Journal of Laparoendoscopic & Advanced Surgical Techniques最新文献

Background: Paraesophageal hernia (PEH) repair via laparoscopy has evolved significantly over the past decades, aiming to reduce the symptoms of recurrence and gastroesophageal reflux disease (GERD). This study evaluates short- and long-term outcomes of laparoscopic PEH repair with emphasis on surgical technique evolution, mesh use, fundoplication, and anterior gastropexy.

Methods: We retrospectively analyzed 341 consecutive patients who underwent laparoscopic repair for primary or recurrent PEH from March 2003 to March 2024. Surgical techniques varied over time, especially concerning mesh type, fundoplication strategy, and use of gastropexy. Main outcomes were recurrence of PEH or GERD. Secondary endpoints included intra- and postoperative complications.

Results: Of 341 patients, 91% received mesh reinforcement and 80% underwent fundoplication. Recurrence occurred in 66.7% of patients treated with suture-only hiatoplasty versus 3.9% with mesh reinforcement (P < .001). GERD recurrence was significantly lower in patients with Nissen-Rossetti (0%) and Toupet (7.5%) fundoplication compared to no fundoplication (40.0%) or suture-only hiatoplasty (66.7%). Anterior gastropexy, introduced systematically since 2020, was associated with improved anatomical stability. Early postoperative complications occurred in 8% of patients. The most common was left pleural opening (66.7%), followed by hemopericardium (11.1%), gas bloat syndrome (11.1%), and one case of splenic injury. Two patients experienced gastric wall perforation after fundoplication, requiring reoperation. Overall mortality was 0.6%.

Conclusion: Tension-free hiatoplasty reinforced with mesh is essential to minimize recurrence. The routine use of anterior gastropexy, particularly in large hernias, further improves anatomical stability. Tailored fundoplication and proper functional assessment complete an effective, individualized surgical approach.

Background: Smoking is associated with higher complication and recurrence rates in ventral and inguinal hernia repairs, but evidence is fragmented. This study evaluated the efficacy of AI-based large language models (LLMs) for identifying literature on the impact of smoking on hernia repairs.

Methods: ChatGPT 4.0, ChatGPT 4o, Microsoft Copilot, and Google Gemini were instructed to search PubMed, Embase, and Scopus for retrospective/prospective studies and randomized controlled trials regarding smoking's effects on ventral and inguinal hernia repairs. The models' outputs were cross-checked against previous systematic reviews to assess accuracy.

Results: The artificial intelligence (AI) tools generated 24 citations, of which only nine (37.5%) proved valid and relevant. Thirteen (54.2%) were fabricated references, and two (8.3%) cited studies that did not match the specified criteria. Additionally, the AIs identified two studies missed by previous systematic reviews but overlooked 35 (79.5%) recognized by those reviews.

Conclusions: Although LLMs can quickly compile potentially relevant references, they are prone to fabricating or omitting crucial studies. Human verification remains essential for conducting reliable, comprehensive literature searches in systematic reviews and meta-analyses.

Background: Retroperitoneal ectopic pregnancy is a rare form of ectopic pregnancy, accounting for less than 1% of all cases. This location carries a high risk of massive hemorrhage due to its proximity to major retroperitoneal vessels.

Case presentation: A 24-year-old female patient, G1P1, presented with a 2-week history of abdominal pain, which had exacerbated in the last 24 hours, accompanied by fever. Laboratory tests revealed elevated serum β-hCG levels (89,331 IU/L), anemia (Hb 8.1 g/dL), and leukocytosis. Abdominal ultrasonography and computed tomography (CT) identified a heterogeneous retroperitoneal mass anterior to the left psoas muscle, consistent with an ectopic pregnancy. An exploratory laparotomy was performed, with the successful removal of the gestational sac and embryo.

Methods: A retrospective review of the medical records of a patient diagnosed with a retroperitoneal ectopic pregnancy was performed. Demographic data, clinical findings, imaging studies (ultrasonography and CT), intraoperative findings, and postoperative follow-up were analyzed. A literature search was conducted across databases (PubMed, SciELO) to compare the case with current literature.

Conclusion: Retroperitoneal ectopic pregnancy is a rare but potentially life-threatening entity that requires early diagnosis via serum β-hCG and imaging studies (ultrasound, CT), as well as immediate surgical treatment to prevent catastrophic complications.

Background: Pancreaticoduodenectomy (PD) is a high-risk surgical procedure associated with significant postoperative morbidity. While complications such as pancreatic fistula and delayed gastric emptying are well-studied, the incidence and risk factors of incisional hernia (IH) following PD remain poorly characterized. This systematic review and meta-analysis aimed to evaluate the incidence of IH and identify associated risk factors in patients undergoing PD.

Methods: We conducted a systematic search of PubMed, Embase, CENTRAL, and Web of Science databases from inception to December 2024, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies reporting IH incidence after PD were included. The primary outcome was the pooled incidence of IH. Secondary outcomes included risk factors associated with IH. A random-effects model was used for meta-analyses, and heterogeneity was assessed using I² statistics. Risk of bias was evaluated using the ROBINS-I tool.

Results: A total of 6 studies comprising 1929 patients met inclusion criteria. The pooled incidence of IH following open PD was 6% (95% CI: 2%-15%), with substantial heterogeneity (I² = 94%). Risk factors significantly associated with IH included BMI ≥ 30 kg/m² (OR range: 1.67-2.6), preoperative hypoalbuminemia (OR 3.4; 95% CI: 1.2-9.4), chronic obstructive pulmonary disease (HR 24.4; 95% CI: 1.6-391.9), elevated preoperative CRP (HR 11.4; 95% CI: 1.2-103.1), postoperative fascial dehiscence (HR 14.1; 95% CI: 1.10-180.4), and wound infection (OR 2.9; 95% CI: 1.8-4.6). Sensitivity analyses confirmed the robustness of incidence estimates.

Conclusion: IH is a relatively underrecognized yet significant complication following PD, with a pooled incidence of 6%. Several modifiable and non-modifiable risk factors contribute to its development. These findings underscore the need for targeted preventive strategies in high-risk patients and further research to inform surgical decision-making and postoperative care.

Background: During robotic total gastrectomy (RTG) for advanced proximal gastric cancer, splenic hilar lymphadenectomy is technically difficult because of the complexity of the vascular anatomy at the splenic hilum. In this report, surgical techniques and initial experience with the cranial approach to the gastrosplenic ligament during robotic spleen-preserving splenic hilar lymphadenectomy (RSPSHL) are presented.

Materials and methods: This procedure was performed for 15 patients with advanced proximal gastric cancer who underwent RTG from January 2021 to December 2024.

Results: Operative time was 383 (290-546) minutes, and estimated blood loss was 43 (5-80) g. The required time for RSPSHL was 85 (50-195) minutes. The numbers of retrieved lymph nodes in total and in the splenic hilum were 54 (40-71) and 4 (2-7). There were no conversions to laparotomy and no postoperative complications of Clavien-Dindo grade ≥III.

Conclusions: This surgical approach provides an excellent operative view at the splenic hilum, making it safe and precise to perform RSPSHL.

Background: Most pediatric inguinal hernias (PIH) result from congenital patency of the processus vaginalis; however, a subset arises from acquired mechanisms involving posterior wall weakness. Representative examples include direct hernias and metachronous contralateral inguinal hernias (MCIH) that develop following negative laparoscopic exploration. In such cases, high ligation alone may be insufficient. This study aimed to evaluate the outcomes of laparoscopic iliopubic tract repair (IPTR) in acquired PIHs, focusing on recurrence, surgical outcomes, and safety.

Methods: From January 2013 to December 2022, 12,792 pediatric patients younger than 10 years underwent laparoscopic inguinal hernia repair. Among them, 21 patients diagnosed with acquired PIHs were treated with laparoscopic IPTR. The repair involved suturing the iliopubic tract to the transversalis fascia using nonabsorbable suture to reinforce the posterior wall. We evaluated surgical outcomes, including recurrence and safety.

Results: Of the 21 patients, 10 had direct hernias and 11 had indirect hernias of MCIH that were initially negative on laparoscopic evaluation but later developed into clinical PIHs. Compared with indirect PIH, direct PIH occurred in patients who were significantly older and heavier (P = .017 and P = .020, respectively). The omentum was the sole herniated organ in direct cases (P < .001). All surgeries were completed laparoscopically without conversion, and no intraoperative or postoperative complications occurred. At a median follow-up of 78 months, no recurrences were observed.

Conclusions: Laparoscopic IPTR is a safe and effective surgical approach for acquired PIHs. It provides reliable posterior wall reinforcement and may reduce the risk of recurrence.

Introduction: Superior mesenteric artery syndrome is a rare condition caused by compression of the third portion of the duodenum between the aorta and the superior mesenteric artery, usually due to an aortomesenteric angle of less than 25°. It presents with chronic abdominal pain, vomiting, early satiety, and weight loss and is more common in young women. Diagnosis is confirmed by imaging studies, primarily computed tomography.

Case presentation: A 20-year-old patient with a history of an eating disorder presented with chronic abdominal pain, vomiting, and weight loss. Computed tomography revealed an aortomesenteric angle of 15° and a distance of 4 mm. After failure of conservative treatment, a laparoscopic duodenojejunostomy was performed, with excellent postoperative outcomes and hospital discharge on postoperative day 5.

Discussion: Superior mesenteric artery syndrome remains a diagnostic and therapeutic challenge due to its low prevalence and nonspecific clinical presentation. Initial management focuses on nutritional rehabilitation. When conservative treatment fails, surgical intervention is indicated. Among surgical options, laparoscopic duodenojejunostomy is the procedure of choice.

Conclusion: This case highlights the importance of early recognition in young patients with weight loss and chronic obstructive symptoms. Laparoscopic duodenojejunostomy represents a reliable and minimally invasive surgical solution for patients who do not respond to conservative therapy.

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.