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Knot tying has been shown to be a technical challenge for laparoscopic sacrocolpopexy due to the limited dexterity of the instruments [67] order 25mg meclizine mastercard. These challenges are not present in the robot-assisted surgery where studies have shown that due to the instrument grip strength sutures can be tightened effectively [68] generic 25mg meclizine overnight delivery. In New York purchase 25 mg meclizine with visa, a study comparing the learning curves for robot versus laparoscopic surgical skills highlighted that with regard to suturing and dexterity skills buy meclizine with american express, the robot allowed for quicker performance than laparoscopy [69]. First, have a designated theater team, with no introduction of new members until 20 cases have been performed. Second, patient positioning is of paramount importance and should be standardized for all cases, and finally, familiarization with the instruments sets is required before any deviation is considered [70]. A recent survey of urologists on intraoperative robot malfunction found that breakdown intraoperatively is uncommon; however, it does occur, highlighting the need to counsel patients and to have a contingency plan. Furthermore, they recommend conventional laparoscopic suturing should be maintained as a requirement on the curriculum, thus allowing the surgery to continue using minimally invasive approach [71]. A report of technical challenges faced by surgeons performing robot-assisted gynecological oncological procedures showed 8% were associated with problems with robotic technology. Of this 8% of cases, 18% involved malfunction of robotic arms, 18% involved light or camera cords, and the remainder included a variety of problems, including malfunction of Maryland bipolar instrument (9%). An estimated average of 25 minutes was added to each case in order to solve the robot-related technological problems. It is noteworthy that the robotic surgeon solved all these problems with the assistance of robotic surgery staff. They conclude that all surgeons performing robotic surgery must become familiar with troubleshooting robotic technology and associated equipment. Instrument failure accounted for 50% (9/18) of cases, 22% (4/18) occurred due to robotic arm failures, 16% (3/18) derived from console errors, the remaining 12% (2/18) failure occurred in the optic unit. Of note, the failure rate decreased with increased operator and team experience [75]. They advocated that surgeons and their team should be specifically trained to troubleshoot for these issues [73]. Neurological Injuries Patient positioning is of great importance to minimize the potential adversarial outcomes associated with long operative times. In a single unit study, nerve injury associated with positioning during 1530 urological robotic surgery had an incidence of 6. The injury rate was significantly affected by operative time and American Society of Anesthesiologists group. Therefore, patients undergoing long surgeries should be counseled regard the risk of nerve injury especially if they have multiple comorbidities [76]. General Safety Checklists have been used as an intervention to prevent these failures by promoting a team-working culture, standardizing practice, allowing the detection of potential errors, and improving patient safety as a whole. It is a step-by-step process that involves the multidisciplinary team in identifying potential causes of error within a system through the use of flow diagrams, hazards scoring, and decision tree analysis. Potential errors are prioritized according to severity, frequency/probability, criticality, detectability, and existing control measures. The final process includes taking steps to implement solutions, minimize errors, and avoid adverse events [77]. A unit-specific robot-specific checklist was developed with the aim of allowing the detection of potential errors and improving patient safety as a whole. Specific improvements associated with robot-assisted surgery include better visualization through the use of three-dimensional magnification, availability of tools with 7 degrees of freedom that mimic hand movements along with improved ergonomics, and more intuitive hand–eye coordination when controlling surgical instruments [79–81]. However, this has been achieved at the cost of haptic and tactile feedback, as a result of the instruments not being directly manipulated by the surgeon [82]. It is yet to be seen whether tactile feedback can be achieved through increased sophistication of the computer software. There is limited primary data available in regard to the effect of using the robotic device on surgeon morbidity and discomfort. They found that robotic cases were associated with more discomfort in the neck, while laparoscopic cases were associated with greater discomfort in the upper back and in both shoulders. Furthermore, analysis of ergonomic positioning during the procedures found that laparoscopic surgery was associated with poorer ergonomic positioning of the upper arm, lower arm, wrist, and wrist twist, while robot-assisted surgery scored lower for trunk positioning. A recent study assessing the ergonomics of the surgeons’ physical workload during both laparoscopic and robot-assisted procedures found the physical workload and the perception of effort were greater for laparoscopic procedures. During the standard laparoscopic procedures, there was a greater physical activity in the trapezius and dorsolumbar muscles. Mental stress was identical for the two groups, while the heart rate was significantly raised in the standard laparoscopy group confirming greater physical expenditure [84]. However, the ability to generalize based on studies for specific surgical indications is limited, as the advantage of robotic-assisted surgery significantly depends on the type of the procedure [81]. This may be secondary to the improved visualization achieved using the robot and subsequent improved surgical precision. The traditional limitations on laparoscopic surgery performed with straight-stick instruments have been superseded by the EndoWrist instruments in robotic-assisted surgery. Furthermore, robot-assisted surgery is associated with improved visualization thus allowing for improved surgical precision, which could account for the associated reduced blood loss when undertaking complicated surgical cases. With obesity increasing throughout the developed world, patient habitus often precludes them from 1531 laparoscopic surgery. More complex procedures can be undertaken robotically than with traditional straight stick surgery. Obesity is traditionally associated with an increase in perioperative morbidity and mortality [85]. They found that morbid obesity did not appear to be associated with an increased risk of morbidity. Furthermore, while morbid obesity is associated with an increased procedure time, it had no effect on outcomes. Therefore, robotic surgery offered an ideal approach, allowing minimally invasive surgery in these technically challenging patients, with no significant increase in morbidity [87]. Robotic surgery may provide benefits in terms of wound infection and conversion rates [88]. Studies have shown a fourfold higher conversion rate with the laparoscopic approach in obese women undergoing hysterectomy compared with nonobese women [91]. Body surface area has been shown as a predictor for conversion during laparoscopic colorectal surgery [92]. However, robot-assisted hysterectomy has not been shown to have a higher conversion rate in obese women [93]. Many authors allude to the potential reduction in surgeon strain with regard to surgery in the obese patient; however, no specific studies have been published. There are significant limitations with the quality of the published data analyzing the advantages and disadvantages of robot-assisted surgery. This makes it difficult to know whether the advantages claimed by the protagonists are genuine, and until robust trials are performed, the validity of the claims of benefits to patients and surgeons must be questioned [8–11]. Some of the limitations include a low quality of evidence when the studies were graded according to the National Health and Medical Council hierarchy of evidence [94]. There is a paucity of long-term functional and outcome data associated with robot-assisted surgery and its effect on the patient’s quality of life. The robot system may allow minimally invasive approaches to be used where conventional laparoscopic approaches would otherwise not be possible [96]. It also allows for improved visualization and subsequent improved surgical precision. From the available published literature, most studies conclude that robot-assisted surgery is feasible and technically safe with acceptable early operative outcomes that appear to be comparable to those achieved with open or laparoscopic surgery. However, more robust studies need to be conducted to answer the question of which modality is associated with the greater long-term results. Meta-analysis of observational studies on the safety and effectiveness of robotic gynaecological surgery. Robot-assisted and laparoscopic repair of ureteropelvic junction obstruction: A systematic review and meta-analysis.

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This zone resembling a bottleneck may be regarded as the starting point of invagination discount meclizine 25 mg. In addition buy cheap meclizine 25mg online, various neurological changes have also been linked with rectal prolapse [12 buy cheap meclizine on line,13] cheap meclizine 25 mg on-line. In contrast to stenosis, this is a dynamic effect that is augmented by straining during defecation and thus leads to functional stenosis. This typically causes severe defecation disorders that may also be designated as obstructed defecation. Due to secondary pelvic floor and sphincter damage, incontinence usually becomes a predominant problem 1443 later in the course of the disease. However, functional stenosis during defecation can cause abdominal complaints, defecation disorders, a sensation of bulging in the rectum, and thus a feeling of incomplete evacuation. Those affected may have frequent or prolonged defecation times or require digital support during defecation. In Grade 2, many patients additionally experience soiling and mild incontinence symptoms. Patients can touch the prolapsed intestine during defecation and push it back in place. Patients often have a considerably reduced quality of life and markedly restricted social life [8]. Fecal incontinence leads to fear of embarrassing situations in everyday life and thus results in social isolation. Prolapse is 1444 classified as Grade 3 if present at rest and as Grade 2 if the rectum protrudes only during straining maneuvers [14]. Rectoscopy, Manometry, Endosonography Rectoscopy, manometry, endosonography, and coloscopy are used as complementary measures. They can indicate the extent of prolapse and possibly exclude concomitant diseases [2,16]. Rectoscopic signs may include mechanical irritation of the mucosa and ulcerations (ulcus simplex, typically on the anterior rectal wall). Endosonography can demonstrate alterations or injuries in the anal sphincter, and coloscopy can exclude important differential diagnoses like cancer. Diagnostic Imaging Cinedefecography is performed to detect Grade 1 rectal prolapse (intussusception) [2,16]. This dynamic examination during defecation can demonstrate a functional obstruction that only becomes manifest in the defecation process (Figure 95. It consists of dietary measures to promote bowel regularity (high-fiber food, plenty of fluids), laxatives, stool softeners, pelvic floor exercises, and biofeedback [14]. Nevertheless, the indication is always dependent on the clinical symptoms and the success of conservative therapy. Intussusception (Grade 1 rectal prolapse) without clinical symptoms may be an incidental imaging finding and is not an indication for therapy [17]. Grade 3 rectal prolapse, on the other hand, is always an indication for surgery, since complications such as ischemia and bleeding may occur if left untreated. Surgical Methods There are many different surgical methods for treating rectal prolapse. The aim of all procedures is anatomical correction to improve bowel function and reduce prolapse-related symptoms. However, there are basic differences in the technical implementation of this principle: the surgical approach can be either abdominal or perineal. The abdominal procedure can be performed by either open or laparoscopic surgery [18]. According to the surgical technique, a distinction is also made between bowel fixation (rectopexy), bowel resection (sigmoidectomy), and a combination of the two (resection rectopexy) [1]. There is no gold standard or clear evidence-based recommendation as to which method is most suitable [1]. Relapse rates reported in the literature are mostly lower for abdominal than for perineal interventions. This procedure is therefore recommended particularly for younger and otherwise healthy patients [3,4,19,20]. On the other hand, perineal procedures are associated with lower morbidity and mortality. Some authors have achieved favorable results with laparoscopic abdominal surgery in older people and therefore recommend this type of surgery for these patients [21–23]. Abdominal Procedures: Rectal Resection and Rectopexy Abdominal procedures can be performed by open or laparoscopic surgery. Various studies have demonstrated less stress and a faster recovery for patients undergoing laparoscopic interventions. The Wells procedure supplements fixation by placement of synthetic mesh in the presacral space [24]. The Ripstein procedure entails wrapping synthetic mesh around the anterior rectal wall and fixing it to the sacrum on both sides [25]. It is a nerve-sparing procedure, since rectal mobilization and fixation with sutures or synthetic mesh is only performed anteriorly. Though very good results have been published for this method, randomized controlled trials are lacking [27,28]. A procedure that combines rectopexy with resection is the resection rectopexy as described by Frykmann und Goldberg. Very good results have also been published for this frequently applied surgical method [28]. It involves complete circular mobilization of the rectum up to the pelvic floor musculature and resection of the rectosigmoid colon. The rectum is then fixed to the promontory with sutures or by placing synthetic mesh anterior to the sacrum. A lower rate of postoperative constipation had been reported for resection rectopexy than for -pexy without resection [1,19]. However, resection also harbors the risk of anastomotic leak and is thus associated with an increased complication rate. The material used for rectal fixation also varies widely and includes meshes made from synthetics such as polypropylene, although fixation can also be performed with simple sutures or laparoscopic staples. No clear evidence-based recommendations have been made as to what material is most suitable [1]. The corresponding muscle layer is unfolded and fixed above the sphincter with single button sutures (Figure 95. The Altemeier procedure entails transanal full-thickness resection of the prolapsed segment. The anastomosis is hand-sutured or mechanically created with a circular stapler [1]. It is important to avoid entrapping any part of the vagina in the staple line, since this may result in necrosis and sepsis [30]. Therapy consists of dietary measures to promote bowel regularity and enemas if necessary. Open or laparoscopic suture rectopexy may be performed in rare cases where spontaneous regression does not occur. The rectum is mobilized and fixed to the periosteum of the sacral promontory [33]. Particularly in Grade 3, patients are at risk for incarceration, gangrene, and sepsis [1]. A complication rate of about 10% and a relapse rate of approximately 6%–15% are reported in the literature [20,21]. The initial complaints—impaired evacuation and incontinence—persist in some patients even after surgery. The literature reports a 30%–40% persistence rate with a higher rate for perineal than for abdominal interventions [20]. Previously masked incontinence may only become manifest after surgical correction of rectal prolapse for impaired evacuation. This means that patients should be informed in detail that their functional problems may not improve even by surgery [4,20]. This leads to incomplete evacuation, frequent and prolonged defecation, digital support during defecation, and rectal pain. The most frequent cause is internal rectal prolapse (intussusception), as described previously [34]. Rectocele involves bulging of the rectal wall, usually anteriorly, due to expansion of the rectovaginal septum.

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