Laparoscopic surgery: A qualified systematic review

Automatic gesture recognition and evaluation in peg transfer tasks of laparoscopic surgery training

BACKGROUND

Laparoscopic surgery training is gaining increasing importance. To release doctors from the burden of manually annotating videos, we proposed an automatic surgical gesture recognition model based on the Fundamentals of Laparoscopic Surgery (FLS) and the Chinese Laparoscopic Skills Testing and Assessment (CLSTA) tools. Furthermore, statistical analysis was conducted based on a gesture vocabulary that had been designed to examine differences between groups at different levels.

METHODS

Based on the CLSTA, the training process of peg transfer can be represented by a standard sequence of seven surgical gestures defined in our gesture vocabulary. The dataset used for model training and testing included eighty videos recorded at 30 fps. All videos were rated by senior medical professionals from our medical training center. The dataset was processed using cross-validation to ensure robust model performance. The model applied is 3D ResNet-18, a convolutional neural network (CNN). An LSTM neural network was utilized to refine the output sequence.

RESULTS

The overall accuracy for the recognition model was 83.8% and the F1 score was 84%. The LSTM network improved model performance to 85.84% accuracy and an 85% F1 score. Every operative process starts with Gesture 1 (G1) and ends with G5, with wrong placement is labeled as G6. The average training time is 92 s (SD = 36). Variance was observed between groups for G1, G3, and G6, indicating that trainees may benefit from focusing their efforts on these relevant operations, while assisting doctors also in more effectively analyzing the training outcome.

CONCLUSION

An automatic surgical gesture recognition model was developed for the peg transfer task. We also defined a gesture vocabulary along with the artificial intelligence model to sequentially describe the training operation. This provides an opportunity for artificial intelligence-enabled objective and automatic evaluation based on CLSTA in the clinic implementation.

A Comprehensive Video Dataset for Surgical Laparoscopic Action Analysis

Laparoscopic surgery has been widely used in various surgical fields due to its minimally invasive and rapid recovery benefits. However, it demands a high level of technical expertise from surgeons. While advancements in computer vision and deep learning have significantly contributed to surgical action recognition, the effectiveness of these technologies is hindered by the limitations of existing publicly available datasets, such as their small scale, high homogeneity, and inconsistent labeling quality. To address the above issues, we developed the SLAM dataset (Surgical LAparoscopic Motions), which encompasses various surgical types such as laparoscopic cholecystectomy and appendectomy. The dataset includes annotations for seven key actions: Abdominal Entry, Use Clip, Hook Cut, Suturing, Panoramic View, Local Panoramic View, and Suction. In total, it includes 4,097 video clips, each labeled with corresponding action categories. In addition, we comprehensively validated the dataset using the ViViT model, and the experimental results showed that the dataset exhibited superior training and testing capabilities in laparoscopic surgical action recognition, with the highest classification accuracy of 85.90%. As a publicly available benchmark resource, the SLAM dataset aims to promote the development of laparoscopic surgical action recognition and artificial intelligence-driven surgery, supporting intelligent surgical robots and surgical automation.

Validation of safety for self-retracting intraperitoneal device for small bowel in minimally invasive surgery

BACKGROUND

Modernly, abdominal surgery has shifted to minimally invasive techniques with an inclination towards fewer incisions. This has made intra-abdominal retraction more challenging. Despite development in retracting instrumentation for solid organs, the mobilization of the bowel remains challenging due to its friable nature. Therefore, there is a need to investigate the safety profile of internal retractors such as the EndoGrab for small-bowel retraction.

METHODS

Twenty locations of small bowel were selected for EndoGrab retraction in two pigs. The locations were studied for iatrogenic injury at acute and delayed stages. Evaluation of injury was assessed clinically and histologically.

RESULTS

After the EndoGrab application, no immediate signs of perforation or ischemia were observed. The clinical post-operative course was uncomplicated. Histopathology findings included serosal compression and minimal mucosal ulceration. Long-term changes showed mild changes of focal edema and fibrosis, with inter-individual variability in severity.

CONCLUSION

While there were no signs of overt macroscopic acute injury, minimal microscopic changes were evident. According to this small-scale study, the EndoGrab can provide an effective and safe solution for small-bowel self-retractors. More research is needed to acquire a higher level of evidence for safety. Such a solution could eliminate ports or assistants previously designed for retraction only.

Intracorporeal versus extracorporeal anastomosis in laparoscopic total gastrectomy: a systematic review and meta-analysis

BACKGROUND

To evaluate outcomes of intracorporeal (IOJ) versus extracorporeal (EOJ) oesophagojejunostomy following laparoscopic total gastrectomy (LTG) for the treatment of gastric cancer.

METHODS

A comprehensive search of various electronic databases was conducted. Comparative studies of IOJ versus EOJ following LTG in patients with gastric malignancy were included. Primary outcomes were anastomotic leak, anastomotic bleeding, and anastomotic stricture formation. Secondary outcomes included operative time, length of hospital stay (LOS), volume of intra-operative haemorrhage, number of harvested lymph nodes, time to flatus, time to soft diet, intra-abdominal infection, pulmonary infection, surgical site infection (SSI), duodenal stump leak, pancreatic fistula occurrence, postoperative ileus, re-operation, and mortality. Combined overall effect sizes were calculated using the random-effects model, and the Newcastle-Ottawa Scale was used to assess risk of bias.

RESULTS

Seventeen non-randomised studies enrolling 2,960 patients divided between an IOJ ( n = 1430) and EOJ ( n = 1530) group were included. IOJ was associated with significantly lower risk of anastomotic stricture ( P = 0.01), volume of intra-operative bleeding ( P = < 0.001), and SSI (P = 0.04) compared to EOJ. No difference was found in anastomotic leak ( P = 0.93); anastomotic bleeding ( P = 0.35); operative time ( P = 0.63); LOS ( P = 0.30); lymph node yield ( P = 0.17); time to first flatus ( P = 0.77); time to resumption of soft diet ( P = 0.32); intra-abdominal infection ( P = 0.22); pulmonary infection ( P = 0.45); duodenal stump leak ( P = 0.46); pancreatic fistula occurrence ( P = 0.16); and paralytic ileus ( P = 0.59), re-operation ( P = 0.50), and mortality ( P = 0.23) between the two groups.

CONCLUSIONS

LTG for gastric malignancy with IOJ may be associated with lower risk of anastomotic stricture and SSI compared to the extracorporeal approach. However, future adequately powered randomized studies are needed to compare the two techniques.

The COMPARE Study: Comparing Perioperative Outcomes of Oncologic Minimally Invasive Laparoscopic, da Vinci Robotic, and Open Procedures: A Systematic Review and Meta-analysis of the Evidence

OBJECTIVE

To assess 30-day outcomes of da Vinci robotic-assisted (dV-RAS) versus laparoscopic or video-assisted thoracoscopic​​​​​ (lap/VATS) or open oncologic surgery.

BACKGROUND

Complex procedures in deep/narrow spaces especially benefit from dV-RAS. Prior procedure-specific comparisons are not generalizable.

METHODS

PubMed, Scopus, and EMBASE were systematically searched (latest: November 17, 2023) following Preferred Reporting Items for Systematic Reviews and Meta-Analyses and PROSPERO (Reg#CRD42023466759). Randomized, prospective, and database studies were pooled as odds ratios (ORs) or mean differences (MDs) in R using fixed effects or random effects (heterogeneity significant). ROBINS-I/RoB 2 were used to assess bias.

RESULTS

Of 56,314 unique references over 12 years from 22 countries, 230 studies (34 randomized, 74 prospective, and 122 database) comparing dV-RAS to lap/VATS or open surgery across 7 procedures, 4 specialties, representing 1,194,559 dV-RAS; 1,095,936 lap/VATS and 1,625,320 open cases were included. Operative time for dV-RAS was longer than lap/VATS [MD: 17.73 minutes (9.80, 25.67), P < 0.01] and open surgery [MD: 40.92 minutes (28.83, 53.00), P < 0.01], whereas hospital stay was shorter [lap/VATS MD: -0.51 days (-0.64, -0.38), P < 0.01; open MD: -1.85 days (-2.09, -1.62), P < 0.01] and blood loss was less versus open [MD: -293.44 mL (-359.53, -227.35)]. There were fewer dV-RAS conversions [OR: 0.44 (0.40, 0.49), P < 0.01], transfusions [OR: 0.79 (0.72, 0.88), P < 0.01], postoperative complications [OR: 0.90 (0.84, 0.96), P < 0.01], readmissions [OR: 0.91 (0.83, 0.99), P = 0.04], and deaths [OR: 0.86 (0.81, 0.92), P < 0.01] versus lap/VATS, and fewer transfusions [OR: 0.25 (0.21, 0.30), P < 0.01], postoperative complications [OR: 0.56 (0.52, 0.61), P < 0.01], readmissions [OR: 0.71 (0.63, 0.81), P < 0.01], operations [OR: 0.89 (0.81, 0.97), P < 0.01], and deaths [OR: 0.54 (0.47, 0.63), P < 0.01] versus open surgery. Blood loss [MD:- 12.26 mL (-29.44, 4.91), P = 0.16] and operations [OR: 1.03 (0.95, 1.11), P = 0.48] were similar for dV-RAS and lap/VATS. There was significant heterogeneity.

CONCLUSIONS

Da Vinci-RAS confers benefits across oncological procedures and study designs. These results provide clinical evidence to multispecialty-care decision-makers considering dV-RAS.

Quality improvement in neurosurgery: A systematic review

Quality improvement (QI) is crucial for advancing patient care and safety in surgical practices. Despite the presence of numerous systematic reviews on various types of surgeries, no current QI systematic review for neurosurgery is available, at least to the best of our knowledge. The present study thus aimed to explore existing QI frameworks, interventions and outcome measures, which are used to enhance patient care and efficiency in neurosurgery. For this purpose, a systematic review was conducted by identifying 75 articles using key words, such as 'Quality', 'Control', 'Improvement', 'Neurosurgical' and 'Neurosurgery' across various databases, including PubMed, Google Scholar, Scopus, Wiley, ScienceDirect and Microsoft Academic. Each article was assessed based on inclusion and exclusion criteria, without a time limit for selection. The analysis of the 75 publications revealed an uneven distribution across neurosurgical fields: Adult neurosurgery (70.5%), spine surgery (22.5%), pediatric neurosurgery (4%) and neuro-oncology (3%). This pattern was reflected in the patient distribution (n=621,293), with 87.07% involved in spine surgery QI initiatives. Cranial-only and combined cranial and spinal studies accounted for only 0.21% of patients. QI interventions included mainly new protocols (18.67%), ERAS (17.33%), data analysis (16%), modified checklists (14.67%) and new sterilization devices (13.3%). By contrast, only a limited number of articles addressed the effectiveness of new technology, prediction models, incident reporting and staff education. On the whole, the QI studies enhanced neurosurgical care, focusing mainly on adult neurosurgery and targeting specifically spinal cases. The main interventions included new protocols, ERAS, data analysis and checklists. Further research is required to address QI initiatives in cranial surgery and evaluate the effectiveness of less commonly used methods, such as new technologies and predictive models.

Vision techniques for anatomical structures in laparoscopic surgery: a comprehensive review

Laparoscopic surgery is the method of choice for numerous surgical procedures, while it confronts a lot of challenges. Computer vision exerts a vital role in addressing these challenges and has become a research hotspot, especially in the classification, segmentation, and target detection of abdominal anatomical structures. This study presents a comprehensive review of the last decade of research in this area. At first, a categorized overview of the core subtasks is presented regarding their relevance and applicability to real-world medical scenarios. Second, the dataset used in the experimental validation is statistically analyzed. Subsequently, the technical approaches and trends of classification, segmentation, and target detection tasks are explored in detail, highlighting their advantages, limitations, and practical implications. Additionally, evaluation methods for the three types of tasks are discussed. Finally, gaps in current research are identified. Meanwhile, the great potential for development in this area is emphasized.

The Impact of Minimally Invasive Surgical Modality and Task Complexity on Cognitive Workload: An fNIRS Study

BACKGROUND

Minimally invasive surgical techniques, including laparoscopic and robotic surgery, have profoundly impacted surgical practice by improving precision, reducing recovery times, and minimizing complications. However, these modalities differ in their cognitive demands and skill acquisition requirements, which can influence the learning curve and operative performance. To assess and evaluate this variability across these modalities, a functional near-infrared spectroscopy (fNIRS) system is used as an objective method for monitoring cognitive activity in surgical trainees. fNIRS can provide insights and further our understanding of the mental demands of different surgical techniques and their association with varying task complexity.

OBJECTIVE

This study seeks to assess the influence of surgical modality (laparoscopy vs. robotic surgery) and task complexity (pick and place (PP) vs. knot tying (KT)) on cognitive workload through fNIRS. We compare real-world and simulation-based training environments to determine changes in brain activation patterns and task performance.

METHODS

A total of twenty-six surgical trainees (general and gynecologic surgery residents and specialists) participated in this study. Participants completed standardized laparoscopic and robotic surgical tasks at varying levels of complexity while their cognitive workload was measured using fNIRS. This study included both simulation-based training and real-world surgical environments. Hemodynamic responses in the prefrontal cortex (PFC), task completion times, and performance metrics were analyzed.

RESULTS

Laparoscopic surgery elicited higher activity changes in the prefrontal cortex, indicating increased cognitive demand compared with robotic surgery, particularly for complex tasks like knot tying. Task complexity significantly influenced mental load, with more intricate procedures eliciting greater neural activation. Real-world training resulted in higher cognitive engagement than simulation, emphasizing the gap between simulated and actual surgical performance.

CONCLUSIONS

Cognitive workload was lower and significantly different during robotic surgery than during laparoscopy, potentially due to its ergonomic advantages and enhanced motor control. Simulation-based training effectively prepares surgeons, but the cognitive workload results indicate that it may not fully replicate real-world surgical environments. These findings reveal the importance of cognitive workload assessment in surgical education and suggest that incorporating neuroimaging techniques such as fNIRS into training programs could enhance skill acquisition and performance.

Comparative evaluation of two different doses of nebulized intraperitoneal dexamethasone on postoperative pain in laparoscopic surgeries

Background and Aims

Postoperative pain is a major cause of discomfort after laparoscopic surgeries and thus necessitates prevention and treatment. This study aims to evaluate and compare two different doses of intraperitoneally nebulized (aerosol size: 0.4-4.5 micrometers) dexamethasone for the prevention of postoperative pain.

Material and Methods

In this double-blind, randomized control study, 135 patients undergoing laparoscopic surgeries were randomly assigned to three groups after obtaining ethical committee clearance and CTRI registration. Intraperitoneal nebulization was performed using the Aeroneb device, with group A receiving 16 mg dexamethasone, group B receiving 8 mg dexamethasone, and group C receiving 0.9% normal saline. The primary outcome was assessed by measuring visceral, somatic, and referred pain using a visual analog scale (VAS) at 6 hours postoperatively. Secondary outcomes included VAS at 1 and 24 hours, the hemodynamic response to pneumo-peritoneum, 24-hour anti-emetics, and opioid consumption.

Results

VAS score at 6 hours was 0.9 ± 1.06 in group A, 1.7 ± 1.45 in group B, and 2.3 ± 1.87 in group C for referred pain; the values were statistically significant (P = 0.01). VAS score was 0.7 ± 0.76 in group A, 1.7 ± 1.82 in group B, and 2.2 ± 2.06 in group C for dull aching pain; the results were statistically significant at 24 hours (P = 0.001). None of the values at any time point were statistically significant (P < 0.05) for incisional pain. The rise in heart rate after 5 minutes of pneumoperitoneum was the least in group A compared to group C (P = 0.01). Group C had the highest consumption of anti-emetics and rescue analgesics (P = 0.001).

Conclusions

Intraperitoneal dexamethasone nebulization of 16 mg and 8 mg both are equi-effective in decreasing the severity of pain after laparoscopic surgeries compared to normal saline nebulization (P = 0.001).

Comparing Safety and Efficacy: Laparoscopic vs. Open Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma: A Meta-analysis of Randomized Control Trials

Pancreatic ductal adenocarcinoma (PDAC) has an estimated 5-year survival rate of 11% and remains a formidable challenge. Despite evolving pancreaticoduodenectomy techniques, the pinnacle status of laparoscopic surgery persists. Technological advancements since Gagner and Pomp's 1994 breakthrough have expanded its reach, yet it remains complex. Although safety reports exist, large-scale studies establishing the viability of laparoscopic surgery for PDAC are scarce. This study aimed to provide an up-to-date meta-analysis, scrutinizing all relevant trials, especially recently published ones, to discern differences between laparoscopic and open pancreaticoduodenectomy procedures. This meta-analysis, following the PRISMA guidelines, systematically searched the PubMed and Cochrane Library databases for randomized controlled trials on pancreaticoduodenectomy up to November 25, 2023. Data extraction, quality assessment, and statistical analysis, including primary and secondary outcomes, were conducted using rigorous methodology. The study employed Review Manager 5.4 for analysis, with significance set at P < 0.05. This meta-analysis, comprising five randomized controlled trials (laparoscopic, 605; open, 601; total, 1206), utilized the Cochrane Risk of Bias 2 tool, revealing minimal bias. Primary outcome analysis indicated a shorter hospital stay with laparoscopic pancreaticoduodenectomy (S.M.D. =  - 0.18, 95% CI - 0.63 - 0.28, P = 0.45) and reduced blood loss (S.M.D. =  - 1.96, 95% CI - 3.05, 0.88, P = 0.0004), but increased operative time (S.M.D. = 1.74, 95% CI 0.95 to 2.53, P < 0.0001). The secondary outcomes showed no significant differences in morbidity, mortality, resection, fistula, gastric emptying, hemorrhage, bile leak, reoperation, readmission, and surgical site infection between the two procedures. Laparoscopic pancreaticoduodenectomy (LPD) offers marginal benefits over open pancreaticoduodenectomy (OPD), including reduced blood loss and shorter hospital stays. However, LPD requires a significantly longer operative time, and no substantial differences have been observed in terms of mortality or other complications. Additional studies with lower heterogeneity are needed to thoroughly evaluate the comparative effectiveness and safety of LPD and OPD.

Can a single-shot abdominal wall nerve block for unexpected open surgery be done without specific consent?

Abdominal wall blocks are simple and safe opioid-sparing adjuncts for abdominal procedures that are generally well tolerated. These blocks have been shown to be effective for open abdominal surgeries, though their utility in laparoscopic or robotic surgery has been questioned. The unanticipated conversion from laparoscopic to open surgery may pose a challenge for the anesthesiologist, if regional anesthesia was not discussed before the start of the case as part of the pain-control regimen. Inability to offer an abdominal wall block leads to increased use of opioid medications and less-than-ideal analgesia during emergence and the immediate postoperative period, often until consent can be obtained and a nerve block offered. In this discourse, we discuss if a single-shot abdominal wall block is within the scope of a typical general anesthetic or if specific consent is needed prior to performance.

The impact of obstructive sleep apnoea on post-operative outcomes

BACKGROUND

Unrecognised obstructive sleep apnoea (OSA) has been associated with adverse cardiorespiratory perioperative outcomes. However, with changing anaesthetic and perioperative management, there is ongoing uncertainty about the importance of OSA as a risk factor for post-operative complications.

METHODS

A cohort study involving subjects undergoing elective surgery was conducted. OSA was diagnosed with a limited channel sleep monitor. In subjects undergoing routine perioperative care, complications were identified based on the assessment of the attending clinical team. The primary outcome was a composite end-point of cardiorespiratory outcomes comprising myocardial infarction, atrial fibrillation, other arrhythmias, bradycardia, need for inotropic support, unplanned intensive care unit admission, pneumonia or respiratory failure.

RESULTS

Four hundred seventy-two subjects were recruited, with 356 being included in the analyses; 281 (79%) had OSA and 66 (19%) had severe OSA. Subjects with OSA did not have a significantly higher incidence of complications (5.7%) compared to those without (2.7%, adjusted relative risk 1.89 (0.23-15.67)). Additionally, complications were not increased in those with severe OSA.

CONCLUSIONS

Unrecognised OSA was not associated with an increase in clinically evident cardiorespiratory complications in this cohort. The lower complication rates compared with earlier studies suggest that increased use of less invasive surgical techniques, improved pain management and increased awareness of OSA have had an impact in reducing postoperative complications in this group. Further research is needed to clarify the impact of severe OSA on post-operative outcomes in different surgical cohorts with varying risk profiles in order to develop optimal perioperative pathways.

Comparison of index and reoperative bowel resections in Crohn's disease

BACKGROUND

There is a scarcity of literature describing outcomes of reoperative Crohn's disease. An in-depth knowledge of these outcomes is critical for managing patient expectations and optimal perioperative planning. We sought to examine outcomes in patients undergoing reoperative surgeries for Crohn's disease compared to index operations.

METHODS

A retrospective chart review of surgeries performed from 2018-2023 at a single tertiary care academic institution was performed. A subgroup analysis of index vs. reoperative ileocolic resections was performed to minimize confounding due to the heterogeneity of operations between the index and reoperative groups.

RESULTS

Out of 119 patients, 70 (59%) underwent index operations, and 49 (41%) were reoperations. Overall complication rates (24.28% vs. 34.69%, P=0.224), EBL (189.5 vs. 193.4 mL, P=0.94), operative time (209 vs. 236 min, P=0.091), length of stay (mean: 7.24 vs. 10.08 days, P=0.0142), utilization of laparoscopy (92.85% vs. 65.3%, P=0.0002) and conversion to open technique (4.61% vs. 9.37%, P=0.392) favored index cases. The laparoscopic approach narrowed the gap in length of stay between the index and reoperative groups from 2.83 to 0.6 days. Subgroup analysis of ileocolic resections (Index: 50, reoperations: 26) also favored the index operations.

CONCLUSIONS

The current study provides valuable insight into managing patient expectations and optimal perioperative planning for reoperative Crohn's disease. Reoperations were associated with longer stays, lower utilization of laparoscopic platforms, and a trend toward higher overall complication rates. Laparoscopy reduces the gap in length of stay between index and reoperations; however, it is associated with a higher reoperation conversion rate.

Advancements in liver retraction techniques for laparoscopic gastrectomy

Traditionally, liver retraction for laparoscopic gastrectomy is done via manual methods, such as the placement of retractors through the accessory ports and using a Nathanson retractor. However, these techniques often posed issues including extra abdominal incisions, risk of liver injury or ischaemia, and the potential for compromised visualization. Over the years, the development of innovative liver retraction techniques has significantly improved the safety and efficacy of laparoscopic gastrectomy and similar other hiatal procedures. This editorial will comment on the article by Lin et al, and compare this to the other liver retractor techniques available for surgeons and highlight the pros and cons of each technique of liver retraction.

Performance optimization of vessel sealing using a hemostatic ultrasonic scalpel

Using ultrasound technology as one of the therapeutic methods, in which ultrasound waves of different frequencies and intensities are employed, has significantly contributed to enhancing and facilitating the treatment process of various diseases. A Hemostatic Ultrasonic Scalpel can entail considerable advantages by simultaneously performing two operations tissue cutting and coagulation of biological tissues. In the present study, employing experimental design through response surface methodology, the effect of ultrasonic power and the duration of vibration application on the tissue has been investigated. Two parameters, namely the burst pressure of the sealed vessel and the length of the thermal seal zone, were measured by pressure testing and analysis image of the thermal effect region at the sealed vessel area, respectively. The pressure test results demonstrated that an input power of 52 W and the application of vibrations for 8 s under a constant force of 10 N, showed the optimized maximum burst pressure equal to 1100 mmHg. Examination of the sealed vessel images revealed a linear increase in thermal damage with increasing input power.

Giant Gastric Trichobezoar: Unveiling the Complexity of a 14-Year-Old's Abdominal Pain

Trichobezoars are accumulations of undigested hair. Usually, this disorder follows a psychiatric etiology; however, sometimes a nonpsychiatric etiology, such as pica, can also be suspected. Rapunzel syndrome is a rare type of trichobezoar in which the hair is usually confined to the stomach and small intestine. The authors present a rare case of trichobezoar in a young female without any psychiatric symptoms. Trichobezoar results in nonspecific GI symptoms and this causes delays in its diagnosis. It should always be considered a differential in a young female with nonspecific GI symptoms, especially in those with evidence of iron deficiency anemia.

Laparoscopic surgery for left ovarian hemorrhage in a patient with an implantable left ventricular assist device on antithrombotic therapy and a history of right salpingo-oophorectomy open surgery for right ovarian bleeding: A case report

Ovarian hemorrhage during antithrombotic therapy is sometimes difficult to manage. A 38-year-old woman, diagnosed with Marfan syndrome and implanted with a left ventricular assist device (LVAD) and taking aspirin and warfarin potassium, had a history of right adnexal oophorectomy via open surgery for a right ovarian hemorrhage at the age of 35 years. Thereafer, she had been treated with dienogest to suppress ovulation as much as possible. The patient was admitted to a local hospital with lower abdominal pain, and computed tomography showed a 10 cm left adnexal mass with suspected ovarian hemorrhage. Two days after the initiation of careful conservative treatment, with the cessation of antithrombotic therapy and monitoring of hemostasis, the patient was referred to a tertiary hospital. As the left ovarian hemorrhage continued 3 days after the transfer, emergency laparoscopic left salpingo-oophorectomy was performed due to the difficulty in conserving the left normal ovary. Although coagulopathy caused continuous oozing of blood from the pelvis after the removal of the left ovarian mass, hemostasis was successfully achieved laparoscopically. No postoperative bleeding was noted, and anticoagulant therapy was resumed on postoperative day 1 to prevent life-threatening thrombotic events associated with the LVAD. Postoperative pathological examination of the left ovary revealed an endometriotic cyst. To manage surgical menopause, complementary therapy using Japanese traditional herbal medicine was administered, as hormone replacement therapy was not recommended, to avoid the risk of fatal LVAD-associated thrombosis. Less invasive laparoscopic surgery for ovarian hemorrhage during anticoagulant therapy can be considered for reducing bleeding during and after surgery.

Trends and Outcomes of Laparoscopic Surgery in Low-Resource Settings: Lessons From Two African Healthcare Systems-A Narrative Review

Introduction

Laparoscopic surgery (LS) has been a promising development in surgical practice globally ever since its introduction. LS has exhibited many an advantage, including bettering patient outcomes, lowering the risk of postoperative infection, and displaying economical affluence. However, its implementation in the African continent still faces various challenges. In this review, we investigated the status of laparoscopic surgery integration in Africa.

Objectives

In this review, we aimed to investigate the challenges posed by the implementation of LS in low resource countries as well as critically evaluating initiatives and their impact within said domiciles. We also provide recommendations that may assist in LS prosperity in these settings by focusing efforts on improving training and financial incentives.

Methods

A comprehensive literature review was conducted to garner up-to-date evidence concerning the fate of LS adoption in low- to middle-income countries. This comprised the analysis of different case studies from countries including Nigeria and Botswana, and investigated relevant recommendations and policies provided by other African countries.

Results

Various challenges face the implementation of LS in countries with low resources comprising poor infrastructure, scarce training programs, and expert training personnel alongside financial boundaries. The adoption of LS in Africa has proved its benefits in improving patient outcomes and reducing hospital admissions. From a perspective of policy, it is crucial to sustain strong ties amongst institutions, stressing the importance of dynamic collaboration and locally tailored policies.

Conclusion

It has been demonstrated that LS implementations in African nations lower infection rates and expedite recovery. A strong collaboration between governments, stakeholders, and healthcare providers is fundamental for successful integration of LS. Such extension in low-resource environments may be achieved by providing proper training programs, funding infrastructure and equipment, and fostering effective financial initiatives.

The Hasson Versus Veress Trocar Wars: Determining the Safety Index of Laparoscopic Surgical Entry Techniques

BACKGROUND

Classically, there are two techniques for establishing pneumoperitoneum in laparoscopic and robotic surgeries: the closed Veress needle technique and Hasson's technique for open placement of laparoscopic ports. Most surgeons prefer the open Hasson technique, even though it is not the gold standard. Some surgeons still favour the Veress needle technique despite literature linking it to visceral and vascular damage.

AIMS

This study aimed at determining the safety index of the two techniques of establishing pneumoperitoneum in laparoscopic and robotic surgeries by evaluating the risk of injuries associated with Veress and Hasson's techniques.

MATERIALS AND METHODS

This is a retrospective cohort study evaluating the incidence of primary port placement injuries (PPPI) using Hasson's open trocar technique and Veress needle technique in 200 laparoscopic and robotic cases (emergency vs. elective) over a three-month period (January to March 2024) at Newcross Hospital. The exclusion criteria were secondary port injuries. IBM SPSS Statistics for Windows, Version 24 (Released 2016; IBM Corp., Armonk, New York) and Microsoft Excel (Microsoft Corporation, Redmond, Washington) were used for data analysis.

RESULTS

Hasson's open technique of primary port placement was used in 74% of emergency cases, while the Veress needle technique was used in 26% of emergency surgeries. Similarly, the most common technique for establishing pneumoperitoneum employed in elective surgical procedures was Hasson's open technique (77%). When comparing the safety index of the two techniques for establishing pneumoperitoneum, we found that there were no major PPPI associated with either technique, with minimal incidence of minor PPPI associated with both techniques. While some cases did involve injuries from secondary port insertions (bowel and vascular injuries), these were excluded according to our exclusion criteria. Additionally, no perioperative mortality associated with primary trocar placement was observed.

CONCLUSION

Although the literature describes the association of the Veress technique with visceral and vascular injuries, our study found it to be as safe as Hasson's open port placement technique. Therefore, either technique can be employed for the safe establishment of pneumoperitoneum in laparoscopic and robotic surgeries.

Efficacy of different preoperative antiseptics in preventing a risk of surgical site infections: a systematic review and meta‑analysis of randomized controlled trials

INTRODUCTION

Surgical site infection (SSI) is a predominant postoperative complication that markedly increases health care expenses. Published systematic reviews, meta‑analyses and international guidelines vary in their recommendations for the most effective preoperative skin antiseptic solutions and their concentrations.

AIM

The aim of this study was to assess the efficacy of different preoperative antiseptics for prevent‑ ing the risk of SSIs.

MATERIALS AND METHODS

A complete search was conducted using PubMed, EMBASE, Scopus, and Cochrane Library databases to collect peer‑reviewed articles.

RESULTS

This meta‑analysis included 10 587 surgical patients from 18 randomized clinical trials to determine the effectiveness of chlorhexidine in alcohol (CHA; 0.5%, 2%-2.5%, and 4%) with aqueous or alcoholic iodine in preventing postoperative SSIs. This meta‑analysis found that 2%-2.5% CHA is the most effective preoperative antiseptic for preventing SSIs, with significant reduction in their incidence and significant antimicrobial activity.

CONCLUSIONS

The findings of this meta‑analysis indicate that for patients undergoing any type of surgery, the use of 2%-2.5% CHA for skin preparation is the most effective method for preventing SSIs.

Assessment of laparoscopic surgery practice, knowledge, and training goals in Liberia: A mixed-methods study among Liberian surgeons

BACKGROUND

Laparoscopy training remains inaccessible in many low- and middle-income countries, including Liberia. We assessed the availability of laparoscopy and feasibility of implementing a laparoscopic program among Liberian surgeons and trainees.

METHODS

This mixed-methods study utilized a 32-item survey and semi-structured interviews on laparoscopic experience, knowledge, desires, barriers, patient perceptions, and training opportunities among surgeons and trainees at Liberia's two main teaching hospitals in March 2023. Data analysis utilized summed knowledge and desirability scores, descriptive statistics, and qualitative content analysis.

RESULTS

31 interns, residents, and consultants participated, comprising 60% of Liberia's surgeons. Laparoscopic training (32%) and experience (16%) was low, with exposure limited to those training outside Liberia (p = 0.001). While laparoscopy knowledge varied (29% low, 55% medium, 16% high), participants expressed high interest in training (100%) and willingness to pay (52%). Interviews revealed four themes: desires for training, patient acceptability, feasibility of technology-based training, and barriers including limited equipment and expert trainers. At the time of survey, the only minimally invasive surgeries ever performed in Liberia were two diagnostic laparoscopies.

CONCLUSIONS

This is the first mixed-methods study assessing laparoscopy in Liberia. Our sample, though small, comprised approximately 60% of Liberian surgeons in both rural and urban hospitals. Findings demonstrated limited experience, variable knowledge, and high desires for training, showing feasibility for laparoscopy implementation in Liberia.

Usability, Ergonomics, and Educational Value of a Novel Telestration Tool for Surgical Coaching: Usability Study

BACKGROUND

Telementoring studies found technical challenges in achieving accurate and stable annotations during live surgery using commercially available telestration software intraoperatively. To address the gap, a wireless handheld telestration device was developed to facilitate dynamic user interaction with live video streams.

OBJECTIVE

This study aims to find the perceived usability, ergonomics, and educational value of a first-generation handheld wireless telestration platform.

METHODS

A prototype was developed with four core hand-held functions: (1) free-hand annotation, (2) cursor navigation, (3) overlay and manipulation (rotation) of ghost (avatar) instrumentation, and (4) hand-held video feed navigation on a remote monitor. This device uses a proprietary augmented reality platform. Surgeons and trainees were invited to test the core functions of the platform by performing standardized tasks. Usability and ergonomics were evaluated with a validated system usability scale and a 5-point Likert scale survey, which also evaluated the perceived educational value of the device.

RESULTS

In total, 10 people (9 surgeons and 1 senior resident; 5 male and 5 female) participated. Participants strongly agreed or agreed (SA/A) that it was easy to perform annotations (SA/A 9, 90% and neutral 0, 0%), video feed navigation (SA/A 8, 80% and neutral 1, 10%), and manipulation of ghost (avatar) instruments on the monitor (SA/A 6, 60% and neutral 3, 30%). Regarding ergonomics, 40% (4) of participants agreed or strongly agreed (neutral 4, 40%) that the device was physically comfortable to use and hold. These results are consistent with open-ended comments on the device's size and weight. The average system usability scale was 70 (SD 12.5; median 75, IQR 63-84) indicating an above average usability score. Participants responded favorably to the device's perceived educational value, particularly for postoperative coaching (agree 6, 60%, strongly agree 4, 40%).

CONCLUSIONS

This study presents the preliminary usability results of a novel first-generation telestration tool customized for use in surgical coaching. Favorable usability and perceived educational value were reported. Future iterations of the device should focus on incorporating user feedback and additional studies should be conducted to evaluate its effectiveness for improving surgical education. Ultimately, such tools can be incorporated into pedagogical models of surgical coaching to optimize feedback and training.

A comparative study on effects of defect closure versus non-closure in laparoscopic totally extraperitoneal repair of direct inguinal hernia

Introduction

Totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) repair are the principal techniques in laparoscopic hernia repair. Seroma formation and pain are frequent complications of moderate-large size laparoscopic direct inguinal hernia mesh repair. This study was conducted to evaluate the feasibility of defect closure in moderate-large direct inguinal hernias and its effect on various outcomes.

Method

This is a prospective cohort study from September 2020 to August 2021, where a total of 88 patients with uncomplicated direct inguinal hernia (M3 or more) were enrolled in the study and divided into two equal groups of TEP defect closure and non-closure, and various outcome measures were noted.

Results

The majority of patients were male (94.31%), with a mean age range of 18-85 years, and had right-sided inguinal hernia (46.5%). Seroma formation at 10th POD in the defect closure and non-closure were 24% and 33% (p value: 0.225), which reduced to 11% and 18%, respectively, at 1 month (p value: 1.000). All seromas resolved within 6 months. Pain in VAS at 10th POD in the defect closure and non-closure were 1.55±0.571 and 1.38±0.527, respectively (p value: 0.121), which gradually decreased to 1.20±0.524 and 1.16±0.420 at a 6-month interval (p value: 0.689). The mean operative time in the bilateral and unilateral defect closure groups was 72.3±4.1 and 56.5±4.3 min, respectively, whereas that in the bilateral and unilateral defect non-closure groups was 62.3±3.7 and 45.7±3.6 min, respectively.

Conclusion

The defect closure was found to have higher pain and less seroma formation at various intervals of time following TEP for moderate-large direct inguinal hernia. Although these findings were statistically insignificant, they may be clinically significant, and further studies with a larger sample size are suggested.

Feeling of pulsations in artificial arteries with a real time haptic feedback laparoscopic grasper: a validation study

INTRODUCTION

Despite the advancements in technology and organized training for surgeons in laparoscopic surgery, the persistent challenge of not being able to feel the resistance and characteristics of the tissue, including pulsations, remains unmet. A recently developed grasper (Optigrip®) with real time haptic feedback, based on photonic technology, aims to address this issue by restoring the tactile sensation for surgeons. The key question is whether pulsations can be detected and at what minimal size level they become clinical significant.

METHODS

To simulate arterial conditions during laparoscopic procedures, four different silicone tubes were created, representing the most prevalent arteries. These tubes were connected to a validated pressure system, generating a natural pulse ranging between 80 and 120 mm Hg. One control tube without pressure was added. The surgeons had to grasp these tubes blindly with the conventional grasper or the haptic feedback grasper in a randomized order. They then indicated whether they felt the pressure or not and the percentage of correct answers was calculated.

RESULTS

The haptic grasper successfully detected 96% of all pulsations, while the conventional grasper could only detect 6%. When considering the size of the arteries, the Optigrip® identified pulsations in 100% the 4 and 5 mm arteries and 92% of the smallest arteries. The conventional grasper was only able to feel the smallest arteries in 8%. These differences were highly significant (p < 0.0001).

CONCLUSION

This study demonstrated that the newly developed haptic feedback grasper enables detection of arterial pulsations during laparoscopy, filling an important absence in tactile perception within laparoscopic surgery.

Pioneering robotic-assisted surgery for insulinoma during pregnancy: The first case report and literature review

Introduction

Insulinoma during pregnancy is a rare condition with vague clinical symptoms, making diagnosis challenging. The standard treatment for insulinoma is surgical tumor removal, preferably using a minimally invasive method. However, there have been no recorded examples of employing a robotic platform in pregnant women with insulinoma. In this report, we present the first successful case of robotic enucleation for insulinoma during pregnancy.

Case presentation

A 30-year-old pregnant woman presented with recurrent hypoglycemic symptoms throughout her first trimester that were relieved by food intake. After confirming endogenous hyperinsulinemia, an abdominal magnetic resonance imaging scan was performed to locate the tumor. A well-defined 2-cm mass was found in the pancreatic body. Robotic enucleation was performed at week 18 of gestation, and the patient experienced relief from hypoglycemic episodes postoperatively. Her blood glucose levels returned to normal, and she had an uneventful pregnancy. The patient eventually delivered a healthy baby via cesarean section without any complications.

Conclusions

For a subset of pregnant individuals with insulinoma, a minimally invasive approach as robotic-assisted surgery is safe and feasible. This innovative technique has the potential to both mothers and fetuses.

Revolutionizing Gastrointestinal Disorder Management: Cutting-Edge Advances and Future Prospects

In recent years, remarkable strides have been made in the management of gastrointestinal disorders, transforming the landscape of patient care and outcomes. This article explores the latest breakthroughs in the field, encompassing innovative diagnostic techniques, personalized treatment approaches, and novel therapeutic interventions. Additionally, this article emphasizes the use of precision medicine tailored to individual genetic and microbiome profiles, and the application of artificial intelligence in disease prediction and monitoring. This review highlights the dynamic progress in managing conditions such as inflammatory bowel disease, gastroesophageal reflux disease, irritable bowel syndrome, and gastrointestinal cancers. By delving into these advancements, we offer a glimpse into the promising future of gastroenterology, where multidisciplinary collaborations and cutting-edge technologies converge to provide more effective, patient-centric solutions for individuals grappling with gastrointestinal disorders.

Current state of minimally invasive general surgical practice in Africa: A systematic review and meta-analysis of the laparoscopic procedures performed and outcomes

BACKGROUND

Minimally invasive surgery, including laparoscopy and robotics, has significantly improved general surgical (GS) practice globally. While robot-assisted GS practice is yet to be adopted in the majority of Africa, laparoscopy has been utilized to improve surgical outcomes. This study aims to review the laparoscopic GS procedures (LGSPs) performed and evaluate outcomes such as conversion to open surgery, morbidity, and mortality in Africa.

METHODS

Four databases (PubMed, Google Scholar, WoS, and AJOL) were searched, identifying 8022 publications. Following screening, 40 studies across Africa that reported LGSPs (n ≥ 2) performed and outcomes met the inclusion criteria. A meta-analysis conducted using R statistical software estimated the pooled prevalences with the 95% CI of conversion, morbidity, and mortality.

RESULTS

A total of 6381 procedures performed in 15 African countries were analyzed in this study. Majority, 72.89%, of the procedures were performed in Senegal, South Africa, and Nigeria. The major procedures performed were cholecystectomy (37.09%), appendicectomy (33.36%), and diagnostic laparoscopy (9.98%). The meta-analysis revealed a conversion rate of 5% [95% CI: 4, 7]. Adhesion (28.13%), hemorrhage (16.67%), technical difficultly (12.50%), and equipment failure (11.46%) were the predominant indications for conversion. Surgical site infection (42.75%) was the major cause of morbidity. The prevalences of morbidity and mortality were 7% [95% CI: 5, 10] and 0.12% [95% CI: 0, 0.29], respectively.

CONCLUSION

A wide range of basic and advanced LGSPs were performed. The outcomes obtained indicate successful implementation of the laparoscopic approach. Importantly, this study serves as a foundational work for further research on minimally invasive surgery in Africa.

Management Strategies for Malignant Left-Sided Colonic Obstruction: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials and Propensity Score Matching Studies

BACKGROUND

The optimal treatment strategy for left-sided malignant colonic obstruction remains controversial. Emergency colonic resection has been the standard of care; however, self-expanding metallic stenting as a bridge to surgery may offer short-term advantages, although oncological concerns exist. Decompressing stoma may provide a valid alternative, with limited evidence.

OBJECTIVE

To perform a systematic review and Bayesian arm random-effects model network meta-analysis comparing the approaches for management of malignant left-sided colonic obstruction.

DATA SOURCES

A systematic review of PubMed, Embase, Cochrane Library, and Google Scholar databases was conducted from inception to August 22, 2023.

STUDY SELECTION

Randomized controlled trials and propensity score-matched studies.

INTERVENTIONS

Emergency colonic resection, self-expanding metallic stent, and decompressing stoma.

MAIN OUTCOME MEASURES

Oncologic efficacy, morbidity, successful minimally invasive surgery, primary anastomosis, and permanent stoma rates.

RESULTS

Nineteen of 5225 articles identified met our inclusion criteria. Stenting (risk ratio 0.57; 95% credible interval, 0.33-0.79) and decompressing stomas (risk ratio 0.46, 95% credible interval: 0.18-0.92) resulted in a significant reduction in the permanent stoma rate. Stenting facilitated minimally invasive surgery more frequently (risk ratio 4.10; 95% credible interval, 1.45-13.13) and had lower overall morbidity (risk ratio 0.58; 95% credible interval, 0.35-0.86). A pairwise analysis of primary anastomosis rates showed increased stenting (risk ratio 1.40; 95% credible interval, 1.31-1.49) compared with emergency resection. There was a significant decrease in the 90-day mortality with stenting (risk ratio 0.63; 95% credible interval, 0.41-0.95) compared with resection. There were no differences in disease-free and overall survival rates, respectively.

LIMITATIONS

There is a lack of randomized controlled trials and propensity score matching data comparing short-term and long-term outcomes for diverting stomas compared to self-expanding metallic stents. Two trials compared self-expanding metallic stents and diverting stomas in left-sided malignant colonic obstruction.

CONCLUSIONS

This study provides high-level evidence that a bridge-to-surgery strategy is safe for the management of left-sided malignant colonic obstruction and may facilitate minimally invasive surgery, increase primary anastomosis rates, and reduce permanent stoma rates and postoperative morbidity compared with emergency colonic resection.

Water-Mediated On-Demand Detachable Solid-State Adhesive of Porous Hydroxyapatite for Internal Organ Retractions

Novel adhesives for biological tissues offer an advanced surgical approach. Here, the authors report the development and application of solid-state adhesives consisting of porous hydroxyapatite (HAp) biocompatible ceramics as novel internal organ retractors. The operational principles of the porous solid-state adhesives are experimentally established in terms of water migration from biological soft tissues into the pores of the adhesives, and their performance is evaluated on several soft tissues with different hydration states. As an example of practical medical utility, HAp adhesive devices demonstrate the holding ability of porcine livers and on-demand detachability in vivo, showing great potential as internal organ retractors in laparoscopic surgery.

Innovations in Hybrid Laparoscopic Surgery: Integrating Advanced Technologies for Multidisciplinary Cases

Combining conventional laparoscopic techniques with cutting-edge technologies, such as robotics, improved imaging, and flexible equipment, hybrid laparoscopic techniques represent a revolutionary advancement in minimally invasive surgery. These methods have several benefits, such as increased accuracy, quicker healing periods, and fewer complications, which makes them especially useful in complicated multidisciplinary situations. The historical evolution, uses, benefits, and drawbacks of hybrid laparoscopic procedures are examined in this narrative review, which also covers urological, gastrointestinal, cardiothoracic, and gynecological surgery. The review focuses on how these methods promote interdisciplinary cooperation and creativity by enabling more accurate and successful surgical operations. It also discusses the equipment needs, integration difficulties, and technical difficulties that need to be resolved to reach the full potential of hybrid laparoscopic surgery. For hybrid laparoscopic procedures to become more widely used and effective in the future, there is a need for specialized training programs, interdisciplinary research collaborations, and ongoing technological advancements.

A Comparative Study of Fixed-Dose Dexmedetomidine and Propofol Infusions on Intraoperative Desflurane Consumption During Bispectral Index-Guided Laparoscopic Surgeries: A Randomized Controlled Study

Background Desflurane is an excellent but expensive volatile anesthetic agent. Dexmedetomidine and propofol may decrease intraoperative desflurane consumption. This study aimed to compare the desflurane-sparing effect of dexmedetomidine and propofol in patients undergoing laparoscopic surgeries under bispectral index (BIS)-guided general anesthesia (GA). Methods Sixty-two adult patients, ASA (American Society of Anesthesiologists) physical status I or II, of either sex, aged between 18 and 60 years, were randomly allocated into group D or group P. Only group D patients received an intravenous (IV) bolus of dexmedetomidine (1 mcg/kg) over 15 minutes before induction. In both groups, GA was induced following the standard protocol with propofol infusion (0.5 mg/kg/min) until the BIS value dropped below 60. For maintenance, group D and group P patients received IV dexmedetomidine infusion (0.5 mcg/kg/h) and propofol infusion (50 mcg/kg/min), respectively. In both groups, desflurane dial concentration was adjusted between 3 and 8% to maintain the BIS within the range of 45-55. An hourly bolus of IV fentanyl (0.5 mcg/kg) and a half-hourly bolus of IV vecuronium (0.02 mg/kg) were administered. The total amount of desflurane consumed, duration of pneumoperitoneum, extra aliquots of propofol used during maintenance, number of boluses of IV atropine, fentanyl, and esmolol, time to attain Ramsay Sedation Score of 2 after extubation, time to first postoperative analgesic request at Numerical Rating Scale (NRS) score ≥ 4, time to reach a Modified Aldrete Score of ≥9, and incidence of any side effects were recorded. All the data were analyzed and compared using appropriate statistical tests, and a p-value of <0.05 was considered significant. Results The final data analysis was performed on 60 patients. The mean desflurane consumption was clinically higher in group P patients than in group D, but the difference was statistically insignificant (p-value > 0.05). The mean induction dose of propofol was significantly less in group D than in group P (p-value < 0.05). After extubation, the difference in time to the first analgesic request (NRS ≥ 4) between the groups was statistically significant (p-value < 0.05). Group D patients had a residual intraoperative analgesic effect. Conclusion The effects of dexmedetomidine and propofol infusions on desflurane consumption in laparoscopic surgeries are comparable, with minimal effects on intraoperative hemodynamics and postoperative recovery profiles.

Laparoscopic repair of a traumatic diaphragmatic rupture

INTRODUCTION AND IMPORTANCE

Traumatic diaphragmatic ruptures following blast injury or penetrating trauma rarely present themselves with chronic symptoms warranting elective surgery.

CASE PRESENTATION

We present the case of a 49-year-old man who survived a grenade explosion and experienced chronic chest pain. Considering the previous trauma, computed tomography imaging was performed and showed a left-sided traumatic diaphragmatic rupture ventral to the spleen, resulting in herniation of the transverse colon and omentum in the thoracic cavity. Metal shrapnel was located between the stomach and spleen, the suspected cause of the diaphragmatic hernia. The patient was eligible for minimal invasive laparoscopic surgery.

CLINICAL DISCUSSION

During surgery, a left diaphragmatic rupture and metal shrapnel on the right side of the rupture were found. The hernia was reduced and the metal shrapnel was removed, aiding in fully repositioning of the omentum and transversed colon. After which the left lower lung lobe was able to fully inflate. The rupture was closed using single V-lock sutures and strips of the Phasix mesh to reinforce the diaphragm repair with single ethibond sutures. No surgical or post-operative complications were observed and the patient did not experience any of his previous complaints.

CONCLUSION

In this case, laparoscopic repair of diaphragmatic rupture after penetrating trauma can be considered as an effective surgical approach.

Laparoscopic vs. open surgery: A comparative analysis of wound infection rates and recovery outcomes

As medical technology continues to evolve, it becomes crucial to distinguish the outcomes of traditional versus modern surgical techniques. This was a retrospective cohort study, conducted to compare the wound infection rates and recovery outcomes between laparoscopic and open surgery (OS) in 180 patients. Participants were divided into laparoscopic (n = 105) and OS (n = 75) groups. Comprehensive data, including demographics, surgical details, and postoperative outcomes, were extracted. Wound infection rates, as measured by Wound Asepsis Score, were prioritized alongside recovery indicators such as duration of hospital stay and postoperative pain. The laparoscopic group had a mean operative time of 57.19 minutes, while the OS group required 85.10 ± 15.18 minutes (p < 0.05). Laparoscopic surgeries resulted in an average blood loss of 120.76 ± 13.3 mL compared to 170.01 ± 17.19 mL for OS (p < 0.05). The laparoscopic group had significantly reduced (p < 0.05) average hospital stays (2.1 ± 1.1 days) than the OS group (4.4 ± 2.1 days). Although the laparoscopic group had lower incidence of surgical site infection (4.76%) than the OS group (9.33%), this difference was not statistically significant (p > 0.05). On postoperative days 1, 3, and 7, the Visual Analog Scale assessment of pain in the laparoscopic group revealed significantly reduced pain (p < 0.05). Laparoscopic surgery appeared to offer distinct advantages over conventional open surgery, especially in terms of operative durations, recovery rates, and postoperative pain management. This study highlighted the potential of laparoscopic approaches for specific surgical interventions, as well as the importance of patient-specific surgical strategy decision-making.

First experience in laparoscopic surgery in low and middle income countries: A systematic review

BACKGROUND

Laparoscopic surgery has reduced morbidity and mortality rates, shorter postoperative recovery periods and lower complication rates than open surgery. It is routine practice in high-income countries and is becoming increasingly common in countries with limited resources. However, introducing laparoscopic surgery in low-and-middle-income countries (LMIC) can be expensive and requires resources, equipment, and trainers.

AIM

To report the challenges and benefits of introducing laparoscopic surgery in LMIC as well as to identify solutions to these challenges for countries with limited finances and resources.

METHODS

MEDLINE, EMBASE and Cochrane databases were searched for studies reporting first experience in laparoscopic surgery in LMIC. Included studies were published between 1996 and 2022 with full text available in English. Exclusion criteria were studies considering only open surgery, ear, nose, and throat, endoscopy, arthroscopy, hysteroscopy, cystoscopy, transplant, or bariatric surgery.

RESULTS

Ten studies out of 3409 screened papers, from eight LMIC were eligible for inclusion in the final analysis, totaling 2497 patients. Most reported challenges were related to costs of equipment and training programmes, equipment problems such as faulty equipment, and access to surgical kits. Training-related challenges were reliance on foreign trainers and lack of locally trained surgeons and theatre staff. The benefits of introducing laparoscopic surgery were economic and clinical, including a reduction in hospital stay, complications, and morbidity/mortality. The introduction of laparoscopic surgery also provided training opportunities for junior doctors.

CONCLUSION

Despite financial and technical challenges, many studies emphasise the overall benefit of introducing laparoscopic surgery in LMICs such as reduced hospital stay and the related lower cost for patients. While many of the clinical centres in LMICs have proposed practical solutions to the challenges reported, more support is critically required, in particular regarding training.

The downtrending cost of robotic bariatric surgery: a cost analysis of 47,788 bariatric patients

The surgical robot is assumed to be a fixed, indirect cost. We hypothesized rising volume of robotic bariatric procedures would decrease cost per patient over time. Patients who underwent elective, initial gastric bypass (GB) or sleeve gastrectomy (SG) for morbid obesity were selected from Florida Agency for Health Care Administration database from 2017 to 2021. Inflation-adjusted cost per patient was collected. Cost-over-time ($/patient year) and change in cost-over-time were calculated for open, laparoscopic, and robotic cases. Linear regression on cost generated predictive parameters. Density plots utilizing area under the curve demonstrated cost overlap. Among 76 hospitals, 11,472 bypasses (223 open, 6885 laparoscopic, 4364 robotic) and 36,316 sleeves (26,596 laparoscopic, 9724 robotic) were included. Total cost for robotic was approximately 1.5-fold higher (p < 0.001) than laparoscopic for both procedures. For GB, laparoscopic had lower total ($15,520) and operative ($6497) average cost compared to open (total $17,779; operative $9273) and robotic (total $21,756; operative $10,896). For SG, laparoscopic total cost was significantly less than robotic ($10,691 vs. $16,393). Robotic GB cost-over-time increased until 2021, when there was a large decrease in cost (-$944, compared with 2020). Robotic SG total cost-over time fluctuated, but decreased significantly in 2021 (-$490 compared with 2020). While surgical costs rose significantly in 2020 for bariatric procedures, our study suggests a possible downward trend in robotic bariatric surgery as total and operative costs are decreasing at a higher rate than laparoscopic costs.

An augmented reality and high-speed optical tracking system for laparoscopic surgery

While minimally invasive laparoscopic surgery can help reduce blood loss, reduce hospital time, and shorten recovery time compared to open surgery, it has the disadvantages of limited field of view and difficulty in locating subsurface targets. Our proposed solution applies an augmented reality (AR) system to overlay pre-operative images, such as those from magnetic resonance imaging (MRI), onto the target organ in the user's real-world environment. Our system can provide critical information regarding the location of subsurface lesions to guide surgical procedures in real time. An infrared motion tracking camera system was employed to obtain real-time position data of the patient and surgical instruments. To perform hologram registration, fiducial markers were used to track and map virtual coordinates to the real world. In this study, phantom models of each organ were constructed to test the reliability and accuracy of the AR-guided laparoscopic system. Root mean square error (RMSE) was used to evaluate the targeting accuracy of the laparoscopic interventional procedure. Our results demonstrated a registration error of 2.42 ± 0.79 mm and a procedural targeting error of 4.17 ± 1.63 mm using our AR-guided laparoscopic system that will be further refined for potential clinical procedures.

Single-incision versus conventional three-port laparoscopic appendectomy for acute appendicitis: A meta-analysis of randomized controlled trials

While consensus on single-incision laparoscopic appendectomy (SILA) for acute appendicitis is lacking, our meta-analysis evaluated the safety and efficacy of SILA compared to conventional three-port laparoscopic appendectomy (CTLA). A computer-based search was conducted in the China National Knowledge Infrastructure (CNKI), VIP, Wanfang, China Biological Medicine (CBM), PubMed, Embase, and Cochrane Library databases to identify randomized controlled trials (RCTs) comparing SILA with CTLA groups. Meta-analysis was performed using RevMan 5.3 software. A total of 26 RCTs were included. The meta-analysis results indicated that, compared to the CTLA group, the SILA group had a longer operation time [MD = 7.97, 95 % CI (5.84, 10.10), P < 0.00001], and a higher rate of conversion to open surgery [RR = 2.60, 95 % CI (1.27, 5.31), P = 0.009], but had a shorter time to return to normal activities [MD = -0.76, 95 % CI (-1.15, -0.37), P = 0.0001]. Additionally, the SILA group had higher satisfaction scores [SMD = 1.21, 95 % CI (0.75, 1.68), P < 0.00001] and cosmetic scores [SMD = 0.68, 95 % CI (0.45, 0.90), P < 0.00001]. There was no significant difference between the two groups in terms of pain scores at 24 h postoperatively [MD = -0.21, 95 % CI (-0.56, 0.14), P = 0.25], the incidence of wound infection [RR = 1.13, 95 % CI (0.74, 1.73), P = 0.58], or the overall complication rate [RR = 0.86, 95 % CI (0.66, 1.12), P = 0.27]. SILA is a safe and effective surgical approach that allows patients to recover to normal activities earlier, particularly for patients with a strong demand for better cosmetic outcomes. However, the quality of some RCTs in this meta-analysis is low, and further verification is needed through future high-quality RCTs.

Efficacy of electroacupuncture in improving postoperative ileus in patients receiving colorectal surgery: a systematic review and meta-analysis

BACKGROUND

This meta-analysis aimed to evaluate the efficacy and safety of electroacupuncture (EA) in improving postoperative ileus after colorectal surgery.

METHODS

Electronic databases (e.g. Medline) were screened to identify randomized controlled trials that focused on the association between EA and postoperative ileus. Time to first flatus served as the primary outcome, while the secondary outcomes included time required for the recovery of other gastrointestinal functions (e.g. bowel sound recovery), time to tolerability of liquid/solid food, postoperative pain scores, risk of overall complications, and hospital length of stay.

RESULTS

Our meta-analysis focusing on 16 studies with a total of 1562 patients demonstrated positive associations of EA with shorter times to the first flatus [mean difference (MD): -10.1 h, P <0.00001, n =1562], first defecation (MD: -11.77 h, P <0.00001, n =1231), bowel sound recovery (MD: -10.76 h, P <0.00001, n =670), tolerability of liquid (MD: -16.44 h, P =0.0002, n =243), and solid food (MD: -17.21 h, P =0.005, n =582) than those who received standard care. The use of EA was also correlated with a lower risk of overall complications (risk ratio:0.71, P =0.04, n =1011), shorter hospital length of stay (MD: -1.22 days, P =0.0001, n =988), and a lower pain score on postoperative days two (standardized MD: -0.87, P =0.009, n =665) and three (standardized MD: -0.45, P <0.00001, n =795), without a difference in time to first ambulation.

CONCLUSION

Our findings showed an association between EA and enhanced gastrointestinal functional recovery and reduced pain severity following colorectal surgery, highlighting the potential benefits of incorporating EA into perioperative care to enhance recovery outcomes in this setting.

Deep neuromuscular blockade in adults undergoing an abdominal laparoscopic procedure

BACKGROUND

Laparoscopic surgery is the preferred option for many procedures. To properly perform laparoscopic surgery, it is essential that sudden movements and abdominal contractions in patients are prevented, as it limits the surgeon's view. There has been a growing interest in the potential beneficial effect of deep neuromuscular blockade (NMB) in laparoscopic surgery. Deep NMB improves the surgical field by preventing abdominal contractions, and it is thought to decrease postoperative pain. However, it is uncertain if deep NMB improves intraoperative safety and thereby improves clinical outcomes.

OBJECTIVES

To evaluate the benefits and harms of deep neuromuscular blockade versus no, shallow, or moderate neuromuscular blockade during laparoscopic intra- or transperitoneal procedures in adults.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 31 July 2023.

SELECTION CRITERIA

We included randomised clinical trials (irrespective of language, blinding, or publication status) in adults undergoing laparoscopic intra- or transperitoneal procedures comparing deep NMB to moderate, shallow, or no NMB. We excluded trials that did not report any of the primary or secondary outcomes of our review.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. all-cause mortality, 2. health-related quality of life, and 3. proportion of participants with serious adverse events. Our secondary outcomes were 4. proportion of participants with non-serious adverse events, 5. readmissions within three months, 6. short-term pain scores, 7. measurements of postoperative recovery, and 8. operating time. We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

We included 42 randomised clinical trials with 3898 participants. Most trials included participants undergoing intraperitoneal oncological resection surgery. We present the Peto fixed-effect model for most dichotomous outcomes as only sparse events were reported. Comparison 1: deep versus moderate NMB Thirty-eight trials compared deep versus moderate NMB. Deep NMB may have no effect on mortality, but the evidence is very uncertain (Peto odds ratio (OR) 7.22, 95% confidence interval (CI) 0.45 to 115.43; 12 trials, 1390 participants; very low-certainty evidence). Deep NMB likely results in little to no difference in health-related quality of life up to four days postoperative (mean difference (MD) 4.53 favouring deep NMB on the Quality of Recovery-40 score, 95% CI 0.96 to 8.09; 5 trials, 440 participants; moderate-certainty evidence; mean difference lower than the mean clinically important difference of 10 points). The evidence is very uncertain about the effect of deep NMB on intraoperatively serious adverse events (deep NMB 38/1150 versus moderate NMB 38/1076; Peto OR 0.95, 95% CI 0.59 to 1.52; 21 trials, 2231 participants; very low-certainty evidence), short-term serious adverse events (up to 60 days) (deep NMB 37/912 versus moderate NMB 42/852; Peto OR 0.90, 95% CI 0.56 to 1.42; 16 trials, 1764 participants; very low-certainty evidence), and short-term non-serious adverse events (Peto OR 0.94, 95% CI 0.65 to 1.35; 11 trials, 1232 participants; very low-certainty evidence). Deep NMB likely does not alter the duration of surgery (MD -0.51 minutes, 95% CI -3.35 to 2.32; 34 trials, 3143 participants; moderate-certainty evidence). The evidence is uncertain if deep NMB alters the length of hospital stay (MD -0.22 days, 95% CI -0.49 to 0.06; 19 trials, 2084 participants; low-certainty evidence) or pain scores one hour after surgery (MD -0.31 points on the numeric rating scale, 95% CI -0.59 to -0.03; 22 trials, 1823 participants; very low-certainty evidence; mean clinically important difference 1 point) and 24 hours after surgery (MD -0.60 points on the numeric rating scale, 95% CI -1.05 to -0.15; 16 trials, 1404 participants; very low-certainty evidence; mean clinically important difference 1 point). Comparison 2: deep versus shallow NMB Three trials compared deep versus shallow NMB. The trials did not report on mortality and health-related quality of life. The evidence is very uncertain about the effect of deep NMB compared to shallow NMB on the proportion of serious adverse events (RR 1.66, 95% CI 0.50 to 5.57; 2 trials, 158 participants; very low-certainty evidence). Comparison 3: deep versus no NMB One trial compared deep versus no NMB. There was no mortality in this trial, and health-related quality of life was not reported. The proportion of serious adverse events was 0/25 in the deep NMB group and 1/25 in the no NMB group.

AUTHORS' CONCLUSIONS

There was insufficient evidence to draw conclusions about the effects of deep NMB compared to moderate NMB on all-cause mortality and serious adverse events. Deep NMB likely results in little to no difference in health-related quality of life and duration of surgery compared to moderate NMB, and it may have no effect on the length of hospital stay. Due to the very low-certainty evidence, we do not know what the effect is of deep NMB on non-serious adverse events, pain scores, or readmission rates. Randomised clinical trials with adequate reporting of all adverse events would reduce the current uncertainties. Due to the low number of identified trials and the very low certainty of evidence, we do not know what the effect of deep NMB on serious adverse events is compared to shallow NMB and no NMB. We found no trials evaluating mortality and health-related quality of life.

Acute Care Surgery: Navigating Recent Developments, Protocols, and Challenges in the Comprehensive Management of Surgical Emergencies

Acute care surgery (ACS) is a crucial medical field that specifically deals with the rapid treatment of surgical emergencies. This investigation encompasses the most recent progress, procedures, and obstacles in ACS, utilizing various sources such as scholarly articles, clinical trials, and expert statements. The development of ACS as a specialized field is a significant area of concentration, particularly emphasizing its contribution to improving patient care. An examination is conducted on the efficacy of contemporary triage systems and prompt response mechanisms, specifically in diminishing the incidence of illness and death rates associated with illnesses such as trauma, acute appendicitis, and obstructed viscera. The emphasis is placed on the surgical protocols and principles that form the basis of ACS. Examining regional and international approaches provides insight into the distinctions and commonalities in surgical techniques. An assessment is conducted to determine the effects of the transition to minimally invasive procedures on patient outcomes, recuperation periods, and healthcare expenses. The assessment also examines the logistical obstacles that ACS encounters, such as resource allocation and managing diverse teams. The examination focuses on the delicate equilibrium between prompt decision-making and care grounded in evidence. It also evaluates the possible contribution of technical breakthroughs such as telemedicine and AI to improving patient care and overcoming current obstacles. The topic of training and education for surgeons in ACS is of utmost importance and requires careful consideration. The evaluation evaluates the sufficiency of existing educational frameworks and the necessity of specific training to equip surgeons for the requirements of ACS. This analysis explores the current discourse surrounding the standardization of ACS training, considering its potential ramifications for the future of surgical procedures. Exploring ethical and legal problems in ACS also includes situations when prompt decision-making may clash with patient autonomy and informed consent. The significance of proficient communication with patients and their families during emergency surgical scenarios is underscored, emphasizing the necessity for ethical awareness and interpersonal aptitude. The investigation of ACS demonstrates its dynamic character, signifying notable advancements while recognizing enduring obstacles. Continual research, interdisciplinary collaboration, and policy adjustments are necessary to improve ACS procedures. This thorough investigation offers valuable insights for professionals and researchers, facilitating future progress in managing surgical crises.

Safety and efficacy of laparoscopic transperitoneal versus retroperitoneal resection for benign retroperitoneal tumors: a retrospective cohort study

BACKGROUND AND OBJECTIVE

Benign retroperitoneal tumors (BRTs) are clinically rare solid tumors. This study aimed to compare the safety and efficacy of laparoscopic transperitoneal versus retroperitoneal resection for BRTs.

METHODS

The clinical data of 43 patients who had pathologically confirmed BRTs and underwent laparoscopic resection in a single center from January 2019 to May 2022 were retrospectively analyzed. Patients were divided into two groups according to the surgical methods: the Transperitoneal approach group (n = 24) and the Retroperitoneal approach group (n = 19). The clinical characteristics and perioperative data between the two groups were compared. The baseline data and surgical variables were analyzed to determine the impact of different surgical approaches on the treatment outcomes of BRTs.

RESULTS

No significant difference was observed between the two groups in gender, age, body mass index, the American Society of Anesthesiologists score, presence of underlying diseases, tumor size, tumor position, operation duration, intraoperative hemorrhage, postoperative hospital stay, intestinal function recovery time, and postoperative complication rate. The conversion rate from laparoscopic to open surgery was significantly lower in the Transperitoneal approach group than in the Retroperitoneal approach group (1/24 vs. 5/19, χ2 = 4.333, P = 0.037). Tumor size was an independent influencing factor for the effect of surgery (odds ratio = 1.869, 95% confidence interval = 1.135-3.078, P = 0.014) and had a larger efficacy on the retroperitoneal group (odds ratio = 3.740, 95% confidence interval = 1.044-13.394, P = 0.043).

CONCLUSION

The laparoscopic transperitoneal approach has the inherent advantages of anatomical hierarchies and surgical space, providing a better optical perspective of the targeted mass and improved bleeding control. This approach may have better efficacy than the retroperitoneal approach, especially in cases of a large tumor or when the tumor is located near important blood vessels.

Safe implementation of a minimally invasive hepatopancreatobiliary program, a narrative review and institutional experience

Laparoscopic and robotic-assisted approaches to hepatopancreatobiliary (HPB) operations have expanded worldwide. As surgeons and medical centers contemplate initiating and expanding minimally invasive surgical (MIS) programs for complex HPB surgical operations, there are many factors to consider. This review highlights the key components of developing an MIS HPB program and shares our recent institutional experience with the adoption and expansion of an MIS approach to pancreaticoduodenectomy.

Effect of driving pressure-guided positive end-expiratory pressure on postoperative pulmonary complications in patients undergoing laparoscopic or robotic surgery: a randomised controlled trial

BACKGROUND

Individualised positive end-expiratory pressure (PEEP) improves respiratory mechanics. However, whether PEEP reduces postoperative pulmonary complications (PPCs) remains unclear. We investigated whether driving pressure-guided PEEP reduces PPCs after laparoscopic/robotic abdominal surgery.

METHODS

This single-centre, randomised controlled trial enrolled patients at risk for PPCs undergoing laparoscopic or robotic lower abdominal surgery. The individualised group received driving pressure-guided PEEP, whereas the comparator group received 5 cm H2O fixed PEEP during surgery. Both groups received a tidal volume of 8 ml kg-1 ideal body weight. The primary outcome analysed per protocol was a composite of pulmonary complications (defined by pre-specified clinical and radiological criteria) within 7 postoperative days after surgery.

RESULTS

Some 384 patients (median age: 67 yr [inter-quartile range: 61-73]; 66 [18%] female) were randomised. Mean (standard deviation) PEEP in patients randomised to individualised PEEP (n=178) was 13.6 cm H2O (2.1). Individualised PEEP resulted in lower mean driving pressures (14.7 cm H2O [2.6]), compared with 185 patients randomised to standard PEEP (18.4 cm H2O [3.2]; mean difference: -3.7 cm H2O [95% confidence interval (CI): -4.3 to -3.1 cm H2O]; P<0.001). There was no difference in the incidence of pulmonary complications between individualised (25/178 [14.0%]) vs standard PEEP (36/185 [19.5%]; risk ratio [95% CI], 0.72 [0.45-1.15]; P=0.215). Pulmonary complications as a result of desaturation were less frequent in patients randomised to individualised PEEP (8/178 [4.5%], compared with standard PEEP (30/185 [16.2%], risk ratio [95% CI], 0.28 [0.13-0.59]; P=0.001).

CONCLUSIONS

Driving pressure-guided PEEP did not decrease the incidence of pulmonary complications within 7 days of laparoscopic or robotic lower abdominal surgery, although uncertainty remains given the lower than anticipated event rate for the primary outcome.

CLINICAL TRIAL REGISTRATION

KCT0004888 (http://cris.nih.go.kr, registration date: April 6, 2020).

Telestration with augmented reality improves the performance of the first ten ex vivo porcine laparoscopic cholecystectomies: a randomized controlled study

INTRODUCTION

The learning curve in minimally invasive surgery (MIS) is steep compared to open surgery. One of the reasons is that training in the operating room in MIS is mainly limited to verbal instructions. The iSurgeon telestration device with augmented reality (AR) enables visual instructions, guidance, and feedback during MIS. This study aims to compare the effects of the iSurgeon on the training of novices performing repeated laparoscopic cholecystectomy (LC) on a porcine liver compared to traditional verbal instruction methods.

METHODS

Forty medical students were randomized into the iSurgeon and the control group. The iSurgeon group performed 10 LCs receiving interactive visual guidance. The control group performed 10 LCs receiving conventional verbal guidance. The performance assessment using Objective Structured Assessments of Technical Skills (OSATS) and Global Operative Assessment of Laparoscopic Skills (GOALS) scores, the total operating time, and complications were compared between the two groups.

RESULTS

The iSurgeon group performed LCs significantly better (global GOALS 17.3 ± 2.6 vs. 16 ± 2.6, p ≤ 0.001, LC specific GOALS 7 ± 2 vs. 5.9 ± 2.1, p ≤ 0.001, global OSATS 25.3 ± 4.3 vs. 23.5 ± 3.9, p ≤ 0.001, LC specific OSATS scores 50.8 ± 11.1 vs. 41.2 ± 9.4, p ≤ 0.001) compared to the control group. The iSurgeon group had significantly fewer intraoperative complications in total (2.7 ± 2.0 vs. 3.6 ± 2.0, p ≤ 0.001) than the control group. There was no difference in operating time (79.6 ± 25.7 vs. 84.5 ± 33.2 min, p = 0.087).

CONCLUSION

Visual guidance using the telestration device with AR, iSurgeon, improves performance and lowers the complication rates in LCs in novices compared to conventional verbal expert guidance.

Trend of minimally invasive and open surgery experience of general surgery residents: Accreditation Council for Graduate Medical Education general surgery case log in Thailand

Purpose

Minimally invasive surgery (MIS) offers patients several benefits, such as smaller incisions, and fast recovery times. General surgery residents should be trained in both open and MIS. We aimed to examine the trends of minimally invasive and open procedures performed by general surgery residents in Thailand.

Methods

A retrospective review of the Royal College of Surgeons of Thailand and Accreditation Council for Graduate Medical Education general surgery case logs from 2007 to 2018 was performed for common open and laparoscopic general surgery operations. The data were grouped by three time periods, which were 2007-2010, 2011-2014, and 2015-2018, and analyzed to explore changes in the operative trends.

Results

For Thai residents, the mean number of laparoscopic operations per person per year increased from 5.97 to 9.36 (56.78% increase) and open increased from 20.02 to 27.16 (35.67% increase). There was a significant increase in the average number of minimally invasive procedures performed among cholecystectomy (5.83, 6.57, 8.10; p < 0.001) and inguinal hernia repair (0.33, 0.35, 0.66; p < 0.001). Compared to general surgery residents in the United States, Thai residents had more experience with open appendectomy, but significantly less experience with all other operations/procedures.

Conclusion

The number of open and minimally invasive procedures performed or assisted by Thai general surgery residents has slowly increased, but generally lags behind residents in the United States. The Thai education program must be updated to improve residents' technical skills in open and laparoscopic surgery to remain competitive with their global partners.

Versatile end effector for laparoscopic robotic scrub nurse

PURPOSE

Integrating robotic scrub nurses in the operating room has the potential to help overcome staff shortages and limited use of available operating capacities in hospitals. Existing approaches of robotic scrub nurses are mainly focused on open surgical procedures, neglecting laparoscopic procedures. Laparoscopic interventions offer great potential for the context-sensitive integration of robotic systems due to possible standardization. However, the first step is to ensure the safe manipulation of laparoscopic instruments.

METHODS

A robotic platform with a universal gripper system was designed to pick up and place laparoscopic as well as da Vinci[Formula: see text] instruments in an efficient workflow. The robustness of the gripper system was studied using a test protocol, which included a force absorption test to determine the operational safety limits of the design and a grip test to determine the system performance.

RESULTS

The test protocol shows results regarding force and torque absorption capabilities of the end effector, which are essential when transferring an instrument to the surgeon to enable a robust handover. The grip tests show that the laparoscopic instruments can be safely picked up, manipulated and returned independent of unexpected positional deviations. The gripper system also enables the manipulation of da Vinci[Formula: see text] instruments, opening the door for robot-robot interaction.

CONCLUSION

Our evaluation tests have shown that our robotic scrub nurse with the universal gripper system can safely and robustly manipulate laparoscopic and da Vinci[Formula: see text] instruments. The system design will continue with the integration of context-sensitive capabilities.

Impact of body mass index on perioperative outcomes of laparoscopic major hepatectomies

BACKGROUND

Data on the effect of body mass index on laparoscopic liver resections are conflicting. We performed this study to investigate the association between body mass index and postoperative outcomes after laparoscopic major hepatectomies.

METHODS

This is a retrospective review of 4,348 laparoscopic major hepatectomies at 58 centers between 2005 and 2021, of which 3,383 met the study inclusion criteria. Concomitant major operations, vascular resections, and previous liver resections were excluded. Associations between body mass index and perioperative outcomes were analyzed using restricted cubic splines. Modeled effect sizes were visually rendered and summarized.

RESULTS

A total of 1,810 patients (53.5%) had normal weight, whereas 1,057 (31.2%) were overweight and 392 (11.6%) were obese. One hundred and twenty-four patients (3.6%) were underweight. Most perioperative outcomes showed a linear worsening trend with increasing body mass index. There was a statistically significant increase in open conversion rate (16.3%, 10.8%, 9.2%, and 5.6%, P < .001), longer operation time (320 vs 305 vs 300 and 266 minutes, P < .001), increasing blood loss (300 vs 300 vs 295 vs 250 mL, P = .022), and higher postoperative morbidity (33.4% vs 26.3% vs 25.0% vs 25.0%, P = .009) in obese, overweight, normal weight, and underweight patients, respectively (P < .001). However, postoperative major morbidity demonstrated a "U"-shaped association with body mass index, whereby the highest major morbidity rates were observed in underweight and obese patients.

CONCLUSION

Laparoscopic major hepatectomy was associated with poorer outcomes with increasing body mass index for most perioperative outcome measures.

Effects of wide-angle laparoscopy on surgical workflow in laparoscopic cholecystectomies

INTRODUCTION

Laparoscopy is now the gold standard approach to many surgical procedures thanks to its many advantages. Minimizing distractions is essential to a safe and successful surgery and an undisrupted surgical workflow. The SurroundScope, a wide angle (270°) laparoscopic camera system has the potential to decrease surgical distractions and increase workflow.

METHODS

Forty-two laparoscopic cholecystectomies were performed by a single surgeon, 21 with the SurroundScope and 21 with standard angle laparoscope. Video recordings of surgeries were reviewed for calculating the number of entries of surgical tools into the field of view, relative time of tools and ports viewed in surgical field and number of times camera was removed due to fog or smoke.

RESULTS

The usage of the SurroundScope resulted in a significantly lower number of entries to the field of view compared to the standard scope (58.50 versus 102; P < 0.0001). Usage of SurroundScope resulted in a significantly higher appearance ratio of tools, with a value of 1.87 compared to 1.63 for standard scope (P-value < 0.0001), and the appearance ratio of ports was also significantly higher, measuring 1.84 compared to 0.27 for the standard scope (P-value < 0.0001). In addition, the SurroundScope had to be removed and reinserted due to smoke or fog in only 2 cases (9.5%), compared to 12 cases (57.1%) in the standard scope group (P-value < 0.01).

CONCLUSIONS

The SurroundScope camera system improves surgical workflow in laparoscopic cholecystectomy. This conceivably increase the safety of the operation due to the utilization of the wide-angle view and "chip on the tip" technology.

Preparing for and passing the fundamentals of laparoscopic surgery (FLS) exam improves general surgery resident operative performance and autonomy

BACKGROUND

The American Board of Surgery made the Fundamentals of Laparoscopic Surgery (FLS) exam a prerequisite for board certification in 2009. Some residency programs have questioned the need for a continued FLS testing mandate given limited evidence that supports the impact of FLS on intraoperative skills. The Society for Improving Medical Professional Learning (SIMPL) app is a tool to evaluate resident intraoperative performance. We hypothesized that general surgery resident operative performance would improve immediately after preparing for the FLS exam.

METHODS

The national public FLS data registry was matched with SIMPL resident evaluations from 2015 to 2021 and de-identified. SIMPL evaluations are scored in three categories: supervision required (Zwisch scale 1-4, 1 = show and tell and 4 = supervision only), performance (scale 1-5, 1 = exceptional and 5 = unprepared), and case complexity (scale 1-3, 1 = easiest and 3 = hardest). Statistical analyses compared pre and post-FLS exam resident average operative evaluation scores.

RESULTS

There were a total of 76 general surgery residents, and 573 resident SIMPL evaluations included in this study. Residents required more supervision in laparoscopic cases performed before compared to after the FLS exam (2.84 vs. 3.03, respectively, p = 0.007). Residents performance scores improved from cases before compared to after the FLS exam (2.70 vs. 2.43, respectively, p = 0.001). Case complexity did not differ before versus after the FLS exam (2.13 vs. 2.18, respectively, p = 0.202). PGY level significantly predicted evaluation scores with a moderate correlation. A sub analysis grouped by PGY level revealed a significant improvement after the FLS exam in supervision among PGY-2 residents (2.33 vs. 2.58, respectively, p = 0.04) and performance among PGY-4 residents (2.67 vs 2.04, respectively, p < 0.001).

CONCLUSIONS

Preparation for, and passing, the FLS exam improves resident intraoperative laparoscopic performance and independence. We recommend taking the exam in the first two years of residency to enhance the laparoscopic experience for the remainder of training.