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Concept: Invasiveness of surgical procedures


BACKGROUND: A few lineages of Group A streptococci (GAS) have been associated with a reemergence of severe invasive streptococcal disease in developed countries. However, the majority of the comparisons between invasive and non-invasive GAS isolates have been performed for collections of reduced genetic diversity or relied on limited typing information to distinguish clones. We characterized by several typing methods and compared a collection of 160 isolates recovered from normally sterile sites with 320 isolates associated with pharyngitis and recovered in the same time period in Portugal. RESULTS: Although most of the isolates belonged to clones that were equally prevalent in invasive infections and pharyngitis, we identified markers of invasiveness, namely the emm types 1 and 64, and the presence of the speA and speJ genes. In contrast, emm4, emm75, and the ssa and speL/M genes were significantly associated with pharyngitis. There was a strong agreement between the emm type, the superantigen (SAg) genes and the clusters defined by pulsed-field gel electrophoresis (PFGE) profiling. Therefore, combinations of particular emm types and SAg genes frequently co-occurred in the same PFGE cluster, but there was no synergistic or antagonistic interaction between them in determining invasiveness. Only macrolide-susceptible PFGE clones were significantly associated with invasive infections or pharyngitis, while the clones of resistant isolates sharing all other molecular properties analyzed were equally prevalent in the two groups of isolates. CONCLUSIONS: This study confirmed the importance of the widely disseminated emm1-T1-ST28 clone in invasive infections but also identified other clones linked to either invasive infections (emm64-ST164) or pharyngitis (emm4-T4-ST39), which may be more limited in their temporal and geographical spread. Clonal properties like some emm types or SAg genes were associated with disease presentation, highlighting the importance of bacterial genetic factors to the outcome of GAS infections, although other, yet unidentified factors may also play an important role.

Concepts: Gene, Genetics, Bacteria, Virus, Streptococcus, Invasive, Invasiveness of surgical procedures, Group A streptococcal infection


Use of robotic systems for minimally invasive surgery has rapidly increased during the last decade. Understanding the causes of adverse events and their impact on patients in robot-assisted surgery will help improve systems and operational practices to avoid incidents in the future.

Concepts: Surgery, Minimally invasive, Invasive, Invasiveness of surgical procedures


The realm of minimally invasive surgery now encompasses the majority of abdominal operations in the field of colorectal surgery. Diverticulitis, a common pathology seen in most colorectal practices, poses unique challenges to surgeons implementing laparoscopic surgery in their practices due to the presence of an inflammatory phlegmon and distorted anatomical planes, which increase the difficulty of the operation. Although the majority of colon resections for diverticulitis are still performed through a standard laparotomy incision, laparoscopic techniques are becoming increasingly common. A large body of literature now supports laparoscopic surgery to be safe and effective as well as to provide significant advantages over open surgery for diverticular disease. Here, we review the most current literature supporting laparoscopic surgery for elective and emergent treatment of diverticulitis.

Concepts: Surgery, Colon, Minimally invasive, Laparoscopic surgery, Invasive, Invasiveness of surgical procedures, Open surgery, Diverticulitis


Treatment options for the Dupuytren contractures vary from percutaneous needle aponeurotomy, open fasciotomy or fasciectomy, dermofasciectomy, and more recently, injectable collagenase. Although utilization of injectable collagenase avoids a formal surgical procedure, not all patients are eligible and some patients do not feel comfortable with an enzyme injection or the associated risks, which may include hematoma, wound dehiscence, or tendon rupture. This study describes the technique and early results of partial fasciectomy through a mini-incision approach as an additional treatment option for Dupuytren contractures. We found that this procedure results in contracture correction with a low rate of complications and thus provides the surgeon with an alternative treatment option to offer patients.

Concepts: Hospital, Surgery, Physician, Minimally invasive, Invasiveness of surgical procedures, Open surgery, Dupuytren's contracture, Hypodermic needle


Abstract Purpose: To evaluate the efficacy and safety of adjunctive mitomycin-c (MMC) during probing in adults with primary nasolacrimal duct (NLD) obstruction. Methods: This is a prospective, comparative, randomized interventional study. A total of 40 adult patients with unilateral epiphora caused by primary NLD obstruction were treated and evaluated. Lacrimal probing and irrigation with adjunctive MMC (1 mL of 0.2 mg/mL, once) in cases and only probing in controls were done. At the end of 3 months, subjective improvement in epiphora and patency on syringing were evaluated. Results: Complete subjective improvement in epiphora was found in 15% of cases as opposed to 0% in controls, at 3 months of follow-up. Moderate improvement was seen in 25% of cases as opposed to 5% of controls. Mild improvement was seen in 25% of cases as opposed to 35% in controls. The overall subjective improvement was seen in 65% of cases as opposed to 40% in controls. On syringing, NLD was patent in 30% of cases as opposed to 10% in controls at 3 months of follow-up, which was not significant. Conclusions: Use of intraoperative MMC improves the success of probing to some extent. Being a minimally invasive procedure, it can be tried in patients who refuse or are not systemically fit for undergoing dacryocystorhinostomy.

Concepts: Minimally invasive, Invasive, Invasiveness of surgical procedures, Tears, Nasolacrimal duct, Nasolacrimal canal


As a result of increased use of CT in both screening and daily practice, the number of early lung cancers has increased enormously. Surgeons pursue both curativity and reduced invasiveness in treating patients with early stage lung cancer; therefore, minimally invasive operations, such as video-assisted thoracoscopic surgery (VATS) lobectomy are now being routinely performed. Most previous reports have shown that there is no difference in mortality and local recurrence between open surgery and VATS in stage I patients. However, surgeons' improved technical experience and patients' demands could soon make VATS lobectomy the operative method of choice for early stage lung cancer. Moreover, the indications for VATS are expanding to encompass complex procedures such as segmentectomy or sleeve resection. Training and dissemination of the technique and the monitoring of outcomes are necessary.

Concepts: Cancer, Lung cancer, Cancer staging, Surgery, Minimally invasive, Invasiveness of surgical procedures, Open surgery, VATS lobectomy


Central pulse pressure (cPP) is increasingly investigated as possible independent predictor of cardiovascular risk and carotid pulse pressure (carPP) can be used as a surrogate of cPP. Despite its importance, carPP measurement remains challenging in clinical practice. The aim of this study was to introduce a new easier-to-use method for noninvasive carPP evaluation based on the use of a MEMS accelerometer.

Concepts: Medical terms, Blood pressure, Evaluation methods, Pulse, Invasiveness of surgical procedures


Minilaparoscopy is an attractive approach for hysterectomy due to advantages such as reduced morbidities and enhanced cosmesis. However, it has not been popularized due to the lack of suitable instruments and high technical demand. We aim to highlight the first case of laparoscopic hysterectomy performed with percutaneous instruments (The Percuvance™ System, Teleflex Incorporated,USA) that represents a significant advance in minimally invasive surgery.

Concepts: Surgery, Minimally invasive, Hysterectomy, Invasiveness of surgical procedures


Prolonged operative time (ORT) is often considered a drawback to minimally invasive surgery (MIS) due to increased morbidity. Limited data exist comparing long laparoscopic ORT to similar or shorter open ORT. This study aims to identify ORT when a minimally invasive procedure becomes inferior to its open counterpart. Minimally invasive and open total and partial nephrectomies, and nephroureterectomies were identified in the National Surgical Quality Improvement Program (NSQIP) from 2005-2012. Procedures were split into open and MIS and stratified into 4 ORT groups: 0-90 minutes, 91 minutes-3 hours, 3-6 hours, and ≥6 hours. 30-day mortality and morbidity were analyzed. Univariate analysis was performed using chi-square and Fishers Exact tests. Significant univariate results were tested using stepwise logistic regression, controlling for demographics, comorbidities, and preoperative treatments. 14,813 patients were identified. Both partial and total minimally invasive kidney procedures had significantly improved outcomes compared to open counterparts of similar ORT. In the total group, MIS had a lower rate of SSI’s, sepsis, pneumonia, return to OR and length of stay when compared to open procedures of the same duration. Length of hospital stay decreased in MIS regardless of operative time, except when comparing minimally invasive cases longer than 6 hours to open cases less than 90 minutes. Transfusion rates also significantly decreased in minimally invasive total nephrectomies. In the partial group, similar outcomes were seen with length of stay and infectious outcomes. Interestingly, transfusion was decreased in the open partial nephrectomy group when comparing cases less than 90 minutes to minimally invasive partials lasting 3-6 hours; otherwise there was no significant correlation with transfusion. Minimally invasive operations are less morbid than open operations of similar ORT. Longer and likely more complex laparoscopic procedures continue to provide a benefit when compared to shorter and possibly less complex open procedures. These data should be considered during a surgeon’s pre-operative and operative decision-making.

Concepts: Kidney, Surgery, Minimally invasive, Invasive, Invasiveness of surgical procedures, Nephrectomy, Open surgery, Minimally-invasive


The most common paradigm in minimally invasive surgery is entry of a single trocar through separate incisions in the abdomen. However, in an effort to decrease postoperative pain and minimize scarring, alternative techniques have been described. Needlescopic surgery uses instruments that are 3 mm or less in diameter. Prior uses of needlescopic instruments have been hindered somewhat by diminished shaft strength and small end-effector size. The Percuvance™ (Teleflex, Wayne, PA) system uses a 2.9-mm shaft with interchangeable 5-mm end effectors in order to minimize abdominal wall trauma while maintaining the functionality of traditional laparoscopic instruments.

Concepts: Surgery, Minimally invasive, Abdomen, Laparoscopic surgery, Invasive, Invasiveness of surgical procedures, Human abdomen