Duration Of Anastomosis Research Articles

Effect of Laterality in Microsurgery: Comparative Study of an Expert and a Novice.

Background: Hand laterality has an impact on surgical gestures. In this study, we sought to measure the multi-parameter variability of the microsurgical gesture depending on the hand used and the differences between expert microsurgeons and novices. Methods: Ten experienced microsurgeons and twenty medical students with no prior microsurgical experience performed arterial anastomosis on a chicken wing artery using dominant and non-dominant hands. We measured time and force using a homemade force-sensing microsurgical needle holder, heart rate variability with a Polar H10 chest strap, anxiety with the STAI-Y questionnaire and anastomosis quality using the MARS 10 scale. Results: In the microsurgeons' group, duration of anastomosis (p = 0.037), force applied to the needle holder (p = 0.047), anxiety (p = 0.05) and MARS10 (p = 0.291) were better with the dominant hand. For novices, there was no difference between the dominant and non-dominant hand pertaining to force, time and stress level. There were no differences between microsurgeons and novices pertaining to force and anxiety using the non-dominant hand. Conclusions: The study highlighted a marked laterality among microsurgical experts, a finding that may be explained by current learning methods. Surprisingly, no laterality is observed in students, suggesting that for a specific gesture completely different from everyday tasks, laterality is not predefined. Ambidexterity training in the residency curriculum seems relevant and may help microsurgeons improve performance and postoperative outcomes.

Systemic assessment of manual circular stapler versus powered circular stapler for anastomosis in rectal cancer: A multicenter prospective cohort study.

e15614 Background: Mechanical anastomosis offers several advantages over traditional hand-sutured anastomosis. However, complications such as anastomotic leaks, strictures, and bleeding persist due to factors like interactions between staples and tissue. Powered circular anastomosis is an effective method to address these issues. Currently, there are no domestic studies on the application of powered-anastomosis technology in colorectal anastomosis. Methods: The study adopted a multicenter, randomized, parallel-controlled, non-inferiority study design, with a 1:1 random allocation ratio. The study involved 187 patients with rectal cancer who underwent Dixon surgery using IntoCare™ disposable powered circular stapler (ICS), and 195 patients who received similar process with manual circular stapler (MCS). The efficacy of stapler was evaluated by anastomosis success rate, anastomosis-related adverse events, anastomosis device performance assessment, operation time, anastomosis time, and postoperative recovery. Safety evaluation indicators included adverse events, vital signs, and laboratory tests. Results: Baseline demographic characteristics showed no notable disparities between two groups (Table 1). A high proportion of patients, 99.47% in the MCS group and 99.49% in the ICS group, successfully completed anastomosis. In the MCS group, the average anastomosis duration was clocked at 2.84 minutes (min) (±2.3), with a median time of 2.0 min (ranging from 1.0 to 22.0 min). In contrast, the ICS group exhibited a slightly quicker average anastomosis duration of 2.40 min (±1.7), and a comparable median time of 2.0 min (but with a narrower range from 1.0 to 15.0 min). Adverse events did not differ significantly between two groups. Conclusions: The results uncovered the powered stapler could considerably reduce stapling time while maintaining a safety profile. Notably, the incidence of patients with anastomotic leakage one month post-surgery, and anastomotic stricture six months post-surgery in the powered stapler group, was lower than those in the manual stapler group. This suggests that the anastomosis created by the powered stapler is more stable and promotes more effective postoperative anastomotic healing. Clinical trial information: NCT05879172 . [Table: see text]

The safety and feasibility assessment of overlap esophagojejunostomy with self-pulling and latter transection technique in totally laparoscopic total gastrectomy

BackgroundThis study presented an innovative technique in totally laparoscopic total gastrectomy (TLTG) for overlap esophagojejunostomy (E-J), termed self-pulling and latter transection (SPLT) (overlap SPLT). It evaluated the effectiveness and short-term outcomes of this novel method through a comparative analysis with the established functional end-to-end (FETE) E-J incorporating SPLT. MethodsFrom September 2018 to September 2023, this study enrolled 68 patients with gastric cancer who underwent TLTG with overlap SPLT anastomosis and 120 patients who underwent TLTG with FETE SPLT anastomosis. Clinicopathologic characteristics and surgical and postoperative outcomes data for overlap SPLT cases were gathered and retrospectively compared with those from FETE SPLT TLTG to evaluate the effectiveness and clinical safety. ResultsThe duration of anastomosis for overlap SPLT was 25.3 ± 7.4 minutes, significantly longer than that for the FETE SPLT (18.1 ± 4.0 minutes, P = .031). Perioperatively, 1 anastomosis-related complication occurred in each group, but this did not constitute a statistically significant difference (P = .682). No statistically significant differences were found between the 2 groups in terms of operative time, postoperative hospital stay, operative cost, surgical margins, or number of lymph nodes removed. Postoperative morbidity rates were similar between the groups (4.4% vs 5.8%, P = .676). ConclusionThe overlap SPLT technique is regarded as a safe and feasible method for anastomosis. There were no apparent differences in complications between overlap SPLT and FETE SPLT, but overlap SPLT costed 1 additional stapler cartridge and required a longer duration.

A novel, easier and safer alternative method for oesophagojejunal reconstruction after totally laparoscopic total gastrectomy

This study presents a novel laparoscopic modified overlapping oesophagojejunostomy anastomosis method which consists of self-pulling and latter transection to perform a safer anastomosis, describes the anastomosis technique in detail and reveals its short-term outcomes. Forty-five patients underwent totally laparoscopic total gastrectomy using the self-pulling and oesophagus latter-cut overlap method anastomosis for gastric cancer from January 2019-2022. During the self-pulling phase, the oesophagus was ligated at the level of the gastroesophageal junction or above and dragged down by a ligature rope to mobilise up to 5-6cm. An entry hole was created on the right side of the oesophagus, and a nasogastric tube was taken out through the hole and tip of the tube was used as a guide for the endoscopic linear stapler to decrease the risk of entering the false lumen and creating a side-to-side anastomosis. The oesophagus was then latter-transected by a second endoscopic linear stapler. The common entry hole was closed using a hand-sewing method. Clinicopathological characteristics and surgical outcomes were collected and retrospectively evaluated. The mean anastomosis duration was 27min. The morbidity rate was 4.4%. Only two patients experienced postoperative complications but subsequently recovered conservatively. None of the patients suffered anastomotic leak or stricture. Self-pulling and latter transection-based overlapping anastomosis is a simple and reliable approach that overcomes most of the limitations of standard overlap method and provides satisfactory surgical outcomes.

Modified mattress inversion suturing with double barbed sutures used for totally laparoscopic esophagojejunostomy overlap anastomosis after radical total gastrectomy

Objective: To explore the advantages and safety of a modified mattress inversion suturing using double barbed sutures compared with the traditional overlap method in totally laparoscopic esophagojejunostomy overlap anastomosis. Methods: A retrospective cohort study was conducted. The inclusion criteria were as follows: (1) patients were aged 18 - 80 years old; (2) adenocarcinoma was preoperatively confirmed by pathological analysis; (3) patients had undergone a complete laparoscopic radical total gastrectomy; (4) patients had undergone esophagojejunostomy using the overlap method; (5) patients received a grade of I-III on the American Society of Anesthesiologists physical status classification system; (6) patients' complete follow-up data had been collected. Patients with a history of other malignant tumors, multi-origin tumors, emergency surgery, non-R0 radical resection or distant metastasis were excluded. The clinical data of 89 gastric cancer patients who underwent total laparoscopic radical total gastrectomy in the Department of Gastrointestinal Surgery in the Sixth Affiliated Hospital of Sun Yat-sen University from January 2019 to December 2020 were collected. These patients were grouped according to the esophagojejunostomy method used. Of 89 patients, 32 received modified mattress inversion suturing with double barbed sutures to close the common opening of esophagojejunostomy (the modified anastomosis group), while 57 received traditional overlap anastomosis in which the common opening was closed by barbed suture (the traditional anastomosis group). The operation conditions (incision length, conversion to laparotomy, duration of esophagojejunostomy) and postoperative recovery (time to commencement of a liquid diet, duration of postoperative hospital stay, anastomotic leakage, anastomotic stenosis, and anastomotic bleeding) were compared between the two groups. Results: There was no significant difference in the baseline data of the two groups for any parameter (all P>0.05). All patients received complete laparoscopic radical gastrectomy without conversion to laparotomy. There were no significant differences in the length of the median incision, the proportion of food intake on the first day after surgery, or in the incidence of anastomotic complications such as anastomotic leakage, anastomotic stenosis, and anastomotic bleeding between the two groups (P>0.05). Compared with the traditional anastomosis group, patients in the modified anastomosis group had shorter anastomosis time [26 (19-62) minutes vs. 36 (20-50) minutes, Z=-2.546, P=0.011] and postoperative hospital stay [7 (6-12) days vs. 9 (7-42) days, Z=-4.202, P<0.001]. The differences were statistically significant (all P<0.05). In a subgroup analysis of tumor TNM stage III, Siewert type II and neoadjuvant chemotherapy patients, there was no significant difference in the incidence of anastomotic complications between the modified group and the traditional group. However, the postoperative hospital stay duration in the modified anastomosis group was less than in the traditional anastomosis group. The duration of anastomosis in Siewert type II patients was also shorter in the modified anastomosis group than in the traditional anastomosis group [26 (19-62) minutes vs. 38 (21-50) minutes, Z=-2.105, P=0.035], and the difference was statistically significant (all P<0.05). Conclusion: Complete laparoscopic esophagojejunostomy using modified mattress inversion suturing with double barbed sutures is a safe and feasible anastomosis method to close the common opening of esophagojejunostomy, with shorter operation time, faster postoperative recovery and shorter hospital stay than the traditional method.

EP-568 A prospective study on single layer bowel repair

AimTo determine the efficacy of single layer bowel repair with respect to postoperative complications such as leakage rates, duration of repair, overall length of hospital stay, cost effectiveness, to assess the morbidity, mortality and outcome.MethodsThis prospective study was done on 21 patients admitted under department of surgery from the period of January 2020 to September 2021. All the patients under bowel repair in continuous single layer extramucosal fashion for various etiology, follow up data was collected and analysed.ResultsIn our study, 81% (17 cases) of the single layer bowel repair were done in an emergency setting. The study consisted of 42.9% (9 cases) of perforation repair and 57.1% (12 cases of resection and anastomosis of large or small bowel). The average time duration of anastomosis was 14.45 minutes with the average hospital stay of 13.2 days. Our study showed an anastomotic leak rate of 9.5% (2 cases) with an overall mortality of 19.04% (4 cases) which included 2 cases with COVID-19 related ARDS.ConclusionOur study was determined to analyse the effectiveness of single layer bowel repair and found that it is a quicker and theoretically better technique for bowel repair which avoids unnecessary tissue ischemia. The leakage rates within the study was comparable with other studies published and the studies with double layer bowel repair technique in terms of leak rates and mortality. A meticulously done single layer repair will best double layer repair and surgical trainees must be trained early to perfect the art of bowel anastomosis.

Learning Curve Analysis of Microvascular Hepatic Artery Anastomosis for Pediatric Living Donor Liver Transplantation: Initial Experience at A Single Institution.

BackgroundThe incidence of hepatic artery thrombosis in pediatric living donor liver transplantation (LDLT) is significantly higher than that in adults, and is closely related to the surgeon’s experience with hepatic artery anastomosis. However, there are few studies on the learning curve of hepatic artery anastomosis among surgeons.MethodsWe collected data related to 75 patients who underwent pediatric LDLT and hepatic artery anastomosis independently by the same surgeon. Cumulative sum method (CUSUM) was used to analyse the duration of hepatic artery anastomosis and determine the cut-off value. Patients were divided into two phases according to CUSUM. We analysed the intraoperative and postoperative data and survival outcomes of the included patients.ResultsTotal anastomosis duration decreased with an increased number of completed procedures, and the average duration was 42.4 ± 2.20 min. A cut-off value and two phases were identified: 1–43 cases and 44–75 cases. Intraoperative blood loss was significantly lower in phase 2 than in phase 1. The immediate functional changes of total bilirubin (TBIL) and direct bilirubin (DBIL) were significantly also lower in phase 2 than in phase 1. Other functional outcomes, postoperative complications, and the long-term survival rate were not significantly different between the two phases.ConclusionsTechnical competence in pediatric LDLT hepatic artery anastomosis may be achieved after completing 43 cases. It is a safe procedure with a surgical loupe that can be systematized and adopted by pediatric surgeons with sufficient experience via a relatively long learning curve.

Early Experience Using a New Robotic Microsurgical System for Lymphatic Surgery.

Summary:Robotic microsurgery has emerged as a new technology with potential benefits for reconstructive surgery. We report the first-in-human use of the Symani surgical system to perform lympho-venous and arterial anastomosis for lymphatic reconstruction. In five patients, 10 robot-assisted anastomoses were performed. Next to lympho-venous anastomoses, two patients received a free vascularized lymph node transfer. Motion scaling was set to 10×. Visualization was either achieved with a 3D system or an optical microscope. All anastomoses were patent as confirmed by ICG. Despite a longer time to perform the first anastomoses with the robot, we observed a decline in duration of anastomosis. Among the advantages of the system were a high accuracy in placing the stitches even in very small and fragile vessels or when performing anastomoses with size mismatches. The challenges encountered included the lack of a touch sensation and the necessity to develop a “see-feel.” This could be achieved surprisingly well because the force necessary to close dilator and needle holder via the manipulators was perceived as comparable to using conventional micro instruments. Our data confirm feasibility and safety of the robotic system to perform lymphatic surgery. Larger patient cohorts and inclusion of surgeons at different training levels will be necessary to investigate the true potential of robotics in microsurgery. In addition, robot-assisted surgery shows a promising potential in opening up new frontiers in reconstructive microsurgery (eg, the reliable performance of anastomoses on even smaller blood and lymphatic vessels or on structures deeper within the body cavities—eg, the thoracic duct).

Randomized controlled trial comparing open anterograde anatomic radical retropubic prostatectomy with retrograde technique

ObjectiveRadical prostatectomy is the recommended treatment for localized prostate cancer; however, it is an invasive procedure that can leave serious morbidity. Robot-assisted radical prostatectomy was introduced with the aim of reducing postoperative morbidity and facilitating rapid recovery compared to the traditional Walsh's open radical retropubic prostatectomy. Therefore, a protocol was developed to perform an open prostatectomy comparable to that performed by robotics, but without involving novel instrumentation. MethodsA total of 220 patients diagnosed with localized prostate cancer underwent radical prostatectomy. They were divided into two groups: anterograde technique (115 patients) and the retrograde method (105 patients). The study outcomes were observed 3 months after surgery. ResultsNo differences were found in terms of surgical time, hospital stay, and suction drainage. However, reduced bleeding was observed in the anterograde technique (p=0.0003), with rapid anastomosis duration (p=0.005). Among the patients, 60.9% undergoing the anterograde technique were continent 3 months after surgery compared to 42.9% treated by the retrograde method (p=0.007). Additionally, fewer complications in terms of the number (p=0.007) and severity (p=0.0006) were observed in the anterograde technique. ConclusionThe anterograde method displayed increased efficiency in reducing complications, compared to the retrograde technique.

A comparative study of suturing technique of intestine between extra-mucosal single layer interrupted and continuous all layers: a single center experience

Background: Gastrointestinal anastomosis has been excited interest in our day to day surgical practice. We have compared efficacy, advantages, disadvantages, and complications following intestinal resection-anastomosis using extra-mucosal interrupted single layer suturing or continuous all layer suturing.Methods: This comparative study included 50 cases (either in emergency or elective undergoing bowel resection and anastomosis), comprising of 2 Groups (25 cases in each Group) between January 2019 to June 2021 at Midnapore Medical College and Hospital. Patients data, operative findings, duration of anastomosis and length of hospital stay, post-operative complications of all patients were followed till discharge.Results: Our comparative study have shown that- the mean duration for intestinal anastomosis in Group A (extra-mucosal interrupted single layer) and Group B (continuous all layers) were 21.43 minutes and 14.35 respectively. Considering duration of the anastomosis continuous all layers intestinal anastomosis appears to represent in shorter duration, anastomotic leak was noted in 3 patients (6%). Anastomotic leak was observed in 1 patient extra-mucosal interrupted single layer bowel anastomosis whereas two patients in the Group of continuous all layered bowel anastomosis had leak (p value 0.5-not significant) and the mean duration of hospital stay in the Group A and Group B were 7.32 days and 7.92 days respectively. (p value -insignificant).Conclusions: Duration required to perform a continuous all layer bowl anastomosis is lesser when compared to an extra-mucosal interrupted single layer intestinal anastomosis. There is no significant difference in complications, final outcome and duration of hospital stay between two Groups.

Various Uses of Laryngeal Mask Airway during Tracheal Surgery.

The use of laryngeal mask airway (LMA) ventilation in surgeries to be performed in upper tracheal stenosis has been reported in the case series. However, there is no generally accepted standardized approach for the use of LMA. In this study, LMA usage areas and advantages of trachea surgery were examined. The records of 21 patients who underwent tracheal surgery using LMA ventilation between March 2016 and May 2020 were evaluated retrospectively. The patient data were analyzed according to age, gender, mean follow-up time, surgical indication, mean tracheal resection length, anastomosis duration, mean oxygen saturation, mean end-tidal CO2 levels, and postoperative complications. Four patients were female and 17 were male, their median age was 43 (11-72 range) and the mean follow-up time was 17.6 months. The most common surgical indication was postintubation tracheal stenosis. The mean tracheal resection length was 26.6 mm and the mean anastomosis duration was 11.3 minutes. The mean pulse oximetry and mean end-tidal CO2 during laryngeal mask ventilation was 97.6% ± 2.1 and 38.1 ± 2.8 mm Hg, respectively. Postoperative complications were higher in patients with comorbidities. LMA-assisted tracheal surgery is a method that can be used safely as a standard technique in the surgery of benign and malignant diseases of both the upper and lower airway performed on pediatric patients, patients with tracheostomy, and suitable patients with tracheoesophageal fistula.

Transplantation rénale robot-assistée avec donneur vivant : expérience d’un centre universitaire français

The main objective was to report the intra-, post-operative and functional outcomes of living-donor robotic-assisted kidney transplantation (RAKT), performed by a surgeon skilled in robotic surgery. The secondary objective was to compare the results of RAKT, based on the surgeon's experience. For this retrospective cohort study, we analyzed data from consecutive patients who underwent living-donor RAKT from July 2015 to March 2020 and compared the results of RAKT according to the surgeon's experience (group 1: 1-14th RAKT versus group 2: 15-29th RAKT). Twenty-nine living-donor RAKT were performed. The median age and BMI of the recipients were: 57.0 (44.0-66.0) years and 32.7 (23.5-39.6)kg/m2. The median overall operative time and median console time were: 140.0 (122.5-165.0) and 120.0 (107.5-137.5) minutes. The median rewarming time, arterial, venous and urinary anastomoses durations were: 35.0 (27.5-45.0), 15.0 (11.0-20.0), 12.0 (10.0-16.0), 20.0 (16.0-23.0) minutes. Two (6.9%) minor and 5 (17.2%) major (Clavien-Dindo≥III) postoperative complications occurred. At 2 years of follow-up, patient and transplant survival was 100% (n=29) and 93.1% (n=27). After the 14th RAKT, the rewarming time (P=0.01) and venous anastomosis duration (P=0.004) were statistically shorter. Living-donor robotic-assisted kidney transplantation, performed by a surgeon skilled robotic surgery, ensures good functional results in the medium term. 3.

A COMPARATIVE STUDY BETWEEN SINGLE LAYER VERSUS DOUBLE LAYER INTESTINAL ANASTOMOSIS

A comparative study between Single Layer versus Double Layer Intestinal Anastomosis,was undertaken at Department of Surgery,Bankura Sammilani Medical College &amp; Hospital,Bankura from April 2019 – September 2020,which included 74 patients, comprising 2 groups: Group A-Single layer and Group B- Double layer with equal number of patients randomly allotted in each group. More number of patients had anastomotic leak in Group B than Group A, though not statistically significant. Difference of Mean Duration of Anastomosis with both groups is statistically significant.Mean Duration of Hospital Stay with both groups is statistically insignificant. Although more number of patients had anastomotic leaks in Group B than Group A,it was statistically insignificant.

Comparison of reverse puncture device and overlap in laparoscopic total gastrectomy for gastric cancer.

Background:Intracorporeal oesophagojejunostomy is one of the key steps in laparoscopic total gastrectomy (LTG). At present, there is no widely accepted anastomosis technique in oesophagojejunostomy.Materials and Methods:We retrospectively studied 63 patients with gastric cancer who underwent LTG. Two types of anastomosis techniques have been applied during LTG: the reverse puncture device (RPD) (28 patients) and overlap (35 patients).Results:A total of 63 patients (51 males and 12 females: mean age = 58 years and mean body mass index [BMI] = 26.3 kg/m2) were enrolled in this study. There were no significant difference in age, BMI, duration of surgery, duration of anastomosis, blood loss, post-operative hospital stay, tumour location, tumour size, degree of tumour differentiation, Borrmann type, total number of lymph nodes, number of positive lymph nodes, hospital stay, hospitalisation costs, intra-operative complications, post-operative complications and prognosis between the RPD group and the overlap group. RPD group showed a significant advantage in terms of the distance between the top border of tumours and the top resection margin (P < 0.001). We further found that the oesophageal lateral negative surgical margin distance of the upper gastric cancer in the RPD group was significantly longer than that in the overlap group (P < 0.001).Conclusions:Both the RPD and overlap techniques are safe and applicable in LTG. However, RPD has the advantage of obtaining an adequate safe margin compared with that of overlap technique, especially in patients with gastro-oesophageal junction carcinoma.

Definition and application of magnetic compression anastomosis

As a new technical discipline, magnetic surgery (MS) has attracted attention of many researchers all over the world for its broad application prospects in the diagnosis and treatment of diseases. MS can be grouped as the following five categories according to different applications and principles: Magnetic compression technique (MCT), magnetic navigation technique (MNT), magnetic anchor technique (MCT), magnetic levitation technique (MLT) and magnetic tracer technique (MTT). Among these techniques, the magnetic compression anastomosis can be used to accomplish certain surgical procedures through the special properties between magnetic materials, such as lumen anastomosis and recanalization, closure of abnormal channels between tissues or organs and restriction anomalous flow of lumen contents. Since being first described in 1978 by Obora, magnetic anastomosis has been initially attempted in treatment of esophageal atresia and diverticula, diversion of gastrointestinal tract, and recanalization of the biliary stricture. Because of the encouraging and broad perspective of magnetic anastomosis in clinical medicine, a new word “magnamosis” has been recommended by Dr. Michael Harrison, one of the leading scientists in this field. Magnetic anastomosis, as an important branch of magnetic compression anastomosis, is essentially a technique that uses magnetic force to transform the lumen anastomosis from the conventional “penetrating” anastomosis to a novel “non-penetrating” anastomosis to greatly simplify the procedure and reduce the rate of postoperative complications. For patients with gastrointestinal lumen occlusion or stenosis, magnetic anastomosis provides a new treatment strategy. This new method can complete the recanalization of digestive tract lumen under intervention method, and avoid major operations, such as laparotomy or thoracotomy. As such, magnetic anastomosis can greatly reduce surgical trauma, as well as incidence of postoperative complications. In addition, magnetic anastomosis can provide treatment options for conditions that cannot be treated with conventional methods, allowing patients to avoid life-long external drainage or fistulas in their lives. More commonly, magnetic anastomosis technology can also be applied to end-to-end, end-to-side, and side-to-side vascular anastomosis. Upon this technique, the time duration of anastomosis can be significantly shortened. Thus, the ischemia and congestion time of target organ can also be shortened, and postoperative complication incidence is significantly reduced. At present, this technique has been successfully applied in coronary and portosystemic bypass surgery, as well as organ transplantation. Surface modification and shape design of magnetic device are two key issues to be considered in magnetic anastomosis technology. The surface modification scheme of the magnetic device mainly depends on the time it remains in the body, while the shape design of the magnetic device mainly depends on the anatomical factors of the lumen to be anastomized, the way of implanting the magnet, and the amount of magnetic force required for the anastomosis. For more than 10 years, we have developed different types of magnets, and performed substantial pre-clinical and clinical studies on utilization of magnetic compression method in vascular, intestines, and biliary lumens connection or anastomosis, demonstrating its safety, which indicates a promising and broad application prospect of magnetic anastomosis. In view of the huge application potential of magnetic anastomosis technology in lumen anastomosis and recanalization, in the future, magnetic anastomosis technology will provide new treatment strategies for other lumen reconstruction (ureteral stenosis, urethral obstruction, etc.).

A prospective comparison of end-to-side and end-to-end renal transplant arterial anastomosis in living donor transplants from an Indian centre

Background: Chronic kidney disease (CKD) is a major epidemic in India today. Renal transplant offers the best quality of life; however, only about 6000 mostly live donor transplants are performed due to socioeconomic hurdles. Live donor transplants involve tenuous (2–6 mm) graft arteries without a cuff; thus meticulous technique is importance. We have prospectively compared graft anastomosis to the external iliac artery end-to-side (EIA ES) with the internal iliac end-to-end (IIA EE) artery. Materials and Methods: This prospective randomized study was conducted in the renal transplant unit of a teaching hospital in north India for over 2 years. After ethics approval and informed consent, patients with donors were randomly divided into two groups using computer-generated tables and the sealed envelope technique; Group 1 underwent EIA ES; Group 2 underwent IIA EE. Donor nephrectomy was by a supra 11th rib flank incision, and triple immunosuppression was used. The vascular techniques were standardized; outcome parameters were the duration of anastomosis and complications, especially delayed graft function. Follow-up was for 3 months. Results: The mean age was 36.85 ± 13.56 and 29.75 ± 8.06 years while female: male ratio of recipients was 3:17 and 6:14 in Groups 1 and 2, respectively. The groups were comparable in venous anastomosis duration, warm ischemia interval, cold ischemia interval and hospital stay, and other complications, but significantly longer arterial anastomosis time was noted in the IIA EE group (P = 0.001). Conclusions: EIA ES took less time than IIA EE, but was equivalent to in most parameters. More data are needed to answer this debate.

Böbrek Naklinde Yeni Bir İnsizyon Metodu: Tek Merkez Deneyimi

Objective: Despite such difficulties and the presence of minimally invasive techniques, open kidney transplant is still a popular method in many clinics worldwide. We tried to identify our incision for kidney transplantation, to present the anatomical limits of the incision and to discuss its advantages-disadvantages. Material and Methods: Patient selection: Ages, number of living donors-cadaver donors, anastomosis durations, operation durations, surgical incision length, surgical site circumference, post-op incisional hernia rate and presence of wound site infection were noted for the 77 patients included. Surgical Technique: After the transverse line drawn at the umbilicus level, a line connecting umbilicus and spina iliaca anterior superior (SIAS) is drawn. The center of the umbilicus-SIAS line is the lateral edge of the rectus abdominis muscle. The endpoint of our incision is 1-2 cm superior to the junction of the tuberculum pubicum with the rectus muscle. Results: Sixty nine of these kidney transplantations (89.6%) were from living and 8 were (10.3%) from cadaver donors. For transplants from a living donor, mean anastomosis duration was 31,8±7.3 min and mean operation duration was 150.6±27 min. For cadaver donors, mean anastomosis duration was 29.6±4.4 min and the mean operation duration was 137±33 min. Post-operative wound site infection was observed in 7 (9.1%) patients in 77 kidney transplantation operations. The postoperative incisional hernia was observed in 7 patients (9.1%). Conclusion: Our incision, named as renal transplantation incision, can reach the surgical site without damaging the anatomic layers and present a quite good view of the surgical site. To provide better evaluation, applications with a higher number of patients are needed.

Outcomes of robot-assisted transperitoneal pyeloplasty: Case series

Aim: Ureteral pelvic junction (UPJ) obstruction, which restricts the passage of urine from the pelvis to the ureter may cause progressive destruction of the kidney if left untreated. Causes of UPJ obstruction include various intrinsic and extrinsic factors. Symptomatic UPJ obstruction should be treated without delay. We herein aimed to present the results of robot-assisted pyeloplasty (RAP) that we performed in our clinic.Methods: Data of 15 patients who underwent RAP between January 2017 and 2019 in our clinic were examined. The diagnosis of ureteropelvic junction obstruction (UPJO) was based on intravenous pyelography (IVP), and diuresis renography (DTPA) was performed during follow-up. Dismembered pyeloplasty was performed on all patients with the DaVinci XI 4-arm robotic system. The results were retrospectively evaluated. Results: The mean age of all patients was 41.3 (8.2) years. There were 7 males and 8 females. None of the cases had previously undergone pyeloplasty. While 6 of the patients had intrinsic obstruction, 9 had extrinsic obstruction associated with aberrant vascular compression. The mean operation time and duration of anastomosis were 155.3 (29.8) and 33.4 (8.1) minutes, respectively. The mean amount of intraoperative bleeding was 48 (10.2) ml. The mean hospital stay was found as 3.6 (1.1) days. There was no conversion to open surgery in any of the patients. None of the patients had intraoperative or postoperative complications. The mean follow-up time was 12.7 (5.4) months. Postoperative IVP and DTPA of all the patients were found to have improved.Conclusion: RAP is a minimally invasive method with successful surgical and functional outcomes in the treatment of UPJO.

Microvascular anastomosis using loupes and smartphone magnification: Experimental study for application to limited-resource environments

Finger revascularization has been performed without a microscope in limited-resource environments only when absolutely necessary. This experimental study sought to assess the feasibility of microvascular anastomosis in rats performed using loupes or smartphone magnification. Thirty rats were divided into three groups of 10 individuals according to the magnification method used: operating microscope (control group M), surgical loupes (group L) and smartphone (group S). The infrarenal aorta was dissected under a microscope, then anastomosed by interrupted sutures using the group-specific magnifying device. The main analytical criteria were vessel diameter, anastomosis duration, immediate flow patency (T0), patency after one hour (T1) and anastomosis quality. Anastomosis duration was comparable between groups M and L, but was twice as long in group S. The number of leaks at clamp removal was higher in group S. Patency rates at T0 and T1 were 100% in groups M and L, but were significantly lower in group S. The anastomosis quality was low in group L and poor in group S. Anastomosis of digital arteries using loupes is possible, but the resulting quality is lower than with a microscope. Current smartphones are not adequate for performslt ing microvascular repairs in a living model.

Laparoscopic pancreaticoduodenectomy: A promising new technique for panreaticojejunostomy using V-Loc suture

Background: Pancreatic fistula rate remains a matter of debate as the most important morbidity after pancreaticoduodenectomy.We have previously described a pancreaticojejunostomy technique using V-Loc suture with promising outcome considering fistula rate.The aim of the present study was to observe whether this new technique,would be feasible and safe during laparoscopic pancreaticoduodenectomy. Methods: Between January 2012-September 2016,39 patients who underwent totally laparoscopic pancreaticoduodenectomy(TLPD) were prospectively included.In all patients, same surgical team performed lateral pancreaticojejunostomy(LPJ) anastomosis using V-Loc suture.Postoperative pancreas fistula(POPF),anastomosis duration,hospital stay, postoperative morbidity and mortality were recorded. POPF was classified up to the international study group definition. Results: There were 22 male and 17 female patients with a mean age of 56 ± 6 (38-76)years.The mean time of surgical procedure and LPJ was 340±36 min(250-385 min) and 36±5 min(30-46 min ),respectively.The number of patients with POPF(12%) were as follows;Grade A:3,GradeB:1,GradeC:1.The rate of overall morbidity was 7.2%(postoperative hemorrhage(n=1) and hepaticojejunostomy stricture(n=1),surgical site infection (n=1),POPF(n=1).There was no 30-d postoperative mortality. Conclusion: This new technique for dunking LPJ anastomosis using V-Loc appears to be remarkably safe and feasible approach to pancreaticojejunostomy without adversely affecting operating time or POPF rate.