Completely Thoracoscopic 3-Port Robotic First Rib Resection for Thoracic Outlet Syndrome.

BACKGROUND: In thoracic outlet syndrome, the constriction between bony and muscular structures leads to compression of the neurovascular bundle to the upper extremity. Traditional surgical techniques using supraclavicular, infraclavicular, or transaxillary approaches to remove the first rib do not usually allow good exposure of the entire rib and neurovascular bundle. We have therefore developed a robotic approach to overcome these limitations. METHODS: Between January 2015 and November 2020, 38 consecutive first rib resections for neurogenic, venous, or arterial thoracic outlet syndrome were performed in 34 patients at our institutions. For our completely portal approach, we used two 8-mm working ports and one 12-mm camera port. RESULTS: The surgery time was between 71 and 270 minutes (median ± SD: 133 ± 44.7 minutes) without any complications. Chest tube was removed on postoperative day 1 in all patients and the hospital stay after surgery ranged from 1-7 days (2 ± 2.1 days). No relevant intraoperative or postoperative complications were observed and complete or subtotal resolution of symptoms was seen in all patients. CONCLUSIONS: The robotic technique described here for first rib resection has proven to be a safe and effective approach. The unsurpassed exposure of the entire first rib and possibility for a robotic-assisted meticulous surgical dissection has prevented both intraoperative and postoperative complications. This makes this technique unique as the safest and most minimally invasive approach to date. It helps improve patient outcomes by reducing perioperative morbidity with an easily adoptable procedure.

Robotic-Assisted Thoracoscopic Resection of the First Rib for Vascular Thoracic Outlet Syndrome: The New Gold Standard of Treatment?

In thoracic outlet syndrome (TOS) the narrowing between bony and muscular structures in the region of the thoracic outlet/inlet results in compression of the neurovascular bundle to the upper extremity. Venous compression, resulting in TOS (vTOS) is much more common than a stenosis of the subclavian artery (aTOS) with or without an aneurysm. Traditional open surgical approaches to remove the first rib usually lack good exposure of the entire rib and the neurovascular bundle. Between January 2015 and July 2021, 24 consecutive first rib resections for venous or arterial TOS were performed in 23 patients at our institutions. For our completely portal approach we used two 8mm working ports and one 12/8 mm camera port. Preoperatively, pressurized catheter-based thrombolysis (AngioJet®) was successfully performed in 13 patients with vTOS. Operative time ranged from 71-270 min (median 128.5 min, SD +/- 43.2 min) with no related complications. The chest tube was removed on Day 1 in all patients and the hospital stay after surgery ranged from 1 to 7 days (median 2 days, SD +/- 2.1 days). Stent grafting was performed 5-35 days (mean 14.8 days, SD +/- 11.1) postoperatively in 6 patients. The robotic approach to first rib resection described here allows perfect exposure of the entire rib as well as the neurovascular bundle and is one of the least invasive surgical approaches to date. It helps improve patient outcomes by reducing perioperative morbidity and is a procedure that can be easily adopted by trained robotic thoracic surgeons. In particular, patients with a/vTOS may benefit from careful and meticulous preparation and removal of scar tissue around the vessels.

[Thoracic Outlet Syndrome: Rare, Often Missed or Over-Diagnosed?] / Das Thoracic-Outlet-Syndrom: selten, vielmals verpasst oder zu häufig diagnostiziert?

Thoracic Outlet Syndrome: Rare, Often Missed or Over-Diagnosed? Abstract. The thoracic outlet syndrome (TOS) presents with various symptoms caused by compression of the neurovascular bundle in the region of the upper thoracic aperture. Since the pathogenesis also determines the therapy of TOS, the classification according to the affected structure into neurogenic, venous and arterial TOS (nTOS, vTOS and aTOS) is useful. However, mixed forms are often to be assumed, which are then usually also classified under the term 'non-specific or disputed TOS' in the group of nTOS. In the absence of a gold standard diagnostic test, accurate history taking and clinical examination continue to be of great importance. Diagnostic experience and therapeutic advances have led to hopeful possibilities in the challenging management of this condition.

Robot-assisted versus laparoscopic single-incision cholecystectomy: results of a randomized controlled trial.

BACKGROUND: Although single-port laparoscopic cholecystectomy (SILC) is safe and effective, inherent surgeons' discomfort has prevented a large-scale adaptation of this technique. Recent advances in robotic technology suggest that da Vinci Single-Site™ cholecystectomy (dVSSC) may overcome this issue by reducing the stress load of the surgeon compared to SILC. However, evidence to objectively assess differences between the two approaches is lacking. METHODS: 60 patients [36 women, 24 men (mean age 52 years)] with benign gallbladder disease were randomly assigned to dVSSC (n = 30) or SILC (n = 30) in this single-centre, single-blinded controlled trial. The primary endpoint was surgeon's stress load. Secondary endpoints included operating time, conversion rates, additional trocar placement, blood loss, length of hospital stay, procedure costs, health-related quality of life, cosmesis and complications. Data were collected preoperatively, during the hospital stay, and at 1 and 12 months' follow-up. RESULTS: The dVSSC group showed a significant reduction of mental stress load of the surgeon compared to SILC [Subjective Mental Effort Questionnaire (SMEQ) score: median 25.0 (range 8-89) vs. 42.5 (range 13-110) points; p = 0.002] and a trend towards reduced physical stress load [Local Experienced Discomfort (LED) score: median 8 (range 2-27) vs. 12 (range 0-64) points; p = 0.088]. The length of hospital stay was longer in the SILC group [mean 3.06 (median 2; range 1-26) vs. 1.9 (median 2; range 1-4) days, p = 0.034] but overall hospital costs were higher for dVSSC [median 9734 (range 5775-16729) vs. 6900 (range 4156-99977) CHF; p = 0.001]. There were no differences in the rate of postoperative complications that required re-intervention (Dindo-Clavien grade ≥ IIIa; SILC n = 2 vs. dVSSC n = 0, p = 0.492) or other secondary endpoints. CONCLUSIONS: Da Vinci Single-Site™ cholecystectomy provides significant benefits over Single-Port Laparoscopic Cholecystectomy in terms of surgeon's stress load, matches the standards of the laparoscopic single-incision approach with regard to patients' outcomes but increases expenses. Clinicaltrials.gov registration-No.: NCT02485392.

First Rib Resection for Thoracic Outlet Syndrome: The Robotic Approach.

OBJECTIVE: First rib resection is a well-recognized treatment option for thoracic outlet syndrome (TOS). In case of a vascular insufficiency that can be provoked and/or progressive neurologic symptoms without response to conservative treatment, surgical decompression of the space between the clavicle and the first rib is indicated. The aim of this paper is to present our experience with a new minimally invasive robotic approach using the da Vinci Surgical System®. METHODS: Between January 2015 and October 2017, eight consecutive first rib resections in seven patients were performed at our institution. Four patients presented with neurologic (one bilateral), and three patients with vascular (venous) impairment. In all cases, a transthoracic robotic-assisted approach was used. The first rib was removed using a 3-port robotic approach with an additional 2-cm axillary incision in the first six patients. The latest resection was performed through only three thoracic ports. RESULTS: Median operative time was 108 min, and the median hospital stay was 2 days. Postoperative courses were uneventful in all patients. Clinical follow-up examinations showed relief of symptoms in all nonspecific TOS patients, and duplex ultrasonography confirmed complete vein patency in the remaining patients 3 months after surgery. CONCLUSIONS: While there are limitations in conventional transaxillary, subclavicular and supraclavicular approaches in the first rib resection, the robotic method is not only less invasive but also allows better exposure and visualization of the first rib. Furthermore, the technique takes advantage of the benefits of the da Vinci Surgical System® in terms of 3D visualization and improved instrument maneuverability. Our early experience clearly demonstrates these advantages, which are also supported by the very good outcomes.

[Colorectal metastases - Current treatment strategies]. / Kolorektale Metastasen ­ Aktuelle Behandlungskonzepte.

Colorectal metastases - Current treatment strategies Abstract. In the course of their disease, more than 50 % of patients with colorectal cancer develop metastases. They are most frequently localized in the liver, followed by the peritoneum and the lungs. The therapeutic options and prognosis of colorectal metastases have improved markedly in recent years. Modern treatment concepts are multimodal and are customized for the individual patient by interdisciplinary tumour boards that follow widely recognised guidelines and norms. The recommendation of an appropriate treatment option in metastasized patients by an interdisciplinary panel of experts is of paramount importance. Besides technical possibilities, factors such as comorbidities, medical outcomes, quality of processes as well as patient-related outcome are all crucial in the decision-making process. In most patients diagnosed with distant metastases, the prognosis is determined by the extent of the liver burden. Hereby, the resection of the liver metastases is of utmost importance to improve the prognosis of a patient, since only those individuals who have successfully undergone resection have a chance for long-term disease free-survival. Whether liver metastases are resectable depends on sufficient volume and function of the future liver remnant (FLR). Manipulation of the FLR as well as upfront oncological treatment of metastases improves the resectability rates in patients with an advanced tumor load in the liver. Laparoscopic liver resection improves patient outcomes by reducing pain and results in a shortened hospital stay. Lung resection for pulmonary metastases as well as cytoreductive surgery for peritoneal metastases are important mainstays of modern personalized treatment concepts. However, results of ongoing trials are eagerly awaited to help quantify the prognostic effects of those therapies and assess their true therapeutic value.

Thoracic surgery in patients with an implanted neurostimulator device.

Movement disorders such as Parkinson's disease are increasingly treated with deep brain stimulators. Being implanted in a subcutaneous pocket in the chest region, thoracic surgical procedures can interfere with such devices, as they are sensible to external electromagnetic forces. Monopolar electrocautery can lead to dysfunction of the device or damage of the brain tissue caused by heat. We report a series of 3 patients with deep brain stimulators who underwent thoracic surgery. By turning off the deep brain stimulators before surgery and avoiding the use of monopolar cautery, electromagnetic interactions were avoided in all patients.

IgG4-related disease of the lung: a rare differential diagnosis to lung cancer after positive positron emission tomography and biopsy.

Immunoglobulin G4-related disease is a rare immune-mediated condition that often causes serious diagnostic problems. Symptoms are unspecific, and several organs can be involved. To date, IgG4-related lung disease has seldom been reported in literature. Nevertheless, a variety of pulmonary involvement has been described, which can mimic malignancy. The gold standard for the diagnosis is the identification of typical histopathological features, even if diagnostic biomarker such as serum IgG4 concentration can be an indicator for a more aggressive course of the disease.

Robot-assisted single-site compared with laparoscopic single-incision cholecystectomy for benign gallbladder disease: protocol for a randomized controlled trial.

BACKGROUND: Recent advances in robotic technology suggest that the utilization of the da Vinci Single-Site™ platform for cholecystectomy is safe, feasible and results in a shorter learning curve compared to conventional single-incision laparoscopic cholecystectomy. Moreover, the robot-assisted technology has been shown to reduce the surgeon's stress load compared to standard single-incision laparoscopy in an experimental setup, suggesting an important advantage of the da Vinci platform. However, the above-mentioned observations are based solely on case series, case reports and experimental data, as high-quality clinical trials to demonstrate the benefits of the da Vinci Single-Site™ cholecystectomy have not been performed to date. METHODS: This study addresses the question whether robot-assisted Single-Site™ cholecystectomy provides significant benefits over single-incision laparoscopic cholecystectomy in terms of surgeon's stress load, while matching the standards of the conventional single-incision approach with regard to peri- and postoperative outcomes. It is designed as a single centre, single-blinded randomized controlled trial, which compares both surgical approaches with the primary endpoint surgeon's physical and mental stress load at the time of surgery. In addition, the study aims to assess secondary endpoints such as operating time, conversion rates, additional trocar placement, intra-operative blood loss, length of hospital stay, costs of procedure, health-related quality of life, cosmesis and complications. Patients as well as ward staff are blinded until the 1st postoperative year. Sample size calculation based on the results of a previously published experimental setup utilizing an estimated effect size of surgeon's comfort of 0.8 (power of 0.8, alpha-error level of 0.05, error margin of 10-15%) resulted in a number of 30 randomized patients per arm. DISCUSSION: The study is the first randomized controlled trial that compares the da Vinci Single Site™ platform to conventional laparoscopic approaches in cholecystectomy, one of the most frequently performed operations in general surgery. TRIAL REGISTRATION: This trial is registered at clinicaltrials.gov (trial number: NCT02485392 ). Registered February 19, 2015.

Completely Thoracoscopic Diaphragmatic Plication.

BACKGROUND: Thoracoscopic diaphragmatic plication for diaphragmatic paralysis with consecutive eventration and respiratory compromise is a desirable alternative to standard thoracotomy. Since minimally invasive techniques usually involve suturing of the diaphragm, most surgeons use a video-assisted approach with a minithoracotomy. Herein we describe our completely thoracoscopic technique for diaphragmatic plication including outcome. METHODS: We present our technique and experience for completely thoracoscopic diaphragmatic plication for the treatment of symptomatic diaphragmatic paralysis in six consecutive patients. The surgical technique basically consisted of stapling of the abundant diaphragm and reinforcement of the staple line using a self-locking thread. Primary outcome measure was the postoperative result (flattened diaphragm) and resolution of symptoms. Secondary outcome was improvement of lung function values 3 months after surgery. RESULTS: Between June 2015 and March 2016, six patients have been operated for symptomatic diaphragmatic paralysis, with one of them suffering from additional transdiaphragmatic hernia. Flattening of the diaphragm was achieved in all 6 patients with resolution of their pre-existing symptoms within days after surgery and without any surgical complications. Lung function volumes measured 3 months postoperative improved markedly with an increase in FEV1 as well as FVC of 540 ml (SD ± 193 ml) and 776 ml (SD ± 121 ml), respectively. CONCLUSIONS: In our experience, the presented technique is a safe and simple minimally invasive way to perform a completely thoracoscopic diaphragmatic plication with excellent results so far.

Cosmesis and Body Image in Patients Undergoing Single-port Versus Conventional Laparoscopic Cholecystectomy: A Multicenter Double-blinded Randomized Controlled Trial (SPOCC-trial).

OBJECTIVE: To evaluate cosmesis, body image, pain, and quality of life (QoL) after single-port laparoscopic cholecystectomy (SPLC) versus conventional 4-port laparoscopic cholecystectomy (4PLC). BACKGROUND: The impact of SPLC on improving cosmesis, body image, pain, and QoL has not been evaluated in double-blinded randomized controlled trials (RCT). This approach therefore remains controversial. METHODS: Between October 2011 and February 2014, 110 patients from 2 centers were randomly assigned to SPLC (n = 55) or 4PLC (n = 55). Primary endpoints were a validated cosmesis (3-24 points) and body image (5-20 points) score after 3 and 12 months. Secondary endpoints included operative duration, postoperative pain, complications, QoL, and length of hospital stay. Patients, physicians, and nurses were blinded until the seventh postoperative day. RESULTS: Demographics were equally distributed between both groups (mean age: 46 years, SD: 14, 62 females, 34 males). The SPLC-group showed superior mean cosmesis and body image compared with the 4PLC-group at 12-weeks (21 vs 16, P < 0.001 and 5 vs 6, P = 0.013, respectively) and at 1-year (24 vs 16, P < 0.001 and 5 vs 6, P < 0.017, respectively). Operation duration was longer in the SPLC-group (mean 101 vs 90 minutes, p = 0.031). Although postoperative pain was less in the SPLC-group (mean VAS 1 vs 2, p = 0.005), there were no differences in complications, and length of hospital-stay. CONCLUSIONS: This is the first multicenter double-blinded RCT reporting superior short- and long-term cosmetic and body image, postoperative pain, and QoL in SPLC compared with 4PLC. Although cost-effectiveness is still a subject of ongoing debate, SPLC should be offered to patients undergoing surgery for benign gallbladder disease.

Mucinous cystadenoma arising in a completely isolated infected ileal duplication cyst.

Gastrointestinal duplications are uncommon congenital lesions that can occur anywhere along the alimentary tract, and the symptoms of which generally develop during infancy or childhood. Completely isolated duplication cysts are an extremely rare variant of duplication, where no communication between the cyst and the adjacent bowel segment is present. We report the unique case of an adult who presented with right lower abdominal pain and systemic signs of inflammation caused by infection of a completely isolated ileal duplication cyst. Histological examination of the cyst additionally revealed a low-grade mucinous cystadenoma. We discuss the clinical presentations, diagnosis and treatment of this rare entity.

Cosmesis and body image after single-port laparoscopic or conventional laparoscopic cholecystectomy: a multicenter double blinded randomised controlled trial (SPOCC-trial).

BACKGROUND: Emerging attempts have been made to reduce operative trauma and improve cosmetic results of laparoscopic cholecystectomy. There is a trend towards minimizing the number of incisions such as natural transluminal endoscopic surgery (NOTES) and single-port laparoscopic cholecystectomy (SPLC). Many retrospective case series propose excellent cosmesis and reduced pain in SPLC. As the latter has been confirmed in a randomized controlled trial, patient's satisfaction on cosmesis is still controversially debated. METHODS/DESIGN: The SPOCC trial is a prospective, multi-center, double blinded, randomized controlled study comparing SPLC with 4-port conventional laparoscopic cholecystectomy (4PLC) in elective surgery. The hypothesis and primary objective is that patients undergoing SPLC will have a better outcome in cosmesis and body image 12 weeks after surgery. This primary endpoint is assessed using a validated 8-item multiple choice type questionnaire on cosmesis and body image. The secondary endpoint has three entities: the quality of life 12 weeks after surgery assessed by the validated Short-Form-36 Health Survey questionnaire, postoperative pain assessed by a visual analogue scale and the use of analgesics. Operative time, surgeon's experience with SPLC and 4PLC, use of additional ports, conversion to 4PLC or open cholecystectomy, length of stay, costs, time of work as well as intra- and postoperative complications are further aspects of the secondary endpoint. Patients are randomly assigned either to SPLC or to 4PLC. Patients as well as treating physicians, nurses and assessors are blinded until the 7th postoperative day. Sample size calculation performed by estimating a difference of cosmesis of 20% (alpha = 0.05 and beta = 0.90, drop out rate of 10%) resulted in a number of 55 randomized patients per arm. DISCUSSION: The SPOCC-trial is a prospective, multi-center, double-blind, randomized controlled study to assess cosmesis and body image after SPLC. TRIAL REGISTRATION: (clinicaltrial.gov): NCT 01278472.

Functional, electrophysiologic, and morphometric evaluation of nerve regeneration from coaptation on regenerated nerve fibers: experimental study in rabbits.

The importance of a sufficient number of nerve fibers at a proximal coaptation site is indisputable for the successful repair of nerves; however, the quality of nerve fibers required at this site has yet to be defined. The present study deals with the question of whether it is necessary to trim nerves back to unaffected neuronal tissue or whether the coaptation on recently regenerated nerve fibers, commonly believed to produce a poor quality of repair can, in fact, produce adequate nerve regeneration. Twenty New Zealand White rabbits received a standardized crush lesion on the peroneal nerves of both hind legs. Four weeks later, the nerves of the left hind legs (n = 20) were transected 10 mm distal to the previous crush lesion and coapted to the freshly regenerated nerve fibers. For comparison, on 10 right hind legs, the nerves were transected at the site of previous crushing (Group A, superimposition) or 10 mm proximal to the site of crushing on unscathed nerve fibers (Group B). Eleven weeks later, the quality of nerve regeneration was assessed by the toe-spreading reflex, electrophysiologic data, muscle weight, and histomorphologic evaluation. In the animals of Group A, the quality of nerve regeneration following coaptation on the regrown axons did not differ in any of the examined parameters from the quality of nerve fibers outgrown from the site of the superimposed lesion. Both lesions led to a completely functional reinnervation. Also in Group B, nerve action potential recording and histologic data on both sides did not reveal a significant difference between the number and maturation of nerve fibers equidistant from the suture site, shortly before muscle entrance. With this coaptation model, it could be demonstrated in the peroneal nerve of rabbits, that coaptation to recently regenerated nerve fibers leads to a significant functional regeneration.