Median Operative Time Research Articles

Efficacy, safety, and advantages of magnetic anchor–guided endoscopic submucosal dissection vs conventional endoscopic submucosal dissection: A retrospective paired cohort study

Endoscopic submucosal dissection (ESD) has been recommended as the first-line treatment for early gastric cancer (EGC). However, poor visualization of the operative field increases both the procedure time and the risk of complications, especially for large and difficult lesions. We introduced a novel technique, magnetic anchor-guided ESD (MAG-ESD) and compared it with conventional ESD (C-ESD) for the treatment of large EGCs in terms of efficacy, safety, and advantages. Patients with large EGCs who underwent MAG-ESD or C-ESD at the First Affiliated Hospital of Xi'an Jiaotong University from March 2020 to March 2022 were retrospectively enrolled in this study. The patients in the MAG-ESD cohort were matched to those in the C-ESD cohort using propensity score-based matching. The operation time, submucosal dissection time, complete resection status, magnetic anchor, adverse event rate, and tumor recurrence rate were evaluated. Twenty-two patients who underwent MAG-ESD were ultimately matched to those who underwent C-ESD. The median operation time of MAG-ESD and C-ESD was 43minutes (IQR, 35.2-49.5) and 50.5minutes (IQR, 42.0-76.0), respectively, among which the submucosal dissection time was 7.6minutes (IQR, 5.2-10.4) and 14.8minutes (IQR, 10.8-19.6), respectively. The operation time of MAG-ESD was shorter than that of C-ESD, especially the submucosal dissection time (P<.05). There was a lower incidence of adverse events associated with MAG-ESD (P<.05) when magnetic anchors were successfully placed and retrieved. MAG-ESD is feasible, effective, safe, and simple for the treatment of large EGCs at different sites and has a high anchor success rate, which could shorten the operation time and reduce the adverse event rate.

Comparison of Outcomes of the Open and Plastibell Methods in 600+ Boys Circumcised by a Single Surgeon-A Quasi-experimental Study from Pakistan (A Lower-middle Income Country)

Background: Circumcision is the most common elective surgical procedure amongst Muslims. The Plastibell method is gaining popularity as it is being considered safer with a lower complication rate. Objective: To compare the Open and Plastibell methods of circumcision in terms of procedural time, outcomes, and parental satisfaction in our cohort of boys up to 5 years of age. Methods: This quasi-experimental study of boys aged ≤5 years was conducted from July 2018 to October 2020 at THQ Ferozewala, Punjab. Boys meeting the inclusion criteria were circumcised, based on parental preference, by the Open method or the Plastibell technique after administering age-appropriate local or general anesthesia. Follow-up was conducted on the 5th, 10th, and 30th post-procedural days. Basic demographic data, procedural duration, and outcomes were documented. Results: Of 646 boys brought for circumcision, 608 met the inclusion criteria with equal participants in both groups. The median age in the Open and Plastibell groups was 3.0 (IQR=1.0-12.2) and 5.0 (IQR=2.0-9.0) months respectively. The Plastibell group had a significantly shorter median operating time compared to the Open method (4.2 min vs. 13 min; p-value: 0.008). Complications were recorded in 15% of children (n=91) and were more frequent but comparatively trivial in nature in the Plastibell group. Comparison of complications between the two methods revealed that the association of over-removal of skin was statistically significant (p-value: 0.007) with the Open method while under-removal of skin (p-value: 0.002) and post-operative phimosis (p-value: 0.037) were significantly associated with the Plastibell technique; the latter two complications being significantly associated with age of the boys in the ≥2 months to 1-year group. No serious adverse outcomes were reported for both groups. The open method was preferred by parents for cosmesis and Plastibell for ease of care. Follow-up contact was established with all families. Conclusion: Plastibell, compared to the Open method, is a quicker and safer method of circumcision for boys up to 5 years of age, under appropriate anesthesia. Follow-up ensures patient safety.

Is Intravenous Access Necessary in Pediatric Patients Undergoing Ophthalmologic Examinations Under Anesthesia? A Prospective Observational Study.

Ophthalmologic examinations under anesthesia (EUA) were employed in pediatric patients due to lower cooperation levels and associated discomfort during comprehensive eye examinations. There remains uncertainty regarding the necessity of intravenous (IV) placement during general anesthesia. The primary aim of the study is to investigate the impact of general anesthesia, with and without IV access, on operation time in pediatric patients undergoing EUA. Secondary objectives include assessing cardiovascular and respiratory complications and measuring parental satisfaction in both the IV and No IV groups. This prospective observational analytic study, conducted as a cross-sectional study, took place between October 2019 and October 2020, in Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Thailand. We included healthy pediatric patients aged 2 to 7 years undergoing elective ambulatory EUA. Eighty-two patients, with 41 in the IV group and 41 in the No IV group, were enrolled and included for analysis. The No IV group showed a significantly shorter median operation time (7.99 (6.63, 9.36) minutes) compared to the IV group (10.9 (9.05, 12.28) minutes), with a median difference of -2.74minutes (95% CI -3.76, -1.69, p < 0.001). In both groups, no cardiovascular or respiratory complications occurred, and there was no need for emergency IV access or drug administration. Children without IV access had higher parental satisfaction in extreme satisfaction (100% vs 48.78%; p < 0.001). Providing general anesthesia for EUA without IV access in healthy pediatric patients, leading to shorter operation times and heightened parental satisfaction, can be conducted safely. The trial registration number is TCTR20191021001 from the Thai Clinical Trials Registry.

Is operation time over the benchmark value a risk factor for worse short-term outcomes after laparoscopic liver resection?

Laparoscopic liver resection is a challenging surgical procedure that may require prolonged operation time, particularly during the learning curve. Operation time significantly decreases with increasing experience; however, prolonged operation time may significantly increase the risk of postoperative complications. To assess whether prolonged operation time over the benchmark value influences short-term postoperative outcomes after laparoscopic liver resection. A retrospective cohort study based on data from the National Polish Registry of Minimally Invasive Liver Surgery was performed. A total of 197 cases consisting of left lateral sectionectomy (LLS), left hemihepatectomy (LH), and right hemihepatectomy (RH) with established benchmark values for operation time were included. Data about potential confounders for prolonged operation time and worse short-term outcomes were exported. Most cases (129; 65.5%) were performed during the learning curve, while the largest rate was observed in LLS (57; 78.1%). Median operation time exceeded the benchmark value in LLS (Me = 210 min) and LH (Me = 350 min), while in RH the benchmark value was exceeded in 39 (44.3%) cases. Textbook outcomes were achieved in 138 (70.1%) cases. Univariate analysis (OR = 1.11; 95% CI: 0.61-2.06; p = 0.720) and multivariate analysis (OR = 1.16; 95% CI: 0.50-2.68; p = 0.734) did not reveal a significant impact of prolonged surgery on failing to achieve a textbook outcome. Prolonging the time of laparoscopic liver resection does not significantly impair postoperative results. There is no reason related to the patients' safety to avoid prolonging the time of laparoscopic liver resection over the benchmark value.

Simultaneous Single-Position Oblique Lateral Interbody Fusion Combined With Unilateral Percutaneous Pedicle Screw Fixation for Single-Level Lumbar Tuberculosis: A 3-Year Retrospective Comparative Study.

To illustrate a simultaneous single-position oblique lateral interbody fusion (SPOLIF) combined with unilateral percutaneous pedicle screw fixation in treating single-level lumbar tuberculosis, compared with posterior-only approach in clinical and radiographic evaluations. Consecutive patients who had undergone surgeries for single-level lumbar tuberculosis from January 2018 to December 2020 were retrospectively reviewed. The patients included were divided into SP-OLIF and posterior-only groups according to surgical methods applied, with follow-up for at least 36 months. Outcomes included estimated blood loss, operative time, and complications for safety evaluation; visual analogue scale (VAS), Oswestry Disability Index (ODI) for efficacy evaluation; erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) for evaluating tuberculosis activity; x-ray and computed tomography scan were used for radiographic evaluation. A total of 136 patients had been enrolled in the study (60 for SP-OLIF and 76 for Posterior-only). The median operative time, blood loss, and hospital stay in SP-OLIF group were significantly less, with a lower complication rate. Meanwhile, the SP-OLIF group showed substantially lower VAS in 1 and 7 days and decreased ODI in the first month postoperatively, without significant difference afterward. Similarly, the median CRP and ESR in SP-OLIF group were significantly lower in 3 and 7 days postoperatively. All indicators had reduced to normal after 3 months. No recurrence had been reported throughout the whole follow-up. SP-OLIF was an efficient minimally invasive protocol for single-level lumbar tuberculosis, facilitating earlier clinical improvement, with decreased blood loss, operative time and hospital stay compared with posterior-only approach.

Indocyanine Green (ICG) Fluorescence-Assisted Open Surgery Using the Rubina® Lens System in the Pediatric Population: A Single-Center Prospective Case Series.

There are scarce papers about the use of fluorescence-guided surgery (FGS) in the open surgical field. This study aimed to assess the usefulness of FGS in an open setting in the pediatric population and to report our preliminary experience using the Rubina® Lens system. All patients undergoing ICG fluorescence-assisted open surgery over the period September 2022-September 2023 were enrolled. Each surgical procedure was performed using the Rubina® Lens for ICG fluorescence visualization. A total of 25 patients, 14 boys and 11 girls with a median age at surgery of 5.8 years-old (range 0-15), were enrolled. Surgical indications were dermoid/epidermoid cysts of the head (n = 7), lymphangiomas of the head/neck (n = 2), thyroglossal duct cysts (n = 7), gynecomastia (n = 3), preauricular fistula (n = 2), second branchial cleft fistula (n = 1), fibrolipoma of the shoulder (n = 1) and myofibroma of the gluteal/perineal region (n = 2). In all procedures, an intralesional injection of 2.5 mg/mL ICG solution using a 30-gauge needle was administered. No adverse reactions to ICG occurred. Median operative time was 68.6 min (range 35-189). The visualization of ICG-NIRF with the Rubina® Lens was achieved in all cases. No intraoperative complications were reported. Postoperative complications occurred in 3/25 patients (12%), with gynecomastia (n = 1), thyroglossal duct cyst (n = 1) and neck lymphangioma (n = 1), who developed a fluid collection in the surgical site, requiring needle aspiration in outpatient care (Clavien-Dindo 2). Complete mass excision was confirmed with pathology reports. Based on this initial experience, FGS using the Rubina® Lens was very helpful in open surgery, providing enhanced visualization of anatomy and identification of margins, real-time reliability and low complication rate. It was easy to use, time saving, feasible and clinically safe. Previous experience in MIS is necessary to adopt this technology. The accuracy of the injection phase is important to avoid diffusion of the ICG into the perilesional tissue.

Use of Barbed Sutures for Congenital Diaphragmatic Hernia Repair.

Congenital diaphragmatic hernia (CDH) repair can be challenging, particularly when a larger defect is present. Barbed sutures prevent the suture from slipping back after approximation of the tissues. Although introduced almost 2 decades ago, barbed sutures have not been widely used for CDH repair. We report our initial experience and pitfalls. All patients presenting with CDH from 2021 onward underwent repair using barbed sutures. Demographics, operative parameters, complications, and outcomes were prospectively recorded. A total of 13 patients underwent CDH repair during the study interval (median age 6 days, range 3 days to 5.75 years). Median operative time was 89 min (range 46 to 288 min). Five thoracoscopic and eight open procedures were performed. Severe pulmonary hypertension and ECMO (extracorporeal membrane oxygenation) were considered contraindications for thoracoscopic repair. The included patients were compared to a historic controlled group performed without barbed sutures. The barbed suture facilitated easy and quick closure of the defects in most cases and obviated the need for knot tying. One patient in the thoracoscopic group had a patch placed due to high tension after the barbed sutures tore the diaphragm. At a median follow-up time of 15 months (range 2 to 34 months), one patient had died, and one patient with complete diaphragmatic agenesis was home-ventilated. There were no recurrences. Median operative time trended lower (89 min) than in the historic control group repaired without barbed sutures (119 min, p < 0.06) after eliminating outliers with large, complex patch repairs. Barbed sutures simplify congenital diaphragmatic hernia repair regardless of whether a minimal-invasive or open approach is performed. Patch repair is not a contraindication for using barbed sutures. The resulting potential time savings make them particularly useful in patients with cardiac or other severe co-morbidities in which shorter operative times are essential. In cases with high tension, though, the barbs may tear through and produce a "saw" effect on the tissue with subsequent damage.

Extracapsular dissection via single cervical incision for parotid pleomorphic adenoma.

Surgical management of parotid pleomorphic adenoma ranges from total parotidectomy to extracapsular dissection (ECD). Minimalistic techniques aim to preserve function and minimize the rate of recurrence. This study assesses functional, aesthetic, and disease control outcomes post-ECD through a sole transverse cervical incision for parotid pleomorphic adenoma. This longitudinal analysis enrolled 36 consecutive patients with pleomorphic adenoma who underwent ECD via a single cervical incision. Complications, satisfaction, salivary function, and tumor recurrence were evaluated. Salivary gland function was assessed using scintigraphy at 6 months post-surgery. Tumors occurred in superficial (83%) or deep (17%) parotid inferior parts according to the European Salivary Gland Society level classification. The median tumor size was 2.8 cm (1.8-6.0 cm); the median operation time was 42 min (30-65 min). No tumor spillage or facial nerve injuries occurred. Facial nerve paralysis was only temporary in two (6%) patients, with minimal other complications. Operated parotid gland function matched the unoperated side. No recurrence was found during the median follow-up of 44 months (24-60 months). ECD via a single transverse cervical incision is a safe approach for benign parotid tumors, yielding excellent functional and disease control outcomes. These findings can provide clinically meaningful minimally invasive recommendations to treat pleomorphic adenoma with minimal complications.

Surgical Outcomes of Modified Technique for Transcutaneous Bone Conduction Hearing Aid Implantation.

To detail a modified surgical technique for implantation of the Osia 2 Bone Conduction Hearing Aid (BCHA) system and to assess intra- and postoperative outcomes of this technique. A retrospective review was performed for cases undergoing implantation of an Osia 2 BCHA at a tertiary academic medical center. Modifications were made to the surgical procedure including: horizontal or curvilinear incisions, placement of the osseointegrated screw slightly superior to the plane of the external auditory canal, and double layer wound closure. Data regarding outcomes including demographics, incision type, surgical time, drilling requirements, and complications were collected using the electronic medical record. A total of twenty-eight cases were evaluated with 57.1% and 42.9% utilizing horizontal and curved incisions, respectively. The median age for recipients was 43.1 years with six pediatric cases included in the study. Median operative time was 58 min (43-126 min). The majority of cases required minimal (60.7%) or no drilling (28.6%) with a significant increase in operative time for those requiring moderate drilling versus minimal to no drilling (F = 8.02, p = 0.002). There were no intraoperative complications. One (3.6%) postoperative seroma occurred which resolved with conservative management. The proposed modified surgical technique is a safe and effective method for implantation of the transcutaneous BCHA system with a low complication rate. Keys include incision design, implant placement, and two-layered closure to minimize wound tension. These modifications can improve ease of the procedure and reduce operative time. These techniques also appear to be applicable to the pediatric population. 3 Laryngoscope, 134:2401-2404, 2024.

Robot-assisted resection of benign splenic tumors in children

PurposeRobotic surgery is becoming increasingly widely used in the field of pediatric surgery. The present study aimed to evaluate the safety and feasibility of robot-assisted resection of benign pediatric splenic tumors and to discuss the technical points.MethodsA total of 32 patients who were diagnosed with benign splenic tumors and underwent minimally invasive surgery from January 2017 to September 2023 were included in the study. The clinical data including demographic criteria, operative details, and postoperative outcomes were analyzed retrospectively.ResultsThirteen patients underwent robot-assisted surgery, and 19 patients underwent laparoscopic surgery. The median operation time was 150 min, with an interquartile range (IQR) of 120 to 200 min for the robot-assisted group and 140 min with an IQR of 105 to 180 min in the laparoscopic group (P = 0.318). Despite four cases in the laparoscopic group (21%) being converted to laparotomy because of intraoperative bleeding, compared with none in the robot-assisted group, there was no significant difference between two groups (P = 0.128). The intraoperative volume of blood loss was significantly less (P = 0.041), and the hospitalization expense was significantly higher (P = 0.000) in the robot-assisted group than for the laparoscopic group. There was no significant difference in patients’ age, tumor size, postoperative feeding time, and the postoperative hospitalization time between two groups (P > 0.05).ConclusionRobot-assisted benign splenic tumor resection was safe and feasible, and it reduced surgical trauma for the pediatric patient.

Effect of Interpectoral-Pectoserratus Plane (PECS II) Block on Recovery Room Discharge Time in Breast Cancer Surgery.

Background and Objectives: The increase in the incidence and diagnosis rate of breast cancer demands the optimization of resources. The aim of this study was to assess whether the supplementation of the interpectoral-pectoserratus plane block (PECS II) reduces surgery and post-anesthesia care unit (PACU) time in patients undergoing breast cancer surgery. Materials and methods: This was a retrospective data-analysis study. In 2016, PECS II block was introduced as a supplement to general anesthesia for all mastectomies with or without axillary resections in South Jutland regional hospital, Denmark. The perioperative data of patients operated 3 years before and 3 years after 2016 was retrieved through the Danish anesthesia database and patient journals and systematically analyzed. Female patients aged over 18 years, with no use of muscle relaxant, intubation, and inhalation agents, were included. The eligible data was organized into two groups, i.e., Block and Control, where the Block group received PECS II Block, while the Control group received only general anesthesia. Parameters such as surgery time, anesthesia time, PACU time, opioid consumption, and the incidence of postoperative nausea and vomiting (PONV) in PACU were retrieved and statistically analyzed. Results: A total of 172 patients out of 358 patients met eligibility criteria. After applying exclusion criteria, 65 patients were filtered out. A total of 107 patients, 51 from the Block and 56 from the Control group, were eligible for the final analysis. The patients were comparable in demographic parameters. The median surgery time was significantly less in the Block group (78 min (60-99)) in comparison to the Control group (98.5 min (77.5-139.5) p < 0.0045). Consequently, the median anesthesia time was also shorter in the Block group (140 min (115-166)) vs. the Control group (160 min (131.5 to 188), p < 0.0026). Patients from the Block group had significantly lower intraoperative fentanyl consumption (60 µg (30-100)) as compared with the Control group (132.5 µg (80-232.5), p < 0.0001). The total opioid consumption during the entire procedure (converted to morphine) was significantly lower in the Block group (16.37 mg (8-23.6)) as compared with the Control group (31.17 mg (16-46.5), p < 0.0001). No statistically significant difference was found in the PACU time, incidences of PONV, and postoperative pain. Conclusions: The interpectoral-pectoserratus plane (PECS II) block supplementation reduces surgery time, anesthesia time, and opioid consumption but not PACU time during breast cancer surgery.

Robotic Lateral Pelvic Lymph Node Dissection in Rectal Cancer: A Feasibility Study from a European Centre.

The role of robotic lateral pelvic lymph node dissection (LPLND) for lateral pelvic nodal disease (LPND) in rectal cancer has yet to be investigated in the Western hemisphere. This study aims to investigate the safety and feasibility of robotic LPLND by utilising a well-established totally robotic TME protocol. We conducted a retrospective study on 17 consecutive patients who underwent robotic LPLND for LPND ± TME for rectal cancer between 2015 and 2021. A single docking totally robotic approach from the left hip with full splenic mobilisation was performed using the X/Xi da Vinci platform. All patients underwent a tri-compartmental robotic en bloc excision of LPND with preservation of the obturator nerve and pelvic nerve plexus, leaving a well-skeletonised internal iliac vessel and its branches. The median operative time was 280 min, which was 40 min longer than our standard robotic TME. The median BMI was 26, and there were no conversions. The median inpatient stay was 7 days with no Clavien-Dindo > 3 complications. One patient (6%) developed local recurrence and metastatic disease within 5 months. The proportion of histologically confirmed LPND was 41%, of which 94% were well to moderately differentiated adenocarcinoma. Median pre-operative lateral pelvic node size was significantly higher in positive nodes (14 mm vs. 8 mm (p = 0.01)). All patients had clear resection margins on histology. Robotic LPLND is safe and feasible with good peri-operative and short-term outcomes, with the ergonomic advantages of a robotic TME docking protocol readily transferrable in LPLND.

Clinical application effect of pedunculated rectus abdominis muscle combined with bilateral ureters for repairing refractory bladder-vaginal stump fistula through external vesical drainage

Objective: To investigate the efficacy and safety of pedunculated rectus abdominis combined with bilateral ureteral extravestheter drainage in the treatment of refractory bladder-vaginal stump fistula. Methods: The clinical data of 8 cases of the refractory bladder-vaginal stump fistula were admitted to the Second Hospital of Hebei Medical University and Henan Cancer Hospital and underwent the clinical treatment of bladder-vaginal stump from December 2019 to December 2022 were collected. The reason of refractory bladder-vaginal stump fistula was analyzed, the operation manner of pedunculated rectus abdominis combined with peduncle and bilateral ureter for the treatment of bladder-vaginal stump through extrabladder drainage was explored. The operation time, bleeding volume and clinical effect were record. Results: The median operation time of 8 patients was 150 minutes(120~180 min), and the median blood loss was 400 ml(200~600 ml). During the perioperative period, there were 2 cases of incision infection, delayed healing by debridement and dressing, 2 cases of incision rupture and suture wound healing after reoperation, and 2 cases of urinary tract infection were cured by anti-infection. When followed up for 6 months, 8 cases of vesicovaginal stump fistula were cured. Conclusion: Bilateral ureteral external drainage of the rectus abdominis muscle, has a practical effect in the treatment of refractory bladder-vaginal stump fistula, which can be one of the clinical repairing treatment.

Initial experience of robotically assisted endometriosis surgery with a novel robotic system: first case series in a tertiary care center.

Endometriosis is a benign disease requiring surgery if medical treatment cannot achieve symptom control. Laparoscopy remains the gold standard and robotic assistance can be beneficial in complex cases. Robot-assisted radical endometriosis excision using the Hugo™ RAS system is a novel approach. The aim of this study is to describe its setting and outcomes in a series of patients in a robotic surgery center. Endometriosis patients who consecutively underwent robot-assisted surgery with the Hugo™ RAS system (Medtronic, USA) were retrospectively enrolled. Disease-specific symptoms before and after surgery, endometriosis stage, as well as perioperative and intraoperative variables including system setup were collected. Early post-operative complications (< 30days) and follow-up (up to 3months) were reported. All procedures were completed robotically. Port placement followed the "bridge" configuration with a "compact" docking. The median operative time was 186.5min (IQR 174-220), the median estimated blood loss 50ml (IQR 0-100). An intraoperative complication occurred in one patient (6.6%), a bladder laceration with postoperative antibiotic treatment. The median lenght of hospital stay (LOS) was 3days (IQR 3-4). Surgery achieved a statistically significant decrease in symptoms: mean dysmenorrhea (9.50 ± 0.83 versus 1.7 ± 2.26; p = 0.001), dyschezia (4.27 ± 3.61 versus 2.40 ± 2.92; p = 0.026), dysuria (2.73 ± 3.39 versus 1.87 ± 2.41; p = 0.358), dyspareunia (6.53 ± 3.15 versus 2.93 ± 2.89; p = 0.002) and chronic pelvic pain (8.8 ± 1.20 versus 3.20 ± 2.39; p = 0.001). The integration of this platform in the described configuration was safe with regular perioperative outcomes and significant improvement in symptoms. Prospective comparative studies with a larger cohort and longer follow-up are needed to assess potential advantages over the current gold standard.

Keyhole Fenestration for Cerebrospinal Fluid Leaks in the Thoracic Spine: Quantification of Bone Removal and Microsurgical Anatomy

BACKGROUND AND OBJECTIVE: A safe working trajectory is mandatory for spinal pathologies, especially in the midline, anterior to the spinal cord. For thoracic cerebrospinal fluid (CSF) leaks, we developed a minimally invasive keyhole fenestration. This study investigates the necessary bone removal for sufficient exposure of different leak types particularly regarding weight-bearing structures. METHODS: In this retrospective case series between January 2022 and June 2023, the volume of bone resection and the axial and sagittal diameter of hemilamina defects after closure through keyhole fenestration were quantified. The involvement of facet joints and pedicles was qualitatively rated. Demographic (age, sex, body mass index, leak type) and surgical data (blood loss, surgery time, discharge after surgery) and complications were analyzed. RESULTS: Thirty-three patients with 34 approaches were included. The volume of resected bone was 1.5 cm3, and the diameter of the hemilamina defect was 17.8 mm in the sagittal and 15.1 mm in the axial plane. Facet joints were uninvolved in 24% and partly resected in 74%, and one facet joint was resected completely. Pedicles remained intact in 71% and were minimally involved in 29%. The median surgery time was 93 minutes, blood loss was 45 mL, and discharge was 4 days after surgery. Three patients (9%) needed revision surgery. No relevant and persisting morbidity occurred. Within the median follow-up period of 10 months, no stabilizing surgery was necessary. No permanent neurological deficit occurred. CONCLUSION: The keyhole fenestration leaves weight-bearing structures like facet joints and pedicles intact in most cases. The limited, penny-sized bone resection is sufficient to reach and close thoracic CSF leaks Type 1, 2, and 3 from the anterior midline to the ganglion. For experienced centers, it is a universal minimally invasive approach for treating all CSF leaks.

Efficacy of endoscopic submucosal dissection assisted by metal-clip pocket creation traction for colorectal tumors

To evaluate the clinical efficacy of endoscopic submucosal dissection (ESD) assisted by metal-clip pocketcreation traction for treatment of colorectal tumors. We retrospectively analyzed the clinical data of 244 patients with colorectal tumors undergoing colorectal ESD treatment between January, 2019 and December, 2022, including 169 patients receiving ESD without metal-clip pocket-creation traction (N-ESD group) and 75 with traction-assisted ESD (M-ESD group). Propensity score matching was used to screen the patients using general clinical data as the covariates for matching. Operative time, surgical resection outcome indicators, incidence of adverse events, and histopathological diagnosis indicators were compared between the two groups of patients after matching. The median operative time was significantly shorter in M-ESD group than in N-ESD group (20.0 [15.0, 30.0] vs 30 [20.0, 45.0] min, P=0.008). No significant difference was found in the en bloc resection rate (100% vs 98.6%), complete resection rate (97.3% vs 96%) and radical resection rate (97.3% vs 96%) between the two groups (P>0.05). The incidence of adverse events was low in both groups and showed no significant difference between them (P>0.05). In patients with colorectal tumors, the use of metal-clip pocket-creation traction can shorten the operative time of ESD although it does not significantly reduce the surgical resection rate or incidence of adverse events.

Parenchyma Sparing Anatomic Liver Resections (Bi- and Uni-Segmentectomies) for Liver Tumours in Children-A Single-Centre Experience.

This study included 23 patients that underwent (bi)segmentectomy. There were 15 malignant tumours (hepatoblastoma-13 patients), 7 benign tumours, and 1 calcifying nested stromal epithelial tumour. The median tumour diameter was 52 mm (range 15-170 mm). Bisegmentectomy 2-3 was most frequently performed (seven patients), followed by bisegmentectomy 5-6 (four patients). The median operative time was 225 min (range 95-643 min). Intraoperative complications occurred in two patients-small bowel perforation in one and an injury of the small peripheral bile duct resulting in biloma in the other. The median resection margin in patients with hepatoblastoma was 3 mm (range 1-15 mm). Microscopically negative margin status was achieved in 12 out of 13 patients. There were two recurrences. After a median follow-up time of 38 months (range 12-144 months), all 13 patients with HB were alive with no evidence of disease. Two relapsed patients were alive with no evidence of disease. From the available literature and data presented here, we propose that (bi)segmentectomy can become a viable surgical option in carefully selected paediatric patients and is sufficient to achieve a cure. Further studies evaluating the impact of parenchymal preservation surgery on surgical and oncological outcome should be conducted with a larger dataset.

Streamlining robotic-assisted abdominoperineal resection

BackgroundRobot-assisted surgery has proven to be a safe and feasible approach for the management of rectal cancer, including abdominoperineal resection (APR). However, it often incurs longer operative times and higher costs. This study aimed to overcome these limitations by adopting a synchronous approach utilizing an optimized team composition.MethodsData on patients who underwent robot-assisted APR at our facility between June 2022 and June 2023 were analyzed. The key points of the optimized approach included the following: At the start of the surgery, the surgeon performed an anococcygeal ligament resection from the perineal side while the bedside assistants set up the ports. Then, through console manipulation, the presacral fascia, elevated by previously placed gauze, was easily and safely incised, providing access to the perineal region.ResultsA total of nine patients were included in this study. The median operation time was 231 min, and the intraoperative blood loss was 170 ml. The operation time was reduced to 167.5 min, and the blood loss was 80.5 ml in cases without a trainee. Surgical site infections, classified as Clavien–Dindo grade II complications, were observed in two cases, but no obvious urinary or erectile dysfunction was observed.ConclusionThe study results indicate that the challenges associated with APR can be efficiently addressed without requiring additional personnel by streamlining team composition and the synchronous approach. This optimization strategy minimizes the need for a larger surgical team, while maximizing the utilization of surgical time and resources.

Laparoscopic partial nephrectomy in obese patients: how can the body mass index influence the surgical and functional outcomes?

Objective: To evaluate the impact of body mass index (BMI) on surgical and functional outcomes of laparoscopic partial nephrectomy (LPN) for T1 renal tumors. Patients and methods: In this single-center retrospective study, 240 consecutive patients underwent LPN for localized, incidentally discovered renal masses of &lt; 7 cm (cT1). Patients were categorized into four groups according to their BMI, as follows: group 1, normal weight (BMI &lt; 25 kg/m2 ); group 2, overweight (BMI 25–29.9 kg/m2 ); group 3, obese (BMI 30–39.9 kg/m2 ); and group 4, morbidly obese (BMI ≥ 40 kg/m2 ). Results: Median operative time presented no statistically significant differences between BMI groups, whereas estimated blood loss was higher in morbidly obese patients than in all other groups. Warm ischemia time (WIT) and changes in eGFR were not influenced by the BMI groups but a decrease in the WIT was reported in obese and morbidly obese patients when an early unclamping technique (EUT) was used. An increase in BMI was not significantly associated with the occurrence of postoperative complications. In fact, the median complication rate was 3.3% for normal BMI, 4.5 % for overweight patients, 4.8% for obese patients, and 3.6% for morbidly obese patients. Conclusion: LPN could be considered a viable treatment option for renal masses amenable to nephron-sparing surgery in patients with higher BMI. An EUT should always be used in obese and morbidly obese individuals, considering the statistically significant decrease in WIT and the higher risk of chronic renal insufficiency in these patients.

Midterm outcomes of rotational atherectomy-assisted endovascular treatment of severe peripheral arterial disease

ObjectiveWe evaluated the midterm results of atherectomy-assisted angioplasty for the treatment of femoropopliteal lesions and the identification of possible subgroups of patients with superior outcomes. MethodsWe conducted a single-center, physician-initiated, nonindustry-sponsored retrospective analysis of patients with Rutherford category ranging from II to V and de novo occlusive or stenotic lesions of the superficial femoral (SFA) and/or popliteal arteries treated with atherectomy-assisted angioplasty (Jetstream rotational atherectomy + drug-eluting ballooning). In cases of subintimal recanalization or patients without an SFA stamp, with previous ipsilateral bypass surgery, systemic coagulopathy, end-stage renal disease requiring hemodialysis, life expectancy of <12 months, and intolerance to aspirin, clopidogrel, and/or heparin were excluded. ResultsIn a total of 103 enrolled patients, the median SFA and/or popliteal lesion length was 80 mm (interquartile range, 61.2 mm) with 73 lesions being occlusive (70.9%) and 84 (81.5%) classified as Fanelli calcification score 3 and 4. Technical success was met in 96.1% of cases (n = 99) at a median operative time of 108 minutes. Adjunctive stenting was needed in 10 patients (9.8%). At a median follow-up of 18.0 ± 10.8 months, Rutherford class clinical improvement was present in 77 patients (74.8%), and 7 patients (6.79%) presented target lesion occlusion needing reintervention in 6 cases (5.82%). The primary patency rates were 97% at 12 months and 83% at 24 months with secondary patency rates of 99% at 12 months and 91% at 24 months of follow-up. There were no significant differences when treating differently located lesions, diabetic vs nondiabetic patients, or comparing experienced vs nonexperienced operators. ConclusionsThe use of rotational atherectomy and drug-eluting balloons for the treatment of severe femoropopliteal disease showed relatively low need for bailout stenting and good midterm primary patency rates. The influence of lesion location, diabetes mellitus, or operator experience did not show statistically different results in terms of patency. Longer term outcomes and comparative analysis are needed to consolidate further clinical evidence.