Surgical Innovation (SURG INNOV)

Publications in this journal

• Article: Transgastric and transperineal natural orifice translumenal endoscopic surgery (NOTES) in an appendectomy test bed.

  Shiva Jayaraman, Christopher M Schlachta
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  ABSTRACT: Our purpose was to establish a NOTES appendectomy test bed to evaluate whether the transgastric or transperineal (transvaginal) approach is most efficient. Using the uterine horns of female pigs as a model for appendectomy, 18 NOTES appendectomies were performed in 2 arms: 9 transgastric and 9 transvaginal. The primary outcome was mean total operative time for each technique excluding access closure. Secondary outcomes were peritoneal access and resection times. Means were compared using Student's t-test. Transgastric cases were faster than transperineal (46.5+/-14.5 vs 60.0+/-20.2 minutes, P=.02). Most of the improvement in transgastric times was due to faster resection (37.9+/-17.4 vs 51.3+/-16.5 minutes, P=.03). Neither approach was faster for peritoneal access (8.2+/-3.4 vs 8.3+/-4.5 minutes, nonsignificant). A significant learning curve was not demonstrated for the transgastric approach (53.0 vs 40.3 minutes, nonsignificant). A significant learning curve was demonstrated for the transperineal approach (76.0 vs 46.7 minutes, P=.02). Transperineal times improved over the study and approached transgastric; however, the last three transgastric cases were still significantly faster than the last three transperineal (40.3 vs 46.7 minutes, P=.02). No complications occurred in either group. The transgastric as compared with transperineal approach to NOTES appendectomy resulted in improved operative time in this model. The transperineal approach demonstrated a significant learning curve with operative times between techniques converging over time. This NOTES appendectomy test bed is suitable for evaluating NOTES innovations.
  Surgical Innovation 09/2009; 16(3):223-7.
• Article: Appendicectomy and cholecystectomy using single-incision laparoscopic surgery (SILS): the first UK experience.

  Andre Chow, Sanjay Purkayastha, Paraskevas Paraskeva
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  ABSTRACT: Single-incision laparoscopic surgery (SILS) has the potential advantages of reduced postoperative pain and reduced port-site complications. Careful attention to closure can lead to virtually "scarless" surgery. In this article, we present our first experiences with SILS appendicectomy and cholecystectomy. SILS appendicectomy and cholecystectomy was performed in 12 and 14 patients, respectively. Data were collected prospectively and analyzed retrospectively from case notes and the theater database. The average operating times were 61.3 and 142.9 minutes for SILS appendicectomy and SILS cholecystectomy, respectively. There was a good correlation between increasing experience and a reduction in operative time with Pearson's coefficient being -1 for appendicectomy and -0.56 for cholecystectomy. There were no postoperative complications in the SILS appendicectomy group. One patient in the SILS cholecystectomy group suffered a postoperative biliary leak from an accessory duct of Lushka. In our series, we have demonstrated SILS to be a safe and efficacious method for appendicectomy and cholecystectomy. Further studies are required to investigate any potential advantages of this method over standard laparoscopic techniques.
  Surgical Innovation 09/2009; 16(3):211-7.
• Article: NOTES-assisted transvaginal splenectomy: the next step in the minimally invasive approach to the spleen.

  Eduardo M Targarona, Cristina Gomez, Ramon Rovira, Juan Carlos Pernas, Carmen Balague, Carlos Guarner-Argente, Sergio Sainz, Manuel Trias
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  ABSTRACT: Natural orifice transluminal endoscopic surgery (NOTES) has marked yet another step forward in less-invasive surgical procedures. Access to solid organs located deep in the left hypochondrium can be difficult using this technique but the transvaginal approach with the patient positioned in full lateral decubitus may be an option. We present the case of a 60-year-old woman with a symptomatic splenic polycystic tumor. The procedure was carried out by a multidisciplinary team using a standard flexible videogastroscope and endoscopic instruments. Transvaginal visualization of the spleen and standard dissection of attachments were feasible, and splenectomy was completed using transvaginal stapling of the splenic hilum. The organ was extracted transvaginally. The postoperative course was uneventful. The patient had minimal postoperative pain and minimal scars, and was discharged on the second postoperative day. Transvaginal access can be safely used for operative visualization, hilum transection, and spleen removal with conventional instrumentation, reducing parietal wall trauma to a minimum. The clinical, esthetic, and functional advantages require further analysis.
  Surgical Innovation 09/2009; 16(3):218-22.
• Article: Information for authors.

  Erin M Nelson
  Surgical Innovation 09/2009; 16(3):274-5.
• Article: A time to raise our voice(s).

  Adrian E Park, Lee L Swanstrom
  Surgical Innovation 09/2009; 16(3):205-6.
• Article: Single-site laparoscopic sleeve gastrectomy: preclinical use of a novel multi-access port device.

  J Esteban Varela
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  ABSTRACT: Single-site laparoscopy (SSL) has emerged as an alternative technique for sleeve gastrectomy. The author describes the preclinical technique of SSL sleeve gastrectomy through a novel multichannel port device in the porcine model. Anesthetized swine underwent 3-cm longitudinal supra-umbilical incision. A multichannel port device was inserted. A gastric sleeve was created by multiple applications of a 60-mm stapler. The access device's channel housing was removed and the sleeve specimen exteriorized. The mean operative time was 60+/-10 minutes, and the mean estimated blood loss was 30+/-5 cc. The multichannel port device allowed induction and maintenance of pneumoperitoneum throughout the procedure (range 12-15 mm Hg) with efficient rotation and substantial abdominal wall torque and minimal instrument clashing. SSL sleeve gastrectomy in the porcine model was facilitated by the use of a novel multichannel port device. Clinical studies are warranted.
  Surgical Innovation 09/2009; 16(3):207-10.
• Article: Feasibility of a high intrathoracic esophagogastric anastomosis without thoracic access after laparoscopic-assisted transhiatal esophagectomy: a pilot experimental study.

  Vasile V Binţinţan, Arianeb Mehrabi, Hamidreza Fonouni, Majid Esmaeilzadeh, Beat P Müller-Stich, Gheorghe Funariu, Constantin Ciuce, Carsten N Gutt
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  ABSTRACT: The aim of the present study was to evaluate the feasibility of a technique that uses solely the transhiatal approach to create a high intrathoracic esophagogastric anastomosis after laparoscopic transhiatal resection of the distal esophagus. Using a laparoscopic approach, the esophagi of 10 midsized pigs were dissected and transected as high as possible in the thorax, and the anvil of a circular stapler was introduced perorally into the esophageal stump. Through a midline short laparotomy, the circular stapler was inserted into the gastric tube and advanced through the hiatus to be connected with the anvil and create the anastomosis. Development of the technique was completed within the first 6 experiments. The last 4 operations were entirely successful, standardized, and easily reproducible. The technique is feasible in this experimental setting. Further studies are required to establish if there is a clinical role for this technique in esophageal surgery.
  Surgical Innovation 09/2009; 16(3):228-36.
• Article: Clinical librarian attendance at general surgery quality of care rounds (Morbidity and Mortality Conference).

  Elisa Greco, Marina Englesakis, Amy Faulkner, Boguslawa Trojan, Lorne E Rotstein, David R Urbach
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  ABSTRACT: Quality of Care rounds, also known as Mortality and Morbidity conferences, are an important and time-honored forum for quality audit in clinical surgery services. The authors created a modification to their hospital's Quality of Care rounds by incorporating a clinical librarian, who assisted residents in conducting literature reviews related to clinical topics discussed during the rounds. The objective of this article is to describe the authors' experience with this intervention. The clinical librarian program has greatly improved the Quality of Care rounds by aiding in literature searches and quality of up-to-date, evidence-based presentations.
  Surgical Innovation 09/2009; 16(3):266-9.
• Article: Attitudes of patients and care providers toward a surgical site marking policy.

  Amanda E Goldberg, Julie L Harnish, Stacey Stegienko, David R Urbach
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  ABSTRACT: In the fall of 2005, the University Health Network in Toronto, Canada, initiated a policy requiring the surgeon-or his or her delegate-to sign the incision site for all operations. Little is known about what health care providers and patients think about official surgical site marking policy. Twenty-one patients and health care providers were interviewed, and the authors conducted field observations of surgeons while they marked their patients. The data were analyzed using grounded theory methods. Surgical site marking was perceived to be a safety precaution for operations involving multiple sides and structures but not for cases where there is no uncertainty about the intended operative site. Participants believed that marking could also facilitate error if the wrong side was marked. Site marking was perceived to have the effect of ensuring that the surgeon meets with the patient prior to the operation on the day of surgery. Concerns were raised with respect to who should mark patients and marking surgical sites for genital surgery or other private body sites. For operations that involve multiple possible surgical sites, site marking should be carried out by individuals who are knowledgeable about the patient and the proposed procedure. For operations in which there is no uncertainty about the intended site, interventions other than site marking could be implemented to ensure patient-surgeon interactions on the day of surgery. Surgical site marking procedures should respect patient dignity and privacy.
  Surgical Innovation 09/2009; 16(3):249-57.
• Article: Acute management of stoma-related colocutaneous fistula by temporary placement of a self-expanding plastic stent.

  Mehrdad Nikfarjam, Brad Champagne, Harry L Reynolds, Benjamin K Poulose, Jeffrey L Ponsky, Jeffrey M Marks
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  ABSTRACT: Colocutaneous fistulas are frequently the result of complications related to previous operative procedures and are a major cause of morbidity. Most are initially treated conservatively, with a large percentage eventually requiring further surgery for definitive treatment. The use of a temporary colonic stent for the management of colostomy-related colocutaneous fistula has not been previously described. Two patients with colocutaneous fistula related to end colostomies and opening into midline laparotomy wounds were treated by temporary plastic stenting. A removable Polyflex silicone stent was inserted into the stoma. Stent redeployment was needed on several occasions following partial stent expulsion. Midline wound healing was achieved in both cases by 6 weeks post-stent insertion, and complete fistula closure occurred in 1 case. Temporary stent placement in certain cases may aid in the management of a colocutaneous fistula associated with a colostomy to allow fecal diversion from wounds and aid fistula closure.
  Surgical Innovation 09/2009; 16(3):270-3.
• Article: Patient-reported recovery after abdominal and pelvic surgery using the Convalescence and Recovery Evaluation (CARE): implications for measuring the impact of surgical processes of care and innovation.

  Ryan C Hedgepeth, J Stuart Wolf, Rodney L Dunn, John T Wei, Brent K Hollenbeck
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  ABSTRACT: Recovery is an integral part of the surgical process and measuring it provides insight into the impact of surgical innovation. This study used a recently validated instrument, the Convalescence and Recovery Evaluation (CARE), to measure return to baseline health after surgery and explore clinical factors associated with recovery. Patient health was measured among 96 patients before and after abdominal and pelvic surgery. Patients were grouped by time to recovery of 90% of baseline status. chi2 Tests and logistic models were used to measure relationships between recovery time and patient characteristics, processes of care, and outcomes. Return to baseline health was reached by 44% of patients within 2 weeks, 28% between 2 and 4 weeks, and 28% after 4 weeks. Patients who recovered faster were younger, female, single, and undergoing ambulatory surgery for benign diseases. Patients who were married, underwent surgery for cancer, or had bowel surgery were more likely to require longer recovery time. Several patient and clinical characteristics were found to be associated with recovery after surgery. CARE appears to be sensitive to these factors and may be useful for informed decision making, assessing changes in processes of care, and evaluating the impact of surgical innovations on recovery.
  Surgical Innovation 09/2009; 16(3):243-8.
• Article: Barbed suture for gastrointestinal closure: a randomized control trial.

  Sebastian V Demyttenaere, Peter Nau, Matthew Henn, Catherine Beck, Jeffrey Zaruby, Michael Primavera, David Kirsch, Jeffrey Miller, James J Liu, Andrew Bellizzi, W Scott Melvin
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  ABSTRACT: In an effort to make laparoscopic suturing more efficient, the V-Loc advanced wound closure device (Covidien, Mansfield, MA) has been produced. This device is a self-anchoring barbed suture that obviates the need for knot tying. The goal of this initial feasibility study was to investigate the use of the barbed suture in gastrointestinal enterotomy closure. A randomized study of 12 pigs comparing enterotomy closure with barbed versus a nonbarbed suture of similar tensile strength was performed. To this end, 25 mm enterotomies were made in the stomach (1 control, 1 treatment), jejunum (2 controls, 2 treatments), and descending colon (1 control, 1 treatment). Animals were killed at 3, 7, and 14 days postoperatively (4 each group) and their gastrointestinal tracts harvested; 6 of the 8 enterotomies from each pig underwent burst strength testing. The remaining 2 were fixed in formalin and sent for histological examination. All 12 pigs survived until they were killed without any major complications. Enterotomy closure with barbed suture revealed adhesion scores, burst strength pressures, and histology scores that were similar to those for the control. Jejunal closures resulted in 6 failures at 7 days (3 control, 3 barbed) and 4 failures at 14 days (2 control, 2 barbed). The barbed suture significantly reduced suturing time in the stomach, jejunum, and colon. The V-Loc wound closure device appears to offer comparable gastrointestinal closure to 3-0 Maxon while being significantly faster. Further studies with V-Loc are required to assess its use in laparoscopic surgery.
  Surgical Innovation 09/2009; 16(3):237-42.
• Article: Implementation of a direct-from-recovery-room discharge pathway: a process improvement effort.

  Jesse M Ehrenfeld, Andreas R Seim, David L Berger, Warren S Sandberg
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  ABSTRACT: The authors describe a process improvement effort to achieve direct-from-recovery-room discharge for elective laparoscopic cholecystectomy patients--without prior patient selection. The authors developed and implemented a new pathway, and then measured the learning curve (ie, success rate over time for direct discharge) and compared patients achieving direct discharge with patients admitted after surgery. The learning curve between the first patient and steady-state performance was 56 patients. A total of 80% of patients achieved direct discharge. Directly discharged patients were younger (P<.001), had lower ASA physical status classifications (P<.005), and left the recovery room earlier in the day (P<.0001). However, elderly patients and those with high ASA scores frequently could be directly discharged from the recovery room. Through small team based rapid cycle process improvement, direct-from-recovery-room discharge of laparoscopic cholecystectomy patients can be achieved in an unselected patient population with a short learning curve.
  Surgical Innovation 08/2009; 16(3):258-65.
• Article: Peroral dual scope for natural orifice transluminal endoscopic surgery (NOTES) gastrotomy closure.

  Misuhiro Asakuma, Silvana Perretta, Ronan A Cahill, Cinthya Solano, Shanker Pasupathy, Bernard Dallemagne, Nobuhiko Tanigawa, Jacques Marescaux
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  ABSTRACT: Although transgastric intraperitoneal surgery is feasible both in experimental models and humans, secure gastrotomy closure remains challenging. As there is still no method that is simple, reliable, inexpensive, and effective, we aimed to evaluate the feasibility, efficacy, and safety of a novel endoscopic approach to this issue that intends to ensure secure healing by obtaining full thickness gastric wall apposition without requiring specialized instrumentation. Six pigs underwent general anesthesia followed by peritoneoscopy through a 12-mm gastrotomy by a double-channel endoscope. Gastrotomy closure was performed by our innovative technique. In short, this involves the insertion of a second single-channel gastroscope alongside the NOTES gastroscope. Both scopes are then worked in tandem within the stomach by separate operators using conventional endoscopic graspers and an endoclip device. The first animal was used to ascertain feasibility and standardize the technical steps, whereas the other five were survived. Postoperative follow-up then included endoscopy 1 week later and repeat endoscopy, laparoscopy, and necropsy on day 14. All closures were immediately successful. Postoperatively, each animal demonstrated appropriate weight gain and behavioral pattern without overt postoperative complication. Necropsy showed normal healing at the gastrotomy site although there were signs of minor peritoneal irritation and infection in 2 pigs. This transoral dual-scope clipping method of gastrotomy closure after NOTES, as well as the general concept of employing 2 separate instruments at the same time perorally, is proven technically feasible, safe, and effective in this model.
  Surgical Innovation 07/2009; 16(2):97-103.
• Article: Preliminary results on efficacy in closure of transsphincteric and rectovaginal fistulas associated with Crohn's disease using new biomaterials.

  Oliver Schwandner, Alois Fuerst
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  ABSTRACT: It was the aim of this prospective study to analyze the efficacy of the Surgisis AFP anal fistula plug and the Surgisis mesh for the closure of complex fistulas in Crohn's disease. All patients with perianal Crohn's disease suffering from transsphincteric and rectovaginal fistulas who underwent surgery using the Surgisis anal fistula plug or the Surgisis mesh were prospectively enrolled in this study. Inclusion criteria included transsphincteric single-tract fistulas and rectovaginal fistulas. Surgery was performed using a standardized technique, including irrigation of the fistula tract, placement and internal fixation of the Surgisis anal fistula plug, and combined transanal/transvaginal excision of rectovaginal fistula with transvaginal placement of the mesh. Success was defined as closure of both internal and external (perianal or vaginal) openings, absence of drainage without further intervention, and absence of abscess formation. Follow-up information was obtained from clinical examination 3, 6, 9, and 12 months postoperatively. Within the observation period, a total of 16 procedures were performed. After a mean follow-up of 9 months and 1 patient lost to follow-up, the overall success rate was 75%. For transsphincteric fistulas, the success rate was 77%, whereas it was 66% in rectovaginal fistulas associated with Crohn's disease. All 4 patients with failure had reoperation. Rate of stoma reversal in those patients who had fecal diversion was 66%. No deterioration of continence was documented. The short-term success rates are promising. Further analysis is needed to explain the definite role of this technique in comparison with traditional surgical techniques.
  Surgical Innovation 07/2009; 16(2):162-8.
• Article: The use of holmium laser technology for the treatment of refractory common bile duct stones, with a short review of the relevant literature.

  Andrew Day, Mazin E Sayegh, Christof Kastner, Tom Liston
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  ABSTRACT: The treatment of common bile duct (CBD) stones can vary in complexity and many methods exist to fragment them before removal. Although holmium laser is frequently used in urological surgery, it is rarely used to achieve this aim. The holmium laser was passed along a fiber introduced via a flexible scope through the cystic duct at the time of laparoscopic cholecystectomy. This energy modality was used to fragment the stones to a size that allowed easy removal. The authors have used this technique once so far and achieved complete clearance of the CBD with no mucosal damage. Holmium laser provides an alternative and realistic treatment option for difficult CBD stones.
  Surgical Innovation 07/2009; 16(2):169-72.
• Article: Training and working in high-stakes environments: lessons learned and problems shared by aviators and surgeons.

  Steven D Schwaitzberg, Charles Godinez, Stephen M Kavic, Erica Sutton, Raymond B Worthington, Brian Colburn, Adrian Park
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  ABSTRACT: Surgeons and naval aviators are both trained to work in high-stakes environments. Any misadventure in either of their working worlds can lead to death. Yet the pathways to certification and implicit attitudes toward training are quite different in these 2 disciplines and provide an opportunity to compare and contrast the methodologies employed. At the 5th annual Innovations in the Surgical Environments Conference, senior and junior aviators and surgeons shared their experiences from the perspective of trainee and trainer and in the process presented an interesting study in parallels and contrasts. The US Navy follows a highly regimented training syllabus with graduated levels of responsibility designed to create the safest possible flying environment. Extensive preflight and postflight effort is required for each mission flown. Surgical training is also hierarchal in responsibility, but graduates demonstrate greater variability in their training experience. The surgical field can only fortify its emphasis on safety by seeking to provide the optimal training experiences necessary in the high-stakes environment of the operating theater. In doing so, surgeons may find reinvigorated commitment through study of the aviation industry's established methods of training and practice.
  Surgical Innovation 07/2009; 16(2):187-95.
• Article: A randomized controlled trial of preperitoneal bupivacaine instillation for reducing pain following laparoscopic inguinal herniorrhaphy.

  Ronnarat Suvikapakornkul, Panisara Valaivarangkul, Patcharee Noiwan, Thanin Phansukphon
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  ABSTRACT: The efficacy of bupivacaine instillation into preperitoneal space following laparoscopic herniorrhaphy for postoperative pain reduction is still in controversy. A randomized controlled trial was conducted to determine the efficacy of bupivacaine instillation. The 40 patients, who had an inguinal hernia with no complication, unilateral or bilateral and recurrence or no recurrence after previous hernia repair, were randomly assigned to receive bupivacaine (n = 19) and normal saline (n = 21). The intervention or placebo was instilled into the preperitoneal space after total extraperitoneal laparoscopic herniorrhaphy. Pain intensity was assessed by using a visual analogue scale and verbal rating scale after the 1st, 2nd, 6th, 12th, and 24th hour postoperatively. For the bupivacaine and placebo group, mean pain scores were 3.5 versus 5.2 (P = .059), 2.9 versus 4.5 (P = .117), 2.1 versus 3.2 (P = .101), 1.5 versus 2.7 (P = .145), and 1.6 versus 2.0 (P = .672) after the 1st, 2nd, 6th, 12th, and 24th hour, respectively. Complications developed in 4 patients in the bupivacaine group and 7 patients in the placebo group after 3 months follow-up time. There is no strong evidence to confirm that bupivacaine instillation into preperitoneal space after laparoscopic herniorrhaphy can reduce postoperative pain.
  Surgical Innovation 07/2009; 16(2):117-23.