Invasive Surgical Repair Research Articles

The first four cases of successful NeoChord procedure in mainland China.

Transapical off-pump NeoChord procedure is a novel minimally invasive surgical repair of degenerative mitral regurgitation (MR). Here, we report the first four cases of NeoChord procedure in patients with mitral valve prolapse in mainland China. Four patients, aged 86, 84, 80 and 60 years, with severe MR due to posterior middle scallop prolapse (P2), underwent transapical off-pump artificial chordae implantation on April 9 and 10, 2019. The procedure was performed by left mini-thoracotomy under general anaesthesia and guided by 2D and 3D dimensional transoesophageal echocardiography (TEE). Mitral valve repair via NeoChord procedure was successfully performed with implantation of 3 artificial chordae in the first patient and 3, 2, and 3 artificial chordae in the following patients, respectively. Intraoperative TEE and pre-discharge transthoracic echocardiography (TTE) showed only mild to moderate MR of these four patients and no postoperative complications were noted. There were no changes of TTE finding between one-month follow-up and pre-discharge. The successful NeoChord procedures in four Chinese indicate that the valve repair using the NeoChord system for Chinese population is feasible.

The Periareolar Approach in Minimally Invasive Surgical Mitral Valve Repair—A Feasible, Safe, and Cosmetically Appealing Technique: A Report on 64 Patients

The Periareolar Approach in Minimally Invasive Surgical Mitral Valve Repair—A Feasible, Safe, and Cosmetically Appealing Technique: A Report on 64 Patients

Erratum to: Minimally Invasive Surgical Mitral Valve Repair: State of the Art Review.

[This corrects the article on p. 14 in vol. 13, PMID: 29593831.].

Endoscopic Gastrojejunostomy: A Novel Approach to Roux Obstruction Following Roux-en-Y Hepaticojejunostomy: 2017 Presidential Poster Award

Roux-en-Y hepaticojejunostomy (RYHJ) is a procedure generating a direct connection between the hepatic bile ducts and the jejunum. Major indications include biliary strictures and iatrogenic injuries while studies have also indicated a role in biliary cancer. We present a novel endoscopic treatment of a Roux limb obstruction following RYHJ for a cholangiocarcinoma. A 75-year-old female with a history significant for cholangiocarcinoma involving the extra-hepatic biliary tract underwent a RYHJ following complete biliary duct resection. Two months following surgery, she presented with abdominal pain with labs suggestive of cholestatic disease. Abdominal CT revealed a very large distended Roux limb (Figure 1), thus a percutaneous biliary drain (PBD) was subsequently placed. One month later, trial of internal biliary drainage was unsuccessful. Cholangiogram noted a patent PBD and hepaticojejunal anastomosis, however again indicated obstruction. To avoid open repair, endoscopic therapy was performed. Following a normal EGD, EUS revealed a dilated Roux limb abutting the gastric antrum (Figure 2). This was confirmed by visualization of both guide wire advancement and contrast injection into the PBD. Initial fistulizing was attempted using a Hot AXIOSTM stent system; however, device deployment failed. Under EUS, a 19g FNA needle was introduced into the limb with advancement of a guide wire. The FNA needle was exchanged for needle-knife instrumentation and multiple cutting passes were performed. The fistula was dilated with an 8mm balloon and two double-pigtail stents were deployed with excellent biliary return (Figure 3). Directional flow was verified under fluoroscopy with contrast injection through her PBD. Lastly, a cholangioscopy performed through the PBD, further confirmed the pigtail catheter placement within the Roux limb. Follow-up cholangiogram 2 weeks later noted patent stents, and the PBD was removed. Multiple EUS-guided techniques have been described in the literature for biliary obstructions. In 2014, a “modified RYHJ” reported fixing the distal Roux limb to the anterior gastric wall for secured endoscopic access should the need arise. However, this has not been universally implemented. Thus, with the recent paradigm shift to minimally invasive endoscopic interventions in an effort to circumvent invasive surgical repair, we have described a safe alternative for the treatment of Roux limb obstructions following a “traditional” RHYJ.Figure: CT abdomen and pelvis noting a distended Roux limb adjacent to the liver.Figure: EUS noting a distended Roux limb abutting the gastric antrum.Figure: Direct visualization with EGD of two double-pigtail stents within the gastric antrum.

Epidemiology and outcomes of Achilles tendon ruptures in the national football league

Rupture of the Achilles tendon is an increasingly common injury, particularly in physically active males, and current evidence favors minimally invasive surgical repair. We describe the case of a 36-year-old male elite bobsled athlete with complete rupture of the Achilles tendon. He was treated with surgical repair of the ruptured tendon using an innovative, minimally invasive procedure based on an internal bracing concept and was able to undergo early mobilization and aggressive physiotherapy rehabilitation. His recovery was such that he returned to training at 13 weeks postoperatively and participated in an international competition at 18 weeks, winning a World Cup silver medal. He subsequently raced at the 2014 Winter Olympic Games at 29 weeks after surgery. At >2 years since his injury, he has experienced no complications or reinjury. This represents an exceptional recovery that far exceeds the standard expected for such injuries. The use of this technique for athletes could enable accelerated return to sporting activity and attainment of their preinjury activity levels.

Minimally Invasive Surgical Mitral Valve Repair: State of the Art Review.

Minimally invasive surgical mitral valve repair (MVRepair) has become routine for the treatment of mitral valve regurgitation, and indications have been expanded to include reoperations. Current European Society of Cardiology/European Association for Cardio-Thoracic Surgery guidelines for the management of valvular heart disease recommended standards in terms of mitral valve disease differentiation, timing of intervention and surgical techniques to improve patient care. Numerous minimally invasive techniques to lessen the invasiveness have been described, such as the minimal-access J-sternotomy (ministernotomy), the parasternal incision, the port-access technique and the right minithoracotomy. Despite the development of catheter-based techniques, surgical repair remains the gold standard today for nearly all patients with degenerative valvular diseases and the majority of patients with other types of valvular diseases. Techniques include resection of the prolapsed segment, neo-chordae implantation and ring annuloplasty. In this review, the current indications for mitral valve surgery are summarised and state-of-the-art MVRepair techniques are highlighted.

Conservative, minimally invasive and open surgical repair for management of acute ruptures of the Achilles tendon: a clinical and functional retrospective study.

At present, it is unclear which is the best management for Achilles tendon rupture. We assess the clinical, functional and imaging outcomes of active patients undergoing 3 different types of management for acute subcutaneous rupture of the Achilles tendon, including conservative cast immobilization, traditional open surgery and percutaneous repair. 26 active patients were managed for a rupture of the Achilles Tendon from January 2007 to March 2008. Anthropometric measurements, Functional assessment, Isometric strength, Ultrasonographic assessment, Patient satisfaction, Working life, Physical activity, Functional score and Complications were recorded retrospectively. All 23 (21 men, 2 women) patients were reviewed at a minimum follow-up of 24 months (average 25.7, range 24 to 32 months, SD: 6.3) from the index injury. Thermann scores and patient satisfaction were significantly higher following surgery than conservative management with no significance between open and minimally invasive operated patients. Sensitive disturbances occur in up to 12% of open repairs and 1.8% of patients managed nonsurgically. Clinical and functional outcomes following surgical repair, percutaneous and open, of the Achilles tendon are significantly improved than following conservative management. Level III.

Minimally invasive endoscopic repair of atrial septal defects via right minithoracotomy.

Atrial septal defect (ASD) repair has been conventionally performed via midline sternotomy with very low operative risk and excellent early and late outcomes. Recently, many of these patients with suitable anatomy are being treated with percutaneous catheter-based closure of their ASD, but issues of prosthetic device implantation, long-term antiplatelet therapy and late device complications persist. Minimally invasive repair of ASD via a 3-cm right minithoracotomy provides patients with a much less invasive surgical repair with all the durable benefits of autologous pericardial patch closure. However, widespread adoption of the minithoracotomy approach to ASD closure remains slow. This study describes the simple steps to ASD repair via a right minithoracotomy.

Hybrid two-stage repair of thoracoabdominal aortic aneurysm.

Thoracoabdominal aortic aneurysm is a challenging disease that often requires an invasive surgical repair. Recently, a less invasive hybrid approach has been proposed to improve postoperative outcomes in high-risk patients. It consists of an open first stage where arterial visceral rerouting is obtained, using a vascular graft followed by a second stage where the remaining thoracoabdominal aorta is covered with a stent graft. Initial results using this approach seem promising. Here, we sought to describe the hybrid two-stage technique that is most frequently used in this extensive aortic pathology.

Transfemoral Device Occlusion and Minimally Invasive Surgical Repair for Doubly Committed Subarterial Ventricular Septal Defects.

Transfemoral device occlusion and minimally invasive surgical repair are performed for doubly committed subarterial ventricular septal defect (dcVSD) to reduce the invasiveness of the conventional surgical repair through a median sternotomy. However, few studies have compared them in terms of effectiveness and cost. Inpatients with isolated dcVSD who had undergone transfemoral device occlusion or minimally invasive surgical repair from January 2011 to June 2014 were reviewed for a comparative investigation between the two procedures. Procedure success was achieved in 36 transfemoral (75%) and in 36 surgical (100%) procedures (p=0.001). Transfemoral patients were older, with a VSD size similar to that of surgical patients (14.5±11.7 vs 4.4±2.9years, p<0.001; 4.5±1.5 vs 4.4±1.3mm, p=0.577, respectively). No significant difference was observed in complication rates between the two treatment groups (p=1). No large residual shunt was observed. Small residual shunt was noted in two transfemoral patients and four surgical patients (p=0.674). All these small residual shunts closed spontaneously during follow-up. The surgical repair costs 26% less than the device occlusion (Yuan 22063.2±343.9 vs Yuan 29970.1±1335.2, p<0.001), where most of the cost was attributed to the occluder in the amount of Yuan 19,500. Compared with device occlusion, minimally invasive surgical repair can provide superior efficacy and comparable complication rates. In addition, it is 26% cheaper than device occlusion. In low-income countries where healthcare resources are limited, medical resources must be judiciously allocated to the treatment that allows for effective treatment of the largest number of patients.

MP18-20 ENDOSCOPIC RENDEZVOUS PROCEDURE FOR URETERAL IATROGENIC DETACHMENT: REPORT OF A CASE SERIES WITH LONG-TERM OUTCOMES

You have accessJournal of UrologyTrauma/Reconstruction: Ureter, Bladder, External Genitalia and Urotrauma I1 Apr 2015MP18-20 ENDOSCOPIC RENDEZVOUS PROCEDURE FOR URETERAL IATROGENIC DETACHMENT: REPORT OF A CASE SERIES WITH LONG-TERM OUTCOMES Antonio Luigi Pastore, Giovanni Palleschi, Luigi Silvestri, Andrea Ripoli, Domenico Autieri, Yazan Al Salhi, and Antonio Carbone Antonio Luigi PastoreAntonio Luigi Pastore More articles by this author , Giovanni PalleschiGiovanni Palleschi More articles by this author , Luigi SilvestriLuigi Silvestri More articles by this author , Andrea RipoliAndrea Ripoli More articles by this author , Domenico AutieriDomenico Autieri More articles by this author , Yazan Al SalhiYazan Al Salhi More articles by this author , and Antonio CarboneAntonio Carbone More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1052AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Injury to the ureter is the most common urologic complication of pelvic surgery, with an incidence that ranges from 1% to 10%. Most cases of ureteral injuries are related to gynecologic procedures. The ureter is particularly vulnerable to detachment or ligation during hysterectomy interventions due to its position from the lateral edge of the cervix. Here, we report a case series of female patients that underwent the ureteral rendezvous procedure for ureteral detachment. METHODS Between January 2009 and April 2013, 18 ureteral rendezvous procedures were performed for complete detachment. We assessed the operative and clinical outcomes of these patients over a mean follow-up duration of 26.5 months, and describe the three most representative cases. RESULTS The endoscopic rendezvous technique was performed in all cases to manage ureteral detachment. Computed tomography urography at discharge, and 6 and 12 months after discharge, confirmed the restored ureteral integrity without any leakage in 66% (12/18) cases, indicated ureteral stenosis in 22% (4/18) cases, and indicated ureteral leakage in 12% (2/18) cases. The overall long-term success rate for all 18 patients was 78% (14/18) at a mean follow-up of 26.5 months. CONCLUSIONS The endoscopic rendezvous procedure reduces the need for invasive open surgical repair and represents the optimal initial option in patients with iatrogenic ureteral lesions before invasive procedures with higher morbidity are attempted. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e214 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Antonio Luigi Pastore More articles by this author Giovanni Palleschi More articles by this author Luigi Silvestri More articles by this author Andrea Ripoli More articles by this author Domenico Autieri More articles by this author Yazan Al Salhi More articles by this author Antonio Carbone More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Initial Experience with Thoracoscopic Esophageal Atresia and Tracheoesophageal Fistula Repair: Lessons Learned and Technical Considerations to Achieve Success

The minimally invasive surgical (MIS) repair of esophageal atresia/tracheoesophageal fistula (EA/TEF) is challenging and requires advanced endoscopic skills. The purpose of this study was to provide insight in successfully introducing the MIS repair based on the initial cases performed by a single pediatric surgeon and review of the experience of others. A retrospective review of all MIS TEF repairs performed by a single surgeon was conducted. Data gathered included patient demographics, technical details of repair including operative time, short- and long-term postoperative morbidity, length of stay, and follow-up. Eight cases (seven Type C, one Type D) were selected for MIS repair based on the judgment of the surgeon with consideration of adequate patient size, stability, type of associated anomalies, and expected length of esophageal gap. Operative time was an average of 207 minutes and there was one conversion to open for successful repair. There were no leaks and only one patient required a single anastomotic dilation at 19 months of age. There were two postoperative pneumothoraces of which one required bronchoscopic laser fistula ablation. Length of stay was an average of 16 days and length of follow-up is a median of 219 days. MIS repair of EA/TEF can be done successfully but requires careful patient selection, advanced MIS skills and meticulous attention to operative technique.

Endoscopic rendezvous procedure for ureteral iatrogenic detachment: report of a case series with long-term outcomes.

Injury to the ureter is the most common urologic complication of pelvic surgery, with an incidence that ranges from 1% to 10%. Most cases of ureteral injuries are related to gynecologic procedures. The ureter is particularly vulnerable to detachment or ligation during hysterectomy because of its position from the lateral edge of the cervix. We report a case series of female patients who underwent the ureteral rendezvous procedure for ureteral detachment. Between January 2009 and April 2013, 18 ureteral rendezvous procedures were performed for patients with complete detachment. We assessed the operative and clinical outcomes of these patients over a mean follow-up duration of 26.5 months and describe the three most representative cases. The endoscopic rendezvous technique was performed in all cases to manage ureteral detachment. CT urography at discharge and 6 and 12 months after discharge confirmed the restoration of ureteral integrity without any leakage in 66% (12/18) patients, indicated ureteral stenosis in 22% (4/18) patients, and indicated ureteral leakage in 12% (2/18) patients. The overall long-term success rate for all 18 patients was 78% (14/18) at a mean follow-up of 26.5 months. The endoscopic rendezvous procedure reduces the need for invasive open surgical repair and represents the optimal initial option in patients with iatrogenic ureteral lesions before invasive procedures with higher morbidity are attempted.

Patient-specific analysis of displacement forces acting on fenestrated stent grafts for endovascular aneurysm repair

Treatment options for abdominal aortic aneurysm (AAA) include highly invasive open surgical repair or minimally invasive endovascular aneurysm repair (EVAR). Despite being minimally invasive, some patients are not suitable for EVAR due to hostile AAA morphology. Fenestrated-EVAR (F-EVAR) was introduced to address these limitations of standard EVAR, where AAA is treated using a Fenestrated Stent Graft (FSG). In order to assess durability of F-EVAR, displacement forces acting on FSGs were analysed in this study, based on patient-specific geometries reconstructed from computed tomography (CT) scans. The magnitude and direction of the resultant displacement forces acting on the FSG were numerically computed using computational fluid dynamics (CFD) with a rigid wall assumption. Although displacement force arises from blood pressure and friction due to blood flow, numerical simulations elucidated that net blood pressure is the dominant contributor to the overall displacement force; as a result, time dependence of the resultant displacement force followed pressure waveform very closely. The magnitude of peak displacement force varied from 1.9N to 14.3N with a median of 7.0N. A strong positive correlation was found between inlet cross-sectional area (CSA), anterior/posterior (A/P) angle and the peak displacement force i.e. as inlet CSA or A/P angle increases, the magnitude of resultant displacement increases. This study manifests that while loads exerted by the pulsatile flow dictates the cyclic variation of the displacement force, its magnitude depends not only on blood pressure but also the FSG morphology, with the latter determining the direction of the displacement force.

Minimally Invasive Endoscopic Surgical Repair of Recurrent Complete Third Branchial Fistula in a Nine Year Old Girl

Congenital anomalies of the branchial arches are well known with fistulas presenting in the head and neck region. A proper diagnosis of this uncommon entity is mandatory for a successful surgical repair in the first attempt itself. In this case report, we profile a patient who was subjected to multiple surgeries only to result in subsequent breakdowns and resurfacing of symptoms. An innovative attempt was made with the use of endoscopes and minimally invasive surgical methods to repair this recurrent fistula and followed up with a repeat fistulogram which showed a complete closure of the tract without any co-morbidity.

Resolution of pericardial effusion after minimally invasive surgical repair of pectus excavatum

Pektus ekskavatum, kalpte sikismaya ve buna bagli olarak perikardiyal sivi dongusunu bozarak perikardiyal efuzyona neden olabilir. Bu yazida pektus ekskavatum ve kronik tekrarlayan perikardiyal efuzyonlu 32 yasinda bir kadin olgu sunuldu. Minimal invaziv pektus ekskavatum tamiri ve perikardiyosentez sonrasinda, bir yillik takipte nuks gozlenmedi. Sternumu kaldirarak ve kalbin sikismasini rahatlatarak, minimal invaziv pektus ekskavatum tamiri perikardiyal sivi uretimi ve yeniden emilim mekanizmasinin tekrar insa edilmesine yardimci olabilir.

Percutaneous Device Occlusion and Minimally Invasive Surgical Repair for Perimembranous Ventricular Septal Defect

Percutaneous device occlusion and minimally invasive surgical repair for perimembranous ventricular septal defect (pmVSD) are two typical methods to reduce the invasiveness of the conventional operation through a median sternotomy. However, few studies have compared them in terms of effectiveness and cost. Inpatients with isolated pmVSD who had undergone percutaneous device occlusion or minimally invasive surgical repair from June 2009 to June 2012 were reviewed for a comparative investigation between the two procedures. Procedure success was achieved in 80 percutaneous (93.0%) and in 113 surgical (98.3%) procedures (p=0.076). Percutaneous patients were older, with a smaller VSD size than surgical patients (16±11.7 vs 3.8±2.4 mm, p<0.001; 4.0±1.2 vs 4.3±1.3 mm, p=0.034, respectively). Major complications occurred in 1 percutaneous (1.2%) and in 4 surgical (3.5%) procedures (p=0.602), and minor complications occurred in 27 percutaneous (33.3%) and in 37 surgical (32.2%) procedures (p=0.991). The surgical repair cost 31% less than the device occlusion (¥20,565±¥3,497 vs ¥29,795±¥2,643, p<0.001), where most of the cost was attributed to the occluder in the amount of ¥19,500. Compared with device occlusion, minimally invasive surgical repair can provide comparable efficacy and complication rates. In addition, it is 31% cheaper than device occlusion. In low-income countries where health care resources are limited, medical resources must be judiciously allocated to the treatment that allows for effective treatment of the largest number of patients.

Minimally invasive mitral valve repair

Meanwhile mitral valve insufficiency is probably the second most common heart valve disease represented in cardiac surgery. Due to low perioperative morbidity and mortality, nowadays mitral valve repair can even be considered in asymptomatic patients. The enhancements of minimally invasive surgical techniques led to a decrease in surgical trauma and accelerated postoperative recovery, resulting in increased acceptance of these operating techniques. Therefore, the present review focuses on the different surgical access ways to the mitral valve and their significance for mitral valve repair. The emergence of transcatheter approaches to mitral valve repair has focused attention on outcomes after surgical mitral valve repair. Results from the EVEREST II trial demonstrated worse short-term major adverse event rates for surgical repair. Recently, several studies were published analyzing contemporary outcomes, morbidity, mortality, and quality of life after conventional and minimally invasive surgical mitral valve repair to establish benchmarks for future therapeutic comparisons. Today mitral valve repair is the gold standard for treatment of significant mitral valve regurgitation with low perioperative morbidity and mortality and excellent long-term results. It can be performed through minimally invasive surgical techniques without compromising long-term durability of repair results, but with a decrease in surgical trauma and accelerated postoperative recovery. Currently, endovascular therapy for mitral regurgitation (e.g., the MitraClip procedure) should be limited to patients who otherwise would not be eligible for surgery.

Live anatomy of the perineal body in patients with third‐degree rectocele

In many pelvic floor disorders, the perineal body is damaged or destroyed. There is still a considerable variation in anatomical descriptions of the perineal body and even more debate with regard to its attachments and relationships. Cadaveric dissections do not always reflect the functional behaviour of structures in the pelvis and description of live anatomy on imaging studies is not always reliable. This study aimed to define the anatomy of the perineal body in patients with rectocele during the live dissection required for minimally invasive surgical repair. From January 2007 to December 2009 consecutive patients requiring surgery for third-degree rectocele and symptoms of obstructed defaecation were recruited. Participants underwent dissection of the perineal body, rectum and vagina preliminary to a tissue fixation system, an operation which inserts a tensioned tape to repair the perineal body. Thirty Caucasian female patients, mean age 61 (range 47-87) years, mean parity 2.6 (range 1-5), were included. Live dissection demonstrated that the perineal body was divided into two parts, joined by a stretched central part, anchored laterally by the deep transverse perineii muscle to the descending ramus of the pubic bone. The mean longitudinal length of the perineal body was 4.5 (3.5-5.5) cm, accounting for 50% of the posterior vaginal support. In women with low rectocele, the perineal body appears to be divided into two parts, severely displaced behind the ischial tuberosities.

Midterm Results of Different Surgical Techniques to Replace Dilated Ascending Aorta Associated With Bicuspid Aortic Valve Disease

This study evaluated effectiveness of three different surgical strategies for treating ascending aorta aneurysm, with or without involvement of the aortic root, associated with bicuspid aortic valve (BAV). Between 2005 and 2011, 150 consecutive patients underwent a Bentall operation in the presence of ascending aorta and aortic root dilation exceeding 45 mm in diameter and malfunctioning BAV (n = 46, group 1); separate aortic valve and ascending aorta replacement in presence of ascending aorta dilation exceeding 45 mm, aortic root of less than 45 mm, and malfunctioning BAV (n = 77, group 2); or ascending aorta replacement, with or without BAV repair, in the presence of ascending aorta dilation exceeding 45 mm, aortic root of less than 45 mm, and normally functioning or mildly insufficient BAV (n = 27, group 3). Compared with groups 2 and 3, group 1 patients were younger and affected by more severe BAV insufficiency and worse left ventricular function. In groups 1, 2, and 3, respectively, operative mortality was 2.1%, 1.3%, and 0%, and 5-year survival was 94% ± 4%, 92% ± 3.4%, and 100%. At 5 years, no patient in any group required reoperation on the ascending aorta or experienced aortic complications. In groups 2 and 3, root dimensions did not increase and were also significantly smaller compared with preoperative measurements (p < 0.05). Aortic regurgitation grade in group 3 (0.5 ± 0.8/4+) did not increase compared with the preoperative grade (0.8 ± 0.9/4+). At midterm follow-up, the Bentall operation remains associated with optimal results for the treatment of BAV, despite a worse preoperative presentation. In presence of a mildly diseased or normal aortic root and normal BAV function at the time of operation, less invasive surgical procedures, BAV-sparing, or repair procedures, appear to offer gratifying results.