Surgical Laparoscopy, Endoscopy & Percutaneous Techniques最新文献

Background: Diastasis recti abdominis (DRA) is a prevalent postpartum condition characterized by the separation of the rectus abdominis muscles with an interrectal distance >2.5 cm, often leading to symptoms like back pain, constipation, and urinary incontinence. Preaponeurotic endoscopic repair (REPA) is a novel, minimally invasive surgical approach for DRA, offering an alternative to traditional abdominoplasty. Despite its minimally invasive nature, REPA surgery poses significant postoperative pain challenges, typically managed with opioids, which carry numerous side effects.

Materials and methods: This retrospective study evaluates the efficacy of combining 2 ultrasound-guided abdominal wall blocks, rectus sheath block (RSB) and transversus abdominis plane block (TAPB), to manage postoperative pain in 55 DRA patients who underwent REPA surgery. We performed lateral TAPB in 28 cases, whereas 27 received an association of TAPB and RSB.

Results: At 6 hours postsurgery, 61% of patients in the TAPB group reported significant pain (Numeric Rating Scale >3), compared with 19% in the TAPB-RSB group (P = 0.001). The TAPB-RSB group also required fewer analgesic rescue doses (P = 0.042) and showed earlier recovery, with faster initiation of oral intake and mobility.

Conclusion: The combination of TAPB and RSB significantly reduces opioid consumption, postoperative pain, and the need for rescue analgesia compared with TAPB alone. The dual-block approach, providing a multi-dermatomal sensory block, suggests a promising strategy for improving postoperative pain management in REPA surgery.

Introduction: Pneumoperitoneum is widely used in gastrointestinal surgery, particularly for laparoscopic or robotic procedures, with suggested advantages associated with low pressure. While existing data predominantly focuses on laparoscopic cholecystectomy, the assessment of intra-abdominal pressures in other gastrointestinal surgeries remains unexplored.

Methods: This study conducted an electronic literature search for randomized control trials comparing low-pressure pneumoperitoneum to standard or high-pressure counterparts.

Results: Out of 26 articles meeting inclusion criteria, encompassing 2077 patients, 15 demonstrated positive associations with low-pressure pneumoperitoneum. No significant difference in postoperative pain was found in the remaining papers. Methodological variations, diverse outcome reporting, and a prevalent high risk of bias precluded meta-analysis.

Conclusions: The study highlights substantial outcome variability, urging cautious interpretation of aggregated results. Despite positive associations in specific cases, insufficient evidence was found to support the superiority of low-pressure pneumoperitoneum. The study recommends future research employing validated patient-reported outcome measures and standardized reporting to help guide the development of evidence-based guidelines and optimize patient care in abdominal surgeries.

Background: Percutaneous endoscopic gastrostomy (PEG) is a safe method of choice for patients who need long-term nutritional support. However, complications and high mortality rates have been reported. Based on 8 years of experience in tertiary care hospitals, we aimed to identify risk factors associated with major complications and 30-day mortality after PEG.

Methods: Patients who underwent PEG in the General Surgery clinic of Tokat Gaziosmanpaşa University, Faculty of Medicine between January 2014 and March 2022 were included in the study. Data regarding patient demographics, comorbidities, laboratory data, drugs used together, and indications for PEG tube placement were collected.

Results: There were 429 patients. The mean age of the patients was 66.9±16.75 years, and 180 (44%) patients were female. The mean follow-up period was 8.84±6.75 months. Twenty patients (4.9%) had major complications. Female sex [Odds Ratio (OR) 0.33, 95% CI, CI=1.23-8.87, P=0.02] and diabetes mellitus (DM) (OR=0.23, 95% CI=1.93-6, P=0.002) were the independent variables associated with major complications. The all-cause 30-day mortality rate was 5.9% (n=24). Malignancy, DM, corticosteroid use, low albumin, and platelet values were associated with increased mortality in multivariate analysis as indications for PEG.

Conclusions: Female sex and patients with DM may potentially face major complications. The patients with cancer, diabetes, and corticosteroid use were associated with higher mortality. In addition, low serum albumin and platelet levels were an effective factor for survival in patients undergoing PEG, and this should be taken into account in decision-making.

Background: Percutaneous transhepatic biliary drainage (PTBD) is a common procedure for biliary obstruction jaundice caused by biliary tract obstruction. PTBD can be performed using external or external-internal methods, by the right or left lobe approach. However, differences in both the method used and the hepatic approach may affect success rates and complications. Therefore, this study aimed to examine the outcomes and complications of PTBD and compare them according to different methods and hepatic approaches.

Methods: Patients who underwent PTBD procedures in our interventional radiology department due to benign or malignant pathologies between March 2021 and March 2024 were included in the study. The diagnoses of the patients, and total and direct bilirubin values before and after the procedure were recorded. The clinical results and the complications of PTBD were compared statistically according to the hepatic approach and method. Univariate logistic regression analysis was performed to determine significant factors associated with PTBD success and complications.

Results: Sixty patients were included in our study (32 men, 28 women; mean age: 67.14±13.61 y). The most common indication was malignant bile duct obstruction (90%). The obstruction was mostly at the level of the common bile duct (46.7%). The success rate of PTBD was the highest with the left-side external biliary drainage approach (left-side external biliary drainage, 81.2%; right-side internal-external biliary drainage, 77.8%; right-side external biliary drainage, 69.2%; P =0.596). The complication rate was higher for right-side access (right side 15.9%, left side 12.5%, P =0.744). Univariate logistic regression analysis revealed that PTBD success in females was 5 times higher than in males [Exp( B ): 5.000, β: 1.609, P <0.05]. Univariate logistic regression analysis revealed that methods used, entry lobes, and entry levels did not significantly affect PTBD success and complication incidence ( P >0.05).

Conclusion: All approaches and methods used during PTBD were associated with low complications and high success rates. Nevertheless, external biliary drainage with right hepatic access has the lowest clinical success rate and a higher complication rate than the left-lobe approach. We observed that left-sided external biliary drainage was the most successful method and had fewer complications.

Background: Data consistently supports a surgery-first approach to common bile duct (CBD) stones in patients with a gallbladder via laparoscopic CBD exploration (LCBDE). LCBDE has equivalent efficacy and decreased cost as compared with cholecystectomy plus endoscopic retrograde cholangiopancreatography (ERCP). However, adoption has been low due to the technical limitations of laparoscopy. We describe a straightforward and highly reproducible robotic CBDE (RBCDE) technique.

Methods: A cystic ductotomy is made after obtaining a critical view of safety. Through a 5 mm port, a wire-ready cholangiogram catheter is secured in the cystic duct and intraoperative cholangiogram performed. Based on stone burden, small versus large, either an antegrade balloon snowplow (push stones forward) or sphincteroplasty is performed over a wire under fluoroscopy. If concern persists for retained stones, choledochoscopy is performed.

Conclusions: Our simplified antegrade-only RCBDE technique allows surgeons to consistently offer a surgery-first, single-stage approach to CBD stones in patients with a gallbladder.

Objective: Pancreatic stump closure in minimally invasive distal pancreatectomy (DP) commonly utilizes staplers due to its simplicity; however, postoperative pancreatic fistula (POPF) remains the most frequent complication. We have developed a novel stump closure technique using a transpancreatic mattress suture with a polyglycolic acid sheet (TP method) under robotic DP. This study aims to evaluate the efficacy of the TP method.

Materials and methods: This study included 145 cases of pure minimally invasive DP performed between February 2011 and July 2024: 34 robotic (R) and 97 laparoscopic (Lap). Surgical outcomes were compared across 3 groups based on the stump closure method: 18 cases using the TP method (TP group; R: 18), 22 with hand-sewn closure in a fish-mouth manner (FM group; Lap: 22), and 91 with a reinforced stapler (S group; R: 16, Lap: 75). Logistic regression analysis was employed to identify risk factors for POPF.

Results: POPF occurred in 20 of 131 cases (grade B: 19, C: 1, 15.3%). The TP group exhibited the lowest POPF rate (TP vs FM vs S: 5.6% vs 27.3% vs 14.3%). Multivariate analysis identified pancreatic thickness ≥12 mm as an independent risk factor. For thickness <12 mm, no significant differences in POPF rates were observed (TP vs FM vs S: 0% vs 25.0% vs 5.6%). However, for thickness ≥12 mm, the TP group had a significantly lower POPF rate compared with the S group (TP vs FM vs S: 7.7% vs 28.6% vs 47.4%).

Conclusion: The TP method is superior to stapler closure in preventing POPF, especially in cases with pancreatic thickness of ≥12 mm.

Objective: The objective of this investigation was to ascertain the effectiveness of an ultrasound-guided erector spinae plane block (ESPB) administered to patients diagnosed with hepatocellular carcinoma who were subjected to laparoscopic left hemihepatectomy.

Methods: A retrospective analysis was conducted on 172 patients, comparing 2 groups: one comprising 90 individuals who were administered intravenous patient-controlled analgesia (PCA) simultaneously with ESPB, and a second group of 82 patients who received PCA monotherapy. To equilibrate covariates across the groups, propensity score matching was executed, yielding 25 matched pairs as a result.

Results: At 12 and 24 hours postprocedure, visual analog scale (VAS) pain scores, both at rest and during movement, were significantly reduced in the group receiving PCA in conjunction with ESPB. Furthermore, this group exhibited a substantially lower incidence of rescue analgesia utilization, a significantly abbreviated duration to ambulation, a reduced hospitalization period, and a significantly elevated level of patient satisfaction.

Conclusion: ESPB serves as an efficacious ancillary analgesic for laparoscopic left hemihepatectomy, offering superior pain management and recuperation relative to the administration of intravenous analgesia in isolation. The implementation of ESPB as an adjunct to PCA in patients with hepatocellular carcinoma undergoing laparoscopic left hemihepatectomy proved to be both safe and efficacious. Notably, PCA augmented with ESPB demonstrated greater efficacy in mitigating postoperative pain compared with PCA as a standalone therapy.

Background: Obesity-associated nonalcoholic fatty liver disease (NAFLD) is a significant cause of chronic liver disease. Our study sought to investigate preoperative NAFLD and the effect at 6 months and 2 years after surgery of one anastomosis gastric bypass (OAGB) and its development 6 months after surgery regarding weight loss outcomes.

Materials and methods: A retrospective cohort study was conducted on patients with severe obesity who underwent primary OAGB at Hazrat-e-Rasool Hospital between March 2020 and June 2021. Preoperative assessments included abdominal ultrasound (US) for NAFLD grading, weight, and biochemical blood tests. Follow-up examinations were performed at 10 days and 1, 3, 6, 9, 12, and 24 months postsurgery, with subsequent US examinations at the 6-month follow-up.

Results: Two hundred thirty-one patients were included, with an average age of 40.3±10.5 years and a percentage of 78.4 women. Their mean weight and BMI were 131.2±26.8 and 48.8±8.5, respectively. Six-month grades of NAFLD showed that patients with grade 3 NAFLD had significantly lower TWL% compared with the lower grades. NAFLD grades improved in 72.3% of our patients, remained the same at 21.2%, and worsened at 6.5%. The 6-month TWL% was 28.4±4.3 in the no-change group, 28.4±5.3 for the improved group, and 25.2±14.6 in the worse group.

Conclusion: The severity and progression of NAFLD can significantly impact weight loss outcomes post-OAGB, highlighting the importance of monitoring and managing NAFLD in patients undergoing bariatric surgery.

Background: Laparoscopic cholecystectomy (LC) is widely performed with generally favorable outcomes, but postoperative pain remains a significant issue, influenced by various factors including the specimen extraction site and gallstone size.

Methods: A prospective randomized controlled study was conducted on 100 patients undergoing LC. Participants were randomized to have the specimen removed through either the epigastric or umbilical trocar. Postoperative pain was assessed using the visual analog scale (VAS) on postoperative days 1, 3, and 7. Statistical analyses were performed to evaluate the impact of trocar site and gallstone size on pain levels.

Results: Patients whose specimens were extracted through the umbilical trocar experienced significantly less pain on postoperative days 1 and 3 ( P =0.006 and 0.014, respectively) than those with epigastric trocar extraction. In addition, patients with gallstones larger than 10 mm reported higher pain levels on day 3 ( P =0.001) irrespective of the extraction site.

Conclusions: The umbilical trocar site for specimen extraction and smaller gallstone size is associated with reduced early postoperative pain following LC. These findings suggest the importance of considering extraction site and gallstone size in managing postoperative pain in LC patients.

Background: Posterior component separation with transversus abdominis release (TAR) is a valuable adjunct to address incisional hernia defects. Currently, bilateral docking is a standard technique for robotic TAR. The aim of this study is to describe our technique for extended totally extraperitoneal (eTEP) repair with bilateral TAR through a bottom single-dock robotic approach for hernias at the level of the umbilicus or higher.

Materials and methods: We retrospectively reviewed a case series of patients who underwent robotic eTEP repair with bilateral TAR using a single bottom docking between November 2021 and November 2023. A comprehensive description of our patient selection, surgical technique, and short-term clinical outcomes is reported.

Results: Ten patients with incisional hernias were included. Their median age was 55 years (IQR: 49.5 to 61.25), 70% were male, the median BMI was 27.25 kg/m (IQR: 22.95 to 33.53), and ASA class was ≥2 in 80%. Median hernia width was 10 cm (IQR: 6.75 to 12.25) and length 11 cm (IQR: 9.25 to 16.25). The median operative time was 178.5 minutes (IQR: 153.75 to 222), and the length of stay was 1 day (IQR: 0.75 to 1.75). At a median follow-up of 5 months (IQR: 2.6 to 9.7), 20% of patients developed a surgical site occurrence requiring procedural intervention.

Conclusion: Bilateral TAR using a single bottom dock is a feasible and safe adjunct to robotic eTEP ventral hernia repair in appropriately selected patients.