Journal of Minimal Access Surgery最新文献

Introduction: Robotic pelvic surgeries offer distinct advantages regarding intraoperative manoeuvrability and post-operative outcomes. However, the steep Trendelenburg position required for these procedures presents significant physiological challenges. The optimal angle that minimises complications while maintaining surgical efficacy remains undefined.

Patients and methods: A prospective, randomised comparative study was conducted involving 100 patients undergoing robotic radical prostatectomy ( n = 50) and robotic hysterectomy ( n = 50). The primary objective was to assess variations in intraocular pressure (IOP) and optic nerve sheath diameter (ONSD) at varying degrees of tilt. The secondary objective was to evaluate haemodynamic stability and surgical feasibility. Patients were randomised in a 1:1 ratio to either a reduced or standard tilt group for their respective procedures.

Results: Haemodynamic parameters, including diastolic blood pressure (DBP), mean arterial pressure and arterial DBP, were significantly lower in the 15° and 20° tilt groups. ONSD measurements were marginally higher in prostatectomy patients (4.9 mm) versus hysterectomy patients (4.8 mm) ( P = 0.075). Significant variations in IOP, intracranial pressure and ONSD were observed between hysterectomy groups (15° and 20°) and prostatectomy groups (20° and 25°), with peak parameters typically occurring mid-surgery. Receiver operating characteristic analysis demonstrated superior sensitivity of IOP over ONSD for distinguishing conditions during hysterectomy. Minimal surgical difficulty was achieved at 20° tilt.

Conclusion: While traditional practices favour angles between 30° and 45°, this study demonstrates that lower angles provide safer alternatives without compromising surgical visualisation. Rather than adhering to a universal rigid angle, we recommend an individualised approach: initiating procedures at moderate tilts (15° for hysterectomy and 20° for prostatectomy) and increasing the angle only if patient-specific anatomical constraints dictate the need for greater exposure.

Objective: This study sought to evaluate the impact of lean management (LM) on improving the on-time start rate of the first scheduled surgery and overall nursing performance in the operating room.

Patients and methods: A total of 150 patients who received the first scheduled surgery from November 2023 to May 2024 were selected as the observation group and 150 patients who received the first scheduled surgery from May to October 2023 were selected as the control group. The observation group implemented LM, while the control group received routine peri-operative management. Work efficiency indicators, on-time start rates, operating room turnover efficiency, nursing quality scores, patient satisfaction and staff competency levels were compared before and after the implementation of LM.

Results: The observation group showed notably reduced surgical duration, preparation time and room acceptance time compared to the control group (all P < 0.001). The on-time start rates of both the first and subsequent surgeries were significantly higher in the observation group (all P < 0.001). In addition, the observation group achieved higher daily surgical volume and surgeries per operating room. Nursing quality assessment scores, patient satisfaction ratings and staff competency scores were all significantly improved following LM implementation (all P < 0.001).

Conclusion: Implementation of LM optimises operating room workflow, enhances nursing quality and improves patient satisfaction, indicating that LM is an effective strategy for improving operating room performance.

Introduction: Anastomotic leak after oesophagectomy remains a major cause of post-operative morbidity and mortality. Endoscopic placement of fully covered self-expandable metal stents (FC-SEMS) has emerged as a minimally invasive therapeutic option; however, real-world outcome data remain limited. We evaluated the outcomes of FC-SEMS placement for post-oesophagectomy leaks and described a novel clip-through-mesh fixation technique to reduce stent migration.

Patients and methods: We conducted a retrospective cohort study of patients with post-oesophagectomy anastomotic leaks treated with FC-SEMS between December 2024 and December 2025 at a tertiary care center. Demographic, clinical, oncologic, surgical and procedural variables were collected. The outcomes assessed included leak characteristics, timing of intervention, stent dwell time, technical success, clinical healing, adverse events, mortality and functional recovery. A modified fixation method was used in all cases, whereby a through-the-scope clip was partially opened, passed through a single diamond-shaped stent mesh cell and deployed at a crossover point into the mucosa.

Results: Ten patients underwent FC-SEMS placement. Median time to leak detection was 12 days (range 7-20), and median maximum defect size was 3.25 cm. Multifocal leaks were present in 50% of patients. Surgical approaches included transhiatal (50%), transthoracic (30%) and subdiaphragmatic resections (20%). Technical success was achieved in all patients (100%), and complete clinical healing occurred in eight patients (80%). Two patients with large defects (>4 cm) and severe sepsis died despite technically successful stenting. No major stent-related adverse events were observed. No stent migration occurred during the follow-up. All surviving patients resumed oral intake after FC-SEMS placement, tolerated progressive diet advancement and remained symptom-free after stent removal during the follow-up.

Conclusion: FC-SEMS placement is a feasible and effective first-line endoscopic therapy for post-esophagectomy anastomotic leaks. Early diagnosis, adequate drainage, antimicrobial therapy and nutritional support remain critical to success. The novel clip-through-mesh fixation technique was safe, reproducible and may help reduce stent migration.

Introduction: Gall bladder wall thickness (GBWT) on ultrasonography is widely considered a predictor of operative difficulty in laparoscopic cholecystectomy; however, its independent predictive value remains to be fully established.

Patients and methods: This prospective, observational study included 196 patients with symptomatic gallstone disease undergoing laparoscopic cholecystectomy at a tertiary care centre. Patients were stratified into four groups based on GBWT (≤2 mm, 3-4 mm, 5-6 mm and >6 mm). Operative outcomes, including adhesions, operative time, conversion to open surgery and post-operative complications, were analysed. Multivariate logistic regression identified independent predictors, and receiver operating characteristic (ROC) analysis determined the optimal GBWT cutoff.

Results: Increasing GBWT was significantly associated with higher operative difficulty, including adhesions (16.4% vs. 40.0%, P = 0.023), longer operative time (52.4 vs. 68.2 min, P = 0.002) and higher conversion rates (3.6% vs. 20.0%, P = 0.045). On multivariate analysis, GBWT >2 mm independently predicted adhesions (adjusted odds ratio [AOR]: 1.82, 95% confidence interval [CI]: 1.05-3.14), conversion (AOR: 2.41, 95% CI: 1.08-5.36) and drain placement (AOR: 2.06, 95% CI: 1.12-3.78). ROC analysis demonstrated moderate predictive accuracy (area under the curve 0.72), with an optimal cutoff of >3 mm (sensitivity - 68.5% and specificity - 70.2%).

Conclusions: GBWT is an independent and clinically useful predictor of operative difficulty in laparoscopic cholecystectomy. Routine pre-operative ultrasonographic assessment can aid in risk stratification and surgical planning.

Introduction: The prevalence of adolescent obesity has increased dramatically over the past several decades. The objective of this investigation was to evaluate the outcomes of Roux-en-Y gastric bypass (RYGB) surgery in adolescents.

Patients and methods: This retrospective case series examined 15 adolescents aged 17 years or younger who underwent RYGB surgery. Of the 15 adolescents, 11 presented with severe obesity-related co-morbidities at the time of surgery. The median follow-up was 84 months.

Results: The mean Roux limb length was 80.9 ± 46.32 cm, and the mean duration of initial hospitalisation was 6.1 ± 1.19 days. Thirteen (86.67%) patients lost weight, whereas two (13.33%) gained weight. The mean weight loss was 53.67 ± 25.6 kg, while the mean weight gain was 14.5 ± 0.7 kg. The mean time to weight loss was 60.8 ± 48 months, and the mean time to weight gain was 132 ± 9.8 months. Regarding post-operative complications, 3 (20%) patients developed incisional hernia, 3 (20%) patients experienced symptomatic cholelithiasis, 2 (13.33%) patients developed protein-calorie malnutrition and 1 (6.67%) patient had a small-bowel obstruction. Six (40%) patients had no reported complications.

Conclusion: RYGB operation is a promising intervention for adolescents with morbid obesity, promoting significant weight loss and alleviating related co-morbidities. However, careful evaluation and preparation are crucial to prepare adolescents for lifestyle changes post-surgery. With proper support and follow-up, RYGB can empower young individuals to achieve and maintain healthier weights, offering a promising solution in the fight against adolescent obesity.

Abstract: We describe a standardised 14-step technique for pilonidal sinus tract ablation using a radial 1470-nm diode laser. The protocol incorporates systematic tract identification, methylene blue staining, pit excision and sequential curettage, followed by a dual curettage-dual ablation cycle with ice-cold saline cooling. Laser ablation is a safe, minimally invasive, day-case procedure offering rapid recovery, minimal post-operative pain and acceptable recurrence rates.

Introduction: Anaesthetic management of thoracic surgery for tuberculous empyema is complex, with traditional fluid strategies often causing intraoperative hypotension or volume overload. Lung ultrasound (LUS) provides real-time assessment of pulmonary fluid status, but its combined effect with prophylactic vasopressor support on anaesthetic outcomes in this population is unclear. This study aimed to evaluate the impact of an integrated strategy combining LUS-guided goal-directed fluid therapy and prophylactic vasopressor support on intraoperative haemodynamics and early post-operative recovery in patients undergoing thoracic surgery for tuberculous empyema.

Patients and methods: This retrospective cohort study included patients who underwent elective decortication for tuberculous empyema between January 2022 and June 2025. Patients were categorised into the LUS-guided group (LGG) and conventional management group. After 1:1 propensity score matching, 40 patients per group were analysed. Primary outcomes included intraoperative hypotension (mean arterial pressure <65 mmHg for >5 min), while secondary outcomes assessed fluid balance, norepinephrine use, recovery time, pain and post-operative complications.

Results: The LGG had a significantly lower incidence and shorter duration of intraoperative hypotension ( P < 0.05). Intraoperative management showed reduced fluid balance, norepinephrine use and fewer vasopressor interventions in the LGG ( P < 0.01). Post-operative recovery was faster, with earlier ambulation and shorter hospital stays ( P < 0.001). The LGG also had lower pain scores and fewer pulmonary complications ( P < 0.05). Multivariable analysis confirmed that the LUS-guided strategy was independently associated with earlier ambulation (β = 6.798, P < 0.001), lower pain scores at rest (β = 0.589, P = 0.018) and reduced pulmonary complications (odds ratio = 3.713, P = 0.049) after adjusting for confounders. Multivariable analysis confirmed the LUS-guided strategy as an independent protective factor against intraoperative hypotension. Diabetes and thoracotomy approach were identified as independent risk factors ( P < 0.05), while fibrous stage empyema showed a trend toward significance ( P = 0.050).

Conclusion: LUS-guided fluid management with prophylactic vasopressor support enhances intraoperative stability, optimises fluid and vasopressor use and accelerates recovery in thoracic surgery for tuberculous empyema.

Introduction: Effective surgical therapy of rectal cancer necessitates meticulous selection of suitable surgical procedures contingent upon tumour location, stage and patient characteristics. This research examines surgical procedural trends and results in a tertiary care facility in Kashmir.

Patients and methods: A 7-year retrospective-prospective research examined 510 rectal cancer patients who had surgical treatment at SKIMS. Surgical interventions were classified as local excision, low anterior resection (LAR), abdominoperineal resection (APR), Hartmann's technique and palliative operations. Data about surgical approaches (open, laparoscopic and robotic), perioperative parameters and complications were gathered and analysed.

Results: Out of 510 patients, 36 (7.05%) had transanal excision, 280 (54.9%) underwent LAR, 145 (28.4%) received APR, 35 (6.9%) were treated with Hartmann's surgery and 14 (2.7%) had unresectable disease necessitating palliative interventions. In the cohort undergoing neoadjuvant treatment, the rates of sphincter-preserving surgery were significantly elevated (62.5% compared to 45.1%, P < 0.05). A laparoscopic technique was employed in 178 individuals (34.9%). Conversion to open surgery was performed in 18 instances (10.1%).

Conclusion: This institutional experience illustrates the progression of surgical practices, highlighting the growing implementation of sphincter-preserving techniques and less invasive methods. Neoadjuvant treatment profoundly impacts surgical decision-making, facilitating an increased number of sphincter-preserving surgeries. Persistent focus on entire mesorectal excision principles and judicious application of sophisticated surgical methods can enhance oncological and functional results.

Background: The presence of metabolic dysfunction-associated steatotic liver disease and liver fibrosis in patients with obesity is associated with poor long-term liver-related outcomes. Liver biopsy is the gold standard. The enhanced liver fibrosis (ELF) panel is a non-invasive test (NIT) with an excellent correlation with liver fibrosis in various liver disorders. The diagnostic utility of this test in the obese population is not yet established. This study aims to assess the diagnostic accuracy of ELF and other NITs in predicting significant and advanced liver fibrosis in obese patients undergoing bariatric surgery.

Patients and methods: This prospective cohort study was performed in a tertiary care academic institute in India. All patients underwent standard pre-operative workup according to the institute protocol. Pre-operative NIT values were determined, which included ELF, liver stiffness measurement (LSM) by FibroScan, aspartate aminotransferase-to-platelet ratio index and fibrosis-4 index. The fibrosis stage was graded based on findings of the liver biopsy performed intraoperatively.

Results: On liver biopsy, significant fibrosis was present in 13 (33.3%) patients, while advanced fibrosis was present in 7 (17.9%) patients. ELF accuracy improved with fibrosis severity (area under the receiver operating characteristic curve: 0.7-0.9), with best performance for ≥F3 (85.7% - sensitivity, 82.8% - specificity and negative predictive value [NPV] - 96%). LSM demonstrated high sensitivity (83%-95%) but lower specificity, with consistently high NPV (88.9%-95.6%).

Conclusion: ELF score and LSM demonstrated good diagnostic accuracy to identify liver fibrosis in obese patients undergoing bariatric surgery. Multi-centre studies involving larger sample sizes are needed for optimisation of ELF cut-off values to predict liver fibrosis.

Abstract: Brunner's gland hamartoma (BGH) is an extremely rare benign duodenal tumour (<0.01% incidence), often asymptomatic but occasionally presenting with dyspepsia, bleeding or obstruction. Small lesions can be managed endoscopically, whereas broad-based masses require surgical resection. We report the first video article describing robotic-assisted segmental duodenectomy for a giant BGH. A male in his early 40s presented with dyspepsia and intermittent melena with anaemia. Endoscopy and contrast-enhanced computed tomography revealed a 7-cm broad-based lesion arising from the first part of the duodenum, provisionally diagnosed with gastrointestinal stromal tumours. Robotic segmental duodenectomy with stapled antecolic loop gastrojejunostomy was performed using the da Vinci Xi system. Operative time was 156 min with negligible blood loss. Histopathology confirmed BGH. Recovery was uneventful and the patient remained symptom-free at 2 months. Robotic segmental duodenectomy is safe, feasible and ensures adequate margins with enhanced recovery.