The Intra-abdominal Environment: What’s It All About?
Douglas E. Ott, MD, MBA
Laparoscopic surgery begins with abdominal entry and gas insufflation. The dynamics of the immediate and long lasting effects of the quality of the gas used has important considerations that are often overlooked. The effects are a combination of chemical, mechanical and biologic. Traditional insufflation is with carbon dioxide that is room temperature and extremely dry compared to the surgical circumstance of body temperature and wet abdominal environment. Continuous intermittent exposure of tissue surfaces to dry gas causes damage that can be mitigated by changing gas characteristics. Humidifying reduces hypothermia and tissue desiccation. Laboratory and clinical evaluations show that traditional dry cool gas and dry warmed gas have no benefit during laparoscopy. Clinical use of humidified gas keeps the intra-abdominal environment in a condition conducive to maintaining thermal balance and morphologic integrity and function of the peritoneum. Preservation of the intra-abdominal environment as close to humidity and temperature are beneficial for improved patient outcomes.
Robotic Radical Prostatectomy: Outcomes of 4000 Cases
Vipul R Patel, MD
Global Robotics Institute, Florida Hospital Celebration Health, Celebration, FL
University of Central Florida School of Medicine, Orlando, FL
The three long-term goals of Radical Prostatectomy (RP) are complete removal of the cancer, recovery of urinary continence, and recovery of sexual potency. However, these individual outcomes are not necessarily independent of each other, i.e., improvement in one outcome may come at the expense of the other two outcomes. Therefore, assessing individual results after RP may not truly inform the patient regarding what to expect in terms of overall cancer control and quality of life after surgery. This has led to the concept of reporting the likelihood of achieving the three outcomes concurrently after RP: the so-called “trifecta”.
Throughout our learning experience, we developed several technical modifications during Robotic-Assisted Radical Prostatectomy (RARP), which presently allow us to perform the procedure with improved functional outcomes while not compromising cancer control; as a result, excellent “trifecta” rates are currently reported in our series. We recently evaluated prospectively 404 consecutive patients who were considered potent preoperatively and underwent bilateral full nerve-sparing RARP. Baseline and postoperative urinary and sexual functions were assessed using self-administered validated questionnaires. The overall trifecta rates were 42.8%, 65.3%, 80.3%, 86% and 91% at 6 weeks, 3, 6, 12, and 18 months after RARP, respectively. The technical refinements developed during our series will be fully described in this presentation, including the periurethral suspension stitch, athermal seminal vesicle dissection, early retrograde release of the neurovascular bundle, incremental/partial nerve-sparing, athermal apical dissection, transverse bladder neck plication/reconstruction and, finally, modified posterior reconstruction of the rhabdosphincter.
Immunological Issues of Laparoscopic Surgery
Sákra Lukáš, MD1, PhD, Lotkova H., MD, PhD2, Kohoutek L. MD2, Siller J. MD, PhD2
Surgical Department of the General Hospital Pardubice, Czech Republic
1Charles University, Faculty of Medicine, Hradec Králové
2The Institute of Medicine of the University of Pardubice, Department of Physiology
Introduction: The advantages of mini-invasive procedures (reduced consumption of analgesics, reduced occurrence of post-operative complications, and earlier restoration of pulmonary and intestinal functions) immediately after surgery are obvious and incontestable. Less adverse effects on the overall immune response were also confirmed. The laparoscopic procedure is followed with a milder overall inflammatory response.
Despite these advantages of laparoscopic procedures some recent studies refer to the fact that the local immune response presented by peritoneal macrophages is more disturbed or even impaired by laparoscopic rather than by laparotomic (traditional) procedures. Should peritoneal macrophages be negatively influenced, it could worsen the results of laparoscopic procedures for malignities. If this premise is confirmed, the routine use of laparoscopic methods in case of malignities should be considered.
Objective and Method: Differences between the effects of laparotomic and laparoscopic approaches on the overall immune response were reviewed. The performed studies refer to a reduced negative impact on the overall immune response after laparoscopic procedures. However, this paper reveals substantially varying opinion on the effects of both types of procedures (laparoscopic and laparotomic) on local immunity represented by peritoneal macrophages. Therefore, our contemporary experimental models (rats) focus on the local immune peritoneal response mediated by macrophages. The presented experiment compared two groups of rats. One group underwent the laparotomic suture of the caecum and the other was treated in a laparoscopically assisted way. After 24 and 72 hours peritoneal macrophages were removed from the abdominal cavity and their production of IL1, IL6 and TNF alpha was determined. The results prove the high production (and subsequently greater influence) of TNF alpha and of IL1-beta produced by macrophages after laparoscopic procedures.
Results and Conclusion: Reduced effect on the total immune response after laparoscopic procedures is considered proven. The impact on the local immune response is not as obvious yet. Although the greater negative influence of the laparoscopic procedure on these macrophage activities has not been clearly confirmed, the first results provided by experimental models support this hypothesis.
Canada and Medical Care From a Gynecologists Point of View
Nicholas Pairaudeau MB. BS, FRCS.(C)
Department of Obstetrics and Gynecology North York General Hospital, Affiliate to the University of Toronto, Toronto, Ontario, Canada
A lively presentation will be made on the medical scene in Canada as seen by a gynecologist working in Canada for 37 years.
An outline of the provision of health care in Canada will include a short history of the background of medical care in Canada from the 1900 to the present day. The audience will understand that Canada is a large country with many provinces, and that health care is under the jurisdiction of the Provincial Government, with economic support from the Federal Government. In times of reduced funding, the impact on medical care can be very significant both to the patient as well as the providers of care. Despite this, many people within Canada as well as potential immigrants value the culture that there should be no obstacle to receiving medical care, whatever your financial means.
Hopefully time will be made to answer questions about this unique, but some say unsustainable, medical system.
Laparoscopic Treatment of Colorectal Diseases: Five Years Experience
Ignazio Massimo Civello, MD, FACS1; Serafino Vanella, MD2 ₁
1Surgical Department, General Surgery Unit, Distretto Ospedaliero “CIVILE-OMPA” Hospitals, ASP Ragusa, Italy 2Surgical Department, Catholic School of Medicine, University Hospital Agostino Gemelli, Rome, Italy
Background: The minimally invasive technique, by means of the undoubted advantages of the method, has become fully accepted in the surgical treatments of the most benign and functional diseases. Today it has been proven that the laparoscopic technique is safely usable also in the surgical treatment of colorectal tumors.
Methods: 125 patients were treated with laparoscopic colorectal resections between January 1st, 2005 and December 31st, 2009. The surgical indication was neoplastic colorectal lesion in 80 cases and diverticular stenosis in 45 patients.
Results: The average age of the patients was 64 years (from 36 to 89 years). 50 patients underwent rectosigmoidal resection, 45 had rectal resection, 20 had right hemicolectomy and 10 had left hemicolectomy. Average operative time: 160.5’ (range 80-360). Conversions to open surgery: 15%. Duration of ileus: 3.75 days (range 1-9). Postoperative hospital stay: 8.67 days (range 6-15). Overall postoperative morbidity rate: 16.67%. Ileostomies were performed in low rectal resections. Ileostomy closure: after two months from original intervention. All oncological patients are alive at different follow-up periods (3 months-4 years).
Conclusions: Under traditional perioperative treatment, laparoscopic colonic resections show clinically relevant advantages in selected patients. Laparoscopic approach presents a rather steep learning curve. The laparoscopic approach does not seem to entail any oncologic disadvantages.
Is Posterior Retroperitoneoscopic Adrenalectomy Better than the Classical Anterior Laparoscopic Technique in Various Adrenal Pathologies?
Dimitrios Linos, MD, FACS
Massachusetts General Hospital, Lecturer on Surgery Harvard Medical School, 1st Surgical Clinic “HYGEIA” Hospital
The majority of surgeons use the anterior (or anteriolateral) approach to remove most adrenal tumors laparoscopically.
We applied the Posterior Retroperitoneoscopic Adrenalectomy on 30 patients (21 F and 9 M) and compared the outcomes with 30 control patients that had undergone the classical Anterior Laparoscopic Adrenalectomy. The median tumor size was 4.5 cm for the posterior and 5.0 cm for the anterior group. The median operative time was similar between the two groups (96 min for the posterior vs 85 min for anterior group) but after the 20th case the operative time for the retroperitoneoscopic approach was reduced significantly. Pain scores were significantly lower for the retroperitoneoscopic group. Median hospital stay was also better (2 days for the posterior versus 3.8 days for anterior group).
Posterior retroperitoneoscopic adrenalectomy compared to laparoscopic adrenalectomy is safe, fast, with less postoperative pain and hospital stay. We believe that this approach should become the gold standard for the removal of most adrenal tumors.
Laparoscopic Ventral Rectopexy for Rectal Prolapse Using Biological Mesh
Sileri, Pierpaolo; Franceschilli, Luana; Lazzaro, Sara; Angelucci, Giulio P.; Patrizi, Lodovico; Fiaschetti, Valeria; Piccione, Emilio; Gaspari, Achille
University of Rome Tor Vergata, Rome, Italy
Background: Laparoscopic Ventral Mesh Rectopexy (LVR) is a novel procedure to correct rectal prolapse improving obstructive defecation symptoms and fecal incontinence. The use of biological mesh has been extended to correct pelvic floor disorders but data is scant. We present our experience with this procedure using biological mesh.
Methods: Prospectively collected data on LVR for rectal prolapse were analyzed. All patients underwent defecating proctography and/or pelvic dynamic MRI, full colonoscopy, anal physiology studies, and endo-anal ultrasound. End-points were surgical complications and functional results such as changes in bowel function (Wexner Constipation Score and Fecal Incontinence Severity Index) at 3 and 6 months. Analysis was performed using Mann-Whitney U-test for unpaired data and Wilcoxon signed rank test for paired data (two-sided p-test).
Results: Twenty-five consecutive patients underwent LVR (median age 61 range 46-78 years). Nineteen patients (76%) had a constipation score >5, while nine (36%) a FISI score >10. Three patients (12%) had mixed OD and FI. One patient required conversion to open (3%). Median length of stay was 2 days. We did not observe mortality or major morbidity. Two patients experienced UTI (8%). Preoperative constipation (median Wexner score 14) and faecal incontinence (median FISI score 11) improved significantly at 3 months (Wexner 3, FISI 4, both p<0.001). One patient (3%) required Stapled Transanal Rectal Resection (STARR) for persisting symptoms 6 months after surgery. No patients had function worsening.
Conclusions: Laparoscopic ventral rectopexy using biological mesh for rectal prolapse is safe and effective in ameliorating symptoms of obstructed defecation and fecal incontinence.
A Rare Transition of EndometriosisJJ van Beek, MD, PhD,
Vie Curi, Venlo, Netherlands
Background and Objectives: Adenosarcoma is an uncommon neoplasm of the uterus and rare in extragenital locations. Endometriosis may transit into adenosarcoma. Most transitions occur within the genital organs. Only one third originates extra genital. The stromal component may vary from low to high grade and may be homologous or, less frequently, heterologous.
Methods: We report on a 47 years old patient with a rare transition of vaginal endometriosis into a low-grade adenosarcoma with a rare heterologous liposarcomatous differentiation, which presented as a vaginal polyp outside the cervix.
Results: We describe the laparoscopic treatment of this low-grade adenosarcoma: The initial removal and the subsequent laparoscopic hysterectomy and oophorectomy with excision of the local shaft and regional lymph nodes.
Conclusion: To our knowledge, this is the first description of a complete laparoscopic treatment of a low-grade adenosarcoma with heterologous liposarcomatous differentiation of the rectovaginal septum in a patient with severe endometriosis.
Hysteroscopic Management of Endometrial Pathologies
Assist. Prof. Gazi Yildirim, MD
Yeditepe University Hospital, Istanbul, Turkey
Fibroids are one of a number of structural abnormalities in the uterus that may cause abnormal bleeding. The list also includes endometrial polyps, endometrial hyperplasia and adenomyosis. Most submucous myomas and clinically significant endometrial polyps are not identified by blind procedures, such as a dilatation and curettage, or endometrial biopsy. Hysteroscopy is an excellent method for not only identifying intrauterine lesions, but also removing them.
Submucous Fibroids: Uterine leiomyomas are benign solid tumors occurring in about 20% to 30% of women during their reproductive years. The unipolar or bipolar resectoscopes are most ideally designed to remove intrauterine lesions. The most commonly used resectoscopes are monipolar instruments, in which case the uterine cavity is distended with a low-viscosity non-electrolyte-containing fluid, such as sorbitol, glycine or mannitol. A bipolar resectoscope is available which has the safety of bipolar energy and must be used with normal saline as a distending medium.
Polyps: A polypoid structure may be a leiomyoma, adenomyoma, or an endometrial polyp. Endometrial polyps originate from the middle or basal third of the endometrium and may or may not be covered by functioning endometrium. When a polypoid structure is being removed, it is possible to transect the base by dropping the 90° electrode into the stalk. It may be necessary to do this in more than one side of the stalk.
Abnormal Uterine Bleeding: In general, abnormal uterine bleeding has been recognized as a frequent and serious problem affecting women for hundreds of years. Its management has included attempts at destruction of the endometrium, especially for women who refuse hysterectomy or are poor candidates for major surgery.
Intrauterine Adhesions: Intrauterine adhesions may interfere with both normal reproduction and menstrual patterns. Three stages of intrauterine adhesions are defined: mild adhesions are filmy adhesions composed of basalis endometrial tissue producing partial or complete uterine cavity occlusion; moderate adhesions are fibromuscular adhesions, characteristically thick, still covered with endometrium that may bleed upon division, which partially or totally occlude the uterine cavity; and severe adhesions are composed of connective tissue only, lacking any endometrial lining, and not likely to bleed upon division, they may partially or totally occlude the uterine cavity. Intrauterine adhesions frequently result in menstrual abnormalities, such as hypomenorrhea or even amenorrhea, depending upon the extent of uterine cavity occlusion. When total amenorrhea and total uterine cavity occlusion exist, the patient will generally be infertile. Other problems associated with intrauterine adhesions are premature labor, fetal demise and ectopic pregnancy. When pregnancy is carried to term, placental insertion abnormalities, such as placenta accreta, percreta or increta, may occur. When surgical treatment is undertaken, results are much improved if the corrective surgery is performed under direct visualization using a hysteroscope. Treatment of intrauterine adhesions with hysteroscopic scissors is the most common method employed. This is performed utilizing flexible, semirigid and, occasionally, rigid or optical scissors. Treatment of intrauterine adhesions utilizing the resectoscope is an alternative to mechanical tools.
Sterilization: The methods for tubal occlusion are: Chemical (caustic substances), Mechanical (tubal blocking devices) and Thermal (electrosurgical and laser). All combinations of access and occlusion methods have been attempted to try to effect high rates of closure, with low complication rates.
Uterine Abnormalities: A septate uterus distorts the symmetry of the uterine cavity and may interfere with normal reproduction. When surgical treatment is required, it can be provided transcervically via the hysteroscope utilizing a variety of methods. These include mechanical hysteroscopic scissors, thermal energies via the resectoscope and laser energy via fiberoptic lasers. Hysteroscopic treatment provides a less-invasive approach to divide the uterine septum.
Management of Distal Ureter During Laparoscopic Nephroureterectomy: Surgical Aspects
Costantino Leonardo, MD, PhD
Due to the high rate of ureteral stump recurrence, reported to be between 30% and 75%, the standard surgical procedure to treat upper urinary tract transitional cell carcinoma (UUTT) is nephroureterectomy with bladder cuff excision (BCE).
The gold standard of open radical nephroureterectomy with resection of a bladder cuff is currently being challenged by minimally invasive approaches. Laparoscopic and, more recently, robotic nephroureterectomy are being used as alternatives to an open procedure.
A standard technique for the management of the distal ureter and bladder cuff has not been established yet and many different methods have been described. These approaches include an open technique, a transurethral incision (TUI) of the ureteral orifice, an intussusceptions technique, a transvesical laparoscopic detachment, and a laparoscopic stapling method. Each technique has distinct advantages and disadvantages. Although open dissection remains one of the most common methods of managing the bladder cuff, an endoscopic approach can provide a minimally invasive technique for treating UUTUC. Urologists are concerned with both technical differences and oncologic outcomes.
Laparoscopic Versus Robotic Radical Prostatectomy: Recent Advances in Technology and Suturing
Dr. Alberto Pansadoro
Dept. of Minimally Invasive Urologic Surgery, S. Maria Hospital, Terni, Italy
In recent years laparoscopic radical prostatectomy has been shown to achieve the same oncological and functional results as open surgery. However, it is technically demanding even for skilled laparoscopists.
Compared to the laparoscopic approach, the robotic way has many advantages: its instruments have 360° degrees of freedom and 7 axis movement and the surgeon sits comfortably at a console and can operate in 3D vision. All these factors contribute to the success of robotic surgery. Actually, around 70 % of radical prostatectomies in the United States are done by robotic approach.
The reconstructive step of the procedure is the most difficult one and is the also the last moment of this operation when the surgeon has already worked for hours. This is a crucial part of the procedure. The quality of the vesico-urethral anastomosis determines the days of post-operative catheterization and can play a role in a faster recovery of the continence.
In the last year a new kind of suture was developed to facilitate this step: the V-Loc. It is a multifilament with many small unidirectional wings. These wings avoid allowing the suture to retract and allow the surgeon to give a uniform tension to the suture. In this way it is possible to perform an accurate and precise anastomosis with perfect water-tightness. Either in laparoscopy or in robotic surgery reconstructive time becomes easier using this suture. The combination of the DaVinci robot and V-loc decreased the complication rate regarding post-operative leakage.
Functional and oncological outcomes are promising and with longer follow-up, hopefully robotic surgery will overtake laparoscopic surgery.
Laparoscopic Radical Nephrectomy vs. Laparoscopic/Robotic Partial Nephrectomy vs. Open Partial Nephrectomy: Choosing the Right Operation for the Right Patient
Oscar M. Schatloff, MD
Partial nephrectomy (PN) should be preferred over radical nephrectomy whenever technically feasible, as it has demonstrated equivalent cancer control and increased overall survival. PN decreases the risk of postoperative chronic kidney disease (CKD), which has been associated with increased risk of death, heart events, and hospitalizations when the glomerular filtration rate (GFR) goes below 60 ml/min.
Laparoscopic PN (LPN) has demonstrated equivalent long-term cancer control for tumors ≤4 cm when compared to open PN (OPN) while offering faster recovery and improved cosmesis with similar complication rates as shown in contemporary series.
Long-term data on cancer control for 4-7 cm tumors treated with LPN is not yet available. An increment in ischemia time and complications might be expected when compared to OPN, however, selected tumors treated by experienced surgeons usually result in excellent results and complications comparable to OPN.
Robotic partial nephrectomy (RPN) is an emergent option that allows an easier transition from open to laparoscopic environment as compared to conventional laparoscopy. Increased range of motion allows easier kidney reconstruction, especially for complicated tumors. Whether RPN can decrease ischemia time in comparison to the other techniques is still a matter of debate.
In conclusion, PN should be performed whenever technically feasible. LPN or RPN should be preferred over OPN when not resulting in increased complications or CKD. Every surgeon should know his results for each technique he offers (open, laparoscopic, robotic), as complications and ischemia time are more related to tumor characteristics and surgeon’s experience than to a specific surgical technique.
The Role of Laparoscopy in Liver Disease, with Special Emphasis on Hepatocellular Carcinoma
Georgios Tsoulfas MD, PhD
Aristoteleion University of Thessaloniki, Greece
The clinical application of laparoscopic surgery has grown rapidly over the last several years as a less invasive method that is capable of achieving similar results compared to the open surgery.
The goal of this presentation is to review the various applications of laparoscopic surgery in the treatment of liver diseases, with a special emphasis in hepatocellular carcinoma (HCC). The open and laparoscopic technique will be compared with regards to efficacy and safety. The types, technique and results of laparoscopic hepatectomy in the management of HCC will be analyzed, as well as the future prospects and potential including the use of robotic surgery and NOTES.
Robotic Versus Laparoscopic Splenectomy: Analysis of an Experience of 350 Cases
Vasilescu C, Tomulescu V, Tudor S, Stanciulea O, Popa M
Fundeni Institute of Digestive Disease and Liver Transplantation, Bucharest, Romania
Background: The authors reviewed their initial experience with robotic splenectomy to identify the indications, success rate, and complications associated with this procedure compared with a series of laparoscopic splenectomy.
Materials and Method: 60 patients aged 6 to 76 years (average 32.6 years) underwent robotic splenectomy between February 2008 and September 2010. 44 robotic total splenectomies for the following indications were performed: idiopathic thrombocytopenic purpura (n=14), splenomegaly, hypersplenism, liver cirrhosis (n=11), splenic tumors or malignant hemopathies (n=10), other hematologic disorders (n=9) and 16 robotic partial/subtotal splenectomy for hereditary microspherocytosis (n=11), splenic hydatid cysts (n=4) and splenic non-parasitic cyst (n=1). 320 patients aged 3 to 76 years (average 29.4 years) underwent laparoscopic splenectomies between October 1995 – September 2010, 295 total splenectomies and 25 partial/subtotal splenectomies.
Results: The mean operative time was 120 min (±37 min) for the robotic group and 110 min (±50 min) for the laparoscopic group. There were no conversions in the robotic group and 24 conversions to open surgery in the laparoscopic group. Hospital time was 3.1±1.2 days in robotic group and 3.8±2 days in laparoscopic group. Morbidity was similar, and no mortalities occurred.
Conclusion: Robotic splenectomy will probably not replace the laparoscopic splenectomy for the most common indications like ITP, hemolytic anemia. It may be a very useful surgical tool in difficult splenectomy: partial splenectomy, splenectomy in liver cirrhosis, splenic tumors or malignant hemopathies. In these cases the robotic approach may shorten the operative time and decrease the blood loss and the risk of hemorrhagic complications during surgery.
Medical Management of Endometriosis: Current and Experimental Treatments
Erkut Attar, MD, PhD
Istanbul University Medical School Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and GynecologyCapa, Istanbul, Turkey
Endometriosis is a common estrogen-dependent disorder that can result in substantial morbidity, including pelvic pain, multiple operations, and infertility. Approximately only half of the women with endometriosis get pain relief from existing medical or surgical treatments. Medical treatments are usually directed at inhibiting estrogen action or its production from the ovaries and do not address local estrogen biosynthesis by the aromatase enzyme in endometriotic lesions. A single gene encodes aromatase, which is the final enzyme in estrogen biosynthesis pathway, and its inhibition effectively eliminates estrogen production. The recently introduced highly specific Aromatase Inhibitors (AIs) have successfully treated pelvic pain and significantly reduced the lesion size. AIs appear to be the first breakthrough in the medical treatment of endometriosis since the introduction of GnRH agonists in the 80’s. The number of clinical trials employing AIs in the treatment of endometriosis strikingly increased after 2004. Patients with endometriosis that do not respond to existing treatments appear to obtain significant pain-relief from AIs. In premenopausal women, an AI alone may induce ovarian folliculogenesis and thus are combined with a progestin, a combination oral contraceptive (OC) or a gonadotropin releasing hormone (GnRH)-analog. AIs administered in combination with an ovarian suppressant represent promising and novel treatments of premenopausal endometriosis. The requirement for calcium, vitamin D or bisphosphonate supplementation in premenopausal women needs further evaluation. Most of the AI regimens are fairly simple consisting of taking one or two tablets a day. The regimens including combinations of an AI with a progestin or OC will gain more popularity over the combination of an AI with a GnRH analog because the former are simpler, cheaper, associated with fewer side effects, and may be administered for longer. The side effect profile of AIs administered in combination with an OC or a progestin is remarkably benign and more favorable compared with treatments using GnRH agonists or danazol. Thus, some of these regimens may potentially be administered over prolonged periods of time. Randomized clinical trials are needed to establish the efficacy and side effects of these regimens. Lower doses of AIs may also be used potentially in the treatment of pain or infertility associated with endometriosis. Many more clinical trials performed over the next decade will provide answers to these questions.
Safety First: The WHO Checklist – the First 2 Years
he New European Surgical Academy
More than 230 million operations are performed globally annually with reported surgical complications of 3-15%. Around 1 million deaths occur yearly due to superfluous surgical complications. Many of these complications are due to failure to use existing safety parameters. Strict protocols for the prevention of iatrogenic complications are still lacking. Anaesthetic complications are 500 times higher in countries that do not adhere to the monitoring standards. Other complications result from a lacking or wrongly timed antibiotic prophylaxis, operating on the wrong patient, or wrong side/site. In order to minimise the iatrogenic surgical complications, the WHO, along with international consultants and organisations from various disciplines, including the New European Surgical Academy (NESA), launched the safety checklist, which is supported by evidence. The NESA together with the HELIOS Hospitals conducted a pilot study in which within 3 months 1,340 major operations using the checklist were performed without one iatrogenic complication. According to a study by Haynes et al., the use of the checklist significantly reduced complications such as surgical site infection. The Checklist alone is not enough to prevent surgical complications. Many operations are still performed using methods that have never been subjected to evidence-based analysis. Standardization of surgical methods is an important step toward the reduction of complications and will enable reliable meta-analyses. We will present the results of the operations performed using the checklist and recommend any surgeon in any setup to use it.