Journal of Laparoendoscopic & Advanced Surgical Techniques

Achalasia is a rare esophageal motility disorder that causes progressive dysphagia and regurgitation. The aim of treatment for achalasia is to provide symptom relief by reducing esophageal outflow resistance by disrupting the muscles at the level of the esophagogastric junction to allow esophageal emptying by gravity.

A review of the literature concerning laparoscopic treatment of esophageal achalasia.

Surgical myotomy with partial fundoplication is very effective in relieving symptoms, and is able to strike a balance between relief of symptoms and control of abnormal reflux.

Since reflux of gastric contents into the aperistaltic esophagus can cause esophagitis, peptic strictures, Barrett's esophagus, and even esophageal carcinoma, the addition of a partial fundoplication is very important. The choice of partial fundoplication is based on surgeons' preference and expertise.

Epiphrenic esophageal diverticula are typically treated with concurrent cardiomyotomy and diverticulectomy. However, resection of these diverticula can be technically difficult and associated with significant morbidity with a staple line leak rate ranging up to 27%. For this reason, and because the diverticulum is secondary to a primary esophageal motility disorder such as achalasia, we decided to adopt a laparoscopic myotomy-first strategy, reserving the diverticulectomy for patients with persistent or recurrent symptoms.

From 2004 to 2018, 22 patients with epiphrenic diverticula were treated by laparoscopic Heller myotomy and partial fundoplication alone, with the plan to add the diverticulectomy as a second stage if needed. There were 13 women and 9 women, with a mean age of 68 years.

Patients had been symptomatic for an average of 36 months. The most common presenting symptom was dysphagia (91%), followed by regurgitation (77%). More than half of the diverticula were solitary and on the right side. Esogphagoscopy ruled out cancer. Esophageal manometry (18 patients) showed achalasia in 14 patients, nutcracker esophagus in 3 patients, and nonspecific motility disorder in 1 patient. There were no perioperative complications, and average length of stay was 2.5 days. At a mean follow-up of 68 months, dysphagia resolved in 77% and regurgitation in 86% of patients. Three patients had persistent symptoms: 2 patients underwent a transthoracic diverticulectomy (1 patient with resolution of symptoms and 1 patient with no improvement). Another patient had per oral endoscopic myotomy, but his dysphagia persisted.

The laparoscopic myotomy-first approach reduces risk and unnecessary surgery. A laparoscopic Heller myotomy and partial fundoplication provide excellent resolution of symptoms for most, whereasonly a few will need a staged resection of the diverticulum.

Both medical weight management (MWM) and bariatric surgery are significantly underutilized by patients with severe obesity, particularly males. Less than 30% of participants in MWM programs are male, and only 20% of patients undergoing bariatric surgery are men.

To identify motivations of males who pursue either MWM or bariatric surgery.

Interviews with males with severe obesity (body mass index ≥35 kg/m²), who participated in a Veteran Affairs weight loss program in the Midwest.

Participants were asked to describe their experiences with MWM and bariatric surgery. Interviews were audio-recorded, transcribed, and uploaded to NVivo for data management and analysis. Five coders iteratively developed a codebook using inductive content analysis to identify relevant themes. We utilized theme matrices organized by type of motivation and treatment pathway to generate higher-level analysis and generate themes.

Twenty-five males participated. Participants were 58.7 (standard deviation 8.6) years old on average, and 24% were non-white. Motivations for pursuing MWM or surgery included a desire to improve physical or psychological health and to enhance quality of life. Patients seeking bariatric surgery were motivated by the fear of death and felt that they had exhausted all other weight loss options. MWM patients believed they had more time to pursue other weight loss options.

The opportunity to improve health, optimize quality of life, and lengthen lifespan motivates males with severe obesity to pursue weight loss treatments. These factors should be considered when providers educate patients about obesity treatment options and outcomes.

Primary laparoscopic approach for the treatment of cancers of the biliary tract is not popular in the surgical community. The aim of this study is to report the short-term data of patients who underwent total laparoscopic radical cholecystectomy for gallbladder cancer (GBC) at a single center of specialized hepatobiliary surgery.

From November 2016 to January 2019, we routinely performed a laparoscopic approach for two groups of patients: (1) patients with primary GBC (diagnosed preoperatively) and (2) patients with incidental GBC (IGBC) discovered after cholecystectomy.

Our retrospective study included 18 patients (7 primary GBCs, 11 IGBCs). Conversion rate from laparoscopy to laparotomy was 28.6% and 9.1%, respectively, for the two groups, but this difference was not statistically significant (P = .28). Only 3 patients had liver recurrence (27.3%) and 1 had liver invasion (14.3%). A more advanced T category and TNM stage were presented in the preoperative suspicion cases (T3–T4 18.2% versus 57.1%, P = .06, stage IVA-B 9.1% versus 71.4%, P = .017). Regional lymphadenectomy was performed in 15 patients, in 73.3% the total number of lymph nodes (total LNs) retrieved was more than 7 (7–12 LNs in 66.7% of patients and >12 LNs in 6.6% of patients). The mean postoperative long stay was 8 days excluding for cases who developed complication.

Laparoscopy can be considered a safe treatment for IGBC or primary GBC. The T3 stage with only liver involvement was not a contraindication. The real reasons that lead to convert the laparoscopic procedure were due to oncological concerns, unrelated to the liver infiltration.

We retrospectively reviewed the perioperative outcomes of mini-laparoscopic procedure in the treatment of ureteropelvic junction obstruction (UPJO) in children and adults.

From August 2009 to March 2017, 229 patients referred to our center to repair UPJO by mini-laparoscopic operation. In 203 cases, dismembered pyeloplasty was accomplished, while in other 26 cases, crossing aberrant vein division and crossing artery upward transposition were performed. A follow-up renal ultrasound was done on the cases 3 and 6 months after surgery. During the follow up period, if the patients had persistent hydronephrosis or sustained clinical complaints, diethylenetriamine pentaacetic acid (DPTA) scan was done to rule out the stenosis.

Among 229 patients, 140 patients were younger than 18 years (Range: 2 months-18 years old, mean: 3.01 ± 1.2 year) and others were scheduled as Adult (Range: 18–57 years old, mean: 35.12 ± 7.54 year). Total clinical and radiological success rates were 99.5% (228/229) and 86.5% (198/229) respectively. Mean operative times were 127.4 ± 20.3 minutes in dismembered pyeloplasty and 110.6 ± 12.7 minutes in crossing vessel transposition surgery. Mean of hemoglobin decreasing in children and adults was 0.3 ± 0.1 mg/dL; P = .26, and 0.5 ± 1.5 mg/dL; P = .13, respectively. Length of hospital stay was 3.41 ± 0.6 days in dismembered pyeloplasty and 2.1 ± 0.6 days in patients with crossing vessel transposition surgery. We did not suture the skin incision in the entrance site of 3 mm ports and the surgical scar was hardly visible after 6 months.

The results of our study suggest that mini-laparoscopic pyeloplasty in adults and particularly in children is feasible, and it seems to be safe and effective in the treatment of UPJO. Furthermore, the patients tolerated the surgery well and they appreciated its outstanding cosmetic outcomes.

There is no evidence indicating that survival improvement is associated with anatomical laparoscopic liver resection (ALLR) rather than non-ALLR (NALLR) to treat solitary hepatocellular carcinoma (HCC). The aim of our study was to compare the oncological outcomes of ALLR versus NALLR.

From January 2008 to September 2014, 231 patients underwent LLR as the primary treatment for solitary HCC without portal vein tumor thrombus. After matching one-to-one propensity scores, 118 patients were included in 2 groups: NALLR (n = 59) and ALLR (n = 59).

In the propensity-matched cohort, the 1-, 3-, and 5-year recurrence-free survival rates were 84.4%, 73.8%, and 68.4% in the ALLR group and 87.7%, 78.7%, and 73.5% in the NALLR group (P = .602). In multivariate analysis, the independent risk factors affecting HCC recurrence were higher preoperative PIVKA-II (prothrombin induced by vitamin K absence or antagonist-II) levels (P = .041) and microvascular invasion (P = .030). The risk factor affecting liver-related mortality was determined to be higher preoperative PIVKA-II levels (P = .007).

In the propensity-matched cohort, long-term outcomes of the NALLR group were not inferior to those of the ALLR group.

Short-term outcomes after laparoscopic pancreaticoduodenectomy (LPD) seem promising, but long-term outcomes of LPD for pancreatic cancer (PC) warrant further investigation.

A systematic research of various databases was performed to identify studies analyzing long-term outcomes in LPD versus open pancreaticoduodenectomy (OPD) for PC. Survival parameters of overall survival (OS) and disease-free survival (DFS) were extracted. The search was last conducted before May 23, 2018.

A total of 10 studies involving 11,180 patients (1437 in LPD and 9743 in OPD) met the final inclusion criteria. Pooled analyses showed that LPD was associated with longer DFS compared with OPD (hazard ratio [HR]: 0.77, 95% confidence interval [CI]: 0.61 to 0.98, P = .033). No significant difference in OS was found between LPD and OPD (HR: 0.98, 95% CI: 0.90 to 1.07, P = .672). In addition, patients of LPD had much shorter time to receive postoperative adjuvant chemotherapy compared with OPD (weighted mean difference: −10.17, 95% CI: −17.90 to −2.45, P = .010).

With regard to long-term survival, LPD is comparable with OPD for PC. Furthermore, LPD is associated with longer DFS compared with OPD. Future well-designed, randomized controlled trials with longer follow-up are still essential to further demonstrate the advantages of LPD for PC.

The aim of this study was to investigate the long-term efficacy of laparoscopic radiofrequency ablation (LRFA) in early hepatocellular carcinoma (HCC) compared with other surgical procedures.

A literature search of Cochrane library, PubMed, and Embase through October 2018 was conducted by two investigators (J.-F.G. and F.Y.) independently. The quality of included studies was estimated by the Newcastle–Ottawa Scale. Review Manager 5.3 software was used for meta-analysis, and either fixed- or random-effects model was used according to the heterogeneity of included studies. The chi-square test was used for heterogeneity analysis of included studies, and subgroup analysis was conducted to estimate the heterogeneity between each study and also to estimate the efficacy of different studies.

A total of 11 studies involving 1691 patients were included in this analysis. Patients undergoing hepatic resection (HR) had higher 3-, 5-year overall survival rate, 3-year disease-free survival rate, and lower local recurrence rate than those undergoing LRFA. However, patients undergoing LRFA had higher 3-, 5-year overall survival rate than those undergoing other minimally invasive ablation, although there was no statistical difference in local recurrence rate or disease-free survival rate.

HR is still an ideal choice for early HCC. If minimally invasive ablation is an alternative treatment, LRFA will be better than other minimally invasive options.

Esophageal thoracic diverticular disease is a rare condition resulting from multiple etiologies. Surgical management is recommended when symptomatic. Traditionally, a thoracotomy was considered the standard approach; however, the use of minimally invasive approaches has been associated with improved outcomes.

We retrospectively reviewed a single surgeon's experience with minimally invasive esophageal diverticulectomy.

Fifteen patients with symptomatic esophageal diverticular disease underwent minimally invasive diverticulectomy between 2005 and 2018. Most patients (86.7%) had epiphrenic diverticula and 53.3% underwent a video-assisted thoracoscopic surgery approach. All patients had a diverticulectomy, while 14 patients (93.3%) also had an esophageal myotomy. Three patients (20%) underwent an extended myotomy, 4 patients (26.7%) underwent a concomitant fundoplication, and 2 patients (13.3%) underwent a concomitant paraesophageal hernia repair. Median length of hospital stay was 2 days (range, 1–16 days). There were no mortalities. Two patients (13.3%) were readmitted with delayed esophageal leaks. Median follow-up was 10.7 months (range, 10 days to 6.3 years). One patient presented with recurrent disease 5 years after his initial operation.

In experienced hands, a minimally invasive diverticulectomy is safe, effective, and associated with excellent patient outcomes. A minimally invasive approach should be performed when possible and should be tailored to the individual patient's disease and preoperative workup.

The diagnosis of traumatic diaphragmatic injuries (TDIs) after penetrating thoracoabdominal trauma is challenging and conventional imaging is unreliable. Laparoscopy and thoracoscopy are minimally invasive modalities of choice in the diagnosis and management of TDI. A little is known on the value of thoracoscopy with single-lumen endotracheal tube intubation (SLETI) in the diagnosis of occult diaphragmatic injuries, and how it compares with laparoscopy.

A prospective study evaluated thoracoscopy with SLETI as a diagnostic tool for occult TDI. Thoracoscopy was followed by diagnostic laparoscopy to confirm the findings and manage diaphragmatic and intra-abdominal injuries.

Thirty-one patients underwent thoracoscopy followed by laparoscopy. Majority were men (n = 27, 87%). The median age was 30 years. Twenty-six patients had stab wounds (83.8%), and 5 had gunshot wounds (16.1%). The incidence of diaphragmatic injury was 42% (n = 13). Thoracoscopy with SLETI correctly identified 12 (92%) patients with diaphragmatic injury, but 1 patient had dense pleural adhesions. Diagnostic laparoscopy identified all injuries.

Thoracoscopy with SLETI and laparoscopy are feasible, safe, and accurate approaches in detecting TDI in stable patients with penetrating thoracoabdominal injuries. However, dense pleural adhesions may prevent thoracoscopy. Laparoscopy allows inspection of both hemidiaphragms and diagnoses associated intra-abdominal injuries. The choice of primary technique will depend on the individual clinical scenario.

To assess the effectiveness and safety of laparoscopic partial nephrectomy (LPN) in T1a and T1b renal tumors using “Trifecta” in partial nephrectomy and determine the predictive factors in respect to the criteria that constitute Trifecta.

We retrospectively analyzed the data harvested from the patients who underwent LPN for T1a or T1b tumors. Preoperative, perioperative, and postoperative outcomes were evaluated and analyzed. Patients who had grade <2 Clavien complications, negative surgical margins, and minimal renal function deterioration (warm ischemia time [WIT] ≤25 minutes and ≤15% postoperative estimated glomerular filtration rate [eGFR] decrease) were acccepted to fit the strict Trifecta outcomes. Multivariate analysis was done using logistic regression test to determine the predictive factors affecting Trifecta.

A total of 128 patients underwent LPN. Of these, 65 (50.8%) patients had cT1a and 63 (49.2%) patients had cT1b renal tumors. The mean age was 55.8 (24–85) years. Mean operative time was 143.6 (100–200) minutes. A total of five (3.9%) patients had positive surgical margins. Mean WIT was 22.1 minutes. Ten patients (7.8%) had a >15% decrease in eGFR after surgery. Complications were observed in 11 (8.6%) patients. A total of 78 (60.9%) patients had strict trifecta outcomes. Tumor size was found to be a predictive factor affecting Trifecta at multivariate analysis.

LPN procedure has been shown to demonstrate improved strict Trifecta outcomes in patients with T1a and T1b renal tumors. Only the tumor size was found to be a predictive factor regarding the Trifecta criteria.

Various approaches for thyroid surgery became possible with the use of robotic systems. Transoral robotic thyroidectomy (TORT) is one of the newest approaches and draws attention because of its cosmetic excellence. In this study, we compared the surgical outcomes of TORT and conventional open thyroidectomy (OT).

We retrospectively reviewed and compared the medical records of consecutive patients who underwent TORT or OT for thyroid carcinoma from April 2016 to March 2017.

The study included 205 patients who underwent TORT (n = 100) or OT (n = 105). Mean tumor size was 0.9 cm in both groups. The two groups showed similar surgical outcomes, except for a longer operative time for TORT.

TORT could be performed safely and had comparable surgical outcomes with OT in the selected patients. TORT may be considered a suitable operative alternative for patients who do not want to leave scars on the neck.

Few studies have assessed the short- and long-term outcomes of laparoscopically assisted natural orifice specimen extraction (NOSE) in patients with sigmoid colon and rectal tumors. We investigated the short- and long-term outcomes of patients undergoing laparoscopic-assisted NOSE for tumors of the sigmoid colon and rectum.

Ninety-eight patients with sigmoid colon and rectal tumors undergoing laparoscopic-assisted NOSE were included. The tumor was classified according to its distance from the anal verge: Group 1 (15–30 cm), Group 2 (5–15 cm), and Group 3 (≤5 cm). In Group 1 patients, a laparoscopic surgical specimen collection bag was used as a special transrectal device. In Group 2 patients, transanal endoscopic microsurgery device and specimen collection bag were used. In Group 3 patients, a Lone-Star retractor was used. The demographic characteristics and intra- and postoperative outcomes were measured.

In Group 1, 1 patient had respiratory disease and 1 had enterocolitis as short-term postoperative complications. One patient showed intestinal obstruction as a long-term postoperative complication. In Group 2, 2 patients had an ileus, 1 had an anastomotic leak, 2 had urinary retention, and 1 had respiratory disease as short-term complications. Only one patient had a long-term complication: anastomotic stenosis. In Group 3, short-term complications were present in 3 patients: 1 had hemorrhage, 1 had urinary retention, and 1 had respiratory disease. Long-term complications included one case of anastomotic stenosis and one of intestinal obstruction.

NOSE is safe and cosmetically and theoretically superior to conventional laparoscopy when different devices are used according to the tumor's location.

Traditional intersphincteric resection is a technically demanding procedure that required a perineal approach dissection and a handsewn coloanal anastomosis. Our study was to investigate the feasibility and the prognostic factors of completely abdominal approach partial intersphincteric resection (APISR) after neoadjuvant chemoradiotherapy (CRT) for low rectal cancer with initial stage cT3.

A total of 101 consecutive patients with initial stage cT3 juxta-anal rectal cancer who underwent APISR after neoadjuvant CRT between January 2010 and March 2015 were enrolled. Survival rates were estimated and compared using the Kaplan–Meier method and log-rank tests. Cox proportional hazard model was utilized for multivariable analysis for disease-free survival (DFS). The cutoff values of residual tumor size calculated by X-tile were used in the multivariate analysis as well.

The median follow-up was 39 months. The local recurrence rate within 3 years was 2.5%. The 3-year DFS rate was 80.2%, and the 3-year overall survival rate was 95.3%. The 3-year DFS in pathological stage 0–III were 96.2%, 94.4%, 85.7%, and 44.7% respectively (Log-rank = 29.791, P < .001). In multivariate analysis, stage ypN1-2 (hazard ratio (HR) = 8.256, 95% confidence interval [CI]: 2.742–24.855, P < .001) and tumor size after CRT more than 2.8 cm (HR = 3.077, 95% CI: 1.036–9.137, P = .043) were the independent factors for worse DFS.

Laparoscopic and open APISR after CRT produces satisfactory mid-term oncological outcomes for juxta-anal rectal cancer downstaged from initial cT3 especially in stage ypN0 or with tumor size after CRT <2.8 cm. Hence, stage ypN1–2 and tumor size after CRT more than 2.8 cm are poor prognostic factors that should be estimated for APISR.

Common bile duct (CBD) injury is a serious complication of laparoscopic and open cholecystectomy. Early identification and minimally invasive repair, when possible, can prevent much of the morbidity associated with this injury.

A 36-year-old woman referred in the immediate perioperative period for CBD injury at the time of laparoscopic cholecystectomy. We present a case of early robot-assisted repair of a Strasberg class E₁ bile duct injury with Roux-en-Y hepaticojejunostomy.

Total console time of 4 hours with minimal blood loss and no requirement for transfusion with length of stay of 3 days. No intra- or perioperative complications of the surgery were noted.

The degrees of freedom and stability of the robotic platform were instrumental during several key steps, including exposure of the hepatic hilum, positioning of the Roux limb, and suturing of the CBD. Successful minimally invasive repair of this patient's CBD injury minimized the morbidity of the index operation, blood loss, hospital length of stay, and potential legal consequences.

Colorectal cancer, one of the most common tumor- and cancer-related deaths worldwide, requires a multidisciplinary management including neoadjuvant chemoradiotherapy and surgery. Laparoscopic surgery for rectal cancer is gaining popularity due to its safety profile and good oncological results, if performed by experienced surgeons in specialized centers. This study describes our 10 years experience in minimally invasive rectal cancer surgery.

We have retrospectively evaluated a series of 140 patients treated with laparoscopic approach for rectal malignant and benign diseases.

A total of 134 patients (95.7%) underwent anterior rectal resection, in the remaining 6 cases (4.3%) abdominoperineal amputation was performed. All but 13 cases have been treated with laparoscopic approach, with conversion rate of 5.7%. Postoperative morbidity rate was 8.6% (2 cases of peritoneal bleeding and 10 cases of anastomotic fistulae; in 2 cases, fistula occurred in patients previously treated with chemoradiation).

Conventional laparoscopy can provide adequate oncological outcomes even in patients with advanced rectal cancer, with advantages in terms of postoperative hospital stay, recovery time, acceptable operative time, and low complication and conversion rates.

The aim of this retrospective study was to present our surgical experience in patients with bronchiectasis who underwent thoracoscopy and to compare the results with those of patients who underwent thoracotomy.

We analyzed the medical records of patients who underwent lung resection to treat bronchiectasis through video-assisted thoracoscopic surgery (VATS) or open lung resection between November 2012 and November 2017.

In total, 99 patients were enrolled. Forty-nine patients with bronchiectasis underwent VATS lung resection and 50 patients underwent thoracotomy. The patients in the VATS group were older (P = .025), but no difference was observed in blood loss (P = .62) or morbidity (P = .67) between the two groups. The patients in the VATS group had a shorter duration of chest tube placement (P = .01) and length of hospital stay (P = .04) but a longer operative time (P = .01). No significant difference was found in symptom improvement between the two groups (P = .694).

Surgical resection for bronchiectasis can be performed with acceptable morbidity and can lead to significant relief of symptoms. Video-assisted thoracoscopic lung resection for localized bronchiectasis is a safe and efficient procedure that results in good recovery.

Modifications to conventional laparoscopic cholecystectomy (LC) aim to reduce trauma to the abdominal wall and improve cosmetic outcomes. Although single-incision laparoscopic surgery (SILS) provides excellent cosmetic results, the procedure is technically demanding. Herein, we describe the LIFT technique (“Less Incisions but Four Trocars”), with four trocars but only one 3-mm visible incision, using conventional instruments.

Retrospective study with the LIFT technique for cholecystectomy during 2017. Access to the abdomen is obtained with two trocars (11 and 5 mm) through the same intraumbilical skin incision, and two extraumbilical 3-mm trocars for a correct triangulation (one of them concealed below the bikini line). The results are compared with a series of patients operated on with LC by the same surgical team during 2016.

During the study period, 90 procedures were performed. Both techniques showed similar results in terms of surgical time, conversion rate, complications, and hospital length of stay. The patients operated on with the LIFT technique reported better cosmetic evaluation and less postoperative pain at 3 months compared with LC.

The LIFT technique is a safe and feasible alternative for cholecystectomy that can provide a significant improvement from the cosmetical point of view, mostly for those patients who are especially concerned with their body image.

There is a lack of experience with stenting for benign pancreaticobiliary disorders in children.

Fifteen children (9 male and 6 female) with a median age of 7.1 years (range 0.7–14.2 years) who underwent treatment with a plastic stent for a benign disorder of the pancreaticobiliary system between May 2003 and September 2017 were recruited to this retrospective study.

Biliary and/or pancreatic plastic stents were inserted into 5 patients with congenital, 4 with post-traumatic, and 6 with idiopathic pathologies. Median duration of individual stent placement was 111 days (range 14–1569 days). Eleven children (73%) were treated with one stent only. In 4 cases, up to 22 stents were successively placed over time. There were no complications during stent insertion or stent removal. Seven patients (47%) experienced adverse effects during stenting, including choledocholithiasis, pancreaticolithiasis, cholangitis, acute pancreatitis, stent obstruction, and stent fracture. At follow-up, in 11 cases (73%), the underlying condition was resolved. In 4 children, all of whom suffered from congenital pancreaticobiliary disorders, stent therapy was considered as a temporary treatment before definite surgery.

Patients with congenital anomalies of the pancreaticobiliary tree often require surgery for definitive management. However, temporary stent placement can be accomplished safely and successfully and this serves as a bridge to temporize their obstructive process while awaiting surgical intervention. Children with post-traumatic or idiopathic disorders can frequently be managed definitively by stenting alone and many of these require only one single stent insertion.

The purpose of this study was to summarize the clinical experience of the laparoscopic percutaneous extraperitoneal closure of the internal ring using an epidural needle for the treatment of inguinal hernias.

There were 1,142 children with an isolated inguinal hernia who participated in this study from January 2013 to May 2018. An epidural needle was used to treat the indirect inguinal hernia with laparoscopic assistance. Symptoms and signs were followed up at 1 week, 3 months, and every 1–2 years after the operation.

All 1,142 children underwent laparoscopic surgery successfully. All patients were discharged 1–2 days after the operation. During the hospitalization and follow-up, there were 21 patients with complications, including 6 cases of hernia recurrence, 7 cases of poor healing of the umbilical incision, 5 cases of suture granuloma and 3 cases of groin traction pain discomfort. None of the following complications occurred: abdominal wall vascular injury, deferent duct injury, umbilical hernia, iatrogenic cryptorchidism, testicular atrophy, hydrocele, or scrotal oedema.

Laparoscopic percutaneous extraperitoneal closure of the internal ring using an epidural needle is a safe and feasible method for the treatment of inguinal hernias in children. This method has the advantages of less trauma, no scarring and a good cosmetic effect.

Thoracoscopic esophageal atresia repair has become increasingly popular, but is still limited to a few expert centers and has some challenges and shortcomings. One of them has a longer operation time compared with conventional thoracotomy. Magnetic compression anastomosis may contribute toward shorter operation times by avoiding the time-consuming anastomotic suturing. We aimed to establish a method of testing sutureless anastomoses in parallel to having swine eating the natural way.

We used four juvenile Pietrain swine—aged 8 weeks, weighing 15 kg—to establish a living animal model after preceding cadaver tests. Esophagi were fully mobilized through right-sided thoracotomy to gain sufficient length to create an esophageal loop that served as a bypass for food after magnet deployment. Six hours later, patency of the bypass esophageal loop was assessed by passing an orogastric tube and by allowing swine to drink methylene blue-stained water. We also tested the device stability using the classical burst pressure test.

The esophageal lumen was patent for feeding tube. Swine were able to drink and methylene blue colored fluid reached the stomach. Clinical signs of obstruction such as regurgitation or coughing were absent. Magnets sustained burst pressures up to 200,000 Pascal until they became disrupted. At 6 hours after magnet placing, we already saw subtle esophageal mucosa erosions indicating the beginning of anastomotic formation.

This animal model is useful to test different magnet designs for sutureless esophageal anastomosis or even future devices for in vivo tissue engineering.

Closure of the hernia defect during laparoscopic ventral hernia repair (LVHR) remains controversial. We aimed to analyze whether closing hernia defects impacts in postoperative morbidity and recurrence rates after LVHR.

A consecutive series of patients undergoing LVHR from January 2014 to June 2017 with a minimum follow-up of 6 months were included. The sample was divided into two groups: DC, patients with fascial defect closure and NDC, patients without closure of the defect. Postoperative morbidity and recurrence rates were compared between both groups.

A total of 100 patients were included, 51 had their defects closed (DC) and the remaining 49 patients had their defects not closed (NDC). There were no significant differences between groups regarding gender, age, smoking, body mass index, or preoperative American Society of Anesthesiologists. Defect area was similar in both groups (DC: 37 cm² versus 42 cm² NDC, P = .6). Patients with defect closure had significantly longer operating time (DC: 111 and NDC: 88 minutes, P < .01). Patients without defect closure showed higher rates of postoperative seroma (DC: 10% versus NDC: 18%) and bulging (DC: 4% versus NDC: 12.2%). After a mean follow-up of 24 (6–36) months, recurrence was 6% in DC and 18% in NDC (P = .07). Closure of the defect in midline hernias showed a significant reduction of the recurrence rate (DC: 2/39 [5%] versus NDC: 5/21 [24%], P = .04).

Defect closure in LVHR seems to reduce postoperative morbidity and recurrence rates, especially in midline defects. Systematic closure of the hernia defect should be encouraged to improve postoperative outcomes.

Traditionally, a laparoscopic approach is used for treatment of congenital hypertrophic pyloric stenosis (CHPS) in newborns and infants. The novel technique–Gastric Per Oral Endoscopic Myotomy (G-POEM) had been proposed as an alternative method. G-POEM is a procedure that is recently being used for treatment of gastroparesis in adults. For the first time, in this study, we demonstrate the performance of G-POEM in an infant and its short-term results.

G-POEM was performed in the Center of Newborn Surgery in Irkutsk (Russia) in August 2018 for a 1-month-old infant, whose weight was 4,200 g. The patient had vomiting for 5 days before admission and a slight deficiency of body weight. The diagnosis of CHPS was confirmed by ultrasound examination of the abdominal cavity. The pyloric muscle thickness was 7 mm. The operative technique of the performed G-POEM was carried out by creation of a submucosal tunnel with a distance of 4 cm toward the pylorus and dissection of the hypertrophied muscle layer in a form of the Ramstedt's incision by using an electrocautery knife. At the end of the procedure, the mucosal membrane incision was closed by special clamps.

The operating time was 65 minutes. There were no intraoperative complications such as bleeding and/or mucosal perforation. The patient began to eat 6 hours after the procedure. The transition time to full enteral nutrition was 24 hours. The infant was discharged from the hospital the next day in good condition. We did not observe early or late postoperative complications such as recurrence of pyloric stenosis and incomplete myotomy during postoperative observation. There were not even minimal scars on the patient's body.

G-POEM is a technically feasible, safe, and successful procedure for treatment of CHPS in newborns and infants. An additional study is needed to perform the comparison between this technique and laparoscopic pyloromyotomy.

Pectus excavatum is an anomaly of chest wall development in which anterior ribs curve inward and the sternum is displaced toward the vertebral column. The Nuss procedure is a minimally invasive technique in which one or more metal bars are implanted to brace the sternum in a corrected position. Over time, the chest wall remodels into an anatomically corrected shape and the bar(s) are removed at a later date. During the procedure, passage of an introducer instrument and then the repair bar(s) may shear the intercostal muscles from the adjacent ribs. This creates larger than necessary defects in the chest wall, improper or unstable bar placement, and inadequate repair.

We report a new surgical instrument for guiding the introducer through the contralateral chest wall. This capture-guidance instrument (CGI) redirects and channels forces to keep the introducer true while preventing muscle stripping during passage of the introducer and repair bar(s).

The CGI has been piloted at two pectus centers with a notable decrease in intercostal muscle stripping.

The CGI addresses the problem of shear and intercostal muscle stripping during traversal of the chest as part of Nuss repair of pectus excavatum.

During laparoscopic excision of choledochal cysts (CDCs), if duodenum injury is encountered, conversion to open repair of duodenal injury is often the standard approach. This study evaluates if it is safe to repair the duodenal injury laparoscopically in CDC children.

CDC children who underwent single-incision laparoscopic repair for iatrogenic duodenal injury between October 2013 and September 2018 were reviewed. According to the pathophysiology, duodenal injuries were categorized into two subtypes: Type 1: injury caused by severe adhesions between perforation site at distal CDC and the duodenum; Type 2: anatomical variation, that is, distal CDC shared the common wall with the duodenum. A transabdominal wall suture was placed through distal end of CDC. Relying on the adhesion between distal CDC and duodenum, the injured duodenum can be clearly exposed when the assistant pulled on the retraction suture. The duodenal injury was repaired by a two-layer 5-0 polydioxanone running suture. The distal CDC was transected after repair was accomplished.

Five children were reviewed (Type 1: n = 4, Type 2: n = 1). Median age at surgery was 1.2 years. Median operative time was 4.0 hours. Median postoperative hospital stay was 7 days. Median duration of full diet resumption and drainage were 5 days, respectively. Median follow-up period was 31 months. Liver function tests and serum amylase levels were normalized within 1 year. None of patients had intestinal leak, anastomotic stenosis, bile leak, cholangitis, pancreatic leak, pancreatitis, or adhesive intestinal obstruction.

Single-incision laparoscopic repair for iatrogenic duodenal injury in CDC children is safe and effective.