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

Background and objectives: To assist in achieving optimal position when deploying over-the-scope (OTS)-clips, the concept of cannulating the defect with a guidewire, backloading the endoscope onto the wire, and firing the OTS-clip over the wire with subsequent wire removal has been demonstrated. The safety of this technique has not been evaluated.

Methods: An ex-vivo porcine foregut model was utilized. Biopsy punches were used to create 3-mm diameter full-thickness gastrointestinal tract defects through which a guidewire was threaded. An endoscope was backloaded over the wire and OTS-clips (OVESCO, Tuebingen, Germany) were fired over the mucosal defect and wire. The wire was removed through the endoscope and the removal difficulty was graded using a Likert scale. This process was repeated for each unique combination of nine OTS-clip types, two wire types, four wire angles, and three tissue types. Statistical analysis included t test and ANOVA.

Results: Two hundred sixteen OTS-clip firings with wire removal attempts were performed with the following Likert score breakdown: 1 - No difficulty (80.6%), 2 - mild difficulty (16.2%), 3 - moderate difficulty (2.3%), 4 - extreme difficulty (0.9%), and 5 - unable to remove (0%). Statistically significant differences were noted in removal difficulty between OTS-clip sizes (p < 0.05). No differences were identified between clip teeth types, wire types, tissue types, and wire angles (p > 0.05).

Conclusion: In this ex-vivo model, the guidewire was successfully removed through the endoscope in all cases. This technique can be employed to facilitate OTS-clip closure of gastrointestinal tract defects, but further study is indicated before wide clinical implementation.

Background/objectives: The benefits of laparoscopic surgery such as swifter recovery and fewer wound complications, elude much of the developing world. Nigeria, a lower middle-income country, is the most populous sub-Saharan nation; an excellent model for studying the impact of laparoscopy in resource-constrained environments. The Department of Surgery at the Obafemi Awolowo University Teaching Hospital and the University of Utah's Center for Global Surgery present a study of laparoscopic surgery cases in sub-Saharan Africa.

Methods: A retrospective chart review of 261 patients compared open and laparoscopic surgical outcomes for three common general surgery procedures: open versus laparoscopic cholecystectomy and appendectomy, and open laparotomy versus diagnostic laparoscopy for biopsy of intra-abdominal mass. The primary outcome was total length of stay (LOS); secondary outcomes included wound complications, analgesia and antibiotic use, time to oral intake, and patient charges.

Results: Total LOS for laparoscopic surgery was significantly shorter compared to analogous open procedures (4.7 vs 11.5 days). Postoperative LOS was also shorter (2.6 vs 8.2 days). There were no differences in wound complications. Median charges to patients were lower for laparoscopic versus open procedures ($184 vs $217 USD).

Conclusions: The introduction of laparoscopy allows for significantly shorter LOS and equivalent wound complications in the context of a sub-Saharan teaching hospital. Concerns regarding higher costs of care for patients do not appear to be a significant issue. Further work is needed to evaluate costs to the hospital system as a whole, including procurement and maintenance of laparoscopic equipment.

Background and objectives: Bowel deep infiltrating endometriosis (DIE) management by colorectal resection is a complex procedure. The purpose of the present study is to delineate a meticulous approach to the assessment of the patient, step-wise surgical technique, pre, and postoperative care, and its short-term and long-term outcomes.

Methods: This is a single-center retrospective study done on patients of bowel DIE managed by colorectal resection between January 1, 2019 to June 30, 2021.

Results: There was a significant improvement in the symptomatology of patients post-surgery. Our surgical technique is feasible with acceptable short-term and long-term outcomes.

Conclusion: Bowel DIE management can be proficiently executed with a proper diagnostic approach, appropriate surgical expertise with exhaustive pelvic anatomy knowledge especially concerning autonomic nerve plexus.

Background and objectives: Patient counseling for treatment of renal masses is complex. It can be difficult for patients to understand their disease and make treatment decisions when being shown standard black-and-white, two-dimensional computed tomography scans or magnetic resonance images. In a telehealth setting, the patient-physician interaction can be even more challenging. We sought to determine the impact of using digital three-dimensional (3D) models during consultation visits for patients with renal masses.

Methods: Forty-seven patients participating in a consultation visit for renal masses, both in-person and virtual, were shown a digital 3D model comprised of their kidney, renal mass, and key adjacent structures as part of their counseling. Patients then completed a five-question survey to assess the impact of the 3D model on their visit, with a sixth question administered to telehealth patients.

Results: Thirty-five patients undergoing telehealth visits and 12 patients seen in-person were shown the digital 3D model and surveyed. Survey results were universally positive, with all Likert scores > 4.7 (1 - 5 scale). There were no differences between the telehealth and in-person groups. Patients noted the digital 3D model made telehealth visits as effective as in-person visits (average Likert score 4.94).

Conclusion: Counseling for patients with renal masses can be augmented with patient-specific digital 3D models, leading to increased provider loyalty, lower levels of patient anxiety, and better understanding and shared decision making.

Background/objectives: Routine intraoperative cholangiography (IOC) for laparoscopic cholecystectomy (LC) remains controversial. The primary outcomes of this meta-analysis were detection rates of choledocholithiasis, bile duct injuries (BDI), and missed stones in LCs.

Methods: A systematic literature search was conducted for the time period January 1, 1990 to July 31, 2022. Some studies reported LCs with conversion to open therefore subgroup analysis in BDI rates was performed for studies which included LCs with and without conversion to open. Studies including primary open cholecystectomies were excluded. I² statistics were used for heterogeneity analysis.

Results: Fourteen studies involving 440659 patients were included. In studies comparing routine and selective IOC policies in LC, 61.1% of patients underwent routine IOC; 38.9% underwent selective IOC. In studies comparing IOC to no IOC in LC, 17.3% of patients had IOC; 82.7% did not. Between the selective and routine IOC groups there was no difference in choledocholithiasis detection rate (odds ratio [OR] = 1.33, p = 0.20, 95% confidence interval [CI] = 0.86 - 2.04), no difference in the rate of missed stones (OR = 1.59, p = 0.58; 95% CI = 0.31 - 8.29), and no difference in BDI rates in selective compared to routine IOC (OR = 0.92, p = 0.92; 95% CI = 0.20 - 4.22). There was no difference in the BDI detection rates in LC with and without IOC (OR = 1.12, p = 0.77; 95% CI = 0.52 - 2.38).

Conclusion: This is the largest meta-analysis on this topic to date. There was no statistically significant difference in choledocholithiasis detection, missed stones, or BDI rates in the analyzed groups.

Background and objectives: In this study, we compare three different surgical approaches at a single institution. Pure laparoscopic donor nephrectomy with Pfannenstiel incision (PLDN) was compared with hand-assisted laparoscopic donor nephrectomy via midline hand port (HALDNM) and hand-assisted laparoscopic donor nephrectomy via left iliac hand port (HALDNL).

Methods: This study included all laparoscopic left donor nephrectomies performed at our institution between January 1, 2020 and December 31, 2021. Donor characteristics including age, sex, body mass index, number of renal arteries, duration of surgical procedure, warm ischemia time (WIT), and length of hospital stay were compared. Cosmetic scores were calculated by totaling the length of all incisions placed. Postoperative complications within 90 days were compared.

Results: During the study period 71 laparoscopic donor nephrectomies were performed of which 26 were HALDNM, 24 were HALDNL, and 21 were PLDN. Donor characteristics were similar in all three groups. Total operative time was significantly lower in HALDNM (181 minutes) than PLDN (233 minutes) and HALDNL (242 minutes) (p < 0.001). The WIT was comparable in all three groups: HALDNL (7.2 minutes), PLDN (4.1 minutes), and HALDM (4.9 minutes) (p = 0.913). Median cosmetic score was significantly better in the PLDN group (8.2 cm) when compared to HALDNM (11.1 cm) and HALDNL (9.9 cm) (p < 0.001).

Conclusion: Our results show that all three technical modifications of laparoscopic donor nephrectomy are safe and feasible with good postoperative outcomes. HALDNM has the added benefit of decreased operative time while PLDN has a cosmetic advantage.

Despite guidelines that assert that the vaginal route for benign hysterectomy is preferred as the most minimally invasive approach, rates of vaginal hysterectomy remain very low in the United States. Vaginal natural orifice transluminal endoscopic surgery (vNOTES) might reverse the trend. Potential advantages of vNOTES compared to traditional laparoscopic and robotic approaches include the potential for less pain, decreased operative time, improved cosmesis, and decreased risks. Importantly, vNOTES might allow for the conversion of laparoscopic and robotic routes back to vaginal due to surgeon factors.

Introduction: Open transplant nephrectomy for failed renal allograft is an invasive procedure associated with significant perioperative morbidity and mortality. Minimally invasive surgical approaches have improved a variety of patient outcomes for many surgeries. Thus, robotic assisted transplant nephrectomy (RATN) potentially offers significant patient benefit. Although previously reported, there remains a paucity of data on RATN outcomes and techniques.

Methods: Four perfused, high-fidelity hydrogel models were created using previously described techniques and used for simulated RATN. Subsequently performed institutional cases were included for analysis. Intra- and postoperative variables along with patient demographics were retrospectively obtained through parsing of patient records.

Results: Simulated nephrectomy time was 67.33 minutes (35.75 - 98.91). Five patients underwent RATN. There were four male and one female patients. The average age was 47 years. The most common indication was abdominal pain secondary to rejection (3/5). Mean blood loss was 188 mL; mean operative time was 243 minutes, and mean length of stay was 4.5 days. Intraoperatively there were two incidences of small cystotomies. One patient was readmitted within 30 days for intraabdominal abscess.

Conclusion: This study adds to the growing literature around RATN, demonstrating the feasibility of the technique and reporting good outcomes for this cohort.

Background and objectives: We aimed to evaluate oncological and functional results of the ultrapreservation anterior-sparing technique in patients with localized prostate cancer.

Methods: In this single-center study, patients with low to intermediate risk prostate cancer, who were treated with the ultrapreservation anterior-sparing technique, were included retrospectively. The oncological and functional outcomes were recorded. After the functional and pathological evaluation in the first month, patients' prostate-specific antigen levels were followed, as well as continence and potency status bimonthly for one year. Continence is defined as no leakage and zero pads for security. Patients' potency was evaluated using the Sexual Health Inventory for Men, with ≥ 17 considered potent.

Results: A total of 118 patients were included in the study. The pathological stage was pT2 in 78% (n = 92) of patients, with pT3 in 22% (n = 26). Surgical margin positivity occurred in 13.5% (n = 16) of patients. No complications were observed intraoperatively. Continence rates were 25.4% after catheter removal, rising to 88.9% in the first month, 91.5% in the third, 93.2% in the fifth, and 95.7% a year later. Thirty-five (40%) of 86 potent patients were potent in the first postoperative month, 48 patients (55.8%) were potent in the third month, and 58 patients (67.4%) were potent in the twelfth. The total complication rate was 8.4%, with no major complications observed.

Conclusion: The ultrapreservation anterior-sparing technique for patients with prostate cancer shows safe, acceptable functional and oncological results in short-term follow-up. However, long-term comparative studies with a larger number of patients are needed.