Journal of Laparoendoscopic & Advanced Surgical Techniques最新文献

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.

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.