Minimally Invasive Surgery Procedures Research Articles

Surgical training trends in the Americas: A cross-continental assessment of minimally invasive surgery and open surgery among surgical trainees.

Minimally invasive surgery (MIS) has become standard of care in many high-income countries, but its adoption in low- and middle-income countries (LICs/MICs) has been impeded by resource- and training-related barriers. We hypothesized that trainees in MICs perform MIS procedures less often, and that as procedure complexity increases, the rate of MIS decreases. A 22-question survey, distributed to representative leaders across Latin America, collected country-specific graduating trainee case requirements and volumes for four index procedures (cholecystectomy, appendectomy, inguinal hernia repair, colectomy) using MIS or open surgery (OS). USA data was obtained from the Accreditation Council for Graduate Medical Education. Kruskal-Wallis and Mann-Whitney U tests were performed to determine whether the rate of MIS differed across all countries, procedure complexity classes, and high income countries (HICs)/MICs. Seven experts (70% response rate) completed the survey, representing: Brazil, Chile, Ecuador, Guatemala, Mexico, Panama, and Paraguay. The percentage of MIS completed by trainees varied with mean and interquartile ranges as follows: cholecystectomy (60%±54%), appendectomy (41%±69%), inguinal hernia repair (19%±23%), colectomy (16%±29%). There was a significant difference in mean MIS experience across the eight countries (H=17.6, p=0.014) and between most complex and least complex procedures (p=0.039). No difference was found between MICs and HICs (p=0.786). We found a significant difference of general surgery trainee exposure to MIS versus OS across the Americas, but the difference was not significantly associated with World Bank Income Groups. Different trainee experiences with MIS and OS may highlight an opportunity for international and bidirectional collaboration.

Surgical Approach and Length of Stay in Octogenarians Undergoing Pancreatic Resection for Malignancy.

Pancreatic surgery often has a lengthy recovery in the elderly. Minimally invasive surgery (MIS) can decrease length of stay (LOS), but it is unknown if this benefit applies to octogenarians (Age > 79). The NSQIP database was used to determine if MIS approaches were associated with reduced LOS among octogenarians undergoing pancreaticoduodenectomy (Whipple) or distal pancreatectomy (Distal). Operative approaches were classified as "Open" or "MIS" and propensity score (PS) matching was performed. For the Whipple, 1665 Open and 101 MIS procedures occurred (median LOS 9, 8 days, p = 0.584). For Distal, 472 Open and 223 MIS procedures occurred (median LOS 6, 5 days, p < 0.01). After PS matching, there were 202 Whipple (101 per group) and 446 Distal (223 per group) patients. There was no difference in LOS by approach in the Whipple group (p = 0.546). The median LOS was 9 (IQR 7-15), Open and 8 (IQR 6-13), MIS. For Distal, there was a difference in LOS in the Open versus MIS approach (p < 0.01) and the median LOS was 6 (IQR 5-8) and 5 (IQR 4-6). Among octogenarians the MIS approach was associated with decreased LOS in distal pancreatectomies, but not in pancreaticoduodenectomies.

EIT probe based intraoperative tissue inspection for minimally invasive surgery

Abstract Electrical impedance tomography (EIT) has become an integral component in the repertoire of medical imaging techniques, particularly due to its non-invasive nature and real-time imaging capabilities. Despite its potential, the application of EIT in minimally invasive surgery (MIS) has been hindered by a lack of specialized electrode probes. Existing designs often compromise between invasiveness and spatial sensitivity: probes small enough for MIS often fail to provide detailed imaging, while those offering greater sensitivity are impractically large for use through a surgical trocar. Addressing this challenge, our study presents a breakthrough in EIT probe design. The open electrode probe we have developed features a line of 16 electrodes, thoughtfully arrayed to balance the spatial demands of MIS with the need for precise imaging. Employing an advanced EIT reconstruction algorithm, our probe not only captures images that reflect the electrical characteristics of the tissues but also ensures the homogeneity of the test material is accurately represented. The versatility of our probe is demonstrated by its capacity to generate high-resolution images of subsurface anatomical structures, a feature particularly valuable during MIS where direct visual access is limited. Surgeons can rely on intraoperative EIT imaging to inform their navigation of complex anatomical landscapes, enhancing both the safety and efficacy of their procedures. Through rigorous experimental validation using ex vivo tissue phantoms, we have established the probe’s proficiency. The experiments confirmed the system’s high sensitivity and precision, particularly in the critical tasks of subsurface tissue detection and surgical margin delineation. These capabilities manifest the potential of our probe to revolutionize the field of surgical imaging, providing a previously unattainable level of detail and assurance in MIS procedures.

Can We Rely on Prophylactic Two-Level Vertebral Cement Augmentation in Long-Segment Adult Spinal Deformity Surgery to Reduce the Incidence of Proximal Junctional Complications?

Background and Objectives: Proximal junctional kyphosis (PJK) and failure (PJF), the most prevalent complications following long-segment thoracolumbar fusions for adult spinal deformity (ASD), remain lacking in defined preventive measures. We studied whether one of the previously reported strategies with successful results-a prophylactic augmentation of the uppermost instrumented vertebra (UIV) and supra-adjacent vertebra to the UIV (UIV + 1) with polymethylmethacrylate (PMMA)-could also serve as a preventive measure of PJK/PJF in minimally invasive surgery (MIS). Materials and Methods: The study included 29 ASD patients who underwent a combination of minimally invasive lateral lumbar interbody fusion (MIS-LLIF) at L1-2 through L4-5, all-pedicle-screw instrumentation from the lower thoracic spine to the sacrum, S2-alar-iliac fixation, and two-level balloon-assisted PMMA vertebroplasty at the UIV and UIV + 1. Results: With a minimum 3-year follow-up, non-PJK/PJF group accounted for fifteen patients (52%), PJK for eight patients (28%), and PJF requiring surgical revision for six patients (21%). We had a total of seven patients with proximal junctional fracture, even though no patients showed implant/bone interface failure with screw pullout, probably through the effect of PMMA. In contrast to the PJK cohort, six PJF patients all had varying degrees of neurologic deficits from modified Frankel grade C to D3, which recovered to grades D3 and to grade D2 in three patients each, after a revision operation of proximal extension of instrumented fusion with or without neural decompression. None of the possible demographic and radiologic risk factors showed statistical differences between the non-PJK/PJF, PJK, and PJF groups. Conclusions: Compared with the traditional open surgical approach used in the previous studies with a positive result for the prophylactic two-level cement augmentation, the MIS procedures with substantial benefits to patients in terms of less access-related morbidity and less blood loss also provide a greater segmental stability, which, however, may have a negative effect on the development of PJK/PJF.

Efficacy and Safety of Minimally Invasive Surgery Techniques in The Treatment of Acute Appendicitis: A literature review.

An appendectomy is often used to treat acute appendicitis, which is characterized by inflammation of the vermiform appendix. Techniques in minimally invasive surgery (MIS), such as endoscopic retrograde appendicitis therapy (ERAT), single-incision laparoscopic surgery (SILS), and laparoscopic appendectomy, have become popular substitutes for open surgery. The purpose of this review is to assess the safety and effectiveness of MIS methods for treating acute appendicitis. A comprehensive analysis of English-language literature from 2019 to 2024 was carried out to evaluate the safety and efficacy of MIS procedures for acute appendicitis. Research that satisfied the inclusion requirements was examined for pertinent information on SILS, ERAT, and laparoscopic appendectomy. Compared to open surgery, laparoscopic appendectomy showed shorter hospital stays, less pain after surgery, and quicker recovery rates. Comparable to traditional laparoscopic methods in terms of effectiveness, SILS and TULS provide potential advantages in terms of cosmesis and patient satisfaction. With faster recovery durations and fewer complications, ERAT showed encouraging results; nonetheless, questions about long-term effectiveness and recurrence rates were raised. In order to treat acute appendicitis, MIS procedures provide viable options that may shorten hospital stays, ease postoperative pain, and increase patient satisfaction. More investigation is necessary to improve patient selection criteria and operative approaches in order to maximize the efficacy of MIS in the therapy of appendicitis.

Role of surgical simulation on self-reported confidence level on cardiothoracic surgical trainees.

Simulated self-practice using simulation models could improve fine motor skills and self confidence in surgical trainees. The purpose of this study is to evaluate on self-reported confidence level in cardiothoracic surgical trainees by using surgical simulation models. We conducted a cross-sectional study on all surgeons (n=10) involved in MIS simulation training. All surgeons are required to perform on three minimally invasive surgery (MIS) procedures (Mitral Valve Repair, Mitral Valve Replacement and Aortic Valve Replacement). A questionnaire was designed based on two existing scales related to self-confidence, the surgical self-efficacy scale [SSES] and the perceived competency scale [PCS]. We assessed their self-confidence (before and after training) in the use of simulation in MIS procedures using rating scales 1-5. The mean score was calculated for each domain and used as the predictor variable. We also developed six questions (PCS) using Objective Structured Assessment of Technical Skills (OSAT) related to each domain and asked participants how confident they were after performing each MICS procedure. The mean score was 4.7 for all assessed domains, except "knowledge" (3.8). Surgeons who had performed one or more MIS procedures had higher scores (P<0.05). There was no correlation between the number of MIS procedures performed and self-confidence scores. The results indicate that the cardiac surgery training based on MIS simulation improves trainees and consultants in terms of the level of self-confidence. Although surgeons generally have high levels of self-confidence after simulation training in MIS cardiac procedures, there is still room for improvement with respect to technical skills related to the procedure itself and its results.

Big surgeons don't need big incisions: Minimally invasive surgery and use of robotics in Otolaryngology: A Narrative Review.

Minimally invasive surgery (MIS) and robotics have revolutionized the field of Otolaryngology. MIS and robotics have reshaped traditional otolaryngological practices, offering patients a multitude of benefits. Reduced incision sizes and tissue manipulation minimize postoperative pain and discomfort, while also improving cosmetic outcomes. MIS has facilitated enhanced visualization and access to intricate anatomical structures, enabling the treatment of previously inaccessible lesions. MIS procedures also offer shorter hospital stays, reduced blood loss, and faster healing times whilst enhancing patient satisfaction and overall quality of life The ongoing progress in minimally invasive approaches solidifies their role as a cornerstone in modern Otolaryngology, and surgeons navigating this transformative landscape must embrace the learning curve associated with these advanced techniques, recognizing the potential for improved patient outcomes. This article explores the transformative impact of MIS and robotics on the diverse branches of Otolaryngology, highlighting the technological advancements that have enabled these techniques to flourish.

The pharmacist's role in optimizing medication management before, during, and after minimally invasive and bariatric surgery.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Minimally invasive surgery (MIS) with integrated enhanced recovery pathways (ERPs) helps reduce length of stay and improve surgical outcomes. As these procedures have become more prevalent over time, pharmacists are in key positions to manage medications in the perioperative space to help optimize transitions of care and reduce safety events. Here we identify several clinical areas across phases of care for these procedures in which the knowledge and guidance of pharmacists, as members of the interprofessional team, are paramount. Perioperative pharmacy expertise is often required for MIS procedures in the areas of acid suppression, antithrombotic management, blood glucose control, drug formulation, immunosuppressant optimization, pain mitigation, and postoperative nausea and vomiting prevention and treatment. For each MIS procedure, pharmacists should identify and consider diet and anatomical changes as well as patient- and surgery-specific risk factors. Pharmacists can then utilize their knowledge of the pharmacokinetics and pharmacodynamics of individual medications along with evidence-based medicine to recommend selection of appropriate agents. Pharmacist contributions to perioperative medication management for MIS procedures can improve care as surgical patients navigate transitions through the perioperative setting. Pharmacists can further incorporate medication expertise through development and implementation of institutional MIS protocols within the context of ERPs. As such, any pharmacist should feel empowered to aid in the care of surgical patients.

Comparison of open and endoscopic posterior component separation with transversus abdominis release: a propensity score-matched study.

Posterior component separation with transversus abdominis release (TAR) is considered to be the optimal technique for large incisional ventral hernia repair. Endoscopic TAR (eTAR) that gets all the benefits of minimally invasive surgery (MIS) gives a possibility to enhance results of the treatment. The aim of our study was to make the comparison between open and endoscopic TAR procedures with an emphasis on frequency and severity of postoperative complications in comparable groups. All patients had midline incisional hernia and underwent either open (open TAR group) or endoscopic (eTAR group) Rives-Stoppa repair in combination with bilateral transversus abdominis release in Moscow City Hospital №1 from January 2018 to December 2022. A propensity score matching (PSM) was used to make groups comparable. Postoperative complications were classified according to Clavien-Dindo Classification, and Comprehensive complication index was calculated. We performed 133 open and endoscopic TAR separation for midline incisional hernia. After PSM analysis 51 patients were matched to each group. Overall surgical morbidity in the open TAR group (56.9%) was statistically significantly higher than in the eTAR group (29.4%) (p = 0.009). There were more severe complications (Clavien IIIa-V) in the open TAR group (11.8% vs. 0%, p = 0.027). Length of hospital stay after surgery was shorter in eTAR group (p < 0.001). The Comprehensive complication index in the open TAR group was significantly higher than in eTAR group, 8.7 (0-20.9) vs. 0 (0-8.7) (p = 0.011). Based on the data from our study, the entire MIS procedure including endoscopic TAR is a safe and optimal technique for surgery of midline incisional ventral hernia, requiring TAR separation in terms of reducing the rate of postoperative complications, their severity and hospital length of stay, compared to open TAR procedure.

The Endoscopic Lumbar Interbody Fusion: A Narrative Review, and Future Perspective.

Lumbar interbody fusion stands as a preferred surgical solution for degenerative lumbar spine diseases. The procedure primarily aims to establish lumbar segment stability, directly addressing patient symptoms associated with spinal complications. Traditional open surgery, though effective, is linked with notable morbidities and extended recovery time. To mitigate these concerns, minimally invasive surgery (MIS) has garnered significant popularity, presenting an appealing alternative with numerous benefits such as reduced soft tissue trauma, decreased blood loss, and expedited recovery. Among MIS procedures, full endoscopic spinal surgery, characterized by its minimal invasiveness, holds the potential to further minimize morbidities while enhancing surgical outcomes. Endoscopic lumbar interbody fusion, a novel procedure within this paradigm, has gained attention for offering advantages comparable to those of minimally invasive transforaminal lumbar interbody fusion. However, the safety, efficacy, and associated surgical techniques and instrument design of this method continue to be subjects of ongoing debate. This paper critically reviews current evidence on the safety, efficacy, and advantages of endoscopic lumbar spinal interbody fusion, examining whether it could indeed supersede existing mainstream techniques.

Experts in Minimally Invasive Surgery are Outperformed by Trained Novices on Suturing Skills

IntroductionLearning minimally invasive suturing can be challenging, creating a barrier to further implementation, especially with the development of easier methods. Nevertheless, mastering intracorporeal knot tying is crucial when alternative techniques prove inadequate. Therefore, the minimally invasive surgery (MIS) suturing skills of MIS experts are compared with a group of novices during their learning curve on a simulator. MethodsThe novice participants repeatedly performed the intracorporeal suturing task on the EoSim MIS simulator (up to a maximum of 20 repetitions). The experts (>50 MIS procedures and advanced MIS experience) completed the same task once. The first and last exercises of the novices and the expert tasks were all blindly recorded and assessed by two independent assessors using the Laparoscopic Suturing Competency Assessment Tool (LS-CAT). Additionally, objective assessment parameters, “time” and “distance”, using instrument tracking, were collected. The scores of the experts were then compared with the novices. ResultsAt the end of the training, novices significantly outperformed the experts on both the expert assessment (LS-CAT: 16.8 versus 26.8, P = 0.001) and objective parameters (median time: 190 s versus 161 s, P < 0.001; median distance: 6.1 m versus 3.6 m, P < 0.001). Although the experts showed slightly better performance than the novices during their first task, the difference was not significant on the expert assessment (LS-CAT experts 16.8, novices 20.5, P = 0.057). ConclusionsOur findings underscore the significance of continued MIS suturing training for both residents and surgeons. In this study, trained novices demonstrated a significant outperformance of experts on both quantitative and qualitative outcome parameters within a simulated setting.

Viral load of SARS-CoV-2 in surgical smoke in minimally invasive and open surgery: a single-center prospective clinical trial

At the beginning of the COVID-19 pandemic, it was assumed that SARS-CoV-2 could be transmitted through surgical smoke generated by electrocauterization. Minimally invasive surgery (MIS) was targeted due to potentially higher concentrations of the SARS-CoV-2 particles in the pneumoperitoneum. Some surgical societies even recommended open surgery instead of MIS to prevent the potential spread of SARS-CoV-2 from the pneumoperitoneum. This study aimed to detect SARS-CoV-2 in surgical smoke during open and MIS. Patients with SARS-CoV-2 infection who underwent open surgery or MIS at Heidelberg University Hospital were included in the study. A control group of patients without SARS-CoV-2 infection undergoing MIS or open surgery was included for comparison. The trial was approved by the Ethics Committee of Heidelberg University Medical School (S-098/2021). The following samples were collected: nasopharyngeal and intraabdominal swabs, blood, urine, surgical smoke, and air samples from the operating room. An SKC BioSampler was used to sample the surgical smoke from the pneumoperitoneum during MIS and the approximate surgical field during open surgery in 15 ml of sterilized phosphate-buffered saline. An RT-PCR test was performed on all collected samples to detect SARS-CoV-2 viral particles. Twelve patients with proven SARS-CoV-2 infection underwent open abdominal surgery. Two SARS-CoV-2-positive patients underwent an MIS procedure. The control group included 24 patients: 12 underwent open surgery and 12 MIS. One intraabdominal swab in a patient with SARS-CoV-2 infection was positive for SARS-CoV-2. However, during both open surgery and MIS, none of the surgical smoke samples showed any detectable viral particles of SARS-CoV-2. The air samples collected at the end of the surgical procedure showed no viral particles of SARS-CoV-2. Major complications (CD ≥ IIIa) were more often observed in SARS-CoV-2 positive patients (10 vs. 4, p = 0.001). This study showed no detectable viral particles of SARS-CoV-2 in surgical smoke sampled during MIS and open surgery. Thus, the discussed risk of transmission of SARS-CoV-2 via surgical smoke could not be confirmed in the present study.

Minimally Invasive Surgery vs Open Approach to First Metatarsophalangeal Joint Arthrodesis: A Comparison of Surgical Outcomes

Category: Midfoot/Forefoot; Other Introduction/Purpose: Minimally invasive surgery (MIS) is becoming increasingly popular among foot and ankle orthopaedic surgeons, as it has been shown to have limited complication rates and faster recovery times. Although there is robust data on MIS to treat hallux valgus, few studies have evaluated the role of MIS for 1st metatarsophalangeal (MTP) fusion to treat hallux rigidus - the most common arthritis of the foot. Hallux rigidus affects 2.5% of the U.S. population over age 50. Given this disease prevalence, it is important to characterize outcomes following MTP fusion procedures to optimize surgical approaches. In this retrospective cohort study, we aim to compare (1) patient-reported pain, (2) rate of successful fusion, and (3) rate of complications between groups who underwent open or MIS 1st MTP arthrodesis. Methods: This retrospective cohort study was conducted by evaluating clinical metrics, surgical outcomes, and radiographic data through chart review of 78 patients (25 male, 53 female), who underwent a 1st MTP fusion procedure at a large urban academic medical center from July 2015 through January 2023. 71 patients had a diagnosis of hallux rigidus, with other common diagnoses including hammertoe (24), hallux valgus (24), additional arthritides (11), and metatarsalgia (11). Two patients were excluded from our analysis due to lack of sufficient orthopaedic follow-up preventing evaluation of joint fusion. Pre- and post-operative pain scores were recorded on a 0-10 scale, though some notes documented subjective experience of pain (e.g., “minimal”). Complications were identified using post-operative clinic notes. The following radiographic data were included: hallux valgus angle, intermetatarsal angle, Coughlin classification, presence of arthritis, pre-operative sesamoid position, fusion construct materials, and success of fusion. Results: Of the 80 1st MTP fusion surgeries (two patients received both left and right foot operations), 51 were open and 29 were minimally invasive. There was no significant difference in the change in pre- to post-operative pain between the two groups (p=0.39). MIS patients had a higher successful fusion rate (100.0%) when compared to open surgery patients (94.1%), though this difference was insignificant (p=0.55). There was no significant difference in overall complication rates between MIS and open surgery groups (p=0.79). However, the MIS patients did not have any cases of deep infection or wound dehiscence and all (5/5) of their complications were related to hardware removal after fusion, whereas half of the complications (5/10) for the open surgery patients were related to infection and wounds. Conclusion: This retrospective analysis of 78 patients treated for hallux rigidus with 1st MTP fusion surgery showed no significant difference in rates of successful fusion and complications among patients who received an MIS procedure compared to an open surgery. There was no difference in patient-reported pain improvement between the two groups. Our main limitation is provider specialization, as only one surgeon in this study performed the MIS cases. Further studies should be done to obtain higher-level evidence to elucidate potential benefits of MIS over open surgery for 1st MTP arthrodesis.

Guidelines in Practice: Minimally Invasive Surgery.

During minimally invasive surgery (MIS), surgeons create small and percutaneous incisions to access internal structures without open surgical incisions. Some MIS equipment is complex and challenging for perioperative nurses to manage. Patients also can experience life-threatening complications during MIS procedures. The updated AORN "Guideline for minimally invasive surgery" provides recommendations that perioperative nurses can use when caring for patients undergoing MIS procedures. This article provides an overview of the guideline and discusses several recommendations, including creating a safe environment in which to perform MIS procedures; using gas distension media, irrigation and fluid distension media, and computer-assisted navigation and robotics; and performing intraoperative magnetic resonance imaging in a hybrid OR. It also includes a scenario describing care of a patient undergoing a hysteroscopy. Perioperative nurses who care for patients undergoing MIS procedures should review the guideline in its entirety and apply the recommendations as applicable in their practice.

Development of a simulation minimally invasive surgery (MIS) training program in a curricula of pediatric surgery: A replicable experience

BackgroundSimulation in MIS can act as a bridge to proficiency by creating a ‘pre-trained’ novice. A MIS simulation program for pediatric and neonatal minimal invasive surgery (PNMIS) included in the curricula and an MIS education fellowship were developed in 2012. AimTo describe the program, analyze its results and inspire other groups to replicate the experience. MethodsIt is structured in 3 stages: initial, intermediate and advanced.The exercises are supervised, structured, including formative feedback and a pre and post test with debriefing. In the final stage,neonatal models are included to integrate the knowledge and specific maneuvers with the techniques of suture learned in previous stages. Low-cost training models’ development has been our sub-specialty. ResultsSince 2013 none of the residents has performed a MIS procedure without having attended the corresponding module.The first MIS education fellow is nowadays the chief of pediatric surgery in his native institution and started PNMIS. Telesimulation for essential skills was incorporated and its effectiveness published [7,21].The team has already run 184 on site and 41 telesimulated courses including 842 individually coached workstations and 1026 hours of telesimulation Seventy five % of participants largely changed their surgical efficiency and 52% significantly increased the complexity of the procedures they were performing.Our academic production includes 8 articles published in peer review journals and 1 European book chapter and 2 research awards [5,7,13,17-23] DiscussionWe encourage all enthusiasts to move forward in basic implementation and move towards the ideal program over time.

Outcomes in Minimally Invasive Sleeve Gastrectomy and Implications for Surgical Resident Education.

Introduction: Resident participation in advanced minimally invasive and bariatric surgeries is controversial. The aim of this study is to evaluate the safety of resident participation in robotic and laparoscopic sleeve gastrectomy (SG). Methods: Prospectively maintained institutional Metabolic and Bariatric Surgery Accreditation Quality Improvement Program database was used to identify patients who underwent SG, which was performed at our institution between January, 2018, and December, 2021. Operative notes were reviewed to determine the training level of the assistant. These were then classified into 7 groups: postgraduate years 1-5 residents, bariatric fellow (6), and attending surgeons (7). Each group was stratified and their outcomes, which included duration of surgery, length of stay (LOS), postoperative complications, readmissions, and reoperations, were compared. Results: Out of 2571 cases, the assistants for the procedures were minimally invasive surgery (MIS) fellows (n = 863, 58.8%), fifth- and fourth-year residents (n = 228, 15.5%), third- and second-year residents (n = 164, 11.2%), no assistants (n = 212, 14.5%), and 134 robotic SG. Mean body mass index was higher in cases wherein the attending surgeon performed by himself (47.1, standard deviation 7.7) when compared with other groups. There were no conversions to open. Mean LOS was 1.3 days, and there was no difference between groups (P = .242). Postoperative complications were low, with 11 reoperations in 30 days (3.3%) and no difference between groups. There was no mortality in 30 or 90 days. Conclusion: Postoperative outcomes were similar for patients who underwent SG regardless of the assistant's level of training. Including residents in bariatric procedures is safe and does not affect patient safety. Encouraging residents to participate in complex MIS procedures is recommended as part of their training.

Minimally Invasive Surgery for Perihilar Cholangiocarcinoma: A Systematic Review of the Short- and Long-Term Results.

Surgery and postoperative systemic chemotherapy represent the standard treatment for patients with perihilar cholangiocarcinoma (PHC). Minimally Invasive Surgery (MIS) for hepatobiliary procedures has spread worldwide in the last two decades. Since resections for PHC are technically demanding, the role of MIS in this field is yet to be established. This study aimed to systematically review the existing literature on MIS for PHC, to evaluate its safety and its surgical and oncological outcomes. A systematic literature review on PubMed and SCOPUS was performed according to the PRISMA guidelines. Overall, a total of 18 studies reporting 372 MIS procedures for PHC were included in our analysis. A progressive increase in the available literature was observed over the years. A total of 310 laparoscopic and 62 robotic resections were performed. A pooled analysis showed an operative time ranging from 205.3 ± 23.9 and 840 (770-890) minutes, and intraoperative bleeding between 101.1 ± 13.6 and 1360 ± 809 mL. Minor and major morbidity rates were 43.9% and 12.7%, respectively, with a 5.6% mortality rate. R0 resections were achieved in 80.6% of patients and the number of retrieved lymph nodes ranged between 4 (3-12) and 12 (8-16). This systematic review shows that MIS for PHC is feasible, with safe postoperative and oncological outcomes. Recent data has shown encouraging results and more reports are being published. Future studies should address differences between robotic and laparoscopic approaches. Given the management and technical challenges, MIS for PHC should be performed by experienced surgeons, in high-volume centers, on selected patients.

Minimally Invasive Instrumentation of the Cervical Spine: Past, Present, and Future.

Posterior cervical instrumentation and fusion procedures are becoming more and more common with the aging population and rising numbers of multisegmental and revision procedures. The instrumentation of the cervical spine has so far been performed almost exclusively via open approaches. Over the past two decades, minimally invasive surgery (MIS) techniques have gained increasing popularity. To date, only a few attempts to instrument the cervical spine in a minimally invasive fashion have been reported. The following article, after a detailed review of the currently available literature, overviews MIS in dorsal cervical instrumentation and past, present and future techniques, and it discusses the current limitations. Nevertheless, and because of the multiple advantages of MIS instrumentation, a lot of work remains to be carried out to fully establish MIS procedures for posterior cervical instrumentation.

The Surgical Treatment of Hallux Valgus Utilization Minimally Invasive and Percutaneous Techniques with a Shannon Burr: A Systematic Review

Category: Midfoot/Forefoot; Bunion Introduction/ Purpose: Recently there has been an increase in minimally invasive surgery (MIS) for the correction of hallux valgus deformity. This systematic review aims to evaluate and present the current literature on MIS hallux valgus correction in studies reporting the use of the Shannon burr with distal metatarsal osteotomies to help establish evidence-based guidelines for surgeons utilizing this technique. Methods: Two independent authors performed a systematic literature search using the following databases: PubMed, Embase, and the Cochrane library. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) protocol and the Cochrane Handbook guidelines were followed. All studies included were published from 2008 to 2022 and included the use of the Shannon burr during distal metatarsal osteotomies minimally invasive surgery for hallux valgus and at least 12-month follow-up. The MINORS score criteria was utilized to evaluate the strength and quality of 17 studies by three authors. Statistical analysis and meta-analysis were not performed due to the heterogeneity of the included studies and the data being descriptive. Results: A total of 17 studies were reviewed. A total of 911 subjects were included, and 1088 MIS procedures were performed. The average follow-up was 23.8 (12-59.1) months. AOFAS and VAS scores improved from 52.1 (41-62.5) to 90.3 (83.3-97.1) and 4.9 (3-8.2) to 0.8 (0-1.9). Satisfaction rates were very high among the studies that reported it. The HVA, IMA and DMAA angle improved from 31.4 (23.5-44.1) to 11.1 (7-17.2).), 13.4 (8.1-18.6) to 7.3 (4.2-10.3), and 12.3 (9-16.3) to 4.1 (1-6.7). Complication rate was 16.6%. Recurrence was 2.2%. Nonunion 0.4%, infections 1.1%, nerve injury 2.2%, avascular necrosis 0%, hallux varus 0.09%, transfer metatarsalgia 0.1% and hardware removal 6.2%. Conclusion: Minimally invasive surgery for the treatment of hallux valgus utilizing the Shannon burr appears to be a safe and effective therapy with appropriate correction of the hallux valgus deformity, improvement in functional outcomes, high patient satisfaction, low recurrence, and acceptable complication rates.

Minimally Invasive Surgery Using a Shannon Burr for the Treatment of Hallux Valgus Deformity: A Systematic Review.

Recently there has been an increase in minimally invasive surgery (MIS) for the correction of hallux valgus deformity. This systematic review aims to evaluate and present the current literature on MIS hallux valgus correction in studies reporting the use of the Shannon burr with distal metatarsal osteotomies to help establish evidence-based guidelines for surgeons using this technique. Two independent authors performed a systematic literature search using the following databases: PubMed, Embase, and the Cochrane library. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) protocol and the Cochrane Handbook guidelines were followed. All studies included were published from 2008 to 2022 and included the use of the Shannon burr during distal metatarsal osteotomies MIS for hallux valgus and at least 12-month follow-up. The MINORS score criteria was used to evaluate the strength and quality of 17 studies by 3 authors. Statistical analysis and meta-analysis were not performed because of the heterogeneity of the included studies and the data being descriptive. A total of 17 studies were reviewed. A total of 911 subjects were included, and 1088 MIS procedures were performed. The average follow-up was 23.8 (12-59.1) months. American Orthopaedic Foot & Ankle Society scale and visual analog scale scores improved from 52.1 (41-62.5) to 90.3 (83.3-97.1) and 4.9 (3-8.2) to 0.8 (0-1.9). Satisfaction rates were very high among the studies that reported it. The hallux valgus angle, intermetatarsal angle, and distal metatarsal articular angle improved from 31.4 (23.5-44.1) to 11.1 (7-17.2), 13.4 (8.1-18.6) to 7.3 (4.2-10.3), and 12.3 (9-16.3) to 4.1 (1-6.7), respectively. The complication rate was 16.6%, and recurrence was 2.2%. Nonunion comprised 0.4%, infections 1.1%, nerve injury 2.2%, avascular necrosis 0%, hallux varus 0.09%, transfer metatarsalgia 0.1%, and hardware removal 6.2%. MIS for the treatment of hallux valgus using the Shannon burr appears to be a safe and effective therapy, with appropriate correction of the hallux valgus deformity, improvement in functional outcomes, high patient satisfaction, low recurrence, and acceptable complication rates. Level II, systematic review.