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

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.

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 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.

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.

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.