Stent graft placement for a tracheoinnominate artery fistula.

A 68-year-old woman with ventilator-dependent respiratory failure and multiple comorbidities developed acute massive hemoptysis. Computed tomographic angiogram revealed a 3.9-cm pseudoaneurysm arising from the innominate artery abutting the trachea. The patient was successfully treated with stent graft insertion via the right common carotid artery, with exclusion of the aneurysm from the proximal innominate to the right common carotid artery, with ligation of the proximal right subclavian artery and right common carotid to subclavian artery bypass. The patient remained medically stable for 3 months after the procedure with no evidence of endoleak or infection. She then developed recurrent hemoptysis with fatal cardiac arrest. Open surgical repair has been the treatment of choice for tracheoinnominate artery fistula. However, direct repair confers a high mortality risk. Endovascular exclusion offers a less invasive treatment option for tracheoinnominate artery fistula and can serve as a bridge for patients with potential for becoming better surgical candidates.

Updated strategies to treat acute arterial complications associated with total knee and hip arthroplasty.

OBJECTIVE: Traditional treatment of acute arterial complications associated with total knee arthroplasty (TKA) and total hip arthroplasty (THA) has generally included arteriography followed by open surgery. The purpose of this study was to describe our evolution from open surgery to preferential endovascular treatment for acute arterial complications of TKA and THA. METHODS: We analyzed our computerized database registry and patient charts for vascular interventions associated with TKA and THA at a hospital with a large volume of orthopedic surgery to determine changing trends in endovascular intervention for these complications. RESULTS: Between 1989 and 2012, 39,196 TKA (26,374 total: 23,205 primary; 3169 revisions) and THA (12,822 total: 10,293 primary; 2529 revisions) were performed. Vascular surgery consultation was provided for the treatment of acute ischemia, hemorrhage, ischemia with hemorrhage, and pseudoaneurysm formation. All interventions were performed within 30 days of joint replacement. A total of 49 (0.13%) acute arterial complications occurred over the 23-year period: 37 (76%) associated with TKA and 12 (24%) with THA. Arterial injury was detected on the same day as the orthopedic procedure in 28 patients, between postoperative days 1 and 5 in 18 patients, and between postoperative days 5 and 30 in three patients. The arterial complications caused ischemia in 28 patients (58%), hemorrhage in six (12%), ischemia with hemorrhage in six (12%), and pseudoaneurysm in nine (18%). Treatment included solely endovascular intervention in 12 (25%), failed endovascular treatment converted to open surgery in one (2%), and open surgery alone in 36 (73%) patients. Before 2002, only 6% (2/32; 2 TKA) of patients were successfully treated with endovascular intervention compared with 59% (10/17; 9 TKA, 1 THA) after June 2002 (P = .0004). There was no mortality, and limb salvage was achieved in all patients. CONCLUSIONS: Although the majority of acute arterial complications after TKA and THA are diagnosed on the day of surgery, a high clinical awareness for acute arterial injury should also be present in the postoperative period. Although not always feasible, endovascular management is now our preferred treatment for injuries associated with TKA or THA. This offers substantially shorter time to vascular restoration, with less morbidity than open repair, and equivalent satisfactory outcomes.

Changing strategies to treat venous thrombotic occlusions of the upper and lower extremities secondary to compressive phenomena.

OBJECTIVES: We reviewed our strategies during the last decade for deep vein thrombosis (DVT) of the upper extremity due to thoracic outlet syndrome (TOS) andthe lower extremity. METHODS: Between 1998 and 2011, we treated 31 patients with 18 subclavian DVTs and 13 iliac DVTs. Management included catheter-directed thrombolysis compared to mechanical thrombolysis (MT; post 2006). Prior to 2006, patients with TOS were treated with total excision of the first rib compared to excision of the anterior half of the rib. Patients were followed up with serial duplex ultrasounds. RESULTS: There was no major morbidity and no mortality in these 31 patients. Three patients developed recurrent DVT but maintained patency after further treatment. CONCLUSION: Use of MT has led to shorter treatment duration and length of hospital stay. Limiting first rib resection to the anterior half of the rib shortened operative time. Patients requiring stents had excellent long-term patency rates.

Robotic single-incision transabdominal and transvaginal surgery: initial experience with intersecting robotic arms.

BACKGROUND: Single-incision laparoscopic and natural orifice translumenal endoscopic surgery (NOTES) are technically challenging methods. Robotics might have the potential to overcome such hurdles with computer technology. METHODS: The da Vinci Standard and S System (Intuitive, Sunnyvale, USA) were used in human cadavers and pigs to perform single-incision transabdominal and transvaginal surgery. Robotic arms were crossed and control-switched to achieve intuitive control. RESULTS: It was possible to perform robotic single-incision laparoscopy in the typical, intuitive fashion. Transvaginal set-up, including docking of the system and introduction of instruments into the abdominal cavity, was possible but no useful manipulation could be performed. CONCLUSIONS: While robotic NOTES with the da Vinci surgical system was not successful, robotic single-incision surgery is feasible using the above set-up. This new approach seems to offer the advantages of single-incision surgery while maintaining the intuitive control of robotic surgery. Clinical application appears justified.

Incisionless revision of post-Roux-en-Y bypass stomal and pouch dilation: multicenter registry results.

BACKGROUND: Surgical revision for weight regain after Roux-en-Y gastric bypass (RYGB) has been tempered by the high complication rates associated with standard approaches. Endoluminal revision of stoma and pouch dilation should intuitively confer a better risk profile. However, questions of clinical safety, durability, and weight loss need to be answered. We report our multicenter intraoperative experience and postoperative follow-up to date using the Incisionless Operating Platform for this patient subset. METHODS: The patients who had regained significant weight >or=2 years after RYGB after losing >or=50% of excess body weight after RYGB were endoscopically screened for stomal and/or pouch dilation. Qualified patients underwent incisionless revision using the Incisionless Operating Platform to reduce the stoma and pouch size by placing anchors to create tissue plications. Data on the safety, intraoperative performance, postoperative weight loss, and anchor durability were recorded to date as a part of 2 years of postoperative follow-up. RESULTS: A total of 116 consecutive patients were prospectively studied. Anchors were successfully placed in 112 (97%) of 116 patients, with an average intraoperative stoma diameter and pouch length reduction of 50% and 44%, respectively. The operating room time averaged 87 minutes. No significant complications occurred. At 6 months after the procedure (n = 96), an average of 32% of weight regain that had occurred after RYGB had been lost. The percentage of excess weight loss averaged 18%. The 12-month esophagogastroduodenoscopy results confirmed the presence of the anchors and durable tissue folds. CONCLUSIONS: Incisionless revision of stoma and pouch dilation using the Incisionless Operating Platform can be performed safely. The data to date have demonstrated mild-to-moderate weight loss, and the early 12-month endoscopic images have confirmed anchor durability. Patients were actively followed up to document the long-term durability of this intervention in the entire patient subset.

Early ambulation after percutaneous femoral access with use of closure devices and hemostatic agents.

BACKGROUND: Patient satisfaction after percutaneous endovascular procedures is significantly influenced by the amount of time to ambulation postprocedure. The purpose of this study was to assess the complication rates of early ambulation after use of closure devices or topical hemostatic agents for femoral access sites for endovascular procedures. METHODS: A retrospective review was performed of all patients who underwent an endovascular procedure from a femoral access site between January 2004 and March 2008. The access site was closed with an Angio-Seal, StarClose, or D-Stat Dry with pressure. Patients ambulated 2 hr postprocedure when a closure device was used and 4 hr postprocedure when a D-Stat pad was applied. Access-site bleeding complications were assessed. Sheath size, closure method, patient characteristics, and antiplatelet status were analyzed. RESULTS: A total of 245 patients with a mean age of 70 years were identified. Of these, 154 (63%) patients were treated with a D-Stat pad with pressure, Angio-Seal was used on 83 (34%), and StarClose was used on eight (3%). The overall complication rate was 5.7%. Complications increased with increasing age (p = 0.003) and use of StarClose (p = 0.0001). The D-Stat pad was associated with a decreased complication rate (p = 0.03). Sheath size did not influence the incidence of bleeding. There was no significant increase in complications in patients taking an antiplatelet agent. CONCLUSION: With a protocol using closure devices and hemostatic agents, early ambulation after percutaneous femoral access can be achieved safely with an acceptable complication rate in patients with peripheral vascular disease.

Video. Magnetic retraction for NOTES transvaginal cholecystectomy.

BACKGROUND: Natural orifice translumenal endoscopic surgery (NOTES) has the potential to decrease the burden of an operation on a patient. Limitations of the endoscopic platform require innovative solutions to provide retraction and create an operation comparable with the gold standard, laparoscopic cholecystectomy. METHODS: Four patients underwent transvaginal cholecystectomy. All procedures were performed under laparoscopic vision to ensure safety. The endoscope and a long articulating RealHand instrument were placed via a 15-mm vaginal trocar. A magnetic retraction system was used to retract the gallbladder safely. Laparoscopic clips were used to ligate the cystic duct and artery. All four gallbladders were successfully removed. No complications occurred. The mean operating time was 102 min. RESULTS: All four procedures were completed without complications. The four patients all were discharged shortly after surgery and reported normal sexual activity without pain. CONCLUSIONS: Transvaginal cholecystectomy can be completed safely using current technology. Further studies are needed to determine the safety of the procedure and to determine whether it confers any benefits other than cosmesis.

Supra-pubic single incision cholecystectomy.

INTRODUCTION: Surgery is moving towards less invasive and cosmetically superior approaches such as single incision laparoscopy (SIL). While trans-umbilical SIL is gaining popularity, incisions may lead to post-operative deformations of the umbilicus and the possibility of an increased rate of incisional hernias. Access within the pubic hairline allows preservation of the umbilicus and results in a scar which is concealed within the pubic hair. METHODS: Supra-pubic single incision cholecystectomy was performed in a 30-year-old patient with symptomatic gallstones. A 2.5-cm transverse incision was placed within the pubic hairline and a subcutaneous tunnel was formed. Three 5-mm ports were introduced into the tunnel and perforated the anterior rectus sheath superior to the skin incision. The surgical procedure was then undertaken with conventional laparoscopic instrumentation. The adjacent 5-mm incisions were merged for gallbladder removal. The entry site was closed under direct vision. RESULTS: The above procedure was technically feasible and without complication. Operative time was 45 min, and the patient was discharged 5 h post-operatively. CONCLUSIONS: Supra-pubic single incision laparoscopic cholecystectomy may offer a more cosmetically appealing result than standard umbilical access. The operation can be performed by surgeons skilled in single incision techniques with good result.

Transrectal endoscopic retrorectal access (TERA): a novel NOTES approach to the peritoneal cavity.

BACKGROUND: As the field of natural orifice translumenal endoscopic surgery (NOTES) expands, new access sites are being investigated. One access site to the peritoneal cavity, which has not been the subject of much investigation, is transrectal access. The aim of this article is to describe a new method to peritoneal access: transrectal endoscopic retrorectal access (TERA). MATERIALS AND METHODS: Three pigs were placed in the supine position under general anesthesia, and an umbilical port was placed for the pneumoperitoneum, as well as visualization of the pelvic dissection and access. A rectotomy was made under direct vision above the dentate line posteriorly. The flexible endoscope was introduced into the retrorectal space, balloon dilation was used to open and dissect the retrorectal plane, and the peritoneal cavity was entered with a needle knife. After peritoneal exploration, the endoscope was withdrawn and the rectotomy was closed under direct vision. RESULTS: Each of the 3 cases was successful with entry into the peritoneal cavity to the right of the sacral promontory. Direct visualization allowed the avoidance of injury to the ureter, vessels, and nervous structures of the pelvis. The flexible endoscope allowed an easy direct visualization of the upper abdominal organs. In addition, retroflexion allowed a view of the pelvic organs. Mean operative time was 40 minutes. CONCLUSIONS: TERA is a novel access route to the peritoneal cavity that can be performed by using readily available instrumentation. When performed under direct view, injury to the adjacent structures can be avoided while obtaining access. Unresolved issues include sterility of the procedure and reproducibility, and future survival studies will delineate long-term safety.

Video. NOTES: transvaginal cholecystectomy with assisting articulating instruments.

BACKGROUND: Transvaginal cholecystectomy has been performed at several institutions using hybrid natural orifice translumenal endoscopic surgery (NOTES) techniques. METHODS: A 42-year-old woman with symptomatic cholelithiasis was taken to the operating room for transvaginal cholecystectomy after giving informed consent. A single 5-mm laparoscope was placed at the umbilicus, followed by a 15-mm trocar through the vaginal conduit. The endoscope and a long flexible RealHand surgical instrument (Novare, Cupertino, CA) were placed via the vaginal trocar. The cystic duct and artery were identified and clipped using laparoscopic clips from the umbilical port. The long articulating laparoscopic instrument provided stable retraction. Hook cautery was used to dissect the gallbladder, which was removed via the vaginal trocar. The vaginal incision was closed using a single figure-of-eight absorbable suture under direct vision. The procedure lasted 96 min. RESULTS: The cholecystectomy was successfully performed without spillage of bile. The patient was kept overnight for observation only as a precaution. She reported no pain and did not require a discharge prescription for narcotics. CONCLUSIONS: The described technique for NOTES cholecystectomy results in a virtually scarless operation. The single 5-mm umbilical trocar allows for safe clipping of the cystic duct. Further work is needed to determine the efficacy of this approach.