High flow insufflation for the maintenance of the pneumoperitoneum during bariatric surgery

Laparoscopic vs. open surgery for rectal cancer in patients with obesity: short-term outcomes and relapse-free survival across age groups

PURPOSE

To investigate the efficacy of laparoscopic surgery for rectal cancer in obese and older patients, who are often characterized by a higher prevalence of comorbidities and physical decline.

METHODS

This large-scale multicenter retrospective cohort study included 524 patients with a body mass index of 25 or higher who underwent either open or laparoscopic surgery for stage II or III rectal cancer between 2009 and 2013. We assessed the short-term outcomes and relapse-free survival by comparing these surgical modalities. The patients were stratified into 404 non-elderly (< 70 years) and 120 elderly (≥ 70 years) patients.

RESULTS

In both patient groups, laparoscopic surgery was associated with a significantly reduced blood loss (non-elderly: 41 vs. 545 ml; elderly: 50 vs. 445 ml) and shorter hospital stays (non-elderly: 10 vs. 19 days; elderly: 15 vs. 20 days) than open surgery. The overall complications and relapse-free survival showed no significant differences between the two surgical techniques in either age group. Additionally, the impact of the laparoscopic procedure on the relapse-free survival remained consistent between the age groups.

CONCLUSION

Laparoscopic surgery offers short-term benefits for patients with obesity and rectal cancer compared to open surgery, regardless of age, without influencing the long-term prognosis.

Impact of laparoscopic surgery on short-term and long-term outcomes in elderly obese patients with colon cancer

Background

Laparoscopic surgery is reported to be useful in obese or elderly patients with colon cancer, who are at increased risk of postoperative complications because of comorbidities and physical decline. However, its usefulness is less clear in patients who are both elderly and obese and may be at high risk of complications.

Methods

Data for obese patients (body mass index ≥25) who underwent laparoscopic or open surgery for stage II or III colon cancer between January 2009 and December 2013 were collected by the Japan Society of Laparoscopic Colorectal Surgery. Surgical outcomes, postoperative complications, and relapse-free survival (RFS) were compared between patients who underwent open surgery and those who underwent laparoscopic surgery according to whether they were elderly (≥70 y) or nonelderly (<70 y).

Results

Data of 1549 patients (elderly, n = 598; nonelderly, n = 951) satisfied the selection criteria for analysis. Length of stay was shorter and surgical wound infection was less common in elderly obese patients who underwent laparoscopic surgery than in those underwent open surgery. There were no significant between-group differences in overall complications, anastomotic leakage, ileus/small bowel obstruction, or RFS. There were also no significant differences in RFS after laparoscopic surgery according to patient age.

Conclusion

Laparoscopic surgery is safe in elderly obese patients with colon cancer and does not worsen their prognosis. There was no significant difference in the effectiveness of laparoscopic surgery between obese patients who were elderly and those who were nonelderly.

Robotics in Implant-Based and Autologous Breast Reconstruction

Autologous and implant-based breast reconstruction continues to evolve as new technology and mastectomy techniques become available. Robotic-assisted breast reconstruction represents a growing field within plastic surgery, with the potential to improve aesthetic and functional outcomes, as well as patient satisfaction. This article provides a review of indications, techniques, and outcome data supporting the use of robotic assistance in both implant-based and autologous breast reconstruction from surgeons around the world.

Comparison of Different Carbon Dioxide Insufflation Rates on Hemodynamic Changes in Laparoscopic Surgeries: A Randomized Controlled Trial

Introduction The injury and detrimental effects of carbon dioxide (CO2) insufflation during laparoscopic surgeries may be due to the higher flow rates used during insufflation. The aim of our study was to study the effects of different CO2 insufflation flow rates on hemodynamic parameters in laparoscopic surgeries. The secondary objectives were to compare the patient and surgeon satisfaction scores, postoperative shoulder scores, and surgical site pain scores. Methods This prospective, randomized, double-blinded trial was commenced after institutional ethical committee approval and The Clinical Trials Registry- India (CTRI) registration (CTRI 2021/10/037595). Ninety patients scheduled for laparoscopic cholecystectomy were randomly divided into three groups based on CO2 insufflation flow rate by computer-generated random numbers and the sealed envelope method: Group-A: 5 L/min; Group-B: 10 L/min; and Group-C: 15 L/min. General anesthesia was standardized in all three groups. Mean arterial pressure (MAP) and heart rate were recorded at different timelines, which included the arrival in the operating room (T0), just before the induction of anesthesia (T1), at the beginning of pneumoperitoneum (T2), 10 minutes (T3), 20 minutes (T4), 30 minutes (T5), and 60 minutes (T6) after the pneumoperitoneum, at the end of the operation (T7), five minutes (T8), and 15 minutes (T9) after arriving at the recovery room. The patient and surgeon satisfaction scores were assessed on a 5-point Likert scale. The visual analog score (VAS) was used to assess the surgical site pain and shoulder pain every four hours for 24 hours. The continuous data were assessed by one-way analysis of variance (ANOVA), and the categorical data were assessed by the Chi-square test. The sample size was estimated based on a pilot study and using the G Power 3.1.9.2 Program (Universitat Kiel, Germany) calculator. Results There was an increase in the mean arterial pressure (MAP) between the groups 60 min after pneumoperitoneum creation with higher flow rates. The baseline MAP was 85.76± 10.11 in group A, 86.03± 9.79 in group B, and 88.13± 8.46 in group C. At 60 min from the creation of the pneumoperitoneum, the MAP increased significantly from 99.17 ± 9.35 in group A, 102.43 ± 8.24 in group B, to 106.83 ± 8.31 in group C. This was statistically significant with a p-value of 0.004. There was a statistically significant difference in heart rate between the groups 10 minutes after pneumoperitoneum creation. No complications were reported in any of the groups. The postoperative shoulder pain was more severe when higher flows were used at 20 and 24 hours. The surgical site pain was also significantly more for up to 12 hours following surgery with higher flows. Conclusion We conclude that low-flow CO2 insufflation during laparoscopic surgeries is associated with fewer hemodynamic changes, better patient satisfaction scores, and lower postoperative pain scores.

Combined Thoracic Spinal-Epidural Anesthesia for Laparoscopic Sleeve Gastrectomy; One Hundred Case Experience

BACKGROUND

Obesity is a growingly impacting human health concern. Laparoscopic sleeve gastrectomy (LSG) is an effective treatment for morbid obesity. However, the general anesthesia (GA) used in this major surgery has its documented drawbacks in obese patients with high risk. On the other hand, combined thoracic spinal-epidural anesthesia (CTSEA), a modern regional anesthesia procedure, has the advantages of both spinal and epidural anesthesia but without their shortcomings. This prospective study is a case experience that assesses the feasibility of CTSEA as an anesthesia option for laparoscopic sleeve gastrectomy (LSG).

METHODS

A total of 100 patients were recruited for LSG as a management procedure for morbid obesity, which was performed under CTSEA. Perioperative events, functional parameters, and patients' satisfaction scores were recorded.

RESULTS

Our prospective study showed successful use of CTSEA in 99% of the patients, except for one patient (1%) in whom CTSEA was converted into GA due to severe pain and anxiety. Few adverse events occurred and were managed accordingly. The satisfaction score revealed that 94% of the patients were satisfied.

CONCLUSIONS

CTSEA was a successful anesthetic alternative procedure for LSG surgery.

Risks of Laparoscopic Harvest of Free Intestinal Flaps for Esophageal Reconstruction

BACKGROUND

Performing ablative surgery using an laparoscope is a common practice. However, its use in the harvest of a segment of intestine for reconstruction has 2 major challenges: risk of damage to the vascular pedicle of the flap as well as to the vessels of other parts of the intestine that remain in the peritoneal cavity and risk of damage to the intestinal flap while pulling it out through a small opening in the abdominal wall. The aim of this study was to report advantages and disadvantages of harvesting free intestinal flaps using the laparoscopic method, explaining the challenges faced and lessons learned from this experience.

PATIENTS AND METHODS

Free intestinal flaps were harvested by laparoscopy in 12 patients aged 28 to 63 years. There were 9 free jejunal flaps for the reconstruction of the cervical esophagus and 3 ileocolic flaps for the reconstruction of both the cervical esophagus and voice reconstruction.

RESULTS

In 1 patient, laparoscopy was converted to laparotomy due to previous colectomy, which resulted in compromised circulation to the rest of the colon. One jejunal flap had leakage at its pharyngeal end; therefore, a pectoralis major myocutaneous flap was used for closure. In addition, 1 ileocolic flap had partial loss of its anterior wall, and a free anterolateral flap was used as a patch for closure. Furthermore, it was very difficult to harvest 1 free jejunal flap due to the thick and fat mesentery.

CONCLUSION

Prolonged operative times, unexpected leakage at the anastomosis sites, partial loss of flaps, possible risk of vascular pedicle damage or venous compromise, demanding pedicle dissection in obese patients, and requirement of conversion to laparotomy are the major drawbacks of harvesting free intestinal flaps by laparoscopy.

Integrating the MasSpec Pen to the da Vinci Surgical System for In Vivo Tissue Analysis during a Robotic Assisted Porcine Surgery

Minimally invasive robotic-assisted surgeries have been increasingly used as a first-line of treatment for patients undergoing oncologic surgeries. In-situ tissue identification is critical to guide tissue resection and assist decision-making. Traditional intraoperative histopathologic analysis of frozen tissue sections can be time-consuming and present logistical challenges which interrupt surgical workflows. We report the development and implementation of a laparoscopic, drop-in version of the MasSpec Pen device integrated into the da Vinci Xi Surgical system for in vivo tissue analysis in a robotic-assisted porcine surgery. We evaluated the performance of the drop-in MasSpec Pen during surgery by introducing the device into the animal upper gastrointestinal system and performing in vivo analyses of the stomach and liver, including charred and bloody tissues after electrocauterization. The molecular profiles obtained included ions tentatively identified as metabolites and lipids typically observed with MasSpec Pen analysis, without causing observable tissue damage. Statistical classifiers built to distinguish porcine liver and stomach tissues using the in vivo data yielded an overall tissue identification accuracy of 98% (n = 53 analyses). The results provide evidence that the drop-in MasSpec Pen developed can be used to acquire mass spectra in vivo during a robotic-assisted surgery and might be used as an in vivo tissue assessment tool to help guide surgical resections and streamline surgical workflows.

Can surgery follow the dictates of the pandemic "keep your distance"? Requirements with COVID-19 for hygiene, resources and the team

Since the beginning of the pandemic, there have been restrictions in the daily care of surgical patients - both elective and emergency. Readying supply capacities and establishing isolation areas and areas for suspected cases in the clinics have led to keeping beds free for treating (suspected) COVID-19 cases. It was therefore necessary to temporarily postpone elective surgery. Now, elective care can be gradually resumed with the second phase of the pandemic in Germany. However, it remains the order of the day to adapt pre-, intra- and post-operative procedures to the new COVID-19 conditions while maintaining specialized hygiene measures. This concerns the correct procedure for the use of personal protective materials as well as process adjustment for parallel treatment of positive and negative patients in the central OR, and handling of aerosols in the operating theater, operating room, and surgical site under consideration of staff and patient protection. Although dealing with surgical smoke in the operating theater has long been criticized, COVID-19 is forcing a renaissance in this area. Finally, the choice of surgical method, whether open surgery or minimally invasive procedures, is critical in determining how many colleagues are exposed to the risk of infection from COVID-19 patients, sometimes for hours. Here, robot-assisted surgery can comply with the pandemic's requirement to "keep your distance" in a unique way, since the surgeon can operate at virtually any distance from the surgical site, at least with regard to aerosol formation and exposure.

From Open to Robotic-assisted Latissimus Dorsi Muscle Flap Harvest

Background:

The latissimus dorsi muscle is the largest muscle in the body. The classic open flap harvest technique of this muscle results in a long posterolateral thoracic vertical oblique incision that can leave an unappealing scar. The minimally invasive robotic approach has the potential to reduce scar length and to overcome technical limitations of endoscopic techniques.

Methods:

Six robotically assisted latissimus dorsi muscle flaps were harvested by a single surgeon. One was used as reversed turnover pedicled flap based on lumbar perforators for lumbosacral bone coverage, another flap was transposed for a Poland syndrome anterior axillary line reconstruction, and the remaining 4 were dissected as free flaps for upper and lower limb reconstruction. All 6 procedures used a short 5-cm axillary crease incision along the posterior axillary fold and two 8-mm port incisions for robotic access.

Results:

The first robotic flap harvest was converted to the classic open technique due to malposition of the 2 lower port incisions too close to the latissimus dorsi anterior border. The 5 other flaps were successfully transferred without flap or donor site complications. The average flap dissection time was 110 minutes; latter surgeries took less time than the early surgeries as the surgeon became more familiar with the robotic system and due to the use of a newer system.

Conclusion:

Robotic-assisted latissimus dorsi muscle flap harvest is a safe, reproducible, and effective tool that offers precise dissection control and that leaves a minimal thoracic scar.

A Novel Strategy of Laparoscopic Insufflation Rate Improving Shoulder Pain: Prospective Randomized Study

BACKGROUND

Laparoscopic surgery is the main trend method in a variety of surgical fields. Post-operative shoulder pain remains a bothersome issue although many surgical techniques have been applied to minimize it. A simple novel approach to reduce shoulder pain without adverse effects during and after laparoscopic surgery is desired.

METHODS

This prospective randomized controlled study was conducted to enroll a total of 140 patients to evaluate the efficacy of low flow rate (1 L/min) for induction followed by high flow rate (10 L/min) for maintaining 12 mmHg pneumoperitoneum (group A, n = 70) during laparoscopic cholecystectomy (LC), compared to the continuous high flow rate group (group B, n = 70) in postoperative shoulder pain and other clinical features. The 10-visual analog scale (VAS) was applied for the severity of shoulder pain and scores were obtained at 1, 6, 12, 24, and 48 h after LC.

RESULTS

There was no obvious difference in baseline characteristics as well as operative time, occurrence of bradycardia, or hospital stay between groups. The incidence of shoulder pain was not significantly different (group A 45.7% vs group B 48.6%, p = 0.866). However, the patients in group A with shoulder pain reported significantly less pain scores (p < 0.001) at 12 and 24 h after surgery, compared with those in group B.

CONCLUSIONS

Applying the strategy of low flow rate to induce pneumoperitoneum followed by high flow rate to maintain the pressure provides advantages to reduce the severity of shoulder pain for patients who underwent LC and then experienced shoulder pain.

ZINC4085554 inhibits cancer cell adhesion by interfering with the interaction of Akt1 and FAK

Perioperative or circulatory forces enhance disseminated cancer cell adhesiveness by modulating focal adhesion kinase (FAK)-Akt1 interaction. Selectively blocking FAK-Akt1 interaction by a peptide derived from the FAK-Four-point-one, ezrin, radixin, moesin (FERM) domain reduces colon cancer cell adhesion in vitro and in mice. A preliminary in silico screening identified two small molecules resembling a peptide that may inhibit pressure-stimulated SW620 cancer cell adhesion to collagen I. The present study selected ZINC4085554 for further study to validate its proposed mechanism of action, using human SW620 colon cancer cells as a model system. At 25 and 50 µM, ZINC4085554 inhibited the pressure-stimulated adhesion of SW620 colon cancer cells to collagen I. This molecule prevented pressure-stimulated FAK-Tyr-397 phosphorylation; however, it did not affect Akt1-Ser-473 phosphorylation, indicating that ZINC4085554 acts downstream of Akt1, while Akt-Thr-308 remains unchanged in the presence of pressure and or ZINC4085554. Indeed, ZINC4085554 inhibited FAK-Akt1 interaction in response to increased extracellular pressure, consistent with the proposed mechanism. ZINC4085554 did not inhibit FAK-Tyr-397 phosphorylation in response to cell adhesion to collagen I, indicating the specificity of the inhibitory effects towards force-stimulated pathways. Finally, the present study confirmed that ZINC4085554 at 50 µM prevented pressure-activation of adhesion to surgical wounds in vivo in parallel to its ablation of intracellular signaling. In summary, ZINC4085554 is a small molecule mimicking part of the structure of FAK that reduces cancer cell adhesion by impairing pressure-stimulated FAK-Akt1 interaction and its downstream consequences. ZINC4085554 does not inhibit conventional outside-in FAK signaling and may be less toxic than global FAK inhibitors, and ZINC4085554 may be an important step towards the inhibition of metastasis.

A novel technique for robot assisted latissimus dorsi flap harvest

BACKGROUND

A robotic surgery technique of harvesting the latissimus dorsi muscle flap has technical advantages over endoscopic harvest and cosmetic advantages over the open technique. The authors introduce a new transaxillary gasless technique using an articulated long retractor for robot assisted latissimus dorsi flap harvest.

METHODS

Twelve robot assisted latissimus dorsi muscle flaps were harvested: 3 cases of delayed reconstruction following tissue expander insertion or breast conserving surgery; 4 cases of immediate reconstruction following nipple-sparing mastectomy; and 5 cases of chest wall deformity correction in patients with Poland syndrome. A specially designed articulated long retractor was used to maintain adequate working space and enable latissimus dorsi muscle dissection without gas insufflation.

RESULTS

Twelve muscle flaps were successfully harvested in 12 patients without converting to an open technique. The mean docking time was 54.6 min, and the mean operative time and robotic time were 400.4 min and 85.8 min, respectively. There were no donor site complications or flap problems. Average follow-up was 15.7 months. All patients were satisfied with their esthetic results, especially the absence of visible scars.

CONCLUSION

The novel robot assisted latissimus dorsi harvest technique is a safe alternative to the conventional method.

Prolonged capnoperitoneum does not cause postoperative ileus in pigs: safety of prolonged capnoperitoneum

INTRODUCTION

Operative time is an accepted risk factor for the development of postoperative ileus (POI). Innovative surgical procedures such as robotic surgery and natural orifice transluminal endoscopic surgery (NOTES) will be associated with longer operative times. Although intraabdominal manipulation is a major factor for POI the impact of prolonged capnoperitoneum on postoperative gastrointestinal transit time (GIT-TT) has rarely been studied.

MATERIAL AND METHODS

IRB approved survival pilot study to assess postoperative GIT-TT using fecal collection and chromium-oxide (Cr2O3) labeling in pigs. Twelve female pigs were randomly assigned to three groups of four animals each. Group A received eight hours anesthesia and pressure-controlled high flow capnoperitoneum (15 mmHg), group B eight hours of anesthesia only and group C no intervention. No intraoperative manipulation. The pilot study was terminated after eight days.

RESULTS

None of the animals developed POI. In Group A one animal died after eight hours of general anesthesia. No differences in postoperative fecal output, Cr2O3 excretion rate or weight gain were found.

CONCLUSION

This study is the first to investigate eight hours of capnoperitoneum in a survival model. GIT-TT is not affected by prolonged capnoperitoneum in pigs. No POI occurred with prolonged capnoperitoneum. Prolonged capnoperitoneum is safe regarding postoperative gastrointestinal function in innovative surgical procedures.

Perioperative optimization of patients undergoing bariatric surgery

Bariatric surgery is fast becoming an efficient and safe method of weight reduction, especially for patients in whom conservative measures have failed. As the obese population of the world increases, so will the number of patients requesting or requiring surgical weight loss methods. Bariatric patients however have numerous co-morbidities that make their operative course more difficult, and therefore is important to have a good understanding of the important issues surrounding their pre, peri and post operative management. This article aims to educate the reader about optimal management of the bariatric surgical patient.