Transvaginal rectopexy using the Flex® Colorectal Drive Robotic System: a proof-of-concept approach to rectal prolapse.

BACKGROUND: The aim of this study was to demonstrate a proof-of-concept approach to rectopexy that would provide the durability of the transabdominal procedure through use of sacral rectopexy with the decreased morbidity of a perineal procedure. This was done by utilizing a transvaginal approach and developing the rectovaginal space to accommodate sacral rectopexy placement using the Flex® Colorectal Drive Robotic System by Medrobotics (Medrobotics Corp., Raynham, MA, USA). METHODS: A fresh female cadaver was acquired and placed in the high lithotomy position. The rectovaginal space was developed to accommodate the trocar of the Flex robot using blunt and sharp dissection between the posterior vaginal wall and anterior rectum. A piece of mesh was introduced into the space and using an endoscopic tacker, which was secured to the sacral promontory. The mesh was secured to the anterior rectal wall using interrupted vicryl sutures. The purse string suture was removed and the rectovaginal orifice was closed using a running vicryl suture. At the completion of the procedure, a low midline laparotomy was conducted to verify anchoring of the mesh appropriately at the sacral promontory. RESULTS: This proof-of-concept protocol is the first description of the Flex® Colorectal Drive being used successfully to perform a transvaginal rectopexy for rectal prolapse in a cadaver. This is also the first description of the Flex® Colorectal Drive robot being used transvaginally. CONCLUSIONS: This proof-of-concept approach demonstrates that transvaginal rectopexy using the Flex® Colorectal Drive is a potential surgical option to address rectal prolapse that could provide patients the durability of a transabdominal approach with the decreased morbidity of a perineal approach. While early results are promising, additional cadaveric studies are required before this procedure can be attempted in vivo.

Laparoscopic repair of a traumatic lumbar hernia: a case report.

Lumbar hernia is an uncommon flank hernia and a rare complication of blunt trauma. We present a case of acute lumbar hernia as a direct result of blunt trauma. Traditionally, exploratory laparotomy with open repair is indicated, but we report a case of a traumatic lumbar hernia explored and repaired laparoscopically.

Extracardiac surgical complications in heart transplant recipients.

As the population of patients undergoing orthotopic heart transplantation increases, more patients are likely to develop surgical complications unrelated to the transplant procedure. This article reviews 38 extracardiac surgical complications sustained in 18 of 48 patients undergoing orthotopic heart transplantation at our institution over a 4-year period. Twenty-seven complications (71.1%) required operative intervention most commonly in an urgent or emergent manner (59.3%). Three patients underwent six laparotomies. Infection was the cause in almost half of all complications and in 65% of those requiring surgery. Gastrointestinal hemorrhage was common and successfully managed nonoperatively in all cases. The overall operative mortality was 11% with only two deaths related to a surgical complication. The satisfactory outcome in these patients can be attributed to the early diagnosis of complications, timely therapeutic intervention, careful adjustment of immunosuppressive agents, and close patient follow-up with the transplant institution.

Myocardial oxygen consumption. Comparison between left atrial pulsatile synchronous and asynchronous bypass.

This controlled study was undertaken to quantitate the effect of R-wave synchronization (counterpulsation) on myocardial oxygen consumption (MVO2) as reflected by the tension time index (TTI) during pulsatile left atrial to aortic bypass. Pulsatile ventricular assist devices were implanted in eight anesthetized, fully hemodynamically instrumented animals. After baseline measurement of TTI, heart rate, cardiac output, mean aortic and left atrial pressures, pulsatile left atrial to aortic bypass was instituted. Measurements were then continuously recorded during both left atrial pulsatile synchronous (LAPS) and asynchronous (LAPAS) bypass periods of pumping. Heart rate and mean aortic pressure were controlled throughout the experiment. TTI = 1819 +/- 95 mmHg-sec (control); 987 +/- 127 mmHg-sec (LAPAS); and 763 +/- 89 mmHg-sec (LAPS). The results indicate TTI, and therefore MVO2, is reduced significantly from control levels by either LAPS or LAPAS bypass. However, R-wave synchronization (counterpulsation) offers no further benefit in reducing TTI over the less complex LAPAS or full-to-empty mode pumping.

Mortality of coronary artery bypass grafting before and after the advent of angioplasty.

In an effort to determine whether the population of patients undergoing isolated coronary artery bypass grafting and the outcome of these operations have changed, we analyzed the records of two patient populations from our institution. Interventional cardiology techniques (angioplasty, thrombolysis) were not used at our institution before 1982. The records of 736 patients (group 1) who underwent isolated coronary artery bypass grafting from January 1975 to July 1981 were reviewed and compared with a group of 603 patients (group 2) who underwent operation from July 1985 to December 1987. The techniques of operation and myocardial preservation were virtually identical during the two periods. During the group 2 analysis period, 343 angioplasty procedures were performed. The patients in group 2 were significantly older, had increased preoperative New York Heart Association classification, had sustained more previous myocardial infarctions, and had more associated morbid medical conditions. There was a threefold increase in patients seen for reoperative revascularization procedures and a fourfold increase in emergency operations. Overall mortality, although not significantly different, did increase slightly from 2.69% in group 1 to 3.83% in group 2. Mortality after elective procedures remained essentially unchanged (2.05% for group 1 and 1.90% for group 2).

Determinants of survival in patients with ventricular assist devices.

Mechanical ventricular assist devices (VADs) have led to survival in patients who develop postcardiotomy cardiogenic shock (PCCS) refractory to conventional therapies. To elicit determinants of survival, the authors reviewed records of 26 patients at our institution who required Pierce-Donachy VADs for PCCS. Thirteen patients were weaned from ventricular assistance (50%), nine (34.6%) achieved long-term survival, and 17 died. Survivors and those that died were equivalent in terms of age, sex, NYHA class, type of operation, and preoperative hemodynamics. Ventricular assist pumping was established earlier in survivors (P = 0.006) although aortic cross-clamp and total cardiopulmonary bypass times were equivalent between the groups. The development of biventricular failure was significantly associated with the inability to wean from mechanical circulatory assistance. Despite an equal incidence of biventricular failure, survivors had milder forms of this entity and all patients with severe biventricular failure requiring a biventricular assist device failed to wean and ultimately died (N = 5). Of all complications, inadequate cardiac output was a significant determinant of weaning. Perioperative myocardial infarction and renal failure were found to be univariate determinants of survival. Inadequate cardiac output and biventricular failure preclude weaning from mechanical circulatory assistance. Survival is associated with the expeditious establishment of assist pumping, and with the avoidance of irreversible perioperative myocardial injury and renal failure.