Complex Robotic Lower Urinary Tract Surgery in Patients with History of Open Surgery.

PURPOSE: We describe our experience with robot-assisted complex lower urinary tract reconstruction in patients with a history of open abdominal surgery. MATERIALS AND METHODS: Patients with any previous open abdominal surgery undergoing robot-assisted complex lower urinary tract reconstruction were included. Complex lower urinary tract reconstruction was defined as bladder neck reconstruction or continent catheterizable conduits or both, redo surgery at the bladder neck for persistent incontinence or any of these procedures with creation of a Malone antegrade continence enema. Ureteral and renal surgeries were excluded. Patient demographics, surgery performed, operative techniques, operative times and outcomes were assessed. RESULTS: A total of 36 patients met inclusion criteria, of whom 21 had undergone multiple laparotomies for ventriculoperitoneal shunt revision, 14 had undergone laparotomy with other adjunct procedures and 1 had undergone laparotomy with colostomy. No access injury occurred and there were 5 conversions. Mean operative time was 8.2 hours (range 4 to 12) and mean length of hospital stay was 74.9 hours (23 to 216). The first 18 cases took longer than the last 18 cases (mean 9.1 vs 7.5 hours, p = 0.002). Patients with multiple ventriculoperitoneal shunt revisions had higher conversion rates (p = 0.01) and longer mean operative times (p = 0.002). Patients with a history of multiple ventriculoperitoneal shunt revisions also had longer hospital stays (p = 0.02). CONCLUSIONS: Robot-assisted complex lower urinary tract reconstruction in patients with previous open abdominal surgery is safe and feasible. Longer operative times should be expected early in the experience of a surgeon. Patients with multiple prior ventriculoperitoneal shunt revisions had higher conversion rates and longer operative times compared to those with other indications for prior surgery.

Use of Iodized Oil and Gelatin Sponge Embolization in Splenic Artery Coiling Reduces Bleeding from Laparoscopic Splenectomy for Cirrhotic Portal Hypertension Patients with Complicating Hypersplenic Splenomegaly: A Comparative Study.

OBJECTIVE: Laparoscopic splenectomy (LS) is relatively contraindicated in cirrhotic portal hypertension (CPH) patients with complicating hypersplenic splenomegaly (HS). This study aimed to evaluate the effectiveness and safety of incorporation of iodized oil and gelatin sponge embolization to conventional splenic artery embolization (cSAE) with coiling in CPH/HS patients undergoing LS. PATIENTS AND METHODS: Between April 2012 and March 2014, eligible CPH/HS patients (n = 56) were assigned to preoperative modified SAE (mSAE) with LS (mSAE+LS group, n = 16), cSAE with LS (cSAE+LS group, n = 20) or LS alone (LS group, n = 20). Main outcome measures included frequency of conversion to laparotomy, operative time, intraoperative bleeding, and transfusion. RESULTS: The three groups had similar baseline characteristics (all P > .05). mSAE and cSAE similarly decreased LS conversion frequency (mSAE+LS versus cSAE+LS versus LS, 0.0% versus 10.0% versus 30.0%, P = .030) and operative time (155 ± 23 minutes versus 170 ± 26 minutes versus 221 ± 42 minutes, P < .001) compared with LS alone. mSAE significantly reduced bleeding (178 ± 22 mL versus 250 ± 27 mL versus 328 ± 67 mL, P < .001) compared with cSAE and LS alone. The three groups had similar postoperative recovery times and surgical morbidities (all P > .05). CONCLUSIONS: In CPH/HS patients, preoperative SAE reduced LS conversion frequency and reduced operative time compared with LS alone, while mSAE further decreased volume of blood loss.

Antibiotics in acute calculous cholecystitis - do Tokyo guidelines influence the surgeons' practices?

OBJECTIVE: To observe changes in surgeons' practice of antibiotic usage in patients with acute cholecystitis before and after the implementation of Tokyo Guidelines. METHODS: This retrospective, descriptive study was conducted at the Aga Khan University Hospital, Karachi, and comprised the medical records of all patients with the diagnosis of acute calculus cholecystitis who presented in 2009 and those who presented in 2014 after the implementation of Tokyo Guidelines. The major variables included patients' demographics, antibiotics used and surgical outcomes. SPSS 19 was used for data analysis. RESULTS: Of the 356 patients, 96(27%) were treated in 2009 and 260(73%) in 2014. The overall mean age was 48.9±14 years. There were 185(52%) females and 171(48%) males. Comparison of the data from 2 years showed no difference in gender, American Society of Anaesthesiologists level, grade of acute cholecystitis and frequency of use of empiric antibiotics (p>0.05 each). However, there was significantly less use of combination therapy (p=0.00) and metronidazole (p=0.00) in 2014than in 2009. Interval cholecystectomy was significantly less practised in 2014 (p=0.03) resulting in shorter hospital stay (p=0.00). Despite improvement in antibiotic usage practices, post-operative infection rates remained the same in both the groups (p=0.58). CONCLUSIONS: Implementation of Tokyo Guidelines not only greatly influenced but also standardised the choice of antibiotics in patients without compromising the infective and surgical outcomes.

Outcome of Laparoscopic Treatment of Anorectal Malformations in Children.

BACKGROUND: Operative correction of anorectal malformations (ARMs) remains a challenge in pediatric surgery. The study aimed to evaluate the outcomes of laparoscopic treatment of ARM in children. METHODS: From 2007 to 2014, we performed 104 laparoscopic-assisted anorectal pull-through procedures in children with a mean age of 11.3 ± 0.4 months and ARMs. Clinical assessment, surgical durations, complications, and postoperative outcome were investigated. RESULTS: The mean duration of the operation was 126.5 ± 17.2 min. Mean intraoperative bleeding was 20 ± 5.7 g. Three (2.9 %) children required conversion to laparotomy. One (0.9 %) child developed a pelvic abscess, requiring an additional intervention. Three to six months after laparoscopic-assisted anorectal pull-through, 72 patients were hospitalized for stoma closure. Good functional results were achieved in 39 (54.2 %) patients. On examination of the perineum, 11 (15.3 %) patients were found to have mucosal prolapse. The circular symmetric anal reflex to tactile stimulation was confirmed in 53 (73.6 %) patients and a tactile weakened anal reflex in 5 (6.9 %) children. At the 1-year follow-up, constipation was present in nine (12.5 %) patients and soling in two (2.8 %) patients. A barium enema study performed after the operation showed good outcomes in 67 (93.1 %) patients and fair outcomes in 5 (6.9 %) patients. None had a poor outcome. CONCLUSIONS: Our experience confirms that laparoscopic-assisted anorectal pull-through enabled complete correction of ARM in the meanwhile avoiding damage to the rectum and anus. Also, the technique of double bipolar myostimulation of muscle complex in laparoscopic ARM might lead to these better results.

Robotic Right Colectomy with Modified Complete Mesocolic Excision: Long-Term Oncologic Outcomes.

BACKGROUND: A modified complete mesocolic excision (mCME) technique for the treatment of right-sided colon cancer recently was shown by Hohenberger and colleagues to provide impressive long-term oncologic outcomes. This report aims to describe the authors' experience with robotic right colectomy using mCME. The safety, feasibility, and efficacy of this procedure are measured by complications, conversion rates, and 4-year oncologic outcomes. METHODS: A retrospective study analyzed 100 consecutive patients who underwent robotic right colectomy with mCME and intracorporeal anastomosis at the authors' institution between November 2005 and November 2013. Intra- and postoperative clinical outcomes, pathologic data, and survival were analyzed. RESULTS: Robotic right colectomy with mCME was successfully performed for all the patients. No conversions or intraoperative complications occurred. The major complication rate (Dindo 3 or 4) was 4 %. During a median follow-up period of 48.5 months (range 24-114 months), the survival rates were 94.5 % for disease-specific survival, 91.4 % for disease-free survival, and 90.3 % for overall survival. CONCLUSIONS: The authors' experience confirms the feasibility and safety of mCME for the treatment of right-sided colon cancer. This technique provided satisfying short-term outcomes with promising 4-year oncologic results. However, the real benefits of the CME technique should be evaluated further by well-conducted randomized studies before its adoption in routine practice is recommended.

Development of a video-assisted thoracoscopic lobectomy program in a single institution: results before and after completion of the learning curve.

BACKGROUND: The development of a video assisted thoracic surgery lobectomy (VATS-L) program provides a dedicated surgical team with a recognized learning curve (LC) of 50 procedures. We analyse the results of our program, comparing the LC with subsequent cases. METHODS: From June 2012 to March 2015, we performed n = 146 VATS major pulmonary resections: n = 50 (Group A: LC); n = 96 (Group B). Pre-operative mediastinal staging followed the National Comprehensive Cancer Network guidelines. All procedures were performed using a standard anterior approach to the hilum; lymphadenectomy followed the NCCN recommendations. During the LC, VATS-L indication was reserved to clinical stages I, therefore evaluated case by case. RESULTS: Mean operative time was 191 min (120-290) in Group A and 162 min (85-360) in Group B (p <0,01). Pathological T status was similar between two Groups. Lymphadenectomy included a mean of 5.8 stations in Group A and 6.6 in Group B resulting in: pN0 disease: Group A n = 44 (88 %), Group B n = 80 (83.4 %); pN1: Group A n = 3 (6 %), Group B n = 8 (8.3 %); pN2: Group A n = 3 (6 %), Group B n = 8 (8.3 %). Conversion rate was: 8 % in group A (n = 4 vascular injuries); 1.1 % in Group B (n = 1 hilar lymph node disease). We registered n = 6 (12 %) complications in Group A, n = 10 (10.6 %) in Group B. One case (1.1 %) of late post-operative mortality (90 days) was registered in Group B for liver failure. Mean hospital stay was 6.5 days in Group A and 5.9 days in Group B. CONCLUSIONS: We confirm the effectiveness of a VATS-L program with a learning curve of 50 cases performed by a dedicated surgical team. Besides the LC, conversion rate falls down, lymphadenectomy become more efficient, indications can be extended to upper stages.

Single-incision versus conventional laparoscopic cholecystectomy in patients with uncomplicated gallbladder disease: a meta-analysis.

BACKGROUND: Laparoscopic cholecystectomy is the gold standard treatment for cholecystectomy. Recently, single-incision laparoscopic cholecystectomy (SILC) has been suggested as an alternative technique. METHODS: Six databases were searched and reference lists of retrieved articles were checked to identify eligible studies. Data from randomized clinical trials related to the safety and effectiveness of SILC versus conventional laparoscopic cholecystectomy (CLC) were extracted by 2 independent reviewers. Odds ratio and mean differences were calculated with 95% confidence intervals based on intention-to-treat analyses whenever possible. RESULTS: Fifteen studies with 1113 patients met the eligibility criteria. Methodologic quality was unclear in most trails. Operating time was significantly longer in the single-incision laparoscopic surgery group compared with the CLC group (P<0.00001). Cosmesis was improved in single-incision laparoscopic patients at 1 month (P<0.00001). The pooled mean difference in pain scores at 24 hours was -0.75 in favor of the SILC technique (P=0.04). There was no significant difference in the conversion rates, adverse events, analgesia requirements, or the length of hospital stay between the 2 groups. CONCLUSIONS: The current evidence shows that patients with uncomplicated cholelithiasis or polypoid lesions of the gallbladder who prefer a better cosmetic outcome, SILC offers a safe alternative to CLC. Further high-powered randomized trials are need to determine whether SILC truly offer any advantages, especially be focused on failure of technique, adverse events, cosmesis, and quality of life.

Neoadjuvant therapy and mini-invasive total mesorectal excision for rectal cancer: feasibility and outcome analysis from a single institution prospectively collected data base.

AIM AND BACKGROUND: Neoadjuvant treatment for rectal adenocarcinoma improves local control and represents the standard for locally advanced disease. Laparoscopic and robotic total mesorectal excision has been increasingly adopted. It provides magnified visualization of the pelvic cavity, thereby facilitating the mesorectal dissection. METHODS: Consecutive patients with locally advanced/ultralow rectal adenocarcinoma received neoadjuvant treatment and mini-invasive total mesorectal excision at our center. We retrospectively reviewed the clinical records by using a prospectively collected data base and focusing on feasibility, tumor response and treatment outcomes. RESULTS: In a 13-year period, 117 rectal adenocarcinoma patients (80 males and 37 females) received neoadjuvant treatment and mini-invasive total mesorectal excision. Median age at diagnosis was 67 years; pre-treatment stage was I in 10 (9%); IIA in 58 (50%); IIC in 5 (4%); IIIA in 10 (9%); IIIB in 31 (26%) and IV in 3 (2%) patients. All patients received external beam radiation therapy, 79 (67%) combined with fluorouracil-based chemotherapy. One-hundred and three patients underwent laparoscopic surgery and 14 robotic surgery. Overall, 90 patients (77%) had anterior resection and 27 (23%) had abdominoperineal resection. Down-staging was obtained in 70 patients (66%). No major intraoperative nor delayed surgical complications were observed. At a median follow up of 52 months, 8 patients (7%) had a local relapse, 7 of them along with distant relapse, and 16 (14%) had distant relapse. The 5-year relapse-free survival was 76.5%. CONCLUSIONS: Our data suggest that in a community hospital mini-invasive surgery after neoadjuvant treatment is feasible in real clinical practice and achieves consistent results in term of disease control rate.