Total Operative Time Research Articles

3D Imaging Reconstruction and Laparoscopic Robotic Surgery Approach to Disseminated Peritoneal Leiomyomatosis

ObjectivesThis video article explores the synergistic approach of 3D imaging reconstruction and laparoscopic robotic surgery for the management of a complex case of disseminated peritoneal leiomyomatosis (1). The primary focus lies in the capability of the reconstruction model to provide diagnostic support to identify fibroids during surgical procedures, potentially enhancing surgical precision, reducing operating times, minimizing uterine incisions, and limiting blood loss. 3D imaging reconstruction techniques were used to facilitate the identification of multiple parasitic and non-serosal myomas, which is particularly challenging when operating with a robotic surgical platform that lacks haptic feedback. SettingTertiary referral center. ParticipantsA case report design was employed, focusing on a 43-year-old nulliparous infertile woman with multiple symptomatic uterine myomas. Our institution has made a further diagnosis of disseminated peritoneal leiomyomatosis(4-5). InterventionsDue to the widespread nature of peritoneal leiomyomatosis and numerous uterine fibroids, robotic surgery was considered a preferable option based on our experience to operate within confined anatomical spaces. 3D imaging reconstruction technology was utilized for preoperative and intraoperative planning, enabling precise determination of the fibroids' location, size, and volume obtained through MRI imaging. Real-time 3D imaging guided rapid myoma localization and surgical strategy adjustment (2-3). The procedure resulted in the removal of 15 fibroids, with minimal blood loss (250 mL) and a total operative time of 120 minutes. Multilayer running hysterorraphy was performed using a barbed monofilament suture to ensure effective hemostasis, incorporating serosal introflection to reduce the risk of post-operative adhesion development. ConclusionsThe combined approach of 3D imaging reconstruction and laparoscopic robotic surgery holds significant potential for the management of disseminated peritoneal leiomyomatosis. This approach can overcome some robotic surgery limitations, particularly the absence of haptic feedback, providing accurate preoperative planning and real-time intraoperative guidance, facilitating efficient fibroid localization, minimizing uterine incisions, and reducing blood loss. Further research is needed to fully evaluate the clinical impact of this promising technology.

Operative Times and Outcomes of Complex Endovascular Repairs of Thoracoabdominal Aneurysms

IntroductionOwing to the significant morbidity and mortality of open thoracoabdominal aortic aneurysm surgery, complex endovascular repairs (eTAAA) have become increasingly common, but still carry substantial risk. These repairs require large bore access, with resultant pelvic and lower extremity ischemia. We therefore hypothesized that operative timing would be associated with outcomes, as efficient surgery would limit the ischemic time as well as anesthesia time. MethodsWe studied all eTAAA repairs (Crawford Types 1-3, 5) incorporating at least one branch vessel from 2014 to 2021 in the Vascular Quality Initiative, and categorized them into quartiles of total operating time. To account for variations in case complexity and intraoperative events, we performed a sub-analysis stratifying each surgeon by their median operating time. Multilevel logistic regression was employed to compare perioperative outcomes including mortality, thoracoabdominal life altering events (TALE:composite of perioperative death, stroke, permanent paralysis and/or dialysis), spinal cord ischemia (SCI), acute kidney injury (AKI), major adverse cardiac events (MACE), myocardial infarction, and dialysis. ResultsThere were 2,925 eTAAA repairs during the study period. Procedure times ranged from <204 minutes in the first quartile to >365 minutes in the fourth. Longer cases more commonly involved older patients who were more often female, and higher rates of prior stroke, and preoperative anemia. They involved larger, more extensive aneurysms, with higher rates of prior aortic surgery, and more commonly employed PMEGs or parallel grafting to incorporate more branch vessels. In addition, they were less often staged procedures, and used more spinal drains, femoral cutdowns, and upper extremity access. Operating time decreased as experience increased. In adjusted analyses, the odds of mortality and every morbidity studied increased stepwise with operating time, with 4 to 13-fold higher odds in the highest quartiles. Spinal cord ischemia had the strongest association with procedure times, with seven-fold higher odds (OR 7.2 [2.9-17.9], P<.001) of any SCI in the highest quartile compared to the lowest, and 13-fold higher odds of permanent SCI (OR 13.1 [3.9-44.7], P<.001). These results were consistent when surgeons were grouped into quartiles by their median operating times. Medium-term mortality was also higher in the upper quartile of operating time (HR 2.7 [1.4-5.1], P=.002). ConclusionLonger operating times for complex eTAAA repairs were associated with markedly higher rates of morbidity and mortality, especially spinal cord ischemia. These results emphasize the importance of expeditious repairs by experienced teams.

Synergetic UPQC Application for Power Quality Enhancement in Microgrid Distribution System: SCSO Approach

Nowadays, Hybrid renewable energy systems (HRES) are increasingly being integrated into grid-connected load systems to lower losses and boost dependability. When the HRES system is connected to the grid system to satisfy needed load demand, power quality issues arise because of imbalanced load circumstances, non-linear load, and critical load. So this manuscript proposed a synergetic Unified Power Quality Conditioner (UPQC) application for power quality enhancement in microgrid distribution systems. The Sand Cat Swarm Optimization (SCSO) technique is based on the proposed sand cat swarm optimization method. The proposed strategy's primary goal is to regulate power flow, minimize harmonic distortion in both voltage and current waveforms, and maximize UPQC. By then, the proposed method's performance has been implemented into practice on the MATLAB platform and contrasted with several currently used techniques. The proposed technique displays the low Total Harmonic Distortion (THD) and operation time in all existing approaches like Moth Flame Optimization (MFO), Genetic Algorithm (GA), Salp Swarm Algorithm (SSA), Ant Lion Optimizer (ALO), Improved Bat Search Algorithm (IBSA), Lion Algorithm (LA), Artificial Bee Colony (ABC), Atom Search Optimization (ASO) and Crow Search Algorithm (CSA). The proposed method attains THD as before UPQC is 31%, after UPQC is 3%, load current is 1.42%, and load voltage is 2%. It also achieves a low operation time of 506ms and a low settling time of 0.15s compared to the existing methods. The significant improvement in power quality metrics demonstrates the effectiveness of the proposed SCSO technique.

Improving surgical technical skills for emergency fixation of unstable pelvic ring fractures: an experimental study using a pelvic ring fracture simulator

BackgroundThe management of hemodynamically unstable pelvic ring injuries necessitates surgical intervention, often involving procedures such as external fixation and percutaneous screw placement. Given the infrequent performance of these procedures, regular training is imperative to ensure readiness for emergencies. Our pre- post simulation study aimed to adapt and validate a realistic simulation model for stabilizing unstable pelvic ring injuries, facilitating participants’ knowledge retention and procedural confidence enhancement.MethodsA standardized simulator of an unstable pelvic ring utilizing synthetic pelvic bones featuring complete disruption of the symphysis and sacroiliac joint was developed. Trauma surgeons of a level one academic hospital were invited to perform external fixation and emergency sacroiliac screw application under C-arm guidance. Prior to and following the simulation session, participants completed a subjective questionnaire assessing their confidence in emergency interventions on a 10-point Likert scale (10-LS). Objective parameters, such as intraoperative imaging quality, reduction accuracy, and the positioning of screws, wires, and external fixators, were also evaluated as secondary outcome measures.ResultsFifteen trauma surgeons (10 residents, 5 consultants) participated in the simulation over the course of one day. The mean total operation time was 20.34 ± 6.06 min, without significant differences between consultants and residents (p = 0.604). The confidence for emergency SI-Screw placement increased significantly after the simulator (10-LS: Before = 3.8 ± 3.08 vs. After = 5.67 ± 2.35; p = 0.002) as well as after external fixation (10-LS: Before = 3.93 ± 2.79 vs. After = 6.07 ± 2.52; p = 0.002). In addition, confidence in (intraoperative) pelvic imaging increased significantly (10-LS: Before = 4.60 ± 3.0 vs. After = 6.53 ± 2.39; p = 0.011). Overall, the model was rated as a realistic simulation of clinical practice (10-LS = 7.87 ± 1.13).ConclusionsOur unstable pelvis fracture model is a tool to practice emergency interventions such as external fixation and percutaneous techniques. Participants benefitted from this in terms of technical instrumentation as well as intraoperative imaging. Further studies are required to validate the objective benefits and improvements that participants undergo through frequent training.

Novel Retractor–Camera System Facilitates Less Traumatic Minimally Invasive Procedures and Declutters the Operation Field

Objective: To develop a novel endoscopic system that reduces trauma to the patient and declutters the surgical field for the surgeon in minimally invasive heart valve surgery. Methods: We designed and developed a retractor–camera combination for minimally invasive heart surgery; the cable and camera were connected to the underbelly of the left atrial retractor blade to provide an illuminated, wide-angle view of the mitral valve. We conducted ex vivo, in vivo, and, ultimately, a first-in-man randomized, nonanonymized clinical trial on 20 patients who required minimally invasive mitral valve surgery. Data from the preoperative period and the immediate postoperative period were gathered, and patients were followed for 3 months. Results: Our camera–retractor combo demonstrated safe and efficient exposure and vision in all detailed studies. The total operation time for the intervention group (316.5 ± 65.1 min) was slightly shorter than for the control group (317.5 ± 50.8 min). There was no significant difference in the ability to provide exposure of the mitral valve and surrounding left atrial tissue for both control and test articles. The novel camera–retractor reduced clutter in the operation field substantially and eliminated chest penetration for the camera. We also observed that the camera did not fog, did not stain with blood, and did not require frequent corrections to its position. Conclusions: We launch a novel atrial retraction–imaging platform that is less invasive for the patient and eliminates clutter and redundant movements for the surgeon.

Indocyanine green in laparoscopic cholecystectomy: utility and correlation with a preoperative risk score

BackgroundThis study aims to compare the visualization of the cystic duct-common bile duct junction with indocyanine green (ICG) among 3 groups of patients divided according to the difficulty of elective laparoscopic cholecystectomy. MethodsConducted at a single center, this non-randomized, prospective, observational study encompassed 168 patients who underwent elective laparoscopic cholecystectomy and were assessed with a preoperative risk score to predict difficult cholecystectomies, including clinical factors and radiological findings. Three groups were identified: low, moderate, and high risk. A dose of 0.25 mg of IV ICG was administered during anesthesia induction and the different objectives were evaluated. ResultsThe visualization of the cystic duct-common bile duct junction was achieved in 28 (100%), 113 (91.1%), and 10 (63%) patients in the low, moderate, and high-risk groups, respectively. The high-risk group had longer total operative time, higher conversion, more complications and longer hospital stay. In the surgeon’s subjective assessment, ICG was considered useful in 36% of the low-risk group, 58% in the moderate-risk group, and 69% in the high-risk group. Additionally, there were no cases where ICG modified the surgeon’s surgical approach in the low-risk group, compared to 11% in the moderate-risk group and 25% in the high-risk group (p < 0.01). ConclusionsThe results of this study confirm that in the case of difficult cholecystectomies, the visualization of the cystic duct-common bile duct junction is achieved in 63% of cases and prompts a modification of the surgical procedure in one out of four patients.

Total Venous Control and Vein-to-the-Right Superior Mesenteric Artery Approach in Robotic Pancreatoduodenectomy.

Robotic pancreatoduodenectomy is an increasingly accepted alternative for the treatment of pancreatic ductal adenocarcinoma (PDAC).1 However, the ability to perform a meticulous robotic-assisted superior mesenteric artery (SMA) dissection to obtain a margin-negative resection remains unknown.2 PDAC within the head of the pancreas (HOP) that involves the superior mesenteric vein (SMV) and portal vein (PV) requires total venous control (TVC) and a 'vein-to-the-right' (or anterior artery-first) approach to SMA dissection to minimize venous congestion and operative blood loss.3-5 Here, we demonstrate a robotic pancreatoduodenectomy with TVC and a 'vein-to-the-right' approach. A 70-year-old woman with cT2N0M0 HOP PDAC with lateral SMV involvement and right gastroepiploic vein occlusion underwent robotic pancreatoduodenectomy after neoadjuvant chemotherapy. After transecting the pancreas, we achieved TVC by dividing the small venous tributaries and encircling the SMV, splenic vein, and PV. We then proceeded with a 'vein-to-the-right' approach. The inferior pancreatoduodenal arteries were divided to minimize HOP inflow and decrease specimen bleeding. Once the specimen was dissected off the periadventitial plane of the distal SMA, the SMV dissection was carefully performed using a partial side-wall vein resection using a vascular stapler. Total operative time was 7.5h and estimated blood loss was 25mL. The patient recovered well postoperatively and was discharged on postoperative day 3. Final pathology exhibited a 2.4cm, moderately to poorly differentiated adenocarcinoma with negative margins (ypT2N1, 2/38 lymph nodes positive). For tumors with lateral vein involvement, robotic pancreatoduodenectomy can be safely performed via TVC and a 'vein-to-the-right' approach.

Analysis of operative duration of image-guided brachytherapy for cervical cancer.

The present study aimed to analyze the operative duration of image-guided brachytherapy (IGBT) for cervical cancer performed at our institution. We enrolled cervical cancer patients who had undergone tandem and ovoid-based intracavitary brachytherapy (ICBT) or intracavitary and interstitial brachytherapy (IC/ISBT) between 2020 and 2024. Cone beam computed tomography (CBCT), CT, or CT + MRI were used for IGBT. For each IGBT session, we retrospectively reviewed the following: application time (AT-defined as the duration from entry into the operating room to the initial image acquisition); planning time (PT-defined as the duration from the initial image acquisition to the start of irradiation); and total operation time (TOT- defined as the duration from entry to exit of the operating room). We analyzed atotal of 126 sessions in 36patients, consisting of 99ICBT-only sessions and 27IC/ISBT sessions. The IC/ISBT sessions had asignificantly longer mean operative duration than the ICBT-only sessions. The IC/ISBT sessions with three or more interstitial needles had significantly longer AT and TOT. However, the IC/ISBT sessions with one needle showed no significant difference in operative duration compared to ICBT-only sessions. CBCT, CT, and CT + MRI were used in 42, 76, and 8sessions, respectively. In the ICBT patients, CT + MRI had the longest PT. However, there was no significant differences in TOT among CBCT, CT, and CT + MRI. IC/ISBT sessions with one needle had no significant difference in operative duration compared to ICBT-only sessions. There was no significant difference in TOT between CT + MRI-based IGBT and CT-based IGBT.

Barbed suture in laparoscopic myomectomy.

Uterine myomas are the most common benign gynecological tumors among women of reproductive age. The laparoscopic approach, when feasible, is considered the most suitable and safe technique for intervention. Typically, uterine muscular wall defects are sutured with absorbable filaments. However, performing intra-corporeal knots during laparoscopic procedures demands significant surgical abilities and experience. While laparoscopic myomectomies are often recommended, they pose a high risk of hemorrhage. Barbed sutures may address the challenges of laparoscopic knotting due to their inherent barbs, leading to filament cohesion with tissues. This characteristic could potentially reduce the total operative time and blood loss during surgery. In consideration of the latest literature meta-analysis on the topic, published in 2018 and cited in the present work, six papers were included in this review, excluding case reports, reviews and articles without a control group. The objective of this narrative review is to explore the literature and establish the safety profile of barbed suture compared to conventional laparoscopic sutures. Additionally, given the potential for postoperative adhesion formation with the use of barbed sutures, the review also emphasizes reproductive outcomes. Consistent with previous literature, patients undergoing barbed suture laparoscopic myomectomy experienced significantly lower suturing time and blood loss. Regarding obstetric outcomes, all studies analyzing this aspect concluded that barbed sutures in myomectomy are as safe as, and represent an easier alternative to, conventional sutures. Importantly, these findings did not adversely affect pregnancy outcomes.

Free vastus lateralis flap combined with skin grafting for repairing small- and medium-sized lacunar defects in non-weight-bearing area of diabetic foot

To explore the feasibility and effectiveness of free vastus lateralis flap combined with skin grafting for repairing small- and medium-sized lacunar defects in the non-weight-bearing area of diabetic foot. Between January 2022 and October 2023, 8 patients (8 feet) with small- and medium-sized lacunar defects in the non-weight-bearing area of diabetic foot were admitted. There were 6 males and 2 females, with an average age of 64.3 years (range, 58-76 years). The duration of the diabetic foot ulcer ranged from 2 to 7 weeks (mean, 4.3 weeks). The wound was located between the metatarsal bones in 4 cases, on the medial side of the foot in 2 cases, on the lateral side of the foot in 1 case, and on the dorsal and lateral sides of the foot in 1 case. The length of wound was 4.0-12.0 cm, the width was 3.0-5.0 cm, and the depth was 1.2-2.0 cm. The free vastus lateralis flaps were designed to repair the wounds, and skin grafting covered the vastus lateralis flaps. The length of the vastus lateralis flap was 5.0-14.0 cm, the width was 3.5-6.0 cm, and the thickness was 1.0-1.5 cm. The donor sites of the muscle flaps were directly sutured. The time for vastus lateralis flaps harvested ranged from 30 to 80 minutes (mean, 55.0 minutes), and the total operation time ranged from 125 to 170 minutes (mean, 147.5 minutes). All muscle flaps and skin grafts survived successfully, and the wounds and the incisions at the donor sites healed by first intention. All patients were followed up 6-24 months, with an average of 12.8 months. The appearances of 3 patients who did not follow the doctor's instructions for pressure treatment of the muscle flaps were a little bloated, and the rest had a good appearance. The texture of the muscle flaps was soft. There were linear scars at the donor sites. There was no recurrence of ulcers during follow-up. All patients could walk independently without limitation of daily activities at last follow-up. The application of free vastus lateralis flap combined with skin grafting to repair small- and medium-sized lacunar defects in the non-weight-bearing area of diabetic foot has the advantages of simple operation and time-saving as well as small damage to the donor site, with good repair effect, especially for the elderly patients who are not suitable for prolonged anesthesia.

Application of modified extralevator abdominoperineal excision for low rectal cancer resection.

Laparoscopic ELAPE surgery has been carried out in our center for a long time, and some modifications have been made in clinical practice. In this study, we compared conventional ELAPE operation with modified ELAPE operation to investigate the efficacy and safety of modified ELAPE operation. We retrospectively analyzed the data from 339 patients with low rectal cancer undergoing abdominoperineal resection from 2017 to 2021 in the Department of General Surgery, Qilu Hospital of Shandong University. Patients were classified into modified ELAPE groups (199 patients) and conventional ELAPE groups (140 patients). Total operation time, reconstruction time, postoperative hospital stay, total cost, intraoperative data, postoperative short-term and long-term complications and tumor recurrence were compared. The baseline characteristics were comparable between the two groups. Total operation time was less with modified ELAPE group compared to conventional ELAPE group (190.6 ± 33.1min vs 230.1 ± 51.6min, P = 0.022). Pelvic floor reconstruction time was also less with modified ELAPE group compared to conventional ELAPE group (4.3 ± 1.2min vs 11.9 ± 1.7min, P = 0.004). Positive CRM was observed in 11 and 9 patients in modified ELAPE groups and conventional ELAPE groups (P = 0.744). IOP occurred in 12 and 7 patients in modified ELAPE group and conventional ELAPE group (P = 0.701). Total cost was also less with modified ELAPE group compared to conventional ELAPE group (9004 ± 1146 USD vs 10,336 ± 2047 USD, P = 0.031). The incidence of parastomal hernia was less with modified ELAPE group compared to conventional ELAPE group (7/199 vs 22/140, P < 0.001). Three-year follow-up data did not show any difference in overall survival rate or local occurrence between the two groups. Modified ELAPE surgery is technically safe and feasible, and oncologically comparable to that of conventional ELAPE surgery, which can be considered for popularization and application.

Development of Machine Learning Models for Predicting the 1-Year Risk of Reoperation After Lower Limb Oncological Resection and Endoprosthetic Reconstruction Based on Data From the PARITY Trial.

Oncological resection and reconstruction involving the lower extremities commonly lead to reoperations that impact patient outcomes and healthcare resources. This study aimed to develop a machine learning (ML) model to predict this reoperation risk. This study was conducted according to TRIPOD + AI. Data from the PARITY trial was used to develop ML models to predict the 1-year reoperation risk following lower extremity oncological resection and reconstruction. Six ML algorithms were tuned and calibrated based on fivefold cross-validation. The best-performing model was identified using classification and calibration metrics. The polynomial support vector machine (SVM) model was chosen as the best-performing model. During internal validation, the SVM exhibited an AUC-ROC of 0.73 and a Brier score of 0.17. Using an optimal threshold that balances all quadrants of the confusion matrix, the SVM exhibited a sensitivity of 0.45 and a specificity of 0.81. Using a high-sensitivity threshold, the SVM exhibited a sensitivity of 0.68 and a specificity of 0.68. Total operative time was the most important feature for reoperation risk prediction. The models may facilitate reoperation risk stratification, allowing for better patient counseling and for physicians to implement measures that reduce surgical risks.

Effect of Da Vinci robotic transanal minimally invasive surgery for rectal neoplasms

Objective: To investigate the efficacy of Da Vinci robotic transanal minimally invasive surgery (R-TAMIS) for rectal neoplasms. Methods: The patients of rectal neoplasms who underwent R-TAMIS and were regularly followed up at the First Medical Center of Chinese PLA General Hospital from January 2021 to January 2024 were retropectively selected. Follow-up visits were conducted at 1, 2, and 4 weeks postoperatively, and then every 3 months until January 20, 2024. The perioperative situation, postoperative histopathological results, and follow-up status of the patients were observed. Results: A total of 17 patients were included, including 10 males and 7 females, aged 35-80 (59±13) years. Eleven patients underwent surgery using the da Vinci® Si robot, while 6 patients underwent surgery using the da Vinci® Xi robot. The height of the resected tumor from the anal verge [M (Q1, Q3)] was 3.5 (3.0, 3.8) cm. The total operative time was 55.0 (50.0, 55.0) minutes, the platform installation time was 32.5 (30.0, 35.0) minutes. The actual surgical operation time was 22.5 (20.0, 27.5) minutes. Intraoperative blood loss was 9.2 (5.0, 10.0) ml. The postoperative hospital stay was 3.2 (3.0, 3.8) days. The total treatment cost was (29 447±4 765) yuan. Two patients who achieved clinical complete remission after neoadjuvant chemoradiotherapy experienced incision dehiscence one week postoperatively, which was resolved after four weeks of rectal irrigation therapy. All surgical specimens were intact, and all resection margins were negative. A total of 44(31,73) weeks were followed up, without local recurrence or distant metastasis. Conclusion: Da Vinci robotic transanal minimally invasive local resection may be a safe and feasible treatment option for rectal neoplasms.

Comparing surgical techniques: ThuLEP and transurethral BPEP for prostate over 80 grams. Intraoperative and postoperative results. A prospective randomized trial

ABSTRACT Background and purpose Though TURP remains the primary treatment for BPH, advancements in energy and technology have introduced innovative transurethral surgical options. In this study, we assessed and compared the effectiveness and safety of using thulium laser and bipolar for endoscopic enucleation of prostate exceeding 80 g. Patients and methods Between January 2022 and July 2023, this study enrolled patients with LUTS due to BPH and a prostate size of ≥80 g. Group A underwent the BPEP procedure using a 26 Fr continuous flow resectoscope with plasma kinetic system enucleation loops, while Group B underwent the ThuLEP procedure using a 120–200 W Revolix DUO® Thulium laser. Data collection included prostate size, PSA levels, enucleation and morcellation time, and postoperative IPSS and IIEF-5 scores at one, 3, 6, and 12 months. Results A total of 108 patients, divided into Group A (BPEP) and Group B (ThuLEP), completed a 12-month follow-up. The mean age for group A was 67.72 ± 7.02 compared to group B which was 62.33 ± 5.86. While Group A compared to group B had higher mean enucleation (75.22 ± 10.55 vs. 67 ± 12.18) and total operative times (117.22 ± 17.76 vs.90.5 ± 18.29) (p = 0.037 & <0.001 respectively), no significant differences were observed in resected tissue weight, blood transfusion, and morcellation time. The ThuLEP group exhibited a shorter mean catheter period 2.94 ± 0.94 d compared to BPEP 3.33 ± 0.91 d and shorter mean hospital stay period of 1.94 ± 0.54 compared to2.11 ± 0.32, though not statistically significant. Postoperative outcomes, including IPSS, Qmax, PVRU, and IIEF-5 at 1, 3, 6, and 12 months, showed no differences between the groups. Conclusion ThuLEP shows better perioperative parameters in comparison to BPEP. Nevertheless, there are no notable differences in functional results and complications between the two techniques.

FP4.13 - Intravenous morphine negatively affects length of stay following minimally invasive colorectal surgery

Abstract Aim Investigate the impact of intravenous (IV) morphine administered as patient controlled analgesia (PCA) following minimally invasive colorectal resections. Method Demographic, peri-operative and follow-up data from a prospectively maintained database were collected for all laparoscopic and robotic assisted colorectal procedures carried out at our centre. Results Our cohort included 38 colorectal resections completed with the DaVinci Xi (Intuitive Surgical, USA) robotic platform and 57 consecutive laparoscopic colorectal resections. 7 patients were excluded due to incomplete data. 51/88 (57.9%) of patients underwent a left sided resection and 24/88 (27.3%) had a stoma formed. We observed a median IV morphine dose of 15.5mg (IQR 15.5-43.5mg) and we sub-divided the cohort into those who received &amp;gt;15 mg of IV morphine and &amp;lt;15mg of morphine via PCA. Patients who received &amp;lt;15mg IV morphine were older (median age 75 Vs 67 years; p&amp;lt;0.001). There was no statistical difference in the body mass index, ASA grade, total operative time, or type of minimally invasive resection. The median length of stay was 4 days for the &amp;lt;15mg IV Morphine cases compared to 5 in the &amp;gt;15mg IV Morphine group (p&amp;lt;0.001). As expected, there was a quicker time to first flatus in the &amp;lt;15mg IV Morphine group (median 2 days Vs 3 days; p&amp;lt;0.001) and a shorter time to opening bowels (median 3 days Vs 4 days; p=0.003). There was no statistically significant difference in post-operative complications between the two groups. Conclusions Reducing postoperative IV Morphine dosing following minimally invasive colorectal resections may lead to prompter recovery.

ThP4.5 - The challenges of the emergency laparoscopic cholecystectomy in the obese patient

Abstract It’s well documented that obesity is a positive predictor of surgical morbidity and with increasing obesity rates it is becoming a challenge for patients presenting with obesity related surgical conditions such as acute cholecystitis. This study aims to assess the impact of the class of obesity on the outcomes following laparoscopic cholecystectomy for acute cholecystitis. Methods A retrospective observational study was performed on patients undergoing emergency laparoscopic cholecystectomy at UHNM from January 2022 to January 2023. These patients were then stratified by their class of obesity as defined by the WHO; Healthy weight (BMI &amp;lt;25), Overweight (BMI 25 – 30), ClassI Obesity (BMI 30-35), ClassII Obesity (BMI 35-40), and ClassIII Obesity (BMI &amp;gt;40). Primary outcomes included LOS, mortality, 30 day readmission rates and postoperative complications. Secondary outcomes included total operative time. Results A total of 643 patients were identified. The classes of obesity were on average a younger cohort (median age, Healthy Weight = 60 [32–82], Overweight = 62 (28-86), Class I = 56 (27-80) ClassII = 50 (22-83) and ClassIII = 47 (28-90); p &amp;lt; 0.001). Length of hospital stay, mortality and operative duration, were similar between groups. However readmission rates were higher for the obese groups (Healthy Weight 8% vs Overweight 8% vs ClassI = 7% vs ClassII = 14% vs ClassIII 16%; p &amp;lt; 0.001) and postoperative complications (p = 0.067). Conclusions Emergency laparoscopic cholecystectomy can be performed safely on patients with higher classes of obesity but an appreciation of the class of obesity needs to be taken into consideration and higher class of obesity is associated with increasing risk of post operative complications.

Beyond the Learning Curve of Robot-Assisted Navigation Spine Surgery: Refinement of Outcomes With Extended Experience.

Objective This study assessed whether robotic-assisted navigation (RAN) spine surgery outcomes, including operative time and pedicle screw accuracy, continue to improve with extended experience beyond 200 cases. Methods This is a retrospective review of 60 patients who underwent lumbosacral transforaminal interbody fusion using RAN. Patients were segmented into three groups of 20 consecutive cases each. The first group represented a surgical performance baseline leading up to the investigating surgeon's 200th RAN case. The subsequent two groups were selected beyond the 200th case with an average of 15 cases between groups. Pedicle screw accuracy and intraoperative outcomes were assessed. Statistical results were significant if p<0.05. Results Measures of surgical efficiency significantly improved beyond the investigating surgeon's 200th RAN case. As case number increased, the following parameters significantly decreased: registration time (group 1: 16.9±6.5, group 2: 12.9±3.0, group 3: 8.7±1.6 minutes; p<0.05), screw insertion time (group 1: 14.9±3.5, group 2: 10.9±2.0, group 3: 8.4±2.7 minutes; p<0.05), and total operative time significantly decreased from group 1 (175.9±58.2 minutes) to group 2 (135.8±23.9 minutes) (p=0.013) with a non-significant decrease to group 3 (121.5±32.3 minutes). Accuracy (Grade = A) significantly increased across groups (group 1: 87%, group 2: 94%, group 3: 98%; p=0.024). Group 1 had the highest misplacement rate of 3.7% (4/108 screws). The overall misplacement rate was 1.4% (4/290 screws) (Grade C-E). There was a higher rate of lateral screw misplacement compared to medial misplacement. Conclusion Even with a small number of initial cases, RAN spine surgery can consistently be performed with high accuracy and acceptable intraoperative outcomes. However, this study demonstrated refined outcomes with extended robotic experience.

Predictive Factors of Transient Urinary Incontinence Following Holmium Laser Enucleation of the Prostate (HoLEP): Single-Center Experience.

Background and Objectives: The aim of this study was to assess the predictive factors associated with transient urine incontinence (TUI) following holmium laser enucleation of the prostate (HoLEP). Materials and Methods: A retrospective analysis was conducted on a prospectively maintained database containing the first 149 consecutive HoLEP cases between June 2022 and December 2023. The study recorded several patient characteristics, and preoperative data such as IPSS score, total gland volume, preoperative catheterization, Qmax, and PVR volume were collected. During the operation, data on total operating time, enucleation time, morcellation time, and weight of enucleated tissue were recorded. Finally, postoperative data were also documented. TUI refers to a patient's complaint of urine leakage, irrespective of type. Univariate and multivariate logistic regression analyses were performed to determine factors that predict TUI. Results: The study included 119 patients with BPH. Nineteen (15.96%) of them experienced postoperative TUI. Of those 19 patients, 15 (78.94%) recovered within three months from the date of the surgery. In the multivariate regression analysis, increased age (odds ratio [OR], 3.47; 95% confidence interval [CI], 1.56~7.78; p = 0.002), prostate volume ≥ 100 mL (OR 1.86; 95% CI 1.54-2.13; p = 0.001), preoperative PVR volume ≥ 250 mL (OR 1.22; 95% CI 1.10-1.32; p = 0.02), preoperative catheterization (OR, 0.56; 95% CI 0.34-0.78; p = 0.003), increased operation time (OR, 3.87; 95% CI 1.62-4.19; p = 0.002), and resected tissue weight ≥ 40 g (OR, 1.032; 95% CI, 1.015-1.048; p = 0.002) were found to be independent predictors of TUI. Conclusions: The incidence of TUI following HoLEP was found to be 15.96% in patients, with a recovery rate of 78.94% within three months post-surgery. Predictive factors for TUI included age at surgery, prostatic volume, preoperative catheterization, high PVR, longer operative time, and resected tissue weight.

Robotic purse-string suture technique for intracorporeal anastomosis using double-stapling technique in robotic resection of rectal and sigmoid colon cancer: a propensity score-matched analysis

BackgroundRobotic three-dimensional magnified visual effects and field of view stabilization have enabled precise surgical operations. Intracorporeal anastomosis in right-sided colorectal cancer surgery is expected to shorten operation times, avoid paralytic ileus, and shorten wound lengths; however, there are few reports of intracorporeal anvil fixation for intestinal anastomosis in left-sided colorectal cancer surgery. Herein, we introduce a simple, novel procedure for using robotic purse-string suture (RPSS) in intracorporeal anastomosis with the double-stapling technique in rectal and sigmoid cancer surgery and report short-term outcomes.MethodsFrom September 2022 to April 2024, 105 consecutive patients underwent robotic surgery with double-stapling technique anastomosis for rectal or sigmoid colon cancer at our institution. Their data were retrospectively analyzed. Intracorporeal anastomosis with the double-stapling technique using RPSS was performed in 26 patients (the RPSS group), while the double-stapling technique anastomosis with extracorporeal anvil fixation was performed in 79 patients (the EC group). A 1:1 propensity score-matched analysis was performed (matching criteria: sex, age, body mass index (BMI), tumor location and tumor size) using a caliper 0.3.In the RPSS group, after tumor-specific or total mesorectal excision, specimens were extracted from the umbilical wound with simultaneous anvil placement in the body cavity. The oral colonic stump was robotically excised and robotically circumferentially stitched with 3–0 Prolene in all layers. After anvil insertion into the stump, the bowel wall of the colon was completely sewn onto the central rod of the anvil. Reconstructions were anastomosed using the double-stapling technique.ResultsThe matched cohort contained 23 patients in each group. The RPSS group had significantly less bleeding than the EC group (p = 0.038). Super-low anterior resection (SLAR) in the RPSS group had shorter total operative times than those in the EC group (p = 0.045). The RPSS group experienced no perioperative complications greater than Clavien–Dindo grade III or any anastomosis-related complications.ConclusionsThe RPSS technique can be performed safely without any anastomosis-related complications and reduces the total operative times in SLAR and blood loss through total robotic surgery. This may be a useful modality for robotic colorectal surgery.

Initial Experience of Single-Port Robotic Lobectomy for Large-Sized Non-Small Cell Lung Cancer: A Single-Center Retrospective Study.

Single-port robotic-assisted thoracic surgery (SP-RATS) lobectomy using the da Vinci Xi system has been performed by several pioneers. However, due to the severe collisions and the steep learning curve, this approach is not yet widely used. This study aimed to evaluate the feasibility of SP-RATS lobectomy for large-sized non-small cell lung cancer (NSCLC). As we believe that for large-sized tumors it is reasonable to make a slightly larger incision, we performed SP-RATS lobectomy for large-sized NSCLC (greater than 5 cm) through a single incision (6-8 cm). Eleven patients underwent SP-RATS lobectomy using the da Vinci Xi system at our institution from April 2022 to May 2024. The median tumor size on computed tomography and on pathology was 6.6 cm [interquartile range (IQR), 6.1-7.5 cm] and 6 cm [IQR, 5.1-7.1], respectively. The median total operative time was 198 min [IQR, 159-260 min], and the median postoperative length of stay was 4 days [IQR, 4-10 days], with no major postoperative complications (≥grade III on the Clavien-Dindo classification). Our approach may combine the benefits of single-port surgery with those of robotic surgery and is safe, feasible, and may promote better outcomes in patients with large-sized NSCLC.