Choosing the cosmetically superior laparoscopic access to the abdomen: the importance of the umbilicus

Background: Single-incision laparoscopy (SIL) is a rapidly growing procedure in the field of surgery. The most frequent site of abdominal access is the umbilicus. Its appearance can be altered during SIL procedures. The literature suggests that the umbilicus plays an important role in the overall physical appearance of patients. This study therefore investigated the perception of the general population regarding the cosmetics of the umbilicus. Methods: An online survey with 10 questions about the aesthetic importance of the umbilicus was circulated worldwide in both the English and French languages. All the answers then were gathered and analyzed. Results: The majority of the participants considered both their umbilicus and that of their partner as "unimportant.” The total loss of their umbilicus and any undesired changes in its size, shape, and skin color were considered disturbing by most participants, but not its depth. In this survey, 39% of the women and 29% of the men agreed on a negative impact of an undesired change in their umbilicus, whereas 19% of the women and 36% of the men agreed on a negative impact of such a change in the umbilicus of their partner. The majority of the participants did not consider the umbilicus as playing a major role in sexual attractiveness. Conclusions: The majority of the participants gave a limited cosmetic role to the umbilicus and would therefore be good candidates for an umbilical surgical access. Among the minority of participants who considered the umbilicus to be cosmetically important, the men tended to be more concerned about the aesthetic aspect of their partner's umbilicus, and a one-third of them agreed on its role in sexual appeal. Although not the majority, a significant proportion of participants were sensitive about the aspect of their umbilicus. Special care should be given to identify this population and choose the appropriate minimally invasive acces

Robotic Single-Port Cholecystectomy Using a New Platform: Initial Clinical Experience

Background: The technique of single-port laparoscopy was developed over the past years in an attempt to reduce the invasiveness of surgery. A reduction of incisions and their overall size might result in enhanced postoperative cosmesis and potentially reduce pain when compared to conventional techniques. While manual single-port laparoscopy is technically challenging, a newly approved robotic platform used with the da Vinci Si System (Intuitive Surgical, Sunnyvale, CA, USA) might overcome some of the difficulties of this technique. Methods: Patients with cholelithiasis were scheduled for robotic single-port cholecystectomy in an initial clinical trial. Demographic data, intra- and short-term postoperative results were assessed prospectively. Results: Twenty-eight patients (22 females/6 males; median age, 48years) underwent robotic single-port cholecystectomy in our first week of clinical cases. Median OR time was 80min with a median docking time of 8min and median robotic console time of 53min. Two patients underwent intraoperative cholangiography. Eight cases presented with adhesions, tissue alterations, or anatomical abnormalities. No conversions, intra- or postoperative complications occurred. Conclusion: Robotic single-port cholecystectomy appears feasible and safe in our early experience. The robotic approach to single-port surgery seems to overcome some of the technical difficulties of manual single-port surgery. This robotic platform may facilitate completion of more complex case

Impact of robotic general surgery course on participants' surgical practice

Background: Courses, including lectures, live surgery, and hands-on session, are part of the recommended curriculum for robotic surgery. However, for general surgery, this approach is poorly reported. The study purpose was to evaluate the impact of robotic general surgery course on the practice of participants. Methods: Between 2007 and 2011, 101 participants attended the Geneva International Robotic Surgery Course, held at the University Hospital of Geneva, Switzerland. This 2-day course included theory lectures, dry lab, live surgery, and hands-on session on cadavers. After a mean of 30.1months (range, 2-48), a retrospective review of the participants' surgical practice was performed using online research and surveys. Results: Among the 101 participants, there was a majority of general (58.4%) and colorectal surgeons (10.9%). Other specialties included urologists (7.9%), gynecologists (6.9%), pediatric surgeons (2%), surgical oncologists (1%), engineers (6.9%), and others (5.9%). Data were fully recorded in 99% of cases; 46% of participants started to perform robotic procedures after the course, whereas only 6.9% were already familiar with the system before the course. In addition, 53% of the attendees worked at an institution where a robotic system was already available. All (100%) of participants who started a robotic program after the course had an available robotic system at their institution. Conclusions: A course that includes lectures, live surgery, and hands-on session with cadavers is an effective educational method for spreading robotic skills. However, this is especially true for participants whose institution already has a robotic system availabl

Übersicht über mögliche ökonomische Auswirkungen von City-Mauts

Dieser Bericht untersucht ökonomische Effekte einer City-Maut anhand existierender theoretischer und empirischer Studien. Zudem werden internationale Beispiele für City Maut-Systeme vorgestellt. Die Erreichung der politischen Ziele einer City-Maut, wie bspw. Minderung des Verkehrsaufkommens, hängt stark von deren Ausgestaltung ab. Eine City-Maut hat Auswirkungen auf Arbeitsmärkte, Einkommen, Immobilienmärkte, Mobilitätsmärkte sowie Märkte für Güter und Dienstleistungen (Einzelhandel). Diese sind – neben den Auswirkungen auf Verkehrsdichte, Staus und Emissionen – in die Betrachtung einzubeziehen

Canary Bornavirus (Orthobornavirus serini) Infections Are Associated with Clinical Symptoms in Common Canaries (Serinus canaria dom.)

While parrot bornaviruses are accepted as the cause of proventricular dilatation disease (PDD) in psittacine birds, the pathogenic role of bornaviruses in common canaries is still unclear. To answer the question of whether canary bornaviruses (species Orthobornavirus serini) are associatednwith a PDD-like disease in common canaries (Serinus canaria f. dom.), the clinical data of 201 canary bird patients tested for bornaviruses using RT-PCR assays, were analyzed for the presence of PDD-like gastrointestinal or central nervous system signs and for other viruses (mainly circovirus and polyomavirus), yeasts and trichomonads. Canary bornavirus RNA was detected in the clinical samples of 40 out of 201 canaries (19.9%) coming from 28 of 140 flocks (20%). All nucleotide sequences obtained could unequivocally be determined as canary bornavirus 1, 2, or 3 supporting the current taxonomy of the species Orthobornavirus serini. PDD-like signs were found associated with canary bornavirus detection, and to a lesser extent, with circoviruses detection, but not with the detection of polyomaviruses, yeasts or trichomonads. The data indicate that canary bornaviruses contribute to a PDD-like disease in naturally infected canaries, and suggest a promoting effect of circoviruses for the development of PDD-like signs

Who Should Do NOTES? Initial Endoscopic Performance of Laparoscopic Surgeons Compared to Gastroenterologists and Untrained Individuals

Introduction: Natural orifice transluminal endoscopic surgery (NOTES) is a multidisciplinary surgical technique. If conventional endoscopic instrumentation can be easily mastered, surgeons with laparoscopic experience could head NOTES interventions. Materials and Methods: Thirty individuals were tested for endoscopic dexterity. Group 1 included seven gastroenterologists, group 2 included 12 laparoscopically experienced surgeons lacking endoscopic experience, and group 3 included 11 interns who had no hands-on endoscopic or surgical experience. Each individual repeated an easy (T1), medium (T2), and difficult (T3) task ten times with endoscopic equipment on a NOTES skills-box. Results: Group 3 had significantly poorer performances for all three tasks compared to the other groups. No significant differences were seen between groups 1 and 2 for T1 and T2. The initial T3 performance of group 1 was better than that of group 2, but their performance after repetition was not statistically different. Groups 2 and 3 improved significantly with repetition, and group 2 eventually performed as well as group 1. Conclusions: The data indicate that laparoscopic surgeons quickly learned to handle the endoscopic equipment. This suggests that a lack of endoscopic experience does not handicap laparoscopic surgeons when performing endoscopic tasks. Based on their knowledge of anatomy and the complication management acquired during surgical education, surgeons are well equipped to take the lead in interdisciplinary NOTES collaboration

Reducing Cost of Surgery by Avoiding Complications: the Model of Robotic Roux-en-Y Gastric Bypass

Background: Robotic surgery is a complex technology offering technical advantages over conventional methods. Still, clinical outcomes and financial issues have been subjects of debate. Several studies have demonstrated higher costs for robotic surgery when compared to laparoscopy or open surgery. However, other studies showed fewer costly anastomotic complications after robotic Roux-en-Y gastric bypass (RYGBP) when compared to laparoscopy. Methods: We collected data for our gastric bypass patients who underwent open, laparoscopic, or robotic surgery from June 1997 to July 2010. Demographic data, BMI, complications, mortality, intensive care unit stay, hospitalization, and operating room (OR) costs were analyzed and a cost projection completed. Sensitivity analyses were performed for varied leak rates during laparoscopy, number of robotic cases per month, number of additional staplers during robotic surgery, and varied OR times for robotic cases. Results: Nine-hundred ninety patients underwent gastric bypass surgery at the University Hospital Geneva from June 1997 to July 2010. There were 524 open, 323 laparoscopic, and 143 robotic cases. Significantly fewer anastomotic complications occurred after open and robotic RYGBP when compared to laparoscopy. OR material costs were slightly less for robotic surgery (USD 5,427) than for laparoscopy (USD 5,494), but more than for the open procedure (USD 2,251). Overall, robotic gastric bypass (USD 19,363) was cheaper when compared to laparoscopy (USD 21,697) and open surgery (USD 23,000). Conclusions: Robotic RYGBP can be cost effective due to balancing greater robotic overhead costs with the savings associated with avoiding stapler use and costly anastomotic complication

Support in bereavement processes in cases of suicide or substance-related death in childhood: a systematic review

Exposure to parental suicide or substance-related death can be a risk factor for unwanted developmental trajectories. The stigma and taboo that often follow a death subject to being morally sanctioned in society (‘special deaths’) pose an extra challenge for the surviving child and family. The support of informal and formal networks is an important factor in adaptive coping; however, when the death is not socially recognised, the child’s access to support can be limited. This article presents the results of a systematic literature review seeking to explore children’s access to support when parentally bereaved as the result of suicide or a substance-related death. All six studies included address access to support after a suicide-related death. All studies focus on how children can be supported by loss-oriented activities, particularly how to facilitate open communication between the child and their surroundings. Based on this review, the authors recommend developing research on: 1) support for child survivors in the aftermath of substance-related death, 2), children’s everyday grieving practices, including their access to support for restoration-oriented activities, 3) the effects of social support on mental health outcomes, and 4) to developing research designs that allow for disturbing the phenomena of stigma production.publishedVersio

Learning curve for robot-assisted Roux-en-Y gastric bypass

Background: Robot-assisted Roux-en-Y gastric bypass (RYGBP) is rapidly evolving as an important surgical approach in the bariatric field. However, the specific learning curve associated with this new approach remains poorly investigated. This study aimed to evaluate the learning curve for robot-assisted RYGBP. Methods: A series of 64 consecutive robot-assisted RYGBP procedures were performed between December 2008 and December 2010 by a single surgeon already experienced in advanced laparoscopic procedures but not in bariatric surgery. All data were collected prospectively in a database and reviewed retrospectively. The learning curve was evaluated using the cumulative sum (CUSUM) method. Results: Women comprised 76.6% and men 23.4% of this series. These patients had a mean age of 43years and a mean body mass index (BMI) of 44.5kg/m2. The mean operative time (OT) was 238.1min (range, 150-400min). A total of six complications occurred (9.4%). The CUSUM learning curve consisted of two distinct phases: phase 1 (the initial 14 cases; mean OT, 288.9min) and phase 2 (the subsequent cases; mean OT, 223.6min), which represented the mastery phase, with a decrease in OT (P=0.0001). The two groups were similar in terms of gender, age, and BMI. The two phases did not differ in terms of complications or hospital stay. Conclusions: This series confirms previous study findings concerning the feasibility and the safety of robotic RYGBP even after a limited experience with laparoscopic RYGBP. The data reported in this article suggest that the learning phase for robot-assisted RYGBP can be achieved with 14 case

Robot-Assisted Roux-en-Y Gastric Bypass for Super Obese Patients: A Comparative Study

Superobese patients (SO) (body mass index (BMI) ≥ 50kg/m2) represent a real surgical challenge and the best management remains debatable. While the safety of a laparoscopic approach has been questioned for this population, robotics has been introduced in the armamentarium of the bariatric surgeon, yet its role remains poorly assessed, especially for a very high BMI. The study aim is thus to report our experience with robot-assisted Roux-en-Y gastric bypass (RYGB) for SO. From July 2006 to May 2012, 288 consecutive robot-assisted RYGB procedures have been performed at a single institution. All data were collected prospectively in a dedicated database. Among those patients, 41 were SO (14.2%). All the peri- and postoperative parameters were compared to the morbidly obese (MO) group (BMI < 50). Data have been reviewed retrospectively. The SO group presented a higher ASA score and more male patients. The operative time was similar between both groups, yet there were more conversions in the SO group (two versus one for MO; p = 0.05). The morbidity and mortality rates were similar between both groups. The length of stay was longer for the SO population (7 vs. 6days; p = 0.03). The percent BMI loss was similar at 1year (34 vs. 34%; p = 1), but the percent excess BMI loss was higher for the MO group (83 vs. 65% for the SO group; p = 0.0007). Robot-assisted RYGB can be performed safely for SO, with complication rates and functional results at 1year comparable to MO, yet this approach for SO has been associated with a slightly increased conversion rate and length of sta