Cardiovascular death and progression to end-stage renal disease after major surgery in elderly patients.

BACKGROUND: Reliable estimates for risk of cardiovascular-specific mortality and progression to end-stage renal disease (ESRD) among elderly patients undergoing major surgery are not available. This study aimed to develop simple risk scores to predict these events. METHODS: In a single-centre cohort of elderly patients undergoing major surgery requiring hospital stay longer than 24 h, progression to ESRD and long-term cardiovascular-specific mortality were modelled using multivariable subdistribution hazard models, adjusting for co-morbidity, frailty and type of surgery. RESULTS: Before surgery, 2·9 and 11·9 per cent of 16 655 patients had ESRD and chronic kidney disease (CKD) respectively. During the hospital stay, 46·9 per cent of patients developed acute kidney injury (AKI). Patients with kidney disease had a significantly higher risk of cardiovascular-specific (CV) mortality compared with patients without kidney disease (adjusted hazard ratio (HR) for CKD without AKI 1·60, 95 per cent c.i. 1·25 to 2·01; AKI without CKD 1·70, 1·52 to 1·87; AKI with CKD 2·80, 2·50 to 3·20; ESRD 5·21, 4·32 to 6·27), as well as increased progression to ESRD (AKI without CKD 5·40, 3·44 to 8·35; CKD without AKI 8·80, 4·60 to 17·00; AKI with CKD 31·60, 19·90 to 49·90). CV Death and ESRD Risk scores were developed to predict CV mortality and progression to ESRD. Calculated CV Death and ESRD Risk scores performed well with c-statistics: 0·77 (95 per cent c.i. 0·76 to 0·78) and 0·82 (0·78 to 0·86) respectively at 1 year. CONCLUSION: Kidney disease in elderly patients undergoing major surgery is associated with a high risk of CV mortality and progression to ESRD. Risk scores can augment the shared decision-making process of informed consent and identify patients requiring postoperative renal-protective strategies.

ANTECEDENTES: No se dispone de estimaciones fiables acerca del riesgo de mortalidad cardiovascular y de progresión a insuficiencia renal terminal (end-stage renal disease, ESRD) en pacientes longevos a los que se realiza cirugía mayor. Este estudio tiene como objetivo desarrollar un sistema de puntuación simple de riesgos para predecir estos eventos. MÉTODOS: En una cohorte de un solo centro de 16.655 pacientes longevos a los que se realizó cirugía mayor con hospitalización de más de 24 horas, se estimó la progresión a ESRD y la mortalidad cardiovascular a largo plazo utilizando modelos multivariables de subdistribucion de riesgos ajustados por comorbilidades, fragilidad y tipo de cirugía. RESULTADOS: Antes de la cirugía, presentaron ESRD y enfermedad renal crónica (chronic kidney Disease, CKD) un 2,9% y un 12,3% de los pacientes, respectivamente. Durante la hospitalización, el 46,9% de los pacientes desarrollaron insuficiencia renal aguda (acute kidney injury, AKI). Los pacientes con enfermedad renal tenían un riesgo significativamente mayor de mortalidad cardiovascular (CV) en comparación con los pacientes sin enfermedad renal para presentar AKI (cociente de riesgos instantáneos, hazard ratio, HR ajustado) 1,6 (i.c. del 95% 1,3-2,0), AKI sin CKD 1,7 (1,5-1,9), AKI en presencia de CKD 2,8 (2,5-3,2) y ESRD 5,2 (4,3-6,3), así como una mayor progresión a ESRD (AKI sin CKD 5,4 (3,4-8,4), CKD sin AKI 8,8 (4,6-17), y AKI en presencia de CKD 31,6 (19,9-49,9)). Se desarrollaron las escalas CV Death y ESRD Risk para predecir la mortalidad cardiovascular y la progresión a ESRD. Ambas escalas funcionaron bien a 1 año con un coeficiente de concordancia de 0,77 (i.c. del 95% 0,76-0,78) y 0,82 (0,78-0,86) respectivamente. CONCLUSIÓN: La enfermedad renal en pacientes longevos tras cirugía mayor se asocia con un elevado riesgo de mortalidad cardiovascular y de progresión a ESRD. Las escalas de riesgo pueden facilitar la toma de decisiones en el momento del consentimiento informado e identificar los pacientes que requieren estrategias de protección renal postoperatorias.

Radiological outcome after treatment of juvenile flatfeet with subtalar arthroereisis: a matched pair analysis of 38 cases comparing neurogenic and non-neurogenic patients.

PURPOSE: Therapy of juvenile neurogenic flatfoot (JNF) with subtalar arthroereisis (SA) is currently under critical clinical investigation. In this retrospective matched pair analysis, the radiological outcome after arthroereisis in paediatric patients with infantile cerebral palsy and JNF was compared with children with juvenile flatfeet (JF) without neurological diseases. METHODS: From October 2007 to April 2018 80 patients with 149 flatfeet underwent surgery with SA. Inclusion criteria were: 1) JNF or JF with age at surgery ≤ 13 years; 2) treatment with SA; 3) presence of three sets of biplane radiographs (preoperative, postoperative and follow-up (FU)). The radiographs were analyzed for: 1) navicular-cuboidal-index (NCI); 2) talocalcaneal angle anteroposterior; 3) talocalcaneal angle lateral; 4) calcaneal-pitch (CP); and 5) talometatarsal-index (TMTI). Following this, 25 patients with 38 flatfeet could be included. RESULTS: The mean age at SA of the JNF group was 9.2 years (JF group: 9.3 years) and the mean time of FU was 35.2 months (JF group: 39.4 months). In comparison with preoperatively, a significant decrease of the NCI was seen in both groups (p = ≤ 0.05 and p = ≤ 0.001) in the FU radiographs. The analysis of CP and TMTI in the JF group also resulted in a significant improvement (p = ≤ 0.001 and p = ≤ 0.05). Overall, the comparison between the JNF and JF group showed no significant differences in regard to the analyzed postoperative parameters. CONCLUSION: Based on this data, treatment of flatfeet by SA in patient with neurological disorders shows an improvement of radiological parameters comparable with neurologically unimpaired patients and might be considered as additional treatment option. LEVEL OF EVIDENCE: IV.

Perineal hernia mesh repair: a fixation with glue, sutures and tacks. How to do it.

Introduction: Many different approaches for the repair of a perineal hernia (PH) after abdomino-perineal rectum amputation (APR) have been described throughout the years. Literature shows us that the use of a mesh had the best results with relatively low rates of recurrence compared to primary suture. Yet there is still no consensus on the best technique for fixation of the mesh in the perineal cavity. Methods: We want to introduce an addition to the surgical repair technique, using laparoscopic glue to ensure a solid fixation of the mesh. This is to prevent small bowel from sliding into the perineal area due to the high abdominal pressure when standing and to avoid the difficulties and risks of laparoscopical suturing in this area. Results: This use of glue for fixation of the mesh has been successful in the three cases described, with no recurrence after one-year follow-up. Conclusion: A recurrent PH can be prevented by a solid fixation of the mesh using the technique of a glued mesh repair. This technique shows to be easy, fast and without recurrence.

Donor Preconditioning After the Onset of Brain Death With Dopamine Derivate n-Octanoyl Dopamine Improves Early Posttransplant Graft Function in the Rat.

Heart transplantation is the therapy of choice for end-stage heart failure. However, hemodynamic instability, which has been demonstrated in brain-dead donors (BDD), could also affect the posttransplant graft function. We tested the hypothesis that treatment of the BDD with the dopamine derivate n-octanoyl-dopamine (NOD) improves donor cardiac and graft function after transplantation. Donor rats were given a continuous intravenous infusion of either NOD (0.882 mg/kg/h, BDD+NOD, n = 6) or a physiological saline vehicle (BDD, n = 9) for 5 h after the induction of brain death by inflation of a subdural balloon catheter. Controls were sham-operated (n = 9). In BDD, decreased left-ventricular contractility (ejection fraction; maximum rate of rise of left-ventricular pressure; preload recruitable stroke work), relaxation (maximum rate of fall of left-ventricular pressure; Tau), and increased end-diastolic stiffness were significantly improved after the NOD treatment. Following the transplantation, the NOD-treatment of BDD improved impaired systolic function and ventricular relaxation. Additionally, after transplantation increased interleukin-6, tumor necrosis factor TNF-α, NF-kappaB-p65, and nuclear factor (NF)-kappaB-p105 gene expression, and increased caspase-3, TNF-α and NF-kappaB protein expression could be significantly downregulated by the NOD treatment compared to BDD. BDD postconditioning with NOD through downregulation of the pro-apoptotic factor caspase-3, pro-inflammatory cytokines, and NF-kappaB may protect the heart against the myocardial injuries associated with brain death and ischemia/reperfusion.

Benefits of Prophylactic Proton Pump Inhibitors after Roux-en-Y Gastric Bypass Surgery: A Retrospective Study.

BACKGROUND: Worldwide, proton pump inhibitors (PPIs) are frequently used to prevent marginal ulcers after Roux-en-Y gastric bypass (RYGB) surgery. The aim of this retrospective study was to assess the prophylactic value of PPIs after a RYGB. METHODS: We retrospectively collected data on 200 patients with morbid obesity, who underwent RYGB surgery between August 2012 and August 2013. The patients were further divided into two groups according to whether or not they had been given prophylactic PPIs after the RYGB. Marginal ulcers were diagnosed based on reported symptoms and confirmed by endoscopy. RESULTS: The average follow-up time was 6.7 months. Postoperative gastroscopy was performed in 23 patients. A marginal ulcer was diagnosed in 13 patients. Only four of these patients were taking prophylactic PPIs, of which three patients had already started taking them prior to surgery. Although marginal ulcers occurred less frequently in patients undergoing prophylactic treatment with PPIs (p-value 0.200), we were unable to demonstrate any statistically significant reduction in the number of ulcers. In addition, major risk factors such as nicotine abuse, NSAIDS and H. pylori did not appear to influence the incidence. CONCLUSIONS: Although our results suggest that PPIs reduce the incidence of marginal ulcers, we were unable to confirm this statistically. Our study was limited by the small study population and short follow-up period. In light of the lack of available scientific evidence and the growing problem of obesity, we believe that robust, large-scale prospective studies are necessary.

Skeletal metastatic disease of the femur: results by management with intramedullary nailing.

PURPOSE OF THE STUDY This study aimed to analyse the outcome following intramedullary nailing for metastases of the femur in a large cohort with special regard to mechanical, implant associated complications and patient survival. Furthermore, we aimed to identify factors influencing the overall survival. MATERIAL AND METHODS All patients (n = 74) that underwent intramedullary nailing for metastatic disease of the femur between 2004 and 2008 and were retrospectively reviewed. Data were recorded from the patients' medical record and the outpatients' clinics files. Details about the tumour biology, the surgery performed as well as the postoperative care were documented. Survival data were extracted from patient records or obtained via communication with outpatient oncologists or the community registration office. RESULTS 74 (28 (37.8%) male, 46 (62.2%) female; p = 0.048) patients with a mean age of 64.4 ± 11.7 years were included. Breast (25, 33.8%), lung (18, 24.3%), bone marrow (7, 9.5%) and kidney (6, 8.1%) were the primary tumours in more than 75% of all patients. The mean overall survival was 17.5 (95% CI: 9.6 - 25.5) months. Patients with osseous metastases had a significant longer survival than patients with visceral and/or cerebral metastases (p = 0.025 and p = 0.032). CONCLUSION Intramedullary nailing represents a valuable fixation method for pathologic fractures or impending fractures of the femur in patients with an advanced stage of metastatic disease. It provides adequate stability to outlast the patient s remaining life-span. However, the balance must be found between therapeutic resignation and surgical overtreatment since operative treatment may be accompanied with serious complications. Key words: bone metastases, intramedullary nailing, metastatic disease, cement augmentation, osteolytic defect.

Surgical management and outcome of skeletal metastatic disease of the humerus.

PURPOSE OF THE STUDY Evaluation of outcome after surgical treatment of humerus metastases with a focus on tumour and patient derived factors, timing and strategy of intervention, surgical outcome and complications. MATERIAL AND METHODS Sixty-fie patients with a mean age of 64.3 years (range 25-89) with 66 metastases of the humerus were surgically treated in a 7-year time-period and retrospectively reviewed. RESULTS Renal cell carcinoma and breast cancer were the most abundant types of primary tumour. The mean time from diagnosis of primary tumour to fist metastasis was 14.5 months (range 0-173). The mean time from diagnosis of metastasis to surgery was 21.4 months (range 0-173). 38/28 intramedullary nails/locking plates were used for 58/8 manifest/impending pathological fractures. Mean cumulative survival was 16.3 months and implant failure rate was 6.1% with a mean time from initial surgery to revision of 22.2-20.6 months. CONCLUSIONS Our data indicate that treatment with intramedullary fiation or cement augmented plate osteosynthesis is successful for the vast majority of patients, but thorough clinical evaluation and precise decision making adapted to the patient's estimated life expectancy must be applied to avoid overtreatment or risk of implant failure. Key words: bone metastases, skeletal metastatic disease, humerus metastasis, pathologic fracture, impending fracture.

Histopathological, immunohistochemical criteria and confocal laser-scanning data of arthrofibrosis.

Arthrofibrosis (af) is defined as a fibrosing disease of the synovial membrane, after joint operations, with painful restricted range of motion. The aim of this paper was to describe the histopathological substrate of af, hitherto only defined by clinical criteria. Based on a group of 222 tissue samples, the characteristic changes to af were analyzed. The control group comprised 29 cases with neosynovialis of the indifferent type. Due to cytoplasmic SM-actin positivity and the absence of specific cytoplasmic reactivity in CD 68 representation, af fibroblasts were characterized as myofibroblasts. In confocal laser-scanning microscopy, ß-catenin-positive aggregates were detected in the cytoplasm. Over and above this, unequivocal colocalization of ß-catenin and the tight junction protein ZO-1 became manifest, particularly on the cell membrane and, partly, in the cytoplasm. A threshold value of 20 ß-catenin-positive cells/HPF was determined. This enables the histopathological diagnosis of an af to be made (sensitivity: 0.733, specificity: 0.867). Af is a fibrosing disease of the synovial membrane with variable grade of fibrotization (fibroblast cellularity). A threshold value of 20 ß-catenin-positive fibroblasts per HPF was defined, which enables the histopathological diagnosis of af.

A gene variant of PNPLA3, but not of APOC3, is associated with histological parameters of NAFLD in an obese population.

OBJECTIVE: Mechanisms explaining the relationship in non-alcoholic fatty liver disease (NAFLD), obesity, and insulin resistance are poorly understood. A genetic basis has been suggested. We studied the association between the genes patatin-like phospholipase domain-containing protein 3 (PNPLA3) and apolipoprotein C3 (APOC3) and metabolic and histological parameters of NAFLD in obese patients. DESIGN AND METHODS: Overweight and obese patients underwent a metabolic and liver assessment. If NAFLD was suspected, liver biopsy was proposed. APOC3 variant rs2854117 and PNPLA3 variant rs738409 were genotyped. RESULTS: Four hundred seventy patients were included (61.1% had liver biopsy). The percentage of patients with non-alcoholic steatohepatitis (NASH) was significantly different according to the PNPLA3 variant. After adjustment for age and body mass index, the PNPLA3 variant was associated with alanine aminotransferase (P < 0.001) and aspartate aminotransferase (P < 0.001). The PNPLA3 variant was associated with more severe features of steatohepatitis: steatosis (P < 0.001), lobular inflammation (P < 0.001), and ballooning (P = 0.002), but not with liver fibrosis, anthropometry, or insulin resistance. No significant difference in liver histology, anthropometric, or metabolic parameters was found between carriers and non-carriers of the APOC3 variant. CONCLUSIONS: PNPLA3 polymorphism rs738409 was associated with NASH and the severity of necroinflammatory changes independently of metabolic factors. No association between APOC3 gene variant rs2854117 and histological or metabolic parameters of NAFLD was found.

[Synovialitis of the arthrofibrotic type: criteria of a new synovialitis type for the diagnosis of arthrofibrosis]. / Synovialitis vom arthrofibrotischen Typ: Kriterien eines neuen Synovialitis-Typus für die Diagnose der Arthrofibrose.

After rheumatologic conservative medical therapy has been exhausted in degenerative and inflammatory joint diseases, arthroplastic operations are an important option to restore quality of life. Endoprosthesis-associated arthrofibrosis is a severe fibrosing disease of the synovial membrane after endoprosthetic operations. Neither the morphological substrate nor histopathological criteria have been described. The aim was to describe the histopathological substrate of arthrofibrosis and to define histological and immunohistochemical criteria of arthrofibrosis on the basis of tissue samples derived from revision. In histopathological analyses arthrofibrosis revealed a synovialitis with varying fibrosis, without detectable ossification and without minimal wear particle reaction (so-called synovialitis of arthrofibrotic type, SAT). A 3-stage grading was determined based on the cellular density of the fibrous tissue (fibroblast cellularity). In 191 cases with SAT, grade 1 was found in 24.1 % (n = 46), grade 2 was found in 51.8 % (n = 99) and grade 3 was found in 24.1 % (n = 46). The control group consisted of 29 cases with synovialitis of indifferent type (type IV membrane). If SAT grades 2 and 3 are summed together, i.e. the distance between the fibroblasts was less than two cell lengths, the difference of the fibroblast cellularity compared with the type IV membrane was significant (p < 0.001). Above SAT grade 2 the diagnosis of arthrofibrosis could be made with a sensitivity 0.7592 and specificity 0.8276. The SM-alpha-actin cytoplasmic positivity of fibroblasts indicates a myofibroblast phenotype and the ß-catenin positivity suggests a resemblance to fibromatosis or a keloid-like process. In the quantitative evaluation of the ß-catenin positive fibroblasts, there was a significant difference (p < 0.001) between type IV membrane and SAT. A threshold value of 20 beta-catenin positive cells per microscopic high power field (HPF) was determined, which represents in conjunction with the clinical information a new histopathological diagnosis component (sensitivity 0.720, specificity 0.867).

Ectopic pancreatic tissue at the umbilicus in childhood: a case report and review of the literature.

Ectopic pancreatic tissue at the umbilicus is very rare. To our best knowledge, only fourteen cases of ectopic pancreatic tissue at the umbilicus are reported. In this paper we present the case of a two-year-old boy with an abrasion at the umbilicus. He had a poorly healing scar that started bleeding after recurrent injuries. Abdominal ultrasound revealed an unclear cystic structure with no communication to intra-abdominal structures. Surgical resection was performed without complications. Histology diagnosed an ectopic pancreatic tissue with reactive epidermal changes. We present a review of the literature and the clinical manifestations and treatment of the previously reported fourteen cases.

Roux-en-Y gastric bypass procedure performed with the da Vinci robot system: is it worth it?

BACKGROUND: The Roux-en-Y gastric bypass procedure (RYGBP) is in many countries the gold standard for obtaining long-lasting weight reduction and improvement of obesity-related comorbidities. However, performing this operation by standard laparoscopic techniques requires important surgical skills because of the anastomoses involved. The da Vinci surgical robot system with its enhanced degrees of freedom in motion and three-dimensional vision is designed to overcome the difficulties encountered in traditional laparoscopic surgery with suturing and delicate tissue handling. METHODS: For this study, 45 patients (9 men) with a mean body mass index (BMI) of 44.2 (range, 35.1-55.4) underwent RYGBP with the aid of the da Vinci robot system. They were compared with 45 consecutive patients with a mean BMI of 43.9 (range, 35.1-56.2) who underwent a laparoscopic RYGBP by the same surgeon during the same period. RESULTS: Overall, the total operating time was shorter for the laparoscopic cases (127 vs 212 min; p < 0.05). However, the last 10 robotic cases were performed in the same time span as the laparoscopic cases (136 vs 127 min). The total robotic setup time remained constant at about 30 min. There were no differences in postoperative complications between the two groups in terms of anastomotic leakage or stenosis. In the robotic group, more conversions to open surgery were noted. Early in the study, four patients (9%) had to undergo conversion to standard laparoscopic techniques due to inadequate setup of the robotic arms. Five patients (11%), however, had to undergo conversion to open surgery because of intestinal laceration during manipulation of the intestines with the robotic instruments. The costs were higher for robotic surgery than for standard laparoscopic RYGBP, mainly because of the extra equipment used, such as ultrasonic devices. CONCLUSION: The RYGBP procedure can be performed safely with the da Vinci robot after a learning curve of about 35 cases. At this writing, however, it is not clear whether the da Vinci system offers a real advantage over standard laparoscopic techniques.

Giant liposarcoma of the stomach involving the mediastinum.

A case of a liposarcoma of the stomach in a 27-year old woman is described. Initially the patient consulted with epigastric pain. MRI showed a giant tumour of the stomach wall, invading the surrounding organs, as well as the mediastinal region. After surgical 'en-bloc' resection of the tumour, histopathologic examination yielded a diagnosis of pleiomorphic liposarcoma. Because of the bad prognosis of this histologic type, the patient received adjuvant chemotherapy: a combination of doxorubicin and ifosfamide (MAI). Nine months after surgery, she represented with a relapse of the tumour that had become inoperable. Palliative chemotherapy was started with the intent to prolong the young patient's life. However 6 months later, the patient died of the recurrent disease. Although liposarcoma is a very common soft tissue sarcoma, it is rarely seen in the stomach. The standard therapy is surgical excision. Over the last years, adjuvant therapy became more accepted. Drugs of choice are doxorubicin and ifosfamide, although the benefits of this therapy are still largely unknown and doubtful.

Intestinal necrosis in a patient with rheumatoid arthritis receiving anti-TNF treatment.

Vasculitis leading to intestinal necrosis is a rare complication of rheumatoid arthritis. The introduction of anti-TNF treatment for methotrexate-resistant cases improved disease-control substantially in these often more aggresive forms of rheumatoid arthritis. As far as we know only two cases of severe vasculitis following anti-TNF treatment have been reported. We describe a 45-year old female patient with severe rheumatoid arthritis, who presented with an epileptic insult, renal failure and a quickly deteriorating general condition due to intestinal vasculitis, while she had been receiving anti-TNF treatment for 6 months.

Association of colonic atresia and Hirschsprung's disease in the newborn: report of a new case and review of the literature.

Colonic atresia (CA) is an infrequent cause of lower gastrointestinal obstruction in the neonate. Coexistence with aganglionosis of the colon (Hirschsprung's disease) has been reported but is generally not recognized in the neonatal period. We report another case and present a review of the literature. A boy with a lower gastrointestinal obstruction, caused by a CA type III, had creation of a proximal colostomy and a distal mucous fistula on the 1st day of life. In the preoperative work-up before restoring the continuity, rectal suction biopsies revealed the presence of Hirschsprung's disease. When the boy was 6 months old, a distal colectomy and reanastomosis were done. Creation of a colostomy and reanastomosis in a second procedure is recommended for treating a type III CA unless distal aganglionosis has been ruled out.

The evaluation of pyrosis and long-term satisfaction after gastric restrictive procedures: a retrospective study.

OBJECTIVE: To compare gastric banding (GB) and vertical banded gastroplasty (VBG) with respect to the evolution of pyrosis and patient satisfaction. SUMMARY BACKGROUND DATA: Although weight loss is the most immediate end-point in the evaluation of surgical treatment of obesity, the demonstration of changes in long-term patient satisfaction and in co-morbidity, like reflux, is an essential outcome measure. MATERIAL AND METHODS: Retrospective study of 243 morbidly obese patients. All patients received a questionnaire regarding the evolution of pyrosis and their satisfaction after surgery. The evolution of pyrosis was compared between 2 patient groups who had different oesophagitis stages. Group A had oesophagitis I, or no oesophagitis, and group B had oesophagitis II, III or IV. RESULTS: In group A of the GB group 57.8% had no complaints, 11.1% had improvement and 22.2% had aggravation of the pyrosis. In group B of the GB group 50.0% had improvement. In group A of the VBG group 51.4% had no complaints, 11.1% improvement and 23.6% aggravation of the pyrosis. In group B of the VBG group 16.7% had no complaints, 66.6% had improvement and 16.7% had aggravation of the pyrosis complaints. Statistically there is no significant difference between GB and VBG. The experience after GB is good with 67.9%, mediocre with 25.0% and bad with 7.1% of the patients ; 60.7% is pleased with the weight loss. The experience after VBG is good with 47.4%, mediocre with 29.5% and bad with 23.1% of the patients. 52.6% is satisfied with the weight loss. CONCLUSION: VBG and GB have a similar effect on pyrosis. From our point of view it has been evidenced that the presence or absence of pyrosis before the operation is a possible predictor of the evolution afterwards. Long-term patient satisfaction is the same after GB and VBG. Other factors influence the satisfaction.

What have we learnt after two years working with the da Vinci robot system in digestive surgery?

Robotic- assisted surgery has been introduced recently in order to overcome some of the difficulties surgeons encounter during advanced laparoscopic surgery. Due to the 3D vision equipment, higher number of degrees of freedom in manipulating instruments and better ergonomics it is hoped that by using robot techniques the indications of minimally invasive surgery in the field of digestive surgery can be broadened or that difficult procedures will be easier to perform. Since the introduction of the system in our hospital now almost two years ago 70 procedures have been performed with the aid of the da Vinci system covering the whole spectrum of GI surgery. Conversion took place in 2.5% and peroperative morbidity related to the use of robotic techniques was 10%. Although we had the subjective feeling that the procedures were indeed easier to perform and more relaxing for the surgeon, some major problems still exist as the complete lack of tactile feedback and the cost effectiveness of these procedures. Before robotics can be introduced in the every day clinical practice of the surgeon, its true benefit still needs to be established. This can only be done by well randomised prospective studies comparing one technique with the other.

A performance study comparing manual and robotically assisted laparoscopic surgery using the da Vinci system.

BACKGROUND: The objective of this study was to compare the efficacy of the da Vinci robotic system using both the three-dimensional view (3D) and two-dimensional (2D) view options with traditional manually assisted laparoscopic techniques in performing standardized exercises. METHODS: To evaluate surgical efficiency in the use of robotically assisted and manual laparoscopic surgery for standardized exercises six, last-year medical students without any surgical experience were selected. The exercises consisted of placing rings over receptacles, grasping a free hanging suture and cutting three pieces of it, running a suture, and performing a surgical knot. Each student performed the exercise twice. The median times needed for completion of the exercises and the median number of errors in performing the tasks were noted. RESULTS: The unexperienced students performed the standardized tasks significantly quicker and with fewer errors when assisted by the da Vinci robot in the 3D optical display mode, as compared with traditional manually assisted laparoscopic surgery. Even when the 2D mode was selected, a significant advantage favoring the da Vinci robotic system was seen both in time and efficacy for most exercises. When the 3D and 2D modes were compared, time differences in favor of the 3D mode remained, but a significant difference in efficacy favoring the 3D mode was seen only in one exercise (exercise 2: suture cutting). CONCLUSIONS: The da Vinci robotic system permits standardized minimal invasive surgical exercises to be performed quicker and more efficiently than traditional minimally invasive techniques. Therefore, with the aid of this robotic system, difficult laparoscopic interventions may become easier to perform, and indications for minimal invasive surgery may be expanded.