Surgical Laparoscopy, Endoscopy & Percutaneous Techniques最新文献

Background: Situs inversus totalis (SIT) is a rare congenital condition characterized by the mirror-image reversal of thoracic and abdominal organs. Its incidence is between 0.04% and 0.30%. Patients with SIT presenting with cholelithiasis pose diagnostic and technical challenges, particularly during laparoscopic cholecystectomy (LC), due to reversed anatomic landmarks and difficulties in orientation.

Methods: We conducted a retrospective review of 12 patients with SIT who underwent LC between September 2006 and April 2023 at our tertiary center. Preoperative evaluation included hematology, liver function tests, ultrasonography, cardiac, and pulmonary assessments. Surgeries were performed under general anesthesia using a modified French technique in mirror-image configuration. A harmonic scalpel (ultracision) was used for dissection in all cases.

Results: Out of 5375 LCs performed during the study period, 12 were in patients with SIT (prevalence: 0.22%). All procedures were completed laparoscopically without conversion. One case required port site modification for optimal clip application. Two patients underwent gallbladder decompression, and one developed postoperative ileus, which resolved conservatively. No intraoperative complications, bile duct injuries, or mortalities were observed.

Conclusion: Laparoscopic cholecystectomy in SIT patients is safe and feasible when performed by experienced surgeons. Modifications in surgical technique and port placement are essential to accommodate the reversed anatomy. Preoperative planning and intraoperative vigilance are key to minimizing complications and achieving outcomes comparable to anatomically normal patients.

Purpose: Obstructive defecation syndrome (ODS) significantly impairs bowel function and often requires surgical intervention. This study evaluated sex-specific differences in outcomes after robotic-assisted resection rectopexy with natural orifice specimen extraction (NOSE).

Methods: A prospective cohort of 57 patients (46 females, 11 males) undergoing robotic NOSE rectopexy for ODS was analyzed. Functional outcomes were assessed using the Wexner Constipation Score (WCS), Incontinence Score (WIS), and Altomare OD Score at baseline, 1, 3, and 12 months. To account for unequal group sizes, entropy balancing was applied and weighted analyses were performed.

Results: Descriptive data indicated that rectocele was more frequent in females (73.9% vs. 27.3%), and male patients had slightly longer hospital stays (6.0 vs. 4.6 d). Constipation, ODS, and incontinence scores improved markedly in both sexes (eg, WCS at 12 mo: 2.0 in males vs. 4.8 in females). While raw values suggested somewhat faster improvement in males, weighted analyses confirmed that no significant sex effects remained. No conversions or anastomotic leaks occurred, and overall patient satisfaction was high (96.5%).

Conclusion: Robotic NOSE rectopexy provides safe and effective treatment for ODS in both sexes. Descriptive analyses suggested a trend toward faster recovery in male patients, but after adjustment with entropy balancing no significant sex effects were found. Both sexes experienced marked functional improvement and high satisfaction, supporting robotic NOSE rectopexy as a valuable treatment option.

Background: Research on lymph node metastasis (LNM) in locally advanced rectal cancer (LARC) remains significantly underexplored. This study investigates the clinicopathological factors associated with LNM in LARC and develops a predictive nomogram for clinical application.

Methods: A retrospective analysis was performed on 1270 patients with LARC who underwent radical surgery between 2018 and 2023. Univariate and multivariate logistic regression analyses were conducted to identify independent predictors of LNM. A nomogram integrating these predictors was constructed and internally validated using bootstrap resampling. Subgroup analyses were carried out to compare stage N1 (n=333) and stage N2 (n=265) patients to determine the risk factors for advanced metastasis.

Results: The detection rate of LNM was 47.0% (598/1270). Independent risk factors included mucinous adenocarcinoma (OR=1.529, P=0.018), bowel obstruction (OR=1.418, P=0.014), poor tumor differentiation (OR=2.468, P<0.001), perineural invasion (OR=1.784, P=0.003), and lymphovascular invasion (LVI, OR=2.741, P<0.001). Conversely, a history of alcohol consumption (OR=0.721, P=0.016) and microsatellite instability-high (MSI-H) status (OR=0.241, P=0.005) appeared to exert protective effects. The nomogram demonstrated moderate predictive accuracy (C-index: 0.657, 95% CI: 0.627-0.686). In subgroup analyses, Ki-67 expression emerged as an additional independent risk factor for stage N2 patients (OR=1.016, P=0.040).

Conclusion: This study elucidated key risk factors for LNM in LARC patients and developed a nomogram for clinical use, offering valuable insights for the design and implementation of multidisciplinary perioperative treatment strategies.

Background: Barbed sutures enable knotless, continuous cruroplasty and are increasingly used in hiatal and paraesophageal hernia repairs. Despite widespread adoption, outcome data specific to the hiatus are limited and diaphragmatic application remains off-label.

Methods: A systematic search of PubMed and MEDLINE (inception-August 2025) identified adult hiatal/paraesophageal hernia repairs using barbed sutures. Data on operative approach, mesh use, operative time, recurrence, and perioperative outcomes were extracted. The FDA MAUDE database (2010 to 2025) was reviewed for device-related events.

Results: Five studies (n=741) met the inclusion criteria. In laparoscopic comparisons, barbed sutures shortened per-stitch closure time compared with interrupted silk, although total closure time was not significantly different. In pooled analysis of 4 comparative studies, the weighted mean difference in operative time was +12.8 minutes (95% CI: -4.3 to 29.8; P=0.14; I²=40%). Individual series demonstrated variable findings: operative time increased with mesh reinforcement but not when mesh was avoided (P=0.45). One study reported that barbed cruroplasty with biosynthetic mesh reinforcement significantly reduced ≥1-year anatomic recurrence (24.7% vs. 44.9%; risk difference -20.3%, 95% CI: -33.7 to -7.0) and symptomatic recurrence (17.2% vs. 42.2%, P=0.003) compared with barbed suture-only repair. Postmarket surveillance analysis of the FDA MAUDE database (2010 to 2025) identified only 2 hiatal-specific adverse events associated with barbed sutures, although underreporting is likely.

Conclusions: Barbed sutures for cruroplasty appear time-efficient and may lower recurrence when combined with mesh in larger hernias. However, current evidence is sparse, heterogeneous, and based largely on retrospective series. Given the off-label nature of diaphragmatic use, prospective studies with standardized recurrence definitions are needed to clarify safety and long-term efficacy.

Introduction: Postoperative pancreatic fistula (POPF) is a serious complication that can lead to potentially fatal outcomes; therefore, early intervention with drainage is warranted whenever clinically feasible. Endoscopic ultrasound-guided transmural drainage (EUS-TD) is becoming an alternative to percutaneous drainage for managing POPF. While EUS-TD is increasingly used, there is no consensus on stent type or the need for external drainage in early postoperative EUS-TD for POPF. This study aimed to evaluate the feasibility of EUS-TD using multiple plastic stents (PSs) without external drainage for managing POPF within postoperative day 15.

Methods: This retrospective case series included 11 patients who developed POPF and underwent EUS-TD within postoperative day 15 between January 2021 and June 2024. The primary outcome was clinical success of EUS-TD with multiple PSs without external drainage. Secondary outcomes included technical success, complications, length of hospital stay, and recurrence rate.

Results: Eleven POPF patients underwent EUS-TD. Two or more PSs were successfully placed in all cases, with clinical success achieved in 10 of 11 cases. One case required additional percutaneous drainage. A pseudoaneurysm rupture occurred in one case and was successfully managed with interventional radiology. The mean length of hospital stay was 19.1 days. No recurrences were observed during a median follow-up period of 26.0 months. Stents were removed after 6 months or later.

Conclusions: EUS-TD using multiple PSs without external drainage may be a feasible approach for managing POPF within postoperative day 15. Further prospective studies are needed to validate these findings and optimize early postoperative management strategies for POPF.

Background: The optimal timing of percutaneous cholecystostomy (PC) in acute cholecystitis remains unclear, despite its increasing adoption as a treatment option for elderly and critically ill patients. This study aimed to evaluate the impact of PC timing on complications, hospital stay, and mortality in high-risk patients with moderate and severe acute calculous cholecystitis.

Materials and methods: Between 2020 and 2024, 124 consecutive patients who underwent PC were retrospectively reviewed. The time periods from admission to PC were measured. Patients with grade II cholecystitis who had a Charlson Comorbidity Index (CCI) score ≥6 and an American Society of Anesthesiologists Physical Status (ASA-PS) score ≥3, and those with grade III cholecystitis who had a CCI score ≥4 and an ASA-PS score ≥3, were defined as high-risk patients using TG18-aligned thresholds. Among these 82 high-risk patients, the median time from admission to PC was 39 hours (range: 21 to 62 h).

Results: Early high-risk group (≤48 h; n=51) had shorter hospital stay [7 (5 to 8) vs. 13 (6 to 20) d; P<0.001], lower ≤90-day mortality rate (5.9% vs. 22.6%; P=0.037) and lower ≤365-day mortality rate (7.8% vs. 25.8%; P=0.049) as compared with delayed high-risk group (>48 h; n=31). Delayed PC (OR=4.80, P=0.004) and complications related to PC (OR=4.37, P=0.015) were independent risk factors for longer hospital stay. A higher CCI Score (≥7) (OR=13.68, P=0.047) and delayed PC (OR=8.64, P=0.04) were independent risk factors for in-hospital mortality.

Conclusions: While emergency cholecystectomy remains the gold standard for the treatment of acute cholecystitis, PC represents a valuable initial treatment alternative in high-risk patients when performed at an early stage. Early PC provides significant advantages, including fewer complications, shorter hospitalization, and reduced in-hospital mortality.

Background: Nonmidline ventral hernias (NMVH) are encountered less frequently than midline ventral hernias. Laparoscopic NMVH repairs are considered technically more difficult than midline hernias. For this reason, various intraperitoneal and extraperitoneal approach methods have been defined in the surgery of this group of hernias. In this study, we aimed to present the clinical data and follow-up results of patients who underwent laparoscopic repair of NMVH using the transabdominal partial extraperitoneal (TAPE) technique.

Methods: In this single-center and retrospective study, demographic information, hernia characteristics, operative findings, and follow-up data of laparoscopic NMVH surgeries performed by a hernia-specific general surgery unit between January 2022 and June 2024 were scanned and analyzed.

Results: Data from 26 patients with NMVH who underwent laparoscopic repair using the TAPE technique were analyzed. The mean age of the patients was 52.9±13.5 years. No intraoperative complications or conversion to open surgery were observed in any case. The median operative time was 100 (82.5 to 120) minutes. The median VAS score on the first postoperative day was 5 (3.75 to 6). Complications developed in 38.5% of patients during hospitalization; 26.9% were Clavien-Dindo class 1 and 11.5% were class 3a. The median hospital stay was 3 (3 to 5) days. The mean follow-up period was 17.8 (9 to 48) months, during which 2 patients (7.7%) experienced recurrence.

Conclusions: The TAPE technique is among the reliable techniques that can be applied in the laparoscopic repair of NMVH with low complication and recurrence rates.

Background: Single-incision laparoscopic cholecystectomy (SILC) offers excellent cosmetic results but is technically challenging. Robotic systems can overcome these limitations, and although the da Vinci Xi is designed for multiport surgery, it can be adapted for single-port procedures. This study reports our experience performing single-port robotic cholecystectomy (SPRC) with straight instruments, emphasizing technical optimization and perioperative outcomes.

Methods: SPRC was performed using an optimized umbilical port configuration and docking technique. Surgical steps were standardized to ensure stable traction and precise dissection, with a crossover method applied in difficult cases to improve exposure (see Supplemental Videos 1, Supplemental Digital Content 1, http://links.lww.com/SLE/A507 , and 2, Supplemental Digital Content 2, http://links.lww.com/SLE/A508 ). Eleven patients underwent SPRC, and demographic, operative, and perioperative data were analyzed.

Results: All procedures were completed without conversion to open or multiport surgery. The mean operative time was 116.7 ± 22.2 minutes, with minimal blood loss (13.8 ± 7.5 mL). No intraoperative complications or gallbladder perforations occurred, and only one patient required temporary drainage for minor oozing. Postoperative VAS scores averaged 3.1 ± 1.0 on day 0 and 1.6 ± 0.5 on day 1, with a mean hospital stay of 2.2 ± 1.1 days. No readmissions or port-site complications were observed.

Conclusions: SPRC with the da Vinci Xi system using straight instruments is feasible and safe. Optimized port placement and instrument coordination yield outcomes comparable to those reported for the SP system or single-site platform, providing an accessible alternative for centers without these platforms.

Background: Choledochoduodenostomy (CDD) has been reconsidered as an alternative to choledocholithiasis, especially in cases where endoscopic clearance is difficult. This study aimed to evaluate the use of laparoscopic CDD and compare the results with open CDD, including long-term outcomes.

Methods: The medical records of 65 patients who underwent laparoscopic or open surgery due to the difficulty of endoscopic treatment between 2011 and 2021 were retrospectively analyzed. Laparoscopic CDD was performed in 20 cases during the latter period, from April 2016, and open CDD was performed in 45 cases during the former period, before April 2016. The laparoscopic and open CDD surgical results were compared. Data on patient demographics, operative time, blood loss, hospital stay, and complications like bile leakage, reflux cholangitis, and anastomosis stenosis were evaluated.

Results: The median operative times, blood losses, and hospital stays were 187 and 125 minutes, 32 and 95 mL, and 8 and 14 days in the laparoscopic and open CDD groups, respectively. The occurrence of minor bile leakage, reflux cholangitis, and anastomosis stenosis was 2/20 (10%) and 1/45 (2.2%), 1/20 (5%) and 2/45 (4.4%), and 2/20 (10%) and 1/45 (2.2%) in the laparoscopic and open CDD groups, respectively. A comparison between the laparoscopic and open CDD groups revealed no significant difference in reflux cholangitis or anastomosis stenosis, but the operative times and incidence of minor bile leakage were higher in the laparoscopic group, and the hospital stays and amount of blood loss were lower in the laparoscopic group.

Conclusions: Laparoscopic CDD is feasible and not inferior to open CDD. The laparoscopic approach is minimally invasive and may be particularly advantageous in some patients.

Background: Acute uncomplicated appendicitis has traditionally been managed surgically, but recent trials suggest nonoperative treatment with antibiotics may be effective in selected adults. This meta-analysis compares long-term outcomes of antibiotics versus surgery and evaluates predictors of treatment failure, including the presence of an appendicolith.

Methods: We systematically searched MEDLINE, Embase, CENTRAL, and clinical trial registries up to July 2024. We included randomized controlled trials (RCTs) comparing antibiotics versus appendectomy in adults with imaging-confirmed uncomplicated appendicitis. The primary outcome was 1-year treatment success. Secondary outcomes included complication rates, recurrence, and subgroup analysis by appendicolith. A meta-regression explored the relationship between appendicolith prevalence and treatment failure.

Results: Seven RCTs (n=3164) were included. The 1-year treatment success rate was significantly lower in the antibiotics group (73.8%) versus surgery (98.1%) (RR 0.78, 95% CI: 0.73-0.84). Complication rates were comparable (RR 0.57, 95% CI: 0.29-1.12). Patients with appendicolith had a significantly higher failure rate (up to 46%). Meta-regression confirmed a positive correlation between appendicolith prevalence and antibiotic failure.

Conclusions: Antibiotics can be effective in selected patients, but recurrence and treatment failure remain concerns, particularly in the presence of appendicolith. Appendectomy remains the definitive treatment. This meta-analysis, including the most recent trials and a novel meta-regression, provides timely insights for shared decision-making.