Journal of Minimal Access Surgery最新文献

Introduction: Stump cholecystitis is managed by performing a completion cholecystectomy, which can be done either laparoscopically or by an open method. The use of indocyanine green (ICG) is known to improve the identification of the biliary tree anatomy, facilitating Calot's triangle dissection and shortening surgery, thereby reducing the risk of bile duct injuries and making laparoscopic cholecystectomy safer.

Patients and methods: A retrospective analysis was performed of prospectively collected data from 15 patients at our institution from March 2016 to March 2021. Magnetic resonance cholangiopancreatography was performed in all 15 cases, showing remnant gall bladder in all cases with calculi within. Four cases had a dilated common bile duct (CBD) with CBD calculi. Endoscopic retrograde cholangiopancreatography (ERCP) and stone removal followed by CBD stenting were performed in the four patients with CBD calculi. These four cases were scheduled for surgery 4 weeks post-ERCP. All 15 patients underwent laparoscopic completion cholecystectomy. The mean operating time was 80 min.

Results: The post-operative period of all cases was uneventful, and the patients were discharged on post-operative day 2 or day 3. All patients remained asymptomatic during 1-5 years of follow-up.

Conclusion: Laparoscopic completion cholecystectomy was performed safely in cases of stump cholecystitis and resulted in symptom relief during short-term follow-up. The use of ICG and near-infrared imaging in such cases helps identify the biliary anatomy, may contribute to the safety of laparoscopic completion cholecystectomy and might reduce the duration of surgery.

Introduction: Chyle leak is a serious complication following oesophagectomy with incidence varies from 1% to 9%. Near infra-red fluorescence imaging of thoracic duct (TD) can provide real-time dynamic imaging during the surgery. In this study, we intend to compare indocyanine green (ICG) dye instillation through inguinal node with subcutaneous first web space instillation for visualisation of TD during robotic-assisted minimally invasive oesophagectomy (RAMIE) procedure.

Patients and methods: A prospective study of 50 patients underwent RAMIE with da Vinci X System. After general anaesthesia, patients were divided into inguinal node and foot first web space ICG instillation group. The former group had 1 ml of ICG dye instilled on bilateral inguinal nodes under ultrasound guidance and while the other group received 1 mL of ICG dye injected at bilateral foot first web space and then underwent surgery. TD was visualised using ICG FireFly™ fluorescence technology, first at the time of docking and subsequently for every 5 min until 60 min of instillation time and analysed.

Results: Twenty-five patients were enrolled in each group. The mean docking time for thoracic phase was 13.76 ± 3.43 min. TD was visualised in 72% (18/25) of cases of first web space instillation group, whereas 100% in ultrasound guidance inguinal node instillation group. None of the patients had a chyle leak.

Conclusion: ICG FireFly™ fluorescence technology for the identification of TD during oesophageal mobilisation is safe and effective and provides real-time dynamic visualisation with high accuracy in ultrasound-guided bilateral inguinal node instillation group. It is an effective method for the surgeons planning to negotiate their initial learning curve in RAMIE procedures.

Introduction: To explore the surgical effect and gastrointestinal functional recovery of laparoscopic-guided total mesorectal excision (LGTME) in patients with rectal cancer.

Patients and methods: A total of 150 rectal cancer patients who underwent surgical treatment in our hospital from July 2022 to July 2023 were selected and randomly divided into two groups using a random number table. There were 75 cases in the control group (CG) who underwent traditional open rectal total mesorectal excision surgery and 75 cases in the experimental group (EG) who underwent LGTME. The surgical effects of the two groups were compared, and the gastrointestinal and anal functional recovery of the two groups were compared before and after treatment.

Results: Intraoperative bleeding, incision length, time to initial feeding and time to anal exhaust in the EG were significantly lower than those in the CG ( P < 0.05). Before treatment, there was no significant difference in gastrointestinal function and anal function between the two groups ( P > 0.05). After treatment, the levels of motilin, gastrin, neuropeptide Y and basic fibroblast growth factor in the EG were significantly higher than those in the CG, with statistical significance ( P < 0.05); the maximum anal systolic pressure and resting anal sphincter pressure in the EG were significantly lower than those in the CG ( P < 0.05); the rectal sensitivity threshold volume (RSTV) and rectal maximum volume threshold in the EG were significantly higher than those in the CG ( P < 0.05). There was no significant difference in most postoperative complications between the two groups ( P > 0.05).

Conclusion: LGTME improves the surgical effects of rectal cancer patients, promotes the recovery of gastrointestinal function and has a small effect on anal function indicators, thereby reducing hospital stay.

Introduction: Intraperitoneal instillation of local anaesthetic agents alone or in combination with opioids, α2 agonists such as Dexmedetomidine have been found to reduce postoperative pain following laparoscopic cholecystectomy. The study was designed to compare the better drug among Bupivacaine alone and Bupivacaine with Dexmedetomidine with respect to their analgesic efficacy and safety profile. in patients undergoing laparoscopic cholecystectomy.

Patients and methods: The study was carried out on sixty patients of the American Society of Anaesthesiologists (ASA) physical status I-II of either sex with ages ranging from 18 to 60 years posted for elective laparoscopic cholecystectomy under General Anaesthesia, equally divided into two groups, randomly allocated to one of the Groups using the table of randomization. Group B received Intraperitoneal Bupivacaine 40 ml 0.25% +5 ml normal saline and Group BD received Intraperitoneal Bupivacaine 40 ml 0.25% + Dexmedetomidine1 μg/kg diluted in 5 ml Normal saline.

Results: The mean heart rate and blood pressure (systolic, diastolic and mean) readings were significantly lower in Group BD than in Group B. The mean duration of analgesia in our study was longer in Group BD (7.5 ± 0.73 hours) when compared to Group B (5.9 ± 0.55 hours) with p-value & 0.0001 and CI 1.27 to 1.9, which was statistically significant. However, the post-operative analgesic requirement (rescue/demand) in Group B was clinically earlier and statistically significant as compared to Group BD. Postoperative VAS score ≥3 was considered the benchmark for providing rescue analgesia in the form of injection of Diclofenac 75 mg IV. In our study, we observed the pain scores via VAS/NRS at 30 min, 1 h, 2 h, 4 h, 6 h, 8 h, 10 h, 12 h, 14 h, 16 h, 18 h, 20 h, 22 h and 24 h postoperatively. A comparison of pain scores from 30 min to 10hrs postoperatively showed a significant difference in both Groups with Group B having significantly higher VAS scores and lower VAS scores with Group BD.

Conclusions: Our study suggests that there is a shorter duration of action of 0.25% Bupivacaine alone as compared to 0.25% Bupivacaine + Dexmedetomidine. Since the laparoscope is still inside the abdominal cavity the drugs are easy to administer with no adverse effects and with a good safety profile because of the visualization of drug deposition in the right place. Intraperitoneal instillation of Bupivacaine with Dexmedetomidine for postoperative analgesia was very promising as a part of multimodal analgesia in laparoscopic cholecystectomy.

Background: The rapid development of less invasive and traumatic medical procedures has resulted in a mixture of terms used to describe them, without any agreed definition for each. This is confusing to both medical professionals and patients and can lead to unrealistic patient expectations. The aim of this article is to show the current confused nomenclature and to suggest a new, simple classification based on access and invasiveness (AI) that can be applied to any medical procedure.

Methods: We performed an online search for definitions for 'non-invasive', 'non-surgical', 'minimally invasive', 'minimal access', 'pinhole' and 'keyhole'. We then searched peer-reviewed medical papers (PRMPs) and patient facing websites (PFWs) for the following index procedures, to see which of the original 6 terms were used to describe them: transvaginal ultrasound, sclerotherapy for leg veins, botulinum toxin injections, dermal fillers, endovenous thermal ablation and laparoscopic gall bladder removal.

Results: We found a wide variety of definitions for each of the initial terms. In both PRMPs and PFWs, there were a variety of terms used for each index procedure (i.e.: transvaginal ultrasound, injections of sclerotherapy, botulinum toxin or dermal fillers being both 'non-invasive' and 'minimally invasive') showing confusion in the classification of procedures. We suggested the 'AI classification' based on access (A - none, B - natural orifice or C - penetrating an epithelial surface) and invasiveness (1 - none, 2 - surface damage, 3 - needle = <21G, 4 - cannula >21G but not a surgical trocar, 5 - surgical trocars or small incisions and 6 - incisions).

Conclusion: The current confusion of terms used for procedures that are less invasive than the open surgical alternatives leads to confusion and possible false patient expectations. We have proposed an AI classification that can be applied easily to any procedure, giving a uniform classification for medical professionals and patients to understand.

Introduction: Minimally invasive surgery (MIS) for limited resections for pancreatic uncinate lesions is not widely performed but can adequately treat benign or low-grade malignant lesions. The aim of this study was to evaluate the short-term outcomes of MIS-limited pancreatic resections for patients with suspected pancreatic neuroendocrine tumours (PNETs).

Patients and methods: This was a retrospective study of six consecutive patients who underwent MIS for PNET within a single institution between 2017 and 2022.

Results: Six patients underwent limited pancreas-preserving MIS of the uncinate process (uncinectomy or enucleation), of which two were performed through the robotic approach and four through laparoscopic approach. The median operation time was 212.5 (175-338.75) min, and the median blood loss was 50 (50-112.5) ml. The median post-operative hospital length of stay was 5.5 (3.75-11.5) days. Two patients (33.3%) had major post-operative morbidities (Clavien-Dindo ≥Grade 3). There were no open conversions or post-operative mortalities. Five patients had histologically proven Grade 1 neuroendocrine tumours. One was T2 and four were T1.

Conclusions: This study suggests that limited MIS resections of pancreatic uncinate PNETs are a feasible procedure with good patient outcomes. It offers a safe alternative to radical surgical resections like pancreatoduodenectomies in selected patients with low-grade malignant or benign tumours.

Introduction: In immunotherapy, antibodies are activated to block immune checkpoints, resist tumour immunosuppression, shrink tumours and prevent a recurrence. As the science behind tumour immunotherapy continuously develops and improves, neoadjuvant immunotherapy bears more prominent advantages: antigen exposure not only enhances the degree of tumour-specific T-cell response but also prolongs the duration of actions. In this study, we evaluated the efficacy and safety of McKeown minimally invasive oesophagectomy (McKeown MIO) following neoadjuvant immunotherapy combined with chemotherapy (NICT) in patients with locally advanced oesophageal cancer (OC).

Patients and methods: In this retrospective study, 94 patients underwent either NICT or neoadjuvant chemotherapy (NCT) followed by MIO at our institution from January 2020 to October 2022. We assessed the therapy-related adverse events and perioperative outcomes and compared them between the two groups.

Results: After completing at least two cycles of neoadjuvant therapy, all patients underwent McKeown MIO with negative margins within 4-7 weeks. Demographic data of the two cohorts were similar. Regarding perioperative characteristics, the median intraoperative blood loss was 50 ml in the NICT group, lower than that of the NCT group (100 ml, P < 0.05). In addition, the NICT group had significantly more harvested lymph nodes than the NCT group ( P < 0.05). No significant differences were found in post-operative complications. The rate of objective response rate in the NICT group was higher than that in the NCT group (88.3% vs. 58.8%). Regarding tumour regression, the number of patients with TRG Grades 1-3 in the NICT group was more than that in the NCT. Adverse events experienced by the two groups included anaemia and elevated transaminase. We found no difference in the adverse events between the two groups.

Conclusions: This study showed the efficacy and feasibility of NICT followed by McKeown MIO in treating locally advanced OC.

Abstract: Natural orifice scarless cosmetic surgeries are becoming a reality with increasing experience of advanced laparoscopic surgeries and availability of modern energy sources. Many techniques of minimally invasive video-assisted thyroidectomy through cervical and extra-cervical routes such as chest wall, trans-axillary, sub-mental, post-auricular and trans-luminal approach have been attempted. However, trans-oral trans-vestibular endoscopic thyroidectomy with its excellent cosmetic effect has become the more popular option among the surgical community with advantages such as decreased hospital stay and minimal complications. In this case report, we describe natural orifice trans-oral, trans-vestibular endoscopic thyroidectomy approach (NO-TOTVET) and add to literature the technique in which NO-TOTVET can be utilised, thus adding to the repertoire of the operating surgeon.

Abstract: For most primary substernal goitre (SG) surgeries, sternotomy is required because the blood supply vessels of tumours come from the mediastinum. However, sternal dehiscence may lead to several surgical complications. We reported an older patient who underwent simultaneous removal of a primary SG and parathyroid adenoma through a gasless transoral endoscopic approach. The patient recovered well with no hoarseness, post-operative bleeding or other complications after the operation. To the best of our knowledge, this is the first reported case of gasless transoral endoscopic parathyroid adenoma and primary SG resection in the real world. We found that gasless transoral endoscopic surgery is feasible in patients with small primary SG and parathyroid adenoma.

Background: Totally extraperitoneal (TEP) repair involves creating a preperitoneal space. The preperitoneal space can be created by balloon or telescopic dissection (TD). Nevertheless, these techniques may have some complications. However, there are very few studies that compare these two techniques. This study aims to assess the impact and comprehensively compare the TD and balloon dissection (BD) methods in patients undergoing laparoscopic TEP inguinal hernia repair.

Patients and methods: This was a single-centre, double-blinded, prospective, randomised, controlled trial comparing BD and TD for the creation of the preperitoneal space. The primary end point was to compare the post-operative pain score, intraoperative complications and surgical site occurrence between the two groups. The secondary end point was to assess the impact of the dissection technique on operative time for the creation of extraperitoneal space during laparoscopic TEP inguinal hernia repair.

Results: A total of 46 patients were included in the study (23 in each group). Baseline parameters were comparable between the groups. The total operative time between the groups (120 min vs. 160 min; P < 0.005) was statistically significant. The incidence of the peritoneal breach was statistically less in the BD group (43% vs. 13%; P < 0.005). Other short-term and long-term complications were less in the BD group but not statistically significant.

Conclusions: BD in TEP inguinal hernia repair reduces the operative time and peritoneal breach. When compared to TD in terms of operative time, routine use of BD can be proposed. It will be beneficial in the early part of the learning curve.