Septic Shock After Endoscopic Sleeve Gastroplasty: A Post-procedural Complication?

BACKGROUND

ESG is a safe and effective technique in the obesity management, usually indicated in class I and II obesity. It is also an acceptable treatment in patients with class III obesity who have high surgical risk or refuse surgery. This procedure results in a significant weight loss and important improvement in metabolic comorbidities. Nevertheless, there are several procedure-related complications. Few cases of gastric perforation following ESG have been reported. We present a case of septic shock after ESG with preoperative diagnostic uncertainties.

METHODS

We present the case of a 54-year-old male with a BMI of 43.6 kg/m2 who underwent ESG 7 days before in an external center. The patient came to the emergency department presenting abdominal pain, nausea, and vomiting since the day after the procedure. Physical examination revealed hemodynamic instability, altered level of consciousness, diffuse abdominal pain, and a painful umbilical lump due to a complicated umbilical hernia. Emergent surgery was decided after preoperative assessment.

RESULTS

Intraoperative gastroscopy was performed, viewing a gastric ischemic ulcer covered with fibrin and a mucosal defect and suspecting a covered gastric perforation. Firstly, we performed an open approach to the complicated umbilical hernia. Subsequently, an exploratory laparoscopy was performed through the hernial ring, where a fibrin-covered area was evidenced in the anterior face of the gastric body, adhered to the round ligament by a transmural suture of the ESG. Additionally, multiple transmural sutures were observed adhered to the greater omentum and lesser sac and an intramural hematoma in the greater gastric curvature. No intra-abdominal free fluid was evidenced. A laparoscopic barbed suture of the area covered with fibrin was performed, after its release from the round ligament. The adhesions of the sutures and metallic material from the ESG were released. Finally, two abdominal drains were placed in the anterior and posterior gastric face. The patient presented superficial incisional surgical site infection and was discharged 6 days after laparoscopic surgery.

CONCLUSIONS

ESG is a novel procedure, which has proven to be an effective alternative in the treatment of obesity. However, this technique may have major complications that can require urgent surgery.

Robotic-assisted plate fixation of the anterior acetabulum - clinical description of a new technique

INTRODUCTION

We present a detailed procedure for the robotic-assisted plate osteosynthesis of an anterior acetabular fracture. The purpose of this work was to describe a robotic-assisted minimally invasive technique as a possible method for reducing complications, pain, and hospitalization. Another goal was to present technical recommendations and to assess potential pitfalls and problems of the new surgical approach.

METHODS

Surgery was performed in an interdisciplinary setting by an experienced orthopedic surgeon and a urologist. The DaVinci System with standard instruments was used. Reduction was achieved through indirect traction of a pin that was introduced into the femoral neck and direct manipulation via the plate. The plate position and fixation were achieved through 7 additional minimally invasive incisions.

RESULTS

The technique has multiple advantages, such as no detachment of the rectus abdominal muscle, a small skin incision, and minimal blood loss. Furthermore, this approach might lower the incidence of hernia formation, infection, and postoperative pain.

DISCUSSION

We see the presented technique as a demanding yet progressive and innovative surgical method for treating acetabular fractures with indications for anterior plate fixation.

TRIAL REGISTRATION

The study was approved by the local institutional review board (Nr. 248/18).

The Transaxillary Approach as a Direct Route in the Management of Upper Thoracic Spine Pathology: A Technical Note with Case Series

This retrospective case series of prospective data aims to describe the transaxillary approach for the treatment of upper thoracic spine pathology. Various surgical techniques and approaches have been reported across the literature to address upper thoracic spine pathology, including the cervicothoracic approach, anterior transsternal approach, posterolateral approach, supraclavicular approach, and lateral parascapular approaches. These techniques are invasive. A minimally invasive, less morbid, and direct access approach to the pathology of the upper thoracic spine has not been reported in the literature. Patients with pathology affecting the first thoracic vertebra up to the sixth thoracic vertebra were classified into the upper thoracic spine group. Patients with pathology below the sixth thoracic vertebra were excluded. Patients not having a minimum follow-up of 12 months were also excluded. The study analyzed 18 patients. The mean preoperative modified Japanese Orthopedic Association score was 7.2±1.44, which improved to 10.16±1.2 (p<0.05). The majority (14/18) of the patients had an excellent outcome. Three patients had good outcomes, and one patient had a fair outcome. Five cases of intraoperative dural leak were recorded, and one patient had postoperative neurological deficit. The transaxillary approach is a safe, viable, muscle-sparing, and minimally invasive approach for ventral pathologies of the upper thoracic spine.

Endoport Assisted Endoscopic Surgery for Hypertensive Basal Ganglia Hemorrhage by Transsylvian Approach: Technical Nuances and Preliminary Clinical Results

BACKGROUND

There is no clear evidence on the indication and surgical approaches on evacuating basal ganglia hemorrhage caused by hypertensive bleeding. Some studies have shown that minimally invasive approaches have therapeutic potentials, but its benefits remain inconclusive. We describe an endoport assisted endoscopic transsylvian approach for basal ganglia hemorrhage evacuation. We evaluate the safety and efficacy of this approach in a cohort study.

METHODS

We included 19 patients (mean age 57 years) who underwent the surgery at a single county-level hospital in Yunan Province, China. The majority had a Glasgow coma scale between 9 and 12 on admission. The midline shift ranged from 16-29 mm (mean 19 mm). Hematoma volume ranged from 46 to 106 ml (mean 67 ml). Six patients (31.6%) presented with intraventricular hemorrhage.

RESULTS

All patients achieved greater than 90% decrease in hematoma volume at postoperative computed tomography scan. The average operative time was 115 minutes and average blood loss of 44 ml. The most common postoperative complication was pulmonary infection (63.2%). No rebleeding, seizure, infectious meningitis, or postoperative mortality was observed. A total of 17 patients (89.5%) achieved good functional recovery at follow up within 90 days after surgery (Glasgow outcome scale 4-5) and 2 patients had severe disability (Glasgow outcome scale 3).

CONCLUSIONS

Endoport assisted endoscopic surgery through transsylvian approach is safe and effective treatment for hypertensive basal ganglia hemorrhage. The majority of patients have good functional recovery and the rate of severe complications is low.

Comparison of bleeding during trochanteric fracture fixation with mini-invasive or conventional side plate fixation: A randomized controlled trial

BACKGROUND

Trochanteric fractures are a public health issue due to the aging of the population. Treatment aims to reduce their related morbidity and mortality and to allow an early return to independence. Postoperative anemia is associated with poorer functional recovery and an increased mortality rate. The aim of this study was to assess whether minimally invasive side plate fixation (Minimal Invasive Screw System, MISS™) resulted in reduced perioperative bleeding compared with conventional fixation (Pertrochanteric Hip Screw, PHS™).

HYPOTHESIS

We hypothesized that minimally invasive side plate fixation (MISS) would result in reduced perioperative bleeding compared with conventional fixation (PHS).

PATIENTS AND METHODS

We conducted an open randomized controlled trial with blinded assessment of the primary outcome. Inclusion criteria were patients aged over 65 years with isolated reducible trochanteric fracture. The 2 surgical implants were of the same shape, the only difference between them being the locking mode of the femoral neck screw on the plate of the MISS device, allowing a percutaneous approach. Primary outcome was perioperative bleeding evaluated with Mercuriali's formula. Secondary outcomes included operating time, scar length, length of hospital stay, radiological criteria such as quality of fracture reduction, implant positioning, bone healing, complications and functional recovery compared between the 2 groups.

RESULTS

One hundred and eight patients met the inclusion criteria and were randomized to receive either PHS (n=54) or MISS (n=54). Osteosynthesis with MISS significatively reduced perioperative bleeding (median 243mL, interquartile range [152-410] vs. 334mL [247-430] [p=0.0299]), operating time (65min [57-73] vs. 79min [66-89] [p=0.0002]) and scar length after 45 days (7cm [5-8] vs. 14cm [12-15] [p<0.0001]). There was no statistically significant difference between groups in postoperative complications, revision surgery or serious adverse events.

CONCLUSION

Compared with PHS, MISS reduced operating time, perioperative bleeding and scar length with no observed functional difference.

LEVEL OF EVIDENCE

I.

Adjustable Continence Therapy Balloons in Female Patients with Stress Urinary Incontinence: A Systematic Review

INTRODUCTION

The aim of this study was to perform a systematic review of studies reporting the outcomes of ACT® balloons in female patients with stress urinary incontinence (SUI) due to intrinsic sphincter deficiency (ISD).

METHODS

In accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) standards, a systematic search of the PubMed (Medline) and Scopus electronic database was performed in June 2022. Terms used for the query were ("female" or "women") and ("adjustable continence therapy" OR "periurethral balloons").

RESULTS

Thirteen studies were included. All were retrospective or prospective case series. The success rates ranged from 13.6% to 68% and the improvement rates from 16% to 83%. The intraoperative complication rate ranged from 3.5 to 25% and consisted of urethral, bladder, or vaginal perforations. The rate of postoperative complications varied from 11 to 56% without major complications. Between 6% and 38% of ACT® balloons were explanted and subsequently reimplanted in 15.2-63% of cases.

CONCLUSION

ACT® balloons can be considered as an option to treat SUI due to ISD in female patients with a relatively modest success rate and quite a high complication rate. Well-designed prospective studies and long-term follow-up data are needed to fully elucidate their role.

The Minimally Invasive Lateral Occipital Infracortical Supra-/Transtentorial Approach in Surgery of Lesions of the Pineal Region: A Possible Alternative to the Standard Approaches

OBJECTIVE

The pineal region is an anatomical region that is difficult to access surgically, especially when it comes to removing neoplasms. Four main surgical approaches to this region are used as standards nowadays: infratentorial supracerebellar, occipital supra-/transtentorial, interhemispheric, and transventricular approaches. All methods have both advantages and disadvantages and are associated to any extent with intra- and postoperative risks. We have developed a lateral minimally invasive occipital infracortical supra-/transtentorial (OICST) approach, which retains the advantages of the standard occipital transtentorial approach while improving tumor exposure and minimizing its disadvantages.

METHODS

We describe 7 consecutive cases of successful complete removals of pineal tumor formations of various quality and size (3 pineal cysts, 2 pineocytomas, 1 meningioma, 1 medulloblastoma) using the OICST approach developed by us. Preoperative 3-dimensional and virtual reality-modeling and the use of a special retractor also contributed to reducing the size of the surgical approach.

RESULTS

All patients underwent surgery for removal of a lesion in the pineal region and suffered from no new and permanent neurological deficits postoperatively. The mean size of the craniotomies was 2.3 × 1.85 cm. The minimally invasive approach developed by us carries the advantages of the standard occipital transtentorial approach, but minimizes its disadvantages. The main disadvantage of the standard occipital approach is excessive retraction of the occipital lobe, which is frequently associated with visual neurological deficits. Also, with occipital approach, the Rosenthal vein lying along the surgical corridor is frequently not good visible since the tumor is approached from its tip rather than side which limits the overview of the surgical field and can pose a risk. Damage to this vein can cause infarction of the basal ganglia. By approaching the pineal region from more laterally the size of the craniotomy can significantly be reduced, excessive retraction of the occipital lobe can be avoided and the risk of damage to large deep veins can be minimized. The cosmetic outcome with a small skin incision of only about 3 cm is also a very good side effect of this minimally invasive technique.

CONCLUSIONS

The minimally invasive lateral OICST approach described by us can be successfully used in the surgery of pineal neoplasms. Reducing the size of the craniotomy does not limit the possibility of complete removal of tumors of various sizes and tissue consistency, and also minimizes the risks of both intra- and postoperative complications.

Laparoscopic pancreatic enucleation: cystic lesions and proximity to the Wirsung duct increase postoperative pancreatic fistula

BACKGROUND

Risk factors for postoperative pancreatic fistula (POPF) following pancreatic enucleation by the open approach (OpenEN) are well known. However, ENs are more frequently performed laparoscopically (LapEN). The aim of this study was to analyze the risk factors of POPF following LapEN.

METHODS AND PATIENTS

All patients in our prospective database who underwent LapEN were evaluated. We report the demographics, surgical, early and long-term outcomes. Numerous variables were analyzed to identify the risk factors of POPF.

RESULTS

From 2008 to 2020, 650 laparoscopic pancreatic resections were performed including 64 EN (10%). The median age was 51 years old (17-79), median BMI was 24 (19-48), and 44 patients were women (69%). The main presentation was an incidental diagnosis (n = 40; 62%), pain (n= 10;16%), and hypoglycemia (n = 8;12%). The main indications were neuroendocrine tumors (40; 63%), mucinous cystadenomas (15; 23%), intraductal papillary mucinous neoplasie (3; 5%), and other benign cysts (6; 9%). Lesions were located on the distal pancreas (43; 67%), head (n = 17; 27%), and neck (4; 6%). The median size was 20 mm (9-110); 30 mm (20-110) for mucinous cystadenoma and 18 mm (8-33) for NET. The median operative time was 90 mn (30-330), median blood loss was 20 ml (0-800) ml, and there were no transfusions and one conversion. There were no mortalities and overall morbidity (n = 22; 34%) included grades B and C POPF (10;16%) and post-pancreatectomy hemorrhage (4; 6%). The median hospital stay was 7 days (3-42). There were no invaded lymph nodes and all cystic lesions were nonmalignant. After a mean follow-up of 24 months, there was no recurrence. The risk factors for grades B/C POPF were mucinous cystadenoma and proximity to the Wirsung duct < 3 mm.

CONCLUSION

In this series, the outcome of LapEN was excellent with no mortality and a low rate of morbidity. However, the risk of POPF is increased with cystic lesions and those close to the Wirsung duct.

Minimally invasive biliary anastomosis after iatrogenic bile duct injury: a systematic review

Major bile duct injuries (BDIs) may require complex surgical repairs that are usually performed with a conventional open approach. This study aims to analyze current evidence concerning the safety and the outcomes of the minimally invasive (MI) approach for biliary anastomosis in post-cholecystectomy BDIs. A systematic search of MEDLINE, Embase, and Web-Of-Science indexed studies involving MI (laparoscopic or robotic) biliary anastomosis in patients with iatrogenic BDIs was performed. The quality of the studies was assessed using the MINORS criteria. A total of 13 studies involving 198 patients were included. One hundred and twenty-five patients (63.1%) underwent a laparoscopic biliary anastomosis, while 73 (36.1%) received an analogue robotic procedure. All the included BDIs were types D and E (E1-E5). The mean OT varied between 190 and 330 (mean = 227) minutes. Ten studies reported the mean intraoperative blood loss that ranged between 50 and 252 (mean = 135.9) mL. No conversions occurred in the robotic series, while four patients required conversion to open surgery among the laparoscopic ones. The mean length of postoperative hospital stay was 6.3 days. The reported overall morbidity was similar among the robotic and laparoscopic series. During the follow-up period, no surgery-related mortality occurred. A growing number of referral centers are showing the safety and feasibility of the MI approach for biliary anastomosis in patients with major BDIs. Further prospective comparative studies are needed to draw more definitive conclusions.

Outcomes of open partial nephrectomy for renal cell carcinoma in the minimally invasive approach era

Background:

We investigated the characteristics and outcomes of patients who underwent open partial nephrectomy (OPN) in the minimally invasive approach era.

Materials and methods:

We retrospectively reviewed 52 patients (55 cases) who underwent OPN from May 2009 to March 2016. We assessed perioperative change in estimated glomerular filtration rate (eGFR), complications, and oncological outcomes. Tumor complexity was evaluated using the R.E.N.A.L nephrometry score (NS) and the modified NS.

Results:

Fifteen cases (27%) had imperative indications and 40 (73%) had elective indications. The elective cases were more likely to have adverse tumor complexity based on NS. The perioperative complication rate defined as a Clavien-Dindo grade ≥IIIa was 11%. The rate of postoperative decline in eGFR at 1 month, 1 year, and 2 years was 22%, 20%, and 21%, respectively. Multivariate analysis revealed that male gender (odds ratio [OR] 11.8, p = 0.03), NS ≥9 (OR 13.9, p = 0.02), modified NS ≥11 (OR 13.5, p = 0.01), and cold ischemic time ≥40 minutes (OR 7.9, p = 0.04) were significantly associated with worsening eGFR at 1 year after surgery. During a median follow-up period of 52 months, the 5-year overall survival and recurrence-free survival rates were 93% and 84%, respectively.

Conclusions:

OPN is acceptable with regard to oncological outcomes and complications in the minimally invasive surgery era. We propose that OPN should be the preferred approach in cases in which it is technically difficult to preserve maximum renal function via a minimally invasive approach.

Pass On What You Have Learned: A Structured Mentor-Mentee Concept for the Implementation of a Minimally Invasive Mitral Valve Surgery Program

INTRODUCTION

Starting a minimally invasive cardiac surgery (MICS) for mitral valve repair (MVR) program is challenging as it requires a new learning curve, but compromising surgical results at the same time is not acceptable. Here, we describe our surgical educational experience of starting a new MICS program at a university heart center in Germany.

METHODS

A dedicated team for the new MICS program including 2 cardiac surgeons, 1 cardiac anesthetist, 1 perfusionist, and 1 scrub nurse was chosen. The use of long shafted instruments was trained in a low-cost self-assembled MICS simulator, and the EACTS endoscopic dry lab course was visited. Thereafter, 1 MICS center was visited for direct observation and peer-to-peer education for 6 weeks. The mentor observed the first 10 cases performed by the mentee. The surgical mitral valve expertise of 1 single cardiac surgeon was retrospectively analyzed between April 2016 and April 2021.

RESULTS

Before the implementation of the MICS-MVR program, 18 mitral valve operations have been performed through sternotomy between April 2016 and October 2018 including 12 replacements and 6 ring annuloplasties. After starting the MICS-MVR program, 73 mitral operations have been performed by the same surgeon of which 53 video-assisted through minithoracotomy (72.6%). 83.1% of the MICS procedures included complex repair (n = 38) and ring annuloplasty (n = 6). Open heart MV surgery was necessary in 20 patients due to concomitant procedures (n = 8), redo procedures (n = 2), severe endocarditis (n = 4), or contraindication for MICS such as PAD (n = 6). There have been no deaths, 1 stroke, and 1 cardiac vascular (RCX) complication. Two patients required conversion to sternotomy and one pericardiocentesis in the long term.

CONCLUSION

Typically, excellent exposure and high repair rates of the MV has led us offer MICS approach to a majority of patients with isolated MV disease. Careful planning and a strict mentor-mentee concept facilitated a safe startup of an MICS program in a busy university heart center.

Initial surgical management of bulky malignant type II tumors of the endometrium by a robotic approach

Type II uterine tumors often present with very large, necrotic tumor burden in the uterus that leads to dilation and effacement of the cervix. In patients with this presentation, conventional hysterectomy poses a much greater challenge as the ureters are composed of the mass of the tumor and are at an increased risk for injury. Given this surgical challenge, many of these patients may begin with neoadjuvant chemo-radiation. However, these treatment modalities are associated with significant toxicity and negatively impact patient quality of life. Therefore, we describe a minimally invasive robotic surgical approach that aims to optimize quality of life without sacrificing prognosis. Outcomes of 4 patients are presented.

Keyhole Supraorbital-Eyebrow Approach for Resection of an Olfactory Groove Meningioma with Intraoperative Endoscopic Assistance

The authors present the case of a 52-year-old male with a history of new-onset seizures who presented in status epilepticus. Computed tomography and magnetic resonance imaging demonstrated an olfactory groove mass. A keyhole supraorbital-eyebrow approach assisted with a microinspection tool was performed for tumor resection.^1-5 A Simpson grade 2 tumor resection was achieved, and histopathology revealed a World Health Organization grade I olfactory groove meningioma. Postoperative and follow-up course has been unremarkable, with early postoperative imaging demonstrating no residual tumoral mass. The operative video highlights the advantages of using the microinspection tool for the visualization of deep lesions.

Launching minimally invasive stand-alone maze procedure for atrial fibrillation

BACKGROUND

Minimally invasive Maze procedure via right mini-thoracotomy approach is reportedly a promising option for paroxysmal and non-paroxysmal atrial fibrillation (AF), although it is not widely performed. This study aimed to validate feasibility and safety of minimally invasive stand-alone Maze procedure in an institutional first case series.

METHODS

This study enrolled an institutional consecutive series of 20 cases who underwent minimally invasive Maze procedure between November 2018 and January 2021. Concomitant tricuspid annuloplasty was performed in five cases who showed moderate tricuspid regurgitation preoperatively.

RESULTS

Minimally invasive Maze procedure using cryo-energy source was successfully accomplished with sinus rhythm being restored at the intensive care unit entry in all cases without conversion to the sternotomy approach. All cases were discharged home, while one case was complicated with stroke postoperatively. Nineteen cases (95%) showed sinus rhythm at the last follow-up, whereas one case, who had large left atrium, showed recurrent persistent AF despite optimum medical therapy. Catheter ablations were performed for residual conductions at box lesions and/or mitral/tricuspid isthmus in three cases, who showed medically refractory atrial tachycardia post-Maze procedure. Consequently, these three cases showed sinus rhythm restoration at the last follow-up Conclusions: Minimally invasive stand-alone Maze procedure with or without tricuspid annuloplasty was feasible and safe for AF in the institutional first case series. Catheter ablations for recurrent AF post-Maze procedure would be warranted.

Spondylolysis Repair Using a Minimally Invasive Modified Buck Technique with Neuronavigation and Neuromonitoring in High School and Professional Athletes: Technical Notes, Case Series, and Literature Review

BACKGROUND

Spondylolysis is a defect in the pars interarticularis of the vertebra that occurs frequently in high-performance young athletes. Although nonsurgical management is the mainstay of treatment, surgery is an option for patients with persistent symptoms despite multiple cycles of nonsurgical treatment. Performing a minimally invasive technique reduces complications, postsurgery pain, and hospitalization time and leads to a quick recovery. The aim of this study was to report the clinical results of a series of 3 patients treated with a modification of the Buck technique with a minimally invasive approach.

METHODS

Three high-performance athletes between 17 and 18 years old who were managed nonsurgically for at least 6 months underwent a modified Buck technique repair with a minimally invasive approach using cannulated compression screws, with neuronavigation and neuromonitoring. Patients were followed at least 6 months with computed tomography scans to assess consolidation and fixation status. Following rehabilitation and in the absence of pain, all 3 athletes returned to their respective sports. No complications were reported.

RESULTS

All patients presented with bilateral spondylolysis, at L3 in 1 case and at L5 in 2 cases. Patients received conservative management for 12-36 months before surgery. After surgery, consolidation was obtained at 4 months in all patients, who returned to their sports activities in <6 months.

CONCLUSIONS

The proposed technique shows the advantages of performing minimally invasive surgery in young high-performance athletes, ensuring consolidation and early return to sports activity without complications.

Central vascular ligation and mesentery based abdominal surgery

In the nineteenth century the idea of a correct surgical approach in oncologic surgery moved towards a good lymphadenectomy. In colon cancer the segment is removed with adjacent mesentery, in gastric cancer or pancreatic cancer a good oncologic resection is obtained with adequate lymphadenectomy. Many guidelines propose a minimal lymph node count that the surgeon must obtain. Therefore, it is essential to understand the adequate extent of lymphadenectomy to be performed in cancer surgery. In this review of the current literature, the focus is on "central vascular ligation", understood as radical lymphadenectomy in upper and lower gastrointestinal cancer, the evolution of this approach during the years and the improvement of laparoscopic techniques. For what concerns laparoscopic surgery, the main goal is to minimize post-operative trauma introducing the "less is more" concept whilst preserving attention for oncological outcomes. This review will demonstrate the importance of a scientifically based standardization of oncologic gastrointestinal surgery, especially in relation to the expansion of minimally invasive surgery and underlines the importance to further investigate through new randomized trials the role of extended lymphadenectomy in the new era of a multimodal approach, and most importantly, an era where minimally invasive techniques and the idea of "less is more" are becoming the standard thought for the surgical approach.

Consensus statement of the Italian society of colorectal surgery (SICCR): management and treatment of pilonidal disease

Pilonidal disease (PD) is a relatively common, benign but challenging condition of the natal cleft. This consensus statement was drawn up by a panel of surgeons, identified by the Italian Society of Colorectal Surgery (SICCR) as having a “special interest” in PD, with the aim of recommending the best therapeutic options according to currently available scientific evidence. A three-step modified-Delphi process was adopted, implying: (1) choice of the panelists; (2) development of a discussion outline and of target issues; and (3) a detailed systematic review of the current literature. The agreement/disagreement level was scored on a five-point Likert scale as follows: “A + : strongly agree; A–: agree; N: unsure/no opinion; D–: disagree; D + : strongly disagree. Each panelist contributed to the production of this manuscript, and the final recommendations were reviewed by the Clinical Practice Guidelines Committee.

Surgical treatment and outcomes of intramedullary tumors by minimally invasive approach: Answer

The surgical outcomes which evaluated in studies depend on preoperative condition, demographic data of patients, surgical approaches or treatment and local factors. Author argues that the neurological deterioration rate 4,2% which is reported in our study is marvelous and he exemplifies the other studies in literature. Neurosurgeons know that the clinical studies in literature do not compare only their results. Authors compare and evaluate studies with preoperative demographic data, surgical approach, local factors or others between their results. Therefore this detail explains paralogism of the author. The neurological deterioration rate is reported as smaller or similar in our study to the contrary of others due to all the preoperative demographical data were evaluated with others. We suppose the author alludes that the neurological deterioration rate is marvelous since he does not compare all of the demographical data in these clinical studies.

Minimally invasive neurectomy for Morton's neuroma with interdigital approach. Long term results

BACKGROUND

"Morton's Neuroma" is a frequent cause of chronic forefoot pain. It can affect general population, including athletes, and can lead to progressive foot pain and discomfort for daily life activities and sports.

HYPOTHESIS/PURPOSE

Our objective is to evaluate the long-term results in a series of 85 feet, operatively treated with minimally invasive interdigital approach for neurectomy.

STUDY DESIGN

Case series.

METHOD

83 patients (85 feet) were treated between January 2003 and December 2019. The AOFAS score and VAS scale were used to evaluate the patients pre and postoperatively. Results were analyzed using the JASP software.

RESULTS

Mean age was 50.58 years (range 23-77). Eleven (11) were men, and seventy-four (74) women, with two bilateral cases. Mean follow up was 49 months. Our series was evaluated with AOFAS and VAS scores, both showing statistically significant improvement posterior to the operative procedure.

CONCLUSIONS

A series of 85 feet operatively treated for Morton's neuroma with minimally invasive interdigital approach for neurectomy is presented. Long term results were similar to other published series with different approaches, with the advantage of minimal incision, minimum soft tissue dissection and no need to release intermetatarsal ligament, immediate weightbearing and quick return to daily activities and sports. It is concluded that minimally invasive neurectomy with interdigital approach is a safe procedure for Morton's neuroma treatment with similar results that other operative procedures.

LEVEL EVIDENCE

Level IV.

The Transorbital Pericranial Flap

OBJECTIVE

The objective of the present study was to describe and evaluate the feasibility, mobility, and surface area provided by the simple and extended transorbital pericranial flap (TOPF). Furthermore, we compared this novel technique with the current practice of pericranial flap harvesting and insetting techniques. We also studied the adequacy of the TOPF in the reconstruction of postoperative anterior cranial fossa (ACF) defects.

METHODS

The TOPF was performed bilaterally in 5 alcohol-preserved, latex-injected human cadaveric specimens. The TOPF was harvested in 2 stages: the orbitonasal stage and the cranial stage. For the orbitonasal stage, a transorbital superior eyelid approach was used. We have described 2 harvesting techniques for creating 2 distinct TOPF types (simple and extended) according to the main vascular pedicle. The superficial flap areas offered by the simple and extended TOPF and the traditional bicoronal pericranial flap were calculated and compared. The distances from the supratrochlear and supraorbital arteries to specified anatomical landmarks were also measured. Additionally, the ACF defect area of relevant surgical cases performed using endoscopic transcribriform approaches were measured on immediate postoperative computed tomography head scans using radiological imaging software.

RESULTS

The harvest of both the simple and the extended TOPFs was efficient. As expected, the areas offered by simple and extended TOPFs were smaller than that offered by the traditional bicoronal flap. However, the surface area offered by either the simple or extended TOPF provides sufficient coverage for most ACF defects. A high spatial distribution was observed between the vascular pedicles and their respective foramen or notch.

CONCLUSIONS

The TOPF represents a novel harvesting, tunneling, and insetting technique that offers a large, versatile, pedicled flap for coverage of most standard ACF defects after endoscopic surgery.

Minimally invasive treatment of forearm double fracture in adult using Acumed forearm intramedullary nail: A case report

BACKGROUND

Currently, open reduction internal fixation is the conventional surgical method for treatment of double ulna and radius fracture. However, open reduction is associated with a high risk of complications. This case of forearm double fracture involved a patient treated using an Acumed intramedullary nail. The patient experienced good follow-up outcomes. The Acumed forearm intramedullary nail enables early functional exercise and hastens healing of the fracture. Few studies have reported on the use of this approach for the treatment of fractures.

CASE SUMMARY

A 23-year-old male patient was admitted to hospital after 5 h of pain, swelling, and limited activity of left forearm caused by a careless fall. Physical examination showed stable basic vital signs, swelling of the left forearm, and severe pain when pressing on the injured part of the forearm. Further, friction was felt at the broken end of the bone; the skin was not punctured. Movement of the left hand was normal, and the left radial artery pulse was normal. Three-dimensional computed tomography examination showed an ulna fracture of the left forearm and comminuted fracture of the radius. The fracture was located in the upper third of the radius, with significant displacement on the fracture side. Clinical diagnosis further confirmed the left radius comminuted fracture and ulna fracture. After analyzing the fracture pattern, age, and other patient characteristics, we chose an Acumed nail for treatment and achieved good follow-up outcomes.

CONCLUSION

Acumed forearm intramedullary nail for fixation of ulna and radius fracture reduced complication risk and resulted in good follow-up outcomes.

Minimally invasive radical trachelectomy: Considerations on surgical approach

Current evidence supports that radical trachelectomy is a safe and feasible alternative to patients with early-stage cervical cancer who wish to preserve fertility. In addition, published retrospective literature supports that oncologic outcomes are equivalent to those of radical hysterectomy. First published as a vaginal approach, a number of other approaches have been reported including laparotomic, laparoscopic, and robotic. In 2018, the first ever prospective randomized trial (LACC) comparing open vs. minimally invasive radical hysterectomy showed worse disease-free and overall survival for the minimally invasive (both laparoscopic and robotic) approach than the open approach. This landmark publication raised concerns regarding the oncologic safety of minimally invasive radical trachelectomy. In the United States, minimally invasive became the dominant approach by 2011 for radical trachelectomy. Given that radical trachelectomy is an infrequent performed procedure, only small retrospective studies, systematic reviews, and large database studies have been published. These studies are limited by their retrospective nature, small sample size, patient selection bias, unbalanced groups, and sequential surgical approach comparisons. However, the available evidence thus far shows that oncologic outcomes for both open and minimally invasive radical trachelectomy are equivalent. Given the rarity of the procedure and the low recurrence and death rates of patients with early-stage cervical cancer undergoing radical trachelectomy, a prospective randomized trial seems unlikely. A multi-institutional international registry study (International Radical Trachelectomy Assessment - IRTA - study) has been recently completed evaluating open vs. minimally invasive radical trachelectomy. There are three ongoing prospective studies evaluating the possibility of less radical surgery in a low-risk early-stage cervical cancer population, ConCerv, SHAPE, and GOG 278. We look forward to the final results of these studies that will hopefully shed light on the optimal treatment option for patients with early-stage cervical cancer wishing to preserve fertility. This article will review the most impacting publications comparing open vs. minimally invasive radical trachelectomy and analyze the limitations of the current available literature.

Imaging and monitoring in minimally invasive valve surgery using an intra-aortic occlusion device: a single center experience

Background

Minimally invasive approach through a right mini-thoracotomy is a world-wide used procedure for mitral valve surgery. We performed a retrospective analysis based on our center experience in order to propose an effective, safe and reproducible method using an intra-aortic occlusion device.

Methods

This is a retrospective analysis on 48 consecutive patients undergoing mitral valve surgery through a right anterolateral mini-thoracotomy in our center. An intra-aortic occlusion device was used for aortic clamping and cardioplegia delivery. Simultaneous multi-plane three-dimensional echocardiography imaging was acquired to detect the venous cannulas position, the intra-aortic device location in the ascending aorta, the balloon inflation, the complete occlusion of the aorta, the cardioplegia delivery, the origin and the blood flow in the right coronary artery. Aortic root pressure was measured by the tip of the intra-aortic occlusion device. A bilateral upper extremity invasive arterial pressure monitoring was detected. Neuromonitoring was performed through bilateral cerebral oximetry.

Results

The analysis has shown no aortic dissection, neurological damage type 1 and myocardial ischemia in the study population. In 3 cases a distal displacement of the intra-aortic occlusion device was promptly detected by the combined use of echocardiographic imaging and by a drop of the right cerebral oximetry saturation and of the right radial artery pressure.

Conclusions

The combined use of transesophageal simultaneous multi-plane three- dimensional echocardiography imaging, bilateral upper extremity invasive arterial pressure monitoring, aortic root pressure and cerebral oximetry is an effective, safe and reproducible method in patients undergoing minimally invasive valve surgery using an intra-aortic occlusion device.

Surgical treatment and outcomes of intramedullary tumors by minimally invasive approach

Intramedullary tumors are uncommon neoplasms which, without treatment, can cause neurologic morbidity or mortality. The goal of the treatment is complete surgical resection with a minimally invasive approach while preserving neurological status and also spinal stability. Out of 1972 patients with tumors of the spinal canal treated between 1994 and 2017, 168 intramedullary tumors of 417 intradural tumors have been presented. All patients had undergone one surgical resection. The mean age is 43 ± 12 years (range 11-67 years). Tumors were subdivided into 4 groups: cervically located-tumors (n = 43), cervicothoracic-region-tumors (n = 32), thoracic-region-tumors (n = 57), and lumbosacral-region-tumors (n = 36). The mean follow-up time was 37 ± 29 months. Gross-total resection rate was higher in cervical located intramedullary tumors compared to the thoracic intramedullary tumors. Cervical intramedullary tumors showed better postoperative functional outcome than the thoracic intramedullary lesions. In intramedullary tumors, extending more than 3 spinal segments, postoperative worsening was significantly increased. A minimally invasive approach (the bilateral decompression via unilateral hemilaminectomy) was used to remove the tumor while preserving spinal stability. Perioperative permanent morbidity was very low. Intramedullary tumors should be surgically treated as soon as neurological symptoms appear. Patients with thoracic intramedullary tumors and tumor extension of more than three segments were at a higher risk for permanent morbidity. The minimally invasive approach allowed complete removal of the intramedullary tumors, and adequate preservation of vertebral stability while providing a good postoperative course.

Comparison between minimally invasive deltoid-split and extended deltoid-split approach for proximal humeral fractures: a case-control study

BACKGROUND

With the rapid aging of the population, the incidence of proximal humeral fracture (PHF) has increased. However, the optimal method for open reduction and internal fixation (ORIF) remains controversial.

METHODS

We performed a retrospective analysis of patients with PHF who underwent locking plate internal fixation at our institution from January 2016 to December 2018. Patients were divided into two groups based on the surgical approach used: an expanded deltoid-split approach group (ORIF group) and minimally invasive deltoid-split approach group (minimally invasive percutaneous plate osteosynthesis, [MIPPO] group). The groups were compared in terms of demographic and perioperative characteristics, and clinical outcomes.

RESULTS

A total of 115 cases of PHF were included in our study, of which 64 cases were treated using the minimally invasive deltoid-split approach and 51 using the extended deltoid-split approach. Fluoroscopy was performed significantly less frequently in the ORIF group and the surgical duration was shorter. However, the postoperative visual analogue scale (VAS) pain score and duration of postoperative hospital stay were significantly higher compared to the MIPPO group. Moreover, secondary loss was significantly less extensive in the ORIF group compared to the MIPPO group, while there was no significant group difference in fracture healing time, Constant shoulder score, or complications at the last follow-up visit.

CONCLUSIONS

The clinical outcomes associated with both the minimally invasive and extended deltoid-split approaches were satisfactory. The data presented here suggest that the extended deltoid-split approach was superior to the minimally invasive deltoid-split approach in terms of operational time, fluoroscopy, and secondary loss of reduction, while the minimally invasive approach was superior in terms of postoperative pain and hospital stay. Accordingly, neither procedure can be considered definitively superior; the optimal surgical procedure for PHF can only be determined after full consideration of the situation and requirements of the individual patient.

Short-term outcomes of laparoscopic approach to colonic obstruction for colon cancer

BACKGROUND

We speculated that a laparoscopic approach to emergent/urgent partial colectomy for colonic obstruction would be associated with less morbidity and shorter length of stay with similar mortality to open colectomy. We compared the outcomes of laparoscopic and open approaches to emergent/urgent partial colectomy for colonic obstruction from colonic cancer using data from the National Surgical Quality Improvement Program (NSQIP) database for the period of 2012-2017.

METHODS

Multivariate analysis compared NSQIP data points following laparoscopic, laparoscopic converted to open, and open colectomy for emergent/urgent colectomy for colonic obstruction from colon cancer from 2012 to 2017.

RESULTS

A total of 1293 patients who underwent emergent colectomy for colon obstruction from colon cancer during 2012-2017 were identified within the NSQIP database. Laparoscopic approach was used for colonic obstruction in 19.3% of operations with a conversion rate of 28.5%. A laparoscopic approach to obstructing colonic cancers was associated with lower morbidity (50% vs. 61.8%, AOR: 0.67, P = 0.01) and shorter hospitalization length (10 days vs. 13 days, mean difference: 3 days, P < 0.01) compared with an open approach. However, the mean operation duration was longer in laparoscopic operations than open operations (159 min vs. 137 min, P < 0.01).

CONCLUSION

A laparoscopic approach to malignant colonic obstruction is associated with decreased morbidity. This suggests that efforts should be directed towards increasing the utilization of laparoscopic approaches for the surgical treatment of colonic obstruction.

Mitral prosthetic size predictor in minimally invasive mitral valve replacement

Background

Minimally invasive mitral valve replacement has become popular across the world. However, annular rupture and patient – prosthetic mismatch (PPM) are still problematic, particularly in the Asian population. To avoid this, a predictor model could be beneficial. Our study aimed to assess the value of mitral valve diameters measured on TTE and CT scan on predicting the actual mitral prostheses.

Methods

From January 2018 to December 2019, a total number of 96 patients underwent minimally invasive mitral valve replacement. The association between imaging measurements and the outcome was checked by scatter plot and Pearson’s correlation coefficient. Univariable linear regression was used to build the prediction model.

Results

The three strongest correlations for the whole population are the following features: Mean TTE diameter (0.702), mean diameter on CT lowest plane through the mitral annulus (0.679), and area-derived diameter on CT highest plane through the mitral annulus (0.665). The prosthetic size of the tissue valve group was more correlated to the calculated annulus diameters than that of the mechanical valve group. Tissue valve size predictor models based on these calculated diameters were 16.19 + 0.27 × d (r = 0.744), 12.74 + 0.44 × d (r = 0.756) and 12.79 + 0.38 × d (r = 0.730), respectively.

Conclusion

Mitral prosthetic size could be predicted based on the mitral diameters measured on TTE and CT scan. The overall correlation coefficient varied from 0.665 (CT Scan) to 0.702 (TTE). These models performed better when applied to bioprosthesis.

Minimally invasive surgical repair of accessory mitral valve tissue: A case report

INTRODUCTION

Accessory mitral valve tissue is a rare congenital disease of the mitral valve. It is usually associated with other cardiac malformations and/or left ventricular outflow tract obstruction. More than 2/3 of patients were diagnosed in their childhood. Treatment can be conservative or surgical. The suitable timing for surgery remains controversial, some authors suggest early intervention to prevent devastating complications.

CASE REPORT

We report a case of an adult patient with accessory mitral valve tissue causing left ventricular outflow tract obstruction, who was treated surgically via the right minithoracotomy.

In silico evaluation of the stress fields on the cortical bone surrounding dental implants: Comparing root-analogue and screwed implants

Tooth loss is a problem that affects both old and young people. It may be caused by several conditions, such as poor oral hygiene, lifestyle choices or even diseases like periodontal disease, tooth grinding or diabetes. Nowadays, replacing a missing tooth by an implant is a very common process. However, many limitations regarding the actual strategies can be enumerated. Conventional screwed implants tend to induce high levels of stress in the peri-implant bone area, leading to bone loss, bacterial bio-film formation, and subsequent implant failure. In this sense, root-analogue dental implants are becoming promising solutions for immediate implantation due to their minimally invasive nature, improved bone stress distribution and because they do not require bone drilling, sinus lift, bone augmentation nor other traumatic procedures. The aim of this study was to analyse and compare, by means of FEA, the stress fields of peri-implant bone around root-analogue and screwed conventional zirconia implants. For that purpose, one root-analogue implant, one root-analogue implant with flaps, two conventional implants (with different threads) and a replica of a natural tooth were modelled. COMSOL was used to perform the analysis and implants were subjected to two simultaneous loads: 100 N axially and 100 N oblique (45°). RESULTS: revealed that root-analogue implants, namely with flaps, should be considered as promising alternatives for dental implant solutions since they promote a better stress distribution in the cortical bone when compared with conventional implants.

Sinus Tarsi Approach with Subcutaneously Delivered Plate Fixation for Displaced Intra-Articular Calcaneal Fractures

Displaced intra-articular calcaneal fractures can be treated with open reduction and internal fixation through various methods, including the extensile lateral approach, sinus tarsi approach, percutaneous reduction and fixation, external fixation, and calcaneoplasty. Although the gold standard is the extensile lateral approach, this method has significant wound-healing complications associated with it. Literature shows that the reduction achieved through minimally invasive techniques is equal to that achieved with the extensile lateral approach, while reducing the amount of postoperative complications. This article outlines a technique that uses the sinus tarsi approach with subcutaneous plate fixation.

Primary or Secondary Subtalar Arthrodesis and Revision of Calcaneal Nonunion with Minimally Invasive Rigid Internal Nail Fixation for Treatment of Displaced Intra-Articular Calcaneal Fractures

Primary or secondary subtalar joint arthrodesis after displaced intra-articular calcaneal fractures makes use of talocalcaneal large-diameter screw fixation after an eventual correction of geometric hindfoot deformity. Despite this procedure usually having a successful functional outcome, potential complications occur, including nonunion and malalignment, with an unknown rate of loss of correction or implant migration during the healing period. Angular stable fixation of the subtalar joint arthrodesis with an interlocking nail applied in a minimally invasive technique affords maintenance of the hindfoot position until osseous healing occurs. The key steps of the surgical technique are described.

Clinical outcomes of symptomatic thoracic disk herniations treated surgically through minimally invasive lateral transthoracic approach

Although symptomatic thoracic disk herniation (TDH) is relatively rare, its treatment is quite difficult. Our aim is to present the outcomes and complications in patients with thoracic disk herniation treated with minimally invasive lateral transthoracic approach (LTTA). Fifty-nine consecutive patients with 69 symptomatic disk herniations that underwent minimally invasive LTTA to treat TDH between 2007 and 2016 were enrolled. Medical records were reviewed retrospectively. The numbers of TDH were as follows: 41 central, 10 paracentral, and 18 both central and paracentral. The number of calcified disk herniations was found to be 32. No patient developed neurological deficit. Postoperative neurological improvement occurred in 39 (90.7%) of 43 patients with myelopathy. Preoperative VAS scores, ODI scores, and SF-36 scores improved at the follow-up, respectively. Mean blood loss, hospitalization period, and follow-up period were found to be 391.2 mL, 4.7 days, and 60 months; respectively. The following complications were observed: dural tear (five patients), intercostal neuralgia (three patients), rib fracture (one patient), pleural effusion requiring chest tube (two patients), hydropneumothorax requiring chest tube (one patient), small pneumothorax (one patient), atelectasis (one patient), pulmonary embolism (one patient), and pneumonia (one patient). Minimally invasive LTTA not only minimizes the manipulation of the thecal sac decreasing the risk for neurological injury compared to traditional posterior methods but also significantly decreases the pulmonary complications associated with traditional open procedures. Based on the authors' experience, anterior approach should be preferred especially in calcified central disk herniations regardless of surgeon's experience.

A Swedish population-based evaluation of benign hysterectomy, comparing minimally invasive and abdominal surgery

OBJECTIVE

The aim was to evaluate surgical routes for benign hysterectomy in a Swedish population, including abdominal and minimally invasive surgery.

STUDY DESIGN

Prospectively collected data from the Swedish National GynOp Registry 2009-2015: 13 806 hysterectomy cases were included: abdominal (AH, n = 7485), vaginal (VH, n = 3767), conventional laparoscopic (LH, n = 1539) and robotically-assisted (RAH, n = 1015).

RESULTS

The VH group had the shortest operation time at 75 min, AH 97 min and RAH 104 min. LH was longest at 127 min (p < 0.005). The mean estimated blood loss was higher in the AH group (250 ml) compared to all minimally invasive surgery (MIS, 65-172 ml); p < 0.005). Conversion rates were 10% for LH, 4.8% for VH and 1.6% for RAH (p < 0.005). Hospitalization and patient-reported time to normal activities of daily living (ADL) were longer for AH compared to MIS (p < 0.005). Time to return to work was eight days longer in the AH group (35 days) compared with the MIS groups (p < 0.005). Complications were fewest in the VH group at 5.4% compared with AH 7.6% and RAH 8.7% (both p < 0.001), but did not significantly differ from the LH group at 6.6%. Overall patient satisfaction was reported to be 86-94% one year after surgery.

CONCLUSION

Women operated on for benign hysterectomy with minimally invasive methods in Sweden 2009-2015 had reduced length of hospitalization, as well as time to resuming normal ADL and return to work, compared to AH. Postoperative outcome measures were improved by minimally invasive methods and MIS should preferably be used.

Treatment of phytobezoars: Tailoring management to diverse presentations

Objective

A minimally invasive approach is feasible and successful for the treatment of phytobezoars. We would like to draw attention to the overconsumption of Sorbus domestica and discuss the management options of patients presenting with different symptoms due to phytobezoars.

Material and Methods

Data from patients diagnosed with phytobezoars in the Department of General Surgery from 2010 to 2016 were prospectively collected and evaluated.

Results

Twenty patients diagnosed with phytobezoars were included in the study. The etiology of phytobezoar was Sorbus domestica seeds in 12 patients, watermelon seeds in two patients, Japanese persimmon seeds in one patient, and unidentified in five patients. Fourteen patients underwent surgery, while the remaining patients were treated conservatively. Minimally invasive surgery was used in all but two cases, where the surgery was converted to laparotomy. Two patients developed postoperative morbidity. There was no mortality.

Conclusion

The treatment modality should be selected for each patient according to the presenting symptoms and characteristics of phytobezoar. In cases where surgery is performed, a minimally invasive approach is feasible and successful for the treatment of ileus.

Arthroscopically assisted fixation is a reliable option for patellar fractures: A literature review

Proper reduction and stable fixation of articular fractures is essential for an early recovery and to avoid late complications. Arthroscopically assisted techniques for minimally invasive fixation have been introduced to reduce local morbidity and improve anatomic reduction of the fragments. However up to date no clear indications for surgery have been given. In addition, the precise rates of functional outcomes and complications are controversial. The hypothesis was the systematic analysis of the available literature would provide precise indications, outcomes and complications of arthroscopically assisted techniques for patellar fracture fixation. A comprehensive literature review was performed using the keywords "patellar fracture", "arthroscopy" with no limit regarding the year of publication. All the selected articles were in English language and were evaluated with the Coleman score by three independent surgeons. The interclass correlation coefficient between the three examiners was calculated. Six full text articles were retrieved. The initial cohort included 60 patients with a displaced transverse fracture in the majority of the cases. At an average FU of 27.2 months the Lysholm score was 91.3. The rate of complication was 7%; Average Coleman score for the three observers was 55.8±6.5 with an ICC of 0.89, indicating adequate inter-rater agreement. Arthroscopically assisted techniques for minimally invasive fixation of patellar fractures represent a reliable option. The positive clinical outcomes and low rates of complications must be confirmed with further studies including larger series and longer FU.

LEVEL OF EVIDENCE

Level IV, systematic review of retrospective series.

Operative Management of Distal Anterior Cerebral Artery Aneurysms Through a Mini Anterior Interhemispheric Approach

BACKGROUND

Distal anterior cerebral artery (DACA) aneurysms, also known as pericallosal artery aneurysms, are present in 1.5%-9% of all intracranial aneurysms. Here we characterize the important microsurgical anatomy of DACAs; describe the surgical approach to treating these aneurysms with a minimally invasive surgical technique, the mini anterior interhemispheric approach (MAIA); and examine the nuances of aneurysm clipping in this region.

METHODS

This was a retrospective and descriptive analysis of a series of aneurysm surgeries performed at the National Institute of Neurology and Neurosurgery in Mexico City. Cadaveric dissections were used to demonstrate relevant cerebrovascular anatomy. We analyzed patient demographic data and aneurysm characteristics. Patients' neurologic grade was evaluated using the Hunt and Kosnik (H-K) scale, and surgical outcomes were evaluated using the Glasgow Outcome Scale (GOS). Other variables were analyzed using the χ² test.

RESULTS

We analyzed a total of 32 DACA aneurysms (10 nonruptured and 22 ruptured), representing 5.8% of all aneurysms. The study cohort was 64.3% females and 35.7% males. H-K grade II was the most frequent classification (32.4%); 42.8% of patients presented with a Fisher grade IV aneurysm. Aneurysm location was classified as supra-genu, genu, or infra-genu. Eight patients had multiple aneurysms, among which 50% were located at the bifurcation of the middle cerebral artery.

CONCLUSIONS

Surgical clipping through a MAIA approach is an excellent treatment option for pericallosal artery aneurysms.

Surgical management of epiphrenic diverticulum: A single-center experience and brief review of literature. Am J Surg. 2018;216:280-285. [PMID: 28778314 DOI: 10.1016/j.amjsurg.2017.06.039]

BACKGROUND

We present single-center experience of surgery for primary epiphrenic diverticulum (PED) over a 12-year period.

METHODS

Prospectively maintained database was queried to identify patients who underwent PED surgery. Preoperative and postoperative symptoms, operative data, perioperative complications, and follow-up were reviewed.

RESULTS

Twenty-seven patients (14 females; mean age-67-years) underwent PED surgery. The most common primary presenting symptoms were dysphagia and regurgitation (mean duration-3.6-years). 82% patients underwent laparoscopic procedures (one conversion), 11% operated via left thoracotomy and 7% via combined laparoscopy-right trans-thoracic approach. All patients received myotomy, all but one received diverticulectomy. Five-patients experienced intraoperative complications that were managed intraoperatively without sequelae. There was no perioperative mortality. Morbidity was seen in 3-patients, including one staple-line leak managed with endoscopic washes and stent placement. 90% patients with ≥1-year follow-up reported "excellent" satisfaction.

CONCLUSIONS

Minimally invasive surgery for PED is both feasible and safe. We observed low morbidity, short hospital stay, and excellent patient-reported outcomes.

Functional and radiological outcomes of a minimally invasive surgical approach to monostotic fibrous dysplasia

Background

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).

Patients and methods

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.

Results

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 no change. Radiological progression was limited in 11 (92%) cases, and none had postoperative complications.

Conclusion

Plain open biopsies for asymptomatic lesions; prophylactic bridge plating for symptomatic, large diaphyseal lytic lesions; and plain ATP reconstructions for both small and large nondiaphyseal symptomatic lytic lesions may be acceptable alternatives to curettage-incorporating procedures for MFD.

The deep layer of the tractus iliotibialis and its relevance when using the direct anterior approach in total hip arthroplasty: a cadaver study

INTRODUCTION

Surgical approaches through smaller incisions reveal less of the underlying anatomy, and therefore, detailed knowledge of the local anatomy and its variations is important in minimally invasive surgery. The aim of this study was to determine the location, extension, and histomorphology of the deep layer of the iliotibial band during minimally invasive hip surgery using the direct anterior approach (DAA).

MATERIALS AND METHODS

The morphology of the iliotibial tract was determined in this cadaver study on 40 hips with reference to the anterior superior iliac spine and the tibia. The deep layer of the tractus iliotibialis was exposed up to the hip-joint capsule and length and width measurements taken. Sections of the profound iliotibial tract were removed from the hips and the thickness of the sections was determined microscopically after staining.

RESULTS

The superficial tractus iliotibialis had a length of 50.1 (SD 3.8) cm, while tensor fasciae latae total length was 18 (SD 2) cm [unattached 15 (SD 2.5) cm]. Length and width of the deep layer of the tractus iliotibialis were 10.4 (SD 1.3) × 3.3 (SD 0.6) cm. The deep iliotibial band always extended from the distal part of the tensor fascia latae (TFL) muscle to the lateral part of the hip capsule (mean maximum thickness 584 μm). Tractus iliotibialis deep layer morphology did not correlate to other measurements taken (body length, thigh length, and TFL length).

CONCLUSIONS

The length of the deep layer is dependent on the TFL, since the profound part of the iliotibial band reaches from the TFL to the hip-joint capsule. The deep layer covers the hip-joint capsule, rectus, and lateral vastus muscles in the DAA interval. To access the precapsular fat pad and the hip-joint capsule, the deep layer has to be split in all approaches that use the direct anterior interval.

Glove port, how do we do it? A low-cost alternative to the single-port approach

BACKGROUND

The need for cosmetic results in our society and the necessity of an early recovery have promoted the development of minimally invasive techniques, including single-port approach. Some studies have tried to demonstrate the advantages of this access compared with conventional laparoscopic approach. This type of approach requires a high-cost multi-port device, so that some surgeons have tried to create a low-cost homemade device.

MATERIALS AND METHODS

With this video we intend to show how to build a glove port, a low-cost alternative for the approach by a single port.

CONCLUSIONS

A glove port is a cost effective approach that could be use instead of multi-port device.

A Proposed Staging Classification for Minimally Invasive Management of Haglund's Syndrome with Percutaneous and Endoscopic Surgery

Haglund's syndrome encompasses several different pathologies, including Haglund's deformity, insertional Achilles tendonopathy, retrocalcaneal bursitis, and superficial bursitis. Traditionally treated with open surgery, there is increasing interest in a more minimally invasive approach to this difficult region to reduce complications and improve the rate and ease of recovery. We review the evidence available for 2 of these techniques: the endoscopic calcaneoplasty and percutaneous Zadek's calcaneal osteotomy (also known as Keck and Kelly's osteotomy). The senior author's classification for management of the condition is presented as well as describing his operative technique for these procedures.

Preliminary results of video-assisted anal fistula treatment (VAAFT) in children

BACKGROUND

Anal fistula is a common acquired anorectal disorder in children. Treatment methods that have been used are associated with inconsistent results and possible serious complications. In 2011 a minimally invasive approach, video-assisted anal fistula treatment (VAAFT) was described for adult patients. The aim of the present study was to assess the first series of pediatric patients treated with VAAFT.

METHODS

All patients who underwent VAAFT between August 2013 and May 2015 were included. Demographics, clinical features, preoperative imaging, surgical details, outcome, and medium-term data were prospectively collected for each patient.

RESULTS

Thirteen procedures were performed in nine patients. The male to female ratio was 8:1, and the median age was 9.6 years. Five fistulas were idiopathic, three iatrogenic, and one associated with Crohn's disease. Eight complete VAAFT procedures were performed. The remaining five procedures were either fistuloscopy and cutting seton placement or fistuloscopy and electrocoagulation, both without mucosal sleeve. The median length of surgery was 41 min. The median hospital stay was 24 h, and the median length of follow-up was 10 months. Resolution of the fistula was observed in all patients who underwent a complete VAAFT. In four out of five patients who underwent an incomplete procedure (without mucosal sleeve), the fistula recurred. No incontinence or soiling was reported in the medium term.

CONCLUSIONS

VAAFT proved to be feasible and safe in children. It also proved to be versatile as it could be applied to fistulas of different etiologies. The key to success seems to be an adequate mucosal sleeve. Older children and adolescents benefit most from VAAFT which is a valid alternative to available surgical procedures.

Solitary plasmacytoma of L3 vertebral body treated by minimal access surgery: Common problem different solution!

INTRODUCTION

Solitary plasmacytoma of bone is a local primary bone tumour consisting of malignant plasma cells without systemic involvement. These tumours are known for large amount of blood loss, and the use of electrocautery is helpful in reducing blood loss and performing surgery in a relatively bloodless field; however, use of unipolar cautery in patients with indwelling cardiac pacemaker is known to cause arrhythmias and cardiac events. Minimally invasive techniques offer potential advantages over open techniques particularly in patients with spinal tumours, where massive amount of blood loss is expected, if open procedure is performed. Here, we present a case of solitary L3 plasmacytoma with progressive neurological deficit with chronic refractory anaemia with indwelling cardiac pacemaker treated by minimally invasive technique.

MATERIALS AND METHODS

A 71-year-old male presented with increasing back pain with Left L3 radiculopathy since 6 months and progressive left lower limb weakness since 5 days. The patient is a known case of chronic renal failure with chronic refractory anaemia. The patient has indwelling cardiac pacemaker for cardiac arrhythmias. Radiology was suggestive of L3 body plasmacytoma. L3 corpectomy and anterior column reconstruction with expandable cage and posterior stabilization by minimally invasive techniques were performed.

RESULTS

Two years of follow-up showed no local recurrence. The patient is ambulatory unaided with no neurological deficit and backache.

DISCUSSION

There is no consensus regarding appropriate surgical approach and perioperative strategies in treatment of solitary plasmacytoma. A solitary plasmacytoma was found in the spine of a patient with cardiac pacemaker where anaesthetic consideration, blood loss and the use of electrocautery were the limiting factors. Minimally invasive approach is a good option.

Major venous resection and reconstruction using a minimally invasive approach during laparoscopic pancreaticoduodenectomy: One step forward

In the current era of technological advancement, the feasibility of laparoscopic pancreaticoduodenectomy has been established. However, major venous resection and reconstruction along with laparoscopic pancreaticoduodenectomy is still considered a complex procedure. A 47-year-old woman presented with obstructive jaundice secondary to carcinoma in the pancreatic head. Triphasic abdominal CT revealed a 2.7 × 3.0-cm heterogenous mass in the pancreatic head with peripancreatic lymphadenopathy without vascular involvement. The patient was scheduled for laparoscopic pancreaticoduodenectomy. During mobilization, the tumor was found adherent to the superior mesenteric vein. Therefore, vascular resection and reconstruction was accomplished laparoscopically along with pancreaticoduodenectomy. The duration of superior mesenteric vein occlusion was 45 min. The patient had an uneventful recovery and was discharged on postoperative day 10. Major venous resection and reconstruction during laparoscopic pancreaticoduodenectomy using a minimally invasive approach is feasible in selected patients. Adequate experience in complex laparoscopic pancreatic surgery is required before attempting this procedure.

Minimally invasive surgery for paediatric inflammatory bowel disease: Personal experience and literature review

The incidence of paediatric inflammatory bowel disease (PIBD) has dramatically increased in the last 20 years. Although first reported in mid 1970s’, diagnostic laparoscopy has started to be routinely adopted in paediatric surgical practice since late 1990s’. Minimally invasive surgery was first limited to diagnostic purposes. After 2002 it was also applied to the radical treatment of PIBD, either Crohn’s disease (CD) or Ulcerative colitis. During the last decade minimally invasive approaches to PIBD have gained popularity and have recently became the “gold standard” for the treatment of such invalidating and troublesome chronic diseases. The authors describe and track the historical evolution of minimally invasive surgery for PIBD and address all available opportunities, including most recent advancements such as robotic surgery, single port approaches and minimally invasive treatment of perianal fistulising CD. A systematic review of all series of PIBD treated with minimally invasive approaches published so far is provided in order to determine the incidence and type of patients’ complications reported up to present days. The authors also describe their experience with minimally invasive surgery for PIBD and will report the results of 104 laparoscopic procedures performed in a series of 61 patients between January 2006 and December 2014.

Giant Paratubal Cyst in Adolescence: Case Report, Modified Minimal Access Surgical Technique, and Literature Review

BACKGROUND

Giant paratubal cysts are rare lesions that can present management challenges due to their enormous size. We present a modified minimally invasive approach for effective surgical management of giant paratubal cysts.

CASE

A 19-year-old adolescent with worsening abdominal distention and metrorrhagia was diagnosed with a giant paratubal cyst. A modified, minimally invasive technique designed to limit spillage of cyst fluid was successfully used for surgical management.

SUMMARY AND CONCLUSION

We evacuated 5500 mL of cyst fluid without spillage, and near-complete excision of cyst was performed with preservation of adnexa. Preservation of the adnexa in female adolescents is critical, and minimally invasive approaches should be used where possible.

Single-session minimally invasive management of common bile duct stones

Up to 18% of patients submitted to cholecystectomy had concomitant common bile duct stones. To avoid serious complications, these stones should be removed. There is no consensus about the ideal management strategy for such patients. Traditionally, open surgery was offered but with the advent of endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) minimally invasive approach had nearly replaced laparotomy because of its well-known advantages. Minimally invasive approach could be done in either two-session (preoperative ERCP followed by LC or LC followed by postoperative ERCP) or single-session (laparoscopic common bile duct exploration or LC with intraoperative ERCP). Most recent studies have found that both options are equivalent regarding safety and efficacy but the single-session approach is associated with shorter hospital stay, fewer procedures per patient, and less cost. Consequently, single-session option should be offered to patients with cholecysto-choledocholithiaisis provided that local resources and expertise do exist. However, the management strategy should be tailored according to many variables, such as available resources, experience, patient characteristics, clinical presentations, and surgical pathology.