Journal of Laparoendoscopic & Advanced Surgical Techniques最新文献

Background: Traditional open surgical repairs, including flap techniques, are associated with high recurrence rates and significant morbidity. Robotic-assisted techniques have emerged as promising alternatives to conventional methods due to improved visualization, precision, and reduced postoperative complications. The robotic transanal minimally invasive surgery (R-TAMIS) technique offers a new route for rectovaginal fistula (RVF) repair, providing enhanced dexterity and access through the transanal approach. Methods: An R-TAMIS technique was employed for same-day repair of RVF using the da Vinci Xi® system. After bowel preparation and prophylactic antibiotics, the patient was positioned in prone Jackknife. The GelPOINT Path was used for transanal access, and robotic ports were placed. The fistula tract was identified and dissected circumferentially. The vaginal wall was closed with absorbable barbed sutures, reinforced with fibrin sealant and acellular dermal mesh. The rectal wall was then closed, and patency was confirmed via endoscopic inspection. Results: The procedure was well tolerated, and the patient was discharged the next day. Minimal postoperative pain was reported but didn't require analgesics. No major complications were observed in the immediate postoperative period. The robotic approach provided enhanced visualization and dexterity, facilitating precise dissection and suturing. The technique has already been successfully applied to benign RVFs and select rectourethral fistulas. Conclusion: Robotic-assisted transanal repair using the R-TAMIS technique is a feasible and effective minimally invasive option for selected patients with benign RVFs. With proper patient selection and dedicated surgical technique, this approach may reduce morbidity and improve outcomes compared to traditional open or laparoscopic methods.

Background: This study aimed to compare the safety and efficacy of laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB) in patients aged 60 and older, focusing on postoperative weight loss, improvement in obesity-related comorbidities, and perioperative outcomes. Methods: This was a retrospective analysis of data from three bariatric surgery centers with surgeries performed between January 2019 and September 2024. The study included patients aged ≥60 years who underwent either LSG or RYGB. The primary outcome was the comparison of weight loss metrics (excess weight loss [%EWL] and total weight loss [%TWL]) between LSG and RYGB. Secondary outcomes included the remission or improvement of type 2 diabetes mellitus (T2DM) and hypertension (HTN), 30-day postoperative complications, operative time, and length of hospital stay. Results: A total of 168 patients aged ≥60 who underwent LSG (n = 130) or RYGB (n = 38) were included. Both procedures resulted in similar weight loss outcomes, with a median %EWL of 58.6% for LSG and 61.2% for RYGB. The median %TWL was 23.1% for LSG and 26% for RYGB, with no significant differences between the groups (P = .275). The operative time was significantly shorter for LSG (60 minutes versus 110 minutes for RYGB, P < .001), and LSG patients had a shorter hospital stay (2 versus 3 days, P < .001). The 30-day complication rate was low for both groups, with no significant difference in complications between LSG and RYGB. Regarding comorbidity resolution, 90.7% of patients with T2DM and 93.6% with HTN experienced improvement or remission. Complete remission was achieved in 39% of all T2DM cases (37.5% in LSG, 42.9% in RYGB) and in 33% of all HTN cases (33.3% in LSG, 31.6% in RYGB), with no statistically significant differences between the groups. Conclusions: Bariatric surgery appears safe in older adults when guided by careful patient and procedure selection through multidisciplinary assessment. Both LSG and RYGB yielded comparable weight loss and remission outcomes for T2DM and HTN in this population.

Background: We describe a novel extracorporeal knotting approach (ECKA) that enables secure mesh fixation via extracorporeal suture manipulation, anchoring the mesh firmly within the abdominal cavity. Methods: A retrospective analysis was conducted on 17 patients (14 males, 3 females) who underwent laparoscopic herniorrhaphy with mesh fixation using the ECKA technique. Key parameters included patient demographics, method of hernia repair (totally extraperitoneal [TEP] or transabdominal preperitoneal [TAPP]), laterality, and operative duration. Hernias were classified by procedure, with each side analyzed independently. Results: From April 2024 to July 2025, a total of 21 hernia procedures were performed on 17 patients using the ECKA technique. The average patient age was 70.3 years (range: 47.1-88.5 years), with a mean body weight of 65.9 kg. Of the hernia types, 15 were direct, 3 were indirect, and 3 were mixed. Laterality distribution was as follows: right-sided (n = 6), left-sided (n = 7), and bilateral (n = 4). Nine procedures utilized the TAPP approach, while 12 were performed using the TEP approach. The average operative time was 88.4 minutes (range: 60.4-145.4 minutes). Postoperative analgesia consisted of diclofenac sodium administered three times daily for three days. No recurrences were observed during a mean follow-up period of 10.3 months (range: 2-17 months). Conclusions: The ECKA technique provides a reproducible, minimally invasive solution for fixing mesh in direct, indirect, and combined hernias via either TEP or TAPP approaches. Its extracorporeal knotting system streamlines mesh fixation, ensures consistent clinical outcomes, and enhances operative efficiency across various hernia configurations.

Background: Intestinal perforation (IP) is one of the most critical surgical emergencies in neonates. It most often occurs in premature infants, with necrotizing enterocolitis (NEC) as the leading cause. Hirschsprung's disease (HD) is another important etiology. In this study, we aimed to investigate the frequency of HD among neonates with non-NEC IP and assessed the value of performing rectal biopsy in these patients. Methods: Neonates who were treated for non-NEC IPs between 2005 and 2021 were evaluated retrospectively. Demographic data, clinical features, operative details, and rectal biopsy results were collected. These features were compared according to the histopathological results of rectal biopsy (aganglionic versus ganglionic). Results: Rectal biopsies were performed in 48 neonates with non-NEC IP (33 preterm [68.8%], 15 term [31.2%]). The most common perforation site was the ileum (52.4%). Rectal biopsy revealed aganglionosis in 12.5% of the patients. Gestational age was higher in aganglionic than ganglionic cases (36.7 versus 32.5 weeks; P = .026). The perforations were colonic in all aganglionic cases (n = 6) and 47.6% (n = 20) of the ganglionic cases (P = .025). Conclusion: This study highlights the importance of considering HD in the differential diagnosis of neonatal IPs. Rectal biopsy should be considered in non-NEC perforations; particularly in term (or near-term) neonates and in cases of colonic perforation, to help identify underlying aganglionosis and guide timely management. Level of Evidence: Level 3 b.

Introduction: Laparoscopic pyeloplasty (LP) for treatment of ureteropelvic junction obstruction (UPJO) in children offers advantages over open surgical correction, including reduced hospitalization times and lower perioperative morbidity, but presents a long learning curve. Robotic-assisted laparoscopic pyeloplasty (RALP) offers the same advantages with reduced technical operative complexity but entails higher costs. No clear superiority of laparoscopy versus robotic surgery has been established. Materials and Methods: We conducted a retrospective comparative cohort study including pediatric patients who underwent minimally invasive pyeloplasty at two tertiary-level centers, those at Evelina Children's Hospital in London (UK) receiving LP and those at Policlinico San Matteo in Pavia (Italy) undergoing RALP. Data concerning preoperative variables and obstruction severity; intraoperative variables and surgical techniques; degree of postoperative obstruction reduction, complications, and redo surgeries were analysed. Results: A total of 75 patients were included, with 47 undergoing LP and 28 receiving RALP, with similar preoperative characteristics across groups. The Anderson-Hynes surgical technique was employed in 71/75 cases (94.7%) with universal stent use. No conversions were recorded. Mean operatives times and postoperative length of stay were longer for RALP. Complications took place in 7/28 (25.0%) of RALP patients and 6/47 (12.7%) of LP patients. Redo surgery was needed for 1/28 (3.6%) RALP and 3/47 (6.4%) LP patients. These differences were not statistically significant. Symptoms resolution and postoperative pelvic diameter decrease were comparable between groups. Conclusions: RALP and LP appeared comparable in terms of safety and efficacy. Adoption of one technique over the other may be justified by the surgeon's preference and the availability of a robot.

Introduction: Benign prostatic hyperplasia is a leading cause of lower urinary tract symptoms in aging men. When medical therapy fails, surgery is indicated. This study evaluates the safety and efficacy of Aquablation compared with transurethral resection of the prostate (TURP) and Holmium laser enucleation of the prostate (HoLEP) in patients with bladder outlet obstruction. Methods and Materials: A prospective analysis of 318 Aquablation patients (2023-2025) was conducted and compared with 83 TURP and 83 HoLEP patients from a retrospective database. Functional outcomes were assessed using International Prostate Symptom Score (IPSS), ICIQ-UI, EF-IIEF, and MSHQ-EJD SF. Complications were graded using the Clavien-Dindo classification. Follow-ups were performed at 3, 6, and 12 months. Results: Aquablation patients had larger prostates than TURP (94 versus 54.7 cc; P < .0001) but smaller than HoLEP (105 cc; P = .002) patients. More Aquablation patients had indwelling catheters and were on anticoagulants (P < .0001). IPSS improvement was the greatest in Aquablation (18.9 points) versus TURP (13.8) and HoLEP (14.7; P = .000). Erectile function was preserved in Aquablation (P = .859), with significantly better ejaculatory function (82.8% preserved) than TURP (36%) and HoLEP (18%). Furthermore, Clavien-Dindo grade 1-2 complications were higher in Aquablation, but serious events (CD 3-4) were comparable. Complication rates declined significantly after the first 30 Aquablation cases. Conclusion: Aquablation is an effective surgical option for medium to large prostates, offering superior symptom relief and preservation of sexual function. Although its learning curve is shorter than HoLEP's, proper training is essential to minimize early complications.

Purpose: Historically, open surgery has been the treatment of choice for soft tissue lesions. This study aims to report an innovative soft tissue endoscopic surgery for subcutaneous and intramuscular lesions at our center. Methods: For this retrospective review, data on sex, age, symptoms, diagnosis, sites of surgery, previous treatment, surgery, and follow-up were collected from our Vascular Anomalies Center database. Patients with soft tissue lesions who had undergone endoscopic surgery between September 2019 and March 2024 were included. Soft tissue endoscopic surgeries included totally endoscopic surgery, endoscopy-assisted surgery, and conversion to open surgery. Results: In total, 122 patients were included: 74 females and 48 males, with ages ranging from 1 to 38 years (median, 7.5 years). Conditions for endoscopic surgery included various vascular anomalies and benign soft tissue tumors. Surgical sites included the lower extremity, upper extremity, abdominal wall, thoracic wall, back, gluteal region, and face. One hundred patients underwent totally endoscopic surgery, and 22 underwent endoscopy-assisted or conversion to open surgery. The operative duration was 40-530 minutes (median, 222 minutes). Blood loss was 1-1400 mL (median, 30 mL). No hemorrhage or wound dehiscence was observed within 30 days after surgery. Conclusions: Various subcutaneous and intramuscular conditions can be successfully managed with soft tissue endoscopic surgery. We think that this novel treatment approach can provide valuable references for clinicians of many specialties, encompassing general surgery, pediatric surgery, vascular surgery, plastic surgery, dermatologic surgery, and orthopedics.

Objective: While robotic-assisted surgery (RAS) has shown benefits in urology, its use in infants and toddlers remains relatively restricted. This study aims to evaluate the safety and feasibility of robotic surgery for renal disorders in this age group. Methods: A retrospective analysis was performed on the clinical data of 122 patients under the age of 3 who underwent robotic and laparoscopic surgeries (LSs) for renal disorders at our institution between December 2021 and September 2023. The analysis included demographic information, surgical techniques, and postoperative complications. Results: The study included 122 patients aged between 2.2 and 35.8 months. Of these, 66 patients underwent RAS (RAS group), whereas 56 patients underwent laparoscopic surgery (LS group). In cases of ureteropelvic junction obstruction (UPJO), RAS group showed shorter operative times and less blood loss than LS (P < .001). For the patients with renal dysplasia who underwent nephrectomy and ureterectomy, no significant differences were observed between the RAS and LS groups in terms of operative time, intraoperative blood loss, or hospital stay (P > .05). In patients with duplicated kidneys, RAS also demonstrated advantages in operative time (P = .001), blood loss (P = .019), and hospital stays (P < .001). However, RAS group incurred higher hospital costs (P < .001), with no significant difference in complication rates (P > .05). Conclusion: Although RAS incurs higher costs compared with LS, it remains both safe and feasible for the treatment of renal disorders in infants and toddlers. Notably, RAS shows significant advantages in managing UPJO and complete duplicated kidneys.

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.