Treatment techniques for rectovaginal fistulas after low rectal resection for deep endometriosis.

Endometriosis is a benign gynecologic affection that may lead to major surgeries, such as colorectal resections. Rectovaginal fistulas (RVF) are among the possible complications. When they occur, it is necessary to adapt the repair surgery as best as possible to limit their functional consequences. This video shows three different techniques for correcting RVF after rectal resection for endometriosis, with a combination of perineal surgery and laparoscopy: a mucosal flap, a transanal transection and single stapled anastomosis (TTSS) and a pull through. Supplementary file1 (MP4 469658 KB).

Patient management after primary rectal cancer diagnosis. Special focus on surgical treatment for non-metastatic disease.

Background: Rectal cancer is a public health priority. Primary objectives of this study were to evaluate the quality of care for non-metastatic rectal cancer using process and outcome indicators. Delay of management, length of stay and readmission rate, sphincter preservation, morbidity, number of examined lymph nodes, mortality, overall and disease-free survivals were evaluated. Secondary objectives were to estimate the relationship between possible predictive parameters for (1) anastomotic leakage (logistic regression), (2) overall or disease-free survivals (cox regression).Methods: We performed a retrospective study on 312 consecutive patients diagnosed with primary rectal cancer between 2016 and 2019. We focused on the 163 patients treated by surgery for non-metastatic cancer.Results: The treatment began within 33 days (range 0-264) after incidence, resection rate was 67%. Digestive continuity rate in lower, middle and upper rectum was 30%, 87% and 96%. Median of 14 lymph nodes (range 1-46) was analyzed. Length of stay and readmission rate were 11 days (range 3-56) and 4%, respectively. Within 90 postoperative days, clinical anastomotic leakage occurred in 9.2% of cases, major morbidity rate was 17%, mortality 1.2%. Multivariate analysis revealed that stoma decreased the risk of anastomotic leakage [hazard ratio: 0.16; 95% confidence intervals: 0.04-0.63; p = 0.008]. The 5-year overall survival after surgery was 85 ± 4%, disease-free survival 83 ± 4%. Patients with major complications, male gender and R1/R2 resection margin had a poorer prognosis.Conclusion: This work showed encouraging results in rectal cancer treatment in our institution, our results were in line with recommendations at the time.

[Clinical pathway evaluation for left colectomy in abdominal surgery]. / Evaluation d'un itinéraire clinique pour colectomie gauche en chirurgie abdominale.

At the end of 2008, a left colectomy clinical pathway was implemented at Clinique Saint-Joseph (CHC) in Liège (Belgium). A sample of 213 patients with benign or malignant pathology requiring laparoscopic left colon resection was included in this clinical pathway during the years 2009 to 2015. We focused on the compliance with the protocol, on the complication rate and the incidence of re-hospitalization within 30 days after surgery. In comparison with a historical control group, we observed that the compliance was excellent (superior to 80 %) from 2009 to 2015. The re-hospitalization did not differ though the complication rate decreased. Although the hospital stay was not our primary objective, it decreased significantly from 8 to 4 days (average). This analysis leads to the conclusion that the introduction of a clinical pathway, when it is well prepared and brings together all the implicated persons with the same goal, is directly beneficial to the patient and the quality of its management.

Fin 2008, l'itinéraire clinique (IC) «colectomie gauche¼ a été mis en place au sein de la Clinique Saint-Joseph (CHC) de Liège. Une série de 213 patients présentant une pathologie bénigne ou maligne nécessitant une résection du côlon gauche par laparoscopie a été incluse dans cet IC entre 2009 et 2015. Nous nous sommes intéressés à l'observance du protocole de l'IC ainsi qu'aux taux de complications et de ré-hospitalisations dans les 30 jours post-opératoires. Nous avons constaté, après comparaison avec un groupe témoin historique, que l'adhésion au protocole IC a été d'emblée excellente (supérieur a 80 %) tout au long de la durée de l'étude. Il n'y a pas eu de modification du taux de ré-hospitalisations et le taux de lâchage de suture a été réduit. Bien que la diminution de la durée de séjour n'était pas l'objectif premier lors de la mise en place de cet IC, elle s'est significativement réduite passant, en moyenne, de 8 à 4 jours. En conclusion, l'introduction d'un IC, pour autant qu'il soit bien préparé et rassemble dans le même objectif l'ensemble des acteurs de soins, est directement bénéfique pour le patient et la qualité de sa prise en charge.

Long-term results after laparoscopic reoperation for failed antireflux procedures.

BACKGROUND: Surgery for failed antireflux procedures is technically more demanding than primary fundoplication. The success rate does not equal that of the primary procedures. This retrospective analysis aimed to assess long-term subjective and objective outcomes in patients who underwent laparoscopic surgery for fundoplication failure. METHODS: Objective and subjective outcomes were assessed by radiological and endoscopic methods, symptom questionnaire and quality-of-life index at a minimum follow-up of 12 (mean 75·8) months. RESULTS: The study included 129 consecutive patients who had laparoscopic redo surgery after fundoplication had failed. The most frequent patterns of failure were hiatal herniation (50 patients) and slippage (45). Resolution of the symptoms that led to redo surgery was achieved in 27 of 37 and 11 of 16 patients operated for recurrence and for dysphagia respectively. Objective failure was demonstrated in 16 of 39 patients with herniation and six of 22 with slippage. Seven patients underwent an additional surgical procedure. CONCLUSION: Long-term assessment of objective and subjective results after laparoscopic repair for failed fundoplication revealed a high failure rate that increased with the length of follow-up. Unexpected and untreated oesophageal shortening may be responsible for this failure rate.

Is there a proper way to treat shortened oesophagus? About a series of 67 patients.

INTRODUCTION AND OBJECTIVE: During the work-up of gastro-oesophageal reflux disease (GORD) patients, barium swallow may show a shortened oesophagus with a non-reducible gastro-oesophageal junction. In our department, in such cases, a Collis-Nissen operation is usually planned. But, the proper reducibility of the gastro-oesophageal junction (GOJ) in the abdomen is difficult to assess peroperatively. The aim of this study is to compare retrospectively the follow-up of an oesophageal lengthening procedure (Collis-Nissen gastroplasty) versus a standard Nissen in the management of patients with primary short oesophagus or secondary to previous Nissen fundoplication. PATIENTS AND METHODS: Between 01/2000 and 12/2009, 67 patients with a short oesophagus on X-Ray were operated on for proven GORD: 27 (Group A) underwent a Collis-Nissen fundoplication. In 40 patients (Group B), the GOJ was reduced easily and a standard Nissen fundoplication was judged sufficient by the experimented surgeon. Follow up included Quality of Life evaluation using the Gastrointestinal Quality of Life Index (GIQLI) and a barium swallow. RESULTS: 64 patients agreed to participate. Mean follow up was 46 months (4-122). Mean postoperative GIQLI score was 108 in group A, 97 in group B. Barium swallow was performed in 61 patients. In group A, seven patients out of 25 (28%) presented a intrathoracic migration on X-Ray while in group B, it was noted in 20 patients (55%). CONCLUSION: According literature, Collis gastroplasty allows a tension-free fundoplication to be performed to correct a shortened oesophagus. Though our series of brachy-oesophagus is small, it confirms a better outcome after a Collis-Nissen gastroplasty, compared to the classical Nissen fundoplication.

Laparoscopic treatment of Barrett's esophagus: long-term results.

BACKGROUND: Gastroesophageal reflux disease (GERD) is considered the main etiologic process in the metaplastic development of Barrett's esophagus (BE). The most serious complication of BE is the possible dysplastic evolution to esophageal carcinoma. Many treatments have been described to prevent the progression of BE. The outcomes of these interventions are controversial. The aim of this study was to assess whether laparoscopic fundoplication for GERD had an impact on the development of BE. METHODS: Prospective data were collected from patients who were treated with a laparoscopic fundoplication for BE. Data was collected and analyzed for a variety of clinical and pathologic outcomes. RESULTS: Laparoscopic fundoplications were completed between 1993 and 2001, with a total sample size of 92 (mean age 53 +/- 11.8 years). Each patient was diagnosed with GERD associated with BE confirmed by both endoscopy and biopsy. A laparoscopic fundoplication was performed in all patients (360 degree fundoplication in 81 patients and partial fundoplication in 11 patients). There was no postoperative mortality or major complications from the procedure. The mean postoperative stay was 3 +/- 1 days. Seventy patients (76% of the overall sample size) were followed up for a mean 4.2 +/- 2.6 years. Of the patients available for follow-up, 33% (n = 23) had a complete regression of their BE; 21% (n = 15) had a decrease in the degree of metaplasia/dysplasia; 39% (n = 27) had no significant change; and 7% (n = 5) experienced a progression of the BE. Five patients required further procedures for three reasons: (1) GERD recurrence (n = 2), (2) progression of BE (n = 2), and (3) intrathoracic migration (n = 1). No patients developed high-grade dysplasia or esophageal carcinoma. CONCLUSIONS: The results of this study suggest that laparoscopic fundoplication offers a safe and effective long-term treatment for BE. The procedure also demonstrated regression of BE in more than 50% of the sample size.

Clinical results of laparoscopic fundoplication at ten years after surgery.

BACKGROUND: Several studies have demonstrated laparoscopic antireflux surgery (LAS) for the treatment of gastroesophageal reflux disease (GERD) to be efficient at short- and midterm follow-up evaluations. The aim of this study was to evaluate the results for LAS 10 years after surgery. METHODS: The 100 consecutive patients who underwent LAS by a single surgeon in 1993 were entered into a prospective database. Nissen fundoplication was performed for 68 patients, and partial posterior fundoplication (modified Toupet procedure) was performed for 32 patients. Evaluations of the outcome were made 5 and 10 years after surgery. A structured symptom questionnaire and upper gastrointestinal barium series were used at 5 years. The same questionnaire and an added quality-of-life questionnaire (the Gastrointestinal Quality of Life Index [GIQLI]) were used at 10 years. RESULTS: Seven patients died of unrelated causes during the 10-year period. Four patients underwent revision surgery: one patient for persistent dysphagia and three patients for recurrent reflux symptoms. Three patients were lost to any follow-up study. At 5 years, 93% of the patients were free of significant reflux symptoms. At 10 years, 89.5% of the patients still were free of significant reflux (93.3% after Nissen, 81.8% after Toupet). Major side effects (flatulence and abdominal distension) were related to "wind" problems. The GIQLI scores at 10 years were significantly better than the preoperative scores of the patients under medical therapy with proton pump inhibitors. CONCLUSIONS: Elimination of GERD symptoms improved quality of life and eliminated the need for daily acid suppression in most patients. These results, apparent 5 years after the operation, still were valid at 10 years.

What becomes of patients one year after the intragastric balloon has been removed?

BACKGROUND: The BioEnterics Intragastric Balloon (BIB) is a saline-filled balloon recommended to remain in the gastric cavity for a maximum of 6 months. Is this short period sufficient to change patients' lifestyle and eating practices to maintain weight reduction after BIB removal? METHODS: 100 patients who received a BIB were included in this prospective study and followed for 1 year after BIB removal. The post-implantation follow-up visits took place monthly, during which the patient was seen by the surgeon, dietitian, and if necessary, psychologist. RESULTS: At BIB removal, mean weight loss for the group was 12.0 kg. Mean percent excess weight loss (%EWL) was 39.8%. 12 months after removal of the BIB, mean weight loss was 8.6 kg and mean %EWL was 26.8% for the group as a whole. CONCLUSIONS: The results 1 year after removal of the BIB were encouraging. Because the BIB is a temporary non-surgical and non-pharmaceutical treatment for obesity that is reversible and repeatable, we recommend it to patients who have previously failed traditional methods of weight reduction. Careful patient follow-up is of primary importance in avoiding complications and supporting efficacy of the treatment. Although 1 year follow-up cannot be considered long term, these results are encouraging. Concurrent behavior modification is needed for durable weight loss.

Intravaginal slingplasty: short term results.

BACKGROUND: Numerous surgical techniques have been described for the treatment of vaginal vault prolapses. In 1997, a new minimally invasive procedure was introduced by Petros: the infracoccygeal sacropexy, also known as Intravaginal Slingplasty (IVS). This technique is used to place a mesh in the recto-vaginal fascia and to reinforce the uterosacral ligament by placing a polypropylene tape between the perineum and the vaginal vault. Since July 2002, we have changed our approach to the treatment of vaginal vault prolapses and now perform IVS. The aim of this study was to report our early experience and short-term results with IVS. METHODS: Prospective single-institution non-randomized trial of patients who underwent IVS. Indications, intra- and post-operative complications were recorded as well as early post-operative results. RESULTS: 34 patients with a mean age of 60+/-13 years, were operated during a 12-month period. Surgical indications included rectoceles (n = 27), enteroceles (n = 26), cystoceles (n = 15) and hysteroceles (n = 9). 85% of the patients (n = 29) had more than one prolapse. Mean operative time was 63+/-19 minutes, with a 0% intra-operative complication rate. Post-operative complication rate was 2.9%: bleeding from an internal haemorrhoid required surgical haemostasis. Median post-operative stay was 3 days (range: 2-7 days). There was also one post operative complication (2.9%, a mesh erosion). Recurrence rate was 8.8% (two cystoceles and one rectocele recurred after surgery). CONCLUSION: Posterior IVS provides a safe and efficacious treatment for posterior vaginal vault prolapses. Long-term results are required to assess the functional results and recurrence rate of the technique.

Laparoscopic liver resection of benign liver tumors.

OBJECTIVE: The objective of this study was to assess the feasibility, safety, and outcome of laparoscopic liver resection for benign liver tumors in a multicenter setting. BACKGROUND: Despite restrictive, tailored indications for resection in benign liver tumors, an increasing number of articles have been published concerning laparoscopic liver resection of these tumors. METHODS: A retrospective study was performed in 18 surgical centres in Europe regarding their experience with laparoscopic resection of benign liver tumors. Detailed standardized questionnaires were used that focused on patient's characteristics, clinical data, type and characteristics of the tumor, technical details of the operation, and early and late clinical outcome. RESULTS: From March 1992 to September 2000, 87 patients suffering from benign liver tumor were included in this study: 48 patients with focal nodular hyperplasia (55%), 17 patients with liver cell adenoma (21%), 13 patients with hemangioma (15%), 3 patients with hamartoma (3%), 3 patients with hydatid liver cysts (3%), 2 patients with adult polycystic liver disease (APLD) (2%), and 1 patient with liver cystadenoma (1%). The mean size of the tumor was 6 cm, and 95% of the tumors were located in the left liver lobe or in the anterior segments of the right liver. Liver procedures included 38 wedge resections, 25 segmentectomies, 21 bisegmentectomies (including 20 left lateral segmentectomies), and 3 major hepatectomies. There were 9 conversions to an open approach (10%) due to bleeding in 45% of the patients. Five patients (6%) received autologous blood transfusion. There was no postoperative mortality, and the postoperative complication rate was low (5%). The mean postoperative hospital stay was 5 days (range, 2-13 days). At a mean follow-up of 13 months (median, 10 months; range, 2-58 months), all patients are alive without disease recurrence, except for the 2 patients with APLD. CONCLUSIONS: Laparoscopic resection of benign liver tumors is feasible and safe for selected patients with small tumors located in the left lateral segments or in the anterior segments of the right liver. Despite the use of a laparoscopic approach, selective indications for resection of benign liver tumors should remain unchanged. When performed by expert liver and laparoscopic surgeons in selected patients and tumors, laparoscopic resection of benign liver tumor is a promising technique.

The sentinel lymph node biopsy in breast cancer.

OBJECTIVE: To evaluate the possibility and accuracy of this new diagnostic approach to the breast cancer disease in our centre. MATERIAL AND METHODS: Since March 1999, every patient presenting with a cT1-T2 N0 breast carcinoma was scheduled for a sentinel lymph node search. An injection of Tc-99 labelled nanocolloïd with a dose of 1 mCu was injected either intramammary or intradermally. The patients have been divided into two groups: in group I, they received their injection intramammarily the day before the operation; because of several failures in identifying the sentinel lymph node (SLN), the protocol was modified, the patients receiving their injection the day of operation, intradermally (group II). Once a lymphoscintigraphy done, the SLN was identified at operation using a detection probe, after the primary tumour had been removed. A routine axillary dissection was then performed to remove the rest of the lymph nodes. All the nodes were then checked routinely for metastatic cells. The SLN was also screened by semi-serial slides and by immuno-assay. RESULTS: From March 1999 till March 2001, sixty patients presented consecutively with a T1 or T2 biopsy proven breast carcinoma with no clinical lymph nodes. They were all scheduled for a sentinel lymph node search according to the protocol. Mean tumour size was 9.9 mm (ranging from 4 to 23 mm). Fourteen patients (group I) received their injection intramammarily but we failed to identify the sentinel node in five patients (35%). The remaining forty-two patients (group II) received their injection intradermally. Sentinel nodes were then identified in forty-three patients (93%). Positive SLN were discovered in eleven cases by routine examination (13 positive nodes among 104 harvested sentinel nodes, i.e. 13%). Micro metastases were discovered in three other SLN by immunohistology. In total, 605 lymph nodes were evaluated through the axillary dissection, representing a mean number of 10.08 lymph nodes per patient. For four patients, positive lymph node were discovered in the axillary dissection while SLN were negative (6.6% of false negative). CONCLUSIONS: During this learning curve period, it appears that the method for screening the SLN is reliable, since the figures encountered are similar to those of the literature. By adding a perioperative blue dye injection, it might be possible to reduce the percentage of false negative results. It is difficult to assess, at present, the impact SLN could have on survival.

The BioEnterics Intragastric Balloon (BIB): how to use it.

BACKGROUND: The authors have been using the new saline-filled BioEnterics intragastric balloon (BIB) since 1995. METHODS: By now, more than 650 BIBs have been implanted on our Unit. RESULTS: Because of close collaboration between the engineers and the users, and after several modifications, an easy-to-use balloon is available. In addition, we have developed 3 instruments which provide easy and quick removal of the BIB. CONCLUSION: The device, supported by a competent motivated team, is another modality available for weight loss.

[Anatomic-clinical presentation. Testicular teratocarcinoma with thoracic-abdominal adenopathy]. / Présentation anatomo-clinique. Térato-carcinome testiculaire avec adénopathies thoraco-abdominales.

This case report of a young man with a testicular germ cell-teratoma tumor illustrates the necessity of a multidisciplinary sequential approach to ensure chance of cure. The outcome of patients with advanced germ cell tumor depends on the optimal clinical management. Residual masses are frequent, and their histology can be different than the initial one (i.e., only residual mature teratoma cells or necrosis-fibrosis). Therefore a second surgery on residual masses with curative intent, may be important to optimalize the treatment and follow up.

[Adenocarcinoma of the pancreas. Palliative surgery]. / Adénocarcinome du pancréas. Chirurgie palliative.

In case of unresectable adenocarcinoma of the pancreas, laparoscopy can allow to perform gastric and biliary by-pass which will improve the quality of life at a lower cost than conventional surgery for the patients.

[Adenocarcinoma of the pancreas. Preoperative staging]. / Adénocarcinome du pancréas. Staging préopératoire.

The authors assess the value of laparoscopy in the preoperative staging of the adenocarcinoma of the pancreas to prevent unnecessary pancreatic resections in a disseminated disease. By laparoscopy, a macroscopic evaluation, a peroperative liver and pancreas ultrasonography as well as biopsies are possible and are more accurate in assessing the extent of the disease than other means.

Continuous delivery of venous 5-fluorouracil and arterial 5-fluorodeoxyuridine for hepatic metastases from colorectal cancer: feasibility and tolerance in a randomized phase II trial comparing flat versus chronomodulated infusion.

High-dose chemotherapy combining regional hepatic artery infusion (HAI) of fluorodeoxyuridine (HAI FUDR) and systemic venous infusion of 5-fluorouracil (i.v. 5-FU) was delivered against liver metastases from colorectal cancer. The hypothesis that chronomodulation of delivery rate along the 24 h time scale would improve the tolerable doses of both drugs was tested. Combined HAI FUDR (80 mg/m2/day) and i.v. 5-FU (1200 mg/m2/day) were administered for five consecutive days every 3 weeks, either as a constant rate infusion (schedule A, 27 patients) or as chronotherapy (schedule B, 29 patients). This latter regimen consisted of a sinusoidal modulation of the delivery rate over the 24 h scale with a maximum at 16:00 for FUDR and 4:00 for 5-FU. Intrapatient dose escalation up to the individual maximum tolerated doses (MTD) was planned for both drugs in the absence of any previous grade 3 or 4 toxicity. All patients had metastatic colorectal cancer, with adjuvant or palliative chemotherapy given to six patients (22%) on schedule A and 12 patients on schedule B (41%). Severe stomatitis occurred in 71% of the patients and was dose limiting. No hepatic toxicity was encountered. Dose reductions of 5-FU and/or FUDR were required for 17 of 27 patients on schedule A (63%) as compared to 11 of 29 patients on schedule B (38%), following reaching the individual MTD (p<0.05). Over the first six cycles, patients on schedule B received higher doses (mg/m2/cycle; FUDR: 522 +/- 85 versus 499 +/- 50, p=0.004 and 5-FU: 5393 +/- 962 versus 5136 +/- 963, p=0.009) and higher dose intensities (mg/m2/week; FUDR: 164 +/- 46 versus 151 +/- 52, p=0.018 and 5-FU: 1652 +/- 478 versus 1553 +/- 535, p<0.041) of both drugs than patients on schedule A. As a result the number of courses with doses of 5-FU above 1200 mg/m2/day and/or FUDR above 110 mg/m2/day was larger in group B than in group A (5-FU, A: 67 of 268, 25% versus B: 133 of 321, 41% and FUDR, A: 86 of 268, 32% versus B: 155 of 321, 48%; p<0.001). Objective responses were observed in 13 patients on schedule A (48%) and 11 patients on schedule B (38%). The results support the need for further exploration of chronotherapy of colorectal cancer liver metastases with combined arterial and venous fluoropyrimidine chemotherapy.

Causes of failures of laparoscopic antireflux operations.

BACKGROUND: Three factors determine the successful outcome after an antireflux operation for gastroesophageal reflux disease (GERD): indication for surgery, choice of the operative procedure, and quality of the operation. Laparoscopic treatment has not changed these concepts. The factor most likely to have been modified is the technical quality of the operative procedure. We evaluated 26 patients presenting with failure after laparoscopic antireflux surgery to determine the causes. METHODS: Nineteen patients came from our series of 503 laparoscopic antireflux procedures and seven patients were referred from other centers. Preoperative, peroperative, and postoperative data were retrospectively reviewed to analyze the responsible factor(s). RESULTS: Nine patients presented with a sphincter mechanism failure to control reflux, 14 patients had severe dysphagia, 3 patients presented with severe epigastric pain. The first operation was a Nissen-Rossetti fundoplication in 17 patients. The technical quality of the operative procedure was the responsible factor in 22/26 patients. The choice of the type of operation was questionable in five patients. Eight patients underwent successful endoscopic treatment, reoperation was necessary in 10 patients. Four patients underwent medical therapy, and four patients had no treatment. CONCLUSIONS: The laparoscopic Nissen-Rossetti fundoplication was associated with a higher rate of failures, in terms of recurrent disease or severe dysphagia. The use of this technique was related to the laparoscopic inexperience of the surgeon, leading to a wrong application of the original procedure. Partial posterior fundoplication and total fundoplication with division of the short gastric vessels are obviously associated with a better outcome, if the selection of the operation is based on a strict preoperative physiopathological evaluation of the disease.

Hepatic resections after chronotherapy: surgical aspects.

Hepatic resection has always been recommended for the treatment of metastatic disease in selected patients. Surgeons have had modified their approach and timing of surgery since the introduction of chemotherapy. The authors report their experiences since the introduction of chronochemotherapy. From 1990 up to 1994, 9 hepatic resections were performed for metastatic colorectal carcinoma. During the same period, 11 arterial accesses were implanted for diffused hepatic disease. Of the 9 resected patients, 5 are still alive with a mean follow-up of 17.7 months with no signs of recurrent disease.

[Laparoscopic surgery of gastroesophageal reflux]. / Chirurgie laparoscopique du reflux gastro-oesophagien.

Complete fundoplication according to Nissen's technique and partial posterior hemifundoplication (Toupet's and Lind's techniques) are effective treatments for gastrooesophageal reflux. Their application in open surgery has already been largely assessed. Since 1991, these operations have been performed by laparoscopic surgery. In this study, the course of 368 patients treated via a laparoscopic approach was evaluated. For 363 patients (98.6%), the operation was completed under laparoscopic control with no operative mortality. The operative morbidity was 4%. Two patients (0.5%) had to be reoperated 6 and 8 months after the initial operation for persistent dysphagia. In september 1993, 126 patients with a minimum postoperative follow-up of 12 months (median: 16.2 months) accepted a follow-up assessment. Visick I and II score were observed for 90.4% of patients. These short-term results are encouraging and suggest that the results obtained are comparable to those of conventional surgery, with a lower morbidity and a reduced hospital stay. Precise selection of patients and surgical techniques is essential.