Pilot study on an innovative biosensor with a range of medical and surgical applications.

OBJECTIVES: The objective of this article is to briefly outline the utilization of biosensors in medicine and surgery and present diagnostic efficacy of thermal product (TP) based biosensor. RESULTS: The working principle of biosensor is based on measuring TP of a material in contact with the sensor. When an electrical square wave pulse of certain amplitude and duration is passed through TP based biosensor, the generated heat from its higher resistance will be dissipated and recorded by the sensor. As the surrounding material composition changes, the dissipated heat split between the sensor substrate and surrounding material changes which can be correlated to the change in TP of the material. For biological tissues, it is known that the thermal properties of tissues are quite different for different layers in the body and hence the heat absorbed will be different. The experiments were conducted on biological and non-biological tissues. For data acquisition software LabView 2014 (64-bit) was used and software used for post-processing was MATLAB R2015a (64-bit). The resulting graphs of TP from various materials (oil, water, saline, acetone) and biological tissue (porcine belly, porcine thigh layers and porcine abdominal viscera) expressed prominent deflections indicating diagnostic efficacy of TP based biosensor.

Early vs delayed closure of loop defunctioning ileostomy in patients undergoing distal colorectal resections: an integrated systematic review and meta-analysis of published randomized controlled trials.

AIMS: The objective of this study was to evaluate the surgical outcomes and feasibility of early loop defunctioning ileostomy closure, within 2 weeks of index surgery, in patients undergoing distal colorectal resection. METHODS: A systematic review of the literature on published randomized controlled trials reporting the feasibility and outcomes on early vs delayed closure of loop defunctioning ileostomy in patients undergoing distal colorectal resection using the principles of meta-analysis on RevMan 5.4 statistical software was undertaken. RESULTS: Four randomized, controlled trials on 446 patients evaluating the feasibility and outcomes on early vs delayed closure of loop defunctioning ileostomy in patients undergoing low colorectal resection were analysed. There were 176 patients in the early closure group and 270 patients in the delayed closure group. The risk of anastomotic leak [risk ratio 0.37 (CI: 0.10-1.42), P = 0.15], anastomotic stenosis [risk ratio 4.79 (CI: 0.23-98.47), P = 0.31] and postoperative complications [risk ratio 0.75 (CI: 0.48-1.16), P = 0.19] was similar in both groups. In addition, there was no significant difference between the groups with regard to the duration of operation [standardized mean difference -0.49 (CI: -01.09, -0.12), P = 0.12] and length of hospitalization [standardized mean difference -0.04 (CI: -0.25, -0.18), P = 0.75]. CONCLUSIONS: Early closure of loop defunctioning ileostomy in patients undergoing distal colorectal resection is feasible with comparable outcomes to delayed closure.

A systematic review of clinical effectiveness of wound edge protector devices in reducing surgical site infections in patients undergoing abdominal surgery.

This article highlights the clinical effectiveness of wound edge protector devices (WEPD) in preventing the post-operative surgical site infections (SSI) in patients undergoing abdominal surgery. Using the principles of meta-analysis and systematic review as recommended by the Cochrane Collaboration, the data from selected randomized, controlled trials (RCTs) were analysed to generate summated outcome and presented in the form of odds ratio (OR). Eighteen RCTs on 3808 reported the effectiveness of WEPD in patients undergoing abdominal surgery. The use of WEPD was associated with the reduced incidence of overall SSI (OR 0.59; 95% CI 0.43-0.81; z = 3.30; p < 0.001) and superficial SSI (OR 0.42; 95% CI 0.18-0.95; z = 2.09; p < 0.04). In addition, WEPD also successfully reduced the risk of SSI in clean-contaminated wounds (OR 0.67; 95% CI 0.46-0.98; z = 2.06; p < 0.04) as well as in contaminated wounds (OR 0.24; 95% CI 0.12-0.49; z = 3.96; p < 0.0001). WEPD seems to be an effective intervention to reduce the risk of post-operative SSI in patients undergoing abdominal surgery.

Local anaesthetic infiltration for the rubber band ligation of early symptomatic haemorrhoids: a systematic review and meta-analysis.

The objective of this article is to systematically analyse the randomized, controlled trials evaluating the effectiveness of local anaesthetic infiltration prior to the rubber band ligation of early symptomatic haemorrhoids. Published randomized, controlled trials comparing the use of local anaesthetic (LA) versus no-local anaesthetic (NLA) for the rubber band ligation of early symptomatic haemorrhoids were analysed using RevMan®, and the combined outcomes were expressed as odds ratios (OR) and standardized mean difference (SMD). Four randomized, controlled trials evaluating 387 patients were retrieved from the standard electronic databases. The risk of treatment failure (OR 0.44; 95% CI 0.07, 2.79; z = 0.87; p = 0.39) and post-procedure complications (OR 0.48; 95% CI 0.08, 2.76; z = 0.83; p = 0.41) was similar between two techniques. However, the post-procedure pain score (SMD -5.19; 95% CI -9.08, -1.30; z = 2.62; p < 0.009) was significantly lower in the group of patients undergoing rubber band ligation of haemorrhoids under local anaesthetic injection. The use of LA appears to have clinically measurable advantages over NLA in the rubber band ligation of early symptomatic haemorrhoids to lessen post-procedure pain.

Carbon dioxide insufflation vs conventional air insufflation for colonoscopy: a systematic review and meta-analysis of published randomized controlled trials.

AIM: Conventional air insufflation (AI) may cause prolonged abdominal bloating, excessive abdominal pain and discomfort during colonoscopy. Carbon dioxide may be an acceptable alternative to avoid these complications. The object of this study was to evaluate systematically the effectiveness of carbon dioxide insufflation (CI) for colonoscopy compared with AI. METHOD: Randomized controlled trials (RCTs) comparing the effectiveness of CI with that of AI during colonoscopy were retrieved from medical electronic databases and combined analysis was performed using the RevMan statistical package. The combined outcome of dichotomous and continuous variables was expressed as an odds ratio (OR) and standardized mean difference (SMD). RESULTS: Twenty-one RCTs comprising 3607 patients were included in the study. There was statistically significant heterogeneity among included studies. CI showed a significant trend towards reduced procedural pain [SMD -1.34; 95% confidence interval (95% CI) -2.23 to -0.45; z = 2.96; P < 0.003] and also postprocedural pain at 1 h (SMD -1.11; 95% CI -1.83 to -0.38; z = 2.97; P < 0.003), 6 and 24 h (OR 0.44; 95% CI 0.23-0.85; z = 2.44; P < 0.01). CI was associated with faster caecal intubation (SMD -0.20; 95% CI -0.37 to -0.02; z = 2.23; P < 0.03) but the caecal intubation rate was similar (P = 0.59) in both colonic insufflation techniques . CONCLUSION: CI seems to have clinical advantages over AI for colonoscopy with regard to pain during and after the procedure.

Systematic review and meta-analysis of published trials comparing the effectiveness of transanal endoscopic microsurgery and radical resection in the management of early rectal cancer.

AIM: A systematic analysis was conducted of trials comparing the effectiveness of transanal endoscopic microsurgery (TEMS) with radical resection (RR) for T1 and T2 rectal cancer. METHOD: An electronic search was carried out of trials reporting the effectiveness of TEMS and RR in the treatment of T1 and T2 rectal cancers. RESULTS: Ten trials including 942 patients were retrieved. There was a trend toward a higher risk of local recurrence (odds ratio 2.78; 95% confidence interval 1.42, 5.44; z = 2.97; P < 0.003) and overall recurrence (P < 0.01) following TEMS compared with RR. The risk of distant recurrence, overall survival (odds ratio 0.90; 95% confidence interval 0.49, 1.66; z = 0.33; P = 0.74) and mortality was similar. TEMS was associated with a shorter operation time and hospital stay and a reduced risk of postoperative complications (P < 0.0001). The included studies, however, were significantly diverse in stage and grade of rectal cancer and the use of neoadjuvant chemoradiotherapy. CONCLUSION: Transanal endoscopic microsurgery appears to have clinically measurable advantages in patients with early rectal cancer. The studies included in this review do not allow firm conclusions as to whether TEMS is superior to RR in the management of early rectal cancer. Larger, better designed and executed prospective studies are needed to answer this question.

Retraction techniques in laparoscopic colorectal surgery: a literature-based review.

AIM: To systematically review the published literature and describe the various techniques of bowel and mesentery retraction available for use in laparoscopic colorectal resection. METHOD: A comprehensive search of the literature was undertaken using MESH terms 'retraction', 'laparoscopic' and 'colorectal'. All articles describing methods of retraction in laparoscopic colorectal surgery were included. RESULTS: Twelve methods of retraction in laparoscopic colorectal surgery were described. Five case-based series and three case studies were reported on 108 patients. Techniques were classified into those offering retraction of the small or large bowel or according to the mode of retraction. CONCLUSION: Many retraction methods are available to the surgeon varying in cost, invasiveness and complexity. Adequate retraction remains a challenge for optimal exposure and dissection during laparoscopic colorectal surgery.

Systematic review and meta-analysis of published, randomized, controlled trials comparing suture anastomosis to stapled anastomosis for ileostomy closure.

The objective of this article is to systematically analyze the randomized, controlled trials comparing the effectiveness of suture anastomosis (SUA) versus stapled anastomosis (STA) in patients undergoing ileostomy closure. Randomized, controlled trials comparing the effectiveness of SUA versus STA in patients undergoing ileostomy closure were analyzed using RevMan(®), and combined outcomes were expressed as odds risk ratio (OR) and standardized mean difference (SMD). Four randomized, controlled trials that recruited 645 patients were retrieved from electronic databases. There were 327 patients in the STA group and 318 patients in the SUA group. There was significant heterogeneity among included trials. Operative time (SMD -1.02; 95 % CI -1.89, -0.15; z = 2.29; p < 0.02) was shorter following STA compared to SUA. In addition, risk of small bowel obstruction (OR 0.54; 95 % confidence interval (CI), 0.30, 0.95; z = 2.13; p < 0.03) was lower in the STA group. Risk of anastomotic leak (OR 0.87; 95 % CI 0.12, 6.33; z = 0.14; p = 0.89), surgical site infection, reoperation and readmission were similar following STA and SUA in patients undergoing ileostomy closure. Length of hospital stay was also similar between STA and SUA groups. In ileostomy closure, STA was associated with shorter operative time and lower risk of postoperative small bowel obstruction. However, STA and SUA were similar in terms of anastomotic leak, surgical site infection, readmission, reoperations and length of hospital stay.

Systematic review of the use of topical diltiazem compared with glyceryltrinitrate for the nonoperative management of chronic anal fissure.

AIM: The study analyzed clinical trials investigating the effectiveness of diltiazem (DTZ) and glyceryltrinitrate (GTN) for the nonsurgical management of chronic anal fissure (CAF). METHOD: Randomized trials on the effectiveness of DTZ and GTN were analyzed systematically using RevMan(®) where combined outcome was expressed as risk ratio (RR). RESULTS: Seven randomized controlled trials that included 481 patients were analyzed. Two-hundred and thirty-eight patients were treated with DTZ and 243 patients were treated with GTN. There was significant heterogeneity [Tau(2) = 0.24, χ2 = 13.16, d.f. = 6 (P < 0.05); I(2) = 54%] among the included trials. In the random-effects model, DTZ was associated with a lower incidence of side effects (RR = 0.48; 95% CI = 0.27, 0.86; z = 2.46; P < 0.01), headache (RR = 0.39; 95% CI = 0.24, 0.66; z = 3.54; P < 0.004) and recurrence (RR = 0.68; 95% CI = 0.52, 0.89; z = 2.77; P < 0.006) of CAF. Both GTN and DTZ were equally effective (RR = 1.10; 95% CI = 0.90, 1.34; z = 0.92; P = 0.36) in the nonsurgical management of CAF. CONCLUSION: This systematic review of seven trials validates and strengthens the finding of a previously published meta-analysis of two randomized trials. Both DTZ and GTN are equally effective in the management of CAF. However, DTZ is associated with a lower incidence of headache and recurrent fissure. Therefore DTZ should be the preferred first line of treatment for CAF.

Use of antibacterial sutures for skin closure in controlling surgical site infections: a systematic review of published randomized, controlled trials.

OBJECTIVE: The objective of this article is to systematically analyse the randomized, controlled trials that compare the use of antibacterial sutures (ABS) for skin closure in controlling surgical site infections. METHODS: Randomized, controlled trials on surgical patients comparing the use of ABS for skin closure in controlling the surgical site infections were analysed systematically using RevMan® and combined outcomes were expressed as odds ratios (OR) and standardized mean differences (SMD). RESULTS: Seven randomized, controlled trials evaluating 1631 patients were retrieved from electronic databases. There were 760 patients in the ABS group and 871 patients in the simple suture group. There was moderate heterogeneity among trials (Tau(2) = 0.12; chi(2) = 8.40, df = 6 [P < 0.01]; I(2) = 29%). Therefore in the random-effects model, the use of ABS for skin closure in surgical patients was associated with a reduced risk of developing surgical site infections (OR, 0.16; 95% CI, 0.37, 0.99; z = 2.02; P < 0.04) and postoperative complications (OR, 0.56; 95% CI, 0.32, 0.98 z = 2.04; P = 0.04). The durations of operation and lengths of hospital stay were similar following the use of ABS and SS for skin closure in patients undergoing various surgical procedures. CONCLUSION: Use of ABS for skin closure in surgical patients is effective in reducing the risk of surgical site infection and postoperative complications. ABS is comparable with SS in terms of length of hospital stay and duration of operation.

Open transinguinal preperitoneal mesh repair of inguinal hernia: a targeted systematic review and meta-analysis of published randomized controlled trials.

OBJECTIVE: The objective of this article is to systematically analyse the randomized, controlled trials comparing transinguinal preperitoneal (TIPP) and Lichtenstein repair (LR) for inguinal hernia. METHODS: Randomized, controlled trials comparing TIPP vs LR were analysed systematically using RevMan® and combined outcomes were expressed as risk ratio (RR) and standardized mean difference. RESULTS: Twelve randomized trials evaluating 1437 patients were retrieved from the electronic databases. There were 714 patients in the TIPP repair group and 723 patients in the LR group. There was significant heterogeneity among trials (P < 0.0001). Therefore, in the random effects model, TIPP repair was associated with a reduced risk of developing chronic groin pain (RR, 0.48; 95% CI, 0.26, 0.89; z = 2.33; P < 0.02) without influencing the incidence of inguinal hernia recurrence (RR, 0.18; 95% CI, 0.36, 1.83; z = 0.51; P = 0.61). Risk of developing postoperative complications and moderate-to-severe postoperative pain was similar following TIPP repair and LR. In addition, duration of operation was statistically similar in both groups. CONCLUSION: TIPP repair for inguinal hernia is associated with lower risk of developing chronic groin pain. It is comparable with LR in terms of risk of hernia recurrence, postoperative complications, duration of operation and intensity of postoperative pain.

Suture mesh fixation versus glue mesh fixation in open inguinal hernia repair: a systematic review and meta-analysis.

OBJECTIVE: To systematically analyse the trials comparing suture mesh fixation (SMF) versus glue mesh fixation (GMF) in open inguinal hernia repair (OIHR). METHODS: Trials comparing the SMF versus GMF in OIHR were analysed systematically using RevMan(®), and combined outcomes were expressed as risk ratio (RR) and standardised mean difference (SMD). RESULTS: Seven randomised controlled trials encompassing 1259 patients were retrieved from the electronic databases. There were 628 patients in the SMF group and 653 patients in the GMF group. In the meta-analysis, postoperative complications (RR, 1.07; 95% CI, 0.72, 1.58; z = 0.34; p = 0.74), postoperative pain (SMD, 0.31; 95% CI, -0.03, 0.64; z = 1.81; p = 0.07), chronic groin pain (RR, 1.60; 95% CI, 0.78, 3.28; z = 1.28; p = 0.20) and length of hospital stay (SMD, 0.06; 95% CI, -0.08, 0.20; z = 0.82; p = 0.41) were statistically comparable between two techniques of mesh fixation in OIHR. However, GMF was associated with a reduced operating time (SMD, 0.15; 95% CI, 0.03, 0.26; z = 2.38; p = 0.02). CONCLUSION: GMF is comparable to SMF in terms of postoperative complications, postoperative pain, chronic groin pain and length of hospital stay. GMF is associated with a reduced operative time compared with SMF. Based on the results of this review the GMF approach may be considered as an alternative for mesh fixation in OIHR. Results should be interpreted cautiously due to relatively short follow up time in studies. A major, multicentre randomised, controlled trial is required to validate these findings.

Parastomal hernia as a consequence of colorectal cancer resections can prophylactically be controlled by mesh insertion at the time of primary surgery: a literature based systematic review of published trials.

AIM: The objective of this article was to systematically analyze the randomized, controlled trials (RCTs) evaluating the role of mesh in the prevention of parastomal hernia (PSH) at the time of primary colorectal resections. METHODS: RCTs evaluating the role of mesh in the prevention of parastomal hernia (PSH) at the time of primary colorectal resections were analysed using RevMan®, and combined outcomes were expressed as odds ratio (OR) and standardized mean difference (SMD). RESULTS: Three RCTs encompassing 128 patients were retrieved for the electronic databases. There were 64 patients in the mesh group and 64 patients in the no-mesh group. In the fixed effects model, the risk of developing postoperative complications (OR, 1.0; 95% CI, 0.36, 3.20; z=0.0; =1.0) was statistically similar after using mesh for PSH prevention at the time of primary colorectal resection and stoma construction in both groups. However, the risk of developing PSH (OR, 0.11; 95% CI, 0.05, 0.27; z=4.88; P<0.00001) was significantly lower after using mesh and mesh insertion to prevent PSH development statistically did not influence (SMD, -0.42; 95% CI, -0.96, 0.12; z=1.51; P=0.13) the duration of operation. CONCLUSION: The incidence of PSH can be reduced by the insertion of mesh at stoma site at the time of primary stoma construction. A major multicentre RCT recruiting higher number of patients and longer follow up is required before recommending the routine use of mesh for PSH prevention.

A meta-analysis examining the use of tacker fixation versus no-fixation of mesh in laparoscopic inguinal hernia repair.

OBJECTIVE: The objective of this article is to systematically analyse the randomised, controlled trials comparing tacker mesh fixation (TMF) versus no-mesh fixation (NMF) in laparoscopic inguinal hernia repair (LIHR). METHODS: Randomised, controlled trials comparing TMF versus NMF in LIHR were analysed systematically using RevMan(®), and combined outcomes were expressed as risk ratio (RR) and standardised mean difference (SMD). RESULTS: Eight randomised, controlled trials encompassing 1386 patients were retrieved from the electronic databases. There were 691 patients in the TMF group and 695 patients in the NMF group. Statistically there was non-significant heterogeneity among trials. In random effects models, operating time (p = 0.15), post-operative pain (p = 0.45), post-operative complications (p = 0.55) and length of hospital stay (p = 0.11) were statistically comparable between two techniques of mesh fixation in LIHR. The risk of developing chronic groin pain (p = 0.67) and risk of hernia recurrence (p = 0.77) was also similar. CONCLUSION: NMF in LIHR does not increase the risk of hernia recurrence. It is comparable with TMF in terms of operation time, post-operative pain, post-operative complications, length of hospital stay and chronic groin pain. Therefore, based upon the results of this review NMF approach may be adopted routinely and safely in LIHR.

A systematic review comparing transanal haemorrhoidal de-arterialisation to stapled haemorrhoidopexy in the management of haemorrhoidal disease.

BACKGROUND: The aim of this study was to systematically analyse the clinical trials on the effectiveness of transanal haemorrhoidal de-arterialisation (THD) and stapled haemorrhoidopexy (SH) in the management of haemorrhoidal disease (HD). METHODS: Clinical trials on the effectiveness of THD and SH in the management of HD were analysed systematically using RevMan(®), and combined outcomes were expressed as risk ratio (RR) and mean difference (MD). RESULTS: Three randomised, controlled trials encompassing 150 patients were analysed systematically. There were 80 THD patients and 70 SH patients. There was no significant heterogeneity (P = 0.40) among included trials. Therefore, in the fixed effects model, THD and SH were statistically equivalent in terms of treatment success rate (P = 0.19), operation time (P = 0.55), postoperative complications (P = 0.11) and recurrence (P = 0.46) of HD. THD was associated with significantly less postoperative pain (MD, -2.00; 95% CI, -2.06, -1.94; z = 63.59; P < 0.00001) compared to SH. CONCLUSIONS: Both THD and SH are equally effective and can be attempted for the management of HD. However, THD is associated with significantly lesser postoperative pain and therefore may be considered a preferred procedure. This conclusion is based only on treating 150 patients by THD or SH in three moderate-quality randomised trials. A major, multicenter, randomised trial is required to validate this conclusion and investigate other variables like hospital stay, cost-effectiveness and health-related quality of life measurement.

Systematic review and meta-analysis of the use of lightweight versus heavyweight mesh in open inguinal hernia repair.

BACKGROUND: The objective of this study was systematically to analyse published randomized trials comparing lightweight mesh (LWM) with heavyweight mesh (HWM) in open inguinal hernia repair. METHODS: Randomized trials on LWM versus HWM were selected from the standard electronic databases. Reported outcomes were analysed systematically using RevMan. Pooled risk ratios were calculated for categorical outcomes, and mean differences for secondary continuous outcomes, using the fixed-effects and random-effects models for meta-analysis. RESULTS: Nine randomized trials containing 2310 patients were included. There was significant heterogeneity among trials. There was no difference in duration of operation, postoperative pain, recurrence rate, testicular atrophy and time to return to work between LWM and HWM groups. The two mesh types had a similar risk of perioperative complications, but LWM was associated with a reduced risk of developing chronic groin pain (risk ratio (RR) 0·61, 95 per cent confidence interval 0·50 to 0·74) and a reduced risk of developing other groin symptoms, such as stiffness and foreign body sensations (RR 0·64, 0·50 to 0·81). CONCLUSION: The use of LWM for open inguinal hernia repair was not associated with an increased risk of hernia recurrence. LWM reduced the incidence of chronic groin pain as well as the risk of developing other groin symptoms.

Comparison of colonic stenting and open surgery for malignant large bowel obstruction.

BACKGROUND: Colonic stents potentially offer effective palliation for those with bowel obstruction attributable to incurable malignancy, and a "bridge to surgery" for those in whom emergency surgery would necessitate a stoma. The current study compared the outcomes of stents and open surgery in the management of malignant large bowel obstruction. METHODS: A literature search of the Medline, Ovid, Embase and Cochrane databases was performed to identify comparative studies reporting outcomes on colonic stenting and surgery for large bowel obstruction. Random effects meta-analytical techniques were applied to identify differences in outcomes between the two groups. Sensitivity analysis of high quality studies, those reporting on more than 35 patients, those solely concerning colorectal cancer and studies performing intention to treat analysis was undertaken to evaluate the study heterogeneity. RESULTS: A total of 10 studies satisfied the criteria for inclusion, with outcomes reported for 451 patients. Stent insertion was attempted for 244 patients (54.1%), and proved successful for 226 (92.6%). The length of hospital stay was shorter by 7.72 days in the stent group (p < 0.001), which also had lower mortality (p = 0.03) and fewer medical complications (p < 0.001). Stoma formation at any point during management was significantly lower than in the stent group (odds ratio, 0.02; p < 0.001), and "bridging to surgery" did not adversely influence survival. CONCLUSIONS: Colonic stenting offers effective palliation for malignant bowel obstruction, with short lengths of hospital stay and a low rate for stoma formation, but data on quality of life and economic evaluation are limited. There is no evidence of differences in long-term survival between those who have stents followed by subsequent resection and those undergoing emergency bowel resection.

Cardiac robotics: a review and St. Mary's experience.

BACKGROUND: The introduction of the laparoscope led to the progress of surgery to a new era, where surgeries that were deemed major are now being performed through keyhole incisions with comparable outcomes to open surgery. However, with this new technique rose several problems like inaccurate depth perception, diminished tactile feedback, need for experienced assistance, and reduction in degrees of motion of the surgeons hands all of which inspired surgeons and engineers to look for mechanical tools to help in reducing these problems. Henceforth; came the application of robotics in surgery. METHODS: A PubMed and Medline search was performed on cardiac robotic surgery and its applications in mitral valve repair and coronary artery surgery. A total of twenty one articles were picked that allude to the subject. A history of robotic surgery was outlined followed by applications of robotic manipulation in cardiac surgery was narrated. A quick overview of this technology in telemedicine was then outlined followed by future prospects of this technology in surgery was contemplated. RESULTS: The experience of the group from St. Mary's Hospital, London in this field was outlined. During the period of 4 years a total of 102 cases of robotic cardiac surgery were performed. The mean length of hospital stay was 3.1 days with a standard deviation of 1.4 days and the morbidity of the series explained. There was no mortality. CONCLUSION: Early studies have shown that minimally invasive cardiac surgery is feasible and yields results similar to conventional cardiac surgery, yet it is more technically demanding on the surgeon. As advantageous as this new modality is, further multicenter studies are needed to prove its efficacy.