Current surgical training: simultaneous training in open and laparoscopic surgery

Survival after laparoscopic surgery versus open surgery for colon cancer: long-term outcome of a randomised clinical trial

Postoperative adhesions appear to be less common following laparoscopic surgery than after conventional open surgery. The purpose of this study was to compare the impact of laparoscopic and conventional open rectal surgery on peristomal adhesion formation. We enrolled 97 subjects who were participants in a trial comparing open versus laparoscopic surgery for mid and low rectal cancer after neoadjuvant chemoradiotherapy. These patients had undergone rectal cancer surgery with ileostomy formation. Peristomal adhesions were assessed during ileostomy takedown using an adhesion grading system: (1) no adhesions or fine, filmy adhesions separable by blunt dissection; (2) dense adhesions, separable by sharp dissection; (3) very dense adhesions, resulting in enterotomy and/or requiring extension of the abdominal wall incision. A total of 57 patients underwent laparoscopic resection (group A) and 40 underwent open resection (group B). Operating time for ileostomy dissection was shorter in group A than in group B (14.6 vs. 19.8 min, respectively; p = 0.047). Dense adhesions (grades 2 and 3) were more common in group B (22/40, 55 %) than in group A (12/57, 21 %; p < 0.001). In particular, grade 3 adhesions were present only in group B (6/40). The present findings suggest that laparoscopic rectal surgery results in less peristomal adhesion formation than does conventional open surgery.

Measuring health-related quality of life (QoL) after surgery is essential for decision making by patients, surgeons, and payers. The aim of this consensus conference was twofold. First, it was to determine for which diseases endoscopic surgery results in better postoperative QoL than open surgery. Second, it was to recommend QoL instruments for clinical research. An expert panel selected 12 conditions in which QoL and endoscopic surgery are important. For each condition, studies comparing endoscopic and open surgery in terms of QoL were identified. The expert panel reached consensus on the relative benefits of endoscopic surgery and recommended generic and disease-specific QoL instruments for use in clinical research. Randomized trials indicate that QoL improves earlier after endoscopic than open surgery for gastroesophageal reflux disease (GERD), cholecystolithiasis, colorectal cancer, inguinal hernia, obesity (gastric bypass), and uterine disorders that require hysterectomy. For spleen, prostate, malignant kidney, benign colorectal, and benign non-GERD esophageal diseases, evidence from nonrandomized trials supports the use of laparoscopic surgery. However, many studies failed to collect long-term results, used nonvalidated questionnaires, or measured QoL components only incompletely. The following QoL instruments can be recommended: for benign esophageal and gallbladder disease, the GIQLI or the QOLRAD together with SF-36 or the PGWB; for obesity surgery, the IWQOL-Lite with the SF-36; for colorectal cancer, the FACT-C or the EORTC QLQ-C30/CR38; for inguinal and renal surgery, the VAS for pain with the SF-36 (or the EORTC QLQ-C30 in case of malignancy); and after hysterectomy, the SF-36 together with an evaluation of urinary and sexual function. Laparoscopic surgery provides better postoperative QoL in many clinical situations. Researchers would improve the quality of future studies by using validated QoL instruments such as those recommended here.

To assess and compare the rate of procedure-related complications after intrauterine treatment of spina bifida by endoscopic surgery and by open fetal surgery. Systematic literature searches in PubMed and SCOPUS databases were performed on 20 September 2015 to identify randomized controlled trials and observational studies on treatment of human spina bifida by endoscopic or open fetal surgery techniques. Only studies with ≥ 10 cases that were published in or after 2000 were included in the meta-analysis in order to reduce the risk of bias. Primary outcomes (complete dehiscence, focal dehiscence and/or markedly thin hysterotomy scar; preterm delivery < 34 weeks; mean gestational age at delivery) and secondary outcomes (oligohydramnios, prelabor rupture of membranes, placental abruption, chorioamnionitis and perinatal death) were assessed for both techniques. Precision of the estimated proportions was evaluated with 95% CIs. Inconsistency was assessed using the I(2) statistic. The search identified 1080 records that were examined based on title and abstract, of which 28 full-text articles were examined completely for eligibility. Nine records were excluded because cases were also described in other studies, leaving 19 records for analysis. When comparing endoscopic vs open fetal surgery, the rate of complete dehiscence, focal dehiscence and/or markedly thin hysterotomy scar was, respectively, 1% (95% CI, 0-4%) vs 26% (95% CI, 12-42%); preterm delivery < 34 weeks was 80% (95% CI, 41-100%) vs 45% (95% CI, 38-53%); oligohydramnios was 39% (95% CI, 9-75%) vs 14% (95% CI, 7-24%); prelabor rupture of membranes was 67% (95% CI, 12-100%) vs 38% (95% CI, 26-50%); and perinatal death was 14% (95% CI, 1-38%) vs 5% (95% CI, 3-8%). Open fetal surgery for spina bifida seems to show lower rates of procedure-related complications than does endoscopic surgery, but the rate of hysterotomy scar complications is high after open surgery. Because of the low quality of evidence, the conclusions should be interpreted with caution. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Long-term outcome of laparoscopic and open surgery in patients with Crohn's disease Martin Hoffmann,1 Dina Siebrasse,1 Erik Schlöricke,2 Ralf Bouchard,1 Tobias Keck,1 Claudia Benecke1 1Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, 2Department of Surgery, Westküstenklinikum Heide, Heide, Germany Aim: To investigate, via data analysis, the long-term outcome of patients who underwent either laparoscopic or open surgery for Crohn’s disease.Methods: A total of 113 patients who had undergone first abdominal surgery due to Crohn’s disease between January 2000 and December 2010 in a maximum care provider facility, were included in the statistical analysis. All patients provided their informed consent prior to inclusion. Data were collected from a database. Follow-up data included data from central mortality registries, general practitioners and a specialized clinic. Statistical analysis of the general patient data and the different operations and approaches were performed with the use of chi-square test, Fisher’s exact test, and the Mann–Whitney U test.Results: The median follow-up period in case of open and laparoscopic surgery was found to be 9 and 6 years, respectively. Statistically significant differences were observed for the following parameters in case of open and laparoscopic surgery, respectively: age (median=44 vs. 36 years, range=15–76 vs. 15–72 years; p=0.007), urgency of operation (23 out of 34 planned vs. 6 out of 70 planned; p

The impact of body mass index (BMI) on outcomes after open or laparoscopic surgery for rectal cancer remains unclear. The objective of this retrospective cohort study was to examine the interaction of body mass index and surgical modality (i.e., laparoscopy versus open) with respect to short-term clinical outcomes in patients with rectal cancer. The ACS-NSQIP database (2012-2016) was reviewed for patients undergoing open or laparoscopic surgery for rectal cancer. The primary outcome was 30-day all-cause morbidity. Logistic regression and Cox proportional hazard models were used for analysis. A total of 16,145 patients were grouped into open (N=6759, 42%) and laparoscopic (N =9386, 58%) cohorts. Patients with higher BMI (p<0.001) and those undergoing open surgery (p<0.001) were at increased risk of all-cause morbidity. There was no significant change in the odds ratio of experiencing all-cause morbidity between open and laparoscopic surgery with increasing BMI (p=0.572). Median length of stay was significantly shorter in the laparoscopy group (4 days vs. 6days; p<0.001), at the cost of increased operative time (239min vs. 210 min, p<0.001). The difference in operative time between laparoscopy and open surgery did not increase with rising BMI (i.e., ∆37min vs. ∆39min at BMI 25kg/m2 vs 50kg/m2, respectively, p=0.491). BMI may not be a strong modifier for surgical approach with respect to short-term clinical outcomes in patients with obesity and rectal cancer. Laparoscopic surgery was associated with improved short-term clinical outcomes, without much change in the absolute difference in operative time compared with open surgery, even at higher BMIs.

Objective To investigate the causes, clinical features, treatment and prognosis of chronic sinusitis and nasal polyps with endoscopic sinus surgery. Methods A total of 10 patients (10 eyes) from clinic of Xi’an No.4 Hospital between January 2001 and December 2016 due to vision loss caused by endoscopic sinus surgery were prospectively examined. All patients were enrolled and administered visual acuity testing, ophthalmic examinations, color photography, and other clinical observations. Results Ten cases of ocular complications occurred, including central retinal artery occlusion in 1 case, optic nerve injury in 6 cases, orbital hemorrhage in 2 cases, and orbital infection in 1 case. Conclusions The complications of endoscopic sinus surgery in patients with chronic rhinosinusitis and nasal polyps are complex, and the preparation, familiarity with nasal endoscopic resection and skilled operation can reduce the occurrence of complications. Timely detection of eye complications can reduce the risk of serious consequences. Visual impairment caused by endoscopic sinus surgery is difficult to treat and result in poor prognosis. Key words: Nasosinusitis; Nasal polyp; Endoscopic surgery; Eye; Complication

The aim of the study was to compare short- and long-term outcomes of laparoscopic surgery and conventional open surgery for colorectal cancer. Published randomized controlled trial (RCT) reports of laparoscopic surgery and open surgery for colorectal cancer were searched, and short- and long-term factors were extracted to perform meta-analysis. A total of 15 RCT reports (6,557 colorectal cancer patients) were included in this study. Blood loss of laparoscopic surgery was less by 91.06 ml than open surgery (p = 0.044). Operation time was longer by 49.34 min (p = 0.000). The length of hospital stay was shorter by 2.64 days (p = 0.003). Incisional length was shorter by 9.23 cm (p = 0.000). Fluid intake was shorter by 0.70 day (p = 0.001). Bowel movement was earlier by 0.95 day (p = 0.000). Incidence of complications, blood transfusion, and 30 days death were significantly lower in laparoscopic surgery than in open surgery (p = 0.011, 0.000, 0.01). But there was no significant difference in lymph nodes (p = 0.535) and anastomotic leak (p = 0.924). There was also no significant difference in 3 and 5 years overall survival (p = 0.298, 0.966), disease-free survival (p = 0.487, 0.356), local recurrence (p = 0.270, 0.649), and no difference in 5 years distant recurrence (p = 0.838). Laparoscopic surgery is a mini-injured approach which can cure colorectal cancer safely and radically, and it is not different from conventional open surgery in long-term effectiveness, so laparoscopic surgery can be tried to widely use in colorectal cancer.

Recovery of Renal Function After Complete Renal Hilar Versus Artery Alone Clamping During Open and Laparoscopic Surgery

BackgroundColorectal cancer is common in elderly patients. Laparoscopy is widely used to approach this kind of disease. This study was to examine short-term outcomes and long-term survival for laparoscopic and open surgery in elderly patients with colorectal cancer.MethodsFrom January 2007 to December 2018, patients with colorectal cancer older than 80 operated at China National Cancer Center were included in the study. Propensity score matching (PSM) was used to minimize the adverse effects. The clinical data between open and laparoscopic surgery was compared, and the effect of factors on overall survival (OS) and disease-free survival (DFS) was analyzed by Cox proportional hazard model.ResultsNinety-three pairs were selected after PSM. Patients in laparoscopic group had less intraoperative blood loss, postoperative complications, time to first flatus, time to oral feeding, postoperative hospital stay, and higher retrieved lymph node (P < 0.05). The OS and DFS rates were similar (P > 0.05), besides the CEA level, III/IV stage, and perineural invasion were independent predictors of survival (P < 0.05).ConclusionIn elderly patients with colorectal cancer, laparoscopic surgery had better short-term outcomes than open surgery. CEA level, III/IV stage, and perineural invasion were reliable predictors for OS and DFS.

Laparoscopy has become the standard surgery mode of right hemicolectomy, including conventional laparoscopy, hand-assisted laparoscopic surgery (HALS), single-port laparoscopic surgery (SPLS), natural orifices translumenal endoscopic surgery (NOTES) and robotic laparoscopy. How to select reasonable laparoscopic mode could be confusing sometimes. For patients, safety, cost-effectiveness and radical cure of the surgery are very important. For doctors, advance and convenience of the surgery must be considered as well. How do we choose a win-win operation method Conventional laparoscopic surgery is the basis of all the minimally invasive surgeries, and total mesocolon resection with D3 lymphadenectomy is an important technical foundation of right hemicolectomy. HALS has some advantages in patients with obesity, abdominal surgery history, intestinal adhesion or intestinal obstruction. SPLS and NOTES have minimized abdominal trauma leading to faster recovery, but have certain technical difficulties, especially NOTES. Although robotic laparoscopic surgery is advanced, but its high cost limits its popularization. Surgeons should integrate their technical levels, hospital equipment, and conditions of patients, then choose reasonable operation mode of right hemicolectomy.

The objective of this study was to compare the total hospital cost of laparoscopic (lap) and open colon surgery at a publicly funded academic institution. Patients undergoing elective laparoscopic or open colon surgery for all indications at the University Health Network, Toronto, Canada, from April 2004 to March 2009 were included. Patient demographic, operative, and outcome data were reviewed retrospectively. Hospital costs were determined from the Ontario Case Costing Initiative, adjusted for inflation, and compared using the Mann-Whitney U test. Linear regression was used to analyze the relationship between length of stay and total hospital cost. There were 391 elective colon resections (223 lap/168 open, 15.4 % conversion). There was no difference in median age, gender, or Charlson score. Body mass index was slightly higher for laparoscopic surgery (27.5/25.9 lap/open; p = 0.008), while the American Society of Anesthesiologists score was slightly higher for open surgery. Median operative time was greater for laparoscopic surgery (224/196 min, lap/open; p = 0.001). There was no difference in complication rates (21.6/22.5 % lap/open; p = 0.900), reoperations (5.8/6.5 % lap/open; p = 0.833) or 30-day readmissions (7.6/12.5 % lap/open; p = 0.122). Number of emergency room visits was greater with open surgery (12.6/20.8 % lap/open; p = 0.037). Operative cost was higher for laparoscopic surgery ($4,171.37/3,489.29 lap/open; p = 0.001), while total hospital cost was significantly reduced ($9,600.22/12,721.41 lap/open; p = 0.001). Median length of stay was shorter for laparoscopic surgery (5/7 days lap/open; p = 0.000), and this correlated directly with hospital cost. Laparoscopic colon surgery is associated with increased operative costs but significantly lower total hospital costs. The cost savings is related, in part, to reduced length of stay with laparoscopic surgery.

Objective To discuss the clinical effects of continuous endothelial suture combined with subcutaneous negative pressure drainage in laparoscopic gastrointestinal surgery. Methods The clinical data of 92 patients who underwent laparoscopic gastrointestinal surgery from September 2016 to September 2017 in Department of General Surgery in Affiliated Cancer Hospital of Zhengzhou University were analyzed retrospectively. According to incision suture methods, patients were divided into observation group (45 cases, selected subcutaneous continuous suture) and control group (47 cases, given internal suture incision). The observation group underwent laparoscopic gastrointestinal surgery by the continuous endothelial suture combined with subcutaneous negative pressure drainage. The control group underwent laparoscopic gastrointestinal surgery by the intermittent mattress suture. The postoperative dressing change times, postoperative incision healing adverse events (including the incision fat liquefaction and infection), postoperative hospitalization time and postoperative incision dehiscence cases were compared between the two group. Results There were statistically significant differences between the two groups in the number of postoperative wound dressing changes (t=5.64, P<0.01), the number of cases of postoperative incision healing adverse events (χ2=4.722, P=0.03), and the postoperative hospitalization time (t=2.88, P<0.01). There was no incision dehiscence in the two groups. Conclusions In laparoscopic assisted gastrointestinal surgery, continuous endothelial suture combined with subcutaneous negative pressure drainage is effective. It can get cosmetic effect, reduce postoperative incision healing adverse events, reduce the postoperative dressing change times and shorten postoperative hospitalization time. It is worthy of clinical application. Key words: Endothelial suture; High negative pressure; Laparoscopic surgery; Incision

Hydatid cyst disease is challenging to treat, and surgery remains curative in the majority of cases. There has been more working done recently on laparoscopic Hydatid cyst disease surgery and comparing the outcomes with the open method. Objectives: To compare the frequency of post-operative outcomes vis. Biliary leakage, post-operative pain, wound infection rate, recurrence of Hydatid cyst disease, and length of hospital stay between open versus laparoscopic surgery in patients with liver Hydatid cyst disease. Methods: This randomized controlled trial was conducted in the Surgical Department of Nishtar Hospital, Multan. 84 patients were enrolled and underwent either laparoscopic or open conservative surgery with external drainage. Outcomes between the two groups in terms of biliary leakage, length of stay, pain, wound infection, and recurrence were compared. Statistical analysis was done using SPSS-25.0. Results: There was no significant difference present between groups in terms of biliary leakage (p=0.33), biliary leak output (p=0.21), and days till leak resolution (p=0.32). Biliary leaks occurred in 16.7% of cases in the open group. Pain scores were significantly lower in the laparoscopic group as compared to the open group (p=0.001). Wound infections occurred in 19% of cases in the open group and 4.8% cases in the laparoscopic group, and were significantly different (p=0.04). 2.4% cases had recurrences in both groups. Conclusions: Biliary leak rates between open and laparoscopic surgery for Hydatid cyst disease are comparable. Open surgery may have greater high-output biliary leaks. Advantages conferred by laparoscopic surgery are shorter length of hospital stay, fewer wound infections, and better pain control.

In Response: We thank Drs. van der Linden and Persson for their comments.1 Our study did not clarify the mechanism by which laparoscopic surgery reduces surgical oxidative stress, as opposed to the increased oxidative stress seen with conventional open abdominal surgery. We have considered two mechanisms for this phenomenon.2 One involves the unique intestinal handling by laparoscopy instruments, which might reduce mechanical injury of the intestine during surgery, resulting in reduction of oxidative stress. Another possible mechanism can be related to the difference in oxygen tension within the abdominal cavity during laparoscopic versus open surgery. Open abdominal surgery abruptly exposes the surface of the abdominal viscera (which exist under very low-oxygen tension in the closed abdominal cavity) to an entirely new environment with high oxygen tension. In contrast, low-oxygen tension is maintained in laparoscopic surgery. Persson et al.3,4 have demonstrated that carbon dioxide gas has the potential to protect against tissue damage in the operative field by maintaining humidity and temperature in the open-heart surgery-related model environment. On the basis of their findings, they proposed a third mechanism that carbon dioxide insufflation into the abdominal cavity might work in a similar way, resulting in the reduction of oxidative stress. Furthermore, other clinical investigators have indicated that insufflation of warmed and humidified carbon dioxide gas instead of dry gas enhances the clinical advantage of laparoscopic surgery.5,6 Thus, humidity and temperature, as well as carbon dioxide, might be additional critical factors determining the overall surgical oxidative stress of laparoscopic surgery. Because humidity, temperature, and carbon dioxide tension can each affect tissue microcirculation,7,8 localized reperfusion injury may also be involved in the mechanism.9 These newly presented possibilities are worth closer examination, thus leading to more efficient reduction of surgical oxidative stress in every type of surgery. Masahiko Tsuchiya, MD, PhD Department of Anesthesiology Osaka City University Medical School Abeno-Ku, Osaka 545-8586, Japan [email protected] Eisuke F. Sato, PhD Masayasu Inoue, MD, PhD Department of Biochemistry and Molecular Pathology Osaka City University, Medical School Abeno-Ku, Osaka 545-8585, Japan Akira Asada, MD, PhD Department of Anesthesiology Osaka City University Medical School Abeno-Ku, Osaka 545-8586, Japan