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Purpose: Minimal-invasive liver surgery (MILS) reduces surgical trauma and is associated with fewer postoperative complications. To amplify these benefits, perioperative multimodal concepts like Enhanced Recovery after Surgery (ERAS), can play a crucial role. We aimed to evaluate the cost-effectiveness for MILS in an ERAS program, considering the necessary additional workforce and associated expenses., Methods: A prospective observational study comparing surgical approach in patients within an ERAS program compared to standard care from 2018-2022 at the Charité - Universitätsmedizin Berlin. Cost data were provided by the medical controlling office. ERAS items were applied according to the ERAS society recommendations., Results: 537 patients underwent liver surgery (46% laparoscopic, 26% robotic assisted, 28% open surgery) and 487 were managed by the ERAS protocol. Implementation of ERAS reduced overall postoperative complications in the MILS group (18% vs. 32%, p = 0.048). Complications greater than Clavien-Dindo grade II incurred the highest costs (€ 31,093) compared to minor (€ 17,510) and no complications (€13,893; p < 0.001). In the event of major complications, profit margins were reduced by a median of € 6,640., Conclusions: Embracing the ERAS society recommendations in liver surgery leads to a significant reduction of complications. This outcome justifies the higher cost associated with a well-structured ERAS protocol, as it effectively offsets the expenses of complications., (© 2024. The Author(s).)

Background: Laparoscopic resection of the sigmoid colon is generally considered as feasible option to open surgery, but standardised guidelines on surgical details have not been adopted yet. The aim of this survey was to investigate which techniques were applied by laparoscopic surgeons who are members of the Surgical Working Group for Minimal Invasive Surgery (CAMIC) of the German Surgical Society., Materials and Methods: In 2005, we conducted a written survey among all members of the CAMIC asking them for their routine surgical strategy of laparoscopic sigmoid resection in a standardised multiple-choice questionnaire. This questionnaire consisted of 20 questions covering main technical issues of laparoscopic sigmoid resection including trocar and team positioning, mobilisation and resection of the left colon, specimen retrieval as well as anastomosing technique. The results were classified into four levels of consensus depending on the level of agreement between participating surgeons., Results: There were 292 surgeons who took part in the survey. Strong consensus (>95% agreement) was only found in 1 of 20 technical details: the operating surgeon standing at the patient right's side. Consensus (75-95% agreement) was found for: position of the first assistant standing to the patient's left side, size of the camera port is 10 mm, lateral mobilisation of the left hemicolon before ligating the inferior mesenteric artery, extracorporeal resection of the sigmoid via minilaparotomy, transrectal stapling of the colorectal anastomosis, intraoperative testing of the anastomosis for leakage, no regular suturing over the anastomosis and irrigating of the abdominal cavity after surgery., Conclusions: Variability of technical details of laparoscopic sigmoidectomy was surprisingly high among German laparoscopic surgeons. This fact should be considered when discussing clinical studies about laparoscopic sigmoidectomy because trocar position, type of minilaparotomy and dissection techniques may very well influence patient outcome after laparoscopic surgery. Therefore, publications of clinical results concerning laparoscopic sigmoid resection should include a precise description of the technical details of the operation.

Background and Aims: An impaired visceral perfusion caused by pneumoperitoneum may contribute to morbidity after laparoscopic surgery. The following three therapeutic concepts: increasing cardiac preload, controlled vasodilation, or selective sympathetic antagonism, were evaluated regarding a possible increase of visceral blood flow during pneumoperitoneum with carbon dioxide., Methods: Forty three pigs were assigned to treatment with an increase of preload and vasodilation (group A) or selective sympathetic antagonism with esmolol (group B). In both groups, pigs were assigned to head-up, head-down, or supine position. Perfusion of the vena porta and renal artery was measured by transonic volume flow meters and documented before capnoperitoneum, after induction of a 14-mmHg capnoperitoneum in each body position, after controlled vasodilation with sodium nitroprusside, and after controlled increase of intravascular volume by colloidal infusion., Results: Increasing intravascular volume improved portal blood flow in all body positions (p<0.05), but not renal blood flow. Medication of esmolol did not alter the measured parameters in any body position compared to control. Vasodilation with sodium nitroprusside reduced renal blood flow in supine and in head-up position., Conclusion: An optimal intravascular volume was most effective in improving portal blood flow during capnoperitoneum in this trial. Esmolol had no negative effects on portal and renal blood flow. Patients with renal dysfunction might be treated carefully with sodium nitroprusside during capnoperitoneum.