Robotic 8-mm trocar fascial wounds: To close or not to close?

BACKGROUND: The aim of this study was to investigate 8-mm robotic trocar site hernia (TSH) rate over the short and long term, providing aids to manage the related fascial wounds. METHODS: A retrospective analysis of 320 patients undergoing robotic surgery was conducted. The primary outcome was 8-mm TSH rate with a minimum follow-up of 12 months. The secondary outcome was the rate of haematomas and infections related to 8-mm wounds and their association with patient comorbidities and trocar position. RESULTS: One case of TSH was observed (0.31%). There were 15 cases of wound infection (4.68%) and 22 cases of wound haematoma (6.87%). Trocar related complications were significantly associated with patient comorbidities, not with trocar position. CONCLUSIONS: Our results do not justify the 8-mm fascial wound closure. Data concerning the association between trocar-related complications and patient comorbidities strengthen the need to implement the control of metabolic state and correct administration of perioperative therapy in high-risk patients.

Advancements in Bariatric Surgery: A Comparative Review of Laparoscopic and Robotic Techniques.

This article examines the evolution of bariatric surgery, with a focus on emerging technologies such as robotics and laparoscopy. In the case of gastric bypass, no significant differences have emerged between the two techniques in terms of hospitalization duration, weight loss, weight regain, or 30-day mortality. Robotic surgery, while requiring more time in the operating room, has been associated with lower rates of bleeding, mortality, transfusions, and infections. In revisional bariatric surgery, the robotic approach has shown fewer complications, shorter hospital stays, and a reduced need for conversion to open surgery. In the case of sleeve gastrectomy, robotic procedures have required more time and longer postoperative stays but have recorded lower rates of transfusions and bleeding compared to laparoscopy. However, robotic surgeries have proven to be more costly and potentially more complex in terms of postoperative complications. The review has also addressed the topic of the single-anastomosis duodeno-ileal switch (SADIS), finding comparable results between robotic and laparoscopic techniques, although robotic procedures have required more time in the operating room. Robotic technology has proven to be safe and effective, albeit with slightly longer operative times in some cases.

Abdominal Wall Hernias-State of the Art of Laparoscopic versus Robotic Surgery.

Abdominal wall hernia repair, a common surgical procedure, includes various techniques to minimize postoperative complications and enhance outcomes. This review focuses on the comparison between laparoscopic and robotic approaches in treating inguinal and ventral hernias, presenting the ongoing situation of this topic. A systematic search identified relevant studies comparing laparoscopic and robotic approaches for inguinal and ventral hernias. Randomized control trials, retrospective, and prospective studies published after 1 January 2000, were included. Search terms such as hernia, inguinal, ventral, laparoscopy, robotic, and surgery were used. A total of 23 articles were included for analysis. Results indicated similar short-term outcomes for robotic and laparoscopic techniques in inguinal hernia repair, with robotic groups experiencing less postoperative pain. However, longer operative times and higher costs were associated with robotic repair. Robotic ventral hernia repair demonstrated potential benefits, including shorter hospital stay, lower recurrence and lower reoperation rates. While robotic surgery offers advantages such as shorter hospital stays, faster recovery, and less postoperative pain, challenges including costs and training requirements need consideration. The choice between laparoscopic and robotic approaches for abdominal wall hernias should be tailored based on individual surgeon expertise and resource availability, emphasizing a balanced evaluation of benefits and challenges.

Dual docking technique for robotic repair of simultaneous inguinal and umbilical hernia: A preliminary single center experience.

BACKGROUND: This study aimed to assess clinical results in terms of intraoperative outcomes, recovery and recurrence of our robotic technique for the treatment of patients affected by simultaneous inguinal and umbilical hernia, providing technical details to facilitate multiquadrant surgery in robotic hernia repair. METHODS: Data from patients affected by simultaneous primary inguinal and umbilical hernia who underwent robotic repair with our dual docking technique was retrospectively analysed. RESULTS: Fifteen patients were included. No intraoperative complications occurred. All patients achieved complete mobilisation within 7 h. The mean length of hospital stay was 21.6 h, with five patients discharged on the same day of surgery. There was no major complication and no recurrence within the median follow-up period of 673 days. CONCLUSIONS: This surgical technique shows optimal postoperative outcomes, such as early mobilisation and short length of stay. Our study provides an aid to surgeons performing multiquadrant robotic surgery for the treatment of abdominal hernias.

Cyanoacrylate in Colorectal Surgery: Is It Safe?

Anastomotic leakage (AL) of a gastrointestinal (GI) anastomosis continues to be an important complication in GI surgery. Since its introduction more than 60 years ago, Cyanoacrylate (CA) has gained popularity in colorectal surgery to provide "prophylaxis" against AL. However, although in surgical practice it is increasingly used, evidence on humans is still lacking. The aim of this study is to analyze in humans the safety of CA to seal colorectal anastomosis. All consecutive patients from Jannuary 2022 through December 2022 who underwent minimally invasive colorectal surgery were retrospectively analyzed from a prospectively maintained database. Inclusion criteria were a histological diagnosis of cancer, a totally minimally invasive procedure, and the absence of intraoperative complications. 103 patients were included in the study; N-butyl cyanoacrylate with metacryloxisulfolane (Glubran 2®) was used to seal colorectal anastomosis, no adverse reactions to CA or postoperative complications related to inflammation and adhesions occurred; and only one case of AL (0.9%) was recorded. We can consider this study an important proof of concept on the safety of CA to seal colorectal anastomosis. It opens the possibility of starting prospective and comparative studies in humans to evaluate the effectiveness of CA in preventing colorectal AL.

Robotic Surgery in Achalasia: State of the Art.

Introduction: Achalasia is a rare primary esophageal disorder characterized by impaired functioning of the lower esophageal sphincter. The goal of treatment is to reduce symptoms and improve the quality of life. The gold standard of surgical approach is Heller-Dor myotomy. The aim of this review is to describe the use of robotic surgery in patients with achalasia. Methods: The literature review was performed by searching on PubMed, Web of Science, Scopus and EMBASE for all studies on robotic surgery for achalasia, published from January 1, 2001, to December 31, 2022. We focused our attention on randomized controlled trials (RCTs), metaanalysis, systematic reviews, and observational studies on large cohorts of patients. Furthermore, we have identified relevant articles from the reference list. Conclusions: Taking into consideration our review and experience, RHM with partial fundoplication is safe, efficient, comfortable for the surgeon and characterized by a reduction of the intraoperative perforation rate of the esophageal mucosa. This approach may represent the future for the surgical treatment of achalasia especially with a reduction in costs.

Robotic Surgery and Functional Esophageal Disorders: A Systematic Review and Meta-Analysis.

The functional disease of the esophago-gastric junction (EGJ) is one of the most common health problems. It often happens that patients suffering from GERD need surgical management. The laparoscopic fundoplication has been considered the gold standard surgical treatment for functional diseases of the EGJ. The aim of our meta-analysis is to investigate functional outcomes after robotic fundoplication compared with conventional laparoscopic fundoplication. A prospective search of online databases was performed by two independent reviewers using the search string "robotic and laparoscopic fundoplication", including all the articles from 1996 to December 2021. The risk of bias within each study was assessed with the Cochrane ROBINS-I and RoB 2.0 tools. Statistical analysis was performed using Review Manager version 5.4. In addition, sixteen studies were included in the final analysis, involving only four RCTs. The primary endpoints were functional outcomes after laparoscopic (LF) and robotic fundoplication (RF). No significant differences between the two groups were found in 30-day readmission rates (p = 0.73), persistence of symptomatology at follow-up (p = 0.60), recurrence (p = 0.36), and reoperation (p = 0.81). The laparoscopic fundoplication represents the gold standard treatment for the functional disease of the EGJ. According to our results, the robotic approach seems to be safe and feasible as well. Further randomized controlled studies are required to better evaluate the advantages of robotic fundoplication.

Re-thoracoscopy for the management of gastric conduit dehiscence after minimally invasive McKeown esophagectomy.

INTRODUCTION AND IMPORTANCE: Gastric conduit dehiscence after esophagectomy represents a severe complication associated with high mortality. Surgical management is achieved through thoracotomy, but often ends up in conduit sacrifice and diversion. CASE PRESENTATION: A 59-years-old man underwent minimally invasive McKeown esophagectomy for esophageal adenocarcinoma. After a worsening of the postoperative course and evidence at the CT scan and endoscopy of highly suspect gastric conduit failure, the patient underwent an exploratory thoracoscopy, which revealed a partial dehiscence of the gastric conduit treated with resection of the dehiscent gastric wall by a linear stapler on the guide of a 36-french orogastric tube. Patient had a regular postoperative course without any complications and was discharged on the 6th postoperative day. CLINICAL DISCUSSION: The management of conduit necrosis is extremely challenging. There are several interventional options and it is difficult to decide the most appropriate treatment for each individual patient. In our case we decided to perform a reintervention with a thoracoscopic approach, resecting the dehiscent area of the gastric conduit. CONCLUSIONS: Minimally invasive surgery is a valid option for the management of post-operative complications, including those in emergency setting. Re-suturing a partial dehiscence of gastric conduit may be feasible if tissue conditions allow.

Endoscopic approach to complex or recurrent pilonidal sinus: A retrospective analysis.

Pilonidal Sinus is a benign, chronic disease that affects the hair follicles of the natal cleft of the sacrococcygeal area. Its ideal treatment is controversial, especially in complex or recurrent cases. The aim of this study is to evaluate the use of minimally invasive endoscopic approach in this setting. We enrolled patients affected by complex or recurrent sacrococcygeal pilonidal sinus from January 2015 through December 2020 who underwent Video-Assisted Ablation of Pilonidal Sinus. All patients enrolled were re-evaluated once a year with a standard physical examination. The patients included were 38. Recurrence rate at 1-, 3- and 5-years follow-ups were 28.9%, 22.2% and 38.1% respectively. Of interest, the mean (SD) distance from the most lateral orifice to the midline was higher in group of patients with recurrence and the multivariate analysis demonstrated that it was the limiting factor, which influences the recurrence rate. In complex or recurrent pilonidal sinus disease with pits off the midline the endoscopic approach should not be the first choice. This makes us think that these cases should have their own classification to be identified and guide surgeons in choosing the appropriate approach.

The Role of Indocyanine Near-Infrared Fluorescence in Colorectal Surgery.

Purposes: The aim of this study was to evaluate the importance of Indocyanine Green in control of anastomosis perfusion and on anastomotic leakage rates during laparoscopic and robotic colorectal procedures. Methods: A retrospective review of patients who underwent elective minimally invasive surgery for colorectal cancer from 1 January 2018 to 31 December 2020 was performed. All patients underwent Near-Infrared Fluorescence-Indocyanine Green system in two moments: before performing the anastomosis and after completing the anastomotic procedure. Primary outcomes were the rate of intraoperative change in the surgical resection due to an inadequate vascularization and the rate of postoperative anastomotic leakage. Secondary outcomes were the postoperative complications, both medical and surgical (intra-abdominal bleeding, anastomotic leakage). Results: Our analysis included 93 patients. Visible fluorescence was detected in 100% of the cases. In 7 patients (7.5%), the planned site of resection was changed due to inadequate perfusion. The mean extension of the surgical resection in these 7 patients was 2.2 ± 0.62. Anastomotic leakage occurred in 2 patients (2.1%). Other complications included 8 postoperative bleedings (8.6%) and 1 pulmonary thromboembolism. Conclusions: The intraoperative use of Near-Infrared Fluorescence-Indocyanine Green in colorectal surgery is safe, feasible, and associated with a substantial reduction in postoperative anastomotic leakage rate.

Histopathological Examination and Endoscopic Sinusectomy: Is It Possible?

Introduction: Although carcinomatous degeneration is a rare occurrence, some authors support the need for a histopathological examination after pilonidal cyst excision. Today, minimally invasive techniques are widely spread for the treatment of pilonidal sinus disease but opposed to standard procedures, these techniques could not allow to perform a histopathological examination because of the absence of a specimen. The aim of this two-institutions study is to evaluate whether histopathological examination of the pilonidal sinus excision material can be successfully performed after an endoscopic ablation of the cyst. Materials and Methods: We identified all consecutive patients from January 2021 to September 2021 with diagnosis of pilonidal sinus disease who underwent Video Assisted Ablation of Pilonidal Sinus (VAAPS) followed by histopathological examination. Results: A total of 45 patients were included in the study. All patients were Caucasians and aged below 50 years. Nine of them underwent surgery due to recurrence of PSD. No evidence of malignancy was detected in the histopathological examination of the pilonidal sinus sampling material. Discussion: We were able to send pilonidal sinus sampling material for a histopathological examination in all patients who underwent minimally invasive technique for the treatment of pilonidal sinus disease. No evidence of malignancy was found in any of the 45 samples. Our findings prove that minimally invasive ablation of pilonidal sinus does not preclude histopathological examination of the cysts.

The Role of Robotic Visceral Surgery in Patients with Adhesions: A Systematic Review and Meta-Analysis.

Abdominal adhesions are a risk factor for conversion to open surgery. An advantage of robotic surgery is the lower rate of unplanned conversions. A systematic review was conducted using the terms "laparoscopic" and "robotic". Inclusion criteria were: comparative studies evaluating patients undergoing laparoscopic and robotic surgery; reporting data on conversion to open surgery for each group due to adhesions and studies including at least five patients in each group. The main outcomes were the conversion rates due to adhesions and surgeons' expertise (novice vs. expert). The meta-analysis included 70 studies from different surgical specialities with 14,329 procedures (6472 robotic and 7857 laparoscopic). The robotic approach was associated with a reduced risk of conversion (OR 1.53, 95% CI 1.12-2.10, p = 0.007). The analysis of the procedures performed by "expert surgeons" showed a statistically significant difference in favour of robotic surgery (OR 1.48, 95% CI 1.03-2.12, p = 0.03). A reduced conversion rate due to adhesions with the robotic approach was observed in patients undergoing colorectal cancer surgery (OR 2.62, 95% CI 1.20-5.72, p = 0.02). The robotic approach could be a valid option in patients with abdominal adhesions, especially in the subgroup of those undergoing colorectal cancer resection performed by expert surgeons.

Barbed suture in gastro-intestinal surgery: A review with a meta-analysis.

BACKGROUND: The laparoscopic approach is a very popular technique for many gastrointestinal operations and barbed sutures may improve the difficulties of intracorporeal anastomosis by eliminating the need for knot tying. The aim of this systematic review with a meta-analysis is to explore literature to establish the security profile of barbed suture compared with conventional laparoscopic sutures. MATERIALS AND METHODS: A systematic search was performed in all electronic databases (PubMed, Web of Science, Scopus, EMBASE) and 12 studies were included in the analysis, involving 27,133 patients, whereof 3372 cases (patients undergone barbed suture usage) and 23,761 controls (patients undergone conventional suture usage). We found 3 studies discussing differences between barbed and conventional sutures in colorectal surgery and 8 studies presenting results in bariatric surgery, both in Roux-en-y gastric bypass and Mini Gastric/One Anastomosis Gastric Bypass. RESULTS: We found comparable rate of leaks, bleedings and stenosis. The meta-regression analysis demonstrated that, both in case of bariatric and colorectal surgery, the demographic characteristic of patients and the oncological features of neoplasms did not impact of these findings. As expected, operative time is significantly shorter when barbed suture is used. CONCLUSION: Our analysis on current literature define an acceptable security profile for barbed suture with effective results particularly in terms of shorter operative time.

Robotic versus laparoscopic colorectal surgery in elderly patients in terms of recovery time: a monocentric experience.

Colorectal cancer has a great socio-sanitary relevance. It represents the third cancer by incidence and mortality. Ageing plays a major role in the development of colorectal cancer and this tumour, in patients aged 65 and older, has gradually increased over the past decade. The robotic technique is considered the evolution of conventional laparoscopy. Few studies evaluate the effects of robotic surgery in elderly patient, and even fewer are those that compare it with laparoscopic surgery in this population. The aim of this study was to evaluate the perioperative outcomes of robotic colorectal surgery compared to laparoscopic colorectal surgery in patients older than 65 years. We conducted a retrospective study enrolling 83 elderly patients (age > 65) undergoing robotic and laparoscopic colectomy (32 and 51, respectively) between January 2019 and January 2021. For statistical analysis, p values were calculated using t test and chi-square test. p < 0.05 is the criterion for statistical significance. Statistical analyses were performed with the Number Cruncher Statistical System (NCSS) 2020 data analysis version 20.0.1 (Utah, USA). The operation time was higher in robotic left (p = 0.003, mean time 249.6 vs 211.7 min) and right (p = 0.004, mean time 238.5 vs 183.5 min) hemicolectomy and similar for procedures on rectosigmoid and rectum when compared to laparoscopic technique. In terms of length of hospital stay and recovery of bowel function, these values were significantly lower for robotic group in left hemicolectomy (p = 0.004), rectum (p = 0.003) and rectosigmoid (p = 0.003), while right hemicolectomy was similar in two groups (p = 0.26). There was no statistically significant difference between the groups regarding conversion rate, postoperative complications, length of specimen, number of lymph nodes encountered and oncological results. Colorectal robotic surgery in elderly patients appears as a feasible and safe surgical approach when compared to the laparoscopic one, showing a shorter recovery and a reduction of length of stay with similar oncological outcomes even if with an increase of operating times.

Robotic Colorectal Cancer Surgery. How to Reach Expertise? A Single Surgeon-Experience.

The complexity associated with laparoscopic colorectal surgery requires several skills to overcome the technical difficulties related to this procedure. To overcome the technical challenges of laparoscopic surgery, a robotic approach has been introduced. Our study reports the surgical outcomes obtained by the transition from laparoscopic to robotic approach in colorectal cancer surgery to establish in which type of approach the proficiency is easier to reach. Data about the first consecutive 15 laparoscopic and the first 15 consecutive robotic cases are extracted, adopting as a comparator of proficiency the last 15 laparoscopic colorectal resections for cancer. The variables studied are operative time, number of harvested nodes, conversion rate, postoperative complications, recovery outcomes. Our analysis includes 15 patients per group. Our results show that operative time is significantly longer in the first 15 laparoscopic cases (p = 0.001). A significantly lower number of harvested nodes was retrieved in the first 15 laparoscopic cases (p = 0.003). Clavien Dindo I complication rate was higher in the first laparoscopic group, but without a significant difference among the three groups (p = 0.09). Our results show that the surgeon needed no apparent learning curve to reach their laparoscopic standards. However, further multicentric prospective studies are needed to confirm this conclusion.

A giant inguinal hernia in a patient with Ehlers-Danlos syndrome.

BACKGROUND: Inguinal hernia formation is a common event in patients with Ehlers-Danlos syndrome. Minimally invasive surgical technique for inguinal hernia repair is the same used in patients without EDS but it is related to more intraoperative and postoperative complications. AIM: Inour study, we present a case of inguinal hernia in a EDS patient successfully treated with a robotic transabdominal preperitoneal procedure (TAPP procedure). MATERIAL AND METHODS: We decided to perform a robotic TAPP with the DaVinci Xi® platform (Intuitive Surgical, Sunnyvale, USA) under general anaesthesia. A robotic docking was performed and three arms were positioned in the abdomen. Total operative timing was 45 mins. RESULTS: During the robotic procedure no intraoperative complications were recorded and no drains were applied. The postoperative period was uneventful and the patient was discharged in the first postoperative day. DISCUSSION: Inguinal hernia occurs more frequently in patients with EDS, mainly men. Many surgeons believe that EDS may have a negative effect on the clinical outcome of hernioplasty because of postoperative complication and recurrence rates. Our strategy has been robotic technology to facilitate the surgical approach. CONCLUSION: Robotic technology is feasible and associated with a shorted recovery and better cosmetic results. The endowrist movement of the robotic arms allows wide instrument articulation in a confined space, bypassing the limitis of laparoscopic instruments. In this way, it is possible to realize an accurate dissection of important elements, to reduce operative timing and intraoperative and postoperative complications. KEY WORDS: Ehlers-Danlos syndrome, Inguinal hernia, TAPP.

Long-Term Functional Results of a Modified Caudal-to-Cranial Approach in Laparoscopic Segmental Left Colectomy for Diverticular Disease.

A modified caudal-to-cranial approach to perform laparoscopic left colectomy for benign diseases has been recently designed to facilitate the low-tie mesenteric dissection. A chart review has been performed including all consecutive patients with uncomplicated diverticulitis who have been treated by segmental left colectomy with a caudal-to-cranial approach. A total of 34 patients were included in the study. 21 patients were male, mean age was 54.1 ± 11.3, and mean BMI was 26 ± 5.5. Patients with ASA Score I were 7, with ASA II were 9, and with ASA Score III were 5. Incontinence Score (IS) resulted in an average of 5 ± 2, 2 grade of incontinence and the CS score showed an average of 10 ± 3, 2 grade of constipation. Health status, evaluated by Short Form-36 questionnaire, was demonstrated in these patients' great physical function, role, general health, and social function. The anorectal manometry performed 6 months after surgery showed a normal value in terms of the anal resting pressure (47 ± 13 mmHg) and an increased volume to stimulate desire to defecate (197 ± 25 ml). The length of the anal sphincter was normal compared to the reference value (37 ± 5.4 mm). Although further studies are required to obtain definitive conclusions, our results are encouraging to propose low-tie segmental colectomy as the standard procedure for the treatment of uncomplicated diverticulitis, and our modified surgical approach could be considered useful to facilitate the surgical approach.

Endoscopic Treatment of Pilonidal Sinus Disease: State of Art and Review of the Literature.

Background: Pilonidal sinus disease (PSD) is a chronic troublesome pathology of the natal cleft of the sacrococcygeal region, with an estimated incidence of 26 cases in every 100,000 inhabitants. The aim of this review is to give a snapshot of the current literature on the endoscopic approach to PSD. Methods: A search on endoscopic treatment of pilonidal disease was performed according to PRISMA guidelines, adopting the following search terms: (pilonidal OR sacrococcygeal) and (endoscopic OR VAAPS OR EPSiT OR minimally invasive OR video-assisted OR video assisted). Results: Thirty-four articles were included in the final analysis, among which 23 were on adults and 11 were on pediatric population. The endoscopic approach is associated with painless postoperative pain, good aesthetic results, short time off work, and high patient satisfaction. Despite these advantages in short-term outcomes, results on recurrence rate in a long-term follow up are needed to definitively confirm the importance of this technique. Conclusions: The endoscopic approach is associated with significant postoperative advantages over other standard surgical approaches, and it should be included in the surgical portfolio for the treatment of PSD. According to the Italian guidelines, this technique could be considered as the gold standard for limited PSD. However, the favorable short-term-outcomes and lack of reliable data on long-term follow-up must be a stimulus to perform further high-quality studies to give definitive conclusions on this technique.

Barbed Suture and Gastrointestinal Surgery. A Retrospective Analysis.

Although minimally invasive surgery is recognized as the gold standard of many surgical procedures, laparoscopic suturing is still considered as the most difficult skill in laparoscopic surgery. The introduction of barbed sutures facilitates laparoscopic suturing because it is not necessary to tie a knot. The efficacy of this method has been evaluated in different types of surgery; however, less is known about general surgery. We retrospectively analysed data from 378 patients who had undergone bariatric or surgical treatment for colic or gastric malignancy requiring a closure of gastroentero, entero-entero or enterocolotomy from January 2014 to January 2019, admitted to the General Surgery Unit and Operative Unit of Surgical Endoscopy of the University Federico II (Naples, Italy). We registered 12 anastomotic leaks (3.1%), 16 anastomotic intraluminal bleedings (4.2%) and 7 extraluminal bleedings. Other complications included 23 cases of postoperative nausea and vomit (6%), 14 cases of postoperative ileus (3.7%) and 3 cases of intra-abdominal abscess (0.8%). Overall complications rate was 19.8% (75/378). No postoperative death was registered. Thus, by pooling together 378 patients, we can assess that barbed suture could be considered safe and effective for closure of holes used for the introduction of a branch of mechanical stapler to perform intracorporeal anastomosis.

Minimally Invasive Pilonidal Sinus Treatment: A Narrative Review.

The management of chronic pilonidal disease remains controversial, but recently, new minimal invasive approaches have been proposed. Whereas in the conventional surgical treatment an elliptical wedge of skin and subcutaneous tissue is created to remove the sinus and its lateral tracks, the basis for our new treatment is to create a minimal elliptical wedge of the subcutaneous tissue, including all the inflamed tissue and debris while leaving the overlying skin intact. The mechanism of an endoscopic approach relies on use of the endoscope without cutaneous tissue damage. Advantages include shorter operative time and time to discharge, which impact resource management in both primary and secondary care: patients undergoing endoscopic technique have a high satisfaction rate, probably due to the low level of postoperative pain and early return to work and daily activities. However, it is mandatory that further studies would analyze surgical approaches to pilonidal sinus disease (PSD) with a consistent and adequate follow-up of at least 5 years. Both sinusectomy and endoscopic approach to PSD were found to be safe and effective compared with conventional techniques. Publishedresults of studies of newer approaches have demonstrated a low short-term complication rate, comparable to conventional surgery results.