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Clinical studies have established the safety and advantages of laparoscopic surgery for gastric cancer; therefore, laparoscopic gastrectomy (LG) in clinical practice is increasing. We report the case of a 77‐year‐old patient with gastric cancer who was referred to our center for LG. Esophagogastroduodenoscopy revealed a type 3 tumor identified as adenocarcinoma on biopsy. Three‐dimensional computed tomography‐angiography revealed two left gastric arteries (LGAs) branching from the celiac trunk. By laparoscopically performing the outermost layer‐oriented lymphadenectomy (OML‐OL), the two LGAs were detected and appropriately divided. Subtotal gastrectomy was completed, and the patient had an uneventful postoperative course. The OML‐OL was appropriate for LG in this situation. This case demonstrates the necessity of preoperative three‐dimensional computed tomography‐angiography with 1‐mm slices and the importance of performing OML‐OL. [ABSTRACT FROM AUTHOR]

Introduction: Surgical experience and hospital procedure volumes have been associated with the risk of severe complications in expert centers for endometriosis in France. However, little is known about other certified units in Central European countries.Material and Methods: This retrospective observational study included 937 women who underwent surgery for colorectal endometriosis between January 2018 and January 2020 in 19 participating expert centers for endometriosis. All women underwent complete excision of colorectal endometriosis by rectal shaving, discoid or segmental resection. Postoperative severe complications were defined as grades III-IV of the Clavien-Dindo classification system including anastomotic leakage, fistula, pelvic abscess and hematoma. Surgical outcomes of centers performing less than 40 (group 1), 40-59 (group 2) and ≥60 procedures (group 3) over a period of 2 years were compared.Results: The overall complication rate of grade III and IV complications was 5.1% (48/937), with rates of anastomotic leakage, fistula formation, abscess and hemorrhage in segmental resection, discoid resection and rectal shaving, respectively, as follows: anastomotic leakage 3.6% (14/387), 1.4% (3/222), 0.6% (2/328); fistula formation 1.6% (6/387), 0.5% (1/222), 0.9%; (3/328); abscess 0.5% (2/387), 0% (0/222) and 0.6% (2/328); hemorrhage 2.1% (8/387), 0.9% (2/222) and 1.5% (5/328). Higher overall complication rates were observed for segmental resection (30/387, 7.8%) than for discoid (6/222, 2.7%, P = 0.015) or shaving procedures (12/328, 3.7%, P = 0.089). No significant correlation was observed between the number of procedures performed and overall complication rates (rSpearman  = -0.115; P = 0.639) with a high variability of complications in low-volume centers (group 1). However, an intergroup comparison revealed a significantly lower overall severe complication rate in group 3 than in group 2 (2.9% vs 6.9%; P = 0.017) without significant differences between other groups.Conclusions: A high variability in complication rates does exist in centers with a low volume of activity. Major complications may decrease with an increase in the volume of activity but this effect cannot be generally applied to all institutions and settings. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this study was to investigate long-term outcomes in terms of pain, quality of life (QoL), and gastrointestinal symptoms in women following colorectal surgery for deep endometriosis.Material and Methods: In this historical cohort, women who underwent surgical treatment for deep endometriosis by either nerve-sparing full-thickness discoid resection (DR) or colorectal segmental resection (SR) between March 2011 and August 2016 were re-evaluated through telephone interviews about their long-term pain symptoms, subjective overall QoL as rated using a score from 0 (worst) to 10 (optimal), and gastrointestinal outcomes reflected by lower anterior resection syndrome (LARS) following a first postsurgical evaluation (visit 1) published previously and a long-term follow-up evaluation (visit 2).Results: The median long-term follow-up time was 35.4 months at visit 1 and 86 months at visit 2. Of 134 patients, 77 were eligible for final analysis and 57 were lost to follow-up. Compared with presurgical values, QoL scores were significantly increased at both postsurgical evaluation visits in both the SR cohort (scores of 3, 8.5, and 10 at the presurgical visit, visit 1, and visit 2, respectively; p < 0.001) and the DR cohort (scores of 3, 9, and 10, respectively; p < 0.001). Pain scores for dysmenorrhea (SR group scores of 8, 2, and 2, respectively; p < 0.001; DR group scores of 9, 2, and 1, respectively; p < 0.001), dyspareunia (SR group scores of 4, 0, and 0, respectively; p < 0.001; DR group scores of 5, 0, and 1, respectively; p = 0.003), and dyschezia (SR group scores of 8, 2, and 2, respectively; p < 0.001; DR group scores of 9, 2, and 1, respectively; p < 0.001) significantly decreased after surgery and remained stable in both cohorts over the follow-up period. Minor and major LARS, reflecting gastrointestinal function, was observed in 6.5% and 8.1% of the SR group and in 13.3% and 6.7% of the DR group, respectively, at visit 1 and in 3.2% and 3.2% of the SR group and 0% and 0% of the DR group, respectively, at visit 2, without significant differences between the SR and DR groups.Conclusions: Colorectal surgery for deep endometriosis, either by DR or SR, provides stable and long-term pain relief with low rates of permanent gastrointestinal function impairment. [ABSTRACT FROM AUTHOR]

Background: The TCGA molecular groups of endometrial carcinoma are "POLE-mutated" (POLEmut), "microsatellite-instable/mismatch repair-deficient" (MSI/MMRd), "TP53-mutated/p53-abnormal" (TP53mut/p53abn), and "no specific molecular profile" (NSMP). Objective: Prognostic assessment of the TCGA groups in uterine carcinosarcoma (UCS). Search strategy: Systematic review from January 2000 to January 2021. Selection criteria: Studies assessing the TCGA groups in UCS. Data collection and analysis: Progression- free survival (PFS) and overall survival (OS) were assessed by Kaplan-Meier and Cox analyses (reference: TP53mut/p53abn group) and compared with endometrioid and serous carcinomas (original TCGA cohort), with a significant P < 0.050. Main results: Five studies with 263 UCS were included. Compared with TP53mut/p53abn UCS, MSI/MMRd UCS showed significantly better PFS (P < 0.001) but similar OS (P = 0.788), whereas NSMP UCS showed similar PFS (P = 0.936) and OS (P = 0.240). Compared with their endometrioid/serous counterparts, NSMP and TP53mut/p53abn UCS showed significantly worse PFS (P < 0.001 and P = 0.004) and OS (P < 0.001 and P < 0.001), while MSI/MMRd UCS showed similar PFS (P = 0.595) but significantly worse OS (P < 0.001). T he P OLEmut group showed n either recurrences nor deaths in both the UCS and the endometrioid/serous carcinoma cohorts. Conclusion: POLEmut UCS show excellent prognosis, whereas TP53mut/p53abn and NSMP UCS show a prognosis even worse than that of TP53mut/p53abn endometrioid/ serous carcinomas. The prognosis of MSI/MMRd UCS remains to be defined. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this study was to analyze the available literature by conducting a systematic review to assess the possible effects of nerve‐sparing segmental resection and conventional bowel resection on postoperative complications for the treatment of colorectal endometriosis. Material and methods: Pubmed, Clinical Trials.gov, Cochrane Library, and Web of Science were comprehensively searched from 1997 to 2021 in order to perform a systematic review. Studies including patients undergoing segmental resection for colorectal endometriosis including adequate follow‐up, data on postoperative complications and postoperative sequelae were enrolled in this review. Selected articles were evaluated and divided in two groups: Nerve‐sparing resection (NSR), and conventional segmental resection not otherwise specified (SRNOS). Within the NSRs, studies mentioning preservation of the rectal artery supply (artery and nerve‐sparing SR – ANSR) and not reporting preservation of the artery supply (NSR not otherwise specified – NSRNOS) were further analyzed. PROSPERO ID: CRD42021250974. Results: A total of 7549 patients from 63 studies were included in the data analysis. Forty‐three of these publications did not mention the preservation or the removal of the hypogastric nerve plexus, or main rectal artery supply and were summarized as SRNOS. The remaining 22 studies were listed under the NSR group. The mean size of the resected deep endometriosis lesions and patients' body mass index were comparable between SRNOS and NSR. A mean of 3.6% (0–16.6) and 2.3% (0–10.5%) of rectovaginal fistula development was reported in patients who underwent SRNOS and NSR, respectively. Anastomotic leakage rates varied from 0% to 8.6% (mean 1.7 ± 2%) in SRNOS compared with 0% to 8% (mean 1.7 ± 2%) in patients undergoing NSR. Urinary retention (4.5% and 4.9%) and long‐term bladder catheterization (4.9% and 5.6%) were frequently reported in SRNOS and NSR. There was insufficient information about pain or the recurrence rates for women undergoing SRNOS and NSR. Conclusions: Current data describe the outcomes of different segmental resection techniques. However, the data are inhomogeneous and not sufficient to reach a conclusion regarding a possible advantage of one technique over the other. [ABSTRACT FROM AUTHOR]

Objective: To compare characteristics, disease course, and prognosis of spontaneous versus iatrogenic benign metastasizing leiomyoma (BML). Methods: A retrospective cohort study comparing iatrogenic and spontaneous BML. Results: Twenty cases were included, 12 (60%) spontaneous and 8 (40.0%) iatrogenic with a median follow up of 3.4 years. The rate of asymptomatic presentation did not differ between study groups (P = 0.157). When symptoms occurred, dyspnea was more common in the spontaneous group (66.6% vs 0%, P = 0.023) and self-palpation was more common in the iatrogenic group (57.1% vs 0%, P = 0.023). Intravascular masses were more common in the spontaneous group (66.6% vs 0%, P = 0.029). Rate of BML located in abdominal/pelvic cavity was higher in the iatrogenic group (100.0% vs 41.6%, P = 0.014). Of the 12 women in the spontaneous group, 50% had recurrent disease following surgical resection or unresectable lesions surgical resection was successfully attempted in seven of the eight (87.5%) women in the iatrogenic group, with no residual/recurrent disease. None of the patients died of her disease. Conclusion: Spontaneous and iatrogenic BML can probably be regarded as two separate etiologies of the same pathologic phenomenon, usually with favorable prognosis. However, spontaneous BML may have a less favorable course. [ABSTRACT FROM AUTHOR]

Background: There is currently limited data to reassure the technical efficacy, particularly in attaining clear margins, through a transgastric laparo‐endoscopic approach to resecting tumours located near the gastroesophageal junction (GOJ) or the pylorus. Methods: Single institution retrospective analysis of all cases from 1 April 2008 to 31 Dec 2019. Results: Overall, 34 patients (38 tumours) underwent transgastric laparo‐endoscopic resection. Of these, 27 (71.1%) and 5 (14.7%) cases were located close to the GOJ and pylorus respectively. Three (8.0%) cases were converted to conventional laparoscopic excision. No anatomical gastric resection was required. The mean (SD) operative time was 167.5 (64.2) minutes and reduced with increasing experience. The median (IQR) length‐of‐stay was 3.0 (3.0–4.5) days. Major post‐operative complication (Clavian–Dindo ≥3) occurred in 1 (2.9%) patient, which required surgical control of staple line bleeding. The most common pathology was gastrointestinal stromal tumour (71.1%), followed by leiomyoma (10.5%), schwannoma (5.2%), dysplastic polyp (5.2%), and neuroendocrine tumour (2.6%). The mean (SD) tumour diameter was 3.9 (2.1) cm (largest 10.1 cm, 10 cases >5 cm). Resection margins were clear in all cases. We found no evidence of tumour recurrence or gastric stenosis at a median follow‐up of 88 months. Conclusion: Transgastric laparo‐endoscopic resection of junctional and pyloric tumours with low metastatic potential is technically feasible. This approach achieved clear resection margins in all our cases, with acceptable perioperative and longer‐term outcomes. [ABSTRACT FROM AUTHOR]

Aims: This study aims to describe our transvaginal natural orifice transluminal endoscopic surgery (vNOTES) technique for ectopic pregnancy that can be performed using conventional laparoscopic equipment with the addition of a self‐constructed pessary port and to evaluate the safety, feasibility, and outcomes of the technique. Methods: This is a retrospective study evaluating outcomes of patients who underwent vNOTES for ectopic pregnancy (n = 21) between August 2019 and April 2021. Results: Twenty‐one patients underwent vNOTES as intended without any intraoperative complications. Three patients (14.3%) were nulliparous, 16 patients (76.2%) had no history of vaginal delivery, and 13 patients (61.9%) had a history of at least one cesarean delivery. Eight patients (38.1%) had a history of previous abdominal surgery other than cesarean section. The mean duration of surgery was 43.4 ± 12.6 min. The mean visual analog scale scores for pain were 2.45 ± 1.13 at 2 h after surgery, 0.45 ± 0.83 at 12 h after surgery, and 0.18 ± 0.36 at 24 h after surgery. The median duration of postoperative hospital stay was 1 day (range, 1–2). There were no postoperative complications within 30 days after surgery. Conclusions: vNOTES can be performed in an existing laparoscopy setup with the addition of a self‐constructed pessary port. vNOTES is a safe and effective surgical treatment option for ectopic pregnancy, even in patients who have not had a vaginal delivery and have had multiple abdominal surgeries. [ABSTRACT FROM AUTHOR]

Background: Hysterectomy is the most commonly performed benign gynaecological surgery. Recently, the rates of minimally invasive hysterectomy have fallen due to the banning of mechanical morcellation techniques that rendered minimal invasive gynaecology surgeons unable to extract large uteri from the relatively small colpotomy incisions. Aims: This study aims to share our experience in utilising Colpo‐V incision to remove large uterine specimens transvaginally and report its success and complication rates to promote a minimal invasive approach in patients with large uteri without the need to perform large abdominal incisions or transabdominal morcellation. Methods: This is a prospective case series study in which women with large uteri and|or narrow vaginal canal underwent total laparoscopic hysterectomy and a subsequent posterior vaginal wall incision (Colpo‐V) to facilitate the intact extraction of the uterus through the vagina. Patients were seen in the clinic six weeks after the surgery for post‐operative assessment and documentation of late complications. Results: Seventeen women underwent the procedure, and the intact extraction of the specimen was successful in 16 out of the 17 cases (94%). No major complications were encountered during or after the procedure. Conclusion: Colpo‐V incision is a simple and effective technique for the intact extraction of larger uterine specimens at hysterectomy. [ABSTRACT FROM AUTHOR]

Background: Although transvaginal natural orifice transluminal endoscopic surgery (NOTES) is gaining importance, knowledge on transvaginal NOTES procedures in gynecologic practice is limited. Objective: We aimed at evaluating the feasibility and safety of performing hysterectomy and bilateral adnexectomy (or bilateral salpingectomy) via transvaginal NOTES using a self‐developed multichannel abdominal port and vaginal support ring. Study Design: A prospective, single‐center, cohort pilot study was conducted from May to December 2017 in patients with benign uterine diseases or endometrial atypical hyperplasia or cervical intraepithelial neoplasia (n = 30) scheduled for laparoscopic hysterectomy. The procedure was performed using a self‐developed five‐channel port and a vaginal support ring. Results: Hysterectomy and bilateral adnexectomy (or bilateral salpingectomy) in all 30 cases (mean age: 51.43 ± 4.60 years and body mass index: 23.42 ± 1.45 kg/m2) were successfully performed completely under transvaginal NOTES. Mean operation time was 95.90 ± 14.60 minutes and mean blood loss during the procedure was 52.50 ± 19.20 mL. Average weight of specimen was 79.97 ± 35.48 g. Only one complication of bladder injury was noted and was rectified accordingly. Visual Analog Score (VAS) at first day after operation was 2.70 ± 0.72. After follow‐up for 4.50 ± 1.85 months, all the patients' vaginal stump healed well without scar formation. Conclusion: Our study showed that use of multichannel abdominal port could make laparoscopic instruments easier to fix and operate wherein the vaginal support ring reduces the leakage of carbon dioxide pneumoperitoneum. There was no scar on the abdomen and VAS was much lower. This study also demonstrated cosmetic benefits and rapid postoperative recovery. [ABSTRACT FROM AUTHOR]

Objective: To compare vaginally‐assisted natural orifices endoscopic transluminal endoscopic surgery (vNOTES) hysterectomy with salpingectomy/salpingo‐oophorectomy with standard laparoscopic access. Methods: Medical records for patients undergoing hysterectomy with adnexectomy for benign disease indication between February 1, 2019 and February 1, 2020 were retrospectively examined. Exclusion criteria were endometriosis, previous pelvic radiotherapy, inflammatory pelvic disease history, any other concurrent surgery, laparotomy, robotic surgery, and/or traditional vaginal hysterectomy. Results: Among 86 patients, 21 (24.4%) were allocated to a vNOTES group and 65 (75.6%) were allocated to a conventional laparoscopy (LAP) group. Mean ages for the groups were 47.19 ± 11.11 years and 46.69 ± 9.11 years, respectively (P = 0.928). There were no statistically significant differences in age, body mass index, arterial hypertension/diabetes, smoking, menopausal status, obstetric history, number of abdominal surgeries, or preoperative hemoglobin level between the two groups. The mean (range) operative times were 111.90 min (80–180 min) in the vNOTES group and 113.98 min (64–350 min) in the LAP group (P = 0.904). There were no statistically significant differences in terms of surgery indication, specific and unspecific complications, conversions, blood transfusion, reoperation, significant ileus/emesis, and hospital stay. Conclusions: Based on the parameters assessed, we found vNOTES to be comparable to laparoscopy among our cohort. SYNOPSIS: Vaginal‐NOTES hysterectomy with adnexectomy was found to be comparable to laparoscopy in regard to each parameter we assessed. [ABSTRACT FROM AUTHOR]

Aim: To evaluate if the long‐term results (on fertility, need of hysterectomy and persistence of endometriosis) after a minimally invasive intervention (transvaginal ultrasound‐guided puncture‐aspiration [TUGPA]) for endometriomas are significantly different from performing the traditional conservative surgery (CS) by laparoscopy or laparotomy. Methods: We performed a retrospective study of cohorts on patients undergoing surgery for ovarian endometriomas between January 1998 and April 2015. Cohort 1 consisted of 75 women whose first intervention for endometriomas had been TUGPA. For the cohort 2, we selected a randomized paired case in which the first operation for endometriomas had been CS by laparoscopic or laparotomy (another set of 75 patients). Results: There were significantly more recurrences and the time to recurrence and repetition of operations were also significantly shorter in patients with TUGPA. However, there were no significant differences in overall pregnancy/delivery outcomes, in hysterectomy performances, or in endometriosis persistence at the last follow‐up visit. There were no significant differences related to the symptoms or to analytical presurgical values but the application of multivariate analysis with binary logistic regression to each dependent variable adjusted for age, symptoms, and presurgical analyses showed a significant risk of recurrence and reoperation of TUGPA versus CS. Conclusions: Those patients with endometriomas who underwent TUGPA (with or without associated medications) had a significant increase in recurrence and the need for reoperation. However, in the long‐term there were no significant differences in the results of pregnancy/childbirth, need for hysterectomy, or in the clinical or doubtful persistence of endometriosis. [ABSTRACT FROM AUTHOR]

Aim: To objectively assess the safety, feasibility, advantages and disadvantages and health economics benefits of vaginal natural orifice transluminal endoscopic surgery (vNOTES) versus transumbilical laparoendoscopic single‐site surgery (TU‐LESS) in ovarian cystectomy. Methods: We retrospectively analyzed the data of all patients in our hospital who had undergone vNOTES and TU‐LESS ovarian cystectomy due to 'unilateral ovarian cyst' from March 2019 to May 2020. Patients were classified into vNOTES group (86) and TU‐LESS group (210) based on surgical paths. The patients' general characteristics and perioperative outcomes were compared. Results: All 296 patients completed surgery with no need to switch to conventional laparoscopy or laparotomy procedures. There were no complications of Grade III, IV, V in Clavien‐Dindo classification. There were two patients in the vNOTES group and four patients in the TU‐LESS group with complications of Grade I, all of whom were treated with antipyretic drugs for postoperative fever. One patient in the TU‐LESS group presented the complication of Grade II and was treated with blood transfusion due to postoperative anemia. The two groups had similar general characteristics. Perioperative outcomes: The visual analogue scale (VAS) scores 24 h postoperation were significantly lower in the vNOTES group than in the TU‐LESS group. The cosmetic scores were significantly higher in the vNOTES group than in the TU‐LESS group. Postoperative stay and time of flatus after surgery were significantly shorter in the vNOTES group than in the TU‐LESS group. There was not significant statistical differences between the two groups in operation time, estimated blood loss, Hb decrease at 48 h postoperation, maximum body temperature in 48 h after surgery and hospital costs. Conclusion: It was proved to be safe and feasible in ovarian cystectomy by vNOTES. It worked better than TU‐LESS in relieving postoperative pain, shortening postoperative stay and improving cosmetic effects and so on. As an emerging surgical path, large sample multicenter randomized controlled trials are required to further verify its safety and advantages. [ABSTRACT FROM AUTHOR]

Minimally invasive surgery for gynecologic cancers is associated with fewer postoperative complications including less blood loss and quicker recovery time compared to traditional laparotomy. The robotic platform has allowed patients access to minimally invasive surgery due to its increased utilization by gynecologic oncologists. Many surgeons have embraced the robotic platform due to its technological advances over traditional laparoscopy including high‐definition 3D optics, wristed instrumentation, camera stability and improved ergonomics. While robotic surgery continues as a mainstay in the management of gynecologic cancers, it remains controversial in regards to its cost effectiveness and more recently, its long‐term impact on clinical and oncologic outcomes. A strong component of the justification of this surgical platform is based on extrapolated data from traditional laparoscopy despite limited prospective randomized trials for robotic‐assisted surgery. In this review, we highlight the use of robotic surgery in the management of gynecologic cancers in special populations: fertility sparing patients, the morbidly obese, the elderly, and patients with a favorable response to neoadjuvant chemotherapy. [ABSTRACT FROM AUTHOR]

Introduction: Patients with advanced endometriosis may be at an increased risk of surgical complications following laparoscopic treatment of endometriosis; however, this relationship has not been examined. We sought to identify predictors of major complications following laparoscopic treatment of endometriosis.Material and Methods: A retrospective cohort study of women who underwent laparoscopic treatment of suspected endometriosis between 2009 and 2016 within the Division of Minimally Invasive Gynecologic Surgery at Brigham and Women's Hospital, Boston, MA, USA. Predictors of major perioperative complications were assessed by comparing the characteristics of women who had any major intraoperative or postoperative complication with those of women who had no complication.Results: A total of 397 women underwent laparoscopic treatment of suspected endometriosis including excision of superficial endometriosis (55.4%), excision of deep-infiltrating endometriosis (24.9%), fulguration of endometriosis (38.3%), hysterectomy (23.2%), ovarian cystectomy (35.5%), salpingectomy (18.6%), oophorectomy (15.1%), and bowel resection (1.0%). Women were followed for 60 days following surgery, over which time 18 women (4.5%) had a major perioperative complication. Patient characteristics and preoperative imaging were similar between women with and without complications. Women with advanced endometriosis, including stage III or IV endometriosis, deep-infiltrating endometriosis, or rectovaginal disease, were more likely to have a complication, though this did not reach statistical significance (77.8% of women with a complication versus 56.7% of women without a complication had advanced endometriosis, P = 0.077). Women who had a complication were more likely to have undergone adhesiolysis or ureterolysis (88.9% of women with a complication versus 52.5% without a complication underwent adhesiolysis, P = 0.002; and 61.1% of women with a complication versus 28.8% without a complication underwent ureterolysis, P = 0.003). The total number of procedures was greater for women who had a complication (4.3 ± 1.2 vs 3.2 ± 1.5, P = 0.003). All other procedure characteristics were similar between women with and without complications.Conclusions: Complications following laparoscopic treatment of suspected endometriosis could not be predicted by preoperative patient characteristics or surgical findings of advanced endometriosis. Adhesiolysis, ureterolysis, and an increased number of total procedures may be predictive of perioperative complications, suggesting that surgical complexity as measured by the procedures performed, rather than the disease severity, may increase the risk of a complication compared with women who do not undergo these procedures. [ABSTRACT FROM AUTHOR]

Introduction: One-third of non-pregnant women worldwide are anemic.1 Anemia is a known independent risk factor for postoperative morbidity.2 Given that the vast majority of hysterectomies are not performed in the emergency setting, we designed this study to evaluate the effect of preoperative anemia on postoperative morbidity following laparoscopic hysterectomy performed for benign indications. Our main goal is to encourage surgeons to use anemia-corrective measures before surgery when feasible.Material and Methods: Retrospective cohort study of 98 813 patients who underwent a laparoscopic hysterectomy between 2005 and 2016 for benign indications identified through the American College of Surgeons National Surgical Quality Improvement Program. Anemia was examined as a function of hematocrit and was analyzed as an ordinal variable stratified by anemia severity as mild, moderate or severe. Associations between preoperative anemia and patient demographics, preoperative comorbidities and postoperative outcomes were evaluated using univariate analyses. Multivariable logistic regression models were used to identify independent associations between hematocrit level and postoperative outcomes after adjusting for confounding covariates. At the multivariable logistic regression level, anemia severity was analyzed using hematocrit as a continuous variable to assess the independent association between each 5% decrease in hematocrit level and several postoperative morbidities.Results: Of the 98 813 patients who met our inclusion and exclusion criteria, 19.5% were anemic. A lower preoperative hematocrit was associated with higher body mass index, younger age, Black or African American race, longer operative times, and multiple other medical comorbidities. After appropriate regression modeling, anemia was identified as an independent risk factor for extended length of stay, readmission and composite morbidity after surgery.Conclusions: Preoperative anemia is common among patients undergoing laparoscopic hysterectomy. Preoperative anemia increases patients' risk for multiple postoperative comorbidities. Given that most hysterectomies are performed in the elective setting, gynecologic surgeons should consider the use of anemia-corrective measures to minimize postoperative morbidity. [ABSTRACT FROM AUTHOR]

Gastrointestinal stromal tumors (GIST) in patients under 18 years of age are classified as pediatric GIST. Pediatric GIST are extremely rare, and there are no reports of laparoscopic‐endoscopic cooperative surgery for these lesions. We report the use of non‐exposed endoscopic wall‐inversion surgery as a laparoscopic‐endoscopic cooperative surgery‐related procedure for the treatment of a pediatric GIST. The case involved a 17‐year‐old male patient who presented with anemia and was found to have a bleeding gastric tumor. The tumor was resected transorally using the non‐exposed endoscopic wall‐inversion surgery technique. No gene mutation of c‐Kit or Platelet‐Derived Growth Factor Receptor α (PDGFRα) was found, and the final pathological diagnosis was epithelial‐type GIST due to a succinate dehydrogenase abnormality. Follow‐up included a CT scan every 4 months. No recurrence has occurred to date. [ABSTRACT FROM AUTHOR]

In recent years, progress in cancer treatment has greatly increased the chances of recovery. Yet, treatment may have irreversible effects on patients' fertility. In order to protect future fertility, preservation of ovarian tissue may be offered today even to very young girls, involving a surgical procedure that may be performed by minimally invasive laparoscopy, under general anesthesia. However, in the tragic event of a girl's death, questions may arise regarding the possible use of the preserved ovarian tissue by her parents. Should posthumous reproductive use of ovarian tissue without the girl's prior consent (due to her young age) be considered a violation of her rights? On the other hand, can it be argued that it is in the interest of a child who died young to leave a genetic trace through posthumous reproduction, because genetic continuity is in the interest of every human being? After presenting the relevant clinical facts, we explore the ethical dimensions of this possible practice through an analysis of the interests of the deceased, her parents, and the child that may be born posthumously. [ABSTRACT FROM AUTHOR]

Background and Aims: Mucosal lifting and its persistence are critical for maintaining the operational space and preventing perforation in endoscopic operation. Although numerous agents have been investigated, optimization is still required for improving their clinical performance. In the present study, we proposed a novel concept of thermoresponsive aerification and tissue vacuolization for submucosal injection. Methods: Lifting performance and operational condition were first evaluated in porcine stomachs in vitro and rabbits in vivo. Dodecafluoropentane (DDFP) injection dosage, lifting persistency and operational assistance were quantitatively recorded. Gross and histological pathology were also analyzed to identify DDFP acute toxicity and long‐term safety. The endoscopic submucosal dissection (ESD) procedure with DDFP was carried out on pigs in vivo to confirm its operational feasibility, efficacy, and safety. Results: Dodecafluoropentane aerification could achieve better mucosal lift with lower dosage (1% of normal saline dosage). Thermoresponsive DDFP aerification could provide continuous replenishment and longer persistence. Meanwhile, its tissue vacuolization effect significantly facilitated submucosal tissue dissection in in vitro study. Similar performance was verified in vivo. The particular vacuole‐like submucosal structure was seen after DDFP onset, which also promoted reepithelization and wound healing. No tissue damage, gas embolism, biotoxicity, and physicochemical risk were observed. Conclusion: Bioinert DDFP was feasible, efficient, and safe as the novel submucosal lifting candidate. [ABSTRACT FROM AUTHOR]

Objectives: To compare perioperative data, functional and oncological outcomes between laparoscopic partial nephrectomy (LPN) and robot‐assisted partial nephrectomy (RAPN) for renal tumours of >4 cm. Patients and Methods: We retrospectively reviewed patients who underwent either LPN or RAPN between 2008 and 2015. To adjust for potential baseline confounders, propensity score matching (1:1) was performed. Perioperative data, functional and oncological outcomes were reviewed. Disease‐free survival, cancer‐specific survival and overall survival were analysed using Kaplan–Meier survival curves with log‐rank tests. Results: In all, 197 patients underwent LPN and 96 underwent RAPN during the study period. After matching, there was no significant difference between the groups for baseline characteristics. Within the matched cohort, the LPN group was associated with significantly higher estimated blood loss (150 vs 100 mL; P < 0.001), longer renal artery clamp time (25 vs 20 min; P < 0.001), longer postoperative hospital stay (7 vs 5 days; P < 0.001), and lower rate of Margin, Ischaemia, and Complications (MIC) achievement (30.2% vs 46.9%; P = 0.018). The postoperative percentage of estimated glomerular filtration rate decline was higher in the LPN group (11.3% vs 5.5%; P = 0.018). Complication and surgical conversion outcomes were similar between LPN and RAPN. There was no significant difference in oncological outcomes between the groups. Conclusions: For patients with renal tumours of >4 cm, RAPN is more favourable than LPN in terms of perioperative outcomes (i.e. estimated blood loss, renal artery clamp time and postoperative hospital stay) and early renal functional preservation. [ABSTRACT FROM AUTHOR]

Abstract: In 2014, the US Food and Drug Administration issued a safety communication warning against the use of power morcellators during laparoscopic hysterectomy or myomectomy. We report a case of peritoneal leiomyosarcomatosis attributable to power morcellation. A 49‐year‐old nulligravid woman presented with a huge uterine tumor measuring 15 × 8 cm that was diagnosed as benign leiomyoma on magnetic resonance imaging. The uterine tumor had shrunk to 13 × 7 cm after five treatment courses with a gonadotropin‐releasing hormone agonist. She underwent laparoscopic hysterectomy using power morcellation; postoperative pathological diagnosis was benign leiomyoma. After 6 months, urinary ascites developed because of right ureteral rupture. She underwent laparotomy and was diagnosed with peritoneal leiomyosarcomatosis. Meticulous and thorough reevaluation of the morcellated specimens revealed a small component of leiomyosarcoma. Use of power morcellation should be minimized until the advent of novel methods that can perfectly differentiate benign from malignant uterine tumors preoperatively. [ABSTRACT FROM AUTHOR]

Abstract: Aim: Obesity is common in Western countries and its prevalence is increasing. Colorectal cancer is common, and surgery for colorectal cancer is technically more challenging in obese patients. Laparoscopic surgery for colon cancer has been shown to be oncologically equivalent, with improved short‐ term outcomes. Laparoscopic surgery for rectal cancer has proven technically challenging, and recent results have raised concerns about oncological equivalence. Our aim was to evaluate the effect of body mass index (BMI) on the clinical and oncological outcomes of surgery for colorectal cancer, including the rate at which laparoscopic surgery is attempted and the rate at which laparoscopic surgery is converted to open surgery. Method: A retrospective analysis of prospectively collected data from two tertiary institutions was performed. Data were obtained from the Cabrini Monash University colorectal neoplasia database for patients having surgical resection for colon and rectal cancers between 1 January 2010 and 30 June 2015. Surgical and medical complications, tumour recurrence and overall survival and laparoscopic surgery and conversion rates were investigated. Results: This large case series of 1464 patients undergoing elective surgery for colorectal cancer has demonstrated that an elevated BMI is associated with a lower likelihood of attempting laparoscopic surgery and a higher conversion rate to open surgery when laparoscopy is attempted. Conversion was 1.9 times more likely in obese patients with colon cancer and 4.1 times more likely in obese patients with rectal cancer. The critical BMI for colon cancer patients was > 35 kg/m2, and for rectal cancer patients > 30 kg/m2. Obesity is also associated with increased rates of surgical complications, including anastomotic leakage and wound complications. Pathological parameters, tumour recurrence and survival were not affected by elevated BMI. Conclusion: In the surgical management of colorectal cancer, obesity is associated with a lower likelihood of laparoscopic surgery being attempted, a higher likelihood of conversion to open surgery when laparoscopic surgery is attempted, and a higher rate of surgical complications. [ABSTRACT FROM AUTHOR]

Aim: Choledochal cyst is characterized by congenital dilatation of the biliary system. Patients with choledochal cyst tend to be symptomatic in their childhood. The aim of this study was to review the current practice in laparoscopic management of choledochal cyst in infants and children. Patients and Methods: A PubMed database search was performed for all the studies on children who underwent laparoscopic excision of choledochal cyst. Additional literature was cited second hand from the first‐tier literatures. Results: Studies on i) laparoscopic excision of choledochal cyst and hepaticojejunostomy in children; ii) laparoscopic management of choledochal cyst in antenatally detected choledochal cyst; iii) single incision laparoscopic surgery (SILS) in children with choledochal cyst; iv) robotic assisted laparoscopic surgery in children with choledochal cyst and v) hepaticoduodenostomy in children with choledochal cyst were reviewed. Conclusions: Laparoscopic excision of choledochal cyst and hepaticojejunostomy remains safe and feasible in children and infants. In centers experienced in MIS, SILS and robotic–assisted laparoscopy in the management of children with choledochal cyst were reported to be an alternative approach. The debate on hepaticoduodenostomy versus hepaticojejunostomy in biliary reconstruction will continue until a longterm outcome is available in the future. [ABSTRACT FROM AUTHOR]

By either laparoscopy or robotic surgery have poorer outcomes Although the recent findings have made MIS-RH less popular, Dr. Uppal and Dr. Ramirez note that some surgeons had already started to find the technique less appealing than in the past. "Enhanced recovery has completely changed how patients recover after open surgery", Dr. Uppal agrees. [Extracted from the article]

Abstract: Introduction: We compared laparoscopic Toupet fundoplication (LTF) and laparoscopic Nissen fundoplication (LNF) in neurologically normal children. Methods: Forty neurologically normal children who were followed up for more than 3 years after LTF (n = 22) or LNF (n = 18) were reviewed retrospectively. LTF and LNF were performed between 2006 and 2012. Results: There were no significant differences in gender (LTF, 15 male and 7 female patients; LNF:, 12 male and 6 female patients), mean age at surgery (LTF vs LNF: 2.5 vs 2.3 years), mean weight at surgery (LTF vs LNF: 9.6 vs 8.9 kg), preoperative symptoms, preoperative pH monitoring (pH <4) (LTF vs LNF: 26.7% vs 21.8%), mean operative time (LTF vs LNF: 117 vs 126 min), postoperative recommencement of enteral feeding (LTF vs LNF: 3.7 vs 3.8 days), or duration of hospitalization (LTF vs LNF: 5.5 vs 6.3 days). Intraoperative complications were esophageal trauma (LTF; n = 1; 4.5%) and liver trauma (LNF; n = 1; 5.6%) (P = 0.70). Post‐LTF complications were wrap stenosis (n = 1; 4.5%), and post‐LNF complications were wrap stenosis (n = 1; 5.5%) and gastric outlet obstruction (n = 1; 5.5%) (P = 0.43); all were managed conservatively. No case required conversion to open repair. There was no recurrence after LTF, but there were three cases (16.7%) after LNF (P = 0.08). Reoperation was performed at 4, 11, and 13 months, respectively. Conclusion: Despite LTF and LNF appearing to be equally effective, three LNF cases required reoperation. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Creating pneumoperitoneum is the most challenging step during laparoscopy. The periumbilical area is the classic site for Veress needle insertion. We adopted a new access point for peritoneal insufflation. Methods: We introduced a new point for Veress needle insertion to create pneumoperitoneum during difficult laparoscopic procedures. The needle is placed between the xiphoid process and the right costal margin, and it then proceeds toward the patient’s right axilla. We collected data to compare using this new method of peritoneal insufflation with using Palmer's point for pneumoperitoneum. Results: Since 2013, we have used this new technique in 570 patients (first group) and Palmer’s point in 459 patients (second group). Among these patients, 196 patients (20%) had had previous abdominal operations, 98 patients (10%) had irreducible ventral hernia, and 735 patients (70%) were morbidly obese. The two groups were comparable in terms of patient characteristics. The mean time to create pneumoperitoneum in the first group was 0.8 ± 0.002 min compared to 1.08 ± 0.007 min in the second group (P ≤ 0.5). The mean number of punctures was 1.57 ± 1.02 in the first group compared to 2.9 ± 1.5 in the second group (P≤ 0.5); in the first group, 97% were successful on the first attempt entry, whereas this figure was 91% in second group. In the first group, the liver was punctured in 13 patients without any further complications; no other viscera were punctured. In the second group, gastric puncture occurred in 5 cases, transverse colon in 2 cases, and omental injury in 12 cases. Conclusion: This new access point may represent a safe, fast, and easy way to create pneumoperitoneum, as well as a promising alternative to Palmer’s point in patients who are not candidates for classic midline entry. [ABSTRACT FROM AUTHOR]

Introduction: Studies have shown that post‐operative telephone follow‐up is satisfactory and effective. As high quality evidence is scant, we conducted a randomized controlled trial to compare it against outpatient clinic review for emergency laparoscopic appendicectomy or cholecystectomy. Method: Patients who received emergency laparoscopic appendicectomy or cholecystectomy were eligible for this study. Once recruited, they were randomly allocated to either clinic review or telephone follow‐up on discharge. Participants were reviewed at 2 weeks after operation and contacted again at 4 weeks after initial follow‐up for satisfaction survey. Results: One hundred and seventy‐nine participants were recruited with one withdrawn consent and six excluded. Ninety‐six underwent laparoscopic appendicectomy and 76 had laparoscopic cholecystectomy. Ninety‐six attended clinic review and 76 had telephone follow‐up. The two groups were similar in baseline variables. Non‐attendance rate was higher for clinic review cohort (24% vs 6.6%, P = 0.002). Participants who received telephone review reported higher satisfaction level (9.31 vs 8.85, P = 0.002), and most patients prefer telephone follow‐up (73.1%, P < 0.0001). No difference was detected for missed complications (P = 0.354). Conclusion: Telephone follow‐up post laparoscopic appendicectomy or cholecystectomy is safe, satisfying and effective. [ABSTRACT FROM AUTHOR]

Introduction: Laparoscopic myomectomy offers women many benefits over conventional open surgery, including an expedited recovery and return to employment. Our study evaluates the time taken for women to return to work after laparoscopic myomectomy and identifies factors prolonging recovery to > 8 weeks.Material and Methods: We prospectively evaluated 94 women undergoing laparoscopic myomectomy by a single surgeon between January 2012 and March 2015. Women had standardized preoperative counseling and completed a validated return to work questionnaire 3 months postoperatively via telephone, post or in clinic.Results: In all, 71/94 (75.5%) women completed the questionnaire. Results were analyzed comparing women who returned to work in ≤ 8 weeks [43/71 (60.6%)] with those who returned > 8 weeks postoperatively [28/71 (39.4%)]. A higher proportion of Asian and Caucasian women returned to work in ≤ 8 weeks (24/29) compared with black African and Caribbean women (19/42) (p = 0.003). Mean number of fibroids removed (2.59 and 5.75, respectively) was the only significantly differing factor between the two groups (p = 0.004). There was a significant difference in body mass index (BMI) and time to return to normal activity between the ≤ 8-week and > 8-week groups (p = 0.027, p = 0.011, respectively). Logistic regression analysis demonstrated that BMI and time to return to normal activity were the only factors prolonging recovery to > 8 weeks (p = 0.039, p = 0.015, respectively).Conclusions: Time to return to normal activity and BMI significantly influenced the time taken for women to work after laparoscopic myomectomy. Further data would support clinicians in counseling women appropriately and optimizing their postoperative return to employment. [ABSTRACT FROM AUTHOR]

No abstract is available for this article. [ABSTRACT FROM AUTHOR]

Background Total laparoscopic hysterectomy ( TLH) is established as a safe method of hysterectomy, with a satisfactory patient experience. However, most published data derive from high-volume centres with experienced teams. It is not clear whether these data translate to smaller centres? Aims To evaluate the implementation of a minimally invasive option for hysterectomy at a regional public hospital in New Zealand. Materials and methods Prospective audit of 120 cases of TLH over three years. We retrospectively compared outcomes to the same number of abdominal ( AH) and vaginal hysterectomy ( VH). Results TLH and AH were predominantly performed for heavy menstrual bleeding (65 and 64%) and VH for prolapse (54%). The largest uteri were AH (range 30-3400 g), TLH (35-550) then VH (21-256). Compared to TLH, both AH and VH had shorter mean operating theatre times ( TLH 126.8 ± 44.8 min, AH 103.2 ± 32.8 and VH 93 ± 26.9), longer mean hospital stay ( TLH 51.3 ± 21.3 h, AH 101.9 ± 36.6 and VH 75.1 ± 31.3) and increased mean blood loss ( TLH 153 ± 116.1 mL, AH 517 ± 672.3 and VH 244 ± 206.8). One TLH was converted to laparotomy and one required interval laparoscopy. Major complications (2.5%) were lowest in the TLH group and were consistent with large international series. Conclusions TLH would appear to be a safe and effective local option. The outcomes for patients at a regional general hospital can replicate the results of larger centres. [ABSTRACT FROM AUTHOR]

Aim The aim of this study was to investigate the clinical data of laparoscopic repair with hysteroscopy of cesarean scar diverticulum (CSD). Methods We retrospectively evaluated 49 patients with CSD in our hospital who had undergone laparoscopic repair with hysteroscopy from January 2014 to June 2015. All patients had a history of cesarean section deliveries and prolonged postmenstrual spotting (duration 16.1 ± 3.4 days). The diagnosis of CSD was established by using 2-D transvaginal ultrasound. Results All patients underwent the surgical repair successfully, without evident complications. The mean operation time was 90.4 ± 9.1 min, the mean volume of blood loss was 31.2 ± 14.3 mL, and the mean length of hospital stay was 4.1 ± 0.3 days. All patients were followed for 6 months after the operation; the mean duration of menstruation was 7.5 ± 2.5 days shorter on average than the pre-surgical menstrual days, and the difference was statistically significant ( P = 0.001). According to the clinical symptoms assessment, 89.8% (44/49) of the surgeries were effective, while according to the anatomic assessment, 95.9% (47/49) were effective. Conclusion Laparoscopic repair with hysteroscopy of CSD was confirmed to be a safe, effective, and minimally invasive treatment, and should be widely used to treat patients with CSD. [ABSTRACT FROM AUTHOR]

Patients experiencing heartburn and acid regurgitation despite proton pump inhibition therapy who are averse to antireflux surgery fall into what is called the gastroesophageal reflux disease (GERD) treatment gap. This gap may be potentially addressed by several endoscopic and laparoscopic techniques, including gastric bypass surgery for those patients who are obese. These novel techniques do not significantly alter the anatomy of the esophagogastric junction, minimizing short- and long-term adverse effects. This review provides an overview of the assessment of patients with refractory GERD and highlights the strengths and weaknesses of these minimally invasive therapies. [ABSTRACT FROM AUTHOR]

Background: Deep neuromuscular blockade during laparoscopic surgery may provide some clinical benefit. We present the 'Pro-' argument in this paired position paper.Methods: We reviewed recent evidence from a basic database of references which we agreed on with the 'Con-' side, and present this in narrative form. We have shared our analysis and text with the authors of the 'Con-' side of these paired position papers during the preparation of the manuscripts.Results: There are a few low risk of bias studies indicating that use of deep neuromuscular blockade improve surgical conditions and improve patient outcomes such as post-operative pain in laparoscopic surgery.Conclusion: Our interpretation of recent findings is that there is reason to believe that there may be some patient benefit of deep neuromuscular blockade in this context, and more detailed study is needed. [ABSTRACT FROM AUTHOR]

Background Assessing the role of laparoscopy in the management of intussusception. Methods A retrospective review of children aged up to 17 years who had surgery for intussusception at this institution between 1 January 2004 and 31 December 2013. Results The cohort of 44 individuals (18 females) presented at a median age of 9 months (range 2.5 months-15.75 years) with intussusception; 36 patients had undergone a failed pneumatic reduction. Thirty-seven patients had an initial laparoscopic approach. Conversion was required in 13 individuals: inability to reduce a 'tight' intussusception in seven individuals, limited working space in four individuals, and inadequate tactile response in two individuals. Twenty-four patients (54%) had the laparoscopic approach completed. An open approach was chosen for seven individuals at a median age of 5 (range 4-11) months: three individuals had marked abdominal distension, two individuals had a pneumoperitoneum and two individuals presented with a large central mass. Together with the 13 conversions, a total of 20 patients (46%) underwent an open approach. The more distal the apex of the intussusception, the more likely open surgery was. Hospital stays for the subgroup of patients with successfully completed laparoscopic intervention ( n = 24) were shorter than for the open surgery group ( n = 20) with P = 0.0145, but the open procedure was used to manage the more challenging cases. The subgroup of seven infants undergoing direct open surgery were significantly younger than the remaining individuals ( P = 0.0046). Conclusion Laparoscopic intervention is meaningful in approximately 50% of children requiring a surgical reduction. [ABSTRACT FROM AUTHOR]

Objective: To describe and validate a gynecologic laparoscopic-surgery training model.Methods: The present prospective observational study was conducted at the Minimally Invasive Surgery Centre Jesús Usón, Cáceres, Spain, between January 2011 and June 2013. Novice gynecologists attended a 3-day course including simulation and animal training. Participants' were assessed before and after training using a virtual reality simulator; during training, gynecologists were timed and assessed using an Objective and Structured Assessment of Technical Skills score. The virtual reality simulator-assessed skills were eye-hand coordination, hand-hand coordination, and transference of objects. Participants were asked to rate various elements of the training program using a five-point scale.Results: The study enrolled 21 gynecologists. Participants performed all tasks faster (P<0.001), using fewer movements (P<0.05 for left and right instruments), after receiving training. During participants' final animal and simulator training sessions, completion times were reduced (P<0.001) and assessment scores (P<0.001) increased for all techniques and tasks. Participants considered suturing to be the most useful aspect of the basic-skills training (4.95±0.22); animal training received a higher rating than simulator training for practicing new techniques (4.81±0.40 vs 4.05±0.86) and maintaining skills (4.76±0.54 vs 3.95±0.97).Conclusion: Combining proficiency-based physical simulation and animal training models under expert guidance is an efficient model for improving basic and advanced laparoscopic skills. Suturing and animal models were the preferred training components. [ABSTRACT FROM AUTHOR]

Aim External rectal prolapse may require emergency admission in the elderly and comorbid population. We report the safety and efficacy of laparoscopic ventral rectopexy in patients having an emergency admission with external rectal prolapse. Method A retrospective analysis was performed of a prospective database of all rectopexies performed from 2006. Outcome and follow-up data were assessed. Results Of 812 rectopexies performed, 28 were included for analysis. The mean length of hospital stay was 13.0 days. All operations were completed successfully and without intra-operative complications. Four patients developed a postoperative complication. Two patients developed a recurrence of prolapse. Conclusion Laparoscopic correction of rectal prolapse following emergency admission is both feasible and safe. It can be considered for both recurring cases and cases with multiple comorbidities. [ABSTRACT FROM AUTHOR]

Introduction Single-incision laparoscopic cholecystectomy ( SILC) is increasingly applied for cholecystectomy and has been reported as safe and feasible, with short-term operative outcomes equivalent to four-port cholecystectomy. Although many investigators in randomized studies have noted the cosmetic advantages of SILC, the benefit of decreased pain in SILC remains controversial. Therefore, this study aimed to assess the efficacy of the rectus sheath block in SILC with respect to subjective pain. Methods From April 2010 to March 2012, 75 patients with symptomatic gallstone or gallbladder polyps were assigned to one of three groups: (i) four-port laparoscopic cholecystectomy ( n = 29); (ii) SILC ( n = 15); and (iii) rectus sheath block in SILC ( n = 30). We evaluated the operative details, length of hospital stay, and the need and usage of analgesia. Postoperative pain was recorded at 2, 6, 12, and 24 h after surgery based on a visual analog scale. Results There was no difference with regard to age, ASA score, BMI, duration of operation, or length of hospital stay among the three groups. A significantly lower pain score was observed in the rectus sheath block in SILC group than in the SILC group at 2 and 6 h after operation. The pain score and need for analgesia were similar between the SILC group and the four-port cholecystectomy group. Conclusion SILC using an ultrasound-guided rectus sheath block significantly reduces postoperative pain. [ABSTRACT FROM AUTHOR]

Introduction In children with choledochal cysts ( CC), obstruction of the discharge of bile or pancreatic juice is frequently observed, and biliary perforation and severe pancreatitis may occur. In such cases, temporary drainage is necessary to stabilize these patients. We employed laparoscopic cholecystostomy followed by laparoscopic cyst excision in cases with complicated CC. Methods Between 2009 and 2013, emergency laparoscopic cholecystostomy for bile drainage was performed in seven girls with complicated CC in whom conservative treatment failed to ameliorate abdominal pain, vomiting, and jaundice; among these seven patients included two with biliary perforation, one with a huge cyst, and four with peribiliary edema suggestive of impending biliary rupture. Protein plugs in the common channel or the terminal portion of the cyst were present in six patients. Results Amelioration of symptoms, such as abdominal pain and jaundice, was achieved in all patients after laparoscopic cholecystostomy. Saline irrigation of the bile duct via cholecystostomy was commenced 2 days postoperatively. All patients underwent laparoscopic cyst resection after improvement of their general condition and detailed evaluation of the intrahepatic and extrahepatic bile ducts and pancreaticobiliary maljunction. Impacted protein plugs or gallstones were eliminated in all patients by the time of laparoscopic cyst excision. Conclusion Laparoscopic cholecystostomy followed by laparoscopic cyst excision is a useful and safe procedure for the treatment of complicated CC. This technique is also favorable from a cosmetic viewpoint because the resultant wound can be reused as the trocar insertion site at the time of laparoscopic cyst excision. [ABSTRACT FROM AUTHOR]

Introduction A number of studies have proven that mechanical bowel preparation ( MBP) has no benefits in elective colorectal surgery. However, studies specifically related to gynecologic laparoscopic surgery are scant. We undertook a meta-analysis to assess the necessity of MBP before gynecologic laparoscopic surgery. Methods The electronic databases MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were systematically searched to identify relevant randomized controlled trials. Two authors independently extracted data from each study. The primary outcome of interest was the quality of surgical field. Secondary outcomes of interest included postoperative pain, abdominal swelling, nausea/vomiting, and length of hospital stay. Results Three studies involving 372 participants were included in the meta-analysis. The results showed that MBP did not significantly increase the overall quality of surgical field exposure (odds ratio, 0.82; 95% confidence interval [ CI], 0.46-1.49; P = 0.52). MBP also did not appear to significantly change the mean scores of postoperative pain (weighted mean difference, 0.09; 95% CI, −0.54-0.71; P = 0.79), the incidence of nausea/vomiting (odds ratio, 1.56; 95% CI, 0.80 to 3.03; P = 0.19), the mean scores of abdominal swelling (weighted mean difference, −0.26; 95% CI, −0.83-0.30; P = 0.36), and length of hospital stay (weighted mean difference, 0.05; 95% CI, −0.13-0.22; P = 0.62). Conclusions Our results suggest that routine use of MBP for gynecologic laparoscopic surgery should not be recommended. However, additional randomized controlled trials using large samples are needed to confirm these findings. [ABSTRACT FROM AUTHOR]

More than 20 years after the introduction of laparoscopic gastrectomy, two ongoing, large-scale randomized controlled trials are currently being conducted in Japan: JCOG0912 for patients with stage I disease and JLSSG0901 for patients with advanced cancer. Both trials are designed to evaluate the non-inferiority of laparoscopic-assisted distal gastrectomy to its open counterpart. The primary end-point of JCOG0912 is overall survival, whereas that of JLSSG0901 is relapse-free survival. Quality control for the surgeries is being strictly performed in each study; eligibility criteria apply to participating surgeons and a central review of the surgical procedure has been conducted. The accrual of patients for JCOG0912 and for JLSSG0901 (phase II) is complete, and the disclosure of level I evidence is being awaited. [ABSTRACT FROM AUTHOR]

A 62-year-old Japanese woman who had developed massive cirrhotic ascites was referred to our hospital for a peritoneovenous shunt implant. However, CT examination revealed an umbilical hernia that had not been observed before the peritoneovenous shunt was implanted. We decided to perform laparoscopic umbilical hernia repair to keep carbon dioxide from flowing backward into the central circulatory system. We first clamped the catheter and set the upper limit of the pneumoperitoneum pressure to 6 mmHg. The central venous pressure was also measured simultaneously. Mesh was then applied over the hernia and fixed by the double-crown technique. Finally, 1000-mL physiological saline was infused into the abdominal cavity while the pneumoperitoneum was slowly released. In this case, we safely performed laparoscopic umbilical hernia repair while making some alterations, specifically catheter clamping, reducing pneumoperitoneum pressure, monitoring central venous pressure, and infusing physiological saline. [ABSTRACT FROM AUTHOR]

Introduction Traditionally, laparoscopy has been based on 2-D imaging, which represents a considerable challenge. As a result, 3-D visualization technology has been proposed as a way to better facilitate laparoscopy. We compared the latest 3-D systems with high-end 2-D monitors to validate the usefulness of new systems for endoscopic diagnoses and treatment in Thailand. Methods We compared the abilities of our high-definition 3-D endoscopy system with real-time compression communication system with a conventional high-definition ( 2-D) endoscopy system by asking health-care staff to complete tasks. Participants answered questionnaires and whether procedures were easier using our system or the 2-D endoscopy system. Results Participants were significantly faster at suture insertion with our system (34.44 ± 15.91 s) than with the 2-D system (52.56 ± 37.51 s) ( P < 0.01). Most surgeons thought that the 3-D system was good in terms of contrast, brightness, perception of the anteroposterior position of the needle, needle grasping, inserting the needle as planned, and needle adjustment during laparoscopic surgery. Several surgeons highlighted the usefulness of exposing and clipping the bile duct and gallbladder artery, as well as dissection from the liver bed during laparoscopic surgery. In an image-transfer experiment with Re Pure- L®, participants at Rajavithi Hospital could obtain reconstructed 3-D images that were non-inferior to conventional images from Chulalongkorn University Hospital (10 km away). Conclusion These data suggest that our newly developed system could be of considerable benefit to the health-care system in Thailand. Transmission of moving endoscopic images from a center of excellence to a rural hospital could help in the diagnosis and treatment of various diseases. [ABSTRACT FROM AUTHOR]

Objective To evaluate the efficacy and systematic impact of different sized endoscopes for pure transgastric natural orifice transluminal endoscopic surgery ( NOTES) peritoneoscopy relative to laparoscopy. Methods A total of 15 dogs were randomly assigned to the small-sized endoscope ( SS), large-sized endoscope ( LS) and standard laparoscopy ( SL) groups. The procedure time, visualization scores for abdominal organs, gastric incision healing times and procedure-associated complications were recorded. Blood samples were collected at 1 h preoperation and at 1 h, 12 h, 2 days and 7 days postoperation. Serum tumor necrosis factor ( TNF)-α and interleukin ( IL)-6 levels as well as peripheral white blood cell ( WBC) counts were analyzed. Results Peritoneoscopy was successfully performed with both pure transgastric NOTES and laparoscopy. The peritoneoscopy required less time to complete in the SL group (44.0 ± 7.0 min) than the LS (83.0 ± 28.9 min) and SS (106.6 ± 81.3 min) groups ( P < 0.01), but no statistical difference was observed between the SS and LS groups ( P > 0.05). The visualization scores of peritoneal organs among the three groups did not differ significantly ( P > 0.05). The gastric incision exhibited satisfactory healing in both the SS and LS groups. Moreover, serum TNF-α and IL-6 levels and WBC counts at each time point were similar among the three groups ( P > 0.05). Conclusions Small-sized endoscope is not superior to a large-sized one for pure transgastric NOTES peritoneoscopy. Pure transgastric NOTES is not less invasive or less time-consuming than laparoscopy. [ABSTRACT FROM AUTHOR]

Objective To investigate surgical procedures for pure endoscopic full-thickness resection (EFTR) using a flexible endoscope and a prototype of a full-thickness suturing device in animal experiments. Methods Six beagles were divided into two groups: sutured with over-the-scope-clip ( OTSC group, n = 3) and with a prototype of the double-arm bar suturing system ( DBSS group, n = 3). The peritoneoscopy, omentectomy and EFTR procedures were performed through the transgastric route. We examined the surgical procedures required to accomplish pure EFTR and survival rates of these dogs after EFTR. Results The duodenal balloon occlusion method maintained a sufficient endoscopic view during peritoneoscopy. Grooves of 10-mm wide were created around the tumor down to the third layer for treating all blood vessels and adding landmark for full-thickness resection lines. Using the muscle layer thin-cutting method, hyaluronic acid was locally injected into the muscle layer and fine incisions were made. Creating tiny perforations provided safe access to the abdominal cavity. Although it was difficult to suture the resected site safely in the OTSC group, the DBSS prototype was useful and reliable for closing the resection sites with 3-0 absorbable thread. After EFTR there were no complications in the DBSS group and the dogs were in good health on POD 30, whereas in the OTSC group two dogs died due to dehiscence and gastric juice leaks. Postmortem examinations showed abscess around the suturing sites and two OTSC were detached from the suturing sites. Conclusions Pure EFTR is feasible with DBSS when systematic methods are established. The high safety of full-thickness resection suturing will permit their clinical application in the near future. [ABSTRACT FROM AUTHOR]

The surgical management of rectal cancer has evolved over the past century, with total mesorectal excision ( TME) emerging as standard of care. As a result of the morbidity associated with open TME, minimally invasive techniques have become popular. Natural orifice translumenal endoscopic surgery ( NOTES) has been held as the next revolution in surgical techniques, offering the possibility of 'incisionless' TME. Early clinical series of transanal TME with laparoscopic assistance ( n = 72) are promising, with overall intraoperative and postoperative complication rates of 8.3% and 27.8%, respectively, similar to laparoscopic TME. The mesorectal specimen was intact in all patients, and 94.4% had negative margins. There was no oncological recurrence in average-risk patients at short-term follow up, and 2-year survivalrates in high-risk patients were comparable to that after laparoscopic TME. These preliminary studies demonstrate transanal NOTES TME with laparoscopic assistance to be clinically feasible and safe given careful patient selection, surgical expertise, and appropriate procedural training. We are hopeful that with optimization of transanal instruments and surgical techniques, pure transanal NOTES TME will become a viable alternative to open and laparoscopic TME in the future. [ABSTRACT FROM AUTHOR]

Introduction Isolated renal hydatid rarely presents, but when it does occur, it requires surgical treatment. We report our experience with a novel technique involving percutaneous management of a giant renal hydatid cyst with single-incision laparoscopic assistance. Material and Surgical Technique First we performed retrograde ureteropyelogram, which did not show any communication between the cyst and the calyceal. A Veress needle was used for pneumoperitoneum. Three conventional laparoscopic trocars used. Under laparoscopic guidance, we punctured the cyst. The scolicidal solution used was 10% povidone-iodine. The endocyst was removed under vision with grasping forceps through the nephroscope. A Portex drain was placed into the cyst cavity. Discussion Percutaneous aspiration and instillation of scolicidal agents followed by re-aspiration have been previously reported. This is an attractive procedure because of its acceptable success rates and reduced morbidity. In our case, simple aspiration of the cyst would not have been successful because the cyst was full of daughter cysts. Also, a blind percutaneous puncture of the cyst and dilatation could have perforated the colon or the mesocolon, which is often wrapped over the surface of such giant cysts thereby making laparoscopic guidance and mobilization of the colon imperative. We devised this unique treatment method for this patient involving three conventional ports at a single umbilical site. We believe this is the first reported case of its kind in the world. Not only this technique is minimally invasive, it is also cost-effective, as only conventional laparoscopic ports and instruments are used during the procedure. [ABSTRACT FROM AUTHOR]

Objective To present outcomes of a randomized, patient-blinded controlled trial on Pfannenstiel laparoendoscopic single-site ( LESS) vs conventional multiport laparoscopic live donor nephrectomy., Patients and Methods Patients presenting as left kidney donors between January 2009 and November 2011 were randomized to LESS donor nephrectomy ( LESS-DN: n = 15) or conventional laparoscopic donor nephrectomy ( LDN: n = 14)., Patients were blinded to the surgical approach preoperatively and attempts to continue patient blinding postoperatively were made by applying dressings consistent with multiple conventional laparoscopic incisions for all patients., De-identified data related to the operation, peri-operative course and postoperative follow-up were prospectively collected and compared between the two groups with an intention-to-treat analysis., Results There were no significant differences between the groups when comparing operating time, estimated blood loss ( EBL), i.v. fluid administration, renal allograft warm ischaemia time ( WIT), length of hospital stay ( LOS) and total inpatient analgesic requirements., Quantitative pain assessment was not significantly different on postoperative day ( POD) #0, however, it was significantly lower in the LESS-DN group, beginning on POD #1 ( P < 0.05)., The changes in haematocrit and serum creatinine in the two groups were not significantly different, and there were no blood transfusions in either group, nor was there a decline in estimated glomerular filtration rate to <60 mL/min per 1.73 m2 of body surface area in any patients., Two patients in the LESS-DN group were converted to conventional LDN, both because of failure to progress effectively., All allografts were functional at the time of transplantation and revascularization, with no cases of hyperacute rejection., Conclusions Peri-operative variables including EBL, WIT and LOS were equivalent when comparing Pfannenstiel LESS-DN with conventional LDN., Patient-reported visual analogue pain scale scores were significantly lower in the LESS-DN group beginning on the first postoperative day. [ABSTRACT FROM AUTHOR]

Objective To evaluate the feasibility and safety of laparoscopic and endoscopic cooperative surgery ( LECS) for the treatment of gastric gastrointestinal stromal tumors ( GISTs). Methods We retrospectively reviewed the data of 69 consecutive patients who underwent LECS, including laparoscopy-assisted endoscopic resection ( LAER) and endoscopy-assisted laparoscopic wedge resection ( EAWR), for pathologically confirmed gastric GISTs of less than 5 cm in diameter from January 2006 to October 2012. Results The tumor was located at the upper third of the stomach in 22 patients, the middle third in 38 and the lower third in nine, with a mean tumor size of 2.8 ± 1.6 cm. The operating time was 81.6 ± 31.8 min in the LAER group and 86.3 ± 28.5 min in the EAWR group ( P = 0.776). Intraoperative blood loss was 29.8 ± 15.4 mL in the LAER group and 31.4 ± 11.6 mL in the EAWR group ( P = 0.561). Most patients had a very low or low risk of tumor recurrence, while six had an intermediate risk of tumor recurrence. The mean length of postoperative hospital stay was 4.6 days. Only two patients had postoperative complications after LECS, both of whom were treated successfully without open surgery. During a median follow-up of 35 months, all patients were disease-free, with no tumor recurrence or metastases. Conclusion LECS is a minimally invasive and safe alternative approach which can achieve fast recovery and satisfactory short-term outcomes for appropriately selected patients with gastric GISTs. [ABSTRACT FROM AUTHOR]

Natural orifice transluminal endoscopic surgery designates a surgical procedure that utilizes one or more patent natural orifices of the body with the intention to puncture a hollow viscera in order to enter the abdominal cavity. First carried out at the beginning of the 2000s in experimental models, it can be considered the natural evolution of laparoscopy towards the ideal of scarless surgery, as the avoidance of a large abdominal scar is associated with better cosmetic results and better recovery. However, the technology currently available does not allow the performance of complete pure natural orifice transluminal endoscopic surgery procedures. The surgical tools used are not specially designed for this approach, so difficulties in retracting organs, bleeding control and clashing of instruments are the main obstacle surgeons face. For this reason, the current available technique is the so-called hybrid approach, where a natural orifice approach is combined with some abdominal trocars, using the natural orifice as the exit door for the specimen removal. As not many comparative studies have been published evaluating the advantages of natural orifice transluminal endoscopic surgery in front of traditional laparoscopic surgery, a review of the history of natural orifice transluminal endoscopic surgery, and an assessment of the available evidence of this technique regarding renal and urological pelvic surgery are performed in this article. [ABSTRACT FROM AUTHOR]