Using laparoscope to remove an ectopic intrauterine device in the anterior wall of urinary bladder:A case report

BACKGROUND An intrauterine device(IUD)is a contraceptive device placed in the uterine cavity and is a common contraceptive method for Chinese women.However,an IUD may cause complications due to placement time,intrauterine pressure and other factors.Ectopic IUDs are among the most serious complications.Ectopic IUDs are common in the myometrium and periuterine organs,and there are few reports of ectopic IUDs in the urinary bladder,especially in the anterior wall.CASE SUMMARY A 52-year-old woman was hospitalized due to a urinary bladder foreign body found via abdominal ultrasound and computed tomography(CT)examination.The patient had a 2-year history of recurrent abdominal distension and lower abdominal pain,accompanied by frequent urination,urgency,dysuria and other discomfort.Ultrasound examination revealed foreign bodies in the bladder cavity,with calculus on the surface of the foreign bodies.CT revealed a circular foreign body on the anterior wall of the urinary bladder,suggesting the possibility of an ectopic IUD.After laparoscopic exploration,an annular IUD was found in the anterior wall of urinary bladder,and an oval calculus with a diameter of approximately 2 cm was attached to the surface of the bladder cavity.The IUD and calculus were successfully and completely removed.The patient recovered well after surgery.CONCLUSION Abdominal ultrasound and CT are effective methods for detecting ectopic IUDs.The IUD is located in the urinary bladder and requires early surgical treatment.The choice of surgical method is determined by comprehensively considering the depth of the IUD in the bladder muscle layer,the situation of complicated calculus,the situation of intravesical inflammation and medical technology and equipment.

Controversy of hand-assisted laparoscopic colorectal surgery

Laparoscopically assisted colorectal procedures are time-consuming and technically demanding and hence have a long steep learning curve. In the technical demand, surgeons need to handle a long mobile organ, the colon, and have to operate on multiple abdominal quadrants, most of the time with the need to secure multiple mesenteric vessels. Therefore, a new surgical innovation called hand-assisted laparoscopic surgery (HALS) was introduced in the mid 1990s as a useful alternative to totally laparoscopic procedures. This hybrid operation allows the surgeon to introduce the non-dominant hand into the abdominal cavity through a special hand port while maintaining the pneumoperitoneum. A hand in the abdomen can restore the tactile sensation which is usually lacking in laparoscopic procedures. It also improves the eye-to-hand coordination, allows the hand to be used for blunt dissection or retraction and also permits rapid control of unexpected bleeding. All of those factors can contribute tremendously to reducing the operative time. Moreover, this procedure is also considered as a hybrid procedure that combines the advantages of both minimally invasive and conventional open surgery. Nevertheless, the exact role of HALS in colorectal surgery has not been well defined during the advanced totally laparoscopic procedures. This article reviews the current status of hand-assisted laparoscopic colorectal surgery as a minimally invasive procedure in the era of laparoscopic surgery.

Surgical outcomes of hand-assisted laparoscopic liver resection vs. open liver resection: A retrospective propensity scorematched cohort study

Objective: Hand-assisted laparoscopic liver resection has the advantages of open and laparoscopic surgeries.There is still lack of comparison of surgical outcomes between hand-assistied laparoscopic liver resection(HALLR)and open liver resection(OLR). This study compared the surgical outcomes of the two approaches between wellmatched patient cohorts.Methods: Patients who received liver resection during January 2014 and October 2017 in Cancer Hospital,Chinese Academy of Medical Sciences and Peking Union Medical College were included in this retrospective study. Propensity score matching(PSM) was performed to reduce selection bias between the two groups. Operation and short-term surgical outcomes were compared between the well matched groups.Results: During this period, 232 patients with a median age of 55.1 years old received OLR, while 49 patients with a median age of 54.7 years old received HALLR. Compared with HALLR group, OLR group has a higher proportion in male patients(190/232, 81.9% vs. 34/49, 69.4%, P=0.048) and lower albumin(43.2±4.5 vs. 44.8±3.7,P=0.020). After PSM, 49 patients from each group were included in the following analysis. Two groups were well balanced in their baseline characteristics, liver functions, preoperative treatments, abdominal surgery history, and surgical difficulty. None perioperative mortality was observed in both groups. Operation time and postoperative complications were similar in two groups(P=0.935, P=0.056). The HALLR group showed less bleeding amount(177.8±217.1 mL vs. 283.1±225.0 mL, P=0.003) and shorter postoperative stay period(6.9±2.2 d vs. 9.0±3.5 d,P=0.001).Conclusions: We demonstrated that hand-assisted laparoscopic surgery is feasible and safe for liver resection,including some difficult cases. HALLR can provide better bleeding control and faster recovery after surgery.

Hand-assisted laparoscopic restorative proctocolectomy for ulcerative colitis

AIM To evaluate the utility of hand-assisted laparoscopic restorative proctocolectomy(HALS-RP) compared with the conventional open procedure(OPEN-RP).METHODS Fifty-one patients who underwent restorative total proctocolectomy with rectal mucosectomy and ileal pouch anal anastomosis between January 2008 and July 2015 were retrospectively analyzed.Twentythree patients in the HALS-RP group and twentyfour patients in the OPEN-RP group were compared.Four patients who had purely laparoscopic surgery were excluded.Restorative total proctocolectomy was performed with mucosectomy and a hand-sewn ilealpouch-anal anastomosis.Preoperative comorbidities,intraoperative factors such as blood loss and operative time,postoperative complications,and postoperative course were compared between two groups.RESULTS Patients in both groups were matched with regards to patient age,gender,and American Society of Anesthesiologists score.There were no significant differences in extent of colitis,indications for surgery,preoperative comorbidities,and preoperative medications in the two groups.The median operative time for the HALS-RP group was 369(320-420) min,slightly longer than the OPEN-RP group at 355(318-421) min; this was not statistically significant.Blood loss was significantly less in HALS-RP [300(230-402) m L] compared to OPEN-RP [512(401-1162) m L,P = 0.003].Anastomotic leakage was noted in 3 patients in the HALS-RP group and 2 patients in the OPEN-RP group(13% vs 8.3%,NS).The rates of other postoperative complications and the length of hospital stay were not different between the two groups.CONCLUSION HALS-RP can be performed with less blood loss and smaller skin incisions.This procedure is a feasible technique for total proctocolectomy for ulcerative colitis.

Hand-assisted laparoscopic splenectomy is a useful surgical treatment method for patients with excessive splenomegaly: A metaanalysis

BACKGROUND Hand-assisted laparoscopic splenectomy(HALS) can help overcome the drawbacks of laparoscopic splenectomy(LS) while maintaining its advantages.AIM To evaluate the efficacy and advantages of HALS for splenomegaly.METHODS The relevant literature was reviewed using the PubMed, EMBASE, Cochrane,Ovid Medline, and Wanfang databases to compare the clinical outcomes of HALS and LS. Odds ratios or mean differences were calculated with 95% confidence intervals for fixed-effects and random-effects models. Overall, 754 patients from16 trials who met the inclusion criteria were selected.RESULTS In pure splenectomy, blood loss volume(P < 0.001) and conversion rate(P =0.008) were significantly lower in the HALS group than in the LS group.Conversely, for splenomegaly, the operative time(P = 0.04) was shorter and blood loss volume(P < 0.001) and conversion rate(P = 0.001) were significantly lower in the HALS group than in the LS group. However, no significant difference was observed in hospital stay length, blood transfusion, time to food intake, complications, or mortality rate between the two groups. Moreover, in splenectomy and devascularization of the upper stomach(DUS), the operative time(P = 0.04) was significantly shorter and blood loss volume(P < 0.001) andconversion rate(P = 0.05) were significantly lower in the HALS + DUS group than in the LS + DUS group. However, no significant difference was observed in hospital stay length, timing of diet, and complications between the two groups.CONCLUSION HALS is an ideal surgical treatment method for splenomegaly because it can maximize the benefits for patients while maintaining the advantages of LS.

Learning curve for hand-assisted laparoscopic D2 radical gastrectomy

AIM:To describe the learning curves of hand-assisted laparoscopic D2 radical gastrectomy(HALG) for the treatment of gastric cancer.METHODS:The HALG surgical procedure consists of three stages:surgery under direct vision via the port for hand assistance,hand-assisted laparoscopicsurgery,and gastrointestinal tract reconstruction.According to the order of the date of surgery,patients were divided into 6 groups(A-F) with 20 cases in each group.All surgeries were performed by the same group of surgeons.We performed a comprehensive and indepth retrospective comparative analysis of the clinical data of all patients,with the clinical data including general patient information and intraoperative and postoperative observation indicators.RESULTS:There were no differences in the basic information among the patient groups(P > 0.05).The operative time of the hand-assisted surgery stage in group A was 8-10 min longer than the other groups,with the difference being statistically significant(P = 0.01).There were no differences in total operative time between the groups(P = 0.30).Postoperative intestinal function recovery time in group A was longer than that of other groups(P = 0.02).Lengths of hospital stay and surgical quality indicators(such as intraoperative blood loss,numbers of detected lymph nodes,intraoperative side injury,postoperative complications,reoperation rate,and readmission rate 30 d after surgery) were not significantly different among the groups.CONCLUSION:HALG is a surgical procedure that can be easily mastered,with a learning curve closely related to the operative time of the hand-assisted laparoscopic surgery stage.

Comparison of hand-assisted laparoscopic radical gastrectomy and laparoscopic-assisted radical gastrectomy:A systematic review and meta-analysis

BACKGROUND Gastrectomy is the optimal treatment for gastric cancer.Laparoscopic-assisted gastrectomy(LAG)has been extensively employed,while hand-assisted laparoscopic gastrectomy(HALG),which is similar to LAG,remains controversial.Although HALG is popular in China,some surgeons do not accept it as a minimal-access technique.AIM To assess the safety and practicability of HALG by comparing the short-term outcomes of HALG and LAG.METHODS The electronic databases of EMBASE,PubMed,China National Knowledge Infrastructure,and Cochrane Library were thoroughly searched,and randomized controlled trials(RCTs)comparing HALG and LAG were included.The study results,including surgery time,blood loss,retrieved lymphatic nodes,incision length,time to first flatus,hospitalization duration,and all postsurgical complications,were compared between the two groups.RESULTS Five RCTs,which included 302 cases with HALG and 298 cases with LAG,were considered eligible for inclusion.Meta-analysis showed that HALG significantly reduced surgery time(P<0.01),hospital duration(P<0.01),and overall postsurgical complications(P<0.01).Additionally,HALG significantly increased the number of retrieved lymphatic nodes(P=0.01)and incision length(P<0.01)compared with LAG.The blood loss and time to first flatus were similar between the two groups(P>0.05).CONCLUSION Compared with LAG,HALG is a simpler and safer technique.Additionally,HALG should be used as a minimal-access technique,especially in technologically undeveloped areas.

Hand-assisted laparoscopic surgery for complex gallstone disease: A report of five cases

AIM: To describe the use of hand-assisted laparoscopic surg-ery (HALS) as an alternative to open conversion for complex gall-stone diseases, including Mirizzi syndrome (MS) and mimic MS.METHODS: Five patients with MS and mimic MS of 232 consecutive patients undergoing laparoscopic cholecystectomies were analyzed. HALS without a hand-port device was performed as an alternative to open conversion if the anatomy was still unclear after the neck of the gallbladder was reached.RESULTS: HALS was performed on three patients with MS type Ⅰ and 2 with mimic MS owing to an undear or abnormal anatomy, or an unusual circumstance in which an impacted stone was squeezed out from the infundibulum or the aberrant cystic duct impossible with laparoscopic approach. The median operative time was 165 min (range, 115-190 min). The median hand-assisted time was 75 min (range, 65-100 min). The median postoperative stay was 4 d (range, 3-5 d). The postoperative course was uneventful, except for 1 patient complicated with a minor incision infection. CONCLUSION: HALS for MS type Ⅰ and mimic MS is safe and feasible. It simplifies laparoscopic procedure, and can be used as an alternative to open conversion for complex gallstone diseases.

Machine learning identifies the risk of complications after laparoscopic radical gastrectomy for gastric cancer

BACKGROUND Laparoscopic radical gastrectomy is widely used,and perioperative complications have become a highly concerned issue.AIM To develop a predictive model for complications in laparoscopic radical gastrectomy for gastric cancer to better predict the likelihood of complications in gastric cancer patients within 30 days after surgery,guide perioperative treatment strategies for gastric cancer patients,and prevent serious complications.METHODS In total,998 patients who underwent laparoscopic radical gastrectomy for gastric cancer at 16 Chinese medical centers were included in the training group for the complication model,and 398 patients were included in the validation group.The clinicopathological data and 30-d postoperative complications of gastric cancer patients were collected.Three machine learning methods,lasso regression,random forest,and artificial neural networks,were used to construct postoperative complication prediction models for laparoscopic distal gastrectomy and laparoscopic total gastrectomy,and their prediction efficacy and accuracy were evaluated.RESULTS The constructed complication model,particularly the random forest model,could better predict serious complications in gastric cancer patients undergoing laparoscopic radical gastrectomy.It exhibited stable performance in external validation and is worthy of further promotion in more centers.CONCLUSION Using the risk factors identified in multicenter datasets,highly sensitive risk prediction models for complications following laparoscopic radical gastrectomy were established.We hope to facilitate the diagnosis and treatment of preoperative and postoperative decision-making by using these models.

Colorectal resections for malignancy: A pilot study comparing conventional vs freehand robot-assisted laparoscopic colectomy

BACKGROUND Laparoscopic colectomy is widely accepted as a safe operation for colorectal cancer,but we have experienced resistance to the introduction of the FreeHandffrobotic camera holder to augment laparoscopic colorectal surgery.AIM To compare the initial results between conventional and FreeHandffrobot-assisted laparoscopic colectomy in Trinidad and Tobago.METHODS This was a prospective study of outcomes from all laparoscopic colectomies per-formed for colorectal carcinoma from November 29,2021 to May 30,2022.The following data were recorded:Operating time,conversions,estimated blood loss,hospitalization,morbidity,surgical resection margins and number of nodes har-vested.All data were entered into an excel database and the data were analyzed using SPSS ver 20.0.RESULTS There were 23 patients undergoing colectomies for malignant disease:8(35%)FreeHandff-assisted and 15(65%)conventional laparoscopic colectomies.There were no conversions.Operating time was significantly lower in patients under-going robot-assisted laparoscopic colectomy(95.13±9.22 vs 105.67±11.48 min;P=0.045).Otherwise,there was no difference in estimated blood loss,nodal harvest,hospitalization,morbidity or mortality.CONCLUSION The FreeHandffrobot for colectomies is safe,provides some advantages over conventional laparoscopy and does not compromise oncologic standards in the resource-poor Caribbean setting.

Identification of clinical subphenotypes of sepsis after laparoscopic surgery

Objective:Some patients exhibit septic symptoms following laparoscopic surgery,leading to a poor prognosis.Effective clinical subphenotyping is critical for guiding tailored therapeutic strategies in these cases.By identifying predisposing factors for postoperative sepsis,clinicians can implement targeted interventions,potentially improving outcomes.This study outlines a workflow for the subphenotype methodology in the context of laparoscopic surgery,along with its practical application.Methods:This study utilized data routinely available in clinical case systems,enhancing the applicability of our findings.The data included vital signs,such as respiratory rate,and laboratory measures,such as blood sodium levels.The process of categorizing clinical routine data involved technical complexities.A correlation heatmap was used to visually depict the relationships between variables.Ordering points were used to identify the clustering structure and combined with Consensus K clustering methods to determine the optimal categorization.Results:Our study highlighted the intricacies of identifying clinical subphenotypes following laparoscopic surgery,and could thus serve as a valuable resource for clinicians and researchers seeking to explore disease heterogeneity in clinical settings.By simplifying complex methodologies,we aimed to bridge the gap between technical expertise and clinical application,fostering an environment where professional medical knowledge is effectively utilized in subphenotyping research.Conclusion:This tutorial could primarily serve as a guide for beginners.A variety of clustering approaches were explored,and each step in the process contributed to a comprehensive understanding of clinical subphenotypes.

Laparoscopic left hemihepatectomy guided by indocyanine green fluorescence: A cranial-dorsal approach

BACKGROUND Advancements in laparoscopic technology and a deeper understanding of intra-hepatic anatomy have led to the establishment of more precise laparoscopic hepatectomy(LH)techniques.The indocyanine green(ICG)fluorescence navi-gation technique has emerged as the most effective method for identifying hepatic regions,potentially overcoming the limitations of LH.While laparoscopic left hemihepatectomy(LLH)is a standardized procedure,there is a need for innova-tive strategies to enhance its outcomes.important anatomical markers,surgical skills,and ICG staining methods.METHODS Thirty-seven patients who underwent ICG fluorescence-guided LLH at Qujing Second People's Hospital between January 2019 and February 2022 were retrospectively analyzed.The cranial-dorsal approach was performed which involves dissecting the left hepatic vein cephalad,isolating the Arantius ligament,exposing the middle hepatic vein,and dissecting the parenchyma from the dorsal to the foot in order to complete the anatomical LLH.The surgical methods,as well as intra-and post-surgical data,were recorded and analyzed.Our hospital’s Medical Ethics Committee approved this study(Ethical review:2022-019-01).RESULTS Intraoperative blood loss during LLH was 335.68±99.869 mL and the rates of transfusion and conversion to laparotomy were 13.5%and 0%,respectively.The overall incidence of complications throughout the follow-up(median of 18 months;range 1-36 months)was 21.6%.No mortality or severe complications(level IV)were reported.CONCLUSION LLH has the potential to become a novel,standardized approach that can effectively,safely,and simply expose the middle hepatic vein and meet the requirements of precision surgery.

First experience in laparoscopic surgery in low and middle income countries: A systematic review

BACKGROUND Laparoscopic surgery has reduced morbidity and mortality rates,shorter post-operative recovery periods and lower complication rates than open surgery.It is routine practice in high-income countries and is becoming increasingly common in countries with limited resources.However,introducing laparoscopic surgery in low-and-middle-income countries(LMIC)can be expensive and requires resour-ces,equipment,and trainers.AIM To report the challenges and benefits of introducing laparoscopic surgery in LMIC as well as to identify solutions to these challenges for countries with limited finances and resources.METHODS MEDLINE,EMBASE and Cochrane databases were searched for studies reporting first experience in laparoscopic surgery in LMIC.Included studies were published between 1996 and 2022 with full text available in English.Exclusion criteria were studies considering only open surgery,ear,nose,and throat,endoscopy,arthro-scopy,hysteroscopy,cystoscopy,transplant,or bariatric surgery.RESULTS Ten studies out of 3409 screened papers,from eight LMIC were eligible for inclusion in the final analysis,totaling 2497 patients.Most reported challenges were related to costs of equipment and training programmes,equipment pro-blems such as faulty equipment,and access to surgical kits.Training-related challenges were reliance on foreign trainers and lack of locally trained surgeons and theatre staff.The benefits of introducing laparoscopic surgery were economic and clinical,including a reduction in hospital stay,complications,and morbidi-ty/mortality.The introduction of laparoscopic surgery also provided training opportunities for junior doctors.CONCLUSION Despite financial and technical challenges,many studies emphasise the overall benefit of introducing laparoscopic surgery in LMICs such as reduced hospital stay and the related lower cost for patients.While many of the clinical centres in LMICs have proposed practical solutions to the challenges reported,more support is critically required,in particular regarding training.

Construction of a nomogram model to predict technical difficulty in performing laparoscopic sphincter-preserving radical resection for rectal cancer

BACKGROUND Colorectal surgeons are well aware that performing surgery for rectal cancer becomes more challenging in obese patients with narrow and deep pelvic cavities.Therefore,it is essential for colorectal surgeons to have a comprehensive understanding of pelvic structure prior to surgery and anticipate potential surgical difficulties.AIM To evaluate predictive parameters for technical challenges encountered during laparoscopic radical sphincter-preserving surgery for rectal cancer.METHODS We retrospectively gathered data from 162 consecutive patients who underwent laparoscopic radical sphincterpreserving surgery for rectal cancer.Three-dimensional reconstruction of pelvic bone and soft tissue parameters was conducted using computed tomography(CT)scans.Operative difficulty was categorized as either high or low,and multivariate logistic regression analysis was employed to identify predictors of operative difficulty,ultimately creating a nomogram.RESULTS Out of 162 patients,21(13.0%)were classified in the high surgical difficulty group,while 141(87.0%)were in the low surgical difficulty group.Multivariate logistic regression analysis showed that the surgical approach using laparoscopic intersphincteric dissection,intraoperative preventive ostomy,and the sacrococcygeal distance were independent risk factors for highly difficult laparoscopic radical sphincter-sparing surgery for rectal cancer(P<0.05).Conversely,the anterior-posterior diameter of pelvic inlet/sacrococcygeal distance was identified as a protective factor(P<0.05).A nomogram was subsequently constructed,demonstrating good predictive accuracy(C-index=0.834).CONCLUSION The surgical approach,intraoperative preventive ostomy,the sacrococcygeal distance,and the anterior-posterior diameter of pelvic inlet/sacrococcygeal distance could help to predict the difficulty of laparoscopic radical sphincter-preserving surgery.

Robotic-assisted versus laparoscopic repair of type II, III and IV hiatal hernias: A retrospective study comparing adverse outcomes

Objective:Robotic-assisted surgery(RAS)is continuing to expand in use in surgical specialties,including foregut surgery.The available data on its use in large hiatal hernia(HH)repair are limited and conflicting.This study sought to determine whether there are significant differences in adverse outcomes following HH repair performed with a robotic approach vs.a laparoscopic approach.This study was limited to outcomes in patients with type II,III,and IV HHs,as these hernias are typically more challenging to repair.Methods:A retrospective analysis was performed from data obtained from TriNetX,a large deidentified clinical database,over a 10-year period.Adult patients who underwent type II,III,or IV HH repair were included in the study.HH with robotic repair was compared to laparoscopic repair.Cohorts were propensity score matched for demographic information and comorbidities.Risk ratios,risk differences(RDs)with 95%confidence intervals(CIs),and t test for each examined adverse outcome were used to estimate the effects of robotic repair vs.laparoscopic repair.Results:In total,20,016 patients who met the inclusion criteria were identified;1,515 patients utilized RAS,and 18,501 used laparoscopy.Prior to matching,there were significant differences in age,sex,comorbidity,and BMI between the two cohorts.After 1:1 propensity score matching,analyses of 1,514 well-matched patient pairs revealed no significant differences in demographics or comorbidities.Patients who underwent robotic repair were more likely to experience major complications,including venous thromboembolism(RD:0.007,95%CI:0.003,0.011;p?0.002),critical care(RD:0.023,95%CI:0.007,0.039;p?0.004),urinary/renal complications(RD:0.027,95%CI:0.014,0.041;p<0.001),and respiratory complications(RD:0.046,95%CI:0.028,0.064;p<0.001).RAS was associated with a significantly shorter length of stay(32.4±27.5 h vs.35.7±50.1 h,p?0.031),although this finding indicated a reduction in the length of stay of less than 4 hours.No statistically significant differences in risk of esophageal perforation,infection,postprocedural shock,bleeding,mortality,additional emergency room visits,cardiac complications,or wound disruption were found.Conclusions:Patients who undergo robotic-assisted large HH repair are at increased risk of venous thromboembolism,need critical care,urinary or renal complications and respiratory complications.Due to variations in RAS technique,experience,and surgical volumes,further study of this surgical approach and complication rates is warranted.

Towards engineering a portable platform for laparoscopic pre-training in virtual reality with haptic feedback

Background Laparoscopic surgery is a surgical technique in which special instruments are inserted through small incision holes inside the body.For some time,efforts have been made to improve surgical pre training through practical exercises on abstracted and reduced models.Methods The authors strive for a portable,easy to use and cost-effective Virtual Reality-based(VR)laparoscopic pre-training platform and therefore address the question of how such a system has to be designed to achieve the quality of today's gold standard using real tissue specimens.Current VR controllers are limited regarding haptic feedback.Since haptic feedback is necessary or at least beneficial for laparoscopic surgery training,the platform to be developed consists of a newly designed prototype laparoscopic VR controller with haptic feedback,a commercially available head-mounted display,a VR environment for simulating a laparoscopic surgery,and a training concept.Results To take full advantage of benefits such as repeatability and cost-effectiveness of VR-based training,the system shall not require a tissue sample for haptic feedback.It is currently calculated and visually displayed to the user in the VR environment.On the prototype controller,a first axis was provided with perceptible feedback for test purposes.Two of the prototype VR controllers can be combined to simulate a typical both-handed use case,e.g.,laparoscopic suturing.A Unity based VR prototype allows the execution of simple standard pre-trainings.Conclusions The first prototype enables full operation of a virtual laparoscopic instrument in VR.In addition,the simulation can compute simple interaction forces.Major challenges lie in a realistic real-time tissue simulation and calculation of forces for the haptic feedback.Mechanical weaknesses were identified in the first hardware prototype,which will be improved in subsequent versions.All degrees of freedom of the controller are to be provided with haptic feedback.To make forces tangible in the simulation,characteristic values need to be determined using real tissue samples.The system has yet to be validated by cross-comparing real and VR haptics with surgeons.

Laparoscopic management of remnant gall bladder with stones: Lessons from a tertiary care centre's experience

Objective:Laparoscopic cholecystectomy is currently the gold standard for treating symptomatic gallstone disease.Despite its success,approximately 10%of patients may experience persistent biliary symptoms,leading to the post-cholecystectomy syndrome.A remnant gallbladder with cystic duct or bile duct stones is one of the causes of this syndrome.The objective of this study was to shed light on the clinical manifestations,evaluation,therapeutic strategies,and outcomes associated with laparoscopic management of symptomatic remnant gallbladders.Methods:This was a retrospective study,conducted over a five-year period(January 2017 to December 2022)at Apollo Hospitals in South India.All patients who underwent laparoscopic completion cholecystectomy for a remnant gall bladder were included.The following data were collected:patient demographics,symptoms,preoperative investigations,intraoperative details and post operative outcomes.Results:In total,36 patients were included and analysed.The majority of patients were male(25,69.4%),with a mean age of 50.7±12.1 years.The most common presentation was pain in the upper abdomen or right upper quadrant region(24,66.7%).The laparoscopic approach was attempted in all patients,with a success rate of 94.4%.Two patients required conversion to open surgery.Cholecystoenteric fistula to the colon was observed in one patient.Choledocholithiasis was observed in 7 patients(19.4%),and stone clearance was successfully achieved using endoscopic retrograde cholangiopancreatography in all patients preoperatively.Conclusion:Incomplete gall bladder removal either intentionally or unintentionally leaves a remnant gall bladder that is at risk for stone formation and infection.Patients who have this clinical entity with symptoms require a redo or complete cholecystectomy,a complex procedure associated with certain risks.This study highlights the feasibility and safety of laparoscopic completion cholecystectomy for the management of remnant gallbladder with cystic duct or bile duct stones.

Indications of pro-inflammatory cytokines in laparoscopic and open liver resection for early-stage hepatocellular carcinoma

Background:Our clinical practice of laparoscopic liver resection(LLR)had achieved better short-term and long-term benefits for patients with hepatocellular carcinoma(HCC)over open liver resection(OLR),but the underlying mechanisms are not clear.This study was to find out whether systemic inflammation plays an important role.Methods:A total of 103 patients with early-stage HCC under liver resection were enrolled(LLR group,n=53;OLR group,n=50).The expression of 9 inflammatory cytokines in patients at preoperation,postoperative day 1(POD1)and POD7 was quantified by Luminex Multiplex assay.The relationships of the cytokines and the postoperative outcomes were compared between LLR and OLR.Results:Seven of the circulating cytokines were found to be significantly upregulated on POD1 after LLR or OLR compared to their preoperative levels.Compared to OLR,the POD1 levels of granulocytemacrophage colony-stimulating factor(GM-CSF),interleukin-6(IL-6),IL-8,and monocyte chemoattractant protein-1(MCP-1)in the LLR group were significantly lower.Higher POD1 levels of these cytokines were significantly correlated with longer operative time and higher volume of blood loss during operation.The levels of these cytokines were positively associated with postoperative liver injury,and the length of hospital stay.Importantly,a high level of IL-6 at POD1 was a risk factor for HCC recurrence and poor disease-free survival after liver resection.Conclusions:Significantly lower level of GM-CSF,IL-6,IL-8,and MCP-1 after liver resection represented a milder systemic inflammation which might be an important mechanism to offer better short-term and long-term outcomes in LLR over OLR.

Robotic vs laparoscopic abdominoperineal resection for rectal cancer:A propensity score matching cohort study and metaanalysis

BACKGROUND Robotic surgery(RS)is gaining popularity;however,evidence for abdominoperineal resection(APR)of rectal cancer(RC)is scarce.AIM To compare the efficacy of RS and laparoscopic surgery(LS)in APR for RC.METHODS We retrospectively identified patients with RC who underwent APR by RS or LS from April 2016 to June 2022.Data regarding short-term surgical outcomes were compared between the two groups.To reduce the effect of potential confounding factors,propensity score matching was used,with a 1:1 ratio between the RS and LS groups.A meta-analysis of seven trials was performed to compare the efficacy of robotic and laparoscopic APR for RC surgery.RESULTS Of 133 patients,after propensity score matching,there were 42 patients in each group.The postoperative complication rate was significantly lower in the RS group(17/42,40.5%)than in the LS group(27/42,64.3%)(P=0.029).There wasno significant difference in operative time(P=0.564),intraoperative transfusion(P=0.314),reoperation rate(P=0.314),lymph nodes harvested(P=0.309),or circumferential resection margin(CRM)positive rate(P=0.314)between the two groups.The meta-analysis showed patients in the RS group had fewer positive CRMs(P=0.04),lesser estimated blood loss(P<0.00001),shorter postoperative hospital stays(P=0.02),and fewer postoperative complications(P=0.002)than patients in the LS group.CONCLUSION Our study shows that RS is a safe and effective approach for APR in RC and offers better short-term outcomes than LS.

Comparative analysis of two digestive tract reconstruction methods in total laparoscopic radical total gastrectomy

BACKGROUND The incidence of gastric cancer has significantly increased in recent years.Surgical resection is the main treatment,but the method of digestive tract reconstruction after gastric cancer surgery remains controversial.In the current study,we sought to explore a reasonable method of digestive tract reconstruction and improve the quality of life and nutritional status of patients after surgery.To this end,we statistically analyzed the clinical results of patients with gastric cancer who underwent jejunal interposition double-tract reconstruction(DTR)and esophageal jejunum Roux-en-Y reconstruction(RY).AIM To explore the application effect of DTR in total laparoscopic radical total gastrectomy(TLTG)and evaluate its safety and efficacy.METHODS We collected the relevant data of 77 patients who underwent TLTG at the Fourth Hospital of Hebei Medical University from October 2021 to January 2023.Among them,35 cases were treated with DTR,and the remaining 42 cases were treated with traditional RY.After 1:1 propensity score matching,the cases were grouped into 31 cases per group,with evenly distributed data.The clinical characteristics and short-and long-term clinical outcomes of the two groups were statistically analyzed.RESULTS The two groups showed no significant differences in basic data,intraoperative blood loss,number of lymph node dissections,first defecation time after operation,postoperative hospital stay,postoperative complications,and laboratory examination results on the 1st,3rd,and 5th days after operation.The operation time of the DTR group was longer than that of the RY group[(307.58±65.14)min vs(272.45±62.09)min,P=0.016],but the first intake of liquid food in the DTR group was shorter than that in the RY group[(4.45±1.18)d vs(6.0±5.18)d,P=0.028].The incidence of reflux heartburn(Visick grade)and postoperative gallbladder disease in the DTR group was lower than that in the RY group(P=0.033 and P=0.038).Although there was no significant difference in body weight,hemoglobin,prealbumin,and albumin between the two groups at 1,3 and 6 months after surgery,the diet of patients in the DTR group was better than that in the RY group(P=0.031).CONCLUSION The clinical effect of DTR in TLTG is better than that of RY,indicating that it is a more valuable digestive tract reconstruction method in laparoscopic gastric cancer surgery.