Journal of Minimal Access Surgery最新文献

Abstract: A gastrointestinal (GI) transmural defect is defined as a total rupture of the GI wall and these defects can be divided into three main categories, including perforation, leaks and fistulae. Recognition of the specific classification of the defect is important for choosing the best therapeutic modality. We present a case series of patients with gastrointestinal transmural defects which were managed with indigenously modified endoluminal vacuum-assisted closure.

Abstract: Chronic pancreatitis is a benign disease which causes recurrent abdominal pain and loss of pancreatic function. Lateral pancreaticojejunostomy (LPJ) is a commonly performed drainage procedure for this condition. While usually performed through an open approach, there have been few cases of laparoscopic approaches for this condition. A literature review was conducted to understand the current status of laparoscopic longitudinal pancreatojejunostomy (LLPJ). We conducted a comprehensive literature search using PubMed, Embase and Cochrane Library to find the articles published until 1 st October 2023. We excluded studies involving paediatric patients or robotic assisted surgeries. Our evaluation focussed on pain relief scores, morbidity, hospital stay length, mortality rates and the development of endocrine and exocrine deficiencies in the patients. The patients in the analysis had a mean age of 36.5 and a male to female ratio of 1.4:1. The mean main pancreatic duct diameter was 11.5 mm. Tropical pancreatitis was identified as the primary cause. The surgical procedure was performed using 4 ports with minimal bleeding and a 13% morbidity rate. The conversion rate was 15%. The average operative time was 260 min and the mean hospital stay was 5.7 days. The results for pain control were excellent, as 90% of patients did not report pain in most series at the end of 3 years. The laparoscopic surgical management of chronic calcific pancreatitis with LPJ offers a safe and effective solution for pain relief in carefully chosen patients. However, further comprehensive studies with large sample sizes are essential to establish a more conclusive comparison between LLPJ and open surgery.

Introduction: Intrathecal opioid is an analgesic option in laparoscopic surgery. We assessed primarily the intraoperative opioid requirement amongst patients receiving intrathecal morphine (ITM) (Group M) versus standard care (Group C) for abdominal surgery. The secondary outcomes were intraoperative haemodynamic changes, extubation on table and pain scores in the intensive care unit (ICU) at 6 th hourly intervals for 24 h postoperatively.

Patients and methods: Patients undergoing laparoscopic abdominal surgery were randomised into Group M ( n = 30) that received ITM at 2 μg/kg while Group C ( n = 30) was control. A rise in mean arterial pressure > 20% from baseline was treated sequentially with 0.3 mg /kg propofol and 0.5 μg/kg fentanyl intravenously (IV). Pain management in the ICU included paracetamol 1G IV 8 th hourly for all patients, while nefopam 20 mg and fentanyl 0.5 μg/kg IV were the second and third tiers of pain management.

Results: Intraoperatively, 10 patients in Group M versus 26 in Group C needed additional fentanyl ( P < 0.001) and 15 versus 26 patients needed additional propofol ( P = 0.0024). Pain scores were superior in Group M at all time points in the ICU and at ambulation and during incentive spirometry. Thirteen patients in Group C versus 3 in Group M needed nefopam at the time of shifting to the ICU ( P = 0.004) and 10 patients versus 1 at 8 h in the ICU ( P = 0.003) while pain management at 16 h and 24 h was comparable.

Conclusion: Pre-operative ITM at 2 μg/kg reduces intraoperative opioid requirement and improves analgesia 24 h postoperatively amongst patients undergoing major laparoscopic abdominal surgery without delay in extubation or changes in haemodynamics.

Introduction: Variations in biliary ductal and hepatic vascular anatomy increase the complexity of surgery for choledochal cysts (CDC). The laparoscopic approach for the management of paediatric CDCs with variant anatomy is underreported. This study aimed to describe anatomical variations, operative techniques and early outcomes of laparoscopic hepaticojejunostomy (HJ) in children with CDCs and variant anatomy.

Patients and methods: We conducted a retrospective review of 40 children who underwent laparoscopic CDC excision with HJ between 2019 and 2024 in a single surgical unit. Patients were divided into Group I (with anatomical variations, n = 20) and Group II (without variations, n = 20). Data on demographic details, clinical presentation, imaging findings, pre-operative interventions, ductal and vascular anatomical variations, surgical techniques, intraoperative variables, post-operative complications and outcomes were collected and analysed.

Results: Ductal variations were found in 10 patients, with aberrant right posterior sectoral duct being the most common. Vascular variations were identified in 12 patients, with anteriorly crossing the right hepatic artery (RHA) being the most frequent. Group I had a higher mean age (7.32 vs. 3.57 years, P = 0.014) and longer operative times (415 vs. 364 min, P < 0.0001). Conversion to laparotomy was necessary in 10% of Group I and 15% of Group II patients ( P = 0.634). Post-operative complications, primarily minor (Clavien-Dindo Grade I or II), occurred in 40% of Group I and 30% of Group II ( P = 0.495). Group I had a significantly shorter time to full feeds (72 vs. 80 h, P = 0.015). Both groups had similar post-operative hospital stays and follow-up durations. At the last follow-up, all patients, except one with liver failure in Group II, were asymptomatic with no significant biliary dilatation or liver function abnormalities.

Conclusion: Laparoscopic management of CDCs with variant ductal and vascular anatomy in children is feasible, safe and effective. Detailed pre-operative imaging, meticulous intraoperative assessment and tailored surgical techniques are crucial for successful outcomes.

Background: We aimed to assess the therapeutic effects of single-port thoracoscopic anatomical segmentectomy on early-stage non-small-cell lung cancer (NSCLC).

Patients and methods: Sixty patients with early-stage NSCLC admitted from December 2022 to July 2023 were selected and divided into a lobectomy group (n = 30) and a segmentectomy group (n = 30) according to the different procedures. Their perioperative indicators, pre-operative and post-operative pulmonary function indicators, pain degree 24 h, 48 h, 72 h and 7 day after operation, the incidence of post-operative complications and recurrence, survival and mortality rates 1 year after operation were compared.

Results: The segmentectomy group had significantly smaller intraoperative blood loss, shorter length of drainage and length of hospital stay and longer operation time than those of the lobectomy group (P < 0.05). The pulmonary function decreased significantly in both groups 1 week, 1 month and 3 months after operation. Compared with the lobectomy group, the forced expiratory volume in 1 s per cent, forced-vital capacity per cent and maximal voluntary ventilation of the segmentectomy group significantly increased at each time point after operation (P < 0.05). The Visual Analogue Scale scores 24 h, 48 h, 72 h and 7 days after operation were significantly lower in the segmentectomy group than those in the lobectomy group (P < 0.05). There were no significant differences in the incidence of post-operative complications and recurrence, survival and mortality rates 1 year after operation between the two groups (P > 0.05).

Conclusions: Single-port thoracoscopic anatomical segmentectomy has obvious therapeutic effects on early-stage NSCLC, characterised by smaller surgical trauma, milder post-operative pain and less impact on pulmonary function.

Abstract: The available options for recurrent incisional hernias (RIH) following previous laparoscopic intraperitoneal onlay mesh (IPOM) plus were open onlay repair, open Rives-Stoppa (RS), laparoscopic enhanced view totally extraperitoneal-RS (ETEP-RS) and laparoscopic subcutaneous onlay mesh repair. Majority of these RIH were managed by open onlay mesh repairs or laparoscopic Redo IPOM plus. There are not much data available in the literature on the ETEP approach for RIH following previous IPOM plus with the placement of mesh in the retrorectus space. In this article, I would like to share technical aspects, challenges faced and tips to overcome these challenges of performing ETEP for RIH following previous IPOM plus repairs.

Abstract: Common bile duct (CBD) stones are usually caused by biliary tract infection, biliary stricture, duodenal peripapillary diverticulum, Oddis sphincter dysfunction, and so on. Treatment is preferably with endoscopic retrograde cholangiopancreatography (ERCP), where an iodine-containing contrast agent is injected into the CBD to display the stone under fluoroscopy and then to confirm complete removal of the stone(s). We described a 65-year-old woman with CBD stones who had undergone cardiac pacemaker implantation and was allergic to iodinated contrast media. We performed ERCP + lithotomy + stent implantation under local anesthesia, with injection of carbon dioxide instead of iodinated contrast into the CBD, and successfully visualized the stones under fluoroscopy and then confirmed complete removal of them. The patient was generally in good condition without complications. Thus, we have demonstrated in this case report that carbon dioxide can be used as a safe, economical, and effective alternative to iodinated contrast agent during ERCP.

Abstract: This report describes the rare case of transverse testicular ectopia (TTE) associated with polyorchidism in a 16-month-old male, successfully managed through laparoscopic surgery. The patient presented with bilateral cryptorchidism, a palpable mass in the right inguinal canal and an absent left-side gonad. Ultrasound revealed three gonad-like structures. Laparoscopy identified duplicated and fused testes at the right deep inguinal ring, and a third testis in the right inguinal canal. Minimally invasive techniques positioned the duplicated testes in the right hemiscrotum and the single testis in the left hemiscrotum. Post-operative follow-up confirmed optimal scrotal positioning, with normal growth. This rare case underscores the efficacy of laparoscopy in diagnosing and managing rare paediatric conditions, providing valuable insights for surgeons facing cryptorchidism or scrotal masses.

Abstract: Foreign body (FB) ingestion results in perforation in 1% of cases and is associated with significant morbidity and rarely mortality. This case reports the delayed presentation of distal ileal perforation following accidental ingestion of solidified root pulp. A 46-year-old male presented to the emergency department with complaints of right iliac fossa pain, clinical diagnosis of appendicitis was made. Computed tomography of the abdomen revealed an FB in the distal ileum with contained perforation. Revised history was suggestive of FB aspiration during root canal therapy 3 weeks back. The patient underwent diagnostic laparoscopy, removal of FB and primary closure of the perforation. FB was revealed to be solidified root pulp macroscopically and hyalinised material microscopically. Localised perforation following ingestion of FB results in significant morbidity due to delayed diagnosis. With the increasing number of dental procedures, this becomes relevant globally as well. Varied clinical presentations pose diagnostic challenges to the clinician.

Introduction: The impact of laparoscopic surgery on homeostatic systems necessitates careful consideration of intra-abdominal pressure (IAP) management. This study investigated the effects of low-pressure pneumoperitoneum with deep neuromuscular blockade (NMB) on surgeon satisfaction, haemodynamics and post-operative outcomes in laparoscopic cholecystectomy patients.

Patients and methods: The study design involves prospective randomised control. Ninety patients were assigned to low (7-10 mmHg, n = 45) or normal (12-16 mmHg, n = 45) IAP groups. Deep NMB, guided by train-of-four monitoring, was administered. This study evaluated surgical rating scale scores, haemodynamics and post-operative outcomes through a literature review. A computer programme (IBM, SPSS) was used for statistical analysis. Chi-square and Mann-Whitney U tests were used to analyse patients' IAP levels, additional NMB requirements, surgical rating scale scores and numerical rating scales. Patient demographics and other intraoperative and post-operative variables were analysed with Student's t-test and the Mann-Whitney U test. Values of P < 0.05 were considered to indicate statistical significance.

Results: No significant demographic differences were observed. The low-pressure group exhibited lower post-operative pain (P < 0.01) and reduced analgesia requirements (P = 0.00). On analysis of the surgeon rating scale, no disparities were evident between the groups. NMB usage correlated with height and weight (P < 0.01). Heart rate showed no intergroup differences. The MAP measured after 15 min was lower in Group L, and the difference was significant (P = 0.023). The SAP measured after 30 min was lower in Group L, and the difference was significant (P = 0.017). Blood gas values and surgical field visibility were unaffected by the IAP. The positive correlations between NMB, height and weight aligned with previous research.

Conclusion: This study highlights successful laparoscopic cholecystectomy under low IAP, deep NMB and favourable post-operative outcomes. Despite these limitations, the findings contribute to optimising laparoscopic surgical approaches.