Percutaneous Instruments Research Articles

Results of care and treatment of patients after atrial septal defect intervention and some related factors in 2020-2021

The study was conducted on 108 patients with atrial septal defect (ASD) who indicated ASD occlusion by percutaneous instrument at the Vietnam Heart Institute-Bach Mai Hospital, Hanoi Medical University Hospital, Hanoi Heart Hospital. from December 2020 to September 2021.Objectives: Describe the clinical and paraclinical characteristics, analyze the results of care for patients with atrial septal defect after intervention and related factors.Research Methods: A prospective descriptive study, a longitudinal study.Results: The majority of patients had good clinical results after 1 month of discharge (65.74%). The rate of pulmonary arterial hypertension after intervention was lower in the group with good results, statistically significant compared with the group with poor results. The group with good results had a lower percentage of patients with anemia, statistically significant compared with the group with poor results. The group with good results had a lower rate of complications after the procedure, which was statistically significant compared with the group with poor results. The difference in the rate of completing 5 steps of implementing the medicine and the rate of meeting the health education requirements between the two groups of good and bad results is statistically significant (p < 0.05). There are 3 factors: Pulmonary artery pressure after intervention still increases (≥35 mmHg); anemia; Postprocedural complications were independently associated with the risk of poor outcome 1 month after discharge. The group with satisfactory health education has a higher rate of patient adherence to treatment than the group that does not meet the requirements of health education (p<0.05).Conclusion: The long-term outcomes of patients with ASD occlusion with percutaneous instruments are related to the treatment, care, and health education counseling of nurses.

Rationale and Advantages of Endoscopic Spine Surgery.

The goal of a spine surgery is to achieve adequate neural tissue decompression, maintenance of spinal stability, and successful stabilization of an unstable spine. To achieve these surgical goals, damage to normal tissues, including the spinal column and surrounding soft tissues, is inevitable after the beginning of a spine surgery. Extensive damage to normal spinal column and paraspinal collateral tissues during operation can lead to unsuccessful outcomes due to persistent axial pain and additional surgeries due to occurrence of spinal instability. Numerous efforts, such as the usage of microscopy, tubular retractor systems, percutaneous instruments, and trials of new operative approaches have been attempted to reduce normal tissue damage and improve surgical outcomes. Endoscopic spine surgery (ESS) was introduced about 3 decades ago as a minimally invasive spine surgery and has been widely spread with the development of endoscopic surgical instruments and adoption of new endoscopic surgical approaches during the past 2 decades. Theoretically, ESS may be the gold standard method of spine surgery because of its minimal tissue damage and good visualization of the surgical field. However, surgeons hesitate to initiate an ESS due to its steep learning curve and the lack of high-level evidence of surgical outcomes. In this article, the rationale and advantages of performing ESS are discussed by reviewing published articles.

Deep learning robotic guidance for autonomous vascular access

Medical robots have demonstrated the ability to manipulate percutaneous instruments into soft tissue anatomy while working beyond the limits of human perception and dexterity. Robotic technologies further offer the promise of autonomy in carrying out critical tasks with minimal supervision when resources are limited. Here, we present a portable robotic device capable of introducing needles and catheters into deformable tissues such as blood vessels to draw blood or deliver fluids autonomously. Robotic cannulation is driven by predictions from a series of deep convolutional neural networks that encode spatiotemporal information from multimodal image sequences to guide real-time servoing. We demonstrate, through imaging and robotic tracking studies in volunteers, the ability of the device to segment, classify, localize and track peripheral vessels in the presence of anatomical variability and motion. We then evaluate robotic performance in phantom and animal models of difficult vascular access and show that the device can improve success rates and procedure times compared to manual cannulations by trained operators, particularly in challenging physiological conditions. These results suggest the potential for autonomous systems to outperform humans on complex visuomotor tasks, and demonstrate a step in the translation of such capabilities into clinical use. Getting safe and fast access to blood vessels is vital to many methods of treatment and diagnosis in medicine. Robot-assisted or even fully autonomous methods can potentially do the task more reliably than humans, especially when veins are hard to detect. In this work, a method is tested that uses deep learning to find blood vessels and track the movement of a patient’s arm.

Complete percutaneous laparoscopic cholecystectomy by employing the Percuvance Percutaneous Surgical System.

Laparoscopic cholecystectomy (LC) has been the gold standard in the treatment of gallbladder disease. More than 50 different techniques of LC have been developed and performed, which seem to offer much in postoperative outcome and cosmesis. However, each has its limitations in practice mainly due to the long learning curve, or lack of appropriate instruments. The current paper studies the application of percutaneous LC employing the Percuvance Percutaneous Surgical System and reports the first documented complete percutaneous LC in the literature. Complete percutaneous LC was performed in fifteen patients diagnosed with cholelithiasis, the Percuvance Percutaneous Surgical System from Teleflex was used. All operations were performed with the use of a single 10 mm Hassan Trocar port and a 30o degree camera. Complete percutaneous LC with the use of percutaneous Instruments was applied in all cases. No conversions to open cholecystectomy were reported. Mean operating time was well within the standard for LC. Postoperatively, no complications were observed, while all patients were discharged the next day. Excellent cosmesis and satisfied patients were the long-term results. Percutaneous LC with the use of a 10 mm Hassan trocar, bears the potential of being a favorable alternative in cholecystectomy.

Technological innovation and personalized surgical treatment for early-stage endometrial cancer patients: A prospective multicenter Italian experience to evaluate the novel percutaneous approach

ObjectiveTo investigate the safety, feasibility and oncological adequacy of the Percutaneous Surgical System - PSS in a consecutive series of low-risk endometrial cancer staging. Study DesignFrom May 2015 to April 2017, we prospectively performed 30 consecutive percutaneous staging for low/intermediate risk endometrial cancer (FIGO stage IA G1-G2, IB G1-G2, IA G3). All patients were divided in two different groups on the basis of surgical procedure received: Group A included patients submitted to radical Class A hysterectomy and bilateral salpingo-oophorectomy; Group B concerned patients that received a lymph nodal assessment also. ResultsThe time needed to install percutaneous instruments and suprapubic trocar was 4 min. (range 2–10). The recorded median operative time (OT) was 80 min. (range 65–120) for Gr.A and 143 min. (range 107–190) for Gr.B, in which the median time of lymph nodal assessment was 55 min. (range 20–76). The median time for hysterectomy was 60 min. (range 40–110) in all cases. Lymph nodal assessment was performed in 14 (46.6%) cases: 7 sentinel node mapping, 7 pelvic lymphadenectomy. No intraoperative complications or LPS/LPT conversions were recorded. Median discharge time was 2 days (range 1–4), 5 patients were discharged in 3rd post-op day, and only 1 patient was discharged in 4th day for fever. All patients conveyed high satisfaction with the cosmetic results. A progressive overall reduction of pain perception was observed at 24 h after surgery. Median follow-up was of 14 months (range 12–36), no recurrences have been detected. ConclusionsPSS seems to be a feasible approach for endometrial cancer staging. Larger experiences and prospective comparative studies are important to assess our assumptions and further investigate the real benefits of percutaneous surgical system.

Technique for Docking and Port Placement Using a Purpose-built Robotic System (SP1098) in Human Cadaver

ObjectivesTo describe step-by-step the port placement and the robot docking of the new purpose-built robotic platform for R-LESS. The feasibility of different approaches to the pelvic fossa and the retroperitoneum was reported in cadaver models. MethodsThis was a preclinical study on human cadavers to assess the feasibility of the da Vinci SP1098 surgical system for R-LESS pelvic fossa and retroperitoneal urological surgeries. We used the SP1098 to perform R-LESS prostatectomies and cystoprostatectomies with transperineal and transvesical approaches, and nephrectomies (radical or partial) with retroperitoneal approach. The primary outcome was to report the port placement and docking. The technical feasibility of the procedures was then demonstrated as measured by the need for adjunctive ports or the occurrence of intraoperative complications. Operative times were recorded. ResultsA total of 14 procedures were performed on 12 human cadavers. Namely 4 prostatectomies and 2 cystoprostatectomies with transperineal approach, 3 transvesical prostatectomies, 1 retroperitoneal radical, and 4 retroperitoneal partial nephrectomies. Operative times were in line with those of standard multiport robotic surgery. Neither additional ports nor percutaneous instruments were required. No intraoperative complications occurred. Limitations include the preclinical model, the small sample size, and the lack of a control group. ConclusionIn this preclinical model, the port placement and robot docking using the SP1098 robotic platform is reproducible and feasible for pelvic fossa and retroperitoneal urological surgeries.

A variable stiffness mechanism for steerable percutaneous instruments: integration in a needle.

Needles are advanced tools commonly used in minimally invasive medical procedures. The accurate manoeuvrability of flexible needles through soft tissues is strongly determined by variations in tissue stiffness, which affects the needle-tissue interaction and thus causes needle deflection. This work presents a variable stiffness mechanism for percutaneous needles capable of compensating for variations in tissue stiffness and undesirable trajectory changes. It is composed of compliant segments and rigid plates alternately connected in series and longitudinally crossed by four cables. The tensioning of the cables allows the omnidirectional steering of the tip and the stiffness tuning of the needle. The mechanism was tested separately under different working conditions, demonstrating a capability to exert up to 3.6N. Afterwards, the mechanism was integrated into a needle, and the overall device was tested in gelatine phantoms simulating the stiffness of biological tissues. The needle demonstrated the capability to vary deflection (from 11.6 to 4.4mm) and adapt to the inhomogeneity of the phantoms (from 21 to 80kPa) depending on the activation of the variable stiffness mechanism. Graphical abstract ᅟ.

Ultra Minimally Invasive Hysterectomy with 2.4 mm Needleoscopic Instruments Assistance: Reducing Invasiveness Maintaining the Technique

Introduction: In the past 5 years, the constant technological improvement has determined a significant “revolution” in the philosophy of surgical approach. Riding the wave of minimal invasiveness, surgical procedures even less invasive than standard laparoscopy have been proposed. In this context it is possible to recognize the specific advantages of well-known ultra minimally invasive techniques such as Single Port and Mini-Laparoscopy.1,2 Nowadays, specific advantages and disadvantages of each approach are widely established: the possibility to maintain the laparoscopic ergonomy with the triangulation between instruments and tissues made Mini-Laparoscopy more suitable for hysterectomy. Based on this assumption, the reduction of instrument dimensions is better than reduction of number of instruments. On this background, the percutaneous technology, characterized by 2.4 mm of maximum diameter needlescopic instruments (MiniLap® System with MiniGrip® handle by Teleflex Ltd), represents, to the best of our knowledge, the ultimate and thinnest tool for minimally invasive gynecologic surgery.3 Our report shows the surgical feasibility and specific characteristics of total laparoscopic hysterectomy with bilateral salpingo-oophorectomy with the assistance of MiniLap percutaneous instruments. Materials and Methods: The patient was a 50-year-old women affected by complex atypical hyperplasia diagnosed by endometrial biopsy and radiologic examinations. She had no previous surgery and the body mass index was 24.91 kg/m2. Informed consent for abdominal or laparoscopic approach was obtained from the patient in accordance with the local legislation. Moreover, the patient signed an informed consent to use image and video of the procedure. IRB approval was not required for this kind of procedure. We performed total hysterectomy with bilateral salpingo-oophorectomy using a 5 mm HD 0° EndoEye camera (Olympus Winter GmBH) in a 5 mm transumbilical Hasson trocar. In place of two standard bilateral ancillary ports, 2.4 mm needleoscopic instruments percutaneously inserted were used. A multifunction device (Thunderbeat, Olympus Winter GmBH) was inserted through a 5 mm supra-pubic trocar. Results: The operation was effectively completed. Operative time was 53 minutes overall, skin-to-skin, and blood loss was 20 mL. No intraoperative complications were registered. The patient was discharged 18 hours after the end of surgery (day 1). Pathology report confirmed complex atypical hyperplasia. In accordance with Dindo classification,4 no early postoperative complications occurred. Conclusions: The needleoscopic assisted hysterectomy seems feasible and safe. The “noninvasive” needleoscopic approach mixed with only 10 mm overall laparoscopic incision allows, for the first time, to perform the “least” invasive hysterectomy. Despite the thinness of 2.4 mm could represent a limit in manipulating tissues in non-well-selected cases, the possibility to choose between three different tips and to make a fine dissection allows an expert laparoscopic surgeon to complete hysterectomy with an operative time similar to that of standard laparoscopy. However, the lack of any type of energy made essential the use of a multifunction instrument. Further studies are mandatory to define the benefits, advantages, and costs of this novel approach with respect to other ultra minimally invasive procedures. No competing financial interests exist. Minigrip Instruments were offered by the TELEFLEX company for the procedure. Runtime of video: 7 mins 36 secs

Pediatric laparoscopic cholecystectomy with 2.3 mm Percutaneous Surgical System (MiniLap®): A new frontier for pediatric mini laparoscopy?

Abstract Mini-laparoscopy represents an evolving and attractive field both in general and in pediatric surgery, with a pressing and increasing technical demand. Although the advantages of the mini-laparoscopic approach (reduced morbidity, less incisional pain and discomfort, better cosmetic results) are well recognized, its technical difficulties due to the lack of suitable and comfortable instruments brought to a limited use. Moreover, in the pediatric population, the need of ergonomic mini-invasive but efficient devices is the key of a widespread use of mini-laparoscopic surgery performed with an effective and safe technique. We aim to highlight the first case of pediatric laparoscopic cholecystectomy performed with 2.3 mm percutaneous instruments (MiniLap ® Percutaneous Surgical System, Teleflex Incorporated, USA) that represents a significant advance in minimally invasive surgery.

Total Laparoscopic Hysterectomy With Percutaneous (Percuvance) Instruments: New Frontier of Minimally Invasive Gynecological Surgery

Study ObjectiveTo highlight the first case of laparoscopic hysterectomy performed with percutaneous instruments (The Percuvance System, Teleflex Incorporated, Wayne, PA). DesignThe basis of the system is a <3-mm diameter shaft that, when connected to an introducer tool tip, can be inserted percutaneously through the skin. The introducer tool tip can then be exchanged outside the body for a wide variety of 5-mm interchangeable surgical tool tips. The shaft is sufficiently strong to hold structures, and surgeons can use its interchangeable tool tips to grasp, cut, and manipulate tissue. We used a 3-dimensional high-definition 10-mm flexible tip endoscope (ENDOEYE FLEX 3D, Olympus Winter & IBE GMBH, Hamburg, Germany). BackgroundMinilaparoscopy is an attractive approach for hysterectomy due to advantages such as reduced morbidities and enhanced cosmesis. However, it has not been popularized because of the lack of suitable instruments and high technical demand. The Percuvance system represents a significant advance in minimally invasive surgery. SettingCatholic University of the Sacred Hearth, Rome, Italy. PatientA 53-year-old, multiparous patient with endometrial endometroid cancer grade 1, Fédération Internationale de Gynécologie et d'Obstétrique stage IA. The patient provided informed consent to use the images and video of the procedure. Institutional review board approval was not required. InterventionThe patient was hysteroscopically diagnosed with endometrial cancer after removal of an endometrial polyp adnexectomy. Once referred to our center, surgical staging was planned, including total hysterectomy and bilateral adnexectomy. Laparoscopy with 2 lateral percutaneous and 1 soprapubic 3-mm instruments was believed to be feasible to achieve these procedures. Main ResultsThe operation was performed successfully with no intraoperative or postoperative complications. Operative time was 80 minutes overall, and blood loss was 50 mL. The pathology report confirmed endometrial endometroid cancer grading 1, Fédération Internationale de Gynécologie et d'Obstétrique stage IA. The patient was discharged on day 1. After 2 months, no late complications or recurrence was detected. ConclusionPercutaneous total hysterectomy is technically feasible, and the use of this novel device permits surgeons to mantain a standard setting. Further studies are mandatory to define the benefits, advantages, and costs of this novel approach with respect to other minimally invasive approaches.

591 Flow matters – how to improve irrigation flow in small calibre percutaneous procedures: The purging effect

Introduction Aim of this study was to investigate whether the combination of high-pressure irrigation inflow combined with simultaneous sensor-controlled suction could improve irrigation turnover without leading to high peak intrarenal pressure in small-calibre percutaneous instruments (SCPI).

Flow matters 2: How to improve irrigation flow in small-calibre percutaneous procedures-the purging effect.

Aim of this study was to investigate whether the combination of high-pressure irrigation inflow combined with simultaneous sensor-controlled suction could improve irrigation turnover without leading to high peak intrarenal pressure in small-calibre percutaneous instruments (SCPI). M + M: A MIP XS sheath (9.5 Fr. outer diameter and 8.5 Fr. inner diameter) and a 7.5-Fr. nephroscope (3-Fr. irrigation channel; MIP XS by Nagele, Karl Storz, Tuttlingen, Germany) was inserted into the collecting system of a non-perfused cadaveric porcine kidney, an 8-Fr. mono-J catheter was introduced through the ureter. Irrigation was performed using a pressure-controlled, combined irrigation/suction pump (Uromat E.A.S.I., Karl Storz, Tuttlingen, Germany) in either single-flow or continuous-flow (=combination of irrigation and suction) mode. Intrarenal pressure was measured and irrigation fluid turnover was measured by a cystometry catheter inserted trans-parenchymally into the renal pelvis. Pressure changes were recorded by a urodynamic workstation. Applying pressure-controlled suction, irrigation fluid turnover could be increased by 5 % at an inflow pressure of 75 mmHg (80-84 ml/min) and 15 % at an inflow pressure of 110 mmHg (196-110 ml/min). Suction decreased the intrarenal pressure by 14 % at 75 mmHg (19-14.5 cm H2O) and 28 % at 110 mmHg inflow pressure (37-26.5 cm H2O). Although combination of pressure irrigation with sensor-controlled suction increases irrigation flow in SCPI, the intrarenal pressure could be reduced with combined suction via a transurethral mono-J catheter. This irrigation method in percutaneous surgery is called purging effect.

Use of 3 mm percutaneous instruments with 5 mm end effectors during different laparoscopic procedures

Background and PurposeWith a recent focus on minimizing the visibility of scars, new techniques have been developed. Minilaparoscopy reemerged as an attractive option for surgery as it limits tissue trauma, reduces post-operative pain and improves cosmesis. This study was designed to describe our experience with percutaneous trocarless 3 mm instruments used in combination with standard 5 mm and 10 mm laparoscopic instruments in different general surgery procedures. MethodsWe used the PSS (Percutaneous Surgical Set, Ethicon Endo surgery, Cincinnati, OH, USA) in different surgical procedures as accessory instruments in combination with standard 5 mm and 10 mm standard laparoscopic instruments. Main findingsThe use of percutaneous instruments was safe and feasible in all performed procedures. The surgical technique was not modified. The percutaneous instruments can assure a good grip and can be used for traction and counter-traction. No complications have been described. No pain at the site of insertion has been reported. The skin, muscle and peritoneal defects were smaller than with the 3 mm laparoscopic traditional instruments. ConclusionsPercutaneous approach seems to be a good option in general surgery in terms of efficiency, offering better cosmetic results and good pain control.

Initial Experience of Single-Port Surgery Assisted by Percutaneous Instruments for Gastric Bypass: a Combination of Safety and Minimally Invasive Surgery

We present here the first reported cases of patients undergoing gastric bypass with a hybrid technique that involves a new concept of percutaneous instruments and provides the advantages of minimally invasive single-port surgery while maintaining the triangulation, safety, and timing of operative procedures. This was a prospective pilot study of eight patients selected for gastric bypass between December 2011 and January 2012 and treated by a technique that combined single SSL port and percutaneous surgical set PPS. We performed hand-sewn gastrojejunostomy in all cases. We analyzed preliminary results at 1month and focused on the feasibility of the technique, duration of surgery, perioperative complications, and cosmetic results. The Ethics Committee of our institution approved this study and we obtained the informed consent of each patient. We completed the procedure successfully in all patients. No conversions to laparotomy or classic laparoscopy were required. The average time of surgery was 112min (85-155). Length of hospital stay was 4days (3-5). One patient was re-admitted on the seventh postoperative day for gastrointestinal bleeding from the gastrojejunostomy suture and treated by endoscopic clipping. Residual scars were less than 2cm for the single midline port and 2mm for the percutaneous instruments. This new technique combines the advantages of single-port surgery with the safety of conventional laparoscopy by using percutaneous instruments and leaves minimal scarring. It is likely that the use of percutaneous instrumentation will become widespread in all areas of laparoscopic surgery.

Magnetically anchored camera and percutaneous instruments maintain triangulation and improve cosmesis compared with single-site and conventional laparoscopic cholecystectomy

This study evaluated operative outcomes and ergonomics for a magnetic camera (MAGS) used in conjunction with percutaneous instruments [percutaneous surgical set (PSS)] compared with single-site laparoscopic (SSL) and conventional laparoscopic (LAP) cholecystectomy techniques. Four surgical trainees each performed three porcine cholecystectomies using three randomized techniques including MAGS/PSS, SSL, and LAP. The operative outcomes, procedure-specific ratings (1-5 scale; 1=superior), workload (1-10 scale; 1=superior), and global impressions (1-10 scale; 10=superior) were recorded. Comparisons used analysis of variance (ANOVA) on ranks (Kruskal-Wallis), and p values lower than 0.05 were considered significant. The operative outcomes were similar except for significantly higher blood loss with SSL (16.3±10.3) versus LAP (2.8±1.5; p<0.05) but not with MAGS/PSS (4.8±3.8). Several inadvertent tissue-damaging events occurred with SSL but not with MAGS/PSS or LAP. The incision was significantly shorter with MAGS/PSS (29.3±2.8mm) and SSL (29.3±2.5mm) than with LAP (48.0±3.6mm; p<0.05). Compared with SSL (3.6±0.5), the procedure-specific ratings significantly favored MAGS/PSS (2.8±0.4) and LAP (1.7±0.2; p<0.05). Ergonomics and technical challenges both were rated significantly inferior with SSL (4.3±1.0 and 3.8±0.5, respectively) versus LAP (1.5±0.6 and 2.0±0.8, respectively; p<0.05) but not with MAGS/PSS (2.5±1.0 and 3.0±0.8, respectively). Both MAGS/PSS (4.5±0.5) and SSL (4.8±1.0) were associated with a significantly greater workload than LAP (2.5±0.6; p<0.05). Global impression ratings were significantly higher for LAP (8.7±1.3) versus SSL (5.8±2.0; p<0.05) but not for MAGS/PSS (7.1±1.8). Cosmesis was significantly better with MAGS/PSS (9.5±0.6) versus LAP (6.5±2.4; p<0.05) but not with SSL (8.8±1.3). The MAGS/PSS technique allows better triangulation and fewer technical difficulties than SSL and better cosmesis than LAP. Further development of these devices is warranted.

Surgical Treatment for Osteoid Osteoma — Experience in Both Conventional Open Excision and CT-guided Mini-incision Surgery

Conventional open excision, or en bloc excision, was the standard treatment for osteoid osteoma until the development of percutaneous treatment for this tumor in the early 1990s. Most percutaneous treatments were performed under the guidance of computed tomography (CT), which could clearly demonstrate the exact location of the tumor and minimize bone destruction or resection. In order to minimize bone resection without adding to the costs of these new percutaneous instruments, we modified the percutaneous technique into a CT-guided mini-incision surgery. The patients treated with this technique were compared with those treated by conventional open excision. We retrospectively reviewed the medical charts of patients with osteoid osteoma treated between 1990 and 2004. The patients diagnosed before 2000 were all treated with conventional open excision. After 2000, some of them were treated with CT-guided mini-incision surgery. Follow-up was done either by phone or on an outpatient basis. There were 23 patients with osteoid osteoma who were treated surgically between 1990 and 2004, of whom 20 were treated with conventional open excision. Six patients were treated with CT-guided mini-incision surgery, including 3 primary cases and 3 patients who had previously been treated with conventional open excision (2 recurrent cases and 1 with incomplete excision). The patients treated with CT-guided mini-incision surgery had smaller bone defects, shorter surgical time, and shorter hospital stay. The rate of recurrence or incomplete excision was 23% for conventional surgery and 0% for mini-incision surgery. CT-guided mini-incision surgery is effective in treating primary as well as recurrent osteoid osteoma.

Combined use of percutaneous and transurethral instruments in the preadolescent children with intravesical pathologies

The approach for the intravesical suspicious lesions or stones in the preadolescent children especially in boys is still a challenging problem. Open surgery, percutaneous suprapubic endoscopy or transurethral endoscopic approaches are the treatments of choice in children. However, there is a group in children between the ages of 10 and 12 years, which can be named as grey zone population; the length of the instruments is insufficient for transurethral intervention such as endoscopic stone extraction, transurethral bladder tumor resection especially for the lesion at the posterior bladder wall in this group. The aim of this study is to describe a new technique using laparoscopic instruments for percutaneous bladder stone and tumoral lesion and determines the efficacy of this procedure. Satisfactory results have been obtained in patients with these pathologies. In selected cases, operation time, urethral and mucosal damage, hospital stay, and cost can be decreased to a minimum with this simple technique.

Effect of Percutaneous Thrombin Injection under Ultrasonography Guidance for Occlusion of Common Femoral Artery Pseudoaneurysm after Failed Ultrasonography-guided Compression: A Case Report

The occurrence of pseudoaneurysm of the femoral artery after catheterization is uncommon. Ultrasonography-guided compression is currently the first choice of treatment, with a success rate of more than 90%. Recently, however, with the increasing use of larger percutaneous instruments and periprocedural anticoagulation, the incidence of pseudoaneurysm unresponsive to ultrasonography-guided compression is increasing. The authors encountered a case of pseudoaneurysm of the common femoral artery which did not respond to the repeated use of this technique, though treatemnt involving was successful. We believe that in ultrasonography-guided percutaneous thrombin injection was successful. We believe that in cases involving oc-clusion of a a pseudoaneurysm in which ultrasonography-guided mpression has failed, this is a simple, safe, and time-saving procedure.

Improving the quality of care for patients with chronic respiratory diseases provided by the community health nurse

To highlight the first case of laparoscopic hysterectomy performed with percutaneous instruments (The Percuvance System, Teleflex Incorporated, Wayne, PA).The basis of the system is a <3-mm diameter shaft that, when connected to an introducer tool tip, can be inserted percutaneously through the skin. The introducer tool tip can then be exchanged outside the body for a wide variety of 5-mm interchangeable surgical tool tips. The shaft is sufficiently strong to hold structures, and surgeons can use its interchangeable tool tips to grasp, cut, and manipulate tissue. We used a 3-dimensional high-definition 10-mm flexible tip endoscope (ENDOEYE FLEX 3D, Olympus Winter & IBE GMBH, Hamburg, Germany).Minilaparoscopy is an attractive approach for hysterectomy due to advantages such as reduced morbidities and enhanced cosmesis. However, it has not been popularized because of the lack of suitable instruments and high technical demand. The Percuvance system represents a significant advance in minimally invasive surgery.Catholic University of the Sacred Hearth, Rome, Italy.A 53-year-old, multiparous patient with endometrial endometroid cancer grade 1, Fédération Internationale de Gynécologie et d'Obstétrique stage IA. The patient provided informed consent to use the images and video of the procedure. Institutional review board approval was not required.The patient was hysteroscopically diagnosed with endometrial cancer after removal of an endometrial polyp adnexectomy. Once referred to our center, surgical staging was planned, including total hysterectomy and bilateral adnexectomy. Laparoscopy with 2 lateral percutaneous and 1 soprapubic 3-mm instruments was believed to be feasible to achieve these procedures.The operation was performed successfully with no intraoperative or postoperative complications. Operative time was 80 minutes overall, and blood loss was 50 mL. The pathology report confirmed endometrial endometroid cancer grading 1, Fédération Internationale de Gynécologie et d'Obstétrique stage IA. The patient was discharged on day 1. After 2 months, no late complications or recurrence was detected.Percutaneous total hysterectomy is technically feasible, and the use of this novel device permits surgeons to mantain a standard setting. Further studies are mandatory to define the benefits, advantages, and costs of this novel approach with respect to other minimally invasive approaches.