Is LESS really more?

Single-Port Mini-Pfannenstiel Robotic Pyeloplasty: Establishing a Non-Narcotic Pathway Along with A Same-Day Discharge Protocol

OBJECTIVE

To analyze the feasibility of a same day discharge protocol following SP robotic pyeloplasty.

PATIENTS AND METHODS

From a single institution series, 23 patients (12 multi-port (MP), 11 single-port (SP)) who underwent primary robotic dismembered pyeloplasty between February 2018 and March 2021 were analyzed. The association between baseline and perioperative characteristics with functional outcome was analyzed using, chi-square, Fisher's exact, Mann Whitney U and t-tests.

RESULTS

All SP cases were completed using the mini Pfannenstiel incision without the need for conversion or additional ports. Baseline characteristics were comparable. No intraoperative complications were seen. Only one patient in the SP group had a Clavien II complication. All patients in the MP group had a drain placed, whereas drain was not placed in the SP group. Length of stay was shorter in the SP group (11.4 vs. 42.6 hours, p<0.001). Although visual analog pain score was comparable at discharge (p=0.633), the SP group had lower opioid usage (morphine milligram equivalent) in the hospital (p<0.001) and a lower rate of opioid prescription during discharge (18.2% vs. 91.7% p<0.001). At a median follow-up of 8 months, no patients had flank pain and all patients had good kidney drainage on follow-up images.

CONCLUSIONS

Single-port robotic dismembered pyeloplasty through a mini-Pfannenstiel access allows a same-day discharge protocol with minimal opiate use.

Laparoscopy-assisted total gastrectomy: a simplified approach

Laparoscopy-assisted total gastrectomy (LATG), esophagojejunostomy is an effective but difficult procedure to perform. We describe a simple modification that substantially facilitates insertion of the anvil into the esophagus and avoids oral injuries and complications. After mobilization of the stomach and esophagus, a semicircumferential esophagotomy is made at the anterior esophageal wall. An OrVil anvil (Orvil, Covidien, Norwalk, CT, USA) is delivered laparoscopically and secured with a POLYSORB (Covidien) suture to the esophagus. The suture is advanced anteriorly so that the center rod penetrates the esophageal wall. The esophagus is transected with the stapler at this point. A circular-stapled esophagojejunostomy is then performed using the hemidouble stapling technique. Laparoscopy-assisted total gastrectomies were performed for 40 patients with gastric cancers (T1N0M0). All procedures were completed laparoscopically without any complications. The time required to place the anvil averaged 5 min compared with 9 min reported by others. There were no major complications or mortality in this series. The major advantage of this technique is that circular stapling is much easier than linear stapling, allowing surgeons without advanced surgical skills in LATG to perform the procedure effectively and safely.