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

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.

Introduction: Although laparoscopic cholecystectomy (LC) is considered the gold standard surgical approach for acute cholecystitis, there has been increased interest in robotic-assisted cholecystectomy (RAC) as an alternative treatment method. This study compares length of operative time and perioperative outcomes between these 2 techniques.

Methods: We identified patients from a single institution between January 1, 2023 and December 31, 2023, who underwent surgical treatment for acute cholecystitis. Gathered data included demographic, clinicopathologic, and perioperative variables. Patients were stratified by LC or RAC surgical approaches. Pearson χ², Fisher's exact, Mann-Whitney U, and unpaired t tests were utilized to compare collected variables.

Results: We identified 259 total patients, with 186 patients in the LC group (71.8%) and 73 in the RAC group (28.2%). Females comprised most both groups (LC, n = 125/186, 67.2%; RAC, n-n = 48/73, 65.8%, P = .884). Median age at surgery for LC patients was 43 years, and 49 for RAC patients (P = .341). As for operative time, the median duration for LC was 108 minutes and 68.2 minutes for RAC (P < .001). Nine LC (4.8%) patients and 1 RAC (1.4%, P = .192) had postoperative complications. Conversion to open or fenestrated cholecystectomy occurred in 8 LC (4.3%) patients and 4 RAC (5.5%, P = .745) patients.

Conclusions: This study demonstrated that RAC has a shorter operative duration in comparison to LC. RAC also has a similar rate of complications and conversions as the laparoscopic approach. Our findings show that RAC is a safe and feasible alternative approach for treating acute cholecystitis.

Background and objectives: Laparoscopic cholecystectomy has remained the gold standard approach for gallbladder surgery for nearly 3 decades. However, adoption of robotics for treatment of gallbladder disease continues to grow. Despite this growth, clinical outcomes regarding laparoscopic versus robotic cholecystectomy remain unclear.

Methods: We conducted a multihospital retrospective cohort study of patients who underwent cholecystectomy between August 1, 2021 and November 30, 2023. We compared demographic and clinical characteristics, surgical details, and postoperative outcomes between laparoscopic and robotic groups. The postoperative outcomes analyzed included conversion to open, bile leak, major duct injury, return to the operating room, surgical site infection, blood transfusion, readmission, and death. The overall complication rate included any of these outcomes. Statistical analysis included χ² tests, t-tests, Wilcoxon rank sum tests, and multivariable logistic regression.

Results: A total of 4,316 patients were analyzed (3,736 laparoscopic, 580 robotic). In bivariate analyses, robotic surgery was associated with lower rates of conversion to open (P = .019), bleeding requiring transfusion (P = .017), and overall complications (2.9% vs 5.5%), respectively (P = .009). Robotic approach was associated with a 5 minute longer average surgery time (P = .002). Using multivariable logistic regression analysis to account for preoperative differences between the groups, robotic surgery was associated with a 62% decreased risk of any complication (odds ratio [OR] = 0.38, 95% confidence interval [CI] [0.20, 0.74]).

Conclusion: Robotic cholecystectomy demonstrates favorable clinical outcomes compared to laparoscopic cholecystectomy. These findings support the advantages of robotic assistance during cholecystectomy. To our knowledge, this represents one of the largest retrospective studies showing a clinical benefit from the robotic approach.

Background and objectives: Minimally invasive hepatectomies, including laparoscopy and robotics, offer potential advantages over traditional open surgery, such as reduced postoperative pain, lower complication rates, and improved oncological outcomes. However, resections involving the caudate lobe remain technically demanding owing to its complex anatomy and proximity to major vasculature. This study aimed to evaluate the feasibility and safety of robotic caudate lobectomy in a small-volume center using both multiport and single-port systems.

Methods: From January 2023 to May 2024, 3 patients underwent robotic caudate lobectomy at Dong-A University Hospital. Two procedures utilized the Da Vinci Xi multiport system, whereas 1 employed the Da Vinci SP single-port system. The surgical techniques and outcomes were analyzed in detail.

Results: The first patient, with a 6.8-cm hemangioma, underwent Spiegel lobectomy with the Xi system in 157 minutes and was discharged on day 3 without complications. The second patient, with a 2.5-cm hepatocellular carcinoma, underwent complete caudate lobectomy using the Xi system and was discharged on day 5. The last patient, with a 3-cm cystic lesion, underwent Spiegel lobectomy with the SP system and was discharged on day 6.

Conclusion: Our findings indicate that robotic caudate lobectomy is feasible and safe even in small-volume centers. Advanced robotic systems enable minimally invasive approaches to challenging liver resections, potentially achieving outcomes comparable with those in larger institutions. Further studies with larger patient cohorts are required to validate these findings.

Background and objectives: Acute appendicitis is an inflammation of the appendix caused by various factors and is the most common cause of acute abdominal pain presenting to the emergency department. Open appendectomy was first described by McBurney in 1894 using an incision method, and in 1983, Semm performed the first laparoscopic appendectomy. The aim of this study is to share the outcomes of patients who underwent open and laparoscopic appendectomy in our center.

Methods: Data from patients who underwent appendectomy between 2014 and 2023 at our center were retrospectively obtained from patient records and the Hospital Information Management System (HIMS). Sociodemographic characteristics, operation durations, hospital stay, complication rates, and pathology results of the patients were evaluated.

Results: A total of 627 patients were operated on for acute appendicitis between 2014 and 2023, of which 298 (47.5%) underwent laparoscopic appendectomy and 329 (52.5%) underwent open appendectomy. No statistically significant differences were found between the groups in terms of age, sex, American Society of Anesthesiologists (ASA) score, operation duration, and final pathological results. However, hospital stay was significantly longer in the open appendectomy group (P = .001). Additionally, the complication rate was higher in the open appendectomy group, with a statistically significant difference (P = .046).

Conclusion: Laparoscopic appendectomy is supported in the literature by lower complication rates, shorter hospital stays, and shorter operation times. Although laparoscopic appendectomy is as safe as open appendectomy, it is thought to provide the surgeon with an advantage in assessing other potential acute intra-abdominal pathologies. Therefore, we recommend laparoscopic surgery for patients with a preoperative diagnosis of appendicitis.

Background: Acute cholecystitis (AC) is among the most frequently encountered surgical problems. Current management typically includes laparoscopic cholecystectomy (LC). Suboptimal outcomes of LC can include bile duct injury, open conversion (OC), and/or subtotal cholecystectomy (SC). Percutaneous cholecystostomy tube (PCT) drainage with interval cholecystectomy has emerged as an alternative in high-risk patients but outcomes vary widely. We describe an evidence-based algorithm for managing AC in high-risk patients via PCT followed by minimally invasive cholecystectomy (MIS-C). We hypothesized that our algorithm would prove safe, effective, and decrease OC and SC rates.

Methods: Retrospective chart review of patients undergoing PCT and MIS-C according to our algorithm from January 2020 to June 2023. The primary outcome was OC or SC. Secondary outcomes included bile leak, bile duct injury, and perioperative complications. Demographic, clinical, and operative data were collected. Statistical analysis was performed using Minitab Software.

Results: Twenty-nine patients met criteria and were treated according to our algorithm during the study period. One patient (3.4%) required conversion to SC. Other complications included 3 postoperative bile leaks (10.4%). There were no bile duct injuries and no deaths. None were lost to follow up. When stratified by LC or robotic-assisted cholecystectomy (RC), complications occurred more frequently in the LC group, including the lone conversion to SC.

Conclusion: Our management protocol of high-grade AC in high-risk patients appears safe, feasible, and may reduce adverse events. Additionally, our data suggest a potential benefit of RC in this setting which may be an underutilized tool in acute care surgery. Prospective data are needed to validate and further refine this algorithm.

Background and objectives: This study aimed to identify the predictors of surgical outcomes in acute cholecystitis (AC).

Methods: Patients undergoing cholecystectomy for AC between January 1, 2007 and December 31, 2019 at a single center were retrospectively reviewed. Conversion rate (CR), laparoscopic success rate (LSR), mortality, and bile duct injury (BDI) were evaluated in light of sex, age, ultrasound morphological diagnoses, severity of cholecystitis, performance status, time frame, and introduction of percutaneous transhepatic gallbladder drainage (PTGBD).

Results: A total of 465 patients underwent early cholecystectomy. CR and LSR were 16.89% and 78.28%, respectively; the mortality rate was 1.62%. Increased severity of cholecystitis (grade I vs II vs III) was associated with increased mortality (1.17 vs 2.27 vs 8.33%, P = .183) and CR (7.09 vs 32.93 vs 28.57%, P < .001) and decreased LSR (91.11 vs 61.11 vs 38.46%, P < .001). Surgery within 72 hours had lower mortality (1.41 vs 2.6%, P = .613) with significantly lower CR (14.45 vs 25.71%, P = .008) and higher LSR (81.69 vs 67.53%, P = .008) compared to surgery after 72 hours. Mortality (0 vs 0.92 vs 6.19%, P = .001) and CR (4.2 vs 16.27 vs 39.53%, P < .001) increased with an increase in Charlson comorbidity index (CCI), while LSR decreased (95.8 vs 79.91 vs 50.49%, P < .001).

Conclusion: CCI and the severity of cholecystitis had the strongest influence on CR and LSR. Cholecystectomies performed within 72 hours were associated with reduced CR and increased LSR. PTGBD is a viable treatment option in elderly high-risk patients.