Factors prolonging the operative time for transumbilical laparoscopic-assisted appendectomy in pediatric patients: a retrospective single-center study.

PURPOSE: Transumbilical laparoscopic-assisted appendectomy (TULAA) is one of the first endoscopic surgeries performed by trainee pediatric surgeons. While the operative time is generally shorter than for conventional laparoscopic appendectomy, the indications for this procedure are unclear and many unknown factors can prolong the operative time. We conducted this study to identify the factors that may prolong the operative time for TULAA. METHODS: This retrospective, single-center study was conducted between 2015 and 2023. We performed multivariate analysis to identify the factors associated with prolonged operative time by analyzing TULAA procedures performed by trainees. RESULTS: The study included 243 patients. The median operative time was 84 min (interquartile range, 69-114 min). Multivariate analysis revealed that an increased body mass index, elevated C-reactive protein level, a history of conservative treatment for acute appendicitis, and appendix perforation, for the patient; < 6 years' experience since graduation for the operating surgeon; and lack of board certification as a supervisor from the Japanese Society of Pediatric Surgeons for the attending surgeon were independent risk factors for prolonging the operative time. CONCLUSION: Having an attending surgeon with board certification as a supervisor by the Japanese Society of Pediatric Surgeons contributes to reducing the operative time required for TULAA.

Surgeon Preference and Clinical Outcome of 3D Vision Compared to 2D Vision in Laparoscopic Surgery: Systematic Review and Meta-Analysis of Randomized Trials.

Objective: To assess the added value of 3-dimensional (3D) vision, including high definition (HD) technology, in laparoscopic surgery in terms of surgeon preference and clinical outcome. Background: The use of 3D vision in laparoscopic surgery has been suggested to improve surgical performance. However, the added value of 3D vision remains unclear as a systematic review of randomized controlled trials (RCTs) comparing 3D vision including HD technology in laparoscopic surgery is currently lacking. Methods: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines with a literature search up to May 2023 using PubMed and Embase (PROSPERO, CRD42021290426). We included RCTs comparing 3D versus 2-dimensional (2D) vision in laparoscopic surgery. The primary outcome was operative time. Meta-analyses were performed using the random effects model to estimate the pooled effect size expressed in standard mean difference (SMD) with corresponding 95% confidence intervals (CIs). The level of evidence and quality was assessed according to the Cochrane risk of bias tool. Results: Overall, 25 RCTs with 3003 patients were included. Operative time was reduced by 3D vision (-8.0%; SMD, -0.22; 95% CI, -0.37 to -0.06; P = 0.007; n = 3003; 24 studies; I 2 = 75%) compared to 2D vision. This benefit was mostly seen in bariatric surgery (-16.3%; 95% CI, -1.28 to -0.21; P = 0.006; 2 studies; n = 58; I 2 = 0%) and general surgery (-6.7%; 95% CI, -0.34 to -0.01; P = 0.036; 9 studies; n = 1056; I 2 = 41%). Blood loss was nonsignificantly reduced by 3D vision (SMD, -0.33; 95% CI, -0.68 to 0.017; P = 0.060; n = 1830; I 2 = 92%). No differences in the rates of morbidity (14.9% vs 13.5%, P = 0.644), mortality (0% vs 0%), conversion (0.8% vs 0.9%, P = 0.898), and hospital stay (9.6 vs 10.5 days, P = 0.078) were found between 3D and 2D vision. In 15 RCTs that reported on surgeon preference, 13 (87%) reported that the majority of surgeons favored 3D vision. Conclusions: Across 25 RCTs, this systematic review and meta-analysis demonstrated shorter operative time with 3D vision in laparoscopic surgery, without differences in other outcomes. The majority of surgeons participating in the RCTs reported in favor of 3D vision.

Robotic-assisted cholecystectomy versus conventional laparoscopic cholecystectomy for benign gallbladder disease: a systematic review and meta-analysis.

Laparoscopic cholecystectomy (LC) is the established gold standard treatment for benign gallbladder diseases. However, robotic cholecystectomy is still controversial. Therefore, we aimed to compare intraoperative and postoperative outcomes in LC and robotic-assisted cholecystectomy (RAC) in patients with nonmalignant gallbladder conditions. PubMed, Scopus, Cochrane Library, and Web of Science were systematically searched for studies comparing RAC to LC in patients with benign gallbladder disease. Only randomized trials and non-randomized studies with propensity score matching were included. Mean differences (MDs) were computed for continuous outcomes and odds ratios (ORs) for binary endpoints, with 95% confidence intervals (CIs). Heterogeneity was assessed with I2 statistics. Statistical analysis was performed using Software R, version 4.2.3. A total of 13 studies comprising 22,440 patients were included, of whom 10,758 patients (47.94%) underwent RAC. The mean age was 48.5 years and 65.2% were female. Compared with LC, RAC significantly increased operative time (MD 12.59 min; 95% CI 5.62-19.55; p < 0.01; I2 = 79%). However, there were no significant differences between the groups in hospitalization time (MD -0.18 days; 95% CI - 0.43-0.07; p = 0.07; I2 = 89%), occurrence of intraoperative complications (OR 0.66; 95% CI 0.38-1.15; p = 0.14; I2 = 35%) and bile duct injury (OR 0.99; 95% CI 0.64, 1.55; p = 0.97; I2 = 0%). RAC was associated with an increase in operative time compared with LC without increasing hospitalization time or the incidence of intraoperative complications. These findings suggest that RAC is a safe approach to benign gallbladder disease.

Longer Operative Time for Lower Extremity Bypass Surgery is Associated With Inferior Outcomes.

INTRODUCTION: This study aims to assess the association of operative time with the postoperative length of stay and unplanned return to the operating room in patients undergoing femoral to below knee popliteal bypasses, stratified by autologous vein graft or polytetrafluoroethylene (PTFE). MATERIALS AND METHODS: A retrospective analysis of vascular quality initiative database (2003-2021). The selected patients were grouped into the following: vein bypass (group I) and PTFE (group II) patients. Each group was further stratified by a median split of operative time (i.e., 210 min for autologous vein and 155 min for PTFE) to study the outcomes. The outcomes were assessed by univariate and multivariate approach. RESULTS: Of the 10,902 patients studied, 3570 (32.7%) were in the autologous vein group, while 7332 (67.3%) were in the PTFE group. Univariate analysis revealed autologous vein and PTFE graft recipients that had increased operative times were associated with a longer mean postoperative length of stay and a higher incidence of all-cause return to the operating room. In PTFE group, patients with prolonged operative times were also found to be associated with higher incidence of major amputation, surgical site infection, and cardiovascular events, along with loss of primary patency within a year. CONCLUSIONS: For patients undergoing femoral to below knee popliteal bypasses using an autologous vein or PTFE, longer operative times were associated with inferior outcomes. Mortality was not found to be associated with prolonged operative time.

Greater Risk of Periprosthetic Joint Infection Associated with Prolonged Operative Time in Primary Total Knee Arthroplasty: Meta-Analysis of 427,361 Patients.

Background/Objectives: Periprosthetic joint infection (PJI) is a severe complication in total knee arthroplasty (TKA) with catastrophic outcomes. The relationship between prolonged operative times and PJI remains debated. This meta-analysis investigated the link between prolonged operative times and the risk of PJI in primary TKA. Methods: A comprehensive search of the MEDLINE/PubMed, Cochrane Library, and EMBASE databases was conducted to identify studies comparing the incidence of PJI in TKAs with prolonged versus short operative times, as well as those comparing operative times in TKAs with and without PJI. Pooled standardized mean differences (SMD) in operative times between groups with and without PJI or surgical site infections (SSI), including superficial SSIs and PJIs, were analyzed. Additionally, the pooled odds ratios (OR) for PJI in TKAs with operative times exceeding 90 or 120 min were examined. Results: Seventeen studies involving 427,361 patients were included. Significant differences in pooled mean operative times between the infected and non-infected TKA groups were observed (PJI, pooled SMD = 0.38, p < 0.01; SSI, pooled SMD = 0.72, p < 0.01). A higher risk of PJI was noted in surgeries lasting over 90 or 120 min compared to those of shorter duration (90 min, pooled OR = 1.50, p < 0.01; 120 min, pooled OR = 1.56, p < 0.01). Conclusions: An association between prolonged operative time and increased risk of PJI in primary TKA has been established. Strategies for infection prevention should encompass thorough preoperative planning aimed at minimizing factors that contribute to prolonged operative times.

Anatomical factor associated with thoracic procedural difficulty in robot-assisted minimally invasive esophagectomy.

BACKGROUND: Robotic surgical systems with full articulation of instruments, tremor filtering, and motion scaling can potentially overcome the procedural difficulties in endoscopic surgeries. However, whether robot-assisted minimally invasive esophagectomy (RAMIE) can overcome anatomical difficulties during thoracoscopic esophagectomy remains unclear. This study aimed to clarify the anatomical and clinical factors that influence the difficulty of RAMIE in the thoracic region. METHODS: Forty-five patients who underwent curative-intent RAMIE with upper mediastinal lymph node dissection for esophageal cancer were included. Using preoperative computed tomography images, we calculated previously reported anatomical indices to assess the upper mediastinal narrowness and vertebral body projections in the middle thoracic region. The factors influencing thoracic operative time were then investigated. RESULTS: During the thoracic procedure, the median operative time was 215 (124-367) min and the median blood loss was 20 (5-190) mL. Postoperatively, pneumonia, anastomotic leakage, and recurrent laryngeal nerve palsy occurred in 17.8%, 2.2%, and 6.7% of the patients, respectively. The multiple linear regression model revealed that a narrow upper mediastinum and greater blood loss during the thoracic procedure were significant factors associated with a prolonged thoracic operative time (P = 0.025 and P < 0.001, respectively). Upper mediastinal narrowing was not associated with postoperative complications. CONCLUSIONS: A narrow upper mediastinum was significantly associated with a prolonged thoracic operative time in patients with RAMIE.

Nitinol Staple Use in Primary Arthrodesis of Lisfranc Fracture-Dislocations.

BACKGROUND: Primary arthrodesis of Lisfranc fracture-dislocations is a reliable treatment option, yet concerns remain about nonunion. Nitinol staple use has recently proliferated in midfoot arthrodesis. The purpose of this study is to examine the union rate of primary arthrodesis of acute Lisfranc fracture-dislocations treated with nitinol staples compared with traditional plate-and-screw fixation. The secondary objective is to assess the difference in operative times and reoperation rates. METHODS: Midfoot fracture-dislocations treated with primary arthrodesis by 7 foot and ankle orthopaedic surgeons were reviewed. Of 160 eligible patients, 121 patients (305 joints) met the required 4-month minimum radiographic follow-up. Radiographic outcomes were analyzed at the individual joint level. Each joint was classified as either staples alone (45 patients, 154 joints), staples plus plates and screws (hybrid) (45 patients, 40 joints), or plates and screws alone (31 patients, 111 joints). The primary outcome was arthrodesis union at each joint fused. RESULTS: Nonunion was more common (9.0%, 10/111) among joints fixed with plate and screws than with hybrid (2.5%, 1/40) or staples only (1.3%, 2/154) (P = .0085). Multivariable regression demonstrated that autograft use was independent associated with union (P = .0035) and plate-and-screw only fixation was an independent risk factor for nonunion (P = .0407). Median operating room and tourniquet times were shorter for hybrid (92 and 83 minutes) and staple only (67 and 63 minutes) constructs compared to plate-and-screw only fixation (105 and 95 minutes) (P ≤ .0001 and .0003). There was no difference in reoperation rates among patients with different fixation types. CONCLUSION: We found that use of nitinol compression staple and bone autograft in primary arthrodesis of Lisfranc and midfoot fracture-dislocations was associated with both improved union rates and shorter tourniquet and operative times compared to traditional plate-and-screw fixation techniques. LEVEL OF EVIDENCE: Level III, therapeutic.

A Novel Endoscopic Approach for Treating Breast Cancer: Haigui-1 Hole.

OBJECTIVE: Endoscopic surgery is an effective technique for preserving the nipple and areola, as well as for sentinel lymph node biopsy and breast implant reconstruction. However, the technical challenges associated with endoscopic surgery have limited its widespread adoption. METHODS: In the normal single-port endoscopic surgery, the ultrasonic knife was accessed through the retractor. In our modified procedure, a tiny 5 mm incision was made at the lateral margin underneath the breast, serving as the second entry port for the ultrasonic scalpel, which was referred to as the "Haigui-1 hole". Preoperative and postoperative indicators such as blood loss, operative time, and postoperative drainage volume were collected. Differences between parameters were compared using Student's t test. RESULTS: Endoscopic surgery with the assistance of the "Haigui-1 hole" led to preserved breast aesthetics with minimal scarring. Moreover, "Haigui-1 hole" surgery significantly reduced the operation time, intraoperative bleeding, and postoperative drainage volume compared to normal single-port endoscopic surgery. CONCLUSION: The "Haigui-1 hole" procedure, which involves the addition of a second entrance to improve the maneuverability of the ultrasonic knife, is worthy of further promotion.

Three-Dimensional Reconstruction Computed Tomography in Thoracoscopic Segmentectomy: A Randomized Controlled Trial.

OBJECTIVES: Thoracoscopic segmentectomy is the recommended treatment option for small peripheral pulmonary nodules. To assess the ability of preoperative 3D reconstruction CT to shorten the operative time and improve perioperative outcomes in thoracoscopic segmentectomy compared with standard chest CT, we conducted this randomized controlled trial. METHODS: The DRIVATS study was a multicentre, randomized controlled trial conducted in three hospitals between July 2019 and November 2023. Patients with small peripheral pulmonary nodules not reaching segments borders were randomized in a 1:1 ratio to receive either 3D reconstruction CT or standard chest CT before thoracoscopic segmentectomy. The primary end-point was operative time. The secondary end-points included incidence of postoperative complications, intraoperative blood loss and operative accident event. RESULTS: A total of 191 patients were enrolled in this study: 95 in the 3D reconstruction CT group and 96 in the standard chest CT group. All patients underwent thoracoscopic segmentectomy except for one patient in the standard chest CT group who received a wedge resection. There is no significant difference in operative time between the 3D reconstruction CT group (median, 100 min [IQR, 85-120]) and the standard chest CT group (median, 100 min [IQR, 81-140]) (P = 0.82). Only one intraoperative complication occurred in the standard chest CT group. No significant difference was observed in the incidence of postoperative complications between the two groups (P = 0.52). Other perioperative outcomes were also similar. CONCLUSIONS: In patients with small peripheral pulmonary nodules not reaching segments borders, the use of 3D reconstruction CT in thoracoscopic segmentectomy was feasible, but it did not result in significant differences in operative time or perioperative outcomes compared to standard chest CT.

Hospital volume-outcome relationships for robot-assisted surgeries: a population-based analysis.

BACKGROUND: Associations between procedure volumes and outcomes can inform minimum volume standards and the regionalization of health services. Robot-assisted surgery continues to expand globally; however, data are limited regarding which hospitals should be using the technology. STUDY DESIGN: Using administrative health data for all residents of Ontario, Canada, this retrospective cohort study included adult patients who underwent a robot-assisted radical prostatectomy (RARP), total robotic hysterectomy (TRH), robot-assisted partial nephrectomy (RAPN), or robotic portal lobectomy using 4 arms (RPL-4) between January 2010 and September 2021. Associations between yearly hospital volumes and 90-day major complications were evaluated using multivariable logistic regression models adjusted for patient characteristics and clustering at the level of the hospital. RESULTS: A total of 10,879 patients were included, with 7567, 1776, 724, and 812 undergoing a RARP, TRH, RAPN, and RPL-4, respectively. Yearly hospital volume was not associated with 90-day complications for any procedure. Doubling of yearly volume was associated with a 17-min decrease in operative time for RARP (95% confidence interval [CI] - 23 to - 10), 8-min decrease for RAPN (95% CI - 14 to - 2), 24-min decrease for RPL-4 (95% CI - 29 to - 19), and no significant change for TRH (- 7 min; 95% CI - 17 to 3). CONCLUSION: The risk of 90-day major complications does not appear to be higher in low volume hospitals; however, they may not be as efficient with operating room utilization. Careful case selection may have contributed to the lack of an observed association between volumes and complications.

Active nerve management for above the knee amputation: A comparison of through the wound versus posterior approach.

Targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) are used to prevent or treat neuromas in amputees. TMR for above-the-knee amputation (AKA) is most commonly performed through a posterior incision rather than the stump wound because recipient motor nerves are primarily located in the proximal third of the thigh. When preventative TMR is performed with concurrent AKA, a posterior approach requires intraoperative repositioning and an additional incision. The purpose of this study was to evaluate feasibility of TMR and operative times for nerve management performed through the wound compared to a posterior approach in AKA patients to guide surgical decision-making. Patients who underwent AKA with TMR between 2018-2023 were reviewed. Patients were divided into two groups: TMR performed through the wound (Group I) and TMR performed through a posterior approach (Group II). If a nerve was unable to undergo coaptation for TMR due to the lack of suitable donor motor nerves, RPNI was performed. Eighteen patients underwent AKA with nerve management were included from Group I (8 patients) and Group II (10 patients). TMR coaptations performed on distinct nerves was 1.5 ± 0.5 in Group I compared to 2.6 ± 0.5 in Group II (p = 0.001). Operative time for Group I was 200.7 ± 33.4 min compared to 326.5 ± 37.1 min in Group II (p = 0.001). TMR performed through the wound following AKA requires less operative time than a posterior approach. However, since recipient motor nerves are not consistently found near the stump, RPNI may be required with TMR whereas the posterior approach allows for more TMR coaptations.

Influence of preoperative antituberculosis chemotherapy duration on perioperative complications in patients treated with epididymectomy for epididymal tuberculosis.

OBJECTIVES: We aimed to investigate the influence of preoperative antituberculosis chemotherapy duration on perioperative epididymectomy complications in patients with epididymal tuberculosis (ETB). METHODS: This retrospective study examined patients with ETB between January 1, 2013, and March 31, 2023, who underwent unilateral epididymectomy at our hospital. We selected preoperative antituberculosis chemotherapy duration of 2, 4, and 8 weeks as the cutoffs for this study, to explore whether there are differences in the incidence of intraoperative and 30-day postoperative complications among the patients with different preoperative antituberculosis chemotherapy durations. Intraoperative complications were graded according to the Satava classification, and 30-day postoperative complications were defined according to the Clavien-Dindo classification. The study groups were compared using the unpaired t-test, Wilcoxon rank-sum test, Pearson's chi-square test, or Fisher's exact test, as appropriate. RESULTS: Overall, 155 patients were included. Statistical analysis revealed that there were no significant differences in the incidence of intraoperative and 30-day postoperative complications between patients with shorter preoperative antituberculosis chemotherapy duration and those with longer preoperative antituberculosis chemotherapy duration. CONCLUSIONS: In patients with ETB, preoperative antituberculosis chemotherapy duration did not significantly affect the incidence of perioperative complications after epididymectomy.

Factors contributing to prolonged operative time for laparoscopic cholecystectomy performed by trainee surgeons: a retrospective single-center study.

PURPOSE: Laparoscopic cholecystectomy for a benign disease is often the initial endoscopic surgery performed by trainee surgeons. However, a lack of surgical experience is associated with prolonged operative times, which may increase the risk of postoperative complications and poor outcomes. This study aimed to identify the factors associated with prolonged operative times for laparoscopic cholecystectomy performed by inexperienced surgeons. METHODS: This retrospective single-center study was conducted between January 2018 and December 2023. We performed a multivariate analysis to identify the factors associated with prolonged operative time by analyzing elective cases of laparoscopic cholecystectomy performed by surgeons with limited experience. RESULTS: The study included 323 patients, subjected to a median operative time of 89 min. Multivariate analysis identified that patient characteristics such as male sex, increased body mass index, and a history of conservative treatment for cholecystitis, as well as operating surgeon's post-graduation years (< 4 years), and an attending surgeon without endoscopic surgical skill certification from the Japan Society of Endoscopic Surgery, were independent risk factors for a prolonged operative time. CONCLUSION: Our findings suggest that endoscopic surgical skill-certified attending surgeons have excellent coaching skills and mitigate the operative time for elective cholecystectomy.

Academic versus Community Retinal Surgery for Primary Retinal Detachment: Characteristics, Duration, and Value Analysis of Teaching Modifier.

PURPOSE: To compare operative time and case characteristics of primary rhegmatogenous retinal detachment (RRD) repairs between academic and community vitreoretinal surgeons. DESIGN: A retrospective, observational clinical study. SUBJECTS: Patients who underwent primary RRD repair surgeries at Massachusetts Eye and Ear between 2019 and 2021. METHODS: A random sample of 20 vitreoretinal surgeons distributed evenly among the academic or community setting was selected. Fifteen consecutive cases of primary RRD repair surgeries were included from each surgeon. A cost analysis was performed for the teaching modifier for the physician fee and for hospital costs. MAIN OUTCOME MEASURES: Length of surgery. RESULTS: Of 300 primary RRD repairs, fellows were present in 75%, which comprised all academic surgeon cases and 50% of community surgeon cases, P < 0.001. Mean operation length was shorter for community surgeon cases without fellows (55.0 ± 24.1) than either academic (73.0 ± 30.8) or community surgeon cases with fellows (75.7 ± 32.5) (P < 0.001). There was a higher percentage of macula-off RRDs in academic versus community surgeon cases (52.7% vs. 38.0%, P = 0.002) and higher rates of combined scleral buckle (SB)/pars plana vitrectomy (PPV) repairs (14% vs. 3%, P < 0.001). When excluding combined SB/PPV cases, there was no difference in operative time between academic and community surgeon cases. Among RRDs repaired by PPV only, there was a 31.4% (16.6 minutes) greater procedure duration in cases with fellows compared with cases without fellows (P < 0.001). Covariates associated with greater surgery time: addition of an SB (ß = 32.6), membrane peel (ß = 18.5), presence of a fellow (ß = 14.5), proliferative vitreoretinopathy (ß = 12.8), and greater number of retinal breaks (ß = 2.4). The teaching modifier adds 16% extra reimbursement ($184.16) to the physician fee, which is 50.9% of what is necessary to cover the percentage increase in surgeon time (31.4%). Using a time-driven activity-based costing for hospital costs, the extra 16.6 minutes leads to an additional $1038.00, which is 5.6 times more than the reimbursement for the modifier. CONCLUSIONS: Retinal detachment repair cases performed by academic surgeons are more likely to be macula-off and include the addition of an SB, which drive longer operative times. Medicare's reimbursement of the assistant modifier in a teaching facility significantly undercompensates the time-driven activity-based costing of trainee participation. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Operative Time and Accrual of Postoperative Complications in Minimally Invasive Versus Open Myomectomy.

STUDY OBJECTIVE: To compare the prevalence and accrual of 30-day postoperative complications by operative time for open myomectomy (OM) and minimally invasive myomectomy (MIM). DESIGN: Retrospective cohort study SETTING: Hospitals participating in the National Surgical Quality Improvement Program database from January 2015 to December 2021. PATIENTS: Female patients aged ≥18 years undergoing OM or MIM. INTERVENTIONS: Patients were categorized into OM and MIM cohorts. Covariates associated with operative time and composite complications were identified using general linear model and chi-square or Fisher's exact test as appropriate. Adjusted spline regression was performed as a test of linearity between operative time and composite complications. Adjusted risk ratios of 30-day postoperative individual, minor, major, and composite complications by 60-minute operative time increments were estimated using Poisson regression with robust error variance. MEASUREMENTS AND MAIN RESULTS: Of 27 728 patients, 11 071 underwent MIM and 16 657 underwent OM. Mean operative times (SD) were 164.6 (82.0) for MIM and 129.2 (67.0) for OM. Raw composite complication rates were 5.5% for MIM and 15.8% for OM. Adjusted spline regression demonstrated linearity between operative time and relative risk of composite postoperative complications for both MIM and OM. MIM had higher adjusted relative risk (aRR, 95% CI) compared to OM of blood transfusion (1.55, 1.45-1.64 versus 1.29, 1.25-1.34), overall minor complications (1.13, 1.03-1.23 versus 1.01, 0.92-1.10), and overall major complications (1.43, 1.35-1.51 versus 1.27, 1.12-1.32). Operative time had greater impact on risk of composite complications for MIM than OM, reaching aRR 2.0 at 296 minutes versus 461 minutes for OM. CONCLUSION: OM has a higher overall rate of composite, minor, and major complications compared to MIM. While operative time is independently and linearly associated with postoperative complications with myomectomy regardless of approach, optimizing surgical efficiency for MIM may be more critical than for OM.

Predictors of surgical difficulty according to surgical proficiency in robot-assisted radical prostatectomy.

BACKGROUND: Robot-assisted radical prostatectomy (RARP) is a standard treatment for localized prostate cancer. We previously reported that a large amount of pelvic visceral fat and a small working space, as measured by three-dimensional image analysis, were significantly associated with prolonged console time in RARP, and these factors could be alternatives to the more clinically practical body mass index (BMI) and pelvic width (PW), respectively. Herein, we further investigated whether surgical proficiency affected surgical difficulty as measured by console time. METHODS: Medical records of 413 patients who underwent RARP between 2014 and 2020 at our institution were reviewed. Surgeons who had experience with over and under 100 cases were defined as "experienced" and "non-experienced," respectively. Multivariate logistic regression analyses were performed to identify factors that prolonged console time. RESULTS: The median console times for RARP by experienced and non-experienced surgeons were 87.5 and 149.0 min, respectively; a difficult case was defined as one requiring time greater than the median. Among inexperienced surgeons, higher BMI (p < 0.001, odds ratio: 1.89) and smaller PW (p = 0.001, odds ratio: 1.86) were significant factors that increased console time; the complication rate was increased in patients with these factors. However, these factors did not significantly affect the console time or complication rate among experienced surgeons. CONCLUSION: This study demonstrates that experienced surgeons may be able to overcome obesity- and small workspace-related surgical difficulties. The current analysis may provide useful information regarding unpredictable surgical risks and identify suitable cases for novices.

Accelerating Fleur-de-lis Panniculectomy with the Absorbable Dermal Stapler-A Study of Efficiency, Aesthetics, and Quality-of-life.

BACKGROUND: Fleur-de-lis panniculectomy (FDL), a contouring technique involving vertical and horizontal tissue resections, often involves longer operative times and potential complications. This study assessed operative time, postoperative outcomes, and patient-reported quality of life (PRO) with Insorb® Absorbable Subcuticular Skin Stapler versus traditional sutures during FDL. METHODS: A retrospective review from 2015 to 2022 of FDL patients excluded those with complex concomitant procedures. Demographics, operative details, and surgical outcomes were compared between patients using the dermal stapler and those with suture-only closures. RESULTS: Forty subjects were identified, with 25 (62.5%) in the dermal stapler cohort. The dermal stapler significantly reduced total procedure time (66.76 vs. 125.33 min, p < 0.05). There were no significant differences in surgical site occurrences, aesthetic outcomes, readmissions, or reoperations. Multivariate regression analysis further highlighted the choice of closure technique as an independent predictor of operative time, with traditional sutures indicating a significantly increased operative time compared to using the dermal stapler (AOR 76.53, CI 38.11-114.95, p < 0.001). Regarding PROs, both groups saw improvements across multiple BODY-Q domains, but the dermal stapler group reported greater enhancements (six out of nine domains vs. three for sutures). CONCLUSION: The absorbable dermal stapler significantly reduces FDL operative time without increasing wound healing or aesthetic dissatisfaction incidents and maintains comparable quality-of-life improvements to standard suture closure. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors https://link.springer.com/journal/00266 .

Efficacy of the 'Five-Needle' method for pancreatojejunostomy in laparoscopic pancreaticoduodenectomy: an observational study.

Objective: The five-needle pancreato-intestinal anastomosis method is used in laparoscopic pancreaticoduodenectomy (LPD). The aim of this study was to explore the clinical efficacy and adverse reactions of this new surgical method and to provide a scientific reference for promoting this new surgical method in the future. Methods: A single-centre observational study was conducted to evaluate the safety and practicality of the five-needle method for pancreatojejunostomy in LPD surgeries. The clinical data of 78 patients who were diagnosed with periampullary malignancies and underwent LPD were collected from the 1st of August 2020 to the 31st of June 2023 at Lanzhou University First Hospital. Forty-three patients were treated with the 'Five-Needle' method (test groups), and 35 patients were treated with the 'Duct-to-Mucosa' method (control group) for pancreatojejunostomy. These two methods are the most commonly used and highly preferred pancreatointestinal anastomosis methods worldwide. The primary outcome was pancreatic fistula, and the incidence of which was compared between the two groups. Results: The incidence of pancreatic fistula in the five-needle method group and the duct-to-mucosa method group was not significantly different (25.6% vs. 28.6%, p=0.767). Additionally, there were no significant differences between the two groups in terms of intraoperative blood loss (Z=-1.330, p=0.183), postoperative haemorrhage rates (p=0.998), length of postoperative hospital stay (Z=-0.714, p=0.475), bile leakage rate (p=0.745), or perioperative mortality rate (p=0.999). However, the operative time in the 'Five-Needle' method group was significantly shorter than that in the 'Duct-to-Mucosa' method group (270 ± 170 mins vs. 300 ± 210 mins, Z=-2.336, p=0.019). Further analysis revealed that in patients with pancreatic ducts smaller than 3 mm, the incidence of pancreatic fistula was lower for the 'Five-Needle' method than for the 'Duct-to-Mucosa' method (12.5% vs. 53.8%, p=0.007). Conclusion: The five-needle method is safe and efficient for pancreatojejunostomy in LPD, and is particularly suitable for anastomosis in nondilated pancreatic ducts. It is a promising, valuable, and recommendable surgical method worthy of wider adoption.

The Learning Curve for Pancreaticoduodenectomy: The Experience of a Single Surgeon.

BACKGROUND AND AIMS: Pancreaticoduodenectomy (PD) is a complex and high-skill demanding procedure often associated with significant morbidity and mortality. However, the results have improved over the past two decades. However, there is a paucity of research concerning the learning curve for PD. Our aim was to report the outcomes of 100 consecutive PDs representing a single surgeon's learning curve and to depict the factors that influenced the learning process. METHODS: We reviewed the first 121 PDs performed at our academic center (2013-2019) by a single surgeon; 110 were PDs (5 laparoscopic and 105 open) and 11 were total PDs (1 laparoscopic and 10 open). Subsequent statistics was performed on the first 100 PDs, with attention paid to the learning curve and survival rate at 5 years. The data were analyzed comparing the first 50 cases (Group 1) to the last 50 cases (Group 2). RESULTS: The most frequent histopathological tumor type was pancreatic ductal adenocarcinoma (50%). A total of 39% of patients had preoperative biliary drainage and 45% presented with positive biliary cultures. The preferred reconstruction technique included pancreaticogastrostomy (99%), in situ hepaticojejunostomy (70%), and precolic gastro-jejunal anastomosis (88%). Postoperative complications included biliary fistula (1%), pancreatic fistula (8%), pancreatic stump bleeding (4%), and delayed gastric emptying (13%). The mean operative time decreased after the first 50 cases (p < 0.001) and blood loss after 60 cases (p = 0.046). R1 resections lowered after 25 cases (p = 0.025). Vascular resections (17%) did not influence the rate of complications (p = 0.8). The survival rate at 5 years for pancreatic adenocarcinoma was 32.93%. CONCLUSIONS: Outcomes improve as surgeon experience increases, with proper training being the most important factor for minimizing the impact of the learning curve over the postoperative complications. Analyzing the learning curve from the perspective of a single surgeon is mandatory for accurate statistical results and interpretation.