Standard Open Surgical Approaches Research Articles

Endoscopic repair of tracheoesophageal fistulas: A contemporary multi-institutional case series and literature review

ObjectivesRecurrent and primary tracheoesophageal fistulas (TEFs) are a challenging surgical pathology to treat, as standard open surgical approaches are associated with high morbidity and mortality. As such, endoscopic modalities have gained interest as an alluring alternative, yet variable success rates have been reported in the literature. The aim of this study was to provide a contemporary update of the literature and describe our institutional experience with the bronchoscopic obliteration of recurrent and primary TEFs. MethodsRetrospective chart review of all pediatric patients having undergone endoscopic TEF repair at two pediatric academic centers in Montreal, Canada and Lille, France between January 1, 2008 to December 31, 2020. Results28 patients with TEFs (20 recurrent, 8 primary) underwent a total of 48 endoscopic procedures. TEF repair was performed under endoscopic guidance using various combinations of techniques, including fistula de-epithelialization (endoscopic brush, thulium laser, trichloroacetic acid-soaked pledgets or electrocautery), tissue adhesives, submucosal augmentation, esophageal clip and stenting. Successful closure was achieved in 16 patients (57 %), while 12 (43 %) required eventual open or thoracoscopic repair. The mean number of endoscopic procedures was 1.7. There were no major treatment-related complications such as pneumothorax, mediastinitis or death (mean follow-up 50.8 months). ConclusionsEndoscopic repair of recurrent or primary TEFs is a valuable component of our therapeutic armamentarium and may contribute to decreased surgical morbidity in this complex patient population. Families should be counselled that endoscopic results may be more modest than with open or thoracoscopic approaches, and multiple procedures may be required.

Arthroscopic-assisted exploration of the axillary nerve through a posterior open approach: A novel technique

Previous studies have described a segment of the axillary nerve (AN) that cannot be surgically explored through standard open surgical approaches (blind zone). This study aimed to evaluate the feasibility of combining the standard posterior approach to the AN by using an arthroscope to visualize all segments of the AN. Four fresh-frozen shoulders in two adult human torsos were included in the study. A standard posterior approach was performed on each shoulder, and a dry arthroscopy was performed through the surgical opening in an attempt to visualize all the segments of the AN. A surgical clip was placed at the most proximal and anterior segment of the AN that could be visualized with the arthroscope. A standard open deltopectoral approach was then performed to determine the exact location of the surgical clip and its relation to the origin of the AN. All segments of the AN (including the blind zone) were visualized from the quadrilateral space to their origin from the posterior cord in all four specimens. The surgical clip was found at an average of 1cm (range from 0.5 to 1.5cm) from the origin of the AN from the posterior cord. This cadaveric study shows that it is feasible to visualize all segments of the AN (including the blind zone) using this novel approach that combines the use of the standard posterior approach to the AN with dry arthroscopic exploration. Clinical studies are necessary to evaluate the utility of this novel approach.

Erratum: Medical and Surgical Advances in Intracerebral Hemorrhage and Intraventricular Hemorrhage.

In recent decades, the medical and surgical treatment of intracerebral hemorrhage (ICH) have become the focus of a number of scientific investigations. This effort has been led by an international group of neurologists and neurosurgeons with the goal of studying functional recovery and developing new medical and surgical treatments to facilitate improved clinical outcomes. Currently, two of the most pressing ICH investigational goals are (1) early blood pressure control, and (2) safe hematoma volume reduction. Answering these questions would support decision-making, level-of-care choices, and the global research strategy of developing biologically informed treatments. The authors review the contemporary medical management and the conventional and minimally invasive surgical approaches to spontaneous ICH, as well as discuss the scope of the problem, recent clinical trials, management issues, and relevant questions for future research. They propose the hypothesis that strategies using minimally invasive techniques, including clot aspiration with stereotactic guidance, may give better results with improved clinical outcomes compared with standard open surgical approaches. They also discuss the level of evidence for the variously known approaches.

Medical and Surgical Advances in Intracerebral Hemorrhage and Intraventricular Hemorrhage.

In recent decades, the medical and surgical treatment of intracerebral hemorrhage (ICH) have become the focus of a number of scientific investigations. This effort has been led by an international group of neurologists and neurosurgeons with the goal of studying functional recovery and developing new medical and surgical treatments to facilitate improved clinical outcomes. Currently, two of the most pressing ICH investigational goals are (1) early blood pressure control, and (2) safe hematoma volume reduction. Answering these questions would support decision-making, level-of-care choices, and the global research strategy of developing biologically informed treatments. The authors review the contemporary medical management and the conventional and minimally invasive surgical approaches to spontaneous ICH, as well as discuss the scope of the problem, recent clinical trials, management issues, and relevant questions for future research. They propose the hypothesis that strategies using minimally invasive techniques, including clot aspiration with stereotactic guidance, may give better results with improved clinical outcomes compared with standard open surgical approaches. They also discuss the level of evidence for the variously known approaches.

Surgical Strategies for Spontaneous Intracerebral Hemorrhage.

In recent decades, the surgical treatment of intracerebral hemorrhage (ICH) has become a focus of scientific inquest. This effort has been led by an international group of neurologists and neurosurgeons with the goal of studying functional recovery and developing new surgical techniques to facilitate improved clinical outcomes. Currently, the two most pressing ICH investigational goals are (1) early blood pressure control, and (2) safe hematoma volume reduction. Achieving these goals would support decision-making, level-of-care choices, and the global research strategy of developing biologically informed treatments. Herein the authors review conventional and minimally invasive surgical approaches to spontaneous ICH, articulating the scope of the problem, recent clinical trials, management issues, and relevant questions for future research. The authors propose that strategies using minimally invasive techniques including clot aspiration with stereotactic guidance may give better results with improved clinical outcomes compared with standard open surgical approaches.

Robot-Assisted Inguinal Lymphadenectomy for Urethral Carcinoma

Introduction: A 69-year-old female with a history of distal invasive urethral squamous cell carcinoma treated with distal urethrectomy was found to have an enlarged left inguinal node during surveillance 17 months after the operation. Positron emission tomography (PET)/computed tomography showed a 1.5 cm lymph node (LN), which displayed increased activity on PET. Biopsy of this lesion revealed a poorly differentiated squamous cell carcinoma. This video describes our technique for a robot-assisted inguinal lymphadenectomy. Methods: The patient was placed on the split leg table. A 2 cm incision was made down to fascia lata in the midthigh 18 cm inferior to the inguinal ligament. Blunt dissection was used to create this plane above fascia lata. A Hassan-type 10 mm trocar was placed through the 2 cm incision and insufflation to 15 mm Hg was initiated. Two robotic ports were placed under direct vision 8 cm on both sides of the camera port. A 10 mm assistant port was also placed between the camera and the lateral robotic ports. The DaVinci Si robot was docked, and fenestrated bipolar grasper and monopolar scissors were used throughout the case as dissecting instruments. The saphenous vein was identified and followed to its insertion into the femoral vein. The split and roll technique was used to remove lymphatic tissue around vessels. Weck and metallic clips were used for vascular and lymphatic control. Weck clips were used as there was adequate overlying adipose tissue and no concern for palpating these from the skin level. The boundary of the LN dissection was the inguinal ligament superiorly, adductor longus muscle medially, and sartorius muscle laterally. LNs from above and below fascia lata were sent separately as superficial and deep LN packets, respectively. Adequate hemostasis was ensured and a 15F Blake drain was placed through a robotic port site. Results: The robotic console time was 3.5 hours with minimal blood loss. There were no intraoperative complications. Postoperatively, she developed minimal lower extremity lymphedema managed with compression stockings. She was discharged home on postoperative day 2 (POD 2). The drain was removed in the clinic on POD 13. Final pathology revealed 1 out 10 LNs positive for metastatic squamous cell carcinoma. At 9 months of follow-up, she had no evidence of recurrent disease and had trace edema of the lower extremity. Conclusion: Robot-assisted inguinal lymphadenectomy can be performed safely for the treatment of distal urethral carcinoma, while utilizing the same technical principles as the standard open surgical approach. The minimally invasive approach may lead to fewer postoperative complications, particularly related to wound healing, while maintaining good oncologic outcomes. Thomas P. Frye and Alex Gorbonos have nothing to disclose. Runtime of video: 6 mins 31 secs

VID-07.08 Better Nerve Handling with Open Prostatectomy? Exploring Retrograde Robotic Radical Prostatectomy

Minimally invasive approaches for treatment of localized prostate cancer are replacing the gold standard open surgical approach, duplicating its results with lower morbidity. Concerns have been raised regarding possible traction injury for an anterograde robotic or laparoscopic approach. To address this concern, we describe our experience with retrograde robotic radical prostatectomy.

VID-05.02: Duplicating Open Principles: Retrograde Robotic Radical Prostatectomy

Minimally invasive approaches for treatment of localized prostate cancer are replacing the gold standard open surgical approach, duplicating its results with lower morbidity. Concerns have been raised regarding possible traction injury for an anterograde robotic or laparoscopic approach. To address this concern, we describe our initial experience with retrograde robotic radical prostatectomy.

Robotic Simple Prostatectomy

Minimally invasive approaches for large, symptomatic benign prostatic hyperplasia are replacing the gold standard open surgical approach, duplicating its results with lower morbidity. We describe our initial experience with robotic simple prostatectomy. Since January 2007, robotic simple prostatectomy was performed via a transperitoneal approach in 7 patients with symptomatic significant prostatomegaly on transrectal ultrasound (mean 77.66 gm). Demographic, perioperative and outcome data were recorded and all procedures were performed by the same surgeon. Average patient age was 63.2 years (range 56 to 72) and estimated blood loss was 298 ml (range 60 to 800). Average operative time was 205 minutes (range 120 to 300). Average hospital stay was 1.4 days (range 1 to 2), average Foley catheter duration was 7 days (range 6 to 9) and drains were removed after an average of 3.75 days (range 3 to 4). Mean specimen weight on pathological examination was 50.48 gm (range 40 to 64.5). Transfusion was necessary in 1 patient. No complications were documented. Considerable improvement from baseline was noted in International Prostate Symptom Score (preoperative vs postoperative 22 vs 7.25) and maximum urine flow (preoperative vs postoperative 17.75 vs 55.5 ml per minute). Four patients were in acute urinary retention preoperatively. Robotic simple prostatectomy is a feasible, reproducible procedure. Further publications are expected with larger series and larger prostatic adenomas.

Effectiveness of laparoscopic varicocelectomy

Laparoscopic varicocelectomy is a new technique which has been described in a limited number of clinical reports. We reviewed the results of 46 patients undergoing laparoscopic repair of 75 varicoceles over a two-year period to assess the effectiveness of this operative technique. The internal spermatic artery was preserved in 80 percent of the varicoceles and two arteries were present in 5 percent. Our ability to preserve the internal spermatic artery improved significantly with the use of the intraoperative Doppler probe after the first six months of performing this operation (p < 0.01). Nineteen patients had a minimum follow-up of twelve months with seminal improvement in 68 percent and a pregnancy rate of 26 percent. Complications occurred in 2 patients (4%), inferior epigastric vessel bleeding in one, and genitofemoral nerve injury in the other. There was one persistent varicocele (1%). Our results with laparoscopic varicocelectomy are comparable with those reported with standard open surgical approaches.