BACKGROUND:Paraesophageal hernias are a prevalent medical condition often treated with surgical intervention, and decisions regarding hernia sac management are involved. Sac excision during PEH repair has emerged as a viable and safe management strategy, with potential implications for patient outcomes. This study aimed to assess the impact of sac excision on hernia recurrence, reoperation rates, and postoperative gastroesophageal reflux disease (GERD) in patients undergoing hernia repair. METHODS:A retrospective analysis was conducted on patients who underwent paraesophageal hernia repair between 2014 and 2022. Data on patient demographics, preoperative evaluation, surgical technique, and long-term follow-up were collected and analyzed. Primary outcomes included hernia recurrence, reoperation rates, and postoperative GERD assessed over a mean follow-up of 1.8 years. RESULTS:Analysis of a 1154-patient cohort revealed that sac excision during paraesophageal hernia repair did not significantly affect hernia recurrence ( P =0.27). Notably, the reoperation rate was similar between patients with and without sac excision ( P =0.28), indicating no significant difference in the need for reoperation. However, sac excision was associated with a lower incidence of persistent postoperative gastroesophageal reflux disease (GERD) ( P =0.03). CONCLUSIONS:Sac excision during paraesophageal hernia repair does not significantly impact hernia recurrence or reoperation rates but may be associated with a lower incidence of persistent postoperative GERD.
Background: Transanal minimally invasive surgery (TAMIS) emerged as a validated technique for local excision of rectal adenomas and early-stage adenocarcinomas. In organ preservation protocols, TAMIS is increasingly used for mid- and low-rectal cancers, achieving complete or major clinical response (cCR/cMR) following neoadjuvant chemoradiotherapy, complementing Watch-and-Wait strategies with low morbidity and favorable outcomes. Robotic platforms, particularly the Da Vinci SP, have improved surgical dexterity and visualization in confined pelvic spaces. Despite CE approval and encouraging feasibility data, widespread adoption of SP-TAMIS remains limited due to docking constraints. This study reports the first European series of rectal cancer cases treated with SP-TAMIS (SPrTAMIS) using a novel small FishBowl docking system and evaluates its feasibility, safety, and short-term outcomes. Materials and Methods: Five patients with rectal adenocarcinoma, selected based on organ preservation criteria, underwent SPrTAMIS using the Da Vinci SP system. Preoperative assessment included endoscopy, MRI, CT, and bowel preparation. Procedures were performed under general anesthesia with CO 2 pneumorectum (12 mm Hg) and robotic instrumentation via the FishBowl docking system. Data collected included tumor characteristics, surgical duration, estimated blood loss (EBL), morbidity, mortality, length of stay (LOS), and functional outcomes (LARS and MSKCC scores). Results: All procedures were completed robotically without conversion. The mean lesion size was 8.8 mm, located 50 mm from the anal verge and 16 mm from the anorectal junction. Mean operative time was 85 minutes. No intraoperative complications or mortality occurred. GI function resumed by postoperative day (POD) 1; all patients were discharged by POD 2. One minor, asymptomatic suture dehiscence was observed. Histology confirmed complete excision with negative margins. The median follow-up was 68 days, and functional and quality-of-life outcomes were favorable. Conclusions: SPrTAMIS using Da Vinci SP and the FishBowl system is feasible and safe for rectal excision, offering ergonomic advantages and minimal anal canal trauma. Further studies are warranted to assess long-term oncologic and functional outcomes.
PURPOSE:Since laparoscopic surgery is performed with carbon dioxide (CO 2 ) insufflation, it is known to have some metabolic consequences. Due to these metabolic changes, some clinicians may prefer open surgery for inguinal hernia in patients with pulmonary comorbidities. Our study aimed to compare the metabolic and systemic perioperative effects of preperitoneal insufflation with those of intraperitoneal insufflation. METHODS:This prospective controlled study included 20 patients who underwent totally extraperitoneal (TEP) inguinal hernia repair and 20 patients who underwent laparoscopic cholecystectomy. End-tidal carbon dioxide (ETCO 2 ), peak inspiratory pressure (PIP), vital parameters, and arterial blood gas analysis results [pH, bicarbonate (HCO 3- ), partial pressure of carbon dioxide (PCO 2 ), and lactate] were recorded before insufflation and at 10 and 20 minutes after insufflation. These parameters were compared between the 2 groups. RESULTS:In comparison between groups, no statistically significant differences were found in terms of age, gender, ASA score, or BMI ( P >0.05). In both groups, within-group analyses of HCO 3 , ETCO 2 , and PCO 2 showed that 10-minute measurements were significantly higher than preinsufflation and 20-minute measurements ( P <0.05), whereas lactate levels did not show significant variation. When vital parameters were evaluated within-group analysis, diastolic blood pressure and pulse were observed to be lower in both groups at preinsufflation compared with the 10- and 20-minute measurements ( P >0.05). No statistically significant difference was observed between the groups when preinsufflation 10-minute and 20-minute analyses were evaluated for all parameters ( P <0.05). CONCLUSION:On the basis of the standardized intergroup analyses of pulmonary and metabolic parameters, preperitoneal and intraperitoneal CO 2 insufflation demonstrated similar perioperative respiratory and metabolic effects. Laparoscopic inguinal hernia repair, which offers rapid postoperative recovery, does not appear to impose a greater metabolic burden than laparoscopic cholecystectomy. Therefore, laparoscopy may be considered a primary surgical approach for inguinal hernia repair, similar to cholecystectomy.
BACKGROUND:Comorbidity burden may influence perioperative outcomes in elderly patients undergoing minimally invasive resection for colorectal cancer (CRC). This study evaluated the association between the Charlson Weighted Comorbidity Index (CCI) and short-term postoperative outcomes in this population. METHODS:A retrospective review of 894 consecutive patients aged 65 years or older who underwent curative minimally invasive resection for CRC at a single institution between January 2014 and August 2023. Surgical approaches included pure laparoscopic, robotic-assisted, and converted-to-open procedures. Comorbidity burden was quantified using the CCI, excluding age and the index colorectal malignancy from score calculation. Patients with and without postoperative complications were compared, and multivariable logistic regression was performed to identify independent factors associated with complications. Patients were divided into 2 groups [low CCI (≤2; n=637) and high CCI (≥3; n=257)] to investigate the relationship between an increased CCI score and the patients' short-term outcomes. RESULTS:Postoperative complications occurred in 319 patients (36%). Age, American Society of Anesthesiologists Physical Status (ASA) score, conversion to open surgery, rectal tumor location, and CCI score were significantly higher in patients with postoperative complications. On multivariable analysis, age 75 years or older, ASA score ≥4, conversion to open surgery, rectal tumor location, and CCI ≥3 were independently associated with an increased risk of postoperative complications. The discriminatory ability of CCI alone was modest (AUC: 0.578). Compared with the low-CCI group, the high-CCI group had higher rates of transfusion (13% vs. 8%, P =0.016), overall complications (46% vs. 31%, P <0.001), and 30-day mortality (2% vs. 1%, P =0.024), as well as a longer postoperative length of stay (6.4 vs. 5.2 days, P <0.001). CONCLUSION:Higher comorbidity burden, as measured by CCI, was associated with worse short-term postoperative outcomes after minimally invasive CRC surgery in elderly patients. Although CCI alone showed limited discriminatory performance for individual prediction, a CCI score ≥3 identified a subgroup with substantially higher postoperative risk and may potentially be useful as a simple adjunct in preoperative risk assessment.
Background and Aims: One of the key challenges in endoscopic submucosal dissection (ESD) is achieving effective intraoperative mucosal traction. Although numerous countertraction technologies have been developed, there is still room for optimization. This randomized controlled trial was designed to assess the comparative effectiveness of a novel robotic assistance system (FASTER) versus conventional ESD techniques for managing colorectal neoplasia. Methods: A total of 24 ESD procedures were performed on 6 different anatomic sites (rectum and sigmoid colon) of 4 pigs. Twelve procedures were performed with the FASTER-assisted method and 12 with the conventional method. Key efficacy outcomes consisted of total procedure time, submucosal dissection time, submucosal dissection speed, and direct visual dissection rate. Secondary outcomes evaluated the complete resection rate and perioperative adverse events. Results: Compared with the conventional ESD group (C-ESD), the total procedure time of the FASTER-assisted ESD group (F-ESD) was significantly lower (11.5 vs. 18.0 min; P <0.001). Compared with the conventional ESD, FASTER-assisted ESD significantly increased the submucosal dissection speed (0.7 vs. 0.4 cm 2 /min; P <0.001), shortened the submucosal dissection time (4.9 vs. 10.7 min; P <0.001), and improved the rate of direct vision dissection (99.0% vs. 83.2%; P <0.001). The operation difficulty score of the F-ESD group was significantly lower than that of the C-ESD group (1.0 vs. 3.0; P <0.001). FASTER-assisted ESD significantly optimized the primary outcome measures in the treatment of sigmoid and rectal lesions. Conclusions: The FASTER system reliably provided continuous visual feedback and dynamic tissue manipulation throughout the ESD procedure. In this prospective preclinical animal investigation, it significantly shortened operation time and reduced surgical adverse events, offering an innovative solution for optimizing ESD procedures in colorectal treatment.
