Surgical Innovation recent issues

A Time to Raise Our Voice(s)

Park, A. E., Swanstrom, L. L. — Fri, 25 Sep 2009 01:42:23 PDT

Single-Site Laparoscopic Sleeve Gastrectomy: Preclinical Use of a Novel Multi-Access Port Device

Varela, J. E. — Fri, 25 Sep 2009 01:42:23 PDT

Introduction: Single-site laparoscopy (SSL) has emerged as an alternative technique for sleeve gastrectomy. The author describes the preclinical technique of SSL sleeve gastrectomy through a novel multichannel port device in the porcine model. Methods: Anesthetized swine underwent 3-cm longitudinal supra-umbilical incision. A multichannel port device was inserted. A gastric sleeve was created by multiple applications of a 60-mm stapler. The access device’s channel housing was removed and the sleeve specimen exteriorized. Results: The mean operative time was 60 ± 10 minutes, and the mean estimated blood loss was 30 ± 5 cc. The multichannel port device allowed induction and maintenance of pneumoperitoneum throughout the procedure (range 12-15 mm Hg) with efficient rotation and substantial abdominal wall torque and minimal instrument clashing. Conclusion: SSL sleeve gastrectomy in the porcine model was facilitated by the use of a novel multichannel port device. Clinical studies are warranted.

Appendicectomy and Cholecystectomy Using Single-Incision Laparoscopic Surgery (SILS): The First UK Experience

Chow, A., Purkayastha, S., Paraskeva, P. — Fri, 25 Sep 2009 01:42:23 PDT

Introduction. Single-incision laparoscopic surgery (SILS) has the potential advantages of reduced postoperative pain and reduced port-site complications. Careful attention to closure can lead to virtually "scarless" surgery. In this article, we present our first experiences with SILS appendicectomy and cholecystectomy. Method . SILS appendicectomy and cholecystectomy was performed in 12 and 14 patients, respectively. Data were collected prospectively and analyzed retrospectively from case notes and the theater database. Results. The average operating times were 61.3 and 142.9 minutes for SILS appendicectomy and SILS cholecystectomy, respectively. There was a good correlation between increasing experience and a reduction in operative time with Pearson’s coefficient being –1 for appendicectomy and –0.56 for cholecystectomy. There were no postoperative complications in the SILS appendicectomy group. One patient in the SILS cholecystectomy group suffered a postoperative biliary leak from an accessory duct of Lushka. Conclusions. In our series, we have demonstrated SILS to be a safe and efficacious method for appendicectomy and cholecystectomy. Further studies are required to investigate any potential advantages of this method over standard laparoscopic techniques.

NOTES-Assisted Transvaginal Splenectomy: The Next Step in the Minimally Invasive Approach to the Spleen

Fri, 25 Sep 2009 01:42:23 PDT

Hypothesis. Natural orifice transluminal endoscopic surgery (NOTES) has marked yet another step forward in less-invasive surgical procedures. Access to solid organs located deep in the left hypochondrium can be difficult using this technique but the transvaginal approach with the patient positioned in full lateral decubitus may be an option. Material and methods. We present the case of a 60-year-old woman with a symptomatic splenic polycystic tumor. The procedure was carried out by a multidisciplinary team using a standard flexible videogastroscope and endoscopic instruments. Transvaginal visualization of the spleen and standard dissection of attachments were feasible, and splenectomy was completed using transvaginal stapling of the splenic hilum. The organ was extracted transvaginally. Results. The postoperative course was uneventful. The patient had minimal postoperative pain and minimal scars, and was discharged on the second postoperative day. Conclusions. Transvaginal access can be safely used for operative visualization, hilum transection, and spleen removal with conventional instrumentation, reducing parietal wall trauma to a minimum. The clinical, esthetic, and functional advantages require further analysis.

Transgastric and Transperineal Natural Orifice Translumenal Endoscopic Surgery (NOTES) in an Appendectomy Test Bed

Jayaraman, S., Schlachta, C. M. — Fri, 25 Sep 2009 01:42:23 PDT

Introduction. Our purpose was to establish a NOTES appendectomy test bed to evaluate whether the transgastric or transperineal (transvaginal) approach is most efficient. Methods. Using the uterine horns of female pigs as a model for appendectomy, 18 NOTES appendectomies were performed in 2 arms: 9 transgastric and 9 transvaginal. The primary outcome was mean total operative time for each technique excluding access closure. Secondary outcomes were peritoneal access and resection times. Means were compared using Student’s t-test. Results. Transgastric cases were faster than transperineal (46.5 ± 14.5 vs 60.0 ± 20.2 minutes, P = .02). Most of the improvement in transgastric times was due to faster resection (37.9 ± 17.4 vs 51.3 ± 16.5 minutes, P = .03). Neither approach was faster for peritoneal access (8.2 ± 3.4 vs 8.3 ± 4.5 minutes, nonsignificant). A significant learning curve was not demonstrated for the transgastric approach (53.0 vs 40.3 minutes, nonsignificant). A significant learning curve was demonstrated for the transperineal approach (76.0 vs 46.7 minutes, P = .02). Transperineal times improved over the study and approached transgastric; however, the last three transgastric cases were still significantly faster than the last three transperineal (40.3 vs 46.7 minutes, P = .02). No complications occurred in either group. Conclusions. The transgastric as compared with transperineal approach to NOTES appendectomy resulted in improved operative time in this model. The transperineal approach demonstrated a significant learning curve with operative times between techniques converging over time. This NOTES appendectomy test bed is suitable for evaluating NOTES innovations.

Feasibility of a High Intrathoracic Esophagogastric Anastomosis Without Thoracic Access After Laparoscopic-Assisted Transhiatal Esophagectomy: A Pilot Experimental Study

Fri, 25 Sep 2009 01:42:23 PDT

Introduction. The aim of the present study was to evaluate the feasibility of a technique that uses solely the transhiatal approach to create a high intrathoracic esophagogastric anastomosis after laparoscopic transhiatal resection of the distal esophagus. Method. Using a laparoscopic approach, the esophagi of 10 midsized pigs were dissected and transected as high as possible in the thorax, and the anvil of a circular stapler was introduced perorally into the esophageal stump. Through a midline short laparotomy, the circular stapler was inserted into the gastric tube and advanced through the hiatus to be connected with the anvil and create the anastomosis. Results. Development of the technique was completed within the first 6 experiments. The last 4 operations were entirely successful, standardized, and easily reproducible. Conclusion. The technique is feasible in this experimental setting. Further studies are required to establish if there is a clinical role for this technique in esophageal surgery.

Barbed Suture for Gastrointestinal Closure: A Randomized Control Trial

Fri, 25 Sep 2009 01:42:23 PDT

In an effort to make laparoscopic suturing more efficient, the V-Loc advanced wound closure device (Covidien, Mansfield, MA) has been produced. This device is a self-anchoring barbed suture that obviates the need for knot tying. The goal of this initial feasibility study was to investigate the use of the barbed suture in gastrointestinal enterotomy closure. A randomized study of 12 pigs comparing enterotomy closure with barbed versus a nonbarbed suture of similar tensile strength was performed. To this end, 25 mm enterotomies were made in the stomach (1 control, 1 treatment), jejunum (2 controls, 2 treatments), and descending colon (1 control, 1 treatment). Animals were killed at 3, 7, and 14 days postoperatively (4 each group) and their gastrointestinal tracts harvested; 6 of the 8 enterotomies from each pig underwent burst strength testing. The remaining 2 were fixed in formalin and sent for histological examination. All 12 pigs survived until they were killed without any major complications. Enterotomy closure with barbed suture revealed adhesion scores, burst strength pressures, and histology scores that were similar to those for the control. Jejunal closures resulted in 6 failures at 7 days (3 control, 3 barbed) and 4 failures at 14 days (2 control, 2 barbed). The barbed suture significantly reduced suturing time in the stomach, jejunum, and colon. The V-Loc wound closure device appears to offer comparable gastrointestinal closure to 3-0 Maxon while being significantly faster. Further studies with V-Loc are required to assess its use in laparoscopic surgery.

Patient-Reported Recovery After Abdominal and Pelvic Surgery Using the Convalescence and Recovery Evaluation (CARE): Implications for Measuring the Impact of Surgical Processes of Care and Innovation

Hedgepeth, R. C., Stuart Wolf, J., Dunn, R. L., Wei, J. T., Hollenbeck, B. K. — Fri, 25 Sep 2009 01:42:23 PDT

Background. Recovery is an integral part of the surgical process and measuring it provides insight into the impact of surgical innovation. This study used a recently validated instrument, the Convalescence and Recovery Evaluation (CARE), to measure return to baseline health after surgery and explore clinical factors associated with recovery. Study design. Patient health was measured among 96 patients before and after abdominal and pelvic surgery. Patients were grouped by time to recovery of 90% of baseline status. ² Tests and logistic models were used to measure relationships between recovery time and patient characteristics, processes of care, and outcomes. Results. Return to baseline health was reached by 44% of patients within 2 weeks, 28% between 2 and 4 weeks, and 28% after 4 weeks. Patients who recovered faster were younger, female, single, and undergoing ambulatory surgery for benign diseases. Patients who were married, underwent surgery for cancer, or had bowel surgery were more likely to require longer recovery time. Conclusions. Several patient and clinical characteristics were found to be associated with recovery after surgery. CARE appears to be sensitive to these factors and may be useful for informed decision making, assessing changes in processes of care, and evaluating the impact of surgical innovations on recovery.

Attitudes of Patients and Care Providers Toward a Surgical Site Marking Policy

Goldberg, A. E., Harnish, J. L., Stegienko, S., Urbach, D. R. — Fri, 25 Sep 2009 01:42:23 PDT

Background: In the fall of 2005, the University Health Network in Toronto, Canada, initiated a policy requiring the surgeon-or his or her delegate-to sign the incision site for all operations. Little is known about what health care providers and patients think about official surgical site marking policy. Method: Twenty-one patients and health care providers were interviewed, and the authors conducted field observations of surgeons while they marked their patients. The data were analyzed using grounded theory methods. Findings: Surgical site marking was perceived to be a safety precaution for operations involving multiple sides and structures but not for cases where there is no uncertainty about the intended operative site. Participants believed that marking could also facilitate error if the wrong side was marked. Site marking was perceived to have the effect of ensuring that the surgeon meets with the patient prior to the operation on the day of surgery. Concerns were raised with respect to who should mark patients and marking surgical sites for genital surgery or other private body sites. Conclusions: For operations that involve multiple possible surgical sites, site marking should be carried out by individuals who are knowledgeable about the patient and the proposed procedure. For operations in which there is no uncertainty about the intended site, interventions other than site marking could be implemented to ensure patient-surgeon interactions on the day of surgery. Surgical site marking procedures should respect patient dignity and privacy.

Implementation of a Direct-From-Recovery-Room Discharge Pathway: A Process Improvement Effort

Ehrenfeld, J. M., Seim, A. R., Berger, D. L., Sandberg, W. S. — Fri, 25 Sep 2009 01:42:23 PDT

Background. The authors describe a process improvement effort to achieve direct-from-recovery-room discharge for elective laparoscopic cholecystectomy patients— without prior patient selection. Methods. The authors developed and implemented a new pathway, and then measured the learning curve (ie, success rate over time for direct discharge) and compared patients achieving direct discharge with patients admitted after surgery. Results. The learning curve between the first patient and steady-state performance was 56 patients. A total of 80% of patients achieved direct discharge. Directly discharged patients were younger (P < .001), had lower ASA physical status classifications (P < .005), and left the recovery room earlier in the day (P < .0001). However, elderly patients and those with high ASA scores frequently could be directly discharged from the recovery room. Conclusions. Through small team based rapid cycle process improvement, direct-from-recovery-room discharge of laparoscopic cholecystectomy patients can be achieved in an unselected patient population with a short learning curve.

Clinical Librarian Attendance at General Surgery Quality of Care Rounds (Morbidity and Mortality Conference)

Fri, 25 Sep 2009 01:42:23 PDT

Quality of Care rounds, also known as Mortality and Morbidity conferences, are an important and time-honored forum for quality audit in clinical surgery services. The authors created a modification to their hospital’s Quality of Care rounds by incorporating a clinical librarian, who assisted residents in conducting literature reviews related to clinical topics discussed during the rounds. The objective of this article is to describe the authors’ experience with this intervention. The clinical librarian program has greatly improved the Quality of Care rounds by aiding in literature searches and quality of up-to-date, evidence-based presentations.

Acute Management of Stoma-Related Colocutaneous Fistula by Temporary Placement of a Self-Expanding Plastic Stent

Thu, 15 Oct 2009 00:00:02 PDT

Colocutaneous fistulas are frequently the result of complications related to previous operative procedures and are a major cause of morbidity. Most are initially treated conservatively, with a large percentage eventually requiring further surgery for definitive treatment. The use of a temporary colonic stent for the management of colostomy-related colocutaneous fistula has not been previously described. Two patients with colocutaneous fistula related to end colostomies and opening into midline laparotomy wounds were treated by temporary plastic stenting. A removable Polyflex silicone stent was inserted into the stoma. Stent redeployment was needed on several occasions following partial stent expulsion. Midline wound healing was achieved in both cases by 6 weeks post—stent insertion, and complete fistula closure occurred in 1 case. Temporary stent placement in certain cases may aid in the management of a colocutaneous fistula associated with a colostomy to allow fecal diversion from wounds and aid fistula closure.

Information for Authors

Nelson, E. M. — Fri, 25 Sep 2009 01:42:23 PDT

From the Sword to Schindler: A Saga of Gastroscopy

Morgenstern, L. — Mon, 22 Jun 2009 02:21:30 PDT

Gastroscopy is an art as well as a science. The art is getting the instrument down; the science is the instrument itself. Rudolf Schindler was a master of both and is properly called "The Father Of Gastroscopy". He can also be called a renaissance man, so varied were his interests. Sword-swallowing played a minor but interesting role in the development of gastroscopy. It is still alive and well.

Peroral Dual Scope for Natural Orifice Transluminal Endoscopic Surgery (NOTES) Gastrotomy Closure

Mon, 22 Jun 2009 02:21:30 PDT

Background: Although transgastric intraperitoneal surgery is feasible both in experimental models and humans, secure gastrotomy closure remains challenging. As there is still no method that is simple, reliable, inexpensive, and effective, we aimed to evaluate the feasibility, efficacy, and safety of a novel endoscopic approach to this issue that intends to ensure secure healing by obtaining full thickness gastric wall apposition without requiring specialized instrumentation. Methods: Six pigs underwent general anesthesia followed by peritoneoscopy through a 12-mm gastrotomy by a double-channel endoscope. Gastrotomy closure was performed by our innovative technique. In short, this involves the insertion of a second single-channel gastroscope alongside the NOTES gastroscope. Both scopes are then worked in tandem within the stomach by separate operators using conventional endoscopic graspers and an endoclip device. The first animal was used to ascertain feasibility and standardize the technical steps, whereas the other five were survived. Postoperative follow-up then included endoscopy 1 week later and repeat endoscopy, laparoscopy, and necropsy on day 14. Results: All closures were immediately successful. Postoperatively, each animal demonstrated appropriate weight gain and behavioral pattern without overt postoperative complication. Necropsy showed normal healing at the gastrotomy site although there were signs of minor peritoneal irritation and infection in 2 pigs. Conclusions: This transoral dual-scope clipping method of gastrotomy closure after NOTES, as well as the general concept of employing 2 separate instruments at the same time perorally, is proven technically feasible, safe, and effective in this model.

Development and Validation of a New Generation of Flexible Endoscope for NOTES

Swanstrom, L., Swain, P., Denk, P. — Mon, 22 Jun 2009 02:21:30 PDT

Background. The concept of intraperitoneal flexible endoscopy has created much interest and investigation. Both gastroenterologists with a surgical leaning and surgeons with advanced endoscopy interests are researching the feasibility of this new approach. Current flexible scopes and instruments are extremely limited for use in natural orifice transluminal endoscopic surgery (NOTES). We describe the development of an endoscopic system specifically designed for endoluminal and NOTES procedures and demonstrates benefits and efficacy in benchtop and cadaver models. Technique. In conjunction with industry, an 18-mm 4-channel rigidizing access device was designed. Measurements of the strength (torsional and lifting) of standard endoscopes and the new scope were made. The new device and instruments are used in 8 cadavers to document its feasibility in a variety of specific tasks: endoluminal plication, upper abdomen and lower abdomen visualization, bowel manipulation, solid organ retraction, cholecystectomy, and enterotomy closure. Results. Benchtop comparison between a standard scope and the new scope showed equal maneuverability but the newer scope had greater force delivery at the tip (0.042 vs 1.96 lb, P < .001) and greater instrument application force (0.09 vs 0.23 lb, P < .002). Introduction of the scope was possible in all cadavers but difficult in cadavers <60 kg. Intragastric manipulation was feasible and exiting the stomach was possible although it required a 2-cm gastrotomy. The scope system was maneuverable in both lower quadrants without difficulty. The upper abdomen was viewable, with variable success in steering the scope between left and right quadrants. The entire gastrointestinal tract was able to be visualized in most cadavers. The scope generated sufficient force to lift and manipulate intraabdominal structures. Cholecystectomy was successful in 5 of 5 attempts. Conclusion. A new flexible access endoscope with 4 large access channels showed utility in a cadaver model—satisfying some of the requirements for performance of NOTES procedures.

Joystick Interfaces Are Not Suitable for Robotized Endoscope Applied to NOTES

Mon, 22 Jun 2009 02:21:30 PDT

Background NOTES has changed the working environment of endoscopy, leading to new difficulties. The limitations of conventional endoscopes call for the development of new platforms. Robotics may be the answer. Materials and methods The authors compared human to robotized manipulation of a flexible endoscope into the abdominal cavity, in an animal model. Thirty-two participants were enrolled. Results were analyzed according to the clinical background of the participants: experienced endoscopists, experienced laparoscopists, and medical students. Two single-channel gastroscopes were used. Whereas one was not modified, the other had the handling wheels replaced by motors controlled through a computer and a joystick. A NOTES transgastric approach was used to access the peritoneal cavity. The time to touch previously positioned intra-abdominal numbered plastic targets was recorded 3 times with each endoscope. Results Mean time to complete the tasks was significantly shorter using the conventional endoscope (2.71 vs 6.96 minutes, P < .001). When the robotized endoscope was used, the mean times of endoscopists (7.42 minutes), laparoscopists (6.84 minutes), and students (6.77 minutes) were statistically identical. No differences were found between laparoscopists and students in both techniques. Discussion Applying robotics to a flexible endoscope fails to enhance ability to move into the abdominal cavity, partly because of the interface. To overcome the limitations of endoscope when performing complex NOTES tasks, robotics may be useful, especially to control the instruments and to stabilize the endoscope itself. Conclusion Robotized endoscope with joystick interface is not sufficient to enhance immediate intuitiveness of flexible endoscopy applied to NOTES.

A Randomized Controlled Trial of Preperitoneal Bupivacaine Instillation for Reducing Pain Following Laparoscopic Inguinal Herniorrhaphy

Suvikapakornkul, R., Valaivarangkul, P., Noiwan, P., Phansukphon, T. — Mon, 22 Jun 2009 02:21:30 PDT

The efficacy of bupivacaine instillation into preperitoneal space following laparoscopic herniorrhaphy for postoperative pain reduction is still in controversy. A randomized controlled trial was conducted to determine the efficacy of bupivacaine instillation. The 40 patients, who had an inguinal hernia with no complication, unilateral or bilateral and recurrence or no recurrence after previous hernia repair, were randomly assigned to receive bupivacaine (n = 19) and normal saline (n = 21). The intervention or placebo was instilled into the preperitoneal space after total extraperitoneal laparoscopic herniorrhaphy. Pain intensity was assessed by using a visual analogue scale and verbal rating scale after the 1st, 2nd, 6th, 12th, and 24th hour postoperatively. For the bupivacaine and placebo group, mean pain scores were 3.5 versus 5.2 (P = .059), 2.9 versus 4.5 (P = .117), 2.1 versus 3.2 (P = .101), 1.5 versus 2.7 (P = .145), and 1.6 versus 2.0 (P = .672) after the 1st, 2nd, 6th, 12th, and 24th hour, respectively. Complications developed in 4 patients in the bupivacaine group and 7 patients in the placebo group after 3 months follow-up time. There is no strong evidence to confirm that bupivacaine instillation into preperitoneal space after laparoscopic herniorrhaphy can reduce postoperative pain.

Laparoscopic Circular Biomesh Hiatoplasty During Paraesophageal Hernia Repair

Varela, J. E., Jacks, S. P. — Mon, 22 Jun 2009 02:21:30 PDT

Laparoscopic approaches for paraesophageal hernia repair and the use of prosthetic reinforcement materials during crural repair have become standard. However, the search for the optimal prosthetic material and techniques for placement and fixation methods are still controversial and under investigation. The authors aimed to determine the technical feasibility of the use of human acellular dermal matrix for hiatoplasty in a circular fashion during paraesophageal hernia repair in a small series of patients. The short-term outcomes of patients who underwent laparoscopic repair of large paraesophageal hernias with biomesh circular hiatal reinforcement were analyzed. Laparoscopic circular hiatal reinforcement with acellular dermal matrix is feasible and reproducible with no associated short-term morbidity. The acellular dermal matrix mesh is very elastic and has excellent intracorporeal handling characteristics during hiatoplasty.

In Vitro Evaluation of the Permeability of Prosthetic Meshes as the Possible Cause of Postoperative Seroma Formation

Jin, J., Schomisch, S., Rosen, M. J. — Mon, 22 Jun 2009 02:21:30 PDT

Introduction Seroma formation is one of the most common post operative complications related to abdominal wall hernia repairs with mesh. We hypothesized that the different biomaterials used to construct commonly used prosthetic mesh may influence permeability to fluid and affect seroma formation rates. Methods We designed an in vitro study where a 5 cm piece of mesh was placed in a closed system where normal saline was forced across the mesh and the pressure (mmHg) required for a constant stream of fluid was recorded. Eight prosthetic materials were studied: polyester/oxidized collagen (PC), expanded PTFE (DM), polypropylene/ePTFE (BC), polypropylene/oxidized cellulose (PR), light weight polypropylene/omega 3 fatty acid (CQ), compressed PTFE (MM), polypropylene (PP) and polyester (P) mesh. Results Each mesh was tested five times and the results averaged. The 3 meshes without anti-adhesive barriers (MM, PP, P) had fluid move across with minimal pressure (<1 mmHg). For the intraperitoneal mesh, there was a significant difference in pressure necessary for fluid movement (PR = 3.6, CQ = 36, PC = 56.6, DM > 350, BC > 350mmHg, p = <0.001). However, the fenestrations at the suture lines necessary to combine the PP and DM in the BC mesh permitted fluid transport at low pressures (<1mmHg). Conclusion Based on our in vitro study, each mesh exhibited different fluid permeability, especially in the case of meshes with anti-adhesive barriers. This study also infers that methods to create pressure gradients across mesh, such as an abdominal binder, may reduce seroma formation of certain meshes.

Gastrectomy and Esophagogastrectomy for Proximal and Distal Gastric Lesions: A Comparison of Open and Laparoscopic Procedures

Francescutti, V., Choy, I., Biertho, L., Goldsmith, C. H., Anvari, M. — Mon, 22 Jun 2009 02:21:30 PDT

Laparoscopic gastrectomy is safe for benign lesions; however, such surgery for cancer remains controversial. The aim of this study is to compare outcomes in open versus laparoscopic gastrectomy. Data on patients undergoing open (n = 15) or laparoscopic (n = 52) gastrectomy revealed a mean age of 61.7 and 70.5 years, respectively (P = .06). Mean operative time was 32.3 minutes longer in the laparoscopic group (P = .24). The difference in median length of hospital stay was 3 days (open 12 days, laparoscopic 9 days). Postoperative morbidity (< 30 days) was not different; however, there were more early respiratory complications in the open group (P = .009). There were 4/6 (66.7%) open and 2/29 (6.9%) cancer recurrences. Laparoscopic approach for treatment of gastric lesions is safe and does not have a deleterious effect on cancer-related outcome.

Does Negative Pressure Wound Therapy Have a Role in Preventing Poststernotomy Wound Complications?

Mon, 22 Jun 2009 02:21:30 PDT

Background: Sternal wound infection (SWI) remains a devastating complication after cardiac surgery, decreasing long-term and short-term survival. In treating documented SWI, negative pressure wound therapy (NPWT) reduces wound edema and time to definitive closure and improves peristernal blood flow after internal mammary artery (IMA) harvesting. The authors evaluated NPWT as a form of "well wound" therapy in patients at substantial risk for SWI based on existing risk stratification models. Methods: Records of 57 adult cardiac surgery patients (September 2006 to April 2008) were reviewed. After preoperative risk assessment, NPWT was instituted on the clean, closed sternotomy immediately after surgery and continued 4 days postoperatively. Adverse postoperative events, including SWI, need for readmission, and other complications, were documented. Results: Mean age was 60.4 ± 10 years, and 89.5% were male; 77.2% were obese (mean body mass index 35.3 ± 6.7), 54.4% were diabetic, and 29 (50.9%) were both obese and diabetic. Coronary artery bypass (CAB) with single IMA was performed in 50.9% of the patients followed in frequency by combined CAB/valve, non-CAB surgery, and CAB with bilateral IMA. Estimated risk for SWI was 6.1 ± 4%. All patients tolerated NPWT to completion. Thirty-day and in-hospital mortality was 1.8% and unrelated to DSWI. No treatment of SWI was required. Conclusions: In this high-risk cohort, 3 postoperative SWI cases were anticipated but may have been mitigated by NPWT. This is an easily applied and well-tolerated therapy and may stimulate more effective wound healing. Among patients with increased SWI risk, strong consideration should be given to NPWT as a form of "well wound" therapy.

Endovascular Stent Graft Treatment of Acute Thoracic Aortic Transections Due to Blunt Force Trauma

Bjurlin, M. A., Tanquilut, E. M., Subram, A., Kalkounos, P., Merlotti, G. J. — Mon, 22 Jun 2009 02:21:30 PDT

Endovascular stent graft treatment of acute thoracic aortic transections is an encouraging minimally invasive alternative to open surgical repair. Between 2006 and 2008, 16 patients with acute thoracic aortic transections underwent evaluation at our institution. Seven patients who were treated with an endovascular stent graft were reviewed. The mean Glasgow Coma Score was 13.0, probability of survival was .89, and median injury severity score was 32. The mean number of intensive care unit days was 7.7, mean number of ventilator support days was 5.4, and hospital length of stay was 10 days. Mean blood loss was 285 mL, and operative time was 143 minutes. Overall mortality was 14%. Procedure complications were a bleeding arteriotomy site and an endoleak. Endovascular treatment of traumatic thoracic aortic transections appears to demonstrate superior results with respect to mortality, blood loss, operative time, paraplegia, and procedure-related complications when compared with open surgical repair literature.

Anal Incontinence Improvement After Silicone Injection May Be Related to Restoration of Sphincter Asymmetry

Mon, 22 Jun 2009 02:21:30 PDT

Background. This study aimed to evaluate manometric parameters that may explain improvement in anal incontinence using a silicone bulking agent. Methods. Incontinent patients having internal sphincter defects were prospectively selected and injected with a silicone bulking agent. Manometry and endoanal ultrasound were performed before and 3 months after injections. Twenty continent healthy volunteers were used only for manometric comparison. Results. Thirty-five patients (28 females; mean age 60.3 years) and 20 controls entered this study. Patients had lower resting and squeeze pressures compared with controls (P < .05). Length of the high-pressure zone increased from 1 to 1.7 cm postinjection (P = .002). Asymmetry index showed a significant change postinjection (P < .001). Conclusion. Despite considerable clinical improvement, no significant increase in manometric pressures was noted posttreatment. There was significant improvement in both high-pressure zone and asymmetry index, and these findings may explain the mechanism of action of the bulking agent injected.

Preliminary Results on Efficacy in Closure of Transsphincteric and Rectovaginal Fistulas Associated With Crohn's Disease Using New Biomaterials

Schwandner, O., Fuerst, A. — Mon, 22 Jun 2009 02:21:30 PDT

Background and aims: it was the aim of this prospective study to analyze the efficacy of the Surgisis® AFP^TM anal fistula plug and the Surgisis® mesh for the closure of complex fistulas in Crohn`s disease. Methods: All patients with perianal Crohn's disease suffering from transsphincteric and rectovaginal fistulas who underwent surgery using the Surgisis® anal fistula plug or the Surgisis® mesh were prospectively enrolled in this study. Inclusion criteria included transsphincteric single-tract fistulas and rectovaginal fistulas. Surgery was performed using a standardized technique, including irrigation of the fistula tract, placement and internal fixation of the Surgisis® anal fistula plug, and combined transanal/transvaginal excision of rectovaginal fistula with transvaginal placement of the mesh. Success was defined as closure of both internal and external (perianal or vaginal) openings, absence of drainage without further intervention, and absence of abscess formation. Follow-up information was obtained from clinical examination 3, 6, 9, and 12 months postoperatively. Results: Within the observation period, a total of 16 procedures were performed. After a mean follow-up of 9 months and 1 patient lost to follow-up, the overall success rate was 75%. For transsphincteric fistulas, the success rate was 77%, whereas it was 66% in rectovaginal fistulas associated with Crohn's disease. All 4 patients with failure had reoperation. Rate of stoma reversal in those patients who had fecal diversion was 66%. No deterioration of continence was documented. Conclusion: The short-term success rates are promising. Further analysis is needed to explain the definite role of this technique in comparison with traditional surgical techniques.

The Use of Holmium Laser Technology for the Treatment of Refractory Common Bile Duct Stones, With a Short Review of the Relevant Literature

Day, A., Sayegh, M. E., Kastner, C., Liston, T. — Mon, 22 Jun 2009 02:21:30 PDT

Background. The treatment of common bile duct (CBD) stones can vary in complexity and many methods exist to fragment them before removal. Although holmium laser is frequently used in urological surgery, it is rarely used to achieve this aim. Methods. The holmium laser was passed along a fiber introduced via a flexible scope through the cystic duct at the time of laparoscopic cholecystectomy. This energy modality was used to fragment the stones to a size that allowed easy removal. Results. The authors have used this technique once so far and achieved complete clearance of the CBD with no mucosal damage. Conclusion. Holmium laser provides an alternative and realistic treatment option for difficult CBD stones.

Causes of Cancellations on the Day of Surgery at Two Major University Hospitals

Mon, 22 Jun 2009 02:21:30 PDT

Cancellations of elective cases on the day of surgery waste valuable operating-room time. The authors studied cancellations at an American hospital and a Norwegian university hospital to test (a) whether the quality of hospital administrative data on cancellations is sufficient for meaningful comparative analysis and (b) whether causes of cancellations at these 2 major academic hospitals are comparable. Large retrospective cause-of-cancellation data sets were obtained from each hospital. The authors then prospectively established root causes of cancellations by on-site investigation and interviews of the hospital personnel involved. The surgical department at the Norwegian hospital cancelled 14.58% of cases in 2003 and 16.07% in 2004. The American hospital cancelled 16.52% of all cases between May 1, 2003, and April 30, 2004. Administrative data may give a rough picture of causes of cancellations. However, most findings at either of the hospitals do not translate easily to the other.

New Hybrid Approach for NOTES Transvaginal Cholecystectomy: Preliminary Clinical Experience

Mon, 22 Jun 2009 02:21:30 PDT

Objectives. Natural orifice translumenal endoscopic surgery (NOTES) represents the first step toward scar-less surgery. The objective of this study is to evaluate early clinical results of transvaginal cholecystectomy using a new technique. Methods. Institutional review board approval was obtained and transvaginal NOTES cholecystectomy was performed in 12 women for cholelithiasis. A 2-channel videoendoscope was inserted in the abdominal cavity through a posterior colpotomy. Two 3-mm trocars were inserted deep in the umbilicus, and a 10-mm trocar was placed through the colpotomy parallel to the endoscope. Dissection was performed with endoscopic instruments combined with 3-mm laparoscopic instruments. Results. Mean operative time was 125.8 minutes. All procedures occurred without intraoperative complications or conversions, except for 1 vulvar laceration. There were no postoperative complications in the clinical follow-up. Conclusion. Transvaginal NOTES is a feasible and safe alternative for cholecystectomy in this preliminary clinical experience, allowing good cosmetic benefits and low analgesic requirement.

Training and Working in High-Stakes Environments: Lessons Learned and Problems Shared by Aviators and Surgeons

Mon, 22 Jun 2009 02:21:30 PDT

Surgeons and naval aviators are both trained to work in high-stakes environments. Any misadventure in either of their working worlds can lead to death. Yet the pathways to certification and implicit attitudes toward training are quite different in these 2 disciplines and provide an opportunity to compare and contrast the methodologies employed. At the 5th annual Innovations in the Surgical Environments Conference, senior and junior aviators and surgeons shared their experiences from the perspective of trainee and trainer and in the process presented an interesting study in parallels and contrasts. The US Navy follows a highly regimented training syllabus with graduated levels of responsibility designed to create the safest possible flying environment. Extensive preflight and postflight effort is required for each mission flown. Surgical training is also hierarchal in responsibility, but graduates demonstrate greater variability in their training experience. The surgical field can only fortify its emphasis on safety by seeking to provide the optimal training experiences necessary in the high-stakes environment of the operating theater. In doing so, surgeons may find reinvigorated commitment through study of the aviation industry's established methods of training and practice.

Aging and the Laparoscopic Revolution: Has the Landscape Changed?

Morgenstern, L., Swanstrom, L. — Sun, 22 Mar 2009 22:35:20 PDT

Commentary

Swanstrom, L. — Sun, 22 Mar 2009 22:35:20 PDT

Natural Orifice Translumenal Thoracoscopic Surgery: Does the Slow Progress and the Associated Risks Affect Feasibility and Potential Clinical Applications?

Sun, 22 Mar 2009 22:35:20 PDT

Context. Natural orifice translumenal endoscopic surgery (NOTES) is an emerging new technique but with much of the focus for the clinical applications of this technique centered on the abdomen. Concequently, its adaptation to the chest has been overlooked. The evidence for safe access, periprocedural complications and potential thoracic applications needs to be evaluated. Objective. This study systematically reviews the evidence for the feasibility and potential clinical applications of natural orifice translumenal thoracoscopic surgery. Data sources. MEDLINE and the Cochrane central database of controlled trials, from the earliest available date to July 2008. Study selection and data extraction. All studies evaluating the use of NOTES involving the thoracic cavity or structures therein were identified. The minimum inclusion criterion for each study was the extraction of discernible trial data. No restrictions were placed on language. Results. The literature search identified 197 citations. Review of abstracts led to 10 full-text articles for assessment; 7 articles were considered for this review, reporting on a total of 37 cases. All cases used the porcine model in both survival (7 to 42 days; mean 16; n = 5) and nonsurvival studies (n = 2). Mortality was 5% (n = 2) and morbidity 19% (n = 7); histopathological leak was detected on autopsy in 1 case. Conclusion. No human trials have currently been performed using NOTES within the thoracic cavity. There is a wide diversity of clinical applications from which cardiothoracic surgery could potentially benefit. There is a great deal of technical improvement that is still required before the technique is viable as an alternative surgical approach in humans.

Prospective Study of Ambulation After Open and Laparoscopic Colorectal Resection

Sun, 22 Mar 2009 22:35:20 PDT

Purpose. Open and laparoscopic surgical approaches each have specific advantages. This study compares ambulation, hospital length of stay (LOS), and incision length after open and laparoscopic colorectal resection. Methods. All consecutive patients undergoing colorectal resection over a 2 year period ending August 2002 were followed prospectively. Ambulation, LOS, and incision length were recorded. Hybrid low anterior resection (LAR) patients had laparoscopic splenic flexure takedown, vessel ligation, and proximal rectal mobilization followed by planned inferior laparotomy to complete the case. Groups were compared using Student's t test. Results. Equivalent open and laparoscopic groups were comparable in terms of gender, age, body mass index, ASA class, indication for operation, and resection performed. Seventy open colectomy patients were compared with 99 laparoscopic-assisted colectomy patients. On average, patients in the open and laparoscopic groups ambulated 67 and 390 feet, respectively, on postoperative day 1 (P < .001), 290 and 752 feet on day 2 (P < .001), and 495 and 965 feet on day 3 (P < .001). The average LOS in the open group was 9.3 days compared with 5.9 days in the laparoscopic group (P < .001). The average incision length in the open group was 19.7 cm compared with 5.3 cm in the laparoscopic group (P < .001). Seventeen open LAR patients were compared with 30 hybrid LAR patients. On average, patients in the open and hybrid groups ambulated 22 and 150 feet, respectively, on postoperative day 1 (P = .003), 105 and 433 feet on day 2 (P = .003), and 369 and 488 feet on day 3 (P = .43). The average LOS in the open group was 10 days compared with 8.5 days in the hybrid group (P = .46). The average incision length in the open group was 19.8 cm compared with 10.8 cm in the hybrid group (P < .001). When all 216 patients were considered, the 91 patients with incisions shorter than 8 cm (average 4.6 cm) ambulated 396, 752, and 956 feet on consecutive days whereas the 125 patients with incisions 8 cm or longer (average 16.9 cm, P < .001) ambulated 101, 334, and 521 feet on consecutive days (all P values <.001). Average LOS in the <8-cm group was 6 days compared with 8.9 days in the ≥8-cm group (P < .001). Conclusions. Patients undergoing minimal-access colorectal surgery ambulated significantly further than equivalent open patients in the early postoperative period and had a shorter LOS.

Ethyl Pyruvate Protects Colonic Anastomosis From Ischemia-Reperfusion Injury

Sun, 22 Mar 2009 22:35:20 PDT

Ethyl pyruvate is a simple derivative in Ca⁺²- and K⁺-containing balanced salt solution of pyruvate to avoid the problems associated with the instability of pyruvate in solution. It has been shown to ameliorate the effects of ischemia-reperfusion (I/R) injury in many organs. It has also been shown that I/R injury delays the healing of colonic anastomosis. In this study, the effect of ethyl pyruvate on the healing of colon anastomosis and anastomotic strength after I/R injury was investigated. Anastomosis of the colon was performed in 32 adult male Wistar albino rats divided into 4 groups of 8 individuals: (1) sham-operated control group (group 1); (2) 30 minutes of intestinal I/R by superior mesenteric artery occlusion (group 2); (3) I/R+ ethyl pyruvate (group 3), ethyl pyruvate was administered as a 50-mg/kg/d single dose; and (4) I/R+ ethyl pyruvate (group 4), ethyl pyruvate administration was repeatedly (every 6 hours) at the same dose (50 mg/kg). On the fifth postoperative day, animals were killed. Perianastomotic tissue hydroxyproline contents and anastomotic bursting pressures were measured in all groups. When the anastomotic bursting pressures and tissue hydroxyproline contents were compared, it was found that they were decreased in group 2 when compared with groups 1, 3, and 4 (P < .05). Both anastomotic bursting pressure (P = .005) and hydroxyproline content (P < .001) levels were found to be significantly increased with ethyl pyruvate administration when compared with group 2. When ethyl pyruvate administration doses were compared, a significant difference was not observed (P > .05). Ethyl pyruvate significantly prevents the delaying effect of I/R injury on anastomotic strength and healing independent from doses of administration.

Are Biologic Grafts Effective for Hernia Repair?: A Systematic Review of the Literature

Hiles, M., Record Ritchie, R. D., Altizer, A. M. — Sun, 22 Mar 2009 22:35:20 PDT

Biologic grafts for hernia repair are a relatively new development in the world of surgery. A thorough search of the Medline database for uses of various biologic grafts in hernia shows that the evidence behind their application is plentiful in some areas (ventral, inguinal) and nearly absent in others (parastomal). The assumption that these materials are only suited for contaminated or potentially contaminated surgical fields is not borne out in the literature, with more than 4 times the experience being reported in clean fields and the average success rates being higher (93% vs 87%). Outcomes prove to be highly dependent on material source, processing methods and implant scenarios with failure rates ranging from zero to more than 30%. Small intestinal submucosa (SIS) grafts have an aggregate failure rate of 6.7% at 19 months whereas acellular human dermis (AHD) grafts have a failure rate of 13.6% at 12 months. Chemically cross-linked grafts have much less published data than the non-cross-linked materials. In particular, the search found 33 articles for SIS, 32 for AHD, and 13 for cross-linked porcine dermis. Furthermore, the cumulative level of evidence for each graft material was fairly low (2.6 to 2.9), and only 1 material (SIS) had level 1 evidence reported in any hernia type (inguinal and hiatal). Together, biologic grafts have published evidence showing success rates better than 90% overall and more than 2000 years of cumulative implant time. Improvements in materials, techniques, and patient selection are likely to improve these numbers as this field of surgery matures.

Technique of Laparoscopic Ventral Hernia Repair Can Be Modified to Successfully Repair Large Defects in Patients With Loss of Domain

Sun, 22 Mar 2009 22:35:20 PDT

Background. Laparoscopic ventral hernia repair (LVHR) can be challenging in patients with large abdominal wall defects and loss of domain (LOD). When hernia contents are reduced, the pneumoperitoneum preferentially fills the sac, leaving no space for mesh manipulation. This study presents a modification for LVHR in LOD patients, as well as outcomes for a series of patients. Methods. Between September 2002 and August 2004, 10 patients with large ventral hernias and LOD underwent attempts at LVHR. The technique is modified by placing additional trocars to allow for fixation from above the mesh. Patient data were harvested from a prospective database and analyzed. Results. All hernias were recurrent in nature. Mean defect size was 626 cm², requiring 1 to 4 pieces of sutured Gore Dualmesh for a tension-free repair. Three patients' procedures were aborted after adhesiolysis, with concerns about missed enterotomies. All 3 underwent delayed mesh placement within the same hospitalization. Only 2 were successful. The third patient had significant bowel edema precluding mesh placement. Two patients were converted to open repairs (Rives—Stoppa and component separation). There were no mortalities, but there were 2 major complications: inferior vena cava thrombosis and transient abdominal compartment syndrome. In follow-up (7.7 months) there were 2 recurrences secondary to excision of infected mesh. Conclusion. It is possible to obtain a successful LVHR in patients with large defects and LOD. The technique is complex and is modified to allow for mesh fixation from above the mesh. Frequent change in patient positioning allows for visualization below the fascial defect.

120-Day Comparative Analysis of Adhesion Grade and Quantity, Mesh Contraction, and Tissue Response to a Novel Omega-3 Fatty Acid Bioabsorbable Barrier Macroporous Mesh After Intraperitoneal Placement

Sun, 22 Mar 2009 22:35:20 PDT

Purpose. This study aimed to evaluate adhesion formation, mesh contraction, and tissue response to an omega-3 fatty acid barrier—coated lightweight polypropylene mesh (C-Qur) after intra-abdominal placement, and compare these properties to those of other commercially available meshes. Materials and methods. After randomization, 3 x 3 cm pieces of Atrium C-Qur, Mesh ProLite Ultra, Composix, Parietex, Proceed, Sepramesh, and DualMesh were sewn to the intact peritoneum on either side of a midline incision in 41 New Zealand white rabbits. Necropsy was performed at 120 days, and explants were evaluated for adhesion grade, adhesion amount, and mesh contraction. Histologic evaluation included extent of capsule formation, abdominal wall tissue ingrowth, degrees of inflammation and vascularization of the surrounding tissue, and the presence of mesothelialization. Results. There were no significant differences between the C-Qur mesh and the commercially available meshes tested with regard to adhesion grade or amount, although percentage adhesion coverage for the C-Qur mesh was much less than for Composix and Proceed. The C-Qur mesh contracted less than all meshes, significantly less (P < .05) than DualMesh or Proceed. DualMesh exhibited the greatest amount of capsule formation and inflammation on its parietal side as compared with the other meshes. Conclusions. Placing lightweight polypropylene mesh with an omega-3 fatty acid barrier coating intraperitoneally results in more favorable adhesion characteristics compared with Composix and Proceed meshes at 120-day explantation after intraperitoneal placement. The minimal amount of contraction and favorable tissue response in comparison to other commercially available meshes makes C-Qur mesh a practical alternative for laparoscopic and open ventral hernia repair.

Minimally Invasive Surgical Technique in Total Knee Arthroplasty: A Learning Curve

Kashyap, S. N., Van Ommeren, J. W., Shankar, S. — Sun, 22 Mar 2009 22:35:20 PDT

Clinical experience of learning a new technique of minimally surgery for total knee arthroplasty is presented. Close monitoring of the technique, pitfalls, learning tips, and tricks are discussed. A "learning phase" is identified as approximately 10 months or 21 knee replacements using minimally invasive technique. It took 50 operations before the surgical time equaled the open technique. There was no incidence of increased complications during the learning phase. Functional results such as stair climbing, walking distance, and walking with aids was significantly better after minimally invasive technique than after standard technique.

Local Cancellous Bone Grafting for Osteonecrosis of the Femoral Head

Yuhan Chang, , Hu, C.-C., Chen, D. W., Ueng, S. W. N., Shih, C.-H., Lee, M. S. — Sun, 22 Mar 2009 22:35:20 PDT

Objective. This study reports a novel local bone graft technique for the treatment of osteonecrosis of femoral head (ONFH). Materials and methods. From 1998 to 2005, a procedure using local bone grafting was performed for the treatment of ONFH in 11 patients. The local bone grafts were obtained from the intertrochanteric region and then impacted into the necrotic lesion. A wire coil was inserted into the remaining space after the grafting. Results. At a mean follow-up of 61 months (range, 30 to 103 months), all 5 ARCO stage IIC hips survived but 3 of the 6 ARCO stage IIIA hips failed. The overall clinical success rate was 73%. Conclusions. This study demonstrates that local cancellous bone grafting combined with a space-filling device implanted into the ONFH is a promising procedure and the wire coil showed no interference to the remodeling of the femoral head after grafting.

Laparoscopic Sleeve Gastrectomy After Gastric Banding Removal: A Feasibility Study

Sun, 22 Mar 2009 22:35:20 PDT

Background and objectives. Laparoscopic adjustable gastric banding (LAGB) is a commonly performed bariatric procedure. When LAGB fails, restrictive procedures such as gastric bypass have been performed. Laparoscopic sleeve gastrectomy (LSG) has been suggested as an alternative, but it has not yet been fully studied. Evaluated in this report are the experiences of patients who underwent LSG, a restrictive procedure, as a rescue procedure for failed LAGB. Methods. From June 2002 to June 2007, charts of patients who underwent LAGB were reviewed to find those who had undergone LSG as a rescue procedure. Results. Of 294 patients who underwent LAGB, 10 later underwent LSG. Median excess weight loss (EWL) prior to LSG had been 34%; after LSG, median EWL was 55%. Before LSG was performed, patients had a median 11.5 comorbidities, all of which improved after LSG. No major complications or deaths resulted. Conclusion. The results suggest LSG might be a reasonable choice for patients who fail LAGB. A formal study comparing LSG with other rescue procedures should be performed.

Novel Hands-Free Pointer Improves Instruction Efficiency in Laparoscopic Surgery

Sun, 22 Mar 2009 22:35:20 PDT

To improve instruction efficiency during advanced laparoscopic surgery, a hands-free, head-controlled, multimonitor pointer was developed. One instructor guided 20 trainees to locate critical points on a simulated laparoscopic cholecystectomy model. Twenty points, visible to the instructor only, were selected on a photo of a partially dissected gallbladder placed within a laparoscopic trainer box. For each trainee, the points were randomized to 2 groups of 10 points with the instructor providing verbal guidance only or guidance assisted by the head-controlled pointer that appeared on both the instructor's and trainees' monitors. The primary outcome was the time to locate 10 points. Total time was shorter with the pointer than with verbal guidance alone (65 ± 14 vs 119 ± 34 seconds, P < .001). The average of mean individual times to locate each point was shorter with the pointer than without (5.4 ± 0.5 vs 11.9 ± 2.4 seconds, P < .001). The instructor's efficiency improved over time with both verbal guidance (P = .007) and with the pointer (P = .001). The benefit of pointer instruction was greater in trainees with laparoscopic experience compared with those without experience (P = .006). Use of a hands-free pointer improved instruction efficiency in simulated laparoscopy. Experienced surgeons benefited the most.

A Single-Port Technique for Laparoscopic Extended Stapled Appendectomy

Nguyen, N. T., Reavis, K. M., Hinojosa, M. W., Smith, B. R., Stamos, M. J. — Sun, 22 Mar 2009 22:35:20 PDT

background data. Natural orifice translumenal endoscopic surgery (NOTES) has become an exciting area of surgical development. Significant limitations to this surgical concept include lack of surgical expertise and appropriate flexible instrumentation. An alternative and competing technology to NOTES is single-incision laparoscopic surgery. Methods. This study describes a patient in whom a laparoscopic surgical technique for appendectomy used incisions that were all placed within the umbilicus. Results. The operative time was 40 minutes. There were no intraoperative complications. The patient did well postoperatively and was discharged on postoperative day 1. There were no perioperative complications at 1-month follow-up. Conclusion. Appendectomy performed through laparoscopic incisions placed within the umbilicus was technically feasible and safe. Development of advanced flexible instrumentation and visualization platform may facilitate this new operative approach.

Reviewer Acknowledgements

Sun, 22 Mar 2009 22:35:20 PDT

An Unsung Hero of the Laparoscopic Revolution: Eddie Joe Reddick, MD

Morgenstern, L. — Tue, 25 Nov 2008 21:01:45 PST

Natural Orifice Management of Anastomotic Leaks After Minimally Invasive Esophagogastrectomy

Nguyen, N. T., Mailey, B. A., Hinojosa, M. W., Ken Chang, — Tue, 25 Nov 2008 21:01:45 PST

A leak after an esophagectomy can lead to significant morbidity and mortality. The treatment options for postoperative leaks include reoperation with pleural drainage and placement of T-tube drainage catheter to control the gastrointestinal leak or complete gastrointestinal diversion, depending on the extent of the leak and tissue viability of the gastric conduit. Both these options require an invasive reoperation. In selected cases, endoscopic deployment of a covered esophageal stent may be an effective minimally invasive option in the management of an esophageal leak. This report describes the indications and techniques for management of an esophageal leak using the natural orifice for drainage of a mediastinal abscess and deployment of an esophageal stent.

Anatomy of NOTES Gastrotomy in Human Tissue

Stadlhuber, R. J., Yano, F., Mittal, S. K., Hunt, B., Filipi, C. J. — Tue, 25 Nov 2008 21:01:45 PST

Background Transoral natural orifice translumenal endoscopic surgery (NOTES) procedural success depends on a secure gastrotomy closure. Balloon gastrotomy is the most common technique to date, but the stomach-layer defect sizes and their relationship in human tissue has not been determined. Methods Ten 2-cm diameter controlled radial expansion balloon gastrotomies were performed in ex vivo human tissue. All gastrotomies were located on the anterior stomach wall. The main axis of the elliptical-shaped serosal and longitudinal muscle layer opening, the mucosal opening, and the circular muscle layer opening (after removal of mucosa) was measured. All steps were photo documented and electronically analyzed for common opening size. Results The average common opening was 1 ± 0.6 to 1.3 cm, although the main axis of a single layer can be as long as 2.2 cm. The average serosal/longitudinal muscle layer defect measured 1.5 cm, the average mucosal defect 1.6 cm, and the average circular muscle layer defect 1.5 cm. Conclusion These findings on NOTES gastrotomy anatomy demonstrate the complexity of the stomach wall opening and the challenge of providing a fail-safe gastrotomy closure. Further in vivo human studies are advised.

Single Port Sigmoidectomy in an Experimental Model With Survival

Leroy, J., Cahill, R. A., Peretta, S., Marescaux, J. — Tue, 25 Nov 2008 21:01:45 PST

Introduction. Single port laparoscopic access could reduce morbidity associated with additional trocar placement and, through the development of a hybrid intermediate, facilitate the clinical adoption of evolving techniques such as natural orifice transluminal endoscopic surgery. Advanced trocar technology, as much as adapted surgical technique, seems necessary to best facilitate this, however. Methods. A novel port (Airseal, Surgiquest) that uses vortex technology to create an air-curtain seal to maintain the pneumoperitoneum while facilitating the simultaneous passage of multiple working instruments was trialed. For this, 6 pigs (30 kg each) underwent sigmoid resection and reanastomosis using the port as the sole laparoscopic access for conventional instrumentation. All animals were thereafter survived for observation during a 2-week convalescence before undergoing repeat general anesthesia, sigmoidoscopy for anastomotic assessment, and forensic laparotomy for determination of intraperitoneal healing and complications. Results. The operation was technically feasible via a single port within a short time in every animal (mean duration 12.3 minutes). One anastomosis had to redone because of staple misfire but this too was accomplishable without additional port placement. All animals survived and convalesced normally without evincing clinical complication. At follow-up, all anastomoses were patent at sigmoidoscopy and only 1 animal had evidence of complicated anastomotic healing (the same animal that had needed anastomotic refashioning). Conclusions. Single port colonic resection and reanastomosis is readily achievable in this animal model. As an operative approach, it may both advance in its own right as much as facilitate the evolution and clinical incorporation of other developmental access routes.

Portal Vein Thrombosis After Laparoscopic Splenectomy: The Size of the Risk

Targarona, E. M. — Tue, 25 Nov 2008 21:01:45 PST

Portal vein thrombosis (PVT) after splenectomy is a potentially life-threatening complication. Clinical symptoms may be insidious, and progression can lead to intestinal infarction and portal hypertension. Interest in PVT has increased as a high incidence has been found in the laparoscopic setting. The higher incidence of PVT found in recent prospective studies of laparoscopically operated patients compared with retrospective reports from the 1990s suggests that PVT may have been underreported. Clinical outcome depends on the extension of the thrombus and the underlying disease. Main risk factors may be myeloproliferative diseases requiring splenectomy and splenomegaly, but PVT may occur after splenectomy for any clinical indication. The extent to which laparoscopy is responsible for PVT remains unclear. Laparoscopic surgeons should be aware of the risk of PVT, and it should be suspected in cases with an atypical outcome after laparoscopic splenectomy. Once diagnosed, prompt anticoagulation therapy may resolve the thrombotic event.

Comparison of Monoscopic Insertable, Remotely Controlled Imaging Device With a Standard Laparoscope in a Porcine Model

Hogle, N. J., Tie Hu, , Allen, P. K., Fowler, D. L. — Tue, 25 Nov 2008 21:01:45 PST

Laparoscopic imaging has remained relatively unchanged since the introduction of the rod—lens system. The intent here is to improve imaging by designing and building sensors and effectors placed directly into the body and controlled remotely. An 11-mm monoscopic insertable pan/tilt endoscopic imaging device with an integrated light source was studied. In vivo testing included simulated appendectomy, nephrectomy, suturing, and running the bowel in a porcine model (n = 6). Subjective impression and time for each procedure were compared using each imaging modality. The insertable imaging device seemed easier and more intuitive to use than a standard laparoscope. Time to perform procedures was better than or equivalent to a standard laparoscope. The insertable camera was subjectively preferred, and times for completion of complex tasks were shorter using the insertable camera. The insertable imaging device has the potential to be an integral part of surgical system platforms.

Outcomes of Laparoscopic and Open Colectomy: A National Population-Based Comparison

Kemp, J. A., Finlayson, S. R. G. — Tue, 25 Nov 2008 21:01:45 PST

Several recent clinical studies have demonstrated that laparoscopic colectomy is safe, feasible, and associated with many short-term benefits compared with open colectomy. It is unknown if outcomes observed in clinical trials can be achieved on a population level. The authors used the Nationwide Inpatient Sample to identify laparoscopic and open elective colon resections performed in the United States for each year from 2000 to 2004. They assessed differences in patient characteristics using demographic information and ICD-9 codes. They then used univariate and multiple logistic regression models to analyze the association between surgical approach and in-hospital morbidity, as well as in-hospital mortality and length of hospital stay. Patients undergoing laparoscopic colectomy tended to be younger (61 years vs 66 years, P < .001) and to have fewer comorbidities (Charlson score of 0 in 58.1% vs 37.0%, P < .001). After adjusting for patient characteristics and comorbidities, laparoscopic colectomy was associated with lower in-hospital mortality (0.6% vs 1.7%, P < .001), lower overall complication rate (32.1% vs 38.2%, P < .001), and shorter median hospital stay (5 vs 7 days, P < .001) compared with open colectomy. Significant benefits were observed in wound problems (0.8% vs 1.44%, P < .001); cardiovascular (12.5% vs 15.1%, P < .001), pulmonary (6.2% vs 8.7%, P < .001), and gastrointestinal (13.7% vs 16.1%, P < .001) morbidity; and reintervention rates (1.33% vs 1.66%, P = .02). Outcome benefits of laparoscopic colectomy previously demonstrated in clinical trials are observed on a population level.

Operative Time and Other Outcomes of the Electrothermal Bipolar Vessel Sealing System (LigaSureTM) Versus Other Methods for Surgical Hemostasis: A Meta-Analysis

Macario, A., Dexter, F., Sypal, J., Cosgriff, N., Heniford, B. T. — Tue, 25 Nov 2008 21:01:45 PST

A meta-analysis was performed of 29 prospective, randomized trials (published January 1, 2000, to August 14, 2007) comparing an electrothermal bipolar vessel sealing system (EBVS-LigaSure^TM, Covidien) (total n = 1107 patients) with either clamping with suture ligation/ electrocauterization (n = 1079 patients) or ultrasonic energy (eg, Harmonic Scalpel®, Johnson & Johnson). Hemorrhoidectomy (12 articles), hysterectomy (4 articles), and thyroidectomy (3 articles) were the most common procedures. For 15 of 26 studies reporting standard deviations, the normalized mean operative time reduction for EBVS equaled 28% (95% confidence interval [CI] 18%-39%, P < .0001) compared with conventional surgical hemostasis. Operative time was reduced with EBVS in 24 of 26 studies (P < .0001). EBVS was associated with 43 mL (95% CI 14-73 mL, P = .0021) less blood loss, fewer complications (odds ratio 0.66, 95% CI 0.47-0.92, P = .02), and mean reduction in postoperative pain of 2.8 units (95% CI 1.5-4.1, P < .0001). Five studies used ultrasonic energy as the comparator, but none reported standard deviation so data could not be pooled.

Bone Anchor Mesh Fixation for Complex Laparoscopic Ventral Hernia Repair

Yee, J.A., Harold, K.L., Cobb, W.S., Carbonell, A.M. — Tue, 25 Nov 2008 21:01:45 PST

Background: Laparoscopic ventral hernia repair (LVHR) has gained wide acceptance by both surgeons and patients, but hernias that approach a bony prominence are more complex due to the difficulty of proper fixation. This study was conducted to evaluate the use of bone anchor mesh fixation for complex LVHR. Methods: A prospective study of patients having complex LVHR with bone anchors was conducted using patients from 2 academic institutions between July 2003 and December 2007. Patient demographic data, characteristics of the hernia, operative details, and postoperative outcomes were recorded. Results: A total of 30 patients who had LVHR using bone anchors were evaluated (20 women, 10 men; mean age 60.9 years, range 41-83 years). In all, 17 suprapubic and 13 lateral hernias were included, requiring a mean of 2.8 and 3.2 bone anchors, respectively. The average hernia defect was 263 cm² (range 35-690 cm²), and the average mesh size was 663 cm² (range 255-1360 cm²). Mean operative time was 218 minutes (range 98-420 minutes), with an estimated blood loss of 46 mL (range 10-100 mL). The average length of stay was 5.2 days (range 1-26 days). Seven patients (23.3%) developed postoperative complications, and 1 patient in this study died (mortality 3.3%). During follow-up of 13.2 months (range 1-26 months), 2 patients (6.7%) developed a recurrent hernia. Conclusions: Bone anchors can be used successfully in the laparoscopic repair of complex ventral hernias, particularly with suprapubic and lateral hernias that approach a bony prominence. The complication rate is acceptable, with a short hospital stay and low recurrence rate.

Radiofrequency Energy Delivery to the Lower Esophageal Sphincter (Stretta Procedure) Does Not Provide Long-term Symptom Control

Tue, 25 Nov 2008 21:01:45 PST

The Stretta procedure (radiofrequency energy application to the lower esophageal sphincter) is a unique endoluminal technique for the management of gastroesophageal reflux. This article reports on the long-term effectiveness of the Stretta procedure in patients with significant gastroesophageal reflux disease (GERD) referred to a surgical practice. Patients who underwent Stretta with a minimum of 36 months follow-up were included. Thirty-two patients with an average follow-up of 53 months were included; 19 proceeded to anti-reflux surgery. Those not undergoing surgery showed a significant improvement in their GERD satisfaction from 3.14 to 1.46 (P = .0006) but had significantly lower preprocedure heartburn scores (2.43) than those who proceeded to surgery (3.66, P = .0401). The Stretta procedure was effective in reducing symptoms in 40% of patients. Responders had less severe preoperative heartburn. Radiofrequency energy delivery to the lower esophageal sphincter may be effective in selected patients for the treatment of gastroesophageal reflux.

Patient Perception of Medicare Fee Schedule of Laparoscopic Procedures

Madan, A. K., Dhawan, N., Tichansky, D. S., Harper, J. — Tue, 25 Nov 2008 21:01:45 PST

Introduction. It seems that public perception is that physicians receive substantial payments for procedures. This investigation explores patient perception and opinion of Medicare reimbursements to surgeons related to laparoscopic surgery. Our hypothesis was that patients think the surgeon Medicare fee schedule is higher than actuality. Methods. Patients filled out an IRB exempted survey. The survey included a written description of laparoscopic gastric bypass, laparoscopic adjustable gastric band placement, laparoscopic cholecystectomy and an initial patient visit for 30 minutes. All participants were asked to give their thoughts of what Medicare currently reimburses for these procedures as well as what the payment should be. The survey also asked other questions about reimbursement related to Medicare. Results. There were 96 participants in the investigation with 43% of patients not filling in reimbursements for at least one procedure. Most patients (88%) looked at their bills from physicians and insurance companies carefully. For each procedure, the mean reimbursements were approximately 10 times higher than the patient perception of both the amount Medicare currently pays and the amount Medicare should pay compared to the actual fee. For the initial patient visit, the patients overestimated the payment by 158% and thought the Medicare should pay 199% of the actual fee. Most of the patients (98%) thought Medicare should pay more for more difficult cases and 85% thought Medicare should pay more if the patient visits the surgeon more times during the global period. While 32% of the patients feel Medicare pay physicians well, 91% thought that Medicare should increase fees. Conclusion. Most of our patients overestimated what Medicare currently pays for some laparoscopic procedures. Surgeons need to do a better job in educating patients and the general public about the Medicare fee schedule.

Objective Analysis of the Accuracy and Efficacy of a Novel Fascial Closure Device

Tue, 25 Nov 2008 21:01:45 PST

Abdominal fascial closure after midline laparotomy can be time-consuming and inaccurate and is a common time for needle-stick injuries. The SuturTek 360° Fascial Closure Device (FCD) is designed to provide a secure fascial closure while reducing the risk of needle-stick injury. To date, the accuracy and efficacy of the fascial closure obtained with this device have never been objectively determined. Ten pigs averaging 18 kg were killed and underwent a midline laparotomy. Idealized suture locations were premarked through the fascia. The animals were then randomly assigned to either a traditional suture closure or the FCD for fascial closure. Surgeons were instructed to place sutures through the idealized markers. Surgeons were then evaluated based on the time to close fascia and distance from the markers. Abdominal bursting pressures were obtained using a manometric balloon. Accuracy was also tested on an ex vivo model on which the participants were again asked to place stitches as close as possible to idealized marks, and absolute distance from the idealized location was calculated. The FCD resulted in a faster closure time when compared with traditional closure (5.9 ± 0.6 vs 7.7 ± 1.0 minute, P = .012), with a similar accuracy of placement from the idealized markers (1.5 ± 1.4 mm vs 0.8 ± 1.1 mm). Bursting pressures were similar between the 2 groups: 470 ± 71 mm Hg for FCD versus 453 ± 94 mm Hg for traditional closure ( P = .76). The FCD resulted in a faster fascial closure with similar accuracy and strength when compared with traditional open techniques. The potential reduction in serious needle-stick injuries warrants prospective trials.

Mechanical Circular Stapler Device Loaded With Nonabsorbable Titanium Staples for Ileo-prostate Capsuloplasty Following Prostate Capsule Sparing Cystectomy: Initial Experience in Cadavers

Abreu, S. C., Abreu, A. L. C., Araujo, M. B., Neves, M. F., Fonseca, G. N. — Tue, 25 Nov 2008 21:01:45 PST

Purpose. Mechanical linear staplers have been safely used in urology with an acceptable 0% to 7.9% rate of stone formation in long-term follow-up. We sought to evaluate the feasibility of using mechanical circular stapler devices to perform ileocapsuloplasty following cystoadenomectomy in cadavers. Material and methods. Three unfrozen cadavers were used in this study. The prostate was enucleated and removed along with the bladder, leaving an ample cavity wherein the 21-mm anvil could be easily accommodated. A 2-0 purse string suture was then placed at the prostate capsule rim and tightly tied around the anvil. Following this, the circular stapler device was introduced into the neobladder through its opened limb and the center rod of the stapler device was passed through an opening made at the most dependent portion of the pouch where another purse string suture was placed and tied around it. Finally, the center rod of the stapler was connected to the anvil and fired, thus completing the anastomosis. Results. The procedure was feasible in all cases and 2 intact rings of prostatic capsule and bowel tissue were obtained, thus attesting the integrity of the anastomoses. Retrograde injection of methylene blue reassured that a watertight anastomosis was achieved whereas cystoscopic and macroscopic examination of the anastomotic site demonstrated a wide patent anastomosis in all cases. Conclusions. Use of mechanical circular stapler to perform ileocapsuloplasty in cadavers is feasible and has potential advantages such as decreased anastomotic time, diminished chances of urinary extravasations, and reduced degree of difficulty.

Can an Advanced Laparoscopic Fellowship Program be Established Without Compromising the Center's Outcomes?

Kothari, S. N., Boyd, W. C., Lambert, P. J., Mathiason, M. A. — Tue, 25 Nov 2008 21:01:45 PST

The objective of this study is to assess the impact of establishing a fellowship training program on a center's laparoscopic gastric bypass (LGB) outcomes. The authors compare their prefellowship and postfellowship LGB outcomes by means of retrospective review of a prospectively maintained bariatric database. Theirs is an academic community hospital that instituted a minimally invasive bariatric program in 2001 and an advanced laparoscopic fellowship with emphasis in laparoscopic gastric bypass in 2003. Participants were patients undergoing LGB from the inception of the program. All prefellowship LGBs were performed and assisted by the same surgeon and assistant. Results show that prefellowship and postfellowship patient demographics were similar. The mean length of stay was 2.17 and 2.35 days, respectively. The percentage excess weight loss was 72% and 72%, respectively (p = 0.990). Major or minor complication rates were not significantly different between groups. The prefellowship operative time was 123 ± 22 minutes, compared with 154 ± 28 minutes postfellowship (P = .001). In conclusion, a training-related increase in operative time was the only difference in the 2 groups. An advanced laparoscopic fellowship training program with emphasis in LGB can be safely established without compromising the center's LGB outcomes.

Beyond the Operating Room: A Simulator for Sacroiliac Screw Insertion

Rush, R., Ginsberg, H. J., Jenkinson, R., Whyne, C. M. — Tue, 25 Nov 2008 21:01:45 PST

Current teaching techniques for orthopedic screw insertions involve "learning by doing" in the operating room. Minimally invasive insertion of sacroilliac (SI) screws is a relatively uncommon operation, providing scant opportunity for training outside of a few major centers. As such, SI screw insertion is a prime candidate for simulator-based training. This work describes the development and implementation of a simulator for minimally invasive SI screw insertion using accurate 3-dimensional (3D) computed tomography (CT)—based visualization of the pelvic and upper sacral anatomy. The simulator was designed in Tool Command Language atop the Amira 3D visualization package. CT images of pelvic regions were automatically segmented to generate 3D surfaces. Using inlet and outlet 3D views, guidewire insertion can be performed followed by an appropriately sized SI screw. The simulator was found to provide a realistic representation of the pelvis, and test users reported increased understanding of the procedure of SI screw insertion following use. The 3D reconstructions of the pelvis allowed for visual correlations between CT slices and inlet and outlet x-ray views. Pilot work with surgical trainees suggests the tool's value in increasing the familiarity of surgical trainees to visualize the pelvis in 3D and perform SI screw insertion.

Letter to (Fellow) Young Doctors: More Kairos With Less Chronos

Cunningham, S. C., Sutton, E. R. H. — Tue, 25 Nov 2008 21:01:45 PST

Current restrictions on work hours have presented residents with a dilemma: how to derive the same or improved surgical experience and expertise but with less time to do so? The answer clearly must include an increase in efficiency, defined here simply as doing more with less time. Ancient Greek distinguished 2 words for time: chronos, chronological, linear, quantitative time as measured by clocks and calendars; and kairos: qualitative time, time in relation to human activity, a moment of indeterminate duration in which something happens. Our goal as residents should be to gain more kairos given limited chronos. Here we review various tools, both concrete and abstract, useful to maximize efficiency and effectiveness in surgical education. We suggest that residents equipped with adequate tools should be able to benefit from more kairos.

A Simple Technical Option for Single-Port Cholecystectomy

Mutter, D., Leroy, J., Cahill, R., Marescaux, J. — Tue, 25 Nov 2008 21:01:45 PST

Topical Application of Luminescent Nanoparticles for Sentinel Lymph Node Imaging

Tez, S., Tez, M. — Tue, 25 Nov 2008 21:01:45 PST