Significant Reduction In Operative Time Research Articles

The use of FOCUS Harmonic scalpel compared to conventional haemostasis (knot and tie ligation) for thyroid surgery: a prospective randomized study.

Haemostasis is crucial in thyroid surgery to avoid intraoperative and postoperative complications. In the present study, we evaluated the efficiency and the safety of Harmonic scalpel when compared to conventional suture ligation in open total thyroidectomy. We enrolled 265 patients who underwent total thyroidectomy for multinodular disease since October 2011 up to October 2013. They were randomized into two groups: 141 in group HS (Harmonic Scalpel), 124 in group CT (Conventional tecnique). We recorded the following data: operative time, post-operative blood loss, length of hospital stay and complications. The patients were monitored for 48 hours after surgery. Several differences were observed between the two groups (HS vs CT): the use of Harmonic scalpel was associated to a significant reduction of surgical operative time (110 min in CT vs 79.36 min in HS, p = 0.00001) and also associated to a lower blood loss (97.38 ml in CT vs 68.72 ml in HS, p = 0.00001). The length of stay was significantly shorter in the HS group (2.75 days in CT vs 1.93 days in HS) Complication rate was similar in the two groups. According to our experience, the Harmonic scalpel represents a safe alternative to conventional haemostasis in thyroid surgery, allowing for a significant reduction of operative time, blood loss and hospitalization. The rate of complication demonstrated no significant difference among the two groups.

Systematic review of laparoscopic versus open surgery in the treatment of non-parasitic liver cysts.

We conducted a systematic review of the literature on the electronic databases Medline, Embase, Ovid and Cochrane to identify studies from 1990 to 2011 regarding the surgical management of non-parasitic liver cysts treated with laparoscopy (LT) and/or laparotomy (OT) to identify short-term and long-term outcomes of the relative treatments. Two reviewers independently extracted data regarding the following parameters: first author, year of publication, type of journal, study design, number of patients operated on, male/female ratio, mean age, mean size of the cysts treated, laparoscopic conversion rate, morbidity, mortality and recurrence in both groups (LT and OT). A qualitative analysis was carried out using the Pearson Chi square test and the Fischer's exact test where necessary. The data analysis was conducted by dividing the sample into three periods in relation to the development of laparoscopic surgery: period 1 (P1), 1990-1995 "pioneering" period of laparoscopy; period 2 (P2), 1996-2000 period of the "development of laparoscopy"; period 3 (P3), 2001-2011 period of "diffusion of laparoscopy." Thirty studies involving 948 patients comparing LT with OT were included in the final pooled analysis. Twenty-two studies were retrospective (73.3 %) and only 8 (26.7 %) were prospective. The number of publications increased during the three periods analysed. The correlation between the type of journal and the year of publication showed an increase (p = 0.048) in journals dedicated to LT during the three periods. In P1, the preferred approach was open surgery (66.3 %) with only 11 cases treated with LT. The conversion rate was 18.1 %. The overall complication rate was 33.3 % with a substantial equivalence between the two approaches (27.2 % for laparoscopic surgery and 36.6 % for laparotomic). The overall recurrence rate was 18.1 % with 36.3 % in the laparoscopic group and 9.2 % in the laparotomic group. In P2, the preferred approach was laparoscopic (56.7 %). The conversion rate was 2.3 %. The overall complication rate was 5.8 % but with some differences between the two approaches (10.3 % for the laparoscopic approach and 0 % for open surgery). The overall recurrence rate was 14.4 % with 17.4 % in the laparoscopic group and 10.4 % in the laparotomic group. In P3, the preferred approach was laparoscopic (69.9 %). The overall recurrence rate was 11.1 %; it was 6.1 % for the laparoscopic approach while it was 11.5 % for laparotomic. In all three periods analysed, the laparoscopic approach showed a statistically significant reduction in operative time (p = 0.009) and hospital stay (p = 0.001) and a significant (p < 0.05) reduction rate in symptomatic recurrences in patients with polycystic liver disease (25 %) as compared with simple liver cysts (7.5 %). The current data in the literature show that the laparoscopic approach may be the treatment of choice in patients with symptomatic non-parasitic cysts of the liver, providing the short-term advantages of minimally invasive surgery. Recurrence rates were acceptable and comparable to those of conventional surgery. Long-term outcomes should be verified by additional randomised controlled trials and long-term follow-ups.

Defining the learning curve for team-based laparoscopic pancreaticoduodenectomy.

The purpose of this study was to define the learning curves for laparoscopic pancreaticoduodenectomy (LPD) with and without laparoscopic reconstruction, using paired surgical teams consisting of advanced laparoscopic-trained surgeons and advanced oncologic-trained surgeons. All patients undergoing PD without vein resection at a single institution were retrospectively analyzed. LPD was introduced by initially focusing on laparoscopic resection followed by open reconstruction (hybrid) for 18months prior to attempting a totally LPD (TLPD) approach. Cases were compared with Chi square, Fisher's exact test, and Kruskal-Wallis analysis of variance (ANOVA). Between March 2010 and June 2013, 140 PDs were completed at our institution, of which 56 (40%) were attempted laparoscopically. In 31/56 procedures we planned to perform only the resection laparoscopically (hybrid), of which 7 (23%) required premature conversion before completion of resection. Following the first 23 of these hybrid cases, a total of 25 TLPDs have been performed, of which there were no conversions to open. For all LPD, a significant reduction in operative times was identified following the first 10 patients (median 478.5 vs. 430.5min; p=0.01), approaching open PD levels. After approximately 50 cases, operative times and estimated blood loss were consistently lower than those for open PD. In our experience of building an LPD program, the initial ten cases represent the biggest hurdle with respect to operative times. For an experienced teaching center using a staged and team-based approach, LPD appears to offer meaningful reductions in operative time and blood loss within the first 50 cases.

Learning curve for endoscopic submucosal dissection of gastric submucosal tumors: is it more difficult than it may seem?

Endoscopic submucosal dissection (ESD), as a minimally invasive technique, is gaining wide acceptance for treating epithelial neoplasms. More recently, some pioneers have developed ESD for the treatment of submucosal tumors (SMTs), but characterization of the learning curve is lacking. In this study we aimed to evaluate the learning curve for ESD of gastric SMTs. From September 2008 to April 2011, ESD was performed in 50 consecutive patients with gastric SMTs by a single experienced endoscopist at our high-volume institution. The cumulative sum (CUSUM) method was performed to analyze the shifts in operative time (OT) and consequently to investigate the learning curve. Analysis of the OT using the CUSUM method identified two distinct phases: Phase 1 (the initial 32 cases) and Phase 2 (the remaining 18 cases). Phase 1 represented the initial learning period, whereas Phase 2 showed the more skilled and higher proficiency period, with a significant reduction in OT (90±29 minutes versus 55±20 minutes; P<.0001). The two phases did not differ significantly with respect to patient characteristics and other perioperative parameters. Mastery of operative technique for ESD of SMTs is evident by a decrease in OT identified by CUSUM graphs. For endoscopists competent in basic endoscopic intervention skills, the learning curve should be achieved after approximately 32 cases. Offering this minimally invasive endoscopic intervention does not result in increased complication rate even in the early phase of the learning curve.

Desogestrel versus danazol as preoperative treatment for hysteroscopic surgery: a prospective, randomized evaluation

The aim of this single-center, prospective, randomized, parallel-group study was to compare desogestrel and danazol as preoperative endometrial preparation for hysteroscopic surgery. We enrolled 200 consecutive eligible patients, in reproductive age, with endouterine diseases. Pre- and post-treatment characterization of endometrium was performed by hysteroscopic visual observation and histologic confirmation. The enrolled patients were randomly assigned to two groups: 100 were treated with 75 μg of desogestrel/die, 100 with 100 mg of danazol/die, both orally for 5 weeks, starting on Day 1 of menstruation. We recorded intraoperative data (cervical dilatation time, operative time, infusion volume and severity of bleeding) and drugs' side effects. Post-treatment comparison of endometrial patterns showed a significant more marked effect of desogestrel, respect to danazol, in atrophying endometrium (“normotrophic non-responders” versus “hypotrophic”—“atrophic”, p = 0.031). Intraoperative data showed no significant differences between the two groups for cervical dilatation time (p = 0.160), while in the desogestrel group we found a significant reduction of operative time (p = 0.020), infusion volume (p = 0.012), and severity of bleeding (p = 0.004). Moreover, desogestrel caused less side effects (p = 0.031). According to our data analysis, desogestrel showed most marked effect in inducing endometrial atrophy, allowed a better intraoperative management and caused less side effects during treatment.

Evaluation of a clinical pathway for ‘radical laparoscopic prostatectomy’: an interrupted time series study

ABSTRACTThe aim of this study was a rigorous evaluation of a clinical pathway (CP) in patients who underwent a radical laparoscopic prostatectomy (RLP). The study was performed at a German university hospital. The Department of Urology has considerable expertise and performs more than 200 RLP per year. The CP for ‘RLP’ was developed based on the best available evidence and introduced in July 2003. It was composed of six modules, and in each module standardized recommendations for clinical examination, therapy and outcome measurement were given. An interrupted time series design with multiple linear regression models was used to measure the effects of a CP for ‘RLP’ on length of hospital stay, and durations of operation and anaesthesia before and after implementation. χ2 tests were used to compare the number of patients admitted to intensive care unit, the number requiring re‐operation during admission, the number requiring transfusion(s) of blood products and 30‐d readmission rates. A total of 254 patients were analysed. A significant reduction in operation time and admission to intensive care but also a significant increase of patients readmitted to the hospital after the implementation of a CP was observed. Inconclusive results always warrant careful exploration, and measures on CP uptake should always be used to evaluate the success or failure of the implementation strategy.

Intraoperative tranexamic acid in pediatric bloodless cardiac surgery

The aim of this study was to evaluate the clinical effects of intraoperative tranexamic acid administration in cardiac surgery without blood transfusion (bloodless cardiac surgery) in children. Seventy-one consecutive patients weighing less than 20 kg, who underwent bloodless cardiac surgery for simple atrial or ventricular septal defects at Kobe Children's Hospital from January 2011 to June 2013, were enrolled in this retrospective study. Tranexamic acid was administered during surgery from January 2012 (TXA group; n = 31), whereas it was not administered before January 2012 (control group; n = 40). Perioperative variables were compared between the TXA and control groups. There were no significant differences in patient characteristics or preoperative data between the 2 groups. Serial changes in perioperative hemoglobin and hematocrit levels, mixed venous oxygen saturation, and regional cerebral oxygenation during cardiopulmonary bypass were significantly higher in the TXA group compared to the control group. There were significant reductions in operative time, dopamine dose, peak serum lactate level, intubation time, chest tube drainage and duration, and hospital stay in the TXA group. Intraoperative tranexamic acid administration was effective for blood conservation, and improved postoperative clinical outcomes in pediatric bloodless cardiac surgery.

Comparison of efficacy of bipolar electrosurgical vessel sealing with conventional suturing in securing vascular pedicles during vaginal hysterectomy

Background: During vaginal hysterectomy, pedicles are usually secured by conventional suturing but it may be difficult many a times. Electrosurgical bipolar vessel sealing in vaginal hysterectomy is safe and effective alternative for securing pedicles. Aims & Objectives: Aim of the study is to compare the efficacy of vessel sealing for securing pedicles in vaginal hysterectomy as compared to conventional suturing in terms of operating time, perioperative blood loss, postoperative pain and short-term surgical complications. Materials and Methods: This was a randomized controlled trial study done in our institute during a period of one year. Two groups were formed, one was control group I (total 60 patients), wherein, conventional suturing was done and other was study group II (total 65 patient) where Ligasure vessel seal was used for securing pedicles, irrespective of age and parity. Data of patients were collected and statistical analysis was performed using SPSS version software. Results: Group II shows significant reduction in operative time compared to control group (p =0.0001). There was significant difference between 2 groups in operative blood loss (p =0.0001) and post-operative pain (p=0.0001). None of the patients had major surgical complications. Conclusion: The Ligasure vessel sealing system is a safe alternative for securing pedicles in vaginal hysterectomy when compare with conventional suture ligation.

Abstract P5-15-04: Clinical benefits of using nomogram for predicting positive resection margins in breast conserving surgery

Abstract Achieving a clear resection margin in breast conserving surgery (BCS) is an important factor in tumor recurrence in breast cancer. To obtain clear resection margins and reduce re-excision rates, some surgeons obtain intraoperative assessments of the margins of excised specimens, using intraoperative frozen biopsy. But intraoperative frozen biopsy has several problems such as low sensitivity or longer operation time. We have previously reported a nomogram for prediction of positive resection margin by integrating preoperatively available clinical and pathologic information. The factors were the presence of microcalcification, mammographic density, tumor size discrepancy between magnetic resonance imaging and ultrasonography, and the presence of ductal carcinoma in situ or lobular carcinoma in needle biopsy specimens. We conducted a prospective trial to examine the accuracy and clinical benefits of the nomogram in 442 breast cancer patients (nomogram group) who underwent BCS between Dec 2011 and March 2013, and compared the clinical outcome with that of the 253 patients (control group) who underwent BCS between Jan 2011 and Oct 2011. For nomogram group, the intraoperative frozen section biopsy was omitted in patients with low nomogram scores. Applying our nomogram did not increase the rate of reoperation due to resection margin positivity when compared to the control group (6.56% vs. 4.25%, respectively, p = 0.22). In the nomogram group, the reoperation rate in patients with low nomogram score who did not undergo intraoperative frozen biopsy was 3.2%, and this is lower than the reoperation rate in the control group. Additionally, we experienced a significant reduction in operation time by 15 minutes when compared to the control group (p&amp;lt;0.001). In conclusion, our results show that out nomogram for predicting positive resection margin for patients who receive BCS can significantly reduce the operation time without increasing reoperation rate. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-15-04.

Thermal sealing systems with and without tissue divider for total thyroidectomy

Sutureless thyroid surgery utilizing thermal sealing is now well established. However, incremental advances in technology still require formal clinical evaluation in order to ensure that added technology does not compromise safety. In this study, we compared a new thermal sealing device incorporating a tissue divider (LigaSure Small Jaw) with the device we have previously reported for use in total thyroidectomy (LigaSure Precise). A cohort study was undertaken of 872 total thyroidectomies over a 2-year period. Patients were selected for each group on the basis of device availability within four institutions and outcomes were obtained from a prospectively maintained database. Small Jaw was used in 399 cases and Precise in 473. No significant differences between patient demographics (sex, age), operation indication or pathology were found. Significantly more Small Jaw operations were performed in private versus public hospitals (P < 0.01). Regarding outcomes, there was no significant difference in the incidence of any complication (haematoma, temporary/permanent hypoparathyroidism or temporary/permanent recurrent laryngeal nerve injury). In a subgroup analysis of operations performed in the public hospital system, Small Jaw was found to be significantly faster (mean operative time: 79 versus 103 min) (95% CI 74-84 and 96-110 min) (P < 0.01). The incorporation of a tissue divider into thermal sealing devices is efficacious and safe, with no compromise in clinical outcome, while providing the added benefit of a significant reduction in operative times.

Vaginal cuff closure with absorbable bidirectional barbed suture during total laparoscopic hysterectomy

ObjectiveHysterectomy represents one of the most performed procedures in gynecological surgery. The minimally invasive approach increases patients’ benefits and reduces hospitalization costs. The aim of this study was to demonstrate the efficacy and safety of double barbed suture in vaginal cuff closure during total laparoscopic hysterectomy. Study designA retrospective cohort study of 88 consecutive patients treated with total laparoscopic hysterectomy for benign or precancerous conditions was undertaken from January 2010 to December 2011. Vaginal cuff suture was performed with traditional interrupted suture with polycolic acid (Vicryl™) in 40 patients and with bidirectional barbed device, Quill SRS™, in 48 patients. ResultsNo difference in vaginal cuff dehiscence, major vaginal bleeding or spotting, and infection was evident between the two groups, with significant reduction in operative times for the bidirectional barbed suture group. ConclusionVaginal cuff suture performed with bidirectional barbed QUILL SRS™ is a safe and well-tolerated procedure that reduces operative times.

Defining the Learning Curve for Robotic-assisted Esophagogastrectomy

IntroductionThe expansion of robotic-assisted surgery is occurring quickly, though little is generally known about the “learning curve” for the technology with utilization for complex esophageal procedures. The purpose of this study is to define the learning curve for robotic-assisted esophagogastrectomy with respect to operative time, conversion rates, and patient safety. MethodsWe have prospectively followed all patients undergoing robotic-assisted esophagogastrectomy and compared operations performed at our institutions by a single surgeon in successive cohorts of 10 patients. Our measures of proficiency included: operative times, conversion rates, and complications. Statistical analyses were undertaken utilizing Spearman regression analysis and Mann–Whitney U test. Significance was accepted with 95 % confidence. ResultsFifty-two patients (41 male: 11 female) of mean age 66.2±8.8 years underwent robotic-assisted esophagogastrectomies for malignant esophageal disease. Neoadjuvant chemoradiation was administered to 30 (61 %) patients. A significant reduction in operative times (p <0.005) following completion of 20 procedures was identified (514 ± 106 vs. 397 ± 71.9). No conversions to open thoracotomy were required. Complication rates were low and not significantly different between any 10-patient cohort; however, no complications occurred in the final 10-patient cohort. There were no in-hospital mortalities. ConclusionsFor surgeons proficient in performing minimally-invasive esophagogastrectomies, the learning curve for a robotic-assisted procedure appears to begin near proficiency after 20 cases. Operative complications and conversions were infrequent and unchanged across successive 10-patient cohorts.

A systematic review of randomised control trials assessing mesh fixation in open inguinal hernia repair

The technique for fixation of mesh has been attributed to adverse patient and surgical outcomes. Although this has been the subject of vigorous debate in laparoscopic hernia repair, the several methods of fixation in open, anterior inguinal hernia repair have seldom been reviewed. The aim of this systematic review was to determine whether there is any difference in patient-based (recurrence, post-operative pain, SSI, quality of life) or surgical outcomes (operative time, length of operative stay) with different fixation methods in open anterior inguinal hernioplasty. A literature search was performed in PubMed, EMBASE and the Cochrane Library databases. Randomised clinical trials assessing more than one method of mesh fixation (or fixation versus no fixation) of mesh in adults (>18 years) in open, anterior inguinal hernia repair, with a minimum of 6-month follow-up and including at least one of the primary outcome measures (recurrence, chronic pain, surgical site infection) were included in the review. Secondary outcomes analysed included post-operative pain (within the first week), quality of life, operative time and length of hospital stay. Twelve randomised clinical trials, which included 1,992 primary inguinal hernia repairs, were eligible for inclusion. Four studies compared n-butyl-2 cyanoacrylate (NB2C) glues to sutures, two compared self-fixing meshes to sutures, four compared fibrin sealant to sutures, one compared tacks to sutures, and one compared absorbable sutures to non-absorbable sutures. The majority of the trials were rated as low or very low-quality studies. There was no significant difference in recurrence or surgical site infection rates between fixation methods. There was significant heterogeneity in the measurement of chronic pain. Three trials reported significantly lower rates of chronic pain with fibrin sealant or glue fixation compared to sutures. A further three studies reported lower pain rates within the first week with non-suture fixation techniques compared to suture fixation. A significant reduction in operative time, ranging form 6 to 17.9 min with non-suture fixation, was reported in five of the studies. Although infrequently measured, there were no significant differences in length of hospital stay or quality of life between fixation methods. There is insufficient evidence to promote fibrin sealant, self-fixing meshes or NB2C glues ahead of suture fixation. However, these products have been shown to be at least substantially equivalent, and moderate-quality RCTs have suggested that both fibrin sealant and NB2C glues may have a beneficial effect on reducing immediate post-operative pain and chronic pain in at-risk populations, such as younger active patients. It will ultimately be up to surgeons and health-care policy makers to decide whether based on the limited evidence these products represent a worthwhile cost for their patients.

Learning curve analysis of robot-assisted radical hysterectomy for cervical cancer: initial experience at a single institution

ObjectiveThe aim of this study was to evaluate the learning curve and perioperative outcomes of robot-assisted laparoscopic procedure for cervical cancer.MethodsA series of 65 cases of robot-assisted laparoscopic radical hysterectomies with bilateral pelvic lymph node dissection for early stage cervical cancer were included. Demographic data and various perioperative parameters including docking time, console time, and total operative time were reviewed from the prospectively collected database. Console time was set as a surrogate marker for surgical competency, in addition to surgical outcomes. The learning curve was evaluated using cumulative summation method.ResultsThe mean operative time was 190 minutes (range, 117 to 350 minutes). Two unique phases of the learning curve were derived using cumulative summation analysis; phase 1 (the initial learning curve of 28 cases), and phase 2 (the improvement phase of subsequent cases in which more challenging cases were managed). Docking and console times were significantly decreased after the first 28 cases compared with the latter cases (5 minutes vs. 4 minutes for docking time, 160 minutes vs. 134 minutes for console time; p<0.001 and p<0.001, respectively). There was a significant reduction in blood loss during operation (225 mL vs. 100 mL, p<0.001) and early postoperative complication rates (28% vs. 8.1%, p=0.003) in phase 2. No conversion to laparotomy occurred.ConclusionImprovement of surgical performance in robot-assisted surgery for cervical cancer can be achieved after 28 cases. The two phases identified by cumulative summation analysis showed significant reduction in operative time, blood loss, and complication rates in the latter phase of learning curve.

Robotic adrenalectomy: technical aspects, early results and learning curve

Adrenal surgery is undergoing continuous evolution, and robotic technology may extend indications for a minimally invasive approach to adrenalectomy. Thirty robot-assisted unilateral transperitoneal adrenalectomy procedures have been performed at our Department over the last 5 years. The presence of bilateral lesions and vascular involvement were the only contra-indications for a minimally invasive approach. Several patients presented with significant co-morbidities: BMI > 35 kg/m(2) (20%); ASA score III-IV (58.7%); and moderate to severe impaired respiratory function (36.6%). In addition, 40% of patients had undergone previous abdominal surgery. Two patients presented with intra-operative complications (6.6%) and only one patient required conversion to an open procedure (3.3%). None of the patients required intraoperative transfusions. Hospital morbidity was 10% but no mortality was recorded. The mean hospital stay was 5.2 ± 2.2 days. The mean size of the resected adrenal mass was 5.1 ± 2.4 cm. A significant reduction in operative times was found with gaining experience. Thanks to robotic technology, some subpopulations of patients with clinical or oncological contra-indications to laparoscopic treatment may be addressed with minimally invasive treatment.

A Standardized Operative Team for Major Head and Neck Cancer Ablation and Reconstruction

Prolonged procedure time in head and neck cancer ablation and free flap reconstruction cases has been shown to significantly increase perioperative complications. The authors' objective was to evaluate the effectiveness of a standardized surgical nursing team for head and neck cancer ablation and free flap reconstruction operations for reducing procedure time. A retrospective cohort analysis of consecutive patients presenting for head and neck cancer ablation and free flap reconstruction between January 1, 2007, and September 1, 2010, was performed. A standardized head and neck surgical nursing team was introduced on May 1, 2009, at our center. Procedure time and case time were measured before and after the introduction of the team. Univariable analyses were performed to evaluate the difference in procedure and case time between the two cohorts. A multivariable linear regression model was developed to control for confounding variables. There were 52 cases before the team was introduced and 49 cases after. Mean procedure time was reduced by 47.1 minutes (p = 0.04) and mean case time was reduced by 68.9 minutes (p = 0.01) after team introduction. The multivariable linear regression analysis demonstrated a significant reduction in operative time after team introduction, controlling for confounding variables. The introduction of a standardized surgical nursing team led to a significant reduction in procedure and case time. A standardized team approach improves operating room efficiency in complex cases such as free flap reconstruction following tumor ablation. Therapeutic, III.

Bipolar Vessel Sealer versus Harmonic Scalpel in Laparoscopic Supracervical Hysterectomy

Aim: The aim of this study was to compare the use of Electrothermal Bipolar Vessel Sealer (EBVS) with Harmonic Scalpel (HS) during laparoscopic supracervical hysterectomy (LSH) with respect to operation time, estimated blood loss and related complications. Methods: A randomized clinical study was conducted in the OB/GYN Department, Maternity Hospital, Kuwait, from March 2009 till January 2011. Forty candidates for Laparoscopic Supracervical Hysterectomy were enrolled and divided randomly into two equal groups of 20 patients each. Twenty hysterectomies (LSH) were performed using the Harmonic Shears (HS) (group I) and the other twenty patients (group II) had LSH operation using Electro-Thermal Blood Vessel Sealer (EBVS) technology. All the operations were performed by the same surgeon. Data about the characteristics of the patients, operation time, estimated blood loss, related complications and length of hospital stay were registered and compared. Results: Mean operation time, Hemoglobin (Hb) and Hematocrite value (Ht) drop, and hospital stay were significantly less in the bipolar vessel sealer group. There was significant reduction in operation time using the EBVS technique (64.15 ± 12.02) minutes as compared to HS technique (138.25 ± 23.41) minutes. Blood loss during operation was significantly lower in group (II) patients compared to group (I) demonstrated by significant greater drop in hemoglobin and hematocrite in the latter compared to the former group. The mean Hemoglobin drop in group (I) patients was (3.15 ± 0.82) while hematocrite drop was (3.72 ± 0.74). The mean hemoglobin drop for group (II) patients was (0.43 ± 0.33), while hematocrite drop was (0.74 ± 0.41). The mean hospital stay time for group (I) patients was 2.0 ± 1.52 days. The mean hospital stay for group (II) was 1.65 ± 0.58 days; the difference was not statistically significant. Conclusion: The bipolar vessel sealer technique seems to be less time-consuming during operation and caused less bleeding when compared with harmonic shears. Further studies with larger number of patients are required for stronger evaluation of the technique.

Comparison of Single Incision Laparoscopic Totally Extraperitoneal and Laparoscopic Totally Extraperitoneal Inguinal Hernia Repair: Initial Experience

Laparoendoscopic single-site (LESS) surgery has been implemented recently in many laparoscopic (LAP) surgical procedures. We report our initial experience with LESS totally extraperitoneal (LESS-TEP) inguinal hernia repair in relation to conventional LAP-TEP. Between November 2008 and May 2009, 25 LESS-TEP repairs of inguinal hernia and 29 LAP-TEP repairs of inguinal hernia were performed in 44 patients. Data regarding patient demographics, type of hernia, operative time, complications, postoperative hospital stay, and recurrence were prospectively collected and analyzed. All 44 patients were men, aged 17 to 84 years. Of 44 men, 3 had bilateral inguinal hernias in the LESS-TEP group and 7 in the LAP-TEP group. The operative time for bilateral LESS-TEP was 60 ± 15.3 min (range 40-70 min) and 40 ± 21.6 min (range 20-100 min) for unilateral LESS-TEP, while for bilateral hernia LAP-TEP it was 60 ± 24.8 min (range 40-100 min) and for unilateral LAP-TEP it was 50 ± 14.2 min (range 40-80 min). Comparison of operative times in the LESS-TEP and LAP-TEP groups between the first and second half cohort resulted in significant reduction of operative time in the second half of the LESS-TEP group (P<0.001). There were no intraoperative complications. Discharge was within 72 hours for most patients in both groups. There was one early recurrence (mesh displacement) during a median follow-up period of 11.5 ± 2.5 months in the LESS-TEP group and no recurrences during the 11 ± 1.6 months in the LAP-TEP group. In our experience, LESS-TEP is a safe and feasible procedure with a short learning curve. In all analyzed parameters, it is comparable to conventional LAP-TEP. Further studies that compare LESS-TEP and conventional multiport LAP-TEP repairs with long-term follow-up evaluation are needed to confirm the initial experience.

Biomechanical analysis of a novel posterior construct in a transforaminal lumbar interbody fusion model an in vitro study

Spinal fusion is a commonly performed surgical procedure. It is used to treat a variety of spinal pathologies, including degenerative disease, trauma, spondylolisthesis, and deformities. A mechanically stable spine provides an ideal environment for the formation of a fusion mass. Instrumented spinal fusion allows early ambulation with minimal need for a postoperative external immobilizer. Several biomechanical and clinical studies have evaluated the stability offered by different posterior instrumentation techniques and the effects of reduced instrumentation. The aim of the study was to compare the biomechanics of a novel pedicle and translaminar facet screw (TLFS) construct. Also, in this study, comparisons were made with the more common pedicle screw/TLFS constructs for posterior fixation. Human cadaveric lumbar spines were tested in an invitro flexibility experiment to investigate the biomechanical stability provided by a novel pedicle and TLFS construct after transforaminal lumbar interbody fusion (TLIF). Seven fresh human lumbar spines (L2-L5) were tested by applying pure moments of ±8 Nm. After intact specimen testing, a left-sided TLIF with a radiolucent interbody spacer was performed at L3-L4. Each specimen was then tested for the following constructs: bilateral pedicle screws (BPS) and rods at L3-L4; unilateral pedicle screws (UPS) and rods at L3-L4; UPS and rods and TLFS at L3-L4 (UPS+TLFS); and unilateral single pedicle screw and TLFS and rod at L3-L4 (V construct). The L3-L4 range of motion (ROM) and stiffness for each construct were obtained by applying pure moments in flexion, extension, lateral bending, and axial rotation. All instrumented constructs significantly reduced ROM in flexion-extension and lateral bending compared with the intact specimen. In axial rotation, only BPS constructs significantly reduced ROM compared with intact specimen. The V construct was able to achieve more reduction in ROM compared with UPS construct and was comparable to UPS+TLFS construct. Unilateral pedicle screws construct was the least stable in all loading modes and was significantly different than BPS construct in lateral bending. The V construct exhibited enhanced stability compared with UPS construct in all loading modes. It provides bilateral fixation and preserves the anatomic integrity of the superior facet joint. The novel construct may offer advantages of less invasiveness, significant reduction in operation time, duration of hospitalization, and costs of implants, which would require further clinical evaluation.

Successful Reconstruction of a Large Helical Rim Defect Using Retroauricular Artery Perforator-Based Island Flap

The retroauricular flap has many applications, providing coverage for various portions of the face as a pedicled flap or a free flap. The retroauricular skin, having similar attributes to the facial skin, is an ideal donor site for facial reconstruction. Also, the donor site can be primarily closed without morbidity, which is also an advantage. In this article, a large helical defect resulting from a traumatic amputation was reconstructed using the contralateral conchal cartilage graft and a retroauricular perforator-based island flap. Using the "perforator pedicled propeller flap" concept, no meticulous dissection around the perforator was done, and the flap was elevated only until sufficient rotation arc was achieved. There was some degree of venous congestion on the flap for 3 days postoperatively, but the flap survived completely. By using the conchal cartilage from the contralateral side, the final contour of the ear was maintained aesthetically. The flap had some bulkiness on the posterior side of the auricle where it was transposed, but it was inconspicuous on frontal or lateral view because the conchoscaphal angle had not changed. The patient was satisfied with the aesthetic results. The retroauricular flap is useful for resurfacing any portion of the ear, and by using the propeller flap method, significant reduction in operative time can be achieved without compromising the final results.