Laparoscopic Endoscopic and Robotic Surgery最新文献

Objective

Endoscope has been used as diagnostic tool for recidivism and as an adjunct to microscopic technique in the management of cholesteatoma. At present transcanal endoscopic ear surgery (TEES) is being used as a minimally invasive alternative for microscopic approach. We aim to evaluate the feasibility, structural, functional and quality of life outcomes of endoscopic technique in middle ear cholesteatoma.

Method

This prospective study was conducted at a tertiary care hospital from January 2017 to January 2018 including 32 adult patients who were treated by TEES for middle ear cholesteatoma. Feasibility of endoscopic technique was assessed by the conversion rates, visualization of middle ear structures and complications. Structural outcomes were evaluated in terms of graft uptake at the third month follow-up and presence of residual or recurrent disease. Functional outcomes were evaluated in terms of post-operative air-bone gap closure at third month follow-up. Patient outcomes in terms of post-operative pain, cosmetic score, day of return to daily activities and patient comfort scores were evaluated. The quality of life outcomes were evaluated using chronic ear survey (CES) and short form questionnaire −12 version 2 (SF-12V2) which are disease specific and general quality of life assessment tools respectively.

Result

Out of 32 patients, endoscopic intact canal wall mastoidectomy was done for 28 and endoscopic canal wall down mastoidectomy in 4 patients. One (3.1%) patient had to be converted to microscopic technique. Median follow-up period was 32.8 months (9–46 months). There were no post-operative complications in any of our patients. The mean middle ear structural visibility index score was 8.4 ± 1.4 with the use of zero-degree endoscope. Graft uptake rate at third month follow-up was 100%. Two (6.3%) patients had recurrent disease at 6 months follow-up and were treated by revision endoscopic surgery. The air conduction (51.3 ± 20.2 dB vs. 34.5 ± 20.4 dB, p < 0.001), and air-bone gap (33.5 ± 11.1 dB vs. 16.9 ± 11.8 dB, p < 0.001) has been significantly improved. The mean pain score at 0 hours, 6 hours and 24 hours after surgery were 2.5/10, 1.6/10 and 0.75/10 respectively. At the discharge, the mean patient comfort score was 9.3 ± 0.6 out of 10. Mean cosmetic score was 9.3 ± 0.5 at the third month follow-up. There was significant post-operative improvement in the sub-scale and total scores of CES and SF-12V2.

Conclusion

Endoscopic approach to middle ear cholesteatoma is feasible and confers excellent structural, functional as well as patient related quality of life outcomes.

Robotic kidney transplantation (RKT) has brought the benefits of minimally invasive surgery to the field of renal transplantation. Techniques across the globe have varied and there is a need for standardization within evidence-based frameworks in order to justify its widespread utilization and ensure safe and effective innovation. A comprehensive literature review was conducted to identify studies reporting on techniques used in RKT between 2010 and 2020. Conference abstracts, published papers and the latest guidelines were reviewed in this rapidly progressing field. Promising results have been demonstrated so far with unique benefits identified for obese patients who would have otherwise been denied an open kidney transplant. Other developments have been found in gasless surgery, scarless surgery, RKT using grafts with multiple vessels and robotic dual kidney transplantation. In order to continue advancing innovation in kidney transplant surgery, further expansion of RKT is needed to deceased donor programs. Progression in the robotic technology itself will also improve technique, and as the financial costs of the technology decrease the use of RKT is set to grow.

Objective

The present study aims to compare the clinical efficacy of laparoscopic partial nephrectomy using a harmonic scalpel versus traditional scissor.

Methods

A retrospective review was conducted in patients with localized renal tumors and scheduled for laparoscopic partial nephrectomy from January 2015 to December 2019. Eventually, 225 patients joined this retrospective study. Patients were divided into the harmonic scalpel group or scissor group based on the method used, with 71 cases and 154 cases respectively. Propensity score matching (1:1) was performed to adjust for potential baseline confounders, and each group had 57 cases. Patient characteristics, perioperative clinical results, complications, and oncological results were compared between the two groups.

Results

After matching, patient characteristics were not significantly different between the two groups. The scissor group was associated with a significantly shorter operative time (105 min vs. 130 min, p < 0.001), shorter warm ischemia time (19.35 min vs. 22.07 min, p = 0.005). However, the harmonic scalpel group was associated with significantly less estimated blood loss (20 mL vs. 30 mL, p = 0.013) and shorter length of stay (8 d vs. 10 d, p = 0.040). There was no significantly difference in indwelling time of drainage tube, perioperative complication, oncological outcomes or recurrence rates.

Conclusions

The harmonic scalpel is used safely and effectively in laparoscopic partial nephrectomy, and has benefits in intraoperative blood loss and length of stay.

Objective

Minimally invasive video-assisted thyroidectomy (MIVAT) is among the most common alternatives to conventional open thyroidectomy. Previous reports have shown it to be safe and effective in patients without neck surgery history. However, this contraindication has been called into question in more recent small series. This study aims to evaluate the efficacy and safety of MIVAT in patients with prior neck surgery.

Methods

We retrospectively reviewed the data of 178 patients who underwent completion thyroidectomy in the Department of Otolaryngology-Head and Neck Surgery at Loma Linda University Medical Center between July 2004 and July 2017. Patients were divided into MIVAT group and Conventional group based on method of surgery, and analysis with two sample tests of proportions was carried out as appropriate.

Results

Patients in MIVAT group had significantly shorter operative time (74.1 ± 26.4 min vs. 99.0 ± 49.3 min, p < 0.001), less estimated blood loss (19.5 ± 15.0 mL vs. 39.0 ± 65.9 mL, p = 0.002), smaller incision size (3.5 ± 1.1 cm vs. 6.2 ± 2.2 cm, p < 0.001), and a lighter thyroid weight (7.5 ± 5.2 g vs. 20.5 ± 31.1 g, p < 0.001). The average length of stay was a half day longer, and post-operative admission was higher (78.8% vs. 51.7%, p = 0.005) in MIVAT group, while most was for routine 23-hour observation (63.6% vs. 35.9%, p = 0.009). There were no differences in complications.

Conclusion

MIVAT is feasible for re-operative patients with equivalent or superior outcomes to those of conventional thyroidectomy, and no significant difference in the incidences of common postoperative complications.

Objective

During the past three decades, laparoscopy has played a significant role in the management of urological disorders. This study aims to standardize the management of major vascular injury, which is a life-threatening complication in the laparoscopic urological procedures.

Methods

A total of 8210 patients with the urological disorder, who underwent laparoscopic surgery at Sir Run Run Shaw Hospital from January 2000 to December 2018, were included in this retrospective study. Patients’ data of the laparoscopic major vascular injury were collected and analyzed, and the basic principles of the procedure were summarized.

Results

A total of 15 (0.18%) cases of major vascular injury were found among the 8210 patients, and 2 of them were converted to open surgery. Although the type of laparoscopic surgery, causes, and management of major vascular injury among the patients were diverse, the main management strategies of major vascular injury in laparoscopic surgery were to keep the vision clear, control bleeding rapidly by clamping and compression, make full preparation for possibly needed liquid resuscitation, and try best to repair under laparoscope. If necessary, converse to open surgery.

Conclusion

Although the reported incidence of major vascular injury in laparoscopic urological surgery is extremely low, such injury can result in high morbidity and mortality. It is important to rapidly identify the cause and strictly follow the standardized management for better outcomes.

Gastrosplenic fistula is a rare complication of gastric or splenic lymphoma. Here we report the case of a 48 years old man who developed a gastrosplenic fistula secondary to splenic diffuse large B-cell lymphoma, successfully managed with hand-assisted laparoscopic splenectomy and gastric wedge resection. A review of the available literature is also presented, 33 cases of gastrosplenic fistula associated to gastric or splenic lymphoma were found, of which 25 were treated surgically. This case represents the first report of laparoscopic treatment of lymphoma-related gastrosplenic fistula described to our knowledge in the available literature.

Paragangliomas are rare neuroendocrine tumors that arise in sympathetic and parasympathetic paraganglion system, derived from neural crest cells. Tympanic paraganglioma is a type of head and neck paraganglioma involving the middle ear cleft. Endoscopic transcanal approach is currently in vogue for the excision of tympanic paragangliomas that is limited to middle ear cleft. We present a series of 3 cases who underwent endoscopic excision of tympanic paraganglioma.

Objective

Port placement is a crucial pre-operative task in robot-assisted minimally invasive surgery. Due to the insufflation process, the abdominal shape is deformed while the internal organs are shifted in position. These changes need to be considered when determining the optimal port locations for the robotic manipulators. However, intra-operative medical image acquisition systems are not always available. In this study, we aim to estimate the shift extent of the abdominal organs in humans by measuring the changed volume and position of the abdominal organs before and after insufflation in three pigs.

Methods

A 3D model of the abdomen and abdominal organs was reconstructed from 3D images of the pigs taken by an MRI scanner before and after insufflation. Position shift and shape changes of the abdominal organs after insufflation were determined. The corresponding shift in port location for the robotic manipulators was determined based on the abdominal model.

Results

Organ movements as a result of insufflation ranged from 6.37 ± 0.10 cm for the spleen, to 1.64 ± 0.22 cm for the liver. Even a slight planar motion of the target organ (e.g., 1.33 ± 0.06 cm, 2.38 ± 0.21 cm in X-Y plane for the left kidney) can shift the access port for the robot manipulator by about 1.6 cm on the abdominal surface.

Conclusions

The target organs’ motion due to insufflation is a critical factor in determining port locations in robot-assisted minimally invasive surgery.

Objective

Rising cesarean section rates have led to an increase in cesarean scar defects. However, there is no consensus regarding the gold standard for treating cesarean scar defects. This study aims to compare the efficacy of laparoscopy combined with hysteroscopy and hysteroscopy in treating cesarean scar defects.

Methods

An electronic search of the MEDLINE, EMBASE, and Clinical Trials.gov databases was conducted in May 2020, utilizing combinations of relevant medical subject headings for “cesarean scar defect”, “laparoscope”, and “hysteroscope”. Reference lists of relevant articles and reviews were hand-searched for additional reports. Observed outcomes included menstruation after surgery, blood loss, operative time, and further fertility.

Results

Eight studies with 467 patients were included. The menstruation duration after surgery for the laparoscopy combined with hysteroscopy group and hysteroscopy group was comparable. While the laparoscopy combined with hysteroscopy group trended to have less blood loss (mean difference 49.60, 95% CI: 42.12–57.09, p < 0.05) and shorter operative time (mean difference 60.40, 95% CI: 53.33–67.48, p < 0.05) compared to hysteroscopy group. And 26 out of 51 patients were able to achieve pregnancy for those choosing the laparoscopy combined with hysteroscopy.

Conclusions

Patients with cesarean scar defect should choose the appropriate technique considering their age, residual myometrial thickness, desire for further fertility, and gynecological inflammation. The current study lacked evidence to prove that laparoscopy combined with hysteroscopy is superior to hysteroscopy.