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

Background: Acute appendicitis is the most frequent cause of emergency surgical procedures performed worldwide. Laparoscopic appendectomy (LA) has gained considerable popularity in the last decades. However, the ideal method for appendicular stump closure during LA is still debatable and depends on the surgeon's preference and intraoperative judgment. The endoloop ligatures (EL) is the most used method but its application is quite challenging. The efficacy of nonabsorbable polymeric clip (PC) has been proven and it was first described for appendicular stump closure in 2007.

Methods: A retrospective comparative cohort study was conducted including all consecutive patients who underwent LA from January 2017 to the end of 2023 in a tertiary university hospital. Data were retrieved from their electronic medical files. The patients were classified into 2 groups. The appendicular stump was closed using EL, in the first group, and using PC, in the second group. The calculated operative time started from the patient's entry to the operating theatre till transfer to the recovery room.

Results: Out of 556 patients who underwent LA, 483 patients were included and classified into Group I (313 patients with EL), and Group II (170 patients with PC). Intraoperatively, complicated acute appendicitis was found in 27.8% and 36.5% and the median diameter of the appendix was reported 10 and 11.4 millimeters, respectively. The procedure was significantly shorter using PC (70 minutes vs 75 minutes, P = .03) and the cost was lower using PC ($42.6 vs $95.8). Intra-abdominal collection was reported in 1.6% and 0.6%, localized abscess was reported in 1% and 0.6%, and the hospital readmission rate was 3.19% and 1.18%, respectively.

Conclusion: The use of nonabsorbable PCs is safe and feasible for appendicular stump closure during LA for acute appendicitis.

Background: Retroperitoneoscopic donor nephrectomy (RDN) approach is an unfamiliar approach to the donor surgeons in Australia and New Zealand due to the background General Surgery training. The learning curve when transitioning from transperitoneal to retroperitonoscopic donor nephrectomy is relatively short with minimal morbidity.

Methods: We detail our standardized surgical approach for performing RDN, including technical tips and maneuvers as well as visual aids that ensure the procedure's safety and efficacy.

Discussion: RDN demonstrates notable advantages over traditional laparoscopic methods, including shorter operative times, less postoperative pain, and quicker recovery, thereby enhancing donor safety and graft function. Our goal is to outline our institution's RDN technique, offering valuable insights to aid donor surgeons in incorporating this method into their surgical repertoire. This approach requires a precise surgical technique and adequate training to maximize outcomes and minimize donor complications.

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.

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.