Three-dimensional (3D) system versus two-dimensional (2D) system for laparoscopic resection of adrenal tumors: a case-control study.

PURPOSE: Laparoscopy is the standard technique for resecting adrenal tumors worldwide. The main drawbacks of conventional 2D laparoscopy are limited depth perception and tactile feedback. Currently available high-quality 3D laparoscopy systems might improve surgical outcomes for adrenalectomy. We compare the safety and efficacy of 3D versus 2D laparoscopy in the treatment of adrenal tumors. METHODS: This case-control study analyzed prospectively collected data from patients with benign or malignant adrenal tumors treated laparoscopically at a single academic medical center between April 2003 and March 2020. We collected demographic, diagnostic, preoperative, and operative variables, and used multiple linear and logistic regression to analyze differences in various short-term outcomes between the two approaches while adjusting for potential confounders. RESULTS: We included 150 patients: 128 with benign tumors and 22 with malignant tumors; 95 treated with 3D laparoscopy (case group); and 55 with 2D laparoscopy (control group). After adjustment for patient, surgical, and tumor characteristics, a 2D vision was associated with a longer operative time (ß = 0.26, p = 0.002) and greater blood loss (ß = 0.20, p = 0.047). There was no significant difference in rates of conversion to open surgery (odds ratio [OR] = 1.47 (95% CI 0.90-22.31); p = 0.549) or complications (3.6% vs. 2.1%; p = 0.624). CONCLUSIONS: With experienced surgeons, laparoscopic adrenalectomy was safer and more feasible with the 3D system than with the 2D system, resulting in less operative blood loss and shorter operative time with no differences in rates of conversion to open surgery or postoperative complications. For adrenal tumors, 3D laparoscopy offers advantages over 2D laparoscopy.

A randomized clinical trial comparing the initial vascular approach to the inferior mesenteric vein versus the inferior mesenteric artery in laparoscopic surgery of rectal cancer and sigmoid colon cancer.

BACKGROUND: The inferior mesenteric artery approach with a selective lateral splenic flexure mobilization is the most widely used initial step in laparoscopic rectal and left colon surgery. Surgery started through the inferior mesenteric vein (IMV) with systematic medial mobilization (MM) has some theoretical advantages that have never been analyzed in a clinical trial. The aim of this study was to compare the two techniques with regards to surgical technique variables (conversion, surgical time, bleeding, morbidity, and mortality) and pathological outcomes. METHODS: A single-blinded, randomized, controlled trial of patients operated electively by laparoscopic with curative intention for rectal or sigmoid cancer was performed at a single, specialized colorectal surgery department from April 2016 to October 2017. RESULTS: 49 patients were included in each group. There were no statistical differences in patient demographics between the two approaches. Pathological outcomes did not differ between the two groups. Intra-operative characteristics showed a higher conversion rate in patients in which the inferior mesenteric artery was dissected first (p = 0.031). The artery approach also increased intra-operative bleeding (p = 0.049), but there were no differences regarding operative time. On multivariate analysis, the artery approach was associated with a higher risk of conversion (OR 8.68; p = 0.050). Post-operatory complications did not differ between artery and vein dissection. CONCLUSIONS: In our study, the initial approach by the IMV with a systematic MM of the splenic flexure has allowed us to reduce the conversion rate without increasing complications or the surgical time. No differences were observed in the pathological results. Both approaches seem to be safe and effective and well-trained laparoscopic surgeons should have the two techniques available to them for use as needed.

Outpatient versus hospitalization management for uncomplicated diverticulitis: a prospective, multicenter randomized clinical trial (DIVER Trial).

OBJECTIVE: We compare the results of 2 different strategies for the management of patients with uncomplicated left colonic diverticulitis and to analyze differences in quality of life and economic costs. BACKGROUND: The most frequent standard management of acute uncomplicated diverticulitis still is hospital admission both in Europe and United States. METHODS: This multicenter, randomized controlled trial included patients older than 18 years with acute uncomplicated diverticulitis. All the patients underwent abdominal computed tomography. There were 2 strategies of management: hospitalization (group 1) and outpatient (group 2). The first dose of antibiotic was given intravenously to all patients in the emergency department and then group 1 patients were hospitalized whereas patients in group 2 were discharged. The primary end point was the treatment failure rate of the outpatient protocol and need for hospital admission. The secondary end points included quality-of-life assessment and evaluation of costs. RESULTS: A total of 132 patients were randomized: 4 patients in group 1 and 3 patients in group 2 presented treatment failure without differences between the groups (P=0.619). The overall health care cost per episode was 3 times lower in group 2, with savings of €1124.70 per patient. No differences were observed between the groups in terms of quality of life. CONCLUSIONS: Outpatient treatment is safe and effective in selected patients with uncomplicated acute diverticulitis. Outpatient treatment allows important costs saving to the health systems without negative influence on the quality of life of patients with uncomplicated diverticulitis. Trial registration ID: EudraCT number 2008-008452-17.

[Risk factors for acute abdominal wall dehiscence after laparotomy in adults]. / Factores de riesgo de dehiscencia aguda de la pared abdominal tras laparotomía en adultos.

INTRODUCTION: Total evisceration consists of protrusion of the abdominal viscera due to dehiscence of all the planes of the abdominal wall after laparotomy. The greater the number of risk factors, the greater the probability of evisceration. PATIENTS AND METHOD: We performed a retrospective study of patients with evisceration treated in the previous 9 years. RESULTS: Among 12,622 patients who underwent laparotomy, 57 eviscerations were detected (45 men, 12 women; mean age 70 years). The diagnosis was peritonitis in 26 patients and intestinal occlusion in 19. Emergency surgery was performed in 48 patients. Reintervention was performed in 12 patients. Postoperative complications were found in all patients, especially wound infection and paralytic ileus. The main clinical finding was staining of the dressing. Laboratory investigations revealed leukocytosis, hypoproteinemia, and anemia. Surgical repair consisted of simple closure and/or retention sutures; mesh was associated in 6 patients. Subsequent morbidity was 77%. Twenty-six patients required admission to the intensive care unit. The mean length of hospital stay was 28.5 days. The were 41 recoveries (72%) and 16 deaths (28%). Review of 18 parameters involved in evisceration showed that 80% (45 patients) presented 9 or more risk factors. CONCLUSIONS: Evisceration is a serious occurrence that produces high morbidity and mortality. The most frequent risk factors in our series were age greater than 65 years, hemodynamic instability, increased intra-abdominal pressure, emergency surgery, infection of the wound or abdominal wall, hypoproteinemia and anemia. Because these risk factors can be predicted, when several are grouped together, reinforcement should be used when closing the abdominal wall.