Lengthy Surgery Research Articles

Laparoscopic right hemicolectomy with complete mesocolic excision provides acceptable perioperative outcomes but is lengthy--analysis of learning curves for a novice minimally invasive surgeon.

Associated with reduced trauma, laparoscopic colon surgery is an alternative to open surgery. Furthermore, complete mesocolic excision (CME) has been shown to provide superior nodal yield and offers the prospect of better oncological outcomes. All oncologic laparoscopic right colon resections with CME performed by a single surgeon since the beginning of his surgical practice were retrospectively analyzed for operative duration and perioperative outcomes. The study included 81 patients. The average duration of surgery was 220.0 (range 206-233) minutes. The initial durations of about 250 minutes gradually decreased to less than 200 minutes in an inverse linear relationship (y = -0.58x × 248). The major complication rate was 3.6% ± 4.2% and the average nodal yield was 31.3 ± 4.1. CumulativeSum analysis showed acceptable complication rates and oncological results from the beginning of surgeon's laparoscopic career. Developing laparoscopic skills can provide acceptable outcomes in advanced right hemicolectomy for a surgeon who primarily trained in open colorectal surgery. Operative duration is nearly triple that reported for conventional laparoscopic right hemicolectomy. The slow operative duration learning curve without a plateau reflects complex anatomy and the need for careful dissection around critical structures. Should one wish to adopt this strategy either based on some available evidence of superiority or with intention to participate in research, one has to change the view of right hemicolectomy being a rather simple case to being a complex, lengthy laparoscopic surgery.

Cerebral tissue O2 saturation during prolonged robotic surgery in the steep Trendelenburg position: an observational case series in a diverse surgical population.

Demands associated with the Trendelenburg position (TP) are well known yet there is little attention given to regional cerebral tissue O2 saturation (SctO2) in those undergoing robotic surgery in the TP with CO2 insufflation (C-INSF). This is the first study to report on SctO2 in a wide range of patients undergoing lengthy TP and robotic surgery. We measured SctO2 during robotic surgery in patients in the TP with C-INSF, as well as a control robotic thyroid surgery group who were supine with no C-INSF. We recorded relevant variables and periods of cerebral desaturation (CD). We studied 42 patients in 25°-45° of TP for ≥125 min. Management was at the providers' discretion. The INVOS(®) 5100C Cerebral Oximeter (Covidien, Boulder, CO) recorded SctO2. CD was defined as a >20 % decrease from baseline SctO2 or a value ≤55 % for ≥10 min. Patients were assessed for adverse outcome. The sample consisted of 13 males and 29 females aged 22-73, BMI 22-36 had general (N = 3), urological (N = 14) and gynecological (N = 25) surgery; two patients had CD lasting 150 and 190 min and two had episodic CD lasting 10-35 min. The four were female aged 22-60 in 38°-45° of TP. Eleven cases had multiple episodic CD for ≤15 min, 27 TP cases had no CD. Other observations included a consistent fall in SctO2 with phenylephrine; an increased SctO2 with ephedrine; and FiO2 and EtCO2 being generally strong, direct modifiers of SctO2. High MAP was inconsistently associated with high SctO2. BMI had no observed effect on SctO2. Pulse oximetry was ≥97 % in all cases. We observed no adverse cerebral events on follow-up. Additional clinical studies are warranted.

Laparoscopic pleat-bag technique: A simple solution to the common problem of endobag insertion

Usage of the endobag is an essential component of extirpative laparoscopic surgery. However, there is scant reference in the literature to the techniques concerning this practice. We describe an easy-to-apply method of endobag insertion. The polythene sleeve that enfolds the suction catheter is used. One edge of the bag is trimmed by 1 cm. The bag is then longitudinally pleated in a specific way. Subsequently, it is reverse-loaded into the metallic reducer and expelled into the peritoneal cavity. As it unfolds further, the mouth opens, and specimen loading becomes much easier and faster. We have applied this method in over 3000 cases and found it to be a more “user-friendly” technique. Specimen retrieval bags markedly reduce the rate of port site infection and metastasis. However, their laparoscopic manoeuvring may be a daunting task from its insertion to specimen loading. Concerns regarding its smooth handling may add to surgical stress, particularly after a lengthy surgery. Our pleat-bag technique seems productive in this regard. Moreover, it can also be applied to larger endobags. The technique of endobag pleating is simple and efficient. It may be considered a standard method of specimen retrieval.

The Use of an Acellular Dermal Matrix “Sandwich” for the Successful Treatment of a Persistent Cranial Cerebrospinal Fluid Fistula

Cerebrospinal fluid (CSF) fistulae are problematic because of the high risk of meningitis and other infectious complications, as well as the potential for critically delaying chemotherapy in cases associated with malignancy. The plastic surgical literature suggests vascularized autologous tissue for the treatment of chronically draining CSF fistulae. Many of these patients, however, are debilitated, have multiple comorbidities, and may have a limited life expectancy, making the lengthy surgery and the associated donor-site morbidity of a regional or free tissue transfer procedure unattractive. There is a need for an alternative procedure that is a less morbid, yet equally effective solution for the obliteration of CSF fistulae. Herein we report the first use of acellular dermal matrix to successfully seal a persistent cranial CSF fistula.

The second “time-out”: a surgical safety checklist for lengthy robotic surgeries

Robotic surgeries of long duration are associated with both increased risks to patients as well as distinct challenges for care providers. We propose a surgical checklist, to be completed during a second “time-out”, aimed at reducing peri-operative complications and addressing obstacles presented by lengthy robotic surgeries. A review of the literature was performed to identify the most common complications of robotic surgeries with extended operative times. A surgical checklist was developed with the goal of addressing these issues and maximizing patient safety. Extended operative times during robotic surgery increase patient risk for position-related complications and other adverse events. These cases also raise concerns for surgical, anesthesia, and nursing staff which are less common in shorter, non-robotic operations. Key elements of the checklist were designed to coordinate operative staff in verifying patient safety while addressing the unique concerns within each specialty. As robotic surgery is increasingly utilized, operations with long surgical times may become more common due to increased case complexity and surgeons overcoming the learning curve. A standardized surgical checklist, conducted three to four hours after the start of surgery, may enhance perioperative patient safety and quality of care.

Bilateral primary total knee arthroplasty using revision implants due to severe varus deformity to achieve maximum functional outcome, was it worth it?

We report a case of 66 years old man with sever osteoarthritis (OA) in both knees with severe varus deformity. Patient was treated with bilateral total knee arthroplasty (TKA) simultaneously with wedge augmentation of medial tibial plateau depression of both knees to restore the weight bearing axis of lower limbs. Although the recent trend and countless studies indicates the effectiveness of unilateral TKA and not to address both knees at the same time, this patient was operated same day keeping in mind the challenging surgery of primary bilateral TKA using revision armamentum, and all the possible complications of a lengthy surgery, but the rational was to provide rehabilitation simultaneously to both knees and to maximize the functional outcome of the surgery. Patient was functionally scored prior and post-surgery using international knee score. We report excellent outcome of the procedure using the full potential of a rehabilitation facility.

Simple maxillary reconstruction following total maxillectomy using artificial bone wrapped with vascularized tissue: five key points to ensure success

Conclusion: Our new method for hard tissue maxillary reconstructions using artificial bone implants provides stable results during long-term follow-up. Objective: To date, vascularized bone/cartilage grafting has been the most popular method for hard tissue reconstruction after total maxillectomy; however, such three-dimensional reconstruction requires complex and lengthy invasive surgery. We have developed a simple maxillary reconstruction procedure using artificial bone. Methods: This study included six patients who had undergone hard tissue reconstructions using artificial bone (CeratiteTM) implants after total maxillectomies between October 2002 and October 2010. We considered the following five key points to ensure success: (1) the procedure was conducted in two stages without communicating with the nasal cavity and sinuses; (2) when constructing the artificial bone, the curvature was reduced; (3) the space for the implant was kept to a minimum; (4) the artificial bone implant was closely and accurately fixed to the stump of the zygomatic arch; and (5) the artificial bone implant was wrapped with a vascularized tissue flap. Results: The follow-up period ranged from 12 to 94 months. The postoperative zygomatic contour was maintained satisfactorily in all patients with no signs of late complications.

CASE REPORT - -Combined General and Spinal Anesthesia for Lumbar decompression in an Opioid-intolerant Patient: Intra-operative Administration of Intrathecal Bupivacaine via the Surgical Incision

We illustrate repeat dosing of spinal anesthesia as a means to avoid opioids during lumbar surgery for a patient intolerant of opioids. A patient required redo lumbar surgery but had a marked history of nausea, vomiting and retching in response to opioids. A propofol-based anesthetic was supplemented with intravenous ketamine and intrathecal bupivacaine. The first dose of bupivacaine receded during the lengthy surgical procedure but was supplemented by means of a 25-gauge pencil-point needle passed through the exposed dura. Postoperatively, there was no spinal fluid leak, no headache, and no nausea. Supplementation of intrathecal anesthesia under direct dural vision during lengthy lumbar surgery is facile, can help to obviate a need for opioids, and can aid in avoidance of postoperative nausea and vomiting.

Associated injuries in casualties with traumatic lower extremity amputations caused by improvised explosive devices

Improvised explosive devices (IEDs) pose a significant threat to military personnel, often resulting in lower extremity amputation and pelvic injury. Immediate management is haemorrhage control and debridement, which can involve lengthy surgery. Computed tomography is necessary to delineate the extent of the injury, but it is unclear whether to perform this during or after surgery. The UK Joint Theatre Trauma Registry was searched to identify all UK service personnel who had a traumatic lower extremity amputation following IED injury between January 2007 and December 2010. Data were collected on injury pattern and survival. There were 169 patients who sustained 278 traumatic lower extremity amputations: 69 were killed in action, 16 died from their wounds and 84 were wounded in action, but survived. The median (interquartile range) Injury Severity Score was 75 (21) for those killed in action, 46 (23) for those who died from wounds and 29 (12) for survivors. There were significantly more severe head, chest and abdominal injuries (defined as a body region Abbreviated Injury Scale score of 3 or more) in patients who were killed in action than in those reaching hospital (P < 0·001). Hindquarter amputations were the most lethal, with a mortality rate of 95 per cent. Of the 100 casualties who reached hospital alive, there were nine thoracotomies, one craniotomy and 34 laparotomies. All head or torso injuries that required immediate operation were clinically apparent on admission. Higher levels of amputation were associated with greater injury burden and mortality. Intraoperative computed tomography had little value in identifying clinically significant covert injuries.

Increased risk for post‐operative corneal injuries in patients who undergo laparoscopic gynecologic surgery

The objective of this study was to verify whether or not the incidence of post-operative corneal injuries (PCIs) in patients who undergo laparoscopic gynecologic surgery is higher than patients who undergo non-laparoscopic gynecologic surgery. The peri-operative variables were extracted from the medical records of patients who underwent gynecologic surgery under general anesthesia at our institute between January 2004 and June 2010. The extracted variables were age, day of week of surgery, type of surgery (laparoscopy vs. non-laparoscopy), surgical scheduling (elective vs. emergent), pre-operative hemoglobin, surgery time, peri-operative transfusions, and PCIs. The association of peri-operative variables with PCIs was examined using univariate and multivariate analyses. A total of 6992 consecutive patients were included in this study. PCIs occurred in 23 patients (0.3%). Based on univariate analysis, the type of surgery and surgery times were associated with PCIs. Based on multivariate analysis, laparoscopy and lengthy surgery times significantly increased the risk for PCIs. The median duration of PCI symptoms was 3 days (range, 1-11 days); no patient had long-term sequalae. Laparoscopic gynecologic surgery increases the incidence of PCI compared with non-laparoscopic gynecologic surgery.

Triple-ostomy: management of perforations to the second part of the duodenum in patients unfit for definitive surgery

Peptic ulcers in the second part of the duodenum are a rare occurrence and present challenging management. Conventional surgical operations are associated with life threatening complications. We describe a case of a perforated duodenal ulcer in a medically unstable patient who was deemed unfit for lengthy definitive surgery. An emergency laparotomy and 'triple-ostomy' was performed. We recommend this procedure as an alternative for the emergency repair of D2 ulcers, especially in patients with multiple co-morbidities.

Modified Approach to the Cervicofacial Rotation Flap in Head and Neck Reconstruction

Objectives: Large cutaneous defects of the cheek and external ear present a reconstructive challenge. While free tissue transfer has been increasingly used for such defects, many patients with these malignancies are poor candidates for lengthy reconstructive surgery. The cervicofacial and cervicothoracic advancement flaps have been previously described as a simple method for reconstructing defects of the face and neck. However, for large facial defects, these flaps typically require wide undermining with the final closure sometimes under tension. We describe our experience utilizing a modified approach to the cervicofacial rotation flap which has little tension of the defect closure and avoids incisions or undermining of tissue inferior to the clavicle. Study Design: Retrospective chart review. Methods: Sixteen patients underwent a modified cervicofacial rotation flap for immediate reconstruction of a cheek and/or total auriculectomy defect. Results: Primary cutaneous malignancies were the most common surgical indication, followed by parotid tumors with overlying skin involvement. Five patients had total auriculectomy defects while 11 patients had defects involving cheek skin without auriculectomy. Defect diameter size varied from 5 to 12 centimeters. Two patients required skin grafting of the donor site. Four patients had minor wound dehiscences that were treated with local wound care and allowed to close by secondary intention. Conclusions: We describe a modified approach to the cervicofacial rotation flap which minimizes undermining to provide a tension-free closure of the defect. Our approach is a simple, reliable method for coverage of large cutaneous defects involving the cheek and external ear.

Fast attainment of computer cursor control with noninvasively acquired brain signals

Brain–computer interface (BCI) systems are allowing humans and non-human primates to drive prosthetic devices such as computer cursors and artificial arms with just their thoughts. Invasive BCI systems acquire neural signals with intracranial or subdural electrodes, while noninvasive BCI systems typically acquire neural signals with scalp electroencephalography (EEG). Some drawbacks of invasive BCI systems are the inherent risks of surgery and gradual degradation of signal integrity. A limitation of noninvasive BCI systems for two-dimensional control of a cursor, in particular those based on sensorimotor rhythms, is the lengthy training time required by users to achieve satisfactory performance. Here we describe a novel approach to continuously decoding imagined movements from EEG signals in a BCI experiment with reduced training time. We demonstrate that, using our noninvasive BCI system and observational learning, subjects were able to accomplish two-dimensional control of a cursor with performance levels comparable to those of invasive BCI systems. Compared to other studies of noninvasive BCI systems, training time was substantially reduced, requiring only a single session of decoder calibration (∼20 min) and subject practice (∼20 min). In addition, we used standardized low-resolution brain electromagnetic tomography to reveal that the neural sources that encoded observed cursor movement may implicate a human mirror neuron system. These findings offer the potential to continuously control complex devices such as robotic arms with one's mind without lengthy training or surgery.

CNS-targeted Viral Delivery of G-CSF in an Animal Model for ALS: Improved Efficacy and Preservation of the Neuromuscular Unit

Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease characterized by progressive loss of motoneurons. We have recently uncovered a new neurotrophic growth factor, granulocyte-colony stimulating factor (G-CSF), which protects α-motoneurons, improves functional outcome, and increases life expectancy of SOD-1 (G93A) mice when delivered subcutaneously. However, chronic systemic delivery of G-CSF is complicated by elevation of neutrophilic granulocytes. Here, we used adeno-associated virus (AAV) to directly target and confine G-CSF expression to the spinal cord. Whereas intramuscular injection of AAV failed to transduce motoneurons retrogradely, and caused a high systemic load of G-CSF, intraspinal delivery led to a highly specific enrichment of G-CSF in the spinal cord with moderate peripheral effects. Intraspinal delivery improved motor functions, delayed disease progression, and increased survival by 10%, longer than after systemic delivery. Mechanistically, we could show that G-CSF in addition to rescuing motoneurons improved neuromuscular junction (NMJ) integrity and enhanced motor axon regeneration after nerve crush injury. Collectively, our results show that intraspinal delivery improves efficacy of G-CSF treatment in an ALS mouse model while minimizing the systemic load of G-CSF, suggesting a new therapeutic option for ALS treatment.

The importance of a double team in brachial plexus surgery

Aim Brachial plexus surgery constitutes a long and complex procedure. The aim of our study is to assess the interest of having a double operating team throughout the duration of this surgery. Patients and methods Seventeen patients with brachial plexus palsy underwent surgery operated by a double team. The operating time corresponding to each step of the procedure and the total operating time were measured for each patient. The separate values were added so as to obtain a simulation of the total duration value for a single surgeon. The operative time of this virtual group of patients (Group I) was compared to that of the real group operated by the double team (Group II). Both values were compared to assess any statistical significance. Results The mean operating time was 259 min with surgery operated by a double team and 371 min in the group I, a difference found to be statistically significant ( p < 0.05). Exploration and preparation of the cervical region lasted 70 min in average with the double team versus 132 min in the group I ( p < 0.05). No perioperative complications were noted. Discussion and conclusion Brachial plexus surgery performed by a double team allows the reduction of the operating time and thus minimizes the drawbacks associated with lengthy surgery such as perioperative bleeding and infection. Microsurgical suturing which is the crucial part of the surgery is easier when performed at the end of a shortened intervention and shared by two senior surgeons with, subsequently, less fatigue. This new organization that improves the operating conditions guarantees best results.

Vascularized Groin Lymph Node Transfer Using the Wrist as a Recipient Site for Management of Postmastectomy Upper Extremity Lymphedema

Sir: We read with interest the article by Lin et al.1 on surgical treatment of postmastectomy lymphedema. We would like to commend them on reporting an exciting and novel technique with good reported results and a low complication rate. We would like to raise a few points regarding their study. The specialist lymphedema team within our unit reported a reduction in arm circumference as high as 50 percent within the first 8 weeks of nonsurgical treatment in the majority of their patients. This gives comparable results to this study without the need for lengthy and complex surgery with its inherent risks. We feel it would be useful to know the extent of lymphedema in this group of patients, using one of the recognized grading systems, as it is has been reported that more severe disease responds less favorably to treatment.2 In addition, we were hoping the authors could provide more details regarding the extent and success of nonoperative management options used in their patients before surgery and whether such treatment was continued in the postoperative period. Our main reservation concerning the study is the lack of information regarding donor-site morbidity. Although the authors state that the superficial inguinal lymph nodes that were transferred mainly drain the abdominal wall, there is presumably a chance that removing them may adversely affect lymphatic drainage of the abdominal wall or even the lower limb. It would clearly be very distressing for the patient to gain improvement in the symptoms of their upper limb at the expense of lymphedema at another site. Despite the ample length of follow-up of the patients in the study, this does not seem to have been noted. Finally, we feel that the results could have been recorded and described in a clearer and more meaningful manner. The main outcome measure was arm circumference, which was reported as a change in circumference relative to the difference between the affected and unaffected arms. We found this to be a confusing method of reporting the results and suggest that absolute changes in arm circumference would be a clearer, simpler method of describing the excellent results that appear to have been achieved by the authors. Frequency of cellulitis was described as an intended outcome measure but was only subjectively reported by the patients, as was hand function. Both of these parameters could have easily been measured objectively during the routine follow-up period. Similarly, lymphoscintigraphy was performed twice in the postoperative period and was described as “improved” but without any real quantitative data to back this up or any comment on whether the transplanted lymph node demonstrated any uptake of the technetium-labeled radiotracer. We would like to congratulate the authors on their description of this novel technique that we hope will prove useful in the management of this troublesome condition. We look forward to seeing their long-term results and hope they may consider some of our suggestions for making the results easier to understand and more applicable to a wider surgical audience. Elizabeth Chipp, M.R.C.S. Louise Ferguson, M.R.C.S. Sukh Rayatt, F.R.C.S.(Plast.) Department of Plastic and Reconstructive Surgery University Hospital North Staffordshire Stoke-on-Trent United Kingdom

Combined use of remifentanil and propofol to limit patient movement during retinal detachment surgery under local anesthesia

Background:One of the drawbacks of performing ophthalmic surgery under local anesthesia is patient movement, which might affect optimal surgical outcome.Purpose:The study aims to evaluate the efficacy of the combined use of propofol and remifentanil as a sedative technique in comparison with the use of propofol alone to limit patient discomfort and movement during local anesthesia for vitreo-retinal surgery lasting for more than two hours.Materials and Methods:A total of 140 patients scheduled for vitreo-retinal surgery under local anesthesia, with an expected surgical time of more than two hours, were included in the study. Patients were divided randomly into two equal groups: group I where patients were given propofol and remifentanil by continuous infusion and group II where patients were given propofol alone by continuous infusion.Results:The two groups were comparable with regard to age, weight, gender, ASA physical status and duration of surgery. There was a significant decrease in heart rate and mean arterial blood pressure (MABP) in each group 10 minutes after the start of sedation compared with pre-sedation data and continued all through the procedure. There was an insignificant difference between the two groups with regard to changes in heart rate and MABP all through surgical procedure. There was no significant difference between the two groups with regard to the incidence of complications except for an increased incidence of breakthrough pain and discomfort which necessitated the use of fentanyl as a rescue treatment in the propofol group P<0.001. There were no instances of movements with a major effect on the surgical field, which could have affected surgical outcome, in the two groups. The number of patients who did not move was significantly higher, 56 (80%), in group I compared with 38 (54.29%) in group II with P<0.001. The ophthalmologist satisfaction scale was significantly higher in group I (4.5±0.63) compared with group II (3.7±1.04) with P=0.0016.Conclusion:The combined use of propofol and remifentanil as a continuous infusion before performance of the block and during lengthy vitreo-retinal surgery was associated with a lower incidence of patient discomfort, breakthrough pain, and patient movement along with high degree of surgeons’ satisfaction and hemodynamic stability.

Deep anterior lamellar keratoplasty

AbstractDespite the long term risk of endothelial rejection, full‐thickness corneal transplantation is still considered the gold standard surgery for replacing a diseased cornea. Deep anterior lamellar keratoplasty (DALK) is not a new procedure, but in the past, its use has been of limited popularity owing to the challenging, lengthy and tedious surgery involved. With the advent of newer surgical techniques and instruments for performing lamellar corneal surgery, DALK has gained in popularity. This presentation discusses the techniques for performing the procedure as well as the clinical outcomes, especially focusing on Big bubble DALK. Results will be compared with the outcomes of penetrating keratoplasty (PK). Results suggest that DALK is the logical choice in the surgical management of corneal stromal disease, in presence of a functional endothelium.

PH-Inducedin situgel for periodontal anesthesia

A pH mediated in situ gelling system was developed using prilocaine hydrochloride for periodontal anesthesia using combination of chitosan and hydroxypropylmethylcellulose. The gel so developed can be used as anaesthetic in lengthy dental surgery. The gel was evaluated for many parameters like gelation pH, viscosity, physicochemical properties, in vitro release, sterility and stability. Gel with chitosan (0.25% w/v) and hydroxypropylmethylcellulose (0.25% w/v) was found to have good gelation near pH 7.4 (pH of mucous) with prolonged action.

Analysis of Early Postoperative Morbidity Among Patients with Rectal Cancer Treated with and without Neoadjuvant Chemoradiotherapy

The impact of neoadjuvant treatment and their subsequent early complications in the treatment of rectal cancer has not been adequately assessed. The aim of this prospective study was to evaluate early postoperative morbidity and mortality among patients with rectal cancer treated with adjuvant radiotherapy and chemotherapy followed by surgery, compared with patients treated with surgery alone. We also identified independent risk factors associated with early major complications. Between 1995 and 2004, 273 consecutive patients underwent treatment for rectal cancer. A total of 170 patients (group A) received preoperative radiotherapy with a total of 45-50.4 Gy (180 cGy per day) and 5-fluorouracil-based chemotherapy, followed by surgery; 103 patients (group B) were treated with surgery alone. Dependent variables related to patients, treatment, radiotherapy, and tumor were analyzed. Both groups were similar with regard to age, sex, body mass index, American Society of Anesthesiologists (ASA) score, and tumor location but not for ileostomy (27% in group A vs. 6.8% in group B). The number of complications was similar in both groups (43.1% in group A vs. 44.6% in group B). No differences in wound infection (8.2% vs. 7.8%), intra-abdominal abscess (4.7% vs. 4.9%), anastomotic dehiscence (4.2% vs. 3.8%), postoperative hemorrhage (3.5% vs. 3.9%), urinary complications (6.5% vs. 4.9%), paralytic ileus (8.9% vs. 9.7%), or general complications (7.1% vs. 9.6%) were found. The global mortality in the first 30 days after surgery was .7%. An ASA score of III-IV and surgery duration longer than 3 hours were identified as independent prognostic factors for early complications. Preoperative chemoradiation in patients with rectal cancer treated with surgery is not associated with a higher incidence of early postoperative complications. The patient's preoperative clinical condition and lengthy surgery time are prognostic factors for early complications.