JSLS : Journal of the Society of Laparoendoscopic Surgeons最新文献

Background: Acute cholecystitis (AC) is among the most frequently encountered surgical problems. Current management typically includes laparoscopic cholecystectomy (LC). Suboptimal outcomes of LC can include bile duct injury, open conversion (OC), and/or subtotal cholecystectomy (SC). Percutaneous cholecystostomy tube (PCT) drainage with interval cholecystectomy has emerged as an alternative in high-risk patients but outcomes vary widely. We describe an evidence-based algorithm for managing AC in high-risk patients via PCT followed by minimally invasive cholecystectomy (MIS-C). We hypothesized that our algorithm would prove safe, effective, and decrease OC and SC rates.

Methods: Retrospective chart review of patients undergoing PCT and MIS-C according to our algorithm from January 2020 to June 2023. The primary outcome was OC or SC. Secondary outcomes included bile leak, bile duct injury, and perioperative complications. Demographic, clinical, and operative data were collected. Statistical analysis was performed using Minitab Software.

Results: Twenty-nine patients met criteria and were treated according to our algorithm during the study period. One patient (3.4%) required conversion to SC. Other complications included 3 postoperative bile leaks (10.4%). There were no bile duct injuries and no deaths. None were lost to follow up. When stratified by LC or robotic-assisted cholecystectomy (RC), complications occurred more frequently in the LC group, including the lone conversion to SC.

Conclusion: Our management protocol of high-grade AC in high-risk patients appears safe, feasible, and may reduce adverse events. Additionally, our data suggest a potential benefit of RC in this setting which may be an underutilized tool in acute care surgery. Prospective data are needed to validate and further refine this algorithm.

Background and objectives: Robotic surgery has facilitated minimally invasive surgery with its enhanced visualization and improved dexterity compared to open and laparoscopic approaches. However, widespread adoption remains limited by steep learning curves. We describe procedural steps, technical considerations, and early clinical outcomes with a 1-stage robotic-assisted cholecystectomy with common bile duct exploration.

Methods: A single-institution case series of 21 patients undergoing robotic-assisted cholecystectomy with common bile duct exploration from October 2022 to August 2024 was retrospectively reviewed.

Results: Nine patients were female (43%), and the median age was 70 (interquartile range [IQR] 64-76). No patient required conversion to laparotomy or laparoscopy. Two patients (10%) required postoperative endoscopic retrograde cholangiopancreatography for duct clearance. The median total operative time was 215 minutes (IQR 180-290). The median fluoroscopy time was 1.5 minutes (IQR 1.2-2.1). We review the bed orientation, overall room set up, and robot arms rearrangements that were required to accommodate the C-arm for intraoperative fluoroscopy.

Conclusion: Robotic-assisted cholecystectomy with common bile duct exploration is possible but requires dedicated equipment and staff arrangements. Engagement of hospital staff including surgeons, anesthesiologists, radiology technicians, operating room nurses, and surgical technologists are paramount for success.

Background: Compared to elective surgery, emergent hernia repairs carry higher morbidity. Additionally, frailty is independently associated with worse postoperative outcomes. This study aimed to assess if the surgical approach, minimally invasive surgery versus open, confers improved outcomes for frail patients who underwent emergent hernia repairs.

Methods: The National Surgical Quality Improvement Program database (2018-2020) was queried for patients who underwent emergency hernia repair by Current Procedural Terminology (CPT) codes (49505-49659). A modified frailty index-5 score was calculated; only frail patients with a score of ≥2 were included. The impact of surgical approach on length of stay, discharge destination, and mortality was determined by multivariate analysis.

Results: A total of 1,893 patients met the inclusion criteria. Most patients (56.5%) were female, and 61.4% of patients were age ≥65. Most patients (83.62%) underwent open repair. After adjusting for covariates, patients who underwent minimally invasive surgery had a shorter length of stay compared to open surgery (hazard ratio = 1.22; 95% confidence interval [1.06,1.41]; P = .006). Surgical approach was not associated with a difference in 30-day mortality (P =.28) or discharge destination (P = .97).

Conclusion: Minimally invasive emergent hernia repairs in frail patients in the National Surgical Quality Improvement Program database cohort are associated with a shorter length of stay compared to open surgery, without increased 30-day mortality or change in discharge destination. Prospective studies are needed to validate best-practices in treating frail surgical patients.

Background: Subtotal cholecystectomy is employed when the hepatocystic triangle cannot be visualized, a surgical maneuver reserved for difficult gallbladders. The current literature compares an open versus laparoscopic approach with little discussion of robotic-assisted procedures. Although the robotic approach offers enhanced visualization and dexterity, its application in subtotal cholecystectomy remains underexplored. This study aims to compare the outcomes of robotic-assisted and laparoscopic subtotal cholecystectomies, focusing on postoperative complications and the learning curve associated with robotic surgery.

Methods: This study population included patients from July 2021 to June 2024 who underwent a subtotal cholecystectomy either laparoscopically or robotically with either fenestrated or reconstituted closure of the remaining biliary structures. A subtotal cholecystectomy was defined as a cholecystectomy with failure to control the cystic duct or view of the hepatocystic triangle of safety leading to at least 50% removal of the gallbladder body. Patients were categorized by their operative techniques: robotic or laparoscopic. The study variables included indication, age, gender, weight, operative variables, closure type, subsequent interventions, and other outcome data.

Results: In a retrospective analysis of 48 subtotal cholecystectomy cases performed between July 2021 and June 2024, 37.5% were robotic, and 62.5% were laparoscopic. Robotic procedures were more often associated with reconstituted closure (72.22%) compared to laparoscopic procedures, which used fenestrated closure (100%). Postoperative endoscopic retrograde cholangiopancreatography (ERCP) was significantly less frequent in the robotic group (11.1%) compared to the laparoscopic group (27.1%, P = .03). No patients in the reconstituted group needed postoperative ERCP, while 31.25% of fenestrated cases did (P = .004). Surgical duration and length of stay were comparable between the 2 techniques, challenging the notion of a steep learning curve for robotic surgery.

Conclusions: Robotic-assisted subtotal cholecystectomy is a practical and potentially superior alternative to laparoscopic methods, particularly in reducing the need for postoperative interventions like ERCP. The findings support the broader adoption of robotics in challenging gallbladder surgeries. Further multicenter studies with larger cohorts are recommended to confirm these findings.

Background and objectives: Minimizing intraoperative bleeding is pivotal in myomectomy, and blockage of uterine arteries has been reported as an effective approach. We developed a novel technique to temporary occlude bilateral uterine arteries at the anterior cul-de-sac in minimally invasive myomectomy (MIS), including minilaparotomy, laparoscopic-assisted myomectomy, and laparoscopic myomectomy. This study aims to evaluate the intraoperative and postoperative outcomes of this technique in complicated myomectomy cases.

Methods: Twenty-seven patients underwent minimally invasive myomectomy by single minimally invasive surgeon using bilateral uterine arteries blockage. To match the complexity of myomectomy, 66 open cases performed by generalists were used for control.

Results: There were no significant differences in fibroid size, number, or weight between MIS and open myomectomy groups. For intraoperative outcomes, the MIS group showed longer operative time (271.3 ± 72.9 vs 179.9 ± 78.8 minutes, P < .05), but fewer cases of intraoperative blood transfusion (3% vs 17%, P < .05) and fewer intraoperative complications (0% vs 3%, P < .005). For postoperative outcomes, the MIS group demonstrated shorter hospital stay (70% vs 29% for 0-1 day; 11% vs 42% for 2 days; 19% vs 29% for 3 or more days, P < .05) and fewer postoperative complications (3% vs 9%, P < .05).

Conclusion: Temporary blockage bilateral uterine arteries enable the safe performance of complicated myomectomy via minimally invasive surgery.

Background: Proficiency with laparoscopic suturing is often the rate-limiting step in performing a total laparoscopic hysterectomy. Intracorporeal suturing is challenging due to difficulties with needle control and tissue handling. Endoscopic suturing devices may improve operator experience.

Objectives: To compare rates of vaginal cuff complications between cuff closures performed with an endoscopic device versus conventional laparoscopic instruments.

Methods: IRB-approved retrospective cohort study from 2018 to 2022. Data were stored in REDCap. Statistical analyses were performed with SAS 9.4.

Results: A total of 223 patients were included; 29 patients experienced a vaginal cuff complication (13%). There was a nonsignificant trend towards increased cuff complications in the Endo Stitch group (19.2% vs 11.4%, P = .16; OR = 1.8, 95% CI 0.78-4.38). Patients with an Endo Stitch closure had significantly more cases of cuff cellulitis (8.5% vs 0%, P = .002). There was no significant difference in pelvic fluid collections or abscess (2.1% vs 1.1%, P = .51). While all cases of cuff dehiscence occurred in the conventional closure group, the difference was not statistically significant (0% vs 2.8%, P = .59). There was no significant difference in vaginal bleeding (14.9% vs 9.1%, P = .24).

Conclusion: No significant difference was observed in composite vaginal cuff complications using barbed suture with the Endo Stitch device versus conventional laparoscopic instruments. However, the trend towards increased cuff complications and the significantly increased rates of cuff cellulitis observed with an Endo Stitch closure is concerning. As the current data is limited by a small sample size, both methods should be considered appropriate. However, more studies at higher power are needed.

Introduction: Retroperitoneal laparoscopic surgery for benign retroperitoneal tumors is often challenging because of variations in the tumor location and size. In this study, we present a retroperitoneal laparoscopic resection technique used at our institution to treat benign retroperitoneal tumors.

Materials and methods: This retrospective case series included nine consecutive patients who underwent retroperitoneal laparoscopic tumor resection between 2011 and 2023. We analyzed patients' clinical characteristics and perioperative outcomes.

Results: There were four women and five men with a median age of 44 (range, 15-70) years and a median body mass index of 22.0 (range, 17.8-29.2) kg/m². Among the nine tumors resected, 7 were located in the right suprahilar region, 1 in the left suprahilar region, and 1 in the left infrahilar region. The median maximal tumor diameter was 3.0 cm (range, 1.8-12). The median operative time and estimated blood loss were 144 minutes (range, 76-358) and 7 mL (range, 1-479), respectively. No major perioperative complications (Clavien-Dindo grade ≥3) or conversion to open surgery were recorded. Pathological examination confirmed negative surgical margins in all cases.

Conclusions: Retroperitoneal laparoscopic resection was found to be a feasible and safe approach for treating benign retroperitoneal tumors.

Background and objectives: The study aims to elucidate the initial results and methodologies employed in utilizing a recently introduced single-port (SP) robotic surgical system for the management for benign and malignant gynecological disorders.

Methods: A total of 33 patients with benign or malignant gynecologic conditions between 2022 and 2024 were included, all patients underwent SP robotic surgery.

Results: A total of 33 patients were successfully enrolled. The study participants demonstrated a mean age of 43.9 ± 11.9 years, a mean body mass index of 21.9 ± 3.0 kg/m², a mean operating time of 105.5 ± 52.4 minutes, and a mean estimated blood loss of 34.6 ± 30.5 mL. There were no cases of conversion to multiport laparoscopy or laparotomy, and only 1 patient developed postoperative fever. The postoperative pain score fell within an acceptable range, and satisfactory scar healing was seen in all cases.

Conclusions: The practicality and safety of the EDGE SP1000 system have been demonstrated in a subset of patients. However, more study and specific surgical skills are required to completely comprehend the benefits and long-term outcomes of robotic surgical systems.

Background: Bariatric surgery has been increasingly utilized to reduce weight, manage obesity related morbidities, and improve quality of life. Racial discrepancies in surgical outcomes have been demonstrated across various surgical disciplines including bariatric surgery. However, studies have been limited to certain procedures, institutional data, or geographic-specific data.

Objective: Our aim is to investigate racial disparities in outcomes of bariatric surgery using the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database.

Methods: Preoperative information and postoperative results and complications were analyzed between January 2008 and December 2021. Statistical analysis was conducted to compare patients' characteristics and clinically relevant outcomes between the different racial groups.

Results: A total of 190,319 patients were included. The majority were White (81.4%) and females (79.8%), with a mean age of 44.7 years. After controlling for relevant demographic and preoperative characteristics, the Black group had higher length of hospital stay (odds ratio [OR] = 1.36 [1.23; 1.50]), higher 30 days postoperative mortality (OR = 1.80 [1.25; 2.60]), higher odds of unplanned readmission (OR = 1.40 [1.31; 1.50]), pulmonary embolism (OR = 2.23 [1.75; 2.85]), acute renal failure (OR = 1.25 [0.87; 1.79]).

Conclusion: Disparities exist between racial groups undergoing bariatric surgery. Additional studies are needed to further investigate these findings and their potential implications.

Background: Optimization of surgical scheduling represents an opportunity to improve resource utilization and increase patient access. Increasing body mass index (BMI) has been associated with increased operating time and may provide an opportunity to more accurately predict operating time.

Objective: To investigate the relationship between BMI and operative time for benign hysterectomy and develop a predictive model for hysterectomy operating time based on patient BMI.

Methods: A secondary analysis of women undergoing benign laparoscopic, abdominal, or vaginal hysterectomy between 2014 and 2019 was performed using the American College of Surgeons National Surgical Quality Improvement Program database, N = 117,691. Our primary outcome was log₁₀ transformation of operative time. Multivariable linear regression was used to analyze the relationship between operative time and BMI. A model to predict operating time was created using variables that could be reliably obtained preoperatively.

Results: From our cohort, 22% of benign hysterectomies were performed abdominally, 16% were vaginal, and 62% were laparoscopic, and mean operative times were 144, 133, and 158 minutes, respectively. For every 10-unit increase in BMI, estimated mean operation time (OT) increased by 12.8%, 8.1%, and 6.5% for abdominal, vaginal, and laparoscopic hysterectomy, respectively. Neither an expanded nor a concise model was able to account for the variability in log₁₀(OT).

Conclusion: Increasing BMI differentially impacts the operative time in abdominal greater than laparoscopic and vaginal hysterectomy. However, operative time for hysterectomy is highly variable, and its estimation is difficult to reliably predict using common preoperative variables.