MIS Procedures Research Articles

Correction potential and outcome of various surgical procedures for hallux valgus surgery: a living systematic review and meta-analysis.

More than 100 surgical techniques are described for hallux valgus (HV) correction, but the most appropriate technique remains debatable. The aim of this study was to develop and conduct a "living systematic review" for the outcome of surgically treated HV. The "living systematic review" was conducted per the PRISMA-P and PICOS guidelines and is the basis for the German AWMF S2e guideline "Hallux valgus" (033-018). Four common databases and the grey-literature were searched. Eligible were studies on adult patients comparing either two different primary surgical interventions or the same primary surgical intervention for different hallux valgus severities. The main outcome parameters were the osseous correction potential and the patient rated outcome. Out of 3022 studies, 46 studies (100 arms) were included. The meta-analysis included 31 studies (53 arms). The IMA (1933 procedures) improved on average by 7.3°, without significant group differences. The HVA (1883 procedures) improved on average by 18.9°, with significantly better results for third generation MIS (21.2°). The AOFAS (1338 procedures) improved on average by 33.8 points without significant group differences. The meta-regression revealed constant AOFAS scores over time. 69%/39% of the correction potential for the IMA/HVA could be explained by the preoperative values and 82% of the AOFAS improvement by the preoperative AOFAS scores. Open and minimally invasive techniques are powerful tools to correct hallux valgus deformity. Third generation MIS procedures revealed a possible superiority for the correction of the HVA. The AOFAS improvement appeared to be constant over time. Level I; living systematic review and meta-analysis of prospective comparative studies (level II) and randomized controlled trials (level I).

Determinants of successful minimally invasive surgery for resectable non–small cell lung cancer after neoadjuvant therapy

ObjectiveMinimally invasive surgery (MIS) (video-assisted thoracoscopic surgery and robot-assisted thoracoscopic surgery) for pulmonary resection is standard in early-stage non–small cell lung cancer because it is associated with better perioperative outcomes than thoracotomy. MIS for resection of more advanced non–small cell lung cancer (Stages IB-IIIB) treated with neoadjuvant therapy has been utilized. However, the determinants of success are not well defined. MethodsA single institution retrospective review of a prospectively maintained database was conducted, querying for patients with clinical Stage IB through IIIB non–small cell lung cancer who had resection after neoadjuvant systemic therapy without radiation from 2013 to 2022. Patients were grouped by surgical approach; that is, open versus MIS. Successful MIS was defined by no conversion, R0 resection, and no major (grade 3 or greater) morbidity. Analyses by intent-to-treat assessed outcomes by Wilcoxon rank-sum test and Fisher exact test. (Multivariable regression analysis identified variables that contributed to successful MIS resection.) ResultsOf 627 eligible patients, 360 (57%) had open and 267 (43%) had MIS procedures. Most patients (79.1%) received neoadjuvant platinum-based chemotherapy, and 21.9% were treated with immunotherapy or targeted therapy alone or combined with chemotherapy. Among MIS resections, 179 (67%) were performed by video-assisted thoracoscopic surgery and 88 (33%) by robot-assisted thoracoscopic surgery. The conversion rate was 16% (n = 43). Successful MIS resection was achieved in 77% of patients. Multivariable regression analysis showed that pretreatment clinical N stage was a significant determinant of success, but not pretreatment clinical T stage or type of neoadjuvant therapy. ConclusionsFollowing neoadjuvant systemic therapy for clinical stage IB or IIIB non–small cell lung cancer, MIS resection can be successfully accomplished and should be considered in appropriate patients. Presence of pretreatment nodal disease is associated with higher odds of conversion, major morbidity, and incomplete resection.

Feasibility evaluation of the Versius surgical system: robot-assisted hysterectomy for benign and malignant gynaecological lesions.

The application of minimally invasive surgery allows for radical and precise removal of the gynaecological lesion while simultaneously reducing the side effects and complications associated with surgical treatment. This paper aims to share our direct experience with the implementation of the CMR Versius robotic platform in the treatment of benign and malignant gynaecological lesions. This study included patients who underwent hysterectomy in the Department of Obstetrics, Gynaecology, and Gynaecologic Oncology at the Regional Polyclinical Hospital in Grudziadz, Poland. A total of 50 patients were included in the study: 29 underwent laparoscopic surgery and 21 underwent robot-assisted surgery using the CMR Versius system. It was found that in the case of non-radical hysterectomy, the duration of surgery differed significantly (96.5 vs. 134.6min, p < 0.01) in the groups of patients undergoing laparoscopic and robotic surgery. There were also no statistically significant differences in loss of blood parameters, rate of complications and conversions to other type of surgery after the laparoscopic and robotic surgeries. Both groups did not differ significantly in terms of hospitalisation time after surgery. Versius CMR surgical robot assistance provides safe and effective support for MIS procedures in gynaecology.

A comparison of three techniques for the osteosynthesis after minimal invasive osteotomies for hallux valgus.

Third and fourth-generation minimal invasive osteotomies (MIO) for the treatment of hallux valgus (HV) have become popular procedures worldwide with promising results due to the improvement in the fixation method. The tricortical cannulated screw placement remains a complex procedure that is technically challenging and requires a long skill learning curve with high radiation exposure mainly in the form of intensifier shots (IS) required for the MIO fixation. This study aims to compare the number of X-ray IS required using three different techniques for the cannulated guide placement. A retrospective cross-sectional observational and comparative study was conducted to assess the number of X-rays IS required for correct cannulated screw guide placement using three different techniques: traditional perforator, the drill and joystick, and K-wire first techniques. A total of 53 MIS procedures from thirty-one patients in two different hospitals were included. IS X-rays were 155.1 ± 29.7 in the traditional technique (n = 14), 143.0 ± 43.2 in the drill and joystick technique (n = 22), and 85 ± 18.7 in the K-wires first technique (n = 17), p = < 0.001 using one-way ANOVA. The K-wire first technique statistically significantly decreases X-ray IS numbers p ≤ 0.001. There were no statistically significant differences between the traditional (after osteotomy K-wire placement) and the drill and joystick techniques (p = 0.36).

Endoscopic versus minimally invasive surgical approach for infected necrotizing pancreatitis: a systematic review and meta-analysis of randomized controlled trials

Background/Aims Acute pancreatitis is a common condition of the digestive system, but sometimes it develops into severe cases. In about 10–20% of patients, necrosis of the pancreas or its periphery occurs. Although most have aseptic necrosis, 30% of cases will develop infectious necrotizing pancreatitis. Infected necrotizing pancreatitis (INP) requires a critical treatment approach. Minimally invasive surgical approach (MIS) and endoscopy are the management methods. This meta-analysis compares the outcomes of MIS and endoscopic treatments. Methods We searched a medical database until December 2022 to compare the results of endoscopic and MIS procedures for INP. We selected eligible randomized controlled trials (RCTs) that reported treatment complications for the meta-analysis. Results Five RCTs comparing a total of 284 patients were included in the meta-analysis. Among them, 139 patients underwent MIS, while 145 underwent endoscopic procedures. The results showed significant differences (p < 0.05) in the risk ratios (RRs) for major complications (RR: 0.69, 95% confidence interval (CI): 0.49–0.97), new onset of organ failure (RR: 0.29, 95% CI: 0.11–0.82), surgical site infection (RR: 0.26, 95% CI: 0.07–0.92), fistula or perforation (RR: 0.27, 95% CI: 0.12–0.64), and pancreatic fistula (RR: 0.14, 95% CI: 0.05–0.45). The hospital stay was significantly shorter for the endoscopic group compared to the MIS group, with a mean difference of 6.74 days (95% CI: −12.94 to −0.54). There were no significant differences (p > 0.05) in the RR for death, bleeding, incisional hernia, percutaneous drainage, pancreatic endocrine deficiency, pancreatic exocrine deficiency, or the need for enzyme use. Conclusions Endoscopic management of INP performs better compared to surgical treatment due to its lower complication rate and higher patient life quality.

Patient Selection Criteria in Ambulatory Spine Surgery: Single Canadian Provincial Experience

Ambulatory spinal surgery is a care delivery model meant to improve patient outcomes and reduce in-hospital length of stay (LOS). We reviewed the experience of implementing an outpatient spine surgery program in Manitoba, Canada and highlight elements that can be used to reduce LOS and re-presentation to hospital. This is a retrospective cohort study using data from the Canadian Spine Outcomes and Research Network and independent chart review of adult patients undergoing outpatient spinal surgery between 2015 and 2018. Patient demographics, comorbidities, perioperative course, LOS, and readmissions were analyzed. We included 217 patients in this analysis. The mean LOS was 36.2 hours; 71.98% of patients had a LOS <24 hours. A Kruskal-Wallis test by ranks analysis was conducted and identified 7 elements that correlated with prolonged length of stay (>1 day): age older than 55 (P= 0.027), body mass index >25 (P= 0.045), uncontrolled diabetes (P= 0.015), preoperative use of opioid medication (P= 0.024), American Society of Anesthesiologists classification of 3 (P= 0.023), non-minimally invasive surgical approach, and multilevel procedures. Most (94.1%) of the patients with none of these elements (i.e., age <55, low body mass index, normal/controlled diabetes, minimal preoperative opioid use, American Society of Anesthesiologist classification <3, minimally invasive surgical procedure) had a favorable LOS, <24 hours, compared with 84.8% with 1 risk factor, 80.4% of those with two, 69.8% with three, 53.1% with four, and 31.2% with 5 or more. A small number of patients (14.98%) presented to an emergency department within 90 days of their operation, and there was a 6.28% readmission rate. We identified several patient and surgical criteria that correlate with prolonged length of stays following planned ambulatory spine surgery. Our work provides some empiric evidence to help guide surgeons on which patients and approaches are ideal for ambulatory surgery.

Personalized Interventional Surgery of the Lumbar Spine: A Perspective on Minimally Invasive and Neuroendoscopic Decompression for Spinal Stenosis.

Pain generator-based lumbar spinal decompression surgery is the backbone of modern spine care. In contrast to traditional image-based medical necessity criteria for spinal surgery, assessing the severity of neural element encroachment, instability, and deformity, staged management of common painful degenerative lumbar spine conditions is likely to be more durable and cost-effective. Targeting validated pain generators can be accomplished with simplified decompression procedures associated with lower perioperative complications and long-term revision rates. In this perspective article, the authors summarize the current concepts of successful management of spinal stenosis patients with modern transforaminal endoscopic and translaminar minimally invasive spinal surgery techniques. They represent the consensus statements of 14 international surgeon societies, who have worked in collaborative teams in an open peer-review model based on a systematic review of the existing literature and grading the strength of its clinical evidence. The authors found that personalized clinical care protocols for lumbar spinal stenosis rooted in validated pain generators can successfully treat most patients with sciatica-type back and leg pain including those who fail to meet traditional image-based medical necessity criteria for surgery since nearly half of the surgically treated pain generators are not shown on the preoperative MRI scan. Common pain generators in the lumbar spine include (a) an inflamed disc, (b) an inflamed nerve, (c) a hypervascular scar, (d) a hypertrophied superior articular process (SAP) and ligamentum flavum, (e) a tender capsule, (f) an impacting facet margin, (g) a superior foraminal facet osteophyte and cyst, (h) a superior foraminal ligament impingement, (i) a hidden shoulder osteophyte. The position of the key opinion authors of the perspective article is that further clinical research will continue to validate pain generator-based treatment protocols for lumbar spinal stenosis. The endoscopic technology platform enables spine surgeons to directly visualize pain generators, forming the basis for more simplified targeted surgical pain management therapies. Limitations of this care model are dictated by appropriate patient selection and mastering the learning curve of modern MIS procedures. Decompensated deformity and instability will likely continue to be treated with open corrective surgery. Vertically integrated outpatient spine care programs are the most suitable setting for executing such pain generator-focused programs.

Ventral hernia repair: an increasing burden affecting abdominal core health.

To estimate the annual volume and cost of ventral hernia repair (VHR) performed in the United States. A retrospective cohort study was performed using the National Inpatient Sample (NIS) and the Nationwide Ambulatory Surgery Sample (NASS) for 2016-2019. Patients over the age of 18 who underwent open (OVHR) or minimally invasive ventral hernia repair (MISVHR) were identified. NIS procedural costs were estimated using cost-to-charge ratios; NASS costs were estimated using the NIS cost-to-charge ratios stratified by payer status. Costs were adjusted for inflation to 2021dollars using US Bureau of Labor Statistics Consumer Price Index. On average 610,998 VHRs were performed per year. Most were outpatient (67.3% per year), and open (70.7%). MIS procedures increased from 25.8% to 32.8% of all VHRs. Inpatient OVHR had significantly higher associated cost than MISVHR [$35,511 (34,100-36,921) vs. $21,165 (19,664-22,665 in 2019]. Outpatient MISVHR was more expensive than OVHR [$11,558 (11,174-11,942 MIS vs. $6807 (6620-6994) OVHR in 2019]. The estimated cost of an inpatient MISVHR remained similar between 2016 and 2019, from $20,076 (13,374-20,777) to $21,165 (19,664-22,665) and increased slightly from $9975 (9639-10,312) to $11,558 (11,174-11,942) in the outpatient setting. The estimated cost of an inpatient OVHR increased from $31,383 (30,338-32,428) to $35,511 (34,100-36,921), while outpatient costs increased from $6018 (5860-6175) to $6807 (6620-6994). VHR costs decreased slightly over the study period to a mean cost of $9.7 billion dollars in 2019. Compared to 2006 national data, VHRs in the United States have almost doubled to 611,000 per year with an estimated annual cost of $9.7 billion. A 1% decrease in VHR achieved through recurrence reduction or hernia prophylaxis could save the US healthcare system at least $139.9 million annually.

Minimally invasive versus open transforaminal lumbar interbody fusion: a prospective, controlled observational study of short-term outcome

Instrumented stabilization with intersomatic fusion can be achieved by open (O-TLIF) or minimally invasive (MIS-TLIF) transforaminal surgical access. While less invasive techniques have been associated with reduced postoperative pain and disability, increased manipulation and insufficient decompression may contradict MIS techniques. In order to detect differences between both techniques in the short-term, a prospective, controlled study was conducted. Thirty-eight patients with isthmic or degenerative spondylolisthesis or degenerative disk disease were included in this prospective, controlled study (15 MIS-TLIF group vs. 23 O-TLIF group) after failed conservative treatment. Patients were examined preoperatively, on the first, third, and sixth postoperative day as well as after 2, 4, and 12 weeks postoperatively. Outcome parameters included blood loss, duration of surgery, pre- and postoperative pain (numeric rating scale [NRS], visual analog scale [VAS]), functionality (Timed Up and Go test [TUG]), disability (Oswestry Disability index [ODI]), and quality of life (EQ-5D). Intraoperative blood loss (IBL) as well as postoperative blood loss (PBL) was significantly higher in the O-TLIF group ([IBL O-TLIF 528 ml vs. MIS-TLIF 213 ml, p = 0.001], [PBL O-TLIF 322 ml vs. MIS-TLIF 30 ml, p = 0.004]). The O-TLIF cohort showed significantly less leg pain postoperatively compared to the MIS-TLIF group ([NRS leg 3rd postoperative day, p = 0.027], [VAS leg 12 weeks post-op, p = 0.02]). The MIS group showed a significantly better improvement in the overall ODI (40.8 ± 13 vs. 56.0 ± 16; p = 0.05). After 3 months in the short-term follow-up, the MIS procedure tends to have better results in terms of patient-reported quality of life. MIS-TLIF offers perioperative advantages but may carry the risk of increased nerve root manipulation with consecutive higher radicular pain, which may be related to the learning curve of the procedure.

Environmental sustainability in robotic and laparoscopic surgery: systematic review.

Minimally invasive surgical (MIS) techniques are considered the gold standard of surgical interventions, but they have a high environmental cost. With global temperatures rising and unmet surgical needs persisting, this review investigates the carbon and material footprint of MIS and summarizes strategies to make MIS greener. The MEDLINE, Embase, and Web of Science databases were interrogated between 1974 and July 2021. The search strategy encompassed surgical setting, waste, carbon footprint, environmental sustainability, and MIS. Two investigators independently performed abstract/full-text reviews. An analysis of disability-adjusted life years (DALYs) averted per ton of carbon dioxide equivalents (CO2e) or waste produced was generated. From the 2456 abstracts identified, 16 studies were selected reporting on 5203 MIS procedures. Greenhouse gas (GHG) emissions ranged from 6 kg to 814 kg CO2e per case. Carbon footprint hotspots included production of disposables and anaesthetics. The material footprint of MIS ranged from 0.25 kg to 14.3 kg per case. Waste-reduction strategies included repackaging disposables, limiting open and unused instruments, and educational interventions. Robotic procedures result in 43.5 per cent higher GHG emissions, 24 per cent higher waste production, fewer DALYs averted per ton of CO2, and less waste than laparoscopic alternatives. The increased environmental impact of robotic surgery may not sufficiently offset the clinical benefit. Utilizing alternative surgical approaches, reusable equipment, repackaging, surgeon preference cards, and increasing staff awareness on open and unused equipment and desflurane avoidance can reduce GHG emissions and waste.

Minimally invasive surgery for spinal cerebrospinal fluid-venous fistula ligation: patient series.

BACKGROUNDCerebrospinal fluid–venous fistulas (CVFs) may cause cerebrospinal fluid leaks resulting in spontaneous intracranial hypotension (SIH). Surgical treatment of CVFs aims to eliminate abnormal fistulous connections between the subarachnoid space and the epidural venous plexus at the level of the nerve root sleeve. The authors propose a percutaneous minimally invasive technique for surgical ligation of CVF as an alternative to the traditional open approach using a tubular retractor system.OBSERVATIONSMinimally invasive surgical (MIS) ligation of spinal CVF was performed in 5 patients for 6 CVFs. The definite disconnection of the CVF was achieved in all patients by clipping and additional silk tie ligation of the fistula. None of the patients experienced surgical complications or required transition to an open procedure. One patient underwent 2 MIS procedures for 2 separate CVFs. Postoperative clinical follow-up and cranial magnetic resonance imaging confirmed resolution of symptoms and radiographic SIH stigmata.LESSONSMIS ligation of CVFs is safe and efficient. It represents an elegant and less invasive procedure, reducing the risk of wound infections and time to recovery. However, preparedness for open ligation is warranted within the same surgical setting in cases of complications and difficult accessibility.

Healthcare Resource Utilization After Surgical Treatment of Cancer: Value of Minimally Invasive Surgery

BackgroundAs the US healthcare system moves towards value-based care, hospitals have increased efforts to improve quality and reduce unnecessary resource use. Surgery is one of the most resource-intensive areas of healthcare and we aim to compare health resource utilization between open and minimally invasive cancer procedures.MethodsWe retrospectively analyzed cancer patients who underwent colon resection, rectal resection, lobectomy, or radical nephrectomy within the Premier hospital database between 2014 and 2019. Study outcomes included length of stay (LOS), discharge status, reoperation, and 30-day readmission. The open surgical approach was compared to minimally invasive approach (MIS), with subgroup analysis of laparoscopic/video-assisted thoracoscopic surgery (LAP/VATS) and robotic (RS) approaches, using inverse probability of treatment weighting.ResultsMIS patients had shorter LOS compared to open approach: − 1.87 days for lobectomy, − 1.34 days for colon resection, − 0.47 days for rectal resection, and − 1.21 days for radical nephrectomy (all p < .001). All MIS procedures except for rectal resection are associated with higher discharge to home rates and lower reoperation and readmission rates. Within MIS, robotic approach was further associated with shorter LOS than LAP/VATS: − 0.13 days for lobectomy, − 0.28 days for colon resection, − 0.67 days for rectal resection, and − 0.33 days for radical nephrectomy (all p < .05) and with equivalent readmission rates.ConclusionOur data demonstrate a significant shorter LOS, higher discharge to home rate, and lower rates of reoperation and readmission for MIS as compared to open procedures in patients with lung, kidney, and colorectal cancer. Patients who underwent robotic procedures had further reductions in LOS compare to laparoscopic/video-assisted thoracoscopic approach, while the reductions in LOS did not lead to increased rates of readmission.

42. Do no harm: a retrospective analysis of the initial risk of complications in robotic spine surgery

<h3>BACKGROUND CONTEXT</h3> Incorporation of open and MIS robotic techniques in spine surgery has been growing over the past decade, resulting in altered surgical techniques and the need for newly developed skills. With the initial learning curve involved in using this new technology, the upfront risk of complications and poor outcomes during the learning process has been understudied in the literature. <h3>PURPOSE</h3> To evaluate the initial risk of complications with the incorporation of robotic assisted spine surgery. <h3>STUDY DESIGN/SETTING</h3> Retrospective review of a national patient database between 2007-2016. <h3>PATIENT SAMPLE</h3> A total of 3,759,824 elective spine surgery patients. <h3>OUTCOME MEASURES</h3> Comorbidity burden, perioperative complication rates, year-to-year complications, mechanical complications. <h3>METHODS</h3> Inclusion criteria: elective spine surgery procedures from 2007-2016 as defined by ICD-9-CM and ICD-10-CM codes. Exclusion criteria: emergency, trauma or nonelective surgery. Descriptive statistics assessed demographic information. Rates of open and MIS robot-assisted procedures were assessed, as well as trends in postoperative complications and length of stay. Logistic regressions were performed to see if robotic use was independently predictive of a postoperative complication. <h3>RESULTS</h3> The study included 3,759,824 elective spine surgery patients. Overall, 4,185 patients underwent robotic spine surgery (0.1%). There was a significant increase from in robotic surgery cases from 2010 to 2016 with 11 patients in 2010 to 1,535 patients in 2016 (p<0.001). During this time, 93% of robotic spine cases were open compared to 7% MIS (p<0.001). Relative to nonrobotic patients, robotic-spine patients presented with higher rates of anemia, rheumatoid arthritis, uncomplicated diabetes, hypertension, hypothyroidism, fluid and electrolyte disorders (all p<0.001). Overall, robotic-spine patients had higher overall perioperative complication rates, including cardiac, urinary and anemia (all p<0.001). Postoperatively, year-to-year overall complications in robotic surgery patients increased from 25% in 2011 to 29.6% in 2016 (p <0.001), with a high of 31.8% in 2015. Robotic-open cases compared to robotic-MIS cases were shown to have significantly higher overall complications (28.2 vs 13.6%, p<0.001), including complications associated with anemia and mechanical complications (both p<0.001). <h3>CONCLUSIONS</h3> The rise of robotic assisted spine surgery has yielded a concurrent rise in perioperative complications as surgeons adjust to this new technology. Until the learning curve lessens for incorporation of robotic techniques in spine surgery, providers should weigh MIS or open robotic procedures with an eye towards perioperative complications. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

A proof-of-concept randomized phase 2 non-inferiority trial on simple versus modified radical hysterectomy in IA2-IB1 cervical cancer ≤2cm (LESSER)

Objectives: To evaluate the safety and efficacy of simple hysterectomy in early stage cervical cancer. Methods: The LESSER (LESs Surgical radicality for EaRly stage cervical cancer) study was a proof of concept randomized phase 2 non-inferiority trial evaluating the safety and efficacy of simple hysterectomy compared to modified radical hysterectomy in patients with stages IA2-IB1 cervical cancer and tumors of ≤2cm in size. Primary end-point was 3y-DFS rates and secondary endpoints were 3y-OS (3-year overall survival), surgical morbidity, indication of adjuvant therapy, and QoL (EORTC QLQ-C30). The study was registered at ClinicalTrials. gov (NCT02613286). Results: A total of 40 patients were randomized 1:1 from May 2015 to April 2018 in 3 oncological centers from Northeast Brazil. All cases had pelvic systematic lymph node dissection. Overall, 10% of patients underwent MIS procedures, 80% of tumors were SCC and 7.5% had lymph node metastasis, whereas inaccuracies for clinical tumor size estimation, LVSI and stromal invasion > 1 cm were found in 20%, 22.5% and 30% of cases, respectively. Clinical and pathological characteristics were well balanced between treatment arms, but the length of surgery and the time for bladder catheterization removal were higher after radical hysterectomy (p=0.003 and p=0.043, respectively). There was no postoperative mortality and rates of any grade postoperative complication were not statistically different between arms (15% and 20%; p=1.00). No major differences in the QoL over time were also observed. A quarter of patients received adjuvant therapy, with no significant difference between groups (30% vs. 20%, p=0.48). There was one death at 25 months of follow-up due to pelvic recurrence in the simple hysterectomy arm. A pathological review of this case found tumor embolus in the lymphovascular space of left parametrium that was missed at the time of former anatomopathological analysis. Another patient died of lung metastasis from a second primary thyroid cancer at 54.4 months of follow-up in the radical hysterectomy arm. A major late complication was also recorded after 3 months from radical surgery in a patient with distal urethral stenosis that was treated with segmental resection and psoas-hitch ureteroneocystostomy. Survival outcomes with a minimum of 3y follow-up will be mature for presentation during the SGO 2021 Annual Meeting on Women's Cancer. Conclusions: Simple hysterectomy is a promising substitute for modified radical hysterectomy in stage IA2-IB1 cervical cancer ≤2cm. To evaluate the safety and efficacy of simple hysterectomy in early stage cervical cancer. The LESSER (LESs Surgical radicality for EaRly stage cervical cancer) study was a proof of concept randomized phase 2 non-inferiority trial evaluating the safety and efficacy of simple hysterectomy compared to modified radical hysterectomy in patients with stages IA2-IB1 cervical cancer and tumors of ≤2cm in size. Primary end-point was 3y-DFS rates and secondary endpoints were 3y-OS (3-year overall survival), surgical morbidity, indication of adjuvant therapy, and QoL (EORTC QLQ-C30). The study was registered at ClinicalTrials. gov (NCT02613286). A total of 40 patients were randomized 1:1 from May 2015 to April 2018 in 3 oncological centers from Northeast Brazil. All cases had pelvic systematic lymph node dissection. Overall, 10% of patients underwent MIS procedures, 80% of tumors were SCC and 7.5% had lymph node metastasis, whereas inaccuracies for clinical tumor size estimation, LVSI and stromal invasion > 1 cm were found in 20%, 22.5% and 30% of cases, respectively. Clinical and pathological characteristics were well balanced between treatment arms, but the length of surgery and the time for bladder catheterization removal were higher after radical hysterectomy (p=0.003 and p=0.043, respectively). There was no postoperative mortality and rates of any grade postoperative complication were not statistically different between arms (15% and 20%; p=1.00). No major differences in the QoL over time were also observed. A quarter of patients received adjuvant therapy, with no significant difference between groups (30% vs. 20%, p=0.48). There was one death at 25 months of follow-up due to pelvic recurrence in the simple hysterectomy arm. A pathological review of this case found tumor embolus in the lymphovascular space of left parametrium that was missed at the time of former anatomopathological analysis. Another patient died of lung metastasis from a second primary thyroid cancer at 54.4 months of follow-up in the radical hysterectomy arm. A major late complication was also recorded after 3 months from radical surgery in a patient with distal urethral stenosis that was treated with segmental resection and psoas-hitch ureteroneocystostomy. Survival outcomes with a minimum of 3y follow-up will be mature for presentation during the SGO 2021 Annual Meeting on Women's Cancer. Simple hysterectomy is a promising substitute for modified radical hysterectomy in stage IA2-IB1 cervical cancer ≤2cm.

Preoperative MRI and LDH in women undergoing intra-abdominal surgery for fibroids: Effect on surgical route.

Our institution implemented a preoperative protocol to identify high-risk cases for which power morcellation should be avoided. In this retrospective cohort study, an institutional protocol requiring preoperative Magnetic Resonance Imaging with diffusion-weighted imaging and serum Lactate Dehydrogenase levels was implemented. Chart review was performed including all women who underwent intra-abdominal surgery for symptomatic fibroids from 4/23/2013 to 4/23/2015. A total of 1,085 women were included, 479 before and 606 after implementation of the Magnetic Resonance Imaging / Lactate Dehydrogenase protocol. The pre-protocol group had more post-menopausal women (4% vs. 2%, p = 0.022) and women using tamoxifen (2% vs. 0%, p = 0.022) than those in the post-protocol group, but baseline patient characteristics were otherwise similar between groups. Incidence of malignant pathological diagnoses did not change significantly over the time period in relation to protocol implementation. The rate of open surgery for both hysterectomy and myomectomy remained the same in the year preceding and the year following initiation of the protocol (open hysterectomy rate was 19% vs. 16% in pre- and post-protocol groups, respectively, P = 0.463, and open myomectomy rate was 10% vs. 9% rates in pre- and post-protocol groups, respectively, P = 0.776). There was a significant decrease in the use of power morcellation (66% in pre- and 50% in post-protocol cohorts, p<0.001) and an increased use of containment bags (1% in pre- and 19% in post-protocol cohort). When analyzing the subset of women who had abnormal Magnetic Resonance Imaging / and Lactate Dehydrogenase results, abnormal Magnetic Resonance Imaging results alone resulted in higher rates of open approach (65% for abnormal vs. 35% for normal). Similarly, a combination of abnormal Magnetic Resonance Imaging and Lactate Dehydrogenase tests resulted in higher rates of open approach (70% for abnormal and 17% for normal). Abnormal Lactate Dehydrogenase results alone did not influence route. Rates of MIS procedures were decreased for women with abnormal preoperative Magnetic Resonance Imaging results. False positive results appear to be one of the main drivers for the use of an open surgical route.

Hanging spleno-mesenteric confluence - approach to minimal invasive pancreatoduodenectomy

Presenter: Omero Costa Filho MD, MSc | Hospital Militar de Área de Porto Alegre (HMAPA) Methods: Description of our conventional technique for LPD using hanging maneuver to expose uncinate process with the principles of “artery-first” approach. Results: LPD is performed with the patient placed in a supine, split-leg position and carefully secured to the operative table, and the surgeon on foot between the patient legs, and an assistant at each side. A 12-mm Hasson trocar is placed at about 16 cm from the xyphoid, and a pneumoperitoneum is established. A total of four additional trocars, two 12 mm and two 5 mm, are placed in the abdomen with a semi-circular pattern centered around the head of the pancreas. All the steps to LPD was following our institutional protocol and we focus on uncinate process time. After the surgeon switches position to the right side of the patient, an instrument is used partially open to retract the uncinate process to the right of the patient and dissect freely the splenic mesenteric venous confluence (SMVC). The uncinate process is carefully dissected from the lateral aspect of the superior mesenteric vein (SMV) while small vessels clipped. To best expose, we ligate the gastrocolic trunk (Henle’s trunk) at this time. Then portal vein (PV) and SMV are carefully looped with two penrose drain number 2 to have proximal and distal control, if needed, and to facilitate retraction by the assistant on the left side of the patient. The SMV is retracted medially with penrose. Care must be taken with the first jejunal vein, that was our inferior limit and start point of dissection. The SMA can be found directly under and slightly medial to the SMV. The SMA dissection is carried out using a vessel sealing device. The inferior pancreaticoduodenal artery is usually ligated with clips. During all dissection, release of hanging PV and SMV was done to ensure hepatic inflow. When the dissection found SMVC, we hung the PV with penrose, to expose the mesopancreas and nodes at take off SMA and celiac trunk (CT). A complete, en-bloc resection of the uncinate process is assured, looking to expose SMA and CT emergence from Abdominal Aorta. Conclusion: This is technique description of our actual LPD in approach of uncinate process but can be extend to robotic pancreatic surgery. We continue to track our cases to improve our results with secure issues and oncology outcomes. Until now, with use of initial experience of hanging spleno-mesenteric confluence show a better view of mesopancreas and SMA. Further evaluation with our historical cohort may show beneficial use of our suggestion to such challenge MIS procedure.

Biomechanical evaluation of patients after severe treatment of Achilles tendon Injuries using MIS procedure

Introduction. Achilles tendon is the strongest tendon in the human body. In 1977 Ma and Griffith described the technique of percutaneous anaplasty of the damaged Achilles tendon as a compromise between surgical and conservative treatment. Choosing an operating method that gives “better” treatment results can facilitate the choice of a more effective treatment. Aim. The aim of the study was to evaluate the biomechanics of surgical treatment of patients with Achilles tendon injury using minimally invasive method. Material and Methods. The study material included 31 patients treated surgically for Achilles tendon injury in the Department of Orthopedics and Traumatology of CSK MSW in Warsaw in years 2011-2016. The research group consisted of 27 men and 4 women. Their average age was 40 years. The following research tools were used to evaluate the treatment results: 1. Measuring instrument for maximum force moments in ankle joint JBA “Staniek” 2. HUR stabilographic platform Conclusions. 1 Patients presented a similar balance control on the stabilographic platform in research groups. 2. Higher values of maximum force moments in ankle joint were recorded in healthy limb.

Trends and Outcomes in Minimally Invasive Surgery for Locally Advanced Non–Small-Cell Lung Cancer With N2 Disease

Few studies examine outcomes by surgical approach in non-small-cell lung cancer (NSCLC) with N2 disease. We examined time trends in surgical approach and outcomes among patients undergoing minimally invasive (MIS, robotic and video-assisted thoracoscopic surgery [VATS]) vs open lobectomy in this patient population. We performed a retrospective analysis of patients from the National Cancer Database diagnosed with clinical Stage IIIA-N2 NSCLC from 2010 to 2016. We examined the yearly proportion of MIS vs open resections. Multivariable regression was used to assess the association of surgical approach with length of stay, unplanned readmissions, 30-day and 90-day mortality. Multivariable Cox proportional hazards modeling was used to assess the association of surgical approach with 5-year overall mortality. We identified 5741 patients who underwent lobectomy for Stage IIIA-N2 NSCLC (459 robotic, 1403 VATS, 3879 open). From 2010 to 2016, the proportion of minimally invasive procedures increased from 20% to 45%. MIS patients, on average, stayed 1 day less in the hospital (95% confidence interval [CI] 0.7, 1.5) and had lower odds of 90-day (odds ratio [OR] 0.74; 95% CI 0.54, 0.99) and 5-year mortality (OR 0.82; 95% CI 0.75, 0.91), compared to open resections. There was no difference in odds of readmission by surgical approach (OR 0.97; 95% CI 0.71, 1.33). Among MIS procedures, robotic resections had lower odds of 90-day mortality (OR 0.42; 95% CI 0.18, 0.97) than VATS. Among patients undergoing lobectomy for locally advanced N2 NSCLC robotic and VATS techniques appear safe and effective compared to open surgery and may offer short- and long-term advantages.

P129. Outcome analysis of expandable cage use in transforaminal lumbar interbody fusions

BACKGROUND CONTEXT Expandable cages (EXP) are more frequently utilized in Transforaminal Lumbar Interbody Fusions (TLIF). Designed to reduce complications related to neurological retraction, enable better lordosis restoration, and improve ease of insertion, particularly in the advent of minimally invasive techniques they are exponentially more expensive than the non-expandable (NE) alternate. PURPOSE To investigate the value of expandable cages given the significantly higher cost. STUDY DESIGN/SETTING Retrospective review at a single institution. PATIENT SAMPLE A total of 257 TLIFs between 2012 and 2018 were included. OUTCOME MEASURES Clinical characteristics, perioperative and neurologic complication rates and radiographic measures. METHODS Patients ≥ 18 years of age who underwent single-level TLIF with minimum 1-year follow-up were included. Outcome measures: clinical characteristics, perioperative complications and neurologic complications. Radiographic analysis included change in pelvic incidence-lumbar lordosis (PI-LL), segmental lumbar lordosis (LL), and disc height restoration. Subsidence was radiographically assessed at 1-year follow-up from intraoperative imaging for breaching of the vertebral endplates, measured from the cage endplate to vertebral endplate and defined as a >2mm. Statistical analysis included independent t-tests and chi-square analysis with significance set at p RESULTS A total of 257 TLIFs between 2012 and 2018 were included, with 155 NE (53.5% female, mean age 59.46±14.07, mean BMI 28.69±5.39) and 102 EXP (49% female, mean age 57.78±11.76, mean BMI 28.72±6.01) with no significant differences in demographics. There were significantly more MIS TLIF cases and BMP use in the EXP group (88.2% MIS, p CONCLUSIONS Once technique was controlled for, TLIFs utilizing EXP do not have significantly different neurologic or radiographic outcomes compared to NE. These results question the value of EXP given the higher cost. The findings require further direct comparison in the MIS population because the benefit on outcomes compared to the alternate remains controversial due to the bias towards increased use in MIS procedures. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Validation of low-cost models for minimal invasive surgery training of congenital diaphragmatic hernia and esophageal atresia

BackgroundMinimal invasive surgery (MIS) is increasingly used for the correction of congenital diaphragmatic hernia (CDH) and esophageal atresia (EA). It is important to master these complex procedures, preferably preclinically, to avoid complications. The aim of this study was to validate recently developed models to train these MIS procedures preclinically. MethodsTwo low cost, reproducible models (one for CDH and one for EA) were validated during several pediatric surgical conferences and training sessions (January 2017–December 2018), used in either the LaparoscopyBoxx or EoSim simulator. Participants used one or both models and completed a questionnaire regarding their opinion on realism (face validity) and didactic value (content validity), rated on a five-point-Likert scale. ResultsOf all 60 participants enrolled, 44 evaluated the EA model. All items were evaluated as significantly better than neutral, with means ranging from 3.7 to 4.1 (p < 0.001). The CDH model was evaluated by 48 participants. All items scored significantly better than neutral (means 3.5–3.9, p < 0.001), with exception of the haptics of the simulated diaphragm (mean 3.3, p = 0.054). Both models were considered a potent training tool (means 3.9). ConclusionThese readily available and low budget models are considered a valid and potent training tool by both experts and target group participants. Type of studyProspective study. Level of evidenceLevel II.