Significant Decrease In Operative Time Research Articles

Nailing precision: a systematic review and meta-analysis of randomized controlled trials comparing piriformis and trochanteric entry points for femoral antegrade nailing.

Entry point selection, a crucial aspect of femoral antegrade nailing, can impact nail fit and consequently fracture reduction. In adults, the standard entry portals used are the piriformis fossa and the tip of the greater trochanter. Previous systematic reviews comparing the two techniques have not been limited to Randomized Controlled Trials (RCTs) and have not consistently included the same available RCTs. A systematic search of comparative studies regarding entry portal selection in femoral antegrade nailing was conducted on seven databases. Only Prospective RCTs comparing trochanteric and piriformis entry in the management of trochanteric or diaphyseal femur fractures were eligible for inclusion. Ultimately, only 6 RCTs were found eligible for inclusion. Five of the six included studies reported on operative time. The resulting mean difference (MD) illustrated a significant decrease in operative time by approximately 21.26min (95% CI - 28.60 to - 13.92, p < 0.001) using trochanteric entry. Fluoroscopy exposure was reported on by four studies, however, only two studies were included in the analysis due to different reporting methods. Trochanteric entry used significantly less fluoroscopy than piriformis entry (MD -50.33s, 95% CI - 84.441 to - 16.22, p = 0. 004). No significant difference in malalignment rates, delayed union rates, nonunion rates, pain scores, or complication rates was found. The significant differences found in operating time and fluoroscopy time align with those in other studies. While we were not able to pool the data on functional outcome scores, none of the included studies found a significant difference in scores by their last follow-up. Both approaches demonstrate comparable functional outcomes and safety profiles, indicating the choice of entry point should be at the discretion of the surgeon based on technique familiarity and fracture characteristics.

Suture passer combined with two-hole laparoscopic peritoneal dialysis catheterization in patients undergoing peritoneal dialysis

Background Laparoscopic techniques are being widely applied for peritoneal dialysis (PD) catheter (PDC) placement. The suture passer is a novel fixation tool that aims to reduce catheter migration. We compared the clinical value of the suture passer combined with two-hole laparoscopic PDC placement to open surgical placement by evaluating preoperative and postoperative conditions, as well as the onset of complications in both groups. Methods A retrospective study was conducted including 169 patients who underwent PDC placement surgery from January 2021 to May 2023. Based on the method employed, patients were divided into two groups: the suture passer combined with a two-hole laparoscopy group (SLG) and the open surgical group (SG). Comprehensive patient information, including general data, preoperative and postoperative indicators, peritoneal function after surgery, and the incidence rate of complications, were collected and analyzed. Results The SLG showed a statistically significant decrease in operative time, intraoperative blood loss, and 6-month postoperative drift rate compared to the SG (p < 0.05). No statistically significant differences were observed between the two groups in terms of sex, age, primary disease, hospitalization time, hospitalization costs, preoperative and postoperative examination indicators, peritonitis, and omental wrapping. Conclusions Suture passer combined with two-hole laparoscopic PDC placement, characterized by simplicity and facilitating secure catheter fixation, was deemed safe and effective for patients undergoing PD. It reduces the catheter migration rate and improved surgical comfort. Overall, this technique demonstrates favorable outcomes in clinical practice.

Outcomes and Complications Associated With the Learning Curve for Endoscopic Cervical Foraminotomy: A Systematic Review and Meta-Analysis.

A systematic review and meta-analysis. The objective of this study is to examine the impact of the learning curve for endoscopic cervical foraminotomy for clinical outcomes and patient safety. Endoscopic cervical foraminotomy is a minimally invasive surgical technique emerging in the literature for surgical management of cervical radiculopathy without the use of open incision. The adoption of endoscopic cervical foraminotomy may be hindered by the learning curve, although no review and meta-analysis exists to date on the topic. A systematic review and meta-analysis was performed using PubMed, CINAHL, and MEDLINE from database inception until July 11, 2023. Inclusion criteria were articles that examined endoscopic cervical foraminotomy, reported outcomes, and/or complications for endoscopic cervical spine surgery relevant to the learning curve and had full-text. A random effects meta-analysis was performed for outcomes and complications. A total of three articles (n=203 patients) were included from 792 articles initially retrieved. The learning curves from four surgeons were examined with a FWM 21 procedures until the competency phase. There was no significant difference in the postoperative hospitalization length ( P =0.669), postoperative recovery room time ( P =0.415), intraoperative blood loss ( P =0.064), and total complication rates (10.9% vs . 1.2%, P =0.139) between endoscopic cervical foraminotomy procedures performed in the learning phase as compared with the competency phase of the learning curve. There was a significant decrease in operative time from the learning phase to the competency phase ( P =0.005). Competency was achieved on the learning curve for endoscopic cervical foraminotomy after about 21 procedures. There is no significant difference in postoperative hospitalization time, postoperative recovery room time, intraoperative blood loss, and complication rates between the learning phase and the competency phase of the learning curve for endoscopic cervical foraminotomy, noting the relatively small sample size of this study that may underpower this finding.

670 Learning Curve Associated With Thoracoscopic Anterior Vertebral Body Tether for Idiopathic Scoliosis: Analysis of Three Independent Surgeons

INTRODUCTION: Anterior vertebral body tethering (VBT) is a fusionless surgery that harnesses growth to correct idiopathic scoliosis. More surgeons are beginning to implement VBT. METHODS: A single-institution retrospective review of three surgeons' experiences of their first 40 single thoracic VBT and 20 double thoracolumbar VBT cases was performed. Patients had skeletally-immature, idiopathic scoliosis and underwent thoracoscopic VBT. Primary outcomes were intraoperative measures and radiographic correction. A pooled and individual surgeon analysis was performed with multivariable modeling. RESULTS: A total of 126 single and 60 double VBT patients were included. Mean age was 12.7 years and 13.4% were male. Mean segments tethered was 8.8 in single and 11.0 in double VBT. Mean preoperative thoracic scoliosis was 50.6°: single (49.3°) and double (53.3°). Mean lumbar scoliosis was 35.9°: single (20.9°) and double (49.0°) (p &lt; 0.001). Average OR time was 273.7 minutes with double VBT taking significantly longer (216.4 vs. 394.0 minutes, p&lt;0.001). Mean blood loss was 194.5 ml and fluoroscopy dose 73.6 mGy with no differences between single and double VBT. For single VBT, there was a significant decrease in operative time per 10 cases performed (287.9 to 174.1. minutes). This trend was present for all surgeons. A nonsignificant decrease in fluoroscopy dosing was evident (70.1 to 53.5 mGy, p=0.154). Single and double VBT achieved 41.1% and 47.3% thoracic curve correction, respectively. Double VBT achieved 51.5% lumbar curve correction. Increased experience was not associated with absolute or percentage curve correction for single and double VBT. CONCLUSIONS: VBT is an exciting fusionless surgical option for scoliosis. Increased experience resulted in shorter operative time but curve correction was adequate even at the start of the learning curve. Additional studies of long-term results of initial case experiences are needed.

MP42-20 TO SEAL OR NOT TO SEAL: EXAMINING THE ROLE OF TISSUE ADHESIVES FOR BLADDER AND URETERAL RECONSTRUCTION

You have accessJournal of UrologyCME1 Apr 2023MP42-20 TO SEAL OR NOT TO SEAL: EXAMINING THE ROLE OF TISSUE ADHESIVES FOR BLADDER AND URETERAL RECONSTRUCTION Juan Ramirez, George E. Aninwene, and Renea M. Sturm Juan RamirezJuan Ramirez More articles by this author , George E. AninweneGeorge E. Aninwene More articles by this author , and Renea M. SturmRenea M. Sturm More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003280.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: While surgical adhesives may be FDA approved as adjunct hemostatic agents or sealants, application is typically off-label for urinary tract tissue. Current literature lacks consensus regarding the role of tissue adhesives for bladder and ureteral reconstruction. This systematic review synthesizes clinical and animal data across key adhesives that have been applied to bladder and ureteral tissue, assessing trade-offs between competing parameters affecting agent selection and effectiveness. METHODS: A literature search was conducted in Pubmed, Web of Science, Embase, and Cochrane databases to identify articles published from 2000-2021 that reported urologic reconstruction and the use of adhesive, hemostatic agents, and/or sealants. Figure 1A illustrates identification and inclusion/exclusion criteria. RESULTS: 29 publications were included (18 human, 11 animal; Figure 1B). Fibrin sealant was the most commonly evaluated adhesive, followed by cyanoacrylate and bovine serum/albumin/glutaraldehyde (bioglue). Clinically, all three adhesive types effectively managed fistulas, with significant decrease in operative time, decrease blood loss, and resolution of urinary leakage. When comparing acute inflammatory and wound healing responses, cyanoacrylate demonstrated higher cytotoxicity in comparison to fibrin sealant. No significant inflammation at 1 week (in comparison to sutured closures) occurred following bioglue application. In prior characterization studies, cyanoacrylate had the strongest tensile strength and adhesive parameters; however, no study assessed mechanical or adhesive parameters of fibrin sealants or bioglues in bladder or ureteral tissue. CONCLUSIONS: This systemic review provides overall low-level evidence for the application of the three major adhesive types to bladder and ureteral reconstruction as a suture reinforcement. However, these three adhesive types are not equivalent, demonstrating trade-offs between adhesive strength and cytotoxicity. Future research is needed to assess comparative parameters of all three major adhesives, including mechanical and adhesive benchtop testing, effects on wound healing, and long-term outcomes of clinical application to bladder and ureteral tissue. Source of Funding: National Science Foundation and UCLA Tech Development Group © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e575 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Juan Ramirez More articles by this author George E. Aninwene More articles by this author Renea M. Sturm More articles by this author Expand All Advertisement PDF downloadLoading ...

PD12-09 OUTCOMES OF 429 PRIMARY ROBOTIC PERITONEAL FLAP GENDER AFFIRMING VAGINOPLASTY CASES

You have accessJournal of UrologyCME1 Apr 2023PD12-09 OUTCOMES OF 429 PRIMARY ROBOTIC PERITONEAL FLAP GENDER AFFIRMING VAGINOPLASTY CASES Gaines Blasdel, Charles Dubach-Reinhold, Elijah Castle, Rachel Bluebond-Langner, and Lee Zhao Gaines BlasdelGaines Blasdel More articles by this author , Charles Dubach-ReinholdCharles Dubach-Reinhold More articles by this author , Elijah CastleElijah Castle More articles by this author , Rachel Bluebond-LangnerRachel Bluebond-Langner More articles by this author , and Lee ZhaoLee Zhao More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003259.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Gender affirming robotic peritoneal flap vaginoplasty is a promising adaptation of established vaginoplasty techniques that has been performed since 2017. We report perioperative factors and patient reported outcomes for all consecutive cases at one center. METHODS: Records of patients undergoing primary robotic peritoneal flap gender affirming vaginoplasty with the senior authors from 9/2017-8/2022 were retrospectively reviewed. Operative time, length of stay, complications, self-report of orgasm and dilation, and date of last follow up were recorded for all patients. Clavien-Dindo grading for severity of complications were organized according to occurrence prior or after 90 days postoperatively. For outcomes with incidence greater than 5%, statistical analysis for change over years was performed using nonparametric tests. RESULTS :Primary robotic peritoneal flap gender affirming vaginoplasty was performed on 429 patients with median follow up of 369 days (interquartile range 186-607). Of these, 413 patients (96%) had 90 day or longer follow up and 16 (4%) had a Clavien-Dindo 3a or 3b complication within that period (Table 1). 245 patients had a follow up of 1 year or greater, and 9 patients (4%) had Clavien-Dindo 3a or 3b complications after 90 days in this cohort. Overall elective revision rate was 17%, with 1% revision for vaginal depth. Significant decrease in operative time was observed (p<.0001), with a mean operative time of 101 mins for cases 400-429 . Rate of dilating using the largest dilator to the deepest dot increased over these first 300 cases (p<.001) and rate of elective revision decreased (p <.001). CONCLUSIONS: Primary robotic peritoneal flap gender affirming vaginoplasty has low morbidity and complication rates with durable vaginal depth and orgasmic function at long term follow up. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e403 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gaines Blasdel More articles by this author Charles Dubach-Reinhold More articles by this author Elijah Castle More articles by this author Rachel Bluebond-Langner More articles by this author Lee Zhao More articles by this author Expand All Advertisement PDF downloadLoading ...

The learning curve of endoscopic endonasal transsphenoidal surgery for pituitary adenomas with different surgical complexity.

To investigate the learning curve under different surgical complexity in endoscopic transsphenoidal approach for pituitary adenoma. 273 patients undergoing endoscopic transsphenoidal surgery for pituitary adenoma were collected retrospectively and divided into three groups chronologically (early, middle, and late periods). Surgical complexity was differentiated based on Knosp classification (Knsop grade 0-2 vs. Knosp grade 3-4), tumor maximum diameter (MD) (macroadenomas vs. giant adenomas), and history of previous surgery for pituitary adenoma (first operation vs. reoperation). Then the temporal trends in operative time, surgical outcomes, and postoperative complications were evaluated from early to late. The median operative time decrease from 169 to 147 min across the three periods (P = 0.001). A significant decrease in operative time was seen in the simple groups [Knosp grade 0-2 adenoma (169 to 137 min, P < 0.001), macroadenoma (166 to 140 min, P < 0.001), and first operation (170.5 to 134 min, P < 0.001)] but not in their complex counterparts (P > 0.05). The GTR rate increased from 51.6% to 69.2% (P = 0.04). The surgical period was an independent factor for GTR in the simple groups [Knosp grade 0-2 adenoma: OR 2.076 (95%CI 1.118-3.858, P = 0.021); macroadenoma: OR = 2.090 (95%CI 1.287-3.393, P = 0.003); first operation: OR = 1.809 (95%CI 1.104-2.966, P = 0.019)] but not in the complex groups. The biochemical cure rate increased over periods without statistical significance (from 37.5% to 56.3%, P = 0.181). Although intraoperative CSF leakage rose (from 20.9% to 35.2%) and postoperative CSF leakage reduced (from 12.1% to 5.5%), there was no statistically significant trend across the three time periods (P > 0.05). This study showed that complex operations might have a prolonged learning curve. Differentiating surgical difficulty and using multivariate combined analysis may be more helpful in clinical practice.

Which renal access technique for percutaneous nephrolithotomy is more difficult to teach using simulation in surgical training?

Percutaneous nephrolithotomy (PCNL) is a challenging procedure that urology trainees should be familiar with during residency. Simulators, such as the PERC Mentor, allows the development of this competency in a safer, stress-free environment. There are two primary fluoroscopic methods of gaining percutaneous renal access: the triangulation method and the bull's eye method. Our goal was to assess which method is easier to teach novices by using the PERC Mentor simulator. A secondary goal is to assess differences in subjective and objective outcomes. Fifteen simulator and procedure-naive medical trainees were randomized into two groups using a crossover, randomized study design. Participants were provided with written, video, in-person demonstrations and hands-on practice for each technique. They then performed each method and were assessed objectively using the PERC Mentor performance data report and subjectively using the PCNL global rating scale (GRS) scoring system. Statistical analysis was performed using Student's T-test and non-parametric Wilcoxon signed rank test. There was no statistical difference in the outcomes and complication rates between the two methods. The bull's eye method of obtaining percutaneous access was associated with a significant decrease in operative time (91 seconds vs. 128 seconds, p=0.03) and fluoroscopy time (87 seconds vs, 123 seconds, p=0.03) compared to the triangulation method. Teaching of both techniques was equally well-acquired by students. Both techniques had similar outcomes; however, the bull's eye method was associated with less operative and fluoroscopy time when compared to the triangulation method among novices.

Management of Complex Acetabular Fractures by Using 3D Printed Models.

Background and Objectives: Using 3D printed models in orthopaedics and traumatology contributes to a better understanding of injury patterns regarding surgical approaches, reduction techniques, and fracture fixation methods. The aim of this study is to evaluate the effectiveness of a novel technique implementing 3D printed models to facilitate the optimal preoperative planning of the surgical treatment of complex acetabular fractures. Materials and Methods: Patients with complex acetabular fractures were assigned to two groups: (1) conventional group (n = 12) and (2) 3D printed group (n = 10). Both groups included participants with either a posterior column plus posterior wall fracture, a transverse plus posterior wall fracture, or a both-column acetabular fracture. Datasets from CT scanning were segmented and converted to STL format, with separated bones and fragments for 3D printing in different colors. Comparison between the two groups was performed in terms of quality of fracture reduction (good: equal to, or less than 2 mm displacement, and fair: larger than 2 mm displacement), functional assessment, operative time, blood loss, and number of intraoperative x-rays. Results: A significant decrease in operative time, blood loss, and number of intraoperative x-rays was registered in the 3D printed group versus the conventional one (p < 0.01), with 80% of the patients in the former having good fracture reduction and 20% having fair reduction. In contrast, 50% of the patients in the conventional group had good reduction and 50% had fair reduction. The functional score at 18-month follow-up was better for patients in the 3D printed group. Conclusions: The 3D printing technique can be considered a highly efficient and patient-specific approach for management of complex acetabular fractures, helping to restore patient′s individual anatomy after surgery.

A cumulative sum (CUSUM) analysis studying operative times and complications for a surgeon transitioning from laparoscopic to robot-assisted pediatric pyeloplasty: Defining proficiency and competency

The transition from laparoscopic to robot-assisted procedures leads to potential increase in operative times and health care costs. Cumulative sum (CUSUM) analysis can objectively study the learning curve to detect significant changes in operative timing and monitor complication rates. The objective of this study is to investigate the total and step-specific times for pediatric robot-assisted pyeloplasty (RAP) to investigate the learning curve of a single surgeon transitioning from laparoscopic to RAP. This prospective cohort study included 50 consecutive RAP procedures performed since the inception of our robotic program from June 2013 to January 2019. The CUSUM of RAP total operative time (OT) was calculated to determine the breakpoints between learning phases using piecewise linear regression. Cumulative-observed-minus-expected failure chart with 80% and 95% reassurance boundary lines was constructed using 5% acceptable and 10% unacceptable complication rates. Step-specific operative times were prospectively recorded by an independent observer for port placement, dissection and hitch stitch placement, pelvis dismemberment and spatulation, suturing and port removal. Piecewise linear regression for OT identified breakpoints at case 13 and 29 suggesting transition at these points between Learning to Proficiency, and Proficiency to Competency. The overall mean OT was 142.2±46.0min. There was a significant difference in the mean OT between Learning (203.9±35.3min, the initial 13 cases), Proficiency (159.2±18.6min, the middle 16 cases), and Competency (126.6±19.7min, the last 21 cases) phases (p<0.001). The complication rate for RAP stabilized around the acceptable level of 5% up to case 41 before finalizing at 8% overall. The step-specific analysis suggested that suturing entered the Competency phase at case 27, with a 50% decrease in suturing time from Learning to Proficiency and Competency. Our study suggests that by case 30 a surgeon transitioning to RAP can achieve a significant decrease in OT. Complication rates remained within acceptable limits throughout, indicating that RAP can be safely adopted, even in low volume RAP centres. Suturing competency seems to be a significant advantage of the robotic platform as suggested by early significant decrease in suturing times noted between the Learning and Proficiency phases. Future studies can confirm these findings and establish reference operative times to aid surgeons and trainees transitioning from laparoscopic pyeloplasty to RAP. Moreover, total OT decreases significantly and relatively soon after transition to RAP.

Learning Curve of Robotic Enhanced-View Extraperitoneal Approach for Ventral Hernia Repairs.

Introduction: The enhanced-view extraperitoneal (eTEP) technique was first described for minimally invasive inguinal hernia repairs and later for laparoscopic ventral hernia repair. The objective of this study was to report our early experience and learning curve (LC) with the robotic-assisted eTEP (R-eTEP) approach. Materials and Methods: We performed a retrospective analysis of patients undergoing R-eTEP repair for ventral hernias from December 2018 to September 2021. A single surgeon operative time (OT)-based LC was evaluated. Results: A total of 81 patients underwent an R-eTEP from December 2018 to September 2021. Sixty-five patients were ultimately included in our analysis. Fifty-seven patients underwent eTEP-Rives-Stoppa (RS) and 8 patients underwent eTEP-transversus abdominis release (TAR). The median age in the whole cohort was 57 years (interquartile range [IQR] 51.5-64.5 years) with no difference between the groups. The median body mass index (BMI) was 31 kg/m2 (IQR 27-34.7 kg/m2) in the eTEP-RS group and 29.7 kg/m2 (IQR 28.5-31 kg/m2) in the eTEP-TAR group. There were 36 incisional hernias (63%) in the eTEP-RS group and 8 (100%) in the eTEP-TAR group. There were 14 recurrent hernias (25%) in the eTEP-RS group and 2 (25%) in the eTEP-TAR group. The LC was evaluated only in the eTEP-RS cases. We divided the cohort into 3 chronological groups (G1, G2, and G3), including 19 cases each. The median OT in each group was 177 (IQR 147-200), 153 (IQR 127-187), and 125 minutes (IQR 106-152 minutes), respectively. There was no difference in the median OT between G1 and G2 (P = .390). G3 had a shorter median OT than G2 (P = .02) and G1 (P = .001). There was no difference between these groups in median age, BMI, defect area, defect width, and mesh area. Conclusions: The R-eTEP approach has been shown to be safe and feasible for ventral and incisional hernia repairs. A statistically significant decrease in OT was observed after 38 cases.

Single surgeon versus co-surgeon bilateral mastectomy: Comparing outcomes and costs based on health economic modeling from the perspective of the hospital system.

Co-surgeon approach for bilateral mastectomy may lead to shorter operative times and improved outcomes compared with single-surgeon approach, but cost differences remain unclear. Economic models were applied to determine whether either approach offered a lower cost opportunity. A retrospective review of 409 patients undergoing single-surgeon or co-surgeon bilateral mastectomy between January 1, 2010 through April 30, 2016 was conducted. Outcomes included narcotic and antinausea doses, length of stay (LOS), and operative time. Analyses stratified by reconstruction and no reconstruction included Wilcoxon tests, Poisson regression, generalized linear models, and a cost calculator. Of 409 patients, 310 had reconstruction and 99 had no reconstruction. Compared with single-surgeon approach, co-surgeon approach was associated with less operative time and shorter LOS (233 vs. 250 min and 1.0 vs. 1.8 days no reconstruction; and 429 vs. 493 min and 2.2 vs. 2.8 days reconstruction). Economic analysis demonstrated less operative time, shorter LOS, and lower average cost for co-surgeon approach ($32,400 vs. $34,400 no reconstruction; and $76,700 vs. $79,400 reconstruction). Compared with the single-surgeon, the co-surgeon approach with reconstruction was associated with a statistically significant decrease in operative time and LOS. Economic analysis estimated the co-surgeon approach could lead to lower costs.

P37. THE VALUE OF PROCESS ANALYSIS: A MULTIVARIATE ANALYSIS SHOWS IMMEDIATE AND SUSTAINED DECREASE IN MORBIDITY AND OPERATIVE TIME

PURPOSE: DIEP flaps are nuanced, multi-step procedures and it can be difficult for surgeons to focus on where to direct their efforts for true improvement. Recent studies have hinted that operational flow can be a sensitive barometer for safety, efficiency and aesthetic outcomes. Here we critically assess the utility of Process Analysis as a tool in the context of morbidity and operative time. METHODS: Co-surgeons at a university hospital implemented two, prospective Process Analysis studies to carefully define and evaluate critical steps in DIEP flap reconstruction. During the 9-month period (June 2018 to February 2019), they assessed eight steps of flap harvest and microsurgery. During the 8-month period (January 2020 to August 2020), they expanded their analysis to encompass the entire operation. To evaluate the immediate and sustained impact of Process Analysis, we divided 375 bilateral DIEP flaps into eight, consecutive 9-month intervals completed before, during and after the two studies (April 2015 to August 2020). Using risk-adjusted multivariate regressions with a Helmert contrast, we compared morbidity and operative time between timing intervals. RESULTS: Timing intervals completed prior to the 1st study had comparable morbidity and operative time. During the 1st study, there is an immediate 63.4% (P<.05) decrease in morbidity. The following 27-months show a sustained decrease in morbidity and operative time between each consecutive timing interval. The most significant decrease in operative time occurs during the 2nd study. CONCLUSION: Process Analysis is a powerful tool capable of generating immediate and sustained decreases in morbidity and operative time.

Comparison of Outcomes of Surgical Repair of Spontaneous Temporal Bone CSF Leaks and Encephaloceles Using Bone Cement and Autologous Material.

To compare outcomes transmastoid repair of spontaneous middle fossa cerebrospinal fluid (CSF) leak using only bone cement (BC) versus only autologous material (AM) or combined materials (CM) with both bone cement and autologous material. Retrospective Chart Review. Tertiary Care Hospital. Forty-three adult patients undergoing transmastoid repair of spontaneous middle fossa CSF leak between 2014 and 2020 (BC:12, AM:15, CR:16). Cortical mastoidectomy, identification of defect, and repair with BC (Cranios® hydroxyapatite), AM (local bone, fascia, fat, and/or cartilage), or CM (Cranios® combined with autologous materials). Successful repair without recurrent CSF leak or encephalocele throughout follow up. Fifty-one percent of subjects were female. Mean age at repair was 58.6 years (SD 10.9). Mean BMI was 35.4 (SD 7.6; BC:36.3, AM:36.5, CM:33.6). Forty (93%) patients had successful repair without known recurrent CSF leak or encephalocele since surgery (BC:11, 91.6%; AM:14, 93.3%; CM:15, 93.8%; p = 0.49) over a mean length of follow up of 49.6 months (BC: 37.9, AM: 59.2, CR: 49.5). The difference in mean operative time amongst the groups was faster for patients using bone cement (BC: 100.2 min, AM: 182.8, CM: 133.2; p < 0.00001). BC, AM, and CM techniques each demonstrate effective and sustained means of repair for middle fossa CSF leak and encephalocele, even in the presence of multiple defects. Use of isolated BC offers a significant decrease in operative time with a noninferior outcome. Active CSF leak at the time of surgery is associated with increased risk of recurrence.

Assessing the phacoemulsification learning curve using duration of each step.

To assess the phacoemulsification learning curve for ophthalmology residents using duration for each step. Single tertiary, training site hospital. Cross-sectional study. Emory ophthalmology postgraduate year (PGY) 3 and PGY-4 residents operating at Grady Memorial Hospital between April 2017 and February 2018 were eligible to participate. Duration in seconds for each step of surgery was calculated for incisions, continuous curvilinear capsulorhexis (CCC), hydrodissection, nucleus disassembly, quadrant removal, cortical cleanup, intraocular lens insertion, and closure, and this outcome was analyzed as a function of different experience levels. A total of 528 surgeries were included of 549 total surgeries recorded. 6 categories of experience levels were established as A to F, increasing by increments of 50. There was an overall downward trend across various steps across the 8 case categories, and several adjacent categories demonstrate statistically significant differences. The 3 most time-intensive steps early in training were nucleus disassembly (336.5 ± 16.5 seconds), quadrant removal (275.1 ± 18.0 seconds), and cortical cleanup (244.2 ± 24.6 seconds). There was a sustained drop in mean duration for all steps through at least category D, with most steps showing a drop through category F. There is a benefit to a higher caseload, well above the Accreditation Council for Graduate Medical Education-mandated 86 cases. Improvements in efficiency were observed after 250 cases, with nuclear disassembly and CCC demonstrating a significant decrease in operative time.

Learning curve for single-port robot-assisted rectal cancer surgery.

PurposeWe analyzed the learning curve of single-port robotic (SPR)-assisted rectal cancer surgery.MethodsFifty-seven consecutive SPR-assisted rectal cancer surgery cases performed by the same surgeon were considered in surgical interventions for rectal cancer. Total operation time (OT), docking time (DT), and surgeon console time (SCT) measured during surgery were used to parametrize the learning curve. The parameters representing the learning curve were evaluated using the cumulative sum (CUSUM).ResultsThe mean value of total OT was 241.8 ± 91.7 minutes, the mean value of DT was 20.6 ± 19.1 minutes, and the mean value of SCT was 135.9 ± 66.7 minutes. The learning curve was divided into phase 1 (initial 16 cases), phase 2 (second 16 cases), and phase 3 (subsequent 25 cases). The peak on the CUSUM graph occurred in the 21st case. The longest OT among phases was in phase 2. Complications were most frequent in phase 2. However, complications of Clavien-Dindo (CD) grade IIIb were most frequent in phase 3 with 2 patients. The most common complications were fluid collection and urinary retention (7 patients each). Complications of CD grade IIIb required one stomal revision due to stoma obstruction and one irrigation and loop ileostomy due to anastomosis leakage.ConclusionImprovement in surgical performance of SPR assisted rectal cancer operation was achieved after 21 cases. The three phases identified in the cumulative sum analysis showed a significant decrease in operative time after the middle stage of the learning curve without an increase in the complication rate.

Técnicas quirúrgicas en cesárea segmentaria. Revisión de evidencias

Aim: To know which have been the variations of the Pfannenstiel-Kerr technique and how they have influenced maternal morbidity and mortality. Methods: An electronic search was carried out in PubMed, Medline and Cochrane, of works in English and Spanish languages, regardless of the country of origin, preferably randomized and controlled between 2010 and 2020, on variations in the original surgical technique, with emphasis on the differences between the PfannenstielKerr and Miglav-Ladash techniques. Results: The more importants variations regarding morbidity and mortality were: 1. Preferring the transverse skin incision, especially the Joel Cohen type; 2. Lateral blunt dissection of the subcutaneous and cranio-caudal aponeurosis, after its incision; 3. Digital and lateral separation of the rectus abdominis muscles; 4. Digitally and laterally prolong the hysterotomy; 5. Uterine incision closure, without externalizing the uterus, in one or two suture planes, indifferently; 6. Do not suture the visceral and parietal peritoneum or approach the rectus abdominis; 7. Closure of the subcutaneous to separate points, if the thickness is greater than 2 cm. Conclusions: Modifications to the original technique achieved a statistically significant decrease in operative time, the number of sutures, the requirement for analgesics, blood loss, febrile morbidity, as well as operative wound infection and hospital stay. Keywords: Cesarean section, Surgical technique, Pfannenstiel-Kerr, Misgav-Ladach.

Bleeding Tendency in People Anesthetized with Sevoflurane Vs Isoflurane

Abstract Background &amp; Purpose The effects of desflurane and sevoflurane, two commonly used inhalation anesthetics for the maintenance of general anesthesia, on peri- and postoperative bleeding is a focus of interest. This study conductd to evaluating that; Sevoflurane can cause bleeding tendencies more than Isoflurane anesthesia or not? Study design Prospective, randomized comparative study. Setting Ain shams university hospitals. Subjects We included 40 tonsillectomy patients (age from 2 – 12 years old), and classified them according to the anesthetic drug used into 2 independent groups: Isoflurane group (20 patients) and Sevoflurane group (20 patients). Methods All patients were subjected to full history taking, oral cavity examination, anterior rhinoscopy nasal examination, basic laboratory studies for bleeding tendencies (e.g. platelets and INR), adenoidal-tonsillectomy operational data (including operative time calculation), bleeding outcomes (blood loss and packs of blood transfusion) will be recorded, and half of the cases will be anesthetized with sevoflurane and another half with isoflurane. Results In the studied population, the mean age of all patients was (7.1 ± 2.7) years, with (57.5%) of patients were males; while (42.5%) were females. Regarding bleeding outcome data; the average blood loss of all patients was (15.5 ± 3.7) cc, and the average packs used were (4.2 ± 1.1). We found a significant decrease in operative time in the Isoflurane group; compared to the Sevoflurane group (p = 0.0017). Regarding Bleeding outcome data; we found, a significant decrease in blood loss, in the Isoflurane group; compared to the Sevoflurane group (p = 0.00014), and a significant decrease in the number of packs used, in Isoflurane group; compared to Sevoflurane group (p = 0.0018). Conclusion To conclude, anesthesia with isoflurane can lead to a lower amount of intraoperative bleeding compared with sevoflurane. Therefore, isoflurane may be preferred as an inhalational agent for the maintenance of general anesthesia during tonsillectomy and adenoidectomy operations.

Use of Bariatric Ports in 4-Arm Robotic Partial Nephrectomy: A Comparative Study With the Standard 3-Arm Technique.

ObjectivesWe aim to compare the outcomes of a 3-arm versus a 4-arm robotic assisted partial nephrectomy (RAPN) using the da Vinci Si model; as well as, illustrate the deployment of long ports to decrease arm collision during the 4-arm approach.Patients and MethodsResults of RAPN in a Middle Eastern tertiary referral center from August 2013 to December 2017 are reported. Comparison between 3 versus 4-arm robotic approaches was done in regards to patient and tumor characteristics, operative parameters, and postoperative outcomes. Statistical analysis was performed with the Student’s t-test and chi-squared test.ResultsForty consecutive 3-arm RAPNs and 40 consecutive 4-arm RAPNs were retrospectively evaluated. Differences in tumor complexity between the two groups were statistically insignificant. Similarly, surgical margin positivity, mean ischemia time, estimated blood loss, length of hospital stay, and mean change in serum creatinine were statistically insignificant between the two groups. Mean operative time was significantly shorter by 42 minutes in the 4-arm vs 3-arm group (p=0.01).ConclusionsThe addition of a 4th arm in RAPN can be of benefit in centers that still rely on the da Vinci Si model. The ease of hilar dissection, retraction, and surgeon independence instigated a statistically significant decrease in operative time with 4-arm use.

Comparison between Single Mesh and Double Mesh Placement in Huge Inguinal Hernia

Background: Recurrence after surgical treatment of inguinal hernia is still a challenge facing surgeons during their daily practice. Aim of the Work: The current trial aims to compare single and double mesh placement in huge inguinal hernia repair. Patients and Methods: 40 cases were involved in the study. They were classified into two equal groups according to the operative technique [A for single mesh and B for double mesh]. The study's candidates were examined and investigated thoroughly regarding their complaint, the presence of a clinically detectable hernia in the inguinal region, its size, characters, onset, duration, and associated symptoms. Then, all were examined clinically and prepared for surgical intervention after lab investigations. Results: The mean ages were 56 and 56.9 years for groups A and B. Both groups were comparable to body mass index, risk factors, type of hernia, hernia side, and intraoperative blood loss. There was a significant decrease in operative time in group A when compared to group B [54.50 ± 8.256 vs. 61.25 ± 6.664 minutes, respectively]. The overall rate of complications was lower in group B when compared to group A [30.0% vs. 50.0%, respectively]. Complications in group A were seroma [10.0%], wound infection [5.0%], scrotal edema [25.0%], and chronic pain [10.0%]; while in group B, seroma [10.0%], scrotal edema [5.0%], chronic pain [15.0%]. Recurrence was confined to group A, and reported to three patients [15.0%]. However, the difference was statistically nonsignificant. Conclusion: Double mesh technique is a safe and efficacious approach for managing huge inguinal hernia. It is associated with lower rate of recurrence than the single mesh approach with comparable operative time, complications, and outcomes.