[Robotic Colorectal Surgery: Analysis of the First Three Years of Activity in a Hospital of the Portuguese National Health Service]. / Cirurgia Robótica em Patologia Colorretal: Análise dos Primeiros Três Anos de Atividade num Hospital do Serviço Nacional de Saúde em Portugal.

INTRODUCTION: Minimally invasive surgery has been increasingly accepted and used in colorectal surgery. Several studies report that robotic surgery may provide advantages over 'conventional' laparoscopy, namely in rectal surgery. This paper provides an account of the first three years of experience with robotic surgery in the Unidade de Patologia Colorretal of the Unidade Local de Saúde S. José. METHODS: Variables were defined to develop a prospective database containing the data of consecutive patients operated by three internationally certified colorectal surgeons using the Da Vinci Xi® system between November 2019 and October 2022. The database was converted into an anonymized version that was used for this study. The analysis was performed on the data of all the patients operated during this period. RESULTS: Eighty patients were included, 47 male, median age 70 years, and median BMI 26 kg/m2 . ASA score was II in 53.7% and III in 41.3% of pa- tients. Of the total, 97.6% had malignant or potentially malignant disease. Operative procedures consisted of 34 colectomies proximal to the splenic flexure, 20 distal colectomies and 26 anterior resections. There were two synchronous resections of liver metastases. Early perioperative outcomes and histopathological results were analyzed: median operative time: 300 minutes; median estimated blood loss: 50 mL; conversion rate: 2.5%; median days until first bowel movement: three days; median length of hospital stay: six days; complication rate: 20%, of which 5% were Clavien III and 0% Clavien IV/V; anastomotic leak rate: 2.5%; 30-day readmission rate: 1.3%; median lymph nodes resected: 20; R0 resection rate: 100%; mesorectal integrity rate: 95,8% complete/near complete. CONCLUSION: Our results show that the adoption of robotic colorectal surgery in our center was safe and resulted in similar or improved short-term clinical outcomes and histopathological results when compared to those described in the literature.

Introdução: A utilização da cirurgia minimamente invasiva no tratamento da patologia colorretal é hoje cientificamente aceite e o seu uso na prática clí- nica diária tem vindo a aumentar de forma sustentada. Diversos estudos indicam que a abordagem robótica pode trazer vantagens sobre a laparoscopia 'convencional', especialmente na cirurgia do reto. Este trabalho descreve e analisa os resultados dos primeiros três anos de cirurgia robótica na Unidade de Patologia Colorretal da Unidade Local de Saúde S. José. Métodos: Foram definidas as variáveis a analisar e construída uma base de dados prospetiva com os dados referentes aos doentes operados conse- cutivamente por três cirurgiões colorretais, acreditados internacionalmente na utilização do sistema Da Vinci Xi®, entre novembro de 2019 e outubro de 2022. A base de dados foi convertida numa versão anonimizada e foi sobre essa mesma que se procedeu à análise de dados. Foram analisados os dados de todos doentes operados nesse período. Resultados: Foram incluídos 80 doentes, 47 homens, mediana de idade de 70 anos e de IMC de 26 kg/m2 . O score ASA era II em 53,7% e III em 41,3% dos doentes. Do total, 97,6% apresentavam doença maligna ou potencialmente maligna. Realizaram-se 34 colectomias proximais ao ângulo esplénico, 20 distais e 26 ressecções anteriores do reto. Houve ressecção síncrona de metástases hepáticas em dois casos. Foram analisados os resultados peri-operatórios a curto prazo e histopatológicos: duração (mediana): 300 minutos; perda hemática estimada (mediana): 50 mL; taxa de conversão: 2,5%; dias até retomar trânsito intestinal (mediana): três dias; dias de internamento (mediana): seis dias; taxa de complicações pós-operatórias: 20%, das quais 5% Clavien III e 0% Clavien IV/V; taxa de deiscência anastomótica: 2,5%; taxa de reintervenção: 2,5%; taxa de readmissão pós-alta: 1,3%; gânglios linfáticos ressecados (mediana): 20; taxa de ressecção R0: 100%; taxa de integridade mesorretal: 95,8% completo/quase completo. Conclusão: Os nossos resultados mostram que a introdução da cirurgia colorretal robótica no nosso centro foi segura e garantiu resultados clínicos a curto prazo e histopatológicos semelhantes ou favoráveis face aos descritos na literatura.

Cardiac arrest during deep brain stimulation: A case report.

We present the case of a 54-year-old male with severe Parkinson's disease and chronic, non-reversible pulmonary artery hypertension who had seizures and a cardiorespiratory arrest during surgery for deep brain stimulation, a minimally invasive procedure usually associated with a low risk of complications. This case illustrates how perioperative changes in antiparkinsonian therapy in patient with multiple comorbidities may significantly affect the risk profile.

An Unusual Complication of Intramedullary Pin Migration during Total Knee Arthroplasty - A Case Report.

Total knee arthroplasty (TKA) is one of the most effective operations to relieve pain and improve function in the end stage of osteoarthritis (when bone on bone contact occurs). The intraoperative complications of TKA include fracture, tendon or ligament injury, and nerve or vascular complications. We herein describe an unusual complication of intramedullary pin migration within the femoral canal during TKA. A 72-year-old male patient underwent TKA with a posterior stabilization system with sacrifice of the posterior cruciate ligament. The distal femur was sectioned and balance was checked in extension. Then to make anterior, posterior, chamfer and notch cuts, the five-in-one anteroposterior (AP) cutting block was placed on the distal femur and the cuts were initiated. As there was a medial overhang of the cutting block, it was shifted laterally. While doing so, the pins had to be shifted too, and one of them was inadvertently hammered into the previously-created medullary canal opening of the femur. As usual orthopedic instruments, like the long straight artery forceps and pituitary rongeurs, failed to remove the migrated pin, an extralong laparoscopic grasper was used under fluoroscopy control to locate, grasp, and remove the migrated pin.

Spray coagulation reduces the use of hemostatic forceps for intraoperative bleeding in gastric endoscopic submucosal dissection.

Aims: During intraoperative bleeding in endoscopic submucosal dissection (ESD), switching to spray coagulation may be beneficial compared with the continuous use of swift coagulation and can reduce the need for hemostatic forceps. We retrospectively assessed the effectiveness of spray modes on intraoperative bleeding during gastric ESD. Methods and Results: A total of 316 bleeding events (156 in the Swift group and 160 in the Spray group) were consecutively recorded. In the Swift group, hemostasis was performed using the swift mode with a retracted tip of the needle-type knife, followed by the hemostatic forceps. In the Spray group, bleeding was treated in a stepwise manner: the swift mode, the spray mode, and the hemostatic forceps. All bleeding events were assigned to one of two groups by an endoscopist who retrospectively reviewed the videos. We compared the use of hemostatic forceps, the total hemostatic time, and the cumulative hemostasis rate between the two groups.The use of hemostatic forceps was significantly lower in the Spray group than in the Swift group (32.7% vs. 13.8%, P < 0.001). There was no significant difference in the total hemostatic time (Swift group, 20 s.; Spray group, 16 s.; P = 0.42), whereas the cumulative hemostasis rate with the knife was significantly higher in the Spray group (P = 0.007). Conclusion: The results suggested that spray coagulation from the tip of the needle-type knife could reduce the use of hemostatic forceps. In gastric ESD, spray coagulation may facilitate the hemostasis of intraoperative bleeding.

Using Electronic Health Record Data to Determine the Safety of Aqueous Humor Liquid Biopsies for Molecular Analyses.

Purpose: Knowing the surgical safety of anterior chamber liquid biopsies will support the increased use of proteomics and other molecular analyses to better understand disease mechanisms and therapeutic responses in patients and clinical trials. Manual review of operative notes from different surgeons and procedures in electronic health records (EHRs) is cumbersome, but free-text software tools could facilitate efficient searches. Design: Retrospective case series. Participants: A total of 1418 aqueous humor liquid biopsies from patients undergoing intraocular surgery. Methods: Free-text EHR searches were performed using the Stanford Research Repository cohort discovery tool to identify complications associated with anterior chamber paracentesis and subsequent endophthalmitis. Complications of the surgery unrelated to the biopsy were not reviewed. Main Outcome Measures: Biopsy-associated intraoperative complications and endophthalmitis. Results: A total of 1418 aqueous humor liquid biopsies were performed by 17 experienced surgeons. EHR free-text searches were 100% error-free for surgical complications, >99% for endophthalmitis (<1% false positive), and >93.6% for anesthesia type, requiring manual review for only a limited number of cases. More than 85% of cases were performed under local anesthesia without ocular muscle akinesia. Although the most common indication was cataract (50.1%), other diagnoses included glaucoma, diabetic retinopathy, uveitis, age-related macular degeneration, endophthalmitis, retinitis pigmentosa, and uveal melanoma. A 50- to 100-µL sample was collected in all cases using either a 30-gauge needle or a blunt cannula via a paracentesis. The median follow-up was >7 months. There was only one minor complication (0.07%) identified: a case of a small tear in Descemet membrane without long-term sequelae. No other complications occurred, including other corneal injuries, lens or iris trauma, hyphema, or suprachoroidal hemorrhage. There was no case of postoperative endophthalmitis. Conclusions: Anterior chamber liquid biopsy during intraocular surgery is a safe procedure and may be considered for large-scale collection of aqueous humor samples for molecular analyses. Free-text EHR searches are an efficient approach to reviewing intraoperative procedures. Financial Disclosures: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

The Role of Extracorporeal Cardiopulmonary Resuscitation in Pediatric Intraoperative Cardiac Arrest.

Refractory pediatric intraoperative cardiac arrest is a rare but challenging situation for the anesthesiologist. This case describes an intraoperative extracorporeal cardiopulmonary resuscitation (ECPR) in a 16-year-old male who suffered a sudden cardiac arrest during elective thoracolumbar stabilization. The patient recovered to his pre-operative baseline without any neurological sequela secondary to cardiac arrest. Good quality of conventional resuscitation measures, prompt activation of the extracorporeal membrane oxygenation (ECMO) team, and a multidisciplinary coordinated approach were key factors in ECPR success. Despite the lack of robust evidence in pediatrics, case reports like ours outline the life-saving potential of intraoperative ECPR in refractory cardiac arrest scenarios.

Temporal Trends and Outcomes of Abdominal Aortic Aneurysm Care in the United States.

BACKGROUND: Endovascular aortic aneurysm repair (EVAR) has had a dynamic impact on abdominal aortic aneurysm (AAA) care, often supplanting open AAA repair (OAR). Accordingly, US AAA management is often highlighted by disparities in patient selection and guideline compliance. The purpose of this analysis was to define secular trends in AAA care. METHODS: The Society for Vascular Surgery Vascular Quality Initiative was queried for all EVARs and OARs (2011-2021). End points included procedure utilization, change in mortality, patient risk profile, Society for Vascular Surgery-endorsed diameter compliance, off-label EVAR use, cross-clamp location, blood loss, in-hospital complications, and post-EVAR surveillance missingness. Linear regression was used without risk adjustment for all end points except for mortality and complications, for which logistic regression with risk adjustment was used. RESULTS: In all, 66 609 EVARs (elective, 85% [n=55 805] and nonelective, 15% [n=9976]) and 13 818 OARs (elective, 70% [n=9706] and nonelective, 30% [n=4081]) were analyzed. Elective EVAR:OAR ratios were increased (0.2 per year [95% CI, 0.01-0.32]), while nonelective ratios were unchanged. Elective diameter threshold noncompliance decreased for OAR (24%→17%; P=0.01) but not EVAR (mean, 37%). Low-risk patients increasingly underwent elective repairs (EVAR, +0.4%per year [95% CI, 0.2-0.6]; OAR, +0.6 points per year [95% CI, 0.2-1.0]). Off-label EVAR frequency was unchanged (mean, 39%) but intraoperative complications decreased (0.5% per year [95% CI, 0.2-0.9]). OAR complexity increased reflecting greater suprarenal cross-clamp rates (0.4% per year [95% CI, 0.1-0.8]) and blood loss (33 mL/y [95% CI, 19-47]). In-hospital complications decreased for elective (0.7% per year [95% CI, 0.4-0.9]) and nonelective EVAR (1.7% per year [95% CI, 1.1-2.3]) but not OAR (mean, 42%). A 30-day mortality was unchanged for both elective OAR (mean, 4%) and EVAR (mean, 1%). Among nonelective OARs, an increase in both 30-day (0.8% per year [95% CI, 0.1-1.5]) and 1-year mortality (0.8% per year [95% CI, 0.3-1.6]) was observed. Postoperative EVAR surveillance acquisition decreased (67%→49%), while 1-year mortality among patients without imaging was 4-fold greater (9.2% versus imaging, 2.0%; odds ratio, 4.1 [95% CI, 3.8-4.3]; P<0.0001). CONCLUSIONS: There has been an increase in EVAR and a corresponding reduction in OAR across the United States, despite established concerns surrounding guideline adherence, reintervention, follow-up, and cost. Although EVAR morbidity has declined, OAR complication rates remain unchanged and unexpectedly high. Opportunities remain for improving AAA care delivery, patient and procedure selection, guideline compliance, and surveillance.

Safety of cholecystectomy performed by surgeons who prefer fundus first versus surgeons who prefer a standard laparoscopic approach.

Background: An alternative method to standard laparoscopic cholecystectomy (SLC) is the "fundus first" method (FFLC). Concerns have been raised that FFLC can lead to misinterpretation of important anatomical structures, thus causing complications of a more serious kind than SLC. Comparisons between the methods are complicated by the fact that FFLC is often used as a rescue procedure in complicated cases. To avoid confounding related to this we conducted a population-based study with comparisons on the surgeon level. Method: In GallRiks, the Swedish registry for Gallbladder surgery, we stratified all cholecystectomies performed 2006-2020 in three groups: surgeries carried out by surgeons that uses FFLC in <20 % of the cases (N = 150,119), in 20-79 % of the cases (N = 10,212) and in 80 % or more of the cases (N = 3176). We compared the groups with logistic regression, adjusting for sex, age, surgical experience, year of surgery and history of acute cholecystitis. All surgical complications (bleeding, gallbladder perforation, visceral perforation, infection, and bile duct injury) were included as outcome. A separate analysis was done with regards to operation time. Results: No difference in incidence of all surgical complications or bile duct injury were seen between groups. The rates of bleeding (OR 0.34 [0.14-0.86]) and gallbladder perforation (OR 0.61 [0.45-0.82]) were significantly lower in the "fundus first > 80% group" and the operative time was shorter (OR 0.76 [0.69-0.83]). Conclusion: In this study including >160,000 cholecystectomies, both methods was found to be equally safe. Key message: During laparoscopic cholecystectomy, the standard method of dissection and fundus first dissection are equally safe surgical techniques. Surgeons need to learn both methods to be able to use the one most appropriate for each individual case.

Feasibility and operative outcomes of surgery in the liver area in advanced ovarian cancer.

OBJECTIVE: The study aimed to characterize intra-and postoperative complications according to a standardized anatomo-surgical classification for ovarian cancer metastases in the liver area. METHODS: Data from all patients with advanced ovarian cancer undergoing primary or secondary surgery with perihepatic liver involvement (May-2016 to May-2022), were retrospectively retrieved and classified according to a standardized anatomo-surgical classification, and clustered into four Classes: Class I "Peritoneal", Class II "Hepatoceliac-lymph-nodes", Class III "Parenchymal" and Class IV Mixed (≥ 2 classes). RESULTS: Data from 615 patients were collected. Intraoperative complications were observed in 15%, and severe postoperative complications in 17.6% of cases. While surgical complexity scores were similar, Class IV had longer operative times, higher blood loss, and a 30.4% intraoperative transfusion rate. Class II showed a higher prevalence of vascular injuries (8%). Classes II and IV were significantly associated with severe postoperative complications. Specific complications varied among classes, such as perihepatic collection and intrahepatic hematoma/abscess in Class III (p = 0.003, p < 0.001, respectively), and pleuric effusion, sepsis, anemia, and "other complications" in Class IV (p = 0.002, p = 0.004, p = 0.03, p = 0.03, respectively). Multivariable analysis identified Class II and IV (Class II: OR 4.991, p = 0.045; Class IV: OR 5.331, p = 0.030), Surgical Complexity Score group 3 (OR:3.922, p = 0.003), and the presence of residual tumor (OR:1.748, p = 0.048) as independent risk factors for severe postoperative complications. CONCLUSIONS: Liver procedures during advanced ovarian cancer surgery are feasible with acceptable complication rates According to the anatomo-surgical classification, metastatic patterns are related to both different surgical outcomes and postoperative complication profiles.

Clinicians' perceptions of "enhanced recovery after surgery" (ERAS) protocols to improve patient safety in surgery: a national survey from Australia.

BACKGROUND: Surgical patients are at risk of postoperative complications, which may lead to increased morbidity, mortality, hospital length-of-stay and healthcare costs. Enhanced Recovery After Surgery (ERAS®) protocols are evidence-based and have demonstrated effectiveness in decreasing complications and associated consequences. However, their adoption in Australia has been limited and the reason for this is unclear. This study aimed to describe clinicians' perceptions of ERAS protocols in Australia. METHODS: A national online survey of anaesthetists, surgeons and nurses was undertaken. Invitations to participate were distributed via emails from professional colleges. The 30-item survey captured respondent characteristics, ERAS perceptions, beliefs, education and learning preferences and future planning considerations. The final question was open-ended for elaboration of perceptions of ERAS. Descriptive and inferential statistics were used to describe and compare group differences across disciplines relative to perceptions of ERAS. RESULTS: The sample included 178 responses (116 nurses, 65.2%; 36 surgeons, 20.2%; 26 anaesthetists, 14.6%) across six states and two territories. More than half (n = 104; 58.8%) had used ERAS protocols in patient care, and most perceived they were 'very knowledgeable' (n = 24; 13.6%) or 'knowledgeable' (n = 71; 40.3%) of ERAS. However, fewer nurses had cared for a patient using ERAS (p <.01) and nurses reported lower levels of knowledge (p <.001) than their medical counterparts. Most respondents agreed ERAS protocols improved patient care and financial efficiency and were a reasonable time investment (overall Md 3-5), but nurses generally recorded lower levels of agreement (p.013 to < 0.001). Lack of information was the greatest barrier to ERAS knowledge (n = 97; 62.6%), while seminars/lectures from international and national leaders were the preferred learning method (n = 59; 41.3%). Most supported broad implementation of ERAS (n = 130; 87.8%). CONCLUSION: There is a need to promote ERAS and provide education, which may be nuanced based on the results, to improve implementation in Australia. Nurses particularly need to be engaged in ERAS protocols given their significant presence throughout the surgical journey. There is also a need to co-design implementation strategies with stakeholders that target identified facilitators and barriers, including lack of support from senior administration, managers and clinicians and resource constraints.

Perioperative adverse cardiac events in maxillofacial surgery: A systematic review and meta-analysis.

Background and Aims: Maxillofacial surgeries, including procedures to the face, oral cavity, jaw, and head and neck, are common in adults. However, they impose a risk of adverse cardiac events (ACEs). While ACEs are well understood for other non-cardiac surgeries, there is a paucity of data about maxillofacial surgeries. This systematic review and meta-analysis report the incidence and presentation of perioperative ACEs during maxillofacial surgery. Methods: We included primary studies that reported on perioperative ACEs in adults. To standardise reporting, ACEs were categorised as 1. heart rate and rhythm disturbances, 2. blood pressure disturbances, 3. ischaemic heart disease and 4. heart failure and other complications. The primary outcome was ACE presentation and incidence during the perioperative period. Secondary outcomes included the surgical outcome according to the Clavien-Dindo classification and trigeminocardiac reflex involvement. STATA version 17.0 and MetaProp were used to delineate proportion as effect size with a 95% confidence interval (CI). Results: Twelve studies (34,227 patients) were included. The incidence of perioperative ACEs was 2.58% (95% CI 1.70, 3.45, I2 = 96.17%, P = 0.001). Heart rate and rhythm disturbances resulted in the greatest incidence at 3.84% among the four categories. Most commonly, these ACEs resulted in intensive care unit admission (i.e. Clavien-Dindo score of 4). Conclusion: Despite an incidence of 2.58%, ACEs can disproportionately impact surgical outcomes. Future research should include large-scale prospective studies that may provide a better understanding of the contributory factors and long-term effects of ACEs in patients during maxillofacial surgery.

Intraoperative adverse events among surgeons in Singapore: a multicentre cross-sectional study on impact and support.

BACKGROUND: It is known that many surgeons encounter intraoperative adverse events which can result in Second Victim Syndrome (SVS), with significant detriment to their emotional and physical health. There is, however, a paucity of Asian studies in this space. The present study thus aimed to explore the degree to which the experience of an adverse event is common among surgeons in Singapore, as well as its impact, and factors affecting their responses and perceived support systems. METHODS: A self-administered survey was sent to surgeons at four large tertiary hospitals. The 42-item questionnaire used a systematic closed and open approach, to assess: Personal experience with intraoperative adverse events, emotional, psychological and physical impact of these events and perceived support systems. RESULTS: The response rate was 57.5% (n = 196). Most respondents were male (54.8%), between 35 and 44 years old, and holding the senior consultant position. In the past 12 months alone, 68.9% recalled an adverse event. The emotional impact was significant, including sadness (63.1%), guilt (53.1%) and anxiety (45.4%). Speaking to colleagues was the most helpful support source (66.7%) and almost all surgeons did not receive counselling (93.3%), with the majority deeming it unnecessary (72.2%). Notably, 68.1% of the surgeons had positive takeaways, gaining new insight and improving vigilance towards errors. Both gender and surgeon experience did not affect the likelihood of errors and emotional impact, but more experienced surgeons were less likely to have positive takeaways (p = 0.035). Individuals may become advocates for patient safety, while simultaneously championing the cause of psychological support for others. CONCLUSIONS: Intraoperative adverse events are prevalent and its emotional impact is significant, regardless of the surgeon's experience or gender. While colleagues and peer discussions are a pillar of support, healthcare institutions should do more to address the impact and ensuing consequences.

Evaluating the optimal management strategy for intraoperative iatrogenic injury to the medial collateral ligament during primary total knee arthroplasty: A systematic review.

INTRODUCTION: Intraoperative iatrogenic MCL injuries during primary TKA are rare complications that lack a gold standard management protocol. This review aims to provide insight into various treatment modalities and evidence-based guidance for improved patient outcomes. METHODS: A comprehensive search across five databases identified relevant randomized control trials and retrospective cohort studies with reported outcomes. A total of 17 studies were included, and variables such as patient demographics, injury type, management, and Knee Society Scores (KSS) were assessed. The quality of included studies was evaluated using the Critical Appraisal Skills Programme tool. RESULTS: Mean age of included patients ranged from 60.0 to 71.4 years. The mean Body Mass Index ranged from 26.75 to 34.40 kg/m2. Among the included knees, 298 were categorized as MCL avulsion, and 167 as midsubstance/transection injuries. Primary repair with sutures or bone staples emerged as the most common management. Intraoperative MCL injury was correlated with reduced preoperative range of motion (ROM) and postoperative KSS clinical, functional, and pain scores compared to control groups. Postoperative ROM was comparable between MCL injury and control groups, ranging from 100.0° to 130.0° and 107.0° to 130.0°, respectively. CONCLUSION: Current evidence supports primary repair as the preferred management for this complication. Factors such as extent of the tear, type of injury, and the surgeon's experience also help to guide treatment. While treatment modalities like allograft or autograft reconstruction show promise, further research with larger sample sizes is needed to enhance future outcomes.

Effects of Indocyanine Green (ICG) Imaging-Assisted Cholecystectomy on Intraoperative and Postoperative Complications: A meta-Analysis.

BACKGROUND: Accurate recognition of Calot's triangle during cholecystectomy is important in preventing intraoperative and postoperative complications. The use of indocyanine green (ICG) fluorescence imaging has become increasingly prevalent in cholecystectomy procedures. Our study aimed to evaluate the specific effects of ICG-assisted imaging in reducing complications. MATERIALS AND METHODS: A comprehensive search of databases including PubMed, Web of Science, Europe PMC, and WANFANGH DATA was conducted to identify relevant articles up to July 5, 2023. Review Manager 5.3 software was applied to statistical analysis. RESULTS: Our meta-analysis of 14 studies involving 3576 patients compared the ICG group (1351 patients) to the control group (2225 patients). The ICG group had a lower incidence of postoperative complications (4.78% vs 7.25%; RR .71; 95%CI: .54-.95; P = .02). Bile leakage was significantly reduced in the ICG group (.43% vs 2.02%; RR = .27; 95%CI: .12-.62; I2 = 0; P = .002), and they also had a lower bile duct drainage rate (24.8% vs 31.8% RR = .64, 95% CI: .44-.91, P = .01). Intraoperative complexes showed no statistically significant difference between the 2 groups (1.16% vs 9.24%; RR .17; 95%CI .03-1.02), but the incidence of intraoperative bleeding is lower in the ICG group. CONCLUSION: ICG fluorescence imaging-assisted cholecystectomy was associated with a range of benefits, including a lower incidence of postoperative complications, decreased rates of bile leakage, reduced bile duct drainage, fewer intraoperative complications, and reduced intraoperative bleeding.

Iatrogenic Bladder Injury During Laparoscopic Hysterectomy: A Case Report and Discussion of Anatomic Variations.

Hysterectomy, one of the most common surgical procedures performed in women worldwide, assumes a very important role in the definitive management of diverse gynecologic conditions. This case report presents a compelling instance of an iatrogenic bladder perforation that occurred during laparoscopically assisted vaginal hysterectomy in a 47-year-old woman with a high body mass index, extensive surgical history, and postural orthostatic tachycardia syndrome. Despite considerable preoperative planning and the use of minimally invasive techniques, the occurrence of physician-induced bladder perforation highlights the significance of understanding anatomical relationships and variations. The patient's previous abdominal surgeries including two cesarean sections, appendectomy, and cholecystectomy likely contributed to scar formation and adhesions, making dissection challenging. The case report and following discussion delve into anatomical variations, as well as the diagnosis and management of iatrogenic bladder injuries. The presented case serves as a valuable addition to the literature, contributing insights into the challenges and considerations surrounding urinary tract injuries during hysterectomy. This paper aims to review current research and guide practicing obstetricians and gynecologists in the management of intraoperative bladder injuries.

Management of Iatrogenic Medial Collateral Ligament Injury in Primary Total Knee Arthroplasty: A Systematic Review.

Objectives: The medial collateral ligament (MCL) injury is one of the possible complications of primary total knee arthroplasty (TKA), which can lead to coronal-plane instability that requires surgical revision. Injured MCL can result in joint instability and polyethylene wear. Different strategies have been proposed for MCL reconstruction based on the location of the injury. However, there is a lack of clarity regarding the optimal method for handling an iatrogenic MCL injury throughout a TKA. Methods: A PRISMA flow diagram was used to guide the systematic literature review. An extensive search was conducted in PubMed, Embase, Scopus, Web of Science, and Google Scholar. Newcastle Ottawa scale checklist was used to assess the methodological quality of the articles. Results: A total of 19 qualitative studies, including non-cadaveric patients with MCL injury during TKA, were identified after analyzing the full text of the articles. All included studies were either retrospective, observational cohort or case series. A total of 486 patients were studied to gather information on the methods used to repair the MCL and their results. Most injuries arose in the tibial attachment, which surgeons mostly realized during the final stages of surgery. Used techniques can be categorized into three main groups: Primary repair, Repair with augmentation, and changing prosthesis characteristics. Conclusion: This systematic review demonstrated that the most popular management of iatrogenic MCL injury was using suture anchors, staples, screws and washers, and more constrained prostheses. The proper method should be decided considering the site of the MCL injury.

Surgical intervention for cerebral amyloid angiopathy-related lobar intracerebral hemorrhage: a systematic review.

OBJECTIVE: The risks and benefits of surgery for cerebral amyloid angiopathy (CAA)-related lobar intracerebral hemorrhage (ICH) are unclear. The aim of this study was to systematically review the literature on this topic. METHODS: The authors conducted a systematic review according to the 2020 PRISMA statement. PubMed, MEDLINE, Embase, Web of Science, Cochrane Library, Emcare, and Academic Search Premier were searched (on December 27, 2022) for relevant articles. Study inclusion criteria were: 1) randomized controlled trial (RCT), cohort study, cross-sectional design, or case series with more than 5 patients; 2) possible, probable, or definite CAA according to the Boston criteria (version 1.0 or 1.5) or autopsy; 3) surgical intervention for acute ICH; and 4) data on peri- and/or postoperative outcomes. Primary outcomes were the presence of intraoperative hemorrhage (IOH), postoperative hemorrhage (POH), and early ICH recurrence. Secondary outcomes were 3-month mortality, late ICH recurrence, functional outcome at discharge, and factors associated with poor outcome. Pooled estimates were calculated, and the Joanna Briggs Institute Critical Appraisal Tool was used to assess risk of bias. RESULTS: Four cohort studies and 15 case series (n = 738 patients, mean age 70 years, 56% women) were included. IOH occurred in 2 (0.6%) of 352 patients. Pooled estimates for POH were 13.0% (30/225) for less than 48 hours and 6.2% (3/437) for 48 hours to 14 days. Overall recurrent ICH (mean follow-up 19 months, n = 5 studies) occurred in 11% of patients. Outcome was predominantly poor with a pooled 3-month mortality rate of 19% and good outcome of 23%. Factors associated with poor outcome were advanced age, poor condition on admission, preexisting dementia, and concomitant intraventricular, subarachnoid, or subdural hemorrhage. All studies contained possible sources of bias and reporting was heterogeneous. CONCLUSIONS: Surgery in CAA-related ICH is safe with no substantial IOH, POH, and early recurrent hemorrhage risk. Outcome appears to be poor, however, especially in older patients, although good quality of evidence is lacking. Patients with CAA should not be excluded from ongoing surgery RCTs in ICH to enable future subgroup analysis of this specific patient population.

Diagnostic accuracy of intrathecal fluorescein versus other radiological modalities in evaluating non-congenital skull base defects: a systematic review and meta-analysis.

PURPOSE: The intraoperative detection of cerebrospinal fluid (CSF) leaks during endoscopic skull base surgery is critical to ensure watertight sealed defects. Intrathecal fluorescein (ITF) is a valuable adjunct to intraoperative investigation. Hence, our aim is to summarize the evidence of the efficacy of ITF as an accurate diagnostic modality and reconstruction guide for non-congenital skull base defects. METHODS: Using the Cochrane Central, MEDLINE, and Embase databases, we identified studies involving the use of ITF in non-congenital CSF leaks which were published until November 2023. The STATA 18 software was used for meta-analysis. RESULTS: Fourteen studies met the inclusion criteria, in which seven studies were included in the meta-analysis. ITF was used in 1898 (90.3%) of patients, with a detection rate of 88.1%. The overall detection rate of non-congenital CSF leaks among ITF concentrations of 5% and 10% had a statistically significant pooled effect size of 2.6 (95% CI = 2.25, 2.95), while when comparing the ITF to other alternative radiological tests, it was not statistically significant with a mean difference of 0.88 (95% CI = - 0.4, 2.16). Moreover, the pooled prevalence was statistically significant in regards of the complications associated with ITF with an effect size of 0.6 (95% CI = 0.39, 0.82), indicating that 60% of patients who underwent ITF would experience at least one of the measured complications. CONCLUSION: ITF is considered as an efficient tool in localizing skull base defects. However, there was no significant results when comparing the ITF to other alternative radiological tests. Accordingly, if the ITF intervention is indicated, patients should be carefully selected based on their clinical need.