Standard Open Surgery Research Articles

Robot-assisted radical cystectomy and intracorporeal neobladder formation: on the way to a standardized procedure.

BackgroundRobot-assisted radical cystectomy (RARC) with intracorporeal diversion has been shown to be feasible in a few centers of excellence worldwide, with promising functional and oncologic outcomes. However, it remains unknown whether the complexity of the procedure allows its duplication in other non-pioneer centers. We attempt to address this issue by presenting our cumulative experience with RARC and intracorporeal neobladder formation.MethodsWe retrospectively identified 62 RARCs in 50 men and 12 women (mean age 63.6 years) in two tertiary centers. Intracorporeal Studer neobladders were created, duplicating the steps of standard open surgery. Perioperative and postoperative variables and complications were analyzed using standardized tools. Functional and oncological results were assessed.ResultsThe mean operative time was 476.9 min (range, 310 to 690) and blood loss was 385 ml (200 to 800). The mean hospital stay was 16.7 (12 to 62) days with no open conversion. Perioperative complications were grade II in 15, grade III in 11, and grade IV in 5 patients. The mean nodal yield was 22.9 (8 to 46). Positive margins were found in in 6.4%. The 90- and 180-day mortality rates were 0% and 3.3%. The average follow-up was 37.3 months (3 to 52). Continence was achieved in 88% of patients. The cancer-specific survival rate and overall survival rate were 84% and 71%, respectively.ConclusionsA RARC with intracorporeal neobladder creation is safe and reproducible in ‘non-pioneer’ tertiary centers with robotic expertise with acceptable operative time and complications. Further standardization of RARC with intracorporeal diversion is a prerequisite for its widespread use.

Comparing Open Radical Cystectomy and Robot-assisted Laparoscopic Radical Cystectomy: A Randomized Clinical Trial

BackgroundOpen radical cystectomy (ORC) and urinary diversion in patients with bladder cancer (BCa) are associated with significant perioperative complication risk. ObjectiveTo compare perioperative complications between robot-assisted radical cystectomy (RARC) and ORC techniques. Design, setting, and participantsA prospective randomized controlled trial was conducted during 2010 and 2013 in BCa patients scheduled for definitive treatment by radical cystectomy (RC), pelvic lymph node dissection (PLND), and urinary diversion. Patients were randomized to ORC/PLND or RARC/PLND, both with open urinary diversion. Patients were followed for 90 d postoperatively. InterventionStandard ORC or RARC with PLND; all urinary diversions were performed via an open approach. Outcome measurements and statistical analysisPrimary outcomes were overall 90-d grade 2–5 complications defined by a modified Clavien system. Secondary outcomes included comparison of high-grade complications, estimated blood loss, operative time, pathologic outcomes, 3- and 6-mo patient-reported quality-of-life (QOL) outcomes, and total operative room and inpatient costs. Differences in binary outcomes were assessed with the chi-square test, with differences in continuous outcomes assessed by analysis of covariance with randomization group as covariate and, for QOL end points, baseline score. Results and limitationsThe trial enrolled 124 patients, of whom 118 were randomized and underwent RC/PLND. Sixty were randomized to RARC and 58 to ORC. At 90 d, grade 2–5 complications were observed in 62% and 66% of RARC and ORC patients, respectively (95% confidence interval for difference, −21% to −13%; p=0.7). The similar rates of grade 2–5 complications at our mandated interim analysis met futility criteria; thus, early closure of the trial occurred. The RARC group had lower mean intraoperative blood loss (p=0.027) but significantly longer operative time than the ORC group (p<0.001). Pathologic variables including positive surgical margins and lymph node yields were similar. Mean hospital stay was 8 d in both arms (standard deviation, 3 and 5 d, respectively; p=0.5). Three- and 6-mo QOL outcomes were similar between arms. Cost analysis demonstrated an advantage to ORC compared with RARC. A limitation is the setting at a single high-volume, referral center; our findings may not be generalizable to all settings. ConclusionsThis trial failed to identify a large advantage for robot-assisted techniques over standard open surgery for patients undergoing RC/PLND and urinary diversion. Similar 90-d complication rates, hospital stay, pathologic outcomes, and 3- and 6-mo QOL outcomes were observed regardless of surgical technique. Patient summaryOf 118 patients with bladder cancer who underwent radical cystectomy, pelvic lymph node dissection, and urinary diversion, half were randomized to open surgery and half to robot-assisted laparoscopic surgery. We compared the rate of complications within 90 d after surgery for the open group versus the robotic group and found no significant difference between the two groups. Trial RegistrationClinicalTrials.gov identifier NCT01076387, www.clinicaltrials.gov.

Minimally invasive techniques for epilepsy surgery: stereotactic radiosurgery and other technologies.

Minimally invasive surgical techniques for the treatment of medically intractable epilepsy, which have been developed by neurosurgeons and epileptologists almost simultaneously with standard open epilepsy surgery, provide benefits in the traditional realms of safety and efficacy and the more recently appreciated realms of patient acceptance and costs. In this review, the authors discuss the shortcomings of the gold standard of open epilepsy surgery and summarize the techniques developed to provide minimally invasive alternatives. These minimally invasive techniques include stereotactic radiosurgery using the Gamma Knife, stereotactic radiofrequency thermocoagulation, laser-induced thermal therapy, and MRI-guided focused ultrasound ablation.

Abstract 19354: Management and Outcomes of Acute Type B Dissection in IRAD Treated with Open Surgery, Endovascular Flap Fenestration or TEVAR

Background: The debate for the optimal treatment of complicated Type B Acute Aortic Dissection (TBAAD) is primarily focused upon open surgical intervention versus thoracic endovascular aortic repair (TEVAR). The technique of fenestration with stenting has been proposed to resolve malperfusion. This study evaluated post-procedural outcomes of all three approaches for TBAAD. Methods: TBAAD patients enrolled in the International Registry of Acute Aortic Dissection were stratified by management type: TEVAR, fenestration and stenting, and surgery. Results: Of the 552 patients with TBAAD, 231 (41.8%) underwent TEVAR, 214 (38.8%) standard open surgery, and 107 (19.4%) fenestration and stenting. TEVAR or fenestration and stenting were more likely to be performed in classic double barrel aortic dissection when compared to open surgery (73.2%, 76.6%, 52.8% respectively; p&lt;0.001). Patients treated with open repair were less likely to have distal extension into the abdominal aorta than those with TEVAR or fenestration and stenting (47.7%, 62.7%, 86.4%, respectively; p&lt;0.001). In-hospital mortality was similar between groups (11.7% TEVAR, 14.0% fenestration and stenting, 15.9% surgery). At five years, Kaplan-Meier post-discharge all-cause survival estimates were highest for TEVAR, followed by endovascular fenestration and finally open surgical intervention (85.2%, 78.3%, 67.2%, respectively; p=0.039). Conclusion: Patients treated by endovascular approaches, whether with flap fenestration or thoracic endovascular aortic repair, had lower five year mortality when compared to patients who required open repair in the setting of TBAAD. Either endovascular approach may be helpful in the treatment of TBAAD. Further research is needed to determine how much of the observed difference represents patient selection versus differential effects of treatment.

Laparoscopic versus open resection for colorectal liver metastases: a single-center study with propensity score analysis.

The aim of the study was to compare the long-term oncologic results of laparoscopic liver resection (LLR) versus open liver resection (OLR) for colorectal liver metastasis (CRLM) using a propensity score analysis. This propensity score matching (PSM) study was based on a prospective database of a single tertiary-care center. Patients with primarily resectable CRLM were selected for a 1:1 PSM between LLR and OLR. Covariates for PSM estimation were age, gender, body mass index, American Society of Anesthesiologists score, primary tumor location, CRLM presentation, location, size, and number. Moreover, the year of surgery was included in the PSM model. Operative, postoperative, and survival rates were compared between groups. From 2000 to 2013, in total, 339 liver resections for CRLM met the selection criteria. Among these, 52 LLR patients were matched with 52 OLR patients. The two surgical approaches showed similar postoperative morbidity and mortality rates. LLR was associated with significantly less blood loss, less frequent need for and shorter duration of pedicle clamping, faster recovery, and shorter hospital stay. Moreover, the overall 3- and 5-year survival rates were, respectively, 83% and 76% for LLR and 87% and 62% for OLR (P=.51). The 3- and 5-year disease-free survival rates were, respectively, 28% and 21% for LLR and 31% and 21% for OLR (P=.71). The LLR achieves similar oncological results to those of the standard open surgery for CRLM, with the additional benefit of significantly faster recovery.

Percutaneous fixation of segmental fractures of the humerus

ObjectiveTo present our experience of treatment of patients with diaphyseal segmental fractures of the humerus using minimal access surgery and a standard low-contact dynamic compression plate.Patients and methodsTwenty four patients (18 men and six women), average age 29.8 years (range 17-46 years), presented with a closed segmental diaphyseal fracture of the humerus without neurological deficit and were operated upon by minimal access and percutaneous fixation to preserve the soft tissue and the fracture hematoma.ResultsTwenty three fractures united, and all patients had good range of motion in the adjacent joints. Axial and rotational malalignment did not exceed 15° and did not affect limb function. In one patient, there was delayed union at the distal level of fracture by the end of the third month and bone grafting was performed without revision of fixation.ConclusionPercutaneous fixation of segmental fractures of the humeral shaft is an alternative to standard open surgery and intramedullary fixation, reducing surgical impact and yielding an excellent functional result.

Our emergency surgical approach in a case with migration of the atrial septal defect occluder device into left atrium and displacement on mitral valve

Results After median sternotomy and vertical incision of the pericardium, standard aortic and bicaval venous cannulation was carried out. Following the cross-clamping of the aorta antegrade blood cardioplegia was introduced. Right atriotomy was done. ASD occluder device was detected within the left atrium settled on the mitral valve which was observed through 50 x 25 mm fossa ovalis type secundum ASD. After transseptal removal of the device from the left atrium, the defect was repaired using a polytetrafluoroethylene cardiac patch. His intensive care unit stay was 2 days and he was discharged from the hospital on 7th postoperative day. His 1st, 3rd and 6th follow-up visits were free of events and repeated echocardiographic examinations revealed no residual shunting. Conclusions One must keep in mind that transcatheter closure has such complications as migration of the device and development of residual shunting. In case of occurrence of such complications, the problem may be solved by standard open cardiac surgery under cardiopulmonary bypass.

Evaluation of surgical treatment for ruptured Achilles tendon in 31 athletes

In the past few decades, the incidence of Achilles tendon rupture has increased in parallel with increased sports participation. Although the optimal treatment remains controversial, there is a trend towards surgical treatment in athletes. Surgical repair of ruptured Achilles tendon in athlete results in good functional and objective recovery, irrespective of the type of surgery performed. Subsidiarily, are the results different between percutaneous surgery (PS) and standard open surgery (OS)? This was a cross-sectional study of 31 patients who presented with a ruptured Achilles tendon that occurred during sports participation. Percutaneous surgery was performed in 16 patients and open surgery in 15 patients between 2005 and 2009. The objective recovery status was evaluated by open chain goniometry, measurement of leg muscle atrophy and assessment of isokinetic strength. The functional analysis was based on the delay, level of sports upon return, AOFAS and VAS for pain. Our series of Achilles tendon rupture patients consisted of 88% men and 12% women, with an average age of 38 years. In 71% of cases, the rupture occurred during eccentric loading. After a follow-up of 15 months, the muscle atrophy was 13 mm after PS and 24 mm after OS (P=0.01). A strength deficit of 19% in the plantar flexors was found in the two groups. No patient experienced a rerupture. The return to sports occurred at 130 days after PS and 178 days after OS (P=0.005). The average AOFAS score was 94 and the VAS was 0.5. There were no differences in ankle range of motion between the two groups. The majority (77%) of patients had returned to their preinjury level of sports activity. The return to activities of daily living was slower in our study than in studies based in Anglo-Saxon countries; this can be explained by the different sick leave coverage systems. Percutaneous surgery resulted in a faster return to sports (about 130 days) and less muscle atrophy than open surgery. Our results for return to sports and return to preinjury levels were similar to published results for athletes and were independent of the type of surgery performed. The AOFAS score was comparable to published studies. We found no difference in muscle strength between the two surgery groups 15 months after the procedure. Apart from venous thrombosis typically described after lower-limb immobilization, secondary postoperative complications mostly consisted of sural paresthesia, which had resolved at the 15-month postoperative follow-up evaluation. The results of surgical treatment for ruptured Achilles tendon are good overall. By combining the simplicity of conservative treatment and the reliability of standard surgical treatment, percutaneous surgery is the treatment of choice to achieve excellent results. The return to sports occurred earlier, the muscle atrophy was less and the functional score was better in our patients treated by percutaneous surgery. Level IV.

Onion skin technique for open surgical replacement of aortic arch following primary endoprothesic thoracic aorta treatment

Endovascular aortic replacement (EVAR) techniques have become the first choice option for many aortic diseases in patients in whom standard open surgery was contraindicated or with high surgical risk. A secondary open surgical treatment, following a primary EVAR procedure, could, however, be challenging depending on the type, the extension and the position of primary endoprosthesis. Here, we describe an original and easy technique capable of simplifying a secondary aortic arch replacement following EVAR treatment of the descending thoracic aorta. The basic concept of such techniques is similar to that of the conventional 'elephant trunk' technique and is based on an inverted straight tube graft inserted into the endoprosthesis and anastomized using a multi-layer double suture with external strip felt of Dacron.

Retroperitoneal laparoendoscopic single-site ureterolithotomy for upper ureteral stone disease

Objective. The aim of this article was to present this group's clinical experience with retroperitoneal laparoendoscopic single-site (LESS) ureterolithotomy for the management of upper ureteral stones in selected patients. Material and methods. From May 2011 to November 2012, retroperitoneal LESS ureterolithotomy was performed in 22 patients at Xiangya Hospital. During the operation, a transverse skin incision was made approximately 2.5 cm in length along the lower margin of the 12th rib at the midaxillary line, and a single port was inserted. Standard steps of a multisite retroperitoneoscopic ureterolithotomy with a combination of conventional straight instruments and bent instruments were performed. Results. All cases were completed successfully without conversion to standard laparoscopy or open surgery. No additional ports or expensive flexible instruments were required. Overall, mean operative time was 98.5 min (range 76--174 min) and mean estimated blood loss was 33.4 ml (range 18--53 ml). Mean hospital stay after surgery was 3.7 days (range 3--5 days). One patient had fever postoperatively due to an Escherichia coli urinary tract infection, which resolved with appropriate antibiotic therapy. There were no major complications. The mean follow-up period was 10.5 months (range 3--21 months). All patients were asymptomatic and did not exhibit signs or symptoms of obstruction or stricture. Conclusions. Retroperitoneal LESS ureterolithotomy is a feasible, safe and effective surgical method for the treatment of upper ureteral stones in select patients. Prospective studies based on more patients are needed to evaluate further its advantages over conventional laparoscopic ureterolithotomy.

Nerve-Sparing Minilaparoscopic Versus Conventional Laparoscopic Radical Hysterectomy Plus Systematic Pelvic Lymphadenectomy in Cervical Cancer Patients

To present our preliminary experience with nerve-sparing minilaparoscopic radical hysterectomy plus pelvic lymphadenectomy for the surgical treatment of cervical cancer and to compare outcomes with those of the conventional laparoscopic approach. Data of 87 consecutive women who underwent minimally invasive surgery for early and locally advanced stage cervical cancer were prospectively collected. Ten women who underwent laparoscopic surgery using a nerve-sparing technique performed through 3-mm ancillary ports were compared with the 77 patients who had standard laparoscopic surgery previously with 3 sovrapubic 5-mm trocars. Minilaparoscopic radical hysterectomy was successfully accomplished in every case with no conversion to standard laparoscopy or open surgery. Two (2.6%) conversions to open surgery occurred in the conventional laparoscopy group. Surgical characteristics (operative time, estimated blood loss, and length of stay) and complication rate were similar between the 2 groups. No differences in the amount of parametrial and vaginal tissue removed were observed. The number of lymph nodes retrieved through minilaparoscopy was higher than conventional laparoscopy (30 [range = 26-38] vs 22 [range = 8-49]; P = .002). However, no difference was observed when the analysis was restricted to the last 10 conventional procedures (30 [range = 26-38] vs 29 [range = 24-49]; P = .81). Our data show that minilaparoscopic radical hysterectomy with pelvic lymphadenectomy is a feasible procedure if performed by skilled surgeons.

Retroperitoneal laparoendoscopic single-site surgery for the treatment of retrocaval ureter

To present our surgical techniques for retroperitoneal laparoendoscopic single-site (LESS) pyelopyelostomy for retrocaval ureter and our initial experience with this method in 4 patients. From June 2010 to May 2011, 4 patients with retrocaval ureter underwent retroperitoneal LESS pyelopyelostomy with a homemade single-port device and standard straight laparoscopic instruments. The single-port device was made with a surgical glove and Foley catheter and allowed the introduction of three trocars. A 3-cm incision was made at the middle axillary line, midway between the iliac crest and the twelfth rib. The retrocaval segment of the ureter was mobilized and transposed anteriorly to the inferior vena cava. The pyelopyelostomy anastomosis was completed with intracorporeal freehand suturing. A double-pigtail ureteral stent assembly was implanted in 3 of the 4 patients. All retroperitoneal LESS pyelopyelostomies were successful without conversion to standard laparoscopy or open surgery. The mean operating time was 105min (range, 90-135min). The mean blood loss was 18mL (range, 5-50mL). None of the patients required blood transfusion. The double-pigtail ureteral stent was removed 4-6weeks postoperatively. The mean postoperative hospital stay was 7.3days (range, 6-9days). No intraoperative or postoperative complications occurred. At a mean follow-up of 10months, excellent improvement in the ureteral obstruction was observed. We report our initial experience using LESS for the treatment of retrocaval ureter. Our results in 4 patients suggest that this minimally invasive approach is a feasible treatment of retrocaval ureter. Long-term follow-up of more cases is needed to confirm its benefits.

Expanding laparoscopic gastrectomy for gastric cancer outside Korea and Japan

During the past four decades, open gastrectomy with D2 lymphadenectomy has been the standard approach for resectable gastric cancer in Japan. But only recently with evidence from western phase 3 randomized controlled trials for the safety and survival benefit of D2 versus D1 surgery [1], D2 surgery can be recommended for wide practical implementation when it results in a complete tumor resection (R0). During the past decade, large retrospective studies and small randomized trials, mostly from Korea and Japan, have reported positive results with laparoscopic surgery mainly for early gastric cancer [2]. However, totally laparoscopic D2 gastrectomy particularly for advanced gastric cancer, is a highly demanded, timeconsuming procedure that requires evaluation in clinical trials for its safety and efficacy considering also cost-benefit analysis compared with standard open D2 surgery [3]. The recent report for laparoscopic D2 gastrectomy for gastric cancer by Moisan and colleagues [4] in the March issue of Surgical Endoscopy comes not from Korea, Japan, or specialized hospitals in the United States or European Union but from Chile. In this country, along with Asia and east European countries, incidence of gastric cancer continues to be high, which may explain advances with laparoscopic surgical treatment. Moisan and colleagues [4] compared early and longterm outcomes of 31 gastric cancer patients who underwent totally laparoscopic D2 gastrectomy (LG) with intracorporeal handsewn esophagojejunostomy between 2003 and 2010 with those of 31 patients who received an open D2 gastrectomy (OG) as the standard group. There were major complications with two vs. no duodenal stump leakages in LG and OG respectively and two esophagojejunostomy anastomotic leakages in each group. After a median followup of 3 years, there was no significant difference in recurrence-free survival or overall survival between the two groups. The authors conclude that laparoscopic D2 surgery is feasible, safe, and as effective as open D2 surgery regarding oncological outcomes. This study provides many positive aspects. Totally laparoscopic gastrectomy with total gastrectomy and D2 lymphadenectomy is a highly demanding procedure that is feasible, safe, and effective with respect to long-term survival only when it is performed by high-volume surgeons with expertise and skill in this technique. The 35 retrieved lymph nodes in the laparoscopic group reveals the standardized and completeness of D2 lymphadenectomy that is essential for locoregional tumor control in advanced lymph node-positive disease. However, some questions raise the relatively high rates of leakages in duodenal stump and esophagojejunostomy. Laparoscopic surgery has evolved rapidly and provides evidence for its superiority for the treatment of colon cancer and positive data for rectal cancer treatment [5–7]. However, at present, totally laparoscopic D2 gastrectomy for advanced potentially curable gastric cancer, despite sporadic reports with enhanced results, requires evaluation within clinical trials and cannot be recommended outside highly specialized hospitals [3]. Although laparoscopic surgery can improve quality of life [8–11], the grand challenge remains of how the cancer genome heterogeneity and complexity of cancer cells in individual patient’s tumors can be overcome. Recently, the addition of trastuzumab to chemotherapy in HER2-positive metastatic or advanced gastric cancer has become the new standard, and new phase 3 trials also may establish its use C. Hottenrott (&) Chirurgische Klinik, St. Elisabethenkrankenhaus, Ginnheimer Strase 3, 60487 Frankfurt, Germany e-mail: info@gastricbreastcancer.com

Same-session video-assisted thoracoscopic surgery and posterior fixation for the treatment of dorsal spine tuberculuos spondylodiscitis

Background As the use of the standard anterior approach to the dorsal spine using thoracotomy is associated with considerable morbidity, video-assisted thoracic surgery (VATS) has been used as a less invasive approach for many intrathoracic disease processes, such as dorsal spine tuberculous infection. We performed VATS in patients with kyphotic deformity secondary to tuberculous vertebral osteomyelitis, attempting to reduce the morbidity attributable to standard open thoracotomy surgery. Methods A total of 42 patients with tuberculous dorsal spine spondylodiscitis were managed by VATS. The technique included simultaneous posterior fixation combined with anterior thoracoscopic debridement and anterior reconstruction with the patient positioned in a prone position. Patients were evaluated using the Oswestry score, American Spinal Injury Association neurological evaluation, plain radiography in anteroposterior, lateral projections measuring the modified Cobb angle, computed tomography-guided biopsy if needed, and MRI. Results Dorsal spine tuberculosis was managed efficiently and safely in all cases using VATS. Except for one case, there was no recurrence of infection, and hence, there was no need for open thoracotomy to revise the procedure. The operative time and blood loss of the endoscopic technique were comparable with those of the open technique. Conclusion VATS is an effective and safe procedure in the management of kyphotic dorsal deformity because of tuberculous spondylodiscitis. Debridement, decompression of the spinal canal, and anterior reconstruction can be performed using the endoscopic approach, with less morbidity compared with thoracotomy.

Transapical Endovascular Aortic Repair to Treat Complex Aortic Pathologies

Clinical condition, hostile anatomy, and previous heart/aortic surgery may preclude standard open surgery and standard endovascular interventions in patients with complex aortic pathologies. We report our initial experience using the transapical endovascular approach to treat a type IA endoleak after transfemoral endovascular graft repair for a contained rupture of a penetrating descending aortic ulcer; an ascending aortic anastomotic pseudoaneurysm after open surgical repair of an ascending aortic dissection; and a type A aortic dissection after minimally invasive mitral valve repair. There were no neurologic or cardiovascular complications, and the 30-day mortality was 0%.

A Comparison between Laparoendoscopic Single-Site and Conventional Laparoscopic Renal Stone Removal Surgery: A Study of Application in Two Cases

Aim: To present our initial experience of applying laparoendoscopic single-site surgery (LESS) nephrolithotomy in the treatment of renal calculi. Methods: In August 2010 and April 2012, the LESS nephrolithotomy technique was applied to treat two patients with a renal calculus. One patient had a calculus measuring 5 × 3 cm, and the second patient's measured 3 × 3 cm. Both patients underwent general anesthesia. The operations were performed through a retroperitoneal approach with a single-port instrument inserted through the retroperitoneal incision. The standard laparoscopic retroperitoneal technique was performed, and the calculi were removed by incising the area of the thin renal cortex and the renal pelvis, respectively. The operating time, estimated blood loss, intraoperative complications, other complications, drainage time, and post-operative hospital stay were recorded. Results: Both procedures were completed successfully. No additional trocars were added. No conversion to standard laparoscopic or open surgery was needed. The operating times were 130 min and 120 min, and the estimated blood losses were 40 mL and 30 mL. There were no intraoperative complications. The wound drainage times were 3 d and 2 d, respectively and the post-operative hospital stays were 8 d and 7 d, respectively. There was no secondary bleeding or wound infection. Follow-up times were 2 years and 3 months, respectively. No incidence of hydronephrosis was recorded. Conclusions: LESS nephrolithotomy is safe and feasible for treating kidney calculi. It can be applied in patients with large renal calculi and regionally thin renal parenchyma.

Laparoendoscopic single-site surgery in urology: a single-center experience

Objective To present our experience on the first 100 cases receiving urological laparoendoscopic single-site surgery(LESS).Methods Between Dec.2008 and May 2011,a cohort of 98patients received a total of 100TriPort TM LESS urologic surgeries for various indications,including 2patients undergoing bilateral surgeries.The proceducres included radical nephrectomy(n=24),partial nephrectomy(n=3),simple nephrectomy(n=10),kidney cyst excision(n=21),adrenlectomy(n=12),transvesical simple prostatectomy(n=9),ureterolithotomy(n=6),and others(n=15).The demographics,perioperative outcomes,and follow-up data were prospectively analyzed.Results Of the 100surgeries,87were smoothly completed.A 5mm ancillary trocar was required in 9cases.Conversion to standard laparoscopy and open surgery were needed in 1and 3patients,respectively.The overall complication rate was 15%,with 6%intraoperatively and 9% postoperatively.The complication rate was 5%for the first 50cases and 10%for the second 50cases.The patients were followed up for 9.9± 5.61(ranging 3-24)months.At the latest follow-up,all patients remained clinically healthy with a delightedly hidden scar.No evidence of recurrence or metastasis was detected in patients receiving tumor resection.Conclusion The LESS is safe and technically feasible for urological surgery,with minimal invasiveness and better cosmesis.Emphasis should be made on patient selection and indication criteria.Improvement in instrumentation,accumulation of clinical practice,and well-designed multicenter prospective clinical trials will promote the use of LESS surgery for treatment of urologic diseases.

Usefulness of dextranomer/hyaluronic acid copolymer in bronchoscopic treatment of recurrent tracheoesophageal fistula in children

Objective Endoscopic repair of recurrent tracheoesophageal fistula (RTF) in infants who underwent surgery at birth for esophageal atresia (EA) is under investigation as an alternative to open surgery, which is technically challenging and associated with high morbidity. The aims of this paper are to present the experience of a single institution in treating RTF using a novel submucosal bronchoscopic injection of biocompatible dextranomer/hyaluronic acid (Dx/HA) copolymer, and to discuss the indications and limitations of this technique. Methods From 2000 to 2007, 6 children (2 boys; 4 girls) aged 1–48 months, weighing 2.5–18 kg were referred to our hospital for respiratory symptoms (pneumonia and failure to thrive) secondary to suspected RTF. All infants had undergone surgery at birth for EA with inferior tracheoesophageal fistula. Bronchoscopy revealed that five infants had RTF and one had a large remnant tracheal upper-pouch fistula. The bronchoscopic intervention was performed under general anesthesia, using a pediatric rigid bronchoscope with a 0° telescope and telemonitoring. The fistula wall mucosa was gently abraded to promote adhesion, and Dx/HA was then injected at two points in the fistula submucosa to obtain a stable swelling of the wall and closure of the RTF. Results In two infants (aged 1 month and 18 months) complete resolution of the RTF was achieved following two separate procedures with a 1-month interval. In three children (aged 2, 18 and 25 months) complete closure of the fistula was not achieved; however, the partial closure was sufficient to address the respiratory symptoms and allow subsequent standard open thoracic surgery without requiring recovery in the intensive care unit. Complete resolution of respiratory symptoms was also obtained following a single endoscopic procedure with two Dx/HA injections in the child with residual pouch fistula. Conclusion Bronchoscopic treatment of RTF with Dx/HA is a simple, minimally invasive, low-risk procedure that enables complete closure of RTF or reduction and resolution of respiratory symptoms, which in turn facilitates uncomplicated thoracic surgery. The technique also provides good results in remnant tracheal upper-pouch fistula.

A comparison of mini-open and open approaches for resection of thoracolumbar intradural spinal tumors

Standard approaches to thoracic intradural tumors often involve a large incision and significant tissue destruction. Minimally invasive techniques have been applied successfully for a variety of surgical decompression procedures but have been rarely used for the removal of intradural thoracolumbar tumors. In this paper, the authors compare the clinical outcome of mini-open resection of intradural thoracolumbar tumors with a standard open technique. The authors retrospectively reviewed their series of 18 consecutive mini-open thoracolumbar, intradural, tumor resection cases and compared the outcomes with a profile-matched cohort of 9 cases of open intradural tumor resection. Operative statistics, functional outcome, and complications were compared. Tumors were removed successfully using both approaches, except for 1 case in the mini-open cohort in which only biopsy was performed for a diffusely infiltrating tumor (glioblastoma). There was no statistically significant difference in operative duration, American Spinal Injury Association scale score improvement, or back pain visual analog scale score improvement between groups. However, the mini-open group demonstrated a significantly lower estimated blood loss (153 vs 372 ml, respectively) and a significantly shorter length of hospitalization (4.9 vs 8.2 days, respectively). There was 1 complication of pseudomeningocele formation in the mini-open cohort and 1 complication of cerebral infarction in the open cohort. Mean follow-up length was 16 months in the mini-open group compared with 20 months in the open group. The mini-open approach allows for adequate treatment of intradural thoracolumbar tumors with comparable outcomes to standard, open approaches. The mini-open approach is associated with less blood loss and a shorter length of stay compared with standard open surgery.

A Systematic Review of the Current Role of Minimally Invasive Spine Surgery in the Management of Metastatic Spine Disease

Although increasingly aggressive decompression and resection methods have resulted in improved outcomes for patients with metastatic spine disease, these aggressive surgeries are not feasible for patients with numerous comorbid conditions. Such patients stand to benefit from management via minimally invasive spine surgery (MIS), given its association with decreased perioperative morbidity. We performed a systematic review of literature with the goal of evaluating the clinical efficacy and safety of MIS in the setting of metastatic spine disease. Results suggest that MIS is an efficacious means of achieving neurological improvement and alleviating pain. In addition, data suggests that MIS offers decreased blood loss, operative time, and complication rates in comparison to standard open spine surgery. However, due to the paucity of studies and low class of available evidence, the ability to draw comprehensive conclusions is limited. Future investigations should be conducted comparing standard surgery versus MIS in a prospective fashion.