Journal of Laparoendoscopic & Advanced Surgical Techniques最新文献

Objectives: We aim to assess whether severely frail patients have an increased risk of complications and worse surgical outcomes after retrograde intrarenal surgery. Methods: The data of 340 consecutive patients undergoing retrograde intrarenal surgery to treat upper tract urinary stones were analyzed retrospectively. The 5-item modified frailty index (mFI-5) was used to assess the frailty status. Using a cutoff value of score 2 in the mFI-5 score, patients were divided into two groups: patients with an mFI-5 score <2 were assigned to a non-frail (Group 1) group, and patients with an mFI-5 score ≥2 were assigned to a frail (Group 2) group. The patients' demographics, stone characteristics, operative outcomes, and complication rates were compared between the groups. The primary objective was to examine whether the surgical outcomes were much better in non-frail patients. Results: After matching confounding factors, Group 1 comprised 255 patients, and Group 2 comprised 85 patients. The baseline characteristics were similar between the groups. There were no statistically significant differences in terms of the median operation time and length of hospital stay among groups. There were no significant differences between groups for intraoperative complication rates (7.6% and 9.4%, respectively; P = .47) and postoperative complication rates (13.8% and 11.8%, respectively; P = .71), and stone-free rates (70.9% versus 72.9%, respectively; P = .73). Conclusions: Retrograde intrarenal surgery is an efficient and feasible treatment option for upper urinary tract stones in severely frail patients.

Background: Gastrointestinal (GI) perforation in the neonatal period can result from different conditions with varying degrees of severity. Optimal timing for surgery is challenging to establish and laparoscopy has been proposed as a diagnostic tool to minimize surgical delays and refine surgical indications. However, no standard animal model is universally accepted for training laparoscopic management of neonatal GI perforations. We aimed to define a small-sized animal model and (1) assess the effectiveness of laparoscopy in identifying GI perforations and (2) evaluate the viability of intracorporeal suturing, in a confined working space. Methods: In total, 30 Sprague Dawley rats underwent laparoscopy. In Part I, a random GI perforation was performed. In Part II, the perforation was identified and sutured. The surgeon of Part II remained blinded during Part I. The suture line was assessed for leaks and strictures once the rats were euthanized. Results: In Part I, 29 perforations were created: 22 in the ileum, 3 in the colon, 2 in the jejunum, 1 in the stomach, and 1 in the duodenum. In one rat, the GI tract was left intact. In Part II, all 29 perforations were identified and sutured. The average duration of Part II was 53 ± 16 minutes. During suture evaluation, a leak was observed in two cases, and a stricture in two additional cases. Conclusions: Laparoscopy was technically feasible and highly sensitive in detecting isolated GI perforation in a rat model. This model holds particular value for training laparoscopic skills in a space-limited setting. Further investigation is needed to see if a learning curve can be achieved.

Background: Video-assisted thoracoscopic surgery (VATS) is considered the treatment of choice in children with subpleural bullous lesions, in which endoscopic staplers are routinely used. Recently, a new generation of electronically powered stapling systems was developed. Our aim is to compare the use of a new 8-mm electronic endostapler with a 12-mm nonelectronic conventional device in thoracoscopic sublobar resection in children. Methods: We performed a retrospective single-center study in patients under 18 years who underwent VATS sublobar resection of subpleural bullae in our institution between January 2022 and December 2023. They were divided into two groups according to the type of endostapler used (8 mm electronic or 12 mm non-electronic). Demographic, clinical, intraoperative and postoperative outcomes were analyzed. Results: We included 8 patients (4 in each group), with a median age of 13.2 years (interquartile range [IQR]: 10.7-15.4 years), without demographic or clinical differences between them. Median surgery time was 42 minutes (IQR 35-55 minutes) in the 8-mm electronic group compared with 53 minutes (IQR 45-65 minutes) in the 12-mm group. There were no intraoperative complications and no reconversions to open surgery. Median length of drainage therapy did not show significant differences between them (3 days in both groups; P = .512). No postoperative complications were reported. Conclusion: Preliminary results of the 8-mm electronic endostapler appear to be comparable with the conventional mechanical stapler. Advantages include smaller incisions, as well as one-handed, push-button operation, which eliminates the manual firing force and possibly enables more precise resection. Further studies are still needed.

Introduction: Retroperitoneal approach for robotic partial nephrectomy (PN) has been shown to offer shorter operative times and hospital stays without differences in complication rates compared with the transperitoneal approach. The single-port (SP) system may be better suited than multiport (MP) for challenges with the retroperitoneal approach such as narrow access geometry. We evaluated if the adoption of SP PN increased the utilization of retroperitoneal approach. Methods: We retrospectively reviewed an IRB-approved multi-institutional database of all PN from 2013 to 2023. The date of the first SP PN split the cohorts before and after SP adoption. The percentage of retroperitoneal and transperitoneal approach cases overall and for SP and MP was determined before and after adoption. Joinpoint analysis assessed changes in rates of the retroperitoneal approach. Logistic regression compared patient and tumor characteristics with retroperitoneal approach PN before and after adoption of SP. Results: Overall 1959 patients were evaluated, of which 654 were performed prior versus 1305 after SP adoption. There was an increased percentage of retroperitoneal approach after adoption, with 7.3% (48/654) before compared with 24.8% (324/1305) after adoption. The percentage of the retroperitoneal approach for SP PN was 52.8% (134/254), increasing over time with 75% (24/32) of SP in 2023 performed with a retroperitoneal approach. Conclusion: The retroperitoneal approach was used more frequently than the transperitoneal approach in the SP cohort. The adoption of SP increased the incidence of the retroperitoneal approach.

Background: Morgagni hernia (MH), a rare type of congenital diaphragmatic hernia, does not have an established protocol for surgical repair. Materials and Methods: A MEDLINE search with terms related to various surgical approaches to repair MH in children was conducted. Articles comprising robotic-assisted surgery, laparoscopy, laparotomy, thoracoscopy, and thoracotomy over the last 20 years were assessed. Results: This narrative review provides an overview of MH in the pediatric population, covering the epidemiology, diagnosis, and management of this rare diaphragmatic hernia. We discuss various surgical techniques, including open and minimally invasive approaches, and compare their advantages and limitations in childhood MH repair. In addition, we address arguments for and against controversial topics such as hernia sac excision and patch reinforcement. Conclusions: Regarding MH in children, transabdominal repair is superior to transthoracic due to improved visualization of bilateral defects and easier reduction of the hernia contents. Laparoscopy has been reported as a popular approach. Single-site laparoscopy has gained attention due to better outcomes than standard three-port laparoscopy. Considering a limited number of children in the literature who underwent robotic MH repair, perioperative complications were reported to be minor.

Background: The Da Vinci single-port (SP) platform is being used more frequently in radical prostatectomy (RP). In this study we aimed to compare the complications and oncological outcomes of the Da Vinci SP platform in robotic-assisted radical prostatectomy (SP-RARP) between elderly and young age-groups and to further examine differences between young-old and old-old patients. Materials and Methods: Data from 193 patients who underwent SP-RARP between December 2018 and June 2024 were analyzed. Patients were categorized into two age-groups: young (18-64 years) and elderly (65+ years). The elderly group was further divided into young-old (65-69 years) and old-old (70+ years) subgroups. The analysis considered variables related to patient characteristics, intraoperative outcomes, complications, and postoperative oncological outcomes. Results: The median age of the patients at the time of surgery was 64 (9.5) years. The intraoperative complication rate of 1.6%, with no cases requiring conversion to open surgery. The overall incidence of postoperative adverse events was 24.4%, and the 30-day readmission rate was 11.4%. Intraoperative complications and 30-day readmission rates were similar between groups (P = .593 and P = .821, respectively), while the postoperative complication rate was significantly higher in the younger patient group (P = .012). The median length of hospital stay (LOS) was 7 (22) hours and 110 (57%) patients were discharged on the same day (SDD). LOS and SDD rates were similar between groups (P = .389 and P = .529, respectively). The 3-year and 5-year biochemical recurrence (BCR)-free survival rates were 80.5% and 75.1%, respectively. The BCR-free survival rates were similar between both young and elderly patients and between the young-old and old-old groups (P = .751, P = .765, respectively). Conclusion: SP-RARP is a feasible option for elderly patients, delivering acceptable oncological outcomes with a low incidence of postoperative complications.

Introduction: In the past, most patients with acute cholecystitis (AC) were treated conservatively. However, strong evidence from various studies has shown that laparoscopic cholecystectomy (LC) is safe and should be the primary treatment for AC. However, this may not be the case for all AC grades. This study aimed to compare two recommended approaches for grade II AC as outlined in the Tokyo guidelines TG18, focusing on early operative outcomes. Methods: We conducted a retrospective review of medical records for all patients diagnosed with grade II AC. The study compared patients who underwent early LC (group A, n = 130) with those who initially received percutaneous cholecystostomy (PC) followed by LC (group B, n = 90). Results: Both groups had similar Tokyo classification parameters. However, there were significant differences in baseline data, operative challenges, and postoperative complications. Cholecystostomy-related complications were observed in seven patients. The conversion rate for was 25% for group A and 5% for group B. The incidence of intraoperative biliary injury was 10% for group A and 2.2% for group B. In group A, 92% of patients with biliary injury and 80% of those who required conversion to open surgery had evidence of localized inflammation around the gallbladder. Conclusion: For selected patients with grade II AC and higher risks, PC placement can be beneficial in preventing life-threatening consequences. The study suggests a 2-month interval between PC and subsequent LC. Overall, performing LC after PC was found to be easier than early LC. Local inflammatory changes, including empyema, were associated with higher complication rates in the early LC group.

Background: Laparo-endoscopic hernia surgery is recommended by various international bodies. However, its uptake by general surgeon is low. We aim to assess the impact of Three Dimensional (3D) endovision system in learning laparoscopic transabdominal preperitoneal (TAPP) repair of groin hernia and transferability of skills acquired from 3D to the Two Dimensional (2D) environment. Methodology: Senior resident doctor with no previous experience in laparoscopic hernia surgery did 20 consecutive cases of TAPP repair using 3D endovision system followed by another five cases of TAPP repair using 2D endovision system. Total operating time, operating time during different phases of hernia surgery, faculty take over time, path length of needle holder, and scissors were recorded. Cumulative sum (CUSUM) and split group analysis were done to assess the learning process. Trainee's operating time was compared with that of experts' from previously published study of the same group. Data were compared between last block of five cases done using 3D system and cases done using 2D system for skill transferability. Results: CUSUM method provided inflection points of total operating time, hernia dissection and mesh placement at 9th case, and peritoneal suturing at 11th case in learning TAPP hernia. After 10th case, trainee's operating time was within the middle 50 percentage of experts operating time. Total operating time in last block of cases done under 3D vision and that of 2D endovision comparable, although peritoneal closure was significantly longer in 2D vision (P = .074, .2, .145, .001). Conclusion: Reduction on operating time appears after ninth case of TAPP hernia repair using the 3D endovision system. The skills acquired under 3D endovision system are transferable to perform the procedure under 2D endovision system, albeit incompletely. Use of 3D technology may facilitate adaptation of TAPP hernia repair by young surgeons.

Background/Objectives: Advancements in surgical stapling devices play a crucial role in improving outcomes for bariatric procedures. This study evaluates the performance and safety of a new endoscopic stapler (EnDrive® Beluga^TM) regarding perioperative results across multiple bariatric surgery types. Methods: A retrospective analysis was conducted on 112 patients who underwent bariatric procedures using the Beluga stapler at two centers in the United Arab Emirates and Kenya over a 6-month period (June-December 2023). Procedures included laparoscopic sleeve gastrectomy (LSG), laparoscopic Roux-en-Y gastric bypass (LRYGB), one anastomosis gastric bypass-mini gastric bypass (OAGB-MGB), and revisions. Perioperative outcomes, complications, and hemoglobin changes were assessed. Results: The cohort included 29 males and 83 females, with a mean age of 32.8 years and preoperative body mass index of 41.1 kg/m². Procedures performed were 88 primary LSG, 3 primary LRYGB, 12 primary OAGB-MGB, and 9 revision surgeries. No conversions, deaths, bleeding, or leaks occurred. Minor complications were observed in 4 patients. One patient required reoperation for intestinal obstruction. The mean hospital stay was 1.5 days. Hemoglobin levels showed minimal change from preoperative (12.8 g/dL) to postoperative day 1 (12.3 g/dL). Conclusions: The new Beluga endoscopic stapler demonstrated safe and effective performance across various bariatric procedures through this retrospective study, with low complication rates and minimal blood loss. Its enhanced articulation capabilities may offer advantages in specific cases. Further studies with larger groups, control groups, and longer follow-up periods are warranted to compare long-term outcomes with established stapling devices.

Background: A primary pull-through for Hirschsprung's disease (HD) requires confirmation of normal ganglionic bowel by intraoperative biopsies to determine the level of resection. Despite this, aganglionic bowel that is not fully resected (so-called "transition zone pull-throughs") is reported in 15%-19% of patients. We hypothesize that this may result from insufficient biopsies sent for intraoperative diagnosis. Methods: A new biopsy protocol has been developed in our institution for patients undergoing a laparoscopic-assisted endorectal pull-through for HD. Laparoscopic seromuscular biopsies are taken as per standard practice and are reported intraoperatively to identify the most distal site of ganglionic bowel. A 5 mm laparoscopic stapling device is used to divide the bowel at the proposed proximal resection margin and 2 cm distally. If there is any evidence of abnormality in the first doughnut, a second, more proximal doughnut is taken. Results: Between 2015 and 2020, 21 patients underwent a primary laparoscopic endorectal pull-through for HD using the doughnut biopsy protocol. Sixteen patients were male. The mean patient age at the time of surgery was 3 months (range 1-6 months), and the mean weight at the time of surgery was 6.5 kg (range 4.1-8.54 kg). In all 21 cases, initial laparoscopic biopsies were reported showing normal ganglionic bowel; in two cases (10%), the laparoscopic doughnut influenced the proximal resection margin. In both cases, aganglionic tissue was identified intraoperatively in the doughnuts, and a second, more proximal doughnut was sent. No patients had transition zone resections on final histology (mean clear margin 45.55 mm, range 11-72 mm). Conclusions: In conclusion, intraoperative frozen sections taken from doughnuts of bowel retrieved using 5 mm laparoscopic stapling devices are safe and have resulted in a 0% rate of transition zone pull-throughs while reducing the potential of spillage of enteric contents. We would recommend this protocol for all patients undergoing primary endorectal pull-throughs.