Laparoscopic Patients Research Articles

Survey on Barriers to Adoption of Laparoscopic Surgery

To identify challenges that impede wider adoption of laparoscopy in gynecologic surgery and assessing whether the current training programs are addressing these challenges adequately. A survey was designed to examine barriers to adoption of laparoscopy for practicing gynecologists. The survey was piloted on gynecologic surgeons and was further refined following their feedback. Finally, the survey was deployed to 4273 gynecologists across the United States via e-mail using the national database of the American Medical Association. Respondents were grouped into two categories based on how often they report referral of patients for laparoscopy. Demographics, training, and practice characteristics were compared using Fisher exact tests for categorical variables and t tests for continuous variables. Participants rated factors that were thought to limit laparoscopy use on a 5-point Likert scale; median values of these scores were compared with Wilcoxon rank sum tests. We received 210 responses (29% of people who opened the e-mail and 93% of those who opened the survey). Physicians who perform their own laparoscopies were on average younger and tended to be more subspecialized. Some of the most highly rated limiting factors included lack of adequate surgical volume, reluctance of managing unexpected surgical scenarios, difficulty with video-eye-hand coordination, altered depth perception, and laparoscopic suturing. This survey identified barriers to adoption of laparoscopic surgical techniques beyond what has previously been identified. Based on these findings, novel simulation and continuing medical education curricula can be created to address the primary barriers in order to increase laparoscopic approach to surgery among gynecologists.

Effects of P6 acustimulation with the ReliefBand on postoperative nausea and vomiting in patients undergoing gynecological laparoscopy.

We investigated the effects of P6 acustimulation on the incidence of postoperative nausea and vomiting (PONV), antiemetic requirements, and side effects in patients undergoing gynecological laparoscopy with a high risk of PONV. Sixty-two patients were divided into 2 groups randomly: a ReliefBand group (RB group) and a sham ReliefBand group (S group). The P6 acustimulation device (ReliefBand Medical Technologies LLC, Chicago, Illinois) was wrapped around the wrists of the patients 15 to 30 minutes before the operation and activated before the induction of anesthesia. The patients' hemodynamic parameters, nausea scale (verbal rating scale), pain scale (visual analogue scale), PONV score, rescue antiemetics, analgesic requirements, adverse effects, and satisfaction scores in the first 24 hours were recorded. The verbal rating scale scores in the early postoperative period and 6 hours postoperatively were significantly higher in the RB group than in the S group. The PONV scores at 15 minutes and at 6 and 12 hours postoperatively were significantly higher in the S group than in the RB group. The verbal rating scale scores of the patients with higher Apfel risk scores (3 or 4 points) in the early postoperative period and 6 hours postoperatively were significantly lower in the RB group than in the S group. The PONV scores of the patients with high Apfel risk scores at 15 minutes and at 6 and 12 hours postoperatively were significantly lower in the RB group than in the S group. The number of patients and doses of antiemetics required were significantly lower in the RB group than in the S group. Patient satisfaction scores were significantly higher in the RB group than in the S group. Acustimulation with the P6 ReliefBand decreased the severity of nausea, PONV scores, and antiemetic requirements in the early postoperative period of gynecological laparoscopy patients.

High serum CA 19-9 but not tumor size should select patients for staging laparoscopy in radiological resectable pancreas head and peri-ampullary cancer

BackgroundThe objective of this study was to validate current recommendations for the selective use of staging laparoscopy in patients with radiological resectable pancreas head and peri-ampullary tumors. MethodsData from a prospectively collected database (2007–2013) of 136 patients with peri-pancreatic head cancer were analyzed. ResultsOver a 6 year time period, 136 patients were evaluated, 126 patients were deemed radiological resectable and underwent laparotomy and 10 patients were characterized radiological unresectable. There were 111 patients with pancreas head resection and 15 without resection (8 due to extensive vascular involvement and 3 due to peritoneal/liver metastases). The sensitivity, specificity, PPV and NPV of pre-operative radiological imaging in determining unresectability due to liver/peritoneal metastases were 42%, 100%, 100% and 94.7% respectively. There was a significant difference in CA 19-9 values between metastatic and non-metastatic disease (p = 0.020). ROC curve analysis calculated the optimal CA 19-9 cutoff point for predicting metastasis at 215.37 U/ml with a sensitivity of 72.7%, a specificity of 58.3%, PPV of 15.1% and NPV of 95.5%. Tumor diameter was not a significant factor in predicting resectability. Laparoscopy would have been useful in only 5.3% of patients in the present series. ConclusionHigh CA 19-9 values (>215 U/ml) and not tumor size should select patients with radiological resectable peri-pancreatic cancer for staging laparoscopy.

Treatment patterns among US women diagnosed with endometriosis: a retrospective claims analyses pre- and post-diagnosis

Treatment patterns among US women diagnosed with endometriosis: a retrospective claims analyses pre- and post-diagnosis

Predictors of Conversion in Laparoscopic-assisted Colectomy for Colorectal Cancer and Clinical Outcomes

This study investigated risk factors and impact of open conversion on outcomes of 207 consecutive patients who had laparoscopic resection of colorectal cancer at our institution. Conversion occurred in 15.9% of patients, mostly because of invasion to adjacent structures (30.3%), bulky tumor (21.2%), and adhesions (18.2%). Converted patients had significant larger tumor size, advanced stage, increased operative blood loss, time to walk independently, prolonged hospital stay, number of massive hemorrhage, ileus, anastomotic hemorrhage, abdominal hemorrhage, peritonitis/septic shock, and wound infection than completed laparoscopy patients. Factors associated with conversion were obesity [relative risk (RR)=6.92; 95% confidence interval (CI), 1.7-28.09], date of operation (RR=0.37; 95% CI, 0.15-0.95), advanced tumor stage (RR=7.67; 95% CI; 1.19-49.2), size (RR=1.97; 95% CI, 1.42-2.72), and rectum location (RR=2.73; 95% CI, 1.09-6.84). Converted patients had worse cumulative disease-free (P<0.001) and overall survival (P<0.001) than laparoscopic completed patients.

Utilization of laparoscopy for resections of stomach and esophagus cancers: Is hospital the deciding factor?

86 Background: Foregut surgery is technically complex. Outcomes for such high-stakes operations receive increasing scrutiny and the use of minimally invasive approaches has been further adopted. This study aims to determine national trends in laparoscopy utilization and patient outcomes for potentially curative cancer resections of the esophagus and stomach. Methods: Retrospective review of all esophageal and gastric cancer resections in the Nationwide Inpatient Sample during 1998 to 2011. Univariate analyses of sex, race, admission status, Elixhauser comorbidity score, year, insurance, hospital characteristics, procedure, and center volume were performed by chi-square. Cochran-Armitage test was used for trends. Logistic regressions were used to model inpatient mortality, complications and laparoscopy. Results: From 1998 to 2011, 120,527 and 25,540 patients (nationally-weighted records) underwent gastrectomies and esophagectomies for cancer. From early (1998-2002) to late (2008-2011) study years, inpatient mortality decreased from 6.69% to 3.88% (&lt;0.0001) and complications increased from 27.41% to 31.63% (&lt;0.0001) for gastrectomy. Similarly, inpatient mortality decreased from 9.75% to 5.53% (&lt;0.0001) and complications increased from 37.69% to 43.07% (&lt;0.0001) for esophagectomy. Use of laparoscopy in gastrectomy increased from 1.64% to 5.89% (p &lt;0.0001) and in esophagectomy from 0.80% to 5.74% (&lt;0.0001). Patients undergoing laparoscopy had lower inpatient mortality (3.13% vs. 5.96%, p=0.0010) and were less likely to experience complications (26.20% vs. 31.47%, p=0.0121). After adjustment, independent predictors of the use of laparoscopy included elective admission, female sex, resection after 2003 and resection at a large (vs. medium), urban, teaching high volume center (vs. low volume center) in the Northeast (vs. Midwest and South). Conclusions: Inpatient mortality and complications for gastrectomy and esophagectomy have improved over the past decade. Use of minimally invasive techniques is expanding with associated superior patient outcomes. Resection hospital characteristics drive which patients undergo laparoscopy for esophagus and stomach cancers.

Perioperative outcomes of robotic assisted laparoscopic surgery versus conventional laparoscopy surgery for advanced-stage endometriosis.

Background and Objectives:To determine perioperative outcome differences in patients undergoing robotic-assisted laparoscopic surgery (RALS) versus conventional laparoscopic surgery (CLS) for advanced-stage endometriosis.Methods:This retrospective cohort study at a minimally invasive gynecologic surgery center at 2 academically affiliated, urban, nonprofit hospitals included all patients treated by either robotic-assisted or conventional laparoscopic surgery for stage III or IV endometriosis (American Society for Reproductive Medicine criteria) between July 2009 and October 2012 by 1 surgeon experienced in both techniques. The main outcome measures were extent of surgery, estimated blood loss, operating room time, intraoperative and postoperative complications, and length of stay, with medians for continuous measures and distributions for categorical measures, stratified by body mass index values. Robotically assisted laparoscopy and conventional laparoscopy were then compared by use of the Wilcoxon rank sum, χ2, or Fisher exact test, as appropriate.Results:Among 86 conventional laparoscopic and 32 robotically assisted cases, the latter had a higher body mass index (27.36 kg/m2 [range, 23.90–34.09 kg/m2] versus 24.53 kg/m2 [range, 22.27–26.96 kg/m2]; P < .0079) and operating room time (250.50 minutes [range, 176–328.50 minutes] versus 173.50 minutes [range, 123–237 minutes]; P < .0005) than did conventional laparoscopy patients. After body mass index stratification, obese patients varied in operating room time (282.5 minutes [range, 224–342 minutes] for robotic-assisted laparoscopy versus 174 minutes [range, 130–270 minutes] for conventional laparoscopy; P < .05). No other significant differences were noted between the robotic-assisted and conventional laparoscopy groups.Conclusion:Despite a higher operating room time, robotic-assisted laparoscopy appears to be a safe minimally invasive approach for patients, with all other perioperative outcomes, including intraoperative and postoperative complications, comparable with those in patients undergoing conventional laparoscopy.

The effect of the time nursing on preoperative anxiety and satisfaction of patients with gynecological laparoscopic surgery

Objective To explore the application effect of time nursing in patients with laparoscopic operation ot gynecology.Methods A total of 100 patients with gynecological laparoscopic operation were divided into the observation group and the control group according to different nursing methods,the control group was received routine nursing,the observation group was given time nursing,nursing effects were compared between the two groups.Results Health knowledge score,operation cooperation and nursing satisfaction scores in the observation group were significantly higher than those in the control group (P ＜ 0.05).Preoperative positive coping scores in the observation group were significantly higher than those in the control group,negative coping scores were significantly lower than those in the control group (P ＜ 0.05).Before anesthesia,the anxiety and depression scores in the observation group were significantly lower than those in the control group (P ＜ 0.05).Conclusions Time nursing can increase health knowledge of gynecological laparoscopy patients,reduce the preoperative anxiety,change coping style and improve nursing satisfaction. Key words: Time nursing; Gynecology ; Laparoscopy ; Preoperative anxiety; Satisfaction

Postoperative Pain Medication Requirements in Patients Undergoing Computer-Assisted (“Robotic”) and Standard Laparoscopic Procedures for Newly Diagnosed Endometrial Cancer

Laparoscopy (LSC) offers superior patient outcomes compared to laparotomy. Small retrospective/prospective series have suggested robotics offers further reduction in postoperative pain and pain medication use compared to standard LSC. Our objective was to compare postoperative pain in patients undergoing robotically assisted (RBT) versus standard LSC for newly diagnosed endometrial cancer. All preoperative endometrial cancer cases scheduled for RBT and LSC from May 1, 2007 to June 9, 2010 were identified. For this analysis, we only included cases not requiring conversion to laparotomy. All patients were offered intravenous (IV) patient-controlled analgesia (PCA) postoperatively. Intraoperative equivalent fentanyl doses (IEFDs) and pain scores in the postanesthesia care unit (PACU) were assessed. IV PCA was used in 206 RBTs (86 %) and 208 LSCs (88 %). Median IEFD was 425 μg for LSCs and 500 μg for RBTs (P = 0.03). Median pain scores on PACU arrival were similar in both groups. Median highest pain score was 5 for LSCs and 4 for RBTs (P = 0.007). Linear regression demonstrated that the IEFD was not correlated with the highest pain score (R = 0.09; P = 0.07). Fentanyl was used postoperatively in 196 of 206 RBTs (95 %) and 187 of 208 LSCs (90 %). The total fentanyl doses were 242.5 (range 0-2705) μg and 380 (range 0-2625) μg, respectively (P < 0.001). The median hourly fentanyl doses were 16.7 (range 0-122.5) μg and 23.5 (range 0-132.4) μg, respectively (P = 0.005). Simultaneous multiple regression analysis further demonstrated RBT was independently associated with a lower total fentanyl dose compared to LSC (P = 0.02). RBT is independently associated with significantly lower postoperative pain and pain medication requirements compared to LSC. The amount of intraoperative fentanyl analgesia does not appear to correlate with postoperative pain.Endometrial cancer is the most common gynecologic malignancy in the United States, with an estimated 47,130 new cases in 2012.1 An estimated 287,100 women were diagnosed with endometrial cancer worldwide in 2008.2 Surgery is the primary treatment of choice for the majority of these women.3 The standard surgical approach has been total abdominal hysterectomy, bilateral salpingo-oophorectomy, and staging via laparotomy. Multiple retrospective series have shown that a less invasive surgical approach via laparoscopy (LSC) is feasible and safe, and also associated with improved perioperative outcomes compared to laparotomy in these patients.4 The Gynecologic Oncology Group (GOG) published results of the largest randomized trial (LAP2) comparing LSC to laparotomy in patients with newly diagnosed endometrial carcinoma in 2009.5,6 This landmark study essentially changed the accepted standard surgical approach in this group. Postoperative complications, median blood loss, and median length of stay (LOS), despite increased operative time, were significantly lower in LSC patients despite 25 % requiring conversion to laparotomy.5 The first 802 eligible patients randomized in LAP2 also participated in a quality-of-life (QOL) study. Within 6 weeks of surgery, patients assigned to LSC reported significantly better QOL on all scales other than fear of recurrence.6 Overall, during this 6-week postoperative period, patients assigned to LSC had superior QOL, fewer physical symptoms, less pain and pain-related interference with functioning, better physical functioning and emotional state, earlier resumption of normal activities, earlier return to work, and better body image compared to those assigned to laparotomy.6 Recurrence-free and overall survivals were the same in both groups.7 Multiple published retrospective series have shown possible benefits, such as reduced postoperative pain, using the robotic (RBT) platform compared to LSC or laparotomy in patients with endometrial cancer.8-11 In a randomized trial, LSC was found to be associated with less postoperative pain compared to vaginal approaches in patients undergoing hysterectomy for benign gynecologic disease.12 A small retrospective series reported further reductions in postoperative pain in patients who had undergone an RBT hysterectomy compared to a standard total LSC hysterectomy for benign indications.13 A recent cost analysis suggested that patients experienced less pain and required less pain medication use after RBT procedures compared to LSC for endometrial cancer.14 Based on these reports, we sought to analyze postoperative pain and the use of pain medication in patients undergoing RBT compared to standard transperitoneal LSC procedures for newly diagnosed endometrial cancer during a concurrent time period. Of note, current RBT surgery is not truly robotic in that it is not autonomous. A more appropriate term is “computer-assisted surgery,” but to satisfy current convention, we refer to it as “robotic surgery” in this manuscript.

RE: CA 19-9 in Potentially Resectable Pancreatic Cancer: Perspective to Adjust Surgical and Preoperative Therapy

I am really not a pessimist, but several concepts continue to surround the surgical management of pancreatic adenocarcinoma: (1) despite improvements in radiologic technology, a significant fraction of patients are still found to have unresectable disease in the operating room, (2) despite improvements in perioperative care and team-based patient management, a significant fraction of patients develop complications of surgical resection that may lead to immediate death, delayed death, or dramatically decreased quality of life, (3) the vast majority of patients will die from recurrent disease despite a a curativea resection, and (4) improvements in adjuvant therapy have lagged behind the treatment of other solid organ malignancies and offer only small improvements in median survival. If I were a pessimist, I would never operate on these patients, but instead I continue to hold out hope that each patient may be that uncommon 5or 10-year survivor following surgical resection of pancreatic cancer. Nearly a decade has passed since the association of carbohydrate antigen (CA) 19-9 with some aspect of the biology of pancreatic cancer was first reported. Since that time, various roles of CA 19-9 in the management of patients with pancreatic adenocarcinoma have been described including the differentiation of benign from malignant pancreatic disease, prediction of resectable disease, identification of patients for selective staging laparoscopy, the identification of patients at risk for early recurrence and death following potentially curative resection, and for use in the surveillance for disease recurrence. Yet for each of these aspects, the specific role of CA 19-9 is only part of clinical assessment and decision making in these patients. Before beginning the discussion, it is critical to understand what CA 19-9 is and how it can be used as a a tumor marker.a CA 19-9 was first identified following the screening patient sera by hybridoma-derived monoclonal antibodies. One such antibody, 1116 NS 19-9 developed by Koprowski et al., 3 was shown to react with a sialylated lacto-N-fucopentaose II, which was present in high levels in sera of patients with colon, gastric, and pancreatic cancer. Based on the screening of a variety of tumors by immunohistochemical methods as well as sera from patients with a variety of gastrointestinal and gynecologic cancers, CA 19-9 was felt to be specific for malignancy and termed a a tumor markera . In screening sera from more than 1,000 blood donors, CA 19-9 was found to be undetectable ino~8o%, and waso\37 U/ml in all but six samples, hence the threshold value of 37 U/ml for a normala . Yet 4o% of a parallel study population of patients with benign disease (such as inflammatory bowel disease, pancreatitis, or gastrointestinal polyps) had CA 19-9 levelso [37 U/ml. Thus, CA 19-9 is not a perfect tumor marker in terms of sensitivity (79o% for pancreatic adenocarcinoma, 50o% for gastric carcinoma, and 46o% for advanced colorectal carcinoma) and specificity (98.5o%). However, it is pretty good when compared with other tumor markers such as CEA, alphafetoprotein or CA 125. There are three important limitations of CA 19-9 that must be recognized as they are critical to the implementation in patients with suspected pancreatic cancer. The first is that CA 19-9 is a sialylated Lewis (a) antigen, which is normally expressed on the surface of erythrocytes. Up to 10o% of the white population will not express any detectable level of CA 19-9 because of absence of fucosyltransferase, one of the enzymes involved in the biosynthesis. Therefore, in up to 10o% of patients with pancreatic adenocarcinoma, CA 19-9 will be undetectable and therefore of no utility in any aspect of clinical decision making. The second aspect relates to the lack of perfect specificity in which patients with benign disease can have Society of Surgical Oncology 2013

Effect of laparoscopic cholecystectomy techniques on postoperative pain: a prospective randomized study.

PurposeMinimally invasive surgical technics have benefits such as decreased pain, reduced surgical trauma, and increased potential to perform as day case surgery, and cost benefit. The primary aim of this prospective, randomized, controlled study was to compare the effects of single incision laparoscopic cholecystectomy (SILC) and conventional laparoscopic cholecystectomy (CLC) procedures regarding postoperative pain.MethodsNinety adult patients undergoing elective laparoscopic cholecystectomy were included in the study. Patients were randomized to either SILC or CLC. Patient characteristics, postoperative abdominal and shoulder pain scores, rescue analgesic use, and intraoperative and early postoperative complications were recorded.ResultsA total of 83 patients completed the study. Patient characteristics, postoperative abdominal and shoulder pain scores and rescue analgesic requirement were similar between each group except with the lower abdominal pain score in CLC group at 30th minute (P = 0.04). Wound infection was seen in 1 patient in each group. Nausea occurred in 13 of 43 patients (30%) in the SILC group and 8 of 40 patients (20%) in the CLC group (P > 0.05). Despite ondansetron treatment, 6 patients in SILC group and 7 patients in CLC group vomited (P > 0.05).ConclusionIn conclusion, in patients undergoing laparoscopic surgery, SILC or CLC techniques does not influence the postoperative pain and analgesic medication requirements. Our results also suggest that all laparoscopy patients suffer moderate and/or severe abdominal pain and nearly half of these patients also suffer from some form of shoulder pain.

Rectal Prolapse in the Elderly: Trends in Surgical Management and Outcomes from the American College of Surgeons National Surgical Quality Improvement Program Database

Full thickness rectal prolapse (FTRP) is managed with an abdominal or perineal operation. Traditionally, the approach has been determined by patient age and comorbidities. Our aim was to determine operative trends and outcomes for repair of FTRP in elderly patients using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. We queried the ACS NSQIP database from 2006 to 2009 for patients with FTRP who were 70 years of age or older. Patients were grouped according to type of surgical repair: laparoscopic (LR), open (OR), or perineal (PR) technique. We reviewed demographics, operative trends of surgical technique, and short-term outcomes for each group. A total of 816 patients were analyzed; 596 (73%) PR, 130 (16%) OR, and 90 (11%) LR patients. Patients who received OR and LR had lower mean American Society of Anesthesiologists (ASA) scores than PR patients (2.6, 2.5, and 2.7, respectively, p < 0.001). The percentage of LR and OR procedures decreased as age increased by decade; the inverse was seen for PR (p < 0.001). The distribution of operative techniques has not changed from year to year. Length of stay was significantly shorter for LR (3.77 days) and PR (3.44 days) patients vs OR patients (6.23 days) (p = 0.01). Complication rates were 2.22%, 8.72%, and 12.31% for LR, PR, and OR, respectively (p = 0.021). Open surgery was the only factor associated with an increased complication rate, with an odds ratio of 6.29 (95% CI 1.38 to 28.6, p < 0.02). Despite the appeal of perineal proctectomy in the elderly and debilitated patient, the approach to FTRP is slowly evolving in the era of laparoscopic surgery. Laparoscopic repair of FTRP in the elderly is associated with improved short-term outcomes when compared with OR and PR.

Is Single-Port Access Laparoscopy Less Painful Than Conventional Laparoscopy for Adnexal Surgery? A Comparison of Postoperative Pain and Surgical Outcomes

This study aimed to compare postoperative pain and surgical outcomes after transumbilical single-port access (SPA) and conventional multiport laparoscopic surgery for adnexal lesions. A retrospective case-control study was conducted matched by age, body mass index, and frequency of previous abdominal surgery. A total of 110 SPA laparoscopy patients (cases) were matched with a cohort of 107 patients who underwent conventional laparoscopy (controls) for benign adnexal lesions. SPA system consisted of a wound retractor, surgical glove, two 5-mm trocars, and one 11-mm trocar. Postoperative pain scores were measured immediately after surgery and at 6, 24, and 48 hours postsurgery using the numerical rating scale. Postoperative pain scores did not differ between the 2 groups (P = .552). However, higher number of painkiller administrations was observed in the SPA laparoscopy group (median 3 vs 1, P < .001). The type of surgery and intraoperative blood loss were the significant factors influencing the number of painkiller administrations after controlling for other parameters by linear regression (P < .0001). The SPA laparoscopy group had less intraoperative blood loss (45.3 vs 87.5 mL, P < .001) and shorter hospital stay (2.1 ± 0.8 vs 2.7 ± 1.0 days, P < .001) compared with the conventional laparoscopy group. Operative time and perioperative complications did not differ between groups. There was no difference in pain intensity between the SPA and conventional laparoscopic group in this study. Future trials are warranted to better define the benefits of SPA surgery in terms of postoperative pain.

Laparoscopy to predict the result of primary cytoreductive surgery in advanced ovarian cancer patients (LapOvCa-trial): a multicentre randomized controlled study

BackgroundStandard treatment of advanced ovarian cancer is surgery and chemotherapy. The goal of surgery is to remove all macroscopic tumour, as the amount of residual tumour is the most important prognostic factor for survival. When removal off all tumour is considered not feasible, neoadjuvant chemotherapy (NACT) in combination with interval debulking surgery (IDS) is performed. Current methods of staging are not always accurate in predicting surgical outcome, since approximately 40% of patients will have more than 1 cm residual tumour after primary debulking surgery (PDS). In this study we aim to assess whether adding laparoscopy to the diagnostic work-up of patients suspected of advanced ovarian carcinoma may prevent unsuccessful primary debulking surgery for ovarian cancer.MethodsMulticentre randomized controlled trial, including all gynaecologic oncologic centres in the Netherlands and their affiliated hospitals. Patients are eligible when they are planned for PDS after conventional staging. Participants are randomized between direct PDS or additional diagnostic laparoscopy. Depending on the result of laparoscopy patients are treated by PDS within three weeks, followed by six courses of platinum based chemotherapy or with NACT and IDS 3-4 weeks after three courses of chemotherapy, followed by another three courses of chemotherapy. Primary outcome measure is the proportion of PDS's leaving more than one centimetre tumour residual in each arm. In total 200 patients will be randomized. Data will be analysed according to intention to treat.DiscussionPatients who have disease considered to be resectable to less than one centimetre should undergo PDS to improve prognosis. However, there is a need for better diagnostic procedures because the current number of debulking surgeries leaving more than one centimetre residual tumour is still high. Laparoscopy before starting treatment for ovarian cancer can be an additional diagnostic tool to predict the outcome of PDS. Despite the absence of strong evidence and despite the possible complications, laparoscopy is already implemented in many countries. We propose a randomized multicentre trial to provide evidence on the effectiveness of laparoscopy before primary surgery for advanced stage ovarian cancer patients.Trial registrationNetherlands Trial Register number NTR2644

Risk Stratification for Serosal Invasion Using Preoperative Predictors in Patients with Advanced Gastric Cancer

PurposeAlthough serosal invasion is a critical predisposing factor for peritoneal dissemination in advanced gastric cancer, the accuracy of preoperative assessment using routine imaging studies is unsatisfactory. This study was conducted to identify high-risk group for serosal invasion using preoperative factors in patients with advanced gastric cancer.Materials and MethodsWe retrospectively analyzed clinicopathological features of 3,529 advanced gastric cancer patients with Borrmann type I/II/III who underwent gastrectomy at Korea Cancer Center Hospital between 1991 and 2005. We stratified patients into low- (≤40%), intermediate- (40~70%), and high-risk (>70%) groups, according to the probability of serosal invasion.ResultsBorrmann type, size, longitudinal and circumferential location, and histology of tumors were independent risk factors for serosal invasion. Most tumors of whole stomach location or encircling type had serosal invasion, so they belonged to high-risk group. Patients were subdivided into 12 subgroups in combination of Borrmann type, size, and histology. A subgroup with Borrmann type II, large size (≥7 cm), and undifferentiated histology and 2 subgroups with Borrmann type III, large size, and regardless of histology belonged to high-risk group and corresponded to 25% of eligible patients.ConclusionsThis study have documented high-risk group for serosal invasion using preoperative predictors. And risk stratification for serosal invasion through the combination with imaging studies may collaboratively improve the accuracy of preoperative assessment, reduce the number of eligible patients for further staging laparoscopy, and optimize therapeutic strategy for each individual patient prior to surgery.

Laparoscopic management of acute small bowel obstruction

Acute small bowel obstruction (SBO) is a common condition encountered by the on-call emergency surgeon. The role of laparoscopy in the management of SBO continues to be defined. This modality can be limited by dilated bowel and inadequate assessment of compromised tissue. This review was undertaken to determine the reliability of laparoscopic evaluation and the subsequent need for bowel resection. A retrospective review of all patients surgically managed for acute SBO between July 2005 and September 2010 was conducted. The clinical presentation, computed tomographic findings, indications for surgery, type of intervention, need for reoperation, length of stay (LOS), and outcomes were all abstracted. A total of 119 patients were surgically managed for acute SBO during this period, 63 with initial laparoscopy and 56 with an open procedure. Twenty-five (40%) of the laparoscopy patients were converted to open, leaving 38 completed laparoscopically. Of the completed group, three patients underwent bowel resection compared with 16 in the converted group (8% vs. 64%, p < 0.0001). No patients in the completed group required a subsequent procedure for bowel resection. Twenty-three (41%) patients in the open cohort required a resection. LOS was significantly reduced in the completed group (7.7 days) compared with the converted (11.0 days, p = 0.01) and open groups (11.4 days, p = 0.002). Overall, 32% of acute SBOs were managed solely with laparoscopy. No patients requiring a bowel resection were missed using this method of evaluation. Laparoscopic management should be considered as safe and effective initial therapy in most cases of acute SBO.

Comparison of Surgical Outcomes between Robotic and Laparoscopic Gastrectomy for Gastric Cancer: The Learning Curve of Robotic Surgery

PurposeLaparoscopic gastrectomy is a widely accepted surgical technique. Recently, robotic gastrectomy has been developed, as an alternative minimally invasive surgical technique. This study aimed to evaluate the question of whether robotic gastrectomy is feasible and safe for the treatment of gastric cancer, due to its learning curve.Materials and MethodsWe retrospectively reviewed the prospectively collected data of 100 consecutive robotic gastrectomy patients, from November 2008 to March 2011, and compared them to 282 conventional laparoscopy patients during the same period. The robotic gastrectomy patients were divided into 20 initial cases; and all subsequent cases; and we compared the clinicopathological features, operating times, and surgical outcomes between the three groups.ResultsThe initial 20 robotic gastrectomy cases were defined as the initial group, due to the learning curve. The initial group had a longer average operating time (242.25±74.54 minutes vs. 192.56±39.56 minutes, P>0.001), and hospital stay (14.40±24.93 days vs. 8.66±5.39 days, P=0.001) than the experienced group. The length of hospital stay was no different between the experienced group, and the laproscopic gastrectomy group (8.66±5.39 days vs. 8.11±4.10 days, P=0.001). The average blood loss was significantly less for the robotic gastrectomy groups, than for the laparoscopic gastrectomy group (93.25±84.59 ml vs. 173.45±145.19 ml, P<0.001), but the complication rates were no different.ConclusionsOur study shows that robotic gastrectomy is a safe and feasible procedure, especially after the 20 initial cases, and provides a satisfactory postoperative outcome.

Is Single Port Access Laparoscopy Less Painful Than Conventional Laparoscopy for Adnexal Surgery? A Comparison of Postoperative Pain and Surgical Outcomes

To compare postoperative pain along with other surgical outcomes after transumbilical single port access (SPA) and conventional multiport laparoscopic surgery for adnexal lesions. Retrospective case-control study matched by age, body mass index, and frequency of previous abdominal surgery. Division of Gynecologic Oncology, Severance Hospital, South Korea – A Tertiary center. One hundred ten SPA laparoscopy patients (cases) were matched with a cohort of 107 patients that underwent conventional laparoscopy (controls) between October 2007 and May 2010. SpA system consisted of a wound retractor, surgical glove, two 5-mm trocars, and one 11-mm trocar. Postoperative pain scores were measured using the numerical rating scale. Postoperative pain scores did not differ between the two groups (P = .552). However, higher number of painkiller administration was observed in the SPA laparoscopy group (median 3 vs. 1, P < .001). Linear mixed model analysis showed no difference in pain intensity between the two groups over time (P = .440). The type of surgery and intraoperative blood loss were the significant factors influencing the number of painkiller administration after controlling for other parameters by linear regression (P < .0001). The SPA laparoscopy group had less intraoperative blood loss (45.3 mL vs. 87.5 mL, P < .001) and similar hospital stay (2.1 ± 0.8 vs. 2.7 ± 1.0 days, P < .001) compared with the conventional laparoscopy group. Operative time and perioperative complications did not differ between groups. Despite the common expectation that minimally invasive surgery may harbor less postoperative pain, there was no statistical difference in pain intensity between the SPA and conventional laparoscopic group in this study. Although SPA laparoscopy is a feasible method for adnexectomies with comparable surgical outcomes, future trials are warranted to better define the benefits of SPA surgery in terms of postoperative pain.

Evolution of surgical management of early-stage endometrial cancer

We sought to examine the evolution of surgical care for early-stage endometrial cancers and factors affecting use of laparoscopy. Women with surgically managed early-stage endometrial cancer were divided into 2 groups corresponding to before and after addition of faculty with formal fellowship training in laparoscopic staging and access to a robotic surgery platform. In all, 502 women were identified. Laparoscopic management increased from 24-69% between time periods (P < .0001). Performance of comprehensive surgical staging, and lymph node counts, increased (P < .0001) despite an increase in median body mass index (P = .001). A traditional "straight stick" technique was performed in 72% of laparoscopic cases during the later period. Laparoscopy patients had lower estimated blood losses and shorter hospital stays (each P < .0001) compared to laparotomy patients. Addition of faculty with formal fellowship training in laparoscopic staging and access to a robotic surgery platform shifted management of early-stage endometrial cancer toward laparoscopy.

Transition from open to robotic-assisted pediatric pyeloplasty: A feasibility and outcome study

PurposeLaparoscopic reconstructive procedures in the pediatric patient are associated with a steep learning curve. Outcomes from robotic-assisted pediatric urology have been reported by surgeons with known facility in laparoscopic surgery. We describe the experience of a single surgeon in transitioning from open to robotic-assisted laparoscopic pyeloplasty (RALP) without previous training in traditional laparoscopic pyeloplasty or intracorporeal suturing. Materials and MethodsWe reviewed our experience with 20 (mean age 7.4 years) consecutive children undergoing RALP for ureteropelvic junction obstruction at our institution over 36 months. Additionally, a literature search was conducted to identify age-similar patient groups who underwent open and laparoscopic pyeloplasty. ResultsLength of hospitalization and postoperative analgesia requirement were greater in the age-similar open pyeloplasty group compared to the other two groups. Intraoperative times were greater in the laparoscopic and RALP groups compared to the open pyeloplasty group. ConclusionsOur experience confirms the feasibility of transitioning from open to robotic-assisted laparoscopic pediatric pyeloplasty without previous experience in conventional laparoscopy. Outcomes, analgesic requirement and hospitalization for the patients from our institution are comparable to the laparoscopy patient group and improved compared to open pyeloplasty patients from the literature