Abdominal Approach Research Articles

The efficacy and safety of laparoscopic pyeloplasty via abdominal approach for the treatment of ureteropelvic junction obstruction in children.

The efficacy and safety of laparoscopic pyeloplasty via abdominal approach for the treatment of ureteropelvic junction obstruction in children.

Perineal Rectosigmoidectomy (Altemeier’s Procedure) in the Treatment of Strangulated Rectal Prolapse: A Case Series and Literature Review

Background: Rectal prolapse (RP) predominantly affects women over the age of 50 and presents as mucosal, internal, or full thickness prolapse. Strangulated rectal prolapse requires immediate medical intervention, and surgical treatment options include both abdominal and perineal approaches. We aim to present a case series of perineal rectosigmoidectomy performed urgently due to strangulation and argue that Altemeier’s procedure is the preferred method for treating strangulated rectal prolapse. Methods: Perineal rectosigmoidectomy, particularly Altemeier’s procedure, is effective for incarcerated cases. Altemeier’s procedure with diverting ileostomy was used in all three patients. Results: All patients were successfully treated, with no recurrence of prolapse and stool incontinence. Conclusions: Altemeier’s procedure is ideal for the treatment of strangulated rectal prolapse.

Literature review, surgical decision making algorithm, and AGREE II-S comparison of national and international recommendations and guidelines in pelvic organ prolapse surgery.

The average lifespan has increased over time due to improvements in quality of life, leading to an aging population that stays healthy for longer. Pelvic organ prolapse (POP), whether uterine or vaginal, is a problem that severely impairs quality of life and imposes significant restrictions. The present study provides the reader with a summary of the many surgical techniques used in POP surgery, comparing international guidelines, offering an algorithm that is simple to understand, and allows the reader to quickly choose the table that includes the best surgical therapy for each individual. Using relevant keywords, the writers searched the PubMed and Scopus databases for relevant publications from 2000 to April 2023. Studies with cases of oncologic disorders or prior hysterectomy performed for another reason were not included in the analysis. Ten distinct international guidelines are highlighted and examined in the present study. We used the Appraisal of Guidelines for Research and Evaluation II-S (AGREE II-S) method to assess their quality, and incorporated the results into the conclusion. Worldwide, anterior colporrhaphy is the preferred method of treating anterior compartment abnormalities, and mesh is virtually always used when recurrence occurs (which happens in about half of the cases). Worldwide, posterior colporrhaphy is commonly used to repair posterior compartment abnormalities. Only a few national guidelines (the Iranian guideline, Acta Obstetricia et Gynecologica Scandinavica [AOGS], and the German-speaking countries) permit the use of mesh or xenograft in cases of recurrence. There is agreement on the abdominal approach (sacrocolpopexy) with mesh for treating apical deformities. Sacrospinous-hysteropexy is the standard method used to guide the vaginal approach; mesh is typically used to aid in this process. There are just three recommendations that do not include vaginal operations: HSE, AOGS, and Iran. Of obliteration techniques, colpocleisis is unquestionably the best. In conclusion, our analysis highlights the significance of customized methods in POP surgery, taking into account the requirements and preferences of each patient. To choose the best surgical therapy, criteria and patient features must be carefully considered.

PRESENTATIONS AND OUTCOMES OF AORTOFEMORAL BYPASS GRAFTING

Objectives: The aim of the study is to study presentations and clinical outcomes in patients undergoing Aortofemoral Bypass Grafting Surgery (AFB). Design: This was a Hospital based prospective study. Materials And Methods: During 18 months period , 20 patients (mean age = 56 years) underwent AFB. Indications comprised of occlusive disease with Intermittent Claudication (IC) (n=10), Critical Limb Ischaemia (CLI)(n=4), Resting Pain (RP) (n=4) and Tissue Loss (TL) (n=2). Results: From Jan 2023 to June 2024, AFB was performed more frequently for IC (50%) vs rest of other indications. 30 day observations / follow up showed infection in 5%, Graft occlusion in 5% for which patient underwent emergency graft thrombectomy, Amputation in 10% due to gangrenous changes and 15% mortality. Graft patency was found to be triphasic in 90% cases. Hypertension was leading risk factor (85%) followed by Diabetes Mellitus(70%) and smoking (65%). Predictors of morbidity included CKD (25%), CAD (25%), COPD (20%), CVA (20%).90% Patients were operated via thoracotomy approach and 10% were operated via abdominal approach depending on level of aortic thrombus. 20% of patients had previous history of endovascular interventions followed by stent occlusion. Conclusion: In era of endovascular intervention, Aortofemoral Bypass Surgery is more likely to be performed for Intermittent Claudication and graft patency has a better outcome.

Septic Abortion at 17 Weeks Gestation after Radical Trachelectomy and Transabdominal Cerclage: A Case Report

Septic abortion can lead to severe maternal morbidity and mortality. The management of septic abortion can be complicated by a history of radical trachelectomy and transabdominal cerclage placement. A 33-year-old G1P0 at 17 weeks and 6 days gestation presented in severe septic shock after being diagnosed 6 days prior with previable rupture of membranes at an outside hospital and managed expectantly. History was notable for cervical adenocarcinoma status post radical trachelectomy and transabdominal cerclage placement. Due to uterine occlusion from the cerclage, the patient underwent emergent uterine evacuation via an abdominal approach. The risks and benefits of expectant management of pre-viable rupture of membranes in patients with abdominal cerclage should be weighed very cautiously. Among women with abdominal cerclage for whom uterine evacuation is indicated, a transabdominal approach may be necessary.

Robot-assisted cervical esophagectomy with simultaneous transhiatal abdominal procedure for thoracic esophageal carcinoma

BackgroundMinimally invasive robot-assisted cervical esophagectomy has been sporadically reported as a novel thoracic esophagectomy technique for patients with thoracic esophageal carcinoma. Most reports indicate that the abdominal component of robot-assisted cervical esophagectomy is performed sequentially after the cervical phase. However, if the cervical and abdominal phases are performed simultaneously using a nerve integrity monitoring system with no administration of muscle relaxants, there are two major advantages: a reduced risk of recurrent nerve palsy and a shorter operative time. We herein report our experience performing novel robot-assisted transcervical esophagectomy with a simultaneous transhiatal abdominal approach using a nerve integrity monitoring system.MethodsThirty cases of robot-assisted cervical esophagectomy performed from 2023 to April 2024 were reviewed. The operative and short-term surgical outcomes of this procedure were compared with those of robot-assisted cervical esophagectomy using a sequential abdominal approach, and the feasibility and efficacy of the simultaneous procedure were analyzed.ResultsAll patients successfully underwent robot-assisted cervical esophagectomy with no intraoperative adverse events. There were no differences in the patients’ demographic or operative data between the two groups. There was no difference in the mean operation time for the cervical procedure (p = 0.23). However, there was a significant difference in the total time for the whole procedure (sequential group: 453.8 ± 26.8 min, simultaneous group: 291.2 ± 36.1 min; p < 0.01). There were no differences in postoperative surgical complications between the groups. There was also no difference in the total number of surgically harvested mediastinal lymph nodes (p = 0.33).ConclusionsRobot-assisted transcervical esophagectomy, a new technique for thoracic esophageal cancer, was safe and feasible under intraoperative management using nerve integrity monitoring without muscle relaxants. This procedure facilitates intraoperative monitoring of recurrent laryngeal nerve activity, significantly shortening the total operative time.

Prognosis and treatment of uterine sarcoma found incidentally after myomectomy

ObjectiveTo determine prognosis and factors associated with survival of women with uterine sarcoma found incidentally after myomectomy. MethodsWe performed a retrospective study for patients who had previously undergone myomectomy for presumed benign uterine fibroid disease and were found to have uterine confined sarcoma after myomectomy surgery. ResultsIn total, 50 patients were identified. There were 23 (46.0 %) patients undergoing myomectomy were performed by minimal invasive surgery: laparoscopic (Lap, n = 22, 44.0 %) or transvaginal (TV, n = 1, 2.0 %) approach; while, 24 (48.0 %) and 3 (6.0 %) patients had myomectomy through abdominal (Abd) or hysteroscopic (Hys) approach. All patients received the re-exploration and staging surgery in our center. The median time from myomectomy to the staging surgery was 43 days (range 15–90 days). 17 patients had remnant sarcomas on the remaining uterus and 6 patients had disseminated disease after re-exploration. In the entire cohort, 5-year RFS and 5-year OS was 79.4 % and 88.0 %, respectively. Patients who received initial Lap/TV myomectomy had a tendency towards a worse 5-year RFS compared with Abd/Hys approach (63.0 % vs 88.9 %, P = 0.080). No difference in 5-year OS was found between the two groups (90.3 % vs 91.8 %, P = 0.768). For stage I disease (n = 44), patients who received Lap/TV myomectomy had a worse 5-year RFS compared with Abd/Hys approach (58.3 % vs 95.7 %, P = 0.009). No difference in 5-year OS was found (P = 0.121). ConclusionPatients with incidental uterine sarcoma who received primary Lap/TV myomectomy may have a worse RFS. Re-exploration can detect remnant or disseminated sarcomas.

Rectal Prolapse Surgery: Balancing Effectiveness and Safety in Abdominal and Perineal Approaches.

The event in which the entire thickness of the rectumprotrudes through the anal canal is called rectal prolapse. This ailment is common in the elderly population and especially in females. It causes some disastrous symptoms, including incontinence to feces and flatus, constipation, and discomfort, because of the weakness in the anorectal junction, making it mandatory for surgical correction. Over time, several surgical techniques have been developed; these are broadly classified into two categories: abdominal and perineal techniques. However, the best approach for surgery that minimizes recurrence while maximizing patient quality of life is still up for debate. A comprehensive review was conducted adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines; a systematic search of the PubMed Database was performed to identify studies published between 2000 and 2024 with the keywords ((Rectal Prolapse) AND ("Perineal" OR "Laparotomy")). The inclusion criteria were focused on studies comparing the outcomes between surgical approaches at the abdominal and perineal locations, particularly on the recurrence rate, postoperative complications, and functional outcomes. In total, 21 studies were included in the review: these ranged from retrospective analysis and prospective studies to a multicentric randomized trial. In this review, abdominal approaches, particularly in the form of laparoscopic rectopexy, consistently demonstrated improved results compared to perineal techniques, with a much lower recurrence rate. The rates of mortality and morbidity were also remarkably lower in laparoscopic operations, which were advocated for suitable patients. However, perineal approaches, while still producing higher rates of recurrence, are a valuable alternative for elderly and high-risk patients due to their being relatively less invasive. Laparoscopic rectopexy can be considered a better surgical method for rectal prolapse, as it has a lower recurrence rate and better functional outcomes. In contrast, perineal approaches will have their place in the management of rectal prolapse, given patient selection for patients at high risk with regard to surgery. Future research should be directed toward multicenter trials with long-term outcomes in order further to fine-tune surgery strategy and criteria for patient selection.

778. ROBOTIC-ASSISTED EPIPHRENIC DIVERTICULECTOMY: 9 YEAR EXPERIENCE OF A TERTIARY CENTER

Abstract Background Epiphrenic esophageal diverticula are rare and often associated with esophageal motor disorders. Surgery is reserved for larger diverticula with symptoms that significantly impair quality of life. When possible, a transhiatal approach can reduce pulmonary complications by preserving pleural integrity; more proximal diverticular openings require a combined transthoracic and abdominal approach to achieve complete excision. Robotic surgery assists in precise dissection and preservation of delicate mediastinal structures. Currently, few reports are available on larger patient cohorts of robotic diverticulectomy. We describe all consecutive cases of robotic-assisted epiphrenic diverticulectomy performed at a high-volume tertiary center, since robotic surgery became available in 2015. Methods A retrospective chart review was conducted and, for all consecutive diverticulectomy cases, surgical techniques, patient characteristics and short and long-term outcomes were recorded. All patients underwent preoperative EGDS and esophagogram. Diverticulectomy was always accompanied by esophagogastric Heller myotomy (&amp;gt;7 cm) and Dor fundoplication with the Xi DaVinci system was performed. One to two SIGNA linear stapler firings were used for diverticular resection. Symptoms, demographic data, and short and long-term surgical outcomes were recorded, including morbidity and mortality and post-operative symptoms. Results Four cases required both an abdominal and intrathoracic approach, none was converted. Intraoperative complications included one occurrence of splenic bleeding controlled by hemostatic. Intraoperative blood loss was negligible. In two cases an esophageal leiomyoma was found incidentally and excised. The only postoperative complication was trocar-related abdominal wall bleeding that led to reintervention for cauterization; mortality was zero. All patients underwent a post-op esophagogram, negative for leaks or strictures, and resumed soft feeding within 7 days. All reported substantial symptom relief at six months. At one year, one patient reported reflux, and two reported dysphagia recurrence without evident structures or recurrences. Conclusion Robotic-assisted diverticulectomy is safe and effective for epiphrenic diverticula. The abdominal approach allows for a thorough esophageal myotomy associated with a For antireflux procedure to reduce recurrences of the disease and long-term dysphagia. In some cases a transthoracic approach is also needed, when employed by experienced upper GI surgeons it doesn't significantly affect surgical outcomes. Quality of life improves after surgery, although symptomatic reflux might occur. Further prospective or experimental studies are needed to evaluate short and long-term outcomes of the robotic approach compared to other surgical approaches.

220. SHORT-AND LONG-TERM OUTCOMES OF ROBOT ASSISTED MINIMALLY INVASIVE ESOPHAGECTOMY FOR ESOPHAGEAL CANCER: A PROPENSITY SCORE-MATCHED STUDY

Abstract Background Conventional minimally invasive esophagectomy (C-MIE) for esophageal cancer has become widespread and standardized. In Japan, robot-assisted MIE (RAMIE) has been covered by national health insurance since 2018. However, the superiority of RAMIE over conventional MIE remains controversial. In this study, we will clarify the short-and long-term outcomes of RAMIE compared to C-MIE. Methods Short-term outcomes were compared using propensity score-matching (PSM) for C-MIE group (324 cases) and RAMIE group (101 cases) performed from 2010 to 2023. Long-term outcomes were compared using PSM for C-MIE group (313 cases) and RAMIE group (69 cases) up to 2021, when a minimum three-year observation period was available. Covariates for PSM were age, sex, tumor location, histological type, cT, cN, preoperative treatment, abdominal approach, and range of lymph node dissection. Results For short-term outcomes, 96 cases were included in each group after PSM. There were no significant differences in age, sex, tumor location, histological type, cT, cN, and preoperative treatment. Operative time was significantly longer in RAMIE group than in C-MIE group (overall procedure: 657 vs. 764 min, P&amp;lt;0.001; thoracic prpcedure: 306 vs. 411 min, P&amp;lt;0.001). Blood loss was significantly lower in RAMIE group than in C-MIE group (145 vs. 64 ml, P&amp;lt;0.001). The rate of recurrent laryngeal nerve palsy (Clavien-Dindo classification, Grade II or higher) was significantly lower in RAMIE group than in C-MIE group (10% vs. 0%, P&amp;lt;0.001). There were no significant differences in the rates of anastomotic leakage and postoperative pneumonia between both groups (P=0.159, 0.709). For long-term outcomes, 69 cases were included in each group after PSM. The 3-year overall survival rate was 70.8% in C-MIE group and 77.1% in RAMIE group, and the 3-year disease-free survival rate was 63.5% in C-MIE group and 58.8% in RAMIE group, both showing no significant difference (P=0.406, P=0.651). Conclusions RAMIE has the potential to reduce recurrent laryngeal nerve palsy compared to C-MIE and long-term outcomes for both procedures were comparable.

European Society for Gynaecological Endoscopy (ESGE) Good Practice Recommendations on surgical techniques for removal of fibroids: part 1 abdominal (laparoscopic and open) myomectomy.

Uterine fibroids are the most common benign tumours of the female reproductive tract and can cause a range of symptoms including abnormal uterine bleeding, pain, pressure symptoms and subfertility. Surgery may be required for some symptomatic fibroids via abdominal or transvaginal routes. The European Society for Gynaecological Endoscopy Uterine Fibroids Working Group developed recommendations based on the best available evidence and expert opinion for the surgical treatment of uterine fibroids. In this first part of the recommendations, abdominal approaches to surgical treatment of fibroids including laparoscopic, robot- assisted and open myomectomy are described.

Safety and feasibility of percutaneous abdominal lavage cytology screening (PACS) prior to surgical resection for pancreatic cancer.

This study aimed to evaluate the feasibility, safety, diagnostic yield, and technical aspects of percutaneous abdominal lavage cytology screening (PACS) in patients with resectable pancreatic cancer. This single-center, retrospective study included patients with resectable pancreatic cancer who underwent PACS before pancreatectomy between May 2022 and October 2023. The technical success rate, position of the drainage tube, volume of fluid administered, volume of fluid retrieved, fluid retrieval rate, and adverse events were evaluated. The cytological results of PACS were compared with those of surgical peritoneal lavage performed during pancreatectomy. Forty-four patients were enrolled in this study. The technical success rate for PACS was 100%. Drainage tube placement was outside the pouch of Douglas in all patients in the right-sided abdominal approach group (n = 10), whereas the placement was in the pouch of Douglas in all patients in the suprapubic approach group (n = 34). The mean volume of fluid administered, mean volume of fluid retrieved, and fluid retrieval rate were 185.0 ± 22.9ml vs. 97.1 ± 32.0ml (p < 0.001), 36.8 ± 25.6ml vs. 50.5 ± 21.6ml (p = 0.059), and 19.0 ± 12.4% vs. 54.9 ± 21.9% (p < 0.001) in the right abdominal approach and suprapubic approach groups, respectively. No adverse events were reported. The cytological results were benign in 42 patients; no discrepancy was observed in the results of surgical peritoneal lavage (n = 36). PACS is a feasible and safe procedure that can be performed before pancreatectomy in patients with resectable pancreatic cancer. the suprapubic approach may be ideal and PACS could be a screening method to detect carcinomatous peritonitis.

On the assessment of the role of new antibiotics in pharmacotherapy algorithms for complicated intra-abdominal infections (literature review)

The goal: To analyze the topical problems in the use of the newest antibiotics in abdominal surgical interventions and approaches to their solution. Material and methods: The large-scale (as a rule) publications mostly of 2019–2023 on the issue were analyzed. The searching had been executed according to keywords in Pubmed (ncbi.nlm.nih.gov). Findings: Modern protected cephalosporins and carbapenems, as well as eravacycline, appear to be valuable tools in the treatment of surgical intra-abdominal infection, caused in particular by resistant microflora, especially when taking into account local data. The value of tigecycline in this nosology seems less obvious.

Approach to radical hysterectomy for cervical cancer after the LACC trial and associated complications: a NSQIP study

BackgroundThe Laparoscopic Approach to Cervical Cancer (LACC) study results revolutionized our understanding of the best surgical management for this disease. Following its publication, guidelines state that the standard and recommended approach for radical hysterectomy is with an open abdominal approach. Nevertheless, the impact of the LACC trial on real-world changes in the surgical approach to radical hysterectomy remains elusive. ObjectiveWe aimed to study the trends and routes of radical hysterectomies and to evaluate post-operative complication rates before and after the LACC trial (2018). Study DesignThe National Surgical Quality Improvement Program registry was used to examine radical hysterectomies performed for cervical cancer between 2012-2022. We excluded vaginal radical hysterectomies and simple hysterectomies. The primary outcome measures were the trends in route of surgery [minimally invasive surgery (MIS) vs. laparotomy] and surgical complications rate, stratified by periods before and after the publication of the LACC trial in 2018 (2012-2017 vs. 2019-2022). The secondary outcome measure was major complications associated specifically with the different routes of surgery. ResultsOf the 3,611 patients included, 2,080 (57.6%) underwent laparotomy and 1,531 (42.4%) underwent MIS radical hysterectomy. There was a significant increase in the MIS approach from 2012 to 2017 (45.6% MIS in 2012 to 75.3% MIS in 2017, p<.001), and a significant decrease in MIS from 2018 to 2022 (50.4% MIS in 2018 to 11.4% MIS in 2022, p<.001).The rate of minor complications was lower in the period before the LACC trial [317 (16.9%) vs. 288 (21.3%), p=.002]. Major complications rate was similar before and after the LACC trial [139 (7.4%) vs. 78 (5.8%), p=.26]. The rates of blood transfusions and superficial surgical site infections were lower in the period before the LACC trial [137 (7.3%) vs. 133 (9.8%), p=.012 and 20 (1.1%) vs. 53 (3.9%), p<.001, respectively]. In a comparison of MIS vs. laparotomy radical hysterectomy during the entire study period, patients in the MIS group had lower rates of minor complications [190 (12.4%) vs. 472 (22.7%), p<.001] and the rate of major complications was similar in both groups [100 (6.5%) in the MIS group vs. 139 (6.7%) in the laparotomy group, p=.89]. In a specific complications analysis, the rates of blood transfusion and superficial surgical site infections were lower in the MIS groups (2.4% vs. 12.7%, and 0.6% vs. 3.4%, p<.001 for both comparisons) and the rate of deep incisional surgical site infections was lower in the MIS group (0.2% vs. 0.7%, p=.048). In a multiple logistic regression analysis, the route of radical hysterectomy was not independently associated with occurrence of major complications [aOR 95% CI 1.02 (0.63-1.65)]. ConclusionWhile the proportion of MIS radical hysterectomy decreased abruptly following the LACC trial, there was no change in the rate of major post-operative complications. In addition, hysterectomy route was not associated with major post-operative complications.

Prospective comparison of two surgical approaches for incarcerated and strangulated inguinal hernia: preperitoneal hernioplasty through the lower abdominal median incision and laparoscope (TAPP).

The optimal surgical approach of incarcerated and strangulated inguinal hernia is controversial. Retrospective studies showed that surgical approaches through lower abdominal median incision or laparoscopic are superior to the oblique inguinal incision, respectively. Whether transabdominal laparoscopic approach is superior to the lower abdominal median incision approach needs prospective research.Prospective comparative study of patients with incarcerated and strangulated groin hernia admitted to Jinshan hospital for emergency surgery from January 2018 to June 2022. They were divided into two groups according to different surgical approach. The open preperitoneal repair group (OPR) was operated through the lower abdominal median incision. Laparoscopic preperitoneal repair group (TAPP) was completed under transabdominal laparoscope. The perioperative complications and long-term results of the two groups were compared and analyzed. Eighty-two patients met the inclusion criteria, 40 in OPR group and 42 in TAPP group. Baseline data of the two groups were comparable. Thirteen cases (15.9%) of the two groups underwent intestinal resection and anastomosis. Seventy cases (90.2%) underwent the 1st stage mesh repair, including 5 cases of preperitoneal hernioplasty after intestinal resection. The average operation time of TAPP group was 13min longer (60.7 ± 13.7min vs 47.8 ± 19.8min P < 0.001), and the visual analogue scale pain score at 24h after operation was lower (3.5 ± 1.2 vs 4.4 ± 1.7 P = 0.019) than that of OPR group. There was 1 case of bladder injury (2.5%) in OPR group and 1 case of inferior abdominal artery injury (2.4%) in TAPP group. There was no difference in the rate of the 1st stage hernioplasty between the two groups. In OPR group, 2 cases (5%) extended the incision for more than 2cm, while in TAPP group, 1 case (2.4%) converted to laparotomy. The time of hospital stay (3.2 ± 1.8 d vs 4.3 ± 2.7 d, P = 0.036) and return to normal activities (7.9 ± 2.7 d vs 11.0 ± 4.4 d, P < 0.001) were shorter in TAPP group. The rate of total postoperative complications including chronic pain, surgical-site infection, seroma, hernia recurrence and so on was 11.9% in TAPP group, which was not significantly different from 25% in OPR group (P = 0.212). There were no cases of mesh related infection and death within 30days in both groups.TAPP is safe and feasible for the operation of acute incarcerated inguinal hernia. TAPP had better comfort and faster recovery over open preperitoneal repair for the appropriate patients with incarcerated/strangulated inguinal hernia, which can reduce acute pain, shorten hospital stay and return to normal activities earlier.

Early bladder dysfunction after vesicovaginal fistula repair: A prospective comparative analysis of transvaginal, open, and laparoscopic abdominal approaches.

We aim to compare the clinical and urodynamic profile oflower urinary tract symptoms (LUTS) in patients undergoing laparoscopic, open transabdominal, and laparoscopic transabdominal vesicovaginal fistulae (VVF) repair at 3 months of repair, that is, in early postoperative period. Fifty-one consecutive patients with endoscopically confirmed VVF were enrolled in our study over 2 years. Malignant fistulae, radiation-induced, and complex fistulae were excluded after cross-sectional imaging. All patients underwent a postoperative assessment for the success of the repair. Then at 3 months, they completed theAmerican Urological Association Symptom Score questionnaire and underwent a dual channel pressure-flow urodynamic study. The results of transvaginal, laparoscopic, and open transabdominal repairs were compared. All patients belonged to the Indian Caucasian race. The mean age was 35.43 ± 6.63 years. Thirty-two patients had supratrigonal and 19 had trigonal fistulae. Laparoscopic transabdominal repair was done in 15 patients, open transabdominal repair in 22 patients, and transvaginal repair in 14 patients. Forty-six patients reported some LUTS at a median follow-up of 5.83 ± 2.37 months postoperatively. Only 18 (35.2%) of these patients had moderate to severe symptoms The postoperative bladder dysfunction rates in open transabdominal, transvaginal and laparoscopic transabdominal groups were 36.4%, 28.6%, and 20%, respectively. Twenty-seven patients (52.9%) had some urodynamic abnormality, that is, small capacity (5), high voiding pressures (14), genuine stress incontinence (3), and poor compliance (3). Bladder capacity was a significant predictor of bladder dysfunction in our patients. In our study, all three surgical approaches were associated with bladder dysfunction, however, it was the least in the laparoscopic transabdominal approach. Postoperative bladder capacity is a significant predictor of bladder dysfunction.

565 Robot-Assisted Surgery for Thoracic Endometriosis Syndrome – a Single-Centre, Retrospective Review of the First Fifty Cases

Abstract Aim Thoracic endometriosis syndrome (TES) is underdiagnosed, due to cyclical thoracic symptoms being underreported. Management of TES also remains controversial, with abdominal and thoracic approaches proposed, both laparoscopically and robotically, and no guidelines available. We aimed to characterise our experience with a multidisciplinary, robot-assisted approach, with a focus on symptom prevalence and surgical outcomes. Method A retrospective review of all consecutive procedures for TES between July 2020 and March 2023 surgery was performed. Robot-assisted removal of endometriosis from the underside of the diaphragm, from the pleura or superior diaphragm, or wedge resection of the lung through videoscope-assisted thoracic surgery, in any combination with or without pelvic endometriosis removal, were included. Presenting symptoms, intra-operative, and histological outcomes were analysed. Results Fifty robotic TES procedures, on forty-six patients were undertaken; median age was 32 (IQR 26–36). Cyclical shoulder tip pain (n = 29, 63%), costal margin pain (n=18, 39.1%), and scapular pain (n=11, 23.9%). There were no major Clavien-Dindo complications. Median blood loss was 10ml (IQR 6.25–27.25), and median length of stay was 1 day (IQR 1–2 ). The majority of the underside of the diaphragm specimen (n=35, 77.8%), and the pleural, and lung specimens (n=17, 85%) were either histologically positive for endometriosis or showed inflammation consistent with endometriosis. Conclusions Robotic-assisted surgery can be safely used for TES. Management of TES should involve an MDT including gynaecologic, hepato-pancreatico-billary, and thoracic surgeons, with minimally invasive experience. Going forward, long-term, patient-reported outcomes need to be analysed to ensure the effectiveness of robot-assisted surgery in TES.

The Outcome of the Laparoscopic Hysterectomy in Al-Yarmouk Teaching Hospital in 2022–2023

Abstract Background: Hysterectomy is a common gynecological procedure used for various benign conditions like abnormal uterine bleeding, uterine prolapse, and fibroids. Different surgical methods, including vaginal, abdominal, laparoscopic, and robotic-assisted approaches, offer unique advantages and disadvantages. Total laparoscopic hysterectomy (TLH), introduced in 1989, offers benefits like smaller incisions, less blood loss, reduced pain, shorter hospital stays, and faster recovery. Objectives: The objective of this study was to evaluate patient outcomes, complications, and satisfaction with laparoscopic hysterectomy surgery. Patients and Methods: This cross-sectional study was conducted in Al-Yarmouk Teaching Hospital in Baghdad, General Surgery Department, from August 2022 to August 2023. Twenty-five patients who underwent laparoscopic hysterectomy for benign conditions were included. Patients were carefully assessed, ruling out malignancies through extensive clinical and radiological examinations, ultimately qualifying for the procedure. Data on patients’ demographics, comorbidities, previous surgical history, uterine size, indication for hysterectomy, type of procedures performed, and postoperative complications were gathered and subjected to analysis. The follow-up duration extended over 3 months, with assessments done on the 3rd day, 10th day, 1st month, and 3rd month postsurgery. Results: The mean age was 51.52 ± 9.47 years. Dysfunctional uterine bleeding was the most common indication (44%), followed by postmenopausal bleeding (32%). Most patients underwent TLH with bilateral salpingo-oophorectomy (BSO) (68%), and the mean operative time was 110 min. Complications were observed in 10 (40%) cases, with common issues being blood transfusion, port-site infection, and bladder injury. Hospitalization lasted 2 days, and postoperative pain reduced gradually over time. Patients who underwent concomitant BSO had significantly higher complications than those with isolated TLH. Postoperative pain levels were comparable between the two groups. Conclusion: Laparoscopic hysterectomy is an effective option for treating benign gynecological conditions, offering benefits like improved postoperative pain control and shorter hospital stays. However, the potential for complications, particularly in cases involving additional procedures, is to be considered.

Endoscopic and Robotic Assisted Transvaginal Hysterectomy: A Feasibility Study

Purpose: To perform a feasibility study of the novel approach “transvaginal natural orifice transluminal endoscopic surgery” (vNOTES) with Da-Vinci robotic assistance. The primary objective of the study is to describe best surgical practices using a case series of robotic-assisted vNOTES in select patients. Methods: An institutional review board approved prospective single-arm, surgical intervention trial was performed. Outcomes measured included operative time, operative complications, estimated blood loss, hemoglobin changes, postoperative pain scores, and need for conversion to traditional robotic or laparoscopic hysterectomy via the abdominal approach. Patients who were referred to the gynecology oncology clinic to undergo hysterectomy for benign indications and met the study’s inclusion and exclusion criteria were consented. Patients were included if they had benign causes of abnormal uterine bleeding or pelvic pain, endometrial hyperplasia, cervical dysplasia, need for risk-reducing surgery for hereditary cancer syndromes or need for transgender-affirming surgery. Patients were excluded if they had prior rectal surgery, evidence of fixed uterus, posterior cul-de-sac obliteration and/or adhesions based on physical exam and/or imaging, evidence of narrowed vagina on physical exam, virginity, current pregnancy or history of advanced pelvic organ prolapse. Furthermore, obesity, nulliparity, or no history of spontaneous vaginal delivery are characteristics that may be deemed as risk factors for failure of a transvaginal approach and clinical judgment was used to determine eligibility for study inclusion. Patients deemed eligible were then enrolled for robotic-assisted transvaginal hysterectomy and bilateral salpingectomy with or without oophorectomy. In the pilot case, the surgery began as a traditional vaginal hysterectomy starting with a posterior colpotomy followed by transection and ligation of the bilateral uterosacral ligaments. Identification of the vesicouterine peritoneal reflection anteriorly was difficult and the GelPoint V-Path was placed only through the posterior colpotomy. The Da Vinci robot was docked and a 0-degree Da Vinci camera, monopolar scissors, Vessel Sealer and AirSeal assist port were placed through the 9.5 cm GelPoint transvaginal platform in a diamond configuration. The Vessel Sealer was used to transect across the uterine arteries. Due to poor visualization, conversion to the traditional abdominal robotic approach was required and the remainder of the surgery was completed in the usual fashion. In the subsequent two cases, a single laparoscopic port was placed abdominally to perform an initial survey of the pelvis. The abdomen was then deflated and the surgery was initiated in a fashion similar to the pilot case. Anterior and posterior colpotomy were successfully performed and the GelPoint platform was optimally placed. Vagina-pneumoperitoneum was obtained to 15 mmHg. In the second case, the 30-degree Da Vinci camera, the Vessel Sealer, ProGrasp Forceps, monopolar scissors, AirSeal assist port and a 9.5 cm GelPoint transvaginal platform were utilized. In the final case, three robotic arms were used rather than four (0-degree Da Vinci camera, the Vessel Sealer, ProGrasp Forceps) along with an AirSeal assist port through a 7 cm GelPoint transvaginal platform to improve ergonomics. The remainder of surgery was completed with robotic assistance with good visualization of the upper abdomen, pelvis and bilateral ureters. The vaginal cuff was closed by placing multiple figure-of-eight sutures similar to a traditional vaginal hysterectomy. Results: Two cases were successfully completed while the pilot case required conversion to the traditional robotic abdominal approach. This was due to difficulty in identifying the anterior vesicouterine peritoneal reflection. Intra-abdominal laparoscopic survey revealed anterior cul-de-sac adhesions with pathology-confirmed endometriosis. The most ergonomic set up was found to consist of three robotic arms (0-degree da Vinci camera, the Vessel sealer, ProGrasp Forceps) and an AirSeal assist port through a 7 cm GelPoint transvaginal platform in a diamond configuration. In the two successful cases, both patients had uncomplicated postoperative courses with pain scores of 2-3 on floor arrival and 0 at their two- and six- week post-op visits. Estimated blood loss of the second and third cases were 75 cc and 30 cc, respectively. The operative time of the third case significantly improved compared to the second case, from 195 minutes to 99 minutes. Conclusion: We demonstrated that robotic-assisted vNOTES is a feasible option in appropriately selected patients. As demonstrated by operative time changes, there exists a learning curve even when performed by experienced robotic surgeons. Compared with traditional vaginal hysterectomy, robotic surgery allows for improved visualization of and access to the adnexal structures and upper abdomen with improved dexterity in comparison to traditional laparoscopy instruments.

Safety of vaginal surgery for early-stage cervical cancer: A retrospective multicenter cohort study

ObjectiveAbdominal Radical hysterectomy (ARH) with pelvic lymph node assessment is considered the standard treatment for early-stage cervical cancer. Accepted routes have previously included laparoscopic or robotic approaches (LRH). Laparoscopy-assisted vaginal or vaginal radical hysterectomy (LVRH) are performed in some centers. The objective of this study is to compare surgical and oncological outcomes of LVRH, to laparoscopic and abdominal approaches. Design patients settingA retrospective multicenter analysis of consecutive cervical cancer cases who underwent a radical hysterectomy between 2007 and 2017 in eleven regional cancer centers across Canada. MeasurementsA comparison of patients stratified by surgical technique was undertaken. T-test, Wilcoxon rank-sum and chi-square were used to compare patient characteristics. Log-rank tests and Cox proportional hazards models were employed to compare recurrence and survival across surgical groups. Main resultsA total of 1071 patients with cervical cancer stage IA1 with lymphovascular invasion to stage IIIC (FIGO 2018) <4 cm were identified. Postoperative complication rate was lowest for women undergoing LVRH (9.1 %, vs 18.3 % and 22.1 % for minimally invasive and open respectively). During follow up, 114 women recurred, and 70 women died. 5-year recurrence-free survival was 85.4 % for LRH, 89.4 % for ARH and 92.2 % for LVRH. LVRH was not found to be associated with a higher risk of recurrence or death than ARH on multivariable analysis (aHR for recurrence 0.62, CI 0.21–1.77; aHR for death 0.63, CI 0.14–2.77) ConclusionIn this retrospective study, vaginal or laparoscopy-assisted vaginal radical hysterectomy for cervical cancer was associated with favorable perioperative and oncological outcomes.