Anastomotic Time Research Articles

Feasibility of laparoscopic orthotopic kidney transplantation: Initial research with a pig model

The objective of this study was to investigate the feasibility of laparoscopic orthotopic kidney transplantation. This study involved bilateral laparoscopic nephrectomy in pigs. One of 2 kidneys harvested from the first or second nephrectomy was chosen as the donor kidney to be transplanted to the left or right side in the second nephrectomy position. Eight laparoscopic orthotopic kidney transplantations were performed. The mean venous anastomotic time was 70 minutes (45-108 minutes). The mean arterial anastomotic time was 31 minutes (23-45 minutes). Three pigs received life-supporting auto-renal allografts. Their serum creatinine levels were 163, 285, and 440 µmol/L (baseline: 133 µmol/L), respectively, at postoperative day 7. One died of a possible anesthetic overdose immediately after the operation. Four pigs died at postoperative days 2, 3, 4, and 4. Of 8 completed laparoscopic orthotopic kidney transplantations, 6 had autopsy-proven reliable artery and vein anastomoses. Histopathologic examination of the autografts demonstrated normal renal architecture in 1 survival, and acute tubular necrosis in the remaining 7 (stenosis in one and arterial thrombus in another). Our study reinforces the feasibility of laparoscopic orthotopic kidney transplantation in pigs. This study comprised only initial practices; further practice is needed to refine the surgical procedures and decrease surgical complications in laparoscopic orthotopic kidney transplantation.

Investigations of a Thermosensitive Gel to Temporarily Occlude Crural Arteries in Femoro-distal Bypass Surgery

Objectives: Long occlusions in calcified crural arteries are a major cause of endovascular technical failure in patients with critical limb ischaemia. Therefore, distal bypasses are mainly performed in patients with heavily calcified arteries and with consequently delicate clamping. A new reverse thermosensitive polymer (RTP) is an alternative option to occlude target vessels. The aim of the study is to report our technical experience with RTP and to assess its safety and efficiency to temporarily occlude small calcified arteries during anastomosis time. Methods: Between July 2010 and December 2011, we used RTP to occlude crural arteries in 20 consecutive patients with 20 venous distal bypasses. We recorded several operative parameters, such as volume of injected RTP, duration of occlusion and anastomotic time. Quality of occlusion was subjectively evaluated. Routine on-table angiography was performed to search for plug emboli. Primary patency, limb salvage and survival rates were reported at 6 months. Results: In all patients, crural artery occlusion was achieved with the RTP without the use of an adjunct occlusion device. Mean volume of RTP used was 0.3 ml proximally and 0.25 ml distally. Mean duration of occlusion was 14.4 ± 4.5 min, while completion of the distal anastomosis lasted 13.4 ± 4.3 min. Quality of occlusion was judged as excellent in eight cases and good in 12 cases. Residual plugs were observed in two patients and removed with an embolectomy catheter, before we amended the technique for dissolution of RTP. At 6 months, primary patency rate was 75% but limb salvage rate was 87.5%. The 30-day mortality rate was 10%. Conclusions: This study shows that RTP is safe when properly dissolved and effective to occlude small calcified arteries for completion of distal anastomosis.

Investigations of a Thermosensitive Gel to Temporarily Occlude Crural Arteries in Femoro-distal Bypass Surgery

ObjectivesLong occlusions in calcified crural arteries are a major cause of endovascular technical failure in patients with critical limb ischaemia. Therefore, distal bypasses are mainly performed in patients with heavily calcified arteries and with consequently delicate clamping. A new reverse thermosensitive polymer (RTP) is an alternative option to occlude target vessels. The aim of the study is to report our technical experience with RTP and to assess its safety and efficiency to temporarily occlude small calcified arteries during anastomosis time. MethodsBetween July 2010 and December 2011, we used RTP to occlude crural arteries in 20 consecutive patients with 20 venous distal bypasses. We recorded several operative parameters, such as volume of injected RTP, duration of occlusion and anastomotic time. Quality of occlusion was subjectively evaluated. Routine on-table angiography was performed to search for plug emboli. Primary patency, limb salvage and survival rates were reported at 6 months. ResultsIn all patients, crural artery occlusion was achieved with the RTP without the use of an adjunct occlusion device. Mean volume of RTP used was 0.3 ml proximally and 0.25 ml distally. Mean duration of occlusion was 14.4 ± 4.5 min, while completion of the distal anastomosis lasted 13.4 ± 4.3 min. Quality of occlusion was judged as excellent in eight cases and good in 12 cases. Residual plugs were observed in two patients and removed with an embolectomy catheter, before we amended the technique for dissolution of RTP. At 6 months, primary patency rate was 75% but limb salvage rate was 87.5%. The 30-day mortality rate was 10%. ConclusionsThis study shows that RTP is safe when properly dissolved and effective to occlude small calcified arteries for completion of distal anastomosis.

HLA-C and HLA-DQ and Renal Transplantation

Background: HLA-A, -B and DR compatibility has long been considered pivotal to successful outcomes in kidney transplantation. There is however a difference of 21% in 10-year survival between best and worst match categories, which would suggest other immunological differences such as HLA-C compatibility may contribute. This study assesses the effects of HLA-C and HLA-DQ on clinical outcomes in renal transplantation. Methods: Demographic, clinical and biochemical data for kidney transplant carried out from January 2007 to April 2010 in a regional renal transplant unit, were collected prospectively in an electronic database. HLA-C and HLA-DQ matched were compared with their mismatch counterparts for outcomes of cytomegalovirus infection, delayed graft function, acute rejection, 1-year graft function/survival, and overall patient survival. Comparison analysis was performed using statistical programme SPSS. Linear regression analysis was also carried-out to include other potential confounding factors. Results: 287 renal transplantations occurred during the study period, with 202 deceased-donor kidneys and 85 living-donor kidneys. Deceased donors were aged 3 - 78 (mean 47), while live donors were aged 21 - 77 (mean 46).Table: [Outcome in deceased and live kidney recipients]There were however, insignificant differences in all outcomes between HLA-C/DQ matched and mismatched groups. All factors in combination do affect the outcome of 1-year creatinine and eGFR on linear regression analysis, however only donor age, cold ischaemic and anastomotic times have statistically significant individual impact. Also, when KIR-1 and KIR-2 ligands were looked at separately, KIR-2 compatibility was found to affect the outcome of 1-year creatinine/eGFR (Mann-Whitney U test) with p0.096/0.072 and p0.033/0.003 for deceased and living groups respectively. Conclusion: Many studies have shown a relationship between HLA- C and short-term graft function. Our results however failed to demonstrate this, although KIR-2 seems to have an effect on 1-year graft function especially in living grafts. This could be due to our relatively small sample size. When compared to the sample size of multicentre trials. Continued study to increase our patient sample size and to assess their 5-year graft survival outcome will be carried out.

A Step toward Nonrobotic Total Endoscopic Coronary Bypass Grafting: 40 Coronary Anastomoses in a Biomechanical Beating Heart Model

Nonrobotic total endoscopic coronary bypass grafting is commonly considered as technically too difficult. After endoscopic practicing in a simple box model, we questioned this statement in a more sophisticated training model. In a handmade chest model containing a mechanically actuated porcine heart, anastomoses between homologous vein and shunted anterior coronary artery were performed using Prolene 7-0 sutures or U-clips in 20 anastomoses each. Commercially available endoscopic instruments and exclusive two-dimensional endoscopic vision were used. As quality control, the procedures were recorded, flow was measured, indocyanine green dye angiograms were performed, vinylpolysiloxane endocasts were produced, and finally the anastomoses were assessed from the endothelial side. Three-dimensional computed tomographic reconstruction was explored for cast measuring. All anastomoses were completed successfully in a time of 51 ± 14 minutes (Prolene) and 48 ± 10 minutes (U-clips). Despite suboptimal equipment, a reproducible sequence of the procedure was established and documented. Improving surgical performance was reflected in a reduction in anastomotic leakage and time requirement. The quality assessment protocol showed a learning curve and problems itself, which are briefly discussed. A beating heart model is an adamant requirement of training for the technically demanding procedure of nonrobotic total endoscopic coronary bypass grafting. Refinement of the model and quality assessment as well as expansion of training to other regions of the heart should prepare for a cost-effective, broad-based clinical application of nonrobotic endoscopic techniques in coronary surgery. Available high-definition three-dimensional vision systems and the development of appropriate (articulating) instruments will make the procedure safer and quicker and will cut the learning curve.

Comparison of 2 Devices in Pigs To Induce Hypothermia in Laparoscopic Orthotopic Kidney Transplant

To laparoscopically compare the effectiveness of 2 cooling devices for renal hypothermia and investigate the feasibility of laparoscopic orthotopic kidney transplant using a pig model. Eight pigs were divided into 2 groups of 4 animals each. Laparoscopic nephrectomy and autotransplant were performed first on only the right kidney. One week later, these procedures were performed on the left kidney, while the first transplanted autograft was removed. After 1 more week, the left autograft was removed for observation. In 1 group, the silicon tube cage was used to induce hypothermia during laparoscopic orthotopic kidney transplant (silicon tube cage group), and in the other group, the plastic bag jacket was used to induce hypothermia during laparoscopic orthotopic kidney transplant (plastic bag jacket group). Two pigs in the silicon tube cage group survived for 7 days after the second autotransplant with serum creatinine levels of 210 μmol/L and 1010 μmol/L. One pig in the plastic bag jacket group survived for 5 days. The mean surface temperature of the grafts was maintained at 9°C ± 3°C and 12°C ± 3°C in the silicon tube cage and plastic bag jacket groups (P = .166). Three of 6 plastic bag jacket devices were ruptured by stitches or instruments. The mean venous and arterial anastomotic times in the silicon tube cage group were significantly shorter than were those in the plastic bag jacket group. Our study shows that the silicon tube cage may be a reliable renal cooling device for use in laparoscopic kidney transplant and indicates the feasibility of laparoscopic orthotopic kidney transplant in pigs.

851 A NEW PLATFORM IMPROVING ERGONOMY OF LAPAROSCOPIC SURGERY: EXPERIMENTAL STUDIES AND INITIAL CLINICAL EVALUATION

INTRODUCTION AND OBJECTIVES: Distribution of laparoscopic surgery is handicapped due to significant ergonomic limitations. We want to present experimental and clinical evaluation of a new operating chair used as a platform for laparoscopic surgery. METHODS: The surgical chair (ETHOS-platform) consists of a saddle-like seat, an adjustable chest-support, two individually adjustable armrests, and footrests. We compared suturing standing laterally to pelvi-trainer (“Torero-position”) versus standing behind pelvi-trainer and sitting on ETHOS. Every participant and surgeon (N 18) filled out a questionnaire focusing on ergonomic issues. Since August 2010, we performed 164 laparoscopic and retroperitoneoscopic procedures using ETHOS involving four different surgeons. Two frequent procedures (radical prostatectomy, pyeloplasty) underwent detailed comparison to matched-paired patients from our laparoscopic database. RESULTS: Ex-vivo, there was no significant different anastomotic time standing behind pelvi-trainer and sitting on ETHOS; the difference became significant compared to Torero-position mimicking clinical scenario (44.4 vs. 37.6 minutes). Independent from laparoscopic experience and workload complaints (total score) were significantly less with ETHOS-assistance (31.6 vs. 13.9). In-vivo comparison did not show different OR-times, but revealed statistically significant differences with respect to anastomotic times of ETHOS and DaVinci (23 vs. 19 vs. 19 minutes). CONCLUSIONS: Ergonomics of laparoscopy may be significantly improved by new platforms supporting the sitting position of the surgeon with armrests and integrated foot pedals.

Extending Anatomic Barriers to Right Laparoscopic Live Donor Nephrectomy

To analyze the effects of a right-sided-complex laparoscopic live donor nephrectomy, defined as bifurcation of the right renal artery behind the inferior vena cava. Right-sided laparoscopic live donor nephrectomy is now a widely accepted procedure when complex anatomy is encountered on the left. The present retrospective case note review involved 59 of 303 laparoscopic live donor nephrectomy procedures performed in a single center from January 2001 to April 2010 (group 1, simple, n=48; and group 2, complex, n=11). The effect of a donor right procedure on warm ischemia, graft function, and donor/recipient complications was analyzed. No difference in donor or recipient age or first and second warm ischemic times was found between the 2 groups. No difference was found in the estimated glomerular filtration rate or serum creatinine at 1 week and 3 and 6 months [estimated glomerular filtration rate (6/12), 49±15 vs 60±9 mL/min, P=.087; and serum creatinine (6 months), 159±116 vs 120±25 μmol/L; P=.356]. No cases of delayed graft function were reported, and none of the grafts developed vascular thrombosis. The cumulative estimated glomerular filtration rate at 6/12 was 51±15 mL/min and the serum creatinine was 153±108 μmol/L. Two patients (4%) required conversion to open surgery in group 1, and the cumulative conversion rate was 3.3%. In the complex group with retrocaval dissection, 8 kidneys were retrieved with a single artery and 3 had multiple vessels (2 with 2 vessels and 1 with 3 vessels; anastomotic time 26±6 minutes). Complex vasculature in a right-sided donation should not be considered a contraindication, because the kidneys procured had excellent function compared with those with single vasculature with no increase in the conversion or vascular thrombosis rate. In addition, the described techniques permit improved arterial length and, importantly, organs procured with a single artery.

Mouse model of orthotopic small bowel transplantation.

To investigate the surgical procedures of orthotopic small bowel transplantation (SBT) model in mice to study the function and rejection of SBT. We established a mouse SBT allograft model as follows: the donor portal vein was anastomosed end by side with the recipient inferior vena cava; the donor superior mesenteric artery with aorta patch was anastomosed end by side with recipient abdominal aorta. After an appropriate length of the recipient's small bowel was removed, the donor's small bowel and the recipient's small bowel were end-to-end anastomosed discontinuously. The mice were fasted for 4 d after the operation, free access to water and subcutaneously injection of 2 mL of 5% glucose saline twice daily. Operation success was regarded as survival for more than 5 d. There is no antibiotic and immunosuppressor. A total of 30 transplantations were done, the 5 d survival rate was 60% (18/30), and 12 died within 5 d. Among the dead recipients, 5 died of arterial anastomotic stenosis and anastomotic thrombosis, 2 of hemorrhagic shock caused by anastomotic bleeding, and the other 5 of intra-abdominal infection caused by postoperative intestinal fistula. The donors' operative time was (40 ± 4.5) min, warm ischemia time was about 0.5 min, donor preparation time was about 3 min, and cold preservation time was (30 ± 7.5) min. The recipients' operative time was (95 ± 8.0) min, among which, the abdominal aorta and inferior vena cava clamping time was (38 ± 3.5) min, the venous anastomotic time was (10 ± 2.0) min and the arterial anastomotic time was (15 ± 3.0) min. The mean intra-operative blood loss of the surviving recipient mice was about 0.2 mL. High quality vascular anastomosis, and rehydration of donors and recipients are crucial factors for improving the success rate of SBT.

Randomized Clinical Trial Comparing a Thermosensitive Polymer (LeGoo) With Conventional Vessel Loops for Temporary Coronary Artery Occlusion During Off-Pump Coronary Artery Bypass Surgery

During off-pump coronary artery bypass graft (OPCABG) surgery, a bloodless surgical field is mandatory for visualization and construction of optimal coronary anastomoses. Presently used temporary vascular occluders are known to cause endothelial dysfunction and vessel injury. The present prospective multicenter randomized clinical trial evaluates safety and efficacy of a novel thermosensitive polymer (LeGoo) as an atraumatic temporary vascular occluder. Between July 2008 and February 2010, 110 patients undergoing OPCABG were randomized between LeGoo (LG) and conventional vessel loops (VL) for coronary artery occlusion during construction of the distal anastomosis. A semiquantitative 4-point scale was used to evaluate the degree of bloodless surgical field and surgical comfort. Duration of coronary artery occlusion was also recorded. Safety during the operation and ensuing 30 days was evaluated by a composite endpoint of major adverse cardiac events that consisted of death from all causes, graft occlusion, myocardial infarction, and low cardiac output. Fifty-six patients (117 distal anastomoses) were randomly assigned to LG and 54 patients (122 anastomoses) to VL. There were 2 anastomoses crossed over from LG to the control arm, and 3 from control to LG. Five anastomoses in LG patients were treated with an alternative device (shunts). Satisfactory hemostasis was achieved in 88.0% of LG anastomoses (103 of 117) compared with 60.7% of VL anastomoses (74 of 122; p < 0.001). Mean total anastomotic time was 12.8 minutes in the LG group and 15.1 minutes in the VL group (p < 0.001). This difference was more pronounced for arteries on the posterior and lateral than on the anterior walls of the heart. Composite adverse events were similar in the two groups: 3 of 48 LG patients and 3 of 46 VL patients. There was 1 death in the LG group. One patient in the LG group and 1 in the VL arm had a myocardial infarction. No operation was converted from OPCABG to CABG with cardiopulmonary bypass. LeGoo is a safe and effective temporary coronary occluder during OPCABG. It provided a dry surgical field for visualization of the anastomotic field and surgical comfort more frequently than conventional vessel loops. In addition, anastomotic times were shorter with LG. Major cardiac adverse events were similar in the LG and VL arms.

Stapled versus handsewn methods for ileocolic anastomoses

Ileocolic anastomoses are commonly performed for right-sided colon cancer and Crohn's disease. The anastomosis may be constructed using a linear cutter stapler or by suturing. Individual trials comparing stapled versus handsewn ileocolic anastomoses have found little difference in the complication rate but they have lacked adequate power to detect potential small difference. This is an update of a Cochrane review first published in 2007. To compare outcomes of ileocolic anastomoses performed using stapling and handsewn techniques. The hypothesis tested was that the stapling technique is associated with fewer complications. MEDLINE, EMBASE, Cochrane Colorectal Cancer Group specialised register SR-COLOCA, Cochrane Library were searched for randomised controlled trials comparing use of a linear cuter stapler with any type of suturing technique for ileocolic anastomoses in adults from 1970 to 2005 and were updated in December 2010. Abstracts presented to the following society meetings between 1970 and 2010 were handsearched: American Society of Colon and Rectal Surgeons, the Association of Coloproctology of Great Britain and Ireland, European Association of Coloproctology. Randomised controlled trials comparing use of linear cutter stapler (isoperistaltic side to side or functional end to end) with any type of suturing technique in adults. Eligible studies were selected and their methodological quality assessed. Relevant results were extracted and missing data sought from the authors. RevMan 5 was used to perform meta-analysis when there were sufficient data. Sub-group analyses for cancer inflammatory bowel disease as indication for ileocolic anastomoses were performed. After obtaining individual data from authors for studies that include other anastomoses, seven trials (including one unpublished) with 1125 ileocolic participants (441 stapled, 684 handsewn) were included. The five largest trials had adequate allocation concealment.Stapled anastomosis was associated with significantly fewer anastomotic leaks compared with handsewn (S=11/441, HS=42/684, OR 0.48 [0.24, 0.95] p=0.03). One study performed routine radiology to detect asymptomatic leaks. For the sub-group of 825 cancer patients in four studies, stapled anastomosis led to significantly fewer anastomotic leaks (S=4/300, HS=35/525, OR 0.28 [0.10, 0.75] p=0.01). In subgroup analysis of non-cancer patients (3 studies, 264 patients) there were no differences for any reported outcomes. All other outcomes: stricture, anastomotic haemorrhage, anastomotic time, re-operation, mortality, intra-abdominal abscess, wound infection, length of stay, showed no significant difference. Stapled functional end to end ileocolic anastomosis is associated with fewer leaks than handsewn anastomosis.

Comparison of Two Different Suture Methods in Laparoscopic Dismembered Pyeloplasty

Objective: Anastomosis of ureteropelvic junction with a laparoscope for the treatment of ureteropelvic junction obstruction (UPJO) is a time-consuming and technically challenging procedure. We present our experience of laparoscopic dismembered pyeloplasty and compare clinical outcomes of two different suture techniques. Methods: From September 2003 to June 2010, 105 laparoscopic dismembered pyeloplasties were performed in our department. All procedures were done using the retroperitoneal approach. According to the suture methods (interrupted or running), the patients were divided into two groups. An indwelling stent was placed intraoperatively in an antegrade manner. Data on operation time, blood loss and complications were collected. Results: All procedures were completed without open conversion. Mean operation time and anastomotic time were 96 (55–150) and 36 min (15–70), respectively. A significant decrease of operation and anastomosis time was seen when running sutures were applied. Mean blood loss was 54 ml (30–100). The total complication rate was 7.6%. No anastomotic stricture occurred. The average hospitalization stay was 7 days. During 5–85 months of follow-up, hydronephrosis was alleviated in all cases. Conclusions: Laparoscopic dismembered pyeloplasty for the treatment of UPJO can provide satisfactory clinical outcomes. Higher surgical efficiency and lower complication rates can be obtained by using the running suture method.

Urethrovesical Anastomosis Using Barbed Suture During Robot-Assisted Radical Prostatectomy

Introduction and Objectives: Barbed polyglyconate suture (V-Loc®; Covidien, Mansfield, Massachusetts) was first used for the urethrovesical anastomosis (UVA) during robot-assisted radical prostatectomy (RARP) beginning January 2010. Safety and feasibility were previously demonstrated in 51 patients.1 In this video, we demonstrate the technique of urethrovesical anastomosis with barbed suture and the results of a randomized, controlled trial assessing perioperative and functional outcomes after urethrovesical anastomosis with barbed polyglyconate versus monofilament poliglecaprone in RARP. Methods: After institutional review board approval, 64 patients meeting all inclusion criteria participated in this multi-surgeon prospective, randomized, controlled trial between May and September 2010. Posterior repair and urethrovesical anastomosis during RARP were performed with barbed polyglyconate (n = 33) or monofilament poliglecaprone (n = 31) suture. Primary outcomes were anastomotic (UVA) and posterior reconstruction time. Secondary outcomes included cystogram leak, bladder neck reconstruction rate, and 6-week functional outcomes assessed by patient-administered questionnaire. Results: Posterior reconstruction was performed in 3.3 minutes versus 4.3 minutes (a 23.3% reduction), and UVA was performed in 10.1 minutes versus 13.8 minutes (a 26.8% reduction). The absolute time difference for the two-layer anastomosis was 4.7 minutes. All other perioperative outcomes were equivalent between groups. Patient urinary functional outcomes, including pad usage and leakage rates, were equivalent at 6 weeks. Conclusions: Anastomosis during RARP with barbed polyglyconate suture can be performed safely and more efficiently than with standard monofilament suture. We demonstrated a 25% decrease in anastomotic time with no increase in adverse events, no instances of urinary retention, and equivalent functional outcomes measured by the patient-administered questionnaire. No competing financial interests exist. Runtime of video: 8 mins 22 secs

Anastomosis During Robot-assisted Radical Prostatectomy: Randomized Controlled Trial Comparing Barbed and Standard Monofilament Suture

To compare perioperative and functional outcomes after urethrovesical anastomosis (UVA) with barbed polyglyconate and monofilament poliglecaprone in robot-assisted radical prostatectomy (RARP). Barbed polyglyconate suture was first used for the UVA during RARP beginning in January 2010; safety and feasibility were previously demonstrated in 51 patients. From May to September 2010, 64 patients meeting all the inclusion criteria participated in the present multisurgeon prospective, randomized, controlled trial and underwent posterior repair and UVA during RARP with either barbed polyglyconate (n=33) or monofilament poliglecaprone (n=31) suture. The primary outcomes were the anastomotic (UVA) and posterior reconstruction times. Secondary outcomes included cystogram leak, bladder neck reconstruction rate, and 6-week functional outcomes assessed by a self-administered validated patient questionnaire. Posterior reconstruction was performed within 3.3 minutes with the barbed suture versus 4.3 minutes with the monofilament poliglecaprone suture (23.3% reduction) and UVA within 10.1 versus 13.8 minutes, respectively (26.8% reduction). The absolute time difference for the 2-layer anastomosis was 4.7 minutes (a 26.0% reduction in the total anastomosis time). All other perioperative outcomes were equivalent between the 2 groups. Urinary functional outcomes, including the pad use and leakage rates, were equivalent at 6 weeks. Anastomosis during RARP with the V-Loc barbed suture can be performed safely and more efficiently than with standard monofilament suture. We demonstrated a 26% decrease in the anastomotic time with no increase in the adverse events, no instances of urinary retention and equivalent functional outcomes were measured with the self-administered patient questionnaire.

Exploration of the Intravascular Stenting Method for Sub 1-mm Vessels

The intravascular stenting (IVaS) method was published by Narushima and Koshima in 2008. This method involves using a monofilament nylon stent to make the anastomosis of small vessels easier. The aim of this study was to explore the IVaS technique to determine its advantages, disadvantages, and usefulness for inexperienced microsurgeons and also for more experienced practitioners during difficult anastomoses. The study was approved by the Catholic University of Louvain Animal Experimentation Ethics Committee. The study was done on 20 Wistar rats; each rat acting as his own control. Group 1 had an anastomosis done with the IVaS technique on the femoral artery. Group 2 had a classic end-to-end anastomosis without a stent. All anastomoses were performed by the same trainee surgeon with 4 months experience in microsurgery. The diameter of the external artery, distance between the double clamp forceps, stent length, number of sutures, stent preparation, and installation time and suture time were all measured. Anastomotic patency was verified using O'Brien's Patency test. The rats were anesthetized 1 week later to reassess the patency of the vessels. While the anastomotic time was shorter in the stent group, the preparation time was longer and so the total time to perform the anastomosis in both groups was the same. All vessels were patent at the completion of the anastomosis. At 1 week, patency rates were identical (83.3%) in both groups. The study shows an improvement in suturing time in the IVaS group. The time saved is equivalent to the time required for preparation and installation of the stent. At 7 days, the Patency test was identical for the two groups (83.3%). IVaS technique is a useful method of vessels anastomosis especially for junior surgeons. The reason why the patency rate was not 100% at 1 week may be because of excessive manipulation of the stent causing thrombosis in the IVaS group and imperfections in suturing technique by a trainee surgeon. Different aspects of the method are open for discussion such as consideration of the stent size and execution of the anastomosis. The IVaS technique helps in the execution of anastomosis in microsurgery and allows for more precise suturing. Care, however, must be taken in its execution and manipulation so as to avoid any lesions of the intima of the vessels.

Use of a Novel Absorbable Barbed Plastic Surgical Suture Enables a “Self-Cinching” Technique of Vesicourethral Anastomosis During Robot-Assisted Prostatectomy and Improves Anastomotic Times

To demonstrate a novel technique of self-cinching anastomosis using a barbed and looped suture during robot-assisted radical prostatectomy (RARP). This is a feasibility study of 50 consecutive patients who underwent this novel self-cinching anastomotic technique using a V-Loc™ 180 absorbable barbed suture after RARP for clinically localized prostate cancer. The results were then compared with 50 consecutive patients who underwent RARP by the same surgeon before this new technique. We examined whether this novel technique had any effects on posterior reconstruction time, vesicourethral anastomosis time, and thus total reconstruction and operative time by inference. The V-Loc 180 group had significantly shorter posterior reconstruction (40 seconds vs 60 seconds; P ≤ 0.001) and vesicourethral anastomotic times (7 min vs 12 min; P ≤ 0.001). By inference, this meant that total reconstruction and operative times were also significantly less (8 minutes vs 13.5 min; P ≤ 0.001 and 106 min vs 114.5 minutes; P ≤ 0.001, respectively). We have shown that this technique is feasible and improves posterior reconstruction and anastomotic times. Further follow-up will determine any benefits of this technique on anastomotic urinary leak rates, continence, and catheter removal times.

Robot-Assisted Pyeloplasty: Follow-Up of First Canadian Experience with Comparison of Outcomes Between Experienced and Trainee Surgeons

Robot-assisted pyeloplasty (RAP) has been established recently as an option in the management of ureteropelvic junction obstruction (UPJO). We present the first Canadian experience with RAP with respect to operative results and outcomes. We compare the surgical outcomes between experienced and trainee surgeons, with respect to operating room times and success rates. Eighty-eight patients underwent transperitoneal RAP for UPJO using the da Vinci robotic platform. Two surgeons performed Anderson-Hynes dismembered pyeloplasty in 85 cases and YV-plasty in 5 cases. Five patients had RAP for secondary UPJO after failure of other treatments. Diuretic renography was performed at 6 weeks, and 6, 12, 18, 24, and 36 months postpyeloplasty. The mean follow-up was 14.1 ± 8.5 months. The mean operative time was 167.7 ± 43.2 minutes, and the mean anastomotic time was 41.9 ± 14.1 minutes. The mean operative duration significantly decreased with time (P < 0.05). Ten patients needed simultaneous nephroscopic stone management via the pyelotomy incision. The mean blood loss was 56.6 ± 55.4 mL, and the mean hospital stay was 2.5 ± 0.5 days. There were five major postoperative (stent migration, urinoma) and three minor complications that were associated with the RAP procedures. Postoperative renal scintigraphy demonstrated only four cases with persistent obstruction. Eighty-three (94.3%) patients experienced improvement of symptoms whereas 5 continued to be symptomatic. Two patients needed secondary procedures to relieve persisting obstruction. There were no statistical differences in outcomes between the experienced surgeons and trainees (P = 0.28). In the first large case series of RAP from Canada, we demonstrate that RAP can be performed with relatively short operative times and is safe and effective, achieving similar long-term results with standard open repair. We show that robot-assisted surgery can be safely transitioned to surgical trainees. With its cost and availability, its role in the Canadian system needs further study.

Modern adjuncts and technologies in microsurgery: An historical and evidence‐based review

While modern reconstructive surgery was revolutionized with the introduction of microsurgical techniques, microsurgery itself has seen the introduction of a range of technological aids and modern techniques aiming to improve dissection times, anastomotic times, and overall outcomes. These include improved preoperative planning, anastomotic aides, and earlier detection of complications with higher salvage rates. Despite the potential for substantial impact, many of these techniques have been evaluated in a limited fashion, and the evidence for each has not been universally explored. The purpose of this review was to establish and quantify the evidence for each technique. A search of relevant medical databases was performed to identify literature providing evidence for each technology. Levels of evidence were thus accumulated and applied to each technique. There is a relative paucity of evidence for many of the more recent technologies described in the field of microsurgery, with no randomized controlled trials, and most studies in the field comprising case series only. Current evidence-based suggestions include the use of computed tomographic angiography (CTA) for the preoperative planning of perforator flaps, the intraoperative use of a mechanical anastomotic coupling aide (particularly the Unilink® coupler), and postoperative flap monitoring with strict protocols using clinical bedside monitoring and/or the implantable Doppler probe. Despite the breadth of technologies introduced into the field of microsurgery, there is substantial variation in the degree of evidence presented for each, suggesting the role for much future research, particularly from emerging technologies such as robotics and modern simulators.

Bioabsorbable device for small‐caliber vessel anastomosis

Although the devices for large-caliber vessel (>2-mm diameter) anastomosis are available, there are no devices for performing anastomosis of small-caliber vessels. We designed a hooked device composed of a bioabsorbable polymer for sutureless anastomosis of small-caliber vessels. The efficacy of this device was evaluated by in vitro degradation and arterial-fixation strength tests as well as in vivo transplantation experiments with common carotid arteries of growing SD rats. A nonabsorbable device without hooks served as the control in the fixation strength and animal experiments. The tensile strength of the bioabsorbable device decreased to 27 and 9% of the initial value after 8- and 24-week incubation, respectively. The fixation strength was greater and the anastomotic time was shorter with this device than with the control. The transplantation experiments showed complete endothelial bridging in both devices at 2 weeks after surgery (n = 6). The control device created a considerable protrusion into the arterial lumen at 8 postoperative weeks, whereas the experimental device did not (n = 6). Arterial diameter measurements detected a significant difference between the inner diameters at the respective anastomotic sites (n = 6, P < 0.05) and demonstrated that the control device hindered the vessel growth while the experimental device did not. Therefore, the bioabsorbable hooked device was an effective tool for anastomosis of small-caliber arteries (ca. 1-mm diameter).

Delta-Shaped Gastroduodenostomy after Totally Laparoscopic Distal Gastrectomy: A Comparison Analysis between Early and Late Experience

Purpose: We conducted this study to evaluate the feasibility and the safety of a delta-shaped gastroduodenostomy after totally laparoscopic distal gastrectomy (TLDG) and to know about the factors having influence on surgeons’ performance of anastomosis and technical details of this operation. Methods: The clinical characteristics and the surgical results of 57 consecutive patients with delta-shaped gastroduodenostomy after TLDG at Incheon St. Mary’s Hospital were reviewed. The patients were divided into 2 groups (before and after 20 cases) and their clinical characteristics and surgical results were compared. The factors which influenced the anastomotic time and the technical details of the operation were also investigated. Results: There was no difference in age, gender, body mass index, surgical results except for operation time, anastomotic time, and starting day of oral feeding between the 2 groups. The experience of the surgeon was the only factor that influenced the anastomotic time. Conclusion: Delta-shaped gastroduodenostomy is a feasible and safe procedure even in the early years of a surgeon’s career. It could feasibly be done in less than 20 minutes in relatively experienced hands. (J Korean Surg Soc 2010;79:110-115)