Minimally Invasive Surgery最新文献

Background: Laparoscopic appendectomy (LA) is most commonly performed using two 5-mm and one 10/12-mm ports. Various attempts to reduce the number and size of ports have been made and new technologies such as single port LA have been introduced. Appendix and mesoappendix are usually divided with a stapler or energy device with electrocautery, clips, and endoloop being cheaper options.

Patients and methods: This study includes 51 consecutive LAs performed at a rural hospital. Patients were divided into 4 groups: group 1 was the standard technique group (n=12), group 2 served as a "try-out" (n=12), group 3 served as feasibility group (n=12), and group 4 was the final patient cohort in which the optimized technique was preferably used (n=15).

Results: Median age of the study cohort was 35.4 (range: 6.2-80.6) years, and 55% of patients were male. Whereas in G1 all patients had standard port placement (10/12-mm, 2x5-mm), in an increasing number of patients in G2-4 only two 5-mm ports and the 2.3-mm Teleflex minigrasper were inserted. Usage of staplers and/or energy devices was reduced from 100% in G1 to 20% in G4, and in the majority of cases both the appendix and the vascular pedicle were secured with an endoloop. The new technique did not add time to the procedure or total OR time. No stump-leaks or surgical site infections were encountered in this series, and there were no conversions to open surgery. Cost savings when not using a stapler or energy device are approximately 400$ per case; the minigrasper added approximately 200$ to the case.

Discussion: LA with use of two ports and a portless needle grasper is feasible in the majority of cases and was associated with high patient satisfaction and excellent cosmetic results. Avoiding energy devices and staplers is cost saving; the endoloop securely controls appendix and mesoappendix.

Laparoscopic cholecystectomy (LC) is widely used for treating early acute cholecystitis (AC) and substantially reduces hospital costs. This study aimed to identify and evaluate risk factors associated with long postoperative hospital stays (PHSs) in patients undergoing emergency LC for AC according to the 2013 Tokyo Guidelines (TG13). Clinical data of patients who underwent emergency LC for AC between 2011 and 2017 were retrospectively collected. Patients were divided into early discharge (ED, discharge in three days or less postoperatively) and late discharge (LD, discharge in more than three days postoperatively) groups based on clinical progression and PHS after LC. Preoperative characteristics and perioperative outcomes were analysed as potential risk factors for LD. Among 149 patients, 104 (69.8%) were discharged within 3 days postoperatively, whereas 45 (30.2%) had long PHSs. Main causes of LD were fever and inflammation. Univariate analysis of preoperative risk factors revealed significant differences in age, white blood cell count, C-reactive protein, total bilirubin (T-bil), and alkaline phosphatase (ALP) levels; anticoagulation therapy; and TG13 severity grade. Multivariate analysis revealed that TG13 severity grade II, age >65 years, and elevated T-bil and ALP levels are independent factors for long PHS. Older age, worse biliary function, and increased TG13 severity grade might predict prolonged PHSs in AC patients undergoing emergency LC.

Objectives: Pathogenesis of gallstone includes bile stasis due to defect in the gallbladder muscle contraction. Our aim of the study is to find out the role of 99mTc-HIDA scan in assessment of gallbladder dyskinesia in cholelithiasis patients before laparoscopic cholecystectomy and compare the gallbladder dyskinesia with various parameters like symptoms of patients, diabetic status of patients, gallstones size and number, and cholecystitis features in histopathology report after surgery.

Material and method: This is a prospective observational study conducted at our hospital for three years. Totally 40 patients with gallstone were subjected to 99mTc-HIDA scan, to assess the ejection fraction of gallbladder. For all these patients detailed clinical history, presence of comorbid illness like diabetics, and symptomatology were elicited. For all patients, ultrasonogram of abdomen was done to assess number and size of stones. All parameters were tabulated and correlated.

Result: While comparing 99mTc-HIDA scan findings with symptoms of patients, 21.2% were asymptomatic and 78.8% symptomatic patients who had ejection fraction less than 80%. All patients in EF >80% group were symptomatic only. It is not statistically significant. On comparing 99mTc-HIDA scan findings with diabetic status of the patients, 42.4% of diabetic and 57.6 % of nondiabetic patients had ejection fraction less than 80%. It is not statistically significant (0.681). While comparing 99mTc-HIDA scan findings with size of the gallstone in ultrasound, 63.6% patients with size less than 1cm and 36.4% with size more than 1cm had ejection fraction < 80%. It is statistically significant (0.048). On comparing 99mTc-HIDA scan findings with number of stones in ultrasound, 18.2% single gallstone patients and 81.8% multiple gallstone patients had EF less than 80% which is statistically significant (0.001). While comparing the 99mTc-HIDA scan findings with histopathology report after laparoscopic cholecystectomy, 21.2% non-cholecystitis patients and 78.8% cholecystitis patients had EF less than 80%, which is statistically (0.017) significant.

Conclusion: 99mTc-HIDA scan can be an accurate method to diagnose the gallbladder dyskinesia. Gallbladder dyskinesia in 99mTc-HIDA scan can be used to predict large size stones and multiple stones before surgery. The sensitivity can be improved by 99mTc-HIDA scan in diagnosing cholecystitis patients.

Laparoscopic cholecystectomy (LC) is one of the highest volume surgeries performed annually. We hypothesized that there is a statistically significant intradepartmental cost variance with supply utilization variability amongst surgeons of different subspecialty. This study sought to describe laparoscopic cholecystectomy cost of care among three subspecialties of surgeons. This retrospective observational cohort study captured 372 laparoscopic cholecystectomy cases performed between June 2015 and June 2016 by 12 surgeons divided into three subspecialties: 2 in bariatric surgery (BS), 5 in acute care surgery (ACS), and 5 in general surgery (GS). The study utilized a third-party software, Surgical Profitability Compass Procedure Cost Manager and Crimson System (SPCMCS) (The Advisory Board Company, Washington, DC), to stratify case volume, supply cost, case duration, case severity level, and patient length of stay intradepartmentally. Statistical methods included the Kruskal-Wallis test. Average composite supply cost per case was $569 and median supply cost per case was $554. The case volume was 133 (BS), 109 (ACS), and 130 (GS). The median intradepartmental total supply cost was $674.5 (BS), $534 (ACS), and $564 (GS) (P<0.005). ACS and GS presented with a higher standard deviation of cost, $98 (ACS) and $110 (GS) versus $26 (BS). The median case duration was 70 min (BS), 107 min (ACS), and 78 min (GS) (P<0.02). The average patient length of stay was 1.15 (BS), 3.10 (ACS), and 1.17 (GS) (P<0.005). Overall, there was a statistically significant difference in median supply cost (highest in BS; lowest in ACS and GS). However, the higher supply costs may be attenuated by decreased operative time and patient length of stay. Strategies to reduce total supply cost per case include mandating exchange of expensive items, standardization of supply sets, increased price transparency, and education to surgeons.

To prevent open surgical procedures, minimally invasive techniques, like Dekompressor (PLDD), have been developed. The absence of reherniation is an important factor correlating with clinical success after lumbar surgery. In this retrospective, observational study, the frequency of additional open surgery after PLDD in a long time retrospective was examined. The correlation between clinical symptoms and outcome was assessed, and the time between PLDD and open surgery was analyzed. Consecutive patients after PLDD between 2005 and 2007 were included. MacNab's outcome criteria were used to evaluate patient satisfaction. The need for additional open surgery of the lumbar spine, the period between Dekompressor and resurgery, and the treated levels were analyzed. In total, 73 patients were included in this study. The patients were seen one month after PLDD. The majority of patients (76.7%) had additional radicular pain. The most common level treated was L4-5 (58.9%). The follow-up time was longer than 5 years in 30.1% of the patients and longer than 10 years in 6.82%. The short-term success rate was 67.1%. Additional surgery was performed in 26.0% of patients, with 78.9% of the reoperations undertaken during the first year after PLDD. These patients had a statistically significant worse outcome (P = 0.025). Radicular pain was present in all patients with an early subsequent surgery, but only in 50% of patients with late surgery (P = 0.035). Significantly more patients with poor pain relief had radicular pain (P = 0.04). The short-term success rate was worsened by a resurgery rate of 26.0%. Subsequent surgery, a short time after PLDD, suggests that PLDD is not a replacement for open discectomy. Because patients with radicular pain had a worse outcome and more frequent resurgeries, whether radicular pain is an ideal indication for PLDD should be discussed.

Objective: To evaluate trends in surgical approach for hysterectomy following the introduction and implementation of a comprehensive robotic surgery program.

Methods: A retrospective review of all hysterectomies done at two institutions, a community hospital and a suburban, tertiary-care teaching hospital, in the same health system over a five-year period, January 2010 through December 2014. A robotic surgery training program was implemented during the first year of the study and trends in route of hysterectomy were evaluated in the subsequent years.

Results: A total of 5175 patients undergoing hysterectomy, for both benign and malignant indications, were included in the study. There was a significant decrease in the percent of cases performed through an abdominal approach at both the community and teaching hospitals (19.3% decline at each institution). There was an inversely related significant increase in the percent of robotic procedures at both the community and teaching hospitals (44.5% and 17%, respectively). A decrease in number of cases performed vaginally over this period was only noted in the community hospital site (25.2% decrease), and there was a slightly higher rate of vaginal hysterectomies at the teaching hospital over this study period (21.9% in 2010, 24.1% in 2014).

Conclusion: The decrease in number of abdominal and laparoscopic hysterectomies and increase in number of robotic hysterectomies that was seen are consistent with national trends. The initiation of a robotic training program did not prevent the proliferation of use of the robot but did aim to ensure proficiency on the robot prior to gaining privileges for patient use. This type of comprehensive training and monitoring program could be applied to future technologic advances to ensure a standard level of surgical proficiency. Trends in route of hysterectomy are clearly multifactorial and involve patient, provider, and location-specific factors that are likely to continue to change.

Background: Undoubtedly, robotic systems have largely penetrated the surgical field. For any new operative approach to become an accepted alternative to conventional methods, it must be proved safe and result in comparable outcomes. The purpose of this study is to compare the short-term operative as well as oncologic outcomes of robotic-assisted and laparoscopic rectal cancer resections.

Methods: This is a prospective randomized clinical trial conducted on patients with rectal cancer undergoing either robotic-assisted or laparoscopic surgery from April 2015 till February 2017. Patients' demographics, operative parameters, and short-term clinical and oncological outcomes were analyzed.

Results: Fifty-seven patients underwent permuted block randomization. Of these patients, 28 were assigned to undergo robotic-assisted rectal surgery and 29 to laparoscopic rectal surgery. After exclusion of 12 patients following randomization, 45 patients were included in the analysis. No significant differences exist between both groups in terms of age, gender, BMI, ASA score, clinical stage, and rate of receiving upfront chemoradiation. Estimated blood loss was evidently lower in the robotic than in the laparoscopic group (median: 200 versus 325 ml, p= 0.050). A significantly more distal margin is achieved in the robotic than in the laparoscopic group (median: 2.8 versus 1.8, p< 0.001). Although the circumferential radial margin (CRM) was complete in 18 patients (85.7%) in the robotic group in contrast to 15 patients (62.5%) in the laparoscopic group, it did not differ statistically (p=0.079). The overall postoperative complication rates were similar between the two groups.

Conclusion: To our knowledge, this is the first prospective randomized trial of robotic rectal surgery in the Middle East and Northern Africa region. Our early experience indicates that robotic rectal surgery is a feasible and safe procedure. It is not inferior to standard laparoscopy in terms of oncologic radicality and surgical complications. Organization number is IORG0003381. IRB number is IRB00004025.

Purposes: Seroma is a postoperative complication following laparoscopic transabdominal preperitoneal repair (TAPP) for inguinal hernioplasty. Seroma naturally resolves in most cases, but it can lead to an increased amount of visits to the outpatient clinic and can result in anxiety of the patient. Local inflammation of the inguinal area is etiology of seroma formation. Strangulated hernia involves severe inguinal pain and can lead to severe inflammation and subsequent seroma. There have been no reports demonstrating the links of seroma and strangulated hernia. This study aimed to retrospectively evaluate the risk of seroma after TAPP and to identify the association between strangulated hernia and seroma.

Methods: We treated 300 inguinal hernias by TAPP between 2013 and 2016 at Kurashiki Central Hospital. We used the Chi-square test. Factors significant in each association were further examined using multiple subsequent logistic regressions.

Results: A total of 222 hernias were eligible for analysis. The incidence of seroma was 11% (n=25). There were nine cases of strangulated hernias, and three (33%) resulted in seroma. The ratio of strangulated hernia of seroma group is significantly high (p<0.03). Multiple subsequent logistic regressions showed that strangulated hernia was associated with a significantly increased risk for seroma formation (p = 0.023; OR 6.564; 95% CI 1.29-33.3).

Conclusion: This study shows that strangulated hernia can be a risk factor in seroma formation. This risk should be incorporated into a management plan of TAPP for strangulated hernia, with careful consideration of patients' concerns.