Mini-invasive Surgery Research Articles

Intestinal Volvolus After Robotic Pancreaticoduodenectomy

Context Intestinal volvulus is an uncommon complication either of open surgery either of mini-invasive surgery. Recent papers report few cases of small bowel obstruction after robotic-assisted surgery, but none due to an intestinal volvulus. In our experience including more than 90 robotic pancreatic resections we have had only one intestinal volvulus. We report the case of a small bowel obstruction because of a volvulus after robotic pancreatico­duodenectomy. Case report A 42-year-old man underwent robot-assisted pancreaticoduodenectomy on July 2011 for choledochus’ adenocarcinoma. On September 2011 he was readmitted to us for an intestinal obstruction. Preoperative imaging included abdomen radiography and computed tomography. The latter showed a twisted small bowel loop with a strong lumen reduction. Robot-assisted pancreatico­duodenectomy was the only previous operation he had had. The patient underwent to a laparotomy, in order to easily diagnose the site of the obstruction. The entire small bowel was found to have rotated clockwise around the mesenteric vessels. Distal ileum, that included the obstruction, was resected. Final pathology disclosed only inflammation and granulation tissue. The postoperative course was uneventful and the patient was discharged on the fifteenth postoperative day. Conclusion The causes of small bowel rotation are not well known. An abnormally mobile bowel or other anatomic predispositions might have a role; another possible causes are post-operative adhesions that may create an axis around which the small bowel can rotate. Our patient have had only pancreaticoduodenectomy that, even if performed robotically, it is a very hard operation but at the repeat surgery the entire small bowel was found to have rotated clockwise around the mesenteric vessels without any adhesion. Robotic surgery needs the pneumoperitoneum induction and tilting table to a suitable position which are possible causes allowing a volvulus creation. In our experience, the posterior repair of peritoneum can avoid the onset of a volvulus and it can be as easily performed by robotic approach as in open surgery.

Polysaccharide-Based Hydrogels: The Key Role of Water in Affecting Mechanical Properties

Different hydrogels were prepared starting from natural or semi-synthetic polysaccharides (carboxymethylcellulose, hyaluronic acid and chitosan) which were cross-linked by the addition of a cross-linking agent chosen according to the chemical groups present along the polymer chains. The cross-linking reaction allows for the formation of a three-dimensional network made of covalent bonds between the polymer chains, which is stable under physiological conditions. The presence of a substantial amount of water within the polysaccharide matrices makes such systems unique among hydrophilic gels. Water itself is responsible for some of their peculiar characteristics, one of which is their injectability which makes these hydrogels suitable for using as matrices for mini-invasive surgery and localized therapy.

Urethral sphincter innervation and clitoral blood flow after the transobturator (TOT) approach

The aim of the study was to exclude neurovascular damage due to prosthetic mini-invasive surgery using transobturator tape (TOT) by pre- and postoperative electromyography (EMG) of the striated urethral sphincter and a color Doppler ultrasonography evaluation of clitoral blood flow. A total of 25 women affected by clinical stress urinary incontinence (SUI) were enrolled. After undergoing urodynamic assessment, pelvic organ prolapse quantification, urine culture, Q-tip test, and stress test, each subject underwent color Doppler ultrasonography to record clitoral blood flow and EMG of the urethral sphincter with a needle electrode inserted through the mucosa into the muscle tissue before surgery. A single urogynecologist performed the TOT surgical technique for the treatment of all patients. Urogynecologic examination, EMG, and color Doppler ultrasound follow-up were performed at 1 and 6 months after surgery. At the urogynecologic examination performed 1 and 6 months after the TOT approach the stress test was negative, urethral hypermobility was reduced, and sling exposure was not observed for each patient. There was no statistically significant difference in electromyographic values (p > 0.05) in both the follow-ups with regard to baseline values. Pulsatility index (PI), resistance index (RI), and peak systolic velocity (PSV) values increased during the first follow-up (p < 0.01); PI and RI values increased during the second follow-up with respect to baseline values (p < 0.01) TOT prosthesis surgery, avoiding denervation and devascularization of pelvic structures, does not damage the urethral sphincter.

Piccoli impianti e navigazione nella ricostruzione protesica bicompartimentale del ginocchio. Tecnica chirurgica e risultati

Recently mini-invasive joint replacement and computer-assisted surgery have become the hottest topics in the orthopaedic world. As the matter of fact small implants as unicompartimental knee prostheses, patello-femoral prostheses and bi-unicompartimental knee prostheses implanted with the assistance of navigation might represent real less-invasive procedures. According to their experience the Authors analyze this real tissue-sparing surgery, not limited only to a small incision, but where the surgeon can respect physiological joint biomechanics, preserving accuracy with navigation.

Perceval S aortic valve implantation in mini-invasive surgery: the simple sutureless solution

The Perceval S bioprosthesis (21 and 23 mm) was approved for clinical use in December 2010 and it is now routinely used. This bioprosthesis is suggested for the treatment of patients undergoing minimally-invasive surgery for reasons of safety and reduction in implantation time. Here we describe the use of the Perceval bioprosthesis in patients undergoing minimally invasive cardiac surgery.

Exploring the new strategy of training and education for hepatobiliary robotic surgeons

Robotic surgery is a major trend of mini-invasive surgery,which is still in its infancy in China.The training and education of robotic surgeons is a problem to be solved imperatively.In our clinical practice,we explored the new strategy of training and education for hepatobiliary robotic surgeons by assimilating the essence of traditional surgery education and by drawing lessons from the successful training of robotic surgery in foreign countries.Satisfactory teaching effect was obtaincd. Key words: Hepatobiliary surgery; Robotic surgery; Training; Education

Klippel-Trenaunay syndrome: a rare cause of disabling pain after a femoral fracture

Klippel-Trenaunay syndrome (KTS) is characterized by a cutaneous vascular nevus of the involved extremity, as well as bone and soft tissue hypertrophy of the extremity and venous malformations. We present the case of a 52-year-old man with a femoral fracture and a history of haemangiomas, limb bone hypertrophy and varicosity. The patient was finally diagnosed with KTS and treated in mini-invasive surgery by endomedullary fracture nailing in general anaesthesia. Clinical management was particularly demanding, not only because of the need to monitor the risk of haemorrhage and thrombosis but also because of the onset of a rare picture of neuropathic pain with hyperalgesia and allodynia, never previously reported in patients affected by KTS, that required the administration of major opioid drugs. According to our knowledge, this is the second case of KTS managed for femoral fracture. Unlike the previous report in literature, in this case a severe disabling neuropathic pain complicated the clinical management.

Mini-invasive open surgery Bankart repair for recurrent traumatic shoulder instability: a single surgeon/single institution's experience

Background Primary traumatic anterior dislocations of the shoulder are common injuries which are complicated by persistent instability in a high proportion of patients. Surgery is successful and has been well described in the literature. Current scientific debate centres on the role of open and arthroscopic techniques. We describe the outcomes of a mini-invasive open surgery modified Bankart technique which was developed within our institution.

New approach in vaginal prolapse repair: mini-invasive surgery associated with application of platelet-rich fibrin

Platelet-rich fibrin (PRF) matrix is an autologous leukocyte and PRF biomaterial. PRF is a fibrin matrix polymerized in a tetramolecular structure with the incorporation of platelets, leukocytes, cytokines, and circulating stem cells. The three-dimensional structure of PRF is optimal for migration of endothelial cells and fibroblasts. It permits rapid angiogenesis and easier remodeling of fibrin in a more resistant connective matrix. In vaginal surgery, PRF may act as a graft material with better healing and better functional outcome. We performed a prospective observational study on ten consecutive women requiring surgery for prolapse recurrence (stage II or higher). These women had high risks for recurrence, erosion with graft materials, and intraoperative and postoperative complications with traditional pelvic reconstructive surgical procedures. ICS score and P-QoL Questionnaire results were assessed preoperatively and postoperatively. Surgery consisted of anterior, posterior, or apical repair plus PRF. Follow-up was performed at 1, 6, 12, 18, and 24 months. Anatomically, the success rate was 80%. Prolapse symptoms improved by 100%. Sexual activity increased by 20% without dyspareunia. The surgical time was satisfactory (mean, 38.5 min). There were no intraoperative or postoperative complications. The use of PRF for site-specific prolapse repair is associated with a good functional outcome because of the healing and mechanical properties of PRF.

The French functional physical therapy method for the treatment of congenital clubfoot

The French method, also called the functional physical therapy method, is a combination of physiotherapy, splinting and surgery à la carte. The French functional physical therapy method consists of daily manipulations of the newborn's clubfoot by a specialized physical therapist, stimulation of the muscles around the foot and temporary immobilization of the foot with elastic and nonelastic adhesive taping. Physiotherapy is optimized by early triceps surae lengthening. Sequences of plaster can also be used. If conservative treatment is no longer effective, surgery should be considered. Mini-invasive surgery is a complementary procedure to nonoperative treatment (surgery 'à la carte'). The French method reduces but does not eliminate the need for mini-invasive surgical procedures. Equinus is the most difficult deformity to treat; posterior release is sometimes necessary in a severe foot. Very severe feet (stiff-stiff; score, 16-20) are still a challenge. However, regular manipulations and splinting improve foot morphology and stiffness, and, ultimately, make surgery easier and less extensive. From the French method to the Ponseti method, the Hybrid method or the 'the third way', combining the advantages of both methods, is the future. The primary reason for relapses is the inability of families to maintain the correction initially achieved. The aim of this work is to provide an overview of the French functional physical therapy method and to help understand how it has evolved over time.

The Corpectomy Using Minimally Invasive Access in Thoracolumbar Fractures

Introduction: In our clinic for several years we are pursuing the concept of mini-invasive surgery applied to the spine. Increasingly we have to our attention patients with comorbidities (figure 1) and for this reason could not face a major surgery. In this work we analyze various patients who suffered an osteoporotic vertebral fracture. The fractures on CT and MRI study, presented a minimal back protrusion of the wall with no images related to compression of the structures (figure 2a, 2b, 2c), but presented deformities,like kyphosis. The deformities in the past would certainly have required anterior surgery and corpectomy with placement of a mesh and interbody stabilization. This method provides access to trans-abdominal peritoneal or retro peritoneal and often requires the collaboration of general and vascular surgeon due to the presence of abdominal viscera and major vessels. Materials and methods: From January 2008 to August 2011, we treated 26 patients, 10 males and 16 females with a mean age 66 years. Most of them presented comorbidities. We decided to use a minimally invasive technique that allowed us to avoid the anterior approach, however, allowing us to attack the affected vertebrae through a less traumatic way possible. The surgery was performed by 2 surgical approaches performed in the same operative session. The first provided a lateral position with incision of about 4 cm. The exhibition allows direct visualization of the lateral side facilitating the disc discectomy, corpectomy, and the placement of a prosthetic vertebral body expansion and bone grafting. Through this technique it is possible to remove the fractured vertebral body and restore the mechanical support of the anterior column. The second half provided a hand lying prone and the insertion of pedicle screws cemented in the vertebral bodies adjacent to the fractured vertebra solidarity by means of two rods. The degree of kyphosis, construct height and the subsidence of the cage in relation to the vertebral endplates were measured preoperatively, early postoperatively, and at the latest follow-up. Results: No intraoperative complications were observed. Faster functional recovery is observed and load was granted from the fifth to ninth day. Pain relief with reduction of VAS values (pre-op 9, post-op 5) and ODI (86% pre-op, post-op 38%). Conclusions: The advent of minimally invasive surgery has allowed us to perform surgeries, such as the vertebral corpectomy, with minimal access, low blood loss, allowing rapid functional recovery with reduced length of stay.

Current status of training on laparoendoscopic single-site surgery and natural orifice transluminal endoscopic surgery

Laparoendoscopic single-site surgery(LESS)and natural orifice transluminal endoscopic surgery(NOTES)are gaining the momentum of mini-invasive surgery,but many technical problems remain to be solved;difficulties in learning the technique hamper its popularization.A satisfactory training system can greatly promote the development of the new technique.In this paper,we introduce the current status of training for LESS and NOTES,and also introduce some valuable experience in our training courses.

Nouveautés dans la prise en charge chirurgicale du cancer thyroïdien en 2011

New developments in surgical treatment of thyroid carcinoma are presented. Nowadays, the main interest of robotic surgery is to avoid skin incision in the neck by transposing it in the armpit and in the nipple. Mini-invasive surgery of the mediastinum (TEMLA, VAXY) are authentic progress. Decision making of the physicians are more standardized by standardization of fine needle aspiration biopsy and Bethesda classification. Unilateral prophylactic central lymph node dissection may be an alternative between systematic bilateral and any lymph node central dissection for thyroid carcinoma.

Value of Postoperative Compression After Surgical Treatment of Varicose Veins

It is customary to recommend wearing of elastic band compression or compression stocking after treatment of varicose veins. We wanted to learn through this study the benefit of wearing elastic compression after surgical treatment of varicose veins (VVs). We have prospectively included all patients operated on for unilateral VVs, and distributing them into two groups: Group 1: putting on a class 2 stocking (18 mmHg) from the operating day until the postoperative consultation (approximately 8 days afterwards). Group 2: putting on a class 2 stocking (18 mmHg) from the operating day until the following day (D1) when it is removed. One hundred patients were included in the study, in equal proportion (50) between group 1 and group 2. The study of the demographic, clinical and hemodynamic characteristics, show no significant difference between the two groups. All the surgical procedures had been carried out under tumescent local anesthesia, in short ambulatory. The procedures carried out were not significantly different between group 1 and group 2, and had been most frequently phlebectomy with conservation of the refluxing saphenous vein (ASVAL) (46% vs. 48%). The patients all returned to postoperative consultation (on average 10.0 days on average for group 1 and 9.4 days group 2, nonsignificant: NS) for evaluation. The average pain score (visual analog scale: VAS) was not significantly different between group 1 and group 2 (0.6 vs. 0.8). The self-evaluation by VAS of the size of ecchymoses reported an average score without significant difference between groups 1 and 2 (1.3 vs. 1.2). The circumference of the ankle measured was not significantly different between the operated limb and the contralateral limb, for group 1 (26.2 cm vs. 25.9 cm) as well as for group 2 (26.2 cm vs. 26.0 cm). The measurement of the quality of life by the CIVIQ questionnaire found an average score of 7.00 in group 1 vs. 8.64 in group 2 (NS). Superficial or deep vein thrombosis was not found in any case. Lastly, 73.3% of the patients in group 1 and 67.7% of the patients in group 2 (NS) did not have sick leave, and the average sick leave was, respectively, 2.6 and 2.3 days in group 1 and 2 (NS). We found no value of wearing the compression after a surgical treatment of the varicose veins beyond the 1st postoperative day for pain, ecchymoses and the quality of life after the procedure. These results were obtained in the context of a mini-invasive surgery carried out under tumescent local anesthesia with immediate ambulation.

Laparoscopic approach for duodenal carcinoid.

Carcinoids are a heterogeneous group of neuroendocrine tumours. Duodenal localization is associated with relatively benign behaviour of the tumour, slow progression, low metastatic potential, and absence of endocrine activity. Type and extent of surgery depend on size and staging of the tumour. In this article, we present a case study of a 27-year-old female patient with well-differentiated carcinoid in the second part of the duodenum. The tumour of a size 5 mm × 3 mm × 2 mm manifested with abdominal symptomatology and did not invade the muscularis propria. Scintigraphy did not demonstrate other pathological deposits of somatostatin receptors. The wedge resection of the duodenal wall was performed laparoscopically with perioperative endoscopic localization and marking of the tumour. Uneventful operation and postoperative course presents a contribution of miniinvasive surgery of specific duodenal lesions.

Osteoid Osteoma of the Mobile Spine

A restrospective review of 81 cases of osteoid osteoma of the mobile spine submitted to surgical treatment. Analyze pro and contras of different techniques (conventional and minimally invasive) for the treatment of osteoid osteoma. Intralesional excision has been considered the standard treatment for spinal osteoid osteoma. The high success rate of minimally invasive surgery in the treatment of a variety of spinal disorders lead us to believe this technique can also be applicable for the treatment of osteoid osteoma of the spine. Eighty-one patients affected by osteoid osteoma were consecutively treated by the same team with intralesional excision using conventional or minimally invasive approach by video-assisted endoscopy, microscope, or percutaneous radiofrequency coagulation. The clinical features, the radiologic findings, and the outcome were reviewed. Pain and neurologic symptoms, were scored before surgery, after surgery and at the follow-up. Complications and local recurrences were also recorded. Immediate relief of pain was observed after surgery in all patients. One patient showed mild neurologic impairment before treatment but became free of neurologic symptoms postoperative. Five local recurrences were found in four patients, always associated with pain. Three of these patients underwent surgery for a second time and one patient for a third time. There were two complications because surgery in two patients. One patient developed a pneumothorax, the other a hematoma. No related cases of kyphosis or scoliosis surgery were observed. Conventional excision therapy is a effective and reliable treatment for osteoid osteoma associated to low morbidity and low local recurrence rate. Minimally invasive surgery is emerging as an alternative method, reducing soft tissue trauma and the collateral damage caused by traditional surgical approach, allow patients a more rapid and complete return to normal function.

Vaginal hysterectomy and multimodal anaesthesia with bipolar vessel sailing (Biclamp® forceps) versus conventional suture technique: quality results’ analysis

The medical and economic benefits of the transvaginal approach over the abdominal and laparoscopic methods are demonstrated in many studies. Vaginal hysterectomy with bipolar vessel sailing (BiClamp(®)) represents an example of mininvasive surgery and could be a valid and cost-benefit alternative in the surgical treatment of benign gynaecologic disease. BiClamp(®) may be carried out according to Clavè's technique with a good result in postoperative pain. Prospective randomized study (Canadian Task Force classification I). We compared the vaginal hysterectomy with salpingo-oophorectomies with BiClamp(®) and multimodal anaesthesia (group A 30 patients) with vaginal hysterectomy with salpingo-oophorectomies and spinal anaesthesia (group B 30 patients). The median operating time was 33.5 min for group A and 54.5 min for group B (p < 0.0001). The median blood loss was 59.25 ml in group A and 81.75 ml in group B. The median hospital stay was 1.6 ± 0.58 days for group A and 2.55 ± 0.66 days for group B. Postoperative pain was statistically different between groups in the immediate postoperatory times, at 2 and at 6 h from the surgery and at 10 p.m. (p < 0.0001). Analyses of cost-effectiveness have stated advantages in terms of costs and indirect-direct benefits but also in earlier resumption of working. BiClamp(®) technique with multimodal anaesthesia has advantages from surgical, anaesthesiology and economic point of view. It is a minimally invasive surgery characterised by lower morbidity, quicker surgery times and reduced costs when compared to classical vaginal hysterectomy. BiClamp(®) technique represents a new border in vaginal surgery.

Periprosthetic femoral fractures treated by locked plating: Feasibility assessment of the mini-invasive surgical option. A prospective series of 36 fractures

The treatment of periprosthetic femoral fractures by conventional plating is associated with problems related to fracture union and eventual refracture. Additionally, locking nailing cannot be used in all cases because of the risk of malunion. To resolve these issues, locking plates have been proposed to combine the advantages of closed reduction and internal fixation while achieving a higher quality reduction with plate fixation. Locking plates put into place by a mini-invasive surgical approach result in fixation without substantial misalignment or non-union. From June 2002 to December 2007 we prospectively treated 35 patients (one bilateral), 28 women and seven men with a fracture around the hip implant (21), around the knee (8), between the hip implant and the knee (2), between a trochanteric internal fixation device and the knee implant (5). The mean age was 76, (39-93). Internal fixation was always attempted by mini-invasive surgery using locking plate system with locking screws (Synthès™). Rehabilitation included immediate weight bearing with as much weight as the patient would tolerate. The preoperative Parker score was 5.25 (0-9). There was one patient lost to follow-up, one early failure, and seven deaths (four of whom were included in the study group since their follow-up was at least 24 months) for a total of 31 fractures (30 patients), the mean follow-up for the series was 26 months (6-67). Twenty-six fixations were performed by mini-invasive approach and 10 through a conventional open surgery. Patients applied full weight (n=20), partial weight (n=3) or no weight for 6 weeks (n=13). Infections developed in two patients and there were three cases of mechanical failure. Fracture union was achieved in 35 out of 36 cases. More than 5° of misalignment was observed in five patients. Loosening of the implant did not occur in any patients during follow-up. The Parker score in patients seen at follow up was 4.3 (0-9). Locking compression plates associated with a mini-invasive surgical approach result in a high rate of union (35/36) with no significant misalignment (only 5/36 cases of misalignment of more than 5°), no refractures (n=0) and a low rate of mechanical failure (3/36) while allowing full weight bearing in most cases (20/36). Locking plates for periprosthetic femoral fractures allow patients to begin walking again, with stable intermediate term results.

Single-Incision Versus Standard Laparoscopic Cholecystectomy: Comparison of Surgical Outcomes from a Single Institution

Laparoscopic cholecystectomy via the three-trocar technique is widely used for symptomatic gallbladder stones. Single-incision laparoscopic surgery (SILS) for cholecystectomy is a well-established procedure and represents the next step in developing the concept of mini-invasive surgery. We here described our 24-month experience SILS cholecystectomy. Between February 2009 and 2011, patients referred for cholecystectomy to the General and Endocrine Unit of our institution who agreed to undergo SILS were included in a prospective study. All operations were performed by the same surgical team specially trained in this type of surgery. The umbilicus was the sole point of entry for all patients. The same operative technique was used in all patients. Data of patients undergoing SILS cholecystectomy were compared with those from an uncontrolled group of patients undergoing standard laparoscopic cholecystectomy during the same study period. The SILS and standard cholecystectomy groups included 120 patients each. SILS was performed in all patients and none of them required conversion to an open procedure. The median operating time of 45 minutes in the SILS group was not significantly different from that in the standard laparoscopic cholecystectomy group. We suture fascial edge with simple stitches under direct vision, thus reducing the risk of incisional hernia in SILS group (P=.046). SILS cholecystectomy was technically feasible and safe and represents a reproducible alternative to standard laparoscopic cholecystectomy in selected patients. The definitive clinical, esthetic, and functional advantages of this technique require further analysis.

Natural Orifice Translumenal Endoscopic Surgery (NOTES): Patients’ Perceptions and Attitudes

Natural orifice translumenal endoscopic surgery (NOTES) has generated a surge of enthusiasm among researchers by virtue of its challenge to the dogma and potential benefits. However, no data is available in the medical literature about NOTES' acceptance by patients in Asia. The aim of the study is to survey patients' perceptions and attitudes towards NOTES. It is a questionnaire-based multi-center study on inpatient subjects with various gastrointestinal disorders from 14 hospitals in 12 cities of China. Procedural details with the benefits and risks of NOTES, laparoscopic surgery, and conventional surgery were explained to all registered candidates. They were required to choose and cite reasons for adopting one of the above three surgical techniques as the preferred mode of treatment. The reasons for selection of the surgical treatment were: safety, efficacy, cost, postoperative pain, abdominal wounds, and scarring. There were 1,797 cases, including 976 (54.3%) males and 821 females (45.7%). Based on their comprehension of the procedure, 802 (44.6%) patients opted for NOTES, 757 (42.1%) for laparoscopic surgery, and 238 (13.2%) for conventional surgery. NOTES was mainly selected by the young and educated persons, especially females and by those with past exposure to laparoscopy or conventional surgery. The choice of treatment was significantly correlated with age (P=0.0021), education (P=0.0209), past medical history (laparoscopy, P=0.0134; open surgery, P<0.0001), and department of admission (P=0.0173). The preference for NOTES was based on safety (37.3%), cost (17.6%), elimination of postoperative scars (16.1%), abdominal wounds (16.0%), and efficacy (13.1%). The vast majority of patients prefer mini-invasive surgery to conventional surgery. The potential recipients of NOTES are educated and younger age groups. However, a few consider NOTES as a safe and effective intervention at present.