Laparoscopic Endoscopic and Robotic Surgery最新文献

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.

Epiphrenic esophageal diverticulum is a rare disorder accounting for <10% of all esophageal diverticula. Surgical treatment may be necessary for larger diverticula causing significant symptoms. In this technical note, we describe a robotic-assisted approach to repair of a giant epiphrenic diverticulum. A 53-year-old female presented to the Department of Surgery, University of Colorado in January 2020 with a long-standing history of dysphagia and regurgitation associated with halitosis. Following a thorough preoperative workup, the patient underwent a robotic-assisted transhiatal approach with resection of the diverticulum followed by complete myotomy and Dor fundoplication. The patient had no perioperative complications and demonstrated complete relief of symptoms at the 6-month follow-up. A robotic-assisted transhiatal approach is a safe and effective technique for the resection of large epiphrenic diverticula. Complete myotomy followed by an antireflux procedure is critical to reducing perioperative complications and maintaining long-term symptom relief. Further prospective studies are needed to evaluate the specific morbidity risks associated with this approach.

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.

Robotic-assisted cholecystectomy (RC) is increasingly common. However, its exact role remains undefined, with multiport conventional laparoscopic cholecystectomy (LC) being regarded as the established gold standard. This review aims to provide an overview of the evidence for RC and to define its current and future role. A literature search was performed on the PubMed and Medline databases to identify relevant articles published between 1994 and February 2022. The evidence obtained was summarised in a narrative style. Greater emphasis was placed on recent 10-year articles and studies of higher methodological quality. RC is noninferior to LC. The robotic platform facilitates the application of minimally invasive surgery in a way conventional laparoscopy cannot. LC remains appropriate for the majority of patients requiring cholecystectomy. The advantages of RC include inherent technical benefits, facilitating the learning of new surgical technology and its potential to reduce the risk of open conversion and bile leakage in certain populations (Mirizzi syndrome, complicated calculous disease, chronic liver disease and possibly malignancy). It also has increasing applicability to related biliary surgery. The limitations include cost, loss of tactile feedback and the learning curve associated with initial implementation. Future applications of robotic surgical systems include utilisation in difficult cholecystectomy, cases of biliary malignancy, telerobotic surgery and telementoring.

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.

Laparoscopic skills training has always been crucial for novice surgeons. Readily accessible equipment, as well as structured training curriculum should be provided to guarantee adequate practice hours and skill proficiency. Dry-lab training is typically adopted before animal model surgery, usually comprising of purpose-built bulky simulators that is neither accessible nor portable. In this technical note, we designed a home-made simulator, using two 4 L water jugs as operating space that are communicated inside, plus an observation hole taped in between to mimic the triangular working space of laparoscopic surgery. Imaging was achieved via smartphone camera, which was wirelessly connected to a laptop and a projector for real-time display on multiple screens, using built-in multi-screen collaboration software. A self-regulated and proficiency-based training curriculum was adopted. This dry-lab simulator is low-cost, highly portable and easily replicable for basic laparoscopic skills training for the beginners to intermediate surgeons, which may serve as a good way for the standardized residency and specialist training program.

Objective

Surgical resection of pancreatic cancer remains the only potentially curative treatment for pancreatic ductal adenocarcinoma. The robotic platform has been introduced to surgical practice and recent large studies from national registries have demonstrated similar or improved peri-operative outcomes compared to the standard open approach. Neo-adjuvant chemotherapy is increasingly being offered to patients with borderline resectable/locally advanced disease but this has led to more challenging resections. Numbers of patients undergoing minimally invasive resection following neo-adjuvant chemotherapy remain low. The aim of this review is to assess the current evidence for the peri-operative safety and long-term oncological outcomes associated with minimally invasive pancreatic resection following neo-adjuvant chemotherapy.

Methods

Medline, Embase and Cochrane Central Register for Clinical Trials were searched up until 31st October 2021. The search terms include “minimally invasive”, “robotic”, “laparoscopic”, “pancreatectomy”, “pancreatic resection”, “whipple's pancreaticoduodenectomy”, “distal pancreatectomy”, “chemotherapy”, “neo-adjuvant chemotherapy”, “radiotherapy”, “neo-adjuvant chemoradiotherapy”, “induction therapy”, and “conversion surgery”. All studies including patients undergoing pancreatic resections were included. Studies which did not clearly state the approach to resection (minimally invasive or open) were excluded.

Results

Seventy-eight studies were identified of which 8 compared open and minimally invasive resection following neo-adjuvant chemotherapy. There was insufficient data to perform a meta-analysis. Robotic surgery was associated with lower blood loss and shorter length of hospital stay. Three-year overall survival rates were similar between patients who underwent robotic or open resection however the robotic approach was associated with higher lymph node yield and a lower R1 resection rate.

Conclusion

Currently the evidence for minimally invasive surgery following neo-adjuvant chemotherapy is limited. Long-term oncological outcomes are similar to patients undergoing open resection and there is some evidence to suggest superior peri-operative outcomes. As numbers are limited, future studies analysing national and international databases on minimally invasive pancreatic resection are required to provide sufficient evidence to support the use of minimally invasive pancreatic resection following neo-adjuvant chemotherapy in high-risk groups.

Objective

Adhesion barriers have not traditionally been used during laparoscopic cholecystectomy (lap-chole), and so there are no data confirming the safety of the dextrin hydrogel adhesion barrier (AdSpray®) for the use during lap-chole. The aim of this prospective study is to investigate the safety of AdSpray® for elective lap-chole.

Methods

Between July 2019 and March 2021, we conducted a prospective study at Saiseikai Kumamoto Hospital to assess the safety of applying AdSpray® around the hepatoduodenal ligament, liver surface, and port area after extraction of the gallbladder during elective lap-chole. We assessed patient morbidity, mortality, and laboratory data on postoperative day 1 and at the outpatient follow-up visit.

Results

A total of 100 patients (43 men, 57 women) received AdSpray® application during elective lap-chole at our institution. The mean patient age was 56.5 ± 14.8 y, and the mean body mass index was 25.1 ± 4.8 kg/m². Preoperative gallbladder drainage was performed in 3 (3.0%) patients as conservative treatment for acute cholecystitis. The mean operative time was 91.7 ± 35.1 min, and the median blood loss was 5 mL (range, 5–120 mL). Intraoperative gallbladder perforation was observed in 4.0% of patients (n = 4). There was no intraoperative bile duct injury. One (1.0%) patient had a postoperative subhepatic fluid collection without bacterial infection. The mean white blood cell count and C-reactive protein level was significantly elevated on postoperative day 1 but returned to preoperative levels by the time of the follow-up visit. All patients were successfully discharged after surgery, and the median postoperative hospital stay was 2 d (range, 2–9 d).

Conclusion

Applying AdSpray® during elective lap-chole is safe, with an acceptable rate of postoperative complications.

With an incidence of 1/500, a horseshoe kidney is not uncommon. Tumours discovered in horseshoe kidney however are quite rare, and prove difficult to surgically manage due to complex vascular anatomy. With variable surgical approaches previously described, only a select few robot-assisted cases have been reported. This case describes one such robot-assisted laparoscopic heminephrectomy, with the use of indocyanine green and an endovascular stapler to successfully demarcate ischemia and achieve hemostasis intraoperatively. No complications were encountered, and pathology revealed a pT1bN0 clear cell renal cell carcinoma with negative surgical margins, demonstrating the feasibility of our approach.