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Concept: Open surgery


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


INTRODUCTION: Paradigms in the management of duodenal fistula have evolved over the last half a century. Despite advances, morbidity and mortality still remain high. This paper provides a comprehensive, up to date, systematic review in the management of duodenal fistula, classifying the various strategies in the management of duodenal fistula MATERIALS AND METHODS: A review was performed on Medline, Embase and Cochrane library databases using the Cochrane systematic reviews methodology. A final population of 42 studies reported on 349 patients, with a median (range) number of patients per study of two (1-68). The manuscripts were broadly divided in to “non-interventional” and “interventional”. The interventional group was subdivided in to “minimally invasive” and the “open surgical approach”. RESULTS: A total of 147 patients were treated conservatively (non-interventional group), with a median duration of 28 days (range 13-42days) with 13 (9%) deaths recorded in this group. No deaths were reported in the 8 reports on minimally invasive approach.166 patients had open surgical approach with a mortality rate of 30% (50 patients). DISCUSSION AND CONCLUSION: In the absence of randomised controlled trials, no one interventional modality can be considered superior. Initial multidisciplinary conservative approach with sepsis control and nutritional augmentation should be for 6 weeks. It would seem reasonable, in those fistulae that fail to close spontaneously, to attempt a low risk “minimally invasive” intervention where necessary expertise is available. More risky open surgical approaches should clearly be reserved for those that fail and are best performed in specialist centres.

Concepts: Medicine, Mortality rate, Demography, Evidence-based medicine, Systematic review, Randomized controlled trial, Minimally invasive, Open surgery


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


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


BACKGROUND: Current guidelines recommend minimally invasive breast biopsy (MIBB) as the gold standard for the diagnosis of breast lesions. The purpose of this study was to describe geographic patterns and time trends in the use of MIBB in Texas. METHODS: We used 100% Texas Medicare claims data (2000-2008) to identify women older than 66 years of age who underwent breast biopsy. Biopsies were classified as open or MIBB. Time trends, racial/ethnic variation, and geographic variation in the use of biopsy techniques were examined. RESULTS: A total of 87,165 breast biopsies were performed on 75,518 breast masses in 67,582 women; 65.8% of the initial biopsies were MIBB. Radiologists performed 70.3% and surgeons performed 26.2% of MIBB. Surgeons performed 94.2% of open biopsies. Hispanic women were less likely to undergo MIBB (55.9%) compared with white (66.6%) and black (68.9%) women (p < 0.0001). Women undergoing MIBB were also more likely to live in metropolitan areas and have higher income and educational levels (p < 0.0001). The rate of MIBB increased from 44.4% in 2001 to 79.1% in 2008 (p < 0.0001). There are clear geographic patterns in MIBB use, with highest use near major cities. Although rates are increasing overall, rates of improvement in the use of MIBB vary considerably across geographic regions and remain persistently low in more rural areas. CONCLUSIONS: Despite an increase in the use of MIBB over time, MIBB use was consistently lower than recommended. We must identify specific barriers in rural areas to effectively change practice and achieve the statewide goal of 90% MIBB.

Concepts: Cancer, Biopsy, Population, City, Minimally invasive, Mammography, Invasiveness of surgical procedures, Open surgery



A congenital or iatrogenic tissue defect often requires closure by open surgery or metallic components that can erode tissue. Biodegradable, hydrophobic light-activated adhesives represent an attractive alternative to sutures, but lack a specifically designed minimally invasive delivery tool, which limits their clinical translation. We developed a multifunctional, catheter-based technology with no implantable rigid components that functions by unfolding an adhesive-loaded elastic patch and deploying a double-balloon design to stabilize and apply pressure to the patch against the tissue defect site. The device uses a fiber-optic system and reflective metallic coating to uniformly disperse ultraviolet light for adhesive activation. Using this device, we demonstrate closure on the distal side of a defect in porcine abdominal wall, stomach, and heart tissue ex vivo. The catheter was further evaluated as a potential tool for tissue closure in vivo in rat heart and abdomen and as a perventricular tool for closure of a challenging cardiac septal defect in a large animal (porcine) model. Patches attached to the heart and abdominal wall with the device showed similar inflammatory response as sutures, with 100% small animal survival, indicating safety. In the large animal model, a ventricular septal defect in a beating heart was reduced to <1.6 mm. This new therapeutic platform has utility in a range of clinical scenarios that warrant minimally invasive and atraumatic repair of hard-to-reach defects.

Concepts: In vivo, Mammal, Minimally invasive, Abdomen, Congenital heart disease, Invasiveness of surgical procedures, Ventricular septal defect, Open surgery


Robotic surgery has been in existence for 30 years. This study aimed to evaluate the overall perioperative outcomes of robotic surgery compared with open surgery (OS) and conventional minimally invasive surgery (MIS) across various surgical procedures.

Concepts: Medicine, Surgery, Minimally invasive, Invasive, Invasiveness of surgical procedures, Open surgery, Minimally-invasive, Robotic surgery


In a single-center, randomized trial comparing robot-assisted laparoscopic radical cystectomy with open surgery, there was no significant between-group difference in the rates of perioperative complications of grade 2 to 5.

Concepts: Randomized controlled trial, Surgery, Laparoscopic surgery, Open surgery