Journal of minimally invasive surgery最新文献

Minimally invasive techniques are increasingly used in hepatobiliary and pancreatic surgeries, but robotic single-port (SP) splenectomy remains uncommon due to the rarity of splenic diseases. We present a case of a 57-year-old woman with left upper quadrant pain and a 4.3-cm splenic mass suggestive of hamartoma. Due to persistent symptoms and cosmetic concerns, robotic SP splenectomy was performed using the da Vinci SP system (Intuitive Surgical, Inc.) via a transumbilical incision, with an additional assist port in the left abdomen. The procedure lasted 264 minutes with minimal blood loss, and the patient was discharged without complications on postoperative day 9. Histopathology confirmed a splenic hamartoma. This case highlights the feasibility and safety of robotic SP splenectomy in adults, suggesting potential for wider application with further experience and refinement.

Purpose: Esophagojejunostomy leakage (EJL) remains one of the most critical complications following total gastrectomy for gastric cancer. This study aimed to evaluate the evolving therapeutic approaches and clinical outcomes of EJL using data from a large-scale multicenter retrospective cohort.

Methods: Among 6,577 patients who underwent total gastrectomy or proximal gastrectomy with double tract reconstruction at nine institutions from 2003 to 2024, 196 (3.0%) developed EJL. Of these, 162 patients with comprehensive clinical data were included in the final analysis. The study examined treatment modalities, changes in management over time, patient characteristics, surgical variables, and clinical outcomes. Four groups were defined according to treatment approach: conservative, endoscopic, reoperation, and multimodal (combined) therapy.

Results: Endoscopic therapy was first introduced in 2011 and has progressively supplanted reoperation, now comprising 32.5% of cases. The average time to EJL diagnosis was 8.4 days after surgery. Overall in-hospital mortality was 6.1% (10/162). When conservative management was excluded, endoscopic treatment demonstrated the highest rate of therapeutic success (94.3%, p = 0.004). Both the duration until diet resumption and length of hospital stay were notably reduced in the endoscopic and conservative groups compared with reoperation and multimodal therapy (p < 0.001). Moreover, although the highest post-leakage hospitalization costs were observed with multimodal treatment (p < 0.001), overall hospitalization expenses were significantly lower for patients managed conservatively or with endoscopic intervention (p < 0.001).

Conclusion: Over the past two decades, management of EJL has shifted toward endoscopic approaches. Endoscopic therapies yield superior clinical outcomes and should be considered a primary option for appropriate candidates.

Purpose: Following laparoscopic surgeries, patients often experience discomfort and dissatisfaction due to postoperative nausea and vomiting (PONV), despite using a multimodal pharmacological approach. The study compared the effects of triple drug prophylaxis with aprepitant-dexamethasone-ondansetron versus dual drug prophylaxis with dexamethasone-ondansetron in high-risk patients undergoing laparoscopic surgeries.

Methods: This randomized controlled trial enrolled 201 female nonsmokers who used opioids postoperatively and underwent elective laparoscopic surgery. Patients were allocated into two groups: dual prophylactic antiemetics and placebo (control group), and triple prophylactic antiemetics with preoperative administration of aprepitant 80 mg (group A). Group A received oral aprepitant 80 mg 2 hours before the surgery, and the control group received a placebo. Patients were assessed at two time points: 2 hours after surgery, either in the postanesthesia care unit or in the ward, and 24 hours after surgery in the ward.

Results: Patients in group A reported a PONV incidence of 10% as compared to 22.7% in the control group (relative risk,0.43; 95% confidence interval [CI], 0.22-0.89; adjusted p = 0.01) at 2 hours in the postoperative period. At 24 hours postoperatively, patients in group A experienced significantly lower incidence of PONV (10%) compared to the control group (29.7%; relative risk, 0.33; 95% CI, 0.17-0.64; p < 0.001). Also, the need for rescue antiemetics was reported to be lower in patients in group A. No adverse effects were reported with any of the drugs used.

Conclusion: The study suggests that prophylaxis with a triple antiemetic regimen consisting of aprepitant-dexamethasone-ondansetron results in a lower incidence of PONV compared with a two-drug regimen using dexamethasone-ondansetron in high-risk patients with three or more risk factors.

Internal hernias are a rare cause of small bowel obstruction. Broad ligament hernias are particularly rare and often present with nonspecific symptoms and subtle imaging findings, complicating diagnosis. Herein, the case of a 34-year-old female with acute colicky pain, obstipation, and intermittent constipation lasting 1 week is reported. Clinical examination revealed tachycardia, abdominal distension, and generalized tenderness. Imaging confirmed small bowel obstruction without an identifiable cause. Emergency laparoscopy revealed a 5-cm defect in the left broad ligament, through which viable bowel had herniated, resulting in a closed-loop obstruction. The herniated bowel was reduced, and the defect was closed with continuous sutures. The patient's recovery was uneventful. This case underscores the diagnostic challenges of broad ligament hernias and highlights the utility of laparoscopy as a diagnostic and therapeutic tool. Despite their rarity, broad ligament hernias should be considered in women with unexplained bowel obstruction.

Robotic surgery systems, including the Korean-developed Revo-i surgical robotic system (Meerecompany Inc.), have expanded from routine cholecystectomies to complex hepatobiliary and pancreatic (HBP) procedures. We report two cases: one of choledochal cyst excision with Roux-en-Y hepaticojejunostomy, and another of extended cholecystectomy for gallbladder cancer, both performed entirely robotically using Revo-i. Both patients recovered without immediate postoperative complications and were discharged on postoperative day 7. These cases are the first to demonstrate the technical feasibility of fully robotic complex HBP surgeries with Revo-i, including the first reported choledochal cyst excision and extended cholecystectomy. Further experience and research are needed to confirm the safety and broader applicability of this system in HBP surgery.

Incisional hernia remains a significant challenge following abdominal surgery, necessitating robust repair strategies to mitigate recurrence and wound complications. While the introduction of synthetic mesh has improved durability, complex defects with significant loss of domain or lateral extension often exceed the limitations of traditional repair techniques. The transversus abdominis release (TAR) has emerged as a cornerstone technique in abdominal wall reconstruction, offering a physiological solution by mobilizing the posterior rectus sheath and creating a wide retromuscular plane for extensive mesh reinforcement. This review provides a comprehensive overview of the TAR procedure, encompassing anatomical considerations, current classification systems, and specific indications. We detail the surgical technique, emphasizing critical steps such as neurovascular preservation and the recent "Madrid modification" for enhanced outcomes. Furthermore, we compare the established open TAR with the emerging robotic TAR, highlighting the latter's benefits in reducing wound morbidity and hospital stay, as evidenced by recent meta-analyses. The review also addresses long-term outcomes, contrasting patient-reported bulges with clinical recurrence, and underscores the importance of patient-reported outcome measures for evaluating true surgical success. Finally, we discuss the evolving role of TAR in Korea, emphasizing the need for cost-effectiveness studies and structured training programs to establish it as a standard of care. This article aims to provide surgeons with an expert-level update on TAR, facilitating its optimal application in complex hernia repair.

The utility of robotic platform remains relatively unexplored in the context of retroperitoneal tumors. The location and complexity of neurovascular anatomy pose additional challenges for surgical planning. Herein, we present the case of a 56-year-old male with a 9 × 7-cm retroperitoneal tumor located within the right iliopsoas muscle, without intraforaminal extent. The surgery was performed using the da Vinci Xi Surgical System (Intuitive Surgical, Inc.). The patient was placed in the left lateral position. Intraoperative and postoperative recovery was uneventful. A transient sensory deficit was noted in the right lower limb, which gradually resolved completely. The patient was discharged on postoperative day 4. Histopathology report confirmed a schwannoma with negative margins. At 1-year follow-up, the patient is doing well with no evidence of disease recurrence. Robotic resection of retroperitoneal tumors appears to be a feasible and safe approach. Proper planning and execution are essential for the successful completion of the surgery and achieving excellent outcomes.