Minimally Invasive Surgery Surgery Research Articles

Long-Term Survival Outcomes After Minimally Invasive Surgery for Ileal Neuroendocrine Tumors

BackgroundIleal neuroendocrine tumors (i-NETs) are characterized by their multifocality and bulky mesenteric mass. Having shown that minimally invasive surgery (MIS) utilizing a hand-access port device has favorable short-term outcomes and achieves the goals of surgery for i-NETs, we sought to analyze long-term survival outcomes of MIS.MethodsOne hundred and sixty-eight patients who underwent resection of primary i-NETs at a single institution between January 2007 and February 2023 were retrospectively studied. Patients were categorized into the MIS or open surgery cohorts on an intention-to-treat basis. Open surgery was selected mainly based on the need for hepatectomy or bulky mesenteric mass resection. Overall survival was analyzed using log-rank tests with propensity score matching (PSM) and Cox proportional hazards regression. PSM was performed to reduce standardized mean differences of the variables to <0.2.ResultsOverall, 129 (77%) patients underwent MIS and 39 (23%) underwent open surgery. Twenty-seven MIS patients were converted to an open procedure. The median follow-up time was 49 months (interquartile range 23–87 months). In the PSM cohorts, overall survival did not differ significantly between the MIS and open surgery cohorts {median 99 months (95% confidence interval [CI] 91–not applicable [NA]) vs. 103 months (95% CI 86–NA), p = 0.77; hazard ratio 0.87 (95% CI 0.33–2.2), p = 0.77}.ConclusionsMIS is an alternative to open surgery for i-NETs, achieving similar short- and long-term oncological outcomes. Bulky mesenteric mass and a plan for concurrent liver resection are potential criteria for open surgery.

Surgical Treatment for Endometrial Cancer, Hysterectomy Performed via Minimally Invasive Routes Compared with Open Surgery: A Systematic Review and Network Meta-Analysis.

Background: Total hysterectomy with bilateral salpingo-oophorectomy via minimally invasive surgery (MIS) has emerged as the standard of care for early-stage endometrial cancer (EC). Prior systematic reviews and meta-analyses have focused on outcomes reported solely from randomised controlled trials (RCTs), overlooking valuable data from non-randomised studies. This inaugural systematic review and network meta-analysis comprehensively compares clinical and oncological outcomes between MIS and open surgery for early-stage EC, incorporating evidence from randomised and non-randomised studies. Methods: This study was prospectively registered on PROSPERO (CRD42020186959). All original research of any experimental design reporting clinical and oncological outcomes of surgical treatment for endometrial cancer was included. Study selection was restricted to English-language peer-reviewed journal articles published 1 January 1995-31 December 2021. A Bayesian network meta-analysis was conducted. Results: A total of 99 studies were included in the network meta-analysis, comprising 181,716 women and 14 outcomes. Compared with open surgery, laparoscopic and robotic-assisted surgery demonstrated reduced blood loss and length of hospital stay but increased operating time. Compared with laparoscopic surgery, robotic-assisted surgery was associated with a significant reduction in ileus (OR = 0.40, 95% CrI: 0.17-0.87) and total intra-operative complications (OR = 0.38, 95% CrI: 0.17-0.75) as well as a higher disease-free survival (OR = 2.45, 95% CrI: 1.04-6.34). Conclusions: For treating early endometrial cancer, minimal-access surgery via robotic-assisted or laparoscopic techniques appears safer and more efficacious than open surgery. Robotic-assisted surgery is associated with fewer complications and favourable oncological outcomes.

Minimally Invasive vs Open Approach for First Metatarsophalangeal Joint Arthrodesis: Short Report of Early Results.

We aim to compare early surgical results between groups who underwent minimally invasive surgery (MIS) vs open first metatarsophalangeal (MTP) arthrodesis to treat end-stage hallux rigidus. We conducted a retrospective cohort review of 65 patients who underwent a first MTP fusion procedure at an academic medical center between 2015 and 2023. Success of fusion was determined radiographically. Postoperative complications were identified through medical record review. Sixty-seven first MTP fusion surgeries (41 open and 26 MIS) were performed on 65 patients with a primary diagnosis of hallux rigidus. Open surgery and MIS groups had similarly high fusion rates: 95% (39/41) and 96% (25/26), respectively (P = .84). We identified no difference in overall complication rates: 20% for open surgery and 23% for MIS (P = .73). This retrospective analysis of 67 first MTP arthrodesis procedures showed no significant differences in fusion success or complications in the short term when comparing MIS to open surgery. Further studies are needed to elucidate potential differences between MIS vs open surgery. Level III, retrospective comparative study.

Changing patterns and surgical outcomes of small bowel obstruction in the era of minimally invasive surgery for colorectal cancer.

This study aimed to investigate whether the incidence, patterns, and surgical outcomes of small bowel obstruction (SBO) have changed in the era of minimally invasive surgery (MIS) for primary colorectal cancer (CRC). Consecutive patients who underwent laparotomy for SBO were divided into MIS and traditional open surgery (TOS) groups based on the previous colorectal cancer operation technique used. The MIS group was selected from 1544 consecutive patients who underwent MIS as a treatment for primary CRCs between 2014 and 2022, while the TOS group was selected from 1604 consecutive patients who underwent TOS as a treatment for primary CRCs between 2004 and 2013. The demographics, clinicopathological features, and surgical outcomes were compared between the two groups. The SBO incidence in patients who underwent MIS for primary CRC was significantly lower than that in patients who underwent TOS (4.4%, n =68/1544 vs. 9.7%, n =156/1604, P <0.0001). Compared with the TOS group, the MIS group had significantly different ( P <0.0001) SBO patterns: adhesion (48.5 vs. 91.7%), internal herniation (23.5 vs. 2.6%), external herniation (11.8 vs. 1.9%), twisted bowel limbs (4.4 vs. 0.6%), ileal volvulus with pelvic floor adhesion (5.9 vs. 1.9%), and nonspecific external compression (5.9 vs. 1.3%). A subset analysis of patients with adhesive SBO (ASBO) showed that the MIS group tended to ( P <0.0001) have bands or simple adhesions (75.8%), whereas the TOS group predominantly had matted-type adhesions (59.4%). Furthermore, SBO in the MIS group had an acute (<3 months) or early (3-12 months) onset (64.7%), while that in the TOS group ( P <0.0001) had an intermediate or a late onset. When the surgical outcomes of SBO were evaluated, the TOS group had significantly more ( P <0.0001) blood loss and longer operation time; however, no significant difference was observed in the surgical morbidity/mortality (Clavien-Dindo classification ≧3, 11.8 vs. 14.1%, P =0.6367), hospitalization, and readmission rates between the two groups. Postoperative follow-up showed that the estimated 3-year (11.37 vs. 18.8%) and 6-year (25.54 vs. 67.4%) recurrence rates of SBO were significantly lower ( P =0.016) in the MIS group than in the TOS group. The wide adoption of MIS to treat primary CRC has led to a lower incidence, altered patterns, and reduced recurrence rates of SBO. Awareness of this new trend will help develop surgical techniques to prevent incomplete restoration of anatomical defects and bowel malalignments specifically associated with MIS for CRC, as well as facilitate timely and appropriate management of SBO complications whenever they occur.

What is the effect of preoperative depression on outcomes after minimally invasive surgery for adult spinal deformity? A prospective cohort analysis.

Depression has been implicated with worse immediate postoperative outcomes in adult spinal deformity (ASD) correction, yet the specific impact of depression on those patients undergoing minimally invasive surgery (MIS) requires further clarity. This study aimed to evaluate the role of depression in the recovery of patients with ASD after undergoing MIS. Patients who underwent MIS for ASD with a minimum postoperative follow-up of 1 year were included from a prospectively collected, multicenter registry. Two cohorts of patients were identified that consisted of either those affirming or denying depression on preoperative assessment. The patient-reported outcome measures (PROMs) compared included scores on the Oswestry Disability Index (ODI), numeric rating scale (NRS) for back and leg pain, Scoliosis Research Society Outcomes Questionnaire (SRS-22), SF-36 physical component summary, SF-36 mental component summary (MCS), EQ-5D, and EQ-5D visual analog scale. Twenty-seven of 147 (18.4%) patients screened positive for preoperative depression. The nondepressed cohort had an average of 4.83 levels fused, and the depressed cohort had 5.56 levels fused per patient (p = 0.267). At 1-year follow-up, 10 patients still reported depression, representing a 63% decrease. Postoperatively, both cohorts demonstrated improvement in their PROMs; however, at 1-year follow-up, those without depression had statistically better outcomes based on the EQ-5D, MCS, and SRS-22 scores (p < 0.05). Patients with depression continued to experience higher NRS leg scores at 1-year follow-up (3.63 vs 2.22, p = 0.018). After controlling for covariates, the authors found that depression significantly impacted only 1-year follow-up MCS scores (β = 8.490, p < 0.05). Depressed and nondepressed patients reported similar improvements after MIS surgery, except MCS scores were more likely to improve in nondepressed patients.

Local resection for solid pseudopapillary neoplasms of the pancreas shows improved postoperative gastrointestinal function and reduced mental stress: a multiquestionnaire survey from a large cohort.

Solid pseudopapillary neoplasm (SPN) of the pancreas is a rare, low-grade malignant pancreatic tumor with a highly favorable prognosis. Most SPN patients are young and middle-aged women. The main controversial topic for SPN is local resection (LR) versus radical resection (RR). Theoretically, LR could lead to better gastrointestinal function (GIF) and less mental stress. However, no data is available to support this hypothesis. All SPN patients undergoing surgical treatment in Peking Union Medical College Hospital from 2001 to 2021 were included in the study. A cross-sectional online multiquestionnaire survey containing 110 questions was sent to them (Clinicaltrial.org, NCT05604716). This online multiquestionnaire survey focused on GIF and mental stress and consisted of eight questionnaires. Multiple linear regression analysis was conducted to identify independent factors impacting GIF and mental stress. A total of 183 cases provided valid results. Among them, 46 patients (25.1%) underwent LR, and 137 (74.9%) underwent RR. Ninety-four cases (51.4%) underwent minimally invasive surgery (MIS), while 89 (48.6%) underwent open surgery. The average GSRS score of the patients was 1.9±0.7, indicating that most suffered from mild gastrointestinal dysfunction. The scores of PHQ-9 and GAD-7 in 16 patients (8.7%) and 27 (14.8%) patients, respectively, were beyond 10.0, which indicated clinical depression and anxiety. Additionally, 19 (10.4%) patients reported poor ability to work, and 31(16.9%) patients had significant body image concerns. Compared to other clinicopathological characteristics, LR (LR vs. RR: PHQ-9 score, P =0.018; WAI average score, P =0.010; EORTC QLQ-C30, nine subdomains, P <0.05; GSRS average score, P =0.006) and MIS (MIS vs. open surgery: EORTC QLQ-C30, three subdomains, P <0.05; GSRS average score, P =0.006) were the most significant factors predicting improved GIF and reduced mental stress. This study systematically presents postoperative GIF and mental stress of SPN patients using validated multiquestionnaires for the first time. It provides solid evidence that LR and MIS can improve GIF and reduce mental stress after surgery for SPN patients, which could be helpful for the surgeons to make more personalized surgical plans for their patients.

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.

Long-term outcome of minimally invasive staging surgery for clinical stage I endometrial cancer: A single institute experience in Taiwan.

Endometrial cancer is the most common gynecological cancer in developed countries. With recent advances in equipment and knowledge, minimally invasive surgery (MIS) is widely accepted for the treatment of endometrial cancer. This study had the largest number of cases to date in Taiwan, comparing outcomes between MIS and laparotomy staging surgery using real-world data with long-term follow-up. We retrospectively reviewed patients with clinical stage 1 endometrial cancer from 2009 to 2020 in our institute. All patients underwent comprehensive surgical staging procedures by MIS or laparotomy. The safety, morbidity, progression-free survival (PFS), and overall survival (OS) rates of the two groups were compared. Clinical and pathologic factors were compared with Chi-square and Fisher Exact test. PFS and OS were estimated by the Kaplan-Meier method. Differences between survival curves were analyzed using the log-rank test. A p value of <0.05 was considered statistically significant. Using Cox proportional hazards models, all factors found to be significantly associated with risk of recurrence on univariate analyses were then assessed together through multivariable models, resulting in a final oncologic outcome between MIS and laparotomy. A total of 665 cases (412 cases in MIS group and 253 cases in laparotomy group) were enrolled for data analysis. Median operation time was shorter in MIS group (244 and 265 minutes, p < 0.001). Median blood loss was also less (75 and 430 mL, p < 0.001). Median postoperative hospitalization duration was longer in the laparotomy group (2 and 7 days, p = 0.001). After adjusting presurgery risk factors, the PFS and OS were no significant difference in MIS and laparotomy groups. Using real-world data with long-term follow-up, we could confirm excellent PFS and OS in selective patients with clinical stage 1 endometrial carcinoma who received MIS, and the surgical time, hospital day, and blood loss were also less.

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.

Localised non-metastatic sarcomatoid renal cell carcinoma: a 31-year externally verified study.

To evaluate post-nephrectomy outcomes and predictors of cancer-specific survival (CSS) between patients with localised sarcomatoid renal cell carcinoma (sRCC) and those with Grade 4 RCC (non-sRCC), as most sRCC research focuses on advanced or metastatic disease with limited studies analysing outcomes of patients with localised non-metastatic sRCC. A total of 564 patients with localised RCC underwent partial or radical nephrectomy between June 1988 to March 2019 for sRCC (n = 204) or World Health Organization/International Society of Urological Pathology Grade 4 non-sRCC (n = 360). The CSS at every stage between groups was assessed. Phase III ASSURE clinical trial data were used to externally validate the CSS findings. The Mann-Whitney U-test and chi-squared test compared outcomes and the Kaplan-Meier method evaluated CSS, overall survival (OS) and recurrence-free survival. Clinicopathological features associated with RCC death were evaluated using Cox proportional hazards regression. The median follow-up was 31.5 months. The median OS and CSS between the sRCC and Grade 4 non-sRCC groups was 45 vs 102 months and 49 vs 152 months, respectively (P < 0.001). At every stage, sRCC had worse CSS compared to Grade 4 non-sRCC. Notably, pT1 sRCC had worse CSS than pT3 Grade 4 non-sRCC. Negative predictors of CSS were sarcomatoid features, non-clear cell histology, positive margins, higher stage (pT3/pT4), and use of minimally invasive surgery (MIS). ASSURE external verification showed worse CSS in patients with sRCC (hazard ratio [HR] 1.63, 95% confidence interval [CI] 1.12-2.36; P = 0.01), but not worse outcomes in MIS surgery (HR 1.39, 95% CI 0.75-2.56; P = 0.30). Localised sRCC had worse CSS compared to Grade 4 non-sRCC at every stage. Negative survival predictors included positive margins, higher pathological stage, use of MIS, and non-clear cell histology. sRCC is an aggressive variant even at low stages requiring vigilant surveillance and possible inclusion in adjuvant therapy trials.

Demographic and practice patterns among minimally invasive surgery fellowship graduates.

Previous reports show that over 85% of general surgery residents choose to pursue fellowship training after completing residency. There continues to be an increase interest among general surgery residents in minimally invasive surgery (MIS) fellowship. Moreover, demographic disparities, particularly gender disparities continue to persist among surgical sub-specialties. In this study, we evaluated the gender disparities and practice patterns among graduating MIS fellows. MIS fellows were surveyed, and 169 results were received from fellows who completed training in the years: 2010, 2015-2019. Surveys collected were used to create a descriptive analysis of the demographics, practice patterns and job finding measures. Loglinear regression model was performed to assess gender trend variation over training years. Fellows self-reported gender showed 65% male, 30% female, and 5% prefer not to say. The cohort of participants was described as 45.3% white, 5.3% African American, and 6.5% Hispanic or Latino. Further, results showed 87.1% of fellows work in MIS surgery with 91.8% reporting their fellowship experience facilitated their ability to find a job. Most alumni pursue a comprehensive MIS practice. Moreover, the proportion of female fellows increased from 29 to 41%, but this increase over time was not significant using loglinear regressions [p-value = 0.0810, Relative risk = 1.1994 (95% CI 0.9778, 1.4711)]. Overall, there is good evidence to support that fellowship training facilitates future career advancements. Further, MIS fellows have differential practice patterns. Finally, females remain underrepresented among the MIS fellows which should call for leadership action to bridge these gaps.

Comparison of Minimally Invasive and Open Surgery for the Treatment of Endometrial Cancer with a High Risk of Recurrence: A Propensity Score Matching Study in Korea and Taiwan.

This study compared oncologic outcomes between minimally invasive surgery (MIS) and open surgery for the treatment of endometrial cancer with a high risk of recurrence. This study included patients with endometrial cancer who underwent primary surgery at two tertiary centers in Korea and Taiwan. Low-grade advanced-stage endometrial cancer (endometrioid grade 1 or 2) or endometrial cancer with aggressive histology (endometrioid grade 3 or non-endometrioid) at any stage was considered to have a high risk of recurrence. We conducted 1:1 propensity score matching between the MIS and open surgery groups to adjust for the baseline characteristics. Of the total of 582 patients, 284 patients were included in analysis after matching. Compared with open surgery, MIS did not show a difference in disease-free survival [hazard ratio (HR) 1.09; 95% confidence interval (CI) 0.67-1.77, P = 0.717] or overall survival (HR 0.67; 95% CI 0.36-1.24, P = 0.198). In the multivariate analysis, non-endometrioid histology, tumor size, tumor cytology, depth of invasion, and lymphovascular space invasion were risk factors for recurrence. There was no association between the surgical approach and either recurrence or mortality in the subgroup analysis according to stage and histology. MIS did not compromise survival outcomes for patients with endometrial cancer with a high risk of recurrence when compared with open surgery.

Perspectives and trends for minimally invasive surgery for hallux valgus deformity in the Asia Pacific region.

Evolving evidence and improved instrumentation have led to increasing importance of minimally invasive surgery (MIS) surgery in the treatment of hallux valgus deformity. This study aims to investigate the current trends of the practice of MIS hallux valgus surgery in the Asia Pacific region. A survey was sent via email to 30 fellowship-trained foot and ankle surgeons in 11 Asia Pacific countries, all registered with their respective national orthopaedic societies. The survey consisted of 8 questions and was designed to assess surgeon experience with MIS hallux valgus surgery, including common contraindications, satisfaction levels, learning curves and post-operative rehabilitation after MIS hallux valgus surgery. The vast majority of surgeons (63%) performed MIS hallux valgus surgery. However, only 18% of surgeons performed MIS surgery in more than half of their hallux valgus cases. A severe deformity was the most common contraindication (81%), followed by the instability of the first tarsometatarsal joint (50%), and abnormal DMAA (Distal Metatarsal Articular Angle) (38%). There was no statistically significant difference between the satisfaction score of MIS versus open surgery (p-value 0.1). The median number of cases the surgeons needed to perform before they considered themselves comfortable performing the surgery was 10 cases (range 1-100). Most surgeons allowed full weight bearing at 4-6weeks after surgery. MIS hallux valgus surgery is gaining popularity in the Asia Pacific region, with the majority of surgeons adopting this practice. The fact that severe deformity is seen as the most frequent contraindication and that MIS surgery is still not the most popular alternative demonstrates that surgeons are still circumspect when it comes to MIS surgery. Surgeons can use the findings of this study to guide their adoption of MIS practices in hallux valgus surgery and gauge well they perform in comparison to their counterparts in the Asia Pacific region.

666 Comparison of Minimally Invasive and Open Surgical Approaches for Intradural-Extramedullary Spine Tumors: A Systematic Review and Meta-Analysis

INTRODUCTION: Traditionally spinal intradural-extramedullary (ID-EM) tumors have been accessed via open surgery. Removal of these tumors involves significant tissue damage, prolonged recovery, and risk of infection. More recent minimally invasive surgery (MIS) techniques aim to reduce these risks and complications while achieving similar goals of surgery as traditional approaches. METHODS: A systematic literature search was employed (PROSPERO#CRD42022302574) with searches through PubMed (MEDLINE), EBSCO, and Wiley Cochrane Library databases from conception till 9th January 2022. Cohort and case series studies with comparisons of minimally-invasive and open surgery for ID-EM spinal tumors were included; pooled sampled data were included in the random-effects (Mantel-Haenszel method) model for meta-analysis. RESULTS: Our search strategy yielded 403 total articles across these databases – after systematic review and exclusion, 13 studies were included for qualitative and quantitative analysis. On meta-analysis, minimally-invasive approaches were non-inferior to open surgery for achieving gross total resection (RR = 1.01, 95% CI 0.94 – 1.09, p = 0.78, I2 = 0%). Intraoperative blood loss (MD = -119.18, 95% CI -157.83 - -80.52, p &lt; 0.0001, I2 = 89%), operative time (MD = -25.94, 95% CI -50.28 – -1.60, p = 0.04, I2 = 91%), and length of stay (MD=-2.50, 95% CI -3.89 – -1.10, p = 0.0004, I2 = 95%) were significantly lower within cohorts undergoing MIS surgery for ID-EM spinal tumor. CONCLUSIONS: Data within the reviewed studies suggest similar rates of gross total resection within MIS and open surgery cohorts for ID-EM spinal tumors. Moreover, MIS affords shorter hospital stays, decreased blood loss, and operative time for patients. For certain patient groups, MIS spinal tumor resection can be preferred over standard surgical approaches, with preservation of function and decreasing overall surgical complications.

Spinal Deformity Complexity Checklist for Minimally Invasive Surgery: Expert Consensus from the Minimally Invasive International Spine Study Group

We developed a spinal deformity complexity checklist (SDCC) to assess the difficulty in performing a circumferential minimally invasive surgery (MIS) for adult spinal deformity. A modified Delphi method of panel experts was used to construct an SDCC checklist of radiographic and patient-related characteristics that could affect the complexity of surgery via MIS approaches. Ten surgeons with expertise in MIS deformity surgery were queried to develop and refine the SDCC with 3 radiographic categories (x-ray, magnetic resonance imaging, computed tomography) and 1 patient-related category. Within each category, characteristics affecting MIS complexity were identified by initial roundtable discussion. Second-round discussion determined which characteristics substantially impacted complexity the most. Thirteen characteristics within the x-ray category were determined. Spinopelvic characteristics, endpoints of instrumentation, and prior hardware/fusion were associated with increased complexity. Vertebral body rotation-as reflected by the Nash-Moe grade-added significant complexity. Psoas anatomy and spinal stenosis added the most complexity for the 5 magnetic resonance imaging characteristics. There were 3 characteristics in the CT category with pre-exisiting fusion, being the variable most highly selected. Of the 5 patient-related characteristics, osteoporosis and BMI were found to most affect complexity. The SDCC is a comprehensive list of pertinent radiographic and patient-related characteristics affecting complexity level for MIS deformity surgery. The value of the SDCC is that it allows rapid assessment of key factors when determining whether MIS surgery can be performed effectively and safely. Patients with scores of 4 in any characteristic should be considered challenging to treat with MIS; open surgery may be a better alternative.

SAGES/AHPBA guidelines for the use of minimally invasive surgery for the surgical treatment of colorectal liver metastases (CRLM).

Colorectal liver metastases (CRLM) occur in roughly half of patients with colorectal cancer. Minimally invasive surgery (MIS) has become an increasingly acceptable and utilized technique for resection in these patients, but there is a lack of specific guidelines on the use of MIS hepatectomy in this setting. A multidisciplinary expert panel was convened to develop evidence-based recommendations regarding the decision between MIS and open techniques for the resection of CRLM. Systematic review was conducted for two key questions (KQ) regarding the use of MIS versus open surgery for the resection of isolated liver metastases from colon and rectal cancer. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Additionally, the panel developed recommendations for future research. The panel addressed two KQs, which pertained to staged or simultaneous resection of resectable colon or rectal metastases. The panel made conditional recommendations for the use of MIS hepatectomy for both staged and simultaneous resection when deemed safe, feasible, and oncologically effective by the surgeon based on the individual patient characteristics. These recommendations were based on low and very low certainty of evidence. These evidence-based recommendations should provide guidance regarding surgical decision-making in the treatment of CRLM and highlight the importance of individual considerations of each case. Pursuing the identified research needs may help further refine the evidence and improve future versions of guidelines for the use of MIS techniques in the treatment of CRLM.

Minimally Invasive Foot and Ankle Surgery: A Primer for Orthopaedic Surgeons.

There is rapidly growing interest in minimally invasive surgery (MIS) of the foot and ankle. Technological advances, specifically with the advent of low-speed high-torque burrs, have enabled the expansion of MIS techniques. Accordingly, there is growing literature reporting excellent outcomes of MIS surgery to address many different pathologies of the foot and ankle. MIS techniques are particularly useful for conducting percutaneous osteotomies and bony débridement. These can be used to address bunion deformity, hammertoes, metatarsalgia, bunionette deformity, bone spurs, and hindfoot deformity. A detailed understanding of the technology, equipment, and techniques is crucial to safely conduct MIS of the foot and ankle. When done safely, MIS provides favorable outcomes with an expedited recovery and limited complications.

Minimally invasive surgery: has it come of age?

Open techniques for foot surgery are well established. Minimally invasive surgery (MIS) offers the potential of less morbidity, scarring and quicker recovery. Small incisions reduce surgical trauma, improving recovery and decreasing rehabilitation times. Evaluation of the literature enables us to assess the benefits of MIS over existing open techniques to support its widespread adoption. Our aim was to assess levels of evidence for the use of MIS surgery in various aspects of foot and ankle surgery. In the field of hallux valgus correction, randomized control trials, or prospective cohort studies have provided level 1 evidence for the use of MIS techniques. Other aspects of foot and ankle surgery are mainly dominated by technical descriptions or case series. MIS techniques have the opportunity to provide satisfactory outcomes in many fields, with many domains reporting promising results. However, more studies are required to provide good level 1/2 evidence for comparative analysis to equivalent open techniques and establish their true benefit. More trials, longer follow-up and larger patient series may provide more meaningful data to justify MIS's use. Comparative analysis of MIS's true benefit compared to open surgery in areas of foot and ankle surgery outside hallux valgus has yet to be established with higher levels of evidence lacking.

OGC P27 A Review of Minimally Invasive Oesophagogastric Cancer Surgery in a High-Volume UK Unit

Abstract Background Oesophagogastric (OG) cancer resections are technically challenging and associated with peri-operative morbidity. Practice has evolved from open to minimally invasive surgery (MIS), with ERAS has seen peri-operative outcomes improve. OG surgeons have not transitioned to MIS at the rate of others; 2021 NOGCA results showed that 17.6% of oesophagectomies and 17% of gastrectomies were performed as MIS. Concerns regarding the technical ability to perform safe anastomoses and appropriate oncological clearance have been cited as common reasons for surgeons not transitioning to MIS. GSTT is a high-volume OG unit which has transitioned from a fully open to predominantly MIS practice. The unit has performed over 100 minimally invasive Ivor Lewis oesophagectomies and 97 laparoscopic gastrectomies, it was therefore decided to analyse the unit's peri-operative outcomes to ensure that appropriate standards were maintained during this change in practice. The primary aim of this study was to examine a decade of peri-operative outcomes for Ivor Lewis oesophagectomy and gastrectomies, comparing parallel open and MIS cohorts. The secondary aim is to perform a sequential cumulative sum control chart (CUSM) analysis of the cohort to determine whether a learning curve effect for OG MIS can be demonstrated. Methods A retrospective analysis of a prospectively maintained comprehensive local database was performed. The results were cross-checked with NOCGA data, and a notes review was performed to capture any missing data.All Ivor Lewis oesophagectomy and gastrectomy (total, extended total and subtotal) performed for adenocarcinoma, squamous cell carcinoma, neuroendocrine tumours and high grade dysplasia at Guy's and St Thomas’ NHS Foundation Trust, London, UK over a ten-year period (January 2012- December 2021) were included. MIS for oesophagectomy was defined as an Ivor Lewis oesophagectomy performed with both laparoscopic and thoracoscopic phases. A hybrid (laparoscopic abdomen and open chest phase) oesophagectomy was grouped with a two-phase open procedure to create an open cohort. Laparoscopic gastrectomy (with a laparoscopic oesophago-jejunostomy or gastro-jejunostomy for sub-total gastrectomy) was used as the definition of MIS. The cohorts were compared for: age, sex, BMI and use of neoadjuvant therapy. Temporal trends in surgical approaches were compared as were Individual surgeon (n=4) volumes. Peri-operative clinical and oncological outcomes including length of stay, anastomotic leak, return to theatre, chest complications, resection margins and lymph node harvest were all examined. A CUSM analysis is currently being completed to further analyse surgeon performance over time. Results 596 patients underwent resection in well matched cohorts, 197 patients had an oesophagectomy (100 MIO), 339 had a gastrectomy (97 laparoscopic). MIS rates increased with no operations being performed as MIS in 2012 compared to 81% of oesophagectomy and 67% of gastrectomy performed as MIS in 2021. Two surgeons performed over 170 resections with MIS rate over 40%. OR of MIS performed by a high-volume surgeon was 3.01 (p&amp;lt;0.001). Lower volume MIS surgeons were more likely to have two consultants present, OR 1.4 (p=0.16). Anastomotic leak rates following gastrectomy were 2% in both groups (p=0.66), 9% following open oesophagectomy and 11% after MIO (p=0.77). 10% of laparoscopic gastrectomy patients experienced a chest complication, 26% after open surgery, 22% MIO and 24% open (p=0.65). Mean length of stay was significantly reduced after MIS. An R0 rate of 96% was seen after laparoscopic gastrectomy, 90% after open (p=0.08). 68% of MIO patients had R0 resection compared to 70% after open. Positive CRM was 29% after MIO. The mean lymph node harvest was 29 after laparoscopic gastrectomy and 26 after open (p=0.24), 29 following MIO, 30 after open oesophagectomy. 97% of MIO harvested over 15 nodes. Conclusions This study demonstrates that a transition from open to MIS practice is achievable in the UK. Outcomes demonstrated similar peri-operative clinical and oncological outcomes between MIS and open surgery which addresses the concerns that prohibited the widespread uptake of MIS in UK centres. Developing a reliable surgical technique for lymphadenectomy and anastomoses that transitioned from open to hybrid and now MIS allowed for appropriate outcomes to be maintained. Unit outcomes compare well to both NOGCA/ECCG data with complication rates following MIO being significantly lower when compared to ECCG. Lymph node harvests were significantly higher in unit MIOs when compared to NOGCA (p=0.01). Volume played an important role in surgeons performing independent MIS. This should be considered when planning unit workload or a transition to MIS. It will be further explored in the CUSM analysis. A positive CRM was seen in more cases (29%) when compared to NOGCA (24%) and may be related to the preferred neoadjuvant regime being chemotherapy over chemoradiotherapy. The future of OG is moving towards robotic surgery. It is proposed that the evolution from open to MIS will make a second transition to robotics less challenging as the strategies needed to perform MIS have been addressed.

Evaluation of Surgical Approaches and Use of Adjuvant Radiotherapy with Respect to Oncologic Outcomes in the Management of Clinically Early-Stage Cervical Carcinoma

The standard of care for early-stage cervix cancer is radical hysterectomy with pelvic lymphadenectomy. Adjuvant radiotherapy (RT) or chemoradiotherapy may be administered to reduce the risk of recurrence in patients considered to be at elevated risk based on a combination of pathologic factors. We performed a retrospective review to determine oncologic outcomes in patients treated for early-stage cervix cancer and to determine if surgical approach impacted oncologic outcomes or the decision to use adjuvant therapy. In total, 174 women underwent radical hysterectomy and pelvic lymphadenectomy over the 15-year period. Most of these women (146) had open surgery and 28 had minimally invasive surgery (MIS). In total, 81 had adjuvant pelvic RT; 76 in the open surgery group (52%) and 5 in the MIS group (18%). Five-year PFS and OS, respectively, were 84% and 91%. Five-year PFS was significantly lower in patients who had MIS vs. open surgery, without a difference in 5-year OS, suggesting MIS should be avoided. Five-year PFS was the same with RT or with its omission, despite those treated with RT having higher risk disease. We have demonstrated excellent outcomes in patients with early-stage cervix cancer after primary surgery and selective use of RT, with few recurrences and excellent survival.