Journal of Minimal Access Surgery最新文献

Background: Enhanced Recovery After Surgery (ERAS) programs represent a shift in perioperative care, combining evidence-based interventions to reduce surgical stress to expedite recovery. ERAS requires cohesive team efforts to facilitate early discharge and reduce hospital stays. Anaesthesia and pneumoperitoneum management within ERAS play crucial roles in influencing postoperative outcomes. Laparoscopic cholecystectomy is widely acknowledged as the foremost approach for managing symptomatic gallstone disease due to its minimally invasive nature and favourable recovery. It has been demonstrated that increased abdominal pressures with prolonged CO2 exposure produce changes in cardio-vascular and pulmonary dynamics, which can be minimized by insufflating at minimum pressure required for adequate exposure, as advocated by European endoscopic guidelines. Dexmedetomidine, a highly selective alpha-2 adrenoreceptor agonist, has gained attention in anaesthesia armamentarium due to its sedative, analgesic, sympatholytic, and opioid-sparing properties. For multimodal opioid sparing postoperative pain management it's advantageous.

Aim: To evaluate combined effect of low-pressure pneumoperitoneum and intra-operative dexmedetomidine infusion in laparoscopic cholecystectomy for ERAS.

Patients and methods: 160 patients of American Society of Anaesthesiologists (ASA) score 1 and 2, undergoing elective laparoscopic cholecystectomy were randomized into low pressure pneumoperitoneum (10-12 mmHg) and standard pressure pneumoperitoneum (13-15 mmHg) groups. Each group is subdivided into, no Dexmedetomidine (ND) and with Dexmedetomidine (WD) infusion (0.7 mcg/kg/hr) intra-operatively. Thus, 40 patients in each of the 4 study arms. Perioperative variables were collected and analysed.

Results and conclusions: Low pressure pneumoperitoneum with intra-operative Dexmedetomidine infusion (0.7 mcg/kg/hr) resulted in stable hemodynamics, reduced post-operative pain, no requirement of additional analgesics and early discharge. Thus, synergistic impact of these interventions significantly improved postoperative outcomes when used as part of ERAS protocols.

Introduction: The 'surgically performed' continuous superficial serratus anterior plane block (continuous s-SAPB) was never described before in uniportal video-assisted thoracic surgery (uniportal VATS) surgery. The aim of the study was to evaluate the safety and efficacy of the technique.

Patients and methods: Between March 2022 and April 2023, 50 patients, undergone uniportal VATS surgery at our thoracic surgery department, were scheduled for a surgically performed continuous s-SAPB as post-operative analgesia protocol.

Results: The mean execution time for the block was 3.92 ± 2.56 min. Ten patients (20%) required morphine for a visual analogue scale (VAS) score >4 immediately after surgery. The recorded VAS score at chest tube removal was 1.87 ± 1.41, whereas 2 h after the manoeuvre was 0.42 ± 0.72. No complication related to block insertion was recorded. The onset of chronic pain was observed in a total of 2 patients (4%).

Conclusions: The surgically performed continuous s-SAPB in uniportal VATS seems to be safe and easy to perform, and it provides a satisfactory analgesic effect.

Abstract: The umbilical pilonidal sinus (UPS) is a rare clinical entity and is not easily diagnosed unless there is a high suspicion. Pilonidal sinuses are most frequently seen around the gluteal cleft, but occasionally can be observed on other areas of the body, including the breast, webs of fingers, axilla and umbilicus. UPS is one of the rarest subtypes. Risk factors for UPS are similar to those for gluteal cleft pilonidal cysts and include young age, male gender, obesity, hairy body and poor personal hygiene. The traditional approach of treatment is usually conservative or surgical excision of the sinus with or without umbilectomy through the open technique. We discuss a case of UPS in an adult male having a concurrent urachal cyst with the urachal tract. We report our experience in laparoscopic management of this case after the failure of a conservative approach, with favourable outcomes at 1-year follow-up.

Abstract: Morbid obesity in infancy or early childhood is a challenging disease to manage. Here, we present the case report of the successful management of a 2-year-old girl child with morbidly obesity who was bedridden and had sleep apnoea and underwent laparoscopic sleeve gastrectomy. Bariatric surgery in this age group comes with a lot of decision-making challenges and technical and ethical considerations, and literature is scant on paediatric bariatric surgery. We describe the case and associated challenges in detail in this report.

Background: Robot-assisted surgeries are increasingly used for the treatment of benign gynaecological conditions. However, their impact in cases of significantly enlarged uteruses remains uncertain. This study aims to investigate whether the weight of the uterus influences the surgical results of robotic hysterectomy.

Patients and methods: Ambispective analysis of 306 cases was performed, of which 265 cases were analysed retrospectively. The outcome measures included total operative time, including docking time, console time and vault closure time, complication rates and quality of life (World Health Organization Quality of Life Brief questionnaire) stratified based on uterine sizes into three groups by every 250 g.

Results: Of the 306 cases, 76.47% of cases (n = 234) had uterine weight <250 g, 18.30% of cases (n = 56) had uterine weight between 250 and 500 g, while 5.23% of cases (n = 16) had a weight of uterine specimen >500 g. The total operative time was significantly lower in the <250 g group compared to >500 g (81.92 ± 22.81 vs. 111.88 ± 40.27 min; P = 0.003), contributed primarily by the console time. Although the need for post-operative blood transfusion was higher in the >500 g group, the overall complication rate between the three groups was similar. The three groups had comparable QOL through all four domains.

Conclusion: The present study underscores the influence of uterine weight on robotic hysterectomy outcomes, revealing increased operative times and post-operative haemoglobin drop for uteri over 500 g. Despite these challenges, complications were not significantly affected by uterine size.

Abstract: The use of robotic surgery has increased worldwide and has the potential to amplify the surgeon's skill owing to its versatile functions. However, robotic surgery requires specific skills that differ from laparoscopic surgery, and the field of robotic surgery training systems is underdeveloped. Therefore, to ensure patient safety, a task protocol should be prepared before the introduction of novel robotic surgeries. This article provides the pioneering description of performing robotic sleeve gastrectomy (RSG) through the medial-to-lateral approach, utilising our newly revised protocol. The preliminary clinical results of 10 patients who underwent RSG using the stapling-first technique between June 2021 and March 2023 showed that RSG is safe and feasible and that the implementation of a task protocol is an effective strategy for the safe introduction of a novel robotic surgical technique.

Introduction: Intra-peritoneal onlay mesh repair (IPOM) still remains the most common approach for laparoscopic repair of small to medium sized hernias worldwide. In this study, we compare our early outcomes of an established procedure, i.e. laparoscopic IPOM plus to robotic transabdominal pre-peritoneal (rTAPP) for small to medium sized primary ventral hernia. To compare laparoscopic IPOM plus with rTAPP in terms of pain score, time to ambulate, hospital stay, time to return to work as well as the expenses.

Patients and methods: This is a retrospective analysis of prospectively collected data at our centre between July 2021 and June 2022. Operative time including docking time was recorded. Cost analysis was done in both set of patients. Pain scores were assessed using Visual Analogue Scale (VAS) at regular intervals for up to 3 months and then at the end of 1 year. Time to ambulate, return of bowel function and return to work were documented. Any complication or recurrence during the study period was recorded.

Results: Mean operative time for IPOM plus and rTAPP groups was 59.00 and 73.55 min, respectively. Mean pain score for IPOM at 6, 12 and 24 h was 7.35, 6.81 and 5.77, while for rTAPP, it was 4.73, 3 and 2.55, respectively. VAS scores at 1 week, 1 month and 3 month also showed similar trends. Mean time to ambulate in minutes for IPOM and rTAPP group was 357.69 and 223.64, respectively. Mean hospital stay in days for IPOM and rTAPP was 2.12 and 1.18, respectively. Mean time to return to work in days was 11.77 and 8.45 for IPOM and rTAPP groups, respectively. Expenditure wise, cost of TAPP was more and statistically significant, owing to the use of robotic platform. The mean overall cost of laparoscopic IPOM plus and rTAPP in rupees was 187,177.69 and 245,174.55, respectively.

Conclusion: Robotic TAPP appears an excellent alternative to laparoscopic IPOM plus. Larger studies with long-term follow-up data are further required to reinforce it.

Abstract: Spontaneous diaphragmatic hernias (DHs) are uncommon, yet potentially hazardous. To prevent consequences, timely diagnosis and treatment are necessary. A 54-year-old male presented to the emergency room with dyspnoea, cough and tachycardia; he had no history of trauma. Diagnostic imaging revealed a substantial left DH, indicating the need for surgical intervention. The intraoperative examination identified a transverse colon and omentum herniation. Dissection, reduction of the contents, primary sutures of the defect and dual mesh reinforcement accomplished the laparoscopic and thoracoscopic DH repair. This case underscores the importance of timely detection, precise surgical intervention and comprehensive post-operative monitoring when utilising a multidisciplinary approach to manage DHs. It serves as a reminder to exercise caution regarding DHs, particularly in circumstances devoid of traumatic aetiology and the benefits of combined laparoscopic and thoracoscopic approaches.

Introduction: Laparoscopic cholecystectomy (LC) is the gold-standard treatment for symptomatic cholelithiasis. To prevent bile duct injuries, various practices are recommended, one of which is the identification of Rouviere's sulcus (RS) and starting dissection above its level. So far, no uniform anatomical description of RS is available in the literature. After prospective observation of 302 patients, we have proposed a new classification based solely on gross morphology. The purpose of this study is to make surgeons well acquainted with its different anatomical variations and its significance for the prevention of complications.

Patients and methods: We performed a prospective analysis of 302 patients during LC, and various morphological variants of RS and its relationship with hepatobiliary anatomy were recorded. We have used the nomenclature as described by previous authors and added a few.

Results: A total of 330 patients were included in our study. We could not visualise the sulcus due to dense adhesion in 28 patients. RS was absent in 24.1% of cases and was present in various forms in 75.8% of cases. Amongst these, the open type was found in 28.8% of cases, fused type was found in 4.8% of cases, groove type was found in 24.8% of cases, pit type was found in 8.2% of cases, close type was found in 14.4% of cases, slit type was found in 8.7% of cases and scar type was found in 10% of cases. Using RS as a landmark, we could perform surgery safely in all cases.

Conclusion: The RS can be described as closed, slit, open, fused, groove, pit or scar type.

Abstract: A Spigelian hernia is an uncommon, atypical protrusion of the peritoneum or abdominal contents via a defect (Spigelian fascia), consisting of the internal oblique aponeuroses and the transversus abdominis. With a frequency ranging from 0.12% to 2% of all abdominal wall hernias, Spigelian hernias are extremely rare. It usually arises from a condition that increases intra-abdominal pressure, the degeneration of the abdominal aponeurotic layers or trauma to the abdominal wall. Herein, we present a case series of patients with varying presentations of Spigelian hernia who presented, who were promptly diagnosed and who were managed successfully with laparoscopic surgical repair.