Enhanced recovery after surgery protocol allows ambulatory laparoscopic appendectomy in uncomplicated acute appendicitis: a prospective, randomized trial.

BACKGROUND: Previous observational studies have demonstrated the safety of discharging patients after laparoscopic appendectomy within the same day without hospitalization. The application of Enhanced Recovery After Surgery (ERAS) guidelines has resulted in shorter length of stay, fewer complications, and reduction in medical costs. The aim of this study was to investigate if ERAS protocol implementation in patients with acute uncomplicated appendicitis decreases the length of stay enough to allow for ambulatory laparoscopic appendectomy. METHODS: In this prospective, randomized controlled clinical trial, 108 patients were randomized into two groups: laparoscopic appendectomy with ERAS (LA-E) or laparoscopic appendectomy with conventional care (LA-C). The primary endpoint was postoperative length of stay. The secondary end points were time to resume diet, postoperative pain, postoperative complications, re-admission rate, and reoperation rate. RESULTS: From January 2016 through May 2017, 50 patients in the LA-E group and 58 in the LA-C were analyzed. There were no significant differences in preoperative data. Regarding the primary end point of the study, the ERAS protocol significantly reduced the postoperative length of stay with a mean of 9.7 h (SD: 3.1) versus 23.2 h (SD: 6.8) in the conventional group (p < 0.001). The ERAS protocol allowed ambulatory management in 90% of the patients included in this group. There was a significant reduction in time to resume diet (110 vs. 360 min, p < 0.001) and less moderate-severe postoperative pain (28 vs. 62.1%, p < 0.001) in the LA-E versus LA-C group. The rate of complications, readmissions, and reoperations were comparable in both groups (p = 0.772). CONCLUSIONS: ERAS implementation was associated with a significantly shorter length of stay, allowing for the ambulatory management of this group of patients. Ambulatory laparoscopic appendectomy is safe and feasible with similar rates of morbidity and readmissions compared with conventional care.

Laparoscopic Choledochoduodenostomy. / Colédoco-duodeno anastomosis laparoscópica.

INTRODUCTION: Today's options for biliary bypass procedures, for difficult choledocholithiasis, range from open surgery to laparo-endoscopic hybrid procedures. The aim of this study was to analyze the outcomes of patients with difficult choledocholithiasis treated with laparoscopic choledochoduodenostomy. METHODS: We performed a prospective observational study from March 2011 to June 2016. We included patients with difficult common bile duct stones (recurrent or unresolved by ERCP) in which a biliary bypass procedure was required. We performed a laparoscopic bile duct exploration with choledochoduodenostomy and intraoperative cholangioscopy. RESULTS: A total of 19 patients were included. We found female predominance (78.9%), advanced mean age (72.4±12 years) and multiple comorbidities. Most patients with previous episodes of choledocholitiasis or cholangitis, mode 1 (min-max: 1-7). Mean common bile duct diameter 24.9±7mm. Mean operative time 218.5±74min, estimated blood loss 150 (30-600)mL, resume of oral intake 3.2±1 days, postoperative length of stay 4.9±2 days. We found a median of 18 (12-32) months of follow-up. All patients with normalization of liver enzymes during follow-up. One patient presented with sump syndrome and one patient died due to nosocomial pneumonia. CONCLUSIONS: Laparoscopic choledochoduodenostomy with intraoperative cholangioscopy seems to be safe and effective treatment for patients with difficult common bile duct stones no resolved by endoscopic procedures. This procedure is a good option for patients with advanced age and multiple comorbidities. We offer all the advantages of minimally invasive surgery to these patients.

A New Era of Bile Duct Repair: Robotic-Assisted Versus Laparoscopic Hepaticojejunostomy.

BACKGROUND: Despite scientific evidence of the safety, efficacy, and in some cases superiority of minimally invasive surgery in hepato-pancreato-biliary procedures, there are scarce publications about bile duct repairs. The aim of this study was to compare the outcomes of robotic-assisted surgery versus laparoscopic surgery on bile duct repair in patients with post-cholecystectomy bile duct injury. METHODS: This is a retrospective comparative study of our prospectively collected database of patients with bile duct injury who underwent robotic or laparoscopic hepaticojejunostomy. RESULTS: Seventy-five bile duct repairs (40 by laparoscopic and 35 by robotic-assisted surgery) were treated from 2012 to 2018. Injury types were as follows: E1 (7.5% vs. 14.3%), E2 (22.5% vs. 14.3%), E3 (40% vs. 42.9%), E4 (22.5% vs. 28.6%), and E5 (7.5% vs. 0), for laparoscopic hepaticojejunostomy (LHJ) and robotic-assisted hepaticojejunostomy (RHJ) respectively. The overall morbidity rate was similar (LHJ 27.5% vs. RHJ 22.8%, P = 0.644), during an overall median follow-up of 28 (14-50) months. In the LHJ group, the actuarial primary patency rate was 92.5% during a median follow-up of 49 (43.2-56.8) months. While in the RHJ group, the actuarial primary patency rate was 100%, during a median follow-up of 16 (12-22) months. The overall primary patency rate was 96% (LHJ 92.5% vs. RHJ 100%, log-rank P = 0.617). CONCLUSION: Our results showed that the robotic approach is similar to the laparoscopic regarding safety and efficacy in attaining primary patency for bile duct repair.

Intraoperative endoscopy prevents technical defect related leaks in laparoscopic Roux-en-Y gastric bypass: A randomized control trial.

BACKGROUND: Postoperative anastomotic leaks, bleeding and stenosis are major causes of morbidity after laparoscopic Roux-en-Y gastric bypass (LRYGB). Retrospective studies suggest that intraoperative endoscopy reduces the incidence of these complications. METHODS: We conducted a prospective randomized controlled trial in a single institution between March 2013 and January 2016. Patients were assigned to one of two groups: LRYGB with Intraoperative Endoscopy (IOE) or LRYGB without IOE. Patient selection criteria were morbidly obese patients, 18 years or older who were candidates to LRYGB. The primary outcome was the frequency of technical defect related anastomotic leaks. Secondary outcomes were operative time, length of hospital stay, anastomotic related complications, reoperations and 30-day mortality. RESULTS: 50 patients were randomly assigned in the IOE group and 50 in the control group. The IOE group had statistically significant lower rate of anastomotic leak (0 vs. 8%, p = .0412), and lower need for reoperation (0 vs. 8%, p = .0412). The IOE group had longer operative time (194.10 vs. 159 min, p < .001), and shorter mean length of hospital stay (2.44 vs. 3.46 days, p = .025). No differences were found in the rate of bleeding of the anastomosis, narrow anastomosis and 30-day mortality. CONCLUSION: This study specifically provides evidence that air leak test performed by intraoperative endoscopy is superior to simple visual inspection in preventing technical defect related leaks after laparoscopic Roux-en-Y gastric bypass.

Minimally invasive approach (robotic and laparoscopic) to biliary-enteric fistula secondary to cholecystectomy bile duct injury.

Spontaneous biliary-enteric fistula after laparoscopic cholecystectomy bile duct injury is an extremely rare entity. Y-en-Roux hepaticojejunostomy has been demonstrated to be an effective surgical technique to repair iatrogenic bile duct injuries. Seven consecutive patients underwent robotic-assisted (n = 5) and laparoscopic (n = 2) biliary-enteric fistula resection and bile duct repair at our hospital from January 2012 to May 2017. We reported our technique and described post-procedural outcomes. The mean age was 52.4 years, mostly females (n = 5). The mean operative time was 240 min for laparoscopic cases and 322 min for robotic surgery, and the mean estimated blood loss was 300 mL for laparoscopic and 204 mL for robotic cases. In both groups, oral feeding was resumed between day 2 or 3 and hospital length of stay was 4-8 days. Immediate postoperative outcomes were uneventful in all patients. With a median of 9 months of follow-up (3-52 months), no patients developed anastomosis-related complications. We observed in this series an adequate identification and dissection of the fistulous biliary-enteric tract, a safe closure of the fistulous orifice in the gastrointestinal tract and a successful bile duct repair, providing the benefits of minimally invasive surgery.

Laparoscopic Versus Open Surgery for Abdominal Trauma: A Case-Matched Study.

BACKGROUND: The use of laparoscopic surgery in abdominal emergencies, such as in trauma, has had a slow acceptance. The advantages described with this approach include less postoperative pain, faster recovery, quicker return to everyday activities, and fewer wound complications. The aim of this retrospective study was to compare outcomes following laparoscopic versus open surgery for abdominal trauma (either blunt or penetrating). MATERIALS AND METHODS: Nineteen patients with abdominal trauma who underwent laparoscopic surgery from January 2013 to May 2016 were compared with 19 patients undergoing open surgery during the same time period. Patients were matched (1:1) for age, gender, body-mass index, American Society of Anesthesiologists score, hemodynamic stability, and injury mechanism. Intra- and postoperative variables were compared between groups. RESULTS: Laparoscopic group displayed a significantly shorter operative time (93.3 versus 134.2 minutes; P < .009), lower estimated blood loss (100 versus 600 mL; P < .019), faster return to normal diet (1.6 versus 2.4 days; P < .039), and shorter hospital length of stay (LOS) (3.8 versus. 5.6 days; P < .042). There were no statistical significant differences in 30-day mortality between both groups. CONCLUSIONS: Laparoscopic surgery for abdominal trauma, either blunt or penetrating, is safe and technically feasible in hemodynamically stable patients. We found in our study that laparoscopic surgery was associated with shorter operative time, lower estimated blood loss, faster return to normal diet, and shorter hospital LOS.

[Skills comparison using a 2D vs. 3D laparoscopic simulator]. / Comparación de destrezas en simulador de laparoscopia: imagen en 2D vs. 3D.

BACKGROUND: The development and application of 3D images in laparoscopic surgery has brought the benefit of in-depth perception that traditional laparoscopic surgery lacked. Previous studies in surgical populations have demonstrated the advantages of 3D technology. To limit bias of the previous experiences of participants, this study was performed in a population without any experience in this area. MATERIAL AND METHODS: An experimental, open, cross-sectional, comparative study between surgical skills achievements using 2D and a 3D laparoscopy equipment, using each subject as their own control. Six skills were evaluated in 2D and 3D modalities. RESULTS: Of the 40 participants included, 20 began the skills in the 2D modality and then performed them in 3D, and the other 20 began in 3D. Of the 118 skills evaluated there was a time improvement in 72% in the 3D group compared to 37% in the 2D modality (P=.000). The accomplishment percentage using the 3D laparoscopy was greater for both groups. There was a statistically significant difference in the better time for the 3D performed tasks. Just over half (52.5%) of participants preferred 3D laparoscopy, 15% preferred 2D, and 32.5% had no preferences. DISCUSSION: As other studies have demonstrated, there was improvement in the overall performance using the 3D laparoscope. Bias was limited by using a population without surgical experience. CONCLUSIONS: 3D laparoscopic surgical skills showed superior to 2D, with higher percentages of tasks completion, less time in performing them, and a shorter learning curve.