Journal of Laparoendoscopic & Advanced Surgical Techniques

Previous abdominal surgery has traditionally been considered an additional element of difficulty to later laparoscopic procedures. The aim of the study is to analyze the effect of previous surgery on the feasibility and safety of laparoscopic liver resection (LLR), and its role as a risk factor for conversion.

After matching, 349 LLR in patients known for previous abdominal surgery (PS group) were compared with 349 LLR on patients with a virgin abdomen (NPS group). Subgroup analysis included 161 patients with previous upper abdominal surgery (UPS subgroup). Feasibility and safety were evaluated in terms of conversion rate, reasons for conversion and outcomes, and risk factors for conversion assessed via uni/multivariable analysis.

Conversion rate was 9.4%, and higher for PS patients compared with NPS patients (13.7% versus 5.1%, P = .021). Difficult adhesiolysis resulted the commonest reason for conversion in PS group (5.7%). However, operative time (P = .840), blood loss (P = .270), transfusion (P = .650), morbidity rate (P = .578), hospital stay (P = .780), and R1 rate (P = .130) were comparable between PS and NPS group. Subgroup analysis confirmed higher conversion rates for UPS patients (23%) compared with both NPS (P = .015) and PS patients (P = .041). Previous surgery emerged as independent risk factor for conversion (P = .033), alongside the postero-superior location and major hepatectomy.

LLR are feasible in case of previous surgery and proved to be safe and maintain the benefits of LLR carried out in standard settings. However, a history of surgery should be considered a risk factor for conversion.

To study the anatomical features and classification of the angle between the right gastroepiploic vein (RGEV) and superior mesenteric vein/portal vein (SMV/PV) and to guide the catheterization of intraportal infusion chemotherapy through RGEV and reduce surgical complications.

A retrospective three-dimensional (3D) computed tomography study was undertaken on 200 consecutive subjects with or without hepatic malignant tumors with a dedicated workstation 3D-MIA (the improved MI-3DVS workstation) developed by ourselves to determine the prevalence of surgically significant angle between RGEV and SMV/PV anatomic variations and its classification.

The mean value of the angles between the end of RGEV and SMV/PV (AERS/P) (200 cases) was 84.2° ± 23.8 (31.4°–151.5°): 40.6° ± 92.3 (−177.9° to 178.0°) (sagittal angle), 81.7° ± 29.8 (−79.3° to 160.7°) (coronal angle), and 10.5° ± 94.3 (−178.7° to 175.8°) (horizontal angle). The mean value of the angles between the right bend of RGEV and SMV/PV (ARRS/P) (168 cases) was 104.8° ± 26.1 (20.5°–159.7°):49.3° ± 117.8 (−175.3° to 179.5°) (sagittal angle), 103.5° ± 37.7 (−178.8° to 168.9°) (coronal angle), and 12.6° ± 102.8 (−179.9° to 179.2°) (horizontal angle). The AERS/P were classified into large angle group (32 cases, 16%), middle angle group (113 cases, 56.5%), and small angle group (55 cases, 27.5%) based on angle variations and risks of catheterization.

Precognition of the variations of AERS/P and ARRS/P before surgery is useful during chemotherapy pump catheterizing through RGEV in reduction of surgical complications by modulating the angle and direction of RGEV running into SMV/PV properly.

Robotic-assisted partial nephrectomy (RAPN) is preferred to radical nephrectomy because it guarantees superior functional outcomes in patients with small renal masses (RMs). Only a few studies so far have evaluated the feasibility of RAPN for the treatment of RM ≥4 cm.

The aim of this study is to evaluate the safety and feasibility of RAPN based on a comparison of trifecta and pentafecta rates for RMs ≥4 cm.

We retrospectively analyzed prospectively collected data from an institutional database of patients undergoing RAPN from September 2013 to November 2016. Demographic and perioperative data were collected and statistically analyzed. Pentafecta is defined as achievement of trifecta (negative surgical margins, no postoperative complications, and warm ischemia time ≤25 minutes) with the addition of two other variables, namely, over 90% estimated glomerular filtration rate preservation and no chronic kidney disease stage progression 1 year after surgery.

Overall, 123 patients underwent RAPN. Of those, 38 (30.9%) had RMs ≥4 cm. Trifecta was achieved in 72.9% of patients with RMs <4 cm and in 44.7% of those with ≥4 cm, whereas pentafecta was achieved by 23.5% of patients with RMs <4 cm and by 10.5% of those with RMs ≥4 cm. No significant predictive factors were found in connection with trifecta, whereas only one was found in connection with pentafecta, namely, age (odds ratio: 0.91; 95% confidence interval 0.85–0.98; P = .01).

RAPN may be considered a feasible and safe surgical approach ensuring good functional outcome even for patients with RMs ≥4 cm. Pentafecta rates after RAPN were comparable between RMs <4 and ≥4 cm in diameter.

It was aimed to concern about the satisfaction and procedural complications of patients during the thoracoscopy exist of hands-on training in this present study.

The patients with non-small-cell carcinoma underwent video-assisted thoracoscopic surgery (VATS) lobectomy during hands-on training courses at thoracoscopic center in our hospital and collected from January 2009 and December 2014. The rates of satisfaction and complications of patients were compared from hands-on training group and control group. Potential risk factors associated with post-VATS complications of patients and thoracoscopist-related variables were analyzed. There were 54 patients join in six meetings with hands-on thoracoscopy training in our center.

There was no significant difference between patients for hands-on training group (n = 54) and control group (n = 54), including sex, age, BMI, smoking, PpoFEV1 and comorbidities. The satisfaction rate and the incidence of complication were similar between the two groups.

Univariate analyses showed that elder age, heart disease, chronic obstructive pulmonary disease, long operative time, and first-time mentorship were significantly associated with post-VATS complications of patients in hands-on training group. We should pay more attention to the characteristics of patent and the experience of mentor before VATS hands-on training courses.

The short-term benefits of laparoscopy for rectal surgery are equivocal. The objective of this study was to determine the clinical and economic impact of an enhanced recovery pathway (ERP) for laparoscopic and open rectal surgery.

All patients who underwent elective rectal resection with primary anastomosis between January 2009 and March 2012 at two tertiary-care, university-affiliated institutions were identified. Patients who met inclusion criteria were divided into four groups, according to surgical approach (laparoscopic [lap] or open) and perioperative management (ERP or conventional care [CC]). Length of stay (LOS), postoperative complications, and hospital costs were compared.

A total of 381 patients were included in the analysis (201 open-CC, 34 lap-CC, 38 open-ERP, and 108 lap-ERP). Patients were mostly similar at baseline. ERPs significantly reduced median LOS after both open cases (open-CC 10 days versus open-ERP 7.5 days, P = .003) and laparoscopic cases (lap-CC 5 days versus lap-ERP 4.5 days, P = .046). ERPs also reduced variability in LOS compared with CC. There was no difference in postoperative complications with the use of ERPs (open-CC 51% versus open-ERP 50%, P = .419; lap-CC 32% versus lap-ERP 36%, P = .689). On multivariate analysis, both ERP (−3.6 days [95% confidence interval, CI −6.0 to −1.3]) and laparoscopy (−3.6 days [95% CI −5.9 to −1.0]) were independently associated with decreased LOS. Overall costs were only lower when lap-ERP was compared with open-CC (mean difference −2420 CAN$ [95% CI −5628 to −786]).

ERPs reduced LOS after rectal resections, and the combination of laparoscopy and ERPs significantly reduced overall costs compared to when neither strategy was used.

Anatomic segmentectomy for stage I nonsmall cell lung cancer (NSCLC) has potential advantages such as preserving pulmonary function and reducing postoperative complications. However, many surgeons are deterred from this procedure for its anatomical complexity. Therefore, we presented our early experience with video-assisted thoracoscopic surgery (VATS) anatomic segmentectomy compared with our most recent VATS lobectomy cases.

Forty patients with cT1aN0M0 (ground-glass opacity [GGO] rate >50%) NSCLC underwent VATS segmentectomy from January 2015 to December 2016. To compare the short-term postoperative outcomes, 47 patients, who underwent VATS lobectomy for cT1aN0M0 NSCLC (GGO rate ≤50% and pure solid nodule) during the same period, were referred to as a control group.

The two groups were similar in age, sex, preoperative pulmonary functional assessment, and associated comorbidities. The tumor size in the segmentectomy group was significantly smaller (median, 0.8 cm versus 1.4 cm, P < .001). Segmentectomy and lobectomy groups had similar operating time, estimated blood loss, duration of chest tube drainage, length of postoperative hospital stay, and postoperative major and minor morbidities. With regard to lymph node evaluation, lobectomy was associated with more lymph nodes (median, 12 versus 9 nodes, P < .001) and mediastinal nodal stations evaluated (median, 3 versus 3 stations, P < .001).

With acceptable morbidity and mortality, VATS segmentectomy may be an acceptable option for the treatment of cT1aN0M0 (GGO rate >50%) NSCLC.

Sleeve gastrectomy (SG) has been a booming technique for 10 years. Bariatric surgery in patients over 50 years can be an effective solution on weight loss and comorbidities. The association with the nutritional and psychological care is essential to allow a true change of life mode. We are studying the mid-term (3-year) outcomes after SG in patients over 50 years of age.

This retrospective study analyzes patients treated between January 2011 and December 2013. The 129 patients were divided into three groups: under 35 years (n = 52), 35–50 years (n = 49), and over 50 years (n = 28).

The excess weight loss at 3 years were 75% for the under 35 years, 82% for the 35–50 years, and 69% for the over 50 years. Follow-up compliance at 3 years was 66%, 68%, 75%, respectively. Comorbidities were improved in all three groups with no significant difference for each comorbidity.

SG is an effective technique on weight and comorbidities. The results at 3 years are similar in patients over the age of 50 who seem more able to follow up and change lifestyle.

To evaluate quality of life after surgery for ulcerative colitis (UC) the gastroenterological and psychological conditions were examined.

Between January 1, 2005 and March 1, 2016, surgery was performed for UC in a total of 75 patients. Our examinations were performed in 58 cases. Quality of life was examined with questionnaires. Functional Scoring System, Gastrointestinal Quality of Life Index (GIQLI), and Short Inflammatory Bowel Disease Questionnaire (SIBDQ) were used for testing gastroenterological conditions; Spielberger's State-Trait Anxiety Questionnaire, Beck Depression Inventory, and Brief Illness Perception Questionnaire (BIPQ) were performed to consider psychological status.

Trait anxiety and the incidence of abdominal pain were significantly lower in patients having undergone laparoscopic surgery. No difference was found between the minimally invasive and conventional methods in the early complications. There were significantly more late complications developing after 30 days in patients who had undergone open surgery. Differences were found in personal control between patients with a stoma and patients without a stoma. Patients with a stoma felt they had less control over their disease. A significant correlation was found between the results of the psychological and gastrointestinal questionnaires.

Minimally invasive technique provides a better long-term outcome for patients with UC, fewer complications, and a more balanced emotional condition. Favorable gastroenterological condition leads to better psychological status, which is negatively influenced by stoma or complications.

Intraperitoneal local anesthetic nebulization is a new and novel technique for providing pain relief following laparoscopic cholecystectomy. We compared the analgesic efficacy of intraperitoneal ropivacaine-fentanyl nebulization with ropivacaine nebulization alone for providing pain relief following laparoscopic cholecystectomy

This prospective, randomized, double-blind, placebo-controlled trial included 75 American Society of Anesthesiologists I/II patients, 18–60 years old, scheduled to undergo laparoscopic cholecystectomy under general anesthesia. Patients were randomly allocated to one of the three groups of 25 patients each to receive intraperitoneal nebulization using normal saline (group I), 30 mg of 0.75% ropivacaine (group II), or 30 mg of 0.75% ropivacaine with 100 μg fentanyl (group III). Visual analogue scale (VAS) scores for pain during rest and movement, shoulder pain, nausea or vomiting, and sedation were recorded for 48 hours postoperatively. Time to providing first rescue analgesia and 48-hour tramadol consumption were also noted.

Significantly greater number of patients in the placebo group had overall VAS >30 both at rest and during movement. Greater number of these patients also complained of postoperative shoulder pain and had significantly more tramadol consumption in the postoperative period. Furthermore, patients in the ropivacaine-fentanyl group demanded first dose of rescue analgesic significantly later than the other two groups.

Nebulization results in better and uniform dispersion of analgesic drug intraperitoneally. Following laparoscopic cholecystectomy surgeries, ropivacaine nebulization of intraperitoneal cavity, with or without fentanyl, provides highly effective postoperative analgesia, with decreased incidence of shoulder pain. Furthermore, addition of fentanyl to ropivacaine prolongs the duration of analgesia.

To evaluate short-term and long-term outcomes of laparoscopic-assisted transhiatal esophagogastrectomy (LTEG) for treatment of adenocarcinoma of the esophagogastric junction (AEG).

Patients with AEG who underwent laparoscopic or open surgery at our department from October 2008 to December 2012 were enrolled in this retrospective study. Patients' demographics, perioperative outcomes, and survival data were collected.

A total of 136 patients with AEG were enrolled (103 patients underwent laparoscopic surgery and 33 patients underwent open surgery). Patient characteristics were comparable between two groups in terms of age, gender, tumor-node-metastasis stage, tumor size, preoperative complications, and type of surgery. The median operative time was longer in laparoscopic group (240 versus 210 minutes, P = .048). However, the estimated blood loss was less, and the rate of pleural rupture was lower in laparoscopic group (20 versus 70 mL, P < .001 and 18.4% versus 36.4%, P = .033, respectively). The rate of patients with pleural rupture requiring prolonged use of mechanical ventilation longer than 12 hours (6/31, 19.4%) was higher than that of patients without pleural rupture (6/105, 5.7%) (P = .019). The incidence of reflux symptoms at postoperative month six was similar in two groups (18.4% in laparoscopic group versus 24.2% in open group, P = .468), as well as the use of proton pump inhibitors (12.6% versus 15.2%, P = .709). Furthermore, the number of lymph nodes harvested (22 versus 25), 2-year cumulative overall survival rates (80.4% versus 57.5%), and the median survival times (51.52 months versus 24.24 months) were similar between two groups (P > .05).

LTEG is a safe, feasible, and oncologically effective procedure for AEG when performed by an experienced surgeon. Laparoscopic surgery is associated with a lower risk of pleural rupture, but pleural rupture in laparoscopic surgery may cause an adverse effect on the recovery of pulmonary function presumably due to tension pneumothorax.

Nissen fundoplication is frequently applied in the surgical treatment of patients with gastroesophageal reflux disease (GERD). When the gastroesophageal junction remains too large or becomes too narrow, persistent GERD or dysphagia may occur. To assure a correct size of the gastroesophageal junction, the fundoplication can be created over a bougie. However, this increases the risk of esophageal perforation. Therefore, we have modified a previously described technique to create a standardized fundoplication without the use of a bougie. In this article, we describe this technique and demonstrate the initial results.

We describe a technique to create a standardized Nissen fundoplication. After suture repair of the hiatal hernia, three marking sutures were placed on the gastric fundus, based on an equilateral triangle. The size of this triangle determines the final diameter of the fundoplication. With these measurements, we assure sufficient patency, minimize rotation, and create a more reproducible fundoplication that may reduce postoperative dysphagia.

We have operated 15 patients according to this technique. Mean operative time was 69.5 (SD 8.4) minutes, no complications occurred. There was no early dysphagia and the mean length of stay was 1.3 days (1–2). Quality of life after 1 year was excellent.

This modified method for standardized Nissen fundoplication is safe and might reduce postoperative dysphagia. Quality of life after 1 year is excellent. The effect on postoperative dysphagia and the reproducibility of this technique should be established in a large prospective study.

Postoperative leaks develop in a low percentage of patients undergoing laparoscopic sleeve gastrectomy (LSG), representing a rare yet devastating postoperative complication increasing morbidity and hospital stay. Leaks can become collections and may be very difficult to manage. Several therapeutic options with variable results, including surgical and nonsurgical methods have been described. Endoscopic abscess septotomy is an alternative method recently performed by a few centers reporting efficacy and safety outcomes. The purpose of this report is to present our successful experience with endoscopic abscess septotomy for the treatment of postsleeve gastrectomy leaks.

Two female patients with post-LSG leaks and abscess formation diagnosed 4 weeks postprocedure, initially managed with diagnostic laparoscopy, peritoneal washout, and drain placement with poor improvement, were chosen for endoscopic abscess septotomy with concomitant lumen dilation and sleeve axis rectification.

Endoscopic abscess septotomy was successfully performed in both patients with no complications. Clinical and radiological resolutions were accomplished at 10 and 12 weeks, respectively, postseptotomy.

This endoscopic approach is a feasible and effective method for the treatment of leaks and collections after LSG. Concomitant balloon dilation of the gastric sleeve improves gastric emptying and reduces intraluminal pressure, hence favoring tissue healing and leak resolution.

The standard surgical procedure for early-stage cervical cancer is abdominal radical hysterectomy, including pelvic lymphadenectomy. Currently, minimally invasive surgical techniques for early cervical cancer are progressing; total laparoscopic radical hysterectomy (TLRH) is a possible alternative to abdominal surgery. In addition, sentinel node navigation surgery (SNNS), which can prevent lower limb edema, has been widely used for radical hysterectomy.

A radioisotope is injected into the uterine cervix 1 day preoperatively and surgeons carefully identify the correct sentinel lymph nodes (SLNs) to prevent picking up the cervical gamma rays during surgery.

It is difficult to identify SLNs in laparoscopic surgery compared to abdominal surgery using the traditional gamma probe, which has the sensor on the tip, since this probe picks up the gamma rays from the uterine cervix. We described 11 cases in which TLRH was combined with SNNS using a new device that accurately detects correct SLNs.

The SLNs were detected using a gamma probe that has a sensor built onto the side, without picking up the cervical gamma rays. We believe that the Neoprobe plays a crucial role in SNNS for accurately detecting SLNs and helping determine whether the patient needs to undergo SNNS.

Transjugular Intrahepatic Portosystemic Shunt (TIPS) is used to control refractory variceal bleeding secondary to portal hypertension. This meta-analysis was conducted to systematically review polytetrafluoroethylene-covered stent grafts (CS) versus bare stents (BS) in TIPS procedure.

Systematic search of literature databases was done from January-1990 till April-2017, using predecided keywords. Outcome measures studied were (1) primary-patency (PP) at 1 year (defined as absence of shunt insufficiency at 1 year), (2) rebleeding (RE) (3) new-onset hepatic encephalopathy ([HE] new-onset or worsening encephalopathy following the procedure), and (4) survival at 1 year (SU). Odds ratio (OR) was calculated for each outcome variable. Between-study heterogeneity was assessed by the I² statistics and χ² Q-test.

Fourteen studies (4 RCTs, 2 prospective nonrandomized, and 8 retrospective) were included with 2519 patients (1548 patients in BS group and 971 patients in CS group). Three-quarter outcome measures showed significantly better results with CS. PP was pooled from 13 studies and showed an OR = 4.75 (95% confidence interval [CI] = 3.32–6.79; P < .00001; I² = 44%) in favor of CS. RE was pooled from six studies with odds ratio (OR) = 0.37(95% CI = 0.24–0.56; P < .00001; I² = 0%) in favor of CS. SU was pooled from 11 studies with OR = 1.85 (95% CI = 1.44–2.38; P < .00001; I² = 0%) in favor of CS. On subset analysis for RCTs, three outcome variables favored CS with minimal heterogeneity [PP: OR = 4.18 (95% CI = 2.66–6.55; P < .00001; I² = 0%). RE: OR = 0.43 (95% CI = 0.25–0.72; P < .001; I² = 0%). SU: OR = 1.85 (95% CI = 1.44–2.38, P < .00001; I² = 0%)]. HE showed no difference between two stents on the overall and subset pooled analysis. Overall: OR = 0.86 (95% CI = 0.68–1.08; P = .19; I² = 4%). Only RCTs: OR = 0.91 (95% CI = 0.63–1.32, P = .63; I² = 0%).

CS is associated with better primary patency and survival and lesser rate of rebleeding than BS in patients undergoing TIPS procedure. There is no difference in new-onset hepatic encephalopathy.

Piriform fossa sinus tracts (PFSTs) are a cause of recurrent neck infections in the pediatric population. Conventional management required open resection, but over the last years minimally invasive approaches have been reported in an attempt to endoscopically obliterate the PFST, using different methods such as electrocautery, laser, trichloroacetic acid, or silver nitrate.

We undertook a retrospective review of the medical records of 12 children (aged 4 months to 14 years) with PFSTs treated with endoscopic sclerosis with diathermy (ESD) between 2010 and 2016 at a tertiary care children's hospital. We also present a technical modification of ESD, using continuous infusion of airflow through the gastroscopy, to distend the piriform sinus and facilitate its recognition. PFST obliteration was performed using diathermy through a guide wire.

Clinical presentation of the 12 affected children included neck tumor (7 [58%]), neck abscesses (4 [33%]), and thyroiditis (5 [41%]). All lesions occurred on the left side. All patients underwent both ultrasonography and barium esophagography (the latter being positive only in 50%). Two patients were treated with ESD after the open approach had failed. There was no procedure-related morbidity. One patient had a recurrence (positive barium swallow without symptoms). The success rate of this procedure in our series was 91% with one attempt and 100% with two attempts.

In our experience, treatment of PFST with ESD is a reproducible, noninvasive, and an effective option. ESD could be considered a primary approach and also for revision after open surgery has failed in these patients.

Traditional methods for securing a laparoscopic gastrostomy (LG) involve the placement of two monofilament transabdominal (TA) sutures to be removed after a short interval of 5 days. A modified technique employing an absorbable suture tunneled subcutaneously has been adopted by many surgeons. The aim of this study was to compare wound complications between these techniques.

A retrospective review of patients who underwent LG placement between 2010 and 2016 was conducted, dividing patients into two cohorts by securing stitch type, TA and subcutaneous (SC), and evaluating for complications.

A total of 740 children underwent laparoscopic gastrostomy tube (GT) placement, of whom 554 (75%) patients had a TA stitch and the remaining 186 (25%) had a SC stitch. Demographic data were comparable in both groups. The most common wound complication was granulation tissue (22%), dislodgement (19%), external drainage (16%), cellulitis (10%), erosion (3%), and abscess formation (2%). Seven patients required operative revision for dislodgement; TA patients comprised the majority of these patients. Operative times were significantly longer in the SC group (22 minutes versus 28 minutes, P < .05). Rates of granulation, erosion, external and internal leakage, and dislodgement were equivalent between cohorts. There were higher rates of cellulitis (7.3% versus 19%, P < .05) and abscess (0.8% versus 7.6%, P < .05) noted in the SC group. Time to external leakage was significantly earlier in the SC group (P < .05); however, all other complications occurred at comparable times following initial operation. Persistent gastrocutaneous fistula requiring surgical closure occurred at equal rates with no difference in times to closure from GT discontinuation in both groups.

While both techniques are feasible, there was a significant increase in infectious complications and operative times observed in the SC stitch patients, suggesting this may not be the optimal securing method.

The laparoscopic repair of Morgagni's hernia (MH) has been reported to be safe and feasible. However, it is still unclear whether laparoscopy is superior to open surgery in repairing MH.

Using a defined search strategy, three investigators independently identified all comparative studies reporting data on open and laparoscopic MH repair in patients <18 years of age. Case reports and opinion articles were excluded. Meta-analysis was conducted according to PRISMA guidelines and using RevMan 5.3. Data are expressed as mean ± SD.

Systematic review - Of 774 titles/abstracts screened, 51 full-text articles were analyzed. Three studies were included (92 patients), with 53 (58%) open approaches and 39 (42%) laparoscopy. Meta-analysis - The length of surgery was shorter in laparoscopy (50.5 ± 17.0 min) than in open procedure (90.0 ± 15.0 min; P < .00001). Laparoscopy shortened the length of hospital stay (2.1 ± 1.4 days) versus open surgery (4.5 ± 2.1 days; P < .00001). There was no difference with regards to complications (laparoscopy: 8.8% ± 5.5%, open: 9.4% ± 1.6%; P = .087) and recurrences (laparoscopy: 2.9% ± 5.0%, open: 5.7% ± 1.8%; P = .84).

Comparative studies indicate that laparoscopic MH repair can be performed in infants and children. Laparoscopy is associated with shortened length of surgery and hospital stay in comparison to open procedure. Prospective randomized studies would be needed to confirm present data.

The Soave pull-through for Hirschsprung's disease leaves a muscular cuff of aganglionosis surrounding the pull-through. In some patients, this cuff can extrinsically compress the pull-through, leading to chronic enterocolitis and failure to thrive. We describe a novel technique for managing the Soave cuff as an alternative to a complete redo pull-through.

A laparoscopic excision of the intraperitoneal portion of the Soave cuff is performed, taking care to avoid injury to bladder, vas deferens, or vagina. The extraperitoneal portion of the cuff, adjacent to the bladder/vagina, is left in place. The excision is tailored to eliminate the obstruction and minimize injury to surrounding structures. Diverting colostomy is not necessary and patients are discharged the next day.

Three patients successfully underwent excision without any operative complications and without the need for a colostomy. They had resolution of their chronic enterocolitis.

In patients with an obstructing Soave cuff, a laparoscopic excision should be considered as a surgical option. We found that the procedure can be effective, with little morbidity.

Mastering proper force manipulation in minimally invasive surgery can take many hours of practice and training. Improper force control can lead to necrosis, infection, and scarring. A force-sensing skin (FSS) has been developed, which measures forces at the distal end of minimal access surgeries' (MAS) instruments without altering the instrument's structural integrity or the surgical workflow, and acts as a minimally disruptive add-on to any MAS instrument.

A proof of concept study was conducted using a FSS-equipped 5 mm straight-tip needle holder. Participants (n = 19: 3 novices, 11 fellows, and 5 staff surgeons) performed one intracorporeal suturing knot task (ISKT). Using participant task video footage, each participant's two puncture forces (each wall of the Penrose drain) and three knot tightening forces were measured. Force metrics from the three expertise groups were compared using analysis of variance (ANOVA) and Tukey's honest significance test with statistical significance assessed at P < .05.

Preliminary ISKT force metric data showed differences between novices and more experienced fellows and surgeons. Of the five stages of the ISKT evaluated, the first puncture force of the Penrose drain seemed to best reflect the difference in skill among participants. The study demonstrated ISKT knot tightening and puncture force ranges across three expertise levels (novices, surgical fellows, and staff surgeons) of 0.586 to 6.089 newtons (N) and 0.852 to 2.915 N, respectively.

The investigation of force metrics is important for the implementation of future force feedback systems as it can provide real-time information to surgeons in training and the operating theater.

Our aims were to develop a training system for camera assistants (CA), and evaluate participants' performance as CA.

A questionnaire on essential requirements to be a good CA was administered to experts in pediatric endoscopic surgery. An infant-sized box trainer with several markers and lines inside was developed. Participants performed marker capturing and line-tracing tasks using a 5-mm 30° scope. A postexperimental questionnaire on the developed system was administered. The task completion time was measured.

The 5-point evaluation scale was used for each item in the questionnaire survey of experts. The abilities to maintain a horizontal line (mean score: 4.5) and to center the target in a specified rectangle on the monitor (4.5) as well as having a full understanding of the operative procedure (4.3) were ranked as highly important. Fifty-two participants, including 5 surgical residents, were enrolled in the evaluation experiment. The completion time of capturing the markers was significantly longer in the resident group than in the nonresident group (244 versus 124 seconds, P = .04), but that of tracing the lines was not significantly different between the groups. The postexperimental questionnaire showed that the participants felt that the line-tracing tasks (3.7) were more difficult than marker-capturing tasks (2.9).

Being proficient in manipulating a camera and having adequate knowledge of operative procedures are essential requirements to be a good CA. The ability was different between the resident and nonresident groups even in a simple task such as marker capturing.

Minimally invasive surgery (MIS) has gained increasing importance in neonatal surgery but the effects on neonatal physiology remain unclear. We aimed to characterize the impact of capnoperitoneum on physiologic parameters in a small animal model for neonatal MIS.

Twenty-four 10-day-old Sprague Dawley rats underwent inhalative anesthesia (1% isoflurane in 100% O₂ 250 mL/minutes) and were allowed to breathe spontaneously. CO₂ was insufflated into the abdominal cavity for 1 hour via a 24G cannula. Anesthetized litter mates without insufflation served as sham controls, those without any treatment as external controls. Continuous monitoring included O₂-saturation, heart and respiration rate, pulse and breath distension. After euthanasia, blood gas analysis was performed.

All animals survived the experiment. Capnoperitoneum was best tolerated at a pressure of 2 mmHg and a flow of 0.5 L/minutes. A significant decrease in heart rate was observed within the first 30 minutes of insufflation comparing the CO₂ and sham group (P < .05). In both, the CO₂ and sham group, postmortem pH-levels were lower and pCO₂ levels were higher compared to external controls (P < .05). Additionally, levels of pCO₂ were higher but pH levels remained unchanged in the CO₂ compared to sham group (P < .05).

We established a small animal model for neonatal laparoscopy. A pressure of 2 mmHg and flow of 0.5 L/minutes induced physiologic alterations but was well tolerated by the animals. These settings can be used in future studies on the impact of the capnoperitoneum in neonatal MIS.