Flat plug and mesh hernioplasty in the “Inguinal box”: description of the surgical technique

Summary  A new anatomical terminology is used for a better understanding of the operation and for more accurate identification of the boundaries and spaces of the inguinal region. Inguinal mesh and plug hernioplasties are performed using prostheses of different sizes and shapes, either sutured or not, to the tissues. A tension-free, sutureless pre-shaped mesh inguinal hernioplasty, performed within the boundaries of the lateral and medial inguinal box has several advantages as compared with other mesh techniques. The sutureless implantation of a flat plug and a pre-shaped prosthesis can be performed in all primary inguinal hernioplasties.The aim of this article is to describe a surgical technique which has been used in 3,422 patients.     

Comparison of intraoperative outcomes using the new and old generation da Vinci® robot for robot-assisted laparoscopic prostatectomy

Study Type – Therapy (case series) Level of Evidence 4

OBJECTIVE

• ? To review and compare intraoperative outcomes for robotic prostatectomy procedures performed on two generations of the da Vinci robotic surgery platform.

MATERIAL AND METHODS

• ? We reviewed 100 consecutive robotic prostatectomy cases and compared intraoperative outcomes for procedures randomly performed on either the da Vinci S robot or first‐generation standard robot.
• ? Baseline demographic data and intra‐operative variables potentially impacting outcomes were reviewed and compared between the two groups.

RESULTS

• ? Mean total operative time was 191 min using the standard da Vinci robot (range 132–266) versus 169 min with S robot (range 98–230), representing a mean difference of 22 min (P = 0.002).
• ? This difference was statistically significant despite no difference in mean patient BMI of 30.6 (range 19–51) for standard versus 29.3 (range 21–37) for S (P = 0.31), no difference in mean prostate size of 54.6 g (range 26–101) for standard versus 57.3 g (range 32–151) for S (P = 0.55), and no difference in frequency of nerve‐sparing (P = 0.99).
• ? There was also no difference in the portions of procedues performed by residents, which in some cases was none and some the entire procedure, but the standard was more often used for the surgeon’s first case of the day (P = 0.006).
• ? There was no difference in blood loss (P = 0.08), positive margins (P = 0.87), or mean number of lymph nodes removed (10.7 vs 10.6).

CONCLUSIONS

• ? Both generations of da Vinci robotic technology are equally effective for PALP, but the S robot appears to allow shorter procedure times.
• ? Further such evaluations are necessary to guide institutions and public policy decision‐makers on investments in newer generations of robotic technology as incremental advances continue.

     

Learning curves in expert and non-expert laparoscopic surgeons for robotic suturing with the da Vinci® Surgical System

We investigated learning curves for robotic suturing of expert and non-expert laparoscopic surgeons to explore the length of time required to reach an acceptable plateau of technical skills. Laparoscopic suturing skills were evaluated in a training box with conventional laparoscopic instrumentation in phase 1. In phase 2, robotic suturing skills were evaluated during a training program on non-surviving animals by analyzing time required for five intracorporal stitches on the small bowel. Learning curves were plotted. A significant difference in technical skills between the expert and non-expert surgeons was demonstrated in phase 1 and at the beginning of phase 2. Both surgeons reached a learning-curve plateau exhibiting similar robotic suturing skills at the end of 90 min of training. Skills were subsequently retained equally by both surgeons. Short duration of training was sufficient for the non-expert laparoscopic surgeon to match the robotic suturing performance of the expert laparoscopic surgeon.     

The kringle suture: maximizing tendon repair stability while limiting hardware utilization—description of the technique and preliminary results

Background

Arthroscopic repair currently represents the gold standard surgical treatment for rotator cuff tears, despite several aspects that are still matter of discussion between surgeons, and it is not clear yet what technique is better with respect to the others. Several evidences, however, support the assumption that the suture configuration is most important than the number of suture anchors used.

Materials and methods

In this work, we describe a new suture technique for arthroscopic supraspinatus tendon repair using a single double-loaded common suture anchor, and based on a continue and multi-passage suture configuration, with final gross resemblance to the nordic kringle pastries or to the kringle protein domain. Between June 2015 and July 2016, 44 patients (44 shoulders) were treated for supraspinatus tendon tear by means of the kringle suture. Of these, 36 patients have been evaluated from the clinical and radiographic site in the setting of this study, with a follow-up time ranging from 18 to 30 months.

Results

During the follow-up period, no major complications were recorded. Two patients reported a transient postoperative stiffness, which completely resolved upon 6 months from surgery. All of the patients referred complete subjective satisfaction and return to their daylife activities without pain. No sign of radiographic subsidence of the suture anchors was found at the radiographic analysis.

Conclusion

The kringle suture technique is cost saving, easy to perform, versatile and provides excellent initial fixation strength as required for tendon to bone healing of the reinserted cuff.

     

Tetrafocal (three osteotomies) and pentafocal (four osteotomies) bone transport using Ilizarov technique in the treatment of distal tibial defect—preliminary outcomes of 12 cases and a description of the surgical technique

ObjectiveTo evaluate the preliminary outcomes of tetrafocal (three osteotomies) and pentafocal (four osteotomies) bone transport using Ilizarov technique for the treatment of distal tibial defect and describe the surgical technique.MethodsA total of 12 eligible patients with distal tibial defect > 6 cm caused by direct trauma or posttraumatic osteomyelitis who were admitted to our institution from January 2017 to January 2019 were treated by tetrafocal or pentafocal bone transport using Ilizarov technique. Detailed demographic data, including age, sex, etiology, defect size, number of osteotomies (three or four), external fixation time (EFT) and external fixation index (EFI), were collected, and the bone and functional outcomes were evaluated by the Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system. Complications during the surgery and the follow-up period were recorded and evaluated by the Paley classification at a minimum follow-up of two years after removal of the fixator.ResultsThere were 9 men and 3 women with an average age of 37.4±7.8 years. The etiology included posttraumatic osteomyelitis in 8 cases and posttraumatic bone loss in 4 cases. The mean bone defect after radical debridement was 7.1±0.6 cm. Tetrafocal bone transport was applied in 9 cases, and pentafocal bone transport was applied in 3 cases. The average EFT and EFI were 5.2±0.8 months and 0.7±0.2 months/cm, respectively. The average time of follow-up after removal of the external fixator was 28.5±3.3 months without recurrence of osteomyelitis. The bone results were good in 7 cases, fair in 4 cases, and poor in 1 case, and the functional results were good in 5 cases, fair in 6 cases, and poor in 1 case. The most common complication was pin tract infection, which occurred in all cases, but there were no major complications, such as nerve or vascular injury.ConclusionTetrafocal and pentafocal bone transport using Ilizarov technique could be an alternative treatment option in selected cases with distal tibial defect > 6 cm. It could shorten the distraction period, fasten regeneration, and reduce the associated complications.     

Urodynamics in the anatomical work of Leonardo da Vinci (1452–1519)

Leonardo da Vinci (1452–1519) incorporates the symbiosis of art and medicine and can be adressed as the founder of medical illustration in the time of the Renaissance. His anatomy studies were not published in his time, which explains why Leonardo's outstanding knowledge of anatomy, physiology, and medicine had no impact on his scientific contemporaries and is therefore primarily of retrospective importance in the history of medicine. The collection of anatomical illustrations remained unknown until their rediscovery in the eighteenth century and their wide publication at the beginning of our century. This article systematically reviews Leonardo's genitourinary drawings with regard to urodynamic aspects of the upper and lower urinary tract, highlighting topics such as vesicoureteral reflux and urinary sphincter mechanisms.     

Robot-assisted (da Vinci) laparoscopy: the beginning of a new era in operative urology?

The da Vinci Surgical System represents a new technology in advanced laparoscopy: Sitting at a console that allows three-dimensional vision of the operating field, the robotic surgeon is enabled to perform complex laparoscopic procedures. The movements of telemanipulators ("masters") are transferred to EndoWrist instruments with all degrees of freedom. Compared with conventional laproscopy, the technology allows more dexterity, a shorter learning curve, improved vision, reduced operating time with reduced staff requirements, and an ergonomically designed work station with minimal burden on the back and joints. The following article describes the principles of this technology and the challenges of the capital investment and the running costs.     

Selecting patients during the “learning curve” of endoscopic Totally Extraperitoneal (TEP) hernia repair

Background

Totally Extraperitoneal (TEP) hernia surgery is associated with little postoperative pain and a fast recovery, but is a technically demanding operative procedure. Apart from the surgeon’s expertise, patient characteristics and hernia-related variations may also affect the operative time and outcome.

Methods

Patient-related factors predictive of perioperative complications, conversion to open anterior repair, and operative time were studied in a cohort of consecutive patients undergoing TEP hernia repair from 2005 to 2009.

Results

A total of 3,432 patients underwent TEP. The mean operative time was 26 min (SD ± 10.9), TEP was converted into an open anterior approach in 26 patients (0.8 %), and perioperative complications were observed in 55 (1.6 %) patients. Multivariable regression analysis showed that a history of abdominal surgery (OR 1.76, 95 per cent confidence interval 1.01–3.06; p = 0.05), and the presence of a scrotal (OR 5.31, 1.20–23.43; p = 0.03) or bilateral hernia (OR 2.25, 1.25–4.06; p = 0.01) were independent predictive factors of perioperative complications. Female gender (OR 5.30. 1.52–18.45; p = 0.01), a history of abdominal surgery (OR 3.96, 1.72– 9.12; p = 0.001), and the presence of a scrotal hernia (OR 34.84, 10.42–116.51, p < 0.001) were predictive factors for conversion. A BMI ≥ 25 (effect size (ES) 1.78, 95 % confidence interval 1.09–2.47; p < 0.001) and the presence of a scrotal (ES 5.81, 1.93–9.68; p = 0.003), indirect (ES 2.78, 2.05– 3.50, p < 0.001) or bilateral hernia (ES 10.19, 9.20–11.08; p < 0.001) were associated with a longer operative time.

Conclusion

Certain patient characteristics are, even in experienced TEP surgeons, associated with an increased risk of conversion and complications and a longer operative time. For the surgeon gaining experience with TEP, it seems advisable to select relatively young and slender male patients with a unilateral (non-scrotal) hernia and no previous abdominal surgery to enhance patient safety and ‘surgeon comfort’.     

Standardize the Surgical Technique and Clarify the Relevant Anatomic Concept for Complete Mobilization of Colonic Splenic Flexure Using da Vinci Xi® Robotic System

World Journal of Surgery - The present study is to set up a standardized approach for complete mobilization of colonic splenic flexure using da Vinci Xi® robotic system, based on clarification...     

Zygoma fixture in the management of advanced atrophy of the maxilla: technique and long‐term results

Despite refinements in surgical technique, including bone grafting and sophisticated prosthetic reconstructions, there are limitations to what can be achieved with bone‐anchored fixed prostheses in patients with advanced atrophy of the maxillae. A new approach was suggested by a long‐term study on onlay bone grafting and simultaneous placement of a fixture based on a new design: the zygoma fixture, and the aim of this study was to assess its potential. Twenty‐eight consecutive patients with severely resorbed edentulous maxillae were included, 13 of whom had previously had multiple fixture surgery in the jawbone that had failed. A total of 52 zygoma fixtures and 106 conventional fixtures were installed. Bone grafting was deemed necessary in 17 patients. All patients have been followed for at least five years, and nine for up to 10 years. All patients were followed up with clinical and radiographic examinations, and in some cases rhinoscopy and sinoscopy as well. Three zygoma fixtures failed; two at the time of connection of the abutment and the third after six years. Of the conventional fixtures placed at the time of the zygoma fixture, 29 (27%) were lost. The overall prosthetic rehabilitation rate was 96% after at least five years of function. There were no signs of inflammatory reaction in the surrounding antral mucosa. Four patients with recurrent sinusitis recovered after inferior meatal antrostomy. To conclude, the zygoma fixture seems to be a valuable addition to our repertoire in the management of the compromised maxilla.     

Single-incision laparoscopic splenectomy using the ��tug-exposure technique�� in adults: results of ten initial cases

Background  

The application of single-incision laparoscopic surgery (SILS) to splenectomy is still challenging with much room for technical improvement. The purpose of this study was to describe the tug-exposure technique, an innovative technique for performing safe single-incision laparoscopic splenectomy (SILS-Sp).