Bencini, Lapo; Annecchiarico, Mario; Farsi, Marco; Bartolini, Ilenia; Mirasolo, Vita; Guerra, Francesco; Coratti, Andrea
Pancreatic surgery for malignancy is recognized as challenging for the surgeons and risky for the patients due to consistent perioperative morbidity and mortality. Furthermore, the oncological long-term results are largely disappointing, even for those patients who experience an uneventfully hospital stay. Nevertheless, surgery still remains the cornerstone of a multidisciplinary treatment for pancreatic cancer. In order to maximize the benefits of surgery, the advent of both laparoscopy and robotics has led many surgeons to treat pancreatic cancers with these new methodologies. The reduction of postoperative complications, length of hospital stay and pain, together with a shorter interval between surgery and the beginning of adjuvant chemotherapy, represent the potential advantages over conventional surgery. Lastly, a better cosmetic result, although not crucial in any cancerous patient, could also play a role by improving overall well-being and patient self-perception. The laparoscopic approach to pancreatic surgery is, however, difficult in inexperienced hands and requires a dedicated training in both advanced laparoscopy and pancreatic surgery. The recent large diffusion of the da Vinci® robotic platform seems to facilitate many of the technical maneuvers, such as anastomotic biliary and pancreatic reconstructions, accurate lymphadenectomy, and vascular sutures. The two main pancreatic operations, distal pancreatectomy and pancreaticoduodenectomy, are approachable by a minimally invasive path, but more limited interventions such as enucleation are also feasible. Nevertheless, a word of caution should be taken into account when considering the increasing costs of these newest technologies because the main concerns regarding these are the maintenance of all oncological standards and the lack of long-term follow-up. The purpose of this review is to examine the evidence for the use of minimally invasive surgery in pancreatic cancer (and less aggressive tumors
Bina, Robert W; Zoccali, Carmine; Skoch, Jesse; Baaj, Ali A
The lateral lumbar interbody fusion approach (LLIF), which encompasses the extreme lateral interbody fusion or direct lateral interbody fusion techniques, has gained popularity as an alternative to traditional posterior approaches. With rapidly expanding applications, this minimally invasive surgery (MIS) approach is now utilized in basic degenerative pathologies as well as complex lumbar degenerative deformities and tumors. Given the intimate relationship of the psoas muscle, and hence the lumbar plexus, to this MIS approach, several authors have examined the surgical anatomy of this approach. Understanding this regional neural anatomy is imperative given the potential for serious injuries to both the motor and sensory nerves of the lumbar plexus. In this review, we critically and comprehensively discuss all published studies detailing the surgical anatomy of the lateral lumbar approach with respect to the MIS LLIF techniques. This is a timely review given the rapidly growing number of surgeons utilizing this technique. Copyright © 2014 Elsevier Ltd. All rights reserved.
Inoue, Shogo; Kajiwara, Mitsuru; Teishima, Jun; Matsubara, Akio
Introduction: The aim of this study was to better understand the impact that public opinion might have on surgical approaches in urologic minimally invasive surgery (MIS). Methods: We collected surveys from 400 participants, including the general population (n = 220) and paramedical staff (n = 180). Participants were anonymous. The survey included 16 questions on the characteristics and preference for the surgical approach if a urologic MIS were performed on them. Results: The responders preferred the transumbilical approach (57.0%) to the subcostal approach (43.0%). In particular, the preference for a transumbilical approach was significantly higher in females (65.1% vs. 49.3%, p = 0.0014). Similarly, when participants were divided into two groups (<50 years and ≥50 years), the preference for the transumbilical approach was significantly higher in the younger group (60.8% vs. 48.0%, p = 0.0187). Logistic regression analysis revealed that preference for this approach was about 2 times more likely to rise in the females (p = 0.032). Conclusions: Preference for the transumbilical approach was significantly higher young female respondents. This patient subset most values the cosmetic benefits of transumbilical approach in urologic MIS. PMID:25624959
Chang, Edward F.; Englot, Dario J.; Vadera, Sumeet
Surgery can be a highly effective treatment for medically refractory temporal lobe epilepsy (TLE). The emergence of minimally invasive resective and nonresective treatment options has led to interest in epilepsy surgery among patients and providers. Nevertheless, not all procedures are appropriate for all patients, and it is critical to consider seizure outcomes with each of these approaches, as seizure freedom is the greatest predictor of patient quality of life. Standard anterior temporal lobectomy (ATL) remains the gold standard in the treatment of TLE, with seizure freedom resulting in 60–80% of patients. It is currently the only resective epilepsy surgery supported by randomized controlled trials and offers the best protection against lateral temporal seizure onset. Selective amygdalohippocampectomy techniques preserve the lateral cortex and temporal stem to varying degrees and can result in favorable rates of seizure freedom but the risk of recurrent seizures appears slightly greater than with ATL, and it is not clear whether neuropsychological outcomes are improved with selective approaches. Stereotactic radiosurgery presents an opportunity to avoid surgery altogether, with seizure outcomes now under investigation. Stereotactic laser thermo-ablation allows destruction of the mesial temporal structures with low complication rates and minimal recovery time, and outcomes are also under study. Finally, while neuromodulatory devices such as responsive neurostimulation, vagus nerve stimulation, and deep brain stimulation have a role in the treatment of certain patients, these remain palliative procedures for those who are not candidates for resection or ablation, as complete seizure freedom rates are low. Further development and investigation of both established and novel strategies for the surgical treatment of TLE will be critical moving forward, given the significant burden of this disease. PMID:26017774
Gul, Vahit Onur; Destek, Sebahattin; Ozer, Serhat; Etkin, Ergin; Ahioglu, Serkan; Ince, Mehmet; Cimin, Vedat; Sen, Deniz; Erbil, Yesim
Pilonidal sinus is considered as a simple and frequently occurring disease localized at the sacrococcygeal area. However, at the intergluteal region, it can often turn into a chronic and complicated disease. In some cases, it can fistulize up to the gluteal region and appear at the secondary orifices. Minimally invasive surgical techniques are becoming widespread in recent years due to the increased experience and development of new instruments. Limited excision of the pilonidal sinus tract can be a better treatment option compared with large excisions in terms of recovery time and patient's comfort. This case study reports the single-phase surgical treatment of complicated and recurrent pilonidal sinus localized at the gluteal area, with minimal tissue loss and inflammation. PMID:26576314
Gonzalez, Tyler; Chien, Bonnie; Ghorbanhoseini, Mohammad; Kwon, John Y.
Wound complications following ankle fracture surgery are a major concern. Through the use of minimally invasive surgical techniques some of these complications can be mitigated. Recent investigations have reported on percutaneous fixation of distal fibula fractures demonstrating similar radiographic and functional outcomes to traditional open approaches. The purpose of this manuscript is to describe in detail the minimally invasive surgical approach for distal fibula fractures. PMID:28271086
Fay, Emily E; Norquist, Barbara; Jolley, Jennifer; Hardesty, Melissa
Background When placenta accreta complicates a delivery, the typical management is to perform a cesarean hysterectomy. Other management strategies, including leaving the placenta in situ, have been attempted and supported in some cases. This may allow for an interval hysterectomy, which can potentially decrease average blood loss and/or allow a minimally invasive approach to the hysterectomy. Cases We present two cases of women with invasive placentation managed conservatively with interval hysterectomy. One woman was managed with robotic-assisted laparoscopic surgery and the other with an open surgical approach. Conclusion These cases highlight the successful use of conservative management for invasive placentation in two stable patients and showcase the novel use of a robotic-assisted laparoscopic surgery for management of invasive placentation.
Fay, Emily E.; Norquist, Barbara; Jolley, Jennifer; Hardesty, Melissa
Background When placenta accreta complicates a delivery, the typical management is to perform a cesarean hysterectomy. Other management strategies, including leaving the placenta in situ, have been attempted and supported in some cases. This may allow for an interval hysterectomy, which can potentially decrease average blood loss and/or allow a minimally invasive approach to the hysterectomy. Cases We present two cases of women with invasive placentation managed conservatively with interval hysterectomy. One woman was managed with robotic-assisted laparoscopic surgery and the other with an open surgical approach. Conclusion These cases highlight the successful use of conservative management for invasive placentation in two stable patients and showcase the novel use of a robotic-assisted laparoscopic surgery for management of invasive placentation. PMID:27294007
Schmierer, Philipp A; Pozzi, Antonio
Minimally invasive plate osteosynthesis (MIPO) is one of the most recent fixation techniques that embody the concept of biological osteosynthesis. Several studies evaluating MIPO in dogs have been published in the recent years. However, there are few clinical reports of MIPO in cats and no description of the surgical approaches. The purpose of our study was to describe the safe corridors for plate insertion in cats using the MIPO technique. The surgical approaches for the humerus, radius-ulna, femur and tibia were developed after reviewing the described techniques and surgical approaches for MIPO in dogs, while considering any relevant anatomical difference between dogs and cats. Following the MIPO approaches, the limbs were anatomically dissected and the relationship between proximal and distal positions of the implants and neurovascular structures was noted. The surgical approaches developed for the humerus and radius-ulna differed from what had been reported previously, because relevant anatomical differences were found between dogs and cats. Anatomical landmarks for safe plate application were described for all the major long bones in cats. No damage to vital structures following plate insertion was detected in the dissection. In this cadaveric study, we evaluated the safety of the surgical approaches for MIPO in cats. By respecting the anatomical landmarks described in this report, damage to the neurovascular structures can be avoided performing the MIPO technique in cats.
Shah, Naseem; Logani, Ajay; Kumar, Vijay
Various conservative approaches have been utilized to manage large periapical lesions. This article presents a relatively new, very conservative technique known as surgical fenestration which is both diagnostic and curative. The technique involves partially excising the cystic lining, gently curetting the cystic cavity, performing copious irrigation, and closing the surgical site. This technique allows for decompression and allows the clinician the freedom to take a biopsy of the lesion, as well as perform other procedures such as root resection and retrograde sealing, if required. As the procedure does not perform a complete excision of the cystic lining, it is both minimally invasive and cost-effective. The technique and the concepts involved are reviewed in 4 cases treated with this novel surgical approach.
Introduction We present a case of penetrating gunshot injury to the high-cervical spinal cord and describe a minimally invasive approach used for removal of the bullet fragment. We present this report to demonstrate technical feasibility of a minimally invasive approach to projectile removal. Case presentation An 18-year-old African-American man presented to our hospital with a penetrating gunshot injury to the high-cervical spine. The bullet lodged in the spinal cord at the C1 level and rendered our patient quadriplegic and dependent on a ventilator. For personal and forensic reasons, our patient and his family requested removal of the bullet fragment almost one year following the injury. Given the significant comorbidity associated with quadriplegia and ventilator dependency, a minimally invasive approach was used to limit the peri-operative complication risk and expedite recovery. Using a minimally invasive expandable retractor system and the aid of a microscope, the posterior arch of C1 was removed, the dura was opened, and the bullet fragment was successfully removed from the spinal cord. Conclusions Here we describe a minimally invasive procedure demonstrating the technical feasibility of removing an intramedullary foreign object from the high-cervical spine. We do not suggest that the availability of minimally invasive procedures should lower the threshold or expand the indications for the removal of bullet fragments in the spinal canal. Rather, our objective is to expand the indications for minimally invasive procedures in an effort to reduce the morbidity and mortality associated with spinal procedures. In addition, this report may help to highlight the feasibility of this approach. PMID:22876811
Lum, Mitchell J H; Rosen, Jacob; Sinanan, Mika N; Hannaford, Blake
With a focus on design methodology for developing a compact and lightweight minimally invasive surgery (MIS) robot manipulator, the goal of this study is progress toward a next-generation surgical robot system that will help surgeons deliver healthcare more effectively. Based on an extensive database of in-vivo surgical measurements, the workspace requirements were clearly defined. The pivot point constraint in MIS makes the spherical manipulator a natural candidate. An experimental evaluation process helped to more clearly understand the application and limitations of the spherical mechanism as an MIS robot manipulator. The best configuration consists of two serial manipulators in order to avoid collision problems. A complete kinematic analysis and optimization incorporating the requirements for MIS was performed to find the optimal link lengths of the manipulator. The results show that for the serial spherical 2-link manipulator used to guide the surgical tool, the optimal link lengths (angles) are (60 degrees, 50 degrees). A prototype 6-DOF surgical robot has been developed and will be the subject of further study.
Harris, Monte O
We are in the midst of exciting times from a demographic standpoint as the population of darker-skinned people grows exponentially in the United States. Although there is a growing demand for facial cosmetic procedures amongst people of color, the total number of individuals undergoing surgical facial rejuvenation is dwarfed by the current Caucasian market. In order to provide optimal options for facial rejuvenation, cosmetic surgeons must have an underlying appreciation for the dynamic interplay among ethnicity, facial morphology, and the progression of aging. The purpose of the present article is to outline the minimally invasive surgical options for facial rejuvenation best suited for the patient of color. Although the population of individuals with darker-pigmented skin is quite vast, the present paper will focus on individuals of African descent, with whom the author has the most experience. Preferred surgical techniques include blepharoplasty, autologous facial fat transplantation, percutaneous cheek lift, and submental liposuction. Cutaneous surgeons familiar with soft-tissue surgery and facial anatomy should feel comfortable performing these techniques.
Yamashita, Hiromasa; Zuo, Siyang; Masamune, Ken; Liao, Hongen; Dohi, Takeyoshi
We developed a nonmagnetic rigid and flexible outer sheath with pneumatic interlocking mechanism using flexible toothed links and a wire-driven bending distal end. The outer sheath can be switched between rigid and flexible modes easily depending on surgical scenes, and the angle of its distal end can be controlled by three nylon wires. All components of flexible parts are made of MRI-compatible nonmagnetic plastics. We manufactured the device with 300-mm long, 16-mm outer diameter, 7-mm inner diameter and 90-mm bending distal end. Holding power of the device in rigid mode was maximum 3.6 N, which was sufficient for surgical tasks in body cavity. In vivo experiment using a swine, our device performed smooth insertion of a flexible endoscope and a biopsy forceps into reverse side of the liver, intestines and spleen with a curved path. In conclusion, our device shows availability of secure approach of surgical instruments into deep cavity.
Peng, Da-ming; Wang, Geng-yuan; Yu, Xue-fei
This article introduces the principle, structure and components of a visualization system for carrying out minimally invasive surgical abortion. Without altering the current surgical approach or increasing the surgical difficulty, the surgical system integrated a mini-CMOS image sensor and LED light and a visual device to allow fixed-point removal of the fetus or embryo in the minimally invasive surgery.
Bonaldi, Giuseppe; Brembilla, Carlo; Foresti, Camillo; Cianfoni, Alessandro
This report describes two elderly patients with large disc fragments extruded into lumbar radicular recesses not treatable by any conventional conservative, minimally invasive or surgical approach. Direct access to the disc fragments was obtained crossing the articular zygapophyseal cavity instead of the interlaminar space and spinal canal, using a small needle through which a laser fibre was inserted to deliver energy for tissue ablation. The procedures obtained regression of both symptoms and the bulk of the fragments at early and late clinical and MR follow-ups.
Rosen, Jacob; Lum, Mitch; Trimble, Denny; Hannaford, Blake; Sinanan, Mika
Recent advances in technology have led to the fusion of MIS techniques and robot devices. However, current systems are large and cumbersome. Optimizing the surgical robot mechanism will eventually lead to its integration into the operating room (OR) of the future becoming the extended presence of the surgeon and nurses in a room occupied by the patient alone. By optimizing a spherical mechanism using data collected in-vivo during MIS procedures, this study is focused on a bottom-up approach to developing a new class of surgical robotic arms while maximizing their performance and minimizing their size. The spherical mechanism is a rotational manipulator with all axes intersecting at the center of the sphere. Locating the rotation center of the mechanism at the MIS port makes this class of mechanism a suitable candidate for the first two links of a surgical robot for MIS. The required dexterous workspace (DWS) is defined as the region in which 95% of the tool motions are contained based on in-vivo measurements. The extended dexterous workspace (EDWS) is defined as the entire abdominal cavity reachable by a MIS instruments. The DWS is defined by a right circular cone with a vertex angle of 60 degrees and the EDWS is defined by a cone with an elliptical cross section created by two orthogonal vertex angles of 60 degrees and 90 degrees. A compound function based on the mechanism's isotropy and the mechanism stiffness was considered as the performance metric cost function. Optimization across both the DWS and the EDWS lead to a serial mechanism configuration with link length angles of 74 degrees and 60 degrees for a serial configuration. This mechanism configuration maximized the kinematic performance in the DWS while keeping the EDWS as its reachable workspace. Surgeons, using a mockup of two mechanisms in a MIS setup, validated these results experimentally. From these experiments the serial configuration was deemed most applicable for MIS robotic applications compared
Rosario, Mamer S; Hayashi, Katsuhiro; Yamamoto, Norio; Takeuchi, Akihiko; Miwa, Shinji; Taniguchi, Yuta; Tsuchiya, Hiroyuki
Reports showing high recurrence rates for intralesional curettage and bone grafting have made the current treatment principle for fibrous dysplasia controversial. This study aimed to report the postoperative clinical outcomes from three minimally invasive surgical strategies we use for monostotic fibrous dysplasia (MFD). Twelve patients with MFD presenting with no pathologic fracture or deformity and treated with one of three surgical strategies-plain open biopsy, plain alpha-tricalcium phosphate (ATP) reconstruction, and prophylactic bridge plating-were included. There were nine men and three women, with median age of 38 years. Mean follow-up was 88 weeks. Five cases involved the proximal femur, two each involved the femoral and tibial diaphyses, and one each involved the distal humerus, radial diaphysis, and proximal tibia. All cases were reviewed for functional and radiological outcomes. Median time to full activity was 1 day (range 1 to 3) for the plain open biopsy group, while the prophylactic bridge-plating and plain ATP reconstruction groups had longer median recovery times (59 days, range 3 to 143, and 52 days, range 11 to 192, respectively). Musculoskeletal Tumor Society scores at last follow-up were excellent for all the cases (mean 29.6, range 25 to 30). Radiological analysis using Gaski et al.'s criteria showed plain open biopsy resulted in partial resolution of proximal femoral lesions, while ATP reconstruction and prophylactic plating resulted in no change and progression in this lesion site, respectively. For femoral diaphyseal lesions, prophylactic plating resulted in partial resolution, while ATP reconstruction resulted in no change. In the tibial diaphysis, prophylactic plating resulted in partial resolution, while plain open biopsy resulted in no change. For the lesions involving the distal humerus and the proximal tibia, plain open biopsy resulted in partial resolution, while for the radial diaphyseal lesion, ATP reconstruction resulted in
Goldstone, Andrew B.; Atluri, Pavan; Szeto, Wilson Y.; Trubelja, Alen; Howard, Jessica L.; MacArthur, John W.; Newcomb, Craig; Donnelly, Joseph P.; Kobrin, Dale M.; Sheridan, Mary A.; Powers, Christiana; Gorman, Robert C.; Gorman, Joseph H.; Pochettino, Alberto; Bavaria, Joseph E.; Acker, Michael A.; Hargrove, W. Clark; Woo, Y. Joseph
Objective Minimally invasive approaches to mitral valve surgery are increasingly used, but the surgical approach must not compromise the clinical outcome for improved cosmesis. We examined the outcomes of mitral repair performed through right minithoracotomy or median sternotomy. Methods Between January 2002 and October 2011, 1011 isolated mitral valve repairs were performed in the University of Pennsylvania health system (455 sternotomies, 556 right minithoracotomies). To account for key differences in preoperative risk profiles, propensity scores identified 201 well-matched patient pairs with mitral regurgitation of any cause and 153 pairs with myxomatous disease. Results In-hospital mortality was similar between propensity-matched groups (0% vs 0% for the degenerative cohort; 0% vs 0.5%, P = .5 for the overall cohort; in minimally invasive and sternotomy groups, respectively). Incidence of stroke, infection, myocardial infarction, exploration for postoperative hemorrhage, renal failure, and atrial fibrillation also were comparable. Transfusion was less frequent in the minimally invasive groups (11.8% vs 20.3%, P = .04 for the degenerative cohort; 14.0% vs 22.9%, P .03 for the overall cohort), but time to extubation and discharge was similar. A 99% repair rate was achieved=in patients with myxomatous disease, and a minimally invasive approach did not significantly increase the likelihood of a failed repair resulting in mitral valve replacement. Patients undergoing minimally invasive mitral repair were more likely to have no residual post-repair mitral regurgitation (97.4% vs 92.1%, P = .04 for the degenerative cohort; 95.5% vs 89.6%, P = .02 for the overall cohort). In the overall matched cohort, early readmission rates were higher in patients undergoing sternotomies (12.6% vs 4.4%, P = .01). Over 9 years of follow-up, there was no significant difference in long-term survival between groups (P = .8). Conclusions In appropriate patients with isolated mitral valve
Carvalho, Luiz; Abrão, Mauricio Simões; Deshpande, Abhishek; Falcone, Tommaso
This systematic review evaluates the role of robotics in the surgical treatment of endometriosis. Electronic database searches were conducted in MEDLINE, Scopus, and ISI Web of Knowledge for relevant studies over the past 10 years. Four published articles were found that used robotic assisted laparoscopy to perform endometriosis surgery. All four studies used the da Vinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA). Three studies were case reports, and one was a cohort study. Robotics appears to be as effective as conventional laparoscopy in the management of endometriosis. There were no reports of any major complications. Few studies have been published and show us that robotic endometriosis surgery is feasible even in severe endometriosis cases without conversion. There is a lack of long-term outcome papers in the literature. Randomized controlled trials are necessary. Copyright © 2011 John Wiley & Sons, Ltd.
Study Design Eight patients who underwent surgery through a single-sided keyhole laminotomy due to intradural extramedullary (IDEM) meningiomas were retrospectively investigated. Purpose To present the surgical outcomes of single-sided keyhole laminotomies aimed to excise large ventral IDEM spinal cord menengiomas. Overview of Literature Less invasive procedures, such as laminotomies and osteoplastic laminotomies, have been previously described in the literature, but an approach that interferes with spinal stability to an even lesser extent would be more desirable. Methods Tumors were removed through a slit-like space between the dura and spinal cord without retraction of the spinal cord. The neurological conditions of patients were evaluated pre- and postoperatively with the Nurick grading system. Pathologic subtypes, preoperative symptom duration, tumor location on the sagittal and axial planes, and the percentage of tumor occupying the intradural space were investigated. On follow-up, magnetic resonance imaging was conducted to evaluate whether the tumor had recurred. Results All tumors were localized either ventrally or ventrolaterally. Of the spinal menengiomas, four were cervical and four were thoracic. All lesions were completely excised, and the neurological condition improved in six patients. The remaining two patients already had preoperative Nurick grades of 0, and this score was maintained postoperatively. Neither kyphotic changes nor instability developed in any patient during the follow-up period. Conclusions Total resection of anterior and anterolateral IDEM menengiomas, without introducing new neurological deficits, can be performed by an isolated posterior approach through a single-sided keyhole laminotomy. However, this approach should be applied cautiously and with a thorough understanding of its limitations. PMID:25901234
Nakamura, Yoshitsugu; Kiaii, Bob; Chu, Michael W. A.
Atrial fibrillation is the most common sustained arrhythmia and is associated with significant risks of thromboembolism, stroke, congestive heart failure, and death. There have been major advances in the management of atrial fibrillation including pharmacologic therapies, antithrombotic therapies, and ablation techniques. Surgery for atrial fibrillation, including both concomitant and stand-alone interventions, is an effective therapy to restore sinus rhythm. Minimally invasive surgical ablation is an emerging field that aims for the superior results of the traditional Cox-Maze procedure through a less invasive operation with lower morbidity, quicker recovery, and improved patient satisfaction. These novel techniques utilize endoscopic or minithoracotomy approaches with various energy sources to achieve electrical isolation of the pulmonary veins in addition to other ablation lines. We review advancements in minimally invasive techniques for atrial fibrillation surgery, including management of the left atrial appendage. PMID:22666609
Elhadi, Ali M; Zehri, Aqib H; Zaidi, Hasan A; Almefty, Kaith K; Preul, Mark C; Theodore, Nicholas; Dickman, Curtis A
We aimed to determine the clinical indications and surgical outcomes for thoracoscopic discectomy. Thoracic disc disease is a rare degenerative process. Thoracoscopic approaches serve to minimize tissue injury during the approach, but critics argue that this comes at the cost of surgical efficacy. Current reports in the literature are limited to small institutional patient series. We systematically identified all English language articles on thoracoscopic discectomy with at least two patients, published from 1994 to 2013 on MEDLINE, Science Direct, and Google Scholar. We analyzed 12 articles that met the inclusion criteria, five prospective and seven retrospective studies comprising 545 surgical patients. The overall complication rate was 24% (n=129), with reported complications ranging from intercostal neuralgia (6.1%), atelectasis (2.8%), and pleural effusion (2.6%), to more severe complications such as pneumonia (0.8%), pneumothorax (1.3%), and venous thrombosis (0.2%). The average reported postoperative follow-up was 20.5 months. Complete resolution of symptoms was reported in 79% of patients, improvement with residual symptoms in 10.2%, no change in 9.6%, and worsening in 1.2%. The minimally invasive endoscopic approaches to the thoracic spine among selected patients demonstrate excellent clinical efficacy and acceptable complication rates, comparable to the open approaches. Disc herniations confined to a single level, with small or no calcifications, are ideal for such an approach, whereas patients with calcified discs adherent to the dura would benefit from an open approach.
A review of the current scientific literature was undertaken to evaluate the efficacy of minimally invasive periodontal regenerative surgery in the treatment of periodontal defects. The impact on clinical outcomes, surgical chair-time, side effects and patient morbidity were evaluated. An electronic search of PUBMED database from January 1987 to December 2011 was undertaken on dental journals using the key-word "minimally invasive surgery". Cohort studies, retrospective studies and randomized controlled clinical trials referring to treatment of periodontal defects with at least 6 months of follow-up were selected. Quality assessment of the selected studies was done through the Strength of Recommendation Taxonomy Grading (SORT) System. Ten studies (1 retrospective, 5 cohorts and 4 RCTs) were included. All the studies consistently support the efficacy of minimally invasive surgery in the treatment of periodontal defects in terms of clinical attachment level gain, probing pocket depth reduction and minimal gingival recession. Six studies reporting on side effects and patient morbidity consistently indicate very low levels of pain and discomfort during and after surgery resulting in a reduced intake of pain-killers and very limited interference with daily activities in the post-operative period. Minimally invasive surgery might be considered a true reality in the field of periodontal regeneration. The observed clinical improvements are consistently associated with very limited morbidity to the patient during the surgical procedure as well as in the post-operative period. Minimally invasive surgery, however, cannot be applied at all cases. A stepwise decisional algorithm should support clinicians in choosing the treatment approach.
Lavelle, William; Carl, Allen; Lavelle, Elizabeth Demers
This article summarizes current issues related to invasive and minimally invasive surgical techniques for back pain conditions. It describes pain generators and explains theories about how discs fail. The article discusses techniques for treating painful sciatica, painful motion segments, and spinal stenosis. Problems related to current imaging are also presented. The article concludes with a discussion about physical therapy.
Hernandez-Alfaro, Federico; Mareque Bueno, Javier; Diaz, Artur; Pagés, Carles Martí
An adequate transverse maxillary dimension is one of the critical aspects of a functional and stable occlusion. Surgically assisted rapid palatal expansion consists of a surgical liberation of the sites of resistance combined using orthopedic forces. Most technical descriptions advocate the use of general anesthesia with hospital admission. Between March 2000 and July 2008, surgery was performed on 283 consecutive cases with transverse skeletal maxillary hypoplasia. The incision ran horizontally to reach the level of the laterals. Osteotomies of lateral walls and pterygoid disjunction were performed in all cases. A V-Y closure was performed in 2 layers. Patients were discharged after recovery from sedation. One hundred seventy-two of the 283 patients were male. Mean age was 18.3 years. Mean surgical time from incision to last suture was 19 minutes. Expanders were Hyrax in 221 cases and Haas in 61, and a bone-borne expander was used in 1 case. At the 1-year follow-up visit, mean expansion was 8.0 at the canines and 8.9 at the mesiovestibular cuspid of the first molar. General anesthesia has been classically advocated for these procedures, the argument being that pterygomaxillary disjunction was too traumatic to be performed under sedation. The surgical technique used sought to attain a balance between maximum mobilization of the maxilla with a complete liberation of all the buttresses and minimum morbidity to avoid further complications. The new technique that we report seeks to combine both aspects and allows for rapid intervention with local anesthesia plus sedation and a minimal approach with a total liberation of the maxillary resistances (piriform aperture pillars, zygomatic buttresses, midpalatal suture, and pterygoid junctions). The minimal approach and incision used in the technique guarantee vascular support to the maxilla via the vestibular corridors. Copyright 2010 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All
Hess, Shane R; Satpathy, Jibanananda; Waligora, Andrew C; Ugwu-Oju, Obinna
A feared complication of temporary surgical drain placement is from the technical error of accidentally suturing the surgical drain into the wound. Postoperative discovery of a tethered drain can frequently necessitate return to the operating room if it cannot be successfully removed with nonoperative techniques. Formal wound exploration increases anesthesia and infection risk as well as cost and is best avoided if possible. We present a minimally invasive surgical technique that can avoid the morbidity associated with a full surgical wound exploration to remove a tethered drain when other nonoperative techniques fail.
Transluminal endoscopic step-up approach versus minimally invasive surgical step-up approach in patients with infected necrotising pancreatitis (TENSION trial): design and rationale of a randomised controlled multicenter trial [ISRCTN09186711
Background Infected necrotising pancreatitis is a potentially lethal disease that nearly always requires intervention. Traditionally, primary open necrosectomy has been the treatment of choice. In recent years, the surgical step-up approach, consisting of percutaneous catheter drainage followed, if necessary, by (minimally invasive) surgical necrosectomy has become the standard of care. A promising minimally invasive alternative is the endoscopic transluminal step-up approach. This approach consists of endoscopic transluminal drainage followed, if necessary, by endoscopic transluminal necrosectomy. We hypothesise that the less invasive endoscopic step-up approach is superior to the surgical step-up approach in terms of clinical and economic outcomes. Methods/Design The TENSION trial is a randomised controlled, parallel-group superiority multicenter trial. Patients with (suspected) infected necrotising pancreatitis with an indication for intervention and in whom both treatment modalities are deemed possible, will be randomised to either an endoscopic transluminal or a surgical step-up approach. During a 4 year study period, 98 patients will be enrolled from 24 hospitals of the Dutch Pancreatitis Study Group. The primary endpoint is a composite of death and major complications within 6 months following randomisation. Secondary endpoints include complications such as pancreaticocutaneous fistula, exocrine or endocrine pancreatic insufficiency, need for additional radiological, endoscopic or surgical intervention, the need for necrosectomy after drainage, the number of (re-)interventions, quality of life, and total direct and indirect costs. Discussion The TENSION trial will answer the question whether an endoscopic step-up approach reduces the combined primary endpoint of death and major complications, as well as hospital stay and related costs compared with a surgical step-up approach in patients with infected necrotising pancreatitis. PMID:24274589
The authors analyze the results of surgical treatment for bilateral destructive pulmonary tuberculosis in 234 patients who have under- gone 449 lung operations. A study group comprised 156 patients who received mini-invasive surgical treatments via mini-accesses under video-assisted thoracoscopic control. A comparison group included 78 patients operated on through standard approaches by the conventional procedures. In the study group, surgery of less duration was attended by less blood loss, a need for fewer blood transfusions, and the lower incidence and severity of intraoperative complications. Complications following mini-invasive surgery occurred 4 times less frequently and postoperative mortality was 5 times less than that in the comparison group. With mini-invasive surgical techniques, a complete clinical effect at surgical hospital discharge was achieved 1.5-fold more frequently and it was more steady-state in the late period.
Goldstone, Andrew B; Joseph Woo, Y
Cardiac surgery is in the midst of a practice revolution. Traditionally, surgery for valvular heart disease consisted of valve replacement via conventional sternotomy using cardiopulmonary bypass. However, over the past 20 years, the increasing popularity of less-invasive procedures, accompanied by advancements in imaging, surgical instrumentation, and robotic technology, has motivated and enabled surgeons to develop and perform complex cardiac surgical procedures through small incisions, often eliminating the need for sternotomy or cardiopulmonary bypass. In addition to the benefits of improved cosmesis, minimally invasive mitral valve surgery was pioneered with the intent of reducing morbidity, postoperative pain, blood loss, hospital length of stay, and time to return to normal activity. This article reviews the current state-of-the-art of minimally invasive approaches to the surgical treatment of valvular heart disease.
Nguyen, P S; Duron, J-B; Bardot, J; Levet, Y; Aiach, G
In the first step of rhinoplasty, the surgical approach will expose through different types of incisions and dissection planes the osteocartilaginous framework of the nasal pyramid prior to performing actions to reduce or increase the latter. This exposure can be performed by a closed approach or by an external approach--the choice depends on the type of nose and the habits of the surgeon. Far from being opposites, closed and external approaches are complementary and should be known and mastered by surgeons performing rhinoplasty.
Ford, Paul J; Deshpande, Abhishek
A clear understanding of distinctions and definitions is necessary before determining which types of surgically invasive neuroscience research should be permitted and how the experimental protocols can properly be undertaken. A failure to clarify the ethical distinctions in invasive neuroscience research hinders attempts at ethical analysis and guidance. At least four main distinctions need to be addressed: "invasiveness" as an important moral characteristic; special brain-mind-related risks; research participant selection; and ideologic interpretation of human function. Harm and not invasiveness is the metric by which to measure the ethical permissibility of research. Because of a class of harms to minds and selves, special attention should be paid to value considerations. These considerations need to be addressed by researchers, funders, and review boards to create proper safeguards from conception of research through final application of results. © 2013 Elsevier B.V. All rights reserved.
Christidis, Daniel; McGrath, Shannon; Perera, Marlon; Manning, Todd; Bolton, Damien; Lawrentschuk, Nathan
The prevalence of benign prostatic hypertrophy (BPH) causing bothersome lower urinary tract symptoms increases with our ageing population. Treatment of BPH traditionally begins with medical therapy and surgical intervention is then considered for those whose symptoms progress despite treatment. Minimally invasive surgical therapies have been developed as an intermediary in the treatment of BPH with the aim of decreasing the invasiveness of interventions. These therapies also aim to reduce morbidity and dysfunction related to invasive surgical procedures. Multiple treatment options exist in this group including mechanical and thermo-ablative strategies. Emerging therapies utilizing differing technologies range from the established to the experimental. We review the current literature related to these minimally invasive therapies and the evidence of their effectiveness in treating BPH. The role of minimally invasive surgical therapies in the treatment of BPH is still yet to be strongly defined. Given the experimental nature of many of the modalities, further study is required prior to their recommendation as alternatives to invasive surgical therapy. More mature evidence is required for the analysis of durability of effect of these therapies to make robust conclusions of their effectiveness.
Campbell, Ashley A.; Grob, Seanna R.; Yoon, Michael K.
Determining safe surgical access to the orbit can be difficult given the complex anatomy and delicacy of the orbital structures. When considering biopsy or removal of an orbital tumor or repair of orbital fractures, careful planning is required to determine the ideal approach. Traditionally, this has at times necessitated invasive procedures with large incisions and extensive bone removal. The purpose of this review was to present newly techniques and devices in orbital surgery that have been reported over the past decade, with aims to provide better exposure and/or minimally invasive approaches and to improve morbidity and/or mortality. PMID:26692713
Campbell, Ashley A; Grob, Seanna R; Yoon, Michael K
Determining safe surgical access to the orbit can be difficult given the complex anatomy and delicacy of the orbital structures. When considering biopsy or removal of an orbital tumor or repair of orbital fractures, careful planning is required to determine the ideal approach. Traditionally, this has at times necessitated invasive procedures with large incisions and extensive bone removal. The purpose of this review was to present newly techniques and devices in orbital surgery that have been reported over the past decade, with aims to provide better exposure and/or minimally invasive approaches and to improve morbidity and/or mortality.
Kimball, Jon; Kusnezov, Nicholas A.; Pezeshkian, Patrick; Lu, Daniel C.
Background: The risk of significant morbidity and mortality often outweighs the benefit of surgical resection as palliative treatment for patients with high systemic disease burden, poor cardiopulmonary status, and previous spinal surgeries. Minimally invasive surgical (MIS) approaches to decompressing metastatic epidural cord compression (MECC) can address these issues and thereby make palliation a feasible option for these patients. Case Description: We present the cases of three consecutively collected patients with severe neurological compromise secondary to lumbar epidural metastases who underwent MIS decompression and achieved improved functional outcome and quality of life. The first patient is a 23-year-old female with metastatic Ewing's sarcoma who presented with 2 weeks of a right foot drop and radiculopathic pain. The next case is that of a 71-year-old male with metastatic prostate cancer who presented with significant radiculopathic L5-S1 pain and severe motor deficits in his lower extremities. The last case is that of a 73-year-old male with metastatic hepatocellular carcinoma who presented with worsening left leg weakness, paresthesia, and dysethesia. Postoperatively, each patient experienced significant improvement and almost complete enduring return of function, strength, and resolution of pain. Conclusion: We demonstrate that MIS approaches to spinal decompression as palliative treatment for metastatic disease is a viable treatment in patients with a focal symptomatic lesion and comes with the benefits of decreased surgical morbidity inherent to the minimally invasive approach as well as excellent functional outcomes. PMID:23869278
Májovský, M; Netuka, D; Beneš, V
The pineal region is a deep-seated part of the brain surrounded by highly eloquent structures. Differential diagnosis of space-occupying lesions in this region encompasses pineal gland cysts, pineal gland tumours, metastases, germ cell tumours, meningiomas, gliomas, hemangioblastomas and neuroectodermal tumours. A treatment strategy is based mainly on tumour anatomical characteristics and histological type. Except germinatous tumours, a surgical excision is the treatment of choice. Microsurgical approaches: The microsurgical supracerebellar-infratentorial approach is an essential approach to the pineal region. Despite certain risks, it allows a straightforward and completely extracerebral approach with a minimal cerebellar retraction. The other basic approach is the microsurgical occipital-transtentorial approach that is advantageous in patients with a supratentorial tumour extension or a steep tentorium. The interhemispheric-transcallosal approach and the transcortical-transventricular approach are possible options in selected cases.Endoscopic approaches: The neuroendoscopy provides a minimally invasive method to perform a tumour biopsy and to treat hydrocephalus in one session. Stereotactic biopsy: The stereotactic needle biopsy represents an alternative to the endoscopic biopsy in patients without hydrocephalus and in patients with dorsally located lesions inaccessible from the third ventricle. Modern neurosurgery offers a rich variety of surgical approaches to the pineal region. The complexity of space-occupying lesions in this region requires an individualised treatment, a prudent preoperative planning and a meticulous surgical technique.
Schmitto, Jan D; Rojas, Sebastian V; Hanke, Jasmin S; Avsar, Murat; Haverich, Axel
The new generation of left ventricular assist devices (LVADs) has enabled minimally invasive surgical procedures for implantation. Herein we present two alternative approaches for minimally invasive LVAD explantation following cardiac recovery, avoiding a sternotomy and improving patient safety. Copyright © 2013 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.
Valerio, Claudia Scigliano; Peyneau, Priscila Dias; de Sousa, Andréia Cruz Pires Ribeiro; Cardoso, Fábio Oliveira; de Oliveira, Davidson Rodarte Félix; Taitson, Paulo Franco; Manzi, Flávio Ricardo
The best-known cervicopharyngeal pain is Eagle syndrome, in which symptomatic elongation of the stylomandibular process occurs and may be accompanied by stylohyoid ligament calcification. Among the causes of elongation of the styloid process, the following may be mentioned: history of trauma, styloid ligament calcification, and formation of bony tissue in the insertion of the styloid ligament. When there is no history of trauma or surgery, it is called the stylohyoid syndrome. In the current study, the clinical case of 34-year-old woman is reported, complaining of pain in the region of the neck, without any history of neck surgery or trauma. A panoramic radiograph and computed tomographic scan showed bilateral elongation of the styloid process. Extraoral surgical intervention was the treatment of choice. It is important to point out that dentists should be aware of this condition to contribute to a better diagnosis and therapeutic procedure.
Unger, A.C; Dirksen, B; Renken, F. G; Wilde, E; Willkomm, M; Schulz, A.P
Purpose : The Direct Anterior Approach (DAA) is well established as a minimal access approach in elective orthopaedic hip surgery. For the growing number of elderly patients with femoral neck fractures treated with Bipolar Hip Hemiarthroplasty (BHH), only a few results do exist. The study shows the clinical and radiological outcome for 180 patients treated by a modified DAA with BHH. Materials and Methods : The data of 180 geriatric patients with medial femoral neck fractures were evaluated retrospectively. The general and surgical complications, mobilisation using the Timed Up and Go test (TUG), the social environment pre- and postoperative and the radiological results have been compared with established approaches for geriatric hip surgery. Results : After joint replacement, 18 (10%) patients were developed pneumonia, of which 3 (1.7%) died during hospitalisation. In 7 cases (4%), surgical revision had to be carried out: three times (1.7%) because of a seroma, three times (1.7%) because of subcutaneous infection, and one time (0.6%) because the BHH was removed, owing to deep wound infection. One dislocation (0.6%) occurred, as well as one femoral nerve lesion (0.6%) occured. 88.3% of patients were mobilised on walkers or crutches; the Timed Up and Go Test showed a significant improvement during inpatient rehabilitation. 83% were discharged to their usual social environment, 10% were transferred to a short-term care facility and 7% were relocated permanently to a nursing home. 3/4 of patients had a cemented stem alignment in the range between -5° and 5°, while 2/3 of patients had a maximum difference of 1 cm in leg length. Conclusion : Using the modified DAA, a high patient satisfaction is achieved after implantation of a BHH. The rate of major complications is just as low as in conventional approaches, and rapid mobilisation is possible. PMID:25136389
Tsunezuka, Yoshio; Yachi, T; Waseda, R; Yamamoto, D
The surgical treatment of Pancoast tumors is associated with difficulties related to its anatomical locations. Different surgical approaches have been reported but every approaches have some advantages and disadvantages. We report 2 Pancoast tumors cases with unique surgical approaches and our techniques. Case 1 : A 38-year-old man complained of face edema. The chest computed tomography (CT) revealed an right anterior apical tumor with direct invasion of the 1st and 2nd rib. Preoperative chemotherapy with 2 courses of carboplatin [area under the blood concentration-time curve (AUC) 6, day 1] and paclitaxel (80 mg/m2, day1, 8, 15) and concurrent extracorporeal radiation (70 Gy) was used to treat the adenocarcinoma. The skin incision was performed according to Masaoka's anterior approach, and a proximal median sternotomy communicated with an incision in the 4th intercostal space. The clavicula was freed by the L-shaped incision on the manubrium and the 1st cartilage section according to Grunenwald method to retract the section. Case 2 : A 65-year-old man complained back pain. The chest CT revealed an right superior sulcus tumor, displaced bronchus (B1+B3 tracheal bronchus, B2) and pulmonary arteries anomalies. Combined Shaw-Paulson incision and 4 intercostal lateral thoracotomy was performed to right upper lobectomy and systematic lymph nodes dissection.
Neurosurgeons have been trying to reduce surgical invasiveness by applying minimally invasive keyhole approaches. Therefore, this paper clarifies the detailed surgical technique, its limitations, proper indications, and contraindications for a superciliary keyhole approach as a minimally invasive modification of a pterional approach. Successful superciliary keyhole surgery for unruptured aneurysms requires an understanding of the limitations and the use of special surgical techniques. Essentially, this means the effective selection of surgical indications, usage of the appropriate surgical instruments with a tubular shaft, and refined surgical techniques, including straightforward access to the aneurysm, clean surgical dissection, and the application of clips with an appropriate configuration. A superciliary keyhole approach allows unruptured anterior circulation aneurysms to be clipped safely, rapidly, and less invasively on the basis of appropriate surgical indications. PMID:25535512
Abdelgawad, Amr A; Kanlic, Enes
Calcaneus fractures in children differ from those in adults. Most calcaneus fractures in children can be managed nonoperatively, with good long-term results expected. The width and height of the calcaneus can remodel with time in children. Recently, there has been a trend toward operative treatment of displaced intra-articular fractures of the calcaneus in children to correct the articular deformity. Studies of calcaneal fracture fixation in children used an extended lateral approach, with its possible complications. In the present report, we describe the operative treatment of 2 children (12 and 13 years old), who had a displaced intra-articular fracture of the calcaneus, using a minimally invasive sinus tarsi approach. Adequate reduction was obtained in both cases with no soft tissue complications or implant discomfort. Fixation was obtained using 3.5-mm cortical screws. Anatomic joint alignment was restored. The children were followed up until they had both resumed their full activities with no complications. We recommend this approach for operative treatment of displaced intra-articular fractures of the calcaneus, because it addresses the intra-articular displacement, which is the most important element of the deformity in children.
Kuo, Lindsay E; Murayama, Kenric; Simmons, Kristina D; Kelz, Rachel R
The goal of this study was to examine regional variation in use of minimally invasive surgical (MIS) operations. Regional variation exists in performance of surgical operations. Variation in the use of MIS has not been studied. Five operations that are performed open or MIS were selected: cholecystectomy, appendectomy, colectomy, antireflux, and bariatric. A 3-state database from 2008 to 2011 was used; states were divided into hospital service areas (HSAs). For each operation, the percentage of MIS operations was calculated. HSAs with less than 50% or more than 150% of the MIS average were considered outliers. Population demographics, geography, and hospital and physician presence were compared between HSAs. Rates of performance by patient disease and the presence of MIS surgeons were also investigated. MIS cholecystectomy was performed with low variation; MIS appendectomy, antireflux, and bariatric operations with medium variation; and MIS colectomy with high variation. With the exception of MIS colectomy, there were no differences in the patient demographics, geography, or disease types treated with an MIS approach between HSAs with low-, non-, or high utilization of MIS. There is no correlation between the number of MIS surgeons and the percentage of procedures performed MIS. Variation in utilization of MIS exists and differs by operation. Patient demographics, patient disease, and the ability to access care are associated only with variation in use of MIS for colectomy. For all other operations studied, these factors do not explain variation in MIS use. Further investigation is warranted to identify and eliminate causes of variation.
Aliev, Iu G; Chinikov, M A; Panteleeva, I S; Kurbanov, F S; Popovich, V K; Sushko, A N
The article presents the results of surgical treatment of 1038 patients with cholelithiasis, acute and chronic calculous cholecystitis and complicated forms of the disease. Operations were performed with traditional laparotomic and minimally invasive approaches. Indications for choosing access, as well as the advantages and disadvantages of various options of surgery in patients with cholelithiasis are discussed.
Minimal invasive anterolateral transthoracic transpleural approach: a novel technique for thoracic disc herniation. A review of the literature, description of a new surgical technique and experience with first 12 consecutive patients.
Deviren, Vedat; Kuelling, Fabrice A; Poulter, Greg; Pekmezci, Murat
A retrospective review of a case series. To describe a novel surgical technique for a minimally disruptive lateral transthoracic transpleural approach to treat thoracic disc herniations. Thoracic disc herniation is a relatively uncommon spinal condition, and surgical treatment is indicated for patients with myelopathy or radiculopathy that failed to respond to conservative therapy. Presently there is no consensus about the best approach to address thoracic disc herniations. Using the novel retractor system (MaXcess), the authors describe a novel minimally disruptive approach that allows the surgeons to perform a standard anterior discectomy and fusion with instrumentation while minimizing approach-related morbidity. A series of 12 patients with single-level thoracic disc herniations who underwent anterior spinal cord decompression followed by instrumented fusion through a novel retractor system is being reported. Demographic and radiographic data, perioperative complications, and clinical outcomes were reviewed. Twelve patients were enrolled with an average age of 51 years (range, 23 to 67 y). The average follow-up was 28 months (range, 12 to 33 mo). The average length of hospital stay was 5 days (range, 2 to 12 d). The average preoperative visual analog scale pain score was 9 (range, 7 to 10), which later decreased to 3 (range, 0 to 5) at final follow-up. All patients with myelopathy and/or sphincter dysfunction had significant improvement of their symptoms. One patient had pleural effusion and 1 patient had intercostal neuralgia. Anterior decompression using a transthoracic transpleural approach provides excellent exposure and allows consistent decompression of thoracic disc herniations. This study demonstrated that a new minimally invasive, transthoracic transpleural decompression technique can be safely performed for single-level thoracic disc herniations. The early results showed that this technique allows less dissection, along with the advantages of
Black, Dalliah M.
SYNOPSIS Significant progress has been made in the surgical management of breast cancer. Historically, women with invasive breast cancer underwent a Halsted radical mastectomy; morbid procedure removing the breast, underlying muscle and regional lymph nodes. In contemporary practice, the majority of women diagnosed with early stage invasive breast cancer can now be managed with breast conserving therapy to include a segmental mastectomy followed by radiation. Axillary lymph nodes are routinely assessed by sentinel lymph node biopsy. Axillary lymph node dissection is reserved for patients with documented nodal metastasis, however, here too progress has been made as a population of low risk patients has been identified in whom a complete dissection is not required even in the setting of a positive sentinel lymph node. This chapter details the landmark clinical trials that have guided the surgical management of breast cancer. PMID:23464699
Madhani, Akhil Jiten
Minimally invasive surgery (MIS) is performed today using hand held instruments passed through small incisions into the body. The internal surgical site and instruments are viewed remotely on a monitor using images obtained with an endoscopic camera. It is well recognized that the marked therapeutic benefits of MIS must be weighed against the increased technical difficulty for the surgeon and the ensuing risk of surgical errors. Here I describe the design, construction, and operation of teleoperated surgical instruments that solve several key problems in current minimally invasive surgical practice. These improvements are primarily achieved through (1) an increase in dexterity and degrees of freedom, (2) force feedback to allow surgeons to feel instrument-tissue interactions, and (3) the elimination of geometrical discrepancies between actual and observed tool motions. I present the design of two teleoperator slave manipulators for minimally invasive surgery, the seven- degree-of-freedom Silver Falcon and the eight-degree-of- freedom Black Falcon. Both systems were tested using an existing PHANToM TM haptic interface which was modified for use as a master manipulator. Position based bilateral force-reflecting teleoperation was implemented using sound cable design principles, without force sensors. Through the design of system dynamics that accommodate a macro-micro control scheme, a substantial reduction was achieved in slave endpoint inertia and friction reflected to the user. The Black Falcon was successfully used to drive surgical sutures along arbitrarily oriented paths, a task which is rarely feasible using today's instruments. This test demonstrates successful kinematic design and range of motion, although the quality of force reflection was not sufficient to be helpful when suturing soft tissue. Force reflection was found to be more useful during rigid contact tasks where force information is not already available to the operator via visual cues. (Copies
Rodríguez, Dayron; Sacco, Dianne E
Minimally invasive interventions for stone disease in the United States are mainly founded on 3 surgical procedures: extracorporeal shock wave lithotripsy, ureteroscopic lithotripsy, and percutaneous nephrolithotomy. With the advancement of technology, treatment has shifted toward less invasive strategies and away from open or laparoscopic surgery. The treatment chosen for a patient with stones is based on the stone and patient characteristics. Each of the minimally invasive techniques uses an imaging source, either fluoroscopy or ultrasound, to localize the stone and an energy source to fragment the stone. Extracorporeal shock wave lithotripsy uses a shock wave energy source generated outside the body to fragment the stone. In contrast, with ureteroscopy, laser energy is placed directly on the stone using a ureteroscope that visualizes the stone. Percutaneous nephrolithotomy requires dilation of a tract through the back into the renal pelvis so that instruments can be inserted directly onto the stone to fragment or pulverize it. The success of the surgical intervention relies on performing the least invasive technique with the highest success of stone removal.
Hadidi, Ahmed T
The purpose of this study was to describe morphological classification of congenital buried penis (BP) and present a versatile surgical approach for correction. Sixty-one patients referred with BP were classified into 3 grades according to morphological findings: Grade 1-29 patients with Longer Inner Prepuce (LIP) only, Grade II-20 patients who presented with LIP associated with indrawn penis that required division of the fundiform and suspensory ligaments, and Grade III-12 patients who had in addition to the above, excess supra-pubic fat. A ventral midline penile incision extending from the tip of prepuce down to the penoscrotal junction was used in all patients. The operation was tailored according to the BP Grade. All patients underwent circumcision. Mean follow up was 3 years (range 1 to 10). All 61 patients had an abnormally long inner prepuce (LIP). Forty-seven patients had a short penile shaft. Early improvement was noted in all cases. Satisfactory results were achieved in all 29 patients in grade I and in 27 patients in grades II and III. Five children (Grades II and III) required further surgery (9%). Congenital buried penis is a spectrum characterized by LIP and may include in addition; short penile shaft, abnormal attachment of fundiform, and suspensory ligaments and excess supra-pubic fat. Congenital Mega Prepuce (CMP) is a variant of Grade I BP, with LIP characterized by intermittent ballooning of the genital area. Copyright © 2014 Elsevier Inc. All rights reserved.
Cuesta, Miguel A; van der Wielen, Nicole; Weijs, Teus J; Bleys, Ronald L A W; Gisbertz, Suzanne S; van Duijvendijk, Peter; van Hillegersberg, Richard; Ruurda, Jelle P; van Berge Henegouwen, Mark I; Straatman, Jennifer; Osugi, Harushi; van der Peet, Donald L
During esophageal dissection and lymphadenectomy of the upper mediastinum by thoracoscopy in prone position, we observed a complex anatomy in which we had to resect the esophagus, dissect vessels and nerves, and take down some of these in order to perform a complete lymphadenectomy. In order to improve the quality of the dissection and standardization of the procedure, we describe the surgical anatomy and steps involved in this procedure. We retrospectively evaluated twenty consecutive and unedited videos of thoracoscopic esophageal resections. We recorded the vascular anatomy of the supracarinal esophagus, lymph node stations and the steps taken in this procedure. The resulting concept was validated in a prospective study including five patients. Seventy percent of patients in the retrospective study had one right bronchial artery (RBA) and two left bronchial arteries (LBA). The RBA was divided at both sides of the esophagus in 18 patients, with preservation of one LBA or at least one esophageal branch in all cases. Both recurrent laryngeal nerves were identified in 18 patients. All patients in the prospective study had one RBA and two LBA, and in four patients the RBA was divided at both sides of the esophagus and preserved one of the LBA. Lymphadenectomy was performed of stations 4R, 4L, 2R and 2L, with a median of 11 resected lymph nodes. Both recurrent laryngeal nerves were identified in four patients. In three patients, only the left recurrent nerve could be identified. Two patients showed palsy of the left recurrent laryngeal nerve, and one showed neuropraxia of the left vocal cord. Knowledge of the surgical anatomy of the upper mediastinum and its anatomical variations is important for standardization of an adequate esophageal resection and paratracheal lymphadenectomy with preservation of any vascularization of the trachea, bronchi and the recurrent laryngeal nerves.
Blaschko, Sarah D.; Brooks, H. Mark; Dhuy, S. Michael; Charest-Shell, Cynthia; Clayman, Ralph V.
Background: The human cadaver remains the gold standard for anatomic training and is highly useful when incorporated into minimally invasive surgical training programs. However, this valuable resource is often not used to its full potential due to a lack of multidisciplinary cooperation. Herein, we propose the coordinated multiple use of individual cadavers to better utilize anatomical resources and potentiate the availability of cadaver training. Methods: Twenty-two postgraduate surgeons participated in a robot-assisted surgical training course that utilized shared cadavers. All participants completed a Likert 4-scale satisfaction questionnaire after their training session. Cadaveric tissue quality and the quality of the training session related to this material were assessed. Results: Nine participants rated the quality of the cadaveric tissue as excellent, 7 as good, 5 as unsatisfactory, and 1 as poor. Overall, 72% of participants who operated on a previously used cadaver were satisfied with their training experience and did not perceive the previous use deleterious to their training. Conclusion: The coordinated use of cadavers, which allows for multiple cadaver use for different teaching sessions, is an excellent training method that increases availability of human anatomical material for minimally invasive surgical training. PMID:18237501
Singh, Harminder; Harrop, James; Schiffmacher, Paul; Rosen, Marc; Evans, James
Chordomas are primarily malignant tumors encountered at either end of the neural axis; the craniovertebral junction and the sacrococcygeal junction. In this article, we discuss the surgical management of craniovertebral junction chordomas. In this paper, we discuss the surgical management of craniovertebral junction chordomas. The following approaches are illustrated: transoral-transpalatopharyngeal approach, high anterior cervical retropharyngeal approach, endoscopic transoral approach, and endoscopic transnasal approach. No single operative approach can be used for all craniovertebral chordomas. Therefore, the location of the tumor dictates which approach or approaches should be used.
Parekh, J; Shepherd, DET; Hukins, DWL; Maffulli, N
A T-handle has been designed to be used for minimally invasive implantation of a dynamic hip screw to repair fractures of the proximal femur. It is capable of being used in two actions: (i) push and hold (while using an angle guide) and (ii) application of torque when using the insertion wrench and lag screw tap. The T-handle can be held in a power or precision grip. It is suitable for either single (sterilised by γ-irradiation) or multiple (sterilised by autoclaving) use. The principles developed here are applicable to handles for a wide range of surgical instruments. PMID:27326394
Laddi, Amit; Bhardwaj, Vijay; Mahapatra, Prasant; Pankaj, Dinesh; Kumar, Amod
This paper proposes a framework for 3D surgical vision for minimal invasive robotic surgery. It presents an approach for generating the three dimensional view of the in-vivo live surgical procedures from two images captured by very small sized, full resolution camera sensor rig. A pre-processing scheme is employed to enhance the image quality and equalizing the color profile of two images. Polarized Projection using interlacing two images give a smooth and strain free three dimensional view. The algorithm runs in real time with good speed at full HD resolution.
Ferreira, Renata Tosoni Rodrigues; Silva, Roberto Rocha e; Marchi, Evaldo
Objective To compare the results of aortic valve replacement with access by sternotomy or minimally invasive approach. Methods Retrospective analysis of medical records of 37 patients undergoing aortic valve replacement by sternotomy or minimally invasive approach, with emphasis on the comparison of time of cardiopulmonary bypass and aortic clamping, volume of surgical bleeding, time of mechanical ventilation, need for blood transfusion, incidence of atrial fibrillation, length of stay in intensive care unit, time of hospital discharge, short-term mortality and presence of surgical wound infection. Results Sternotomy was used in 22 patients and minimally invasive surgery in 15 patients. The minimally invasive approach had significantly higher time values of cardiopulmonary bypass (114.3±23.9 versus 86.7±19.8min.; P=0.003), aortic clamping (87.4±19.2 versus 61.4±12.9 min.; P<0.001) and mechanical ventilation (287.3±138.9 versus 153.9±118.6 min.; P=0.003). No difference was found in outcomes surgical bleeding volume, need for blood transfusion, incidence of atrial fibrillation, length of stay in intensive care unit and time of hospital discharge. No cases of short-term mortality or surgical wound infection were documented. Conclusion The less invasive approach presented with longer times of cardiopulmonary bypass, aortic clamping and mechanical ventilation than sternotomy, however without prejudice to the length of stay in intensive care unit, time of hospital discharge and morbidity. PMID:28076618
Treon, Katrina; Craig, Niall John Angus
Low back pain (LBP) is a worldwide phenomenon. The UK studies place LBP as the largest single cause of absence from work; up to 80% of the population will experience LBP at least once in their lifetime. Most individuals do not seek medical care and are not disabled by their pain once it is managed by nonoperative measures. However, around 10% of patients go on to develop chronic pain. This review outlines the basics of the traditional approach to spinal surgery for chronic LBP secondary to osteoarthritis of the lumbar spine as well as explains the novel concepts and terminology of back pain surgery. Traditionally, the stepwise approach to surgery starts with local anaesthetic and steroid injection followed by spinal fusion. Fusion aims to alleviate pain by preventing movement between affected spinal segments; this commonly involves open surgery, which requires large soft tissue dissection and there is a possibility of blood loss and prolonged recovery time. Established minimally invasive spine surgery techniques (MISS) aim to reduce all of these complications and they include laparoscopic anterior lumbar interbody fusion and MISS posterior instrumentation with pedicle screws and rods. Newer MISS techniques include extreme lateral interbody fusion and axial interbody fusion. The main problem of fusion is the disruption of the biomechanics of the rest of the spine; leading to adjacent level disease. Theoretically, this can be prevented by performing motion-preserving surgeries such as total disc replacement, facet arthroplasty, and non fusion stabilisation. We outline the basic concepts of the procedures mentioned above as well as explore some of the novel surgical therapies available for chronic LBP. PMID:26240729
Borges, Lawrence F
Intramedullary Ependymomas are uncommon tumors that can occur within the medullary substance of the spinal cord. Despite this difficult location, they are typically benign tumors that can most often be removed completely with an acceptable surgical risk. Therefore, the recommended management approach is usually surgical excision. This review will consider the historical context in which surgeons began treating these tumors and then review the more recent literature that guides their current management.
Klotz, Stefan; Scheld, Hans H
End-stage heart failure is a challenging disease with growing incidence. With decreasing heart transplant rates worldwide organ preserving therapies become, again, of interest. The purpose of the present review is to examine the potential challenges of surgical therapies in patients with end-stage heart failure. The gold-standard for end-stage heart failure is and will be cardiac transplantation. However, due to organ shortage this therapy is limited to a few patients. Therefore implantation of ventricular assist devices (VADs) or long-term minimal-invasive partial support devices will increase. Improvements in device design with smaller devices, easier implantation techniques, and modified anticoagulation outcome and long-term success will likely improve. In addition, good quality of life as destination therapy is almost available. Organ conservation surgery (coronary artery bypass grafting and surgical ventricular restoration or surgical repair of mitral valve regurgitation) in end-stage heart failure patients could not prove the expected results. Transcatheter or minimal-invasive approaches of these therapies might become routine in the near future. Due to the overwhelming outcome rates, cardiac transplantation is the most established surgical therapy for end-stage heart failure. VAD therapy is increasing and minimized VADs might further open the market for destination therapy/permanent support.
Schultz, Loren G.; Tyler, Jeff W.; Moll, H. David; Constantinescu, Gheorghe M.
Bovine practitioners are often presented with dystocias that require a cesarean section. Many practitioners perform this surgery using the same approach each time due to their comfort with one specific approach or lack of familiarity of other available options. The goal of this article is to explain the advantages, disadvantages, and indications for each of the different approaches to aid the practitioner in achieving better surgical success rate. PMID:18624065
Patel, Ravish Shammi; Dutta, Shumayou
Study Design Retrospective review of prospectively collected data. Purpose To evaluate the incidence of surgical site infections (SSIs) in minimally invasive spine surgery (MISS) in a cohort of patients and compare with available historical data on SSI in open spinal surgery cohorts, and to evaluate additional direct costs incurred due to SSI. Overview of Literature SSI can lead to prolonged antibiotic therapy, extended hospitalization, repeated operations, and implant removal. Small incisions and minimal dissection intrinsic to MISS may minimize the risk of postoperative infections. However, there is a dearth of literature on infections after MISS and their additional direct financial implications. Methods All patients from January 2007 to January 2015 undergoing posterior spinal surgery with tubular retractor system and microscope in our institution were included. The procedures performed included tubular discectomies, tubular decompressions for spinal stenosis and minimal invasive transforaminal lumbar interbody fusion (TLIF). The incidence of postoperative SSI was calculated and compared to the range of cited SSI rates from published studies. Direct costs were calculated from medical billing for index cases and for patients with SSI. Results A total of 1,043 patients underwent 763 noninstrumented surgeries (discectomies, decompressions) and 280 instrumented (TLIF) procedures. The mean age was 52.2 years with male:female ratio of 1.08:1. Three infections were encountered with fusion surgeries (mean detection time, 7 days). All three required wound wash and debridement with one patient requiring unilateral implant removal. Additional direct cost due to infection was $2,678 per 100 MISS-TLIF. SSI increased hospital expenditure per patient 1.5-fold after instrumented MISS. Conclusions Overall infection rate after MISS was 0.29%, with SSI rate of 0% in non-instrumented MISS and 1.07% with instrumented MISS. MISS can markedly reduce the SSI rate and can be an
Jones, Vinci S; Biesheuvel, Cornelis J; Cohen, Ralph C
We conducted a survey among pediatric surgeons to examine the impact of the advent of minimally invasive surgery (MIS) on the pediatric surgical profession with respect to job satisfaction and training challenges. An invitation to participate in a web-based questionnaire was sent out to 306 pediatric surgeons. Apart from demographic details and training recommendations, parameters relevant to job satisfaction, including patient interaction, peer pressure, ethical considerations, academic progress, ability to train residents, and financial remuneration, were studied. The response rate was 38.2%. Working in a unit performing MIS was identified by 71% of respondents as the most effective and feasible modality of training in MIS. Inability to get away from a busy practice was the most common reason cited for inability to acquire MIS training. The overall responses to the job satisfaction parameters showed a positive trend in the current MIS era for patient interaction, ethical considerations, academic progress, and training residents, with a negative trend for peer pressure and financial remuneration. The enthusiastic minimally invasive surgeons (EMIS) were defined as those having more than 5 years of MIS experience and also performing more than 10% of their work using MIS. Of the 113 responses analyzed, 67 belonged to the EMIS category. Those belonging to the EMIS group were less likely to feel inadequate in training their residents, in meeting the felt needs of the patients, or to complain about peer pressure. They were more likely to consider MIS to be as relevant and beneficial in children as in adults. Embracing MIS, as represented by the EMIS group, correlated with an overall greater job satisfaction.
Patel, Neal B; Dodd, Zachary H; Voorhies, Jason; Horn, Eric M
We present a series of patients with discitis and osteomyelitis who were surgically treated via a minimally invasive lateral transpsoas approach to the lumbar spine. Surgical treatment for spinal discitis and osteomyelitis presents challenges because of comorbidities that are common in patients undergoing this procedure. A retrospective review found six patients who met strict operative criteria including instability, intractable pain, neurological deficit, and disease progression. All patients were non-ambulatory before surgery because of intractable back pain. The patients underwent standard lateral minimally invasive surgery using either the extreme lateral interbody fusion (NuVasive, San Diego, CA, USA) or direct lateral interbody fusion (Medtronic Sofamor Danek, Memphis, TN, USA) system. The patients underwent debridement with a discectomy and partial or complete corpectomy, with polyetheretherketone or titanium cage placement. Two patients had additional posterior fixation with percutaneous pedicle screws, and none had immediate perioperative complications. The postoperative CT scans demonstrated satisfactory debridement and hardware placement. All patients experienced significant pain improvement and could ambulate within a few days of surgery. So far, the 1 year follow-up data have demonstrated stable hardware with solid fusion and continued pain improvements. One patient demonstrated hardware failure secondary to refractory infection, 2 months postoperatively, and required additional posterior decompression and debridement with pedicle screw fixation. The lateral transpsoas approach permits debridement and fixation coupled with percutaneous pedicle screw fixation to further stabilize the spine in a minimally invasive fashion. Due to the significant comorbidities in this patient population, a minimally invasive approach is a suitable surgical technique. A close follow-up period is necessary to detect early hardware failure which may necessitate more
Halderman, Ashleigh; Shrestha, Rabin; Sindwani, Raj
Chronic granulomatous invasive fungal sinusitis (CGIFS) is rare and a consensus on ideal management is lacking. We present an extensive case managed successfully with a conservative approach. Case report and literature review. The patient presented with unilateral proptosis, papilledema, and headache. Imaging revealed an infiltrative process with extensive intracranial and intraorbital involvement. Biopsy showed fungal elements and granulomatous reaction consistent with CGIFS. The patient was managed with conservative surgery and long-term oral voriconazole. This case supports a conservative surgical approach in some patients with extensive CGIFS. Oral voriconazole is effective and has significant advantages over more toxic agents administered intravenously. © 2014 ARS-AAOA, LLC.
Leblanc, E; Querleu, D; Narducci, F; Chauvet, M P; Chevalier, A; Lesoin, A; Vennin, P; Taieb, S
Early stage epithelial ovarian carcinoma is defined pathologically as a tumor strictly limited to one or both ovaries without any extra-ovarian disease (i.e., Stage IA or B of the International Federation of Gynecology and Obstetrics (FIGO) classification). This diagnosis can be obtained only after an exhaustive surgical staging procedure, performed as soon as the diagnosis of epithelial invasive ovarian carcinoma is established. This staging surgery currently encompasses a peritoneal cytology, the thorough inspection of all the visceral and parietal peritoneal surfaces with biopsy of any abnormality, total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH + BSO), random peritoneal biopsies, omentectomy, appendectomy and bilateral pelvic and para-aortic lymphadenectomies, up to the left renal vein. The results of this staging procedure and its indications are discussed. In all of the cases, the radical removal of the pathologic adnexa is indicated, along with the complete peritoneal and retroperitoneal staging. While fertility-sparing surgery (avoiding hysterectomy and contralateral adnexectomy, if possible) seems to be safe for young women, a TAH + BSO is the rule for the others. Adjuvant chemotherapy can be omitted in well-differentiated tumors with a negative staging operation, but currently it remains indicated in all other cases. Indeed, the ultimate goal in early stage ovarian carcinoma is to not impair by inadequate management the high chance of a cure. Copyright 2000 Wiley-Liss, Inc.
Nakamura, Makoto; Roser, Florian; Struck, Melena; Vorkapic, Peter; Samii, Madjid
operative morbidity and mortality, the frontolateral and pterional approach provided remarkable improvement compared with the bifrontal approach. These approaches allowed quick access to the tumor and were minimally invasive with less brain exposure, but still engendered high rates of total tumor removal. By comparison, the frontolateral approach provided the best results concerning visual outcome while representing the least invasive surgical approach.
Toquart, A; Graillon, T; Mansouri, N; Adetchessi, T; Blondel, B; Fuentes, S
Spinal metastasis are getting more frequent. This raises the question of pain and neurological complications, which worsen the functional and survival prognosis of this oncological population patients. The surgical treatment must be the most complete as possible: to decompress and stabilize without delaying the management of the oncological disease. Minimal invasive surgery techniques are by definition, less harmful on musculocutaneous plan than opened ones, with a comparable efficiency demonstrated in degenerative and traumatic surgery. So they seem to be applicable and appropriate to this patient population. We detailed different minimal invasive techniques proposed in the management of spinal metastasis. For this, we used our experience developed in degenerative and traumatic pathologies, and we also referred to many authors, establishing a literature review thanks to Pubmed, Embase. Thirty eight articles were selected and allowed us to describe different techniques: percutaneous methods such as vertebro-/kyphoplasty and osteosynthesis, as well as mini-opened surgery, through a posterior or anterior way. We propose a surgical approach using these minimal invasive techniques, first according to the predominant symptom (pain or neurologic failure), then characteristics of the lesions (number, topography, type…) and the deformity degree. Whatever the technique, the main goal is to stabilize and decompress, in order to maintain a good quality of life for these fragile patients, without delaying the medical management of the oncological disease. Copyright © 2016 Elsevier Masson SAS. All rights reserved.
Vincent, Charles; Moorthy, Krishna; Sarker, Sudip K.; Chang, Avril; Darzi, Ara W.
Objective: This approach provides the basis of our research program, which aims to expand operative assessment beyond patient factors and the technical skills of the surgeon; to extend assessment of surgical skills beyond bench models to the operating theater; to provide a basis for assessing interventions; and to provide a deeper understanding of surgical outcomes. Summary Background Data: Research into surgical outcomes has primarily focused on the role of patient pathophysiological risk factors and on the skills of the individual surgeon. However, this approach neglects a wide range of factors that have been found to be of important in achieving safe, high-quality performance in other high-risk environments. The outcome of surgery is also dependent on the quality of care received throughout the patient's stay in hospital and the performance of a considerable number of health professionals, all of whom are influenced by the environment in which they work. Methods: Drawing on the wider literature on safety and quality in healthcare, and recent papers on surgery, this article argues for a much wider assessment of factors that may be relevant to surgical outcome. In particular, we suggest the development of an “operation profile” to capture all the salient features of a surgical operation, including such factors as equipment design and use, communication, team coordination, factors affecting individual performance, and the working environment. Methods of assessing such factors are outlined, and ethical issues and other potential concerns are discussed. PMID:15024308
Magee, Mitchell J; Mack, Michael J
Myasthenia gravis is an autoimmune disorder of neuromuscular transmission affecting 2 out of every 100,000 people. Neurologists and surgeons still debate what role surgery should play in its management. Many patients who might benefit from thymectomy are denied the opportunity because of misconceptions, ignorance, or trepidation. By offering effective methods of less invasive thymectomy to these patients, a significant number of patients and treating neurologists previously unwilling to consider surgery may realize the benefits of this established, proven treatment alternative. The surgical approaches reviewed include: transcervical, videothoracoscopic, robotic-assisted, transsternal, and combined transcervical-transsternal maximal thymectomy.
Goldberg, Robert A; Mancini, Ronald; Demer, Joseph L
With a detailed understanding of the pertinent surgical anatomy, the transcaruncular approach provides safe access and excellent exposure of the medial orbit and orbital apex. We herein describe our technique of the transcaruncular approach and delineate the pertinent associated surgical anatomy via dissection, magnetic resonance imaging, and histologic examination. The isolated transcaruncular approach provides exposure of the medial orbital floor from the region of the maxilloethmoidal strut to the orbital roof area superior to the frontoethmoidal suture. When combined with an inferior fornix incision, the transcaruncular approach allows for continuous exposure from the frontozygomatic suture laterally to the frontoethmoidal suture medially. Attention to anatomical details promotes creation of an effective and safe caruncular incision. The conjunctival incision should be ample. The orbital septum should be carefully dissected from the posterior surface of the Horner muscle to minimize fat spillage, and the periosteum should be opened widely at the beginning of surgery.
Opdenakker, Y; Swennen, G; Abeloos, J
The key to the success of surgical navigation based on computer-aided design and computer-aided manufacturing (CAD/CAM) planning is the registration process. This has to be precise and adapted to the surgical needs. However, the application of a conventional rigid skull-fixed navigation star for accurate registration is limited for use in the paediatric population, because of the risk of unstable fixation, dural perforation, and intracranial bleeding. The authors describe their experience with a non-invasive reference headband that was used in combination with a custom-made acrylic resin dental registration splint for resection of a rare infraorbital zygomatic desmoplastic fibroma in a 2-year old patient. This approach appears not to have been reported in the literature to date.
The incidence of thyroid cancer is increasing rapidly. A large percentage of new cases identified fall into a low-risk category. As the incidence has increased, clinical experience has confirmed that the majority of patients will have excellent outcomes and that those at risk of doing badly can be reliably identified. Treatment for thyroid cancer is predominantly surgical. The decision about how aggressively this disease should be managed has remained controversial due to the excellent outcomes irrespective of the nature of surgical procedure chosen. This article reviews the developments in our understanding of the biology of thyroid cancer and the evidence that supports the approach to management. PMID:26918146
Handle, Markus; Bonfatti-Ribeiro, Luiz M; Barcaro-Machado, Bárbara H; Pitanguy, Ivo
Removal of excess skin from the aging hand can cause scarring in one of the body's most visible areas, which is highly undesirable for patients. A minimal-scar approach to tightening this skin, in conjunction with the rejuvenating effects of minimally-invasive procedures, is therefore needed. The authors describe a new technique for limiting scar size and visibility by locating the incision in a unique position on the ulnar side of the dorsum of the hand. Eleven patients were treated with the authors' method between March and September 2009. Both hands were treated for each patient, but these procedures occurred separately, at an interval of two to four months. The surgical approach included skin flap advancement and rotation, and the procedure took place under local anesthesia and sedation. The resultant scar was S-shaped. Changes in postoperative stress ratio were visualized. Patients reported being highly satisfied with this procedure with regard to scar size, quality, and location. No major complications were observed, such as infection, flap necrosis, and nerve damage. All minor complications were treated conservatively. Patients with Fitzpatrick skin types I-III profited from less scar visibility in their outcomes. All patients experienced quick recovery with minimal downtime, independent of skin type. The minimal-scar handlift technique is an effective surgical approach to rejuvenating the hand and can be implemented concurrently with minimally-invasive techniques for volume restoration. The complication rate is low, and patient/surgeon satisfaction with outcomes is high.
Abdullah, Walid Ahmed; Khalil, Hesham S; Alhindi, Maryam M; Marzook, Hamdy
Excessive gingival display is a problem that can be managed by variety of procedures. These procedures include non-surgical and surgical methods. The underlying cause of gummy smile can affect the type of procedure to be selected. Most patients prefer minimally invasive procedures with outstanding results. The authors describe a minimally invasive lip repositioning technique for management of gummy smile. Twelve patients (10 females, 2 males) with gingival display of 4 mm or more were operated under local anesthesia using a modified lip repositioning technique. Patients were followed up for 1, 3, 6 and 12 months and gingival display was measured at each follow up visit. The gingival mucosa was dissected and levator labii superioris and depressor septi muscles were freed and repositioned in a lower position. The levator labii superioris muscles were pulled in a lower position using circumdental sutures for 10 days. Both surgeon's and patient's satisfaction of surgical outcome was recorded at each follow-up visit. At early stage of follow-up the main complaints of patients were the feeling of tension in the upper lip and circum oral area, mild pain which was managed with analgesics. One month postoperatively, the gingival display in all patients was recorded to be between 2 and 4 mm with a mean of (2.6 mm). Patient satisfaction records after 1 month showed that 10 patients were satisfied with the results. Three months postoperatively, the gingival display in all patients was recorded and found to be between 2 and 5 mm with a mean of 3 mm. Patient satisfaction records showed that 8 patients were satisfied with the results as they gave scores between. Surgeon's satisfaction at three months follow up showed that the surgeons were satisfied in 8 patients. The same results were found in the 6 and 12 months follow-up periods without any changes. Complete relapse was recorded only in one case at the third postoperative month. This study showed that the proposed lip
Yurteri-Kaplan, Ladin A; Andriani, Leslie; Kumar, Anagha; Saunders, Pamela A; Mete, Mihriye M; Sokol, Andrew I
To develop a valid and reliable survey to measure surgical team members' perceptions regarding their institution's requirements for successful minimally invasive surgery (MIS). Questionnaire development and validation study (Canadian Task Force classification II-2). Three hospital types: rural, urban/academic, and community/academic. Minimally invasive staff (team members). Development and validation of a minimally invasive surgery survey (MISS). Using the Safety Attitudes questionnaire as a guide, we developed questions assessing study participants' attitudes regarding the requirements for successful MIS. The questions were closed-ended and responses based on a 5-point Likert scale. The large pool of questions was then given to 4 focus groups made up of 3 to 6 individuals. Each focus group consisted of individuals from a specific profession (e.g., surgeons, anesthesiologists, nurses, and surgical technicians). Questions were revised based on focus group recommendations, resulting in a final 52-question set. The question set was then distributed to MIS team members. Individuals were included if they had participated in >10 MIS cases and worked in the MIS setting in the past 3 months. Participants in the trial population were asked to repeat the questionnaire 4 weeks later to evaluate internal consistency. Participants' demographics, including age, gender, specialty, profession, and years of experience, were captured in the questionnaire. Factor analysis with varimax rotation was performed to determine domains (questions evaluating similar themes). For internal consistency and reliability, domains were tested using interitem correlations and Cronbach's α. Cronbach's α > .6 was considered internally consistent. Kendall's correlation coefficient τ closer to 1 and with p < .05 was considered significant for the test-retest reliability. Two hundred fifty participants answered the initial question set. Of those, 53 were eliminated because they did not meet
Mollo, Ernesto; Gavagnin, Margherita; Carbone, Marianna; Castelluccio, Francesco; Pozone, Ferdinando; Roussis, Vassilios; Templado, José; Ghiselin, Michael T.; Cimino, Guido
The Mediterranean Sea is losing its biological distinctiveness, and the same phenomenon is occurring in other seas. It gives urgency to a better understanding of the factors that affect marine biological invasions. A chemoecological approach is proposed here to define biotic conditions that promote biological invasions in terms of enemy escape and resource opportunities. Research has focused on the secondary metabolite composition of three exotic sea slugs found in Greece that have most probably entered the Mediterranean basin by Lessepsian migration, an exchange that contributes significantly to Mediterranean biodiversity. We have found toxic compounds with significant activity as feeding deterrents both in the cephalaspidean Haminoea cyanomarginata and in the nudibranch Melibe viridis. These findings led us to propose aposematism in the former and dietary autonomy in producing defensive metabolites in the latter case, as predisposing factors to the migration. In the third mollusk investigated, the anaspidean Syphonota geographica, the topic of marine invasions has been approached through a study of its feeding biology. The identification of the same compounds from both the viscera of each individual, separately analyzed, and their food, the seagrass Halophila stipulacea, implies a dietary dependency. The survival of S. geographica in the Mediterranean seems to be related to the presence of H. stipulacea. The initial invasion of this exotic pest would seem to have paved the way for the subsequent invasion of a trophic specialist that takes advantage of niche opportunities. PMID:18337492
Biological invasions increasingly threaten natural resources and reduce biological diversity worldwide. To curtail biological invasions, developed countries have adopted multitire approaches that systematically address the process of invasion, encompassing introduction, establishment, spread and nat...
Qinfeng Guo; Songlin Fei; Jeffrey S. Dukes; Christopher M. Oswalt; Basil V. Iannone III; Kevin M. Potter
Habitat invasibility is a central focus of invasion biology, with implications forÂ basic ecological patterns and processes and for effective invasion management. ââInvasibilityââÂ is, however, one of the most elusive metrics and misused terms in ecology. Empirical studiesÂ and meta-analyses of invasibility have produced inconsistent and even conflicting results. ThisÂ ...
Petrowsky, Henrik; Busuttil, Ronald W
The growing discrepancy between the need and the availability of donor livers has resulted in evolving surgical approaches in liver transplantation during the last two decades to expand the donor pool. One approach is to transplant partial grafts, obtained either from a living donor or splitting a cadaveric donor liver. For both surgical methods, it is important to obtain a minimal viable graft volume to prevent small-for-size syndrome and graft failure. This minimal volume, expressed as graft-to-whole body ratio, must be between 0.8 and 1%. Living donor liver transplantation (LDLT) became the primary transplant option in many Asian countries and is increasingly performed as an adjunct transplant option in countries with low donation rates. Split liver transplantation (SLT) is a surgical method that creates two allografts from one deceased donor. The most widely used splitting technique is the division of the liver into a left lateral sectoral graft (segments 2 and 3) for a pediatric patient and a right trisegmental graft (segments 1 and 4 to 8) for an adult patient. Both LDLT and SLT are also important and established methods for the treatment of pediatric patients. Another evolving surgical approach is auxiliary liver transplantation, which describes the transplanting a whole or partial graft with preservation of the partial native liver. This bridging technique is applied in patients with fulminate liver failure and should allow the regeneration of the injured liver with the potential to discontinue immunosuppression. Other methods such as xenotransplantation, as well as hepatocyte and stem cell transplantation, are promising approaches that are still in experimental phases.
Leon, H O; Blanco, C E; Guthrie, T B
We present a simple surgical technique created by the authors to address degenerative chondral lesions of the knee and its application in a limited prospective case series. The technique assumes the concept of beneficial epiphyseal changes caused by disruption of the subchondral bone in improving symptoms, as with drilling, microfracture, periarticular osteotomy, and other invasive procedures. Minimally invasive selective osteotomy (MISO) is an expansion of the arthroscopic treatment of the knee, specifically targeting symptomatic lesions with minimal additional trauma and cost, while avoiding disruption of the articular surface of the subchondral bone. The technique involves a mimimal access approach with selective saw cuts placed with a 1-cm oscillating blade parallel to the joint surface 1 to 1.5 cm deep to identified lesions. The technique does not address malalignment but can address lesions not addressed by classic osteotomies and, as such, may be combined with other corrective alignment procedures as necessary. We present the results of MISO of the knee in a case series of 62 outpatients carried out at the Orthopaedic Division of the Clinical and Surgical Hermanos Ameijeiras Hospital in Havana, Cuba. At 2-year follow-up, there was improvement of symptoms without significant complications.
Al-Mohrej, Omar A.; Al-Kenani, Nader S.
Ankle sprains fall into two main categories: acute ankle sprains and chronic ankle instability, which are among the most common recurrent injuries during occupational activities, athletic events, training and army service. Acute ankle sprain is usually managed conservatively and functional rehabilitation failure by conservative treatment leads to development of chronic ankle instability, which most often requires surgical intervention. Enhancing the in-depth knowledge of the ankle anatomy, biomechanics and pathology helps greatly in deciding the management options. Cite this article: Al-Mohrej OA, Al-Kenani NS. Acute ankle sprain: conservative or surgical approach? EFORT Open Rev 2016;1:34-44. DOI: 10.1302/2058-5241.1.000010. PMID:28461926
Ceylan, Savas; Anik, Ihsan; Koc, Kenan
There are two major problems for the pituitary adenomas invading the Cavernous Sinus (CS); differentiation of extension and invasion and inability to demonstrate the medial wall via preoperative imaging methods. Two important corridors are defined in endoscopic cavernous sinus approaches; the lateral and medial corridor. A retrospective analysis was performed in 400 endoscopic transphenoidal approaches and 360 pituitary adenomas underwent endoscopic transphenoidal surgery in our department between September 1997 and December 2010. 48 patients affected by the tumours involving the cavernous sinus were included in this study. We performed an intraoperative evaluation of cavernous sinus invasion considering visualization of the medial wall defect, intracavernous ICA segments, minor tumour extensions through small focal pit holes of the medial wall of CS or confirming carotid segments of CS by micro-doppler. Cavernous sinus involvement was classified into three types according to the medial and lateral corridor extension of the tumor as 25 isolated medial corridor involvement (Type I), 5 isolated lateral corridor involvement (Type II) and 18 total involvement (Type III). Our classification depends on fully surgical endoscopic approach supported by neuroimaging techniques and anatomical studies and shows a good predictive value for all cavernous sinus involvement.
Trevisanuto, D; Marchetto, L
Respiratory distress syndrome (RDS) is the most common respiratory morbidity in preterm infants. In addition to respiratory support, the current clinical treatment includes endotracheal intubation and rapid instillation of exogenous surfactant. However, this approach needs skilled operators and has been associated with complications such as hemodynamic instability and electroencephalogram abnormalities. New, less invasive methods for surfactant administration are needed. In this article, we reviewed the available noninvasive procedures for surfactant administration. In particular, we focused on aerosolized surfactant and surfactant administration through LMA.
Tarola, Christopher L; Al-Amodi, Hussein A; Balasubramanian, Sankar; Fox, Stephanie A; Harle, Christopher C; Iglesias, Ivan; Sridhar, Kumar; Teefy, Patrick J; Chu, Michael W A; Kiaii, Bob B
Contemporary anesthetic techniques have enabled shorter sedation and early extubation in off-pump and minimally invasive coronary artery bypass (CABG) surgery. Robotic-assisted CABG represents the optimal surgical approach for ultrafast track anesthesia, with patients able to bypass the cardiac surgical intensive care unit with recovery in the postanesthesia care unit (PACU) and inpatient ward. In-hospital postoperative outcomes from ninety patients who underwent either elective or urgent robotically-assisted CABG at our institution were reviewed. These patients were carefully selected by a multidisciplinary team to undergo fast-track anesthesia: extubation in the operating room, 4-hour recovery in the postanesthesia care unit and transfer to the inpatient ward. Intrathecal, paravertebral local, and patient-controlled anesthesia techniques were used to facilitate transition to oral analgesics. Average patient age was 61 ± 9 years. Sixty-six patients (73%) were male. Seventy cases were elective, and 20 patients required urgent revascularization. All patients underwent intraoperative angiography after graft construction, which revealed Fitzgibbon class A grafts. There were no in-hospital mortalities. One patient required re-exploration for bleeding, through the same minimally invasive incision, did not require conversion to sternotomy for bleeding, and was transferred to the intensive care unit postexploration for bleeding for standard postoperative care. Postoperative complications were limited to one superficial wound infection. The mean hospital length of stay was 3.5 ± 1.17 days. In patients undergoing robotic-assisted CABG, ultrafast-track cardiac surgery with immediate postprocedure extubation and transfer to the inpatient ward has been demonstrated to be safe with no increase in perioperative morbidity or mortality. It requires a dedicated heart team with a carefully selected group of patients. Avoiding cardiac surgical intensive care unit expedites recovery
Pinheiro, Hugo; Ferronha, Frederico; Morales, Jorge; Campos Pinheiro, Luís
The retrocaval ureter is a rare congenital entity, classically managed with open pyeloplasty techniques. The experience obtained with the laparoscopic approach of other more frequent causes of ureteropelvic junction (UPJ) obstruction has opened the method for the minimally invasive approach of the retrocaval ureter. In our paper, we describe a clinical case of a right retrocaval ureter managed successfully with laparoscopic dismembered pyeloplasty. The main standpoints of the procedure are described. Our results were similar to others published by other urologic centers, which demonstrates the safety and feasibility of the procedure for this condition. PMID:27635277
Pillunat, Lutz E; Erb, Carl; Jünemann, Anselm GM; Kimmich, Friedemann
Over the last decade several novel surgical treatment options and devices for glaucoma have been developed. All these developments aim to cause as little trauma as possible to the eye, to safely, effectively, and sustainably reduce intraocular pressure (IOP), to produce reproducible results, and to be easy to adopt. The term “micro-invasive glaucoma surgery (MIGS)” was used for summarizing all these procedures. Currently MIGS is gaining more and more interest and popularity. The possible reduction of the number of glaucoma medications, the ab interno approach without damaging the conjunctival tissue, and the probably safer procedures compared to incisional surgical methods may explain the increased interest in MIGS. The use of glaucoma drainage implants for lowering IOP in difficult-to-treat patients has been established for a long time, however, a variety of new glaucoma micro-stents are being manufactured by using various materials and are available to increase aqueous outflow via different pathways. This review summarizes published results of randomized clinical studies and extensive case report series on these devices, including Schlemm’s canal stents (iStent®, iStent® inject, Hydrus), suprachoroidal stents (CyPass®, iStent® Supra), and subconjunctival stents (XEN). The article summarizes the findings of published material on efficacy and safety for each of these approaches. PMID:28919702
Yokoyama, Yuhei; Chen, Fengshi; Aoyama, Akihiro; Sato, Toshihiko; Date, Hiroshi
Video-assisted thoracoscopic surgery (VATS) has been widely used, but surgical resections of superior sulcus tumours remain challenging because of their anatomical location. For such cases, less-invasive procedures, such as the anterior transcervical-thoracic and transmanubrial approaches, have been widely performed because of their excellent visualization of the subclavian vessels. Recently, a combined operative technique with an anterior surgical approach and VATS for anterior superior sulcus tumours has been introduced. Herein, we report three cases of anterior superior sulcus tumours successfully resected by surgical approaches combined with a VATS-based lobectomy. In all cases, operability was confirmed by VATS, and upper lobectomies with hilar and mediastinal lymph node dissections were performed. Subsequently, dissections of the anterior inlet of the tumours were performed using the transmanubrial approach in two patients and the anterior trans-cervical-thoracic approach in one patient. Both approaches provided excellent access to the anterior inlet of the tumour and exposure of the subclavian vessels, resulting in radical resection of the tumour with concomitant resection of the surrounding anatomical structures, including the chest wall and vessels. In conclusion, VATS lobectomy combined with the anterior surgical approach might be an excellent procedure for the resection of anterior superior sulcus tumours.
Shah, Jatin P.
Purpose: A variety of surgical approaches used to treat primary oral cavity tumors are described to delineate the technique and rationale behind each treatment choice. Methods and Materials: Size, location, proximity to bone, lymph node status, histology, and prior treatment considerations are employed to determine the most appropriate surgical approach for primary oral cavity tumors. Results: Oncologic outcomes and physical function show the best results from surgical treatment of many primary oral cavity, but necessitates careful selection of surgical approach. Conclusion: Each surgical approach must be selected based upon relevant tumor, patient and physician factors.
Krohn-Hansen, Dag; Nicolaissen, Bjørn; Meling, Torstein R; Haaskjold, Erling
Access to the superior mid-orbit is required for procedures on the levator muscle in the correction of upper eyelid ptosis and in surgery aimed at local lesions in this region. The purpose with this human cadaver study was to clarify the anatomical substrate for a surgical approach to the levator muscle and the upper mid-orbit structures, in which the orbital septum and the retroseptal fat pad is not harmed during surgery. Macro-anatomical dissections and histological examinations were performed on five human orbits from three formalin embalmed cadaver heads. It was found that the orbital septum extends posteriorly from its junction with the levator aponeurosis. This posterior continuation of the orbital septum encloses the superior orbital fat pad and separates this from the anterior surface of the levator muscle. In between the orbital septum and the levator, there is a dissection space that provides a minimal invasive access corridor to the structures in the upper mid-orbit.
Lurgi, Miguel; Wells, Konstans; Kennedy, Malcolm; Campbell, Susan; Fordham, Damien A
modelling framework provides a simple approach for identifying the best possible management strategy for invasive species based on metapopulation structure and control capacity. This information can be used by managers trying to devise efficient landscape-oriented management strategies for invasive species and can also generate insights for conservation purposes.
Lurgi, Miguel; Wells, Konstans; Kennedy, Malcolm; Campbell, Susan; Fordham, Damien A.
modelling framework provides a simple approach for identifying the best possible management strategy for invasive species based on metapopulation structure and control capacity. This information can be used by managers trying to devise efficient landscape-oriented management strategies for invasive species and can also generate insights for conservation purposes. PMID:27471853
Giordano, L; Pilolli, F; Toma, S; Bussi, M
Metastases to parapharyngeal or retropharyngeal lymph nodes are rare in well-differentiated thyroid cancers. A review of English literature found only 112 cases reported in the last two decades, with an incidence of parapharyngeal lymph nodes metastases ranging from 0.43 to 2.5%. Surgical resection is the most effective treatment for patients with parapharyngeal lymph node metastasis from thyroid carcinoma. We describe two cases of thyroid cancer parapharyngeal lymph node metastases that were surgically removed using a traditional transcervical approach, with the help of a minimally-invasive video-assisted technique. A video-assisted minimally-invasive transcervical approach is a new technique for excision of sizable benign tumours and selected malignant tumours. The endoscopic technique allows clear identification of critical surgical landmarks that guide the dissection through the correct cleavage plane in a nearly bloodless surgical field, thus decreasing the rate of complications. In both patients postoperative follow-up showed no sequelae and recurrence after 20 and 15 months from surgery.
Bresadola, Vittorio; Feo, Carlo V
Achalasia is a rare disease of the esophagus, characterized by the absence of peristalsis in the esophageal body and incomplete relaxation of the lower esophageal sphincter, which may be hypertensive. The cause of this disease is unknown; therefore, the aim of the therapy is to improve esophageal emptying by eliminating the outflow resistance caused by the lower esophageal sphincter. This goal can be accomplished either by pneumatic dilatation or surgical myotomy, which are the only long-term effective therapies for achalasia. Historically, pneumatic dilatation was preferred over surgical myotomy because of the morbidity associated with a thoracotomy or a laparotomy. However, with the development of minimally invasive techniques, the surgical approach has gained widespread acceptance among patients and gastroenterologists and, consequently, the role of surgery has changed. The aim of this study was to review the changes occurred in the surgical treatment of achalasia over the last 2 decades; specifically, the development of minimally invasive techniques with the evolution from a thoracoscopic approach without an antireflux procedure to a laparoscopic myotomy with a partial fundoplication, the changes in the length of the myotomy, and the modification of the therapeutic algorithm.
Cheung, Sing T; Lee, Kim H; Yeung, Tse H; Tse, Cheong Y; Tam, Yuk H; Chan, Kin W; Yeung, Chung K
Intussusception is one of the most common causes of intestinal obstruction in infancy. Non-operative reduction using air enema or other hydrostatic reduction methods has been the standard treatment in most cases. However, if the non-operative method is not indicated or fails, open surgery is still necessary. With the tremendous development of the minimally invasive approach in handling surgical conditions in children in the last decade, this has been applied recently for the reduction of intussusception in children. We herein reviewed our experience of using the combined approach, namely, pneumatic reduction and, if failed, laparoscopic reduction in the management of childhood intussusception. We carried out a retrospective analysis of all children with intussusception managed at Prince of Wales Hospital between December 1998 and December 2004. The minimally invasive approach was used as far as possible. The method of reduction, success rate and the incidence of complication were analysed. Over a 6-year period, there were 146 patients with 167 episodes of intussusception. Pneumatic reduction was carried out in 160 occasions and was successful in 134 (83.8%). In 33 patients, operative reduction was required. Of these, laparoscopic reduction was attempted in 15 and was successful in 13 (86.7%). In those with either pneumatic or laparoscopic reduction, no procedure-related complication was encountered and they had a significant shorter hospital stay (median 3.0 day) than those requiring laparotomy (median 8.0 day) (t-test, P < 0.0001). The minimally invasive approach, that is, pneumatic and/or laparoscopic reduction, was successful in reducing intussusception in 88% of patients with minimal morbidity and shorter hospital stay.
Meriggi, F; Forni, E
A posthepatitic cirrhotic patient may undergo elective or urgent abdominal operation for an extra-hepatic or hepatic disease. According to the high postoperative morbidity (61%), surgery is indicated only for symptomatic or complicated cholelithiasis. A surgical procedure for refractory ascites has been devised to create a permanent peritoneo-venous shunt by a one way pressure-sensitive valve (Leveen). The procedure is simple and brings a long lasting relief with recovery in strength and nutrition and improved kidney function. Sclerotherapy is widely used to treat acute variceal bleeding while repeated sclerotherapy is used in the long-term management to eradicate varices. When indicated, liver transplantation is the best treatment to prevent variceal bleeding recurrence. Also portosystemic shunts effectively prevent recurrent variceal bleeding. They are, however, major operations with an important morbidity and mortality, particularly in poor risk patients. The most advocated shunts today are the Warren distal splenorenal shunt and the Sarfeh portacaval shunt using a small diameter prosthetic H-graft. The transjugular intrahepatic portosystemic stent-shunt (TIPSS) is a new treatment for portal hypertension and its complications. From a haemodynamic point of view it allows balanced hepatic perfusion. Postoperative mortality is rare; further bleeding and encephalopathy are reasonably acceptable. The most relevant complications concern dislocation of the prosthesis, stenosis and thrombosis of the shunt, which can be corrected by non-invasive dilatation. Encephalopathy is the main complication of surgical portosystemic shunts. It is usually controlled by protein diet restriction, and administration of lactulose or oral antibiotics. In severe forms the patients may be treated by an oesophageal transection with oesophagogastric devascularization, and by a postoperative suppression of the portosystemic shunt using external maneuvers. Posthepatitic liver cirrhosis is
Fodero, Kenneth; King, H Hawkeye; Lum, Mitchell J H; Bland, Clint; Rosen, Jacob; Sinanan, Mika; Hannaford, Blake
As the field of surgical robotics continues to evolve, it is important to keep patient safety in mind. This paper describes a safety control architecture aimed at moving an experimental system in the direction of intrinsically safe operation. The system includes safety features such as: a small number of states, Programmable Logic Controller (PLC) state transition control, active enable, brakes, E-STOP, and a surgeon foot pedal.
Tanwar, Harshwardhan V; Fernandes, Gwendolyn; Patil, Bhushan; Patwardhan, Sujata K
Renal cell carcinoma (RCC) is a very rare phenomenon in an ectopic kidney. We come across a 61-year-old gentleman with a history of 2 months of gross, painless haematuria and palpable pelvic mass on examination. CT scan showed 6.5cm X 5.1cm X 5.8cm mass in pelvic kidney with bilateral iliac vein invasion. With the help of intra-operative ultra-sound, tumour thrombus was extracted from both iliac veins with en mass removal of tumour. Patient was well intraoperatively as well as in postoperatively. We also presented an elegant imaging for the case. PMID:27134940
Rodrigues, Isabel; Estevão-Costa, José; Fragoso, Ana Catarina
The surgical management of complete ureteral duplication anomalies is not consensual. To characterize the pediatric population who underwent surgery for complete ureteral duplication and assess the outcomes of different approaches. Clinical records from patients treated between January 2008 and June 2014 were retrospectively reviewed. Epidemiology, diagnosis, clinical manifestations and surgical procedures were collected and analysed. Ureteral units were divided into two groups: A, with ureterocele; and B, without it. Forty-one ureteral units from 32 patients with complete duplication underwent surgery. In group A (n = 18), the selected primary procedure was: ureterocele punction (12); ureter reimplantation (3); pyelopyelostomy (2); heminephrectomy (1). A reintervention was required in 3 of the 12 units submitted to punction: heminephrectomy (1), ureteroureterostomy (1), and ureteric reimplantation (1). In group B (n = 23), STING was performed in 10 units, ureteric reimplantation in 3, pyelopyelostomy in 3, ureteroureterostomy in 1, and heminephrectomy in 6; two cases required reintervention. A conservative primary approach was favoured in cases with ureterocele and/or reflux in hemisystems worth preserving (53.7%); it was effective per se in 75% (n = 9/12) units in group A and 80% (n = 8/10) in group B. An ablative primary procedure was adopted in 17% (n = 7/41) cases, 5.6% of group A (n = 1/18) and 26.1% of group B (n = 6/23). A conservative approach is effective as a primary and isolated procedure in the majority of cases with ureterocele or vesicoureteral reflux. Further studies are needed to establish the advantages over primary invasive or ablative approaches.
Bainbridge, J; Herbert, E; Gregor, Z
Idiopathic full-thickness macular holes develop as a result of anteroposterior and tangential traction exerted by the posterior vitreous cortex at the fovea. Vitreoretinal relationships during the development of macular holes can be demonstrated in detail by ocular coherence tomography, facilitating an improved understanding of their pathogenesis and guiding clinical management. Surgical strategies for the repair of macular holes are designed to relieve vitreofoveal traction and to promote flattening and reapposition of the macular hole edges by intraocular gas tamponade. A period of face-down positioning postoperatively is conventionally advised. However, the evidence to support this recommendation is weak and practice varies considerably. Surgical removal of the inner limiting membrane (ILM) is advocated to ensure thorough removal of any tangential tractional components including any residual cortical vitreous. Current evidence suggests that ILM peeling can improve anatomical outcomes but the effect on visual function is less predictable; unsuccessful attempts to peel the ILM can be associated with poor visual outcome. The use of vital dyes can facilitate visualisation of the ILM and help achieve complete, atraumatic peeling. Indocyanine green dye can enable high rates of macular hole closure but has been associated with poorer visual outcomes suggesting a dose-dependent toxicity. Trypan blue dye offers an alternative that may have a more favourable risk profile. An improved understanding of vitreoretinal relationships may facilitate a tailored approach to surgery in individuals with macular holes. Vitrectomy to relieve anteroposterior traction is central in the management of all full-thickness holes. The use of long-acting gases, prolonged face-down positioning, and ILM peeling may be more valuable for larger holes, longstanding holes, and those that have failed to close following conventional surgery.
De Palma, Giovanni D
The rate of choledocholithiasis in patients with symptomatic cholelithiasis is estimated to be approximately 10%-33%, depending on the patient's age. Development of Endoscopic Retrograde Cholangiopancreatography and Laparoscopic Surgery and improvement of diagnostic procedures have influenced new approaches to the management of common bile duct stones in association with gallstones. At present available minimally-invasive treatments of cholecysto-choledocal lithiasis include: single-stage laparoscopic treatment, perioperative endoscopic treatment and endoscopic treatment alone. Published data evidence that, associated endoscopic-laparoscopic approach necessitates increased number of procedures per patient while single-stage laparoscopic treatment is associated with a shorter hospital stay. However, current data does not suggest clear superiority of any one approach with regard to success, mortality, morbidity and cost-effectiveness. Considering the variety of therapeutic options available for management, a critical appraisal and decision-making is required. Endoscopic retrograde cholangiopancreatography/EST should be adopted on a selective basis, i.e., in patients with acute obstructive suppurative cholangitis, severe biliary pancreatitis, ampullary stone impaction or severe comorbidity. In a setting where all facilities are available, decision in the selection of the therapeutic option depends on the patients, the number and size of choledocholithiasis stones, the anatomy of the cystic duct and common bile duct, the surgical history of patients and local expertise.
Lujan, Henry J; Bisland, William B
Colonic gallstone ileus is an unusual cause of colonic obstruction. Management of these patients is not standardized and can be challenging. As these patients are often ill and frail at presentation, surgical management needs to be individualized to decrease morbidity and mortality. We report a case that was managed by staged minimally invasive techniques with an excellent outcome.
Louis, Robert G.; Eisenberg, Amy; Barkhoudarian, Garni; Griffiths, Chester; Kelly, Daniel F.
Introduction Given advancements in endoscopic image quality, instrumentation, surgical navigation, skull base closure techniques, and anatomical understanding, the endonasal endoscopic approach has rapidly evolved into a widely utilized technique for removal of sellar and parasellar tumors. Although pituitary adenomas and Rathke cleft cysts constitute the majority of lesions removed via this route, craniopharyngiomas, clival chordomas, parasellar meningiomas, and other lesions are increasingly removed using this approach. Paralleling the evolution of the endonasal route to the parasellar region, the supraorbital eyebrow craniotomy has also been increasingly used as an alternative minimally invasive approach to reach this skull base region. Similar to the endonasal route, the supraorbital route has been greatly facilitated by advances in endoscopy, along with development of more refined, low-profile instrumentation and surgical navigation technology. Objectives This review, encompassing both transcranial and transsphenoidal routes, will recount the high points and advances that have made minimally invasive approaches to the sellar region possible, the evolution of these approaches, and their relative indications and technical nuances. Data Synthesis The literature is reviewed regarding the evolution of surgical approaches to the sellar region beginning with the earliest attempts and emphasizing technological advances, which have allowed the evolution of the modern technique. The surgical techniques for both endoscopic transsphenoidal and supraorbital approaches are described in detail. The relative indications for each approach are highlighted using case illustrations. Conclusions Although tremendous advances have been made in transitioning toward minimally invasive transcranial and transsphenoidal approaches to the sella, further work remains to be done. Together, the endonasal endoscopic and the supraorbital endoscope-assisted approaches are complementary
Nuño-Guzmán, Carlos M.; García-Carrasco, Daniel; Haro, Miguel; Arróniz-Jáuregui, José; Corona, Jorge L.; Salcido, Macario
Zenker's diverticulum (ZD), also known as cricopharyngeal, pharyngoesophageal or hypopharyngeal diverticulum, is a rare condition characterized by an acquired outpouching of the mucosal and submucosal layers originating from the pharyngoesophageal junction. This false and pulsion diverticulum occurs dorsally at the pharyngoesophageal wall between the inferior pharyngeal constrictor and the cricopharyngeus muscle. The pathophysiology of ZD involves altered compliance of the cricopharyngeus muscle and raised intrabolus pressure. Decreased compliance of the upper esophageal sphincter and failure to open completely for effective bolus clearance both lead to an increase in the hypopharyngeal pressure gradient. Different open surgical techniques and transoral endoscopic approaches have been described for the management of ZD, although there is no consensus about the best option. We report the case of a 61-year-old patient with a 7-year history of dysphagia and odynophagia for solid food, which after 2 months progressed to dysphagia for liquids and after 4 months to regurgitation 2–6 h after meals. The patient experienced a 12-kg weight loss. Diagnosis was established by esophagogram, which showed a diverticulum through the posterior pharyngeal wall, suggestive of a ZD. Esophagogastroduodenoscopy showed a pouch with erythematous mucosa. Under general anesthesia, diverticulectomy and myotomy were performed. After an uneventful recovery and adequate oral intake, the patient remains free of symptoms at 4 months of follow-up. PMID:25759630
(1) Infections following invasive endoscopy are rare and are usually of endogenous origin. Nevertheless, infections do occur due to inadequate cleaning and disinfection and the use of contaminated rinse water and processing equipment. (2) Rigid and flexible operative endoscopes and accessories should be thoroughly cleaned and preferably sterilized using properly validated processes. (3) Heat tolerant operative endoscopes and accessories should be sterilized using a vacuum assisted steam sterilizer. Use autoclavable instrument trays or containers to protect equipment during transit and processing. Small bench top sterilizers without vacuum assisted air removal are unsuitable for packaged and lumened devices. (4) Heat sensitive rigid and flexible endoscopes and accessories should preferably be sterilized using ethylene oxide, low temperature steam and formaldehyde (rigid only) or gas plasma (if appropriate). (5) If there are insufficient instruments or time to sterilize invasive endoscopes, or if no suitable method is available locally, they may be disinfected by immersion in 2% glutaraldehyde or a suitable alternative. An immersion time of at least 10 min should be adopted for glutaraldehyde. This is sufficient to inactivate most vegetative bacteria and viruses including HIV and hepatitis B virus (HBV). Longer contact times of 20 min or more may be necessary if a mycobacterial infection is known or suspected. At least 3 h immersion in glutaraldehyde is required to kill spores. (6) Glutaraldehyde is irritant and sensitizing to the skin, eyes and respiratory tract. Measures must be taken to ensure glutaraldehyde is used in a safe manner, i.e., total containment and/or extraction of harmful vapour and the provision of suitable personal protective equipment, i.e., gloves, apron and eye protection if splashing could occur. Health surveillance of staff is recommended and should include a pre-employment enquiry regarding asthma, skin and mucosal sensitivity problems and
Zhang, Tao; Zhang, Xiao-ming; Shen, Chen-yang; Zhang, Xue-min; Li, Qing-le
To summarize the vascular surgical strategies for chest and abdomen tumors with the invasion of great vessels. The clinical data were collected for 67 patients undergoing surgical treatment for tumors with the invasion of thoracic and abdominal great vessels at our hospital from January 2001 to June 2009. Then a retrospective analysis was performed. Among this dataset, there were 31 cases with only vessel wall invasion and 20 cases with only intravascular tumor thrombus. In the meanwhile, both the invasion of vascular walls and the formation of tumor thrombus were located in 16 patients. Among 67 operated patients, various strategies were used, including surgical adhesion lysis (n = 15), vascular resection direct suture (n = 24), artificial blood vessel patch (n = 10), pericardial patch (n = 3), artificial vascular replacement or bypass (n = 15) and cavity thrombectomy (n = 36). Cavity thrombectomy was performed under cardiopulmonary bypass for 8 patents with tumor invasion of right atrium. Among them, 58 patients received radical tumor resection while palliative resection was performed for 9 patients with a rate of complete resection at 86.6%. There was no intraoperative mortality with the perioperative death of 8 cases. A follow-up study was successfully conducted for 52 patients. And 7 patients were lost to follow-up. The overall follow-up rate was 88.1%. By June 2009, the survival period of this group of patients was as follows: 18 cases (> 48 months), 29 cases (> 24 months), 38 cases (> 12 months), 50 cases (> 6 months) and 2 cases (≤ 6 months). Among these patients, the major cause of mortality was tumor metastasis. The patients with kidney cancer showed the most favorable surgical outcomes. Managed by a variety of vascular surgical techniques, the patients with tumors involving major blood vessels may achieve an excellent success rate of tumor resection and a better postoperative quality-of-life.
Liu, Yi; Zhang, Cheng; Song, Mei; Liu, Ping; Zhang, Xian-Ying; Xiao, Bin
Adhesions between the auricle and retroauricular cranial wall and mastoid occur after burns to this area due to cicatricial contracture, leading to the distortion of the otocranial angle and obscuring the remnant auricle in the scar. A definition of cicatricial cryptotia was devised to describe the ear deformity after burn by the authors, and a novel surgical approach to cicatricial cryptotia was employed to reconstruct the auricle. A total of 33 ears in 26 adult patients were operated upon. As many as 19 cases of cicatricial cryptotia were unilateral, seven cases bilateral. The patients' age ranged from 19 to 31 years. Because of a lack of normal tissues surrounding the remnant ear, a periauricular cicatricial flap was designed to repair the helix and antihelix defect and a horizontal bifoliate skin flap for earlobe reconstruction. Two triangular cicatricial flaps located at the cephalic or caudal direction of the survival ear were used for shaping the otocranial angle and auriculotemporal sulci, combined with zoned transplantation of a full-thickness skin graft. All cicatricial flaps demonstrated nearly 100% survival and the take rate of transplanted skin grafts was approximately 95%. The main structures were visible and cosmetically acceptable; the otocranial angle and auriculotemporal sulci were acceptably restored. The function of wearing eye glasses or a mask was regained. The patients were followed up from 3 months to 6 years after surgery; the mean follow-up period was 3.2 years. The contour of the reconstructed auricle was maintained well, and the scar contracture was acceptable. Periauricular cicatricial flaps combined with skin grafting is a new approach to cicatricial cryptotia when auricle reconstruction after burn is limited by a scarcity of supple, elastic local skin and fascia. Copyright © 2013 Elsevier Ltd and ISBI. All rights reserved.
Lexow, G. Jakob; Kluge, Marcel; Majdani, Omid; Lenarz, Thomas; Rau, Thomas S.
Several research groups have proposed individual solutions for surgical assistance devices to perform minimally invasive cochlear implantation. The main challenge is the drilling of a small bore hole from the surface of the skull to the inner ear at submillimetric accuracy. Each group tested the accuracy of their device in their respective test bench or in a small number of temporal bone specimens. This complicates the comparison of the different approaches. Thus, a simple and inexpensive phantom based evaluation method is proposed which resembles clinical conditions. The method is based on half-skull phantoms made of bone-substitute material - optionally equipped with an artificial skin replica to include skin incision within the evaluation procedure. Anatomical structures of the temporal bone derived from segmentations using clinical imaging data are registered into a computer tomographic scan of the skull phantom and used for the planning of the drill trajectory. Drilling is performed with the respective device under conditions close to the intraoperative setting. Evaluation of accuracy can either be performed through postoperative imaging or by means of added targets on the inside of the skull model. Two different targets are proposed: simple reference marks only for measuring the accuracy of the device and a target containing a scala tympani model for evaluation of the complete workflow including the insertion of the electrode carrier. Experiments using the presented method take place under reproducible conditions thus allowing the comparison of the different approaches. In addition, artificial phantoms are easier to obtain and handle than human specimens.
Kuo, Chin-Hsing; Dai, Jian S; Dasgupta, Prokar
Kinematic design is a predominant phase in the design of robotic manipulators for minimally invasive surgery (MIS). However, an extensive overview of the kinematic design issues for MIS robots is not yet available to both mechanisms and robotics communities. Hundreds of archival reports and articles on robotic systems for MIS are reviewed and studied. In particular, the kinematic design considerations and mechanism development described in the literature for existing robots are focused on. The general kinematic design goals, design requirements, and design preferences for MIS robots are defined. An MIS-specialized mechanism, namely the remote center-of-motion (RCM) mechanism, is revisited and studied. Accordingly, based on the RCM mechanism types, a classification for MIS robots is provided. A comparison between eight different RCM types is given. Finally, several open challenges for the kinematic design of MIS robotic manipulators are discussed. This work provides a detailed survey of the kinematic design of MIS robots, addresses the research opportunity in MIS robots for kinematicians, and clarifies the kinematic point of view to MIS robots as a reference for the medical community. Copyright © 2012 John Wiley & Sons, Ltd.
Casale, Manuele; Capuano, Francesco; Sabatino, Lorenzo; Pace, Annalisa; Oliveto, Giuseppe; Vella, Paola; Moffa, Antonio; Salvinelli, Fabrizio
The management of parapharyngeal tumor is surgical, but the approach remains a challenge. Attention should be paid to avoidance intra-operative bleeding or cranial nerves damage. We report a case of a 67-year-old male complaining of left-ear fullness. A submucosal mass arising from the lateral wall of oropharynx on the left side was observed. Magnetic resonance imaging detected a mass arising from the parotid gland, in particular from the deep lobe, and a fine needle biopsy was compatible with "Warthin tumor." We performed a mini-invasive transoral approach under magnification, previous isolation of homolateral vessels. The decision on which surgical approach to be used is determined by site, size vascularity, and histology of the tumor. A literature review of the main surgical approaches was performed. We performed a combined transoral dissection under magnification with cervicotomic exposure of the neck vascular bundle allowing to dissect the tumor and manage any intra-operative complications.
Ha, Kevin; Dumpuri, Prashanth; Miga, Michael I.; Thompson, Reid C.
Often within the clinical environment of a neurosurgical brain tumor procedure, the surgeon is faced with the difficulty of orienting the patient's head to maximize the success of removing the pathology. Currently, these decisions are based on the experience of the surgeon. The primary objective of this paper is to demonstrate how a mathematical model can be used to evaluate the different patient positioning for tumor resection therapies. Specifically, therapies involving gravity-induced shift are used to demonstrate how a series of candidate approaches to the tumor can result in significantly different deformation behavior of brain tissue. To quantitatively assess the advantages and disadvantages of potential approaches, three different midline tumor locations were used to evaluate for the extent of tumor exposure and the magnitude of tensile stress at the brain-tumor interface, both of which are reliable indicators of the ease of resection. Preliminary results indicate that the lateral decubitus position is best suited for midline tumors.
Redondo-González, Luis-Miguel; Verrier-Hernández, Alberto
Introduction: Invasive aspergillosis of the paranasal sinuses is a rare disease and often misdiagnosed; however, its incidence has seen substancial growth over the past 2 decades. Definitive diagnosis of these lesions is based on histological examination and fungal culture. Case Report: An 81-year-old woman with a history of pain in the left maxillary region is presented. The diagnosis was invasive maxillary aspergillosis in immunocompetent patient, which was successfully treated with voriconazole and surgical debridement. Possible clinical manifestations, diagnostic imaging techniques and treatment used are discussed. Since the introduction of voriconazole, there have been several reports of patients with invasive aspergillosis who responded to treatment with this new antifungal agent. Conclusions: We report the importance of early diagnosis and selection of an appropriate antifungal agent to achieve a successful treatment. Key words:Invasive aspergillosis, voriconazole, fungal sinusitis, antifungal agent, open sinus surgery. PMID:25593673
Iacobone, Maurizio; Citton, Marilisa; Viel, Giovanni; Schiavone, Donatella; Torresan, Francesca
Endocrine tumors of thyroid, adrenal and parathyroid glands may be due to germline and inheritable mutations in 5-30% of patients. Medullary Thyroid Carcinoma, Pheochromocytoma, Paraganglioma, and Familial Primary Hyperparathyroidism are the most frequent entity. Hereditary endocrine tumors usually have a suggestive familial history; they occur earlier than sporadic variants, are multifocal, and have increased recurrence rates. They may be present as isolated variant or associated to other neoplasms in a syndromic setting. Genetic diagnosis should be preferably available before surgery because specific and targeted operative management are needed to achieve the best chance of cure. This review was aimed to discuss the surgical approaches for some of the most frequent hereditary endocrine tumors of thyroid, adrenal and parathyroid glands, focusing on medullary thyroid carcinoma, Pheochromocytoma, Paraganglioma and hereditary primary hyperparathyroidism (pHPT). Hereditary Medullary Thyroid Carcinoma is caused by RET mutations, and may be associated to Pheochromocytomas in MEN 2 setting. Total thyroidectomy and at least central neck nodal dissection is required. The availability of genetic screening allows prophylactic or early surgery in asymptomatic patients, with subsequent definitive cure. Hereditary Pheochromocytomas may be present in several syndromes (MEN 2, VHL, NF1, Paraganglioma/Pheochromocytoma syndrome); it may involve both adrenals; in these cases, a cortical sparing adrenalectomy should be performed to avoid permanent hypocorticosurrenalism. Hereditary Primary Hyperparathyroidism may frequently occur associated to MEN 1, MEN 2A, MEN 4, Hyperparathyroidism-Jaw Tumor Syndrome; it may involve all the parathyroid glands, requiring subtotal parathyroidectomy or total parathyroidectomy plus autotransplantation. In some cases, a selective parathyroidectomy might be performed.
Maggiori, Léon; Panis, Yves
For IBD surgical management, laparoscopic approach offers several theoretical advantages over the open approach. However, the frequent presence of adhesions from previous surgery and the high rate of inflammatory lesions have initially questioned its feasibility and safety. In the present review article, we will discuss the role of laparoscopic approach for IBD surgical management, along with its potential benefits as compared to the open approach.
Joos, Karen; Shah, Rohan; Shen, Jin
Purpose: Orbital tumors and pseudotumor cerebri are sometimes treated with surgical approaches. Our previous studies suggest that potentially endoscopy may be useful for minimally invasive orbital surgery. This study proposed to improve the approach technique for accessing the posterior orbital space via endoscopy, as well as assess visibility improvements with CO II insufflation to posterior orbital tissues. Methods: An inferior transconjunctival approach accessed the posterior orbital space in non-survival pigs. Various guidance tubes were compared to assess ability to guide the endoscope to the posterior orbit with the greatest ease and visibility. FEL energy application (6.1 μm, 2.7 +/- 0.5 mJ, 30 Hz, delivered via glass-hollow waveguide) was attempted via endoscopy. The effect of CO II gas insufflation was assessed by analyzing visibility of the stuctures before and after CO II application. Results: The posterior orbit was accessed via endoscopy in all except the first attempted eye. A beveled transparent butyrate tube provided the best guidance for the endoscope and an opaque metal tube provided the worst guidance. The optic nerve was encountered and FEL energy was applied with the butyrate tube in 8 orbits. Visibility was adequate without CO II insufflation, and did not improve with CO II. Conclusions: The posterior orbit was successfully accessed using endoscopy. The optic nerve was exposed and treated with FEL energy. CO II insufflation did not further enhance visibility in this study. Application of endoscopy for posterior orbital procedures is feasible, but extreme surgical care is required and further study with human cadaveric eyes is needed.
Arabagi, Veaceslav; Felfoul, Ouajdi; Gosline, Andrew H.; Wood, Robert J.; Dupont, Pierre E.
This paper presents 800-μm thick, biocompatible sensing skins composed of arrays of pressure sensors. The arrays can be configured to conform to the surface of medical instruments so as to act as disposable sensing skins. In particular, the fabrication of cylindrical geometries is considered here for use on endoscopes. The sensing technology is based on polydimethylsiloxane synthetic silicone encapsulated microchannels filled with a biocompatible salt-saturated glycerol solution, functioning as the conductive medium. A multi-layer manufacturing approach is introduced that enables stacking sensing microchannels, mechanical stress concentration features, and electrical routing via flexcircuits in a thickness of less than 1 mm. The proposed approach is inexpensive and does not require clean room tools or techniques. The mechanical stress concentration features are implemented using a patterned copper layer that serves to improve sensing range and sensitivity. Sensor performance is demonstrated experimentally using a sensing skin mounted on a neuroendoscope insertion cannula and is shown to outperform previously developed non-biocompatible sensors. PMID:27642266
Arabagi, Veaceslav; Felfoul, Ouajdi; Gosline, Andrew H; Wood, Robert J; Dupont, Pierre E
This paper presents 800-μm thick, biocompatible sensing skins composed of arrays of pressure sensors. The arrays can be configured to conform to the surface of medical instruments so as to act as disposable sensing skins. In particular, the fabrication of cylindrical geometries is considered here for use on endoscopes. The sensing technology is based on polydimethylsiloxane synthetic silicone encapsulated microchannels filled with a biocompatible salt-saturated glycerol solution, functioning as the conductive medium. A multi-layer manufacturing approach is introduced that enables stacking sensing microchannels, mechanical stress concentration features, and electrical routing via flexcircuits in a thickness of less than 1 mm. The proposed approach is inexpensive and does not require clean room tools or techniques. The mechanical stress concentration features are implemented using a patterned copper layer that serves to improve sensing range and sensitivity. Sensor performance is demonstrated experimentally using a sensing skin mounted on a neuroendoscope insertion cannula and is shown to outperform previously developed non-biocompatible sensors.
Cassetta, M; Pandolfi, S; Giansanti, M
Accelerating orthodontic tooth movement is a topical issue. Despite the different techniques described in the literature, the corticotomy is the only effective and safe means of accelerating orthodontic tooth movement. Although effective, the corticotomy presents significant postoperative discomfort. The aggressive nature of these particular methods, related to the elevation of mucoperiosteal flaps and to the length of the surgery, has resulted in reluctance to proceed with this technique among both patients and the dental community. To overcome the disadvantages of the corticotomy, this technical note describes an innovative, minimally invasive, flapless procedure combining piezoelectric surgical cortical micro-incisions with the use of a 3D Printed CAD/CAM surgical guide.
Sun, Jingyuan; Yan, Zhiyuan; Du, Zhijiang
Surgical robot with a remote center-of-motion (RCM) plays an important role in minimally invasive surgery (MIS) field. To make the mechanism has high flexibility and meet the demand of movements during processing of operation, an optimized RCM mechanism is proposed in this paper. Then, the kinematic performance and workspace are analyzed. Finally, a new optimization objective function is built by using the condition number index and the workspace index.
Weeden, Alyssa Marie; Degner, Daniel Alvin
The nasal cavity and sinuses may be exposed primarily via a dorsal or ventral surgical approach. Surgical planning involves the use of advanced imaging, such as computed tomography or MRI. Surgical treatment of lesions of the nasal cavity usually is limited to benign lesions or can also be used in combination with adjunctive therapy, such as radiation therapy. Extreme caution must be exercised with a dorsal approach to the nasal cavity to avoid complications of inadvertent penetration into the brain case. Gentle tissue handling and careful closure of the mucoperiosteum must be exercised following a ventral approach to minimize the risk of oronasal fistula formation.
The ecological impacts of alien species invasion are a major threat to global biodiversity. The increasing number of invasion events by alien species and the high cost and difficulty of eradicating invasive species once established require the development of new methods and tools for predicting the most susceptible areas to invasion. Invasive pollinators pose serious threats to biodiversity and human activity due to their close relationship with many plants (including crop species) and high potential competitiveness for resources with native pollinators. Although at an early stage of expansion, the bumblebee species Bombus terrestris is becoming a representative case of pollinator invasion at a global scale, particularly given its high velocity of invasive spread and the increasing number of reports of its impacts on native bees and crops in many countries. We present here a methodological framework of habitat suitability modeling that integrates new approaches for detecting habitats that are susceptible to Bombus terrestris invasion at a global scale. Our approach did not include reported invaded locations in the modeling procedure; instead, those locations were used exclusively to evaluate the accuracy of the models in predicting suitability over regions already invaded. Moreover, a new and more intuitive approach was developed to select the models and evaluate different algorithms based on their performance and predictive convergence. Finally, we present a comprehensive global map of susceptibility to Bombus terrestris invasion that highlights priority areas for monitoring. PMID:26882479
Acosta, André L; Giannini, Tereza C; Imperatriz-Fonseca, Vera L; Saraiva, Antonio M
The ecological impacts of alien species invasion are a major threat to global biodiversity. The increasing number of invasion events by alien species and the high cost and difficulty of eradicating invasive species once established require the development of new methods and tools for predicting the most susceptible areas to invasion. Invasive pollinators pose serious threats to biodiversity and human activity due to their close relationship with many plants (including crop species) and high potential competitiveness for resources with native pollinators. Although at an early stage of expansion, the bumblebee species Bombus terrestris is becoming a representative case of pollinator invasion at a global scale, particularly given its high velocity of invasive spread and the increasing number of reports of its impacts on native bees and crops in many countries. We present here a methodological framework of habitat suitability modeling that integrates new approaches for detecting habitats that are susceptible to Bombus terrestris invasion at a global scale. Our approach did not include reported invaded locations in the modeling procedure; instead, those locations were used exclusively to evaluate the accuracy of the models in predicting suitability over regions already invaded. Moreover, a new and more intuitive approach was developed to select the models and evaluate different algorithms based on their performance and predictive convergence. Finally, we present a comprehensive global map of susceptibility to Bombus terrestris invasion that highlights priority areas for monitoring.
Lensing, Forrester D; Abele, Travis A; Sivakumar, Walavan; Taussky, Philipp; Shah, Lubdha M; Salzman, Karen L
The anatomy of the pineal region is complex. Despite advances in surgical techniques since the first reported successful pineal region surgery in the early 20th century, pineal region surgery remains challenging owing to the proximity of deep cerebral veins and dorsal midbrain structures critical for vision. In this article, we review the relevant surgical anatomy of the pineal region and discuss historically important and current surgical approaches. We describe specific imaging features of pineal region masses that may affect surgical planning and review neoplastic and nonneoplastic masses that occur in the pineal region.
Jazini, Ehsan; Weir, Tristan; Nwodim, Emeka; Tannous, Oliver; Saifi, Comron; Caffes, Nicholas; Costales, Timothy; Koh, Eugene; Banagan, Kelley; Gelb, Daniel; Ludwig, Steven C
Complex sacral fractures with vertical and anterior pelvic ring instability treated with traditional fixation methods are associated with high rates of failure and poor clinical outcomes. Supplemental lumbopelvic fixation (LPF) has been applied for additional stability to help with fracture union. The study aimed to determine whether minimally invasive LPF provides reliable fracture stability and acceptable complication rates in cases of complex sacral fractures. This is a retrospective cohort study at a single level I trauma center. The sample includes 24 patients who underwent minimally invasive LPF for complex sacral fracture with or without associated pelvic ring injury. Reoperation for all causes, loss of fixation, surgical time, transfusion requirements, length of hospital stay, postoperative day at mobilization, and mortality were evaluated. Patient charts from 2008 to 2014 were reviewed. Of the 32 patients who underwent minimally invasive LPF for complex sacral fractures, 24 (12 male, 12 female) met all inclusion and exclusion criteria. Outcome measures were assessed with a retrospective chart review and radiographic review. The authors did not receive external funding for this study. Acute reoperation was 12%, and elective reoperation was 29%. Two (8%) patients returned to the operating room for infection, one (4.2%) required revision for instrumentation malposition, and seven (29%) underwent elective removal of instrumentation. No patient experienced failure of instrumentation or loss of correction. Average surgical time was 3.6 hours, blood loss was 180 mL, transfusion requirement was 2.1 units of packed red blood cells, and postoperative mobilization was on postoperative day 5. No mortalities occurred as a result of the minimally invasive LPF procedure. Compared with historic reports of open LPF, our results demonstrate reliable maintenance of reduction and acceptable complication rates with minimally invasive LPF for complexsacral fractures. The
Palamarchuk, V A
The possibilities and efficacy of performance of simultant operations for invasive thyroid gland cancer in initial neuropathic laryngeal stenosis and dysphonic syndrome, aimed at minimization of the residual volume of thyroid gland tissue and surgical laryngeal reinnervation, were studied. The results of laryngeal surgical reinnervation, in accordance to data of videolaryngoscopy, aerodynamical and spectral analysis of the voice, self estimation of the vocal disorders impact on the patients quality of life were analyzed. Postoperatively in all the patients the improvement of phonation and quality of life was noted. Primary neurorhaphia of recurrent laryngeal nerve secures restoration of normal or nearly normal talkative voice due to restoration of the tone and volume of m. cricoarytenoideus lateralis and m. thyroarytenoideus on the side of affection and may be effectively applied for correction of consequences of laryngeal neuropathic paralysis in surgical treatment of the thyroid gland cancer.
Aubry, K; Lerat, J; Herman, P; Guichard, J-P; Tran Ba Huy, P
We report a case of an eustachian tube melanoma treated by a double surgical approach. A 56-year-old man consulted for a recurrent left serous otitis media. CT-scan and MRI showed a lesion filling completely the middle ear, extending along the Eustachian tube up to the nasopharynx, with enhancement after injection. The biopsy of the lesion confirmed the diagnosis of malignant melanoma. After left internal carotid artery occlusion, the removal of the lesion was performed by a double surgical approach: combination of an endoscopic transnasal and a retroauricular approach. Radiotherapy was adjuvant therapy. Eustachian tube melanoma is a rare occurrence. Surgical treatment must be radical, what represents a challenge considering the localization; it can be obtained with the double surgical approach proposed in our case report.
Lühmann, Dagmar; Burkhardt-Hammer, Tatjana; Borowski, Cathleen; Raspe, Heiner
posterior approach are included. Methods In order to assess safety, efficacy and effectiveness of minimally-invasive procedures as well as their economic implications systematic reviews of the literature are performed. A comprehensive search strategy is composed to search 23 electronic databases, among them MEDLINE, EMBASE and the Cochrane Library. Methodological quality of systematic reviews, HTA reports and primary research is assessed using checklists of the German Scientific Working Group for Health Technology Assessment. Quality and transparency of cost analyses are documented using the quality and transparency catalogues of the working group. Study results are summarised in a qualitative manner. Due to the limited number and the low methodological quality of the studies it is not possible to conduct metaanalyses. In addition to the results of controlled trials results of recent case series are introduced and discussed. Results The evidence-base to assess safety, efficacy and effectiveness of minimally-invasive lumbar disc surgery procedures is rather limited: Percutaneous manual discectomy: Six case series (four after 1998) Automated percutaneous lumbar discectomy: Two RCT (one discontinued), twelve case series (one after 1998) Chemonucleolysis: Five RCT, five non-randomised controlled trials, eleven case series Percutaneous laserdiscectomy: One non-randomised controlled trial, 13 case series (eight after 1998) Endoscopic procedures: Three RCT, 21 case series (17 after 1998) There are two economic analyses each retrieved for chemonucleolysis and automated percutaneous discectomy as well as one cost-minimisation analysis comparing costs of an endoscopic procedure to costs for open discectomy. Among all minimally-invasive procedures chemonucleolysis is the only of which efficacy may be judged on the basis of results from high quality randomised controlled trials (RCT). Study results suggest that the procedure maybe (cost)effectively used as an intermediate therapeutical
Samuel, Soumi; Mistry, Freddy K; Chopra, Shilpa; Pillai, Ajay
Ameloblastoma occurs in a wide variety of forms. Various forms of ameloblastomas have various treatment modalities ranging from a conservative approach to surgical resection with reconstruction. We report a case of unicystic ameloblastoma with mural proliferation in a 17-year-old girl, who presented with a swelling in the lower left jaw associated with dull aching pain and was managed initially by a conservative approach followed by surgical enucleation on recurrence. PMID:25103487
Sorensen, Hayley L; Card, Carrie A; Malley, Mary T; Strzelecki, Jessica M
Child life specialists in surgical and perioperative programs use a systematic approach to provide continuous preparation for pediatric surgical patients. Within the context of family-centered care, all staff members share in the ongoing responsibility of minimizing stress and maximizing effective coping for children and their parents or caregivers. Multidisciplinary collaboration increases positive outcomes for pediatric patients and their families. Detailed descriptions of the procedures used at Children's Hospital Boston and a case study are discussed to exemplify the coping benefits of using a collaborative child life approach to provide continuous preparation for surgical patients.
Aranda-Narváez, José Manuel; González-Sánchez, Antonio Jesús; Montiel-Casado, Custodia; Sánchez-Pérez, Belinda; Jiménez-Mazure, Carolina; Valle-Carbajo, Marta; Santoyo-Santoyo, Julio
Presacral tumors are rare, but can comprise a great variety of histological types. Congenital tumors are the most common. Once the diagnosis is established, surgical resection is essential because of the potential for malignancy or infection. Previous biopsy is not necessary or may be even harmful. To decide the best surgical approach (abdominal, sacral or combined) an individual and multidisciplinary analysis must be carried out. We report three cases of cystic presacral masses in which a posterior approach (Kraske procedure) enabled complete resection, the only way to decrease local recurrence. All patients had a satisfactory recovery. A brief overview of retrorectal tumors is presented, focusing on classification, clinical presentation, diagnosis and surgical management.
Memeo, Riccardo; de'Angelis, Nicola; de Blasi, Vito; Cherkaoui, Zineb; Brunetti, Oronzo; Longo, Vito; Piardi, Tullio; Sommacale, Daniele; Marescaux, Jacques; Mutter, Didier; Pessaux, Patrick
Hepatocellular carcinoma (HCC) is the sixth most common cancer worldwide, with an increasing diffusion in Europe and the United States. The management of such a cancer is continuously progressing and the objective of this paper is to evaluate innovation in the surgical treatment of HCC. In this review, we will analyze the modern concept of preoperative management, the role of laparoscopic and robotic surgery, the intrao-perative use of three dimensional models and augme-nted reality, as well as the potential application of fluore-scence.
Memeo, Riccardo; de’Angelis, Nicola; de Blasi, Vito; Cherkaoui, Zineb; Brunetti, Oronzo; Longo, Vito; Piardi, Tullio; Sommacale, Daniele; Marescaux, Jacques; Mutter, Didier; Pessaux, Patrick
Hepatocellular carcinoma (HCC) is the sixth most common cancer worldwide, with an increasing diffusion in Europe and the United States. The management of such a cancer is continuously progressing and the objective of this paper is to evaluate innovation in the surgical treatment of HCC. In this review, we will analyze the modern concept of preoperative management, the role of laparoscopic and robotic surgery, the intrao-perative use of three dimensional models and augme-nted reality, as well as the potential application of fluore-scence. PMID:27168871
Neuman, Brian J; Ailon, Tamir; Scheer, Justin K; Klineberg, Eric; Sciubba, Daniel M; Jain, Amit; Zebala, Lukas P; Passias, Peter G; Daniels, Alan H; Burton, Douglas C; Protopsaltis, Themi S; Hamilton, D Kojo; Ames, Christopher P
A surgical invasiveness index (SII) has been validated in general spine procedures but not adult spinal deformity (ASD). To assess the ability of the SII to determine the invasiveness of ASD surgery and to create and validate a novel ASD index incorporating deformity-specific factors, which could serve as a standardized metric to compare outcomes and risk stratification of different ASD procedures for a given deformity. Four hundred sixty-four patients who underwent ASD surgery between 2009 and 2012 were identified in 2 multicenter prospective registries. Multivariable models of estimated blood loss (EBL) and operative time were created using deformity-specific factors. Beta coefficients derived from these models were used to attribute points to each component. Scoring was iteratively refined to determine the R 2 value of multivariate models of EBL and operative time using adult spinal deformity-surgical (ASD-S) as an independent variable. Similarly, we determined weighting of postoperative changes in radiographical parameters, which were incorporated into another index (adult spinal deformity-surgical and radiographical [ASD-SR]). The ability of these models to predict surgical invasiveness was assessed in a validation cohort. Each index was a significant, independent predictor of EBL and operative time ( P < .001). On multivariate analysis, ASD-S and ASD-SR explained more variability in EBL and operative time than did the SII ( P < .001). The ASD-SR explained 21% of the variation in EBL and 10% of the variation in operative time, whereas the SII explained 17% and 3.2%, respectively. The ASD-SR, which incorporates deformity-specific components, more accurately predicts the magnitude of ASD surgery than does the SII.
Seino, Yutomo; Allen, Jacqui E
Aging may affect the voice through either physiological or pathological changes. Globally society is aging and the working lifetime is extending. Increasing numbers of elderly will present with voice issues. This review examines current thinking regarding surgical treatment of the aging voice. The mainstay of surgical treatment remains injection laryngoplasty and medialization thyroplasty. In-office injection laryngoplasty is increasingly common. Data suggest that patients with vocal fold atrophy do not achieve as much benefit from augmentation treatments as other causes of glottal incompetence. In addition the timing of injection laryngoplasty may influence the rate of subsequent medialization thyroplasty. Disease-specific treatments can provide some benefit to voice, such as deep brain stimulation in Parkinson's disease. Novel treatments including growth factor therapy are entering clinical practice and will provide new options for the clinician in future. Voice disorders affect approximately 20% of the elderly population. Causes include neurologic, malignant, iatrogenic and benign vocal fold disorders. These should be ruled out before accepting dysphonia is age-related in nature. Treatment should be specific to recognized vocal disorders but may also address physiologic changes in the glottis. Injection laryngoplasty and thyroplasty remain effective options for treating glottal incompetence but novel therapies are showing promising results.
Aita, Marcio Aurélio; Mos, Paulo Augusto Castro; de Paula Cardoso Marques Leite, Gisele; Alves, Rafael Saleme; Credídio, Marcos Vinicius; da Costa, Eduardo Fernandes
Objective To analyze the clinical-functional parameters and quality of life of patients undergoing minimally invasive surgical treatment for extra-articular fractures of the proximal phalanx, using an intramedullary screw (Acutrak®). Methods Between January 2011 and September 2014, a prospective study was conducted on 41 patients (48 fingers) with unstable extra-articular fractures of the proximal phalanx, who underwent minimally invasive surgical treatment using an intramedullary screw (Acutrak®). These patients were evaluated 12 months after the surgery by means of the DASH quality-of-life questionnaire, VAS pain scale, measurement of range of motion (ROM, in degrees) and radiographic assessment. Results All the patients achieved adequate reduction and consolidation of their fractures. There were statistically significant improvements in quality of life on the DASH scale, pain on the VAS scale and range of motion. Conclusion The minimally invasive technique for treating unstable extra-articular fractures of the proximal phalanx using an intramedullary screw (Acutrak®) is effective and safe, and it presents satisfactory clinical-functional results. PMID:26962488
Rajan, Ginu; Callaghan, Dean; Semenova, Yuliya; Farrell, Gerald
This paper presents the concept of implementing miniature temperature insensitive optical fiber sensors into minimally invasive surgical devices such as graspers, staplers and scissors. The lack of temperature insensitive and accurate force feedback end effectors make the current minimally invasive surgeries (MIS) less effective especially in the area of electrosurgery. The failure to provide accurate force feedback information reduces the user's sense of immersion in the operating procedure. In this paper we present fiber sensors based on photonic crystal fibers (PCF) for force feedback from the end effectors. Two types of miniature temperature insensitive PCF sensors can be implemented for MIS applications; a Fabry-Perot interferometric sensor based on hollow core PCF and a tapered modal interferometric sensor based on a solid core PCF. A concept for interrogating these sensors effectively at minimal cost is also presented. The integration of sensors onto the end effectors is also important as one has to find an optimum position for maximum strain/force transfer to the fiber sensor without interfering with the operation of the surgical tool. We have also presented the methodology for incorporating the sensors into surgical end-effectors in this paper.
Slaughter, Katrina N; Frumovitz, Michael; Schmeler, Kathleen M; Nick, Alpa M; Fleming, Nicole D; dos Reis, Ricardo; Munsell, Mark F; Westin, Shannon N; Soliman, Pamela T; Ramirez, Pedro T
Recent literature in ovarian cancer suggests differences in surgical outcomes depending on operative start time. We sought to examine the effects of operative start time on surgical outcomes for patients undergoing minimally invasive surgery for endometrial cancer. A retrospective review was conducted of patients undergoing minimally invasive surgery for endometrial cancer at a single institution between 2000 and 2011. Surgical and oncologic outcomes were compared between patients with an operative start time before noon and those with a surgical start time after noon. A total of 380 patients were included in the study (245 with start times before noon and 135 with start times after noon). There was no difference in age (p=0.57), number of prior surgeries (p=0.28), medical comorbidities (p=0.19), or surgical complexity of the case (p=0.43). Patients with surgery starting before noon had lower median BMI than those beginning after noon, 31.2 vs. 35.3 respectively (p=0.01). No significant differences were observed for intraoperative complications (4.4% of patients after noon vs. 3.7% of patients before noon, p=0.79), estimated blood loss (median 100 cc vs. 100 cc, p=0.75), blood transfusion rates (7.4% vs. 8.2%, p=0.85), and conversion to laparotomy (12.6% vs. 7.4%, p=0.10). There was no difference in operative times between the two groups (198 min vs. 216.5 min, p=0.10). There was no association between operative start time and postoperative non-infectious complications (11.9% vs. 11.0%, p=0.87), or postoperative infections (17.8% vs. 12.3%, p=0.78). Length of hospital stay was longer for surgeries starting after noon (median 2 days vs. 1 day, p=0.005). No differences were observed in rates of cancer recurrence (12.6% vs. 8.8%, p=0.39), recurrence-free survival (p=0.97), or overall survival (p=0.94). Our results indicate equivalent surgical outcomes and no increased risk of postoperative complications regardless of operative start time in minimally invasive
Okamoto, Kazuma; Kudo, Mikihiko; Shimizu, Hideyuki
Although minimally invasive cardiac surgery (MICS) via right minithoracotomy is attracting attention as a minimally invasive approach in cardiac surgery, it has not become a standard, routine approach for mitral valve repair. Although it has spread rapidly in Germany (43%) and USA (20.4%), the proportion of MICS in isolated mitral valve repair still comprises only 15.6% of mitral valve repair surgeries in Japan. For safe, assured introduction of MICS as a routine approach under quality control for good surgical and mid- and long-term results, surgeons experienced in mitral valve repair who perform at least 10 mitral valve repairs per year are necessary. A team approach with surgeons, anesthesiologists, perfusionists, and nurses who are highly motivated is also important.
Cochet, Anthony A; Bellin, Daniel A
A 42-year-old male admitted with a non-ST elevation myocardial infarction was referred for invasive angiographic assessment. Based on preprocedural assessment, the right radial artery approach was selected. Despite possessing none of the consensus risk factors for radial artery spasm, in addition to receiving standard arterial spasm prophylaxis and conscious sedation, the patient suffered very severe radial artery spasm with initial catheter placement, resulting in entrapment of a 5 Fr pigtail catheter within the left ventricle. After exhausting traditional methods for resolution of radial artery spasm, surgical intervention appeared to be the only remaining option for removal of the entrapped catheter. Prior to committing to surgery, use of an axillary nerve block to hinder sympathetic vascular tone was suggested and attempted. This intervention resulted in atraumatic catheter removal. We present a case of very severe radial artery spasm refractory to customary interventions, alleviated with a novel, minimally invasive technique, which spared surgical intervention.
Pesce, Vito; Speciale, Domenico; Sammarco, Giulio; Patella, Silvio; Spinarelli, Antonio; Patella, Vittorio
Osteoporotic fractures represent one of the most common cause of disability and one of the major voice in the health economic budget in many countries of the world. Fragility fractures are especially meta-epiphyseal fractures, in skeletal sites with particular biomechanic characteristic (hip, vertebrae), complex and with more fragments, with slow healing process (mineralization and remodeling) and co-morbidity. The healing of a fracture in osteoporotic bone passes through the normal stages and concludes with union of the fracture although the healing process is prolonged. Fractures in the elderly osteoporotic patients represent a challenge to the orthopaedic surgeons. Osteoporosis does not only increase the risk of fracture but also represents a problem in osteofixation of fractures in fracture treatment. The major technical problem that surgeons face, is the difficulty to obtain a stable fixation of an implant due to osteoporotic bone. The load transmitted at the bone-implant interface can often exceed the reduced strain tolerance of osteoporotic bone. In the treatment of osteoporotic fractures it is important to consider different aspects: general conditions of elderly patient and comorbidity, the reduced muscular and bone mass and the increased bone fragility, structural modifications as medullary expansion. The aim of surgical treatment is to obtain a stable fixation that reduces pain and permits an early mobilization. PMID:22461162
Metzlaff, S; Rosslenbroich, S; Forkel, P H; Schliemann, B; Arshad, H; Raschke, M; Petersen, W
This study was performed to compare the clinical results of a minimally invasive technique for acute acromioclavicular (AC) joint dislocation repair with the traditional hook plate fixation. Forty-four patients with an acute (within 2 weeks after trauma) complete AC joint separation (35 male, nine female; median age 36.2 years, range 18-56) underwent surgical repair with either a minimally invasive AC joint repair or a conventional hook plate. Functional outcome was evaluated using the Constant-Murley Score (CMS), the TAFT score and the AC joint instability score (ACJI). Radiographic evaluation was performed with bilateral anterior-posterior (a.p.) stress and Alexander views. All patients were available after a median follow-up of 32 months (range 24-51). There were no significant differences in the mean CMS, Taft score and the ACJI between the two groups. The radiological assessment revealed no significant difference in the coracoclavicular distance. In both groups, a slight loss of reduction was observed. Periarticular ossification was seen in 11 patients of the minimally invasive AC joint repair and eight patients of the hook plate group but this did not affect the final outcome. Hook plates were removed after a median interval of 11.9 weeks (range 10-13). Good clinical results can be achieved with both minimally invasive AC joint repair and hook plate fixation. However, in the hook plate group a second operation is mandatory for plate removal. III.
Mattes, Dietmar; Silajdzic, Edah; Mayer, Monika; Horn, Martin; Scheidbach, Daniel; Wackernagel, Werner; Langmann, Gerald; Wedrich, Andreas
The aim of this study was to investigate the use of surgical smoke-producing procedures such as laser ablation or electrosurgery in minimally invasive microendoscopic procedures. This study proposes a technical solution to efficiently remove surgical smoke from very small endoscopic cavities using microports as small as 20 G (0.9 mm) in diameter. The experimental laboratory study used small, rigid, transparent plastic cavity models connected with tubes and pressure sensors to establish an endoscopic in vitro laboratory model. A Kalium-Titanyl-Phosphate (KTP) laser with a 0.5-mm fiber optic probe was used to produce smoke from bovine scleral tissue in the cavity. Endoscopic gas insufflation into the model was generated by pressurized air and a microvalve. A laboratory vacuum pump provided smoke and gas suction via a microvalve. A self-built control and steering system was utilized to control intracavital pressure during experimental insufflation and suction. Problems related to smoke-generating processes, such as laser vaporization or electrocautery, in small closed cavities were first analyzed. A theoretical and mechatronic laboratory model was established and tested. Intracavital pressure and gas flow were measured first without and then with smoke generation. A new construction design for the suction tube was proposed due to rapid obstruction by smoke particles. Surgical smoke evacuation from endoscopic cavities that are as small as 2 cm in diameter via minimally invasive ports as small as 20 G (0.9 mm) in diameter may be safe and efficient if sufficient gas exchange is provided during smoke generation by laser or electrosurgical instruments. However, maintaining a low and constant pressure in the cavity during gas exchange and adopting a special construction design for the suction tube are essential to provide an excellent view during the surgical maneuver and to minimize potential toxic side effects of the smoke.
The goal of haemodynamic care is to ensure adequate organ blood flow and oxygen supply. Clinical signs of organ perfusion have limited value in estimation of tissue perfusion, but invasive haemodynamic monitoring is needed to gain information of the underlying pathological condition and to guide oxygen delivery and haemodynamic therapy. Many of the available haemodynamic measurements involve pulmonary artery (PA) catheterization. Pressure measurements from PA catheters require meticulous attention to the dynamic properties of the transducer-pressure line system and appreciation of pressure variation owing to respiration. New techniques of continuous measurement of mixed venous oxygen saturation and cardiac output provide valuable trend data, allowing immediate diagnosis and treatment of pathological changes. Fast-response thermistor PA catheters are useful tools for estimating right ventricular function. Although clinicians generally regard PA-catheter data as a valuable therapy guide, few studies showing the beneficial influence on overall outcome have been carried out, and some studies have reported suboptimal understanding and utilization of these data. Transoesophageal echocardiography (TEE) is also a valuable monitor of left ventricular systolic and diastolic function and myocardial ischaemia in anaesthetized patients and in intensive care settings, but it requires a trained operator and is time-consuming. Continuously displayed TEE data, obtainable with automatic border detection, will make TEE even more useful in the near future. More effective monitors of perfusion and oxygenation of individual organs are needed. Less invasive techniques are also constantly sought. Combining data from several noninvasive monitors, including measurements of pulse oximetric O2 saturation, transthoracic impedance cardiac output and transcutaneous oxygen tension, has been reported to reflect closely changes obtained with more invasive monitoring.
Onen, Mehmet R.; Simsek, Mehmet; Naderi, Sait
Objective: To review the diagnoses and surgical approach characteristics of giant spinal schwannomas (GSS) patients. Methods: We reviewed the preoperative and postoperative radiological and clinical data, and the surgical aspects of 18 GSS patients who underwent surgery in the Department of Neurosurgery, Umraniye Teaching Hospital and Research State Hospital, Istanbul, Turkey between January 2008 and December 2013. Results: There were 15 (83.3%) female and 3 (16.6%) male patients. The age range was 16-70 years (average: 45.8). Average symptom duration was 1.5 months: (range: 1-48). There was local pain in 15 cases, and radicular pain in 6 cases. The GSSs were most frequently located in the lumbosacral area (11 cases, 61.1%). An extraforaminal surgical approach was employed in 7 cases, a posterior approach was employed in 6 cases, a combined anterior transabdominal and posterior approach was employed in 2 cases, a combined posterior and extraforaminal approach was employed in 2 cases, and a retroperitoneal approach was applied in one case. The tumors were completely excised in all cases. The mean follow-up period was 38.5 months (range: 20-68). Conclusion: Giant spinal schwannomas exhibit unique diagnostic and surgical factors. The selection of an appropriate approach significantly influences the success of the treatment. PMID:26818164
Gesell, Mark W; Tria, Alfred J
Unicondylar arthroplasty of the knee has seen a resurgence of interest in the United States. The principles of unicondylar arthroplasty of the knee are different from those for total knee arthroplasty, allowing replacement of only the affected joint compartment with less bone loss. Minimally invasive surgery allows for less soft tissue dissection with the potential for less morbidity. The key question is: will the changes associated with the minimally invasive surgery procedure improve the clinical results of the standard unicondylar arthroplasty of the knee or will the changes make the procedure too difficult and lead to an increasing failure rate? This study reviews the surgical technique and presents the 2 to 4 year results of the minimally invasive unicondylar arthroplasty of the knee 47 knees in 41 patients. The average range of motion increased from 121 degrees -132 degrees . The Knee Society pain score improved from 45-80 and the function score improved from 47-78. Only one knee has been revised. With proper patient selection, minimally invasive unicondylar arthroplasty of the knee allows for results that are at least equal to those of the standard open procedure at 2 to 4 years after the surgery.
Garcia Y Sanchez, J M; Davila Torres, J; Pacheco Rubio, G; Gómez Rodríguez, C L
The temporomandibular joint (TMJ) is anatomically complex; with its close proximity to neurovascular structures, including the facial nerve that gives a high degree of difficulty during surgical exposure. When the first description on TMJ surgery by Orlow in 1913 was published it gave an account describing the basic retroauricular, preauricular, endoaural and submandibular approaches, on treatment of articular pathologies as used today. The proposed study of the 'Bat Wing' approach, first described in 1993 by Garcia y Sanchez J.M. as a surgical alternative, offers great advantages is that it avoids the section of the ear canal and provides a wide surgical field. The management of the proposed technique has wide application with multiple joints addressed, achieving major objectives such as avoiding facial nerve damage, as well as avoiding the section of the external auditory canal with an optimum visibility of the operative field. The Department of Maxillofacial Surgery National Medical Center XXI Century records over a period of approximately 18 months have completed twenty TMJ surgeries using the 'Bat Wing', approach. The bat wing approach is a surgical alternative that offers broad exposure of the surgical field in TMJ, it is effective and meets the goal of exposing the area to intervene safely, good visibility and access to the site to intervene. It perfectly fulfills the above described.
Comparing open and minimally invasive surgical procedures for oesophagectomy in the treatment of cancer: the ROMIO (Randomised Oesophagectomy: Minimally Invasive or Open) feasibility study and pilot trial.
Metcalfe, Chris; Avery, Kerry; Berrisford, Richard; Barham, Paul; Noble, Sian M; Fernandez, Aida Moure; Hanna, George; Goldin, Robert; Elliott, Jackie; Wheatley, Timothy; Sanders, Grant; Hollowood, Andrew; Falk, Stephen; Titcomb, Dan; Streets, Christopher; Donovan, Jenny L; Blazeby, Jane M
BACKGROUND Localised oesophageal cancer can be curatively treated with surgery (oesophagectomy) but the procedure is complex with a risk of complications, negative effects on quality of life and a recovery period of 6-9 months. Minimal-access surgery may accelerate recovery. OBJECTIVES The ROMIO (Randomised Oesophagectomy: Minimally Invasive or Open) study aimed to establish the feasibility of, and methodology for, a definitive trial comparing minimally invasive and open surgery for oesophagectomy. Objectives were to quantify the number of eligible patients in a pilot trial; develop surgical manuals as the basis for quality assurance; standardise pathological processing; establish a method to blind patients to their allocation in the first week post surgery; identify measures of postsurgical outcome of importance to patients and clinicians; and establish the main cost differences between the surgical approaches. DESIGN Pilot parallel three-arm randomised controlled trial nested within feasibility work. SETTING Two UK NHS departments of upper gastrointestinal surgery. PARTICIPANTS Patients aged ≥ 18 years with histopathological evidence of oesophageal or oesophagogastric junctional adenocarcinoma, squamous cell cancer or high-grade dysplasia, referred for oesophagectomy or oesophagectomy following neoadjuvant chemo(radio)therapy. INTERVENTIONS Oesophagectomy, with patients randomised to open surgery, a hybrid open chest and minimally invasive abdomen or totally minimally invasive access. MAIN OUTCOME MEASURE The primary outcome measure for the pilot trial was the number of patients recruited per month, with the main trial considered feasible if at least 2.5 patients per month were recruited. RESULTS During 21 months of recruitment, 263 patients were assessed for eligibility; of these, 135 (51%) were found to be eligible and 104 (77%) agreed to participate, an average of five patients per month. In total, 41 patients were allocated to open surgery, 43 to the
Gronnier, C; Mariette, C
Lymph node invasion is an early event in the oesophageal carcinogenesis and represents the main prognostic factor in the curative setting. Even though the primacy of surgical resection has been challenged by the definitive radiochemotherapy for locally advanced squamous cell carcinomas of the oesophagus, surgery is now again a gold standard, in combination with (radio)chemotherapy, to improve locoregional disease control and long term survival. Surgery, especially lymphadenectomy, has consequently to be standardized through quality criteria. Lymph node stations invaded in œsophageal and junctional cancers, lymphadenectomy, and its impact on outcomes are discussed in this review based on the highest level of evidence published data.
Gassner, Holger G.; Schwan, Franziska; Schebesch, Karl-Michael
Minimally invasive approaches are becoming increasingly popular to access the anterior skull base. With interdisciplinary cooperation, in particular endonasal endoscopic approaches have seen an impressive expansion of indications over the past decades. The more recently described transorbital approaches represent minimally invasive alternatives with a differing spectrum of access corridors. The purpose of the present paper is to discuss transorbital approaches to the anterior skull base in the light of the current literature. The transorbital approaches allow excellent exposure of areas that are difficult to reach like the anterior and posterior wall of the frontal sinus; working angles may be more favorable and the paranasal sinus system can be preserved while exposing the skull base. Because of their minimal morbidity and the cosmetically excellent results, the transorbital approaches represent an important addition to established endonasal endoscopic and open approaches to the anterior skull base. Their execution requires an interdisciplinary team approach. PMID:27453759
Ben-Menachem, E; Revesz, D; Simon, B J; Silberstein, S
Vagus nerve stimulation (VNS) is effective in refractory epilepsy and depression and is being investigated in heart failure, headache, gastric motility disorders and asthma. The first VNS device required surgical implantation of electrodes and a stimulator. Adverse events (AEs) are generally associated with implantation or continuous on-off stimulation. Infection is the most serious implantation-associated AE. Bradycardia and asystole have also been described during implantation, as has vocal cord paresis, which can last up to 6 months and depends on surgical skill and experience. The most frequent stimulation-associated AEs include voice alteration, paresthesia, cough, headache, dyspnea, pharyngitis and pain, which may require a decrease in stimulation strength or intermittent or permanent device deactivation. Newer non-invasive VNS delivery systems do not require surgery and permit patient-administered stimulation on demand. These non-invasive VNS systems improve the safety and tolerability of VNS, making it more accessible and facilitating further investigations across a wider range of uses. © 2015 The Authors. European Journal of Neurology published by John Wiley & Sons Ltd on behalf of European Academy of Neurology.
Pagni, Giorgio; Rasperini, Giulio
Guided tissue regenerative (GTR) therapies are performed to regenerate the previously lost tooth supporting structure, thus maintaining the aesthetics and masticatory function of the available dentition. Alveolar ridge augmentation procedures (GBR) intend to regain the alveolar bone lost following tooth extraction and/or periodontal disease. Several biomaterials and surgical approaches have been proposed. In this paper we report biomaterials and surgical techniques used for periodontal and bone regenerative procedures. Particular attention will be adopted to highlight the biological basis for the different therapeutic approaches. PMID:23843792
Grigg, Cheri; Kinsey, Cara Bicking; Keckler, M. Shannon; Moulton-Meissner, Heather; Cooper, Emily; Soe, Minn M.; Noble-Wang, Judith; Longenberger, Allison; Walker, Shane R.; Miller, Jeffrey R.; Perz, Joseph F.; Perkins, Kiran M.
Invasive nontuberculous mycobacteria (NTM) infections may result from a previously unrecognized source of transmission, heater–cooler devices (HCDs) used during cardiac surgery. In July 2015, the Pennsylvania Department of Health notified the Centers for Disease Control and Prevention (CDC) about a cluster of NTM infections among cardiothoracic surgical patients at 1 hospital. We conducted a case–control study to identify exposures causing infection, examining 11 case-patients and 48 control-patients. Eight (73%) case-patients had a clinical specimen identified as Mycobacterium avium complex (MAC). HCD exposure was associated with increased odds of invasive NTM infection; laboratory testing identified patient isolates and HCD samples as closely related strains of M. chimaera, a MAC species. This investigation confirmed a large US outbreak of invasive MAC infections in a previously unaffected patient population and suggested transmission occurred by aerosolization from HCDs. Recommendations have been issued for enhanced surveillance to identify potential infections associated with HCDs and measures to mitigate transmission risk. PMID:28418290
Lyman, Meghan M; Grigg, Cheri; Kinsey, Cara Bicking; Keckler, M Shannon; Moulton-Meissner, Heather; Cooper, Emily; Soe, Minn M; Noble-Wang, Judith; Longenberger, Allison; Walker, Shane R; Miller, Jeffrey R; Perz, Joseph F; Perkins, Kiran M
Invasive nontuberculous mycobacteria (NTM) infections may result from a previously unrecognized source of transmission, heater-cooler devices (HCDs) used during cardiac surgery. In July 2015, the Pennsylvania Department of Health notified the Centers for Disease Control and Prevention (CDC) about a cluster of NTM infections among cardiothoracic surgical patients at 1 hospital. We conducted a case-control study to identify exposures causing infection, examining 11 case-patients and 48 control-patients. Eight (73%) case-patients had a clinical specimen identified as Mycobacterium avium complex (MAC). HCD exposure was associated with increased odds of invasive NTM infection; laboratory testing identified patient isolates and HCD samples as closely related strains of M. chimaera, a MAC species. This investigation confirmed a large US outbreak of invasive MAC infections in a previously unaffected patient population and suggested transmission occurred by aerosolization from HCDs. Recommendations have been issued for enhanced surveillance to identify potential infections associated with HCDs and measures to mitigate transmission risk.
Gu, Jiangning; Zhu, Yi; Qin, Kai; Zhan, Qian; Cheng, Dongfeng; Chen, Hao; Deng, Xiaxing; Shen, Baiyong; Peng, Chenghong
Background The most effective and radical treatment for pancreatic neuroendocrine tumors (PNETs) is surgical resection. Minimally invasive surgery has been increasingly used in pancreatectomy. Initial results in robotic distal pancreatectomy (RDP) have been encouraging. Nonetheless, data comparing outcomes of RDP with those of laparoscopic distal pancreatectomy (LDP) in treating PNETs are rare. The aim of this study was to compare the safety and efficacy of RDP and LDP for PNETs. Methods From September 2010 to January 2017, operative parameters and perioperative outcomes in an initial experience with 43 consecutive patients undergoing RDP were collected and compared with those in 31 patients undergoing LDP. Results Patients undergoing RDP and LDP demonstrated equivalent age, sex, ASA score, tumor location and tumor size. Operating time, length of resected pancreas, postoperative length of hospital stay and rates of conversion to open, pancreatic fistula, transfusion and reoperation were not statistically different. Patients in the RDP group were associated with significantly higher overall (79.1 vs. 48.4 %, P = 0.006) and Kimura spleen preservation rates (72.1 vs. 16.1%, P < 0.001) and had reduced risk of excessive blood loss (50 vs. 200mL, P < 0.001). Oncological outcomes in this series were superior for the RDP group with more lymph node harvest for G2 and G3 PNETs (3.5 vs. 2, P = 0.034). Conclusions Both RDP and LDP are efficacious and safe methods in treating PNETs located in the body or tail of pancreas. Robotic approach offers advantages with less intraoperative blood loss, higher spleen preservation rate and more lymph node harvest. It may be sensible to choose RDP for patients who fit indications for scheduled spleen preservation. PMID:28477012
Zenoni, Scott A; Arnoletti, J Pablo; de la Fuente, Sebastian G
Over the past decade, minimally invasive surgery has been introduced as a means to allow manipulation of delicate tissues with outstanding visualization of the surgical field. The purpose of this article is to review the available literature regarding early postoperative outcomes and the technical challenges of minimally invasive pancreaticoduodenectomy, including robotic techniques. Herein, we provide a retrospective review of all published studies in the English literature in which a minimally invasive pancreaticoduodenectomy was performed. The reported advantages of minimally invasive pancreaticoduodenectomy include better visualization, faster recovery time, and decreased length of hospital stay. In cases of robotic approaches, some of the proposed advantages include increased dexterity and a superior ergonomic position for the operating surgeon. To our knowledge, few studies have reported results comparable to open techniques in oncologic outcomes with regard to the number of lymph nodes resected and clear margins obtained. An increasing number of pancreatic resections are being performed using minimally invasive approaches. It remains to be determined if the benefits of this technique outweigh its longer operative times and higher costs.
Aranda-Narváez, José Manuel; González-Sánchez, Antonio Jesús; Montiel-Casado, Custodia; Sánchez-Pérez, Belinda; Jiménez-Mazure, Carolina; Valle-Carbajo, Marta; Santoyo-Santoyo, Julio
Presacral tumors are rare, but can comprise a great variety of histological types. Congenital tumors are the most common. Once the diagnosis is established, surgical resection is essential because of the potential for malignancy or infection. Previous biopsy is not necessary or may be even harmful. To decide the best surgical approach (abdominal, sacral or combined) an individual and multidisciplinary analysis must be carried out. We report three cases of cystic presacral masses in which a posterior approach (Kraske procedure) enabled complete resection, the only way to decrease local recurrence. All patients had a satisfactory recovery. A brief overview of retrorectal tumors is presented, focusing on classification, clinical presentation, diagnosis and surgical management. PMID:22655127
Lang, Nora; Pereira, Maria J; Lee, Yuhan; Friehs, Ingeborg; Vasilyev, Nikolay V; Feins, Eric N; Ablasser, Klemens; O'Cearbhaill, Eoin D; Xu, Chenjie; Fabozzo, Assunta; Padera, Robert; Wasserman, Steve; Freudenthal, Franz; Ferreira, Lino S; Langer, Robert; Karp, Jeffrey M; del Nido, Pedro J
Currently, there are no clinically approved surgical glues that are nontoxic, bind strongly to tissue, and work well within wet and highly dynamic environments within the body. This is especially relevant to minimally invasive surgery that is increasingly performed to reduce postoperative complications, recovery times, and patient discomfort. We describe the engineering of a bioinspired elastic and biocompatible hydrophobic light-activated adhesive (HLAA) that achieves a strong level of adhesion to wet tissue and is not compromised by preexposure to blood. The HLAA provided an on-demand hemostatic seal, within seconds of light application, when applied to high-pressure large blood vessels and cardiac wall defects in pigs. HLAA-coated patches attached to the interventricular septum in a beating porcine heart and resisted supraphysiologic pressures by remaining attached for 24 hours, which is relevant to intracardiac interventions in humans. The HLAA could be used for many cardiovascular and surgical applications, with immediate application in repair of vascular defects and surgical hemostasis.
Fu, Sue J.; Ho, Vanessa P.; Ginsberg, Jennifer; Perry, Yaron; Delaney, Conor P.; Linden, Philip A.
Background. Minimally invasive esophagectomy (MIE) techniques offer similar oncological and surgical outcomes to open methods. The effects of MIE on hospital costs are not well documented. Methods. We reviewed the electronic records of patients who underwent esophagectomy at a single academic institution between January 2012 and December 2014. Esophagectomy techniques were grouped into open, hybrid, MIE, and transhiatal (THE) esophagectomy. Univariate and multivariate analyses were performed to assess the impact of surgery on total hospital cost after esophagectomy. Results. 80 patients were identified: 11 THE, 11 open, 41 hybrid, and 17 MIE. Median total cost of the hospitalization was $31,375 and was similar between surgical technique groups. MIE was associated with higher intraoperative costs, but not total hospital cost. Multivariable analysis revealed that the presence of a complication, increased age, American Society of Anesthesiologists class IV (ASA4), and preoperative coronary artery disease (CAD) were associated with significantly increased cost. Conclusions. Despite the association of MIE with higher operation costs, the total hospital cost was not different between surgical technique groups. Postoperative complications and severe preoperative comorbidities are significant drivers of hospital cost associated with esophagectomy. Surgeons should choose technique based on clinical factors, rather than cost implications. PMID:28053785
Flory, S. Luke; Lorentz, Kimberly A.; Gordon, Doria R.; Sollenberger, Lynn E.
There is growing concern that non-native plants cultivated for bioenergy production might escape and result in harmful invasions in natural areas. Literature-derived assessment tools used to evaluate invasion risk are beneficial for screening, but cannot be used to assess novel cultivars or genotypes. Experimental approaches are needed to help quantify invasion risk but protocols for such tools are lacking. We review current methods for evaluating invasion risk and make recommendations for incremental tests from small-scale experiments to widespread, controlled introductions. First, local experiments should be performed to identify conditions that are favorable for germination, survival, and growth of candidate biofuel crops. Subsequently, experimental introductions in semi-natural areas can be used to assess factors important for establishment and performance such as disturbance, founder population size, and timing of introduction across variable habitats. Finally, to fully characterize invasion risk, experimental introductions should be conducted across the expected geographic range of cultivation over multiple years. Any field-based testing should be accompanied by safeguards and monitoring for early detection of spread. Despite the costs of conducting experimental tests of invasion risk, empirical screening will greatly improve our ability to determine if the benefits of a proposed biofuel species outweigh the projected risks of invasions.
Briski, Elizabeta; Allinger, Lisa E; Balcer, Mary; Cangelosi, Allegra; Fanberg, Lana; Markee, Tom P; Mays, Nicole; Polkinghorne, Christine N; Prihoda, Kelsey R; Reavie, Euan D; Regan, Deanna H; Reid, Donald M; Saillard, Heidi J; Schwerdt, Tyler; Schaefer, Heidi; TenEyck, Matthew; Wiley, Chris J; Bailey, Sarah A
Nonindigenous species (NIS) cause global biotic homogenization and extinctions, with commercial shipping being a leading vector for spread of aquatic NIS. To reduce transport of NIS by ships, regulations requiring ballast water exchange (BWE) have been implemented by numerous countries. BWE appears to effectively reduce risk for freshwater ports, but provides only moderate protection of marine ports. In the near future, ships may be required to undertake ballast water treatment (BWT) to meet numeric performance standards, and BWE may be phased out of use. However, there are concerns that BWT systems may not operate reliably in fresh or turbid water, or both. Consequently, it has been proposed that BWE could be used in combination with BWT to maximize the positive benefits of both management strategies for protection of freshwater ports. We compared the biological efficacy of "BWE plus BWT" against "BWT alone" at a ballast water treatment experimental test facility. Our comparative evaluation showed that even though BWT alone significantly reduced abundances of all tested organism groups except total heterotrophic bacteria, the BWE plus BWT strategy significantly reduced abundances for all groups and furthermore resulted in significantly lower abundances of most groups when compared to BWT alone. Our study clearly demonstrates potential benefits of combining BWE with BWT to reduce invasion risk of freshwater organisms transported in ships' ballast water, and it should be of interest to policy makers and environmental managers.
Bitetto, W V; Brown, N O
In no other area of veterinary surgery is the selection and performance of the appropriate surgical approach more important than neurosurgery. An adequate, atraumatic, and anatomically sound exposure is an important part of the battle in most orthopaedic procedures and is an even more important consideration when related to neurosurgery. The delicate and often unforgiving nature of the tissue involved dictates that careful planning and attention to detail become high priority concerns for the veterinary neurosurgeon. Most veterinarians recommend surgery for dogs with severe impairment, recurrent disease, and progressively deteriorating neurologic signs. Difficulties remain in the timing of surgery and in the choice of what surgical approach is most appropriate for the neurologically impaired dog in question. Surgical approaches in the cervical region include ventral and dorsal. In the thoracolumbar spine, either dorsal or dorsolateral approaches are used. In the lumbosacral region, a dorsal approach is preferred. The objective of this chapter will be to compare and contrast each of these approaches and to guide the reader in the selection of the appropriate approach for each patient.
Griessenauer, Christoph J.; McGrew, Benjamin; Matusz, Petru; De Caro, Raffaele; Loukas, Marios; Tubbs, R. Shane
Introduction Multiple surgical approaches and combinations thereof have been described to gain access to the jugular foramen. In an area laden with important neurovascular structures, care must be taken in choosing the best surgical approach for treatment of rare pathologies involving this region. Methods This manuscript provides a comprehensive review of the relevant anatomy along with an overview of the various approaches to the jugular foramen. In an attempt to simplify the various concepts, we propose a basic distinction into anterolateral and posterolateral approaches based on the main trajectory targeting the jugular foramen. Conclusion The anatomy surrounding the jugular foramen is exceedingly complex and requires in-depth understanding of skull base and head and neck relationships. PMID:27175322
Ibsen, Stuart; Tong, Ada; Schutt, Carolyn; Esener, Sadik; Chalasani, Sreekanth H.
A major challenge in neuroscience is to reliably activate individual neurons, particularly those in deeper brain regions. Current optogenetic approaches require invasive surgical procedures to deliver light of specific wavelengths to target cells to activate or silence them. Here, we demonstrate the use of low-pressure ultrasound as a non-invasive trigger to activate specific ultrasonically sensitized neurons in the nematode, Caenorhabditis elegans. We first show that wild-type animals are insensitive to low-pressure ultrasound and require gas-filled microbubbles to transduce the ultrasound wave. We find that neuron-specific misexpression of TRP-4, the pore-forming subunit of a mechanotransduction channel, sensitizes neurons to ultrasound stimulus, resulting in behavioural outputs. Furthermore, we use this approach to manipulate the function of sensory neurons and interneurons and identify a role for PVD sensory neurons in modifying locomotory behaviours. We suggest that this method can be broadly applied to manipulate cellular functions in vivo. PMID:26372413
Raygor, Kunal P; Than, Khoi D; Chou, Dean; Mummaneni, Praveen V
OBJECT Spinal tumor resection has historically been performed via open approaches, although minimally invasive approaches have recently been found to be effective in small cohort series. The authors compare surgical characteristics and clinical outcomes of surgery in patients undergoing mini-open and open approaches for intradural-extramedullary tumor resection. METHODS The authors retrospectively reviewed 65 consecutive intradural-extramedullary tumor resections performed at their institution from 2007 to 2014. Patients with cervical tumors or pathology demonstrating neurofibroma were excluded (n = 14). The nonparametric Mann-Whitney U-test and Pearson chi-square test were used to compare continuous and categorical variables, respectively. Statistical analyses were performed using SPSS, with significance set at p < 0.05. RESULTS Fifty-one thoracolumbar intradural-extramedullary tumor resections were included; 25 were performed via the minimally invasive transspinous approach. There were no statistically significant differences in age, sex, body mass index, preoperative American Spinal Injury Association (ASIA) score, preoperative symptom duration, American Society of Anesthesiologists (ASA) physical status class, tumor size, or tumor location. There was no statistically significant difference between groups with respect to the duration of the operation or extent of resection, but the mean estimated blood loss was significantly lower in the minimally invasive surgery (MIS) cohort (142 vs 320 ml, p < 0.05). In each group, the 2 most common tumor pathologies were schwannoma and meningioma. There were no statistically significant differences in length of hospitalization, ASIA score improvement, complication rate, or recurrence rate. The mean duration of follow-up was 2 years for the MIS group and 1.6 years for the open surgery group. CONCLUSIONS This is one of the largest comparisons of minimally invasive and open approaches to the resection of thoracolumbar
Robson, Caroline D; MacDougall, Robert D; Madsen, Joseph R; Warf, Benjamin C; Robertson, Richard L
Children with surgically treated hydrocephalus commonly undergo multiple neuroimaging studies. The purpose of this article is to share an experience with use of the as low as reasonably achievable (ALARA) principle to guide the imaging approach to these patients. A reasonably achievable strategy for minimizing ionizing radiation in patients with surgically treated hydrocephalus includes rapid-sequence MRI and judicious use of dose-optimized head CT. Rapid-sequence MRI is particularly useful in the care of patients who have undergone endoscopic third ventriculostomy.
Schnabl, Johannes; Wolf-Magele, Astrid; Pok, Stefan Marcel; Url, Christoph; Zorowka, Patrick; Sprinzl, Georg
In 2011, Med-El (Innsbruck, Austria) introduced a new cochlear implant system, designed to require a minimally invasive surgical technique and allow greater positional flexibility for its fixation on the skull. The Concerto Pin implant system is a good option for patients with thinner bone, such as children and elderly. The aim of this study was to investigate the implant’s stability in children using our minimally invasive surgical technique. This was a prospective, longitudinal study with a single-subject, repeated-examination design. Six children, implanted with a Concerto Pin using our minimally invasive surgical technique between October 2011 and September 2012, were assessed 1, 3 and 6 months after surgery. In each case, the implant remained in a stable position and no adverse events or problems with healing were observed at any time during the investigation. The minimally invasive technique and the method of implant fixation that bypass drilling a deep implant bed constitute a good option for patients with thinner bone, such as children. This clinical study shows the safety and stability of the Concerto Pin implant system using a minimally invasive surgical technique.
Souza, Juliana; Santos-Pinto, Lourdes; Pansani, Cyneu
ABSTRACT Aim: This paper reports two clinical cases in which the application of low-level laser therapy (LLLT) enhanced the postoperative symptoms after pediatric surgical procedures. Background: The uses of novel technologies allow more comfort to the patients and ensure a rapid procedure, and LLLT application has shown a positive effect in the prevention of discomfort after invasive procedures. Case description: Low-level laser therapy protocol was applied after surgical removal of supernumerary tooth and frenectomy resulting in less swallow and pain with no need of medication intake. Conclusion: The laser application was well accepted by both children and parents and showed a clinical efficiency in the follow-up examinations beyond the satisfactory quality of wound healing. Clinical significance: The LLLT approach is an excellent adjuvant therapy resource for delivery an optimal postoperative after surgical procedures in children. How to cite this article: Paschoal M, Souza J, Santos-Pinto L, Pansani C. Alternative Approach to the Management of Postoperative Pain after Pediatric Surgical Procedures. Int J Clin Pediatr Dent 2014;7(2):125-129. PMID:25356012
Casale, Manuele; Capuano, Francesco; Sabatino, Lorenzo; Pace, Annalisa; Oliveto, Giuseppe; Vella, Paola; Moffa, Antonio; Salvinelli, Fabrizio
The management of parapharyngeal tumor is surgical, but the approach remains a challenge. Attention should be paid to avoidance intra-operative bleeding or cranial nerves damage. We report a case of a 67-year-old male complaining of left-ear fullness. A submucosal mass arising from the lateral wall of oropharynx on the left side was observed. Magnetic resonance imaging detected a mass arising from the parotid gland, in particular from the deep lobe, and a fine needle biopsy was compatible with “Warthin tumor.” We performed a mini-invasive transoral approach under magnification, previous isolation of homolateral vessels. The decision on which surgical approach to be used is determined by site, size vascularity, and histology of the tumor. A literature review of the main surgical approaches was performed. We performed a combined transoral dissection under magnification with cervicotomic exposure of the neck vascular bundle allowing to dissect the tumor and manage any intra-operative complications. PMID:28228953
Park, Paul; La Marca, Frank
Surgery for scoliosis requires extensive exposure, resulting in significant tissue injury and longer recovery times. To minimize morbidity in scoliosis surgery, several studies have shown successful application of a combination of minimally invasive techniques; however, the extent of scoliosis treated has been modest. To achieve some of the benefits of minimally invasive surgery and yet treat curves of greater degree, we have used a combined approach, incorporating both open and minimally invasive techniques. We analyzed a prospectively acquired database in addition to reviewing electronic records of patients undergoing hybrid surgery for thoracolumbar scoliosis. Nine patients were identified. The minimally invasive portion involved the lumbar region in all cases. Pain was assessed by the visual analog scale and disability was measured by the Oswestry Disability Index. Mean preoperative scoliosis was 47.8 degrees, which was corrected to a mean 15.2 degrees. An average of 7.8 spinal levels was treated. Estimated blood loss averaged 1094.4 mL, and length of hospital stay averaged 7.2 days. Acute complications occurred in 2 patients. Longer term complications occurred in 2 patients, consisting of adjacent segment disease. The mean improvement in the visual analog scale score was 3.7 and the mean improvement on the Oswestry Disability Index was 30.5. Average follow-up was 29.2 months. The hybrid approach for the treatment of scoliosis results in acceptable radiographic and clinical outcomes. Complications did not appear increased compared with those expected with scoliosis surgery. Although decreased adjacent tissue injury was achieved with the minimally invasive component of the procedure, a larger comparative study is required to determine magnitude of this benefit.
Stieger, C; Caversaccio, M; Arnold, A; Zheng, G; Salzmann, J; Widmer, D; Gerber, N; Thurner, M; Nauer, C; Mussard, Y; Kompis, M; Nolte, L P; Häusler, R; Weber, S
To present the auditory implant manipulator, a navigation-controlled mechanical and electronic system which enables minimally invasive ('keyhole') transmastoid access to the tympanic cavity. The auditory implant manipulator is a miniaturised robotic system with five axes of movement and an integrated drill. It can be mounted on the operating table. We evaluated the surgical work field provided by the system, and the work sequence involved, using an anatomical whole head specimen. The work field provided by the auditory implant manipulator is considerably greater than required for conventional mastoidectomy. The work sequence for a keyhole procedure included pre-operative planning, arrangement of equipment, the procedure itself and post-operative analysis. Although system improvements are necessary, our preliminary results indicate that the auditory implant manipulator has the potential to perform keyhole insertion of implantable hearing devices.
Kania, Romain; Kania, Romain; Hammami, Hassene; Vérillaud, Benjamin; Blancal, Jean-Philippe; Sauvaget, Elisabeth; Tran, Hugo; Leclerc, Nicolas; Altabaa, Khaled; Herman, Philippe; Pons, Yoann
The objectives of this study were first to show principles of the minimally invasive video-assisted thyroidectomy (MIVAT), based on a video highlighting critical steps, and second to discuss tips and pearls to assist surgical teams that would like to start using this technique. Based on a video, we described tips and pearls of a MIVAT. MIVAT includes 5 main steps: (1) skin incision and identification of the common carotid artery, (2) dissection and ligation of the upper pedicle, (3) identification of the inferior laryngeal nerve and parathyroid glands, (4) isthmectomy and lobe extraction, and (5) closure. Coordination between the surgeon and the 2 assistants is of paramount importance for the performance of MIVAT. Appropriate material is also required. The magnification and tissue contrast emphasizes the identification of the vessels, the superior and inferior laryngeal nerves, and parathyroid glands, on a large-view screen.
Eslami, Sohrab; Fischer, Gregory S; Song, Sang-Eun; Tokuda, Junichi; Hata, Nobuhiko; Tempany, Clare M; Iordachita, Iulian
This paper undertakes the modular design and development of a minimally invasive surgical manipulator for MRI-guided transperineal prostate interventions. Severe constraints for the MRI-compatibility to hold the minimum artifact on the image quality and dimensions restraint of the bore scanner shadow the design procedure. Regarding the constructive design, the manipulator kinematics has been optimized and the effective analytical needle workspace is developed and followed by proposing the workflow for the manual needle insertion. A study of the finite element analysis is established and utilized to improve the mechanism weaknesses under some inevitable external forces to ensure the minimum structure deformation. The procedure for attaching a sterile plastic drape on the robot manipulator is discussed. The introduced robotic manipulator herein is aimed for the clinically prostate biopsy and brachytherapy applications.
Eslami, Sohrab; Fischer, Gregory S.; Song, Sang-Eun; Tokuda, Junichi; Hata, Nobuhiko; Tempany, Clare M.; Iordachita, Iulian
This paper undertakes the modular design and development of a minimally invasive surgical manipulator for MRI-guided transperineal prostate interventions. Severe constraints for the MRI-compatibility to hold the minimum artifact on the image quality and dimensions restraint of the bore scanner shadow the design procedure. Regarding the constructive design, the manipulator kinematics has been optimized and the effective analytical needle workspace is developed and followed by proposing the workflow for the manual needle insertion. A study of the finite element analysis is established and utilized to improve the mechanism weaknesses under some inevitable external forces to ensure the minimum structure deformation. The procedure for attaching a sterile plastic drape on the robot manipulator is discussed. The introduced robotic manipulator herein is aimed for the clinically prostate biopsy and brachytherapy applications. PMID:24683502
Wang, Wei; Li, Jianmin; Wang, Shuxin; Su, He; Jiang, Xueming
Robot-assisted minimally invasive surgery has shown tremendous advances over the traditional technique. However, currently commercialized systems are large and complicated, which vastly raises the system cost and operation room requirements. A MIS robot named 'MicroHand' was developed over the past few years. The basic principle and the key technologies are analyzed in this paper. Comparison between the proposed robot and the da Vinci system is also presented. Finally, animal experiments were carried out to test the performance of MicroHand. Fifteen animal experiments were carried out from July 2013 to December 2013. All animal experiments were finished successfully. The proposed design method is an effective way to resolve the drawbacks of previous generations of the da Vinci surgical system. The animal experiment results confirmed the feasibility of the design. Copyright © 2015 John Wiley & Sons, Ltd.
Rajan, Ginu; Mathews, Sunish; Callaghan, Dean; Farrell, Gerald; Peng, Gang-Ding
A feasibility study on using polymer fiber Bragg sensors (PFBG) for providing force feedback to minimally invasive surgical devices is carried out. For this purpose a 3 mm long PFBG is fabricated and characterized for strain and temperature sensitivities. The PFBG sensor is then integrated onto a commercial laparoscopic clip applicator which is used as a proof of concept device. The force characterization of the clip applicator is carried out, with a replica setup which simulates the clip forming process of the device. An original clip is then formed without and with synthetic tissue samples of different hardness. The replica device force profile and original clip forming force profile follows the same pattern and thus the calibration data can be used to calculate the original force exerting on the tissues which can help in optimizing the clip formation process or can be used for providing force feedback capability to the device.
Hayashi, Keiko; Kosaka, Yoshimasa; Sengoku, Norihiko; Enomoto, Takumo; Kajita, Sabine; Kuranami, Masaru; Watanabe, Masahiko
Patient 1 was a 63-year-old woman whose chief complaint was a mass in the left breast. Physical examination revealed an inverted left nipple, a very large mass on the anterior aspect of the sternum, and erythema. Because the tumor had directly invaded the sternum, T4cN3M0, stage IIIC breast cancer was diagnosed. The patient preoperatively received chemotherapy with 6 courses of FEC100 (5-fluorouracil, epirubicin, and cyclophosphamide) and 5 courses of nanoparticle albumin -bound paclitaxel (260 mg/m2), which enabled a partial response. Patient 2 was an 83-year-old woman whose chief complaint was a mass in the upper internal and external quadrants of the right breast measuring 20×15 cm and erythema. The mass was accompanied by enlarged right axillary lymph nodes(T4bN1M0, stage IIIB breast cancer). Both patients underwent core needle biopsy of the skin and breast masses. They were both diagnosed with invasive, lobular, triple-negative breast cancer (estrogen receptor negative, progesterone receptor negative, human epidermal growth factor receptor 2 negative). The surgical resection line was drawn to include the extensive skin invasion, and mastectomy and axillary dissection were performed. Skin grafting was scheduled but the retromammary space on the healthy side was dissected to the anterior border of the latissimus dorsi muscle, and the skin of the healthy side was used to cover the defect on the affected side. Consequently, the pendulous breast on the healthy side was elevated. This surgical technique provided an excellent aesthetic outcome without any skin problems, because autologous skin was used to fill the defect. Radiotherapy could subsequently be administered as scheduled. This procedure may be useful for elderly patients.
Mandel, Mauricio; Tutihashi, Rafael; Mandel, Suzana Abramovicz; Teixeira, Manoel Jacobsen; Figueiredo, Eberval Gadelha
Although recent technological advances have led to successful endovascular treatment, middle cerebral artery (MCA) aneurysms are still prone to surgery. Because minimally invasive options are limited and possess several functional and cosmetic drawbacks, a transpalpebral approach is proposed as a new alternative. To describe and assess surgical results of the minimally invasive transpalpebral approach in patients with MCA aneurysms. The data of 25 patients with unruptured MCA aneurysms from 2013 to 2016 were included in a cohort prospective database. We describe modifications of the approach and technique for MCA aneurysm clipping, in a step-by-step manner. The outcome was based on complications, procedural morbidity and mortality, and clinical and angiographic outcomes. All procedures were successfully performed in a standardized way, and no major complications related to the new approach were observed. Twenty-two patients were discharged the day after surgery (88%). The majority of aneurysms were 5 to 6 mm in diameter (mean, 7 mm; range 4-21 mm). All patients underwent postoperative angiographic control, which showed no significant residual neck. A 3-mo follow-up was sufficient to show no visible scars with excellent cosmetic results. The mean duration of follow-up was 16 mo. The transpalpebral approach comes as a minimally invasive, safe, definitive, and cosmetically adequate solution for MCA aneurysms at the present time.
Adawi, Mohammed M; Abdelbaky, Abdelaal M
Many approaches were recommended for surgical treatment of orbital lesions via either transorbital or transcranial routes. The frontolateral craniotomy through eyebrow skin incision (lateral supraorbital approach) is a combined cranio-orbital approach that could be used in different orbital lesions. To evaluate the efficacy and safety of the lateral supraorbital approach for resection of orbital lesions. Ten patients with different orbital lesions were treated by this minimally invasive technique. The technique is described in details. The postoperative outcome was evaluated with casting light on the specific parameters related to this approach. This study included 6 females and 4 males, ranging in age from 2 years to 65 years with mean age of 37.3 years. Proptosis was the most common presenting complaint. Six patients were operated on via the right supraorbital approach, and 4 patients via the left supraorbital approach. Various pathological lesions were treated. The excision was total in 7 patients, subtotal in 1 patient, and partial in 2 patients. Two patients suffered transient supraorbital hypothesia, 1 patient showed temporary superficial wound infection with CSF leak and 1 patient died within 6 months. The lateral supraorbital approach is a minimally invasive approach that provides excellent exposure of the superior, lateral, and medial orbit, as well as the orbital apex. Copyright © 2015 Elsevier Inc. All rights reserved.
Penchyna-Grub, J; Alvarez-Neri, H; Blanco-Rodríguez, G; Porras Hernández, J D
Laryngotracheoesophageal clefts (LTEC) are rare and potentially lethal malformations. Their therapeutic approach is still controversial. We report on a one month old infant with a type III LTEC who presented with aspiration and was fed through an orogastric tube for three weeks. Rigid endoscopy assessed the defect precisely. A percutaneous transendoscopic gastrostomy was done one week before the one stage anterior translaryngeal approach of the defect with a two-layer repair. The patient was orotracheally intubated, sedated and relaxed for four days after the repair. Three years later, his larynx and esophagus function normally. Rigid endoscopy and an anterior translaryngeal surgical approach were helpful in his management.
Apatzidou, Danae Anastasia
The subgingival dental plaque is a microbial biofilm consisting of highly variable bacterial microcolonies embedded within a self-produced matrix of extracellular polymeric substance. In contrast to microorganisms growing in a planktonic state, the inhabitants of a biofilm are effectively protected within this dense structure from host defense mechanisms and from therapeutic agents, including antimicrobials. The mechanical removal of the microbial biofilm and the establishment of meticulous plaque control measures comprise the key elements for the success of non-surgical periodontal treatment. Ultrasonic devices are effective in disrupting the biofilm, and carefully remove soft and hard deposits from a root surface with minimal trauma to the tooth structure. Controversies and modern trends in non-surgical periodontal therapy - such as quadrant-wise treatment modalities versus full-mouth approaches, hand-versus power-driven instrumentation, and the time frame of non-surgical periodontal therapy - are discussed here in depth in order to provide an insight into modern approaches to non-surgical biofilm management. Clinical, microbiological and immunological findings following different treatment protocols, in addition to cost-effective benefits of these clinical modalities, are discussed.
Gareau, Dan; Bar, Anna; Snaveley, Nicholas; Lee, Ken; Chen, Nathaniel; Swanson, Neil; Simpson, Eric; Jacques, Steve
For rapid, intra-operative pathological margin assessment to guide staged cancer excisions, multimodal confocal mosaic scan image wide surgical margins (approximately 1 cm) with sub-cellular resolution and mimic the appearance of conventional hematoxylin and eosin histopathology (H&E). The goal of this work is to combine three confocal imaging modes: acridine orange fluorescence (AO) for labeling nuclei, eosin fluorescence (Eo) for labeling cytoplasm, and endogenous reflectance (R) for marking collagen and keratin. Absorption contrast is achieved by alternating the excitation wavelength: 488 nm (AO fluorescence) and 532 nm (Eo fluorescence). Superposition and false-coloring of these modes mimics H&E, enabling detection of cutaneous squamous cell carcinomas (SCC). The sum of mosaic Eo+R is false-colored pink to mimic the appearance of eosin, while the AO mosaic is false-colored purple to mimic the appearance of hematoxylin in H&E. In this study, mosaics of 10 Mohs surgical excisions containing invasive SCC, and five containing only normal tissue were subdivided for digital presentation equivalent to 4 × histology. Of the total 50 SCC and 25 normal sub-mosaics presented, two reviewers made two and three type-2 errors (false positives), respectively. Limitations to precisely mimic H&E included occasional elastin staining by AO. These results suggest that confocal mosaics may effectively guide staged SCC excisions in skin and other tissues.
Cassetta, M; Giansanti, M; Di Mambro, A; Calasso, S; Barbato, E
The aim of this prospective study was to evaluate the effectiveness of an innovative, minimally invasive, flapless corticotomy procedure in orthodontics. The STROBE guidelines were followed. Ten patients with severe dental crowding and a class I molar relationship were selected to receive orthodontic treatment with clear aligners and corticotomy-facilitated orthodontics. The mean age of these patients was 21 years (range 17-28, standard deviation 6.08 years); the male to female ratio was 2:1. The main outcome was a reduction in the total treatment time to correct dental crowding. The secondary outcomes were periodontal index changes, the degree of root resorption, and patient perceptions of the method used, assessed using the short-form Oral Health Impact Profile (OHIP-14). The occurrence of early surgical complications or unexpected events was also recorded. All patients completed the treatment to correct dental crowding. The average treatment time was reduced by two-thirds. The procedure did not significantly modify the periodontal indices or oral health-related quality of life. No early surgical complications or unexpected events were observed. In short, the results indicate that this new procedure is safe and accelerates tooth movement without periodontal complications or discomfort. However, the efficacy of this procedure must be confirmed in controlled clinical trials. Copyright © 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Gareau, Dan; Bar, Anna; Snaveley, Nicholas; Lee, Ken; Chen, Nathaniel; Swanson, Neil; Simpson, Eric; Jacques, Steve
For rapid, intra-operative pathological margin assessment to guide staged cancer excisions, multimodal confocal mosaic scan image wide surgical margins (approximately 1 cm) with sub-cellular resolution and mimic the appearance of conventional hematoxylin and eosin histopathology (H&E). The goal of this work is to combine three confocal imaging modes: acridine orange fluorescence (AO) for labeling nuclei, eosin fluorescence (Eo) for labeling cytoplasm, and endogenous reflectance (R) for marking collagen and keratin. Absorption contrast is achieved by alternating the excitation wavelength: 488 nm (AO fluorescence) and 532 nm (Eo fluorescence). Superposition and false-coloring of these modes mimics H&E, enabling detection of cutaneous squamous cell carcinomas (SCC). The sum of mosaic Eo+R is false-colored pink to mimic the appearance of eosin, while the AO mosaic is false-colored purple to mimic the appearance of hematoxylin in H&E. In this study, mosaics of 10 Mohs surgical excisions containing invasive SCC, and five containing only normal tissue were subdivided for digital presentation equivalent to 4× histology. Of the total 50 SCC and 25 normal sub-mosaics presented, two reviewers made two and three type-2 errors (false positives), respectively. Limitations to precisely mimic H&E included occasional elastin staining by AO. These results suggest that confocal mosaics may effectively guide staged SCC excisions in skin and other tissues.
Kim, Sara; Jabori, Sinan; O'Connell, Jessica; Freeman, Shanna; Fung, Cha Chi; Ekram, Sahrish; Unawame, Amruta; Van Norman, Gail
We conducted a review of informed consent studies involving surgical and invasive procedures and report the degree to which current research targets a broader scope of patient outcomes beyond comprehension. Using PubMed, Cumulative Index to Nursing and Allied Health Literature, and Excerpta Medical Database, we identified 97 articles for review. Six members coded articles and generated scores of study design quality. The mean quality score (10.7 out of a total score of 20) was low. Most studies were single institution-based, relying on one-time data collections. Randomly assigning subjects to study conditions, using power analysis to determine subject numbers, and reporting psychometric evidence, such as reliability and validity, were not widely reported. Most frequently targeted patient outcomes were knowledge, understanding and satisfaction. Core informed consent outcomes (e.g. capacity, voluntariness, decision making) and emotional factors (e.g. anxiety) were not extensively addressed. Informed consent research may benefit from applying qualitative methods to more directly tap into patients' beliefs and decisions by eliciting in patients' own words their emotions and reasoning around processing informed consent content. Research that addresses patient perspectives toward surgical interventions should tap into underexplored ethical and emotional factors that shape decision making. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.
Mehri Turki, Imen
Objective: The webbed neck deformity or pterygium colli is the number one symptom of the Turner syndrome that leads the patient to consult a doctor. Various but rare surgical approaches have been described to correct this deformity. We reviewed our experience with the surgical correction of the pterygium colli. Methods: Through five clinical cases, we describe the surgical technique with a lateral approach which provides a better control of the operative site, allows for the excision of the underlying trapezial fascial web, thus preventing recurrence seen in the posterior approach, and restores a normal hairline. Results: No postoperative wound infection occurred. No recurrence was observed through 24 months. Three patients developed hypertrophic scars. Conclusion: The lateral approach associated with an advanced flap and a Z-plasty is an effective technique for correction of this neck deformity. The presence of a multidisciplinary team, formed with maxillofacial and plastic surgeons, endocrinologists and psychologists, is required to treat these patients allowing reintegration into society and family. PMID:28275532
Brethauer, Stacy A; Chao, Alex; Chambers, Lowell W; Green, Donald J; Brown, Carlos; Rhee, Peter; Bohman, Harold R
The transition from maneuver warfare to insurgency warfare has changed the mechanism and severity of combat wounds treated by US Marine Corps forward surgical units in Iraq. Case series comparison. Forward Resuscitative Surgical System units in Iraq. Three hundred thirty-eight casualties treated during the invasion of Iraq in 2003 (Operation Iraqi Freedom I [OIF I]) and 895 casualties treated between March 2004 and February 2005 (OIF II). Definitive and damage control procedures for acute combat casualties. Mechanism of injury, procedures performed, time to presentation, and killed in action (KIA) and died of wounds (DOW) rates. More major injuries occurred per patient (2.4 vs 1.6) during OIF II. There were more casualties with fragment wounds (61% vs 48%; P = .03) and a trend toward fewer gunshot wounds (33% vs 43%; P = .15) during OIF II. More damage control laparotomies (P = .04) and more soft tissue debridements (P < .001) were performed during OIF II. The median time to presentation for critically injured US casualties during OIF I and OIF II were 30 and 59 minutes, respectively. The KIA rate increased from 13.5% to 20.2% and the DOW rate increased from 0.88% to 5.5% for US personnel in the First Marine Expeditionary Force area of responsibility. The transition from maneuver to insurgency warfare has changed the type and severity of casualties treated by US Marine Corps forward surgical units in Iraq. Improvised explosive devices, severity and number of injuries per casualty, longer transport times, and higher KIA and DOW rates represent major differences between periods. Further data collection is necessary to determine the association between transport times and mortality rates.
Agnetis, Alessandro; Coppi, Alberto; Corsini, Matteo; Dellino, Gabriella; Meloni, Carlo; Pranzo, Marco
This research aims at supporting hospital management in making prompt Operating Room (OR) planning decisions, when either unpredicted events occur or alternative scenarios or configurations need to be rapidly evaluated. We design and test a planning tool enabling managers to efficiently analyse several alternatives to the current OR planning and scheduling. To this aim, we propose a decomposition approach. More specifically, we first focus on determining the Master Surgical Schedule (MSS) on a weekly basis, by assigning the different surgical disciplines to the available sessions. Next, we allocate surgeries to each session, focusing on elective patients only. Patients are selected from the waiting lists according to several parameters, including surgery duration, waiting time and priority class of the operations. We performed computational experiments to compare the performance of our decomposition approach with an (exact) integrated approach. The case study selected for our simulations is based on the characteristics of the operating theatre (OT) of a medium-size public Italian hospital. Scalability of the method is tested for different OT sizes. A pilot example is also proposed to highlight the usefulness of our approach for decision support. The proposed decomposition approach finds satisfactory solutions with significant savings in computation time.
Bonavina, Luigi; Bona, Davide; Abraham, Medhanie; Saino, Greta; Abate, Emmanuele
AIM: To assess the effectiveness of minimally invasive versus traditional open surgical approach in the treatment of Zenker diverticulum. METHODS: Between 1976 and 2006, 297 patients underwent transoral stapling (n = 181) or stapled diverticulectomy and cricopharyngeal myotomy (n = 116). Subjective and objective evaluations of the outcome of the two procedures were made at 1 and 6 mo after operation, and then every year. Long-term follow-up data were available for a subgroup of patients at a minimum of 5 and 10 years. RESULTS: The operative time and hospital stay were markedly reduced in patients undergoing the endosurgical approach. Overall, 92% of patients undergoing the endosurgical approach and 94% of those undergoing the open approach were symptom-free or were significantly improved after a median follow-up of 27 and 48 mo, respectively. At a minimum follow-up of 5 and 10 years, most patients were asymptomatic after both procedures, except for those individuals undergoing an endosurgical procedure for a small diverticulum (< 3 cm). CONCLUSION: Both operations relieve the outflow obstruction at the pharyngoesophageal junction, indicating that cricopharyngeal myotomy has an important therapeutic role in this disease independent of the resection of the pouch and of the surgical approach. Diverticula smaller than 3 cm represent a formal contraindication to the endosurgical approach because the common wall is too short to accommodate one cartridge of staples and to allow complete division of the sphincter. PMID:17552006
Pirozzi, Kelly M; Piraino, Jason
Pseudoainhum is a disorder of unknown etiology that is usually congenital and nonprogressive. One theory states it is caused by amnion band constriction in utero. These constriction bands lead, not only to a less cosmetically appealing foot, but also to long-term neurovascular compromise, resulting in amputation of the digit. The described surgical approaches have been limited within published data. The 2 procedures that have been described are either a Z-plasty or amputation, depending on the degree of the deformity. The present case report provides an alternative surgical approach to a pseudoainhum deformity of a third digit. Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Gil-Jaurena, J M; Castillo, R; Zabala, J I; Conejo, L; Cuenca, V; Picazo, B
Mid-line sternotomy is the routine approach for surgical repair of congenital heart diseases. However, its noticeable scar is a constant reminder of having undergone heart surgery. Several alternative approaches have been developed for simple cardiac conditions to hide the scar. Our series, consisting of 26 patients with axillary closure of atrial septal defect, is presented. The median age was 5.45 years (range 3-13), and median weight was 19.84 Kg. (range 13-37). The defect was closed directly in 13 cases, and with an autologous pericardial patch in the other 13. The number of surgical steps and time taken were the same as in median sternotomy. Functional recovery, intensive care unit stay, and hospital discharge were also standard. The cosmetic result, assessed both by patients and relatives, was excellent.
Mei, Feng; Yili, Fu; Bo, Pan; Xudong, Zhao
In order to enhance the dexterity of surgical instruments in robotic-assisted minimally invasive surgery, the robot is generally configured so as to have a wrist. However, this configuration has a problem in that there is a coupling of the motions of the wrist and the end-effector. In this paper an improved surgical instrument is proposed that eliminates the coupled motion using a compensation mechanism. The design concept behind the compensation mechanism can be applied to other types of surgical instruments. The performance of the proposed surgical instrument is validated by mechanical performance testing and animal experiments, which indicate that the problem of the coupled motion is successfully solved and the instrument is able to perform surgical tasks.
Cuming, Richard G.
Exposure to certain bloodborne pathogens can prematurely end a person's life. Healthcare workers (HCWs), especially those who are members of surgical teams, are at increased risk of exposure to these pathogens. The proper use of personal protective equipment (PPE) during operative/invasive procedures reduces that risk. Despite this, some HCWs fail…
Cuming, Richard G.
Exposure to certain bloodborne pathogens can prematurely end a person's life. Healthcare workers (HCWs), especially those who are members of surgical teams, are at increased risk of exposure to these pathogens. The proper use of personal protective equipment (PPE) during operative/invasive procedures reduces that risk. Despite this, some HCWs fail…
Dickens, Jonathan F; Kilcoyne, Kelly; Kluk, Matthew; Rue, John-Paul
Injuries to the posterolateral corner (PLC) of the knee can lead to profound knee instability, especially when combined with anterior cruciate or posterior cruciate ligament injury. With increased recognition of this injury, as well as improved understanding of the pathoanatomy, surgical treatment of these injuries has evolved in favor of acute treatment including reconstructive techniques to minimize recurrent laxity and allow for early rehabilitation. This article describes the approach to the PLC and the technique for figure of 8 reconstruction.
Thomas, Sarah Boby; Balasubramaniam, Deepak; Hiran, K. R.; Dinesh, M.; Pavithran, K.
Esthesioneuroblastoma is a rare tumor arising from the olfactory mucosa of upper respiratory tract. The primary modality of treatment has been surgery with craniofacial resection followed by post-operative radiotherapy. There are only a few reported cases of non-surgical approaches. We report a case of esthesioneuroblastoma with intracranial extension treated with Vincristine, Adriamycin, Cyclophosphamide, Ifosfamide, Etoposide protocol followed by radiation with 5 years of follow-up. This is the first reported case using this chemotherapy schedule. PMID:27366272
Thomas, Sarah Boby; Balasubramaniam, Deepak; Hiran, K R; Dinesh, M; Pavithran, K
Esthesioneuroblastoma is a rare tumor arising from the olfactory mucosa of upper respiratory tract. The primary modality of treatment has been surgery with craniofacial resection followed by post-operative radiotherapy. There are only a few reported cases of non-surgical approaches. We report a case of esthesioneuroblastoma with intracranial extension treated with Vincristine, Adriamycin, Cyclophosphamide, Ifosfamide, Etoposide protocol followed by radiation with 5 years of follow-up. This is the first reported case using this chemotherapy schedule.
Background A reduction in orthodontic treatment time can be attained using corticotomies. The aggressive nature of corticotomy due to the elevation of muco-periosteal flaps and to the duration of the surgery raised reluctance for its employ among patients and dental community. This study aims to provide detailed information on the design and manufacture of a 3D-printed CAD-CAM (computer-aided design and computer-aided manufacturing) surgical guide which can aid the clinician in achieving a minimally-invasive, flapless corticotomy. Material and Methods An impression of dental arches was created; the models were digitally-acquired using a 3D scanner and saved as STereoLithography ( STL ) files. The patient underwent cone beam computed tomography (CBCT): images of jaws and teeth were transformed into 3D models and saved as an STL file. An acrylic template with the design of a surgical guide was manufactured and scanned. The STLs of jaws, scanned casts, and acrylic templates were matched. 3D modeling software allowed the view of the 3D models from different perspectives and planes with perfect rendering. The 3D model of the acrylic template was transformed into a surgical guide with slots designed to guide, at first, a scalpel blade and then a piezoelectric cutting insert. The 3D STL model of the surgical guide was printed. Results This procedure allowed the manufacturing of a 3D-printed CAD/CAM surgical guide, which overcomes the disadvantages of the corticotomy, removing the need for flap elevation. No discomfort, early surgical complications or unexpected events were observed. Conclusions The effectiveness of this minimally-invasive surgical technique can offer the clinician a valid alternative to other methods currently in use. Key words:Corticotomy, orthodontics, CAD/CAM, minimally invasive, surgical template, 3D printer. PMID:27031067
Diaz-Vera, Jesica; Palmer, Sarah; Hernandez-Fernaud, Juan Ramon; Dornier, Emmanuel; Mitchell, Louise E.; Macpherson, Iain; Edwards, Joanne; Zanivan, Sara
ABSTRACT We have previously shown that Rab17, a small GTPase associated with epithelial polarity, is specifically suppressed by ERK2 (also known as MAPK1) signalling to promote an invasive phenotype. However, the mechanisms through which Rab17 loss permits invasiveness, and the endosomal cargoes that are responsible for mediating this, are unknown. Using quantitative mass spectrometry-based proteomics, we have found that knockdown of Rab17 leads to a highly selective reduction in the cellular levels of a v-SNARE (Vamp8). Moreover, proteomics and immunofluorescence indicate that Vamp8 is associated with Rab17 at late endosomes. Reduced levels of Vamp8 promote transition between ductal carcinoma in situ (DCIS) and a more invasive phenotype. We developed an unbiased proteomic approach to elucidate the complement of receptors that redistributes between endosomes and the plasma membrane, and have pin-pointed neuropilin-2 (NRP2) as a key pro-invasive cargo of Rab17- and Vamp8-regulated trafficking. Indeed, reduced Rab17 or Vamp8 levels lead to increased mobilisation of NRP2-containing late endosomes and upregulated cell surface expression of NRP2. Finally, we show that NRP2 is required for the basement membrane disruption that accompanies the transition between DCIS and a more invasive phenotype. PMID:28062852
Fisher, Timothy K; Scimeca, Christy L; Bharara, Manish; Mills, Joseph L; Armstrong, David G
Diabetic foot disease frequently leads to substantial long-term complications, imposing a huge socioeconomic burden on available resources and health-care systems. Peripheral neuropathy, repetitive trauma, and peripheral vascular disease are common underlying pathways that lead to skin breakdown, often setting the stage for limb-threatening infection. Individuals with diabetes presenting with foot infection warrant optimal surgical management to affect limb salvage and prevent amputation; aggressive short-term and meticulous long-term care plans are required. In addition, the initial surgical intervention or series of interventions must be coupled with appropriate systemic metabolic management as part of an integrated, multidisciplinary team. Such teams typically include multiple medical, surgical, and nursing specialties across a variety of public and private health-care systems. This article presents a stepwise approach to the diagnosis and treatment of diabetic foot infections with emphasis on the appropriate use of surgical interventions and includes the following key elements: incision, wound investigation, debridement, wound irrigation and lavage, and definitive wound closure.
Sivarajan, Ganesh; Borofsky, Michael S; Shah, Ojas; Lingeman, James E; Lepor, Herbert
Lower urinary tract symptoms (LUTS) secondary to benign prostatic hypertrophy (BPH) are among the most common medical issues for aging men. Population-based studies suggest that 13.8% of men in their 40s and more than 40% of men over age 60 have BPH. When LUTS are refractory to medical therapy and bothersome enough to warrant surgical intervention, transurethral resection of the prostate and open simple prostatectomy have been the historical reference-standard procedures for decades. Both procedures are highly effective and offer durable improvements in urinary functional outcomes. However, they also have the potential for considerable perioperative complications and morbidity. In an effort to limit surgical morbidity, a variety of minimally invasive surgical techniques to treat BPH have been introduced. Herein we present a comprehensive, evidence-based review of the efficacy and safety profile of modern minimally invasive treatments for large-gland BPH. PMID:26543428
Sivarajan, Ganesh; Borofsky, Michael S; Shah, Ojas; Lingeman, James E; Lepor, Herbert
Lower urinary tract symptoms (LUTS) secondary to benign prostatic hypertrophy (BPH) are among the most common medical issues for aging men. Population-based studies suggest that 13.8% of men in their 40s and more than 40% of men over age 60 have BPH. When LUTS are refractory to medical therapy and bothersome enough to warrant surgical intervention, transurethral resection of the prostate and open simple prostatectomy have been the historical reference-standard procedures for decades. Both procedures are highly effective and offer durable improvements in urinary functional outcomes. However, they also have the potential for considerable perioperative complications and morbidity. In an effort to limit surgical morbidity, a variety of minimally invasive surgical techniques to treat BPH have been introduced. Herein we present a comprehensive, evidence-based review of the efficacy and safety profile of modern minimally invasive treatments for large-gland BPH.
Billingham, M J; Basterfield, S J
The laparoscopic treatment of pediatric populations remains controversial. This review was conducted to compare the clinical and cost effectiveness of laparoscopic and open surgical approaches for a variety of surgical indications in pediatric populations. A computerized comprehensive search supplemented by a manual review of the literature was performed for all peer-reviewed publications comparing laparoscopic and open appendectomy, fundoplication and hernia repair cohorts. Outcomes of interest were length of stay (LOS), operating room (OR) time, complication rates and total hospital costs; aggregation of outcome rates was performed with the Mantel-Haenszel method. A total of 24 articles were identified that met the search and inclusion criteria. LOS was found to be significantly reduced in favor of the laparoscopic approach, with a weighted mean difference of -1.44 days, although the OR time was significantly increased, with a weighted mean difference of +12.8 min. Laparoscopic intervention was associated with a significantly reduced complication rate compared to the open approach (10.6 vs. 15.6%). Total hospital costs of the laparoscopic approaches were found to be insignificantly increased compared to the open techniques. This review further supports the use of minimally invasive surgery (MIS) in pediatric populations, demonstrating that the three types laparoscopic procedures reviewed resulted in better patient outcomes compared to open procedures, in the form of reduced LOS and overall complication rates. Increased utilization of this approach may prove beneficial to pediatric patients.
Migirov, Lela; Wolf, Michael; Greenberg, Gahl; Eyal, Ana
To investigate a correlation between preoperative non-echo planar diffusion-weighted magnetic resonance imaging (non-EPI DW MRI) with surgical findings of localization and extension of cholesteatoma and to develop criteria for surgical planning. Preoperative non-EPI DWMRI was available and positive for cholesteatoma in 27 patients with primary and 23 with residual/recurrent lesions. Patients with cholesteatoma limited to the middle ear and its extensions were managed with a transcanal endoscopic approach. Patients with extension of the cholesteatoma posteriorly to the lateral semicircular canal underwent retroauricular mastoidectomy combined with an endoscopic approach. Comparison of preoperative radiologic to surgical findings. DWI showed isolated tympanic and attic extension in 33 cases and attico-antral and mastoid extension in 17 cases. MRI findings correlated with surgical findings in all patients with primary cholesteatoma, 19 of whom were managed with a transcanal endoscopic approach and 8 with endoscope-assisted ear surgery. The transcanal endoscopic approach was applied in 14 of the patients with residual/recurrent cholesteatoma, and the other 9 residual/recurrent lesions were eradicated using endoscope-assisted mastoidectomy. DWI overestimated cholesteatoma sites in 1 patient with residual lesion. The smallest cholesteatoma detected on DWI was a 3-mm lesion in the middle ear over the facial nerve. Primary and residual/recurrent cholesteatoma was accurately detected on non-EPI DWI with 98% clinical and radiologic concordance. Lesions less than 8 mm confined to the middle ear and its extensions can be eradicated with a minimally invasive endoscopic transcanal technique, whereas endoscope-assisted retroauricular mastoidectomy is preferred for larger lesions.
Hanba, Curtis; Svider, Peter F; Shkoukani, Mahdi A; Sheyn, Anthony; Jacob, Jeffrey T; Eloy, Jean Anderson; Folbe, Adam J
Although there has been extensive study evaluating adult pituitary surgery, there has been scant analysis among children. Our objective was to evaluate a population-based resource to characterize nationwide trends in surgical approach, hospital stay, and complications among children undergoing pituitary surgery. The Kids' Inpatient-Database (KID) files (2009/2012) were evaluated for pituitary gland excisions. Procedure, patient demographics, length of inpatient stay, inpatient costs, hospital setting, and surgical complications were analyzed. A weighted incidence of 1071 cases were analyzed; the majority (77.6%) underwent transsphenoidal resections. These patients had significantly decreased hospital costs and lengths of stay. Patients undergoing transfrontal approaches had significantly greater rates of postoperative diabetes insipidus (DI) (66.5%), panhypopituitarism (38.8%), hydrocephalus, and visual deficits. Among transsphenoidal patients, males had greater rates of postoperative hydrocephalus (5.5%) and panhypopituitarism (17.5%) than females, and patients ≤10 years old had greater rates of these 2 complications (14.5%, 19.4%, respectively) as well as DI (61.3%). A greater proportion of children undergo transfrontal approaches for pituitary lesions than in their adult counterparts. This difference may harbor a potential to influence future sellar resection approaches in children toward a transsphenoidal operation when surgically feasible. Patients undergoing transfrontal procedures have greater risks for many intraoperative and postoperative complications relative to individuals undergoing transsphenoidal resections. Among patients undergoing transsphenoidal approaches, males had significantly greater rates of postoperative hydrocephalus and panhypopituitarism, and younger children had greater rates of postoperative DI, hydrocephalus, and panhypopituitarism. These data reinforce the need for greater vigilance in the postoperative care of younger children
Pilolli, F; Giordano, L; Galli, A; Bussi, M
The purpose of the present study was to evaluate the advantages of a video-assisted, minimally invasive transcervical approach to benign and malignant parapharyngeal space (PPS) tumours. Ten patients affected by benign and malignant PPS neoplasms underwent a combined transcervical and video-assisted minimally invasive approach, using Hopkins telescopes. We describe the operative technique and perform a review of the literature. Definitive histology revealed 3 pleomorphic adenomas, 2 schwannomas, 2 metastatic papillary thyroid carcinomas, one carcinoma ex pleomorphic adenoma, one cavernous haemangioma and one basal cell adenoma. Mean tumour size was 37.2 mm (range: 19-60). Operation time ranged from 75 min to 185 min (mean: 146.7). One case was converted to transcervical-transparotid approach. Patients were discharged on postoperative day 2-5. One patients presented hypoglossal nerve paresis. The minimally invasive video-assisted transcervical approach is safe and feasible for selected benign and malignant PPS tumours. Furthermore, it offers harmless dissection in a deep and narrow space, accurate haemostasis and continuous control of critical anatomic structures.
Simon, E; Afif, A; M'Baye, M; Mertens, P
The pineal region is situated in the posterior part of the incisural space. This region includes the pineal body inside the quadrigeminal arachnoidal cistern. This article reviews the anatomic features of this region, with particular emphasis on those aspects of importance for surgical access to the pineal region. Five cadaver heads fixed in 10% formalin and injected with colored latex were used for anatomic dissection (five other specimens were also prepared and dissected to illustrate the articles on surgical techniques and approaches presented elsewhere in this issue). The pineal body is surrounded by several important structures such as: posterior part of the third ventricle, tectum, the complex of the great cerebral vein of Galen, pulvinar nuclei of the thalamus and splenium of corpus callosum. The surgical approach of the pineal body, whatever the route or the technique used (microsurgical, endoscopic or stereotactic), creates a great challenge for the neurosurgeons due to its location in the deep part of the brain and its close relationships with complex surrounded vascular structures. Copyright © 2014 Elsevier Masson SAS. All rights reserved.
Wang, Lin; Cao, Lan; Shansky, Janet; Wang, Zheng; Mooney, David; Vandenburgh, Herman
Repair of injured skeletal muscle by cell therapies has been limited by poor survival of injected cells. Use of a carrier scaffold delivering cells locally, may enhance in vivo cell survival, and promote skeletal muscle regeneration. Biomaterial scaffolds are often implanted into muscle tissue through invasive surgeries, which can result in trauma that delays healing. Minimally invasive approaches to scaffold implantation are thought to minimize these adverse effects. This hypothesis was addressed in the context of a severe mouse skeletal muscle injury model. A degradable, shape-memory alginate scaffold that was highly porous and compressible was delivered by minimally invasive surgical techniques to injured tibialis anterior muscle. The scaffold controlled was quickly rehydrated in situ with autologous myoblasts and growth factors (either insulin-like growth factor-1 (IGF-1) alone or IGF-1 with vascular endothelial growth factor (VEGF)). The implanted scaffolds delivering myoblasts and IGF-1 significantly reduced scar formation, enhanced cell engraftment, and improved muscle contractile function. The addition of VEGF to the scaffold further improved functional recovery likely through increased angiogenesis. Thus, the delivery of myoblasts and dual local release of VEGF and IGF-1 from degradable scaffolds implanted through a minimally invasive procedure effectively promoted the functional regeneration of injured skeletal muscle. PMID:24769909
IACOANGELI, Maurizio; NOCCHI, Niccolò; NASI, Davide; DI RIENZO, Alessandro; DOBRAN, Mauro; GLADI, Maurizio; COLASANTI, Roberto; ALVARO, Lorenzo; POLONARA, Gabriele; SCERRATI, Massimo
The most important target of minimally invasive surgery is to obtain the best therapeutic effect with the least iatrogenic injury. In this background, a pivotal role in contemporary neurosurgery is played by the supraorbital key-hole approach proposed by Perneczky for anterior cranial base surgery. In this article, it is presented as a possible valid alternative to the traditional craniotomies in anterior cranial fossa meningiomas removal. From January 2008 to January 2012 at our department 56 patients underwent anterior cranial base meningiomas removal. Thirty-three patients were submitted to traditional approaches while 23 to supraorbital key-hole technique. A clinical and neuroradiological pre- and postoperative evaluation were performed, with attention to eventual complications, length of surgical procedure, and hospitalization. Compared to traditional approaches the supraorbital key-hole approach was associated neither to a greater range of postoperative complications nor to a longer surgical procedure and hospitalization while permitting the same lesion control. With this technique, minimization of brain exposition and manipulation with reduction of unwanted iatrogenic injuries, neurovascular structures preservation, and a better aesthetic result are possible. The supraorbital key-hole approach according to Perneckzy could represent a valid alternative to traditional approaches in anterior cranial base meningiomas surgery. PMID:26804334
Iacoangeli, Maurizio; Nocchi, Niccolò; Nasi, Davide; DI Rienzo, Alessandro; Dobran, Mauro; Gladi, Maurizio; Colasanti, Roberto; Alvaro, Lorenzo; Polonara, Gabriele; Scerrati, Massimo
The most important target of minimally invasive surgery is to obtain the best therapeutic effect with the least iatrogenic injury. In this background, a pivotal role in contemporary neurosurgery is played by the supraorbital key-hole approach proposed by Perneczky for anterior cranial base surgery. In this article, it is presented as a possible valid alternative to the traditional craniotomies in anterior cranial fossa meningiomas removal. From January 2008 to January 2012 at our department 56 patients underwent anterior cranial base meningiomas removal. Thirty-three patients were submitted to traditional approaches while 23 to supraorbital key-hole technique. A clinical and neuroradiological pre- and postoperative evaluation were performed, with attention to eventual complications, length of surgical procedure, and hospitalization. Compared to traditional approaches the supraorbital key-hole approach was associated neither to a greater range of postoperative complications nor to a longer surgical procedure and hospitalization while permitting the same lesion control. With this technique, minimization of brain exposition and manipulation with reduction of unwanted iatrogenic injuries, neurovascular structures preservation, and a better aesthetic result are possible. The supraorbital key-hole approach according to Perneckzy could represent a valid alternative to traditional approaches in anterior cranial base meningiomas surgery.
Morales-Dalmau, Jordi; Aguirre, Juan; Funk, Lutz; Jara, Francesc; Turon, Pau; Durduran, Turgut
The characterization of the degradation of surgical sutures (~500 μm diameter) up to ~9 mm in tissue phantoms and up to ~3 mm depth in euthanized mice, and its potential application in in vivo animals is demonstrated using a custom dark-field photo-acoustic microscope (PAM). By using a simple theoretical approach and modelling the characteristics of our ultrasound transducer, both theoretical and experimental observations are in good agreement. The implications of this work for industrial applications are discussed by comparing the measurements with an optical microscope and with a developed algorithm on tissue simulating phantoms and with ex vivo measurements using PAM.
Abu-El Naaj, Imad; Braun, Refael; Leiser, Yoav; Peled, Micha
The aim of the present study is to suggest a convenient way to classify the position of the impacted third mandibular molar relative to the mandibular canal and to suggest indications for the use of each surgical approach for mandibular third molar extraction. The presented new typing system, Third Molar Classification (TMC), is a simple and easy-to-apply method for the surgical management of mandibular third molars and can be extended for any ectopic or impacted mandibular tooth. There are 3 major types of third molar positions. The second type is subdivided further into 2 subtypes. In the present study, 9 patients with high-risk mandibular third molars were treated according to the present classification and are presented and discussed. Patients typed as TMC IIb were treated with a sagittal split osteotomy approach and patients typed as TMC III were treated with an extraoral approach. The operative classification was successfully implemented in very rare cases of deeply impacted mandibular third molars. In 3 of 9 cases (33%) minor complications included some degree of hypoesthesia using the extraoral approach; these complications resolved spontaneously without the need for any intervention. The present study describes the use of a new surgical classification system for treatment planning in all types of mandibular third molar extractions. We believe that the present classification could help the oral and maxillofacial surgeon in decision-making and limit the possible risks that are present when attempting to extract impacted mandibular third molars. Copyright (c) 2010 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Kaur, Parjeet; Gattani, Raghav; Singhal, Alka Ashmita; Sarin, Deepak; Arora, Sowrabh Kumar; Mithal, Ambrish
Context: Preoperative localization of parathyroid adenoma is essential in deciding the surgical approach of parathyroidectomy. Aim: To describe clinical and biochemical profile, evaluate preoperative imaging modalities and surgical approach in patients with primary hyperparathyroidism (PHPT). Methodology: This was a retrospective study conducted at the single institution. All patients who underwent evaluation and surgery for PHPT from 2011 to 2015 were included in the study. Results: A total of 100 patients underwent surgery for PHPT. Mean (standard deviation) age was 51.6 (15.9) years with female to male ratio of 1.7:1. Forty patients had severe symptoms, and sixty had mild to moderate symptoms. The sensitivity of technetium-99m hexakis (2-methoxyisobutylisonitrile) (MIBI) scan and ultrasonography (USG) neck in identifying abnormal parathyroid gland was 93% (93/100) and 98% (98/100), respectively. The MIBI scan results of 90/93 (96.7%) patients corresponded with their surgical findings whereas preoperative USG findings of 96/98 patients (98%) showed correlation with operative findings. Intraoperative intact parathyroid hormone (IOPTH) levels at 10 min postexcision were measured in forty patients (minimally invasive parathyroidectomy = 38, bilateral neck exploration = 1, and unilateral neck exploration = 1). All patients except two had <50% fall in IOPTH. Adenoma weight was positively correlated with preoperative intact PTH. Conclusion: We found that USG has higher sensitivity (98%) than MIBI scan (93%) in localizing abnormal parathyroid gland. Moreover, USG had a higher preoperative localization accuracy (93%) than MIBI scan (90%), allowing to choose an appropriate surgical approach. A higher proportion of patients (60%) had mild/asymptomatic form of PHPT. PMID:27730071
Parsons, J. Kellogg; Messer, Karen; Palazzi, Kerrin; Stroup, Sean; Chang, David
IMPORTANCE Surgical innovations disseminate in the absence of coordinated systems to ensure their safe integration into clinical practice, potentially exposing patients to increased risk for medical error. OBJECTIVE To investigate associations of patient safety with the diffusion of minimally invasive radical prostatectomy (MIRP) resulting from the development of the da Vinci robot. DESIGN, SETTING, AND PARTICIPANTS A cohort study of 401 325 patients in the Nationwide Inpatient Sample who underwent radical prostatectomy during MIRP diffusion between January 1, 2003, and December 31, 2009. MAIN OUTCOMES AND MEASURES We used Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs), which measure processes of care and surgical provider performance. We estimated the prevalence of MIRP among all prostatectomies and compared PSI incidence between MIRP and open radical prostatectomy in each year during the study. We also collected estimates of MIRP incidence attributed to the manufacturer of the da Vinci robot. RESULTS Patients who underwent MIRP were more likely to be white (P = .004), have fewer comorbidities (P = .02), and have undergone surgery in higher-income areas (P = .005). The incidence of MIRP was substantially lower than da Vinci manufacturer estimates. Rapid diffusion onset occurred in 2006, when MIRP accounted for 10.4% (95% CI, 10.2-10.7) of all radical prostatectomies in the United States. In 2005, MIRP was associated with an increased adjusted risk for any PSI (adjusted odds ratio, 2.0; 95% CI, 1.1-3.7; P = .02) vs open radical prostatectomy. Stratification by hospital status demonstrated similar patterns: rapid diffusion onset among teaching hospitals occurred in 2006 (11.7%; 95% CI, 11.3-12.0), with an increased risk for PSI for MIRP in 2005 (adjusted odds ratio, 2.7; 95% CI, 1.4-5.3; P = .004), and onset among nonteaching hospitals occurred in 2008 (27.1%; 95% CI, 26.6-27.7), with an increased but nonsignificant risk for PSI in 2007
Rasch, Sebastian; Phillip, Veit; Reichel, Stephanie; Rau, Bettina; Zapf, Christian; Rosendahl, Jonas; Halm, Ulrich; Zachäus, Markus; Müller, Martin; Kleger, Alexander; Neesse, Albrecht; Hampe, Jochen; Ellrichmann, Mark; Rückert, Felix; Strauß, Peter; Algül, Hana
Background Necrotising pancreatitis, and particularly infected necrosis, are still associated with high morbidity and mortality. Since 2011, a step-up approach with lower morbidity rates compared to initial open necrosectomy has been established. However, mortality and complication rates of this complex treatment are hardly studied thereafter. Methods The German Pancreatitis Study Group performed a multicenter, retrospective study including 220 patients with necrotising pancreatitis requiring intervention, treated at 10 hospitals in Germany between January 2008 and June 2014. Data were analysed for the primary endpoints "severe complications" and "mortality" as well as secondary endpoints including "length of hospital stay", "follow up", and predisposing or prognostic factors. Results Of all patients 13.6% were treated primarily with surgery and 86.4% underwent a step-up approach. More men (71.8%) required intervention for necrotising pancreatitis. The most frequent etiology was biliary (41.4%) followed by alcohol (29.1%). Compared to open necrosectomy, the step-up approach was associated with a lower number of severe complications (primary composite endpoint including sepsis, persistent multiorgan dysfunction syndrome (MODS) and erosion bleeding: 44.7% vs. 73.3%), lower mortality (10.5% vs. 33.3%) and lower rates of diabetes mellitus type 3c (4.7% vs. 33.3%). Low hematocrit and low blood urea nitrogen at admission as well as a history of acute pancreatitis were prognostic for less complications in necrotising pancreatitis. A combination of drainage with endoscopic necrosectomy resulted in the lowest rate of severe complications. Conclusion A step-up approach starting with minimal invasive drainage techniques and endoscopic necrosectomy results in a significant reduction of morbidity and mortality in necrotising pancreatitis compared to a primarily surgical intervention. PMID:27668746
Haponiuk, Ireneusz; Kwasniak, Ewelina; Chojnicki, Maciej; Steffens, Mariusz; Sendrowska, Aneta; Gierat-Haponiuk, Katarzyna; Leszczyńska, Katarzyna; Paczkowski, Konrad; Zielinski, Jacek
Introduction Cardiac tamponade is excessive collection of fluid in the pericardial sac surrounding the heart that leads to restriction of cardiac function and causes critical cardiogenic shock and rapid circulatory depression. Despite the potential variety of different etiologies in the face of a dangerous decrease of cardiac output, the emergency life-saving procedure is surgical pericardial fluid evacuation. Aim To perform a retrospective analysis of clinical data and the results of minimally invasive transxiphoid pediatric cardiac tamponade evacuation procedures performed in a cardiac surgery center. Material and methods We performed a retrospective analysis of all consecutive patients referred for treatment in our department in a period of 6 years (15 patients) who underwent emergency pericardial drainage after an echocardiographically proven diagnosis. The procedure of choice was minimally invasive transxiphoid fluid evacuation with routine pericardial drainage. Retrospective operative data analysis was performed: clinical symptoms, pre-admission and initial emergency diagnostics and interventions, the morphology and total amount of drained pericardial fluid, length of stay, final results, and overall survival rate. We introduced an original pediatric tamponade index (PTI). The PTI was analyzed according to catecholamine support before the drainage and the length of hospital stay after the procedure. Results All patients survived the procedure. No early complications of the presented minimally invasive subxiphoid approach were noted. Mean PTI in patients with intensive catecholamine support before the operation was significantly higher than in patients without it. Conclusions Minimally invasive surgical transxiphoid interventions appear to be a safe and effective method to provide life-saving support with retrieval of the fluid for further laboratory investigations. PMID:25960801
Gerboni, G.; Brancadoro, M.; Tortora, G.; Diodato, A.; Cianchetti, M.; Menciassi, A.
Minimally invasive surgery (MIS) applications require lightweight actuators that can generate a high force in a limited volume. Among pressure driven actuators, fluid elastic actuators demonstrate high potential for use in the medical field. They are characterized by nearly no friction and wear and they can be made of low-cost biocompatible elastomers. However, when compared to traditional piston-cylinder fluid actuators, fluid elastic actuators often result in smaller output forces as well as weaker return forces. This work is about the design of a linear elastic actuator (LEA) which is able to develop relevant pulling-pushing force in one direction. The LEA is composed of entirely disposable materials and it requires a simple manufacturing process. Thanks to its design, the LEA can be compared to traditional piston-cylinders actuators in terms of output forces (up to 7 N) with the advantage of using relative low working pressures (0, 2 MPa). The actuator has been used for the actuation of a gripper for MIS, as a case study. The whole range of gripping forces developed by the tool actated by the LEA has been evaluated, thus verifying that the gripping device, is able to meet the force requirements for accomplishing typical surgical tasks.
Kim, Dae-Hyeong; Lee, Mincheol; Lee, Hyunjae
Recent advances in soft electronics have attracted great attention, largely due to their potential applications in personalized, bio-integrated healthcare devices. The mechanical mismatch between conventional electronic/optoelectronic devices and soft human tissues/organs have presented many challenges, such as the low signalto- noise ratio of biosensors because of the incomplete integration of rigid devices with the body, inflammation and excessive immune responses of implanted stiff devices originated from friction and their foreign nature to biotic systems, and the considerable discomfort and consequent stress experienced by users when wearing/implanting these devices. Ultra-flexible and stretchable electronic devices are being highlighted due to their low system modulus and the intrinsic system-level softness that are important to solve these issues. Here, we describe our unique strategies for the nanomaterial synthesis and fabrication, their seamless assembly and integration, and the design and development of corresponding wearable healthcare devices and minimally invasive surgical tools. These bioelectronic systems fully utilize recent breakthroughs in unconventional soft electronics based on nanomaterials to address unsolved issues in clinical medicine and to provide new opportunities in the personalized healthcare.
Hastenteufel, Mark; Yang, Siwei; Christoph, Carsten; Vetter, Marcus; Meinzer, Hans-Peter; Wolf, Ivo
Atrial fibrillation (AF) is the most common arrhythmia and results in an increased risk of ischemic stroke. Recently, a european consortium has developed a new minimally invasive device for surgical AF treatment. It consists of a micro-robot holding an end-effector called "umbrella" containing 22 radiofrequency powered electrodes. Surgery using this new device can only be performed having an appropriate navigation technique. Therefore, we have developed an image-based navigation workflow and a prototypic navigation application. First, a navigation workflow including an appropriate intra-operative image-modality was defined. Intraoperative ultrasound became the imaging modality of choice. Once the umbrella is unfolded inside the left atrium, data is acquired and segmented. Using a reliable communication protocol, mobility values are transferred from the control software to the navigation system. A deformation model predicts the behavior of the umbrella during repositioning. Prior to surgery, desired ablation lines can be interactively planned and actually made ablation lines are visualized during surgery. Several in-vitro tests were performed. The navigation prototype has been integrated and tested within the overall system successfully. Image acquisitions of the umbrella showed the feasibility of the navigation procedure. More in-vitro and in-vivo tests are currently performed to make the new device and the described navigation procedure ready for clinical use.
Smith, T O; Hedges, C; MacNair, R; Schankat, K
The less invasive surgical stabilisation (LISS) plate fixation method is an orthopaedic procedure for the fixation of distal femoral fractures. Early physiotherapy treatments of motion and mobilisation have been advocated following this procedure. This article critically appraises the evidence base assessing the early rehabilitation of patients following LISS fixation for distal femoral fractures. A review of EMBASE, Medline, CINAHL and AMED, and a hand search were undertaken. Two independent reviewers identified all eligible articles. Two reviewers extracted the data, which were verified by a third reviewer. All included articles were critically appraised by two independent reviewers using the Critical Appraisal Skills Programme tool. Seventeen case series assessing 508 patients with 535 fractures were reviewed. No clinical trials comparing physiotherapy programmes were identified. The review identified that following LISS fixation for distal femoral fractures, patients begin range-of-motion exercises immediately and are initially required to restrict weight-bearing following surgery. It remains unclear whether casts, braces or immobilisation aids are applied during the initial postoperative period. The efficacy of different physiotherapy protocols following LISS fixation for distal femoral fractures remains unclear. Further well-designed randomised controlled trials are required to compare different postoperative physiotherapy rehabilitation programmes for patients following LISS fixation of distal femoral fractures in order to determine the optimal postoperative management for this complex patient group.
Ramamoorthy, Sripriya; Zhang, Yuan; Petrie, Tracy; Fridberger, Anders; Ren, Tianying; Wang, Ruikang; Jacques, Steven L.; Nuttall, Alfred L.
Sound processing in the inner ear involves separation of the constituent frequencies along the length of the cochlea. Frequencies relevant to human speech (100 to 500 Hz) are processed in the apex region. Among mammals, the guinea pig cochlear apex processes similar frequencies and is thus relevant for the study of speech processing in the cochlea. However, the requirement for extensive surgery has challenged the optical accessibility of this area to investigate cochlear processing of signals without significant intrusion. A simple method is developed to provide optical access to the guinea pig cochlear apex in two directions with minimal surgery. Furthermore, all prior vibration measurements in the guinea pig apex involved opening an observation hole in the otic capsule, which has been questioned on the basis of the resulting changes to cochlear hydrodynamics. Here, this limitation is overcome by measuring the vibrations through the unopened otic capsule using phase-sensitive Fourier domain optical coherence tomography. The optically and surgically advanced method described here lays the foundation to perform minimally invasive investigation of speech-related signal processing in the cochlea.
Ramamoorthy, Sripriya; Zhang, Yuan; Petrie, Tracy; Fridberger, Anders; Ren, Tianying; Wang, Ruikang; Jacques, Steven L.; Nuttall, Alfred L.
Abstract. Sound processing in the inner ear involves separation of the constituent frequencies along the length of the cochlea. Frequencies relevant to human speech (100 to 500 Hz) are processed in the apex region. Among mammals, the guinea pig cochlear apex processes similar frequencies and is thus relevant for the study of speech processing in the cochlea. However, the requirement for extensive surgery has challenged the optical accessibility of this area to investigate cochlear processing of signals without significant intrusion. A simple method is developed to provide optical access to the guinea pig cochlear apex in two directions with minimal surgery. Furthermore, all prior vibration measurements in the guinea pig apex involved opening an observation hole in the otic capsule, which has been questioned on the basis of the resulting changes to cochlear hydrodynamics. Here, this limitation is overcome by measuring the vibrations through the unopened otic capsule using phase-sensitive Fourier domain optical coherence tomography. The optically and surgically advanced method described here lays the foundation to perform minimally invasive investigation of speech-related signal processing in the cochlea. PMID:26836207
Hasemaki, Natasha; Vaggelis, Georgios; Karampa, Anastasia; Anastasiadi, Zoi; Lianou, Aikaterini; Papanikolaou, Sarantis; Floras, Grigorios; Bali, Christina D.; Lekkas, Epameinondas; Katsios, Christos; Mitsis, Michail
Complete (R0) resection and regional lymph nodes (LNs) dissection represent undoubtedly the basic surgical tools for patients with gastric cancer. It is reported that the LN metastasis rate in patients with early gastric cancer (EGC) is approximately 15–20%. Therefore, the innovative clinical application of sentinel node navigation surgery (SNNS) for EGC might be able to prevent unnecessary LN dissection as well as to reduce significantly the volume of gastric resection. Recent evidence suggests that double tracer methods appear superior compared to single tracer techniques. However, the researchers’ interest is now focused on the identification of new LN detection methods utilizing sophisticated technology such as infrared ray endoscopy, fluorescence imaging and near-infrared technology. Despite its notable limitations, hematoxylin-eosin is still considered the mainstay staining for assessing the metastatic status of LNs. In this review, we summarize the current evidences and we provide the latest scientific information assessing safety, efficacy and potential limitations of the innovative sentinel node (SN) navigation technique for gastric cancer. We try also to provide a “view” towards a future potential application of personalized minimally invasive surgery in gastric cancer field. PMID:28138656
Gonzalez-Neira, Eliana Maria; Jimenez-Mendoza, Claudia Patricia; Rugeles-Quintero, Saul
Objective: This study aims at determining if a collection of 16 motor tests on a physical simulator can objectively discriminate and evaluate practitioners' competency level, i.e. novice, resident, and expert. Methods: An experimental design with three study groups (novice, resident, and expert) was developed to test the evaluation power of each of the 16 simple tests. An ANOVA and a Student Newman-Keuls (SNK) test were used to analyze results of each test to determine which of them can discriminate participants' competency level. Results: Four of the 16 tests used discriminated all of the three competency levels and 15 discriminated at least two of the three groups (α= 0.05). Moreover, other two tests differentiate beginners' level from intermediate, and other seven tests differentiate intermediate level from expert. Conclusion: The competency level of a practitioner of minimally invasive surgery can be evaluated by a specific collection of basic tests in a physical surgical simulator. Reduction of the number of tests needed to discriminate the competency level of surgeons can be the aim of future research. PMID:27226664
Burton, Elizabeth; Chase, Dana; Yamamoto, Maki; de Guzman, Jayson; Imagawa, David; Berman, Michael L
lymph node excision above the renal vessels; thus, collaboration with a surgical oncologist is a viable option. In this small descriptive study, the feasibility of this reasonably well-tolerated approach, with possible survival benefit, is documented. Copyright © 2010 Elsevier Inc. All rights reserved.
Piaggesi, A; Schipani, E; Campi, F; Romanelli, M; Baccetti, F; Arvia, C; Navalesi, R
To test the efficacy of surgical treatment of non-infected neuropathic foot ulcers compared to conventional non-surgical management, a group of diabetic outpatients attending our diabetic foot clinic were studied. All patients who came to the clinic for the first time from January to December 1995 inclusive with an uncomplicated neuropathic ulcer were randomized into two groups. Group A received conservative treatment, consisting of relief of weight-bearing, regular dressings; group B underwent surgical excision, eventual debridement or removal of bone segments underlying the lesion and surgical closure. Healing rate, healing time, prevalence of infection, relapse during a 6-month period following intervention and subjective discomfort were assessed. Twenty-four ulcers in 21 patients were treated in group A (17 Type 2 DM/3 Type 1 DM, age 63.24 +/- 13.46 yr, duration of diabetes 18.2 +/- 8.41 yr, HbA1c 9.5 +/- 3.8%) and 22 ulcers in 21 patients in group B (19 Type 2 DM/2 Type 1 DM, age 65.53 +/- 9.87yr, duration of diabetes 16.84 +/- 10.61 yr; HbA1c 8.9 +/- 2.2%). Healing rate was lower (79.2% = 19/24 ulcers) in group A than in group B (95.5% = 21/22 ulcers; p < 0.05), and healing time was longer (128.9 +/- 86.60 days vs 46.73 +/- 38.94 days; p < 0.001). Infective complications occurred significantly more often in group A patients (3/24, 12.5% vs 1/22, 4.5%; p < 0.05), as did relapses of ulcerations (8 vs 3; p < 0.01). There were only two minor perioperative complications in group B patients. Patients reported a higher degree of satisfaction in group B (p < 0.01) as well as lower discomfort (p < 0.05) and restrictions (p < 0.05). Thus surgical treatment of neuropathic foot ulcers in diabetic patients proved to be an effective approach compared to conventional treatment in terms of healing time, complications, and relapses, and can be safely performed in an outpatient setting.
Leopardi, G; Chiarella, G; Conti, S; Cassandro, E
Summary Congenital preauricular sinus is a malformation of the preauricular soft tissues with an incidence ranging between 0.1 and 0.9% in Europe and the United States. It presents a high risk of recurrence when treated by a standard surgical technique (simple sinectomy), the incidence of which is reported to be between 19% and 40%. The supra-auricular approach, proposed by Prasad et al. in 1990, is easier to perform and presents a lower recurrence risk. Personal experience is presented in the treatment of congenital preauricular sinus with the supra-auricular approach as first choice or in the case of recurrence following previous standard surgery. This report includes a short review of the literature in order not only to focus on the supra-auricular approach and check the efficacy as far as concerns reduction of recurrence risk but also to contribute to a more widespread use of this method. PMID:19205595
Parshin, V D; Rusakov, M A; Parshin, V V; Mirzoian, O S; Khoruzhenko, A I
At present time several surgical approaches are being used for cicatrical tracheal stenosis including cervicotomy, longitudinal- circumferential sternotomy and thoracotomy. Besides location of stenosis an approach is being determined by constitutional and anatomical features of patient, surgeon's and anesthesiologist's experience, well-coordinated work of operating team. If pathological process is placed in cervico-laryngeal, cervical and upper thoracic segment cervicotomy is preferable. Partial longitudinal-circumferential sternotomy is believed to be adequate in case of lesion of thoracic trachea and its bifurcation. This approach provides all types of tracheal reconstructions. Technical difficulties appear if process is localized in membranous wall of suprabifurcational part, bifurcation and primary bronchus. In these cases we recommend thoracotomy through the bed of resected the 3rd or the 4th ribs and patient's position on his front. Interventions including pulmonary tissue resection and tracheal edges convergence are possible through thoracotomy.
Magdy, Emad A
Surgical repair of postlaryngectomy pharyngocutaneous fistula (PCF) can be challenging. Although several studies describe separate reconstruction methods, only few address the variability in defect characteristics and hence flap selection. The current clinical study presents a retrospective review of 19 patients who underwent surgical repair of persistent PCFs, over a 4-year period in a tertiary referral institute by a single primary surgeon. All but one patient were men with a mean age of 61 +/- 10 years. Nine patients had previous unsuccessful attempts for surgical closure. Previous neck irradiation was the most common comorbid condition encountered (52.6%), followed by low hemoglobin level (47.4%), hepatic disease (36.8%) and diabetes mellitus (31.6%). According to defect characteristics, six patients received a local cervical skin procedure, ten patients had reconstructions using the pectoralis major musculocutaneous flap and three patients required a radial forearm free flap repair. All PCFs were eventually successfully closed with no major complications. Patients were followed-up for an average of 19.7 months (range, 5-38 months). Acceptable oral swallowing results were achieved in all but one patient. In conclusion, successful results are achievable in difficult persistent PCF cases with a defect based reconstruction approach kept in mind.
Botta, Luca; Cannata, Aldo; Bruschi, Giuseppe; Fratto, Pasquale; Taglieri, Corrado; Russo, Claudio Francesco; Martinelli, Luigi
Redo cardiac surgery represents a clinical challenge due to a higher rate of peri-operative morbidity and mortality. Mitral valve re-operations can be particularly demanding in patients with patent coronary artery bypass grafts, previous aortic valve replacement, calcified aorta or complications following a previous operation (abscesses, perivalvular leaks, or thrombosis). Risk of graft injuries, hemorrhage, the presence of dense adhesions and complex valve exposure can make redo valve operations challenging through a median sternotomy. In this review article we provide an overview of minimally invasive approaches for redo mitral valve surgery discussing indications, techniques, outcomes, concerns and controversies. Scientific literature about minimally invasive approach for redo mitral surgery was reviewed with a MEDLINE search strategy combining "mitral valve" with the following terms: 'minimally invasive', 'reoperation', and 'alternative approach'. The search was limited to the last ten years. A total of 168 papers were found using the reported search. From these, ten papers were identified to provide the best evidence on the subject. Mitral valve reoperations can be safely and effectively performed through a smaller right thoracotomy in the fourth intercostal space termed "mini" thoracotomy or "port access". The greatest potential benefit of a right mini-thoracotomy is the avoidance of sternal re-entry and limited dissection of adhesions, avoiding the risk of injury to cardiac structures or patent grafts. Good percentages of valve repair can be achieved. Mortality is low as well as major complications. Minimally invasive procedures with an unclamped aorta have the potential to combine the benefits of minimally invasive access and continuous myocardial perfusion. Less invasive trans-catheter techniques could be considered as the natural future evolution for management of structural heart disease and mitral reoperations. The safety and efficacy of these
Recently, various video-assisted thoracoscopic surgical techniques have been reported with occasional success in treating hepatic hydrothorax (HH). In 2 patients with refractory HH, we applied a combination of four therapeutic modalities as a single procedure named as a "four-step approach": (1) pneumoperitoneum for localization of diaphragmatic defects, (2) thoracoscopic pleurodesis, (3) postoperative continuous positive airway pressure, and (4) drainage of ascites for abdominal decompression. The treatment was successful in both patients, without recurrence during the follow-up period of 24 and 3 months, respectively.
Del Curto, David; Tamaoki, Marcel Jun; Martins, Délio E; Puertas, Eduardo Barros; Belloti, João Carlos
The choice of surgical approach for the management of subaxial cervical spine facet dislocations is a controversial subject amongst spine surgeons. Reasons for this include differences in the technical familiarity and experience of surgeons with the different surgical approaches, and variable interpretation of image studies regarding the existence of a traumatic intervertebral disc herniation and of the neurological status of the patient. Moreover, since the approaches are dissimilar, important variations are likely in neurological, radiographical and clinical outcomes. To compare the effects (benefits and harms) of the different surgical approaches used for treating adults with acute cervical spine facet dislocation. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (9 May 2014), The Cochrane Central Register of Controlled Trials (The Cochrane Library, 2014 Issue 4), MEDLINE (1946 to April Week 5 2014), MEDLINE In-Process & Other Non-Indexed Citations (8 May 2013), EMBASE (1980 to 2014 Week 18), Latin American and Caribbean Health Sciences (9 May 2014), trial registries, conference proceedings and reference lists of articles to May 2014. We included randomised and quasi-randomised controlled trials that compared surgical approaches for the management of adults with acute cervical spine facet dislocations with and without spinal cord injury. Two review authors independently selected studies, assessed risk of bias and extracted data. We included one randomised and one quasi-randomised controlled trial involving a total of 94 participants and reporting results for a maximum of 84 participants. One trial included patients with spinal cord injuries and the other included patients without spinal cord injuries. Both trials compared anterior versus posterior surgical approaches. Both trials were at high risk of bias, including selection bias (one trial), performance bias (both trials) and attrition bias (one trial). Data were pooled for one
Yura, Shinya; Kato, Takumi; Ooi, Kazuhiro; Izumiyama, Yuri
We describe a combination of 3 surgical procedures for implant placement in the posterior maxilla with insufficient bone quantity and quality. In these situations, we have performed 3 minimally invasive, safe, and reliable surgical procedures: buccal bone graft with bone harvested from the mandibular molar region, submucous vestibuloplasty using artificial dermis, and bone-added osteotome sinus floor elevation under endoscopic control. These modified procedures can be performed in the office setting under outpatient local anesthesia and may minimize patient discomfort and reduce postoperative complications.
Martin, Jeremiah T.; Durbin, Eric B.; Chen, Li; Gal, Tamas; Mahan, Angela; Ferraris, Victor; Zwischenberger, Joseph
Background Recent reports demonstrate that thoracoscopic lobectomy for lung cancer may be associated with lower rates of surgical upstaging. We queried a state-wide cancer registry for differences in upstaging rates and survival by surgical approach. Methods The Kentucky Cancer Registry (KCR) collects data, including centralized pathology reporting, on cancer patients treated statewide. We performed a retrospective review from 2010-2012 to examine clinical and pathologic stage. We assessed rates of upstaging and whether or not the surgical approach, thoracotomy (THOR) versus minimally invasive techniques (VATS), had an impact on final pathologic stage and survival. Results The KCR database from 2010 to 2012 contained information on 2830 lung cancer cases, 1964 having THOR and 500 having VATS resections. Preoperatively, 36.4% of THOR were clinically stage 1a vs. 47.4% % VATS (p=0.0002). Of these, final pathologic stage remained stage 1a in 30.5% of THOR and 38.0% of VATS (p=0.0002). The overall nodal upstaging rate for THOR was 9.9% and 4.8% for VATS (p=0.002). There was decreased nodal upstaging with VATS, independent of tumor size and extent of resection (OR 0.6, 95% CI 0.387-0.985, p=0.04). However there was improved survival with VATS compared with THOR (HR 0.733, 95% CI 0.592-0.907, p = 0.0042). Conclusions Consistent with other reports, we demonstrate a lower upstaging rate with VATS. Nevertheless, there is a survival advantage in VATS patients. Although selection bias may play a role in these observed differences, the improved quality of life measures associated with VATS, may explain survival improvement despite lower surgical upstaging. PMID:26428690
Rugiu, M G; Piemonte, M
Retrosternal goitre is defined as a goitre with a portion of its mass > or = 50% located in the mediastinum. Surgical removal is the treatment of choice and, in most cases, the goitre can be removed via a cervical approach. Aim of this retrospective study was to analyse personal experience in the surgical management of retrosternal goitres, defining, in particular, the features requiring sternotomy. Over a 5-year period (2004-2008), 986 patients underwent thyroidectomy in the ENT Department of the University Hospital of Udine, Italy; in 53 patients, 37 females, 16 males (mean age: 64 years, range: 35-85), thyroidectomy was performed for a retrosternal goitre, which extended, at computed tomography at least 3 cm below the cervico-thoracic isthmus. Retrosternal goitres were removed via a cervical approach in 49 patients; a sternotomy was necessary in 4 patients (7.5%), due to an ectopic intra-thoracic thyroid in one patient, and a very large thyroid reaching the main bronchial bifurcation in the other 3 (mean weight of goitres: 883 g, range: 520-1600). Histo-pathological studies revealed a benign lesion in 50 patients and a carcinoma in 2 (3.7%). The incidence of transient and permanent hypoparathyroidism was 13% and 3.7%, respectively. Transient recurrent laryngeal nerve palsy occurred in one patient (1.8%), post-operative bleeding in 3 patients (5.6%) and respiratory complications, requiring a tracheotomy in one case, in 2 patients (3.7%). Surgical removal of a retrosternal goitre is a challenging procedure; it can be performed safely, in most cases, via a cervical approach, with a complication rate slightly higher than the average rate for cervical goitre thyroidectomy, especially concerning hypoparathyroidism and post-operative bleeding. The most significant criteria for selecting patients requiring sternotomy are computed tomography features, in particular the presence of an ectopic goitre, the thyroid gland volume and the extent of the goitre to or below the
Usuelli, Federico Giuseppe; Indino, Cristian; Maccario, Camilla; Manzi, Luigi; Salini, Vincenzo
Purpose: Recently, the Zimmer Trabecular Metal Total Ankle Replacement (Zimmer TM TAR) was developed to be used through a lateral transfibular approach. The purpose of this paper is to describe the surgical technique and early outcomes of the TAR via the lateral approach using the Zimmer TM TARs. Methods: Sixty-seven patients underwent primary TAR using the Zimmer TM TAR between May 2013 and May 2015. Patients were clinically evaluated preoperatively and postoperatively at six and twelve months and annually using the American Orthopaedic Foot & Ankle Society (AOFAS) ankle and hindfoot scores, visual analogue scale (VAS) pain score, and the Short Form Health Survey (SF-12) questionnaire. The minimum follow-up was 12 months. Results: The mean AOFAS hindfoot score increased from 32.8 preoperatively to 85.0 at the latest follow-up (p-value < 0.001). The mean VAS pain score decreased from 8.0 to 2.0 at the latest follow-up (p-value < 0.001). The Physical and Mental Health Composite Scale scores (PCS and MCS) of the SF-12 passed from a mean value of 30.2 preoperatively to 43.1 (p-value < 0.001) and from a mean value of 44.6 to 53.5 at the latest follow-up (p-value < 0.001), respectively. Conclusions: We present our surgical tips and the early results of this prosthetic design which are encouraging. They could be useful as an adjunct to the manufacturer’s surgical technique guidance for surgeons who utilize these implants. PMID:27855774
Pepper, Jon-Paul; Hecht, Sarah L; Gebarski, Stephen S; Lin, Erin M; Sullivan, Stephen E; Marentette, Lawrence J
To describe surgical outcomes and radiographic features of olfactory groove meningiomas treated by excision through the subcranial approach. Special emphasis is placed on paranasal sinus and orbit involvement. Retrospective review of a series of patients. Nineteen patients underwent excision of olfactory groove meningioma (OGM) via the transglabellar/subcranial approach between December 1995 and November 2009. Nine patients had previously undergone prior resection at outside institutions, and four had prior radiotherapy in addition to a prior excision. Transglabellar/subcranial surgical approach to the anterior skull base was performed. Tumor histology included three World Health Organization (WHO) grade III lesions, one WHO grade II lesion, and 15 WHO grade I lesions. Fourteen patients had evidence of extension into the paranasal sinuses, with the ethmoid sinus being most commonly involved. Kaplan-Meier estimates of mean overall and disease-free survival were 121.45 months and 93.03 months, respectively. The mean follow-up interval was 41.0 months, and at the time of data analysis three patients had recurrent tumors. Seven (36.8%) patients experienced a major complication in the perioperative period; there were no perioperative mortalities. Orbit invasion was observed in four patients, with optic nerve impingement in 11 patients. Of these, three patients had long-term diplopia. No patients experienced worsening of preoperative visual acuity. Olfactory groove meningiomas demonstrate a propensity to spread into the paranasal sinuses, particularly in recurrent cases. Given a tendency for infiltrative recurrence along the skull base, this disease represents an important area of collaboration between neurosurgery and otolaryngology. The subcranial approach offers excellent surgical access for excision, particularly for recurrences that involve the paranasal sinuses and optic apparatus. Copyright © 2011 The American Laryngological, Rhinological, and Otological Society
Marchioni, Daniele; Soloperto, Davide; Genovese, Elisabetta; Rubini, Alessia; Presutti, Livio
Facial nerve hemangiomas are rare benign tumors arising from the venous plexus surrounding the facial nerve. Surgical management of these tumors is controversial. The goal of surgery is complete tumor removal with restoration of facial nerve function and preservation of hearing, wherever possible. The approaches most used are the translabyrinthine and middle cranial fossa approaches. In this report, we describe the first facial hemangioma treated with an endoscopic transcanal approach, combined with a retroauricular transmastoid minicraniotomy for closure of the dural defect. A great auricular nerve graft was used to reconnect interrupted nerve segments. Histopathological examination confirmed the diagnosis of a hemangioma of the first genu of the facial nerve. With magnification of the structures, the transcanal endoscopic approach allowed a radical excision of the neoplasm permitting hearing function preservation, with the possibility to work with a minimally invasive approach with respect to the labyrinthine block and cochlea. Compared to a middle cranial fossa approach, the transcanal endoscopic approach avoided labyrinthine block removal and brain retraction. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
Zhu, Qing; Liang, Bin; Wang, Xingsong; Sun, Xiaogang; Wang, Liming
Minimally invasive surgical operation of intramedullary (IM) nailing is a standard technique for treating diaphyseal fractures. However, in addition to its advantages, there are some drawbacks such as the frequent occurrence of malalignment, physical fatigue and high radiation exposure to medical staff. The use of robotic and navigation techniques is promising treatments for femoral fractures. This paper presents a novel robot-assisted manipulator for femoral shaft fracture reduction with indirect contact with the femur. An alternative clinical testing model was proposed for orthopedic surgeons to practice femoral fracture reduction. This model imitates the human musculoskeletal system in shape and functional performance. The rubber tube simulate muscles providing contraction forces, and the silicone simulates passive elasticity of muscles. Two-group experiments were performed for studying feasibility of the teleoperated manipulator. The average operative time was about 7min. In the first group experiments, the femur axial, antero-posterior (AP) and lateral views mean errors were 2.2mm, 0.7mm and 1.1mm, respectively, and their maximums were 3.0mm, 0.9mm and 1.5mm; the mean errors of rotation were 0.8° around x-axis, 1.6° around y-axis, 2.0° around z-axis, and their maximums were 1.1°, 2.2°, 2.9°, respectively. For the second group experiments, the femur axial, AP and lateral views mean errors were 1.8mm, 0.4mm and 0.8mm, respectively, and their maximums were 2.2mm, 0.7mm and 1.1mm; the mean errors of rotation were 1.2° around x-axis, 1.6° around y-axis, 1.9° around z-axis, and their maximums were 2.4°, 1.8°, 2.7°, respectively. Reduction for AP view displacement is easier than lateral (p<0.05) because of the tube-shaped anatomy and the muscle contraction forces. Errors around x-axis are smaller than those around y-, and z- axes (p<0.05), i.e., electro-mechanical actuator is easier to control than pneumatic. An experimental model for simulating human
Bhattacharyya, Mayukh; Gerber, Bruno
The surgical benefit of minimally invasive tendo Achilles repair (n = 25) with early weight-bearing mobilisation after rupture of the tendo Achilles was compared with operative treatment using an open technique (n = 34) with full weight-bearing after 8 weeks of surgical repair. The minimally invasive technique provided no evidence of wound problems and a functional benefit from early weight-bearing mobilisation. However, we noted that increased post-operative morbidity in terms of wound infection (n = 7) leading to delayed wound healing and wound pain requiring opiate-based analgesia post-operatively in the open repair group may have an additional impact on the patients and health care providers. This study showed that the mini-invasive open surgical repair of the Achilles tendon with the Achillon instrument and early weight-bearing mobilisation in an orthosis for the accelerated rehabilitation may offer cost-effectiveness and less financial burden on the health care provider in terms of associated nursing and physiotherapy costs.
Lucarelli, Giuseppe; Spilotros, Marco; Vavallo, Antonio; Palazzo, Silvano; Miacola, Carlos; Forte, Saverio; Matera, Matteo; Campagna, Marcello; Colamonico, Ottavio; Schiralli, Francesco; Sebastiani, Francesco; Di Cosmo, Federica; Bettocchi, Carlo; Di Lorenzo, Giuseppe; Buonerba, Carlo; Vincenti, Leonardo; Ludovico, Giuseppe; Ditonno, Pasquale; Battaglia, Michele
Abstract Primary urethral carcinoma (PUC) is a rare and aggressive cancer, often underdetected and consequently unsatisfactorily treated. We report a case of advanced PUC, surgically treated with combined approaches. A 47-year-old man underwent transurethral resection of a urethral lesion with histological evidence of a poorly differentiated squamous cancer of the bulbomembranous urethra. Computed tomography (CT) and bone scans excluded metastatic spread of the disease but showed involvement of both corpora cavernosa (cT3N0M0). A radical surgical approach was advised, but the patient refused this and opted for chemotherapy. After 17 months the patient was referred to our department due to the evidence of a fistula in the scrotal area. CT scan showed bilateral metastatic disease in the inguinal, external iliac, and obturator lymph nodes as well as the involvement of both corpora cavernosa. Additionally, a fistula originating from the right corpus cavernosum extended to the scrotal skin. At this stage, the patient accepted the surgical treatment, consisting of different phases. Phase I: Radical extraperitoneal cystoprostatectomy with iliac-obturator lymph nodes dissection. Phase II: Creation of a urinary diversion through a Bricker ileal conduit. Phase III: Repositioning of the patient in lithotomic position for an overturned Y skin incision, total penectomy, fistula excision, and “en bloc” removal of surgical specimens including the bladder, through the perineal breach. Phase IV: Right inguinal lymphadenectomy. The procedure lasted 9-and-a-half hours, was complication-free, and intraoperative blood loss was 600 mL. The patient was discharged 8 days after surgery. Pathological examination documented a T4N2M0 tumor. The clinical situation was stable during the first 3 months postoperatively but then metastatic spread occurred, not responsive to adjuvant chemotherapy, which led to the patient's death 6 months after surgery. Patients with advanced stage tumors of
Lee, Kong Hwee; Yeo, William; Soeharno, Henry; Yue, Wai Mun
Prospective cohort study. This study aimed to evaluate the learning curve of minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). Very few studies have evaluated the learning curve of this technically demanding surgery. We intend to evaluate the learning curve of MIS TLIF with a larger sample size and assess surgical competence based not only on operative time but with perioperative variables, clinical and radiologic outcomes, incidence of complications, and patient satisfaction. From 2005 to 2009, the first 90 single-level MIS TLIF, which utilized a consistent technique and spinal instrumentation, performed by a single surgeon at our tertiary institution were studied. Variables studied included operative time, perioperative variables, clinical (Visual Analogue Scores for back and leg pain, Oswestry Disability Index, North American Spine Society Scores for neurogenic symptoms) and radiologic outcomes, incidence of complications and patient rating of expectation met, and the overall result of surgery. The asymptote of the surgeon's learning curve for MIS TLIF was achieved at the 44th case. Comparing the early group of 44 patients to the latter 46, the demographics were similar. For operative parameters, only 3 variables showed differences between the 2 groups: mean operative duration, fluoroscopy duration, and usage of patient-controlled analgesia. At the final follow-up, for clinical outcome parameters, the 2 groups were different in 3 parameters: VAS scores for back, leg pain, and neurogenic symptom scores. For radiologic outcome, both groups showed similar good fusion rates. For complications, none of the MIS TLIF cases were converted to open TLIF intraoperatively. In the early group, there were 3 complications: 1 incidental durotomy and 2 asymptomatic cage migrations; and in the latter group, there was 1 asymptomatic cage migration. In our study, technical proficiency in MIS TLIF was achieved after 44 surgeries, and the latter patients benefited
Méndez-Gallart, R; Bautista, A; Estévez, E; Rodríguez-Barca, P
Abdominal Cystic lymphangiomas (ACL) are uncommon benign masses usually presented during infancy. Although extremely rare, they may cause complications; therefore, the recommended therapy is surgical excision. The purpose of this study is to report our experience with the diagnosis and surgical treatment of ACL in pediatric population. From January 1994 to December 2009, 10 patients (6 females; 4 males) with diagnostic confirmation of ACL were retrospectively included in study. Children's age ranged between 9 months and 8 years (mean age at diagnosis was 2.5 years). Clinical presentation, cyst location, imaging studies employed, surgical approach and pathologic features were analyzed. The most common symptom was abdominal pain but three cases were incidentally detected. One case had presented with acute abdomen after traumatic haemorrhage of the tumor. All patients were diagnosed with ultrasonography as first-line radiological study. MRI was used in last three cases. At surgery, concomitant bowel resection was necessary in 3 children. Location of the lesion (omentum, mesentery) did not influence the outcome but surgery was more difficult (operative time over three hours) in patients with lymphangioma affecting mesentery of the jejunum. Mean hospital stay after surgery was 6.7 days. Mean follow-up was 5.1 years. No recurrence of the cystic lymphangioma was noticed during follow-up. One case developed an intestinal occlusion due to bowel adhesions 1 year after surgery. ACL usually affect infants and young children and may present with spectrum of symptoms from an incidental finding to an acute life-threatening abdominal obstruction. Complete excision of the tumor is a safe and effective method in the management of ACL in pediatric population. Surgery is mandatory to avoid potential complications.
Cannata, Aldo; Bruschi, Giuseppe; Fratto, Pasquale; Taglieri, Corrado; Russo, Claudio Francesco; Martinelli, Luigi
Redo cardiac surgery represents a clinical challenge due to a higher rate of peri-operative morbidity and mortality. Mitral valve re-operations can be particularly demanding in patients with patent coronary artery bypass grafts, previous aortic valve replacement, calcified aorta or complications following a previous operation (abscesses, perivalvular leaks, or thrombosis). Risk of graft injuries, hemorrhage, the presence of dense adhesions and complex valve exposure can make redo valve operations challenging through a median sternotomy. In this review article we provide an overview of minimally invasive approaches for redo mitral valve surgery discussing indications, techniques, outcomes, concerns and controversies. Scientific literature about minimally invasive approach for redo mitral surgery was reviewed with a MEDLINE search strategy combining “mitral valve” with the following terms: ‘minimally invasive’, ‘reoperation’, and ‘alternative approach’. The search was limited to the last ten years. A total of 168 papers were found using the reported search. From these, ten papers were identified to provide the best evidence on the subject. Mitral valve reoperations can be safely and effectively performed through a smaller right thoracotomy in the fourth intercostal space termed “mini” thoracotomy or “port access”. The greatest potential benefit of a right mini-thoracotomy is the avoidance of sternal re-entry and limited dissection of adhesions, avoiding the risk of injury to cardiac structures or patent grafts. Good percentages of valve repair can be achieved. Mortality is low as well as major complications. Minimally invasive procedures with an unclamped aorta have the potential to combine the benefits of minimally invasive access and continuous myocardial perfusion. Less invasive trans-catheter techniques could be considered as the natural future evolution for management of structural heart disease and mitral reoperations. The safety and
Koitschev, Assen; Stingl, Katarina; Bartz-Schmidt, Karl Ulrich; Braun, Angelika; Gekeler, Florian; Greppmaier, Udo; Sachs, Helmut; Peters, Tobias; Wilhelm, Barbara; Zrenner, Eberhart; Besch, Dorothea
In hereditary retinal diseases photoreceptors progressively degenerate, often causing blindness without therapy being available. Newly developed subretinal implants can substitute functions of photoreceptors. Retina implant extraocular surgical technique relies strongly on cochlear-implant know-how. However, a completely new surgical approach providing safe handling of the photosensor array had to be developed. The Retina Implant Alpha IMS consisting of a subretinal microphotodiode array and cable linked to a cochlear-implant-like ceramic housing was introduced via a retroauricular incision through a subperiosteal tunnel above the zygoma into the orbit using a specially designed trocar. Implant housing was fixed in a bony bed within a tight subperiosteal pocket in all patients. Primary outcomes were patient short term safety as well as effectiveness. Nine patients participated in the first part of the multicenter trial and received the subretinal visual implant in one eye. In all cases microphotodiode array pull-through procedure and stable positioning were possible without affecting the device function. No intraoperative complications were encountered. The minimally invasive suprazygomatic tunneling technique for the sensor unit as well as a subperiosteal pocket fixation of the implant housing provides a safe extraocular implantation approach of a subretinal device with a transcutaneous extracorporeal power supply. PMID:26783453
Koitschev, Assen; Stingl, Katarina; Bartz-Schmidt, Karl Ulrich; Braun, Angelika; Gekeler, Florian; Greppmaier, Udo; Sachs, Helmut; Peters, Tobias; Wilhelm, Barbara; Zrenner, Eberhart; Besch, Dorothea
In hereditary retinal diseases photoreceptors progressively degenerate, often causing blindness without therapy being available. Newly developed subretinal implants can substitute functions of photoreceptors. Retina implant extraocular surgical technique relies strongly on cochlear-implant know-how. However, a completely new surgical approach providing safe handling of the photosensor array had to be developed. The Retina Implant Alpha IMS consisting of a subretinal microphotodiode array and cable linked to a cochlear-implant-like ceramic housing was introduced via a retroauricular incision through a subperiosteal tunnel above the zygoma into the orbit using a specially designed trocar. Implant housing was fixed in a bony bed within a tight subperiosteal pocket in all patients. Primary outcomes were patient short term safety as well as effectiveness. Nine patients participated in the first part of the multicenter trial and received the subretinal visual implant in one eye. In all cases microphotodiode array pull-through procedure and stable positioning were possible without affecting the device function. No intraoperative complications were encountered. The minimally invasive suprazygomatic tunneling technique for the sensor unit as well as a subperiosteal pocket fixation of the implant housing provides a safe extraocular implantation approach of a subretinal device with a transcutaneous extracorporeal power supply.
Yang, Yunsu; Hong, Kihwan
The intraoral approach for removal of the plunging ranula is a safe and effective surgical approach as a primary treatment modality for plunging ranula. Although sclerotherapy is applied for plunging ranula, it can be primarily treated with surgery such as marsupialization, simple excision, and transcervical excision. This study was performed to assess the results of the intraoral approach for the treatment of plunging ranula. This prospective clinical study comprised a total of 23 patients with plunging ranula treated by the intraoral approach. All patients had complete removal of the sublingual gland with evacuation of cystic fluid. The cystic wall of the ranula could be dissected completely in only four patients, and in eight patients it was only possible to drain the cystic fluid. However, in 11 patients we could not dissect the cystic wall completely. Rupture of ranula developed in all patients during the intraoral dissection. Recurrence was not detected in any of the patients during the median follow-up period of 14 months after the intraoral excision. There were no complications or external scarring.
Tobias-Machado, Marcos; Mattos, Pablo Aloisio Lima; Reis, Leonardo Oliveira; Juliano, César Augusto Braz; Pompeo, Antonio Carlos Lima
ABSTRACT Purpose: Vesicorectal fistula is one of the most devastating postoperative complications after radical prostatectomy. Definitive treatment is difficult due to morbidity and recurrence. Despite many options, there is not an unanimous accepted approach. This article aimed to report a new minimally invasive approach as an option to reconstructive surgery. Materials and Methods: We report on Transanal Minimally Invasive Surgery (TAMIS) with miniLap devices for instrumentation in a 65 year old patient presenting with vesicorectal fistula after radical prostatectomy. We used Alexis® device for transanal access and 3, 5 and 11 mm triangulated ports for the procedure. The surgical steps were as follows: cystoscopy and implant of guide wire through fistula; patient at jack-knife position; transanal access; Identification of the fistula; dissection; vesical wall closure; injection of fibrin glue in defect; rectal wall closure. Results: The operative time was 240 minutes, with 120 minutes for reconstruction. No perioperative complications or conversion were observed. Hospital stay was two days and catheters were removed at four weeks. No recurrence was observed. Conclusions: This approach has low morbidity and is feasible. The main difficulties consisted in maintaining luminal dilation, instrumental manipulation and suturing. PMID:26689530
Gonzalez, Nestor R; Liebeskind, David S; Dusick, Joshua R; Mayor, Fernando; Saver, Jeffrey
Ten percent of all strokes occurring in the USA are caused by intracranial arterial stenosis (IAS). Symptomatic IAS carries one of the highest rates of recurrent stroke despite intensive medical therapy (25 % in high-risk groups). Clinical results for endovascular angioplasty and stenting have been disappointing. The objectives of this study were to review the contemporary understanding of symptomatic IAS and present potential alternative treatments to resolve factors not addressed by current therapies. We performed a literature review on IAS pathophysiology, natural history, and current treatment. We present an evaluation of the currently deficient aspects in its treatment and explore the role of alternative surgical approaches. There is a well-documented interrelation between hemodynamic and embolic factors in cerebral ischemia caused by IAS. Despite the effectiveness of medical therapy, hemodynamic factors are not addressed satisfactorily by medications alone. Collateral circulation and severity of stenosis are the strongest predictors of risk for stroke and death. Indirect revascularization techniques, such as encephaloduroarteriosynangiosis, offer an alternative treatment to enhance collateral circulation while minimizing risk of hemorrhage associated with hyperemia and endovascular manipulation, with promising results in preliminary studies on chronic cerebrovascular occlusive disease. Despite improvements in medical management for IAS, relevant aspects of its pathophysiology are not resolved by medical treatment alone, such as poor collateral circulation. Surgical indirect revascularization can improve collateral circulation and play a role in the treatment of this condition. Further formal evaluation of indirect revascularization for IAS is a logical and worthy step in the development of intracranial atherosclerosis treatment strategies.
Levinson, M L; Fonger, J
Atrial septal defects in adults are associated with paradoxical emboli, atrial tachyarrythmias, and congestive heart failure. Surgical closure is highly efficacious with low operative mortality and morbidity. However, in young women sternotomy scars are unsightly reminders of an otherwise curative procedure. Alternatives such as lateral thoracotomy or extended transverse incisions are more cosmetic but associated with breast maldevelopment, numbness and other side effects. The authors are proposing a new surgical approach based on their observation that the right atrium and septum actually lie only 1 inch superior to the xyphisternal junction. A 4 inch transverse inframammary incision is used and the linea alba divided. The lower sternum is lifted forward with a commericial cable-pully retractor system (Rultract). Using femoral bypass augmented by a balloon tipped cannula in the superior vena cava, the septal defect is easily visualized and closed with conventional techniques and equipment. Two young women have undergone closure of a patent foremen ovale (N=1) and a large ostium secundum (N=1) defect through this approach. One patient had minor fat necrosis in the incision which subsequently healed without incident. Close anatomic proximity between the atrial septum and the lower sternum make it feasible to approach ostium secundum defects using a purely subxyphoid exposure. Visualization of the defect is excellent without the need for thoractomy and sternotomy. The use of a small transverse incision in the inframammary crease makes the result cosmetically invisible.
Sze Li, Siow; Kenneth Kher Ti, Voon
Obturator hernia is a rare condition that may present in an acute or subacute setting in correlation with the degree of small-bowel obstruction. Pre-operative diagnosis is difficult, as symptoms are often non-specific. A high index of suspicion should be maintained for emaciated elderly women with small-bowel obstruction without a previous abdominal operation and a positive Howship–Romberg sign. When diagnosis is in doubt, computed tomography scan of the abdomen and the pelvis (if available) or laparotomy should be performed immediately, as high mortality rate is related to the perforation of gangrenous bowels. We present 2 cases of strangulated obturator hernia, managed differently with both open and laparoscopic approaches. The diagnostic accuracy of computed tomography scan is highlighted followed by a brief literature review with an emphasis placed on surgical management. PMID:22977378
Quadri, Humair S; Hong, Young K; Al-Refaie, Waddah B
The rates of gastric cancer, which is the third leading cause of cancer-related deaths worldwide, vary depending on geographic location. Margin-negative gastrectomy and adequate lymphadenectomy (removal of ≥15 lymph nodes) are the cornerstones of multimodal treatment for operable gastric cancer. Diagnostic laparoscopy should be included in the armamentarium for newly diagnosed gastric cancer in order to overcome the limitations of cross-sectional imaging in identifying sub-radiographic hepatic or peritoneal metastases. The benefit of surgical therapy is enhanced by at least 13% when it is integrated with multimodal therapy: either surgery followed by adjuvant chemoradiotherapy or surgery with perioperative systemic therapy. This multidisciplinary approach to treatment will continue to be an evolving paradigm, especially with the emergence of systemic and targeted therapies.
Quadri, Humair S; Hong, Young K; Al-Refaie, Waddah B
The rates of gastric cancer, which is the third leading cause of cancer-related deaths worldwide, vary depending on geographic location. Margin-negative gastrectomy and adequate lymphadenectomy (removal of ≥15 lymph nodes) are the cornerstones of multimodal treatment for operable gastric cancer. Diagnostic laparoscopy should be included in the armamentarium for newly diagnosed gastric cancer in order to overcome the limitations of cross-sectional imaging in identifying sub-radiographic hepatic or peritoneal metastases. The benefit of surgical therapy is enhanced by at least 13% when it is integrated with multimodal therapy: either surgery followed by adjuvant chemoradiotherapy or surgery with perioperative systemic therapy. This multidisciplinary approach to treatment will continue to be an evolving paradigm, especially with the emergence of systemic and targeted therapies.
GRANO, GIOVANNI F.; PAVLIDOU, MARIA; TODESCO, ALBERTO; PALERMO, AUGUSTO; MOLFETTA, LUIGI
Purpose the purpose of the present paper is to present the short-term results of a “detachment-free” (DF) anterolateral approach for primary total hip replacement (THR) performed in a large series of patients. Methods two hundred patients submitted to primary THR were retrospectively reviewed for the present study. In all cases, the surgery was performed using a minimally invasive DF anterolateral approach, which entails no disconnection of tendons and no muscle damage. The study population consisted of 96 men (48%) and 104 women (52%), with an average age of 69.4 years (range 38–75). Clinical and radiographic follow-up was performed after 12 months. Results the clinical results, evaluated using the Harris Hip Score, were excellent in 95% of the cases and good in 5%; no cases had fair or poor results. X-rays taken at 3, 6 and 12 months after surgery did not show heterotopic ossification, mobilization of the prosthetic components, or hip dislocation. No infections, deep vein thrombosis, or failure of the gluteal muscles were reported. Conclusions the DF anterolateral approach for THR proved safe and provided effective results at short-term follow-up. Level of evidence Level IV, therapeutic case series. PMID:27900306
Mouchaty, Homère; Perrini, Paolo; Conti, Renato; Di Lorenzo, Nicola
The aim of this study is to review our experience with the transoral surgical management of anterior craniovertebral junction (CVJ) lesions with particular attention to the decision making and to the indication for a consecutive stabilization. During 10 years (1998-2007), 52 consecutive patients presenting exclusively fixed anterior compression at the cervicomedullary junction underwent transoral surgery. Mean age was 55.85 years (range 17-75 years). Encountered lesions were: malformation (32 cases), rheumatoid arthritis (11 cases), tumor (5 cases) or trauma (4 cases). A total of 79% of patients presented with chronic/recurrent headache (cranial and/or high-cervical pain), 73% with varying degrees of quadrip aresis, and 29% with lower cranial nerve deficits. All of the patients but two, with posterior stabilization performed elsewhere, underwent synchronous anterior decompression and posterior occipitocervical fixation. Adjuncts to the transoral approach (Le Fort I with or without splitting of the palate), tailored to the local anatomy and to the extension of the lesions, were performed in seven cases. Follow-up ranged between 4 and 96 months. Of 35 patients with severe preoperative neurological deficits, 33 improved. The remaining 15 patients who presented with mild symptoms, healed throughout the follow-up. Perioperative mortality occurred in two cases and surgical morbidity in eight cases (dural laceration, cerebrospinal fluid leak with meningitis, malocclusion, oral wound dehiscence and occipital wound infection). Delayed instability occurred in one patient because of cranial settling of C2 vertebral body. A successful surgery achieving a stable decompression at the CVJ is an expertise demanding procedure. It requires accurate preoperative evaluation and, appropriate choice of decompression technique and stabilization instruments. Enlarged transoral approaches (despite higher morbidity) are a supportive means in cases of severe basilar invagination, cranial
Chen, Hong-Wei; Bi, Qing
Background This study compared the efficacy of combined lateral and medial approach, lateral approach, and anterior medial approach in treatment of terrible triad of the elbow (TTE). Material/Methods Thirty-eight TTE patients hospitalized in our center were retrospectively analyzed, among which 14 patients were arranged for combined lateral and medial approach, 12 for lateral approach, and 12 for anterior medial approach. All included patients underwent open reduction, collateral ligament repair, and postoperative function exercise. Follow-up was conducted for 13~22 months. The elbow motion, excellent and good rate, healing time, and complication rate were recorded and compared. Results These 3 approaches significantly improved the postoperative elbow motion, MEPS, VAS, excellent and good rate, and open reduction (all P<0.05). The VAS score for lateral approach was evidently higher than that for combined lateral and medial approach (P<0.05). Combined lateral and medial approach and anterior medial approach had better performance on elbow motion, MEPS, and excellent and good rate than lateral approach (both P<0.05). Lateral approach and anterior medial approach had a significantly reduced healing time compared with combined lateral and medial approach (both P<0.05), while anterior medial approach had a higher complication rate compared with anterior medial approach and lateral approach (both P<0.05). Conclusions Lateral combined medial surgery approach contributes to wide surgical exposure, facture stability, and decreased complication rate, and thus has superior efficacy than the other 2 surgical approaches. PMID:27841255
Carson, Jeffrey S; Smith, Lynette; Are, Madhuri; Edney, James; Azarow, Kenneth; Mercer, David W; Thompson, Jon S; Are, Chandrakanth
The aim of this study was to analyze national trends in minimally invasive and open cases of all graduating residents in general surgery. A retrospective analysis was performed on data obtained from Accreditation Council for Graduate Medical Education logs (1999-2008) of graduating residents from all US general surgery residency programs. Data were analyzed using Mantel-Haenszel χ(2) tests and the Bonferroni adjustment to detect trends in the number of minimally invasive and open cases. Minimally invasive procedures accounted for an increasing proportion of cases performed (3.7% to 11.1%, P < .0001), with a proportional decrease in open cases. An increase in minimally invasive procedures with a proportional decrease in open procedures was noted in subcategories such as alimentary tract, abdominal, vascular, thoracic, and pediatric surgery (P < .0001). The results of this study demonstrate that general surgery residents in the United States are performing a greater number of minimally invasive and fewer open procedures for common surgical conditions. Copyright © 2011 Elsevier Inc. All rights reserved.
Khreiss, Mohammad; Zenati, Mazen; Clifford, Amber; Lee, Kenneth K; Hogg, Melissa E; Slivka, Adam; Chennat, Jennifer; Gelrud, Andres; Zeh, Herbert J; Papachristou, Georgios I; Zureikat, Amer H
Walled-off pancreatic necrosis (WON) is a sequela of acute necrotizing pancreatitis in 15-40% of cases. We sought to compare the outcomes of minimally invasive surgical and endoscopic cyst gastrostomy (CG) and necrosectomy for the management for sterile WON at a tertiary care high-volume pancreas center. This is a retrospective review of patients who underwent minimally invasive surgical or endoscopic CG and necrosectomy for clinically sterile WON between 2008 and 2013. Peri-procedural outcomes including costs were analyzed and compared. Twenty patients underwent minimally invasive surgical (robotic = 14, laparoscopic = 6) CG and necrosectomy, and 20 patients underwent endoscopic treatment. The surgical cohort had a larger median cyst size and higher CCI score. For the surgical cohort, median OR time was 167.5 min, estimated blood loss was 30 ml, and 65% underwent concomitant cholecystectomy. There was no mortality in either group and no difference in complication rates (20%). The failure rate was similar (15 versus 10%, P = 0.66). Although surgery was associated with a lower re-intervention rate (0 versus 1, P = 0.008), the endotherapy group was associated with shorter total LOS (inclusive of re-interventions) (7 versus 3 days, P = 0.032). The cost of the index procedure was significantly higher for the surgery group (P = 0.014); however, when considering all readmissions and re-interventions until resolution of the WON, the total cost was similar for both groups. Minimally invasive surgical and endoscopic CG and necrosectomy are comparable treatments for sterile WON in terms of outcomes and overall cost. The surgical approach may be considered advantageous when a concomitant cholecystectomy is required.
LeClaire, Edgar L; Mukati, Marium S; Juarez, Dianna; White, Dena; Quiroz, Lieschen H
The objective was to investigate the relationship between new onset postoperative stress urinary incontinence (SUI) after sacrocolpopexy (SCP) and anatomical change/surgical approach. We analyzed a retrospective cohort of patients with negative preoperative testing for SUI who underwent SCP from 2005 to 2012. Our primary outcome was new onset postoperative SUI. Logistic regression was used to examine the relationship among anatomical change, defined as ΔAa, ΔBa, ΔC, and ΔTVL, and surgical approach, categorized as abdominal (ASCP) for open cases and minimally invasive (MISCP) for laparoscopic and robot-assisted cases, and postoperative SUI. Of 795 cases, 33 ASCP (43%) and 44 MISCP (57%) met the inclusion criteria for analysis. New onset SUI was demonstrated by 15 patients (45%) of the ASCP group and 7 patients (15%) of the MISCP group (p = 0.005). New onset SUI was significantly associated with route of SCP and ΔAa (p = 0.006 and p = 0.033 respectively). Controlling for ΔAa, the odds of new onset SUI were 4.4 times higher in the ASCP group compared with the MISCP group (OR 4.37, 95% CI 1.42, 13.48). Controlling for route of SCP, the odds of new onset SUI were 2.2 times higher with moderate ΔAa compared with low ΔAa (OR 2.16 95% CI 1.07, 4.38). The odds of new onset SUI was 4.7 times higher in those with high ΔAa than in those with low ΔAa (OR 4.67 95% CI 1.14, 19.22). ΔBa, ΔC, and ΔTVL were not associated with new onset SUI. Greater reduction in point Aa and abdominal surgical route are risk factors for new onset postoperative SUI after SCP.
Ding, Dale; Przybylowski, Colin J; Starke, Robert M; Sterling Street, R; Tyree, Amber E; Webster Crowley, R; Liu, Kenneth C
We describe the technical nuances of a minimally invasive anterior skull base approach for microsurgical evacuation of a large basal ganglia hematoma through an endoport. Patients who suffer from large spontaneous intracerebral hemorrhages (ICH) of the basal ganglia have a very poor prognosis. However, the benefit of surgery for the management of ICH is controversial. The development of endoport technology has allowed for minimally invasive access to subcortical lesions, and may offer unique advantages over conventional surgical techniques due to less disruption of the overlying cortex and white matter fiber tracts. A 77-year-old man presented with a hypertensive ICH of the right putamen, measuring 9 cm in maximal diameter and 168 cm(3) in volume. We planned an endoport trajectory through the long axis of the hematoma using frameless stereotactic neuronavigation. In order to access the optimal cortical entry point at the lateral aspect of the basal frontal lobe, a miniature modified orbitozygomatic skull base craniotomy was performed through an incision along the superior border of the right eyebrow. Using the BrainPath endoport system (NICO, Indianapolis, IN, USA), the putaminal hematoma was successfully evacuated, resulting in an 87% postoperative reduction in ICH volume. Thus, we show that, in appropriately selected cases, endoport-assisted microsurgery is safe and effective for the evacuation of large ICH. Furthermore, minimally invasive anterior skull base approaches can be employed to expand the therapeutic potential of endoport-assisted approaches to include subcortical lesions, such as hematomas of the basal ganglia. Copyright © 2015 Elsevier Ltd. All rights reserved.
Wiegmann, Douglas A.; Eggman, Ashley A.; ElBardissi, Andrew W.; Henrickson, Sarah E.; Sundt, Thoralf M.
Over the past 50 years, significant improvements in cardiac surgical care have been achieved. Nevertheless, surgical errors that significantly impact patient safety continue to occur. In order to further improve surgical outcomes, patient safety programs must focus on rectifying work system factors in the operating room (OR) that negatively impact the delivery of reliable surgical care. The goal of this paper is to provide an integrative review of specific work system factors in the OR that may directly impact surgical care processes, as well as the subsequent recommendations that have been put forth to improve surgical outcomes and patient safety. The important role that surgeons can play in facilitating work system changes in the OR is also discussed. The paper concludes with a discussion of the challenges involved in assessing the impact that interventions have on improving surgical care. Opportunities for future research are also highlighted throughout the paper. PMID:20202623
Ee, Wen Wei Gerard; Lau, Wen Liang Joel; Yeo, William; Von Bing, Yap; Yue, Wai Mun
Surgical site infection (SSI) ranges from 1.9% to 5.5% in most large series. Minimally invasive surgery (MIS) has been postulated to reduce SSI rates. (1) Is MIS associated with a lower incidence of SSI compared with open spinal surgery? (2) Are there other independent risk factors associated with SSI? (3) What bacteria are most common in spinal SSI? Medical records of 2299 patients who underwent transforaminal lumbar interbody fusion, laminectomy, or discectomy were analyzed and selected for a nested case-control analysis. Twenty-seven cases with SSI were matched with 162 control subjects without SSI stratified based on procedure performed within 28 days of the case's date of surgery. Patients were identified from an institutional database at a tertiary care hospital. MIS involved spinal procedures performed through a tubular retractor system. Univariate and multivariate analyses were performed. Patients undergoing open spinal surgery were 5.77 times more likely to develop SSI compared with MIS approaches (odds ratio [OR], 5.77; 95% confidence interval [CI], 1.0-32.7; p = 0.048). Also, from the multivariate regression model, diabetes (OR, 4.7; 95% CI, 1.3-17.0; p = 0.018), number of levels operated on (OR, 3.5; 95% CI, 1.6-7.5; p = 0.001), and body mass index (OR, 1.2; 95% CI, 1.0-1.3; p = 0.010) were predictive of an increased risk in SSI. Staphylococcus aureus was most frequently identified, being present in 12 of 21 (52.4%) patients in whom positive cultures were obtained. Four of the 12 patients had methicillin-resistant S aureus infection. In our series, MIS has a lower incidence of SSI. The risk factors predictive of SSI should be further evaluated in well-designed prospective trials. Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Saini, Aditya; Hu, Yuhning L; Kasirajan, Vigneshwar; Han, Frederick T; Khan, Muhammad Z; Wolfe, Luke; Gunda, Sampath; Koneru, Jayanthi N; Ellenbogen, Kenneth A
Minimally invasive surgical atrial fibrillation (AF) ablation (MISAA) delivers radiofrequency energy via a thoracoscopic approach to perform pulmonary vein isolation and left atrial ganglionic plexi ablation. Data on long-term outcomes of MISAA are lacking. We report 5-year follow-up data from a prospective cohort of patients who underwent MISAA at a single center. One hundred nine consecutive patients (60 paroxysmal, 49 persistent; mean age 62.7 ± 9.3 years) underwent MISAA with left atrial appendage exclusion by a single surgeon between 2006 and 2012. Patients were followed with transtelephonic monitoring at 1, 6, and 12 months and annually thereafter for up to 5 years. Recurrence was defined as any atrial tachyarrhythmia lasting ≥30 seconds from 90 days after surgery onward. Mean follow-up duration was 1738.5 ± 661.5 days. Single-procedure success rate was 38% (37 of 98 patients). Atrial arrhythmias occurred in 22%, 42%, 55%, 59%, and 62% of patients by 1, 2, 3, 4, and 5 years. Seventy-eight (79.6%) patients remained AF free with or without additional interventions including catheter ablation, antiarrhythmic drugs, or cardioversion. There was no significant difference in AF-free survival between paroxysmal and persistent AF groups (P = .725). Multivariate analyses showed hypertension to be a significant predictor of AF recurrence (odds ratio 6.6, confidence interval 1.41-30.80; P = .016). Five (5.1%) patients had a stroke or transient ischemic attack during follow-up. AF-free survival was 38% at 5 years after MISAA. A total of 79.6% of patients remained AF free with or without additional intervention. Patients may have an ongoing risk of stroke even in the absence of AF recurrences. Copyright © 2017 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.
Konovalov, N A; Shevelev, I N; Nazarenko, A G; Asiutin, D S; Korolishin, V A; Timonin, S Iu; Zakirov, B A; Onoprienko, R A
To conduct a comparative analysis of outcomes in patients with extramedullary tumors operated on using a minimally invasive approach and traditional laminectomy. The study included 40 patients (13 males and 27 females) who underwent surgical treatment at the Department of Spinal Neurosurgery of the Burdenko Neurosurgical Institute. The mean age of patients was 47 years (range: 41-60 years). Tumors were located in the cervical, thoracic and lumbar spine. All patients were divided into two groups. In the control group, 20 patients underwent traditional laminectomy using a yard retractor or an Egorov-Freidin retractor. In the study group, 20 patients underwent hemilaminectomy using a retractor for minimally invasive surgery (Caspar and MAST Qudrant). The outcomes were evaluated 3, 6, and 12 months after surgery. The McCormik and VAS scales were used for the evaluation. MRI data were also evaluated. Total tumor resection was reached in all cases. The mean surgery duration was 247 min (range: 180-320 min) for the first group and 105.25 min (range: 60-190 min) for the second one. The volume of blood loss was 297 mL (range: 100-600 mL) for the first group and 210 mL (50 to 400 mL) for the second group. The histological nature of the tumors was as follows: neurinoma, meningioma, and ependymomas of the cauda equina. The evaluation of the pain syndrome in the early postoperative period revealed that the pain syndrome intensity according to VAS was reduced in patients of the second group compared to that in patients of the first group. The evaluation using the McCormik scale revealed no obvious difference in the results between the study and control groups. MRI studies performed in the postoperative period showed no tumor recurrence. Surgical treatment of patients with intradural extramedullary tumors can be safely and effectively performed using minimally invasive approaches. A potential reduction in surgery duration, intraoperative blood loss, the amount of anesthetic drugs
Zygomalas, Apollon; Giokas, Konstantinos; Koutsouris, Dimitrios
Aim. Modular mini-robots can be used in novel minimally invasive surgery techniques like natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single site (LESS) surgery. The control of these miniature assistants is complicated. The aim of this study is the in silico investigation of a remote controlling interface for modular miniature robots which can be used in minimally invasive surgery. Methods. The conceptual controlling system was developed, programmed, and simulated using professional robotics simulation software. Three different modes of control were programmed. The remote controlling surgical interface was virtually designed as a high scale representation of the respective modular mini-robot, therefore a modular controlling system itself. Results. With the proposed modular controlling system the user could easily identify the conformation of the modular mini-robot and adequately modify it as needed. The arrangement of each module was always known. The in silico investigation gave useful information regarding the controlling mode, the adequate speed of rearrangements, and the number of modules needed for efficient working tasks. Conclusions. The proposed conceptual model may promote the research and development of more sophisticated modular controlling systems. Modular surgical interfaces may improve the handling and the dexterity of modular miniature robots during minimally invasive procedures. PMID:25295187
Zygomalas, Apollon; Giokas, Konstantinos; Koutsouris, Dimitrios
Aim. Modular mini-robots can be used in novel minimally invasive surgery techniques like natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single site (LESS) surgery. The control of these miniature assistants is complicated. The aim of this study is the in silico investigation of a remote controlling interface for modular miniature robots which can be used in minimally invasive surgery. Methods. The conceptual controlling system was developed, programmed, and simulated using professional robotics simulation software. Three different modes of control were programmed. The remote controlling surgical interface was virtually designed as a high scale representation of the respective modular mini-robot, therefore a modular controlling system itself. Results. With the proposed modular controlling system the user could easily identify the conformation of the modular mini-robot and adequately modify it as needed. The arrangement of each module was always known. The in silico investigation gave useful information regarding the controlling mode, the adequate speed of rearrangements, and the number of modules needed for efficient working tasks. Conclusions. The proposed conceptual model may promote the research and development of more sophisticated modular controlling systems. Modular surgical interfaces may improve the handling and the dexterity of modular miniature robots during minimally invasive procedures.
Bonutti, Peter M; Zywiel, Michael G; Ulrich, Slif D; Stroh, D Alex; Seyler, Thorsten M; Mont, Michael A
The mini-subvastus and the mini-midvastus approaches are among the most common alternatives to the medial parapatellar approach for total knee arthroplasty. The purpose of this study was to compare the early clinical outcomes of these two approaches. In this prospective, randomized study of fifty-one patients who underwent bilateral total knee arthroplasty, the mini-subvastus approach was used in one knee and the mini-midvastus approach, in the contralateral knee. There were forty-two women and nine men who had a mean age of seventy years at the time of the index arthroplasties, and they were followed for two years postoperatively. Clinical outcome was assessed and compared with use of the Knee Society pain and function scores, the straight-leg-raising test, range of motion, and isokinetic strength testing. Operating time and blood loss for each approach were also compared. In addition, patients were surveyed concerning which knee they preferred. Comparisons of postoperative Knee Society scores between both approaches at the time of the two-year follow-up did not yield a significant difference in outcome. Isokinetic strength testing at twelve weeks postoperatively revealed no significant differences in muscle strength, with a mean extensor peak torque-to-body weight ratio of 0.14 Nm/kg for both groups. No significant difference was found with respect to total blood loss, straight-leg-raising test, range of motion, or patient preference. There was no clinically relevant difference in operative times between the two approaches. The minimally invasive subvastus and midvastus approaches for total knee arthroplasty were both associated with excellent short-term clinical results. Some surgeons believe that the subvastus approach completely avoids damage to the quadriceps mechanism and therefore would be associated with improved muscle function. This prospective series did not identify a substantive difference between the two approaches. We believe that the decision
Jordan, Jens F; Dietlein, Thomas S; Dinslage, Sven; Lüke, Christoph; Konen, Walter; Krieglstein, Günter K
In glaucoma filtration surgery, the problem of subconjunctival scarring has still not been satisfactorily solved. Suprachoroidal drainage of aqueous humour offers a promising, alternative option for intractable glaucoma. We here present a clinical study on the surgical approach of gonioscopic cyclodialysis ab interno. Twenty-eight eyes of 20 patients with intractable glaucoma were included in this prospective, consecutive, case-control study. The eyes had had a mean of 4.4 +/- 2.4 previous antiglaucomatous interventions. Baseline intraocular pressure (IOP) was 34.3 +/- 10.5 mmHg despite maximum therapy. Under gonioscopic control, cyclodialysis ab interno was performed over two clock times to gain access to the suprachoroidal space. No additional trabecular meshwork surgery was performed. Success was defined as a lowering of IOP to below 21 mmHg without the need for further medication or intervention. Mean postoperative IOP was 14.6 +/- 12.4 mmHg. Mean follow-up (FU) for all eyes was 121.8 days. After a mean of 60 days, 21 eyes (75%) needed further surgical intervention. Qualified success was seen in four eyes (14.3%), with a mean FU of 383.6 days. Three eyes (10.7%) showed absolute success after a mean FU period of 202.7 days. In our series, we obtained the best results for phakic eyes, followed by pseudophakic and aphakic eyes. The results of this study do not provide convincing evidence of the functional efficacy of cyclodialysis ab interno. Nevertheless, the technique is easy to perform and offers safe and atraumatic access to the resorptive capability of the choroid. Conjunctival manipulation is avoided. Contrary to reports in the current literature, in our series, the best results were obtained for phakic eyes, though the small number of eyes included does not allow reliable statistics. Further studies will need to focus on the use of different space-retaining substances or a widening of the cyclodialysis cleft to improve surgical outcome.
Eris, Cengiz; Akbulut, Sami; Yildiz, Mehmet Kamil; Abuoglu, Hasan; Odabasi, Mehmet; Ozkan, Erkan; Atalay, Suleyman; Gunay, Emre
The benefits and risks of surgery for splenic hydatid cyst (SHC) remain controversial. We aimed to share our experience about a surgical approach for SHC. Sixteen consecutive patients with SHC disease who underwent open splenectomy at our hospital between January 2006 and July 2012 were retrospectively evaluated. Data on the patients' demographic features, clinical findings, radiological and serological diagnostic methods, and surgical and medicinal treatment options were collected and used to generate descriptive profiles of diagnosis, treatment course, and outcome. The patient population was composed of 6 females and 10 males, with an age range of 18 to 79 years (mean age: 47.0 ± 18.0). Radiological examinations detected hydatid cysts in spleen alone (n = 7) or both spleen and liver (n = 9). Preoperative serological testing identified 13 of the patients as IHA positive. All except 1 patient received a 10- to 21-day preoperative course of albendazole therapy and all patients received vaccination 1 week prior to surgery. Seven patients underwent splenectomy. The remaining patients underwent splenectomy with partial cystectomy and omentopexy (n = 6), partial cystectomy and unroofing (n = 1), pericystectomy (n = 1), or pericystectomy with partial nephrectomy (n = 1). All except one patient received a 10- to 45-day postoperative course of albendazole. No patients developed serious complications or signs of recurrence during the follow-up. The clinical profile of SHC disease at our hospital includes diagnosis by radiological methods, splenectomy treatment by simple or concomitant procedures according to the patient's symptoms, cyst size, number and localization, and compression of adjacent organs, and adjunct vaccination to decrease risk of postoperative septic complications. This profile is associated with low risk of complications and high therapeutic efficacy.
Ameri, Ebrahim; Ghandhari, Hasan; Nabizadeh, Naveed
Introduction: Cervical hyperlordosis is a rare pediatric deformity leading to gaze and postural disturbances. The cornerstone of treatment consists of spinal manipulative therapy (SMT) combined with positional traction. Case Presentation: We report a new surgical approach in a 7-year-old female patient suffering from stiff cervical hyperlordosis, desiring to correct forward head posture as well as gaze disturbance. The patient had a chief complaint of restricted range of motion of the neck for the past 4 years. Posture examination revealed several abnormalities, including apparent thoracic hump with shifting to right side, slight elevation of the right shoulder, with back pain. She also had difficulties performing her assignments. Radiological investigations revealed a 95˚ cervical lordosis and forward head posture (FHP) assessed by two separate measurements. There was no considerable response to conservative treatment, (which included 30 sessions of SMT combined with positional traction). Consequently, she underwent radical resection of cervical paraspinal muscles, followed by halo traction. She was discharged with a halo-vest. Specific instructions for home exercise were provided to the patient. Post-trial radiographs showed a reduction of cervical lordosis to 51˚ and a reduction in FHP of 73 mm. The symptoms were alleviated at the end of the treatment. Discussion: This new approach appeared to correct postural abnormalities, and had an obvious positive effect on the patient’s chief complaint. PMID:25337515
Pemán, Javier; Zaragoza, Rafael
For the specialist, the management of invasive candidiasis infections, from diagnosis to selection of the therapeutic protocol, is often a challenge. Although early diagnosis and treatment are associated with a better prognosis, apart from cases with positive blood cultures or fluid/tissue biopsy, diagnosis is neither sensitive nor specific, relying on many different factors, clinical and laboratory findings but there is certainly a need for the specific markers in this disease. Recently, new serodiagnostic assays as Candida albicans germ-tube antibodies or (1,3)-beta-D-glucan detection and molecular techniques for the detection of fungal-specific DNA have been developed with controversial results in critical care setting. One of the main features in diagnosis is the evaluation of risk factor for infection, which will identify patients in need of preemptive or empirical treatment. Clinical scores were built from those risk factors. For these reasons, an approach to the new diagnosis tools in the clinical mycology laboratory and an analysis of the new prediction rules and its application situations has been made. Currently, the combination of prediction rules and non-culture microbiological tools could be the clue for improving the diagnosis and prognosis of invasive fungal infections in critically ill patients.
Ceccaroni, Marcello; Clarizia, Roberto; Roviglione, Giovanni; Ruffo, Giacomo
Efforts to improve approaches to the so called "parametrium" with minimally invasive and less dangerous techniques have led to a better study of the anatomic location and composition of that region. Nevertheless, many misconceptions and confusions about the anatomy of the posterior parametrium and its structures still remain. This study aimed to review anatomic and surgical data and to identify several clear landmarks and surgical steps for a nerve-sparing approach to posterior parametrectomy in the course of radical pelvic surgery with or without rectal resection. The literature and anatomic dissections of fresh, embalmed, and formalin-fixed female pelvis cadavers were reviewed. The authors' laparotomic and laparoscopic case series also was reviewed for deep-infiltrating endometriosis as well as uterine, ovarian, and rectal cancer. The anatomic entity commonly termed the "posterior parametrium" can be identified as the conjunction of three important anatomic structures (ligaments): the cranial structure (uterosacral ligaments), the caudad structure (rectovaginal ligaments), and the laterocaudad structure (lateral rectal ligaments). Identification of these structures (containing autonomic innervations for pelvic viscera) may allow an accurate nerve-sparing surgical approach in many radical pelvic operations. The incidences of urinary, rectal, and sexual morbidity after radical pelvic surgical procedures for oncologic diseases (rectal/ovarian cancer, advanced endometrial/cervical cancer, posterior pelvic recurrences) and deep severe endometriosis can be reduced by better knowing and dissecting the right embryo-anatomic planes of the so-called "posterior parametrium."
Usmanova, T É
The results of 95 patients treatment with benign brest gland tumours (BBGT) were studied. For improve the results of treatment the introduction of surgical techniques that reduce the invasiveness of operations were applied. The performance of preoperative ultrasound (US) marking BB GT, cosmetically non-traumatic incisions, US dissector, combined cosmetic suture applay for the glandular tissue after sectoral resection of brest gland contribute to improving the results of surgical treatment, which is confirmed by the auspicious course of the early postoperative period.
Bogani, Giorgio; Borghi, Chiara; Leone Roberti Maggiore, Umberto; Ditto, Antonino; Signorelli, Mauro; Martinelli, Fabio; Chiappa, Valentina; Lopez, Carlos; Sabatucci, Ilaria; Scaffa, Cono; Indini, Alice; Ferrero, Simone; Lorusso, Domenica; Raspagliesi, Francesco
Few studies investigated the efficacy and safety of minimally invasive surgery (MIS) for the treatment of early stage epithelial ovarian cancer (eEOC). In this context, we aimed to review the current evidence comparing laparoscopy and laparotomic approach for staging procedures in eEOC This systematic review was registered in the International Prospective Register of Systematic Review. Overall, 3,065 patients were included: 1,450 undergoing laparoscopy and 1,615 undergoing laparotomic staging. Patients undergoing laparoscopy experienced a longer (but not statistically significant) operative time (WMD: 28.3 minutes; 95%CI: -2.59, 59.2), lower estimated blood loss (WMD: -156.5 ml; 95%CI: -216.4, -96.5), shorter length of hospital stay (WMD: -3.7 days; 95%CI: -5.2, -2.1) and lower postoperative complication rate (OR: 0.48; 95%CI: 0.29, 0.81) than patients undergoing laparotomy. Upstaging (OR: 0.81; 95%CI: 0.55, 1.20) and cysts' rupture (OR: 1.32; 95%CI: 0.52, 3.38) rates were similar between groups. Laparoscopic staging is associated with a shorter time to chemotherapy than laparotomic procedures (WMD: -5.16 days; 95%CI: -8.68, -1.64). Survival outcomes were not influence by route of surgery. Pooled data suggested that MIS approach is equivalent to laparotomy for the treatment of eEOC and may be superior in terms of perioperative outcomes. However, owing to the low level of evidence of the included studies, further prospective randomized trials are warranted.
Yamazaki, Shintaro Kuramoto, Kenmei; Itoh, Yutaka; Watanabe, Yoshika; Ueda, Toshisada
Pancreas fistula is a well-known and severe complication of pancreaticoduodenectomy. It is difficult to control with conservative therapy, inducing further complications and severe morbidity. Until now, re-operation has been the only way to resolve pancreatic fistula causing complete dehiscence of the pancreatic-enteric anastomosis (complete pancreatic fistula). Percutaneous transgastric fistula drainage is one of the treatments for pancreatic fistula. This procedure allows both pancreas juice drainage and anastomosis re-construction at the same time. This is effective and minimally invasive but difficult to adapt to a long or complicated fistula. In particular, dilatation of the main pancreatic duct is indispensable. This paper reports the successful resolution of a postoperative pancreatic fistula by a two-way-approach percutaneous transgastric fistula drainage procedure. Using a snare catheter from the fistula and a flexible guidewire from the transgastric puncture needle, it can be performed either with or without main pancreatic duct dilatation.
Najjar, A; Zairi, F; Sunna, T; Weil, A; Estrade, L; Weill, A; Shedid, D
Vascular lesions of the spinal cord are increasingly recognized. The most common types of these lesions are dural arteriovenous fistulas (AVFs) whereas, extradural AVFs are a very rare type of spinal AVF and can be associated with either extradural or intradural venous reflux. This results in neurological deficits through congestive or compressive myeloradiculopathy. These lesions must be treated to allow stabilization or improvement of neurologic status, either by endovascular therapy or microsurgical interruption. However, because some patients are not amenable to endovascular treatment, surgery is often warranted, which usually involves hemi- or bilateral laminectomy following a midline approach with bilateral muscle stripping. The main drawback of this procedure is directly related to the morbidity of the approach. Although, minimally invasive approaches are likely to overcome this drawback, there is a lack of reported experience supporting their use for treating spinal dural AVFs. Two patients, aged 62 and 79 years old, presented with rapidly progressive myelopathy characterized by paraparesis and sphincter disturbance. Spinal magnetic resonance imaging showed spinal cord oedema with perimedullary flow voids in both cases. Digital subtraction angiography revealed extradural AVFs associated with perimedullary venous reflux. Endovascular therapy was not feasible. Both patients were treated with microsurgical interruption of the intradural vein through a non-expendable retractor. Complete exclusion was confirmed on postoperative angiography, resulting in resolution of spinal cord edema and improved neurological functional status at 2-year follow-up. The minimally invasive surgical treatment of spinal AVFs with epidural venous reflux is safe and effective. This approach is a valuable alternative to endovascular therapy and the standard open microsurgical approach. Copyright © 2016 Elsevier Masson SAS. All rights reserved.
Notani, Naoki; Miyazaki, Masashi; Kanezaki, Shozo; Ishihara, Toshinobu; Kawano, Masanori; Tsumura, Hiroshi
Spinal meningioma is a relatively common tumor among intradural extramedullary spinal tumors. When the locus of the meningioma is located on the ventral side, tumor removal, dura mater resection, and reconstruction via a posterior approach safety become technically difficult. Twelve patients, who received surgical treatment for ventral spinal meningioma via a posterior approach, were included. There were three male and nine female patients, with an average age of 66.3 years (47-88 years). The average observation period was 55.4 months (22-132 months). In these cases, we analyzed the spinal level of tumor position, histopathological type (subtype), the grade of tumor resection (Simpson grade), pre- and post-operative walking state (Nurick grade), perioperative neurological complications, and the recurrence. Spinal meningioma occurred in the cervical spinal cord in three cases, with a further nine cases in the thoracic spinal cord. Histopathologically, all 12 tumors were assessed as grade I on the WHO classification system (eight cases of meningothelial type and four cases of psammomatous type). The level of tumor resection was Simpson grade I resection for two cases and Simpson grade II resection for the remaining ten cases. The average of Nurick grade improved from 3.3 preoperatively to 1.3 postoperatively. In all cases, we identified no neurological complications. One incident of tumor recurrence was identified 11 years after an operation involving a Simpson grade II resection CONCLUSION: Posterior approaches provide adequate exposure to safely remove ventrally located meningioma. Posterior exposures with lateral bone resection, dentate ligament division, provide also adequate exposure for safe removal.
López, María Mercedes; Guasch, Emilia; Schiraldi, Renato; Maggi, Genaro; Alonso, Eduardo; Gilsanz, Fernando
Aortic stenosis increases perioperative morbidity and mortality, perioperative invasive monitoring is advised for patients with an aortic valve area <1.0 cm(2) or a mean aortic valve gradient >30 mmHg and it is important to avoid hypotension and arrhythmias. We report the anaesthetic management with continuous spinal anaesthesia and minimally invasive haemodynamic monitoring of two patients with severe aortic stenosis undergoing surgical hip repair. Two women with severe aortic stenosis were scheduled for hip fracture repair. Continuous spinal anaesthesia with minimally invasive haemodynamic monitoring was used for anaesthetic management of both. Surgery was performed successfully after two consecutive doses of 2mg of isobaric bupivacaine 0.5% in one of them and four consecutive doses in the other. Haemodynamic conditions remained stable throughout the intervention. Vital signs and haemodynamic parameters remained stable throughout the two interventions. Our report illustrates the use of continuous spinal anaesthesia with minimally invasive haemodynamic monitoring as a valid alternative to general or epidural anaesthesia in two patients with severe aortic stenosis who are undergoing lower limb surgery. However, controlled clinical trials would be required to establish that this technique is safe and effective in these type or patients. Copyright © 2013 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.
Kaya, Ramazan Alper; Aydin, Yunus
Conventional transpedicular decompression of the neural canal requires a considerable amount of lamina, facet joint and pedicle resection. The authors assumed that it would be possible to remove the retropulsed bone fragment by carving the pedicle with a high-speed drill without destroying the vertebral elements contributing to spinal stabilization. In this way, surgical treatment of unstable burst fractures can be performed less invasively. The purpose of this study is to demonstrate both the possibility of neural canal decompression through a transpedicular approach without removing the posterior vertebral elements, which contribute to spinal stabilization, and the adequacy of posterior stabilization of severe vertebral deformities after burst fractures. Twenty-eight consecutive patients with complete or incomplete neurological deficits as a result of the thoracolumbar burst fractures were included in this study. All patients had severe spinal canal compromise (mean, 59.53%+/-14.92) and loss of vertebral body height (mean, 45.14%+/-7.19). Each patient was investigated for neural canal compromise, degree of kyphosis at fracture level and fusion after operation by computed tomography and direct roentgenograms taken preoperatively, early postoperatively and late postoperatively. The neurological condition of the patients was recorded in the early and late postoperative period according to Benzel-Larson grading systems. The outcome of the study was evaluated with regard to the adequate neural canal decompression, fusion and reoperation percents and neurological improvement. Modified transpedicular approach includes drilling the pedicle for removal of retropulsed bone fragment under surgical microscope without damaging the anatomic continuity of posterior column. Stabilization with pedicle screw fixation and posterior fusion with otogenous bone chips were done after this decompression procedure at all 28 patients included in this study. Twenty-three of 28 patients
del Prete, F; Nizegorodcew, T; Regazzoni, P
Fixation of pertrochanteric fracture is undoubtedly an additional trauma after the fracture itself. In elderly patients, it might have an important impact on the whole organism. In the literature we find various techniques to perform this type of surgery. Up to now, there are no parameters validated for quantification of the invasiveness of a surgical procedure; it is therefore still not demonstrated that any method is less invasive than any other. In an effort to find a way to quantify the invasiveness of a surgical procedure, inflammatory markers were collected in patients undergoing fixation of trochanteric fracture with gliding hip screw [dynamic hip screw (DHS)] using either a conventional (DHS conv) or minimally invasive (DHS MIO) technique. Two groups of patients were investigated prospectively; 36 of them were treated with conventional DHS technique and 32 with minimally invasive technique. Mean age was 84.7 ± 7.20 and 82.78 ± 7.71 years, respectively. Fracture type was classified according to the AO classification. Interleukin (IL)-6, IL-10, IL-8, and tumor necrosis factor (TNF)-α were measured 1 h before and 1 h after surgery. Student's t test, chi-square test, and multivariate logistic regression were used for statistical analysis. Preoperative levels of interleukins showed no significant differences between the two groups. In contrast, the postoperative blood level of IL-6 in patients operated with DHS conv technique (78.41 ± 67.04 pg/ml) was on average higher than in patients operated by DHS MIO technique (39.02 ± 37.36 pg/ml), the mean difference being 39.39 pg/ml [95 % confidence interval (CI) 12.65-66.13 pg/ml; p = 0.0045]. Multivariate logistic regression (backward method with limit of significance 0.05) confirmed that patients operated by conventional technique were significantly more likely to have increased IL-6 after surgery than those operated by MIO technique. IL-8 was measured in only 36 patients (20 for DHS conv, 16 for DHS MIO). No
Yamamoto, Takumi; Yoshimatsu, Hidehiko; Hayashi, Akitatsu; Koshima, Isao
The treatment of deep pressure ulcer with a wide wound edge undermining (pocket) is challenging, especially when conservative treatments are ineffective. As most patients with a pressure ulcer suffer from systemic comorbidities, invasive surgery cannot be performed on all patients, and less invasive treatment is required. Less invasive surgical intervention to a deep pressure ulcer, parallel pocket incision (PPI), was performed on 10 patients with intractable pressure ulcers with a pocket formation. In PPI procedures, two parallel skin incisions were made to open up the deepest fold of the pocket and to preserve the skin overlying the pocket lesion; through the created incisions, the necrotic tissues around the deepest fold of the undermining could be easily removed, which facilitated spontaneous wound healing. Postoperative results and complications were evaluated. All PPI procedures were safely performed under local infiltration anesthesia without major postoperative complication; minor bleeding was seen intraoperatively in three patients, which could be easily controlled with electric cautery coagulation. Nine of 10 ulcers were cured after PPI, and one could not be followed up due to the patient's death non-related to the pressure ulcer. For the nine cured patients, the average time for cure was 14.9 weeks, and no recurrence was observed at postoperative 6 months. PPI is a simple, technically easy, and less invasive surgical intervention to an intractable pressure ulcer with a pocket, which can be safely performed under local infiltration anesthesia even on a patient with severe systemic comorbidities. Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Jargin, Sergei V.
Some aspects of pathogenesis and therapeutic approach to the gingival recession are discussed in this short communication with the example of a typical case from Russia, where excessive socket curettage after a tooth extraction resulted in a marked gingival recession. Subgingival plaque and calculus can be secondary to recession. An argument about plaque as a source of microorganisms might be plausible in case of inflammation, although various microorganisms are normal for the oral cavity. From the viewpoint of general pathology, being an atrophic condition, recession can progress due to repeated damage. On the author's opinion, calculus removal is not indicated at least for aged patients with marked gingival recession, having modest esthetic demands. Socket curettage after exodontia should be gentle. Surgical treatment of the gingival recession is beyond the scope of this communication. PMID:24049345
VECCHIO, R.; MARCHESE, S.; FAMOSO, F.; LA CORTE, F.; MARLETTA, S.; LEANZA, G.; ZANGHÌ, G.; LEANZA, V.; INTAGLIATA, E.
Aim Colorectal cancer is one of the most common malignancies in general population. The incidence seems to be higher in older age. Surgery remains the treatment of choice and laparoscopic approach offers numerous benefits. We report our personal experience in elderly patients operated on for colorectal cancer with laparoscopic resection. Patients and methods From January 2003 to September 2013, out of 160 patients aged 65 years or older and operated with minimally invasive techniques, 30 cases affected by colorectal cancer and operated on with laparoscopic approach were analyzed in this study. Results Male/female ratio was 1.35 and mean age 72 years. Constipation, weight loss, anemia and rectal bleeding were the most commonly reported symptoms. Lesions involved descending-sigmoid colon in 53% of cases, rectum in 37% and ascending colon in 10%. Among laparoscopic colorectal operations laparoscopic left colectomy was the most frequently performed, followed by right colectomy, abdominoperineal resection and Hartmann procedure. Operative times ranged from 3 to 5 hours depending on surgical procedure performed. Mean hospital stay was 6 days (range 4–9). Conversion to open approach occurred only in a case of laparoscopic right colectomy (3%) for uncontrolled bleeding. A single case of mortality was reported. In two cases (7%) anastomotic leakage was observed, conservatively treated in one patient and requiring reoperation in the other one. Conclusions Laparoscopic colorectal surgery is feasible and effective for malignancies in elderly population offering several advantages including immunologic and oncologic ones. However an experienced surgical team is essential in reducing risks and complications. PMID:25827663
Soliman, Pamela T.; Frumovitz, Michael; Sun, Charlotte C.; dos Reis, Ricardo; Schmeler, Kathleen M.; Nick, Alpa M.; Westin, Shannon N.; Brown, Jubilee; Levenback, Charles F.; Ramirez, Pedro T.
Objective To compare intra-operative, postoperative and pathologic outcomes of three surgical approaches to radical hysterectomy and bilateral pelvic lymph node dissection over a three year time period during which all three approaches were used. Methods We reviewed all patients who underwent radical hysterectomy with pelvic lymph node dissection between 1/2007 and 11/2010. Comparison was made between robotic, laparoscopic and open procedures in regard to surgical times, complication rates, and pathologic findings. Results A total of 95 radical hysterectomy procedures were performed during the study period: 30 open (RAH), 31 laparoscopic (LRH) and 34 robotic (RRH). There were no differences in age, body mass index or other demographic factors between the groups. Operative time was significantly shorter in the RAH compared to LRH and RRH (265 vs 338 vs 328 min, p=0.002). Estimated blood loss was significantly lower in LRH and RRH compared with RAH (100 vs 100 vs 350 mL, p<0.001). Thirteen (24%) of RAH required blood transfusion. Conversion rates were higher in the LRH (16%) compared to RRH (3%) although not significant (p=0.10). Median length of stay was significantly shorter in RRH (1 days) vs LRH or RAH (2 vs 4 days, p<0.01). Pathologic findings were similar among all groups. Conclusion Minimally invasive surgery has made a significant impact on patients undergoing radical hysterectomy including decrease in blood loss and transfusion rates however; operative times were significantly longer compared to open radical hysterectomy. Our findings suggest that the robotic approach may have the added benefit of even shorter length of stay compared to traditional laparoscopy. PMID:21872911
Cucchi, Alessandro; Vignudelli, Elisabetta; Franco, Simonetta; Corinaldesi, Giuseppe
Extremely atrophic maxillae can be considered the most important indication for three-dimensional maxillary reconstruction. Different bone-augmentation techniques have been suggested to accomplish this. This article illustrates a minimally invasive approach to rehabilitation of the extremely atrophic maxilla. A 63-year-old male patient was referred for restoration of his totally edentulous maxilla with a fixed full-arch implant-prosthetic rehabilitation. Four short implants in the premaxillary region and 2 longer implants in the pterygomaxillary regions were inserted with piezoelectric implant site preparation. At the 1-year follow-up appointment, no clinical or radiographic changes in the soft-tissue contours or crestal bone levels were observed. This surgical approach, based on the combination of short implants in the premaxillary regions and pterygoid implants in the pterygomaxillary regions, represents a way to shorten treatment timing, minimize the risk of surgical complications, and reduce patient discomfort and costs.
Zahoor, B A; Piercey, J E; Wall, D R; Tetsworth, K D
Mucormycosis as a consequence of trauma is a devastating complication; these infections are challenging to control, with a fatality rate approaching 96% in immunocompromised patients. We present a case where a proactive approach was successfully employed to treat mucormycosis following complex polytrauma. Aggressive repeated surgical debridement, in combination with appropriate antifungal therapy, proved successful in this instance. In our opinion, mucormycosis in trauma mandates an aggressive surgical approach. This prevents ascending dissemination of mucormycosis and certainly reduces the risk of patient mortality as a direct result. Anti-fungal therapy should be used secondarily as an adjunct together with surgical debridement, or as an alternative when surgical intervention is not feasible.
Martinez, Emilio A; Martinez, Cristina A; Nohalez, Alicia; Sanchez-Osorio, Jonatan; Vazquez, Juan M; Roca, Jordi; Parrilla, Inmaculada; Gil, Maria A; Cuello, Cristina
Surgical procedures are prevalent in porcine embryo transfer (ET) programs, where the use of vitrified embryos is quasi non-existent. This study compared the effectiveness of surgical vs nonsurgical deep uterine (NsDU) ET using vitrified, in vivo-derived embryos (morulae and blastocysts) on the reproductive performance and welfare of the recipients. The recipient sows (n=122) were randomly assigned to one of the following groups: surgical ET with 30 vitrified-warmed embryos (S-30 group, control); NsDU-ET with 30 vitrified-warmed embryos (NsDU-30 group) and NsDU-ET with 40 vitrified-warmed embryos (NsDU-40 group). Regardless of embryo stage, the NsDU-ET with 40 embryos presented similar rates of farrowing (72.7%) and litter size (9.9 ± 2.1 piglets) as the customary surgical procedure (75.0% and 9.6 ± 2.7 piglets). Numbers of ET-embryos appeared relevant, since the NsDU-ET with 30 embryos resulted in a decrease (P<0.05) in farrowing rates (38.9%) and litter sizes (5.7 ± 2.4 piglets). In conclusion, we demonstrate for the first time that farrowing rate and litter size following a NsDU-ET procedure increase in function of a larger number of transferred vitrified embryos, with fertility equalizing that obtained with the invasive surgical approach. The results open new possibilities for the widespread use of non-invasive ET in pigs.
Martinez, Emilio A.; Martinez, Cristina A; Nohalez, Alicia; Sanchez-Osorio, Jonatan; Vazquez, Juan M.; Roca, Jordi; Parrilla, Inmaculada; Gil, Maria A.; Cuello, Cristina
Surgical procedures are prevalent in porcine embryo transfer (ET) programs, where the use of vitrified embryos is quasi non-existent. This study compared the effectiveness of surgical vs nonsurgical deep uterine (NsDU) ET using vitrified, in vivo-derived embryos (morulae and blastocysts) on the reproductive performance and welfare of the recipients. The recipient sows (n = 122) were randomly assigned to one of the following groups: surgical ET with 30 vitrified-warmed embryos (S-30 group, control); NsDU-ET with 30 vitrified-warmed embryos (NsDU-30 group) and NsDU-ET with 40 vitrified-warmed embryos (NsDU-40 group). Regardless of embryo stage, the NsDU-ET with 40 embryos presented similar rates of farrowing (72.7%) and litter size (9.9 ± 2.1 piglets) as the customary surgical procedure (75.0% and 9.6 ± 2.7 piglets). Numbers of ET-embryos appeared relevant, since the NsDU-ET with 30 embryos resulted in a decrease (P < 0.05) in farrowing rates (38.9%) and litter sizes (5.7 ± 2.4 piglets). In conclusion, we demonstrate for the first time that farrowing rate and litter size following a NsDU-ET procedure increase in function of a larger number of transferred vitrified embryos, with fertility equalizing that obtained with the invasive surgical approach. The results open new possibilities for the widespread use of non-invasive ET in pigs. PMID:26030839
Linsler, Stefan; Fischer, Gerrit; Skliarenko, Volodymyr; Stadie, Axel; Oertel, Joachim
Keyhole approaches are under investigation for skull base tumor surgery. They are expected to have a low complication rate with the same successful resection rate compared with endoscopic endonasal procedures. In this study, we compare our current series of tuberculum sellae meningiomas resected via an endoscopic endonasal or microsurgical supraorbital keyhole approach. Between 2011 and 2016, 16 patients were treated using the supraorbital keyhole procedure and 6 patients received an endoscopic endonasal procedure. Both surgical techniques were analyzed and compared concerning complications, surgical radicality, endocrinologic, and ophthalmologic outcome and recurrences in patients' follow-up. The 2 different approaches yielded similar rates of gross total resection (endonasal 83% [5 of 6] vs. supraorbital 87% [14 of 16]), near total resection (17% [1 of 6] vs. 13% [2 of 16]), and visual recovery (endonasal 66% [2 of 3] vs. supraorbital 60% [3 of 5]). An extension lateral to the internal carotid artery was noted in 81% (13 of 16) of the supraorbital cases and in none of the endonasal cases. Tumor volume was 14.9 cm(3) (±8.2 cm(3)) for supraorbital tumors versus 2.1 cm(3) (±0.8 cm(3)) for the endonasal approach. Both approaches provide minimally invasive surgical routes accessing meningiomas of the sellar region. The ideal approach should be tailored to the individual patient considering the tumor anatomy, lateral extension, and the experience of the surgeon with both surgical approaches. We suggest using the supraorbital approach for larger meningiomas of sellar region with far lateral extension or broad vascular encasement. Copyright © 2017 Elsevier Inc. All rights reserved.
Kalchenko, Vyacheslav; Brill, Alexander; Fine, Ilya; Harmelin, Alon
Physiological blood coagulation is an essential biological process. Current tests for plasma coagulation (clotting) need to be performed ex vivo and require fresh blood sampling for every test. A recently published work describes a new, noninvasive, in vivo approach to assess blood coagulation status during mechanical occlusion1. For this purpose, we have tested this approach and applied a controlled laser beam to blood micro-vessels of the mouse ear during mechanical occlusion. Standard setup for intravital transillumination videomicroscopy and laser based imaging techniques were used for monitoring the blood clotting process. Temporal mechanical occlusion of blood vessels in the observed area was applied to ensure blood flow cessation. Subsequently, laser irradiation was used to induce vascular micro-injury. Changes in the vessel wall, as well as in the pattern of blood flow, predispose the area to vascular thrombosis, according to the paradigm of Virchow's triad. In our experiments, two elements of Virchow's triad were used to induce the process of clotting in vivo, and to assess it optically. We identified several parameters that can serve as markers of the blood clotting process in vivo. These include changes in light absorption in the area of illumination, as well as changes in the pattern of the red blood cells' micro-movement in the vessels where blood flow is completely arrested. Thus, our results indicate that blood coagulation status can be characterized by non-invasive, in vivo methodologies.
Fernández-Palomo, L J
Surgical treatment of acetabular fractures is indicated in displaced cases in order to restore and stabilize the hip joint and the pelvic ring integrity. Posterior structure fractures must be treated through posterior pelvic surgical approaches. The Kocher-Langenbeck is the most recommended approach for the majority of posterior acetabular fractures.
Donker, M; Hage, J J; Woerdeman, L A E; Rutgers, E J Th; Sonke, G S; Vrancken Peeters, M-J T F D
Neoadjuvant chemotherapy is gaining acceptance as an option for breast cancer treatment, particularly in young women. These women may seek immediate breast reconstruction after mastectomy even though it is not known whether such preoperative chemotherapy may be detrimental to post-reconstruction wound healing. Therefore, we set out to assess the influence of neoadjuvant chemotherapy for invasive breast cancer on the short-term complications after skin sparing mastectomy and immediate prosthetic reconstruction. The short-term surgical outcome of 48 immediate breast reconstructions in 37 women treated with neoadjuvant chemotherapy from 2006 through 2009 was prospectively compared to that of 215 immediate reconstructions in 176 women who were operated in the same period without neoadjuvant chemotherapy. The overall rate of short-term postoperative complications was significantly less among neoadjuvantly treated women (15% vs. 29%; p = 0.042) but this did not result in a reduction of loss of prostheses (8% vs. 11%; p = 0.566). Because neoadjuvant chemotherapy is not associated with an increase in short-term complications after skin sparing mastectomy and immediate prosthetic reconstruction in patients with invasive breast cancer, such combined surgical therapy may be offered as treatment option for this particular group of patients also. Copyright © 2011 Elsevier Ltd. All rights reserved.
Sato, Sayuri; Nakamura, Yasuhiro; Teramoto, Yukiko; Yeh, Yu-Wen; Maruyama, Hiroshi; Nakamura, Yoshiyuki; Fujisawa, Yasuhiro; Fujimoto, Manabu; Yamamoto, Akifumi
Inguinal lymph node dissection (ILND) for skin cancer is associated with a high incidence of wound complications. The traditional skin approaches are associated with a high risk of wound/flap necrosis of the inguinal skin, which leads to wound dehiscence and wound infection. We report a novel approach for ILND without inguinal skin incision for patients with invasive extramammary Paget disease (EMPD) to minimize the wound complications inherent in conventional ILND. We totally performed this procedure in 3 patients with invasive EMPD with inguinal nodal metastases. No patient had complications, including flap necrosis, wound dehiscence, or wound infection. Our novel surgical approach would retain the vascular supply because there was no inguinal skin incision, preventing postoperative wound complications. In addition, ILND was easily performed with satisfactory exposure of the surgical field. However, the number of patients was small and the follow-up period was short. Further evaluation of a larger case series with longer follow-up is essential to investigate the effect, safety, and indications for this novel approach.
Ditto, Antonino; Martinelli, Fabio; Bogani, Giorgio; Gasparri, Maria L; Di Donato, Violante; Zanaboni, Flavia; Lorusso, Domenica; Raspagliesi, Francesco
To investigate the safety, feasibility and effectiveness of laparoscopic approach in the management patients undergoing modified radical hysterectomy for early stage cervical cancer. Consecutive data of 157 women who had class II radical hysterectomy, for stage IA2 and stage IB1 <2 cm cervical cancer, were prospectively collected. Data of patients undergoing surgery via laparoscopy (LRH) were compared with those undergoing open surgical operations (RAH). A propensity-matched comparison (1:1) was carried out to minimize as possible selection biases. Post-operative complications were graded per the Clavien-Dindo classification. Five-year survival outcomes were assessed using Kaplan-Meier model. After the exclusion of 37 (23.5%) patients on the basis of propensity-matching, 60 patients undergoing LRH were compared with 60 patients undergoing RAH. No between-group differences in baseline, disease and pathological variables were observed (p > 0.05). Patients undergoing surgery via laparoscopy experienced longer operative time than patients undergoing RAH; while LRH correlated whit shorter length of hospitalization and lower blood loss in comparison to RAH. Intra- and post-operative complication rate was similar between groups (p = 1.00). The execution of LRH or RAH did not influence site of recurrence (p > 0.2) as well as survival outcomes, in term of 5-year disease-free (p = 0.29, log-rank test) and overall survivals (p = 0.50, log-rank test). Laparoscopic approach is a safe procedure, upholds the results of RAH, reducing invasiveness of open surgical operations. Further large prospective investigations are warranted. Copyright © 2014 Elsevier Ltd. All rights reserved.
Hrusztics, Aminett; Bogdán, Sándor; Fellegi, Veronika; Szabó, György
The term of apicectomy has been well-known for more than 200 years, nevertheless it is not performed frequently on molars. As a result of this a lot of molars became extracted. The aim of the authors was to present the new surgical technique which is described in detail. The radicular cyst localised on the palatal root of the first maxillary molar was operated on. Uneventful healing was obtained. This surgical technique is recommended in some special cases.
Lim, Kun-Eng; Shen, Ta-Chung
A 53-year-old male with an invasive thymoma extending to the superior vena and right atrium, presenting as superior vena cava syndrome is herein reported. However invasive thymoma with this growth pattern is extremely rare. In this case, the tumor was successfully resected via median sternotomy with cardiopulmonary bypass. After 17 months of follow-up, the patient was still free from any signs and symptoms indicative of superior vena cava syndrome, but recurrent tumor in the right pleura was observed on the follow-up chest computed tomography. PMID:28344425
Erdoes, Gabor; Lippuner, Christoph; Kocsis, Istvan; Schiff, Marcel; Stucki, Monika; Carrel, Thierry; Windecker, Stephan; Eberle, Balthasar; Stueber, Frank; Book, Malte
To investigate the periprocedural inflammatory response in patients with isolated aortic valve stenosis undergoing surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI) with different technical approaches. Patients were prospectively allocated to one of the following treatments: SAVR using conventional extracorporeal circulation (CECC, n = 47) or minimized extracorporeal circulation (MECC, n = 15), or TAVI using either transapical (TA, n = 15) or transfemoral (TF, n = 24) access. Exclusion criteria included infection, pre-procedural immunosuppressive or antibiotic drug therapy and emergency indications. We investigated interleukin (IL)-6, IL-8, IL-10, human leukocyte antigen (HLA-DR), white blood cell count, high-sensitivity C-reactive protein (hs-CRP) and soluble L-selectin (sCD62L) levels before the procedure and at 4, 24, and 48 h after aortic valve replacement. Data are presented for group interaction (p-values for inter-group comparison) as determined by the Greenhouse-Geisser correction. SAVR on CECC was associated with the highest levels of IL-8 and hs-CRP (p<0.017, and 0.007, respectively). SAVR on MECC showed the highest descent in levels of HLA-DR and sCD62L (both p<0.001) in the perioperative period. TA-TAVI showed increased intraprocedural concentration and the highest peak of IL-6 (p = 0.017). Significantly smaller changes in the inflammatory markers were observed in TF-TAVI. Surgical and interventional approaches to aortic valve replacement result in inflammatory modulation which differs according to the invasiveness of the procedure. As expected, extracorporeal circulation is associated with the most marked pro-inflammatory activation, whereas TF-TAVI emerges as the approach with the most attenuated inflammatory response. Factors such as the pre-treatment patient condition and the extent of myocardial injury also significantly affect inflammatory biomarker patterns. Accordingly, TA-TAVI is to be classified not as
Dengfeng, Zhang; Haojie, Wu; Xiao, Wang
The clinical effect and safety of the anterior surgical approach and posterior surgical approach in the treatment of thoracolumbar spinal fracture was compared. Retrospective analyses of clinical data for 91 patients observed from March 2010 to September 2014 were made. The pre-operation and post-operation comparisons between two sets of Cobb’s angle, affected vertebra height, Frankel’s classification of spinal nerves, motion functions, and tactile functions showed statistically significant differences (P<0.05). After having the operation, the Cobb’s angle and affected vertebra height of the patient in the anterior approach group were both significantly higher than that of patients in the posterior approach group (P<0.05). The bone graft fusion rate of the patients in the anterior approach group 3 months after operation was higher than that of patients in the control group while the status of complications was worse than that of patients in the posterior approach group, both with a remarkable difference (P<0.05). Both the anterior surgical approach and posterior surgical approach have good clinical outcome for spinal fractures but they all have their respective adaption diseases. The key in the treatment of thoracolumbar spinal fractures lies in choosing proper operative approach. PMID:28352728
Lee, Hyeong-Jin; Ryu, Kyeong-Sik
Background. Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is a widely accepted surgical procedure. But there are only a few reports of MIS-TLIF using the unilateral approach and single cage in elderly patients. Objective. The study investigated the clinical and radiological outcomes of MIS-TLIF using the unilateral approach and single cage in the patients over 65 years of age. Methods. Thirty-eight patients were followed for a mean of 15.5 ± 11.61 months. Radiological data include fusion rate, change of disc height, and central canal area. The numeric rating scale (NRS) and Oswestry disability index (ODI) were used to assess clinical outcomes. Results. The mean age of these patients at operation was 71.82 ± 4.71 years (range, 65–82 years). Evidence of fusion was observed radiologically in 64.71% at 6 months and 87.5% at 12 months after surgery, giving a final fusion rate of 100%. The mean NRS scores for back and leg pain and ODI scores improved significantly at the final follow-up. Conclusions. Clinical and radiologic outcomes of MIS-TLIF using unilateral approach and single cage in elderly patients indicate an acceptable method for the treatment of various kinds of lumbar spinal diseases. PMID:28119927
Gandhi, Neeraj; Kim, Sungmin; Kazanzides, Peter; Lediju Bell, Muyinatu A.
Minimally invasive surgery carries the deadly risk of rupturing major blood vessels, such as the internal carotid arteries hidden by bone in endonasal transsphenoidal surgery. We propose a novel approach to surgical guidance that relies on photoacoustic-based vessel separation measurements to assess the extent of safety zones during these type of surgical procedures. This approach can be implemented with or without a robot or navigation system. To determine the accuracy of this approach, a custom phantom was designed and manufactured for modular placement of two 3.18-mm diameter vessel-mimicking targets separated by 10-20 mm. Photoacoustic images were acquired as the optical fiber was swept across the vessels in the absence and presence of teleoperation with a research da Vinci Surgical System. When the da Vinci was used, vessel positions were recorded based on the fiber position (calculated from the robot kinematics) that corresponded to an observed photoacoustic signal. In all cases, compounded photoacoustic data from a single sweep displayed the four vessel boundaries in one image. Amplitude- and coherence-based photoacoustic images were used to estimate vessel separations, resulting in 0.52-0.56 mm mean absolute errors, 0.66-0.71 mm root mean square errors, and 65-68% more accuracy compared to fiber position measurements obtained through the da Vinci robot kinematics. Results indicate that with further development, photoacoustic image-based measurements of anatomical landmarks could be a viable method for real-time path planning in multiple interventional photoacoustic applications.
Steven R. Radosevich; Bryan A. Endress; Catherine G. Parks
Invasive plants are now recognized as a serious threat to most extensive management systems, such as forests, meadows, deserts, and riparian areas [1-3]. Vitousek et al.  described exotic plant invasion as a significant element of global environmental change because exotic plants can alter primary productivity, decomposition, hydrology, nutrient cycling, and natural...
We developed a nonimage-guided navigation system for unicompartmental knee replacement, suitable for both conventional and minimally invasive approaches. We performed a radiologic analysis of the accuracy of implantation with conventional nonnavigated instrumentation, conventional, open navigated instrumentation, minimally invasive navigated experimental instrumentation derived from conventional instruments, and minimally invasive navigation-dedicated instrumentation. Navigated technique allowed improving the accuracy of the radiologic implantation. Minimally invasive implantation was effective, but the accuracy may not reach that of the conventional navigated technique. Minimal invasive techniques have to be validated, because a loss of accuracy will negatively influence longterm outcomes.
Rachbauer, Franz; Krismer, Martin
Minimally invasive total hip arthroplasty via direct anterior approach aims at reducing soft-tissue damage, diminishing blood loss and postoperative pain, shortening stay in hospital, accelerating rehabilitation, and keeping scars small. The technique is suitable for primary and secondary osteoarthritis as well as fractures of the femoral neck. Complex distortions of the proximal femur should be exempted. Complex malalignment of the proximal femur. The femoral neck is exposed in the interval between tensor fasciae latae, glutei medius and minimus muscles laterally, and sartorius and rectus femoris muscles medially. After osteotomy of the neck and extraction of the head the acetabulum is reamed to prepare for cup prosthesis. Following peritrochanteric capsulotomy the externally rotated, adducted and elevated femor is broached. Cemented and cementless implants may be used. The patients are allowed to walk full weight bearing beginning on the 1st postoperative day. As soon as they are able to safely master the transfers and stairs, they are discharged. The method is a safe procedure that allows correct placement of acetabular and femoral components. It may be performed in a reasonable time, the blood loss is little. The procedure preserves the muscles and leads to small, cosmetically pleasing scars. Patients usually do not suffer from pronounced pain, rehabilitation is accelerated. They therefore agree in an short postoperative stay in hospital.
Afathi, M; Peltier, E; Adetchessi, T; Graillon, T; Dufour, H; Fuentes, S
Minimally invasive surgery has expanded over the past two decades and was initially used for the treatment of lumbar disc herniation. Later, this approach was used to treat other spine pathologies, as well as to perform spinal fusion and extended spinal decompression. In this study, we report our experience regarding the use of a minimal surgical approach in the treatment of intradural extramedullary spinal cord tumours. Between January 2008 and July 2013, 18 patients with an intradural extramedullary tumour were included in the study (13 thoracic, 4 lumbar and one cervical tumours). The mean age was 59 years. We operated on 11 meningiomas, 6 neurinomas and one ependymoma. All patients underwent minimally invasive surgery using a tubular retractor system to perform a hemilaminectomy in order to access the spinal canal. Fifteen patients had a neurological deficit and 7 suffered from radicular pain prior to surgery. Gross completed resection was performed in all patients. Mean time of surgery was 95 min. Blood loss was less than 200 cc. Fifteen patients out of 18 were able to get up the day after surgery. Mean hospital stay was 6 days. There were no complications. A minimal surgical approach using a tubular retractor permits an effective resection of intradural extramedullary tumours. This procedure may be a useful tool to decrease the risk of secondary spine instability and postoperative kyphosis, and could also be used for spinal junctions and in fragile patients. Copyright © 2015 Elsevier Masson SAS. All rights reserved.
Ahmadi, Roozbeh; Packirisamy, Muthukumaran; Dargahi, Javad
During conventional surgical tasks, surgeons use their tactile perception in their finger tips to sense the degree of softness of biological tissues to identify tissue types and to feel for any abnormalities. However, in robotic-assisted surgical systems, surgeons are unable to sense this information because only surgical tools interact with tissues. In order to provide surgeons with such useful tactile perception, therefore, a tactile sensor is required that is capable of simultaneously measuring contact force and resulting tissue deformation. Accordingly, this paper discusses the design, prototyping, testing, and validation of an innovative tactile sensor that is capable of measuring the degree of softness of soft objects such as tissues under both static and dynamic loading conditions and which is also magnetic resonance compatible and electrically passive. These unique characteristics of the proposed sensor would also make it a practical choice for use in robotic-assisted surgical platforms. The prototype version of this sensor was developed by using optical micro-systems technology and, thus far, experimental test results performed on the prototyped sensor have validated its ability to measure the relative softness of artificial tissues.
Thella, Ashok Kumar; Rizkalla, James; Helmy, Ahdy; Suryadevara, Vinay Kumar; Salama, Paul; Rizkalla, Maher
The existing modalities of bone diagnosis including X-ray and ultrasound may cite drawback in some cases related to health issues and penetration depth, while the ultrasound modality may lack image quality. Photo acoustic approach however, provides light energy to the acoustic wave, enabling it to activate and respond according to the propagating media (which is type of bones in this case). At the same time, a differential temperature change may result in the bio heat response, resulting from the heat absorbed across the multiple materials under study. In this work, we have demonstrated the features of using photo acoustic modality in order to non-invasively diagnose the type of human bones based on their electrical, thermal, and acoustic properties that differentiate the output response of each type. COMSOL software was utilized to combine both acoustic equations and bio heat equations, in order to study both the thermal and acoustic responses through which the differential diagnosis can be obtained. In this study, we solved both the acoustic equation and bio heat equations for four types of bones, bone (cancellous), bone (cortical), bone marrow (red), and bone marrow (yellow). 1 MHz acoustic source frequency was chosen and 10(5) W/m(2) power source was used in the simulation. The simulation tested the dynamic response of the wave over a distance of 5 cm from each side for the source. Near 2.4 cm was detected from simulation from each side of the source with a temperature change of within 0.5 K for various types of bones, citing a promising technique for a practical model to detect the type of bones via the differential temperature as well as the acoustic was response via the multiple materials associated with the human bones (skin and blood). The simulation results suggest that the PA technique may be applied to non-invasive diagnosis for the different types of bones, including cancerous bones. A practical model for detecting both the temperature change via
Tejwani, Nirmal C; Lee, James; Weatherall, Justin; Sherman, Orrin
We retrospectively compared the outcomes of early functional weight-bearing after use of 2 different approaches (minimally invasive, standard) for surgical repair of the Achilles tendon. We reviewed the cases of 63 consecutive patients who underwent repair of an acute closed Achilles tendon rupture and had follow-up of at least 6 months. Of these 63 patients, 33 were treated with a minimally invasive posterolateral approach (minimal group), and 30 were treated with a standard posteromedial approach (standard group). Two weeks after surgery, each patient was allowed to weight-bear as tolerated in a controlled ankle movement boot with a 20° heel wedge. At 6 weeks, the patient was placed in a regular shoe with a heel lift. We examined range of motion and incidence of reruptures, sural nerve injuries, and wound complications at 6 weeks and 3 months and calf strength at 6 months. Neither group had any reruptures. Mean incision length was 2.5 cm (minimal group) and 7.2 cm (standard group). One patient (3.2%) in the minimal group and 6 patients (20%) in the standard group developed a superficial wound infection. Four (12.9%) of 31 minimal patients and no standard patients developed a sural nerve deficit. There were statistically significant differences between the groups' wound complication rates (P=.04) and nerve injury rates (P=.043). At final follow-up, the groups did not differ in their functional outcomes (ability to perform a single heel raise, American Orthopaedic Foot and Ankle Society scores). Used after a minimally invasive posterolateral or standard posteromedial approach, early functional weightbearing is an effective and safe method for treating acute ruptures of the Achilles tendon, and it has a lower rate of soft-tissue complications. A standard posteromedial approach has a higher rate of wound complications, and a minimally invasive posterolateral approach has a higher rate of sural nerve injury.
Hong, Seung-Chyul; Kim, Jong-Soo
Objective The lateral supraorbital (LSO) approach is a modified method of the classic pterional approach and it has advantages of short skin incision and small craniotomy compared with the pterional approach. This study was designed to compare the two approaches in the surgical treatment of unruptured intracranial aneurysms. Methods We retrospectively reviewed 122 patients with 137 unruptured intracranial aneurysms treated by clipping, from July 2009 to April 2011. Between August 2010 and April 2011, 61 patients were treated by clipping via the lateral supraorbital approach and the same number of patients treated by clipping via the pterional approach were retrospectively enrolled. We analyzed the two groups and compared demographic, radiologic and clinical variables. Results The mean age of patients in the two groups was 54.6 years (LSO group) and 55.7 years (Pterion group). The mean duration of hospitalization was shorter in the LSO group than in the Pterion group (7.9 days vs. 9.0 days, p=0.125) and the mean operation time was also significantly shorter in the LSO group (117.1 minutes vs. 164.3 minutes, p<0.001). Furthermore, the mean craniotomy area was much smaller in the LSO group (1275.4 mm2 vs. 2858.9 mm2, p<0.001). The two groups showed similar distributions of aneurysm location and postoperative complications. Conclusion The lateral supraorbital approach for the clipping of unruptured intracranial aneurysm could be a good alternative to the classic pterional approach. PMID:22949961
Cha, Ki-Chul; Hong, Seung-Chyul; Kim, Jong-Soo
The lateral supraorbital (LSO) approach is a modified method of the classic pterional approach and it has advantages of short skin incision and small craniotomy compared with the pterional approach. This study was designed to compare the two approaches in the surgical treatment of unruptured intracranial aneurysms. We retrospectively reviewed 122 patients with 137 unruptured intracranial aneurysms treated by clipping, from July 2009 to April 2011. Between August 2010 and April 2011, 61 patients were treated by clipping via the lateral supraorbital approach and the same number of patients treated by clipping via the pterional approach were retrospectively enrolled. We analyzed the two groups and compared demographic, radiologic and clinical variables. The mean age of patients in the two groups was 54.6 years (LSO group) and 55.7 years (Pterion group). The mean duration of hospitalization was shorter in the LSO group than in the Pterion group (7.9 days vs. 9.0 days, p=0.125) and the mean operation time was also significantly shorter in the LSO group (117.1 minutes vs. 164.3 minutes, p<0.001). Furthermore, the mean craniotomy area was much smaller in the LSO group (1275.4 mm(2) vs. 2858.9 mm(2), p<0.001). The two groups showed similar distributions of aneurysm location and postoperative complications. The lateral supraorbital approach for the clipping of unruptured intracranial aneurysm could be a good alternative to the classic pterional approach.
Stolzenburg, Jens Uwe; Kyriazis, Iason; Fahlenbrach, Claus; Gilfrich, Christian; Günster, Christian; Jeschke, Elke; Popken, Gralf; Weißbach, Lothar; von Zastrow, Christoph; Leicht, Hanna
In this study, we document trends in radical prostatectomy (RP) employment in Germany during the period 2005-2012 and compare the morbidity of open (ORP), laparoscopic and robotic-assisted RP based on nationwide administrative data of Allgemeine Ortskrankenkassen (AOK) German local healthcare funds. Administrative claims data of all AOK patients subjected to RP during 2005-2012 (57,156 cases) were used to evaluate the employment of minimally invasive RP (MIRP) procedures, pelvic lymph node dissection (PLND) and nerve-sparing approaches during this period. In addition, data from the most recent three-year period of our dataset (2010-2012) were used to compare the morbidity among the different surgical approaches. Study end points comprised 30-day mortality, 30-day transfusion, 1-year reintervention and 30-day adverse events, as well as 1-year overall complications. A 20 % reduction in RP utilization from 2007 to 2012 was documented. ORP remained the predominant RP approach in Germany. MIRP approaches carried a lower risk of 30-day transfusions, 1-year reinterventions and 1-year overall complications than ORP when adjusting for confounding factors. PLND was associated with an increased risk of complications, while age in the highest quintile and the presence of comorbidities were independent risk factors for morbidity and mortality. Lack of pathological data was the main limitation of the study. RP utilization in Germany is dropping, but the use of MIRP has risen steadily during the years 2005-2012, which is expected to have a positive impact on the morbidity of the operation.
Doyle, Edward John; Phillips, Grady W; Gratton, Michael Anne; Long, John P; Varvares, Mark A
Surgical manipulation of the sensory and motor nerves of the rat tongue is often employed in studies evaluating the oral cavity functions of mastication and deglutition. A noninvasive, atraumatic approach that will then facilitate sufficient manipulation of these structures is required. In this study, we detail an approach that consistently allows identification of the hypoglossal (motor) and lingual (sensory) nerves of the rat. Six Wistar rats (250-500 g) were anesthetized and dissected either as fresh tissue (N = 3) or following transcardial perfusion with 4% paraformaldehyde (N = 3). Both fixed and non-fixed specimens of the rat head and neck were incised in the right submandibular region. The first animal in each group was used to gain a basic understanding of the regional muscular anatomy with reference to the hypoglossal and lingual nerves. Subsequent animals were used for the development of an efficient and minimally invasive approach to these nerves. The resultant approach begins as an incision through skin and platysma, followed by medial reflection of the digastric muscle. This allows visualization of the hypoglossal nerve in the region of the bifurcation of the common trunk into medial and lateral subdivisions. Next, the lingual nerve dissection is approached by reflection rostrally of the transversus mandibularis muscle and a caudal reflection of the mylohyoid muscle. This dissection reveals the geniohyoid muscle which when separated bluntly using forceps, exposes the lingual nerve. The anatomical approach described and illustrated herein will aid investigators in consistent identification of these two nerves as fundamental methods of their projects.
Liu, Quanquan; Kobayashi, Yo; Noguchi, Takahiko; Inko, Elgezua; Sekiguchi, Yuta; Zhang, Bo; Ye, Jing; Toyoda, Kazutaka; Hashizume, Makoto; Fujie, Masakatsu G
This paper presents a 6-DOF manipulator which consists of four parts, 1-DOF translational joint, two 2-DOF bending joints (segment1 and segment2), and 1-DOF rotational gripper. The manipulator with "flexible shaft and Double Screw Drive (DSD) mechanism" structure can obtain omni-directional bending motion through rotation of flexible shafts. In the first prototype, the flexible shafts were connected directly with the actuators in the manipulator. Compared with the first prototype, in the second prototype, flexible shafts for power transmission are connected to the base of the manipulator. Universal joints are used for power transmission to realize distal motion. The improvement done with the design of the second prototype reduced the torque necessary to drive the flexible shafts during motion in surgical interventions. Experiment results show that the manipulator has enough range of movement for surgical intervention.
Phan, Kevin; Dunn, Alexander E.; Rao, Prashanth J.
Lumbar disc herniation arises when the annulus fibrosus of the vertebral disc fails, thus allowing displacement of the nucleus pulposus and other tissue. The term far lateral is used variably in the literature and usually refers to an extraforaminal displacement in the peridiscal zone peripheral to the sagittal plane of the most lateral part of the pedicle at the same level. Non-surgical treatments of far lateral disc herniation include physical therapy, anti-inflammatory medication, and corticosteroid injections. Where these conservative measures fail, surgical intervention may be required. Several surgical techniques for the treatment of far lateral herniations have been investigated, including total or medial facetectomy, laminectomy, hemilaminectomy, approaches through the pars interarticularis, and lateral approaches between the transverse processes via the intertransverse muscle and ligament. We present our far lateral microdiscectomy technique which involves accessing the nerve root lateral to the foramen through a small paramedian incision and use of an operating microscope. Far lateral microdiscectomy offers the prospect of better long-term results than other surgical techniques because of less extensive muscle dissection and preservation of the integrity of the facet joint. PMID:27683697
Wang, Wen Lin; Cai, Kai Can; Zeng, Wei Sheng; Jiang, Ren Chao
In order to reach a clear understanding of minimally invasive approaches in cardiac operations, the authors review clinical experience in using three such approaches: inferior partial median sternotomy, right anterolateral minor thoracotomy, and the right parasternal approach. Sternotomy and the three different minimally invasive approaches were applied in and 2431 and 323 patients respectively. The approaches were selected according to the circumstances of the individual case. Both external and internal cardiac structures were observed during the operations. The length of the incision, the postoperative drainage, operative time, and cardiopulmonary bypass time were investigated. The postoperative complications occurring after minimally invasive approaches were observed. In inferior partial median sternotomy, all structures except for the ascending aorta could be exposed well. In right anterolateral minor thoracotomy, only the structures on the right side of the heart could be exposed, but the mitral valve could also be exposed well. The exposure of the right parasternal approach was similar to that of right anterolateral minor thoracotomy. There were statistically significant differences between sternotomy and the minimally invasive approaches in terms of incision length and postoperative drainage, but no difference in operative time and cardiopulmonary bypass time. The postoperative complications of MIAs included air embolism (n = 3), chest pain (n = 9), chest wall malacia (n = 1), rib fracture (n = 2), and sternum fracture (n = 2). The total incidence of complications in minimally invasive approaches was 5.3%. The minimally invasive approaches can have satisfactory clinical results if the approaches are correctly chosen and performed.
Bruschini, Luca; Forli, Francesca; Vito, Andrea De; Berrettini, Stefano
Objectives The direct acoustic cochlear implant (DACI) is among the latest developments in the field of implantable acoustic prostheses. The surgical procedure requires a mastoidectomy and a posterior-inferior tympanotomy, with access to the facial recess at the level of the oval window, in a complex and lengthy surgical approach. Here, we report a new and considerably shorter surgical approach. Methods The new approach involves positioning of artificial incus above the oval window through the superior-anterior tympanotomy. We performed DACI placement in temporal bone specimens (n=5) to assess the feasibility of the new approach. Results The average time for the DACI implant in the temporal bones was only 112 minutes (range, 94 to 142 minutes) and there was little clinical risk associated with the procedure. Access was easy and drilling was minimal. Conclusion Our approach simplified the surgical procedure and consequently reduced the time required for DACI placement. PMID:27334513
Losenno, Katie L; Jones, Philip M; Valdis, Matthew; Fox, Stephanie A; Kiaii, Bob; Chu, Michael W A
Reoperative mitral valve (MV) surgery is associated with significant morbidity and mortality; however, endoscopic minimally invasive surgical techniques may preserve the surgical benefits of conventional mitral operations while potentially reducing perioperative risk and length of stay (LOS) in hospital. We compared the outcomes of consecutive patients who underwent reoperative MV surgery between 2000 and 2014 using a minimally invasive endoscopic approach (MINI) with those of patients who underwent a conventional sternotomy (STERN). The primary outcome was in-hospital/30-day mortality. Secondary outcomes included blood product transfusion, LOS in hospital and in the intensive care unit (ICU), and postoperative complications. We included 132 patients in our study: 40 (mean age 68 ± 14 yr, 70% men) underwent MINI and 92 (62 ± 13 yr, 40% men) underwent STERN. The MINI group had significantly more comorbidities than the STERN group. While there were no significant differences in complications, all point estimates suggested lower mortality and morbidity in the MINI than the STERN group (in-hospital/ 30-day mortality 5% v. 11%, p = 0.35; composite any of 10 complications 28% v. 41%, p = 0.13). Individual complication rates were similar between the MINI and STERN groups, except for intra-aortic balloon pump requirement (IABP; 0% v. 12%, p = 0.034). MINI significantly reduced the need for any blood transfusion (68% v. 84%, p = 0.036) or packed red blood cells (63% v. 79%, p = 0.042), fresh frozen plasma (35% v. 59%, p = 0.012) and platelets (20% v. 40%, p = 0.024). It also significantly reduced median hospital LOS (8 v. 12 d, p = 0.014). An exploratory propensity score analysis similarly demonstrated a significantly reduced need for IABP (p < 0.001) and a shorter mean LOS in the ICU (p = 0.046) and in hospital (p = 0.047) in the MINI group. A MINI approach for reoperative MV surgery reduces blood product utilization and hospital LOS. Possible clinically relevant
Losenno, Katie L.; Jones, Philip M.; Valdis, Matthew; Fox, Stephanie A.; Kiaii, Bob; Chu, Michael W.A.
Background Reoperative mitral valve (MV) surgery is associated with significant morbidity and mortality; however, endoscopic minimally invasive surgical techniques may preserve the surgical benefits of conventional mitral operations while potentially reducing perioperative risk and length of stay (LOS) in hospital. Methods We compared the outcomes of consecutive patients who underwent reoperative MV surgery between 2000 and 2014 using a minimally invasive endoscopic approach (MINI) with those of patients who underwent a conventional sternotomy (STERN). The primary outcome was in-hospital/30-day mortality. Secondary outcomes included blood product transfusion, LOS in hospital and in the intensive care unit (ICU), and postoperative complications. Results We included 132 patients in our study: 40 (mean age 68 ± 14 yr, 70% men) underwent MINI and 92 (62 ± 13 yr, 40% men) underwent STERN. The MINI group had significantly more comorbidities than the STERN group. While there were no significant differences in complications, all point estimates suggested lower mortality and morbidity in the MINI than the STERN group (in-hospital/30-day mortality 5% v. 11%, p = 0.35; composite any of 10 complications 28% v. 41%, p = 0.13). Individual complication rates were similar between the MINI and STERN groups, except for intra-aortic balloon pump requirement (IABP; 0% v. 12%, p = 0.034). MINI significantly reduced the need for any blood transfusion (68% v. 84%, p = 0.036) or packed red blood cells (63% v. 79%, p = 0.042), fresh frozen plasma (35% v. 59%, p = 0.012) and platelets (20% v. 40%, p = 0.024). It also significantly reduced median hospital LOS (8 v. 12 d, p = 0.014). An exploratory propensity score analysis similarly demonstrated a significantly reduced need for IABP (p < 0.001) and a shorter mean LOS in the ICU (p = 0.046) and in hospital (p = 0.047) in the MINI group. Conclusion A MINI approach for reoperative MV surgery reduces blood product utilization and hospital LOS
Chapin, John; Bamme, Jaqueline; Hsu, Fraustina; Christos, Paul; DeSancho, Maria
Adults with hemophilia A (HA), hemophilia B (HB), and von Willebrand disease (VWD) frequently require surgery and invasive procedures. However, there is variability in perioperative management guidelines. We describe our periprocedural outcomes in this setting. A retrospective chart review from January 2006 to December 2012 of patients with HA, HB, and VWD undergoing surgery or invasive procedures was conducted. Type of procedures, management including the use of continuous factor infusion, and administration of antifibrinolytics were reviewed. Adverse outcomes were defined as acute bleeding (<48 hours), delayed bleeding (≥48 hours), transfusion, inhibitor development, and thrombosis. We identified 59 patients with HA and HB. In all, 24 patients had severe hemophilia and 12 had mild/moderate hemophilia. Twelve patients had inhibitors. There were also 5 female carriers of HA and 6 patients with VWD. There were 34 major surgeries (26 orthopedic, 8 nonorthopedic) and 129 minor surgeries. Continuous infusion was used in 55.9% of major surgeries versus 8.5% of minor surgeries. Antifibrinolytics were administered in 14.7% of major surgeries versus 23.2% of minor surgeries. In all, 4 patients developed acute bleeding and 10 patients developed delayed bleeding. Delayed bleeding occurred in 28.6% of genitourinary procedures and in 16.1% of dental procedures. Five patients acquired an inhibitor and 2 had thrombosis. In conclusion, patients with HA, HB, or VWD had similar rates of adverse outcomes when undergoing minor surgeries or major surgeries. This finding underscores the importance of an interdisciplinary management and procedure-specific guidelines for patients with hemophilia and VWD prior to even minor invasive procedures.
Wurnig, P N; Hollaus, P H; Wurnig, C H; Wolf, R K; Ohtsuka, T; Pridun, N S
Documentation of surgical procedures is limited to the accuracy of description, which depends on the vocabulary and the descriptive prowess of the surgeon. Even analog video recording could not solve the problem of documentation satisfactorily due to the abundance of recorded material. By capturing the video digitally, most problems are solved in the circumstances described in this article. We developed a cheap and useful digital video capturing system that consists of conventional computer components. Video images and clips can be captured intraoperatively and are immediately available. The system is a commercial personal computer specially configured for digital video capturing and is connected by wire to the video tower. Filming was done with a conventional endoscopic video camera. A total of 65 open and endoscopic procedures were documented in an orthopedic and a thoracic surgery unit. The median number of clips per surgical procedure was 6 (range, 1-17), and the median storage volume was 49 MB (range, 3-360 MB) in compressed form. The median duration of a video clip was 4 min 25 s (range, 45 s to 21 min). Median time for editing a video clip was 12 min for an advanced user (including cutting, title for the movie, and compression). The quality of the clips renders them suitable for presentations. This digital video documentation system allows easy capturing of intraoperative video sequences in high quality. All possibilities of documentation can be performed. With the use of an endoscopic video camera, no compromises with respect to sterility and surgical elbowroom are necessary. The cost is much lower than commercially available systems, and setting changes can be performed easily without trained specialists.
In the hospital setting, dermatologists are often required to evaluate inflammatory skin lesions arising during surgical procedures performed in other departments. These lesions can be of physical or chemical origin. Povidone iodine is the most common reported cause of such lesions. If this antiseptic solution remains in contact with the skin in liquid form for a long period of time, it can give rise to serious irritant contact dermatitis in dependent or occluded areas. Less common causes of skin lesions after surgery include allergic contact dermatitis and burns under the dispersive electrode of the electrosurgical device. Most skin lesions that arise during surgical procedures are due to an incorrect application of antiseptic solutions. Special care must therefore be taken during the use of these solutions and, in particular, they should be allowed to dry.
Farouk, Ahmed; Nady, Mohammed Alaa; Abdel Hafez, Mohammed Farouk
Background Bullous lung disease is characterized by formation of blebs, bullae and emphysema. We investigate the role of oxidative stress in the pathogenesis of bullous lung disease and compare between conventional thoracotomy versus video assisted thoracoscopic approach in surgical management of such patients. Methods This study was a prospective case control study and it was carried out on 21 patients (16 males and 5 females) with bullous lung disease selected as candidate for surgical interference. This was in addition to 21 apparently healthy age and sex matched subjects selected as control group. Plasma levels of α1-antitrypsin were estimated using commercially available ELISA assay kit, while plasma levels of malondialdehyde (MDA), β-carotene, vitamin A, vitamin C and vitamin E were estimated using spectrophotometric methods. Conventional thoracotomy approach was done in thirteen patients, while, videothoracoscopic approach was done in eight patients. Results There were significant higher plasma levels of MDA (P<0.001) and lower plasma levels of β-carotene (P<0.01), vitamin A, vitamin C and vitamin E (P<0.001 for each) among patients with bullous lung disease when compared with the control group. There was non-significant difference regarding the air leakage and the hospital stay among patients with bullous lung disease who managed via conventional thoracotomy approach when compared with those managed via videothoracoscopic approach. Conclusions This study proves that the oxidative stress plays an important role in the pathogenesis of bullous lung disease. Also there are no significant outcome differences between conventional thoracotomy versus video assisted thoracoscopic approach in surgical treatment of such patients. PMID:27867571
Maruyama, Hiroshi; Yoshida, Hiroshi; Hirakata, Atsushi; Matsutani, Takeshi; Yokoyama, Tadashi; Suzuki, Seiji; Matsushita, Akira; Sasajima, Koji; Kikuchi, Yuta; Uchida, Eiji
We describe the surgical treatment of a patient with diaphragmatic invasion by a ruptured hepatocellular carcinoma (HCC) associated with biliary and portal venous tumor thrombi. A 67-year-old man was admitted because of jaundice (total serum bilirubin, 6.6 mg/dL). The serum concentration of alpha-fetoprotein was 236.1 ng/mL. The anti-hepatitis C virus antibodies were present in the serum. Computed tomography showed a large hypervascular mass in the right subphrenic region, surrounded by local effusion. Endoscopic retrograde cholangiography revealed dilatation of the left intrahepatic bile duct caused by biliary tumor thrombi extending from the right hepatic duct to the common bile duct. Endoscopic nasobiliary drainage was performed, and the total serum bilirubin level returned to the normal range. Angiography revealed a hypervascular tumor without extravasation of contrast medium in the right lobe and obstruction of the right anterior branch of the portal vein. Right hepatectomy was attempted 15 days after drainage. Severe invasion of the diaphragm by the ruptured HCC was detected. Bleeding of the ruptured HCC stopped spontaneously. Partial resection of the diaphragm was performed, followed by primary suture, without an artificial patch. Tumor thrombectomy was performed from the common bile duct. Macroscopic examination revealed that the ruptured HCC had invaded the diaphragm. Biliary and portal venous tumor thrombi were present. Histopathological examination showed a moderately differentiated HCC with biliary and portal venous tumor thrombi. The postoperative course was uneventful. The patient was discharged on postoperative day 14. Five months after the operation, local and intrahepatic recurrences of HCC were detected. Six months after operation, the patient died of liver failure. In conclusion, the outcome of a patient with diaphragmatic invasion by a ruptured HCC with biliary tumor thrombi was poor, even after curative hepatic resection.
Shapiro, Mark; Korst, Robert J.
Thymic epithelial tumors (TET) are rare mediastinal neoplasms that can metastasize to the pleural space (stage IVA). Complete surgical resection remains the backbone of therapy for patients with early stage TET, however, the role of surgery in the management of patients with stage IVA disease is not fully defined. Published reports in this regard are mainly small, retrospective, and uncontrolled, with unclear inclusion criteria. Surgical options to manage pleural disease include metastasectomy, extrapleural pneumonectomy, and metastasectomy/pleurectomy combined with heated intrapleural chemotherapy. The choice of the most appropriate surgical strategy needs to be individualized according to the quantity and location of disease, the patient’s overall condition, as well as operator and institutional expertise. In the majority of cases, metastasectomy of pleural implants will be sufficient to achieve a complete resection. The available literature suggests that in selected patients with stage IVA TET, delivery of neoadjuvant chemotherapy followed by complete resection is a viable treatment option that can be associated with long-term survival. PMID:24459636
Shapiro, Mark; Korst, Robert J
Thymic epithelial tumors (TET) are rare mediastinal neoplasms that can metastasize to the pleural space (stage IVA). Complete surgical resection remains the backbone of therapy for patients with early stage TET, however, the role of surgery in the management of patients with stage IVA disease is not fully defined. Published reports in this regard are mainly small, retrospective, and uncontrolled, with unclear inclusion criteria. Surgical options to manage pleural disease include metastasectomy, extrapleural pneumonectomy, and metastasectomy/pleurectomy combined with heated intrapleural chemotherapy. The choice of the most appropriate surgical strategy needs to be individualized according to the quantity and location of disease, the patient's overall condition, as well as operator and institutional expertise. In the majority of cases, metastasectomy of pleural implants will be sufficient to achieve a complete resection. The available literature suggests that in selected patients with stage IVA TET, delivery of neoadjuvant chemotherapy followed by complete resection is a viable treatment option that can be associated with long-term survival.
Frede, Thomas; Hammady, Ahmed; Klein, Jan; Teber, Dogu; Inaki, Noriyuki; Waseda, Masahiro; Buess, Gerhard; Rassweiler, Jens
Complex laparoscopic procedures in urology are technically demanding with an extended learning curve. Robotic systems add significant cost to laparoscopic procedures. We therefore evaluated the use of the Radius Surgical System (RSS), a mechanical manipulator, for complex laparoscopic cases in urology. The RSS (Tuebingen Scientific) consists of two hand-guided surgical manipulators and provides a deflectable and rotatable tip allowing six degrees of freedom. We evaluated the system by using a series of standardized models in the pelvitrainer. We analyzed the effectiveness of the system and the learning curve. We then evaluated the system in the clinical setting during laparoscopic radical prostatectomy. Surgeons with experience on the RSS were compared to surgeons without previous experience on the system. We identified a learning curve in those participants without experience on the system only when performing complete anastomoses in the pelvitrainer. However, this learning curve included less than 10 anastomoses. The first clinical experiences during laparoscopic extraperitoneal radical prostatectomy (n=10) are promising. All anastomoses were patent on routine (X-ray) examination 8 days after surgery. The RSS system is easy to use and we identified a very short learning curve. We now optimize the system for use in urology. This device may facilitate complex laparoscopic procedures without the use of costly robotic systems and should be further evaluated in the experimental and clinical setting.
Daly, Frank J; Bolender, David L; Jain, Deepali; Uyeda, Sheryl; Hoagland, Todd M
Integrated medical curricular changes are altering the historical regional anatomy approach to abdominal dissection. The renal system is linked physiologically and biochemically to the cardiovascular and respiratory systems; yet, anatomists often approach the urinary system as part of the abdomen and pelvic regions. As part of an integrated curriculum, the renal system must be covered relatively quickly after the thorax in the cadaver laboratory, often without the opportunity to fully appreciate the rest of the abdominal contents. This article provides dissection instructions that follow one of the historical surgical approaches for nephrectomy, including preservation of the posterior abdominal wall neurovasclature. Dissection procedures were developed for first-year medical students, intending this posterior approach to the kidneys to be their first introduction to the renal system. It has been successfully implemented with the first-year medical students at the University of New England, College of Osteopathic Medicine. Utilizing this posterior approach to the kidney enabled the study of the anatomy of the kidneys, suprarenal glands, and renal vessels, as well as the muscles of the lumbar spine, while maintaining the integrity of the anterior abdominal wall and peritoneal cavity for future gastrointestinal and reproductive system-based dissections.
Calandra, Thierry; Roberts, Jason A; Antonelli, Massimo; Bassetti, Matteo; Vincent, Jean-Louis
Invasive fungal infections, particularly those caused by Candida species, are not uncommon in critically ill patients and are associated with considerable morbidity and mortality. Diagnosis and management of these infections can be challenging. In this review, we will briefly discuss recent epidemiological data on invasive candidiasis and current diagnostic approaches before concentrating on antifungal treatments.
To identify whether less proximal muscle damage during minimally invasive surgery will allow faster recovery after total knee arthroplasty in comparison with a quadriceps incision approach. A limited medial parapatellar approach without tibial medial collateral ligament (MCL) release was compared to a subvastus approach without tibial medial collateral ligament release (far medial subvastus). One hundred and eighty patients were studied. In the mini-parapatellar group, ninety patients and in the far medial subvastus group, the remaining ninety patients were included. The evaluation was based on the Knee Society Score, VAS, morphine consumption, range of motion, time to straight leg raising, walking without aid, stairs and period of hospitalization. Alignment on full leg radiographs and component position on plain films were measured. The far medial subvastus group showed faster recovery with earlier straight leg raising (1.7 ± 0.5 vs. 2.7 ± 0.4 days), postoperative weight bearing without aid (1.7 ± 0.6 vs. 2 ± 0.8 days) and stair negotiation (3 ± 0.4 vs. 4 ± 0.3 days) resulting in shorter length of stay (4 ± 0.5 vs. 5 ± 1.2 days). Comparable Knee Society Scores (88.5 ± 6.8 vs. 90 ± 10), Function Scores (90 ± 10) and alignment (5.4° ± 2.1° vs. 5.0° ± 2.4°) between the medial parapatellar and far medial subvastus group were observed at a follow-up of 24 months. An increase in operative time for the far medial subvastus was observed (55 ± 10.6 min vs. 67 ± 12 min tourniquet time) but without complications. The MCL sparing far medial subvastus approach allows good surgical exposure, faster straight leg raising, full weight bearing without aid and shorter length of stay with most importantly no radiological malalignment. Therapeutic study, Level II.
Wilson, Charles B.; Grollmus, John M.; Levin, Seymour; Goldfield, Edythe; Schneider, Victor; Hosobuchi, Yoshio; Rand, Robert W.; Heuser, Gunnar; Linfoot, John
Improved surgical microscopes and intraoperative radiofluoroscopic television have revived the transsphenoidal approach to pituitary tumors. The transsphenoidal approach offers an alternative to craniotomy, and in certain situations it has distinct advantages. The reported experience includes the common pituitary tumors, hypersecreting microadenomas, cerebrospinal rhinorrhea and parasellar aneurysms. The surgical technique, indications and contraindications, and results in 44 transsphenoidal operations are described. ImagesFigure 1. PMID:4638402
Damle, Sheela R; Krzyzanowska, Agata; Frawley, Robert J; Cunningham, Matthew E
Surgical models in animals are used extensively to study small molecules and devices for lumbar intervertebral disc repair, replacement, and fusion. Although the ventral lumbar animal models themselves are well described, critical assessment of morbidity and mortality avoidance when using the models have not been reported. Hypothesizing that technique modifications and the relative prevalence and severity of complications would be correlated, we collected and examined peri- and postoperative data stratified by surgical technique. We here report complications associated with the transperitoneal approach to the lumbar spine in 268 Lewis rats and offer data-driven suggestions regarding complication avoidance through technique modification. Compared with wider exposure, limiting the width of exposure to a maximum of 3 mm resulted in fewer neurologic complications in the lower limbs. In addition, avoiding extracorporeal reflection of the small intestine during the exposure was associated with lower incidence of postoperative gastrointestinal distress and fewer situations requiring euthanasia. These findings underscore the importance of detailed approaches in minimizing postoperative morbidity and attrition in surgical models.
Lutz, Brock D; Jin, Jiankang; Rinaldi, Michael G; Wickes, Brian L; Huycke, Mark M
An outbreak of Aspergillus infection at a tertiary care hospital was identified among inpatients who had amputation wounds, peritonitis, allograft nephritis, or mediastinitis. During a 2-year period, 6 patients were identified, all of whom had Aspergillus species recovered from samples from normally sterile sites. All cases clustered in the operating theater during a single 12-day period. To assess operating theater air quality, particle counts were measured as surrogate markers for Aspergillus conidia. A substantial increase in the proportion of airborne particles > or =3 microm in size (range, 3-fold to 1000-fold) was observed in many operating rooms. A confined space video camera identified moisture and contamination of insulating material in ductwork and variable airflow volume units downstream of final filters. No additional invasive Aspergillus wound infections were identified after the operating theater air-handling systems were remediated, suggesting that this unusual outbreak was due to the deterioration of insulating material in variable airflow volume units.
Oderiz, Carolina Cuello; Aberastury, Marina; Besocke, Ana Gabriela; Sinner, Jorge; Comas-Guerrero, Betiana; Ciraolo, Carlos Alberto; Pasteris, Maria Concepción; Silva, Walter Horacio; García, María Del Carmen
Neurosurgery appears to be a reasonable alternative in carefully selected patients with refractory status epilepticus (RSE) and super-refractory status epilepticus (SRSE). We discuss the optimal timing of the surgery and the use of previous stereoelectroencephalography (SEEG) invasive evaluation. We identified 3 patients (two pediatric and one adult) who underwent epilepsy surgery because of RSE or SRSE from our epilepsy surgery database, one of them with previous SEEG. Status epilepticus resolved acutely in all of them with no mortality and no substantial morbidity. At follow-up (median: 2 years), 1 patient was seizure-free, and 2 had significant improvement. Surgery should be considered in all cases of RSE and SRSE early in the course of the evolution of the disease.
Bravo-Calderón, Diego Mauricio; Lauand, Gustavo Amaral; Assao, Agnes; Suárez-Peñaranda, José-Manuel; Pérez-Sayáns, Mario; García-García, Abel; Marana, Aparecido Nilceu; Nonogaki, Suely; Lauris, José Roberto Pereira; Kowalski, Luiz Paulo
Background. The beta-2 adrenergic receptor is expressed by neoplastic cells and is correlated with a wide spectrum of tumor cell mechanisms including proliferation, apoptosis, angiogenesis, migration, and metastasis. Objectives. The present study aimed to analyze the expression of the beta-2 adrenergic receptor (β2-AR) in tumor-free surgical margins of oral squamous cell carcinomas (OSCC) and at the invasive front. Sixty-two patients diagnosed with OSCC, confirmed by biopsy, were selected for the study. The clinicopathological data and clinical follow-up were obtained from medical records and their association with β2-AR expression was verified by the chi-square test or Fischer's exact test. To verify the correlation of β2-AR expression in tumor-free surgical margins and at the invasive front of OSCCs, Pearson's correlation coefficient test was applied. Results. The expression of β2-AR presented a statistically significant correlation between the tumor-free surgical margins and the invasive front of OSCC (r = 0.383; p = 0.002). The immunohistochemical distribution of β2-AR at the invasive front of OSCC was also statistically significant associated with alcohol (p = 0.038), simultaneous alcohol and tobacco consumption (p = 0.010), and T stage (p = 0.014). Conclusions. The correlation of β2-AR expression in OSCC and tumor-free surgical margins suggests a role of this receptor in tumor progression and its expression in normal oral epithelium seems to be constitutive. PMID:27042179
Ozer, A. F.; Keskin, F.; Oktenoglu, T.; Suzer, T.; Ataker, Y.; Gomleksiz, C.; Sasani, M.
Surgery of lumbar disc herniation is still a problem since Mixter and Barr. Main trouble is dissatisfaction after the operation. Today there is a debate on surgical or conservative treatment despite spending great effort to provide patients with satisfaction. The main problem is segmental instability, and the minimally invasive approach via microscope or endoscope is not necessarily appropriate solution for all cases. Microsurgery or endoscopy would be appropriate for the treatment of Carragee type I and type III herniations. On the other hand in Carragee type II and type IV herniations that are prone to develop recurrent disc herniation and segmental instability, the minimal invasive techniques might be insufficient to achieve satisfactory results. The posterior transpedicular dynamic stabilization method might be a good solution to prevent or diminish the recurrent disc herniation and development of segmental instability. In this study we present our experience in the surgical treatment of disc herniations. PMID:23653862
Diaz-Ledezma, Claudio; Parvizi, Javad
Currently, three surgical approaches are available for the treatment of cam femoroacetabular impingement (FAI), namely surgical hip dislocation (SHD), hip arthroscopy (HA), and the miniopen anterior approach of the hip (MO). Although previous systematic reviews have compared these different approaches, an overall assessment of their performance is not available. We therefore executed a multidimensional structured comparison considering the benefits, opportunities, costs, and risk (BOCR) of the different approaches using multicriteria decision analysis (MCDA). A MCDA using analytic hierarchical process (AHP) was conducted to compare SHD, HA, and MO in terms of BOCR on the basis of available evidence, institutional experience, costs, and our understanding of pathophysiology of FAI. A preclinical decision-making model was created for cam FAI to establish the surgical approach that better accomplishes our objectives regarding the surgical treatment. A total score of an alternative's utility and sensitivity analysis was established using commercially available AHP software. The AHP model based on BOCR showed that MO is the best surgical approach for cam FAI (normalized score: 0.38) followed by HA (normalized score: 0.36) and SHD (normalized score: 0.25). The sensitivity analysis showed that HA would turn into the best alternative if the variable risks account for more than 61.8% of the priority during decision-making. In any other decision-making scenario, MO remains as the best alternative. Using a recognized method for decision-making, this study provides supportive data for the use of MO approach as our preferred surgical approach for cam FAI. The latter is predominantly derived from the lower cost of this approach. Our data may be considered a proxy performance measurement for surgical approaches in cam FAI.
Huang, Xiao-ming; Sun, Wei; Hong, Yun; Cai, Qian; Liang, Fa-ya; Han, Ping
To evaluate the feasibility and safety of endoscopic thyroidectomy via anterior chest approach for early papillary thyroid cancer (T1N0M0). From July 2004 to December 2010, 91 patients with early papillary thyroid cancer underwent minimally invasive endoscopic thyroidectomy via anterior chest approach. The clinical and pathologic characteristics of patients, operation types, operative time, postoperative hospital stay time, and postoperative complications were analyzed retrospectively. All 91 operations were successfully performed endoscopically. There was no case conversed to open surgery. The mean tumor size was (0.96 ± 0.71) cm. The operation types included unilateral lobectomy (41 cases), unilateral subtotal lobectomy (3 cases), ipsilateral lobectomy and contralateral subtotal lobectomy (42 cases), and bilateral total thyroidectomy (5 cases). Central compartment node dissection was carried out in 39 cases with the tumor diameter less than 1.0 cm and in 29 cases with the tumor diameter of 1.0 - 2.0 cm. The mean operating time was (99 ± 17) min, the mean bleeding volume was (18 ± 12) ml, and the mean post-operative hospital stay time was (3 ± 1) days. Temporary recurrent laryngeal nerve (RLN), paresis occurred in 2 cases and recovered within 1 to 2 months after the surgery. One patient showed permanent RLN paralysis. Two patients showed temporary hypoparathyroidism. No patient showed post-operative seroma and tracheal injury. There was no case with injury to the superior laryngeal nerve. No further complications, such as irritating cough, tetany, and emphysema developed after the operation. With the anterior chest wall approach, all patients had no surgical scar on the neck and thus they were satisfied with the cosmetic outcomes. All patients were disease free by follow-up of 7 to 85 (58.4 ± 17.2) months. Minimally invasive endoscopic thyroid surgery through anterior chest approach is a feasible and safe method for the treatment of early papillary thyroid
Elhadi, Ali M; Hardesty, Douglas A; Zaidi, Hasan A; Kalani, M Yashar S; Nakaji, Peter; White, William L; Preul, Mark C; Little, Andrew S
Microscopic and endoscopic transsphenoidal approaches to the sellar are well established. Surgical freedom is an important skull base principle that can be measured objectively and used to compare approaches. To compare the surgical freedom of 4 transsphenoidal approaches to the sella turcica to aid in surgical approach selection. Four transsphenoidal approaches to the sella were performed on 8 silicon-injected cadaveric heads. Surgical freedom was determined with stereotactic image guidance using previously established techniques. The results are presented as the area of surgical freedom and angular surgical freedom (angle of attack) in the axial and sagittal planes. Mean total exposed area surgical freedom for the microscopic sublabial, endoscopic binostril, endoscopic uninostril, and microscopic endonasal approaches were 102 ± 13, 89 ± 6, 81 ± 4, and 69 ± 10 cm2, respectively. The endoscopic binostril approach had the greatest surgical freedom at the pituitary gland and ipsilateral and contralateral internal carotid arteries (25.7 ± 5.4, 28.0 ± 4.0, and 23.0 ± 3.0 cm2) compared with the microscopic sublabial (21.8 ± 3.5, 21.3 ± 2.4, and 19.5 ± 6.3 cm2), microscopic endonasal (14.2 ± 2.7, 14.1 ± 3.2, and 16.3 ± 4.0 cm2), and endoscopic uninostril (19.7 ± 4.8, 22.4 ± 2.3, and 19.5 ± 2.9 cm2) approaches. Axial angle of attack was greatest for the microscopic sublabial approach to the same targets (14.7 ± 1.3°, 11.0 ± 1.5°, and 11.8 ± 1.1°). For the sagittal angle of attack, the endoscopic binostril approach was superior for all 3 targets (16.6 ± 1.7°, 17.2 ± 0.70°, and 15.5 ± 1.2°). Microscopic sublabial and endoscopic binostril approaches provided superior surgical freedom compared with the endonasal microscopic and uninostril endoscopic approaches. This work provides objective baseline values for the quantification and evaluation of future refinements in surgical technique or instrumentation.
Hellinger, Michael D; Al Haddad, Abdullah
Traditionally, stoma creation and end stoma reversal have been performed via a laparotomy incision. However, in many situations, stoma construction may be safely performed in a minimally invasive nature. This may include a trephine, laparoscopic, or combined approach. Furthermore, Hartmann's colostomy reversal, a procedure traditionally associated with substantial morbidity, may also be performed laparoscopically. The authors briefly review patient selection, preparation, and indications, and focus primarily on surgical techniques and results of minimally invasive stoma creation and Hartmann's reversal.
Tokar, Baran; Karacay, Safak; Arda, Surhan; Alici, Umut
minimal invasive surgery may consider PASEA as an alternative to the open approach in CMT. The surgeon should be familiar with surgical anatomy of the neck and must be highly competent in management of possible complications in the region. Georg Thieme Verlag KG Stuttgart · New York.
Hegde, Vivek; Morawala, Abdul; Gupta, Abhilasha; Khandwawala, Naqiyaa
Dens invaginatus, also known as dens in dente, is a rare anomaly affecting human dentition. The condition results in invagination of an amelodental structure within the pulp. This case report discusses the current management protocol of dens invaginatus using a minimally invasive and nonsurgical treatment option. As with most conditions, early diagnosis and preventive measures help minimize complications in dens invaginatus cases. PMID:27656073
Background A minimal invasive approach for elective hip surgery has been implemented in our institution in the past. It is widely hypothesized that implanting artificial hips in a minimal invasive fashion decreases surgical trauma and is helpful in the rehabilitation process in elective hip surgery. Thereby geriatric patients requiring emergency hip surgery also could theoretically benefit from a procedure that involves less tissue trauma. Methods Sixty patients who sustained a fractured neck of femur were randomly assigned into two groups. In the minimal invasive arm, the so called “direct anterior approach” (DAA) was chosen, in the conventional arm the Watson-Jones-Approach was used for implantation of a bipolar hemi-arthroplasty. Primary outcome parameter was the mobility as measured by the four-item-Barthel index. Secondary outcome parameters included pain, haemoglobin-levels, complications, duration of surgery, administration of blood transfusion and external length of incision. Radiographs were evaluated. Results A statistically significant difference (p = 0,009) regarding the mobility as measured with the four-item Barthel index was found at the 5th postoperative day, favouring the DAA. Evaluation of the intensity of pain with a visual analogue scale (VAS) showed a statistically significant difference (p = 0,035) at day 16. No difference was evident in the comparison of radiographic results. Conclusions Comparing two different approaches to the hip joint for the implantation of a bipolar hemi-arthroplasty after fractured neck of femur, it can be stated that mobilization status is improved for the DAA compared to the WJA when measured by the four-item Barthel index, there is less pain as measured using the VAS. There is no radiographic evidence that a minimal invasive technique leads to inferior implant position. Level of Evidence: Level II therapeutic study. PMID:22873207
Castilho, Arthur Menino; Pauna, Henrique Furlan; Fernandes, Fernando Laffitte; Bonhin, Rodrigo Gonzales; Guimarães, Alexandre Caixeta; de Melo, Tatiana Mendes; Cheng, Margareth; Sartorato, Edi Lucia; de Carvalho, Guilherme Machado; Paschoal, Jorge Rizzato
Cochlear implants have been used for almost 30 years as a device for the rehabilitation of individuals with severe-to-profound hearing loss. One of the important aspects of cochlear implantation is the type of electrode selected and proper insertion of the electrode array in scala tympani to minimize cochlear damage. The HiFocus Helix™ electrode is a precurved design aimed at placing the electrode contacts close to the spiral ganglion cells in the modiolus. The prescribed insertion techniques are intended to minimize the likelihood of damage to the basilar membrane or lateral wall of the cochlea. To describe the first insertion of a HiFocus Helix™ electrode in Brazil exposing surgical particularities and device details in a patient with profound hearing loss, due to Mondini's dysplasia. No problems were encountered during the surgical procedure. The patient experienced improvement in hearing thresholds and speech perception. The HiFocus Helix™ electrode proved easy to insert and provided expected hearing benefits for the patient. This manuscript indicates that the HiResolution™ Bionic Ear System with HiFocus Helix™ electrode comprise a cochlear implant system that is practical and beneficial for the treatment of severe-to-profound hearing loss.
Jara, J; Lledó, E
Throughout human history, erectile dysfunction has represented one of the most omnipresent health problems. This has resulted in a search for solutions that, one after the other, have been shown to be fruitless. In this context, the emergence of possible surgical solutions at the start of the 20th century represented a revolution that, even then, would take several decades to demonstrate their effectiveness. We performed a literature review that shows the process in the development of potential surgical treatments for hormonal restoration for erectile dysfunction, followed by the sudden emergence of vascular surgery, with new anastomosis techniques, and in the future, the development of penile prosthetic implants as alternative treatments. The publication of results from erectile dysfunction surgery has been lagging for decades due to a lack of objectivity, given that sexual function is a topic restricted by patients' privacy. This situation has led to a reliance on results reported by various authors whose actual credibility could not be verified, with subsequent demonstrations showing that some of these results were not reproducible. This article reviews some of the most important milestones in the progress of surgeries designed to treat erectile dysfunction. The achievements and apparent failures provide a reason for reflection on how we far we have come and how far we can go in the near future. Copyright © 2012 AEU. Published by Elsevier Espana. All rights reserved.
SPUNTARELLI, M.; CECCHETTI, F.; ARCURI, L.; TESTI, D.; MELONE, P.; BIGELLI, E.; GERMANO, F.
SUMMARY Impaction of maxillary canine is a relatively frequent orthodontic anomaly which could represent fuctional and aesthetic problems for patients. Nowadays, the conventional technique to impacted canines consists of a combined orthodontic and surgical approach, aimed to guide cuspids at the center of the alveolar ridge in a stable position and surrounded by healthy hard and soft tissues. This article presents three cases studies with different combined surgical-orthodontic approaches for the treatment of infraosseous impacted canines. An impacted maxillary canine could be guided, after adequate space is created orthodontically, to the center of the ridge through an orthodontic traction directly applied to the crown of impacted cuspid. Several surgical techniques have been proposed to expose the crown of impacted tooth. Location (buccal or palatal side) of impactation and depth influence surgical approach in order to obtain best aesthetic and functional results. PMID:27555906
Rittmeister, M; König, D P; Eysel, P; Kerschbaumer, F
The manuscript features the different minimally invasive approaches to the hip for joint replacement. These include medial, anterior, anterolateral, and posterior approaches. The concept of minimally invasive hip arthroplasty makes sense if it is an integral part of a larger concept to lower postoperative morbidity. Besides minimal soft tissue trauma, this concept involves preoperative patient education, preemptive analgesia, and postoperative physiotherapy. It is our belief that minimal incision techniques for the hip are not suited for all patients and all surgeons. The different minimally invasive approaches to the knee joint for implantation of a knee arthroplasty are described and discussed. There have been no studies published yet that fulfill EBM criteria. The data so far show that minimally invasive approaches and implantation techniques for total knee replacements lead to quicker rehabilitation of patients.
Jacono, Andrew A; Rousso, Joseph J
Because modern facelift patients desire a less-invasive approach or minimally invasive approach to reduce visible scarring and decrease the recovery phase, achieving the surgeon's goal of optimal, reliable, and long-term aesthetic results with few complications becomes a challenge. The authors use the terms minimal access and traditional access to describe rhytidectomy approaches based solely on incision size. A short-incision, minimal-access approach with a deep-plane extended dissection is presented. A preoperative physical examination maneuver to evaluate a patient's candidacy for a minimal-access approach and guidelines for when to include platysmaplasty with the procedure to further improve cervicomental contour are described.
Cargill, Abbey; Farkas, Nicholas; Black, John; West, Nicholas
We report a rare case of large bowel obstruction secondary to a gallstone impacted within the sigmoid colon, in the presence of sigmoid diverticular disease. An 89-year-old woman presented with an 8-day history of increasing abdominal distension, pain and associated nausea. Abdominal X-ray demonstrated large bowel dilation. CT scan revealed a fistula between an inflamed gallbladder and the hepatic flexure of the colon, with a large gallstone in the sigmoid colon. Proximal dilated large bowel was evident to the caecum. Flexible sigmoidoscopy was performed as the least invasive potential treatment method with a view to basket retrieval or fragmentation of the stone. Owing to poor views and risk of diverticular perforation, the procedure was abandoned, hence laparotomy was performed. Antegrade manipulation and per-rectal evacuation were attempted but failed due to a thickened, angulated sigmoid colon. Retrograde milking of the stone to the caecum and retrieval via modified appendicectomy was successful.
Cargill, Abbey; Farkas, Nicholas; Black, John; West, Nicholas
We report a rare case of large bowel obstruction secondary to a gallstone impacted within the sigmoid colon, in the presence of sigmoid diverticular disease. An 89-year-old woman presented with an 8-day history of increasing abdominal distension, pain and associated nausea. Abdominal X-ray demonstrated large bowel dilation. CT scan revealed a fistula between an inflamed gallbladder and the hepatic flexure of the colon, with a large gallstone in the sigmoid colon. Proximal dilated large bowel was evident to the caecum. Flexible sigmoidoscopy was performed as the least invasive potential treatment method with a view to basket retrieval or fragmentation of the stone. Owing to poor views and risk of diverticular perforation, the procedure was abandoned, hence laparotomy was performed. Antegrade manipulation and per-rectal evacuation were attempted but failed due to a thickened, angulated sigmoid colon. Retrograde milking of the stone to the caecum and retrieval via modified appendicectomy was successful. PMID:26150623
Lee, Jung-Shun; Scerrati, Alba; Zhang, Jun; Ammirati, Mario
Surgical approaches to the pons lump together different areas of the pons, such as the anterosuperior and the anteroinferior pons. These areas are topographically different, and different approaches may be best suited for one or the other area. We evaluated the exposure of the anterosuperior pons using different surgical approaches. We quantify the surgical exposure and surgical freedom to the anterosuperior pons afforded by the pterional transtentorial (PT), the orbitozygomatic with anterior clinoidectomy (OZ), and the anterior petrosal (AP) approaches. Five embalmed cadaver heads were used. The three approaches were executed on each side, for a total of 30 approaches. The area of maximal exposure of the anterosuperior pons was measured with the aid of neuronavigation. We also evaluated the feasible angles of approach in the vertical and horizontal planes. We were able to successfully expose the anterosuperior pons using all the selected approaches. In the PT and OZ approaches, mobilization of the sphenoparietal sinus can prevent over-retraction of the temporal bridging veins, while use of the endoscope can help in preserving the integrity of the fourth nerve while cutting the tentorium. The mean exposure area was largest for the AP and smallest for the PT; the surgical freedom was similar among all the approaches. However, there was no statistically significant difference among all the approaches in the exposure area or in the surgical freedom. There is no significant difference among the three evaluated approaches in exposure of the anterosuperior pons.
Ataka, Keiji; Tsuchiya, Kazuhiko; Yamagishi, Hiroyuki; Maeda, Hiromi; Okada, Masayoshi
There are three ways to approach and resect the caudate lobe of the liver, that is; and isolated caudate lobectomy, a combined resection of the liver overlying the caudate lobe, and a transhepatic anterior approach by splitting parenchyma of the liver. We had two patients with neoplasms originating in the caudate lobe who underwent a complete caudate lobectomy. Both patients have been doing well without liver dysfunction. Although after the transhepatic anterior approach we anticipated an adverse effect from splitting the parenchyma of the liver, the postoperative course was uneventful and similar to that of the right side approach. PMID:9893238
van den Haak, Lukas; Alleblas, Chantal; Rhemrev, Johann P; Scheltes, Jules; Nieboer, Bertho; Jansen, Frank Willem
New technology should be extensively tested before it is tried on patients. Unfortunately representative models are lacking. In theory, fresh frozen human cadavers are excellent models. To identify strengths and weaknesses of fresh frozen human cadavers as research models for new technology prior to implementation in gynecological surgery. During pre-clinical validation studies regarding the MobiSep uterine manipulator, test procedures were performed on fresh frozen cadavers. Both the experimental setup as the performance of the prototype were assessed. Five tests including six human cadavers were performed. Major changes were made to the MobiSep prototype design. The cadavers of two tests closely resembled surgical experiences as found in live patients. The anatomy of 4 of the 6 cadavers was not fully representative due to atrophy of the internal genitalia caused by age and due to the presence of pathology such extensive tumorous tissue. The cadaver tests provided vital information regarding design and functionality, that failed to emerge during the in-vitro testing. However, experiments are subject to anatomical uncertainties or restrictions. Consequently, the suitability of a cadaver should be carefully assessed before it is used for testing new technology.
Nakib, Ghassan; Calcaterra, Valeria; Scorletti, Federico; Romano, Piero; Goruppi, Ilaria; Mencherini, Simonetta; Avolio, Luigi; Pelizzo, Gloria
Robotic assisted surgery is not yet widely applied in the pediatric field. We report our initial experience regarding the feasibility, safety, benefits, and limitations of robot-assisted surgery in pediatric gynecological patients. Descriptive, retrospective report of experience with pediatric gynecological patients over a period of 12 months. Department of Pediatric Surgery, IRCCS Policlinico San Matteo Foundation. Children and adolescents, with a surgical diagnosis of ovarian and/or tubal lesions. Robot assembly time and operative time, days of hospitalization, time to cessation of pain medication, complication rate, conversion rate to laparoscopic procedure and trocar insertion strategy. Six children and adolescents (2.4-15 yrs), weighing 12-55 kg, underwent robotic assisted surgery for adnexal pathologies: 2 for ovarian cystectomy, 2 for oophorectomy, 1 for right oophorectomy and left salpingo-oophorectomy for gonadal disgenesis, 1 for exploration for suspected pelvic malformation. Mean operative time was 117.5 ± 34.9 minutes. Conversion to laparatomy was not necessary in any of the cases. No intra- or postoperative complications occurred. Initial results indicate that robotic assisted surgery is safely applicable in the pediatric gynecological population, although it is still premature to conclude that it provides better clinical outcomes than traditional laparoscopic surgery. Randomized, prospective, comparative studies will help characterize the advantages and disadvantages of this new technology in pediatric patients. Copyright © 2013 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.
Khadaroo, Rachel G; Padwal, Raj S; Wagg, Adrian S; Clement, Fiona; Warkentin, Lindsey M; Holroyd-Leduc, Jayna
It is estimated that seniors (≥65 years old) account for >50% of acute inpatient hospital days and are presenting for surgical evaluation of acute illness in increasing numbers. Unfortunately, conventional acute care models rarely take into account needs of the elderly population. The failure to consider these special needs have resulted in poor outcomes, longer lengths of hospital stay and have likely increased the need for institutional care. Acute Care for the Elderly models on medical wards have demonstrated decreased cost, length of hospital stay, readmissions and improved cognition, function and patient/staff satisfaction. We hypothesize that specific Elder-friendly Approaches to the Surgical Environment (EASE) interventions will similarly improve health outcomes in a cost-effective manner. Prospective, before-after study with a concurrent control group. Four cohorts of 140 consecutively-screened older patients (≥65 years old) will be enrolled (560 patients in total). The EASE interventions involves co-locating all older surgical patients on a single unit, involving an interdisciplinary care team (including a geriatric specialist) in the development of individual care plans, implementing evidence-informed elder-friendly practices, use of a reconditioning program, and optimizing discharge planning. Subjects will be followed via chart review for their hospital stay, and will then complete in-person or telephone interviews at 6 weeks and 6 months after discharge. Measured outcomes include clinical (postoperative major in-hospital complication or death [primary composite outcome]; death or readmission within 30-days of initial discharge; length of hospital stay), humanistic (quality of life; functional, cognitive, and nutritional status) and economic (health care resource utilization and costs) endpoints. Within-site mean change scores will be computed for the composite primary outcome and the overall covariate-adjusted between-site pre-post difference will
Background Rectovaginal fistulas (RVFs) have multiple causes, size and location on which the surgical treatment depends. Description The Authors consider different approaches to RVFs and describe a clinical case of recurrent high RVF. Conclusions Most RVFs can be successfully repaired, although many interventions may be necessary. A colostomy with delayed repair may improve RVFs outcome. Moreover, several authors indicate Mucosal Advancement Flap and Babcock-Bacon technique as the treatments of choice respectively for low and high RVFs (complex and recurrent) and emphasize the placement of endoscopic prothesis in cases of difficult healing of the anastomosis. PMID:24266908
Bozkurt, Ibrahim Halil; Yonguc, Tarik; Arslan, Burak; Degirmenci, Tansu; Gunlusoy, Bulent; Aydogdu, Ozgu; Koras, Omer
Introduction: The management of patients with large impacted upper ureteral stones is difficult; there is no standard treatment. We compared the outcomes of percutaneous nephrolithotomy (PCNL) and ureteroscopic lithotripsy (UL) to treat large (≥1.5 cm), impacted, upper ureteral stones. Methods: In total, 86 patients with large impacted upper ureteral stones were included in this study. Of these patients 41 underwent UL and 45 underwent PCNL. The inclusion criteria were: longest diameter of stone ≥1.5 cm, the localization of stone between the lower border of L4 spine and ureteropelvic junction and impacted stone. Results: In the UL group, we were unable to reach the stone in 3 patients because of ureteral stricture and edema despite balloon dilation. Of these 3 patients, we were unable to optimally visualize the stone in 2 patients due to bleeding and mucosal injury following balloon dilation. The stricture was too firm and could not be passed in the third patient. Also in the UL group, 15 patients had stones or big fragments which migrated into the renal collecting system. In the PCNL group, 21 patients had concurrent renal stones <1 cm and stones were successfully removed in all patients. No statistically significant difference was found between groups in terms of operation time. Mean hospital stay was significantly shorter in the UL group. Success rates were 82.3% in the UL group and 97.6% in the PCNL group (p = 0.001). Conclusion: The recent study confirms that PCNL is a safe and effective minimally invasive procedure with acceptable complication rates in the treatment of patients with large, impacted upper ureteral stones. PMID:25844097
Luo, Hong; Wang, Jing; Qiao, Chenhui; Zhang, Xin; Zhang, Weihua; Song, Laichun
Minimally invasive cardiac surgery is becoming a safe and cosmetic alternative to standard median sternotomy (SMS). In the present retrospective study, we reviewed our results and experience with the totally thoracoscopic (TTS) and right vertical infra-axillary thoracotomy (RVIAT) techniques for atrial septal defect closure compared with SMS. From December 2010 to February 2012, 198 patients underwent repair of atrial septal defect using the TTS technique (n = 66), RVIAT (n = 59), or SMS (n = 73). Cardiopulmonary bypass was achieved peripherally in the TTS group and directly in the RVIAT and SMS groups. The procedures were performed successfully in all 3 groups, and no in-hospital mortality occurred. No patient required conversion to SMS in the TTS group, although 2 patients did so in the RVIAT group. The cardiopulmonary bypass time was 87.26 ± 21 minutes in the TTS group, 41.81 ± 13.97 minutes in the RVIAT group, and 36.99 ± 10.84 minutes in the SMS group (P < .01). The crossclamp time was 32.86 ± 13.36, 22.54 ± 9.08, and 19.23 ± 6.92 minutes in the TTS, RVIAT, and SMS groups, respectively (P < .01). The total incision length in the SMS group (7.45 ± 1.54 cm) was longer than that in the other groups (TTS group, 5.21 ± 0.63 cm; RVIAT group, 6.48 ± 1.37 cm); the difference was statistically significant (P < .01). The TTS technique and RVIAT can both be performed with favorable cosmetic and acceptable clinical results for closing atrial septal defects. They are promising alternatives to SMS and merit additional study. Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.
Dengler, Julius Dengler; Kools, Djaya; Pflugmacher, Robert; Gasbarrini, Alessandro; Prestamburgo, Domenico; Gaetani, Paolo; van Eeckhoven, Eddie; Cher, Daniel; Sturesson, Bengt
Low back pain (LBP) emanating from the sacroiliac joint (SIJ) is a common finding. Devices to fuse the SIJ are now commercially available, but high-quality evidence supporting their effectiveness is limited. To compare the safety and effectiveness of conservative management (CM) to minimally invasive sacroiliac joint fusion (SIJF) in patients with chronic LBP originating from the SIJ. Prospective, multicenter randomized controlled trial. One hundred three adults in spine clinics with chronic LBP originating from the SIJ. Patients were randomly assigned to CM (n = 51) or SIJF using triangular titanium implants (n = 52). CM consisted of optimization of medical therapy, individualized physiotherapy, and adequate information and reassurance as part of a multifactorial treatment. The primary outcome was the difference in change in self-rated LBP at 6 months using a 0 - 100 visual analog scale (VAS). Other effectiveness and safety endpoints, including leg pain, disability using Oswestry Disability Index (ODI), quality of life using EQ-5D, and SIJ function using active straight leg raise test (ASLR), were assessed up to 12 months. At 12 months, mean LBP improved by 41.6 VAS points in the SIJF group vs. 14.0 points in the CM group (treatment difference of 27.6 points, P < 0.0001). Mean ODI improved by 25.0 points in the SIJF group vs. 8.7 points in the CM group (P < 0.0001). Mean improvements in leg pain and EQ-5D scores were large after SIJF and superior to those after CM. CM patients were allowed to crossover to SIJF after 6 months. Patients who crossed to surgical treatment had no pre-crossover improvement in pain and ODI scores; after crossover, improvements were as large as those originally assigned to SIJF. One case of postoperative nerve impingement occurred in the surgical group. Two SIJF patients had recurrent pain attributed to possible device loosening and one had postoperative hematoma. In the CM group, one crossover surgery patient had recurrent pain requiring
Jones, Alex P; Sidhom, Sameh; Sefton, Graham
Although stabilization of the lateral ankle ligament complex (LALC) with augmented techniques is known to be successful, it is associated with a number of complications. We hypothesize that successful stabilization of LALC can be achieved with a woven polyester tape implant via a minimally invasive procedure, as an alternative to tenodesis. Four men with chronic instability of the ankle underwent a minimally invasive surgical stabilization of LALC with a woven polyester tape. This tape was passed through the distal fibula to the base of the fifth metatarsal and then back to the fibula once more before being tied. The foot was immobilized in a neutral position for 2 weeks. Partial weightbearing with a walking stick began on the same day, and physiotherapy began for 10 weeks. Evaluation was performed at a mean follow-up of 24.5 months postoperatively. Preoperatively, all patients had a chronically unstable index ankle both functionally and clinically. At a mean of 24.5 months postoperatively, functional stability for all patients was normal (Sefton grade 1). Subjective ankle performance grades were normal in all cases, and all patients felt the outcome was excellent. Objective measurement with clinical stress testing showed anterior drawer and inversion tests to be the same as the contralateral ankle in all patients. However, each displayed limited inversion of the ankle. No complications such as wound dehiscence, infection, pain, or nerve injury were observed after the procedure. All were able to return to their preinjury activity level within 3 months. Stabilization of LALC may be simply and successfully achieved with a woven polyester graft as an alternative to tenodesis.
Aygören-Pürsün, E; Martinez Saguer, I; Kreuz, W; Klingebiel, T; Schwabe, D
Hereditary angioedema (HAE), caused by deficiency in C1-inhibitor (C1-INH), leads to unpredictable edema of subcutaneous tissues with potentially fatal complications. As surgery can be a trigger for edema episodes, current guidelines recommend preoperative prophylaxis with C1-INH or attenuated androgens in patients with HAE undergoing surgery. However, the risk of an HAE attack in patients without prophylaxis has not been quantified. This analysis examined rates of perioperative edema in patients with HAE not receiving prophylaxis. This was a retrospective analysis of records of randomly selected patients with HAE type I or II treated at the Frankfurt Comprehensive Care Centre. These were examined for information about surgical procedures and the presence of perioperative angioedema. A total of 331 patients were included; 247 underwent 700 invasive procedures. Of these procedures, 335 were conducted in 144 patients who had not received prophylaxis at the time of surgery. Categories representing significant numbers of procedures were abdominal (n = 113), ENT (n = 71), and gynecological (n = 58) procedures. The rate of documented angioedema without prophylaxis across all procedures was 5.7%; in 24.8% of procedures, the presence of perioperative angioedema could not be excluded, leading to a maximum potential risk of 30.5%. Predictors of perioperative angioedema could not be identified. The risk of perioperative angioedema in patients with HAE type I or II without prophylaxis undergoing surgical procedures ranged from 5.7% to 30.5% (CI 3.5-35.7%). The unpredictability of HAE episodes supports current international treatment recommendations to consider short-term prophylaxis for all HAE patients undergoing surgery. © 2013 University Hospital Frankfurt, Goethe University. Allergy published by John Wiley & Sons Ltd.
di Somma, Lucia; Iacoangeli, Maurizio; Nasi, Davide; Balercia, Paolo; Lupi, Ettore; Girotto, Riccardo; Polonara, Gabriele; Scerrati, Massimo
Background: Intraorbital encephalocele is a rare entity characterized by the herniation of cerebral tissue inside the orbital cavity through a defect of the orbital roof. In patients who have experienced head trauma, intraorbital encephalocele is usually secondary to orbital roof fracture. Case Description: We describe here a case of a patient who presented an intraorbital encephalocele 2 years after severe traumatic brain injury, treated by decompressive craniectomy and subsequent autologous cranioplasty, without any evidence of orbital roof fracture. The encephalocele removal and the subsequent orbital roof reconstruction were performed by using a modification of the supraorbital keyhole approach, in which we combine an orbital osteotomy with a supraorbital minicraniotomy to facilitate view and access to both the anterior cranial fossa and orbital compartment and to preserve the already osseointegrated autologous cranioplasty. Conclusions: The peculiarities of this case are the orbital encephalocele without an orbital roof traumatic fracture, and the combined minimally invasive approach used to fix both the encephalocele and the orbital roof defect. Delayed intraorbital encephalocele is probably a complication related to an unintentional opening of the orbit during decompressive craniectomy through which the brain herniated following the restoration of physiological intracranial pressure gradients after the bone flap repositioning. The reconstruction of the orbital roof was performed by using a combined supra-transorbital minimally invasive approach aiming at achieving adequate surgical exposure while preserving the autologous cranioplasty, already osteointegrated. To the best of our knowledge, this approach has not been previously used to address intraorbital encephalocele. PMID:26862452
Wang, Biao; Zhu, Yue; Jiao, Ying; Wang, Feng; Liu, Xinchun; Zhu, Haitao; Tu, Guanjun; Liang, Deyong
The preliminary results from a new anterior-posterior surgical approach are reported. To report a novel surgical approach, which was successfully applied to treat 8 cervical facet dislocation patients. The combined anterior-posterior surgical procedure is used as a common approach in the treatment of cervical facet dislocations. However, some problems may arise during the application of this approach, and as a result, surgeons must change the initial surgical plan to anterior-posterior-anterior approach. Between December 2011 and June 2012, 8 patients had facet dislocations were surgically treated by the new anterior-posterior approach. After anterior discectomy, a peek frame cage containing autologous iliac bone particles or tricalcium phosphate bone substitute was inserted in the interspace and fixed with a peek composite buttress plate screwed into the inferior vertebral body. Then, the anterior wound was closed and the patient was turned prone. Through a posterior midline approach, the posterior elements were exposed and the reduction was gradually achieved by posteriorly translating the superior segment and progressively positioning the patient's neck into extension. Then lateral mass or pedicle screws and titanium rods were placed in a favorable and satisfactory position, which was demonstrated by the intraoperative plain radiographs. A posterolateral fusion was performed and the posterior wound was closed. With the use of this new approach, all the patients had obtained successful reduction and satisfactory anatomic sagittal alignment. No instances of neurological deterioration and instrument failure occurred, no complications were owing to the use of this technique, and 4 patients existed neurological functional recovery at the most recent follow-up visit. This reported surgical approach is an efficient and safe way for the treatment of traumatic cervical facet dislocations.
Pereira, Paulo; Buzek, David; Franke, Jörg; Senker, Wolfgang; Kosmala, Arkadiusz; Hubbe, Ulrich; Manson, Neil; Rosenberg, Wout; Assietti, Roberto; Martens, Frederic; Barbanti Brodano, Giovanni; Scheufler, Kai-Michael
Minimally invasive lumbar interbody fusion (MILIF) offers potential for reduced operative morbidity and earlier recovery compared with open procedures for patients with degenerative lumbar disorders (DLD). Firm conclusions about advantages of MILIF over open procedures cannot be made because of limited number of large studies of MILIF in a real-world setting. Clinical effectiveness of MILIF in a large, unselected real-world patient population was assessed in this Prospective, monitored, international, multicenter, observational study. Objective: To observe and document short-term recovery after minimally invasive interbody fusion for DLD. Materials and Methods: In a predefined 4-week analysis from this study, experienced surgeons (≥30 MILIF surgeries pre-study) treated patients with DLD by one- or two-level MILIF. The primary study objective was to document patients’ short-term post-interventional recovery (primary objective) including back/leg pain (visual analog scale [VAS]), disability (Oswestry Disability Index [ODI]), health status (EQ-5D) and Patient satisfaction. Results: At 4 weeks, 249 of 252 patients were remaining in the study; the majority received one-level MILIF (83%) and TLIF was the preferred approach (94.8%). For one-level (and two-level) procedures, surgery duration was 128 (182) min, fluoroscopy time 115 (154) sec, and blood-loss 164 (233) mL. Time to first ambulation was 1.3 days and time to study-defined surgery recovery was 3.2 days. Patients reported significantly (P < 0.0001) reduced back pain (VAS: 2.9 vs 6.2), leg pain (VAS: 2.5 vs 5.9), and disability (ODI: 34.5% vs 45.5%), and a significantly (P < 0.0001) improved health status (EQ-5D index: 0.61 vs 0.34; EQ VAS: 65.4 vs 52.9) 4 weeks postoperatively. One adverse event was classified as related to the minimally invasive surgical approach. No deep site infections or deaths were reported. Conclusions: For experienced surgeons, MILIF for DLD demonstrated early benefits (short time to
Ugelvig, Line V; Drijfhout, Falko P; Kronauer, Daniel JC; Boomsma, Jacobus J; Pedersen, Jes S; Cremer, Sylvia
Background The invasive garden ant, Lasius neglectus, is the most recently detected pest ant and the first known invasive ant able to become established and thrive in the temperate regions of Eurasia. In this study, we aim to reconstruct the invasion history of this ant in Europe analysing 14 populations with three complementary approaches: genetic microsatellite analysis, chemical analysis of cuticular hydrocarbon profiles and behavioural observations of aggression behaviour. We evaluate the relative informative power of the three methodological approaches and estimate both the number of independent introduction events from a yet unknown native range somewhere in the Black Sea area, and the invasive potential of the existing introduced populations. Results Three clusters of genetically similar populations were detected, and all but one population had a similar chemical profile. Aggression between populations could be predicted from their genetic and chemical distance, and two major clusters of non-aggressive groups of populations were found. However, populations of L. neglectus did not separate into clear supercolonial associations, as is typical for other invasive ants. Conclusion The three methodological approaches gave consistent and complementary results. All joint evidence supports the inference that the 14 introduced populations of L. neglectus in Europe likely arose from only very few independent introductions from the native range, and that new infestations were typically started through introductions from other invasive populations. This indicates that existing introduced populations have a very high invasive potential when the ants are inadvertently spread by human transport. PMID:18302731
Qin, Bin; Ying, Guang-yu; Hu, Hua; Chen, Gao; Zhang, Jian-min; Wang, Lin
To evaluate the efficacy of the surgery with lateral supraorbital approach for clipping anterior circulation aneurysms. The clinical data of 99 patients with anterior circulation aneurysms who underwent a clipping via lateral supraorbital approach from October 2012 to September 2014 and 75 patients, who underwent a clipping via pterional approach from January 2010 to December 2011 in the second Affiliated Hospital, Zhejiang University School of Medicine were reviewed. The operative duration, prognosis, residual rate and rupture rate during surgery were compared between two groups. The patients by lateral supraorbital approach had a shorter operative duration, namely 37~61 min less than that in the patients by pterional approach. No difference were found in residual rate and rupture rate between two groups. The Glasgow Outcome Scale (GOS) at 3 months after surgery showed no significant difference between two groups. The lateral supraorbital approach can be used safely and effectively with shorter operative duration and less tissue damage for treatment of patients with anterior circulation aneurysms.
Clarke, John R
Surgical errors with minimally invasive surgery differ from those in open surgery. Perforations are typically the result of trocar introduction or electrosurgery. Infections include bioburdens, notably enteric viruses, on complex instruments. Retained foreign objects are primarily unretrieved device fragments and lost gallstones or other specimens. Fires and burns come from illuminated ends of fiber-optic cables and from electrosurgery. Pressure ischemia is more likely with longer endoscopic surgical procedures. Gas emboli can occur. Minimally invasive surgery is more dependent on complex equipment, with high likelihood of failures. Standardization, checklists, and problem reporting are solutions for minimizing failures. The necessity of electrosurgery makes education about best electrosurgical practices important. The recording of minimally invasive surgical procedures is an opportunity to debrief in a way that improves the reliability of future procedures. Safety depends on reliability, designing systems to withstand inevitable human errors. Safe systems are characterized by a commitment to safety, formal protocols for communications, teamwork, standardization around best practice, and reporting of problems for improvement of the system. Teamwork requires shared goals, mental models, and situational awareness in order to facilitate mutual monitoring and backup. An effective team has a flat hierarchy; team members are empowered to speak up if they are concerned about problems. Effective teams plan, rehearse, distribute the workload, and debrief. Surgeons doing minimally invasive surgery have a unique opportunity to incorporate the principles of safety into the development of their discipline.
Laffosse, J-M; Chiron, P; Tricoire, J-L; Giordano, G; Molinier, F; Puget, J
There have been few prospective studies comparing minimally invasive approaches for total hip replacement. We wanted to ascertain the contribution of the minimally invasive posterior approach in comparison with the standard posterolateral approach in terms of early outcome. This was prospective comparative consecutive series of patients. Patients with major architectural problems or undergoing revision arthroplasty were excluded. One hundred ten patients (116 hips) were divided into two groups which were comparable for number of patients, gender, age, body mass index, indication for surgery, and preoperative function scores. The preoperative ASA score was lower in the minimally invasive group (p=0.04). The patients were in the lateral reclining position for the two approaches and classical instrumentation using the same implants (stems and cemented or non-cemented cups) were used. We noted operative time and blood loss (using the Brecher method based on the hematocrit at day 1 and 5 and the number of blood transfusions), postoperative pain, and implant position. Functional outcome was assessed with the modified Harris score and the WOMAC index (at 6 weeks and 3 and 6 months). Statview(R) was used to search for statistical significance considering p<0.05 as significant. Mean length of incision was 8.5 cm versus 15.1 cm. Mean blood loss was significantly less in the minimally invasive group (p=0.027) as was the level of postoperative pain as confirmed by the lesser consumption of morphine analgesics (p=0.006). Other operative variables as well as implant position were comparable. There were no major complications in the minimally invasive group. In the standard group, there was one case of common peroneal nerve palsy, two dislocations, and two fractures related to falls after prosthesis implantation. The WOMAC index was better after the minimally invasive approach at six weeks and at three months (p<0.05). The modified Harris score was better only at six weeks
Rabadán, Alejandra T; Campero, Alvaro; Hernández, Diego
Medulla oblongata (MO) tumors are uncommon in adults. Controversies about their treatment arise regarding the need for histological diagnosis in this eloquent area of the brain, weighing benefits of a reliable diagnosis, and the potential disadvantages of invasive procedures. As a broader variety of pathological findings could be found in this localization, the accurate histopathological definition could not only allow an adequate therapy but also can prevent the disastrous consequences of empiric treatments. There are few publications about their surgical management and all belongs to small retrospective cohorts. In this scenario, we are reporting two patients with exophytic or focal lesions in the inferior half of the medulla, who underwent surgery by suboccipital midline subtonsillar approach. This approach was not specifically described to reach MO before, and we found that the lesions produced a mild elevation of the tonsils providing a wide surgical view from the medulla to the foramen of Luchska laterally, and up to the middle cerebellar peduncle, offering a wide and safe access.
E. Rosenstein, Ruth; Belforte, Nicolás
Glaucoma is a leading cause of blindness worldwide, characterised by specific visual field defects due to the degeneration of retinal ganglion cells and damage to the optic nerve head (ONH). Elevated intraocular pressure (IOP) is the most important risk factor for glaucoma development. One of the clinical hallmarks of glaucomatous optic neuropathy is the excavation of the ONH, which consists of a progressive posterior displacement of the ONH surface and excavation of the pre-laminar tissues beneath the anterior-most aspect of the scleral canal, known as the anterior scleral ring. Radial optic neurotomy (RON) is a surgical technique that has been proposed for treating central retinal vein occlusion. While the original rationale of RON was the relief of increased tissue pressure within the optic nerve that results from occlusion of the central retinal vein, recent results are discussed here which suggest that by relaxing of the scleral ring of the prelaminar and laminar regions of the ONH, RON may alleviate the IOP-related connective tissue stress, and in turn, prevent the onset and reduce the progression of glaucomatous neuropathy. PMID:24600623
Bruneau, S; Scolozzi, P
Orbital floor fractures may be reached through 2 types of conjunctival approaches, the preseptal one and the retroseptal one. While the retroseptal approach offers a more direct and easier route to the orbital rim and floor, it is associated with a significantly higher rate of lower lid complications compared to the preseptal approach. We will focus on the preseptal transconjunctival approach. The conjunctival incision is performed with a guarded needle-tip electrocautery or with a long-handled scalpel (blade No. 15) from the inferior extremity of the semilunar fold to the lateral canthal region. The subconjunctival plane is divided with Stevens scissors medially and laterally. This plane, located between the preseptal cranial conjunctival flap covered by the orbital septum and the caudal conjunctival flap covered by the orbicular muscle's fascia, is opened with the scissors toward the inferior orbital rim. The periosteum over the inferior orbital rim is incised and reflected. The subperiosteal dissection is continued toward the orbital floor. The incarcerated periorbital tissues are repositioned to expose the stable bone margins of the fracture before orbital reconstruction. The closure of the periorbita is performed with uninterrupted 5-0 Vicryl sutures. The conjunctiva is closed with a running 6-0 Maxon suture. Although technically more demanding than the retroseptal approach, the preseptal approach enables a large and safe access to the entire orbital floor by passing through an anatomical bloodless plane. This approach can also be combined with a lateral canthotomy/cantholysis and with a medial caruncular transconjunctival incision, thus providing extended exposure of the entire orbit. Copyright © 2015 Elsevier Masson SAS. All rights reserved.
Alastrué Vidal, Antonio; Navinés López, Jordi; Julián Ibáñez, Juan Francisco; De la Ossa Merlano, Napoleón; Botey Fernandez, Mireia; Sampere Moragues, Jaume; Sánchez Torres, Maria del Carmen; Barluenga Torres, Eva; Fernández-Llamazares Rodríguez, Jaime
Introduction Adrenohepatic fusion means union between the adrenal gland and the liver, intermingling its parenchymas. It is not possible to identify this condition by image tests. Its presence implies radical and multidisciplinar approach. Presentation of cases We report two female cases of 45 and 50 years old with clinical virilization and palpable mass on the abdominal right upper quadrant corresponding to adrenocortical carcinoma with hepatic fusion. The contrast-enhanced tomography showed an indistinguishable mass involving the liver and the right adrenal gland. In the first case, the patient had a two-time operation, the former removing only the adrenal carcinoma, and the second performing a radical surgery after an early relapse. In the second case, a radical right en bloc adrenohepatectomy was performed. Both cases were pathologically reported as liver-infiltrating adrenal carcinoma. Only in the second case the surgery was radical effective as first intention to treat, with 3 years of disease-free survival. Discussion ACC is a rare entity with poor prognosis. The major indicators of malignancy are tumour diameter over 6 cm, local invasion or metastasis, secretion of corticosteroids, virilization and hypertension and hypokalaemia. The parenchymal fusion of the adrenal cortical layer can be misdiagnosed as hepatocellular carcinoma with adhesion with the Glisson capsule. AHF in such cases may be misinterpreted during surgery, what may impair its resectability, and therefore the survival. The surgical treatment must be performed en bloc, often using liver vascular control. Postoperative treatment must be offered immediately after surgery. Conclusion We report two consecutive rare cases of adrenohepatic fusion in giant right adrenocortical carcinoma, not detectable by imaging, what has important implications for the surgical decision-making. As radical surgery is the best choice to offer a curative treatment, it has to be performed by a multidisciplinary well
POZZI, A.; GARGARI, M.; BARLATTANI, A.
SUMMARY Background: The advent of modern endosseous implant design and improved surface technology has allowed the development of new restorative techniques that decrease patient’s total treatment time. Utilizing the latest scanning, CAD/CAM and manufacturing technolgies we are able to manufacture individualized dental restoration with high accuracy and a perfect precision of fit. Materials and methods: This report describes the rehabilitation of a completely edentulous patient utilizing a CT-based implant planning with computer-assisted surgical design, simultaneous CAD/CAM fabrication of a surgical template, a flapless surgical placement of the implants, and a prefabricated fixed complete denture for an immediately loaded restoration according to Nobel Biocare’s Teeth-in-an-Hour™ (Nobel Biocare Goteborg, Sweden) protocol. This systematic approach to full mouth rehabilitation reduces the time necessary for an edentulous patient to go from severely atrophic alveolar support to implant retained prosthetic restoration. These aspects of minimally invasive and simplified surgery, along with reducing the treatment time and postsurgical discomfort, are beneficial to the patient, and allowing for rehabilitation with the same level of success as in flap surgery. Conclusion: The Teeth-in-an-Hour protocol is a unique solution made possible by the Procera System. With the aid of the CT scans and a virtual planning software, a custom fabricated precision drill guide and a pre-manufactured prosthesis can be made before surgery. The execution of implant placement is performed with a flapless procedure that results in minimal surgical intervention. This results in a short and non-traumatic surgery with a minimum of postoperative complications, allowing the patient to leave the chair with a fixed prosthesis. Utilizing the latest scanning, CAD/CAM and manufacturing technologies the dental team is able to develop individualized zirconia full arch framework with high accuracy
Schlegel, Peter N
The treatment of nonobstructive azoospermia was developed and has evolved rapidly over the past decade. Extraction of spermatozoa from the limited sites of sperm production in the testes of men with nonobstructive azoospermia has been a primary challenge to the successful treatment of these patients. Using a microsurgical approach referred to as microdissection testicular sperm extraction, sperm retrieval is effective in 60% of men with nonobstructive azoospermia, including 70% of difficult cases, such as men with Klinefelter syndrome. Pregnancy is possible in 45% of couples once sperm are obtained. The microdissection approach seems to be safer than other sperm retrieval approaches and with a higher yield of sperm from men with nonobstructive azoospermia. Its specific application for subsets of men with nonobstructive azoospermia is described.
Tang, Cynthia L; Schlich, Thomas
This article uses the case of the first randomized controlled trial (RCT) evaluating laparoscopic cholecystectomy to investigate the introduction of minimally invasive surgery in the 1990s and explore the meaning of RCTs within the context of the introduction of a new surgical technology. It thus brings together the history of the use of laparoscopic cholecystectomy to remove the gallbladder, and the history of the RCT, shedding light on particular aspects of both. We first situate the RCT in the context of the history of the various treatment options for gallstones, or cholelithiasis, then characterize the specific situation of the rapid, patient-driven spread of laparoscopic cholecystectomy, and in a next step describe how the local context of laparoscopic cholecystectomy as a new technology made it possible and desirable to conduct an RCT, despite numerous obstacles. This article then shows that in order to capture and understand the rationale of an RCT it is worth it to explore the various levels and dimensions of its context, demonstrating how even the RCT as an ostensibly universal tool draws its meaning from its contexts and that this meaning goes beyond the simple determination of efficiency and safety, including, maybe most importantly, the control and management of new technologies. © The Author 2016. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: firstname.lastname@example.org.
Nigim, Fares; Thomas, Ajith J.; Papavassiliou, Efstathios; Schneider, Benjamin E.; Critchlow, Jonathan F.; Chen, Clark C.; Siracuse, Jeffrey J.; Zinn, Pascal O.; Kasper, Ekkehard M.
Objectives: Ventriculoperitoneal shunting (VPS) is a mainstay of hydrocephalus therapy, but carries a significant risk of device malfunctioning. This study aims to compare the outcomes of laparoscopic ventriculoperitoneal shunting versus open ventriculoperitoneal shunting (OVPS) VPS-placement and reviews our findings in the pertinent context of the literature from 1993 to 2012. Materials and Methods: Between 2003 and 2012, a total of 232 patients underwent first time VPS placement at Beth Israel Deaconess Medical Center. Of those, 155 were laparoscopically guided and 77 were done conventionally. We analyzed independent variables (age, gender, medical history, clinical presentation, indication for surgery and surgical technique) and dependent variables (operative time, post-operative complications, length of stay in the hospital) and occurrence of shunt failure. Results: Mean operative time was 43.7 min (18.0-102.0) in the laparoscopic group versus 63.0 min (30.0-151.0) in the open group, (P < 0.05). Length of stay was similar, 5 days in the laparoscopic and in the open group, (P = 0.945). The incidence of shunt failure during the entire follow-up period was not statistically different between the two groups, occurring in 14.1% in the laparoscopic group and 16.9% in the open group, (P = 0.601). Kaplan-Meier analysis demonstrated no difference in shunt survival between the two groups (P = 0.868), with functionality in 85% at 6-months and 78.5% at 1-year. Conclusion: According to our study, LVPS-placement results compare similarly to OVPS placement in most aspects. Since laparoscopic placement is not routinely indicated, we suggest a prospective study to assess its value as an alternate technique especially suitable in obese patients and patients with previous abdominal operations. PMID:25126122
Nigim, Fares; Thomas, Ajith J; Papavassiliou, Efstathios; Schneider, Benjamin E; Critchlow, Jonathan F; Chen, Clark C; Siracuse, Jeffrey J; Zinn, Pascal O; Kasper, Ekkehard M
Ventriculoperitoneal shunting (VPS) is a mainstay of hydrocephalus therapy, but carries a significant risk of device malfunctioning. This study aims to compare the outcomes of laparoscopic ventriculoperitoneal shunting versus open ventriculoperitoneal shunting (OVPS) VPS-placement and reviews our findings in the pertinent context of the literature from 1993 to 2012. Between 2003 and 2012, a total of 232 patients underwent first time VPS placement at Beth Israel Deaconess Medical Center. Of those, 155 were laparoscopically guided and 77 were done conventionally. We analyzed independent variables (age, gender, medical history, clinical presentation, indication for surgery and surgical technique) and dependent variables (operative time, post-operative complications, length of stay in the hospital) and occurrence of shunt failure. Mean operative time was 43.7 min (18.0-102.0) in the laparoscopic group versus 63.0 min (30.0-151.0) in the open group, (P < 0.05). Length of stay was similar, 5 days in the laparoscopic and in the open group, (P = 0.945). The incidence of shunt failure during the entire follow-up period was not statistically different between the two groups, occurring in 14.1% in the laparoscopic group and 16.9% in the open group, (P = 0.601). Kaplan-Meier analysis demonstrated no difference in shunt survival between the two groups (P = 0.868), with functionality in 85% at 6-months and 78.5% at 1-year. According to our study, LVPS-placement results compare similarly to OVPS placement in most aspects. Since laparoscopic placement is not routinely indicated, we suggest a prospective study to assess its value as an alternate technique especially suitable in obese patients and patients with previous abdominal operations.
Kanaan, I N
Pituitary adenomas are the third most common benign intracranial tumor seen in neurosurgical practice. They represent >or= 15 % of all primary intracranial tumors with 25 % prevalence as reported in autopsy series. Advances in biomedical assays, imaging studies support their diagnosis and tailor their management. The direct endonasal transsphenoidal surgery is the recommended intervention for adenoma resection in more than 95 %. The safety and efficacy of this intervention was enhanced by microsurgery and more recently by the introduction of neuronavigation, assisted endoscopy and intraoperative MRI. Anticipation of clinical, biochemical, radiological and surgical pitfalls by a multidisciplinary team is of paramount importance in improving treatment and preventing potential complications.
Raghavan, Derek; Burgess, Earle; Gaston, Kris E; Haake, Michael R; Riggs, Steven B
Deeply invasive bladder cancer, representing approximately 20% of incident cases, is cured by radical cystectomy or radiotherapy in less than 50% of cases. In an effort to improve cure rates, based on objective response rates in metastatic disease of 40%-70% from combination chemotherapy regimens, systemic chemotherapy has been incorporated into programs of definitive treatment for this disease. Several randomized trials and a meta-analysis have confirmed a survival benefit from neoadjuvant chemotherapy followed by definitive local treatment, reflecting both median survival figures and cure rates. Despite several promising phase II trials, no randomized trial of classical adjuvant chemotherapy for bladder cancer has demonstrated an overall survival benefit, despite increments in disease-free survival. Molecular prognostication has been studied in an effort to improve the utility of systemic therapy for invasive non-metastatic bladder cancer, but randomized trials have not shown associated survival benefit. Despite level 1 evidence of a survival benefit from neoadjuvant MVAC (methotrexate, vinblastine, doxorubicin [Adriamycin], cisplatin) or cisplatin, methotrexate, and vinblastine (CMV) chemotherapy, more than 50% of incident cases do not receive such treatment.
Lenchus, Joshua; Issenberg, S Barry; Murphy, Daniel; Everett-Thomas, Ruth; Erben, Laura; Arheart, Kristopher; Birnbach, David J
This study assessed the impact of a blended, standardized curriculum for invasive bedside procedural training on medical knowledge and technical skills for Internal Medicine residents. The investigators developed a curriculum in procedural instruction and performance for Internal Medicine house staff, and implemented the program at a tertiary care academic medical center with a primary affiliation with a US medical school. The investigators chose procedures recommended for technical competence by the American Board of Internal Medicine: lumbar puncture, thoracentesis, paracentesis, central venous catheter insertion, and knee arthrocentesis. The program included: (1) assessment of baseline medical knowledge and technical proficiency on mannequins, (2) video instruction of procedure, (3) faculty-led discussion of critical concepts, (4) faculty demonstration of the procedure on mannequin, (5) individual practice on simulators, (6) post-intervention knowledge evaluation, and (7) post-intervention skills evaluation. The performance achieved during the initial skills evaluation on a mannequin was compared to the performance achieved on the first patient subsequent to the instructional portion. All participants with complete data demonstrated a statistically significant pre-intervention to post-intervention improvement (p < 0.05) in comprehensive medical knowledge and procedural skills. A blended, standardized curriculum in invasive bedside procedural instruction can significantly improve performance in participants' medical knowledge and technical skills.
Arìstegui, Miguel; Cokkeser, Yasar; Saleh, Essam; Naguib, Maged; Landolfi, Mauro; Taibah, Abdel; Sanna, Mario
The extended middle cranial fossa approach includes removal of the petrous bone from its subtemporal surface in order to expose widely the internal auditory canal and the posterior fossa dura around its porus while preserving all the important and closely related anatomical structures. We have dissected 25 temporal bones and five fresh cadavers in order to define the limits of this approach. Measurements were obtained between the different structures to find reliable angles and distances that could guide working in this area. A new method of identification of the internal auditory canal is discussed based on the measurements taken. The results of the present work showed wide variations in the different structures. The arcuate eminence was coincident with the superior semicircular canal in only 48% of bones. Dehiscence of the geniculate ganglion and of the internal carotid artery was noted in 16% and 20% of specimens, respectively. The angles measured between the different structures showed great variations. However, the angle between the internal auditory canal and superior petrosal sinus was constant. Though the extended middle cranial fossa is a versatile approach, it affords a limited access to the cerebellopontine angle. A thorough understanding of the complex and variable anatomy of this area is necessary should this approach be utilized. ImagesFigure 1p183-bFigure 2Figure 3Figure 4Figure 5 PMID:17171170
Abbas, Syed F; Spurgas, Morgan P; Szewczyk, Benjamin S; Yim, Benjamin; Ata, Ashar; German, John W
OBJECTIVE Minimally invasive posterior cervical decompression (miPCD) has been described in several case series with promising preliminary results. The object of the current study was to compare the clinical outcomes between patients undergoing miPCD with anterior cervical discectomy and instrumented fusion (ACDFi). METHODS A retrospective study of 74 patients undergoing surgery (45 using miPCD and 29 using ACDFi) for myelopathy was performed. Outcomes were categorized into short-term, intermediate, and long-term follow-up, corresponding to averages of 1.7, 7.7, and 30.9 months, respectively. Mean scores for the Neck Disability Index (NDI), neck visual analog scale (VAS) score, SF-12 Physical Component Summary (PCS), and SF-12 Mental Component Summary (MCS) were compared for each follow-up period. The percentage of patients meeting substantial clinical benefit (SCB) was also compared for each outcome measure. RESULTS Baseline patient characteristics were well-matched, with the exception that patients undergoing miPCD were older (mean age 57.6 ± 10.0 years [miPCD] vs 51.1 ± 9.2 years [ACDFi]; p = 0.006) and underwent surgery at more levels (mean 2.8 ± 0.9 levels [miPCD] vs 1.5 ± 0.7 levels [ACDFi]; p < 0.0001) while the ACDFi patients reported higher preoperative neck VAS scores (mean 3.8 ± 3.0 [miPCD] vs 5.4 ± 2.6 [ACDFi]; p = 0.047). The mean PCS, NDI, neck VAS, and MCS scores were not significantly different with the exception of the MCS score at the short-term follow-up period (mean 46.8 ± 10.6 [miPCD] vs 41.3 ± 10.7 [ACDFi]; p = 0.033). The percentage of patients reporting SCB based on thresholds derived for PCS, NDI, neck VAS, and MCS scores were not significantly different, with the exception of the PCS score at the intermediate follow-up period (52% [miPCD] vs 80% [ACDFi]; p = 0.011). CONCLUSIONS The current report suggests that the optimal surgical strategy in patients requiring dorsal surgery may be enhanced by the adoption of a minimally invasive
Objective To assess the prognosis of surgically-staged non-invasive uterine clear cell carcinoma (UCCC), and to determine the role of adjuvant therapy. Methods A multicenter, retrospective department database review was performed to identify patients with UCCC who underwent surgical treatment between 1997 and 2016 at 8 Gynecologic Oncology Centers. Demographic, clinicopathological, and survival data were collected. Results A total of 232 women with UCCC were identified. Of these, 53 (22.8%) had surgically-staged non-invasive UCCC. Twelve patients (22.6%) were upstaged at surgical assessment, including a 5.6% rate of lymphatic dissemination (3/53). Of those, 1 had stage IIIA, 1 had stage IIIC1, 1 had stage IIIC2, and 9 had stage IVB disease. Of the 9 women with stage IVB disease, 5 had isolated omental involvement indicating omentum as the most common metastatic site. UCCC limited only to the endometrium with no extra-uterine disease was confirmed in 41 women (73.3%) after surgical staging. Of those, 13 women (32%) were observed without adjuvant treatment whereas 28 patients (68%) underwent adjuvant therapy. The 5-year disease-free survival rates for patients with and without adjuvant treatment were 100.0% vs. 74.1%, respectively (p=0.060). Conclusion Extra-uterine disease may occur in the absence of myometrial invasion (MMI), therefore comprehensive surgical staging including omentectomy should be the standard of care for women with UCCC regardless of the depth of MMI. Larger cohorts are needed in order to clarify the necessity of adjuvant treatment for women with UCCC truly confined to the endometrium. PMID:28541637
Sankhla, Suresh K.; Jayashankar, Narayan; Khan, Ghulam M.
Objective: Surgical treatment of retrochiasmatic craniopharyngioma still remains a challenge. While complete removal of the tumor with preservation of the vital neurovascular structures is often the goal of the treatment, there is no optimal surgical approach available to achieve this goal. Transcranial and transsphenoidal microsurgical approaches, commonly used in the past, have considerable technical limitations. The extended endonasal endoscopic surgical route, obtained by removal of tuberculum sellae and planum sphenoidale, offers direct midline access to the retrochiasmatic space and provides excellent visualization of the undersurface of the optic chiasm. In this report, we describe the technical details of the extended endoscopic approach, and review our results using this approach in the surgical management of retrochiasmatic craniopharyngiomas. Methods: Fifteen children, including 9 girls and 6 boys, aged 8 to 15 years underwent surgery using extended endoscopic transsphenoidal approach between 2008 and 2014. Nine patients had a surgical procedure done previously and presented with recurrence of symptoms and regrowth of their residual tumors. Results: A gross total or near total excision was achieved in 10 (66.7%) patients, subtotal resection in 4 (26.7%), and partial removal in 1 (6.7%) patient. Postoperatively, headache improved in 93.3%, vision recovered in 77.3%, and the hormonal levels stabilised in 66.6%. Three patients (20%) developed postoperative CSF leaks which were managed conservatively. Three (20%) patients with diabetes insipidus and 2 (13.3%) with panhypopituitarism required long-term hormonal replacement therapy. Conclusions: Our early experience suggests that the extended endonasal endoscopic approach is a reasonable option for removal of the retrochiasmal craniopharyngiomas. Compared to other surgical approaches, it provides better opportunities for greater tumor removal and visual improvement without any increase in risks. PMID:26962333
Hoffmann, Ralf Thorsten Nikolaou, Konstantin; Boekstegers, Peter; Reichart, Bruno; Reiser, Maximilian F.
Ventricular free wall rupture remains the most serious complication after acute myocardial infarction. In early-recognized, subacute cases a surgical intervention using patches can be lifesaving. However, in the rare case of postoperative patch leakage, a relapse of a pseudoaneurysm may occur. This is the first case in the literature-to the best of our knowledge-describing a minimally invasive strategy using CT fluoroscopic guidance to perform an injection of thrombin into the perfused pseudoaneurysm to seal a leakage. This therapeutical regimen was chosen-in accordance with cardiac surgeons, cardiologists, and interventional radiologists-due to the high risk of adverse event after repeated surgery in this particular patient. The follow-up images showed complete occlusion of the pseudoaneurysm after the thrombin injection. This approach could be discussed in a multidisciplinary setting in similar cases, especially due to the described negligible recurrence rate after successful initial thrombosis after treating femoral pseudoaneurysms, pseudoaneurysms of the pancreatic artery, or even endoleaks after stenting of aneurysms of the aorta.
Benet, Arnau; Hervey-Jumper, Shawn L; Sánchez, Jose Juan González; Lawton, Michael T; Berger, Mitchel S
Transcortical and transsylvian corridors have been previously described as the main surgical approaches to the insula, but there is insufficient evidence to support one approach versus the other. The authors performed a cadaveric comparative study regarding insular exposure, surgical window and freedom, between the transcortical and transsylvian approaches (with and without cutting superficial sylvian bridging veins). Surgical anatomy and skull surface reference points to the different insular regions are also described. Sixteen cadaveric specimens were embalmed with a customized formula to enhance neurosurgical simulation. Two different blocks were defined in the study: first, transsylvian without (TS) and with the superficial sylvian bridging veins cut (TSVC) and transcortical (TC) approaches to the insula were simulated in all (16) specimens. Insular surface exposure, surgical window and surgical freedom were calculated for each procedure and related to the Berger-Sanai insular glioma classification (Zones I-IV) in 10 specimens. Second, the venous drainage pattern and anatomical landmarks considered critical for surgical planning were studied in all specimens. In the insular Zone I (anterior-superior), the TC approach provided the best insular exposure compared with both TS and TSVC. The surgical window obtained with the TC approach was also larger than that obtained with the TS. The TC approach provided 137% more surgical freedom than the TS approach. Only the TC corridor provided complete insular exposure. In Zone II (posterior-superior), results depended on the degree of opercular resection. Without resection of the precentral gyrus in the operculum, insula exposure, surgical windows and surgical freedom were equivalent. If the opercular cortex was resected, the insula exposure and surgical freedom obtained through the TC approach was greater to that of the other groups. In Zone III (posterior-inferior), the TC approach provided better surgical exposure than
Yamashima, Tetsumori; Lee, Joung H; Tobias, Samuel; Kim, Chang-Hyun; Chang, Jong Hee; Kwon, Jeong-Taik
Previously, we reported surgical results of the simplified retrosigmoid approach for vestibular nerve sectioning in the cases with intractable vertigo. Here, we introduce in details surgical procedures of the simplified retrosigmoid (also called "subasterional" here for simplification) approach developed by one of the authors (J.H.L.). This approach is to operate cerebello-pontine (C-P) angle lesions through a small upper lateral window below the transverse-sigmoid junction. The retroauricular 4-5 cm skin incision, triangular craniectomy 2 cm in width, dural opening and closure, special considerations, and reconstruction of the skull defect were outlined. The bony landmarks for triangle craniectomy below asterion were described in detail. The C-P angle was appropriately approached for microvascular decompression, removal of C-P angle tumors, and vestibular nerve resection. This subasterional approach was characterized by short operation time of 1-3 h and less postoperative discomforts compared to the conventional retrosigmoid approach.
Yüksel, Ahmet; Saba, Davit; Velioğlu, Yusuf; Ener, Serdar; Özkan, Hayati
Objective We aimed to present clinical features, surgical approaches, importance of surgical technique and long-term outcomes of our patients with cardiac myxoma who underwent surgery. Methods We retrospectively collected data of patients with cardiac myxoma who underwent surgical resection between February 1990 and November 2014. Biatrial approach is the preferred surgical method in a large proportion of patients that are operated due to left atrial myxoma because it provides wider exposure than the uniatrial approach. To prevent recurrence during surgical resection, a large excision is made so as to include at least 5 mm of normal area from clean tissue around the tumor. Moreover, special attention is paid to the excision that is made as a whole, without digesting the fragment of tumor with gentle dissections. Results Forty-three patients (20 males, mean age of 51.7±8.8 years) were included. Most common symptom was dyspnea (48.8%). Tumor was located in the left atrium in 37 (86%) patients. Resections were achieved via biatrial approach in 34 patients, uniatrial approach in 8 patients, and right atriotomy with right ventriculotomy in 1 patient. One patient died due to low cardiac output syndrome in the early postoperative period. Mean follow-up time was 102.3±66.5 months. Actuarial survival rates were 95%, 92% and 78% at five, 10 and 15 years, respectively. Recurrence was observed in none of the patients during follow-up. Conclusion Although myxomas are benign tumors, due to embolic complications and obstructive signs, they should be treated surgically as soon as possible after diagnosis. To prevent recurrence, especially in cardiac myxomas which are located in left atrium, preferred biatrial approach is suggested for wide resection of the tumor and to avoid residual tumor. PMID:27849304
Huang, Ai-Bing; Wang, Hai-Jun; Yu, Jia-Kuo; Yang, Bo; Ma, Dong; Zhang, Ji-Ying
Patellofemoral syndrome is still a common complication after total knee arthroplasty (TKA). However, the effects of specific surgical approaches on patellar tracking and alignment remain incompletely understood. In this study, we compared patellar alignment in patients who underwent TKA via three different techniques. A total of 96 patients who completed a minimum follow-up of five years were involved in three groups: 30 patients were treated with the traditional medial parapatellar approach (MPP group), 35 patients were treated with the mini-medial parapatellar approach (MMP group) and 31 were treated with a quadriceps-sparing approach (QS group). Radiographic data for patellar alignment and clinical results were compared. Patellar tilt and patellar displacement at the final follow-up evaluation differed significantly among the three groups [P < 0.01, analysis of variance (ANOVA)]. The MMP and QS groups exhibited more proper patellar alignment than the MPP group. The clinical results did not differ significantly among the groups (P > 0.05, ANOVA). In addition, there were no correlations between postoperative patellar alignment and clinical scores. The results of this study indicate that TKA performed using minimally invasive approaches yields superior patellar alignment compared to the traditional MPP approach.
Mauch, J; Helbling, C; Schlumpf, R
Acute symptomatic groin hernias with potential or definite ischemia represent a special group of all the groin hernias. The method of choice to treat these hernias has to fulfill the following criteria: 1. Easy reduction of the hernia sac and its contents without causing damage. 2. Good exposure and easy access for possible resection. 3. Safe hernia repair through the same access. According to our experience with 44 incarcerated and strangulated groin hernias operated between 1993 and 1997 and after a literature review, we took the following procedure as our routine: Posterior approach and mesh repair. We do not use a meshgraft only in the presence of colonic necrosis or peritonitis.
Krishnapriya, V; Sriram, CH; Reddy, Maheshwar KR
ABSTRACT Surgical derotation is a method of placing a rotated tooth in normal alignment in a dental arch; surgically, immediately and permanently. It is a potentially convenient and cost-effective treatment modality as compared to conventional orthodontic procedure for rotated maxillary incisor with open apex. Here is a presentation of a severely rotated maxillary left permanent central incisor in a nine and half years old girl, with a radiographic evidence of immature root apex which was surgically derotated, orthodontically retroclined and intruded to its normal position. Postsurgical clinical and radiographic evaluation was done for a period of one and half years to confirm the vitality and continued physiological root formation of the affected tooth. How to cite this article: Dutta B, Krishnapriya V, Sriram CH, Reddy MKR. Surgical Derotation Technique: A Novel Approach in the Management of Rotated Immature Permanent Incisor. Int J Clin Pediatr Dent 2015;8(3):220-223. PMID:26604541
Díaz, Roberto; Berbeo, Miguel E; Villalobos, Luis M; Vergara, Manuel F; Osorio, Enrique
The C1-C2 joint is affected by multiple entities that may produce biomechanical instability. Optimal management for atlantoaxial instability has been searched by ways of different surgical techniques with different results, generating discussion between second effects of a particular treatment. Lateral dissections can place the axial neck musculature and ligaments at risk of neural denervations or vascular compromise. Either of these entities may result in significant postoperative atrophy, pain, and instability. Minimally invasive techniques for the treatment of spinal disorders allow to our patients less morbid procedures with equal or better results compared to conventional surgery. In the following paper, we review the anatomy of the atlantoaxial joint and propose a minimally invasive trans-muscular C1-C2 fusion technique using C1 lateral-mass screws and C2 pedicular screws. We describe cases with surgical, clinical, and radiographic follow-up.
Saeed, Diyar; Maxhera, Bujar; Albert, Alexander; Westenfeld, Ralf; Hoffmann, Till; Lichtenberg, Artur
PURPOSE Left ventricular assist device (LVAD) pump thrombosis is one of the devastating complications following mechanical circulatory support implantation. Surgical pump exchange is a known high-risk surgery with a high perioperative mortality rate. We aim to summarize our experience with several other alternative approaches in patients with suspected HeartWare HVAD (HeartWare, Framingham, MA, USA) pump thrombosis. METHODS The outcome of HeartWare HVAD implantations performed at single institution from January 2010 to September 2015 was studied. Inclusion criteria were patients with suspected HeartWare HVAD pump thrombosis. Patients’ preoperative characteristics and outcome following various interventions were reviewed. RESULTS A total of 94 HeartWare HVAD pumps were implanted in 91 patients. The inclusion criteria were met by 13 patients (14%) with a mean age of 55 ± 14 years old and a median total pump support duration of 467 days (11–937 days). A conservative approach using systemic thrombolysis (recombinant tissue plasminogen activator) + heparin was used in the majority of the patients (15 events = 65%). Heart transplantation was performed in 4 patients and device explantation in 2 patients. Other approaches were used in the rest of patients. Considering thrombolysis-related complications, 1 patient required resternotomy for bleeding after thrombolysis, which was necessary a few days after LVAD implant surgery and 2 patients developed minor intracranial bleeding after thrombolysis. One-year survival after the latest intervention was 69%. CONCLUSIONS This report showed the feasibility of several alternative conservative approaches combining medications, minimally invasive and interventional methods for patients with HeartWare pump thrombosis. The outcome may be better than immediate surgical pump exchange. PMID:26993475
Biro, Peter; Sermeus, Luc; Jankovic, Radmilo; Savić, Nenad; Onuţu, Adela Hilda; Ionescu, Daniela; Godoroja, Daniela; Gurman, Gabriel
Objective There is still a lack of a universally applicable and comprehensive scoring system for documenting the invasiveness of surgical procedures. The proposed preliminary ‘Universal Surgical Invasiveness Score’ (pUSIS) is intended to fill this gap. Methods We used the recently developed pUSIS to obtain values from 8 types of surgery and 80 individual interventions. The results were analysed using descriptive statistical methods. The degree of difficulty on a scale from 0 (very easy) to 10 (extremely difficult) and time expenditures for assessing pUSIS were documented. Results Individual pUSIS values ranged from 8 in a laparoscopic cholecystectomy case to 36 in a total hip replacement case. The lowest median pUSIS value of 11.5 was found for laparoscopic cholecystectomy and the highest value of 24.5 was found for open thoracic surgery. The correlation between pUSIS values and the duration of surgery resulted in a tight linear regression (R2=0.6419). The lowest mean (±SD) difficulty level to obtain pUSIS values was 1.6±0.6 for sleeve gastrectomy and the highest one was 2.9±0.6 for knee replacement. The duration to finalise the calculations was 4.1±1.1 min for video-assisted thoracoscopy (VATS) and 9.4±1.3 min for sleeve gastrectomy. Conclusion We concluded that pUSIS has the potential to be a useful, simply obtainable and universal assessment tool for quantification of the magnitude and invasiveness of individual surgical operations and can serve as a means to quantify surgical interventions for outcome research and evaluate surgical performance. PMID:28377835
Nørgaard, Sandra L; Riber, Sara S; Danielsson, Frederik B; Pedersen, Niels W; Viberg, Bjarke
When using elastic stable intramedullary nailing in children's distal radius shaft fractures, the surgical approach can either be lateral or dorsal. The aim of this article was to carry out a systematic review of the literature comparing the two types of approaches in terms of complications. An electronic search of databases was performed. Titles of articles were screened, and abstracts and full text were read. Data were extracted in terms of demographics and complications. The dorsal approach had a 2.6% rate of extensor pollicis longus tendon rupture, whereas the lateral approach had a 2.9% rate of transient superficial radial nerve palsy and 0.3% rate of permanent damage. These complications should be considered when deciding between the two surgical approaches.
subcapital, mid cervical , and basicervical femoral neck fractures. Key Words: Smith Petersen, surgical exposure, anterior hip approach, femoral neck...two senior authors (TLG and JRH). These authors are fellowship- trained in arthroplasty and trauma, respectively. A minimally Accepted for publication...intermuscular plane and thus places the superior gluteal nerve at risk. The direct anterior approach was initially used for hip arthroplasty but
Cour, F; Vidart, A
The never ending debate over the surgical approach of genital prolapse repair (abdominal versus vaginal route) is as passionate as ever. The available literature may support a multidisciplinary analysis of our expert daily practice. Our purpose was to define selection criteria for surgical approach between abdominal and vaginal route in the management of genital prolapse by reviewing the literature. Systematically review of the literature concerning comparative anatomical and functionnal results of surgery of pelvic organ prolaps by vaginal or abdominal route. We were confronted to the lack of data in the literature, with few prospective randomized comparative studies. Many limitations were identified such as small populations in the studies, no description of sub-population, multiplicity of surgical procedures. Moreover, vaginal route was compared to sacral colpopexy by open abdominal approach, whereas laparoscopic sacrocolpopexy is now recommended. Only one prospective randomized comparative trial assessed laparoscopic sacrocolpopexy and vaginal approach, in which was used a mesh withdrawn from the market. The lack of available randomized trials makes it impossible to define HAS compliant guidelines on this topic. However, selection criteria for each surgical approach and technique were drawn from experts' advices. © 2016 Published by Elsevier Masson SAS. © 2016 Elsevier Masson SAS. Tous droits réservés.
Background The treatment for deep surgical site infection (SSI) following primary total hip arthroplasty (THA) varies internationally and it is at present unclear which treatment approaches are used in Australia. The aim of this study is to identify current treatment approaches in Queensland, Australia, show success rates and quantify the costs of different treatments. Methods Data for patients undergoing primary THA and treatment for infection between January 2006 and December 2009 in Queensland hospitals were extracted from routinely used hospital databases. Records were linked with pathology information to confirm positive organisms. Diagnosis and treatment of infection was determined using ICD-10-AM and ACHI codes, respectively. Treatment costs were estimated based on AR-DRG cost accounting codes assigned to each patient hospital episode. Results A total of n=114 patients with deep surgical site infection were identified. The majority of patients (74%) were first treated with debridement, antibiotics and implant retention (DAIR), which was successful in eradicating the infection in 60.3% of patients with an average cost of $13,187. The remaining first treatments were 1-stage revision, successful in 89.7% with average costs of $27,006, and 2-stage revisions, successful in 92.9% of cases with average costs of $42,772. Multiple treatments following ‘failed DAIR’ cost on average $29,560, for failed 1-stage revision were $24,357, for failed 2-stage revision were $70,381 and were $23,805 for excision arthroplasty. Conclusions As treatment costs in Australia are high primary prevention is important and the economics of competing treatment choices should be carefully considered. These currently vary greatly across international settings. PMID:23497364
The PCR methods published for the diagnosis of invasive aspergillosis (IA) are diverse in terms of amplification protocols and methods, equipment, fluorescent detection dyes, PCR chemistries, and clinical specimens used. This explains why PCR is still not included in the revised EORTC/MSG definitions of IA despite encouraging results. Therefore, achieving consensual PCR procedures at the international level is mandatory. When using PCR as a diagnostic tool, emphasis must be put on limiting false positive results due to contamination either with previously amplified products or with environmental commensals. Internal amplification controls are compulsory to evidence false negative results. For most of these aspects, quantitative PCR (qPCR) should improve both the results' reliability and the clinicians' confidence. A checklist of items (Minimum information for publication of quantitative real-time PCR experiments) has been proposed to help scientists and reviewers. Currently, the main limitation relies in the DNA extraction procedure the choice of which dramatically depends on the still unknown origin of the Aspergillus DNA to amplify. There is an urgent need for basic studies to elucidate the origin and kinetics of Aspergillus DNA in blood. Once a technical consensus is achieved, clinical studies should be initiated to integrate qPCR in the diagnostic armentarium of IA.
Gause, Colin D; Hsiung, Grace; Schwab, Ben; Clifton, Matthew; Harmon, Carroll M; Barsness, Katherine A
Mandates for improved patient safety and increasing work hour restrictions have resulted in changes in surgical education. Educational courses increasingly must meet those needs. We sought to determine the experience, skill level, and the impact of simulation-based education (SBE) on two cohorts of pediatric surgery trainees. After Institutional Review Board (IRB) exempt determination, a retrospective review was performed of evaluations for an annual advanced minimally invasive surgery (MIS) course over 2 consecutive years. The courses included didactic content and hands-on skills training. Simulation included neonatal/infant models for rigid bronchoscopy-airway foreign body retrieval, laparoscopic common bile duct exploration, and real tissue diaphragmatic hernia (DH), duodenal atresia (DA), pulmonary lobectomy, and tracheoesophageal fistula models. Categorical data were analyzed with chi-squared analyses with t-tests for continuous data. Participants had limited prior advanced neonatal MIS experience, with 1.95 ± 2.84 and 1.16 ± 1.54 prior cases in the 2014 and 2015 cohorts, respectively. The 2015 cohort had significantly less previous experience in lobectomy (P = .04) and overall advanced MIS (P = .007). Before both courses, a significant percentage of participants were not comfortable with DH repair (39%-42%), DA repair (50%-74%), lobectomy (34%-43%), and tracheoesophageal fistula repair (54%-81%). After course completion, > 60% of participants reported improvement in comfort with procedures and over 90% reported that the course significantly improved their perceived ability to perform each operation safely. Pediatric surgery trainees continue to have limited exposure to advanced MIS during clinical training. SBE results in significant improvement in both cognitive knowledge and trainee comfort with safe operative techniques for advanced MIS.
Öberg, S; Andresen, K; Rosenberg, J
Guidelines recommend that the reoperation of a recurrent inguinal hernia should be by the opposite approach (anterior-posterior) than the primary repair. However, the level of evidence supporting the guidelines is partially low. The purpose of this study was to compare re-reoperation rates between repairs performed according to the guidelines with the ones performed against it. This cohort study was based on the Danish Hernia Database, including 4344 patients with two inguinal hernia repairs in the same groin. Four groups were compared as follows: Lichtenstein-Lichtenstein vs. Lichtenstein-Laparoscopy, and Laparoscopy-Laparoscopy vs. Laparoscopy-Lichtenstein. The outcome was re-reoperation rates, which were compared by crude rates, cumulated rates, and hazard ratios. There was no difference in the re-reoperation rates when the primary repair was laparoscopic, regardless of the type of reoperation. However, Lichtenstein-Lichtenstein had a significantly higher re-reoperation rate compared with Lichtenstein-Laparoscopy (crude rate 8.7 vs. 3.1 %, p value <0.0005; Hazard Ratio 2.46, 95 % CI 1.76-3.43). Further analysis showed that the higher risk of re-reoperation for Lichtenstein-Lichtenstein was only seen if the primary hernia was medial. A primary Lichtenstein repair of a primary medial hernia should be reoperated with a laparoscopic repair. A primary Lichtenstein repair of a primary lateral hernia can be reoperated with either a Lichtenstein or a laparoscopic repair according to surgeon's choice. For a primary laparoscopic operation, the method of repair of a recurrent hernia did not affect the re-reoperation rate.
Uchii, Kimiko; Doi, Hideyuki; Minamoto, Toshifumi
The invasion of non-native species that are closely related to native species can lead to competitive elimination of the native species and/or genomic extinction through hybridization. Such invasions often become serious before they are detected, posing unprecedented threats to biodiversity. A Japanese native strain of common carp (Cyprinus carpio) has become endangered owing to the invasion of non-native strains introduced from the Eurasian continent. Here, we propose a rapid environmental DNA-based approach to quantitatively monitor the invasion of non-native genotypes. Using this system, we developed a method to quantify the relative proportion of native and non-native DNA based on a single-nucleotide polymorphism using cycling probe technology in real-time PCR. The efficiency of this method was confirmed in aquarium experiments, where the quantified proportion of native and non-native DNA in the water was well correlated to the biomass ratio of native and non-native genotypes. This method provided quantitative estimates for the proportion of native and non-native DNA in natural rivers and reservoirs, which allowed us to estimate the degree of invasion of non-native genotypes without catching and analysing individual fish. Our approach would dramatically facilitate the process of quantitatively monitoring the invasion of non-native conspecifics in aquatic ecosystems, thus revealing a promising method for risk assessment and management in biodiversity conservation. © 2015 John Wiley & Sons Ltd.
Kobiela, Jarek; Łaski, Dariusz; Stróżyk, Aneta; Proczko-Markuszewska, Monika; Stefaniak, Tomasz; Sworczak, Krzysztof; Łachiński, Andrzej J; Śledziński, Zbigniew
Complete surgical resection of hyperfunctioning parathyriod tissue is essential for the treatment of primary hyperparathyroidism. During recent years, minimally invasive surgery has been successfully applied in neck exploration, because of significant developments of guidance by intraoperative scans, the use of quick, intraoperative PTH assay, and also preoperative imaging procedures such as high resolution ultrasonography and sestamibi scintigraphy. The results of operations which are performed with minimally invasive techniques are comparable to those of conventional surgery, and provide advantages with regard to cosmetic result, length of hospitalisation, and reduced post-operative pain.
Putzer, David; Klug, Sebastian; Moctezuma, Jose Luis; Nogler, Michael
Time-of-flight (TOF) cameras can guide surgical robots or provide soft tissue information for augmented reality in the medical field. In this study, a method to automatically track the soft tissue envelope of a minimally invasive hip approach in a cadaver study is described. An algorithm for the TOF camera was developed and 30 measurements on 8 surgical situs (direct anterior approach) were carried out. The results were compared to a manual measurement of the soft tissue envelope. The TOF camera showed an overall recognition rate of the soft tissue envelope of 75%. On comparing the results from the algorithm with the manual measurements, a significant difference was found (P > .005). In this preliminary study, we have presented a method for automatically recognizing the soft tissue envelope of the surgical field in a real-time application. Further improvements could result in a robotic navigation device for minimally invasive hip surgery. © The Author(s) 2014.
Hironaka, Yasuo; Morimoto, Tetsuya; Motoyama, Yasushi; Park, Young-Su; Nakase, Hiroyuki
Surgical treatment for degenerative spinal disorders is controversial, although lumbar fusion is considered an acceptable option for disabling lower back pain. Patients underwent instrumented minimally invasive anterior lumbar interbody fusion (mini-ALIF) using a retroperitoneal approach except for requiring multilevel fusions, severe spinal canal stenosis, high-grade spondylolisthesis, and a adjacent segments disorders. We retrospectively reviewed the clinical records and radiographs of 142 patients who received mini-ALIF for L4-5 degenerative lumbar disorders between 1998 and 2010. We compared preoperative and postoperative clinical data and radiographic measurements, including the modified Japanese Orthopaedic Association (JOA) score, visual analog scale (VAS) score for back and leg pain, disc height (DH), whole lumbar lordosis (WL), and vertebral wedge angle (WA). The mean follow-up period was 76 months. The solid fusion rate was 90.1% (128/142 patients). The average length of hospital stay was 6.9 days (range, 3–21 days). The mean blood loss was 63.7 ml (range, 10–456 ml). The mean operation time was 155.5 min (range, 96–280 min). The postoperative JOA and VAS scores for back and leg pain were improved compared with the preoperative scores. Radiological analysis showed significant postoperative improvements in DH, WL, and WA, and the functional and radiographical outcomes improved significantly after 2 years. The 2.8% complication rate included cases of wound infection, liquorrhea, vertebral body fractures, and a misplaced cage that required revision. Mini-ALIF was found to be associated with improved clinical results and radiographic findings for L4-5 disorders. A retroperitoneal approach might therefore be a valuable treatment option. PMID:24140782
Denys Yemshanov; Frank H. Koch; D. Barry Lyons; Mark Ducey; Klaus Koehler
Aim Uncertainty has been widely recognized as one of the most critical issues in predicting the expansion of ecological invasions. The uncertainty associated with the introduction and spread of invasive organisms influences how pest management decision makers respond to expanding incursions. We present a model-based approach to map risk of ecological invasions that...
Palacios, M García; Somoza, I; Lema, A; Molina, M E; Veiras, J Gómez; Tellado, M; Ríos, J; Dargallo, T; Pais, E; Vela, D
Helix valgus or procident ears is a common problem that affects about 5% of the population. The folds of the antehelix and the overdevelopment of the concha are the most commonly found anatomic alterations of the ear pavilion. In children this pathology usually causes anxiety and an emotional trauma that may interfere in their normal development. There are a few tipes of techniques to correct helix valgus. We present the application of the technique in our service. We conduct the otoplastia with an outer puntiform technique which allows us to cut the cartilage partially from the outside. Next we fold from the rear the antehelix and hide the concha. We analysed 7 years of the application of this technique and we now present 87 otoplastias conducted to 44 children. The 97% of them were bilateral. No precocious complications have been observed after the surgery. All cases except for one of them have been bilateral. All the patients were satisfied with the aesthetic results. None of them showed relapse. In one case there was a hypertrophic scar that required cutting and in 2 of the cases there was a slight hypercorrection. Procident ears may occasion a psychological trauma in children. We believe that this technique, which is minimally invasive, provides very satisfactory aesthetic results, the puntiform scar being hardly noticed fifteen days before surgery. The patients need to stay in hospital for a short period, 24-48 hours, and complications are very rare, recidiva has not been described. We strongly recommend this technique for the correction of procident ears.
Janson, Marcos; Janson, Guilherme; Sant'Ana, Eduardo; Simão, Tassiana Mesquita; de Freitas, Marcos Roberto
Despite the different orthodontic approaches to Class II subdivision malocclusions one has also to consider the skeletal components before undertaking any treatment protocol. Significant involvement of the skeletal structures may require a combined surgical orthodontic treatment, which has remained stable for more than four years, as illustrated in this case report.
Zhu, Ning-Xi; Meng, You-Qiang; Feng, Bao-Hui; Wang, Xu-Hui; Li, Xin-Yuan; Yang, Min; Zhu, Shu-Gan; Li, Shi-Ting
To study the surgical anatomy and approaches of intracranial oculomotor nerve (OMN) and inferior obliquus (IO), and the methods of their electrode implantation in dogs. The research was performed on 30 adult beagle dogs at Shanghai Jiaotong University Medical College, Shanghai, China from November 2007 to August 2008. All animals were subjected to a right transfrontotemperal approach to intracranial OMN, a transconjunctival route to IO, and the neuro-stimulating and recording electrode implantation under general anaesthesia. The OMN was stimulated and the electromyography of IO recorded and analyzed with the Powerlab System. The security and reliability of the implanted electrodes were investigated. The surgical anatomy and approaches of both the OMN from its exit from midbrain to the entrance into cavernous sinus and the IO were described. Moreover, the implantation methods of OMN stimulating electrode and the electromyographic recording electrode of IO were displayed. The implanted electrodes were safe and reliable. Some electrophysiologic data of IO were obtained in the healthy dogs. Also, some perioperative precautions for intracranial and ophthalmic surgical procedures in dog were exhibited. The mortality rate of the dogs was 0%, and no operative complications were observed. With the data provided, these surgical approaches and the methods of electrode implantation offer a choice to construct an animal model for studying various aspects of OMN regeneration.
Janson, Marcos; Janson, Guilherme; Sant′ana, Eduardo; Simão, Tassiana Mesquita; de Freitas, Marcos Roberto
Despite the different orthodontic approaches to Class II subdivision malocclusions one has also to consider the skeletal components before undertaking any treatment protocol. Significant involvement of the skeletal structures may require a combined surgical orthodontic treatment, which has remained stable for more than four years, as illustrated in this case report. PMID:19466264
Sadrizadeh, Ali; Haghi, Seyed Ziaollah; Masuom, Seyed Hossein Fattahi; Bagheri, Reza; Dalouee, Marziyeh Nouri
Purpose: A hydatid cyst is the most common lung parasitic disease and is endemic in Iran. A hydatid cyst is more common in the right lung and lower lobes. Objective: The aim of this study was to assess surgical treatment of pulmonary hydatid cysts and whether the location of cyst affects surgical technique approaches. Materials and Methods: This study was performed on 87 patients with a pulmonary hydatid cyst who were referred to Qaem Hospital from 2010 to 2012. Selection of surgical technique was according to size, location, and the number of cysts. Patients were divided into two groups: (1) surgery with preserving lung parenchyma and (2) lobectomy. Afterward, the relationship between the location of cyst and surgical technique approaches was evaluated. Data was analyzed by Chi-square and Fisher exact tests. Results: In this study, no significant relation was found between the size (P = 0.682) and number (P = 0.344) of cysts and lobectomy necessity. But, there was a significant relation between the occurrence of cyst in middle lobe and lobectomy necessity (P = 0.016). Conclusions: According to the results, type of surgical technique does not depend on the size and number of cysts, but it may be related to the location of the cyst and the ratio of lung destruction. PMID:25378844
O'Connor, R; McGurk, M
Plunging ranulas arise when a simple ranula extends beyond the floor of the mouth into the neck. Diagnosis is difficult even with modern imaging techniques as they mimic other neck lesions, and traditional treatment involves enucleation of the cyst from the neck. Despite this invasive surgery they tend to recur. We describe a less invasive approach to treatment and review the diagnostic pitfalls. From 2002 to 2011, eight patients presented with a plunging ranula. They were split into two groups: those for whom an incorrect diagnosis was made and those where a less invasive treatment approach was employed. Three patients were misdiagnosed with cervical lymphangioma and had inappropriately invasive surgery. Five patients with established plunging ranulas were treated using an intraoral approach alone, eliminating the need for a cervical incision. Misdiagnosis of a plunging ranula leads to extensive and unnecessary surgery. We propose an algorithm to simplify investigation that employs a low threshold for fine-needle aspiration cytology. The cases presented indicate that these lesions can be managed by a less invasive procedure than currently practised.
Chabernaud, D; Baulot, E; Turlin, F; Perez, A; Grammont, P M
The surgical approach to the circumflex nerve is difficult. Based on an illustrative clinical example, the authors describe a method using a coracoid osteotomy that permits a simplified approach to the circumflex nerve. This trick permits en bloc retraction of the superficial plane of the brachial plexus without sectioning of the muscle and without excessive traction on the musculocutaneous nerve. The stable fixation of the coracoid at the end of the procedure permits early and effective rehabilitation.
Bachelet, J T; Shipkov, H; Breton, P; Berhouma, M; Jouanneau, E; Gleizal, A
The surgical management of posterior orbital tumors is complex because it is an anatomical area located at the borders between the face and the skull base. The goal of the procedures carried-out in this area is to resect the tumor while preserving vision by using the safest possible approach. The aim of our work was to determine, in the light of our experience and of a review of the literature, the advantages and drawbacks of the numerous approaches described.
Bordeianou, Liliana; Maguire, Lillias
Management of medically refractory ulcerative collitis (UC) is a significant challenge to the surgeon. Operative morbidity is high and the potential for mortality remains. Medical therapies have the potential to meaningfully improve the patient, or may dangerously delay and complicate surgery. Operative planning must appropriately address the patient's acuity without losing sight of the patient's long-term need for definitive surgical care and adequate functional outcome. State-of-the-art treatment hinges on prompt recognition of patients with acute severe UC, multidisciplinary coordination of medical therapy, and mature surgical judgment. Biologic therapies and minimally invasive surgical technologies represent the vanguard in UC. However, state-of-the-art treatment of acute severe UC is not employment of the newest drug or technology, but early performance of standard of care surgery, ileal pouch anal anastomosis, for every eligible patient. As the range of therapies available for UC continues to expand, the challenge for the surgeon is incorporating these new drugs and devices without losing sight of the standard of care.
Sodhi, Harsimrat Bir S.; Singla, Navneet; Gupta, Sunil K.
Background: Posterior clinoid process (PCP) meningiomas are rare lesions. In close proximity to these lesions are the perforators from internal carotid artery and the oculomotor nerve, which need to be considered while deciding the appropriate surgical approach. Case Description: We describe a basal frontotemporo-orbito-zygomatic approach with splitting of the sylvian fissure to resect an eccentrically placed PCP meningioma. Conclusion: A basal frontotemporo-orbito-zygomatic approach with splitting of the sylvian fissure is a safe approach to resect an eccentrically placed PCP meningioma. PMID:25722927
Jones, Kirk D; Urisman, Anatoly
Interpretation of lung biopsy specimens is an integral part in the diagnosis of interstitial lung disease (ILD). The process of evaluating a surgical lung biopsy for disease involves answering several questions. Unlike much of surgical pathology of neoplastic lung disease, arriving at the correct diagnosis in nonneoplastic lung disease often requires correlation with clinical and radiologic findings. The topic of ILD or diffuse infiltrative lung disease covers several hundred entities. This article is meant to be a launching point in the clinician's approach to the histologic evaluation of lung disease. Copyright Â© 2012 Elsevier Inc. All rights reserved.
Cucchietti, Cristina; Pisano, Calogera; Hyde, Jonathan
We report our method of surgically repairing an unruptured giant aneurysm of the right coronary sinus of Valsalva, a lesion that caused moderate aortic regurgitation but no symptoms in a 61-year-old woman. We excised the aneurysm, reconstructed the right sinus of Valsalva with use of a patch, performed mechanical aortic valve replacement directly through the excised aneurysm's cavity, and constructed a single bypass graft to the right coronary artery. The patient was discharged from the hospital after 5 days. Twelve months postoperatively, her clinical and echocardiographic results were normal, and she was doing well. To our knowledge, our surgical approach to this repair has not been described previously. PMID:27047284
Hochban, W; Ellers, M; Umstadt, H E; Juchems, K I
In a case series 54 patients with 61 subcondylar fractures had been treated by surgical repositioning and miniplate-fixation by an intraoral approach. Functional results with special regard to the function of the temporomandibular joint TMJ were registered not earlier than 1 year postoperatively and compared to a case series of 48 patients with 63 conservatively treated subcondylar fractures. Axiographic or pantographic investigation proved higher incidence of TMJ-disorders as it was the case for the common clinical functional examination. TMJ-function was worse in the conservatively treated cases especially in dislocated fractures. Therefore dislocated fractures especially with luxation of the TMJ should be surgically treated. Surgical repositioning and fixation by an intraoral approach is difficult and allows only limited access and view of the fracture, but avoids complications by scaring or facial nerve damage and seems to be sufficient for adequate repositioning. Minor dislocations showed no influence on TMJ-function. Of course surgical repair of disrupted TMJ-ligaments is not possible by an intraoral approach-disrupted TMJ-ligaments in luxated joints seem to be of major importance for the later TMJ-function.
Kerwin, Leonard Y; El Tal, Abdel Kader; Stiff, Mark A; Fakhouri, Tarek M
Cosmetic, functional, and structural sequelae of scarring are innumerable, and measures exist to optimize and ultimately minimize these sequelae. To evaluate the innumerable methods available to decrease the cosmetic, functional, and structural repercussions of scarring, pubMed search of the English literature with key words scar, scar revision, scar prevention, scar treatment, scar remodeling, cicatrix, cicatrix treatment, and cicatrix remodeling was done. Original articles and reviews were examined and included. Seventy-nine manuscripts were reviewed. Techniques, comparisons, and results were reviewed and tabulated. Overall, though topical modalities are easier to use and are usually more attractive to the patient, the surgical approaches still prove to be superior and more reliable. However, advances in topical medications for scar modification are on the rise and a change towards medical treatment of scars may emerge as the next best approach. Comparison studies of the innumerable specific modalities for scar revision and prevention are impossible. Standardization of techniques is lacking. Scarring, the body's natural response to a wound, can create many adverse effects. At this point, the practice of sound, surgical fundamentals still trump the most advanced preventative methods and revision techniques. Advances in medical approaches are available, however, to assist the scarring process, which even the most advanced surgical fundamentals will ultimately lead to. Whether through newer topical therapies, light treatment, or classical surgical intervention, our treatment armamentarium of scars has expanded and will allow us to maximize scar prevention and to minimize scar morbidity.
Amarasekera, H. W.; Campbell, P. C.; Parsons, N.; Achten, J.; Masters, J.; Griffin, D. R.; Costa, M. L.
Objectives We aimed to determine the effect of surgical approach on the histology of the femoral head following resurfacing of the hip. Methods We performed a histological assessment of the bone under the femoral component taken from retrieval specimens of patients having revision surgery following resurfacing of the hip. We compared the number of empty lacunae in specimens from patients who had originally had a posterior surgical approach with the number in patients having alternative surgical approaches. Results We found a statistically significant increase in the percentage of empty lacunae in retrieval specimens from patients who had the posterior approach compared with other surgical approaches (p < 0.001). Conclusions This indicates that the vascular compromise that occurs during the posterior surgical approach does have long-term effects on the bone of the femoral head, even if it does not cause overt avascular necrosis. Cite this article: Bone Joint Res 2013;2:200–5. PMID:24049140
Lin, Bin; Shi, Ji-Sheng; Zhang, Hai-Shen; Xue, Chao; Zhang, Bi; Guo, Zhi-Min
Abstract The objective of the present study was to evaluate the clinical, radiological, and functional outcomes of a subscapularis transthoracic surgical approach and a posterolateral surgical approach with debridement, bone graft fusion, and internal fixation for the treatment of upper thoracic tuberculosis. There is currently debate over the best surgical approach for the treatment of upper thoracic tuberculosis. Traditionally, the subscapularis transthoracic approach has been preferred; however, the posterolateral approach has gained popularity in the past few years. A prospective, consecutive cohort of 43 upper thoracic tuberculosis patients with a mean age of 39 years (range: 20–52 years) was followed up for a minimum of 12 months (range: 12–60 months). Patients were randomly divided into 2 groups. Group A (n = 21) was treated by the subscapularis transthoracic approach and group B (n = 22) was treated by the posterolateral approach. All cases were evaluated for clinical, radiological, and functional outcomes. Intraoperative blood loss, operative duration, intraoperative and postoperative complications, hospital stay, the cure rate, fusion time, and the Frankel scale were used for clinical and functional evaluation, whereas the kyphosis angle was used for radiological evaluation. Grafted bones were fused by 10 months in all cases. There was no statistically significant difference between groups before surgery in terms of gender, age, segmental tuberculosis, erythrocyte sedimentation rate (ESR), Frankel scale, or Cobb's angle (P > 0.05). The average operative duration for Group B was lower than that of Group A. There were no significant differences in intraoperative blood loss, intraoperative and postoperative complications, hospital stay, grafted bone fusion time, or cure rate between groups (P > 0.05). The Cobb's angle correction rate for group B (68.5%) was significantly better than that of group A (30.9%). The neurological score showed
Lum, Siew Kheong
The Association of Southeast Asian Nations (ASEAN) Mutual Recognition Arrangement (MRA) on medical practitioners' agreement will become a reality in the year 2015. Doctors registered in one ASEAN country will be given reciprocal recognition in another country under this agreement. Rapid and excessive movement of human resources between countries in a short span of time is undesirable and can be destabilizing. The surgical fraternity in the ASEAN countries should plan for a common surgical curriculum, a common examination and an ASEAN Board of Surgery so that standards of future trainees in different countries are comparable. The curriculum should take into consideration the diversity of the countries in socio-economic development. Ideally, it should be based on a public health approach to bring affordable quality surgical care to the masses in an efficient and effective manner. © 2013 The Author. ANZ Journal of Surgery © 2013 Royal Australasian College of Surgeons.
Marchioni, Daniele; Alicandri-Ciufelli, Matteo; Mattioli, Francesco; Nogeira, Joao Flavio; Tarabichi, Muuaz; Villari, Domenico; Presutti, Livio
Surgical approaches to the inner ear and internal auditory canal (IAC) are well known and well documented. The objective of this study is to analyze the morphology, and surgical and anatomic findings of an exclusive endoscopic transcanal approach (EETA) to the IAC. Cadaveric dissections were performed on 11 temporal bones, approaching the internal auditory meatus directly through the external ear canal and avoiding mastoidectomy. In all cases, it was possible to dissect the internal carotid artery and jugular bulb with a 0° endoscope, and with good control of these two structures. The medial wall of the bony labyrinth guaranteed good landmarks for IAC dissection, such as the spherical recess, and the labyrinthine tract of the facial nerve. The IAC can be thoroughly visualized in the cadaver using EETA, avoiding mastoidectomy, extensive temporal bone tissue removal and external incisions. Clinically based reports will be required in future to strengthen our preliminary results.
Cuda, Scott P; Srinivasan, Arun K; Kalisvaart, Jonathan; Kirsch, Andrew J
The surgical approach to palpable and nonpalpable testicles has changed with increasing use of a single scrotal incision and laparoscopy, respectively. We identified current trends in the surgical approach to undescended testicles in the practice of a single surgeon at our institution. A total of 580 orchiopexies were performed in 554 patients by a single surgeon between January 2002 and July 2009. Study inclusion criteria were palpable and nonpalpable primary undescended testicles. Patients were stratified into groups based on the date of the initial procedure by year. A retrospective chart review was performed and the surgical approach in each patient was recorded as laparoscopic, transinguinal abdominal, inguinal or scrotal. During the 7-year period the percent of orchiopexies performed through a single scrotal incision increased from approximately 15% to a high of 63%. The overall percent of cases performed through a standard inguinal incision decreased from 65% to 17% and the percent performed through a transinguinal abdominal approach decreased from 15% to 0% in the 2 most recent years tabulated. The use of laparoscopy increased from 3% to 17%. Substantial trends were observed among the 3 groups. The percent of procedures performed through a scrotal incision increased during the 7-year period while the percent of inguinal and transinguinal abdominal procedures decreased concomitantly with no increase in morbidity. Selected use of scrotal approach orchiopexy is safe and effective for palpable undescended testicles. Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
Kou, K O; Poon, C F; Kwok, S L; Chan, K Yk; Tang, M Hy; Kan, A Sy; Leung, K Y
In Hong Kong, universal combined first-trimester screening for Down's syndrome was started as a 'free service' in July 2010. Non-invasive prenatal testing was available as a self-financed item in August 2011. This study aimed to determine whether the introduction of non-invasive prenatal testing as a contingent approach influenced the indications for invasive prenatal diagnosis and the consequent prenatal detection of Down's syndrome. This historical cohort study was conducted at the Prenatal Diagnosis Clinic of Queen Elizabeth Hospital in Hong Kong. We compared the indications for invasive prenatal diagnosis and prenatal detection of Down's syndrome in singleton pregnancies 1 year before and 2 years following the availability of non-invasive prenatal testing as a contingent test after a positive aneuploidy test. All pregnant women who attended our hospital for counselling about universal Down's syndrome screening between August 2010 and July 2013 were recruited. A total of 16 098 women were counselled. After the introduction of non-invasive prenatal testing, the invasive prenatal diagnosis rate for a positive aneuploidy screening reduced from 77.7% in 2010-11 to 68.8% in 2012-13. The new combined conventional plus non-invasive prenatal testing strategy was associated with a lower false-positive rate (6.9% in 2010-11 vs 5.2% in 2011-12 and 4.9% in 2012-13). There was no significant increase in invasive prenatal diagnosis for structural anomalies over the years. There was no significant trend in the overall prenatal detection rate of Down's syndrome (100% 1 year before vs 89.1% 2 years after introduction of non-invasive prenatal testing). Four (2.6%) of 156 women who underwent non-invasive prenatal testing for a screen-positive result had a high-risk result for trisomy 21, which was subsequently confirmed by invasive prenatal diagnosis. There were no false-negative cases. The introduction of non-invasive prenatal testing as a contingent approach reduced the invasive
Background HPV infection is a worldwide problem strictly linked to the development of cervical cancer. Persistence of the infection is one of the main factors responsible for the invasive progression and women diagnosed with intraepithelial squamous lesions are referred for further assessment and surgical treatments which are prone to complications. Despite this, there are several reports on the spontaneous regression of the infection. This study was carried out to evaluate the effectiveness of a long term polyhexamethylene biguanide (PHMB)-based local treatment in improving the viral clearance, reducing the time exposure to the infection and avoiding the complications associated with the invasive treatments currently available. Method 100 women diagnosed with HPV infection were randomly assigned to receive six months of treatment with a PHMB-based gynecological solution (Monogin®, Lo.Li. Pharma, Rome - Italy) or to remain untreated for the same period of time. Results A greater number of patients, who received the treatment were cleared of the infection at the two time points of the study (three and six months) compared to that of the control group. A significant difference in the regression rate (90% Monogin group vs 70% control group) was observed at the end of the study highlighting the time-dependent ability of PHMB to interact with the infection progression. Conclusions The topic treatment with PHMB is a preliminary safe and promising approach for patients with detected HPV infection increasing the chance of clearance and avoiding the use of invasive treatments when not strictly necessary. Trial registration ClinicalTrials.gov Identifier NCT01571141 PMID:23009652
Taheri, Ahmad Reza; Farahvash, Mohamad Reza; Fathi, Hamid Reza; Ghanbarzadeh, Koorosh; Faridniya, Bijan
BACKGROUND Surgery, as the main approach in higher stages of gynecomastia, has different techniques regarding the staging of the disease. The more the grade of gynecomastia, the more complicated the used surgical techniques, conventionally. This study assessed the success rate of the simplest surgical technique in higher grades of gynecology as well as the satisfaction rate in patients and surgeon to offer using the technique for higher grades of the disease. METHODS To evaluate the success and the satisfaction rates of periareolar incision and liposuction among patients with grade II and III gynecomastia, this cross-sectional study was conducted. RESULTS The satisfaction rate was the main concern of the present study. The patients had a mean satisfaction score of 8.1±1.396 with the range of 5-10 from total 10 score. The majority of the patients expressed their satisfaction by 9 score. The total mean of physician satisfaction score was 8.36 at all levels. CONCLUSION Like aesthetic reasons which lead individuals to seek solutions for their annoying gynecomastia, aesthetic satisfaction is a prominent concern for people who undergo surgical approach. So, the least surgical scar and complications are absolutely the most area of focus in this regard. PMID:27853693
Rodriguez, Joseph F; Packiam, Vignesh T; Boysen, William R; Johnson, Scott C; Smith, Zachary L; Smith, Norm D; Shalhav, Arieh L; Steinberg, Gary D
To compare outcomes and survival of open-, robotic-, and laparoscopic nephroureterectomy (ONU, RNU, LNU) using population-based data. Using the National Cancer Database, we identified patients who underwent nephroureterectomy for localized upper tract urothelial carcinoma between 2010 and 2013. Demographic and clinicopathologic characteristics were compared among the three operative approaches. Multivariate regression analyses were used to determine the impact of approach on performance of lymphadenectomy (LND), positive surgical margins (PSM), and overall survival (OS). In total, there were 9401 cases identified for analysis, including 3199 ONU (34%), 2098 RNU (22%), and 4104 LNU (44%). From 2010 to 2013, utilization of RNU increased from 14% to 30%. On multivariate analysis, LND was more likely in RNU (odds ratio [OR] 1.52; p < 0.01) and less likely in LNU (OR 0.77; p < 0.01) compared with ONU. RNU was associated with decreased PSM compared with ONU (OR = 0.73; p = 0.04). After adjusting for other factors, OS was not significantly associated with surgical approach. RNU utilization doubled over the study period. While RNU was associated with greater likelihood of LND performance as well as lower PSM rates when compared with ONU and LNU, surgical approach did not independently affect OS.
Sesoko, Natália Ferreira; Rahal, Sheila Canevese; Bortolini, Zara; Merlini, Natalie Bertelis; Teixeira, Carlos Roberto
Anteater forelimbs are distinguished morphologically from domestic animals, especially due to their unique movement and their natural habits. A knowledge of the pectoral limb anatomy and the proper surgical approach are fundamental to success in osteosynthesis and other surgeries. This study aimed to describe the muscles and neurovascular structures of the pectoral limb and the surgical approach to the humeral shaft of the giant anteater ( Myrmecophaga tridactyla ). Dissections of the forelimbs of seven cadavers were performed to identify the major muscles and neurovascular structures. Three of these animals' contralateral forearms were used to simulate the surgical approach to the humeral shaft. Some specific characteristics of the muscle morphology were biceps muscle had two heads, triceps muscle had three heads, and there was an olecranon-epicondylar muscle. To expose the shaft of the humerus, it was necessary to incise the superficial pectoral muscle and separate the heads of the biceps muscle. Due to the anatomical characteristics of the humerus, the craniomedial approach was the most appropriate because it accommodated the anatomical peculiarities of the giant anteater.
Gómez-Montes, Enery; Herraiz, Ignacio; Mendoza, Alberto; Escribano, David; Martínez-Moratalla Valcárcel, José Manuel; Galindo, Alberto
To evaluate the capacity of fetal echocardiography for predicting the more likely surgical approach in newborns with coarctation of the aorta (CoAo) (left thoracotomy vs. median sternotomy). We selected all cases of suspected CoAo prenatally diagnosed in 2003-2012 (n = 95). 49/95 were considered at high-risk and 46/95 at low-risk of CoAo, and 38/49 and 7/46 were postnatally confirmed, respectively. We firstly evaluated in 40 cases of CoAo surgically repaired (24 thoracotomy, 16 sternotomy) whether there were differences in fetal echocardiographic parameters between both groups. Secondly, we assessed the performance of these parameters for predicting the surgical approach in fetuses at high risk of CoAo. Sternotomy approach was associated with higher rate of postoperative complications and longer hospital stay compared with thoracotomy (81.3 vs. 41.7%, p = 0.014; 30.5 vs. 15.4 days, p = 0.0004, respectively). The Z-score of the aortic isthmus, measured in the sagittal plane, was significantly smaller in the sternotomy group. In fetuses at high-risk of having CoAo a cut-off value of the isthmus Z-score ≤ -2.5 had sensitivity of 78% and specificity of 82% for predicting sternotomy approach, with 9% false positive cases in which CoAo was not confirmed. The surgical approach for CoAo repair may be prenatally predicted by means of the Z-score of aortic isthmus, measured in the sagittal plane. © 2013 S. Karger AG, Basel.
ARDÒ, N.P.; LOIZZI, D.; DE PALMA, A.; LOIZZI, M.; CAPORALE, D.; DE BELLIS, R.; CIALDELLA, F.; TANGO, S.; SIMONE, V.; SOLLITTO, F.
Aim The authors report a retrospective study on surgical treatment of primary spontaneous pneumothorax (PSP). Surgical approaches by Videoassisted axillary mini-thoracothomy (VAMT) and three-port VATS (t-VATS) are compared. Mean post-operative stay (MPS) and ipsilateral recurrence rate (IRR) are assessed. Secondary endpoints were about complications, early post-operative pain and long term neurologic symptoms. Patients and Methods From January 2009 to December 2011 we consecutively observed 85 cases of PSP. Treatment was represented by surgery in 52 patients: the approach was by VAMT in 39 instances and t-VATS in 13. Median follow up was 30 months. Results Patients submitted to surgery had a MPS of 6.62 ± 1.5 days for VAMT and 6.69 ± 3.4 days for t-VATS (p=0,94). The IRR was 0% in both surgical approaches, comparing to 7,2% for the group of patients treated by simple drainage. Complications were observed in VAMT group: 2 conversions to thoracothomy for technical difficulties (extensive pleural adherences) and one case of re-thoracothomy for hemothorax. Mean Visual Analogic Scale (VAS) score for early post-operative pain was: 2.10±0.71 for VAMT and 1.92±0.64 for t-VATS, p=0.42 at t-student test. Paresthesia complain rate was 33.3% (VAMT) vs 30.7% (t-VATS) for moderate symptoms (p=0.72 at chi square test). The remaining patients complained only slight symptoms or no symptoms at all. Conclusions Our experience suggested that both surgical approaches to PSP are safe and effective. No differences were found for early post-operative pain and long term paresthesia rate, between the two approaches. No recurrence occurred during follow up. PMID:24979102
Campillo, Fabien; Champagnat, Nicolas; Fritsch, Coralie
We present two approaches to study invasion in growth-fragmentation-death models. The first one is based on a stochastic individual based model, which is a piecewise deterministic branching process with a continuum of types, and the second one is based on an integro-differential model. The invasion of the population is described by the survival probability for the former model and by an eigenproblem for the latter one. We study these two notions of invasion fitness, giving different characterizations of the growth of the population, and we make links between these two complementary points of view. In particular we prove that the two approaches lead to the same criterion of possible invasion. Based on Krein-Rutman theory, we also give a proof of the existence of a solution to the eigenproblem, which satisfies the conditions needed for our study of the stochastic model, hence providing a set of assumptions under which both approaches can be carried out. Finally, we motivate our work in the context of adaptive dynamics in a chemostat model.
Vicente, Jose Ricardo Negreiros; Croci, Alberto Tesconi; de Camargo, Olavo Pire
AIMS Our primary aim was to evaluate whether there is really less bleeding in patients for whom the minimally invasive posterior approach is used in comparison with the direct lateral approach for primary total hip arthroplasty. Our secondary aim was to evaluate the clinical functional results after six months as well as the postoperative radiographic result. METHODS In a comparative non-random prospective study, 76 adult patients underwent elective total hip arthroplasty using one of two approaches. The minimally invasive posterior approach (34 cases; mini-incision group) was compared with the standard direct lateral approach (42 cases; control group). RESULTS Lower total estimated bleeding (means of 1083.5 ml versus 1682.3 ml; p < 0.001) and lower intraoperative bleeding (means of 745.6 ml versus 1282.8 ml; p < 0.001) were found in the mini-incision group. There was, however, no difference in the volume of blood drained after the operation (means of 340 ml and 399 ml; p = 0.77). There was also a difference between the two groups regarding the need for allogenic transfusion (8.8% in the mini-incision group versus 28.6%, p = 0.02). We observed a better clinical result in the mini-incision group (p = 0.002) despite the lack of difference between the two groups in relation to the radiographic result. DISCUSSION Our results draw attention to the possibility that other authors may have underestimated blood losses when using minimally invasive approaches. CONCLUSION The minimally invasive approach gave rise to a positive final impression with regard to lower blood loss. PMID:18568245
Abla, Adib A; Benet, Arnau; Lawton, Michael T
Pontine cavernous malformations (CMs) located on a peripheral pontine surface or the fourth ventricular floor are resectable lesions, but those deep within the pons away from a pial surface are typically observed. However, the anterior bulge of the pons formed by the brachium pontis creates a unique entry point for access to deep pontine lesions from below, working upward through the pontomedullary sulcus. We developed a transpontomedullary sulcus (TPMS) approach to these lesions. The TPMS approach used the far lateral craniotomy and upper vagoaccessory triangle to define the surgical corridor. The entry point was above the olive, lateral to the pyramidal tracts and cranial nerve (CN) VI, above the preolivary sulcus and CN XII, and medial to CNs VII and VIII and CNs IX through XI. Four patients underwent this approach. All presented with hemorrhage and CN VI palsies. All pontine CMs were resected completely. Three patients were improved or unchanged, with good outcomes (modified Rankin Scale score ≤2) in all patients. The central pons remains difficult territory to access, and new surgical corridors are needed. The bulging underbelly of the pons allows access to pontine lesions deep to the pial surface from below. The far lateral TPMS approach is a novel and more direct alternative to the retrosigmoid transmiddle cerebellar peduncle approach. Unlike the retrosigmoid approach, the TPMS approach requires minimal parenchymal transgression and uses a brainstem entry point medial to most lower CNs. Favorable results demonstrate the feasibility of resecting pontine CMs that might have been previously deemed unresectable.
Boschi, Vladimir; Pogorelic, Zenon; Gulan, Gordan; Vilovic, Katarina; Stalekar, Hrvoje; Bilan, Kanito; Grandic, Leo
Background There are few surgical approaches for treating humeral shaft fractures. Here we present our results using a subbrachial approach. Methods We conducted a retrospective case series involving patients who had surgery for a humeral shaft fracture between January 1994 and January 2008. We divided patients into 4 groups based on the surgical approach (anterior, anterolateral, posterior, subbrachial). In all patients, an AO 4.5 mm dynamic compression plate was used. Results During our study period, 280 patients aged 30–36 years underwent surgery for a humeral shaft fracture. The average duration of surgery was shortest using the subbrachial approach (40 min). The average loss of muscle strength was 40% for the anterolateral, 48% for the posterior, 42% for the anterior and 20% for the subbrachial approaches. The average loss of tension in the brachialis muscle after 4 months was 61% for the anterolateral, 48% for the anterior and 11% for the subbrachial approaches. Sixteen patients in the anterolateral and anterior groups and 6 patients in the posterior group experienced intraoperative lesions of the radial nerve. No postoperative complications were observed in the subbrachial group. Conclusion The subbrachial approach is practical and effective. The average duration of the surgery is shortened by half, loss of the muscle strength is minimal, and patients can resume everyday activities within 4 months. No patients in the sub-brachial group experienced injuries to the radial or musculocutaneous nerves. PMID:23187037
Başar, Hakan; Başar, Betül; Erol, Bülent; Tetik, Cihangir
Background: Volar and/or dorsal surgical approaches are used for surgical treatment of perilunate and lunate dislocations. There are no accepted approaches for treatment in the literature. We evaluated the functional results of isolated volar surgical approach for the treatment of perilunate and lunate dislocation injuries. Materials and Methods: 9 patients (6 male and 3 female patients average age 34.5 ± 3.6 years) diagnosed with perilunate or lunate dislocations between January 2000 and January 2009 were involved in the study. The reduction was performed through isolated volar surgical approach and K-wire fixation, fracture stabilization with volar ligament repair was performed. Range of wrist joint motion, fracture healing, carpal stability, grip strength, return to work were evaluated and also direct radiographs were taken routinely at each control. The scapholunate interval and the scapholunate angle were evaluated radiographically. Evaluations of the clinical results were done using the DASH, VAS and Modified Mayo Wrist Scores. Results: The physical rehabilitation was started at 6th week, after the K-wires were removed. The average followup was 18.2 months (range 12-28 months). At the final followup, the average flexion extension arc was 105.0 ± 9.6° (74.6% of the other side), the average rotation arc was 138.8 ± 7.8° (81.5% of the other side) and the average radioulnar arc was 56.1 ± 9.9° (86.4% of the other side). The grip strength was 0.55 bar; 83.2% that the uninjured arm. According to the Mayo Modified Wrist score, the functional result was excellent in five patients and good in four and the average DASH score was 22.8. The scapholunate interval was 2.1 mm and scapholunate angle was 51°. Conclusion: The clinical and radiological results of the isolated volar surgical approach were satisfactory. The dorsal approach was not needed for reduction of dislocations during operations. Our results showed that an isolated volar approach was adequate. PMID
Sharma, Richa; Amitava, Abadan K; Bani, Sadat AO
Introduction: Minimal access surgery is common in all fields of medicine. We compared a new minimally invasive strabismus surgery (MISS) approach with a standard paralimbal strabismus surgery (SPSS) approach in terms of post-operative course. Materials and Methods: This parallel design study was done on 28 eyes of 14 patients, in which one eye was randomized to MISS and the other to SPSS. MISS was performed by giving two conjunctival incisions parallel to the horizontal rectus muscles; performing recession or resection below the conjunctival strip so obtained. We compared post-operative redness, congestion, chemosis, foreign body sensation (FBS), and drop intolerance (DI) on a graded scale of 0 to 3 on post-operative day 1, at 2-3 weeks, and 6 weeks. In addition, all scores were added to obtain a total inflammatory score (TIS). Statistical Analysis: Inflammatory scores were analyzed using Wilcoxon's signed rank test. Results: On the first post-operative day, only FBS (P =0.01) and TIS (P =0.04) showed significant difference favoring MISS. At 2-3 weeks, redness (P =0.04), congestion (P =0.04), FBS (P =0.02), and TIS (P =0.04) were significantly less in MISS eye. At 6 weeks, only redness (P =0.04) and TIS (P =0.05) were significantly less. Conclusion: MISS is more comfortable in the immediate post-operative period and provides better cosmesis in the intermediate period. PMID:24088635
Janis, Jeffrey E.; Haas, Eric M.; Ramshaw, Bruce J.; Nihira, Mikio A.; Dunkin, Brian J.
Background: Provision of optimal postoperative analgesia should facilitate postoperative ambulation and rehabilitation. An optimal multimodal analgesia technique would include the use of nonopioid analgesics, including local/regional analgesic techniques such as surgical site local anesthetic infiltration. This article presents a novel approach to surgical site infiltration techniques for abdominal surgery based upon neuroanatomy. Methods: Literature searches were conducted for studies reporting the neuroanatomical sources of pain after abdominal surgery. Also, studies identified by preceding search were reviewed for relevant publications and manually retrieved. Results: Based on neuroanatomy, an optimal surgical site infiltration technique would consist of systematic, extensive, meticulous administration of local anesthetic into the peritoneum (or preperitoneum), subfascial, and subdermal tissue planes. The volume of local anesthetic would depend on the size of the incision such that 1 to 1.5 mL is injected every 1 to 2 cm of surgical incision per layer. It is best to infiltrate with a 22-gauge, 1.5-inch needle. The needle is inserted approximately 0.5 to 1 cm into the tissue plane, and local anesthetic solution is injected while slowly withdrawing the needle, which should reduce the risk of intravascular injection. Conclusions: Meticulous, systematic, and extensive surgical site local anesthetic infiltration in the various tissue planes including the peritoneal, musculofascial, and subdermal tissues, where pain foci originate, provides excellent postoperative pain relief. This approach should be combined with use of other nonopioid analgesics with opioids reserved for rescue. Further well-designed studies are necessary to assess the analgesic efficacy of the proposed infiltration technique. PMID:28293525
Lukšić, Ivica; Suton, Petar; Macan, Darko; Dinjar, Kristijan
Adenoid cystic carcinoma is the most common malignancy of the minor salivary glands, and its biological behaviour is characterised by slow and indolent growth; rare involvement of regional lymph nodes; a high propensity for perineural invasion; multiple or delayed recurrences, or both; and a high incidence of distant metastases. Our aim was to find out the relation between the presence of perineural invasion and these factors. Between 1 January 1984 and 1 May 2008, 26 cases of adenoid cystic carcinoma of the intraoral salivary glands, which had initially been treated surgically, were reviewed retrospectively. The most common site was the palate, and perineural invasion was reported in 13 of the 26 resected specimens. There was no significant association between it and the size of the primary tumour (OR=1.0; p=1.00), invasion of the surgical margins (OR=2.08; p=0.4), the presence of distant metastases (OR=3.43; p=0.197), or local control (p=0.76). It was exclusively present in patients with local extension, and was significantly associated with outcome (p=0.04). Resection with clear margins is the gold standard of care for patients with intraoral adenoid cystic carcinoma, and the role of adjuvant irradiation remains controversial. Given its paradoxical and complex biological behaviour, large studies with long term follow-up are needed to define the clinicopathological and immunohistochemical variables associated with outcome, as well as the optimal treatment. Copyright © 2013 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
A Comparison of 30-Day Perioperative Outcomes in Open Versus Minimally Invasive Nephroureterectomy for Upper Tract Urothelial Carcinoma: Analysis of 896 Patients from the American College of Surgeons-National Surgical Quality Improvement Program Database.
Hanske, Julian; Sanchez, Alejandro; Schmid, Marianne; Meyer, Christian P; Abdollah, Firas; Feldman, Adam S; Kibel, Adam S; Sammon, Jesse D; Menon, Mani; Eswara, Jairam R; Noldus, Joachim; Trinh, Quoc-Dien
Minimally invasive surgery for nephroureterectomy (MINU) in patients with upper tract urothelial carcinoma (UTUC) is increasingly used among urologists with reported equivalent oncologic outcomes compared with open nephroureterectomy (ONU). Population-level data comparing perioperative outcomes between these approaches remain limited, however. We sought to compare perioperative outcomes between MINU and ONU in a prospectively collected national cohort of patients. Between 2006 and 2012, patients who underwent nephroureterectomy for UTUC within the American College of Surgeons-National Surgical Quality Improvement Program database were categorized into MINU or ONU. Our primary outcome of interest was 30-day perioperative complications. Secondary outcomes included use of lymph node dissection (LND), transfusion, reintervention and readmission rate, operative time, length of stay (LOS), and perioperative mortality. Multivariable logistic regression analyses were used to examine the association between outcomes and surgical approach. A total of 599 (66.9%) and 297 (33.1%) patients underwent MINU and ONU, respectively. Overall, 12.7% of patients experienced a complication within 30 days postoperatively, and the rate did not differ among surgical approaches. Patients in the MINU group, however, had a decreased LOS (P<0.001). On multivariable analysis, patients receiving MINU were less likely to undergo a LND (OR 0.13; P<0.001), had decreased risk of thromboembolic complications (odds ratio [OR] 0.13; P=0.018), decreased need for transfusion (OR 0.39; P=0.001), and decreased need for operative reintervention (OR 0.24; P=0.024). Patients receiving MINU have similar overall complication rates compared with ONU. MINU, however, was associated with a decreased risk of blood transfusions, thromboembolic events, reintervention, and overall LOS compared with ONU. MINU should be considered as a primary approach in select groups of patients with UTUC.
Chandra, Malavika; Vishwanath, Karthik; Fichter, Greg D.; Liao, Elly; Hollister, Scott J.; Mycek, Mary-Ann
A method to non-invasively and quantitatively characterize thick biological tissues by combining both experimental and computational approaches in tissue optical spectroscopy was developed and validated on fifteen porcine articular cartilage (AC) tissue samples. To the best of our knowledge, this study is the first to couple non-invasive reflectance and fluorescence spectroscopic measurements on freshly harvested tissues with Monte Carlo computational modeling of time-resolved propagation of both excitation light and multi-fluorophore emission. For reflectance, quantitative agreement between simulation and experiment was achieved to better than 11%. Fluorescence data and simulations were used to extract the ratio of the absorption coefficients of constituent fluorophores for each measured AC tissue sample. This ratio could be used to monitor relative changes in concentration of the constituent fluorophores over time. The samples studied possessed the complexity and variability not found in artificial tissue-simulating phantoms and serve as a model for future optical molecular sensing studies on tissue engineered constructs intended for use in human therapeutics. An optical technique that could non-invasively and quantitatively assess soft tissue composition or physiologic status would represent a significant advance in tissue engineering. Moreover, the general approach described here for optical characterization should be broadly applicable to quantitative, non-invasive molecular sensing applications in complex, three-dimensional biological tissues.
Yemshanov, Denys; McKenney, Daniel W; de Groot, Peter; Haugen, Dennis; Pedlar, John; Sidders, Derek; Joss, Brent
We present the idea of using potential infringements on annual allowable harvest targets as an approach to estimate threats from invasive species to the forest products sector. The approach uses present-day harvest levels as a reference level to estimate when and where the impact of a nonnative forest pest could become economically damaging. We use a generic model that simulates spread and damage by nonnative invasive species, basic harvest and forest growth through time. The concept is illustrated with a case study of a new nonnative invasive pest, Sirex noctilio Fabricius on pine resources in eastern Canada. Impacts of invasion on wood supply, in particular, the point at which present-day harvest levels are not attainable, were identified for 77 non-overlapping geographical regions that delimit the primary wood supply areas around large mills and wood processing facilities in eastern Canada. The results identify the minimum area of a pest outbreak that could trigger harvest shortages (approximately 12.5-14 M ha of pine forests in Ontario and Quebec). Beyond this level, the amount of host resource available for harvesting in any given year declines rapidly. The failure to sustain broad-scale harvest targets may be an attractive and intuitive indicator for policy makers and regulators interested in developing control and "slow-the-spread" programs for non-native forest pests.
Buda, Alessandro; Passoni, Paolo; Reato, Claudio; Di Martino, Giampaolo
To show a novel minimally invasive approach to sentinel lymph node (SLN) detection of the ovary with near-infrared-guided surgery using indocyanine green (ICG). A step by step description of the technique with video and figures (educational video). The standard surgical staging of early-stage I-II ovarian cancer includes systematic pelvic and aortic lymphadenectomy even in the absence of clear evidence regarding the survival benefits associated with comprehensive retroperitoneal staging. The ideal candidates are all women undergoing a surgical approach with frozen section analysis for highly suspicious ovarian masses or patients in whom an adnexal mass has been removed that appeared to be malignant and an open or laparoscopic surgical staging procedure is planned. A 31-year-old woman with occult ovarian cancer after simple left ovarian cystectomy. Laparoscopic surgical staging including simple hysterectomy, bilateral salpingo-oophorectomy, omentectomy, pelvic and aortic bilateral lymphadenectomy, and sentinel node biopsy from the left ovary. The surgical intervention was performed with the PinPoint 0 degree HD S1 SPY fluorescence camera (PinPoint Endoscopic Fluorescence Imaging System; NOVADAQ, Mississauga, ON, Canada). After the induction of the pneumoperitoneum, ICG was injected with 2 separate injections in the proper ovarian ligament and the infundibulopelvic ligament, just below the peritoneum, at a concentration of 1.25 mg/mL. A total amount of 0.4 mL ICG solution was injected using a percutaneous abdominal approach with a 12-cm-long 22-G spinal needle. SLN mapping should be preceded by the exposure of the aortic region with a gentle dissection on both sides along the Toldt fascia up to the left renal vein. Two SLNs were identified in the left inframesenteric para-aortic and superficial left common areas. Both SLNs were negative. The minimally invasive approach in combination with the ICG near-infrared fluorescence S1 PinPoint fluorescence system seems
Kepler, Christopher K; Bogner, Eric A; Herzog, Richard J; Huang, Russel C
Lateral transpsoas interbody fusion (LTIF) is a minimally invasive technique that permits interbody fusion utilizing cages placed via a direct lateral retroperitoneal approach. We sought to describe the locations of relevant neurovascular structures based on MRI with respect to this novel surgical approach. We retrospectively reviewed consecutive lumbosacral spine MRI scans in 43 skeletally mature adults. MRI scans were independently reviewed by two readers to identify the location of the psoas muscle, lumbar plexus, femoral nerve, inferior vena cava and right iliac vein. Structures potentially at risk for injury were identified by: a distance from the anterior aspect of the adjacent vertebral bodies of <20 mm, representing the minimum retraction necessary for cage placement, and extension of vascular structures posterior to the anterior vertebral body, requiring anterior retraction. The percentage of patients with neurovascular structures at risk for left-sided approaches was 2.3% at L1-2, 7.0% at L2-3, 4.7% at L3-4 and 20.9% at L4-5. For right-sided approaches, this rose to 7.0% at L1-2, 7.0% at L2-3, 9.3% at L3-4 and 44.2% at L4-5, largely because of the relatively posterior right-sided vasculature. A relationship between the position of psoas muscle and lumbar plexus is described which allows use of the psoas position as a proxy for lumbar plexus position to identify patients who may be at risk, particularly at the L4-5 level. Further study will establish the clinical relevance of these measurements and the ability of neurovascular structures to be retracted without significant injury.
Fisher, Timothy K; Scimeca, Christy L; Bharara, Manish; Mills, Joseph L; Armstrong, David G
Diabetic foot disease frequently leads to substantial long-term complications, imposing a huge socioeconomic burden on available resources and health care systems. Peripheral neuropathy, repetitive trauma, and peripheral vascular disease are common underlying pathways that lead to skin breakdown, often setting the stage for limb-threatening infection. Individuals with diabetes presenting with foot infection warrant optimal surgical management to effect limb salvage and prevent amputation; aggressive short-term and meticulous long-term care plans are required. In addition, the initial surgical intervention or series of interventions must be coupled with appropriate systemic metabolic management as part of an integrated, multidisciplinary team. Such teams typically include multiple medical, surgical, and nursing specialties across a variety of public and private health care systems. This article presents a stepwise approach to the diagnosis and treatment of diabetic foot infections with special emphasis on the appropriate use of surgical interventions and includes the following key elements: incision, wound investigation, debridement, wound irrigation and lavage, and definitive wound closure. Copyright © 2010 Society for Vascular Surgery and the American Podiatric Medical Association. Published by Mosby, Inc. All rights reserved.
Martinez, Gabriela; Bernard, Brian J.; Larson, David W.; Pasupathy, Kalyan S.; Sir, Mustafa Y.
This work analyzes strategies for better allocation of surgeon resources in an elective surgical practice. Among the metrics considered to evaluate the assignment of tasks are OR-to-Clinic ratio per provider, OR-to-Clinic ratio per day, patient access to clinic, and patient access to surgery. In addition, a simulation model is used to evaluate the clinical and surgical capacity of the calendar to identify potential inefficiencies and propose strategic changes to the calendar. PMID:28269884
Majdani, Omid; Rau, Thomas S; Baron, Stephan; Eilers, Hubertus; Baier, Claas; Heimann, Bodo; Ortmaier, Tobias; Bartling, Sönke; Lenarz, Thomas; Leinung, Martin
The aim of this study was to create an access canal to the inner ear, by drilling, and perform the cochleostomy for cochlear implant surgery using robot guidance. A robot, a surgical drill and an Image-Guided Surgery (IGS) system were combined in a closed-loop setup. Ten temporal bones were scanned at the planning stages of the procedure. The robot guided the drill along the preplanned trajectory and created the approach. Postoperative scans were obtained. The cochleostomy was performed completely in nine out of ten cases. This did not prove possible for one of the specimens, the target site selected being in too superficial a location in relation to the round window. No violation of the facial nerve took place, although the chorda tympani nerve was violated in one case and the stapes in two. It was obvious during preoperative planning that these structures would be violated, but this was accepted in order to maintain a safety margin from the facial nerve. No other unforeseen damage occurred. This preliminary study suggests that robot-guided drilling of a minimally invasive approach to the cochlea might be feasible, but further improvements are necessary before any clinical application becomes possible. Where the width of the facial recess is less than 2.5 mm, the chorda tympani nerve and the ossicles are at risk.
Broughton, Gregory J; Clark, Peter E; Barocas, Daniel A; Cookson, Michael S; Smith, Joseph A; Herrell, S Duke; Chang, Sam S
association with planned PN vs RN. PN was planned in 120/154 patients (77.9%). Minimally invasive surgical approaches were planned in 66/154 cases overall (42.9%) and in 40/120 PN cases (33.3%). On univariate analysis, lower American Society of Anesthesiologists (ASA) score, planned open approach, smaller tumour size, left-sided tumour, and lower RENAL-NS were associated with planned PN. On multivariate analysis three factors remained independently associated with PN: tumour size (each 1 cm decrease in tumour size odds ratio [OR] 2.2, 95% confidence interval [CI] 1.2-4.0, P= 0.011), tumour complexity quantified by RENAL-NS (each 1 point decrease OR 2.4, 95% CI 1.5-3.7, P < 0.001), and planned open surgical approach (OR 7.3, 95% CI 2.2-25, P= 0.001). The decision to perform elective PN is based primarily on tumour anatomical features but is also associated with surgical approach. The RENAL-NS accurately predicts nephrectomy type in clinical T1a renal cortical tumours. © 2011 THE AUTHORS. BJU INTERNATIONAL © 2011 BJU INTERNATIONAL.
Swofford, John; Whang, Peter G.; Frank, Clay J.; Glaser, John A.; Limoni, Robert P.; Cher, Daniel J.; Wine, Kathryn D.; Sembrano, Jonathan N.
Background Sacroiliac joint (SIJ) dysfunction is an important and underappreciated cause of chronic low back pain. Objective To prospectively and concurrently compare outcomes after surgical and non-surgical treatment for chronic SIJ dysfunction. Methods One hundred and forty-eight subjects with SIJ dysfunction were randomly assigned to minimally invasive SIJ fusion with triangular titanium implants (SIJF, n = 102) or non-surgical management (NSM, n = 46). SIJ pain (measured with a 100-point visual analog scale, VAS), disability (measured with Oswestry Disability Index, ODI) and quality of life scores were collected at baseline and at scheduled visits to 24 months. Crossover from non-surgical to surgical care was allowed after the 6-month study visit was complete. Improvements in continuous measures were compared using repeated measures analysis of variance. The proportions of subjects with clinical improvement (SIJ pain improvement ≥20 points, ODI ≥15 points) and substantial clinical benefit (SIJ pain improvement ≥25 points or SIJ pain rating ≤35, ODI ≥18.8 points) were compared. Results In the SIJF group, mean SIJ pain improved rapidly and was sustained (mean improvement of 55.4 points) at month 24. The 6-month mean change in the NSM group (12.2 points) was substantially smaller than that in the SIJF group (by 38.3 points, p<.0001 for superiority). By month 24, 83.1% and 82.0% received either clinical improvement or substantial clinical benefit in VAS SIJ pain score. Similarly, 68.2% and 65.9% had received clinical improvement or substantial clinical benefit in ODI score at month 24. In the NSM group, these proportions were <10% with non-surgical treatment only. Parallel changes were seen for EQ-5D and SF-36, with larger changes in the surgery group at 6 months compared to NSM. The rate of adverse events related to SIJF was low and only 3 subjects assigned to SIJF underwent revision surgery within the 24-month follow-up period. Conclusions In this Level
Paterson, Rachel A; Dick, Jaimie T A; Pritchard, Daniel W; Ennis, Marilyn; Hatcher, Melanie J; Dunn, Alison M
Predatory functional responses play integral roles in predator-prey dynamics, and their assessment promises greater understanding and prediction of the predatory impacts of invasive species. Other interspecific interactions, however, such as parasitism and higher-order predation, have the potential to modify predator-prey interactions and thus the predictive capability of the comparative functional response approach. We used a four-species community module (higher-order predator; focal native or invasive predators; parasites of focal predators; native prey) to compare the predatory functional responses of native Gammarus duebeni celticus and invasive Gammarus pulex amphipods towards three invertebrate prey species (Asellus aquaticus, Simulium spp., Baetis rhodani), thus, quantifying the context dependencies of parasitism and a higher-order fish predator on these functional responses. Our functional response experiments demonstrated that the invasive amphipod had a higher predatory impact (lower handling time) on two of three prey species, which reflects patterns of impact observed in the field. The community module also revealed that parasitism had context-dependent influences, for one prey species, with the potential to further reduce the predatory impact of the invasive amphipod or increase the predatory impact of the native amphipod in the presence of a higher-order fish predator. Partial consumption of prey was similar for both predators and occurred increasingly in the order A. aquaticus, Simulium spp. and B. rhodani. This was associated with increasing prey densities, but showed no context dependencies with parasitism or higher-order fish predator. This study supports the applicability of comparative functional responses as a tool to predict and assess invasive species impacts incorporating multiple context dependencies.
Paterson, Rachel A; Dick, Jaimie T A; Pritchard, Daniel W; Ennis, Marilyn; Hatcher, Melanie J; Dunn, Alison M
Summary Predatory functional responses play integral roles in predator–prey dynamics, and their assessment promises greater understanding and prediction of the predatory impacts of invasive species. Other interspecific interactions, however, such as parasitism and higher-order predation, have the potential to modify predator–prey interactions and thus the predictive capability of the comparative functional response approach. We used a four-species community module (higher-order predator; focal native or invasive predators; parasites of focal predators; native prey) to compare the predatory functional responses of native Gammarus duebeni celticus and invasive Gammarus pulex amphipods towards three invertebrate prey species (Asellus aquaticus, Simulium spp., Baetis rhodani), thus, quantifying the context dependencies of parasitism and a higher-order fish predator on these functional responses. Our functional response experiments demonstrated that the invasive amphipod had a higher predatory impact (lower handling time) on two of three prey species, which reflects patterns of impact observed in the field. The community module also revealed that parasitism had context-dependent influences, for one prey species, with the potential to further reduce the predatory impact of the invasive amphipod or increase the predatory impact of the native amphipod in the presence of a higher-order fish predator. Partial consumption of prey was similar for both predators and occurred increasingly in the order A. aquaticus, Simulium spp. and B. rhodani. This was associated with increasing prey densities, but showed no context dependencies with parasitism or higher-order fish predator. This study supports the applicability of comparative functional responses as a tool to predict and assess invasive species impacts incorporating multiple context dependencies. PMID:25265905
Alberti, Olaf; Wickboldt, Jürgen; Becker, Ralf
Neurosurgical textbooks describe an infrainguinal approach as the standard or preferred option for the surgical treatment of meralgia paresthetica (MP), the most frequent entrapment neuropathy of the lower limb. However, inhomogeneous results led the authors to adopt a suprainguinal, retroperitoneal approach for decompression of the lateral femoral cutaneous nerve. In this paper the authors' aim was to study the outcome of patients harboring MP treated via this different surgical approach. The outcome of 55 consecutive patients who underwent surgery for MP via the suprainguinal retroperitoneal approach during a 15-year period was ascertained through postal questionnaires (in 47 patients) and follow-up visits (in 8 patients). The male to female ratio was 1:0.67, and the mean patient age was 50 +/- 12.9 years. The mean follow-up was 3.2 +/- 3.3 years. Seven of the patients underwent bilateral surgery. Intraoperatively the lateral femoral cutaneous nerve was consistently found in close anatomical relationship to the anterior superior iliac spine, although some variations regarding the diameter, number of branches, and underlying pathological entity were observed. Eighty-seven percent of patients showed improvement (21 patients) or complete remission (27 patients) of painful dysesthesia in the anterolateral thigh, and 13% (7 patients) remained unchanged. In addition 82% had improvement (31 patients) or complete remission (14 patients) of hypesthesia, leaving 18% with unchanged (9 patients) or worsened (1 patient) hypesthesia. In the patient-evaluated group 66% (31 of 47) were completely satisfied with the outcome, 23% (11 of 47) were partially satisfied, and 11% (5 of 47) were not satisfied with the outcome. Two cases each of recurrence, seroma, wound infection, and 1 case of hematoma requiring revision were encountered as complications. The suprainguinal retroperitoneal approach is a viable first-choice option for the surgical relief of MP.
Lehr, Shannon C.
Background: The most frequent wound complication following repair of large incisional hernias is seroma formation, especially when the use of a mesh onlay requires extensive subcutaneous undermining. Treatment options for postoperative seromas include observation for spontaneous resolution, percutaneous aspiration, closed suction drainage, abdominal binders, and sclerosant. Methods: A novel technique for treating persistent postoperative seromas is presented herein. This technique involves a 3-puncture minimally invasive approach that can be performed in an outpatient setting. Evacuation of serous fluid and fibrinous debris is followed by argon beam scarification of the seroma cavity lining. Talc slurry is then introduced into the cavity. Three patients have been treated with this technique. Results: All 3 patients had successful ablation of seromas that had persisted despite standard treatment modalities. Conclusion: A minimally invasive approach is a reasonable and safe alternative for treating persistent postoperative seromas. PMID:11548834
Iacono, Calogero; Ruzzenente, Andrea; Bortolasi, Luca; Guglielmi, Alfredo
Central pancreatectomy (CP) is a parenchyma-sparing surgical procedure. The aims are to clarify the history and the development of CP and to give credits to those from whom it came. Ehrhardt, in 1908, described segmental neck resection (SNR) followed, in 1910, by Finney without reconstructive part. In 1950 Honjyo described two cases of SNR combined with gastrectomy for gastric cancer infiltrating the neck of the pancreas. Guillemin and Bessot (1957) and Letton and Wilson (1959) dealt only with the reconstructive aspect of CP. Dagradi and Serio, in 1982, performed the first CP including the resective and reconstructive aspects. Subsequently Iacono has validated it with functional endocrine and exocrine tests and popularized it worldwide. In 2003, Baca and Bokan performed laparoscopic CP and, In 2004, Giulianotti et al performed a robotic assisted CP. CP is performed worldwide either by open surgery or by using minimally-invasive or robotic approaches. This confirms that the operation does not belong to whom introduced it but to everyone who carries out it; however credit must be given to those from whom it came.
Iacono, Calogero; Ruzzenente, Andrea; Bortolasi, Luca; Guglielmi, Alfredo
Central pancreatectomy (CP) is a parenchyma-sparing surgical procedure. The aims are to clarify the history and the development of CP and to give credits to those from whom it came. Ehrhardt, in 1908, described segmental neck resection (SNR) followed, in 1910, by Finney without reconstructive part. In 1950 Honjyo described two cases of SNR combined with gastrectomy for gastric cancer infiltrating the neck of the pancreas. Guillemin and Bessot (1957) and Letton and Wilson (1959) dealt only with the reconstructive aspect of CP. Dagradi and Serio, in 1982, performed the first CP including the resective and reconstructive aspects. Subsequently Iacono has validated it with functional endocrine and exocrine tests and popularized it worldwide. In 2003, Baca and Bokan performed laparoscopic CP and, In 2004, Giulianotti et al performed a robotic assisted CP. CP is performed worldwide either by open surgery or by using minimally-invasive or robotic approaches. This confirms that the operation does not belong to whom introduced it but to everyone who carries out it; however credit must be given to those from whom it came. PMID:25400451
A prospective trial of postoperative vaginal radium/cesium for grade 1-2 less than 50% myometrial invasion and pelvic radiation therapy for grade 3 or deep myometrial invasion in surgical stage I endometrial adenocarcinoma
Piver, M.S.; Hempling, R.E. )
A prospective trial was performed to evaluate the recurrence rate and 5-year disease-free survival rate in patients with surgical Stage I endometrial adenocarcinoma. Patients with Stage I, Grade 1 or 2 disease, less than 50% myometrial invasion, and no evidence of disease outside the corpus of the uterus were treated by hysterectomy and bilateral salpingo-oophorectomy and postoperative vaginal radium/cesium (Group 1). Patients with surgical Stage I, Grade 3 disease or deep myometrial invasion, and histologically negative paraaortic lymph nodes were treated with postoperative pelvic radiation therapy (5000-5040 cGY) (Group 2). Patients with malignant peritoneal cytologic findings also received progesterone therapy. Of the 92 Group 1 patients, there have been no recurrences and the 5-year estimated disease-free survival rate was 99%. Of the 41 Group 2 patients, there have been four (9.7%) recurrences but only one (2.4%) within the treated field (pelvis), and the 5-year estimated disease-free survival rate was 88%. Of the 133 patients, the 5-year estimated disease-free survival rate was 96%, and only one patient (0.7%) had a local pelvic recurrence. Of the 16 patients with malignant peritoneal cytologic findings who were treated with progesterone therapy, none has had a recurrence.
Kaiser, Susanne; Thiel, Cetina; Kramer, Martin; Peppler, Christine
Evaluation of intra- and postoperative complications and prognosis of cervical sialoceles in the dog when using the lateral surgical approach for extirpation of the mandibular and sublingual salivary glands. Medical records of 16 dogs with 19 sialoceles were evaluated retrospectively. Long-term follow-up was evaluated by telephone questionnaire to the owners or the referring veterinarian. The surgical technique is depicted in detail. Dogs were of various breeds. Mean age was 5.6 years (1-13 years) and mean weight was 19.1 kg (6.5-33.6 kg). Eleven dogs were male (two castrated) and five were female (two castrated). The main complaint was a cervical swelling, which was present for one year or longer in three animals, for more than one month in eight animals, and between one day and one month in five animals. At initial presentation, 12 patients were pretreated. Three patients showed a bilateral sialocele initially or later. In all cases, the diagnosis of a sialocele was made correctly by ultrasonography. Intraoperatively, no complications occurred. Postoperatively, one patient developed a bleeding and two patients a seroma. In one patient a ranula was diagnosed 14 weeks postoperatively. The lateral approach is well suited for surgical treatment of isolated cervical sialoceles, has a low complication rate and a very good prognosis. Conservative treatment using aspiration or drainage of the cyst's content is not indicated. Sialoceles can occur bilaterally, either initially or later.
Ugenti, I.; Digennaro, R.; Martines, G.; Caputi Iambrenghi, O.
Introduction Esophageal perforation in adults is most frequently caused by ingested foreign bodies. They can migrate through the esophageal wall, damaging the nearby organs such as the aorta or the trachea, with fatal outcome. After the diagnosis, the viable treatments for extracting the foreign body and repairing the perforation are several. The appropriate treatment, may be endoscopic, surgical or combined, depending on the level of the perforation, on the co-morbidities of the patient and on the available resources. Presentation of case This paper describes a case of a 68 years old patient with a double EP caused by a meat-bone that perforated the thoracic esophageal wall, approaching the aorta on the left side and the azygos vein on the right side. Discussion Because of the double transfixion and the position near the aorta and the azygos, it was no