Minimally Invasive Surgery最新文献

Background: Superior mesenteric artery (SMA) syndrome is a rare disorder that may be managed surgically if conservative management fails. Different surgical techniques have been described, division of the ligament of Treitz, gastrojejunostomy, and duodenojejunostomy. The aim of this case series is to show that laparoscopic duodenojejunostomy is a safe and technically feasible management for superior mesenteric artery syndrome.

Methods: In this case series, we retrospectively identified all patients who underwent laparoscopic duodenojejunostomy for SMA syndrome in our tertiary university center between December 2016 and July 2019. Data collected included demographics, presenting symptoms, comorbidities, pre and postoperative body mass index (BMI), operative approach, operative blood loss, operative duration, clinical and radiological results, in hospital/30-day complications, mortality, and postoperative follow-up outcomes.

Results: We identified eleven patients, 10 females and 1 male, with a median age 23 years (range 17-43 years). All patients had refractory symptoms after a minimum of two months of conservative management and subsequently underwent laparoscopic duodenojejunostomy. There were no intraoperative complications and no in-hospital or 30-day postoperative mortality or complications were identified. Follow-up data showed complete resolution in 73% of patients (n = 8) and only one patient with no improvement postoperatively. Results also showed a median BMI increase of 2 kg/m² (range 1-9 kg/m²) at a median follow-up of 16 months (range 4-48 months).

Conclusion: Laparoscopic duodenojejunostomy is a safe treatment option for SMA syndrome and should be considered when patients do not respond to conservative management.

Introduction: Laparoscopic cholecystectomy (LC) is the gold standard operation for gallstone disease. Primary port placement into the abdomen is a blind procedure and is challenging with chances of unforeseen complications. The complication rate has remained the same during the past 25 years. Both closed/Veress and open/Hasson's techniques are commonly employed and have their typical indications for use.

Materials and methods: This prospective study was carried out in the Department of General Surgery, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), Shillong, from January 2014 to January 2016, with the aim to compare the safety profile of closed/Veress and open/Hasson's methods of access to the abdomen during laparoscopic cholecystectomy (LC). The study had 400 eligible cases undergoing LC who were randomly allotted into 2 groups with 200 cases each: group A: closed/Veress needle method and group B: open/Hasson's method.

Results: Closed/Veress and open/Hasson's method of establishing pneumoperitoneum in laparoscopic cholecystectomy is equally safe in terms of major complications. The closed/Veress method gives faster access to the abdomen as compared to the open method (5.62 ± 2.23 minutes and 7.18 ± 2.52 minutes, respectively, p value <0.0001). The open/Hasson's method is associated with more primary port site complications (9/200 vs. 0/200, p value 0.0036) and troublesome intraoperative gas leaks (39/200 vs. 2/200, p value <0.0001). The open technique for primary peritoneal access port for laparoscopic cholecystectomy does not impart any additional benefits in terms of safety and morbidity profile in patients undergoing LC.

Conclusion: The closed/Veress method of establishing pneumoperitoneum in laparoscopic cholecystectomy is equally safe in terms of major complications and gives quicker access to the abdomen as compared to the open method.

Aim: To assess incidence and characteristics of post-laparoendoscopic single-site donor nephrectomy (LESS DN) testicular pain.

Materials and methods: A prospective comparative study of all male donors post-left LESS DN (group A) vs. postopen nephrectomies (group B) was performed at our center. Patients' demographics, perioperative data, and postoperative consultation reports were reviewed. Testicular pain, swelling, numbness, urinary symptoms, and sexual dysfunction were evaluated. Patients with a history of scrotal pathology or surgical procedure were excluded. Pain and tenderness were scored on a standard 10-point scale.

Results: From September 2017 to December 2020, 85 and 35 male patients of groups A and B met the evaluation criteria. Ipsilateral testicular pain developed in 11 patients (15.3%) and 2 patients (9.5%) in groups A and B, respectively. In most instances, the pain was mild to moderate in severity, started after 6 ± 2.1 and 4 ± 1.1 days postoperatively in groups A and B, respectively. Six patients in group A were evaluated with transscrotal ultrasonography that showed no abnormalities. All patients in both groups responded well to medical treatment.

Conclusions: Post-LESS DN ipsilateral testicular pain is usually mild and self-limited. Preoperative patient education and discussion of the possibility of development of testicular pain and its management should be an integral component of laparoscopic donor nephrectomy informed consent.

Background: The complexities of surgery require an efficient and explicit method to evaluate and standardize surgical procedures. A reliable surgical evaluation tool will be able to serve various purposes such as development of surgery training programs and improvement of surgical skills.

Objectives: (a) To develop a modeling framework based on integration of dexterity analysis and design structure matrix (DSM), to be generally applicable to predict total duration of a surgical procedure, and (b) to validate the model by comparing its results with laparoscopic cholecystectomy surgery protocol.

Method: A modeling framework is developed through DSM, a tool used in engineering design, systems engineering and management, to hierarchically decompose and describe relationships among individual surgical activities. Individual decomposed activities are assumed to have uncertain parameters so that a rework probability is introduced. The simulation produces a distribution of the duration of the modeled procedure. A statistical approach is then taken to evaluate surgery duration through integrated numerical parameters. The modeling framework is applied for the first time to analyze a surgery; laparoscopic cholecystectomy, a common surgical procedure, is selected for the analysis.

Results: The present simulation model is validated by comparing its results of predicted surgery duration with the standard laparoscopic cholecystectomy protocols from the Atlas of Minimally Invasive Surgery with 2.5% error and that from the Atlas of Pediatric Laparoscopy and Thoracoscopy with 4% error.

Conclusion: The present model, developed based on dexterity analysis and DSM, demonstrates a validated capability of predicting laparoscopic cholecystectomy surgery duration. Future studies will explore its potential applications to other surgery procedures and in improving surgeons' performance and training novices.

Introduction: Conservative therapy, including appropriate antibiotics and bracing, is usually adequate for most patients with pyogenic spondylodiscitis. If conservative treatment fails, surgical intervention is needed. However, major spinal surgery comprising anterior debridement and accompanying bone grafting with or without additional instrumentation is often related to undesired postoperative complications. In recent years, with minimally invasive surgery, the diagnostic and therapeutic value of endoscopic lavage and drainage has been proven. This study reports a case series of patients who required open revision surgery after treatment with endoscopic surgery using the full endoscopic discectomy system (FED), indicating the surgical limitations of endoscopic surgery for pyogenic spondylodiscitis.

Methods: We retrospectively investigated the medical records of 4 patients who underwent open debridement and anterior reconstruction with posterior instrumentation following endoscopic surgery for their advanced lumbar infectious spondylitis. They had been receiving conservative treatment with antibiotics for 12-15 days. They also had various comorbidities, including kidney disease, heart failure, and diabetes. Numerical rating scale pain response, perioperative imaging studies, and C-reactive protein (CRP) levels were determined, and causative bacteria were identified. Primarily, the bone destruction stage was classified using computed tomography with reference to Griffiths' scheme.

Results: All patients had severe back pain before surgery with no relief of the pain after FED. Increased pain, including radicular pain after FED, was noted in one case. Causative pathogens from biopsy specimens were identified in 3 (75%) of the 4 cases. In preoperative radiological evaluation, all cases were classified as destructive stage in Griffiths' scheme. The CRP levels of all the patients decreased slightly after endoscopic surgery. Relapse of spinal infection after revision surgery was not noted in any patient during the follow-up period.

Conclusion: The surgical treatment of destructive-stage spondylitis with FED alone can increase low back pain due to aggressive debridement.

Background: Surgical patients frequently seek information from digital sources, particularly before common operations such as laparoscopic cholecystectomy (LC). YouTube provides a large amount of free educational content; however, it lacks regulation or peer review. To inform patient education, we evaluated the quality of YouTube videos on LC.

Methods: We searched YouTube with the phrase "laparoscopic cholecystectomy." Two authors independently rated quality of the first 50 videos retrieved using the JAMA, Health on the Net (HON), and DISCERN scoring systems. Data collected for each video included total views, time since upload, video length, total comments, and percentage positivity (proportion of likes relative to total likes plus dislikes). Interobserver reliability was assessed using an intraclass correlation coefficient (ICC). Association between quality and video characteristics was tested.

Results: Mean video quality scores were poor, scoring 1.9/4 for JAMA, 2.0/5.0 for DISCERN, and 4.9/8.0 for HON. There was good interobserver reliability with an ICC of 0.78, 0.81, and 0.74, respectively. Median number of views was 21,789 (IQR 3000-61,690). Videos were mostly published by private corporations. No video characteristic demonstrated significant association with video quality.

Conclusion: YouTube videos for LC are of low quality and insufficient for patient education. Treating surgeons should advise of the website's limitations and direct patients to trusted sources of information.

Laparoscopic surgery has been one of the most common procedures for abdominal surgery at pediatric age during the last few decades as it has several advantages compared to laparotomy, such as shorter hospital stays, less pain, and better cosmetic results. However, it is associated with both local and systemic modifications. Recent evidence demonstrated that carbon dioxide pneumoperitoneum might be modulated in terms of pressure, duration, temperature, and humidity to mitigate and modulate these changes. The aim of this study is to review the current knowledge about animal and human models investigating pneumoperitoneum-related biological and histological impairment. In particular, pneumoperitoneum is associated with local and systemic inflammation, acidosis, oxidative stress, mesothelium lining abnormalities, and adhesion development. Animal studies reported that an increase in pressure and time and a decrease in humidity and temperature might enhance the rate of comorbidities. However, to date, few studies were conducted on humans; therefore, this research field should be further investigated to confirm in experimental models and humans how to improve laparoscopic procedures in the spirit of minimally invasive surgeries.

Introduction: Laparoscopic repair of perforated peptic ulcer (PPU) remains controversial mainly due to its safety and applicability in critically ill patients. The aim of this study is to compare the outcomes of laparoscopy versus laparotomy in the treatment of PPU.

Methods: Single-institutional, retrospective study of all patients submitted to surgical repair of PPU between 2012 and 2019.

Results: During the study period, 169 patients underwent emergent surgery for PPU. A laparoscopic approach was tried in 60 patients and completely performed in 49 of them (conversion rate 18.3%). The open group was composed of 120 patients (included 11 conversions). Comparing the laparoscopic with the open group, there were significant differences in gender (male/female ratio 7.2/1 versus 2.2/1, respectively; p=0.009) and in the presence of sepsis criteria (12.2% versus 38.3%, respectively; p=0.001), while the Boey score showed no differences between the two groups. The operative time was longer in the laparoscopic group (median 100' versus 80', p=0.01). Laparoscopy was associated with few early postoperative complications (18.4% versus 41.7%, p=0.004), mortality (2.0% versus 14.2%; p=0.02), shorter hospital stay (median 6 versus 7 days, p=0.001), and earlier oral intake (median 3 versus 4 days, p=0.021).

Conclusion: Laparoscopic repair of PPU may be considered the procedure of choice in patients without sepsis criteria if expertise and resources are available. This kind of approach is associated with a shorter length of hospital stay and earlier oral intake. In patients with sepsis criteria, more data are required to access the safety of laparoscopy in the treatment of PPU.

Background: Sleeve gastrectomy is the most commonly performed bariatric procedure. Laparoscopic longitudinal gastrectomy (LLG) may be indicated for other indications. Patients and Methods. Two men and two women aged 67, 72, 77, and 80 years underwent LLG for nonbariatric indications with two having normal weight, one being cachectic, and one severely obese.

Results: LLG was discussed with patients prior to surgery, but decision for LLG was made during surgery after contemplating other surgical options. A wide sleeve over a 42 French bougie was created with the staple line being oversewn with running 3-0 silk. Indications included a bleeding Dieulafoy lesion that failed endoscopic clipping, fundus gland polyposis found during paraesophageal hernia repair, fundus nodules suspected to be leiomyosarcoma metastases revealing splenosis on final pathology, and significant gastric dilatation associated with organoaxial gastric volvulus. Three patients had an uneventful recovery; the severely obese patient temporarily lost weight but died after two years from a stroke. The last patient developed dysphagia due to an alpha-loop in the sleeve, which was managed by endoscopic stenting. The device subsequently migrated and was laparoscopically removed, with a side-side gastrogastrostomy performed to straighten the alpha-loop. The patient tolerated food better and with overnight PEG tube feeds gained weight but continued heavy smoking. He died after one year from COPD exacerbation.

Conclusion: LLG seems to be an appropriate intervention for various gastric pathologies. Training of residents and fellows in the minimally invasive surgical steps of LLG is encouraged.