Comparison of minimally invasive fusion and instrumentation versus open surgery for severe stenotic spondylolisthesis with high-grade facet joint osteoarthritis

Purpose

The object of this study was to compare minimally invasive surgery (MIS) with open surgery in a severely affected subgroup of degenerative spondylolisthetic patients with severe stenosis (SDS) and high-grade facet osteoarthritis (FJO).

Methods

From January 2009 to February 2010, 49 patients with severe SDS and high-grade FJO were treated using either MIS or open TLIF. Intraoperative and diagnostic data, including perioperative complications and length of hospital stay (LOS), were collected, using retrospective chart review. Surgical short- and long-term outcomes were assessed according to the Oswestry disability index (ODI) and visual analog scale (VAS) for back and leg pain.

Results

Comparing MIS and open surgery, the MIS group had lesser blood loss, significantly lesser need for transfusion (p = 0.02), more rapid improvement of postoperative back pain in the first 6 weeks of follow-up and a shorter LOS. On the other hand, we experienced in the MIS group a longer operative time. The distribution on the postoperative ODI (p = 0.841), VAS leg (p = 0.943) and back pain (p = 0.735) scores after a mean follow-up of 2 years were similar. The overall proportion of complications showed no significant difference between the groups (29 % in the MIS group vs. 28 % in the open group, p = 0.999).

Conclusion

Minimally invasive surgery for severe SDS leads to adequate and safe decompression of lumbar stenosis and results in a faster recovery of symptoms and disability in the early postoperative period.     

A Multi-institutional Analysis of Open Versus Minimally-Invasive Surgery for Gastric Adenocarcinoma: Results of the US Gastric Cancer Collaborative

Background

Surgical experience with minimally invasive surgery (MIS) has increased; however, published reports on MIS resection of gastric adenocarcinoma are limited.

Methods

Between 2000 and 2012, 880 patients who underwent surgical resection of gastric adenocarcinoma were identified from a multi-institutional database. Clinicopathological characteristics, operative details, and outcomes were stratified by operative approach (open vs. MIS) and analyzed.

Results

Overall, 70 (8 %) patients had a MIS approach. Patients who underwent a MIS resection were more likely to have a smaller tumor (open 4.5 cm vs. MIS 3.0 cm, p?p?p?=?0.03) and median lymph node yield was good in both groups (open 17 vs. MIS 14, p?=?0.10). MIS had a similar incidence of complications (open 33.1 % vs. MIS 20 %, p?=?0.07) and a similar length of stay (open 9 days vs. MIS 7 days, p?=?0.13) compared with open surgery. In the propensity-matched analysis, median recurrence-free and overall were not impacted by operative approach.

Conclusion

An MIS approach to gastric cancer was associated with adequate lymph node retrieval, a high incidence of R0 resection, and comparable long-term oncological outcomes versus open gastrectomy.     

Minimally Invasive Technique Leads to Decreased Morbidity and Mortality in Small Bowel Resections Compared to an Open Technique: An ACS-NSQIP Identified Target for Improvement

Background

We hypothesize that currently minimally invasive techniques are underutilized, leading to unnecessary morbidity and mortality. The objective of the study was to compare morbidity and mortality rates in patients receiving a minimally invasive (MIS) small bowel resection to patients receiving an open (OP) small bowel resection.

Methods

Patients in the National Surgical Quality Improvement Program (NSQIP) database who underwent a small bowel resection between 2007 and 2011 were enrolled in the study and grouped whether they received a MIS procedure (n?=?1,780) or an OP procedure (n?=?17,701). The primary endpoint of the study was to evaluate the difference in morbidity (excluding mortality) and mortality in patients undergoing a minimally invasive procedure compared to an open procedure.

Results

The MIS technique is utilized in 9.0 % of patients undergoing a small bowel resection. Significantly lower mortality rate (2.9 vs. 8.2 %; p?<?0.001) and mean morbidity rate (1.7 vs. 4.3 %; p?<?0.001) were demonstrated in the MIS group. Significantly lower mean major morbidity rate (1.4 vs. 3.9 %; p?<?0.001) and mean minor morbidity rate (2.6 vs. 5.5 %; p?<?0.001) were demonstrated in the MIS group.

Conclusion

The MIS technique in small bowel resections appears to be underutilized, with only 9.0 % of patients in need of a small bowel resection undergo the minimally invasive approach. Wider utilization of the MIS technique could lead to significantly decreased morbidity and mortality.     

Clinical outcomes of minimally invasive versus open approach for one-level transforaminal lumbar interbody fusion at the 3- to 4-year follow-up

Purpose

Supporters of minimally invasive approaches for transforaminal lumbar interbody fusion (TLIF) have reported short-term advantages associated with a reduced soft tissue trauma. Nevertheless, mid- and long-term outcomes and specifically those involving physical activities have not been adequately studied. The aim of this study was to compare the clinical outcomes of mini-open versus classic open surgery for one-level TLIF, with an individualized evaluation of the variables used for the clinical assessment.

Methods

A prospective cohort study was conducted of 41 individuals with degenerative disc disease who underwent a one-level TLIF from January 2007 to June 2008. Patients were randomized into two groups depending on the type of surgery performed: classic open (CL-TLIF) group and mini-open approach (MO-TLIF) group. The visual analog scale (VAS), North American Spine Society (NASS) Low Back Pain Outcome instrument, Oswestry Disability Index (ODI) and the Short Form 36 Health Survey (SF-36) were used for clinical assessment in a minimum 3-year follow-up (36–54 months).

Results

Patients of the MO-TLIF group presented lower rates of lumbar (p = 0.194) and sciatic pain (p = 0.427) and performed better in daily life activities, especially in those requiring mild efforts: lifting slight weights (p = 0.081), standing (p = 0.097), carrying groceries (p = 0.033), walking (p = 0.069) and dressing (p = 0.074). Nevertheless, the global scores of the clinical questionnaires showed no statistical differences between the CL-TLIF and the MO-TLIF groups.

Conclusions

Despite an improved functional status of MO-TLIF patients in the short term, the clinical outcomes of mini-open TLIF at the 3- to 4-year follow-up showed no clinically relevant differences to those obtained with open TLIF.     

Disc Space Preparation in Transforaminal Lumbar Interbody Fusion: A Comparison of Minimally Invasive and Open Approaches

Background

Minimally invasive surgical (MIS) approaches to transforaminal lumbar interbody fusion (TLIF) have been developed as an alternative to the open approach. However, concerns remain regarding the adequacy of disc space preparation that can be achieved through a minimally invasive approach to TLIF.

Questions/purposes

The purpose of this cadaver study is to compare the adequacy of disc space preparation through MIS and open approaches to TLIF. Specifically we sought to compare the two approaches with respect to (1) the time required to perform a discectomy and the number of endplate violations; (2) the percentage of disc removed; and (3) the anatomic location where residual disc would remain after discectomy.

Methods

Forty lumbar levels (ie, L1-2 to L5-S1 in eight fresh cadaver specimens) were randomly assigned to open and MIS groups. Both surgeons were fellowship-trained spine surgeons proficient in the assigned approach used. Time required for discectomy, endplate violations, and percentage of disc removed by volume and mass were recorded for each level. A digital imaging software program (ImageJ; US National Institutes of Health, Bethesda, MD, USA) was used to measure the percent disc removed by area for the total disc and for each quadrant of the endplate.

Results

The open approach was associated with a shorter discectomy time (9 versus 12 minutes, p = 0.01) and fewer endplate violations (one versus three, p = 0.04) when compared with an MIS approach, percent disc removed by volume (80% versus 77%, p = 0.41), percent disc removed by mass (77% versus 75%, p = 0.55), and percent total disc removed by area (73% versus 71%, p = 0.63) between the open and MIS approaches, respectively. The posterior contralateral quadrant was associated with the lowest percent of disc removed compared with the other three quadrants in both open and MIS groups (50% and 60%, respectively).

Conclusions

When performed by a surgeon experienced with MIS TLIF, MIS and open approaches are similar in regard to the adequacy of disc space preparation. The least amount of disc by percentage is removed from the posterior contralateral quadrant regardless of the approach; surgeons should pay particular attention to this anatomic location during the discectomy portion of the procedure to minimize the likelihood of pseudarthrosis.     

Evaluation of a new type of titanium mesh cage versus the traditional titanium mesh cage for single-level, anterior cervical corpectomy and fusion

Study design

A retrospective review of prospectively collected data in an academic institution.

Objective

To evaluate the safety and efficacy of a new type of titanium mesh cage (TMC) in single-level, anterior cervical corpectomy and fusion (ACCF).

Methods

Fifty-eight patients consecutive with cervical spondylotic myelopathy (CSM) from cervical degenerative spondylosis and isolated ossification of the posterior longitudinal ligament were treated with a single-level ACCF using either a new type of TMC (28 patients, group A) or the traditional TMC (30 patients, group B). We evaluated the patients for TMC subsidence, cervical lordosis (C2–C7 Cobb and Cobb of fused segments) and fusion status for a minimum of 30 months postoperatively based on spine radiographs. In addition, neurologic outcomes were evaluated using the Japanese Orthopedic Association (JOA) scores. Neck pain was evaluated using a 10-point visual analog scale (VAS).

Results

The loss of height of the fused segments was less for group A than for group B (0.8 ± 0.3 vs. 2.8 ± 0.4 mm) (p < 0.01); also, there was a lower rate of severe subsidence (≥3 mm) in group A (4 %, 1/28) than in group B (17 %, 5/30) (p < 0.01). There were no differences in the C2–C7 Cobb and Cobb of fused segments between the groups preoperatively or at final follow-up (p > 0.05), but the Cobb of fused segments immediately postoperative were significantly less for group B than for group A (p < 0.01). All patients, however, had successful fusion (100 %, each). Both groups had marked improvement in the JOA score after operation (p < 0.01), with no significant differences in the JOA recovery ratio (p > 0.05). The postoperative VAS neck pain scores for group A were significantly less than that for group B (p < 0.05); severe subsidence was correlated with neck pain.

Conclusions

The new type of TMC provides comparable clinical results and fusion rates with the traditional TMC for patients undergoing single-level corpectomy. The new design TMC decreases postoperative subsidence (compared to the traditional TMC); the unique design of the new type of TMC matches the vertebral endplate morphology which appears to decrease the severity of subsidence-related neck pain in follow-up.     

Outcomes of posterior facet versus pedicle screw fixation of circumferential fusion: a cohort study

Purpose

To compare single-level circumferential spinal fusion using pedicle (n = 27) versus low-profile minimally invasive facet screw (n = 35) posterior instrumentation.

Method

A prospective two-arm cohort study with 5-year outcomes as follow-up was conducted. Assessment included back and leg pain, pain drawing, Oswestry disability index (ODI), pain medication usage, self-assessment of procedure success, and >1-year postoperative lumbar magnetic resonance imaging.

Results

Significantly less operative time, estimated blood loss and costs were incurred for the facet group. Clinical improvement was significant for both groups (p < 0.01 for all outcomes scales). Outcomes were significantly better for back pain and ODI for the facet relative to the pedicle group at follow-up periods >1 year (p < 0.05). Postoperative magnetic resonance imaging found that 20 % had progressive adjacent disc degeneration, and posterior muscle changes tended to be greater for the pedicle screw group.

Conclusion

One-level circumferential spinal fusion using facet screws proved superior to pedicle screw instrumentation.     

Influence of transforaminal lumbar interbody fusion procedures on spinal and pelvic parameters of sagittal balance

Introduction

Restitution of sagittal balance is important after lumbar fusion, because it improves fusion rate and may reduce the rate of adjacent segment disease. The purpose of the present study was to describe the impact of transforaminal lumbar interbody fusion (TLIF) procedures on pelvic and spinal parameters and sagittal balance.

Materials and methods

Forty-five patients who had single-level TLIF were included in this study. Pelvic and spinal radiological parameters of sagittal balance were measured preoperatively, postoperatively and at latest follow-up.

Results

Age at surgery averaged 58.4 (±9.6) years. Mean follow-up was 35.1 months (±4.1). Twenty-nine percent of the patients exhibited anterior imbalance preoperatively, with high pelvic tilt (17.6° ± 7.9°). Of the 32 (71%) patients well balanced before the procedure, 22 (70%) had a large pelvic tilt (>20°), due to retroversion of the pelvis as an adaptive response to the loss of lordosis. Three dural tears (7%) were reported intraoperatively. Interbody cages were more posterior than intended in 27% of the cases. Disc height and lumbar lordosis at fusion level significantly increased postoperatively (p < 0.05 and p < 0.001). Pelvic tilt was significantly reduced (p < 0.01) postoperatively, whereas the global sagittal balance was not significantly modified (p = 0.07).

Conclusion

Single-level circumferential fusion helps patients reducing their pelvic compensation, but the amount of correction does not allow for complete correction of sagittal imbalance.     

Effect of preoperative consumption of high carbohydrate drink (Pre-Op®) on postoperative metabolic stress reaction in patients undergoing radical prostatectomy

Aim

To investigate the effects of oral carbohydrate solution consumed until 2 h before the surgery in the patients that would undergo open radical retropubic prostatectomy on postoperative metabolic stress, patient anxiety, and comfort.

Method

A total of 50 adult patients, who were in ASA I–II group and would undergo open radical retropubic prostatectomy, were included in the study. While Group 1 = CH (n = 25) received oral glucose solution, Group 2 = FAM (n = 25) was famished starting from 24:00 h. Blood glucose, insulin, and procalcitonin levels of the patients were recorded, and the patients completed state-trait anxiety inventory (STAI) test, which reflects the anxiety level of the patients, both before surgery and on the postoperative 24th hour. In order to evaluate patient comfort, senses of hunger, thirst, nausea, and cold were assessed in the morning prior to the surgery.

Results

No difference was observed between the two groups in terms of demographic data and insulin resistance levels (p > 0.05). Comparing with the preoperative levels, insulin resistance showed statistically significant elevation in both groups (p < 0.05). Procalcitonin levels were similarly increased in both groups in the postoperative period (p < 0.05). Preoperative and postoperative STAI state scores were similar in both groups (p > 0.05). With regard to preoperative patient comfort, sense of hunger was present in lesser number of subjects and at lower level in Group 1 (p < 0.05).

Conclusion

Preoperative consumption of high carbohydrate drink (Pre-op^®) decreases insulin resistance and enhances patient comfort leading to lesser sense of hunger and thirst in the preoperative period in open radical retropubic prostatectomies.     

Risk factors affecting operative approach, conversion, and morbidity for adrenalectomy: a single-institution series of 402 patients

Background

Risk factors for selecting patients for open adrenalectomy (OA) and for conversion are limited in most series. This study aimed to investigate variables that are important in selecting patients for OA, predict risk of conversion from laparoscopic adrenalectomy (LA), and impact 30-day outcomes of OA and LA.

Methods

A retrospective cohort study of prospectively collected data was conducted. Patients (≥16 years old) who underwent adrenalectomy in the Division of General Surgery at Barnes-Jewish Hospital (1993–2010) were grouped by operative approach (LA vs. OA) and compared using nonparametric tests and regression analyses (α < 0.05).

Results

In total, 402 patients underwent 422 adrenalectomies. Compared to LA patients, those in the OA group were older (p = 0.02), had higher ASA scores (p = 0.04), larger tumor size (p < 0.01), and fewer functioning lesions (p < 0.01). OA patients more often required concurrent procedures (p < 0.01), had a longer operative time (p = 0.04), more intraoperative complications (p = 0.02), higher estimated blood loss (EBL), and larger transfusion requirement. Preoperative factors that predicted selection for OA were higher patient age (p = 0.01), higher ASA score (p = 0.03), larger tumor size (p < 0.01), nonfunctioning lesion (p < 0.01), diagnosis of adrenocortical carcinoma (p < 0.01), and the need for concomitant procedures (p < 0.01). Conversion to open or hand-assisted approach occurred in 6.2 % of LA patients. Preoperative risks for conversion included large tumor size (>8 cm) and need for concomitant procedures (p < 0.01). Multivariate analysis revealed that large indeterminate adrenal mass, adrenocortical carcinoma, tumor size (>6 cm), an open operation, conversion, concomitant procedures, operative time >180 min, and EBL >200 mL were predictors of 30-day morbidity.

Conclusions

Adrenal tumor size and need for concurrent procedures significantly impact the selection of patients for OA, the likelihood of conversion, and perioperative morbidity. These metrics should be considered when assessing operative approach and risks for adrenalectomy.     

Minimally invasive surgery adoption into an established surgical practice: impact of a fellowship-trained colleague

Background

Practicing general surgeons adopt minimally invasive techniques using training opportunities such as weekend courses, videos, hands-on conferences, and traveling proctors with varying success. By integrating a fellowship-trained surgeon into an established practice, we show that minimally invasive techniques can be readily adopted.

Methods

A retrospective review of operative reports from July 2004 through June 2008 obtained the number of laparoscopic and open appendectomies, colectomies, ventral/incisional hernias, and inguinal hernias performed by five practicing surgeons. Three time intervals were formed: 18 months before arrival of the MIS-trained surgeon, a 12-month transition period, and the 18 months following. Only cases performed by the five surgeons, and not by the MIS-trained surgeon, were included. A survey elicited the opinions of the five surgeons on various aspects of the transition, including barriers and effectiveness of different methods for learning MIS techniques.

Results

A total of 4,016 cases were reviewed. The percentage of total cases performed laparoscopically increased from 12.1 to 48.3 %. Laparoscopic appendectomies significantly increased across time periods from 19 to 80 % (p < 0.0001). Adoption of laparoscopic ventral/incisional hernia repairs increased from 4.8 to 20.1 % (p = 0.0322). Laparoscopic inguinal hernias increased from 0.6 to 31.1 % (p < 0.0001). Finally, laparoscopic colectomies significantly increased from 25 to 52 % (p < 0.0001). Survey responses indicated that “mentoring by a colleague with MIS training” was superior to other methods for learning MIS procedures (p = 0.0327–0.0516).

Conclusions

The integration of a fellowship-trained MIS colleague into a general surgery practice resulted in a 300 % increase in the proportion of appendectomies, ventral hernias, inguinal hernias, and colectomies performed laparoscopically by the other members of the practice. When surveyed, the surgeons felt that mentoring by a colleague with MIS training was the most effective method for adopting MIS procedures into their practice.     

Open Versus Minimally Invasive Resection of Gastric GIST: A Multi-Institutional Analysis of Short- and Long-Term Outcomes

Background

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract. Overall surgical experience with minimally invasive surgery (MIS) has increased; however, published reports on MIS resection of GIST are limited to small, single-institution experiences.

Methods

A total of 397 patients who underwent open surgery (n = 230) or MIS (n = 167) for a gastric GIST between 1998 and 2012 were identified from a multicenter database. The impact of MIS approach on recurrence and survival was analyzed using propensity-score matching by comparing clinicopathologic factors between patients who underwent MIS versus open resection.

Results

There were 19 conversions (10 %) to open; the most common reasons for conversion were tumor more extensive than anticipated (26 %) and unclear anatomy (21 %). On multivariate analysis, smaller tumor size and higher body mass index (BMI) were associated with receipt of MIS. In the propensity-matched cohort (n = 248), MIS resection was associated with decreased length of stay (MIS, 3 days vs open, 8 days) and fewer ≥ grade 3 complications (MIS, 3 % vs open, 14 %) compared with open surgery. High rates of R0 resection and low rates of tumor rupture were seen in both groups. After propensity-score matching, there was no difference in recurrence-free or overall survival comparing the MIS and the open group (both p > 0.05).

Conclusions

An MIS approach for gastric GIST was associated with low morbidity and a high rate of R0 resection. The long-term oncological outcome following MIS was excellent, and therefore the MIS approach should be considered the preferred approach for gastric GIST in well-selected patients.     

Laparoscopic versus open repair of parastomal hernias: an ACS-NSQIP analysis of short-term outcomes

Background

Parastomal hernia (PSH) is a frequent complication following the creation of a stoma. While a significant number of cases require operative management, data comparing short-term outcomes of laparoscopic versus open repair of parastomal hernias are limited.

Methods

The ACS-NSQIP was retrospectively reviewed from 2005 to 2011 for all PSH cases that underwent open or laparoscopic repair. Patients characteristics, operative details, and outcomes were listed for both procedure types. Selected end points were compared on multivariate regression analysis.

Results

Among the 2,167 identified parastomal hernia cases, only 222 (10.24 %) were treated laparoscopically. The open and laparoscopic groups were similar with respect to mean patient age (63 vs. 63 years; p = 1) and gender distribution as the majority of patients were females (56.8 %). However, open repair was more likely to be performed in patients with a higher ASA class (III and IV) (p < 0.001). Also, the open approach was more likely to be used emergently (8.64 vs. 3.60 %; p = 0.01) and for recurrent hernias (6.99 vs. 3.15 %; p < 0.05). After adjusting for all potential confounders including age, gender, ASA, emergency designation of the operation, hernia type, and wound class, laparoscopy was associated with shorter operative time (137.5 vs. 153.4 min; p < 0.05), shorter length of hospital stay by 3.32 days (p < 0.001), lower risk of overall morbidity (OR = 0.42; p < 0.001), and a lower risk of surgical site infections (OR = 0.35; p < 0.01) compared to open repair. Mortality rates were similar in the laparoscopic and open groups (0.45 vs. 1.59 %, respectively; p = 0.29).

Conclusions

Laparoscopic parastomal hernia repair is safe and appears to be associated with better short-term outcomes compared to open repair in selected cases. Large prospective randomized trials are needed to confirm those results and to assess long-term recurrence rates.     

Thirty-day outcomes of laparoscopic versus open appendectomy in elderly using ACS/NSQIP database

Background

Although laparoscopic appendectomy is becoming the procedure of choice over open appendectomy in the treatment of appendicitis, its role in the elderly has not been widely studied. The objective of this study was to compare the 30-day outcomes after laparoscopic versus open for appendicitis in the elderly patients.

Methods

Using the American College of Surgeons National Surgical Quality Improvement Program (ACS/NSQIP) databases for years 2005–2009, 3,674 patients (age >65 years) who underwent an appendectomy for appendicitis were identified. Seventy-two percent of the procedures were performed laparoscopically. In addition to aggregate cohort analysis, propensity score 1:1 matching was used to minimize the treatment selection bias. The association between surgical approach and morbidity, mortality, and length of stay (LOS) were analyzed.

Results

In the aggregate cohort analysis, patients who underwent an open appendectomy had a higher rate of minor morbidity (9.3% vs. 4.5%; p < 0.001), overall morbidity (13.4% vs. 8.2%, p < 0.001), and mortality (2% vs. 0.9%, p = 0.003). However, in the matched cohort analysis, open appendectomy was only associated with a higher rate of minor morbidity (9.3% vs. 5.7%; p = 0.002) and overall morbidity (13.4% vs. 10.1%; p = 0.02) but similar mortality rates (2% vs. 1.5%; p = 0.313). In matched cohort analysis, open appendectomy also was associated with a higher rate of superficial surgical site infection (SSI) (3.8% vs. 1.4%; p < 0.001) and a lower rate of organ/space SSI (1.3% vs. 2.9%; p = 0.009). Laparoscopic appendectomy was associated with a shorter LOS in both aggregate and matched cohorts compared with open appendectomy (p < 0.001).

Conclusions

Within ACS NSQIP hospitals, elderly patients benefited from a laparoscopic approach to appendicitis with regards to a shorter LOS and a lower minor and overall morbidity. Laparoscopic appendectomy was associated with lower superficial SSI and higher organ/space SSI rates.     

Laparoscopic Colectomy Decreases the Time to Administration of Chemotherapy Compared with Open Colectomy

Background

Minimally invasive colon surgery (MIS) has been shown to minimize pain and decrease overall recovery time. No studies have shown a clear oncologic benefit. Some literature suggests that the time to administration of chemotherapy can be important to improve outcomes for advanced colon cancer. The goal of this study is to evaluate the effect of minimally invasive surgery on the timing of chemotherapy administration.

Methods

This was a retrospective review of all patients undergoing surgery for colon cancer at a tertiary institution between 2004 and 2013.

Results

A total of 668 partial colectomies for cancer were performed; 241 were stage III and above and deemed appropriate for chemotherapy. Eighty-five patients did not receive chemotherapy (patient’s wishes, age/comorbidities or lost to follow-up). Of the 156 patients who received chemotherapy, 57 underwent MIS and 99 had open colectomy. Average time to chemotherapy after MIS colectomy was 42.9 versus 60.3 days for open surgery (p < 0.001). In the open group, 52 (53 %) people had postoperative complications and readmissions versus 24 (39 %) in the MIS group. Postoperative complications increased the time to chemotherapy for all patients. However, among patients with complications, patients in the MIS group were still able to start chemotherapy earlier (p < 0.05) than open colectomy patients. Multivariate analysis revealed the MIS approach as the only factor lowering time between surgery and chemotherapy.

Conclusions

Laparoscopic colectomy decreases the time interval from surgery to the start of chemotherapy compared with open colectomy. Postoperative complications increase the time to chemotherapy for both open and MIS surgery.     

Costs analysis of laparoendoscopic,single-site laparoscopic and open surgery for cT1 renal masses in a European high-volume centre

Objective

To analyse intraoperative costs and healthcare reimbursements of partial/radical nephrectomy in open and minimal invasive surgery (MIS), as laparoscopy and laparoendoscopic single-site surgery (LESS), for the treatment of renal tumour.

Materials and methods

In a non-randomized retrospective study, we selected 90 patients who underwent (01/2010–12/2011) partial and radical nephrectomy for clinical renal masses ≤7 cm (cT1N0M0) and divided them into laparoscopic [laparoscopic partial nephrectomy (LPN), laparoscopic radical nephrectomy (LRN)], LESS [laparoendoscopic single-site partial nephrectomy (LESS-PN), laparoendoscopic single-site radical nephrectomy (LESS-RN)] and open groups [open partial nephrectomy (OPN), open radical nephrectomy (ORN)]. Patients were matched for age, sex, body mass index, ASA score and tumour side. Primary endpoints were evaluation of intraoperative costs (general, laparoscopic, sutures, haemostatic agents, anaesthesia, and surgeon/nurses fee), total insurance and estimated daily reimbursement.

Results

MIS showed longer operative time (p ≤ .02) and shorter hospital stay (p ≤ .04). Total costs were higher (p ≤ .03) in MIS (LRN: 4,091.5 €; LPN: 4,390.4 €; LESS-RN: 3,866 €; and LESS-PN: 3,450 €) if compared with open (OPN: 2,216.8.8 €, ORN: 1,606.4 €). Laparoscopic materials incised mainly in total costs of MIS (38–58.1 %). Reusable instruments reduced LESS laparoscopic costs (LESS-PN: 1,312.2 € vs. LRN: 2,212.2 €, p < .0001). Intraoperative frozen section and DJ ureteric stenting (general costs) (p ≤ .008) and haemostatic agents use (p ≤ .01) were higher in nephron sparing surgery (NSS), due to more frequent use of ancillary procedures necessary for a safe management of such an approach. Estimated anaesthesia costs and doctor/nurses fee were higher in MIS (p ≤ .02). Whereas total final reimbursements were comparable (p ≥ .8), estimated daily reimbursements were lower in MIS (p < .001) due to higher intraoperative costs and longer operative time.

Conclusion

Well-known advantages offered by MIS/NSS face higher total intraoperative costs and ‘paradoxical’ reduced healthcare reimbursement. We believe that local health systems should consider a subclassification with different compensations, which will incentive NSS and MIS approaches.     

National Trends in Postoperative Outcomes and Cost Comparing Minimally Invasive Versus Open Liver and Pancreatic Surgery

Background

Although minimally invasive surgery (MIS) has been associated with improved postoperative clinical outcomes, the widespread use of MIS by procedure and hospital has been limited. We sought to report on national trends postoperative clinical outcomes for minimally invasive liver and pancreatic surgery.

Methods

Patients undergoing an elective liver or pancreatic resection were identified using the Nationwide Inpatient Sample between 2002 and 2012. Multivariable regression analysis was used to compare postoperative outcomes, and total hospital costs between patients who underwent a MIS versus an open resection over the study time period.

Results

A total of 47,685 patients were identified; 21,280 (44.6 %) patients underwent a hepatic resection while 26,405(55.4 %) patients underwent a pancreatic resection. MIS was performed in 2674 (5.6 %) patients and increased from 2.6 % in 2002 to 9.6 % in 2012 (p?<?0.001); this trend was observed for both pancreatic and liver resections (both p?<?0.001). Over the study time period, use of MIS was consistently associated with improved postoperative outcomes including decreased postoperative morbidity (open vs. MIS: 32.9 vs. 29.6 %) and a shorter length-of-stay (≤4 days; MIS, 21.4 %; Open, 13.7 %; both p?<?0.05). The median costs associated with MIS decreased over time compared with the open surgical approach and were on average $572 lower than the cost associated with open surgery.

Conclusion

Compared to open resection, MIS was associated with lower postoperative morbidity, a shorter length-of-stay, and lower cost. The use of MIS should be encouraged in order to improve postoperative outcomes and decrease healthcare spending via value enhancement.

     

Interoperative efficiency in minimally invasive surgery suites

Background

Performing minimally invasive surgery (MIS) in a conventional operating room (OR) requires additional specialized equipment otherwise stored outside the OR. Before the procedure, the OR team must collect, prepare, and connect the equipment, then take it away afterward. These extra tasks pose a thread to OR efficiency and may lengthen turnover times. The dedicated MIS suite has permanently installed laparoscopic equipment that is operational on demand. This study presents two experiments that quantify the superior efficiency of the MIS suite in the interoperative period.

Methods

Preoperative setup and postoperative breakdown times in the conventional OR and the MIS suite in an experimental setting and in daily practice were analyzed. In the experimental setting, randomly chosen OR teams simulated the setup and breakdown for a standard laparoscopic cholecystectomy (LC) and a complex laparoscopic sigmoid resection (LS). In the clinical setting, the interoperative period for 66 LCs randomly assigned to the conventional OR or the MIS suite were analyzed.

Results

In the experimental setting, the setup and breakdown times were significantly shorter in the MIS suite. The difference between the two types of OR increased for the complex procedure: 2:41 min for the LC (p < 0.001) and 10:47 min for the LS (p < 0.001). In the clinical setting, the setup and breakdown times as a whole were not reduced in the MIS suite. Laparoscopic setup and breakdown times were significantly shorter in the MIS suite (mean difference, 5:39 min; p < 0.001).

Conclusion

Efficiency during the interoperative period is significantly improved in the MIS suite. The OR nurses’ tasks are relieved, which may reduce mental and physical workload and improve job satisfaction and patient safety. Due to simultaneous tasks of other disciplines, an overall turnover time reduction could not be achieved.     

Minimally invasive surgery training using multiple port sites to improve performance

Background

Structural learning theory suggests that experiencing motor task variation enables the central nervous system to extract general rules regarding tasks with a similar structure—rules that can subsequently be applied to novel situations. Complex minimally invasive surgery (MIS) requires different port sites, but switching ports alters the limb movements required to produce the same endpoint control of the surgical instrument. The purpose of the present study was to determine if structural learning theory can be applied to MIS to inform training methods.

Methods

A tablet laptop running bespoke software was placed within a laparoscopic box trainer and connected to a monitor situated at eye level. Participants (right-handed, non-surgeons, mean age = 23.2 years) used a standard laparoscopic grasper to move between locations on the screen. There were two training groups: the M group (n = 10) who trained using multiple port sites, and the S group (n = 10) who trained using a single port site. A novel port site was used as a test of generalization. Performance metrics were a composite of speed and accuracy (SACF) and normalized jerk (NJ; a measure of movement ‘smoothness’).

Results

The M group showed a statistically significant performance advantage over the S group at test, as indexed by improved SACF (p < 0.05) and NJ (p < 0.05).

Conclusions

This study has demonstrated the potential benefits of incorporating a structural learning approach within MIS training. This may have practical applications when training junior surgeons and developing surgical simulation devices.