Development of a high-fidelity minimally invasive mitral valve surgery simulator Sardari Nia, Peyman; Daemen, Jean H.T.; Maessen, Jos G.
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
April 2019, 2019-04-00, 20190401, Volume:
157, Issue:
4
Journal Article
Peer reviewed
Open access
The aim of this study was to develop a high-fidelity minimally invasive mitral valve surgery (MIMVS) simulator.
The process of industrial serial design was applied based on pre-set requirements, ...acquired by interviewing experienced mitral surgeons. A thoracic torso with endoscopic and robotic access and disposable silicone mitral valve apparatus with a feedback system was developed. The feedback system was based on 4 cameras around the silicone valve and an edge detection algorithm to calculate suture depth and width. Validity of simulator measurements was assessed by comparing simulator-generated values with measurements done manually on 3-dimensional reconstructed micro-computed tomography scan of the same sutures. Independent surgeons tested the simulator between 2014 and 2018, whereupon an evaluation was done through a questionnaire.
The feedback system was able to provide width and depth measurements, which were subsequently scored by comparison to pre-set target values. Depth did not significantly differ between simulator and micro-computed tomography scan measurements (P = .139). Width differed significantly (P = .001), whereupon a significant regression equation was found (P < .0001) to calibrate the simulator. After calibration, no significant difference was found (P = .865). In total, 99 surgeons tested the simulator and more than agreed with the statements that the simulator is a good method for training MIMVS, and that the mitral valve and suture placement looked and felt realistic.
We successfully developed a high-fidelity MIMVS simulator for endoscopic and robotic approaches. The simulator provides a platform to train skills in an objective and reproducible manner. Future studies are needed to provide evidence for its application in training surgeons.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Introduction
Seroma formation after axillary lymph node dissection (ALND) remains a troublesome complication with significant morbidity. Numerous studies have tried to identify techniques to prevent ...seroma formation. The aim of this systematic review and network meta-analysis is to use available literature to identify the best intervention for prevention of seroma after standalone ALND.
Methods
A literature search was performed for all comparative articles regarding seroma formation in patients undergoing a standalone ALND or ALND with breast-conserving surgery in the last 25 years. Data regarding seroma formation, clinically significant seroma (CSS), surgical site infections (SSI), and hematomas were collected. The network meta-analysis was performed using a random effects model and the level of inconsistency was evaluated using the Bucher method.
Results
A total of 19 articles with 1962 patients were included. Ten different techniques to prevent seroma formation were described. When combining direct and indirect comparisons, axillary drainage until output is less than 50 ml per 24 h for two consecutive days results in significantly less CSS. The use of energy sealing devices, padding, tissue glue, or patches did not significantly reduce the incidence of CSS. When comparing the different techniques with regard to SSIs, no statistically significant differences were seen.
Conclusions
To prevent CSS after ALND, axillary drainage is the most valuable and scientifically proven measure. On the basis of the results of this systematic review with network meta-analysis, removing the drain when output is < 50 ml per 24 h for two consecutive days irrespective of duration seems best. Since drainage policies vary widely, an evidence-based guideline is needed.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Various definitions of myocardial infarction type 5 after coronary artery bypass grafting (CABG) have been proposed (myocardial infarction MI-5, also known as peri-procedural MI), using different ...biomarkers and different and arbitrary cut-off values. This meta-analysis aims to determine the expected release of high-sensitivity cardiac troponin T (hs-cTnT) after CABG in general and after uncomplicated surgery and off-pump CABG in particular. A systematic search was applied to 3 databases. Studies on CABG as a single intervention and reporting on postoperative hs-cTnT concentrations on at least 2 different time points were included. All data on hs-cTnT concentrations were extracted, and mean concentrations at various points in time were stratified. Eventually, 15 studies were included, encompassing 2,646 patients. Preoperative hs-cTnT was 17 ng/L (95% confidence interval CI 13 to 20 ng/L). Hs-cTnT peaked at 6 to 8 hours postoperatively (628 ng/L, 95% CI 400 to 856 ng/L; 45x upper reference limit URL) and was still increased after 48 hours. In addition, peak hs-cTnT concentration was 614 ng/L (95% CI 282 to 947 ng/L) in patients with a definite uncomplicated postoperative course (i.e., without MI). For patients after off-pump CABG compared to on-pump CABG, the mean peak hs-cTnT concentration was 186 ng/L (95% CI 172 to 200 ng/L, 13 × URL) versus 629 ng/L (95% CI 529 to 726 ng/L, 45 × URL), respectively. In conclusion, postoperative hs-cTnT concentrations surpass most of the currently defined cut-off values for MI-5, even in perceived uncomplicated surgery, suggesting thorough reassessment. Hs-cTnT release differences following on-pump CABG versus off-pump CABG were observed, implying the need for different cut-off values for different surgical strategies.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
The Nuss procedure is the gold standard surgical treatment for pectus excavatum in young patients. Its use in adults has also been described, although it may be associated with increased ...postoperative morbidity resulting from higher chest wall rigidity. This study aimed to examine the risk of complications after the Nuss procedure in adult patients compared with young patients with pectus excavatum.
This single-center retrospective cohort study evaluated all patients who underwent the Nuss procedure between 2006 and 2018. Patients were stratified by age as young (≤24 years old) and adult (>24 years old). The primary end point was the occurrence of perioperative or postoperative complications, subdivided into major (Clavien-Dindo class IIIa or higher) and minor (less severe than Clavien-Dindo class III). Between-group differences were analyzed using the Mann-Whitney U and the χ2 test with post hoc analysis.
A total of 327 participants were included, 272 in the young group (median age, 16 years; interquartile range IQR, 15 to 18 years; range, 11 to 24 years) and 55 in the adult group (median age, 32 years; IQR, 27 to 38 years; range, 25 to 47 years). The median Haller index was similar between groups (young, 3.7; IQR, 3.2 to 4.4 vs adult,3.6; IQR, 3.0 to 4.3; P = .44). The median follow-up was 34 and 36 months, respectively. The incidence of major complications was comparable between young and adult participants (P = .43). Minor complications occurred more often among adults (young, 4% vs adult, 11%; P = .002). Chronic postoperative pain was the only minor complication with a significant difference in incidence (young, 1% vs adult, 7%; P = .008).
The Nuss procedure is a safe surgical treatment for pectus excavatum in both young and adult patients. The risk of major complications is comparable. However, adults more often have chronic pain.
Reoperative mitral valve surgery (MVS) through a median sternotomy (ST-MVS) can be particularly challenging due to dense adhesions and is known to carry a substantial risk of injuries to vascular ...structures. These injuries occur in 7-9% of cases and are associated with increased mortality rates. A valid alternative that could avoid the risks associated with redo ST-MVS is the right anterolateral minithoracotomy (MT-MVS) approach. The aim of this study was to quantify the effects of MT-MVS compared with those of ST-MVS on morbidity and mortality among patients who underwent prior cardiac surgery through a sternotomy. The MEDLINE and EMBASE databases were searched through 1 November 2017. Data regarding mortality, stroke, reoperation for bleeding and length of hospital stay were extracted and submitted to a meta-analysis using random effects modelling and the I2-test for heterogeneity. Six retrospective observational studies were included, enrolling a total of 777 patients. In a pooled analysis, MT-MVS demonstrated reduced mortality rates compared to a standard sternotomy odds ratio (OR) 0.41, 95% confidence interval (CI) 0.18-0.96; P = 0.04. MT-MVS was, moreover, associated with reduced length of hospital stay difference between the means was -3.81, 95% CI -5.53 to -2.08; P < 0.0001) and reoperation for bleeding (OR 0.32, 95% CI 0.10-0.99; P = 0.0488). The incidence of stroke was similar (OR 1.51, 95% CI 0.65-3.54; P = 0.34), all in the absence of heterogeneity. In conclusion, reoperative minimally invasive MVS through a minithoracotomy is a safe alternative to standard sternotomy, with reduced mortality rates, length of hospital stay and reoperations for bleeding and a comparable risk of stroke. However, because the existing literature provided limited, low-quality evidence, more methodologically rigorous randomized controlled trials are needed.
Summary
Primary spontaneous pneumothorax affects up to 28 patients per 100 000 population yearly and is commonly resolved by chest tube drainage. However, drainage is also known to be associated with ...ipsilateral recurrence rates ranging from 25% to 43%. Preventive video-assisted thoracoscopic surgery (VATS) may be an effective alternative to diminish these recurrence rates and its associated morbidity. The aim of this study was to compare the efficacy of chest tube drainage and VATS as first line treatments of an initial episode of primary spontaneous pneumothorax. The MEDLINE, EMBASE, CENTRAL and Clinicaltrials.gov databases were searched through 16 September 2018. Data regarding the ipsilateral recurrence rate and the length of hospitalization were extracted and submitted to meta-analysis using the random-effects model and the I2 test for heterogeneity. Two randomized controlled trials and 2 observational studies were included, enrolling a total of 479 patients. Pairwise analysis demonstrated significantly reduced ipsilateral recurrence rates odds ratio 0.15, 95% confidence interval (CI) 0.07–0.33; P < 0.00001 and length of hospitalization (standardized mean difference −2.19, 95% CI −4.34 to −0.04; P = 0.046) in favour of VATS. However, a significant level of heterogeneity was detected for the length of hospitalization (I2 = 97%; P < 0.00001). Subgroup analysis that stratified study design found no statistical differences regarding recurrence rate. In conclusion, VATS can be an effective and attractive alternative to standard chest tube drainage, with reduced ipsilateral recurrence rates and length of hospitalization. However, given the low quality of the majority of included studies, more well-designed randomized controlled trials are necessary to strengthen the current evidence.
Abstract
OBJECTIVES
The aim of this study was to develop a process for modelling and 3-dimensional (3D) printing of different mitral valve diseases for procedural planning and simulation, based on 3D ...transoesophageal echocardiography (TOE).
METHODS
3D TOE was used to reconstruct a fully dynamic 3D view of the diseased valve. Reconstructions were cropped at the level of the valve and captured in mid-systole to assess the coaptation defect. Reconstructions were then exported as a surface mesh. To ensure a watertight and noise-reduced model, the mesh was processed using computer-modelling programmes, whereupon the valve was printed in 3D. For simulation purposes, deformable models were created based on negative mould fabrication and cast in tissue-mimicking silicone. Model validation was performed by intraoperative assessment of the valvular disease and repair strategy.
RESULTS
The mitral valves of 10 prospective patients with different diseases were modelled. In 6 patients, a 3D printed rigid plastic mitral valve was created for procedural planning, and in 4 patients, a silicone-cast replica was created for procedural simulation. All models were created to scale, implying conservation of in vivo dimensions. Models were validated by in vivo comparison. Total workaround time ranged from 3 to 4 h and 2 to 3 days for rigid plastic and silicone models, respectively. Costs were €15 to €40 and €300, respectively.
CONCLUSIONS
We demonstrated the feasibility of creating rigid plastic and tissue-mimicking silicone mitral valve replications. These models could be used in the future to enhance surgical anatomical interpretation, to facilitate planning and simulation of complex surgeries and for training purposes.
To define the learning process of minimally invasive repair of pectus excavatum by the Nuss procedure through assessment of consecutive procedural metrics.
A single-center retrospective observational ...cohort study was conducted of all consecutive Nuss procedures performed by individual surgeons without previous experience between June 2006 and December 2018. Surgeons were proctored during their initial 10 procedures. The learning process after the proctoring period was evaluated using nonrisk-adjusted cumulative sum (ie, observed minus expected) failure charts of complications. An acceptable and unacceptable complication rate of 10% and 20% were used. Logarithmic trend lines were used to assess over-time performance regarding operation time.
Two-hundred twenty-two consecutive Nuss procedures by 3 general thoracic surgeons were evaluated. Cumulative sum charts showed an average performance from the first procedure after being proctored onward for all surgeons, whereas surgeon B demonstrated a statistically significant complication rate equal to or less than 10% after 59 cases. Post-hoc sensitivity analyses using a stricter acceptable and unacceptable complication rate of 6% and 12% also showed an average performance for all surgeons. Although, the median time between consecutive procedures ranged from 7 to 35 days, no frequency–outcome relationship was observed. In addition, surgeons required the same average operation time throughout their entire experience.
After a 10-procedure proctoring period, repair of pectus excavatum by the Nuss procedure is a safe procedure to adopt and perform without a typical (complication based) learning curve while performing at least 1 procedure per 35 days.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
IntroductionEpidural analgesia is currently considered the gold standard in postoperative pain management for the minimally invasive Nuss procedure for pectus excavatum. Alternative analgesic ...strategies (eg, patient-controlled analgesia and paravertebral nerve block) fail in accomplishing adequate prolonged pain management. Furthermore, the continuous use of opioids, often prescribed in addition to all pain management strategies, comes with side effects. Intercostal nerve cryoablation seems a promising novel technique. Hence, the primary objective of this study is to determine the impact of intercostal nerve cryoablation on postoperative length of hospital stay compared with standard pain management of young pectus excavatum patients treated with the minimally invasive Nuss procedure.Methods and analysisThis study protocol is designed for a single centre, prospective, unblinded, randomised clinical trial. Intercostal nerve cryoablation will be compared with thoracic epidural analgesia in 50 young pectus excavatum patients (ie, 12–24 years of age) treated with the minimally invasive Nuss procedure. Block randomisation, including stratification based on age (12–16 years and 17–24 years) and sex, with an allocation ratio of 1:1 will be performed.Postoperative length of hospital stay will be recorded as the primary outcome. Secondary outcomes include (1) pain intensity, (2) operative time, (3) opioid usage, (4) complications, including neuropathic pain, (5) creatine kinase activity, (6) intensive care unit admissions, (7) readmissions, (8) postoperative mobility, (9) health-related quality of life, (10) days to return to work/school, (11) number of postoperative outpatient visits and (12) hospital costs.Ethics and disseminationThis protocol has been approved by the local Medical Ethics Review Committee, METC Zuyderland and Zuyd University of Applied Sciences. Participation in this study will be voluntary and informed consent will be obtained. Regardless of the outcome, the results will be disseminated through a peer-reviewed international medical journal.Trial registration numberNCT05731973.
Postoperative pleural drainage omission after video-assisted thoracoscopic surgery (VATS) for wedge resections may facilitate faster recovery. This retrospective cohort study presents our 12-year ...experience with omitting thoracic drainage in patients who underwent a VATS wedge resection, aiming to assess its safety and efficacy.
Records from consecutive patients who underwent a VATS wedge resection at our hospital between February 2008 and October 2020 were retrospectively reviewed and assessed for eligibility. Patient and surgical characteristics as well as postoperative data were collected and compared between patients who received a chest drain (CD) or received no chest drain (NCD) after surgery. Univariable and multivariable analyses were performed to determine whether drain placement was associated with complications (primary outcome), and major complications requiring pleural drainage or length of hospital stay (secondary outcomes).
Data of 348 patients were analyzed. The drainless group (n = 98) and drain group (n = 237) were significantly different in the following baseline and surgical characteristics: sex, pulmonary function, interstitial lung disease, final pathology, number of wedges, and surgical approach. No significant differences were detected in postoperative complications (NCD 8.2%, CD 14.8%; P = .10), major complications (NCD 5.1%, CD 5.1%; P > .99), or complications requiring pleural drainage (NCD 5.1%, CD 3.8%; P = .56). The drainless group did show a significantly shorter hospitalization (NCD 2 ± 2, CD 3 ± 2 days; P < .001). Multivariable analyses revealed that drain placement was not significantly correlated with postoperative complications. In contrast, prolonged hospitalization was significantly influenced by drain placement.
Our findings suggest that a no-chest-drain policy after VATS wedge resections can safely fast-track rehabilitation for selected patients.
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