Laparoscopic Endoscopic and Robotic Surgery最新文献

Objective

Even though enhanced recovery after surgery (ERAS) has been applied to liver resection worldwide, there is a lack of evidence covering its feasibility in laparoscopic major hepatectomy. This study aimed to preliminarily evaluate the superiority of ERAS in major liver resection.

Methods

The data were collected from patients who underwent laparoscopic major hepatectomy from July 2014 to November 2020 in Sir Run Run Shaw Hospital, Zhejiang University School of Medicine. The baseline characteristics, pathological features, surgical outcomes, medical costs, and postoperative pain scores were compared before and after propensity score matching (PSM). The patients were divided into the ERAS group and the routine group based on the treatment protocols.

Results

Eighty-one patients who underwent laparoscopic major hepatectomy were retrospectively enrolled in the study. Before PSM, there were differences in pathology (p = 0.037) and surgical extent (p = 0.011) between the ERAS group (n = 42) and routine group (n = 39). After PSM, 26 patients from each group were matched. For surgical outcomes, patients in the ERAS group had a significantly lower postoperative complication incidence than patients in the routine group (28.6% vs. 53.8%, RR: 0.531 [0.303, 0.929], p = 0.021) before PSM. However, after PSM, superiority was not observed in the ERAS group (30.8% vs. 53.8%, RR: 0.571 [0.290, 1.13], p = 0.092). The duration of abdominal tube retention (before PSM: 5.0 d vs. 10.0 d, p < 0.001; after PSM: 6.0 d vs. 9.0 d, p = 0.001), the duration of urinary tube retention (before PSM: 1.0 d vs. 2.0 d, p < 0.001; after PSM: 1.0 d vs. 2.0 d, p = 0.002), and hospital stay (before PSM: 6.0 d vs. 11.0 d, p < 0.001; after PSM: 7.0 d vs. 11.5 d, p < 0.001) was significantly shorter in the ERAS group than in the routine group. A significant benefit on postoperative day 3 (2 vs. 3, p = 0.038) was observed with respect to the alleviation of pain after PSM.

Conclusions

Our preliminary study revealed the superiority of ERAS in the setting of major liver resection, although further investigations in a large number of patients from multiple institutions are needed to evaluate the feasibility of ERAS.

Causal inference prevails in the field of laparoscopic surgery. Once the causality between an intervention and outcome is established, the intervention can be applied to a target population to improve clinical outcomes. In many clinical scenarios, interventions are applied longitudinally in response to patients’ conditions. Such longitudinal data comprise static variables, such as age, gender, and comorbidities; and dynamic variables, such as the treatment regime, laboratory variables, and vital signs. Some dynamic variables can act as both the confounder and mediator for the effect of an intervention on the outcome; in such cases, simple adjustment with a conventional regression model will bias the effect sizes. To address this, numerous statistical methods are being developed for causal inference; these include, but are not limited to, the structural marginal Cox regression model, dynamic treatment regime, and Cox regression model with time-varying covariates. This technical note provides a gentle introduction to such models and illustrates their use with an example in the field of laparoscopic surgery.

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.