Comparison of Early Clinical and Long-Term Oncological Outcomes of Laparoscopic Versus Converted Rectal Cancer Resection: A Retrospective Cohort Study.

Aim The effects of conversion to open surgery during laparoscopic resection in rectal cancer on perioperative clinical and long-term oncological outcomes are still controversial. This study aimed to evaluate and compare the impact of conversion to laparoscopic resection for rectal cancer on perioperative and long-term oncological outcomes. Material and methods Between January 2019 and December 2023, 84 consecutive patients who underwent curative surgery for rectal cancer at a single academic center were evaluated retrospectively. Patients were classified and compared as the laparoscopic (LAP-G) and converted (CONV-G) groups. Perioperative, pathological, and long-term oncological outcomes were compared. Results Of the 84 consecutive patients included, 18 were converted to open surgery, leading to a 21.4% conversion rate. Intraoperative blood loss was higher in CONV-G (180 ml vs. 80 ml, p<0.001), but early clinical outcomes were similar in both groups. The median follow-up period was 23.5 (range 3-65) and 30.5 (range 6-61) months in the LAP-G and CONV-G, respectively, and recurrence occurred in 11 (16.7%) and 3 (16.6%) patients, respectively. Three-year overall survival was 96.9% and 89.4% (p=0.609) and 3-year disease-free survival was 92.4% and 83.3% (p=0.881) in LAP-G and CONV-G, respectively, and the results were similar. Conclusion Conversion from laparoscopic rectal resection to open surgery does not have a significant negative impact on morbidity and long-term oncological outcomes.

Navigating Through the Rare and Accepting the New Shift: Laparoscopic Gastro-Jejunostomy for Gastric Outlet Obstruction Secondary to Eosinophilic Gastritis in a Pediatric Patient.

Eosinophilic gastritis, a rare variant of gastritis, presents with inflammation of the stomach lining due to eosinophil infiltration. This case report describes a complex presentation of eosinophilic gastritis in a 12-year-old boy, highlighting the challenges encountered in management. A 12-year-old male presented with symptoms consistent with gastritis, including abdominal pain, nausea, and vomiting. Despite extensive medical workup to identify potential etiologies (parasitic infections, autoimmune conditions), the diagnosis of eosinophilic gastritis was established. Unfortunately, the patient exhibited persistent symptoms despite aggressive medical management. The case was further complicated by pyloric stenosis, a narrowing of the stomach outlet. Laparoscopic intervention, a minimally invasive surgical approach, was initially attempted but deemed challenging due to the patient's specific condition. The presence of metabolic abnormalities added further complexity. Alternative approaches, such as endoscopic dilatation, were considered but ultimately deemed unsuitable due to the severity of the stenosis and the desire for a minimally invasive solution compared to laparotomy. This case exemplifies the challenges associated with managing rare gastrointestinal conditions like eosinophilic gastritis, particularly in pediatric patients. The report emphasizes the importance of a multidisciplinary approach, involving collaboration between gastroenterologists, surgeons, and potentially other specialists depending on the specific complications, to achieve optimal outcomes. This case highlights the complexities in managing this patient, especially when accompanied by complications like pyloric stenosis. It underscores the crucial role of a multidisciplinary team in navigating challenging presentations and exploring minimally invasive surgical options when feasible.

Comparison of minimal access and open breast surgery: a propensity score-matched study on postoperative immune function in breast cancer.

BACKGROUND: Minimal access breast surgery (MABS) is commonly employed in the management of breast cancer, but there is limited research on the postoperative immune function associated with MABS. OBJECTIVE: This study aimed to assess the postoperative immune function in breast patients who underwent MABS or conventional open breast surgery (COBS). METHODS: We retrospectively analyzed the medical records of 829 breast cancer patients treated with either MABS or COBS at a single hospital between January 2020 and June 2023. Among them, 116 matched pairs were obtained through 1:1 propensity score matching (PSM). Flow cytometry was used to measure the percentages of CD3+, CD4+, and CD8+ cells, as well as the CD4+/CD8+ ratio, on three different time points: preoperative day 1 (PreD1), postoperative day 1 (PostD1), and postoperative day 7 (PostD7). RESULTS: Both the MABS and COBS groups demonstrated a significant reduction in the percentages of CD3+, CD4+, and CD8+ cells, along with the CD4+/CD8+ ratio, from PreD1 to PostD1. Interestingly, the MABS group showed a reversal of these parameters, returning to preoperative levels by PostD7. Conversely, the COBS group showed an increase in these parameters from PostD1 to PostD7, but they still remained significantly lower than preoperative levels at PostD7. CONCLUSION: MABS treatment may result in reduced postoperative immune suppression and faster recovery of preoperative immune function compared to COBS in patients.

Implementation of Laparoscopic Nissen Fundoplications in a Developing South African Pediatric Surgical Service.

Introduction: Pediatric laparoscopic Nissen fundoplication (LNF) has become the standard approach at many centers. We developed a minimal access surgery (MAS) training curriculum to enhance the delivery of MAS for pediatric patients in a resource-limited setting. We reviewed our 10-year experience in implementing and performing LNF at our institution. Methods: We described the challenges of implementing MAS training for LNF and how we addressed them. Beneficial technical considerations were described. A retrospective review was performed on all pediatric LNFs performed. Results: We performed 268 LNFs. Specialists or trainees under supervision performed all LNFs. The trainee group performed 43 LNFs (16%). The median operative time for the specialists was 94 min (interquartile range [IQR] 50), and the trainee group was 140 min (IQR 62.5). The median number of cases performed until we improved operative time amongst the trainees was nine (IQR 3). There were seven repeat LNFs, and 11 cases were converted to open. The overall complication rate was 8.9%. A reduction in complications among specialists occurred over the years. The 30-day mortality post-LNF was 0.7%. Conclusion: LNF can be successfully introduced at a tertiary training centre in South Africa with good outcomes. A comprehensive quality improvement program, including MAS training, supported this.

Minimal Access in Pediatric Surgery: An Overview on Progress towards Dedicated Instrument Developments and Anesthesiologic Advances to Enhance Safe Completion of Procedures.

Surgical techniques are evolving in Pediatric Surgery, especially in the area of minimal access surgery (MAS) where indications for applications are expanding. Miniaturization of instruments, using natural orifices, single incisions, or remotely controlled robot-assisted procedures, promises to increase the benefits of MAS procedures in pediatrics. Many pediatric pathologies are rare, and specialized surgical and anesthesiologic instruments are necessary to manage them, defined as "orphan devices", for which development and dissemination on the market are slowed down or sometimes hindered by regulatory standards and limiting financial conflicts of interest. In pediatric surgery, it is of utmost importance to work in a multidisciplinary way to offer a surgical path that is safe and supported by technological advances. For this reason, optimizing pediatric anesthesia is also a crucial factor where technological advances have made monitoring more precise, thereby enhancing safety in the operative room. The development of customized instruments and technologies should be supported by pediatric research and should be adapted to the individualities of the small patient. This overview outlines the importance of dedicated instruments developed for the safe completion of MAS procedures in pediatrics.

Effects of Access Cavity Design and Placement Techniques on Mineral Trioxide Aggregate Obturation Quality in Simulated Immature Teeth: A Micro-Computed Tomography Study.

Background and Objectives: In teeth with open apices, performing single session apexification is a challenging treatment due to the difficulty in handling mineral trioxide aggregate (MTA). Minimally invasive approaches in dentistry have also influenced the cavity designs in endodontics. Until now, different techniques have not been investigated in addition to manual condensation during the process of placing MTA in traditional (TradACs) or conservative (ConsACs) endodontic access cavities. The aim of this in vitro study was to compare and evaluate the obturation quality of MTA apical plugs placed with different techniques in TradACs or ConsACs. Materials and Methods: Sixty upper central teeth were divided into two main groups based on cavity design, and then each main group was further divided into three subgroups according to MTA placement techniques (n = 10): TradAC-manual, TradAC-manual + indirect ultrasonic activation, TradAC-manual + XP-endo Shaper (XPS), ConsAC-manual, ConsAC-manual + indirect ultrasonic activation, and ConsAC-manual + XPS. Subsequently, the porosity percentages in the MTA apical plug were analyzed using micro-computed tomography. The statistical analysis was performed using the Kruskal-Wallis H test and Mann-Whitney U test. Statistical significance was set at p < 0.05. Results: There were differences in volume of porosity percentages (%) according to cavity designs and MTA application techniques (p < 0.05). Except for the XPS group, more porosity was observed in ConsACs compared to TradACs. In TradACs, the significantly lowest open and total porosity was observed in the manual, ultrasonic, and XPS techniques, respectively. In ConsACs, the significantly lowest porosity was observed in the manual, XPS, and ultrasonic techniques, respectively (p < 0.05). Conclusions: In MTA obturation, cavity designs and application techniques had an impact on the MTA porosity. Creating an apical plug in ConsACs may result in more porosity compared to TradACs, especially when manual or indirect ultrasonic activation is preferred. Opting for the manual technique alone may be considered sufficient for controlling porosity for both TradACs and ConsACs.

Advancing women's health: The imperative for public health screening of uterine fibroids for personalized care.

Uterine fibroids represent the most prevalent genital tract tumours among women, with a disproportionately higher impact on ethnic minority groups, notably black women. These hormonally dependent monoclonal tumours, characterized by excessive extracellular matrix and influenced by genetic, epigenetic, and lifestyle factors, significantly affect women's quality of life and pose substantial economic burdens on healthcare systems. Recent advances in early detection and minimally invasive treatment options have shifted management paradigms towards personalized care, yet challenges in early diagnosis, education and access to treatment persist. This review synthesizes current knowledge on uterine fibroids, highlighting the impact of fibroids on women's health, risk factors, principles of screening, diagnostic tools, and treatment modalities. It emphasizes the importance of early screening and individualized management strategies in improving patient outcomes and reducing healthcare costs. The article also discusses the socio-economic and health disparities affecting the disease burden, underscoring the need for improved patient education, clinician training, and public health strategies to enhance fibroid management. This review proposes a pathway to not only ameliorate the quality of life for women with fibroids, but also to advance global women's health equity.

The 'Manchester' method of minimal access fixation of the zygomatic arch in zygomatic complex fractures: a case series.

We have introduced a minimally invasive approach for the fixation of the zygomatic arch during the surgical management of zygomatic complex fractures. Access for this technique is provided by a preauricular approach and eyelid incisions with the addition of transcutaneous stab incisions overlying the arch. These stab incisions allow transcutaneous drilling and screw placement through a size CH 20 (5.0 mm) paediatric nasopharyngeal airway (NPA). We present a case series of seven patients. In all patients the arch component was successfully reduced and fixed, and no intraoperative or postoperative complications were observed. The use of an NPA is novel. It functions as a flexible self-irrigating sleeve and protects the skin from mechanical and thermal damage. The technique uses readily available equipment, is easy to learn, and simplifies surgery to the zygomatic arch.

A review of minimal access surgery provision and training within the United Kingdom.

When combined with healthcare pressures, the exponential growth of robotic-assisted surgery (RAS) has impacted UK-based training outcomes, including the learning curve to competency. Aim: To ascertain the current provision of RAS and investigate differences in access to minimal access surgical (MAS) facilities and training across the UK. A two-armed electronic survey was conducted. The first arm questioned clinical leads regarding robotic practice and future training provisions. The second investigated trainee and trainers' perceptions of MAS training and facilities. 64% (52/81) of responding trusts utilise a robotic system. The majority (68% [55/81]) have plans to expand or acquire a system within 3 years. 171 responses from 112 UK and Republic of Ireland hospitals were collected for Arm 2. Laparoscopic categories queried whether trainees had access to a formal curriculum, training days and sim-boxes. Most consultants (51.9%) and trainees (51.6%) reported that there was no formal local training curriculum for robotic surgery. Combined responses demonstrated 42.1% (n = 195/463) said "yes", 39.5% (n = 183) "no" and 18.4% (n = 85) "don't know". For combined robotic categories (simulation, training days and operative lists) 28.3% (n = 134/473) responded "yes", 51.6% (n = 244) said "no" and 20.1% (n = 95) said "don't know". This study provides insight into the current provision of robotic-assisted surgery at UK trusts and highlights the need to facilitate regular clinical training and equitable access to MAS simulation within a formal curriculum. This may aid regulation of training in parallel with the expansion of robotic practice and avoid a significant skill acquisition gap and risks to patient safety.

Surgical Treatment for Endometrial Cancer, Hysterectomy Performed via Minimally Invasive Routes Compared with Open Surgery: A Systematic Review and Network Meta-Analysis.

Background: Total hysterectomy with bilateral salpingo-oophorectomy via minimally invasive surgery (MIS) has emerged as the standard of care for early-stage endometrial cancer (EC). Prior systematic reviews and meta-analyses have focused on outcomes reported solely from randomised controlled trials (RCTs), overlooking valuable data from non-randomised studies. This inaugural systematic review and network meta-analysis comprehensively compares clinical and oncological outcomes between MIS and open surgery for early-stage EC, incorporating evidence from randomised and non-randomised studies. Methods: This study was prospectively registered on PROSPERO (CRD42020186959). All original research of any experimental design reporting clinical and oncological outcomes of surgical treatment for endometrial cancer was included. Study selection was restricted to English-language peer-reviewed journal articles published 1 January 1995-31 December 2021. A Bayesian network meta-analysis was conducted. Results: A total of 99 studies were included in the network meta-analysis, comprising 181,716 women and 14 outcomes. Compared with open surgery, laparoscopic and robotic-assisted surgery demonstrated reduced blood loss and length of hospital stay but increased operating time. Compared with laparoscopic surgery, robotic-assisted surgery was associated with a significant reduction in ileus (OR = 0.40, 95% CrI: 0.17-0.87) and total intra-operative complications (OR = 0.38, 95% CrI: 0.17-0.75) as well as a higher disease-free survival (OR = 2.45, 95% CrI: 1.04-6.34). Conclusions: For treating early endometrial cancer, minimal-access surgery via robotic-assisted or laparoscopic techniques appears safer and more efficacious than open surgery. Robotic-assisted surgery is associated with fewer complications and favourable oncological outcomes.

Novel technique of laparoscopic mid-urethral autologous rectus fascial sling for stress urinary incontinence.

Serious concerns have been raised over the safety of vaginal mesh tapes for stress urinary incontinence (SUI). Autologous rectus fascial sling and the more recent 'sling on a string' through a laparotomy are gaining popularity as native tissue options for SUI. We describe a novel technique of laparoscopic mid-urethral autologous rectus fascial sling for SUI. Ten patients underwent this new technique safely. At 12 months, all patients reported cure of SUI with normal voiding. The advantages of this technique include the minimal access approach, introduction of the sutures under laparoscopic guidance, and avoidance of over-tightening of the sling.

Current state of minimally invasive general surgical practice in Africa: A systematic review and meta-analysis of the laparoscopic procedures performed and outcomes.

BACKGROUND: Minimally invasive surgery, including laparoscopy and robotics, has significantly improved general surgical (GS) practice globally. While robot-assisted GS practice is yet to be adopted in the majority of Africa, laparoscopy has been utilized to improve surgical outcomes. This study aims to review the laparoscopic GS procedures (LGSPs) performed and evaluate outcomes such as conversion to open surgery, morbidity, and mortality in Africa. METHODS: Four databases (PubMed, Google Scholar, WoS, and AJOL) were searched, identifying 8022 publications. Following screening, 40 studies across Africa that reported LGSPs (n ≥ 2) performed and outcomes met the inclusion criteria. A meta-analysis conducted using R statistical software estimated the pooled prevalences with the 95% CI of conversion, morbidity, and mortality. RESULTS: A total of 6381 procedures performed in 15 African countries were analyzed in this study. Majority, 72.89%, of the procedures were performed in Senegal, South Africa, and Nigeria. The major procedures performed were cholecystectomy (37.09%), appendicectomy (33.36%), and diagnostic laparoscopy (9.98%). The meta-analysis revealed a conversion rate of 5% [95% CI: 4, 7]. Adhesion (28.13%), hemorrhage (16.67%), technical difficultly (12.50%), and equipment failure (11.46%) were the predominant indications for conversion. Surgical site infection (42.75%) was the major cause of morbidity. The prevalences of morbidity and mortality were 7% [95% CI: 5, 10] and 0.12% [95% CI: 0, 0.29], respectively. CONCLUSION: A wide range of basic and advanced LGSPs were performed. The outcomes obtained indicate successful implementation of the laparoscopic approach. Importantly, this study serves as a foundational work for further research on minimally invasive surgery in Africa.

Minimally Invasive Simultaneous Colorectal and Liver Resection for Synchronous Colorectal Liver Metastasis-Short-Term Outcomes.

Surgical management of colorectal disease and liver metastatectomy can be staged or synchronous. A minimally invasive approach in synchronous resection in the selected group of patients may improve postoperative outcomes. The present study aimed to explore the safety and feasibility of simultaneous liver and colorectal resection for synchronous metastasis by a minimally invasive approach in terms of major morbidity and R0 resection rates. The present study is a retrospective review of a prospectively maintained database. All patients who underwent minimally invasive simultaneous resection of colorectal malignancy and liver metastases between January 2020 and April 2023 were included. A total of 39 patients were included in the study. The median age was 54 (23-79) years with 28 male (72%) and 11 female (28%) patients. Rectum (n = 21, 54%) was the most common primary location. The most commonly performed procedures were low anterior resection (n = 12) and parenchymal sparing non-anatomical resection (n = 23, 59%). The median surgery duration was 280 (150-520) min, and the median blood loss was 400 (50-2100) ml. The median hospital stay was 7 (5-18) days. Five (12.6%) patients had major complications. With a median follow-up of 12 months, the 2-year overall survival (OS) and disease-free survival (DFS) were 84.6% and 37%, respectively. Simultaneous liver and colorectal resection by minimal access approach is feasible in selected groups of patients depending on the extent of hepatectomy, the patient's general condition, and surgical team experience. A minimal access approach leads to faster recovery without compromising on the oncological radicality.

Ventral hernia repair in India: a Delphi consensus.

PURPOSE: While research on inguinal hernias is well-documented, ventral/incisional hernias still require investigation. In India, opinions on laparoscopic ventral hernia repair (LVHR) techniques are contested. The current consensus aims to standardize LVHR practice and identify gaps and unfulfilled demands that compromise patient safety and therapeutic outcomes. METHODS: Using the modified Delphi technique, panel of 14 experts (general surgeons) came to a consensus. Two rounds of consensus were conducted online. An advisory board meeting was held for the third round, wherein survey results were discussed and the final statements were decided with supporting clinical evidence. RESULTS: Experts recommended intraperitoneal onlay mesh (IPOM) plus/trans-abdominal retromuscular/extended totally extraperitoneal/mini- or less-open sublay operation/transabdominal preperitoneal/trans-abdominal partial extra-peritoneal/subcutaneous onlay laparoscopic approach/laparoscopic intracorporeal rectus aponeuroplasty as valid minimal access surgery (MAS) options for ventral hernia (VH). Intraperitoneal repair technique is the preferred MAS procedure for primary umbilical hernia < 4 cm without diastasis; incisional hernia in the presence of a vertical single midline incision; symptomatic hernia, BMI > 40 kg/m2, and defect up to 4 cm; and for MAS VH surgery with grade 3/4 American Society of Anaesthesiologists. IPOM plus is the preferred MAS procedure for midline incisional hernia of width < 4 cm in patients with a previous laparotomy. Extraperitoneal repair technique is the preferred MAS procedure for L3 hernia < 4 cm; midline hernias < 4 cm with diastasis; and M5 hernia. CONCLUSION: The consensus statements will help standardize LVHR practices, improve decision-making, and provide guidance on MAS in VHR in the Indian scenario.

Do we still need Crile or Hayes Martin approach for cervical lymphadenectomy? A retrospective study of 56 patients with minimal access neck dissection.

The concept of neck dissection was introduced by Crile more than a century ago. Since then, multiple modifications have been adopted to ensure the preservation of vital structures. With the new era of minimal access surgery, the incorporation of laparoscopic, endoscopic, and robotic surgery is becoming the new normal. Over the years we have carried out neck dissections using minimal access incisions. Although there is no definitive answer about the average nodal yield required in selective or modified neck dissections, it has been reported that the average nodal yield of more than 18 is associated with better survival rate. In this publication we share the results of our three-year retrospective study of 56 patients who underwent minimal access neck dissection. We look at the nodal yield, assess operating duration, complications, outcome with a three-year follow up from a single unit. Our results demonstrate that minimal access neck dissection should be considered in head and neck lymphadenectomies.

Thoracoscopic Left Atrial Appendage Occlusion with the AtriClip PRO2: An Experience of 144 Patients.

AIM: To report the clinical outcomes of thoracoscopic left atrial appendage occlusion (LAAO) with the AtriClip PRO2 device (Atricure Inc, Mason, OH, USA). Stroke risk reduction with LAAO in patients with atrial fibrillation is now well-established. Many surgical and percutaneous techniques have been used, with varying rates of success. The percutaneous devices have had issues with procedural complications and peridevice flow. Thoracoscopic AtriClip offers an epicardial linear closure of the appendage at its ostium. This study sought to evaluate its safety and efficacy in achieving complete LAA closure. METHOD: This is a prospective series of thoracoscopic AtriClip PRO2 as a standalone procedure or a thoracoscopic AtriClip deployed as an adjunct to minimal access cardiac and thoracic surgery. Study ethical approval was granted by the hospital Human Research Ethics Committee. RESULTS: In total, 144 thoracoscopic AtriClip procedures were conducted by a single surgeon from 2017 to 2022, 56 standalone and 88 concomitant. There was no mortality or major morbidities. A 100% success in complete LAA closure was observed, with 87% complete follow-up imaging. For patients that underwent standalone AtriClip after cessation of anticoagulation, no thromboembolic phenomena were seen in the 180 patient-years of follow-up. CONCLUSIONS: This study demonstrates that thoracoscopic placement of AtriClip is safe and effective in achieving consistent and complete LAAO. Future randomised trials will be useful to compare outcomes with percutaneous devices.

Outcomes of minimal access cytoreductive surgery (M-CRS) and HIPEC/EPIC vs. open cytoreductive surgery (O-CRS) and HIPEC/EPIC in patients with peritoneal surface malignancies: a meta-analysis.

Introduction: Minimal Access Surgery (MAS) has shown better peri-operative outcomes with equivalent oncological outcomes in gastrointestinal and thoracic oncology. Open CRS (O-CRS) procedure accompanies inevitable and significant surgical morbidity in patients. The aim of the review article is to compare outcomes of M-CRS and HIPEC/EPIC with open procedure in peritoneal surface malignancies. Content: Comprehensive search of databases was done and total 2,807 articles were found (2793-PubMed and 14-Cochrane review). PRISMA flow chart was prepared and 14 articles were selected. Meta-analysis was performed according to PRISMA guidelines using random-effects model (DerSimonian Laird) and fixed effect model. Publication bias was tested with Funnel plot and Egger's regression test. Quality of studies was assessed by Newcastle-Ottawa scale. Summary and Outlook: Patients in both groups [total (732), M-CRS(319), O-CRS(413)] were similar in demographic characteristics. Peri-operative outcomes were significantly better in M-CRS group in terms of blood loss SMD=-2.379, p<0.001 (95 % CI -2.952 to -1.805), blood transfusion RR=0.598, p=0.011 (95 % CI 0.402 to 0.889), bowel recovery SMD=-0.843, p=0.01 (95 % CI -1.487 to -0.2), hospital stay SMD=-2.348, p<0.001 (95 % CI -3.178 to -1.519) and total morbidity RR=0.538, p<0.001 (95 % CI 0.395 to 0.731). Duration of surgery SMD=-0.0643 (95 % CI -0.993 to 0.865, p=0.892) and CC0 score RR=1.064 (95 % CI 0.992 to 1.140, p=0.083) had no significant difference. Limited studies which evaluated survival showed similar outcomes. This meta-analysis shows that M-CRS and HIPEC/EPIC is feasible and has better peri-operative outcomes compared to open procedure in patients with limited peritoneal carcinoma index (PCI) peritoneal surface malignancies. Survival outcomes were not calculated. Further studies are warranted in this regard.

Incidence of incisional hernia following liver surgery for colorectal liver metastases. Does the laparoscopic approach reduce the risk? A comparative study.

Backgrounds/Aims: No reports to compare incisional hernia (IH) incidence between laparoscopic and open colorectal liver metastases (CRLM) resections have previously been made. This is the first comparative study. Methods: Single-center retrospective review of patients who underwent CRLM surgery between January 2011 and December 2018. IH relating to liver surgery was confirmed by computed tomography. Patients were divided into laparoscopic liver resection (LLR) and open liver resection (OLR) groups. Data collection included age, sex, presence of diabetes mellitus, steroid intake, history of previous hernia or liver resection, subcutaneous and peri-renal fat thickness, preoperative creatinine and albumin, American Society of Anesthesiologists (ASA) score, major liver resection, surgical site infection, synchronous presentation, and preoperative chemotherapy. Results: Two hundred and forty-seven patients were included with a mean follow-up period of 41 ± 29 months (mean ± standard deviation). Eighty seven (35%) patients had LLR and 160 patients had OLR. No significant difference in the incidence of IH between LLR and OLR was found at 1 and 3 years, respectively ([10%, 19%] vs. [10%, 19%], p = 0.95). On multivariate analysis, previous hernia history (hazard ratio [HR], 2.22; 95% confidence interval [CI], 1.56-4.86) and subcutaneous fat thickness (HR, 2.22; 95% CI, 1.19-4.13) were independent risk factors. Length of hospital stay was shorter in LLR (6 ± 4 days vs. 10 ± 8 days, p < 0.001), in comparison to OLR. Conclusions: In CRLM, no difference in the incidence of IH between LLR and OLR was found. Previous hernia and subcutaneous fat thickness were risk factors. Further studies are needed to assess modifiable risk factors to develop IH in LLR.

Scarless totally implantable venous access port (TIVAP) implantation: Surgical technique, preliminary results, learning curve, and patients-reported outcome in 125 breast cancer patients.

BACKGROUND: Minimal-access (endoscopic or robotic-assisted) breast surgery has been increasingly performed and shown better cosmetic results. However, location of totally implantable venous access port (TIVAP) for systemic treatment at anterior chest may compromise its aesthetic benefits. Therefore, we proposed a new scarless technique for TIVAP implantation, and reported the preliminary results, learning curve, and patients-surveyed outcome. METHODS: Surgical technique of the new "scarless" TIVAP implantation was proposed. Patients receiving this procedure in a single institution were included. The preliminary results of the scarless TIVAP implantation, learning curve, and patient-reported outcome were analyzed and reported. RESULTS: A total of 125 breast cancer patients received scarless TIVAP procedures were enrolled. The primary success rate of the scarless TIVAP implantation was 100%. Mean operative time was 46 ± 14 min. Mean amount of blood loss was 8.5 ± 3.2 ml. The cumulative sum plot showed operation time significantly decreased after 24th cases. In the initial learning phase, the mean operative time was 55 ± 17 min, and decreased to 43 ± 12 min in the later mature phase (P = 0.003). There were 5 (4%) complications detected, which included 1 (0.8%) seroma formation, 2 (1.6%) revisions, and 2 (1.6%) unplanned explantations. From patients-evaluated questionnaires, more than 90% of responders were satisfied with aesthetic results, experience during surgery, and application of scarless TIVAP for systemic therapy. CONCLUSIONS: The scarless TIVAP implantation is a safe & reliable procedure with high patients-reported aesthetic satisfaction, and could be an alternative TIVAP procedure for patients requiring chemotherapy and desiring a less noticeable scar.