Increase In Surgical Time Research Articles

Robotic arm assisted total knee arthroplasty workflow optimization, operative times and learning curve

Robotic arm assisted total knee arthroplasty (RTKA) has many potential benefits including advanced preoperative templating, restoration of mechanical alignment, accuracy of bony resection, robust safety mechanisms, and dynamic gap balancing. One of the most frequently quoted drawbacks preventing experienced surgeons from adopting this technology is the perceived increase in surgical time. This technique paper outlines the general concepts used to improve operating room efficiency as well as the step-by-step workflow to consistently perform RTKA with surgical times under 60 minutes. Although the clinical and functional results of RTKA are just beginning to be described in literature, this manuscript demonstrates that with proper technique and workflow, surgical time should not be a significant factor to deter surgeons from adopting this new technology.

Complicated Tibial Plateau Fractures In Young Patients: Functional Outcome With Dual Plating Via two Incision Technique

Objective: Motorbike accidents contribute one of the most important factors of tibial plateau fracture among young populations in Karachi Pakistan. Most surgeons feel challenging to treatment complicated bicondylar fractures of the tibial plateau.This prospective study was designed to evaluate the functional outcomes of dual plating through a two-incisions technique for the fixation of complicated bicondylar tibial plateau fractures in young patients in Karachi Pakistan. Methods: This prospective study includes 94 cases of Type V and VI tibial plateau fractures of young patient’s age range from 15 to 45 years, operated between January 2014 and December 2016 conducted in two public sector hospital of Karachi Pakistan (Jinnah Post Graduate Medical Center, Civil Hospital Karachi). Exclusion criteria include patients with multiple fractures on the same side or same bone, age >45 years, open contaminated fracture, open fracture,and patients with head injuries. All cases were operated either by lateral locking plate fixation by anterolateral approach or dual plating through double incisions. These all cases were followed for a minimum of 24 months radiologically and clinically. The statistical analysis was performed using software SPSS 20.0 to analyze the data. Results: A total of 94 patients (45 Single Plating and 49 Dual Plating)were operated during the study period of 2 years. However, four patients (4 single plating and 0 dual plating) were lost during follow-up who could not be tracked. Both groups were somewhat similar in relation to the age, mechanism of injury, fracture pattern, and soft tissue injury. Preoperatively, there was a significant increase in surgical time with the dual plating group; however, the mean time of reduction between the two groups was not significant. The decision to put bone graft was at the choice of the operating surgeon and was an intra operative decision with 74 (78.7%) patients receiving the bone graft. Post-operatively, there was no immediate difference in between the groups considering thermal alignment and reduction. It took approximately 4–5 months for the fractures to get united. There was normal union,non union or implant failure seen among those patients. There were 10 cases with superficial infection in wounds of dual plating group which were treated with culture sensitive antibiotics for average 2 weeks, healed subsequently. There were three patients found having an incidence of deep infection in a double plating group, wherein 2 patients were positive with Staphylococcus aureus and 1 patient with Escherichia coli was isolated. Extensive wound irrigation and lavage with antibiotic cement beads were given. Repeated irrigation and lavage were done again after 2 weeks with the removal of beads followed by prolonged course of antibiotic therapy for 6 weeks after which the infection resolved.A total of 38 (77%) patients in a double plating group regained full flexion (135°) and full extension (0°) with a good alignment and no pain and instability as compared to single plating group, seen in 30 (66%) patients at follow-up. Conclusion: Dual plating by two-incision method resulted in better functional outcome regarding limb alignment and range of movements at knee joint with an acceptable soft tissue complication rate in young patients. Keywords: Complicated tibial plateau fracture, Young patients, Double incision, Dual plating.

A Prospective, Randomized Study of Surgical Positioning Software Shows Improved Cup Placement in Total Hip Arthroplasty.

Several technologies are available to assist surgeons with acetabular component positioning in total hip arthroplasty. The purpose of this study was to determine whether surgical positioning software would improve cup position compared with fluoroscopy. This prospective, randomized study compared 200 primary total hip arthroplasty cups placed with and without surgical positioning software. All cases were performed by a single surgeon using the direct anterior approach with fluoroscopy. The target abduction and anteversion angles were set at 40° and 20°, respectively, and measured postoperatively. Cup placement time, total fluoroscopy time, and cup position were compared between groups. Mean abduction was 40.4° (range, 32.7°-49.0°) in the software group compared with 42.3° (range, 33.7°-51.1°) in the control group. The cups placed using software were significantly closer to the target abduction angle (P<.001) with fewer outliers. Mean anteversion was 20.8° (range, 11.2°-31.7°) in the software group compared with 21.8° (range, 11.3°-34.3°) in the control group (P=.063). Eighty-seven percent of cups in the software group fell within 5° of the abduction target, compared with only 68% in the control group (P<.01). Cup placement took longer in the software group (7:04 minutes vs 4:58 minutes, P<.001), and 2 seconds more total fluoroscopy time was used in that group as well (12.9 seconds vs 11.1 seconds, P<.001). The software improved both the accuracy and the precision of cup placement, with only modest increases in surgical time and fluoroscopy time. [Orthopedics. 2019; 42(1):42-47.].

INGUINAL REPAIR VIA ROBOTIC ASSISTED TECHNIQUE: LITERATURE REVIEW.

ABSTRACTIntroduction:Inguinal hernia is one of the most frequent surgical diseases. Currently, with the advantages of minimally invasive surgery, new questions arise: what will be the best approach for correction of inguinal hernia? Is there real benefit to the robotic approach? Objective:To compile results of the published studies that used the robot-assisted technique in the repair of inguinal hernia, analyzing its limitations, complications and comparing it with those of the pre-existing techniques. Method:The review was performed from the Medline database with the following descriptors: (inguinal hernia repair OR hernioplasty OR hernia) AND (robot OR robotic OR robotic assisted) being retrieved 391 articles. After verification of the titles and abstracts, we identified eight series of cases congruent with the objectives of this review. Three reviewers participated in the extraction and selection of results. Results:Comparative studies showed an increase in surgical time in relation to the open and videolaparoscopic approach. The complications present similar rates with the other repair routes. Conclusion:This technique has been shown to be effective for the correction of inguinal hernia, but the benefits of using robotic surgery are unclear. So, there is a need for randomized studies comparing laparoscopic to robotic repair

Intraoperative Cone Beam Tomography and Navigation for Displaced Acetabular Fractures: A Comparative Study.

To evaluate the accuracy of reduction of the acetabular articular surface using an intraoperative computed tomography scanner (O-Arm) and screw navigation compared with a classical open technique. Prospective matched cohort study. Tertiary referral center. Adult patients with acute acetabular fractures were included in the study. All patients were treated by 2 senior surgeons using intraoperative imaging and screw navigation. The primary outcome measure was articular reduction. Secondary outcomes were radiation dosage, operative variables [operative time, time for image acquisition, intraoperative bleeding (cell saver), number of surgical plates, and number of screws], and postoperative variables (first postoperative day pain on the visual analog scale, postoperative transfusion, and hemoglobin change). P < 0.05 was considered statistically significant. Thirty-five patients were treated in the inclusion period (2016-2017) and were matched to 35 cases in our database (2013-2016). Mean age was 43 years, and the most common fracture type was a both-column fracture (OTA/AO type C). Postoperative image analysis showed that reduction was achieved in 87.1% of the cases in the O-Arm group versus 64.7% in the control group (P < 0.05). Mean gap of the articular fragments was 3.6 mm in the O-Arm group compared with 5.6 mm (P = 0.01) in the control group. There was no significant difference between the 2 groups in regards to all other studied variables except a decrease in intraoperative blood loss and transfusions and an increase in surgical time with the O-Arm group. Finally, the total radiation dose was decreased using the intraoperative O-Arm compared with a routine postoperative computed tomography scan (dose length product in O-Arm: 498 mGy.cm; dose length product in historical group: 715 mGy.cm). Using intraoperative imaging and screw navigation for displaced acetabular fractures allow screw navigation with increasing articular surface reduction accuracy. Operative and anesthesia times were not increased, whereas radiation exposure to the patient was significantly decreased. We recommend the use of intraoperative imaging for the treatment of displaced acetabular fractures. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Surgical management of U/H type sacral fractures: outcomes following iliosacral and lumbopelvic fixation.

U and H-type sacral fractures are under diagnosed injuries resulting from significant axial loading that are often associated with neurological deficits. No studies to date have compared two common methods of surgical fixation, iliosacral screw fixation (ISF) and lumbopelvic fixation (LPF). Patients with sacral fractures from 2009-2015 at one level 1 trauma center were identified by current procedural terminology (CPT) code and imaging reviewed for U/H type sacral fractures. Four hundred and fifty-three sacral fractures were identified during the study period, of which sixteen patients met inclusion criteria for the study. Six patients had the presence of a documented neurological injury at the time of presentation, 9 patients had concurrent spine fractures and 10 patients had concurrent pelvic fractures. Eight patients underwent ISF and 8 patients underwent LPF. There was no significant difference between the two groups in regards to age, intensive care unit (ICU) requirement, length of stay, or estimated blood loss. There was a significant increase in surgical time in the LPF group (P=0.002). In addition, there was a significant difference between those patients that underwent ISF that were discharged to a rehab facility compared to those treated with LPF (P=0.04). Patients with U/H type sacral fractures can be treated with ISF or LPF without an expected increase in hospital length of stay (LOS) or need for ICU. Treatment with LPF may increase operative time however; the patient is more likely to be discharged to home instead of a rehab facility.

Effect of body mass index on patient outcomes of surgical intervention for the lumbar spine.

Conflicting findings exist on the effect of obesity on outcomes of lumbar spine surgery; results depend on the diagnosis studied, procedure evaluated, definition of obesity, and specific outcomes measured. The purpose of this retrospective cohort study is to examine the effect of increasing body mass index (BMI) on surgical-related, health-related, and long-term outcomes of lumbar spine surgery in a single representative patient sample. Using a surgical registry from an integrated health care system, 8,049 instrumented lumbar spine cases were identified between 1/1/2009 and 09/30/2013. The sample was stratified into five BMI categories. Outcomes of interest included: (I) surgical-related factors and complications; (II) health-related complications; and (III) long-term complications. Mixed linear models, conditional logistic regressions, and survival analysis using a Cox regression model were conducted controlling for surgeon effects. Age, gender, diabetes status, smoking status, admitting diagnosis, and surgical approach were included as covariates. Every 5 kg/m2 increase in BMI was associated with a significant increase in surgical time (7.8 minutes), estimated blood loss (EBL) (36.5 mL), risk of deep infection (OR =1.7 times), and deep vein thrombosis (DVT) (OR =1.5). BMI was not associated with increased incidence of other intraoperative or health-related complications. Rate of re-operation was 1.1 times higher with every 5 kg/m2 increase in BMI, but rate of re-operation due to adjacent segment disease (ASD) was not associated with BMI. Obesity had an adverse effect on certain surgical-related, health-related and long-term surgical outcomes. The magnitude of this effect increased with increasing levels of obesity, which increases the medical burden associated with obesity.

Robotic radical prostatectomy with concomitant repair of inguinal hernia: is it safe?

Robotic radical prostatectomy (RARP) is well established as a safe and effective treatment for prostate cancer. According to published studies, patients undergoing RARP are at increased risk of being diagnosed with an inguinal hernia after RARP and are four times more likely to have an inguinal hernia repair (IHR) following RARP. Several studies have demonstrated the effectiveness and safety of IHR during RARP. Overall, it has been observed that IHR adds on average, 12-15min in total surgical time and there were no significant differences between RARP with or without IHR with respect to postoperative complications. This study analyzes a large series of patients undergoing RARP (1100) and compares them to a group that underwent RARP with IHR (39). Between December 2008 and January 2015, 1139 patients underwent RARP at Florida Hospital in Celebration, FL. Of the total patients, 39 underwent concomitant IHR. All procedures were performed by the same surgeons (urologist and general surgeon), using the same techniques of RARP and TAPP inguinal hernia repair. After 30days, the differences were evaluated between groups regarding surgical time, EBL and postoperative complications. The average age of patients undergoing the procedure was 61.65years. The mean procedure time was approximately 120min (min), with an additional period of 68min for IHR (mean=188; p=0.0001). There was a significant difference in BMI between the groups, 28.3kg/m2 for patients undergoing RARP and 26.8kg/m2 for those who underwent RARP and IHR (p=0.028). The EBL averaged 110.87mL, with no significant difference between groups (p=0371). There was no significant association between clinical stage of the patient and the type of procedure performed (p=12:35). There was no significant difference in the presence of comorbidities and the operation preformed. There were 61 events recorded postoperatively, 57 (5.2%) among patients who underwent only RARP and 4 (10.26%) among those who had both. Taken together, the small amounts of complications in both groups prevent statistical significance. This study compared two groups of patients undergoing RARP: those with IHR and those without. Our study demonstrated an increase in surgical time; however, there was no increase in postoperative complications. From the data presented, we suggest that the performance of both procedures concomitantly is feasible and safe.

Operative Intervention of Supracondylar Humerus Fractures More Complicated in July: Analysis of the July Effect.

The "July Effect" involves the influx of new interns and residents early in the academic year (July and August), which may have greater potential for poorer patient outcomes. Current orthopaedic literature does not demonstrate the validity of this concept in arthroplasty, spine, hand, and arthroscopy. No study has investigated the possibility of this effect on common pediatric orthopaedic procedures, such as closed reduction and percutaneous pin fixation of supracondylar humerus fractures. A retrospective review of all type II or III supracondylar humerus fractures that underwent primary closed reduction and percutaneous pin fixation (CPT code 24538) at a single pediatric level 1 trauma center from July 2009 to June 2013. Patients were grouped according to time in the academic year: early (July and August) and late (May and June). Demographic data included length of follow-up, age at surgery, sex, side of injury, and Wilkin's modified Gartland classification. Outcomes included length of operation, number of pins used, length of stay, complications, and the need for repeat surgery. There were 245 patients, 101 in the early and 144 in the late group. There was no increase in surgical time [33.32±24.74 (early) vs. 28.63±10.06 (late) min, P=0.07) or complication rates [7.0% (early) vs. 2.1% (late), P=0.06) between the early and the late groups. Cases performed with junior residents demonstrated longer operative (31.72±17.07 vs. 28.96±18.71 min, P=0.02) and fluoroscopy (48.63±30.96 vs. 34.12±27.38 s, P=0.01) times. The academic orthopaedic surgeon must ensure the education of residents, while providing the highest level of safety to patients. Our study shows that education of young residents early in the academic year results in no increase in operative times, radiation exposure, or complications. Level III.

Low field intra-operative magnetic resonance imaging for brain tumour surgery: Preliminary experience

ObjectivesIntra-operative magnetic resonance imaging (iMRI) is a recently introduced tool in the most advanced neurosurgical operating rooms worldwide. We present our preliminary experience in brain tumour surgery with low field PoleStar N30® intraoperative MRI since its introduction in 2013 in the Barcelona Clinic Hospital. Material and methodsA prospective non-randomised study was conducted on cases operated on using iMRI and intention of complete removal up to October 2015. A record was made of the data as regards surgical times, resection rates, histological diagnosis, hospital stay, and survival rates during follow-up. ResultsThe study included 50 patients, with a mean age of 55 years (±13.7), a preoperative mean Karnofsky of 92 (being 81 post-operatively), and a mean follow-up of 10.5 months (±6.5). There were 26% re-operations due to recurrence. High-grade gliomas were reported in 56%, low-grade gliomas in 24%, and 20% “Other” tumours. Overall hospital stay was 10 days (±4.5). Depending on the histologiacl diagnosis, the “Others” group had a longer hospital stay. Overall, there were 52% complete removal, 18% of maximum removals, and 30% of partial removals. The overall survival rates during follow-up was 84%. ConclusionsiMRI is a safe and effective tool for brain tumour surgery. Its use allows an increase in resection rates, and minimises post-operative complications. Its implementation involves an increase in surgical time, which improves with the characteristic learning curve. More studies are needed to establish its role in the long-term survival of patients.

Safety outcomes of female sterilization by salpingectomy and tubal occlusion

ObjectiveCompare immediate and short-term complications and surgical times among women having laparoscopic salpingectomy or tubal occlusion for female sterilization. Study designWe used billing data to identify women having laparoscopic sterilization at our training institution between July 1, 2011, and June 30, 2015. We performed a retrospective chart review to extract demographic information, surgical times and complications within 30 days, including unscheduled clinic or emergency room visits. We categorized complications as immediate (prior to discharge) and short-term (within 30 days after the procedure). Surgeries including additional procedures other than IUD removal were considered mixed operations. Mixed operations and unilateral sterilization procedures were only included in safety evaluations. ResultsThe 149 procedures included 81 salpingectomies (including 18 mixed operations and 2 unilateral salpingectomies) and 68 tubal occlusions (including 8 mixed operations). All procedures involved Obstetrics and Gynecology residents. Salpingectomy and occlusion procedures had similar immediate (2.5% vs. 2.9%, p=1.0) and short-term (4.9% vs. 14.7%, p=.051) complication rates. Surgical time averaged 6 min longer for salpingectomies than occlusion procedures (44 vs. 38 min, respectively, p=.018). Average surgical times were shorter with more experienced (3rd/4th year) residents than less experienced (1st/2nd year) residents for both salpingectomy (32±18 min vs. 46±13 min, respectively, p=.124) and occlusion procedures (32±13 min vs. 41±12 min, respectively, p=.026). ConclusionSalpingectomy for female sterilization takes slightly longer to complete than tubal occlusion procedures without evidence that it increases complications. Implications statementLaparoscopic salpingectomy is a safe alternative to tubal occlusion with only a small increase in surgical time. Because salpingectomy offers higher efficacy and more ovarian cancer protection than occlusion procedures, salpingectomy should be an option offered to women seeking laparoscopic sterilization.

Comparison of Direct Pars Repair Techniques of Spondylolysis in Pediatric and Adolescent Patients

Retrospective clinical cohort study. To compare the clinical and radiographic outcomes of patients who were treated with intrasegmental pars fixation by either laminar compression screw (LS) or a pedicle screw, rod, and laminar hook (PSRH) construct. Spondylolysis is a nonunion defect of the pars interarticularis. In symptomatic spondylolysis, direct repair of the pars interarticularis defect can preserve motion and prevent abnormal stresses at the adjacent levels. Sixteen patients who failed nonoperative treatment and underwent direct pars repair by using LS (n=9) or PSRH (n=7) constructs were included in the study. Clinical outcome was assessed by using the MacNab criteria. Radiologic fusion and complications were evaluated using plain radiographs or computed tomography images and patient charts. The healing rate was 100% after 6 months. The healing time was similar in both the groups: LS, 6.5 months; PSRH, 6.2 months. Patients with PSRH (5.9 mo) were more likely to return to sports earlier relative to patients with LS (7.7 mo). There were no complications in the LS group; in the PSRH group, 1 patient had mild sensory deficit and 2 had superficial wound infections. The MacNab criteria for pain assessment showed an excellent or good outcome in 8 of 9 patients in LS group and 6 of 7 patients in PSRH group. Relative to LS patients, there was a significant increase in surgical time and estimated blood loss among PSRH patients. Either of the mentioned 2 techniques appears to produce acceptable results. Biplanar fluoroscopy and navigation systems could minimize the risk of screw misplacement with LS construct. Familiarity with the various fixation techniques will allow the surgeon to select the most appropriate surgical technique.

Laparoscopic or traditional bitch spay? A comparison of surgical technique, associated risks and benefits

ABSTRACT:In the bitch, surgical sterilisation can be achieved by a number of different methods. Ovariohysterectomy via a midline coeliotomy is the method traditionally used in the UK. An alternative to ovariohysterectomy, which is being used more widely, is laparoscopic ovariectomy (LapOVE). Laparoscopic surgery involves the introduction of a camera and specialised instruments into the abdomen through small incisions, and is routinely used in human medicine.The benefits of laparoscopy include a faster return to normal activity and decreased post-operative pain, as well as a lower risk of haemorrhage and other recognised complications. Some complications, such as gas embolism and increased arterial CO2 levels, are specific to laparoscopy.Laparoscopy requires specialist equipment which carries a high start-up cost; this can deter many practitioners from offering it to their clients. In addition, significant increases in surgical time are documented with LapOVE.Due to the risk of complications and the specialist equipment required, it is imperative that veterinary nurses have complete and up-to-date knowledge regarding laparoscopic neutering in order to provide the best possible patient care.

Robotic Assisted Surgery for Endometriosis—“Is the Way Forward?”

Endometriosis is a chronic and progressive gynecologic disorder that affects 10% - 50% of women of reproductive age worldwide. Chronic pain and infertility are the most debilitating problems associated with it requiring both medical and surgical treatment. Laparoscopy is considered the gold standard for diagnosis and treatment. However, a 10% rate of conversion to laparotomy has been reported when performed by skilled laparoscopic surgeons and much higher in low volume less skilled surgeons. To improve surgical outcomes, robotic assistance is the logical next step in performing minimally invasive gynecological surgeries, especially in complex endometriosis cases. Enhanced 3D visualization and 10× magnification along with Endowrist instruments with seven degrees of freedom facilitates precise and careful dissection. Firefly technology using ICG green dye can improve detection of small and invisible lesions. Robotics is useful in deep infiltrating disease manifesting as lesions deeper than the superficial tissues of rectovaginal septum, vaginal fornix, pelvic sidewalls, parametrium, bowel or ureter and bladder. Trials show no increase in surgical time, blood loss, or intra- or postoperative complications and similar clinical outcome when robotics is compared with laparoscopy. At present, it is more appropriate to compare it with laparotomy rather than laparoscopy. Robotics can be used to manage recurrence of endometriosis after hysterectomy. Surgeons experienced in conventional laparoscopy can utilize robotic platform for deep infiltrating endometriosis for performing complex surgical dissection and achieving the surgical goals in mind and reduce conversions to open surgery. Robotic assistance can bridge the gap in performance of laparoscopic surgery in advanced endometriosis.

Surgical team turnover and operative time: An evaluation of operating room efficiency during pulmonary resection

ObjectiveHealth care resources are costly and should be used judiciously and efficiently. Predicting the duration of surgical procedures is key to optimizing operating room resources. Our objective was to identify factors influencing operative time, particularly surgical team turnover. MethodsWe performed a single-institution, retrospective review of lobectomy operations. Univariate and multivariate analyses were performed to evaluate the impact of different factors on surgical time (skin-to-skin) and total procedure time. Staff turnover within the nursing component of the surgical team was defined as the number of instances any nurse had to leave the operating room over the total number of nurses involved in the operation. ResultsA total of 235 lobectomies were performed by 5 surgeons, most commonly for lung cancer (95%). On multivariate analysis, percent forced expiratory volume in 1 second, surgical approach, and lesion size had a significant effect on surgical time. Nursing turnover was associated with a significant increase in surgical time (53.7 minutes; 95% confidence interval, 6.4-101; P = .026) and total procedure time (83.2 minutes; 95% confidence interval, 30.1-136.2; P = .002). ConclusionsActive management of surgical team turnover may be an opportunity to improve operating room efficiency when the surgical team is engaged in a major pulmonary resection.

Quantifying and Predicting Surgeon Work Input in Primary vs Revision Total Hip Arthroplasty

BackgroundPrimary total hip arthroplasties (THAs) performed annually are projected to increase 174% by 2030, causing a parallel increase for revision THA. Increased surgical effort and readmission rates associated with revision THA may discourage surgeons from performing them. Although revision THA Medicare reimbursement is greater, it may be disproportionate to time and effort. We examined work input between primary and revision THA, assessing predictive factors. We also compared surgeon work input to current reimbursement. MethodsA total of 156 patients were identified, 80 primary and 76 revision THA. Demographic, clinical, and radiographic data were collected. Radiographic data were collected from the most recent preoperative radiographs taken before primary or revision THA. Multiple linear and logistic regression models were used to identify patient factors contributing to select outcome variables by a stepwise method, with a probability value for entry (P = .05) and removal (P = .10). Residual analysis was performed, confirming validity of these models. ResultsAverage age, body mass index, and percentage of female patients were similar between cohorts. There was no statistically significant difference between the demographic variables, although data revealed patient variables contributing to statistically significant increases in surgical time, length of stay, blood loss, and complications with revision THA. ConclusionDespite a 66% increase in “percent effort” and 3-fold higher readmission rate, revision THA requires at least a 2-fold increase because of nonquantifiable factors. Revision THA demonstrates a substantial increase in work effort not commensurate with current Medicare reimbursement, which may force surgeons to limit or eliminate revision arthroplasties performed reducing access to patient care.

Perioperative risk factors for surgical site infection in tibial tuberosity advancement: 224 stifles.

To examine perioperative factors affecting surgical site infection (SSI) rate following tibial tuberosity advancement (TTA). Retrospective case series. 224 stifles in 186 dogs. Medical records of dogs that underwent TTA in a single institution were reviewed. Information on signalment, anaesthetic and surgical parameters, as well as occurrence of SSI was recorded. Dogs were followed for a minimum of three months postoperatively. The association between perioperative factors and SSI was assessed using Chi-squared tests and binary logistic regression. The prevalence of SSI was 5.3% (12/224 TTA). Surgical time (p = 0.02) and anaesthesia time (p = 0.03) were significantly associated with SSI. For every minute increase in surgical time and anaesthesia time, the likelihood of developing SSI increased by seven percent and four percent respectively. The use of postoperative antimicrobial therapy was not significantly associated with lower SSI (p = 0.719). Implants were removed in 1.3% of cases (3/224 TTA). The findings of this study suggest that increased surgical and anaesthesia times are significant risk factors for SSI in TTA, and that there is no evidence that postoperative prophylactic antimicrobial therapy is associated with SSI rate.

Place de la robotique dans l’endométriose pelvienne profonde : à propos du registre de la SERGS

ObjectivesTo assess the interest of robotic-assisted laparoscopy in the context of deep infiltrating endometriosis and to investigate perioperative results. Patients and methodsFrom November 2008 to April 2012, 164 women with stage IV endometriosis who underwent robotic-assisted laparoscopy (DA VINCI Intuitive Surgical System®) were included by eight international participating clinical centers. Patients were divided in 4 groups according to the localization of the nodule(s): rectum (n=88), bladder (n=23), ureter and uterosacral ligaments (n=115) et hysterectomy (n=28). We evaluated the procedures performed, the duration of intervention, the complications, the recurrence and the impact on fertility. ResultsIn the rectum group, there was a laparotomy conversion, 2 sutured rectal injuries and a red cells blood transfusion. In the bladder group, there was a vesicovaginal hematoma and a prolongated intermittent self-catheterization. In the ureter and uterosacral ligaments group, there was 2 ureteral fistulas and there was no complication in the hysterectomy group. Discussion and conclusionThis study is the largest series published in the literature on robotic-assisted laparoscopy for deep infiltrating endometriosis. The interest of robotic-assisted laparoscopy in deep infiltrating endometriosis seems to be promising while no increase in surgical time, blood loss, and intra- and postoperative complications were observed.

Biomechanical Comparison of Arthroscopic Repair Constructs for Meniscal Root Tears

Background: Complete meniscal root tears render the meniscus nonfunctional. Repair constructs have been presented and tested; however, prior studies have evaluated suture patterns placed ex vivo without simulating an in vivo surgical setting. This study introduces a new double-locking loop suture pattern and compares its biomechanical properties and execution time with commonly used suture patterns. All constructs were performed using an all-inside arthroscopic technique. Hypothesis: Complex suture repair constructs have higher failure loads, stiffness, and execution times compared with simple constructs. Study Design: Controlled laboratory study. Methods: Sutures were placed arthroscopically into the posterior horn root region of the medial and lateral menisci in 21 cadaveric knees. Four repair constructs were evaluated: 2 simple sutures (2SS), 1 inverted mattress suture (1MS), 1 double-locking loop suture (1DLS), and 2 double-locking loop sutures (2DLS). In total, 40 posterior meniscal roots were tested, with 10 trials for each construct. After arthroscopic placement of the root repair constructs, each meniscus was explanted and tested to failure on a uniaxial materials testing machine. The Kruskal-Wallis test was used to evaluate for the significance of maximum failure loads and stiffness between groups. Results: The mean maximum failure loads were 137 ± 49 N (2SS), 126 ± 44 N (1MS), 186 ± 43 N (1DLS), and 368 ± 76 N (2DLS). Interconstruct comparison revealed a statistical difference between 2DLS and all 3 remaining constructs (P < .01) and 1DLS when compared with 2SS and 1MS (P < .01 for both). Statistical significance was not found between 2SS and 1MS (P = .8). The mean times for repair of the 4 fixation techniques were 1.8 ± 0.9 minutes (2SS), 2.4 ± 1.9 minutes (1MS), 4.7 ± 2.0 minutes (1DLS), and 5.4 ± 0.6 minutes (2DLS). Conclusion: The double-locking loop suture repair technique had significantly higher failure loads compared with the 3 other methods tested. As the complexity of repair constructs increases, failure loads and surgical times increase. Clinical Relevance: Complex suture patterns can be placed via an all-inside arthroscopic technique delivering higher failure loads for meniscal root repair with little increase in surgical time.

Strength of Arthroscopic Meniscal Root Repair Constructs

Clinical study has illustrated the prevalence of meniscal root injury and potential for degenerative sequel without repair. Repair constructs have been presented by authors, and repair strengths determined. However, prior studies have evaluated constructs placed ex vivo without method to place the strongest construct in an arthroscopic fashion nor strength evaluation of constructs placed arthroscopically. We present two new meniscal root repair constructs with arthroscopic technique and strength evaluation of arthroscopically placed repair constructs. Pullout strength, stiffness, and time of suture construct for the different meniscal repair patterns was evaluated. This will aid the clinician in determining the best method for arthroscopic meniscal root repair and aid in the development of appropriate postoperative rehabilitation plans. The hypothesis of this study is that maximum failure load, stiffness, and repair execution time will vary based upon suture construct, with higher strengths and execution times with increased repair technique complexity. Twenty cadaveric knees were mounted in a simulated surgical position, and sutures were placed arthroscopically at the root of the medial and lateral menisci. Four repair constructs were tested including 2 novel repair constructs: 2 simple stitches, 1 inverted mattress stitch, 1 double locking loop stitch, and 2 double locking loop stitches. Arthroscopic placement of suture repair construct was timed. In total 40 posterior meniscal roots, both lateral and medial from 21 cadaveric specimens were tested, with 10 trials for each construct. Specimens were dissected, and the medial and lateral menisci harvested. Individual meniscus specimens were cycled and then tested to failure on an Instron machine with a custom baseplate mimicking the transosseous suture tunnel utilized in meniscal root repair. The Kruskal-Wallis Test was used to evaluate for statistical significance between groups. The mean maximum failure loads were: 2 simple stitches (2SS) 137±49 N, 1 inverted mattress stitch (1MS) 126±44 N, 1 double loop locking stitch (1DLS) 201±44 N, 2 double loop locking stitches (2DLS) 396±69 N. Inter-construct comparison revealed statistical difference between 2DLS (p < 0.01) and all three remaining constructs (< 0.01), and 1DLS when compared to 2SS and 1MS (p <0.01, <0.01). Statistical significance was not found between 2SS and 1MS (p=0.8). The average time for repair of the 4 fixation techniques were: 2SS 1.78 ± 0.87 minutes, 1MS 2.40 ± 1.90 minutes, 1DLS 4.67 ± 2.01minutes, 2DLS 5.38 ± 0.62 minutes. Constructs with four suture limbs within the simulated repair tunnel illustrated stiffer constructs. Arthroscopically placed locking loop repair constructs are stronger than current arthroscopic techniques with increase in time of repair. As complexity of the repair construct increases so does time for fixation and pullout strength. With this study, an arthroscopic technique is presented to produce stronger meniscal root repair constructs with little increase in surgical time.