Journal of Minimal Access Surgery最新文献

Background: The effectiveness of virtual reality (VR) simulation training for improving robotic surgical skills is not firmly established. This systematic review and meta-analysis aimed to evaluate the impact of VR simulator training on surgeons' robotic surgical performance in the operating room (OR).

Aim: To synthesize evidence regarding the association between VR-based robotic surgery training and subsequent technical performance inside the OR.

Data sources: A comprehensive literature search was conducted in PubMed, Scopus, Embase, and CINAHL databases, adhering to PRISMA 2020 guidelines.

Eligibility criteria and study selection: Studies evaluating VR simulator training for robotic surgeons with subsequent performance assessment in the OR were included. Risk of bias assessment was performed using the Medical Education Research Study Quality Instrument and the modified Newcastle-Ottawa Scale for Education (NOS-E), along with funding source appraisal.

Data synthesis: A total of 294 records were screened, resulting in 13 studies (281 participants) included in the systematic review, and 4 studies (72 participants) suitable for meta-analysis. Metaanalysis was conducted using a random-effects model to pool correlation coefficients between preand post-training performance.

Results: Of the included studies, nine reported positive evidence, three found no evidence, and one found negative evidence regarding VR training's role. The meta-analysis of before-after studies revealed a significant positive correlation ( r = 0.717, P < 0.05) between simulation performance and intraoperative outcomes.

Limitations: The small number of studies included in the meta-analysis and methodological heterogeneity may limit generalisability of results.

Conclusions: VR simulator training is associated with improved robotic surgical performance in the OR. Incorporation of VR simulation into robotic surgical curricula is likely beneficial for skill acquisition and operative readiness.

Abstract: We report two cases of successful oesophageal diverticulectomy through uniportal video-assisted thoracoscopic surgery (VATS). In both cases, a chest computed tomography showed huge mid-oesophageal diverticulum. Gastrointestinal endoscopy confirmed a diverticulum on the right wall. Surgical treatment through uniportal VATS was planned and performed successfully. We recommend that uniportal VATS could be a feasible method for oesophageal diverticulectomy.

Introduction: Conventional umbilical access can be time-consuming, surgically challenging due to inadequate 'Critical View of Safety' and pneumoperitoneum maintenance for high body mass index (BMI) patients undergoing laparoscopic cholecystectomy (LC). The aim of the study is to assess the feasibility, safety and outcome of our modified access for patients of BMI ≥30.

Patients and methods: A prospective study of 1762 consecutive patients undergoing LC in a large district general hospital (2007-2023) that included age, sex, BMI, American Society of Anesthesiologists (ASA), grade of operation with stay and complications were analysed. Group A: Veress needle pneumoperitoneum through Palmer's point. After 2 L (minimum) insufflations, an optical port was introduced at the intersection of two imaginary lines: A 15-cm oblique line starting from where the right mid-clavicular line cuts the right lower costal margin and directed medially meeting the other vertical line running 3 cm to the right of midline. Remaining 3 ports at standard positions (10 mm epigastric port [I] at or just right of midline below the xiphoid process, 5 mm port [II] at the midclavicular line below the costal cartilage and another 5 mm port [III] between 5 cm and 10 cm lateral to port II) as used in LC. Group B (BMI <30): Conventional umbilicus entry followed by 3 standard remaining ports for LC (as above).

Results: Group A: 549 with female: male 4:1, the median of age 49 (16-83) years, BMI 36 (30-65), ASA 2 (1-3), Grade 1 (1-4), operating time 50 (15-200) min and post-operative (PO) stay 0 (0-15) day. One conversion, 2 bile leaks, 5 collections and 4 wound infections. Group B: 1213 with female: male 3:1, the median of age 53 (16-89) years, BMI 26 (17-29), ASA 2 (1-3), Grade 1 (1-4), operating time 45 (15-240) min and PO stay 0 (0-12) day.

Conclusion: Our modified abdominal access is quick and safe that maintains sustained pneumoperitoneum and provides an excellent 'Critical view of Safety' for obese patients undergoing LC with a good outcome.

Abstract: Inverted appendicitis is a rare surgical event, which mostly leads to the wrong pre-operative diagnosis. Nevertheless, the therapy is usually correct. In case of clinical acute appendicitis, we usually proceed to surgery without further examinations. We report about a 65-year-old woman who presented with abdominal pain for 4 days and typical pain at the McBurney's point. Blood examination showed only a slight elevation of the C-reactive protein with 4.62 mg/dl. The ultrasound strengthened the suspicion of acute appendicitis. Laparoscopy was performed, and a severe purulent pericaecal infection was detected, but the appendix was absent. However, the caecum had typical palpatory aspects of cancer. Consequently, we converted to laparotomy and performed a radical right hemicolectomy. The pathology report revealed the inverted appendicitis without any signs of malignancy. It remains difficult to make the correct pre-operative diagnosis. The type of treatment has to be chosen individually.

Abstract: Traumatic diaphragmatic hernia (TDH) is a rare acquired condition usually occurring due to blunt thoracoabdominal trauma, most commonly in road traffic accidents (RTAs). It may also occur due to penetrating trauma. Diagnosis may be delayed due to the masking effect of other severe injuries in a patient with polytrauma. Here, we present the case of a 23-year-old male patient having a history of thoracoabdominal injury due to RTA before 3 months, presenting with severe vomiting, respiratory discomfort and weight loss. He was treated at other places symptomatically for gastritis and flatulence. He was diagnosed with gastric outlet obstruction due to left-sided TDH. He was successfully treated with laparoscopic repair and mesh placement. He needed thoracotomy for left lung decortication in post-operative period owing to persistent pleural effusion and lung collapse. He recovered well and remains asymptomatic on follow-up. Upon asking detailed history, he remembered that he had trauma following being struck by a vehicle. We aim to present this case to highlight the importance of detailed history taking for arriving at a timely diagnosis.

Introduction: Bariatric surgery (BS) is the most effective treatment for morbid obesity. Despite a high number of BS performed in India, there is limited research on post-operative nutritional follow-up. The study aimed to assess patient compliance and adequacy of nutritional supplementation protocols in the post-operative period.

Patients and methods: This prospective, single-centre observational study (August 2022-July 2023) assessed post-operative nutritional status in the Indian patients undergoing BS. Baseline and follow-up nutritional assessments (serum albumin, ferritin, B12, calcium and D3) were performed, and patients were given a supplementation regimen based on the American Society for Metabolic and BS guidelines. Compliance with prescribed supplementation was monitored. Patients were considered compliant if they took ≥80% of the prescribed doses.

Results: The study involved 32 patients, with 65.6% (21) undergoing sleeve gastrectomy and 34.4% (11) undergoing Roux-en-Y gastric bypass. Over 6 months, the mean body mass index decreased from 47 to 36.1 kg/m2. Compliance rates for supplementation varied, with high rates for iron (96.9%) but lower rates for protein (28.1%) and Vitamin B12 (43.7%). However, compliance with supplements did not statistically affect deficiencies for most nutrients, except for Vitamin B12. After 6 months post-surgery, Vitamin B12 deficiency was significantly higher in non-compliant patients than in compliant ones (50% vs. 0%, P = 0.001).

Conclusion: This study suggests that the prescribed supplements are adequate in maintaining nutrient levels post-surgery. Compliance is particularly important in preventing Vitamin B12 deficiency, as non-compliant patients tend to show persistent deficiency. The level of other nutrients improved regardless of compliance.

Introduction: Umbilical hernias are a frequent subset of ventral hernias. Although laparoscopic intraperitoneal onlay mesh with defect closure (IPOM-plus) repair is widely used, concerns remain about mesh contact with viscera and associated pain. The transabdominal pre-peritoneal with defect closure for umbilical hernias (TAPPu-plus, where 'u' denotes umbilical) approach attempts to mitigate such complications by placing the mesh in a pre-peritoneal pocket. This study compares the feasibility, operative time, post-operative pain, hospital stay and recurrence rates between TAPPu-plus and IPOM-plus techniques for small-sized (≤4 cm) umbilical hernias.

Patients and methods: A prospective, single-centre randomised controlled trial was conducted on 50 symptomatic patients with primary umbilical hernias measuring ≤4 cm. Patients were randomised in a 1:1 ratio into Group A (TAPPu-plus, n = 25) or Group B (IPOM-plus, n = 25) using block randomisation with sealed opaque envelopes. Mesh repair was performed in all patients. The primary outcome was procedural feasibility. Secondary outcomes included operative time, estimated blood loss, post-operative pain visual analogue scale, analgesic use, hospital stay and 1-year recurrence.

Results: All procedures were completed laparoscopically. Two patients in the TAPPu-plus group were converted to IPOM-plus due to restricted dissection space, resulting in 23 patients in Group A and 27 in Group B for final analysis. TAPPu-plus was associated with a longer operative time (117.3 ± 14.9 min vs. 80.5 ± 19.7 min), but significantly lower post-operative pain scores throughout follow-up. Estimated intraoperative blood loss was lower in the TAPPu-plus group (mean 1.68 vs. 2.55 soaked gauze pieces [6 cm × 6 cm]; P < 0.01). The mean hospital stay was also shorter in the TAPPu-plus group (5.4 vs. 6.9 days, P < 0.01). No recurrences were observed in either group at 1-year follow-up.

Conclusion: Both techniques were safe and effective for laparoscopic repair of small umbilical hernias. TAPPu-plus, although more technically demanding, demonstrated superior outcomes in post-operative pain control and recovery. It represents a promising alternative to IPOM-plus in appropriately selected patients when performed by experienced surgeons.

Abstract: Brunner's gland hyperplasia (also referred to as adenoma or hamartoma) is a rare, benign proliferative lesion of the duodenum. Although often asymptomatic, it can occasionally present with gastrointestinal (GI) bleeding, anaemia or obstructive symptoms. We report a case of a 65-year-old woman who presented with melena and symptomatic anaemia. Upper GI (UGI) endoscopy revealed multiple sessile polyps in the duodenum, with the largest measuring 2 cm. Given her history of a recent myocardial infarction and ongoing antiplatelet therapy, an endoscopic approach was chosen. Endoscopic mucosal resection (EMR) was successfully performed after temporarily withholding antiplatelets. Histopathology confirmed Brunner's gland hamartoma with no dysplasia or malignancy. The patient's haemoglobin levels improved, and follow-up endoscopy at 1 and 6 months showed no recurrence. Brunner's gland hyperplasia is a rare but important differential for upper GI bleeding. EMR or endoscopic snare polypectomy is a safe and effective treatment modality, particularly in high-risk surgical candidates.

Introduction: Patients with obstructive upper gastrointestinal malignancies often suffer from severe dysphagia and cachexia, necessitating enteral feeding. While open feeding jejunostomy (OFJ) is the traditional approach, laparoscopic feeding jejunostomy (LFJ) offers a minimally invasive alternative. This study aimed to compare the safety and outcomes of LFJ versus OFJ.

Patients and methods: A prospective, randomised controlled trial was conducted at a tertiary care centre in South India from April 2022 to June 2023. Patients with obstructive upper gastrointestinal cancers were randomised to undergo LFJ or OFJ. The primary endpoint was the incidence of early major complications (Clavien-Dindo grade ≥3). The secondary endpoints included operative time, intraoperative complications, post-operative pain, time to initiate and reach full-strength jejunal feeding, hospital stay and minor complications (Clavien-Dindo grade ≤2). Patients were followed for 30 days postoperatively.

Results: Fifty-nine patients met the inclusion criteria (30 LFJ, 29 OFJ). Baseline characteristics were similar, except for a higher rate of comorbidities in the OFJ group. The incidence of major complications was not significantly different (LFJ 10% vs. OFJ 17%, P = 0.472). LFJ was associated with significantly fewer minor complications (26.6% vs. 89.6%, P < 0.001), reduced post-operative pain, earlier initiation of feeds and shorter hospital stay. Operative time was longer in the LFJ group (100.4 ± 12.5 vs. 59.2 ± 6.9 min, P < 0.001).

Conclusions: LFJ is a safe and effective alternative to OFJ, offering better post-operative recovery despite a longer operative time and is recommended in appropriate candidates.