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Background Laparoscopic liver resection (LLR) is a highly demanding procedure with great variability. Previously published randomized trials have proven oncological safety of laparoscopic liver resection (LLR) as compared to open surgery. However, these were started after the learning curve (LC) was established. This leaves the question of whether the LC of LLR in the early laparoscopic era has affected the survival of patients with colorectal liver metastasis (CRLM). Methods All consecutive LLRs performed by a single surgeon between 2000 and 2019 were retrospectively analysed. A risk-adjusted cumulative sum (RA-CUSUM) chart for conversion rate and the log regression analysis of the blood loss identified two phases in the LC. This was then applied to patients with CRLM, and the two subgroups were compared for recurrence-free (RFS) and overall survival (OS). The analysis was repeated with propensity score-matched (PSM) groups Results A total of 286 patients were included in the LC analysis, which identified two distinct phases, the early (EP; 68 patients) and the late (LP; 218 patients) phases. The LC was applied to 192 patients with colorectal liver metastasis (EPc, 45 patients; LPc, 147 patients). For patients with CRLM, R0 resection was achieved in 93 per cent: 100 per cent in the EPc group and 90 per cent in the LPc group (P  = 0.026). Median OS and RFS were 60 and 16 months, respectively. The 5-year OS and RFS were 51 per cent and 32.7 per cent, respectively. OS (hazard ratio (h.r.) 0.78, 95 per cent confidence interval (c.i.) 0.51 to 1.2; P  = 0.286) and RFS (h.r. 0.94, 95 per cent c.i. 0.64 to 1.37; P  = 0.760) were not compromised by the learning curve. The results were replicated after PSM. Conclusion In our experience, the development of a laparoscopic liver resection programme can be achieved without adverse effects on the long-term survival of patients with CRLM. [ABSTRACT FROM AUTHOR]

Background: Staple line bleeding (SLB) is a common intraoperative complication following resection in laparoscopic sleeve gastrectomy (SG). Opinion is divided on the best measure to deal with SLB which includes expensive reinforcement strategies, suturing the staple line or diathermy. Tranexemic acid is a relatively inexpensive drug known to reduce bleeding in trauma and surgery. The aim of this study was to evaluate whether intraoperative tranexemic acid reduces staple line bleeding. Methods: In this prospective matched comparative study of SG, one cohort of patients was administered tranexemic acid (1 g) after induction and compared to a control group. The primary outcome compared the number of staple line bleeding points requiring intervention intra-operatively. Secondary outcomes included estimated blood loss and operating time. The anaesthetic and thromboprophylaxis protocols were uniform. Operative technique and stapling equipment were identical in all patients. Results: Twenty-five patients were allocated to both the control and treatment arms. Patient characteristics in both groups were similar in age (median 34 vs 43 years), body mass index (median 54.7 vs 52 kg/m), gender distribution (female:male = 20:5) and co-morbidities. The treatment group receiving tranexemic acid, required significantly less number of haemostatic stitches for staple line bleeding (19 vs 46, p < 0.05), incurred less intraoperative blood loss ( p < 0.01) and had quicker operating times (median 66 vs 80 min, p < 0.05). There was no difference in morbidity or mortality in both groups. Conclusion: Intraoperative prophylactic tranexemic acid use is a simple and economical option for effectively reducing staple line bleeds leading to significant decrease in operating times. [ABSTRACT FROM AUTHOR]

Single-incision surgery in the morbidly obese patient has not been widely adopted, but remains a popular choice amongst patients. In the bariatric patient, it presents its own surgical challenges with hepatomegaly and increased abdominal adiposity. Here, we present our experience of 275 single-incision laparoscopic gastric bands.Between June 2009 and April 2013, 275 obese patients underwent single-incision laparoscopic adjustable gastric banding through a single incision using a multichannel single port and via a pars flaccida approach. Prospective data collection was undertaken including operating time, additional ports and additional procedures undertaken.In this series, median operative time was 60 (range 34-170) min. An additional port was placed in 15 patients (5 %), including two conversions to four-port technique (0.7 %). Of these patients ( n = 15), the majority were male ( p < 0.0001). Reasons for additional port placement included bleeding and anatomical abnormalities. Additional port placement occurred more often within the first 50 cases (5/50, 10 % vs 10/225, 4 %). An umbilical incision resulted in more wound-related complications than a transverse incision in the upper abdomen ( p < 0.001). There were no 30-day mortality and minimal morbidity with two wound infections resulting in band removal.Single-incision laparoscopic adjustable gastric banding can be performed safely with minimal morbidity in the morbidly obese patient, and our technique has a high rate of success for all BMIs. Following 275 single-incision band insertions additional port placements were more commonly required in male patients, BMI >45 and earlier in the learning curve. [ABSTRACT FROM AUTHOR]

Abstract: Background: As single incision surgery increases in popularity, the feasibility of offering this approach in bariatric surgery is further progression of this surgical technique. With the technical challenges that both operating on the morbidly obese patient and single incision surgery present, we describe our initial experience undertaking 111 single-incision gastric band insertions. Methods: From June 2009 to October 2010, 111 obese patients underwent single-incision laparoscopic adjustable gastric banding through a single transverse incision using a multichannel single port and a pars flaccida technique. Prospective data collection was undertaken, including visual analog scores. Results: In this initial series, the median operative time was 65 minutes (range 34–165). There was 1 conversion to a 5-port laparoscopic technique (.9%), and an additional port was placed in 7 patients (6%). Male patients were more likely to require an additional port (P < .05). The single-incision size ranged from 26 to 45 mm (median 35). At 23 hours postoperatively, the median pain score was 2.5 on a 0–10 visual analog score. On multivariate analysis, pain was found to increase with operation time (P < .001). The median length of stay was 24 hours (range 5.5–48). There was no mortality and minimal morbidity, with 1 wound infection necessitating band removal. Conclusions: Single-incision laparoscopic adjustable gastric banding can be performed safely with minimal morbidity and mortality in the morbidly obese patient, and our technique has a high rate of success. The benefits compared with the traditional laparoscopic approach and long-term outcomes are yet to be established. However, if the intra-abdominal operative time is >60 minutes, one should consider the placement of an additional port, especially in male patients. [Copyright &y& Elsevier]

Background: Single incision laparoscopic bariatric surgery has developed over the last few years, with single incision laparoscopic adjustable gastric banding (SILS-AGB) being performed most commonly. However, there are no randomised controlled trials and few matched studies comparing SILS-AGB to conventional laparoscopic multi-port multiport adjustable gastric banding (LAGB). Our aim was to study any differences in outcome and analgesic requirements between two matched groups of gastric band patients (SILS-AGB and LAGB). Methods: Between June 2009 and September 2010, 111 patients underwent SILS-AGB and 99 patients underwent LAGB performed by a single surgeon (AGP). Patients were matched for age, sex, weight, BMI and co-morbidities. Forty six SILS-AGB and LAGB patients were included for analysis. Their outcomes were compared for operating times, conversions, analgesia requirements, morbidity and mortality. Results: Patients characteristics between the SILS-AGB and LAGB groups were similar with no differences in their median age (44 vs 47 years), sex (m:f; 7:39 vs 4:42), body mass index (43.1 vs 44.4 kg/m) or co morbidities respectively. In the SILS-AGB group the median operating time (70 min) was not significantly longer than in LAGB group (61.5 min, p = 0.07). However, SILS-AGB patients used less opiates ( p < 0.01) than the LAGB patients. There was no difference in morbidity, mortality or readmission rates. Conclusion: SILS-AGB is a safe and feasible option and is comparable with LAGB. Post operative demand for analgesia was significantly less in the SILS-AGB group. Further comparisons of post operative pain and long term outcomes are required; however preliminary results are promising. [ABSTRACT FROM AUTHOR]

Background and Purpose: Laparoscopic radical prostatectomy (LRP) is an established treatment for patients with prostate cancer in selected centers with appropriate expertise. We studied our single-center experience of developing a LRP service and subsequent training of two additional surgeons by the initial surgeon. We assessed the learning curve of the three surgeons with regard to perioperative outcomes and oncologic results. Patients and Methods: Three hundred consecutive patients underwent a LRP between January 2005 and April 2011. Patients were divided into three equal groups (1-100 group 1], 101-200 [group 2], and 201-300 [group 3]). Age, American Society of Anesthesiologists score, preoperative comorbidities, and indications for LRP were comparable for all three patient groups. Perioperative and oncologic outcomes were compared across all three groups to assess the impact of the learning curve for LRP. All surgical complications were classified using the Clavien-Dindo system (CDS). Results: The mean age was 61.9 years (range 46-74 y). There was a significant reduction in the mean operative time ( P<0.05), mean blood loss ( P<0.05), mean duration of hospital stay ( P<0.05), and duration of catherization ( P<0.05) between the three groups as the series progressed. The two most important factors predictive of positive surgical margins at LRP were the initial prostate-specific antigen level and tumor stage at diagnosis. The overall positive margin rate was 27.7%. For pT2 tumors, the positive margin rate was 21%, while patients with pT3 tumors had a positive margin of 44%. For pT2 tumors, positive margin rates decreased with increasing experience (group 1, 27% vs group 2, 17% vs group 3, 19%). The incidence of major complications-ie, grade CDS score ≤III-was 4.6% (14/300). Conclusion: LRP is a safe procedure with low morbidity. As surgeons progress through the learning curve, perioperative parameters and oncologic outcomes improve. Using a carefully mentored approach, LRP can be safely introduced as a new procedure without compromising patient outcomes. [ABSTRACT FROM AUTHOR]

Background: An increasing number of techniques are emerging in the literature describing single-incision laparoscopic cholecystectomy (SILC). The advent of a new surgical approach is a reminder of the increase in bile duct injuries in the past when laparoscopic cholecystectomy was first introduced. With this in mind, the authors describe a safe and reproducible approach to SILC. Methods: Between August 2008 and August 2009, 20 patients with symptomatic gallbladder disease underwent SILC using a totally transumbilical fundus-first approach with an intraoperative cholangiogram. Data including pain scores were collected prospectively. Results: In this initial series, the median operative time was 103 min (range, 55-177 min), including the time for two patients undergoing additional procedures at the time of surgery. Intraoperative cholangiograms were completed for 18 of 19 patients. Additional ports were required in four patients for safe completion of the procedure. The mean pain score 12 h postoperatively was 2.5 on a visual analogue scale with a range of 0-10. There was no morbidity or mortality. Conclusion: According to the findings, SILC with an intraoperative cholangiogram can be performed safely using a fundus-first approach. However, for SILC to become the operation of choice for the treatment of gallbladder disease, evidence is required to demonstrate its advantage over laparoscopic cholecystectomy. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the accuracy of operative assessment of the condition of the appendix during laparoscopic and open appendicectomy, and to assess whether a normal-looking appendix should be excised routinely during a laparoscopic operation. Design: Prospective study. Setting: District general hospital, UK. Subjects: 387 patients who presented with signs and symptoms of appendicitis and underwent appendicectomy. Intervention: 63 patients (16%) were operated on laparoscopically, of whom 48 were female. Main outcome measures: Correlation of operative with histological findings. Results: The positive predictive value of operative assessment was increased during the laparoscopic procedure in both male (94.4% to 100%) and female (78% to 88%) patients. Of 21 female patients whose appendixes looked normal at laparoscopy, 5 had other conditions (appendixes normal on histological examination) and 4 were inflamed. Conclusion: In women of childbearing age a normal-looking appendix should be resected during laparoscopic appendicectomy unless another condition is obviously the cause of the signs and symptoms. [ABSTRACT FROM AUTHOR]

Background: This study examines the effect of alcohol intake on surgical dexterity immediately after and the morning after alcohol intake and minimal sleep deprivation by simulating a typical night out on the town. Methods: Five surgeons (all men, aged 31–40 years) were trained on a laparoscopic surgical simulator (minimally invasive surgical trainer-virtual reality) to reach a desired standard of performance. Three experimental settings were used: (i) a control night with no alcohol and full night's sleep; (ii) a sham night out (sleep deprived) without alcohol; and (iii) a night out with alcohol ad libitum. The parameters recorded were the average time taken to carry out a task, error rate, average diathermy time and diathermy (damage) time to main object. Comparisons between baseline readings, those in the middle of the night and those of the following morning were made by applyingANOVA methods after logarithmic transformation of the data. Results: The candidates consumed, on average, 10.33 units (range, 6–15 units) of alcohol and had 0.86% (range, 0.71–1.1%) of breath alcohol levels and an average of 3.75 h (range, 3–5 h) of sleep after a typical night out. The morning-after breath alcohol levels were 0%. There was significant deterioration in performance, as measured by all indicators, immediately after alcohol consumption. The adverse effects on time taken to complete the task and total diathermy time were still apparent the morning after. The sham night out appeared to affect only ‘time parameters’. No significant changes in performance were seen in the control setting. Conclusion: Both alcohol consumption and sleep deprivation adversely affect the ability to carry out surgical procedures. Our simulation study suggests that the adverse effects of alcohol intake persist the following morning. [ABSTRACT FROM AUTHOR]

Laparoscopic surgery via a single port is an evolving technique being applied to an increasing variety of operations [1]. Multiple series over the past 3 years have shown single-incision laparoscopic cholecystectomy to be feasible and safe [2]. The ergonomic difficulties of single-port laparoscopy include a loss of instrument triangulation and operation with camera and instruments in parallel. Many different modifications of techniques and equipment have been used to compensate. Single-port techniques have been applied by a few authors to laparoscopic nephrectomy [3], splenectomy [4], and obesity surgery [5, 6]. Laparoscopic liver resection is well established and shown to be safe in multiple series [7]. The laparoscopic approach is accepted as the gold standard for resection of segments 2 and 3 [8]. To the authors' knowledge, no reports of laparoscopic liver resection via a single port have been published. They report the use of their technique for single-incision laparoscopic left lateral segmentectomy in a patient with a solitary segment 2 colorectal liver metastasis. The authors maintained strict oncologic principles and adhered to their standard laparoscopic technique as far as possible. They used a TriPort (Advanced Surgical Concepts, Wicklow, Ireland) placed via a 12-mm incision at the umbilicus. Following diagnostic laparoscopy and intraoperative liver ultrasound, hepatic attachments were divided using electrocautery. Parenchymal transection and vascular control were achieved using an ultrasonic dissector and laparoscopic staplers. Standard straight laparoscopic instruments were used. A number of technical challenges were apparent. Movement of instruments was jerky at times, either because instruments were clashing with one another other or deflecting the camera. The multiport device can be stiff, requiring copious lubrication throughout surgery. Crossing hands facilitates internal triangulation of the operating instruments to allow retraction or to apply tension, for example, during the division of hepatic attachments. Control of minor hemorrhage is possible with judicious and patient application of pressure using small pieces of surgical gauze. An articulating laparoscopic stapler is useful to achieve the ideal angle of staple deployment during transection of vascular pedicles. The specimen was extracted by extending the umbilical incision. No complications occurred. The patient was able to resume an oral diet and full mobility free of opioid analgesia on the first postoperative day. The resection margin was clear. This video demonstrates that the authors' technique is feasible and oncologically safe for selected patients requiring liver resection. [ABSTRACT FROM AUTHOR]

We report a case of vesicovaginal fistula in 71-year-old lady who had previously undergone a lapascopic assisted nephroureterectomy for transitional cell carcinoma in her right ureter and kidney. The surgery was uncomplicated with no post-operative problems and was discharged on day on seven. She later presented five weeks following the initial operation with signs and symptoms suggestive of a vesicovaginal fistula, which was confirmed on cystogram and flexible cystosopy. She proceeded to have an abdominal (O'Connor's) repair of the fistula together with cystodiathermy for a few superficial bladder recurrences. The area of the fistula (within the bladder) was noted to be tumour free. She had an uneventful post-operative recovery and was discharged from hospital on day 11. At six month follow-up, there was another superficial recurrence in the bladder that was resected, with no sign of fistula. [ABSTRACT FROM AUTHOR]