Conventional Laparoscopy Research Articles

Polarization enhanced laparoscope for improved visualization of tissue structural changes associated with peritoneal cancer metastasis.

A polarization enhanced laparoscopy (PEL) imaging system was developed to examine the feasibility of utilizing PEL to augment conventional white light laparoscopy (WLL) in the visualization of peritoneal cancer metastases. The system includes a modified tip to illuminate tissue with linearly polarized light and elements in the detection path enabling recording of corresponding images linearly co- and cross-polarized relative to the incident light. WLL and PEL images from optical tissue phantoms with features of distinct scattering cross-section confirm the enhanced sensitivity of PEL to such characteristics. Additional comparisons based on images acquired from collagen gels with different levels of fiber alignment highlight another source of PEL contrast. Finally, PEL and WLL images of ex vivo human tissue illustrate the potential of PEL to improve visualization of cancerous tissue surrounded by healthy peritoneum. Given the simplicity of the approach and its potential for seamless integration with current clinical practice, our results provide motivation for clinical translation.

Short- and long-term outcomes as well as anal function of transanal natural orifice specimen extraction surgery versus conventional laparoscopic surgery for sigmoid colon or rectal cancer resection: a retrospective study with over 5-year follow-up.

IntroductionTo date, long-term safety including functional outcomes of transanal natural orifice specimen extraction surgery (NOSES) for colorectal cancer resection has not been confirmed.AimTo explore the short- and long-term outcomes as well as anal function of transanal NOSES versus conventional laparoscopic surgery for sigmoid colon or rectal cancer resection.Material and methodsA retrospective review of data from a prospectively maintained database was performed to analyze the data of 69 patients who underwent transanal NOSES for sigmoid colon or rectal cancer resections and another 69 matched patients who underwent conventional laparoscopic (CL) surgery. Anal function of patients was evaluated using the Wexner fecal incontinence scale postoperatively.ResultsTransanal NOSES resulted in faster recovery of intestinal function, shorter postoperative length of stay, less incisional pain, fewer postoperative complications and shorter scars than CL surgery (p < 0.05). The two groups had similar overall survival (p = 0.863) and disease-free survival (p = 0.961). Wexner scores of the NOSES group at 1, 3 and 6 months after surgery were higher than in the CL group (p < 0.05), and there was no difference between the two groups at 12, 18 and 24 months after surgery.ConclusionsTransanal NOSES achieves similar survival outcomes to CL surgery. Transanal NOSES has the advantages of faster recovery, shorter postoperative hospital stay, less incisional pain, shorter scars, etc. However, transanal NOSES can indeed impair anal function, needing more attention.

FreeHand Robot-Assisted Gynecologic Surgery in Trinidad &amp; Tobago: Case Reports

Background: Minimally invasive surgery is still at a relatively early stage throughout the Anglophone Caribbean and robotic surgery has been largely non-existent. There have been many unique obstacles to the introduction of robotic surgery in the Caribbean. Methods: We present a case report to document the initial experience with the use of the FreeHand surgical robot during gynecologic operations in Trinidad &amp; Tobago. Results: Two cases are presented to highlight the use of the FreeHand robot for gynecologic operations. We outline our experiences introducing the FreeHand® robotic arm to facilitate minimally invasive gynecologic surgery in the Caribbean. Conclusions: The FreeHand® system is a good intermediary between conventional laparoscopy and a full surgical robot. We believe this technology can be incorporated into the armamentarium of gynecologic surgeons in resource-poor nations, once there is appropriate training and intra-operative mentoring from experts familiar with the technology.

Robotic-Assisted Surgery for the Treatment of Breast and Cervical Cancers.

Background:Robotic-assisted surgery facilitates the performance of numerous, complex procedures, namely conferring precision, flexibility, and control that is otherwise unavailable with conventional laparoscopy; and compared to open surgery, robotic-assisted surgery is ostensibly associated with fewer complications, reduced intraoperative complications, and shorter hospital stay duration. Nevertheless, the American College of Obstetricians and Gynecologists and the Food and Drug Administration have criticized the pervasive acceptance of robotic-assisted surgery, given the absence of randomized clinical trial data compared to traditional laparoscopy and open procedures, not to mention the increased surgical cost.Conclusions:While the research data continue to be borne out, surgeons should exercise considerable discretion in selecting the surgical approach from which their patients would derive the greatest clinical benefit.

Comparative study on gasless laparoscopy using a new device versus conventional laparoscopy for surgical management of postmenopausal patients.

Objective:To compare gasless laparoscopy with conventional laparoscopy for the surgical management of postmenopausal patients.Methods:The medical records of 80 postmenopausal patients who underwent laparoscopic surgeries between February 2016 and February 2020 were reviewed. Forty patients underwent gasless laparoscopy and 40 patients underwent conventional single-port access (SPA) laparoscopy. The two groups were compared in terms of surgical outcomes.Results:Of 80 patients, 42 underwent adnexal surgeries and 38 underwent uterine surgeries such as total hysterectomy or myomectomy. Between the gasless SPA and conventional SPA laparoscopic groups, no significant differences were observed in terms of age, body mass index, parity or history of previous abdominal surgery. The mean retraction setup time from skin incision was 6.8 ± 1.2 min with gasless laparoscopic surgery. There was no significant difference in mean total operation times for the gasless (71.3 ± 31.4 min) and conventional (82.5 ± 36.4 min) groups. There was also no significant difference between the groups in terms of operation type, laparotomy conversion rate or duration of hospitalisation. There were no major complications in either group.Conclusions:Gasless laparoscopy is a safe and feasible alternative to conventional laparoscopy for postmenopausal women.

Long-term satisfaction of patients after laparoscopic and robotic-assisted hysterectomy

IntroductionDa-Vinci-Xi is the most recent device used in gynecologic robotic surgery. The aim of the present study was to compare the long-term satisfaction of patients who had undergone conventional laparoscopic hysterectomy or robotic assisted laparoscopic hysterectomy using the Da-Vinci-Xi surgical system.MethodsAll hysterectomies performed at the University Hospital of Luebeck from 2018 to 2019 were reviewed. Postoperative outcomes were compared between women who had undergone total hysterectomy with da Vinci Xi (n = 42) or conventional laparoscopy (n = 97). Postoperative outcomes included pain, elimination of complaints after surgery, bladder function, sexual function, satisfaction with the cosmetic outcome, positive experiences after robotic surgery, and satisfaction with the surgeon’s preoperative explanation. Obese patients were evaluated separately in a subgroup analysis.ResultsBoth groups had similar baseline characteristics and complication rates. Preoperative complaints subsided after surgery in a little more than 90% of patients. No significant differences were noted between groups in this regard (p = 0.262), or with reference to postoperative pain after one week (p = 0.866) and one month (p = 0.580), stress incontinence (p = 0.343), sexual function (p = 0.766) and the cosmetic outcome of the abdominal incisions (p = 0.273). The majority of patients who had undergone robotic surgery (96.8%) would be willing to undergo the procedure again if necessary. The subgroup analysis of obese patients revealed no significant differences.ConclusionThe Da-Vinci-Xi device did not improve the long-term surgical satisfaction of normal-weight or obese patients who underwent hysterectomy compared with patients who underwent conventional laparoscopy performed by experienced laparoscopic surgeons.

Safety and Efficiency of an Articulating Needle Driver in Advanced Laparoscopic Abdominal Surgery.

Objective: Robotic platforms offer articulating needle drivers but are associated with high costs and lack tactile feedback. The recently developed mechanical Laparoscopic Articulating Needle Driver (LAND) (Flexdex®) for conventional laparoscopy offers enhanced dexterity without these limitations. The goal of this study was to assess safety and efficiency during the implementation of the LAND, and describe its learning curve, in an expert center for laparoscopic surgery. Methods: All LAND-assisted procedures after clinical implementation for a period of 16 months were included into this study. Primary outcome domains were safety (intra- and postoperative complications within 30 days) and efficiency (operative time, suturing, and knot tying time of staple defects of enteroenterostomy). CUmulative SUM (CUSUM) analysis was utilized to describe the enteroenterostomy suturing time learning curve across consecutive cases by plotting the deviation from the series mean. Results: Forty-five procedures (34 Roux-en-Y gastric bypass [of which 7 including diaphragmatic hernia repair], 2 diaphragmatic hernia repair with Nissen fundoplication, and 2 right-sided hemicolectomy) were included into this study. Median (range) operative time and enteroenterostomy suturing time were 68 (46-177) minutes and 161 (112-241) seconds, respectively, comparable with conventional needle driver standards. One procedure was converted to the conventional needle driver due to device malfunctioning and one patients' postoperative course was complicated by a Clavien-Dindo grade 3a complication (intraluminal bleeding requiring gastroscopy). CUSUM chart displays a progression toward the mean from case 22 onward, indicating a limited learning curve. Conclusion: The LAND can be implemented safely and efficiently at a center of excellence for laparoscopic surgery and is associated with a limited learning curve.

The effect of the robotic platform in hepatectomy after prior liver and non-liver abdominal operations: a comparative study of clinical outcomes.

Improvements in outcomes after primary hepatectomy have increased the eligibility of patients for reoperative hepatectomies, but this can be fraught with technical difficulties, particularly via a minimally invasive approach. The robotic approach provides superior visualization, articulated instrumentation, platform stability, and increased dexterity when compared to conventional laparoscopy. We sought to investigate the effect brought by the robotic system in the outcome of these operations. We followed 234 patients who underwent robotic liver resection from 2012 to 2021 for retrospective analysis. Patients were classified as: no prior abdominal operation, prior abdominal operation(s), and prior liver resection. Cohorts were compared by one-way ANOVA and 2 × 3 contingency table analyses. For illustrative purposes, data are presented as median (mean ± SD). Significance was accepted at p < 0.05. Of the 234 patients studied, 114 underwent primary hepatectomy, 105 had a prior laparoscopic or open abdominal operation (cholecystectomy, herniorrhaphy, colectomy, and appendectomy), and 15 had a redo hepatectomy. Demographic and preoperative ASA, MELD, neoplasm size, and extent of liver resection were similar among the cohorts. There were no statistically significant differences between the three cohorts for all outcome variables including blood loss, operative duration, intensive care unit length of stay, overall length of stay, morbidity, mortality, and readmission rate. There were no differences in morbidity nor mortality between patients undergoing primary nor reoperative robotic hepatectomy. The advantages afforded by the robotic platform may have contributed to the equalization of outcomes.

Robotic Central Hepatectomy for the Treatment of Gallbladder Carcinoma. Outcomes of Minimally Invasive Approach.

Gallbladder cancer (GBC) is an uncommon but very aggressive malignancy with poor prognosis. Concerns for oncological inferiority related to the technical difficulties in performing laparoscopic portal lymphadenectomy discourage many surgeons to undertake this operation minimally invasively. With wide application of robotic technology to solve limitations of conventional laparoscopy, we describe our initial outcomes of robotic central hepatectomy and portal lymphadenectomy for gallbladder carcinoma in 15 consecutive patients. Data were presented as median (mean ± SD). Patients were 70 (73 ± 10.9) years old with BMI of 26 (26 ± 3.6) kg/m2. Tumor size was 3(4 ± 1.9) cm. Operative duration was 222 (237 ± 85.7) minutes and estimated blood loss was 200 (222 ± 135.4) mL. There were no intraoperative complications and complete resection (R0) was obtained in nearly all patients. Postoperative complications were seen in two patients (bile leak (n = 1) and respiratory failure (n = 1)). Length of stay was 3 (4 ± 4.0) days without 30-day mortality. Robotic approach is safe and effective for the treatment of GBC.

Conversions in pediatric robot-assisted laparoscopic surgery

BackgroundNew technology attracts necessary concerns regarding safety and effectiveness, including the risk and circumstances of conversions. This study analyses our 11-year experience of conversions from a dedicated pediatric robot-assisted laparoscopic surgery service. MethodsConsecutive patients were evaluated from a prospective database for the period March 2006 to May 2017. Descriptive and quantitative data for conversions were analysed. Variables were investigated including year of surgery, patient age, operation type, surgeon, and experience. ResultsA total of 539 children underwent 601 procedures. There were 45 different types of procedures. Mean (± SD) age was 7.0 ± 5.2 years, and youngest 4 weeks old. There were 31 conversions (5.8%). Conversion rates were significantly higher in younger children, with rates of 10.0%, 6.1% and 4.2% for age groups 0–2, 2–6, and 6–18 years respectively (p = 0.01). There was a significant difference in conversion rates amongst procedures (p<0.001). Intravesical (9/26, 34.6%), liver cyst (2/8, 25.0%) and choledochal cyst (8/60, 13.3%) procedures were the highest. The most frequent reason for conversion was anesthetic related issues caused by dilated intestine and/or inadequate muscle relaxation (16/31, 52%). Three conversions were attributable to mechanical failures, none attributed to intraoperative complication. ConclusionsConversion rates are low even in the learning phase and comparable favourably to conventional laparoscopy, supporting the safety and effectiveness of robot-assisted technology for advanced laparoscopy in children. The importance of optimization of surgical conditions cannot be overemphasised.

Robotic versus laparoscopic colorectal surgery in elderly patients in terms of recovery time: a monocentric experience.

Colorectal cancer has a great socio-sanitary relevance. It represents the third cancer by incidence and mortality. Ageing plays a major role in the development of colorectal cancer and this tumour, in patients aged 65 and older, has gradually increased over the past decade. The robotic technique is considered the evolution of conventional laparoscopy. Few studies evaluate the effects of robotic surgery in elderly patient, and even fewer are those that compare it with laparoscopic surgery in this population. The aim of this study was to evaluate the perioperative outcomes of robotic colorectal surgery compared to laparoscopic colorectal surgery in patients older than 65 years. We conducted a retrospective study enrolling 83 elderly patients (age > 65) undergoing robotic and laparoscopic colectomy (32 and 51, respectively) between January 2019 and January 2021. For statistical analysis, p values were calculated using t test and chi-square test. p < 0.05 is the criterion for statistical significance. Statistical analyses were performed with the Number Cruncher Statistical System (NCSS) 2020 data analysis version 20.0.1 (Utah, USA). The operation time was higher in robotic left (p = 0.003, mean time 249.6 vs 211.7 min) and right (p = 0.004, mean time 238.5 vs 183.5 min) hemicolectomy and similar for procedures on rectosigmoid and rectum when compared to laparoscopic technique. In terms of length of hospital stay and recovery of bowel function, these values were significantly lower for robotic group in left hemicolectomy (p = 0.004), rectum (p = 0.003) and rectosigmoid (p = 0.003), while right hemicolectomy was similar in two groups (p = 0.26). There was no statistically significant difference between the groups regarding conversion rate, postoperative complications, length of specimen, number of lymph nodes encountered and oncological results. Colorectal robotic surgery in elderly patients appears as a feasible and safe surgical approach when compared to the laparoscopic one, showing a shorter recovery and a reduction of length of stay with similar oncological outcomes even if with an increase of operating times.

Conventional versus single-incision laparoscopy for the surgical treatment of ovarian torsion.

Aim:The aim of the study was to compare the effectiveness of single-incision laparoscopy with conventional laparoscopy in cases of ovarian torsion.Materials and Methods:Patients who were surgically treated for ovarian torsion in our clinic were retrospectively analysed. The demographic information and surgical records of the patients were obtained from the patient files. Patients treated with single-incision laparoscopy and conventional laparoscopy were compared in terms of demographic characteristics, surgical procedure performed, duration of surgery, amount of bleeding, laboratory results, post-operative pain scores and length of hospital stay.Results:There were 19 patients in the single-incision laparoscopy and 30 in the conventional laparoscopy groups. The two groups were similar in terms of age, obstetric history and body mass index (P > 0.05). The mean operation time was 56.26 ± 15.34 min in the single-incision laparoscopic surgery (SILS) group and 55.07 ± 10.78 min in the conventional laparoscopic surgery group (P > 0.05). There was no significant difference between the two groups in terms of complications, duration of hospital stay, pre- and post-operative haematocrit difference and visual analogue scale-pain scores at hours 0, 6, 12 and 24 (P > 0.05).Conclusion:SILS appears to be as feasible, effective and safe as conventional laparoscopy in the treatment of ovarian torsion cases.

Cervicovaginal reconstruction with small intestinal submucosa graft in congenital cervicovaginal atresia: A report of 38 cases

ObjectiveTo evaluate the quality of life and surgical outcomes in patients with congenital cervicovaginal malformation after cervicovaginal reconstruction. Study designThirty-eight patients diagnosed with congenital cervicovaginal aplasia and underwent cervicovaginal reconstruction using acellular porcine small intestinal submucosa (SIS) grafts were included in the study from January 2012 to December 2019. Of these, twenty-one patients underwent conventional laparoscopy, nine underwent robotic surgery, and eight underwent laparoendoscopic single-site (LESS) surgery. Clinical characteristics, perioperative data, condition of the neovagina and neocevix, post-operation complications, body image, resumption of menstruation, sexual function, and quality of life were assessed. ResultsThe average age of the patients was 16.4 ± 5.78 years. The operative procedure lasted 182.29 ± 70.85 min, with a hemoglobin decrease of 12.53 ± 7.55 g/dl. All surgery was completed successfully without complications. The total cost was highest in the robotic surgery group (P < 0.001). The cosmetic scores were significantly higher in the LESS group (P < 0.001). At a median follow-up of 49.79 ± 31.02 months, all patients resumed menstruation, except one patient who underwent hysterectomy due to vaginal obstruction. The average length of neovagina was 8.11 ± 0.75 cm, and the length of the cervix was 1.73 ± 1.00 cm. There were one patient with vaginal stenosis, two patients with cervical occlusion, two patients with cervical stenosis, and six patients with intrauterine device loss. Fourteen patients experienced sexual activity, with the total female sexual function index scores of 26.83 ± 3.49. Six patients had a desire of pregnancy, and one patient had pregnant via assisted-reproduction techniques. No differences in the mean physical component score (PCS) and mental component score (MCS) were identified among three different groups at baseline and all post-surgery time points (P > 0.05), but with the extension of follow-up, both PCS and MCS increased significantly in all groups (P < 0.001). ConclusionCervicovaginal reconstruction using an SIS graft is safe and efficient to the management of congenital cervicovaginal atresia whatever by the conventional laparoscopy, robotic surgery or LESS, with good surgical outcomes and high of quality of life.

Novel Articulated Laparoscopy in Gynecologic Surgery

<h3>Study Objective</h3> To discuss the advantages and disadvantages of articulated laparoscopy versus conventional laparoscopy. To demonstrate the benefits of a novel articulated laparoscopic device in a cadaveric model. <h3>Design</h3> Educational video. <h3>Setting</h3> Cadaver Laboratory and Simulation Center- Laparoscopic surgery performed in a cadaveric model. <h3>Patients or Participants</h3> We present a novel articulated laparoscopic instrument and our experience with the implementation of this device in a cadaveric model. <h3>Interventions</h3> Cadaveric laparoscopic wristed dissection including adhesiolysis, retroperitoneal dissection, salpingo-oophorectomy, and hysterectomy. <h3>Measurements and Main Results</h3> The advantages of robotic surgery include that it represents a less morbid alternative to laparotomy, it gives a minimally invasive surgery option for a broader patient population, and it improves precision with wristed instruments. On the other hand, Limitations of robotic surgery include the absence of haptic or tactile feedback and a higher cost. Additionally, depending on the practice setting, availability may be a problem. We present a novel hand-held articulated laparoscopic device that provides haptic feedback, short set up time, lower cost while improving precision and dexterity with wristed instruments. <h3>Conclusion</h3> This novel articulated laparoscopic instrument may be an option to offer MIS surgery with potential increased dexterity at a lower cost compared with robotic surgery. This option potentially combines the benefits of conventional laparoscopy and robotic surgery. Future research is needed to determine the learning curve and operative cost of this device.

Laparoscopic Myomectomy for 16cm Pedunculated Myoma with Extensive Small and Large Bowel Adhesions Using Honda Lasso Knot

Study Objective To describe a technique for laparoscopic loop ligation of a large pedunculated myoma using a Honda knot for hemostasis when attempting myomectomy with massive myoma. Design Surgical video detailing indications, evidence, technique and course of a single patient treated with loop myoma ligation. Setting Conventional laparoscopy within academic hospital operating room. Patients or Participants Single patient. Interventions A Honda slipknot was prepared using 0 polyglactin suture. The free end was passed through a laparoscopic trocar and around the myoma base. The Honda knot end was brought into the peritoneal cavity and the free end passed through this loop. This was tightened around the base of the myoma until it blanched. Measurements and Main Results We describe a 38-year-old G5P1041 who presented with multiple emergency visits for lower abdominal pain in the month following an 8-week termination of pregnancy. Ultrasound confirmed a 16cm pedunculated myoma and myomatous uterus but no retained products of conception. She was added for laparoscopic myomectomy and D&C after failing endometritis antibiotics and NSAIDs. Laparoscopy revealed extensive small and large bowel adhesions to the 16cm myoma. A Honda knot was placed around the base of the myoma to facilitate a lysis of bowel adhesions in a plane close to the myoma serosa. After injecting vasopressin into the pseudocapsule, laparoscopic myomectomy was completed, and the specimen removed through a 3-cm umbilical incision via manual in-bag morcellation. The patient recovered well after a 600mL intraoperative blood loss and reported resolution of all symptoms at follow-up. Conclusion Loop ligature around the base of a pedunculated myoma can aid in hemostasis prior to complex lysis of adhesions and during laparoscopic myomectomy. Hemostatic benefits were previously shown in a small, randomized trial of patients undergoing laparoscopic myomectomy for lesions averaging 5cm. To describe a technique for laparoscopic loop ligation of a large pedunculated myoma using a Honda knot for hemostasis when attempting myomectomy with massive myoma. Surgical video detailing indications, evidence, technique and course of a single patient treated with loop myoma ligation. Conventional laparoscopy within academic hospital operating room. Single patient. A Honda slipknot was prepared using 0 polyglactin suture. The free end was passed through a laparoscopic trocar and around the myoma base. The Honda knot end was brought into the peritoneal cavity and the free end passed through this loop. This was tightened around the base of the myoma until it blanched. We describe a 38-year-old G5P1041 who presented with multiple emergency visits for lower abdominal pain in the month following an 8-week termination of pregnancy. Ultrasound confirmed a 16cm pedunculated myoma and myomatous uterus but no retained products of conception. She was added for laparoscopic myomectomy and D&C after failing endometritis antibiotics and NSAIDs. Laparoscopy revealed extensive small and large bowel adhesions to the 16cm myoma. A Honda knot was placed around the base of the myoma to facilitate a lysis of bowel adhesions in a plane close to the myoma serosa. After injecting vasopressin into the pseudocapsule, laparoscopic myomectomy was completed, and the specimen removed through a 3-cm umbilical incision via manual in-bag morcellation. The patient recovered well after a 600mL intraoperative blood loss and reported resolution of all symptoms at follow-up. Loop ligature around the base of a pedunculated myoma can aid in hemostasis prior to complex lysis of adhesions and during laparoscopic myomectomy. Hemostatic benefits were previously shown in a small, randomized trial of patients undergoing laparoscopic myomectomy for lesions averaging 5cm.

Diagnostic Accuracy of Intraoperative Tools for Detecting Endometriosis

<h3>Study Objective</h3> To evaluate the diagnostic accuracy of intraoperative laparoscopic imaging tools in reference to that of histopathology for detecting endometriotic lesions and to compare them with conventional white-light inspection by performing a systematic review with meta-analysis. <h3>Design</h3> We performed a systematic review and meta-analysis and searched the MEDLINE, EMBASE, and CENTRAL databases in addition to citations and reference lists. Two authors screened 1038 citations for eligibility. <h3>Setting</h3> Randomized controlled trials or prospective cohort studies published in English. <h3>Patients or Participants</h3> Women with endometriosis undergoing laparoscopic surgery. <h3>Interventions</h3> The accuracy of intraoperative imaging tools (narrow-band imaging, 5-aminolevulinic acid−induced fluorescence, autofluorescence imaging, indocyanine green, and a 3-dimensional robotic laparoscopy) for diagnosing endometriosis during laparoscopy was assessed. <h3>Measurements and Main Results</h3> Seven studies were eligible, representing 472 women. Two authors extracted data and assessed the validity of the included studies. In all studies, additional endometriotic lesions were diagnosed with the enhanced imaging tool compared with white-light inspection alone. In the 4 studies that appropriately performed control biopsies, enhanced imaging techniques were associated with a higher sensitivity and specificity compared with white-light inspection (0.84 and 0.89 compared with 0.75 and 0.76, p ≤.001, bivariate random-effect model). Biopsies of normal-looking peritoneum were not performed to verify the results in 3 studies leading to the overestimation of the sensitivity and underestimation of the specificity of imaging tools. Adverse events were uncommon (n = 5) and reported only with the use of exogeneous photosensitizers. There were no reports of long-term changes in patient-reported outcomes arising from better detection of endometriosis lesions. <h3>Conclusion</h3> Studies report that enhanced imaging allows for the detection of additional endometriotic lesions missed by conventional white-light laparoscopy. The benefits of finding these additional lesions using enhanced imaging compared with white-light inspection alone on long-term postoperative outcomes have not been determined, and these tools should be considered only in a research context at this time.

Robotic-Assisted Laparoscopic Treatment of Bladder Endometriosis

<h3>Study Objective</h3> To show the combined surgical approach of cystoscopy and robotic-assisted laparoscopy for a complete and safe resection of bladder endometriosis. <h3>Design</h3> A clinical case and surgical cystoscopic and robotic approach of bladder endometriosis resection demonstrated by video. <h3>Setting</h3> Bladder endometriosis is defined as the presence of endometrial glands and stroma in the detrusor muscle and is the most common site affected in urinary tract endometriosis. Surgical treatment should guarantee complete removal of the bladder nodule to minimize recurrence, so transurethral surgery alone should be avoided in favor of segmental bladder resection. Robotic-assisted laparoscopy provides advantages as 3D visualization and facilitation of suturing techniques compared to conventional laparoscopy. <h3>Patients or Participants</h3> A 32-year-old nulliparous patient, complaining of sensation of incomplete emptying of the bladder and dysuria, with worsening in the menstrual period. Patient had been using combined oral contraception but reported worsening of symptoms since she stopped the use in 2019. During letrozole treatment for infertility she discovered a bladder nodule of probable endometriotic origin. MRI showed signs of deep endometriosis in the vesicouterine recess, with infiltration of the anterior uterine serosa and left round ligament, measuring around 3.0 × 2.0 × 0.9 cm, in addition to the nodular lesion that infiltrates and retracts the upper wall of the bladder, projecting to the bladder lumen of 3.8 × 2.5 × 2.1 cm. <h3>Interventions</h3> It was performed cystoscopy and bilateral double-J catheter passage, followed by robotic-assisted laparoscopic resection of bladder endometriosis with partial cystectomy. Surgical field was prepared and the paravesical accessed to the bladder nodule. Bladder was sutured with barbed thread and surgical specimen removed by colpotomy. <h3>Measurements and Main Results</h3> Anatomopathological exam confirms endometriosis. <h3>Conclusion</h3> Endometriosis of urinary tract can have an appropriate surgical resection by laparoscopic management with or without robotic assistance. Having knowledge of the surgical technique and the platform allows a safe and complete resection, minimizing complications.

Systematic Review on Hysterectomy By Vaginal Natural Orifice Transluminal Endoscopic Surgery Compared to Laparoscopic Hysterectomy

<h3>Study Objective</h3> We aimed to report an update of the systematic review and meta-analysis published in 2016, comparing hysterectomy by vaginal natural orifice transluminal endoscopic surgery (vNOTES) to the laparoscopic approach for benign indications. <h3>Design</h3> This was a systematic review and meta-analysis. We searched MEDLINE, EMBASE, CENTRAL and additional sources and aimed to retrieve randomised controlled trials (RCTs), controlled clinical trials (CCTs) and prospective/retrospective cohort studies in human subjects that allowed direct comparison of vNOTES to laparoscopy. Primary outcome was the proportion of women successfully treated with the intended approach to perform hysterectomy without conversion to any other technique. <h3>Setting</h3> N/A. <h3>Patients or Participants</h3> We included studies in the adult female population, undergoing removal of the uterus for benign gynecological disease. Studies on interventions for genital prolapse or gynecological malignancy were excluded. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> Our search yielded one RCT and five retrospective cohort trials. Pooled analysis of two subgroups showed that, compared to conventional laparoscopy, vNOTES is equally effective to successfully remove the uterus in individuals meeting the inclusion criteria. vNOTES had significantly lower values for operation time, length of stay and estimated blood loss. There was no significant difference in intra-operative and post-operative complications, readmission, pain scores at 24 hours post-operative and change in haemoglobin on day 1 post-operative. <h3>Conclusion</h3> The available randomised and observational data show that vNOTES hysterectomy is an effective and safe novel technique for women eligible for endoscopic surgery.

Needlescopic Disconnection and Peritoneal Closure for Pediatric Inguinal Hernia Repair: A Novel Technique.

There are many laparoscopic techniques for pediatric congenital inguinal hernia repair. Needlescopic surgery was introduced recently in pediatric patients aiming at getting excellent cosmetic outcomes. The aim of this study was to describe a novel technique for needlescopic inguinal hernia repair in children. Needlescopic division of the hernial sac was carried out on 369 children in 6 pediatric tertiary centers during the period from August 2016 to May 2019. All hernias were repaired by a novel needlescopic procedure that replicates all the steps of the open herniotomy. A total of 369 patients with 410 hernias were included in this study. They were 232 (62.9%) males and 137 (37.1%) females, with a mean age of 3.58±1.26 (range=2 to 8 y) and mean internal inguinal ring diameter was 13.65±3.85 mm (range=8 to 20 mm). The mean operative time was 23.36±4.67 minutes for bilateral and 14.28±2.98 minutes for unilateral cases. All cases were completed without conversion to conventional laparoscopy. All cases were followed up for a mean of 19.6±3.2 months. None of our patients developed recurrence or testicular atrophy and the scars were nearly invisible 3 months postoperatively. Needlescopic pediatric inguinal hernia repair using disconnection of the hernia sac at internal inguinal ring with purse-string suture closure of peritoneum is feasible and safe with no recurrence and with outstanding cosmetic results.

Gynecological natural orifice transluminal endoscopic surgeries from an anesthesiologist’s perspective: A retrospective cohort study

Background/Aim: Natural orifice transluminal endoscopic surgical (NOTES) approach allows either transgastric or transvaginal access to the targeted organs by endoscopes without a skin incision. This study aimed to evaluate the intraoperative and postoperative outcomes of patients who underwent vaginally assisted NOTES (VaNOTES) for gynecological surgery. Methods: One hundred ten patients who underwent hysterectomy and/or bilateral salpingo-oophorectomy (BSO) under general anesthesia either with conventional laparoscopy (CL) or VaNOTES methods were examined. The data of the patients were obtained from the medical records retrospectively. Demographic data, perioperative hemodynamic data, Visual Analogue Scale (VAS) scores, and analgesic consumption at the 1st, 6th, and 24th postoperative hours were assessed. Results: Among all patients, the median duration of anesthesia, median operation time, and hospital stay were lower in the VaNOTES group compared to those in CL (P