Robotic pelvic lymphadenectomy is a well established procedure in the urologic and gynecologic literature. To our knowledge robotic pelvic lymphadectomy for metastatic melanoma has yet to be described. Herein we present the first report of robot-assisted pelvic lymphadenectomy in malignant melanoma. After placement of six laparoscopic ports (12 mm camera, three 8-mm robotic ports, 12-mm and 5-mm assistant ports) the DaVinci S robot (Intuitive Surgical, CA, USA) was docked in standard fashion with the patient in low lithotomy. In both cases the patients had enlarged pelvic lymph nodes on computed tomography and complete excision of these masses was accomplished along with complete lymphadenectomy extending from Cooper’s ligament to just below the hypogastric artery in case 1 and to level of the bifurcation of aorta in case 2. A PK Maryland Dissector and monopolar scissors were used for dissection. Both patients were discharged on postoperative day #1. Robotic pelvic lymphadenectomy can be safely used for management of patients with metastatic melanoma involving the pelvic lymph nodes. Compared with the standard open procedure, pelvic lymphadenectomy with robotic assistance is associated with excellent vision and minimum morbidity.
Robotic; Lymphadenectomy; Melanoma; Laparoscopic; Minimally-invasive surgery; Metastasis; Metastatectomy
AIM: To determine the effectiveness of using multidetector computed tomography (MDCT) data in preoperative planning of robot-assisted surgery.
METHODS: Fourteen patients indicated for surgery underwent MDCT using 64 and 256-slice MDCT. Before the examination, a specially constructed navigation net was placed on the patient’s anterior abdominal wall. Processing of MDCT data was performed on a Brilliance Workspace 4 (Philips). Virtual vectors that imitate robotic and assistant ports were placed on the anterior abdominal wall of the 3D model of the patient, considering the individual anatomy of the patient and the technical capabilities of robotic arms. Sites for location of the ports were directed by projection on the roentgen-positive tags of the navigation net.
RESULTS: There were no complications observed during surgery or in the post-operative period. We were able to reduce robotic arm interference during surgery. The surgical area was optimal for robotic and assistant manipulators without any need for reinstallation of the trocars.
CONCLUSION: This method allows modeling of the main steps in robot-assisted intervention, optimizing operation of the manipulator and lowering the risk of injuries to internal organs.
Virtual modeling; Robotic surgery; Multidetector computed tomography; Abdominal surgery; Virtual surgery
To summarize our initial experience in robot-assisted thoracoscopic lobectomy. Methods Five patients underwent lobectomy using da Vinci S HD Surgical System (Intuitive Surgical, Sunnyvale, California). During the operation, we respectively made four ports over chest wall for positioning robotic endoscope, left and right robotic arms and auxiliary instruments without retracting ribs. The procedure followed sequential anatomy as complete video-assisted thoracoscopic surgery lobectomy did, and lymph node dissection followed international standard.
All patients successfully underwent complete robot-assisted thoracoscopic lobectomy. Neither additional incisions nor emergent conversion to a thoracotomy happened. Frozen dissection during lobectomy showed non-small-cell lung cancer in four patients, who afterwards underwent systemic lymph node dissection, while the case left was with tuberculoma and didn't undergo lymph node dissection. Recurrent air leak occurred in one case, so chest tube was kept for drainage, and one week later, the patient was extubated due to improvement. All other patients recovered well postoperatively without obvious postoperative complications.
Robot-assisted thoracoscopic surgery is feasible with good operability, clear visual field, reliable action and its supriority of trouble free; exquisite operative skills are required to ensure a stable and safe operation; robot-assisted surgery is efficiency and patients recover well postoperatively.
Robotics; thoracoscopy; minimally invasive; lobectomy
The purpose of this review is to outline the most common objections about robotic coronary artery bypass graft (CABG), often expressed by cardiac surgeons, cardiologists, and administrators who have little direct knowledge of the procedure. The summarized objections include the high intraoperative costs of robotic versus traditional CABG, a prolonged and difficult learning curve for members of the surgical team, and concerns about compromising graft patency with this technique. Arguments for continued procedure development in robotically assisted CABG are provided.
Robotically assisted totally endoscopic coronary artery bypass surgery has emerged as a feasible and efficient alternative to conventional full sternotomy coronary artery bypass graft surgery in selected patients. This minimally invasive approach using the daVinci robotic system allows fine intrathoracic maneuvers and excellent view of the coronary arteries. Both on-pump and off-pump operations can be performed to treat single and multivessel disease. Hybrid approaches have the potential of offering complete revascularization with the “best of both worlds” from surgery (internal mammary artery anastomosis in less invasive fashion) and percutaneous coronary intervention (least invasive approach).
In this article we review the indications, techniques, short and long term results, as well as current developments in totally endoscopic robotic coronary artery bypass operations.
Minimally invasive; robotic; coronary artery bypass surgery
Previous studies of robotic-assisted radical prostatectomy (RARP) have suggested that obesity is a risk factor for worse perioperative outcomes. We evaluated whether body mass index (BMI) adversely affected perioperative outcomes.
A prospective database of 153 RARP (single surgeon) was analyzed. Obesity was defined as BMI ≥ 30 kg/m2; normal BMI < 25 kg/m2; and overweight as 25 to 30 kg/m2. Two separate analyses were performed: the first 50 cases (the initial learning curve) and the entire cohort of 153 RARP.
In the initial cohort of 50 cases (14 obese patients), there was no statistically significant difference with regards to operative times, port-placement times and estimated blood loss (EBL). Length of stay (LOS) was longer in the obese group (4.3 vs. 2.9 days); BMI remained an independent predictor of increased LOS on multivariate linear regression analysis (p = 0.002). There was no statistically significant difference in the postoperative outcomes of leak rates, margin rates and incisional herniae. In the entire cohort, when comparing obese patients to those with a normal BMI, there was no statistically significant difference in operative times, EBL, LOS, or immediate postoperative outcomes. However, on multivariate linear regression analysis, BMI was an independent predictor of increased operative time (p = 0.007).
Obese patients do not have an increased risk of blood loss, positive margins or the postoperative complications of incisional hernia and leak during the learning curve. They do, however, have slightly longer operative times; we also noted an increased LOS in our first 50 cases.
Robotically assisted cardiac surgery has been presented as less invasive than conventional surgery, with shortened hospital stays and faster return to daily activities. We evaluated our experience with the da Vinci robot to determine whether we could in fact demonstrate those findings.
All mitral and tricuspid valve repairs were performed by the same surgeon. Cardiopulmonary bypass was performed with femoral cannulation, antegrade cardioplegia, and transthoracic aortic cross-clamping. Multiple valve repair techniques were used, including quadrant resection, cord replacement, Alfieri leaflet coaptation, and ring annuloplasty. Access was by 2 ports and a 5-cm right anterolateral thoracotomy. All annuloplasty rings were secured using surgical clips.
From October 2003 through September 2004, 32 patients underwent robotically assisted mitral valve repair. The mean age of our population was 67.6 years (range, 43–82 years). Four patients also underwent the 1st tricuspid valve repair using the da Vinci robot in the United States. There were 3 conversions for irreparable valves, 1 stroke, and 2 deaths. The average procedure time, cardiopulmonary bypass time, and aortic cross-clamp time were all reduced, when the first 20 patients were compared with the last 12. Length-of-stay also improved. One patient required early mitral valve replacement for recurrent regurgitation. Two patients required late (>3 month) mitral valve replacement for recurrent regurgitation.
We have shown that a dedicated nonacademic institute can develop a robotic cardiac surgery program and perform mitral and tricuspid valve repairs successfully. There is a several-case learning curve, and patient selection is paramount.
Annuloplasty; mitral valve/surgery; robotics; surgery, computer-assisted; surgical procedures, minimally invasive/methods; tricuspid valve/surgery; thoracic surgery, video-assisted
The role of post-operative radiotherapy (PORT) is controversial for some cancer sites. In the absence of large randomized controlled trials, survival prediction models can help estimate the predicted benefit of PORT for specific settings. The purpose of this study was to compare the performance of two types of prediction models for estimating the benefit of PORT for two cancer sites. Using data from the Surveillance, Epidemiology, and End Results database, we constructed prediction models for gallbladder (GB) cancer and non-small cell lung cancer (NSCLC) using Cox proportional hazards (CPH) and Random Survival Forests (RSF). We compared validation measures for discrimination and found that both the CPH and RSF models had comparable C-indices. For GB cancer, PORT was associated with improved survival for node positive patients, and for NSCLC, PORT was associated with a survival benefit for patients with N2 disease.
Pyeloplasty is the gold standard therapy for ureteropelvic junction obstruction. Robotic assisted pyeloplasty has been widely adopted by urologists with and without prior laparoscopic pyeloplasty experience. However, difficult situations encountered during robotic assisted pyeloplasty can significantly add to the difficulty of the operation. This paper provides tips for patient positioning, port placement, robot docking, and intraoperative dissection and repair in patients with the difficult situations of obesity, large floppy liver, difficult to reflect colon (transmesenteric pyeloplasty), crossing vessels, large calculi, and previous attempts at ureteropelvic junction repair. Techniques presented in this paper may aid in the successful completion of robotic assisted pyeloplasty in the face of the difficult situations noted above.
A 1 mm minilaparoscope (Lifeline Biotechnoligies, Florida, USA) was assessed for aiding port site insertions.
Ten consecutive patients having laparoscopic procedures in a gynaecological oncology unit were included. Minilaparoscopy was feasible in all cases and was used to insert the umbilical port under direct vision in all patients. In one case, a thick band of abdominal adhesions was identified and a further lateral port site was inserted to aid their dissection.
The minilaparoscope correctly identified all 10 patients with peritoneal disease and identified all patients who were suitable for debulking procedures.
Minilaparoscopy with the 1 mm endoscope appears to be safe and accurate and we feel that it has a place in helping the surgeon identify adhesions and peritoneal disease as well as assisting further port site insertion safely and with minimal complications.
A survey of current clinical practice was carried out among the 84 consultant cardiac surgeons currently performing coronary artery bypass surgery in the United Kingdom. The 80 surgeons who returned the questionnaire performed an estimated total of 17,100 coronary artery bypass graft operations in 1987, a mean case load of 214 operations each. Sixty two of the 80 surgeons regarded the internal mammary artery as the graft conduit of choice, and seven preferred the saphenous vein. The internal mammary artery was used in 73% of bypass grafts to the left anterior descending coronary artery but in only 4% of grafts to the circumflex and right coronary systems. Contraindications to the use of the internal mammary artery included advanced age of the patient (51 surgeons), insufficient flow through the internal mammary artery (49), and endarterectomy (35). Seventy four of the 80 surgeons considered intraoperative damage to the saphenous vein to be a possible cause of vein graft failure, but there was no agreement about how it should be reduced. All surgeons advocated pharmacological measures to enhance graft patency. Dipyridamole and aspirin constituted the most popular regimen (58 surgeons), though only 28 started dipyridamole preoperatively. Warfarin was prescribed postoperatively on occasion by 22 surgeons, but 14 of these used it only after endarterectomy.
To illustrate a surgical method in which the infusion port during a three-port pars plana vitrectomy is moved intraoperatively from the traditional infra-temporal location and placed supra-nasally, thus permitting a temporal surgical approach to better tackle superior and inferior vitreoretinal pathology.
Description of surgical technique.
When the location of the vitreoretinal pathology and/or the patient's anatomy prevents adequate visualization or surgical access and/or the instrument flexibility precludes sufficient maneuvering of the eyeball, a temporal approach to the vitrectomy may be employed by utilizing the interchangeable microcannulas of 23- and 25-gauge vitrectomy systems. The infusion port is dis-inserted from the traditional infra-temporal microcannula and reaffixed in the supra-nasal microcannula. The surgeon, the operating microscope, and the foot pedals are then adjusted to a temporal orientation, and the instruments inserted through the temporally placed microcannulas.
The flexibility of interchangeable microcannulas in 23- and 25-gauge PPV systems permits intraoperative switching between superior and temporal surgical sites to better manage posterior segment pathology.
Vitrectomy; intraoperative switch; vitreoretinal; transconjunctival; microcannula.
To determine the efficacy of using the harmonic scalpel and robotic assistance to facilitate thoracoscopic harvest of the internal thoracic artery (ITA).
A case series.
London Health Sciences Centre, University of Western Ontario, London, Ont.
Patients and methods
Fifteen consecutive patients requiring harvest of the ITA for coronary artery bypass grafting.
Robot-assisted, video-enhanced coronary artery bypass (RAVECAB) through limited-access incisions, using the harmonic scalpel and a voice-activated robotic assistant.
Main outcome measures
Ease and duration of the harvesting technique, complications of the procedure, graft flow and patency, and duration of postoperative hospitalization.
RAVE-CAB facilitated thoracoscopic dissection of the ITA with the harmonic scalpel in all cases. There were no conversions to a standard approach and no reoperations for bleeding. The mean (and standard deviation) ITA harvest time was 64.1 (22.9) minutes (range from 40 to 118 minutes). Robotic voice command capture rate was greater than 95%. Mean (and SD) intraoperative graft flows were 33.1 (26.8) mL/min (range from 14 to 126 mL/min). There was 100% graft patency on postoperative angiography. There were no deaths, perioperative myocardial infarction or arrhythmias. Mean (and SD) postoperative hospitalization was 3.3 (0.8) days.
RAVECAB is a demanding procedure that addresses many of the disadvantages of the “conventional” minimally invasive coronary artery bypass. It allows complete pedicle dissection with minimal ITA manipulation and assures sufficient conduit length and a tension-free coronary artery anastomosis. All anastomoses were performed under direct vision through a 5- to 8-cm inferior mammary incision.
The aim of this retrospective study was to evaluate the clinical outcome of three different minimally invasive surgical techniques for left anterior descending (LAD) coronary artery bypass grafting (CABG): Port-Access surgery (PA-CABG), minimally invasive direct CABG (MIDCAB) and off-pump totally endoscopic CABG (TECAB).
Over a decade, 160 eligible patients for elective LAD bypass were referred to one of the three techniques: 48 PA-CABG, 53 MIDCAB and 59 TECAB. In MIDCAB group, Euroscore was higher and target vessel quality was worse. In TECAB group, early patency was systematically evaluated using coronary CT scan. During follow-up (mean 2.7 ± 0.1 years, cumulated 438 years) symptom-based angiography was performed.
There was no conversion from off-pump to on-pump procedure or to sternotomy approach. In TECAB group, there was one hospital cardiac death (1.7%), reoperation for bleeding was higher (8.5% vs 3.7% in MIDCAB and 2% in PA-CABG) and 3-month LAD reintervention was significantly higher (10% vs 1.8% in MIDCAB and 0% in PA-CABG). There was no difference between MIDCAB and PA-CABG groups. During follow-up, symptom-based angiography (n = 12) demonstrated a good patency of LAD bypass in all groups and 4 patients underwent a no LAD reintervention. At 3 years, there was no difference in survival; 3-year angina-free survival and reintervention-free survival were significantly lower in TECAB group (TECAB, 85 ± 12%, 88 ± 8%; MIDCAB, 100%, 98 ± 5%; PA-CABG, 94 ± 8%, 100%; respectively).
Our study confirmed that minimally invasive LAD grafting was safe and effective. TECAB is associated with a higher rate of early bypass failure and reintervention. MIDCAB is still the most reliable surgical technique for isolated LAD grafting and the least cost effective.
With increasing surgeon experience, laparoscopic cholecystectomy has undergone many refinements including reduction in port number and size. Three-port laparoscopic cholecystectomy has been reported to be safe and feasible in various clinical trials. However, whether it offers any additional advantages remains controversial. This study reports a randomized trial that compared the clinical outcomes of 3-port laparoscopic cholecystectomy versus conventional 4-port laparoscopic cholecystectomy.
Seventy-five consecutive patients who underwent elective laparoscopic cholecystectomy were randomized to undergo either the 3-port or the 4-port technique. Four surgical tapes were applied to standard 4-port sites in both groups at the end of the operation. All dressings were kept intact until the first follow-up 1 week after surgery. Postoperative pain at the 4 sites was assessed on the first day after surgery by using a 10-cm unscaled visual analog scale (VAS). Other outcome measures included analgesia requirements, length of the operation, postoperative stay, and patient satisfaction score on surgery and scars.
Demographic data were comparable for both groups. Patients in the 3-port group had shorter mean operative time (47.3±29.8 min vs 60.8±32.3 min) for the 4-port group (P=0.04) and less pain at port sites (mean score using 10-cm unscaled VAS: 2.19±1.06 vs 2.91±1.20 (P=0.02). Overall pain score, analgesia requirements, hospital stay, and patient satisfaction score (mean score using 10-cm unscaled VAS: 8.2±1.7 vs 7.8±1.7, P=0.24) on surgery and scars were similar between the 2 groups.
Three-port laparoscopic cholecystectomy resulted in less individual port-site pain and similar clinical outcomes with fewer surgical scars and without any increased risk of bile duct injury compared with 4-port laparoscopic cholecystectomy. Thus, it can be recommended as a safe alternative procedure in elective laparoscopic cholecystectomy.
Conventional laparoscopic Roux-en-Y gastric bypass (LRYGB) is a gold standard for bariatric surgery, but the procedure requires five to seven incisions for placement of multiple trocars and thus may produce less-than-ideal cosmetic results. We have developed a new approach, single-incision transumbilical LRYGB (SITU-LRYGB) to treat morbid obesity. We compared the surgical results and patient satisfaction in a study of five-port LRYGB and SITU-LRYGB. Fifty morbidly obese patients (14 males, 36 females) underwent either Roux-en-Y gastric bypass with five-port LRYGB or the SITU-LRYGB approach. During the operation, we used a novel intraoperative liver traction method with a “liver suspension tape” that we specifically designed for SITU-LRYGB. Compared to five-port surgery with SITU-LRYGB, there were no intraoperative complications, wound healing was excellent, and there was no abdominal scarring. SITU surgical time was longer than that with five-port LRYGB (99.8 vs. 67.6 min, P < 0.001). Patients treated with the five-port method were more obese than those in the SITU group (127.9 vs. 112.4 kg, P = 0.016). After the bariatric surgery, no difference in comorbidity was found in both groups. Patient satisfaction was greater with SITU than with the five-port method (4.48 vs. 3.96, P = 0.006). Roux-en-Y gastric bypass can be successfully achieved via a single umbilical incision, a method that provides a short operative time and good recovery and eliminates abdominal scarring.
Laparoscopic Roux-en-Y gastric bypass; Single-incision transumbilical laparoscopic surgery; SILS; Gastric bypass; Laparoscopy; Bariatric surgery
Port-site herniation is a rare but potentially dangerous complication after laparoscopic surgery. Closure of port sites, especially those measuring 10 mm or more, has been recommended to avoid such an event.
We herein report the only case of a port site hernia among a series 52 consecutive cases of laparoscopy-assisted distal gastrectomy (LADG) carried out by our unit between July 2002 and March 2007. In this case the small bowel herniated and incarcerated through the port site on day 4 after LADG despite closure of the fascia. Initial manifestations experienced by the patient, possibly due to obstruction, and including mild abdominal pain and nausea, occurred on the third day postoperatively. The definitive diagnosis was made on day 4 based on symptoms related to leakage from the duodenal stump, which was considered to have developed after severe obstruction of the bowel. Re-operation for reduction of the incarcerated bowel and tube duodenostomy with peritoneal drainage were required to manage this complication.
We present this case report and review of literature to discuss further regarding methods of fascial closure after laparoscopic surgery.
New coronary artery revascularization strategies are developing: improved quantification of coronary artery disease by the SYNTAX score, new-generation drug-eluting stents and increased use of stents for multivessel disease, ongoing evaluation of stents for left main disease, new strategies for minimally invasive coronary artery bypass grafting (CABG) including the use of robotic-assisted CABG, hybrid procedures, and off pump CABG. In comparisons of all these strategies, the impact on survival is arguably the most important parameter. It has long been accepted that using the left internal mammary artery (LIMA) to bypass the left anterior descending coronary artery (LAD) is the gold standard and may confer the survival advantage reported for CABG compared with percutaneous coronary intervention in the literature. The survival advantage of using additional arterial conduits as compared to the conventional use of LIMA with saphenous veins only has long been debated. Our study, which involved a large cohort of 8,622 patients with multivessel disease, followed over a long period of time, has shown that in primary isolated CABG surgery performed more than 15 years ago with the use of LIMA to the LAD, bypassing the non-LAD targets with at least 1 additional arterial graft, either the right internal mammary artery and/or the radial artery, was an independent predictor of increased survival during the following 15 years. The results were confirmed with both a propensity-matched analysis that included 1,153 patients in each group and a multivariate analysis that was able to control for all differences between the groups because of the power of the large cohort in this series. The significant survival advantage of coronary artery bypass surgery with the use of multiple arterial grafting cannot be ignored in patients with multivessel coronary artery disease as various revascularization strategies are considered.
Internal mammary artery; radial artery; revascularization; saphenous vein grafts
To determine the effectiveness of postgraduate training for learning extraperitoneal robot-assisted radical prostatectomy (EP-RARP) and to identify any unmet training needs.
Materials and Methods
The training resources used were live surgery observations, digital video disc instruction, postgraduate courses, and literature review. Modifications to the transperitoneal (TP) setup in equipment, patient positioning, port placement, and access technique were identified. A surgeon who had previous experience with 898 TP robot-assisted radical prostatectomies (TP-RARPs) performed EP-RARP in 30 patients. We evaluated setup results, emphasizing access-related difficulties, and compared the EP cohort with a nonrandomized, concurrent TP cohort of 62 patients for short-term outcomes.
The median setup time for EP was 26 minutes (range 15–65 min) for EP compared with 14 to 17 minutes for the comparable TP setup and dropping the bladder. During EP setup and dissection, peritoneal entry occurred in 37%, incorrect port spacing in 10%, epigastric vessel injury in 10%, and other minor pitfalls in 10%. No significant differences were found between EP and TP in postsetup operative times, hospital stay, complications, surgical margin status with organ-confined disease, or lymph node dissection yield. EP had significantly higher estimated blood loss (300 vs 200 mL, P=0.001) and more symptomatic lymphoceles when extended pelvic lymph node dissection was performed (3/16 vs 0/47, P=0.001).
Using postgraduate education resources, an experienced TP-RARP surgeon successfully transitioned to EP-RARP, achieving the major objectives of safety and equivalent outcomes. We identified several minor nuances in the setup that need further refinement in future education models.
Laparoscopic surgery is widely practiced and offers realistic benefits over conventional surgery. There is considerable variation in results between surgeons, concerning port-site complications. The aim of this study was to evaluate the laparoscopic port closure technique and to explore the factors associated with port-site incisional hernia.
Between January 2000 and January 2007, 5541 laparoscopic operations were performed by a single consultant surgeon for different indications. The ports were closed by the classical method using a J-shaped needle after release of pneumoperitoneum. The incidence of port-site incisional hernias was calculated. All patients were followed up by outpatient clinic visits and by their general practitioners.
During a 6-year period, 5541 laparoscopic operations were performed. Eight patients (0.14%) developed port-site hernia during a mean follow-up period of 43 months (range, 25 to 96) and required elective surgery to repair their hernias. No major complications or mortality was reported.
Laparoscopic port closure using the classical method was associated with an acceptable incidence of port-site hernia. Modification of the current methods of closure may lead to a new technique to prevent or reduce the incidence of port-site incisional hernias.
Port-site incisional hernia; Pneumoperitoneum; Port closure
The incidence of port-site metastasis following robotic-assisted laparoscopic hysterectomy is unknown.
PRESENTATION OF CASE
We present a case of a 78-year-old female diagnosed with an incidental grade 3 endometrial adenocarcinoma on a final hysterectomy specimen. She subsequently underwent a robotic staging surgery with a gynecologic oncologist where nodal pathology was found to be negative; her final stage was 1B. One year following diagnosis, she developed a recurrence on her abdominal wall at the former port-sites with concomitant vaginal cuff recurrence.
We hypothesize possible modes of metastasis and present limited published data to date on port site metastasis following robotic hysterectomy for endometrial cancer.
This is the second reported case of port-site metastasis following robotic surgery for endometrial cancer.
Robotic; Endometrial cancer; Grade 3; Port-site metastasis; Staging surgery
Currently there are no direct estimates of mortality reduction afforded by coronary-artery bypass grafting (CABG) that take into account the deaths among patients for whom coronary revascularization was indicated but who did not undergo the treatment. The objective of this analysis was to compare survival after the treatment decision between patients who underwent CABG and those who remained untreated.
We used a population-based registry to identify patients with established coronary artery disease who were to undergo first-time isolated CABG. We measured the effect of surgical revascularization on survival after the treatment decision in two cohorts of patients categorized by symptoms, coronary anatomy, and left ventricular function.
One in 10 patients died during the five years after treatment decision. The hazard of death among patients who underwent CABG was 51 percent of that for the untreated group, the adjusted hazard ratio was 0.51 (95 percent confidence interval, 0.43 to 0.61). The effect was stronger when CABG was performed within the recommended time: adjusted hazard ratios were 0.43 (95 percent confidence interval, 0.35 to 0.53) and 0.58 (95 percent confidence interval, 0.48 to 0.70) for early and late intervention, respectively; chi-square for the difference between hazard ratios was 12.2 (P < 0.001).
Estimates that account for patients who died before they could undergo a required CABG indicate a significant survival benefit of performing early surgical revascularization even for patients registered to undergo the operation on the non-urgent basis.
The conventional three-port technique for laparoscopic appendicectomy has proven its worth in the management of appendicular pathologies. From a cosmetic viewpoint, the umbilical and suprapubic port-sites are hidden by natural camouflages, the right Iliac fossa (RIF) port is the only visible external sign of surgery. The two-port technique avoids even this marker of abdominal invasion. In this study, we describe the technique of two-port laparoscopic appendicectomy (TPA) and compare it with conventional laparoscopic appendicectomy (CLA).
MATERIALS AND METHODS:
All patients studied underwent operation for acute appendicitis during a 6-month period. Data were collected prospectively for the TPA and retrospectively for the CLA. The TPA was performed with one 10 mm umbilical working port and one 5 mm suprapubic camera port. A hypodermic needle was introduced in the RIF to retract the appendix. The appendicular artery was controlled with diathermy or ultrasonic shears. The base was ligated with a loop knotted extracorporeally. CLA was performed via the conventional 10 mm umbilical, 5 mm suprapubic and 5 mm RIF ports. The appendicular stump was ligated with an endoloop or an intracorporeal knot.
A total of 146 patients underwent surgery over the 6-month period for appendicitis. Out of 62 cases attempted, the TPA was successful in 51 cases, with conversion to the three-port technique in 11. The operative time, complication rates, return to work were comparable between the two groups. Patients who had TPA had a shorter postoperative stay.
This is an initial experience with TPA. There is little difference in the operative time, postoperative stay and complications rates between this technique and the conventional three-port one. There is hence little to be lost and a likely benefit to be gained by performing the TPA although a randomised study is necessary.
Laparoscopic appendicectomy; two-port appendicectomy; two port vs. three port
Anastomosis to the superficial temporal artery is suitable in patients with functional and structural impairment of the middle cerebral artery (i.e., complex aneurysms and skull base tumors), as either definitive treatment or an additional safety measure. A shorter occlusion time or a non-occlusive technique is expected to reduce the risk of cerebral ischemia following the procedure. In this cadaver study, we assessed the fitness of C-Port xA® device for use in superficial temporal artery (STA)–middle cerebral artery (MCA) bypass.
Materials and Methods:
Seven fixed human head specimens were prepared through eight pterional craniotomies. The superficial temporal artery was dissected and the sylvian fissure was opened to access the MCA. The C-Port xA was tested on each of the eight exposures. We recorded the lengths of both donor and recipient vessel, the durations of the procedure and the craniotomy, and sylvian scissure opening sizes. The bypass was then assessed by pressure injection of methylene blue in the donor vessel.
C-Port xA-assisted STA–MCA anastomosis was successfully accomplished in seven dissections. A minimum STA length of 7 cm, a sylvian scissure opening larger than 5 cm, and a craniotomy size of at least 6 × 6 cm appeared to be the requisites for a safe maneuverability of the device. The MCA occlusion time lasted in all cases less than 4.5 min, and we observed a clear improvement in time performance with growing experience.
The results suggest that the C-Port xA device is suitable for STA–MCA bypass. We experienced a shorter occlusion time and a shorter learning curve compared to conventional techniques. Further miniaturization and special adaptation of this device may allow a future application even to deeper intracranial vessels. Clinical trials will have to assess the long-term results and benefits of this minimal occlusive technique.
Automated end-to-side anastomosis; bypass; human cadavers; middle cerebral artery; superficial temporal artery
Since the advent of four-port laparoscopic cholecystectomy, many modifications regarding port number and size have been tried. The feasibility of three-port technique has been found comparable to the conventional four-port laparoscopic cholecystectomy. To assess the feasibility and safety of three-port laparoscopic cholecystectomy in a prospective study. Between March 2007 and March 2009, fifty patients with cholelithiasis aged between 15 and 56 years underwent three-port cholecystectomy in a prospective study in Government medical college, Srinagar. A single surgeon did all the cases and there was no criterion for the patient selection. These were consecutive fifty surgeries done by the surgeon. The outcome was assessed in terms of intra-operative and post-operative parameters. The mean (range) age was 45 (15–56) years and there were thirty-nine females and eleven males in the study. All the procedures were completed successfully without any conversions to open or any major complications; though three patients needed the addition of a fourth port as in conventional laparoscopic cholecystectomy. The mean (range) operative time was 55 (30–90) min and the average blood loss was 30 ml. The mean (range) hospital stay was 1 (1–3) days. All patients returned to routine work within 1 week of surgery. The mean follow-up was 5 (2–7) months. We conclude, from the results above, that three-port laparoscopic cholecystectomy is safe and feasible. There are only two visible surgical scars, better cosmetic appearance with no increased risk of bile duct injury. It reduces the manpower in the form of a second assistant. Thus, it can be recommended as a safe alternative procedure to conventional four-port laparoscopic cholecystectomy.
Laparoscopic cholecystectomy; Three ports; Feasibility