Result of IOFIX (Intra Osseous FIXation) device for first metatarsophalangeal joint arthrodesis: A single surgeon’s series

Background

Arthrodesis of the first metatarsophalangeal joint (MTPJ) is a common procedure to treat significant first MTPJ arthritis. However, dorsal plates used for this have been associated with high incidence of metalwork removal. The IOFIX (Intra-Osseous FIXation) is a fixed angle device that is noted to provide a more uniform compression over a larger aspect of the fusion surfaces than a screw construct alone with the advantage of minimizing soft tissue irritation which can reduce the need for subsequent implant removal.

A single surgeon’s experience transitioning to robotic-assisted right colectomy with intracorporeal anastomosis

Surgical Endoscopy - Despite substantial evidence demonstrating benefits of minimally invasive surgery, a large percentage of right colectomies are still performed via an open technique. Most...     

Laparoscopic versus robotic right colectomy: a single surgeon’s experience

There is increased interest in robotic techniques for colon resection, but the role of robotics in colorectal surgery has not yet been defined. The purpose of this study was to compare our recent experience with robotic right colectomy to that with laparoscopic right colectomy. From November 2008 to June 2011, a total of 47 consecutive patients underwent elective, right colectomy: 25 laparoscopic right colectomies (LRC) and 22 robotic right colectomies (RRC). All procedures in this study were performed by a single, board-certified colon and rectal surgeon (H.J.L.). Main outcomes recorded included conversion rate, operative time (OT), estimated blood loss (EBL), length of extraction sites, length of stay (LOS), and complications. Data studied were prospectively recorded in a database and were retrospectively reviewed. Mean OT for LRC was 107 ± 36.7 min (median 98, range 48–207) and for RRC was 189.1 ± 38.1 min (median 185, range 123–288, P < 0.001). Mean total operating room time (TORT) for LRC was 158.6 ± 38.1 min (median 149, range 104–274) and for RRC was 258.3 ± 40.9 (median 251, range 182–372, P < 0.001). The tendency lines for both OT and TORT decreased over time for RRC. EBL for LRC was 70.2 ± 52.9 ml (median 50, range 10–200) and for RRC was 60.8 ± 71.3 ml (median 40, range 10–300, P = 0.037). The mean extraction site length for the laparoscopic group was 5.3 ± 1.3 cm (median 5, range 4–11) and for the robotic group was 4.6 ± 0.7 cm (median 4.5, range 3.5–6, p = 0.008). LOS was similar for both groups, as were complications. No cases were converted to open. No leaks occurred and there was no 30-day mortality. RRC is safe and feasible, with similar outcomes to LRC. Operative times were longer for RRC; however, they compare favorably with times for LRC published in the literature. Extraction site length and EBL were less for RRC. However, further study is necessary to demonstrate the clinical relevance of these findings. We are optimistic that OT and TORT will continue to improve.     

A hand surgeon’s guide to common onychodystrophies

The human fingernail contributes to the precise dexterity of the fingers, enhances sensibility, allows manipulation of fine objects, and shields the fingertip from traumatic injury. Nail abnormalities are a common incidental finding in the course of a hand surgeon’s daily practice. These abnormalities may be clues to systemic, dermatologic, traumatic, and infectious processes that would benefit from further evaluation and treatment. The purpose of this review is to discuss common nail dystrophies and their related diagnoses.     

Robot-assisted spleen-preserving distal pancreatectomy: a single surgeon’s experiences and proposal of clinical application

Background

Advanced and delicate laparoscopic techniques are usually required for safe and successful laparoscopic spleen-preserving distal pancreatectomy. The unique characteristics of robotic surgical system are thought to be useful for this minimally invasive procedure.

Methods

From September 2007 to May 2011, patients who underwent robot-assisted, spleen-preserving, distal pancreatectomy for benign and borderline malignant tumors of the pancreas were retrospectively reviewed. Perioperative clinicopathologic surgical outcomes were evaluated.

Results

Twenty-two patients were attempted for robot-assisted, spleen-preserving, distal pancreatectomy, and in 21 patients (95.5 %), the spleen was saved either by splenic vessels conservation (SVC; n = 17, 81 %) or by splenic vessels sacrifice (SVS; n = 4, 19 %). Seven patients were male and 15 were female with a mean age of 43.2 ± 15.2 years. Pathologic diagnosis included MCT in five patients, SCT in five, SPT in four, IPMT in three, NET in three, and other benign conditions in two. The mean operation time was 398.9 ± 166.3 min, but it gradually decreased as experiences were accumulated (Rsq = 0.223, p = 0.023). Intraoperative blood loss was 361.3 ± 360.1 ml, and intraoperative transfusion was required in four patients (18.1 %). A soft diet was given for 1.2 ± 0.4 days, and the length of hospital stay was 7.0 ± 2.4 days postoperatively. Clinically relevant pancreatic fistula was noted in two patients (9.1 %) but was successfully managed conservatively. Most patients (87.5 %) showed patency in conserved both splenic vessels, and only two patients (12.5 %) had partially or completely obliterated in splenic veins in the SVC-SpDP group. Partially impaired splenic perfusion was observed in one patient in the SVS-SpDP group. The perfusion defect area decreased without any clinical symptom after 4 months.

Conclusions

The robotic surgical system is thought to be beneficial for improving the spleen-preservation rate in laparoscopic distal pancreatectomy. Robot-assisted approach can be chosen for patients who require spleen-preserving distal pancreatectomy.     

Two-year outcomes after robotic renal surgery: a single surgeon’s experience

The purpose of this study is to validate the feasibility of the robotic technology for various types of renal surgery and to outline the 2-year clinical and pathological outcomes post surgery. In a retrospective chart review with IRB approval of 55 robotic renal surgeries, clinical data and pathological outcomes were recorded, including estimated glomerular filtration rate (eGFR), serum creatinine, radiological surveillance of tumor recurrences and overall quality of life on pre- and postoperative visits at 6, 12, 18 and 24 months. There were 26 robotic partial nephrectomy (RPN), 23 radical nephrectomy (RRN), 3 simple nephrectomy (RSN), and 3 radical nephroureterectomy (RNU) procedures. Twelve patients in the RPN group, 17 in the RRN group and all in the RSN and RNU groups had eGFR <60 ml/min/1.73 m² and one or more risk factors for chronic kidney disease (CKD) preoperatively. Mean serum creatinine was 1.2, 1.3, 1.2, and 1.8, and eGFR was 66.4, 61.2, 55.8, and 41.0, respectively. There were two distant metastasis and four local recurrences in the RRN group, and two local recurrences in the RNU group. Serum creatinine and changes in eGFR were statistically similar in all groups postoperatively. Cancer-specific survival was 100% for RPN, 83% for RRN, and 100% for RNU while overall survival was 100% for RPN, 76% for RRN, 100% for RSN, and 100% for RNU at 2 years. Robotic renal surgery is a feasible, minimally invasive alternative with promising outcomes in our short-term follow-up. Long-term and comparative studies with open or conventional laparoscopic approaches are needed.     

One-layer pancreaticojejunostomy using reinforcing sutures in pancreaticoduodenectomy: A single surgeon’s experience with 122 cases

BackgroundDiscussions about pancreaticojejunostomy (PJ), which can reduce the incidence of postoperative pancreatic fistula (POPF) in pancreaticoduodenectomy (PD), are ongoing. Here we introduce the surgical technique of PJ performed at our hospital and analyze its safety and advantages.MethodsWe retrospectively analyzed 122 patients who underwent one-layer PJ using reinforcing sutures in PD. PJ was performed with reinforcing sutures on the pancreatic stump, including the insertion of a soft silastic catheter for internal drainage followed by suturing of the pancreas and jejunum with one layer.ResultsOf the 122 patients who underwent PJ with this technique, 62 (50.8%) developed POPF. However, 37 (30.3%) had grade A that did not affect the hospital course. Critical POPF occurred in 25 patients: grade B in 20 (16.4%) and grade C in 5 (4.1%). There was no significant difference in the critical POPF patient group according to the pancreas related disease related to pancreatic texture.ConclusionAlthough this technique cannot prevent POPF, we noted no significant difference in POPF versus other surgical techniques. In addition, this technique, which was designed to increase pancreatic texture, is practical and simple for PJ. Therefore, the inexperienced hepatobiliary and pancreatic surgeon can perform it without major complications.     

The learning curve for hand-assisted laparoscopic colectomy: a single surgeon’s experience

Background Surgical experience and outcomes for hand-assisted laparoscopic colectomy were evaluated to define a learning curve. Methods This study included 60 patients who underwent hand-assisted laparoscopic colectomies performed by a single surgeon. They were analyzed as three consecutive equal groups: A, B, and C. Pearson’s chi-square test and one-way analysis of variance (ANOVA) were used to compare differences in demographics and perioperative parameters. Operative times were analyzed to document the learning curve for the procedure. Results There were no significant differences between the three groups in terms of age, sex, operative procedure, or comorbidity. Groups B and C showed significantly shorter operative times, significantly earlier recoveries of gastrointestinal function, less blood loss, and shorter hospital stays than group A. The incidence of operative complications was not significantly different among the three groups (35% vs 5% vs 15%; p = 0.07). Conclusions Approximately 21 to 25 cases were needed to achieve proficiency in this series. Presented at the meeting of The American Society of Colon and Rectum Surgeons, New Orleans, Louisiana, 21–26 June 2003     

A comparison of surgeon’s postural muscle activity during robotic-assisted and laparoscopic rectal surgery

This study compared the muscular activity in the surgeon’s neck and upper limbs during robotic-assisted laparoscopic (R-Lap) surgery and conventional laparoscopic (C-Lap) surgery. Two surgeons performed the same procedure of R-Lap and C-Lap low anterior resection, and real-time surface electromyography was recorded in bilateral cervical erector spinae, upper trapezius (UT) and anterior deltoid muscles for over 60 min in each procedure. In one surgeon, forearm muscle activities were also recorded during robotic surgery. Similar levels of cervical muscle activity were demonstrated in both types of surgery. One surgeon showed much higher activity in the left UT muscle during robotic surgery. In the second surgeon, C-Lap was associated with much higher levels of muscle activity in both UT muscles. This may be related to the bilateral abducted arm posture required in maneuvering the laparoscopic instruments. In the forearm region, the “ulnaris” muscles for wrist flexion and extension bilaterally showed high amplitudes during robotic-assisted surgery. Robotic-assisted surgery seemed to demand a higher level of muscle work in the forearm region while greater efforts of shoulder muscles were involved during laparoscopic surgery. There are also individual variations in postural habits and motor control that can affect the muscle activation patterns. This study demonstrated a method of objectively examining the surgeon’s physical workload during real-time surgery in the operating theatre, and further research should explore the surgeon’s workload in a larger group of surgeons performing different surgical procedures.     

Harvey Cushing’s case series of trigeminal neuralgia at the Johns Hopkins Hospital: a surgeon’s quest to advance the treatment of the ‘suicide disease’

Background  

A review of Dr. Harvey Cushing’s surgical cases at the Johns Hopkins Hospital provided insight into his early work on trigeminal neuralgia (TN). There was perhaps no other affliction that captured his attention in the way that TN did, and he built a remarkable legacy of successful treatment. At the time, surgical interventions carried an operative mortality of 20%.     

Discordance between the patient’s and surgeon’s perception of complications following hernia surgery

Background: The study was undertaken in order to assess the degree of concordance between the patients and surgeons perceptions of adverse events after groin hernia surgery.Methods: 206 patients who underwent elective surgery for groin hernia at Samariterhemmet, Uppsala, Sweden in 2003 were invited to a follow-up visit after 3–6 weeks. At this visit the patient was instructed to answer a questionnaire including 12 questions concerning postoperative complications. A postoperative history was taken and a clinical examination performed by a surgeon who was not present at the operation and did not know the outcome of the questionnaire. All complications noted by the physician were recorded for corresponding questions in the questionnaire.Results: 174 (84.5%) patients attended the follow up, 161 men and 13 women. A total of 190 complications were revealed by the questionnaire, 32 of which had caused the patient to seek help from the health-care system. There were 131 complications registered as a result of the follow-up clinical examinations and history. Kappa levels ranged from 0.11 for urinary complications to 0.56 for constipation.Conclusion: In general, the concordance was poor. These results emphasise the importance of providing detailed information about the usual postoperative course prior to the operation. Whereas the surgeon, from a professional point of view, has a better idea about what should be expected in the postoperative period and how any complications should be categorised, only the patient has a complete picture of the symptoms and adverse events. This makes it impossible to reach complete agreement between the patients and surgeons perceptions of complications, even under the most ideal circumstances.     

Gossypiboma-an unusual cause of surgical abdomen and surgeon’s nightmare: A rare case report

IntroductionThe term Gossypiboma is used to describe a retained surgical sponge in body after surgical procedure. It is an infrequent but serious surgical complication which is seldom reported because of the medicolegal implications. It can present within days as a surgical emergency or years after the operation.Case presentationWe report a case of 30-year-old female who presented in emergency with acute pain abdomen and severe distention of abdomen. She had history of caesarean section 15 days ago at another hospital. On clinical examination and investigation, it appeared like a surgical abdomen. Contrast enhanced computed tomography suspected an intrabdominal Gossypiboma. On exploratory laparotomy there was a lump in left side of abdominal cavity. Retained surgical sponge was removed that confirmed the diagnosis of Gossypiboma.DiscussionGossypiboma is a real, serious but preventable surgical complication. It affects the patient safety, cost of treatment and may cause mortality if there is delay in diagnosis and treatment. It is commonly seen in emergency and difficult surgeries. Its clinical presentation is extremely variable. It can cause acute surgical abdomen, that needs urgent surgical intervention.ConclusionMeticulous counts of surgical items with careful inspection of surgical site can lessen these complications. Radio frequency chip identification verification by barcode scanner can reduce the error rate.     

Single-port laparoscopic surgery is applicable to most gynecologic surgery: a single surgeon’s experience

Background  

The aim of this study was to evaluate the use of single-port laparoscopic surgery in benign gynecologic diseases and to examine its impact on surgical outcomes.     

Minimally invasive repair of pectus carinatum: a retrospective analysis based on a single surgeon’s 10 years of experience

Objectives

Over the past decade, minimal invasive surgery for correction of pectus carinatum has gained worldwide acceptance. This study reviews our clinical experience with minimally invasive repair of pectus carinatum (MIRPC) since 2008.

Methods

Between 2008 and 2018, 101 patients (77 male, 24 female) underwent correction of pectus carinatum with the MIRPC technique. The mean age of the patients was 14.7?±?4.8 (3–38) years. Over an 8 years’ experience we slightly modified the original Abramson technique. All patients presented with cosmetic complaints and all had a flexible chest wall on “compression test”. Early follow-up was on postoperative day 15 and 30.

Results

The mean operative time was 42.1?±?16.9 min. The mean hospital stay was 4.2?±?0.9 days. Postoperative complications included pneumothorax (n?=?2, 1.9%), wound infection (n?=?2, 1.9%), skin perforation (n?=?2, 1.9%), intolerable pain (n?=?1, 0.9%), skin hyperpigmentation (n?=?1, 0.9%), and overcorrection (n?=?1, 0.9%). Initial postoperative results were excellent in all patients. The bars were removed at a median of 24.8?±?4.5 months in 44 of 101 patients. 43 of 44 (97.7%) patients whose bar were removed reported excellent results.

Conclusions

MIRPC is a feasible procedure with low morbidity and excellent cosmetic results in the treatment of pectus carinatum deformities in selected patients.

     

Hip fractures and Parkinson’s disease: A case series

There are no specific guidelines for treating Parkinson’s disease patients who present with a hip fracture. Here we present a large cohort of patients with Parkinson’s disease who suffered hip fractures. Our aim was to assess for differences between a Parkinson’s disease population and a non-Parkinson’s disease population with hip fractures and make recommendations on management guidelines.We performed a comprehensive analysis of prospectively collected data on all patients with hip fracture who were admitted into our department over a period of 29 years.In total 9225 patients with hip fractures were included in this study, 452 (4.9%) patients had Parkinson’s disease. The mobility scores were worse pre- and post-operatively in the Parkinson’s group as were mini-mental scores and ASA grade. Post-operative complications were similar between the two groups, with no difference in dislocation rate or wound complications. However, other outcomes including mobility and mortality rate at 1 year were worse in the Parkinson’s group. These patients also had a longer hospital stay and were more likely to be immobile and discharged to an institution.We recommend that Parkinson’s disease patients should be assessed more thoroughly in the peri-operative period and arrangement for rehab and discharge planning should commence as soon as possible following admission. The consent process should reflect longer hospital stays, worse mobility, higher mortality and increased likelihood of discharge to institution but concern over increased complications, specifically dislocation was not evident in our data.     

A pediatric surgeon’s 35-year experience with pilonidal disease in a Canadian children’s hospital

Background

There is an ongoing debate regarding the optimal surgical management for pilonidal disease in the pediatric population. The purpose of this study was to evaluate a pediatric surgeon’s experience at a Canadian children’s hospital over 35 years.

Methods

We performed a retrospective review of the charts of patients seen and treated from July 1969 to December 2003, inclusive. All patients were evaluated for age, sex, clinical diagnosis, infection, treatment, healing time, complications and results.

Results

In all, 121 adolescents with pilonidal disease (64 boys, 57 girls) with a mean age of 15 (range 12–19) years were evaluated at the same children’s hospital. The 107 (88%) patients with infection (46% acute) underwent surgery. At operation, all 107 pilonidal cysts were either excised and packed open, marsupialized or excised and closed primarily without drainage under general anesthesia; the operation performed was arbitrarily chosen. Vacuum-assisted closure was not used. All patients received antibiotics. The time for healing after the initial operation in the group whose cysts were excised and packed open was at least twice as long (75 d) as in the other 2 groups (p = 0.031). Disease recurred in 24 (22%) patients, 6 (25%) of whom experienced 2 recurrences. Among the 90 patients in the excised and packed open group, 20 (22%) experienced recurrences and 5 (25%) experienced 2 recurrences. Among the 13 patients in the marsupialized group, 3 (23%) experienced recurrences and 1 (33%) experienced 2 recurrences. Among the 4 patients in the excised and closed primarily without drainage group, 1 (25%) experienced a recurrence and none experienced 2 recurrences (p = 0.12). Each recurrence was smaller than the original. All wounds eventually healed. There were no other complications and no deaths. A multivariable logistic regression analysis revealed that the type of surgical approach was not predictive of recurrence after controlling for age and sex.

Conclusion

Age, sex and surgical approach were not predictive of recurrence. From our experience, excision and packing open the wound produced a longer morbidity but offered the same results compared with marsupialization or excision and primary closure without drainage.     

Influence of surgeon’s experience on fluoroscopy time during endourological interventions

Introduction and objective

Fluoroscopy time influences radiation exposure of both surgeons and patients during endourological interventions. Changes in fluoroscopy habits of endourological surgeons after being informed about their fluoroscopy times were evaluated depending on their endourological experience.

Materials and methods

From April 2010 to April 2011, 402 endourological interventions in 337 Patients were assessed. Evaluated interventions were ureter stent placement (USP), ureter stent change (USC) nephrostomy change (NC), ureterorenoscopy (URS) and percutaneous nephrolithotomy (PCNL). Fluoroscopy time (FT) and operation time (OT) were recorded. For USP, USC and NC, the surgeons were divided into two groups: group I with >2 years of endourological experience and group II with <2 years experience. URS and PCNL only were performed by experienced surgeons. After 6 months, all surgeons were informed about their mean detected results. Both groups were compared, and changes in FT and OT in the second part of the study were analysed.

Results

Surgeons reduced their median fluoroscopy times up to 55 % after being informed about their fluoroscopy manners. Experienced surgeons reduced both operation and fluoroscopy times significantly for USP, USC and NC. For URS and PCNL, and OT and FT, the differences were not statistically significant. Inexperienced surgeons were not able to reduce both OT and FT significantly.

Conclusion

If experienced surgeons are informed about their fluoroscopy time during endourological interventions, fluoroscopy times can be reduced significantly in easy procedures, which leads to less radiation exposure of surgeons and patients. Inexperienced surgeons have less possibility to influence their fluoroscopy manners.