Using the “Summa Set-up” in robotic assisted gynecologic surgery

During challenging gynecologic (GYN) procedures, the conventional robotic set-up can limit a surgeon’s ability to effectively and efficiently perform these procedures. We present a novel set-up using a parallel-docking approach of the da Vinci ^® Surgical System with only three robotic arms and incorporating two patient side assist ports to overcome the difficulties presented during challenging GYN procedures. The Summa Set-up (SS) uses 4 ports actively, 2 assist ports and 2 robotic ports, compared to the traditional set-up which uses 4 ports: 1 assist port and 3 robotic ports. With the SS format, the patient-side assistant stands at the head of the bed and can simultaneously retract the uterus and aide in surgical dissection along with the console surgeon. While there are many possibilities of da Vinci ^® docking, port placement and assistant placement during robotic-assisted GYN surgery, we believe the SS can be an alternative for many GYN surgeons, especially those in teaching hospitals, for increased mobility and efficiency during complex GYN procedures.     

Transoral robotic surgery using the Medrobotic Flex® system: the Adelaide experience

Journal of Robotic Surgery - Transoral robotic surgery (TORS) has become an accepted treatment option for a variety of benign and malignant pathologies of the head and neck. The Medrobotics...     

Vascular clips versus ligatures in thyroid surgery—results of a multicenter randomized controlled trial (CLIVIT Trial)

Background

New techniques using vascular clips or ultrasonically activated shears have been suggested to shorten operation time without compromising safety. The objective of the CLIVIT Trial was to compare ligatures with vascular clips for hemostasis in elective benign thyroid surgery.

Methods

This multicenter, randomized, controlled, parallel group superiority trial was conducted in 13 German surgical centers. Patients scheduled for at least subtotal resection bilaterally were intraoperatively randomized. The primary endpoint was resection time. Secondary endpoints were the amount of postoperative bleeding, reoperation due to bleeding, wound infection, temporary (reversal within 12?months) and permanent (over 1?year) recurrent laryngeal nerve (RLN) paralysis, length of hospital stay, and safety. Registration: ISRCTN 96901396.

Results

Two hundred fifty patients were treated with ligatures and 241 with vascular clips. No differences in patients' baseline and surgical characteristics were observed. No difference was detected for mean resection time (clip 63.5?min?±?29.6, ligature 66.1?min?±?29.3, P?=?0.258). Postoperative bleeding (mean 86?ml?±?93), reoperation due to bleeding (clips 4, ligature 2), wound infections (clips 4, ligature 4), postoperative hospital stay (mean 3.0?±?1.9), and safety data also did not vary significantly. The rates of temporary and permanent RLN paralysis were 6.9?% (34/491) and 2.9?% (14/491), respectively. Not using a surgical drain (123 patients) was not associated with a higher rate of complications.

Conclusion

Vascular clips did not reduce the resection time. However, a 2.9?% rate of permanent RLN paralysis is of concern. Drains in elective surgery may be of no benefit.     

Are pedicled flaps feasible in robotic surgery? Report of an anatomical study of the kite flap in conventional surgery versus robotic surgery

Reconstruction of cutaneous defects of the hand has dramatically progressed. It should also benefit from the development of robot-assisted surgery. The aim of the present study was to consider the feasibility of a kite flap in robotic surgery. Two cadaver hands were used in this study, one for a conventional procedure, and one for a robotic surgical procedure using a da Vinci Si robot. The operative duration was measured, and all difficulties encountered during the procedures were reported. The total duration of the intervention was 19 minutes with the conventional procedure and 30 minutes with the robotic technique. Some difficulties were encountered, related both to lack of specific instrumentation and haptic feedback. Robotic surgery presents interesting advantages such as the suppression of physiological tremor, increased degrees of freedom, and enhanced precision and accuracy of hand maneuvers. In this study, it allowed the realization of a pedicled flap without any external help.     

Controlling intraoperative hemorrhage during burn surgery: A prospective,randomized trial comparing NuStat® hemostatic dressing to the historic standard of care

Introduction

One of the primary intraoperative challenges during burn surgery is to adequately excise the burn while avoiding massive hemorrhage. This has become increasingly important, as we see more burn patients that are older and with more medical comorbidities. While adequate excision down to healthy tissues for deep burns is essential for skin graft to take, it also leads to active bleeding that can be a challenge to control. Good hemostasis is imperative as a hematoma is the most common cause of graft loss. Several new products have become available to help control intraoperative hemorrhage. A new hemostatic dressing, NuStat^®, is available and approved by FDA in United States.

Bupivacaine use in the Insuflow® device during laparoscopic cholecystectomy: results of a prospective randomized double-blind controlled trial

Background

Recent evidence [Surg Endosc (2007) 21: 602–606] demonstrates that intraperitoneal bupivacaine administered as an aerosol via a special catheter is safe and significantly decreases postoperative pain in laparoscopic surgery. We currently use the Insuflow^® device (Lexion Medical) routinely to warm and humidify gas in laparoscopic surgery. The purpose of this study is to determine whether using bupivacaine instead of water in existing technology already in use (Insuflow) will result in decreased postoperative pain, without increasing operative time or cost.

Methods

Using a double-blind methodology, 50 patients undergoing elective outpatient laparoscopic cholecystectomy were randomized to a study drug: either 10 ml of 0.5% bupivacaine (50 mg) or 10 ml of sterile water. The study drug was injected into the Insuflow in the standard fashion and the operation commenced routinely. No perioperative nonsteroidal anti-inflammatory drugs were used. Using a standard 0–10 pain-scoring scale, patients were assessed by perioperative nurses at 1 and 2 h postoperatively. Pain was again assessed at 24 h by telephone interview, along with the number of narcotic oral analgesics used in the first 24 h.

Results

Fifty patients were randomized, 25 in each group; the groups were comparable. All patients completed the study and 100% follow-up was obtained. All patients were discharged the same day and there were no significant complications in either group, and specifically no complications attributed to bupivacaine or use of the Insuflow device. There were no differences in pain at 1 and 2 h. There was less pain in the bupivacaine group at 24 h, but this was not statistically significant (P = 0.055).

Conclusions

Bupivacaine use in the Insuflow device is safe. No significant differences in postoperative pain were noted in this study compared to using water.     

A randomised controlled trial comparing two insertion techniques for the Laryngeal Mask Airway Flexible™ in patients undergoing dental surgery

The Laryngeal Mask Airway Flexible^TM (LMA Flexible) has been widely utilised for dental, ophthalmology and otorhinolaryngology‐related procedures. Our study evaluates two different techniques of inserting the LMA Flexible for patients undergoing day‐case dental surgery. One hundred and eight patients were randomly assigned into two groups based on the LMA Flexible insertion technique – either laryngoscopy‐guided (n = 54) or digital manipulation (standard technique; n = 54). Patient and airway characteristics were recorded before induction of anaesthesia. The primary outcome was success rate at first insertion. Other outcomes assessed included fibreoptic assessment of laryngeal mask airway placement, haemodynamic changes, need for airway adjustment during surgery and sore throat. The success rate of insertion on the first attempt was higher for the laryngoscopy‐assisted technique compared with the standard technique (96.3% vs 81.5%, respectively, p < 0.05). Fibreoptic assessment showed that the former group had better placement of the laryngeal mask airway than the latter (59.3% vs 37% p < 0.05). There were no significant differences between the two groups for haemodynamic changes. Sore throat was more common in the group with the standard technique (35.2% vs 16.7%, p < 0.05). Our study suggests the use of the laryngoscope to guide insertion of the LMA Flexible for dental surgery is a better option compared with the standard technique of digital manipulation.     

Postoperative continuous-flow cryocompression therapy in the acute recovery phase of hip fracture surgery—A randomized controlled clinical trial

BackgroundThe acute recovery phase after hip fracture surgery is often complicated by severe pain, postoperative blood loss with subsequent transfusion, and delirium. Prevalent comorbidity in hip fracture patients limit the use of opioid-based analgesic therapies, yielding a high risk for inferior pain treatment. Postoperative cryotherapy is suggested to provide an analgesic effect, and to reduce postoperative blood loss. In this prospective, open-label, parallel, multicentre, randomized controlled, clinical trial, we aimed to determine the efficacy of continuous-flow cryocompression therapy (CFCT) in the acute recovery phase after hip fracture surgery.MethodsPatients with an intra or extracapsular hip fracture scheduled for surgery were included. Subjects were allocated to receive postoperative CFCT or usual care. The primary endpoint was numeric rating scale (NRS) pain the first 72 postoperative hours. Secondly, analgesic use; postoperative haemoglobin change and transfusion incidence; functional outcome; length of stay; delirium incidence; location of rehabilitation; patient-reported health outcome; complications and feasibility were assessed.ResultsSixty-one subjects in the control group, and 64 subjects in the CFCT group were analysed. Within the CFCT group, post treatment NRS pain declined 0.31 (p = 0.07) at 24 h, 0.28 (p = 0.07) at 48 h, and 0.47 (p = 0.002) at 72 h relative to pre treatment NRS pain. Sensitivity analysis at 72 h showed that NRS pain was 0.92 lower in the CFCT group when compared to the control group (1.50 vs. 2.42; p = 0.03). Postoperative analgesic use was comparable between groups. Between postoperative day one and three haemoglobin declined 0.29 mmol/l in the CFCT group and 0.51 mmol/l in controls (p = 0.06), and transfusion incidence was comparable. The timed up and go test and length of stay were also comparable between both groups. Complications, amongst delirium and cryotherapy-related adverse events were not statistically significantly different. Discharge locations did not differ between groups. At outpatient follow-up subjects did not differ in patient-reported health outcome scores. Subjects rated CFCT satisfaction with an average of 7.1 out of 10 points.ConclusionsNo evidence was recorded to suggest that CFCT has an added value in the acute recovery phase after hip fracture surgery. If patients complete the CFCT treatment schedule, a mild analgesic effect is observed at 72 h.     

Does minimally invasive lumbar disc surgery result in less muscle injury than conventional surgery? A randomized controlled trial

The concept of minimally invasive lumbar disc surgery comprises reduced muscle injury. The aim of this study was to evaluate creatine phosphokinase (CPK) in serum and the cross-sectional area (CSA) of the multifidus muscle on magnetic resonance imaging as indicators of muscle injury. We present the results of a double-blind randomized trial on patients with lumbar disc herniation, in which tubular discectomy and conventional microdiscectomy were compared. In 216 patients, CPK was measured before surgery and at day 1 after surgery. In 140 patients, the CSA of the multifidus muscle was measured at the affected disc level before surgery and at 1 year after surgery. The ratios (i.e. post surgery/pre surgery) of CPK and CSA were used as outcome measures. The multifidus atrophy was classified into three grades ranging from 0 (normal) to 3 (severe atrophy), and the difference between post and pre surgery was used as an outcome. Patients’ low-back pain scores on the visual analogue scale (VAS) were documented before surgery and at various moments during follow-up. Tubular discectomy compared with conventional microdiscectomy resulted in a nonsignificant difference in CPK ratio, although the CSA ratio was significantly lower in tubular discectomy. At 1 year, there was no difference in atrophy grade between both groups nor in the percentage of patients showing an increased atrophy grade (14% tubular vs. 18% conventional). The postoperative low-back pain scores on the VAS improved in both groups, although the 1-year between-group mean difference of improvement was 3.5 mm (95% CI; 1.4–5.7 mm) in favour of conventional microdiscectomy. In conclusion, tubular discectomy compared with conventional microdiscectomy did not result in reduced muscle injury. Postoperative evaluation of CPK and the multifidus muscle showed similar results in both groups, although patients who underwent tubular discectomy reported more low-back pain during the first year after surgery.     

An occupation-based intervention in patients with hand-related disorders grouped using the sense of coherence scale—A randomized controlled trial

Study DesignA nonblinded randomized controlled trial.IntroductionOccupation-based interventions are superior to physical exercise–based interventions in patients with activity limitations. However, only a few studies have examined the effect in patients with hand-related disorders. Patients recover heterogeneously, which could be due to personal factors, such as sense of coherence (SOC).Purpose of the studyTo investigate the effectiveness of an occupation-based intervention for patients with hand-related disorders and whether SOC can give an indication of the expected effects.MethodsA total of 504 patients were stratified into three SOC groups and then randomized to either an occupation-based intervention, including physical exercises (OBI) or a physical exercise–based occupation-focused intervention. The primary outcome, functioning, was measured using the Disability of the Arm, Shoulder and Hand questionnaire. Primary endpoint was at three months. Patients were followed up for a year.ResultsNo significant difference was found in primary outcome analysis. Nevertheless, patients receiving OBI had a statistically significant and greater change in satisfaction with their occupational performance at one, two, and three months follow-up. Patients with a weak SOC had worse functioning and lower health-related quality of life than those in the other groups, at all times.ConclusionsOBI as delivered in this study was not superior to physical exercise–based occupation-focused intervention in this patient group. However, in taking a client-centered approach, we recommend that OBI be based on individual needs, given that patients had a statistically greater change in score regarding satisfaction with their occupational performance. It is evident that patients with a weaker SOC have a lower level of functioning. This knowledge should inform clinical practice.     

Direct comparison of Seprafilm® versus Adept® versus no additive for reducing the risk of small-bowel obstruction in colorectal cancer surgery

Purpose

To assess the effectiveness of using sodium hyaluronate-based bioresorbable membrane (Seprafilm^®) versus 4 % icodextrin solution (Adept^®) versus no additive intraoperatively and to prevent postoperative small-bowel obstruction in patients undergoing colorectal cancer (CRC) surgery.

Methods

The subjects of this retrospective study were 454 patients, who underwent CRC surgery between February 2007 and January 2010. Among the 454 enrolled patients, 114 patients received Seprafilm^®, 180 patients received Adept^®, and 160 patients received no additive, based on the year of their surgery.

Results

The overall incidences of small-bowel obstruction were 8.8, 4.3, and 6.9 %, for the Adept^®, Seprafilm^®, and no additive (control) groups, respectively. The cumulative incidence was significantly higher in the Adept^® group than in the Seprafilm^® and control groups (Adept^® vs. Seprafilm^®, P = 0.043; Adept^® vs. control group, P = 0.002). No significant difference was found between the Seprafilm group and the control group (P = 0.549). Adept^® solution and Seprafilm^® did not alter the liver and renal function, as assessed by blood chemistry.

Conclusions

The use of Adept^® significantly increased the incidence of small-bowel obstruction in patients undergoing CRC surgery.