The first robotic-assisted hysterectomy below the bikini line with the Dexter robotic system™.

Background: Robotic-assisted hysterectomy (RAH) is a widely accepted minimally invasive approach for uterus removal. However, as RAH is typically performed in the umbilical region, it usually results in scars in cosmetically suboptimal locations. This is the first case of RAH with cervicosacropexy performed below the bikini line, using the new Dexter robotic system™. Objectives: The aim of this article is to show the surgical steps of the first RAH with cervicosacropexy performed below the bikini line with the new Dexter robotic system™ (Distalmotion), and furthermore assess the feasibility of this approach using this robotic platform. Materials and Methods: A 43-year-old woman with uterine adenomyosis and recurrent uterine prolapse underwent a robotic-assisted subtotal hysterectomy with cervicosacropexy, performed below the bikini line, using the Dexter robotic system™, at the Clinic of Gynecology and Obstetrics at Universitätsklinikum Schleswig-Holstein (UKHS) in Kiel, Germany. Main outcome measures: Perioperative data, surgical approach specifics, objective, and subjective outcomes of this new approach. Results: The procedure was performed without intra-operative complications; estimated blood loss was 10 ml. Operative time was 150 minutes, console time 120 minutes, total docking time 6 minutes. Dexter performed as expected; no device-related issues or robotic arm collisions occurred. The patient did not require pain medication and was released on the second postoperative day. Conclusion: RAH performed below the bikini line using the Dexter robotic system™ is a feasible, safe, and adequate procedure. These initial results should be confirmed and further extensively refurbished with larger patient cohorts, and functional and psychological outcomes need further investigation.

Abdominal fascia dehiscence: is there a connection to a special microbial spectrum?

INTRODUCTION: Acute fascia dehiscence (FD) is a threatening complication occurring in 0.4-3.5% of cases after abdominal surgery. Prolonged hospital stay, increased mortality and increased rate of incisional hernias could be following consequences. Several risk factors are controversially discussed. Even though surgical infection is a known, indisputable risk factor, it is still not proven if a special spectrum of pathogens is responsible. In this study, we investigated if a specific spectrum of microbial pathogens is associated with FD. METHODS: We performed a retrospective matched pair analysis of 53 consecutive patients with an FD after abdominal surgery in 2010-2016. Matching criteria were gender, age, primary procedure and surgeon. The primary endpoint was the frequency of pathogens detected intraoperatively, the secondary endpoint was the occurrence of risk factors in patients with (FD) and without (nFD) FD. RESULTS: Intraabdominal pathogens were detected more often in the FD group (p = 0.039), with a higher number of Gram-positive pathogens. Enterococci were the most common pathogen (p = 0.002), not covered in 73% (FD group) compared to 22% (nFD group) by the given antibiotic therapy. Multivariable analysis showed detection of Gram-positive pathogens, detection of enterococci in primary laparotomy beside chronic lung disease, surgical site infections and continuous steroid therapy as independent risk factors. CONCLUSION: Risk factors are factors that reduce wound healing or increase intra-abdominal pressure. Furthermore detection of Gram-positive pathogens especially enterococci was detected as an independent risk factor and its empirical coverage could be advantageous for high-risk patients.

Serum C-reactive protein level after ventral hernia repair with mesh reinforcement can predict infectious complications: a retrospective cohort study.

PURPOSE: Infectious complications (ICs) after mesh-reinforced ventral hernioplasty often lead to prolonged and complicated hospitalizations. As early diagnosis and management can mitigate complications, early prediction is important. Our aim was to determine whether postoperative blood tests are valuable predictors of IC. METHODS: We retrospectively analyzed 373 patients who underwent conventional ventral hernioplasty with mesh augmentation between 2008 and 2011. The clinical outcome was correlated with postoperative serum C-reactive protein (CRP) and white blood cell counts (WBC) and assessed by area under the curve (AUC) analysis of the receiver operating characteristics curve. RESULTS: ICs occurred in 51 (13.7%) patients, who required further management. Among these, 48 patients developed a procedure-related complication, the most frequent being surgical site infection (n = 44). The infections appeared after a median postoperative delay of 12 days. Serum CRP was superior to WBC in the prediction of a complicated course. A maximum CRP < 105 mg/L on postoperative day (POD) 2 or 3 had the highest negative predictive value (NPV; 100%) in ruling out ICs [positive predictive value (PPV) 29%; sensitivity 100%; specificity 55%]. The PPV for occurrence of IC improved each day after surgery, reaching up to 46% on POD 5 or 6 for a CRP cut-off of 63.2 mg/L (NPV 93%; sensitivity 69%; specificity 83%). The AUC was 0.80 at both time points. CONCLUSIONS: Our results indicate that postoperative serum CRP allows for early prediction of the postoperative course. Low CRP during the initial PODs is associated with lower risk of ICs. Higher levels on POD 5 or 6 behoove close surveillance.

[Spectrum of pathogens in postoperative complications of visceral surgery : The problem of multidrug resistance]. / Erregerspektrum postoperativer Komplikationen in der Viszeralchirurgie : Das Problem der Multiresistenz.

In general surgery the etiology of surgical site infections has not significantly changed over the last 30 years. Gram-positive bacteria, e.g. coagulase negative staphylococci (CNS), Staphylococcus aureus and Enterococcus spp. as well as Gram-negative bacteria, e.g. Escherichia coli, Enterobacter spp., Klebsiella spp. and Pseudomonas aeruginosa, are the most common findings. Although in general surgery 10% of the S. aureus causing postoperative wound infections were methicillin resistant (MRSA), no cases of multidrug-resistant Gram-negative (MRGN) bacteria were reported. Yeasts (particularly Candida spp.) are rarely the pathogen causing surgical site infections (≤3%) and concomitant risk factors are typical (e.g. diabetes, chemotherapy, immunosuppression and malnutrition). Viruses are rarely the cause of surgical site infections. Transmission can occur by HBV, HCV or HIV positive surgical staff or in organ transplantations and postoperative reactivation of persistent infections is possible (especially for HBV, HCV, CMV, EBV and HIV). The principles for prevention of surgical site infections are dealt with as consequences of preoperative colonization by MRSA, methicillin-sensitive S. aureus (MSSA) and MRGN and reviewed with respect to screening, perioperative antibiotic prophylaxis and decolonization. In nosocomial peritonitis, the selection of antibiotics should consider previous antibiotic treatment. A single intra-abdominal detection of Candida spp. usually does not require antimycotic treatment in postoperatively stable and immunocompetent patients but is recommended in severe community-acquired or nosocomial peritonitis. Viral infections can be avoided by screening of organ donors and serological surveillance of surgery personnel.

[Enterococci and surgical site infections : Causal agent or harmless commensals?] / Enterokokken und postoperative Wundinfektionen : Verursacher oder harmloser Kommensale?

BACKGROUND: The role of enterococci in the context of peritonitis and surgical site infections (SSI) has not yet been definitively clarified but enterococci are being detected more frequently. Numerous resistances reduce the available antibiotic options. OBJECTIVE: This article gives an overview of the pathogenic importance of enterococci and of current recommendations for therapy and prophylaxis. On the basis of our own data we discuss the relevance of enterococci for SSI. MATERIAL AND METHODS: All colorectal resections carried out between January 2008 and September 2016 were retrospectively documented. Revision surgery, SSI and intra-abdominally or subcutaneously detected pathogens were recorded. RESULTS: A total of 2713 interventions were evaluated with 28.3% having primary peritonitis. In 587 patients (21.6%) SSI followed, and pathogen determination was possible in 431 cases (73.4%). Enterococci were frequently found in re-operations (58.4%) and SSI (46.1%), with E. faecalis and E. faecium in approximately equal proportions. If intra-abdominal enterococci were detectable in patients with primary peritonitis, it was more common to develop SSI and enterococci were more frequently detected subcutaneously. Enterococci in SSI were found to be significantly more frequent in left hemicolectomies as well as in pre-existing renal insufficiency. CONCLUSION: It can be inferred that enterococci are not adequately covered by commonly used perioperative antibiotic therapy or preoperative prophylaxis, which increases the risk for SSI by enterococci. This could be favored by selection of these pathogens due to the use of antibiotics without enterococcal efficacy (e. g. cephalosporins). The consideration in the choice of perioperative antibiotic prophylaxis by the additional administration of ampicillin or vancomycin could be advantageous.