Robotic versus laparoscopic versus open nephrectomy for live kidney donors.

BACKGROUND: Waiting lists for kidney transplantation continue to grow. Live kidney donation significantly reduces waiting times and improves long-term outcomes for recipients. Major disincentives to potential kidney donors are the pain and morbidity associated with surgery. This is an update of a review published in 2011. OBJECTIVES: To assess the benefits and harms of open donor nephrectomy (ODN), laparoscopic donor nephrectomy (LDN), hand-assisted LDN (HALDN) and robotic donor nephrectomy (RDN) as appropriate surgical techniques for live kidney donors. SEARCH METHODS: We contacted the Information Specialist and searched the Cochrane Kidney and Transplant Register of Studies up to 31 March 2024 using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing LDN with ODN, HALDN, or RDN were included. DATA COLLECTION AND ANALYSIS: Two review authors independently screened titles and abstracts for eligibility, assessed study quality, and extracted data. We contacted study authors for additional information where necessary. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) or standardised mean difference (SMD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS: Thirteen studies randomising 1280 live kidney donors to ODN, LDN, HALDN, or RDN were included. All studies were assessed as having a low or unclear risk of bias for selection bias. Five studies had a high risk of bias for blinding. Seven studies randomised 815 live kidney donors to LDN or ODN. LDN was associated with reduced analgesia use (high certainty evidence) and shorter hospital stay, a longer procedure and longer warm ischaemia time (moderate certainty evidence). There were no overall differences in blood loss, perioperative complications, or need for operations (low or very low certainty evidence). Three studies randomised 270 live kidney donors to LDN or HALDN. There were no differences between HALDN and LDN for analgesia requirement, hospital stay (high certainty evidence), duration of procedure (moderate certainty evidence), blood loss, perioperative complications, or reoperations (low certainty evidence). The evidence for warm ischaemia time was very uncertain due to high heterogeneity. One study randomised 50 live kidney donors to retroperitoneal ODN or HALDN and reported less pain and analgesia requirements with ODN. It found decreased blood loss and duration of the procedure with HALDN. No differences were found in perioperative complications, reoperations, hospital stay, or primary warm ischaemia time. One study randomised 45 live kidney donors to LDN or RDN and reported a longer warm ischaemia time with RDN but no differences in analgesia requirement, duration of procedure, blood loss, perioperative complications, reoperations, or hospital stay. One study randomised 100 live kidney donors to two variations of LDN and reported no differences in hospital stay, duration of procedure, conversion rates, primary warm ischaemia times, or complications (not meta-analysed). The conversion rates to ODN were 6/587 (1.02%) in LDN, 1/160 (0.63%) in HALDN, and 0/15 in RDN. Graft outcomes were rarely or selectively reported across the studies. There were no differences between LDN and ODN for early graft loss, delayed graft function, acute rejection, ureteric complications, kidney function or one-year graft loss. In a meta-regression analysis between LDN and ODN, moderate certainty evidence on procedure duration changed significantly in favour of LDN over time (yearly reduction = 7.12 min, 95% CI 2.56 to 11.67; P = 0.0022). Differences in very low certainty evidence on perioperative complications also changed significantly in favour of LDN over time (yearly change in LnRR = 0.107, 95% CI 0.022 to 0.192; P = 0.014). Various different combinations of techniques were used in each study, resulting in heterogeneity among the results. AUTHORS' CONCLUSIONS: LDN is associated with less pain compared to ODN and has comparable pain to HALDN and RDN. HALDN is comparable to LDN in all outcomes except warm ischaemia time, which may be associated with a reduction. One study reported kidneys obtained during RDN had greater warm ischaemia times. Complications and occurrences of perioperative events needing further intervention were equivalent between all methods.

Does single-port laparoscopic sleeve gastrectomy result in improved short-term perioperative outcomes compared to conventional multi-port laparoscopic sleeve gastrectomy?

A best evidence topic in bariatric surgery was written according to a structured protocol. The question asked whether single-port laparoscopic sleeve gastrectomy produces better short-term perioperative outcomes compared to the conventional multi-port laparoscopic sleeve gastrectomy in the treatment of morbid obesity. A Pubmed search generated 82 papers, 6 of which represented the best evidence to answer the clinical question. Of the 6, 1 paper was an updated analysis of the same patient cohort. The evidence on this subject is good. Five papers were level III, nonrandomized studies, 2 of which were prospective and 3 were retrospective cohort studies. The sixth paper was a level II, randomized, prospective study. We conclude that single-port laparoscopic sleeve gastrectomy results in less use of postoperative analgesia and better cosmetic satisfaction compared to multi-port laparoscopic sleeve gastrectomy in the short-term. The two groups showed comparable results in terms of mean operative time, mean hospitalization, and percentage excess weight loss. There was no difference in rate of postoperative complications including trocar site incisional hernia, staple line leaks, and bleeding.

A structured teaching curriculum for medical students improves their performance on the National Board of Medical Examiners shelf examination in surgery.

BACKGROUND: The aim of this study was to evaluate the effect of a resident-driven, student taught educational curriculum on the medical students' performance on the National Board of Medical Examiners surgery subject examination (NBME). METHODS: On daily morning rounds, medical students or the chief resident delivered preassigned brief presentations on 1 or 2 of the 30 common surgical topics selected for the curriculum. An initial assessment of student knowledge and an end-rotation in-house examination (multiple choice question examination) were conducted. The mean scores on the NBME examination were compared between students in teams using this teaching curriculum and those without it. RESULTS: A total of 57 third-year medical students participated in the study. The mean score on the in-house postclerkship multiple choice question examination was increased by 23.5% (P < .05). The mean NBME scores were significantly higher in the students who underwent the teaching curriculum when compared with their peers who were not exposed to the teaching curriculum (78 vs 72, P < .05). CONCLUSION: The implementation of a resident-driven structured teaching curriculum improved performance of medical students on the NBME examination.

Postoperative complications in bariatric surgery using age and BMI stratification: a study using ACS-NSQIP data.

BACKGROUND: Bariatric surgery results in long-term weight loss and significant morbidity reduction. Morbidity and mortality following bariatric surgery remain low and acceptable. This study looks to define the trend of morbidity and mortality as it relates to increasing age and body mass index (BMI) in patients undergoing bariatric surgery. METHODS: We queried the ACS/NSQIP 2010-2011 Public Use File for patients who underwent elective laparoscopic adjustable banding (LAGB), sleeve gastrectomy (LSG) and gastric bypass (LGBP). Total morbidity and 30-day mortality were evaluated. Logistic regression models were created to estimate the effect of increasing age and BMI on morbidity for these bariatric procedures. RESULTS: A total of 20,308 laparoscopic bariatric procedures were reviewed (11617 LGBP, 3069 LSG and 5622 LAGB). Overall mortality and morbidity rates were 0.11 and 3.84%, respectively. The odds of postoperative complications increased by 2% with each additional year of age (OR 1.02, 95% CI 1.02-1.03) and every point increase in BMI (OR 1.02, 95% CI 1.01-1.03). Multiple logistic regression identified COPD, Diabetes, Hypertension, and Dyspnea as major risk factors for postoperative morbidity. Postoperative complications were three times more likely after LGBP (OR 2.87, 95% CI 2.31-3.57) and two times more likely after LSG (OR 2.06, 95% CI 1.57-2.72) when compared to patients undergoing LAGB. CONCLUSION: Morbidity and mortality increase on a predictable trend with increasing age and BMI. There is increased risk of morbidity for stapling procedures when compared to gastric banding, but this must be considered in context of surgical efficacy when choosing a bariatric procedure. These data can be used in preoperative counseling and evaluation of surgical candidacy of bariatric surgical patients.

Association of radiographic morphology with early gastroesophageal reflux disease and satiety control after sleeve gastrectomy.

BACKGROUND: Variable gastric morphology has been identified on routine upper gastrointestinal series after laparoscopic sleeve gastrectomy. This test might give us useful information beyond the presence of leak and obstruction. The aim of this study is to standardize a morphologic classification of gastric sleeve based on water-soluble contrast upper gastrointestinal series, and to determine possible clinical implications. STUDY DESIGN: One hundred morbidly obese patients underwent laparoscopic sleeve gastrectomy and had routine upper gastrointestinal on postoperative day 1 or 2. Images were reviewed by 4 radiologists who were blinded to outcomes, and sleeve shape was classified as upper pouch, lower pouch, tubular, or dumbbell. Inter-observer agreement was calculated. Clinical outcomes including weight loss, satiety control, and reflux symptoms were recorded. Comparisons were determined by 1-way ANOVA and t-test. RESULTS: Mean age was 46 ± 12 years and mean BMI was 45.1 ± 6 kg/m(2). Overall inter-observer agreement level for the sleeve shape classification was 76.3%. Sleeve shapes were tubular in 37%, dumbbell in 32%, lower pouch in 22%, and upper pouch in 8%. Mean excess body weight loss at 1, 3, and 6 months was 16.8%, 29.9%, and 39.1%, respectively. Excess body weight loss was not associated with sleeve shape. Mean hunger score was 213 ± 97, and patients with dumbbell shape had higher hunger scores (p = 0.003). Mean reflux score was 5.7 ± 8. Upper pouch shape was associated with greater severity of reflux symptoms (p = 0.02). CONCLUSIONS: This study suggests a standardized radiographic classification of gastric sleeve morphology. Although sleeve shape is not correlated with weight loss, gastric sleeves with retained fundus result in lower satiety control and higher severity of reflux symptoms. An adequate resection of the gastric fundus might avoid this potential complication.

Is there a place for medical students as teachers in the education of junior residents?

BACKGROUND: The aim of this study was to investigate a novel resident education model that turns the traditional surgical hierarchy upside down, termed a "reverse" peer-assisted learning curriculum. METHODS: Thirty surgical topics were randomized between medical students and chief residents on each clinical team, with 1 topic being presented briefly during morning rounds. An exam evaluating junior residents' knowledge of these topics was administered before and after 1 month of presentations. A questionnaire was distributed to evaluate the junior residents' perceptions of this teaching model. RESULTS: Thirty-four residents participated. There was a significant improvement in the mean examination score (54 vs 74, P < .05). No significant difference was noted in the mean score differentials of topics presented by either the medical students or the chief resident (21 vs 18, P = .22). More than 80% of the residents responded positively about the effectiveness of this exercise and agreed that they would like to see this model used on other services. CONCLUSIONS: This study confirms the hypothesis that medical students can teach surgical topics to junior residents at least as effectively as their chief residents.

Pericecal hernia: a rare form of internal hernias.

We report a rare and interesting case of a pericecal hernia. A 34-year-old male presented to the emergency department with severe periumbilical pain, emesis and a prior syncopal episode. He noted a 3-month history of intermittent, colicky periumbilical pain. His abdominal examination demonstrated a palpable mass in the right lower quadrant, involuntary guarding and rebound tenderness. CT demonstrated dilated small-bowel loops and findings suggestive of ischemia. The patient was immediately taken to the operating room where a diagnosis of pericecal hernia was made. The patient underwent a reduction of the hernia and a repair of the mesenteric defect.

Ileal diverticulitis: an uncommon diagnosis for right lower quadrant pain.

We report an interesting case of ileal diverticulitis which posed a diagnostic challenge. A 75-year-old female presented to the emergency department with severe right lower quadrant pain for 3 days. The clinical history, examination and imaging suggested a diagnosis of acute appendicitis. The patient was taken to the operating room for an open appendectomy. The intra-operative findings demonstrated a large mass at the ileocecal junction involving the appendix as well as multiple nodular masses in the ileum and cecum. The patient underwent a right hemicolectomy with ileocecal anastomosis. The pathology result revealed Ileal diverticulitis. Ileal diverticulitis is a rare form of diverticulitis. It can often mimic other processes such as acute appendicitis. Once ileal diverticulitis is diagnosed, it should be treated with the same principles as for sigmoid diverticulitis. Though rare, ileal diverticulitis should be considered in the differential diagnosis of a patient who presents with right lower quadrant pain, and a computed tomography scan that shows an inflammatory process in the right lower quadrant, in the setting of a normal appendix.

Laparoscopic versus open nephrectomy for live kidney donors.

BACKGROUND: Waiting lists for kidney transplantation continue to grow and live organ donation has become more important as the number of brain stem dead cadaveric organ donors continues to fall. The major disincentive to potential kidney donors is the pain and morbidity associated with open surgery. OBJECTIVES: To identify the benefits and harms of using laparoscopic compared to open nephrectomy techniques to recover kidneys from live organ donors. SEARCH METHODS: We searched the online databases CENTRAL (in The Cochrane Library 2010, Issue 2), MEDLINE (January 1966 to January 2010) and EMBASE (January 1980 to January 2010) and handsearched textbooks and reference lists. SELECTION CRITERIA: Randomised controlled trials comparing laparoscopic donor nephrectomy (LDN) with open donor nephrectomy (ODN). DATA COLLECTION AND ANALYSIS: Two review authors independently screened titles and abstracts for eligibility, assessed study quality, and extracted data. We contacted study authors for additional information where necessary. MAIN RESULTS: Six studies were identified that randomised 596 live kidney donors to either LDN or ODN arms. All studies were assessed as having low or unclear risk of bias for selection bias, allocation bias, incomplete outcome data and selective reporting bias. Four of six studies had high risk of bias for blinding. Various different combinations of techniques were used in each study, resulting in heterogeneity in the results. The conversion rate from LDN to ODN ranged from 1% to 1.8%. LDN was generally found to be associated with reduced analgesia use, shorter hospital stay, and faster return to normal physical functioning. The extracted kidney was exposed to longer warm ischaemia periods (2 to 17 minutes) with no associated short-term consequences. ODN was associated with shorter duration of procedure. For those outcomes that could be meta-analysed there were no significant differences between LDN or ODN for perioperative complications (RR 0.87, 95% CI 0.47 to 4.59), reoperations (RR 0.57, 95% CI 0.09 to 3.64), early graft loss (RR 0.31, 95% CI 0.06 to 1.48), delayed graft function (RR 1.09, 95% CI 0.52 to 2.30), acute rejection (RR 1.41, 95 % CI 0.87 to 2.27), ureteric complications (RR 1.51, 95% CI 0.69 to 3.31), kidney function at one year (SMD 0.15, 95% CI -0.11 to 0.41) or graft loss at one year (RR 0.76, 95% CI 0.15 to 3.85). AUTHORS' CONCLUSIONS: LDN is associated with less pain compared with open surgery; however, there are equivalent numbers of complications and occurrences of perioperative events that require further intervention. Kidneys obtained using LDN procedures were exposed to longer warm ischaemia periods than ODN-acquired grafts, although this has not been reported as being associated with short-term consequences.

Renal transplantation with kidneys affected by tumours.

Renal transplantation confers improvement in quality of life and survival when compared to patients on dialysis. There is a universal shortage of organs, and efforts have been made to overcome this shortage by exploring new sources. One such area is the use of kidneys containing small tumours after resection of the neoplasm. This paper looks at the current evidence in the literature and reviews the feasibility of utilizing such a source.

Staples or sutures for chest and leg wounds following cardiovascular surgery.

A best evidence topic in cardiovascular surgery was written according to a structured protocol. The question asked was whether the use of skin sutures or skin staples for chest and leg wounds in patients following cardiovascular surgery reduces the incidence of wound infections. Altogether 119 abstracts were found using the reported search, of which five randomized controlled trials, represented the best evidence on this topic. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We concluded in the five randomized controlled trials in cardiovascular surgery that compared staples with suture closure, three out of five found that the complication rate was lower with sutures and the other two found no difference. With regard to cosmesis, two of the five studies found sutures to be superior and the remaining papers found no difference. We conclude that sutured skin closure for leg and chest wounds is superior to stapled closure.

Should chest drains be put on suction or not following pulmonary lobectomy?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether the use of suction applied to chest drains in patients undergoing lobectomy reduces the incidence of prolonged air leak. Altogether 391 papers were found using the reported search, of which 6 represented the best evidence on this topic, including 5 well conducted prospective randomised controlled trials. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that of the 6 studies presented, no studies found in favour of suction to reduce the incidence of air leak, 2 studies found no difference between the two strategies, and 4 studies found evidence that water seal drainage without suction reduced the incidence of air leak. Five of the 6 studies used a short period of suction in the immediate post-operative period and the one study looking at immediate water seal drainage found no differences in outcome. Exceptions to the water seal strategy may be patients with a large air leak, or a large pneumothorax on CXR.

Does magnesium prophylaxis reduce the incidence of atrial fibrillation following coronary bypass surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether prophylactic magnesium reduces the incidence of atrial fibrillation post cardiac surgery. Altogether 113 papers were found using the reported search, of which 21 represented the best evidence on this topic. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses were tabulated. We conclude that prophylactic magnesium reduces the incidence of arrhythmias post cardiac surgery with a number needed to treat of only 13 to prevent an episode of supraventricular arrhythmia.

Continuous subglottic suction is effective for prevention of ventilator associated pneumonia.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether subglottic suction is an effective preventative measure for ventilator associated pneumonia (VAP) after cardiac surgery. Altogether 457 papers were found using the reported search, of which 13 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude Subglottic suction significantly reduces the incidence of VAP in high risk patients (NNT of 8 if ventilated over 3 days), although the benefit is lower in elective cardiac patients. Subglottic suction is currently not commonly used, but even with marginal benefits, its use is likely to be highly cost effective.

Is sympathectomy of benefit in critical leg ischaemia not amenable to revascularisation?

A best evidence topic in vascular surgery was written according to a structured protocol. The question addressed was whether the use of sympathectomy was of benefit in non-revascularisable critical leg ischaemia. Altogether 387 papers were found using the reported search, of which 13 represented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses were tabulated. We conclude that lumbar sympathectomy is a minimally invasive procedure with a low complication rate. Randomized controlled trials have failed to identify any objective benefits for lumbar sympathectomy, but subjective improvements in symptoms for patients with highly symptomatic critical leg ischaemia have been consistently demonstrated in multiple cohort studies with sustained symptom improvements in approximately 60% of patients. Lumbar sympathectomy should be considered for symptomatic patients with critical leg ischaemia as an alternative to amputation in patients with otherwise viable limbs.

Is transmyocardial revascularisation of benefit in addition to coronary artery bypass grafting for patients with diffuse coronary disease?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the use of transmyocardial revascularisation (TMR) in addition to coronary artery bypass grafting (CABG) is of benefit in patients with ischaemic heart disease with areas of ungraftable myocardium. Altogether 233 papers were found using the reported search, of which 9 represented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses were tabulated. We conclude that while the society of thoracic surgeons now recommend TMR+CABG, and the available studies indicate that mortality is not increased by this additional procedure, it is currently not clear whether TMR reduces symptoms of angina in addition to CABG alone.

Is transmyocardial revascularisation of benefit to people with 'no option' angina?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the use of transmyocardial revascularisation is of benefit in patients with severe angina but ungraftable areas of myocardium. Altogether 345 papers were found using the reported search, of which 11 represented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses were tabulated. We conclude that in selected stable patients with 'no option' CCS grade III-IV angina, TMR can significantly reduce the grade of angina at the cost of a perioperative mortality of around 5%.