Adoption of Robotic Sacrocolpopexy at an Academic Institution

Objectives:

To describe the introduction of robotic sacrocolpopexy (RSC) in a urogynecology fellowship program, including operative times and patient outcomes.

Methods:

Data were retrospectively extracted from all women who underwent RSC between May 1, 2009 and December 31, 2011 by a single urogynecologist with fellow and resident assistance. Patient demographics, operative times, intraoperative complications, length of hospital stay, and postoperative course were analyzed. Cases were grouped chronologically in blocks of 10 for analysis. Trend analysis of operative time was done with linear and negative binomial regression. Fisher''s exact test was used to compare complications among blocks.

Results:

Fifty-two patients (mean age 58.5 ± 8.4 years) underwent RSC. The majority (75%) had stage III prolapse. Forty-one patients (79%) had concomitant procedures, including supracervical hysterectomy (44%), bilateral salpingo-oophorectomy (9.6%), midurethral sling (9.6%), and lysis of adhesions (40.4%). There was no trend toward decreased operative time with increased surgical experience (linear regression P = .453, negative binomial regression P = .998). Mean operative time was 301.1 ± 53.1 minutes (range 205–440). Overall complication rate was not associated with number of robotic cases performed (P = .771). Nine cases (17.3%) were converted to laparotomy. Five of these occurred in the first 15 cases. There were 2 bladder injuries (3.8%) and no bowel injuries.

Conclusions:

Although a learning curve was not demonstrated, the adoption of RSC into a urogynecology fellowship program yields similar rates of bladder/bowel injuries, postoperative complications, and operative times when compared with other published studies.     

Robot-assisted Sacrocolpopexy for Pelvic Organ Prolapse: A Systematic Review and Meta-analysis of Comparative Studies

Context

Surgery represents the mainstay of treatment for pelvic organ prolapse (POP). Among different surgical procedures, abdominal sacrocolpopexy (SC) is the gold standard for apical or multicompartmental POP. Research has recently focused on the role of robot-assisted sacrocolpopexy (RASC).

Objective

To conduct a systematic review on the outcomes of RASC.

Evidence acquisition

PubMed, Scopus, and Web of Science databases as well as ClinicalTrials.gov were searched for English-language literature on RASC. A total of 509 articles were screened; 50 (10%) were selected, and 27 (5%) were included. Studies were evaluated per the Grading of Recommendations, Assessment, Development, and Evaluation system and the European Association of Urology guidelines.

Evidence synthesis

Overall, data on 1488 RASCs were collected from 27 studies, published from 2006 to 2013. Objective and subjective cures ranged from 84% to 100% and from 92% to 95%, respectively. Conversion rate to open surgery was <1% (range: 0–5%). Intraoperative, severe postoperative complications, and mesh erosion rates were 3% (range: 0–19%), 2% (range: 0–8%), and 2% (range: 0–8%), respectively. Surgical-related outcomes have improved with increased experience, with an estimated learning curve of about 10–20 procedures. Laparoscopic SC is less costly than RASC, although the latter has lower costs than abdominal SC.

Conclusions

RASC is a safe and feasible procedure for POP; it allows the execution of complex surgical steps via minimally invasive surgery without medium- and long-term anatomic detriments. Further prospective studies are needed to confirm these findings.

Patient summary

We looked at the outcomes of robotic sacrocolpopexy for prolapse. We found that the use of robotic technology is safe and effective for the treatment of prolapse in women.     

Pneumomediastinum and Subcutaneous Emphysema Unusual Complications of Blunt Facial Trauma

We described a rare case of pneumomediastinum following an isolated facial trauma. Traumatic pneumomediastinum is usually secondary to a blunt or penetrating neck, chest or abdominal trauma.     

The Current Status of Laparoscopic Sacrocolpopexy: A Review

Context

Pelvic organ prolapse (POP) is a common problem in women that causes morbidity and a decreased quality of life. Sacrocolpopexy can treat women with vaginal vault prolapse (VVP), multicompartmental POP, and/or a history of failed prolapse procedures. Abdominal sacrocolpopexy (ASC) is the gold standard for VVP and is superior to vaginal sacrocolpopexy, with fewer recurrent prolapses and less dyspareunia. Vaginal prolapse repairs, however, are often faster and offer patients a shorter recovery time. Laparoscopic sacrocolpopexy (LSC) aims to bridge this gap and to provide the outcomes of ASC with decreased morbidity.

Objective

This review evaluates the recent literature on LSC as a therapy for POP.

Evidence acquisition

A PubMed search of the available English literature on LSC was performed. The reference lists of selected articles were reviewed, and additional on-topic articles were included. Some 50 articles were screened, 22 articles were selected, and the reported outcomes from 11 series are presented in this review.

Evidence synthesis

Laparoscopic experience with POP has advanced tremendously, and LSC results from >1000 patients in 11 series support this. Conversion rates and operative times have decreased with increased experience. Mean operative time was 158 min (range: 96–286 min) with a 2.7% conversion rate (range: 0–11%) and a 1.6% early reoperation rate (range: 0–3.9%). With a mean follow-up of 24.6 mo (range: 11.4–66 mo), there was, on average, a 94.4% satisfaction rate, a 6.2% prolapse reoperation rate, and a 2.7% mesh erosion rate. Several centers have demonstrated that excellent outcomes with LSC are reproducible in terms of operative parameters, durable results, minimal complications, and high levels of patient satisfaction.

Conclusions

LSC upholds the outcomes of the gold standard ASC with minimal morbidity. Longer prospective and randomized trials are needed to confirm these results.     

Medium-Term Anatomic and Functional Results of Laparoscopic Sacrocolpopexy Beyond the Learning Curve

Background

Limited prospective data on the anatomic and functional outcome after laparoscopic sacrocolpopexy (LSC) are available in the literature.

Objective

To describe the medium-term anatomic and functional outcome of LSC.

Design, setting, and participants

Prospective consecutive series of 132 women with vaginal vault prolapse undergoing LSC between 2001 and 2006, which was after our learning curve. Patients with urodynamically proven stress incontinence (SI) underwent a concomitant tension-free vaginal tape (TVT) procedure.

Intervention

Patients underwent LSC with a polypropylene implant.

Measurements

Principal outcome measures were anatomic cure (stage 1 or lower) assessed by the Pelvic Organ Prolapse Quantification (POPQ) system and subjective cure and impact on quality of life measured by a standardised interview and, since its introduction in 2004, by a prolapse-specific quality-of-life questionnaire (P-QOL).

Results and limitations

At a mean follow-up of 12.5 mo, the anatomic cure rate for the apex was 98%. Anatomic failures elsewhere were mainly at the posterior compartment (18%). Subjective prolapse cure rate was 91.7%, and no patients required reoperation for recurrent prolapse. Symptoms of preoperative SI, urge incontinence, or constipation were cured in 43%, 46%, and 42% of patients, respectively. The rate of de novo SI was 7.3%. De novo constipation developed in 5% and de novo dyspareunia developed in 19%. Patients’ quality of life improved significantly. Erosions occurred in 4.5%, all within 1 yr. A limitation of the study is that the quality-of-life assessment score became available halfway through the study, limiting the number of preoperative observations (n = 36).

Conclusions

We demonstrated that LSC results in good anatomic outcome and subjective cure of prolapse symptoms at medium term. The posterior compartment was most vulnerable for recurrence.     

Subcutaneous emphysema: a rare manifestation of a perforated diverticulitis in a patent inguinal canal

Patients with complicated diverticulitis rarely present with extraperitoneal manifestations but the manifestation of subcutaneous emphysema appears even more seldom. We present the case of a patient with a history of diabetes and immunosuppression, who was admitted with sepsis in association with cellulitis and subcutaneous emphysema of the left groin. The absence of peritonism due to corticosteroid treatment, a history of a recent fall with an ilio- and ischio-pubic fracture and subcutaneous emphysema led to a delay in the diagnosis. The final diagnosis was a perforated diverticulitis in a patent inguinal canal, which was only revealed after surgery. The various complications of diverticulitis, including extraperitoneal manifestations, and associated microorganisms implicated in cellulitis and subcutaneous emphysema are briefly reviewed.     

Massive subcutaneous emphysema, pneumomediastinum, and pneumopericardium in children

Massive subcutaneous emphysema (SE), pneumomediastinum (PM), and pneumopericardium (PP) are rare conditions in the pediatric population. Air leak syndrome is a constellation of disorders that include SE, PM, PP, and pulmonary interstitial emphysema. In children, SE, PM, and PP are associated with obstructive airway disease most often in the case of asthma. Management may be conservative or involve invasive procedures that require surgical intervention. Here, we describe a case of massive SE, PM, and PP in a 10-year-old child after placement of a peripherally inserted central line and review the literature.     

Subcutaneous mastectomy — surgical techniques and complications in 176 women

Summary Since the 1960's, subcutaneous mastectomy (SCM) and reconstruction with an implant has been used to treat recurrent benign breast tumors and in situ breast carcinomas. It has also been used as a prophylactic operation in women with a high risk of developing breast carcinoma and to achieve symmetry following breast reconstruction. Reports on surgical complications have been discordant. Recent prospective studies have revealed negative psychosocial effects. Therefore, a retrospective analysis of the techniques used and early and late complications in the first 176 SCM performed from 1968 to 1981 was performed. Necrosis of the skin or nipple-areolar complex left persistent scar deformities in most patients. Necrosis over a submuscular implant never led to implant loss, in contrast to several subcutaneous implants. Smoking was associated with an increased frequency of necrosis. Infection of the implant pocket resulted in removal of 75% of the implants. The most common complication was capsular contracture (CC), this was less frequent with submuscular implants — no causative factor was found in this study. Indentation tonometry was found to be a useful means to quantify CC. Although results have improved and complications decreased during the period studied, SCM is still an operation that should be performed only with well defined indications.     

A new device for bone anchor fixation in laparoscopic sacrocolpopexy: The Franciscan laparoscopic bone anchor inserter

Background A laparoscopic modification of the sacrocolpopexy procedure with mesh and bone anchor fixation with the Franciscan laparoscopic bone anchor inserter was developed.Methods We developed a laparoscopic bone anchor inserter for the placement of a titanium bone anchor in sacral segment 3 as fixation for the mesh in laparoscopic sacrocolpopexy procedures performed in women with posthysterectomy vault prolapse.Results Surgery successfully corrected vaginal vault prolapse. Laparoscopic bone anchor insertion with this new and simple device took 2 minutes and provided a firm anchor for mesh fixation. MRI demonstrated an anatomically preferable vaginal axis toward the hollow of the sacrum.Conclusion Application of the newly developed Franciscan laparoscopic bone anchor inserter in laparoscopic sacrocolpopexy is an easy and safe procedure that provides firm fixation and excellent anatomical results.     

Pressurized Air Injection Causing Subcutaneous Emphysema in a Pediatric Patient

This report describes the case of a young boy who sustained a bicycle-spoke puncture wound during which the tire air nozzle penetrated the cutaneous barrier about the ankle. Pressurized air was injected into the tissues resulting in subcutaneous emphysema. The subcutaneous gas was confirmed by roentgenogram, and a full recovery resulted after local wound care and antibiotic therapy. Care was taken to distinguish traumatic air injection from gas gangrene. ACFAS Level of Clinical Evidence: 4.     

Current Status of Robotic Surgery

Surgery has increasingly become a technology-driven specialty. Robotic assistance is considered one innovation within abdominal surgery over the past decade that has the potential to compensate for the drawbacks of conventional laparoscopy. The dramatic evolution of robotic surgery over the past 10 years is likely to be eclipsed by even greater advances over the next decade. We review the current status of robotic technology in surgery. The Medline database was searched for the terms “robotic surgery, telesurgery, and laparoscopy.” A total of 2,496 references were found. All references were considered for information on robotic surgery in advanced laparoscopy. Further references were obtained through cross-referencing the bibliography cited in each work. There is a paucity of control studies on a sufficient number of subjects in robot-assisted surgeries in all fields. Studies that meet more stringent clinical trials criteria show that robot-assisted surgery appears comparable to traditional surgery in terms of feasibility and outcomes but that costs associated with robot-assisted surgery are higher because of longer operating times and expense of equipment. While a limited number of studies on the da Vinci robotic system have proven the benefit of this approach in regard to patient outcomes, including significantly reduced blood loss, lower percentage of postoperative complications, and shorter hospital stays, there are mechanical and institutional risks that must be more fully addressed. Robotic assistance will remain an intensively discussed subject since clinical benefits for most procedures have not yet been proven. While the benefit still remains open to discussion, robotic systems are spreading and are available worldwide in tertiary centers.     

腹腔镜二氧化碳气腹致皮下气肿的临床分析

目的:探讨腹腔镜手术二氧化碳气腹致皮下气肿的原因、防治措施及处理方法。方法:回顾分析腹腔镜手术二氧化碳气腹导致皮下气肿187例患者的临床资料;其中64例重症患者气肿弥漫至肩、颈部或面部,PETCO2、Paw显著升高,SpO2下降,予以粗针头于气肿明显处穿刺抽气、降低气腹压力、增加潮气量、增快呼吸频率、尽快结束手术;123例轻症患者气肿局限于切口附近或肋缘胸壁,未特殊处理。结果:患者完全清醒,潮气量及呼吸频率恢复正常,PETCO2、SpO2指标正常后,拔除气管插管,皮下气肿于24～72 h后消失;合并气胸者行胸腔穿刺或闭式引流;2例患者拔管困难,转ICU。结论:术中规范操作,严密监测患者体征及SpO2、PETCO2等各项参数的变化,及时发现、正确处理皮下气肿,是避免发生不良后果的关键。     

Perioperative Outcomes of Robotic Versus Laparoscopic Hysterectomy for Benign Disease

Background and Objectives:

We compared the perioperative outcomes of hysterectomy performed by robotic (RH) versus laparoscopic (LH) routes for benign indications using the Dindo-Clavien scale for classification of the surgical complications.

Methods:

Retrospective chart review of all patients who underwent robotic (n=288) and laparoscopic (n=257) hysterectomies by minimally invasive surgeons at the University of Michigan from March 2001 until June 2010.

Results:

Age, body mass index, operative time, and estimated blood loss were not statistically different between groups. The RH subgroup had a larger uterine weight (LH 186.4±130.6 g vs RH 234.9±193.9 g, P=.001), higher prevalence of severe adhesions (13.2% vs 23.3%, respectively, P=.003), and stage III–IV endometriosis (4.7% vs 15.3%, respectively, P<.05). There were no differences in the rates of Dindo-Clavien grade I, grade II, and grade III surgical complications between the RH and LH groups (9.7%, 13.2%, and 3.1%, respectively, in the RH group vs 6.2%, 9.3%, and 5.8%, respectively, in the LH group, P>.05). However, the rates of urinary tract infection were higher in the RH group (LH 2.7% vs RH 6.9%, P=.02), whereas the conversion to laparotomy rate was higher in the LH group (LH 6.2% vs RH 1.7%, P=.007).

Conclusions:

Perioperative outcomes for laparoscopic and robotic hysterectomy for benign indications appear to be equivalent.     

Subcutaneous emphysema after associated colonoscopy and transanal excision of rectal adenoma

Non-traumatic subcutaneous emphysema (NSE) is a rare complication of procedures of the digestive tract. To the best of our knowledge, it has never been reported to occur after transanal surgery. Herein we present the first known case of NSE accompanied by retropneumoperitoneum and pneumomediastinum to develop after colonoscopy and full-thickness transanal removal of a rectal polyp.     

Robotic Laparoscopic Pyeloplasty

Background and Objectives:

We aimed to assess the feasibility and outcomes of complex ureteropelvic junction obstruction cases submitted to robotic-assisted laparoscopic pyeloplasty.

Methods:

The records of 131 consecutive patients who underwent robotic-assisted laparoscopic pyeloplasty were reviewed. Of this initial population of cases, 17 were considered complex, consisting of either atypical anatomy (horseshoe kidneys in 3 patients) or previous ureteropelvic junction obstruction management (14 patients). The patients were divided into 2 groups: primary pyeloplasty (group 1) and complex cases (group 2).

Results:

The mean operative time was 117.3 ± 33.5 minutes in group 1 and 153.5 ± 31.1 minutes in group 2 (P = .002). The median hospital stay was 5.19 ± 1.66 days in group 1 and 5.90 ± 2.33 days in group 2 (P = .326). The surgical findings included 53 crossing vessels in group 1 and 5 in group 2. One patient in group 1 required conversion to open surgery because of technical difficulties. One patient in group 2, with a history of hemorrhagic rectocolitis, presented with peritonitis postoperatively due to a small colonic injury. A secondary procedure was performed after the patient had an uneventful recovery. At 3 months, significant improvement (clinical and radiologic) was present in 93% of cases in group 1 and 88.2% in group 2. At 1 year, all patients in group 2 showed satisfactory results. At a late follow-up visit, 1 patient in group 1 presented with a recurrent obstruction.

Conclusions:

Robotic pyeloplasty appear to be feasible and effective, showing a consistent success rate even in complex situations. Particular care should be observed during the colon dissection in patients with previous colonic pathology.     

直肠阴道疝Y型补片修补与悬吊的初步研究

目的探讨应用倒“Y”字形补片对直肠阴道疝进行修补,并行骶前阴道悬吊术的临床效果。方法从门诊盆底功能不全的患者中,选择具有具有直肠阴道疝的妇科患者共8例作为研究对象。常规缝合直肠阴道疝的疝囊,应用到“Y”型补片加强阴道后壁,并将阴道顶端悬吊于第2～3骶骨的前筋膜处。结果直肠阴道疝修补均成功,手术时间（110．0±16．9）min,出血（91．6±52．0）ml,排气时间（33．5±5．8）h,住院时间（6．8±0．7）d。所有患者术后1年,POP—Q评估均为。度。1例患者术后出现补片排斥反应,出现阴道腐蚀。结论直肠阴道疝应用倒Y型补片修补并行骶前阴道悬吊术效果确切,消除了临床症状,比单纯的修补效果佳,不易复发,加强了盆底功能,对防止复发及盆腔脏器的脱垂具有重要意义。．     

Robotic surgery update

Background Minimally invasive surgical techniques have revolutionized the field of surgery. Telesurgical manipulators (robots) and new information technologies strive to improve upon currently available minimally invasive techniques and create new possibilities.Methods A retrospective review of all robotic cases at a single academic medical center from August 2000 until November 2002 was conducted. A comprehensive literature evaluation on robotic surgical technology was also performed.Results Robotic technology is safely and effectively being applied at our institution. Robotic and information technologies have improved upon minimally invasive surgical techniques and created new opportunities not attainable in open surgery.Conclusions Robotic technology offers many benefits over traditional minimal access techniques and has been proven safe and effective. Further research is needed to better define the optimal application of this technology. Credentialing and educational requirements also need to be delineated.