Implant-Bone Interface of Sacroiliac Joint Fusion Using iFuse Implant System

Introduction. Treatment of patients with SI joint pain is mostly limited to conservative care. However, in those with chronic pain and consequently prolonged mobilisation, internal fixation of the SI joint is often indicated. The aim of the present study was to assess stability and bone ingrowth of minimally invasive SI joint arthrodesis using a series of triangular, porous plasma coated implants (iFuse Implant System) using SPECT/CT. Material. We report ten cases of SI joint arthrodesis with a novel MIS SI joint fusion system. SPECT/CT was performed in all cases after a mean time of 5.8 months to evaluate bony ingrowth and stability within the SI joint. Results. In eight cases, no or only low tracer uptake could be visualized as an indicator of stability and bone ingrowth. Two patients have increased tracer uptake due to a second trauma-related ipsilateral sacral fracture and a low-grade infection. Conclusion. We could visualize satisfying osseous integration as well as stability within the SI joint after arthrodesis using iFuse Implant System. Therefore iFuse Implant System seems to be an effective treatment option in selected patients.

Skin Closure in Laparoscopic Living Donor Nephrectomy: Modern Tissue Adhesive versus Conventional Intracutaneous Suture—A Randomized Study

Purpose. To compare the modern tissue adhesive cyanoacrylate (Liquiband) to conventional, intracutaneous suture and dressing, with regard to wound characteristics, time consumption, donors’ self-satisfaction, and cost. Methods. Sixty-four kidney donors, subjected to laparoscopic hand-assisted nephrectomy, were randomly assigned to skin closure either with tissue adhesive (n=32) or suture (n=32). The follow-up assessments were carried out on postoperative days 2, 4 and at departure, evaluated by the use of a previously set numerical scale for rubor, secretion, gaps, oedema, and blisters. Infections and complications/reinterventions were recorded, as well as operative/skin closure time and costs. The donors’ self-satisfaction was evaluated by means of a questionnaire. Results. There were significant results in favour of tissue adhesive regarding wound closure time and the wound characteristics “rubor,” “blisters,” and “oedema.” Although, the wound parameters “secretion” and “gaps” altogether showed a rather evident tendency in favour of suture, partially at significant levels. A low rate of complications/reoperations/infections did not give rise to any significant differences. Conclusion. Our study concludes that gluing is significantly faster, less traumatic by avoiding needle penetrations, but associated with an increased rate of secretion and gaps—presumably depending on gluing technique. Glue seems particularly suitable for small, laparoscopic/trocar incisions.

The Efficacy and Outcome of Ministernotomy Compared to Those of Standard Sternotomy for Aortic Valve Replacement

Background. Benefits of ministernotomy have been reported but not yet fully established in the current literature. Ministernotomy may be associated with less bleeding, less need for transfusion, and reduced hospital length of stay. Methods. We retrospectively evaluated 347 patients who underwent aortic valve replacement between 2007 and 2011 at our institution. Results. Standard sternotomy was performed in 303 patients (154 males, 50.8% and 149 females, 49.2%) and ministernotomy in 44 patients (13 males, 30% and 30 females, 70%); most of the patients in ministernotomy group were female (75%) (P=.0095). The mean age for ministernotomy patients was 71.8±12.6 years and for sternotomy patients 67.4±13.8 years (P=.045). Significant preoperative morbidities (for ministernotomy and sternotomy, resp.) included stroke (11%, n=5 versus 18%, n=55; P=.39), PVD (23%, n=10 versus 16%, n=49; P=.29), COPD (25%, n=11 versus 17%, n=52; P=.21), renal failure (0.0%, n=0 versus 8.8%, n=26; P=.06), and previous heart surgery (9%, n=4 versus 9.5%, n=29; P=1.0). Intraoperative blood transfusion was required in 23% of ministernotomy patients (n=9) and 30% of sternotomy patients (n=91), P=.16. Major postoperative complications (for ministernotomy and sternotomy, resp.) included exploration for bleeding (4.5%, n=2 versus 6%, n=18; P=1) and adverse neurologic events (4.5%, n=2 versus 1.6%, n=5; P=.05). The length of stay (LOS) in the CCU was 75.4±57.1 hours for the ministernotomy group and 125.4±160.3 hours for the sternotomy group (P=.12). The LOS was slightly shorter following ministernotomy (9.00±7.78 days) compared to sternotomy (10.0±9.46 days) (P=.31). Perioperative mortality was 2.3% (n=1) for ministernotomy and 3.3% (n=10) for sternotomy (P=1.0). The 1-, 3-, and 7-year survival following ministernotomy was 93.8%, 93.8%, and 88.3%, respectively; following sternotomy, these rates were 87.7%, 83.7%, and 82.6%, respectively (95% CI 0.273 to 1.325, P=.20). Conclusion. Ministernotomy is less invasive and is associated with less perioperative and postoperative bleeding and reduced LOS in CCU and in hospital.

Early versus Delayed Laparoscopic Cholecystectomy for Acute Cholecystitis: A Prospective Randomized Trial

Introduction. Very few studies demonstrate the feasibility of laparoscopic cholecystectomy for acute cholecystitis. However, most surgeons prefer to delay surgery in the acute phase. The aim of this prospective randomized study was to evaluate the safety and feasibility of laparoscopic cholecystectomy for acute cholecystitis. Materials and Methods. Between August 2010 and March 2012, 30 patients with a diagnosis of acute cholecystitis underwent early laparoscopic cholecystectomy within 72 h of admission. This study group was compared with a control group of 30 patients of acute cholecystitis, who underwent delayed laparoscopic cholecystectomy after an initial period of conservative treatment. Results. There was no significant difference in the conversion rates (3 early versus 2 delayed), postoperative analgesia requirements, postoperative pain scores, or duration of postoperative stay (1.67 days early versus 1.47 days delayed). However, duration of surgery was significantly more in the early group (65.78 minutes early versus 56.83 minutes delayed). Surgery was abandoned in 2 patients from the early group because of difficult anatomy. No complications and mortality were seen in either group. Conclusions. Early laparoscopic cholecystectomy for acute cholecystitis is safe and feasible, offering the additional benefit of a shorter hospital stay. It should be offered to patients with acute cholecystitis, provided the surgery is performed within 72 h from the onset of symptoms.

Transperitoneal Laparoscopic Adrenalectomy: Assessment of the Surgical Learning Curve

Background. We report a single surgeon’s experience of 52 transperitoneal laparoscopic adrenalectomies (LAs) performed between 2001 and 2010. In addition, we compared this series with our first published series of LAs performed between 1994 and 2001. Methods. Our series includes 24 left, 20 right, and 4 bilateral LAs performed in 48 patients. To estimate the learning curve, we chronologically divided the sample of unilateral LAs into two groups of 22 patients and compared the operating time, estimated blood loss, maximum diameter of the lesion, complications, and length of hospital stay. Results. Mean operating time was significantly lower (94 versus 78 min, ) and mean intraoperative blood loss was significantly lower (156 versus 60 mL, ) after more experience had been gained. Additionally, a trend towards removing larger lesions was observed. There was no significant difference in terms of hospital stay. Conclusions. Observing a single surgeon’s experience of nine years in laparoscopic adrenalectomy, this study indicates that it takes approximately 20–25 procedures to flatten the learning curve. Thus, for single centers with a volume of approximately five LAs performed per year, we suggest a selection of a few experienced surgeons to perform LAs in order to improve outcomes.

Lift-Assisted Laparoscopy in Hysterectomy: A Retrospective Study of 32 Consecutive Cases

A large uterus is the most commonly reported obstacle to laparoscopic hysterectomy. It reduces the intra-abdominal free space, limits visualization and instrumentation, causes technical difficulties, and increases the potential for complications. The logical solution to this dilemma is to address the underlying problem and increase the intra-abdominal free space. This can be done readily by supplementing the conventional pneumoperitoneum by concurrent mechanical lifting of the abdominal wall using the camera trocar as an anchoring device. Such lift-assisted laparoscopy augments the intra-abdominal free space formation, and lifts the laparoscope to a higher position to give a panoramic view, even when the uterus is large. This retrospective study of 32 consecutive cases of laparoscopic hysterectomy indicates that the use of lift-assisted laparoscopy is safe for the patient and that a large uterus is not a contraindication. The operations were long, but complications were few. Lift-assisted laparoscopy is an option to improve patient care by modifying surgical procedures. Operating time, per se, is not a valid measure of quality in laparoscopic hysterectomy. The more traumatic abdominal hysterectomy procedures need not be selected in preference over lengthy minimally invasive techniques. Other techniques, such as solo surgery and in-office surgery, are also discussed.

Two-Level Minimally Invasive Transforaminal Lumbar Interbody Fusion: Surgical Technique and Illustrative Cases

Transforaminal lumbar interbody fusion (TLIF) is a common procedure performed by spine surgeons. The indications for TLIF include back pain and radiculopathy as a consequence of canal or foraminal stenosis, degenerative disc disease, spondylolisthesis, or deformity. Minimally invasive techniques (MIS) have proven to be effective for single-level TLIF and are associated with less blood loss, fewer wound complications and infections, faster recovery, and decreased hospital cost. To date, there is very little data on 2-level MIS TLIF. We present our technique for 2-level MIS TLIF with case illustrations and a review of the literature.

Expanded Endoscopic Endonasal Treatment of Primary Intracranial Tumors within the Paranasal Sinuses

Objective. Meningiomas and schwannomas represent a subset of primary intracranial tumors that are rarely identified exclusively in the paranasal sinuses. Here, we describe our experience with minimally invasive endoscopic endonasal approaches for the treatment of these tumors. Methods. We retrospectively reviewed the clinical, surgical, and radiographic characteristics of adults with pathologically confirmed sinonasal meningiomas and schwannomas located within the paranasal sinuses that were resected via an expanded endoscopic endonasal approach. Results. Five patients (1 male, 4 females) underwent an endoscopic endonasal approach for resection of sinonasal tumor. Clinical symptomatology most commonly included nasal obstruction, in addition to headache, jaw pain, anosmia, and chronic rhinosinusitis. Tumors were located exclusively within the sinonasal cavity and were on average 2.2 cm (range 1.4–3.8 cm). Pathology revealed 2 cases of meningioma and 3 cases of schwannoma. No evidence of tumor recurrence occurred over average followup of 1.5 years (range 0.11–3.9 years). Conclusion. Our case series suggests that an expanded endoscopic endonasal approach with a combined neurosurgical-otorhinolaryngologic team for the resection of sinonasal meningiomas and schwannomas offers an effective treatment option. Further studies that include a larger number of patients over a longer follow-up period are required to compare outcomes between minimally invasive and open approaches.

Objective versus Subjective Assessment of Laparoscopic Skill

Background. The equality of subjective- and objective-assessment methods in laparoscopic surgery are unknown. The aim of this study was to compare a subjective assessment method to an objective assessment method to evaluate laparoscopic skill. Methods. A prospective observational cohort study was conducted. Seventy-two residents completed a basic laparoscopic suturing task on a box trainer at two consecutive assessment points. Laparoscopic skill was rated subjectively using the Objective Structured Assessment of Technical Skills (OSATS) list and objectively using the TrEndo, an augmented-reality simulator. Results. TrEndo scores between the two assessment points correlated. OSATS scores did not correlate between the two assessment points. There was a correlation between TrEndo and OSATS scores at the first assessment point, but not at the second assessment point. Overall, OSATS scores correlated with TrEndo scores. There was a greater spread within OSATS scores compared to TrEndo scores. Conclusion. OSATS scores correlated with TrEndo scores. The TrEndo may be more responsive at rating individual’s laparoscopic skill, as demonstrated by a smaller overall spread in TrEndo scores. The additional value of objective assessment methods over conventional assessment methods as provided by laparoscopic simulators should be investigated.

Experimental Rat and Mouse Carotid Artery Surgery: Injury and Remodeling Studies

In cardiovascular research, translation of benchtop findings to the whole body environment is often critical in order to gain a more thorough and comprehensive clinical evaluation of the data with direct extrapolation to the human condition. In particular, developmental and/or pathophysiologic vascular growth studies often employ in vitro approaches such as cultured cells or tissue explant models in order to analyze specific cellular, molecular, genetic, and/or biochemical signaling factors under pristine controlled conditions. However, validation of in vitro data in a whole body setting complete with neural, endocrine, and other systemic contributions provides an essential proof of concept from a clinical perspective. Several well-characterized experimental in vivo models exist that provide excellent proof-of-concept tools to examine vascular growth and remodeling in the whole body. This paper will examine the rat carotid artery balloon injury model, the mouse carotid artery wire denudation injury model, and rat and mouse carotid artery ligation models with particular emphasis on minimally invasive surgical access to the site of intervention. Discussion will include key scientific and technical details as well as caveats, limitations, and considerations for the practical use of each of these valuable experimental models.