Journal of Laparoendoscopic & Advanced Surgical Techniques最新文献

Background: Laparoscopic appendectomy is the preferred treatment for acute appendicitis, offering reduced morbidity and quicker recovery compared with open surgery. The positioning of the patient during surgery can significantly impact both the ergonomics for the surgeon and the operational outcomes. This study compares the conventional supine positioning with an innovative left lateral decubitus approach for surgical efficiency and recovery outcomes. Methods: This prospective, comparative study included 30 pediatric patients undergoing interval appendectomy at the Department of Pediatric Surgery, from October 2023 to March 2024. Patients were randomly assigned to undergo appendectomy either in the traditional supine position (Group A) or a modified left lateral position (Group B). The study measured operative times, complication rates, and surgical outcomes using the modified Objective Structured Assessment of Technical Skills (OSATS). Results: The study consisted of 15 patients in each group, with comparable demographics and baseline characteristics. Group B showed a significant reduction in mean operating time (55.25 ± 3.62 minutes) compared with Group A (62.45 ± 4.15 minutes) (P < .001). There were fewer complications in Group B, with no serosal tears reported compared with a 15.3% incidence in Group A. The modified OSATS scores were higher in Group B, indicating better flow of operation and overall performance. Conclusion: The left lateral positioning in pediatric laparoscopic appendectomy demonstrated a potential to enhance surgical efficiency, reduce operative time, and minimize complications compared with the traditional supine approach. These findings suggest that the left lateral position could be considered a preferable alternative in pediatric appendectomy, particularly beneficial for surgical trainees due to improved ergonomics.

Background: Telesurgery represents a revolutionary milestone in medicine, allowing surgeons to perform complex procedures at a distance through advanced robotic systems. Although the first telesurgery in Brazil was performed in 2000 with a single-arm robotic platform between São Paulo and Baltimore (USA), no telesurgery had ever been conducted between two distinct Brazilian cities with a state-of-the-art robotic system. The aim is to report the first telesurgery performed between two Brazilian cities, connecting Scolla-Surgical Training Center in Campo Largo and CEONC Hospital in Cascavel, both in the state of Paraná, approximately 600 km apart, using high-performance fiber optic technology with 5G redundancy to perform robotic cholecystectomy in a swine model. Methods: A prospective experimental study was conducted using a 40 kg swine (Sus scrofa) as an animal model. Connectivity was established through high-speed fiber optic cable, allowing minimal latency and real-time data transmission. A robotic cholecystectomy was performed remotely, with continuous monitoring of delay parameters and connection quality. Results: Telesurgery was performed without complications, demonstrating the technical feasibility and safety of the procedure between two Brazilian cities. Transmission delays remained within acceptable limits for robotic surgery, and no technical or surgical complications were observed during the procedure. Image quality and responsiveness of robotic commands remained stable throughout the surgery. Conclusion: This study establishes a historic milestone in Brazilian medicine, demonstrating that telesurgery between Brazilian cities is technically feasible and safe. The results open promising perspectives for expanding access to specialized surgical care in remote regions of Brazil, potentially revolutionizing the distribution of medical expertise in the country and Latin America.

Introduction: A steady increase in the prevalence of obesity in patients over 50 years old has led to a growing number of laparoscopic sleeve gastrectomy (LSG) in this population. Yet the efficacy for those patients is still debated. We evaluated the impact of age on the short-term results of LSG. Methods: This retrospective study analyzed patients who underwent LSG between 2013 and 2020. Patients were divided into three groups: young (≤35 years, n = 35), intermediate (36-49 years, n = 58), and older age (≥50 years, n = 52). Body mass index (BMI), total weight loss (TWL), excess weight loss (EWL), and obesity-related comorbidities (ORC) were assessed 2 years after LSG. Results: The mean reduction in BMI, TWL, and EWL was 9.5 kg/m², 21%-51.7% in the "older age" group, 11.9 kg/m², 26.3%-64.6% in the "intermediate" group, and 13.3 kg/m², 30.1%-74.4% in the "young" group, respectively. The LSG failure rate (EWL <50%) was 48.1% in the "older age" group, higher than in the "young" group (14.3%) (P = .001). The rate of remission or improvement in hypertension (HTN) was 31% in the ≥50 age group, significantly lower than in the other groups (36-49 years: 58%, ≤35 years: 100%) (P = .034). There was no significant difference between the groups in terms of other ORC. 10.5% of patients were lost to follow-up. Conclusion: Age appears to have a significant negative impact on weight loss results two years after LSG, with no impact on remission or improvement in ORC other than HTN.

Introduction: Gastroparesis is a progressive disease that may require endoscopic or surgical intervention, such as gastric per oral endoscopic myotomy (G-POEM), when conservative measures are ineffective or not tolerated. Limited data exist on redo G-POEM safety and effectiveness. We describe outcomes of patients undergoing repeat G-POEM for refractory gastroparesis. Methods: A retrospective review of patients who underwent redo G-POEM at our center from 2008 to 2024. Data included demographics, gastroparesis etiology, previous treatments, Gastroparesis Cardinal Symptom Index (GCSI), gastric emptying studies (GES), and clinical outcomes. Results: Three patients (mean age at first G-POEM 52.3 ± 19 years) were identified. All procedures were technically successful, and all 3 patients survived to discharge without major complications. Patient A (sarcoidosis-induced gastroparesis) had transient symptomatic improvement after the first G-POEM, but symptoms deteriorated the following year. GES showed initial improvement (26% to 14% 4-hour retention) but returned to baseline (26%) after the second G-POEM. She ultimately required jejunostomy tube placement. Patient B (idiopathic gastroparesis) with a history of renal transplant showed no objective improvement in GES after either procedure (40% to 41% 4-hour retention) and remained noncompliant with dietary recommendations. He died at age 35 from cardiac arrhythmia 2 years after the second G-POEM. Patient C (postsurgical gastroparesis) had improvement in GES after the first G-POEM (88% to 53% 4-hour retention) but then deteriorated to 73% despite symptomatic improvement. After symptom recurrence, redo G-POEM provided an excellent symptomatic response, but she remained total parenteral nutrition-dependent until death 4 years later. Conclusion: While redo G-POEM is technically feasible and safe, our case series demonstrates poor long-term clinical outcomes across different gastroparesis etiologies. All 3 patients experienced treatment failure, with 2 requiring permanent nutritional support and 1 showing a lack of symptomatic response. These findings may suggest limited utility of redo G-POEM and highlight the need for careful patient selection.

Objective: To evaluate whether renal pelvis urine density (RPUD), measured on preoperative computed tomography (CT), predicts infectious complications following percutaneous nephrolithotomy (PCNL). Methods: This retrospective study included patients who underwent PCNL between June 2019 and June 2024 at a tertiary care center. Patients with preoperative infection signs, drainage devices, or incomplete data were excluded. All included patients had sterile urine cultures preoperatively. RPUD was measured on noncontrast CT by two independent urologists, and interobserver agreement was calculated. Patients were grouped according to the presence of postoperative infectious complications (fever, sepsis, or septic shock). Demographic and perioperative variables were compared. Logistic regression was used to identify independent predictors of infection. Results: A total of 226 patients were analyzed. Patients with postoperative infections had significantly higher RPUD values (13.7 versus 6.0 Hounsfield units, P = .001) and longer operative times (70 versus 50 minutes, P = .001). On multivariate analysis, both RPUD (odds ratio: 1.238) and operative time (odds ratio: 1.055) were independent predictors. ROC analysis showed that an RPUD cutoff of 9.250 predicted infection with 80.0% sensitivity and 80.1% specificity (AUC: 0.875). Interobserver reliability for RPUD was excellent (intraclass correlation coefficient: 0.942). Conclusions: Preoperative RPUD is a reliable, noninvasive radiological marker for predicting infectious complications after PCNL. Routine measurement of RPUD may improve preoperative risk stratification and optimize perioperative management. These findings should be validated in future prospective, multicenter studies.

Background: The RefluxStop (RS) is an innovative surgical procedure for the treatment of gastroesophageal reflux disease (GERD). Prior research has demonstrated encouraging results in medium-term follow-ups, suggesting that this procedure is a worthwhile alternative to conventional laparoscopic antireflux surgery (LARS). Despite the standardization of the surgical technique, the procedure may be laborious and demanding even for an expert foregut surgeon. Aim: Evaluate the surgeon learning curve for the RS procedure. Methods: A single-center prospective study (December 2023-January 2025) was conducted. All the procedures were performed by one surgeon experienced in LARS. The cumulative summation (CUSUM) methodology was applied to visualize the learning curve. A broken-line regression model was employed to identify transitions between phases, thus defining competency (phase 1), proficiency (phase 2), and mastery (phase 3). Results: Fifty consecutive RS procedures were included. The mean age was 46.7 years (standard deviation [SD]: 11.4), and 68% patients were females. Heartburn (100%), regurgitation (88%), and dysphagia (28%) were common symptoms. Hiatal hernia axial length ranged from 2 to 5 cm. The mean preoperative GERD-HRQL was 39.1 (SD: 9.2). None of the patients underwent concomitant procedures, and the mean operative time was 70.6 minutes (SD: 17.3). The regression analysis found breakpoints at case 9.32 (95% CI: 8.5-9.9) and case 23.27 (95% CI: 22.9-23.8). Thus, the competency phase was achieved after 9 cases, followed by the proficiency phase, which was completed after an additional 14 cases (up to case 23). The surgeon achieved mastery of the RS procedure upon completing 23 cases. Conclusions: The CUSUM learning curve for the laparoscopic RS procedure demonstrates that a surgeon experienced in LARS requires 9 cases to overcome competency and 23 cases to master the technique.

Background: Postesophagectomy diaphragmatic hernia (PEDH) is a rare yet potentially life-threatening complication following esophagectomy, particularly when acute symptoms such as ischemia or organ perforation arise. Prompt diagnosis and emergency surgical intervention are crucial. This study reports the experience of a tertiary care center in managing acute symptomatic PEDH. Methods: We performed a retrospective analysis of patients who underwent esophagectomy for cancer at our institution between 2013 and 2023. Early PEDH was defined as hernia onset within 30 days postoperatively. Patients presenting with respiratory symptoms, volvulus, ischemia, or perforation underwent emergency surgery. Primary outcomes included the method of diaphragmatic repair, use of mesh, and surgical success. Results: Out of 358 patients, 11 (3.1%) developed PEDH requiring emergency surgery. Five cases were early PEDH and 3 developed an anastomotic leak. Organ or omental resection was performed in 4 patients. Laparoscopic repair was successful in 8 cases, while 2 patients required laparotomy and thoracotomy. Cruroplasty was performed in 8 patients, in 2 a mesh was added and in 6 the falciform ligament was used to buttress the closure. Mortality was nil. Recurrence rate was 18%. No preoperative risk factors for PEDH were identified. Conclusions: Diaphragmatic hernia is a rare but serious complication after esophagectomy, often associated with high morbidity and mortality. Early recognition is critical and life-saving. In high-volume centers, laparoscopic repair is the preferred approach and the decision to perform cruroplasty with or without mesh reinforcement should be individualized based on patient characteristics.

Introduction: This study aims to perform a systematic review and meta-analysis to compare the laparoscopic intraperitoneal onlay mesh (IPOM) versus the robotic retromuscular (RM) techniques and their respective outcomes for small and medium-sized ventral hernia repair. Methods: A comprehensive online search was conducted using PubMed, Cochrane, and Embase. Studies comparing laparoscopic IPOM to robotic RM techniques were included. The results analyzed were the length of stay (LOS), surgical site infection (SSI), surgical site occurrence (SSO), readmission, and reoperation. Statistical analysis was performed with R Studio version 4.4.1 using a random-effects model. Results: From 956 records, three retrospective observational studies were included, encompassing 1351 patients (laparoscopic IPOM n = 882; robotic RM n = 469). Primary hernias represented 63%, and 88% had horizontal defects between 3.1 and 3.4 cm. Overall analysis showed comparable results between groups regarding LOS (mean difference: 0.58; 95% confidence interval [CI]: -0.07 to 1.24; P = .08), SSI (risk ratio (RR): 0.90; 95% CI: 0.28-2.85; P = .85), and SSO rates (RR: 1.07; 95% CI: 0.17-6.55; P = .94). In addition, no statistically significant results were seen for readmission (RR: 1.50; 95% CI: 0.79-2.85; P = .21) and reoperation rates (RR: 1.16; 95% CI: 0.47 to 2.86; P = .74). Conclusion: This meta-analysis found similar postoperative outcomes for both laparoscopic IPOM and robotic RM techniques. Future studies are still required to evaluate the role of these operative methods following small- and medium-sized VHR.

Introduction: The rising prevalence of obesity in the United States is paralleled by an increase in type II diabetes (T2D) and metabolic-associated steatotic liver disease. While lifestyle changes often do not afford sustainable weight loss, bariatric surgery, particularly sleeve gastrectomy (SG), offers a durable solution. This study investigates long-term outcomes in Veterans who underwent SG with concurrent liver biopsy. Methods: All patients undergoing SG with a liver biopsy from January 2018 to March 2021 were included. Baseline demographics and comorbidities included age, gender, race, preoperative BMI, hemoglobin A1c (HgbA1c), T2D, hypertension (HTN), gastroesophageal reflux disease (GERD), obstructive sleep apnea (OSA), and presence of steatosis and fibrosis. Patients were followed postoperatively at 1, 3, and 5 years. Patient demographics and comorbidities were stratified by liver scores and compared pre- and postoperatively. A paired t-test compared variables. Multivariate linear regression assessed associations between liver pathology and BMI. Multivariate logistic regression analyzed associations between comorbidities and liver pathology. A P < .05 was significant. Results: A total of 95 patients underwent a laparoscopic SG with a liver biopsy. There was a level of steatosis (81%) or fibrosis (76.8%) in the majority of biopsies. For the entire cohort, there was a significant BMI reduction from baseline (40.6 ± 3.0 kg/m²) at 1, 3, and 5 years (33.9 ± 4.2, 35.0 ± 4.6, 34.7 ± 4.9 kg/m²; P < .001). At 5 years, % total weight loss (TWL) for no, low, and high liver scores was 18.3 ± 7.5, 13.5 ± 1.6, and 13.7 ± 2.5(P = .82). At 5 years postoperatively, there were significant reductions in mean HgbA1c level (6.2 versus 5.7, P < .001), T2D (47.4% versus 36.8%, P < .001), HTN (56.8% versus 39.0%, P < .001), GERD (49.5% versus 31.6%, P < .001), and OSA (66.3% versus 42.1%, P < .001). There was no significant difference in any postoperative comorbidity, BMI, or %TWL based on pathological liver scores (P > .05). Conclusion: This study underscores the long-term efficacy of SG in a predominantly African American Veteran cohort, irrespective of liver pathology. These results advocate for bariatric surgery to treat obese patients with liver disease, and even those with advanced hepatic conditions can achieve substantial health benefits.

Background: The aim of this study is to compare the postoperative outcomes of laparoscopic intracorporeal rectus aponeuroplasty (LIRA) technique with the defect closure technique using sutures and intraperitoneal mesh (IPOM plus), evaluating recurrence and bulging rates at least one year postoperatively. The secondary objective is to compare postoperative complications: seroma and pain at 30 days, 6 months, and 1 year post-surgery. Methods: Patients with midline primary ventral and incisional hernias between 4 and 10 cm were included. A CT scan was performed on all patients to assess the correct spatial values preoperatively and at 1 month, 6 months, and 12 months postoperatively. Pain was evaluated using the visual analog scale. Results: A total of 50 patients underwent LIRA, and 48 patients underwent IPOM plus between January 2022 and May 2023. The mean defect area in the LIRA group was larger than in the IPOM plus group (63.5 ± 37.5 cm² versus 55.2 ± 33.9 cm²). In the LIRA group, 2/48 instances of bulging (4.4%) occurred, whereas in the IPOM plus group, there were 6/50 instances of bulging (21.3%) and 2/50 recurrences (6.4%). One month post-surgery, a clinical seroma was observed in 8/48 patients (16%) and 9/50 patients (18.7%) in the LIRA and IPOM plus groups, respectively, with complete resolution at 6 months. Postoperative pain was found to be lower in the LIRA group. Conclusions: In this study, the LIRA technique demonstrated lower rates of bulging, recurrence, and postoperative pain compared with IPOM plus at 1 year of follow-up. Further multicentric prospective studies with a larger patient sample and longer follow-up are necessary to draw definitive conclusions.