Advanced Laparoscopic Surgery Research Articles

Outcomes of anterior resection after laparoscopic and open surgery

Background The introduction of the laparoscope has improved the feasibility and patient health, owing to being a less invasive procedure. The use of a laparoscope for colorectal cancer surgery was debatable for fear of recurrence, tumor spillage, and nonradical tumor excision. However, the tendency for using laparoscopy in colorectal cancer surgery is in favor nowadays. Aim The aim was to compare the results of laparoscopic and open surgical techniques in colorectal cancer located in the rectosigmoid region. Patients and methods This prospective study included 50 patients with upper rectal cancer attending the outpatient clinic of Ain Shams University Hospitals, who were treated over a 3-year period. Patients underwent anterior resection either by open technique (first group) or using laparoscopy (second group). Comparative items included operative events (time, blood loss, efficacy of tumor resection, etc.), early postoperative complications (wound infection, anastomotic leakage, etc.), and late postoperative complications (stricture and local recurrence). Results This study shows no significant difference between the two groups regarding length of specimen, safety margins, number of retrieved lymph nodes, tumor recurrence, or mortality. However, it shows significantly longer procedure, less blood loss, and less wound complications in the laparoscopic group. Conclusion Both laparoscopic and open procedures for rectal cancer surgeries can achieve the same radical resection; however, wound complications seemingly are more frequent in cases having open colorectal resections. The time consumption problem of advanced laparoscopic surgery will improve by gaining more experience and using the best equipment.

Laparoscopic right hemicolectomy: the SICE (Societ\xe0 Italiana di Chirurgia Endoscopica e Nuove Tecnologie) network prospective trial on 1225 cases comparing intra corporeal versus extra corporeal ileo-colic side-to-side anastomosis

BackgroundWhile laparoscopic approach for right hemicolectomy (LRH) is considered appropriate for the surgical treatment of both malignant and benign diseases of right colon, there is still debate about how to perform the ileo-colic anastomosis. The ColonDxItalianGroup (CoDIG) was designed as a cohort, observational, prospective, multi-center national study with the aims of evaluating the surgeons’ attitude regarding the intracorporeal (ICA) or extra-corporeal (ECA) anastomotic technique and the related surgical outcomes.MethodsOne hundred and twenty-five Surgical Units experienced in colorectal and advanced laparoscopic surgery were invited and 85 of them joined the study. Each center was asked not to change its surgical habits. Data about demographic characteristics, surgical technique and postoperative outcomes were collected through the official SICE website database. One thousand two hundred and twenty-five patients were enrolled between March 2018 and September 2018.ResultsICA was performed in 70.4% of cases, ECA in 29.6%. Isoperistaltic anastomosis was completed in 85.6%, stapled in 87.9%. Hand-sewn enterotomy closure was adopted in 86%. Postoperative complications were reported in 35.4% for ICA and 50.7% for ECA; no significant difference was found according to patients’ characteristics and technologies used. Median hospital stay was significantly shorter for ICA (7.3 vs. 9 POD). Postoperative pain in patients not prescribed opioids was significantly lower in ICA group.ConclusionsIn our survey, a side-to-side isoperistaltic stapled ICA with hand-sewn enterotomy closure is the most frequently adopted technique to perform ileo-colic anastomosis after any indications for elective LRH. According to literature, our study confirmed better short-term outcomes for ICA, with reduction of hospital stay and postoperative pain.Trial registrationClinical trial (Identifier: NCT03934151).

2198 New Laparoscopic Entry Port for Previous Surgery Cases: Jain Point

Study Objective Laparoscopy in previous surgery cases is a challenge due to risk of encountering adhesions during the first blind trocar entry. This study demonstrates the technique, and relative benefits of a new entry point. Design It is a retrospective study undertaken at a high volume tertiary care referral center for advanced gynecological laparoscopic surgery. Setting Tertiary Care Centre Patients or Participants The total number of patients from January 2011 to March 2019. Total 6830 laparoscopic cases were done between January 2011 to March 2019. In 1948 patients there was a history of previous abdominal surgeries. Interventions Working over the years we found that post surgical adhesions are encountered usually in the midline or right side. The left side is spared as the colon adheres at the pelvic brim and stomach and spleen lie higher up at T 10 level. So we developed a point which is at L4 level and on the left side. It is at the level of umbilicus on a straight line drawn vertically upwards from a point 2.5 cm medial to the anterior superior iliac spine. We first introduce the veress needle perpendicular to the abdomen and then the 5mm telescope from this point, and optimize the 10 mm telescope entry. Jain Point port doubles up as the main working port in due course of surgery. Measurements and Main Results All of the 6830 cases were entered by the Jain Point in an identical manner. Out of these 1948 case were of previous one or multiple surgeries. Conclusion Jain Point offers an alternate safe entry point in previous surgery cases, applicable to upper, mid and lower abdominal scars. Laparoscopy in previous surgery cases is a challenge due to risk of encountering adhesions during the first blind trocar entry. This study demonstrates the technique, and relative benefits of a new entry point. It is a retrospective study undertaken at a high volume tertiary care referral center for advanced gynecological laparoscopic surgery. Tertiary Care Centre The total number of patients from January 2011 to March 2019. Total 6830 laparoscopic cases were done between January 2011 to March 2019. In 1948 patients there was a history of previous abdominal surgeries. Working over the years we found that post surgical adhesions are encountered usually in the midline or right side. The left side is spared as the colon adheres at the pelvic brim and stomach and spleen lie higher up at T 10 level. So we developed a point which is at L4 level and on the left side. It is at the level of umbilicus on a straight line drawn vertically upwards from a point 2.5 cm medial to the anterior superior iliac spine. We first introduce the veress needle perpendicular to the abdomen and then the 5mm telescope from this point, and optimize the 10 mm telescope entry. Jain Point port doubles up as the main working port in due course of surgery. All of the 6830 cases were entered by the Jain Point in an identical manner. Out of these 1948 case were of previous one or multiple surgeries. Jain Point offers an alternate safe entry point in previous surgery cases, applicable to upper, mid and lower abdominal scars.

Laparoscopic Liver Resection by Distance Mentoring - Trinidad to Barbados: A Report.

Laparoscopic liver resections require advanced laparoscopic skill sets. In the Caribbean, a unique situation exists where centers of excellence for liver resections exist, but surgeons who are trained in advanced laparoscopic surgery are not available throughout the region. Therefore, many patients who are candidates for liver resection in the Caribbean do not have the opportunity to receive laparoscopic operations. We report a case of distance mentoring using readily available, inexpensive equipment to complete a laparoscopic liver resection, mentored by an expert hepatobiliary surgeon. It may be considered, in special cases, as a way to increase the availability of laparoscopic operations. We acknowledge that there are many limitations to the use of this technology and we discuss the pros and cons of distance mentoring for this purpose.

Evidence Based Surgical Approach to Locally Advanced Gastric Cancer.

Gastric cancer is endemic in China, Japan, Korea, Brazil and Former Soviet Union. Patients are diagnosed usually in locally advanced stage. Endoscopy, Positron Emission Therapy- Computed Tomography, Endoscopic ultrasound and staging laparoscopy are the tools for proper evaluation of such patients. Locally advanced gastric cancer (T2-4N0 or TanyN+) requires multimodality treatment including surgery. Resection is the cornerstone of cure for gastric adenocarcinoma; however, several aspects of surgical intervention remain controversial or are suboptimally applied at a population level. Current evidence shows a D2 gastrectomy has got the best survival results. At least 15 lymph nodes should be assessed for adequate staging. Laparoscopic resections should be performed to the same standards as those for for open resections, by surgeons who are experienced in both advanced laparoscopic surgery and gastric cancer management. Keywords: Curative surgery; gastrectomy; stomach neoplasms.

Editorial introductions

Current Opinion in Obstetrics and Gynecology was launched in 1989. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of obstetrics and gynecology is divided into nine sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Section Editors for this issue. SECTION EDITORS David L. OliveDavid L. OliveDr David L. Olive is certified by the American Board of Obstetrics and Gynecology in both Obstetrics and Gynecology as well as Reproductive Endocrinology and Infertility. Dr Olive received his medical degree from Baylor College of Medicine, Houston, USA in 1979. He completed a residency in Obstetrics and Gynecology at Northwestern University, Chicago, USA and a fellowship in reproductive endocrinology at Duke University, Durham, NC. Dr Olive was previously a faculty member at the University of Arkansas, USA, the University of Texas, USA, Professor and Chief of Reproductive Endocrinology at Yale University, USA, and more recently Professor, Chief of Reproductive Endocrinology, and Vice Chairman of Academic Development at the University of Wisconsin-Madison, USA. Dr Olive has authored more than 300 publications in scientific journals and the popular press. He has acted as an Editor or Reviewer for over 20 professional journals and has been an investigator on numerous scientific grants. He has lectured extensively around the world on topics such as infertility, endometriosis, fibroids, and clinical epidemiology. He is a past president of the American Association of Gynecologic Laparoscopists. Dr Olive is currently President of Wisconsin Fertility and Reproductive Surgery Associates and co-founder of the Wisconsin Fertility Institute, USA. Matthew SiedhoffMatthew SiedhoffMatthew Siedhoff completed his medical degree at Stanford University and OB/GYN residency training at New York University, USA. He then went on to complete an AAGL fellowship in Minimally Invasive Gynecologic Surgery (MIGS) at the University of North Carolina in Chapel Hill, USA and received a Master's Degree in Clinical Research from UNC's Gillings School of Public Health, USA during fellowship. As faculty at UNC, he served as MIGS Fellowship and Division Director, and now is the director of the Center for Minimally Invasive Gynecologic Surgery at Cedars-Sinai in Los Angeles, USA. He performs advanced laparoscopic surgery for a range of gynecologic conditions, with special interest and expertise in large fibroids and complicated endometriosis. His research interests focus on surgical outcomes and he has published important trials on topics such as bowel preparation and opportunistic salpingectomy, as well as decision analysis research on uterine tissue extraction. He is very involved with AAGL Advancing Minimally Invasive Surgery Worldwide, serving as course faculty in the United States and internationally. He is currently the Immediate Past President for its fellowship board and on the editorial board for its journal, the Journal of Minimally Invasive Gynecologic Surgery.

Clinical Evaluation of Intraoperative Near Misses in Laparoscopic Rectal Cancer Surgery.

To investigate the frequency, nature, and severity of intraoperative adverse near miss events within advanced laparoscopic surgery and report any associated clinical impact. Despite implementation of surgical safety initiatives, the intraoperative period is poorly documented with evidence of underreporting. Near miss analyses are undertaken in high-risk industries but not in surgical practice. Case video and data from 2 laparoscopic total mesorectal excision randomized controlled trials were analyzed (ALaCaRT ACTRN12609000663257, 2D3D ISRCTN59485808). Intraoperative adverse events were identified and categorized using the observational clinical human reliability analysis technique. The EAES classification was applied by 2 blinded assessors. EAES grade 1 events (nonconsequential error, no damage, or need for correction) were considered near misses. Associated clinical impact was assessed with early morbidity and histopathology outcomes. One hundred seventy-five cases contained 1113 error events. Six hundred ninety-eight (62.7%) were near misses (median 3, IQR 2-5, range 0-15) with excellent inter-rater and test-retest reliability (κ=0.86, 95% CI 0.83-0.89, P < 0.001 and κ=0.88, 95% CI 0.85-0.9, P < 0.001 respectively). Significantly more near misses were seen in patients who developed early complications (4 (3-6) vs. 3 (2-4), P < 0.001). Higher numbers of near misses were seen in patients with more numerous (P = 0.002) and more serious early complications (P = 0.003). Cases containing major intraoperative adverse events contained significantly more near misses (5 (3-7) vs. 3 (2-5), P < 0.001) with a major event observed for every 19.4 near misses. Intraoperative adverse events and near misses can be reliably and objectively captured in advanced laparoscopic surgery. Near misses are commonplace and closely associated with morbidity outcomes.

Quality Improvement in Laparoscopic Donor Nephrectomy by Self-Imposed Proctored Preceptorship Model

Initiation of an advanced laparoscopic surgery program requires skill and proper training. Despite description of multiple surgical training modules, an ideal method for training of surgeons for advanced laparoscopic procedures is lacking. We propose an abbreviated self-imposed proctored preceptorship training model as the optimum training method for training skilled laparoscopic surgeons in advanced laparoscopic procedures like laparoscopic donor nephrectomy. The laparoscopic donor nephrectomy program was started at the Institute using preceptorship-proctorship model. One hundred left laparoscopic donor nephrectomies were performed over the course of 2 years. Outcomes in terms of performance related (Surgeon) outcomes in the form of learning curve and patient outcomes in terms of donor outcomes and recipient results and were studied. Learning curve was calculated using the moving average method and calculation of mean operative time of every five consecutive cases. Mean operative time for laparoscopic donor nephrectomy was 108.1 ± 26.5 min, the warm ischemia time averaged at 3.5 ± 1.3 min and the mean blood loss was 130.1 ± 54.9 ml. Moving average analysis revealed that approximately 20 LDN cases were needed to complete the learning phase. According to the mean operative time of every five consecutive cases, learning phase of LDN was completed between 26 and 30 cases. We believe that the abbreviated self-imposed proctored preceptorship model of training is an optimum model for starting a new advanced laparoscopic surgery program and can help surgeons to overcome the initial learning curve.

Risk Assessment and Learning Curve in Laparoscopic Transperitoneal Adrenalectomy - Early and Late Experience of a Single Team.

Since its first description in 1992, laparoscopic adrenalectomy has become the standard of treatment for most benign and low grade small adrenal tumors but due to the low incidence of adrenal disease, it remains a rarely performed intervention outside referral or excellence centers. Although laparoscopic surgery had a positive impact on complications of adrenalectomy, surgical risk should be thoroughly assessed when it comes to secreting or large tumors. This is a retrospective analysis of laparoscopic adrenalectomies performed in the first 4 years of practice 2007-2010 - the early experience including the learning curve of the senior surgeon, and our late experience from 2016 to 2019. All interventions were performed by a single team led by a senior surgeon with extensive experience in advanced laparoscopic surgery, using the lateral transperitoneal approach. In total, 82 cases were included, out of 153 laparoscopic adrenalectomies performed between 2007 and 2019. Only one conversion was recorded during the early experience and two laparoscopic reinterventions were needed for hemostasis and drainage. Non-secreting adenoma was the most frequent indication for surgery (26 cases) followed by Cushing's Syndrome (22 cases) while adrenocortical carcinoma was diagnosed in 3 cases. Significant differences were found between the two periods regarding operative time and length of postoperative hospital stay (p 0.001). With growing experience in laparoscopic transperitoneal adrenalectomy, less complications and shorter operative time and postoperative hospital stay are to be expected.

Laparoscopic liver resection: evolution of a single Surgeon's experience in MILS with 129 cases

Background: Interest in MILS is increasing,showing significant postoperative advantages for patients Methods: A single Surgeon with advanced expertise in both open HBP surgery as well as in advanced laparoscopic GI surgery,started a development program for introducing MILS at a large tertiary referral institution in northern Italy, in 2006.In 10 years activity 129 patients underwent laparoscopic liver resection. Results: Preoperative diagnosis was CLM in 33,5%, HCC in 15.5%, IHCC+CCC in 7%, Non-Colorectal Liver Metastases in 2%,Benign Lesions in 42%.Median operation time was 154 min.Transfusion were necessary in 10%. Liver-specific conversion rate 18.6%. Most common procedures were Single wedge(29.5%), Segmentectomy(16.3%), Left lateral sectionectomy(21.7%).Major complication (Clavien-Dindo>= 3) rate was 10% and median LOS was 5 days.Mortality occurred in none. Conclusion: TECHNICAL TIPS& RICKS (Educational Video):Intraoperative ultrasound was performed to confirm the number and location of hepatic lesions as well as their proximity to portal pedicles and hepatic veins. Liver parenchyma was transected using ultrasonic scalpel with need of #2 Pringle maneuvers (duration 20 min each-20 min off). Parenchymal transection with ultrasonic scalpel was undertaken following the US-guided demarcation line. Branches of bile ducts, portal and hepatic veins,were controlled by Hem-o-lok clips or single stitches. Trisegmentectomy (IVbs-Vs-VIs) was performed.Patients are managed post-operatively according to ERAS institutional protocol

Single institute 5 consecutive robotic single site plus one port pancreatic surgery: short term perioperative outcomes

Background: In benign and borderline malignant tumor of the pancreas, function-preserving minimally invasive pancreatectomy is ideal approach. Nowadays, we have been able to perform more advanced laparoscopic single-site surgery due to the development of robotic single-site devices. Methods: Five consecutive patients underwent robotic single-site plus one port (RSSP1) pancreatic surgery from January 2017 to December 2017. We investigate of short term perioperative outcomes for feasibility and safety of RSSP1 for beginner. We were using robotic single site surgical system (the da Vinci Xi® Surgical System (Intuitive Surgical®, Sunnyvale, CA)) with one additional robotic 12mm port. Single-site Port was placed at the umbilicus and one additional port was placed left side of umbilicus at the axillary line. We used the 3rd robot arm, Tri-staple technology 600 mm medium/thick Endo-GIA Universal stapler and EndoWrist® Vessel Sealer™ through the additional port. Results: Five female patients underwent RSSP1 pancreatic surgery. Among them four patients underwent spleen preserving distal pancreatectomy and the other one patient underwent central pancreatectomy with duct to mucosa pnacreaticojejunostomy. The mean operative time was 431 min. And estimated blood loss was 390 ml but there was no intraoperative transfusion. The mean length of hospital day was 8.4 days without any problem except for the small amount of fluid collection on the pancreas resection surface. Conclusion: Robotic single-site plus one port pancreatectomy was technically feasible and safe even in beginner.

Laparoscopic hepaticojejunostomy

Introduction: In laparoscopic pancreaticoduodenectomy (LPD) and resection of choledocal cysts (LRCC), hepaticojejunostomy (LHJ) is required for less invasive surgery. The authors present our procedure and feasibility. Methods: Between June 2014 and December 2017, 25 patients underwent LHJ (19 LPD and 6 LRCC). Synopsis of surgical procedure: Operators were limited to 2 surgeons with experiences more than 250 advanced laparoscopic surgeries. Cauterized jejunal orifice was placed in the ventral side. A polydioxanone surture (PDS II, 5-0) was placed in the 9 o'clock position for suturing the anterior wall. Another PDS II was placed in the 8 o'clock and ligated for continuous suture of the posterior wall toward 3 o'clock positon. Former thread was ligated and sutured continuously from the right side to the left side and tied together accomplishing LHJ. To avoid excessive tension to the anastomosis, jejunum was fixed to the cystic plate. Results: Median age was 62 year-old in LPD and 43.5 in LRCC, and male to female ratio was 12:13 and BMI 23 kg/m2. Although LHJ duration of the first 5 cases were 35 to 50 minutes, median time of the latest 5 cases was 19 (range 17–21) minutes. Anastomosis insufficiency was observed in one (4%) patient of LPD followed by biliary stricture after 11 months. No other biliary complications were observed with median follow-up time of 18 (1–41) months. Conclusion: Laparoscopic bilioenteric reconstruction is feasible within 30 minutes with acceptable morbidity. Further follow-up is required for long time outcomes.

Laparoscopic Pancreatoduodenectomy With Modified Blumgart Pancreaticojejunostomy

Minimally invasive pancreatic resections are technically demanding but rapidly increasing in popularity. In contrast to laparoscopic distal pancreatectomy, laparoscopic pancreatoduodenectomy (LPD) has not yet obtained wide acceptance, probably due to technical challenges, especially regarding the pancreatic anastomosis. The study describes and demonstrates all steps of LPD, including the modified Blumgart pancreaticojejunostomy. Indications for LPD are all pancreatic and peri-ampullary tumors without vascular involvement. Relative contra-indications are body mass index >35 kg/m2, chronic pancreatitis, mid-cholangiocarcinomas and large duodenal cancers. The patient is in French position, 6 trocars are placed, and dissection is performed using an (articulating) sealing device. A modified Blumgart end-to-side pancreaticojejunostomy is performed with 4 large needles (3/0) barbed trans-pancreatic sutures and 4 to 6 duct-to-mucosa sutures using 5/0 absorbable multifilament combined with a 12 cm, 6 or 8 Fr internal stent using 3D laparoscopy. Two surgical drains are placed alongside the pancreaticojejunostomy. The described technique for LPD including a modified Blumgart pancreatico-jejunostomy is well standardized, and its merits are currently studied in the randomized controlled multicenter trial. This complex operation should be performed at high-volume centers where surgeons have extensive experience in both open pancreatic surgery and advanced laparoscopic gastro-intestinal surgery.

Laparoscopic Pancreatoduodenectomy With Modified Blumgart Pancreaticojejunostomy.

Minimally invasive pancreatic resections are technically demanding but rapidly increasing in popularity. In contrast to laparoscopic distal pancreatectomy, laparoscopic pancreatoduodenectomy (LPD) has not yet obtained wide acceptance, probably due to technical challenges, especially regarding the pancreatic anastomosis.The study describes and demonstrates all steps of LPD, including the modified Blumgart pancreaticojejunostomy. Indications for LPD are all pancreatic and peri-ampullary tumors without vascular involvement. Relative contra-indications are body mass index >35 kg/m2, chronic pancreatitis, mid-cholangiocarcinomas and large duodenal cancers.The patient is in French position, 6 trocars are placed, and dissection is performed using an (articulating) sealing device. A modified Blumgart end-to-side pancreaticojejunostomy is performed with 4 large needles (3/0) barbed trans-pancreatic sutures and 4 to 6 duct-to-mucosa sutures using 5/0 absorbable multifilament combined with a 12 cm, 6 or 8 Fr internal stent using 3D laparoscopy. Two surgical drains are placed alongside the pancreaticojejunostomy.The described technique for LPD including a modified Blumgart pancreatico-jejunostomy is well standardized, and its merits are currently studied in the randomized controlled multicenter trial. This complex operation should be performed at high-volume centers where surgeons have extensive experience in both open pancreatic surgery and advanced laparoscopic gastro-intestinal surgery.

Laparoscopic Surgery Compared to Open Surgery in Excision of Rectal Cancer : A Systematic Review

Background: The laparoscopic surgery for rectal cancer, such as open surgery, is associated with many surgical complications, especially if the surgeon does not have sufficient experience in open total mesorectal excision and advanced laparoscopic surgery. This review aiming at comparing the effectiveness and the complications rate of laparoscopic surgery to those of open surgery. Methods: The comprehensive electronic search was conducted in Medline and Embase databases. The search resulted in 102 relevant clinical trials, which were subjected to primary screening and exclusion of ineligible studies. Finally, 32 potentially relevant clinical trials were included in the secondary screening from which nine clinical trials were included in this review. Data were collected from included studies using data extraction forms, then the qualitative synthesis of extracted data was conducted. Results: Small differences between interventions were reported by the included studies. Five-years survival rates tend to be slightly higher in the open surgery, whereas 3-years survival rates were higher in the laparoscopic surgery. It be attributed to the wider safe margin for tumor excision obtained in open surgery. The complications rates were slightly lower in the laparoscopy groups among most of the included studies. Conclusions: This review found comparable outcomes of laparoscopy and open surgery in treatment of rectal cancer with minimal differences in survival and complications rates.

Evaluation and patient selection for minimally invasive esophagectomy

Minimally invasive esophagectomy (MIE) is an evolving surgical alternative to traditional open esophagectomy. Despite considerable technical challenges, it was considered that MIE could be performed effectively by surgeons experienced in open esophageal resection and advanced laparoscopic surgery. This chapter illustrates the preoperative evaluation and operative indications of MIE for esophageal cancer. Firstly, a complete history and physical exam is required for counseling on preoperative optimization. Then, the operation can be conducted after standard preoperative work-up includes several parts, such as positron-emission tomography (PET), endoscopic ultrasound (EUS), esophagography and computed tomography (CT). To our knowledge, the operative indications for MIE is now extended due to the rapid development of surgical technique and detailed preoperative evaluation. Limited node invasion and neoadjuvant chemoradiation are not rigorous contraindications for MIE any more. Optimal results require elaborate evaluation, appropriate patient selection and a multidisciplinary team experienced in the management of esophageal cancer.

Neuropelveology: An Emerging Discipline for the Management of Chronic Pelvic Pain.

Chronic pelvic pain (CPP) is a common condition involving multiple, organ-specific medical specialties, each with its own approach to diagnosis and treatment. Management requires knowledge of the interplay between pelvic organ function and neuro-functional anatomy, and of the neurologic and psychological aspects of CPP, but no current specialty fully encompasses this approach. Neuropelveology is an emerging discipline focusing on pathologies of the pelvic nervous system on a cross-disciplinary basis. It involves a neurological/neurosurgical approach, combining the knowledge required for a proper neurologic diagnosis, confirmation by transvaginal/transrectal examination of the pelvic nerves, and advanced laparoscopic surgery in selected cases of CPP. The management of CPP requires multidisciplinary contributions, and neuropelveology may offer an educational framework for the interdisciplinary exchange of knowledge between clinical physicians and basic researchers.

Standard port placement for laparoscopic pancreatic surgery: How we do it

Advanced laparoscopic surgeries are technically demanding, among which laparoscopic pancreatic surgeries are the most challenging. One of the technical difficulties is the improper port placement. As there is no standard port placement for laparoscopic pancreatic surgeries, it is difficult to get proper angle to work at different steps of the surgery if ports are not well placed. It is also responsible for musculoskeletal problems to the operating surgeon. Here we propose a standard port placement for laparoscopic pancreatic surgery which gives ergonomic comfort in all laparoscopic pancreatic surgeries.

Staging and surgical approaches in gastric cancer: a clinical practice guideline.

Resection is the cornerstone of cure for gastric adenocarcinoma; however, several aspects of surgical intervention remain controversial or are suboptimally applied at a population level, including staging, extent of lymphadenectomy (lnd), minimum number of lymph nodes that have to be assessed, gross resection margins, use of minimally invasive surgery, and relationship of surgical volumes with patient outcomes and resection in stage iv gastric cancer. Literature searches were conducted in databases including medline (up to 10 June 2016), embase (up to week 24 of 2016), the Cochrane Library and various other practice guideline sites and guideline developer Web sites. A practice guideline was developed. One guideline, seven systematic reviews, and forty-eight primary studies were included in the evidence base for this guidance document. Seven recommendations are presented. All patients should be discussed at a multidisciplinary team meeting, and computed tomography (ct) imaging of chest and abdomen should always be performed when staging patients. Diagnostic laparoscopy is useful in the determination of M1 disease not visible on ct images. A D2 lnd is preferred for curative-intent resection of gastric cancer. At least 16 lymph nodes should be assessed for adequate staging of curative-resected gastric cancer. Gastric cancer surgery should aim to achieve an R0 resection margin. In the metastatic setting, surgery should be considered only for palliation of symptoms. Patients should be referred to higher-volume centres and those that have adequate support to manage potential complications. Laparoscopic resections should be performed to the same standards as those for open resections, by surgeons who are experienced in both advanced laparoscopic surgery and gastric cancer management.

Association of Centers for Medicare & Medicaid Services Overall Hospital Quality Star Rating With Outcomes in Advanced Laparoscopic Abdominal Surgery

The Centers for Medicare & Medicaid Services (CMS) recently released the Overall Hospital Quality Star Rating to help patients compare hospitals based on a 5-star scale. The star rating was designed to assess overall quality of the institution; thus, its validity toward specifically assessing surgical quality is unknown. To examine whether CMS high-star hospitals (HSHs) have improved patient outcomes and resource use in advanced laparoscopic abdominal surgery compared with low-star hospitals (LSHs). Using the University HealthSystem Consortium database (which includes academic centers and their affiliate hospitals) from January 1, 2013, through December 31, 2015, this administrative database observational study compared outcomes of 72 662 advanced laparoscopic abdominal operations between HSHs (4-5 stars) and LSHs (1-2 stars). The star rating includes 57 measures across 7 areas of quality. Patients who underwent advanced laparoscopic abdominal surgery, including bariatric surgery (sleeve gastrectomy, Roux-en-Y gastric bypass), colorectal surgery (colectomy, proctectomy), or hiatal hernia surgery (paraesophageal hernia repair, Nissen fundoplication), were included. Risk adjustment included exclusion of patients with major and extreme severity of illness. Main outcome measures included serious morbidity, in-hospital mortality, intensive care unit admissions, and cost. A total of 72 662 advanced laparoscopic abdominal operations were performed in patients at 66 HSHs (n = 38 299; mean [SD] age, 51.26 [15.25] years; 12 096 [31.5%] male and 26 203 [68.4%] female; 28 971 [75.6%] white and 9328 [24.4%] nonwhite) and 78 LSHs (n = 34 363; mean [SD] age, 49.77 [14.77] years; 9902 [28.8%] male and 24 461 [71.2%] female; 21 876 [67.6%] white and 12 487 [32.4%] nonwhite). The HSHs were observed to have fewer intensive care unit admissions (1007 [2.6%] vs 1711 [5.0%], P < .001) and lower mean cost ($7866 vs $8708, P < .001). No significant difference was found in mortality between HSHs and LSHs for any advanced laparoscopic abdominal surgery. No significant difference was found in serious morbidity between HSHs and LSHs for bariatric or hiatal hernia surgery. However, for colorectal surgery, serious morbidity was lower at HSHs compared with LSHs (258 [2.2%] vs 276 [2.9%], P = .002). This study found that HSHs treat fewer ethnic minorities and have similar outcomes as LSHs for advanced laparoscopic abdominal operations. However, HSHs may represent hospitals with improved resource use and cost.