Use Of Minimally Invasive Surgery Techniques Research Articles

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

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

Minimally invasive surgery: has it come of age?

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

Retrospective comparison of open vs minimally invasive cystotomy in 28 cats using a composite outcome score.

The aim of this study was to compare the outcomes of cats undergoing open cystotomy with those undergoing minimally invasive surgery (MIS) for removal of cystic calculi by use of a composite outcome score. Twenty-eight cats were retrospectively enrolled and divided into two groups: open cystotomy (n = 14) and MIS (n = 14). The primary outcome measure was a composite outcome score, including three variables: pain scores ⩾2 at either 6 or 12 h postoperatively; failure to remove all stones as determined by postoperative radiographs; and postoperative complications requiring a visit to the hospital separate from the planned suture removal appointment. Other data collected included signalment, history, other procedures performed during anesthesia, willingness to eat the day after surgery and the financial cost of the procedures. There was no significant difference in age, weight, sex or breed between the two groups. The risk of experiencing the composite outcome was 3/14 (21.4%) in the MIS group and 10/14 (71%) in the open procedure group (P = 0.02). The cats in the open surgery group had 8.3 times greater odds of developing the composite outcome than cats in the MIS group (odds ratio 8.3, 95% confidence interval 1.3-74.4; P = 0.02). In the MIS group, 10/14 cats were eating the day after surgery vs 3/14 in the open procedure group (P = 0.02). The procedural cost was higher in the MIS group, with a median cost of US$945 (interquartile range [IQR] US$872-1021) vs US$623 (IQR US$595-679) in the open group (P <0.01). In this study the composite outcome score provided evidence to support the use of MIS techniques in cats with cystic calculi. The composite outcome score should be considered in future veterinary studies as a promising method of assessing clinically relevant outcomes.

Use of minimally invasive surgery in emergency general surgery procedures.

Minimally invasive surgery (MIS) has demonstrated superior outcomes in many elective procedures. However, its use in emergency general surgery (EGS) procedures is not well characterized. The purpose of this study was to examine the trends in utilization and outcomes of MIS techniques in EGS over the past decade. The 2007-2016 ACS-NSQIP database was utilized to identify patients undergoing emergency surgery for four common EGS diagnoses: appendicitis, cholecystitis/cholangitis, peptic ulcer disease, and small bowel obstruction. Trends over time were described. Preoperative risk factors, operative characteristics, outcomes, morbidity, and trends were compared between MIS and open approaches using univariate and multivariate analysis. During the 10-year study period, 190,264 patients were identified. The appendicitis group was the largest (166,559 patients) followed by gallbladder disease (9994), bowel obstruction (6256), and peptic ulcer disease (366). Utilization of MIS increased over time in all groups (p < 0.001). There was a concurrent decrease in mean days of hospitalization in each group: appendectomy (2.4 to 2.0), cholecystectomy (5.7 to 3.2), peptic ulcer disease (20.3 to 11.7), and bowel obstruction (12.9 to 10.5); p < 0.001 for all. On multivariate analysis, use of MIS techniques was associated with decreased odds of 30-day mortality, surgical site infection, and length of hospital stay in all groups (p < 0.001). Use of MIS techniques in these four EGS diagnoses has increased in frequency over the past 10years. When adjusted for preoperative risk factors, use of MIS was associated with decreased odds of wound infection, death, and length of stay. Further studies are needed to determine if increased access to MIS techniques among EGS patients may improve outcomes.

The Prevalence of the Use of MIS Techniques in the Treatment of Adult Spinal Deformity (ASD) Amongst Members of the Scoliosis Research Society (SRS) in 2016

Study DesignElectronic survey administered to Scoliosis Research Society members. ObjectiveTo determine the prevalence of minimally invasive surgery (MIS) techniques for the treatment of adult spinal deformity. Summary of Background DataThere is a paucity of data available on the practice pattern, prevalence of minimally invasive spine surgery, and the preferred minimally invasive techniques in the treatment of adult spine deformity. MethodsAn electronic nine-question survey regarding individual usage pattern of minimally invasive spine surgery techniques was administered in 2016 to the members of the Scoliosis Research Society. Determinants included complexity in condition of patient population, prevalence of use of minimally invasive techniques in the surgeon's practice, prevalence of use of a particular MIS technique, strategy elected during surgery, adoption of staging of procedures and timing between staging of procedures. ResultsA total of 357 surgeons responded (61.3% response rate), and 154 (43.1%) of the respondents said that they use MIS as a part of their surgical treatment of adult spinal deformity. However, of these 154 respondents, 67 (43.5%) said that their MIS usage in deformity practice was between 1% and 20%. Only 11 (7.2%) said that they used MIS 81% to 100% of the time. The top MIS approaches that surgeons chose were MIS lateral lumbar interbody fusion 109 (70.59%) and MIS percutaneous screws 91 (58.8%). ConclusionsThe low rate of adoption of these techniques among the SRS members may be due to the false perception that there is not enough data to support that MIS techniques are better. This and the fact that a practitioner needs to be facile at different MIS techniques may be the true impediment to the adoption of MIS techniques in the treatment of ASD. Level of EvidenceLevel IV.

Minimally Invasive Pediatric Surgery During Remote Humanitarian Missions Is Feasible, Safe, and Effective

There remains a critical need for the provision for pediatric humanitarian aid worldwide. Historically, the emphasis of global pediatric health needs has been focused on infectious diseases. Today, we are witnessing a shift in this paradigm, with growing attention being paid toward the surgical needs of children. The use and deployment of minimally invasive surgery (MIS) in these austere environments with its concomitant reduction in length of hospitalization, pain, and morbidity is logical. The goal of this study was to report our deployment strategy and review our experience with pediatric MIS during humanitarian missions to determine if it is safe, feasible, and efficacious. As part of the World Pediatric Project (WPP), data were collected retrospectively from the general pediatric surgery (GPS) team missions from January 2007 to January 2017. All cases were performed at a single medical center in the Eastern Caribbean Island Nation of St. Vincent and the Grenadines (SVG). Data included patient demographics, diagnosis, procedure, conversion to open procedure, complications, and postoperative course. The teams utilized a dedicated WPP operating theater, prepositioned and deployed GPS supplies, and MIS resources. All anesthesia, surgical, and nursing personal were board certified and trained professionals functioning as part of the WPP team. One hundred thirty-four children underwent general and thoracic pediatric surgical procedures during the study period. Mean age 9.2 years (2-19 years). Thirty-seven children underwent MIS procedures (27%). There were no conversions to open procedures. There were only two postoperative complications, cellulitis following laparoscopic appendicostomies, which required intravenous antibiotics and were discharged on a course of oral antibiotics. The postoperative course for all children was uneventful and no child required readmission. There were no technical failures in the MIS systems or instrumentation. Our retrospective review supports the use of MIS techniques as part of GPS humanitarian missions. We have found it to be a safe, feasible, and effective modality that may reduce length of stay, pain, and morbidity compared with open procedures in these remote environments. Although our MIS systems and instrumentations functioned effectively, concerns regarding the storage and sustainability for future missions are significant. Onsite health care partners, redundant systems, and remote technical support access could potentially alleviate these concerns.

Open versus minimally invasive surgical approaches in pediatric urology: Trends in utilization and complications

Minimally invasive surgery (MIS) techniques are anecdotally reported to be increasingly used, but little objective data supports this. Our objective was to assess trends in MIS utilization across various procedures in pediatric urology and to compare postoperative complication rates between MIS and open procedures. We analyzed the 1998-2012 Nationwide Inpatient Sample. We identified children (<18 years old) undergoing open and MIS inpatient procedures and any in-hospital post-operative complications that occurred during that postoperative hospitalization. We utilized propensity score matching and multivariable logistic regression to adjust for confounding factors. We identified 163,838 weighted encounters in the "overall cohort," 70,273 of which were at centers performing more than five MIS procedures over the years studied. Use of MIS techniques increased significantly over time for several procedures, most prominently for nephrectomy (Fig.). The overall rate of complications was lower in patients undergoing MIS compared with open surgery (6% vs. 11%, p<0.001). Specialized centers had a significantly lower overall rate of complications than unspecialized centers (9% vs. 12%, p<0.001). Within specialized centers, MIS had lower complication rates than open procedures (7% vs. 9%, p<0.001); this finding was consistent even after adjusting for other factors (OR 0.71, p=0.02). Limitations include that these data may not be generalizable to encounters not in the sample pool. As a large, retrospective, administrative database, NIS may be affected by miscoding bias - rendering our analysis sensitive to the accuracy of procedure coding in NIS. Although the accuracy level of NIS is high for an administrative database, it is possible at least some portion of our cohort may be incorrectly coded. Further, the NSQIP complications we identified may represent associated comorbidities and not true postoperative complications, as NIS does not provide temporal relationships between different diagnosis codes. Despite these limitations, we note that the NIS database is rigorously monitored and audited for coding accuracy and, therefore, represents a reasonably reliable panorama of the characteristics of an inpatient surgical cohort. However, it is important to note that the choice of operative modality is, undoubtedly, multifactorial and patient/setting-specific. There is increasing use of MIS for pediatric urology procedures, although utilization rates vary among procedures. MIS was associated with a lower postoperative complication rate than for open procedures. Higher-volume MIS centers have a lower complication rate than lower-volume centers.

Management of intended durotomy in minimally invasive intradural spine surgery: clinical article.

Minimally invasive surgery (MIS) has been increasingly used for the treatment of various intradural spinal pathologies in recent years. Although MIS techniques allow for successful treatment of intradural pathology, primary dural closure in MIS can be technically challenging due to a limited surgical corridor through the tubular retractor system. The authors describe their experience with 23 consecutive patients from a single institution who underwent MIS for intradural pathologies, along with a review of pertinent literature. A retrospective review of a prospectively collected surgical database was performed to identify patients who underwent MIS for intradural spinal pathologies between November 2006 and July 2013. Patient demographics, preoperative records, operative notes, and postoperative records were reviewed. Primary outcomes include operative duration, estimated blood loss, length of bed rest, length of hospital stay, and postoperative complications, which were recorded prospectively. Twenty-three patients who had undergone MIS for intradural spinal pathologies during the study period were identified. Fifteen patients (65.2%) were female and 8 (34.8%) were male. The mean age at surgery was 54.4 years (range 30-74 years). Surgical pathologies included neoplastic (17 patients), congenital (3 patients), vascular (2 patients), and degenerative (1 patient). The most common spinal region treated was lumbar (11 patients), followed by thoracic (9 patients), cervical (2 patients), and sacral (1 patient). The mean operative time was 161.1 minutes, and the mean estimated blood loss was 107.2 ml. All patients were allowed full activity less than 24 hours after surgery. The median length of stay was 78.2 hours. Primary sutured dural closure was achieved using specialized MIS instruments with adjuvant fibrin sealant in all cases. The rate of postoperative headache, nausea, vomiting, and diplopia was 0%. No case of cutaneous CSF fistula or symptomatic pseudomeningocele was identified at follow-up, and no patient required revision surgery. Primary dural closure with early mobilization is an effective strategy with excellent clinical outcomes in the use of MIS techniques for intradural spinal pathology. Prolonged bed rest after successful primary dural closure appears unnecessary, and the need for watertight dural closure should not prevent the use of MIS techniques in this specific patient population.

A Comparison of Open and Minimally Invasive Surgery for Hepatic & Pancreatic Resections Using the Nationwide Inpatient Sample (NIS)

Minimally-invasive surgery (MIS) for complex abdominal operations has increased over time. However, the use of MIS techniques for pancreatic and liver operations remains ill defined. We sought to compare inpatient outcomes among patients undergoing open versus MIS pancreas and liver operations using a nationally representative cohort.

Innovations in total knee replacement: new trends in operative treatment and changes in peri-operative management

The human knee joint can sustain damage due to injury, or more usually osteoarthritis, to one, two or all three of the knee compartments: the medial femorotibial, the lateral femorotibial and the patellofemoral compartments. When pain associated with this damage is unmanageable using nonsurgical techniques, knee replacement surgery might be the most appropriate course of action. This procedure aims to restore a pain-free, fully functional and durable knee joint. Total knee replacement is a well-established treatment modality, and more recently, partial knee replacement—more commonly known as bi- or unicompartmental knee replacement—has seen resurgence in interest and popularity. Combined with the use of minimally invasive surgery (MIS) techniques, gender-specific prosthetics and computer-assisted navigation systems, orthopaedic surgeons are now able to offer patients knee replacement procedures that are associated with (1) minimal risks during and after surgery by avoiding fat embolism, reducing blood loss and minimising soft tissue disruption; (2) smaller incisions; (3) faster and less painful rehabilitation; (4) reduced hospital stay and faster return to normal activities of daily living; (5) an improved range of motion; (6) less requirement for analgesics; and (7) a durable, well-aligned, highly functional knee. With the ongoing advancements in surgical technique, medical technology and prosthesis design, knee replacement surgery is constantly evolving. This review provides a personal account of the recent innovations that have been made, with a particular emphasis on the potential use of MIS techniques combined with computer-assisted navigation systems to treat younger, more physically active patients with resurfacing partial/total implant knee arthroplasty.

Accuracy of Implant Positioning for Minimally Invasive Total Knee Arthroplasty in Patients With Severe Varus Deformity

Minimally invasive surgery (MIS) in total knee arthroplasty (TKA) reportedly yields decreased patient morbidity and a rapid return of function, but how much deformity can be accepted for MIS-TKA remains unclear. This study investigated 238 knees from 218 consecutive patients who underwent MIS-TKA. Patients were divided into groups with tibiofemoral mechanical axis (TFM) 195° or greater and TFM less than 195°, then clinical and radiographic results were compared. Similar improvements in knee score at 3 months postoperatively were obtained in the both groups, whereas radiographic accuracy of the coronal alignment in the TFM ≥195° group was inferior to that in TFM <195° group. Postoperative TFM was significantly worsened in patients with lateral bowing angle of the femoral shaft (LBFS) 4° or greater, and 53% of patients in the TFM ≥195° group displayed LBFS 4° or greater, explaining the inferior radiographic accuracy in this group compared with the TFM <195° group. These results indicate that use of MIS techniques decreases radiographic accuracy, particularly in patients with severe genu varum and increased LBFS.

Pediatric Laparoscopy

Significant developments in minimally invasive surgery (MIS) for the adult population have led to increased application of MIS techniques for pediatric patients. Laparoscopy is the most common MIS procedure used in pediatrics. Traditional surgical procedures that are now being performed laparoscopically include gastrostomy, pyloromyotomy, and repair of congenital diaphragmatic hernia and imperforate anus. All perioperative team members must be prepared to provide appropriately sized instruments and equipment to facilitate use of MIS techniques in the pediatric population and must ensure safe patient care to achieve optimal patient outcomes.

Disparate use of minimally invasive surgery in benign surgical conditions

Disparities in outcome across race and ethnicity have been consistently described for medical and surgical care. Given that surgery is a rapidly evolving field, we hypothesized that racial disparities exist in access to minimally invasive surgery (MIS), which importantly influences outcome. Cohort analysis of all patients who underwent appendectomy, gastric fundoplication, and gastric bypass in the Nationwide Inpatient Sample, a 20% stratified random sample of US hospital discharge abstracts. To determine the effect of race on the use of MIS techniques and morbidity and mortality, we controlled for patient characteristics, comorbidity, and hospital characteristics including surgical volume and MIS conversion to open surgery. Blacks were consistently less likely to be treated with MIS despite adjustment for socioeconomic status, comorbidity, and treatment setting. In addition, in-hospital mortality and complications such as pneumonia, heart disease, infections, and surgical misadventures were higher in black than white patients. These outcomes differences remained despite adjustment for hospital volume, the use of MIS, and MIS conversion to open surgery. We demonstrate evidence of racial disparities in the use of MIS for benign surgical conditions and worse outcomes for patients of black race. Although, the racial differences in outcome were attenuated with adjustment for MIS, further studies are needed to help resolve remaining differences in outcomes across race.

Minimally invasive surgery and childhood cancer

Over the last 2 decades, minimally invasive surgery (MIS) has become a significant tool for the diagnosis and treatment of malignant disease in adults. Despite initial reports of port-site metastases and peritoneal spread following laparoscopic resection of colorectal cancer in the 1990s, MIS is now commonly used for many applications in adult surgical oncology, including biopsy and resection of malignant disease in the chest and abdominal cavities, mediastinal and retroperitoneal lymph node dissection, staging of abdominal, pelvic and thoracic malignancies, and management of therapeutic complications. The use of MIS techniques in children is growing with the availability of smaller instruments and equipment more suitable to the pediatric patient. Herein, we review the role of MIS in the diagnosis, staging and treatment of malignant disease in children. We will also evaluate MIS as it applies to the palliation of disease and the management of treatment complications in childhood cancer.