Advanced Laparoscopic Techniques Research Articles

Advancing excellence: a national peer-coaching program for advanced laparoscopic HPB techniques

BackgroundSurgical coaching is valuable for disseminating knowledge, refining skills, and fostering continuous professional development for surgeons in practice. This work aims to implement a national coaching program for Canadian HPB surgeons, emphasizing advanced laparoscopic techniques, and to assess subsequent adoption. Secondary objectives include evaluating surgeon perceptions, barriers, and experiences. MethodsMid-to-late career HPB surgeons across Canada joined a peer surgical coaching program for advanced laparoscopic skills. The program included didactic sessions followed by practical coaching with case observation, simulation labs, and real-time coaching in the operating room. One lead surgeon from each center was invited to participate in the exit interview. ResultsEight centers across four provinces completed the program, and one lead surgeon from each site was interviewed. Surgeons reported a 34.9 % increase in self-perceived comfort levels in laparoscopic HPB surgeries, with a 24.2 % and 56.7 % increase in laparoscopic liver and pancreas resections, respectively. Participants acknowledged challenges in implementing surgical coaching, citing barriers related to surgeon and societal factors. Overcoming these challenges required mutual respect, openness to learning, and building sustained change through team collaboration and long-term coach relationships. DiscussionThis work demonstrated the practicality of a nationwide coaching program and its capacity to effect substantial, long-term change in clinical practice.

SIV Infection Is Associated with Transient Acute-Phase Steatosis in Hepatocytes In Vivo.

Metabolic-dysfunction-associated fatty liver disease (MAFLD) is a major cause of morbidity and mortality in HIV-infected individuals, even those receiving optimal antiretroviral therapy. Here, we utilized the SIV rhesus macaque model and advanced laparoscopic techniques for longitudinal collection of liver tissue to elucidate the timing of pathologic changes. The livers of both SIV-infected (N = 9) and SIV-naïve uninfected (N = 8) macaques were biopsied and evaluated at four time points (weeks -4, 2, 6, and 16-20 post-infection) and at necropsy (week 32). SIV DNA within the macaques' livers varied by over 4 logs at necropsy, and liver SIV DNA significantly correlated with SIV RNA in the plasma throughout the study. Acute phase liver pathology (2 weeks post-infection) was characterized by evidence for fat accumulation (microvesicular steatosis), a transient elevation in both AST and cholesterol levels within the serum, and increased hepatic expression of the PPARA gene associated with cholesterol metabolism and beta oxidation. By contrast, the chronic phase of the SIV infection (32 weeks post-infection) was associated with sinusoidal dilatation, while steatosis resolved and concentrations of AST and cholesterol remained similar to those in uninfected macaques. These findings suggest differential liver pathologies associated with the acute and chronic phases of infection and the possibility that therapeutic interventions targeting metabolic function may benefit liver health in people newly diagnosed with HIV.

The initial outcomes of laparoscopic surgery for the hiatal hernia repair: a tertiary center study

Background: The surgical approach to hiatal hernia has changed with the advent of laparoscopic techniques. We sought to evaluate the short-term outcomes of laparoscopic hiatal hernia repair. Methods: We conducted a cross-sectional study with a retrospective approach of patients receiving laparoscopic hiatal hernia repair from January 2018 to June 2023 at People’s Hospital 115. Results: In 25 patients included in this study, the male-to-female ratio was 2:1, with a mean age of 46. The types of hiatal hernia included type I (n = 2), III (n = 16), and IV (n = 7). The most common symptoms were epigastric pain (44%), dysphagia (16%), heartburn (25%), vomiting (76%), chest pain (32%), and shortness of breath (20%). Nissen fundoplication was also performed in 19 cases (76%). The median operative time was 130 min, and the median hospital stay was 3 days. No case was converted to open surgery, and minor or major complications occurred in 3 patients (12%). Conclusion: Laparoscopic repair for hiatal hernia is feasible and safe. The short-term outcomes included early return daily activities, and most patients experienced good to excellent functional and symptomatic results and quality-of-life improvement.

Laparoscopic vs open surgical insertion of peritoneal dialysis catheters: A propensity score-matched cohort study

BackgroudThe optimal peritoneal dialysis (PD) catheterization method remains under debated. To minimize catheter-related complications, we developed a novel modified low-position two-port laparoscopic technique, and evaluated the efficacy and safety of traditional open and advanced laparoscopic techniques. MethodsA total of 743 patients with uremia who underwent PD catheterization were retrospectively reviewed. For the placement of PD catheters, patients underwent low-position two-port laparoscopic surgery (Lap group) or traditional open surgery (open group). To minimize confounding bias, we performed a 1-to-2 propensity-score matching adjusted for the most clinically relevant potential confounders. The baseline characteristics, perioperative conditions, complications and outcomes were compared between the two groups. ResultsAfter propensity-score matching, a well-balanced cohort comprising 148 matched pairs were identified. In the matched analysis, patients in the Lap group showed significantly shorter operative time (43.0 ± 16.6 versus 81.6 ± 19.8 minutes, P < 0.001) and lower postoperative pain score within 24 hours (0.24 ± 0.62 versus 1.00 ± 1.41, P = 0.002). The incidence of catheter migration in the Lap group was significantly lower than those in the open group (0.7% versus 6.5%, P = 0.006), while other complications, such as catheter occlusion, omentum wrapping, dialysate leakage, bloody effluent, organ injury, hernia, hydrothorax, early tunnel infection and peritonitis, showed no difference (P > 0.05). The Lap group patients had a favorable catheter survival rate compared with group B (log rank, P = 0.032). ConclusionsOur low-position two-port laparoscopic technique is a safe, simple, and fast method that can minimize patient discomfort without additional cost and offers better catheter survival with minimal risk of migration.

Advanced Image-Guided Percutaneous Technique Versus Advanced Laparoscopic Surgical Technique for Peritoneal Dialysis Catheter Placement

Timely placement of a functional peritoneal dialysis (PD) catheter is crucial to long-term PD success. Advanced image-guided percutaneous and advanced laparoscopic techniques both represent best practice catheter placement options. Advanced image-guided percutaneous is a minimally invasive procedure that does not require general anesthesia. Retrospective cohort study comparing time from referral to procedure, complication rate, and 1-year catheter survival between placement techniques. Patients who had advanced laparoscopic or advanced image-guided percutaneous PD catheter placement from January 1, 2011 to December 31, 2013 in an integrated Northern California health care delivery system. PD catheter placement using advanced laparoscopic or advanced image-guided percutaneous techniques. One-year PD catheter survival; major, minor, and infectious complications; time from referral to PD catheter placement; and procedure time. Wilcoxon rank sum tests to compare referral and procedure times; χ2/Fisher exact tests to compare complications; and modified least-squares regression to compare adjusted 1-year catheter survival between PD placement techniques. We identified 191 and 238 PD catheters placed through advanced image-guided percutaneous and advanced laparoscopic techniques, respectively. Adjusted 1-year PD catheter survival was 80% (95% CI, 74%-87%) using advanced image-guided percutaneous technique vs 91% (87%-96%) using advanced laparoscopic technique (P=0.01). Major complications were<1% in both groups. Minor and infectious complications were 45.6% and 38.7% in advanced image-guided percutaneous and advanced laparoscopic techniques, respectively (P=0.01). Median days from referral to procedure were 12 and 33 for patients undergoing advanced image-guided percutaneous and advanced laparoscopic techniques, respectively (P<0.001). Median procedure time was 30 and 44.5 minutes for patients undergoing advanced image-guided percutaneous and advanced laparoscopic techniques, respectively (P<0.001). Retrospective study with practice preference influenced by timing, local expertise, and resources. Both advanced image-guided percutaneous and advanced laparoscopic techniques reported rare major complications and demonstrated excellent (advanced laparoscopic) and acceptable (advanced image-guided percutaneous) 1-year PD catheter survival. For patients referred for PD catheter placement at centers where advanced laparoscopic resources or expertise remain limited, the advanced image-guided percutaneous technique can provide a complementary and timely option to support the utilization of PD. Peritoneal dialysis is a preferred dialysis modality for many patients. However, the lack of available skilled surgeons can limit the placement of the peritoneal dialysis catheter in a timely manner. In the past decade, interventional radiology has developed expertise in placing peritoneal dialysis catheters. Using data from an integrated health care system, we compared the outcome of peritoneal dialysis catheters placed using laparoscopic surgery and interventional radiology techniques. Our results showed excellent 1-year patency of peritoneal dialysis catheters placed using laparoscopic surgery, whereas interventional radiology placement of catheters had lower but acceptable1-year patency survival, based on best practice guideline criteria. Hence, interventional radiology placement of peritoneal dialysis catheters may be a viable alternative when laparoscopic surgery is not available or feasible.

Laparoscopic adhesiolysis versus open adhesiolysis in acute adhesive small bowel obstruction.

Exploratory laparotomy is still the standard therapy for patients who need surgical intervention for adhesive small bowel obstruction (SBO). However, the use of laparoscopy in the management of adhesive SBO is still controversial. We aimed to detect the short-term outcomes between open and laparoscopic adhesiolysis for SBO. This is a retrospective study of patients with adhesive SBO who underwent either laparoscopic or open surgery from June 2019 to July 2022 at Ain Shams University Hospitals. Intraoperative and early post-operative outcomes were compared in the two groups. A total of 89 patients with adhesive SBO were included in our study. Fifty-one cases underwent open adhesiolysis and 38 cases underwent laparoscopic adhesiolysis. Laparoscopic adhesiolysis is associated with a remarkable decrease in the operative time (71 min vs. 107 min, P = 0.001) and blood loss (50 ml vs. 120 ml, P = 0.001) in comparison to open adhesiolysis. In addition to that, those who underwent adhesiolysis by laparoscopy had a short hospital stay (2.4 days vs. 3.8 days, P = 0.001), early recovery (time to pass flatus 1.3 days vs. 2.8 days) and less post-operative complications (surgical site infection [SSI] 2.6% vs. 19.6%, P = 0.001). Moreover, open adhesiolysis is associated with a higher rate of early post-operative mortality. In addition to that, the incidence of iatrogenic injury was higher in the open group. Laparoscopic adhesiolysis is a safe and feasible approach for the management of SBO and has better short-term outcomes, especially if done by skilled surgeons in advanced laparoscopic techniques.

Laparoscopic Excision of Retroperitoneal Adnexal Cyst

To demonstrate the laparoscopic excision of a retroperitoneal adnexal cyst and describe the advanced surgical techniques and anatomic considerations in a patient with previous abdominopelvic surgery. Stepwise demonstration of advanced laparoscopic techniques with narrated video footage. Adnexal masses after hysterectomy are a common reason for repeat abdominal surgery.1 Up to 9% of patients may require future adnexal surgery if ovarian preservation was chosen at the time of hysterectomy.2 Indications for surgery can include persistent adnexal masses, masses with concern for malignancy, chronic pelvic pain, and risk-reducing surgery.2 This patient is a 53-year-old postmenopausal female with a history of a total abdominal hysterectomy and left salpingectomy who underwent excision of an 8 cm retroperitoneal left adnexal cyst (Still 1). Excision of a retroperitoneal adnexal cyst can be performed through a laparoscopic approach with several key strategies: CONCLUSION: Knowledge of retroperitoneal anatomy is crucial in the surgical management of retroperitoneal adnexal masses because dissection can be technically challenging and anatomy may be distorted due to pelvic adhesive disease. Use of advanced laparoscopic techniques and understanding surgical planes are important for safe dissection. High and early ligation of the infundibulopelvic ligament at the pelvic brim and a complete ureterolysis with parametrial excision are often necessary to remove all ovarian tissue to prevent an ovarian remnant.

Comparative study of dissection of Calot’s triangle and gallbladder using monopolar hook versus harmonic scalpel in laparoscopic cholecystectomy

Background: Laparoscopic cholecystectomy (LC) using surgical electrocautery is considered to be the gold standard procedure for the treatment of uncomplicated cholecystitis and cholelithiasis. The objective of the current study was to evaluate the effectiveness and safety of the Harmonic scalpel, an advanced laparoscopic technique when compared to electrocautery. Methods: From June, 2021 through December 2022, a total of 50 patients were randomly allocated to LC with a harmonic scalpel (group 2, 25 patients) or conventional monopolar electrocautery (group 1, 25 patients). The main outcome measures were gall bladder perforation during surgery (bile leakage), stone spillage, duration of surgery, hospital stay. Results: The 2 groups were comparable with respect to baseline patient characteristics. When compared to conventional monopolar electrocautery, Gall bladder perforation during surgery (bile leakage) 12% vs. 8%, stone spillage 4% vs. 8%, duration of surgery 52.13 min vs. 54.89 min, hospital stay 2.09 days vs. 2.04 days. Conclusions: LC using conventional monopolar electrocautery is as effective and safe as that with the harmonic scalpel, for treating uncomplicated cholecystitis and cholelithiasis.

Minimally invasive radical cholecystectomy as a safe alternative to open radical cholecystectomy

Background: Gallbladder cancer today accounts for an estimated 1.2% of all new cancer diagnoses worldwide. For localized stage T1b gallbladder cancer and above, the treatment of choice is a radical cholecystectomy with negative gross and histologic margins. This procedure involves removal of the gallbladder and a portion of the liver, with or without concurrent resection of the bile duct and regional lymph nodes. In the past, performing this resection laparoscopically has been contraindicated due to fears of increased metastasis and inadequate lymph node sampling. With the advancement of laparoscopic techniques, however, minimally invasive radical cholecystectomies have the potential to be as safe and effective as the classic, open approach. This study seeks to use the current available literature to compare outcomes between an open and a laparoscopic radical cholecystectomy.

Laparoscopic Excision of Retroperitoneal Adnexal Cyst

<h3>Study Objective</h3> To demonstrate the laparoscopic excision of a retroperitoneal adnexal cyst and describe the advanced surgical techniques and anatomic considerations in a patient with prior abdominopelvic surgery. <h3>Design</h3> Stepwise demonstration of advanced laparoscopic techniques with narrated video footage. <h3>Setting</h3> Adnexal masses after hysterectomy are a common reason for repeat abdominal surgery. Up to 9% of patients may require future adnexal surgery if ovarian preservation was chosen at the time of hysterectomy. Indications for surgery can include persistent adnexal masses, masses with concern for malignancy, chronic pelvic pain, and risk-reducing surgery. <h3>Patients or Participants</h3> 53-year-old post-menopausal female with a history of a total abdominal hysterectomy and left salpingectomy who underwent the excision of an 8-centimeter retroperitoneal left adnexal cyst. <h3>Interventions</h3> Excision of a retroperitoneal adnexal cyst can be performed through a laparoscopic approach with several key strategies: 1. Use of advanced laparoscopic techniques, such as the "push and spread" method and quick bursts of bipolar energy to prevent injury to vessels, bowel and bladder 2. Use of traction and counter-traction techniques to aid in dissection 3. Knowledge of retroperitoneal anatomy and avascular spaces to assist with dissection 4. Early ligation of the infundibulopelvic ligament to minimize blood loss 5. High ligation of the infundibulopelvic ligament and complete ureterolysis from the level of the pelvic brim to bladder to completely excise ovarian tissue <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> Knowledge of retroperitoneal anatomy is crucial in the surgical management of retroperitoneal adnexal masses as dissection can be technically challenging and anatomy may be distorted due to pelvic adhesive disease. Use of advanced laparoscopic techniques and understanding surgical planes are important for safe dissection. High ligation of the infundibulopelvic ligament at the pelvic brim and a complete ureterolysis with parametrial excision are often necessary to remove all ovarian tissue to prevent an ovarian remnant.

SP2.1.1 Safety of Bariatric Surgery in The Older Patients During the COVID-19 Pandemic

BackgroundThe progressive growth of the older patients with obesity represents a challenge to the weight management teams. Although initially, old age was a relative contraindication to the surgical option, current advances in laparoscopic techniques and perioperative optimization protocols have changed the old notion. However, the performance of bariatric procedures in the older patients during the ongoing COVID-19 pandemic carries a potential risk. This study aimed to assess the safety of bariatric surgery (BS) in older patients during the pandemic.MethodsWe conducted a prospective international study of patients who underwent BS between 1/05/2020 and 31/10/2020. Patients were divided into two groups - older patients ≥65-year-old (Group I) and young < 65-year-old (Group II). Two groups were compared for 30-day morbidity and mortality.ResultsWe included 7084 patients, the mean age was 40.35±11.9 years, and 5197 (73.4%) were females. The mean preoperative weight and BMI were 119.49±24.4 Kgs and 43.03±6.9 Kg/m2, respectively.The overall comorbidities were significantly higher in Group I, p= <0.001. In Group II, 14.8% were current smokers, compared to 7.4% of Group I. The complications in Group I were significantly higher (11.4%) compared to Group II (6.6%), p= 0.022. However, the mortality rate and COVID-19 infection within 30 days were not significantly different between the two groups.ConclusionsBariatric surgery during the COVID-19 pandemic in the older patients (≥65 years old) is associated with a higher complication rate than the younger age group. However, the mortality and postoperative COVID-19 infection rates are comparable to the younger age group.

Peritoneal dialysis in the modern era.

The practice and clinical outcomes of peritoneal dialysis (PD) have demonstrated significant improvement over the past 20 years. The aim of this review is to increase awareness and update healthcare professionals on current PD practice, especially with respect to patient and technique survival, patient modality selection, pathways onto PD, understanding patient experience of care and use prior to kidney transplantation. These improvements have been impacted, at least in part, by greater emphasis on shared decision-making in dialysis modality selection, the use of advanced laparoscopic techniques for PD catheter implantation, developments in PD connecting systems, glucose-sparing strategies, and modernising technology in managing automated PD patients remotely. Evidence-based clinical guidelines such as those prepared by national and international societies such as the International Society of PD have contributed to improved PD practice underpinned by a recognition of the place of continuous quality improvement processes.

Comparison of Early Outcomes in Patients Undergoing Suture Fixation Versus Tack Fixation of Mesh in Laparoscopic Transabdominal Preperitoneal (TAPP) Repair of Inguinal Hernia

Introduction: The advent of laparoscopic techniques in repairing inguinal hernia has significantly improved outcomes of inguinal hernia surgery. However, acute and chronic postoperative pain after fixation of mesh with tacks and the cost of tacking devices are major hindrances to the widespread use of laparoscopic transabdominal preperitoneal (TAPP) repair in resource-poor settings. This study sought to introduce a method of mesh fixation that will reduce the cost of laparoscopic TAPP repair and might help reduce postoperative pain.Objective: To compare outcomes in the early postoperative period like pain, seroma, hematoma, urinary retention, and neuralgia after fixation with suture versus the tack fixation of mesh in laparoscopic TAPP repair of inguinal hernia. Subjects and methods: This study was conducted from 1st June 2019 to 31st May 2020. A total of 144 patients between ages 18 and 60 years with an inguinal hernia on any side and having an American Society of Anaesthesiologists (ASA) score of I/II were included in this study. Patients with a recurrent hernia, large scrotal hernia, strangulated and obstructed hernias, ASA III and ASA IV, prostatism, and chronic cough were excluded. Seventy-two patients were in Group A (tack fixation group) while 72 were in Group B (suture fixation group). Separate investigators were assigned to collect pre-operative and post-operative data from both groups, recorded on specially designed proforma.Results: The age range was 18 to 60 years with a mean age of 46.53 years ±10.01 S.D in Group A and 46.19 ±9.58 S.D in Group B. In Group A 98.6% of patients were male, and 1.4% were females while in Group B 100% of patients were male. It was found that mean pain in Group A was 4.88 ±0.887 and 5.29± 0.777 at 6 hours and 24 hours respectively. Mean pain in group B was 3.43 ±0.962 and 4.11±0.703 at 6 hours and 24 hours respectively. Moreover, mean pain in Group B was significantly less than mean pain in Group A both at 6 hours and 24 hours intervals with a p-value < 0.001. The early postoperative complications were not significantly different in both groups. Conclusion: In TAPP repair, suture fixation of mesh is less painful than tack fixation. However, there is no significant difference in the rate of other early postoperative outcomes like seroma, hematoma, urinary retention, and neuralgia. Further multicentric studies with a longer duration of follow-up are needed to validate our results.

Clinical Feasibility of Duct-To-Mucosa Pancreaticojejunostomy in Laparoscopic Pancreaticoduodenectomy : Comparison with the Same Technique in Open Pancreaticoduodenectomy

Introduction: Duct-to-mucosa pancreaticojejunostomy (DM-PJ) is one of the most commonly used technique in pancreaticoduodenectomy (PD). However, DM-PJ can be considered technically a challenge procedure in laparoscopic PD (L-PD), especially in cases with small pancreatic duct. Therefore, we will present the clinical feasibility and technical tips for DM-PJ in L-PD. Methods: Between January 2016 and December 2019, we performed 120 cases of PD. Among them, 60 patients underwent totally L-PD. We retrospectively reviewed the medical records to ascertain the safety and the reproducibility of DM-PJ and compared with open DM-PJs. Results: Significant pancreatic fistula [International Study Group on Pancreatic Fistula (ISGPF) grade B or C] in L-PD was less than 10%, and this complication was even more higher than open DM-PJ group. The postoperative mortality in L-PD was nil and this result was also lower than open DM-PJ. The postoperative complication than Clavien-Dindo classification III was identified in 4 patients in L-PD, but recovered by interventional management. The conversion to open PD was required in one patient with tumor invasion to the superior mesenteric vein, but there was no open conversion because of technical difficulty of DM-PJ. Conclusion: We believe that DM-PJ in L-PD can be the standard method as in open PD, because of the magnification of laparoscope and advancement of laparoscopic techniques. And, further development of laparoscopic instruments is essential.

Advanced Laparoscopic Adenomyomectomy Technique for Focal Uterine Adenomyosis by Three-step Approach.

Owing to the increasing trend of preserving fertility in adenomyomectomy, the need for laparoscopic adenomyomectomy has increased. This study aimed to introduce a new surgical technique, an advanced laparoscopic adenomyomectomy technique, and to evaluate its efficacy, benefits, and safety in focal uterine adenomyosis. From February 1, 2019 to February 29, 2020, 47 patients who underwent laparoscopic adenomyomectomy using the new surgical technique were enrolled in the study. The inclusion criteria were: (1) Focal-type adenomyosis, diagnosed by ultrasound or magnetic resonance imaging that was refractory to medical treatments. (2) A strong desire to preserve the uterus. All the operations were performed by a single surgeon with a uniform technique. The mean patient age was 40.53 ± 5.93 years (median 38.5, range 32-47). The mean diameter of the adenomyoma lesions was 4.57 ± 1.21 cm and the mean weight of the excised lesions was 40.53 ± 35.65g (range, 15-209 g). The mean total operation time was 70.11 ± 15.05 minutes. The mean estimated blood loss was 88.88 ± 20.0 mL (20 - 500 ml). There was no conversion to laparotomy or major complications requiring reoperation. At the seven-month follow-up, there was complete remission of dysmenorrhea and menorrhagia in 97.4% and 88.9% of the patients, respectively. The new advanced laparoscopic adenomyomectomy technique with a three-step approach could be a safe and effective therapeutic method.

International survey on opinions and use of minimally invasive surgery in small bowel neuroendocrine neoplasms

IntroductionAlthough minimally invasive surgery is becoming the standard technique in gastrointestinal surgery, implementation for small bowel neuroendocrine neoplasms (SB-NEN) is lagging behind. The aim of this international survey was to gain insights into attitudes towards minimally invasive surgery for resection of SB-NEN and current practices. MethodsAn anonymous survey was sent to surgeons between February and May 2021 via (neuro)endocrine and colorectal societies worldwide. The survey consisted of questions regarding experience of the surgeon with minimally invasive SB-NEN resection and training. ResultsA total of 58 responses from five societies across 20 countries were included. Forty-one (71%) respondents worked at academic centers. Thirty-seven (64%) practiced colorectal surgery, 24 (41%) endocrine surgery and 45 (78%) had experience in advanced minimally invasive surgery. An open, laparoscopic or robotic approach was preferred by 23 (42%), 24 (44%), and 8 (15%) respondents, respectively. Reasons to opt for a minimally invasive approach were mainly related to peri-operative benefits, while an open approach was preferred for optimal mesenteric lymphadenectomy and tactile feedback. Additional training in minimally invasive SB-NEN resection was welcomed by 29 (52%) respondents. Forty-three (74%) respondents were interested in collaborating in future studies, with a cumulative median (IQR) annual case load of 172 (86–258). ConclusionsAmong respondents, 69% applies minimally invasive surgery for resection of SB-NEN. Arguments for specific operative approaches differ, and insufficient training in advanced laparoscopic techniques seems to be a barrier. Future collaborative studies can provide better insight in selection criteria and optimal technique.

Introduction of advanced laparoscopy for peritoneal dialysis catheter placement and the outcome in a University Hospital

BackgroundPeritoneal dialysis (PD) catheters can be obstructed by omental wrapping or migration, leading to catheter malfunction. Multiple catheter placement techniques have been described. Advanced laparoscopy with fixation of the catheter and omentum has been reported to improve functional outcome compared to basic laparoscopy without fixation. This feasibility study describes surgical technique, complications, and comparison of the functional outcome of advanced versus basic laparoscopic catheter placement.MethodsBetween July 2016 and April 2019, the advanced laparoscopy technique was applied in all eligible patients. Two experienced surgeons placed the catheters in a standardized procedure. Peri-operative complications and functional outcome of the catheter were scored. Results were compared to a historical cohort retrieved from our RCT performed earlier using basic laparoscopy.FindingsThe basic laparoscopic group (BLG) consisted of 46 patients and the advanced laparoscopic group (ALG) of 32. Complication rate in both groups was similar and low with 7% in the BLG and 6% in the ALG (p = 1.0). There was a trend toward better functional catheter outcome in the ALG (88%) compared to the BLG (70%) (p = 0.1). Part of the catheter failures in the ALG could be related to the learning curve. After revision surgery, 94% of patients in the ALG had a functional catheter. These findings lead to the set-up of a multi-center randomized-controlled trial, currently running, comparing basic to advanced laparoscopic techniques.

Laparoscopic Appendectomy: Surgical Techniques for the Benign Gynecologist

<h3>Study Objective</h3> To demonstrate two methods of performing a laparoscopic appendectomy in the setting of endometriosis. <h3>Design</h3> Stepwise demonstration of advanced laparoscopic techniques with narrated video footage. <h3>Setting</h3> Laparoscopic appendectomies may be performed incidentally at the time of a gynecologic procedure or for treatment purposes. In our practice, we typically perform appendectomies in the setting of endometriosis, where appendiceal endometriosis rates may range from 10-40%, especially in the presence of deep infiltrating endometriosis or ovarian endometriomas. In these cases, an appendectomy may be warranted to perform a complete resection of endometriosis and may be diagnostic or therapeutic in patients with chronic pelvic pain. <h3>Patients or Participants</h3> Patients undergoing laparoscopic excision of endometriosis requiring a concurrent appendectomy. <h3>Interventions</h3> Although uncommonly performed by gynecologists, appendectomies may be performed for complete disease management of endometriosis or prevention of future appendicitis. Sound surgical technique and knowledge of the anatomy will allow most laparoscopists to safely perform this procedure. Several key strategies include: 1. Identification of the appendix and its surrounding landmarks. 2. Division of the mesoappendix in order to ligate the appendiceal artery and to skeletonize the appendix. 3. Transection of the appendix with either Endoloops or the endoscopic gastrointestinal stapler. 4. Containment of the appendix within a specimen retrieval bag to avoid contamination. <h3>Measurements and Main Results</h3> This video provides a narrated stepwise demonstration displaying two methods of how to perform a laparoscopic appendectomy featuring the Endoloop and the endoscopic gastrointestinal stapler. <h3>Conclusion</h3> Laparoscopic appendectomies can be performed successfully by benign gynecologists and are particularly useful in the complete management of endometriosis. Here we demonstrate two common methods for performing a laparoscopic appendectomy, highlight relevant surgical anatomy, and provide key surgical strategies for the safe completion of this procedure.

Experience with placing peritoneal dialysis catheters in the iliac fossa in cases of frozen pelvis.

Peritoneal dialysis (PD) is a modality frequently preferred by patients for the management of their end-stage kidney disease; however, a major factor in its success is PD catheter placement and subsequent function. Optimal placement of PD catheters is generally accepted to be in the true pelvis, for this reason, many patients who are found to have a pelvic cavity obliterated by adhesions are often denied the opportunity to do PD. We report on four cases of an alternative advanced laparoscopic technique used in patients with inaccessible pelvic cavities, with three catheter placements in the intraperitoneal left iliac fossa/paracolic gutter and one case in the right paracolic gutter with subsequent good outcomes. This report suggests that a 'frozen pelvis' is not a contraindication to successful PD, with alternative catheter tip placement in the iliac fossa.

Robotic versus laparoscopic anterior resections for rectal and rectosigmoid cancer: an institutional experience.

Colorectal surgery has evolved with the advent of laparoscopic techniques and now robotic-assisted surgery. There is significant literature supporting the use of laparoscopic techniques over open surgery with evidence of enhanced post-operative recovery, reduced use of opioids, smaller incisions and equivalent oncological outcomes. Robotic minimally invasive surgery addresses some of the limitations of laparoscopic surgery, providing surgical precision and improvements in perception and dexterity with a resulting decrease in tissue damage. We retrospectively reviewed the medical records of patients who underwent robotic-assisted anterior resection for cancer of the rectum or rectosigmoid junction in our institution since our robotic programme began in 2017. Patient demographics were identified via electronic databases and patient charts. A matched cohort of laparoscopic cases was identified. A total of 51 consecutive robotic-assisted anterior resections were identified and case matched with laparoscopic resections for comparison. Robotic-assisted surgery was associated with a shorter length of stay (p = 0.04), reduced initial post-operative analgesia requirements (p < 0.01) and no significant difference in time to bowel movement or stoma functioning (p = 0.84). All patients had an R0 resection, and there was no statistical difference in lymph node yield between the groups (p = 0.14). Robotic surgery was associated with a longer operative duration (p < 0.001). In this early experience, robotic surgery has proven feasible and safe and is comparable to laparoscopic surgery in terms of completeness of resection and recovery. As costs and operating times decline and as technology progresses, robotic surgery may oneday replace traditional laparoscopic techniques.