Laparoscopic Endoscopic and Robotic Surgery最新文献

Objective

In recent years, minimally invasive surgery has been emphasized in gynecological surgery, and total laparoscopic hysterectomy has been increasingly reported. In this retrospective single-center study, the main objective was to identify risk factors for the development of surgical-site infection (SSI) after total laparoscopic hysterectomy. The secondary objective was to investigate the efficacy of transvaginal drainage as a treatment for SSI.

Methods

This retrospective study investigated 377 patients who underwent total laparoscopic hysterectomy in the Department of Obstetrics and Gynecology at the Saitama Medical Center, Saitama Medical University, Japan between January 1, 2015 and December 31, 2019. Patients were divided into the SSI group and non-SSI group based on whether they suffered from SSI. The data of preoperative, intraoperative, and postoperative risk factors for SSI were collected and analyzed.

Results

Of the 377 patients who underwent total laparoscopic hysterectomy, 21 patients were in the SSI group and 356 patients were in the non-SSI group. After the comparison between the two groups and the multivariate analysis, only the C-reactive protein level on postoperative day 3 (OR = 1.556, 95% CI: 1.233–1.964, p < 0.001) showed a significant correlation with SSI. The receiver operating characteristic curve revealed that the C-reactive protein level >7.6 mg/dL on postoperative day 3 could detect the SSI onset early. In the SSI group, the hospital stay was longer for patients with transvaginal drainage than for patients without (17.40 ± 3.21 d vs. 10.90 ± 2.39 d, p = 0.0027). However, none required reoperation.

Conclusions

Patients with a high postoperative C-reactive protein level may be experiencing SSI, and ultrasonography and other imaging procedures should be performed immediately. If a vaginal abscess is confirmed on imaging, transvaginal drainage should be performed early, which may prevent reoperation.

With an incidence of 0.005%, unscarred uterine rupture is extremely rare. It is difficult to diagnose uterine rupture because of the absence of characteristic clinical symptoms. Here, we report a rare case of a 31-year-old woman with a uterine rupture that was accurately diagnosed and repaired by laparoscopy and hysteroscopy on postpartum day 69. The patient recovered uneventfully and was discharged on postoperative day 4. Three months after surgery, pelvic magnetic resonance imaging was performed, which confirmed wound repair. In women with a stable condition, laparoscopy with hysteroscopy could be an alternative choice for the diagnosis and treatment of suspected uterine rupture; however, more substantial studies are needed to confirm this surgical approach.

Partial nephrectomy is now a standard approach for small renal masses and tumour recurrences after partial nephrectomy are uncommon. In the absence of spillage, port site recurrences are most commonly reported. We report a case of tumour recurrence near the surgical site as well as beyond the posterior renal fascia and Gerotas fascia in a 60-year-old woman who underwent robot-assisted partial nephrectomy for a 4.6 cm suspicious left renal tumour despite the absence of gross tumour spillage or rupture intraoperatively. Histology showed a 5 cm clear cell renal cell carcinoma with negative surgical margins, nuclear grade 4 with focal malignant rhabdoid differentiation. The practice of not bagging the specimen immediately after tumour excision especially for higher risk tumours should be reviewed as there may be inadvertent microscopic spillage of tumour cells.

Lymphatic drainage is typically in the direction of arterial supply, and lymphatic drainage for right-sided colon cancers typically travels to ileocolic lymph nodes. It is rare for right-sided colon cancers to metastasize to the lateral pelvic side wall lymph nodes in the absence of local invasion or other distant metastases. In this report, we present an unusual case of a young female with pT4a right-sided ascending colon cancer with isolated metastases to the pelvic iliac lymph nodes. The patient underwent minimally invasive laparoscopic right hemicolectomy and pelvic lymph node dissection with curative intent. She recovered well with no intraoperative complications and was referred for urgent adjuvant chemotherapy and radiotherapy.

Objective

Surgeons are required to wear heavy personal protective equipment while delivering care to patients during the COVID-19 pandemic. We examined the impact of wearing double gloves on surgeons’ performance in laparoscopic surgery.

Methods

Eleven surgeons-in-training at the Surgical Simulation Research Lab of the University of Alberta were recruited to perform laparoscopic cutting tasks in simulation while wearing none, one pair, and two pairs of surgical gloves. Forces applied to laparoscopic instruments were measured.

Results

Wearing gloves prolonged task times (one pair of gloves: 301.6 ± 61.7 s; two pairs of gloves: 295.8 ± 65.3 s) compared with no gloves (241.7 ± 46.9 s; p = 0.043). Wearing double gloves increased cutting errors (20.4 ± 5.1 mm²) compared with wearing one pair of gloves (16.9 ± 5.5 mm²) and no gloves (14.4 ± 4.6 mm²; p = 0.030). Wearing gloves reduced the peak force (one pair of gloves: 2.4 ± 0.7 N; two pairs of gloves: 2.7 ± 0.6 N; no gloves: 3.4 ± 1.4 N; p = 0.049), and the total force (one pair of gloves: 10.1 ± 2.8 N; two pairs of gloves: 10.3 ± 2.6 N; no glove: 12.6 ± 1.9 N; p = 0.048) delivered onto laparoscopic scissors compared with wearing no glove.

Conclusion

The combined effects of wearing heavy gloves and using tools reduced the touching sensation, which limited the surgeons’ confidence in performing surgical tasks. Increasing practice in simulation is suggested to allow surgeons to overcome difficulties brought by personal protective equipment.

Objective

Traditionally, gallbladder is routinely removed during left hepatectomy even if there is no gallbladder pathology. However, adverse consequence after cholecystectomy, though rare, still occasionally occurs. This study aims to evaluate the feasibility of gallbladder preservation during robotic left hepatectomy.

Methods

All consecutive robotic left hepatectomy cases between December 2010 and January 2022 in Prince of Wales Hospital, the Chinese University of Hong Kong were retrieved from a prospectively collected database. The gallbladder was preserved by moving the liver transection line just away from the gallbladder fossa. Patients were divided into two groups: gallbladder preservation (GBP) and non-gallbladder preservation (NGBP). Operative results and long-term outcomes were compared between these two groups.

Results

There were 11 cases in the GBP group and 25 cases in the NGBP group. The two groups were comparable in terms of the patient demographics and disease characteristics. There was no operative mortality. There was no difference between the two groups in operative time (GBP 270 min vs. NGBP 332 min, p = 0.132), blood loss (GBP 50 mL vs. NGBP 150 mL, p = 0.115) or complication rate (GBP 27.3% vs. NGBP 24.0%, p > 0.999). There was also no difference in 5-year overall survival. In the GBP group, no patient developed specific symptoms or complications related to the preserved gallbladder. Follow-up ultrasound or computed tomography revealed a normal appearance of the preserved gallbladders except in one patient who developed a 3-mm gallbladder polyp. On the other hand, one (4%) patient in the NGBP group developed troublesome diarrhoea after surgery.

Conclusion

Gallbladder preservation is safe and feasible during robotic left hepatectomy. The preserved gallbladder does not lead to any symptoms, while postcholecystectomy diarrhoea can be avoided.

Objective

This study aims to evaluate the surgical morbidity and obstetric outcomes following in-pregnancy or pre-pregnancy laparoscopic abdominal cerclage (LAC) for patients who were diagnosed with refractory cervical insufficiency or had a short cervix.

Methods

A retrospective study was conducted on patients undergoing LAC between May 2017 and May 2019 at the Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital. The patients were diagnosed with refractory cervical insufficiency based upon a previous failed transvaginal cervical cerclage (TVC), or had a short cervix who were considered unsuitable for a TVC after a previous cervical procedure. All patients were followed-up after surgery with transperineal ultrasonography until May 2020. Subsequently, surgical and obstetric data were collected and analyzed.

Results

In total, 44 patients underwent LAC, with 8 patients in-pregnancy and 36 pre-pregnancy. For the patient with pre-pregancy LAC, the pregnancy rate was 80.6% (29/36), including 3 patients with first-trimester loss, 1 patient with an ectopic pregnancy, and 25 patients with a delivery. For the remaining 7 patients, 3 did not conceive, and another 4 had no pregnancy plans. All the patients with in-pregnancy LAC had a delivery. The “take-home baby” rate was 89.2% (33/37), with a live-birth rate of 100% and a neonatal survival rate of 100% for both patients with in-pregnancy and pre-pregnancy LAC. For patients with in-pregnancy LAC, 75.0% (6/8) patients delivered at ≥37 wk of gestation, 12.5% (1/8) delivered between 34 and 36⁺⁶ wk, and 12.5% (1/8) delivered between 28 and 33⁺⁶ wk. For patients with pre-pregnancy LAC, 80.0% (20/25) patients delivered at ≥37 wk of gestation, 16.0% (4/25) delivered between 34 and 36⁺⁶ wk, and 4.0% (1/25) delivered between 28 and 33⁺⁶ wk. No adverse-event intra-operative or post-operative sequelae were noted.

Conclusions

LAC is an effective and safe procedure that results in remarkable obstetric outcomes for women with refractory cervical insufficiency, or with a short cervix who are considered unsuitable for a TVC. The success rate of in-pregnancy or pre-pregnancy LAC depends on a full evaluation of patients, a proper peri-operative management and close follow-up.

Minimally invasive surgeries, including laparoscopic, endoscopic, and robotic surgeries, have gained great popularity and have gradually replaced conventional open surgeries. Commonly, patients may have perioperative psychological issues such as anxiety, depression, sleep disturbance, and delirium. A comprehensive literature review was conducted to identify how these psychological issues occur in minimally invasive surgeries and how nurses can take better care of patients to alleviate these issues. Only papers focusing on psychological issues during the perioperative period were included in the review, and preexisting issues before the setting of surgical treatment plan were not discussed. Compared to conventional surgeries, the incidence of postoperative anxiety, preoperative depression, and sleep disturbance is lower in minimally invasive surgeries, the incidence of postoperative depression may be higher with limited evidence, and the incidence of preoperative anxiety and delirium is inconclusive. Systematic perioperative nursing programs not only alleviate psychological issues, but also reduce postsurgical complications and accelerate recovery. However, special nursing programs to handle delirium are lacking.

Anastomotic leakage is one of the most serious postoperative complications after colorectal surgery. A fistula or chronic sinus formation is one kind of anastomotic leakage. Most fistulas may heal after conservative treatment, but some patients will develop a chronic anastomotic leakage, which definitely requires elective surgery due to the formation of a sinus tract or an internal fistula. This study reports a case of an 88-year-old man with sigmoid colon cancer who developed a chronic anastomotic leakage after colorectal surgery. Endoscopic mucosal advancement combined with titanium clips was successfully performed to close the fistula. The patient was discharged 12 days after the operation and resumed a normal diet 1 week after discharge. Endoscopic mucosal advancement could be an alternative choice for the treatment of chronic anastomotic leakage and can prevent a secondary surgery; however, good bowel preparation and strict inclusion criteria are required.

Objective

It is important to minimize the risk of major vascular injury during pneumoperitoneum establishment in laparoscopic surgeries for patients with unusual variations in the levels of the abdominal aorta, the inferior vena cava (IVC), and the left renal vein, which will decrease the morbidity and mortality. The study aims to assess the variations regarding the bifurcation level of the abdominal aorta, formation level of the IVC, and insertion level of the left renal vein into the IVC.

Methods

This retrospective study was conducted on 100 patients (50 males and 50 females) referred to the Department of Radiology, Jordan University Hospital for abdomino-pelvic CT with intra-venous contrast from January 2018 to December 2019. The three vessels were determined on the axial plane, the coronal plane, and the midsagittal plane. The central vertebral body height as well as the distance of the level of the point of interest to the upper end plate of the vertebrae were measured. Afterwards, the results were classified into the following categories, upper end plate, lower end plate, intervertebral disc, upper half, and lower half of the vertebra.

Results

The aortic bifurcation was mainly found at the level of the L4 vertebral body (65, 65%). In the remaining cases, the bifurcation was found to be variably located spanning from L3 in 11 (11%) cases to 3 (3%) cases at L5. As for the iliocaval junction, the most common site was also at the level of L4 with 41 (41%) cases followed by 39 (39%) cases at the level of L5, and 20 (20%) cases at the intervertebral disc of L4/L5. The left renal vein most commonly joined the IVC at the level of L1 with 62 (62%) cases followed by 20 (20%) cases at the intervertebral disc T12/L1. There was wide variation in its entry to the IVC spanning from 4 (4%) cases at T12/L1 to 1 (1%) case at L4.

Conclusion

The anatomical variation of the major vessels can be found in the normal population. Therefore, sufficient investigation of the anatomical position of these vessels is essential for patients before laparoscopic surgery.