Journal of Laparoendoscopic & Advanced Surgical Techniques最新文献

Background: Opioid use has become an epidemic problem. There has been a recent push toward strategies that minimize postoperative opioid use. Appendectomy is one of the most common procedures performed in the pediatric population. Single-incision appendectomy through the umbilicus is a safe and well-tolerated procedure. The aim of this project was to review opioid utilization in children who have undergone single incision appendectomy for perforated and nonperforated appendicitis. Methods: A retrospective review, approved by the University of Illinois College of Medicine Institutional Review Board, of 500 patients at a single institution under the age of 18 who had an appendectomy between May 1, 2018, and December 1, 2021, was performed. A final population cohort of 432 was assembled after excluding non-single-incision cases (67) and non-appendectomy cases (1). Outcomes of interest were length of stay, age, appendix perforation status, and opioids at discharge status. All patients were sent home without opioids. Results: A total of 432 patients underwent a single incision laparoscopic appendectomy, with an overall average length of stay of 2.1 days, average age of 11.1 years, and zero patients were sent home on opioids. The perforated appendix population (n = 169) yielded a less than 4-day stay, an average age of 10.33 years, and 61.5% male. Meanwhile, the nonperforated appendix population (n = 264) revealed a 0.8-day stay, an average age of 11.59, years and 54.2% male. The differences between perforated and nonperforated appendectomies are significant for average length of stay (P < .001) and average age (P < .01). Conclusion: Being cognizant of opioid utilization in the management of postoperative pain control is important to address the current opioid crisis. The single incision laparoscopic approach for pediatric appendectomy can potentially decrease the need for postoperative narcotics. No children were sent home with narcotics in our population. The procedure is well tolerated and can be performed with traditional laparoscopic equipment.

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.

Aim: Single-incision laparoscopic surgery (SILS) provides improved cosmesis compared with multiport laparoscopy. However, it involves hand-clashing and cross-triangulation, making it challenging even for experienced surgeons to adopt in their practice. This study aims to assess the effect of providing an additional view of the surgeon's hands on task performance in SILS. Methods: Surgically naive participants were recruited via volunteer sampling and instructed to perform tasks using a laparoscopic trainer set and a singular triport access device. A head-mounted camera was worn by the participant and angulated inferiorly to provide an additional view of the operators' hands. Both views were displayed on a 90″ monitor. Tasks were performed with and without the additional view in an alternating manner. Attempts were recorded and assessed blindly for duration and success. Chi-squared and Mann-Whitney U tests were applied as required. A P value <.05 was considered significant. Results: A total of 467 attempts were conducted by 30 volunteers. The pass rates were 79.09% and 69.23% for the additional and traditional views, respectively (P = .015). A trend toward shorter durations was seen in attempts using the additional view (P = .128). Males (P = .003) and PC video game players (P = .022) were more likely to pass and mobile video game players were more likely to fail (P = .003). Conclusion: The use of a head-mounted camera to directly visualize surgeon's hands enhances performance in an ex vivo setting. More research is needed to assess clinical impact.

Background: In laparoscopic surgery, a 30° lens is frequently used to obtain a wider field of view. However, it is difficult for inexperienced surgeons to maintain the horizontal state of the image in laparoscopic camera navigation (LCN). If there is a great deviation in the camera's horizontal axis, it may result in ambiguous anatomical recognition, which could impair patient safety. Scientific assessment of the degree of camera's horizontal axis deflection in camera holders with differing proficiencies is necessary for improving novice surgeons' fundamentals of laparoscopic surgery. This study aims to develop an evaluation and training system based on the deflection angle (refers to the change in the angle of the camera axis from its preset vertical position) and assess its potential value in the training and clinical application of laparoscopic surgery. Methods: A total of 15 postgraduates without laparoscopic surgery experience and 15 skilled senior attending physicians with an experience in more than 50 cases of laparoscopic surgery were recruited. The participants completed an LCN exercise. An inclinometer module was used to measure the camera's horizontal axis deflection angle and the difference in the deviation angle was compared between the two groups. Results: A deflection angle greater than ±15° was found in 57.98% and 31.76% of participants in the novice group and skilled group, respectively, whereas a deflection angle greater than ±30° was found in 18.4% and 7.58% of participants in the novice group and the skilled group, respectively. The thresholds (we designate 15°, 30°, 45°, and 60° as the checkpoints) for all angles were significantly different for the two groups. Conclusions: There was a significant difference in the technique of maintaining the camera's horizontal axis within an acceptable range between the novice and the skilled participants. Training that focuses on this deflection angle may be helpful for novice camera holders.

Background: Laparoscopic fundoplication is commonly performed in patients with neurological impairment. However, these patients often have spinal deformities that can complicate achieving a clear surgical view. This study aimed to identify factors associated with poor visibility in pediatric laparoscopic fundoplication. Methods: Operative videos, medical records, and radiographs of patients who underwent laparoscopic fundoplication between 2015 and 2023 were retrospectively reviewed. The videos were reviewed by two pediatric surgeons and classified into good or poor visibility groups. Age, sex, height, weight, history of abdominal surgery, lordosis, operative time, blood loss, and intraoperative complications were compared between the two groups. Lordosis was evaluated using the sagittal view of computed tomography images, and the anterior vertebral depth and abdominal thickness were measured to calculate the ratio. Results: Forty-one patients were included in this study. Based on the video review, the patients were classified into good (20 patients) and poor (21 patients) visibility groups. The median age, height, and weight were 6 years, 110 cm, and 16.1 kg, respectively. In the poor visibility group, 23.8% of patients had a history of abdominal surgery (P = .048). Additionally, the anterior vertebral depth to abdominal thickness ratios at the first and third lumbar vertebrae were significantly lower in the poor visibility group (P = .016 and P = .0018, respectively). There were no significant differences in the operative time, blood loss, or intraoperative complications between the two groups. Conclusions: Lordosis and a history of abdominal surgery may be risk factors for poor visibility in pediatric laparoscopic fundoplication.

Background: In the surgical treatment of colorectal cancers, disease-free survival and life expectancy are inversely proportional to the increase in complications. We evaluated the superiority of colonoscopy and air and water tests in detecting anastomotic leaks in sigmoid and rectosigmoid junction colon cancers. Methods: Data of patients who underwent robotic/laparoscopic surgical procedures for sigmoid and rectosigmoid junctional colon cancers at a single center between January 2018 and February 24 were retrospectively evaluated. The anastomoses were evaluated by intraoperative colonoscopy (IOC) and intraoperative air leak test (IALT), and two groups were formed. Intraoperative leaks, intraoperative repair techniques, and postoperative anastomotic leaks were evaluated. Results: In our study, there were 125 patients in the IOC group and 148 patients in the IALT group, totaling 273 patients. Leakage was detected in 7 patients (4.7%) in the IALT group and 14 patients (11.2%) in the IOC group (P = .06). In the IALT group, 5 of 7 patients were repaired primary, and the anastomosis was reconstructed in 2 patients. In the IOC group, 10 of 14 patients were repaired primary, 2 patients underwent reanastomosis, and 2 patients needed colostomy. Of these 15 patients with postoperative leakage, 4 had intraoperative leakage (2 patients in the IALT group and 2 patients in the IOC group), and all of them underwent primary repair. Conclusion: In the anastomotic evaluation of sigmoid colon and rectosigmoid junction tumors, we found that IOC detected more leaks than IALT, but in these leaks, reanastomosis and/or diversion ostomy was superior to primary repair.

Background: Minimally invasive surgery (MIS) for adrenal pathologies in children is still developing because of its low incidence in pediatric population and the discrepancy between the big volume of the masses and the reduced child's size especially in younger patients. In the literature, there are no guidelines about the use of laparoscopic andrenalectomy in children. The aim of this study is to evaluate the outcomes of MIS through a bicenter data analysis in order to propose a standardized protocol. Materials and Methods: Children who underwent minimally invasive adrenalectomy performed at two European Departments of Pediatric Surgery between 2000 and 2020 were included in this study. Data were collected and analyzed using X-square, Fisher tests, and multiple regression model. Results: Thirty-four patients (38 adrenal masses) were included. Mean age was 52 months (3-176). Median lesion diameter was 60 mm (40-125 mm). Histological examination revealed 24 neuroblastomas (NBs), 11 pheochromocytomas, 1 teratoma, 1 adrenal cyst, and 1 myelolipoma. Laterality was 52.6% left, 36.8% right, and 10.5% bilateral. Surgical access was transperitoneal in all patients. Mean operative time was 108 minutes for unilateral lesions and 270 minutes for bilateral ones. Mean hospital stay was 4.4 days. No major intraoperative complications were observed. 21.05% NBs were preemtively approached with a laparoscopic access and were converted to open surgery. Median follow-up was 88 months (24-264). Four patients affected by neuroblastoma reported metastatic dissemination and three died. Conclusions: Pediatric minimally invasive adrenalectomy is a safe and effective procedure, allowing surgeons to reduce the size of incision starting the dissection of the masses, and it has low rate of complication if we consider small masses. The only absolute contraindication is persistent image-defined risk factors for NBs. It should be considered as the first-line treatment for selected adrenal masses in centers with good experience in laparoscopy.

Background: Minimally invasive surgery is the preferred method for treating colorectal disease. Laparoscopic suturing is complex, and barbed sutures (BS) can improve the process by eliminating the need for surgical knots and constant traction on the suture line. This study compares intraoperative and postoperative outcomes in patients undergoing laparoscopic-assisted colorectal surgery (LCS) with anastomosis using BS and conventional sutures (CS). Methods: PubMed, Scopus and Cochrane Library were systematically searched for studies comparing BS to CS in patients undergoing LCS. Continuous outcomes were compared using mean differences (MDs), and odds ratios (ORs) were computed for binary endpoints with 95% confidence intervals (CIs). Heterogeneity was assessed with I² statistics. Statistical analysis was performed using Software R, version 4.2.3. Results: A total of four studies comprising 285 patients were included, of whom 143 patients (50.17%) underwent BS. Compared with CS, BS significantly reduced the total operative time (MD -16.25 minutes; 95% CI: -25.94, -6.56; P < .01; I² = 0%). However, there were no significant differences between groups in the occurrence of intraoperative complications (OR .74; 95% CI: .26-2.12; P = .58; I²=0%), anastomotic leakage (OR 1.00; 95% CI: .14-7.26; P = 1.00), and Clavien-Dindo ≥III complications (OR 1.80; 95% CI: .41-7.95; P = .44, I² = 0%). Conclusion: In this meta-analysis, BS significantly reduced the operative time in the anastomotic closure compared to CS in LCS. Furthermore, there were no significant differences between the groups in anastomotic leakage, intraoperative complications, and severe postoperative complications.

Background: Minimally invasive treatments for cholelithiasis have gained popularity. The complexity of diagnosing and treating choledocholithiasis offers multiple surgical options, including laparoscopic common bile duct exploration plus laparoscopic cholecystectomy (LCBDE+LC) and endoscopic retrograde cholangiopancreatography and/or endoscopic sphincterotomy plus laparoscopic cholecystectomy (ERCP/EST+LC). Objective: To compare outcomes in patients with typical signs, symptoms, laboratory, and imaging features of cholelithiasis combined with common bile duct stones, we retrospectively analyzed the short-term outcomes of LCBDE+LC and ERCP/EST+LC. Methods: We analyzed 318 patients with gallbladder stones treated between January 2022 and May 2024. Of these, 152 underwent LCBDE+LC, and 166 underwent ERCP/EST+LC. We compared patients' baseline characteristics, perioperative outcomes, and short-term complications between the two groups. The primary outcome was the effectiveness of choledochal stone removal, while secondary outcomes included length of stay, hospitalization costs, and patient satisfaction. Results: Patients' baseline characteristics were similar between the LCBDE+LC and ERCP/EST+LC groups. Stone clearance rates were comparable (97.37% versus 95.18%, P = .306), with a slight advantage in the LCBDE+LC group. The length of hospitalization was significantly shorter in the LCBDE+LC group (6.49 ± 1.18 days versus 6.77 ± 1.11 days, P < .05). The LCBDE+LC group also had lower total hospitalization costs ($5188.78 ± 861.26 versus $6498.76 ± 1190.58 P < .01). Additionally, the incidence of pancreatitis was lower in the LCBDE+LC group (0.66% versus 6.02%, P < .01). There were no significant differences between the groups in other short-term complications such as abdominal infection, cholangitis, biliary bleeding, or bile leakage. Postoperative follow-up indicated higher patient satisfaction and acceptance in the LCBDE+LC group (SSQ-8, 85.84 ± 4.31 points versus 81.20 ± 4.54 points, P < .01). Conclusion: Our findings suggest that the LCBDE+LC holds promise as a safe and efficacious approach for the management of cholelithiasis combined with common bile duct stones. However, further prospective clinical trials are essential to corroborate these results and confirm their broader applicability.