Journal of Laparoendoscopic & Advanced Surgical Techniques最新文献

Background: Laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB) remain the most commonly performed bariatric operations worldwide; however, LSG is increasingly associated with weight regain, and the optimal revisional strategy remains debated. Bypass procedures offer potent metabolic effects but carry substantial long-term risks of micronutrient deficiencies, particularly iron and calcium, due to duodenal exclusion. Emerging evidence supports the role of both foregut and hindgut mechanisms in metabolic improvement, though neither theory fully explains the complexity of postoperative glucose homeostasis. This has stimulated interest in procedures that preserve duodenal continuity while still providing metabolic benefits.

Methods: A new concept of intestinal bipartition-jejunal bipartition associated with sleeve gastrectomy (JB + SG)-was developed to maintain complete duodenal passage while introducing a controlled hypoabsorptive component. The technique divides the ileum according to BMI-based criteria and creates two anastomoses: a proximal jejuno-ileal anastomosis at 30 cm from the Treitz angle and a distal jejuno-ileal anastomosis connecting the remaining jejunum to the terminal ileum. This configuration ensures full intestinal continuity and individualized malabsorptive effect.

Results: JB + SG preserves duodenal transit, promoting physiological iron, calcium, and fat-soluble vitamin absorption. The dual stimulation of the proximal and terminal ileum enhances incretin release, potentially improving metabolic outcomes beyond standard LSG. Compared with RYGB, JB + SG reduces risks of marginal ulcers, dumping syndrome, severe hypoglycemia, and long-term micronutrient deficiencies. Despite requiring two anastomoses, the procedure remains technically feasible and maintains options for future revisions, including conversion to a full duodenal switch.

Conclusions: Jejunal bipartition represents a promising physiological alternative to traditional bariatric procedures, offering enhanced metabolic benefits with improved nutritional safety. Long-term, multicenter clinical studies are essential to validate its efficacy, durability, and safety.

Background: Laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass (RYGB) are effective bariatric procedures but are associated with long-term complications, including gastroesophageal reflux and marginal ulcers. The metabolic reversible sleeve (MRS) is a novel, reversible procedure designed to preserve gastric anatomy while providing metabolic benefits. The aim of the current article is to report the safety outcomes of the first 10 consecutive patients undergoing MRS.

Methods: Preoperative evaluation included nutritional, psychiatric, and radiological assessments. The operative technique involved laparoscopic gastric bipartition and jejunal bypass, preserving the stomach. Perioperative management followed a standardized protocol. Safety outcomes, including intraoperative complications, postoperative morbidity, and early readmissions, were recorded.

Results: Ten patients (5 females, 5 males; mean BMI: 50.74 kg/m²) underwent MRS. All procedures were completed laparoscopically without conversion. Operative time averaged 159 ± 31 minutes. There were no intraoperative complications. Postoperative recovery was uneventful in all patients: no anastomotic leaks, bleeding, or need for reoperation occurred. All patients were discharged between postoperative day 2 and 3. Early postoperative laboratory values (hemoglobin and C Reactive protein (CRP)) were within expected ranges (mean of hemoglobin = 13.3 ± 1.0 g/dL, mean of CRP = 90.4 ± 36.9 mg/L). Mild, transient nausea occurred in 2 patients and resolved spontaneously.

Conclusion: In this initial series, MRS appears to be a safe and feasible bariatric procedure, with no major perioperative complications. Larger studies with long-term follow-up are required to confirm safety and efficacy.

Over the past two decades, sleeve gastrectomy has become the most widely performed bariatric operation, yet growing long-term evidence has highlighted limitations such as weight recurrence, gastroesophageal reflux, and declining metabolic durability, prompting a shift toward refining rather than abandoning sleeve-based strategies. The articles in this special issue collectively demonstrate how thoughtful innovations-ranging from metabolic enhancements and reflux-preserving solutions to reversible procedures and preventive diagnostic measures-can expand the therapeutic scope of sleeve gastrectomy while maintaining physiological continuity and minimizing long-term morbidity. Together, they articulate a unifying vision for the future of bariatric surgery: individualized, adaptable, and physiology-respecting interventions that prioritize durable outcomes and quality of life over increasingly radical anatomical alteration.

Purpose: This exploratory study aimed to compare the surgical outcomes of ultrasonic dissection and monopolar electrocautery in single-incision laparoscopic totally extraperitoneal repair (SILS-TEP) for inguinal hernia.

Methods: A single-center exploratory randomized controlled trial was conducted between July 2022 and December 2023, enrolling 62 patients with unilateral inguinal hernias. Patients were randomized to undergo SILS-TEP using ultrasonic dissection (U group, n = 30) or monopolar electrocautery (E group, n = 32). The primary outcome was the completion rate of SILS-TEP. Secondary outcomes included the intraoperative complication rate, operative time, blood loss, and postoperative complication rate.

Results: Patient characteristics were similar, except for a higher proportion of right-sided hernias in the U group (66.7% versus 31.3%, P = .010). Completion rates were comparable (96.7% versus 96.9%, P = 1.00). Operative time (60 [interquartile range {IQR} 53.5-71.5] minutes versus 62.5 [IQR: 51-74.5] minutes, P = .72) and blood loss were also similar. Lens cleaning was more frequently required in the U group (4 [IQR: 2.5-5] times versus 1 [IQR: 1-4] time, P = .025). Intraoperative and postoperative complications, length of postoperative hospital stay, and recurrence rates showed no notable differences.

Conclusion: In this exploratory analysis, monopolar electrocautery in SILS-TEP showed comparable surgical outcomes to ultrasonic dissection. Larger confirmatory studies are warranted to validate these findings. (UMIN000057091).

Aims: Robot-assisted laparoscopic pyeloplasty (RALP) pyeloplasty in infants with pelvi-ureteric junction obstruction (PUJO) poses distinct challenges due to limited working space, small anatomical structures, and the need to adapt adult robotic systems for pediatric use. This study presents surgical experience and highlights technical refinements that optimize the procedure and reduce complications.

Methods: A retrospective review was conducted of infants who underwent RALP between January 2023 and May 2025 using the da Vinci Xi system. Operative challenges were analyzed, and standardized strategies were implemented to improve exposure, minimize complications, and achieve precise anastomosis. Postoperative outcomes were assessed using renal ultrasonography and EC scans.

Results: Eleven male infants (mean age: 5.9 months; mean weight: 6.7 kg) underwent unilateral robotic dismembered pyeloplasty. All had antenatally detected hydronephrosis, with postnatal confirmation of PUJO (left: 6; right: 5). Presenting features included urinary tract infection (18.1%), palpable lump (45.4%), and asymptomatic cases (36.3%). Associated anomalies were noted in 45%-crossing vessels (n = 2), crossing vessel with malrotated kidney (n = 1), undescended testis (n = 1), and left renal agenesis (n = 1). All surgeries were completed robotically without conversion. Three robotic arms were used, omitting the assistant port. Mean operative time was 168 minutes, with a console time of 133.3 minutes. The average hospital stay was 4.4 days. Several technical refinements-preoperative bowel decompression, aspiration of the dilated renal pelvis, supraumbilical camera port placement, optimal port spacing, burping of trocars, and precise alignment of the remote center-were crucial in facilitating effective surgery within the restricted working space. No intraoperative complications were encountered. On follow-up (mean duration: 17.8 months), 90% of patients demonstrated improved drainage, while one required a redo pyeloplasty.

Conclusion: RALP in infants is a technically feasible, safe, and effective procedure when performed with appropriately tailored technical modifications and refinements.

Background: Robotic-assisted laparoscopic adrenalectomy (RALA) became a useful tool for the treatment of adrenal lesions. This study aims to identify areas where RALA may offer better outcomes than laparoscopic techniques.

Methods: We conducted a retrospective study between August 2014 and November 2024. We involved 321 patients who underwent adrenalectomy during this time. Among these patients, 170 had laparoscopic adrenalectomy (LA), and 151 underwent RALA. We grouped these patients according to the surgical approach, collected, and analyzed preoperative data, and compared their perioperative and postoperative outcomes.

Results: In this study, we compared two groups, showing the robotic approach was associated with a significantly shorter operative time compared with the laparoscopic group, 100.5 (±51.7) minutes versus 117.9 (±67.4) minutes, P = .02. There were no significant differences in estimated blood loss (P = .97) or conversion to open (P = .6) between the two groups. But robotic patients did exhibit a shorter duration of hospital stay, a median of 1 versus 2 days in the case of the laparoscopic approach, P value <0.01, and statistically lower 30-day complication rates in the robotic approach, 7.3% versus 14.7%, P = .035. Other short- and long-term complications were comparable between the two groups. Subanalysis of large tumor mass (>5 cm) showed comparable outcomes, with robotic cases showing statistically lower early complication rates (P = .05).

Conclusion: The study shows that RALA offers some advantages compared to the traditional LA, particularly with shorter operative time, lesser hospital stay, and fewer early complications. More randomized trials will help to confirm the findings and reach a more definitive conclusion.

Background: Intragastric balloons (IGB) have been used for more than 40 years to reduce weight in overweight and obese patients. The purpose of the current study will be to evaluate our case series regarding different types of IGB.

Methods: A total of 2454 patients who underwent IGB placement between 2002 and2022 were included in a retrospective single-center study. There were used in the majority of cases 3 types of IGB. The primary outcome of the current study was the evaluation of weight loss results at 6 and 12 months after IGB. The secondary outcome was the evaluation of the results between different approaches for the IGB placement: by endoscopy versus balloon placed without endoscopy; with adjuvant therapy (e.g., hypnosis) versus without.

Results: Various intragastric devices were employed, including the Orbera® intragastric balloon for 6 months in 1290 cases (52.6%), Orbera 365® in 614 cases (25.1%), the Allurion® intragastric balloon in 508 cases (20.7%), and other devices in 42 cases (1.7%). We have recorded 22 cases (0.89%) with different types of complications as follows: 14 cases (63.6%) severe hypokalemia requiring hospitalization; 4 cases (18. %) of spontaneous balloon deflation; 2 patients (9.1%) who necessitated a laparoscopic surgery; 1 case (4.5%) of hyperinflation; 1 case (4.5%) of Mendelson syndrome. The percentage total body weight loss was 12.1% ± 5.2%. There were no major intra-procedure adverse events and no mortality recorded.

Conclusions: Recent advancements, such as the integration of robust multidisciplinary support-especially hypnotherapy-and the systematic application of ultrasound to reduce premature withdrawals, require validation through multicentric studies.

Background: Biliary tree cysts (BTCs) are rare congenital dilatations of the bile ducts associated with an increased risk of acute cholangitis and cholangiocarcinoma (CCA). Over the past two decades, surgical resection has become the standard of care in the management of BTCs. The most widely accepted classification, introduced by Todani in 1977, is based on cyst morphology. However, from a surgical perspective, BTCs can also be categorized by location as intrahepatic, extrahepatic, or mixed.

Methods: We conducted a retrospective analysis of 31 patients who underwent surgical resection for BTCs between 2005 and 2021 at two centers: Hospital de la Santa Creu i Sant Pau (Barcelona, Spain) and Ospedale San Paolo (Savona, Italy). Patients were divided into two groups based on cyst location: intrahepatic (IHG) and extrahepatic (EHG). Perioperative data, postoperative complications, oncological outcomes, and long-term survival were compared between groups.

Results: A total of 31 patients were included: 15 in the IHG and 16 in the EHG. Baseline characteristics were similar across groups. The median operative time was 196 minutes (range: 120-300) in the IHG and 156 minutes (range: 90-240) in the EHG (P = .073). There were no significant differences in postoperative complications. Median postoperative hospital stay was 12 days (range: 5-34) in the IHG and 18 days (range: 7-39) in the EHG (P = .123). After a median follow-up of 68 months, 26 patients (83.9%) were alive and in good clinical condition. Three patients died from causes unrelated to surgery, while 2 patients-both with histologically confirmed CCA-died from disease progression. No significant difference in overall survival was observed between the two groups (P = .192).

Conclusion: Surgical resection of BTCs is safe and feasible. Perioperative outcomes and long-term survival are comparable between intrahepatic and extrahepatic BTCs, supporting surgery as an effective treatment regardless of cyst location.

Background: Chat Generative Pre-Trained Transformer (ChatGPT) has emerged as a widely accessible large language model (LLM) with potential applications in medicine. While early literature has explored ChatGPT's role in various surgical specialties, its impact on general surgery remains less defined. This systematic review evaluates current evidence on the educational, clinical, and research applications of ChatGPT within the field of general surgery.

Methods: A comprehensive search was performed of PubMed, Cochrane Central, Scopus, SciELO, and LILACS from inception to December 2023. Studies were included if they evaluated the utility of ChatGPT in general surgery across educational, research, and clinical domains. We included both analytic data and descriptive studies. Studies involving other AI platforms and conference abstracts were excluded.

Results: Of 550 screened studies, 23 met inclusion criteria and demonstrated ChatGPT's broad applicability across surgical domains. Specifically, 6 studies demonstrated its capability to answer common questions about surgical diseases, 7 assessed its utility in clinical practice, 11 focused on educational applications, and 5 examined its potential role in research. Notably, ChatGPT exhibited proficiency in providing anatomical explanations and answering open-ended questions, achieving up to 87% accuracy for colorectal surgical questions, though performance was more variable for appendicitis queries. In board exam-style assessments, its accuracy ranged from 48% to 66% for open-ended questions and 68% to 76.4% in multiple-choice formats. Patient-facing responses were generally rated favorably, particularly in bariatric, transplant, and pancreatic surgery domains, with several studies highlighting ChatGPT's clarity and comprehensiveness compared to traditional medical literature. In clinical decision-making scenarios, ChatGPT's concordance with clinical experts varied widely across studies, from 0% to 86.7% in colorectal surgery studies and 30% in bariatric cases. ChatGPT proved effective in drafting informed consent documents and comprehensive surgical notes. However, limitations were observed in its ability to provide accurate references and in data extraction, though it did show promise in generating research ideas. Overall, while ChatGPT shows potential across education, clinical practice, and research, its reliance on human evaluation remains crucial.

Conclusion: Overall, while ChatGPT shows significant potential across the realms of surgical education, clinical practice, and research, its outputs require ongoing human oversight and expert validation.PROSPERO Registration:CRD420251107155.

Background: Minimally invasive surgery in intravesical ureteral reimplantation has proven to be safe and successful in patients with vesicoureteral reflux. This study investigates a novel application of the Leadbetter-Politano procedure for primary obstructive megaureter, focusing on specific challenges in vesicoscopic reimplantation of ureters with large diameters in pediatric patients.

Methods: Between 2010 and 2024, 26 children underwent ureteral reimplantation according to Leadbetter-Politano without tapering for primary obstructive megaureter in our clinic. A total of 12 children were operated on vesicoscopically, 14 patients were operated on open-surgically. This retrospective single-center case-control study compares open and vesicoscopic groups with regard to perioperative data and postoperative course.

Results: All vesicoscopic Leadbetter-Politano reimplantations started were performed safely, even in young infants of 6 months. The operation time was longer for vesicoscopy (vesicoscopic: 149 minutes, open: 119 minutes, P = .013). Furthermore, vesicoscopic patients had a shorter hospital stay (vesicoscopic: 4.8 days, open: 10.4 days, P < .001), as well as a lower need for continuous analgesic administration (vesicoscopic: 0.5 days, open: 3.8 days, P < .001). There was no extravasation, recurrence, or postoperative vesicoureteral reflux found in any patient.

Conclusions: The vesicoscopic Leadbetter-Politano procedure proves to be feasible in reimplantation of primary obstructive megaureter, even in very young infants. Reduced need for pain medication, shorter bladder drainage, and faster mobilization, and thus shorter hospital stay, show that this method offers major advantages to patients at an equivalent success rate compared to its open counterparts.