Journal of Minimal Access Surgery最新文献

Abstract: Laparoscopic transabdominal pre-peritoneal (TAPP) inguinal hernia repair in patients with post-appendectomy scarring presents unique technical challenges due to adhesions, fibrosis and altered anatomy. Conventional surgical approaches require adaptation to mitigate risks such as bowel or bladder injury. Initiating dissection in unaffected medial peritoneal areas before progressing laterally allows for safer navigation. Precise, sharp dissection, complemented by controlled energy device utilisation, is essential for separating fibrotic peritoneum from underlying structures while preserving anatomical integrity. Avoiding dissection below the scar level optimises mesh placement and prevents compromise on repair. Pre-operative computed tomography imaging aids in assessing the severity of adhesion and helps in individualised surgical planning. Surgeon expertise is paramount in modifying techniques to accommodate complex anatomical variations. Literature underscores the heightened intraoperative risks associated with prior abdominal surgery, reinforcing the necessity for meticulous planning and skilful execution. With appropriate technique modifications, TAPP remains a viable and effective approach in patients with post-appendectomy scarring, ensuring safe and durable repair.

Introduction: The use of extraperitoneal mesh over intraperitoneal mesh is gaining popularity in minimally invasive ventral hernia repair. We adopted a laparoscopic lateral approach with retromuscular mesh placement by opening the posterior rectus fascia on the ipsilateral side of trocar insertion. This study aims to evaluate operative times and early outcomes of this laparoscopic alternative to a conventionally robotic procedure for ventral hernia repair.

Patients and methods: This single-centre retrospective study included 23 patients treated between 2022 and 2025. Data were reviewed from a retrospectively maintained database of patients undergoing laparoscopic transabdominal retromuscular umbilical prosthetic hernia repair (L-TARUP).

Results: Both operative time and hospital stay were reduced compared to the conventional approach. No intraoperative or major post-operative complications were observed. Two cases of seroma were identified during the first 4 weeks of follow-up. No hernia recurrences or wound infections were reported.

Conclusion: Our preliminary results suggest that laparoscopic transabdominal prosthetic retromuscular ventral hernia repair (L-TARUP) is a safe and effective technique, with favourable operative times for ventral hernia management.

Abstract: Displacement of screw following acetabular fracture is rare and causes significant complications resulting in pain, functional impairment, neurovascular compromise, infection and intrapelvic migration requiring additional surgical intervention. This case describes the successful laparoscopic retrieval of a displaced 40 mm × 4.5 mm cortical screw from the psoas muscle who underwent open reduction and internal fixation for a complex acetabular fracture. A 54-year-old male patient was referred from the orthopaedic department with persistent left lower abdominal pain radiating to the lower limb after open reduction and internal fixation. Computed tomography revealed screw migration into retroperitoneum abutting external iliac artery (EIA). Laparoscopy confirmed the screw's retroperitoneal position and was abutting EIA posterior to it, embedded in psoas muscle and was removed through 10 mm port without any visceral or vascular injury. The patient had uneventful recovery. Intrapelvic migration of screw after hip screw fixation has been reported at 4.8%, rising to 6.2%. It poses dangerous complications if vascular structures are involved like in our case as abutting EIA. Open surgical approaches were used for screw retrieval. Few cases have been reported where diagnostic laparoscopy was used, and successful laparoscopic removal of a migrated screw was performed from pelvis. This case highlights the efficacy of laparoscopy over open approaches for retrieving displaced screw in anatomically challenging locations. Laparoscopy can be considered in cases of implant migration for safe and effective retrieval while avoiding the risks of extensive dissection. With expertise and adequate equipment, it reduces operative morbidity, shorter recovery and provides better visualisation of retroperitoneal structures.

Abstract: Spigelian hernia (SH) is a rare lateral abdominal wall defect that poses diagnostic and technical challenges, especially in large cases. Conventional laparoscopic approaches, such as intra peritoneal onlay meshplasty, total extra peritoneal and standard transabdominal preperitoneal (TAPP), may fall short in achieving ideal closure and mesh placement. We report two female patients presented with left flank swelling and intermittent pain. Imaging confirmed SHs measuring 4-5 cm. Both patients underwent laparoscopic repair using a modified TAPP plus technique. This approach combines transfascial sutures with intracorporeal reinforcement, enabling tension-free closure and optimal mesh fixation while preserving neurovascular structures. Both patients recovered uneventfully, were discharged on post-operative day 1, reported minimal pain and returned to normal activities within 10 days. At 8-month follow-up, no complications or recurrences were observed. The modified TAPP plus technique represents a novel and feasible technique for SH repair, ensuring tension-free closure, secure mesh fixation and early recovery.

Abstract: Morgagni hernia is a rare congenital diaphragmatic defect, often asymptomatic and incidentally discovered. Its co-occurrence with gallstone disease is exceedingly rare. We present the case of an 84-year-old female, planned for laparoscopic cholecystectomy, with an incidental diagnosis of a 3 cm × 2 cm Morgagni hernia during laparoscopy. She underwent simultaneous primary repair of the hernia along with laparoscopic cholecystectomy. Post-operative recovery was uneventful, and the patient remains asymptomatic at 6-month follow-up. This case highlights the rare co-existence of gallstone disease and Morgagni hernia. Existing literature reports few such cases, and simultaneous laparoscopic management remains infrequent. This case also emphasises the benefit of laparoscopy, offering both diagnostic clarity and therapeutic benefit in managing concurrent intra-abdominal pathologies.

Introduction: Acute obstructive suppurative cholangitis (AOSC) is a life-threatening biliary tract infection requiring urgent intervention. With the advancement of endoscopic techniques, endoscopic retrograde cholangiopancreatography (ERCP) has become a preferred alternative to traditional surgery. This study aimed to compare the clinical efficacy and safety of ERCP with laparoscopic common bile duct exploration (LCBDE) in patients with AOSC.

Patients and methods: This retrospective study included 174 patients diagnosed with AOSC at Shangrao Municipal Hospital between December 2021 and December 2024. Participants were retrospectively assigned to two exposure groups based on treatment received: ERCP group ( n = 70) and LCBDE group ( n = 104). No matching was performed. Clinical outcomes, including intraoperative parameters, post-operative recovery, complications and treatment efficacy within 30 days, were analysed. Logistic regression was used to identify independent predictors of treatment success.

Results: Compared to the laparoscopic group, the ERCP group showed markedly reduced intraoperative blood loss and shorter operation time ( P < 0.001). On post-operative day 7, the ERCP group had lower white blood cell (WBC) counts and serum aspartate aminotransferase levels ( P < 0.05). The overall complication rate (17.14% vs. 35.58%, P = 0.008) was lower, and the treatment efficacy rate (85.71% vs. 66.35%, P = 0.004) was higher in the ERCP group. Multivariate analysis identified ERCP, higher pre-operative alanine aminotransferase and lower post-operative WBC as independent predictors of successful treatment.

Conclusion: ERCP is a safe and effective minimally invasive treatment for AOSC, offering advantages in recovery and complication reduction. It is especially suitable for elderly and high-risk patients.

Introduction: Laparoscopic cholecystectomy is associated with significant post-operative pain, often hindering same-day discharge. Multimodal analgesia (MMA) combining non-opioid agents is advocated to address this challenge, yet standardised protocols remain elusive. This trial evaluates the efficacy of a structured MMA regimen versus standard care (SOC) in reducing pain, opioid use and surgical stress.

Patients and methods: This randomised controlled trial enrolled 121 patients undergoing laparoscopic cholecystectomy, assigning 60 to standard care and 61 to MMA. The MMA group received intraoperative 0.5% ropivacaine at incision sites, gall bladder fossa and subdiaphragmatic region. The primary outcome was 24-h post-operative pain intensity, measured using the Visual Analogue Scale (VAS). The secondary outcomes included rescue analgesia requirements, inflammatory markers such as C-reactive protein (CRP), cortisol, interleukin-6 (IL-6) and tumour necrosis factor-alpha (TNF-α). Intention-to-treat and per-protocol analyses were conducted using the Mann-Whitney U -test, the Chi-square test and linear mixed-effects models.

Results: MMA significantly reduced median VAS scores by 40% at 3 h (5 [Interquartile range: 4-8] vs. 9 [8-10], P < 0.001, effect size r = 0.61) and 20% at 24 h (3 [1-4] vs. 5 [4-6], P < 0.001, r = 0.49). Rescue analgesia use was 63% lower in the MMA group (67.2% vs. 85%, odds ratio = 0.37, P = 0.02). Inflammatory markers - CRP and cortisol were significantly reduced in the MMA group, while IL-6 and TNF-α showed no differences at the 24 h post-operative period.

Conclusion: The MMA regimen effectively reduces post-operative pain, opioid reliance and surgical stress in laparoscopic cholecystectomy, aligning with enhanced recovery protocols. The attenuation of CRP and cortisol highlights MMA's anti-inflammatory benefits.

Introduction: Laparoscopic Heller myotomy (LHM) is the preferred treatment approach to reducing lower oesophageal sphincter pressure (LOSP). However, less than half of the patients show high LOSP. This study primarily aims to evaluate how LOSP affects operative results.

Patients and methods: From 2019 to 2023, a total of 52 patients were treated with LHM combined with partial fundoplication, diagnosed by integrated relaxing pressure (IRP) >15 mmHg on high-resolution manometry (HRM). Based on HRM, patients were assigned into two arms: normal LOSP (≤35 mmHg, n = 30) and high LOSP (>35 mmHg, n = 22). Symptoms were assessed preoperatively, and the median duration of follow-up of 24 months using the Eckardt score (ES), the achalasia-specific quality of life (ASQ) score and the SF-36 questionnaire quality of Life (QOL). Treatment failure was defined as ES ≥4 or an ASQ score ≥16.

Results: Pre-operative Eckardt and ASQ scores were similar between groups. The high LOSP group had significantly younger populations (≤50 years: 90.90% vs. 60%, P = 0.013). The normal LOSP group had significantly less dysphagia ( P = 0.007) and regurgitation ( P = 0.011), reflecting significantly lower post-operative ES (0.80 vs. 2.00, P = 0.002). In addition, post-operative ASQ scores (11 vs. 14, P = 0.005) and QOL were significantly better in the normal LOSP group. The high LOSP group experienced a significantly greater failure rate (31.80% vs. 6.7%, P = 0.027).

Conclusion: Normal LOSP results in better surgical outcomes and QOL, as younger patients with high LOSP have poorer responses, due to higher LOS muscle tone.

Abstract: Simultaneous occurrence of colonic adenocarcinoma and appendiceal lymphoma in a patient with chronic lymphocytic leukaemia (CLL) is exceedingly rare. This unique coexistence presents diagnostic and therapeutic challenges, particularly in elderly patients with comorbidities. We report an unusual case of caecal adenocarcinoma and diffuse large B-cell lymphoma (DLBCL) of the appendix in a patient with known CLL. An 87-year-old male with a known diagnosis of CLL presented with a suspected caecal mass on imaging. Colonoscopy revealed a polypoidal caecal lesion, and biopsy confirmed adenocarcinoma. He underwent laparoscopic right hemicolectomy. Histopathology revealed moderately differentiated adenocarcinoma (pT3N0M0) and synchronous DLBCL in the appendix and mesenteric nodes, consistent with Richter's transformation. The patient was restarted on ibrutinib postoperatively. At 1.5 years, he developed an anastomotic recurrence managed with laparoscopic re-resection. He remains disease-free 3 years post-index surgery under multidisciplinary follow-up. This case highlights the importance of considering dual pathology in CLL patients presenting with gastrointestinal symptoms. Curative surgical resection, combined with targeted haematological therapy and regular surveillance, can result in favourable outcomes even in elderly patients with complex malignancies.

Introduction: Neoadjuvant chemoimmunotherapy has emerged as a promising strategy in the multimodal treatment of locally advanced non-small cell lung cancer (NSCLC). However, concerns remain regarding its impact on surgical complexity and the feasibility of video-assisted thoracic surgery (VATS) in this setting.

Patients and methods: Between April 2021 and August 2024, 17 patients who received neoadjuvant chemoimmunotherapy (PD-1 inhibitor plus chemotherapy) underwent lung resection. A significant proportion of cases (58.8%) were managed through VATS (primarily biportal approach), with no conversions to open surgery. The remaining patients underwent thoracotomy or Dartavelle incision due to anatomical complexity.

Results: The mean operative time was 135 ± 25 min for VATS and 172.9 ± 30 min for open surgery ( P = 0.068). While hospital stay was similar between VATS (5.9 days) and open surgery (6.4 days) ( P = 0.449), ıntensive care unit stay was significantly shorter in the VATS group (0.5 vs. 1.3 days, P = 0.007). Significant tumour downstaging was observed in 88.2% of patients, with four achieving complete pathological response and three demonstrating a major pathological response ( P < 0.05). Post-operative complications were observed in 41.2% of patients, but no 90-day mortality occurred.

Conclusion: VATS appears to be a feasible and safe approach for selected NSCLC patients after neoadjuvant chemoimmunotherapy, demonstrating favourable short-term outcomes. These findings contribute to the growing evidence supporting minimally invasive surgery as a viable option in complex, locally advanced cases following immunotherapy.