Gasless laparoscopy-assisted subtotal gastrectomy for early gastric cancer: a novel minimally invasive surgery

Clinical effectiveness of gasless laparoscopic surgery for abdominal conditions: systematic review and meta-analysis

BACKGROUND

In high-income countries, laparoscopic surgery is the preferred approach for many abdominal conditions. Conventional laparoscopy is a complex intervention that is challenging to adopt and implement in low resource settings. This systematic review and meta-analysis evaluate the clinical effectiveness of gasless laparoscopy compared to conventional laparoscopy with CO2 pneumoperitoneum and open surgery for general surgery and gynaecological procedures.

METHODS

A search of the MEDLINE, EMBASE, Global Health, AJOL databases and Cochrane Library was performed from inception to January 2021. All randomised (RCTs) and comparative cohort (non-RCTs) studies comparing gasless laparoscopy with open surgery or conventional laparoscopy were included. The primary outcomes were mortality, conversion rates and intraoperative complications.

SECONDARY OUTCOMES

operative times and length of stay. The inverse variance random-effects model was used to synthesise data.

RESULTS

63 studies were included: 41 RCTs and 22 non-RCTs (3,620 patients). No procedure-related deaths were reported in the studies. For gasless vs conventional laparoscopy there was no difference in intraoperative complications for general RR 1.04 [CI 0.45-2.40] or gynaecological surgery RR 0.66 [0.14-3.13]. In the gasless laparoscopy group, the conversion rates for gynaecological surgery were high RR 11.72 [CI 2.26-60.87] when compared to conventional laparoscopy. For gasless vs open surgery, the operative times were longer for gasless surgery in general surgery RCT group MD (mean difference) 10 [CI 0.64, 19.36], but significantly shorter in the gynaecology RCT group MD - 18.74 [CI - 29.23, - 8.26]. For gasless laparoscopy vs open surgery non-RCT, the length of stay was shorter for gasless laparoscopy in general surgery MD - 3.94 [CI - 5.93, - 1.95] and gynaecology MD - 1.75 [CI - 2.64, - 0.86]. Overall GRADE assessment for RCTs and Non-RCTs was very low.

CONCLUSION

Gasless laparoscopy has advantages for selective general and gynaecological procedures and may have a vital role to play in low resource settings.

Gasless laparoscopic assisted surgery for abdominal trauma

BACKGROUND

Numerous studies have described the effectiveness of laparoscopy for trauma patients. In gas-filling laparoscopic surgery, most of the disadvantages are related to a positive pressure pneumoperitoneum that compromises the cardiopulmonary function. The main advantage of gasless laparoscopic assisted surgery (GLA) is that it does not affect the haemodynamic status, which is particularly critical for trauma patients. The purpose of this study was to investigate the feasibility and safety of GLA for abdominal trauma.

MATERIALS AND METHODS

This was a retrospective, 1:2 matched case-control study of all trauma gasless assisted laparoscopies performed from January 2010 until January 2013 in a Level I trauma centre. In total, 965 patients with abdominal trauma were admitted. According to the abdominal trauma protocol, a total of 93 hemodynamically stable patients required the operation; we selected fifteen patients to undergo GLA and matched 30 other patients to undergo laparotomy. Demographic information, perioperative findings, injury severity score, and postoperative recovery were recorded and analyzed.

RESULTS

A total of fifteen patients (ten men, five women) with a mean age of 44.4, standard deviation (SD) 13.2 years underwent GLA for abdominal trauma. Eight patients had penetrating injuries, while seven had blunt injuries. Overall, 73% patients had multiple injuries. The mean time to the identified lesion was 23.1, SD 10.9min, and the mean operative time was 109.7, SD 33.5min. Most of the lesions were repaired concurrently by GLA. One conversion to laparotomy was done. The mean length of hospital stay (HLOS) was 9.1, SD 4.5 days. No mortality occurred in this series. The mean follow-up was 22.0, SD 7.9 months, and there were no significant events during this period. The mean operative times were comparable in the GLA and open surgery group (109.7, SD 33.5 vs. 131.2, SD 43.6min; p=0.076). Compared with the open surgery group, the HLOS was significantly shorter in the GLA group (9.1, SD 4.5 vs.16.3, SD 6.4 days; p=0.030).

CONCLUSION

GLA offers both therapeutic and diagnostic advantages for patients with abdominal trauma. GLA shares the advantages of laparoscopy and prevents the cardiopulmonary function from being compromised due to pneumoperitoneum, which is especially critical for trauma patients.

Light-guided hysteroscopic resection of complete septate uterus with preservation of duplicated cervix

The objective of the present study, performed at a tertiary university hospital, was to propose a novel method of hysteroscopic resection of complete septate uterus with preservation of duplicated cervix. The retrospective study included 5 women with complete septate uterus and cervical duplication and who also experienced infertility with or without pregnancy loss. All patients underwent bougie-guided or light-guided hysteroscopic perforation of the uterine septum above the endocervix, followed by septum resection. The success rate of complete uterine septum perforation under bougie guidance was 60% (3 of 5 procedures), and of light guidance was 100% (2 procedures). After hysteroscopic septum resection, 2 of 5 women achieved pregnancy within 3 months and delivered uneventfully at term. It is concluded that light guidance is superior to bougie guidance for hysteroscopic perforation of complete septate uterus with preservation of the duplicated cervix.

Comparison of three different minimally invasive procedures of distal gastrectomy for Nonoverweight patients with T1N0-1 gastric cancer

Laparoscopic-assisted distal gastrectomy has recently come to be a standard procedure for the treatment of early gastric cancer (1 - 5) in select patients. The minimal invasiveness associated with laparoscopic procedures for the resection of gastrointestinal cancer has been repeatedly explained in part by the short incision that is required. (6 - 11) We used two different approaches to perform distal gastrectomies for the resection of gastric cancer as minimally invasive alternatives to a standard laparoscopic approach prior to our surgical team's complete mastery of the skills required for laparoscopic oncological surgery for gastric cancer. (9 , 12) If the minimal invasiveness associated with laparoscopic-assisted gastrectomy can be explained by the small incision, a gastrectomy via a small incision without the use of a pneumoperitoneum may provide a similar outcome in patients. However, to our knowledge, such a comparison has not been previously made. We compared the minimal invasiveness of three different approaches (minilaparotomy, minilaparotomy approach with laparoscopic assistance, and standard laparoscopic-assisted approach) to performing a distal gastrectomy for T1N0-1 gastric cancer in nonoverweight patients (body mass index, ≤ 25 kg/m(2)) performed within a limited study period.

A gasless laparoscopic technique of wide excision for gastric gastrointestinal stromal tumor versus open method

Background

Traditional open surgery for gastrointestinal stromal tumors (GIST) requires a long incision. Moreover, the gas-filling laparoscopic technique used in GIST surgery still has its limitations. Therefore, we developed a gasless laparoscopic (GL) surgery for GIST and compared it with traditional open surgery.

Methods

Between October 2007 and September 2009, 62 GIST patients in the National Taiwan University Hospital received wide excisions. Of these 62 patients, 30 underwent the new procedure (GL group) and 32 had open surgery (OS group). Preoperative and postoperative clinicopathologic characteristics were compared between the groups.

Results

There were no significant differences in preoperative characteristics or blood loss. However, the days to first flatus, postoperative hospital stay, wound length, white blood cell count at postoperative day one, and peak daily body temperature were all significantly improved in the GL group. Usage of postoperative analgesia on postoperative days one to five was also significantly lower in the GL group.

Conclusions

Wide-excision laparoscopy for gastric GIST can be performed more safely, more effectively, and with faster postoperative recovery using the gasless technique as compared with the open method. We, therefore, recommend this new surgical technique, which hybridizes the advantages of both the traditional open method and pure laparoscopic surgery.

Laparoscopic versus open distal gastrectomy for gastric cancer: a meta-analysis of randomized controlled trials and high-quality nonrandomized studies

OBJECTIVE

To perform a meta-analysis of high-quality published trials, randomized and observational, comparing laparoscopic distal gastrectomy (LDG) and open distal gastrectomy (ODG) for gastric cancer.

BACKGROUND

Controversy persists about the clinical utility of minimally invasive techniques for the treatment of gastric cancer. Prospective data is limited to a few small randomized trails.

METHODS

: Studies published from January 1992 to March 2010 that compare LDG and ODG were identified. No restrictions in pathologic stage were applied. All randomized controlled trials (RCTs) were included. Selection of high-quality, nonrandomized comparative studies (NRCTs) was based on a validated tool (Methodological Index for Nonrandomized Studies). Mortality, complications, harvested lymph nodes, operative time, blood loss, and hospital stay were compared using weighted mean differences (WMDs) and odds ratios (ORs).

RESULTS

Twenty-five studies were included in the analyses, 6 RCTs and 19 NRCTs, compromising 3055 patients (1658 LDG, 1397 ODG). LDG was associated with longer operative times (WMD 48.3 minutes; P < 0.001) and lower overall complications (OR 0.59; P < 0.001), medical complications (OR 0.49; P = 0.002), minor surgical complications (OR 0.62; P = 0.001), estimated blood loss (WMD -118.9 mL; P < 0.001), and hospital stay (WMD -3.6 days; P < 0.001). Mortality and major complications were similar. Patients in the ODG group had a significantly higher number of lymph nodes harvested (WMD 3.9 nodes; P < 0.001), although the estimated proportion of patients with less than 15 retrieved nodes was similar (OR 1.26, P = 0.09).

CONCLUSIONS

LDG can be performed safely with a shorter hospital stay and fewer complications than open surgery. The long-term significance of a difference of less than 5 nodes in the number of harvested lymph nodes remains unclear. Lymph node staging appears to be unaffected. These results need to be validated in Western patients with advanced gastric cancer.

Is there any benefit to incorporating a laparoscopic procedure into minimally invasive esophagectomy? The impact on perioperative results in patients with esophageal cancer

BACKGROUND

The benefit of using the laparoscopic approach in minimally invasive esophagectomy (MIE) has not been established. We therefore compared the outcome of esophagectomy for patients with esophageal cancer performed with open surgery, video-assisted thoracic surgery (VATS)/laparotomy (hybrid MIE), and VATS/ laparoscopy (total MIE).

METHODS

Patients with esophageal cancer undergoing tri-incisional esophagectomy with three different approaches between 2005 and 2009 were analyzed from a prospective database.

RESULTS

Three groups of patients underwent esophagectomy by open surgery (n = 64), hybrid MIE (n = 44), and total MIE (n = 30). The total MIE group had significantly longer operative times but had shorter postoperative ventilator usage times postoperative hospital stay, and they began jejunostomy feeding sooner (P < 0.05, compared with the other groups). There was a significant trend toward a decrease in postoperative pulmonary complications and anastomotic leakage in parallel to the proportion of minimally invasive procedures for esophagectomy (P < 0.05 for the trend test), with a significant difference between the open surgery and total MIE groups (30% vs. 6.7%, and 28% vs. 6.7%, respectively; P < 0.05).

CONCLUSIONS

Use of a laparoscopic procedure in MIE for patients with esophageal cancer might provide benefit by facilitating postoperative recovery and reducing the rates of post-esophagectomy pulmonary complications and anastomotic leakage.

Gasless laparoscopy-assisted distal gastrectomy for early gastric cancer: analysis of initial results

BACKGROUND

Laproscopic surgery is widely used in treating gastrointestinal disease. This study investigated the clinical result, short-term outcomes, and cost analysis of the newly developed gasless laparoscopy-assisted distal gastrectomy (GLADG) and compared it with conventional open distal gastrectomy (ODG).

METHODS

Seventy-five patients underwent distal gastrectomy with radical lymph node dissection for early gastric cancer from December 2005 to January 2008. Thirty-one patients underwent GLADG and 44 underwent ODG. Postoperative pain, morphine use, disease-free and overall survival, and surgical and hospital costs were measured postoperatively and compared between the two groups.

RESULTS

Patients in the two groups were comparable by age, sex, body mass index, tumor size, tumor location, cancer staging, and operative time. The GLADG group had early start of oral intake and shorter postoperative hospital stay (P < .05). There was less morphine use from postoperative day 1 to 4 in the GLADG group than in the ODG group (P < .05), and body temperature from postoperative day 1 to 2 was lower in the GLADG than in the ODG group (P < .05). Cost analysis showed that operation cost (100,242 ± 5385 versus 36,455 ± 1419) and equipment cost (65,909 ± 5385 versus 2122 ± 1419) was higher in the GLADG group, but its total hospital cost (193,552 ± 12,715 versus 206,676 ± 41,920) was lower than in the ODG group (P < .05). The 2-year disease-free and overall survival rates were not different between the two groups.

CONCLUSIONS

GLADG is feasible for early gastric cancer. It is advantageous because of less pain, less postoperative inflammatory response, less blood loss, and shorter total hospital stay while achieving the same oncologic results as ODG.

Gasless laparoscopy-assisted surgery for intraabdominal/retroperitoneal tumor of unknown origin: a bridge between total laparoscopic surgery and conventional open surgery

INTRODUCTION

Gasless laparoscopy-assisted surgery has been utilized in many abdominal diseases, and it has been proved to be effective and efficient compared with conventional open surgery. The study was conducted to evaluate the efficacy of gasless laparoscopy-assisted surgery in management of intraabdominal/retroperitoneal tumor of unknown origin.

METHODS

From June 2004 to April 2009, nine patients who underwent gasless laparoscopy-assisted surgery for intraabdominal/retroperitoneal tumor of unknown origin were recruited. Intraabdominal/retroperitoneal tumor of unknown origin was defined as (1) diagnosis of enlarged retroperitoneal lymph node; (2) evaluation of peritoneal or mesenteric lesion, or tumor of nondigestive systems; and (3) staging of intraabdominal malignancy.

RESULTS

Four patients underwent gasless laparoscopy-assisted surgery for retroperitoneal enlarged lymph nodes, four for evaluation of intraabdominal lesion, and two for staging of the malignancy. Sufficient tissue was obtained from all patients, and the diagnosis was as follows: three lymphomas, three peritoneal carcinomatoses, two chronic imflammations, and one benign tumor.

CONCLUSIONS

Three purposes can be achieved: a familiar method for the surgeon compared with total laparoscopic surgery, easy accessibility for further oncological management, and intraoperative miniconversion for peritoneal examination. It is a safe and effective way to obtain tissue for pathology and feasible in case of necessary sequential tumor resection.

Gasless laparoscopic aorto-bifemoral bypass grafting using self-designed abdominal lifting system

Severe aorto-iliac occlusive disease can cause disabling symptoms. The treatment of aorto-iliac occlusive disease has dramatically changed with the introduction of endoluminal techniques. However, according to the Trans-Atlantic Inter-Society Consensus for severe aorto-iliac disease, aorto-bifemoral bypass remains the therapy of choice. A recent addition to the open repair is laparoscopic-assisted aorto-bifemoral bypass, especially in occlusive arterial disease. In this article, we describe a new technique of performing gasless laparoscopic-assisted aorto-bifemoral bypass grafting with a self-designed abdominal wall-lifting system. We dealt with a patient who had a history of coronary artery disease and poor cardiopulmonary functional reserve. He had disabling symptoms of claudication and rest pain on bilateral lower extremities. Aorto-biliac-femoral occlusive disease was diagnosed in him, and he underwent the gasless laparoscopic-assisted aorto-bifemoral bypass. The total procedure time was 260 minutes. The patient was extubated 5 hours postoperatively. He was discharged home without complications 5 days after the surgery. This procedure is attractive not only to minimize the length of the wound and the time to extubation but also to avoid the possible lethal complications associated with the traditional laparascopic pneumoperitoneum. This device and technique can also provide a bridge for young or less-experienced surgeons to be familiar with total laparoscopic aortic surgery from traditional open repair.

Gasless single-port access endoscopic surgery in urology: minimum incision endoscopic surgery, MIES

Abstract Minimum incision endoscopic surgery (MIES) is a gasless, single-port access, cost-effective, and minimally invasive surgery that has been in development since the late 1990s. Use of MIES has steadily increased in Japan and Asia and has been introduced into Europe and the USA. In 2006, MIES was certified by the Japanese government as an advanced surgery and since 2008 it has been covered by the Japanese universal health insurance system as a new surgical technique. Briefly, MIES involves an initial minimum incision (a single port) that permits extraction of the target specimen. A wide working space through the port is then made by separating the anatomical plane extraperitoneally. This is maintained with special retractors instead of gas insufflation. All instruments including an endoscope are inserted through the port and the operation is completed. The size of the port can be tailored to the situation if necessary, which contributes to preclusion of patient selection. The procedure uses only two disposable devices that are inexpensive, resulting in low equipment costs. Surgeons have the benefits of magnified vision through endoscopy as well as stereovision and panoramic vision of naked eyes through the port, which reduces the technical demands of the procedure. Techniques for two basic MIES procedures allow MIES to be performed for most urological organs and in extraordinary cases by their modifications. Thus, the MIES system permits minimally invasive surgery without use of CO(2) gas, which is ideal from medical, environmental and economic perspectives, is cost-effective and minimizes patient selection.