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1.
Taichi Sakaguchi Toshinori Totsugawa Kentaro Tamura Arudo Hiraoka Genta Chikazawa Hidenori Yoshitaka 《General thoracic and cardiovascular surgery》2018,66(6):321-326
Objective
Despite excellent long-term results reported for a trans-aortic septal myectomy for hypertrophic obstructive cardiomyopathy (HOCM), surgery for patients with diffuse hypertrophy is very challenging. In addition, a left ventricular outflow obstruction is often aggravated by an abnormal mitral valve and subvalvular apparatus.Methods
We performed video-assisted minimally invasive trans-mitral septal myectomy procedures in 3 patients with diffuse-type HOCM, who were highly symptomatic despite maximal medical therapy. Each had at least moderate mitral regurgitation (MR) due to systolic anterior motion (SAM). Using a right mini-thoracotomy, the anterior mitral leaflet was detached, through which an extended septal myectomy could easily be performed. Abnormal bridging chordae between the septum and papillary muscle (PM) were divided, then anterior mitral leaflet continuity was restored with direct closure or augmentation using a glutaraldehyde-treated autologous pericardium. A PM reorientation procedure was performed in 1 case in which both PMs were approximated and sutured onto the posterior ventricular wall.Results
The postoperative course was uneventful in all patients, with marked improvement of symptoms in each. The peak ventricular outflow gradient decreased from 134?±?40 to 23?±?5 mmHg with significantly diminished SAM, especially in the patient who underwent the PM reorientation procedure. During a mean follow-up period of 42?±?14 months, no MR has been detected in any case.Conclusions
We believe that a minimally invasive trans-mitral septal myectomy is preferable for HOCM-patients with diffuse hypertrophy and mitral valve abnormality. Aggressive PM reorientation may also be useful for those with an abnormal PM orientation.2.
Objective
One of the techniques used in the treatment of tracheoesophageal fistula is applying the umbrella catheter, designed for closure of atrial septal defects, in this region. In the literature, we have encountered only 9 case reports in this regard. We shared a successfully closed tracheoesophageal fistula case with this technique.Case
A tracheoesophageal fistula in a 47-year-old male patient was successfully closed with an atrial septal defect occluder device. The patient died on the 42nd day after the procedure with no atrial septal defect occluder device-related problems.Conclusion
Using of atrial septal defect occluder device may be an appropriate option for tracheoesophageal fistula treatment. It can be said that the procedure is successful when the device is completely covered. Even so, there is a need for multi-centered, randomized, controlled studies of large series about the subject.3.
Objective
To investigate the feasibility and necessity of endoscopic thyroidectomy with central lymph node dissection via the combined breast and trans-oral approaches.Methods
Six patients with papillary thyroid carcinoma who underwent endoscopic total thyroidectomy with central node dissection via combined breast and trans-oral approaches from November 2014 to January 2015 in Zhongshan Hospital, Xiamen University, were analyzed.Results
After completion of endoscopic central lymph node dissection via the traditional breast approach, eight pieces of lymph nodes could still be dissected via the trans-oral approach. Two of these eight pieces were positive for thyroid cancer metastasis.Conclusions
It is advisable to perform endoscopic central lymph node dissection for thyroid carcinoma via the breast approach combined with the trans-oral approach.4.
Introduction
Laparoscopic and robotic surgery of the pancreas has only recently emerged as viable treatment options for benign and malignant disease. This review seeks to evaluate the current body of evidence on these approaches to pancreaticoduodenectomy and distal pancreatectomy.Methods
A systematic review of large published series was performed utilizing the PubMed search engine.Results
Based on these reports, both the laparoscopic and robotic techniques for these complex procedures appear to be safe and effective, if performed by high volume experienced pancreatic surgeons. The advantages of each approach are highlighted, emphasizing the data available on the learning curve and potential dissemination.Conclusions
Both minimally invasive approaches to pancreatic resection are safe and feasible.5.
Purpose
Bladder exstrophy is defined by urogenital and skeletal abnormalities with cosmetic and functional deformity of the lower anterior abdominal wall. The primary management objectives have historically been establishment of urinary continence with renal function preservation, reconstruction of functional and cosmetically acceptable external genitalia, and abdominal wall closure of some variety. The literature has focused on the challenges of neonatal approaches to abdominal wall closure; however, there has been a paucity of long-term followup to identify the presence and severity of abdominal wall defects in adulthood. Our goal was to characterize the adult disease and determine effective therapy.Methods
A retrospective review of a consecutive series of six patients was performed.Results
We report and characterize the presence of severe abdominal wall dysfunction in these adult exstrophy patients treated as children. We tailored an abdominal wall and pelvic floor reconstruction with long-term success to highlight a need for awareness of the magnitude of the problem and its solvability.Conclusions
The natural history of abdominal wall laxity and the long-term consequences of cloacal exstrophy closure have gone unexplored and unreported. Evaluation of our series facilitates understanding in this complex area and may be valuable for patients who are living limited lives thinking that no solution is available.6.
Hirano Y Ishikawa N Omura K Inaki N Hiranuma C Waseda R Watanabe G 《Surgical endoscopy》2007,21(11):2112-2114
Background
Intragastric surgery is accepted as a minimally invasive procedure for mucosal or submucosal lesions. Robotic surgery promises to extend the capabilities of the minimally invasive surgeon and many surgical specialties are applying this new technology. However, there is no report of robotic intragastric surgery. We describe the use of the da Vinci® Surgical System for intraluminal mucosal resection of the stomach.Methods
We developed our porcine intragastric surgery model using the Tuebingen MIS Trainer. We set a tentative lesion on the posterior wall near the esophagocardiac junction (ECJ) of the stomach and performed mucosal resection of the lesion using the da Vinci Surgical System. We also performed closure of the defect after mucosal resection and subsequent closure of the intentional gastric perforation.Results
Using our porcine intragastric surgery model, we successfully performed mucosal resection of the tentative lesion. We also smoothly completed closure of the defect and closure of the perforation without any complications. The mean size of the mucosa was 6 cm and the mean duration of the procedure was only 12 min.Conclusions
The safety and efficacy of robotic intragastric surgery was preliminarily established in this study. However, further studies are needed to prove its practical feasibility in humans using the da Vinci Surgical System to make it an effective operation.7.
Leontine H. Wijngaarden Sophie L. van Veldhuisen René A. Klaassen Erwin van der Harst Charles C. van Rossem Ahmet Demirkiran Steve M. M. de Castro Frederik H. W. Jonker 《Obesity surgery》2018,28(12):3801-3808
Background
Internal herniation (IH) is one of the most common long-term complications after laparoscopic Roux-en-Y gastric bypass (LRYGB). Diagnosis of IH may be difficult, and not all patients with suspected IH will have full relief of symptoms after closure of both mesenteric defects.Objectives
To investigate possible predictive factors for relief of symptoms in patients with suspected IH.Methods
All patients that underwent reoperation for (suspected) IH after LRYGB from June 2009 to December 2016 were retrospectively evaluated in this multicentre cohort study. Logistic regression analysis was used to identify predictive factors for pain relief after closure of the mesenteric defects.Results
A total of 193 patients underwent laparoscopy for (suspected) IH during the study period. The median interval between LRYGB and reoperation was 18.3?±?19.0 months. In 40.2% of cases, IH was identified on computed tomography (CT), and IH was objectified during surgery in 61.1%. Postoperative symptom relief was observed in 146 patients (77.2%). For patients in which IH was present during surgery, 82.8% had relief of pain postoperatively, as compared to 68.5% for those procedures in which no IH was found. The only significant predictor for postoperative pain relief was a swirl sign on CT (OR 4.24, 95%CI 1.63–11.05).Conclusions
Pain relief after closure of the mesenteric defects for IH remains unpredictable. A positive CT for IH was a predictive factor for symptom relief after reoperation for (suspected) IH after LRYGB. However, many patients benefit from closure of the mesenteric defects, irrespective of perioperative presence of IH.8.
Gurpreet S. Gandhoke Zachary J. Tempel Christopher M. Bonfield Ricky Madhok David O. Okonkwo Adam S. Kanter 《European spine journal》2015,24(3):353-360
Purpose
Contemporary minimally invasive techniques have evolved to enable direct access to the anterior spinal column via the extreme lateral approach. We have employed this access approach to treat selected burst fractures. We report our technique. Thoracolumbar burst fractures that require surgical intervention have traditionally been managed with anterior, posterior, or combined approaches.Methods
We have applied the minimally invasive extreme lateral approach to perform vertebral corpectomy, cage placement, and lateral instrumentation to treat burst fractures. Indications for surgery were incomplete spinal cord injury with persistent neural element compression due to ventral fracture fragments in the canal. We present the technical nuances of this surgical approach for the treatment of thoracolumbar burst fractures with two case illustrations.Results
There were no peri- or intra-operative complications. Both patients in our series remained neurologically intact at their last follow-up (11 and 29 months, respectively), and maintained their correction of kyphosis.Conclusion
The minimally invasive extreme lateral approach is an effective treatment option for the management of thoracolumbar burst fractures.9.
Background
It is universally agreed that successful and gentle initial bladder closure is decisive for favorable long-term outcome. Due to a number of reasons, including a lack of comparable multicenter studies, there are numerous concepts for initial exstrophy closure.Discussion
Therefore, we describe our concept of delayed, staged reconstruction without osteotomy in classical bladder exstrophy, while taking into considerion the available literature on long-term follow-up as well as on own clinical and research data.Conclusion
Most notably there are multiple medical but also psychological advantages of a delayed procedure. Primary closure without osteotomy is feasible and has no disadvantages in the long-term follow-up when compared to the invasive procedure of osteotomy. Due to high intravesical pressure, initial bladder neck surgery might have negative effects on bladder development and on the upper urinary tract.10.
Introduction
Minimally invasive esophagectomy has gained popularity over the past two decades. The procedural goal is to decrease the high overall morbidity of a traditional open esophageal resection. The entire spectrum of open esophagectomy techniques has been successfully replicated in a minimally invasive fashion.Discussion
Esophagectomy remains one of the most technically challenging operations, and developing the skills necessary for minimal invasive esophagectomy is associated with a steep learning curve. Minimally invasive approaches show most promise for benign disease and select early esophageal cancers, but their role in more advanced cancer remains controversial due to lack of long-term results.Conclusion
As minimally invasive esophagectomy matures, its true value in both benign and malignant disorders will become better defined.11.
Purpose
To investigate whether defect closure in laparoscopic ventral hernia repair reduces the re-operation rate for recurrence compared with no defect closure.Methods
Data were extracted from the Danish Ventral Hernia Database. Adults with an elective laparoscopic ventral hernia repair with tacks used as mesh fixation were included, if their first repair was between the 1st of January 2007 and the 1st of January 2017. Patients with defect closure were compared with no defect closure. Re-operation rates are presented as crude rates and cumulated adjusted re-operation rates. Sub-analyses assessed the effect of the suture material used during defect closure and also whether defect closure affected both primary and incisional hernias equally.Results
Among patients with absorbable tacks as mesh fixation, 443 received defect closure and 532 did not. For patients with permanent tacks, 393 had defect closure and 442 did not. For patients with permanent tacks as mesh fixation, the crude re-operation rates were 3.6% with defect closure and 7.2% without defect closure (p?=?0.02). The adjusted cumulated re-operation rate was significantly reduced with defect closure and permanent tacks (hazard ratio?=?0.53, 95% confidence interval?=?0.28–0.999, p?=?0.05). The sub-analysis suggested that defect closure was only beneficial for incisional hernias, and not primary hernias. We did not find any benefits of defect closure for patients with absorbable tacks as mesh fixation.Conclusion
This nationwide cohort study showed a reduced risk of re-operation for recurrence if defect closure was performed in addition to permanent tacks as mesh fixation during laparoscopic incisional hernia repair.12.
Background
A minority of patients undergoing posterior component separation (PCS) have abdominal wall defects that preclude complete reconstruction of the visceral sac with native tissue. The use of absorbable mesh bridges (AMB) to span such defects has not been established. We hypothesized that AMB use during posterior sheath closure of PCS is safe and provides favorable outcomes.Methods
We performed a retrospective review of consecutive patients undergoing PCS with AMB at two hernia centers. Main outcome measures included demographics, comorbidities, and post-operative complications.Results
36 patients were identified. Post-operative wound complications included five surgical site infections. At a median of 27 months, there were five recurrent hernias (13.9%), 2 of which were parastomal, but no episodes of intestinal obstruction/fistula.Conclusions
Utilization of AMB for large posterior layer deficits results in acceptable rates of perioperative wound morbidity, effective PCS repairs, and does not increase intestinal morbidity or fistula formation.13.
Louise T. S. Arenholt Bodil Ginnerup Pedersen Karin Glavind Marianne Glavind-Kristensen John O. L. DeLancey 《International urogynecology journal》2017,28(5):661-673
Introduction and hypothesis
The paravaginal defect has been a topic of active discussion concerning what it is, how to diagnose it, its role in anterior vaginal wall prolapse, and if and how to repair it. The aim of this article was to review the existing literature on paravaginal defect and discuss its role in the anterior vaginal wall support system, with an emphasis on anatomy and imaging.Methods
Articles related to paravaginal defects were identified through a PubMed search ending 1 July 2015.Results
Support of the anterior vaginal wall is a complex system involving levator ani muscle, arcus tendineus fascia pelvis (ATFP), pubocervical fascia, and uterosacral/cardinal ligaments. Studies conclude that physical examination is inconsistent in detecting paravaginal defects. Ultrasound (US) and magnetic resonance imaging (MRI) have been used to describe patterns in the appearance of the vagina and bladder when a paravaginal defect is suspected. Different terms have been used (e.g., sagging of bladder base, loss of tenting), which all represent changes in pelvic floor support but that could be due to both paravaginal and levator ani defects.Conclusion
Paravaginal support plays a role in supporting the anterior vaginal wall, but we still do not know the degree to which it contributes to the development of prolapse. Both MRI and US are useful in the diagnosis of paravaginal defects, but further studies are needed to evaluate their use.14.
Background
Endoscopic vacuum therapy is a widespread method in the postoperative treatment of lower and upper gastrointestinal (GI) tract leakage.Objective
There is an absence of further technical development of the standardized material from 2007 for the lower GI tract.Material and methods
New strategies and new materials for endoscopic vacuum therapy are presented.Results
Alternative strategies in sponge placement, use of open-pore film drainage, use of a multiple sponge system, rinsing catheter, electronic pumps etc. enable the successful treatment of very complex pelvic defects.Conclusion
The wide variability of pelvic defects often necessitates a change in therapeutic strategies during the course of treatment for an optimized outcome.15.
Alberto Martini Eugenio Dattolo Jacopo Frizzi Donata Villari Maria Cristina Paoletti 《International urogynecology journal》2016,27(8):1277-1278
Introduction and hypothesis
A vesico-vaginal fistula (VVF) is a fistulous tract that connects bladder and vagina, causing urine leakage via the vagina. In the developed world, iatrogenic postoperative VVF is the most common case. Classically, when treating a VVF via the abdominal route, an abdominal flap is mobilized and interposed between the bladder and the vagina.Methods
In our video, we describe a robotic VVF repair technique with no omental flap interpositioning for a vaginal vault-located fistula.Results
Duration of surgery was 95 min, estimated blood loss was <50 ml. The postoperative course was uneventful. At the 6-month follow-up, which included clinical and cystographic examinations, the patient had not experienced any recurrence.Conclusion
In our opinion, a two-layered suturing technique using two semi-continuous sutures for vaginal closure and perpendicular interrupted stitches for bladder closure does not require omental flap mobilization, reducing operating time and possible complications related to accidental peritoneal injuries.16.
17.
Rodolfo Milani Stefano Manodoro Alice Cola Stefania Palmieri Claudio Reato Matteo Frigerio 《International urogynecology journal》2018,29(11):1705-1707
Introduction and hypothesis
Enterocele repair represents a challenge for pelvic surgeons. Surgical management implies enterocele sac removal. Subsequently, hernial port closure and adequate suspension may be achieved with Shull uterosacral ligament suspension (ULS).Methods
A 55-year-old woman with symptomatic stage 3 enterocele was admitted for transvaginal uterosacral ligaments suspension according to the described technique.Results
Surgical procedure was successfully achieved without complications. Final examination revealed excellent pelvic supports and preservation of vaginal length. This step-by-step video tutorial may represent an important tool to improve surgical know-how.Conclusions
Transvaginal uterosacral ligaments suspension provides a safe and effective technique for enterocele repair without the use of prosthetic materials. Identifying uterosacral ligaments, proper suture placement, and reapproximation of pubocervical and rectovaginal fascias with closure of the hernial port are the key points to achieve surgical success.18.
Background
Open fractures continue to be a challenge to orthopedic trauma surgeons and controversies with respect to best clinical practice are common. Meticulous management of soft tissue damage is of particular importance to achieve the optimal course; however, many treatment protocols lack evidence-based data.Methods
The authors performed a critical review of the literature involving recommendations on the management of soft tissue damage in open fractures. Studies were selected based on their relevance to clinical treatment of open fractures.Results
A total of 29 studies were included. The review focused on timing of initial débridement, time until wound closure, utilitization of negative pressure wound therapy (NPWT), the necessity for plastic surgery and and administration of antibiotics in the therapy of open fractures.Conclusion
Open fractures require urgent debridement. Timely wound closure dependent on successful removal of all necrotic tissue decreases the rate of complications. A calculated short-term administration of antibiotics is essential to avoid infections. Finally, despite the utmost importance of NPWT in the treatment of wounds associated with open fractures, flap coverage of tissue defects remains an integral component of the limb salvage algorithm.19.
Purpose
Evaluation and surgical management for adult spinal deformity (ASD) patients varies between health care providers. The purpose of this study is to identify appropriateness of specific approaches and management strategies for the treatment of ASD.Methods
From January to July 2015, the AOSpine Knowledge Deformity Forum performed a modified Delphi survey where 53 experienced deformity surgeons from 24 countries, rated the appropriateness of management strategies for multiple ASD clinical scenarios. Four rounds were performed: three surveys and a face-to-face meeting. Consensus was achieved with ≥70% agreement.Results
Appropriate surgical goals are improvement of function, pain, and neural symptoms. Appropriate preoperative patient evaluation includes recording information on history and comorbidities, and radiographic workup, including long standing films and MRI for all patients. Preoperative pulmonary and cardiac testing and DEXA scan is appropriate for at-risk patients. Intraoperatively, appropriate surgical strategies include long fusions with deformity correction for patients with large deformity and sagittal imbalance, and pelvic fixation for multilevel fusions with large curves, sagittal imbalance, and osteoporosis. Decompression alone is inappropriate in patients with large curves, sagittal imbalance, and progressive deformity. It is inappropriate to fuse to L5 in patients with symptomatic disk degeneration at L5–S1.Conclusions
These results provide guidance for informed decision-making in the evaluation and management of ASD. Appropriate care for ASD, a very diverse spectrum of disease, must be responsive to patient preference and values, and considerations of the care provider, and the healthcare system. A monolithic approach to care should be avoided.20.