Minimal Access Techniques Research Articles

O-114 The use of robotic surgery in the management of uterine fibroids

Abstract “Optimizing Robotics in the Surgical Management of Uterine Fibroids” Uterine leiomyomas are very common, occurring in up to 80% of reproductive-aged women. Over half of women with uterine leiomyomas are symptomatic, with the majority presenting with abnormal uterine bleeding, bulk symptoms, pelvic pain, recurrent pregnancy loss, and even infertility thereby posing a significant health burden. Management of uterine leiomyomas can be organized into four different categories: expectant, medical, interventional, and surgical. For those who are symptomatic and desiring fertility-preservation/optimization or simply a uterine-sparing procedure, myomectomy is the principal intervention. Historically performed via laparotomy, the advent of minimal access techniques introduced the laparoscopic approach to myomectomy. However, the technical challenges of enucleating the fibroid along the correct dissection plane and performing a subsequent multilayered hysterotomy closure made widespread adoption of conventional laparoscopic myomectomy difficult. This difficulty is only further compounded in patients with multiple leiomyomas (due to multiple hysterotomy incisions requiring suturing), difficult locations (i.e. posterior, cervical, broad ligament), and those of a large size and transmural that often are proximal to the endometrial cavity and require a multi-layered closure. As a result, robot-assisted laparoscopic myomectomy has become an essential part of the surgical armamentarium for a growing number of reproductive surgeons around the world. It was only natural that robotics would be applied as an alternative approach to overcome the limitations of conventional laparoscopy. The key features of robotics that make its application to myomectomy appealing are the improved ergonomics, enhanced three-dimensional depth perception and the 7 degrees of freedom and wristed articulation of its instruments which make the robot an excellent tool for performing suture-intensive procedures such as myomectomy. This presentation will focus on the optimized surgical approach to uterine leiomyomas via a robot-assisted laparoscopic myomectomy in addition to current techniques in contained tissue extraction. The appropriate workup and preparation recommended prior to performing a robot-assisted laparoscopic myomectomy will be addressed in addition to demonstrating various surgical principles and best-practice techniques unique to robotics.

Kidney Transplantation: Our Experience in a Private Tertiary Center in Abuja

<i>Introduction:</i> The success of kidney transplantation depend on the effectiveness in certain key factors including excellent donor compatibility, immunosuppression and good surgical techniques. Exciting prospects in kidney transplantation is envisaged especially with the launching of standards and guidelines for the establishment and coordinating organ/tissue transplantation services by the Federal Government of Nigeria in March, 2025. We have come a long way with our five year experience in kidney transplantation. The use of branded immunosuppressive agents, excellent HLA/DSA typing and compatibility as well as ‘top notch’ surgical and medical team of experts have exponentially achieved a favorable outcome. Challenges are not unusual but we are hopeful that the future is promising and will offer more advancement in ‘tips and tricks’ of successful lifelong kidney transplantation. We report our experience in kidney transplantation over a 5 year period in our center. <i>Methodology: </i>This is a retrospective cohort study involving patients who had kidney transplantation in our facility over a 5 year period from January 2020 to December 2024. A proforma was designed to obtain existing records from our data base. Data analysis was conducted using Python with its libraries including Pandas, Numpy and Matplotib. P value of less than 0.05 was considered statistically significant. <i>Results:</i> Descriptive Statistics showed that a total of 104 patients had kidney transplantation surgery over the prescribed period. 66.35% were males while 33.65% were females. The average age of recipients was 46.27 years with a range of 24 to 72 years while the average age donors was 26.12 years with a range of 18 to 50 years. The average length of hospital stay after donor nephrectomy was 4.14 days while the average length of hospital stay for recipients post-surgery was 9.50 days with a range of 7-12 days. The etiology of renal failure were mainly long-term hypertension in 38.46%, diabetic mellitus in 29.81%, combination of both comorbid condition in 28.85%, autoimmune disease in 1.92% and genetic factor in 0.96%. Prognosis six months post-surgery was good in 82.69% and only 17.31% had unfavorable outcome. No donor mortality was observed. <i>Conclusion:</i> We have come a long way with our 5 years experience in management of end stage kidney disease in tropical Africa with excellent outcome. Though challenges are inevitable, the future still hold a promising exiting prospects as we envisage progressive experience and welcome new innovations including the use of minimal access techniques to achieve improved results.

Emergency Minimally Invasive Surgery for Obturator Hernias: A Systematic Review.

Despite their rarity, obturator hernias pose significant clinical challenges due to their high complication rate and frequent emergency presentation. While minimally invasive surgery has proven effective and safe for elective groin hernia repair, its application in emergency settings, particularly for obturator hernias, lacks robust evidence, highlighting a critical knowledge gap in this area. This systematic review aims to evaluate the feasibility of a minimally invasive approach for the repair of obturator hernias in emergency settings. A systematic review was conducted searching PubMed, OVID, MEDLINE, Embase, and Cochrane reviews for ((obturator hernia) AND (laparoscop* OR minimal access OR robotic)) AND (strangulat* OR obstruct* OR incarcerat*). The time of the literature is from the establishment of each database to 1 September 2023. Critical appraisal used the Joanna Briggs Institute (JBI) appraisal checklist. A systematic review of 337 manuscripts identified 47 relevant studies, including 39 case reports, 4 case series, and 4 retrospective studies. Minimally invasive approaches, particularly totally extraperitoneal (TEP), transabdominal preperitoneal (TAPP), and the Kugel procedure, demonstrated favourable outcomes for obturator hernias, including shorter operative times, reduced hospital stays, low recurrence rates, effective management of complications, and improved diagnostics, with success dependent on timely intervention, bowel viability, and patient selection. The findings suggest that minimal access surgery can effectively avoid unnecessary laparotomy for hernial content assessment, particularly when employing the TAPP approach. While emergency repair of obturator hernias using minimal access techniques appears feasible and safe, achieving outcomes comparable to open surgery requires further high-quality evidence. PROSPERO: CRD42024503724.

EP39 Emergency Minimally Invasive Surgery for Obturator Hernias: A Systematic Review of the Literature

Abstract Background Despite their rarity, obturator hernias pose significant clinical challenges due to their high complication rate and frequent emergency presentation. While minimally invasive surgery has proven effective and safe for elective groin hernia repair, its application in emergency settings, particularly for obturator hernias, lacks robust evidence, highlighting a critical knowledge gap in this area. Methods A systematic review was conducted searching PubMed, OVID, Embase, and Cochrane reviews for ((Obturator hernia) AND (laparoscop* OR minimal access OR robotic)) AND (strangulat* OR obstruct* OR incarcerat*). Results A systematic review of 337 manuscripts identified 47 relevant studies, including 39 case reports, 3 case series, and 5 retrospective studies. Conclusion The findings suggest that minimal access surgery can effectively avoid unnecessary laparotomy for hernial content assessment, particularly when employing the TAPP approach. While emergency repair of obturator hernias using minimal access techniques appears feasible and safe, achieving outcomes comparable to open surgery requires further high-quality evidence.

Minimally invasive thymectomy for patients with thymoma: surgical, oncological and neurological outcomes.

Traditionally, sternotomy has been the gold standard approach for the treatment of thymomas. However, interest in minimally invasive techniques such as video-assisted and robot-assisted thymectomy is gaining momentum. Concerns have been raised over the possibility of en-bloc resection using minimal access techniques due to limited working space and increased tumour manipulation leading to tumour breach and recurrence. An observational cohort study was conducted at a tertiary referral centre from 1 April 2012 to 31 December 2020 and followed up until 31 March 2023. Consecutive patients of thymoma were evaluated for demography, symptoms and imaging preoperatively and included for the study. Post minimally invasive thymectomy, surgical, neurological and oncological outcomes were evaluated through out-patient and telephonic follow-up. Fifty-two patients underwent minimally invasive thymectomy. Video-assisted thoracoscopic surgery for thymectomy was used in 49 patients (94.2%) with 3 (5.8%) patients undergoing robot-assisted thoracoscopic surgery. Median tumour size was 4cm (interquartile range (IQR)3-5) with a median operative duration of 150min (IQR 120-180), blood loss of 135ml (IQR 42.5-250), post-operative stay of 3days (IQR 2-4) and no 30-day surgery related morbidity and mortality. Annual contrast-enhanced computed tomography imaging, available in 46 (88.5%) patients, showed no recurrence at a median follow-up of 43 (IQR, 21-75) months. No symptoms suggesting recurrence was noted at a median clinical follow-up of 57 (IQR 44-95.5) months and 88.5% patients were expected to survive a period of 10years. Minimally invasive thymectomy is technically feasible with minimal morbidity and acceptable intermediate-term oncological outcomes in patients suffering with thymoma. Institute ethical committee approval: Ref no. IECPG-551/14.11.2018.Clinical Trial Registry of India: Ref no. CTRI/2019/04/018784.

Clinical, radiological and surprise diagnosis of femoral hernia

The author has treated three cases of femoral hernias over the years. Femoral hernias are rare compared to inguinal hernias. Here, there were varied clinical presentations of all femoral hernias. Obstruction, strangulation and groin swelling were the presentations observed. Management of all varies according to presentation. Because of narrow neck and stiff femoral canal chances of complications are more. Use of minimal access techniques may reduce the morbidity of surgical treatment in emergency.

Supraorbital Rim and Roof Reconstruction with Vascularized Fascia Lata and Autogenous Rib Graft.

Describe a novel technique for reconstruction of complex defects involving supraorbital rim and orbital roof. Retrospective chart review and description of surgical technique. Four patients underwent tumor resection with neurosurgery (2 intraosseous hemangioma, 1 meningioma, and 1 ossifying fibroma), with mean tumor size of 42.6 cubic centimeters on preoperative imaging. All defects involved supraorbital rim and orbital roof. Patients were reconstructed with autogenous osseous rib graft for structure and contour and anterolateral thigh fascia lata (ALTFL) free flap to provide robust vascularity to rib bone and as a barrier between skull base dura and the orbit and/or sinonasal cavities. Two patients underwent resection and reconstruction using minimal access incisions, and two underwent major cranial and skull base resections. All flaps are vascularized via superficial temporal vessels. On postoperative follow-up (mean 33.5 months, range 8-48), all patients report no vision change or diplopia, with excellent contour symmetry to contralateral orbit. Follow-up imaging (mean 29.5 months, range 3-48) demonstrated maintained orbital volume and retention of rib bone graft compared to immediate postoperative imaging. There were no complications related to graft use. Minor complications include 1 patient with cerebrospinal fluid leak managed with lumbar drain placement and 1 patient with mild enophthalmos at 7-month follow-up. We describe a series of patients who underwent a novel technique for reconstruction of complex defects involving supraorbital rim and orbital roof with autogenous osseous rib and vascularized ALTFL-free flap with excellent functional and cosmetic outcomes. This can be accomplished using minimal access techniques to minimize patient morbidity. 4 Laryngoscope, 134:654-658, 2024.

Endoscopic totally extraperitoneal repair for groin hernia: Experience from a tertiary care centre

Background:Totally extra-peritoneal (TEP) and transabdominal preperitoneal (TAPP) repair are two established minimal access techniques of groin hernia surgery. TEP offers the advantage of avoiding violation of the peritoneal cavity.Aim:This study aims to describe the decade-long experience of TEP in groin hernia repair in a tertiary care teaching institute and the feasibility of the same in difficult scenarios.Materials and Methods:Retrospective analysis of the database of patients undergoing TEP repair for inguinal hernia in a single surgical unit at a tertiary teaching hospital between January 2008 and December 2019 was performed. Detailed pre-operative clinical details, operative duration, intraoperative and post-operative complications, including pain, length of post-operative hospital stay and hernia recurrence data were analysed.Results:Over 12 years’ duration, 511 patients underwent endoscopic TEP mesh repair and the total number of hernias repaired was 614. Majority (97.45%) of patients were male. The mean age of the patient population was 51.3 years. Primary hernia was seen in 490 patients. The mean operating time for unilateral inguinal hernia repair was 56.8 ± 16 min and for bilateral repair 80.9 ± 25.2 min. TEP in previous lower abdominal/suprapubic surgical scars was attempted in 17 (3.3%) patients, with only one requiring conversion. The intraoperative peritoneal breach was the most common documented complication (34.8%). Seroma was seen in 9.4% of patients. Seventeen patients required conversion (14 TAPP and 3 open). Recurrence was seen in 4 (0.7) patients.Conclusion:TEP repair is an effective method of groin hernia repair and can be attempted in the majority of patients groin hernia, including patients with previous lower abdominal incisions.

Short-stay sutureless total thyroidectomy

Background and objective: Thyroid surgery has traditionally been done on an inpatient basis. With the advent of minimal access techniques. This study aimed to assess the outcome of short-stay total thyroidectomy in comparison with a longer stay in terms of postoperative complications. Methods: This was an observational comparative study which was carried out at the surgical units of Erbil of Rizgary Teaching Hospital and private hospitals in Erbil city. The data were collected in the period between January 2017 and March 2021. Data of 192 patients’ records who underwent thyroidectomy were collected. Results: In this study, 33 (17.1%) patients were males while 159 (82.8%) were females. Out of 192 patients, 137 underwent sutureless technique while 55 of them underwent sutured way of hemostasis. Majority of patients 173 (90.1%) were discharged before 23 hours, while 19 (9.9%) were discharged after 23 hours. Significantly, higher percentage of males (24.2%) stayed more than 23 hours in the hospital compared with 6.9% of females (P = 0.006). The majority of indications with goiter, Graves’ disease, toxic nodule and solitary stayed between 12-23 hours while half of those with cancer stayed more than 23 hours (P = 0.023). Conclusion: Short-stay thyroid surgery is a feasible and safe procedure when combined with sutureless technique: this returns to overall less postoperative complications; day-case and short-stay procedures account for an expanding area of modern-day surgery.

The pioneering past and cutting-edge future of interventional neuroradiology.

This review provides a thorough understanding of the developments in the field of interventional neuroradiology (INR). A concise overview of the pioneering past and current state of this field is presented first, followed by a greater emphasis on its future. Five main aspects predicted to undergo significant developments are identified and discussed. These include changes in 'education and training', 'clinical practice and logistics', 'devices and equipment', 'techniques and procedures', and 'relevant diagnostic imaging'. INR is at the crossroads of neuroradiology, neurosurgery, neurology, and the neurosciences. To progress we must value the uniqueness and vitality of this multidisciplinary aspect. While minimal access techniques offer very good anatomical accessibility to treat multiple pathologies of the central nervous system, it is also important to recognise its limitations. Medical, surgical, and radiosurgery modalities retain an important role in the management of some complex neuropathology. This review is certainly not exhaustive of all ongoing and predicted developments, but it is an important update for INR specialists and other interested professionals.

Robotic pyeloplasty in a horseshoe kidney: A case report

Objective: To deliver a case report showing that robotic pyeloplasty in a patient with a horseshoe kidney is not only successful but also potentially superior to laparoscopic surgery. To the best of our knowledge, this is the first case report of its kind in the United Kingdom. Method: PubMed was used to do a literature search. We have excluded papers that were written in foreign languages, or were paediatric case studies. Results: Horseshoe kidneys are the commonest congenital abnormality of the renal and are often associated with pelvic-ureteric junction obstruction (PUJO) – in the order of 30%. Minimally invasive surgery is the gold standard for management of PUJO. With the advancement of the Da Vinci robot, this case report presents a patient undergoing pyeloplasty in a horseshoe kidney with PUJO on the left side, using a robotic technique. We performed a robotic pyeloplasty on a 32-year-old woman, with a horseshoe kidney. We felt this is a case worth discussion, giving the alteration in the surgical technique in conjunction with the anatomical abnormalities, and the lack of similar reported cases in the literature. We propose that in some cases, the robotic operative technique is superior to standard laparoscopic technique. Although there is an increased cost when using the Da Vinci robot, this may be offset by the 3D visualisation, enhanced dexterity, tremor filtering and movement scaling, increased range of motion, as well as the reduction of operative time, hospital stay, blood loss, complications, and indeed patient satisfaction. In addition to the benefits of robotic surgery itself, we demonstrate that robotic surgery in this particular case was preferable to other techniques, given the anatomical exclusivity of a horseshoe kidney. Conclusion: We propose that in some cases, the robotic operative technique is superior to other minimal access techniques in urological surgery. Level of Evidence: 4

Implication of a novel postoperative recovery protocol to increase day 1 discharge rate after anatomic lung resection.

BackgroundChest-tube drainage and prolonged air leak after anatomic lung resection (ALR) continue to drive admission days for most programs employing minimal access techniques. The aim of the study was to evaluate the impact of a novel postoperative recovery protocol with revised chest tube management strategies to target discharge on post-operative day 1 (POD1) after ALR.MethodsThis is a pilot study investigating a novel enhanced recovery protocol which either allowed chest tube removal on POD1 or ambulatory management with indwelling chest tube using a portable closed drainage system. We included all patients undergoing video-assisted thoracoscopic surgery (VATS)-ALR; exclusion criteria were open surgery, non-anatomic or extended resections.ResultsA total of 139 patients were included in the study [N=29 portable drainage (PD), N=110 standard pathway (SP)]. POD1 discharge rate was 72% in PD vs. 15% in SP cohort (P<0.001). Median length of stay (LOS) was 1 day [interquartile range (IQR), 1–2 days] in PD cohort, while it was 3 days (IQR, 2–5 days) in SP cohort (P<0.001). There were no significant differences in length of indwelling chest-tube, rate of discharge with chest-tube, post-operative complications, or readmissions. On multivariate analysis, PD pathway as well as short surgical time were significant predictors of discharge on POD1.ConclusionsOur results indicate that POD1 discharge rates of 72% after VATS-ALR can be safely achieved by a well-developed perioperative care pathway and simple chest tube drainage interventions. Based on these findings we are currently drafting a follow-up study to investigate the possibility of performing ALRs as day surgery.

Diaphragmatic eventration plication repair with minimal access techniques: a case series

Diaphragmatic eventration is a rare pathological condition occurring in &lt;0.05% individuals causing the diaphragm to permanently ascend into the chest due to partial or complete replacement of diaphragmatic musculature by fibroblastic tissue. Congenital diaphragmatic eventration rarely presents among adults with most patients remaining asymptomatic only to be diagnosed incidentally after chest radiography. Symptomatic patients can present with dyspnoea, orthopnoea, recurrent lower respiratory tract infections or gastrointestinal symptoms. Management varies according to symptoms with asymptomatic cases requiring no intervention and plication being the standard, well-described technique for symptomatic cases. Here we described two cases with eventration approached using different minimal access techniques.

Standard work tools for dynamic stereoelectroencephalography using ROSA: naming convention and perioperative planning.

The grid-based orthogonal placement of depth electrodes (DEs), initially defined by Jean Talairach and Jean Bancaud, is known as stereo-electroencephalography (sEEG). Although acceptance in the United States was initially slow, advances in imaging and technology have spawned a proliferation of North American epilepsy centers offering sEEG. Despite publications highlighting minimal access techniques and varied indications, standard work for phase I targeted DE has not been defined. In this article, the authors propose the term "dynamic sEEG" and define standard work tools and related common data elements to promote uniformity in the field. A multidisciplinary approach from July to August 2016 resulted in the production of 4 standard work tools for dynamic sEEG using ROSA: 1) a 34-page illustrated manual depicting a detailed workflow; 2) a planning form to collocate all the phase I data; 3) a naming convention for DEs that encodes the data defining it; and 4) a reusable portable perioperative planning and documentation board. A retrospective review of sEEG case efficiency was performed comparing those using standard work tools (between July 2016 and April 2017) with historical controls (between March 2015 and June 2016). The standard work tools were then instituted at another epilepsy surgery center, and the results were recorded. The process for dynamic sEEG was formally reviewed, including anesthesia, positioning, perioperative nursing guidelines, surgical steps, and postoperative care for the workflow using cranial fixation and ROSA-guided placement. There was a 40% improvement in time per electrode, from 44.7 ± 9.0 minutes to 26.9 ± 6.5 minutes (p = 0.0007) following the development and use of the manual, the naming convention, and the reusable portable perioperative planning and documentation board. This standardized protocol was implemented at another institution and yielded a time per electrode of 22.3 ± 4.4 minutes. The authors propose the term dynamic sEEG for stereotactic depth electrodes placed according to phase I workup data with the intention of converting to ablation. This workflow efficiency can be optimized using the standard work tools presented. The authors also propose a novel naming convention that encodes critical data and allows portability among providers. Use of a planning form for common data elements optimizes research, and global adoption could facilitate multicenter studies correlating phase I modality and seizure onset zone identification.

Comparison of efficacy and safety of the enhanced-view totally extraperitoneal (eTEP) and transabdominal (TARM) minimal access techniques for retromuscular placement of prosthesis in the treatment of irreducible midline ventral hernia

Background:Retromuscular plane for mesh placement is preferred for ventral hernia repair. With the evolution of minimal access surgeries, newer techniques to deploy a mesh in the sublay plane have evolved. We compared two such minimally invasive approaches for repair of irreducible ventral midline hernia with respect to the efficacy and safety of the procedures.Patients and Methods:This is a retrospective study of a prospectively maintained database of 73 patients operated with retromuscular placement of mesh for irreducible ventral midline hernia by enhanced-view totally extraperitoneal (eTEP) or transabdominal retromuscular (TARM) repair. We recorded and compared the intraoperative and post-operative complications, post-operative pain score, recovery, recurrence, subjective technical ease of procedure and patient satisfaction after 3 months and 12 months of the surgery.Results and Conclusion:Thirty-eight patients were operated by eTEP technique and the subsequent 35 were operated by TARM repair. There was no significant difference in the outcome of surgery and complications by the two techniques. However, there was a significant subjective technical ease in the TARM group due to ergonomic triangulated port placement and adhesiolysis and reduction of hernia contents under vision. The number of ports used and post-operative pain were, however, higher in the TARM group as compared to that of the eTEP group. Nearly 96% of the patients belonging to both groups were satisfied with their surgery after a year on telephonic follow-up. However, further studies and follow-up of patients would be required to establish the advantage of one technique over the other.

Laparoscopic Hepatico-jejunostomy for Benign Bile Duct Strictures - Our Experience

Laparoscopic Hepatico-jejunostomy for Benign Bile Duct Strictures - Our Experience

Fewer Cardiopulmonary Complications and Shorter Length of Stay in Anterolateral Thoracolumbar Spine Exposures Using a Small-Incision Specialized Retractor System †

Objectives: One of the challenges of spine surgery is the need for adequate exposure of the anterolateral spinal column. Improved retractor systems with integrated lighting minimize the need for large thoracotomy, flank, or abdominal incisions. In 2013, we began using the NuVasive MaXcess® system via a minimal-access lateral incision for thoracic and thoracolumbar spine exposures. These small-access approaches may not offer adequate exposure when bleeding and other complications arise. We sought to determine the feasibility and outcomes of a minimal-access retractor during anterolateral spine exposures. Methods: An institutional-review-board-approved retrospective chart review was performed of all patients who underwent anterolateral thoracic and lumbosacral spine exposure at an academic hospital between December 1999 and April 2017. Cervical and posterior spine exposures were not included. Information regarding patient demographics, comorbid conditions, operative techniques, exposure, estimated blood loss, length of stay, and intraoperative and postoperative complications was collected. Data for standard exposure vs. minimally invasive exposures were compared. Results: Between December 1999 and April 2017, 223 anterolateral spinal exposures were performed at our institution. Of those, 122 (54.7%) patients had true lateral exposures, with 22 (18%) using the minimally invasive retractor. The mean age of our patient population was 57 years (19–89), with 65 (53%) men and a mean body mass index of 29.0 (17.4–58.6). In the standard exposure group, complications occurred in 22 (22%) patients, whereas only two (9%) complications occurred in the minimal-access group. There were no significant differences in overall intraoperative and postoperative complications, except for cardiopulmonary complications, which were reduced in the minimally invasive group (p < 0.019). Patients with minimally invasive exposure had a significantly shorter length of stay than those with standard exposure (7 vs. 13 days, p = 0.001). Conclusions: Minimal-access techniques using advanced retractor systems are both feasible and safe compared to standard techniques allowing for similar lateral spine exposure, but with smaller incisions, fewer cardiopulmonary complications, and shorter lengths of stay.

A rare clinical entity of asymptomatic adult bochdalek hernia

Bochdalek hernia (BH) is the commonest congenital diaphragmatic hernia, caused by the failure of the posterolateral diaphragmatic foramina to fuse properly. It is extremely rare in adults and accounts for 5-10%. Presenting a case of 48 years female with complaints of dry cough and left chest pain for 1 week. Diminished breath sounds and abnormal gurgling sounds heard on auscultation of left chest wall. X-ray chest showed elevated left hemi diaphragm and gastric bubble. Computed tomography (CT) chest revealed left diaphragmatic hernia with splenic flexure, transverse colon, mesocolon, spleen and upper pole of left kidney as content and atelectasis of left lung lower lobe. Patient underwent laparoscopic repair of hernia with mesh plasty. Intraoperatively, the contents were reduced into the abdominal cavity and left lung expansion noted. The defect of size 6×10 cm in the left diaphragm was sutured and composite mesh placed. Post-operative chest x-ray showed expanded left lung. On follow up of patient after 2 weeks and 1 month, patient was asymptomatic. BH in adults is an uncommon. The contents can be reduced via thoracic or abdominal approach, with abdominal approach having easier access. With the advent of minimal access techniques, delineating clear anatomy, more working space, early recovery, and early return to home and work is possible. Thus, laparoscopic repair of adult diaphragmatic hernia is a safe and effective modality of surgical treatment.

Image-guided Endoscopic Parathyroidectomy Using the Axillo-breast Approach in the Treatment of Primary Hyperparathyroidism.

Focused parathyroidectomy is currently performed using minimal access techniques. Here, we aim to evaluate the outcomes of the axillo-breast totally endoscopic approach (ABTEA) in patients with primary hyperparathyroidism caused by a single parathyroid adenoma. Ten patients with primary hyperparathyroidism were retrospectively evaluated. In all patients, the presence of a single parathyroid adenoma was confirmed using cervical ultrasonography by an expert radiologist with or without the use of parathyroid scintigraphy. All patients underwent focused parathyroidectomy using ABTEA. Clinicopathologic characteristics, surgical outcomes, biochemical cure rates, and cosmetic outcomes were evaluated. The parathyroid adenoma was successfully excised in all patients without significant complications and without conversion to open approach. All patients were cured, with ≥6 months of follow-up. Temporary hoarseness of the voice was observed in 1 case. The mean surgical time was 91±17.61 minutes. The mean blood loss was 20 mL. The postoperative pain scores were satisfactory and 90% of patients were extremely satisfied with the procedure. With accurate preoperative sonographic localization of a single parathyroid adenoma, focused parathyroidectomy using ABTEA is a safe and feasible technique even for posteriorly located parathyroid adenomas.

Minimally invasive techniques for transthoracic oesophagectomy for oesophageal cancer: systematic review and network meta-analysis.

BackgroundOesophagectomy is a demanding operation that can be performed by different approaches including open surgery or a combination of minimal access techniques. This systematic review and network meta‐analysis aimed to evaluate the clinical outcomes of open, minimally invasive and robotic oesophagectomy techniques for oesophageal cancer.MethodsA systematic literature search was conducted for studies reporting open oesophagectomy, laparoscopically assisted oesophagectomy (LAO), thoracoscopically assisted oesophagectomy (TAO), totally minimally invasive oesophagectomy (MIO) or robotic MIO (RAMIO) for oesophagectomy. A network meta‐analysis of intraoperative (operating time, blood loss), postoperative (overall complications, anastomotic leaks, chyle leak, duration of hospital stay) and oncological (R0 resection, lymphadenectomy) outcomes, and survival was performed.ResultsNinety‐eight studies involving 32 315 patients were included in the network meta‐analysis (open 17 824, 55·2 per cent; LAO 1576, 4·9 per cent; TAO 2421 7·5 per cent; MIO 9558, 29·6 per cent; RAMIO 917, 2·8 per cent). Compared with open oesophagectomy, both MIO and RAMIO were associated with less blood loss, significantly lower rates of pulmonary complications, shorter duration of stay and higher lymph node yield. There were no significant differences between surgical techniques in surgical‐site infections, chyle leak, and 30‐ and 90‐day mortality. MIO and RAMIO had better 1‐ and 5‐year survival rates respectively compared with open surgery.ConclusionMinimally invasive and robotic techniques for oesophagectomy are associated with reduced perioperative morbidity and duration of hospital stay, with no compromise of oncological outcomes but no improvement in perioperative mortality.