Surgical endoscopy
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Case Reports
Laparoscopic bisegmentectomy 6 and 7 using a Glissonian approach and a half-Pringle maneuver.
Despite accumulated experience and advancing techniques for laparoscopic hepatectomy, surgeons still face challenging resections that require specific and innovative intraoperative maneuvers. The right posterior sectionectomy presents special concerns about its location, the extensive transection area, and the difficult access to the pedicle. The intrahepatic Glissonian approach allows safe en masse control of the portal structures without prolonged dissection. Its association with the half-Pringle maneuver results in less bleeding during parenchymal transection. ⋯ Technical issues initially hindered the development of laparoscopic liver resections [7-10]. Surgeons were concerned about hemostasis, bleeding control, safe and effective parenchymal transection, adequate visualization, and the feasibility of working on deeper regions of the liver. During the past decade, many limitations were overcome, but lesions located on the posterosuperior liver are still considered tough to beat. Large series and extensive reviews show that resections located on the posterior segments still are infrequent. Limited access to the portal triad, difficult pedicle control, and a large transection area and its anatomic location, attached to the diaphragm and retroperitoneum and hidden from the surgeon's view, makes such resections defying. The authors' team has performed 97 laparoscopic hepatectomies, including resection of 6 lesions in the right posterior sector. In their series, half-pedicle clamping was used for 12 patients, and they adopt such a maneuver as an inflow control when operating on peripheric lesions with difficult vascular control (e.g., enucleations or posterosuperiorly located segmentectomies). This technique is safe and useful because it reduces liver ischemic aggression, a very important issue with diseased livers (e.g., steatosis, steatohepatitis, prolonged chemotherapy, cirrhosis). In their series, the authors applied the Glissonian intrahepatic approach in 7 cases (2 left hepatectomies and 5 right hepatectomies). They understand that laparoscopy applies perfectly to oddly (posterosuperior) located tumors and that right posterior sectionectomy can be accomplished safely. In fact, they share the opinion of other specialized hepatobiliary centers, believing that this may be the preferred approach.
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Several factors may affect volume and dimensions of the working space in laparoscopic surgery. The precise impact of these factors has not been well studied. In a porcine model, we used computed tomographic (CT) scanning for measuring working space volume and distances. In a first series of experiments, we studied the relationship between intra-abdominal pressure (IAP) and working space. ⋯ CT allows for precise calculation of the actual CO₂ pneumoperitoneum volume, whereas the volume of CO₂ released by the insufflator does not. Increasing IAP up to 10 mmHg achieved most gain in volume and in internal anteroposterior diameter. At an IAP of 10 mmHg, higher peak inspiratory pressure was significantly elevated.
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Surgeons performing laparoscopy need a high degree of psychomotor skills, which can be trained and assessed on virtual reality (VR) simulators. VR simulators simulate the surgical environment and assess psychomotor skills according to predefined parameters. This study aimed to validate a proficiency-based training setup that consisted of two tasks with predefined threshold values and handles with haptic feedback on the LapSim(®) VR simulator. The two tasks have been found to have construct validity in previous studies using handles without haptic feedback. ⋯ The setup employed in this study failed to establish construct validity for more than one parameter. This indicates that the simulation of haptic feedback influences the training performance on laparoscopic simulators and is an important part of validating a training setup. A haptic device should generate haptic sensations in a realistic manner, without introducing frictional forces that are not inherent to laparoscopy.
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Comparative Study Clinical Trial
Comparison of the incidence of postoperative nausea and vomiting between women undergoing open or robot-assisted thyroidectomy.
Open thyroidectomy is associated with a high incidence of postoperative nausea and vomiting (PONV) in up to 70 % of cases. Use of the recently introduced robot-assisted endoscopic thyroidectomy using a gasless transaxillary approach has been increasing because of its several advantages over open thyroidectomy. This study compared the incidence of PONV in the women who underwent open or robot-assisted thyroidectomy. ⋯ Robotic thyroidectomy reduces the incidence and severity of PONV compared to open thyroidectomy during a 0-24-h postoperative period.
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Clinical Trial
Impact of a trimodal prehabilitation program on functional recovery after colorectal cancer surgery: a pilot study.
Patients undergoing colorectal cancer resections are at risk for delayed recovery. Prehabilitation aims to enhance functional capacity preoperatively for better toleration of surgery and to facilitate recovery. The authors previously demonstrated the limited impact of a prehabilitation program using exercise alone. They propose an expanded trimodal prehabilitation program that adds nutritional counseling, protein supplementation, and anxiety reduction to a moderate exercise program. This study aimed to estimate the impact of this trimodal program on the recovery of functional capacity compared with standard surgical care. ⋯ In this pilot study, a 1-month trimodal prehabilitation program improved postoperative functional recovery. A randomized trial is ongoing (NCT01356264).