Minimally Invasive Surgical Approach Research Articles

Minimally invasive surgical approach for radicalization of incidental post-cholecystectomy gallbladder carcinoma: safety, feasibility and outcomes

Background and aims: Gallbladder carcinoma is a rare but aggressive malignant neoplasm. The incidence of intra- or post-operative incidental gallbladder carcinoma diagnosis following laparoscopic cholecystectomy is estimated to be 1–2%. Aggressive re-resection is warranted as the majority of patients have residual disease either in the liver or the lymph nodes. However the use of a minimally invasive surgical approach (MISA) to perform a radicalization in these patients has not been investigated yet. We retrospectively analyzed surgical and oncologic outcome of a small selected cohort of patients with incidental gallbladder carcinoma whom underwent redo radicalization surgery by MISA.Material and methods: From April 2012 to June 2014 at our department six patients (three females and three males) with incidental findings of gallbladder carcinoma pT1b (stage I) following laparoscopic cholecystectomy, and referred to our center from other secondary-level referral hospitals, underwent a redo surgery for radicalization by means of laparoscopic (n. 3) or robotic approach (n. 3). A retrospective analysis of prospective collected data was performed.Results: The redo procedure consisted of a liver resection (segments IVb + V) and lymph nodes clearance of hepatoduodenal hilum and common hepatic artery. Conversion rate was zero. Median operative time was 290 (250–310) min. Estimate blood loss was 175 (100–350) ml. Total hospital stay was 6 (5–10) days. All liver resections were performed without inflow vascular clamping. One patient was re-operated for hemoperitoneum while peri-operative mortality was zero. Oncologically, an R0 resection was always achieved with a mean number of lymph nodes retrieved of 17,5 (14–22). The stage of the neoplasm was confirmed in all cases but one, who was found to have a pN1 status (stage IIIb). At 21 (6–32) months follow-up all patients are alive and no recurrence has been observed.Conclusions: Our data suggest that radicalization of patients with stage I incidental postoperative gallbladder carcinoma can be done by a MISA without compromising the oncologic outcome. Larger studies are needed to validate these results.

Concomitant unruptured intracranial aneurysms and ischemic cerebrovascular diseases: a surgical experience of 31 cases

Objective: To summarize the clinic experience of preventing cerebral ischemic events during perioperative period in patients which concomitant unruptured intracranial aneurysms and ischemic cerebrovascular diseases. Methods: The clinical materials of 31 consecutive patients with concomitant unruptured intracranial aneurysms and ischemic cerebrovascular diseases from April 2010 to April 2014 were retrospectively reviewed.A total of 35 aneurysms were detected, and all of them were unruptured aneurysms.Among them, 17 cases were located on the ipsilateral side of artery stenosis or occlusion, and 18 cases were detected in the contralateral side. Minimal invasive surgical approaches such as small pterional approach and lateral sub-frontal approach were adopted.The better management of perioperative blood pressure was performed. Intraoperative electroencephalogram and somatosensory evoked potential monitoring, indocyanine green video angiography and/or microvascular Doppler ultrasonography were regularly used to guarantee the safety of the surgery. The follow-up by digital subtraction angiography or computed tomography angiography were made. Results: All of 35 aneurysms were clipped. Major infarction occurred in one patient with posterior communicating artery aneurysm concomitant with common cervical carotid artery stenosis.Large bone flap was resected and dural-matter were got enlarged to tolerate the edema period.Paralysis and aphasia accompanied at discharge.Minor infarction in posterior limb of internal capsule occurred in one patient.Twenty-nine patients were favorable with Glasgow Outcome Scale (GOS) score 5 at discharge, one patient with minor neurological defect (GOS 4), and one patient with severe neurological defect (GOS 3). The follow-up period was 6 to 40 months.Four patients were lost.The modified Rankin scale (MRS) of last follow-up were 0-1 in 25 patients, 2 in one patient and 3 in one patient.Third months after operation, 3 cases were performed carotid artery stenosis, 1 patients were performed carotid endarterectomy. Conclusion: Reinforcing the management of perioperative blood pressure, adjusting the perioperative blood coagulation function, and combine application of intraoperative monitoring technology can effectively prevent the occurrence of cerebral ischemia.

Lateral malleolus closed reduction and internal fixation with intramedullary fibular rod using minimal invasive approach for the treatment of ankle fractures

BackgroundAnkle fractures are extremely common and represent nearly one quarter of all lower-limb fractures. Techniques for fixation of displaced fractures of the lateral malleolus have remained essentially unchanged in recent decades. The current gold standard of treating unstable fractures is with open reduction and internal fixation (ORIF), using plates and screws construct. This study evaluates the use of fibula intramedullary nailing based on minimal invasive surgical approach. MethodsThirty-nine cases treated with fibula intramedullary nailing between the years 2014–2016 were retrospectively studied. A fibular nail was utilized for the treatment of various ankle fractures either as the sole method of fixation or combined with another method. Patient charts were reviewed for fracture patterns, comorbidities, quality of reduction, complications and additional surgeries. ResultsOut of 39 cases in the study cohort, 37 were closed fractures while 2 had an associated medial malleolus open injury. According to Weber classification of lateral malleolus fractures, 20 cases were type B, 18 cases type C, and one case of a pathologic fracture type B like fracture.Quality of reduction was based on previously published criteria. It was determined to be good in 32 cases, fair in 5 cases and poor in 2 cases that were revised intraoperatively to plate fixation.Overall no systemic complications occurred. Eight patients have undergone additional surgeries, namely hardware removals. In two cases, the nail was later revised to a different fixation method: one case to a plate, due to secondary displacement at 2 weeks, and one to an intramedullary tibiotalocalcaneal arthrodesis secondary to hardware failure and Charcot neuroarthropathy. ConclusionIntramedullary fibular nail offers a satisfactory and safe procedure to establish good reduction and fixation of lateral malleoli fractures. It may be considered as treatment of choice for patients with soft tissue problems due to its minimal invasive approach. The current study shows that while good fracture reduction can be achieved, without major complications, more than fifth of patients, required secondary procedures, mainly hardware removals.Level of evidence: Level IV

MP61-02 MINIMALLY INVASIVE VERSUS OPEN URETERAL REIMPLANTATION: IS THERE A DIFFERENCE IN RATES OF REOPERATION? COMPARISON FROM A LARGE NATIONAL DATABASE

You have accessJournal of UrologyPediatrics: Urinary Tract Infection and Vesicoureteral Reflux1 Apr 2017MP61-02 MINIMALLY INVASIVE VERSUS OPEN URETERAL REIMPLANTATION: IS THERE A DIFFERENCE IN RATES OF REOPERATION? COMPARISON FROM A LARGE NATIONAL DATABASE Eric D. Schadler, William R. Boysen, Christopher Lyttle, Vignesh T. Packiam, Charles U. Nottingham, and Mohan S. Gundeti Eric D. SchadlerEric D. Schadler More articles by this author , William R. BoysenWilliam R. Boysen More articles by this author , Christopher LyttleChristopher Lyttle More articles by this author , Vignesh T. PackiamVignesh T. Packiam More articles by this author , Charles U. NottinghamCharles U. Nottingham More articles by this author , and Mohan S. GundetiMohan S. Gundeti More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1860AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Minimally invasive surgical (MIS) approaches to ureteral reimplantation (UR) for vesicoureteral reflux (VUR) are being used with increasing frequency, despite variability in published rates of complications and reoperation. We assessed rates of secondary procedures following ureteral reimplantation in a prospectively maintained national database. METHODS We queried MarketScan, a national employer based insurance database, to identify patients less than 18 years of age who underwent an open or MIS UR between 2008 and 2014. Rates of secondary procedures related to ureteral obstruction (placement of stent or nephrostomy tube, or dilation of ureteral stricture) within 120 days of UR and rates of repeat UR at any time point were assessed. Statistical analysis was performed using t-test, chi-square test, Wilcoxon rank-sum test, and multivariate regression. RESULTS Between 2008 and 2014, 2,752 patients underwent UR with an open approach in 2,601 (94.5%) and MIS in 151 (5.5%). There was a trend toward increased utilization of MIS, with MIS comprising 2.5% of cases in 2008 and 9.3% in 2014 (p=0.026). Relative to the open group, mean age in years was higher in the MIS group (5.6 vs 4.3, p<0.01) and mean length of stay in days was shorter (1.44 vs 2.15, p<0.01). Mean inpatient hospital charges did not differ between the groups ($21,660 vs $20,621, p=0.59). The rate of secondary ureteral procedures within 120 days did not differ between the MIS and open groups (0.7% vs 0.3%%, p=0.76), but rate of subsequent open UR at any time was higher in the MIS group (3.97% vs 0.69%, p<0.01). On univariate analysis, patient age, gender, LOS, and surgical approach did not predict subsequent secondary procedures within 120 days (Table 1). CONCLUSIONS From 2008 to 2014 there has been a trend toward increased utilization of MIS UR. Relative to the open approach, MIS approach is associated with a shorter length of hospital stay with no difference in inpatient hospital charges. The rate of secondary ureteral procedure within 120 days of UR did not differ by approach, but patients treated with MIS UR had a higher rate of subsequent open UR. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e798-e799 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Eric D. Schadler More articles by this author William R. Boysen More articles by this author Christopher Lyttle More articles by this author Vignesh T. Packiam More articles by this author Charles U. Nottingham More articles by this author Mohan S. Gundeti More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Impact of minimally invasive surgery on healthcare utilization, cost, and workplace absenteeism in patients with Incisional/Ventral Hernia (IVH).

Incisional hernia repair is one of the most common general surgery operations being performed today. With the advancement of laparoscopy since the 1990s, we have seen vast improvements in faster return to normal activity, shorter hospital stays and less post-operative narcotic use, to name a few. The key aims of this review were to measure the impact of minimally invasive surgery versus open surgery on health care utilization, cost, and work place absenteeism in the patients undergoing inpatient incisional/ventral hernia (IVH) repair. We analyzed data from the Truven Health Analytics MarketScan® Commercial Claims and Encounters Database. Total of 2557 patients were included in the analysis. Of the patient that underwent IVH surgery, 24.5% (n = 626) were done utilizing minimally invasive surgical (MIS) techniques and 75.5% (n = 1931) were done open. Ninety-day post-surgery outcomes were significantly lower in the MIS group compared to the open group for total payment ($19,288.97 vs. $21,708.12), inpatient length of stay (3.12 vs. 4.24 days), number of outpatient visit (5.48 vs. 7.35), and estimated days off (11.3 vs. 14.64), respectively. At 365 days post-surgery, the total payment ($27,497.96 vs. $30,157.29), inpatient length of stay (3.70 vs. 5.04 days), outpatient visits (19.75 vs. 23.42), and estimated days off (35.71 vs. 41.58) were significantly lower for MIS group versus the open group, respectively. When surgical repair of IVH is performed, there is a clear advantage in the MIS approach versus the open approach in regard to cost, length of stay, number of outpatient visits, and estimated days off.

The Role of Minimally Invasive Techniques in the Treatment of Thoracolumbar Trauma

Context: Thoracolumbar injuries are common manifestations of spinal trauma. While non-operative therapy is indicated in certain cases of isolated injury, operative therapy via open approaches are widely utilized. Recently, minimally invasive surgical (MIS) approaches have been adapted for the management of thoracolumbar trauma in an effort to avoid the operative morbidity of open thoracolumbar procedures.Purpose: The purpose of this review is to perform a critical analysis of the literature regarding the clinical efficacy and safety of MIS procedures in the management of thoracolumbar trauma.Evidence Acquisition: PubMed and MEDLINE databases were searched for articles published on the topic of MIS treatment of traumatic thoracolumbar injuries. Studies included in this review were comprised of clinical case series, retrospective cohort studies, non-randomized prospective cohort studies, prospective randomized controlled trials, and meta-analyses.Results: The majority of published studies were retrospective clinical case series comprising level IV evidence. The majority of studies demonstrated the viability of MIS approaches as a treatment modality for thoracolumbar trauma in regards to clinical outcomes, radiographic outcomes, and complication rates. Additionally, MIS procedures were associated with reductions in operative time, intraoperative blood loss, and immediate postoperative pain.Conclusions: MIS approaches to thoracolumbar trauma are viable treatment strategies in regards to clinical efficacy and safety. While the results for MIS procedures are promising, more high-quality prospective studies are necessary in order to make definitive conclusions regarding the superiority of MIS over open surgical strategies.

Evidence for the use of robotically assisted surgery in gynecologic cancers.

Robotically assisted laparoscopy has been introduced in the armamentarium of gynaecologic oncology surgeons. A lot of studies compared robotic surgery and laparotomy when the real issue is to demonstrate the interest and added value of robotically assisted laparoscopy versus standard laparoscopy. In this review, we will describe the most meaningful indications and advantages of robotically assisted laparoscopy in gynaecologic oncology. The learning curve for advanced procedures in robot-assisted laparoscopy is shorter and easier than with the standard laparoscopy, especially for beginners. In most of the series, operating time is longer with robot, but complication rates are often decreased, especially in obese patients with a conversion rate to laparotomy that is decreased compared with standard laparoscopy. Robot-assisted laparoscopy can be used for surgery of high-risk endometrial cancer, staging of early-ovarian cancer, and pelvic exenteration in case of recurrent malignancies. Furthermore, more recent robots allow performing sentinel node biopsy in endometrial or cervical cancer using fluorescence detection with indocyanine green. The spreading of robotic surgery led to an enhancement of minimal invasive surgical approach in general, and to the development of new indications in gynaecologic oncology. The superiority of robot-assisted laparoscopy still has to be demonstrated with properly designed trials.

Laparoscopic Confocal Laser Microscopy Without Fluorescent Injection: A Pilot Ex Vivo Study in Colon Cancer.

Introduction Histological analysis of surgical specimen is the gold standard for cancer classification. In particular, frozen histological diagnosis of vague peritoneal spots or uncertain excision of tumors plays a crucial role for proceeding with or without change of the operation procedure. Confocal laser microscopy (CLM) enables in vivo and real-time high-resolution tissue analysis. To evaluate a novel technique of CLM without any fluorescent dye, this pilot ex vivo study demonstrates a CLM camera device for minimal invasive surgical approach. Methods In 5 cases, a laparoscopic CLM camera was used for examining colon and rectum specimen. Images of nonmalignant and malignant intestinal mucosa were characterized in terms of specific signal-patterns. No fluorescent dye was used. Correlations to findings in conventional histology were systematically recorded and described. Results Using this CLM camera device, it is possible to analyze colon specimen mucosa. Nonmalignant and malignant intestinal mucosa show specific signal patterns. Nonmalignant mucosa is defined by honeycomb structure. There is deregulated structure in colon and rectum carcinoma mucosa. The inside lumen is irregular. The radial border appears swollen with reduced contrast. Discussion This pilot study shows that the assessment of colon mucosa with a prototype of CLM camera for minimally invasive surgical approach without any fluorescent dye is feasible. It is possible to differentiate between benign and malignant mucosa in colon specimen by easy to evaluate and reproducible parameters. These first steps of this pioneering achievement to establish CLM in minimal invasive surgical procedures show a great potential for a more reliable intraoperative evaluation of suspect foci.

Overview on cardiac, pulmonary and cutaneous toxicity in patients treated with adjuvant radiotherapy for breast cancer.

Conservative management of breast cancer represents the standard treatment for early disease. Breast conserving surgery associated with radiotherapy for stage I-II has been proven to be as equally effective as mastectomy in term of local control, distant disease, and overall survival. The growing minimal invasive surgical approach on the axillary region, and the new breast reconstructive techniques, will probably lead to a significant decrease of the rate of side-effects related to mastectomy. Therefore, the adverse events caused by adjuvant radiation still remain a challenge. Cutaneous, pulmonary and cardiac toxicity represent the main toxicities of adjuvant radiotherapy for breast cancer. Safety profile of radiation is strongly dependent on the multidisciplinary management of the single case (systemic treatment, endocrine therapy, surgery), individual characteristics (i.e., co-morbidities, age, habits), and radiation-related aspects. Radiation techniques development, and facilities implementation concerning organs-at-risk sparing systems (i.e., image-guided radiotherapy, tracking systems, respiratory gating), represent brand new tools for the clinical oncologist, that would certainly minimize toxicity profile in the next future. However, data reported from published literature will greatly help physicians, to give to the patients appropriate counseling regarding the efficacy and potential adverse events of treatments, thus optimizing the informed decision-making process.

V1-11 SIMULTANEOUS ROBOTIC-ASSISTED MITROFANOFF PROCEDURE AND URETHRECTOMY FOR URETHRAL CARCINOMA

You have accessJournal of UrologyRobotics-Bladder/Reconstruction1 Apr 2016V1-11 SIMULTANEOUS ROBOTIC-ASSISTED MITROFANOFF PROCEDURE AND URETHRECTOMY FOR URETHRAL CARCINOMA David Crawley, James Bienvenu, Richard Kershen, and Joseph Wagner David CrawleyDavid Crawley More articles by this author , James BienvenuJames Bienvenu More articles by this author , Richard KershenRichard Kershen More articles by this author , and Joseph WagnerJoseph Wagner More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2125AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Urethrectomy with appendicovesicostomy is a treatment option for low stage urethral cancer. We present a novel minimally-invasive surgical approach which allows for robotic appendicovesicostomy to be performed simultaneously with open urethrectomy. METHODS A 71 year-old man presented with clinically-localized squamous cell carcinoma of the urethra. He underwent a traditional open urethrectomy with simultaneous robotic-assisted bladder neck closure, omental J flap interposition, and appendicovesicostomy. The robot was side-docked to allow for a perineal surgeon to work in tandem with the robotic surgeon. RESULTS Total operating room time was 391 minutes. Robotic console time was 281 minutes. Length of stay was four days. There were no complications, and no secondary procedures were required. Final pathology demonstrated T2 squamous cell carcinoma with negative margins. At 6 months follow up, the patient is continent and cancer-free. CONCLUSIONS Simultaneous extirpative surgery and minimally-invasive urinary tract reconstruction is possible for patients with urethral cancer. Side-docking the robot allows for two surgical teams to work concurrently. This approach may be applicable to other procedures requiring both open perineal and laparoscopic intraabdominal access. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e65 Advertisement Copyright & Permissions© 2016MetricsAuthor Information David Crawley More articles by this author James Bienvenu More articles by this author Richard Kershen More articles by this author Joseph Wagner More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V1-12 ROBOTIC-ASSISTED RADICAL PROSTATECTOMY AND CONTINENT URINARY STOMA (MITROFANOFF) IN A 7 YEAR CHILD.

INTRODUCTION AND OBJECTIVES: Urethrectomy with appendicovesicostomy is a treatment option for low stage urethral cancer. We present a novel minimally-invasive surgical approach which allows for robotic appendicovesicostomy to be performed simultaneously with open urethrectomy. METHODS: A 71 year-old man presented with clinically-localized squamous cell carcinoma of the urethra. He underwent a traditional open urethrectomy with simultaneous robotic-assisted bladder neck closure, omental J flap interposition, and appendicovesicostomy. The robot was side-docked to allow for a perineal surgeon to work in tandem with the robotic surgeon. RESULTS: Total operating room time was 391 minutes. Robotic console time was 281 minutes. Length of stay was four days. There were no complications, and no secondary procedures were required. Final pathology demonstrated T2 squamous cell carcinoma with negative margins. At 6 months follow up, the patient is continent and cancer-free. CONCLUSIONS: Simultaneous extirpative surgery and minimally-invasive urinary tract reconstruction is possible for patients with urethral cancer. Side-docking the robot allows for two surgical teams to work concurrently. This approach may be applicable to other procedures requiring both open perineal and laparoscopic intraabdominal access.

Fifteen Years of Minimally Invasive Mitral Valve Surgery: Single Centre Results in 1006 Patients

Objectives: The aim of the current study was to evaluate our institutional experience in mitral valve surgery with two different minimal invasive surgical approaches.

Minimalism in Art, Medical Science and Neurosurgery.

The word "minimalism" is a word derived from French the word "minimum". Whereas the lexical meaning of minimum is "the least or the smallest quantity necessary for something", its expression in mathematics can be described as "the lowest step a variable number can descend, least, minimal". Minimalism, which advocates an extreme simplicity of the artistic form, is a current in modern art and music whose origins go to 1960s and which features simplicity and objectivity. Although art, science and philosophy are different disciplines, they support each other from time to time, sometimes they intertwine and sometimes they copy each other. A periodic schools or teaching in one of them can take the others into itself, so, they proceed on their ways empowering each other. It is also true for the minimalism in art and the minimal invasive surgical approaches in science. Concepts like doing with less, avoiding unnecessary materials and reducing the number of the elements in order to increase the effect in the expression which are the main elements of the minimalism in art found their equivalents in medicine and neurosurgery. Their equivalents in medicine or neurosurgery have been to protect the physical integrity of the patient with less iatrogenic injury, minimum damage and the same therapeutic effect in the most effective way and to enable the patient to regain his health in the shortest span of time. As an anticipation, we can consider that the minimal approaches started by Richard Wollheim and Barbara Rose in art and Lars Leksell, Gazi Yaşargil and other neurosurgeons in neurosurgery in the 1960s are the present day equivalents of the minimalist approaches perhaps unconsciously started by Kazimir Malevich in art and Victor Darwin L"Espinasse in neurosurgery in the early 1900s. We can also consider that they have developed interacting with each other, not by chance.

87 Robotic partial nephrectomy for clinical stage T1 tumors: Experience in 42 cases

Theaim ofthis study was to evaluate outcomes ofrobotic partial nephrectomy(RAPN) procedures. At two centers, 42 patients underwent RAPN. Radius, Exo/Endophytic, Nearness, Anterior/Posterior, Location (R.E.N.A.L.) nephrometry and PADUA scores of patients were calcu- lated by computed tomography (CT) or magnetic resonance imaging (MRI). Intra- and periopera- tive (0e30 days) complications were evaluated using modified Clavien classification. A four-arm da Vinci-S robotic surgical system was used and outcomes were evaluated retrospectively. Mean age of the patients was 52.3 � 6.5 years. Mean tumor size was 3.1 � 1.0 (1.4e6.6) cm. R.E.N.A.L. nephrometryand PADUAscoreswere 6.0 � 1.5 and 7.5 � 0.9,respectively. Meansurgical timewas 127.7 � 18.7 minutes and estimated blood loss was 100 � 18.1 cc. Mean warm ischemia time was 16.0 � 8.9 (0e30) minutes. Intraoperative complications did not develop in any patient. Median hospital stay was 3.0 (2e6) days. Except for 17 patients, hilar clamping was performed in 25 pa- tients. Histopathology results included 34 renal cell carcinoma (22 clear cell, 7 chromophobe cell, 4 papillary cell, and 1 clear papillary cell). Oncocytoma (n Z 4), adenoma (n Z 1), fibroadipose tissue (n Z 1), papillary epithelial hyperplasia (n Z 1), and chronic pyelonephritis (n Z 1) were present. Surgical margins were negative in all patients. During a median follow-up period of 15.5 � 10.9 (3e46) months, neither local recurrence nor distant metastasis was detected. In conclusion, RAPNisa safe,minimallyinvasivesurgical approach, withexcellentsurgicalandonco- logical outcomes in T1 kidney tumors. Zero ischemia off-clamp RAPN is also safe in selected masses with the advantage of avoiding complete renal ischemia. Copyright a 2015, Kaohsiung Medical University. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/ by-nc-nd/4.0/).

Minimally invasive open reduction and fixation of avulsed tibial insertion of posterior cruciate ligament

Background Surgical treatment of bony avulsions of the posterior cruciate ligament (PCL) through a classic posterior approach carries a high risk of neurovascular compromise, and arthroscopic techniques are demanding. The purpose of this study is to report results of safe, minimal invasive surgical approach using pull-out suture fixation technique.

Minimally invasive resection of lumbar intraspinal synovial cysts via a contralateral approach: review of 13 cases.

The authors sought to determine patient-related outcomes after minimally invasive surgical (MIS) lumbar intraspinal synovial cyst excision via a tubular working channel and a contralateral facet-sparing approach. All the patients with a symptomatic lumbar intraspinal synovial cyst who underwent surgery at the University of Iowa Hospitals and Clinics with an MIS excision via a contralateral approach were treated between July 2010 and August 2014. There was a total of 13 cases. Each patient was evaluated with preoperative neurological examinations, lumbar spine radiography, MRI, and visual analog scale (VAS) scores. The patients were evaluated postoperatively with neurological examinations and VAS and Macnab scores. The primary outcomes were improvement in VAS and Macnab scores. Secondary outcomes were average blood loss, hospital stay duration, and operative times. There were 5 males and 8 females. The mean age was 66 years, and the mean body mass index was 28.5 kg/m(2). Sixty-nine percent (9 of 13) of the cysts were at L4-5. Most patients had low-back pain and radicular pain, and one-third of them had Grade 1 spondylolisthesis. The mean (± SD) follow-up duration was 20.8 ± 16.9 months. The mean Macnab score was 3.4 ± 1.0, and the VAS score decreased from 7.8 preoperatively to 2.9 postoperatively. The mean operative time was 123 ± 30 minutes, with a mean estimated blood loss of 44 ± 29 ml. Hospital stay averaged 1.5 ± 0.7 days. There were no complications noted in this series. The MIS excision of lumbar intraspinal synovial cysts via a contralateral approach offers excellent exposure to the cyst and spares the facet joint at the involved level, thus minimizing risk of instability, blood loss, operative time, and hospital stay. Prospective randomized trials with longer follow-up times and larger cohorts are needed to conclusively determine the superiority of the contralateral MIS approach over others, including open or ipsilateral minimally invasive surgery.

Complications of minimally invasive calcaneal osteotomy versus open osteotomy.

Calcaneal osteotomy is an established technique for correcting hindfoot deformity. Patients traditionally receive an osteotomy through the open lateral approach to the calcaneus. To reduce the rate of wound complications associated with a direct open lateral approach, a minimally invasive surgical (MIS) technique has been adopted. This uses a low-speed, high-torque burr to perform the same osteotomy under radiographic guidance. We hypothesized that the new MIS calcaneal osteotomy would be a safe alternative to open calcaneal osteotomy while obtaining the same displacement. The safety of the new MIS technique was investigated with a case controlled study on all patients who underwent displacement calcaneal osteotomy at the Nuffield Orthopaedic Centre from 2008 to 2014. The primary outcome measure was 30 day postoperative complication rate. Secondary outcome measures included operating time, duration of stay, fusion rates, and calcaneal displacement. Eighty-one patients underwent calcaneal osteotomy as part of their corrective surgery, 50 in the Open approach group and 31 in MIS group. The average age was 47.7 years (range 16-77) for the Open group and 50.1 (range 21-77) in the MIS group. A mean calcaneal displacement of 9.4 mm (SD = 1.16, 8 to 11 mm) and 10.2 mm (SD = 1.06, 8 to 13 mm) was achieved through the MIS and Open approaches, respectively. There were significantly fewer wound complications in the MIS group (6.45%) compared to the Open group (28%, P = .022). The MIS group was associated with significantly lower rate of wound infection (3% versus 20%, P = .044). Three patients in the Open group experienced sural peripheral neuropathy. The average length of stay was 3.8 days following MIS and 4.3 days following open calcaneal osteotomy. Nonunion occurred in only 1 patient in the MIS group and none in the open group. MIS calcaneal osteotomy was found to be a safe technique. It was technically as effective as calcaneal osteotomy performed through an open lateral approach but was associated with significantly fewer wound complications and fewer nerve complications. Level III, comparative study.

A comparison of registration errors with imageless computer navigation during MIS total knee arthroplasty versus standard incision total knee arthroplasty: a cadaveric study

Optimal component alignment in total knee arthroplasty has been associated with better functional outcome as well as improved implant longevity. The ability to align components optimally during minimally invasive (MIS) total knee replacement (TKR) has been a cause of concern. Computer navigation is a useful aid in achieving the desired alignment although it is limited by the error during the manual registration of landmarks. Our study aims to compare the registration process error between a standard and a MIS surgical approach. We hypothesized that performing the registration error via an MIS approach would increase the registration process error. Five fresh frozen lower limbs were routinely prepared and draped. The registration process was performed through an MIS approach. This was then extended to the standard approach and the registration was performed again. Two surgeons performed the registration process five times with each approach. Performing the registration process through the MIS approach was not associated with higher error compared to the standard approach in the alignment parameters of interest. This rejects our hypothesis. Image-free navigated MIS TKR does not appear to carry higher risk of component malalignment due to the registration process error. Navigation can be used during MIS TKR to improve alignment without reduced accuracy due to the approach.

Shape Deposition Manufacturing of a Soft, Atraumatic, Deployable Surgical Grasper1

Laparoscopic pancreaticoduodenectomy (also known as the Whipple procedure) is a highly-complex minimallyinvasive surgical (MIS) procedure used to remove cancer from the head of the pancreas. While mortality rates of the MIS approach are comparable with those of open procedures, morbidity rates remain high due to the delicate nature of the pancreatic tissue, proximity of high-pressure vasculature, and the number of complex anastomoses required [1]. The sharp, rigid nature of the tools and forceps used to manipulate these structures, coupled with lack of haptic feedback, can result in leakage or hemorrhage, which can obfuscate the surgeon’s view and force the surgeon to convert to an open procedure. We present a deployable atraumatic grasper with onboard pressure sensing, allowing a surgeon to grasp and manipulate soft tissue during laparoscopic pancreatic surgery. Created using shape deposition manufacturing, with pressure sensors embedded in each finger enabling real-time grip force monitoring, the device offers the potential to reduce the risk of intraoperative hemorrhage by providing the surgeon with a soft, compliant interface between delicate pancreatic tissue structures and metal laparoscopic forceps that are currently used to manipulate and retract these structures on an ad-hoc basis. Initial manipulation tasks in a simulated environment have demonstrated that the device can be deployed though a 15mm trocar and develop a stable grasp on a pancreas analog using Intuitive Surgical’s daVinci robotic end-effectors.

Treatment of femoral neck fracture with a minimal invasive surgical approach for hemiarthroplasty - clinical and radiological results in 180 geriatric patients.

Purpose : The Direct Anterior Approach (DAA) is well established as a minimal access approach in elective orthopaedic hip surgery. For the growing number of elderly patients with femoral neck fractures treated with Bipolar Hip Hemiarthroplasty (BHH), only a few results do exist. The study shows the clinical and radiological outcome for 180 patients treated by a modified DAA with BHH.Materials and Methods : The data of 180 geriatric patients with medial femoral neck fractures were evaluated retrospectively. The general and surgical complications, mobilisation using the Timed Up and Go test (TUG), the social environment pre- and postoperative and the radiological results have been compared with established approaches for geriatric hip surgery.Results : After joint replacement, 18 (10%) patients were developed pneumonia, of which 3 (1.7%) died during hospitalisation. In 7 cases (4%), surgical revision had to be carried out: three times (1.7%) because of a seroma, three times (1.7%) because of subcutaneous infection, and one time (0.6%) because the BHH was removed, owing to deep wound infection. One dislocation (0.6%) occurred, as well as one femoral nerve lesion (0.6%) occured. 88.3% of patients were mobilised on walkers or crutches; the Timed Up and Go Test showed a significant improvement during inpatient rehabilitation. 83% were discharged to their usual social environment, 10% were transferred to a short-term care facility and 7% were relocated permanently to a nursing home. 3/4 of patients had a cemented stem alignment in the range between -5° and 5°, while 2/3 of patients had a maximum difference of 1 cm in leg length.Conclusion : Using the modified DAA, a high patient satisfaction is achieved after implantation of a BHH. The rate of major complications is just as low as in conventional approaches, and rapid mobilisation is possible.