Advances In Minimal Access Surgery Research Articles

Partial Nephrectomy for Renal CancerA Phoenix Risen from the Ashes: A Case Series on Totally Laparoscopic Partial Nephrectomy with Review of Literature

Partial nephrectomy, also called Kidney-sparing Surgery (KSS) or Nephron-sparing Surgery (NSS), is an operation wherein, only a cancerous renal tumour or diseased renal tissue is surgically removed; leaving behind as much healthy renal tissue as possible. Understandably, it was initially preferred in patients with solitary kidney and those, with concurrent bilateral tumours. Over the first two decades of the 21st century, Partial Nephrectomy (PN) has become the standard procedure for many renal tumours; even in unilateral disease. This is because of early pick up due to significant developments in imaging modalities and also, due to better understanding of the biology of renal tumours. With advances in minimal access surgery, partial nephrectomy too has come under its ambit. In the present case series, it's fascinating journey has been discussed- its exciting rise, subsequent downfall and then its unique rise again; as the preferred surgical therapy for many renal tumours, around the world. The purpose of reporting the present case series on Laparoscopic Partial Nephrectomy (LPN) performed for renal cancer, was to share the authors’ early experience and results on the topic and to compare them with the world literature. Also, the aim was to underscore the fact that, in an advanced laparoscopy set up, with optimum patient selection and availability of advanced laparoscopic skills, it is an effective and feasible operation. Herein, the authors have described three cases of totally LPN and review of literature on the same. Over an average follow-up period of 23 months, all three patients continue to be asymptomatic and disease free.

Single-site, multiple port, antireflux laparoscopic fundoplication is a feasible cost-effective technique

Advances in minimal access surgery have led to the emergence of single-incision laparoscopic surgery. Single-incision laparoscopic fundoplication for gastroesophageal reflux disease is safe and feasible in experienced hands. However, the main drawback of this technique is the increased cost factors considering the port devices and specialized instrumentation required. We did single-incision, multiple port laparoscopic Nissen fundoplication with conventional trocars and instruments.

Recent Advances in Minimal Access Surgery

Recent Advances in Minimal Access Surgery

Laparoscopic Management of Retrograde Jejuno-Gastric Intussusception: a Case Report

Jejuno-gastric intussusception is a rare but lethal complication of gastric surgeries with a reported incidence of 0.15%. A high index of suspicion is required to diagnose this condition in a patient with a history of gastric surgery. With advances in minimal access surgery, reduction of the intussusceptum is possible through laparoscopy or endoscopy. We present an elderly male who had undergone a Billroth II procedure before 27 years. The patient was diagnosed with jejuno-gastric intussusception based on ultrasound and endoscopic findings. The patient was successfully managed under laparoscopy.

The Role of Minimal Access Surgery in the Treatment of Spinal Metastatic Tumors.

Study Design:Literature review.Objective:To provide an overview of the recent advances in minimal access surgery (MAS) for spinal metastases.Methods:Literature review.Results:Experience gained from MAS in the trauma, degenerative and deformity settings has paved the road for MAS techniques for spinal cancer. Current MAS techniques for the treatment of spinal metastases include percutaneous instrumentation, mini-open approaches for decompression and tumor resection with or without tubular/expandable retractors and thoracoscopy/endoscopy. Cancer care requires a multidisciplinary effort and adherence to treatment algorithms facilitates decision making, ultimately improving patient outcomes. Specific algorithms exist to help guide decisions for MAS for extradural spinal metastases. One major paradigm shift has been the implementation of percutaneous stabilization for treatment of neoplastic spinal instability. Percutaneous stabilization can be enhanced with cement augmentation for increased durability and pain palliation. Unlike osteoporotic fractures, kyphoplasty and vertebroplasty are known to be effective therapies for symptomatic pathologic compression fractures as supported by high level evidence. The integration of systemic body radiation therapy for spinal metastases has eliminated the need for aggressive tumor resection allowing implementation of MAS epidural tumor decompression via tubular or expandable retractors and preliminary data exist regarding laser interstitial thermal therapy and radiofrequency ablation for tumor control. Neuronavigation and robotic systems offer increased precision, facilitating the role of MAS for spinal metastases.Conclusions:MAS has a significant role in the treatment of spinal metastases. This review highlights the current utilization of minimally invasive surgical strategies for treatment of spinal metastases.

Open versus laparoscopic repair of perforated duodenal ulcer: a comparative study

Background: Surgery is the mainstay of the treatment for perforated duodenal ulcer by closing the perforation with or without omental patch. There are no controversies in the surgical treatment of perforated duodenal ulcer but the best approach to surgery is still debatable. Advances in minimal access surgery has made it possible to close the perforated duodenal ulcer laparoscopically. The present study was conducted to compare the results of open and laparoscopic repair of perforated duodenal ulcer in terms of operative time, postoperative pain, hospital stay, and post-operative complications etc.Methods: The study was conducted in Dr. V. M. Government Medical College and Hospital located in Solapur (Maharashtra) from December 2008 to December 2010. It was a prospective comparative study. Patients were randomly divided into 2 groups alternately where group A and B were operated by conventional and laparoscopic techniques respectively and their outcomes were compared.Results: Most commonly affected age in this study was 51 to 60 years with male preponderance. Post-operative pain, analgesic requirement, wound infection, hospital stay, was significantly less in laparoscopic group as compared to open group (p<0.05).Conclusions: Laparoscopic repair of perforated duodenal ulcer is safe and feasible in properly selected patients and has superior results as compared to open surgery.

Future Perspectives in Hypopharyngeal Cancer Care.

Recent advances in minimal access surgery have shown promise in the treatment of limited hypopharyngeal lesions. In spite of their functionally excellent results in individual patients, it currently remains unlikely that these approaches will gain a more major universal impact on hypopharyngeal cancer care. In advanced stage hypopharyngeal cancer, the use of the traditional radical surgery, such as laryngo-pharyngectomy, is no longer accepted by many patients. In recent years, most would rather opt for less mutilating treatment, preferring a non-surgical option. Patients, families and medical practitioners frequently ignore or misunderstand the associated mortality and morbidity consequence of such an approach. Although synergy between chemotherapy and radiotherapy enhances the efficacy of the treatment, chemo-radiation as currently used achieves a tumour response in < 80%, with relapses of the tumour during the follow-up period, indicating that surgery is the only effective treatment option as salvage. Advances in molecular research have improved our understanding of oncogenesis, tumour spread and the mechanisms of metastases. Innovative strategies have become available that manipulating tumours or the host to favour conditions receptive for disease eradication. These advances have gone through pre-clinical testing and are currently being used in early clinical trials using approaches such as replacement of defective genes, suicide gene therapy, and immunologic gene therapy. Precision oncology may eventually be able to predict which patients are more likely to respond to specific cancer therapies based on increasingly accurate, high-resolution biomarkers based on molecular diagnostics of individual tumours. Currently concentrating cancer treatment at specialised head and neck cancer institutions is likely to contribute faster and more sustained results at improving patient outcomes for hypopharyngeal cancer care than any individual innovation in surgery, radiation oncology or systemic treatment. Preventative work should continue by governments with the elimination of the preventable risk factors (abusive use of alcohol, tobacco and betel nut chewing) may reduce the incidence of the disease.

Laparoscopic distal pancreatectomy: our experience in tertiary care center

Introduction: With advances in minimal access surgery, laparoscopic DP with or without splenectomy is slowly gaining acceptance as an alternative to open surgery in selected cases. Methods and materials: A retrospective review of our data was carried out. From 2010-2016, we performed eight DP by the laparoscopic approach. A 5 port approach was used. The specimen was divided using endo-GIA stapler (purple/green cartridge). The decision of spleen preserving was made if the splenic vessels and the splenic hilum were free. The specimen was retrieved in endobag using Pfannenstiel incision. The perioperative parameters, morbidity, and follow-up results were analyzed. Results: From 2010–2016, eight patients underwent laparoscopic DP. All eight were females. Two patients underwent spleen preserving DP. None of the cases were converted to open surgery. The mean operative time was 4 hours (5–6 hours). The mean diameter of tumor was 4 cm (3–5 cm). Two patients developed post operative pancreatic fistula ISGPF grade 1–2 which was managed conservatively. The mean hospital stay was 7 days (6–8 days). The final diagnosis was serous cystadenoma in one patient, mucinous cystadenoma in four patients, NET in one patient and solid pseudopapillary tumor in two patients. The mean follow up period was 3 years (2–4 years) with no recurrence. Conclusion: Laparoscopic distal pancreatectomy is safe and technically feasible for selected patients with benign and low grade malignant pancreatic tumor with acceptable morbidity and clinical outcomes.

Surgical approaches for varicocele in pediatric patient.

Varicocele represents one of the most common surgically correctible urologic anomalies in adolescent males. The best procedure for the treatment of adolescent varicocele has not been established, but with recent advances in minimal access surgery, there have been many reports praising the safety and efficacy of laparoscopy and retroperitoneoscopy for the surgical correction of varicocele in adolescent. The aim of this review is to compare the results of Palomo's technique, with retroperitoneoscopic and transperitoneoscopic approaches in adolescent, analyzing recurrence, testicular growth and complications. A literature search on PubMed and Cochrane Database was conducted with regard to management of varicocele in adolescent population. Twenty two English language studies that compared outcome of different minimally invasive treatments or outcome of minimally invasive and traditional surgical treatments for adolescent diagnosed with varicocele were included. Intraoperative complications of minimally invasive approaches occur in early cases, but in pediatric urology these procedures would become more efficient with experience and these approaches continue to increase in number. Postoperative hydrocele is the most postoperative compliance of Palom technique, and reports have shown a wide range of variability for his incidence, depending on the technique used for surgical treatment. Literature showed an increase of testicular volume for real growth of testis after surgery, and an intratesticular improvement in sperm quality after minimally invasive approach. In laparoscopic approach reports have showed very low recurrence because allows better vision of collateral veins, and a lymphatic sparing technique permit to identify lymphatic vessels in 100% of cases. The literature has shown that laparoscopic varicocelectomy is the surgical approach most commonly reported in adolescent patients, and that its use is increasing for better training for surgeons and the ability to avoid operational hydrocele that is a main complication after technical Palomo's technique.

New Developments in Robotics and Single-site Gynecologic Surgery.

Within the last 10 years there have been significant advances in minimal-access surgery. Although no emerging technology has demonstrated improved outcomes or fewer complications than standard laparoscopy, the introduction of the robotic surgical platform has significantly lowered abdominal hysterectomy rates. While operative time and cost were higher in robotic-assisted procedures when the technology was first introduced, newer studies demonstrate equivalent or improved robotic surgical efficiency with increased experience. Single-port hysterectomy has not improved postoperative pain or subjective cosmetic results. Emerging platforms with flexible, articulating instruments may increase the uptake of single-port procedures including natural orifice transluminal endoscopic cases.

Management of necrotizing pancreatitis and its outcome in a secondary healthcare institution

Background: Surgical debridement is the “gold standard” for infected pancreatic necrosis. Advances in imaging methods and minimal access techniques have changed the management of many surgical conditions and even infected pancreatic necrosis has successfully been treated in selected patients. However, technical advances don’t obviate sound clinical judgment. Aim was to consider recent advances in minimal access surgery, this article retrospectively analyses the role of open surgery and laparoscopic techniques in the management of necrotizing pancreatitis.Methods: A retrospective study of 30 cases of pancreatic necrosectomy admitted and managed during 2012-2016 was carried out and compared with results available in the existing literature.Results: Out of 30 cases, 20 were men and 10 were women. Patients' age ranged from 23 to 70 years (mean age - 49.8 years). The mean operating time was 103.8 min (range, 60-120 min). Timing of necrosectomy was 21-32 days (average - 25.5 days). The average duration of hospital stay after the procedure was 17.4 days (range, 10-21 days).Conclusions: Comparative analysis of results of different surgical techniques reveals that there is no significant difference in terms of mortality. However, overall rate of complications and failure (inadequate debridement and drainage) are still higher with minimally invasive techniques.

Outcomes of open partial nephrectomies performed by Australian trainees.

Partial nephrectomy (PN) has become the standard of care for small renal tumours, with open partial nephrectomy (OPN) being superseded by minimally invasive PN. Advances in minimal access surgery have resulted in fewer relative contraindications, with subsequently fewer OPN being performed. Consequentially, trainees have less opportunity to gain skills and experience in open renal surgery. The aims of this study were to assess the standard of OPN performed by Australian urological trainees and to define whether OPN is a safe and suitable training opportunity. A retrospective review was undertaken on patients who underwent OPN performed by urology trainees from 2010 to 2014 at two training hospitals in Western Australia. Data collected included patient demographics, surgical and oncological outcomes and morbidity. Sixty patients underwent OPN, with a mean age of 56 years. Most tumours were single, with mean size 31 mm. Mean operative time was 157 min, with a mean cold ischaemic time of 27 min. Mean pre- and post-operative creatinine levels were equivalent (77 μmol/L). The overall complication rate was 18%, with no documented urinary leaks, and 1.7% blood transfusion rate. Median length of stay was 4 days. There were no oncological positive margins or recurrence after a median follow-up of 2 years. Our data support the notion that Australian urological trainees can perform the majority of OPN cases, with equivalent oncological outcomes. We would advocate that when an OPN is being performed, the supervising consultant should use the case as an adjuvant for open renal surgery training.

Laparoscopically assisted radical vaginal hysterectomy versus radical abdominal hysterectomy for the treatment of early cervical cancer

Cervical cancer is the second most common cancer among women and is the most frequent cause of death from gynaecological cancers worldwide. Standard surgical management for selected early-stage cervical cancer is radical hysterectomy. Traditionally, radical hysterectomy has been carried out via the abdominal route and this remains the gold standard surgical management of early cervical cancer. In recent years, advances in minimal access surgery have made it possible to perform radical hysterectomy with the use of laparoscopy with the aim of reducing the surgical morbidity and promoting a faster recovery. To compare the effectiveness and safety of laparoscopically assisted radical vaginal hysterectomy (LARVH) and radical abdominal hysterectomy (RAH) in women with early-stage (1 to 2A) cervical cancer. We searched the Cochrane Gynaecological Cancer Group Trials Register, and Cochrane Register of Controlled Trials (CENTRAL) Issue 7, 2013, MEDLINE, and EMBASE up to July 2013. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field. Randomised controlled trials (RCTs) that compared laparoscopically assisted radical hysterectomy and radical abdominal hysterectomy, in adult women diagnosed with early (stage 1 to 2A) cervical cancer. Two review authors independently abstracted data and assessed risk of bias. We found one RCT, which included 13 women, that met our inclusion criteria and this trial reported data on LARVH versus RAH.Women who underwent LARVH for treatment of early-stage cervical cancer appeared to have less blood loss compared with those who underwent RAH. The trial reported a borderline significant difference between the two types of surgery (median blood loss 400 mL (interquartile range (IQR): 325 to 1050) and 1000 mL (IQR: 800 to 1025) for LARVH and RAH, respectively, P value = 0.05). RAH was associated with significantly shorter operation time compared with LARVH (median: 180 minutes with LARVH versus 138 minutes with RAH, P value = 0.05).There was no statistically significant difference in the risk of perioperative complications in women who underwent LARVH and RAH. The trial reported two (29%) and four (57%) cases of intraoperative and postoperative complications, respectively, in the LARVH group and no (0%) reported cases of intraoperative complications and five (83%) cases of postoperative complications in the RAH group. There were no reported cases of severe perioperative complications.Bladder and bowel dysfunction of either a transient or chronic nature remain major morbidities after radical hysterectomy, and the one included study showed that there may be significantly less after LARVH. The included trial lacked statistical power due to the small number of women in each group and the low number of observed events. Therefore, the absence of reliable evidence, regarding the effectiveness and safety of the two surgical techniques for the management of early-stage cervical cancer, precludes any definitive guidance or recommendations for clinical practice. The trial did not report data on long-term outcomes, but was at moderate risk of bias due to very low numbers of included women.

Bilateral Simultaneous Laparoscopic Adrenalectomy in Cushing's Syndrome: Safe, Effective, and Curative

Surgical morbidity and mortality rates are high in patients with Cushing's syndrome. Nevertheless, simultaneous bilateral laparoscopic adrenalectomy (LA) is feasible in these patients with less morbidity and good long-term results. Consecutive 22 patients who underwent LA for Cushing's syndrome between 2003 and 2010 in our institute were retrospectively studied. Ninteen patients underwent bilateral simultaneous and three underwent unilateral LA. Seven patients had Cushing's syndrome after failed pituitary surgery and five each had ectopic adrenocorticotrophic hormone dependent syndrome and bilateral macronodular hyperplasia respectively. LA was bilaterally done by lateral transabdominal adrenalectomy in 15 patients and retroperitoneal endoscopic adrenalectomy in 4 on the right side. Mean operative time for simultaneous bilateral cases was 199.45±72.43 minutes with mean blood loss of 72.72±48.6 mL. Patients were fit for discharge by the fifth postoperative day from the surgical aspect. Surgical complication rate was 26% that included wound infections in two, port site hernia, pleural effusion, and atelectasis in one each. One patient died of sepsis (5% mortality). Satisfactory metabolic control was achieved in all observable patients in the long term although Addisonian crisis and Nelson syndrome were seen in 26% and 15% respectively. LA has all advantages of minimal access surgery in patients with Cushing's syndrome who are immunocompromised and at high risk of delayed wound healing and infections. Magnification decreases the risk of retained adrenal remnants. Despite advances in minimal access surgery, perioperative morbidity continues to be significant for the procedure.

Advances in Minimal Access Surgery in the Surgical Staging of Carcinoma Endometrium

The concept of minimal access surgery for gynecologic malignancies has gone from a perceived near impossibility to a fullyrecognized option for many patients over the past 10 years. This article reviews the different minimal access techniques used forsurgical staging of carcinoma endometrium, their outcome, feasibility and safety in comparison to conventional staging laparotomy.After review of literature, it is concluded that laparoscopic and robotic-assisted procedures are acceptable and safer alternatives totraditional laparotomy in the staging of carcinoma endometrium, especially in obese women. Long-term outcome reports for roboticsurgery is awaited.

Laparoscopic management of genital prolapse

Genital prolapse is one of the most common indications for gynaecological surgery. Surgery is performed traditionally via abdominal, vaginal and laparoscopic approaches. A MEDLINE computer search was performed to explore the recent evidence behind laparoscopic surgery for female pelvic organ prolapse. Advances in minimal access surgery have led to an increase in adoption of laparoscopic techniques. Current evidence supports the use of laparoscopy for sacrocolpopexy and colposuspension as an alternative to open surgery. However, the introduction of less invasive midurethral sling procedures for stress incontinence has reserved laparoscopic colposuspension for special indications. The scientific evidence regarding uterosacral suspension procedures and paravaginal and vaginal prolapse repairs are sparse. The current evidence supports the outcome of laparoscopic sacrocolpopexy as an alternative to open surgery. Further studies are required on the long-term efficiency in laparoscopic paravaginal repair and vaginal wall prolapse.

Surgical management of urological malignancy: Anaesthetic and critical care considerations

Surgical resection of urological malignancy is increasingly performed due to advances in minimal access surgery and the capability to operate on patients with greater comorbidities. The ageing population implies that these procedures may feature even more frequently in the anaesthetic workload in the future. Here we describe the major pre-operative considerations for renal, bladder, prostate and testicular tumours. An overview of each of the specific procedures involved is provided, detailing operative parameters such as monitoring and patient positioning as well as common complications. Analgesia and fluid management in the post-operative period are addressed. We also summarise adjunctive radiotherapy and chemotherapy, and comment on their implications for peri-operative management.

Surgical, Anesthetic, Perfusion-Related Advances in Minimal Access Surgery

As we enter the fifth decade in cardiac surgery, traditionally cardiac surgery has been performed using a median sternotomy with cardiopulmonary bypass providing great access to the heart and all the surrounding structures. During the last decade, there has been a paradigm shift in the methods by which surgery has been performed. The invasiveness of many procedures has been dramatically reduced, with significantly superior outcomes, as evidenced by improved survival, fewer complications, and quicker return to functional health and productive life. This resulted in significant interest and excitement in adopting less invasive techniques in cardiac surgery. Unfortunately, this was an unrealistic expectation due to the limitations that existed in cardiac surgical techniques and conventional endoscopic instruments, cardiac anesthesia, and cardiopulmonary bypass techniques. In this article, the advances in minimally invasive surgical, cardiac anesthesia, and cardiopulmonary bypass techniques in the evolution of minimal access cardiac surgery are summarized.

Recent Advances in Minimal Access Surgery for Infants and Children

Paediatric surgeons were among the pioneers of laparoscopic surgery in the early 1970s. However, the vast potential of minimal access surgery in infants and children has only been more fully realised in the past decade. This has been brought about by increasing experience in paediatric laparoscopic procedures, and advances in video technology and miniaturised instruments. Very few complex paediatric surgical conditions are now beyond the scope of minimal access surgery. Benefits of minimal access surgery may include reduced postoperative pain, shortened length of stay, and faster resumption of normal activities. The question now is no longer whether laparoscopic surgery should be done in children, but what conditions should be treated laparoscopically. In this review, we will discuss the scope of laparoscopic surgery in children and focus on recent advance and controversial issues. Keywords: Laparoscopy, Thoracoscopy, Minimally access surgery, Paediatric

Combined Use of Preoperative Methylene Blue Dye and Microcoil Localization Facilitates Thoracoscopic Wedge Resection of Indeterminate Pulmonary Nodules in Children

The ability to biopsy indeterminate pulmonary lesions in children has evolved with advances in minimal access surgery. Recent advances in preoperative localization including image-guided dye injection or wire implantation have expanded the types of lesions that are accessible via minimal access surgery. We present a case of a 13-year-old boy who underwent preoperative localization using both methylene blue dye and microcoil labeling, and a subsequent thoracoscopic pulmonary wedge resection under the same anesthesia. The combined use of both dye and microcoil localization provides the advantage of superior intraoperative visualization of the lesion and the ability to use fluoroscopy to confirm the presence of the nodule in the surgical specimen. We recommend this technique for the biopsy of indeterminate pulmonary lesions that would not otherwise be accessible via a minimally invasive approach.