Lucian Panait

Management of Median Arcuate Ligament Syndrome: A New Paradigm

Median arcuate ligament (MAL) syndrome is an anatomic and clinical entity characterized by extrinsic compression on the celiac axis, which leads to postprandial epigastric pain, vomiting, and weight loss. Although characterized a few decades ago, the existence of this syndrome is still challenged by several authors. We reviewed the management of MAL syndrome, with special emphasis on the minimally invasive approaches. We also report the first case of successful combination of minimally invasive surgery and endovascular therapy in the treatment of this syndrome. A PubMed search was carried out to identify articles in English from 1963 to 2008 using the keywords median arcuate ligament syndrome and celiac artery compression syndrome. Additional articles were identified by a manual search of the references from the key articles. All clinical and experimental studies that contained material applicable to the topic were considered. Classic treatment of the condition is represented by open MAL release. However, permanent changes in the celiac artery wall lead to poor long-term outcomes, and associated complex vascular procedures have been employed. Laparoscopic treatment of MAL syndrome was reported in five cases. All patients had resolution of symptoms, but long-term follow-up is not available. Laparoscopic release of arcuate ligament syndrome with intraoperative duplex ultrasound may be used in patients with symptoms suggestive of the diagnosis. In patients with persistent celiac flow abnormalities noted on duplex ultrasound or postoperative imaging, celiac angioplasty and stenting are advocated. If this option is not available or does not relieve symptoms, vascular reconstruction should be employed.

Complications of transvaginal natural orifice transluminal endoscopic surgery: a series of 102 patients.

Objective:To review the complications encountered in our facility and in previously published studies of transvaginal (TV) natural orifice transluminal endoscopic surgery (NOTES) to date. Background:TV NOTES is currently observed with critical eyes from the surgical community, despite encouraging data to suggest improved short-term recovery and pain. Methods:All TV NOTES procedures performed in female patients between 18 and 65 years of age were included. The median follow-up was 90 days. The TV appendectomies and ventral hernia repairs were pure NOTES, through a SILS port in the vagina, whereas TV cholecystectomies were hybrid procedures with the addition of a 5-mm port in the umbilicus. Results:A total of 102 TV NOTES procedures, including 72 TV cholecystectomies, 24 TV appendectomies, and 6 TV ventral hernia repairs, were performed. The average age was 37 years old and body mass index was 29 kg/m2. Three major and 7 minor complications occurred. The first major complication was a rectal injury during a TV access port insertion. The second major complication was an omental vessel bleed after a TV cholecystectomy. The third complication was an intra-abdominal abscess after a TV appendectomy. Seven minor complications were urinary retention (4), transient brachial plexus injury, dislodgement of an intrauterine device, and vaginal granulation tissue. Conclusions:As techniques in TV surgery are adopted, inevitably, complications may occur due to the inherent learning curve. Laparoscopic instruments, although adaptable to TV approaches, have yet to be optimized. A high index of suspicion is necessary to identify complications and optimize outcomes for patients.

Construct and face validity of a virtual reality–based camera navigation curriculum

INTRODUCTIONnCamera handling and navigation are essential skills in laparoscopic surgery. Surgeons rely on camera operators, usually the least experienced members of the team, for visualization of the operative field. Essential skills for camera operators include maintaining orientation, an effective horizon, appropriate zoom control, and a clean lens. Virtual reality (VR) simulation may be a useful adjunct to developing camera skills in a novice population. No standardized VR-based camera navigation curriculum is currently available. We developed and implemented a novel curriculum on the LapSim VR simulator platform for our residents and students. We hypothesize that our curriculum will demonstrate construct and face validity in our trainee population, distinguishing levels of laparoscopic experience as part of a realistic training curriculum.nnnMETHODSnOverall, 41 participants with various levels of laparoscopic training completed the curriculum. Participants included medical students, surgical residents (Postgraduate Years 1-5), fellows, and attendings. We stratified subjects into three groups (novice, intermediate, and advanced) based on previous laparoscopic experience. We assessed face validity with a questionnaire. The proficiency-based curriculum consists of three modules: camera navigation, coordination, and target visualization using 0° and 30° laparoscopes. Metrics include time, target misses, drift, path length, and tissue contact. We analyzed data using analysis of variance and Students t-test.nnnRESULTSnWe noted significant differences in repetitions required to complete the curriculum: 41.8 for novices, 21.2 for intermediates, and 11.7 for the advanced group (P < 0.05). In the individual modules, coordination required 13.3 attempts for novices, 4.2 for intermediates, and 1.7 for the advanced group (P < 0.05). Target visualization required 19.3 attempts for novices, 13.2 for intermediates, and 8.2 for the advanced group (P < 0.05). Participants believe that training improves camera handling skills (95%), is relevant to surgery (95%), and is a valid training tool (93%). Graphics (98%) and realism (93%) were highly regarded.nnnCONCLUSIONSnThe VR-based camera navigation curriculum demonstrates construct and face validity for our training population. Camera navigation simulation may be a valuable tool that can be integrated into training protocols for residents and medical students during their surgery rotations.

Completion of a Novel, Virtual-Reality-Based, Advanced Laparoscopic Curriculum Improves Advanced Laparoscopic Skills in Senior Residents

INTRODUCTIONnVirtual reality simulators contribute to basic laparoscopic skill acquisition. These trainers have not yet been shown to contribute to the acquisition of more advanced laparoscopic skills as measured by the Fundamentals of Laparoscopic Surgery (FLS). We have customized novel basic and advanced curricula for the LapSim trainer (Surgical Science, Göteborg, Sweden). Successful completion of these programs is required of our residents. We hypothesize that the successful completion of our advanced curriculum will result in the significant improvement of our residents advanced laparoscopic skills as measured by the FLS skills scores.nnnMETHODSnIn all, 23 surgical residents (PGY 1-4), who had already passed our basic skills curriculum, completed our advanced LapSim curriculum. All individuals underwent FLS skills testing before and after completing the training. Laparoscopic case experience during the training period was documented for all trainees. FLS scores were analyzed by t test and controlled for case experience.nnnRESULTSnPosttraining FLS scores demonstrate a significant increase for all residents from a mean of 57-66 (p < 0.02), especially for seniors (PGY 3-4): 56-68 (p < 0.01). The operative laparoscopic case volume ranged from 1-90 (mean, 30) for juniors (PGY 1-2) and 12-76 (mean 50) for seniors during the training period. Junior resident FLS improvement was dependent on case volume during the period of training; residents with less than 30 cases had a mean improvement of 0, whereas those with at least 30 cases had a 15 point improvement (p < 0.01). Senior resident FLS score improvement was independent of case numbers during the training period.nnnCONCLUSIONSnCompletion of our advanced LapSim curriculum results in improved advanced laparoscopic skills in senior residents as measured by FLS scores. This skill improvement is independent of laparoscopic case experience. Continuing to mandate the use of this skills curriculum should improve our residents performance in advanced laparoscopic surgical procedures.

Transvaginal natural orifice transluminal endoscopic surgery in the morbidly obese

BackgroundThe objective of this study is to assess the safety and efficacy of transvaginal (TV) natural orifice transluminal endoscopic surgery (NOTES) operations in morbidly obese patients.MethodsOne hundred seven NOTES operations have been performed at our institution to date, of which 17 were completed in patients with body mass index (BMI) between 35 and 45xa0kg/m2. These included 14 cholecystectomies, one appendectomy, and two ventral hernia repairs. The patients had average age of 36.2xa0years (range 19–62xa0years) and average BMI of 38.9xa0kg/m2 (range 35.2–44.9xa0kg/m2). The mean number of previous abdominal operations was 1. The TV cholecystectomies were hybrid NOTES procedures, while TV appendectomy and ventral hernia repair were pure NOTES. All operations were completed with standard straight laparoscopic instruments.ResultsThe mean operative time was 60xa0min for cholecystectomy, 41xa0min for TV appendectomy, and 90xa0min for ventral hernia repair. No significant difference was encountered between the operative time for NOTES cholecystectomies in obese versus nonobese (60 vs. 61xa0min, pxa0=xa00.86). No conversions to traditional laparoscopy or open surgery were made, and no major complications were encountered.ConclusionsNOTES is an attractive alternative to laparoscopy in female patients with morbid obesity. The procedures are safe and have short operative times, good postoperative outcomes, and improved cosmesis compared with laparoscopy.

Pure Transvaginal Ventral Hernia Repair in Humans

Introduction. Transvaginal natural orifice transluminal endoscopic surgery procedures are at the forefront of minimally invasive innovation, remarkable for shorter recovery times and decreased postoperative pain. We aim to demonstrate a novel technique of pure transvaginal laparoscopic ventral hernia repair in a series of patients performed in our institution. Technique Description. The patient was placed in lithotomy position and steep Trendelenburg. A 2-cm transverse colpotomy incision was made and a SILS port was introduced. One 12-mm trocar and two 5-mm trocars were placed through the SILS port and standard straight laparoscopic instruments were used. An appropriately sized round mesh was deployed within a specimen retrieval bag into the peritoneal cavity. Complete anterior circumferential fixation of the mesh was achieved using an AbsorbaTack device. The colpotomy incision was closed. Results. There were a total of 6 pure transvaginal ventral hernia repair procedures performed in our institution between November 2010 and February 2012. The first case was converted to an open procedure after a rectal injury was recognized and repaired. Two patients had transient urinary retention that resolved after 24 hours. One patient had vaginal wound granulation noted at 2 months postoperatively. No long-term complications or recurrences were noted with a median follow-up of 9 months. The mean operative time was 107 minutes. Conclusion. Our initial experience with transvaginal ventral hernia repair in humans suggests that this procedure is feasible, safe, and associated with improved cosmetic results.

Transvaginal Cholecystectomy Effect on Quality of Life and Female Sexual Function

IMPORTANCEnTransvaginal cholecystectomy (TVC) is the leading natural orifice transluminal endoscopic surgery to date and has the potential to offer improved cosmesis, less pain, and shorter recovery times for female patients.nnnOBJECTIVEnTo investigate quality of life and female sexual function in our patients undergoing TVC.nnnDESIGNnA prospective cohort study from August 14, 2009, to June 12, 2012, of TVCs performed at our institution to date.nnnSETTINGnTertiary academic referral center.nnnPARTICIPANTSnThe first 47 consecutive female patients (aged 18-65 years) who received a TVC by a single surgeon.nnnINTERVENTIONSnA hybrid TVC was performed by a 5-mm umbilical trocar and a 12-mm transvaginal trocar with standard laparoscopic instruments.nnnMAIN OUTCOMES AND MEASURESnQuality-of-life index (36-Item Short Form Health Survey) and female sexual function (Female Sexual Function Index) scores.nnnRESULTSnA total of 47 TVCs were performed, with a mean age of 39 years, mean body mass index (calculated as weight in kilograms divided by height in meters squared) of 31, and mean operative time of 65 minutes. No difference was noted in overall female sexual function from preoperatively to 1 and 3 months postoperatively. When comparing quality of life preoperatively vs 1 and 3 months postoperatively, there were significant improvements in physical function (P = .02), energy and fatigue (P = .001), emotional well-being (P = .01), pain (P < .001), and general health (P = .03). No significant changes were noted in physical limitations (P = .18), emotional problems (P = .72), and social function (P = .12).nnnCONCLUSIONS AND RELEVANCEnIn our experience to date, female sexual function is unchanged and quality of life either is unchanged or improves at 1 and 3 months following TVC. Undergoing TVC does not appear to negatively affect female sexual function or quality of life in the short term.

Pure transvaginal umbilical hernia repair

BackgroundTransvaginal natural orifice transluminal endoscopic surgery (NOTES) procedures are at the forefront of minimally invasive innovation, remarkable for shorter recovery times and decreased postoperative pain [1, 2]. Most transvaginal procedures are performed as hybrid procedures [3]. To our knowledge, this is the first video depiction of a pure transvaginal umbilical hernia repair in a human.MethodsThis is a 38-year-old woman, body mass index 36.4xa0kg/m2, with a symptomatic port site hernia in the umbilical region after a previous laparoscopic cholecystectomy. The patient was positioned in stirrups in a steep Trendelenburg position. Sterilization of vaginal cavity was performed with 10xa0% povidone–iodine solution. A 2xa0cm transverse incision at the posterior fornix was made, and a SILS port (Covidien, North Haven, CT) was introduced. One 12xa0mm trocar and two 5xa0mm trocars were placed through SILS port. Standard straight laparoscopic instruments were used. A 12xa0cm round Parietex mesh (Covidien) was placed in a specimen retrieval bag and deployed into the peritoneal cavity. The mesh was extracted, unfolded in the abdominal cavity, and circumferentially fixated to the abdominal wall with an AbsorbaTack device (Covidien). The colpotomy incision was closed with a running absorbable suture.ResultsThe procedure lasted 103xa0min and was performed on an outpatient basis. No intraoperative complications occurred. The patient was doing well and had no pain or recurrence at 2, 6, and 9xa0months’ follow-up.ConclusionsOur initial experience with transvaginal ventral hernia repair in humans suggests that this procedure is feasible and safe. This approach may improve cosmesis and decrease the risk of future ventral hernias. Potential cons may include a longer operative time, mesh infection, and risk of visceral injury with a pure transvaginal approach. As transvaginal surgery evolves, techniques and devices will become increasingly refined to tackle these challenges.

Closing the gap: medialization of fascia with laparoscopic incisional hernia repair.

PurposeLaparoscopic incisional hernioplasty (LIH) bridges the fascial gap between the rectus muscles with a posteriorly placed mesh, and is a low recurrence alternative to other reconstructions. It is unclear if this repair optimizes the function of the abdominal wall. We hypothesize that significant medialization of the fascial edges occurs in patients who undergo LIH.MethodsTwo hundred fifty-eight patients underwent LIH by a single surgeon between 2004 and 2012. 44 of these had pre- and postoperative CT scans that illustrated the gap between the rectus muscles. All 44 patients underwent LIH with polyester composite mesh, with suture and tack fixation. The distance between the fascial edges on the pre- and postoperative CT scans was compared. Percent medialization was calculated for each defect.ResultsAverage fascial separation reduction was 0.8xa0cm (6.56–5.76xa0cm, 12.2xa0% medialization, pxa0<xa00.0001). 36 of 44 patients demonstrated a reduction in hernia defect width (81.8xa0%): these defects reduced 1.09xa0cm (6.47–5.38xa0cm, 16.9xa0% medialization, pxa0<xa00.0001). In defects wider than 5xa0cm, the width reduced by 0.94xa0cm (8.48–7.54xa0cm, nxa0=xa026, 10.6xa0% medialization, pxa0=xa00.004). The use of meshes ≥500xa0cm2 reduced the defect by 0.95xa0cm (8.42–7.47xa0cm, 11.23xa0% medialization, nxa0=xa022, pxa0=xa00.005).ConclusionsSignificant medialization of the rectus muscles is evident in most patients undergoing LIH. Although the rectus muscles are not ideally approximated, this may help improve the function of the anterior abdominal wall. Further technical refinements and material improvements may improve the reconstructive results of the LIH.

SAGES Technology and Value Assessment Committee safety and effectiveness analysis on immunofluorescence in the operating room for biliary visualization and perfusion assessment

The ability to assess tissue perfusion and identify vital structures in the operating room in order to potentially decrease complication rates remains a key goal for surgeons. The introduction of immunofluorescence utilizing indocyanine green intraoperatively to evaluate areas such as an anastomosis, a free flap, biliary anatomy, or lymphatics has the possibility of decreasing postoperative complications by addressing identification and perfusion concerns at the time of surgery. The use of laser-induced immunofluorescence using indocyanine green relies on similar principles as fluorescein technique, which was first proposed in 1942. Fluorescein angiography was initially used to evaluate vascularity of the eye and skin. Fluorescein angiography did not become clinically significant, however, due to difficulties with the tracer. Indocyanine green, a secondgeneration tracer, was developed in order to overcome the limitations of fluorescein. Indocyanine green (ICG) is a water-soluble lyophilized powder with a chemical formula of C43H47N2O6S2Na. It is a fluorophore that responds to near-infrared irradiation and absorbs light between the wavelengths of 790 and 805 nm and re-emits it with an excitation wavelength of 835 nm. The compound is administered intravenously, and when injected it binds to plasma proteins. ICG binds nearly exclusively to albumin on electrophoresis, with only minor binding to other serum proteins, as shown in Table 1 [1]. It is then taken up in the liver and excreted in bile. The half-life of ICG is 3–5 min and excreted by the liver in 15–20 min. Its short half-life, hepatic excretion, and unique wavelength emission in tissue providing images of both circulation and lymphatics make it well suited for use in the operative field. Contraindications for use of ICG are limited, but include patients with a known allergy or adverse reaction to ICG or iodine and those women who are pregnant or lactating. There have been reports of rare cases of anaphylactic shock and urticaria associated with ICG usage. ICG and Near-Infrared (NIR) imaging modalities have been used in a wide array of surgical procedures. Minimally invasive colorectal surgery, encompassing both laparoscopic and robotic techniques, has employed the use of immunofluorescence to evaluate the perfusion of the anastomosis. This includes anastomoses for colorectal cancer of the right and left colon, as well as rectal cancer resections. Further immunofluorescence imaging has been used to assess blood supply of anastomoses following pancreaticoduodenectomy and esophagectomy. Additional uses of this technology in general surgery include lymphadenectomy, donor nephrectomy, and liver resection to evaluate perfusion, and biliary anatomy during cholecystectomy. Fluorescence-guided surgery has been utilized in oncology surgery in attempts to achieve improved marginnegative status [2] although this analysis will not cover this use as it is outside of the focus of this evaluation. Finally, immunofluorescence has been used with some success in & David Renton david.renton@osumc.edu