Dissection Time Research Articles

Taming the exoscope: a one-year prospective laboratory training study.

Digital 3D exoscopes have been recently introduced as an alternative to a surgical microscope in microneurosurgery. We designed a laboratory training program to facilitate and measure the transition from microscope to exoscope. Our aim was to observe the effect of a one-year active training on microsurgical skills with the exoscope by repeating a standardized test task at several time points during the training program. Two board-certified neurosurgeons with no previous exoscope experience performed the same test tasks in February, July, and November during a 12-month period. In between the test tasks, both participants worked with the exoscope in the laboratory and assisted during clinical surgeries on daily basis. Each of the test segments consisted of repeating the same task 10 times during one week. Altogether, 60 test tasks were performed, 30 each. The test task consisted of dissecting and harvesting the ulnar and radial arteries of the second segment of a chicken wing using an exoscope (Aesculap AEOS). Each dissection was recorded on video and analyzed by two independent evaluators. We measured the time required to complete the task as well as several metrics for evaluating the manual skills of the dissection and handling of the exoscope system. There was a clear reduction in dissection time between the first and the last session, mean 34 min (SD 5.96) vs. 26 min (SD 8.69), respectively. At the end of the training, both neurosurgeons used the exoscope more efficiently utilizing more available options of the device. There was correlation between the dissection time and several of the factors we used for evaluating the work flow: staying in focus, zoom control, reduction of unnecessary movements or repetitive manual motions, manipulation technique of the vessel under dissection, handling of the instruments, and using them for multiple dissection purposes (stretching, cutting, and splitting). Continuous, dedicated long-term training program is effective for microsurgical skill development when switching from a microscope to an exoscope. With practice, the micromotor movements become more efficient and the use of microinstruments more versatile.

Preserving or peeling the inferior mesenteric arterial sheath during laparoscopic rectal cancer surgery: a prospective study of surgical outcomes

BackgroundWe mainly evaluated whether preserving the inferior mesenteric artery (IMA) sheath to dissecting IMA root lymph nodes (also called No.253 lymph nodes) would benefit patients in terms of comparable lymph-node yield removed during operation and postoperative complications in laparoscopic radical resection of rectal cancer.MethodsThis is a prospective study included 141 rectal cancer patients who received laparoscopic radical resection during September 2018 to December 2020. All patients were randomly assigned to the preserved group (n = 71) and the peeled group (n = 70). The baseline characteristics, pathological features, intraoperative and postoperative data outcomes and complications were analyzed by independent samples t test, chi-square test or Fisher’s exact test between the 2 groups.ResultsThe baseline characteristic and pathological features had no statistical difference between the 2 groups. The preserved group had a shorter operative time (P = 0.002), a shorter lymph node dissection time (P < 0.001), less intraoperative bleeding (P = 0.004), an earlier time to first flatus (P = 0.013), an earlier time to fluid intake (P = 0.033) and a shorter length of hospitalization (P = 0.012) than the peeled group. The differences between the 2 groups were not statistically significant (P > 0.05) in regard to the total number of lymph nodes cleared, positive lymph nodes, bleeding, anastomotic leakage, pneumonia, wound infection, abscess, ileus, urinary retention, urinary tract infection and chyle leakage.ConclusionPreserving of the IMA sheath in laparoscopic radical surgery for rectal cancer will reduce the total operation time and the length of hospitalization. This surgical method could lead to lower complication rate and faster recovery.Trial registrationThe study was approved by the Ethics Committee of The First Affiliated Hospital of Wannan Medical College and registered by the China Clinical Trials Registry (ChiCTR2200060830, Date of Registration:2022-06-12 -retrospective registration) http://www.chictr.org.cn/index.aspx.

Supermicrovascular anastomosis training using chicken wings and colored water

Plastic surgeons require experience in supermicroscopic vascular anastomosis. Herein, we report a simple, rapid, and cost-effective training method using chicken wings and colored water. The avian ventral metacarpal artery was selected for dissection and anastomosis to mimic supermicrosurgery. Over 14 weeks (one anastomosis per day), the ulnar artery in 100 chicken wings was exposed by dissection, cut proximally, and injected with blue food dye-colored water by an inexperienced surgeon. After ligating the artery branches, it was cut and subjected to end-to-end anastomosis. Next, colored water was injected into the ulnar artery to check for suture sufficiency. The vessel was re-dissected to inspect the lumen and sutures qualitatively. Of the 100 wings, the first and last 20 wings' ventral metacarpal artery dissection, anastomosis times, and leakage frequency were compared. Avian ventral metacarpal artery diameter was recorded, and the cumulative anastomosis time where individual anastomosis times started decreasing was determined. Leakage rates before and after this point were compared. The avian ventral metacarpal artery diameter was 0.7-0.8mm. The last 20 wings had significantly shorter median dissection times (12:27 vs. 17:45min), anastomosis times (9:02 vs. 12:29min), and leakage rates (15% vs. 70%); more even stitching and parallel ligature points; and less vessel layer inversion than the first 20 wings. After a cumulative anastomosis time of 10h 26min, individual times sharply decreased, and the leakage rate decreased significantly (58.3% vs. 23.8%). The proposed method significantly improved supermicrosurgical anastomosis. Thus, we believe that this method will help surgeons improve their supermicrosurgical skills.

Biological reproduction of mackerel scad, Decapterus macarellus (Cuvier, 1833) caught by purse-seine net in Majene Waters, West Sulawesi, Indonesia

Abstract. Tenriware, Nur M, Nasyrah AFA. 2023. Biological reproduction of mackerel scad, Decapterus macarellus (Cuvier, 1833) caught by purse-seine net in Majene Waters, West Sulawesi, Indonesia. Biodiversitas 24: 3012-3018. Mackerel scad, Decapterus macarellus Cuvier, 1833 is an economically important fish resource as an income source for fishermen in Majene waters, West Sulawesi. This study aims to determine some aspects of reproductive biology, including sex ratio, gonadal somatic index (GSI), gonad maturity stage (GMS), and the size at the first maturity. The sampling was carried out at the Fish Landing Sites in the Coastal Waters of Pangali-Ali Village, East Banggae District, Majene District, West Sulawesi Province, Indonesia. Each specimen was measured to the total length with digital calipers and body weight using a digital weighing scale. Initial sex assessment was noticed at the time of dissection, and gonadal maturity was also assessed. A total of 275 specimens consisting of 177 males and 98 females were obtained from April to July 2017. The result indicates that the sex ratio between males and females deviated from an expected 1:1: and was not balanced. This species spawns in April at the size of 173.4 mm and 168.6-178.3 mm for males and 189.1 mm or the range of 182.6-195.8 mm for females.

Cystic Duct Dissection Time as a Predictor of Difficult Laparoscopic Cholecystectomy

Background: The Tokyo 2018 guidelines call for the study of quantitative predictors of surgical difficulty in laparoscopic cholecystectomy for complete cholecystectomy in a safe context. Objective: To evaluate the cystic duct (CD) dissection time as a predictor of surgical difficulty. Materials and methods: This prospective study included 193 patients who underwent laparoscopic cholecystectomy in 2022 and were grouped according to the indication for cholecystectomy: Urgent, Delayed, and Elective. Multiple linear regression and multinomial logistic regression analyses were used to identify the preoperative and operative predictive variables of surgical difficulty. The predictive value of the time spent dissecting the CD was estimated using a ROC curve. Results: The CD dissection time of 13 min had 100% sensitivity and 99% specificity, PPV 100%, NPV 1%, OR 3.3 to predict the use of bailout techniques. Conclusions: The time required to dissect the cystic duct, with or without success, is a practical predictor of the subsequent use of bailout procedures and, consequently, predicts the "Risk/Difficult Cholecystectomy". Keywords: Difficult laparoscopic cholecystectomy, predictors of difficult cholecystectomy, bailout procedures, cystic dissection time, risk of cholecystectomy.

First case of robot-assisted radical cystectomy and intracorporeal neobladder reconstruction with the Hugo RAS system: step-by-step surgical setup and technique.

Robotic assisted radical cystectomy (RARC) is a standard option for the treatment of bladder cancer. Currently, novel platforms are entering the market and the Hugo RAS (Medtronic, Minneapolis, MN, USA) is a new system consisting of an open console with 3D-HD screen and a multi-modular fashion. Even if several series are already available for radical prostatectomy, to now a full description of RARC performed with Hugo RAS is still lacking. We report the first case of RARC with intracorporeal neobladder performed with the Hugo RAS-and another case of RARC with ureterostomy. Both patients were affected by MIBC. Case 1 was a 61-year-old patient without comorbidities (CCI 4), in which a Bordeaux ileal neobladder was scheduled after previous NAC. The second was the case of a 70-year-old one with CCI 7 and BMI 35; in this case, a ureterostomy was planned. Details of the robotic system: one 11mm endoscope port was placed on the midline 2cm above the umbilicus. Another two 8mm robotic ports were symmetrically placed under vision on a transversal line-located 1cm below the umbilicus. A third robotic port was positioned on the left side in a W configuration. All ports were located at least 9cm between each other. Finally, two assistant ports were positioned in the right abdominal site. All arm-carts were parked 45-60cm from the operative bed, before the docking process begins. Three arm-carts were parked on the left side, the assistant and the scrub nurse worked on the right side, while the energy tower stayed at the foot of the bed, according to the previous description of Hugo RAS robotic radical prostatectomy. The endoscope arm-cart is docked first, then the adjacent left carts are docked; finally, the surgeon's right-hand cart is docked from the right side of the bed. The docking angles and tilt we applied were: endoscope: 175°; minus 45°; surgeon left hand 140°; minus 30°; surgeon right hand 225°; minus 30°; fourth arm 125°; plus 15°. The instruments we used were those fitting our conventional four-instrument setup for RARC: monopolar shears, Maryland forceps, needle driver and Cadiere as the fourth arm. The procedures were completed without technical errors or technological failures-requiring a change in surgical strategy. Docking time was approximately 35min; console time up to urethral dissection was 150 and 140min in Case 1 and 2. The time for pelvic nodal dissection was approximately 37min for both. The multi-modularity fashion of the Hugo RAS allowed an easy management of the bowel in Case 1; the absence of robotic staplers required the use of the laparoscopic ones, managed by an adjunctive assistant with room within the cart. In conclusion, RARC with the Hugo RAS is a feasible procedure able to reproduce all surgical steps without critical errors or complications requiring a change in surgical planning. Urinary diversion with intracorporeal reconstruction is feasible as well, with adequate preliminary outcomes.

“Does the Exploration of the Temporomandibular Joint Using a Deep Subfascial Technique Result in a Superior Operative Outcome?”

The literature is replete with various approaches for the temporomandibular joint (TMJ), each with its own distinct advantages and disadvantages. None of these approaches, however, have been associated with superior operative outcomes. The purpose of this study was to measure the efficacy of three operative approaches to TMJ, namely superficial, subfascial, and deep subfascial approaches. The aim was to contrast selected intraoperative and postoperative outcomes among these surgical approaches. This was a prospective randomized clinical trial of subjects presenting to outpatient department. The primary predictor variables were three dissection planes of TMJ: Group-I (superficial), Group-II (subfascial), and Group-III (deep subfascial). The primary outcome variables were quality of surgical field employing fromme scale, dissection time in minutes, amount of blood loss in milliliters, and facial nerve function (FNF) using House-Brackmann scale. The secondary outcome variables were postoperative pain using visual-analog scale and swelling in millimeters measured on 1st, 3rd, and 7th postoperative days and quality of life using facial clinimetric evaluation questionnaire at 6-month follow-up. Age, gender, side, diagnosis, and type of surgery were the covariates. The data were analyzed using descriptive, comparative, and regression analysis. A P value of less than .05 was considered statistically significant. The study included thirty subjects (8 males and 22 females) with various TMJ disorders ranging in age from 8 years to 65years (mean 27.83±10.52). On evaluation of intraoperative parameters, subfascial approach had statistically significant superior quality of surgical field (Group-I: 1.90±0.57; Group-II: 1.10±0.32; Group-III: 1.40±0.52; P value=.006), statistically significant shortest dissection time (Group-I: 18.30±3.74min; Group-II: 13.240±1.96min; Group-III: 16.20±1.99min; with P value=.03), and statistically significant lower amount of blood loss compared with other groups(Group-I: 92.40±4.74ml: Group-II: 82.30±3.77ml; Group-III: 84.60±3.06ml; Pvalue<.001). On assessment of postoperative parameters, only FNF of temporal branch showed statistically significant difference from 24 hours till 3 months with better outcome in deep subfascial approach. Mean scores of FNF at 24 hours and 1-week (Group-I: 4.20±2.39; Group-II: 2.40±2.27; Group-III: 1.50±1.58 P=.02) and 1-month and 3-month (Group-I: 2.70±1.82; Group-II: 1.20±0.63; Group-III: 1.00±0.00 P=.04). The subfascial approach significantly improved intraoperative outcomes and deep subfascial approach was comparatively safe with fewer incidence of facial nerve injury.

Single-Port Robotic Intersphincteric Resection for the Treatment of Rectal Cancer.

The da Vinci Single-port (SP) system is designed to facilitate single-incision robotic surgery in a narrow space. We developed a new procedure of intersphincteric resection (ISR) using the SP platform and evaluated the technical safety and feasibility of this procedure for the treatment of very low rectal cancer. Eleven rectal cancer patients who underwent SP robotic ISR between August 2020 and July 2021 were included. Patients' clinical characteristics, operative and pathologic findings of the patients were retrospectively analyzed. The median tumor height was 3cm (range, 2-4cm). A single docking was performed, and the median docking time was 3min 10sec (range, 2min 50sec-3min 30sec). The median total operation time was 210min (range, 150-280min), and the median time of pelvic dissection was 57min (range, 45-68min). All patients presented with negative distal resection margins [median 1cm (range, 0.5-2.0cm)], and only one patient had less than 1mm of circumferential resection margin (0.9mm). Our initial experience suggests that SP robotic ISR is safe and feasible.

Automated analysis of intraoperative phase in laparoscopic cholecystectomy: A comparison of one attending surgeon and their residents

This study compares the intraoperative phase times in laparoscopic cholecystectomy performed by an attending surgeon and supervised residents over 10-years to assess operative times as a marker of performance and any impact of case severity on times. Laparoscopic cholecystectomy videos were uploaded to Touch Surgery™ Enterprise, a combined software and hardware solution for securely recording, storing, and analysing surgical videos, which provide analytics of intraoperative phase times. Case severity and visualisation of the critical view of safety (CVS) were manually assessed using modified 10-point intraoperative gallbladder scoring system (mG10) and CVS scores, respectively. Attending and residents' times were compared unmatched and matched by mG10. Secondary analysis of anonymized laparoscopic cholecystectomy video, recorded as standard of care. Adult patients who underwent elective laparoscopic cholecystectomy a single UK hospital. Cases were performed by one attending and their residents. 159 (attending=96, resident=63) laparoscopic cholecystectomy videos and intraoperative phase times were reviewed on Touch Surgery™ Enterprise and analyzed. Attending cases were more challenging (p=0.037). Residents achieved higher CVS scores (p=0.034) and showed longer dissection of hepatocystic triangle (HCT) times (p=0.012) in more challenging cases. Residents' total operative time (p=0.001) and dissection of HCT (p=0.002) times exceeded the attending's in low-severity matched cases (mG10=1). Residents' total operative times (p<0.001), port insertion/gallbladder exposure (p=0.032), and dissection of HCT (p<0.001) exceeded the attending's in matched cases (mG10=2). Residents' total operative (p<0.001), dissection of HCT (p<0.001), and gallbladder dissection (p=0.010) times exceeded the attendings in unmatched cases. Residents' total operative and dissection of HCT times significantly exceeded the attending's unmatched cases and low-severity matched cases which could suggest training need, however, also reflects an expected assessment of competence, and validates time as a marker of performance.

Outcome of Stanford type B dissection in patients with Marfan syndrome.

The aim of this study was to determine the outcome of Stanford type B aortic dissection in patients with Marfan syndrome (MFS) and to evaluate aortic diameters at time of dissection as well as the impact of previous aortic root replacement. Analysis of all patients with MFS fulfilling Ghent criteria seen at this institution since 1995 until 2022. Thirty-six (19%) out of 188 patients with MFS suffered from Stanford type B aortic dissection during the study period. The Mean aortic diameter at the time of dissection was 39.0 mm [95% confidence interval (CI): 35.6-42.3]. The mean pre-dissection diameter (available in 25% of patients) was 32.1 mm (95% CI: 28.0-36.3) and the mean expansion was 19% (95% CI: 11.9-26.2). There was no correlation between age and diameter at the time of dissection (<20, 21-30, 31-40, 41-50, 51-60, <61 years; P = 0.78). Freedom from intervention after dissection was 53%, 44% and 33% at 1, 5 and 10 years. Aortic growth rate in those patients that had to undergo intervention within the 1st year after dissection was 10.2 mm/year (95% CI: 4.4-15.9) compared to 5.8 mm/year (95% CI: 3.3-8.3, P = 0.109) in those thereafter. The mean time between dissection and intervention was 1.8 years (95% CI: 0.6-3.0). While type B dissection seems more frequent after previous elective aortic repair (58% vs 42%), there was no difference between valve-sparing root replacement (VSRR) compared to Bentall procedures [Hazard ratio (HR) for VSRR 0.78, 95% CI: 0.31-2.0, P-value = 0.61]. The mean age of the entire population at the end of follow-up was 42 years (95% CI: 39.2-44.7). The mean follow-up time was 9 years (95% CI: 7.8-10.4). Stanford type B dissection in patients with MFS occurs far below accepted thresholds for intervention. Risk for type B dissection is present throughout lifetime and two-thirds of patients need an intervention after dissection. There is no difference in freedom from type B dissection between a Bentall procedure and a VSRR.

First clinical experience with esophageal ESD using a novel adjustable traction device.

Background and study aims In esophageal endoscopic submucosal dissection (ESD), the effectiveness of traction including clip-thread method has been reported, but it is difficult to adjust the direction of traction. Therefore, we developed a dedicated over-tube type traction device (ENDOTORNADO) that has a working channel and allows traction from any directions by rotating itself. We investigated the clinical feasibility and potential usefulness of this new device in esophageal ESD. Patients and methods This was a single-center, retrospective study. Six cases of esophageal ESD with ENDOTORNADO from January to March 2022 (tESD group) were compared with 23 cases of conventional esophageal ESD performed by the same operator from January 2019 to December 2021 (cESD group) in terms of clinical treatment outcomes. Results In all cases, en bloc resection was achieved without intraoperative perforation. The total procedure speed was significantly increased in tESD group (23 vs. 30 mm 2 /min, P = 0.046). In particular, the submucosal dissection time was significantly reduced to about one-quarter in tESD group (11 vs. 42 min, P = 0.004). Conclusions ENDOTORNADO creates the adjustable traction from any directions and may have the clinical feasibility. It would be an option for human esophageal ESD.

Feasibility of a single-port thoracoscopy-assisted five-step laparoscopic procedure via transabdominal diaphragmatic approach for No.111 lymphadenectomy in patients with Siewert type II esophageal gastric junction adenocarcinoma

Objective: We aimed to explore the feasibility of a single-port thoracoscopy- assisted five-step laparoscopic procedure via transabdominal diaphragmatic(TD) approach(abbreviated as five-step maneuver) for No.111 lymphadenectomy in patients with Siewert type II esophageal gastric junction adenocarcinoma (AEG). Methods: This was a descriptive case series study. The inclusion criteria were as follows: (1) age 18-80 years; (2) diagnosis of Siewert type II AEG; (3) clinical tumor stage cT2-4aNanyM0; (4) meeting indications of the transthoracic single-port assisted laparoscopic five-step procedure incorporating lower mediastinal lymph node dissection via a TD approach; (5) Eastern Cooperative Oncology Group performance status (ECOG PS) 0-1; and (6) American Society of Anesthesiologists classification I, II, or III. The exclusion criteria included previous esophageal or gastric surgery, other cancers within the previous 5 years, pregnancy or lactation, and serious medical conditions. We retrospectively collected and analyzed the clinical data of 17 patients (age [mean ± SD], [63.6±11.9] years; and 12 men) who met the inclusion criteria in the Guangdong Provincial Hospital of Chinese Medicine from January 2022 to September 2022. No.111 lymphadenectomy was performed using five-step maneuver as follows: superior to the diaphragm, starting caudad to the pericardium, along the direction of the cardio-phrenic angle and ending at the upper part of the cardio-phrenic angle, right to the right pleura and left to the fibrous pericardium , completely exposing the cardio-phrenic angle. The primary outcome includes the numbers of harvested and of positive No.111 lymph nodes. Results: Seventeen patients (3 proximal gastrectomy and 14 total gastrectomy) had undergone the five-step maneuver including lower mediastinal lymphadenectomy without conversion to laparotomy or thoracotomy and all had achieved R0 resection with no perioperative deaths. The total operative time was (268.2±32.9) minutes, and the lower mediastinal lymph node dissection time was (34.0±6.0) minutes. The median estimated blood loss was 50 (20-350) ml. A median of 7 (2-17) mediastinal lymph nodes and 2(0-6) No. 111 lymph nodes were harvested. No. 111 lymph node metastasis was identified in 1 patient. The time to first flatus occurred 3 (2-4) days postoperatively and thoracic drainage was used for 7 (4-15) days. The median postoperative hospital stay was 9 (6-16) days. One patient had a chylous fistula that resolved with conservative treatment. No serious complications occurred in any patient. Conclusion: The single-port thoracoscopy-assisted five-step laparoscopic procedure via a TD approach can facilitate No. 111 lymphadenectomy with few complications.

Aortic Size at the Time of Type A and Type B Dissections

BackgroundAortic diameter at time of dissection remains an indispensable risk-determining characteristic for prophylactic repair of thoracic aortic aneurysms. Histograms of aortic size at the time of dissection have the potential to shed more light on this relationship. MethodsSize of the thoracic aorta at the time of dissection was determined from imaging of 407 naturally occurring, acute, flap-type ascending or descending aortic dissections treated at 1 institution (1990-2022). Histograms were constructed to depict aortic size at the time of dissection. Data were analyzed by logistic regression. ResultsThere were 170 (69.11%) of 246 type A dissections (median, 5.07 cm; interquartile range, 4.60-5.67 cm) and 130 (80.75%) of 161 type B dissections (median, 4.2 cm; interquartile range, 3.60-4.87 cm) that occurred at diameters <5.5 cm. By unadjusted regression, factors associated with significantly increased odds of type A dissection at diameters <5.5 cm were female sex (odds ratio [OR], 2.06; P = .023), hypertension (OR, 1.82; P = .036), and smoking (OR, 1.92; P = .029). Patients with bicuspid aortic valve had significantly decreased odds of type A dissection at diameters <5.5 cm (OR, 0.3; P = .047). The recent "left shift" to 5.0 cm in the criterion for ascending aortic intervention could prevent an additional 29.3% of type A dissections. ConclusionsAortic diameter at the time of type A dissection is consistent with the new guidelines that recommend surgical intervention at 5.0 cm. Type B dissection occurs at small sizes and cannot be prevented with a size criterion.

Early Hepatoduodenal Ligament Occlusion Versus Classic Technique During Recipient Hepatectomy for Living Donor Liver Transplant.

Intraoperative bleeding is commonly encountered during living donor liver transplant procedures and is associated with greater need for blood transfusion, which increases morbidity. Herein, we hypothesized that early and continuous occlusion ofthe hepatic inflow would have a beneficial effect on the living donor liver transplant procedure regarding intraoperative blood loss and operative time. This comparative study prospectively included 23 consecutive patients (the experimental group) who had early inflow occlusion during recipient hepatectomy for living donor liver transplant and compared the outcomes versus 29 consecutive patients who had previously received (immediately before the start of our study) living donor liver transplant by the classic technique. Blood loss and time for hepatic mobilization and dissection were compared between the 2 groups. Patient criteria and indication for living donor liver transplant showed no significant difference between the 2 groups. There was a significant decrease in blood loss during hepatectomy in the study group versus the control group (2912 vs 3826 mL, respectively; P = .017). Packed red blood cell transfusion was less in the study group versus the control group (1550 vs 2350 cells, respectively; P < .001). The skin-to-hepatectomy time was not different between the 2 groups. Early hepatic inflow occlusion is a simple and effective technique to reduce intraoperative blood loss and reduce the need for blood transfusion products during living donor liver transplant.

PD31-12 THE CANADIAN ANATOMIC KIDNEY SCORE (CAKS): ASSESSMENT OF REPRODUCIBILITY AMONG SURGEONS AND TRAINEES ACROSS CANADA

You have accessJournal of UrologyCME1 Apr 2023PD31-12 THE CANADIAN ANATOMIC KIDNEY SCORE (CAKS): ASSESSMENT OF REPRODUCIBILITY AMONG SURGEONS AND TRAINEES ACROSS CANADA William Luke, Juliano Chrystian Mello Offerni, Danny Matti, Haider Abed, Yanbo Guo, Pavel Roshanov, Carol Wang, Alp Sener, and Patrick Luke William LukeWilliam Luke More articles by this author , Juliano Chrystian Mello OfferniJuliano Chrystian Mello Offerni More articles by this author , Danny MattiDanny Matti More articles by this author , Haider AbedHaider Abed More articles by this author , Yanbo GuoYanbo Guo More articles by this author , Pavel RoshanovPavel Roshanov More articles by this author , Carol WangCarol Wang More articles by this author , Alp SenerAlp Sener More articles by this author , and Patrick LukePatrick Luke More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003324.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: As the Canadian population has aged the gap between renal graft availability and recipient need has continued to widen. Intra-operative organ assessment is known to be associated with organ discard. The Canadian Anatomic Kidney Score (CAKS) is a numeric, multifactorial system, we have shown to be correlated with delayed graft function as well as KDPI. We hypothesize that this system is highly reproducible across clinicians with variable levels of experience, enabling implementation across institutions. METHODS: An anonymous survey was distributed to surgical attendings, fellows and residents at teaching centres across Canada. These surveys contained images of 6 separate kidneys (2 images each) at the time of intra-operative back table dissection. Participant demographics were collected. Images were given scores for 3 factors: vascular (calcifications/location), anatomic (cysts/scars), and sticky fat (proportion of adherent fat); with scores between 0 points (ideal) and 2 points (unfavourable). Respondents were stratified by level of training and specialty. Participant scores were compared in subgroups of residents, fellows and staff using a one way ANOVA. Pair-wise exclusion a Cronbach’s alpha was calculated overall and for each scoring factor RESULTS: Of the 46 respondents, 31 had undergone or were undergoing Urology residency, 12 General Surgery, and 2 Vascular Surgery (Table 1). 61% of participants were attending physicians, 13% fellows and 26% residents. Of the 18 questions during the survey there was no significant difference between fellow, resident and attending scoring except for 2/6 sticky fat image sets (Table 2). Cronbach α=0.98, for overall CAKS. CONCLUSIONS: Overall the CAKS represents a reproducible scoring system across multiple levels of training, in centres across Canada. These scores were reliably generated, despite only 2 images shown of each kidney. Increasing training level correlated with consistency in rating suggesting that this score can capture some degree of surgical judgement. CAKS may offer a concrete system to incorporate clinical judgement into prognostication and graft selection in kidneys with an equivocal KDPI score. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e905 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information William Luke More articles by this author Juliano Chrystian Mello Offerni More articles by this author Danny Matti More articles by this author Haider Abed More articles by this author Yanbo Guo More articles by this author Pavel Roshanov More articles by this author Carol Wang More articles by this author Alp Sener More articles by this author Patrick Luke More articles by this author Expand All Advertisement PDF downloadLoading ...

Indocyanine green direct injection into gallbladder during laparoscopic cholecystectomy: a safety method to outline biliary anatomy

Background One of the most frequently done operations in digestive surgery is the laparoscopic cholecystectomy (LC). Despite several safety precautions and guidelines, iatrogenic bile duct damage (BDI) during LC still occurs at a very high incidence. Fluorescence of biliary system may minimise surgical difficulties that might emerge owing to unintended harm to the common bile duct. Methods We outline a technique for directly injecting Indocyanine Green (ICG) into the gallbladder to clarify the architecture of the cystic duct and common bile duct. Fifty patients who underwent elective laparoscopic cholecystectomy participated in the study, which was a randomised controlled clinical trial. Patients who had intraoperative direct injection of ICG into the gallbladder were chosen at random using closed envelope technique, then using near-infrared fluorescence (NIF) imaging during LC) and controls (who underwent standard LC technique) Twenty five patients in each limb. Patients were studied pre-operative, intraoperative &amp; postoperative. 50 patients in all, 25 of whom received LC with intracholecystic ICG injection, and 25 of whom underwent standard LC without the use of ICG, were included in our study. Results ICG dye was successful to delineate extrahepatic biliary anatomy well in 20 cases out of 25, while without ICG, 9 cases out of 25 were without clear delineation of common bile duct intraoperative even if cystic duct was clear enough to avoid complications in both groups . Operative Time average in cases with ICG-assisted LC was 78±15.0 min which was less than the average of time consumed in LC without ICG to dissect cystic duct and visualize critical view of safety, 101±11.87 min Conclusion Direct gallbladder ICG infusion enables quick extrahepatic biliary system imaging and clarifies the dissection, increasing protection against BDI and reducing intraoperative dissection time.

Novel Port Placement in Robot-Assisted DIEP Flap Harvest Improves Visibility and Bilateral DIEP Access: Early Controlled Cohort Study.

To minimize donor-site damage, robot-assisted (RA) deep inferior epigastric perforator (DIEP) flap harvest has been suggested. Current robotic approaches favor port placement, which either does not allow a bilateral DIEP flap harvest through the same ports or necessitates additional scars. In this article, the authors propose a modification of port configuration. In a retrospective controlled cohort study, RA-DIEP and conventional DIEP surgery were compared. The perforator and pedicle were visualized conventionally until the level behind the rectus abdominis muscle. Next, the robotic system was installed to dissect the retromuscular pedicle. The authors assessed patient age; body mass index; history of smoking, diabetes mellitus, and hypertension; and additional surgical time. The length of the anterior rectus sheath (ARS) incision was measured. Pain was quantified using the visual analogue scale. Donor-site complications were assessed. Thirteen RA-DIEP flaps (11 unilateral and two bilateral) and 87 conventional DIEP flaps were harvested without flap loss. The bilateral DIEP flaps were raised without readjustments of the ports. The mean time for pedicle dissection was 53.2 ± 13.4 minutes. The length of the ARS incision was significantly shorter in the RA-DIEP group (2.67 ± 1.13 cm versus 8.14 ± 1.69 cm; 304.87% difference; P < 0.0001). There was no statistical difference in postoperative pain (day 1: 1.9 ± 0.9 versus 2.9 ± 1.6, P = 0.094; day 2: 1.8 ± 1.2 versus 2.3 ± 1.5, P = 0.319; day 3: 1.6 ± 0.9 versus 2.0 ± 1.3, P = 0.444). Preliminary results show that the authors' RA-DIEP approach is safe and allows dissection of bilateral RA-DIEP flaps with short ARS incision lengths. Therapeutic, III.

Clinical effect and follow-up of laparoscopic radical proximal gastrectomy for upper gastric carcinoma.

To evaluate the safety and clinical effect of tubular esophagogastric anastomosis in laparoscopic radical proximal gastrectomy. A retrospective analysis was conducted involving 191 patients who underwent laparoscopic radical proximal gastrectomy in the Department of Gastrointestinal Surgery, Qilu Hospital of Shandong University from January 2017 to October 2020. Patients were divided into tubular esophagogastric anastomosis group (TG group) and traditional esophagogastric anastomosis group (EG group) according to the digestive tract reconstruction. Their intraoperative conditions, perioperative recovery and postoperative follow-up were compared. Patients were also divided into indocyanine green group and non-indocyanine green group according to whether or not indocyanine green tracer technology was used during the operation. Their intraoperative condition and perioperative recovery were compared and analyzed after propensity score matching. The operation was successfully completed in all patients. Compared with the EG group, the TG group had less volume of gastric tube drainage, shorter gastric tube drainage time and proton pump inhibitors application time, and lower reuse rate of proton pump inhibitors. However, the TG group had a higher anastomotic stenosis at three months after surgery, as measured using anastomotic width and dysphagia score. Nevertheless, the incidence of reflux esophagitis and postoperative quality of life score in the TG group were lower compared with the EG group at 1st and 2nd year after surgery. In the indocyanine green analysis, the indocyanine green group had significantly shorter total operation time and lymph node dissection time and less intraoperative blood loss compared with the non-indocyanine green group. However, compared with the non-indocyanine green group, more postoperative lymph nodes were obtained in the indocyanine green group. Laparoscopic radical proximal gastrectomy is safe and effective treatment option for upper gastric cancer. Tubular esophagogastric anastomosis has more advantages in restoring postoperative gastrointestinal function and reducing reflux, but it has a higher incidence of postoperative anastomotic stenosis compared with traditional esophagogastrostomy. The application of indocyanine green tracer technique in laparoscopic radical proximal gastrectomy has positive significance.

Anterolateral thigh harvesting for head and neck reconstruction without Doppler: Risky or not?

BackgroundAnterolateral thigh flap (ALT) is used as a workhorse flap for head and neck reconstruction. The most used method to map the perforators nowadays is hand-held Doppler although several more sophisticated techniques have been described. This paper is to investigate whether harvesting the ALT flap without preoperative mapping is safe. Materials and methodsTwenty consecutive patients were randomly assigned to one of two groups: A or B. Patients of A group (n = 10) were marked before the operation with the use of a Doppler probe whilst patients of group B (n = 10) were not marked preoperatively using Doppler to detect the perforators. Complications and time of ALT dissection were documented. ResultsThere was no statistical difference of complications between the two groups. Mean time of flap harvesting (skin incision up to main pedicle) was approximately 140 min in group A and 165 min in group B (statistically significantly less in group A p = 0.008). ConclusionsThis paper is an indication that harvesting the ALT flap without preoperative mapping, even with hand-held Doppler, does not compromise safety of the procedure although operative time is prolonged.

The Novel Use of Rare Earth Magnets for the Extraction of Metallic Soft Tissue Foreign Bodies in Children.

Metallic foreign bodies (mFB) are common following penetrating injuries in children. The mFB commonly occur in the head and neck region and extremity soft tissues. Removal may be indicated due to morbidity related to pain or migration. Extraction can be challenging to localize, often requiring wide exposure, and may be difficult to achieve in cosmetically sensitive areas. Different technological adjuncts have been used to facilitate foreign body removal including fluoroscopy, ultrasound, and more recently in adults, surgical magnets. The most powerful commercially available magnets are rare earth magnets comprised of neodymium iron and boron (Ndy). With the goal of reducing radiation exposure and the morbidity of mFB removal with associated soft tissue injury in children, a strategy was introduced utilizing Ndy to optimize extraction with minimal soft tissue surgical dissection. Two children with extremity mFB treated with Ndy between January 2021 and July 2021 were analyzed. We utilized commercially available ring type neodymium-iron-boron magnets with dimensions of 1 3/8-inch outer diameter x 1/8-inch inner diameter and 1/16 inch thick with a power of 13200 gauss that were processed for use according to our hospital protocols. Our main clinical indication was for the detection and retrieval of small ferromagnetic foreign bodies embedded in superficial extremity soft tissues. In the operating room under general anesthesia, the mFB were localized utilizing fluoroscopy. A 1.0cm skin incision was made into the subdermal soft tissues overlying the area of the mFB. No surgical tissue dissection was performed. The mFB could not be visualized in the soft tissue. Using fluoroscopy to localize the mFB, the Ndy was then placed into the wound in close proximity to the mFB. The mFB were immediately magnetized to the Ndy and the mFB were extracted from the soft tissues without any further surgical dissection. Two simple interrupted nylon sutures were placed to close the incision. The total operative time was 2 and 2.5minutes respectively. The children recovered uneventfully and are without complication. The use of Ndy to remove extremity soft tissue mFB in children appears to be feasible, safe, and efficient. Use of the Ndy allowed extraction via a small incision, optimizing the aesthetic result and avoiding the need for cross-sectional imaging, extensive surgical dissection, tissue reconstruction and prolonged operative time or x-ray exposure. The development of magnets of increasing energy density may be indicated to further optimize metallic soft tissue foreign body extraction in children in a minimally invasive manner.