Surgical Technology International
42nd Edition
September 2023 - ISSN:1090-3941
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3D Transoral Endoscopic Thyroidectomy
Francesco Frattini, MD, Gianlorenzo Dionigi, MD, Professor, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Istituto Auxologico Italiano, Milan, Italy, Andrea Casaril, MD, Endocrine Surgery Unit, Pederzoli Hospital, Peschiera del Garda, Verona, Italy, Daqi Zhang, MD, Professor, Hui Sun, MD, Professor, Ozer Makay, MD, Professor, Ege University Faculty of Medicine, Izmir, Turkey, Che Wei Wu, MD, Professor, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, Hoon Yub Kim, MD, Korea University Hospital, Korea University College of Medicine, Seoul, South Korea, Anuwong Angkoon, MD, Police General Hospital, Bangkok, Thailand, Ralph P. Tufano, MD, Sarasota Memorial Health Care System, Sarasota, Florida, Oded Cohen, MD, Professor, Ben Gurion University of the Negev, Beer-Sheva, Israel
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Transoral endoscopic thyroidectomy with vestibular approach (TOETVA) is a feasible new surgical procedure that does not require visible incisions. We describe our experience with three-dimensional (3D) TOETVA. We recruited 98 patients who were willing to undergo 3D TOETVA. Inclusion criteria were: (a) patients with a neck ultrasound (US) with an estimated thyroid diameter of 10cm or less; (b) estimated US gland volume ≤45ml; (c) nodule size ≤50mm; (d) benign tumor, such as thyroid cyst, goiter with one nodule, or goiter with multiple nodules; (e) follicular neoplasia; and (f) papillary microcarcinoma without evidence of metastases. The procedure is performed using a three-port technique at the oral vestibule, a 10mm port for the 30° endoscope, and two additional 5mm ports for dissecting and coagulation instruments. The CO2 insufflation pressure is set at 6mmHg. An anterior cervical subplatysmal space is created from the oral vestibule to the sternal notch and laterally to the sternocleidomastoid muscle. Thyroidectomy is performed entirely 3D endoscopically with conventional endoscopic instruments and intraoperative neuromonitoring. There were 34% total thyroidectomies and 66% hemithyroidectomies. Ninety-eight 3D TOETVA procedures were successfully performed without any conversions. The mean operative time was 87.6 minutes (59–118 minutes) for lobectomy and 107.6 minutes (99–135 minutes) for bilateral surgery. We observed one case of transient postoperative hypocalcemia. Paralysis of the recurrent laryngeal nerve did not occur. The cosmetic outcome was excellent in all patients. This is the first case series of 3D TOETVA.
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When Should We Operate on the Elderly with Acute Pancreatitis Requiring Emergency Surgery? , A 10-Year Study of a National Inpatient Sample Using a Generalized Additive Model of 110,289 Patients
Matthew McGuirk, MD, Abbas Smiley, MD, PhD, Assistant Professor, Mahir Gachabayov MD, PhD, Department of Surgery, Westchester Medical Center, Valhalla, New York, Rifat Latifi MD, FACS, FICS, FKCS, Adjunct Professor, Department of Surgery, University of Arizona, College of Medicine, Tucson, Arizona
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Introduction: Elderly patients with acute pancreatitis have longer hospital length of stay (HLOS) and higher mortality compared to adult patients. We aimed to assess the optimal timing to operate for acute pancreatitis and to evaluate the relationship between HLOS and mortality.
Materials and Methods: This was a retrospective cohort study of 110,289 elderly patients diagnosed with acute pancreatitis requiring emergency admission using the National Inpatient Sample (NIS) between 2005–2014. The ICD9 code 577.0 was used to select patients with a diagnosis of acute pancreatitis. Stratified analysis was performed to compare male versus female, survived versus deceased, and no operation versus operation. Multivariable logistic regression models were created to assess independent risk factors of mortality. Generalized additive models (GAM) were created to assess the linearity of the relationship between HLOS and in-hospital mortality.
Results: The mean age of the cohort was 76 years old, and 56.3% were female. The mean frailty index was 1.65. Twenty-five percent of patients underwent an operation, with a mean time to operation being 3.44 days for females and 3.77 days for males. Overall mortality was 2.3%. For patients who had an operation, each additional day of delay until operation increased the odds of mortality by 8.8%. Each additional point for the modified frailty index increased the odds of mortality by 30.2%. HLOS had a non-linear relationship with mortality, with an estimated degree of freedom of 22.05 and a nadir at three to seven days. Each additional day in hospital after day seven increased the odds of mortality by 6.7%.
Conclusions: In those who required an operation, every day of delay in operation increased the odds of mortality by almost 9%. The lowest mortality for elderly patients with acute pancreatitis occurred with a hospital length of stay of three to seven days. After seven days, each additional day increased the odds of mortality by 6.7%.
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Safety in Senhance™ Robotic Gastrointestinal Surgery in 530 Patients
Ludger Staib, Professor , Clemens Poth , Florian Schilcher , Klinikum Esslingen, Esslingen, Germany, Olaf Hansen, Vivianda Menke , Evangelisches Krankenhaus, Wesel, Germany, Dietmar Stephan , Professor , St.-Marien-Krankenhaus, Siegen, Germany, Frank Willeke, Professor, Clinic for General and Visceral Surgery, St.- Marien-Krankenhaus, Siegen, Germany
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The Senhance Robotic System™ (Asensus Surgical, Durham, NC, USA) has been used in abdominal surgery since 2016, and provides an eye-tracker for camera movement and haptic tactile feedback. Safety aspects are very important in robotic surgery, such as regarding the presence of system malfunctions and surgical outcomes. The data for robotic function in gastrointestinal surgical procedures in 530 patients (colorectal surgery, fundoplication, others) were prospectively listed in the TRUST registry after informed patient consent in three German gastrointestinal surgery centers (center A, N = 46 patients; center B, N = 457; center C, N =27). Adverse events were noted in 14.3% (76/530 patients) of the overall surgeries, with an equal distribution among the procedures. Robotic malfunctions, such as console/camera/arm malfunctions, collisions, or limited motion, were experienced in 5.5 % (29/530 patients), with some differences among the centers (A, 0.0%; B, 4.2%; C, 37%). These differences were explained in terms of team experience and case load. In conclusion, the Senhance™ Robotic System can be safely applied to routine abdominal surgery procedures.
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Dressings for Wound Infection Prophylaxis in Colorectal Surgery: A Review
Jay Redan, MD, Professor of Surgery, Caline McCarthy, MS, Caroline Baughn, BS, University of Central Florida College of Medicine, Orlando, Florida
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Introduction: In patients who require colorectal surgery, the rate of surgical site infection (SSI) is amongst the highest of any surgical specialty. Guided by the enhanced recovery after surgery (ERAS) guidelines for colorectal surgery, there is a large focus on preoperative and intraoperative measures to reduce the risk of bacterial transmission and surgical site inoculation There are many novel and developing dressing types being explored for colorectal surgery. To date, no consensus guidelines for surgical dressings that optimize healing outcomes and reduce infection from postoperative incisions have been established. The purpose of this review is to discuss various dressings used for surgical site wound infection prophylaxis for patients who have colorectal surgery.
Materials and Methods: The database, PubMed, was used for this literature review. Keywords included: colorectal surgery or abdominal surgery or clean-contaminated surgery + surgical site infection prophylaxis or negative-pressure wound therapy or bandages or biological dressings or occlusive dressings + surgical wound infection.
Results: Five prophylactic dressings were selected for discussion. This article will review current use and research surrounding the utilization of negative pressure wound therapy devices, silver-containing dressings, mupirocin dressings, gentamicin-c sponge, and vitamin- e and silicon sponges.
Conclusion: Alternative dressings discussed in this article show significant promise in reducing SSI compared to conventional dressing. Additional studies to assess cost-benefit analysis and integration into general practice are needed to determine practical application.
Hospital Length of Stay Independently Predicts Mortality in Patients Emergently Admitted for Esophageal Hemorrhage: Sex, Frailty, and Age as Additional Mortality Factors
Guy Elgar, BS, Abbas Smiley, MD, MSc, PhD, Assistant Professor, Arjun Syal, BS, New York Medical College, Valhalla, New York , Rifat Latifi, MD, FACS, FICS, FKCS, Adjunct Professor of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
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Introduction: Upper gastrointestinal bleeding results in greater than $7.6 billion of in-hospital economic burden in the United States yearly. With a worldwide incidence between 40–100/100,000 individuals and a mortality rate of approximately 2–10%, upper gastrointestinal bleeding represents a major source of mortality and morbidity. The goal of this study was to describe mortality risk factors in patients emergently admitted with esophageal hemorrhage, the second most common etiology of upper gastrointestinal bleeding.
Materials and Methods: Patients emergently admitted with esophageal hemorrhage between 2005–2014 were evaluated using the National Inpatient Sample database. Patient characteristics, clinical outcomes, and therapeutic trends were obtained. Relationships between morality and all other variables were determined via univariable and multivariable logistic regression analyses.
Results: In total, 4,607 patients were included, of which 2,045 (44.4%) were adults, 2,562 (55.6%) were elderly, 2,761 (59.9%) were males, and 1,846 (40.1%) were females. The average age of adult and elderly patients were 50.1 and 78.7 years, respectively. The multivariable logistic regression analysis revealed, for every additional day of hospitalization, the odds of mortality for nonoperatively treated adult and elderly patients increased by 7.5% (p=<0.001) and 6.6% (p=<0.001), respectively. Every additional year of age was associated with a 5.4% (p=0.012) increase in mortality odds for nonoperatively managed adult patients. Frailty increased the odds of mortality by 31.1% (p=0.009) in nonoperatively treated elderly patients. Undergoing invasive diagnostic procedures in conservatively treated adults reduced mortality significantly (odds ratio=0.400, p=0.021). Frailty, age, and hospital length of stay demonstrated no significant association with mortality in surgically managed adult and elderly patients.
Conclusion: Nonoperatively managed patients emergently admitted for esophageal hemorrhage with longer hospital length of stay and higher modified frailty index exhibited higher odds of mortality. Invasive diagnostic procedures were negatively correlated with mortality in nonoperatively treated adult patients. Age is only associated with higher mortality rates in adults, while elderly patients revealed no association between age and mortality.
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Assessment of the Safety and Effectiveness of Colorectal Robotic-Assisted Surgery: The First 50 Consecutive Cases at a Single Centre
Maria A. Bantounou, MPharm1, Ahmed Nassar, MBChB, MSc, MRCS, PGCert, Shafaque Shaikh, PhD, MRCS, FRCS, MBBS, University of Aberdeen, Aberdeen, UK
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Background: Colorectal robotic-assisted-surgery (RAS) is a novel technology with scarce real-world evidence. The aim of this retrospective review was to ascertain the safety and effectiveness of colorectal RAS.
Methods: The da Vinci® Xi™ robot system (Intuitive Surgical, Inc., Sunnyvale, CA, USA) was used to perform the first 50 colorectal resections in our centre. Outcomes regarding safety and efficacy were analysed and learning curves (LC) were plotted using RStudio.
Results: The median patient age and BMI were 65 years (IQR, 50.25-76.5) and 28.3kg/m2 (IQR, 25.2-30.7), respectively, and 27 patients were female. Malignancy (66%) followed by rectal prolapse (18%) was the most frequent diagnosis, and all malignant tumours were completely resected. High anterior resection was the most frequently performed operation (36%). The median operative time was 256.5 minutes (IQR, 202.2-332.8). Twenty-seven patients had anastomosis (54%), a stoma was formed in 7 (14%) and 7 anastomoses required defunctioning loop ileostomy (14%). Two unexpected intra-operative events occurred, and neither required conversion to an open procedure. Thirty-eight complications occurred in 21 patients, and most were minor by the Clavien-Dindo classification: CD 1 (17, 44.7%) or 2 (11, 28.9%). Moreover, 5 patients developed an anastomotic leak (14.7%), 5 developed infections (10%), 2 required transfusions (4%) and 3 needed re-operation (6%). There was no 30-day mortality and the readmission rate was 8%. The median length of stay in hospital was 6 days (IQR,4-8). All resections, except for low anterior resections, resulted in a significantly longer stay compared to rectopexies. Finally, projections from LCs indicated that outcome optimization can be achieved after experience with 33-39 cases.
Conclusions: Colorectal RAS in our centre was both safe and effective. In the initial 50 cases, there was no 30-day mortality and no need for conversion to an open surgery. The readmission and complication (>CD 2) rates were 8% and 20%, respectively.
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Laparoscopic vs Open Treatment for Gastric and Non-Gastric Gastrointestinal Stromal Tumors: a Two-Center Experience
Vincenzo Pappalardo, MD, Stefano Rausei, MD, PhD, Contract Professor of Surgery, Cittiglio-Angera Hospital - ASST Sette Laghi, Varese, Georgios D. Lianos, MD, MSc, PhD , Assistant Professor of Surgery, Giulio Carcano, MD, Professor of Surgery , University Hospital of Ioannina, Ioannina, Greece, Marika Morabito, MD, Simone Gianazza, MD, University of Insubria, ASST Settelaghi, Varese, Italy, Elisa Cassinotti, MD, PhD, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy, Francesco Frattini, MD, Antonella Pino, MD, Istituto Auxologico Italiano Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
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We retrospectively reviewed the medical records of 109 patients who underwent curative laparoscopic or open resection for different types of gastrointestinal stromal tumors (GIST). Only primary GIST patients who did not receive preoperative chemotherapy or oral imatinib treatment were included in the analysis. We divided the patients into 2 groups according to the surgical approach:a laparoscopic group (LAP) and a laparotomic group (OPEN). Our aim was to confirm the feasibility and safety of laparoscopic surgery for GISTs that differed in size and location, and to assess its long-term oncologic outcome in terms of overall survival (OS) and disease-free survival (DFS). Furthermore, we performed a surgical short-term outcome analysis. The two groups did not differ with respect to age at operation, gender, BMI or comorbidities. Even the NIH and AFIP risk classifications were not significantly different between the two groups. Furthermore, in our analysis, there was no significant difference in mean tumor size or location between the two groups. Wedge resection was the most frequently performed procedure. The conversion rate was 7.8%. The operative time was 194.75 (60- 350) min for the open group and 181.70 (57-480) min for the laparoscopic group. Our data clearly indicated that the long-term oncologic outcome and DFS of laparoscopic resection were not inferior to those of traditional open operations and laparoscopic resection was still feasible in cases with large tumors: the median size of the tumor was 4.5 cm (3-25) and the tumor was larger than 4.5 cm in 47.7% of the cases in the LAP group. With regard to short-term outcomes, our study demonstrated that the LAP group had fewer complications, faster gastrointestinal recovery, reduced use of analgesic drugs and shorter postoperative hospital stay (each p<0.05). In conclusion, our experience confirms that GISTs are very uncommon cancers for which the prognosis is closely related to size, localization and class of risk. In light of our clinical data, laparoscopic resection for gastric and non-gastric GISTs is a safe, feasible and oncologically correct procedure. The most important advantage of this technique is that it ensures a better postoperative outcome compared with open surgery, without worsening the prognosis.
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Acellular Fish Skin Graft Use in Open Abdomen Management
Rifat Latifi, MD, FACS, FICS, FKCS, Adjunct Professor of Surgery, University of Arizona, Tucson,
AZ, Abbas Smiley, MD, PhD, University of Rochester, Rochester, New York
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Introduction: Open abdomen (OA) management post damage control laparotomy (DCL) is common in complex abdominal trauma and intra-abdominal catastrophe (IAC). Use of polyglactin 910 mesh (VICRYL™, Johnson & Johnson, New Brunswick, New Jersey) to cover the intra-abdominal contents and wound vacuum-assisted closure (VAC) is current practice in the management of temporary abdominal closure (TAC). This may have complications and requires two to three weeks for granulations to be ready for skin grafting. Acellular fish skin graft (AFSG; Kerecis™, Reykjavik, Iceland), use in wound care management has proven beneficial in the management of both chronic and acute wounds, such as burns, by increasing wound granulation. However, to our knowledge, its utility in OA management has not been reported.
Objective: The objective of this report is to introduce a novel use of AFSG (Kerecis™) in open abdomen to decrease the time of TACs by accelerating formation of granulation tissue and placement of skin grafts in patients with post damage control laparotomy (DCL) for trauma and IAC when committed to open abdomen management is presented.
Materials and Methods: Illustration of application of AFSG (Kerecis™) in two patients who underwent DCL for IAC and OA management is presented. Results: Two patients with intra-abdominal catastrophe post-DCL and fistulae were enrolled; one with postoperative enteric fistula and the other with post-anastomotic ileo-colonic fistula breakdown and major intra-abdominal sepsis resulting in multiple organ system failure (MOSF). In both cases, a hostile abdomen was present. The application of AFSG accelerated the placement of skin grafts in both patients and decreased the use of wound VAC and hospital length of stay.
Conclusion: This report illustrates the use of AFSG (Kerecis™) to accelerate placement of skin grafts in patients post-DCL and OA management. AFSG (Kerecis™) could be considered as part of the OA management strategy.
How Do We Physicians and Surgeons Deal With our Own Disease?
Rifat Latifi, MD, FACS, FKCS, Adjunct Professor of Surgery, University of Arizona, Tucson, AZ,
Rahim Hirani, MS, School of Medicine, New York, NY, Abbas Smiley, MD, MS, PhD, School of
Medicine, University of Rochester, Rochester, NY
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It is a “known secret” that physicians and surgeons do not make good patients and neglect their own health by ignoring early warning signs of physical and psychological problems. Moreover, often, they seek help late. What are the reasons for this self-neglect? Is it because we think we are “super humans,” or we think that we will not get sick, cannot get sick, should not get sick, have no “right” to get sick, as we must care for others? Do we ignore ourselves because we must go to one more meeting, do one more thing, write or present one more paper, give one more lecture, or take the call even with a fever, cough, and chills? Why can’t we call in sick? Is this the “macho” effect? Is this culture of denial pervasive everywhere, even though we should know better? Yes, it is! Don’t we need to remember the advice given by airlines to put on an oxygen mask on yourself first before helping others? Unfortunately, many of us do not do it. In this article, we will present a personal reflection as an example and review how we physicians and surgeons neglect our own health, ignoring the early warning signs of physical and psychological problems, and how we often seek help late. We also discuss potential reasons for this becoming a “norm” for many of us. Lastly, we review measures taken by some healthcare systems to remedy this situation.
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