Routine Laparoscopic Procedures Research Articles

Efficiency in image-guided robotic and conventional camera steering: a prospective randomized controlled trial

Robotic camera steering systems have been developed to facilitate endoscopic surgery. In this study, a randomized controlled trial was conducted to compare conventional human camera control with the AutoLap™ robotic camera holder in terms of efficiency and user experience when performing routine laparoscopic procedures. Novelty of this system relates to the steering method, which is image based. Patients undergoing an elective laparoscopic hemicolectomy, sigmoid resection, fundoplication and cholecystectomy between September 2016 and January 2018 were included. Stratified block randomization was used for group allocation. The primary aim of this study was to compare the efficiency of robotic and human camera control, measured with surgical team size and total operating time. Secondary outcome parameters were number of cleaning moments of the laparoscope and the post-study system usability questionnaire. A total of 100 patients were randomized to have robotic (50) versus human (50) camera control. Baseline characteristics did not differ significantly between groups. In the robotic group, 49/50 (98%) of procedures were carried out without human camera control, reducing the surgical team size from four to three individuals. The median total operative time (60.0 versus 53.0min, robotic vs. control) was not significantly different, p = 0.122. The questionnaire showed a positive user satisfaction and easy control of the robotic camera holder. Image-based robotic camera control can reduce surgical team size and does not result in significant difference in operative time compared to human camera control. Moreover, robotic image-guided camera control was associated with positive user experience.

Case Report: Pelvic abscess formation secondary to the use of commercial hemostatic topical agent in an immunocompromised patient?

Various hemostatic agents are currently available for routine laparoscopic procedures, avoiding thermal lesions due to energy devices and the complexity of intracorporeal sutures, however, evidence of complications in immunocompromised patients is still lacking.

Evaluation of Subendometrial and Intramyometrial Blood Flow after Intravenous Tranexamic Acid for Prevention of Postpartum Hemorrhage in Vaginal Delivery: A Randomized Controlled Study

Various hemostatic agents are currently available for routine laparoscopic procedures, avoiding thermal lesions due to energy devices.

RESULTS OF OPERATIONS IN COLON SURGERY WITH USAGE OF LAPAROSCOPIC TECHNIQUE AND ROBOTIC ASSISTANCE

The analysis of short-term results of 117 laparoscopic and 16 robotic-assistant colon surgeries, performed in NMSC N.I.Pirogov between January 2011 and May 2015 was undertaken. There were 90 resections for colon cancer, 31 for diverticular disease and one for megacolon. Also results of 11 reconstructive operation after Hartmann procedure was investigated. In 74 cases of cancer operation were performed with mesocolonectomy and central vessels ligature. In 16 patients sceletization of inferior mesenteric artery and paraortal lymphadenectomy was performed. Morbidity rate was 11,3 % among all patients. The use of robotic technology in colon surgery is not an optimal option due to low cost effectiveness and prolonged operating time comparing to those after routine laparoscopic procedures.

Unusual Drainage of the Right Testicular Vein: A Case Report

Routine dissection was carried out on a 75-year-old male cadaver and the drainage pattern of the testicular veins was identified and photographed. Dissection showed that the right testicular vein demonstrated an abnormal drainage pattern by terminating into the right renal vein. The left testicular vein demonstrated a normal drainage pattern by terminating into the left renal vein. The unusual drainage of the right testicular vein into the right renal vein may complicate hemodynamics thus causing a varicocele. Complications of a varicocele could lead to testis atrophy and/or infertility. Knowing the anatomical variants of the testicular veins drainage pattern may help the surgeon avoid potential complications during routine laparoscopic procedures and may also uncover a reason for male infertility.

Surgeons strive hard to break the Da Vinci code

Although performing effective laparoscopic gastrectomy remains a challenge, especially for cancer in the upper part of the stomach and for advanced-stage cancer, it is no longer considered a topic of great interest in terms of novelty. Current new topics on gastric cancer surgery in the Japanese surgical meetings are more or less focused on single-incision laparoscopic surgery (SILS, or reduced-port surgery) [1] and robotic surgery, both of which should be attempted only by surgeons who are armed with significant expertise in laparoscopic surgery. Perhaps these two techniques could be related to each other in that novel robotic devices that would greatly facilitate surgical procedures in the SILS approach may appear in future [2]. However, the current aims of robotic (or Da Vinci) surgery and SILS in gastric cancer surgery are completely different. To the eyes of this narrow-minded editor, SILS can be viewed as a highly demanding procedure with modest, if any, benefit and with potential harm to the patient. Any highly skilled surgeon who can accomplish gastrectomy by the SILS approach will undoubtedly be able to more comfortably perform the same surgery through the ‘‘conventional’’ laparoscopic approach without greater cost or additional risk of disease recurrence. A greater proportion of people, this editor included, would gladly accept accommodating a few more ‘‘holes’’ measuring 5 mm in diameter if he or she could then expect to receive surgery utilizing a wellestablished and more secure technique. On the other hand, Da Vinci gastrectomy could currently be viewed as a highly expensive procedure with little benefit to the patient, because a patient concedes a similar number of ‘‘holes’’ as the ‘‘conventional’’ laparoscopic approach, whereas a proficient laparoscopic surgeon who is qualified to operate a Da Vinci system in Japan would easily perform gastrectomy laparoscopically. This fact does not reflect the true value of the Da Vinci system, however. The Da Vinci system has strengths such as additional degrees of freedom, elimination of the fulcrum effect, three-dimensional vision that can be magnified, and reduced human tremor along with several other benefits [3]. After sufficient training, a surgeon should be able to perform finer and more complex surgical procedures, particularly suturing and knot-tying in demanding situations such as pancreaticojejunostomy. In addition, the robot would certainly be able to give meaningful assistance to the older generation of surgeons who have difficulty adjusting to techniques peculiar to laparoscopic surgery. In other words, it would enable proficient laparoscopic surgeons to add extra meticulous touches to their routine laparoscopic procedures and then to expand their repertoire to include more complex types of surgery. At the same time, Da Vinci might be able assist surgeons who are familiar only with open surgery to step into the area of minimally invasive surgery with a more favorable learning curve. Unfortunately, the learning curve issue has only been discussed in situations in which an established laparoscopic surgeon challenged robotic surgery [4]. Somewhat paradoxically, only proficient laparoscopic surgeons who can perform gastrectomy laparoscopically without any help from either an instructor or a robot are considered appropriate to seek assistance from this device in Japan, which is essentially because Da Vinci has not been approved by their social insurance system. Use of an unapproved drug This editorial refers to the article doi:10.1007/s10120-013-0293-3.

How to Meet the Challenge of Flexible Exposure of the Calot Triangle in SILS Cholecystectomy

Single-incision laparoscopy was developed to further reduce the operative trauma in routine laparoscopic procedures. However, the method remains challenging because the exposure of the Calot triangle is more difficult as the use of a singular traction device does not allow the flexible 3-dimensional mounting of the structures. We introduce a technical improvement involving both exposure and traction. After installation of the technical devices for single-incision laparoscopy cholecystectomy, as usual, a suture on a Keith needle is inserted subcostally from the right side of the patient, passed midway through the infundibulum, and extracted subcostally on the left side of the patient. The suture is fixed with 2 metal clips on each side of the gallbladder. The gallbladder can be tilted both medially and laterally on a horizontal line and the Calot triangle can be dissected from medial and lateral aspects following the "critical view of safety" criteria used in conventional laparoscopy.

Lift laparoscopy in dogs and cats: 12 cases (2008–2009)

To describe clinical and physiologic changes during lift laparoscopy in dogs and cats and determine immediate surgical outcome. Retrospective case series. Client-owned dogs (n = 7) and cats (5). A custom-made lift device was used to retract the abdominal wall for laparoscopic instrumentation. The lift device was used first in 3 dog cadavers to assess the risk of complications. Thereafter, the device was used for routine laparoscopic procedures in client-owned animals. Data collected from medical records included signalment, body weight, clinical signs, diagnosis, surgery type and duration, conversion from laparoscopic to open surgery, preoperative American Society of Anesthesiologists score, mean intraoperative respiratory rate, mean and peak end-tidal partial pressure of CO(2) during the laparoscopic surgery, ventilation method, mean saturation of hemoglobin with O(2), mean and systolic arterial pressures during the laparoscopic surgery, total anesthesia time, signs of pain immediately after recovery, duration of hospitalization, and postoperative complications. Lift laparoscopy was successfully performed in 10 of the 12 patients. No adverse effects were noted with the use of this technique. However, in 1 dog and 1 cat, conversion to laparotomy was necessary because of poor visualization. Results suggested that lift laparoscopy is feasible in dogs and cats and is an option that can be used in clinical practice, especially if creation of positive-pressure pneumoperitoneum is not desirable.

Veress Needle: A Simple Liver Retraction Technique for Lap Band Positioning in (Single Incision Laparoscopic Technique) SILS

To the Editor:Sir,We read with interest the recent articles of Nguyen et al. [ 1]and of Reavis et al. [ 2] reporting their experience withadjustable gastric banding and sleeve gastrectomy, respec-tively, utilizing a novel minimally invasive surgical approach:single incision laparoscopic surgery (SILS).Recent publications confirm the rapid increase in the useof SILS, not only for bariatric surgery but for a wide rangeof routine laparoscopic procedures [3–10]. In most of thepublished reports, it is argued that SILS has the potentialadvantage of reduced post-operative pain and port-sitecomplications, as well as being virtually ‘scarless’. Optimalcosmetic outcomes would seem to be especially relevant topatientsundergoinggastricbanding,whoareoftendisappoint-ed with the degree of post-operative scarring. The standardapproach to band implantation typically requires a 3- to 4-cmincision for the access port site, together with three to foursmaller (5–10 mm) trocar incisions. Where technicallyfeasible, therefore, a SILS approach would appear to be anattractive alternative.A key problem in the application of SILS to gastricbanding (and other gastric surgeries) is how to achieveadequate retraction of the liver, without resorting to thestandard trocar placement.Huang et al., in order to retract left liver lobe for aSILS procedure of a gastric bypass, proposed a systemconsisting of a Jackson–Pratt drainage penetrated with a2-0 Prolene and fixed with Kelly clamps at the skin [11].As the author confirmed, mean time to carry out thisprocedure is 5 min.Hamzaoglu et al. [12], in order to carry out a singleincision Nissen fundoplication and considering a left liverretraction system of Sakaguchi et al’s lap gastrectomy [13],adopted a Penrose drain of 8 cm long and 1 cm large tiedwith two silk sutures of 10 cm in length and fixed at theskin externally. Also, in this case, the procedure isconsidered fixed and carried out for 5–7 min.Tanigawa [14] as well proposed, for a laparoscopicesophagogastric procedure, a 17-cm-long and 6-mm-largehand-made Penrose drain fixed with three heavy ties alongits length at the peritoneum.More recently, Ganta [15] proposed the ‘Ganta stitch’ forleft lobe liver retraction in single incision LapBand. Itconsists of a 2-0 Ethibond suture placed from the crura of

“Single-Port” Laparoscopic Cholecystectomy—The Aberdeen Technique

Laparoscopic cholecystectomy remains the most frequently performed minimally invasive operation for general surgeons. The next step toward "scar-less" surgery uses a modified single multichannel port inserted through the umbilicus. The use of a single port requires modification of the currently established technique for laparoscopic cholecystectomy with a single-port protocol. This new method presents a few technical difficulties and challenges compared with the conventional 3-port or 4-port laparoscopic cholecystectomy. We discuss maneuvers to help overcome these difficulties based on our initial experiences. All the data for the procedures that were performed were prospectively collected and analyzed. Single port cholecystectomy was attempted in 30 patients (all females) with no intraoperative/postoperative complications from September 2008 to March 2008. In all, 20 of 30 patients had their operation completed with the use of a single port. An extra 5-mm epigastric port was required in 8 of the 20 patients. Another 2 of 20 patients required conversion of the operation into a standard laparoscopic technique (1x3-port and 1x4-port procedure). All the patients were discharged within 24 hours. There were no intraoperative or postoperative complications or mortalities. The single-port technique is feasible for performing routine laparoscopic procedures. With further advances in surgical technique, technology, and instrumentation, this technique can be reproduced to perform more complex biliary and other procedures in future.

Can a structured checklist prevent problems with laparoscopic equipment?

A high incidence of problems with the technical equipment is known to occur during routine laparoscopic procedures. Use of a structured checklist of preparatory measures could help to prevent these problems. This study aimed to determine the extent to which a checklist reduced the number of incidents with technical laparoscopic equipment. A 28-item checklist was developed based on frequently occurring laparoscopic equipment problems during 30 laparoscopic cholecystectomies (the control group). A further 30 procedures were conducted with the checklist (the checklist group). The number and type of incidents with the technical equipment were compared between the groups. All the procedures were recorded using a special audio-video system (black-box). In the checklist group, the total number of incidents per procedure was 53% lower than in the control group (23/30 versus 49/30). The checklist led to fewer incidents of wrong positioning (9/30 versus 22/30), and wrong settings and connections (7/30 versus 12/30) of the equipment. Defects or malfunctions decreased from 15/30 in the control group to 7/30 in the checklist group. One or more incidents with the equipment occurred in 47% (14/30) of the checklist procedures compared with 87% (26/30) of the control procedures. Median time taken to complete the checklist items was 3.3 min (range 1.0-8.3 min). Use of a checklist was feasible and helped to reduce problems with the laparoscopic equipment in the operating room. Future research should aim to implement checklists for different procedures and investigate their effects.

Changes in pH of peritoneal fluid associated with carbon dioxide insufflation during laparoscopic surgery in dogs

To evaluate changes in pH of peritoneal fluid associated with CO2 insufflation during laparoscopy in dogs. 13 client-owned dogs and 10 purpose-bred teaching dogs. Laparotomy was performed on control dogs; peritoneal fluid pH was measured at time of incision of the abdominal cavity (time 0) and 30 minutes later. Laparoscopic insufflation with CO2 was performed and routine laparoscopic procedures conducted on the teaching dogs. Insufflation pressure was limited to 12 mm Hg. Intraperitoneal fluid pH was measured by use of pH indicator paper at 4 time points. Arterial blood gas analysis was performed at the same time points. Peritoneal fluid pH did not change significantly between 0 and 30 minutes in the control dogs. For dogs with CO2 insufflation, measurements obtained were a mean of 8.5, 24.5, 44.5, and 72.0 minutes after insufflation. The pH of peritoneal fluid decreased significantly between the first (7.825 +/- 0.350) and second (7.672 +/- 0.366) time point. Blood pH decreased significantly between the first (7.343 +/- 0.078), third (7.235 +/- 0.042), and fourth (7.225 +/- 0.038) time points. The PaCO2 increased significantly between the first (39.9 +/- 9.8 mm Hg) and fourth (54.6 +/- 4.4 mm Hg) time points. Base excess decreased significantly between the first and all subsequent time points. Pneumoperitoneum attributable to CO2 insufflation caused a mild and transient decrease in peritoneal fluid pH in dogs. Changes in peritoneal fluid associated with CO2 insufflation in dogs were similar to those in other animals.

Analysis of Procedure Time in Robot-Assisted Surgery: Comparative Study in Laparoscopic Cholecystectomy

Introduction: Robotic surgery systems have been introduced to deal with the basic disadvantages of laparoscopic surgery. However, working with these systems may lead to time loss due to additional robot-specific tasks, such as set-up of equipment and sterile draping of the system. To evaluate loss of time in robot-assisted surgery, we compared 10 robot-assisted cholecystectomies to 10 standard laparoscopic cholecystectomies.Materials and Methods: The robot-assisted procedures were performed with the da Vinci telemanipulation system. The total time in the operating room (OR) was scored and divided into preoperative, operative, and postoperative phases. These phases were further divided into smaller timeframes to precisely define moments of time loss.Results: The most significant difference between the two groups was found in the preoperative phase. Robot-related tasks led to time loss in all time-frames of this phase. In the operative phase, the trocar entry time-frame was longer in robot-assisted cases than in standard procedures. Additionally, postoperative OR clearing was longer in the robot-assisted cases. Total operating time did not differ significantly between the two procedures.Conclusion: Robot-assisted surgery leads to time loss during preparation of routine laparoscopic procedures.