Safety and efficacy of percutaneous nephrolithotomy for the treatment of paediatric urolithiasis

INTRODUCTION

Paediatric percutaneous nephrolithotomy (PCNL) has revolutionised the treatment of paediatric nephrolithiasis. Paediatric PCNL has been performed using both adult and paediatric instruments. Stone clearance rates and complications vary according to the technique used and surgeon experience. We present our experience with PCNL using adult instruments and a 28Fr access tract for large renal calculi in children under 18 years.

METHODS

All patients undergoing PCNL at our institution between 2000 and 2009 were reviewed. Demographics, surgical details and post-operative follow-up information were obtained to identify stone clearance rates and complications.

RESULTS

PCNL was performed in 32 renal units in 31 patients (mean age: 10.8 years). The mean stone diameter was 19mm (range: 5–40mm). Twenty-six cases required single puncture and six required multiple tracts. Overall, 11 staghorn stones, 10 multiple calyceal stones and 11 single stones were treated. Twenty-seven patients (84%) were completely stone free following initial PCNL. Two cases had extracorporeal shock wave lithotripsy for residual fragments, giving an overall stone free rate of 91% following treatment. There was no significant bleeding or sepsis encountered either during the operation or in the post-operative setting. No patient required or received a blood transfusion.

CONCLUSIONS

Paediatric PCNL can be performed safely with minimal morbidity using adult instruments for large stone burden, enabling rapid and complete stone clearance.     

Outpatient tubeless percutaneous nephrolithotomy: the initial case series

Introduction:

Percutaneous nephrolithotomy (PCNL) has traditionally been performed on an inpatient basis. To the best of our knowledge, this is the first report of tubeless PCNL on a completely outpatient basis. The purposes of this study were to assess the safety and efficacy of outpatient PCNL.

Methods:

We reviewed the initial consecutive outpatient tubeless PCNLs performed at our institution by a single surgeon. Patients were discharged home the day of surgery only after meeting strict discharge criteria. Preoperative, intraoperative and postoperative data were collected prospectively.

Results:

Outpatient tubeless PCNL was performed in 3 patients. The mean maximum stone diameter was 14 mm. The average hospital stay was 175 minutes. All 3 patients were discharged home in stable condition after meeting all of the inclusion criteria. There were no emergency room visits or hospital readmissions postoperatively. The mean follow-up period was 47 days. All stones were calcium oxalate and the stone free rate was 100%. There were no minor or major complications.

Conclusion:

In properly selected patients, outpatient tubeless PCNL is safe and effective. Our initial experience with outpatient PCNL has been favourable and warrants further investigation in a larger patient population.     

Considerations in Minimally Invasive Surgery for Renal and Ureteric Calculi: A Bicenter Quality Control Study

Background

The use of minimally invasive surgery is increasing. Evaluating the quality of care brings new sights in the optimization of operating techniques.

Methods

We included all procedures performed in two hospitals during 2010 and 2011. A total of 264 patients were included in the ureterorenoscopy (URS) group and 77 patients in the percutaneous nephrolitholapaxy (PCNL) group. Data were gathered by retrospectively reviewing medical records.

Results

Mean stone diameter in the URS group was 9 mm. Patients suffered from a single stone in 79% of the cases. Calculi in the distal ureter, defined as the part of the ureter below the lower border of the sacroiliac joint, were most likely to be removed. A stone-free status was reached in 69% of the cases using URS. Mean stone diameter in the PCNL group was 23 mm. PCNL was successful in 70% of the cases in Haga Hospital versus 53% in Medisch Centrum Haaglanden. Incidence of complications was comparable between the hospitals (p = 0.5). Outcome and quality of both PCNL and URS was not influenced by sex, age or body mass index.

Conclusion

The clinical results were comparable with results in the literature. Further improvement can be made by optimization of technical aspects and centralization of treatment by urologists experienced in minimally invasive techniques.Key Words: Urolithiasis, Percutaneous nephrolithotomy, Ureterorenoscopy, Minimally invasive surgery     

Preliminary Study of Percutaneous Nephrolithotomy on an Ambulatory Basis

Objective

Preliminary study to assess the feasibility and safety of percutaneous nephrolithotomy (PCNL) as an ambulatory procedure.

Patients and Methods

Between February 2011 and September 2012, 84 patients with renal calculi fulfilling the inclusion criteria were admitted to the Urology Department of Benha University Hospitals for PCNL. All patients were subjected to a full medical history, clinical, laboratory and radiological examinations. Tubeless PCNLs were done in the supine position, and an antegrade double-J stent was inserted. Operative time and intraoperative complications were recorded. Postoperatively, the hematocrit value, postoperative pain and analgesics, need of blood transfusion, stone-free rate, and length of hospital stay were recorded. Stable patients that could be safely discharged within 24 hours after surgery were considered ambulatory.

Results

All cases of tubeless PCNL were successfully done and no cases converted to open surgery. The overall stone-free rate was 91.7%, the mean postoperative pain score measured by the visual analog scale was 4.4 ± 1.2, the mean overall hematocrit deficit was 4.8 ± 2.2% and the mean hospital stay was 33.4 ± 17.5 hours. Ambulatory PCNL was accomplished in 60 out of 84 patients (71.4%) and double-J stents were removed 7-10 days postoperatively. In the non-ambulatory cases, double-J stents were removed after auxillary procedures were done according to each case.

Conclusion

PCNL can be safely done on an ambulatory basis under strict criteria, but further studies are needed to confirm and expand these findings.Key Words: Stones, Percutaneous nephrolithotomy     

‘Nephrostomy-Free’ Percutaneous Nephrolithotomy: Experience in a UK District General Hospital

INTRODUCTION

Percutaneous nephrolithotomy (PCNL) is the first-line treatment for large and complex renal calculi. Accepted UK practice is to insert a nephrostomy tube at the end of the procedure to drain the kidney and reduce potential complications. ‘Tubeless’ or ‘nephrostomy-free’ PCNL has been advocated in selected patients as it is thought to reduce length of hospital stay, analgesia requirements and pain experienced. We present our outcomes of a consecutive series (n = 101) of ‘nephrostomy-free’ PCNLs compared to standard PCNL over a 4-year period.

PATIENTS AND METHODS

Between January 2004 and October 2006, we performed 55 standard (with nephrostomy tube) PCNLs (Group 1). From October 2006 onwards, we changed our technique and have performed 46 consecutive ‘nephrostomy-free’ PCNLs (JJ stent inserted), independent of patient and stone factors (Group 2). We have compared the two groups in terms of length of hospital stay (LOS), analgesia requirements, transfusion rates, haemoglobin (Hb) decrease and immediate, early and late complications.

RESULTS

‘Nephrostomy-free’ PCNL significantly reduced the length of hospital stay (2.8 vs 5.1 days; P < 0.001), morphine-based analgesia requirements (23% no morphine required vs 2.8%; P < 0.001), transfusion rate (2.5% vs 7%; P < 0.01) and mean Hb decrease (1.89 g/dl vs 2.25 g/dl; P > 0.05). Overall, no patient experienced a serious complication. All attempted ‘nephrostomy-free’ PCNLs were completed (stone clearance 95%) and no patient needed an unplanned nephrostomy. Only 5% in Group 2 needed their ureteric JJ stent removing earlier than planned secondary to pain. Both groups were comparable in terms of immediate, early and late complications, though three patients in Group 1 developed chronic loin pain and one patient in the ‘nephrostomy-free’ group developed a delayed perirenal haematoma.

CONCLUSIONS

‘Nephrostomy-free’ percutaneous nephrolithotomy is a safe, effective and feasible procedure independent of patient and stone factors. It decreases the length of hospital stay, the pain experienced and the need for morphine-based analgesia; we feel it should be the standard of care for patients undergoing a PCNL.     

Early results of a prospective study on the pyrolytic carbon (pyrocarbon) Amandys? for osteoarthritis of the wrist

INTRODUCTION

The preliminary results of a pyrocarbon interpositional radiocarpal implant in a small cohort of patients were reviewed. As it is currently only a limited release product, we describe to potential users early complications and negative outcomes.

METHODS

Patients were assessed using pain levels, ranges of motion, grip strength, type of and time to return to work as well as pre-operative and post-operative DASH (Disabilities of the Arm, Shoulder and Hand) scores. Radiographs were taken and patient satisfaction was recorded.

RESULTS

All six patients were contacted. One was not satisfied. Three had reduced motion. None experienced squeaking. There were no immediate or late post-operative complications. There was one early volar displacement of an implant.

CONCLUSIONS

Although our early results are somewhat encouraging, further and longer studies are warranted before supporting the use of this particular pyrocarbon implant as a primary procedure.     

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Purpose:

Percutaneous nephrolithotomy (PCNL) is conventionally performed with the patient in the prone position. In this study, we assess the safety and efficacy of PCNL in the supine position.

Methods:

Between November 2004 and January 2010, we performed 159 percutaneous nephrolithotomies. The patient is placed in a supine modified position with an air bag underneath the operating flank. If necessary, a modified lithotomy position allowing the simultaneous antegrade and retrograde endourological access was used. The access has been realized with progressive Alken dilators or with the one-shot technique. Operative times, mean stay in hospital, complications and success rates were analyzed.

Results:

The mean age was 47 ± 13.1 years (range: 22–70). Twenty-one patients had previous kidney surgery. Twenty-one had solitary kidneys and 3 patients had congenital renal abnormalities. The mean stone size was 3.4 ± 1.9 cm (range: 1.3–5.4). Twenty patients (29.5%) had complete staghorn stones. Ten patients (11.4%) also had ureteral stones and underwent concomitant ureteroscopy. The mean operative time was 60 ± 29 min, including patient positioning. In 2 patients it was necessary to suspend the procedure due to of bleeding. Postoperative complications included prolonged fever in 3 patients, nephrocutaneous fistula requiring double pigtail stent placement. Arterial embolization was never required. The colon was never damaged and we had no cases of hydrothorax or kidney loss. A second early treatment using the same percutaneous access during the same hospital stay was needed in 8 patients. The stone-free rate was 91.8%.

Conclusions:

Percutaneous nephrolithotripsy with the patient in a modified supine position is effective and safe. It offers obvious advantages from the point of view of the patient’s comfort and use of anesthetic. There is no risk of vitiated positions or traumatisms due to the change of bed-position and no thoracic compression occurs, which makes the procedure safe in patients with associated cardiorespiratory pathologies or obese patients. Also, the risk of colon perforation is reduced, which allowed for allows access to the entire urinary collecting system.     

Contemporary practice of percutaneous nephrolithotomy: review of practice in a single region of the UK

INTRODUCTION

Most series of percutaneous nephrolithotomy (PCNL) from single specialised centres represent optimum results achievable and may not reflect outcomes of everyday practice. We analysed the practice in our region.

PATIENTS AND METHODS

Medical records of 178 patients undergoing PCNL in 2002 in 12 participating hospital trusts were retrospectively analysed.

RESULTS

Even outside the tertiary referral centres, there was a 6-fold difference between trusts in the frequency of PCNL. In 28% of cases, another stone-removing modality had been tried first. Failed renal puncture was a major cause of abandoning surgery (9%). An indication of the difficulty in obtaining complete stone clearance is that only 107 (60%) operation notes recorded complete clearance, while 75 (42%) patients required a subsequent procedure (13% a secondary PCNL). Use of supra 12th rib punctures was small (6%) as was the rate of ‘tube-less’ PCNL (4%). Some 22% had simultaneous ureteric stent insertion. Approximately 8% of cases required a blood transfusion. Thirty-eight patients (23%) had a proven infection (UTI) pre-operatively (> 10⁴ organisms; > 10 white blood cells) with almost all patients receiving antibiotics at anaesthesia induction. Postoperative sepsis rates (temperature > 38.5°C) were similar in those with and without a pre-operative UTI (18.4% versus 14.3%) and pre-operative antibiotics appeared to have little extra protective effect. Severe sepsis was rare with no patient requiring intensive care admission for this reason. Median length of stay postoperatively was 5 days.

CONCLUSIONS

These results present important figures to quote when counselling patients pre-operatively, albeit that the degree of difficulty (and hence the likelihood of problems) is identifiable from stone and anatomical configurations. In addition, the present data are a more accurate reflection of urinary stone surgery in non-tertiary, general urological practice.     

The Use of the Amplatz Sheath in Percutaneous Nephrolithotomy: Does Amplatz Sheath Size Matter?

Objectives

To evaluate the effect of Amplatz sheath size used in percutaneous nephrolithotomy (PCNL) on postoperative outcome, bleeding, and renal impairment rates.

Materials and Methods

One-hundred and ten patients who underwent uneventful percutaneous nephrolithotomy between November 2011 and October 2012 were included in the study. The patients were divided into 5 groups based on Amplatz sheath size (22, 24, 26, 28 and 30 Fr). Groups were comppared in terms of pre- and post-operative mean hemoglobin, creatinine, nephrostomy time, nephrostomy tube diameter, operative time, and fluoroscope time.

Results

Mean operative time, preoperative hemoglobin and creatinine values were similar in all groups. Postoperative mean hemoglobin level was significantly lower and postoperative mean creatinine level was significantly higher in patients who were treated with a larger Amplatz sheath when compared to a smaller size (p < 0.05). It was observed that nephrostomy time and nephrostomy tube size significantly increased as the Amplatz sheath size increased. Seven patients presented with postoperative infection (1, 2, 1, 0 and 3 patients in Group I, II, III, IV, and V respectively), 13 patients presented with bleeding requiring blood transfusion (2, 4, and 7 patients in Group III, IV, and V respectively), and residual stone was observed in 9 patients (5, 2, 0, 1, and 1 patients in Group I, II, III, IV, and V respectively).

Conclusion

Although the use of a larger Amplatz sheath for larger stones seems to be suitable, this is not the case for smaller stones. For smaller stones, a smaller Amplatz sheath size would be useful to decrease the bleeding and renal impairment rates.Key Words: Percutaneous nephrolithotomy, Nephrostomy, Amplatz sheath, Treatment outcome     

The operative treatment of pressure sores in the pelvic region: A 10-year period overview

Context

Pelvic region pressure sores often develop following spinal cord injury. Surgery is often necessary for long standing, large-sized pressure sores not responding to conservative treatment. Authors analyze their results of a 10-year period, and identify factors contributing to the reduction of the recurrence rate.

Methods

A total of 119 pressure sores were operated on 98 patients in two institutions during a 10-year period (1 January 2003 to 31 December 2012). The encountered perioperative complications are summarized, and the recurrence rate is analyzed with a patient follow-up questionnaire.

Results

We experienced 15 perioperative complications (12.6%). All complications were fully resolved by conservative treatment. Fifty-eight returned patient replies were processed. The average follow-up time after surgery was 5.2 years. The recurrence rate was 5.47%.

Conclusion

The strict adherence to surgical indications, full patient compliance, specialized pre- and post-operative patient care, our routinely used preferred surgical method, all contribute to a low post-operative complication rate, long-term flap survival, and an extended recurrence free period.     

Splenic Injury During Percutaneous Nephrolithotomy

Background:

Injury to the spleen is a recognized complication during percutaneous renal access due to the close anatomical relationship of the spleen and the left kidney. However, transsplenic renal access is a rare complication of percutaneous nephrolithotomy and can also result in considerable morbidity, often requiring emergent splenectomy.

Methods:

We present our experience with splenic injury during percutaneous nephrolithotomy managed conservatively with the use of a collagen-thrombin hemostatic sealant (D-Stat; Vascular Solutions, Inc., Minneapolis, MN) after delayed removal of the nephrostomy tubes.

Results:

The patient had an uneventful recovery and was discharged home on postoperative day 6.

Conclusion:

In select hemodynamically stable patients, nonoperative management with the adjunctive use of hemostatic sealants may be considered.     

Liposuction infiltration: The Quito formula �C a new approach based on an old concept

INTRODUCTION:

Liposuction is a highly sought after surgical procedure. Despite its popularity, not all of the factors associated with its execution are well understood. No well-established guidelines exist for plastic surgeons regarding the subcutaneous infiltration of fluid and, thus, the procedure is often performed subjectively.

OBJECTIVE:

To establish the usefulness of the Quito formula (infiltrate volume = weight [kg] × percentage of body surface to be liposuctioned × 2.4 [mL]) for calculating the volume of fluid to be infiltrated subcutaneously during small-volume liposuction performed under epidural anesthesia.

METHODS:

A prospective study was conducted on a group of 50 patients who were candidates for liposuction on multiple body parts between November 2004 and February 2010.

RESULTS:

The maximum volume of infiltrate was 5000 mL and the maximum volume of aspirate was 4500 mL, with a 30% total aspirated area. No patient required blood transfusion, and there were no major complications. However, one patient presented with a small local infection, another with a sacral seroma and two patients had postdural puncture headaches. No patient showed clinical signs consistent with overhydration, dehydration, pulmonary embolism, fat embolism or lidocaine intoxication.

CONCLUSIONS:

When performing small-volume liposuction, subcutaneous infiltration using the Quito formula to calculate the volume of infiltrate proved to be useful, safe and objective.     

Open transversus abdominis plane block and analgesic requirements in patients following right hemicolectomy

INTRODUCTION

Reducing exogenously administered opioids in the post-operative period is associated with early return of bowel function and decreased post-operative complication rates. We evaluated the effectiveness of a surgeon-delivered open transversus abdominis plane (TAP) block as a method to reduce post-operative opioid requirements, sedation and inpatient stay.

METHODS

The patient cohort was identified from those who had undergone a right hemicolectomy for colonic cancer. Patients received either an open TAP block and post-operative patient controlled anaesthesia (PCA) (n=20) or were part of a control group who received subcutaneous local anaesthetic infiltration and PCA (n=16).

RESULTS

PCA morphine use was reduced within the first 24 hours post-operatively in the TAP block group compared with controls (42.1mg vs 72.3mg, p=0.002). Sedation was also reduced significantly in the early post-operative period (p<0.04). There was a non-significant trend towards reduced length of stay in the intervention group (8.2 vs 8.73 days). There were no recorded complications attributable to the open TAP block.

CONCLUSIONS

Open TAP blocks are safe and reduce post-operative opioid requirements and sedation after right hemicolectomies. They should be considered as part of a multimodal enhanced recovery approach to patients undergoing abdominal surgery via a transverse incision.     

Is there a need for early post-operative x-rays in primary total knee replacements? Experience of a centre in the UK

INTRODUCTION

Early post-operative x-rays are often taken in total knee replacements (TKRs). Patient mobilisation may be delayed until these x-rays are obtained and this may prolong discharge. The aim of this study was to assess the value of such early x-rays and whether they influenced the early post-operative management of these patients.

METHODS

A total of 624 consecutive TKRs performed at the Blackpool Victoria Hospital over a 34-month period were evaluated. Plain anteroposterior and lateral x-rays were examined.

RESULTS

Two patients were found to have significant abnormalities: an undisplaced peri prosthetic tibial fracture and a partial inferior pole patellar avulsion. Neither of these required further treatment or influenced mobility. No other complications were noted that changed routine post-operative management.

CONCLUSIONS

These results question the need for immediate x-rays in primary TKRs.     

Surgical treatment of hydatid cysts of the lung: analysis of 405 patients

Objective

The choice of operation, postoperative success and complications of surgery in patients with pulmonary hydatid cysts.

Design

A series of patients seen over 15 years.

Setting

A university clinic.

Patients

Four hundred and five patients (209 male, 196 female) ranging in age from 4 to 72 years (mean 29 years). Most (367 patients) had isolated lung cysts; 38 had both liver and lung cysts.

Interventions

A variety of procedures to remove cysts, including enucleation and capitonnage, wedge resection, segmentectomy, lobectomy and pneumonectomy. Six patients with bilateral cysts were operated on through a median sternotomy approach. Others underwent posterolateral thoracotomy.

Main outcome measures

Value of diagnostic tests, the most efficacious approach for cyst removal and recurrence and death rates.

Results

Chest radiography gave a correct diagnosis in 99% of patients. The Casoni and Weinberg tests were discontinued because of high false-negative rates (up to 35%). Hospital mortality was 1.2% and postoperative complications occurred in 5.2%. The recurrence rate was 1.5%.

Conclusions

Lung-preserving surgical interventions are the treatment of choice for pulmonary hydatid disease. In patients with bilateral cysts, the median sternotomy approach is preferred, and in the patients with right lung disease and coexisting liver cysts the transdiaphragmatic approach is the one of choice to remove cysts in 1 stage.     

Breast reconstruction with deep inferior epigastric perforator flaps

INTRODUCTION

Approximately 45,000 women are diagnosed with breast cancer in the UK each year. The success of screening and the introduction of adjuvant therapies have meant that prognosis is improving and an increasing number of patients are seeking reconstruction following mastectomy. The purpose of this study was to evaluate the deep inferior epigastric perforator (DIEP) flap reconstructions performed in Stoke Mandeville Hospital and, through analysis of complications, detail the evolution of the current care pathway.

METHODS

A retrospective analysis was performed of all the DIEP flap reconstructions performed by the senior author (MT) between July 2003 and December 2010.

RESULTS

Overall, 159 flaps were performed on 141 patients (including 36 bilateral flaps). The average patient age was 49 years (range: 28–70 years) and 13% of flaps were risk reducing for BRCA1/2. Twenty-six per cent of patients suffered one or more complication post-operatively, including systemic complications (pulmonary embolism 2%) and flap specific complications (partial flap necrosis 9%, reanastomosis 3%, fat necrosis 9%). Seventy-four per cent had further elective operations including nipple reconstruction (72%), contralateral breast reduction (36%) and scar revision (21%).

CONCLUSIONS

DIEP flaps are a safe and reliable option for breast reconstructions. This series illustrates the significant leaning curve, with complications, operative time and ischaemic time reducing through the series and post-operative haemoglobin increasing. The complications experienced in this series of 159 flaps with no total flap loss provide the framework for the evolution of the current care pathway including pre-operative imaging, peri-operative deep vein thrombosis prophylaxis and analgesia.     

Indications for intensive care unit care after carotid endarterectomy

Objectives

To describe the complications of carotid endarterectomy and the interventions performed in the intensive care unit (ICU) after carotid endarterectomy. To identify preoperative and recovery room (RR) risk markers for these complications and interventions.

Design

A retrospective case study.

Setting

The ICU of a university hospital.

Patients

One hundred and one patients who required carotid endarterectomy over a 15-month period.

Intervention

Carotid endarterectomy (bilateral procedures in 11 patients).

Outcome Measures

Demographic data including Goldman’s cardiac risk index and the therapeutic intervention scoring system (TISS) score to measure the risk of complications.

Results

Most of interventions conducted in the RR and ICU were to control high blood pressure. In the RR, three patients experienced a neurologic event, one patient was reintubated for vocal cord paralysis and one had electrocardiographic abnormalities. Overall, 5 of the 101 patients had neurologic complications and 2 suffered a myocardial infarction. Two patients died, one as a result of a massive stroke and the other of myocardial infarction with cardiogenic shock. The mean (and standard deviation ) TISS score in the ICU was 12.6 (3.8). Analysis of all events in the RR was not predictive of events in the ICU. However, the absence of major complications in the RR had a negative predictive value of 97%.

Conclusions

The decision to admit patients to the ICU after carotid endarterectomy should be based on major complications occurring in the RR. A low TISS score and low incidence of complications does not warrant routine admission.     

A Comparison of Epidural Versus General Anesthesia for Outpatient Endoscopic Preperitoneal Herniorrhaphy

Objectives:

To study the efficacy of epidural versus general anesthesia on length of stay, patient recovery and anesthetic-related complications in patients undergoing endoscopic preperitoneal herniorrhaphy.

Methods:

One hundred sixty-seven consecutive patients undergoing endoscopic preperitoneal herniorrhaphy from July, 1994, to August, 1995, were retrospectively studied. A total of 243 herniorrhaphies were performed. Four patients required conversion of epidural anesthesia to general anesthesia because of inadequate sensory blockade (67/71; 94% success rate). One-hundred-forty-eight patients were available for review. Sixty-seven patients underwent successful epidural anesthesia during the case, while 81 patients were managed with general anesthesia.

Results:

Thirty patients (37%) receiving general anesthesia required interventions for nausea compared to only six patients (9.0%) in the epidural anesthesia group (p<0.001). Thirty patients (37%) in the general anesthesia group required intervention because of complaints of pain, compared to 13 (19.4%) in the epidural group (p<0.05). There were no differences between the two groups for length of stay in OR, PACU, or total hospital times.

Conclusions:

The use of epidural anesthesia during the performance of endoscopic preperitoneal herniorrhaphy was associated with a decrease in the incidence of postoperative pain and nausea. The technique was successful in 94% of the cases in which it was used. Epidural anesthesia is recommended as an effective alternative to general anesthesia for the performance of outpatient endoscopic preperitoneal herniorrhaphy.     

Opening the pleura during internal mammary artery harvesting: advantages and disadvantages

Objective

To evaluate the findings of previous studies that opening of the pleura during internal mammary artery (IMA) dissection might be an important factor in increasing the operative morbidity.

Design

A randomized control trial.

Setting

A university hospital.

Patients

Two hundred and eighty consecutive patients with no significant pulmonary disease.

Intervention

Harvesting of the IMA with (130 patients) or without (150 patients) opening the pleura.

Main Outcome Measures

Comparison of the incidence of pleural effusion, cardiac tamponade, postoperative respiratory complications and the hospital stay.

Results

Pleural effusion occurred more often in the patients who had opening of the pleura (20% versus 5%); however, none of the patients required tapping. Postoperative bleeding with cardiac tamponade occurred in five patients in the closed pleura group. Six patients in the open pleura group had postoperative bleeding but without tamponade. The average postoperative hospital stay was 7 days for both groups. No significant differences were recorded in postoperative respiratory complications.

Conclusions

Opening of the pleura during IMA harvesting does not increase the operative morbidity. It may have other advantages and is recommended in most cases of IMA harvesting.     

RealHand High Dexterity Instruments for the Treatment of Stage I Uterine Malignancy

Background:

The purpose of this pilot study was to evaluate the impact of RealHand instruments on laparoscopic-assisted vaginal hysterectomy (LAVH) for the treatment of stage I uterine cancer.

Methods:

This was a single-center, nonrandomized, consecutive patient pilot study. Patient status was evaluated in terms of operative morbidity, length of surgery, anesthesia time, body mass index (BMI), estimated blood loss, uterine weight, and hospital stay.

Results:

In the group of 10 patients, mean operative time was 1.7 hours, and anesthesia time was 2.3 hours. Mean estimated blood loss was 70mL, and patient hospital stay was 31.8 hours. No intra- or postoperative complications occurred. Blood loss, anesthesia time, BMI, and uterine weight were significant predictors of operative time. In one patient, LAVH using the RealHand instruments was canceled because of deep pelvic visualization difficulties, resulting in a conversion to laparotomy.

Conclusion:

We present the first reported individual physician LAVH experience using RealHand instruments for the treatment of clinical stage I uterine cancer. The reported operative time, reasonable patient complication rates, and acceptable postoperative stay suggest that these innovative surgical instruments may have significant promise in the treatment of patients diagnosed with this gynecologic disease.