Cholecystectomy: from Langenbuch to natural orifice transluminal endoscopic surgery

Transvaginal natural orifice transluminal endoscopic surgery for tubal ectopic pregnancy(vNOTESTEP): a protocol for a randomized controlled trial

BACKGROUND

Tubal ectopic pregnancy is a life-threatening condition in early pregnancy. Minimally invasive laparoscopic surgery is increasingly used for the treatment of this disease. Retrospective studies suggest that Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) offers lower perioperative complications, faster recovery, and better cosmetic outcomes compared to other approaches. However, the lack of comprehensive perioperative and long-term postoperative data limits its widespread adoption in gynecology.

METHODS

The vNOTESTEP study is a randomized controlled trial (RCT) enrolling 72 patients requiring laparoendoscopic surgery for tubal ectopic pregnancy. After obtaining informed consent, preoperative assessments will be conducted. Following randomization, salpingectomy will be performed using either vNOTES or TU-LESS approach. The postoperative assessment and a structured 5-year follow-up, including eight visits, will be conducted. Baseline sociodemographic and clinical data will be collected from the Hospital Information System and patient interviews. Outcomes will be assessed perioperatively and postoperatively at designated time points (1st, 2nd, and 3rd postoperative day; 1st, 3rd, and 6th month; 1st-5th year). Key long-term outcomes include sexual function, pregnancy, vaginal delivery, and incisional hernia.

DISCUSSION

This RCT aims to provide robust clinical evidence on the perioperative and long-term outcomes of vNOTES versus TU-LESS for tubal ectopic pregnancy, focusing on key reproductive and surgical outcomes. The study seeks to refine patient selection criteria and contribute to guideline development for gynecologic vNOTES.

TRIAL REGISTRATION NUMBER

ChiCTR2400082909 (registered on April 10th, 2024).

Three-port laparoscopic cholecystectomy is safe and efficient in the treatment of surgical biliary disease: a retrospective cohort study

Multiple studies have suggested that three-port laparoscopic cholecystectomy is both feasible and safe. However, this approach has failed to gain acceptance outside of clinical trials, leaving adopters of this approach vulnerable to medico-legal scrutiny. We hypothesized that the three-port approach to laparoscopic cholecystectomy (LC) is safe and efficient in experienced hands. All LC (including robotic) cases were performed on patients 18 years and older between November 2018 and March 2020. Operations utilizing three ports were compared to those performed using more than three ports. The primary outcomes measured were total operative time, conversion-to-open rate, and the complication rate. A two-sample test was performed to compare operative times, and a Fisher's exact test was used to compare conversion-to-open and complication rates. Linear regression models were used to account for the effect of confounders. 924 total LCs were performed by 30 surgeons in the study period (71 three-port, 853 four or more ports). The mean operative time was 10 min shorter in the three-port group in comparison (64.1 ± 1.4 min vs. 74.4 ± 1.8 min, p < 0.01), despite a threefold higher rate of intraoperative cholangiogram in these cases (23.0% vs. 7.9%, p < 0.001). There was no significant difference in either the conversion-to-open rate (1.6% vs. 5.1%, p = 0.35), or the overall complication rate (7.1% vs. 8.7%, p = 0.82). Operative time for LC performed through three ports was significantly less than those performed through the traditional four port approach, despite utilizing intraoperative cholangiogram nearly three times as often. There was no difference in the conversion-to open rate or complication rate. These results provide considerable evidence that three-port laparoscopic cholecystectomy is comparable to four-port laparoscopic cholecystectomy in operative duration, conversion-to-open rate, and complication rate.

Endoscopic minimally invasive cholecystolithotomy in a patient with duplicate gallbladder: a case report

Gallstone disease is common in China and is generally treated with laparoscopic cholecystectomy. For some patients with normal contraction function and a small number of stones, endoscopic minimally invasive cholecystolithotomy is an additional possible treatment method that avoids complications related to laparoscopic cholecystectomy. Here, we describe a 45-year-old woman who underwent endoscopic minimally invasive cholecystolithotomy and was found to have duplicate gallbladder, which was not diagnosed preoperatively. We discuss the usefulness of the endoscopic minimally invasive cholecystolithotomy procedure and the management of duplicate gallbladder in patients undergoing endoscopic minimally invasive cholecystolithotomy.

Cost analysis of single-incision versus conventional laparoscopic surgery for colon cancer: A propensity score-matching analysis

BACKGROUND/OBJECTIVE

Although many studies have demonstrated similar perioperative outcomes for single-incision laparoscopic surgery (SILS) and conventional laparoscopic surgery (CLS) for colon cancer, few have directly compared the costs of them. We aimed to compare costs between SILS and CLS for colon cancer.

METHODS

We analyzed the clinical outcomes and overall hospital costs of patients who underwent laparoscopic surgery for colon cancer from July 2009 to September 2014 at our institution; 288 were used for analysis after propensity score matching. The total hospital charge, including fees for the operation, anesthesia, preoperative diagnosis, and postoperative management was analyzed.

RESULTS

The total hospital charges were similar in both groups ($8770.40 vs. $8352.80, P = 0.099). However, the patients' total hospital bill was higher in the SILS group than in the CLS group ($4184.82 vs. $3735.00, P < 0.001) mainly due to the difference of the cost of access devices. There was no difference in the additional costs associated with readmission due to late complications between the two groups ($2383.08 vs. $2288.33, P = 0.662). Incremental cost-effectiveness ratio for total incision length in 'total hospital charge' and patient's bill and government's bill in 'cost of instruments and supplies' were -$107.08/1 cm, -$109.70/1 cm, and $80.64/1 cm, respectively.

CONCLUSION

SILS for colon cancer yielded similar costs as well as perioperative and long-term outcomes compared with CLS. Therefore, SILS can be considered a reasonable treatment option for colon cancer for selective patients.

A Comparative Study of Single Incision versus Conventional Four Ports Laparoscopic Cholecystectomy

INTRODUCTION

Cholelithiasis is one of the most common disorders of the digestive tract encountered by general surgeons worldwide. Conventional or open cholecystectomy was the mainstay of treatment for a long time for this disease. In the 1980s laparoscopic surgery revolutionized the management of biliary tract diseases. It brought about a revolutionary change in the basic concepts of surgical principles and minimal access surgery gradually started to be acknowledged as a safe means of carrying out surgeries.

AIM

To investigate the technical feasibility, safety and benefit of Single Incision Laparoscopic Cholecystectomy (SILC) versus Conventional Four Port Laparoscopic Cholecystectomy (C4PLC).

MATERIALS AND METHODS

This prospective randomized control trial was conducted to compare the advantages if any between the SILC and C4PLC. Thirty two patients underwent SILC procedure and C4PLC, each. The age of the patients ranged from 16-60years. Other demographic data and indications for cholecystectomy were comparable in both the groups. Simple comparative statistical analysis was carried out in the present study. Results on continuous variables are shown in Mean ± SD; whereas results on categorical variables are shown in percentage (%) by keeping the level of significance at 5%. Intergroup analysis of the various study parameters was done by using Fisher exact test. SPSS version 22 was used for statistical analysis.

RESULTS

The mean operating time was higher in the SILC group (69 ± 4.00 mins vs. 38.53 ± 4.00 mins) which was of statistical significance (p=<0.05). Furthermore, the patients of the SILC group had less post-operative pain, with lesser analgesic requirements (p=<0.05), shorter hospital stay and earlier return to normal activity.

CONCLUSION

SILC is feasible and safe in trained hands. It did not compromise the procedural safety, or lead to any complication. The operating time was longer otherwise it has almost similar clinical outcomes to those of C4PLC.

Management of gallstones and its related complications

The majority of gallstone patients remain asymptomatic; however, interest toward the gallstone disease is continuing because of the high worldwide prevalence and management costs and the development of gallstone symptoms and complications. For cholesterol gallstone disease, moreover, a strong link exists between this disease and highly prevalent metabolic disorders such as obesity, dyslipidemia, type 2 diabetes, hyperinsulinemia, hypertriglyceridemia and the metabolic syndrome. Information on the natural history as well as the diagnostic, surgical (mainly laparoscopic cholecystectomy) and medical tools available to facilitate adequate management of cholelithiasis and its complications are, therefore, crucial to prevent the negative outcomes of gallstone disease. Moreover, some risk factors for gallstone disease are modifiable and some preventive strategies have become necessary to reduce the onset and the severity of complications.

Can single incision laproscopic cholecystectomy replace the traditional four port laproscopic approach: a review

The major aim of surgeons has always been a minimalist approach towards surgery, thereby reducing the complications associated with the surgery. The gold standard treatment for cholelithiasis with cholecystitis is currently the four port laparoscopic cholecystectomy (4 PLC). Recently, a newer technique has been introduced which uses a single port, rather than the four ports, for the removal of the gall bladder laparoscopically; it is known as Single Incision Laparoscopic Cholecystectomy (SILC). This is a comparatively minimal approach towards surgery. Therefore the purpose of this review is to compare the advantages and the disadvantages of SILC versus 4PLC, and hence, to give an idea of whether SILC is ready to replace the traditional approach as the new treatment of choice.

Cost analysis and effectiveness comparing the routine use of intraoperative fluorescent cholangiography with fluoroscopic cholangiogram in patients undergoing laparoscopic cholecystectomy

BACKGROUND

Despite the standardization of laparoscopic cholecystectomy (LC), the rate of bile duct injury (BDI) has risen from 0.2 to 0.5%. Routine use of intraoperative cholangiography (IOC) has not been widely accepted because of its cost and a lack of evidence concerning its use in preventing BDI. Fluorescent cholangiography (FC), which has recently been advocated as an alternative to IOC, is a novel intraoperative procedure involving infrared visualization of the biliary structures. This study evaluated costs and effectiveness of routinely implemented FC and IOC during LC.

MATERIALS AND METHODS

Between February and June 2013, the authors prospectively collected the data of all patients undergoing laparoscopic cholecystectomy. We retrospectively reviewed and compared the use of FC and IOC. Procedure time, procedure cost, and effectiveness of the two methods were analyzed and compared. The surgeons involved in the cases completed a survey on the usefulness of each method.

RESULTS

A total of 43 patients (21 males and 22 females) were analyzed during the study period. Mean age was 49.53 ± 14.35 years and mean body mass index was 28.35 ± 8 kg/m(2). Overall mean operative time was 64.95 ± 17.43 min. FC was faster than IOC (0.71 ± 0.26 vs. 7.15 ± 3.76 min; p < 0.0001). FC was successfully performed in 43 of 43 cases (100%) and IOC in 40 of 43 cases (93.02%). FC was less expensive than IOC (US$14.10 ± 4.31 vs. US$778.43 ± 0.40; p < 0.0001). According to the survey, all surgeons found routine use of FC useful.

CONCLUSION

In this study, FC was effective in delineating important anatomic structures. It required less time and expense than IOC, and was perceived by the surgeons to be easier to perform, and at least as useful as IOC. Further prospective studies are warranted to evaluate the effectiveness of FC in decreasing BDI.

Diagnosis and management of gallbladder calculus disease

BACKGROUND

The number and rate of cholecystectomy are increasing worldwide, although indications for operative treatment remain empirical, and several issues in the understanding of the condition are not concisely outlined. Our intention is to summarize and interpret current opinion regarding the indications and timing of cholecystectomy in calculous gallbladder disease.

METHODS

Publications concerned with gallstone disease and related topics were searched for in MEDLINE using PubMed and summarized according to clinical scenarios with an emphasis on recent research.

RESULTS

Only one randomized controlled trial has investigated the management (conservative vs. surgery) of patients with acute cholecystitis and several have compared early with deferred surgery. Two RCTs have examined treatment of uncomplicated, symptomatic gallstone disease. Apart from these, the overwhelming majority of publications are retrospective case series.

CONCLUSIONS

Recent literature confirms that cholecystectomy for an asymptomatic or incidental gallstone is not justified. Symptomatic, uncomplicated gallstone disease may be classified into four severity groups based on severity and frequency of pain attacks, which may guide indication for cholecystectomy. Most patients below the age of 70 seem to prefer operative treatment. Acute cholecystitis may be treated with early operation if reduction of hospital days is an issue. Patients older than 70 years with significant comorbidities may forego surgical treatment without undue hazard. Symptoms following cholecystectomy remain in 25% or more and recent evidence suggest these are caused by a functional gastrointestinal disorder.

Single-incision laparoscopic cholecystectomy: is it a plausible alternative to the traditional four-port laparoscopic approach?

The current standard-of-care for treatment of cholecystectomy is the four port laparoscopic approach. The development of single incision/laparoendoscopic single site surgery (SILC/LESS) has now led to the development of new techniques for removal of the gallbladder. The use of SILC/LESS is now currently being evaluated as the next step in treatment of cholecystectomy. This review is an attempt to consolidate the current knowledge and analyze the feasibility of world-wide implementation of SILC/LESS.