A 76-year-old male patient was referred to our institution with moderate-to-severe aortic and mitral insufficiency. The patient underwent totally endoscopic robot-assisted aortic valve replacement and mitral valve repair. In this article, we present our lateral approach to the robotic double valve surgery.

Previous studies have shown that the endoaortic balloon occlusion (EABO) can provide satisfactory aortic cross-clamping with comparable surgical outcomes to thoracic aortic clamping in the setting of minimally invasive and robotic cardiac surgery. We described our approach to EABO use in totally endoscopic and percutaneous robotic mitral valve surgery. Preoperative computed tomography angiography is required to evaluate the quality and size of the ascending aorta, identify access sites for peripheral cannulation and endoaortic balloon insertion, and screen for other vascular anomalies. Continuous bilateral upper extremity arterial pressure and cranial near-infrared spectroscopy monitoring are essential to detect obstruction of the innominate artery due to distal balloon migration. Transesophageal echocardiography is needed for continuous monitoring of balloon positioning and antegrade cardioplegia delivery. Direct fluorescent visualization of the endoaortic balloon on the robotic camera allows for verification of balloon and efficient repositioning if needed. The surgeon should assess hemodynamic and imaging information simultaneously during the balloon inflation and delivery of antegrade cardioplegia. Aortic root pressure, systemic blood pressure, and balloon catheter tension affect the position of the inflated endoaortic balloon in the ascending aorta. The surgeon should eliminate all slack in the balloon catheter and lock it into position to prevent proximal balloon migration after the completion of antegrade cardioplegia. Using scrupulous preoperative imaging assessment and continuous intraoperative monitoring, the EABO can achieve adequate cardiac arrest in totally endoscopic robotic cardiac surgery, even in patients with previous sternotomy without compromise of surgical outcomes.

No abstract

Background The use of tourniquets and their role in extremity-based microsurgery has not been thoroughly investigated. The purpose of this study was to investigate tourniquet use and its associated outcomes and complications. Methods Approval from the Institutional Review Boards was granted at each site. A retrospective chart review was completed for patients who had undergone extremity-based microsurgery with the use of a tourniquet between 01/01/2018 and 02/01/2021 at two large academic institutions. Demographic characteristics, initial reasons for surgery, complications, and outcomes were recorded. Patients were separated into groups based on tourniquet-use during three operative segments: (1) flap elevation, (2) vessel harvest and (3) microvascular anastomosis. An internal comparison of complication rate was performed between cases for which a tourniquet was used for one operative segment to all cases in which it was not used for the same operative segment. Univariate and multivariate statistical analyses were performed to identify statistically significant results. Results A total of 99 patients (106 surgeries) were included in this study across sites. The mean age was 41.2 years and 67.7% of the patients were male. The most common reason for microsurgical reconstruction was a traumatic event (50.5%). The need for an additional unplanned surgery was the most common surgical complication (16%). 70% of procedures used a tourniquet for flap elevation. When these cases were compared to those that did not use a tourniquet for flap elevation, there was no difference in complication rates. 61% of procedures used a tourniquet for vessel harvest and 32% for anastomosis. Similarly, additional analyses identified no difference in complication rates when compared to procedures for which a tourniquet was not used for the intervention. Conclusions Based on these results, the authors encourage the use of tourniquets for extremity-based microsurgery to enable bloodless dissection without the concern of increased complication rates.

No abstract

Introduction Injury to the scapholunate interosseous ligament (SLIL) is a common cause of carpal instability, yet surgical management of chronic SLIL disruption remains challenging with no optimal technique identified. Purpose The purpose of this meta-analysis was to comparatively review the available evidence of clinical, radiographic, and patient-reported outcome measures among popular techniques of SLIL reconstruction (capsulodesis, tenodesis, and bone-tissue-bone graft) to better guide management of SLIL injuries. Methods A total of 1,172 patients from 42 included studies were assessed. Standardized data extraction and analysis were performed. The mean of postoperative outcome assessments with standard deviation was used to calculate pooled standardized mean difference with 95% confidence interval. Results Visual Analog Scale (VAS) score for postoperative pain was lowest in bone-tissue-bone patients at 0.9 (p = 0.0360). Bone-tissue-bone patients had the highest percentage of “excellent” functional outcomes at 64.5% (p < 0.0001). Disabilities of the Arm, Shoulder, and Hand (DASH)/QuickDASH score was best in bone-tissue-bone patients at 9.7 (p < 0.0001). Patient-Rated Wrist Evaluation (PRWE) score was best in tenodesis patients at 37.8 (p = 0.0255). There were no statistically significant differences in grip strength, range of motion, or radiographic outcomes among the techniques. Conclusion Existing data demonstrate some benefit of bone-tissue-bone reconstruction over capsulodesis and tenodesis in pain reduction and functional improvement of the injured wrist. No statistically significant differences among radiographic outcomes could be ascertained, possibly attributable to the heterogeneity of procedures. This review provides an updated reference and highlights the need for multicenter trials with longer term follow-up and more standardized outcome measures.

Robotic mitral valve repair (MVR) is an emerging option to treat degenerative valve disease.Compared to open thoracotomy, robotic mitral valve surgery has been shown to afford decreased postoperative length of stay with comparable rates of mortality and morbidity. Among the variety of techniques for robotic MVR, the totally endoscopic approach remains the least invasive method to date. In this report, we describe our technique for totally endoscopic robotically-assisted MVR. In particular, we seek to highlight the use of several unique techniques in MVR. Percutaneous cannulation with use of the endoballoon is employed for cardiopulmonary bypass (CPB), thus avoiding traditional aortic cross-clamping.Moreover, intercostal nerve cryoanesthesia is performed from T3-T9 to reduce post-operative pain and aid in reducing opioid management. Barbed, nonabsorbable sutures are used throughout the procedure (for left atrial appendage closure, mitral valve annuloplasty band placement, left atrial closure, pericardial reapproximation), eliminating the need for knot-tying at several steps. We also detail the installation of two sets of neochords for mitral regurgitation and the fastening of the mitral annuloplasty band. Finally, we would like to highlight the small size of each port used in the case (eight millimeters maximum diameter).Taken together, these features of the robotic platform make it notable for its minimally invasive approach to MVR.

A 61-year-old male presented via referral for mitral regurgitation and was deemed an appropriate robotic surgery candidate for complex mitral valve repair with the maze procedure and patent foramen ovale and left atrial appendage closures, using all percutaneous cannulation. We report upon the first case in the literature that describes the use of only 4 robotic ports, with no working port used.