Bipolar Scissors Research Articles

BipoJet Scissors as an Alternative to Laser in Lung Wedge Resection.

An important goal in every lung resection is airtight closure of the resected lung surface. This can be achieved with several techniques, including clamp resection, stapler, laser, and various high-frequency methods.By quantitatively measuring the air fistulaacross the resection surface of porcine lungs, two resection techniques were compared in our study: BipoJet dissecting scissors (Aesculap, Inc., Tuttlingen,Germany) and laser (Ceralas HPD®, Biolitec Inc., Jena, Germany). Following a stencil, wedge resections were performed in porcine lungs using water-irrigated bipolar scissors and laser (1350nm, 40watts, non-contact mode). The volumeof the air fistula was then measured. The irrigation technique involved the attachment of an irrigation channel to a pair of standard surgical scissors. Asodium chloride (NaCl) solution was fed at a defined flow rate, along the blades of the scissors onto the parenchyma. This technique was used on a total of 10 specimens each. Somewhat better pneumostasis was achieved with laser resection, though the difference was small and not statistically significant. The flow rate was 124mL/min/cm² after laser resection and 145 mL/min/cm² after using the BipoJet scissors. The difference was not statistically significant.Water irrigation during resection with the BipoJet scissors prevents the temperature in the tissue from exceeding 100°Cthus avoiding tissue carbonization. These scissors offer the following advantages: ease of use, no need to change instruments, no need for staff training, no protective measures, all-in-one incision/coagulation/dissection, low cost, and a clear surgical field due to the irrigation effect. Resection of lung parenchyma, e.g., during resection of metastases, is easier with BipoJet scissors and comparable to laser resection. This was established both experimentally and by resecting lung metastases.

Tonsillitis Index: Classification, Epidemiology, Prevention of Tonsillitis and Different Tonsillectomy Techniques for Recurrent Acute Tonsillitis

Tonsils function as a defense system and aid in keeping your body free of infections. About 5% to 40% of cases of tonsillitis are caused by bacterial infection, which is the most frequent cause of the condition. There are several different forms of tonsillitis, including viral tonsillitis and bacterial tonsillitis, which is brought on by bacteria like streptococcal pharyngitis. Tonsil redness and swelling are its symptoms. Tonsils that are covered in white or yellow patches or have a sore throat, swallowing problems, fever, swollen tonsils, etc. There are just a few treatment options, including surgery to remove the tonsils, medication such NASIDs and antibiotics, and home remedies. A tonsillectomy is a surgical procedure that totally removes the tonsil. Different methods are used to accomplish it. Any method of tonsillectomy is acceptable as long as the crypts are kept open and some tonsil tissue is left behind, including laser, radiofrequency, shaver, coblation, bipolar scissor, and Colorado needle. Even the finest surgeon will have a postoperative haemorrhage because bleeding is a possibility with all surgical methods. After cold dissection with ligature or suturing, there is the least chance of haemorrhage. A increased risk of late bleeding exists with all "hot" procedures using laser, radiofrequency, coblation, mono- or bipolar forceps. In seriously afflicted infants with recurrent tonsillitis, an antibiotic allergy, PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis), and peritonsillar abscess, total extracapsular tonsillectomy is still advised. It affects the patients' immunity.

Safety Parameters of Quantum Molecular Resonance Devices During Thyroid Surgery: Porcine Model Using Continuous Neuromonitoring.

ObjectivesQuantum molecular resonance (QMR) devices have been applied as energy-based devices in many head and neck surgeries; however, research on their use in thyroid surgery is lacking. This study aimed to investigate the safety parameters of QMR devices during thyroidectomy when dissection was adjacent to the recurrent laryngeal nerve (RLN).MethodsThis study included eight piglets with 16 RLNs, and real-time electromyography (EMG) signals were obtained from continuous intraoperative neuromonitoring (C-IONM). QMR bipolar scissor (BS) and monopolar unit (MU) were tested for safety parameters. In the activation study, QMR devices were activated at varying distances from the RLN. In the cooling study, QMR devices were cooled for varying time intervals, with or without muscle touch maneuver (MTM) before contacting with the RLN.ResultsIn the activation study, no adverse EMG change occurred when QMR BS and MU were activated at distances of 2 mm or longer from the RLNs. In the cooling study, no adverse EMG change occurred when QMR BS and MU were cooled in 2-second intervals or immediately after MTM.ConclusionQMR devices should be carefully used when performing RLN dissection during thyroid surgery. According to the activation and cooling safety parameters in this study, surgeons can avoid RLN injury by following standard procedures when using QMR devices.

Laparoscopic Heminephrectomy in Horseshoe kidney: single-center experience of four cases

BackgroundHorseshoe kidney (HSK) is the most common congenital fusion anomaly and found in 1 in 400 of the general population (Grainger et al. in Ir Med J 76:315–317, 1983 Jul). Impaired drainage due to anomalous anatomy leads to ureteric obstruction resulting in hydronephrosis and nonfunctioning kidney.Conventionally heminephrectomy is done by open technique; however, in the era of minimally invasive surgery, laparoscopic heminephrectomy in HSK has been described. Kidney location, aberrant vasculature and isthmus division are the most common obstacle encountered by the operating surgeon. Here we report our single-center experience in laparoscopic heminephrectomy in four patients with HSK.MethodsRetrospective data were analyzed for four cases of laparoscopic heminephrectomy for nonfunctioning moiety in HSK operated between 2012 and 2020. Of these four patients, one case was converted to open approach in view of intra-operative bleeding. Computed tomography urogram (CTU) was done pre-operatively in all patients. Laparoscopic surgery was performed via transperitoneal approach.ResultsThe mean age of the patients was 37 ± 5.38 years. Flank pain was noted in all cases while dysuria seen in two patients and one patient had fever. Mean operative time was 145 ± 26.92 min and estimated blood loss was 85 ± 55 ml. Various techniques for isthmectomy and lower pole resection were used including use of monopolar hook in laparoscopic suite, Ligasure and bipolar scissor in minimal invasive milieu and monopolar cautery in laparoscopic conversion to open procedure. Histopathological examination revealed chronic pyelonephritis in three cases and squamous cell carcinoma of renal pelvis in one case which was converted to open.ConclusionsLaparoscopic heminephrectomy in HSK is doable. Preoperative CT urography along with CT angiography may provide important anatomical and vascular information which reduces intra-operative risks of vascular injury or calyceal entry. Vascular control of isthmus and transection of dilated and thinned out lower pole with cauterization of pelvicalyceal mucosa will provide uneventful surgical course.

Bladder dissection for cesarean hysterectomy in case of severe placenta percreta: tips and tricks

Objective: In this article, we report a severe case of placenta percreta in order to present our surgical approach for bladder dissection in a pregnancy with placenta accreta spectrum (PAS). Case(s): Bladder dissection was performed using bipolar forceps and bipolar scissors and with a meticulous lateral-to-medial dissection on each side. Conclusion: We recommend electrodissection of the bladder using bipolar forceps. Bipolar device may indeed help in the hemostasis of the placenta vessels while performing the bladder dissection.

MP10-03 SUPER TRANSURETHRAL BLADDER TUMOR RESECTION

You have accessJournal of UrologySurgical Technology & Simulation: Instrumentation & Technology I (MP10)1 Sep 2021MP10-03 SUPER TRANSURETHRAL BLADDER TUMOR RESECTION Shengkun Sun, Yong Xu, Weijun Fu, Guangfu Chen, and Xu Zhang Shengkun SunShengkun Sun More articles by this author , Yong XuYong Xu More articles by this author , Weijun FuWeijun Fu More articles by this author , Guangfu ChenGuangfu Chen More articles by this author , and Xu ZhangXu Zhang More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001983.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The existing TURBT technology has a history of more than 80 years. The fragmented resection of tumors are inherent defects of traditional TURBT. The objective of this study was to explore a safe and effective method of TURBT. We performed a novel transurethral bladder tumor resection under air cystoscope. Since the depth of resection is limitless under pneumocystoscope, and there is no previous report, we named this novel operation as “Super Transurethral Resection of Bladder Tumor” (STURBT). METHODS: The operation was performed under general or epidural anesthesia. The Super Scope (S-Scope) was inserted through the urethra, and the bladder was filled with carbon dioxide, and the pressure was set as 12 mmHg. The novel S-Scope has a channel to accommodate conventional laparoscopic surgical instruments, such as supersonic scalpel, bipolar scissors, forceps, and suctions. First the normal bladder mucosa 1 cm from the tumor was marked with a supersonic scalpel. Blunt separation and sharp resection were performed from periphery to the central base of the tumor to achieve en bloc resection. The β basket, a bladder tumor retrieving device, was inserted through the channel, and the tumor was removed in whole or by dividing into 2 to 3 parts. The urethral stent was placed, and the bladder was flushed with normal saline. RESULTS: 5 patients underwent STURBT, and 6 tumors were resected with the largest diameter of 3∼5cm. The average resection time was 28±16.4 minutes, and the tumor was retrieved en bloc or sub-en bloc. There was no obturator nerve reflex or bleeding during operation. Pathological diagnosis showed 1 case of pheochromocytoma and 4 cases of high grade urothelial carcinoma with stage T1∼T2a. Bladder muscle layer was visible in all cases. 3 cases of bladder cancer with muscle invasion received adjuvant intravenous chemotherapy. 4 cases with high grade urothelial carcinoma also received intravesical irragation of BCG periodically. Cystoscopy 3 months post-operation showed well healing of the bladder. There was no tumor recurrence during a mean follow-up of 11.8 (3-18) months. CONCLUSIONS: STURBT is a novel surgical method to treat bladder tumor, which has several advantages over traditional TURBT. No fluid irrigation was needed, and no urine extravasation developed. The supersonic scalpel will not stimulate the obturator nerve. The en bloc tumor resection decreased tumor dissemination and an accurate pathological TNM stage could be obtained. S-Scope assisted STURBT could make full use of the current laparoscopic surgical instruments, which had obvious advantages in transurethral treatment of bladder tumors. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e169-e169 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Shengkun Sun More articles by this author Yong Xu More articles by this author Weijun Fu More articles by this author Guangfu Chen More articles by this author Xu Zhang More articles by this author Expand All Advertisement Loading ...

P-748 Diode laser hysteroscopic metroplasty for dysmorphic uterus: a pilot study

Abstract Study question Whether diode laser hysteroscopic metroplasty for dysmorphic uterus is a safe and efficacious procedure and its effect on reproductive outcomes. Summary answer Diode laser hysteroscopic metroplasty is a safe and effective procedure for infertile women with dysmorphic uterus with comparable results to those reported in the literature. What is known already A T-shaped uterine anomaly is categorized by the ESHRE/ESGE consensus as dysmorphic uterus class U1a, characterized by an abnormal hypoplastic uterine cavity. A Y-shaped uterus is a dysmorphic uterus with a fundal subseptum. Dysmorphic uteri are associated with infertility, recurrent implantation failure (RIF), recurrent pregnancy loss (RPL), and adverse pregnancy outcomes. According to several studies, it seems that hysteroscopic metroplasty may improve the chances of conception and live birth. Previous studies described the procedure using bipolar systems, monopolar needle or scissors. The purpose is to achieve a uterine cavity of normal shape and volume by cutting the thickened lateral walls. Study design, size, duration This was a retrospective pilot study with a prospective follow-up. We retrospectively evaluated all cases operated between February 2018 to February 2020, at Hillel Yaffe Medical Center, Hadera, Israel. Reproductive outcomes for women who underwent the procedure were followed until September 2020. Pregnancies that were ongoing on September 2020 were followed until January 31st 2021. Participants/materials, setting, methods Nulliparous women with a diagnosis of infertility or RPL, who were diagnosed with dysmorphic uterus by three-dimensional ultrasound (3D-US) and underwent diode laser hysteroscopic metroplasty were included. All the metroplasties were done in one tertiary center by the same specialist. Reproductive outcomes were evaluated retrospectively and prospectively for a total follow-up time of 32 months. Reproductive performances before and after metroplasty were compared where possible. Main results and the role of chance Twenty-five women underwent diode laser hysteroscopic metroplasty for dysmorphic uterus in our institute. No perforations, excessive bleeding, or other complications were encountered during the procedures. Follow-up hysteroscopy and 3D-US were satisfactory in all cases 2 months after the metroplasty. A total of 15 nulliparous women returned to fertility treatments afterwards, among whom 9 conceived (60% pregnancy rate). Their infertility period before the procedure was 56.6 ± 36.1 months. The duration between the metroplasty to pregnancy was 5.2 ± 3.5 months. The rate of deliveries and ongoing pregnancies (pregnancies beyond 20 weeks of gestation) was 78% (7/9), with five successful liveborn deliveries and two ongoing pregnancies. All deliveries were between 36-37 weeks. The 10 women who were not treated by our infertility unit were contacted, among whom 6 discontinued their attempt to conceive. The other 4 conceived; three of them spontaneously. Among those 4 women,the rate of deliveries and ongoing pregnancies was 75%, with one term delivery and two ongoing pregnancies. Limitations, reasons for caution First, we included both T-shaped and Y-shaped uteri as both represent close versions of dysmorphic uteri, but in fact they differ. The subseptum might interfere with reproduction in a different mechanism. Second, the small and heterogeneous sample as well as the short duration of follow-up limit the conclusions. Wider implications of the findings We present the first application of diode laser in hysteroscopic metroplasty for dysmorphic uteri. This technique seems promising and our results are comparable with other series using different cutting devices. Only larger controlled trials with a longer follow-up can confirm the safety, efficacy, and impact on reproductive outcomes. Trial registration number Not Applicable

P–748 Diode laser hysteroscopic metroplasty for dysmorphic uterus: a pilot study

Abstract Study question Whether diode laser hysteroscopic metroplasty for dysmorphic uterus is a safe and efficacious procedure and its effect on reproductive outcomes. Summary answer Diode laser hysteroscopic metroplasty is a safe and effective procedure for infertile women with dysmorphic uterus with comparable results to those reported in the literature. What is known already A T-shaped uterine anomaly is categorized by the ESHRE/ESGE consensus as dysmorphic uterus class U1a, characterized by an abnormal hypoplastic uterine cavity. A Y-shaped uterus is a dysmorphic uterus with a fundal subseptum. Dysmorphic uteri are associated with infertility, recurrent implantation failure (RIF), recurrent pregnancy loss (RPL), and adverse pregnancy outcomes. According to several studies, it seems that hysteroscopic metroplasty may improve the chances of conception and live birth. Previous studies described the procedure using bipolar systems, monopolar needle or scissors. The purpose is to achieve a uterine cavity of normal shape and volume by cutting the thickened lateral walls. Study design, size, duration This was a retrospective pilot study with a prospective follow-up. We retrospectively evaluated all cases operated between February 2018 to February 2020, at Hillel Yaffe Medical Center, Hadera, Israel. Reproductive outcomes for women who underwent the procedure were followed until September 2020. Pregnancies that were ongoing on September 2020 were followed until January 31st 2021. Participants/materials, setting, methods Nulliparous women with a diagnosis of infertility or RPL, who were diagnosed with dysmorphic uterus by three-dimensional ultrasound (3D-US) and underwent diode laser hysteroscopic metroplasty were included. All the metroplasties were done in one tertiary center by the same specialist. Reproductive outcomes were evaluated retrospectively and prospectively for a total follow-up time of 32 months. Reproductive performances before and after metroplasty were compared where possible. Main results and the role of chance Twenty-five women underwent diode laser hysteroscopic metroplasty for dysmorphic uterus in our institute. No perforations, excessive bleeding, or other complications were encountered during the procedures. Follow-up hysteroscopy and 3D-US were satisfactory in all cases 2 months after the metroplasty. A total of 15 nulliparous women returned to fertility treatments afterwards, among whom 9 conceived (60% pregnancy rate). Their infertility period before the procedure was 56.6 ± 36.1 months. The duration between the metroplasty to pregnancy was 5.2 ± 3.5 months. The rate of deliveries and ongoing pregnancies (pregnancies beyond 20 weeks of gestation) was 78% (7/9), with five successful liveborn deliveries and two ongoing pregnancies. All deliveries were between 36–37 weeks. The 10 women who were not treated by our infertility unit were contacted, among whom 6 discontinued their attempt to conceive. The other 4 conceived; three of them spontaneously. Among those 4 women,the rate of deliveries and ongoing pregnancies was 75%, with one term delivery and two ongoing pregnancies. Limitations, reasons for caution First, we included both T-shaped and Y-shaped uteri as both represent close versions of dysmorphic uteri, but in fact they differ. The subseptum might interfere with reproduction in a different mechanism. Second, the small and heterogeneous sample as well as the short duration of follow-up limit the conclusions. Wider implications of the findings: We present the first application of diode laser in hysteroscopic metroplasty for dysmorphic uteri. This technique seems promising and our results are comparable with other series using different cutting devices. Only larger controlled trials with a longer follow-up can confirm the safety, efficacy, and impact on reproductive outcomes Trial registration number Not applicable

Vessel-preserving en-bloc excision of groin recurrence of vulval carcinoma with tensor fasciae latae flap reconstruction in a previously irradiated field

Objectives: Groin node dissection for recurrent vulval cancer in a previously irradiated field presents many surgical challenges - risk of vascular involvement, ill-defined planes and poor tissue quality for closure and healing. Our case demonstrates the feasibility of surgical management and value of flap reconstruction in managing disease relapse in such patients. Methods: We present the surgical approach to recurrent squamous cell carcinoma (SCC) vulva in a patient who has undergone previous radical radiotherapy to the site of relapse. Download : Download high-res image (268KB) Download : Download full-size image Results: In 2019 - a 70 year old lady underwent radical vulvectomy and left gluteal fold flap reconstruction, followed by radical radiotherapy and concomitant cisplatin for stage IIIc SCC vulva. A total of 12 months later, the patient presented with a clinically palpable, fixed left groin swelling. Imaging confirmed an FDG-avid 2.6 x 4.2 centimetre (cm) partially necrotic left inguinal lymph node, engulfing the femoral vessels. The patient was counselled pre-operatively by both gynae-oncology and plastic surgery – offering surgical excision of this single site recurrence, anticipating the need for further flap reconstruction for wound closure. Additional challenges included body mass index (BMI) of over 40 kilograms/metre2 and chronic candida of the abdominal pannus. Joint examination under anaesthetic by gynae-oncology and plastic surgery confirmed no vulval recurrence and no palpable right groin nodes. Left thigh perforator vessels were identified and marked using doppler. An 8.6 x 3.1cm elliptical incision was made around the fixed underlying node; and systematic inguino-femoral lymph node dissection performed using both bipolar scissors and an advanced energy device. An en-bloc specimen measuring 6.6 x 3.1 x 6.1cm was obtained. The femoral artery and vein were identified; and long saphenous vein preserved. Wound closure was achieved by raising an 18 x 8cm tensor fasciae latae (TFL) islanded flap, rotating and anchoring into place. Postoperatively, the patient was managed jointly under gynae-oncology and plastic surgery. Intravenous antibiotics, anti-fungals and thromboprophylaxis were given. The patient was advised to avoid sitting for 2 weeks. Drain outputs were monitored; and drains removed day 14. A small area of wound dehiscence occurred along the inferior border of the groin flap – which was healing well by secondary intention at the time of 4 week post-operative review, without need for further management. Final histopathology confirmed excised metastatic SCC, with a plan for ongoing surveillance arranged. Conclusions: In patients having undergone previous radiotherapy - surgery remains the main therapeutic option for recurrence. Undertaking such surgery, however, in a previously irradiated field - with altered anatomy and compromised perfusion - significantly increases the risk of inadvertent vessel or nerve injury and wound breakdown. We have demonstrated an approach, however, in an obese patient that achieved disease clearance through meticulous dissection, achieving wound closure and healing by incorporating TFL flap reconstruction.

Current Trends in and Indications for Endoscopy-Assisted Breast Surgery for Breast Cancer.

Endoscopic oncoplastic breast surgery represents a minimal invasive approach with the aim of both safe excision of cancer and preserving the breast shape. It has less noticeable scar, excellent cosmetic outcomes, high patient satisfaction rate. Recently, relative long-term follow-up results have been reported to be very safe (Soybir and Fukuma, J Breast Health 11:52-58, 2015; Fan et al., Chin Med J 122:2945-2950, 2009; Jiang, Zhonghua Wai Ke Za Zhi 45:439-441, 2007).Operative techniques for both endoscopic breast-conserving surgery and endoscopic nipple/areola/skin-sparing mastectomy have been described in detail. Two different working planes in which one of them is subcutaneous and the other one is sub-mammary planes are being used during the surgery. Surgical technique needs some instruments such as endoscopic retractor, light guided specific mammary retractor, wound protector, and energy device such as bipolar scissor, Harmonic Scalpel, LigaSure, Thunderbeat. Endoscopic breast retractors provide magnified visualization and extensive posterior dissection facility. Tunneling method and the hydro-dissection simplify the technique in the subcutaneous field (Soybir and Fukuma, J Breast Health 11:52-58, 2015; Fan et al., Chin Med J 122:2945-2950, 2009). Oncoplastic reconstruction techniques are also applied after the tumor resection by endoscopic method. The complication rate of endoscopic breast surgery is similar with the rate of open breast surgery. Quite successful local recurrence, distant metastasis, and overall survival rates have been declared. However, it looks reasonable to wait for the results with longer follow-up before having a judgement about oncologic efficiency and safety of the endoscopic breast cancer surgery (Tamaki et al., Nihon Geka Gakkai Zasshi 103(11):835-838, 2002; Leff et al., Breast Cancer Res Treat 125(3):607-625, 2011; Fukuma, Nihon Geka Gakkai Zasshi 116(5):316-319, 2015).Recently some surgeons reported about robotic nipple sparing mastectomy and immediate breast reconstruction with Gel implant procedure. Nevertheless, experience with application of a robotic surgery platform in the management of breast cancer is limited. From the preliminary experiences, R-NSM and IBR with Gel implant is a safe procedure, with good cosmetic results, and could be a promising new technique for breast cancer patients indicated for mastectomy (Lai et al., Ann Surg Oncol 26(1):42-52, 2019).

New Electrosurgical Technologies for High Amputations of the Lower Limbs

We present here results obtained using hightech bipolar instruments with an electrosurgical device and a non-linear dynamic feedback system for excision of large tissue blocks. The effectiveness of using bipolar scissors with blades made of nanostructured zirconium dioxide and thermostabilized bipolar forceps was assessed using high amputation of the lower limbs as an example. Significant results were obtained showing that the use of innovatory electrosurgical technologies for transfemoral amputation in patients with terminal-stage peripheral arterial disease increases the typical clinical measures of efficacy by an average of 39%. The results can be taken as the basis for a new method of using electrosurgical technology for high amputations of the lower limbs.

European multicenter survey on approaches in pediatric laparoscopic appendectomy

This survey reviewed the practice of laparoscopic appendectomy in pediatric surgical centers across Europe. An online survey questionnaire was created and data obtained analyzed. There were 58 responders (52 Consultants and 6 trainees), of them n = 24 performed > 100 laparoscopic procedures per year. Procedures were performed by trainee with scrubbed consultant supervision n = 30, trainee with unscrubbed consultant n = 14, independent trainees n = 8 and consultants n = 6. Optic port preferences were 10 mm (n = 29), 5 mm (n = 24) and 12 mm (n = 3). Working port placement preference was sectorization n = 32, triangulation n = 16 and n = 10 decided based on intraoperative findings. Mesoappendix was dissected by monopolar hook n = 26, bipolar forceps n = 20, harmonic devices n = 8, and bipolar scissors n = 4. Appendix ligation was done with 3 vicryl endoloops (n = 36), 2 vicryl endoloops (n = 13), 3 polydioxanone (PDS) endoloops (n = 7) and endostaplers (n = 2). Appendix was removed through optic 10–12 mm port (n = 27), exchanging 5 mm for 10–12 mm port (n = 9), endobag (n = 8), sterile glove digit endobag (n = 7), through 5 mm ports (n = 5) and along 5 mm port (n = 2). In complicated appendicitis, n = 48/58 would proceed with laparoscopy on prior confirmed perforation and n = 53/58 would continue with laparoscopy when intraoperative findings showed complicated appendicitis. In the presence of pus, n = 52/58 would perform peritoneal lavage and n = 4/58 would only suction pus. Complicated appendices were removed via endobag n = 30, through 10–12 mm port n = 10, sterile glove digit n = 10, exchange 5 mm for 10–12 mm port n = 7 and along with work port n = 1. Opinions were divided with regards to approach in performing various steps of pediatric laparoscopic appendectomy in institutions throughout Europe.

Robotic Assisted Laparoscopic Resection of Uterine Isthmocele

Video Objective Uterine isthmoceles are pouchlike defects in the anterior uterine wall, at the site of a prior cesarean section scar. Its prevalence has increased in direct relation to the increase in cesarean rates worldwide. Isthmoceles cause abnormal uterine bleeding, secondary infertility, and pain. There is no standard treatment for isthmoceles. This video demonstrates a robotic assisted laparoscopic approach to the resection of a uterine isthmocele. Setting The patient is a 36 year old with a history of one cesarean section with abnormal uterine bleeding. She was diagnosed with an isthmocele by transvaginal ultrasound performed in preparation for embryo transfer. The patient was treated at a tertiary care centre in Brooklyn, New York. Interventions The risks, benefits, and alternatives of a robotic assisted laparoscopic resection of a uterine isthmocele were discussed with the patient and consent was obtained. The robot was docked and simultaneous hysteroscopy was performed. The fenestrated bipolar and monopolar scissors were used to perform lysis of adhesions and dissection of the bladder off the uterine isthmus and cervix. Robotic fluorescence imaging was used to identify the isthmocele defect via the “lantern sign” where the hysteroscopic light shines through the tissue similar to a lantern. The isthmocele was excised and the defect was reapproximated with an absorbable monofilament suture. A barbed suture was then used for a second imbricating layer, with excellent hemostasis. Fluorescence imaging was used again and the hysteroscopic light could no longer be identified, as the isthmocele had been resected and repaired. Conclusion Uterine isthmoceles are increasing in relation to the increased rate of cesarean sections. Symptomatic and asymptomatic women who desire future pregnancy should be offered surgical treatment. Robotic assisted laparoscopic management of uterine isthmoceles can be associated with increased patient satisfaction with faster recovery times, and decreased length of hospitalization, and should be considered when possible.

Safety of outpatient admission and comparison of different surgical techniques in adult tonsillectomy.

To investigate the safety of outpatient admission and the effects of surgical technique in tonsillectomy operations of adult patients. The digital database was scanned for patients aged ≥ 15years that underwent tonsillectomy in our institution between years 2014 and 2018. Demographic and clinical characteristics, the surgical technique, length of stay (LOS) in hospital, re-admissions after discharge, complications and interventions performed were recorded. A total of 276 patients met the inclusion criteria, comprising 139 (50.4%) females and 137 (49.6%) males with a mean age of 27.17 ± 9.41years. The most common indication was recurrent tonsillitis (n = 223, 80.8%), and surgical techniques used were bipolar scissors (CURIS®, Sutter Medizintechnik, Germany) (n = 137, 49.6%), cold dissection (n = 75, 27.2%) and/or plasma blade (PEAK Surgical, Medtronic, USA) (n = 64, 23.2%). A total of 43 (15.5%) re-admissions from 37 (13.4%) patients were recorded because of bleeding (n = 33, 70.2%) and/or odynodysphagia (n = 13, 27.7%). Non-surgical interventions were sufficient in 32 (74.4%) cases, while surgical interventions were required in 11 (25.6%) patients. In patients where "hot" techniques (bipolar scissors, plasma blade) were used and in patients with complaints in the first 24h postoperatively, significantly increased rates of elongated LOS values for more than 1day were determined (p < 0.01, p < 0.001). Adult tonsillectomy is a safe surgical procedure with low complication, re-operation and mortality rates. Significantly increased rates of elongated LOS values for more than 1day and re-admissions after discharge were determined in those patients having complications in the first 24h postoperatively. Cold dissection seems to be more advisable than hot techniques for outpatient tonsillectomy among adult patients.

Bladder Endometriosis: Management by Cystoscopic and Laparoscopic Approaches

Study ObjectiveEndometriosis of the urinary system accounts for less than 1% of all endometriosis, wherein bladder endometriosis is the most common. Bladder endometriosis is defined as endometriosis infiltrating the detrusor muscle and represents 85% of urinary tract endometriosis [1,2]. Segmental bladder resection/partial cystectomy is the bladder-preserving surgery and offers the complete removal of bladder endometriotic nodules [3,4]. Laparoscopic/robotic excision increases the chances of complete removal of nodules but may lead to inadvertent removal of excess bladder wall and increase the risk of complications, especially in cases of large lesions in close proximity to ureteric orifices. Thus, simultaneous laparoscopy and cystoscopy offers the most effective way of complete resection of bladder endometriotic nodules, relieving symptoms and minimizing intraoperative and postoperative complications and recurrence rates in patients [5–11]. This article with accompanying video describes the systematic approach and step-by-step surgical excision of a bladder endometriotic nodule in a patient with frozen pelvis. DesignStep-by-step surgical excision of a bladder endometriotic nodule by simultaneous cystoscopy and laparoscopy. (Canadain Task Force classification: level III) SettingJyoti Hospital and Minimum Invasive Surgery Center, Ahmedabad, India. PatientA 41-year-old women, P2L2, presented with cyclical dysmenorrhea, dysuria, and chronic pelvic pain. Informed consent was obtained from the patient, and the local institutional board provided the approval. InterventionSimultaneous cystoscopy and laparoscopy. Measurements and Main ResultsA preoperative assessment was done with transvaginal ultrasonography with a partially full bladder that showed an intravesical 3-cm endometriotic nodule along with chocolate cysts of the ovary and adenomyosis of the uterus. A simultaneous cystoscopy by a urologist and laparoscopy by a gynecologist was performed. On cystoscopy the nodule was seen away from both the ureteric orifices. The nodule was marked cystoscopically with a monopolar needle and laparoscopically with bipolar scissors. Laparoscopy began with a full inspection of the abdomen, pelvis, and adhesions. Dissection started from the left round ligament, and both paravesical spaces were dissected gently, keeping the bladder partially full. Good uterine manipulation helped to delineate vaginal fornices during dissection. Dissection continued over the isthmus, and bladder was gently separated from the isthmus. The bladder was partially filled with methylene blue and intentionally cut opened to excise the demarcated bladder nodule with a monopolar hook, taking a disease-free margin of 5 mm [12]. Two stay sutures were taken at both the lateral angles of the bladder, and suture ends were brought outside the abdomen to facilitate closure of the bladder transversely. After mobilization of the bladder, both uterine vascular bundles were desiccated with bipolar and laparoscopic hysterectomy. Vaginal closure was done away from bladder stitches. The patient was discharged on day 3 with catheter and DJ stents. On day 21, 3-dimensional computed tomography cystogram showed adequate bladder volume. Catheter and DJ stents were removed, low-pressure cystoscopy showed a smooth stitch line with mucosa over it and no residual endometriosis. The patient was found to have no symptoms at the 2-year follow up. ConclusionThe video demonstrates the feasibility of simultaneous laparoscopic and cystoscopic approach for excision of a bladder endometriotic nodule. Marking the nodule by simultaneous cystoscopy and laparoscopy before excision helps in removing the disease completely and avoiding unnecessary normal bladder wall excision, thus reducing the risk of recurrence and resultant small bladder symptoms.

Outcome of harmonic scalpel circumcision in children with hemophilia

Background: There are many techniques described to decrease the risk of bleeding after circumcision in patients with bleeding diathesis such as monopolar diathermy, bipolar scissors and fibrin glue. Up to our knowledge, no previous study described the use of the harmonic scalpel in patients with bleeding diathesis. Our aim was to evaluate postoperative outcome after harmonic scalpel circumcision in boys with hemophilia.Methods: This was a prospective observational study carried out in Sohag University Hospitals, Sohag, Egypt. The patients were recruited from Outpatient pediatric hematology clinic from January 2014 till January 2017. All procedures were done under general anesthesia. After strict sterilization, the dorsal aspect of the prepuce was incised using harmonic scalpel up to the coronal sulcus, then the whole prepuce was cut circumferentially using the harmonic scalpel. It is a sutureless technique.Results: 26 boys with hemophilia A and 5 with hemophilia B were included. Their median age was 5 and 8 years respectively. The most common indication for circumcision was religious (20/31), the intraoperative blood loss ranged between 0-5 ml, operative time ranged between 3-5 minutes, there was no intraoperative complication, one case of rebleeding managed conservatively by factor administration, two cases of wound infection responded to antibiotic therapy, hospital stay ranged between 1-3 days. It was a sutureless technique.Conclusions: Harmonic scalpel circumcision is a safe technique in children with hemophilia, it decreased the risk of rebleeding, decreased operative time and it is also a sutureless technique and may decrease the cost by reducing the amount of factor replacement.

Post-tonsillectomy pain after using bipolar diathermy scissors or the harmonic scalpel: a randomised blinded study

ObjectiveTo compare the postoperative pain following bipolar diathermy scissors tonsillectomy (higher temperature dissection) with harmonic scalpel tonsillectomy (lower temperature dissection).MethodsSixty patients aged 7–40 years planned for tonsillectomy with no other concurrent surgery were randomised to either bipolar diathermy scissors or harmonic scalpel as surgical technique. Blinded to the surgical technique, the patients recorded their pain scores (VAS, 0–10) at awakening and the worst pain level of the day in the postoperative period. All intake of pain medication was also recorded.ResultsNo statistically significant differences were found between the two groups regarding postoperative pain levels or consumption of pain medication.ConclusionUsage of the harmonic scalpel does not render less postoperative pain following tonsillectomy when compared with usage of the bipolar diathermy scissors.

Factors affecting secondary post-tonsillectomy hemorrhage: a case\u2014control study

BackgroundTonsillectomy is one of the commonest otolaryngological procedures performed. Multiple reports have demonstrated the safety of ambulatory (outpatient) pediatric Tonsillectomy, however Post-tonsillectomy hemorrhage remains the most serious complication of tonsillectomy.Patients and methodsIn this work, we analyzed different parameters including patient’s age, gender, type of surgery “Tonsillectomy or Adenotonsillectomy”, technique “Cold dissection or Bipolar”, evidence of tonsillar bed infection and pre-operative hemoglobin level in two groups of patients indicated for tonsillectomy. One group of 80 patients didn’t suffer from posttonsillectomy bleeding as a control group; the other of 20 patients having secondary post-tonsillectomy bleeding.ResultsAccording to our statistical analysis and data, no significant difference between the two groups regarding the occurrence of secondary post-tonsillectomy in the following parameters: patient’s age, gender, type of surgery “Tonsillectomy or Adenotonsillectomy” and preoperative hemoglobin level.ConclusionHowever there was higher incidence of secondary post tonsillectomy bleeding in patients operated by bipolar scissors. Also evidence of tonsillar bed infection raises the possibility of secondary post-tonsillectomy bleeding occurrenc.

Viability of Airborne Tumor Cells during Excision by Ultrasonic Device.

Background. Laparoscopic surgery has become more widely used, but peritoneal dissemination and port-site metastasis have been reported to occur in these surgeries. One reason for these problems is the ultrasonically activated scalpel (UAS) used for laparoscopic surgery. This study aimed to investigate the viability of airborne cells released during cancer dissection using a UAS. Methods. Flank tumors measuring about 2 cm were induced in male NOD-Cg-Rag1tm1MomIL2rgtm1wjl/SzJ mice by subcutaneous injection of 1 × 106 HepG2 cells. Dissection was performed with UAS (in high or low power modes) and PowerStar bipolar scissors. The mist of released tissue was collected in cell culture medium. The viability of the cellular material was assessed with trypan blue exclusion cell counting, counting after immunofluorescence staining, and flow cytometric analysis. Results. Large quantities of cellular debris were trapped in the tissue dispersed by both devices. In all experiments, there were significantly more viable cells produced by the UAS in high power mode. By using suction at the excision site, the number of viable cancer cells was reduced. Conclusions. This study demonstrates that viable cancer cells can be released into the nearby environment during tumor ablation with a UAS.

Risk factors for secondary post-tonsillectomy haemorrhage following tonsillectomy with bipolar scissors: four-year retrospective cohort study

To analyse risk factors associated with secondary post-operative bleeding when only one technique, namely bipolar scissors, is used. The medical records of all consecutive patients aged six years or older who underwent tonsillectomy or adenotonsillectomy between 1 December 2010 and 30 November 2014 were retrospectively analysed. A total of 1734 patients were included in the study. A secondary haemorrhage occurred in 208 patients (12 per cent). Patients aged 15 years or older were 4.5 times (95 per cent confidence interval = 2.6-7.9; p < 0.001) more likely to experience secondary haemorrhage. In cases of acute quinsy, patients aged 15 years or older had an 8.1-fold (95 per cent confidence interval = 1.1-59.6; p = 0.02) increased likelihood of experiencing secondary haemorrhage. Patients aged 15 years or older have a higher risk for bleeding regardless of the primary indication for the tonsillectomy. The risk for secondary haemorrhage does not seem to depend on the primary indication itself.