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

Aim: Cystic duct stump remnant causing "postcholecystectomy syndrome" is an uncommon but clinically significant complication. Symptomatic cystic duct stump stones often necessitate redo completion cholecystectomy. Here, we share our experience with the clinical presentation and surgical management of this condition.

Patients and methods: This prospective study included 60 patients with residual cystic duct disease who underwent completion cholecystectomy between August 2016 and September 2024. Investigations included abdominal ultrasound and magnetic resonance cholangiopancreatography. The demographic, clinical, surgical and early post-operative variables of these patients were prospectively maintained and analyzed.

Results: The study included 43 women and 17 men with symptomatic cystic duct remnant. The median age was 43.5 years (range, 14-80 years). The median duration between index surgery and completion cholecystectomy was 66 months (range, 2-384 months) (interquartile range, 105 months). The initial surgery was open cholecystectomy in 44 and laparoscopic cholecystectomy in 16 patients. Fifty-six (93.3%) patients with residual stump stone presented with pain, while 24 (40%) patients complained of dyspepsia. Completion cholecystectomy could be performed laparoscopically in 47 cases, whereas 10 patients underwent open surgery. The mean operative time was 85 minutes (standard deviation = 32.1, confidence interval = 95%). The mean hospital stay was 3 days (interquartile range [IQR], 1-4.5 days). Iatrogenic bile duct injury occurred in 2 (3.3%) cases out of which one was repaired laparoscopically and the other required conversion to open and repair over T tube.

Conclusion: Laparoscopic completion cholecystectomy is feasible and safe, even in patients with prior open cholecystectomy. It is becoming the treatment of choice where expertise is available.

Background: The levonorgestrel-releasing intrauterine system (LNG-IUS) is a widely recognized method for contraception and the management of various gynecological conditions. However, the placement of LNG-IUS can be particularly challenging in patients with large or anatomically irregular uteri. The objective of this study was to evaluate the efficacy and safety of hysteroscopic cold-knife-assisted suture fixation of the LNG-IUS in the uteri of patients diagnosed with adenomyosis.

Methods: We retrospectively analyzed the data of patients who underwent LNG-IUS placement with the assistance of cold-knife hysteroscopy. The evaluation criteria included surgical success rates, postoperative complications, and subsequent follow-up of LNG-IUS.

Results: Our findings indicated that LNG-IUS placement was successfully achieved with cold-knife hysteroscopy, even in cases characterized by large uterine volume or abnormal uterine morphology. The procedure demonstrated a low incidence of postoperative complications, with no instances of device expulsion or displacement. Additionally, it resulted in a reduction of vaginal bleeding and alleviation of dysmenorrhea.

Conclusion: Hysteroscopic cold-knife-assisted suture fixation of LNG-IUS offers an effective solution for patients with a history of device expulsion, significantly reducing the expulsion rate and demonstrating high safety and efficacy.

Objective: Aim was to analyze and compare the oncological outcomes, genitourinary quality of life (QOL), disease-free survival (DFS), and overall survival (OS) of patients treated by laparoscopic radical hysterectomy (LRH) and laparoscopic nerve-sparing radical hysterectomy (LNSRH) for early cervical cancer.

Design: Retrospective study in patients of carcinoma cervix FIGO (2009) grade 1A to 2A1 from January 1, 2016 until the publication of Laparoscopic Approach to Cervical Cancer (LACC) trial in 2018, after which only 1A and 1B1 were included up to December 31, 2020.

Setting: Total of 285 patients operated over 5 years at the center were placed in 2 groups, LRH and LNSRH, based on surgical approach.

Measurements: Tumor characteristics, clinical profile, tumor clearance, histopathology, adjuvant treatment, period of follow-up and recurrence were compared. The QOL was analyzed in terms of bladder and sexual function.

Results: LNSRH group had significantly faster recovery of bladder (lesser number of days required for PVR <50 mL, quicker catheter removal time, less requirement of self-catheterization, less incidence of urinary retention and incontinence) and sexual function as compared to LRH group. There was no significant difference in radicality of the procedure. None of them had vault recurrences. DFS at 5 years for LRH and LNSRH was 95.3% and 94.1%, respectively. OS at 2 years for LRH and LNSRH was 95.9% and 96.3%, respectively, whereas the OS at 5 years was 95.3% and 94.1%, respectively.

Conclusion: LNSRH group had significantly better genitourinary QOL as compared to the LRH group without compromising on oncological clearance. The survival is comparable to the results of open surgery in LACC trial.

Background: In swimming, a combination of strength, endurance, and targeted skill training significantly enhances performance, particularly by balancing aerobic and anaerobic conditioning. Similarly, in surgery, improving motor control and stamina during lengthy operations, particularly for precise movements like suturing or tissue manipulation, is essential. This literature review aims to explore the parallels between the training paradigms of elite swimming and robotic-assisted surgical practice, focusing on skill acquisition, training methodologies, and performance-guided feedback systems. The hypothesis suggests a significant link between these training principles, offering opportunities to optimize surgeon training, particularly in robotic-assisted surgery.

Database: A systematic review was conducted following PRISMA guidelines. A thorough examination of existing literature in both elite swimming and robotic-assisted surgery training identified key elements of skill development, feedback mechanisms, and structured progression. Sources included peer-reviewed studies on swimming techniques, cognitive training in surgery, and simulation-based training programs that emphasize performance-driven improvements.

Conclusion: The review identified significant parallels between swimming and robotic-assisted surgery training, with both fields emphasizing structured, feedback-driven approaches to enhance precision and skill. Techniques such as video analysis in swimming and real-time digital feedback in surgery were found to be effective in improving outcomes. Simulation-based training also plays a crucial role in refining skills and promoting adaptability in both disciplines. Applying elite swimming methodologies, particularly those centered on feedback, precision, and structured progression, could help develop key metrics to enhance surgical training programs, in robotic-assisted surgery. Future research could further optimize surgeon training, potentially leading to improved performance and better patient outcomes in robotic procedures.

[This retracts the article on p. 267 in vol. 12.].

Objective: Determine whether the quadratus lumborum block (QLB) is an effective adjunct to control postoperative pain during the first 24 hours after minimally invasive hysterectomy.

Methods: Prospective cohort observational study of patients who underwent laparoscopic or robotic hysterectomy. Patients either received a QLB or did not. Initial postoperative pain scores were recorded in the postanesthesia recovery area using a numeric rating scale. Patients were then called to collect 24-hour scores and analgesic medication usage. The primary outcome was the 3-hour pain score. Secondary analysis evaluated use of analgesic medication.

Results: Fifty patients were enrolled in the study: 25 patients in the no-QLB cohort and 25 patients in the QLB group. The median postoperative pain scores (out of 10) were 4, 2, and 6 at 1, 3, and 24 hours in the no-QLB group. Scores were 5 (P = .541), 3 (P = .418), and 6 (P = .358), respectively, in the QLB group. A total of 11 of 25 patients at 1 hour, 8 of 25 patients at 3 hours, and 21 of 25 patients at 24 hours used analgesia postoperatively in the no-QLB group, compared to 11 of 25 patients at 1 hour (P = 1.0), 18 of 25 patients at 3 hours (P = .005), and 23 of 25 patients at 24 hours (P = .384) in the QLB group. Opioid, acetaminophen, and ibuprofen usage was not significantly different between groups.

Conclusion: There was no significant pain difference between the no-QLB and QLB groups. Patients who received a QLB were more likely to receive pain medication 3 hours after surgery. Thus, the use of a QLB does not appear to be a suitable adjunct for postoperative pain.

Background and objectives: Colovesical and colovaginal fistulas are a complication of diverticular disease that often requires surgical intervention. Minimally invasive surgery is associated with improved postoperative outcomes, but reported laparoscopic rates of conversion to open for these patients have been relatively high. There are limited studies evaluating robotic-assisted management of these fistulas. This study aims to report our single-center experience of robotic management of such fistulas, with the primary outcome being the conversion rate to open.

Methods: All elective robotic sigmoid resections for diverticular colovaginal and colovesical fistulas performed from January 2018 to August 2023 were included. Patient demographic variables and 30-day postoperative outcomes were retrospectively collected.

Results: Thirty-five patients were included, 21 with colovesical and 14 with colovaginal fistulas. Overall, the conversion to open rate was 8.6% (3 out of 35). All patients converted to open were patients with colovesical fistulas. Operating time (median of 354 vs 347 minutes, P = .583) and estimated blood loss (median of 100 vs 100 mL, P = .538) were similar for colovesical and colovaginal fistulas, respectively. Two patients required ostomy creation, both in the colovaginal group. Three patients in the colovesical group developed an ileus compared to one in the colovaginal group. There were 2 urinary tract infections (UTIs), both in the colovesical group. Thirty-day readmission (2 vs 1, P = .652) and length of stay (median 2 vs 2 days, P = .855) were similar for colovesical and colovaginal fistulas, respectively.

Conclusion: Diverticular fistulas can be managed successfully with a robotic approach and appropriate surgeon experience, having minimal morbidity or complications.

Objective: A common perception is that physician-owned practices are in decline in the United States. However, there has been a lack of recent academic research to comprehensively characterize these trends. Our aim is to assess the current trends in physician employment over the last 2 decades to assess the interplay between private practices and hospital employment.

Methods and procedures: We analyzed data from the United States Census Bureau's Statistics of U.S. Businesses (SUSB) and the Bureau of Labor Statistics' Occupational Employment and Wage Statistics (OEWS). Industry classifications were defined under the North American Industry Classification System.

Results: In 2022, the United States had 760,000 physicians, a 22% increase over the past decade. Hospital employment rose by 33%, while private medical practices grew by 17%. Currently, 55% of physicians work in private practices, down 3% from a decade ago, and 27% are hospital employed, up from 25% from a decade ago. Government employment decreased from 14% in 2013 to 12%. University employment remained stable (3%). There were 213,000 private medical practices in 2020, with 73% being small practices. There has been an increase in large practices(≥50 employees), while small practices (<50 employees) decreased by 16% over 2 decades.

Conclusion: Private practices continue to be the dominant employment for physicians. Hospital employment over the last decade increased to just over one-quarter of employed physicians. Small private practices continue to be the most common type of private practice, despite an increase in larger private practices over the last decade.

Background and objectives: To evaluate the effectiveness and impact of the retroperitoneal tunneling technique on the surgical time and outcomes of laparoscopic sacral hysteropexy (SHP) for treating pelvic organ prolapse (POP).

Materials and methods: This is a retrospective single-center cohort study in a tertiary referral center. Thirty-two consecutive patients underwent laparoscopic SHP for apical prolapse between 2016 and 2023. Laparoscopic SHP with or without right pelvic side wall retroperitoneal tunneling. The primary outcome was surgical time. Secondary outcomes included blood loss, intra-and postoperative complications, length of hospital stay, postoperative pain scores, and improvement in POP quantification (POP-Q) scores. Statistical analyses were performed using t-tests and multiple regression. Statistical significance was set at P < .05.

Results: The tunneling group (n = 14) demonstrated significantly shorter surgical times than the nontunneling (n = 18) group (60.79 ± 22.35 minutes vs 98.06 ± 26.28 minutes, P < .001). There were no significant differences between the groups regarding blood loss, intra-and postoperative complications, length of hospital stay, pain scores, or point-C positions during 3 months and 1 year of follow-up. Multiple regression analysis confirmed a significant reduction in surgical time in the tunneling group after adjusting for confounders (-62.36 minutes [95% confidence interval (CI) = -102.7, -21.99, P = .0038]).

Conclusion: The retroperitoneal tunneling technique in laparoscopic SHP significantly reduces the surgical time without increasing the risk of complications. These findings suggest that tunneling is a safe and efficient method that can be routinely adopted for SHP.

Objective: While robotic surgery platforms are widely used, there is a dearth of literature on robotic assistants. This study aims to provide a comprehensive understanding of the role and functions of a valuable assistant in robotic surgery.

Methods: The first author has garnered over 10 years of experience as an assistant at a high-volume urological center, where more than 10,000 robotic operations have been performed. This paper delves into the specific intricacies of how an assistant collaborates with the chief surgeon.

Results: The assistant's primary responsibilities encompass ensuring the precise placement of trocars to facilitate the chief surgeon's manipulation of the robot and assisting in the optimal exposure of the surgical area according to the chief surgeon's requirements.

Conclusions: The assistant assumes a pivotal role in robot-assisted surgery, necessitating a profound understanding of the chief surgeon's intentions and the ability to effectively expose the operative field.