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Background: Many centers worldwide are shifting from laparoscopic to robotic minimally invasive hepato-pancreato-biliary resections (MIS-HPB) but large single center series assessing this process are lacking. We hypothesized that the introduction of robot-assisted surgery was safe and feasible in a high-volume center. Methods: Single center, post-hoc assessment of prospectively collected data including all consecutive MIS-HPB resections (January 2010–February 2022). As of December 2018, all MIS pancreatoduodenectomy and liver resections were robot-assisted. All surgeons had participated in dedicated training programs for laparoscopic and robotic MIS-HPB. Primary outcomes were in-hospital/30-day mortality and Clavien-Dindo ≥ 3 complications. Results: Among 1875 pancreatic and liver resections, 600 (32%) were MIS-HPB resections. The overall rate of conversion was 4.3%, Clavien-Dindo ≥ 3 complications 25.7%, and in-hospital/30-day mortality 1.8% (n = 11). When comparing the period before and after the introduction of robotic MIS-HPB (Dec 2018), the overall use of MIS-HPB increased from 25.3 to 43.8% (P < 0.001) and blood loss decreased from 250 ml [IQR 100–500] to 150 ml [IQR 50–300] (P < 0.001). The 291 MIS pancreatic resections included 163 MIS pancreatoduodenectomies (52 laparoscopic, 111 robotic) with 4.3% conversion rate. The implementation of robotic pancreatoduodenectomy was associated with reduced operation time (450 vs 361 min; P < 0.001), reduced blood loss (350 vs 200 ml; P < 0.001), and a decreased rate of delayed gastric emptying (28.8% vs 9.9%; P = 0.009). The 309 MIS liver resections included 198 laparoscopic and 111 robotic procedures with a 3.6% conversion rate. The implementation of robotic liver resection was associated with less overall complications (24.7% vs 10.8%; P = 0.003) and shorter hospital stay (4 vs 3 days; P < 0.001). Conclusion: The introduction of robotic surgery was associated with greater implementation of MIS-HPB in up to nearly half of all pancreatic and liver resections. Although mortality and major morbidity were not affected, robotic surgery was associated with improvements in some selected outcomes. Ultimately, randomized studies and high-quality registries should determine its added value. [ABSTRACT FROM AUTHOR]

Graph B Correction to: Surgical Endoscopy b https://doi.org/10.1007/s00464-022-09735-4 The original online version of this article was revised to correct a typo in the presentation of "for HPB-Amsterdam" in the contributors' list and to correct an error in the graphical abstract. Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. The original article can be found online at https://doi.org/10.1007/s00464-022-09735-4. [Extracted from the article]

Background: Bilateral adrenalectomy (BLA) is a treatment option to alleviate symptoms in patients with ectopic Cushing's syndrome (ECS) for whom surgical treatment of the responsible nonpituitary tumor is not possible. ECS patients have an increased risk for complications, because of high cortisol levels, poor clinical condition, and metabolic disturbances. This study aims to evaluate the safety and long-term efficacy of endoscopic BLA for ECS.Methods: From 1990 to present, 38 patients were diagnosed and treated for ECS in the Erasmus University Medical Center, a tertiary referral center. Twenty-four patients were treated with BLA (21 endoscopic, 3 open), 9 patients were treated medically, and 5 patients could be cured by complete resection of the adrenocorticotropic hormone (ACTH)-producing tumor. The medical records were retrospectively reviewed and entered into a database. For evaluation of the efficacy of BLA, preoperative biochemical and physical symptoms were assessed and compared with postoperative data.Results: Endoscopic BLA was successfully completed in 20 of the 21 patients; one required conversion to open BLA. Intraoperative complications occurred in two (10%) patients, and postoperative complications occurred in three (14%) patients. Median hospitalization was 9 (2-95) days, and median operating time was 246 (205-347) min. Hypercortisolism was resolved in all patients. Improvements of hypertension, body weight, Cushingoid appearance, impaired muscle strength, and ankle edema were achieved in 87, 90, 65, 61, and 78% of the patients, respectively. Resolution of diabetes, hypokalemia, and metabolic alkalosis was achieved in 33, 89, and 80%, respectively.Conclusion: Endoscopic BLA is a safe and effective treatment for patients with ectopic Cushing's syndrome. [ABSTRACT FROM AUTHOR]

Background: One of the main ergonomic problems during surgical procedures is the surgeon's awkward body posture, often accompanied by repetitive movements of the upper extremities, increased muscle activity, and prolonged static head and back postures. In addition, surgeons perform surgery so concentrated that they tend to neglect their posture. These observations suggest the advantage of supporting the surgeon's body during surgical procedures. This study aimed to design a body support and to test its potential.Methods: The optimum working condition for a surgeon is a compromise between the spine and arm positions and the level of effort and fatigue experienced performing a procedure. The design vision of the Medisign group has led to the development of an ergonomic body support for surgeons that is suitable for use during both open and minimally invasive procedures. The feasibility of the newly designed ergonomic body support was assessed during seven surgical procedures. Electromyography (EMG) was performed for back and leg muscles using the body support in an experimental setting.Results: Six of seven participating surgeons indicated that the body support was comfortable, safe, and simple to use. The EMG results show that supporting the body is effective in reducing muscle activity. The average reduction using chest support was 44% for the erector spinae muscle, 20% for the semitendinosus muscle, and 74% for the gastrocnemius muscle. The average muscle reduction using semistanding support was 5% for the erector spinae, 12% for the semitendinosus muscle, and for 50% for the gastrocnemius muscle.Conclusion: The results of this study imply that supporting the body is an effective way to reduce muscle activity, which over the long term may reduce physical problems and discomfort. Additionally, the product supports the surgeon in his natural posture during both open and minimally invasive procedures and can easily be adapted to the current layout of the operating theater. [ABSTRACT FROM AUTHOR]

Chronic groin pain, especially in professional sportsmen, is a difficult clinical problem. From January 1999 to August 2005, 55 professional and semiprofessional sportsmen (53 males; mean age, 25 ± 4.5 years; range, 17–36 years) with undiagnosed chronic groin pain were followed prospectively. All the patients underwent an endoscopic total extraperitoneal (TEP) mesh placement. Incipient hernia was diagnosed in the study athletes: 15 on the right side (27%), 12 on the left side (22%), and 9 bilaterally (16%). In 20 patients (36%), an inguinal hernia was found: 3 direct inguinal hernias (5%) and 17 indirect hernias (31%). All the athletes returned to their normal sports level within 3 months after the operation. A TEP repair must be proposed to patients with prolonged groin pain unresponsive to conservative treatment. If no clear pathology is identified, reinforcement of the wall using a mesh offers good clinical results for athletes with idiopathic groin pain. [ABSTRACT FROM AUTHOR]

Background: This metaanalysis aimed to compare endoscopic linear stapling and loop ligatures used to secure the base of the appendix.Methods: Randomized controlled trials on appendix stump closure during laparoscopic appendectomy were systematically searched and critically appraised. The results in terms of complication rates, operating time, and hospital stay were pooled by standard metaanalytic techniques.Results: Data on 427 patients from four studies were included. The operative time was 9 min longer when loops were used (p = 0.04). Superficial wound infections (odds ratio [OR], 0.21; 95% confidence interval (CI), 0.06-0.71; p = 0.01) and postoperative ileus (OR, 0.36; 95% CI, 0.14-0.89; p = 0.03) were significantly less frequent when the appendix stump was secured with staples instead of loops. Of 10 intraoperative ruptures of the appendix, 7 occurred in loop-treated patients (p = 0.46). Hospital stay and frequency of postoperative intraabdominal abscess also were comparable in loop-treated and staple-treated patients.Conclusions: The clinical evidence on stump closure methods in laparoscopic appendectomy favors the routine use of endoscopic staplers. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic splenectomy (LS) for idiopathic thrombocytopenic purpura (ITP) appears, when compared to open splenectomy (OS), associated with immediate important advantages. However, in a number of patients splenectomy does not lead to an adequate response, or after initial adequate response a relapse occurs after some time. A relapse may be associated to the presence of accessory spleens and splenosis. The purpose of this study was to compare the operative outcome and the hematological results on the long term of a series of LS with a historic series of OS for the treatment of ITP.Methods: A retrospective review was done of 50 consecutive patients who underwent LS for ITP. Patient characteristics, outcome of surgery, and hematological results were compared to a historical group of patients who underwent conventional splenectomy for ITP (n = 31). Response to splenectomy was defined in three groups: complete remission, partial remission, and no response. Grouping was based on hematological data.Results: Concerning operative outcome and postoperative complications, there was a significant difference in favor of LS. Moreover, the hematological outcome of both groups showed no differences after a median period of 66 months (OS) and 35 months (LS), respectively.Conclusions: Hematological results after laparoscopic splenectomy for ITP are comparable to those after open splenectomy in both the short and the long term. [ABSTRACT FROM AUTHOR]

Background: This study aims to create new ergonomic guidelines for the design of foot pedals used during surgery.Methods: Observations in the operating room, a questionnaire among 45 laparoscopic surgeons/residents, an ergonomic literature study, and clog measurements were used to assess the problems occurring during use and to compile new guidelines for foot pedals. Based on these guidelines a new foot pedal was designed and a prototype was manufactured.Results: During the surgical procedure 91% of the subjects occasionally loses contact with the foot pedal, which 56% experience as very annoying. All subjects think that the current foot pedals obstruct their freedom of movement; 75% occasionally hit the wrong switch and 53% experience physical discomfort in their legs and/or feet. Therefore, 93% of the subjects would like to control the diathermy in a different way. The new prototype of a foot pedal was evaluated in a pilot test and proved to be ergonomically better than the currently used foot pedals.Conclusion: The new guidelines for foot pedals result in an ergonomic improvement in their design. [ABSTRACT FROM AUTHOR]

Background: The aim of this study is to create new ergonomic guidelines for the design of laparoscopic needle holders.Methods: An ergonomic literature study, observations in the operating room, handle-shaft angle measurements, and anthropometric data were used to compile new ergonomic criteria, specified to the function of a laparoscopic needle holder. Based on these guidelines a new needle holder was designed. The prototype and three currently available needle holders were evaluated according to the new guidelines. In addition, a pelvi-trainer test was done to measure the extreme wrist excursions.Results: The ergonomic evaluation of three commonly used handles and the new prototype indicate that the new handle is an ergonomic improvement in the field of laparoscopic needle holders: only the new handle satisfies all criteria. This is validated by the results of the pelvi-trainer test, which showed that the new prototype significantly (p <0.001) reduced the extreme wrist excursions.Conclusion: The new design guidelines for a laparoscopic needle holder result in an ergonomic improvement of the instrument. [ABSTRACT FROM AUTHOR]

Background: Recent developments in laparoscopic solid organ surgery suggest a possible reduction in postoperative discomfort and disability for kidney donors. Technical aspects and the influence of surgical experience in laparoscopic donor nephrectomy were evaluated.Methods: The clinical outcome of 57 laparoscopic donor nephrectomies (LapNx) was compared with that for a historic control group of 27 open donor nephrectomies (OpenNx).Results: Three conversions to open nephrectomy (5.2%) were necessary. Postoperative complications were minor and comparable in both groups. Patients who underwent laparoscopic surgery demonstrated significantly less postoperative pain and a shorter hospital stay, but operative time and warm ischemia time were significantly longer. Graft survival after LapNx was 100% during a median follow-up period of 13 months. Operative time for LapNx decreased considerably with experience gained and seemed to be less for right nephrectomy. Stenotic ureter-bladder anastomoses occurred after LapNx in four patients during the first half year (7.0%), but this problem seemed to be resolved after modification of the technique.Conclusion: LapNx is associated with less postoperative discomfort and improved convalescence. [ABSTRACT FROM AUTHOR]

A correction to the article "Videolaparoscopic appendectomy: the current outlook" that was published in a previous issue is presented.

A letter to the editor is presented to the article "Minilaparoscopic Appendectomy Using a Needle Loop Retractor Offers Optimal Cosmetic Results" published in the December 23, 2005 issue.