flagstaff, AZ, USA) in thoracic aortic repair, focusing on deployment accuracy and aortic wall apposition.
Methods: All patients who underwent thoracic endovascular aortic repair (TEVAR) using the Gore® C-TAG® endograft with ACS from September 2017 to September 2021 were enrolled in a dedicated database and retrospectively analysed. We collected anatomic data on aortic arch angulation and tortuosity, proximal and distal landing zones, and the target for deployment accuracy. Proximal and distal deployment accuracies (PDA and DDA) were measured through intraoperative digital subtraction angiography (DSA), and postoperative computed tomography angiography (CTA) was required to define endograft apposition to the aortic wall.
Results: Twenty-eight patients who underwent TEVAR with the Gore® C-TAG® with ACS at our institution were selected for this study: 46% presented with a type 3 aortic arch and a proximal landing zone < 3 was used in 53% of cases. Mean PDA and DDA were 1.89 ± 3.5 mm and 0.6 ± 1.4 mm, and were obtained in 93% and 100% of procedures, respectively. Mean proximal and distal wall apposition were 91 ± 17% and 98 ± 5.9%. Fifteen patients required an associated planned procedure, either to revascularize supra-aortic vessels when PLZ was < 3 or to assure optimal distal fixation with EndoAnchors™ (Medtronic, Minneapolis, MN, USA) delivery in selected cases. Two patients required reintervention during the same hospitalisation because of type 1a endoleak onset. No further reinterventions were needed during follow-up.
Conclusions: Our single-centre analysis found promising results using the Gore® C-TAG® with ACS, with an optimal accuracy in deployment and wall apposition at both proximal and distal landing zones.
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Frozen Elephant Trunk Completion: Endovascular Extension in The Distal Thoracic Aorta
Steven J.G. Leeuwerke, MD, Ben R. Saleem, MD, PhD, Clark J. Zeebregts, MD, PhD, Professor, University Medical Center Groningen, Groningen, The Netherlands, Patrick Bohan, BA, MLitt, Terumo Aortic, Sunrise, Florida, Jamie Clucas, BSc, Terumo Aortic, Glasgow, United Kingdom, Michel M.P.J. Reijnen, MD, PhD, Professor, Rijnstate Hospital, Arnhem, The Netherlands1519
Introduction: Complex pathologies involving the aortic arch can be treated using the frozen elephant trunk (FET) technique, which is versatile and continues to be improved with different innovations to further reduce, for example, circulatory arrest time and the need for hypothermia. FET may or may not be a definitive repair, however. Distal extension or completion—especially endovascular—is common but not well described in the literature. This review describes the considerations that are necessary during FET planning and preparation, how pathology specifics and sizing decisions will affect the subsequent need for treatment, and how outcomes might be better reported to improve understanding of the advantages and limitations of the technique.
Materials and Methods: This literature review was performed to identify reports of second-stage endovascular completion after FET repair, and included any literature that described such interventions after index FET, for any aortic arch pathology.
Results: Secondary intervention after FET is an important parameter to establish the success or failure of the index procedure. However, unplanned extensions are often reported with insufficient detail and follow up, and studies rarely differentiate between unplanned or adjunctive procedures. In addition, prediction of the need for extension is complicated by the response of the pathology to the index procedure.
Conclusion: FET is a versatile, established surgical technique that allows for several applications in different pathologies and innovative adaptations. How, when, and why FET is extended needs to be reported in greater detail, with specific consideration given to the interaction of FET and endovascular devices in sizing, integrity, and possible complications.
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Technology Review: CT Scan-Guided, 3-Dimensional, Robotic-Arm Assisted Lower Extremity Arthroplasty
Zhongming Chen, MD, Michael A. Mont, MD, Sandeep S. Bains, MD, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, Peter M. Bonutti, MD, Sarah Bush Lincoln Bonutti Clinic, Effingham, Illinois, Wael K. Barsoum, MD, Cleveland Clinic, Weston, Florida, David J. Jacofsky, MD, The CORE Institute, Phoenix, Arizona
1540
Robotic-arm assisted lower extremity arthroplasty using computed tomography scan (CT)-based 3-dimensional (3D) modeling operative technologies has increasingly become mainstream over the past decade with over 550,000 procedures performed between first use in 2006 and November 2021. Studies have demonstrated multiple advantages with these technologies, such as decreased postoperative pain and subsequent decreased narcotic usage, decreased lengths of stay, less complications, reduced damage to soft tissues, decreased readmissions, as well as economic advantages in the form of meaningful cost savings for payors. The purpose of this report was to clearly and concisely summarize the good-to-high methodology peer-reviewed, published literature regarding CT scan-based, 3-dimensional robotically-assisted unicompartmental knee arthroplasty, total knee arthroplasty, and total hip arthroplasty stratified by: (1) prospective randomized studies; (2) database comparison studies; (3) national registry studies; (4) health utility studies; (5) comparison studies; and (6) basic science studies. A literature search was conducted and, after applying inclusion criteria, each study was graded based on the modified Coleman methodology score (“excellent” 85–100, “good” 70–84, “fair” 55–69, “poor” <54 points). A total of 63 of 63 good-to-excellent methodology score reports were positive for this technology, including 11 that demonstrated decreased pain and/or opioid use when compared to traditional arthroplasty techniques. The summary results of these high-quality, peer-reviewed published studies demonstrated multiple advantages of this CT scan-based robotic-arm assisted platform for lower extremity arthroplasty.
Watch and Wait Strategy for Rectal Cancer: How Long Should We Wait for a Clinical Complete Response?
Oktar Asoglu, MD, Professor of Surgery, Bogazici Academy for Clinical Sciences of General Surgery, Istanbul, Turkey, Beslen Goksoy, MD, Sehit Prof. Dr. Ilhan Varank Sancaktepe Training and Research Hospital University of Health Sciences, Istanbul, Turkey, Vusal Aliyev, MD, Teuta Zoto Mustafayev, MD, Banu Atalar, MD, Professor of Radiation Oncology, Koray Guven, MD, Professor of Radiology, Gokhan Demir, MD, Professor of Medical Oncology, Suha Goksel, MD, Professor of Pathology, Acibadem University Maslak Hospital, Istanbul, Turkey, Baris Bakir, MD, Professor of Radiology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
1507
Background: The objective of this study was to determine how long to wait in locally advanced rectal tumor (LARC) patients who receive total neoadjuvant therapy (TNT) and achieve a clinical complete response (cCR), and to identify the clinical parameters that affect the waiting period for the watch-and-wait strategy (W&W).
Materials and Methods: The data of patients who achieved cCR between February 2015 and June 2020 were examined retrospectively. The week in which patients with cCR at the end of TNT achieved clearance was determined by reanalyzing recorded endoscopy video images. In the assessment at the time of the initial diagnosis, tumor characteristics, such as digital rectal examination findings, MRI stage, location with respect to the puborectalis muscle, annularity, and tumor size, were recorded prospectively.
Results: A total of 54 patients were included in this study. According to the MRI-T stage, 14 cases were cT3a, 22 were cT3b, and 18 were cT3c-T4. Forty-four percent of the cases achieved cCR at 8-10 weeks, 19% at 12-16 weeks, 20% at 16-22 weeks, and 17% at 20-26 weeks. Patients with tumors that were early MRI-T stage (cT3a), negative clinical circumferential resection margin, mobile, small (≤4 cm), located above the puborectalis muscle and showed <180 degrees annularity achieved cCR significantly earlier than those with other tumors (p <0.05).
Conclusion: In this study, cCR was achieved in less than half (44%) of the cases during the 8-10 week waiting period. In the W&W strategy, the initial assessment for cCR seems insufficient, and we may need to wait up to 26-30 weeks, especially in patients with advanced-stage tumors.
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