The learning curve for modified hand-assisted retroperitoneoscopic living donor nephrectomy.

BACKGROUND: We aimed to introduce our modified hand-assisted retroperitoneoscopic living donor nephrectomy (HARPLDN) technique and define the learning curve. METHODS: One hundred thirty-eight kidney donors who underwent modified HARPLDN by the same surgeon between May 2015 and March 2022 were included. A cumulative sum (CUSUM) learning curve analysis was performed with the total operation time as the study outcome. RESULTS: In total, the mean operative time was 138.2 ± 32.1 min. The median warm ischemic time (WIT) and estimated blood loss were 90 s and 50 ml, respectively. The learning curve for the total operative time was best modeled as a second-order polynomial with the following equation: CUSUMOT (min) = (-0.09 case number2) + (12.88 case number) - 67.77 (R2 = 0.7875; p<0.05). The CUSUM learning curve included the following three unique phases: phase 1 (the initial 41 cases), representing the initial learning curve; phase 2 (the middle 43 cases), representing expert competence; and phase 3 (the final 54 cases), representing mastery. The overall 6-month graft survival rate was 99.3%, with 94.9% immediate onset of graft function without delayed graft function and 0.7% ureteral complications. CONCLUSIONS: Our modified method is safe and effective for living donor nephrectomy and has the advantages of a shorter operating time and optimized WIT. The surgeon can become familiar with the modified HARPLDN after 41 cases and effectively perform the next 97 cases.

Relationship between surgical difficulty and postoperative complications of hand-assisted laparoscopic living donor nephrectomy and establishment of prediction model.

BACKGROUND: Few studies have systematically explored the factors influencing the difficulty of hand-assisted laparoscopic living donor nephrectomy. To investigate the relationship between the difficulty of hand-assisted laparoscopic living donor nephrectomy and postoperative complications of the donor as well as the recipient, and then build a model for predicting the difficulty of surgery. METHODS: In this study, 60 patients who underwent hand-assisted laparoscopic living donor nephrectomy by the same surgeon from September 2022 to March 2024 were included as the modeling group. 20 patients operated on by another surgeon served as the external validation group. The subjective score (1-3 points) of surgical difficulty was used as the quantitative index of surgical difficulty. Pearson and Spearman correlation tests were used to explore the correlation between preoperative data and surgical difficulty scores of kidney donors, and finally built a prediction model through multiple linear regression analysis. RESULTS: With the increase in the difficulty of operation, both donors and recipients' complications were increased. Linear regression analysis showed that only the number of renal arteries, visceral fat thickness and MAP score were independent risk factors for the difficulty of hand-assisted laparoscopic living donor nephrectomy. The prediction equation is as follows: Difficulty score = 0.584*Number of renal arteries + 0.731*MAP score + 0.110*visceral fat thickness. CONCLUSIONS: Donors with higher surgical difficulty are more likely to have serious complications after surgery as well as the recipient. We also established a reliable prediction model for the difficulty of hand-assisted laparoscopic donor nephrectomy.

Usefulness of hand-assisted retroperitoneal laparoscopic radical nephrectomy for extreme obese patients -a case report.

We report a case of retroperitoneal laparoscopic radical nephrectomy (LRN) in which the addition of a hand port was necessary and effective. A 52-year-old man with obesity (BMI 40.6 kg/m2) was diagnosed with a 52-mm left renal cell carcinoma (cT1bN0M0). To avoid thick subcutaneous and visceral fat in the abdomen, we selected LRN using a retroperitoneal approach with four ports in the kidney position. During surgery, a large amount of flank pad and perirenal fat prevented us from securing a sufficient surgical field through traction of the kidney with a retractor. A pure laparoscopic procedure was not feasible;therefore, we added a hand port. Subsequently, we removed the flank pad from the hand port and secured the surgical field by tracing the kidney manually. Finally, hand-assisted LRN was completed without an open conversion. In retroperitoneal LRN, we rarely encounter patients for whom a pure laparoscopic procedure is not feasible because of the large amount of flank pad or perirenal fat. It is important to preoperatively confirm not only the BMI but also the amount of flank pad and perirenal fat on imaging. Hand-assisted LRN via the retroperitoneal approach can be safely performed even in extremely obese patients. J. Med. Invest. 71 : 187-190, February, 2024.

Robotic living donor nephrectomy is associated with reduced post-operative opioid use compared to hand-assisted laparoscopic approach.

BACKGROUND: Robotic donor nephrectomy (RDN) has emerged as a safe alternative to laparoscopic donor nephrectomy (LDN). Having previously demonstrated comparable efficacy, this study aims to examine postoperative analgesia use (opioid and non-opioid) in the two groups. METHODS: We conducted a retrospective review of 300 living donor nephrectomies performed at our center, comparing 150 RDN's with a contemporary cohort of 150 hand-assisted LDN's. In addition to clinical and demographic information, data on postoperative inpatient opioid and non-opioid analgesia (from patient's arrival to the surgical floor after surgery till the time of discharge) was collected. Opioid dosages were standardized by conversion to morphine milligram equivalents (MME). All patients were managed post-operatively under a standardized ERAS pathway for living donor nephrectomy patients. RESULTS: There were no significant differences in donor age, gender, and BMI between RDN and LDN groups. Total post-operative opioid use (MME's) was significantly lower in RDN patients (RDN 27.1 vs. LDN 46.3; P < 0.0001). Breakdown of opioid use with post-operative (POD) day demonstrated significantly lower use in RDN group on POD1 (RDN 8.6 vs. LDN 17.0; P < 0.05), and POD2 (RDN 3.9 vs LDN 10; P < 0.05). RDN patients had a shorter post-operative length of stay (LOS) (RDN 1.69 days vs. LDN 1.98; P = 0.0003). There were no differences between groups in non-opioid medication use, complications, and readmission rates. CONCLUSION: RDN has comparable safety to hand-assist LDN and offers additional benefits of lower postoperative opioid requirement and a shorter hospital LOS.

Hand-assisted laparoscopic donor nephrectomy: 1864 cases in 15 years of experience.

BACKGROUND: To evaluate hand-assisted laparoscopic donor nephrectomy (HALDN) in terms of intraoperative and postoperative results. METHODS: After institutional review board approval was obtained, a total of 1864 HALDN operations performed between March 2007 and January 2022 were retrospectively analyzed. Age, sex, body mass index (BMI), status of smoking and presence of previous abdominal surgery, laterality, operative time, transfusion requirement, port counts, length of extraction incision, time until mobilization, time until oral intake, donor serum creatinine levels before and one week after the surgery, length of postoperative hospital stay, intraoperative complications, and postoperative recovery and complications were recorded and statistically analyzed. Multiple renal arteries, BMI, right nephrectomy and male sex were also separately evaluated as risk factors for complications and operative time. RESULTS: A total of 825 (44.26%) male and 1039 (55.74%) female patients were enrolled in the study. The mean age of the patients was 45.79 ± 12.88 years. There were a total of 143 complications (7.67% of the total 1864 cases) consisting of 68 (3.65%) intraoperative and 75 (4.02%) postoperative complications. Open conversion was necessary for 10 patients (0.53%) to manage intraoperative complications. Reoperation was needed for 1 patient due to bleeding 6 h after the operation. Multiple renal arteries were a risk factor for intraoperative complications and prolonged operative time. Right nephrectomy and male sex were also related with longer operative times. DISCUSSION: HALDN is a safe procedure associated with low complication rates.

Midline Rotation of the Right Renal Hilum During Hand-Assisted Laparoscopic Living Donor Nephrectomy.

BACKGROUND/OBJECTIVES: Laparoscopic living donor nephrectomy (LLDN) of the right kidney is currently considered as part of standard of care; however, dealing with the renal hilum when performing ligation/division of its renal vessels is still a main concern. Here, we describe a simple-to-perform technique, i.e., flipping the fully mobilized right kidney to the midline so that the renal artery becomes anteriorly, which offers better visualization and easier dissection of the renal vessels (achieving maximized lengths) when performing hand-assisted LLDN of the right kidney. METHODS: Living donors who underwent hand-assisted LLDN of the right kidney, along with their respective renal transplant recipients, were included in this report. Donor characteristics included renal artery and vein lengths; recipient characteristics included creatinine at months 12 - 36. Graft vein and arterial anastomosis data were also reported. RESULTS: Nineteen living donors and 19 recipients, with median donor and recipient ages being 39 (24 - 60) and 53 (3 - 81) years, respectively, were included. None of the 38 patients had intra- or postoperative complications. Donor renal vein was anastomosed to the right external iliac vein (n = 16), right common iliac vein (n = 2), and inferior vena cava (n = 1). Gonadal vein (n = 1) and deceased donor iliac vein (n = 2) were used to increase the right renal vein length in 3 cases. Four donor kidneys had 2 arteries reconstructed side by side. None of the recipients developed any vascular or urological complications. CONCLUSIONS: The laparoscopic technique described is safe and allows better visualization of the right hilum, mainly the renal artery, and helps in stapling the renal vein and renal artery.

Short- and long-term outcomes of 486 consecutive laparoscopic splenectomy in a single institution.

ABSTRACT: Since its introduction in 1991, laparoscopic splenectomy (LS) has become the gold standard in elective spleen surgery in many centres. However, there still lack the report of long-term outcomes of LS with the large-scale cases. The aim of the present study was to analyze the short- and long-term outcomes of LS in a single institution over 16 years, and to compare the perioperative outcomes of totally laparoscopic splenectomy (TLS) and hand-assisted laparoscopic splenectomy (HALS) for splenomegaly.Between November 2002 and December 2018, 486 consecutive patients undergoing elective LS were enrolled in this study, including 222 TLS and 264 HALS. The intraoperative, postoperative, and follow-up data were retrospectively analyzed.The 5 most common indications were hypersplenism (71.0%), immune thrombocytopenia (14.8%), splenic benign tumor (4.5%), splenic cyst (2.9%), and splenic malignant tumor (2.9%). The mean operative time, intraoperative blood loss, and length of stay were 149.4 ±â€Š63.3 minutes, 230.1 ±â€Š225.1 mL, and 6.7 ±â€Š3.2 days, respectively. The morbidity, mortality, reoperation, and conversion rate were 23.0%, 0, 0.4%, and 1.9%, respectively. Portal vein system thrombosis (PVST) was the most frequent complication with an incidence of 19.8%. The incidence of PVST in HALS was higher than that in TLS (23.9% vs 14.9%, P = .013). Compared with TLS, HALS had a shorter operative time (P = .000), lower intraoperative blood loss (P = .000), comparable conversion rate (P = .271), and morbidity (P = .922) for splenomegaly > 17.0 cm. During the follow-up period, the overall respond rate for immune thrombocytopenia was 77.8%, and the esophagogastric variceal bleeding rate was 6.9% in 320 patients with hypersplenism secondary to hepatic cirrhosis.LS is a safe, feasible, and effective procedure with satisfactory short- and long-term outcomes. HALS is a reasonable technique in patients with massive spleens.

Learning curves of minimally invasive donor nephrectomy in a high-volume center: A cohort study of 1895 consecutive living donors.

BACKGROUND: Few studies have investigated the learning curves of minimally invasive donor nephrectomy (MIDN) using the cumulative sum (CUSUM) analysis. In addition, no study has compared the learning curves of the different surgical MIDN techniques in one cohort study using the CUSUM analysis. This study aims to evaluate and compare learning curves for several MIDN using the CUSUM analysis. METHODS: A retrospective review of consecutive donors, who underwent MIDN between 1997 and 2019, was conducted. Three laparoscopic-assisted techniques were applied in our institution and included for analysis: laparoscopic (LDN), hand-assisted retroperitoneoscopic (HARP), and robot-assisted laparoscopic (RADN) donor nephrectomy. The outcomes were compared based on surgeon volume to develop learning curves for the operative time per surgeon. RESULTS: Out of 1895 MIDN, 1365 (72.0%) were LDN, 427 (22.5%) were HARP, and 103 (5.4%) were RADN. The median operative time and median blood loss were 179 (IQR, 139-230) minutes and 100 (IQR, 40-200) mL, respectively. The incidence of major complication was 1.2% with no mortality, and the median hospital stay was three (IQR, 3-4) days. The CUSUM analysis resulted in learning curves, defined by decreased operative time, of 23 cases in LDN, 45 cases in HARP, and 26 cases in RADN. CONCLUSIONS: Our study shows different learning curves in three MIDN techniques with equal post-operative complications. The LDN and RADN learning curves are shorter than that of the hand-assisted donor nephrectomy. Our observations can be helpful for informing the development of teaching requirements for fellows to be trained in MIDN.

Hand-Assisted Retroperitoneoscopic Donor Nephrectomy Compared to Anterior Approach Open Donor Nephrectomy: Improved Long-Term Physical Component Score in Health-Related Quality of Life in Living Kidney Donors.

BACKGROUND: Health-related quality of life (HRQL), fatigue, anxiety, and depression are crucial for the living kidney donor (LKD). Follow-up data for HRQL of LKDs comparing surgical techniques, especially regarding hand-assisted retroperitoneoscopic donor nephrectomy (HARP), are sparse. The aim of this study was to evaluate the influence of abdominal wall trauma minimized by HARP in comparison to open anterior approach donor nephrectomy (AA) on HRQL and additional psychosocial aspects of LKDs during the long-term follow-up. MATERIAL AND METHODS: This is a cross-sectional study comparing psychosocial aspects of LKD between HARP and AA. RESULTS: This study included 100 LKDs (68 HARP, 28 AA, and 4 were excluded secondary to incomplete data). The time to follow-up was 22.6 ± 11.7 (HARP) vs 58.7 ± 13.9 (AA) months (P < .005). Complications ≥3a° due to Clavien-Dindo classification was 0% in both groups. There were higher scores in all physical aspects for HARP donors vs AA donors at that time (physical function: 89.8 ± 14.6 vs 80.0 ± 19.9, P = .008, and the physical component score: 53.9 ± 7.6 vs 48.6 ± 8.5, P = .006). One year later (follow-up time + 12 months), HRQL for HARP donors was still higher. Mental items showed no significant differences. HARP donors showed better physical scores compared to the age-matched nondonor population (AA donors had lower scores). Neither the Multidimensional Fatigue Inventory-20 (MFI-20) or the Hospital Anxiety and Depression Scale (HADS) showed any differences between the 2 groups. Fatigue scores were higher for HARP and for AA compared to the age-matched population. CONCLUSIONS: LKDs undergoing HARP showed better physical performance as part of HRQL in the long-term follow-up.

A propensity-matched study of full laparoscopic versus hand-assisted minimal-invasive liver surgery.

BACKGROUND AND AIM: The implications of multi-incision (MILS) and hand-assisted (HALS) laparoscopic techniques for minimally invasive liver surgery with regard to perioperative outcomes are not well defined. The purpose of this study was to compare MILS and HALS using propensity score matching. METHODS: 309 patients underwent laparoscopic liver resections (LLR) between January 2013 and June 2018. Perioperative outcomes were analyzed after a 1:1 propensity score match. Subgroup analyses of matched groups, i.e., radical lymphadenectomy (LAD) as well as resections of posterosuperior segments (VII and/or VIII), were performed. RESULTS: MILS was used in 187 (65.2%) and HALS in 100 (34.8%) cases, with a significant decrease of HALS resections over time (p = 0.001). There were no significant differences with regard to age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) Score, previous abdominal surgery and cirrhosis between both groups. Patients scheduled for HALS were characterized by a significantly higher rate of malignant tumors (p < 0.001) and major resections (p < 0.001). After propensity score matching (PMS), 70 cases remained in each group and all preoperative variables as well as resection extend were well balanced. A significantly higher rate of radical LAD (p = 0.039) and posterosuperior resections was found in the HALS group (p = 0.021). No significant differences between the matched groups were observed regarding operation time, conversion rate, frequency of major complications, length of intensive care unit (ICU) stay, overall hospital stay and R1 rate. CONCLUSION: Our analysis suggests MILS and HALS to be equivalent regarding postoperative outcomes. HALS might be particularly helpful to accomplish complex surgical procedures during earlier stages of the learning curve.

Simultaneous Hand-assisted Laparoscopic Bilateral Native Nephrectomy and Kidney Transplantation for Patients With Large Polycystic Kidneys.

OBJECTIVE: To describe our technique of simultaneous hand-assisted laparoscopic bilateral native nephrectomy (BNN) and kidney transplantation (KT) in patients with autosomal dominant polycystic kidney disease and present our experience. MATERIALS AND METHODS: We retrospectively reviewed a cohort of adult ESRD patients with symptomatic autosomal dominant polycystic kidney disease who underwent a hand-assisted laparoscopic BNN at the time of KT. We reviewed patients' and donor characteristics, and perioperative and postoperative outcomes. RESULTS: A total of 52 patients underwent hand-assisted laparoscopic BNN at the time of KT from January 2014 to October 2019. The median age of the recipients was 53.4 years, 57.7% were males, and the median body mass index was 29.0 kg/m2. All but one received a kidney from a living donor and the majority (86.5%) were pre-emptive. One patient required a small bowel resection due to an intraoperative small bowel injury. There was no solid organ injury during the procedure. All patients showed immediate allograft function and a steady decline in serum creatinine. The median decline in the creatinine and hemoglobin on day 1 was 1.2 mg/dL (inter quartile range 0.6-2.3) and 2.2 g/dL (inter quartile range 1.4-3.0), respectively. CONCLUSION: Simultaneous hand-assisted laparoscopic bilateral nephrectomy with KT through a modified Gibson incision is feasible and safe in the hands of an experienced laparoscopic surgeon without compromising allograft function.

Hand-Assisted Laparoscopic vs Hand-Assisted Retroperitoneoscopic Living-Donor Nephrectomy: A Retrospective, Single-Center, Propensity-Score Analysis of 840 Transplants Using 2 Techniques.

INTRODUCTION: Living-donor kidney transplantation (LDKT) is the most realistic option for patients with end-stage kidney disease because of a severe shortage of deceased donors. Hand-assisted laparoscopic donor nephrectomy (HALDN) and hand-assisted retroperitoneoscopic donor nephrectomy (HARDN) have been undertaken at our institute. We compared these 2 surgical procedures with respect to donor outcome and the graft function of recipients. METHODS: We reviewed data from 840 consecutive live-donor kidney transplants from October 2003 to April 2019. Propensity scores were calculated for each patient using bivariate logistic regression. RESULTS: After propensity-score matching, the 2 groups each contained 205 patients. Donors in the HALDN group had a longer procedure time (217 minutes, P < .0001), less estimated blood loss (51 mL, P < .0001), lower serum levels of C-reactive protein at postoperative day (POD) 1 (7.9 mg/dL, P < .0001) than those in the HARDN group. There were 22 modified Clavien-classifiable complications among the study groups. A significantly higher conversion to open surgery was noted in the HARDN group (P = .0181) than in the HALDN group, but there was no significant difference in the prevalence of complications in either group. There was no significant difference in the estimated glomerular filtration rate of recipients at POD14 between the 2 groups. CONCLUSIONS: Safety and early graft function of HALDN in LDKT are comparable to or even better than that of HARDN.

A meta-analysis comparing hand-assisted laparoscopic right hemicolectomy and open right hemicolectomy for right-sided colon cancer.

BACKGROUND: Mini-invasive colorectal cancer surgery was adopted widely in recent years. This meta-analysis aimed to compare hand-assisted laparoscopic surgery (HALS) with open right hemicolectomy (OS) for malignant disease. METHODS: PRISMA guidelines with random effects model were adopted using Review Manager Version 5.3 for pooled estimates. RESULTS: Seven studies that involved 506 patients were included. Compared to OS, HALS improved results in terms of blood loss (MD = 53.67, 95% CI 10.67 to 96.67, p = 0.01), time to first flatus (MD = 21.11, 95% CI 14.99 to 27.23, p < 0.00001), postoperative pain score, and overall hospital stay (MD = 3.47, 95% CI 2.12 to 4.82, p < 0.00001). There was no difference as concerns post-operative mortality, morbidity (OR = 1.55, 95% CI 0.89 to 2.7, p = 0.12), wound infection (OR = 1.69, 95% CI 0.60 to 4.76, p = 0.32), operative time (MD = - 16.10, 95% CI [- 36.57 to 4.36], p = 0.12), harvested lymph nodes (MD = 0.59, 95% CI - 0.18 to 1.36, p = 0.13), and recurrence (OR = 0.97, 95% CI 0.30 to 3.15, p = 0.96). CONCLUSIONS: HALS is an efficient alternative to OS in right colectomy which combines the advantages of OS with the mini-invasive surgery.

Outcomes of Minimally Invasive Versus Open Major Hepatic Resection.

Introduction: Minimally invasive major hepatic resection (MIMHR) is increasingly being performed in tertiary centers using either hand-assisted laparoscopic surgery (HALS) or totally laparoscopic surgery (TLS). The outcomes data of MIMHR are scarce, especially in comparison to open major hepatic resection (OMHR). Our aim was to compare 90-day outcomes in major hepatic resections when minimally invasive approaches are attempted. Methods and Procedures: At our institution, minimally invasive liver resection was formally introduced in January 2007, initially using the HALS approach. Since then, the use of TLS approach has increased. We collected data on all patients who underwent major liver resection between January 2007 and December 2017 at our institution. In an intention to treat fashion, we then compared MIMHR to OMHR. Results: From January 2007 to December 2017, 669 patients underwent liver resection. Of these, 203 patients (30%) underwent major hepatic resection and MIMHR and OMHR were performed in 68 (33%) and 135 (67%) patients, respectively. The rate of conversion from minimally invasive to open was 30.9%. Overall, there were no significant differences in 90-day mortality (2.9% versus 1.5%; P = .499) or major complications (14.7% versus 14.8%; P = .985). MIMHR was associated with a shorter average postoperative hospital stay (6.2 days versus 7.9 days; P = .0110) and shorter average ICU stay (0.66 days versus 0.90 days; P = .0299) compared with OMHR. Conclusions: The minimally invasive approach to major liver resection is a safe and reasonable alternative to an open approach when performed by a surgeon experienced with the relevant surgical techniques. MIMHR may be associated with similar outcomes and a shorter postoperative hospital stay with no increase in 90-day postoperative complications to OMHR.

Evolution of Laparoscopic Donor Nephrectomy Techniques and Outcomes: A Single-Center Experience with More than 1000 Cases.

BACKGROUND Laparoscopic donor nephrectomy (LDN) has evolved and has been established as a surgical standard of care for kidney transplantation. MATERIAL AND METHODS This study retrospectively reviews 1132 patients who underwent 4 different laparoscopic living-donor nephrectomies: hand-assisted laparoscopic nephrectomy (HALDN), pure laparoscopic donor nephrectomy (PLDN), laparoendoscopic single-site plus 1-port donor nephrectomy (LESSOP-DN), and mini laparoscopic donor nephrectomy (MLDN). RESULTS The mean estimated blood loss (EBL) for the HALDN group was meaningfully higher than those of LESSOP-DN and MLDN (57.5±52.2 mL versus 21.0±30.0 mL versus 18.2±28.7 mL) (P<0.001). The EBL for PLDN (53.3±35.3 mL) was also significantly higher than those of LESSOP-DN and MLDN (P<0.001). Length of stay (LOS) for HALDN was longer than that for LESSOP-DN (4.2±1.2 day versus 4.0±1.4 days, P=0.002). There was 1 intraoperative open conversion in the HALDN group and 2 HALDN surgeries that required postoperative exploratory laparotomy. LESSOP-DN had 3 (0.8%) postoperative incisional hernias. For recipients, the results revealed no significant differences between all 4 groups in terms of estimated glomerular filtration rate (eGFR) and the 1-year graft failure rate. CONCLUSIONS The LESSOP-DN group was associated with a shorter incision length than those of HALDN and PLDN and shorter LOS than that of HALDN. Recipient results showed no meaningful difference regarding laparoscopic donor nephrectomy technique.

Hand-assisted Laparoscopic Nephrectomy: Evaluation of the Learning Curve.

BACKGROUND: Hand-assisted laparoscopic donor nephrectomy (HALDN) has rapidly become the best alternative to open nephrectomy for living kidney donation. As more centers continue to adopt the laparoscopic technique, the safety of the initial transplants must be ensured while ascending the learning curve (LC). This study looks to determine the safety of HALDN and to describe the results of the LC in our center. METHODS: We conducted a retrospective review of 500 HALDNs performed in our center from July 2003 to July 2017. We analyzed demographic and perioperative characteristics and complications during the first postoperative month. We divided HALDNs into 2 groups: before and after completing the LC (50 nephrectomies). For each group, we assessed operating room time, estimated blood loss, length of stay, and complication and conversion rates. RESULTS: A total of 500 HALDNs were performed in the study period. Of those, 454 were analyzed in the 2 groups. The median operating room time was 2 hours, length of stay was 2 days, and blood loss was 50 cc. The overall rate of complication was 6.8%. There were significant differences between the 2 groups in operating time, blood loss, and length of stay (P < .05). No differences were found in terms of complication (P = .42) and conversion (P = .28) rates. CONCLUSION: There was a significant decrease in operating time, blood loss, and length of stay in patients who underwent laparoscopic donor nephrectomy by an experienced laparoscopist. However, no differences were found in complication and conversion rates, which suggests that improvement in surgical training can be accomplished without altering the donor safety.

Living donor hand-assisted laparoscopic nephrectomy in a healthy individual with situs inversus totalis: no need to turn down the donor.

A 70-year-old healthy male individual offered to undergo a living donor hand-assisted laparoscopic nephrectomy to enable kidney transplantation for a close relative. As required for all living transplant donor candidates, extensive screening was performed to exclude potential contraindications for donation. Tests revealed a situs inversus totalis, meaning a complete transposition of the thoracic and abdominal organs in the sagittal plane. As other contraindications for living kidney donation were absent, the feasibility of this procedure was determined multidisciplinary. A successful donation procedure was performed without surgical complications for the donor and good short-term transplant outcomes. In line with current developments that have resulted in more liberal criteria for potential living kidney donors, major anatomical deviations should not automatically be a contraindication. With multidisciplinary efforts and thorough surgical preparation at a high-volume transplant centre, this procedure is feasible and safe.

Retroileal anastomosis in hand-assisted laparoscopic left colectomy: experience at a single institution.

BACKGROUND: Left hemicolectomy and complicated sigmoid colectomy require an anastomosis between the transverse colon and rectum. Generous mobilization will typically allow the colon to reach to the rectum. However, despite full mobilization of the splenic flexure and extensive work on the mesentery, there are cases in which reach to the pelvis is still an issue. Retroileal routing of the colon is one technique for overcoming such a reach problem and achieving a tension-free anastomosis. Performing retroileal routing using laparoscopic techniques has been reported rarely, and to date, there are no data on this technique when performed in a hand-assisted laparoscopic fashion. This study aimed to describe the feasibility of doing a retroileal routing using a hand-assisted laparoscopic technique. METHODS: This was a retrospective chart review of patients who underwent a colon or rectal resection, either open or laparoscopic, with a pelvic anastomosis, by a single colorectal surgeon at an academic institution between 2008 and 2015 with a focus on the immediate and long-term postoperative complications, estimated blood loss, and operating room time for patients having an operation that included retroileal routing for construction of a colorectal anastomosis. RESULTS: A total of 340 patients fit inclusion criteria and of these, 13 underwent hand-assisted laparoscopic procedures with retroileal routing of the proximal colon to the colorectal anastomosis. Postoperative morbidity included intubation for CO2 retention in one patient and a RLL effusion in another patient; there were no anastomotic leaks. Long-term morbidities included two ventral hernias at 2 years postoperatively. Mean operating room time was 208 min. There were no 30- or 90-day mortalities. CONCLUSIONS: Hand-assisted laparoscopic retroileal routing is a feasible and safe technique in accomplishing a tension-free colorectal anastomosis when proximal colon length makes standard routing of the colon to the rectum an issue.

"Peek port": avoiding conversion during laparoscopic colectomy-an update.

PURPOSE: To assess the efficacy of a method to avoid conversion to laparotomy in patients considered for laparoscopic colectomy. Patients considered being at high risk for conversion to formal laparotomy were initially approached via a small midline incision ("peek port") with the laparoscopic equipment readily available but unopened. If intraperitoneal conditions were favorable, the procedure was performed using hand-assisted laparoscopy (HALS); if intraperitoneal conditions were unfavorable, the incision was extended to a formal laparotomy. METHODS: Data from 664 patients from a single surgeon brought to the operating room with the intention of proceeding with laparoscopic colectomy (either via straight laparoscopy or HALS) were retrieved from a prospective database. Comparison of conversion rates between groups was performed using χ2 analysis. RESULTS: The study population consisted of 361 men and 303 women with a mean age of 61 years. Inflammatory conditions accounted for 40% of the diagnoses and enteric fistulas were present in 12%. Of the 79 patients who underwent initial "peek port" exploration, 38 (48%) underwent immediate extension to formal laparotomy, whereas 41 (52%) underwent HALS colectomy, with one subsequent conversion from HALS to formal laparotomy. Of the 585 patients initially approached laparoscopically, 14 (2%) required conversion to laparotomy. Of the 626 patients from both groups who underwent laparoscopy, the overall conversion to laparotomy rate was 15/626 (2%). DISCUSSION: The "peek port" approach to the patients with a potentially hostile abdomen allows for prompt assessment of intraperitoneal conditions and is associated with an overall low rate of conversion from laparoscopy to laparotomy during colectomy. This technique may reduce expense and morbidity for patients who ultimately require laparotomy, while allowing some patients with complex disease to be managed laparoscopically who would not normally be considered for a minimally invasive procedure.

A Gesture Recognition Algorithm for Hand-Assisted Laparoscopic Surgery.

Minimally invasive surgery (MIS) techniques are growing in quantity and complexity to cover a wider range of interventions. More specifically, hand-assisted laparoscopic surgery (HALS) involves the use of one surgeon's hand inside the patient whereas the other one manages a single laparoscopic tool. In this scenario, those surgical procedures performed with an additional tool require the aid of an assistant. Furthermore, in the case of a human-robot assistant pairing a fluid communication is mandatory. This human-machine interaction must combine both explicit orders and implicit information from the surgical gestures. In this context, this paper focuses on the development of a hand gesture recognition system for HALS. The recognition is based on a hidden Markov model (HMM) algorithm with an improved automated training step, which can also learn during the online surgical procedure by means of a reinforcement learning process.