Laparoscopic surgery and surgical infection

Construction and validation of a risk prediction model for postoperative ICU admission in patients with colorectal cancer: clinical prediction model study

BACKGROUND

Transfer to the ICU is common following non-cardiac surgeries, including radical colorectal cancer (CRC) resection. Understanding the judicious utilization of costly ICU medical resources and supportive postoperative care is crucial. This study aimed to construct and validate a nomogram for predicting the need for mandatory ICU admission immediately following radical CRC resection.

METHODS

Retrospective analysis was conducted on data from 1003 patients who underwent radical or palliative surgery for CRC at Ningxia Medical University General Hospital from August 2020 to April 2022. Patients were randomly assigned to training and validation cohorts in a 7:3 ratio. Independent predictors were identified using the least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression in the training cohort to construct the nomogram. An online prediction tool was developed for clinical use. The nomogram's calibration and discriminative performance were assessed in both cohorts, and its clinical utility was evaluated through decision curve analysis (DCA).

RESULTS

The final predictive model comprised age (P = 0.003, odds ratio [OR] 3.623, 95% confidence interval [CI] 1.535-8.551); nutritional risk screening 2002 (NRS2002) (P = 0.000, OR 6.129, 95% CI 2.920-12.863); serum albumin (ALB) (P = 0.013, OR 0.921, 95% CI 0.863-0.982); atrial fibrillation (P = 0.000, OR 20.017, 95% CI 4.191-95.609); chronic obstructive pulmonary disease (COPD) (P = 0.009, OR 8.151, 95% CI 1.674-39.676); forced expiratory volume in 1 s / Forced vital capacity (FEV1/FVC) (P = 0.040, OR 0.966, 95% CI 0.935-0.998); and surgical method (P = 0.024, OR 0.425, 95% CI 0.202-0.891). The area under the curve was 0.865, and the consistency index was 0.367. The Hosmer-Lemeshow test indicated excellent model fit (P = 0.367). The calibration curve closely approximated the ideal diagonal line. DCA showed a significant net benefit of the predictive model for postoperative ICU admission.

CONCLUSION

Predictors of ICU admission following radical CRC resection include age, preoperative serum albumin level, nutritional risk screening, atrial fibrillation, COPD, FEV1/FVC, and surgical route. The predictive nomogram and online tool support clinical decision-making for postoperative ICU admission in patients undergoing radical CRC surgery.

TRIAL REGISTRATION

Despite the retrospective nature of this study, we have proactively registered it with the Chinese Clinical Trial Registry. The registration number is ChiCTR2200062210, and the date of registration is 29/07/2022.

Comparing surgical site wound infection after laparoscopic and open radical cystectomies in patients with bladder cancer

This study comprehensively compared the effects of laparoscopic and open radical cystectomies on postoperative wound infections and complications in patients with bladder cancer. We conducted a systematic search for relevant studies in PubMed, Embase, Google Scholar, Cochrane Library, China National Knowledge Infrastructure, and Wanfang databases, from database inception to October 2023. Two researchers independently screened the literature, extracted data, and assessed the quality based on the inclusion and exclusion criteria. Data analysis was performed using Stata 17.0 software. Overall, 16 studies involving 1427 patients with bladder cancer were included. The analysis revealed that, compared with open radical cystectomy, laparoscopic radical cystectomy significantly reduced the incidence of wound infections (odds ratio [OR] = 0.38, 95% confidence interval [CI]: 0.23-0.64, p < 0.001) and complications (OR = 0.35, 95%CI: 0.26-0.47, p < 0.001) and significantly shortened the hospital stay duration (standardised mean difference [SMD] = -1.85, 95%CI: -2.34 to -1.36, p < 0.001). Thus, this study determined that laparoscopic radical cystectomy for the treatment of bladder cancer effectively reduced the occurrence of wound infections and complications, and significantly shortened the patient's hospital stay, demonstrating notable therapeutic effectiveness worthy of clinical application.

Anti-infective therapy durations predict psychological stress and laparoscopic surgery quality in pelvic abscess patients

BACKGROUND

The degree of psychological stress and the difficulty and efficacy of laparoscopic surgery differ in patients with pelvic abscesses after different durations of anti-infection treatment.

AIM

To compare and analyse the effects of different durations of anti-infective therapy on patients’ preoperative psychological stress level and the clinical efficacy of laparoscopic surgery in patients with pelvic abscesses to offer a reference for the selection of therapy plans.

METHODS

A total of 100 patients with pelvic abscesses who were admitted to the Department of Gynecology of Suzhou Ninth Hospital affiliated to Soochow University (Suzhou Ninth People's Hospital) from January 2018 to December 2022 were retrospectively enrolled. According to the different durations of anti-infective therapy, they were divided into Group S (50 patients, received anti-infective therapy for 24-48 h) and Group L (50 patients, received anti-infective therapy for 48-96 h). Baseline data, state-trait anxiety score at admission and before surgery, self-rating anxiety scale (SAS) + self-rating depression scale (SDS) score, surgery time, adhesion grading score, intraoperative blood loss, presence or absence of intraoperative intestinal injury, ureteral injury or bladder injury, postoperative body temperature, length of hospital stay, and presence or absence of recurrence within 3 mo after surgery, chronic pelvic pain, incision infection, dysmenorrhea, menstrual disorder or intestinal obstruction were compared between the S group and the L group.

RESULTS

There was no significant difference in the background data between the S group and the L group (P < 0.05). There was no significant difference in the state-trait anxiety score or SAS + SDS score between the S group and the L group on admission (P < 0.05). The state-trait anxiety score and SAS + SDS score of the S group were lower than those of Group L after receiving different durations of anti-infective therapy (P < 0.05). There was no significant difference in the incidence of intestinal, ureteral or bladder injury between the S group and the L group (P < 0.05). The surgery time of Group S was shorter than that of Group L, and the adhesion score and intraoperative blood loss volume were lower than those of Group L (P < 0.05). There was no significant difference in the incidence of incision infection, dysmenorrhea, menstrual disorder or intestinal obstruction between the S group and the L group (P < 0.05). The postoperative body temperature of Group S was lower than that of Group L (P < 0.05), and the hospital stay was shorter than that of Group L (P < 0.05). The incidences of recurrence and chronic pelvic pain within 3 mo after surgery were lower than that of Group L (P < 0.05).

CONCLUSION

Twenty-four to forty-eight hours of anti-infective therapy is better than 48-96 h of anti-infective therapy for patients with pelvic abscesses because the degree of psychological stress is lower, which is more conducive to achieving better outcomes after laparoscopic surgery.

Association of antimicrobial perioperative prophylaxis with cefuroxime plus metronidazole or amoxicillin/clavulanic acid and surgical site infections in colorectal surgery

OBJECTIVE

To compare intravenous (IV) amoxicillin/clavulanic acid (A/CA) to IV cefuroxime plus metronidazole (C + M) for preventing surgical site infections (SSI) in colorectal surgery.

BACKGROUND

Given their spectra that include most Enterobacterales and anaerobes, C + M is commonly recommended as prophylaxis of SSI in colorectal surgery. A/CA offers good coverage of Enterobacterales and anaerobes as well, but, in contrast to C + M, it also includes Enterococcus faecalis which is also isolated from patients with SSI and could trigger anastomotic leakage.

METHODS

Data from a Swiss SSI surveillance program were used to compare SSI rates after class II (clean contaminated) colorectal surgery between patients who received C + M and those who received A/CA. We employed multivariable logistic regression to adjust for potential confounders, along with propensity score matching to adjust for group imbalance.

RESULTS

From 2009 to 2018, 27,922 patients from 127 hospitals were included. SSI was diagnosed in 3132 (11.2%): 278/1835 (15.1%) in those who received A/CA and 2854/26,087 (10.9%) in those who received C + M (p < 0.001). The crude OR for SSI in the A/CA group as compared to C + M was 1.45 [CI 95% 1.21-1.75]. The adjusted OR was 1.49 [1.24-1.78]. This finding persisted in a 1:1 propensity score matched cohort of 1835 patients pairs with an OR of 1.60 [1.28-2.00]. Other factors independently associated with SSI were an ASA score > 2, a longer duration of operation, and a reoperation for a non-infectious complication. Protective factors were female sex, older age, antibiotic prophylaxis received 60 to 30 min before surgery, elective operation, and endoscopic approach.

CONCLUSIONS

Despite its activity against enterococci, A/CA was less effective than C + M for preventing SSI, suggesting that it should not be a first choice antibiotic prophylaxis for colorectal surgery.

Comparative Study of Percutaneous Dilatational Tracheostomy and Conventional Surgical Tracheostomy in Critically Ill Adult Patients

The present study was aimed to compare percutaneous dilatational tracheostomy (PDT) with that of conventional surgical tracheostomy (ST) in critically ill adult patients requiring tracheostomy for respiratory management. For this purpose 32 critically ill patients, admitted to the ICU between July 2016 and June 2018, were subjected to tracheostomy and randomly divided into two groups (PDT and ST) of 16 patients each. Mean duration of intubation was similar between the two procedures while the mean size of the tracheostomy tube was smaller in percutaneous technique. In comparison, post-operative infection after 7 days seem to be statistically lowered and the length of scar tend to be smaller in PDT patients. Although early and late post-operative complication rates are not statistically significant in the PDT groups, yet investigations of the long-term outcome following PDT are, therefore, necessary. Generally, PDT has lower acute complications than ST, although this may vary by the specific PDT technique. Patient factor may also influence complications. In view of the benefit versus risks in tracheostomy, PDT may be considered the "procedure of choice" for performing elective tracheostomies in critically ill adult patients.

Two-point fixation enhanced the outcome of laparoscopy-assisted ventriculoperitoneal shunt in adult patients with hydrocephalus: a retrospective study

Objective

In patients with hydrocephalus, laparoscopy significantly improved ventriculoperitoneal shunt (VPS) outcomes. However, abdominal complications still occur, which require revision surgeries. In this study, we aimed to examine whether laparoscopy-assisted VPS with two-point fixation (LAVPS-TPF) has better outcomes than those of VPS (open-VPS) and laparoscopy-assisted VPS with no fixation (LAVPS-NF).

Methods

We retrospectively reviewed clinical records of 105 open-VPS, 40 LAVPS-NF, and 49 LAVPS-TPF cases from 2015 to 2020. Data including body mass index, etiology, abdominal surgery history, Glasgow coma scale (GCS), operation time, in-hospital days, shunt failure, complications, and modified Rankin scores were analyzed, as well as subgroups of patients with history of abdominal surgery, GCS scores, and revision surgeries.

Results

The LAVPS-TPF group demonstrated decreased shunt failure rates at 12 months (2.04%) compared to those of the open-VPS group (14.29%, P = 0.020) and reduced abdominal shunt-related complications (P = 0.004 vs. open-VPS and LAVPS-NF) and shunt revisions. In the LAVPS-TPF group with abdominal history (n = 51), 12-month shunt failure rates (P = 0.020 vs. open-VS), repair frequency (P = 0.020 vs. open-VS), and abdominal complications (P = 0.003 and 0.006 vs. open-VS and LAVPS-NF) were reduced. In the LAVPS-TPF group with GCS scores of 13-15 (n = 152), shunt failure rates at 12 months, abdominal complications, and revision frequency were decreased (P < 0.05 vs. other groups). Compared to the LAVPS-NF group, neurological complications were also reduced (P = 0.001). Among revision surgeries (n = 28), fixed shunts resulted in improved shunt survival rates at 12 months, reduced abdominal complications, and secondary revisions (P < 0.05). Moreover, a more optimal recovery without neurological sequelae was achieved by shunt fixation than that by LAVPS-NF (P < 0.01).

Conclusions

LAVPS-TPF significantly improved shunt survival rates at 12 months and reduced the incidence of abdominal shunt-related complications compared to open-VPS and LAVPS-NF, especially in patients with history of abdominal surgery, higher GCS scores, and revision surgeries. However, further studies are required to confirm these benefits.

Differences in risk factors for surgical site infection between laparotomy and laparoscopy in gastrointestinal surgery

Extensive gastrointestinal surgery surveillance data in Japan were analyzed to examine the differences in the risk factors for surgical site infection (SSI) between laparotomy and laparoscopic abdominal procedures. Surgical procedures investigated in the study were gastrectomy, cholecystectomy, colectomy, rectal resection, and appendectomy. A total of 32,629 patients were included in the study. The study participants were divided into two groups according to the year of surgery, 2003–2009 (first study period) and 2010–2015 (second study period), due to the increase in the number of laparoscopic surgeries in the second study period. The incidence of SSI was stratified by three SSI classifications (superficial incisional, deep incisional, and organ/space SSI). Multiple logistic regression analysis was performed to predict the risk factors for SSI. The percentage of laparoscopic surgeries performed has increased linearly since 2010. Patients in the second study period were significantly older and had a higher prevalence of SSI risk factors compared with those in the first study period. In addition, the predictive factors changed substantially in most surgical procedures between the two study periods. Wound class ≥ 3 was a ubiquitous risk factor for superficial incisional SSI (SI-SSI) and organ/space SSI (OS-SSI) in both open (laparotomy) and laparoscopic procedures in the first study period. Meanwhile, in the second study period, operative duration was a ubiquitous risk factor in both procedures. The risk factors for SI-SSI differed from those for OS-SSI in the five abdominal surgeries investigated in the study. Periodic examination of risk factors for SSI is recommended in an aging society.

Transanal endoluminal repair for anastomotic leakage after low anterior resection

BACKGROUND

There is still no consensus on the management of colorectal anastomotic leakage after low anterior resection. The goal was to evaluate the outcomes of patients who underwent transanal endoluminal repair + laparoscopic drainage ± stoma vs. drainage only ± stoma.

METHODS

Retrospective chart review of patients sustaining anastomotic leakage after laparoscopic low anterior resection between January 2013 and September 2020 who required laparoscopic reoperation.

RESULTS

Forty-nine patients were included, 22 patients underwent combined laparoscopy and transanal endoluminal repair and 27 patients had drainage with a stoma (n = 16) or drainage alone (n = 11), without direct anastomotic repair. The overall morbidity rate was 30.6% and the mortality rate was 2%. Combined laparoscopic lavage/drainage and transanal endoluminal repair of anastomotic leakage was associated with a lower complication rate (13.6% vs. 44.4%, p = 0.03) and fewer intraabdominal infections (4.5% vs. 29.6%, p = 0.03) compared with no repair.

CONCLUSIONS

Combined laparoscopic lavage/drainage and transanal endoluminal repair is effective in the management of colorectal anastomosis leakage and was associated with lower morbidity-in particular intraabdominal infection-compared with no repair. However, our results need to be confirmed in larger, and ideally randomized, studies.

Optimal management of peripancreatic fluid collection with postoperative pancreatic fistula after distal pancreatectomy: Significance of computed tomography values for predicting fluid infection

Peripancreatic fluid collections have been observed in most patients with postoperative pancreatic fistula after distal pancreatectomy; however, optimal management remains unclear. This study aimed to evaluate the management and outcomes of patients with postoperative pancreatic fistula and verify the significance of computed tomography values for predicting peripancreatic fluid infections after distal pancreatectomy. We retrospectively investigated 259 consecutive patients who underwent distal pancreatectomy. Grade B postoperative pancreatic fistula patients were divided into two subgroups (B-antibiotics group and B-intervention group) and outcomes were compared. Predictive factor analysis of peripancreatic fluid infection was performed. Clinically relevant postoperative pancreatic fistulas developed in 88 (34.0%) patients. The duration of hospitalization was significantly longer in the B-intervention (n = 54) group than in the B-antibiotics group (n = 31; 41 vs. 17 days, p < 0.001). Computed tomography values of the infected peripancreatic fluid collections were significantly higher than those of the non-infected peripancreatic fluid collections (26.3 vs. 16.1 Hounsfield units, respectively; p < 0.001). The outcomes of the patients with grade B postoperative pancreatic fistulas who received therapeutic antibiotics only were considerably better than those who underwent interventions. Computed tomography values may be useful in predicting peripancreatic fluid collection infection after distal pancreatectomy.

Advantages of, and Adaptations to, Enhanced Recovery Protocols for Perioperative Care during the COVID-19 Pandemic

Objective

This review formulates the rationale for using enhanced recovery protocols (ERPs) to standardize and optimize perioperative care during this high-risk time to minimize poor outcomes owing to provider, patient, and system vulnerabilities.

Data Sources

n/a

Methods of Study Selection

A literature review using key Medical Subject Headings terms was performed—according to methods described by the Cochrane Collaboration and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines—on studies that described enhanced recovery and coronavirus disease (COVID-19).

Tabulation, Integration, and Results

Modifications to our existing ERPs related to the COVID-19 pandemic should include new accommodations for patient education, preoperative COVID-19 testing, prehabilitation, and intraoperative infection as well as thromboembolism risk reduction.

Conclusion

ERPs are evidence-based, best practice guidelines applied across the perioperative continuum to mitigate surgical stress, decrease complications, and accelerate recovery. These benefits are part of the high-value–care equation needed to solve the clinical, operational, and financial challenges of the current COVID-19 pandemic. The factors driving outcomes on ERPs, such as the provision of minimally invasive surgery, warrant careful consideration. Tracking patient outcomes and improving care in response to outcomes data are key to the success of clinical care protocols such as ERPs. Numerous emerging clinical registries and reporting systems have been activated to provide outcomes data on the impact of COVID-19. This will inform and change surgical practice as well as provide opportunity to learn if the advantages that surgeons, patients, and the healthcare system might gain from using ERPs during a pandemic are meaningful.

Laparoscopic versus open management of adult intussusception

BACKGROUND

Laparotomy has been the traditional approach for the treatment of adult intussusception. The aim of the present study was to compare the short-term clinical outcomes of laparoscopic surgery to those of open surgery in adult patients with intussusception.

METHODS

We retrospectively reviewed data of all adult patients with intussusception admitted to our hospital between 2007 and 2017. The patients' characteristics, presentation, operation details, postoperative outcomes and pathology were analyzed. Comparisons were made between the laparoscopic and open surgery procedures performed during the study period.

RESULTS

Seventeen open and 20 laparoscopic-assisted resections were performed. No significant differences were found between the two groups for the following parameters: age (45.3 ± 16.8 vs. 54.9 ± 19.1, p = 0.160); gender (41 vs. 60% males, p = 0.330); American Society of Anesthesiologists score (p = 0.609); history of cardiovascular disease (5.9% vs. 5.6%, p = 0.950), COPD/asthma (0% vs. 5.6%, p = 0.950), diabetes (11.8% vs. 11.1%, p = 0.950), and renal impairment (5.9% vs. 0%, p = 0.486); body mass index (20.6 vs. 21.9, p = 0.433); timing of presentation (p = 1.000); type of intussusception (p = 0.658); type of procedures (p = 0.446); operative time (173.7 ± 45.4 vs. 191.5 ± 43.9, p = 0.329); and length of postoperative stay (6.7 ± 5.4 vs. 4.5 ± 1.1 days, p = 0.153). However, the open surgery group had fewer patients with hypertension (17.6% vs. 61.1%, p = 0.009) and demonstrated a delayed oral intake (4.0 ± 1.7 days vs. 2.5 ± 0.7 days, p = 0.010) and a higher comprehensive complication index (11.5 ± 27.1 vs. 0, p = 0.038).

CONCLUSIONS

The laparoscopic approach was associated with earlier oral intake and a lower comprehensive complication index. It is a safe and feasible technique that confers the advantages of minimally invasive surgery. It can be considered the preferred surgical option when the surgical expertise is available.

COVID-19 and Laparoscopic Surgery: Scoping Review of Current Literature and Local Expertise

BACKGROUND

The current coronavirus disease (COVID-19) pandemic is holding the world in its grip. Epidemiologists have shown that the mortality risks are higher when the health care system is subjected to pressure from COVID-19. It is therefore of great importance to maintain the health of health care providers and prevent contamination. An important group who will be required to treat patients with COVID-19 are health care providers during semiacute surgery. There are concerns that laparoscopic surgery increases the risk of contamination more than open surgery; therefore, balancing the safety of health care providers with the benefit of laparoscopic surgery for the patient is vital.

OBJECTIVE

We aimed to provide an overview of potential contamination routes and possible risks for health care providers; we also aimed to propose research questions based on current literature and expert opinions about performing laparoscopic surgery on patients with COVID-19.

METHODS

We performed a scoping review, adding five additional questions concerning possible contaminating routes. A systematic search was performed on the PubMed, CINAHL, and Embase databases, adding results from gray literature as well. The search not only included COVID-19 but was extended to virus contamination in general. We excluded society and professional association statements about COVID-19 if they did not add new insights to the available literature.

RESULTS

The initial search provided 2007 records, after which 267 full-text papers were considered. Finally, we used 84 papers, of which 14 discussed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Eight papers discussed the added value of performing intubation in a low-pressure operating room, mainly based on the SARS outbreak experience in 2003. Thirteen papers elaborated on the risks of intubation for health care providers and SARS-CoV-2, and 19 papers discussed this situation with other viruses. They conclude that there is significant evidence that intubation and extubation is a high-risk aerosol-producing procedure. No papers were found on the risk of SARS-CoV-2 and surgical smoke, although 25 papers did provide conflicting evidence on the infection risk of human papillomavirus, hepatitis B, polio, and rabies. No papers were found discussing tissue extraction or the deflation risk of the pneumoperitoneum after laparoscopic surgery.

CONCLUSIONS

There seems to be consensus in the literature that intubation and extubation are high-risk procedures for health care providers and that maximum protective equipment is needed. On the other hand, minimal evidence is available of the actual risk of contamination of health care providers during laparoscopy itself, nor of operating room pressure, surgical smoke, tissue extraction, or CO₂ deflation. However, new studies are being published daily from current experiences, and society statements are continuously updated. There seems to be no reason to abandon laparoscopic surgery in favor of open surgery. However, the risks should not be underestimated, surgery should be performed on patients with COVID-19 only when necessary, and health care providers should use logic and common sense to protect themselves and others by performing surgery in a safe and protected environment.

The Memo Slide: An explorative study into a novel mechanical follow-the-leader mechanism

Follow-the-leader propagation allows for the insertion of flexible surgical instruments along curved paths, reducing the access required for natural orifice transluminal endoscopic surgery. Currently, the most promising follow-the-leader instruments use the alternating memory method containing two mechanical memory-banks for controlling the motion of the flexible shaft, which reduces the number of actuators to a minimum. These instruments do, however, require concentric structures inside the shaft, limiting its miniaturization. The goal of this research was, therefore, to develop a mechanism conforming the principles of the alternating memory method that could be located at the controller-side instead of inside the shaft of the instrument, which is positioned outside the patient and is therefore less restricted in size. First, the three-dimensional motion of the shaft was decoupled into movement in a horizontal and vertical plane, which allowed for a relatively simple planar alternating memory mechanism design for controlling planar follow-the-leader motion. Next, the planar movement of the alternating memory mechanism was discretized, increasing its resilience to errors. The resulting alternating memory mechanism was incorporated and tested in a proof-of-concept prototype called the MemoSlide. This prototype does not include a flexible shaft, but was fully focused on proving the function of the alternating memory mechanism. Evaluation of the MemoSlide shows the mechanism to work very well, being able to transfer any planar path that lays within its physical boundaries along the body of the mechanism without accumulating errors.

Risk Factors for Transumbilical Wound Complications in Laparoscopic Gastric and Colorectal Surgery

AIM

To investigate the risk factors of transumbilical incision for organ removal in laparoscopic surgery.

PATIENTS AND METHODS

We enrolled 643 consecutive patients undergoing laparoscopic surgery from 2010 to 2013. Superficial surgical site infection (SSI) and transumbilical port site hernia were recorded.

RESULTS

The participants underwent gastric (n=253) and colorectal (n=390) resections. SSI was observed in 17 cases (colorectal in 15; gastric in two) (2.64%) with colorectal resection having a high rate of SSI [odds ratio (OR)=5.020; p=0.022]. Hernia occurred in 23 cases (colorectal in 22; gastric in one) (3.53%), with a significantly higher rate for colorectal resection (OR=13.052; p<0.001). Female (OR=5.410; p=0.021) and history of diabetes mellitus (OR=4.437; p=0.009) contributed to the risk for developing a hernia.

CONCLUSION

Especially in relation to hernia, being female and having diabetes mellitus were considered independent risk factors.

Towards autonomous motion control in minimally invasive robotic surgery

INTRODUCTION

While autonomous surgical robotic systems exist primarily at the research level, recently these systems have made a strong push into clinical settings. The autonomous or semi-autonomous control of surgical robotic platforms may offer significant improvements to a diverse field of surgical procedures, allowing for high precision, intelligent manipulation of these systems and opening the door to advanced minimally invasive surgical procedures not currently possible.

AREAS COVERED

This review highlights those experimental systems currently under development with a focus on in vivo modeling and control strategies designed specifically for the complex and dynamic surgical environment. Expert review: Novel methods for state estimation, system modeling and disturbance rejection, as applied to these devices, continues to improve the performance of these important surgical tools. Procedures such as Natural Orifice Transluminal Endoscopic Surgery and Laparo-Endoscopic Single Site surgery, as well as more conventional procedures such as Colonoscopy, serve to benefit tremendously from the development of these automated robotic systems, enabling surgeons to minimize tissue damage and shorten procedure times while avoiding the consequences of laparotomy.

Comparison of postoperative immune function in patients with thoracic esophageal cancer after video-assisted thoracoscopic surgery or conventional open esophagectomy

AIM

The aim of the study was to compare postoperative immune function in patients with thoracic esophageal cancer (EC) after video-assisted thoracoscopic surgery (VATS) or conventional open esophagectomy.

PATIENTS AND METHODS

Medical records were retrospectively analyzed for 228 patients with thoracic EC treated at a single hospital using VATS (n = 52) or conventional open esophagectomy (n = 176). Proportions of CD3(+), CD4(+), CD8(+), and natural kill (NK) cells, as well as the ratio of CD4(+) to CD8(+) cells, were measured in the two groups using flow cytometry on preoperative day (PrD) 1 and postoperative days (PoD) 1 and 7.

RESULTS

Proportions of CD3(+), CD4(+), and NK cells as well as the CD4+/CD8+ ratio decreased significantly from PrD1 to PoD1 in both the VATS and open esophagectomy groups. In the VATS group, these parameters had returned to preoperative levels (PrD1) by PoD7. These parameters in open esophagectomy group increased from PoD1 to PoD7 but also lowered significantly to PrD1 by PoD7. The proportion of CD8(+) cells was similar between the two groups at all time points tested.

CONCLUSION

Patients may experience less postoperative immune suppression after VATS than after conventional open esophagectomy, and they may recover preoperative immune function more quickly.

Bacteria repelling on highly-ordered alumina-nanopore structures

Bacteria introduce diseases and infections to humans by their adherence to biomaterials, such as implants and surgical tools. Cell desorption is an effective step to reduce such damage. Here, we report mechanisms of bacteria desorption. An alumina nanopore structure (ANS) with pore size of 35 nm, 55 nm, 70 nm, and 80 nm was used as substrate to grow Escherichia coli (E. coli) cells. A bacteria repelling experimental method was developed to quantitatively evaluate the area percentage of adherent bacterial cells that represent the nature of cell adhesion as well as desorption. Results showed that there were two crucial parameters: contact angle and contact area that affect the adhesion/desorption. The cells were found to be more easily repelled when the contact angle increased. The area percentage of adherent bacterial cells decreased with the decrease in the contact area of a cell on ANS. This means that cell accessibility on ANS depends on the contact area. This research reveals the effectiveness of the nanopored structures in repelling cells.

On-table urethral catheterisation during laparoscopic appendicectomy: Is it necessary?

INTRODUCTION

Laparoscopic appendicectomy (LA) is the most commonly performed surgical emergency procedure. The aim of this study was to highlight a series of iatrogenic bladder injuries during LA and suggest a simple method of prevention.

METHODS

A retrospective review was carried out of all LA performed in a university teaching hospital over a two year period 2012-2013. Iatrogenic visceral injuries were identified and operative notes examined.

RESULTS

During the study period 1124 appendicectomies were performed. Four iatrogenic bladder injuries occurred related to secondary trocar insertion. No patient was catheterised preoperatively. One of the injuries was identified intra-operatively, another in the early postoperative period where as two re-presented acutely unwell post-discharge from hospital. Three were repaired by laparotomy and one laparoscopically.

CONCLUSION

Iatrogenic secondary trocar induced bladder injuries are a rare but preventable and potentially serious complication of LA. Urethral catheterisation during LA is a safe and simple method which can prevent this complication.

Inflammatory response in laparoscopic vs. open surgery for gastric cancer

OBJECTIVE

Laparoscopic surgery may offer advantages compared to open surgery, such as earlier mobilization, less pain and lower post-surgical morbidity. Surgical stress is thought to be associated with the postoperative immunological changes in the body as an impaired immune function, which may lead to an increased susceptibility to complications and morbidity. The aim of this review was to investigate if laparoscopic surgery reduces the immunological response compared to open surgery in gastric cancer.

METHODS

We conducted a literature search identifying relevant studies comparing laparoscopy or laparoscopic-assisted surgery with open gastric surgery. The main outcome was postoperative immunological status defined as surgical stress parameters, including inflammatory cytokines and blood parameters.

RESULTS

We identified seven studies that addressed the immunological status in patients undergoing laparoscopic or laparoscopy-assisted surgery compared to open surgery. IL-6 in circulation was found to be significantly reduced in laparoscopic patients. Furthermore, the plasma concentration of C-reactive protein was significantly lower in laparoscopic patients compared to patients undergoing laparotomy. Finally, most studies reported lower levels of white blood cell count in laparoscopic patients, although this result did not reach statistical significance in a small number of studies.

CONCLUSIONS

Laparoscopy-assisted gastric surgery seems to attenuate the immune response compared to open surgery. Larger and prospective studies are needed to further evaluate if the immunological status is relatively preserved in minimal invasive surgery and if this may reduce the postoperative complications compared to open surgery.

Reducing the Cost of Laparoscopy: Reusable versus Disposable Laparoscopic Instruments

Cost-effectiveness in health care management is critical. The situation in debt-stricken Greece is further aggravated by the financial crisis and constant National Health System expense cut-downs. In an effort to minimize the cost of laparoscopy, our department introduced reusable laparoscopic instruments in December 2011. The aim of this study was to assess potential cost reduction of laparoscopic operations in the field of general surgery. Hospital records, invoice lists, and operative notes between January 2012 and December 2013, were retrospectively reviewed and data were collected on laparoscopic procedures, instrument failures, and replacement needs. Initial acquisition cost of 5 basic instrument sets was €21,422. Over the following 24 months, they were used in 623 operations, with a total maintenance cost of €11,487. Based on an average retail price of €490 per set, projected cost with disposable instruments would amount to €305,270, creating savings of €272,361 over the two-year period under study. Despite the seemingly high purchase price, each set amortized its acquisition cost after only 9 procedures and instrument cost depreciated to less than €55 per case. Disposable instruments cost 9 times more than reusable ones, and their high price would almost equal the total hospital reimbursement by social security funds for many common laparoscopic procedures.

Percutaneous dilational tracheostomy

Tracheostomy is a commonly performed intervention with several benefits in the treatment of patients with chronic respiratory failure. Percutaneous dilational tracheostomy techniques have allowed bedside tracheostomy placement in the modern intensive care unit. Percutaneous dilational tracheostomy can be safely performed by interventional pulmonologists, medical intensive care physicians, and surgical specialists. When performed with the assistance of adjuncts, such as flexible bronchoscopy, the percutaneous dilational method has a favorable complication rate, efficiency, and cost profile compared with surgical tracheostomy.

Analysis of laparoscopic port site complications: A descriptive study

CONTEXT:

The rate of port site complications following conventional laparoscopic surgery is about 21 per 100,000 cases. It has shown a proportional rise with increase in the size of the port site incision and trocar. Although rare, complications that occur at the port site include infection, bleeding, and port site hernia.

AIMS:

To determine the morbidity associated with ports at the site of their insertion in laparoscopic surgery and to identify risk factors for complications.

SETTINGS AND DESIGN:

Prospective descriptive study.

MATERIALS AND METHODS:

In the present descriptive study, a total of 570 patients who underwent laparoscopic surgeries for various ailments between August 2009 and July 2011 at our institute were observed for port site complications prospectively and the complications were reviewed.

STATISTICAL ANALYSIS USED:

Descriptive statistical analysis was carried out in the present study. The statistical software, namely, SPSS 15.0 was used for the analysis of the data.

RESULTS:

Of the 570 patients undergoing laparoscopic surgery, 17 (3%) had developed complications specifically related to the port site during a minimum follow-up of three months; port site infection (PSI) was the most frequent (n = 10, 1.8%), followed by port site bleeding (n = 4, 0.7%), omentum-related complications (n = 2; 0.35%), and port site metastasis (n = 1, 0.175%).

CONCLUSIONS:

Laparoscopic surgeries are associated with minimal port site complications. Complications are related to the increased number of ports. Umbilical port involvement is the commonest. Most complications are manageable with minimal morbidity, and can be further minimized with meticulous surgical technique during entry and exit.

Intra-abdominal collections following laparoscopic versus open appendicectomy: an experience of 516 consecutive cases at a district general hospital

BACKGROUND

The objective of this study is to evaluate the incidence of intra-abdominal collections (IACs) in all patients undergoing laparoscopic (LA) and open appendicectomy (OA) from April 2009 to October 2011 in a district general hospital with expertise in minimally invasive surgery (MIS).

METHODS

A retrospective review of all patients undergoing appendicectomy in the specified time period was carried out. IACs were identified from various in-hospital data resources. Severity of appendicitis was assessed from histology reports.

RESULTS

516 patients were identified, of whom 242 (47 %) underwent OA and 274 (53 %) LA. Twenty-six (5 %) patients were found to have IACs postoperatively. Fifteen (5.5 %) IACs were identified in the laparoscopic group and 11 (4.5 %) in the open group. There was no statistically significant difference in the risk of developing IACs in open versus laparoscopic groups [odds ratio (OR) 1.22, confidence interval (CI) 0.55-2.70, P = 0.63]. Patients were twelve times more likely to develop IACs with an appendix identified as being necrotic or perforated on histology (OR 12.24, CI 5.29-28.32, P < 0.0001). There was a trend towards shorter total hospital stay in the LA (3.58 days, CI 3.0-4.1 days) compared with OA (4.31 days, CI 3.7-4.9 days, P = 0.082) group, although this was not statistically significant.

CONCLUSIONS

Increased rates of IAC following LA have been identified in some studies. Our series shows that, in a centre with adequate MIS experience, the IAC rate following LA is comparable to that of the open approach and should not deter surgeons with adequate support and resources.

A systematic review and meta-analysis of studies comparing laparoscopic and open distal pancreatectomy

OBJECTIVES

Currently, laparoscopic distal pancreatectomy (LDP) is regarded as a safe and effective surgical approach for lesions in the body and tail of the pancreas. This review compares outcomes of the laparoscopic technique with those of open distal pancreatectomy (ODP) and assesses the efficacy, safety and feasibility of each type of procedure.

METHODS

Comparative studies published between January 1996 and April 2012 were included. Studies were selected based on specific inclusion and exclusion criteria. Evaluated endpoints were operative outcomes, postoperative recovery and postoperative complications.

RESULTS

Fifteen non-randomized comparative studies that recruited a total of 1456 patients were analysed. Rates of conversion from LDP to open surgery ranged from 0% to 30%. Patients undergoing LDP had less intraoperative blood loss [weighted mean difference (WMD) -263.36.59 ml, 95% confidence interval (CI) -330.48 to -196.23 ml], fewer blood transfusions [odds ratio (OR) 0.28, 95% CI 0.11-0.76], shorter hospital stay (WMD -4.98 days, 95% CI -7.04 to -2.92 days), a higher rate of splenic preservation (OR 2.98, 95% CI 2.18-3.91), earlier oral intake (WMD -2.63 days, 95% CI -4.23 to 1.03 days) and fewer surgical site infections (OR 0.37, 95% CI 0.18-0.75). However, there were no differences between the two approaches with regard to operation time, time to first flatus and the occurrence of pancreatic fistula and other postoperative complications.

CONCLUSIONS

Laparoscopic resection results in improved operative and postoperative outcomes compared with open surgery according to the results of the present meta-analyses. It may be a safe and feasible option for patients with lesions in the body and tail of the pancreas. However, randomized controlled trials should be undertaken to confirm the relevance of these early findings.

Percutaneous dilatational versus conventional surgical tracheostomy in intensive care patients

Background:

Tracheostomy is usually performed in patients with difficult weaning from mechanical ventilation or some catastrophic neurologic insult. Conventional tracheostomy involves dissection of the pretracheal tissues and insertion of the tracheostomy tube into the trachea under direct vision. Percutaneous dilatational tracheostomy is increasingly popular and has gained widespread acceptance in many intensive care unit and trauma centers.

Aim:

Aim of the study was to compare percutaneous dilatational tracheostomy versus conventional tracheostomy in intensive care patients.

Patients and Methods:

64 critically ill patients admitted to intensive care unit subjected to tracheostomy and randomly divided into two groups; percutaneous dilatational tracheostomy and conventional tracheostomy.

Results:

Mean duration of the procedure was similar between the two procedures while the mean size of tracheostomy tube was smaller in percutaneous technique. In addition, the Lowest SpO₂ during procedure, PaCO₂ after operation and intra-operative bleeding for both groups were nearly similar without any statistically difference. Postoperative infection after 7 days seen to be statistically lowered and the length of scar tend to be smaller among PDT patients.

Conclusion:

PDT technique is effective and safe as CST with low incidence of post operative complication.

Prospective evaluation of laparoscopic assisted cystectomy and ileal conduit in advanced multiple sclerosis

OBJECTIVE

To assess the morbidity, mortality, and impact on quality of life and renal function after laparoscopic cystectomy and ileal conduit in patients with multiple sclerosis with lower urinary tract symptom refractory to conservative management.

MATERIALS AND METHODS

A prospective study was conducted between February 2004 and December 2010 on 44 consecutive patients with multiple sclerosis who underwent laparoscopic cystectomy and ileal conduit for lower urinary tract symptom. Median Expanded Disability Status Scale score was 8 (6.5-8.5). Mean duration of multiple sclerosis was 19.3 ± 7.9 years. The quality of life was determined using the validated Qualiveen questionnaire preoperatively and at minimum 6 months after the surgery.

RESULTS

No conversion to open surgery was required. Postoperative morbidity rate was 18.2%; minor (Clavien ≤ 2) and major (Clavien ≥ 3) complications occurred in 13.6% and 6.8%, respectively. Mean follow-up was 44.5 ± 20.6 months. Complications noted were asymptomatic ureteroileal stenosis (n = 6) and pyelonephritis (n = 3). Neurological status and Expanded Disability Status Scale score remained stable throughout. Renal function remained unchanged. Limitations, constraints, and specific urinary impact index subscores of the Qualiveen were significantly improved at 6 months time.

CONCLUSION

Laparoscopic cystectomy and ileal conduit for lower urinary tract symptom in advanced multiple sclerosis is a safe procedure with low complications. Neurological status and renal function remain stable and quality of life improves and continues to remain improved during long-term follow-up, suggesting this to be an attractive option in patients with advanced multiple sclerosis with lower urinary tract symptom refractory to conservative treatment.

Laparoscopic distal pancreatectomy is associated with significantly less overall morbidity compared to the open technique: a systematic review and meta-analysis

OBJECTIVE

To compare laparoscopic distal pancreatectomy (LDP) versus open distal pancreatectomy (ODP) by using meta-analytical techniques.

BACKGROUND

LDP is increasingly performed as an alternative approach for distal pancreatectomy in selected patients. Multiple studies have tried to assess the safety and efficacy of LDP compared with ODP.

METHODS

A systematic review of the literature was performed to identify studies comparing LDP and ODP. Intraoperative outcomes, postoperative recovery, oncologic safety, and postoperative complications were evaluated. Meta-analysis was performed using a random-effects model.

RESULTS

Eighteen studies matched the selection criteria, including 1814 patients (43% laparoscopic, 57% open). LDP had lower blood loss by 355 mL (P < 0.001) and hospital length of stay by 4.0 days (P < 0.001). Overall complications were significantly lower in the laparoscopic group (33.9% vs 44.2%; odds ratio [OR] = 0.73, 95% confidence interval [CI] 0.57-0.95), as was surgical site infection (2.9% vs 8.1%; OR = 0.45, 95% CI 0.24-0.82). There was no difference in operative time, margin positivity, incidence of postoperative pancreatic fistula, and mortality.

CONCLUSIONS

LDP has lower blood loss and reduced length of hospital stay. There was a lower risk of overall postoperative complications and wound infection, without a substantial increase in the operative time. Although a thorough evaluation of oncological outcomes was not possible, the rate of margin positivity was comparable to the open technique. The improved complication profile of LDP, taken together with the lack of compromise of margin status, suggests that this technique is a reasonable approach in selected cancer patients.

Metaanalysis of trials comparing minimally invasive and open distal pancreatectomies

BACKGROUND

The current literature suggests that minimally invasive distal pancreatectomy (MIDP) is associated with faster recovery and less morbidity than open surgery. However, most studies have been limited by a small sample size and a single-institution design. To overcome this problem, the first metaanalysis of studies comparing MIDP and open distal pancreatectomy (ODP) has been performed.

METHODS

A systematic literature review was conducted to identify studies comparing MIDP and ODP. Perioperative outcomes (e.g., morbidity and mortality, pancreatic fistula rates, blood loss) constituted the study end points. Metaanalyses were performed using a random-effects model.

RESULTS

For the metaanalysis, 10 studies including 349 patients undergoing MIDP and 380 patients undergoing ODP were considered suitable. The patients in the two groups were similar with respect to age, body mass index (BMI), American Society of Anesthesiology (ASA) classification, and indication for surgery. The rate of conversion from full laparoscopy to hand-assisted procedure was 37%, and that from minimally invasive to open procedure was 11%. Patients undergoing MIDP had less blood loss, a shorter time to oral intake, and a shorter postoperative hospital stay. The mortality and reoperative rates did not differ between MIDP and ODP. The MIDP approach had fewer overall complications [odds ratio (OR), 0.49; 95% confidence interval (CI), 0.27-0.89], major complications (OR, 0.57; 95% CI, 0.34-0.96), surgical-site infections (OR, 0.32; 95% CI, 0.19-0.53), and pancreatic fistulas (OR, 0.68; 95% CI, 0.47-0.98).

CONCLUSIONS

The MIDP procedure is feasible, safe, and associated with less blood loss and overall complications, shorter time to oral intake, and shorter postoperative hospital stay. Furthermore, the minimally invasive approach reduces the rate of pancreatic leaks and surgical-site infections after ODP.

Clinical outcomes of laparoscopic versus open appendectomy

BACKGROUND

Appendectomy, being the most common surgical procedure performed in general surgery, is still being performed by both open and laparoscopic methods due to a lack of consensus as to which is the most appropriate method. Because further trials are necessary and few such studies have been performed in developing countries, we decided to evaluate the outcomes of the 2 procedures to share our experience with the international community.

METHODS

Consecutive patients with suspected acute appendicitis who underwent laparoscopic (LA) (n=48) and open (n=52) appendectomy (OA) over a period of 3 years were studied. Clinical outcomes were compared between the 2 groups in relation to operative time, analgesia used, length of hospital stay, return to work, resumption of a regular diet, and postoperative complications.

RESULTS

Mean age of patients was 25.8 years in the laparoscopic and 25.5 years in the open group. Patient demographics were similar in both groups (P>0.05). There was significantly less need for analgesia (1.0+/-0.5 in LA and 1.5+/-0.6 doses in OA), a short hospital stay (1.4+/-0.7 in LA and 3.4+/-1.0 days in OA), early return to work (12.6+/-3.3 in LA and 19.1+/-3.1 days in OA), and less time needed to return to a regular diet (20.1+/-2.9 in LA and 22.0+/-4.7, P<0.05 in OA) in the laparoscopic appendectomy group. Operative time was significantly shorter (54.9+/-14.7 in LA and 13.6+/-12.6 minutes in OA) in the open group. Total number of complications was less in the laparoscopic group; however, there was no statistically significant difference.

CONCLUSION

The laparoscopic technique is a safe and clinically beneficial operative procedure. It provides certain advantages over open appendectomy, including short hospital stay, decreased requirement of postoperative analgesia, early food tolerance, and earlier return to normal activities. Where feasible, laparoscopy should be undertaken as the initial procedure of choice for most cases of suspected appendicitis.

An Isolator System for minimally invasive surgery: the new design

BACKGROUND

The risk of obtaining a postsurgical infection depends highly on the air quality surrounding the exposed tissue, surgical instruments, and materials. Many isolators for open surgery have been invented to create a contained sterile volume around the exposed tissue. With the use of an isolator, a surgical procedure can be performed outside sterile environments. The goal of this study was to design an Isolator System (IS) for standard laparoscopic instruments while instrument movements are not restricted.

METHODS

The developed IS consists of a sleeve to protect the instrument shaft and tip and a special balloon to protect the incision and trocar tube. A coupling mechanism connected at the sleeve allows instrument changes without contamination of the isolated parts. Smoke tests were performed to show that outside air does not enter the new IS during a simulated laparoscopic procedure. Eight test runs and one baseline run inside a contained volume filled with thick smoke were performed to investigate whether smoke particles entered the Isolator System. Filters were used to identify smoke entering the Isolator System.

RESULTS

Seven filters showed no trace of smoke particles. In one test run, a part of the IS loosened and a small brown spot was visible. The filter from the baseline run was completely covered with a thick layer of particles, proving the effectiveness of the test. During all test runs, the isolated instrument was successfully locked on and unlocked from the isolated trocar. Instrument movements gave no complications. After removal of the isolated instrument, it took three novices an average of 3.1 (standard deviation (SD), 0.7) seconds to replace it correctly on the isolated trocar.

CONCLUSIONS

The designed IS for laparoscopy can increase sterility in environments where sterility cannot be guaranteed. The current design is developed for laparoscopy, but it can easily be adapted for other fields in minimally invasive surgery.

CO(2) pneumoperitoneum prolongs survival in an animal model of peritonitis compared to laparotomy

BACKGROUND

The advantages of laparoscopic surgery have been well documented. However, the impact of pneumoperitoneum on sepsis sequelae is still equivocal. This study aimed to evaluate the effect of CO(2) pneumoperitoneum, applied under different pressures and exposure times, on sepsis cascade and mortality.

MATERIAL AND METHODS

In 42 New Zealand rabbits, peritonitis was induced by the cecum ligation and puncture model. After 12 h, the animals were randomized in seven groups: a control group, four groups with pneumoperitoneum (10-15 mmHg for 60-180 min), and two groups with laparotomy (for 60 and 180 min). Blood samples were collected before cecum ligation and puncture, 12 h later and 1, 3, and 6 h after pneumoperitoneum desufflation or abdominal trauma closure to evaluate bacteremia, endotoxemia, white blood cells count, C-reactive protein, and procalcitonin levels. Furthermore, the mortality time was recorded in all animals.

RESULTS

Bacteremia and endotoxemia were induced in all groups. Endotoxemia levels were significantly more elevated in the group where pneumoperitoneum was performed under 15 mmHg for 180 min compared with all other groups at 1 and 3 h after pneumoperitoneum desufflation (P < 0.05), except when compared with the group where pneumoperitoneum was performed under 10 mmHg for 180 min. White blood cell and C-reactive protein levels showed similar trends for all groups. However, serum procalcitonin reached statistically higher levels (P < 0.05) in groups with laparotomy compared with groups with pneumoperitoneum and with the control group at 6 h. Survival was lower in the laparotomy groups compared with the pneumoperitoneum groups and with the control group (P < 0.05).

CONCLUSIONS

In the presence of peritonitis, CO(2) pneumoperitoneum applied in clinically standard pressures, even for extended time intervals, reduces the severity of sepsis and prolongs survival.

Laparoscopic-assisted vs. open colectomy for cancer: comparison of short-term outcomes from 121 hospitals

BACKGROUND

Overall postoperative morbidity and mortality after laparoscopic-assisted colectomy (LAC) and open colectomy (OC) have been shown to be generally comparable; however, differences in the occurrence of specific complications are unknown. The objective of this study was to determine whether certain complications occurred more frequently after LAC vs. OC for colon cancer.

METHODS

Using the American College of Surgeons-National Surgical Quality Improvement Project's (ACS-NSQIP) participant-use file, patients were identified who underwent colectomy for cancer at 121 participating hospitals in 2005-2006. Multiple logistic regression models including propensity scores were developed to assess the risk-adjusted association between surgical approach (LAC vs. OC) and 30-day outcomes. Patients were excluded if they underwent emergent procedures, were ASA class 5, or had metastatic disease.

RESULTS

Of the 3,059 patients who underwent elective colectomy for cancer, 837 (27.4%) underwent LAC and 2,222 (72.6%) underwent OC. There were no significant differences in age, comorbidities, ASA class, or body mass index (BMI) between patients undergoing LAC vs. OC. Patients undergoing LAC had a lower likelihood of developing any adverse event compared to OC (14.6% vs. 21.7%; OR 0.64, 95% CI 0.51-0.81, P < 0.0001), specifically surgical site infections, urinary tract infections, and pneumonias. Mean length of stay was significantly shorter after LAC vs. OC (6.2 vs. 8.7 days, P < 0.0001). There were no differences between LAC and OC in the reoperation rate (5.5% vs. 5.8%, P = 0.79) or 30-day mortality (1.4% vs. 1.8%, P = 0.53).

CONCLUSIONS

Laparoscopic-assisted colectomy was associated with lower morbidity compared to OC in select patients, specifically for infectious complications.

Factors influencing the risk of surgical site infection following diagnostic exploration of the abdominal cavity

OBJECTIVES

We assessed the contribution of the surgical approach and the NNIS system's surgical component variables to surgical site infection (SSI) risk after diagnostic exploration of the abdominal cavity.

METHODS

Retrospective cohort study with prospective data collection (1993-2006) in five private, non-universitary, secondary or tertiary healthcare facilities. Outcome variable was SSI development within 30 days after surgery. Explanatory variables were age, gender, surgical approach (laparoscopic/open), elective/emergency/trauma procedure, hospital, surgeon, year, additional procedures, wound class, operation duration and ASA-PS score.

RESULTS

Consecutive in-patients (6761) were included. Mean age was 38.1 (+/-14.1) years and 87.3% were female; 68% procedures were laparoscopic. Postdischarge follow-up was obtained for 57.7% patients. Patients operated on laparoscopically had reduced adjusted overall risk of SSI (OR=0.40, 95% CI=0.28-0.56), incisional infection (OR=0.43, 95% CI=0.29-0.62) and organ/space infection (OR=0.19, 95% CI=0.07-0.49). Older age, longer procedures, emergency or trauma procedures, medium- or high-risk surgeons and year <or=1999 increased the adjusted risk of incisional infection. Adjusted risk of organ/space infection was higher in older patients, emergency or trauma procedures, additional procedures and procedures performed by high-risk surgeons.

CONCLUSIONS

Laparoscopy was associated with lower risk of incisional and organ/space infection. NNIS system's surgical component variables contributed variably to SSI risk.

[Laparoscopic cystectomy and transileal ureterostomy for neurogenic vesicosphincteric disorders. Evaluation of morbidity]

OBJECTIVES

To evaluate the morbidity and mortality of laparoscopic cystectomy combined with transileal ureterostomy to treat neurogenic vesicosphincteric disorders.

MATERIAL

Prospective study performed between february 2004 and april 2006 on 26 consecutive patients with a mean age of 55.0 +/- 12.7 years treated by laparoscopic cystectomy for neurogenic vesicosphincteric disorders. The underlying neurological disease was multiple sclerosis (MS) in 20 cases, spinal cord injury in 4 cases and transverse myelitis in 2 cases. The median preoperative ASA score was 3 (range: 2-3).

RESULTS

No open conversion was necessary. One intraoperative complication was observed (vascular injury). No perioperative death was observed. The nasogastric tube was maintained postoperatively for an average of 8.69 +/- 5.9 hours. The mean time to resumption of oral fluids was 1.4 +/- 0.7 days and mean time to resumption of solids was 2.6 +/- 1.0 days. The mean time to resumption of bowel movements was 3.8 +/- 3.2 days. The mean intensive care stay was 3.9 +/- 1.1 days. Two postoperative complications were observed in the same patient (ileus and bronchial congestion). Postoperative narcotic analgesics were necessary in 60% of cases. The mean hospital stay was 10.3 +/- 4.1 days. Two late postoperative complications were observed in the same patient (two episodes of pyelonephritis).

CONCLUSION

Laparoscopic cystectomy has a low morbidity in neurological patients, allowing early return of feeding and a moderate length of hospital stay.

Outcomes after open versus laparoscopic gastric bypass

In expert hands, laparoscopic gastric bypass (LGB) is associated with reduced morbidity and mortality compared with open bariatric surgery. The purpose of our study was to determine whether or not the results of LGB have been realized in the general US population. We used data from the nationwide inpatient sample to define differences in outcomes after LGB versus open techniques (OGB). We calculated hospital stay, in-hospital mortality, and major complications for both OGB and LGB. We noted a total of 26,940 gastric bypass procedures: LGB was coded in 16.3% and OGB in 83.7%. The mean hospital stay, mortality, wound, gastrointestinal, pulmonary, and cardiovascular complications were significantly lower after LGB (P<0.001). After we adjusted for covariates, hospital stay, pulmonary morbidity, and mortality remained significantly lower after LGB (P<0.001). In conclusion, LGB is associated with significantly lower mean hospital stay and with reduced morbidity and mortality as compared with OGB.

Percutaneous dilatational tracheostomy versus surgical tracheostomy in critically ill patients: a systematic review and meta-analysis

Introduction

Tracheostomy is one of the more commonly performed procedures in critically ill patients yet the optimal method of performing tracheostomies in this population remains to be established. The aim of this study was to systematically review and quantitatively synthesize all randomized clinical trials (RCTs), comparing elective percutaneous dilatational tracheostomy (PDT) and surgical tracheostomy (ST) in adult critically ill patients with regards to major short and long term outcomes.

Methods

MEDLINE, EMBASE, CINAHL and the Cochrane Controlled Clinical Trials Register databases were searched to identify relevant studies. Additionally, bibliographies and selected conference proceedings were reviewed, and experts in the field and manufacturers of two PDT kits were contacted. Randomized clinical trials comparing any method of elective PDT to ST that included critically ill adults and reported at least one clinically relevant outcome were included. Data extracted included trial characteristics, measures of study validity, and clinically relevant outcomes.

Results

Seventeen RCTs involving 1,212 patients were included. Most PDTs used a multiple dilator technique and were performed in the intensive care unit (ICU). The pooled odds ratio (OR) for wound infection was 0.28 (95% confidence interval (CI), 0.16 to 0.49, p < 0.0005), indicating a significant reduction with PDT compared to ST. Overall, PDT was equivalent to ST for bleeding, major peri-procedural and long-term complications; however, subgroup analysis suggested PDT resulted in a lower incidence of bleeding (OR = 0.29 (95% CI 0.12 to 0.75, p = 0.01)) and death (OR = 0.71 (95% CI 0.50 to 1.0, p = 0.05)) when the STs were performed in the operating theatre.

Conclusion

PDT reduces the overall incidence of wound infection and may further reduce clinical relevant bleeding and mortality when compared with ST performed in the operating theatre. PDT, performed in the ICU, should be considered the procedure of choice for performing elective tracheostomies in critically ill adult patients.

Infective complications in laparoscopic surgery

BACKGROUND AND PURPOSE

One of the main benefits of minimally invasive surgery compared with open surgery is the significant reduction in the incidence of postoperative infections. Possible explanations include the smaller incision, minimal use of central venous catheters for parenteral nutrition, faster mobilization, reduction in postoperative pain, and better preservation of immune system function with a limited inflammatory response to tissue injury. We compare the incidence of postoperative infections after the most common laparoscopic surgical procedures with that after the corresponding open operation, and review the possible mechanisms behind these results.

METHOD

Review of the pertinent literature.

RESULTS

Several randomized controlled trials (RCTs), as well as most retrospective studies, show a significant reduction in incisional complications with laparoscopic cholecystectomy in comparison with open surgery (mean 1.1% vs. 4%), as well as in urinary tract and pulmonary infections. In colorectal resection, laparoscopic surgery was characterized by a significant reduction in surgical site infections (mean 5% vs. 9.5%), and the infections that did occur tended to be less severe. Again, there were fewer urinary and pulmonary infections postoperatively. Acute appendicitis represents an interesting setting to study the effect of minimally invasive surgery on infections, as it involves a potentially contaminated field. Most of the results confirm that the rates of surgical site (mean 2% versus 8%) and respiratory (mean 0.3% versus 3%) infections favor laparoscopic surgery, but minimally invasive surgery seems to be characterized by a higher incidence of postoperative intra-abdominal abscess. The laparoscopic approach to splenectomy is clearly superior to standard laparotomy in terms of postoperative complications, including infections, although the rate of overwhelming postsplenectomy infection (OPSI) remains similar because this complication is related more to spleen removal than to the surgical approach.

CONCLUSIONS

Most of the literature is in agreement that laparoscopic surgery is associated with better preservation of immune function and a reduction of the inflammatory response compared with open surgery. The rate of postoperative infections seems to be significantly lower.

[Radical laparoscopic cystectomy]

Radical laparoscopic cystectomy is being adopted by most groups with proven experience in laparoscopic surgery, especially by those who have already completed the learning curves in radical laparoscopic prostatectomy. It is still considered a highly complex technique, which has not yet been mastered in many Urology Units. In this article, we review the surgical technique and available literature on this approach, with special emphasis on its indications, advantages and most frequent morbidity.

Inflammatory response and bacterial dissemination afterlaparotomy and abdominal CO2 insufflation in a murine model of peritonitis

BACKGROUND

The immunologic repercussions due to cavity insufflation are the focus of great discussion. The aim of this study was to compare the inflammatory response and bacterial dissemination after laparotomy and abdominal CO2 insufflation in a murine model of peritonitis.

METHODS

Swiss mice were inoculated intraperitoneally with 0.5 ml of a solution containing 1 x 10(8) colony-forming units (CFU)/ml of Escherichia coli and were divided into three groups as follow: control (anesthesia for 30 min), laparotomy (2.5-cm midline incision for 30 min), and CO2 pneumoperitoneum (CO2 cavity insufflation for 30 min). The number of leukocytes, CFU/ml counting, and the levels of interleukin (IL)-6, tumor necrosis factor-alpha (TNF-alpha), and IL-10 were evaluated in blood, peritoneal, and pleural fluid samples obtained at 90 min and 18 h after the procedures.

RESULTS

The laparotomy group showed a greater bacterial dissemination to the blood, peritoneum, and pleural cavity and also greater neutrophil migration to the peritoneal cavity compared to the CO2 insufflated and control groups. The 24-h mortality was also significantly higher in the laparotomy group. The IL-6 levels showed a precocious rise in all groups submitted to bacterial inoculation at the 90-min time point. At the 18-h time point, IL-6 levels in the peritoneum were significantly higher in the laparotomy group than in the control or CO2 insufflated groups. At the same time, TNF-alpha levels were higher in the laparotomy and CO2 insufflated groups than in controls; IL-10 levels showed no differences among the groups.

CONCLUSIONS

Our results suggest that cavity insufflation with CO2 is a more effective method of access, inducing less bacterial dissemination and also a less intense inflammatory response. Cavity insufflation with CO2 may present a good option for the surgical treatment of patients with bacterial peritonitis.