Videosurgery and Other Miniinvasive Techniques

INTRODUCTION Postoperative constipation is a frequent complication following lumbar surgery under general anesthesia, potentially associated with intraoperative nerve root irritation. However, the incidence of postoperative constipation following unilateral biportal endoscopic (UBE) lumbar surgery and the potential preventive role of intraoperative neurophysiological monitoring (IONM) remain underexplored. AIM We aimed to evaluate whether the application of IONM, anal sphincter free-running electromyogra- phy (frEMG), and the bulbocavernosus reflex (BCR) reduced the incidence of postoperative constipation in patients undergoing UBE lumbar surgery. MATERIALS AND METHODS This retrospective cohort study included 153 patients who underwent UBE lumbar decompression between January and December 2024. The patients were divided into the IONM group (n = 50) and the non -IONM group (n = 103). Intraoperative frEMG activity and the BCR were recorded. The incidences of postoperative constipation, Visual Analog Scale scores, and perioperative outcomes were compared between the cohorts. RESULTS Intraoperative frEMG activity and BCR amplitude reductions were observed in response to surgical manipulation. However, all BCR amplitudes returned to baseline prior to surgical closure. The in- cidence of postoperative constipation was 48% in the IONM group and 65.1% in the non -IONM group (P = 0.04). The rate of delayed bowel movements (within 2 days postoperatively) was 64% in the IONM group, as compared with 80.6% in the non -IONM cohort (P = 0.03). CONCLUSIONS The use of IONM provides real -time neurophysiological feedback during UBE lumbar surgery. It facilitates minimization of aggressive nerve root manipulation, which may be associated with a reduced incidence of postoperative constipation.

INTRODUCTION Periumbilical adhesions may complicate laparoscopic entry and increase the risk of intraoperative injury, yet the isolated effect of prior cesarean section (CS) remains unclear. AIM We aimed to evaluate the association between a history of CS and periumbilical adhesions in total laparoscopic hysterectomy, and assess the value of the visceral slide. MATERIALS AND METHODS A total of 100 patients undergoing total laparoscopic hysterectomy were enrolled and divided into 2 groups: individuals with a history of CS and those with no prior abdominal surgeries. Preoperative visceral slide and intraoperative adhesion assessment were performed. Periop- erative outcomes were recorded and a multivariable analysis was conducted. RESULTS Adhesions were more frequent in the CS group (22% vs 10%; P = 0.06) than the individuals without a history of abdominal surgery. A history of CS was not an independent predictor of adhesions (odds ratio, 0.468; P = 0.23). No major entry -related complications occurred. Perioperative outcomes were similar between the groups. The visceral slide showed low sensitivity (25%) but high specificity (100%). CONCLUSIONS A history of CS alone does not significantly increase periumbilical adhesions or compro- mise entry safety in total laparoscopic hysterectomy. Routine modification of the entry strategy may not be necessary. The visceral slide is useful for confirming adhesions, but does not exclude them.

Introduction:Metabolic and bariatric surgery (MBS) is associated with various postoperative complications and extended hospital stays. Standardized management protocols may enhance patient outcomes. Aim:This study aimed to evaluate the impact of a checklist-based management protocol on postoperative recovery, length of hospital stay (LOS), and complication rates in patients undergoing laparoscopic MBS. Materials and methods:A retrospective analysis was conducted on 209 patients who underwent laparoscopic MBS between December 2021 and December 2022. The patients were divided into 2 groups based on the perioperative management protocol used. The observational group (n = 112) received checklist-based management, while the control group (n = 97) received standard care. Primary outcomes included LOS, time to first flatus, and time to first mobilization. Secondary outcomes comprised postoperative complications classified according to the Clavien-Dindo scale, postoperative nausea and vomiting (PONV), and analgesic consumption. Health literacy and self-efficacy were assessed using the Newest Vital Sign (NVS) questionnaire and the Self-Rated Abilities for Health Practices (SRAHP) scale. Results:The observational group demonstrated shorter median (interquartile range) LOS (4 [4-5] vs 6 [5-7] d; P <⁠0.001), earlier mean (SD) first flatus (36.76 [10.23] vs 48.32 [12.62] h), and shorter mean time to first mobilization (12.58 [4.68] vs 18.5 [6.29] h), as compared with the control group. The total complication rate was lower in the observational group (4.46% vs 16.49%; P = 0.004), and this cohort also showed lower incidence of PONV and reduced analgesic consumption in comparison with the controls. There were no intergroup differences in the NVS or SRAHP scores before application of the checklist-based management, but postmanagement, the observational group scored higher. Conclusions:Checklist-based perioperative management was associated with improved postoperative recovery, reduced complications, as well as enhanced health literacy and self-efficacy in the patients undergoing MBS.

Introduction:Duodenal stump leakage (DSL) is a serious complication after laparoscopic gastrectomy due to gastric cancer (GC). It is associated with increased morbidity and mortality rates, prolonged hospital stay, and complex management. Aim:The aim of this study was to evaluate whether a novel, technically simple clipping technique could help reduce the rate of DSL. Materials and methods:This retrospective multicenter study included patients who underwent laparoscopic radical gastrectomy with D2 lymphadenectomy for gastric adenocarcinoma at 2 tertiary centers. The patients were categorized according to the use of duodenal stump clipping during the procedure. Demographic, clinical, intraoperative, and postoperative variables were compared. The risk factors for DSL were evaluated using univariate and multivariable analyses. Results:A total of 381 patients at a median (interquartile range [IQR]) age of 63 (55-71) years were analyzed; 175 (45.9%) underwent duodenal stump clipping, and 248 (65.1%) were men. The incidence of DSL was lower in the clipping group than the nonclipping group (1.7% vs 5.8%; P = 0.04). The clipping cohort also demonstrated reduced median (IQR) hospital stay (7 [6-10] vs 10 [8-13] d; P <⁠0.001) and a lower 30-day major complication rate (9.1% vs 16%; P = 0.046). In the multivariable analysis, duodenal clipping was not significantly associated with DSL. Conclusions:Duodenal clipping is a simple and technically feasible method for reinforcing the duodenal stump during laparoscopic GC surgery.

Introduction:Nissen sleeve gastrectomy (NSG) is a procedure that combines SG with an antireflux component. However, its impact on weight loss outcomes remains controversial. Comparative data between SG and NSG are limited. Aim:The aim of this study was to compare weight loss after NSG and SG at a minimum of 12 months postsurgery. Materials and methods:This retrospective matched-cohort study included patients who underwent NSG at a high-volume bariatric center between 2023 and 2025. The NSG patients were matched at a 1:2 ratio with individuals undergoing standard SG, using propensity score matching based on age, preoperative body mass index, and date of surgery. Weight loss outcomes, including percentage of total weight loss (%TWL) and percentage of excess weight loss (%EWL), were assessed at a minimum follow-up of 12 months. Subgroup analyses were performed according to follow-up duration (<⁠20 vs ≥20 mo). Results:A total of 25 patients undergoing NSG were matched with 50 SG patients. All study participants were women. At median (interquartile range) follow-up of 20.4 (16-23.1) months, SG was associated with significantly higher %TWL and %EWL, as compared with NSG (32.2% vs 29.3%; P = 0.01 and 87.3% vs 78.5%; P = 0.02, respectively). After stratification by follow-up duration, significant differences were observed only in the patients followed for less than 20 months, whereas weight loss outcomes were comparable between the procedures in the individuals followed for 20 months or longer. Operative time was significantly longer for NSG, while length of hospital stay was similar between the groups. One Clavien-Dindo grade III complication occurred in the NSG group. Conclusions:SG was associated with greater early weight loss than NSG. However, these differences diminished with longer follow-up.

INTRODUCTION:Conversion from sleeve gastrectomy (SG) to Roux -en -Y gastric bypass (RYGB) is increasingly performed for refractory gastroesophageal reflux disease (GERD), recurrent weight gain, and anatomical complications, although outcome data from Middle Eastern centers remain limited. AIM:This study evaluated the effectiveness of conversion from SG to RYGB in a Middle Eastern cohort. RESULTS:The cohort included 32 women at a mean (SD) age of 46 (8) years. Mean (SD) pre‑SG BMI in the study population was 42 (7.2) kg/m2 . According to the main indications for conversion, at 1 year, mean (SD) BMI decreased to 24 (1.9) kg/m2 (GERD), 28 (3.3) kg/m2 (recurrent weight gain), and 27 (2.8) kg/m2 (GERD + recurrent weight gain; P <0.001). Mean (SD) %EWL was 82%, 65%, and 67%, respectively. GERD symptoms improved in 85% of the patients. Type 2 diabetes remission occurred in 58%, hypertension improved in 72%, and complications occurred in 9.1% of the study cohort. Descriptive comparison of laparoscopic and robotic approaches showed similar outcomes, but should be interpreted with caution given the noncontemporaneous treatment periods. CONCLUSIONS:Conversion to RYGB after SG is effective for weight reduction and GERD symptom improvement, with acceptable morbidity rates.

Introduction:Minimally-invasive procedures in breast surgery have gained popularity due to their favorable cosmetic outcomes and oncological results comparable to those achieved with conventional techniques. However, this approach has not been yet widely adopted in Poland, and its availability is limited to a small number of hospitals in Europe. Aim:This study aimed to evaluate the safety and feasibility of the first Polish endoscopic breast-conserving surgeries (E-BCSs). Materials and methods:A total of 30 patients who underwent E-BCS at 2 breast cancer centers in Poland between July 2024 and September 2025 were included in the study. We assessed short-term outcomes of E-BCS in women with early breast cancer or precancerous lesions qualified for local wide excision. Median (interquartile range) observation time was 8 (6-13.25) months. Results:All procedures were completed without conversion to open surgery. No severe complications were observed. Postoperative surgical site infection occurred in 1 patient (3.3%). Three patients (10%) required reoperation due to positive margins. Conclusions:Our preliminary data indicate that E-BCS offers a low risk of complications and short-term safety and feasibility. Its outcomes are comparable to those of conventional surgery, making it a viable alternative to standard procedures.

In this note, we present laparoscopy-assisted endoscopic full-thickness gastric resection with lymphatic mapping-guided regional lymphadenectomy for a G2 gastric neuroendocrine tumor located on the lesser curvature. The procedure achieved complete R0 resection, node-negative status, and uneventful recovery with no recurrence. This experience supports further evaluation of hybrid strategies in selected localized gastric neuroendocrine lesions.

Introduction:Unilateral biportal endoscopic unilateral laminotomy for bilateral decompression (UBE-ULBD) is a minimally-invasive yet technically demanding procedure for lumbar spinal stenosis. Aim:This study aimed to compare the learning curves of 2 generations of surgeons performing UBE-ULBD under a structured mentorship model. Materials and methods:We retrospectively analyzed 200 consecutive surgeries performed between January 2020 and June 2024. The first-generation surgeon (FGS) performed all procedures independently. The second-generation surgeon (SGS) assisted in 30 surgeries and then received on-site supervision for the first 15 independent cases. Data on operative time, blood loss, complications, and clinical outcomes, including the Visual Analog Scale and Oswestry Disability Index, were collected. Operative time-based cumulative sum analysis was used to evaluate the learning curves. Results:The FGS achieved proficiency after 37 and the SGS after 29 procedures. The SGS had significantly shorter mean (SD) operative time of 127.6 (13.2) vs 137.1 (19.3) minutes and lower blood mean (SD) loss of 49 (13.6) vs 57.7 (20.6) milliliters, as compared with his first-generation counterpart. Complications and clinical outcomes were comparable. After achieving proficiency, both surgeons showed improved efficiency without differences in safety or outcomes. Conclusions:Under the guidance of the FGS, the SGS achieved proficiency in UBE-ULBD more rapidly, as reflected in the shorter operative time. Moreover, once proficiency was reached, no notable differences were observed between the 2 surgeons in terms of postoperative complications or clinical outcomes.

Introduction: Effective postoperative analgesia is crucial for recovery after laparoscopic cholecystectomy (LC). Although local anesthetic infiltration (LAI) is commonly used, transversus abdominis plane (TAP) block may offer improved outcomes. Aim: We aimed to evaluate the efficacy and safety of unilateral laparoscopic-assisted TAP (L-TAP) block, LAI, and their combination (L-TAP+LAI) for postoperative pain management after LC. Materials and methods: In this prospective, randomized clinical trial, 160 eligible patients undergoing LC were allocated into 4 equal-sized groups: L-TAP, LAI, L-TAP+LAI, and control, and were blinded to group assignment. The primary outcome was pain intensity measured using the Numerical Rating Scale (NRS) at 2, 6, and 24 hours postoperatively. Secondary outcomes comprised pain intensity at the umbilical, subcostal, and substernal wounds, the number of patients requiring analgesics, and local complications assessed postoperatively. Results: Each group comprised 40 patients. The L-TAP group had lower NRS scores at 2, 6, and 24 hours postoperatively than the LAI group (P = 0.003, P = 0.02, and P = 0.046, respectively). Similarly, subcostal pain was lower in the L-TAP than in the LAI cohort (P = 0.008, P = 0.01, and P <⁠0.001, respectively). No major complications were observed. Ecchymosis occurred most frequently in the LAI group (P = 0.03). Conclusions: Laparoscopic-guided unilateral TAP block is a safe and effective method for postoperative analgesia in LC. It provides superior pain control and fewer wound-related complications than LAI, supporting its use as a practical intraoperative alternative to trocar-site infiltration.

Introduction:Diagnostic laparoscopy (DL) is increasingly used in the preoperative evaluation of patients with peritoneal metastasis (PM) who are considered for cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). Cross-sectional imaging has limited accuracy for assessing small-bowel and mesenteric disease, which are key determinants of resectability. DL may improve patient selection and reduce the frequency of nontherapeutic laparotomy. Aim:We aimed to summarize current evidence on the feasibility, diagnostic performance, and clinical impact of DL in patients with PM undergoing qualification for CRS-HIPEC. Materials and methods:A narrative review of the literature was conducted. The studies were identified through a search of the PubMed, MEDLINE, and Scopus databases, supplemented by manual reference screening. Eligible publications included prospective retrospective cohorts, multicenter studies, diagnostic accuracy trials, and reviews reporting outcomes of DL for CRS-HIPEC. The data were synthesized thematically. No meta-analysis was performed. Results:A total of 29 studies were included. Across 3632 procedures, DL was successfully completed in 98.3% of the patients. As many as 1034 individuals (28.5%) were excluded from CRS-HIPEC based on laparoscopic findings. Reduction in the frequency of futile laparotomy was reported across various tumor types, including colorectal metastasis (approximately 12%-17%), gastric cancer (approximately 30%), and ovarian cancer (approximately 58%, when combined with computed tomography findings). Peritoneal cancer index underestimation occurred in 40%-63% of the mixed cohorts, mainly due to limited visualization of the small bowel. Positive predictive value for complete cytoreduction ranged from 80% to 95%. Major morbidity was below 2% in most series. Conclusions:DL is a safe and accurate staging tool that improves patient selection for CRS-HIPEC, reduces the need for nontherapeutic laparotomy, and supports timely initiation of appropriate therapy. It should be considered a key component of contemporary staging pathways for PM.

Introduction:The prevalence and risk factors for postoperative incisional hernia (IH) following cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) remain uncertain, with published studies reporting highly variable outcomes. Aim:This systematic review and meta-analysis aimed to estimate the pooled prevalence of IH after CRS-HIPEC and risk factors associated with it. Materials and methods:A comprehensive search of the PubMed, Embase, and Cochrane Library databases was conducted to identify relevant observational studies. A total of 12 studies reporting IH after CRS-HIPEC were included. Study quality was assessed using the Newcastle-Ottawa Scale, and random-effects models were applied to calculate pooled prevalence and risk factors for postoperative IH following CRS-HIPEC. Subgroup, sensitivity, and publication bias analyses were performed to evaluate robustness of the findings. Results:A total of 12 studies comprising 2170 patients were qualified for this review. The estimated average pooled prevalence of IH after CRS-HIPEC was 13% (95% CI, 9-16), with individual study estimates ranging from 6.9% to 26.9%, and substantial heterogeneity (I 2 = 85.2%). Subgroup analyses showed lower prevalence in prospective studies and larger cohorts, while multicenter studies demonstrated lower prevalence rates, as compared with single-center cohorts. Several risk factors were significantly associated with IH, including perioperative chemotherapy, bowel anastomosis or stoma formation, older age, obesity, and postoperative complications. Sensitivity analysis confirmed stability of the results, and the Egger test did not indicate significant small-study effects. Conclusions:IH is a notable and clinically relevant long-term complication following CRS-HIPEC. The risk of IH is driven primarily by patient age, obesity, perioperative chemotherapy exposure, gastrointestinal reconstruction, and postoperative complications.