Minimally Invasive Surgery The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Retrograde Intrarenal Surgery in Patients Who Previously Underwent Open Renal Stone Surgery Tue, 18 Aug 2015 13:34:37 +0000 Purpose. To ascertain whether retrograde intrarenal surgery (RIRS) is as effective in patients treated previously with open renal stone surgery (ORSS) on the same kidney as in patients with no previous ORSS. Methods. There were 32 patients with renal stones who had previous ORSS and were treated with RIRS in the study group (Group 1). A total of 38 patients with renal stones who had no previous ORSS and were treated with RIRS were selected as the control group (Group 2). Recorded data regarding preoperative characteristics of the patients, stone properties, surgical parameters, outcomes, SFRs (no fragments or small fragments <4 mm), and complications between groups were compared. Results. Mean age, mean BMI, mean hospital stay, and mean operative time were not statistically different between groups. Mean stone size (10.1 ± 5.6 versus 10.3 ± 4.2; ) and mean stone burden (25.4 ± 14.7 versus 23.5 ± 9.9; ) were also similar between groups. After the second procedures, SFRs were 100% and 95% in groups 1 and 2, respectively . No major perioperative complications were seen. Conclusion. RIRS can be safely and effectively performed with acceptable complication rates in patients treated previously with ORSS as in patients with no previous ORSS. Erdal Alkan, Ali Saribacak, Ahmet Oguz Ozkanli, Mehmet Murad Başar, Oguz Acar, and Mevlana Derya Balbay Copyright © 2015 Erdal Alkan et al. All rights reserved. Tactile Electrosurgical Ablation: A Technique for the Treatment of Intractable Heavy and Prolonged Menstrual Bleeding Thu, 30 Jul 2015 12:37:35 +0000 Objective. To study the efficacy and safety of tactile electrosurgical ablation (TEA) in stopping a persistent attack of abnormal uterine bleeding not responding to medical and hormonal therapy. Methods. This is a case series of 19 cases with intractable abnormal uterine bleeding, who underwent TEA at the Women’s Health Center of Assiut University. The outcomes measured were; patient’s acceptability, operative time, complications, menstrual outcomes, and reintervention. Results. None of the 19 counseled cases refused the TEA procedure which took 6–10 minutes without intraoperative complications. The procedure was successful in the immediate cessation of bleeding in 18 out of 19 cases. During the 24-month follow-up period, 9 cases developed amenorrhea, 5 had scanty menstrual bleeding, 3 were regularly menstruating, 1 case underwent repeat TEA ablation, and one underwent a hysterectomy. Conclusions. TEA represents a safe, inexpensive, and successful method for management of uterine bleeding emergencies with additional long-term beneficial effects. However, more studies with more cases and longer follow-up periods are warranted. Ali M. El Saman, Faten F. AbdelHafez, Kamal M. Zahran, Hazem Saad, Mohamed Khalaf, Mostafa Hussein, Ibrahim M. A. Hassanin, and Saba M. Shugaa Al Deen Copyright © 2015 Ali M. El Saman et al. All rights reserved. The Role of VATS in Lung Cancer Surgery: Current Status and Prospects for Development Wed, 29 Jul 2015 09:09:41 +0000 Since the introduction of anatomic lung resection by video-assisted thoracoscopic surgery (VATS) 20 years ago, VATS has experienced major advances in both equipment and technique, introducing a technical challenge in the surgical treatment of both benign and malignant lung disease. The demonstrated safety, decreased morbidity, and equivalent efficacy of this minimally invasive technique have led to the acceptance of VATS as a standard surgical modality for early-stage lung cancer and increasing application to more advanced disease. Formerly there was much debate about the feasibility of the technique in cancer surgery and proper lymph node handling. Although there is a lack of proper randomized studies, it is now generally accepted that the outcome of a VATS procedure is at least not inferior to a resection via a traditional thoracotomy. Dariusz Dziedzic and Tadeusz Orlowski Copyright © 2015 Dariusz Dziedzic and Tadeusz Orlowski. All rights reserved. Corrigendum to “Transvaginal Appendectomy: A Systematic Review” Sun, 28 Jun 2015 14:23:56 +0000 Cuneyt Kayaalp, Kerem Tolan, and Mehmet Ali Yagci Copyright © 2015 Cuneyt Kayaalp et al. All rights reserved. Early Experience in Da Vinci Robot-Assisted Partial Nephrectomy: An Australian Single Centre Series Mon, 08 Jun 2015 13:22:29 +0000 Introduction and Objectives. To demonstrate the safety and efficacy of the robot-assisted partial nephrectomy (RAPN) technique in an Australian setting. Methods. Between November 2010 and July 2014, a total of 76 patients underwent 77 RAPN procedures using the Da Vinci Surgical System© at our institution. 58 of these procedures were performed primarily by the senior author (PB) and are described in this case series. Results. Median operative time was 4 hours (range 1.5–6) and median warm ischaemic time (WIT) was 8 minutes (range 0–30) including 11 cases with zero ischaemic time. All surgical margins were clear with the exception of one patient who had egress of intravascular microscopic tumour outside the capsule to the point of the resection margin. Complications were identified in 9 patients (15.8%). Major complications included conversion to open surgery due to significant venous bleeding (), reperfusion injury (), gluteal compartment syndrome (), DVT/PE (), and readmission for haematuria (). Conclusion. This series demonstrates the safety and efficacy of the RAPN technique in an Australian setting when performed by experienced laparoscopic surgeons in a dedicated high volume robotic centre. Francis Ting, Richard Savdie, Sam Chopra, Carlo Yuen, and Phillip Brenner Copyright © 2015 Francis Ting et al. All rights reserved. Clinical Effectiveness of Modified Laparoscopic Fimbrioplasty for the Treatment of Minimal Endometriosis and Unexplained Infertility Wed, 06 May 2015 10:28:41 +0000 Objective. To study the reproductive outcomes of modified laparoscopic fimbrioplasty (MLF), a surgical technique designed to increase the working surface area of the fimbriated end of the fallopian tube. We postulated that an improvement in fimbrial function through MLF will improve reproductive outcomes. Design. Retrospective cohort study. Setting. Academic tertiary-care medical center. Patients. Women with minimal endometriosis or unexplained infertility, who underwent MLF during diagnostic laparoscopy () or diagnostic laparoscopy alone (). Intervention. MLF involved gentle, circumferential dilatation of the fimbria and lysis of fimbrial adhesions bridging the fimbrial folds. Main Outcome Measures. The primary outcome was pregnancy rate and the secondary outcome was time to pregnancy. Results. The pregnancy rate for the MLF group was 40.0%, compared to 28.7% for the control group. The average time to pregnancy for the MLF group was 13 weeks, compared to 18 weeks for the control group. The pregnancy rate in the MLF group was significantly higher for patients ≤35 ys (51.5% versus 28.8%), but not for those >35 ys (17.6% versus 28.6%). Conclusion. MLF was associated with a significant increase in pregnancy rate for patients ≤35 ys. Sarah E. Franjoine, Mohamed A. Bedaiwy, Faten F. AbdelHafez, Cuiyu Geng, and James H. Liu Copyright © 2015 Sarah E. Franjoine et al. All rights reserved. Stability Outcomes following Computer-Assisted ACL Reconstruction Thu, 26 Mar 2015 12:57:54 +0000 Purpose. The purpose of this study was to determine whether intraoperative prereconstruction stability measurements and/or patient characteristics were associated with final knee stability after computer-assisted ACL reconstruction. Methods. This was a retrospective review of all patients who underwent computer-assisted single-bundle ACL reconstruction by a single surgeon. Prereconstruction intraoperative stability measurements were correlated with patient characteristics and postreconstruction stability measurements. 143 patients were included (87 male and 56 female). Average age was 29.8 years (SD ± 11.8). Results. Females were found to have significantly more pre- and postreconstruction internal rotation than males (P < 0.001 and P = 0.001, resp.). Patients with additional intra-articular injuries demonstrated more prereconstruction anterior instability than patients with isolated ACL tears (P < 0.001). After reconstruction, these patients also had higher residual anterior translation (P = 0.01). Among all patients with ACL reconstructions, the percent of correction of anterior translation was found to be significantly higher than the percent of correction for internal or external rotation (P < 0.001). Conclusion. Anterior translation was corrected the most using a single-bundle ACL reconstruction. Females had higher pre- and postoperative internal rotation. Patients with additional injuries had greater original anterior translation and less operative correction of anterior translation compared to patients with isolated ACL tears. Melissa A. Christino, Bryan G. Vopat, Alexander Mayer, Andrew P. Matson, Steven E. Reinert, and Robert M. Shalvoy Copyright © 2015 Melissa A. Christino et al. All rights reserved. Two Ports Laparoscopic Inguinal Hernia Repair in Children Mon, 16 Feb 2015 09:30:32 +0000 Introduction. Several laparoscopic treatment techniques were designed for improving the outcome over the last decade. The various techniques differ in their approach to the inguinal internal ring, suturing and knotting techniques, number of ports used in the procedures, and mode of dissection of the hernia sac. Patients and Surgical Technique. 90 children were subjected to surgery and they undergone two-port laparoscopic repair of inguinal hernia in children. Technique feasibility in relation to other modalities of repair was the aim of this work. 90 children including 75 males and 15 females underwent surgery. Hernia in 55 cases was right-sided and in 15 left-sided. Two patients had recurrent hernia following open hernia repair. 70 (77.7%) cases were suffering unilateral hernia and 20 (22.2%) patients had bilateral hernia. Out of the 20 cases 5 cases were diagnosed by laparoscope (25%). The patients’ median age was 18 months. The mean operative time for unilateral repairs was 15 to 20 minutes and bilateral was 21 to 30 minutes. There was no conversion. The complications were as follows: one case was recurrent right inguinal hernia and the second was stitch sinus. Discussion. The results confirm the safety and efficacy of two ports laparoscopic hernia repair in congenital inguinal hernia in relation to other modalities of treatment. Medhat M. Ibrahim Copyright © 2015 Medhat M. Ibrahim. All rights reserved. Laparoscopic Watson Fundoplication Is Effective and Durable in Children with Gastrooesophageal Reflux Wed, 31 Dec 2014 11:29:50 +0000 Gastroesophageal reflux (GOR) affects 2–8% of children over 3 years of age and is associated with significant morbidity. The disorder is particularly critical in neurologically impaired children, who have a high risk of aspiration. Traditionally, the surgical antireflux procedure of choice has been Nissen’s operation. However, this technique has a significant incidence of mechanical complications and has a reoperation rate of approximately 7%, leading to the development of alternative approaches. Watson’s technique of partial anterior fundoplication has been shown to achieve long-lasting reflux control in adults with few mechanical complications, but there is limited data in the paediatric population. We present here short- and long-term outcomes of laparoscopic Watson fundoplication in a series of 76 children and infants, 34% of whom had a degree of neurological impairment including severe cerebral palsy and hypoxic brain injury. The overall complication rate was 27.6%, of which only 1 was classified as major. To date, we have not recorded any incidences of perforation and no revisions. In our experience, Watson’s laparoscopic partial fundoplication can be performed with minimal complications and with durable results, not least in neurologically compromised children, making it a viable alternative to the Nissen procedure in paediatric surgery. Matthew G. Dunckley, Kapil M. Rajwani, and Anies A. Mahomed Copyright © 2014 Matthew G. Dunckley et al. All rights reserved. Transvaginal Appendectomy: A Systematic Review Mon, 29 Dec 2014 00:10:18 +0000 Background. Natural orifice transluminal endoscopic surgery (NOTES) is a new approach that allows minimal invasive surgery through the mouth, anus, or vagina. Objective. To summarize the recent clinical appraisal, feasibility, complications, and limitations of transvaginal appendectomy for humans and outline the techniques. Data Sources. PubMed/MEDLINE, Cochrane, Google-Scholar, EBSCO, and congress abstracts, were searched. Study Selection. All related reports were included, irrespective of age, region, race, obesity, comorbidities or history of previous surgery. No restrictions were made in terms of language, country or journal. Main Outcome Measures. Patient selection criteria, surgical techniques, and results. Results. There were total 112 transvaginal appendectomies. All the selected patients had uncomplicated appendicitis and there were no morbidly obese patients. There was no standard surgical technique for transvaginal appendectomy. Mean operating time was 53.3 minutes (25–130 minutes). Conversion and complication rates were 3.6% and 8.2%, respectively. Mean length of hospital stay was 1.9 days. Limitations. There are a limited number of comparative studies and an absence of randomized studies. Conclusions. For now, nonmorbidly obese females with noncomplicated appendicitis can be a candidate for transvaginal appendectomy. It may decrease postoperative pain and enable the return to normal life and work off time. More comparative studies including subgroups are necessary. Mehmet Ali Yagci and Cuneyt Kayaalp Copyright © 2014 Mehmet Ali Yagci and Cuneyt Kayaalp. All rights reserved. Antimullerian Hormone Changes after Laparoscopic Ovarian Cystectomy for Endometrioma Compared with the Nonovarian Conditions Sun, 14 Dec 2014 12:14:19 +0000 Laparoscopic ovarian cystectomy is recommended for surgical procedure of endometrioma. The negative impact on ovarian reserve following removal had been documented. Little evidence had been reported for nonovarian originated effects. Objective. To evaluate the impact of laparoscopic ovarian cystectomy for endometrioma on ovarian reserve, measured by serum antimullerian hormone (AMH), compared to nonovarian pelvic surgery. Materials and Methods. A prospective study was conducted. Women who underwent laparoscopic ovarian cystectomy (LOC) and laparoscopic nonovarian pelvic surgery (NOS) were recruited and followed up through 6 months. Clinical baseline data and AMH were evaluated. Results. 39 and 38 participants were enrolled in LOC and NOS groups, respectively. Baseline characteristics (age, weight, BMI, and height) and preoperative AMH level between 2 groups were not statistically different. After surgery, AMH of both groups decreased since the first week, at 1 month and at 3 months. However, as compared to the LOC group at 6 months after operation, the mean AMH of the NOS group had regained its value with a highly significant difference. Conclusion. This study demonstrated the negative impact of nonovarian or indirect effects of laparoscopic surgery to ovarian reserve. The possible mechanisms are necessary for more investigations. Chamnan Tanprasertkul, Sakol Manusook, Charintip Somprasit, Sophapun Ekarattanawong, Opas Sreshthaputra, and Teraporn Vutyavanich Copyright © 2014 Chamnan Tanprasertkul et al. All rights reserved. Comment on “Video-Assisted Thoracic Surgery for Tubercular Spondylitis” Sun, 07 Dec 2014 06:55:01 +0000 Safak Ekinci, Serkan Bilgic, Kenan Koca, Mehmet Agilli, and Omer Ersen Copyright © 2014 Safak Ekinci et al. All rights reserved. Changing Trends in Use of Laparoscopy: A Clinical Audit Thu, 04 Dec 2014 10:11:53 +0000 Aim. To find out the changing trends in indications for use of laparoscopy for diagnostic or operative procedures in gynaecology. Methods. This was a clinical audit of 417 women who underwent laparoscopic procedures over a period of 8 years from January 2005 to December 2012 in the Department of Obstetrics and Gynaecology at a tertiary care centre in Delhi. Results. A total of 417 diagnostic and operative laparoscopic procedures were performed during the period from January 2005 to December 2012. Out of 417 women, 13 women were excluded from the study due to inadequate data. 208 (51.4%) women had only diagnostic laparoscopy whereas 196 (48.6%) patients had operative laparoscopy after the initial diagnostic procedure. Change in trend of diagnostic versus operative procedures was observed from 2005 to 2012. There was increase in operative procedures from 10 (37.03%) women in 2005 as compared to 51 (73.91%) in 2012. The main indication for laparoscopy was infertility throughout the study period (61.38%), followed by chronic pelvic pain (CPP) (11.38%) and abnormal uterine bleeding (AUB) (9.4%). Conclusion. Over the years, there has been a rise in the rate of operative laparoscopy. Though the indications for laparoscopy have remained almost similar during the years, laparoscopy for diagnosis and treatment of CPP and AUB has now increased. Ritu Khatuja, Geetika Jain, Sumita Mehta, Nidhi Arora, Atul Juneja, and Neerja Goel Copyright © 2014 Ritu Khatuja et al. All rights reserved. Laparoscopic versus Open Surgery for Colorectal Cancer: A Retrospective Analysis of 163 Patients in a Single Institution Sun, 23 Nov 2014 14:28:13 +0000 Background. The present study aimed to compare the clinical outcomes of laparoscopic versus open surgery for colorectal cancers. Materials and Methods. The medical records from a total of 163 patients who underwent surgery for colorectal cancers were retrospectively analyzed. Patient’s demographic data, operative details and postoperative early outcomes, outpatient follow-up, pathologic results, and stages of the cancer were reviewed from the database. Results. The patients who underwent laparoscopic surgery showed significant advantages due to the minimally invasive nature of the surgery compared with those who underwent open surgery, namely, less blood loss, faster postoperative recovery, and shorter postoperative hospital stay (). However, laparoscopic surgery for colorectal cancer resulted in a longer operative time compared with open surgery (). There were no statistically significant differences between groups for medical complications (). Open surgery resulted in more incisional infections and postoperative ileus compared with laparoscopic surgery (). There were no differences in the pathologic parameters between two groups (). Conclusions. These findings indicated that laparoscopic surgery for colorectal cancer had the clear advantages of a minimally invasive surgery and relative disadvantage with longer surgery time and exhibited similar pathologic parameters compared with open surgery. Abdulkadir Bedirli, Bulent Salman, and Osman Yuksel Copyright © 2014 Abdulkadir Bedirli et al. All rights reserved. The Arrowhead Ministernotomy with Rigid Sternal Plate Fixation: A Minimally Invasive Approach for Surgery of the Ascending Aorta and Aortic Root Tue, 18 Nov 2014 09:09:01 +0000 Background. Ministernotomy incisions have been increasingly used in a variety of settings. We describe a novel approach to ministernotomy using arrowhead incision and rigid sternal fixation with a standard sternal plating system. Methods. A small, midline, vertical incision is made from the midportion of the manubrium to a point just above the 4th intercostal mark. The sternum is opened in the shape of an inverted T using two oblique horizontal incisions from the midline to the sternal edges. At the time of chest closure, the three bony segments are aligned and approximated, and titanium plates (Sternalock, Jacksonville, Florida) are used to fix the body of the sternum back together. Results. This case series includes 11 patients who underwent arrowhead ministernotomy with rigid sternal plate fixation for aortic surgery. The procedures performed were axillary cannulation (), aortic root replacement (), valve sparing root replacement (), and replacement of the ascending aorta () and/or hemiarch (). Thirty-day mortality was 0%; there were no conversions, strokes, or sternal wound infections. Conclusions. Arrowhead ministernotomy with rigid sternal plate fixation is an adequate minimally invasive approach for surgery of the ascending aorta and aortic root. Mark J. Russo, John Gnezda, Aurelie Merlo, Elizabeth M. Johnson, Mohammad Hashmi, and Jaishankar Raman Copyright © 2014 Mark J. Russo et al. All rights reserved. Ureteral Stenting after Uncomplicated Ureteroscopy for Distal Ureteral Stones: A Randomized, Controlled Trial Sun, 09 Nov 2014 09:43:34 +0000 Objectives. We compared outcome and complications after uncomplicated ureteroscopic treatment of distal ureteral calculi with or without the use of ureteral stents. Materials and Methods. 117 patients, prospectively divided into three groups to receive a double j stent (group 1, 42 patients), ureteral stent (group 2, 37 patients), or no stent (group 3, 38 patients), underwent ureteroscopic treatment of distal ureteral calculi. Stone characteristics, operative time, postoperative pain, lower urinary tract symptoms (LUTS), analgesia need, rehospitalization, stone-free rate, and late postoperative complications were all studied. Results. There were no significant differences in preoperative data. There was no significant difference between the three groups regarding hematuria, fever, flank pain, urinary tract infection, and rehospitalisation. At 48 hours and 1 week, frequency/urgency and dysuria were significantly less in the nonstented group. When comparing group 1 and group 3, patients with double j stents had statistically significantly more bladder pain (), frequency/urgency (), dysuria (), and need of analgesics (). All patients who underwent imaging postoperatively were without evidence of obstruction or ureteral stricture. Conclusions. Uncomplicated ureteroscopy for distal ureteral calculi without intraoperative ureteral dilation can safely be performed without placement of a ureteral stent. Y. El Harrech, N. Abakka, J. El Anzaoui, O. Ghoundale, and D. Touiti Copyright © 2014 Y. El Harrech et al. All rights reserved. In Silico Investigation of a Surgical Interface for Remote Control of Modular Miniature Robots in Minimally Invasive Surgery Tue, 09 Sep 2014 09:37:22 +0000 Aim. Modular mini-robots can be used in novel minimally invasive surgery techniques like natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single site (LESS) surgery. The control of these miniature assistants is complicated. The aim of this study is the in silico investigation of a remote controlling interface for modular miniature robots which can be used in minimally invasive surgery. Methods. The conceptual controlling system was developed, programmed, and simulated using professional robotics simulation software. Three different modes of control were programmed. The remote controlling surgical interface was virtually designed as a high scale representation of the respective modular mini-robot, therefore a modular controlling system itself. Results. With the proposed modular controlling system the user could easily identify the conformation of the modular mini-robot and adequately modify it as needed. The arrangement of each module was always known. The in silico investigation gave useful information regarding the controlling mode, the adequate speed of rearrangements, and the number of modules needed for efficient working tasks. Conclusions. The proposed conceptual model may promote the research and development of more sophisticated modular controlling systems. Modular surgical interfaces may improve the handling and the dexterity of modular miniature robots during minimally invasive procedures. Apollon Zygomalas, Konstantinos Giokas, and Dimitrios Koutsouris Copyright © 2014 Apollon Zygomalas et al. All rights reserved. Endovascular Recanalization for Chronic Symptomatic Intracranial Vertebral Artery Total Occlusion Wed, 03 Sep 2014 10:38:16 +0000 Purpose. The outcome of recanalization in patients with chronic symptomatic intracranial vertebral artery (ICVA) total occlusion is poor. This paper reports the technical feasibility and long-term outcome of ICVA stenting in patients with chronic symptomatic total occlusion. Methods. Retrospective review of our prospectively maintained intracranial intervention database to identify patients with symptomatic total occlusion of ICVA with revascularization attempted >1 month after index ischemic event. Results. Eight patients (mean age 58 years) were identified. One had stroke and 7 had recurrent transient ischemic attacks. Four had bilateral ICVA total occlusion and 4 had unilateral ICVA total occlusion with severe stenosis contralaterally. Seven of 8 patients underwent endovascular recanalization, which was achieved in 6. Periprocedural complications included cerebellum hemorrhage, arterial dissection, perforation, and subacute in-stent thrombosis which occurred in 3 patients. One patient died of cerebellum hemorrhage. The other patients improved clinically after endovascular therapy. Conclusions. Stent-supported recanalization of ICVA total occlusion is technically feasible, and may become a viable treatment option in selected patients. Ziqi Xu, Ning Ma, Dapeng Mo, Edward Ho chung Wong, Feng Gao, Liqun Jiao, and Zhongrong Miao Copyright © 2014 Ziqi Xu et al. All rights reserved. Operative Outcome and Patient Satisfaction in Early and Delayed Laparoscopic Cholecystectomy for Acute Cholecystitis Thu, 14 Aug 2014 00:00:00 +0000 Introduction. Early laparoscopic cholecystectomy is usually associated with reduced hospital stay, sick leave, and health care expenditures. Early diagnosis and treatment of acute cholecystitis reduce both mortality and morbidity and the accurate diagnosis requires specific diagnostic criteria of clinical data and imaging studies. Objectives. To compare early versus delayed laparoscopic cholecystectomy regarding the operative outcome and patient satisfaction. Patients and Methods. Patients with acute cholecystitis were divided into two groups, early (A) and delayed (B) cholecystectomy. Diagnosis of acute cholecystitis was confirmed by clinical examination, laboratory data, and ultrasound study. The primary end point was operative and postoperative outcome and the secondary was patient’s satisfaction. Results. The number of readmissions in delayed treatment group B was three times in 10% of patients, twice in 23.3%, and once in 66.7% while the number of readmissions was once only in patients in group A and the mean total hospital stays were higher in group B than in group A. The overall patient’s satisfaction was in group A compared with in group B. Conclusion. Early laparoscopic cholecystectomy resulted in significant reduction in length of hospital stay and accepted rate of operative complications and conversion rates when compared with delayed techniques. Aly Saber and Emad N. Hokkam Copyright © 2014 Aly Saber and Emad N. Hokkam. All rights reserved. How to Evaluate Adenomyosis in Patients Affected by Endometriosis? Tue, 12 Aug 2014 09:22:53 +0000 Objective. The aim of the study is to evaluate adenomyosis in patients undergoing surgery for different type of endometriosis. It is an observational study including women with preoperative ultrasound diagnosis of adenomyosis. Demographic data and symptoms were recorded (age, body mass index, parity, history of previous surgery, dysmenorrhea, dyspareunia, dyschezia, dysuria, and abnormal uterine bleeding). Moreover a particular endometrial shape “question mark sign” linked to the presence of adenomyosis was assessed. Results. From 217 patients with ultrasound diagnosis of adenomyosis, we found 73 with ovarian histological confirmation of endometriosis, 92 with deep infiltrating endometriosis, and 52 patients who underwent surgery for infertility. Women with adenomyosis alone represented the oldest group of patients ( years, ). Deep endometriosis patients were nulliparous more frequently (), had history of previous surgery (), and complained of more intense pain symptoms than other groups. Adenomyosis alone was significantly associated with abnormal uterine bleeding (). The question mark sign was found to be strongly related to posterior deep infiltrating endometriosis (). Conclusion. Our study confirmed the strong relationship between adenomyosis and endometriosis and evaluated demographic aspects and symptoms in patients affected by different type of endometriosis. Nadine Di Donato and Renato Seracchioli Copyright © 2014 Nadine Di Donato and Renato Seracchioli. All rights reserved. Reducing the Cost of Laparoscopy: Reusable versus Disposable Laparoscopic Instruments Tue, 22 Jul 2014 10:19:20 +0000 Cost-effectiveness in health care management is critical. The situation in debt-stricken Greece is further aggravated by the financial crisis and constant National Health System expense cut-downs. In an effort to minimize the cost of laparoscopy, our department introduced reusable laparoscopic instruments in December 2011. The aim of this study was to assess potential cost reduction of laparoscopic operations in the field of general surgery. Hospital records, invoice lists, and operative notes between January 2012 and December 2013, were retrospectively reviewed and data were collected on laparoscopic procedures, instrument failures, and replacement needs. Initial acquisition cost of 5 basic instrument sets was €21,422. Over the following 24 months, they were used in 623 operations, with a total maintenance cost of €11,487. Based on an average retail price of €490 per set, projected cost with disposable instruments would amount to €305,270, creating savings of €272,361 over the two-year period under study. Despite the seemingly high purchase price, each set amortized its acquisition cost after only 9 procedures and instrument cost depreciated to less than €55 per case. Disposable instruments cost 9 times more than reusable ones, and their high price would almost equal the total hospital reimbursement by social security funds for many common laparoscopic procedures. Dimitrios K. Manatakis and Nikolaos Georgopoulos Copyright © 2014 Dimitrios K. Manatakis and Nikolaos Georgopoulos. All rights reserved. Novel Axillary Approach for Brachial Plexus in Robotic Surgery: A Cadaveric Experiment Mon, 21 Jul 2014 11:49:24 +0000 Brachial plexus surgery using the da Vinci surgical robot is a new procedure. Although the supraclavicular approach is a well known described and used procedure for robotic surgery, axillary approach was unknown for brachial plexus surgery. A cadaveric study was planned to evaluate the robotic axillary approach for brachial plexus surgery. Our results showed that robotic surgery is a very useful method and should be used routinely for brachial plexus surgery and particularly for thoracic outlet syndrome. However, we emphasize that new instruments should be designed and further studies are needed to evaluate in vivo results. Cihangir Tetik and Metin Uzun Copyright © 2014 Cihangir Tetik and Metin Uzun. All rights reserved. Complications of Minimally Invasive, Tubular Access Surgery for Cervical, Thoracic, and Lumbar Surgery Mon, 07 Jul 2014 00:00:00 +0000 The object of the study was to review the author’s large series of minimally invasive spine surgeries for complication rates. The author reviewed a personal operative database for minimally access spine surgeries done through nonexpandable tubular retractors for extradural, nonfusion procedures. Consecutive cases () were reviewed for complications. There were no wound infections. Durotomy occurred in 33 cases (2.7% overall or 3.4% of lumbar cases). There were no external or symptomatic internal cerebrospinal fluid leaks or pseudomeningoceles requiring additional treatment. The only motor injuries were 3 C5 root palsies, 2 of which resolved. Minimally invasive spine surgery performed through tubular retractors can result in a low wound infection rate when compared to open surgery. Durotomy is no more common than open procedures and does not often result in the need for secondary procedures. New neurologic deficits are uncommon, with most observed at the C5 root. Minimally invasive spine surgery, even without benefits such as less pain or shorter hospital stays, can result in considerably lower complication rates than open surgery. Donald A. Ross Copyright © 2014 Donald A. Ross. All rights reserved. Prospective Observational Study of Single-Site Multiport Per-umbilical Laparoscopic Endosurgery versus Conventional Multiport Laparoscopic Cholecystectomy: Critical Appraisal of a Unique Umbilical Approach Wed, 30 Apr 2014 07:24:12 +0000 Purpose. This prospective observational study compares an innovative approach of Single-Site Multi-Port Per-umbilical Laparoscopic Endo-surgery (SSMPPLE) cholecystectomy with the gold standard—Conventional Multi-port Laparoscopic Cholecystectomy (CMLC)—to assess the feasibility and efficacy of the former. Methods. In all, 646 patients were studied. SSMPPLE cholecystectomy utilized three ports inserted through three independent mini-incisions at the umbilicus. Only the day-to-day rigid laparoscopic instruments were used in all cases. The SSMPPLE cholecystectomy group had 320 patients and the CMLC group had 326 patients. The outcomes were statistically compared. Results. SSMPPLE cholecystectomy had average operative time of 43.8 min and blood loss of 9.4 mL. Their duration of hospitalization was 1.3 days (range, 1–5). Six patients (1.9%) of this group were converted to CMLC. Eleven patients had controlled gallbladder perforations at dissection. The Visual Analogue Scores for pain on postoperative days 0 and 7, the operative time, and the scar grades were significantly better for SSMPPLE than CMLC. However, umbilical sepsis and seroma outcomes were similar. We had no bile-duct injuries or port-site hernias in this study. Conclusion. SSMPPLE cholecystectomy approach complies with the principles of laparoscopic triangulation; it seems feasible and safe method of minimally invasive cholecystectomy. Overall, it has a potential to emerge as an economically viable alternative to single-port surgery. Priyadarshan Anand Jategaonkar and Sudeep Pradeep Yadav Copyright © 2014 Priyadarshan Anand Jategaonkar and Sudeep Pradeep Yadav. All rights reserved. A New Proposal for Learning Curve of TEP Inguinal Hernia Repair: Ability to Complete Operation Endoscopically as a First Phase of Learning Curve Wed, 23 Apr 2014 11:39:29 +0000 Background. The exact nature of learning curve of totally extraperitoneal inguinal hernia and the number required to master this technique remain controversial. Patients and Methods. We present a retrospective review of a single surgeon experience on patients who underwent totally extraperitoneal inguinal hernia repair. Results. There were 42 hernias (22 left- and 20 right-sided) in 39 patients with a mean age of years. Indirect, direct, and combined hernias were present in 18, 12, and 12 cases, respectively. The mean operative time was minutes. Peritoneal injury occurred in 9 cases (21.4%). Conversion to open surgery was necessitated in 7 cases (16.7%). After grouping of all patients into two groups as cases between 1–21 and 22–42, it was seen that the majority of peritoneal injuries (7 out of 9, 77.8%, ) and all conversions () occurred in the first 21 cases. Conclusions. Learning curve of totally extraperitoneal inguinal hernia repair can be divided into two consequent steps: immediate and late. At least 20 operations are required for gaining anatomical knowledge and surgical pitfalls based on the ability to perform this operation without conversion during immediate phase. Mustafa Hasbahceci, Fatih Basak, Aylin Acar, and Orhan Alimoglu Copyright © 2014 Mustafa Hasbahceci et al. All rights reserved. Transforaminal Approach in Thoracal Disc Pathologies: Transforaminal Microdiscectomy Technique Tue, 15 Apr 2014 11:36:09 +0000 Objective. Many surgical approaches have been defined and implemented in the last few decades for thoracic disc herniations. The endoscopic foraminal approach in foraminal, lateral, and far lateral disc hernias is a contemporary minimal invasive approach. This study was performed to show that the approach is possible using the microscope without an endoscope, and even the intervention on the discs within the spinal canal is possible by having access through the foramen. Methods. Forty-two cases with disc hernias in the medial of the pedicle were included in this study; surgeries were performed with transforaminal approach and microsurgically. Extraforaminal disc hernias were not included in the study. Access was made through the Kambin triangle, foramen was enlarged, and spinal canal was entered. Results. The procedure took 65 minutes in the average, and the mean bleeding amount was about 100cc. They were mobilized within the same day postoperatively. No complications were seen. Follow-up periods range between 5 and 84 months, and the mean follow-up period is 30.2 months. Conclusion. Transforaminal microdiscectomy is a method that can be performed in any clinic with standard spinal surgery equipment. It does not require additional equipment or high costs. Sedat Dalbayrak, Onur Yaman, Kadir Öztürk, Mesut Yılmaz, Mahmut Gökdağ, and Murat Ayten Copyright © 2014 Sedat Dalbayrak et al. All rights reserved. Prospective Comparison of Nonnarcotic versus Narcotic Outpatient Oral Analgesic Use after Laparoscopic Appendectomy and Early Discharge Mon, 14 Apr 2014 09:35:44 +0000 Purpose. To compare narcotic versus nonnarcotic outpatient oral pain management after pediatric laparoscopic appendectomy. Methods. In a prospective study from July 1, 2010, to March 30, 2011, children undergoing laparoscopic appendectomy on a rapid discharge protocol were treated with either nonnarcotic or narcotic postoperative oral analgesia. Two surgeons in a four-person faculty group employed the nonnarcotic regimen, while the other two used narcotics. Days of medication use, time needed for return to normal activity, and satisfaction rate with the pain control method were collected. Student’s t-test was used for statistical analysis. Results. A total of 207 consecutive children underwent appendectomy for acute, nonperforated appendicitis or planned interval appendectomy. The age and time to discharge were equivalent between the nonnarcotic () and narcotic () groups. Both had an equivalent number of medication days and similar times of return to normal activity. Ninety-seven percent of the parents of children in the nonnarcotic group stated that the pain was controlled by the prescribed medication, compared to 90 percent in the narcotic group (). Conclusion. This study indicates that after non-complicated pediatric laparoscopic appendectomy, nonnarcotic is equivalent to narcoticbased therapy for outpatient oral analgesia, with higher parental satisfaction. Fuad Alkhoury, Colin Knight, Steven Stylianos, Jeannette Zerpa, Raquel Pasaron, JoAnne Mora, Alexandra Aserlind, Leopoldo Malvezzi, and Cathy Burnweit Copyright © 2014 Fuad Alkhoury et al. All rights reserved. Erratum to “Minimally Invasive Treatment of the Thoracic Spine Disease: Completely Percutaneous and Hybrid Approaches” Sun, 06 Apr 2014 06:57:16 +0000 Francesco Ciro Tamburrelli, Laura Scaramuzzo, Maurizio Genitiempo, and Luca Proietti Copyright © 2014 Francesco Ciro Tamburrelli et al. All rights reserved. Video-Assisted Thoracic Surgery for Tubercular Spondylitis Thu, 03 Apr 2014 13:36:41 +0000 The present study evaluated the outcome of video-assisted thoracic surgery (VATS) in 9 patients (males = 6, females = 3) with clinico-radiological diagnosis of tubercular spondylitis of the dorsal spine. The mean duration of surgery was 140.88 ± 20.09 minutes, mean blood was 417.77 ± 190.90 mL, and mean duration of postoperative hospital stay was 5.77 ± 0.97 days, Seven patients had a preoperative Grade A neurological involvement, while at the time of final followup the only deficit was Grade D power in 2 patients. In patients without bone graft placement (n = 6), average increase in Kyphosis angle was 16°, while in patients with bone graft placement (n = 3) the deformity remained stationary. At the time of final follow up, fusion was achieved in all patients, the VAS score for back pain improved from a pretreatment score of 8.3 to 2, and the function assessment yielded excellent (n = 4) to good (n = 5) results. In two patients minithoracotomy had to be resorted due to extensive pleural adhesions (n = 1) or difficulty in placement of graft (n = 1). Videoassisted thoracoscopic surgery provides a safe and effective approach in the management of spinal tuberculosis. It has the advantages of decreased blood loss and post operative morbidity with minimal complications. Roop Singh, Paritosh Gogna, Sanjeev Parshad, Rajender Kumar Karwasra, Parmod Kumar Karwasra, and Kiranpreet Kaur Copyright © 2014 Roop Singh et al. All rights reserved. National Trends in the Adoption of Laparoscopic Cholecystectomy over 7 Years in the United States and Impact of Laparoscopic Approaches Stratified by Age Thu, 20 Mar 2014 06:50:32 +0000 Introduction. The aim of this study was to characterize national trends in adoption of laparoscopic cholecystectomy and determine differences in outcome based on type of surgery and patient age. Methods. Retrospective cross-sectional study of patients undergoing cholecystectomy. Trends in open versus laparoscopic cholecystectomy by age group and year were analyzed. Differences in outcomes including in-hospital mortality, complications, discharge disposition, length of stay (LOS), and cost are examined. Results. Between 1999 and 2006, 358,091 patients underwent cholecystectomy. In 1999, patients aged ≥80 years had the lowest rates of laparoscopic cholecystectomy, followed by those aged 65–79, 64–50, and 49–18 years (59.7%, 65.3%, 73.2%, and 83.5%, resp., ). Laparoscopic cholecystectomy was associated with improved clinical and economic outcomes across all age groups. Over the study period, there was a gradual increase in laparoscopic cholecystectomy performed among all age groups during each year, though elderly patients continued to lag significantly behind their younger counterparts in rates of laparoscopic cholecystectomy. Conclusion. This is the largest study to report trends in adoption of laparoscopic cholecystectomy in the US in patients stratified by age. Elderly patients are more likely to undergo open cholecystectomy. Laparoscopic cholecystectomy is associated with improved clinical outcomes. Anahita Dua, Abdul Aziz, Sapan S. Desai, Jason McMaster, and SreyRam Kuy Copyright © 2014 Anahita Dua et al. All rights reserved.