A novel two-surgeon technique of simultaneous bilateral cataract surgery with complete delinking.

Though technological advancements have transcended beyond expectation, phacoemulsification remains a challenge in uncooperative patients, where the procedure may be contemplated under general anesthesia, with simultaneous bilateral cataract surgery (SBCS) being the surgery of choice. In this manuscript, we have reported a novel two-surgeon technique of SBCS on a 50-year-old mentally subnormal patient. Under general anesthesia, two surgeons performed phacoemulsification simultaneously, using two separate microscopes, irrigation lines, phaco machines, instruments, and assistants. Intraocular lens (IOL) implantation was performed in both eyes (OU). The patient had a visual recovery from 5/60, N36 in OU preoperatively to 6/12, N10 in OU on post-operative day 3 and 1 month, with no complications. This technique can potentially reduce the risk of endophthalmitis, repeated and prolonged anesthesia, and the number of hospital visits. To the best of our knowledge, this two-surgeon technique of SBCS has never been reported in the literature.

Middle Hepatic Vein-Guided Cranial and Hilar Approach Using a Modified Two-Surgeon Technique in Laparoscopic Extended Left Medial Sectionectomy: A Technical Case Report With Videos.

Anatomical liver resection and liver resection close to major blood vessels are quite challenging and require a high level of expertise. In addition, anatomical hepatectomy requires extensive knowledge of the positions of blood vessels and techniques for hemostasis because the resection surface is extensive and operations around blood vessels are required. A hepatic vein-guided cranial and hilar approach using a modified "two-surgeon technique" is effective in resolving these problems. Herein, we present a middle hepatic vein (MHV)-guided cranial and hilar approach using a modified two-surgeon technique in laparoscopic extended left medial sectionectomy to resolve these problems. This procedure is feasible and effective.

The Impact of Modified Two-Surgeon Technique for Laparoscopic Liver Resection on the Training of Surgeons-in-Training.

Introduction Although laparoscopic liver resection (LLR) has gained widespread acceptance over the last decade, it is associated with a much steeper learning curve than other laparoscopic procedures. We currently perform a modified two-surgeon technique for LLR. We assessed the effect of our LLR technique on the surgical outcome and the learning curve of surgeons-in-training when pure non-anatomical LLR was performed. Methods Between 2017 and 2021, 118 LLRs were conducted at our institution, 42 of which were pure non-anatomical LLRs performed by five surgeons-in-training (with a career of 6-13 years). The perioperative outcomes of these cases were compared to those performed by the board-certified attending surgeon. Regarding the learning curve of surgeons-in-training, the duration of operation was used as an index of the proficiency level, and the number of surgical cases in which the surgeons reached the median duration of operation was examined. Results Mortality was zero, and neither postoperative bleeding nor bile leak was experienced in the whole cohort. There were no differences between surgeons-in-training and the board-certified surgeon in the duration of the operation, intraoperative blood loss, rate of postoperative complications, or length of postoperative stay (LOS). Among the operations performed by five surgeons-in-training, the rate of LLR with a difficulty score of 4 or higher was 52% (30%-75%). Concerning the learning curve, all five surgeons-in-training gradually shortened the duration of operation for each additional case and reached the median duration (218 minutes) by experiencing a median of five cases (3-8 cases). Conclusion A modified two-surgeon technique during LLR is feasible, with a relatively low number of cases (five cases) required to shorten the duration of operation in non-anatomical LLR. This technique is safe and beneficial to the education of surgeons-in-training.

Modified Two-Surgeon Technique for Laparoscopic Liver Resection.

While minimizing intraoperative blood loss during liver resection is one of the most important tasks, it is more difficult to control the refractory bleeding during laparoscopic liver resection than with an open approach. We herein provide a modification of the two-surgeon technique that enables laparoscopic liver parenchymal transection to be performed as quickly and securely as open liver resection. To achieve proper "role sharing," the "transection mode" and the "hemostatic mode" are independent sets in place in this procedure, and these modes are switched rigidly according to the surgical field condition. By thoroughly sharing the roles, rapid laparoscopic liver parenchymal transection comparable to open liver resection can be accomplished. The present modified approach achieves satisfactory transection and hemostasis of the liver parenchyma and is also advantageous for teaching young surgeons and the entire surgical team.

Adrenalectomy in ectopic Cushing's syndrome: A retrospective cohort study from a tertiary care centre.

Neuroendocrine neoplasms (NENs) causing ectopic Cushing's syndrome (ECS) are rare and challenging to treat. In this retrospective cohort study, we aimed to evaluate different approaches for bilateral adrenalectomy (BA) as a treatment option in ECS. Fifty-three patients with ECS caused by a NEN (35 females/18 men; mean ± SD age: 53 ± 15 years) were identified from medical records. Epidemiological and clinical parameters, survival, indications for surgery and timing, as well as duration of surgery, complications and surgical techniques, were collected and further analysed. The primary tumour location was thorax (n = 30), pancreas (n = 14) or unknown (n = 9). BA was performed in 37 patients. Median time from diagnosis of ECS to BA was 2 months (range 1-10 months). Thirty-two patients received different steroidogenesis inhibitors before BA to control hypercortisolaemia. ECS resolved completely after surgery in 33 patients and severe peri- or postoperative complications were detected in 12 patients. There were fewer severe complications in the endoscopic group compared to open surgery (p = .030). Posterior retroperitoneoscopic BA performed simultaneously by a two surgeon approach had the shortest operating time (p = .001). Despite the frequent use of adrenolytic treatment, BA was necessary in a majority of patients to gain control over ECS. Complication rate was high, probably as a result of the combination of metastatic disease and metabolic disorders caused by high cortisol levels. The two surgeon approach BA may be considered as the method of choice in ECS compared to other BA approaches as a result of fewer complications and a shorter operating time.

Single- versus dual-attending strategy for spinal deformity surgery: 2-year experience and systematic review of the literature.

OBJECTIVE: Adult spinal deformity (ASD) surgery is complex and associated with high morbidity and complication rates. There is growing evidence in the literature for the beneficial effects of an approach to surgery in which two attending physicians rather than a single attending physician perform surgery for and oversee the surgical care of a single patient in a dual-attending care model. The authors developed a dual-attending care collaboration in August 2017 in which a neurosurgeon and an orthopedic surgeon mutually operated on patients with ASD. METHODS: The authors recorded data for 2 years of experience with ASD patients operated on by dual attending surgeons. Analyses included estimated blood loss (EBL), transfusions, length of stay (LOS), discharge disposition, complication rates, emergency room visits and readmissions, subjective health status improvement, and disability (Oswestry Disability Index [ODI] score) and pain (visual analog scale [VAS] score) at last follow-up. In addition, the pertinent literature for dual-attending spinal deformity correction was systematically reviewed. RESULTS: The study group comprised 19 of 254 (7.5%) consecutively operated patients who underwent thoracolumbar fusion during the period from January 2017 to June 2019 (68.4% female; mean patient age 65.1 years, ODI score 44.5, VAS pain score 6.8). The study patients were matched by age, sex, anesthesia risk, BMI, smoking status, ODI score, VAS pain score, prior spine surgeries, and basic operative characteristics (type of interbody implants, instrumented segments, pelvic fixation) to 19 control patients (all p > 0.05). There was a trend toward less EBL (mean 763 vs 1524 ml, p = 0.059), fewer intraoperative red blood cell transfusions (mean 0.5 vs 2.3, p = 0.079), and fewer 90-day readmissions (0% vs 15.8%, p = 0.071) in the dual-attending group. LOS and discharge disposition were similar, as were the rates of any < 30-day postsurgery complications, < 90-day postsurgery emergency room visits, and reoperations, and ODI and VAS pain scores at last follow-up (all p > 0.05). At last follow-up, 94.7% vs 68.4% of patients in the dual- versus single-attending group stated their health status had improved (p = 0.036). In the authors' literature search of prior articles on spinal deformity correction, 5 of 8 (62.5%) articles reported lower EBL and 6 of 8 (75%) articles reported significantly lower operation duration in dual-attending cases. The literature contained differing results with regard to complication- or reoperation-sparing effects associated with dual-attending cases. Similar clinical outcomes of dual- versus single-attending cases were reported. CONCLUSIONS: Establishing a dual-attending care management platform for ASD correction was feasible at the authors' institution. Results of the use of a dual-attending strategy at the authors' institution were favorable. Positive safety and outcome profiles were found in articles on this topic identified by a systematic literature review.

Surgical Treatment of Developmental Spondylolisthesis: Contemporary Series With a Two-Surgeon Team.

STUDY DESIGN: Retrospective case series. OBJECTIVES: To report operative outcomes of contemporary surgical treatment of spondylolisthesis in the pediatric population. SUMMARY OF BACKGROUND DATA: Surgical treatment of developmental spondylolisthesis is controversial, with limited data on complication and reoperation rates. METHODS: A retrospective study followed pediatric patients with either L5-S1 high-grade spondylolisthesis (HGS) or L5-S1 symptomatic low-grade spondylolisthesis (LGS) for a minimum of two years. All patients underwent a contemporary, single-stage decompression, partial reduction, and posterior instrumented fusion (DRPF) or in situ stabilization by a combined orthopedic and neurosurgeon team at a single institution during 2005-2015. Clinical examination and radiographic data were collected preoperatively and at discharge, 1 year, 2 years, and terminal visit (defined as the last follow-up at >2 years). RESULTS: Thirty-four patients (79% HGS), mean (±standard deviation) age at surgery 13.5 (±3.3) years, were followed for 4.8 (±2.3) years. The patients who underwent DRPF (n = 26) had mean lumbosacral angle increase from 79.8° (±20.8) to 92.5° (±16.1) (p < .001) and mean listhesis reduce from 63.2% (±21.9) to 26.0% (±20.1) (p < .001). Preoperatively, 18 (53%) had neurologic symptoms. At one- and two-year follow-up, new or residual neurologic symptoms were present in four patients (12%) (p < .001). Postoperative symptoms were not significantly related to amount of reduction. Sixteen (47%) underwent reoperation at an average of 24.8 months, 10 for planned prominent instrumentation removal, and 6 for true complications. CONCLUSIONS: Surgical reduction and decompression of spondylolisthesis in the pediatric population restores spinopelvic alignment. We found no evidence that a greater amount of reduction was associated with a higher incidence of postoperative complications. However, patients should be advised that prominent instrumentation may require future removal. Although previous reports suggest complication rates and permanent neurologic sequelae in up to 20% after operative treatment of spondylolisthesis, our results suggest that a contemporary approach with a two-surgeon team may provide improved results. LEVEL OF EVIDENCE: Level IV.

Technical notes on the endoscopic endonasal approach to the craniovertebral junction for odontoidectomy.

INTRODUCTION: Odontoidectomy can help decompress ventral compression of the brainstem and upper cervical spinal cord in the presence of bony abnormalities of the craniovertebral junction (CVJ), e.g., an odontoid pannus. Endonasal approaches have been shown to be associated with lower morbidity compared with traditional transoral approaches. We demonstrated an entirely endonasal approach to the CVJ. MATERIALS AND METHODS: We presented our technique for performing an endoscopic endonasal odontoidectomy. RESULTS: The patient underwent an open posterior cervical spinal fusion to stabilize the CVJ due to destabilization that occurs with odontoidectomy either as part of a single procedure or in a staged manner, depending on the surgeon's preference. By using a two-surgeon, multihanded technique in collaboration with neurosurgery, the anterior CVJ was safely approached endoscopically through the nasopharynx. A midline incision was created and the soft tissue was lateralized widely. The first cervical vertebra (C1) arch was removed with a drill exposing the odontoid process and any associated pannus, which were then resected. Because this approach was entirely extradural, no reconstruction was necessary. Closure was accomplished by placing absorbable packing material in the defect and medializing the nasopharyngeal tissues. CONCLUSION: Endoscopic endonasal odontoidectomy offers excellent exposure and less morbidity than traditional transoral approaches. This technique should be considered in appropriately selected patients.

Impact of laparoscopic liver resection on bleeding complications in patients receiving antithrombotics.

AIM: To assess the impact of laparoscopic liver resection (LLR) on surgical blood loss (SBL), especially in patients with antithrombotics for thromboembolic risks. METHODS: Consecutive 258 patients receiving liver resection at our institution between 2010 and 2016 were retrospectively reviewed. Preoperative antithrombotic therapy (ATT; antiplatelets and/or anticoagulation) was regularly used in 100 patients (ATT group, 38.8%) whereas not used in 158 (non-ATT group, 61.2%). Our perioperative management of high thromboembolic risk patients included maintenance of preoperative aspirin monotherapy for patients with antiplatelet therapy and bridging heparin for patients with anticoagulation. In both ATT and non-ATT groups, outcome variables of patients undergoing LLR were compared with those of patients receiving open liver resection (OLR), and the independent risk factors for increased SBL were determined by multivariate analysis. RESULTS: This series included 77 LLR and 181 OLR. There were 3 thromboembolic events (1.2%) in a whole cohort, whereas increased SBL (≥ 500 mL) and postoperative bleeding complications (BCs) occurred in 66 patients (25.6%) and 8 (3.1%), respectively. Both in the ATT and non-ATT groups, LLR was significantly related to reduced SBL and low incidence of BCs, although LLR was less performed as anatomical resection. Multivariate analysis showed that anatomical liver resection was the most significant risk factor for increased SBL [risk ratio (RR) = 6.54, P < 0.001] in the whole cohort, and LLR also had the significant negative impact (RR = 1/10.0, P < 0.001). The same effects of anatomical resection (RR = 15.77, P < 0.001) and LLR (RR = 1/5.88, P = 0.019) were observed when analyzing the patients in the ATT group. CONCLUSION: LLR using the two-surgeon technique is feasible and safely performed even in the ATT-burdened patients with thromboembolic risks. Independent from the extent of liver resection, LLR is significantly associated with reduced SBL, both in the ATT and non-ATT groups.

Changes and optimization of operator model in laparoscopic anastomic hepatectomy / 中华消化外科杂志

Laparoscopic anatomical resection (LAR) is a highly-demanding and high risky procedure.Traditional single-surgeon technique appears to be frustrating when dealing with intro-operative emergency and ensuring the safety of complicated LAR.The authors' department has applied two-surgeon technique when performing LAR since 2014.In complicated cases of LAR,two skillful surgeons cooperate to perform surgeries.The two surgeons stand at each side of the patient and switch their duties as the surgeon or the assistant during the operation.Experience of the authors' department shows that compared with single-surgeon technique,two-surgeon technique can help better deal with intro-operative accidental events such as hemorrhage and guarantee the safety of LAR,as well as enhance the efficiency and quality of procedures.Two-surgeon technique benefits team building and training young laparoscopic liver surgeons,and help them pass the learning curve more safely and quickly.

Comparing results of posterior spine fusion in patients with AIS: Are two surgeons better than one?

AIMS: Spinal deformity surgery is one of the most complicated procedures performed in pediatric orthopedics. These surgeries can account for long operative times and blood losses. Finding ways to limit patient morbidity undergoing these procedures may benefit many. We hypothesized that utilizing two fellowship trained pediatric spinal deformity surgeons would lead to decreased operative time and blood loss when compared with single surgeon. We felt very little difference would be found in terms of curve correction. METHODS: A retrospective review of spinal deformity surgeries performed at two institutions was performed. At one institution, the standard of care was to have two fellowship deformity trained surgeons perform all deformity surgeries simultaneously, while at the second institution posterior spinal fusions performed by individual surgeons were performed. The single surgeon cohort was further divided based on instrumentation type (pedicle screw vs hybrid constructs). Cases for this review were limited to posterior spinal fusions without osteotomies in patients with idiopathic or idiopathic like curves. Cohorts were compared pre-operatively for age at surgery, sex, BMI, largest Cobb angle. Intra-operative comparisons included total EBL, instrumentation type screws vs hybrid, levels fused, and operative time. Comparisons between largest remaining Cobb, EBL/level, time/level, lowest recorded Hb, allogenic transfusion requirements, length of PICU stay, and total length of hospital stay were then made. Pair-wise student t-tests was performed between cohorts with significance defined as a p-value of 0.05 or less. CONCLUSIONS: Twenty-four patients were found in the (BMP) cohort, where as eighty-two were found in the control group. No significant difference in age, sex, starting hemoglobin, BMI*, or maximum pre-operative Cobb between cohorts was found. A significantly lower number of levels were fused in the BMP cohort than the control (9 ± 2 vs 11 ± 2) p < 0.001, and likewise a significantly shorter operative time (average >2 h) was seen in the BMP cohort. Interestingly, no difference in estimated blood loss, blood loss/level fused, operative time/level fused was observed, yet a significantly greater drop in hemoglobin (average 1 g) p = 0.001 and allogenic transfusion rate was seen in the control group (4% (1/24) vs 29% (24/82)) p = 0.01. A greater improvement in Cobb angle was seen in the BMP group 46 ± 8 vs 35 ± 10° p < 0.001. No differences were seen in nights in the PICU and peri-operative complications, however patients in the BMP averaged nearly 1day less in the hospital than in the control group. Utilizing a blood management program including two surgeons in spinal deformity surgery appears to decrease operative time, blood loss, and improve curve correction. Confounding factors such as differences in number of fusion levels, curve types, instrumentation type, and institutional practices prevents drawing definitive conclusions. This is the first study to show potential benefits of utilizing a blood management program with dual surgeons in spinal deformity cases.

Hemi-hepatectomy in pediatric patients using two-surgeon technique and a liver hanging maneuver.

AIM: To evaluate the efficacy of the two-surgeon technique with the liver hanging maneuver (LHM) for hepatectomies in pediatric patients with hepatoblastoma. METHODS: Three pediatric patients with hepatoblastoma were enrolled in this study. Two underwent right hemi-hepatectomies and one underwent a left hemi-hepatectomy using the two-surgeon technique by means of saline-linked electric cautery (SLC) and the Cavitron Ultrasonic Surgical Aspirator (CUSA; Valleylab, Boulder, CO) and the LHM. RESULTS: The mean operative time during the parenchymal transections was 50 min and the mean blood loss was 235 g. There was no bile leakage from the cut surface after surgery. No macroscopic or microscopic-positive margins were observed in the hepatic transections. CONCLUSION: The two-surgeon technique using SLC and CUSA with the LHM is applicable to even pediatric patients with hepatoblastoma.