Morbidity and Mortality After Laparoscopy-Assisted Distal Gastrectomy and Totally Laparoscopic Distal Gastrectomy to Treat Gastric Cancer: An Interim Report: A Phase III Multicenter, Prospective, Randomized Trial (The KLASS-07 Trial).

PURPOSE: We conducted a randomized prospective trial (KLASS-07 trial) to compare laparoscopy-assisted distal gastrectomy (LADG) and totally laparoscopic distal gastrectomy (TLDG) for gastric cancer. In this interim report, we describe short-term results in terms of morbidity and mortality. METHODS AND METHODS: The sample size was 442 participants. At the time of the interim analysis, 314 patients were enrolled and randomized. After excluding patients who did not undergo planned surgeries, we performed a modified per-protocol analysis of 151 and 145 patients in the LADG and TLDG groups, respectively. RESULTS: The baseline characteristics, including comorbidity status, did not differ between the LADG and TLDG groups. Blood loss was somewhat higher in the LADG group, but statistical significance was not attained (76.76±72.63 vs. 62.91±65.68 mL; P=0.087). Neither the required transfusion level nor the operation or reconstruction time differed between the 2 groups. The mini-laparotomy incision in the LADG group was significantly longer than the extended umbilical incision required for specimen removal in the TLDG group (4.79±0.82 vs. 3.89±0.83 cm; P<0.001). There were no between-group differences in the time to solid food intake, hospital stay, pain score, or complications within 30 days postoperatively. No mortality was observed in either group. CONCLUSIONS: Short-term morbidity and mortality rates did not differ between the LADG and TLDG groups. The KLASS-07 trial is currently underway. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03393182.

A novel technique for the single-port laparoscopic percutaneous extraperitoneal closure (SLPEC) of paediatric isolated giant inguinal hernias using double-modified hernia needles.

The objective was to explore the efficacy of single-port laparoscopic percutaneous extraperitoneal closure using double-modified hernia needles with hydrodissection (SLPEC group) and two-port laparoscopic percutaneous extraperitoneal closure (TLPEC group) for the treatment of giant indirect inguinal hernias in children. We performed a retrospective review of all children with giant indirect inguinal hernias (inner ring orifice diameter ≥ 1.5 cm) who underwent laparoscopic high ligation of the hernia sac at FuJian Children's Hospital from January 2019 to December 2021. We collected data from the medical records of all the children and analysed their clinical characteristics and operation-related and follow-up information. Overall, this study included a cohort of 219 patients with isolated giant inguinal hernias who had complete clinical data and who had undergone laparoscopic high ligation of the hernia sac at our centre. All procedures were successfully performed for the 106 patients who underwent SLPEC and for the 113 patients who underwent TLPEC at our centre. There were no statistically significant differences in patient age, sex, body weight, follow-up time or the side of inguinal hernia between the SLPEC group and the TLPEC group (P = 0.123, 0.613, 0.121, 0.076 and 0.081, respectively). However, there were significant differences in the bleeding volume, visual analogue scale (VAS) score, and postoperative activity time between the two groups (P ≤ 0.001). The operation times in the TLPEC group were significantly longer than those in the SLPEC group (P = 0.048), but there were no significant differences in hospital length of stay or hospitalization costs between the two groups (P = 0.244 and 0.073, respectively). Incision scars were found in 2 patients in the SLPEC group and 9 patients in the TLPEC group, and there was a significant difference between the two groups (P = 0.04). However, the incidence of ipsilateral hernia recurrence, surgical site infection, suture-knot reactions and chronic inguinodynia did not significantly differ between the two groups (P = 0.332, 0.301, 0.332 and 0.599, respectively). Postoperative hydrocele occurred in only 1 male child in the SLPEC group and in no male children in the TLPEC group, and there was no difference between the two groups (P = 0.310). In this study, there were no cases of testicular atrophy or iatrogenic ascent of the testis. Compared with the TLPEC group, the SLPEC group had the advantages of a concealed incision, light scarring, minimal invasiveness, a reduced operation time, minimal bleeding, mild pain and rapid recovery. In conclusion, SLPEC using double-modified hernia needles with hydrodissection and high ligation of the hernia sac is a safe, effective and minimally invasive surgery. The cosmetic results are impressive, and the follow-up results are promising.

Laparoscopic Pancreatoduodenectomy: Twenty years later, where are we?

In its 20th anniversary, laparoscopic pancreatoduodenectomy, while feasible and safe in the hands of experienced surgeons, has not seen the anticipated popularity observed in other digestive surgery procedures. The primary hurdle remains the absence of a clear advantage over traditional open surgery, paired with the procedures complexity and a consequent steep learning curve. In regions with limited pancreatic surgery services, conducting this procedure without adequate training can have serious repercussions. Given the advent of robotic platforms and the anticipation of prospective and randomized studies on this new technology, it is imperative to engage in comprehensive discussions, endorsed by surgical societies, on the value, application, and implementation strategies for various minimally invasive pancreatoduodenectomy techniques. Such dialogue is crucial for advancing the field and ensuring optimal patient outcomes.

Evaluation of the effect of trendelenburg position duration on intracranial pressure in laparoscopic hysterectomies using ultrasonographic optic nerve sheath diameter measurements.

BACKGROUND: During laparoscopic surgery, pneumoperitoneum and Trendelenburg positioning applied to provide better surgical vision can cause many physiological changes as well as an increase in intracranial pressure. However, it has been reported that cerebral autoregulation prevents cerebral edema by regulating this pressure increase. This study aimed to investigate whether the duration of the Trendelenburg position had an effect on the increase in intracranial pressure using ultrasonographic optic nerve sheath diameter (ONSD) measurements. METHODS: The near infrared spectrometry monitoring of patients undergoing laparoscopic hysterectomy was performed while awake (T0); at the fifth minute after intubation (T1); at the 30th minute (T2), 60th minute (T3), 75th minute (T4), and 90th minute (T5) after placement in the Trendelenburg position; and at the fifth minute after placement in the neutral position (T6). RESULTS: The study included 25 patients. The measured ONSD values were as follows: T0 right/left, 4.18±0.32/4.18±0.33; T1, 4.75±0.26/4.75±0.25; T2, 5.08±0.19/5.08±0.19; T3, 5.26±0.15/5.26±0.15; T4, 5.36±0.11/5.37±0.12; T5, 5.45±0.09/5.48±0.11; and T6, 4.9±0.24/4.89±0.22 ( p < 0.05 compared with T0). ). No statistical difference was detected in all measurements in terms of MAP, HR and ETCO2 values compared to the T0 value (p > 0.05). CONCLUSIONS: It was determined that as the Trendelenburg position duration increased, the ONSD values ​​increased. This suggests that as the duration of Trendelenburg positioning and pneumoperitoneum increases, the sustainability of the mechanisms that balance the increase in intracranial pressure becomes insufficient. TRIAL REGISTRATION: This study was registered at Clinical Trials.gov on 21/09/2023 (registration number NCT06048900).

Are the complications after laparo-assisted endo-rectal pull-through for Hirschsprung disease related to the change of the anal tone?

The main advantage of the laparo-assisted transanal endorectal pull-through technique (LA - TERPT) for Hirschsprung Disease (HD) is the respect to the rectal-anal anatomy. Postoperative complications have been observed recently. The present study aims to determine how often these postoperative complications occur in these patients. From January 2009 to December 2018, a retrospective analysis was conducted on 36 children (25 males) with HD who underwent LA-TERPT. Data were collected on the age of diagnosis and surgery, sex, the presence of other pathologies, and cases of enterocolitis. In all cases, anorectal manometry (ARM) was performed to evaluate the anal tone. The median age at diagnosis was 2 months and the mean age at surgery was 5 months. Nine related pathologies were identified: five cases of Down syndrome, one case of hypertrophic stenosis of the pylorus, atresia of the esophagus, polydactyly, and anorectal malformation. A patient with total colonic aganglionosis was identified through laparoscopic serummuscular biopsies. Enterocolitis was diagnosed in 7 cases before and 6 after surgery. At follow-up, the complications recorded were: 5 cases of constipation (treated with fecal softeners), one case of anal stenosis (patient with anorectal malformation), 16 cases of soiling (treated with enemas) and 1 child with fecal incontinence (treated with a transanal irrigation system). The ARM was performed in all 36 cases and showed normal anal tone, except for one case with anal hypotonia. LA-TERPT is an important surgical technique for HD. According to the literature, soiling is the most main complication after HD surgery, probably due to "pseudo-incontinence" with normal anal sphincter tone.

Fully ambulatory robotic single anastomosis duodeno-ileal bypass (SADI): 40 consecutive patients in a single tertiary bariatric center.

BACKGROUND: Single Anastomosis Duodeno-Ileal bypass (SADI) is becoming a key option as a revision procedure after laparoscopic sleeve gastrectomy (LSG). However, its safety as an ambulatory procedure (length of stay < 12 h) has not been widely described. METHODS: A prospective bariatric study of 40 patients undergoing SADI robotic surgery after LSG with same day discharge (SDD), was undertaken in April 2021. Strict inclusion and exclusion criteria were applied and the enhanced recovery after bariatric surgery protocol was followed. Anesthesia and robotic procedures were standardized. Early follow-up (30 days) analyzed postoperative (PO) outcomes. RESULTS: Forty patients (37 F/3 M, mean age: 40.3yo), with a mean pre-operative BMI = 40.5 kg/m2 were operated. Median time after LSG was 54 months (21-146). Preoperative comorbidities included: hypertension (n = 3), obstructive sleep apnea (n = 2) and type 2 diabetes (n = 1). Mean total operative time was 128 min (100-180) (mean robotic time: 66 min (42-85)), including patient setup. All patients were discharged home at least 6 h after surgery. There were four minor complications (10%) and two major complications (5%) in the first 30 days postoperative (one intrabdominal abscess PO day-20 (radiological drainage and antibiotic therapy) and one peritonitis due to duodenal leak PO day-1 (treated surgically)). There were six emergency department visits (15%), readmission rate was 5% (n = 2) and reintervention rate was 2.5% (n = 1) There was no mortality and no unplanned overnight hospitalization. CONCLUSIONS: Robotic SADI can be safe for SDD, with appropriate patient selection, in a high-volume center.

Laparoscopic Management of Pelvic Organ Prolapse: A Case Series.

Background: Pelvic static disorders have an important impact on patients' quality of life, constituting a real public health problem, despite the fact that they are not life-threatening. Minimally invasive procedures of pelvic organ prolapse has many advantages, laparoscopic hysteropexy and colpopexy being a standard with real benefits: minimal incisions, reduced postoperative complications, shorter hospital stay and a low recurrence rate. Laparoscopic management of such cases is recommended, but requires teams well trained in minimally invasive surgery. Case presentation: We presented a series of successful cases of two patients with grade III hysterocele, respectively vaginal vault prolapse, who were treated minimally invasively with a lateral laparoscopic hysteropexy, respectively lateral laparoscopic colpopexy. Given the well-known benefits of minimally invasive surgery, we chose laparoscopic surgery because of the smaller surgical impact and faster return to normal life. The surgical procedures were performed successfully, without complications, with rapid recovery, without recurrence. Conclusion: Hysteropexy and laparoscopic colpopexy are safe and effective surgical procedures in selected cases.

Specific Features of Diagnostic and Treatment Tactics in Patients with Crushed Abdominal Hernias Without Resection of a Hollow Organ.

The purpose of the work is to analyze the results of the use of optimized diagnostic and therapeutic tactics in patients with strangulated abdominal hernias without resection of the hollow organ. Materials and methods: The work is based on the analysis of the results of surgical treatment of 665 patients with strangulated abdominal hernias without resection of the hollow organ, who were divided into 2 groups depending on the features of the diagnostic and treatment tactics. Unlike the patients of group 1, the following diagnostic tactics were used in group 2: substantiated laparoscopic diagnosis of abdominal organs; mandatory biochemical assessment of hernia water; mandatory intraoperative instrumental assessment of the state of the strangulated organ; expansion of indications for the use of laparoscopic interventions and components of the comprehensive Fast track program; substantiated complex prevention of malignancy. The clinical diagnostic algorithm included laboratory, instrumental and biochemical research methods. Results: The use of priority diagnostic and therapeutic tactics in the patients of group 2 allowed to increase the number of laparoscopic hernioplasty by 49.34%, the number of allohernioplasty by 18.62%, among which the "Sublay" technique was preferred for strangulated ventral hernias. This was accompanied by a decrease in the pain syndrome on the VAS scale during the four days of observation, both during coughing and at rest, and amounted to only 2.21 ± 0.29 points on the fourth day when at rest. In addition, and after 12 months, the patients of group 2 observed a better recovery according to the SF-36 questionnaire, which amounted to 76.77±6.63 points for the assessment of the general state of health, 70.81±5.86 points for the assessment of physical functioning, 68.88±5.37 points for the assessment of role functioning due to physical condition, 68.03±5.92 points for the assessment of role functioning due to emotional state, and social activity was characterized by 72.82±5.52 points. Conclusions: 1. The proposed diagnostic and treatment tactics in the patients of group 2 with strangulated abdominal hernias without resection of a hollow organ, in contrast to patients in group 1, made it possible to increase the number of laparoscopic operations to 227 (66.37%) in contrast to 55 (17.03%) in the first group, which was accompanied by a decrease in pain syndrome on the VAS scale on the fourth day when coughing from 4.35 ± 0.38 points to 2.97 ± 0.43 points. 2. The expansion of indications for the use of laparoscopic operations in patients of group 2, in contrast to patients of group 1, led to a decrease in the postoperative complications by 10.48% and the postoperative mortality by 2.29% and was characterized by better postoperative rehabilitation according to the assessment of the patients' condition after 12 months according to the SF-36 questionnaire..

[D2 and D3 lymph node dissection for colon cancer]. / Rezul'taty limfodissektsii d2 i d3 pri rake obodochnoi kishki.

OBJECTIVE: To evaluate surgical and oncological results of standard and extended lymph node dissection (D2 and D3) in patients with colon cancer. MATERIAL AND METHODS: We analyzed treatment outcomes in 74 patients with colon cancer stage T1-4aN0-2M0 who underwent right- and left-sided hemicolectomy, resection of sigmoid colon with standard and extended lymph node dissection (D2 and D3). RESULTS: Surgical approach and level of D3 lymph node dissection did not increase intra- and postoperative morbidity. Laparoscopic interventions were followed by significantly lower intraoperative blood loss and earlier gas discharge. Metastatic lesion of apical lymph nodes was observed in 5 out of 36 patients who underwent D3 lymph node dissection (13.8%), and metastases in regional lymph nodes rN1-2 were found in all these patients. Overall 5-year survival was 86%. Disease-free and overall 5-year survival were similar after D2 and D3 lymph node dissection. CONCLUSION: D3 lymph node dissection is safe for colon cancer. Metastatic lesions of apical lymph nodes during D3 lymph node dissection were detected only in patients with lesions of regional lymph nodes (rN1-2). Disease-free and overall 5-year survival were similar after D2 and D3 lymph node dissection.

[Laparoscopic nephrectomies and kidney resections in children]. / Nachal'nyi opyt laparoskopicheskikh nefrektomii i rezektsii pochek u detei.

OBJECTIVE: To present the experience of laparoscopic nephrectomies and kidney resections in children. MATERIAL AND METHODS: There were 28 minimally invasive surgeries for renal tumors between July 2015 and March 2023 (92 months). There were 16 (57%) boys and 12 (43%) girls who underwent 22 nephrectomies and 6 kidney resections. The median age of patients was 54 (38; 76.5) months. RESULTS: In the laparoscopic nephrectomy group, the median surgery time was 135 (108-188) min, blood loss - 10 (3.75-15) ml. Total resection was confirmed in all patients. In the group of minimally invasive kidney resections, these values were 182.5 (157.5; 265) min and 50 (42.5; 117.5) ml, respectively. Histological examination confirmed total resection in all patients. In both groups, none patient developed postoperative complications. Event-free survival was 86.72% with a median follow-up of 82 months, and local recurrence-free survival was 95.8% with a median follow-up of 89.8 months. CONCLUSION: Minimally invasive nephrectomies and resections are safe in children in case of careful patient selection.

Real-Time Tool Localization for Laparoscopic Surgery Using Convolutional Neural Network.

Partially automated robotic systems, such as camera holders, represent a pivotal step towards enhancing efficiency and precision in surgical procedures. Therefore, this paper introduces an approach for real-time tool localization in laparoscopy surgery using convolutional neural networks. The proposed model, based on two Hourglass modules in series, can localize up to two surgical tools simultaneously. This study utilized three datasets: the ITAP dataset, alongside two publicly available datasets, namely Atlas Dione and EndoVis Challenge. Three variations of the Hourglass-based models were proposed, with the best model achieving high accuracy (92.86%) and frame rates (27.64 FPS), suitable for integration into robotic systems. An evaluation on an independent test set yielded slightly lower accuracy, indicating limited generalizability. The model was further analyzed using the Grad-CAM technique to gain insights into its functionality. Overall, this work presents a promising solution for automating aspects of laparoscopic surgery, potentially enhancing surgical efficiency by reducing the need for manual endoscope manipulation.

Modifications of surgical techniques in laparoscopic percutaneous extraperitoneal closure of inguinal ring for childhood inguinal hernia to achieve zero recurrence and zero subcutaneous stitch granuloma.

PURPOSE: To present our technical modifications of single incision laparoscopic percutaneous extraperitoneal closure (SILPEC) of the internal inguinal ring (IIR) for pediatric inguinal hernia (PIH). METHODS: The prospectively collected data of all children diagnosed with PIH undergoing SILPEC at our center from 2016 to 2023 were reviewed and divided into two groups for result comparison: Group A: before and Group B: after the implementation of full modifications. Our modifications included using a nonabsorbable monofilament suture, creating a peritoneal thermal injury at the internal inguinal ring (IIR), employing a cannula to ensure the suture at the IIR ligates only the peritoneum, and double ligation of the IIR in selected cases. RESULTS: 1755 patients in group A and in group B (1 month to 14 years old) were enrolled. There were no significant differences regarding baseline patient characteristics between the two groups. At a median follow-up of 40 months, the rate of recurrent CIH and subcutaneous stitch granuloma (SSG) was 2.3% and 1.5% in group A vs. 0% and 0% in group B (p < 0.001). There were no hydroceles, no ascended or atrophic testis. CONCLUSIONS: Our SILPEC technical modifications can achieve zero recurrence and zero SSG for PIH.

Comparison of outcomes after unplanned conversion for patients undergoing robotic when compared with laparoscopic colectomy.

The robotic approach improves the feasibility of minimally invasive colectomy even where there may be an anatomic challenge with laparoscopy. Whether a failure in completing colectomy with this newer technology is associated with worse consequences needs to be considered when evaluating the relative benefit of robotic colectomy. The aim of this study is to evaluate rates of conversion to open surgery after robotic and laparoscopic colectomy and whether outcomes after conversion vary after the two techniques since this has not been well studied. From the American College of Surgeons (ACS) - National Surgical Quality Improvement Program (NSQIP) (2015-2016), patients who underwent elective minimally invasive colectomy were identified. Converted robotic were compared to laparoscopic procedures for patient demographics, co-morbidities; primary procedure and diagnosis, prolonged operation and postoperative complications. Of 36,046 colectomy procedures, 30,808 (85.5%) were laparoscopic, while 5238 (14.5%) were robotic-assisted. There were 3271 (9.1%) conversions to open surgery (laparoscopic: 2959 [9.6%]; robotic: 312 [6%]). Thirty-day postoperative surgical site infection, anastomotic leak, ileus, sepsis, bleeding requiring transfusion, urinary tract infection, reoperation; pulmonary, renal, cardiac/cerebrovascular complications; readmission, hospital stay, and mortality, were similar between the two groups. However, deep vein thrombosis/pulmonary embolism was higher after robotic conversion (4.5% vs. 2.2%, p = 0.01). Conversion was lower after robotic when compared to laparoscopic colectomy. Converted patients had similar outcomes except for vein thromboembolism which was higher after robotic surgery. Robotic technology seems to improve the feasibility of minimally invasive surgery without negatively affecting safety and efficacy even when conversion is required.

The feasibility and safety of laparoscopic transcystic common bile duct exploration after prior gastrectomy.

The increased incidence of gallstones can be linked to previous gastrectomy (PG). However, the success rate of endoscopic retrograde cholangiopan-creatography after gastrectomy has significantly reduced. In such cases, laparoscopic transcystic common bile duct exploration (LTCBDE) may be an alternative. In this study, LTCBDE was evaluated for its safety and feasibility in patients with PG. We retrospectively evaluated 300 patients who underwent LTCBDE between January 2015 and June 2023. The subjects were divided into 2 groups according to their PG status: PG group and No-PG group. The perioperative data from the 2 groups were compared. The operation time in the PG group was longer than that in the No-PG group (184.69 ±â€…20.28 minutes vs 152.19 ±â€…26.37 minutes, P < .01). There was no significant difference in intraoperative blood loss (61.19 ±â€…41.65 mL vs 50.83 ±â€…30.47 mL, P = .087), postoperative hospital stay (6.36 ±â€…1.94 days vs 5.94 ±â€…1.36 days, P = .125), total complication rate (18.6 % vs 14.1 %, P = .382), stone clearance rate (93.2 % vs 96.3 %, P = .303), stone recurrence rate (3.4 % vs 1.7 %, P = .395), and conversion rate (6.8 % vs 7.0 %, P = .941) between the 2 groups. No deaths occurred in either groups. A history of gastrectomy may not affect the feasibility and safety of LTCBDE, because its perioperative results are comparable to those of patients with a history of No-gastrectomy.

Role of indocyanine green-guided near-infrared fluorescence imaging in identification of the cause of neonatal cholestasis.

To evaluate the efficacy and safety of indocyanine green (ICG)-guided near-infrared fluorescence (NIRF) imaging during surgery to diagnose the cause of neonatal cholestasis (NC). Data on NC patients who underwent both NIRF with ICG and conventional laparoscopic bile duct exploration (the gold standard) at our institute from January 2022 to December 2022 were retrospectively analyzed. The patients' baseline characteristics and liver function outcomes were collected and analyzed, and the diagnostic consistency was compared between the 2 methods. In total, 16 NC patients were included in the study, comprising 8 (50%) male and 8 (50%) female patients, ranging in age from 42 to 93 days, with a median age of 54.4 ±â€…21 days. During surgery, all the patients underwent NIRF with ICG, followed by conventional laparoscopic bile duct exploration. Finally, 15 of the patients were diagnosed with biliary atresia (BA) (1 with type-I BA, and 14 with type-II BA). The other patient was diagnosed with cholestasis. The diagnostic results from fluorescence imaging with ICG were consistent with those from conventional laparoscopic bile duct exploration. ICG-guided NIRF is associated with an easy operation, less trauma, and good safety. Also, its diagnostic accuracy is similar to conventional laparoscopic bile duct exploration.

A phase III randomized clinical trial comparing laparoscopic radical hysterectomy based on open state with abdominal radical hysterectomy in patients with early-stage cervical cancer.

BACKGROUND: Cervical cancer is the fourth most frequently diagnosed cancer and the fourth leading cause of cancer death in women, The standard treatment recommendation for women with early cervical cancer is radical hysterectomy with pelvic lymph node dissection, however, articles published in recent years have concluded that the treatment outcome of laparoscopic surgery for cervical cancer is inferior to that of open surgery. Thus, we choose a surgically new approach; the laparoscopic cervical cancer surgery in the open state is compared with the traditional open cervical cancer surgery, and we hope that patients can still have a good tumor outcome and survival outcome. This trial will investigate the effectiveness of laparoscopic cervical cancer surgery in the open-state treatment of early-stage cervical cancer. METHOD AND DESIGN: This will be an open-label, 2-armed, randomized, phase-III single-center trial of comparing laparoscopic radical hysterectomy based on open state with abdominal radical hysterectomy in patients with early-stage cervical cancer. A total of 740 participants will be randomly assigned into 2 treatment arms in a 1:1 ratio. Clinical, laboratory, ultrasound, and radiology data will be collected at baseline, and then at the study assessments and procedures performed at baseline and 1 week, 6 weeks, and 3 months, and follow-up visits begin at 3 months following surgery and continue every 3 months thereafter for the first 2 years and every 6 months until year 4.5. The primary aim is the rate of disease-free survival at 4.5 years. The secondary aims include treatment-related morbidity, costs and cost-effectiveness, patterns of recurrence, quality of life, pelvic floor function, and overall survival. CONCLUSIONS: This prospective trial aims to show the equivalence of the laparoscopic cervical cancer surgery in the open state versus the transabdominal radical hysterectomy approach for patients with early-stage cervical cancer following a 2-phase protocol. TRIAL REGISTRATION: ChiCTR2300075118. Registered on August 25, 2023.

Comparing the long-term follow-up anal function between robot-assisted and laparoscopic surgery for low rectal cancer: A meta-analysis and systematic review.

BACKGROUND: Robotic-assisted surgery (RAS) is increasingly used for treating low rectal cancer. Its comparative effectiveness against laparoscopic surgery (LAS) in enhancing long-term anal function remains uncertain. METHODS: A meta-analysis was conducted to compare long-term anal function outcomes between patients undergoing RAS and LAS. Meta-regression and sensitivity analyses were performed to assess available evidence. Studies published up to September 2023 in English or Chinese were included. RESULTS: Seven studies were identified. RAS patients exhibited lower low anterior resection syndrome (LARS) scores (standardised mean difference [SMD] = -1.39; 95% confidence interval [CI]: -2.64 to -0.15) and Wexner scores (SMD = -0.74; 95% CI: -1.20 to -0.27) compared with LAS patients. However, RAS did not significantly reduce major LARS risk (odds ratio = 0.85; 95% CI: 0.68-1.04). CONCLUSIONS: RAS slightly improved postoperative anal function compared with LAS. Further studies with large samples are warranted to confirm or update our findings.

Transabdominal pre-peritoneal (TAPP) versus totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair.

BACKGROUND: An inguinal hernia occurs when part of the intestine protrudes through the abdominal muscles. In adults, this common condition is much more likely in men than in women. Inguinal hernia can be monitored by 'watchful waiting', but if symptoms persist or worsen, surgery is usually required, which can be open or laparoscopic. Laparoscopic (keyhole) repair of inguinal hernias in adults is generally performed using either the transabdominal preperitoneal (TAPP) or the totally extraperitoneal (TEP) method. Both methods include the use of mesh placed in front of the peritoneal lining of the abdominal wall, but for the TAPP technique, the abdominal cavity needs to be entered to place the mesh, and for the TEP technique, the whole procedure is done on the outside of the peritoneal lining of the abdominall wall. Whether one method is superior to the other has not been established, and there is debate about their relative benefits and harms. An advantage of TEP is its avoidance of the abdominal cavity; the downside is that it requires a steeper learning curve for clinicians. TAPP is considered simpler and makes it possible to inspect the contralateral side, but TAPP may have a higher risk of visceral injury compared to TEP. This is an update of a Cochrane review first published in 2005. OBJECTIVES: To compare the benefits and harms of laparoscopic TAPP technique versus laparoscopic TEP technique for inguinal hernia repair in adults. SEARCH METHODS: On 25 October 2022, the authors searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library; Ovid MEDLINE(R) Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily, and Ovid MEDLINE(R); and Ovid Embase, for published randomised controlled trials. To identify studies in progress, we searched ClinicalTrials.gov and the WHO International Clinical Trial Registry Platform (ICTRP). SELECTION CRITERIA: All prospective randomised, quasi-randomised, and cluster-randomised trials that compared the laparoscopic TAPP technique with the laparoscopic TEP technique for inguinal hernia repair in adults were eligible for inclusion. We included studies that involved a mix of different types of groin hernia if we could extract data for the inguinal hernias. Studies may have also included a group of participants receiving hernia repair by open surgery, but these groups were not included in our review. DATA COLLECTION AND ANALYSIS: Both review authors independently evaluated trial eligibility, extracted data from included studies, and assessed the risk of bias in the included studies. The review's primary outcomes were serious adverse events, chronic pain (persisting for at least six months after surgery), and hernia recurrence. We also assessed a variety of secondary outcomes at perioperative, early postoperative, and late postoperative time points. We performed statistical analyses using the random-effects model, and expressed the results as odds ratios (ORs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, with their respective 95% confidence intervals (CIs). We used GRADE to assess the certainty of evidence for key outcomes as high, moderate, low or very low. MAIN RESULTS: We included 23 studies in this review update, which randomised 1156 people to TAPP and 1110 people to TEP, all requiring repair of inguinal hernias. Study sample sizes varied from 40 to 316 participants. The vast majority of study participants were male. We judged most studies to be at 'high' or 'unclear' risk of bias. Our judgements of the certainty of the evidence were low or very low for all outcomes we assessed. There may be little to no difference between TAPP and TEP laparoscopic techniques for serious adverse events (0.4% versus 0.7%; OR 0.58, 95% CI 0.15 to 2.32, P = 0.45, I2 = 0%; 19 studies, 1735 participants; low certainty of evidence); and hernia recurrence (1.2% versus 1.1%; OR 1.14, 95% CI 0.49 to 2.62, P = 0.97, I2 = 0%; 17 studies, 1712 participants; low certainty of evidence). The evidence is very uncertain about the effects of TAPP versus TEP techniques on chronic pain (OR 0.62, 95% CI 0.20 to 1.97, P = 0.68, I2 = 0%; 6 studies, 860 participants; very low certainty of evidence). In terms of secondary outcomes, the evidence is very uncertain for TAPP versus TEP techniques for perioperative visceral and vascular injury (15 studies, 1523 participants; very low certainty of evidence), and for haematoma or seroma during the early (≤ 30 days) postoperative phase (OR 0.86, 95% CI 0.54 to 1.37, P = 0.3861, I2 = 0%; 15 studies, 1423 participants; very low certainty of evidence). TEP technique may carry a higher risk of conversion to another hernia repair method (either TAPP technique or open surgery) when compared to TAPP (2.5% versus 0.7%; OR 0.28, 95% CI 0.09 to 0.84, P = 0.02, I2 = 0%; 13 studies, 1178 participants; low certainty of evidence). Only two studies (474 participants) reported quality of life in the late (> 30 days) postoperative phase; overall, there was an improvement in quality of life from the pre- to post-operative assessment, but the evidence suggests little to no difference between the techniques (low certainty of evidence). AUTHORS' CONCLUSIONS: This review update found that there may be little to no difference between the TAPP and TEP techniques for serious adverse events, hernia recurrence, or chronic pain (low- to very-low-certainty evidence). Decisions about which method to use will most likely reflect surgeon and patient preference until high-certainty evidence becomes available. There may be a higher risk of needing to convert from TEP to TAPP or open surgery when compared to the risk of needing to convert from TAPP to open surgery (low-certainty evidence). If surgeons opt for TEP as their standard laparoscopic method, they could consider having a strategy for how to handle the potential need for conversion. This might include proficiency in the TAPP approach or having informed the patient about the risk of conversion to open surgery. For surgeons or surgical departments, the choice of a laparoscopic technique should involve shared decision-making with patients and their families or carers. Future research could focus on patient-reported outcomes, such as quality of life.

High peritoneal incision approach in endoscopic transabdominal preperitoneal patch plasty (TAPP) for inguinal hernia after radical prostatectomy.

BACKGROUND: Inguinal hernia develops as one of the common complications after robotic or laparoscopic radical prostatectomy (RP). Transabdominal preperitoneal patch plasty (TAPP) for an inguinal hernia after RP is difficult to perform due to postoperative severe adhesions in the preperitoneal cavity. We have introduced a high peritoneal incision approach (HPIA) in TAPP for inguinal hernia patients in whom peritoneal dissection is difficult due to severe adhesions after RP. We evaluate the safety and efficacy of TAPP with a HPIA for patients with an inguinal hernia after robot-assisted RP (RARP). METHODS: Patients characteristics and surgical outcome were evaluated by a retrospective analysis. RESULTS: From January 2014 to December 2017, 21 consecutive patients underwent TAPP for an inguinal hernia after RARP. Twenty-four lesions were the type 3b and three were type 3a according to the Nyhus classification. A circular incision TAPP was performed for 10 hernia lesions in eight patients and TAPP with HPIA was utilized for 17 lesions in 13 patients. The mean operation time for the unilateral hernia in the HPIA (137.8 ± 20.7 min) was significantly shorter than that (182.2 ± 42.0 min) in the circular incision TAPP (p = .038). The HPIA was complete in all patients, while the circular incision TAPP was converted to intraperitoneal onlay mesh (IPOM)intraperitoneal onlay mesh in five patients (55.6%, p = .008) due to dense adhesions with difficult dissection. No recurrent was observed after follow-up period of 48 months in both groups. CONCLUSIONS: The TAPP with HPIA is feasible and a safe and reliable treatment of choice in patients with an inguinal hernia after RARP.