Ali Akdemir

Single-site robotic total hysterectomy: standardization of technique and surgical outcomes.

STUDY OBJECTIVES To evaluate the safety and feasibility of robotic single-site total hysterectomy and to compare the outcomes of newly implemented robotic single-site bipolar and external vessel-sealing device. DESIGN Retrospective study (Canadian Task Force classification II-1). SETTING University hospital. PATIENTS Twenty-four patients with benign indications for hysterectomy. INTERVENTIONS All patients underwent robotic-assisted single-incision transumbilical total hysterectomy using the novel da Vinci Single-Site Platform. Vaginal cuff closures were performed intracorporeally using the same technique in all cases. MEASUREMENTS AND MAIN RESULTS The median age of the patients was 49.5 years (range, 40-61), and body mass index was 28.5 (range, 21-34). Blood loss was 22.5 mL (range, 7-120 mL). Docking time was 5.5 minutes (range, 3-10 minutes), console time was 74.5 minutes (range, 60-160 minutes), vaginal cuff closure time was 25 minutes (range, 16-41 minutes), and total operative time was 98.5 minutes (range, 71-183 minutes). When 2 groups were created according to the energy devices used during the procedures, console time in the newly implemented bipolar group was shorter than in the external sealing device group (69.5 minutes vs. 77 minutes; p = .03); however, no differences were found for uterus removal time (50.5 minutes vs. 53.5 minutes; p = .13). Differences were observed in vaginal cuff closure time (18.5 minutes vs 23 minutes; p = .01). CONCLUSION Robotic single-site total hysterectomy using a newly implemented bipolar grasping instrument and even with intracorporeal cuff closure is a safe and feasible procedure in appropriately selected patients.

Comparison of melatonin and oxytocin in the prevention of critical illness polyneuropathy in rats with experimentally induced sepsis

BACKGROUND Critical illness polyneuropathy is an acute neuromuscular disorder of critically ill patients and is characterized by limb and respiratory muscle weakness. The purpose of the study was to evaluate the neuroprotective effects of melatonin (MEL) and oxytocin (OT) on the early stage of sepsis by recording compound muscle action potentials and measuring plasma tumor necrosis factor (TNF)-α levels, lipid peroxidation (malondialdehyde; MDA), and total antioxidant capacity. MATERIALS AND METHODS One hundred adult male Sprague-Dawley rats were included in the study. The cecal ligation and puncture (CLP) procedure was performed to induce the sepsis model. MEL (10, 20, and 40 mg/kg), OT (0.4, 0.8, and 1.6 mg/kg), and a combination of MEL (20 mg/kg) and OT (0.8 mg/kg) were administered intraperitoneally in the first hour of surgery. Electromyography (EMG) studies were achieved 24 h after CLP surgery and then blood samples were collected for biochemical measurements. RESULTS EMG findings revealed that compound muscle action potential amplitude was significantly decreased and distal latency was prolonged in the CLP group compared with the sham group (P < 0.05 and P < 0.0005). Moreover, the animals that received CLP surgery showed significantly higher TNF-α and MDA levels and lower total antioxidant capacity values than the sham group. The administration of MEL and OT to rats significantly abolished the EMG alterations and suppressed oxidative stress and TNF-α release in CLP-induced rats. CONCLUSIONS The inflammatory processes and imbalance in oxidative/antioxidative status play important roles in the pathogenesis of critical illness polyneuropathy. We suggest that both oxytocin and melatonin may have beneficial effects against sepsis-induced polyneuropathy in critical illness.

Protective effect of oxytocin on ovarian ischemia-reperfusion injury in rats

Oxytocin (OT), a neurohypophysial nonapeptide, plays dual role as a neurotransmitter/neuromodulator and a hormone. It has also well known protective properties against ischemia/reperfusion organ damage. This study investigated the effect of OT on experimentally induced ovarian torsion/de-torsion ischemia/reperfusion (I/R) injury in rats. Sprague-Dawley rats were assigned to five treatment groups (n=7/group): Group 1, sham-operated; Group 2, torsion; Group 3, 80 IU/kg of OT administration 30 min prior to torsion; Group 4, torsion/de-torsion; and Group 5, torsion followed by 80 IU/kg of OT administration 30 min prior to de-torsion. OT administration significantly decreased the tissue malondialdehyde (MDA) levels in both the torsion and OT group (Group 3), and torsion/de-torsion OT group (Group 5) in comparison with the torsion-only group (Group 2) and torsion/de-torsion group (Group 4). Histopathological finding scores including follicular degeneration, edema, hemorrhage, vascular congestion, and infiltration by inflammatory cells were found to be significantly decreased in the torsion and OT group (Group 3), and torsion/de-torsion OT group (Group 5) when compared with the torsion-only group (Group 2) and torsion/de-torsion group (Group 4). In conclusion, these results, verified with histopathologic evaluation and biochemical assays, suggest a probable protective role for OT in ischemia and I/R injury in rat ovaries.

Innovative technique for enclosed morcellation using a surgical glove.

OBJECTIVE: To describe an innovative approach for enclosed morcellation using a surgical glove in multiport laparoscopic surgery. METHODS: Power morcellation was performed within an insufflated surgical glove in a completely enclosed manner between January and May 2014. The specimen was placed into the glove within the abdomen. The glove opening and thumb were exteriorized through the umbilical and left lower abdominal trocar incisions, respectively. The optical trocar and optic were inserted into the glove, which was then insufflated. The thumb tip was cut, and a power morcellator was inserted through this finger. The morcellation was accomplished within the completely enclosed glove. The thumb tip was closed, and the glove, containing residual specimens and bloody fluid, was removed from the abdomen through the umbilical incision. Thus, the risks of bag piercing and leakage during contained power morcellation were eliminated. Demographic and operative data were collected and analyzed for all cases. RESULTS: Thirty multiport laparoscopic myomectomy and morcellation procedures were performed during the study period. The median operative time was 85 minutes (range 60–140 minutes). The median morcellation preparation time, total morcellation time, and withdrawal time were 6 (range 4.5–14), 32 (range 15–55), and 1.2 (range 1–1.5) minutes, respectively. No intraoperative complications or bag ruptures were recorded. CONCLUSION: With our innovative technique, a disposable latex glove can be used for an enclosed morcellation that avoids piercing the enclosure container within the abdominal cavity, thereby offering decreased risks related to bag perforation and leakage compared with previous contained power morcellation techniques. LEVEL OF EVIDENCE: III

Robotic single-incision transumbilical total hysterectomy using a single-site robotic platform: initial report and technique.

The benefits of laparoscopic surgery over open abdominal surgery have been well documented. Efforts continue for development of strategies that further reduce the size of abdominal incisions and the number of trocars used. Laparoendoscopic single-site surgery (LESS) is a promising approach that can further enhance cosmetic satisfaction and reduce the risks of laparoscopic surgery. Loss of triangulation, instrument crowding and clashing, poor visualization, and ergonomic problems are the most challenging issues associated with the use of LESS. The combination of LESS and the robotic system seems to be a promising choice to overcome the technical difficulties of LESS. The da Vinci Single-Site Surgical Platform is a novel semi-rigid robotic operating system. We present our initial clinical experience with robotic-assisted single-incision transumbilical total hysterectomy using the novel da Vinci Single-Site Surgical Platform.

Learning Curve Analysis of Intracorporeal Cuff Suturing During Robotic Single-Site Total Hysterectomy

STUDY OBJECTIVE To analyze the learning curve of intracorporeal cuff suturing during robotic single-site total hysterectomy. DESIGN Retrospective study (Canadian Task Force classification II-1). SETTING University hospital. PATIENTS Twenty-four patients with benign indications for hysterectomy. INTERVENTIONS Twenty-four patients who underwent robotic single-site total hysterectomy to treat benign indications were included in the study. Surgical procedures were performed by a single surgeon with extensive experience in laparoscopy, using the single-site platform of the da Vinci Surgical System. All vaginal cuffs were closed intracorporeally using semi-rigid single-site instruments. MEASUREMENTS AND MAIN RESULTS An exponential learning curve technique was used to analyze the learning curve. The overall mean (SD) vaginal cuff closure time was 23.2 (7) minutes. Learning curve analysis revealed a decrease in vaginal closure time after 14 procedures. CONCLUSIONS An experienced robotic surgeon requires approximately 14 procedures to achieve proficiency in intracorporeal cuff suturing during robotic single-site total hysterectomy. Novel instruments that create perfect triangulation are needed to overcome the current challenges of suturing and to shorten operative time.

Contained Morcellation: Review of Current Methods and Future Directions

Power morcellation of surgical specimen during laparoscopic surgery is a practical technology that provides the opportunity to perform several minimally invasive procedures. However, this technology brought forward additional risks and complications associated with dissemination of both benign and malignant tissues inside the abdominal cavity. Based on startling cases, Food and Drug Administration (FDA) announced a discouraging statement on the use of power morcellators that decreased the number of minimally invasive approaches in the following period. As a response to these concerns and negative impacts of the FDA statement, researchers developed several new approaches resulting in contained or in-bag morcellation methods. In this review, we aimed to discuss these current methods and provide an insight for future developments.

Montelukast prevents ischaemia/reperfusion-induced ovarian damage in rats

OBJECTIVE To investigate the efficacy of montelukast for prevention of ischaemia/reperfusion (I/R) injury in rat ovary. STUDY DESIGN Twenty-four female adult rats were included in the study. I/R injury was induced by CO2 pneumoperitoneum in a laparoscopic rat model. The rats were divided at random into three groups: the sham group was subjected to catheter insertion but was not subjected to pneumoperitoneum; the saline group was subjected to 60 min of pneumoperitoneum and 30 min of reperfusion, with 1 mg/kg physiological saline administered 10 min before pneumoperitoneum; and the montelukast group was subjected to 60 min of pneumoperitoneum and 30 min of reperfusion, with 20mg/kg montelukast administered 10 min before pneumoperitoneum. Damage to ovarian tissue was scored by histopathological evaluation. Caspase-3 expression was determined immunohistochemically. Ovarian tissue levels of malondialdehyde and glutathione, and plasma total antioxidant capacity were measured biochemically. RESULTS In comparison with the sham group, ovarian sections in the montelukast group had higher scores for follicular degeneration and oedema (p<0.001). Montelukast treatment prevented tissue damage in ovaries, and this result was significant. Caspase-3 expression was only observed in ovarian surface epithelium in the saline and montelukast groups. However, the mean caspase-3 expression score was higher in the saline group than the montelukast group (p<0.001). Tissue levels of malondialdehyde were higher in the montelukast group than the sham group, but plasma total antioxidant capacity and tissue levels of glutathione were significantly lower. Pretreatment with montelukast reduced lipid peroxidation (p<0.005) and improved antioxidant status in rats (p<0.001). CONCLUSION Montelukast is effective for the prevention of I/R-induced damage in rat ovary.

Restless legs syndrome is related to obstructive sleep apnea symptoms during pregnancy

BackgroundTo investigate the relation between restless legs syndrome (RLS) and obstructive sleep apnea symptoms during pregnancy.MethodsA questionnaire consisting of diagnostic criteria of restless legs syndrome, demographic characteristics, personal behavior, muscle cramps during pregnancy, past medical illnesses, family history of RLS, and the major symptoms of obstructive sleep apnea syndrome was administered during a face-to-face interview. Pregnant women with and without RLS were compared in terms of serum hemoglobin, hematocrit, calcium, phosphor, iron, folate, vitamin B12 levels, and obstructive sleep apnea symptoms.ResultsThere were statistically significant differences between two groups in terms of two of the obstructive sleep apnea symptoms (witnessed apnea and fatigue) (p < 0.01). No statistically significant difference was found with regard to serum calcium, magnesium, iron, hemoglobin, hematocrit, vitamin B12, phosphor, and folate levels; however, there were significant differences in terms of total iron-binding capacity.ConclusionsIncreasing awareness of restless legs syndrome among obstetricians is essential as it might be related to obstructive sleep apnea syndrome, which is associated with adverse pregnancy outcomes.

Laparoscopic virtual reality simulator and box trainer in gynecology

To investigate whether a virtual reality simulator (LapSim) and traditional box trainer are effective tools for the acquisition of basic laparoscopic skills, and whether the LapSim is superior to the box trainer in surgical education.