Journal of Laparoendoscopic & Advanced Surgical Techniques最新文献

Objective: To describe a standardized surgical approach for 3D transperitoneal laparoscopic radical prostatectomy (3D T-LRP) performed in a single high-volume surgical center and to assess its impact on early urinary continence, erectile function, oncological outcomes, and overall safety.

Methods: We conducted a retrospective analysis of 360 patients with clinically localized prostate cancer (cT1-T2, N0, and M0) who underwent 3D T-LRP at Romolo Hospital (Italy) between January 2018 and December 2022. Procedures were performed by two experienced surgical teams with standardized operative protocols. All patients followed a structured pelvic floor rehabilitation protocol initiated immediately after catheter removal. Perioperative variables, functional outcomes (continence and erectile function), oncological parameters, and complications were prospectively recorde.d in an institutional database and retrospectively analyzed.

Results: The median operative time was 180 minutes (interquartile range [IQR]: 150-210), with pelvic lymph node dissection performed in 44.2% of cases. Positive surgical margins were observed in 15% of patients. Continence (defined as 0-1 pad/day) was achieved in 75.8% at 1 week, 83.4% at 3 months, and 92.5% at 6-12 months post-catheter removal. The median pad weight decreased from 350 g at T0 to 50 g at T1. In the nerve-sparing subgroup, the median IIEF-5 score at 6-12 months was 18 (IQR: 16-20), with 83% achieving a score ≥16. The postoperative complication rate was 10.3%, with no Clavien-Dindo grade ≥IIIb events.

Conclusion: 3D T-LRP performed with a standardized technique by experienced teams and followed by immediate pelvic floor rehabilitation yielded encouraging results in terms of early continence, erectile function, oncological safety, and low morbidity. These outcomes support 3D-LRP as a technically effective and economically sustainable minimally invasive alternative to robotic surgery.

Introduction: Postoperative urinary retention (POUR) is a common complication following inguinal hernia repair (IHR), and it can be influenced by the type of neuromuscular blockade reversal medication used, especially acetylcholinesterase inhibitors. Among the available options for neuromuscular blockade reversal, Sugammadex has gained significant popularity due to its effectiveness, speed, and safety profile. Additionally, some studies suggest that it prevents POUR compared to acetylcholinesterase inhibitors. We aimed to perform a systematic review and meta-analysis to assess the POUR rates with the use of Sugammadex after IHR.

Methods: PubMed, EMBASE, Cochrane, LILACS, and Web of Science databases were systematically searched without date or language restrictions from inception to October 2024. The databases were searched for studies comparing Sugammadex with other medications for neuromuscular blockade reversal after IHR. The primary outcome was POUR.

Results: From 212 records, 3 retrospective cohort studies and 1 clinical trial were included in our pooled analysis, totaling 1390 patients. 573 (41.2%) patients were in the Sugammadex group, compared to 817 (58.8%) patients in the non-Sugammadex group. 135 (9.7%) patients underwent open IHR, compared to 468 (33.6%) patients who underwent minimally invasive repairs. Our meta-analysis revealed that the use of Sugammadex was associated with a significantly lower risk of POUR compared to other medications (RR 0.11; 95% CI 0.05, 0.28; P < .001), with a relative risk reduction of 89%.

Conclusion: Sugammadex is associated with a significantly lower risk of POUR following IHR when compared to other medications for neuromuscular blockade reversal following IHR. Despite its higher cost and decreased availability in some centers, the use of Sugammadex should be strongly considered as the preferred option to prevent POUR and minimize the need for hospital readmissions.

Aim: To report our experience with laparoscopic-assisted anorectoplasty (LAARP) for anorectal malformations (ARM) performed without ligation of the rectourinary fistula (RUF).

Methods: In this single-center study, we retrospectively analyzed all consecutive primary LAARP procedures for ARM without RUF ligation performed between 2004 and 2022. Forty patients were included (19 rectobulbar, 16 rectoprostatic, 5 rectobladder). Colostomy was performed at a median age of 1 day and LAARP at 147 days (median weight 6 kg). Median operative time was 180 minutes, and 1 patient required conversion. No early complications were associated with omission of RUF ligation. Foley catheters were kept for a median of 10 days, postoperative stay was 5 days, and colostomy closure occurred at 7 months. The median follow-up was 6.7 years. Cystoscopy and cystography were performed in 17% and 20% of patients, respectively, with no remnants of the original fistula (ROOF). Eight patients (20%) had urological issues: neurogenic bladder (n = 3), bladder dyssynergia (n = 2), urinary retention (n = 2), and non-LAARP-related urethral stenosis (n = 1). Regarding late outcomes, 2 patients (5%) underwent redo anorectoplasty, 11 (27%) required prolonged dilations, 4 (10%) underwent redo anoplasty, and 2 (5%) underwent revision for mucosal prolapse. Among those >4 years, 84% had voluntary bowel movements, 76% soiling, and 52% constipation; 53% of those <4 years required laxatives.

Conclusions: LAARP without ligation of the RUF for ARM appears to be a safe and effective technique, with favorable long-term urological and functional outcomes. No patients experienced urethral injury or ROOF.

Background: To determine the optimal preoperative timing of indocyanine green (ICG) administration for effective fluorescence-guided imaging during laparoscopic common bile duct exploration (LCBDE).

Methods: A retrospective analysis was conducted on 150 patients who underwent ICG-guided LCBDE between June 2024 and June 2025. All patients received an intravenous injection of 2.5 mg ICG and were allocated into five groups according to the interval between ICG administration and surgery: 0-1 hours, 1-3 hours, 3-6 hours, 6-9 hours, and 9-12 hours. Baseline characteristics, intraoperative fluorescence visualization, bile duct-to-liver fluorescence intensity contrast, and perioperative outcomes were compared among groups.

Results: Visualization rates of the cystic duct, common hepatic duct, and common bile duct (CBD) did not differ significantly among groups (P > .05). In contrast, liver fluorescence visualization differed significantly (P = .002) and was lowest in the 9-12 hours group. The bile duct-to-liver fluorescence intensity difference was greatest in the 6-9 hours group. The time to identify the CBD differed significantly among groups (P < .001), with shorter identification times observed in the 1-3 hours, 3-6 hours, and 6-9 hours groups compared with the 0-1 hours group.

Conclusion: Preoperative intravenous administration of 2.5 mg ICG 6-9 hours before LCBDE is associated with optimal biliary fluorescence contrast and improved intraoperative identification of the CBD.

Introduction: Laparoscopic cholecystectomy is widely performed and safe, but may present rare complications such as retained gallstones ("dropped gallstones"), which can act as a nidus for infection and cause late intra-abdominal or retroperitoneal abscesses.

Methods: A 40-year-old male with prior laparoscopic cholecystectomy presented with fever and right lumbar pain. Examination showed an inflammatory lumbar mass with leukocytosis and elevated C-reactive protein. Imaging revealed a right paravertebral collection with a fistulous tract to the abdominal cavity. Despite antibiotics and percutaneous drainage, recurrence occurred. Surgical lumbotomy revealed multiple gallstones, confirming the etiology, with subsequent clinical improvement.

Results: Retained gallstones may migrate, act as foreign bodies, and cause recurrent infection. Magnetic resonance imaging was key to identifying the abdominal origin, and surgical stone removal was required for definitive treatment.

Conclusion: Lumbar abscesses in patients with previous cholecystectomy should raise suspicion of retained gallstones. Definitive management requires drainage and complete stone removal to prevent recurrence.

Background: Metabolic and bariatric surgery is the most effective treatment for severe obesity. While short- and mid-term results are well documented, very long-term data (≥10 years) remain scarce, particularly for newer procedures. This review aims to synthesize the available evidence on weight loss outcomes, comorbidity resolution, and complications at 10 years and beyond for the five main bariatric procedures.

Methods: A comprehensive literature review was performed using PubMed, MEDLINE, and Cochrane databases. Studies reporting outcomes at ≥10 years for sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), one-anastomosis gastric bypass (OAGB), biliopancreatic diversion with duodenal switch (BPD-DS), and single-anastomosis duodeno-ileal bypass with sleeve (SADI-S) were included.

Results: At 10 years, weighted mean %TWL ranged from 24.4% for SG to approximately 40% for BPD-DS. The SLEEVEPASS randomized controlled trial demonstrated superior weight loss with RYGB compared to SG (%EWL 51.9% versus 43.5%, P < .05). OAGB showed excellent durability with a %EWL of 64.1% at 10 years. BPD-DS achieved the highest sustained weight loss (%EBMIL 76.5%-78%) but with significant nutritional concerns. SADI-S data at 10 years showed %EWL of 80% with acceptable complication rates. Type 2 diabetes remission rates varied from 26% to 33% (SG/RYGB) to >90% (BPD-DS). Gastroesophageal reflux disease (GERD) emergence was a major concern after SG (31% esophagitis at 10 years versus 7% after RYGB).

Conclusions: All five procedures demonstrate durable weight loss at 10+ years, with a clear hierarchy favoring malabsorptive procedures for weight loss efficacy. Procedure selection should consider patient-specific factors, including baseline BMI, presence of GERD, metabolic comorbidities, and capacity for long-term nutritional follow-up.

Background: Conversion from laparoscopic to open cholecystectomy is associated with increased morbidity. A low conversion rate, together with a low complication rate, may serve as a surrogate marker of surgical quality. This study aimed to analyze the conversion rate at a secondary referral center in relation to bile duct injuries and to identify risk factors associated with conversion.

Methods: We performed a retrospective analysis of all laparoscopically initiated cholecystectomies between January 2013 and December 2022. Demographic and clinical data, surgical indication, timing, difficulty level (Nassar and Randhawa scores), conversion rates, and bile duct injuries (Neuhaus system) were evaluated.

Results: A total of 1534 laparoscopic cholecystectomies were performed. The overall conversion rate was 2.0% (n = 31), with 84% of conversions occurring in emergency cases. Converted patients showed a high prevalence of known risk factors. Most converted cholecystectomies (80.6%) were performed during daytime hours; only 6.5% of conversions occurred after midnight. The incidence of bile duct injuries was 0.26%, well below the average reported in the literature.

Conclusion: A low conversion rate combined with a low rate of bile duct injuries can serve as a surgical quality indicator. Risk stratification using established scoring systems, laparoscopic skills such as intraoperative cholangiography, appropriate timing of surgery, and team composition may contribute to achieving a low conversion rate.

Introduction: Ventral hernia repair (VHR) is one of the most frequently performed surgical procedures. However, the selection of the most appropriate mesh type remains a subject of considerable debate. Moreover, the current body of evidence regarding the choice of mesh for VHR in contaminated fields remains insufficient. Given these limitations, this study aims to systematically evaluate and analyze existing data on the comparative efficacy and safety of biologic versus synthetic mesh in VHR.

Materials and methods: A comprehensive online search was conducted across databases (PubMed/MEDLINE, EMBASE, Web of Science, and Cochrane Library) from January 2000 until January 2025. Randomized controlled trials (RCTs) exclusively comparing biologic and synthetic mesh in patients undergoing VHR were included, with no restrictions on language. The primary outcomes were surgical site occurrence (SSO), surgical site infection (SSI), reoperation, and hernia recurrence. Secondary outcomes included hematoma and seroma formation, operative time (OT), and length of stay (LOS). Trial sequential analysis (TSA) was performed using TSA Software 0.9.5.10 Beta (Copenhagen Trial Unit, Center for Clinical Interventional Research), and the Fragility Index (FI) and Reverse Fragility Index (RFI) were calculated using R Statistical Software (v4.1.2; R Core Team 2021).

Results: A total of 762 studies were screened, of which 16 were fully reviewed. Four RCTs including 758 patients were analyzed in the TSA; 48% of patients had Wound Classification II-IV, and 83.4% underwent open procedures. Only OT reached the required information size (RIS), providing conclusive evidence favoring synthetic mesh. For all other outcomes-including SSO, SSI, reoperation, hernia recurrence, seroma, hematoma, and LOS-the RIS was not reached, reflecting underpowered evidence. Fragility and reverse fragility analyses revealed highly unstable results across most studies, with FI values of 0 in nearly all nonsignificant outcomes and RFI ranging from 1 to 11.

Conclusions: Biologic and synthetic mesh demonstrated comparable results in VHR across multiple clinical parameters. However, the TSA indicated that only OT reached the RIS, providing conclusive evidence favoring synthetic mesh by demonstrating a significantly shorter duration of surgery. For all other outcomes, the analysis suggests that current evidence remains inconclusive regarding the superiority of either mesh type.

Background: Solid pseudopapillary neoplasm (SPN) is a rare pancreatic tumor with low malignant potential, predominantly affecting young women. Early diagnosis and complete surgical excision are associated with excellent outcomes.

Case presentation: A 17-year-old female presented with epigastric pain and postprandial vomiting. Contrast-enhanced CT revealed a well-circumscribed solid-cystic mass in the pancreatic body-tail. Endoscopic ultrasound with core needle biopsy confirmed SPN. The patient underwent open distal splenopancreatectomy, including systematic coloepiploic division, extended Kocher maneuver, controlled dissection of the superior mesenteric vein, and mechanical transection of the pancreatic neck with reinforced stapled closure. The procedure was completed en bloc without intraoperative complications. Postoperative recovery was uneventful. Final histopathology is pending.

Discussion: SPN typically demonstrates favorable biological behavior, and complete resection is curative in most cases. This case underscores key technical aspects of distal pancreatectomy, such as early vascular control, careful mobilization of the splenic hilum, and reinforcement of the pancreatic stump to reduce the risk of postoperative pancreatic fistula.

Conclusion: Distal splenopancreatectomy remains the standard surgical approach for SPN located in the pancreatic body and tail. Meticulous operative technique and adherence to oncologic principles are essential to ensure optimal outcomes in these patients.

Background and objectives: Postoperative pancreatic fistula (POPF) is one of the most severe complications after pancreaticoduodenectomy (PD), particularly in the presence of high-output fistulas, infection, and radiological evidence of anastomotic dehiscence. Percutaneous transhepatic biliary drainage (PTBD) with external bile diversion may promote fistula healing by reducing intraluminal pressure, microbial exposure, and bile reflux. This study aimed to evaluate the role of PTBD in high-risk POPF management after PD.

Methods: Between January 2022 and December 2024, 122 PDs were performed at our center. Seventeen patients (13.9%) developed clinically relevant POPF. Nine were treated conservatively with antibiotics ± percutaneous drainage, while eight met criteria for high-risk POPF (very high output >400 mL/day, positive cultures, CT evidence of dehiscence) and underwent PTBD.

Results: In the PTBD group, 7/8 patients (87.5%) achieved fistula resolution with a median of 15 days (IQR: 12-19) from surgery, but only 5 days (IQR 4-6; mean 5.4) after PTBD placement. One patient (12.5%) progressed to Grade C, and 2 (25%) required additional percutaneous drainage. No PTBD-related complications occurred, and follow-up cholangiograms confirmed the absence of bile leaks. Importantly, no biliary fistulas were observed. In the non-PTBD group, 7/9 patients achieved resolution with a median of 19 days (IQR 15-22; mean 18.0); 2 patients (22.2%) progressed to Grade C, and 5 (55.5%) required percutaneous drainage.

Conclusions: PTBD with external bile diversion is a safe and effective tool for managing high-risk pancreatic fistulas following PD. By modifying intraluminal pressure and microbial exposure in the child's limb, PTBD significantly promotes fistula healing and may prevent progression to Grade C. Our findings support the incorporation of PTBD into POPF management protocols for selected patients. Larger prospective studies are needed to confirm these results.