Journal of Laparoendoscopic & Advanced Surgical Techniques最新文献

Background: Colorectal surgery continues to exhibit variability in outcomes despite advancements in minimally invasive and robotic techniques. Increasing evidence suggests that this inconsistency is driven less by technical proficiency than by unstructured, experience-dependent decision-making.

Objective: This article presents a hybrid narrative review and perspective that examines the cognitive underpinnings of surgical strategy. It evaluates how cognitive augmentation-particularly through artificial intelligence (AI)-enabled decision support-can improve consistency, reproducibility, and equity in colorectal care.

Methods: We conducted a structured synthesis of literature from surgical cognition, naturalistic decision-making, and augmented intelligence. The review integrates perspectives from behavioral science, digital health, and colorectal surgery. AI-assisted dialogue (ChatGPT-4o) was used under human supervision to support hypothesis generation, narrative framing, and linguistic refinement. Approximately 30% of the article was developed using AI-generated suggestions, which were critically reviewed and edited by the authors to ensure clinical and scientific accuracy. Practical examples from elective and emergency settings illustrate clinical relevance.

Results: Experience-based heuristics and tacit knowledge, though valuable, are susceptible to bias and variability, particularly in complex scenarios. Cognitive augmentation tools demonstrate potential in improving decision-making reliability when carefully incorporated into clinical workflows. Nevertheless, their deployment encounters obstacles such as data heterogeneity, insufficient standardization, and barriers to clinician adoption. Robotic platforms provide enhanced technical execution but necessitate integration with cognitive tools to facilitate strategic reasoning.

Conclusion: Strategic consistency in colorectal surgery requires more than technological refinement; it demands a shift toward cognitively structured decision-making. Augmenting surgeon judgment through intelligent, context-aware support systems represents a critical next step toward reproducible, high-quality surgical care.

Introduction: Extragonadal germ cell tumors in pediatric patients are rare, accounting for approximately 10 to 15% of all germ cell tumors. High-risk chemotherapy followed by surgical resection represents the standard of care. Post-hepatectomy biliary complications, such as hepatic duct stenosis, constitute a relevant clinical challenge.

Case presentation: We present the case of a 10-year-old pediatric patient with a retroperitoneal and mediastinal extragonadal germ cell tumor treated with high-risk chemotherapy according to the GALOP 2017 protocol and multiple surgical procedures, including laparoscopic atypical left hepatectomy for residual disease. The patient subsequently developed stenosis of the main hepatic duct. Percutaneous biliary drainage and balloon cholangioplasty were performed, successfully restoring biliary patency and normalizing liver function tests, without immediate complications.

Discussion: Post-hepatectomy biliary complications in pediatric patients, although uncommon, may be related to mechanical trauma or metallic clip placement. Percutaneous management is effective and safe, allowing avoidance of open reintervention. Multidisciplinary planning is essential to optimize outcomes in high-risk pediatric germ cell tumors.

Conclusion: Post-hepatectomy biliary stenosis should be considered in pediatric patients presenting with jaundice and cholestasis. Percutaneous management of biliary complications is a safe and effective alternative, highlighting the importance of early intervention and close follow-up to preserve liver function.

Introduction: Retained surgical foreign bodies are underreported due to legal concerns. They may remain asymptomatic or cause acute complications with nonspecific imaging findings, leading to delayed diagnosis. Awareness in previously operated patients is essential, and their impact has driven preventive measures such as standardized counts, detection technologies, and surgical checklists.

Case presentation: A 38-year-old woman with prior urologic and gynecological surgeries presented with 3 days of left flank pain, fever, nausea, and vomiting. Imaging revealed a large heterogeneous abdominal mass. Exploratory laparoscopy identified a cystic lesion with dense adhesions to the abdominal wall, small bowel, and sigmoid colon. Adhesiolysis exposed purulent material and a retained foreign body. The lesion and foreign body were removed, bowel defects were repaired, and the abdomen was irrigated. The postoperative course was uneventful, and the patient was discharged on day 6. The second case is a 68-year-old man with cardiovascular comorbidities and a remote history of pulmonary tuberculosis who was followed for an asymptomatic 6 cm anterior mediastinal mass. Due to suspected malignancy, thoracoscopic resection was performed. Intraoperatively, dense fibrosis was found, and conversion to a utility thoracotomy was required. Opening the mediastinal pleura revealed purulent material and a retained surgical gauze. Removal caused significant bleeding from vessel erosion, which was controlled with packing, vascular clamping, and suturing.

Discussion: The cases demonstrate that retained surgical items are preventable "never events" with significant clinical, ethical, and legal consequences. They often present with nonspecific symptoms and delayed diagnosis, requiring reoperation. Despite standard precautions, human and procedural factors persist, emphasizing the need for improved surgical safety culture, advanced prevention strategies, and meticulous reintervention techniques.

Background: Isolated splenic metastasis from malignant melanoma is exceedingly rare and is usually associated with disseminated disease.

Methods: A 68-year-old man with a history of stage IIB nodular melanoma of the scalp (Breslow thickness 4 mm), treated with wide excision, negative sentinel lymph node biopsy, and adjuvant immunotherapy, was found on routine surveillance positron emission tomography/computed tomography to have a solitary hypermetabolic splenic lesion (SUVmax 8.8). No other metastatic sites were identified.

Results: A laparoscopic splenectomy was performed without intraoperative or postoperative complications. Histopathological analysis confirmed metastatic melanoma. The patient recovered uneventfully and remains under oncological follow-up.

Conclusion: This case highlights the role of laparoscopic splenectomy as a safe and effective diagnostic and therapeutic approach for isolated splenic metastasis in selected melanoma patients.

Background: En bloc and R0 resection of nonpedunculated colonic lesions by conventional endoscopic mucosal resection (EMR) are challenging. Preliminary lesion molding-aided EMR (PM-EMR) is useful for reducing snaring slippage, which may increase successful en bloc and R0 resection rates. Herein, we compared PM-EMR and conventional EMR outcomes.

Methods: Overall, 112 patients with nonpedunculated colonic lesions measuring 8-15 mm were randomly allocated to either the PM-EMR group or the conventional EMR group. Baseline characteristics and treatment results were analyzed between the groups.

Results: En bloc resection and R0 resection were achieved in the PM-EMR group (100%, 94.6%) and the conventional EMR group (76.8%, 67.9%). For lesions ≥ 10 mm, en bloc and R0 resection rates were greater for PM-EMR than for conventional EMR (100.0% versus 74.4%; 94.4% versus 62.8%, respectively). For lesions with macroscopic morphologies indicating Is/IIa located in the left/right colon, PM-EMR was significantly better than conventional EMR for en bloc resection (100.0% versus 69.2%, 100% versus 76.5%; 100.0% versus 75.0%, 100.0% versus 68.2%, respectively) and R0 resection (100.0% versus 65.4%, 88.9% versus 52.9%; 100.0% versus 60.0%, 90.0% versus 63.6%, respectively).

Conclusions: PM-EMR is significantly better than conventional EMR regarding en bloc and R0 resection of 10-15 mm nonpedunculated colorectal lesions.

Background: Despite advancements, specimen extraction through mini-laparotomy in traditional minimally invasive surgery still carries risks of wound-related complications such as infection, incisional hernia, and poor cosmetic results. Natural orifice specimen extraction (NOSE) has been suggested as an alternative to eliminate the need for an abdominal incision, potentially improving postoperative recovery and reducing complications. This systematic review aims to critically compare the clinical and oncologic outcomes of NOSE with conventional laparoscopic anterior resection.

Methods: Our search was conducted in line with the most recent Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. An electronic search was conducted of the PubMed and EMBASE databases up to March 2025.

Results: After screening, 14 studies including 1149 patients undergoing anterior resection of rectal, sigmoid, and rectosigmoid tumors were included in this review, comprising 502 NOSE and 647 conventional patients. Compared with conventional transabdominal specimen extraction, NOSE was associated with longer operative time (weighted mean difference [WMD]: 12.44 minutes; 95% CI: 1.54-23.35; P = .03), lower estimated blood loss (WMD: -13.75 mL; 95% CI: -25.33 to -2.16; P = .02), and shorter hospital stays (WMD: -0.75 days; 95% CI: -1.03 to -0.48; P < .001). The tumor diameter was smaller in the NOSE cohort (WMD: -0.43 cm; 95% CI: -0.73 to -0.14; P < .01), but there were no significant differences in total lymph node harvest or number of metastatic nodes compared with the conventional approach. Overall complication rates favored NOSE (OR: 0.54; 95% CI: 0.34-0.86; P = .01), driven largely by reduced infections (OR: 0.24; P = .003), while anastomotic leak, hemorrhage, ileus, and reoperation rates did not differ significantly.

Conclusions: NOSE is a potential alternative in select patients undergoing anterior resection. However, it is associated with longer operative times, and there is a lack of data on long-term outcomes, such as hernia formation or oncologic safety.

Background: Minimally invasive colorectal surgery (MIS) offers reduced pain, faster bowel recovery, and shorter hospitalization compared with open surgery. In patients requiring a stoma, the stoma site can be used for specimen extraction, reducing the number of incisions. However, stoma-related complications, particularly parastomal hernia, may be increased. We synthesized evidence comparing stoma-site specimen extraction (SSE) with alternative extraction sites in MIS.

Methods: A systematic review and meta-analyses were conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Searches of PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and gray literature were performed (1990-2025). Eligible studies included adults undergoing elective laparoscopic or robotic colorectal surgery with SSE compared against midline or other extraction sites. Outcomes included stoma-related and nonstoma complications, perioperative parameters, and oncologic safety. Random-effect models were applied. Risk of bias was assessed using a modified Newcastle-Ottawa Scale. The study was prospectively registered with PROSPERO (CRD420251137576).

Results: Eighteen studies comprising 5699 patients (SSE: 1363; midline: 539; other incisions: 3797) were included. Overall, stoma-related complication rates were comparable between groups (SSE versus midline: OR: 1.04, 95% confidence interval [CI]: 0.37-2.89; SSE versus others: OR: 1.13, 95% CI: 0.75-1.68). The risk of parastomal hernia did not differ significantly between SSE and comparators (SSE versus midline: OR: 2.67, 95% CI: 0.53-13.54; SSE versus others: OR: 1.36, 95% CI: 0.69-2.67). Non-stoma-related complications (OR: 0.96, 95% CI: 0.66-1.38) and readmission rates were also similar. Perioperative outcomes favored SSE, with shorter operative time (mean difference -22.6 minutes versus others) and earlier return of flatus.

Conclusions: SSE is a safe and effective technique in MIS, offering perioperative benefits without increasing overall complication rates. Although parastomal hernia incidence was not significantly higher, vigilance is required, particularly in patients with permanent stomas. With appropriate case selection and meticulous closure, SSE represents a technique of MIS that reduces abdominal wall trauma while maintaining surgical safety.

Background: There has been systematic review and meta analysis (SRMA) on comparison of hepaticoduodenostomy (HD) and hepaticojejunostomy (HJ) in choledochal cysts (CDC), which included both open and laparoscopic procedures. There is no SRMA, comparing them in pediatric CDC which were managed exclusively by laparoscopy.

Methods: Studies comparing laparoscopic HD and HJ after CDC excision were identified from Medline, Ovid, Google Scholar, and Cochrane library. Suitable studies were reviewed and meta-analyzed. Outcomes evaluated included operative time, hospital stay, and incidence of postoperative bile leak, cholangitis, reflux/gastritis, anastomotic stricture, bleeding, intestinal obstruction, and re-operative rate.

Results: Nine retrospective studies were included, comprising total of 1903 patients, 457 of whom (24%) underwent HD, and 1446 (76%) underwent HJ. There was higher incidence of cholangitis in HJ (3.05%) than in HD (1.55%), though the difference was not statistically significant (P = .54). Reflux gastritis in the HD was 8.83% while that from the HJ was 0.87%. Meta-analysis favored HJ (odds ratio [OR]: 20.38, 95% confidence interval [CI]: 4.24 to 97.94; P = .002). For the mean operative time, Pooled Mean difference (MD: -56.93; 95% CI: -66.11, -45.75; P = .00001) was significant favoring HD. Outcomes such as hospital stay, bile leak, anastomotic stricture, bleeding, reoperation rate, and adhesive obstruction were comparable.

Conclusion: Laparoscopic HD and HJ show comparable short-term safety after CDC excision, with no significant difference in bile leak or cholangitis. HD, however, carries a higher risk of bile reflux and gastritis, though the operative time is significantly shorter with HD, offering a technical advantage.

Purpose: Gastropexy during laparoscopic gastrostomy tube (GT) placement is commonly achieved using transfascial sutures (TFS), transabdominal sutures (TAS), or T-fasteners (TF). It is unknown whether the method of gastropexy influences the incidence of postoperative complications. We aimed to determine if the gastropexy approach impacts rates of common complications after laparoscopic GT placement.

Methods: A single-center retrospective review of children who underwent laparoscopic GT placement from January 2018 to May 2023 was conducted. Patients with concomitant procedures labeled wound class II (clean-contaminated) or greater were excluded. Primary outcomes included cellulitis, tube dislodgement, granulation tissue, emergency department visits, readmission, and reoperation. Comparisons were made between gastropexy approaches.

Results: A total of 332 patients were analyzed. One hundred seventy-nine children had TFS, 110 had TAS, and 43 had TF. Children with TF were older than other cohorts and more likely to have a GT placed for medication/fluid access. Patients with TAS placed less phone calls to the pediatric surgery clinic postoperatively compared to those with TFS or TF. All other complications were comparable between cohorts.

Conclusions: The gastropexy approach does not significantly impact rates of postoperative complications following laparoscopic GT placement in pediatric patients. The gastropexy approach may impact the number of postoperative phone calls, but the reasoning for this is unclear.