Robot-assisted surgery in thoracic and visceral indications: an updated systematic review.

BACKGROUND: In surgical advancements, robot-assisted surgery (RAS) holds several promises like shorter hospital stays, reduced complications, and improved technical capabilities over standard care. Despite extensive evidence, the actual patient benefits of RAS remain unclear. Thus, our systematic review aimed to assess the effectiveness and safety of RAS in visceral and thoracic surgery compared to laparoscopic or open surgery. METHODS: We performed a systematic literature search in two databases (Medline via Ovid and The Cochrane Library) in April 2023. The search was restricted to 14 predefined thoracic and visceral procedures and randomized controlled trials (RCTs). Synthesis of data on critical outcomes followed the Grading of Recommendations, Assessment, Development, and Evaluation methodology, and the risk of bias was evaluated using the Cochrane Collaboration's Tool Version 1. RESULTS: For five out of 14 procedures, no evidence could be identified. A total of 20 RCTs and five follow-up publications met the inclusion criteria. Overall, most studies had either not reported or measured patient-relevant endpoints. The majority of outcomes showed comparable results between study groups. However, RAS demonstrated potential advantages in specific endpoints (e.g., blood loss), yet these findings relied on a limited number of low-quality studies. Statistically significant RAS benefits were also noted in some outcomes for certain indications-recurrence, quality of life, transfusions, and hospitalisation. Safety outcomes were improved for patients undergoing robot-assisted gastrectomy, as well as rectal and liver resection. Regarding operation time, results were contradicting. CONCLUSION: In summary, conclusive assertions on RAS superiority are impeded by inconsistent and insufficient low-quality evidence across various outcomes and procedures. While RAS may offer potential advantages in some surgical areas, healthcare decisions should also take into account the limited quality of evidence, financial implications, and environmental factors. Furthermore, considerations should extend to the ergonomic aspects for maintaining a healthy surgical environment.

[Surgical treatment of patients with urogenital tuberculosis].

Despite the modest positive trends in the epidemic situation for tuberculosis, the incidence of extrapulmonary tuberculosis is not consistent. The relevance of urogenital tuberculosis remains high, as well as its social significance. Tuberculosis of the kidneys and urinary tract is often diagnosed late, when drug therapy is not enough and surgical treatment is required. A total of 78 national and foreign publications dedicated to surgical treatment of patients with urogenital tuberculosis were analyzed. Various surgical techniques for renal and bladder tuberculosis are described with a comparison of their advantages and disadvantages. Tuberculosis of the urinary system, like any infectious disease, can and must be cured with drug therapy. Unfortunately, there are complicating subjective (low alertness of doctors regarding tuberculosis, low adherence to national and international guidelines) and objective (absence of pathognomonic symptoms of urogenital tuberculosis, which results in late diagnosis, increased drug resistance of the pathogen, high comorbidity) factors. The advancements in surgical techniques and modern drugs for neoadjuvant therapy give patients the opportunity to receive minimally invasive treatment that saves not only life, but also provides them acceptable quality of life.

Comparison of pediatric choledochal cyst excisions with open procedures, laparoscopic procedures and robot-assisted procedures: a retrospective study.

BACKGROUND: The main treatment of choledochal cysts is the complete resection of the cyst with Roux-en-Y hepaticojejunostomy, which includes open procedures, laparoscopic procedures, and robot-assisted procedures using a da Vinci surgical system. The aim of this current study was to investigate the safety and effectiveness of these three different surgical methods in pediatric choledochal cyst excisions. METHODS: Between January 2015 and December 2018, patients with choledochal cysts treated with open procedures, laparoscopic procedures, or robot-assisted procedures were retrospectively analyzed. The data collected included demographic information of all patients, type and size of cyst, operative details, and postoperative outcomes. RESULTS: A total of 371 episodes of patients were enrolled which consist of the open procedures group (n = 226), laparoscopic procedures group (n = 104), and robot-assisted procedures group (n = 41). The operation time was significantly longer in the laparoscopic procedures group (212.79 ± 34.94) than open procedures group (115.88 ± 13.50) and robot-assisted procedures group (180.61 ± 14.07) (p < 0.001). The volume of intraoperative bleeding were higher in the open procedures group (40.12 ± 55.51) than in the laparoscopic procedures group (21.73 ± 11.44) and robot-assisted procedures group (21.34 ± 9.42), while there was no significant difference between the latter groups. The time to taking water, time to starting liquid diet, and the average length of postoperative hospital stay were similar between the laparoscopic and robot-assisted procedures group, which are shorter than the open procedures group with significant differences. There was no signifcant difference in complications among the three groups. CONCLUSION: Choledochal cyst excision with robotic-assisted procedures had identical surgical effects as open procedures and had lower technical requirements. But it had higher medical cost and better cosmetic effects. Open procedures had largely positive surgical outcomes with fewest complications but poor cosmetic effects. Laparoscopic procedures were the most technique-demanding approaches with positive cosmetic and economic effect. The incidence of complications of laparoscopic procedures decreased with the learning curve.

Effect of dexamethasone on analgesic efficacy of transverse abdominis plane block in laparoscopic gynecological procedures: A prospective randomized clinical study.

BACKGROUND AND AIMS: Dexamethasone has been increasingly used as an adjuvant to local anesthetics in peripheral nerve blocks with various studies showing an opioid sparing the effect of intravenous (IV) dexamethasone as well in a multimodal analgesia technique. It is not clear whether this effect of dexamethasone is because of its peripheral action or because of its systemic absorption. In our study, we compared the effectiveness of dexamethasone on duration of analgesia when used as an adjuvant with local anesthetic in transverse abdominis plane block (TAP) versus when given systemically by IV route along with block only, in patients undergoing laparoscopic gynecological procedures under general anesthesia (GA). MATERIAL AND METHODS: This is a prospective, randomized, parallel treatment, double-blinded study. The primary outcome of our study was the time to administration of first rescue analgesia. Forty patients were randomly assigned to perineural (PN) and IV Group using a computer-generated random numbers table and allocated using sealed opaque envelopes technique. After induction of GA, PN group received ultrasound guided TAP block with 15 ml of 0.25% levobupivacaine plus 4 mg (1 ml) dexamethasone on each side. Patients in IV group received TAP block on both sides with 15 ml of 0.25% levobupivacaine and 8 mg IV dexamethasone. RESULTS: Time to request for first rescue analgesia was 6.63 ± 1.5 h in PN group and 5.04 ± 1.7 h in IV group. Pain scores were comparable in both the groups. CONCLUSION: Dexamethasone administered in either of the routes has comparative effect on quality of analgesia of TAP block with 0.25% levobupivacaine.

Restoration of Pulmonary Compliance after Laparoscopic Gynecologic Surgery Using a Recruitment Maneuver.

BACKGROUND/OBJECTIVES: This study aimed to investigate the hypothesis that an alveolar recruitment maneuver can restore lung compliance to initial values after laparoscopic gynecological surgery. METHODS: A total of 31 patients who underwent laparoscopic gynecological surgery were enrolled. Protective mechanical ventilation was applied, and the radial artery was catheterized in all patients. An alveolar recruitment maneuver (incremental and decremental positive end-expiratory pressure) was applied ten minutes after the release of pneumoperitoneum. The respiratory mechanics and blood gas results were recorded at eight different time points: after induction of anesthesia (T1), in the lithotomy position (T2), in the Trendelenburg position (T3), 10 and 90 min after insufflation of carbon dioxide (T4 and T5), in the supine position (T6), after desufflation (T7), and 10 min after an alveolar recruitment maneuver at the end of surgery (T8). RESULTS: Pneumoperitoneum and the Trendelenburg position caused a decline of 15 units in compliance (T7 vs. T1; p < 0.05) compared to baseline. After the alveolar recruitment maneuver, compliance increased by 17.5% compared with the mean value of compliance at time T1 (T8 vs. T1; p < 0.05). The recruitment maneuver had favorable results in patients with low initial compliance (41.5 mL/cmH2O, IQR: 9.75 mL/cmH2O), high Body Mass Index 30.32 kg/m2 (IQR: 1.05 kg/m2), and high initial plateau airway pressure (16.5 cmH2O, IQR: 0.75 cmH2O). CONCLUSIONS: Lung compliance does not return to initial values after performing laparoscopic gynecological procedures. However, after the release of pneumoperitoneum, an alveolar recruitment maneuver is beneficial as it improves compliance and gas exchange.

Surgical outcomes of robotic-assisted cyst excisions and hepaticojejunostomies in patients with perforated choledochal cysts: a single-center retrospective study.

Perforated choledochal cysts is usually treated by open approach through a one- or two-stage procedure. Laparoscopic procedures are gradually being used more commonly with advancements in minimally invasive technology, while the level of difficulty and conversion rate are still high due to adhesions and deranged anatomy. Robot-assisted choledochal cyst excisions have been proposed as another minimally invasive procedure that is thought to improve operability and precision compared with laparoscopic surgery. However, there is still a lack about the use of robotic assistance for bilio-enteric reconstruction in pediatric patients with perforated choledochal cyst excisions. The aim of this current study was to investigate the safety and effectiveness of robotic-assisted procedures in pediatric perforated choledochal cyst excisions. Patients suffering from perforated choledochal cysts and treated with surgical procedures including open, laparoscopic, and robotic procedures between January 2009 and December 2021 were retrospectively analyzed. Robotic cyst excisions and hepaticojejunostomies were mainly used to a one-stage procedure (the pseudocyst formation or intra-mural perforation) or in stage 2 of two-stage procedures (complete perforation). Data collection included patient characteristics, intraoperative outcomes, and postoperative complications. There were a total of 64 patients suffering from perforated choledochal cysts were treated at our institution. Thirty-one cases of cyst excisions and hepaticojejunostomies were completed by open procedures. Twenty-two cases of cyst excisions and hepaticojejunostomies were completed by laparoscopic procedures and 11 cases were completed by robotic procedures. The operating times were significantly longer in the laparoscopic procedures group (214.32 ± 51.33 min) than found with either the open procedures group (130.55 ± 10.51 min) or the robot-assisted procedures group (188.82 ± 16.55 min) (p < 0.001). The time to oral intake, total complication, and hospital stay were similar among all three groups (3.53 ± 0.28 days vs 3.47 ± 0.30 days vs 3.46 ± 0.29 days, 19.35% vs 27.27% vs 18.18%, 11.48 ± 1.29 days vs 11.95 ± 2.75 days vs 11.55 ± 2.38 days, respectively) (p > 0.05). The number of biliary complications was higher in the laparoscopic procedures group (18.18%) than in both the open procedures and robot-assisted procedures groups (0.00%) (p = 0.016). Robotic-assisted cyst excision and hepaticojejunostomy procedures in patients with perforated choledochal cysts are both safe and feasible. What is more, they can achieve the same results as open procedures and also reduce the level of difficulty of operations and bring fewer biliary complications compared with laparoscopic procedures.

Clinical efficacy and safety of robot assisted surgery for choledochal cysts excisions: a systematic review and meta-analysis.

BACKGROUND: This study aimed to evaluate the safety and therapeutic effect of Robot-assisted surgery (RAS) for choledochal cysts (CCs) excisions. RESEARCH DESIGN AND METHODS: PubMed, EMBASE, Cochrane Library, Web of Science, CNKI, WanFang, VIP, and CBM were searched from database inception to 1 May 2022. The Newcastle-Ottawa scale (NOS) was used to conduct quality assessments, and RevMan (Version 5.4) was used to perform the meta-analysis. RESULTS: In all, 9 studies, involving 623 patients, were analyzed. RAS compared with LAS was associated with less intraoperative blood loss, shorter time to start solid diets, shorter postoperative hospital stay, and lower complications. There was no significant difference in operative time between the two groups, but the total costs were higher in RAS. Our subgroup analysis showed that RAS had significant advantages over LAS in the child group: minor bleeding, shorter length of hospital stay, and fewer postoperative complications. CONCLUSIONS: The available evidence indicates that the RAS system has the advantages of less intraoperative blood loss, minor tissue damage, quick recovery, and sound healing in treating choledochal cyst, which proves that the RAS is safely feasible. Especially in children, RAS tends to be a better choice.

Combined Retroperitoneal and Transperitoneal Laparoscopic Procedures by a Single Surgeon: Boon to Economically and Medically Backward Areas.

Introduction This study was done to evaluate our experience of combining a retroperitoneal laparoscopic urological operation with other transperitoneal laparoscopic operations. Materials and methods We present a retrospective study of a series of 20 cases of retroperitoneal laparoscopic urological surgeries combined with at least one transperitoneal laparoscopic procedures, performed by a senior minimally invasive surgeon, between March 2013 and August 2020. We have excluded three patients where either of the procedures required conversion to open surgery. We retrospectively reviewed all the data regarding the patient's demographics, combined surgical procedures done, operative time taken, blood loss, intraoperative and postoperative complications, and days of hospital stay. Results Total of 20 patients had undergone simultaneous retroperitoneal and transperitoneal laparoscopic procedures. A total of nine (45%) cases comprised a combination of retroperitoneal laparoscopic ureterolithotomy and laparoscopic cholecystectomy. Two patients had undergone a combination of three laparoscopic procedures in the same operation. The mean hospital stay was 3.6 days. Blood loss was minimal to moderate in all the patients, none needed any perioperative blood transfusion. No major complications were noted in any patients. Conclusion Combining a retroperitoneal laparoscopic urological procedure with another transperitoneal laparoscopic surgery is very much feasible. It becomes even easier and relevant provided both the procedures are performed by a single, experienced laparoscopic surgeon.

Laparoscopic procedures experience in Mexico during 2015: ¿Where are we?

BACKGROUND: 26 years have passed from the first laparoscopic cholecystectomy in Mexico. Since then the laparoscopy has been adopted of variable way and has extended into different specialties. OBJECTIVE: To identify the place that laparoscopic approaches occupy at the present time in Mexico. METHOD: We searched the codes that had the word laparoscopy or laparoscopic in the records of the Automated System of Hospitable Discharges in 2015. Based on the obtained information there was realized a descriptive and retrospective study. RESULTS: We found 55 different procedures in a total of 30,174. Of them, 79.7% in women and 20.3% in men. The most common age was between 25 and 29 years. The ten first ones were cholecystectomy, appendectomy, total abdominal laparoscopic hysterectomy, procedures to create esophago-gastric sphincter competence, unilateral salpingo-oophorectomy, partial cholecystectomy, ovarian resection, umbilical hernia repair, incidental appendectomy and unilateral oophorectomy (94.6%). The States with the major number are Mexico City, State of Mexico, Jalisco, Guanajuato and Sonora. CONCLUSIONS: The laparoscopic procedures have increase in the national health systems and there is concordance of the most common with the international statistics. However, is necessary to diversify them and reduce the times of hospital stay. Its application is in process and it still face challenges in relation to availability of organizational elements, equipment, infrastructure and training, although there are different ways to overcome them.

ANTECEDENTES: Han pasado 26 años desde la primera colecistectomía laparoscópica en México. Desde entonces, la laparoscopía se ha adoptado de forma variable y se ha extendido a diferentes especialidades. OBJETIVO: Identificar el sitio que ocupan los abordajes laparoscópicos en México. MÉTODO: Se buscaron los códigos que tuvieran la palabra laparoscopia o laparoscópica en los registros del Sistema Automatizado de Egresos Hospitalarios en 2015. Con los datos obtenidos se realizó un estudio descriptivo y retrospectivo. RESULTADOS: Se encontraron 55 procedimientos diferentes en un total de 30,174. De ellos, el 79.7% en mujeres y el 20.3% en hombres. La edad más común fue entre los 25 y 29 años. Los diez primeros fueron colecistectomía, apendicectomía, histerectomía total abdominal laparoscópica, procedimientos para creación de competencia esfinteriana esofagogástrica, salpingo-ooforectomía unilateral, colecistectomía parcial, escisión local o destrucción de ovario, plastia umbilical, apendicectomía incidental y ooforectomía unilateral (94.6% del total). Los Estados con el mayor número reportado fueron Ciudad de México, Estado de México, Jalisco, Guanajuato y Sonora. CONCLUSIONES: Los procedimientos laparoscópicos han ido en aumento en los sistemas de salud nacionales y hay concordancia de los más comunes con las estadísticas internacionales. Sin embargo, es necesario diversificarlos y disminuir los tiempos de estancia hospitalaria. Su aplicación está en proceso y aún enfrentan retos en relación con la disponibilidad de elementos organizacionales, equipo, infraestructura y entrenamiento, aunque existen diferentes alternativas para vencerlos.

The effect of pulmonary hypertension on inpatient outcomes of laparoscopic procedures.

The purpose of our analysis was to assess the effects of pulmonary hypertension (PH) on clinical outcomes of patients undergoing laparoscopic procedures. Pulmonary hypertension alters physiologic patterns that has the potential to complicate laparoscopic procedures, however, an in-depth analysis evaluating survival outcomes, complications, and associated comorbidities has not been done before. Data from the National Inpatient Survey were used to identify 179,663 patients without PH and 1453 patients with PH undergoing laparoscopic procedures from the years 2003-2013. In patients with pulmonary hypertension, the presence of the following comorbidities, congestive heart failure (OR 3.56) diabetes with chronic complications (OR 3.74) fluid and electrolyte disorders (OR 7.34) metastatic cancer (OR 14.42) and peripheral vascular disease (OR 3.12) increased in-patient mortality. In regards to post-operative complications, patients with PH were more likely to have cardiac complications defined as cardiac arrest, cardiac insufficiency, cardiorespiratory failure, or heart failure (OR 3.74). Patients with PH were also more likely to develop iatrogenic pneumothorax (OR 4.13) iatrogenic pulmonary embolism (OR 7.65) and post-operative urinary complications (OR 1.92). Overall, the comorbidity with the highest association with in-patient mortality was metastatic cancer and of all complications, patients with PH were most likely to develop iatrogenic pulmonary embolism. Preparing for these adversities, notably in patients with certain associated conditions has the potential to improve patient outcome.

Hemostasis with the Ultrasonic Scalpel.

BACKGROUND AND OBJECTIVES: The ultrasonically activated scalpel is a surgical instrument that is used in minimally invasive surgery to safely cut and seal vessels. This study reported the experimental observations of the use of a laparoscopic ultrasonic scalpel, including its safety and feasibility. in sealing vessels of different diameters in an in vivo animal model during both physiological and supraphysiological blood pressure (BP) conditions. METHODS: One healthy female swine was used. We performed resections of the omentum, biopsies in different regions of the liver, and a hysterectomy. Vessels with diameters ranging from 2 to 10 mm were sealed with the ultrasonic scalpel under regular hemodynamic conditions and during pharmacologically induced arterial hypertension (BP challenge). RESULTS: For 10 random cuts made in the omentum and during the hysterectomy, the ultrasonic scalpel was effective and fast, with no immediate or delayed bleeding. Bipolar energy, sutures, and hemoclips were not required to control bleeding. No bleeding was observed in sealed vessels up to 8 mm, even during BP challenges sustained for longer than 5 minutes. When testing vessels of 10 mm, bleeding occurred in 1 common iliac vein before 10 minutes of waiting (the point of bleeding was easily identified) and bleeding occurred in 1 of the common iliac arteries during the BP challenge. CONCLUSION: Our findings corroborate that the ultrasonic scalpel can safely seal arteries up to 8 mm in diameter to prevent or control bleeding during laparoscopic procedures, even when BP exceeds normal levels.

Cornelia de Lange syndrome - characteristics and laparoscopic treatment modalities of reflux based on own material.

Cornelia de Lange syndrome (typus degenerativus amstelodamensis, CdLS, Brachmann syndrome) is a complex, congenital, multi-gene anomaly characterized by mental retardation. Its features include growth inhibition, hirsutism, structural anomalies of the limbs and abnormal development of osseous structures of the face. Independent of the phenotype of the disease, 85% of patients are assumed to have symptoms of gastroesophageal reflux disease (GERD). Aspiration pneumonia is one of the complications of GERD and a main cause of death in these patients. Patients not responding to medical treatment qualify for surgery. Until recently, anti-reflux procedures for GERD in CdLS patients were performed solely via laparotomy. The contemporary gold standard is a procedure performed laparoscopically. There are a few case reports of patients with CdLS operated on for GERD with laparoscopy available in the literature. The goal of this paper is to present two cases of Cornelia de Lange syndrome treated with laparoscopic antireflux procedures. We have performed two such procedures in 14 and 16 year-old girls with typical symptoms of the syndrome, i.e. developmental and mental retardation, hirsutism, structural limb anomalies and abnormal face development. The main indications for surgery in both cases were ineffective medical treatment and persistent aspiration pneumonia and its complications as a result of the gastroesophageal reflux. Oesophageal hiatus hernia and reflux were confirmed with accessory tests in both cases. During 36 months of follow-up, according to Barents, no episode of oesophageal reflux with acidic gastric content was noted. The treated children slept well during the night and did not need hospitalization for aspiration pneumonia. Neither of them required proton pump inhibitors. It should be concluded that laparoscopic Nissen fundoplication is a safe and effective method of GERD treatment in children with CdLS.