Transverse Closure Research Articles

Large ileal fecalith presenting as subacute obstruction and mimicking appendicitis: a case report

In patients with right lower quadrant pain post-appendectomy, consideration of alternative diagnoses is crucial. This case illustrates the rare presentation of a large ileal fecalith masquerading as constipation and McBurney's tenderness, emphasising the role of radiographic assessment in decision-making. Early diagnostic laparoscopy was instituted for a thorough survey of the abdomen for causes of fecalith. A single fecalith was identified 15 cm from the ileocolic junction while the rest of the bowel was normal. The 4×3.6 cm stone was retrieved by longitudinal enterotomy 10 cm proximal to the site of impaction followed transverse closure to prevent stricture formation. The extraction performed via minilaparotomy under laparoscopic guidance proved pivotal, leveraging the advantages of minimally invasive surgery and facilitating a swift recovery process.

Ex vivo comparison of full-thickness biopsy techniques in the equine small intestine.

To compare the practicability and tissue sample quality between different intestinal biopsy techniques. Experimental, randomized ex vivo study. Small intestine of nine horses. Four different biopsy techniques were evaluated in the aboral jejunum and the ileum within 1 h after euthanasia. One segment was used as control (C), and the applied techniques included an 8 mm biopsy punch (BP), transverse wedge resection (TW), longitudinal wedge resection with transverse closure (LW) and a longitudinal sample using Eppendorfer biopsy forceps (EF). Defects were closed using a single-layer continuous Lembert pattern. Duration of the procedure, intestinal diameter, contamination, and bursting pressure were determined. The quality of the obtained tissue samples for histological assessment was evaluated using a semiquantitative score. The jejunal and ileal samples were analyzed separately. All biopsy procedures including defect closure were completed within 5 min, with shorter closure times for BP (p = .03). Minimal contamination could be noted in 1/8 TW and 2/8 LW cases, without significant differences between the groups. Longitudinal closure techniques (BP, EF) showed more constriction than transverse closures (TW, LW) (p < .05). Bursting pressure was >75 mmHg in all cases. Technique BP showed significantly lower biopsy quality scores (p = .009). The tested biopsy techniques could all be applied effectively within a reasonable time frame, yet the biopsy punch was associated with significant artifacts and risk of missing mucosa. The findings provide insights into the possible advantages and limitations of the different techniques and alert the surgeon to potential issues with the quality of the tissue sample.

Fatigue and Ultimate Strength Evaluation of GFRP-Reinforced, Laterally-Restrained, Full-Depth Precast Deck Panels with Developed UHPFRC-Filled Transverse Closure Strips

A depth precast deck panel (FDDP) is one element of the prefabricated bridge element and systems (PBES) that allows for quick un-shored assembly of the bridge deck on-site as part of the accelerated bridge construction (ABC) technology. This paper investigates the structural response of full-depth precast deck panels (FDDPs) constructed with new construction materials and connection details. FDDP is cast with normal strength concrete (NSC) and reinforced with high modulus (HM) glass fiber reinforced polymer (GFRP) ribbed bars. The panel-to-girder V-shape connections use the shear pockets to accommodate the clustering of the shear connectors. A novel transverse connection between panels has been developed, featuring three distinct female-to-female joint configurations, each with 175-mm projected GFRP bars extending from the FDDP into the closure strip, complemented by a female vertical shear key and filled with cementitious materials. The ultra-high performance fiber reinforced concrete (UHPFRC) was selectively used to joint-fill the 200-mm transverse joint between adjacent precast panels and the shear pockets connecting the panels to the supporting girders to ensure full shear interaction. Two actual-size FDDP specimens for each type of the three developed joints were erected to perform fatigue tests under the footprint of the Canadian Highway Bridge Design Code (CHBDC) truck wheel loading. The FDDP had a 200-mm thickness, 2500-mm width, and 2400-mm length in traffic direction; the rest was over braced steel twin girders. Two types of fatigue test were performed: incremental variable amplitude fatigue (VAF) loading and constant amplitude fatigue (CAF) loading, followed by monotonically loading the slab ultimate-to-collapse. It was observed that fatigue test results showed that the ultimate capacity of the slab under VAF loading or after 4 million cycles of CAF exceeded the factored design wheel load specified in the CHBDC. Also, the punching shear failure mode was dominant in all the tested FDDP specimens.

Randomized Trial of Transverse vs Vertical Extraction Site Incision After Robotic Radical Prostatectomy.

Incisional hernias are a frequent complication following robotic radical prostatectomy. Observational data in men undergoing robotic prostatectomy suggest that transverse closure resulted in lower hernia rates than vertical closure. We sought to compare the incidence of incisional hernia after robotic radical prostatectomy after vertical and transverse extraction site closure. We conducted a clinically integrated, crossover, cluster randomized trial at a single tertiary referral center (January 2016-September 2021) comparing the rate of hernia after transverse vs vertical extraction site excision in 1356 patients treated with minimally invasive radical prostatectomy. The primary outcome was between-group incidence of incisional hernia within 15 months of prostatectomy defined by physical examination and self-reported patient surveys. Overall, 197 (20%) patients developed an incisional hernia within 15 months, 797 did not have an incisional hernia within this period, and 362 had missing outcome data regarding incisional hernia. We found no significant difference in hernia rates between the 2 incision types (absolute between-group difference 1.8%; 95% CI -3.4%, 6.6%; P = .5) in the primary analysis or in the 3 sensitivity analyses. Notably, because of the inclusive definition of hernia used, these data cannot be used as an estimate of the true prevalence of incisional hernia. Surgeons should choose the incision and closure approach they are most comfortable with when extracting specimens. Studies of modifications to the surgical technique are best conducted as randomized comparisons, and the clinically integrated, crossover, cluster randomized trial allows large trials to be completed at a single center and at low cost. ClinicalTrials.gov: NCT01407263.

Natural Umbilicoplasty Without Visible Scarring: An Easily Taught and Reproducible Technique

Abstract Goals/Purpose The umbilicus is a focal point in an abdominoplasty, but the variety of published techniques can create confusion when deciding which incision is optimal for inset. Recently, an excellent technique was described that results in a scarless caudal umbilicus with superior hooding (2022 Samargandi). A similar technique has been used by this abstract’s senior author (J.G.) for over 20 years and has subsequently been implemented in our residency training. The inset is accomplished through an inverted-V incision in the abdominoplasty flap. The technique avoids excessive vertical tension on the abdominoplasty closure, a complicating factor of aggressive abdominoplasty advancement that can lead to vascular compromise in the inferomedial aspect of the flap. Insetting the umbilicus prior to resection of this inferior excess can allow for greater advancement of the abdominoplasty and decreased risk of flap over-resection. Methods/Technique The umbilical inset through an inverted-V incision in the abdominoplasty flap has been performed in all the senior author’s (J.G.) patients over the past 20 years. Following inferior wedge resection of the native umbilical stalk, the apex of the inferiorly based (inverted-V) flap is sutured to the dermis of the umbilical stalk and to the rectus fascia. The superolateral margins of the native umbilicus are approximated to the abdominoplasty skin. The sole deep suture inferomedially tethers the most visible aspect of the umbilicoplasty to the abdominal wall. The inverted-V incision in the abdominoplasty flap prior to low transverse closure increases the vertical tension on the flap and enables a safe resection of the inferior excess tissue. This technique has been taught to all residents in our training program and quickly incorporated in our abdominoplasty closures. Results/Complications Incising the inverted-V in the abdominoplasty flap eases tension on the low transverse wound closure. All residents have been able to independently perform this technique. Among the patients who have undergone this technique, none have experienced necrosis of the inferior aspect of the abdominoplasty flap or of the umbilical stalk base. As gravity encourages relaxation of the abdominoplasty skin, the superior aspects of the umbilicoplasty are overshadowed by the resulting superior hooding. This technique yields a natural-appearing umbilicus with adequate depth and a camouflaged inferior inset. Our patients frequently comment on the “untouched” appearance of their umbilici. No patients have required revisions of the umbilical inset, and none have experienced necrosis of the inferomedial aspect of the abdominoplasty flap. Residents have reported quick integration and predictable umbilical positioning with this technique. Conclusion The technique is easy to teach and can be rapidly incorporated by surgeons in practice, as well as in training. We are excited to see this technique having recently been described and feel strongly that its widespread adoption should be entertained. The inset during abdominoplasty flap advancement, prior to final resection of the inferior excess skin, can simplify decision-making for where to position the umbilicus and how much inferior excess tissue to resect. In addition to realizing the aesthetic superiority of this umbilicoplasty technique, it is important to proclaim the benefit of insetting prior to final abdominoplasty closure and the intuitive sense with which the new position of the umbilicus can be determined.

Intestinal hypomotility due to longitudinal enterotomy can be alleviated by transverse closure

Heineke-Mikulicz (HM) strictureplasty is commonly used to treat short stenoses in Crohn's disease. However, the degree to which intestinal motility is maintained remains unclear. We compared the peristalsis and transport capacity of the sutured intestines with HM configuration and transverse (TS) and longitudinal (LS) incisions.The intestinal diameter, intraluminal pressure, and bead transit time of each sutured group were compared with that of the non-treatment (NT) group in the isolated proximal colon of rats. Propulsive contractions were induced using hydroxy-?-sanshool (HAS), a constituent of Japanese pepper.There was no change in the intestinal diameter between HM, TS, and NT groups ; however, it was significantly narrowed at the suture site and its distal side in the LS group. After HAS administration, the intestinal diameter at the suture site in the HM group was higher than that in the LS group. The intraluminal pressure was higher and the transit time was shorter in the HM group compared to those in the LS group.The HM configuration, which widens the incision site and distal diameter and shortens the cut surface of the circular muscle in the longitudinal direction, may help maintain basal and HAS-induced intestinal peristalsis and motility. J. Med. Invest. 70 : 180-188, February, 2023.

Delayed presentation of duodenal atresia.

The most common type of duodenal atresia (DA) (Type I), also known as duodenal web or membrane can present later in infancy or early childhood if the membrane or web is fenestrated. We describe six patients with delayed presentation of DA. Retrospective review of hospital records of six patients with delayed presentation of DA due to fenestrated web managed in Paediatric Surgery Department at a tertiary care institute over a period of 2 years (January 2019 to December 2020) was done. The data of these patients were analysed on the basis of age at presentation, clinical presentation, associated anomalies, radiological findings, intra-operative findings, management and postoperative course. The median age at presentation was 6.5 months (range: 1 month to 10 years). There were four males and two females. The most common presentation was emesis seen in all six patients. Two patients had Down syndrome. Associated congenital anomalies were cardiac in one patient, anterior ectopic anus in one patient and malrotation of midgut in one patient. Upper gastrointestinal contrast suggested incomplete duodenal obstruction in all patients. At laparotomy, fenestrated duodenal membrane was observed in all patients - preampullary in three patients and postampullary in three patients. Lateral duodenotomy, web excision and transverse closure was done in all six patients. The postoperative period was uneventful in all patients and mean duration of hospital stay was 9 days. Fenestrated duodenal webs present a diagnostic challenge to the paediatric surgeons because of delayed and variable clinical presentation. A modification of the present classification of DA has been proposed in this study which would help in better reporting of epidemiology and aid in early diagnosis of this congenital anomaly.

A new incision in the correction of radial longitudinal deficiency: The double Y sliding flap approach

One concern in the surgical treatment of radial longitudinal deficiency (RLD) is certainly the skin incision. Over the years many different types have been proposed and used. We propose a new skin incision technique: a double Y sliding flap with the main body along the dorsal wrist crease, followed by raising a proximal and a distal flap providing wide access to the dorsal surface of the wrist joint. After correction of the wrist deformity, skin triangles are resected on the radial and ulnar sides of the incision. Then the skin of the distal flap is slid radially and proximally, filling the defect left by the resected radial triangle, while the proximal flap is slid in the opposite direction, enabling transverse closure along the ulnar side of the incision. The final scar comprises a central body along the dorsal wrist crease, and a radial branch. The aim of this study was to analyze the clinical results of this new double Y sliding flap approach for the surgical treatment of type III and IV RLD. We retrospectively reviewed medical records of surgical correction of RLD using our new incision, between January 2016 and December 2018 in our department of hand surgery. Endpoints comprised correction of redundant skin, scar appearance, and complications. Twelve limbs in 9 patients treated with this double Y sliding flap approach were reviewed: correction of redundant skin was systematic, only 2 limbs showed postoperative complications (1 case of notable edema and 1 of delayed wound healing), and scar aspect was graded good in 11 of the 12 cases. The double Y sliding flap was safe, with minimal complications, adequate skin restoration, wide exposure of the wrist, and esthetically good scar. Level of evidenceIV

Long-term Surgical Outcomes in Patients of Centurion Syndrome: A Mystic Etiology of Epiphora in Young

ABSTRACT Aim To describe the clinical features and long-term outcomes of the medial canthal tendon (MCT) release procedure in patients with Centurion Syndrome (CS). Methods We performed a retrospective analysis of the diagnosed patients with CS from July 2013 to December 2019. CS was diagnosed clinically based on the anterior displacement of MCT, anterior dislocation of lacrimal punctum out of tear lake, prominent nasal bridge, beak sign, and synophyrs. All symptomatic patients were advised the anterior limb of MCT release with modified closure of the skin incision. The outcome measures were based on Munk’s score (subjective) and the fluorescein dye disappearance test (objective). A minimum postoperative follow-up of 12 months was an inclusion criterion. Results We studied 22 patients (44 eyes) having a median age of 14.5 years. Anteriorly displaced MCT and lacrimal punctum were noted in 44 eyes (100%), prominent nasal bridge in 20 patients (90.9%), beak sign in 36 eyes (81.8%), and synophyrs in 17 (77.3%) patients. All 44 eyes underwent MCT release with adjunctive punctoplasty (n = 6 eyes) or lower eyelid retractor plication (n = 4 eyes). At a mean follow-up of 12.6 months, 26 eyes (59.1%) showed complete response, i.e., negative FDDT and grade 0 Munk score. Partial response was noted in 14 (31.8%) eyes, i.e., delayed FDDT and reduction of ≥2 grades on Munk score. Conclusion Along with the classic features of CS, beak sign and synophyrs are important diagnostic ophthalmic-facial features of CS. The transverse closure of surgical wounds may provide effective long-term benefits in the medial canthal tendon release procedure.

“Triple duodenal obstruction” complicated with intestinal malrotation and several cardiovascular malformations

Triple duodenal obstruction is an extremely rare disorder—apparently only two cases were reported in the English literature. We present a third case complicated with some cardiovascular anomalies (interrupted inferior vena cava, left-sided inferior vena cava, preduodenal portal vein, and ventricular septal defect) and intestinal malrotation. Operative procedure to reconstruct continuity of the duodenal lumen was a combination of longitudinal incision, partial web resection, and transverse closure at the first obstruction site together with diamond-shaped duodeno-duodenostomy between the oral side of the second obstruction and the anal side of the third obstruction.

Surgical management of duodenal web in an adult presenting with melaena; Case report and literature review.

IntroductionDuodenal web is a rare pathology presenting infrequently in adults. Diagnosis is challenging and definitive management is commonly delayed. We present a case of a patient with a late diagnosis of duodenal web, who underwent laparotomy, intraoperative gastroscopy and surgical removal of the web performed by two general surgeons.Case presentationA 32-year-old woman with a previous diagnosis of irritable bowel syndrome presented with a three day history of abdominal pain, nausea and anorexia, and a one day history of melaena and haematemesis. Investigations including a magnetic resonance enterography, barium swallow study and gastroscopy revealed the diagnosis. The patient underwent laparotomy and excision of duodenal web. Intraoperative gastroscopy assisted with identification of the web's anatomical location. A longitudinal duodenotomy was performed and this was closed in a transverse fashion using the Heineke-Mikulicz technique.DiscussionThis case reports successful application of intraoperative gastroscopy during laparotomy and duodenotomy. Longitudinal duodenotomy with excision of the web and transverse closure of the duodenum appears to be the best approach. There are no previous publications detailing gastroscopy at the time of laparotomy with duodenal web. This technique may be utilised in appropriate situations to improve operative accuracy.ConclusionDuodenal web is a rare entity in adults, and delayed diagnosis may lead to significant patient morbidity. Incorporating intraoperative endoscopy ensures accurate anatomical visualisation. This technique avoids duodenectomy, organ damage, bypass, or an unnecessarily large incision.

Setting up a division of HBP surgery at a local university hospital

Setting up a division of HBP surgery at a local university hospital

Primary Transverse Closure Compared to Open Wound Treatment for Primary Pilonidal Sinus Disease in Children.

We aimed to compare the outcome of two different operative methods to correct pilonidal sinus disease (PSD) in children, i.e., excision and open wound care (OW) versus excision and primary transverse closure (PC) of the wound. In this retrospective, observational study, we extracted data from the medical records of 56 patients who underwent surgery for PSD at our institution between 1 January 2006 and 31 December 2016. To test whether the primary variable, i.e., rate of PSD recurrence, differed between the two surgical groups, a logistic regression model was fitted. Secondary explanatory variables were total length of stay (LOS) at the hospital, complications, sex and age of patients, seniority of the surgeon in charge, and volume of excised specimen. Overall, 32 (57%) children and young adults underwent OW, while 24 (43%) patients were treated by PC. Mean age at operation was 15.5 years in either group. PSD recurred in 12 of 32 (37.5%) children in the OW group and in 3 of 24 (12.5%) children in the PC group (ratio: 0.19, 95% confidence interval [95% CI] 0.03–1.07). Thus, treatment of primary PSD by PC proved superior with respect to PSD recurrence. Moreover, our study did not bring to light any high-grade complications in the PC group, and postoperative pain was minimal. Less invasive treatment approaches for chronic PSD are typically performed in an outpatient setting and offer reduced morbidity, low rates of PSD recurrence, and shortened periods of time to return to work or social activities. More radical operations of PSD should be reserved for recurrent PSD where less invasive approaches have failed several times.

Late diagnosis of duodenal obstruction associated with down syndrome: Similar presentation of different pathologies

Down syndrome is the most common chromosomal abnormality and is associated with a high incidence of upper gastrointestinal anomalies. Although these anomalies are commonly identified antenatally or in the early prenatal period, delayed presentation is possible. Herein, we describe two patients with Down syndrome who presented with persistent vomiting associated to a partial duodenal obstruction. Both patients presented for evaluation after a prolonged period of vomiting and severe dehydration. In both cases, gastrointestinal reflux had been suspected, resulting in inappropriate treatment. We proceeded with upper gastrointestinal radiographic series and endoscopy in both cases, which revealed classic features of duodenal obstruction, including dilation of the stomach and first/second segments of the duodenum. Laparotomy was used to confirm the diagnosis in both cases. In case one, findings of massive dilation of the esophagus and the stomach were reflective of a long-standing obstruction. In the second case, examination revealed a duodenal bulb with an annular structure and no appreciable lumen. Both patients were treated via open laparotomy, with a corrective duodeno-duodenostomy procedure performed for the patient in case one with annular pancreas and enterotomy and transverse closure performed for the patient in case 2 with an external obstruction. Both patients recovered without complications, with complete resolution of symptoms. As delayed diagnosis is associated with significant morbidities and unneeded interventions, physicians treating children with Down syndrome should have a high index of suspicion of the possibility of late presenting duodenal obstruction.

Less is more: creation and validation of a novel, affordable suturing simulator for anorectal surgery.

Duty hour restrictions have increased the role of simulation in surgical education. A simulation that recreates the unique visual, anatomic, and ergonomic challenges of anorectal surgery has yet to be described. The aim of this study was to develop a low-cost, low-fidelity anorectal surgery simulator and provide validity evidence for the model. A novel, low-fidelity simulator was constructed, and anorectal surgery workshops were implemented for general surgery interns at a single institution. Face and content validity were assessed with separate questionnaires using a 5-point Likert scale. Participants performed a simulated hemorrhoid excision with longitudinal wound closure, and transverse wound closure. Time-to-task completion and quality of suturing/knot tying were evaluated by a blinded observer to assess construct validity. Material cost was US $11 per simulator. We recruited 20 first-year surgery residents (novices) and 4 practicing colorectal surgeons (experts), and conducted 3 workshops in 2014-2016. All face and content validity measures achieved a median score greater than 4 (range 4.0-5.0). Time-to-task completion was significantly lower in the expert cohort (hemorrhoid excision with longitudinal wound closure: 195 vs. 477s and transverse closure: 79 vs. 192s, p < 0.001 for both). Suturing and knot-tying scores were significantly higher in the expert cohort for both tasks (p < 0.05 for all comparisons). Our low-fidelity, low-cost anorectal surgery model demonstrated evidence of face, content, and construct validity. We believe that this simulator could be a useful instrument in the education of junior surgical trainees and will allow residents to obtain proficiency in anorectal suturing tasks in conjunction with traditional surgical training.

Evaluation of a Monofile, Ultra-Long Absorbable Suture with High Elasticity for Abdominal Wall Closure Under Daily Clinical Routine MULTIMAC a Prospective Observational Study

Recent meta-analyses have shown that the application of a monofile, late-absorbable suture using a continuous suture technique with a suture-to-wound length ratio of at least 4:1 is the method of choice for the closure of midline laparotomies. Monomax, a new ultra-long term absorbable, high elastic monofilament suture, was approved in 2009 and its safety and efficacy were proven in a selected patient population under controlled conditions for elective midline abdominal wall closure (ISSAAC Study). The present multi-centric, international, prospective observational study is aimed at evaluating the performance of Monomax suture for transverse and midline abdominal wall closure in daily clinical practice even in high risk patients. A total of 200 patients undergoing a primary elective laparotomy using either a midline or transverse incision were examined regarding the frequency of short-term complications (e.g. reoperation due to burst abdomen, wound infection, wound healing disorders), until discharge and 1 month after surgery. Postoperative length of hospital stay was also reported. Frequency of reoperation due to burst abdomen was 2.5% and a wound infection rate of 3.5% was reported up to day of discharge. Seven patients developed a wound healing disorder (3.5%). Average length of postoperative hospital stay was 10.3 days. Our results indicate that the ultra-long term absorbable, elastic monofilament suture is safe and efficient for transverse and midline abdominal wall closure performed under daily clinical routine even in high risk patients.

Validation of a Simulation-training Model for Robotic Intracorporeal Bowel Anastomosis Using a Step-by-step Technique

ObjectiveTo develop and validate a training model for the robotic intracorporeal bowel anastomosis. MethodsFor simulation, surgeons with varying levels of experience were instructed about bowel anastomosis robotic surgical simulation in a short educational video. All participants performed the required steps for the intracorporeal bowel anastomosis under standardized conditions. The procedure consists of the following steps: division of the bowel with a stapler (1), incision and opening of the bowel limbs at the antimesenteric angle (2), insertion of the stapler into the 2 bowel limbs for the side-to-side anastomosis (3), and transverse closure of the anastomosis with the stapler (4). All simulations were performed using the daVinci SI robotic system. Face and content validity were assessed using a standardized questionnaire. Construct validity was evaluated using the Global Evaluative Assessment of Robotic Skills, a validated global performance rating scale. ResultsTwenty-two surgeons participated including 6 robotic experts and 16 trainees. The expert participants rated the bowel anastomosis model highly for face validity (median 4/5; 64% agree or strongly agree), and all participants rated the content as a training model very highly (median 4.5/5; 100% agree or strongly agree). Discrimination between experts and trainees using Global Evaluative Assessment of Robotic Skills demonstrated construct validity (novice 17.6 vs expert 24.7, P = .03). ConclusionWe demonstrate that the bowel anastomosis robotic surgical simulator is a reproducible and realistic simulation that allows for an objective skills assessment. We establish face, content, and construct validity for this model. This step-by-step technique may be utilized in training surgeons desiring to acquire skills in robotic intracorporeal urinary diversion.

Performance Evaluation of Transverse High-Performance Concrete Closure Pour Connection for Use in Modular Bridge Construction

Because of the potential for concrete crushing, the negative moment transfer mechanism of the transverse connections above the pier support is still a point of concern. The objective of this study was to evaluate the behavior of a transverse closure pour connection used for the constructed Little Silver Creek Bridge in Iowa and to validate its adequacy for modular bridge application. To evaluate the need for the complicated compression block, two transverse connection specimens with and without the compression block were designed, fabricated, instrumented, and tested under a negative bending moment. Finite element models were established to further understand the specimens’ performance, and hand calculations were performed to estimate their moment capacity. No significant difference was found between the crack patterns of the two specimens, and the diaphragm concrete tended to crush in the bottom regardless of the configuration. The established finite element models were sufficient at representing the structural behavior of the two transverse connection specimens. The connection with a compression block had higher yield and ultimate moment capacity than the connection without a compression block. To design both types of connections according to the classic theory of reinforced concrete design, an effective width equal to the width of the steel girder bottom flange and the centroid of the compression force at the bottom of the steel girder bottom flange can be assumed for the connections with and without a compression block, respectively. Hand calculations reasonably estimated the moment capacity of the two specimens, and the two connections were safe under the codified, factored loads.

Transverse closure of mesenterico-portal vein after vein resection in pancreatoduodenectomy

BackgroundResection of the involved mesenteric-portal vein (MPV) is increasingly performed in pancreatoduodenectomy. The primary aim of this study is to assess the rate of R0 resection in transverse closure (TC) versus segmental resection with end-to-end (EE) closure and the secondary aims are to assess the short-term morbidity and long-term survival of TC versus EE. MethodsPatients undergoing pancreatoduodenectomy with MPV resection were identified from a prospectively database. The reconstruction technique were examined and categorized. Clinical, pathological, short-term and long-term survival outcomes were compared between groups. Results110 patients underwent PD with MPV resection of which reconstruction was performed with an end-to-end technique in 92 patients (84%) and transverse closure technique in 18 patients (16%). Patients undergoing transverse closure tended to have had a shorter segment of vein resected (≤2 cm) compared to the end-to-end (83% vs. 43%; P = 0.004) with no difference in R0 rate. Short-term morbidity was similar. The median and 5-year survival was 30.0 months and 18% respectively for patients undergoing transverse closure and 28.6 months and 7% respectively for patients undergoing end-to-end reconstruction (P = 0.766). ConclusionWithout compromising the R0 rate, transverse closure to reconstruct the mesenteric-portal vein is shown to be feasible and safe in the setting when a short segment of vein resection is required during pancreatoduodenectomy.Synopsis – We describe a vein closure technique, transverse closure, which avoids the need for a graft, or re-implantation of the splenic vein when resection of the mesenteric-portal vein confluence is required during pancreatoduodenectomy.

V8-03 STEP-BY-STEP TECHNIQUE FOR ROBOTIC INTRACORPOREAL BOWEL ANASTOMOSIS AND DEVELOPMENT OF A SIMULATION TRAINING MODEL

You have accessJournal of UrologyBladder Oncology/Testis/Transplantation/Trauma1 Apr 2015V8-03 STEP-BY-STEP TECHNIQUE FOR ROBOTIC INTRACORPOREAL BOWEL ANASTOMOSIS AND DEVELOPMENT OF A SIMULATION TRAINING MODEL Friedrich-Carl von Rundstedt, Selcuk Silay, Monty Aghazadeh, and Alvin Goh Friedrich-Carl von RundstedtFriedrich-Carl von Rundstedt More articles by this author , Selcuk SilaySelcuk Silay More articles by this author , Monty AghazadehMonty Aghazadeh More articles by this author , and Alvin GohAlvin Goh More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2127AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Our group has previously reported on the development and validation of an inanimate robotic skills simulator. There is an increased utility of robotic cystectomy in the treatment of bladder cancer. The performance of a completely intracorporeal urinary diversion requires an effective technique for an intracorporeal bowel anastomosis. We present a surgical approach that has deconstructed the procedure to 4 essential steps. Our goal was to create a novel training model for the intracorporeal bowel anastomosis in robotic surgery (BARS). METHODS The BARS technique consists of the following steps: division of the bowel with a stapler (1), incision and opening of the bowel limbs at the antimesenterial angle (2), insertion of the stapler into the two bowel limbs for the side-to-side anastomosis (3), transverse closure of the anastomosis with the stapler (4). For the simulation surgeons with varying levels of experience were instructed about BARS in a short educational video. The simulation setup included an abdominal trainer with porcine bowel as well as a bedside surgeon who operated the stapling device. All participants performed the required steps for the intracorporeal bowel anastomosis under standardized conditions. Face and content validity were derived from participants' rating of the tasks on a 5-point Likert scale. RESULTS A total of 14 participants completed all four tasks of the BARS simulation. 2 experts and 10 trainees in robotic surgery completed the online-based survey that we shared with all participants for the evaluation of the BARS exercise. 67% of participants agreed that the technical skills required to complete the training model reflected technical skills required to perform actual robotic intracorporeal reconstruction. 91% of participants found the model to be appropriate in difficulty. 91% of participants agreed that a robotic surgeon skilled in urinary diversion should be able to perform the tasks presented. 88 % of participants agreed that the model would be useful for the evaluation of robotic technical skills proficiency and 91% thought it to be useful for training robotic surgical skills. CONCLUSIONS We were able to demonstrate that the BARS simulator is a reproducible and realistic simulation which allows for an objective skills assessment. This can have implications for the training of surgeons engaged in robotic intracorporeal urinary diversions. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e714-e715 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Friedrich-Carl von Rundstedt More articles by this author Selcuk Silay More articles by this author Monty Aghazadeh More articles by this author Alvin Goh More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...