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

Background: Postoperative hypoparathyroidism is the most common complication of total thyroidectomy, often resulting from injury or devascularization of the parathyroid glands.

Objective: Indocyanine green fluorescence (ICG) technique has been applied in the last 10 years in different kinds of surgery including colorectal, oncological lymph node and endocrine surgery. Minimally invasive thyroidectomy, introduced more than 25 years ago, is a valid surgical option for selected benign and malignant thyroid disease with advantages in terms of cosmetic results and postoperative pain. Aim of this study is to evaluate the feasibility and safety of ICG during minimally invasive thyroidectomy to assess and predict parathyroid gland perfusion and guide preservation.

Methods: We report the initial experience in our center of ICG during minimally invasive video-assisted total thyroidectomy in a case series of 9 patients, using the Striker System® to assess parathyroid perfusion and guide preservation. Demographic and surgical data were registered with special attention to hypoparathyroidism.

Results: All patients underwent standard minimally invasive video-assisted total thyroidectomy; a standardized dose of ICG was administered intravenously. Real-time near-infrared imaging allowed for clear visualization of parathyroid vascularization, enabling the preservation of well-perfused glands and the auto transplantation of those removed into the sternothyroid muscle. Postoperative assessments, including serial measurements of serum calcium and parathyroid hormone levels, revealed a transient drop in two patients with overall correspondence to indocyanine green evaluation.

Conclusion: These findings suggest that ICG angiographic imaging is a valuable adjunct in thyroid surgery, potentially reducing the risk of hypocalcemia by optimizing parathyroid preservation. Further studies are needed to standardize the technique and the evaluation score to confirm preliminary results on definitive hypoparathyroidism.

Background and objectives: Robotic platforms are increasingly employed in colorectal surgery for their technical and ergonomic benefits. However, surgeons face a significant learning curve, and there is no standardized definition or threshold to proficiency. This systematic review aimed to evaluate published evidence on learning curves in robotic colorectal surgery, focusing on proficiency thresholds, analytic methodologies, and the effect of experience on clinical and oncological outcomes.

Methods: A systematic literature search of PubMed was performed through April 7, 2025. Studies reporting learning curve data for robotic colorectal procedures were included. Screening and selection were conducted using Rayyan. Extracted data included operative time, case numbers to proficiency, conversion and complication rates, and oncological metrics. Study quality was assessed using the Newcastle-Ottawa Scale. A narrative synthesis was undertaken due to heterogeneity in study design and outcomes.

Results: Nineteen studies met inclusion criteria. The number of cases required to reach proficiency ranged from 15-55, with operative time being the most analyzed parameter. CUSUM and RA-CUSUM were the predominant analytic methods. Improved outcomes such as reduced complications, lower conversion rates, and enhanced oncological quality were generally observed in the post-proficiency phase. Variability in learning curve definitions and analytic approaches was significant across studies.

Conclusion: Robotic colorectal surgery involves a measurable learning curve that impacts both technical and patient-centered outcomes. While most studies demonstrate improved metrics with experience, the lack of standardized methodology limits cross-study comparisons. Structured training pathways and consensus on learning curve analysis are needed to support safe adoption and credentialing in robotic colorectal surgery.

Background and objectives: This study aimed to compare the efficiency and diagnostic performance of carbon dioxide (CO₂) versus saline as a distension medium during routine cystoscopy performed after laparoscopic gynecologic surgery.

Methods: We conducted a prospective, comparative study involving patients undergoing total laparoscopic hysterectomy for benign indications. Participants were randomly assigned to undergo diagnostic cystoscopy using either CO₂ or saline for bladder distension. Primary outcomes included total cystoscopy duration and time to visualize bilateral ureteral jets. Secondary outcomes were intraoperative detection rates of lower urinary tract injuries and any postoperative urinary complications.

Results: A total of 529 patients were included (CO₂ group: 270; 51.1%; saline group: 259; 48.9%). Cystoscopy duration was significantly shorter in the CO₂ group compared to the saline group (150 vs 120 seconds; P < .001). Time to visualize ureteral jets was also reduced in the CO₂ group (43 seconds; P < .001). One bladder injury and 1 ureteral obstruction were identified intraoperatively and successfully repaired in the same surgical session. The use of CO₂ eliminated the need for diuretics or chromatic dyes, streamlining the diagnostic process and potentially reducing costs.

Conclusion: CO₂ cystoscopy is a safe, efficient, and diagnostically effective alternative to conventional saline cystoscopy following gynecologic laparoscopy. Its use significantly reduces procedural time without compromising the detection of urinary tract injuries and avoids the need for additional agents such as dyes or diuretics. These findings support the integration of CO₂ cystoscopy into routine intraoperative surveillance protocols during minimally invasive gynecologic surgery.

Objective: To assess the impact of laparoscopic treatment of endometriosis on pregnancy outcomes in women with infertility, performed either before or after failed fertility enhancement technology (FET). Secondary aims included evaluating the influence of age, body mass index (BMI), prior pregnancies, endometriosis stage, and the presence of endometriomas on reproductive outcomes.

Design: Retrospective cohort study of 95 women aged 18-45 with primary or secondary infertility who underwent treatment of endometriosis laparoscopically with or without robotic assistance between January 2015 and January 2023. All surgeries were performed by a single gynecologic surgeon. Patients were grouped based on whether they had prior FET failure or no prior FET. Comparisons were made between pregnant and nonpregnant patients across both groups.

Main outcome measures: Postsurgical pregnancy rates (spontaneous vs assisted reproductive technology [ART]) and factors associated with pregnancy outcomes, including age, BMI, endometriosis stage, and presence of endometriomas.

Results: Of 44 patients with prior failed FET, 82% conceived postsurgery, with 97% requiring ART. In the 51 patients without prior FET, 78% conceived, and 31% did so spontaneously. Younger age was significantly associated with pregnancy in the nonprior FET group (P = .011). Endometriosis stage did not significantly influence outcomes. Patients with endometriomas were more likely to be referred for surgery before FET.

Conclusions: Laparoscopic surgery for endometriosis is associated with high pregnancy rates, regardless of prior FET status. These findings support the role of surgery as a key component in fertility management for women with endometriosis, especially prior to initiating FET.

Technique: Troubleshooting unexpected complications during laparoscopic surgery demands a wealth of experience and skills. Importantly, a rapid and accurate suture technique is essential when addressing intraoperative issues such as bile leakage or bleeding. The LapraTy® suture clip, an absorbable clip that eliminates the need for ligation, has been recognized for its effectiveness. Here, we present a versatile suturing technique with LapraTy® suture clip for intraoperative accidental bile leakage (ABL). Our technique consists of 2 steps: suturing the hole of ABL using a LapraTy® suture clip and covering with the omentum.

Results: The suturing technique using LapraTy® suture clip could offer rapid suture without applying excessive tension. Therefore, it is not only suitable for fragile tissues such as bile ducts but also could prevent Glissonial stenosis. Omental coverage may partly help to prevent postoperative bile leakage.

Conclusion: This report highlights a closure technique utilizing LapraTy® suture clips with omental covering for ABL following Laparoscopic hepatectomy. Our findings revealed that the LapraTy® suture clip allows for suturing or anastomosis, even in emergent or difficult situations. Particularly, its advantage lies in the absence of ligation requirements, allowing for adjustable tightening without compromising tension in cases involving thickened or fragile tissues.

Background and aims: Laparoscopic cholecystectomy (LC) often causes significant postoperative pain. While low-pressure pneumoperitoneum (8 mmHg) may reduce pain, optimal patient selection remains unclear. This trial compared pain outcomes between low-pressure (LPLC) and standard-pressure (SPLC) LC and identified predictors for pressure conversion.

Methods: This prospective randomized controlled trial (June 2023 to September 2024) randomized 200 elective LC patients 1:1 to 8 or 12 mmHg groups. Postoperative pain was assessed using a facial visual analog scale at 1-72 hours and analyzed by both intention-to-treat (ITT) and per-protocol (PP) approaches. Intraoperative parameters, recovery outcomes, and biochemical markers were also compared. Risk factors for pressure conversion were analyzed using univariate/multivariate methods.

Results: LPLC significantly reduced: visceral pain at 12 hours (ITT: P = .046, PP: P = .005), incisional pain at 48 hours (ITT: P = .017, PP: P = .003), postoperative aspartate aminotransferase (AST)/alanine aminotransferase (ALT) elevation (P < .05). Preoperative C-reactive protein (CRP) ≥12.70 mg/L predicted intraoperative conversion from 8 to 12 mmHg (odds ratio [OR] 1.053, area under the curve [AUC] = 0.704).

Conclusion: The use of low-pressure pneumoperitoneum (8 mmHg) for LC significantly reduces postoperative pain and decreases the impact on liver function. LPLC demonstrates comparable safety and feasibility to SPLC. To achieve maximum benefit in patients with LC, we recommend that patients with preoperative CRP ≥12.70 mg/L carefully choose LPLC as the initial procedure.

Background: Peritoneal endometriosis is the most common form of endometriosis and often overlooked due to its variable and nonpigmented appearance. Despite advances, identifying occult lesions remains challenging. The Aqua Blue Contrast Technique (ABCt), using retroperitoneal methylene blue infusion, was developed to enhance lesion visibility.

Method: A total of 126 specimens from 14 women undergoing laparoscopic surgery for peritoneal endometriosis were evaluated using a sequential inspection protocol: initial visual assessment by a gynecology resident, followed by an experienced surgeon, and finally after applying the ABCt. The primary outcome was the number of endometriosis lesions identified by each observer. Secondary outcomes included lesion distribution and positive predictive values.

Results: In excised specimens, 78 (61.9%) of them were histologically confirmed as endometriosis. Endometriosis lesions were distributed as follows: posterior pelvic sidewall, 35 (44.9%); anterior pelvic sidewall, 22 (28.2%); and cul-de-sac, 21 (26.9%). For total specimen counts, the surgeon identified 59/78 lesions from 76 specimens (75.6%), and the resident 43/78 from 52 specimens (55.1%). Compared with these groups, ABCt identified 24.4% more lesions than the surgeon and 44.9% more than the resident. Subgroup analysis confirmed that ABCt achieved significantly higher detection rates than the resident across all pelvic sites and outperformed the surgeon at the cul-de-sac and posterior pelvic sidewall.

Conclusions: Retroperitoneal contrast staining with ABCt improves the intraoperative detection of occult and nonpigmented peritoneal endometriosis lesions, supporting more comprehensive excision and reducing the chance of missed lesions.

Background and objective: Minimally invasive endometriosis surgery can be done laparoscopically or with robotic assistance. The choice of modality of this procedure could impact postprocedure pain levels and the need for opioids to manage pain. The objective of this study is to evaluate differences in opioid prescription fill rates following endometriosis surgery between robotic-assisted and laparoscopic approaches.

Methods: A retrospective cohort study using the Merative MarketScan (United States employer-based claims database) from 2016 to 2021. Opioid prescription fills were examined in three time periods: preoperative (12 months to 30 days before surgery), perioperative (29 days before to 14 days after), and postoperative (15 days to 24 months after). Logistic regression models estimated average marginal effects (AME) for perioperative and postoperative opioid use, adjusting for demographics, health conditions, concomitant procedures, and prior opioid use.

Results: Of the 28,088 individuals who underwent endometriosis surgery, 6.24% (1,752 patients) had robotic-assisted procedures. In the postoperative period, laparoscopic surgery was associated with a higher probability of postoperative opioid prescription fills compared to robotic-assisted surgery (adjusted AME = 3.2; 95% CI: 0.7, 5.7; P ≤ .01). Among patients with baseline pain disorders, robotic-assisted surgery was associated with lower postoperative opioid prescription fills (adjusted AME = 3.2; 95% CI: 0.2, 6.2; P = .04).

Conclusions: Robotic-assisted procedures were associated with a reduced likelihood of opioid prescription fills in the postoperative period following surgery compared to laparoscopic procedures, including for patients with baseline pain disorders.

Objective: Lumboperitoneal shunts (LPS) allow cerebrospinal fluid diversion in cases of communicating hydrocephalus. Placement of the abdominal limb of the catheter historically relied upon laparotomy, but more recently has been performed laparoscopically. Lateral decubitus positioning of the patient poses a challenge to the laparoscopic surgeon gaining access to the peritoneum.

Methods: A series of 22 patients undergoing 34 LPS procedures performed by a single surgeon from April 2009 to January 2025 was retrospectively analyzed. The catheter is tunneled towards the flank by the neurosurgical service with the patient in the lateral decubitus position. Veress needle is placed in the subcostal position and pneumoperitoneum is established. A 5-mm port is inserted through an ipsilateral midabdominal incision. Through a 10-French introducer sheath, the tubing is tunneled into the abdomen. Adequate flow of cerebrospinal fluid is observed.

Results: Twenty-two patients with a mean age of 37 ± 7.3 years underwent 34 LPS procedures which included 22 primary LPS placements, 10 replacements, and 2 revisions. LPS indications were idiopathic intracranial hypertension (17), pseudo meningocele (2), and other diagnoses (3). All secondary procedures were performed due to dysfunction of the lumbar portion of the catheter. There were no cases of peritonitis, intra-abdominal infection, or hemorrhage.

Conclusion: We suggest a simple technique for laparoscopic peritoneal catheter placement during LPS insertion, which can be done with the patient in the lateral decubitus position utilizing a single port, and without mobilization of the colon.

Background: Totally minimally invasive Ivor-Lewis esophagectomy (ILMIE) is a particularly challenging procedure. Despite recent improvements, technical difficulties, mainly in creating intrathoracic anastomosis, still account for a high rate of anastomotic leaks. We present a modified ILMIE technique, with a transhiatal esophageal transection during the laparoscopic stage, aimed at facilitating the thoracoscopic approach and overcoming some of its pitfalls.

Methods: Twenty-four consecutive patients with Siewert I and Siewert II esophago-gastric junction tumors with a 8 cm maximum involvement of distal esophagus were included in the study and underwent modified ILMIE with transhiatal esophageal transection and transabdominal (Pfannestiel) specimen extraction. A frozen section examination of specimen margin was obtained while repositioning the patients for thoracoscopic access in prone position. An end-to-side mechanical anastomosis, reinforced by a 3-0 running suture, was performed.

Results: There were no major intraoperative complications. Eleven patients (45.8%) had a Clavien-Dindo grade higher than 2 postoperative complication, including one (4.2%) type II anastomotic leak. The mean number of harvested lymph nodes was 31.5 ± 17.2 and we recorded 1 R1 resection (4.2%). Disease free survival rate at 1 year, irrespective of the pathologic stage, was 67%.

Conclusions: Modified ILMIE seems to be a safe alternative to the traditional technique. Transabdominal specimen extraction allows a reduced minithoracotomy, a better thoracoscopic workspace and early availability of a frozen section for examination. Larger series are needed to assess possible benefits on postoperative and oncological outcomes.