Dissection Time Research Articles

Effect of a Three‐Dimensional Anatomy Atlas on Medical Education Under Pandemic Restrictions

IntroductionThe COVID‐19 pandemic posed significant challenges to the instruction of in‐person cadaveric dissection. Compared to previous years, there was a 66% reduction in student lab dissection times for the first‐year medical students (MS1s) at Texas Tech University Health Sciences Center. Complete Anatomy (CA), a three‐dimensional (3D) anatomy atlas, was provided as an additional educational resource to supplement the in person cadaveric dissection labs. The aim of this study is to increase student engagement by producing tailored anatomical modules in CA and to evaluate their effects on students’ stress levels and summative practical exam performance throughout the Clinically Oriented Anatomy (COA) block. We hypothesized that the CA modules would allow current MS1s to perform to the same academic standard as students who did not have these COVID‐19 limitations and reduce their exam stress.MethodsLearning modules were created that displayed 3D anatomical structures corresponding to each of the 27 COA in person dissection labs. The CA modules consisted of content and quizzes that MS1s could access either outside or inside the lab. At the end of each of the three COA units and at the end of the COA block, students were surveyed about their participation and satisfaction with the modules. Students’ performance on module quizzes was compared to their performance on summative practical exams. Additionally, the Class of 2023’s performance in COA was compared to the Class of 2024’s, with the latter taking the block under pandemic restrictions.ResultsThroughout the block, 82%‐95% (unit 1 n=97/102, unit 2 n=67/72, unit 3 n=107/130) of survey respondents reported using the modules as a study aid and 55%‐79% used the modules for all 27 anatomy labs. Additionally, 75%‐87% of MS1s rated the modules as “very useful” or higher on a Likert‐scale survey, with a majority of surveyed students using both the content and quizzes. At the end of the block a second survey showed 74% (n=70/94) of students “strongly agreed” or “agreed” that using the modules reduced their stress, and 80% (n=75/94) “strongly agreed” or “agreed” that modules allowed them to continue their learning outside of the lab. MS1 performance in the COA block was positively correlated with performance on CA quizzes (r=0.46, p<0.0001). Further, there was no significant difference between the 2023 and 2024 MS1 classes in summative practical exam scores for units 1 and 3, as well as in the National Board of Medical Examiners (NBME) exam. However, there was a significant increase in summative practical exam performance in the Class of 2024 for unit 2 (p<0.0001) as compared to the Class of 2023.ConclusionFindings suggest that the CA modules facilitated student engagement in anatomy and positively enhanced their medical education throughout the COA block. Although dissection time and lab access were limited, the CA modules benefitted the students and could have potentially compensated for that lost time.

Endoscopic Thyroidectomy With Level Vb Dissection Via a Chest-breast Approach: Technical Updates for Selective Lateral Neck Dissection.

To determine the feasibility of endoscopic thyroidectomy with level Vb dissection using a chest-breast approach. Lateral neck level Vb dissection by endoscopic surgery using a chest-breast approach was performed as an update to the previously reported endoscopic selective lateral neck dissection. The demographic data, surgical outcomes, and adverse events were analyzed. A total of 12 cases were performed successfully, and no patient was converted to the open procedure. The sex ratio was 16/2 (female/male). The average age and primary lesion diameter were 36.3±5.8 years old, and 1.97±0.58 cm, respectively. The average total and lateral lymph nodes dissection time of duration was 154.6±17.0 and 276.3±19.2 minutes, respectively. The lymph node ratio (mean number of metastasis/total number of dissected nodes) at levels II, III+IV, VI, and Vb were 1.6±1.4/6.8±2.0, 5.8±2.4/14.4±3.6, 3.2±1.1/6.5±1.9, and 0.8±0.9/5.8±1.6, respectively. One of 12 patients had lymphatic leakage and 2 of 12 patients had transient hypocalcemia. There was no incidence of uncontrolled bleeding, mental nerve injury, permanent hypoparathyroidism, permanent recurrent laryngeal nerve injury, skin bruise on neck, infection, asphyxia/dyspnea, large blood vessel injury or other complications like tracheal injury, esophageal injury, etc., nor was there any death or recurrence in either of the 2 groups during a short follow-up period. It is feasible to perform endoscopic thyroidectomy with level Vb dissection using a chest-breast approach. Such strategy represents another option for selective papillary thyroid carcinoma patients with levels II, III, IV, and Vb lymph node metastasis.

Staged neck dissection prior to trans-oral surgery provides a safe and effective treatment paradigm for early oropharyngeal carcinoma

Background: Increasing evidence shows transoral robotic surgery (TORS) is a feasible option in treating early oropharyngeal squamous cell carcinoma (SCC). Like any treatment modality, it inherently has risks. Post-operative haemorrhage is the most common cause for both morbidity and mortality in the acute post-surgical period and although rare, pharyngocutaneous fistula can have dire consequences. Varying evidence exists on the timing of neck dissection (ND) and whether a two-staged approach with early neck dissection including vessel ligation followed by TORS reduces complications. This single-institution case series aims to show why a staged approach can be effective in minimizing post-operative complications.

Transoral Endoscopic Thyroidectomy Vestibular Approach Versus Endoscopic Thyroidectomy Via Areola Approach for Patients With Unilateral Papillary Thyroid Carcinoma: A Retrospective Study.

Endoscopic thyroidectomy via areola approach (ETA) has been widely used in thyroidectomy for many years as it can effectively avoid a scar in the neck. Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is newly applied and has gained popularity quickly. This study is to compare the safety and effectiveness of TOETVA and ETA. A total of 95 patients who underwent TOETVA or ETA with unilateral papillary thyroid carcinoma were enrolled in this study from March 2019 to February 2020. The basic information (such as gender, age), intraoperative hemorrhage, postoperative drainage volume, hospital durations, intraoperative and postoperative complications, operative time, central lymph node dissection time, total number of central lymph nodes, and number of metastatic central lymph nodes were compared. The operative time of the TOETVA group was significantly longer than the ETA group (148.11±19.78 vs. 135.90±12.77 min, P<0.05). However, the result was opposite when central lymph node dissection time was compared (10.31±2.93 vs. 12.48±3.55, P<0.05). TOETVA had an advantage on total number of central lymph nodes over ETA (7.82±3.35 vs. 5.26±2.45, P<0.05). No differences were found between the 2 groups on other data. TOETVA and ETA have the similarity on surgical safety and effectiveness. TOETVA has its advantage on central lymph node dissection and might be a reasonable alternative for ETA and open surgery in the future.

Giant cell arteritis-related aortic dissection: A multicenter retrospective study

PurposeTo describe characteristics and outcomes of patients with giant cell arteritis (GCA)-related aortic dissection. Patients and methodsWe retrospectively included, through a nationwide GCA network, all patients who had an aortic dissection either revealing GCA or occurring during follow-up. ResultsA total of 46 patients were included in this study. Aortic dissection was inaugural and led to GCA diagnosis in 21 patients, whereas it occurred during follow-up in the 25 others, at a median of 53 [1–265] months after GCA diagnosis.Large-vessel vasculitis (LVV) was diagnosed through imaging before or at the time of aortic dissection in 31 (67%) patients. In patients who developed an aortic dissection during follow-up, the aortic event occurred 22 [1–143] months post GCA diagnosis in the patients with previous aortitis, whereas it occurred after 72 [19–265] months in patients without previously diagnosed aortitis (p = 0.005).Aortic surgery was performed in 27 (59%) patients and 23 of them survived. A total of 15 (32%) patients died following the aortic dissection, including 11 who were not operated on. In a multivariate analysis, aortic surgery was the single predictor of survival (HR: 4.3; 95% CI: 1.47— 15.7; p = 0.007). ConclusionPatients with prior LVV are more prone to develop early aortic dissection and require close monitoring of aortic morphology. One third of patients died from the aortic dissection. Surgery remains the best predictive factor for survival.

Intraoperative nerve monitoring in thyroid surgery: Analysis of recurrent laryngeal nerve identification and operative time.

ObjectiveTo evaluate the clinical value of intraoperative nerve monitoring (IONM) by comparing the procedure times for thyroidectomies performed with and without IONM.MethodsA prospective, randomized, controlled study was conducted on 32 patients (representing 41 nerves at risk) undergoing thyroidectomies carried out by two experienced head and neck surgeons (CC & WP). Sixteen thyroidectomies were performed without IONM (the “non‐IONM group”), while 16 thyroidectomies were performed with IONM (the “IONM group”). The measured datapoints were setup time, time to visual identification of the recurrent laryngeal nerve (RLN), time to confirm the RLN electrophysiologically, dissection time, and total operative time.ResultsWith both surgeons, the IONM group had shorter visual times to RLN identification than the non‐IONM group (CC: 3.7 minutes vs 5.3 minutes; WP: 3.4 minutes vs 9.7 minutes). Additionally, the electrophysiological identification time for the IONM group was shorter than the visual identification time for the non‐IONM group. The setup times, dissection times, and total operative times of the 2 groups did not significantly differ (P > .05). No RLN injuries were observed.ConclusionsIONM reduces the time needed for RLN identification in thyroidectomies. Functional RLN confirmation can reassure surgeons of the operative results. Moreover, use of IONM does not significantly impact setup and total operative times.Level of evidence2.

Comparison of three-dimensional (3D) endovision system versus ultra-high-definition 4K endovision system in minimally invasive surgical procedures: a randomized-open label pilot study.

Experimental work comparing 3-Dimensional (3D) and 4K ultra-high-definition endovision system (4K) indicates that the latter with double the resolution of standard 2D high-definition systems may provide additional visual cues to compensate for the lack of stereoscopic vision. There is paucity of studies comparing 3D and 4K system in clinical settings. This randomized study compares 3D and 4K systems in three laparoscopic procedures of increasing complexity. 139 patients undergoing laparoscopic cholecystectomy (60 patients), transabdominal preperitoneal (TAPP) repair (49 patients) and laparoscopic Heller's cardiomyotomy with anti- reflux procedure (30 patients) between May 2018 and February 2020 were randomized to undergo surgery using either 3D or 4K systems. Primary objective was to measure total operative time. Secondary objectives were to compare workload perceived by surgeons using SURG-TLX and surgeon satisfaction score. Timings of key surgical steps and peri-operative course of the patients was also recorded. Data were analyzed using Stata Corp. 2015. Patients undergoing surgery with 3D and 4K systems were comparable in their clinical and demographic profiles. The mean total operative time in 3D and 4K groups was comparable in cholecystectomy (52.7 vs 56.2, p = 0.50), TAPP (63.8 vs 69.6, p = 0.25) and Heller's cardiomyotomy (124.7 vs 143.3, p = 0.14) with faster hiatal dissection in 3D group (8min, p = 0.02). Operative time was better in patients undergoing Heller's myotomy with Angle of His accentuation with 3D by 28min (p = 0.03). Total workload was similar in 3D and 4K groups in all the procedures but mental & physical demand was lower in 3D group in Heller's cardiomyotomy (p = 0.03, p = 0.01), Surgeon satisfaction score was comparable in all three procedures. Overall, 3D HD and 4K systems are comparable in performing laparoscopic cholecystectomy, TAPP and Heller's Cardiomyotomy. Hiatal dissection time, mental and physical task load was better with 3D in Heller's Cardiomyotomy.

Expansion of tumor-infiltrating lymphocytes (TIL) from penile cancer patients

Penile cancer is a rare but highly lethal cancer, and therapeutic options for patients presenting with lymph nodal disease are very limited. Adoptive cell therapy (ACT) using tumor-infiltrating lymphocytes (TIL) was shown to provide durable objective response in patients with metastatic melanoma and TIL have been expanded from solid tumors at rates between 70 and 90% depending on the specific diagnosis. We evaluated whether TIL could be expanded from surgical specimens of patients with penile cancer. Tumor samples from metastatic lymph nodes obtained at the time of inguinal lymph node dissection were collected, minced into fragments, placed in individual wells of a 24-well plate, and propagated in high dose IL-2 for four weeks. The phenotype of expanded TILs was assessed by flow cytometry and their anti-tumor reactivity was assessed by IFN-γ ELISA. TIL were expanded from 11 out of 12 (91.6%) samples of metastatic lymph nodes. Expanded TIL were predominantly CD3+ (mean 67.5%, SD 19.4%) with a mean of 46.8% CD8+ T cells (SD 21.1%). Five out of 11 samples (45.4%) from expanded TIL secreted IFN-γ in response to autologous tumor. TIL expansion and phenotype of expanded T cell lymphocytes were independent of previous HPV infection and treatment with neoadjuvant chemotherapy. This is the first report demonstrating successful expansion of tumor-reactive TIL from penile cancer patients, which support development of ACT strategies using TIL for the treatment of advanced and recurrent penile cancer.

Immediate Lymphatic Reconstruction: Technical Points and Literature Review.

Summary:Recent studies have provided evidence that lymphovenous bypass—microsurgical re-routing of divided lymphatics to an adjacent vein—performed at the time of lymph node dissection decreases the rate of lymphedema development. Immediate lymphatic reconstruction in this setting is technically demanding, and there is a paucity of literature describing the details of the surgical procedure. In this report, we review the literature supporting immediate lymphatic reconstruction and provide technical details to demystify the operation for surgeons who wish to provide this option to their patients.

Palisade technique as an effective endoscopic submucosal dissection tool for large colorectal tumors.

Background and study aims Endoscopic submucosal dissection (ESD) has become the standard treatment for colorectal ESD, but large colorectal tumors remain difficult to remove. We developed a new method, called the palisade technique, by modifying the multiple tunneling technique. In this method, a palisade of submucosal tissue is left beneath the tumor to anchor a dissected specimen, maintaining effective submucosal traction. Patients and methods The study included 11 patients with large colorectal tumors that were over half the circumference of the colorectal lumen which were treated using the palisade technique from August 2017 to October 2019. Overall resection outcomes were assessed. Results All 11 lesions were removed en bloc. The R0 resection rate was 45.6 % because of marginal burning of the specimen, but no local recurrence was found after a median observation period of 31 months. The median submucosal dissection time (SDT) and submucosal dissection speed (SDS) were 170 minutes and 23.1 mm 2 /min, respectively. One case of post-ESD hemorrhage was successfully managed endoscopically, and two cases of post-colorectal ESD coagulation syndrome were managed conservatively. Conclusion The palisade technique can be an effective and safe technique for treating large colorectal tumors that extend over half the luminal circumference.

Isolated caudate lobectomy using a modified hanging maneuver.

The caudate lobe is located deep in the dorsal portion of the liver. Complete resection is an extremely demanding surgery due to the limited surgical field, especially in cases with severe intra-abdominal complications. A major concern of isolated caudate lobectomy is the difficulty associated with securing the contralateral visual field during parenchymal transection. To overcome this issue, we present a new technique for isolated caudate lobectomy that uses a modified hanging maneuver. We performed an anatomical isolated caudate lobectomy via the high dorsal resection technique using our new modified hanging maneuver in two patients with HCC in November and December 2019. Patient 1 was severely obese, so the upper abdominal cavity was occupied by a large amount of great omental fat, and fibrous adhesions were observed around the spleen. Patient 2 had undergone six preoperative treatments, and a high degree of adhesion was observed in the abdominal cavity around the liver. It was difficult to secure the surgical field due to severe abdominal complications in both cases. The total operation times in these two cases were 617 and 763min, respectively, while the liver parenchymal dissection times of the caudate lobe were 96 and 108min, respectively. The resection margin was negative in both patients (R0). Neither patient had any complications after surgery; both were discharged on postoperative day 14. Our modified hanging maneuver is useful, particularly in cases with a narrow surgical field due to severe adhesions, bulky tumors, and/or hypertrophy of the Spiegel lobe.

Predictive Factors of Difficult Laparoscopic Cholecystectomy

Background: Laparoscopic cholecystectomy is considered the gold standard treatment of symptomatic cholelithiasis, preoperative prediction of the difficult surgery is an important aspect of planning laparoscopic surgery. Objective: The purpose of this prospective study is to evaluate, analyze, and document different predictive factors of difficult laparoscopic cholecystectomy and whether conversion rate to open surgery and complications can be minimized during laparoscopic cholecystectomy. Patients and Methods: This is a prospective clinical study done on 100 patients complaining of calcular cholecystitis admitted to having (LC) at the Department of Surgery Faculty of Medicine Al-Azhar University Hospital in Assiut and Al-Arish General Hospital from May 2018 to January 2020. Results: Univariate analysis of pre-operative risk factors versus operative data variables showed that male gender was associated with prolonged operative time. Age above 45 years was associated with prolonged dissection time, GB bed dissection time. BMI of 30 or more was associated with prolonged GB bed dissection time. Palpable GB was associated with prolonged operative time, prolonged GB bed dissection time, prolonged GB extraction time, and increased risk for conversion to open surgery. Distended GB in ultrasound was associated with prolonged operative time. Solitary stone in GB was associated with prolonged extraction time. Conclusion: Pre-operative factors can help to predict a difficult LC. This information may be useful to both the patient and the treating surgeon. Prediction of a difficult procedure would allow the surgeon to discuss the likelihood of conversion with the patient and prepare him/her psychologically as well as planning their recovery and explaining their absence from work.

Eliminating the Burden of Lymphedema in Cancer Patients Requiring Nodal Dissections Using Prophylactic Immediate Lymphatic Reconstruction – A Case Report and Review of the Literature

Immediate lymphatic reconstruction (ILR), performed concurrently with nodal dissection, has shown promise in reducing the rates of lymphedema in patients with various types of cancers. Herein, we detail the case of a 42-year-old patient who underwent nodal dissection in the management of their melanoma. This patient underwent ILR at the time of lymph node dissection of the right axilla and was followed for 24 months. Circumferential measurements of both the operative and non-operative limbs, as well as lymphedema-specific quality of life questionnaire (LYMQOL) data, were collected at each appointment. Our patient developed lymphedema transiently at 3 months which had resolved by the 6-month follow-up and maintained favorable measures of quality of life over the course of 2 years. This novel approach has yet to be implemented as a standard of care in Canada. Such an outcome would be overwhelmingly positive for our cancer population, and on our health-care system overall.

Robot-Assisted Thyroidectomy Versus Open Thyroidectomy in the Treatment of Well Differentiated Thyroid Carcinoma.

Background:The incidence of thyroid cancer has increased worldwide during the last decade, becoming the most common endocrine malignancy and accounting for 3.8% of new cancer diagnosis. Surgical resection, namely conventional thyroidectomy, remains at the frontline of therapy, as surgical outcomes are undoubtedly successful. Minimally invasive techniques gained popularity through the years, in terms of feasibility, safety, and cosmesis. However, endoscopic approach could be characterized by some limitations concerning thyroid surgery. Robotic technology with its unique features was introduced to overcome these limitations. Since then, robotic thyroidectomy has been used for both benign and malignant thyroid disease.Database:This study presents the use of robot-assisted transaxillary thyroidectomy in well-differentiated thyroid carcinoma through an extensive review of the literature in the PubMed database, including previous meta-analyses and case series.Conclusion:In terms of oncological efficacy, morbidity, and quality of life, outcomes seem comparable in thyroid cancer patients undergoing either open or robotic thyroidectomy. Surgical completeness also appears similar. Moreover, the rates of locoregional recurrence and survival outcome at 5 years are similar between the former and the latter, thus confirming the oncological value of robotic thyroidectomy for differentiated thyroid cancer. In order for more surgeons to adopt robotic approaches several issues need to be resolved, namely: expansion of robotic thyroidectomy in treating larger well-differentiated carcinomas and neck dissection, equipment costs, and prolonged operation times.

Comparison of the internal thoracic artery flow dissected by video endoscopy or conventional technique.

ABSTRACTPurpose:To compare the blood flow in the internal thoracic artery when dissected endoscopically in a conventional manner, in addition to develop a reliable experimental training model for the surgical team.Methods:Paired experimental study. Ten pigs were operated and had both internal thoracic arteries dissected, the right with a conventional technique and the left by video endoscopy. The main outcomes to be studied were flow, length, and time of dissection of each vessel.Results:Blood flow measurements were performed with mean heart rate of 100 ± 16 bpm and mean arterial pressure of 89.7 ± 13 mm Hg. The mean blood flow of endoscopic dissection of the internal thoracic artery was 170.2 ± 66.3 mL/min and by direct view was 180.8 ± 70.5 (p = 0.26). Thus, there was no statistically significant difference between the flows, showing no inferiority between the methods.Conclusions:The minimally invasive dissection of the internal thoracic artery was shown to be not inferior to the dissection by open technique in relation to the blood flow in the present experimental model. In addition, the model that we replicated was shown to be adequate for the development of the learning curve and improvement of the endoscopic abilities.

Real-time navigation by three-dimensional virtual reconstruction models in robot-assisted laparoscopic pyeloplasty for ureteropelvic junction obstruction: our initial experience.

BackgroundThe aim of this study was to evaluate the effectiveness and safety of real-time surgical navigation by three-dimensional (3D) virtual reconstruction models in robot-assisted laparoscopic pyeloplasty (RALP).MethodsBetween November 2018 and January 2020, 38 patients with ureteropelvic junction obstruction (UPJO) who underwent RALP were retrospectively enrolled. The operations were assisted in real time by 3D models in 16 patients, while 22 patients underwent surgery without navigation. Based on whether patients had a prior intervention history, crossing vessels or congenital deformities, we further divided them into the “complicated UPJO” cohort and the “regular UPJO” cohort for subgroup analysis. The demographic characteristics, intraoperative parameters, perioperative data and follow-up data were recorded and compared between the groups.ResultsAll of the procedures were successfully performed without open or laparoscopic conversion. The mean dissection time to the UPJ was shorter in the navigation group than in the non-navigation group, both in the whole cohort (15.3 vs. 24.8 min, P=0.011) and in the complicated cohort (15.4 vs. 27.5 min, P=0.004), while there was no significant difference in the regular cohort. The overall operative time and estimated blood loss in the navigation group tended to be less, although the difference was not statistically significant. No difference in anastomosis time, postoperative hospital stay or complications was noted between the two groups in either cohort. At a mean follow-up of 11.2 months, the overall success rate was 94.7% (36/38), and there was no significant difference between the two groups.ConclusionsReal-time navigation by 3D virtual reconstruction models might be helpful to improve surgical efficiency and safety of RALP by facilitating the dissection around the UPJ, especially for cases of complicated UPJO. However, the prospective study with larger sample size is further needed to confirm the results.

Extended Lymphadenectomy during Robotic Pancreatico-duodenectomy: Case Reporting a Right Hepatic Artery Coming from SMA and a Median Arcuate Ligament Syndrome

Purpose: The video shows the dissection time with an extended lymphadenectomy during a pancreatico-duodenectomy performed by robotic approach. Method: The patient is a 63-years-old woman diagnosed with a pancreatic head cancer. In the CT-Scan, a median arcuate ligament is observed causing a stenosis of the celiac trunk and a right hepatic artery coming from the superior mesenteric artery (SMA). After a multidisciplinary tumor committee, we decided to perform a pancreatico-duodenectomy (PD) with total meso-pancreas excision by robotic approach. Results: The surgery begins with an extreme Kocher maneuver that allows us to access the posterior face of the duodenopancreatic block. After this we proceed to dissect the origin of the SMA and the origin of the celiac trunk cutting the median arcuate ligament in order to release the celiac trunk. During the dissection of the SMA the right hepatic artery is dissected and preserved. We continue with lymphadenectomy of the hepatic artery and the bile duct section.The next step is the gastric section that allows us to access the anterior pancreatic face. The retropancreatic tunnelisation allows us to put a loop in order to achieve the pancreatic hanging maneuver and sectioning the pancreas safely. The meso-pancreas is totally resected. Conclusion: Robotic approach is safe, effective and reproductible. Through a standardised technique, it may overcome some of the technical difficulties of laparoscopic PD.

Snare Tip Is an Alternative Tool for Colorectal Endoscopic Submucosal Dissection.

Colorectal endoscopic submucosal dissection is typically performed by specialized knife, such as a dual knife. However, it is not covered by Taiwan's National Health Insurance. In the literature review, using a traditional snare tip for endoscopic submucosal dissection has been reported for stomach lesions only. The purpose of this study was to evaluate the outcomes of colorectal endoscopic submucosal dissection using a snare tip. We retrospectively reviewed the clinical using of a snare tip compared with a dual knife for colorectal endoscopic submucosal dissection. Postoperative short- and long-term outcomes were investigated after the procedure. This study was conducted at a single tertiary care institution. Patients who could not afford the expense of a specialized knife were included. Dissection time, dissection speed, and perioperative complications were used for short-term outcome measurement. Recurrence-free rate was used for long-term outcome measurement. Twenty-one lesions were in the snare tip group and 57 lesions in the dual knife group. The outcomes, including rate of en bloc resection, complication, local recurrence, and recurrence-free interval, between the 2 groups were similar. The mean resected specimen diameter in the dual knife group is larger than the snare tip group (p = 0.041). The dissection time of the snare tip group was shorter than the dual knife group (p = 0.025). However, the dissection speed was significantly slower in the snare tip group than in the dual knife group (p = 0.008). This study was a retrospective and single doctor chart review in nature with a limited patient number. The snare tip is an alternative tool for colorectal endoscopic submucosal dissection in a selected population without the support of specialized knives, such as the dual knife. Although the dissection speed is slower using a snare tip, it is still a recommended technique for developing country or low-income patients.

Initial experiences of robotic SP cholecystectomy: a comparative analysis with robotic Si single-site cholecystectomy.

PurposeThe da Vinci SP robotic surgical system (Intuitive Surgical) offers pure SP with 4 lumens, which accommodates the fully-wristed endoscope and 3 arms with multijoint feature. We herein present our initial experience of the da Vinci SP surgical system in robotic single-site cholecystectomy.MethodsThirty consecutive patients with a preoperative diagnosis of gallstones and/or chronic cholecystitis who underwent robotic SP cholecystectomy (RSPC) using da Vinci SP surgical system from January to May 2019 were reviewed. The perioperative outcomes were assessed and compared with those performed using Si-robotic single-site surgical system.ResultsMean docking time was 5.2 minutes. The mean actual dissection time was 14.6 minutes while the mean operation time was 75.1 minutes. Postoperative course was unremarkable and patients were discharged after a mean hospital stay of 1.5 days. In comparative analysis, operation time (109.5 ± 30.0 minutes vs. 75.1 ± 17.5 minutes, P = 0.001), docking time (11.9 ± 4.3 minutes vs. 5.2 ± 1.9 minutes, P = 0.001), actual dissection time (34.6 ± 18.4 minutes vs. 14.6 ± 5.1 minutes, P = 0.001), console time (58.7 ± 23.0 minutes vs. 32.4 ± 11.6 minutes, P = 0.001), immediate postoperative pain (4.6 ± 1.3 vs. 3.2 ± 1.0, P = 0.001), and pain prior to discharge (2.0 ± 0.6 vs. 1.4 ± 0.0, P = 0.002) were significantly improved in RSPC.ConclusionRSPC is feasible, safe, and effective. The perioperative outcomes are better compared with Si-robotic single-site surgical systems.

Free tissue transfer with supermicrosurgical perforator-to-perforator (P-to-P) technique for tissue defect reconstruction around the body: Technical pearls and clinical experience

BackgroundResorting to perforators as recipient vessels is a valid alternative that might offer a series of advantages in many situations. They allow the use of a shorter pedicle, reduce the time of dissection, and are a good solution when deep vessels are difficult to reach. The aim of this study is to investigate the efficacy of P-to-P tissue transfer for reconstructing defects in different areas of the body. Patients and MethodsBetween April 2018 and February 2020, 40 patients presenting soft tissue defects were reconstructed by using P-to-P-anastomosed free flap transfer. The cause of the defect was trauma in 16 cases and surgically excised tumor in 24. Five defects were located in the upper extremities, 1 in the neck, 1 in the thorax, and 21 in the lower limb, and 13 cases were breast reconstructions, 2 of which bilateral (43 total flaps). ResultsOf all 43 flaps, 22 were abdominal flaps, 17 flaps were harvested from the upper thigh, and 4 were harvested from the lower leg. At the 9 month follow-up, 42 flaps were successfully healed, 36 without complications, 3 after wound dehiscence, and 3 after wound infection, and only 1 flap was lost requiring further surgery. Flap failure rate was 2.3%. ConclusionsFree flaps anastomosed in perforator-to-perforator fashion can be safely used in different settings throughout the body. Even if they are technically more demanding, they may allow a quicker operation time and lower morbidity. With the developments in microsurgical instruments, we believe that this technique may become the gold standard for tissue-defect reconstruction.