A Reproducible and Effective Technique for Coronary Sinus Injury Repair.

Objective: Coronary sinus injury related to the use of a retrograde cardioplegia catheter is a rare but potentially life-threatening complication with mortality reported as high as 20%. We present a series of iatrogenic coronary sinus injuries as well as an effective method of repair without any ensuing mortality. Methods: There were 3,004 cases that utilized retrograde cardioplegia at our institution from 2007 to 2018. Of these, 15 patients suffered a coronary sinus injury, an incidence of 0.49%. A pericardial roof repair was performed in 14 cases in which autologous pericardium was sutured circumferentially to normal epicardium around the injury with purified bovine serum albumin and glutaraldehyde injected into the newly created space as a sealant. Incidence of perioperative morbidity and mortality, operative time, and length of stay were collected. Results: In our series, there were no intraoperative or perioperative mortalities. Procedure types included coronary artery bypass grafting (CABG), valve replacement and repair, or combined CABG and valve procedures. Median (interquartile range) cross-clamp time was 100 (88 to 131) minutes, cardiopulmonary bypass duration was 133 (114 to 176) minutes, and length of stay was 6 (4 to 8) days. None of the patients returned to the operating room for hemorrhage, and there were no complications associated with the repair of a coronary sinus injury when using the pericardial roof technique. Conclusions: Coronary sinus injuries can result in difficult to manage perioperative bleeding and potentially lethal consequences from cardiac manipulation. Our series supports the pericardial roof technique as an effective solution to a challenging intraoperative complication.

Minimally Invasive Repair of Adult Slipped Rib Syndrome Without Costal Cartilage Excision.

BACKGROUND: Slipped rib syndrome (SRS) is a painful disorder caused when 1 or more of the 8th-10th false ribs become abnormally mobile. Established treatment modalities include analgesia, intercostal nerve injection, and costal cartilage excision. No definitive surgical correction of SRS without cartilage excision has been previously described. We aimed to determine whether a nonexcisional repair technique in affected adults could demonstrate significant relief from SRS using standardized outcome measures. METHODS: We performed a retrospective review of cases of SRS treated at our institution in 2019. We obtained data by survey before and after sutured 10th rib fixation, using a self-reported rating scale from 0-10 at defined intervals. Surveyed outcome measures were compared pre- and postoperatively using the Wilcoxon signed rank sum test. The use of neural modulating, narcotic, and nonsteroidal antiinflammatory drug medications was also compared pre- and postoperatively using McNemar's test where applicable. RESULTS: SRS was diagnosed using clinical examination alone in 42 adults and repaired in 29 patients. Median postoperative improvement in pain at 1 and 6 months was 75% (P < .001) and 80% (P < .001), respectively. Improvements in other outcome measures were similar. In patients who took pain medications preoperatively, narcotics were discontinued at 1 month by 100%, neural modulators by 86%, and nonsteroidal antiinflammatory drugs by 92% (all P values < .001). Pain medication use remained minimal at 6 months in 23 (79%) of patients completing follow-up. CONCLUSIONS: Minimally invasive slipped rib repair in adults provides significant relief of SRS, offering a useful alternative to costal cartilage excision. It is well tolerated and effective.

REBOA as a rescue strategy for catastrophic vascular injury during robotic surgery.

Catastrophic bleeding is a feared complication of robotic abdominal procedures that involve dissection in close proximity to major vessels. In the event of uncontrollable hemorrhage, standard practice involves emergency undocking with conversion to laparotomy. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a rapid and life-saving technique gaining acceptance in the trauma setting for the management of catastrophic hemorrhage. The purpose of this study was to evaluate feasibility of REBOA for emergency hemostasis during robotic surgery. The surgical robot was docked to a REBOA mannequin to simulate an upper abdominal surgery. A femoral arterial line was placed in the mannequin. Supplies needed for REBOA insertion were opened and arranged on the surgical back table. The surgeon was seated at the console with an assistant scrubbed. A catastrophic vascular injury was announced. The time it took the surgeon to achieve aortic occlusion by the REBOA was recorded. Four surgeons participated and performed three timed trials each. Each surgeon, irrespective of experience with REBOA or years in surgical practice, was able to obtain aortic occlusion in less than 2 min. The mean time to aortic occlusion for all surgeons was 111 s. No manipulation of the robotic arms was required to perform the procedure. Aortic occlusion was achieved rapidly with REBOA. Ability to achieve prompt aortic control was not associated with surgical experience or prior familiarity with the REBOA device. Prophylactic femoral access and preparation of supplies facilitates prompt placement of the occlusion balloon. REBOA should be considered as a viable alternative to open laparotomy for temporary hemorrhage control during robotic surgery.

Evaluation of a Novel Surgical Skills Training Course: Are Cadavers Still the Gold Standard for Surgical Skills Training?

BACKGROUND: An increasing body of literature describing use of high-fidelity surgical training models is challenging long-held dogma that cadavers provide the best medium for postgraduate surgical skills training. The purpose of this study was to describe a surgical skills course comprising entirely synthetic training models developed by resident and attending neurosurgeons and to evaluate their perceptions of the overall usefulness of this course and its usefulness compared with cadaveric courses. METHODS: Ten high-fidelity neurosurgical training models were developed. A neurosurgical skills course for residents was structured to include 7 spinal and 3 cranial learning stations, each with its own model and assigned attending expert. Resident and attending neurosurgeons were asked to complete surveys on their overall impressions of the course and models and on workload comparisons between models and real cases. Student t tests were used for statistical comparisons. RESULTS: Survey responses were collected from 9 of 16 participating residents (56.3%) and 3 of 10 attending neurosurgeons (30.0%). Both groups believed that the course was very helpful overall to resident education. Respondents furthermore believed that the course was more helpful overall than cadaveric courses. Task load index testing showed no significant workload difference between models and real cases (P ≥ 0.17), except in temporal demand (P < 0.001). CONCLUSIONS: Resident and attending neurosurgeons subjectively believe that high-fidelity synthetic models were superior to cadavers as a surgical skills teaching platform. This study raises the question of whether cadavers should remain the gold standard for surgical skills courses. Expanded use of these teaching models and further study are warranted.