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

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.

Introduction: Biliary dyskinesia is a functional gallbladder disorder characterized by altered gallbladder motility. This often presents as history of biliary symptoms without imaging evidence of gallstones, sludge, or other structural pathology. The diagnosis is made by demonstration of abnormal gallbladder emptying on hepatic iminodiacetic acid analogue scan with cholecystokinin administration (HIDA-CCK). The aim of this study was to determine if patients with biliary dyskinesia who undergo cholecystectomy have abnormal pathology and resolution of symptoms.

Methods: This is a retrospective cohort study reviewing patients with symptomatic cholelithiasis or biliary dyskinesia who underwent cholecystectomy by a single surgical practice from 2015 to 2019. Clinical symptoms, radiologic findings and surgical pathology were assessed. The primary endpoints were pathologic changes and symptom resolution after cholecystectomy. Secondary endpoints were correlation of symptomatic disease with gender, age, and body mass index (BMI). Variables are presented as median (interquartile range [IQR] or frequency [%]).

Results: Four hundred and fifteen patients met inclusion criteria. Of these patients, 89 patients (21%) had biliary dyskinesia. The age of patients with biliary dyskinesia was 46 (33-58) years with the BMI of patients with biliary dyskinesia being 28 (24-33). A total of 82 patients with biliary dyskinesia were women (92%). Patients diagnosed with calculus disease (symptomatic cholelithiasis, acute calculous cholecystitis, choledocholithiasis) had an age of 55 (35-69) years. The majority (214 [66%]) of patients were women with calculus disease and 153 (71%) women had symptomatic cholelithiasis. Significance was observed in BMI between the groups, with the overall being 29 (25-35). The most common presenting symptom was abdominal pain, reported by 86 (97%) patients with biliary dyskinesia. The median ejection fraction (EF) was 18% (11-27%). Three patients with biliary dyskinesia (3%) had a median EF of 94% (86-99%), consistent with hyperkinetic biliary dyskinesia (>80%). Pathology demonstrated chronic cholecystitis in 75 specimens (84%), normal in 9 specimens (10%), and cholesterolosis alone in 5 specimens (7%). All patients experienced resolution of symptoms postoperatively.

Conclusion: Symptomatic patients with evidence of biliary dyskinesia were more likely to be younger and have a lower BMI than those with cholelithiasis and occurred most commonly for women. Most patients with biliary dyskinesia had histologic evidence of chronic gallbladder inflammation. Cholecystectomy resulted in resolution of symptoms in all patients with biliary dyskinesia. Cholecystectomy should be considered for first-line treatment of patients presenting with biliary symptoms, negative ultrasound findings and scintigraphic evidence of abnormal biliary function.

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.

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.

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: 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.

Background: Orthotopic murine models of pancreatic cancer represent an important tool for evaluating treatment strategies. Several genetically modified mouse tumors and xenograft models have been reported. Genetic models have unpredictable growth and variable waiting period, while orthotopic models are operative ones, difficult to create and result in irregular metastasis. There is a constant endeavor to create an orthotopic model which replicates the human disease process.

Study design: Orthotopic human pancreatic tumors were induced in 20 SCID mice using a novel technique. Low dose electrocoagulation of pancreas under laparoscopic guidance (using Coloview-mouse colonoscope) with thin electrode, followed by injection of 0.1 cc BxPC3 pancreatic cancer cells was done (n = 12, study group). Control mice underwent electrocoagulation alone (n = 4, group 1) and tumor cell injection alone (n = 4, group 2). Mice were evaluated for tumor growth and metastasis by necropsy (4 and 8 weeks for experimental group; 8 weeks for control group).

Results: Tumors were detected in 11/12 mice in experimental group, 1/4 in control group 2, and none in control group 1. Over time there was an increase in tumor growth, tumor volume, lymphovascular invasion of pancreas, with metastasis to lymph nodes and surrounding organs.

Conclusion: We report a novel concept of tumor cell implantation at site of electrocoagulation of pancreas. Combined with the minimally invasive technique, yields a replicative orthotopic murine model of pancreatic cancer. Our model is minimally invasive, easy to create, and overcomes the limitations of the existing models while questions the possibility free floating tumor cell implantation at resection site.

Background and objectives: Operating rooms (ORs) are critical for hospital revenue and cost management, with utilization efficiency directly affecting financial outcomes. Traditional surgical scheduling often results in suboptimal OR use. We aim to build a machine learning (ML) model to predict incision times for robotic-assisted hysterectomies, enhancing scheduling accuracy and hospital finances.

Methods: A retrospective study was conducted using data from robotic-assisted hysterectomy cases performed between January 2017 and April 2021 across 3 hospitals within a large academic health system. Cases were filtered for surgeries performed by high-volume surgeons and those with an incision time of under 3 hours (n = 2,702). Features influencing incision time were extracted from electronic medical records and used to train 5 ML models (linear ridge regression, random forest, XGBoost, CatBoost, and explainable boosting machine [EBM]). Model performance was evaluated using a dynamic monthly update process and novel metrics such as wait-time blocks and excess-time blocks.

Results: The EBM model was selected for its superior performance compared to the other models. The model reduced the number of excess-time blocks from 1,113 to 905 (P < .001, 95% CI [-329 to -89]), translating to approximately 52-hours over the 51-month study period. The model predicted more surgeries within a 15% range of the true incision time compared to traditional methods. Influential features included surgeon experience, number of additional procedures, body mass index (BMI), and uterine size.

Conclusion: The ML model enhanced the prediction of incision times for robotic-assisted hysterectomies, providing a potential solution to reduce OR underutilization and increase surgical throughput and hospital revenue.