Predicting ventricular arrhythmia inducibility in ajmaline-induced Brugada type I pattern: Validation of the dST-Tiso interval.

INTRODUCTION: The dST-Tiso is a newly proposed electrocardiographic (ECG) marker during Brugada (BrS) type I pattern, that predicts the likelihood of ventricular arrhythmia (VA) inducibility in patients with ajmaline-induced pattern. The objective of this study was to validate the effectiveness of this criterion using an independent data set. METHODS: Consecutive patients exhibiting a BrS type I ECG pattern following ajmaline administration underwent programmed ventricular stimulation (PVS). dST-Tiso interval was measured in all patients and tested as a predictor for positive VA inducibility. RESULTS: Among 128 patients (median age 43 years, 59% male) with drug-induced BrS type I ECG pattern who underwent PVS, 32 (25.0%) had VA inducibility that required defibrillation. Compared to noninducible subjects, those with positive PVS were more commonly male (81% vs. 51%, p = 0.003), had longer PQ (165 vs. 160 ms, p = 0.016) and dST-Tiso (310 vs. 230 ms, p < 0.001) intervals, and shorter QT interval (412 vs. 420 ms, p = 0.022). When treated as a continuous variable, dST-Tiso confirmed significant association with VA inducibility, with an adjusted odds ratio of 1.02 (95% confidence interval: 1.01-1.03, p < 0.001) for each 1 ms increase in duration. A dST-Tiso interval >300 ms yielded a sensitivity of 75%, a specificity of 86%, and positive and negative predictive values of 69% and 91%, respectively. CONCLUSION: The validation of the model based on the dST-Tiso interval >300 ms confirmed its high accuracy in predicting VA inducibility in drug-induced BrS type I pattern. This straightforward ECG marker might be linked to the extent of the electrical substrate of the disease.

Temperature and ST-segment morphology remote monitoring: new perspectives for implantable cardiac monitors in Brugada syndrome.

INTRODUCTION: Patients with Brugada syndrome (BrS) face an increased risk of ventricular arrhythmias and sudden cardiac death. Implantable cardiac monitors (ICMs) have emerged as effective tools for detecting arrhythmias in BrS. Technological advancements, including temperature sensors and improved subcutaneous electrocardiogram (subECG) signal quality, hold promise for further enhancing their utility in this population. METHODS AND RESULTS: We present a case of a 40-year-old man exhibiting a BrS type 2 pattern on 12-lead ECG, who underwent ICM insertion (BIOMONITOR IIIm, BIOTRONIK) due to drug-induced BrS type 1 pattern and a history of syncope, with a negative response to programmed ventricular stimulation. The device contains an integrated temperature sensor and can transmit daily vital data, such as mean heart rate and physical activity. Several months later, remote alerts indicated a temperature increase, along with transmitted subECGs suggesting a fever-induced BrS type 1 pattern. The patient was promptly advised to commence antipyretic therapy. Over the following days, remotely monitored parameters showed decreases in mean temperature, physical activity, and mean heart rate, without further recurrence of abnormal subECGs. CONCLUSION: ICMs offer valuable insights beyond arrhythmia detection in BrS. Early detection of fever using embedded temperature sensors may improve patient management, while continuous subECG morphological analysis has the potential to enhance risk stratification in BrS patients.

Investigating Deep Sedation With Intravenous Ketamine in Spontaneous Respiration During Pulsed-Field Ablation.

OBJECTIVES: The authors report their experience of a protocol for deep sedation with ketamine in spontaneous respiration during the pulsed-field ablation (PFA) of atrial fibrillation (AF). DESIGN: Observational, prospective, nonrandomized fashion. SETTING: Single-center hospitalized patients. PARTICIPANTS: All consecutive patients undergoing PFA of AF. INTERVENTIONS: Patients undergoing deep sedation with intravenous ketamine. MEASUREMENTS AND MAIN RESULTS: The authors' sedation protocol involves the intravenous administration of fentanyl (1.5 µg/kg) and midazolam (2 mg) at low doses before local anesthesia with lidocaine. A ketamine adjunct (1 mg/kg) in 5-minute boluses was injected about 5 minutes before the first PFA delivery. The authors enrolled 117 patients (age = 59 ± 10 y, 74.4% males, body mass index = 27.6 ± 5 kg/m2, fluoroscopy time = 24 ± 14 minutes, skin-to-skin time = 80 ± 40 minutes and PFA LA dwell time = 24 ± 7 minutes). By the end of the procedure, pulmonary vein isolation had been achieved in all patients using PFA alone. The mean time under sedation was 54.9 ± 6 minutes, with 92 patients (79%) being sedated for <1 hour. A satisfactory Ramsay Sedation Scale level before ketamine administration was achieved in all patients, except one (80.3% of the patients with rank 3; 18.4% with rank 2). In all procedures, the satisfaction level was found acceptable by both the patient and the primary operator (satisfactory in 98.2% of cases). All patients achieved a Numeric Rating Scale for Pain ≤3 (none or mild). No major procedure or anesthesia-related complications were reported. CONCLUSION: The authors' standardized sedation protocol with the administration of drugs with rapid onset and pharmacologic offset at low doses was safe and effective, with an optimal degree of patient and operator satisfaction.

Non-invasive cardiac activation mapping and identification of severity of epicardial substrate in Brugada Syndrome: a case report.

Introduction: It has recently been shown that electrocardiographic imaging (ECGi) can be employed in individuals undergoing an ajmaline test who have Brugada Syndrome (BrS), to evaluate the extent of substrate-involved arrhythmia in the right ventricular overflow tract (RVOT). For the first time, we stratify the risk of sudden cardiac death (SCD) in BrS during ajmaline testing using the dST-Tiso interval (a robust predictor of the inducibility of ventricular arrhythmias (VAs) in the presence of drug-induced BrS type-1 pattern) in combination with ECGi technology. Case presentation: We studied a 48-year-old man with BrS ECG type-2 pattern and presence of J-wave without a family history of SCD but with a previous syncope. Transthoracic echocardiography and cardiac magnetic resonance imaging were performed, showing normal results. The ECG was performed to assess the novel ECG marker "dST-Tiso interval." The 3D epicardial mapping of the RVOT surface was performed with the support of a non-contact cardiac mapping system in sinus rhythm during ajmaline infusion. The examination of the propagation map unveiled the presence of multiple conduction blocks in this pathologic epicardial region, and the conduction blocks were identified within the central part and/or near the boundary separating the normal and slow conduction areas. Conclusion: The dST-Tiso interval, which lies between the onset and termination of the coved ST-segment elevation and serves as a robust predictor of VA inducibility in cases of drug-induced BrS type-1 pattern, was utilized in conjunction with ECGi technology (employed for the non-invasive confirmation and identification of the pathological substrate area). This combined approach was applied to stratify the risk of SCD in BrS during ajmaline testing, alongside clinical scores.

Lesion effects in terms of local impedance variations after pulsed-field ablation during pulmonary vein isolation: a case report.

Background: To date, no information is available on highly localized impedance (LI) measurements during the ablation of pulmonary veins (PVs) via a new form of energy such as electroporation by means of pulsed-field ablation (PFA). Case summary: A 55-year-old man with a history of paroxysmal atrial fibrillation was admitted to our hospital for PV isolation (PVI). The procedure was performed with the new multi-electrode PFA catheter (FARAWAVE™). Before energy delivery, a high-density map of the left atrium was constructed with the Rhythmia™ system, while the IntellaNAV Mifi™ OI catheter was used to assess the baseline LI values of the four PVs. A manual tag was used to record the exact position where the IntellaNAV™ catheter measured the LI values for each segment of the vein before and after PVI. The LI values displayed a significant variation after PFA delivery (124.3 ± 5â€…Ω for baseline LI vs. 96.8 ± 6â€…Ω after PFA, P < 0.0001) with a mean absolute LI variation of 27.5 ± 7Ω and a mean percentage LI variation of 25.8 ± 8%. The differences between the average LI values pre- and post-PFA were 28.0 ± 5, 26.5 ± 9, 26.8 ± 3, and 28.8 ± 10â€…Ω for the superior, anterior, posterior, and inferior portions of the PV. Discussion: This is the first instance of the acute characterization, in terms of LI drop, of antral lesions created by a new PFA system. Local impedance variations at ablation sites seem to be larger than those recorded at successful ablation spots obtained by means of thermal energy sources.

[Laparoscopic appendectomy. Our experience]. / Appendicectomia laparoscopica. Esperienza personale.

The advantages and applications of the videolaparoscopic technique (VL) versus open surgery in the treatment of acute and complicated appendicitis are not well defined. Our study examined 150 patients, 67 males and 83 females. They underwent surgery for acute appendicitis in emergency. The choice between open or laparoscopic tecnique was due to patient's clinical conditions and surgeon's experience. Two of these patients had no infiammatory process. Eleven patients were affected by gynaecological diseases. The last 137 patients underwent surgery for acute appendicitis and the diagnosis was confirmed. Among them, 35 (25%) were affected by a complicated appendicitis with diffuse or clearly defined peritonitis. In 134 patients the surgery was completed laparoscopically. The conversion rate was 2%. Morbility rate was 3%, due to intra abdominal abscesses secondary to acute complicated appendicitis. The mean operative time was 76 min and the mean hospital stay was 4.8 days. The death rate was 0%. In our experience, laparoscopic appendectomy has significant advantages over traditional open surgery in both acute and complicated appendicitis, especially in young women. In this way, we can diagnose pelvic disease that could be characterized by the same symptoms of acute appendicitis, then we suggest laparoscopic appendectomy even just to complete the diagnostic iter. Laparoscopy is useful in terms of convalescence, postoperative pain, hospital stay, aesthetic outcome and an easier exploration of the peritoneal cavity.

dST-Tiso Interval, a Novel Electrocardiographic Marker of Ventricular Arrhythmia Inducibility in Individuals With Ajmaline-Induced Brugada Type I Pattern.

The aim of this study was to investigate the reliability of a novel electrocardiographic (ECG) marker in predicting ventricular arrhythmia (VA) inducibility in individuals with drug-induced Brugada syndrome (BrS) type I pattern. Consecutive patients with drug-induced type I BrS pattern underwent programmed ventricular stimulation (PVS) and, according to their response, were divided into 2 groups. Clinical characteristics and 12-lead ECG intervals before and after ajmaline infusion were compared between the 2 groups. A novel ECG marker named dST-Tiso interval consisting in the interval between the onset of the coved ST-segment elevation and its termination at the isoelectric line was also evaluated. Our cohort included 76 individuals (median age 44 years, 75% male). Twenty-five (32.9%) had VA inducibility requiring defibrillation. As compared with not inducible subjects, those with VA inducibility were more frequently male (92% vs 65%, p = 0.013), had longer PQ interval (basal: 172 vs 152 ms, p = 0.033; after ajmaline: 216 vs 200 ms, p = 0.040), higher J peak (0.6 vs 0.5 mV, p = 0.006) and longer dST-Tiso (360 vs 240 ms, p < 0.001). The dST-Tiso showed a C-statistics of 0.90 (95% confidence interval: 0.82 to 0.99) and an adjusted odds ratio for VA of 1.03 (1.01 to 1.04, p < 0.001). A dST-Tiso interval >300 ms yielded a sensitivity of 92.0%, a specificity of 90.2%, positive and negative predictive values of 82.1% and 95.8%. In conclusion, the dST-Tiso interval is a powerful predictor of VA inducibility in drug-induced BrS type I pattern. External validation is needed, but this marker might be useful in the clinical counseling process of these individuals before invasive PVS.

Remote monitoring of cardiac implantable devices during COVID-19 outbreak: "keep people safe" and "focus only on health care needs".

BACKGROUND: The COVID-19 pandemic has challenged the ability of health care organisations to provide adequate care. We report the experience of a national tertiary electrophysiology centre in the management of patients with cardiac implantable electronic devices (CIEDs) through the use of a fully remote follow-up model. METHODS: We daily and prospectively collected remote monitoring (RM) relevant findings and following clinical actions performed from March 10th to April 3rd 2020, a period of suspension of routine ambulatory activity due to the national lockdown. RESULTS: During the study period (25 days), we received 2,215 transmissions from 2,955 devices. Among them, 129 patients reported potential clinically actionable RM observations (event rate: 12.0/1000 patient-week). In 77 patients (60%), RM events triggered a clinical action, but only 5 patients needed an urgent in-hospital access (4 urgent procedures and 1 device reprogramming). CONCLUSIONS: In the unprecedented COVID-19 pandemic, RM became an essential tool in healthcare delivery for CIED patients. We observed that RM was effective in "keep people safe" and "focus only on individuals with health care needs".

[Incidental carcinoma in thyroid pathology: our experience and review of the literature]. / Il carcinoma incidentale nella patologia tiroidea. La nostra esperienza e revisione della letteratura.

The diagnosis of incidental thyroid carcinoma in patients submitted to thyroidectomy for a benign disease is quite frequent. A retrospective analysis was performed on 240 patients submitted to surgical intervention in order to establish the incidence of the carcinoma. One hundred sixty five patients (68.75%) were affected by benign disease (132 multinodular goiter, 30 uninodular goiter, 2 Plummer and 1 Basedow) and 75 (31.25%) by carcinoma. In 30 of 165 patients (18.2 %), affected by benign disease, occurred a histological diagnosis of thyroid carcinoma, (18 papillary carcinoma, 6 follicular carcinoma, 5 papillary carcinoma follicular variant and 1 oncocytic carcinoma). In this study it's considered incidental thyroid carcinoma the one occurred in patients who never underwent FNA and there were no suspicious features in all exams that may suggest the presence of carcinoma. Fifteen of the 30 incidental carcinoma (50%) were microcarcinomas; in the other 13, dimensions were more than 1 cm, but less than 2 cm in 9 cases. Two patients had a synchronous carcinoma. Actually these patients are still in a follow up program and no recurrency of disease is occasionally observed. This study shows that the only way to put doubts on the real benignity of the disease is the fine needle aspiration; there are no other instruments that could let think about the occurrence of the carcinoma. Moreover in the majority of cases the incidental carcinoma is a microcarcinoma, it doesn't reach significant volume, may be not centered by a FNAB, but in must cases it's not really biologically aggressive.

Intestinal endometriosis: role of laparoscopy in diagnosis and treatment.

Endometriosis is a disease in women in which endometrial tissue is found in abnormal sites, frequently in the peritoneum and pelvic viscera. Endometriosis may therefore affect the genital organs, particularly the left ovary, or it may occur elsewhere in the abdomen, principally the digestive tract in the sigmoid-rectum. The difficulty of prompt diagnosis of nongenital endometriotic lesions, whose symptoms are usually nonspecific, and the inadequacy of traditional diagnostic approaches mean the disease has time to progress. A case report is used here to show the use of laparoscopy with immediate histologic examination for the prompt diagnosis and intraoperative treatment of intestinal endometriosis. For patients with extragenital endometriosis, laparoscopic resection offers immediate postoperative advantages but also gives gradual relief of symptoms and in some cases improves reproductive capacity; there is also less formation of adhesions in this disease, which by definition tends to cause them, often making a second look indispensable.

[Role of laparoscopy in acute obstruction of the small bowel: personal experience and analysis of the literature]. / Ruolo della laparoscopia nelle occlusioni acute del tenue: esperienza personale e analisi della letteratura.

Small bowel obstruction is caused by postoperative adhesions in most patients. The traditional surgical treatment has been laparotomy with adhesiolysis and possible resection of the ischaemic intestine. The laparoscopic approach has proved feasible but not without risks. We analysed our experience in the management of acute small bowel obstruction and then reviewed the literature in an attempt to identify the real role of laparoscopy. From January 2003 to June 2008, 19 patients operated on for small bowel obstruction were identified. We evaluated our performance in terms of the aetiology of the obstruction, operative time, length of postoperative hospital stay, conversion rate, and major morbidity and mortality. Postoperative adhesions were responsible for the occlusion in 13 cases; a single band was identified in 47% of patients (9 cases). Neoplastic disease (3 cases), a gallstone ileus, Crohn's disease and an internal hernia were the remaining cases. Laparoscopic treatment was only possible in 7 patients with single adhesions (77%), and a conversion was carried out in the remaining 12 cases (63%), including "laparoscopy-assisted" cases (6 cases). The duration of the intervention (89 +/- 21 min vs 135 +/- 27.5 min) and postoperative hospitalisation (3.6 +/- 1 days vs 6.25 +/- 1.6 days) were in favour of the completely laparoscopic group as compared to the laparoscopy-assisted group. A case of postoperative peritonitis due to bowel perforation required a second intervention. With an appropriate selection of patients, confirming the high incidence of the single adhesions responsible for the occlusion and the resulting high success rate of laparoscopy, we believe that only an initial laparoscopic approach can help identify such favourable situations.

[The conservative treatment in the splenic trauma]. / Il trattamento conservativo nel trauma splenico.

The Authors mention the historical evolution that led to consider the splenectomy as the ideal operation in patients with post-traumatic lesions of the spleen. They linger then on the actual knowledges about the pathophysiology of this organ that determined a substantial change of mind toward a conservative treatment, when possible, reporting data from the literature. In haemodynamically stable patients with splenic trauma, conservative treatment is recommended to preserve the spleen and prevent potentially lethal post-splenectomy infectious complications. A personal observation of a 17-years-old boy who suffered splenic hematoma after a trauma is referred. The decision to adopt a non-operative strategy allowed the preservation of the spleen without complications. Every therapeutic choice must be consequent to an accurate clinical evaluation of the single patient, either it suggests a surgical abdomen's exploration in urgency or the monitoring of the patient. This curative strategy is supported by the considerable contribution offered by sophisticated methods of radiological imaging and by the commercialization of substances with an high sticking power. Laparoscopic management of spleen trauma can be used once a positive diagnosis has been made. It is useful for assessing the degree of splenic injury. It is an effective procedure for the evaluation and treatment of haemodynamic stable patients with splenic injuries for whom non operative treatment is controversial. In conclusion conservative procedure for splenic lesions must find a growing consent, but warning against a too large widening of the indications for the conservative treatment beyond true safety conditions.

[Intestinal endometriosis: a case report]. / L'endometriosi intestinale: caso clinico.

Endometriosis is seldom of interest to the general surgeon, since it is generally an exclusively gynaecological condition. Atypical locations, however, do fall within the domain of general surgery. Extra-gynaecological endometriosis denotes an ectopic localization of functional endometrial tissue, a finding whose incidence is increasing due to the increasingly widespread use of laparoscopic procedures in chronic abdominal pain and infertility. We report our experience with complete laparoscopic management of deep pelvic endometriosis with isolated bowel involvement. In those patients without a past history of this condition, extragonadal endometriosis is rarely diagnosed preoperatively because the disease may mimic other abdominal pathologies. An accurate diagnosis can be provided by laparoscopy and especially by an intraoperative histopathological examination. Operative laparoscopy is a safe and effective method for treating intestinal endometriosis, significantly improves the patient's quality of life, is followed by resolution of the gynaecological and digestive symptoms and can enhance fertility.

Laparoscopy-assisted endoscopic mucosal resection in the colon: a preliminary report.

Endocopic mucosal resection of flat villous tumours or giant polyps (> 3 cm) may give rise to local complications such as haemorrhage or perforation because of the very thin wall of the colon, above all in the right half. Our aim was to evaluate whether laparoscopy-assisted endoscopic excision of flat villous tumours or giant polyps (> 3 cm) can be safely performed, avoiding critical septic complications and can also help in the selection of patients to be submitted to colonic resection without increasing morbidity or mortality. The procedure is a new minimally invasive therapeutic approach in selected cases with large, sessile or awkwardly located polyps. Unlike other techniques such as polypectomy, endoscopic mucosal resection completely removes the affected mucosa by resecting through the middle or deeper part of the submucosa. Another purpose of the procedure is to obtain specimens for accurate pathological staging. Our experience consisted in the treatment of two patients, one of whom with a laterally spreading tumour of the transverse colon with the suck and cut cap-assisted technique, and one with a large sessile polyp of the caecum with the lift and cut technique. The patients presented no complications and no recurrence was observed during the subsequent follow-up.

Management of intrahepatic biliary lithiasis after pancreatic cancer surgery.

Intrahepatic biliary lithiasis is fairly rare in western countries. In the case described here, liver stones had developed as a late consequence of biliary derivative surgery, which is well known to lead to this complication. However, this case is unusual because people who have undergone radical surgery for cancer of the head of the pancreas seldom survive long enough for liver stones to develop. Treatment for this 65-year-old woman, previously submitted to duodeno-cephalopancreatectomy, involved percutaneous balloon bilioplasty, with several passages in order to open the anastomosis. We then positioned two inner-outer biliary drains, through which repeated lavages were done. Finally, the patient underwent laser lithotripsy of the intrahepatic calculi and the fragments were cleared using a Dormia basket. Repeated cholangiographic monitoring showed progressively fewer stones, until the intrahepatic biliary tree was finally completely clear 120 days after the initial diagnosis. At the last follow-up, the patient was healthy, with normal blood values, considering her overall condition.

[Laparoscopic treatment of GISTs in our experience]. / Il trattamento laparoscopico dei GISTs: nostra esperienza.

Gastrointestinal stromal tumours are rare neoplasms originating from the connective tissue of the digestive tract and constitute most of the non-epithelial primitive digestive tumours. The origin from the interstitial cell of Cajal is appreciated because of this tumours constantly present the expression of the surface antigens CD34 and CD 117 which can be determined immunohistochemistry. In the majority of cases, GISTs are symptomatic and symptoms are most commonly related to mass effect or bleeding. Asymptomatic GISTs are often found incidentally on physical examination, radiologic imaging, endoscopy, laparotomy or laparoscopy. US endoscopy and fine needle aspiration with subsequent immunohistochemistry analysis afford the best diagnostic accuracy. In primary and localized GISTs surgery is always indicated and laparoscopic technique is feasible and is recommended as the treatment of choice for all the patients. Imatinib should be started in metastatic or recurrent disease and neoadjuvant imatinib is also experimental, although its use may be justified in unresectable or marginally resectable GIST. Sunitinib has recently been approved for patients with GIST principally those who fail imatinib therapy. Our experience is based on the study of 7 GISTs: only in 2 cases the neoplasm was found occasionally; in the other, symptoms were related to mass effect or bleeding. Laparoscopic tumour resection was then performed in all the patients. The definitive diagnosis of gastrointestinal stromal tumour, was made postoperatively by analysis of the histopathological and immunohistochemical findings. We confirmed constant high positivity for CD34 and for CD117. Even in the absence of unfavourable prognostic indicators, all patients are regularly followed-up.

Large bowel multiple tumours.

The medical records of all patients with colorectal cancer seen at the "G. Marinaccio" Department of Surgery in Bari between 1997 and 2004 were examined. Cases included in the study met the criteria advocated by Warren and Gates and Moertel et al. Over such period we operated on 103 patients with colon neoplasms, mostly males (64 patients) and aged over 65 (64 patients). Both palliative and radical operations were performed either as elective treatment or as emergency surgery; in some of the latter cases the diagnosis of neoplasm was made casually following the final histological test on the operative specimen. Ten cases of multiple malignant tumours were recorded, corresponding to 9.7%; in particular 1 synchronous-metachronous tumour (0.97%), 3 synchronous tumours (2.7%) and 6 metachronous tumours (5.8%) were observed; two of the metachronous tumours were detected in the same patient and one in a patient that had previously been operated on for a synchronous carcinoma, thus making a total of 8 patients in all. It is concluded that full examination of the colon in all patients presenting with primary colorectal cancer is mandatory and that, in the light of this experience and recent reports in the literature, this should be done by pre- or perioperative colonoscopy. Colonoscopy not only provides accurate detection of lesions, but also allows the surgeon to perform polypectomies, thereby obviating the need for extending surgery at the time of resection of the coexisting cancer. In conclusion, we recommend preoperative colonoscopy for all patients who present non-obstructive colorectal neoplasms.

[The acute cholecystitis: the operative timing for the laparoscopic approach]. / La colecistite acuta: il timing operativo con l'approccio laparoscopico.

The aim of this study is to evaluate the results of early cholecystectomy in patients with acute cholecystitis. In the past, acute cholecystitis was a contraindication to laparoscopic cholecystectomy because of the greater risk of injury to the biliary duct, but acute gallbladder inflammation was a contraindication to open cholecystectomy, too. With greater experience and new technology, laparoscopic cholecystectomy is today the gold standard in the treatment of acute cholecystitis, in empyema and gangrenous cholecystitis. In recent years, attention has turned to surgical timing, rather than surgical management--open versus laparoscopy--because there is no advantage in delaying cholecystectomy for acute cholecystitis. In our experience, we always choose laparoscopic technique in all the patients without general contraindications to mini-invasive surgery and operate as soon as possible in a patient with unfavourable conditions. We believe that the patient must be quickly stabilized with preoperative medical procedures, and surgical treatment must be performed within 72-96 hours after the onset of symptoms. During this period, laparoscopic approach allows a reduction of operative time, operative risk and the conversion rate with medical and economic advantages.