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

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.

Objective: Retrospective clinical report to demonstrate the use of abdominal wall elevation device with closed technique direct entry with 3-mm port.

Design: An abdominal wall elevation device (LevaLap 1.0) was used during abdominal entry for laparoscopic and robotic gynecologic procedures. The primary outcomes were major vascular or visceral injury. Other events assessed included number of entry attempts, failed entry, and adverse events during entry. Descriptive statistics were used to characterize the patient population and the incidence of abdominal entry injuries or events.

Setting: Tertiary hospital.

Patients: Female patients undergoing laparoscopic gynecologic procedures with or without robotic assistance using an abdominal wall elevation device with direct entry technique from July 2023 to May 2024. Exclusion criteria were patients less than 18 years of age.

Interventions: Use of abdominal elevation device at initial entry.

Measurements and main results: The elevation device was used in 25 patients with a 3-mm direct trocar. Entry was achieved on the first attempt in all cases. There were no major vascular, visceral injuries, or failed entry events.

Conclusion: Use of a device to elevate the abdominal wall in a standardized fashion is feasible with direct entry using 3-mm port may help reduce the risk of retroperitoneal major vascular injury; however, larger comparative studies are required to confirm efficacy.

Background and objectives: Little is known about predictors of opioid use in the acute postoperative phase after hysterectomy. Inadequate pain support during this time can result in increased postoperative complications, and persistent postoperative pain. Objective is to determine predictors of increased opioid use in the acute perioperative phase (intraoperatively and 1 hour and 24 hours postoperatively).

Methods: A prospective cohort study involving 200 participants undergoing nonurgent hysterectomy via laparoscopic, vaginal, abdominal, or robotic approaches at an academic tertiary hospital in Toronto, Canada. Data collected included demographics, preoperative validated pain questionnaire scores, pain scores at 1 and 24 hours postoperatively, and analgesic medications used. Nonparametric statistical methods and multivariate analyses were used to examine the association between clinical predictors and opioid use. Opioid use was converted into morphine equivalent dose (MED).

Results: Pain sensitivity questionnaire (PSQ) score and body mass index were strongly associated with increased intraoperative MED. Twenty-four-hour postoperative opioid use was negatively correlated to age. Multivariate analysis identified PSQ total score and open hysterectomy as predictors of higher intraoperative MED. The number of preoperative pain medications, open hysterectomy, and PSQ total score were significant predictors of total MED requirements. One additional pain medication and one additional total PSQ point were associated with an increase in total MED of 10.76 and 5.17 mg, respectively.

Conclusions: This study is the first step in identifying clinical predictors of increased opioid requirements in the first 24 hours postoperatively. These predictors can inform patient-tailored management plans to ensure adequate pain support and appropriate opioid use.

Background: An important step during laparoscopic cholecystectomy that has a proven effect on postoperative morbidity and outcomes is the site of gallbladder retrieval, which is either through the umbilical or epigastric port. Currently, no guidelines recommend the superiority of one port over the other, and it is mainly based on the surgeon's preference. This study aimed to address the outcomes and complications of gallbladder retrieval through the epigastric port in comparison with the umbilical port and to identify the associated risk factors.

Methods: A retrospective review of 658 patients who underwent laparoscopic cholecystectomy between 2020 and 2021 was conducted. Patient demographics, preoperative workups, intraoperative findings, and postoperative outcomes were compared between retrieval via the epigastric and umbilical ports.

Results: Gallbladder retrieval occurred through the epigastric port in 441 patients and through the umbilical port in 217 patients. The epigastric group had a greater mean age (44.2 ± 14.90 vs 41.3 ± 14.47 years; P = .0109), and most the study population was female (7.2%). Intraoperative duration and bleeding were comparable, but fascial plane extension was more common in the umbilical group (6.9%; P = .0179). Port site hernias occurred in 1.8% of patients, all of whom were females (P = .0222), and were associated with older age, higher body mass index (BMI), and gallbladder needle decompression (P = .0356). The length of hospital stay was similar across both groups.

Conclusion: Epigastric port retrieval during laparoscopic cholecystectomy offers comparable intraoperative outcomes to those of umbilical retrieval. However, hernia risk, which is linked to specific factors, warrants further research to improve outcomes.

Objective: The current study aimed to compare clinical outcomes and postoperative complications of two endoscopic treatments (endoscopic isolated papillary small balloon dilation [EIPSBD] and endoscopic sphincterotomy [EST]) with endoscopic papillary balloon dilation (EPBD) in patients with choledocholithiasis.

Methods: A total of 316 patients diagnosed with and treated for choledocholithiasis from January 2014 to December 2024 were enrolled in this nonrandomized study. The patients were divided into EIPSBD (n = 178) and EST + EPBD groups (n = 138). Postoperative morbidities, including pancreatitis, cholangitis, bleeding, and hyperamylasemia, were assessed at 3 and 24 hours. Stone clearance was also evaluated.

Results: The incidence of pancreatitis was 9.55% in the EIPSBD group and 7.97% in the EST + EPBD group (P = .5). Hyperamylasemia occurred in 41.57% of the patients in the EIPSBD group and 42.03% in the EST + EPBD group (P = .9). The incidence of cholangitis, bleeding, and stone clearance was not significantly different between the two groups. The incidence of pancreatitis in female patients was greater than male patients (χ² = 5.12, P = .025). The total complication rate was 10.67% and 10.14% in the EIPSBD and EST ± EPBD groups, respectively, and was not significantly different (P = .9).

Conclusion: EIPSBD and EST ± EPBD were shown to be equally effective in the treatment of choledocholithiasis with comparable postoperative complication rates. EIPSBD may be an acceptable alternative to traditional EST for stones ≤10 mm in size. Follow-up studies of longer duration will be helpful to assess long-term outcomes.

Background: With the rise in bariatric surgeries, conversions for issues like poor weight loss or reflux are becoming more common. Gastric bypass is a standard solution, but as robotic use grows, its advantage over laparoscopy remains in question.

Objective: Compare the short and long-term outcomes of robotic versus laparoscopic sleeve conversion to Roux-en-Y gastric bypass (RYGB) surgeries.

Methods: We conducted a retrospective analysis analyzing patients' demographics, comorbidities, reasons for conversion, preoperative body mass index (BMI), and perioperative metrics (operative time, blood loss, hospital stay). We compared surgical outcomes, including early complications, rehospitalization, reintervention, weight loss, and resolution of comorbidities, between the robotic and laparoscopic approaches.

Results: This cohort included 126 patients who underwent revisional surgery from sleeve gastrectomy to gastric bypass surgery. Out of which 27 underwent laparoscopic approaches and 99 robotic approaches. The mean age of patients was 52.5 (±11.6), and the mean pre-RYGB BMI was 36.1 (±7.1). Most patients were female (87.3%, n = 110), with 72.2% white. Robotic approach had a significantly shorter operative time than laparoscopic approach 184.1 vs 215.5 minutes, with P-value < .001, respectively. Other outcomes did not show any statistical significance between the two groups. However, the late reoperation rate revealed a significant difference, with 29.6% in the laparoscopic group required additional surgical intervention, whereas only 13.1% in the robotic group with P-value .041, suggesting advantage for the robotic approach.

Conclusion: Both techniques demonstrated similar complication rates. Notably, the robotic approach resulted in shorter operating times and fewer late reoperations. Further research is necessary to strengthen our findings.

Background and objectives: This study aimed to compare the outcomes of laparoscopic nephron-sparing surgery (LNSS) and laparoscopic radical nephrectomy (LRN) for treatment of T1 renal cell carcinoma (RCC).

Methods: A total of 69 T1 RCC were retrospectively analyzed and divided into an LRN group (n = 34) and an LNSS group (n = 35) according to differences in surgical methods.

Results: The 2 groups were not significantly different in length of surgery, intraoperative blood loss, postoperative drainage tube indwelling time, length of stay, RCC recurrence, RCC distant metastasis rates, RCC-related mortality, complication rate as well as blood urine nitrogen (BUN), serum creatinine (Scr), and glomerular filtration rate (GFR) levels before the surgery (P > .05); at 1, 3, 6, and 12 months after the surgery, BUN and Scr levels in the LNSS group were significantly lower than those in the LRN group, while GFR levels in the LNSS group were significantly higher than those in the LRN group (P < .05). The preoperative WHOQOL-BREF scores in the physiological, psychological, environmental, and social relationship domains showed no significant differences between the LNSS group and LRN group (P > .05). However, at 12 months postoperatively, all scores in the LNSS group were significantly higher than those in the LRN group (P < .05). However, renal function was better preserved in the LNSS group.

Conclusions: Both LNSS and LRN demonstrated favorable outcomes in terms of surgical safety and short-term tumor control in the laparoscopic treatment of T1 RCC. However, LNSS exhibited a distinct advantage in preserving renal function and enhancing the patients' quality of life.