Are natural orifice transluminal endoscopic surgery and single-incision surgery viable techniques for cholecystectomy?

Enhanced U-Net with GridMask (EUGNet): A Novel Approach for Robotic Surgical Tool Segmentation

This study proposed enhanced U-Net with GridMask (EUGNet) image augmentation techniques focused on pixel manipulation, emphasizing GridMask augmentation. This study introduces EUGNet, which incorporates GridMask augmentation to address U-Net's limitations. EUGNet features a deep contextual encoder, residual connections, class-balancing loss, adaptive feature fusion, GridMask augmentation module, efficient implementation, and multi-modal fusion. These innovations enhance segmentation accuracy and robustness, making it well-suited for medical image analysis. The GridMask algorithm is detailed, demonstrating its distinct approach to pixel elimination, enhancing model adaptability to occlusions and local features. A comprehensive dataset of robotic surgical scenarios and instruments is used for evaluation, showcasing the framework's robustness. Specifically, there are improvements of 1.6 percentage points in balanced accuracy for the foreground, 1.7 points in intersection over union (IoU), and 1.7 points in mean Dice similarity coefficient (DSC). These improvements are highly significant and have a substantial impact on inference speed. The inference speed, which is a critical factor in real-time applications, has seen a noteworthy reduction. It decreased from 0.163 milliseconds for the U-Net without GridMask to 0.097 milliseconds for the U-Net with GridMask.

Efficacy of transumbilical laparoendoscopic single-site surgery versus multi-port laparoscopic surgery for endometrial cancer: a retrospective comparison study

Background

Although single-port laparoscopy surgery has been evaluated for several years, it has not been widely adopted by gynecologic oncologists. The objective was to compare the perioperative outcomes and survival of endometrial cancer (EC) patients undergoing transumbilical laparoendoscopic single-site surgery (TU-LESS) with multi-port laparoscopic surgery (MLS).

Materials and methods

This is a retrospective comparative monocentric study including patients treated between December 2017 and October 2021. The perioperative outcomes and survival of EC patients who had surgery via TU-LESS or MLS were compared, by propensity matching.

Results

A total of 156 patients were included (TU-LESS vs. MLS: 78 vs. 78). The conversion rate of TU-LESS and MLS was 5.13% and 2.56%, respectively (P=0.681). The operation time was comparable between the two groups [207.5min (180-251) vs. 197.5min (168.8-225), P=0.095]. There was no significant difference between the two groups in exhaustion time, perioperative complications, or postoperative complications. While, the TU-LESS group had a shorter out-of-bed activity time [36 hours (24-48) vs. 48 hours (48-72), P<0.001] and a lower visual analog pain scale 36 hours after surgery [1 (1-2) vs. 2 (1-2), P<0.001] than the MLS group. The length of hospital stay was similar in the two groups [5(4-6) vs. 5(4-5), P=0.599]. Following surgery, 38.5% of the TU-LESS patients and 41% of the MLS patients got adjuvant therapy (P=0.744). The median follow-up time for TU-LESS and MLS cohorts was 45 months (range: 20-66) and 43 months (range: 18-66), respectively. One TU-LESS patient and one MLS patient died following recurrence. The 4-year overall survival was similar in both groups (98.3% vs. 98.5%, P=0.875).

Conclusion

TU-LESS is a feasible and safe option with comparable perioperative outcomes and survival of MLS in endometrial cancer. With the growing acceptance of sentinel lymph node biopsy, TU-LESS of endometrial cancer may be a viable option for patients and surgeons.

Conventional laparoscopic appendectomy versus double-incision, three-port laparoscopic appendectomy: A 1-year randomized controlled trial

INTRODUCTION

Management of appendicitis has evolved dramatically in the last 120 years, from McBurney's large incision to minimally invasive laparoscopic appendectomy to hardly noticeable incisions with SILS. As a bridge between conventional laparoscopic surgery and SILS, double-incision laparoscopic surgery further minimizes the invasiveness of laparoscopic surgery by reducing the number of incisions. This study aimed to establish the efficacy of double-incision, three-port laparoscopic appendectomy (DILA) as an alternative to conventional three-port laparoscopic appendectomy.

METHODS

A total of 60 patients were divided randomly into two groups: the conventional laparoscopic appendectomy (CLA) group and the DILA appendectomy group. Demographics, diagnostic history, additional intraoperative findings, and duration of operation were recorded. Postoperative pain after 6 h and 24 h and cosmetic outcome after the surgery were also evaluated. Statistical analysis was done using Fisher's exact test, χ² test, and Student's t-test.

RESULTS

No significant difference was observed in demographic and clinical characteristics in either group (P > 0.05). No significant difference in mean postoperative pain was observed between the two groups at 6 h (P = 0.62) or 24 h (P = 0.484). However, patients in the DILA group were more satisfied with their cosmetic outcomes than those in the CLA group (P = 0.04). The mean operative time was 26.4 min in the CLA group and 27.6 min in the DILA group (P = 0.62).

CONCLUSION

DILA can be performed with operative outcomes that are equivalent to CLA but with superior cosmetic outcomes.

Evaluation of systemic inflammatory responses in cholecystectomy by means of access. Single-port umbilical incision, transvaginal NOTES, laparoscopy and laparotomy

PURPOSE

To evaluate and compare clinical and inflammatory responses to the surgical trauma caused by cholecystectomy via several access approaches: single-port umbilical incision (SILS), transvaginal natural orifice transluminal endoscopic surgery (NOTES), laparoscopy, and Laparotomy.

METHODS

Twenty-eight female pigs were equally divided into four groups and submitted to cholecystectomy by single-port umbilical incision, transvaginal NOTES, laparoscopy, or Laparotomy. An additional five animals served as controls (sham group). Animals were monitored perioperatively regarding anesthesia and surgical procedure times, as well as for the presence of complications. Postoperatively, they were evaluated regarding time to ambulation and feeding, and the presence of clinical events. Procalcitonin, C-reactive protein (CRP), and AQUI feron-gamma (IFN-γ) measurements were performed before surgery and immediately, two days, and seven days after surgery. Animals were sacrificed and necropsied at seven days after surgery.

RESULTS

All procedures were successfully performed as proposed in each group. Only minor complications, such as gallbladder perforation and bleeding from the liver bed, were observed during surgery in all groups. The vaginal NOTES group showed higher anesthesia and surgical procedure times compared to the other groups (p<0.001). No other between-group differences in perioperative or postoperative times, clinical evolution, or serum inflammatory markers were observed. Only adhesions were found on necropsy, with no differences between groups.

CONCLUSION

The single-port umbilical and transvaginal NOTES access approaches were feasible and safe compared to laparoscopic and laparotomy for cholecystectomy.

Short-term outcomes of single-site robotic cholecystectomy versus four-port laparoscopic cholecystectomy: a prospective, randomized, double-blind trial

BACKGROUND

Randomized studies could not demonstrate significant outcome benefit after single-incision laparoscopic cholecystectomy compared to classic four-port laparoscopic cholecystectomy (CLC). The new robotic single-site platform might offer potential benefits on local inflammation and postoperative pain due to its technological advantages. This prospective randomized double-blind trial compared the short-term outcomes between single-incision robotic cholecystectomy (SIRC) and CLC.

METHODS

Two groups of 30 eligible patients were randomized for SIRC or CLC. During the first postoperative week, patients and study monitors were blinded to the type of procedure performed by four dressing tapes applied on the abdomen. Pain was assessed at 6 h and on day 1, 7 and 30 after surgery, along with a 1-10 cosmetic score.

RESULTS

No significant difference in postoperative pain occurred in the two groups at any time point nor for any of the abdominal sites. Nineteen (63 %) SIRC patients reported early postoperative pain in extra-umbilical sites. Intraoperative complications which might influence postoperative pain, such as minor bleeding and bile spillage, were similar in both groups and no conversions occurred. The cosmetic score 1 month postoperatively was higher for SIRC (p < 0.001). Two SIRC patients had wound infection, one of which developed an incisional hernia.

CONCLUSIONS

SIRC does not offer any significant reduction of postoperative pain compared to CLC. SIRC patients unaware of their type of operation still report pain in extra-umbilical sites like after CLC. The cosmetic advantage of SIRC should be balanced against an increased risk of incisional hernias and higher costs.

TRIAL REGISTRATION NUMBER

ACTRN12614000119695 ( http://www.anzctr.org.au ).

Role of transgastric natural orifice transluminal endoscopic surgery in the diagnosis of ascites of unknown origin (with videos)

BACKGROUND

Natural orifice transluminal endoscopic surgery (NOTES) has been established in animal models and human studies.

OBJECTIVE

The aim of this study was to assess the feasibility and efficacy of applying transgastric NOTES to diagnose patients with ascites of unknown origin.

DESIGN

Prospective study.

SETTING

Two university and teaching hospitals.

PATIENTS

Patients with ascites of unknown origin.

INTERVENTIONS

Diagnostic transgastric NOTES.

MAIN OUTCOME MEASUREMENTS

Characteristic of ascites cases, conditions of the abdominal cavity, diagnostic accuracy, adverse events, and follow-up time.

RESULTS

Transgastric NOTES was performed successfully in 78 patients with ascites of unknown origin, and 72 cases (92.3%) were clearly diagnosed. They included malignant tumors (39 cases), tuberculous peritonitis (28 cases), chronic hepatic inflammation (3 cases), necrotizing lymphadenitis (1 case), and eosinophilic serositis of the small intestine (1 case). In addition, there were 6 nondiagnostic cases, and no severe adverse events were found.

LIMITATIONS

Nonrandomized control analysis.

CONCLUSION

Transgastric NOTES in combination with biopsy can elucidate the causes of ascites of unknown origin in the majority of cases. Therefore, it is a feasible and effective approach to access the peritoneal cavity and also a valuable modality to detect the cause of diseases with ascites of unknown origin.

Transumbilical endoscopic cholecystectomy in a porcine model

PURPOSE

Natural orifice transluminal endoscopic surgery (NOTES) is a new technique. This study describes our initial experience of NOTES and investigates the feasibility of transumbilical endoscopic cholecystectomy (TUEC).

METHODS

Eight domestic pigs were submitted to TUEC. After establishment of pneumoperitoneum, a bi-channel endoscope was placed through an infra-umbilical trocar. The gallbladder fundus was lifted by a grasper. The cystic duct and artery was dissected with a flexible hook and clipped by a clip fixing device. The specimen was extracted through the infra-umbilical trocar.

RESULTS

The mean operation time was 114 minutes, ranging from 75 to 155 minutes. All the gallbladders were removed successfully. There was one case of subtotal resection, two cases of bleeding and three cases of bile leakage.

CONCLUSION

Transumbilical endoscopic cholecystectomy is feasible although it needs more support of experiments and techniques before being applied on human subjects.

Danish surgeons' views on minimally invasive surgery

BACKGROUND AND AIM

Advancements in minimally invasive surgery have led to increases in popularity of single-incision laparoscopic surgery (SILS) and natural orifice translumenal surgery (NOTES(®); American Society for Gastrointestinal Endoscopy [Oak Brook, IL] and Society of American Gastrointestinal and Endoscopic Surgeons [Los Angeles, CA]) due to their postulated benefits of better cosmesis, less pain, and quicker recovery. This questionnaire-based study investigated Danish surgeons' attitudes toward these new procedures.

SUBJECTS AND METHODS

A 26-item questionnaire was developed and distributed electronically via e-mail to a total of 1253 members of The Danish Society of Surgeons and The Danish Society of Young Surgeons.

RESULTS

In total, 352 (approximately 30%) surgeons completed the questionnaire, 54.4% were over 50 years of age, and 76.6% were men. When choosing surgery, the most important factors taken into consideration were the risk of complication and short convalescence, whereas the least important factors were cosmesis and option of local anaesthesia. If the surgeons themselves were to undergo cholecystectomy, 35.5% would choose SILS, and 14.5% would choose NOTES provided that the risk was equal to traditional laparoscopy (3%). The fraction of surgeons willing to learn SILS and NOTES was 44.6% and 32.7%, respectively. The desire to learn was higher among less experienced and surgically active surgeons. Of the responders, 68.8% considered SILS and 43.2% considered NOTES would become standard techniques for cholecystectomy within 6 years.

CONCLUSIONS

The importance of risk of complications has not surprisingly a high priority among surgeons in this questionnaire. Why this is has to be investigated further before implementing SILS and NOTES as standard of care.

Single-port cholecystectomy versus multi-port cholecystectomy: a prospective cohort study with 222 patients

BACKGROUND

The aim of this study was to compare single-port access cholecystectomy (SPA) with the standard laparoscopic technique (LC) regarding the duration of the operation, complications, learning curve, late postoperative quality of life (QoL) and the incidence of incisional hernias.

METHODS

Between June 2009 and December 2011, a total of 122 SPA cholecystectomies were performed in our hospital. Simultaneously, 310 patients were operated on with the LC technique. In the LC group, 100 patients met the same criteria defined for SPA surgery. The two groups (SPA and LC) were compared by multivariable regression analysis. Endpoints of this study were quality of life (QoL) after 6 months by the EQ-5D questionnaire 5L and the incidence of incisional hernia 1 year after surgery. Operating time, hospital stay, and perioperative complications were also measured and compared. The median follow-up was 9.2 months (3-25 months).

RESULTS

The patients in the SPA group were younger and more often female. The mean operating time for group SPA was 73 min (35-136 min)-significantly longer than that for group LC with 60 min (33-190 min) (p < 0.001). Additional trocars were used in 8 of 122 (6.5 %) SPA patients. A conversion to open cholecystectomy was not necessary in SPA patients. The conversion rate in the LC group to open cholecystectomy was 2 % (2/100). The perioperative and postoperative complications and incisional hernia (5.5 %) were the same in both groups. QoL was significantly better in the SPA group in terms of mobility (p = 0,002), usual activity (p = 0.036), and overall anxiety (p = 0.026).

CONCLUSIONS

SPA cholecystectomy is safe, although the operation is significantly longer. No differences in terms of major complications or the incidence of incisional hernia were seen after 1 year. QoL was significantly better in patients operated on with the SPA technique.

[Minimally invasive surgical therapy of acute cholecystitis]

Acute cholecystitis is the most common complication of cholecystolithiasis. It develops in about 10 % of symptomatic patients and gangrenous cholecystitis, gallbladder perforation, gallbladder empyema, or abscesses are typical complications. Cholecystectomy is the most relevant therapy to achieve pain reduction, to prevent the progression of inflammation or local complications and to minimize the risk of recurrence. Surgical therapy can be supported by medical and interventional treatment modalities depending on the severity of the disease. The present review summarizes the surgical aspects in acute cholecystitis with a focus on laparoscopic cholecystectomy which is the gold standard of therapy.

Comparison of short-term surgical outcomes after single-incision laparoscopic versus multiport laparoscopic right colectomy: a two-center, prospective case-controlled study of 100 patients

BACKGROUND

Recent case studies have demonstrated the feasibility of single-incision laparoscopic colectomy (SILC). Few comparative studies for SILC and multiport laparoscopic colectomy (MLC) have been conducted. The aim of this case-controlled study was to compare the short-term surgical outcomes between SILC and MLC for right-sided colectomies.

METHODS

Between January 2010 and February 2012, data from the first 50 consecutive patients that underwent right SILS at one of the two institutions were compared with a group of 50 consecutive patients that underwent right MLC in the same period.

RESULTS

Median operative time was significantly shorter in SILC (97 vs. 112 min; p < 0.001). Between both groups, no statistically significant differences were found regarding number and nature of short-term complications, number of reoperations [4 (8%) vs. 6 (12%)], and mortality rate [1 (2%) vs. 2 (4%)]. Median postoperative hospital stay was 6 days for both groups.

CONCLUSION

SILC is a safe and feasible procedure when performed by experienced laparoscopic surgeons. Length of hospital stay and overall complication rates are comparable with MLC. Until today, no clear advantages of SILC over MLC have been demonstrated. However, due to its smaller incisional trauma, SILC could be a major step in improving cosmetic outcomes.

Single-incision laparoscopic cholecystectomy vs. conventional laparoscopic cholecystectomy: a meta-analysis of randomized controlled trials

INTRODUCTION

We analyzed different morbidity parameters between single-incision laparoscopic cholecystectomy (SILC) and conventional laparoscopic cholecystectomy (CLC).

METHODS

Pubmed, Ovid, Embase, SCI database, Cochrane, and Google Scholar were searched. The primary endpoints analyzed were cosmetic result and the postoperative pain (at 6 and 24 h) and the secondary endpoints were operating time, hospital stay, incidence of overall postoperative complications, wound-related complications, and port-site hernia.

RESULTS

Six hundred fifty-nine patients (SILC-349, CLC-310) were analyzed from nine randomized controlled trials. The objective postoperative pain scores at 6 and 24 h and the hospital stay were similar in both groups. The total postoperative complications, wound-related problems, and port-site hernia formation, though higher in SILC, were also comparable in both groups. SILC had significantly favorable cosmetic scoring compared to CLC [weighted mean difference = 1.0, p = 0.0001]. The operating time was significantly longer in SILC [weighted mean difference = 15.63, p = 0.0001].

CONCLUSIONS

Single-incision laparoscopic cholecystectomy does not confer any benefit in postoperative pain (6 and 24 h) and hospital stay as compared to conventional laparoscopic cholecystectomy while having significantly better cosmetic results at the same time. Postoperative complications, though higher in SILC, were statistically similar in both the groups.

Serum level of intercellular adhesion molecule-1 in children with malignant lymphoma

OBJECTIVE

To estimate the serum levels of soluble intercellular adhesion molecule-1 (s-ICAM-1) in children newly diagnosed with lymphoma and to correlate levels of s-ICAM-1 in lymphoma patients with clinical stage, pathological types, clinical and laboratory data and patient outcome.

SUBJECTS AND METHODS

Thirty-five children with newly-diagnosed malignant lymphoma (Non-Hodgkin's lymphoma, NHL: 23), Hodgkin's disease (HD: 12), and 8 apparently healthy subjects of matched age and sex taken as a control group were studied. For the patients and control group, the following tests were performed: complete blood count, and the following biochemical investigations: liver function tests, lactate dehydrogenase (LDH), and soluble ICAM-1 estimation using ELISA. In addition, for patients, pathological examination of lymph node biopsy for pathological grading, bone marrow aspiration and biopsy were done. Patients were observed for over 12 months or until death.

RESULTS

Serum ICAM-1 increased more in HD and NHL than in the control group (p < 0.000); also s-ICAM-1 increased in advanced stages and high-grade NHL (p < 0.008, 0.04, respectively). LDH levels were higher in patients compared to controls (p < 0.000). There was a positive correlation between high levels of s-ICAM-1 and increased levels of LDH in HD (r = 0.72, p < 0.008) and a positive correlation between high levels of s-ICAM-1 and increased ALT in NHL patients. A positive correlation between s-ICAM-1 levels and the presence of B symptoms in HD and NHL, and a positive correlation between elevated s-ICAM-1 levels and worse outcome in HD and NHL were detected.

CONCLUSIONS

The data indicate that in children with malignant lymphoma, high serum levels of ICAM-1 correlated with tumor aggressiveness, and quantification of s-ICAM-1 levels may identify a subgroup of children with worse prognosis. Therefore, detection of s-ICAM-1 levels in children with malignant lymphoma might represent an additional disease-associated marker for use in the clinical management of the patients.