Perioperative outcomes of utilizing infrahepatic inferior vena cava clamping and Pringle maneuver during hepatectomy: a meta-analysis.

PURPOSE: Intraoperative bleeding during hepatectomy is primarily controlled through anaesthesiological interventions or surgical techniques such as Pringle maneuver (PM). Infrahepatic IVC clamping (IIVCC) is an alternative surgical technique to reduce central venous pressure and prevent retrograde hepatic venous bleeding. The aim of the meta-analysis was to compare IIVCC+PM with PM alone in terms of intraoperative outcomes and perioperative complications. METHODS: Medline, Cochrane Library, Scopus, Web of Science, and EMBASE were searched for comparative studies till 16.04.2024, resulting in 679 articles, of which eight studies met inclusion criteria. Data on patient demographics, surgical technique, and perioperative outcomes was assessed. Cochrane Risk of Bias 2.0 (RoB 2.0) Tool and Newcastle-Ottawa Scale (NOS) were used for risk of bias assessment. RESULTS: Two randomized controlled trials, one prospective, and five retrospective cohort studies with 358 patients in IIVCC+PM and 397 patients in PM alone group were included. IIVCC+PM resulted in significantly greater CVP reduction, less intraoperative blood loss (MD (95% CI) = - 233.03 (- 360.48 to - 105.58), P < 0.001), and less intraoperative blood transfusion (OR (95% CI) = 0.38 (0.25 to 0.57), P < 0.001) compared to PM alone. The two groups had comparable total operative time, transection time and total intraoperative fluid infusion. Patients undergoing IIVCC+PM had significantly shorter length of stay (MD (95% CI) = - 0.63 days (- 1.21 to - 0.05 days), P = 0.03) and overall complication rates (OR (95% CI) = 0.63 (0.43-0.92), P = 0.02) compared to PM alone group. CONCLUSION: The utilization of IIVCC along with PM during liver resection may be beneficial in reducing intraoperative bleeding and blood transfusion without adversely influencing operative times or perioperative outcomes compared to PM alone.

Comparing proficiency of obstetrics and gynaecology trainees with general surgery trainees using simulated laparoscopic tasks in Health Education England, North-West: a prospective observational study.

BACKGROUND: Training programmes for obstetrics and gynaecology (O&G) and general surgery (GS) vary significantly, but both require proficiency in laparoscopic skills. We sought to determine performance in each specialty. DESIGN: Prospective, observational study. SETTING: Health Education England North-West, UK. PARTICIPANTS: 47 surgical trainees (24 O&G and 23 GS) were subdivided into four groups: 11 junior O&G, 13 senior O&G, 11 junior GS and 12 senior GS trainees. OBJECTIVES: Trainees were tested on four simulated laparoscopic tasks: laparoscopic camera navigation (LCN), hand-eye coordination (HEC), bimanual coordination (BMC) and suturing with intracorporeal knot tying (suturing). RESULTS: O&G trainees completed LCN (p<0.001), HEC (p<0.001) and BMC (p<0.001) significantly slower than GS trainees. Furthermore, O&G found fewer number of targets in LCN (p=0.001) and dropped a greater number of pins than the GS trainees in BMC (p=0.04). In all three tasks, there were significant differences between O&G and GS trainees but no difference between the junior and senior groups within each specialty. Performance in suturing also varied by specialty; senior O&G trainees scored significantly lower than senior GS trainees (O&G 11.4±4.4 vs GS 16.8±2.1, p=0.03). Whilst suturing scores improved with seniority among O&G trainees, there was no difference between the junior and senior GS trainees (senior O&G 11.4±4.4 vs junior O&G 3.6±2.1, p=0.004). DISCUSSION: GS trainees performed better than O&G trainees in core laparoscopic skills, and the structure of O&G training may require modification. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry (NCT05116332).

The effect of the enhanced recovery programme on long-term survival following liver resection for colorectal liver metastases.

BACKGROUND: Enhanced recovery programmes are associated with improved short-term outcomes following liver surgery. The impact of enhanced recovery programmes on medium- and long-term outcomes is incompletely understood. This study aimed to assess the impact of an enhanced recovery programme on long-term survival in patients undergoing surgery for colorectal liver metastases. METHODS: At a tertiary hepatobiliary centre, we analysed short-, medium- and long-term outcomes in consecutive patients undergoing liver resection for colorectal liver metastases. A five-year retrospective review was carried out comparing the enhanced recovery programme to standard care. RESULTS: A total of 172 patients were included in the analysis: 87 on standard care and 85 on an enhanced recovery programme. Open surgery was performed in 122 patients: 74 (85.1%) and 48 (56.5%) patients in the standard care and enhanced recovery programme, respectively (p < 0.001). There was a significant reduction in the median (IQR) length of hospital stay in the enhanced recovery programme compared with standard care (7 (5) days vs. 8 (3) days, p = 0.0009). There was no significant difference in survival between standard care and the Enhanced Recovery Programme at one (p = 0.818), three (p = 0.203), and five years (p = 0.247). CONCLUSION: An enhanced recovery programme was associated with a reduced length of hospital stay. There was no effect on the one-, three- and five-year survival.

Synchronous robotic repair of anterior diaphragmatic (Morgagni) hernia & low anterior resection for rectal cancer.

BACKGROUND: We present the case report of synchronous trans-fascial repair of a large congenital Morgagni hernia (MH) and low anterior resection using a fully robotic approach. METHODS: A 61-year old female presented with fresh red blood in her stool. She had a previous history of abdominal hysterectomy and a performance status of 0. Imaging revealed a low rectal cancer and incidental large MH. RESULTS: Using the Da Vinci X platform the procedure was successfully performed; total operating time of 450 min, <200 ml blood loss and 5 days hospital stay. Post-operative scan at 6 months, 1 and 2 years showed no evidence of hernia or cancer recurrence. CONCLUSION: We have demonstrated that complex multi-visceral procedures can be safely performed on fully robotic platforms, even in previously disturbed surgical fields. The robotic approach may provide the opportunity for seamless multi-speciality operating simultaneously in multiple body cavities.

There is no dose-response relationship between the amount of exercise and improvement in HbA1c in interventions over 12 weeks in patients with type 2 diabetes: a meta-analysis and meta-regression.

AIMS: Aerobic exercise is well recognised as an effective treatment for people with type 2 diabetes but the optimal amount of aerobic exercise to improve glycaemic control remains to be determined. Thus, the aim of this meta-analysis and meta-regression was to assess the impact of volume and intensity of aerobic exercise on glycaemic control. METHODS: Medline, Cochrane, Embase, and Web of Science databases were searched up until 15 December 2020 for the terms "aerobic exercise AND glycaemic control", "type 2 diabetes AND exercise", and "exercise AND glycaemic control AND Type 2 diabetes AND randomised control trial". We included (i) randomised control trials of ≥ 12 weeks, (ii) trials where participants had type 2 diabetes and were aged 18 or over, and (iii) the trial reported HbA1c concentrations pre- and post-intervention. Two reviewers selected studies and extracted data. Data are reported as standardised mean difference (SMD) and publication bias was assessed using funnel plots. RESULTS: A total of 5364 original titles were identified. Sixteen studies were included in the meta-analysis. Aerobic exercise reduced HbA1c versus control (SMD = 0.56 (95% CI 0.3-0.82), p < 0.001). There were also significant reductions in BMI (SMD = 0.76 (95% CI 0.25-1.27), p < 0.05). There was no dose-response relationship between improvement in HbA1c and the intensity and volume of the intervention (p > 0.05). CONCLUSIONS: Twelve-week or longer aerobic exercise programmes improve glycaemic control and BMI in adults with type 2 diabetes. Longer or more intense interventions appear to confer no additional benefit on HbA1c.

Should All Minimal Access Surgery Be Robot-Assisted? A Systematic Review into the Musculoskeletal and Cognitive Demands of Laparoscopic and Robot-Assisted Laparoscopic Surgery.

BACKGROUND: Surgeons are among the most at risk of work-related musculoskeletal health decline because of the physical demands of surgery, which is also associated with cognitive fatigue. Minimally invasive surgery offers excellent benefits to patients but the impact of robotic or laparoscopic surgery on surgeon well-being is less well understood. This work examined the musculoskeletal and cognitive demands of robot-assisted versus standard laparoscopic surgery. METHODS: Medline, Embase and Cochrane databases were systematically searched for 'Muscle strain' AND 'musculoskeletal fatigue' AND 'occupational diseases' OR 'cognitive fatigue' AND 'mental fatigue' OR 'standard laparoscopic surgery' AND 'robot-assisted laparoscopic surgery'. Primary outcomes measured were electromyographic (EMG) activity for musculoskeletal fatigue and questionnaires (NASA-TLX, SMEQ, or Borg CR-10) for cognitive fatigue. A systematic review was conducted in accordance with the Synthesis Without Meta-analysis (SWiM) Guidelines. The study was preregistered on Prospero ID: CRD42020184881. RESULTS: Two hundred and ninety-eight original titles were identified. Ten studies that were all observational studies were included in the systematic review. EMG activity was consistently lower in robotic than in laparoscopic surgery in the erector spinae and flexor digitorum muscles but higher in the trapezius muscle. This was associated with significantly lower cognitive load in robotic than laparoscopic surgery in 7 of 10 studies. CONCLUSIONS: Evidence suggests a reduction in musculoskeletal demands during robotic surgery in muscles excluding the trapezius, and this is associated with most studies reporting a reduced cognitive load. Robotic surgery appears to have less negative cognitive and musculoskeletal impact on surgeons compared to laparoscopic surgery.

Indocyanine green colonic perfusion demonstration following robotic da Vinci X inferior mesenteric artery ligation for the treatment of type II endoleak.

BACKGROUND: We describe the technical operative details of the robotic repair of a type II endoleak (T2E) following endovascular abdominal aortic aneurysm repair (EVAR). We demonstrate that indocyanine green (ICG) can be used intra-operatively to demonstrate perfusion of the colon following ligation of the inferior mesenteric artery (IMA) vessel feeding the aneurysm sac. METHODS: A 74-year old male underwent EVAR for a 5.8 cm infra-renal abdominal aortic aneurysm using an E-Tegra, Jotec Device (JOTEC Gmb, Lotzenäcker 23,D-72379 Hechingen). Surveillance contrast CT (CTA) over the ensuing 30 months confirmed progressive sac expansion. RESULTS: ICG confirmed colonic perfusion via the marginals after IMA ligation. Total operative time 56 min < 50 mls blood loss and 1-day hospital stay. 3-month follow-up: CTA and ultrasound demonstrated complete resolution of T2E and adequately perfused colon. CONCLUSION: A total robotic approach can be performed safely with intra-operative ICG used to demonstrate colonic perfusion as an added safety measure.

The Impact of Prehabilitation on Patient Outcomes in Hepatobiliary, Colorectal, and Upper Gastrointestinal Cancer Surgery: A PRISMA-Accordant Meta-analysis.

OBJECTIVE: To determine the impact of prehabilitation on hospital length of stay, functional capacity, complications, and mortality after surgery in patients with hepatobiliary, colorectal, and upper gastrointestinal cancer. BACKGROUND: "Prehabilitation" encompasses exercise, nutrition, and psychosocial interventions to optimize health before surgery. The benefits of prehabilitation are ill-defined. METHODS: Medline, Embase and Cochrane Databases were searched systematically for the terms "prehabilitation AND exercise," "perioperative care AND cancer surgery," and "colorectal AND hepatobiliary AND hepatopancreatobiliary AND esophagogastric AND recovery AND outcomes." Primary outcomes analyzed were hospital length of stay, functional capacity, significant postoperative complications (Clavien Dindo ≥ III), and mortality. A meta-analysis was conducted on the effect of all-modality prehabilitation for patients with colorectal, hepatopancreatobiliary and upper gastrointestinal cancer surgery using the raw mean difference, risk difference, and a random-effects model. RESULTS: Three hundred and seventy seven original titles were identified. Fifteen studies (randomized controlled trials; n = 9 and uncontrolled trials; n = 6) were included in the meta-analysis. Prehabilitation reduced hospital length of stay by 1.78 days versus standard care (95% CI: -3.36, -0.20, P < 0.05). There was no significant difference in functional capacity with prehabilitation determined using the 6-minute walk test (P = 0.816) and no significant reduction in postoperative complications (P = 0.378) or mortality rates (P = 0.114). CONCLUSIONS: Prehabilitation was associated with reduced hospital length of stay but had no effect on functional capacity, postoperative complications, or mortality rates. Thus, prehabilitation should be recommended to accelerate recovery from cancer surgery, demonstrated by reduced hospital length of stay.