Asian Journal of Endoscopic Surgery最新文献

Introduction

The optimal surgical approach for bilateral intraabdominal testes remains controversial. The Shehata technique has shown promising results as a fertility-preserving method by elongating the gonadal vessels without vessel division.

Materials and Methods

We present a case of bilateral intraabdominal testes treated with simultaneous bilateral Shehata technique.

Surgical Technique

At 9 months of age, bilateral testes were identified laparoscopically. After dissection of the spermatic cords, a one-stage bilateral orchidopexy was attempted. Due to significant tension in the testicular vessels, the testes were crossed and fixed to the contralateral abdominal wall following the Shehata technique. Nine weeks later, the spermatic cords were found to be fused. Adhesions were carefully dissected laparoscopically while preserving both cords, and the testes were successfully fixed in the scrotum.

Discussion

This case highlights the risk of cord adhesion when applying the Shehata technique bilaterally and simultaneously. A staged approach is recommended to prevent this complication.

Introduction

Management of distal ureteral urothelial carcinoma remains challenging, with kidney-sparing surgery (KSS) emerging as a viable alternative to radical nephroureterectomy in selected cases. We report our initial experience with robot-assisted partial ureterectomy using the da Vinci Xi surgical system.

Materials and Surgical Technique

Between 2024 and 2025, five patients underwent robot-assisted KSS for distal ureteral tumors. All procedures were performed using the da Vinci Xi system with a transperitoneal approach in lithotomy position. The surgical technique involved extensive proximal ureteral mobilization to the level just distal to the common iliac artery crossing, excision with adequate margins including bladder cuff, and neo-ureterocystostomy to intact bladder mucosa using V-Loc suture. Frozen section analysis of the proximal margin was performed with conversion to nephroureterectomy planned if positive. Written informed consent was obtained from all patients.

Discussion

Median operative time was 205 min (range: 174–253) with median console time of 170 min. Median estimated blood loss was 65 mL (range: 5–215 mL). Pathological examination revealed urothelial carcinoma in all cases: two patients had pT3 disease and three had pTa disease. Surgical margins were negative in four cases and indeterminate in one. One patient (20%) experienced a Clavien-Dindo Grade 2 complication. All patients maintained stable renal function. At a median follow-up of 6 months, no local recurrence or upper tract recurrence was observed. Robot-assisted KSS with extensive proximal ureteral resection appears feasible and safe for selected patients with distal ureteral tumors. Longer follow-up and larger series are needed to confirm oncological efficacy.

Introduction

A lateral and posterior basal (S9 + 10) segmentectomy via the posterior approach is a helpful procedure that can be used for patients with incomplete lobulation. It has another benefit in that the procedure can be performed with minimal dissection of visceral pleurae in patients who may have multiple operations in the ipsilateral side of the lung. However, the difficulty associated with this procedure lies in encircling or dividing A9 + 10 and B9 + 10 in the narrow surgical field of the hilum. Therefore, we now introduce a modified posterior approach to facilitate encircling and dividing A9 + 10 and B9 + 10.

Materials and Surgical Technique

First, V9 + 10 is divided in the hilum; V7 is also divided in the right-side surgery. Second, the entire intersegmental plane between the superior (S6) and S9 + 10 segments (S6/S9 + 10) is divided along with V6b + c and its extension line. After that, B9 + 10 and A9 + 10 can be divided in the good surgical field of the hilum. Finally, the intersegmental plane between the anterior basal (S8) and S9 + 10 is divided after identifying it by using indocyanine green fluorescence imaging; the intersegmental plane between the medial basal (S7) and S9 + 10 segments is also identified and divided in the right-side surgery.

Discussion

When we perform a thoracoscopic S9 + 10 segmentectomy via the posterior approach, dividing the entire S6/S9 + 10 along the run of V6b + c before encircling or dividing A9 + 10 and B9 + 10 ensures a good surgical field for the structures.

Background

Anastomotic leakage (AL) remains a major postoperative complication after rectal cancer surgery, even with advances in minimally invasive techniques. Indocyanine green (ICG) fluorescence imaging is widely used to assess bowel perfusion, but conventional methods rely heavily on subjective visual interpretation. The SPY-QP software enables quantitative evaluation of ICG fluorescence, potentially improving the accuracy of perfusion assessment.

Methods

The SPECTACLE study is a multicenter, prospective, single-arm trial designed to evaluate whether SPY-QP-based quantitative blood flow assessment can reduce AL rates compared with historical controls from the EssentiAL study. Perfusion assessment is performed according to an algorithm we developed based on our previous retrospective analysis. We plan to enroll 400 patients undergoing laparoscopic or robotic rectal cancer resection with anastomosis. The primary endpoint is the incidence of AL (Grades A–C) within 30 days postoperatively. Secondary endpoints include changes in surgical strategy based on perfusion findings, operative time, intraoperative complications, and other postoperative outcomes.

Discussion

This study aims to provide robust evidence on whether objective perfusion assessment using SPY-QP can reduce AL after rectal cancer surgery, potentially leading to broader adoption of quantitative imaging in colorectal surgery.

Trial Registration: Japan Registry of Clinical Trials: jRCTs032230212

Introduction

The Senhance Surgical System is the second robotic surgical platform approved for laparoscopic procedures in Japan. It is unique compared to other systems, offering eye-tracking camera control, haptic feedback, and reusable instruments. Although its application in colon surgery has shown favorable outcomes, reports on its utility in rectal cancer surgery are limited. We aimed to evaluate the surgical outcomes of patients who underwent Senhance-assisted low anterior resection for rectal cancer.

Materials and Surgical Technique

We retrospectively analyzed 16 patients who underwent low anterior resection for rectal cancer using the Senhance system between February 2020 and December 2022. Surgical indications included resectable rectal cancer without adjacent organ invasion or emergency presentation. Demographic data, perioperative outcomes, pathological findings, and recurrence were assessed. The median duration of the operation was 308.5 min, with minimal blood loss (median 0 mL). Conversion to laparoscopy occurred in 5 patients (31.3%) due to pelvic dissection difficulty. There was no case of conversion to open surgery. No Clavien–Dindo grade ≥ 2 complications were observed. The median duration of hospitalization was 8 (6–14) days. R0 resection was achieved in 14 cases, and R2 resection was performed in 2 cases with synchronous distant metastases. The median number of harvested lymph nodes was 22. Four patients (28.6%) experienced recurrence, excluding those with stage IV disease.

Discussion

Senhance-assisted low anterior resection can be safely performed with acceptable short-term oncological outcomes. However, its limitations in deep pelvic dissection and system setup require further investigation. Larger studies are needed to validate its utility in rectal surgery.

Introduction

The Tokyo Guidelines 2018 recommend early laparoscopic cholecystectomy for acute cholecystitis once the diagnosis is made. In surgical high-risk patients, however, initial management with antibiotics and gallbladder drainage is advised, followed by standby surgery. The optimal timing of standby surgery after percutaneous transhepatic gallbladder drainage remains unclear. This study aimed to evaluate the timing of standby cholecystectomy after gallbladder drainage in surgical high-risk patients.

Methods

We retrospectively reviewed 97 patients who underwent cholecystectomy after percutaneous transhepatic gallbladder drainage between January 2019 and July 2024 at our hospital. Patients were classified as surgical high-risk (n = 56) or low-risk (n = 41) according to the Tokyo Guidelines 2018. In the high-risk group, both the total cohort and a propensity score-matched cohort (n = 22) were analyzed, comparing an early group (surgery within 7 days after gallbladder drainage) and a delay group (surgery ≥ 8 days); patients with Grade III acute cholecystitis were excluded before matching. Clinical characteristics and surgical outcomes were compared.

Results

In the total cohort, C-reactive protein levels at initial presentation were significantly higher in the delay group (p < 0.05). All patients with Grade III acute cholecystitis (n = 9) were included in the delay group. In the matched cohort, surgical outcomes did not differ significantly between groups. However, total hospitalization was significantly shorter in the early group (p < 0.05).

Conclusions

In surgical high-risk patients, standby surgery within 7 days after percutaneous transhepatic gallbladder drainage may be preferable, as it shortens hospitalization without compromising surgical outcomes.

Background

With the increasing use of minimally invasive surgery, understanding of the precise anatomy involved in median arcuate ligament syndrome (MALS) has advanced. However, surgical strategies and treatment principles for MALS remain unclear.

Methods

At the 37th Annual Meeting of the Japan Society for Endoscopic Surgery, an expert consensus conference titled “AOB Consensus Meeting” was held. Eleven experts in upper gastrointestinal, hepatobiliary-pancreatic, and vascular surgery discussed five clinical questions (CQs) regarding MALS. Systematic literature reviews were conducted, and draft consensus statements were developed. Evidence levels were assessed based on the MINDS guideline, and final consensus statements were established through a second-round Delphi voting process.

Results

Thirteen consensus statements were formulated across the five CQs, all achieving over 75% agreement among the experts.

Conclusion

This consensus provides evidence- and experience-based recommendations for the diagnosis and surgical treatment of MALS. These consensus statements are expected to serve as a practical guide for specialists and surgeons, promoting the safe execution and appropriate global dissemination of MALS treatment.

Introduction

Upper pole renal tumors, despite the unique surgical techniques and preparations necessitated by their anatomical location, are assigned the same numerical complexity as lower pole tumors by the RENAL nephrometry score. Consequently, this study aimed to compare the perioperative outcomes of robot-assisted partial nephrectomy (RAPN) for upper versus lower pole renal tumors.

Methods

Out of 484 consecutive patients who underwent RAPN at our institution, this retrospective study included 186 patients with renal polar tumors. Upper and lower pole tumors were defined as those with a RENAL nephrometry score L component of 1, indicating polar tumors not overlapping the superior or inferior polar lines. RAPN procedures were performed using either the da Vinci Xi or the hinotori system, a newly developed robotic platform in Japan. For upper pole tumor excision in a transperitoneal approach, a 30° down-angle robotic camera was inserted via a camera port previously positioned approximately 3 cm more superolaterally than the standard placement, alongside two robotic arms, irrespective of the robotic platform.

Results

The study population was divided into lower (n = 109) and upper (n = 77) pole tumor groups; tumors located centrally, including hilar tumors, were entirely excluded. No significant differences were observed in baseline patient characteristics between the two groups. Following surgery, significant differences were found in operative time (165 vs. 179 min, p = 0.010) and robotic time (98 vs. 116 min, p = 0.004) between the lower and upper pole groups, respectively. However, other major perioperative outcomes, including the Trifecta achievement rate (94.5% vs. 98.7%, p = 0.24), showed no significant differences. Uni- and multivariate analyses identified sex, tumor size, and tumor polar location as independent factors for prolonged robotic time; however, robotic platform type was not.

Conclusions

With proper technical preparation, RAPN for upper pole tumors can achieve comparable perioperative outcomes to that for lower pole tumors, despite requiring longer operative and robotic times.