Trocar and instrument positioning system TISKA. An assist device for endoscopic solo surgery

The assistance received by the surgeon from support personnel during surgical laparoscopy is extremely important. This includes the retracting of instruments and the positioning of the endoscope. However, human assistance is costly and often does not provide satisfaction for the surgeon. The aim of the project was to develop a mechanical arm capable of manipulating a laparoscopic instrument under the control of the operating surgeon. The system design is based on a particular kinematic construction that maintains an invariant point of constraint motion coincident with the trocar puncture site through the abdominal wall. The guidance system allows transparent and intuitive operation, and its setup is easy and quick. It may be adapted either as an instrument retractor or as an optic positioning device. A new generation of instrument positioning systems, with improved ergonomy, will be a first step toward the diffusion of solo surgery techniques in minimally invasive therapy. We believe this prototype represents a valid compromise between human and robotic control for conventional laparoscopic instruments.

[The role of drainage and antibiotic prophylaxis in thyroid surgery]

BACKGROUND

It is our habit to employ an open drainage after thyroid surgery in our department. We have also found a large number of surgical infections in these patients (5.8% vs 2.5). Aim of the study is to evaluate prospectively if contamination happens during surgical procedure or in a later time according to the presence of the open drainage.

METHODS

From October 1995 to November 1996, 113 patients who underwent a subtotal thyroidectomy were randomized into two groups: group A with antibiotic prophylaxis (57 patients) and group B without it (56 patients).

RESULTS

One case (1.7%) of sepsis among 57 patients of group A and 2 cases (3.4%) among 56 patients of group B were observed.

CONCLUSIONS

No statistical difference was found between the two groups despite antibiotic prophylaxis covering surgical procedure. It is personal opinion that sepsis arose after surgical procedure, due to the presence of the open drainage.

Is euthyroidism the goal of surgical treatment of diffuse toxic goitre?

OBJECTIVE

To find out by studying a homogeneous group of patients whether euthyroidism is achievable by surgical treatment of diffuse toxic goitre.

DESIGN

Retrospective study.

SETTING

Teaching hospital, Italy.

SUBJECTS

128 of the 152 patients operated on for diffuse toxic goitre during the period January 1971-December 1994 and followed up for a median of 83 months (range 6-289). INTERVENTION. Standard subtotal thyroidectomy.

MAIN OUTCOME MEASURES

Operative mortality, recurrence, hypothyroidism and late complications.

RESULTS

There were no operative deaths. After 10 years follow up, 11 patients (9%) had developed recurrences and 61 (48%) were euthyroid. In the univariate analysis the risk of hypothyroidism was significantly associated with the year of operation (p = 0.04), the duration of symptoms (p < 0.01), and the degree of lymphocytic infiltration (p < 0.01). The last two were confirmed by multivariate analysis.

CONCLUSION

Subtotal thyroidectomy seems to be an effective treatment of diffuse toxic goitre as a stable euthyroid state can be achieved in nearly half the patients after a prolonged follow up.

Mucoepidermoid carcinoma of the thyroid gland arising from a papillary epithelial neoplasm

We report a case of mucoepidermoid carcinoma of the thyroid gland. The simultaneous association of papillary and mucoepidermoid carcinoma in a Hashimoto's thyroiditis makes the present observation unusual. Surgery was limited due to local extension of the neoplasm. The patient consequently underwent external radiotherapy followed by radiometabolic therapy. The patient survived 11 months after diagnosis. As far as the histogenesis of the neoplasm is concerned, we believe that mucoepidermoid areas correspond to squamous and mucinous metaplasia of a preexisting papillary carcinoma. Transition areas between elements morphologically characteristic of both neoplasms were observed. Histochemical and immunohistochemical studies confirmed the diagnosis of a carcinoma with multiple aspects showing a focal positive reaction for thyroglobulin or keratin antisera. Therefore, this demonstrates different functional activities of the neoplastic cells. There is still debate about adjuvant therapies, the results of which appear for the moment very poor.

[Connection between the type of drainage and sepsis in thyroid surgery]

Drainage in thyroid surgery, although still controversial, is used at our service routinely, as it guarantees the output of serum, sometimes abundant after thyroidectomy, and allows the immediate check of hemorrhage. It is nevertheless known that the presence of drainage can favour the occurrence of infection of the surgical bed. Through a randomized trial, we tested the incidence of sepsis after thyroidectomy, using in one group a double open Silastic drain and in another group a double aspirative drain. We registered 3 cases of wound infection and 4 cases of seroma in the group treated with open drainage versus one case of wound infection and 2 cases of seroma in the group treated with aspirative drainage. Such difference, although evident, did not result significant. Nevertheless, it is our opinion to conclude that the aspirative draining system guarantees a better sterility of the surgical wound, and therefore a lower incidence of wound complications.

Toxic thyroid adenoma: absence of DNA mutations of the TSH receptor and Gs alpha

DNA point mutations of the TSH receptor and of the alpha subunit of the stimulatory GTP-binding protein (Gs alpha) have been suggested as major causes of hyperfunctioning thyroid adenomas. However, significant differences in the prevalence of these mutations (from 0.3 to 84%) have been found in different populations. The present study was designed to evaluate further the presence of mutations in discrete fragments of cDNA encoding critical regions of the TSH receptor and of the Gs alpha involved in signal transduction and cAMP production. Genomic DNA extracted from 15 thyroid adenomas and surrounding quiescent thyroid tissues was used as a template to amplify four DNA fragments of TSH receptor and one DNA fragment of Gs alpha. TSH receptor and Gs alpha DNAs were analyzed by a number of techniques. We did not detect any mutations (new or previously described) in our patients. These results confirm that the causes of solitary toxic adenomas are protean, and only some of them may be somatic DNA point mutations. Since the clinical features of solitary toxic adenoma are homogeneous, it could be important to establish the specific molecular defect underlying each case, in order to follow up the patients and to assess their clinical evolution.

Surveillance after colorectal cancer surgery

Early diagnosis of local and distant recurrences of colorectal cancer remains difficult and there is no agreement on the effectiveness of follow-up in these patients. The aim of this study is to assess the value of our method of follow-up. We consider 239 patients with colorectal cancer and at least 2 years follow-up following radical resection. A local recurrence appeared in 26 patients (10.9%), a distant metastasis in 41 (17.1%), while in seven (2.9%) local and distant recurrences appeared simultaneously. Local recurrence was detected because of an increase in carcinoembryonic antigen (CEA) level in 15 patients (57.7%), during a scheduled endoscopy in four (15.4%) and because of symptoms in seven (26.9%). In seven patients (26.9%) a radical resection was possible. Distant metastases were detected by CEA levels in 20 patients (48.8%), by ultrasonography (U.S.) in 12 (29.3%) and by chest X-ray in five (12.2%). In 13 of 26 patients with liver metastases a resection was performed. This study shows that few patients benefit from follow-up and only CEA levels and liver U.S. performed intensively between 15 and 36 months after surgery are useful in early detection of recurrences. A modification of the follow-up to the single patient, according to the stage, location and grading of cancer, could improve the results, so lowering the costs of this expensive practice.

[Comparison of colorectal mechanical suture techniques]

Objective of this study is to establish which kind of stapled anastomosis is the most reliable in rectal surgery. 67 patients randomly assigned to three groups underwent low anterior resection of the rectum with end-to-end, side-to-end or double stapling anastomosis. Main outcome measures were incidence of leakage at the intraoperative check of the suture, postoperative leakage, stenosis, mortality, mean post-operative stay. Side-to-end anastomosis were followed by 4 intra-operative (19%) and one post-operative (4.7%) leakages with one case of mortality (4.7%). Four intra-operative (18.2%) and 5 post-operative (22.7%) leakages, 3 stenosis (13.6%) and one case of mortality (4.5%) were observed after double-stapling procedures. No intra- or post-operative anastomotic complications were seen after end-to-end anastomosis. Mean post-operative stay was 20, 31 and 13 days for the three methods respectively.

CONCLUSIONS

In this series of colo-rectal anastomoses, the end-to-end stapling technique appears to be safer and more reliable than others.

Giant hemangiomas of the liver: surgical treatment by liver resection

BACKGROUND

The correct therapeutic strategy of giant hemangiomas of the liver is debated and based on two main techniques: resection and enucleation.

MATERIALS AND METHODS

We report seven consecutive typical hepatic resections for giant cavernous hemangiomas in symptomatic patients. Most frequent symptom was pain at the right hypochondrium, associated with epigastric discomfort. Hepatectomy was carried out after extraparenchymal ligation of the hilary structures and parenchymal resection was performed with kellyclasia and ligation of the intraparenchymal vessels with clips. In all cases the resection was performed after intermittent clamping of the hepatic pedicle.

RESULTS

Three right hepatectomies, 1 right extended hepatectomy, 1 left hepatectomy and 2 left lobectomies (segments 2 and 3) were performed. Estimated blood loss ranged from 350 to 1000 ml with a mean loss of 550 ml. No major postoperative complication and no long term sequela occurred. Two episodes of cholangitis in an old patient after emergency operation regressed under medical treatment.

CONCLUSIONS

Enucleation is an option when a lesion is small and superficial. In the case of large and deep hemangiomas in proximity of vascular structures, typical liver resection is a safe operation entailing lower morbidity and blood loss.

Differentiated thyroid cancer: surgical treatments of 190 patients

Between 1968 and 1991, 190 patients (51 men, 139 women) with a mean age of 46.3 years underwent surgery for differentiated thyroid cancer (148 papillary and 42 follicular carcinomas). In 29.5% of the cases a concomitant goitre was histologically demonstrated. These patients were significantly older (mean: 54.7 years) (P<0.01). The patients who had previously received cervical radiotherapy were significantly younger (mean: 29.7 years) (P<0.01). The analysis of historical and clinical findings failed to identify predictive factors of biological aggressiveness. Hyperthyroidism occurred in 5.7% of patients: this subgroup did not show any difference in clinical behaviour. Occult carcinoma (14.7%) and multifocality (9.4%) were found more frequently in the glands with a pre-existent goitre (P<0.05), but the clinical significance of these aspects is uncertain. The surgical treatment of choice was total thyroidectomy (135 patients); more conservative procedures were performed only in younger patients with small lesions, without a difference in survival. Post-operatively a permanent recurrent laryngeal nerve injury occurred in four patients (2.1%) and nine patients (4.7%) required a permanent calcium supplementation. Among patients in follow-up (91.6%), those who underwent a total thyroidectomy were studied using a total body scinti scan. A poor prognosis was associated with age (>40 years), pT, stage, pM and symptomatic metastases.

[Surgical treatment of multinodular goiter]

A homogeneous series of 361 patients operated on for multinodular goitre was analyzed. Minimum and mean follow-up were 10 and 18.6 years, respectively. In most cases a subtotal or near total thyroidectomy was performed, while total thyroidectomy was reserved for patients with cancer. The goal of the study was to verify the long term outcome of this therapeutic strategy in terms of complications, disease recurrence, need of complementary therapies (TSH-suppressive or substitutive) and reinterventions. Global recurrences were 14.7%, and 4.9% of these needed a second operation for indications similar to those of the first operation. Long term complications were vocal cord palsy 1.1% and permanent hypoparothyroidism 0.3%, while the global complications of reinterventions were 3% (n.s.). Nearly half of the patients had not followed any functional or instrumental check-up for at least 5 years nor undergone any hormonal therapy. Among the patients who had a TSH-suppressive therapy, the recurrence rate was not significantly different compared to the group that had no treatment. On the basis of these data, it seems that subtotal thyroidectomy is adequate intervention for multinodular goitre, as long as the number of clinical recurrences is not significantly high. On the contrary, it might be expected that total interventions, performed in non specialized centers, would introduce a higher rate of complications. The need for TSH-suppressive therapy to reduce recurrences was not proven.

[Recurrent goiter: analysis of 134 reinterventions]

Reoperative surgery for thyroid disease still plays a predominant role in the treatment of goiter recurrences. At the moment, neither useful biological nor clinical indicators exist to prevent such recurrences. The effectiveness of TSH-suppressive therapy is still debatable and some authors have proposed total thyroidectomy for this benign disease in order to eliminate the risk of relapse. We analyzed 134 patients who underwent reintervention for recurrence of goitre in order to: 1) study possible clinical or epidemiological characteristics that could influence recurrence, 2) to verify the indications to reoperation, and 3) to evaluate the incidence of complications. For the study of complications, we adopted as a control group a series of 361 patients operated on by the same medical staff and undergoing subtotal thyroidectomy for multinodular goitre, with a minimal follow-up of 10 years. The surgical technique is described and several peculiarities are discussed. In the group of patients who had reoperation two cases (1.5%) of laryngeal palsy and two cases (1.5%) of hypoparathyroidism were recorded and this was not significantly different from the control group. A positive correlation was found between recurrence and young age at the time of first surgery (p < 0.006), female sex (p = 0.045) and esthetic results (p = 0.013). No further clinical recurrence was found in 101 patients after a mean follow-up of 122 months, while in 16 cases the echography revealed nodules in the residual parenchyma. In our opinion total thyroidectomy is not justified as a first standard procedure for this benign disease caused by the activity of various not yet well understood, growth factors.

[Surgical treatment of cervico-mediastinal goiter]

Over the last decades definitions and classifications of cervico-mediastinal goiters have been proposed. According to the definition of Valdoni and Tonelli, from 1968 to 1991 237 patients were operated on for cervico-mediastinal goiter. There were 168 simple forms (141 anterior and 27 posterior) and 69 complex forms according to Borrelly's classification. We analyse and discuss the clinical presentation, the diagnostic procedures and the surgical technique in relation to post-operative complications and long term results. The mean duration of symptoms before surgery in patients with cervico-mediastinal goiter was longer than in subjects with cervical goiters. All but 8 operations were performed through a cervical incision. Two patients, both with advanced tumor, died postoperatively. Post-operative complications were: hemorrhage 0.8%, dysphonia 4.6% and transient hypoparathyroidism 2.9%. A clinical follow-up was available for 194 patients. Permanent dyspnea was observed in 1.0%, dysphonia in 4.6% and transient hypoparathyroidism in 2.9%. Tracheotomy was necessary in 5 cases. Complications were more frequent after total thyroidectomy than after partial resection (p < 0.05), after surgery for malignancy than for benign disease (p < 0.05) and in complex than in simple forms (p < 0.05). Almost all cervico-mediastinal goiters can be treated by a cervical incision. Sternotomy, when required, does not influence mobility and mortality. The lacking of an alternative treatment, the relatively high incidence of malignancy and the risk of acute airway obstruction should induce the early removal of all substernal goiters.

Surgical management of substernal goiter: analysis of 237 patients

Between 1968 and 1991, 237 patients underwent thyroidectomy for substernal goiter. Sixteen of them presented malignancies (6.8%). Mean age of the 159 women and 78 men was 57.7 years. Twenty-five patients had undergone previous thyroid surgery. The initial symptoms were cervical mass (72%), compression (16.2%), hyperthyroidism (13.1%), hypothyroidism (1.3%), and 5.5 per cent were asymptomatic. Most patients had long-standing goiter (mean duration: 12.9 yrs). All but eight operations were performed through a cervical incision. There were two postoperative deaths (0.8%), both in patients with advanced neoplasms. Early postoperative complications were hemorrhage (0.8%), dysphonia (4.6%), and transient hypocalcemia (2.9%). Five patients (2.1%) required tracheotomy. Complications were more frequent after total thyroidectomy than partial resection (P < 0.05), after surgery for malignancy than for benign disease (P < 0.05), and in complex than in simple forms (P < 0.05). One hundred ninety-four patients were followed after surgery; dyspnea was found in two patients (1.0%), dysphonia in seven (3.6%), and hypoparathyroidism in one. Analysis of our data indicates that 1) substernal goiter arose in elderly patients more than a decade later than cervical goiter; 2) goiters with a "complex" endothoracic development had an increased rate of short and long term complications; 3) cancer occurred in a significant number of patients, without any specific symptoms of malignancy; 4) the group of patients with hyperthyroidism was characterized by a significantly longer clinical history than euthyroid patients; 5) nearly all substernal goiters could be approached through a cervical collar incision; 6) the morbidity and mortality were low also after sternotomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Sexual dysfunction, erectile impotence and obstructive azoospermia in respiratory disease. Relevance of lung-mediated regulation of prostaglandins

Background

Acute diverticulitis (AD) presents a unique diagnostic and therapeutic challenge for general surgeons. This collaborative project between EAES and SAGES aimed to summarize recent evidence and draw statements of recommendation to guide our members on comprehensive AD management.

Methods

Systematic reviews of the literature were conducted across six AD topics by an international steering group including experts from both societies. Topics encompassed the epidemiology, diagnosis, management of non-complicated and complicated AD as well as emergency and elective operative AD management. Consensus statements and recommendations were generated, and the quality of the evidence and recommendation strength rated with the GRADE system. Modified Delphi methodology was used to reach consensus among experts prior to surveying the EAES and SAGES membership on the recommendations and likelihood to impact their practice. Results were presented at both EAES and SAGES annual meetings with live re-voting carried out for recommendations with < 70% agreement.

Results

A total of 51 consensus statements and 41 recommendations across all six topics were agreed upon by the experts and submitted for members’ online voting. Based on 1004 complete surveys and over 300 live votes at the SAGES and EAES Diverticulitis Consensus Conference (DCC), consensus was achieved for 97.6% (40/41) of recommendations with 92% (38/41) agreement on the likelihood that these recommendations would change practice if not already applied. Areas of persistent disagreement included the selective use of imaging to guide AD diagnosis, recommendations against antibiotics in non-complicated AD, and routine colonic evaluation after resolution of non-complicated diverticulitis.

Conclusion

This joint EAES and SAGES consensus conference updates clinicians on the current evidence and provides a set of recommendations that can guide clinical AD management practice.

Electronic supplementary material

The online version of this article (10.1007/s00464-019-06882-z) contains supplementary material, which is available to authorized users.