Conventional Surgical Access Research Articles

Robotic Setup Promises Consistent Effects of Multilocular Gastrointestinal Electrical Stimulation: First Results of a Porcine Study

Background: Electrical stimulation (ES) of several gastrointestinal (GI) segments is a promising therapeutic option for multilocular GI dysmotility, but conventional surgical access by laparotomy involves a high degree of tissue trauma. We evaluated a minimally invasive surgical approach using a robotic surgical system to perform electromyographic (EMG) recordings and ES of several porcine GI segments, comparing these data to an open surgical approach by laparotomy. Materials and Methods: In 5 acute porcine experiments, we placed multiple electrodes on the stomach, duodenum, jejunum, ileum, and colon. Three experiments were performed with a median laparotomy and 2 others using a robotic platform. Multichannel EMGs were recorded, and ES was sequentially delivered with 4 ES parameters to the 5 target segments. We calculated pre- and poststimulatory spikes per minute (Spm) and performed a statistical Poisson analysis. Results: Electrode placement was achieved in all cases without complications. Increased technical and implantation time were required to achieve the robotic electrode placement, but invasiveness was markedly reduced in comparison to the conventional approach. The highest calculated (c)Spm values were found in the poststimulatory period of the small bowel with both the conventional and robotic approaches. Six of the 20 Poisson test results in the open setup reached statistical significance and 12 were significant in the robotic experiments. Conclusions: The robotic setup was less invasive, revealed more consistent effects of multilocular ES in several GI segments, and is a promising option for future preclinical and clinical studies of GI motility disorders.

Robotic Totally Endoscopic Coronary Artery Bypass Grafting: Systematic Review of Clinical Outcomes from the Past two Decades.

Robotic totally endoscopic coronary artery bypass grafting (TECAB) was introduced in 1998 and has over a period of two decades gradually emerged from single-vessel revascularization to multivessel bypass grafting. Dedicated centers have continuously evolved and further developed this minimally invasive method of coronary bypass surgery. A literature review was conducted to assess intra- and postoperative outcomes of TECAB. PubMed returned 19 comprehensive articles on TECAB. Investigation was focused on perioperative outcome parameters, i.e.: operative time, conversion to larger incision, revision for bleeding, atrial fibrillation, stroke, acute renal failure, and mortality. Outcome from the analysis of 2,397 reported cases showed an average operative time of 291 ± 57 minutes (range 112 to 1,050), conversion rate to larger incisions at 11.5%, and perioperative mortality at 0.8%. Pooled data demonstrated 4.2% operative revision rate due to postoperative hemorrhage, 1.0% stroke incidence, 1.6% acute renal failure, and 13.3% de novo atrial fibrillation. The mean length of hospital stay measured 5.8 ± 1.7 days. Conversion rates and operative times decreased over time. According to data in the literature, coronary bypass surgery carried out in completely endoscopic fashion utilizing robotic assistance can require relatively extensive operative times and conversion rates are somewhat higher than in other robotic cardiac surgery. However, major postoperative events lie in an acceptable range. TECAB remains the surgical revascularization method with the least tissue trauma and represents an opportunity for coronary artery bypass grafting via port access. Rates of major complications are at least similar to conventional surgical access procedures.

Single-Center Experience with Minimally Invasive Mitral Operations through Right Minithoracotomy.

Background: To report single-institution experience with minimally invasive mitral valve operations through the right minithoracotomy over a 5-year period.Methods: Patients who underwent minimally invasive mitral valve surgery (MIMVS) between January 2012 and December 2016 were included. Clinical follow-up data were collected in a prospective database and analyzed retrospectively.Results: Data from 151 patients were assessed (mean age, 63.4 ± 9.7 years; 55% were females). Overall 30-day mortality was 0.7% (n = 1). Mean operating time, cardiopulmonary bypass, and aortic cross-clamp times were 254.9 ± 48.7, 140.5 ± 36.1, and 94.8 ± 27.0 minutes, respectively. Associated procedures were tricuspid valve annuloplasty (37.1%, n = 56) and closure of atrial septal defect (6.0%, n = 9). Cryoablation was performed in 43.7% of patients (n = 66). One patient (0.7%) required conversion to median sternotomy and six patients (4.0%) underwent re-explorations due to bleeding. Median postoperative hospital stay was 12 days. Overall survival at 5 years was 94.1% ± 2.0%. Freedom from reoperation was 94.6% ± 2.9% at 5 years.Conclusions: MIMVS is a feasible, safe, and reproducible approach with low mortality and morbidity. Mitral valve surgery through a small thoracotomy is a good alternative to conventional surgical access.

Percutaneous cannulation for cardiopulmonary bypass in minimally invasive surgery is associated with reduced groin complications.

Femoral cutdown is standard in most centres if groin cannulation is used for cardiopulmonary bypass in minimally invasive cardiac surgery (MICS). Arterial closure devices (ACDs) allow placement of larger cannulas percutaneously, but its benefit in MICS is unclear. We assessed our results with percutaneous groin cannulation using ACDs in comparison with conventional surgical access in patients undergoing MICS. We reviewed 445 consecutive patients having undergone MICS between October 2010 and March 2015. Of those, 92 (21%) were performed with conventional surgical access to the groin vessels and 353 (79%) with the use of ACDs. Operative risk was higher in the ACD group [logistic EuroSCORE 7.9% (SD: 8.1) vs 10.6% (SD: 12.3); P = 0.010]. The use of ACDs significantly reduced operation time [193 min (SD: 43.8) vs 173 min (SD: 47.1); P < 0.001] and hospital stay [Cutdown: median 9 days (8, 14); ACD: median 9 days (7, 12), P = 0.040] without affecting the time to full mobilization. The incidence of any complication was significantly lower in the ACD group (2.3% vs 8.7%; P = 0.007). Complications with conventional cannulation consisted of lymphatic fistulae (n = 4), wound infections (n = 2), stenosis (n = 1) and haematoma (n = 1). In the ACD group, there were local dissections (n = 2) and stenoses (n = 3). There was 1 haematoma in both groups. There were 2 vascular injuries in the ACD group (n = 2), leading to conversion to surgical access. Percutaneous groin cannulation using ACDs for establishing cardiopulmonary bypass in minimally invasive valve surgery significantly reduces groin complications, operation time and hospital stay. However, the remaining complications are mainly of vascular nature versus wound infection and lymph fistulae with cutdown.

Percutaneous Access for Cardiopulmonary Bypass Reduces Complication Rates in Minimally Invasive Cardiac Surgery

Background: Femoral cutdown is standard in most centers if groin cannulation is used for cardiopulmonary bypass (CPB) in minimally invasive cardiac surgery (MICS). Arterial closure devices (ACDs) allow placement of larger cannulas percutaneously, but its benefit in MICS is unclear. We assessed our results with ACDs in comparison with conventional surgical access in patients undergoing MICS.

THE MINUS® SYSTEM MINIMALLY INVASIVE TECHNIQUE FOR THE TREATMENT OF TRANTROCHANTERIC FRACTURES

The MINUS system was developed as a minimally invasive procedure that uses a diaphyseal cephalic extramedullary implant for the treatment of transtrochanteral fractures of the femur in elderly patients. The implant consists of a sliding screw coupled to a plate adapted to the minimally invasive technique. The surgical access is approximately three centimeters in length located on the lateral surface of the hip, below the projection of the small trochanter. A perfectly adapted instrument was used for the procedure, which also requires the use of an image intensifier, reducing surgery time and rate of bleeding. The objective of this study is to present a new instrument and implant, developed specifically for treatment with the minimally invasive technique, reducing the length of the conventional surgical access from 10 to three centimetres. This new implant was given the commercial name of MINUS System.

PROXIMAL TIBIAL OSTEOTOMY: STABILIZATION OF THE MEDIAL OPENING WITH A TRICORTICAL ILIAC BONE GRAFT

Objective: Radiographic assessment of lower limb alignment, in the frontal and sagittal planes, after high tibial osteotomy. To stabilize the osteotomy, a tricortical iliac graft was used, along with a positioning screw. Methods: Prospective study on 46 patients with ages ranging from 17 to 61 years. Among them, 42 patients presented genu varum secondary to knee osteoarthritis and four from other causes. Teleradiography was performed for surgical planning, using the Frank Noyes method, as modified by Fugizawa. A conventional surgical access of 3 cm was made to harvest a tricortical iliac graft. Osteotomy was performed under radioscopic control, by means of an anteromedial incision of 3 cm with release of the superficial portion of the medial collateral ligament. The graft was placed in the posterior portion of the osteotomy, to maintain an unaltered tibial slope. The screw crossed the osteotomy orthogonally to protect the lateral cortex. Pre and postoperative radiographic criteria were established to assess the results. Results: There was consolidation in 100% of the cases and maintenance of the mechanical axis, obtained intraoperatively, in 94% of the cases. The posterior slope of the tibial plateau in the sagittal plane ranged from 7° to 12°. Joint mobility was restored in all the patients. Eleven patients presented temporary pain at the site of graft harvesting, but none had paresthesia. The incidence of complications was 8% (infection, loss of correction and joint fracture). Conclusion: The technique was shown to be reproducible, simple, biological, accurate and low-cost, and it may be an alternative to the existing techniques.

Osteotomia proximal da tíbia: estabilização da abertura medial com enxerto tricortical de ilíaco

OBJETIVO: Avaliacao radiografica do alinhamento do membro inferior, nos planos frontal e sagital, apos osteotomia alta da tibia. Para estabilizacao da osteotomia foi utilizado enxerto tricortical de iliaco e parafuso de posicionamento. METODOS: Estudo prospectivo envolvendo 46 pacientes com idade entre 17 e 61 anos, sendo 42 portadores de geno varo secundario a osteoartrose e quatro por outras causas. A telerradiografia foi realizada para planejamento cirurgico, utilizando o metodo de Frank Noyes modificado por Fugizawa. Foi realizado acesso cirurgico convencional de 3cm para retirada do enxerto tricortical de iliaco. A osteotomia foi realizada sob controle de radioscopia, por incisao anteromedial de 3cm com liberacao da porcao superficial do ligamento colateral medial. O enxerto foi colocado na porcao posterior da osteotomia, para manter inalterado o slope tibial. O parafuso cruzou a osteotomia ortogonalmente para proteger a cortical lateral. Foram estabelecidos criterios radiograficos pre e pos-operatorios para avaliacao dos resultados. RESULTADOS: Houve consolidacao em 100% dos casos e manutencao do eixo mecânico, obtido no intraoperatorio, em 94%. A inclinacao posterior do plato tibial, no plano sagital, variou entre 7o e 12o. A mobilidade articular foi restabelecida em todos os pacientes operados. Onze pacientes apresentaram dor temporaria no local da retirada do enxerto; no entanto, nenhum apresentou parestesia. A incidencia de complicacoes foi de 8% (infeccao, perda da correcao, fratura articular). CONCLUSAO: A tecnica mostrou-se reprodutivel, simples, biologica, precisa e com baixos custos, podendo ser uma alternativa as tecnicas ja existentes.

Totally endoscopic Ivor Lewis esophagectomy.

Esophagectomy is associated with significant risks of perioperative morbidity and mortality, as well as prolonged convalescence due to effects of the incisions used for conventional surgical access. Because the outcome of this procedure is palliative in the majority of patients, it is possible that laparoscopic techniques could improve initial postoperative outcomes and therefore make surgery more acceptable for patients with esophageal cancer. A new technique is described for Ivor Lewis esophagectomy, which incorporates a hand-assisted laparoscopic approach for gastric mobilization and a thoracoscopic approach for esophageal dissection and anastomosis. Initial experience in two patients has been encouraging, with postoperative hospital stay and convalescence shortened.

Endoscopic surgery of the oesophagus.

Conventional surgical access to the oesophagus often requires a thoracotomy. The application of techniques borrowed from laparoscopic surgery allows transthoracic dissection of oesophagus without thoracotomy. These techniques are useful in treatment of oesophageal leiomyomas, motility disorders and iatrogenic perforations. Oesophageal resection for cancer can be accomplished using minimal access, either thoracoscopically or with the aid of an operating mediastinoscope. Whether these techniques should replace transthoracic or transhiatal oesophagectomy for most patients with cancer remains to be seen.

Video assisted thoracoscopic surgery (VATS) in Asia--its impact and implications.

Within a short period of time, video assisted thoracoscopic surgery (VATS) has revolutionised the practice of thoracic surgery. Most of the existing literature, however, is concentrated on the technical aspects. We examined the impact of VATS on our practice and its implications. We reviewed our thoracic case load two years before and two years after the introduction of VATS in our hospital. We have witnessed a rapid and progressive increase in our thoracic case load since the introduction of VATS. With increased experience, proportionally more cases were performed using VATS compared to conventional surgical access. The increased case load covered a wide range of thoracic diseases with the majority for spontaneous pneumothorax and pleural diseases. The higher case load is due to increased referrals which at least partly reflect earlier acceptance by both the patients and their physicians for surgical intervention. The changing indications for surgery and the high cost associated with VATS, however, could place extra demand on the healthcare, especially for some countries in Asia. Cost containment is therefore a high priority here. More research is greatly needed in this area.

Anaesthesia for minimally invasive therapy

Minimally invasive or minimal access surgery is associated with significantly less trauma than conventional surgical access. The technology required is expensive and its adoption has major implications for patient services, hospital design, operating room equipment, surgical speciality alignment, and training. Intraoperative complications are mostly due to traumatic injuries sustained during blind trocar insertion and physiological changes associated with pneumoperitoneum and patient position.