The initial experience of robot-assisted transabdominal transversalis fascial and preperitoneal repair for small ventral hernia.

PURPOSE: Despite the widespread of ventral hernia repairs globally, the approach method, dissection planes, defect closure, and the choice and placement layer of mesh are an ongoing debate. We reported the details of surgical techniques, safety and feasibility for robot-assisted transabdominal transversalis fascial and preperitoneal repair (R-TATFPP) for small ventral hernia. METHODS: This study included 5 cases of R-TATFPP repair among 22 cases performed by robot-assisted ventral hernia repair from 2018 to 2023 with the approval of the Institutional Review Board at St. Luke's International University and clinical ethical committee at St. Luke's International Hospital (19-R147, 22-012). RESULTS: There were four males and one female, with mean age of 64.4 ± 10.0 years, inclusive of two umbilical and three incisional hernias. Mean height, weight, body mass index (BMI), hernia defect length, width, operation time, console time, and hospital stay were 171.2 ± 11.8 cm, 82.4 ± 13.4 kg, 28.0 ± 2.1 kg/m2, 2.8 ± 1.4 cm, 3.0 ± 1.3 cm, 180 min, 133.8 min, and 2.4 days, respectively. No conversion nor complication was observed except for one acute urinary retention. CONCLUSION: Robot-assisted transversalis fascial and preperitoneal repair was safe and feasible for small ventral hernia with the minimal disruption to the abdominal wall architecture and structures.

Safety and short-term outcomes of robotic-assisted transabdominal preperitoneal repair for inguinal hernia in pioneering hospitals in Japan: A nationwide retrospective cohort study.

INTRODUCTION: We aimed to evaluate the safety and short-term outcomes of robotic-assisted transabdominal preperitoneal repair for inguinal hernia in 12 pioneering hospitals in Japan. METHODS: Clinical data of patients who underwent robotic-assisted transabdominal preperitoneal repair between September 1, 2016, and December 31, 2021 were collected. Primary outcome measures were intra-operative adverse events and post-operative complications, whereas secondary outcomes were surgical outcomes, including chronic pain, recurrence, and learning curve. RESULTS: In total, 307 patients were included. One case of inferior epigastric arterial injury was reported; no cases of bowel or bladder injury were reported. Thirty-five seromas were observed, including four (1.3%) cases that required aspiration. The median operative time of a unilateral case was 108 minutes (interquartile range: 89.8-125.5), and post-operative pain was rated 1 (interquartile range: 0-2) on the numerical rating scale. In complicated cases, such as recurrent inguinal hernias and robotic-assisted radical prostatectomy-associated hernias, dissection and suture were safely achieved, and no complications were observed, except for non-symptomatic seroma. All patients underwent robotic procedures, and there was no chronic post-operative inguinal pain, although one case of hernia recurrence was reported. Regarding the learning curve, plateau performance was achieved after 7-10 cases in terms of operative time (P < .001). CONCLUSION: Robotic-assisted transabdominal preperitoneal repair can be safely introduced in Japan. Regardless of the involvement of many surgeons, the mastery of robotic techniques was achieved relatively quickly. The advantage of robotic technology such as wristed instruments may expand the application of minimally invasive hernia repair for complicated cases.

The endoscopic-assisted or endoscopic mini- or less-open preperitoneal (E/MILOP) approach for primary and incisional ventral hernia repair.

INTRODUCTION: The endoscopic-assisted or endoscopic mini- or less-open sublay (E/MILOS) concept describes a contemporary approach of trans-hernial repair of ventral hernia via sublay mesh placement. The term sublay often causes confusion, and preperitoneal placement of mesh should be considered as a distinctive approach. We hereby present our experience of a novel approach, the E/MILOP approach, for the repair of primary and incisional ventral hernias. METHODS: All patients who underwent E/MILOP between January 2020 and December 2022 were identified and their preoperative and perioperative characteristics, as well as postoperative outcomes, were retrospectively analyzed. The surgical procedure entailed an incision over the hernia defect and careful entrance into, and development of, the preperitoneal space trans-hernially. A synthetic mesh was placed in the preperitoneal space and the defect was closed with sutures. RESULTS: A total of 26 patients with primary and/or incisional ventral hernias who underwent E/MILOP were identified. Three patients (11.5%) presented with two coexistent types of hernias, and out of a total of 29 hernias, there were 21 (72.4%) umbilical, four epigastric (13.8%) and four incisional (13.8%) hernias. The mean defect width was 2.7 ± 0.9 cm. All cases utilized a mesh with a mean mesh-to-defect ratio of 12.9. The mean postoperative stay was 1.9 days. Surgical site occurrence was observed in eight (30.1%) patients, but none required intervention. No recurrence was observed during a mean follow-up period of 286.7 days. CONCLUSION: The E/MILOP approach is a novel alternative for primary and incisional ventral hernia repair.

Arteriovenous malformation of the spermatic cord mimicking reducible inguinal hernia.

Arteriovenous malformations are a vascular anomaly most often found in the central nervous system; however, they can present ubiquitously in any organs or tissues. We present the case of a 55-year-old man who developed a tender, reducible inguinal bulge and underwent laparoscopic transabdominal preperitoneal inguinal hernia repair under the clinical diagnosis of an inguinal hernia. Intraoperative observation revealed no hernia sac, but a poorly defined spermatic cord mass, appearing to be responsible for the patient's symptoms, was found and removed. The pathology of the mass was consistent with the diagnosis of an arteriovenous malformation of the spermatic cord. Surgeons should keep in mind the small possibility of arteriovenous malformations in patients with clinical presentation of an inguinal hernia, as they may cause massive bleeding during and after the operation unless handled appropriately.

The first case of robotic-assisted transabdominal retrorectus repair for incisional hernia in Japan.

Extraperitoneal mesh repair for ventral hernia has garnered attention and its rate has been increasing due to concerns for the potential complications of intraperitoneal mesh repair. Recently, robotic-assisted ventral hernia repair is highlighted as a solution to the technically demanding nature of laparoscopic transabdominal or enhanced-view totally extraperitoneal retrorectus ventral hernia repair. A 78-year-old man, who had undergone robot-assisted radical prostatectomy 10 months earlier, presented with an incisional hernia of European Hernia Society Classification M3W2, length 4 cm, width 5 cm with rectus diastasis. A right single-docking robotic-assisted transabdominal retrorectus repair was performed using a 21 by 14 cm self-gripping mesh and anterior wall reconstruction was done by 0 barbed nonabsorbable running suture. There were no complications and recurrence observed during a 7 months postoperative period. Single-docking robotic-assisted transabdominal retrorectus repair was considered a good option for midline moderate-size incisional hernias from the point of view of the ease of suturing, adequateness of dissection and prevention of bowel injury.

Implementation of advance care planning decision aids for patients undergoing high-risk surgery: a field-testing study.

BACKGROUND: Patients undergoing high-risk surgery are at a risk of sudden deterioration of their health. This study aimed to examine the feasibility of the development of two patient decision aids (PtDAs) to assist patients undergoing high-risk surgeries in informed decision-making about their medical care in a crisis. METHODS: This field testing implemented two PtDAs that met the international criteria developed by the researchers for patients before surgery. Study participants were patients scheduled to be admitted to the intensive care unit after surgery at one acute care hospital in Japan and their families. The study used a mixed-methods approach. The primary outcome was patients' decision satisfaction evaluated by the SURE test. Secondary outcomes were the perception of the need to discuss advance care planning (ACP) before surgery and mental health status. The families were also surveyed on their confidence in proxy decision-making (NRS: 0-10, quantitative data). In addition, interviews were conducted after discharge to assess the acceptability of PtDAs. Data were collected before (preoperative outpatients, baseline: T0) and after providing PtDAs (in the hospital: T1) and following discharge (T2, T3). RESULTS: Nine patients were enrolled, of whom seven agreed to participate (including their families). The SURE test scores (mean ± SD) were 2.1 ± 1.2 (T0), 3.4 ± 0.8 (T2), and 3.9 ± 0.4 (T3). The need to discuss ACP before surgery was 8.7 ± 1.3 (T1) and 9.1 ± 0.9 (T2). The degree of confidence in family surrogate decision-making was 6.1 ± 2.5 (T0), 7.7 ± 1.4 (T1), and 8.1 ± 1.5 (T2). The patients reported that using PtDAs provided an opportunity to share their thoughts with their families and inspired them to start mapping their life plans. Additionally, patients wanted to share and discuss their decision-making process with medical professionals after the surgery. CONCLUSIONS: PtDAs supporting ACP in patients undergoing high-risk surgery were developed, evaluated, and accepted. However, they did not involve any discussion of patients' ACP treatment wishes with their families. Medical providers should be coached to provide adequate support to patients. In the future, larger studies evaluating the effectiveness of PtDAs are necessary.

Long-term results after robot-assisted radical prostatectomy of a simplified inguinal hernia prevention technique without artificial substance use.

INTRODUCTION: Durable techniques that prevent postoperative inguinal hernia (IH) after robot-assisted radical prostatectomy (RARP) have not been established. This study evaluated the long-term efficacy of a postoperative IH prevention technique that uses no artificial agents to assess the characteristics of IH occurrence after introducing this technique. PATIENTS AND METHODS: We retrospectively analyzed 201 consecutive patients who underwent RARP at our institution between September 2011 and February 2014. In total, 189 cases were eligible for the study. The non-IH prevention and IH prevention groups comprised 72 and 117 cases, respectively. We compared the incidence of IH between the two groups using Kaplan-Meier curves. Risk factors for IH in the prevention group were determined via multivariable logistic regression analysis. RESULTS: The rate of IH occurrence was 20.8% (15 cases) in the nonprevention group and 8.5% (10 cases) in the prevention group, with median follow-up periods of 99.5 and 89.9 months, respectively. The Kaplan-Meier curves indicated a significant difference between the two groups (p = 0.011). Only cutting of the vas deferens significantly contributed to reduced occurrence of IH in multivariable analysis (p = 0.047). After reviewing the intraoperative videos, insufficient separation of the vas deferens was considered the main cause of IH in the prevention group. CONCLUSION: Our simple prevention technique with no artificial agents had a durable effect on IH prevention after RARP over a median follow-up period of more than 7 years. Cutting the vas deferens effectively prevented IH after RARP.

Indocyanine green fluorescence-guided laparoscopic removal of infected mesh with chronic sinus formation after inguinal mesh plug repair.

Chronic mesh infection with sinus formation is usually amenable to open method with dye. Recently, intraoperative real-time fluorescent imaging has been applied to various organs but not to mesh infection. A 72-year-old man with the history of two times removal of infected mesh was referred for groin bulge with purulent discharge. Laparoscopy assisted infected mesh removal was undertaken using intraoperative real-time fluorescent imaging with indocyanine green injection via the sinus orifice. We experienced the first case of the infected mesh with chronic sinus formation treated by the help of intraoperative indocyanine green fluorescent. This method is simple and easy to apply for laparoscopic assisted removal of chronic mesh infection with sinus.

Fruitful first experience with an 8K ultra-high-definition endoscope for laparoscopic colorectal surgery.

We performed laparoscopic surgery for three cases of colorectal cancer using an 8K ultra-high-definition endoscopic system, which offers 16-fold higher resolution than the current 2K high-definition endoscope. The weight of the camera has been successfully reduced to 370 g. To maximize the advantages of the 8K ultra-high-definition endoscope, surgery was performed by darkening the room and placing a large 85-in. display as close to the surgeon as possible. As a result, the autonomic nerve was preserved, and the membrane structure could be clearly observed. Moreover, we were able to feel the stereoscopic effect near the 3-D image. This suggests the possibility of improved curability and function preservation with the 8K endoscope. Although there are some disadvantages that need to be overcome, the 8K ultra-high-definition endoscope will surely contribute to further progress in laparoscopic surgery.

Age is the Most Significantly Associated Risk Factor With the Development of Delirium in Patients Hospitalized for More Than Five Days in Surgical Wards: Retrospective Cohort Study.

OBJECTIVE: The primary purpose of this study was to assess risk factors for delirium in patients staying in a surgical ward for more than 5 days. The secondary purpose was to assess outcomes in patients with delirium. BACKGROUND: Delirium is a syndrome characterized by acute fluctuations in mental status. Patients with delirium are at increased risk of adverse inpatient events, higher mortality and morbidity rates, prolonged hospital stays, and increased health care costs. METHODS: Participants in this study were 2168 patients who had been admitted to the surgical ward of St. Luke's International Hospital for 5 days or more between January 2011 and December 2014. Data on these patients were collected retrospectively from hospital medical records. Firstly, univariate and multivariate analyses were conducted to identify risk factors for delirium. Secondly, morbidity and mortality associated with delirium were analyzed. RESULTS: Delirium occurred in 205 of 2168 patients (9.5%). Age, physical restraint, past history of a cerebrovascular disorder, malignancy, intensive care unit stay, pain, and high blood urea nitrogen value were significant risk factors for delirium in the multivariate analysis. Among these, age was the strongest factor, with an odds ratio for delirium of 12.953 in patients 75 years of age or older. The length of hospital stays and the mortality rates were higher in patients with delirium. CONCLUSIONS: Results showed that age, and also physical restraint, past history of cerebrovascular disorder, malignancy, intensive care unit stay, pain, and high serum blood urea nitrogen were important factors associated with delirium in patients hospitalized for more than 5 days in a surgical ward.

Modified esophagogastrostomy in laparoscopy-assisted proximal gastrectomy: A reverse-Tornado anastomosis.

INTRODUCTION: The aim of this study was to introduce and examine a modified mechanical end-to-side esophagogastrostomy method ("reverse-Tornado" anastomosis) in laparoscopy-assisted proximal gastrectomy. METHODS: Five patients with gastric cancer who underwent laparoscopy-assisted proximal gastrectomy were analyzed retrospectively. Esophagogastrostomy in the anterior wall was performed in three patients, and esophagogastrostomy in the posterior wall was performed in two patients. Clinicopathological features, operative outcomes (operative time, operative blood loss), and postoperative outcomes (complications, postoperative hospital stay, reflux esophagitis) were evaluated. RESULTS: Operative time was normal (278 min). There was no marked operative blood loss, postoperative complications, prolonged hospital stay, or reflux esophagitis. CONCLUSION: Esophagogastrostomy was completed in a normal time with reverse-Tornado anastomosis. This method can be safe and can enable good postoperative quality of life.

Pre-operative diagnosis and successful surgery of a strangulated internal hernia through a defect in the falciform ligament: a case report.

INTRODUCTION: Internal hernia within the falciform ligament is exceedingly rare. A literature search revealed only 14 cases of internal herniation of the small bowel through a congenital defect of the falciform ligament, most of which were found intra-operatively. CASE PRESENTATION: A 77-year-old Japanese woman presented to our emergency department with sudden hematemesis, occurring at least four to five times over a 12-hour period. No ulcer or gastrointestinal bleeding was detected on gastroendoscopy. A 40mm mass in the inferior lobe of the right lung was found on a chest X-ray, and our patient's symptoms were therefore initially ascribed to aspirated blood from lung tumor-associated hemoptysis. However, our patient continued to show signs of severe abdominal pain and decreased urine output despite aggressive hydration, leading her examining physicians to search for a possibly severe, occult abdominal pathology. On emergent computed tomography imaging, we found an acute strangulated internal hernia within the falciform ligament. Diagnosis was made by helical computed tomography, permitting rapid surgical intervention. CONCLUSIONS: Our findings on computed tomography imaging assisted with the pre-operative diagnosis and enabled us to make a rapid surgical intervention. Early diagnosis may help preclude significant strangulation with unnecessary resection.

Development of a simple model for predicting need for surgery in patients who initially undergo conservative management for adhesive small bowel obstruction.

BACKGROUND: Among patients with adhesive small bowel obstruction (ASBO) initially managed with a conservative strategy, predicting risk of operation is difficult. METHODS: We investigated ASBO patients at 2 different periods to derive and validate a clinical prediction model for risk of operation. RESULTS: One hundred fifty-four patients were enrolled into the derivation cohort and 96 into the validation cohort. Based on the derived scoring, including age > or =65 years, presence of ascites, and gastrointestinal drainage volume >500 mL on day 3, each patient was classified into 1 of 4 risk classes from low risk to high risk. When applied to the validation cohort, the positive predictive value (PPV) for operation in the high-risk class was 72%, while the negative predictive value (NPV) in the low-risk class was 100% with high sensitivity (100%) and specificity (96%). CONCLUSIONS: The prediction model performs well for risk stratification of need for surgical intervention following conservative strategy among ASBO patients.

A new technique to achieve sufficient mesorectal excision in upper rectal cancer.

BACKGROUND: Appropriate partial mesorectal excision (PME) is extremely important for prevention of local recurrence even in upper rectal cancer. However, it is not always easy to conduct PME in the narrow pelvic cavity. We devised a new surgical technique that involves a rectal transection followed by PME. METHODS: After rectal mobilization in the layer targeted for total mesorectal excision, only the rectal wall was bluntly dissected at an appropriate distance from the tumor. Initial transection of the rectum allows drawing the rectum toward the anal side so that the mesorectum can be confirmed with a good visual field. Excision of the mesorectum was easy, and it could be resected in a short time. RESULTS: This technique was conducted on seven patients with upper rectal cancer and on four patients with rectosigmoid cancer. Separation of the rectal wall was comparatively easy, and we had no incidence of wall injury. The average distance from the rectal stump to the distal mesorectum in the freshly resected specimen was 15 mm, indicating satisfactory PME. CONCLUSIONS: This easily performed method is a promising procedure for achieving sufficient PME in upper rectal cancer.

Pancreas-sparing tumor enucleation for pancreatic mucinous cystic neoplasms: experience with two patients.

BACKGROUND: Because mucinous cystic neoplasms (MCNs) occur in the body and tail of the pancreas, distal pancreatectomy has been conventionally performed. However, enucleation can be adopted in selected patients, preserving the pancreatic parenchyma. METHODS: We experienced two patients with MCN who underwent pancreatic tumor enucleation. Case 1 involved a very large MCN, 23 cm across. Connective tissues between the tumor and the pancreatic parenchyma were not dense, so it was relatively easy to perform pancreatic cyst resection. Case 2 involved a MCN, 5 cm across, located next to the body of the pancreas. Fibrotic changes were so dense that it was difficult to separate the tumor from the pancreatic parenchyma. Careful and gentle dissection enabled pancreas-sparing enucleation without injury to the cyst wall. RESULTS: Enucleation of MCNs were performed successfully, preserving the pancreatic parenchyma. No complications were observed in either case. CONCLUSIONS: It is important to adopt the appropriate surgical procedure for MCN, considering the balance between radical resection and preservation of pancreatic function. Although careful attention should be paid to the assessment of malignant potential in each case of MCN, pancreas-sparing tumor enucleation can be considered as one of the treatment options in selected patients.