Surgical Technology International
45th Edition
ISSN:1090-3941
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both electronic and print versions
Mako Robotic-Arm Assisted Total Knee Arthroplasty: Updated Software
Robert Marchand, MD, South County Orthopedics, Wakefield, Rhode Island, Sean B. Sequeira, MD, Medstar Union Memorial Hospital, Baltimore, Maryland, Daniel Hameed, MD, Michael A. Mont, MD, LifeBridge Health, Sinai Hospital of Baltimore, Nathan Angerett, DO, Orthopaedic Institute of Pennsylvania, Harrisburg, Pennsylvania, Laura Scholl, MS, Implant and Robotic Research, Stryker, Mahwah, New Jersey
1817
Recently, robotic-arm assisted total knee arthroplasties have become popular because of their promise to lead to enhanced accuracy and efficient planning of the procedure, as well as improved radiographic and clinical outcomes. One robotic system is based on computed tomography (CT) to help with preoperative planning, intraoperative adjusting, and bone cutting for these procedures. The purpose of this article is to describe the second-generation iteration of this CT-based robotic technique by describing the new features using an actual total knee arthroplasty case. This article then becomes a step-by-step guide to performing the procedure, as well as describing the new features of this upgraded system.
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Patient-Reported Outcome Measures in the Repair of Chondral Defects: How Well Do the Scores Relate to Each Other?
Justus Gille, Prof. Dr., Martin Nauroz, MD, Regio Kliniken, Hamburg, Germany, Eric Reiss, MD, OrthoPraxis, Zofingen, Switzerland, Jan Schagemann, Prof. Dr., Orthopaedics and Trauma Surgery, Coesfeld, Germany, Sven Anders, Assistant Professor, University of Regensburg, Asklepios Clinical Center Bad Abbach, Bad Abbach, Germany, Thomasz Piontek, Prof. Dr., University of Medical Sciences, Poznan, Poland
1814
Introduction: In the repair of focal chondral defects, there are several patient-reported outcome measures (PROMs) that are used to assess the patient’s well-being. However, the question remains as to how well one scoring system relates to another, which may restrict the comparison of results from different studies. Therefore, we examined the strength of correlations between the Lysholm and KOOS scores.
Materials and Methods: The data for this analysis was obtained from the Autologous Matrix-Induced Chondrogenesis (AMIC®; Geistlich Pharma AG, Wolhusen, Switzerland) knee registry, which is an ongoing, multicentre database designed to record changes over time in knee function and symptoms. This is done using the Lysholm score, the Visual Analogue Scale (VAS) for pain, and the five domains of the Knee injury and Osteoarthritis Outcome Score (KOOS). All patients had preoperative and postoperative scores at one-year follow up. The results were evaluated using the Spearman’s rank correlation test.
Results: We identified 79 patients in the registry, all of whom were treated by the co-authors and had preoperative scores and postoperative scores at one year for the Lysholm, VAS, and the KOOS domains. The Lysholm score demonstrated a significant correlation (p <0.0001) to all KOOS domains. The correlation coefficients were 0.81, 0.82, 0.83, 0.84, and 0.76 for the KOOS domains of symptoms, pain, activities of daily living (ADL), quality of life (QoL), and Sport, respectively. The correlation between VAS pain and the KOOS domain for pain was significant (p <0.0001) but notably lower, with a correlation coefficient of 0.71.
Conclusion: Our data provides evidence that the outcome of the Lysholm knee score is strongly correlated with the KOOS scores, with the KOOS domains of ADL and pain exhibiting the highest correlation. Thus, it may be possible, through formulae calculations, to predict a KOOS score from the Lysholm score. With regard to assessment of outcomes over larger numbers of studies, the pooling of substantially more data could facilitate the conduct of systematic reviews and meta-analyses pertaining to the surgical treatment of chondral injuries of the knee.
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Favorable Early Patient-Reported Outcome Measures and Clinical Retear Rates in High-Risk Rotator Cuff Repairs Augmented with a Reinforced Bio-Inductive Implant at One-Year Follow Up
Sean McMillan, DO, Chief of Orthopedics, Virtua Our Lady of Lourdes & Virtua Willingboro Hospitals, Elizabeth Ford, DO, Orthopedic Surgeon, Inspira Health Network, Vineland, New Jersey, Shariff K. Bishai, DO, MS, Assistant Clinical Professor, Michigan State University College of Osteopathic Medicine, East Lansing, Michigan
1819
Introduction: The purpose of this article is to examine the risk of early clinical rotator cuff repair failures in high-risk patients who were augmented with a reinforced bio-inductive implant (RBI).
Materials and Methods: A retrospective chart review was performed identifying full-thickness rotator cuff repairs (RCR) augmented with an RBI. Inclusion criteria for “high risk of retear” were: large (>3cm) and massive (>5cm, >/= 2 tendons) tears, anterior to posterior (AP) tear >2.5cm, infraspinatus fatty atrophy (Goutalier >/= 2), recurrent tears, and at least one comorbidity (diabetes, hypertension, active smoker). ROM, VAS, and ASES scores were collected at preoperative, three-month, six-month, and 12-month visits. Clinical failures were defined as complete retear based upon imaging, repeat rotator cuff surgery, VAS score >5 at one-year postoperative, and ASES MCID <27-point improvement.
Results: Forty-nine patients were found to have undergone RCR with an RBI augmentation. Mean follow up was 26.1 months. Clinical healing rate was 94% (46/49). The need for surgical intervention post RCR was 8.2% (4/49). The complication rate was 14.3% (7/49). VAS scores at three, six, and 12 months compared to preop revealed statistically significant decreases at all timepoints (D-3.9, D-4.6, D-5.2, respectively, p<0.001). ASES scores at three, six, and 12 months compared to pre-surgical scores met the MCID and were found to have statistically significant improvements at all timepoints (D30.7, D40.8, D49.8, respectively, p<0.001). Shoulder ROM (forward flexion/abduction) at three, six, and 12 months compared to preop was found to be statistically significant at all timepoints (p<0.01).
Conclusion: The addition of an RBI to RCR in patients at high risk of failure demonstrated favorable outcomes in terms of range of motion, pain, and functional outcome scores with a low rate of clinical retear at a minimum of one-year follow up. Clinical Relevance: Many risk factors have been attributed to high retear rates and poor clinical outcomes in patients undergoing RCR. Numerous variations to RCR have been explored to aid in outcomes and decrease failures. This manuscript is the first to examine the use of an RBI as an RCR augment. The implant’s bio-inductive properties and strength profile demonstrate promising benefits at early timepoints in this study, indicating that it can improve patient-reported outcomes while decreasing clinical failures in patients at high risk of retear.
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Major Risk Factors of Mortality in Adult and Elderly Patients Emergently Admitted for Intestinal Fistulas, Excluding the Rectum and Anus
Zachary Thomas, MS, Cailan Feingold, BS, New York Medical College, School of Medicine, Valhalla, New York, Abbas Smiley, MD, PhD, School of Medicine, University of Rochester, Rochester, New York, Rifat Latifi, MD, FACS, FICS, FKCS, Adjunct Professor , University of Arizona, Tucson, Arizona
1807
Introduction: In the United States, intestinal fistulas accounts for $500 million (USD) of healthcare expenditures and 28,000 admissions annually. They are also associated with significant morbidity and mortality. Despite the high prevalence of intestinal fistulas, risk factors of mortality have yet to be fully elucidated. The aim of this study was to identify risk factors of mortality in emergently admitted patients with fistulas of the intestine, excluding the rectum and anus.
Materials and Methods: Adult and elderly patients emergently admitted with intestinal fistulas, between 2004–2014 were investigated using the National Inpatient Sample Database, ICD-9-CM code 569.81. Clinical outcomes, therapeutic management, demographics, and comorbidities were collected. Associations between mortality and all other variables were established via univariable and multivariable logistic regression models. The final multivariable regression model elucidated the odds ratios (95% confidence interval, p-value) of pertinent mortality risk factors.
Results: A total of 7,377 patients were included, of which the average adult and elderly ages were 48.9 and 74.6 years, respectively. Of these patients, 4,241 (57.5%) were female and 3,136 (42.5%) were male. Elderly patients demonstrated a higher mortality rate than adult patients—4.5% and 1.7%, respectively. In the adult group, the odds ratio for mortality was 1.020 for hospital length of stay in days (95% CI: 1.015–1.026, p<0.001), 1.035 for age (95% CI: 1.011–1.060, p=0.004), and 1.033 for days to the first procedure (95% CI: 1.021–1.044, p<0.001), among others. For the elderly group, the odds ratio for mortality was 1.012 for hospital length of stay in days (95% CI: 1.005–1.019, p=0.001), 1.075 for age (95% CI: 1.050–1.101, p<0.001), and 1.026 for days to the first procedure (95% CI: 1.009–1.043, p=0.002), among others.
Conclusion: In adult and elderly patients emergently admitted for intestinal fistulas, multiple comorbidities were risk factors for in-hospital mortality. In the elderly cohort, increased age and increased days to operation were additional risk factors for in-hospital mortality.
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Robotic Total Knee Arthroplasty is Associated with Thinner and Less Constrained Polyethylene Inserts
Travis R. Weiner, BS, William K. Crockatt, MD, Roshan P. Shah, MD, Associate Professor, Jeffrey A. Geller, MD, Associate Professor, Alexander L. Neuwirth, Associate Professor, H. John Cooper, MD, Associate Professor, Columbia University Medical Center, New York, New York
1821
Introduction: Accurate pre-resection assessment of gap measurements during total knee arthroplasty (TKA) may reduce the need for thicker polyethylene inserts or those with higher constraint by allowing the surgeon to address potential imbalance through guiding bony resections and implant position. This study aimed to determine whether robotic assistance with pre-planning allowed for the use of thinner and less-constrained polyethylene inserts compared to conventional methods.
Materials and Methods: Records were retrospectively reviewed for 408 patients who underwent primary TKA. Patients were divided into cohorts based on the technique utilized—conventional, manual methods with a jig-based system (CM-TKA, 169 knees) versus robotic-assisted TKA (RA-TKA, 237 knees). Operative notes were reviewed for implant brand, thickness of the polyethylene insert, degree of constraint of the polyethylene insert, and whether robotic assistance was used to complete the operation. Statistical analysis was performed using Chi-square tests for categorical and t-tests for continuous variables.
Results: There were no significant differences in demographic characteristics between the RA-TKA and CM-TKA groups. Statistically significant differences were observed between cohorts in mean polyethylene insert thickness (11.0mm ± 1.3mm vs. 11.7mm ± 1.7mm, p<0.0001), rate of use of the thinnest 10mm insert (43% vs. 34%, p=0.048), rate of “outlier” insert sizes ≥14mm (5% vs. 18%, p<0.0001), and rate of constrained insert use (4% vs. 18% of knees, p<0.0001).
Conclusion: In a review of 408 consecutive TKA patients, use of robotic-assisted techniques allowed for the use of thinner polyethylene inserts, fewer “outlier” polyethylene sizes, and reduced need for constrained inserts compared to conventional, manual methods.
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Outcomes on 287 Patients with Complex Abdominal Wall Defects Undergoing Abdominal Wall Reconstruction with a Porcine-Derived Acellular Matrix
Rifat Latifi, MD, Professor of Surgery, The University of Arizona, Tucson, Arizona , David J. Samson, MPH, Kartik Prabhakaran, MD, Professor of Surgery, New York College of Medicine, Valhalla, New York, Kenji Okumura, MD, Department of Surgery, Westchester Medical Center Health, Valhalla, New York, Shekhar Gogna, MD, MedStar Georgetown Transplant Institute, Washington, DC, Mathew McGuirk, MD, New York Medical College, Valhalla, New York, James Choi, MD, Signature Healthcare, Brockton, Massachusetts
1800
Introduction: Complex abdominal wall defects (CAWD) requiring complex abdominal wall reconstruction (CAWR) represent an important surgical challenge in the presence of significant comorbidities. We aimed to report the results on a large patient cohort and identify independent outcome predictors. Materials and Methods: All patients who underwent CAWR with biologic mesh (Strattice™; Reconstructive Tissue Matrix ®, a porcine-derived acellular dermal matrix; Allergan plc, Branchburg, New Jersey) between July 2016 and November 2021 at the tertiary academic center were studied using univariable and multivariable regressions.
Results: During the study period, 287 patients that underwent CAWR emergently and electively were included. The mean age was 59.1±13.4 years, 45.3% were female, and the mean body mass index (BMI) was 32.4±8.3 kg/m2. Elderly patients (≥65 years) represented 35.5%, and 36.6% of patients were operated for recurrent incisional/ ventral hernia. Mean hospital length of stay was 17.7±22.4 days. During the median follow up of two years, the hernia recurrence rate was 3.5%, similar to deaths within 90 days that occurred in 3.5% patients. The most frequent specific adverse outcomes were surgical site infection (22.6%), reoperation (20.9%), seroma (10.1%) and wound necrosis (9.4%). On multivariable regression, the most consistent independent predictors of adverse outcomes were emergency operation requiring damage control laparotomy, extensive lysis of adhesions, obesity, contaminated The Centers for Disease Control and Prevention (CDC) wound class, loss of abdominal domain, and delayed wound closure.
Conclusions: Overall, most patients undergoing CAWR electively or in emergency settings have excellent outcomes with a recurrence rate of 3.5% at two years. High-risk patients for recurrence and mortality are those requiring damage control laparotomy (DCL) during the index emergency operation, fistula take-down, intestinal resection, patient undergoing extensive lysis of adhesions and have a BMI >35kg/m2. Furthermore, patients who have a CDC wound class of III/IV have higher rates of perioperative complications, including the need for reoperation and increased hospital length of stay.
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What Happens to Endometriosis During the Menstrual Cycle?
Ray Garry, BA, MD, FRCOG, FRANZCOG, Professor of Obstetrics and Gynecology (Retired) King Edward Hospital, University of Western Australia,Perth, Australia
1826
Introduction: The objective of this study is to determine the structural changes in endometriosis throughout the menstrual cycle. Materials and Methods: This retrospective comparative study was undertaken in a gynaecological unit of a university teaching hospital and looked at the immunohistochemical appearances of epithelial cells of the endometrium and endometriosis in 17 cases at various stages of the menstrual cycle, particularly during menstruation.
Results: The epithelium in endometriosis lesions undergoes the same cyclical morphologic changes that are observed in eutopic endometrium. In particular, each of the six cases of endometriosis observed during the active bleeding phase showed evidence of epithelial shedding of the terminally differentiated secretory-phase epithelial cells and their almost immediate replacement by small undifferentiated cells.
Conclusion: The cyclical shedding/regeneration of endometriotic epithelium during menstruation has not previously been recognised, and it may have significant implications for the understanding of the aetiology and best management of endometriosis.
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Cardiophrenic Lymph Node Resection Through Abdominal Subxiphoid Approach: Surgical Technique
Christian Mouawad, MD, MSc, Chetana Lim MD, PhD, Hôpital de la Pitié-Salpêtrière, Paris, France, Rui Bernardino, MD, Hospital de Santa Maria – Centro Hospitalar Lisboa Norte, Lisbon, Portugal
1820
While metastatic extension to the cardiophrenic lymph nodes (CPN) is relatively rare, cardiophrenic lymphadenectomy may be performed for diagnostic and/or therapeutic purposes. The subxiphoid approach is appropriate, especially for CPN in the prepericardiac area, offering adequate exposure while avoiding the morbidity associated with pleural or pericardial breach. In this article, we describe the surgical technique—detailing the retrosternal liberation section of the tranversus abdominis muscle, followed by cardiophrenic dissection and lymphadenectomy.
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Robotic versus Laparoscopic Partial Nephrectomy: A Systematic Review and Meta-Analysis of Randomised Trials
Benjamin Buckland, B. Med, M. Surg, Oliver Best, MBBS (Hons), Bridget Heijkoop, MBBS (Hons), Marcus Handmer, MBBS (Hons), FRACS (Urol), Urology Department, John Hunter Hospital, Newcastle, Australia, Tharindu Senanayake, B. Med, M. Surg, Surgical and Perioperative Care Research Group, Hunter Medical Research Institute, Kevin Tree, MBBS, Department of Surgery, Lismore Hospital, Gosford, Australia
1805
Introduction: The objective of this article is to compare outcomes of robotic-assisted partial nephrectomy (RAPN) versus laparoscopic partial nephrectomy (LPN) for surgical management of renal tumours by performing a systematic review.
Materials and Methods: Prospective randomised controlled trials comparing robotic to laparoscopic partial nephrectomy were included in this analysis. No date or language restriction was imposed. Studies on paediatric patients (<16 years old) were excluded. No specific outcomes were required for inclusion in the analysis. The authors independently extracted data and assessed the risk of bias using the risk of bias tool (RoB 1). Meta-analysis was performed using ReviewManager (RevMan) Software (Cochrane Collaboration, London, United Kingdom).
Results: Two prospective randomised controlled trials involving 190 participants were included. A comparative analysis of 190 patients undergoing partial nephrectomy showed no significant difference in overall complication rates. However, RAPN was associated with a reduced risk of minor complications (Clavien-Dindo grade 1-2).
Operatively, LPN demonstrated a marginally shorter duration; whereas, RAPN showed a slight advantage in warm ischemia time. Regarding renal function, RAPN resulted in a less pronounced increase in serum creatinine levels six months postoperatively. In contrast, changes in estimated glomerular filtration rate did not significantly differ between the groups. Length of hospital stay and positive surgical margin rates were comparable between approaches.
Conclusion: There is limited low-quality evidence in small-scale trials that may indicate robotic partial nephrectomy is comparable to laparoscopic partial nephrectomy. RAPN has lower minor complication rates, with potential advantages in warm ischemia time and complication rates.
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Textbook Outcome Following Liver Transplantation: A Systematic Review
Christian Mouawad, MD, MSc,Chetana Lim, MD, PhD, Hôpital de la Pitié-Salpêtrière, Paris, France
1832
Introduction: Despite advances in perioperative care and immunosuppressive therapy in liver transplantation (LT), and the broadening of eligibility criteria and indications for LT, the complexity of this procedure makes the configuration of a textbook outcome (TO) rather difficult to define an optimal postoperative follow up. In this article, we evaluate and summarize the data in the literature concerning textbook outcome in liver transplantation (TOLT).
Materials and Methods: Four studies discussing TOLT were included and evaluated in our literature review. Three studies had, as inclusion criteria, adult patients who had undergone elective primary LT, without association with another organ transplant, with a deceased donor. The fourth study included patients who had undergone an enhanced recovery after surgery (ERAS) protocol prior to their LT during the study period, with no other selection criteria.
Results: The frequency of TOLT in the four studies described ranged from 31 to 37.5%. The definition of TOLT was variable between the different authors, with an “all or nothing” rule. Three criteria were rather predominant: length of hospital stay, mortality, and need for hospital readmission, with variability in the times adopted by the authors for each criterion.
Conclusion: Our systematic review summarizes the international experience regarding the conceptualization of the TOLT to date. The impact of TOLT on graft and patient survival is debated, especially with the complexity of this surgery and its postoperative follow up. Multicenter studies are needed to achieve a standardization of TOLT on a global scale.
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Robotic Assisted Lapendoscopic Single-Site Surgery for Ileal Deep Endometriosis. A Case Report and Review of Literature
Devon Marks, MD, University of South Florida/Morsani College of Medicine, Tampa, Florida, Ashley J. Alden, DO, Robert D. Bennett, MD, Associate Professor, Diana Encalada Soto, MD, Assistant Professor, Emad Mikhail, MD, FACOG, FAC, Associate Professor & Chief, University of South Florida/Morsani College of Medicine, Tampa, Florida
1827
The prevalence of deep endometriosis invading the bowel is unknown but has been estimated to affect between 3.8% and 37% of women with endometriosis. The most common locations of bowel endometriosis are the sigmoid colon and rectum. Endometriosis affecting the small bowel is exceedingly rare. Laparoendoscopic single-site port surgery (LESS) and robotic-assisted LESS (R-LESS) offer potential advantages in cosmesis and surgical recovery while safely and effectively treating disease. R-LESS is an effective and safe technique for surgical excision of deep endometriosis of the small bowel while utilizing the same access incision as a retrieval site for the surgical specimen. We present a case of a surgical excision of double nodules of deep endometriosis of the small bowel, that was managed using the R-LESS technique, and discuss the proposed advantages and technical challenges.
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