Textbook Outcome of Delta-Shaped Anastomosis in Minimally Invasive Distal Gastrectomy for Gastric Cancer in 4,505 Consecutive Patients.

PURPOSE: Textbook outcome is a comprehensive measure used to assess surgical quality and is increasingly being recognized as a valuable evaluation tool. Delta-shaped anastomosis (DA), an intracorporeal gastroduodenostomy, is a viable option for minimally invasive distal gastrectomy in patients with gastric cancer. This study aims to evaluate the surgical outcomes and calculate the textbook outcome of DA. MATERIALS AND METHODS: In this retrospective study, the records of 4,902 patients who underwent minimally invasive distal gastrectomy for DA between 2009 and 2020 were reviewed. The data were categorized into three phases to analyze the trends over time. Surgical outcomes, including the operation time, length of post-operative hospital stay, and complication rates, were assessed, and the textbook outcome was calculated. RESULTS: Among 4,505 patients, the textbook outcome is achieved in 3,736 (82.9%). Post-operative complications affect the textbook outcome the most significantly (91.9%). The highest textbook outcome is achieved in phase 2 (85.0%), which surpasses the rates of in phase 1 (81.7%) and phase 3 (82.3%). The post-operative complication rate within 30 d after surgery is 8.7%, and the rate of major complications exceeding the Clavien-Dindo classification grade 3 is 2.4%. CONCLUSIONS: Based on the outcomes of a large dataset, DA can be considered safe and feasible for gastric cancer.

Robotic assisted vs open radical cystectomy: an updated systematic review and meta-analysis.

Several randomized control trials (RCTs) have been published comparing open (ORC) with robot-assisted radical cystectomy (RARC). However, uncertainty persists regarding this issue, as evidences and recommendations on RARC are still lacking. In this systematic review and metaanalysis, we summarized evidence in this context. A literature search was conducted according to PRISMA criteria, using PubMed/Medline, Web Of Science and Embase, up to March 2024. Only randomized controlled trials (RCTs) were selected. The primary endpoint was to investigate health-related quality of life (QoL) both at 3 and 6 months after surgery. Secondary endpoints include pathological and perioperative outcomes, postoperative complications and oncological outcomes. Furthermore, we conducted a cost evaluation based on the available evidence. Eight RCTs were included, encompassing 1024 patients (515 RARC versus 509 ORC). QoL appeared similar among the two groups both after 3 and 6 months. No significant differences in overall and major complications at 30 days (p = 0.11 and p > 0.9, respectively) and 90 days (p = 0.28 and p = 0.57, respectively) were observed, as well as in oncological, pathological and perioperative outcomes, excepting from operative time, which was longer in RARC (MD 92.34 min, 95% CI 83.83-100.84, p < 0.001) and transfusion rate, which was lower in RARC (OR 0.43, 95% CI 0.30-0.61, p < 0.001). Both ORC and RARC are viable options for bladder cancer, having comparable complication rates and oncological outcomes. RARC provides transfusion rate advantages, however, it has longer operative time and higher costs. QoL outcomes appear similar between the two groups, both after 3 and 6 months.

Transabdominal pre-peritoneal (TAPP) versus totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair.

BACKGROUND: An inguinal hernia occurs when part of the intestine protrudes through the abdominal muscles. In adults, this common condition is much more likely in men than in women. Inguinal hernia can be monitored by 'watchful waiting', but if symptoms persist or worsen, surgery is usually required, which can be open or laparoscopic. Laparoscopic (keyhole) repair of inguinal hernias in adults is generally performed using either the transabdominal preperitoneal (TAPP) or the totally extraperitoneal (TEP) method. Both methods include the use of mesh placed in front of the peritoneal lining of the abdominal wall, but for the TAPP technique, the abdominal cavity needs to be entered to place the mesh, and for the TEP technique, the whole procedure is done on the outside of the peritoneal lining of the abdominall wall. Whether one method is superior to the other has not been established, and there is debate about their relative benefits and harms. An advantage of TEP is its avoidance of the abdominal cavity; the downside is that it requires a steeper learning curve for clinicians. TAPP is considered simpler and makes it possible to inspect the contralateral side, but TAPP may have a higher risk of visceral injury compared to TEP. This is an update of a Cochrane review first published in 2005. OBJECTIVES: To compare the benefits and harms of laparoscopic TAPP technique versus laparoscopic TEP technique for inguinal hernia repair in adults. SEARCH METHODS: On 25 October 2022, the authors searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library; Ovid MEDLINE(R) Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily, and Ovid MEDLINE(R); and Ovid Embase, for published randomised controlled trials. To identify studies in progress, we searched ClinicalTrials.gov and the WHO International Clinical Trial Registry Platform (ICTRP). SELECTION CRITERIA: All prospective randomised, quasi-randomised, and cluster-randomised trials that compared the laparoscopic TAPP technique with the laparoscopic TEP technique for inguinal hernia repair in adults were eligible for inclusion. We included studies that involved a mix of different types of groin hernia if we could extract data for the inguinal hernias. Studies may have also included a group of participants receiving hernia repair by open surgery, but these groups were not included in our review. DATA COLLECTION AND ANALYSIS: Both review authors independently evaluated trial eligibility, extracted data from included studies, and assessed the risk of bias in the included studies. The review's primary outcomes were serious adverse events, chronic pain (persisting for at least six months after surgery), and hernia recurrence. We also assessed a variety of secondary outcomes at perioperative, early postoperative, and late postoperative time points. We performed statistical analyses using the random-effects model, and expressed the results as odds ratios (ORs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, with their respective 95% confidence intervals (CIs). We used GRADE to assess the certainty of evidence for key outcomes as high, moderate, low or very low. MAIN RESULTS: We included 23 studies in this review update, which randomised 1156 people to TAPP and 1110 people to TEP, all requiring repair of inguinal hernias. Study sample sizes varied from 40 to 316 participants. The vast majority of study participants were male. We judged most studies to be at 'high' or 'unclear' risk of bias. Our judgements of the certainty of the evidence were low or very low for all outcomes we assessed. There may be little to no difference between TAPP and TEP laparoscopic techniques for serious adverse events (0.4% versus 0.7%; OR 0.58, 95% CI 0.15 to 2.32, P = 0.45, I2 = 0%; 19 studies, 1735 participants; low certainty of evidence); and hernia recurrence (1.2% versus 1.1%; OR 1.14, 95% CI 0.49 to 2.62, P = 0.97, I2 = 0%; 17 studies, 1712 participants; low certainty of evidence). The evidence is very uncertain about the effects of TAPP versus TEP techniques on chronic pain (OR 0.62, 95% CI 0.20 to 1.97, P = 0.68, I2 = 0%; 6 studies, 860 participants; very low certainty of evidence). In terms of secondary outcomes, the evidence is very uncertain for TAPP versus TEP techniques for perioperative visceral and vascular injury (15 studies, 1523 participants; very low certainty of evidence), and for haematoma or seroma during the early (≤ 30 days) postoperative phase (OR 0.86, 95% CI 0.54 to 1.37, P = 0.3861, I2 = 0%; 15 studies, 1423 participants; very low certainty of evidence). TEP technique may carry a higher risk of conversion to another hernia repair method (either TAPP technique or open surgery) when compared to TAPP (2.5% versus 0.7%; OR 0.28, 95% CI 0.09 to 0.84, P = 0.02, I2 = 0%; 13 studies, 1178 participants; low certainty of evidence). Only two studies (474 participants) reported quality of life in the late (> 30 days) postoperative phase; overall, there was an improvement in quality of life from the pre- to post-operative assessment, but the evidence suggests little to no difference between the techniques (low certainty of evidence). AUTHORS' CONCLUSIONS: This review update found that there may be little to no difference between the TAPP and TEP techniques for serious adverse events, hernia recurrence, or chronic pain (low- to very-low-certainty evidence). Decisions about which method to use will most likely reflect surgeon and patient preference until high-certainty evidence becomes available. There may be a higher risk of needing to convert from TEP to TAPP or open surgery when compared to the risk of needing to convert from TAPP to open surgery (low-certainty evidence). If surgeons opt for TEP as their standard laparoscopic method, they could consider having a strategy for how to handle the potential need for conversion. This might include proficiency in the TAPP approach or having informed the patient about the risk of conversion to open surgery. For surgeons or surgical departments, the choice of a laparoscopic technique should involve shared decision-making with patients and their families or carers. Future research could focus on patient-reported outcomes, such as quality of life.

Transoral endoscopic thyroidectomy submental vestibular approach for early-stage papillary thyroid carcinoma: a systematic review and meta-analysis.

PURPOSE: Our study aimed to compare the effectiveness and complications of the transoral endoscopic thyroidectomy submental vestibular approach (TOETSMVA) versus the transoral endoscopic thyroidectomy vestibular approach (TOETVA) or conventional open thyroidectomy (COT) in patients with early-stage papillary thyroid carcinoma (PTC). METHODS: We searched online databases up to January 2024. The outcomes were analyzed using RevMan 5.4 and inverse variance. RESULTS: Seven studies (two RCTs and five retrospective cohort studies) were included. We established higher significance differences for TOETSMVA in comparison with TOETVA in terms of all primary outcomes; operation time, hospital stay, number of resected lymph nodes [MD -21.05, 95% CI= -30.98, -11.12; p < 0.0001], [MD -1.76, 95% CI= -2.21, -1.32, p < 0.00001], [MD -2.99, 95% CI= -19.75, 13.76, p < 0.73], [MD -0.83, 95% CI = -1.19 to -0.47; p < 0.00001], respectively, except the drainage volume, it showed no difference [MD -2.99, 95% CI= -19.75, 13.76, p < 0.73]. In secondary outcomes, it was favored only in mandibular numbness and return to normal diet outcomes. Additionally, TOETSMVA compared with COT showed a significant difference in drainage volume, pain, cosmetic effect, and satisfaction score. CONCLUSIONS: TOETSMVA showed a significant improvement compared to the TOETVA in operation time, hospital stay, number of resected lymph nodes, mandibular numbness, and return to normal diet but did not show a difference in drainage volume. However, TOETSMVA was better in cosmetic effect, drainage volume, satisfaction, and pain scores compared with COT. Further RCTs with larger sample size, multicentral, and longer follow-up are necessary to evaluate the limitations.

Robotic versus laparoscopic general surgery in the emergency setting: a systematic review.

Robot-assisted general surgery, an advanced technology in minimally invasive procedures, is increasingly employed in elective general surgery, showing benefits over laparoscopy in specific cases. Although laparoscopy remains a standard approach for common acute abdominal conditions, the role of robotic surgery in emergency general surgery remains uncertain. This systematic review aims to compare outcomes in acute general surgery settings for robotic versus laparoscopic surgeries. A PRISMA-compliant systematic search across MEDLINE, EMBASE, Science Citation Index Expanded, and the Cochrane Library was conducted. The literature review focused on articles comparing perioperative outcomes of emergency general surgery managed laparoscopically versus robot-assisted. A descriptive analysis was performed, and outcome measures were recorded. Six articles, involving 1,063 patients, compared outcomes of robotic and laparoscopic procedures. Two articles covered cholecystectomies, while the others addressed ileocaecal resection, subtotal colectomy, hiatal hernia and repair of perforated gastrojejunal ulcers. The level of evidence was low. Laparoscopic bowel resection in patients with inflammatory bowel disease (IBD) had higher complications; no significant differences were found in complications for other operations. Operative time showed no differences for cholecystectomies, but robotic approaches took longer for other procedures. Robotic cases had shorter hospital length of stay, although the associated costs were significantly higher. Perioperative outcomes for emergency robotic surgery in selected general surgery conditions are comparable to laparoscopic surgery. However, recommending robotic surgery in the acute setting necessitates a well-powered large population study for stronger evidence.

Endoscopic pilonidal sinus treatment (EPSiT) for sacrococcygeal pilonidal sinus disease: A prospective long-term study.

Objectives: To assess short-term and long-term outcomes of endoscopic pilonidal sinus treatment for pilonidal sinus disease. METHODS: The prospective study was conducted at Shifa International Hospital, Islamabad, Pakistan, from July 2015 to July 2021, and comprised all pilonidal sinus cases undergoing minimal invasive endoscopic pilonidal sinus treatment who were treated by a single surgical team. The primary outcomes were duration of healing, post-operative morbidities, persistence of discharge and recurrence at 1-7 years. The secondary outcomes were operative time, return to work, cosmetic results and patient satisfaction. The patients were observed for wound healing and discharge on follow-up in the out-patient department at 1, 3, 6 and 24 weeks. They were further followed up every year through telephonic survey for persistence or recurrence of symptoms. Patient satisfaction was assessed using the 36-item Short Form Survey questionnaire filled at admission and then at 6 weeks post-surgery. Data was analysed using SPSS 23. RESULTS: Of the 67 patients, 55(82%) were males and 12(18%) were females. The overall mean age was 25.69±8.305 years. There were 13(19.4%) patients with a history of recurrent disease and previous procedures for pilonidal sinus, while 54(80.6%) had no previous surgery. The median operative time was 35 minutes (interquartile range: 20-45 minutes). Complete wound healing was achieved in 60(89.6%) patients, while recurrence was seen in 7(10.4%). The median time off work was 2.5 days (interquartile range: 1-3 days). Patient satisfaction with the procedure was significantly high (p<0.05). CONCLUSIONS: Endoscopic pilonidal sinus treatment appeared to be a good minimally invasive surgical technique for the treatment of pilonidal sinus disease in terms of both short-term and long-term outcomes.

Peri-operative, oncological and functional outcomes of robotic versus transanal total mesorectal excision in patients with rectal cancer: A systematic review and meta-analysis.

BACKGROUND: Comparative outcomes of robotic low anterior resection (rTME) and trans-anal total mesorectal excision (TaTME) in patients with low rectal cancer were evaluated. METHODS: A systematic online search was conducted using the following databases: PubMed, Scopus, Cochrane database, The Virtual Health Library, Clinical trials.gov and Science Direct. Comparative studies of rTME versus TaTME for low rectal cancer were included. Primary outcomes were postoperative complications, including anastomotic leak, surgical site infection, and Clavien-Dindo complication rate. Total operative time, conversion to open surgery, intra-operative blood loss, intensive therapy unit (ITU) and total hospital length of stay (LOS), oncological outcomes and functional outcomes were the other evaluated outcome parameters. RESULTS: A total of 12 studies with a total number of 3025 patients divided between rTME (n = 1881) and TaTME (n = 1144) groups were included. There was no significant difference between the two groups for total operative time (P = 0.39), conversion to open surgery (P = 0.29) and intra-operative blood loss (P = 0.62). Clavien-Dindo ≥ 3 complication rate (P = 0.47), anastomotic leak (P = 0.89), rates of re-operation (P = 0.62) and re-admission (P = 0.92), R0 resections (P = 0.52), ITU LOS (P = 0.63) and total hospital LOS (P = 0.30) also showed similar results between the two groups. However, the rTME group had higher rates of total harvested lymph nodes (P = 0.04) and complete total mesorectal excision (TME) resections (P = 0.05). Albeit with a limited dataset, the Wexner and low anterior resection syndrome (LARS) scores showed better functional results in the rTME group compared with the TaTME group (P = 0.0009 and P = 0.00001, respectively). CONCLUSION: Compared with TaTME, rTME seems to provide better functional outcomes, higher lymph node yield and more complete TME resections with a similar post-operative complications profile.

Robotic gastrectomy using hinotori™ Surgical Robot System: Initial case series.

BACKGROUND: This study aims to prove the feasibility and safety of robotic gastrectomy using the hinotori™ Surgical Robot System (Medicaroid Corporation, Kobe, Japan). METHODS: We retrospectively enrolled the 16 patients who underwent gastrectomy by the hinotori™ Surgical Robot System for gastric cancer at our hospital between June 2023 and January 2024. Console surgeons performed almost all lymphadenectomies, including the clipping of vessels. Assistant surgeons supported the lymphadenectomy using vessel sealing devices and during reconstruction. RESULTS: Thirteen patients were cStage I, one patient was cStage II, and two patients were cStage III. Distal gastrectomy, proximal gastrectomy, and total gastrectomy were performed in 11, 1, and 4 patients, respectively. D1+ and D2 lymphadenectomies were performed in 11 and 5 patients, respectively. Billroth-I, Billroth-II, Roux-en-Y, and esophagogastrostomy were performed in three, six, six, and one patients, respectively. The median operation time was 282 (245-338) min, and the median console time was 226 (185-266) min. The median blood loss was 28 (12-50) mL, and the median amylase levels in drainage fluid were 280 (148-377) U/L on postoperative day 1 and 74 (42-148) U/L on postoperative day 3. There was anastomotic leakage (Clavien-Dindo [CD] IIIa) in one patient who underwent proximal gastrectomy. The median postoperative hospital stay was 12.5 (12-14) days. CONCLUSION: In this initial case series, the hinotori™ Surgical Robot System was found to be safe and feasible for patients with gastric cancer and is suggested to be appropriate for gastrectomy, including distal gastrectomy and total gastrectomy.

Ideal suturing technique for robot-assisted microsurgical anastomoses.

The development of novel robotic devices specifically designed for open microsurgery leads to increasing applications in reconstructive procedures. While initial studies revealed improved precision and surgical ergonomics upon robotic assistance, surgical time was consistently observed to be increased. This study compares two robotic suturing techniques using the Symani Surgical System and RoboticScope in a preclinical setting, to further leverage the benefits of novel robotic devices in microsurgery. Six experienced microsurgeons performed three microvascular anastomoses with a "steady-thread" suturing technique and a "switch-thread" technique on 1.0-mm-diameter artificial silicone vessels. Time for anastomosis and participant's satisfaction with the techniques and robotic setup were recorded. Anastomosis quality and microsurgical skills were assessed using the Anastomosis Lapse Index and Structured Assessment of Microsurgery Skills. Lastly, technical error messages and thread ruptures were quantified. Knot tying was significantly faster and evaluated significantly better by participants using the steady-thread technique (4.11 ± 0.85 vs. 6.40 ± 1.83 min per anastomosis). Moreover, microsurgical skills were rated significantly better using this technique, while both techniques consistently led to high levels of anastomosis quality (2.61 ± 1.21 vs. 3.0 ± 1.29 errors per anastomosis). In contrast, the switch-thread technique was associated with more technical error messages in total (14 vs. 12) and twice as many unintended thread ruptures per anastomosis (1.0 ± 0.88 vs. 0.5 ± 0.69). This study provides evidence for the enhanced performance of a steady-thread suturing technique, which is suggested to be applied upon robot-assisted microsurgical procedures for optimized efficiency.

Timing Considerations for Sleeve Gastrectomy in Kidney Transplant Patients: A Single Center Evaluation.

Current scientific literature is deficient in detailing the optimal timing for conducting bariatric surgery in relation to kidney transplantation. In this study, we performed a retrospective evaluation of kidney transplant recipients with BMI >35 kg/m2. It aimed to provide data on those who received both sleeve gastrectomy (SG) and kidney transplantation (KT) simultaneously, as well as on patients who underwent SG and KT at different times, either before or after. In addition, the acceptance levels of the bariatric surgery among different scenarios were assessed. Our findings demonstrated that combined KT and SG led to successful weight loss, in contrast to undergoing kidney transplant alone, while maintaining comparable rates of graft and patient survival. Weight loss was similar between recipients who had a combined operation and those who underwent SG following the transplant. Additionally, over a median time frame of 1.7 years, patients who underwent SG before KT exhibited a statistically significant reduction in BMI at the time of the transplant. Notably, our study highlights that patients offered the combined procedure were significantly more likely to undergo SG compared to those for whom SG was presented at a different operative time than the transplant.

[Robotic Colorectal Surgery: Analysis of the First Three Years of Activity in a Hospital of the Portuguese National Health Service]. / Cirurgia Robótica em Patologia Colorretal: Análise dos Primeiros Três Anos de Atividade num Hospital do Serviço Nacional de Saúde em Portugal.

INTRODUCTION: Minimally invasive surgery has been increasingly accepted and used in colorectal surgery. Several studies report that robotic surgery may provide advantages over 'conventional' laparoscopy, namely in rectal surgery. This paper provides an account of the first three years of experience with robotic surgery in the Unidade de Patologia Colorretal of the Unidade Local de Saúde S. José. METHODS: Variables were defined to develop a prospective database containing the data of consecutive patients operated by three internationally certified colorectal surgeons using the Da Vinci Xi® system between November 2019 and October 2022. The database was converted into an anonymized version that was used for this study. The analysis was performed on the data of all the patients operated during this period. RESULTS: Eighty patients were included, 47 male, median age 70 years, and median BMI 26 kg/m2 . ASA score was II in 53.7% and III in 41.3% of pa- tients. Of the total, 97.6% had malignant or potentially malignant disease. Operative procedures consisted of 34 colectomies proximal to the splenic flexure, 20 distal colectomies and 26 anterior resections. There were two synchronous resections of liver metastases. Early perioperative outcomes and histopathological results were analyzed: median operative time: 300 minutes; median estimated blood loss: 50 mL; conversion rate: 2.5%; median days until first bowel movement: three days; median length of hospital stay: six days; complication rate: 20%, of which 5% were Clavien III and 0% Clavien IV/V; anastomotic leak rate: 2.5%; 30-day readmission rate: 1.3%; median lymph nodes resected: 20; R0 resection rate: 100%; mesorectal integrity rate: 95,8% complete/near complete. CONCLUSION: Our results show that the adoption of robotic colorectal surgery in our center was safe and resulted in similar or improved short-term clinical outcomes and histopathological results when compared to those described in the literature.

Introdução: A utilização da cirurgia minimamente invasiva no tratamento da patologia colorretal é hoje cientificamente aceite e o seu uso na prática clí- nica diária tem vindo a aumentar de forma sustentada. Diversos estudos indicam que a abordagem robótica pode trazer vantagens sobre a laparoscopia 'convencional', especialmente na cirurgia do reto. Este trabalho descreve e analisa os resultados dos primeiros três anos de cirurgia robótica na Unidade de Patologia Colorretal da Unidade Local de Saúde S. José. Métodos: Foram definidas as variáveis a analisar e construída uma base de dados prospetiva com os dados referentes aos doentes operados conse- cutivamente por três cirurgiões colorretais, acreditados internacionalmente na utilização do sistema Da Vinci Xi®, entre novembro de 2019 e outubro de 2022. A base de dados foi convertida numa versão anonimizada e foi sobre essa mesma que se procedeu à análise de dados. Foram analisados os dados de todos doentes operados nesse período. Resultados: Foram incluídos 80 doentes, 47 homens, mediana de idade de 70 anos e de IMC de 26 kg/m2 . O score ASA era II em 53,7% e III em 41,3% dos doentes. Do total, 97,6% apresentavam doença maligna ou potencialmente maligna. Realizaram-se 34 colectomias proximais ao ângulo esplénico, 20 distais e 26 ressecções anteriores do reto. Houve ressecção síncrona de metástases hepáticas em dois casos. Foram analisados os resultados peri-operatórios a curto prazo e histopatológicos: duração (mediana): 300 minutos; perda hemática estimada (mediana): 50 mL; taxa de conversão: 2,5%; dias até retomar trânsito intestinal (mediana): três dias; dias de internamento (mediana): seis dias; taxa de complicações pós-operatórias: 20%, das quais 5% Clavien III e 0% Clavien IV/V; taxa de deiscência anastomótica: 2,5%; taxa de reintervenção: 2,5%; taxa de readmissão pós-alta: 1,3%; gânglios linfáticos ressecados (mediana): 20; taxa de ressecção R0: 100%; taxa de integridade mesorretal: 95,8% completo/quase completo. Conclusão: Os nossos resultados mostram que a introdução da cirurgia colorretal robótica no nosso centro foi segura e garantiu resultados clínicos a curto prazo e histopatológicos semelhantes ou favoráveis face aos descritos na literatura.

Postoperative outcomes of minimally invasive versus conventional nipple-sparing mastectomy with prosthesis breast reconstruction in breast cancer: a meta-analysis.

Breast cancer is the most common malignant tumor worldwide, and mastectomy remains the primary strategy for treating early stage breast cancer. However, the complication rates, surgical variables, and oncologic safety of minimally invasive nipple-sparing mastectomy (MINSM) have not been fully addressed. We systematically searched PubMed, Web of Science, Embase, and the Cochrane Library for randomized-controlled trials (RCTs) and non-RCTs that compared MINSM with conventional nipple-sparing mastectomy (CNSM), both followed by Prosthesis Breast Reconstruction (PBR). The main outcomes observed included overall complications, (Grade III) complications, skin and nipple necrosis, wound dehiscence, infection, seroma, hematoma, implant loss, and oncologic safety (positive margins and recurrence). Secondary outcomes included operation time, blood loss, hospital stay, cost-effectiveness, and patient satisfaction. Binary and continuous variables were compared using odds ratios (OR) and mean differences (MD) with 95% confidence intervals (CI). A total of 10 studies involving 2,166 patients were included. There were no statistically significant differences between MINSM and CNSM in terms of skin necrosis, wound dehiscence, infection, seroma, hematoma, implant loss, or oncologic safety. However, MINSM significantly reduced overall complications (OR = 0. 74, 95% CI [0. 58, 0. 94], p = 0. 01) and (Grade III) complications (OR = 0. 47, 95% CI [0. 31, 0. 71], p = 0. 0003). Nipple necrosis events were also significantly reduced in the MINSM group (OR = 0. 49, 95% CI [0. 30, 0. 80], p = 0. 005). Patient satisfaction improved notably in the MINSM group. Additionally, compared with the CNSM group, the MINSM group had longer operating times (MD = 46. 88, 95% CI [19. 55, 74. 21], p = 0. 0008) and hospital stays (MD = 1. 39, 95% CI [0. 65, 2. 12], p < 0. 001), while intraoperative blood loss was significantly reduced (MD = -29. 05, 95% CI [-36. 20, -21. 90], p < 0. 001). Compared with CNSM, MINSM offers advantages in reducing complications and intraoperative blood loss, as well as improving aesthetic outcomes and patient satisfaction. Therefore, MINSM may become a viable option for breast surgery. Nevertheless, a long-term evaluation of the oncologic safety of this approach is necessary to ensure its efficacy and safety for patients.

Robot-Assisted MIDCAB Using Bilateral Internal Thoracic Artery: A Propensity Score-Matched Study With OPCAB Patients.

OBJECTIVE: Robot-assisted minimally invasive direct coronary artery bypass (RA-MIDCAB) is an attractive strategy for coronary revascularization. Growing evidence supports the use of total arterial grafting in coronary surgery. We evaluated total arterial left-sided coronary revascularization with bilateral internal thoracic artery (BITA) using RA-MIDCAB and compared it with a propensity score-matched (PSM) off-pump CAB (OPCAB) surgery population. METHODS: We retrospectively included all isolated OPCAB and RA-MIDCAB surgery using BITA without saphenous vein graft from January 1, 2015, to October 31, 2022. We analyzed all our RA-MIDCAB patients and performed PSM to compare them with our OPCAB population. Primary outcomes were major adverse cardiovascular and cerebrovascular events (MACCE) and mortality. Secondary outcomes were surgical parameters, length of hospital stay, and learning curve. RESULTS: We included 601 OPCAB and 77 RA-MIDCAB procedures, which resulted in 2 cohorts of 54 patients after PSM. Mortality and MACCE survival analysis showed no significant difference. There was less blood transfusion in the RA-MIDCAB (16.7%) compared with the OPCAB group (38.9%; P = 0.02). We observed fewer intensive care unit (ICU) admissions (24.1% vs 96.6%), shorter ICU stay (0.78 ± 1.7 vs 1.91 ± 1.01 days), and shorter hospital stay (6.78 ± 2.4 vs 8.01 ± 2.5 days) in the RA-MIDCAB versus OPCAB group (P < 0.01). Surgery time decreased from 400.0 ± 70.8 to 325.0 ± 38.0 min with more experience in RA-MIDCAB BITA harvesting (P < 0.01). CONCLUSIONS: This is a first publication of 77 consecutive RA-MIDCAB BITA harvesting for left coronary artery system revascularization. This technique is safe in terms of MACCE and mortality. Additional advantages are shorter length of hospital stay, fewer ICU admissions, and less blood transfusion.

New surgery technique combining robotics and laparoscopy using the Hugo™ RAS system.

INTRODUCTION: Hybrid total laparoscopic hysterectomy combines conventional laparoscopic surgery and robot-assisted devices: the camera and assistant forceps are operated by a robotic device, whereas the surgeon performs laparoscopic procedures, enabling surgery with a completely fixed field of view and significantly reducing errors in forceps grasping and needle misalignment. Here, we examined whether using two arms of the Hugo™ robot-assisted surgery system, one for the camera and one for the assistant, would improve surgical accuracy compared with conventional total laparoscopic hysterectomy. MATERIALS AND SURGICAL TECHNIQUE: The surgical system reduced surgeon errors in grasping the forceps during training and stabilized forceps operation. Compared with conventional laparoscopic surgery, the use of the surgical system did not result in different operative durations. The stable surgical procedure was considered a major advantage. DISCUSSION: This new technique involving new equipment can improve surgeon training and performance. In the future, we will develop new techniques to improve surgical performance.

Comparison of the therapeutic effects of three minimally invasive approaches for laparoscopic cholecystectomy combined with common bile duct exploration-- a 5-year retrospective analysis.

OBJECTIVE: The aim of this retrospective study was to explore the indications for three minimally invasive approaches-T-tube external drainage, double J-tube internal drainage, and primary closure-in laparoscopic cholecystectomy combined with common bile duct exploration. METHODS: Three hundred eighty-nine patients with common bile duct stones who were treated at the Second People's Hospital of Hefei between February 2018 and January 2023 were retrospectively included. Patients were divided into three groups based on the surgical approach used: the T-tube drainage group, the double J-tube internal drainage group, and the primary closure group. General data, including sex, age, and BMI, were compared among the three groups preoperatively. Surgical time, length of hospital stay, pain scores, and other aspects were compared among the three groups. Differences in liver function, inflammatory factors, and postoperative complications were also compared among the three groups. RESULTS: There were no significant differences among the three groups in terms of sex, age, BMI, or other general data preoperatively (P > 0.05). There were significant differences between the primary closure group and the T-tube drainage group in terms of surgical time and pain scores (P < 0.05). The primary closure group and double J-tube drainage group differed from the T-tube drainage group in terms of length of hospital stay, hospitalization expenses, and time to passage of gas (P <0.05). Among the three groups, there were no statistically significant differences in inflammatory factors or liver function, TBIL, AST, ALP, ALT, GGT, CRP, or IL-6, before surgery or on the third day after surgery (P > 0.05). However, on the third day after surgery, liver function in all three groups was significantly lower than that before surgery (P<0.05). In all three groups, the levels of CRP and IL-6 were significantly lower than their preoperative levels. The primary closure group had significantly lower CRP and IL-6 levels than did the T-tube drainage group (P < 0.05). The primary closure group differed from the T-tube drainage group in terms of the incidences of bile leakage and electrolyte imbalance (P < 0.05). The double J-tube drainage group differed from the T-tube drainage group in terms of the tube dislodgement rate (P < 0.05). CONCLUSION: Although primary closure of the bile ducts has clear advantages in terms of length of hospital stay and hospitalization expenses, it is associated with a higher incidence of postoperative complications, particularly bile leakage. T-tube drainage and double J-tube internal drainage also have their own advantages. The specific surgical approach should be selected based on the preoperative assessment, indications, and other factors to reduce the occurrence of postoperative complications.

Preoperative CT Scan is not Associated with Shorter Surgical Time or Improved Patient Outcomes for Trimalleolar Ankle Fractures.

Background: Posterior malleolar involvement can drastically affect patient outcomes. Literature has supported the use of preoperative Computed Tomography (CT) to assess posterior malleolar fracture morphology. The purpose of this study is to determine whether preoperative CT is associated with significant improvement in surgical time, postoperative complications, reoperation rates in trimalleolar ankle fractures. Surgeons were also asked to complete survey regarding use of CT scans to gauge utility preoperatively. Methods: Adult patients with trimalleolar ankle fractures who underwent operative fixation between 2018-2020 were retrospectively reviewed. Primary outcomes included surgical time, postoperative complications, and reoperations. Secondary outcome was presence of posterior malleolar fixation. 15 surgeons who performed ankle ORIF were surveyed to gain information regarding why or why not preoperative CT scan was obtained. Results: 288 patients with trimalleolar ankle fractures were included, 94 had preoperative CT scans (32.6%). No significant differences found in patient age, gender, BMI, smoking status between the groups that did and did not have preoperative CT scan. No significant differences were observed in AO/OTA classification between groups. Average surgical time was significantly higher in group that received a preoperative CT (114 without CT vs. 145 with CT, p<0.05). Complications (10.3% no CT vs 7.4% with CT, p=0.55) and reoperations (6.7% without CT vs. 7.4% with CT, p=0.16) not significantly different between groups. No significant difference was observed in rate of posterior malleolus fixation between groups (43.8% without CT vs 39.4% with CT; p=0.52). Of surveyed surgeons, 87% reported they don't routinely obtain preoperative CT scan for trimalleolar ankle fractures. Most common reasons for preoperative scans were deciding on approach/positioning, assessing for impaction, determining the size of the posterior malleolus. Conclusion: Although preoperative CT scans are obtained in one third of patients with operative trimalleolar ankle fractures, we did not find an improvement in surgical time, complications, and reoperation. Level of Evidence: III.

Laparoscopic Warshaw procedure in pediatric solid pseudopapillary neoplasm of the pancreas: Technical feasibility and oncological outcomes.

Achieving margin-negative resection is crucial in treatment of solid pseudopapillary neoplasm (SPN) of the pancreas, while preserving the spleen during distal pancreatectomy is highly desirable in pediatric cases. Laparoscopic Warshaw procedure (Lap-WT) is invaluable when tumor involvement in splenic vessels complicates preservation. However, the feasibility of Lap-WT in pediatric patients remains contentious. This study presents the clinical outcomes of three pediatric SPN cases who underwent Lap-WT. The median age was 10 years, with a median tumor size of 50 mm. Lap-WT demonstrated successful outcomes with a median operation time of 311 min and blood loss of 12 mL. No postoperative complications occurred, with a median length of hospital stay of 8 days. Long-term follow-up showed mild thrombocytopenia and increased spleen volume in two cases, perigastric varices in one, with no bleeding complications. No instances of tumor recurrence were observed. Lap-WT emerges as a feasible approach for pediatric SPN, ensuring spleen preservation without compromising oncological outcomes.

Influence of patient characteristics on microbial composition in surgical-site infections: insights from national surveillance study.

BACKGROUND: Although the impact of surgery- and patient-dependent factors on surgical-site infections (SSIs) have been studied extensively, their influence on the microbial composition of SSI remains unexplored. The aim of this study was to identify patient-dependent predictors of the microbial composition of SSIs across different types of surgery. METHODS: This retrospective cohort study included 538 893 patients from the Swiss national infection surveillance programme. Multilabel classification methods, adaptive boosting and Gaussian Naive Bayes were employed to identify predictors of the microbial composition of SSIs using 20 features, including sex, age, BMI, duration of surgery, type of surgery, and surgical antimicrobial prophylaxis. RESULTS: Overall, SSIs were recorded in 18 642 patients (3.8%) and, of these, 10 632 had microbiological wound swabs available. The most common pathogens identified in SSIs were Enterobacterales (57%), Staphylococcus spp. (31%), and Enterococcus spp. (28%). Age (mean feature importance 0.260, 95% c.i. 0.209 to 0.309), BMI (0.224, 0.177 to 0.271), and duration of surgery (0.221, 0.180 to 0.269) were strong and independent predictors of the microbial composition of SSIs. Increasing age and duration of surgical procedure as well as decreasing BMI were associated with a shift from Staphylococcus spp. to Enterobacterales and Enterococcus spp. An online application of the machine learning model is available for validation in other healthcare systems. CONCLUSION: Age, BMI, and duration of surgery were key predictors of the microbial composition of SSI, irrespective of the type of surgery, demonstrating the relevance of patient-dependent factors to the pathogenesis of SSIs.

Local infections are a frequent problem after surgery. The risk factors for surgical infections have been identified, but it is unclear which factors predict the type of microorganisms found in such infections. The aim of the present study was to assess patient factors affecting the composition of microorganisms in surgical infections. Data from 538 893 patients were analysed using standard statistics and machine learning methods. The results showed that age, BMI, and the duration of surgery were important in determining the bacteria found in the surgical-site infections. With increasing age, longer operations, and lower BMI, more bacteria stemming from the intestine were found in the surgical site, as opposed to bacteria from the skin. This knowledge may help in developing more personalized treatments for patients undergoing surgery in the future.

Comparison between umbilical and right upper transverse abdominal incisions for pyloromyotomy: a systematic review and meta-analysis.

The aim of this study was to compare the operative parameters and complication rates between the umbilical (UMB) and right upper quadrant (RUQ) skin incisions for Ramstedt's pyloromyotomy for the treatment of infantile hypertrophic pyloric stenosis (IHPS). PubMed, EMBASE, Web of Science and Scopus databases were systematically searched. The studies where any one of the main outcomes of interest, i.e., operative time, wound infection rate, mucosal perforation rate were reported were eligible for inclusion. The statistical analysis was performed using a random-effects model. The methodological quality of the studies was assessed utilizing the Newcastle-Ottawa Scale. Fifteen studies comprising 2964 infants were included. As compared to the UMB group, the RUQ group showed a significantly lower mean operative time (p = 0.0004), wound infection rate (p < 0.0001) and mucosal perforation rate (p = 0.02). Although UMB incision produces an almost undetectable scar, this approach results in significantly more complications. Therefore, the risks and benefits must be weighed and discussed with the caregivers in deciding the surgical approach in patients with IHPS. However, due to a poor methodological quality of nine out of fifteen studies, further studies need to be conducted for an optimal comparison between the two groups.