European association for endoscopic surgery (EAES) consensus statement on single-incision endoscopic surgery.

BACKGROUND: Laparoscopic surgery changed the management of numerous surgical conditions. It was associated with many advantages over open surgery, such as decreased postoperative pain, faster recovery, shorter hospital stay and excellent cosmesis. Since two decades single-incision endoscopic surgery (SIES) was introduced to the surgical community. SIES could possibly result in even better postoperative outcomes than multi-port laparoscopic surgery, especially concerning cosmetic outcomes and pain. However, the single-incision surgical procedure is associated with quite some challenges. METHODS: An expert panel of surgeons has been selected and invited to participate in the preparation of the material for a consensus meeting on the topic SIES, which was held during the EAES congress in Frankfurt, June 16, 2017. The material presented during the consensus meeting was based on evidence identified through a systematic search of literature according to a pre-specified protocol. Three main topics with respect to SIES have been identified by the panel: (1) General, (2) Organ specific, (3) New development. Within each of these topics, subcategories have been defined. Evidence was graded according to the Oxford 2011 Levels of Evidence. Recommendations were made according to the GRADE criteria. RESULTS: In general, there is a lack of high level evidence and a lack of long-term follow-up in the field of single-incision endoscopic surgery. In selected patients, the single-incision approach seems to be safe and effective in terms of perioperative morbidity. Satisfaction with cosmesis has been established to be the main advantage of the single-incision approach. Less pain after single-incision approach compared to conventional laparoscopy seems to be considered an advantage, although it has not been consistently demonstrated across studies. CONCLUSIONS: Considering the increased direct costs (devices, instruments and operating time) of the SIES procedure and the prolonged learning curve, wider acceptance of the procedure should be supported only after demonstration of clear benefits.

Outcomes after laparoscopic ventral hernia repair: does the number of previous recurrences matter? A prospective study.

BACKGROUND: It is not yet clearly known whether laparoscopic ventral hernia repair (LVHR) is superior to the open approach in recurrent hernias. The aim of this study is to determine the safety and efficacy of laparoscopic technique for ventral hernias and investigate whether these outcomes are affected by the number of previous failed repairs. METHODS: Data from 124 consecutive patients who underwent LVHR using a standardized technique between September 2007 and June 2014 were collected prospectively. In all repairs, a composite prosthesis was tailored to overlap the defect by at least 5 cm and fixed with a double crown of spiral tacks. Clinical follow-up visits were performed at 1 week, 1, 6, and 12 months, and yearly thereafter. Patients were classified in 3 groups (0, 1, and ≥ 2) according to the number of previous hernia repairs for further statistical analysis. RESULTS: Long-term surveillance was available in 116 (93%) patients. Of these, 96 (82.8%) were recurrent hernias. There were 2 (1.7%) conversions, both in recurrent cases, and in 3 (2.6%) patients a hybrid access was used. Mean operating time was 55 min. There was an overall postoperative complication rate of 16%, with no mortality. During a mean follow-up of 30 (range 20-90) months, 3 (2.6%) recurrences were diagnosed 6, 8, and 9 months after surgery, respectively. A univariate analysis related to demographic, clinical, and perioperative variables did not find any significant relationship between the number of previous recurrences and operating time, conversion rate, hospital length of stay, overall morbidity, or recurrence. CONCLUSIONS: This study suggests that laparoscopic approach in recurrent incisional hernias is a safe and feasible alternative to open techniques. Furthermore, our experience supports the idea that LVHR may be the best option for recurrent cases in properly selected patients, independently of the number of previous recurrences.

Colorectal anastomosis facilitated by the use of the LigaSure(®) sealing device: comparative study in an animal model.

BACKGROUND: Recently, there has been speculation about the possibility of fusing intestinal tissue using bipolar sealing devices. In this study we compare in a porcine model the anastomoses created using the LigaSure(®) device with those created with a stapler after section and closure of a rectal stump. METHODS: Thirty pigs underwent laparoscopic colorectal anastomosis. In group A (n = 15), the division of the intestine and distal stump closure were done with a 10-mm LigaSure Atlas(®) device. In group B, these steps were carried out using an endoscopic stapler. Subsequently, the colorectal anastomosis was performed using circular stapling in both groups. The 4-week follow-up included health status, weight gain, blood tests, X-rays, and colonoscopy. Anastomotic tissue was processed to study the mechanical tensile strength and histopathology. RESULTS: There was no difference in the rate of conversion to open surgery or in average operating time between the groups. In the sealing device group, there was a significantly higher rate of failure in rectal stump closure (p = 0.042). There was one death in group B due to anastomotic leak. There was no difference in adhesion formation or stenosis. Mid-section anastomosis area was 89.7 mm(2) in group A compared with 100 mm(2) in group B (p = 0.52). In tensile strength studies, the maximum load resisted by the sample was 13.8 ± 4.9 N (group A) versus 15.7 ± 4.4 N (group B) (p = 0.17). There was no difference between the groups in degree of reepithelialization, number of inflammatory cells, or the presence of microabscesses. CONCLUSIONS: Division and sealing of the rectal stump with the LigaSure(®) device is feasible in the proposed experimental model, but it is less reliable than conventional closure with a stapler, since it has a significantly greater failure rate. Therefore, The LigaSure(®) device should not be used for this purpose in the clinical setting as this could lead to serious and dramatic complications.

Systematic review and meta-analysis of randomized controlled trials comparing single incision versus conventional laparoscopic appendectomy.

BACKGROUND: Single incision laparoscopic appendectomy (SILA) has been proposed as an alternative to conventional laparoscopic appendectomy (CLA). OBJECTIVE: The aim of this study was to evaluate the safety and efficacy of SILA when compared with CLA through a systematic review. METHODS: We performed an electronic search of EMBASE, PubMed, MEDLINE, and Cochrane Central Register of Controlled Trials. Randomized controlled trials (RCTs) that compared SILA with CLA were included. RESULTS: Six RCTs met eligibility criteria, which included a total of 800 patients, 401 in the SILA group and 399 in the CLA group. There were no significant differences in terms of overall complications (odds ratio [OR] 0.93; 95% confidence interval [CI] 0.59-1.47; p = 0.77). SILA had a higher technical failure rate (OR 3.30; 95% CI 1.26-8.65; p = 0.01) and required a longer operative time (mean difference [MD] 4.67; 95% CI 1.76-7.57; p = 0.002). SILA was associated with better cosmetic results (standardized MD -0.4; 95% CI -0.64 to -0.16; p = 0.001) and earlier return to normal activity (MD -0.64; 95% CI -1.09 to -0.20; p = 0.005), although these advantages should be taken with caution due to the small number of studies reporting these two items and the short follow-up in the evaluation of cosmetic results. There were no significant differences in terms of postoperative pain or length of hospital stay between groups. CONCLUSIONS: SILA is comparable to CLA in selected patients, although it is associated with a higher technical failure rate and longer operative time. Further randomized trials are needed to determine if SILA really offers benefits over CLA.

[25 years of laparoscopic surgery in Spain]. / 25 años de cirugía laparoscópica en España.

INTRODUCTION: The introduction of laparoscopic surgery (LS) can be considered the most important advancement in our specialty in the past 25 years. Despite its advantages, implementation and consolidation has not been homogenous, especially for advanced techniques. The aim of this study was to analyse the level of development and use of laparoscopic surgery in Spain at the present time and its evolution in recent years. MATERIAL AND METHODS: During the second half of 2012 a survey was developed to evaluate different aspects of the implementation and development of LS in our country. The survey was performed using an electronic questionnaire. RESULTS: The global response rate was 16% and 103 heads of Department answered the survey. A total of 92% worked in the public system. A total of 99% perform basic laparoscopic surgery and 85,2% advanced LS. Most of the responders (79%) consider that the instruments they have available for LS are adequate and 71% consider that LS is in the right stage of development in their environment. CONCLUSIONS: Basic laparoscopic surgery has developed in our country to be considered the standard performed by most surgeons, and forms part of the basic surgical training of residents. With regards to advanced LS, although it is frequently used, there are still remaining areas of deficit, and therefore, opportunities for improvement.

[Single incision laparoscopic surgery: analysis of the national register]. / Cirugía laparoscópica a través de incisión única. análisis del registro nacional.

INTRODUCTION: Laparoscopic surgery through a single incision is an innovative concept which is a challenge for surgeons to implement and develop. The interest aroused by these techniques in Spain led to the Endoscopy Section of the Spanish Association of Surgeons (AEC) to start a National Register for Single-Incision Surgery (RNCIU). The aim of this study was to collect the primary clinical data, techniques, and the possible complications of these techniques in Spain. MATERIAL AND METHODS: Data were gathered using a form available on the AEC website. The forms included in this study correspond to those received between June 2010 and June 2011. RESULTS: A total of 35 centers had taken part during the study period, with 1,198 forms being collected. The surgeries performed included 62.2% cholecystectomies, 22% appendectomies, and 7.8% colectomies. Procedures on solid organs (3.4%), bariatric surgery (2.7%), and various hernia repairs (1.9%), were also registered. The overall incidence of complications was 0.8%. The mortality rate in the series was 0.1%. CONCLUSIONS: Single incision laparoscopic surgery is a novel concept that is not beyond our scientific community. The results of the Register demonstrate the feasibility of numerous effective and safe procedures. Finally, the RNCIU is an important data source to be able to study sub-groups of diseases in detail, with the aim of advancing the knowledge of these techniques and generating scientific evidence.

[Pelvic reconstruction after abdominoperineal resection of the rectum]. / Reconstrucción pélvica tras amputación abdominoperineal del recto.

Despite the advances in the treatment of cancer of the rectum and the expansion of the multimodal therapeutic technique, abdominoperineal resection (APR) still needs to be performed as radical treatment in 20-30% of cases. APR of the rectum involves a significant morbidity, including intestinal obstruction and wound complications, with radiotherapy-induced enteritis being able to develop in 15% of cases subjected to post-operative radiotherapy. Furthermore, with the aim of improving local oncology results, an extended APR is recommended; a technique that requires a perineal reconstruction technique that allows a tension free closure in a previously radiated tissue and may prevent perineal hernias developing. The objective of this article is to review pelvic and perineal repair methods after APR due to cancer, with special attention to the new prosthetic repair techniques.

Modified Intraumbilical Versus Infraumbilical Entry Method at Laparoscopy: A Cohort Study.

BACKGROUND: There is no consensus on the optimal laparoscopic entry method. Whether a transumbilical or periumbilical incision is beneficial for the initial peritoneal access has been debated. These 2 methods have their own advocates, since each has its own benefits and disadvantages. Furthermore, the lack of consensus extends to the type of entry technique [Hasson, Veress needle (VN), direct trocar]. We have conducted a study comparing a modified intraumbilical technique (MIT), a novel method that combines a VN insertion through a modified direct-trocar access, with the standard infraumbilical VN technique. Our aim is to determine which technique is a better route for the initial umbilical trocar. MATERIALS AND METHODS: A retrospective cohort study of 406 patients from a prospectively maintained database has been performed. Two cohorts of cases have been analyzed (VN=198; MIT=208). Primary outcomes were intraoperative access-related events, entry failure, and long-term wound complications. Clinical follow-up was performed at 1 and 6 months and yearly thereafter. RESULTS: Subcutaneous emphysema, extraperitoneal insufflation, and difficult entry (>2 VN insertions) occurred more frequently in the VN group (P=0.011, 0.023, and 0.023, respectively). There were 5 (2.52%) failed entries in the VN group and none in the MIT group (P=0.085). Regarding postoperative complications, seroma of the wound occurred more frequently in the VN group (P=0.033). At a mean follow-up of 18.4 months, 13 (3.20%) trocar-site hernias were detected, equally distributed among both groups. CONCLUSIONS: MIT eliminates the risk of failed entries and some complications associated with the VN technique without an increase in umbilical wound infection and facilitates a proper closure of the umbilical incision to secure a low trocar-site hernia rate. Halfway between open and closed techniques for laparoscopic entry, MIT is a safe and feasible procedure that embodies the advantages of both methods and may constitute an advantageous alternative to the infraumbilical VN entry approach.

Long-Term Anorectal Manometry Outcomes After Laparoscopic and Transanal Total Mesorectal Excision.

Background: During transanal total mesorectal excision (TaTME), sustained dilation of the anal canal occurs, which can cause anatomical and functional damage to the sphincter complex. This study aimed to analyze the impact of laparoscopic total mesorectal excision (LaTME) and TaTME in anorectal sphincter function. Materials and Methods: An observational study was conducted comparing two cohorts of patients who underwent LaTME or TaTME for rectal cancer. The two groups were paired for comparison based on age, gender, and distance of the neoplasm to the anal margin. The anorectal function was assessed by manometry before surgery and at least 6 months after primary intervention or stoma closure. The intestinal function was assessed using the low anterior resection syndrome (LARS) score. Results: Twenty-two patients were included. There were no significant differences in baseline characteristics between groups except for the time between surgery and testing. A decrease in the mean resting and squeeze pressures between pre- and postoperative manometry was observed in both the treatment groups, the difference being only significant in the squeeze pressure values (TaTME P = .003; LaTME P = .004). After surgery, squeeze pressure reduction correlated with a worsening of the LARS point count (rho 0.587; P = .004). The time elapsed since surgery was negatively correlated with the LARS point count (rho -0.696; P = .001) and the difference between pre- and postoperative mean squeeze pressures (rho -0.499; P = .018). Conclusion: Manometric findings after TME are comparable between the laparoscopic and the transanal approach. Deterioration of both anal sphincter function and LARS improves with time after surgery.

[Parastomal hernias: background, current status and future prospects]. / Eventración paraestomal: antecedentes, estado actual y expectativas de futuro.

Parastomal hernia (PH) is the most common delayed complication in stoma surgery. Only a third of these are operated on, something which is partly explained by the high recurrence rate observed after repair. The use of prosthetic materials has improved the results, although they continue to be below the ideal. For this reason, it has been proposed that the best solution may be in preventing the PH. Several studies show promising results, with very marked reductions in the percentage of IH, on placing a prophylactic peristomal prosthesis. In this article we present a review of the risk factors associated with PH, a classification of the existing diversity of repair techniques, and an algorithm is proposed for the management of PH, including its prevention.

[NOTES. History and current situation of natural orifice transluminal endoscopic surgery in Spain]. / NOTES. Historia y situación actual de la cirugía endoscópica por orificios naturales en nuestro país.

Natural orifice transluminal endoscopic surgery (NOTES), involves a group of new endoscopic approaches to the abdominal cavity, with potential advantages over conventional laparoscopic surgery. It is based on the possibility of performing intra-peritoneal surgical techniques through natural orifices by entering the peritoneal cavity through natural orifices perforating the organ that allows direct access to that cavity (stomach, vagina, rectum, bladder). The possibility of using this same route to access the retroperitoneum and mediastinum has subsequently been postulated. Comments are made on how the technique has been developed, as well as how it has been applied in our country, attempting to give a general view on the risks and benefits of NOTES and the basic requirements to be able to start in this new surgery.

[Single incision laparoscopic surgery]. / Cirugía laparoscópica a través de incisión única.

One of the aims of the new technologies and techniques in minimally invasive surgery (MIS) is to achieve a surgery without or with minimal visible scars. Natural orifice transluminal endoscopic surgery (NOTES) might be considered to be a paradigm of this development but it has not yet been possible to implement this universally. Nevertheless, the resultant innovation of research into NOTES has enabled "bridge technologies" to be introduced that allow MIS to be developed with the required standards of efficiency and safety. The aim of this paper is to review the concept of single incision surgery and to classify the available tools for its development and implementation.

Incidence and Risk Factors of Incisional Hernia After Single-Incision Endoscopic Surgery.

Introduction: Abdominal wall complications are one of the most controversial issues regarding single-incision endoscopic surgery. The aim of this study was to analyze the incidence and risk factors of incisional hernia after single-incision endoscopic cholecystectomy. Materials and Methods: An observational retrospective study was performed, on a cohort of patients cholecystectomized laparoscopically through a transumbilical single incision due to gallbladder lithiasis or polyps. Postoperative complications were analyzed, with special interest in the incisional hernia rate, whose results were assessed in the long-term follow-up. Univariate and multivariate analyses were also performed to evaluate possible variables associated with the appearance of incisional hernia. Cumulative sum charts (CUSUM) were used to identify trends in the incisional hernia risk. Results: Some 109 patients were included in the study. With a mean follow-up of nearly 38 months, an incisional hernia incidence of 5.5% was found, with 67% being diagnosed during the first year of follow-up. In the Cox regression analysis, two variables showed an independent association with the emergence of incisional hernia, body mass index (hazard ratio [HR] 1.30; 95% confidence interval [CI 1.053-1.606]; P .015), and wound infection (HR 26.32; [3.186-217.40]; P .002]. CUSUM charts showed a decrease in the risk of incisional hernia after the first 10 cases. Conclusions: Single-incision endoscopic cholecystectomy is associated with a substantially high risk of postoperative incisional hernia (5.5%).

Use of social networks by general surgeons. Results of the national survey of the Spanish Association of Surgeons. / Uso de las redes sociales por parte de los cirujanos generales. Resultados de la encuesta nacional de la Asociación Española de Cirujanos.

INTRODUCTION: The use and utility of social media (SM) among Spanish general surgeons is unknown. METHODS: Between October and December 2017 an online survey was carried out to the members of the Spanish Association of Surgeons, in which data on the profile of use and opinion on the usefulness of SM were collected. RESULTS: 360 valid responses were obtained, 310 from surgeons who had an active SM profile. The most popular networks were: Facebook (86%), LinkedIn (61,6%), YouTube (60,6%) and Twitter (54,2%). LinkedIn and Twitter stood out as the most used SM for professional purposes. Surgeons with a SM profile were younger (42.4±11 years versus 51.6±8 years; P<.001). Gender did not show influence on presence in SM. The majority of respondents have profiles in more than one network (3.6±1 accounts) and 73.5% reported daily access to them; 19.7% of the surgery departments to which the respondents belong have a SM account. Among SM utilities in the professional field, training activities (87%) and connectivity among professionals (84%) were the most outstanding; 14.1% of respondents use SM to interact with patients. CONCLUSIONS: SM is useful as a tool for the acquisition, updating and dissemination of scientific knowledge, also proving valuable as a new form of interaction among surgeons. Other issues such as privacy or surgeon-patient relationship represent a barrier to its use.

Division of the small bowel with the LigaSure Atlas device during the right laparoscopic colectomy.

BACKGROUND: Bowel division and anastomosis were facilitated greatly with the advent of stapling techniques. Since then, there have not been any new evolving technologies to facilitate these maneuvers. For this reason, we recently applied the LigaSure Atlas device (Valleylab, Boulder, CO) to the division of the small bowel during this procedure to obtain a reliable and low-cost division of the ileum. METHODS: After vessel ligation and ileocolic mobilization, the terminal ileum is sealed and divided with the LigaSure Atlas. This device is applied sequentially along the small bowel twice to ensure an adequate seal before the cut. A terminolateral ileotransversostomy is performed extracorporeally with a mechanical circular stapling device, installing the anvil of the circular stapler into the ileal stump. RESULTS: We have not encountered any problems with this technique since its introduction in our institution, and no leakage or bursting of the ileal stumps. CONCLUSIONS: This technique enables an easy, reliable, and inexpensive technical option to optimize the right laparoscopic colectomy procedure.

Laparoscopic appendectomy during pregnancy: between personal experiences and scientific evidence.

BACKGROUND: Although laparoscopic appendectomy is a safe and effective procedure for management of acute appendicitis, data about the feasibility and safety during pregnancy are limited. We aimed to study our experience in this field and to review the scientific evidence available. STUDY DESIGN: All patients undergoing laparoscopic appendectomy during pregnancy, from January 2003 to December 2005, were included. Medical files were reviewed retrospectively. In addition, 133 cases from the literature were reviewed. General features of the cases, surgical technique details, and outcomes were analyzed. RESULTS: All laparoscopic procedures were completed without conversion to open operation. No substantial hemodynamic or gasometric changes were detected during the procedures. Tocolytic medication was not administered in any patient. All patients were discharged from hospital within the first 48 postoperative hours, and no complications were recorded during this period or in the followup. All newborns had an adequate weight for gestational age, satisfactory parameters of well-being at birth, and an uneventful development after 1-year followup. CONCLUSIONS: Laparoscopic appendectomy during pregnancy is as effective and safe as the conventional approach and has all the benefits of minimally invasive operation, provided that specific recommendations for these types of patients are strictly followed. It must be mentioned that there is only limited scientific evidence to support this statement.

Experience with a Spanish-language laparoscopy website.

INTRODUCTION: Although there are no clearly defined electronic tools for continuing medical education (CME), new information technologies offer a basic platform for presenting training content on the internet. Due to the shortage of websites about minimally invasive surgery in the Spanish language, we set up a topical website in Spanish. MATERIALS AND METHODS: This study considers the experience with the website between April 2001 and January 2005. To study the activity of the website, the registry information was analyzed descriptively using the log files of the server. To study the characteristics of the users, we searched the database of registered users. RESULTS: We found a total of 107,941 visits to our website and a total of 624,895 page downloads. Most visits to the site were made from Spanish-speaking countries. The most frequent professional profile of the registered users was that of general surgeon. CONCLUSION: The development, implementation, and evaluation of Spanish-language CME initiatives over the internet is promising but presents challenges.