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.

Efficacy and safety of minimally invasive laparoscopic surgery under general anesthesia for ovarian cancer

BACKGROUND Ovarian cancer is one of the most common malignant tumors in female reproductive system in the world,and the choice of its treatment is very important for the survival rate and prognosis of patients.Traditional open surgery is the main treatment for ovarian cancer,but it has the disadvantages of big trauma and slow recovery.With the continuous development of minimally invasive technology,minimally invasive laparoscopic surgery under general anesthesia has been gradually applied to the treatment of ovarian cancer because of its advantages of less trauma and quick recovery.However,the efficacy and safety of minimally invasive laparoscopic surgery under general anesthesia in the treatment of ovarian cancer are still controversial.AIM To explore the efficacy and safety of general anesthesia minimally invasive surgery in the treatment of ovarian cancer.METHODS The clinical data of 90 patients with early ovarian cancer in our hospital were analyzed retrospectively.According to the different surgical treatment methods,patients were divided into study group and control group(45 cases in each group).The study group received minimally invasive laparoscopic surgery under general anesthesia for ovarian cancer,while the control group received traditional open surgery for ovarian cancer.The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire(EORTC QLQ-C30),clinical efficacy and safety of the two groups were compared.RESULTS The intraoperative blood loss,length of hospital stay,postoperative gas evacuation time,and postoperative EORTC QLQ-C30 score of the study group were significantly better than those of the control group(P<0.05).The incidence of postoperative complications in the study group was significantly lower than in the control group(P<0.05).The two groups had no significant differences in the preoperative adrenocorticotropic hormone(ACTH),androstenedione(AD),cortisol(Cor),cluster of differentiation 3 positive(CD3+),and cluster of differentiation 4 positive(CD4+)indexes(P>0.05).In contrast,postoperatively,the study group's ACTH,AD,and Cor indexes were lower,and the CD3+and CD4+indexes were higher than those in the control group(P<0.05).CONCLUSION Minimally invasive laparoscopic surgery under general anesthesia in patients with early ovarian cancer can significantly improve the efficacy and safety,improve the short-term prognosis and quality of life of patients,and is worth popularizing.

Exploring the landscape of minimally invasive pancreatic surgery: Progress, challenges, and future directions

Minimally invasive surgery(MI)has become the standard of care for many surgical procedures aimed at reducing the burden on patients.However,its adoption in pancreatic surgery(PS)has been limited by the pancreas’s unique location and the complexity of the dissection and reconstruction phases.These factors continue to contribute to PS having one of the highest morbidity and mortality rates in general surgery.Despite a rough start,MIPS has gained widespread acceptance in clinical practice recently.Robust evidence supports MI distal pancreatectomy safety,even in oncological cases,indicating its potential superiority over open surgery.However,definitive evidence of MI pancre-aticoduodenectomy(MIPD)feasibility and safety,particularly for malignant lesions,is still lacking.Nonetheless,reports from high-volume centers are emer-ging,suggesting outcomes comparable to those of the open approach.The robotic PS increasing adoption,facilitated by the wider availability of robotic platforms,may further facilitate the transition to MIPD by overcoming the technical con-straints associated with laparoscopy and accelerating the learning curve.Alth-ough the MIPS implementation process cannot be stopped in this evolving world,ensuring patient safety through strict outcome monitoring is critical.Investing in younger surgeons with structured and recognized training programs can promote safe expansion.

Impact of minimally invasive surgery on immune function and stress response in gastric cancer patients

BACKGROUND Gastric cancer remains a leading cause of cancer-related mortality globally.Traditional open surgery for gastric cancer is often associated with significant morbidity and prolonged recovery.AIM To evaluate the effectiveness of laparoscopic minimally invasive surgery as an alternative to traditional open surgery for gastric cancer,focusing on its potential to reduce trauma,accelerate recovery,and achieve comparable oncological out-comes.METHODS This study retrospectively analyzed 203 patients with gastric cancer who underwent surgery at the Shanghai Health Medical College Affiliated Chongming Hospital from January 2020 to December 2023.The patients were divided into two groups:Minimally invasive surgery group(n=102),who underwent laparoscopic gastrectomy,and open surgery group(n=101),who underwent traditional open gastrectomy.We compared surgical indicators(surgical incision size,intraop-erative blood loss,surgical duration,and number of lymph nodes dissected),recovery parameters(time to first flatus,time to start eating,time to ambulation,and length of hospital stay),immune function(levels of IgA,IgG,and IgM),intestinal barrier function(levels of D-lactic acid and diamine oxidase),and stress response(levels of C-reactive protein,interleukin-6,and procalcitonin).RESULTS The minimally invasive surgery group demonstrated significantly better outcomes in terms of surgical indicators,including smaller incisions,less blood loss,shorter surgery time,and more lymph nodes dissected(P<0.05 for all).Recovery was also faster in the minimally invasive surgery group,with earlier return of bowel function,earlier initiation of diet,quicker mobilization,and shorter hospital stays(P<0.05 for all).Furthermore,patients in the minimally invasive surgery group had better preserved immune function,superior intestinal barrier function,and a less pronounced stress response postoperatively(P<0.05 for all).CONCLUSION Laparoscopic minimally invasive surgery for gastric cancer not only provides superior surgical indicators and faster recovery but also offers advantages in preserving immune function,protecting intestinal barrier function,and mitigating the stress response compared to traditional open surgery.These findings support the broader adoption of laparoscopic techniques in the management of gastric cancer.

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.

Benefits and drawbacks of radiofrequency ablation via percutaneous or minimally invasive surgery for treating hepatocellular carcinoma

The management of early stage hepatocellular carcinoma(HCC)presents significant challenges.While radiofrequency ablation(RFA)has shown safety and effectiveness in treating HCC,with lower mortality rates and shorter hospital stays,its high recurrence rate remains a significant impediment.Consequently,achieving improved survival solely through RFA is challenging,particularly in retrospective studies with inherent biases.Ultrasound is commonly used for guiding percutaneous RFA,but its low contrast can lead to missed tumors and the risk of HCC recurrence.To enhance the efficiency of ultrasound-guided percutaneous RFA,various techniques such as artificial ascites and contrast-enhanced ultrasound have been developed to facilitate complete tumor ablation.Minimally invasive surgery(MIS)offers advantages over open surgery and has gained traction in various surgical fields.Recent studies suggest that laparoscopic intraoperative RFA(IORFA)may be more effective than percutaneous RFA in terms of survival for HCC patients unsuitable for surgery,highlighting its significance.Therefore,combining MIS-IORFA with these enhanced percutaneous RFA techniques may hold greater significance for HCC treatment using the MIS-IORFA approach.This article reviews liver resection and RFA in HCC treatment,comparing their merits and proposing a trajectory involving their combination in future therapy.

Traditional craniotomy versus current minimally invasive surgery for spontaneous supratentorial intracerebral haemorrhage:A propensity-matched analysis

BACKGROUND Minimally invasive surgery(MIS)and craniotomy(CI)are the current treatments for spontaneous supratentorial cerebral haemorrhage(SSTICH).AIM To compare the efficacy and safety of MIS and CI for the treatment of SSTICH.METHODS Clinical and imaging data of 557 consecutive patients with SSTICH who underwent MIS or CI between January 2017 and December 2022 were retrospectively analysed.The patients were divided into two subgroups:The MIS group and CI group.Propensity score matching was performed to minimise case selection bias.The primary outcome was a dichotomous prognostic(favourable or unfavourable)outcome based on the modified Rankin Scale(mRS)score at 3 months;an mRS score of 0–2 was considered favourable.RESULTS In both conventional statistical and binary logistic regression analyses,the MIS group had a better outcome.The outcome of propensity score matching was unexpected(odds ratio:0.582;95%CI:0.281–1.204;P=0.144),which indicated that,after excluding the interference of each confounder,different surgical modalities were more effective,and there was no significant difference in their prognosis.CONCLUSION Deciding between MIS and CI should be made based on the individual patient,considering the hematoma size,degree of midline shift,cerebral swelling,and preoperative Glasgow Coma Scale score.

Minimally invasive reconstruction of extensive mid-lower ureteral strictures using a bilateral Boari flap

Objective:To describe and evaluate the technique using bilateral Boari flap ureteroneocystostomy(BBFUNC)for bilateral mid-lower ureteral strictures.Methods:We retrospectively reviewed five patients who underwent minimally invasive BBFUNC in our institution(Union Hospital,Wuhan,China)between July 2019 and December 2021.The bilateral ureters were mobilized and transected above the stenotic segments.The bladder was isolated and incised longitudinally from the middle of the anterior wall.Then,an inverted U-shaped bladder flap was created on both sides,fixed onto the psoas tendon,and anastomosed to the ipsilateral distal normal ureter.Following double-J stenting,the Boari flaps were tubularized,and the bladder was closed with continuous sutures.The patients’perioperative data and follow-up outcomes were collected,and a descriptive statistical analysis was performed.Results:No case converted to open surgery,and no intraoperative complication occurred.The median surgical time was 230(range 203-294)min.The median length of the bladder flaps was 6.2(range 4.3-10.0)cm on the left and 5.5(range 4.7-10.5)cm on the right side.All patients had not developed recurrent ureteral stenosis during the median follow-up time of 17(range 16-45)months and had a normal maximum flow rate after surgery.The median post-void residual was 7(range 0-19)mL.The maximal bladder capacity was decreased in one(20%)patient.Conclusion:The present study demonstrates that minimally invasive BBFUNC is feasible and safe in treating is limited.

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.

Outcomes following minimally invasive dorsal cheilectomy for hallux rigidus:A systematic review

BACKGROUND Cheilectomy of the 1^(st)metatarsophalangeal joint(MTPJ)is one of the most common procedures for the management of hallux rigidus.However,there is no consensus regarding outcomes following minimally invasive dorsal cheilectomy(MIDC)for the management of hallux rigidus.AIM To evaluate outcomes following MIDC for the management of hallux rigidus.METHODS During November 2023,the PubMed,EMBASE and Cochrane Library databases were systematically reviewed to identify clinical studies examining outcomes following MIDC for the management of hallux rigidus.RESULTS Six studies were included.In total,348 patients(370 feet)underwent MIDC for hallux rigidus at a weighted mean follow-up of 37.9±16.5 months.The distribution of patients by Coughlin and Shurna's classification was recorded in 4 studies as follows:Ⅰ(58 patients,27.1%),Ⅱ(112 patients,52.3%),Ⅲ(44 patients,20.6%).Three studies performed an additional 1^(st)MTPJ arthroscopy and debridement following MIDC.Retained intra-articular bone debris was observed in 100%of patients in 1 study.The weighted mean American orthopedic foot and ankle society score improved from a preoperative score of 68.9±3.2 to a postoperative score of 87.1.The complication rate was 8.4%,the most common of which was persistent joint pain and stiffness.Thirty-two failures(8.7%)were observed.Thirty-three secondary procedures(8.9%)were performed at a weighted mean time of 8.6±3.2 months following the index procedure.CONCLUSION This systematic review demonstrated improvements in subjective clinical outcomes together with a moderate complication rate following MIDC for the management of hallux rigidus at short-term follow-up.A moderate reoperation rate at short-term follow-up was recorded.The marked heterogeneity between included studies and paucity of high quality comparative studies limits the generation of any robust conclusions.

Application Research of PETD Combined with MRI Nerve Root Water Imaging in the Minimally Invasive Treatment of LDH

Objective: This study aims to evaluate the safety and efficacy of PETD combined with nerve root water imaging of MRI for the treatment of lumbar disc herniation. Methods: A retrospective review was performed on 62 patients with lumbar disc herniation from March 2019 to March 2021. The study included an experimental group of 30 patients and a control group of 32 patients. The experimental group underwent PETD combined with nerve root water imaging of MRI, while the control group received traditional PETD treatment. The visual analogue scoring method (VAS score), and JOA lumbar spine function score before and after surgery were compared between the two groups, and efficacy was assessed and compared using the MacNab score. Results: The mean operation time was significantly reduced in the experimental group (56.43 &#177;10.40 minutes) compared to the control group (65.69 &#177;14.12 minutes). The VAS score was compared between the two groups with preoperative (p = 0.624), one month after surgery (p = 0.325), three months after surgery (p = 0.676), one year after surgery (p = 0.341);The JOA score was compared between the two groups with preoperative (p = 0.961), one month after the surgery (p = 0.266), three months after surgery (p = 0.185), one year after surgery (p = 0.870), they were no significant statistical difference;The efficacy evaluation of the last follow-up Macnab showed that all the 30 patients in the experimental group were excellent, 31 of 32 patients in the control group were excellent, 1 case was good;There was no statistical difference in the comparison between the two groups (p > 0.05). Conclusion: The study concludes that the combined approach of PETD with nerve root water imaging of MRI is a safe, effective, and more efficient alternative to conventional PETD for treating lumbar disc herniation.

Background,techniques,applications,current trends,and future directions of minimally invasive endoscopic spine surgery:A review of literature

Across many of the surgical specialties,the use of minimally invasive techniques that utilize indirect visualization has been increasingly replacing traditional techniques which utilize direct visualization.Arthroscopic surgery of the appendicular skeleton has evolved dramatically and become an integral part of musculoskeletal surgery over the last several decades,allowing surgeons to achieve similar or better outcomes,while reducing cost and recovery time.However,to date,the axial skeleton,with its close proximity to critical neural and vascular structures,has not adopted endoscopic techniques at as rapid of a rate.Over the past decade,increased patient demand for less invasive spine surgery combined with surgeon desire to meet these demands has driven significant evolution and innovation in endoscopic spine surgery.In addition,there has been an enormous advancement in technologies that assist in navigation and automation that help surgeons circumvent limitations of direct visualization inherent to less invasive techniques.There are currently a multitude of endoscopic techniques and approaches that can be utilized in the treatment of spine disorders,many of which are evolving rapidly.Here we present a review of the field of endoscopic spine surgery,including the background,techniques,applications,current trends,and future directions,to help providers gain a better understanding of this growing modality in spine surgery.

Minimally Invasive Maxillofacial Surgery Using Digital Work Surgery: A Case of Alveolar Ridge Reconstruction after Maxillary Cystectomy

Introduction: Iliac particulate cancellous bone and marrow (PCBM) is commonly used as a high-quality reconstruction material;however, PCBM cannot be extracted in sufficient amounts to meet demand. To determine the appropriate amount of iliac PCBM to be collected, we used digital technology to measure the volume required for jaw reconstruction before surgery. Clinical Case: The patient, a 23-year-old man, underwent surgery for a calcifying odontogenic cyst. A maxillary cyst occupied the left anterior-premolar region (tooth 21 - 25) and the deciduous canine remained;a permanent canine was included in the cyst. We planned to preserve the teeth except for the impacted canine, completely excise the maxillary cyst, and preserve the alveolar ridge morphology. Preoperative digital imaging was used to determine the amount of alveolar ridge reconstruction required and accordingly determine the amount of iliac cancellous bone to be harvested. We used a titanium mesh tray and grafts of iliac particulate cancellous bone and marrow to reconstruct the alveolar ridge. The amount of iliac cancellous bone that needed to be collected was clarified and the supply amount could be collected in just the right amount;thus, the cortical bone of the iliac inner plate could be preserved. The alveolar bone morphology was reconstructed to allow the placement of dental implants as per the preoperative digital surgery. Three years after the operation, no sign of recurrence has been observed. Conclusion: Minimally invasive surgery was performed by clarifying the amount of iliac cancellous bone graft that needs to be harvested, which improved the accuracy of surgery.

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.

Clinical Application of Minimally Invasive Surgery in Pain and Complications after Spinal Trauma

Objective:To study and evaluate the incidence of pain and complications in patients with spinal trauma after minimally invasive treatment.Methods:The research period was selected from January 2018 to December 2020,and 40 patients with spinal trauma were selected.According to the random number table scheme,they were divided into the study group and the control group.The treatment scheme of the control group was traditional surgery,and the treatment scheme of the study group was minimally invasive surgery.The indicators of the two groups were compared and analyzed.Results:Compared with the two groups of surgery and postoperative recovery related indicators,the study group had more advantages(P<0.05);Compared two groups of postoperative NRS score,VAS score and the incidence of complications,the study group had more advantages(P<0.05).Conclusion:Minimally invasive treatment of spinal trauma has significant clinical effect,which can effectively relieve postoperative pain and reduce the incidence of various complications.

Global dissemination of minimally invasive living donor hepatectomy: What are the barriers?

Minimally invasive donor hepatectomy(MIDH)is a relatively novel procedure that can potentially increase donor safety and contribute to faster rehabilitation of donors.After an initial period in which donor safety was not effectively validated,MIDH currently seems to provide improved results,provided that it is conducted by experienced surgeons.Appropriate selection criteria are crucial to achieve better outcomes in terms of complications,blood loss,operative time,and hospital stay.Beyond a pure laparoscopic technique,various approaches have been recommended such as hand-assisted,laparoscopic-assisted,and robotic donation.The latter has shown equal outcomes compared to open and laparoscopic approaches.A steep learning curve seems to exist in MIDH,mainly due to the fragility of the liver parenchyma and the experience needed for adequate control of bleeding.This review investigated the challenges and the opportunities of MIDH and the barriers to its global dissemination.Surgeons need expertise in liver transplantation,hepatobiliary surgery,and minimally invasive techniques to perform MIDH.Barriers can be categorized into surgeon-related,institutionalrelated,and accessibility.More robust data and the creation of international registries are needed for further evaluation of the technique and the acceptance from more centers worldwide.

Lymph node dissection in esophageal carcinoma: Minimally invasive esophagectomy vs open surgery

AIM: To compare lymph node dissection results of minimally invasive esophagectomy(MIE) and open surgery for esophageal squamous cell carcinoma.METHODS: We retrospectively reviewed data from patients who underwent MIE or open surgery for esophageal squamous cell carcinoma from January 2011 to September 2014. Number of lymph nodes resected, positive lymph node(p N+) rate, lymph node sampling(LNS) rate and lymph node metastatic(LNM) rate were evaluated. R E S U LT S : A m o n g 4 4 7 p a t i e n t s i n c l u d e d, 1 2 3 underwent MIE and 324 underwent open surgery. The number of lymph nodes resected did not significantly differ between the MIE and open surgery groups(21.1 ± 4.3 vs 20.4 ± 3.8, respectively, P = 0.0944). The p N+ rate of stage T3 esophageal squamous cell carcinoma in the open surgery group was higher than that in the MIE group(16.3% vs 11.4%, P = 0.031), but no differences was observed for stages T1 and T2 esophageal squamous cell carcinoma. The LNS rate at left para-recurrent laryngeal nerve(RLN) site was significantly higher for open surgery than for MIE(80.2% vs 43.9%, P < 0.001), but no differences were noted at other sites. The LNM rate at left para-RLN site in the open surgery group was significantly higher than that in the MIE group, regardless of pathologic T stage. CONCLUSION: For stages T1 and T2 esophageal squamous cell carcinoma, the lymph node dissection result after MIE was comparable to that achieved by open surgery. However, the efficacy of MIE in lymphadenectomy for stage T3 esophageal squamous cell carcinoma, particularly at left para-RLN site, remains to be improved.

Prognostic value of intracranial pressure monitoring for the management of hypertensive intracerebral hemorrhage following minimally invasive surgery

BACKGROUND:The incidence of hypertensive intracerebral hemorrhage(HICH)has been increasing during the recent years in low-and middle-income countries.With high mortality and morbidity rates,it brings huge burden to the families.It lacks evidence regarding the application of intracranial pressure(ICP)monitoring in HICH.In the current study,the authors aimed to evaluate whether ICP monitoring could make any difference on the prognosis of HICH patients after minimally invasive surgery.METHODS:A retrospective review of 116 HICH patients admitted to the Second Affiliated Hospital of Zhejiang University School of Medicine,between 2014 and 2016,was performed.The effects of ICP monitoring on 6-month mortality and favorable outcomes were evaluated by univariate and logistic regression analysis.RESULTS:ICP monitors were inserted into 50 patients.Patients with ICP monitoring had a significantly better outcome(P<0.05).The average in-hospital duration in patients with ICP monitoring was shorter than that in the patients without ICP monitoring(16.68 days vs.20.47 days,P<0.05).Mortality rates between ICP monitoring and no ICP monitoring did not differ significantly(16.0%vs.15.1%,P=0.901).On univariate analysis,age,Glasgow Coma Scale(GCS)on admission and presence of ICP monitor were independent predictors of 6-month favorable outcomes.CONCLUSION:ICP monitoring is associated with a better 6-month functional outcome compared with no ICP monitoring.Future study is still needed to confirm our results and elucidate which subgroup of HICH patients will benefit most from the minimally invasive surgical intervention and ICP monitoring.

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.

Surgical specimen extraction via a prophylactic ileostomy procedure: A minimally invasive technique for laparoscopic rectal cancer surgery

AIM To retrospectively evaluate the safety and feasibility of surgical specimen extraction via a prophylactic ileostomy procedure in patient with rectal cancer. METHODS We systematically reviewed 331 consecutive patients who underwent laparoscopic anterior resection for rectal cancer and prophylactic ileostomy in our institution from June 2010 to October 2016, including 155 patients who underwent specimen extraction via a prophylactic ileostomy procedure(experimental group), and 176 patients who underwent specimen extraction via a small lower abdominal incision(control group). Clinical data were collected from both groups andstatistically analyzed. RESULTS The two groups were matched in clinical characteristics and pathological outcomes. However, mean operative time was significantly shorter in the experimental group compared to the control group(161.3 ± 21.5 min vs 168.8 ± 20.5 min; P = 0.001). Mean estimated blood loss was significantly less in the experimental group(77.4 ± 30.7 mL vs 85.9 ± 35.5 mL; P = 0.020). The pain reported by patients during the first two days after surgery was significantly less in the experimental group than in the control group. No wound infections occurred in the experimental group, but 4.0% of the controls developed wound infections(P = 0.016). The estimated 5-year disease-free survival and overall survival rate were similar between the two groups.CONCLUSION Surgical specimen extraction via a prophylactic ileostomy procedure represents a secure and feasible approach to laparoscopic rectal cancer surgery, and embodies the principle of minimally invasive surgery.