Update on the Minimally Invasive Approach in Paediatric Urology: Remote Help for Human Hands?

The innovations of minimally-invasive surgery have successfully been applied to pediatric surgery. Some special caveats apply to children, however. Confinements of space and the small intravsacular blood volume pose special risks in small infants. Unlike in adults, placement of the first troikar should always be under direct vision. There is no consensus whether minimally-invasive approaches should be used in children under one year of age.Single-port approaches have also been used in children and for renal surgery both the transabdominal and the retroperitoneosocopic approach are feasible. Pneumovesicoscopy has successfully been used for ureteral reimplantation and robotic-assisted surgery for children has also been established. The cost-effectiveness of many techniques remains an unsolved problem.     

Does Robotic Technology Make Minimally Invasive Cardiac Surgery Too Expensive? A Hospital Cost Analysis of Robotic and Conventional Techniques

BACKGROUND: While potential benefits of robotic technology include decreased morbidity and improved recovery, some have suggested a prohibitively high cost. This study was undertaken to compare actual hospital costs of robotically assisted cardiac procedures with conventional techniques. METHODS: We conducted a retrospective review of clinical and financial data of 20 patients who underwent atrial septal defect (ASD) closure and 20 patients who underwent mitral valve repair (MVr) using either robotic techniques or a conventional approach with a sternotomy. Total hospital cost (actual resource consumption) was subdivided into operative and postoperative costs. RESULTS: Robotic technology did not significantly increase total hospital cost for ASD closure or MVr (p = 0.518 and p = 0.539). However, when including the initial capital investment for the robot through amortization of institutional costs, total hospital cost was increased by $3,773 for robotic ASD closure and $3,444 for robotic MVr (p = 0.021 and p = 0.004). The major driver of cost for robotic cases (operating room time) decreased over time. CONCLUSIONS: Robotic technology did not significantly increase hospital cost. While the absolute cost for robotic surgery was higher than conventional techniques after taking into account the institutional cost of the robot, the major driver of cost for robotic procedures will likely continue to decrease, as the surgical team becomes increasingly familiar with robotic technology. Furthermore, other benefits, such as improvement in postoperative quality of life and more expeditious return to work may make a robotic approach cost-effective. Thus, it is possible that the benefits of robotic surgery may justify investment in this technology.     

Use of Epidural Analgesia in Sigmoidectomy: Is There Any Advantage in the Era of Minimally Invasive Surgery?

Background

There is no consensus as to the effects of epidural analgesia on postoperative outcomes after laparoscopy in the context of the Enhanced Recovery Programs. The aim of this study was to evaluate the effects of epidural analgesia on postoperative outcomes after elective laparoscopic sigmoidectomy.

Methods

The use of epidural analgesia was discontinued in elective laparoscopic sigmoidectomy and substituted by the perioperative administration of systemic lidocaine. Data from patients undergoing elective laparoscopic sigmoidectomy between January 2014 and September 2016 was prospectively analysed. Patients with epidural analgesia were compared with patients without, in analgesics administrated postoperatively, length of stay, day of first defecation and mobilisation, and complication and reoperation rates.

Results

A total of 160 patients (male 85; female 75), median age 68 (30–92 years), were included. The groups consisted of 80 patients each. Mean length of stay (5.6 vs. 7.2 days, p?=?0.03) and day of first mobilisation (mean 1.2 vs. 1.6 days, p?=?0.004) were significantly shorter in the group without epidural analgesia. Reoperation rate (7.5 vs. 2.5%) was not statistically different. Complication rate was significantly lower (12.5 vs. 30%, p?=?0.007) in the group without epidural. Day of first defecation was shorter in the epidural group (1.4 vs. 1.7 days, p?=?0.04). Mean amount of analgesics administrated was not statistically different between groups, except for metamizole, that was administrated more in the group without epidural.

Conclusions

Epidural analgesia did not offer benefits on postoperative analgesia or outcomes after elective laparoscopic sigmoidectomy, causing longer length of stay, later mobilisation and higher complication rate.

     

Editorial Commentary: Which Procedure Contributes to Best Outcomes After Arthroscopic Reduction and Minimally Invasive Surgery for Ankle Fractures?

The algorithm of arthroscopic reduction and minimally invasive surgery (ARMIS) can decrease the incidence of complications and reoperations, in spite of longer operative times and higher doses of irradiation for the patients with a supination–external rotation ankle fracture. At the present time, however, we cannot identify which procedure contributes to improved outcomes with use of the ARMIS algorithm.     

Early Results from a Novel Quality Outcomes Program: The American Society of Breast Surgeons’ Mastery of Breast Surgery

Background

In 2008, the American Society for Breast Surgeons launched its Mastery in Breast Surgery Pilot Program to demonstrate feasibility of a Web-based tool for breast surgeons to document and monitor quality outcomes.

Methods

Participating surgeons report performance of three quality measures for breast procedures: Was a needle biopsy performed to evaluate the breast lesion before the procedure? Was the surgical specimen oriented? For nonpalpable lesions localized with image guidance, was there intraoperative confirmation of removal? Data are collected through the American Society for Breast Surgeons’ Web-based software using a secure server and encrypted identification numbers. Surgeon demographic/practice characteristic data were collected, and logistic regression models were used to identify factors that affected quality measures.

Results

From October 2008 to December 2009, a total of 696 surgeons entered data for 28,798 breast procedures. Participants were diverse in years in practice, geographic location, practice setting and type, and proportion of practice made up of breast procedures. Delivery of “optimal care” (defined as delivery of all quality measures for which there was no valid clinical reason for nonperformance) was high for all surgeon demographic/practice characteristics, ranging from 81% to 94%. Statistically significant differences in delivery of quality measures were observed within all physician demographic/practice characteristic variables, but many absolute differences were small.

Conclusions

The high level of participation and volume of breast procedures for which quality measure data was entered demonstrate this is a feasible means of collecting quality performance data. Future development will include identifying/developing additional quality measures and establishing evidence-based benchmarks for care on the basis of data collected.

     

Predictive Factors of Type 2 Diabetes Remission 1 Year After Bariatric Surgery: Impact of Surgical Techniques

Type 2 diabetes (T2D) remission after bariatric procedures has been highlighted in many retrospective and some recent prospective studies. However, in the most recent prospective study, more than 50 % of patients did not reach T2D remission at 1 year. Our aim was to identify baseline positive predictors for T2D remission at 1 year after bariatric surgery and to build a preoperative predictive score. We analysed the data concerning 161 obese operated on between June 2007 and December 2010. Among them, 46 were diabetic and were included in the study—11 laparoscopic adjustable gastric banding (LAGB), 26 Roux-en-Y gastric bypass (RYGB) and 9 sleeve gastrectomy (SG). We compared anthropometric and metabolic features during 1 year of follow-up. A receiver operating characteristic analysis was performed to predict T2D remission. RYGB and SG were similarly efficient for body weight loss and more efficient than LAGB; 62.8 % of patients presented with T2DM remission at 1 year, with no significant difference according to the surgical procedure. A 1-year body mass index (BMI) <35 kg?m^?2 was predictive of T2DM remission whatever the procedure. The preoperative predictive factors of diabetes remission were baseline BMI ≤50 kg?m^?2, duration of type 2 diabetes ≤4 years, glycated haemoglobin ≤7.1 %, fasting glucose <1.14 g/l and absence of insulin therapy. A short duration of diabetes and good preoperative glycaemic control increase the rate of T2DM remission 1 year after surgery. Preoperative metabolic data could be of greater importance than the choice of bariatric procedure.     

Five Year Follow-Up of a Randomized Controlled Trial on Warming and Humidification of Insufflation Gas in Laparoscopic Colonic Surgery—Impact on Small Bowel Obstruction and Oncologic Outcomes

Warming and humidification of insufflation gas has been shown to reduce adhesion formation and tumor implantation in the laboratory setting, but clinical evidence is lacking. We aimed to test the hypothesis that warming and humidification of insufflation CO₂ would lead to reduced adhesion formation, and improve oncologic outcomes in laparoscopic colonic surgery. This was a 5-year follow-up of a multicenter, double-blinded, randomized, controlled trial investigating warming and humidification of insufflation gas. The study group received warmed (37°C), humidified (98%) insufflation carbon dioxide, and the control group received standard gas (19°C, 0%). All other aspects of patient care were standardized. Admissions for small bowel obstruction were recorded, as well as whether management was operative or nonoperative. Local and systemic cancer recurrence, 5-year overall survival, and cancer specific survival rates were also recorded. Eighty two patients were randomized, with 41 in each arm. Groups were well matched at baseline. There was no difference between the study and control groups in the rate of clinical small bowel obstruction (5.7% versus 0%, P 0.226); local recurrence (6.5% versus 6.1%, P 1.000); overall survival (85.7% versus 82.1%, P 0.759); or cancer-specific survival (90.3% versus 87.9%, P 1.000). Warming and humidification of insufflation CO₂ in laparoscopic colonic surgery does not appear to confer a clinically significant long term benefit in terms of adhesion reduction or oncological outcomes, although a much larger randomized controlled trial (RCT) would be required to confirm this. ClinicalTrials.gov Trial identifier: {"type":"clinical-trial","attrs":{"text":"NCT00642005","term_id":"NCT00642005"}}NCT00642005; US National Library of Medicine, 8600 Rockville Pike, Bethesda, MD 20894, USA.Key words: Adhesions, Small bowel obstruction, Laparoscopy, humidification, colectomy, ColorectalIn laparoscopic surgery, the abdominal wall is commonly distended using carbon dioxide (CO₂) insufflation to provide pneumoperitoneum.¹ The gas is delivered at room temperature (19–21°C) with a relative humidity approaching 0% at the point of entry into the peritoneal cavity.² Early data suggested that unconditioned gas can cause structural and biochemical injury to the peritoneal mesothelium, and that warming and humidification of the insufflation CO₂ resulted in reduced postoperative pain after laparoscopic procedures.^3–7 However, more recent evidence from high quality, randomized controlled trials and a Cochrane meta-analysis have shown this not to be the case, with no difference in postoperative pain scores or opiate use with warming and humidification.^8–10With no demonstrable difference in short-term clinical outcomes, attention has now shifted toward long-term outcomes, namely adhesion formation and oncological response. There is now laboratory evidence to suggest that conditioning of insufflation gas may in fact reduce postoperative adhesion formation,^11,12 and peritoneal tumor implantation.¹³ It is thought that this is because conditioning insufflation gas reduces the peritoneal inflammatory response. However, clinical evidence to confirm these findings has been lacking.We previously published a multicenter, double-blinded, randomized controlled trial investigating warming and humidification of insufflation gas in laparoscopic colonic surgery.⁸ This study showed that warming and humidification did not confer any clinically significant short-term recovery benefit in laparoscopic colonic surgery. In light of the recent laboratory study findings mentioned above, we aimed to test the hypothesis that warming and humidification of insufflation CO₂ leads to reduced adhesion formation, and improved oncologic outcomes in laparoscopic colonic surgery.