Good Operative View Research Articles

Intrauterine Instillation of Tranexamic Acid in Hysteroscopic Myomectomy: A Double-Blind, Placebo-Controlled, Parallel-Group Randomized Clinical Trial

To evaluate the hemostatic effect of intrauterine instillation of tranexamic acid (TXA) with the distention medium during hysteroscopic myomectomy. Prospective, parallel-group, double-blind, placebo-controlled randomized clinical trial. Early Cancer Detection Unit in Ain Shams University Maternity Hospital, Cairo, Egypt. Eighty women with type 0 or I submucous myoma undergoing hysteroscopic myomectomy using unipolar resectoscope. The participants were randomly assigned to receive either 1 g of TXA for every 1000 mL of the distending medium (intervention group) or 10 mL of placebo (10 mL of 1.5% glycine) in the same form inside every 1000 mL of the distention medium. The primary outcome was a change in hemoglobin level 24 hours after surgery compared with preoperative values, and the secondary outcomes were the surgeon's rating of intraoperative bleeding and the quality of operative view, the duration of surgery, the volume of injected media, intraoperative complications, and the completion of myomectomy in 1 procedure. The mean difference in hemoglobin level was 1.11 ±.58 g/dL in the TXA group and 1.46 ± 0.61 g/dL in the placebo group (p = .015). The quality of hysteroscopic view was better in the TXA group (p = .001), with good operative view in 23 (60.5%) cases in TXA vs 8 (20.5%) in the placebo group. The surgeon's rating of bleeding as excessive was reported in 1 (2.6%) case in the TXA group and in 9 (23.1%) cases in the placebo group. There was no difference between the groups regarding the duration of surgery, the volume of injected media, completion of myoma resection in 1 session, and intraoperative complications. Three cases of uterine perforation with the thermal loop were reported, and all were associated with poor operative field in the placebo group. Intrauterine instillation of TXA with the distention medium during hysteroscopic myomectomy resulted in a statistically significant decrease in hemoglobin level 24 hours after surgery, albeit with minimal clinical significance. TXA resulted in better visualization of the field throughout the procedure.

Subxiphoid robotic extended thymectomy - The first Indian report.

Background:Minimally invasive thymectomy is fast becoming the preferred approach for myasthenia gravis and non-invasive thymoma. The most commonly employed approach for minimally invasive thymectomy is the lateral thoracic approach. Safe achievement of radical resection requires adequate visualisation of both the phrenic nerves along their entire course. In our experience, such visualisation is rather difficult with unilateral transthoracic approaches. We herein describe our technique and initial experience of 25 cases with subxiphoid robotic thymectomy (SRT) for myasthenia gravis with or without thymoma. To the best of our knowledge, this is the first such report from India.Subjects and Methods:We retrospectively analysed data of patients who underwent SRT at our centre from June 2017 to September 2018. Twenty-five consecutive patients were analysed, and demographic data, total duration of the procedure, console time, blood transfusion requirement, duration of chest drainage, length of hospital stay, pain score on post-operative day (POD) 1 and day of discharge and post-operative morbidity and mortality within 90 days were recorded.Results:A total of 25 patients underwent SRT. All our patients had myasthenia gravis with 4 of them having thymoma. There were 11 males and 14 females with mean age of 29.30 years (range 23–48). The mean console time was 102.85 min (range 88–120) while the mean total operative time was 199.14 (range 180–220). On first POD 1, visual analogue scale score average was 5, and at discharge, it was 2. There was no 30-day or 90-day mortality. All cases of thymoma had a complete R0 resection.Conclusion:Our experience suggests that subxiphoid approach offers a good operative view of the thymus in cervical region along with easy identification of bilateral phrenic nerves. Thus, SRT can be performed safely with comparable results.

Our tips for bronchoplasty using suture holder and tourniquet.

Bronchial anastomosis is an important part of successful bronchoplasty, but it takes time to achieve stable results because of few opportunities to do it. To ensure a stable outcome, we have applied some tips for bronchial anastomosis. One of the tips is the use of a suture holder to obtain appropriate suture pitches, adjusting the discrepancy of the bronchial diameter, and another one is the use of a tourniquet to obtain an adequate tension upon tying the knots, ensuring good operative view.

Safe approach to the splenic hilum by first mobilizing the pancreatic tail in laparoscopic splenectomy.

We employed a safe approach during laparoscopic splenectomy by first mobilizing the pancreatic tail and then dissecting the splenic vessels at the splenic hilum before mobilizing the spleen. Patients were placed in the lithotomy position, and only the upper body was twisted to the right side. Five trocars were placed. After the bursa omentalis was opened, an avascular layer was identified behind the pancreas. This avascular layer was bluntly dissected, and the pancreatic tail was isolated from the retroperitoneum. The tissue surrounding the splenic hilum was dissected by a handling tape that was placed around the pancreatic tail. Because the spleen remained connected to the retroperitoneum with the splenorenal ligament, a good operative view of the splenic hilum was obtained with proper extension. After sufficient space was secured between the pancreatic tail and the spleen, the splenic vessels were divided with a linear stapler. The spleen was detached in the final stage. The current standardized procedure is highly recommended for a safe laparoscopic splenectomy.

The efficacy of thoracoscopic fissureless lobectomy in patients with dense fissures

Prolonged air leakage after a lobectomy remains a frequent complication in patients with dense fissures. To avoid postoperative air leakage, we used the "thoracoscopic fissureless technique" for patients with dense fissures. A thoracoscopic approach is useful for the fissureless technique because it gives a good operative view from various angles without dividing the fissure. In this study, we compared the peri- or intraoperative results of thoracoscopic fissureless lobectomies to traditional lobectomies with fissure dissection for pulmonary artery (PA) exposure in order to identify the efficacy of thoracoscopic fissureless lobectomy. Between April 2012 and November 2015, 175 patients underwent a thoracoscopic lobectomy with three or four ports, of whom 14 underwent a fissureless lobectomy because of dense fissures. We compared the characteristics and perioperative outcomes of the patients who underwent the fissureless technique (fissureless technique group, n=14) and the traditional fissure dissection technique for PA exposure (traditional technique group, n=161). In our department, fissureless lobectomy is indicated for patients with a fused fissure (fissural grade III or IV as proposed by Craig in 1997) or inflammation makes it difficult to expose the PA, while the traditional technique is used for other patients. Although the fissureless technique group had longer operation time than the traditional technique group (P=0.0045), there was no significant inter-group difference about blood loss (P=0.85), occurrence rate of intraoperative massive bleeding (P=0.6) or conversion rate to thoracotomy (P=0.31). According to postoperative results, there was no significant inter-group difference in duration of chest tube drainage (P=0.56), length of postoperative hospital stay (P=0.14), or morbidity rate (P=0.16). No mortality occurred in either group. A thoracoscopic fissureless lobectomy is feasible and safe, and useful to avoid postoperative air-leakage in patients with dense fissures.

Modified Transsubxiphoid Thoracoscopic Extended Thymectomy in Patients with Myasthenia Gravis.

We developed a new minimally invasive thoracoscopic technique of extended thymectomy for myasthenia gravis by combining a subxiphoid incision with dual costal margin incisions. In our experience of 31 consecutive cases, this procedure provides a good operative view in the neck region and makes verification of the bilateral phrenic nerves easy. All the patients recovered smoothly with less trauma, less bleeding, less complication, and good cosmetic results. This modified transsubxiphoid approach is a satisfactory procedure for performing extended thymectomy in patients with myasthenia gravis.

Trans-subxiphoid robotic thymectomy

Minimally invasive surgery has replaced median sternotomy for resectable anterior mediastinal masses and is performed by various approaches. We developed a new minimally invasive surgical procedure by combining the subxiphoid approach performed through a midline camera port with the use of a robotic surgery system (Intuitive Surgical, Sunnyvale, CA, USA). A 3-cm transverse incision was made 1 cm below the xiphoid process. Then, a port designed for single-port surgery was inserted. Through this port, CO2 gas was injected at 8 mmHg. The thymus was then detached from the back of the sternum. A 1-cm skin incision was made bilaterally in the sixth intercostal space, followed by insertion of a port for the robotic system. A camera port was inserted into the subxiphoid port, to which the camera scope was mounted, and thymectomy was performed. We have performed the operation in 3 patients. In our experience, this procedure provides a good operative view in the neck region and makes verification of the phrenic nerve easy. Furthermore, with the da Vinci surgical system, which enables surgical manipulation from a correct angle due to the multijoint robotic arms, trans-subxiphoid robotic thymectomy may be a promising new thymectomy procedure.

Bronchoplasty with continuous sutures for non-small-cell lung cancer

Bronchoplasty is sometimes performed in patients with compromised lung function to preserve functional lung parenchyma. Although the bronchial anastomosis was generally performed with interrupted sutures, we applied it with continuous sutures by using monofilament absorbable material in two patients with non-small-cell lung cancers to obtain a good operative view and shorten the operating time. These patients recovered uneventfully with good healing of the bronchial anastomosis. Bronchial anastomosis with continuous sutures is considered a useful technique.

Main bronchial sleeve resection and bronchoplasty without removing lung parenchyma

We applied main bronchial sleeve resections without removing lung parenchyma and bronchoplasty in two patients with metastatic lung cancer and squamous cell carcinoma in situ. Main bronchial sleeve resection without removing lung parenchyma is generally considered technically difficult, as the remaining lung prevents the surgeon from obtaining good operative views; this means that the bronchial anastomosis must be performed in the deep, narrow space of the thorax. However, the two patients showed excellent results. Postoperative bronchoscopy ensured patency of the bronchial lumen in both patients. We believe that the surgeon can obtain a good operative view by resecting Botallo's ligament or by traction of the trachea and main pulmonary artery in cases involving lesions such as polypoid tumors toward the internal lumen of the bronchus, leading to successful results.

Intrapericardial approach via median sternotomy for hilar non-small cell lung cancer invading the main pulmonary artery

We describe a successful resection of the main pulmonary artery (MPA) using an intrapericardial approach via a median sternotomy in a patient with large hilar non-small cell lung cancer (NSCLC) invading the left MPA and Botallo's ligament. This approach was able to provide a good operative view even for the large hilar tumor, with easier and safer resection of the MPA, unlike the anteroaxial or posterolateral approach. This approach is a useful option for easy, safe and complete surgical resection in patients with NSCLC invading the MPA.

Selective segmental jet injection to distinguish the intersegmental plane using jet ventilation.

We used the selective jet injection method under bronchofiberscopy to distinguish the intersegmental plane. This method can reveal the intersegmental line clearly, quickly and easily with a good operative view even through a miniature utility thoracotomy or a thoracoscope, since only the burdened segment and not the entire lobe is inflated.

下行性壊死性縦隔炎に対する前方アプローチによる縦隔ドレナージ

We report a case of descending necrotizing mediastinitis treated by“anterior transmediastinal drainage”providing a good operative field view and excellrent drainage. A 56-year-man with a history of uncontrolled diabetes and chronic hepatitis transferred to our center had been diagnosed with phlegmon of the left anterior chest, neck and mediastinum. We conducted emergency cervical open drainage using a bilateral oblique incision to preserve the skin on the median side for tracheostomy and transcervical mediastinal drainage along the left vascular sheath. A tracheostomy tube was inserted obliquely from the right anterior, and anterior transmediastinal drainage conducted by partially resecting the third rib without thoracotomy directly reaching perivena caval space.

LAPAROSCOPIC CHOLECYSTECTOMY WITH AN ABDOMINAL LIFTING METHOD USING AN ORIGINAL LIFTING BAR

Since 1992 we have performed the laparoscopic cholecystectomy with an abdominal lifting method using an original lifting bar which was newly devised at our department for 100 patients with good results. Our original lifting bar is made of a stainless steel, 5 mm in diameter. It is inserted into the abdominal cavity beyond the right costal arch, is retracted enourh, and then offers a good operative view. This modified lifting bar is especially effective for the obese patients. Our lifting method enables us to use usual operating instruments such as gauze, electric cautery with a long hilt used for laparotomy, and is convenient for aspiration and washing. The method has the advantage that laparoscopic cholecystectomy can be safely performed for the patients with cardiopulmonary complications or those with poor goneral condition without risk of causing pneumoperitoneum.

Abdominal wall lifting with subcutaneous wiring: an experience of 50 cases of laparoscopic cholecystectomy without pneumoperitoneum.

Abdominal wall lifting is a method to produce operative space between the anterior abdominal wall and the intra-abdominal organs during laparoscopic surgery. We devised a hanger lifting procedure for the anterior abdominal wall to avoid complications as well as reduce the costs related to the pneumoperitoneum. In our series, we performed 50 cases of laparoscopic cholecystectomy with this abdominal wall-lifting procedure. Though at the beginning we performed laparoscopic cholecystectomy by the pneumoperitoneum, we discarded the insufflator for this operation since starting the new procedure. There was no incidence of conversion to pneumoperitoneum and a fairly good operative view was achieved enabling a smooth laparoscopic cholecystectomy.