Volkan Ozben

Excision of Nonpalpable Breast Cancer with Indocyanine Green Fluorescence-Guided Occult Lesion Localization (IFOLL)

Background: Currently employed techniques for the localization of nonpalpable breast lesions suffer from various limitations. In this paper, we report on 2 patients in order to introduce an alternative technique, indocyanine green fluorescence-guided occult lesion localization (IFOLL), and determine its applicability for the surgical removal of this type of breast lesions. Case Reports: Preoperatively, one of the patients had a needle biopsyproven diagnosis of breast cancer, and the other one had suspicious findings for malignancy. Lesion localization was performed within 1 h before surgery under ultrasonography control by injecting 2 ml and 0.2 ml of indocyanine green into the lesion and its subcutaneous tissue projection, respectively. During surgery, the site of skin incision and the resection margins were identified by observing the area of indocyanine-derived fluorescence under the guidance of a near-infrared-sensitive camera. In both cases, the breast lesion was correctly localized, and the area of fluorescence corresponded well to the site of the lesions. Subsequent surgical excision was successful with no complications. On histopathologic examination, the surgical margins were found to be clear. Conclusion: IFOLL seems to be a technically applicable and clinically acceptable procedure for the removal of nonpalpable breast cancer.

Is da Vinci Xi Better than da Vinci Si in Robotic Rectal Cancer Surgery? Comparison of the 2 Generations of da Vinci Systems.

Background: We aimed to compare perioperative outcomes for procedures using the latest generation of da Vinci robot versus its previous version in rectal cancer surgery. Patients and Methods: Fifty-three patients undergoing robotic rectal cancer surgery between January 2010 and March 2015 were included. Patients were classified into 2 groups (Xi, n=28 vs. Si, n=25) and perioperative outcomes were analyzed. Results: The groups had significant differences including operative procedure, hybrid technique and redocking (P>0.05). In univariate analysis, the Xi group had shorter console times (265.7 vs. 317.1 min, P=0.006) and total operative times (321.6 vs. 360.4 min, P=0.04) and higher number of lymph nodes harvested (27.5 vs. 17.0, P=0.008). In multivariate analysis, Xi robot was associated with a shorter console time (odds ratio: 0.09, P=0.004) with no significant differences regarding other outcomes. Conclusions: Both generations of da Vinci robot led to similar short-term outcomes in rectal cancer surgery, but the Xi robot allowed shorter console times.

Analysis of laparoscopic colorectal surgery in high-risk patients.

The aim of this retrospective study is to examine the feasibility and safety of laparoscopic colorectal resection for colorectal malignancies to determine “high-risk” patients. In our classification, 3 minor criteria including patients over 70 years of age, body mass index over 30u2009m/kg2, and cigarette smoking and 5 major criteria including cardiac, pulmonary, renal, liver disease, and diabetes mellitus were selected to determine a high-risk group. Patients carrying 1 minor and 1 major criteria were classified as the high-risk group. Concerning patients and operations, hemodynamic values (mean arterial systolic and diastolic pressures and heart rates), oxygen saturations, end-expiratory carbon dioxide levels, respiratory mechanics (dynamic compliance, peak inspiratory pressure, airway resistance) were analyzed. Cardiovascular system (myocardial infarction, arrhythmia, hypertension), pulmonary system (respiratory insufficiency), digestive system (anastomotic leak, fistula, and paralytic ileus), fever, thrombophlebitis, urinary infections, wound infections, and central nervous system (delirium and cerebrovascular accident) were also investigated. A total number of 85 high-risk patients were included in the study. Gastrointestinal leaks in 2.3%, fistula in 1.1%, ileus in 3.5%, postoperative bleeding in 2.3%, postoperative fever in 5.8%, wound infection in 5.8%, and cerebrovascular accidents in 1.1% of patients were detected. The lowest values of hemodynamic and respiratory mechanics were observed at the induction of pneumoperitoneum and in this period the compliance and mean arterial pressure were determined to be 36±14u2009mm Hg and 84±14u2009mm Hg, respectively. No mortalities occurred. In experienced hands, laparoscopic colorectal resection can be performed safely for “high-risk” surgical patients.

Application of advancement flap after loose seton placement: a modified two-stage surgical repair of a transsphincteric anal fistula.

Purpose A number of techniques have been described for the treatment of a transsphincteric anal fistula. In this report, we aimed to introduce a relatively new two-stage technique, application of advancement flap after loose seton placement, to present its technical aspects and to document our results. Methods Included in this retrospective study were 13 patients (10 males, 3 females) with a mean age of 42 years who underwent a two-stage seton and advancement flap surgery for transsphincteric anal fistula between June 2008 and June 2013. In the first stage, a loose seton was placed in the fistula tract, and in the second stage, which was performed three months later, the internal and external orifices were closed with advancement flaps. Results All the patients were discharged on the first postoperative day. The mean follow-up period was 34 months. Only one patient reported anal rigidity and intermittent pain, which was eventually resolved with conservative measures. The mean postoperative Wexner incontinence score was 1. No recurrence or complications were observed, and no further surgical intervention was required during follow-up. Conclusion The two-stage seton and advancement flap technique is very efficient and seems to be a good alternative for the treatment of a transsphincteric anal fistula.

Single Incision Laparoscopic Total Gastrectomy and D2 Lymph Node Dissection for Gastric Cancer Using a Four-Access Single Port: The First Experience

Single incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) have been developed to reduce the invasiveness of laparoscopic surgery. SILS has been frequently applied in various clinical settings, such as cholecystectomy, colectomy, and sleeve gastrectomy. So far, there have been four reports on single incision laparoscopic distal gastrectomy and one report on single incision laparoscopic total gastrectomy with D1 lymph node dissection for gastric cancer. In this report, we present our single incision laparoscopic total gastrectomy with D2 lymph node dissection technique using a four-hole single port (OctoPort) in a patient with gastric cancer.

The Use of Tacker and Arthroscopy Cannules in SILS Cholecystectomy

BACKGROUNDnThe invasiveness of laparoscopic cholecystectomy was further minimized by reducing the number of incisions with the introduction of single-incision laparoscopic surgery (SILS) cholecystectomy. In order to solve the challenges posed by SILS cholecystectomy, an increasing number of techniques have been reported with the advent of new surgical instruments and refinements to existing technology. We describe, in this article, two new techniques that utilize existing instrumentations: an access and a retraction technique.nnnMETHODSnA consecutive series of 23 selected patients with symptomatic cholelithiasis underwent SILS cholecystectomy from April 10, 2009 to August 12, 2009. The overall procedure was similar to SILS cholecystectomy described in the literature. Hovewer, the access technique, with small-size arthroscopy cannules, was used to overcome the technical difficulty resulting from the collision of large-size caps of the laparoscopy trocars, and the retraction technique with a tacker was used to suspend the fundus of the gallbladder without taking the risk of gallbladder perforation.nnnRESULTSnAll patients were female, and the mean age was 34 years (range, 27-65). The body mass index of all patients was below 30 kg/m(2). The use of arthroscopy cannules provided a wider range of movement, and the retraction of the gallbladder was achieved safely with the tacker. These techniques reduced the operative times considerably.nnnCONCLUSIONSnMost of the challenges posed by SILS cholecystectomy can be easily solved with simple technical modifications.

Robotic complete mesocolic excision for right-sided colon cancer.

Complete mesocolic excision (CME) with central vascular ligation for right-sided colon cancer has been proven to provide superior oncologic outcomes and survival advantage when compared to standard lymphadenectomy [1]. A number of studies comparing conventional laparoscopic versus open CME have shown feasibility and safety of the laparoscopic approach with acceptable oncological profile and postoperative outcomes [2, 3]. The introduction of robotic systems with its technical advantages, including improved vision, better ergonomics and precise dissection, has further revolutionized minimally invasive approach in colorectal surgery. However, there seems to be a relatively slow adoption of robotic approach in the CME technique for right-sided colon cancer. This video demonstrates our detailed operative technique and feasibility for performing right-sided CME robotically. The surgical procedure is performed with a medial-to-lateral approach through four 8-mm robotic and one assistant ports. First, the ileocolic vessels are isolated, clipped and transected near their origins. Cephalad dissection continues along the ventral aspect of the superior mesenteric vein. Staying in the embryological planes between the mesocolon and retroperitoneal structures, mesenteric dissection is extended up to the root of the right colic vessels, if present, and the middle colic vessels, which are clipped and divided individually near their origins. After the terminal ileum is transected using an endolinear staple, the colon is mobilized fully from gastrocolic tissue and then from its lateral attachments. The transverse colon is transected under the guidance of near-infrared fluorescence imaging. Creation of an intracorporeal side-to-side ileotransversostomy anastomosis and extraction of the specimen complete the operation. We consider robotic CME to be feasible, safe and oncologically adequate for the treatment of right-sided colon cancer. Its technical advantages may lead to further dissemination of the robotic approach and better standardization of this surgical technique.

Robotic Complete Mesocolic Excision for Splenic Flexure of Colon Cancer

Robotic surgery, with its enhanced dexterity and increased range of motion, is being increasingly used in colorectal surgery. In addition to the rectal approaches, where laparoscopic limitations are overcome by the dexterity and superior vision of robotics, colon cancer procedures could also be perf

An Atypical Etiology of Suprasphincteric Fistula: A Forgotten Surgical Material

While the majority of fistulas in ano result from infection of the anal crypts, complex, recurrent, and/or nonhealing fistulas should always raise the suspicion of a chronic underlying condition. In this paper, we present a 30-year-old male patient with a diagnosis of a complex suprasphincteric fistula caused by a surgical thread left behind after an orthopedic hip operation performed sixteen years ago. Partial fistulectomy, extraction of the foreign material, and debridement procedures were performed. Few cases of such complex fistulas in ano due to foreign materials have been described in the literature. After careful history-taking, meticulous physical examination under general anesthesia should be done in order to deal with this rare type of fistula.

An Effective Bundled Approach Reduces Surgical Site Infections in a High-Outlier Colorectal Unit

BACKGROUND: Surgical site infections are the most common hospital-acquired infection after colorectal surgery, increasing morbidity, mortality, and hospital costs. OBJECTIVE: The purpose of this study was to investigate the impact of preventive measures on colorectal surgical site infection rates in a high-volume institution that performs inherent high-risk procedures. DESIGN: This was a prospective cohort study. SETTINGS: The study was conducted at a high-volume, specialized colorectal surgery department. PATIENTS: The Prospective Surgical Site Infection Prevention Bundle Project included 14 preoperative, intraoperative, and postoperative measures to reduce surgical site infection occurrence after colorectal surgery. Surgical site infections within 30 days of the index operation were examined for patients during the 1-year period after the surgical site infection prevention bundle was implemented. The data collection and outcomes for this period were compared with the year immediately before the implementation of bundle elements. All of the patients who underwent elective colorectal surgery by a total of 17 surgeons were included. The following procedures were excluded from the analysis to obtain a homogeneous patient population: ileostomy closure and anorectal and enterocutaneous fistula repair. MAIN OUTCOME MEASURES: Surgical site infection occurring within 30 days of the index operation was measured. Surgical site infection–related outcomes after implementation of the bundle (bundle February 2014 to February 2015) were compared with same period a year before the implementation of bundle elements (prebundle February 2013 to February 2014). RESULTS: Between 2013 and 2015, 2250 abdominal colorectal surgical procedures were performed, including 986 (43.8%) during the prebundle period and 1264 (56.2%) after the bundle project. Patient characteristics and comorbidities were similar in both periods. Compliance with preventive measures ranged between 75% and 99% during the bundle period. The overall surgical site infection rate decreased from 11.8% prebundle to 6.6% at the bundle period (P < 0.001). Although a decrease for all types of surgical site infections was observed after the bundle implementation, a significant reduction was achieved in the organ-space subgroup (5.5%–1.7%; P < 0.001). LIMITATION: We were unable to predict the specific contributions the constituent bundle interventions made to the surgical site infection reduction. CONCLUSIONS: The prospective Surgical Site Infection Prevention Bundle Project resulted in a substantial decline in surgical site infection rates in our department. Collaborative and enduring efforts among multiple providers are critical to achieve a sustained reduction See Video Abstract at http://links.lww.com/DCR/A438.