Laparoscopic Assistance Research Articles

Rectal Prolapse Repair with Abdominal Fixation Under Sedation and Local or Epidural Anesthesia: Prospective Pilot Study in 10 Elderly Subjects.

Background: Rectal prolapse (RP) is primarily a disease of the elderly, where treatment may be associated with significant postoperative morbidity including that related to anesthesia. Objective: The aim of this study was to evaluate the safety and feasibility of a novel abdominal approach to RP repair under sedation and local anesthesia and to assess short- and long-term clinical outcomes in elderly patients (>70 years). Design Settings: This is a prospective pilot study with 10 patients using a novel RP repair. The anesthesia type was local or epidural with sedation. Follow-up was done at 30 days, 12, and 24 months. Patients: Patients were men and women >70 years of age with RP. Main Outcome Measures: (1) Feasibility: successful completion of RP repair using the novel abdominal approach with laparoscopic assistance. (2) Safety: safety was measured by the incidence of the intraoperative complications (bowel perforation, organ injury, and bleeding requiring blood transfusion). (3) Sedation and local anesthesia feasibility: surgery was safely completed without patient intubation. Results: Ten female patients >70 years of age underwent RP repair using the novel abdominal approach. General anesthesia was not required in any of the 10 patients. Two patients recurred within 6 months. One of the patients with recurrence of RP subsequently underwent laparoscopic rectopexy, and the other was minimal and required no further treatment. One mortality occurred at 3 months unrelated to the procedure. No other anesthetic or surgical intraoperative and postoperative complications were observed. Limitations: This is a single-institution pilot study. Conclusions: Abdominal RP repair under sedation and regional anesthesia appears feasible and safe in elderly patients and may, in the future, provide an effective alternative to current treatment options for RP, avoiding general anesthesia. ClinicalTrial.gov registration number: NCT01980043.

Robotic Assisted Laparoscopic Treatment of Cornual Ectopic Pregnancy

Study Objective Demonstrate the treatment of a cornual ectopic pregnancy using robotic assisted laparoscopy. Design NA Setting Operating Room. Patients or Participants 1. Interventions Robotic Assisted Laparoscopy was used to treat the cornual ectopic pregnancy. Measurements and Main Results NA Conclusion Patient was sent home the same day, estimated blood loss was

Morcellation Not Required: Mini-Laparotomy Does Not Alter Same-Day Discharge Plan

Study Objective The study objective was to evaluate whether the need for mini-laparotomy (ML) for intact specimen extraction adversely impacted the feasibility or safety of same-day discharge (SDD) in patients undergoing minimally invasive surgery (MIS) for gynecologic malignancies. Design We performed a retrospective, matched, case-control study in patients undergoing MIS for gynecologic malignancy from January 2013 through December 2019. Setting Single institution. Patients or Participants Patients underwent traditional laparoscopy or robotic assisted laparoscopy and were planned for SDD. Interventions Patients requiring ML for specimen extraction were identified and matched to randomly selected patients not requiring ML (2:1, controls:cases). Clinical demographics, peri-operative outcomes and post-operative contact within 30 days were collected. Standard statistical analyses were performed to evaluate the data. Measurements and Main Results A total of 891 patients were identified. Fifty-two patients required ML for specimen extraction. From the remainder, 104 patients were selected as controls. There was no difference in age (61 vs. 63 years p=0.42) or BMI (32 vs. 30 p=0.29) between the cases and controls. SDD rate was 79% (ML) vs. 83% (control) (p=0.67). There was no difference in mean pain scores (2.3 vs. 2.2 p=0.78), length of stay (LOS) (0 days for both) (p=0.67), 30-day readmission rate (7% vs. 3%) (p=0.17), ED/Urgent care visit (21% vs. 14%) (p=0.28) or any patient contact (36% vs. 37%) (p=0.97), between the groups. Specimen weight was higher for ML (485g vs 135g, p Conclusion Mini-laparotomy for specimen extraction does not affect SDD rates after MIS. It is a safe and feasible strategy for patients with no apparent increase in complication rate or unscheduled patient contact.

Emergency right colectomy: is there a role for minimally invasive surgery?—A systematic review and meta-analysis of short-term clinical outcomes

Background: In well selected emergency settings, laparoscopic-assisted (LA) right colectomy can be safely performed with similar results to elective right colectomy in terms of intra-operative blood loss, postoperative complications and length of recovery. However, evidence is still lacking in regards to whether laparoscopy can safely replace traditional open surgery (OS) for patients needing emergency right colectomy. This systematic review and meta-analysis is aiming to present an updated evaluation of the short-term clinical outcomes of laparoscopic and open approaches for right colectomy performed in emergency settings, by analyzing safety and feasibility of the two techniques.

Robotic Surgery Versus Laparotomy in Elderly Patients with Endometrial Cancer: Perioperative Outcomes and Complications

Objective: To evaluate perioperative outcomes and complications in elderly patients with endometrial cancer undergoing surgical staging with robotic assisted laparoscopy (RAL) versus laparotomy. De...

Back pain outcomes after minimally invasive anterior lumbar interbody fusion: a systematic review.

Minimally invasive anterior lumbar interbody fusion surgery (MIS ALIF) is a technique that restores disc height and lumbar lordosis through a smaller exposure and less soft-tissue trauma compared to open approaches. The mini-open and laparoscopic assistance techniques are two main forms of MIS ALIF. The authors conducted a systematic review that sought to critically summarize the literature on back pain following MIS ALIF. In March 2020, the authors searched the PubMed, Web of Science, and Cochrane Library databases for studies describing back pain visual analog scale (VAS) outcomes after MIS ALIF. The following exclusion criteria were applied to studies evaluated in full text: 1) the study included fewer than 20 patients, 2) the mean follow-up duration was shorter than 12 months, 3) the study did not report back pain VAS score as an outcome measure, and 4) MIS ALIF was not studied specifically. The methodology for the included studies were evaluated for potential biases and assigned a level of evidence. There were a total of 552 patients included from 13 studies. The most common biases were selection and interviewer bias. The majority of studies were retrospective. The mean sample size was 42.3 patients. The mean follow-up duration was approximately 41.8 months. The mean postoperative VAS reduction was 5.1 points. The mean VAS reduction for standalone grafts was 5.9 points, and 5.0 points for those augmented with posterior fixation. The most common complications included bladder or urinary dysfunction, infection, and hardware-related complications. This was a systematic review of back pain outcomes following MIS ALIF. Back pain VAS score was reduced postoperatively across all studies. The complication rates were low overall. MIS ALIF is safe and effective at reducing back pain in appropriate patient populations.

Efficacy and safety of gastric exposed endoscopic full-thickness resection without laparoscopic assistance: a systematic review.

Background and study aims Exposed endoscopic full-thickness resection (Eo-EFTR) without laparoscopic assistance is a minimally invasive natural orifice transluminal endoscopic surgery (NOTES) technique that has shown promising efficacy and safety in resection of gastric submucosal tumors (G-SMTs) arising from muscularis propria (MP). However, data on the efficacy and safety of gastric Eo-EFTR mostly come from relatively small retrospective studies and concern regarding its use still exists. The aim of our systematic review was to assess the efficacy and safety of gastric Eo-EFTR without laparoscopic assistance. Methods A detailed MEDLINE and EMBASE search was performed for papers published from January 1998 to November 2019 and reporting on gastric Eo-EFTR without laparoscopic assistance. The search strategy used the terms “endoscopic full thickness resection” and “gastric” or “stomach”. The primary outcomes were complete resection and surgical conversion rates. The secondary outcomes were overall major adverse events, delayed bleeding, delayed perforation, peritonitis, abdominal abscess and/or abdominal infection and successful Eo-EFTR. Results Fifteen Asian studies were included in our final review, providing data on 750 Eo-EFTR-treated G-SMTs. The per-lesion rate of complete resection and surgical conversion were 98.8 %\\0.8 %, respectively. The per-lesion rate of major adverse events, delayed bleeding, delayed perforation and peritonitis, abdominal abscess and/or abdominal infection was 1.6 %\\0.5 %\\0.1 %\\0.9 %, respectively. The per-lesion rate of successful Eo-EFTR (i. e. complete tumor resection and effective endoscopic defect closure) was 98.3 %. Conclusions Eo-EFTR without laparoscopic assistance appears to be highly effective and safe NOTES for removing deep G-SMTs, particularly those arising from MP layer.

Post-operative management and follow-up of surgical treatment in the case of rectovaginal and retrocervical endometriosis

IntroductionDeep infiltrating endometriosis (DIE) affects between 3.8% and 37% of all endometriosis patients, mostly affecting rectovaginal septum or retrocervical space and characterized by the severe endometriosis-related complaints. Nowadays, generally managed with surgery. However, this is associated with a risk of postoperative complications. To better evaluate intra- and postoperative complications and outcomes for rectovaginal (RVE) and retrocervical endometriosis (RCE), the preoperative management should be accurately described and compared.MethodologyThis is a cohort retrospective study performed at the Endometriosis Centre of Charité-University Clinic, Berlin. 34 patients were investigated in their reproductive age, n = 19 with RVE and n = 15 RCE, operated between 2011 and 2015. The surgical approach was divergent in both groups. Single laparoscopy was performed in RCE patients (RCEP) and vaginal assisted laparoscopy in RVE patients (RVEP). Long-term postoperative outcome included complications, fertility rate and recurrence rate.ResultsThe median follow-up time was three years (y). Symptom-free status was revealed in n = 12 RVEP and n = 9 RCEP. Postoperatively, endometriosis-related complaints were presented in n = 7 RVEP and n = 6 RCEP, but with significant pain relief. From n = 8 RVE patients seeking fertility, pregnancy occurred in n = 7 and from n = 9 RCEP pregnancy appeared in n = 5 patients in the meantime of 6 months. Postoperative complications were reported in n = 1 RVEP with early postoperative bleeding, after ureter leakage and n = 1 RCEP with postoperative anastomotic insufficiency. The postoperative recurrence rate was equivalent to zero.ConclusionThe appropriate surgical approach for each group, preserving anatomy and functionality of the organs, seems to be very essential and efficient.

Abdominal Insufflation Is Associated With Increase of Intracranial Pressure in Patients With Normal Pressure Hydrocephalus.

Ventriculoperitoneal shunting (VPS) is effective for the treatment of normal-pressure hydrocephalus (NPH) and sometimes requires laparoscopic assistance with abdominal insufflation. To evaluate the association of abdominal insufflation with opening pressure (OP) in NPH patients undergoing VPS implantation. Between March 2016 and April 2019, 52 consecutive patients who underwent first-time VPS implantation surgery were retrospectively identified by reviewing electronic health records. OP during the large volume lumbar tap test (OPLP) and VPS implantation surgery (OPSURGERY) were measured in 29 patients. Laparoscopic assistance with abdominal insufflation was used in 20 (69%) cases. There were no differences in patient age (P=.589), gender (P=.822), body mass index (P=.289), weight (P=.789), height (P=.542), and OPLP (P=.476) in patients operated with and without laparoscopic assistance. When compared to patients operated without laparoscopic assistance, laparoscopic assistance was associated with a greater rate of OP increase during surgery relative to OPLP (40% vs 100%, P=.002), a greater increase in OPSURGERY relative to OPLP (-0.40±5.38 vs 10.17±5.53 cm H2O, P<.001), and a greater proportion of patients with OPSURGERY of ≥25 cm H2O during the VPS surgery (0% vs 78%, P<.001). Abdominal insufflation is associated with an increase in intracranial pressure with OPs often exceeding 25 cm H2O. This should be considered when selecting optimal VPS pressure settings.

Quality-based assessment of camera navigation skills for laparoscopic fundoplication.

Laparoscopic fundoplication is considered the gold standard surgical procedure for the treatment of symptomatic hiatus hernia. Studies on surgical performance in minimally invasive hiatus hernia repair have neglected the role of the camera assistant so far. The current study was designed to assess the applicability of the structured assessment of laparoscopic assistance skills (SALAS) score to laparoscopic fundoplication as an advanced and commonly performed laparoscopic upper GI procedure. Randomly selected laparoscopic fundoplications (n = 20) at a single institute were evaluated. Four trained reviewers independently assigned SALAS scoring based on synchronized video and voice recordings. The SALAS score (5-25 points) consists of five key aspects of laparoscopic camera navigation as previously described. Experience in camera assistance was defined as at least 100 assistances in complex laparoscopic procedures. Nine different surgical teams, consisting of five surgical residents, three fellows, and two attending physicians, were included. Experienced and inexperienced camera assistants were equally distributed (10/10). Construct validity was proven with a significant discrimination between experienced and inexperienced camera assistants for all reviewers (P < 0.05). The intraclass correlation coefficient of 0.897 demonstrates the score's low interrater variability. The total operation time decreases with increasing SALAS score, not reaching statistical significance. The applied SALAS score proves effective by discriminating between experienced and inexperienced camera assistants in an upper GI surgical procedure. This study demonstrates the applicability of the SALAS score to a more advanced laparoscopic procedure such as fundoplication enabling future investigations on the influence of camera navigation on surgical performance and operative outcome.

Transanal total mesorectal excision (TaTME) using flexible endoscope with laparoscopic assistance: a pilot study in porcine models.

Transanal total mesorectal excision (TaTME) is routinely performed to excise low rectal tumors. TaTME often relies on transanal endoscopic microsurgery (TEM) or transanal minimally invasive surgery (TAMIS) platform, all using rigid endoscopes. Our study reported a novel approach to TaTME which was completed using flexible endoscope, and we named it F-TaTME. The feasibility of rectum resection using F-TaTME was evaluated in five pigs. Firstly, the superior rectal artery and vein were managed under the assistance of laparoscopy. Secondly, the flexible endoscope was used to complete the full-thickness rectotomy and rectal mobilization. Finally, the specimen was removed and the manual colon-rectal anastomosis was performed under direct vision. F-TaTME was accomplished in all 5 pigs. The mean procedure time was 136.6min (97-162min). The mean length from the lower edge of the lesion to circumferential dissection line was 1.4cm (1.0-1.8cm) and mean length of exteriorized rectum was 12.6cm (11-14cm). No injury to colorectal wall, adjacent pelvic or abdominal organs was found. Our preliminary data suggested that F-TaTME may be a feasible method for TaTME.

Laparoscopic-assisted gastrotomy for foreign body retrieval in four dogs

Four dogs with gastric foreign bodies were treated by laparoscopic-assisted gastrotomy. Techniques included two-port technique (n=two dogs), single-port with Alexis wound retractor (one) and single-port GelSeal cap with three cannulae...

A novel and simplified closure method for defect closure after endoscopic full-thickness resection of gastric submucosal tumors: short-term outcomes of "Shao-Mai" closure method

Objective: To evaluate the feasibility and short-term efficacy of a novel and simplified closure method developed by our team for the defect closure after endoscopic full-thickness resection (EFTR) for gastric submucosal tumors (SMT) in the gastric wall. Methods: A prospective single-arm clinical study was used. Inclusion criteria: (1) the lesion was located in the fundus or the greater curvature of the stomach, and was confirmed to originate from the muscularis propria layer; (2) the diameter of the tumor was ≤3.5 cm, and the tumor had no extensive adhesion to the peritoneal tissues and organs in extraperitoneal cavity; (3) the tumor had no malignant features under ultrasound endoscopy; (4) the patient agreed to participate in the study; (5) patients with severe complications were excluded. Based on the above criteria, 20 patients with gastric SMT at the Endoscopy Center of Zhongshan Hospital of Fudan University from January 2015 to March 2018 were enrolled in this study, including 5 males and 15 females with mean age of 61.1 (38 to 70) years. Grasping forceps-assisted endo-loop snare ligation device which is called "Shao-Mai" method was used to close the defect site. All the patients underwent EFTR and "Shao-Mai" method to perform defect closure. After successful tumor resection by EFTR, an endo-loop was anchored onto the edge of the gastric defect with grasping forceps assistance and closed tightly. The observation indicators included tumor size, en bloc resection, operation time, postoperative complications and hospital stay. The follow-up indicators included tumor residual, local recurrence, and metachronous lesions. Results: All the 20 lesions were located in the muscularis propria with a size of 0.5-3.5 (mean 1.4) cm. Three of them were located in the greater curvature of the mid-upper gastric body, 17 were located in the fundus. The endoscopic "Shao-Mai" closure was successfully performed after EFTR in all the 20 cases. Endoscope was used uniquely through the entire process, without laparoscopic assistance. The operative time was 20-100 (mean 43.8) minutes, while the "Shao-Mai" closure procedure took a range of 3-30 (mean 10.1) minutes. The en bloc resection rate was 100%. The pathological diagnosis included 17 gastrointestinal stromal tumors and 3 leiomyomas. No major complications occurred during or after surgery. All the patients were discharged 1-11 (mean 3.1) days after operation. The wounds of all the cases were healed completely six months after operation and only scar was observed without ulcer. No residual lesion, tumor recurrence or metastasis, leakage or fistula of digestive tract were found during the follow-up period of 15-54 (median 41) months. Conclusion: The endoscopic "Shao-Mai" closure method is a simplified novel way, which is feasible, effective, and safe for closing the gastric defect after EFTR.

Laparoscopic-Assisted Transanal Pull-Through in Hirschsprung Disease: Does Laparoscopic Dissection Minimize Anal Overstretching?

Introduction: Surgical treatment for Hirschsprung disease (HD) has evolved from a staged repair to a primary operation but is still associated with significant complications. Extensive transanal dissection may overstretch the sphincter and cause partial tear; however, laparoscopic dissection can decrease rectal overstretching. Thus, this study aimed to evaluate the outcome of surgical management of HD and the efficacy of laparoscopic-assisted transanal endorectal pull-through in infants and children in our center. Patients and Methods: We reviewed the medical records of 74 patients who underwent surgical repair of HD from 2006 to 2019. However, we excluded 42 patients with HD (patients with stoma [n = 33] and total colonic aganglionosis [n = 9]). The remaining 32 patients were divided into two groups. Group A included patients who had transanal pull-through with laparoscopic assistance only to visualize the transition zone, take a biopsy, and check for twisting or bleeding. Group B included patients who had laparoscopic-assisted transanal pull-through with dissection of the rectum. All patients had Soave repair with an approximate cuff length of 5 cm. Results: Group A included 18 patients, whereas group B included 14 patients. Demographic data were comparable between the two groups with no significant difference in age or gender (P = .12 and .67, respectively). Patients in group A had longer operative time (210 ± 20.75 minutes versus 178 ± 18.92 minutes; P < .001) and hospital stay (6 ± 1.33 days versus 5 ± 1.24 days; P = .033). No significant difference was observed in postoperative complications between both groups (anastomotic site stricture, P = .295; persistent soiling, P = .238). Conclusion: Laparoscopic rectal dissection for managing HD is associated with less operative time and hospital stay. In addition, all procedures required for the repair can be safely performed using laparoscopy.

Application of the accelerated rehabilitationprotocol (ERAS) in the perioperative period from the position of an anesthesiologist

Introduction. Application of laparoscopic techniques corresponds to the principles of the ERAS maximally.&#x0D; Aim – assess the impact of the early multimodal rehabilitation concept use on the postoperative period.&#x0D; Material and methods. The study involved 49 patientswhowererandomizedbymethodofenvelopes into two groups. In the basic group (30 patients) a multimodal protocol of early rehabilitation was used. In the control group (19 patients) a traditional perioperative regimen was performed. In both groups, vaginal hysterectomy with laparoscopic support under general anesthesia combined with mechanical ventilation was carried out. Fentanyl analgesia (3–5 mcg/kg/hr), and 0,5% bupivacaine solution into epidural space (6,8 mL). The volume of the infusion in the main group was 6 ml/kg/h, in the control group – 10 ml/kg/hr. Noninvasive monitoring carried by monitor "Leon" (blood pressure, heart rate, capnogram), the hourly diuresis. Postoperatively the two groups used 24 hours prolonged epidural small boluses of 0,25% bupivacaine solution (4 ml/hour) in combination with systemic administration of dexketoprofen (100–150 mg/day) + ketorolac (60 mg/day) + paracetamol (2000 mg/day).&#x0D; Result. The groups were homogeneous in anamnestic (onset of menstruation, number of pregnancies, childbirth, abortion, miscarriage), anthropometric and demographic characteristics, duration of operations and the beginning levels of systolic, diastolic, mean arterial pressure and heart rate. The volume of blood loss (ml) in patients with ERAS was (282 ± 22), in patients of the control group – (347 ± 21), p˂0,05. Intraoperative gemohydrobalance (ml) in patients with ERAS was (547 ± 57), in the control group – (942 ± 62), p ˂ 0,05. The postoperative hospital stay in patients of the main group (ERAS) was significantly shorter (5,00 ± 0,26) than in the control group of patients without ERAS (7,16 ± 0,40), p ˂ 0,05.&#x0D; Conclusion. Optimal anesthetic tactic allows patients to be fast extubated and to eliminate postoperative pain in the first 24 hours effectively. Using the early multimodal rehabilitation protocol reduces the time of patient recovery after vaginal hysterectomy with laparoscopic assistance.

Robotic Surgery Is Less Physically Demanding Than Laparoscopic Surgery: Paired Cross Sectional Study.

To study musculoskeletal workload in experienced surgeons during laparoscopic surgery (LS) compared with robotic assisted laparoscopy (RALS). 70-90% of surgeons who regularly perform LS report musculoskeletal symptoms, mainly in neck and shoulders. Data regarding the potential ergonomic benefits of RALS in a clinical setting is very limited. Twelve surgeons with advanced experience in both LS and RALS each performed 2 hysterectomies on the same day. LS was performed standing, RALS sitting, the latter allowing forearm and head support. Bipolar surface electromyogram (EMG) was recorded from several muscles and was expressed relative to EMG during maximum contractions (%EMGmax). Gaps per minute plus static (p0.1), mean (p0.5), and peak (p0.9) muscle activation were calculated. Perceived exertion was rated before and just after each surgery. Neck muscle activity (p0.1 4.7 vs. 3.0%EMGmax, p0.5 7.4 vs. 5.3%EMGmax, p0.9 11.6 vs. 8.2%EMGmax, all P < 0.05) and static shoulder muscle activity (p0.1 5.7 vs. 2.8%EMGmax, P < 0.05) were higher for LS than for RALS. Both a higher level of gaps during RALS and a lower rating of perceived exertion, also for the legs, after RALS supported these observations. However, low back muscle activity was higher for RALS. RALS is significantly less physically demanding than LS, and also feels less strenuous for the surgeons. However, for both types of surgeries, there still is room for improvement of working conditions. To further optimize these, we suggest a scheme to regularly observe and advise the surgeons.

Transanal Endorectal Pull-Through With or Without Laparoscopic Assistance

Hirschsprung’s disease requires surgical treatment. Depending on the form of aganglionosis and severity of pathology, open or minimally invasive, transanal endorectal pull-through with or without laparoscopic assistance may be used.&#x0D; The objective of the research was to study the efficiency of using transanal endorectal pull-through with and without laparoscopic assistance for treating Hirschsprung’s disease in children. We compared outcomes between approaches.&#x0D; Materials and Methods. Over the period 2011-2016, 145 children with Hirschsprung’s disease were surgically treated using transanal endorectal pull-through (n=81) and laparoscopic-assisted transanal endorectal pull-through (n=64). A systematic literature review and meta-analysis were carried out.&#x0D; Results. We noticed that transanal endorectal pull-through without laparoscopic assistance could be easily used in children under 4 years of age with aganglionosis including the sigmoid colon without significant colon dilatation considering a significant mesosigmoid mobility at such age. In other cases, we used laparoscopic-assisted transanal endorectal pull-through. The advantages of laparoscopic stage included the possibility for correct planning of surgical strategy, a thorough revision of the affected colon, determination of aganglionosis level, mobilization of the mesenterium, elimination of the adhesions and ligaments holding the colon, thereby avoiding tension in coloanal anastomosis, control and prevention of pull-through colon twisting which may cause an obstruction. In older patients, the proximal end of the rectum could be dissected laparoscopically. This allowed transanal endorectal pull-through to be performed quicker and safer. In the postoperative period, patients underwent rehabilitation with good functional results. Two children developed coloanal anastomotic dehiscence which was corrected by open stage treatment.&#x0D; Conclusions. Age-related and anatomical features of the colon in the patients with Hirschsprung’s disease allowed performing transanal endorectal pull-through with or without laparoscopic assistance. Significant dilation of the colon, aganglionosis above the sigmoid area and the patient’s age over 4 years were indications for performing transanal endorectal pull-through with laparoscopic assistance. In other cases, transanal endorectal pull-through could be performed without laparoscopic assistance. The laparoscopic-assisted transanal endorectal pull-through procedure turned to be a safe and feasible technique for patients with Hirschsprung’s disease.

Laparoscopic-Assisted Ventriculoperitoneal Shunt Placement and Reduction in Operative Time and Total Hospital Charges

In ventriculoperitoneal shunt (VPS) placement, distal placement of the peritoneal catheter will typically be performed by a neurosurgeon. More recently, laparoscopic-assisted (LA) placement of the distal peritoneal catheter by general surgeons has become common. The present study examined whether LA placement of a VPS (LAVPS) is associated with a reduced operative time, lower hospital costs, and fewer distal revisions. A retrospective review was performed of the data from all patients who had received a new VPS at our institution from 2013 to 2016. Age, sex, diagnosis, previous abdominal surgery, operative time, anesthesia grade, incidence of 30-day shunt failure, and total hospital charges were analyzed. A total of 680 patients had undergone first-time VPS placement, including 199 with LAVPS and 481 with non-LAVPS placement (non-LAVPS). The mean age of the LAVPS patients was significantly older than that of the non-LAVPS patients (64.1 vs. 59.3 years; P= 0.002). The mean operative time was shorter in the LAVPS group than in the non-LAVPS group (55 vs. 75 minutes; P < 0.001). Distal shunt revision within 30 days occurred more often for the non-LAVPS patients (6 of 481 [1.2%]) than for the LAVPS patients (0 of 199 [0%]). A subset analysis of patients with normal-pressure hydrocephalus found decreased total hospital charges in the LAVPS group ($67,124 vs. $80,890; P= 0.009). Compared with non-LAVPS, LAVPS was associated with significantly shorter operative times and fewer distal shunt revisions within 30 days. The findings from a subset analysis supported a decrease in total hospital charges. Additional studies are needed; however, these data suggest that LAVPS is a safer, less-expensive alternative to non-LAVPS.

Robotic Lateral Pancreaticojejunostomy for Chronic Pancreatitis.

Lateral pancreaticojejunostomy (LPJ) has shown good postoperative outcomes in patients with painful, morphine dependent, chronic pancreatitis (CP). The recent rise of robotic and laparoscopic pancreatic surgery has found benefits such as reduced time to functional recovery. Few studies have reported on the feasibility, technique and outcome of robotic LPJ, especially including transection of the gastroduodenal artery. The present study describes the main steps for robotic LPJ in a patient with painful chronic pancreatitis with a dilated main pancreatic duct. The patient underwent robotic LPJ. The LPJ anastomosis is performed using a running suture technique in a longitudinal side-to-side manner. Routinely, the gastroduodenal artery is transected to drain the entire length of the main pancreatic duct. The patient is in French position; 7 trocars are placed (4 robotic, 2 laparoscopic assistants, 1 liver-retractor). After docking of the robot system, the omental bursa is opened, and the right gastroepiploic artery and vein are ligated at their base at the lower border of the pancreas. Intraoperative ultrasonography is performed in order to determine trajectory of the dilated main pancreatic duct which is opened for its entire length after the gastroduodenal artery has been suture ligated both cranially and caudally from the main pancreatic duct. A Roux limb is created, and a latero-lateral PJ is fashioned using several 3-0 barbed sutures. A stapled jejuno-jejunostomy is created at sufficient distance from the pancreatic anastomosis, aided by a 50 cm suture. The described technique for robotic LPJ is a complex but feasible operation for patients with treatment refractory CP and a dilated main pancreatic duct. Due to its complexity, implementation in high volume centers with extensive experience with CP surgery may improve outcomes.

Pure transanal total mesorectal excision for rectal cancer: experience with 55 cases.

BackgroundAlthough the anatomic difficulties of laparoscopic surgery for rectal cancer have been resolved by hybrid transanal total mesorectal excision (h-taTME), a completely incisionless surgical procedure has not yet been developed. This study was performed to explore the efficacy of pure taTME (p-taTME) without laparoscopic assistance as a completely non-invasive surgical procedure for rectal cancer.MethodsWe retrospectively evaluated all patients with rectal cancer who underwent p-taTME between December 2015 and April 2018. Relevant patient characteristics and clinical information including the surgical procedure, specimens, pathological characteristics, and patients’ post-operative state were analysed and the feasibility of p-taTME in patients with rectal cancer was assessed.ResultsFifty-five patients who had undergone p-taTME were included in this study. They comprised 32 (58.2%) men and 23 (41.8%) women with a mean age of 65.6 ± 10.6 years and mean body mass index of 23.4 ± 3.3 kg/m2. The median surgical time was 180.0 (range, 130–360) min and estimated blood loss was 25.0 (range, 15–80) mL. The commonest post-operative complication was varying degrees of faecal incontinence (56.4%). However, such incontinence greatly improved after pelvic-floor-function-rehabilitation exercises and did not seriously affect the patients’ quality of life.Conclusionsp-taTME is a relatively safe and incisionless procedure for patients with middle and low rectal cancer, especially in those with obesity or a narrow pelvis. However, further studies of the indications and long-term efficacy are needed to verify the suitability of this procedure.