New direction for surgery:Super minimally invasive surgery

The top goal of modern medicine is treating disease without destroying organ structures and making patients as healthy as they were before their sickness.Minimally invasive surgery(MIS)has dominated the surgical realm because of its lesser invasiveness.However,changes in anatomical structures of the body and reconstruction of internal organs or different organs are common after traditional surgery or MIS,decreasing the quality of life of patients post-operation.Thus,I propose a new treatment mode,super MIS(SMIS),which is defined as“curing a disease or lesion which used to be treated by MIS while preserving the integrity of the organs”.In this study,I describe the origin,definition,operative channels,advantages,and future perspectives of SMIS.

Removal of a large rectal polyp with endoscopic submucosal dissection-trans-anal rectoscopic assisted minimally invasive surgery hybrid technique:A case report

BACKGROUND Endoscopic submucosal dissection(ESD)can be used for the en-bloc removal of superficial rectal lesions;however,the lack of a traction system makes the procedure long and difficult in the presence of extensive lesions.CASE SUMMARY A large polyp occupying 2/3 of the rectal circumference and extending 5 cm in length was removed by ESD with the help of laparoscopic forceps introduced via trans-anal rectoscopic assisted minimally invasive surgery,a disposable platform designed to aid in transanal minimally invasive surgery.Traction of the polyp by forceps during the operation was dynamic,and applied at various points and in various directions.The polyp was removed en-bloc without complications in 1 h and 55 min.A sigmoidoscopy performed 50 d later showed normal healing without polyp recurrence.CONCLUSION The technique presented here could overcome the issues caused by lack of traction during ESD for rectal lesions.

Role of minimally invasive surgery for rectal cancer

Rectal cancer is one of the most common malignancies worldwide.Surgical resection for rectal cancer usually requires a proctectomy with respective lymphadenectomy(total mesorectal excision).This has traditionally been performed transabdominally through an open incision.Over the last thirty years,minimally invasive surgery platforms have rapidly evolved with the goal to accomplish the same quality rectal resection through a less invasive approach.There are currently three resective modalities that complement the traditional open operation:(1)Laparoscopic surgery;(2)Robotic surgery;and(3)Transanal total mesorectal excision.In addition,there are several platforms to carry out transluminal local excisions(without lymphadenectomy).Evidence on the various modalities is of mixed to moderate quality.It is unreasonable to expect a randomized comparison of all options in a single trial.This review aims at reviewing in detail the various techniques in regard to intra-/perioperative benchmarks,recovery and complications,oncological and functional outcomes.

Minimally invasive surgery for gastric cancer: A comparison between robotic, laparoscopic and open surgery

AIM To investigate the role of minimally invasive surgery for gastric cancer and determine surgical, clinical, and oncological outcomes.METHODS This is a propensity score-matched case-control study, comparing three treatment arms: robotic gastrectomy(RG), laparoscopic gastrectomy(LG), open gastrectomy(OG). Data collection started after sharing a specific study protocol. Data were recorded through a tailored and protected web-based system. Primary outcomes: harvested lymph nodes, estimated blood loss, hospital stay, complications rate. Among the secondary outcomes, there are: operative time, R0 resections, POD of mobilization, POD of starting liquid diet and soft solid diet. The analysis includes the evaluation of type and grade of postoperative complications. Detailed information of anastomotic leakages is also provided.RESULTS The present analysis was carried out of 1026 gastrectomies. To guarantee homogenous distribution of cases, patients in the RG, LG and OG groups were 1:1:2 matched using a propensity score analysis with a caliper = 0.2. The successful matching resulted in a total sample of 604 patients(RG = 151; LG = 151; OG = 302). The three groups showed no differences in all baseline patients characteristics, type of surgery(P = 0.42) and stage of the disease(P = 0.16). Intraoperative blood loss was significantly lower in the LG(95.93 ± 119.22) and RG(117.91 ± 68.11) groups compared to the OG(127.26 ± 79.50, P = 0.002). The mean number of retrieved lymph nodes was similar between the RG(27.78 ± 11.45), LG(24.58 ± 13.56) and OG(25.82 ± 12.07) approach. A benefit in favor of the minimally invasive approaches was found in the length of hospital stay(P < 0.0001). A similar complications rate was found(P = 0.13). The leakage rate was not different(P = 0.78) between groups.CONCLUSION Laparoscopic and robotic surgery can be safely performed and proposed as possible alternative to open surgery. The main highlighted benefit is a faster postoperative functional recovery.

Short-term effect and long-term prognosis of neuroendoscopic minimally invasive surgery for hypertensive int-racerebral hemorrhage

BACKGROUND Hypertensive intracerebral hemorrhage is a common critical disease of the nervous system,comprising one fifth of all acute cerebrovascular diseases and has a high disability and mortality rate.It severely affects the patients’quality of life.AIM To analyze the short-term effect and long-term prognosis of neuroendoscopic minimally invasive surgery for hypertensive intracerebral hemorrhage.METHODS From March 2018 to May 2020,118 patients with hypertensive intracerebral hemorrhage were enrolled in our study and divided into a control group and observation group according to the surgical plan.The control group used a hard-channel minimally invasive puncture and drainage procedure.The observation group underwent minimally invasive neuroendoscopic surgery.The changes in the levels of serum P substances(SP),inflammatory factors[tumor necrosis factor-α,interleukin-6(IL-6),IL-10],and the National Hospital Stroke Scale(NIHSS)and Barthel index scores were recorded.Surgery related indicators and prognosis were compared between the two groups.RESULTS The operation time(105.26±28.35)of the observation group was min longer than that of the control group,and the volume of intraoperative bleeding was 45.36±10.17 mL more than that of the control group.The hematoma clearance rates were 88.58%±4.69%and 94.47%±4.02%higher than those of the control group at 48 h and 72 h,respectively.Good prognosis rate(86.44%)was higher in the observation group than in the control group,and complication rate(5.08%)was not significantly different from that of the control group(P>0.05).The SP level and Barthel index score of the two groups increased(P<0.05)and the inflam-matory factors and NIHSS score decreased(P<0.05).The cytokine levels,NIHSS score,and Barthel index score were better in the observation group than in the control group(P<0.05).CONCLUSION Neuroendoscopic minimally invasive surgery is more complicated than hard channel minimally invasive puncture drainage in the treatment of hypertensive intracerebral hemorrhage;however,hematoma clearance is more thorough,and the short-term effect and long-term prognosis are better than hard channel minimally invasive puncture drainage.

Association of Satellite Sign with Postoperative Rebleeding in Patients Undergoing Stereotactic Minimally Invasive Surgery for Hypertensive Intracerebral Haemorrhage

There are few studies regarding imaging markers for predicting postoperative rebleeding after stereotactic minimally invasive surgery(MIS)for hypertensive intracerebral haemorrhage(ICH),and little is known about the relationship between satellite sign on computed tomography(CT)scans and postoperative rebleeding after MIS.This study aimed to determine the value of the CT satellite sign in predicting postoperative rebleeding in patients with hypertensive ICH who undergo stereotactic MIS.We retrospectively examined and analysed 105 patients with hypertensive ICH who underwent standard stereotactic MIS for hematoma evacuation within 72 h following admission.Postoperative rebleeding occurred in 14 of 65(21.5%)patients with the satellite sign on baseline CT,and in 5 of the 40(12.5%)patients without the satellite sign.This diiTerence was statistically significant.Positive and negative values of the satellite sign for predicting postoperative rebleeding were 21.5%and 87.5%,respectively.Multivariate logistic regression analysis verified that baseline ICH volume and intraventricular rupture were independent predictors of postoperative rebleeding.In conclusion,the satellite sign on baseline CT scans may not predict postoperative rebleeding following stereotactic MIS for hypertensive ICH.

Prognostic factors of minimally invasive surgery for gastric cancer: Does robotic gastrectomy bring oncological benefit?

BACKGROUND Gastric cancer is the third leading cause of cancer-related death worldwide and surgical resection remains the sole curative treatment for gastric cancer.Minimally invasive gastrectomy including laparoscopic and robotic approaches has been increasingly used in a few decades.Thus far,only a few reports have investigated the oncological outcomes following minimally invasive gastrectomy.AIM To determine the 5-year survival following minimally invasive gastrectomy for gastric cancer and identify prognostic predictors.METHODS This retrospective cohort study identified 939 patients who underwent gastrectomy for gastric cancer during the study period.After excluding 125 patients with non-curative surgery(n=77),other synchronous cancer(n=2),remnant gastric cancer(n=25),insufficient physical function(n=13),and open gastrectomy(n=8),a total of 814 consecutive patients with primary gastric cancer who underwent minimally invasive R0 gastrectomy at our institution between 2009 and 2014 were retrospectively examined.Accordingly,5-year overall and recurrence-free survival were analyzed using the Kaplan–Meier method with the log-rank test and Cox regression analyses,while factors associated with survival were determined using multivariate analysis.RESULTS Our analysis showed that age>65 years,American Society of Anesthesiologists(ASA)physical status 3,total or proximal gastrectomy,and pathological T4 and N positive status were independent predictors of both 5-year overall and recurrencefree survival.Accordingly,the included patients had a 5-year overall and recurrence-free survival of 80.3%and 78.2%,respectively.Among the 814 patients,157(19.3%)underwent robotic gastrectomy,while 308(37.2%)were diagnosed with pathological stage II or III disease.Notably,our findings showed that robotic gastrectomy was an independent positive predictor for recurrence-free survival in patients with pathological stage II/III[hazard ratio:0.56(0.33-0.96),P=0.035].Comparison of recurrence-free survival between the robotic and laparoscopic approach using propensity score matching analysis verified that the robotic group had less morbidity(P=0.005).CONCLUSION Age,ASA status,gastrectomy type,and pathological T and N status were prognostic factors of minimally invasive gastrectomy,with the robot approach possibly improving long-term outcomes of advanced gastric cancer.

Complete mesocolic excision and central vascular ligation in colorectal cancer in the era of minimally invasive surgery

Since the 19th century,appropriate lymphadenectomy has been considered a cornerstone of oncologic surgery and one of the most important prognostic factors.This approach can be applied to any surgery for gastrointestinal cancer.During surgery for colon and rectal cancer,an adequate portion of the mesentery is removed together with the segment of bowel affected by the disease.The adequate number of lymph nodes to be removed is standardized and reported by several guidelines.It is mandatory to determine the appropriate extent of lymphadenectomy and to balance its oncological benefits with the increased morbidity associated with its execution in cancer patients.Our review focuses on the concept of“complete mesenteric excision(CME)with central vascular ligation(CVL),”a radical lymphadenectomy for colorectal cancer that has gained increasing interest in recent years.The aim of this study was to evaluate the evolution of this approach over the years,its potential oncologic benefits and potential risks,and the improvements offered by laparoscopic techniques.Theoretical advantages of CME are improved local-relapse rates due to complete removal of the intact mesocolic fascia and improved distance recurrence rates due to ligation of vessels at their origin(CVL)which guarantees removal of a larger number of lymph nodes.The development and worldwide diffusion of laparoscopic techniques minimized postoperative trauma in oncologic surgery,providing the same oncologic results as open surgery.This has been widely applied to colorectal cancer surgery;however,CME entails a technical complexity that can limit its wide minimally-invasive application. This review analyzesresults of these procedures in terms of oncological outcomes, technical feasibilityand complexity, especially within the context of minimally invasive surgery.

Open surgery in the era of minimally invasive surgery

The benefits and popularity of minimally invasive surgery are undeniable around the globe.However,open surgery is necessary and learning open surgery skills is still a necessity.Open surgery allows for better exposure to the surgical field and provides tactile sensation to facilitate the stereo visual assessment to precisely remove the lesion.Open surgery is still the key to surgical training,and the skills learned from open surgeries remain crucial for unforeseen circumstances and certain conditions like emergencies,challenge cases,or patients with compromised status.

Transanal minimally invasive surgery using laparoscopic instruments of the rectum:A review

Transanal minimally invasive surgery(TAMIS)was first described in 2010 as an alternative to transanal endoscopic microsurgery(TEM).The TAMIS technique can be access to the proximal and mid-rectum for resection of benign and earlystage malignant rectal lesions and also used for noncurative intent surgery of more advanced lesions in patients who are not candidates for radical surgery.TAMIS has a shorter learning curve,reduced device setup time,flexibility in instrument use,and versatility in application than TEM.Also,TAMIS shows similar results in a view of the operation time,conversion rate,reoperation rate,and complication to TEM.For these reasons,TAMIS is an easily accessible,technically feasible,and cost-effective alternative to TEM.Overall,TAMIS has enabled the performance of high-quality local excision of rectal lesions by many colorectal surgeons.As TAMIS becomes more broadly utilized such as pelvic abscess drainage,rectal stenosis,and treatment of anastomotic dehiscence,the acquisition of appropriate training must be ensured,and the continued assessment and assurance of outcome must be maintained.

Innovations promote the development of minimally invasive surgery

For helping millions of patients to live longer and possess higher quality life,the innovation of novel surgical procedures is very necessary and urgent.This paper introduces a series of innovations of Dr.Xiujun Cai,such as Laparoscopic Peng's multifunctional operative dissector,curettage and aspiration procedure,Cai's associating liver partition with portal vein ligation for staged hepatectomy,sutureless anastomosisetc in minimally invasive field.The paper advocates the pace of medical invention should be accelerated,inspiring hope for better clinical outcomes with less invasive procedures and shorter recovery time.

Miniature 6-axis force/torque sensor for force feedback in robot-assisted minimally invasive surgery

In order to restore force sensation to robot-assisted minimally invasive surgery(RMIS),design and performance evaluation of a miniature 6-axis force/torque sensor for force feedback is presented.Based on the resistive sensing method,a flexural-hinged Stewart platform is designed as the flexible structure,and a straightforward optimization method considering the force and sensitivity isotropy of the sensor is proposed to determine geometric parameters which are best suited for the given external loads.The accuracy of this method is preliminarily discussed by finite element methods(FEMs).The sensor prototype is fabricated with the development of the electronic system.Calibration and dynamic loading tests for this sensor prototype are carried out.The working ranges of this sensor prototype are 30 N and 300 N·mm,and resolutions are 0.08 N in radial directions,0.25 N in axial direction,and 2.4 N·mm in rotational directions.It also exhibits a good capability for a typical dynamic force sensing at a frequency close to the normal heart rate of an adult.The sensor is compatible with surgical instruments for force feedback in RMIS.

Minimally invasive surgery vs laparotomy in patients with colon cancer residing in high-altitude areas

BACKGROUND Colon cancer is associated with a higher incidence among residents in highaltitude areas.Hypoxic environment at high altitudes inhibits the phagocytic and oxygen-dependent killing function of phagocytes,thereby increasing the inflammatory factors,inhibiting the body’s innate immunity and increasing the risk of colon cancer.AIM To examine the effect of minimally invasive surgery vs laparotomy in patients with colon cancer residing in high-altitude areas.METHODS Ninety-two patients with colon cancer in our hospital from January 2019 to February 2021 were selected and divided into the minimally invasive surgery and laparotomy groups using the random number table method,with 46 patients in each group.Minimally invasive surgery was performed in the minimally invasive group and laparotomy in the laparotomy group.Operative conditions,inflammatory index pre-and post-surgery,immune function index and complication probability were measured.RESULTS Operative duration was significantly longer and intraoperative blood loss and recovery time of gastrointestinal function were significantly less(all P<0.05)in the minimally invasive group than in the laparotomy group.The number of lymph nodes dissected was not significantly different.Before surgery,there were no significant differences in serum C-reactive protein,interleukin-6 and tumor necrosis factor-αlevels between the groups,whereas after surgery,the levels were significantly higher in the minimally invasive group(26.98±6.91 mg/L,146.38±11.23 ng/mL and 83.51±8.69 pg/mL vs 41.15±8.39 mg/L,186.79±15.36 ng/mL and 110.65±12.84 pg/mL,respectively,P<0.05).Furthermore,before surgery,there were no significant differences in CD3+,CD4+and CD4+/CD8+levels between the groups,whereas after surgery,the levels decreased in both groups,being significantly higher in the minimally invasive group(55.61%±4.39%,35.45%±3.67%and 1.30±0.35 vs 49.68%±5.33%,31.21%±3.25%and 1.13±0.30,respectively,P<0.05).Complication probability was significantly lower in the minimally invasive group(4.35%vs 17.39%,P<0.05).CONCLUSION Laparoscopic minimally invasive procedures reduce surgical trauma and alleviate the inflammatory response and immune dysfunction caused by invasive operation.It also shortens recovery time and reduces complication probability.

Minimally invasive surgery for glycogen storage disease combined with inflammatory bowel disease:A case report

BACKGROUND Inflammatory bowel disease(IBD)is rare in patients with glycogen storage disease(GSD).In GSD patients,a decrease in the number of neutrophils leads to prolonged intestinal infection,leading to the formation of chronic inflammation and eventually the development of IBD.Minimally invasive surgery for patients with IBD has been proven to reduce inflammatory responses and postoperative risks and ultimately promote rapid recovery.Herein we discuss minimally invasive surgery and the perioperative management in a patient with GSD and IBD.CASE SUMMARY A 23-year-old male had GSD Ib associated with IBD-like disease for 10 years.Despite standard treatments,such as mesalazine,prednisone and adalimumab,the patient eventually developed colonic stenosis with incomplete ileus.After adequate assessment,the patient was treated with minimally invasive surgery and discharged in stable condition.CONCLUSION Minimally invasive surgery for patients with IBD and GSD is safe,feasible and effective.

Vascular resections in minimally invasive surgery for pancreatic cancer

Pancreatic ductal adenocarcinoma(PDAC)is characterised by poor oncological outcome and is the seventh cause of cancer-related deaths worldwide.With the advances in surgical technology,oncological treatment,and critical care,extended pancreatic resections including vascular resections have become more frequently performed in specialised centres.Furthermore,the boundaries of resectability continue to be pushed in order to achieve a potentially curative approach in selected patients in combination with neoadjuvant and adjuvant treatment strategies.This review gives an overview on the current state of venous and arterial resections in PDAC surgery with particular attention given to the minimally invasive approach.

Current status of minimally invasive surgery for pancreatic cancer

Pancreatic cancer(PC)is the most lethal cancer among digestive system cancers.Although the only way to radically cure PC is surgical resection,complex surgical procedures and severe post-operative complications lead to high mortality.In recent years,minimally invasive surgery has become more common for PC.Minimally invasive pancreatic resection(MIPR)with the laparoscopic or robotic method has shown its superiority compared with traditional surgery.However,increasing evidence indicates that the long-term or even short-term outcomes of MIPR for PC patients remain controversial.Moreover,the indications and learning curve of MIPR require further assessment.This review aims to discuss the progress in current MIPR,analyze the specific problems and obstacles in the development of MIPR,and try to standardize MIPR procedures and improve the outcomes of MIPR.

Transanal minimally invasive surgery to rescue anastomosis following leak after low anterior resection: A case report

Restorative low anterior resection(LAR)for rectal cancer carries a significant risk of anastomotic leak:One of the most feared complications in colorectal surgery.Operative management may include takedown of the anastomosis and end colostomy which,in some cases,is permanent.Other contemporary operative measures include over the scope clips and Endosponge.Recently,there have been case reports and a Society of American Endoscopic and Gastrointestinal Surgeons video on the novel use of transanal minimally invasive surgery(TAMIS)in the management of anastomotic leak.We present a 59-year-old female who underwent LAR after declining radiotherapy for a bulky 9 cm rectal tumour 9-10 cm from the anal verge.Following clinical deterioration,computed tomography demonstrated an anastomotic leak communicating with a 5-cm pelvic collection containing gas.At laparoscopy,pus and faeculent material were washed from the pelvic cavity and drains were placed.Intra-operative endoscopy demonstrated a 7-8 mm dehiscence at the anastomosis.The defect(approximately 7 cm from the anal verge)was successfully closed using TAMIS and a running V-lock suture.The patient recovered well and was discharged home on post-operative day 20.In this case,a low colorectal anastomotic leak was successfully rescued with TAMIS.This novel technique may be useful in the armamentarium of colorectal surgeons experienced in TAMIS.

Imaging for Minimally Invasive Surgery

The successful outcome of any minimally invasive procedure is highly dependent on the imaging chain, as the medical team has to rely on indirect visualization of the surgical field during the entire procedure. During the last decade, the quality of the images obtainable pre- and intraoperatively has evolved significantly. In addition to the introduction of intra-operative image acquisition techniques such as ultrasound, X-ray, CT or MR, optical imaging technology as well as the corresponding processing units have undergone a rapid development. The article will review the activity related to minimally invasive procedures at the Operating Rooms of the Future (FOR) at St. Olavs Hospital, University Hospital of Trondheim, Norway. The imaging related demands of several surgical fields are introduced and the evolution of the imaging and visualization techniques at FOR will be presented. Subsequently, ongoing research projects in a dedicated visualization laboratory will be discussed and the advantages of updating the imaging equipment continuously in order to keep up with the latest developments in the field will be presented. It will be shown that the quality of the image acquisition and display can be significantly improved when compared to today’s standard. In addition to increasing the surgeon’s confidence, better imaging will lead to increased patient safety as well as more efficient interventions.

Incidence of surgical site infection in minimally invasive colorectal surgery

BACKGROUND Surgical site infection(SSI)is a common complication of colorectal surgery.Minimally invasive surgery notably reduces the incidence of SSI.This study aimed to compare the incidences of SSI after robot-assisted colorectal surgery(RACS)vs that after laparoscopic assisted colorectal surgery(LACS)and to analyze associated risk factors for SSI in minimally invasive colorectal surgery.AIM To compare the incidences of SSI after RACS and LACS,and to analyze the risk factors associated with SSI after minimally invasive colorectal surgery.METHODS Clinical data derived from patients who underwent minimally invasive colorectal surgery between October 2020 and October 2022 at the First Affiliated Hospital of Soochow University were collated.Differences in clinical characteristics and surgeryrelated information associated with RACS and LACS were compared,and possible risk factors for SSI were identified.RESULTS A total of 246 patients(112 LACS and 134 RACS)were included in the study.Fortythree(17.5%)developed SSI.The proportions of patients who developed SSI were similar in the two groups(17.9%vs 17.2%,P=0.887).Diabetes mellitus,intraoperative blood loss≥100 mL,and incision length were independent risk factors for SSI.Possible additional risk factors included neoadjuvant therapy,lesion site,and operation time.CONCLUSION There was no difference in SSI incidence in the RACS and LACS groups.Diabetes mellitus,intraoperative blood loss≥100 mL,and incision length were independent risk factors for postoperative SSI.

Present situation of minimally invasive surgical treatment for early gastric cancer

Minimally invasive surgery is a kind of surgical operation,which is performed by using professional surgical instruments and equipment to inactivate,resect,repair or reconstruct the pathological changes,deformities and wounds in human body through micro-trauma or micro-approach,in order to achieve the goal of treatment,its surgical effect is equivalent to the traditional open surgery,while avoiding the morbidity of conventional surgical wounds.In addition,it also has the advantages of less trauma,less blood loss during operation,less psychological burden and quick recovery on patients,and these minimally invasive techniques provide unique value for the examination and treatment of gastric cancer patients.Surgical minimally invasive surgical techniques have developed rapidly and offer numerous options for the treatment of early gastric cancer(EGC):endoscopic mucosal resection(EMR),underwater EMR(UEMR),endoscopic submucosal dissection(ESD),endoscopic full-thickness resection(EFTR),endoscopic submu-cosal excavation(ESE),submucosal tunnel endoscopic resection,laparoscopic and endoscopic cooperative surgery(LECS);Among them,EMR,EFTR and LECS technologies have a wide range of applications and different modific-ations have been derived from their respective surgical operations,such as band-assisted EMR(BA-EMR),conven-tional EMR(CEMR),over-the-scope clip-assisted EFTR,no-touch EFTR,the inverted LECS,closed LECS,and so on.These new and improved minimally invasive surgeries are more precise,specific and effective in treating different types of EGC.