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

Background and objectives: Robotic surgery has facilitated minimally invasive surgery with its enhanced visualization and improved dexterity compared to open and laparoscopic approaches. However, widespread adoption remains limited by steep learning curves. We describe procedural steps, technical considerations, and early clinical outcomes with a 1-stage robotic-assisted cholecystectomy with common bile duct exploration.

Methods: A single-institution case series of 21 patients undergoing robotic-assisted cholecystectomy with common bile duct exploration from October 2022 to August 2024 was retrospectively reviewed.

Results: Nine patients were female (43%), and the median age was 70 (interquartile range [IQR] 64-76). No patient required conversion to laparotomy or laparoscopy. Two patients (10%) required postoperative endoscopic retrograde cholangiopancreatography for duct clearance. The median total operative time was 215 minutes (IQR 180-290). The median fluoroscopy time was 1.5 minutes (IQR 1.2-2.1). We review the bed orientation, overall room set up, and robot arms rearrangements that were required to accommodate the C-arm for intraoperative fluoroscopy.

Conclusion: Robotic-assisted cholecystectomy with common bile duct exploration is possible but requires dedicated equipment and staff arrangements. Engagement of hospital staff including surgeons, anesthesiologists, radiology technicians, operating room nurses, and surgical technologists are paramount for success.

Background: Morcellation has allowed patients with enlarged uteri to obtain a minimally invasive hysterectomy with improved outcomes; however, there is little information regarding postoperative pain. Our study aims to compare pain scores and opioid requirements in patients undergoing umbilical morcellation during benign minimally invasive hysterectomy versus those who do not require morcellation.

Methods: A retrospective cohort study was performed at a tertiary care center including patients who underwent total laparoscopic or supracervical hysterectomy by one high volume surgeon from 2019 to 2022. Baseline characteristics, postoperative pain scores, and morphine milligram equivalents in the acute and late setting were recorded. Two-sample t test for continuous variables and χ² or Fisher's exact test for categorical variables were used to compare differences. A multiple regression model evaluated the effect of groups with the adjustment of confounders.

Results: A total of 232 patients underwent hysterectomy in which 57 underwent umbilical manual morcellation and 175 did not. There was no difference in postoperative complications, readmissions, or blood products required (P > 0.05). Individuals that underwent umbilical morcellation had longer operative times (226.6 vs 120.1 minutes, P < 0.01), more blood loss (311.1 vs 82.0 mL, P < 0.01), longer length of stay (0.60 vs 0.44 days, P < 0.01), increased uterine weight (1,293.2 vs 151.6 g, P < 0.01), and fibroid pathology (93.0% vs 46.3%, P < 0.01). There were no differences in postoperative pain scores, immediate and later opioid use between groups on multivariate analysis.

Conclusions: Patients who undergo umbilical morcellation, typically for large fibroid uteri, have similar postoperative pain scores, opioid use, and postoperative complications to those who undergo hysterectomy for other indications.

Objective: Minimally invasive surgical techniques for colorectal surgery have continued to grow in prevalence with robotic surgery potentially providing advantages in complex pelvic operations. We sought to examine the outcomes of laparoscopic versus robotic elective sigmoid colon resection for complicated diverticulitis.

Methods: We performed a retrospective review of patients at an academic tertiary care center from 2018-2023 who underwent elective minimally invasive sigmoid colon resections for complicated diverticulitis. Multiple regression analysis was performed with primary outcomes being reoperation within 30 days and overall complications. Secondary outcomes included conversion to open, estimated blood loss, operative time, days until return of bowel function, and length of stay.

Results: In this cohort of 131 patients, 38 underwent laparoscopic colectomy and 93 patients underwent robotic colectomy. There were no significant differences between rate of reoperation (7.7% vs 2.1%, P = .42), complications (5.1% vs 8.4%, P = .52), conversion to open (5.1% vs 2.1%, P = .25), days until return of bowel function (1.87 vs 2.01, P = .41), or length of stay (5.2 vs 5.2, P = .92). There were significant differences in operative time and estimated blood loss. Robotic approach was 128.11 minutes longer (β = 128.11, SE = 12, p < .001) and had 33.4 cc less estimated blood loss (β = -33.4, SE = 16.6, P = .046), when adjusting for other confounders.

Conclusion: Robotic sigmoid colectomy for complicated diverticulitis had mostly equivalent outcomes at this institution. There was some decrease in estimated blood loss, however, operative time was increased in the robotic group.

Background: Compared to elective surgery, emergent hernia repairs carry higher morbidity. Additionally, frailty is independently associated with worse postoperative outcomes. This study aimed to assess if the surgical approach, minimally invasive surgery versus open, confers improved outcomes for frail patients who underwent emergent hernia repairs.

Methods: The National Surgical Quality Improvement Program database (2018-2020) was queried for patients who underwent emergency hernia repair by Current Procedural Terminology (CPT) codes (49505-49659). A modified frailty index-5 score was calculated; only frail patients with a score of ≥2 were included. The impact of surgical approach on length of stay, discharge destination, and mortality was determined by multivariate analysis.

Results: A total of 1,893 patients met the inclusion criteria. Most patients (56.5%) were female, and 61.4% of patients were age ≥65. Most patients (83.62%) underwent open repair. After adjusting for covariates, patients who underwent minimally invasive surgery had a shorter length of stay compared to open surgery (hazard ratio = 1.22; 95% confidence interval [1.06,1.41]; P = .006). Surgical approach was not associated with a difference in 30-day mortality (P =.28) or discharge destination (P = .97).

Conclusion: Minimally invasive emergent hernia repairs in frail patients in the National Surgical Quality Improvement Program database cohort are associated with a shorter length of stay compared to open surgery, without increased 30-day mortality or change in discharge destination. Prospective studies are needed to validate best-practices in treating frail surgical patients.

Background and objectives: Additional support for the safety and feasibility of combined paraesophageal hernia repair and Roux-en-Y gastric bypass is needed. We sought to analyze both the short- and long-term outcomes of patients who underwent this combined operation.

Methods: Single institution retrospective analysis of overall morbidity and mortality of patients who underwent primary Roux-en-Y gastric bypass with paraesophageal hernia repair from January 2014 to July 2023.

Results: Fifty-two patients met inclusion criteria. Mean preoperative body mass index was 40 kg/m². Most patients underwent a robotic approach. Six and three patients were noted to have minor and major postoperative complications, respectively. Ample comorbidity resolution and weight loss outcomes were noted. A robotic approach was associated with a significantly decreased operative time.

Conclusion: Minimally invasive paraesophageal hernia repair with concurrent Roux-en-Y gastric bypass is a feasible and effective procedure, which leads to significant weight loss and associated comorbidity resolution. This simultaneous operation may be accomplished safely and potentially faster via a robotic approach.

Background and objectives: In 2009, we designed the sutureless "Slim-Mesh" laparoscopic technique to facilitate and promote repair of ventral hernias in the obese/superobese populations, including cases with large-giant/massive and multiple widely-spaced hernias. We also aimed to reduce surgical time and intra- and postoperative complications.

Methods: Cases were divided into Class I (body mass index [BMI] 30.0-34.9 kg/m²), II (35.0-39.9 kg/m²), III (40.0-49.9 kg/m²), and superobese (50.0-59.9 kg/m²). A ventral hernia was small-medium (∅ 2-9.9 cm), or large (∅ 10-14.9 cm)-giant (∅ 15-19.9 cm)/massive (∅ ≥ 20 cm). Between September 2009 and May 2023, 64 obese/superobese ventral-hernia patients were enrolled prospectively (81%)-retrospectively and treated with the Slim-Mesh technique.

Results: We operated on 35 males and 29 females. Mean age and BMI were 60 years old and 33 kg/m², respectively. Class I cases numbered 48, II 13, III 2, with 1 superobese case. Small-medium, large-giant, and massive ventral hernias were found intraoperatively in 40, 21, and 3 cases, respectively. Mean surgical time for all cases was 104 minutes. Mean length of hospital stay was 2 days and mean follow-up time was 5 years. We had 1 case of chronic abdominal-wall pain and 6 late postoperative-complications: 4 (6%) hernia recurrences, and 2 trocar-site hernias.

Conclusion: The sutureless "Slim-Mesh" technique implements the laparoscopic approach to repair ventral hernias in the obese/superobese populations rather than open surgery or traditional transfixation suture-based laparoscopy, including cases with large-giant/massive and multiple widely-spaced hernias. This study proves that "Slim-Mesh" is safe, straightforward, quick, easy-to-reproduce, and economical.

Background and objectives: Patients with an inguinal hernia usually report an inguinal bulge and pain. Inguinal canal fat can cause lower abdominal pain, swelling, and an inguinal hernia. Round ligament lipomas (RLLs) and inguinal cord lipomas (CLs) comprise invagination of extraperitoneal fat in the inguinal canal through the deep inguinal ring, with or without a hernia sac. During open surgery, The Inguinal canal fat mass (ICFM) previously labeled CL or RLL is usually excised and considered a CL, RLL, or inguinal canal lipoma. A lipoma is a benign tumor; therefore, it is not optimal to label inguinal fat as a lipoma. Moreover, lipoma incidence is 1 in 1,000; however, CL incidence is as high as 72.1%. During laparoscopy, it is difficult to observe the inguinal canal. CLs and RLLs can be missed during transabdominal preperitoneal and total extraperitoneal repair. We evaluated the importance of the anatomical identification and management of ICFM, previously labeled CL or RLL in laparoscopic inguinal hernia repair.

Methods: All patients (n = 102; 93 male and 9 female patients) with an inguinal hernia who underwent laparoscopic examination and management of the ICFM, previously labeled CL or RLL between May 2016 and May 2022 were included. All fatty mass of the inguinal were excised preserving the fat around the spermatic cord or round ligament.

Results: More inguinal fat was observed in female patients. After surgery, the patients' symptoms improved dramatically.

Conclusion: Laparoscopic retromuscular repair and exploration of the inguinal canal and excision of ICFM, previously labeled CL or RLL are less likely to result in missed inguinal hernias and more likely to result in good outcomes and fewer postoperative complications.

Background: Acute appendicitis is the most frequent cause of emergency surgical procedures performed worldwide. Laparoscopic appendectomy (LA) has gained considerable popularity in the last decades. However, the ideal method for appendicular stump closure during LA is still debatable and depends on the surgeon's preference and intraoperative judgment. The endoloop ligatures (EL) is the most used method but its application is quite challenging. The efficacy of nonabsorbable polymeric clip (PC) has been proven and it was first described for appendicular stump closure in 2007.

Methods: A retrospective comparative cohort study was conducted including all consecutive patients who underwent LA from January 2017 to the end of 2023 in a tertiary university hospital. Data were retrieved from their electronic medical files. The patients were classified into 2 groups. The appendicular stump was closed using EL, in the first group, and using PC, in the second group. The calculated operative time started from the patient's entry to the operating theatre till transfer to the recovery room.

Results: Out of 556 patients who underwent LA, 483 patients were included and classified into Group I (313 patients with EL), and Group II (170 patients with PC). Intraoperatively, complicated acute appendicitis was found in 27.8% and 36.5% and the median diameter of the appendix was reported 10 and 11.4 millimeters, respectively. The procedure was significantly shorter using PC (70 minutes vs 75 minutes, P = .03) and the cost was lower using PC ($42.6 vs $95.8). Intra-abdominal collection was reported in 1.6% and 0.6%, localized abscess was reported in 1% and 0.6%, and the hospital readmission rate was 3.19% and 1.18%, respectively.

Conclusion: The use of nonabsorbable PCs is safe and feasible for appendicular stump closure during LA for acute appendicitis.

Background: Retroperitoneoscopic donor nephrectomy (RDN) approach is an unfamiliar approach to the donor surgeons in Australia and New Zealand due to the background General Surgery training. The learning curve when transitioning from transperitoneal to retroperitonoscopic donor nephrectomy is relatively short with minimal morbidity.

Methods: We detail our standardized surgical approach for performing RDN, including technical tips and maneuvers as well as visual aids that ensure the procedure's safety and efficacy.

Discussion: RDN demonstrates notable advantages over traditional laparoscopic methods, including shorter operative times, less postoperative pain, and quicker recovery, thereby enhancing donor safety and graft function. Our goal is to outline our institution's RDN technique, offering valuable insights to aid donor surgeons in incorporating this method into their surgical repertoire. This approach requires a precise surgical technique and adequate training to maximize outcomes and minimize donor complications.

Background: Subtotal cholecystectomy is employed when the hepatocystic triangle cannot be visualized, a surgical maneuver reserved for difficult gallbladders. The current literature compares an open versus laparoscopic approach with little discussion of robotic-assisted procedures. Although the robotic approach offers enhanced visualization and dexterity, its application in subtotal cholecystectomy remains underexplored. This study aims to compare the outcomes of robotic-assisted and laparoscopic subtotal cholecystectomies, focusing on postoperative complications and the learning curve associated with robotic surgery.

Methods: This study population included patients from July 2021 to June 2024 who underwent a subtotal cholecystectomy either laparoscopically or robotically with either fenestrated or reconstituted closure of the remaining biliary structures. A subtotal cholecystectomy was defined as a cholecystectomy with failure to control the cystic duct or view of the hepatocystic triangle of safety leading to at least 50% removal of the gallbladder body. Patients were categorized by their operative techniques: robotic or laparoscopic. The study variables included indication, age, gender, weight, operative variables, closure type, subsequent interventions, and other outcome data.

Results: In a retrospective analysis of 48 subtotal cholecystectomy cases performed between July 2021 and June 2024, 37.5% were robotic, and 62.5% were laparoscopic. Robotic procedures were more often associated with reconstituted closure (72.22%) compared to laparoscopic procedures, which used fenestrated closure (100%). Postoperative endoscopic retrograde cholangiopancreatography (ERCP) was significantly less frequent in the robotic group (11.1%) compared to the laparoscopic group (27.1%, P = .03). No patients in the reconstituted group needed postoperative ERCP, while 31.25% of fenestrated cases did (P = .004). Surgical duration and length of stay were comparable between the 2 techniques, challenging the notion of a steep learning curve for robotic surgery.

Conclusions: Robotic-assisted subtotal cholecystectomy is a practical and potentially superior alternative to laparoscopic methods, particularly in reducing the need for postoperative interventions like ERCP. The findings support the broader adoption of robotics in challenging gallbladder surgeries. Further multicenter studies with larger cohorts are recommended to confirm these findings.