Advanced Laparoscopic Surgery

STUDY OBJECTIVE:
To report the detection rate (DR) of sentinel lymph nodes (SLNs) in endometrial cancer (EC) patients after hysteroscopic injection of indocyanine green (ICG) and laparoscopic near-infrared (L-NIR) fluorescence mapping.
DESIGN:
Prospectively collected data (Canadian Task Force classification II-2).
SETTING:
Gynecologic oncology referral center.
PATIENTS:
Consecutive patients with apparent early-stage endometrioid EC scheduled for surgical treatment: total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, SLN mapping.
INTERVENTIONS:
The mapping technique consisted in an intraoperative hysteroscopic peritumoral injection of 5 mg ICG followed by L-NIR fluorescence mapping. Evaluations of the SLN DR and sites of mapping were performed.
MEASUREMENTS AND MAIN RESULTS:
A total of 57 procedures was performed. Patient mean age was 60 years (range, 28-80) and mean body mass index was 28.2 kg/m2 (range, 19-43). At least 1 SLN was detected in 89.5% of the whole population (51/57). After the first 16 cases, L-NIR camera technical improvement led to a 95% DR (39/41). The mean number of harvested SLNs was 4.1 (range. 1-8), and in 47% of cases SLNs mapped to aortic nodes (24/51). Bilateral pelvic mapping was found in 74.5% of cases (38/51). Three patients had SLN metastases: 1 in the pelvic area only, 1 both in the pelvic and aortic area, and 1 presented with 2 metastatic aortic SLNs with negative pelvic SLNs. Overall, 2 of 3 node-positive patients (67%) had aortic SLN involvement. No adverse events were reported.
CONCLUSIONS:
Laparoscopic SLN mapping after the hysteroscopic injection of ICG has comparable DRs with both radioactive tracer series and ICG series with cervical injection, overcoming the need for radioactive substances. Hysteroscopic injection leads to a higher mapping in the aortic area compared with cervical injection. Further investigation is warranted on this topic

Objective
To evaluate the severity of fallopian tubal conditions in patients with previous EP after methotrexate or laparoscopic conservative treatment using the second-look laparoscopy (SLL).

Methods
This was a retrospective clinical study in a university hospital. After reviewing medical records, thirty-eight women with EP were divided into group I (methotrexate therapy) and II (laparoscopic salpingotomy) according to the conservative treatment options they previously received. Then, the secondlook laparoscopy was carried out to evaluate the severity of the fallopian tubal conditions (including integrity, patency and adhesion).

Results
The integrity and patency rates of the treated tubes in group I were 94.12% (16/17) and 52.94% (9/17), higher than those in group II (with 57.69% and 7.69%), respectively. But no difference was found in the adhesion rate of peri homolateral tubes between groups I (41.18%) and II (57.69%).

Conclusion
Our results suggested that conservative medical treatment with MTX by SLL could protect the tubal conditions better than laparoscopic salpingotomy, confirming that methotrexate treatment would be a very good way to preserve the tubes and improve future fertility. The second-look laparoscopy could be recommended to the EP patients with a desire for pregnancy.

Biliary stones that are seen in the Asian population are very different from those seen in the west. It is frequent to see multiple, large, and impacted stones and a hugely dilated Common Bile Duct (CBD). Many of these patients have been managed by open cholecystectomy, even after the advent of Laparoscopic Cholecystectomy (LC) because these large stones pose significant challenges for extraction by endoscopic retrograde cholangio-pancreatography. This study represents an experience of managing intra and extra hepatic bile ducts using a laparoscopic approach. A retrospective data analysis was done during the period of November 2010-April 2015 and correspondingly 85 patients with documented intra and extra hepatic biliary stones were treated laparoscopically at Qilu Hospital under Shandong University, School of Medicine. There were 23 men and 62 women patients with age ranging from 23 to 76 years. The mean diameter of the CBD was 12mm. The number of stones extracted varied from 1 to 35 and the size of the extracted stones from 0.3X0.3X0.3 to 4X3.5X3.5 mm. The average duration of surgery was 170 min. There were 7 conversions to open procedures and 24 patients (29%) had nonfatal postoperative complications. Four patients had retained stones (4.7%). Though patients presented with multiple and impacted CBD stones, laparoscopy presents a unique approach for a minimally invasive procedure with its benefits in the form of laparoscopic intra and extra hepatic bile ducts exploration.

Laparoscopic procedures are routinely performed in most surgical centers today. Surgical site infections at port sites following laparoscopy are not uncommon. However, port site tuberculosis (TB) is a rare complication following a laparoscopic procedure. The possible causes of its development include improper sterilization of instruments, use of tap water containing resistant atypical mycobacteria to clean these instruments before immersion into glutaraldehyde solution; and seeding at the port site due to gall bladder TB. We report here a case of a young female who underwent laparoscopic cholecystectomy outside our hospital and then developed a discharging sinus at the epigastric port site. Three attempts of debridement and wound closure had already been done before and every time there was a recurrence. Sinus tract was excised after getting the sinogram, and the histopathology showed features consistent with TB. The patient was put on anti‑tubercular therapy, and she had no recurrence after 3 months of follow‑up.

PURPOSE:
To evaluate reproductive and maternal-fetal outcomes after integrated approach for endometriosis-associated infertility (EAI).

METHODS:
We retrospectively analyzed reproductive and maternal-fetal outcomes of 277 women affected by EAI, subdividing patients in two groups: in the first one (surgery group), we included all women who underwent laparoscopic surgery for EAI; in the second one (integrated group), we included women who failed to conceive spontaneously after surgery within 6-12 months and underwent in vitro fertilization and embryo transfer (IVF). We evaluated delivery rate (DR), maternal and neonatal outcomes of the first pregnancies, and, finally, the type (spontaneous or IVF) of subsequent pregnancies.

RESULTS:
We did not find significant difference regarding DR between surgery and integrated groups. We found significantly lower birth weight (p < 0.001) and gestational age at delivery (p < 0.001) in integrated group respect to surgery group; conversely, we found higher rate of preterm birth (p < 0.001), small for gestational age (p = 0.003), and admission to the neonatal intensive care unit (p < 0.001) respect to surgery group. Finally, 92 women became pregnant for the second time: 8% were spontaneous and 20% were IVF pregnancies.

CONCLUSIONS:
We suggest the integrated approach as gold standard treatment for carefully selected patients (young, good ovarian reserve, partner with normal semen parameters) affected by EAI. As consequence, IVF should be reserved as the secondary treatment for women who fail to conceive spontaneously after surgery within 6-12 months, since it is able to increase DR significantly.

OBJECTIVES: The aim of this study was to conduct a meta-analysis of randomized evidence to determine the
relative merits of laparoscopic anti-refl ux surgery (LARS) and open anti-refl ux surgery (OARS) for proven gastro-esophageal refl ux disease (GERD).
METHODS: A search of the Medline, Embase, Science Citation Index, Current Contents, and PubMed databases identifi ed all randomized clinical trials that compared LARS and OARS and that were published in the English language between 1990 and 2007. A meta-analysis was carried out in accordance with the QUOROM (Quality of Reporting of Meta-Analyses) statement. The six outcome variables analyzed were operating time, hospital stay, return to normal activity, perioperative complications, treatment failure, and requirement for further surgery. Randomeffects meta-analyses were carried out using odds ratios (ORs) and weighted mean differences (WMDs).
RESULTS: Twelve trials were considered suitable for the meta-analysis. A total of 503 patients underwent
OARS and 533 had LARS. For three of the six outcomes, the summary point estimates favored LARS over OARS. There was a signifi cant reduction of 2.68 days in the duration of hospital stay for the LARS group compared with that for the OARS group (WMD: − 2.68, 95 % confi dence interval (CI): − 3.54 to − 1.81; P < 0.0001), a signifi cant reduction of 7.75 days in return to normal activity for the LARS group compared with that for the OARS group (WMD: − 7.75, 95 % CI: − 14.37 to − 1.14; P = 0.0216), and fi nally, there was a statistically signifi cant reduction of 65 % in the relative odds of complication rates for the LARS group compared with that for the OARS group (OR: 0.35, 95 % CI: 0.16 – 0.75; P = 0.0072). The duration of operating time was signifi cantly longer (39.02 min) in the LARS group (WMD: 39.02, 95 % CI: 17.99 – 60.05; P = 0.0003). Treatment failure rates were comparable between the two groups (OR: 1.39, 95 % CI: 0.71 – 2.72; P = 0.3423). Despite this, the requirement for further surgery was signifi cantly
higher in the LARS group (OR: 1.79, 95 % CI: 1.00 – 3.22; P = 0.05).
CONCLUSIONS: On the basis of this meta-analysis, the authors conclude that LARS is an effective and safe alternative to OARS for the treatment of proven GERD. LARS enables a faster convalescence and return to productive activity, with a reduced risk of complications and a similar treatment outcome, than an open approach. However, there is a signifi cantly higher rate of re-operation (79 % ) in the LARS group.

Different techniques have been proposed over the last decades to avoid the vaginal vault prolapse following hysterectomy for severe (stage III-IV) apical pelvic organ prolapse. In this scenario, the laparoscopic duplication of the uterosacral ligaments to the vaginal apex might represent a simple alternative procedure, associated with low morbidity and optimal surgical outcomes. In this paper, we present the preliminary results of 25 consecutive patients, who underwent total laparoscopic hysterectomy followed by uterosacral ligament duplication for stage III-IV apical pelvic organ prolapse. A detailed description of the surgical procedure is also provided.

Currently, laparoscopic liver resections are routinely performed at an increasing number of centres and has extended to include major liver resections as well as more challenging segments of the liver. We believe that patient positioning and port placement is a critical yet under described component of successful laparoscopic liver resection to achieve optimal visualisation and allow for an ergonomic and safe dissection. In this article, we describe the advantages of various types of patient positioning as well as provide illustrations for an array of trocar configurations previously described in literature. Whilst there is no universally accepted standardization of port placement for various resection types, this descriptive article can serve as a guide for the various possibilities of port configurations that can be individually adapted by surgeons based on their preference as well as the patient&#39;s physique and anatomy.

Objective: Report our experience in the treatment of choledochal cyst with robot-assisted surgery in children and perform a current analysis of both approaches of minimally invasive surgery, for this anomaly. Results: We treated 4 patients with choledochal cyst, relation 1:3 female, the averages was in age 3 years, weight 15 kg and height 94.2 cm. Type 1-A cysts were three and one 1-C, the average size of the cysts, 9.6 cm. Clinically, they presented: abdominal mass 3, jaundice episode 3 and fever 2. The following are average values of: total surgical times 360 min and console surgery time 230 min, bleeding 32.5 ml, and postoperative stay 4.7 days. Conversions, complications and mortality 0%. Follow-up average 29 months, and all patients are asymptomatic. Currently, the number of children with choledochal cyst treated with robotic surgery, barely reaches about 3%, in relation to those treated with conventional laparoscopy. The initial experience was published with laparoscopy in Oct-1995 and with robotic surgery in Apr-2006. Conclusions: Our results are encouraging, and show the advantages of robotic surgery, although our experience is limited to a few cases. Robotic surgery for the treatment of choledochal cyst is feasible and safe. The current results with both minimally invasive approaches are very similar, but we consider that it represents an important bias, the great advantage in the application that conventional laparoscopy takes to robotic surgery. To date, very few pediatric surgeons in the world have applied robotic surgery to the choledochal cyst. Material and Methods: Study observational, prospective, and longitudinal, in pediatric patients with choledochal cyst treated with robotic-assisted surgery, from Jul-2016 to Apr-2019. The diagnosis was made with laboratory studies, USG and cholangioresonance. The surgery performing one part by laparoscopy, the extracorporeal Roux-en-Y, and other part with robotic assistance (cholecys-tectomy, retrocolic Roux-en-Y, and the hepaticojejunostomy). We use 5 trocars, 4 robotics and a laparoscopic. Registered variables: demographic data, cysts according to Todani's classification, size, clinic, total and robotic surgery time, bleeding, conversions, complications , postoperative stay and follow-up. We carry out a detailed non-systematic review of previous publications on this pathology with conventional laparoscopic and robotic surgery.

Keywords: Choledochal Cyst; Biliary Cyst; Biliary Tract Anomalies; Robotic Surgery; Robot-Assisted Surgery; Laparoscopy; Laparoscopic
Surgery; Minimally Invasive Surgery; Hepaticojejunostomy; Extracorporeal Roux-en-Y; Children

We report an extremely rare case of recurrent gastric volvulus after open splenectomy for hereditary spherocytosis. The initial episode was managed by endoscopic derotation. Later, for recurrent symptoms, she was successfully managed by laparoscopic anterior gastropexy.

Background : The most frequent benign tumours in females are fibroids which are muscular and classically seen throughout the middle and later fertile years of reproductive cycle. Fibroid tumours are arise from the smooth muscle layer of the uterus. The surgical option for submucous uterine fibroid is either myomectomy or hysterectomy, but nowadays when women have the freedom to choose, we can offer the best for them. Cases Presentation: Submucous uterine fibroids tumours are the fibroids situated on inner side of the uterus under the inner lining of the uterine cavity.. Transvaginal Saline infusion sonohysterography finding showed massive soft tissue mass with diameter 6,2 cm II Submucous fibroid >50% uterine wall invasion originating from uterine cavity type. This article demonstrates a case of a 42 year-old premenopausal lady with heavy bleeding and painful mass in lower abdomen, gradually increasing and significant anaemia. The Lasmar's pre-surgical score is 8, so an alternative approach non hysteroscopy technique,the laparoscopy myomectomy is considered. Conclusions : Surgical excision of fibroid tumour was done. Post operatively patient recovery without obstacle.

Background: Gastric bypass is most commonly performed via the laparoscopic approach. However, some believe that the robotic approach could overcome limitations of laparoscopic surgery. In this study we seek to compare the outcomes of robotic and laparoscopic approaches to gastric bypass. Methods: We analyzed data of patients who underwent gastric bypass surgery using the National Inpatient Sample database between 2008-2013. Utilization and outcome measures including demographics, primary expected payer, in-hospital mortality, pre-existing comorbidities, complications, length of hospital stay, and total hospital charge were compared between the two different surgical approaches. These parameters were analyzed by chi-square, non-parametric tests and multivariate linear regression. Results: The six-year number of patients who underwent elective Roux-en-Y gastric bypass procedures in the United States from 2008 to 2013 is estimated to be 395,954. Of these, 97.9% were conducted via the laparoscopic approach, while 2.1% were conducted via the robot-assisted approach. The mean ages at the time of procedure were 44.82 ± 11.9 and 46.19 ± 12.2 in laparoscopic and robotic approaches, respectively (p<0.001). Females represented most of the patients (79% and 76.5% in laparoscopic and robotic groups, respectively, p=0.013). No significant differences existed between the two groups when compared in respect to race, diabetes mellitus, hypertension, ischemic heart disease, chronic kidney disease, and chronic obstructive pulmonary disease (COPD). Postoperative complications were comparable between groups with respect to pulmonary embolism, deep venous thrombosis, pain, bleeding, bowel obstruction, paralytic ileus, abscess, atelectasis, adhesion, and anastomotic leak. The overall mortality was similar between both the laparoscopic and robot-assisted groups (0.1% vs. 0.2%, respectively, p=0.44). Length of hospital stay was statistically significantly longer in the robotic approach (mean 2.7 days vs. 2.4 days, p<0.001). Patients who underwent robotic surgery had significantly higher total hospital charges compared to patients who underwent laparoscopic surgery (median $56,114 vs. $39,765 USD, p<0.001). Conclusions: Most gastric bypass procedures are done via the laparoscopic approach. The robotic technique has no clinical advantages in relation to morbidity and mortality. Additionally, the robotic procedure has significantly higher total charges.

Pancreatic incidentaloma is an asymptomatic incidentally lesion detected on a radiologic imaging performed for unrelated indication. This definition has been proposed for adrenal mass but actually the term is used for asymptomatic masses discovered in different solid organs such as pituitary gland, kidney, liver, prostate and pancreas. Its incidence is increasing because of the widespread use of cross-sectional imaging. The small size of lesions and the location in the body and tail of the pancreas could give reason of the lack of symptoms for left-sided locations. Pancreatic incidentalomas (PIs) include a variety of benign, premalignant, malignant lesions, and unusual histotypes are frequently encountered. Specific guidelines for diagnosis and treatment of PIs are lacking and consequently their diagnostic assessment and clinical management is still debated. Fig. 1. A. Surgical specimen of distal pancreatectomy containing a 9.5 cm large encapsulated pancreatic tail mass with areas of cystic degeneration. The histological diagnosis was solid pseudopapillary neoplasm. B. The microscopic pattern of the neoplasm is solid and pseudopapillary with poorly cohesive monomorfic cells, admixed with thin-walled blood vessels. In the center of the image there are the characteristic cholesterol crystals, surrounded by foreign-body giant cells (hematoxylin-eosin; magnification 200X). Currently, intravenous contrast-enhanced multidetector CT is considered the pivotal radiologic technique for the detection and staging of pancreatic tumors allowing the definition of size, localization, texture (solid or cystic), and vascularization of the mass. Magnetic resonance imaging and endoscopic ultrasonography should be performed selectively. Endoscopic ultrasound (EUS) with fine-needle aspiration has become increasingly used in the differential diagnosis of pancreatic masses. This exam provides high-resolution images of the pancreas and it presents a relevant sensibility and specificity for the solid lesions of the pancreatic head. PIs could be categorized into solid and cystic lesions. Cystic PIs frequently present a benign or premalignant nature while solid PIs are usually considered malignant tumors.

Hypothesis: We hypothesized that hand-assisted laparoscopic
surgery (a new technique that involves a surgeon’s hand passing through a pneumoperitoneumprotecting sleeve device and assisting in laparoscopic surgery) is feasable and outcomes are comparable to purely laparoscopic procedures in selected cases.
Design: A prospective, multicenter, nonrandomized,
noncontrolled study was conducted with the participation
of expert laparoscopic surgeons.
Setting: Academic and community medical centers in
16 states.
Patients: Any patient 18 years or older requiring abdominal
surgery and determined to be suitable for laparoscopic
surgery.
Main Outcome Measures: Incision size, duration of the
procedure, conversion rate to anopentechnique, detection
of subtle disease, return of bowel function, length of hospital
stay, complication rate, and subjective evaluation.
Results: The device was used in 58 patients for 24 different
procedures, most commonly during colectomy (n = 21) and splenectomy (n = 7). Twenty-two percent of
cases required conversion to open technique because of
failure to maintain pneumoperitoneum or failure to complete
the anticipated operation by this method. Average incision size was 7.6 cm. Mean duration of all procedures was 223 minutes (range, 110-415 minutes) and for nonconverted procedures was 178 minutes (range, 65-540 minutes). Preoperatively undetectable, subtle disease was palpated in 14 patients (24%). Mean length of hospital stay for all patients was 7.9 days and for the nonconverted group was 6.7 days. Twenty-four percent of patients developed complications, most commonly either
wound complications (n = 4) or prolonged ileus (n = 3). In 58% of cases, surgeons thought that the technique shortened surgery, and 88% of surgeons found the technique “helpful” in all the completed procedures.
Conclusions: This technique seems to be a useful tool
in the management of cases that either are too complex
or take too long to be managed with purely minimally
invasive techniques. To further define the potential benefits
of this technique in selected procedures, prospective
randomized trials are needed.

""A.J. Orr3, 4, 6, 7,&, C.F. Watson&, MBA, N. Herbots1, 5,7, & ir, PhD, E.J. Culbertson&,#, MD, Gen. Surg., A.J. Acharya1, 2, &, S.D. Whaley, PhD,  M. Matiski2, 6, 7, &, R.B. Bennett-Kennett1, 6, 7,&, A.M. Murphy2, 6, 7, &
1Physics, 2 Chttps://www.academia.edu/7064507/Vitre_Ox_1-3_pm_Nanostructured_Coatings_Surfaces_and_Membranes#hemistry & Biochemistry, 3School of Life Sciences, 4Mathematics, 5LeRoy Eyring Center for Solid State Science (LE-CSSS), 6Ion beam Analysis for Materials  (IBeAM) User’s Facility, 7Combined Ion & Molecular Deposition (CIMD) Laboratory
*ARIZONA STATE UNIVERSITY, TEMPE, AZ
R&D Medical Products Division
&SIO2 NANOTECH LLC, PHOENIX, AZ
Reconstructive Plastic Surgery
# UNIVERSITY OF CALIFORNIA AT LOS ANGELES (UCLA), LOS ANGELES, CA
Surgical grade lenses in laparoscopes and arthroscopes fog during surgery, due to high humidity and temperature in body cavities in relation to the operating room [2]. Fogging completely obscures the surgeon’s vision, so the scope must be repeatedly removed, cleaned, and reinserted before surgery can continue [1, 2]. Fogging thereby increases surgery duration, frustrates the surgeon, and increases potential for infection and scarring due to air exposure from repeated removal and reinsertion of the scope. Current methods to address fogging introduce other complications: thick gels distort the surgeon’s view, alcohol-based solutions are too acidic for contact with tissue and quickly evaporate, and many require re-heating or re-application of the product every 5 to 20 minutes (see Table 1) [2]. Our anti-fogging solution is an ophthalmological, bio-compatible, pH neutral (7.2-7.4) emulsion called VitreOx™ that overcomes all of these shortfalls. Classical thin film nucleation and growth theory can be applied to fluid films like water to describe 3 possible mechanisms of condensation: 2-D (resulting in a transparent film), 3-D (resulting in fogging), or mixed [3]. On a surface as hydrophobic as a scope lens, water condenses into highly spherical 3-D droplets via the Volmer-Weber growth model. The droplets trap air and independently scatter light at their high curvature air/water interface. What is commonly called fog is the opaque, translucent film formed by water droplets now covering the surface. By applying VitreOx™ on the otherwise hydrophobic surface of a lens, it is rendered super-hydrophilic, causing the water film to nucleate rapidly via the Frank Van-der-Merwe growth mode (Figure 1). The resulting flatter droplets form a two dimensional film through which light does not scatter, thereby preventing fogging on any surface to which the emulsion is applied.

[1] Eaton AM, Jaffe GJ, McCuen BW 2nd, Mincey GJ. Condensation on the posterior surface of silicone intraocular lenses during fluid-air exchange. (1995). Ophthalmology. 102(5):733-736
[2] Lawrentschuk N, Fleshner NE, Bolton DM. “Laparoscopic Lens Fogging: A Review of Etiology and Methods to Maintain a Clear Visual Field” (2010). Journal of Endourology. 24(6):905-913
[3] Bauer, E. “Phänomenologische Theorie der Kristallabscheidung an Oberflächen (1958). I” Zeitschrift für Kristallographie. 110(1-6):372-394
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