A Branched and Double Alpha-Gal-Bearing Synthetic Neoglycoprotein as a Biomarker for Chagas Disease.

Chagas disease (CD) is caused by the parasite Trypanosoma cruzi and affects 6-7 million people worldwide. The diagnosis is still challenging, due to extensive parasite diversity encompassing seven genotypes (TcI-VI and Tcbat) with diverse ecoepidemiological, biological, and pathological traits. Chemotherapeutic intervention is usually effective but associated with severe adverse events. The development of safer, more effective therapies is hampered by the lack of biomarker(s) (BMKs) for the early assessment of therapeutic outcomes. The mammal-dwelling trypomastigote parasite stage expresses glycosylphosphatidylinositol-anchored mucins (tGPI-MUC), whose O-glycans are mostly branched with terminal, nonreducing α-galactopyranosyl (α-Gal) glycotopes. These are absent in humans, and thus highly immunogenic and inducers of specific CD anti-α-Gal antibodies. In search for α-Gal-based BMKs, here we describe the synthesis of neoglycoprotein NGP11b, comprised of a carrier protein decorated with the branched trisaccharide Galα(1,2)[Galα(1,6)]Galß. By chemiluminescent immunoassay using sera/plasma from chronic CD (CCD) patients from Venezuela and Mexico and healthy controls, NGP11b exhibited sensitivity and specificity similar to that of tGPI-MUC from genotype TcI, predominant in those countries. Preliminary evaluation of CCD patients subjected to chemotherapy showed a significant reduction in anti-α-Gal antibody reactivity to NGP11b. Our data indicated that NGP11b is a potential BMK for diagnosis and treatment assessment in CCD patients.

Novel Combinatorial Strategy Using Thermal Inkjet Bioprinting, Chemotherapy, and Radiation on Human Breast Cancer Cells; an In-Vitro Cell Viability Assessment.

BACKGROUND: Breast cancer (BC) continues to have the second highest mortality amongst women in the United States after lung cancer. For 2021, the American Cancer Association predicted 281,550 new invasive breast cancer cases besides 49,290 new cases of non-invasive breast cancer and 43,600 deaths from the metastatic disease. A treatment modality is radiation therapy, which is given for local control as well as palliation of patient symptoms. The initial step of new drug development is in-vitro cell studies, which help describe new drug properties and toxicities. However, these models are not optimal, and better ones have yet to be determined. This study uses bioprinting technology to elucidate the sensitivity of tumor cells to the combination of palbociclib (PD) and letrozole (Let) treatment. We hypothesize that this technology could serve as a model to predict treatment outcomes more efficiently. METHODS: The breast cancer cell lines MCF7 and MDA-MB-231 as well as the normal breast epithelial cell line, MCF-10A, were treated with PD-Let with and without radiotherapy (RT), and cell viability was compared in pairwise fashion for thermally inkjet bioprinted (TIB) and manually seeded (MS) cells. RESULTS: In absence of radiation, the TIB MCF7 cells have 2.5 times higher viability than manually seeded (MS) cells when treated with 100 µM palbociclib and 10 µM letrozole, a 36% higher viability when treated with 50 µM palbociclib and 10 µM letrozole, and an 8% higher viability when treated with 10 µM palbociclib and 10 µM letrozole. With 10 Gy of radiation, TIB cells had a 45% higher survival rate than MS cells at the lowest palbociclib concentration and a 29% higher survival rate at the intermediate palbociclib concentration. Without radiation treatment, at a concentration of 10 µM PD-Let, TIB MDA-MB-231 cells show a 8% higher viability than MS cells when treated with 10 µM PD and 10 µM Let; at higher drug concentrations, the differences disappeared, but some 1.7% of the TIB MDA-MB-231 cells survived exposure to 150 µM of PD + 10 µM letrozole vs. none of the MS cells. These cells are more radiation sensitive than the other cell lines tested and less sensitive to the combo drug treatments. We observed an 18% higher survival of TIB MCF-10A cells without radiation treatment when exposed to 10 µM PD + 10 µM Let but no difference in cell survival between the two groups when radiation was applied. Independent of growth conditions, TIB cells did not show more resistance to radiation treatment than MS cells, but a higher resistance to the combo treatment was observed, which was most pronounced in the MCF-7 cell line. CONCLUSION: Based on these results, we suggest that TIB used in in-vitro models could be a feasible strategy to develop and/or test new anticancer drugs.

Recording patient bodyweight in hospitals: are we doing well enough?

Recording patient weight is a standard practice for all hospital admissions, with this measurement influencing other daily practices that rely on the delivery of safe and effective patient care. Patient weight is important in the areas of medication prescribing, fluid balance and assessment of nutrition. In particular, prescribing narrow therapeutic index medications may result in significant harm as a potential consequence of inaccurate dosing. Despite its importance, it is evident that bodyweight measurements are recorded in only 13.5-55% of hospital patients, in a variety of settings including the emergency department, intensive care unit, medical and surgical wards. Barriers to compliance of healthcare staff include additional workload, patient handling and availability of appropriate weighing equipment. Hospitals and patients would benefit from enhancing compliance with the systematic weighing of patients, staff training and removing barriers to performing this task.

Thyroidectomy for the treatment of Graves' thyrotoxicosis in thioamide-induced agranulocytosis and sepsis.

A 51 year old man presented with sepsis in the setting of thioamide-induced agranulocytosis. Empiric broad-spectrum antibiotics was followed by directed narrow-spectrum antibiotics, and his neutrophil count recovered with support from granulocyte-colony stimulating factor (G-CSF) analogue transfusions. After a brief period of multi-modal therapy for nine days including potassium iodide (Lugol's iodine), cholestyramine, propanolol and lithium to temper his persisting hyperthyroidism, a total thyroidectomy was performed while thyroid hormone levels remained at thyrotoxic levels. Postoperative recovery was uncomplicated and he was discharged home on thyroxine. There is limited available evidence to guide treatment in this unique cohort of patients who require prompt management to avert impending clinical deterioration. This case report summarises the successful emergent control of thyrotoxicosis in the setting of thioamide-induced agranulocytosis complicated by sepsis, and demonstrates the safe use of multi-modal pharmacological therapies in preparation for total thyroidectomy. LEARNING POINTS: Thioamide-induced agranulocytosis is an uncommon but potentially life-threatening complication of which all prescribers and patients need to be aware.A multi-modal preoperative pharmacological approach can be successful, even when thioamides are contraindicated, when needing to prepare a thyrotoxic patient for semi-urgent total thyroidectomy.There is not enough evidence to confidently predict the safe timing when considering total thyroidectomy in this patient cohort, and therefore it should be undertaken when attempts have first been made to safely reduce thyroid hormone levels.Thyroid storm is frequently cited as a potentially severe complication of thyroid surgery undertaken in thyrotoxic patients, although the evidence does not demonstrate this as a common occurrence.

Umbilical Negative Pressure Dressing for Transumbilical Appendectomy in Childern.

BACKGROUND AND OBJECTIVES: Transumbilical laparoscopic-assisted appendectomy (TULAA) carries a high risk for surgical site infection. We investigated the effect of a bio-occlusive umbilical vacuum dressing on wound infection rates after TULAA for patients with acute appendicitis and compared to it with a conventional 3-port appendectomy with a nonvacuum dressing. METHODS: This study was a retrospective chart review of 1377 patients (2-20 years) undergoing laparoscopic appendectomy for acute appendicitis in 2 tertiary care referral centers from January 2007 through December 2012. Twenty-two different operative technique/dressing variations were documented. The 6 technique/dressing groups with >50 patients were assessed, including a total of 1283 patients. RESULTS: The surgical site infection rate of the 220 patients treated with TULAA and application of an umbilical vacuum dressing with dry gauze is 1.8% (95% CI, 0.0-10.3%). This compares to an infection rate of 4.1% (95% CI, 1.3-10.5%) in 97 patients with dry dressing without vacuum. In the 395 patients who received an umbilical vacuum dressing with gauze and bacitracin, the surgical site infection rate was found to be 4.3% (95% CI, 2.7-6.8%). CONCLUSIONS: Application of an umbilical negative-pressure dressing with dry gauze lowers the rate of umbilical site infections in patients undergoing transumbilical laparoscopic-assisted appendectomy for acute appendicitis.

Early transition to oral antibiotics for treatment of perforated appendicitis in pediatric patients: Confirmation of the safety and efficacy of a growing national trend.

PURPOSE: We performed a quality improvement initiative to monitor the change in protocol from purely intravenous therapy for perforated appendicitis to oral antibiotics at discharge once patients could tolerate eating. METHODS: Standardized prospective data were gathered on all children with perforated appendicitis treated under the new oral protocol from January 1 to December 31, 2014. Retrospective data through chart review were gathered on all children treated for perforated appendicitis during 2013. We compared demographics, clinical parameters, and hospital charges. RESULTS: Comparing 115 patients in 2013 and 144 in 2014, demographics and clinical characteristics were similar. In 2014, 95% of patients were discharged on oral therapy. Compared to the intravenous group, the enteric group had statistically lower rates of repeat ultrasound imaging (49.6% vs 35.1%) and PICC placement (98.3% vs 9.1%) and similar rates of intraabdominal abscess (20.9% vs 16.0%) and antibiotic change (26.1% vs 22.2%). In 2014, 55% of patients were discharged by postoperative day 5, compared to 33% in 2013. Total antibiotic days and readmission rate were similar, while hospital charges decreased by half. CONCLUSION: Our results reaffirm that transition to oral antibiotics is safe, effective, and cost-efficient in treatment of perforated appendicitis in the child.

Single-Incision Single-Instrument Adnexal Surgery in Pediatric Patients.

Introduction. Pediatric surgeons often practice pediatric gynecology. The single-incision single-instrument (SISI) technique used for appendectomy is applicable in gynecologic surgery. Methods. We retrospectively analyzed the records of patients undergoing pelvic surgery from 2008 to 2013. SISI utilized a 12 mm transumbilical trocar and an operating endoscope. The adnexa can be detorsed intracorporeally or extracorporealized via the umbilicus for lesion removal. Results. We performed 271 ovarian or paraovarian surgeries in 258 patients. In 147 (54%), the initial approach was SISI; 75 cases (51%) were completed in patients aged from 1 day to 19.9 years and weighing 4.7 to 117 kg. Conversion to standard laparoscopy was due to contralateral oophoropexy, solid mass, inability to mobilize the adnexa, large mass, bleeding, adhesions, or better visualization. When SISI surgery was converted to Pfannenstiel, the principal reason was a solid mass. SISI surgery was significantly shorter than standard laparoscopy. There were no major complications and the overall cohort had an 11% minor complication rate. Conclusion. SISI adnexal surgery is safe, quick, inexpensive, and effective in pediatric patients. SISI was successful in over half the patients in whom it was attempted and offers a scarless result. If unsuccessful, the majority of cases can be completed with standard multiport laparoscopy.

Management of spontaneous pneumomediastinum in children.

PURPOSE: We characterize the outcomes of pediatric spontaneous pneumomediastinum in the largest series to date and propose a management pathway. METHODS: All patients at our institution with ICD-9 code 518.1 confirmed to have isolated radiographic findings of spontaneous pneumomediastinum between January 2003 and February 2014 were retrospectively reviewed for admission, intensive care unit (ICU) stay, complications, and outcome. RESULTS: We identified 96 children with 99 episodes, median age 14.1 years (IQR: 8.7-16.4). Primary symptoms were chest pain, cough, and dyspnea. Most were hospitalized (n=91, 91.9%), with 20 (20.2%) admitted to ICU. Median lengths of stay (LOS) were 1 day (IQR: 1-2) for non-ICU admissions and 3 days (IQR: 2-3) for ICU admissions. The surgical service discharged non-ICU patients 0.94 days earlier than medical services (95% CI 0.38-1.50, p=0.0014). Asthma affected neither LOS nor ICU admission rates. Follow-up imaging, when obtained (n=81, 81.8%), did not alter management. Recurrences occurred in three asthmatics, all after one year. Each was rehospitalized and discharged uneventfully. No patient developed pneumomediastinum-related complications (e.g., pneumothorax, pneumopericardium, or mediastinitis). CONCLUSION: Spontaneous pneumomediastinum without associated comorbidities can be managed with expectant outpatient observation without further imaging. Children with asthma should be treated independent of spontaneous pneumomediastinum.

Nitrous oxide procedural sedation in non-fasting pediatric patients undergoing minor surgery: a 12-year experience with 1,058 patients.

BACKGROUND: Nitrous oxide's safety and efficacy for minor procedures is an alternative to general anesthesia, complex sedation protocols, or local anesthetic alone. METHODS: A retrospective review of prospectively-collected data (2000-2012) identified 1,058 children who received single-agent nitrous oxide for minor surgery. RESULTS: Children (n = 1,058, male 42 %, female 58 %) aged 1-23 years (mean = 9.8 + 5.1 years) were identified. Only nine children (0.9 %) fasted. ASA status was I-II in 1,053 (99.5 %) of patients; five (0.5 %) had an ASA III. There were no major complications (desaturation, emergency admission, apnea, airway obstruction, bradycardia) or aborted procedures. Minor complications occurred in 1.8 %; there was no association between these complications and ASA, fasting status or maximum nitrous oxide percentage administered (all p > 0.05). Post-operatively, 98 % of patients denied getting an injection. Eighty-two percent reported mild or no procedural pain. CONCLUSION: This is the longest reported study using non-anesthesiologist-administered nitrous oxide as a single-agent for minor surgical procedures. The technique provides safe sedation and excellent amnesia, allowing pain and anxiety-reduced surgery with no fasting or postoperative monitoring.

Prospective Comparison of Nonnarcotic versus Narcotic Outpatient Oral Analgesic Use after Laparoscopic Appendectomy and Early Discharge.

Purpose. To compare narcotic versus nonnarcotic outpatient oral pain management after pediatric laparoscopic appendectomy. Methods. In a prospective study from July 1, 2010, to March 30, 2011, children undergoing laparoscopic appendectomy on a rapid discharge protocol were treated with either nonnarcotic or narcotic postoperative oral analgesia. Two surgeons in a four-person faculty group employed the nonnarcotic regimen, while the other two used narcotics. Days of medication use, time needed for return to normal activity, and satisfaction rate with the pain control method were collected. Student's t-test was used for statistical analysis. Results. A total of 207 consecutive children underwent appendectomy for acute, nonperforated appendicitis or planned interval appendectomy. The age and time to discharge were equivalent between the nonnarcotic (n = 104) and narcotic (n = 103) groups. Both had an equivalent number of medication days and similar times of return to normal activity. Ninety-seven percent of the parents of children in the nonnarcotic group stated that the pain was controlled by the prescribed medication, compared to 90 percent in the narcotic group (P = 0.049). Conclusion. This study indicates that after non-complicated pediatric laparoscopic appendectomy, nonnarcotic is equivalent to narcoticbased therapy for outpatient oral analgesia, with higher parental satisfaction.

Treatment of suspected acute perforated appendicitis with antibiotics and interval appendectomy.

BACKGROUND: Initial antibiotics with planned interval appendectomy (interval AP) have been used to treat patients with complicated perforated appendicitis; however, little experience exists with this approach in children with suspected acute perforated appendicitis (SAPA). We sought to determine the outcome of initial antibiotics and interval AP in children with SAPA. METHODS: Over an 18-month period, 751 consecutive patients underwent appendectomy including 105 patients with SAPA who were treated with initial intravenous antibiotics and planned interval AP ≥ 8 weeks after presentation. All SAPA patients had symptoms for ≤ 96 hours. Primary outcome variables were rates of readmission, abscess formation, and need for interval AP prior to the planned ≥ 8 weeks. RESULTS: Intraabdominal abscess rate was 27%. Appendectomy prior to planned interval AP was 11% and readmission occurred in 34%. All patients underwent eventual appendectomy with pathologic confirmation confirming the previous appendiceal inflammation. White blood cell (WBC) count >15,000, WBC >15,000 plus fecalith on imaging, and WBC >15,000 plus duration of symptoms >48 hours were all significantly associated with higher rates of readmission (p=0.01, p=0.04, p=0.02) and need for interval AP prior to the planned ≥ 8 weeks (p=0.003, p=0.05, p=0.03). CONCLUSIONS: Treatment of SAPA with antibiotics and planned interval AP is successful in the majority of patients; however, complications such as abscess formation and/or readmission prior to planned interval AP occur in up to one-third of patients. Certain clinical variables are associated with increased treatment complications.

A simple postoperative umbilical negative-pressure dressing.

Application of umbilical wound dressings is challenging because of the shape and depth of the navel. Dressing changes and umbilical wound cleaning as practiced by many surgeons are painful procedures. The authors describe a simple and durable postoperative umbilical vacuum dressing, providing the advantages of topical negative-pressure wound therapy.

Routine same-day discharge after acute or interval appendectomy in children: a prospective study.

HYPOTHESIS: The outcomes of and parental satisfaction with same-day discharge in children undergoing laparoscopic appendectomy warrant making it the usual and customary pathway. DESIGN: Prospective cohort study. SETTING: Tertiary care children's hospital. PATIENTS: Between July 1, 2010, and March 30, 2011, a total of 207 children were considered for same-day discharge after acute or interval laparoscopic appendectomy. The all-in-one single-incision single-instrument technique was used in 95.7% of children. INTERVENTIONS: Same-day discharge vs overnight admission. MAIN OUTCOME MEASURES: Operative details, postoperative length of stay, adverse events, and parental satisfaction. RESULTS: Of 207 consecutive children undergoing acute (n = 186) or interval (n = 21) appendectomy, 162 (78.3%) were discharged on the day of surgery. The remaining 45 children were admitted overnight because the hour was too late for discharge in 35 (77.8%), medical indications dictated admission in 5 (11.1%), and social reasons required admission in 5 (11.1%). In all the children, oral medication alone was used for postoperative pain. The complication rates were similar in the same-day discharge group (8.0%) and in the admitted group (6.6%), as were the rates of urgent postoperative visits (7.4% vs 4.4%%) and the readmission rates (2.5% vs 2.2%) (P > .05 for all). The same-day discharge group had a reduced postoperative length of stay compared with the admitted group (mean, 5 vs 16 hours, P < .05). At the time of discharge, most parents (87.0%) stated they were happy with the expeditious discharge, whereas 8.0% indicated they felt nervous but were ultimately satisfied. In retrospect, 8 of 162 parents (4.9%) were not sure early discharge was best, but only 1 parent would insist on admission if faced with the situation again. CONCLUSION: Routine same-day discharge after pediatric appendectomy seems safe, with good parental satisfaction.

A prospective study of safety and satisfaction with same-day discharge after laparoscopic appendectomy for acute appendicitis.

BACKGROUND/PURPOSE: This study examines the safety and patient satisfaction in discharging children undergoing laparoscopic appendectomy (LapAppy) for acute appendicitis on the day of surgery. METHODS: After institutional review board approval, data were collected prospectively for 158 consecutive patients undergoing LapAppy for simple appendicitis. Time from operation to discharge and complications were analyzed. At follow-up, parents completed a satisfaction survey. The Student t test was used for statistical analysis. RESULTS: Laparoscopic appendectomy was performed in 158 children ranging from age 2 to 19 years (mean, 12 years) over a 6-month period. Single-port, single-instrument LapAppy was possible in 152 patients (96%). Eighty percent of patients (n = 126) were discharged on the day of surgery, a mean of 4.8 hours postoperatively (range, 1-12 hours). Of the remaining 32, 24 (75%) were admitted because the operation ended too late for postoperative discharge; 3 (9%), for medical reasons; and 5 (16%), when the families declined to leave. One hundred nine parents (87%) whose children went home postoperatively stated that they were happy with the expeditious discharge, whereas 17 (13%) felt nervous. In addition, 116 parents (92%) stated that, in retrospect, same-day discharge was preferable, whereas 10 parents (8%) were not sure that it was the best decision. None, however, would insist on admission if faced with the situation again. There were no major complications and no significant difference in the rate of umbilical wound infections for same-day discharge patients (2%) and admitted patients (3%). CONCLUSION: Routine same-day discharge after pediatric LapAppy for acute appendicitis is safe, with good parent satisfaction.

The "all-in-one" appendectomy: quick, scarless, and less costly.

BACKGROUND: A technique for laparoscopic appendectomy (LAP APPY) that involves brief surgeon and operating room times, results in no appreciable scar, and requires few disposable supplies would be desirable. METHODS: During 2009, 508 children underwent LAP APPY at our institution including 398 (78%) for acute, non-perforated appendicitis. Our "all-in-one" operative procedure involves use of a single instrument through a side-arm viewing operative laparoscope which is inserted through a single, trans-umbilical port. Successful procedure completion rates and operative times ("cut-to-close") were determined. Our data for surgeon-directed, disposable supply costs per procedure were collated by Child Health Corporation of America and compared with 2009 LAP APPY data (n = 5692) from 17 other children's hospitals in the United States. RESULTS: We successfully completed 359 (90.2%) LAP APPY procedures using the all-in-one technique resulting in no appreciable scar. Additional ports were used in 9.8% and there were no conversions to open procedures. Median operative time for the all-in-one technique was 24 minutes (5-66 min). Our median surgeon-directed, disposable supply cost was the lowest in the study group and significantly less than the other 17 children's hospitals ($166 vs $748, P < .001). Median variation of supply costs among surgeons within each institution was $448 ($3-$870). Aggregate savings of nearly $1.3 million are predicted if all study surgeons were to reduce their disposable costs per procedure to the 25th percentile ($551). CONCLUSIONS: We conclude that the all-in-one laparoscopic appendectomy technique is quick, scarless, and less costly than conventional multi-port techniques. Wider application of the all-in-one technique seems indicated.

Diagnosis and laparoscopic treatment of ileoileal intussusception secondary to heterotopic pancreas in an infant: case report and review of the literature.

Small bowel intussusception in infancy owing to a pathologic lead point is a rare event requiring immediate surgical attention. We report a case of a 7-month-old patient presenting with ileoileal intussusception with isolated heterotopic pancreas as the lead point. We review the literature of small bowel intussusception focusing on diagnosis and treatment. In contrast to comparable previous reports of infants with heterotopic pancreas and intussusception, the diagnosis was based solely on ultrasound findings followed by operative management using a laparoscopically assisted surgical approach.

Pediatric robotic surgery: lessons from a clinical experience.

PURPOSE: Robotic surgery may improve minimally invasive surgery at high magnification by tremor filtration, motion-scaling, and improved dexterity with the provision of a wrist at the end of the robotic instrument. MATERIALS AND METHODS: We chose the Zeus Microwrist robotic surgical system as more applicable to small children than the competing da Vinci surgical system. We attempted 57 surgical procedures and completed 54. RESULTS: Completed procedures included Nissen fundoplication (n = 25), cholecystectomy (n = 18), Heller myotomy (n = 2), splenectomy (n = 2), Morgagni hernia repair (n = 2), and single cases of complex pyloroplasty in the chest, bowel resection, left Bochdalek congenital diaphragmatic hernia repair, esophageal atresia and tracheoesophageal fistula repair, and choledochal cyst excision. There were no complications related to the use of the robot. The mean time for the surgeon at the console using the robot was 117 +/- 39 minutes for Nissen fundoplication, and the total operating room time was 250 +/- 60 minutes. Surgeons found dissection, suturing, and knot tying easier than with conventional laparoscopy. None of the surgeons thought the lack of touch feedback (haptics) was crucial. CONCLUSION: Robotic surgery offers increased dexterity to the pediatric minimally invasive surgeon, but procedures require more time, and there is no defined patient benefit. The fact that robotic surgery digitalizes minimally invasive surgery creates exciting possibilities for training surgeons, planning operations, and performing surgery at great distances from the operator.

Laparoscopic Morgagni hernia repair in children using robotic instruments.

BACKGROUND: Robotic surgery enhances minimally invasive surgery through tremor filtration, motion scaling, indexed movement, articulation, and improved ergonomics. We report 2 cases of computer- assisted, robot-enhanced, laparoscopic repair of Morgagni hernia in a 23-month-old weighing 10.2 kg and a 5-year-old weighing 21.6 kg. METHODS: Four 5 mm trocars were used to gain access to the abdomen. In the first case, standard laparoscopic instruments were used to dissect the liver from the rim of the defect and then reduce the hernia. In the second, robotic instruments were used for this dissection. In both cases, the robot- enhanced instruments were used to close the hernia defects with interrupted, nonabsorbable suture, using intracorporeal knot tying. RESULTS: Both cases were completed laparoscopically without a patch. The robotic system took 9 minutes to set up and drape. The average operative time was 227 minutes. The older child tolerated oral intake the day of surgery and went home the following day. The younger child tolerated oral intake and went home on postoperative day 2. CONCLUSION: Robot-assisted laparoscopic Morgagni hernia repair is feasible.

Computer-assisted, robot-enhanced open microsurgery in an animal model.

BACKGROUND: Computer-assisted, robot-enhanced surgery improves laparoscopic and thoracoscopic surgery through tremor filtration, motion scaling, articulation, and improved ergonomics. Surgeons perform many open cases under magnification that magnifies the tremor present in all surgeons' hands, so the tremor filtration and motion scaling of robotic surgery may improve microsurgery. Our goal was to compare microvascular anastomoses performed with a robot-enhanced technique with a standard technique. METHODS: We performed end-to-end anastomoses in 1-mm rat femoral arteries with interrupted 10-0 suture. We compared the anastomotic time, patency, and leak rates between traditional microsurgery techniques (by hand) and a robot-enhanced technique using the Zeus robotic surgery system (Computer Motion, Goleta, California). The surgeon used an operative microscope for visualization in both techniques. RESULTS: We performed 30 anastomoses by hand and 31 with Zeus. We observed a remarkable degree of tremor filtration in the robot-enhanced cases. Anastomotic times for both techniques demonstrated a learning curve. Anastomoses done by hand (mean time, 17.2 minutes) were significantly faster than those done with Zeus (mean time, 27.6 minutes) (P = 0.0006). All anastomoses from both groups were patent, and none leaked after 3 minutes. CONCLUSION: The Zeus system is effective at performing complex, open, microsurgery tasks in vivo. There was no measurable benefit from the remarkable tremor filtration and motion scaling offered by robot-enhanced surgery.

Totally minimally invasive robot-assisted unstented pyeloplasty using the Zeus Microwrist Surgical System: an animal study.

BACKGROUND: Minimally invasive pyeloplasty is a difficult procedure even for an expert laparoscopic surgeon. The major difficulty is associated with the limitations of intracorporeal suturing and knot tying. Surgical robots, which hold minimally invasive surgical instruments, have wrists and provide tremor filtration and motion scaling that might be expected to facilitate complex procedures in newborns. METHODS: Seven survival piglets (4.0-7.5 kg) underwent a totally minimally invasive robot-assisted unstented pyeloplasty employing the Zeus Robotic Microwrist System. The ureter was transected at the level of the ureteropelvic junction and 8 mm was resected. The unstented anastomosis was fashioned with running suture and intracorporeal knot tying. The animals were recovered and intravenous urography was performed at 1 month. After sacrifice, the anastomosis and the kidney were evaluated grossly and histologically for leak, caliber, and healing. RESULTS: All animals survived the procedure without postoperative complications. The mean robotic setup time was 19 minutes (range, 10-30 min), mean anastomosis time 51 minutes (range, 39-63 min), and mean total operation time 76 minutes (range, 57-87 min). The urography showed hydronephrosis in the first animal. The other 6 animals had no abnormalities. Histopathology demonstrated severe hydronephrosis in the first pig and moderate hydronephrosis in the sixth and seventh. All other animals had no sign of hydronephrosis. All anastomoses were well healed and intact. CONCLUSIONS: Robot-assisted laparoscopic pyeloplasty is a technically feasible procedure with acceptable morbidity in an animal model. The robotic technology enhances surgical dexterity and precision. Robotic assistance can increase the applicability of minimally invasive surgery to complex procedures in children.