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Background: We aimed to introduce our modified hand-assisted retroperitoneoscopic living donor nephrectomy (HARPLDN) technique and define the learning curve., Methods: One hundred thirty-eight kidney donors who underwent modified HARPLDN by the same surgeon between May 2015 and March 2022 were included. A cumulative sum (CUSUM) learning curve analysis was performed with the total operation time as the study outcome., Results: In total, the mean operative time was 138.2 ± 32.1 min. The median warm ischemic time (WIT) and estimated blood loss were 90 s and 50 ml, respectively. The learning curve for the total operative time was best modeled as a second-order polynomial with the following equation: CUSUM OT (min) = (-0.09 case number 2 ) + (12.88 case number) - 67.77 (R 2  = 0.7875; p<0.05). The CUSUM learning curve included the following three unique phases: phase 1 (the initial 41 cases), representing the initial learning curve; phase 2 (the middle 43 cases), representing expert competence; and phase 3 (the final 54 cases), representing mastery. The overall 6-month graft survival rate was 99.3%, with 94.9% immediate onset of graft function without delayed graft function and 0.7% ureteral complications., Conclusions: Our modified method is safe and effective for living donor nephrectomy and has the advantages of a shorter operating time and optimized WIT. The surgeon can become familiar with the modified HARPLDN after 41 cases and effectively perform the next 97 cases., (© 2024. The Author(s).)

Background: Few studies have systematically explored the factors influencing the difficulty of hand-assisted laparoscopic living donor nephrectomy. To investigate the relationship between the difficulty of hand-assisted laparoscopic living donor nephrectomy and postoperative complications of the donor as well as the recipient, and then build a model for predicting the difficulty of surgery., Methods: In this study, 60 patients who underwent hand-assisted laparoscopic living donor nephrectomy by the same surgeon from September 2022 to March 2024 were included as the modeling group. 20 patients operated on by another surgeon served as the external validation group. The subjective score (1-3 points) of surgical difficulty was used as the quantitative index of surgical difficulty. Pearson and Spearman correlation tests were used to explore the correlation between preoperative data and surgical difficulty scores of kidney donors, and finally built a prediction model through multiple linear regression analysis., Results: With the increase in the difficulty of operation, both donors and recipients' complications were increased. Linear regression analysis showed that only the number of renal arteries, visceral fat thickness and MAP score were independent risk factors for the difficulty of hand-assisted laparoscopic living donor nephrectomy. The prediction equation is as follows: Difficulty score = 0.584*Number of renal arteries + 0.731*MAP score + 0.110*visceral fat thickness., Conclusions: Donors with higher surgical difficulty are more likely to have serious complications after surgery as well as the recipient. We also established a reliable prediction model for the difficulty of hand-assisted laparoscopic donor nephrectomy., (© 2024. The Author(s).)

Some patients with refractory esophagogastric varices require surgery, such as gastric devascularization and splenectomy (Hassab's procedure). However, these patients are at risk of perioperative morbidities when undergoing devascularization to develop collateral vessels. We performed a more simplified procedure, splenectomy, and en bloc gastropancreatic fold division (GPFD) with hand-assisted laparoscopic surgery. Four patients with refractory esophagogastric varices and portal hypertension underwent splenectomy and GPFD. We reviewed patients' perioperative laboratory and morphological data, operative variables, and postoperative outcomes. Esophagogastric varices improved in 3 (75%) of the 4 patients. In one patient, esophageal varices (F1RC0) were observed 3 years after surgery, but they required no treatment and only received follow-up. Treatment with splenectomy and GPFD is not only less invasive than Hassab's procedure but also provides effective outcomes for refractory esophagogastric varices., (© 2023. The Author(s) under exclusive licence to Springer Nature Singapore Pte Ltd.)

Background: Robotic donor nephrectomy (RDN) has emerged as a safe alternative to laparoscopic donor nephrectomy (LDN). Having previously demonstrated comparable efficacy, this study aims to examine postoperative analgesia use (opioid and non-opioid) in the two groups., Methods: We conducted a retrospective review of 300 living donor nephrectomies performed at our center, comparing 150 RDN's with a contemporary cohort of 150 hand-assisted LDN's. In addition to clinical and demographic information, data on postoperative inpatient opioid and non-opioid analgesia (from patient's arrival to the surgical floor after surgery till the time of discharge) was collected. Opioid dosages were standardized by conversion to morphine milligram equivalents (MME). All patients were managed post-operatively under a standardized ERAS pathway for living donor nephrectomy patients., Results: There were no significant differences in donor age, gender, and BMI between RDN and LDN groups. Total post-operative opioid use (MME's) was significantly lower in RDN patients (RDN 27.1 vs. LDN 46.3; P < 0.0001). Breakdown of opioid use with post-operative (POD) day demonstrated significantly lower use in RDN group on POD1 (RDN 8.6 vs. LDN 17.0; P < 0.05), and POD2 (RDN 3.9 vs LDN 10; P < 0.05). RDN patients had a shorter post-operative length of stay (LOS) (RDN 1.69 days vs. LDN 1.98; P = 0.0003). There were no differences between groups in non-opioid medication use, complications, and readmission rates., Conclusion: RDN has comparable safety to hand-assist LDN and offers additional benefits of lower postoperative opioid requirement and a shorter hospital LOS., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

We report a case of retroperitoneal laparoscopic radical nephrectomy (LRN) in which the addition of a hand port was necessary and effective. A 52-year-old man with obesity (BMI 40.6 kg/m2) was diagnosed with a 52-mm left renal cell carcinoma (cT1bN0M0). To avoid thick subcutaneous and visceral fat in the abdomen, we selected LRN using a retroperitoneal approach with four ports in the kidney position. During surgery, a large amount of flank pad and perirenal fat prevented us from securing a sufficient surgical field through traction of the kidney with a retractor. A pure laparoscopic procedure was not feasible;therefore, we added a hand port. Subsequently, we removed the flank pad from the hand port and secured the surgical field by tracing the kidney manually. Finally, hand-assisted LRN was completed without an open conversion. In retroperitoneal LRN, we rarely encounter patients for whom a pure laparoscopic procedure is not feasible because of the large amount of flank pad or perirenal fat. It is important to preoperatively confirm not only the BMI but also the amount of flank pad and perirenal fat on imaging. Hand-assisted LRN via the retroperitoneal approach can be safely performed even in extremely obese patients. J. Med. Invest. 71 : 187-190, February, 2024.

Background: To evaluate hand-assisted laparoscopic donor nephrectomy (HALDN) in terms of intraoperative and postoperative results., Methods: After institutional review board approval was obtained, a total of 1864 HALDN operations performed between March 2007 and January 2022 were retrospectively analyzed. Age, sex, body mass index (BMI), status of smoking and presence of previous abdominal surgery, laterality, operative time, transfusion requirement, port counts, length of extraction incision, time until mobilization, time until oral intake, donor serum creatinine levels before and one week after the surgery, length of postoperative hospital stay, intraoperative complications, and postoperative recovery and complications were recorded and statistically analyzed. Multiple renal arteries, BMI, right nephrectomy and male sex were also separately evaluated as risk factors for complications and operative time., Results: A total of 825 (44.26%) male and 1039 (55.74%) female patients were enrolled in the study. The mean age of the patients was 45.79 ± 12.88 years. There were a total of 143 complications (7.67% of the total 1864 cases) consisting of 68 (3.65%) intraoperative and 75 (4.02%) postoperative complications. Open conversion was necessary for 10 patients (0.53%) to manage intraoperative complications. Reoperation was needed for 1 patient due to bleeding 6 h after the operation. Multiple renal arteries were a risk factor for intraoperative complications and prolonged operative time. Right nephrectomy and male sex were also related with longer operative times., Discussion: HALDN is a safe procedure associated with low complication rates.

Background and Aim: The implications of multi-incision (MILS) and hand-assisted (HALS) laparoscopic techniques for minimally invasive liver surgery with regard to perioperative outcomes are not well defined. The purpose of this study was to compare MILS and HALS using propensity score matching., Methods: 309 patients underwent laparoscopic liver resections (LLR) between January 2013 and June 2018. Perioperative outcomes were analyzed after a 1:1 propensity score match. Subgroup analyses of matched groups, i.e., radical lymphadenectomy (LAD) as well as resections of posterosuperior segments (VII and/or VIII), were performed., Results: MILS was used in 187 (65.2%) and HALS in 100 (34.8%) cases, with a significant decrease of HALS resections over time (p = 0.001). There were no significant differences with regard to age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) Score, previous abdominal surgery and cirrhosis between both groups. Patients scheduled for HALS were characterized by a significantly higher rate of malignant tumors (p < 0.001) and major resections (p < 0.001). After propensity score matching (PMS), 70 cases remained in each group and all preoperative variables as well as resection extend were well balanced. A significantly higher rate of radical LAD (p = 0.039) and posterosuperior resections was found in the HALS group (p = 0.021). No significant differences between the matched groups were observed regarding operation time, conversion rate, frequency of major complications, length of intensive care unit (ICU) stay, overall hospital stay and R1 rate., Conclusion: Our analysis suggests MILS and HALS to be equivalent regarding postoperative outcomes. HALS might be particularly helpful to accomplish complex surgical procedures during earlier stages of the learning curve.

Abstract: Since its introduction in 1991, laparoscopic splenectomy (LS) has become the gold standard in elective spleen surgery in many centres. However, there still lack the report of long-term outcomes of LS with the large-scale cases. The aim of the present study was to analyze the short- and long-term outcomes of LS in a single institution over 16 years, and to compare the perioperative outcomes of totally laparoscopic splenectomy (TLS) and hand-assisted laparoscopic splenectomy (HALS) for splenomegaly.Between November 2002 and December 2018, 486 consecutive patients undergoing elective LS were enrolled in this study, including 222 TLS and 264 HALS. The intraoperative, postoperative, and follow-up data were retrospectively analyzed.The 5 most common indications were hypersplenism (71.0%), immune thrombocytopenia (14.8%), splenic benign tumor (4.5%), splenic cyst (2.9%), and splenic malignant tumor (2.9%). The mean operative time, intraoperative blood loss, and length of stay were 149.4 ± 63.3 minutes, 230.1 ± 225.1 mL, and 6.7 ± 3.2 days, respectively. The morbidity, mortality, reoperation, and conversion rate were 23.0%, 0, 0.4%, and 1.9%, respectively. Portal vein system thrombosis (PVST) was the most frequent complication with an incidence of 19.8%. The incidence of PVST in HALS was higher than that in TLS (23.9% vs 14.9%, P = .013). Compared with TLS, HALS had a shorter operative time (P = .000), lower intraoperative blood loss (P = .000), comparable conversion rate (P = .271), and morbidity (P = .922) for splenomegaly > 17.0 cm. During the follow-up period, the overall respond rate for immune thrombocytopenia was 77.8%, and the esophagogastric variceal bleeding rate was 6.9% in 320 patients with hypersplenism secondary to hepatic cirrhosis.LS is a safe, feasible, and effective procedure with satisfactory short- and long-term outcomes. HALS is a reasonable technique in patients with massive spleens., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Health-related quality of life (HRQL), fatigue, anxiety, and depression are crucial for the living kidney donor (LKD). Follow-up data for HRQL of LKDs comparing surgical techniques, especially regarding hand-assisted retroperitoneoscopic donor nephrectomy (HARP), are sparse. The aim of this study was to evaluate the influence of abdominal wall trauma minimized by HARP in comparison to open anterior approach donor nephrectomy (AA) on HRQL and additional psychosocial aspects of LKDs during the long-term follow-up., Material and Methods: This is a cross-sectional study comparing psychosocial aspects of LKD between HARP and AA., Results: This study included 100 LKDs (68 HARP, 28 AA, and 4 were excluded secondary to incomplete data). The time to follow-up was 22.6 ± 11.7 (HARP) vs 58.7 ± 13.9 (AA) months (P < .005). Complications ≥3a° due to Clavien-Dindo classification was 0% in both groups. There were higher scores in all physical aspects for HARP donors vs AA donors at that time (physical function: 89.8 ± 14.6 vs 80.0 ± 19.9, P = .008, and the physical component score: 53.9 ± 7.6 vs 48.6 ± 8.5, P = .006). One year later (follow-up time + 12 months), HRQL for HARP donors was still higher. Mental items showed no significant differences. HARP donors showed better physical scores compared to the age-matched nondonor population (AA donors had lower scores). Neither the Multidimensional Fatigue Inventory-20 (MFI-20) or the Hospital Anxiety and Depression Scale (HADS) showed any differences between the 2 groups. Fatigue scores were higher for HARP and for AA compared to the age-matched population., Conclusions: LKDs undergoing HARP showed better physical performance as part of HRQL in the long-term follow-up., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background/objectives: Laparoscopic living donor nephrectomy (LLDN) of the right kidney is currently considered as part of standard of care; however, dealing with the renal hilum when performing ligation/division of its renal vessels is still a main concern. Here, we describe a simple-to-perform technique, i.e., flipping the fully mobilized right kidney to the midline so that the renal artery becomes anteriorly, which offers better visualization and easier dissection of the renal vessels (achieving maximized lengths) when performing hand-assisted LLDN of the right kidney., Methods: Living donors who underwent hand-assisted LLDN of the right kidney, along with their respective renal transplant recipients, were included in this report. Donor characteristics included renal artery and vein lengths; recipient characteristics included creatinine at months 12 - 36. Graft vein and arterial anastomosis data were also reported., Results: Nineteen living donors and 19 recipients, with median donor and recipient ages being 39 (24 - 60) and 53 (3 - 81) years, respectively, were included. None of the 38 patients had intra- or postoperative complications. Donor renal vein was anastomosed to the right external iliac vein (n = 16), right common iliac vein (n = 2), and inferior vena cava (n = 1). Gonadal vein (n = 1) and deceased donor iliac vein (n = 2) were used to increase the right renal vein length in 3 cases. Four donor kidneys had 2 arteries reconstructed side by side. None of the recipients developed any vascular or urological complications., Conclusions: The laparoscopic technique described is safe and allows better visualization of the right hilum, mainly the renal artery, and helps in stapling the renal vein and renal artery., Competing Interests: Conflict of interests: none., (© 2021 by SLS, Society of Laparoscopic & Robotic Surgeons.)

Background: Few studies have investigated the learning curves of minimally invasive donor nephrectomy (MIDN) using the cumulative sum (CUSUM) analysis. In addition, no study has compared the learning curves of the different surgical MIDN techniques in one cohort study using the CUSUM analysis. This study aims to evaluate and compare learning curves for several MIDN using the CUSUM analysis., Methods: A retrospective review of consecutive donors, who underwent MIDN between 1997 and 2019, was conducted. Three laparoscopic-assisted techniques were applied in our institution and included for analysis: laparoscopic (LDN), hand-assisted retroperitoneoscopic (HARP), and robot-assisted laparoscopic (RADN) donor nephrectomy. The outcomes were compared based on surgeon volume to develop learning curves for the operative time per surgeon., Results: Out of 1895 MIDN, 1365 (72.0%) were LDN, 427 (22.5%) were HARP, and 103 (5.4%) were RADN. The median operative time and median blood loss were 179 (IQR, 139-230) minutes and 100 (IQR, 40-200) mL, respectively. The incidence of major complication was 1.2% with no mortality, and the median hospital stay was three (IQR, 3-4) days. The CUSUM analysis resulted in learning curves, defined by decreased operative time, of 23 cases in LDN, 45 cases in HARP, and 26 cases in RADN., Conclusions: Our study shows different learning curves in three MIDN techniques with equal post-operative complications. The LDN and RADN learning curves are shorter than that of the hand-assisted donor nephrectomy. Our observations can be helpful for informing the development of teaching requirements for fellows to be trained in MIDN., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Objective: To describe our technique of simultaneous hand-assisted laparoscopic bilateral native nephrectomy (BNN) and kidney transplantation (KT) in patients with autosomal dominant polycystic kidney disease and present our experience., Materials and Methods: We retrospectively reviewed a cohort of adult ESRD patients with symptomatic autosomal dominant polycystic kidney disease who underwent a hand-assisted laparoscopic BNN at the time of KT. We reviewed patients' and donor characteristics, and perioperative and postoperative outcomes., Results: A total of 52 patients underwent hand-assisted laparoscopic BNN at the time of KT from January 2014 to October 2019. The median age of the recipients was 53.4 years, 57.7% were males, and the median body mass index was 29.0 kg/m 2 . All but one received a kidney from a living donor and the majority (86.5%) were pre-emptive. One patient required a small bowel resection due to an intraoperative small bowel injury. There was no solid organ injury during the procedure. All patients showed immediate allograft function and a steady decline in serum creatinine. The median decline in the creatinine and hemoglobin on day 1 was 1.2 mg/dL (inter quartile range 0.6-2.3) and 2.2 g/dL (inter quartile range 1.4-3.0), respectively., Conclusion: Simultaneous hand-assisted laparoscopic bilateral nephrectomy with KT through a modified Gibson incision is feasible and safe in the hands of an experienced laparoscopic surgeon without compromising allograft function., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: To assess the efficacy of a method to avoid conversion to laparotomy in patients considered for laparoscopic colectomy. Patients considered being at high risk for conversion to formal laparotomy were initially approached via a small midline incision ("peek port") with the laparoscopic equipment readily available but unopened. If intraperitoneal conditions were favorable, the procedure was performed using hand-assisted laparoscopy (HALS); if intraperitoneal conditions were unfavorable, the incision was extended to a formal laparotomy., Methods: Data from 664 patients from a single surgeon brought to the operating room with the intention of proceeding with laparoscopic colectomy (either via straight laparoscopy or HALS) were retrieved from a prospective database. Comparison of conversion rates between groups was performed using χ 2 analysis., Results: The study population consisted of 361 men and 303 women with a mean age of 61 years. Inflammatory conditions accounted for 40% of the diagnoses and enteric fistulas were present in 12%. Of the 79 patients who underwent initial "peek port" exploration, 38 (48%) underwent immediate extension to formal laparotomy, whereas 41 (52%) underwent HALS colectomy, with one subsequent conversion from HALS to formal laparotomy. Of the 585 patients initially approached laparoscopically, 14 (2%) required conversion to laparotomy. Of the 626 patients from both groups who underwent laparoscopy, the overall conversion to laparotomy rate was 15/626 (2%)., Discussion: The "peek port" approach to the patients with a potentially hostile abdomen allows for prompt assessment of intraperitoneal conditions and is associated with an overall low rate of conversion from laparoscopy to laparotomy during colectomy. This technique may reduce expense and morbidity for patients who ultimately require laparotomy, while allowing some patients with complex disease to be managed laparoscopically who would not normally be considered for a minimally invasive procedure.

Background: Left hemicolectomy and complicated sigmoid colectomy require an anastomosis between the transverse colon and rectum. Generous mobilization will typically allow the colon to reach to the rectum. However, despite full mobilization of the splenic flexure and extensive work on the mesentery, there are cases in which reach to the pelvis is still an issue. Retroileal routing of the colon is one technique for overcoming such a reach problem and achieving a tension-free anastomosis. Performing retroileal routing using laparoscopic techniques has been reported rarely, and to date, there are no data on this technique when performed in a hand-assisted laparoscopic fashion. This study aimed to describe the feasibility of doing a retroileal routing using a hand-assisted laparoscopic technique., Methods: This was a retrospective chart review of patients who underwent a colon or rectal resection, either open or laparoscopic, with a pelvic anastomosis, by a single colorectal surgeon at an academic institution between 2008 and 2015 with a focus on the immediate and long-term postoperative complications, estimated blood loss, and operating room time for patients having an operation that included retroileal routing for construction of a colorectal anastomosis., Results: A total of 340 patients fit inclusion criteria and of these, 13 underwent hand-assisted laparoscopic procedures with retroileal routing of the proximal colon to the colorectal anastomosis. Postoperative morbidity included intubation for CO 2 retention in one patient and a RLL effusion in another patient; there were no anastomotic leaks. Long-term morbidities included two ventral hernias at 2 years postoperatively. Mean operating room time was 208 min. There were no 30- or 90-day mortalities., Conclusions: Hand-assisted laparoscopic retroileal routing is a feasible and safe technique in accomplishing a tension-free colorectal anastomosis when proximal colon length makes standard routing of the colon to the rectum an issue.

Introduction: Minimally invasive major hepatic resection (MIMHR) is increasingly being performed in tertiary centers using either hand-assisted laparoscopic surgery (HALS) or totally laparoscopic surgery (TLS). The outcomes data of MIMHR are scarce, especially in comparison to open major hepatic resection (OMHR). Our aim was to compare 90-day outcomes in major hepatic resections when minimally invasive approaches are attempted. Methods and Procedures: At our institution, minimally invasive liver resection was formally introduced in January 2007, initially using the HALS approach. Since then, the use of TLS approach has increased. We collected data on all patients who underwent major liver resection between January 2007 and December 2017 at our institution. In an intention to treat fashion, we then compared MIMHR to OMHR. Results: From January 2007 to December 2017, 669 patients underwent liver resection. Of these, 203 patients (30%) underwent major hepatic resection and MIMHR and OMHR were performed in 68 (33%) and 135 (67%) patients, respectively. The rate of conversion from minimally invasive to open was 30.9%. Overall, there were no significant differences in 90-day mortality (2.9% versus 1.5%; P  = .499) or major complications (14.7% versus 14.8%; P  = .985). MIMHR was associated with a shorter average postoperative hospital stay (6.2 days versus 7.9 days; P  = .0110) and shorter average ICU stay (0.66 days versus 0.90 days; P  = .0299) compared with OMHR. Conclusions: The minimally invasive approach to major liver resection is a safe and reasonable alternative to an open approach when performed by a surgeon experienced with the relevant surgical techniques. MIMHR may be associated with similar outcomes and a shorter postoperative hospital stay with no increase in 90-day postoperative complications to OMHR.

Introduction: Living-donor kidney transplantation (LDKT) is the most realistic option for patients with end-stage kidney disease because of a severe shortage of deceased donors. Hand-assisted laparoscopic donor nephrectomy (HALDN) and hand-assisted retroperitoneoscopic donor nephrectomy (HARDN) have been undertaken at our institute. We compared these 2 surgical procedures with respect to donor outcome and the graft function of recipients., Methods: We reviewed data from 840 consecutive live-donor kidney transplants from October 2003 to April 2019. Propensity scores were calculated for each patient using bivariate logistic regression., Results: After propensity-score matching, the 2 groups each contained 205 patients. Donors in the HALDN group had a longer procedure time (217 minutes, P < .0001), less estimated blood loss (51 mL, P < .0001), lower serum levels of C-reactive protein at postoperative day (POD) 1 (7.9 mg/dL, P < .0001) than those in the HARDN group. There were 22 modified Clavien-classifiable complications among the study groups. A significantly higher conversion to open surgery was noted in the HARDN group (P = .0181) than in the HALDN group, but there was no significant difference in the prevalence of complications in either group. There was no significant difference in the estimated glomerular filtration rate of recipients at POD14 between the 2 groups., Conclusions: Safety and early graft function of HALDN in LDKT are comparable to or even better than that of HARDN., (Copyright © 2020. Published by Elsevier Inc.)

Background: Mini-invasive colorectal cancer surgery was adopted widely in recent years. This meta-analysis aimed to compare hand-assisted laparoscopic surgery (HALS) with open right hemicolectomy (OS) for malignant disease., Methods: PRISMA guidelines with random effects model were adopted using Review Manager Version 5.3 for pooled estimates., Results: Seven studies that involved 506 patients were included. Compared to OS, HALS improved results in terms of blood loss (MD = 53.67, 95% CI 10.67 to 96.67, p = 0.01), time to first flatus (MD = 21.11, 95% CI 14.99 to 27.23, p < 0.00001), postoperative pain score, and overall hospital stay (MD = 3.47, 95% CI 2.12 to 4.82, p < 0.00001). There was no difference as concerns post-operative mortality, morbidity (OR = 1.55, 95% CI 0.89 to 2.7, p = 0.12), wound infection (OR = 1.69, 95% CI 0.60 to 4.76, p = 0.32), operative time (MD = - 16.10, 95% CI [- 36.57 to 4.36], p = 0.12), harvested lymph nodes (MD = 0.59, 95% CI - 0.18 to 1.36, p = 0.13), and recurrence (OR = 0.97, 95% CI 0.30 to 3.15, p = 0.96)., Conclusions: HALS is an efficient alternative to OS in right colectomy which combines the advantages of OS with the mini-invasive surgery.

BACKGROUND Laparoscopic donor nephrectomy (LDN) has evolved and has been established as a surgical standard of care for kidney transplantation. MATERIAL AND METHODS This study retrospectively reviews 1132 patients who underwent 4 different laparoscopic living-donor nephrectomies: hand-assisted laparoscopic nephrectomy (HALDN), pure laparoscopic donor nephrectomy (PLDN), laparoendoscopic single-site plus 1-port donor nephrectomy (LESSOP-DN), and mini laparoscopic donor nephrectomy (MLDN). RESULTS The mean estimated blood loss (EBL) for the HALDN group was meaningfully higher than those of LESSOP-DN and MLDN (57.5±52.2 mL versus 21.0±30.0 mL versus 18.2±28.7 mL) (P<0.001). The EBL for PLDN (53.3±35.3 mL) was also significantly higher than those of LESSOP-DN and MLDN (P<0.001). Length of stay (LOS) for HALDN was longer than that for LESSOP-DN (4.2±1.2 day versus 4.0±1.4 days, P=0.002). There was 1 intraoperative open conversion in the HALDN group and 2 HALDN surgeries that required postoperative exploratory laparotomy. LESSOP-DN had 3 (0.8%) postoperative incisional hernias. For recipients, the results revealed no significant differences between all 4 groups in terms of estimated glomerular filtration rate (eGFR) and the 1-year graft failure rate. CONCLUSIONS The LESSOP-DN group was associated with a shorter incision length than those of HALDN and PLDN and shorter LOS than that of HALDN. Recipient results showed no meaningful difference regarding laparoscopic donor nephrectomy technique.

A 70-year-old healthy male individual offered to undergo a living donor hand-assisted laparoscopic nephrectomy to enable kidney transplantation for a close relative. As required for all living transplant donor candidates, extensive screening was performed to exclude potential contraindications for donation. Tests revealed a situs inversus totalis, meaning a complete transposition of the thoracic and abdominal organs in the sagittal plane. As other contraindications for living kidney donation were absent, the feasibility of this procedure was determined multidisciplinary. A successful donation procedure was performed without surgical complications for the donor and good short-term transplant outcomes. In line with current developments that have resulted in more liberal criteria for potential living kidney donors, major anatomical deviations should not automatically be a contraindication. With multidisciplinary efforts and thorough surgical preparation at a high-volume transplant centre, this procedure is feasible and safe., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Hand-assisted laparoscopic donor nephrectomy (HALDN) has rapidly become the best alternative to open nephrectomy for living kidney donation. As more centers continue to adopt the laparoscopic technique, the safety of the initial transplants must be ensured while ascending the learning curve (LC). This study looks to determine the safety of HALDN and to describe the results of the LC in our center., Methods: We conducted a retrospective review of 500 HALDNs performed in our center from July 2003 to July 2017. We analyzed demographic and perioperative characteristics and complications during the first postoperative month. We divided HALDNs into 2 groups: before and after completing the LC (50 nephrectomies). For each group, we assessed operating room time, estimated blood loss, length of stay, and complication and conversion rates., Results: A total of 500 HALDNs were performed in the study period. Of those, 454 were analyzed in the 2 groups. The median operating room time was 2 hours, length of stay was 2 days, and blood loss was 50 cc. The overall rate of complication was 6.8%. There were significant differences between the 2 groups in operating time, blood loss, and length of stay (P < .05). No differences were found in terms of complication (P = .42) and conversion (P = .28) rates., Conclusion: There was a significant decrease in operating time, blood loss, and length of stay in patients who underwent laparoscopic donor nephrectomy by an experienced laparoscopist. However, no differences were found in complication and conversion rates, which suggests that improvement in surgical training can be accomplished without altering the donor safety., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Live donor nephrectomy is an important donor source. Donor nephrectomy can be performed by laparoscopy or hand-assisted laparoscopy. Different types of hand port devices can be used for assistance. In the literature there are few studies about hand-assisted laparoscopy without a hand port. In this study, we aimed to evaluate the impact of not using a hand port for hand-assisted laparoscopic donor nephrectomy for kidney transplantation., Methods: Patients who were operated on for kidney donation between January 2011 and June 2018 evaluated retrospectively. The patients were divided into 2 groups: group A, on whom a hand port was used, and group B, whose surgeries did not involve a hand port. The groups were compared for sex, age, body mass index, amount of intraoperative bleeding, warm ischemia time, duration of surgery, perioperative complications, duration of hospital stay, and postoperative complications., Results: There were 159 patients in group A and 146 patients in group B. There was no difference between the groups considering intraoperative bleeding, warm ischemia time, duration of surgery and postoperative early complications (P > .05 for all)., Conclusion: Hand-assisted laparoscopic donor nephrectomy without a hand port can be considered an easy and effective method of laparoscopic nephrectomy., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: The current study aims to explore the effect of myocardial infarction associated transcript (MIAT) level on the long-term prognosis of hand-assisted laparoscopic colectomy (HALC) or laparoscopic-assisted colectomy (LAC) for colorectal cancer (CC)., Materials and Methods: A total of 320 CC patients were included. Patients were randomized into HALC and LAC group., Results: MIAT level in CC tissue was upregulated, and had a significant positive association with its level in serum. MIAT levels in both CC tissue and serum were correlated with lymph node metastasis and histologic grading. Survival analysis showed that the overall survival rate in 3 years after operation was significantly lower in HALC-High MIAT group (P<0.05). When MIAT level is <10.9 in CC tissue or 8.7 in serum, 100% of patients who underwent HALC will be alive for >3 years., Conclusions: For patients with low MIAT level, both HALC and LAC are available, otherwise, LAC is more recommended.

Minimally invasive surgery (MIS) techniques are growing in quantity and complexity to cover a wider range of interventions. More specifically, hand-assisted laparoscopic surgery (HALS) involves the use of one surgeon's hand inside the patient whereas the other one manages a single laparoscopic tool. In this scenario, those surgical procedures performed with an additional tool require the aid of an assistant. Furthermore, in the case of a human-robot assistant pairing a fluid communication is mandatory. This human-machine interaction must combine both explicit orders and implicit information from the surgical gestures. In this context, this paper focuses on the development of a hand gesture recognition system for HALS. The recognition is based on a hidden Markov model (HMM) algorithm with an improved automated training step, which can also learn during the online surgical procedure by means of a reinforcement learning process.

Minimally invasive approaches to total abdominal colectomy (TAC) in ulcerative colitis (UC) patients include straight laparoscopy (SL), hand-assisted laparoscopic surgery (HALS), and robotics. In this study, short-term outcomes of patients undergoing SL and HALS TAC were compared. Prospectively collected data on UC patients undergoing TAC were tabulated. The study cohort included 36 (27%) patients in the SL group and 95 (73%) patients in the HALS group. The groups were comparable in terms of preoperative characteristics and demographics. The mean operative time was 151 (range, 73-225) minutes in the SL group versus 164 (range, 103-295) minutes in the HALS group ( P = 0.09). Total 48-hour IV morphine use was 30 (range, 0-186) mg in the SL group compared with 56 (0-275) mg in the HALS group ( P < 0.01). Although overall morbidity was comparable between the groups, Clavien-Dindo Class III complications did not occur in any of the SL group patients versus 11 (11%) of the HALS group patients ( P = 0.03). The postoperative length of stay was 3 (3-21) days in the SL group versus 5 (3-15) days in the HALS group ( P < 0.01). Compared with HALS, SL is associated with lower postoperative narcotic use and hospital length of stay in UC patients undergoing TAC.

Background: Laparoscopic splenectomy (LS) is generally applied for splenectomy, However, it also brings some technical challenges, especially for splenomegaly. Hand-assisted laparoscopic splenectomy (HALS) can help to overcome these drawbacks while maintaining the superiority of LS. This study was aimed to evaluate the efficacy and advantage of HALS for splenomegaly., Materials and Methods: Between January 2014 and November 2017, 91 patients with splenomegaly in 2 surgical centers were randomly assigned to either HALS (n=45) or LS (n=46). The patients' characteristics, intraoperative details, and the postoperative outcomes in both groups were compared., Results: Baseline features (sex, age, main diameter, Child-Pugh grade) of both groups had no significant difference (P<0.05). Compared with LS group, the HALS group operation time (141±46 vs. 172±43 min; P=0.001) was shorter, intraoperative blood loss [215 (122.332) vs. 230 (130.740) mL; P=0.026], hospital expenses (5.5±1.5 vs. 6.4±2.4 WanRMB; P=0.022), and conversion rate (1/45 vs. 9/46; P=0.015) were lower. However, there was no significant difference for hospital stay (6.4±2.8 vs. 6.7±3.0 d; P=0.662) and complications (15/45 vs. 12/46; P=0.893) between the 2 groups. In addition, there were no significant differences in postoperative white blood cell (10.6±2.9 vs. 10.9±3.5; P=0.747), AST [61 (47.94) vs. 57 (37.86) U/L; P=0.513], and ALT [68 (54.120) vs. 55 (36.99) U/L; P=0.302] levels., Conclusions: HALS can maximize the benefits for patients, while maintaining the advantages of LS and open splenectomy. It is the ideal surgical treatment for splenomegaly.

Purpose: In this study, we described our initial experience and analyze the learning curve of segmental renal artery branch clamping with hand-assisted laparoscopic partial nephrectomy (PN) using special instruments., Materials and Methods: We conducted a retrospective review of consecutive cases of hand-assisted laparoscopic PN (LPN) between May 2015 and April 2018. Patient demographics, tumor characteristics, perioperative details, postoperative complications, and warm ischemic time for segmental artery branch clamping were included in our analysis. We used the cumulative sum (CUSUM) method to generate learning curves., Results: Segmental renal artery branch clamping was successfully completed in 16 of 20 patients. The median tumor size was 2.9 cm (range, 1.7-7.0 cm), median operation time was 185 minutes (range, 140-245 minutes), median blood loss was 291 mL (range, 100-600 mL), and median hospital stay was 5 days (range, 4-7 days). The median selective ischemic time was 21 minutes (range, 16-35 minutes). No patient had postoperative complications, acute or delayed bleeding. The median pre- and postoperative serum creatinine levels (0.91 and 0.98 mg/dL, respectively), and the pre- and postoperative estimated glomerular filtration rate (89.7 and 79.6 mL/min per 1.73 m 2 , respectively) were similar. Upon visual assessment of the CUSUM plots, a downward inflection point for decreasing total operation time was observed in the 9th case and estimated blood loss in the 12th case., Conclusions: Our study shows that segmental renal artery branch clamping hand-assisted LPN for localized renal tumors is feasible, safe, and has a relatively short learning curve., Competing Interests: CONFLICTS OF INTEREST: The authors have nothing to disclose.

Background: In light of the modern surgical trend towards minimally invasive surgery, we aim to assess the feasibility of hand-assisted laparoscopic (HAL) cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in peritoneal surface malignancy (PSM)., Methods: Patients with PSM secondary to colorectal cancer or pseudomyxoma peritonei with peritoneal cancer index (PCI) of ≤ 10 were considered for HAL CRS and HIPEC. One patient had PCI of 15 but based on the disease distribution laparoscopic-assisted CRS and HIPEC was thought to be feasible, thus was also included. These patients were compared to matched controls who underwent open CRS and HIPEC for similar pathologies. Matching was performed on age and PCI to reflect a comparable complexity of the operation, and tumor grade for comparable risk of disease recurrence., Results: Eleven patients were included in each group. In both groups, mean PCI was 4.1, mean age was 58.5 years, and 81.8% were well-moderately differentiated tumors. Complete cytoreduction was achieved in all patients. Upon comparison, HAL patients had significantly less blood loss and 3-day shorter hospitalization. No difference was demonstrated in operative time, number of visceral resections, and rate of omentectomy/peritonectomy. Also, no difference was detected in morbidities and 30-day readmission rates. No intraperitoneal recurrences have been reported in the HAL group after a median follow-up of 11 months., Conclusion: HAL CRS and HIPEC is a feasible procedure and can be considered for PSM with low PCI. It offers very acceptable and comparable short-term outcomes to the conventional open approach.

Background/purpose: This study aims to investigate the safety and feasibility of laparoscopic adrenalectomy for benign adrenal tumor without peri-operative NGT decompression., Methods: From July 2010 to March 2014, 82 consecutive patients with benign unilateral adrenal tumor underwent elective laparoscopic adrenalectomy by a single surgeon were recruited for this study. We compared the clinico-demographic profile, estimated blood loss, operative time, time to full diet, time to ambulate, the length of hospital staying, analgesics use and complications between two groups stratified by the use of NGT., Results: There were no significant differences in the clinico-demographic profile of the two groups, including age, laterality, body mass index, gender, ASA classification, tumor diameter and histologic types between two groups. Peri-operative parameters were similar between NGT and Non-NGT groups (estimated blood loss, 55.85 vs. 54.4 ml; operative time, 110.3 vs. 112.3 min; p > 0.05) The post-operative outcome of interests, including days to full oral intake (3.32 vs. 3.34 days), days to ambulate (2.07 vs. 2.10 days), hospital stay (4.32 vs. 4.34 days), and analgesics use (6.00 vs. 5.83 mg; all p > 0.05) showed no significant difference between NGT and non-NGT group., Conclusion: Laparoscopic adrenalectomy in patients with benign unilateral adrenal tumor without the use of peri-operative nasogastric tube decompression is safe and feasible., (Copyright © 2018. Published by Elsevier B.V.)

Background: To analyze our initial results of hand-assisted laparoscopic living donor nephrectomy, executed by a skilled gastrointestinal surgeon., Methods: A total of 22 consecutive patients underwent the hand-assisted laparoscopic living donor nephrectomy between December 2014 and January 2017. We retrospectively analyze the patient's perioperative clinical data, which were collected prospectively., Results: The right kidney was harvested in 12 patients. The mean operative time and intraoperative blood loss was 241.0 ± 43.4 minutes (range, 140-310 min) and 293.2 ± 203.1 mL (range, 50-700 mL), respectively. The mean warm ischemic time was 288.4 ± 103.4 seconds (range, 179-610 s). Postoperative complications included chyle leakage in 2 patients who were left kidney donors and oliguria in 1 patient who was a right kidney donor. All patients recovered with conservative care, and the mean hospital stay was 7.5 ± 1.7 days. The mean creatinine level was 0.7 ± 0.2 mg/dL before surgery, 1.1 ± 0.3 mg/dL at postoperative day (POD) 1, and 1.0 ± 0.2 mg/dL after discharge. The mean glomerular filtration rate was 97.9 ± 18.2 mL/min/1.73 m 2 before surgery, 60.7 ± 10.4 at POD 1, and 67.3 ± 11.1 after discharge. Operation time was not associated with patient body mass index and case number. No significant differences, other than postoperative complications, were found in the perioperative data for the side of kidney donation., Conclusion: A skilled surgeon with experience in laparoscopic abdominal surgery (such as gastrectomy or colectomy) might safely perform hand-assisted donor nephrectomy. However, we could not identify a clear case number to complete the learning curve., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Bilobar liver metastasis is challenging for laparoscopic liver resection. Especially, subphrenic liver tumors in S7 or S8 are technically difficult to be resected out because the space is limited and the angle of instruments to lesions cannot be perpendicular. 1,2 Major liver lobectomy is also challenging for laparoscopic liver resection. Glissonian pedicle approach has benefit that any variation of vascular and bile duct elements does not need to be considered in the hepatoduodenal ligament under the hilar plate. Glissonian pedicle approach is simpler and faster than individual dissection of hepatoduodenal ligament., Methods: This video illustrates a hand-assisted laparoscopic left lobectomy and partial liver resection of S8 in a 48-year-old male with metastatic colorectal carcinoma to the liver. He received 6 cycle of FOLFOX as neoadjuvant chemotherapy. The patient was positioned in semi left lateral decubitus so that a lesion in S8 was easily approached. A tumor in S8 was approached after right lobe mobilization. The liver resection was performed by a harmonic scalpel. A 5-mm balloon port was placed in 6th intercostal space to approach the lesion perpendicular. For left hepatectomy, glissonian pedicle approach was applied to control vascular inflow. Dissections was performed at bifurcation on the right glissonian and left glissonian pedicles. Dissection direction to the left side was above hepatogastric ligament. The tunnel was created including all left glissonian sheath, and a vessel loop was taped. An endovascular stapler was inserted and fired with dividing the left glissonian pedicle as en bloc. Hepatic parenchymal dissection was performed by the harmonic scalpel. Left hepatic vein was divided using an endoscopic vascular stapler. The specimens were removed from a hand-port., Results: The operative time was 290 min. Blood loss was 250 ml, and no blood transfusion was required. He resumed a regular diet the next day and was discharged on postoperative day 4., Conclusions: Intercostal approach is useful for subphrenic liver tumors, and glissonian pedicle approach is also useful for major lobectomy for laparoscopic liver resection.

Aim: To compare the results of total laparoscopic distal gastrectomy (TLDG) and laparoscopy-assisted distal gastrectomy (LADG) and explore the safety and feasibility of TLDG., Methods: Data were collected and analyzed from patients underwent TLDG and LADG from January 2009 to December 2011 at our institution., Results: 127 LADG cases and 104 TLDG cases were included and balanced for age, sex, BMI, ASA scores, and CEA level in this study. A decrease in postoperative pain (P < 0.001), wound infection rate (P = 0.013), and hospitalization time after surgery (P < 0.001) was found in the TLDG group. Compared with the LADG group, there was no increase in operative time (P = 0.084), intraoperative blood loss (P = 0.061), or anastomotic fistula rate (P = 0.473). Statistical differences did not exist in recurrence and (or) metastasis (P = 0.204), 5-years disease-free survival (DFS) rate and overall survival (OS) (P = 0.570 and 0.560, respectively)., Conclusion: As long as it follows the surgical principles of malignant tumor, TLDG can achieve the same therapeutic effect as LADG does. TLDG is safe and feasible for gastric cancer patients though further studies are needed., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Today, colorectal surgeons globally are practicing in an exciting era where surgical technologies are constantly emerging. Most of these cutting-edge technologies are readily available in Australia and New Zealand at present. Thus the 'modern surgeon' should always be defined by this open-minded attitude towards these new and emerging surgical technologies. This review article highlights current modalities that we have been using in our north-Brisbane public and private hospitals for cases predicted to be technically challenging using minimally invasive approaches for most of them. We examined the current evidence regarding the following modalities and critiqued their use in clinical practice: lighted ureteric stents, minimally invasive surgery approaches of laparoscopy and robotic surgery, pressure barrier insufflation devices, 3D camera systems, hand-assist device ports and indocyanine green dye fluorescence angiography. The objective of this review paper is to alert colorectal surgeons to new surgical technologies available to them, to encourage colorectal surgeons' familiarization with these many technologies, and to support evidence-based consideration for the clinical use of such. These technologies should be supplemental aides to the safe, oncologically adequate and efficient operation that they already routinely perform., (© 2018 Royal Australasian College of Surgeons.)

BACKGROUND In this study, we analyzed the learning curve of hand-assisted laparoscopic donor nephrectomy (HALDN). MATERIAL AND METHODS The first 198 consecutive donors (110 cases by expert surgeon and 88 cases by newbie surgeon) operated on using HALDN were included in this study. The primary outcome measures were warm ischemic time (WIT), total operation time and estimated blood loss (EBL). The secondary outcome measures included length of hospital stay (LOS), graft outcome, and surgery-related complications. We used the cumulative sum (CUSUM) method to generate learning curves. RESULTS Except for WIT, all operative and convalescence parameters of donors and graft outcomes were similar for the 2 groups, including the total operation time (174.13 minutes vs. 171.75 minutes, P=0.140), EBL (108.27 cc vs. 116.82 cc, P=0.494), LOS (4.80 days vs. 4.92 days, P=0.144), and overall rates of intraoperative and postoperative complications (P>0.05). A significant difference was observed in WIT between the 2 groups (140.59 sec vs. 106.85 sec, P=0.027). Upon visual assessment of the CUSUM plots, a downward inflexion point for decreasing WIT was observed in 4 cases, total operation time in 12 cases, and EBL in 15 cases. CONCLUSIONS HALDN has a relatively short learning curve and similar results may be expected from newbie urologists who are trained in minimally invasive surgery fellowship.

Purpose: Hand-assisted laparoscopic colectomy (HALC) and laparoscopic-assisted colectomy (LAC) have been shown to have comparable short-term outcomes while there are limited data regarding costs. The aim of our study was to compare the short-term outcomes and costs of HALC and LAC., Materials and Methods: In total, 46 patients who underwent HALC or LAC for benign or malignant disease between January 2011 and December 2014 at our institution were included in the study. Patients were randomized into HALC or LAC group. Patients' demographics and characteristics, operative details, short-term outcomes, and costs were evaluated., Results: There were 25 patients in LAC group and 21 patients in HALC group. Patient's demographics and characteristics and short-term outcomes were comparable between the LAC and HALC groups. Conversion rate was significantly lower in the HALC group (4.7% vs. 28%, P=0.03) while surgical costs ($1706.83±203.70 vs. $1304.93±305.67, P=0.038) and total costs ($2427.18±254.27 vs. $2044.03±215.22, P=0.021) were significantly higher in HALC group., Conclusions: HALC is associated with increased surgical and total hospital costs, and decreased rate of conversion. Although it is more expensive, HALC may be helpful by providing a step between LAC and open surgery before considering conversion.

An increasing proportion of patients aged more than 70 years old are suffering from colorectal cancers. This study aimed to compare the short- and long-terms outcomes between open surgery (OS) or conventional laparoscopic surgery (LS) and hand-assisted laparoscopic surgery (HALS) in treatment of these elderly patients with right colon cancers.We retrospectively reviewed patients who underwent right colon resections for cancers in our institution between June, 2009 and December, 2014. Short- and long-terms outcomes including surgical endpoints, postsurgical recovery data, postoperative morbidity and mortality, overall survival and disease-free survival were compared among OS, LS, and HALS groups. All data were analyzed by SPSS 22.0.Finally, 69 consecutive patients (OS = 26, LS = 24, HALS = 19) with right colon cancers were included in the analysis. Compared with OS, HALS was associated with less time to first anus exhaust (P = .013), first liquid diet (P = .045), and first soft diet (P = .036). Meanwhile, there were significant less operative time (P = .0027), blood loss (P < .001), and less time to first liquid diet (P = .009) in HALS, compared with LS. In regards to long-term outcomes, there were no significant differences in overall survival and disease-free survival among the 3 groups.Compared with OS or LS, HALS may be more favorable in the treatment of elderly right colon cancers with decreased surgical time and postoperative recovery, and comparable cancer-specific survivals.

Objective: Although there are several variations of laparoscopic living-donor nephrectomies, there is no consensus as to the best technique. Our objective was to describe our technique and assess the outcomes of our approach to hand-assisted laparoscopic retroperitoneal donor nephrectomies., Methods: From July 2001 to October 2015, 507 consecutive hand-assisted laparoscopic retroperitoneal donor nephrectomies were performed. Their clinical information was retrospectively reviewed including warm ischemia time, skin incision to kidney ready time, estimated blood loss, adverse intraoperative events, and postoperative complications., Results: Mean incision time to kidney removal was 135 minutes (55-260), mean warm ischemia time was 125 seconds (30-390), and mean blood loss was 83 mL (20-500). Average length of stay was 3 days (1-6). There were no significant differences between left and right kidney donors based on demographics, length of hospital stay, or warm ischemia time. There were no conversions to open surgery. Complications occurred in 4.9% of patients (25/507), including 4 cases of perioperative bleeding., Conclusions: This is a single-center series describing the safety and efficacy of the hand-assisted laparoscopic retroperitoneal donor nephrectomy for both right and left sides. It does not require intraperitoneal manipulation and allows for safe extraction of either kidney with minimal warm ischemia time., (© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Living-donor nephrectomy (LDN) is challenging, as surgery is performed on healthy individuals. Minimally invasive techniques for LDN have become standard in most centers. Nevertheless, numerous techniques have been described with no consensus on which is the superior approach. Both hand-assisted retroperitoneoscopic (HARS) and hand-assisted laparoscopic (HALS) LDNs are performed at Zurich University Hospital. The aim of this study was to compare these two surgical techniques in terms of donor outcome and graft function., Method: Retrospective single-center analysis of 60 consecutive LDNs (HARS n = 30; HALS n = 30) from June 2010 to May 2012, including a one-year follow-up of the recipients., Results: There was no mortality in either group and little difference in the overall complication rates. Median warm ischemia time (WIT) was significantly shorter in the HARS group. The use of laxatives and the incidence of postoperative vomiting were significantly greater in the HALS group. There was no difference between right- and left-sided nephrectomies in terms of donor outcome and graft function., Conclusions: Both techniques appear safe for both donors and donated organs. The HARS technique is associated with a shorter WIT and a reduced incidence of postoperative paralytic ileus. Therefore, we consider HARS LDN a valuable alternative to HALS LDN.

Background: Continuous efforts to reduce the numbers and size of incisions led to the emergence of a new technique, single-incision laparoscopic surgery (SILS). It has been rapidly accepted as the preferred surgical approach in the colorectal area. In the age of SILS, what is the role of hand-assisted laparoscopic surgery (HALS)? We introduce the way to take advantage of it, as an effective alternative to avoid open conversion., Methods: This is a retrospective review of prospectively collected data of SILS colectomies performed by a single surgeon in Samsung Medical Center between August 2009 and December 2012., Results: Out of 631 cases of SILS colectomy, 47 cases needed some changes from the initial approach. Among these, five cases were converted to HALS. Four of them were completed successfully without the need for open conversion. One patient with rectosigmoid colon cancer invading bladder was finally opened to avoid vesical trigone injury. The mean operation time of the 4 patients was 265.0 minutes. The mean estimated blood loss was 587.5 mL. The postoperative complication rate associated with the operation was 25%., Conclusions: Conversion from SILS to HALS in colorectal surgery was feasible and effective. It seemed to add minimal morbidity while preserving advantages of minimally invasive surgery. It could be considered an alternative to open conversion in cases of SILS, especially when the conversion to conventional laparoscopy does not seem to be helpful.

Adrenal cysts are not common and are most often non-functional and asymptomatic. Most of these cysts are found incidentally. These lesions exhibit a broad histomorphologic spectrum and may vary from benign cysts to malignant cystic neoplasms. Our patient was a 21-year male who presented with abdominal discomfort and epigastric pain and was diagnosed with left adrenal cyst on ultrasound, which was later confirmed by CT scan.

Background: Hand-assisted laparoscopic nephrectomy (HALDN) is currently the procedure of choice for obtaining living donor kidneys for transplantation. In our institution, it has been the standard procedure for 5 years. Previous studies have shown the same function of the graft as that obtained by open surgery, with a lower rate of bleeding and no differences in complications. We sought to demonstrate the experience and safety of HALDN compared with open donor nephrectomy in healthy donors for kidney transplantation., Methods: A retrospective analytical observational study was conducted, reviewing the records of the living donors for kidney transplant undergoing open donor nephrectomy or HALDN in our center from March 1, 2009, to March 1, 2016. Renal function was assessed by the estimated glomerular filtration rate by the Modification of Diet in Renal Disease method before and after donation, as well as bleeding (mL), and complications (according to Clavien), performing a comparative analysis between the two techniques using parametric or nonparametric tests., Results: A total of 179 living donor nephrectomies were performed during the study period-31 open donor nephrectomy (17.3%) and 148 HALDN (82.7%)-without relevant baseline differences, except for creatinine. HALDN has a shorter surgical time (156,473 ± 87.75 minutes vs 165,484 ± 69.95 minutes) and less bleeding (244.59 ± 416.08 mL vs 324.19 ± 197.986 mL) and a shorter duration of hospital stay (3.74 ± 1.336 days vs 4.75 ± 1.226 days). There were no significant differences in surgical complications at 30 days, or graft loss reported; there were 3 conversions (1.7%) from the HALDN to the open technique. There were no differences in renal function in the donors or recipients at the 5th day or the month after surgery., Conclusions: Laparoscopic nephrectomy has replaced open surgery as the gold standard for living kidney donors. HALDN is a safe and feasible procedure when compared with open donor nephrectomy, achieving a shorter surgical time with less bleeding, and no difference in the number of complications. This procedure lowers costs by decreasing the duration of the hospital stay, making is feasible to perform it at any institution with appropriately trained personnel., (Copyright © 2017 Elsevier Inc. All rights reserved.)

This study undertook the in vivo measurement of surface pressures applied by the fingers of the surgeon during typical representative retraction movements of key human abdominal organs during both open and hand-assisted laparoscopic surgery. Surface pressures were measured using a flexible thin-film pressure sensor for 35 typical liver retractions to access the gall bladder, 36 bowel retractions, 9 kidney retractions, 8 stomach retractions, and 5 spleen retractions across 12 patients undergoing open and laparoscopic abdominal surgery. The maximum and root mean square surface pressures were calculated for each organ retraction. The maximum surface pressures applied to these key abdominal organs are in the range 1 to 41 kPa, and the average maximum surface pressure for all organs and procedures was 14 ± 3 kPa. Surface pressure relaxation during the retraction hold period was observed. Generally, the surface pressures are higher, and the rate of surface pressure relaxation is lower, in the more confined hand-assisted laparoscopic procedures than in open surgery. Combined video footage and pressure sensor data for retraction of the liver in open surgery enabled correlation of organ retraction distance with surface pressure application. The data provide a platform to design strategies for the prevention of retraction injuries. They also form a basis for the design of next-generation organ retraction and space creation surgical devices with embedded sensors that can further quantify intraoperative retraction forces to reduce injury or trauma to organs and surrounding tissues.

Pancreatic mucinous cystic neoplasms (MCNs) are rare tumors typically of the distal pancreas that harbor malignant potential. Although resection is recommended, data are limited on optimal operative approaches to distal pancreatectomy for MCN. MCN resections (2000-2014; eight institutions) were included. Outcomes of minimally invasive and open MCN resections were compared. A total of 289 patients underwent distal pancreatectomy for MCN: 136(47%) minimally invasive and 153(53%) open. Minimally invasive procedures were associated with smaller MCN size (3.9 vs 6.8 cm; P = 0.001), lower operative blood loss (192 vs 392 mL; P = 0.001), and shorter hospital stay(5 vs 7 days; P = 0.001) compared with open. Despite higher American Society of Anesthesiologists class, hand-assisted (n = 46) had similar advantages as laparoscopic/robotic (n = 76). When comparing hand-assisted to open, although MCN size was slightly smaller (4.1 vs 6.8 cm; P = 0.001), specimen length, operative time, and nodal yield were identical. Similar to laparoscopic/robotic, hand-assisted had lower operative blood loss (161 vs 392 mL; P = 0.001) and shorter hospital stay (5 vs 7 days; P = 0.03) compared with open, without increased complications. Hand-assisted laparoscopic technique is a useful approach for MCN resection because specimen length, lymph node yield, operative time, and complication profiles are similar to open procedures, but it still offers the advantages of a minimally invasive approach. Hand-assisted laparoscopy should be considered as an alternative to open technique or as a successive step before converting from total laparoscopic to open distal pancreatectomy for MCN.

Objective: The objective of this study is to systematically assess the clinical efficacy of hand-assisted laparoscopic surgery (HALS) and laparoscopic right colectomy (LRC)., Methods: The randomized controlled trials (RCTs) and non-RCTs were collected by searching electronic databases (Pubmed, Embase, and the Cochrane Library). The outcomes included intraoperative outcomes, postoperative outcomes, postoperative morbidity, and oncologic outcomes. Meta-analysis was performed using of RevMan 5.3 software., Results: A total of five studies involving 438 patients were finally included, with 202 cases in HALS group and 236 cases in LRC group. Results of meta-analysis showed that there was no statistical difference between HALS and LRC in terms of conversion rate, length of hospital stay, reoperation rate, postoperative morbidity, and oncologic outcomes. The operative time was 6.5 min shorter in HALS group; however, it was not a clinically significant difference. Although the incision length was longer in HALS, it did not influence the postoperative recovery., Conclusions: HALS can be considered an alternative to LRC which combines the advantages of open as well as laparoscopic surgery.

Background: The rates of thoracoscopic esophagectomy performed in the prone and left lateral decubitus positions are similar in Japan. We retrospectively reviewed short- and long-term outcomes of thoracoscopic esophagectomy for esophageal cancer performed in the left lateral decubitus position., Methods: Between 1996 and 2015, 654 patients with esophageal cancer underwent thoracoscopic esophagectomy in the left lateral decubitus position. Patients were divided into early (1996-2008) and late groups (2009-2015, with standardization of the procedure and formalized training), and their clinical outcomes reviewed., Results: The completion rate of thoracoscopic esophagectomy was 99.5%, and the procedure was converted to thoracotomy in three patients, due to hemorrhage. The mean intrathoracic operative time, intrathoracic blood loss, and number of dissected mediastinal lymph nodes were 205.0 min, 127.3 mL, and 24.7, respectively. Postoperative complications included pneumonia (8.5%), anastomotic leakage (7.5%), and recurrent nerve paralysis (3.5%). Postoperative (30d) mortality was 4/654 (0.61%) due to anastomotic leak and pneumonia. The five year overall survival rate was 70%. A comparison of the 289 early- and 365 late-study period cases revealed significant differences in mean intrathoracic blood loss (174.0 vs. 94.2 mL), number of mediastinal lymph nodes dissected (20.0 vs. 28.4), hospital length of stay (33.4 vs. 20.0 days, p < 0.001), and postoperative anastomotic leakage (14% vs. 1.6%, p < 0.0001)., Conclusions: Standardization of the procedure for thoracoscopic esophagectomy in the left lateral decubitus position, with a standardized clinical pathway for perioperative care led to significant improvements in surgical outcomes.

Purpose: To analyze the outcomes of j-pouch and side-to-end anastomosis in rectal cancer patients treated with laparoscopic hand-assisted low anterior resection., Methods: Prospective trial on cases randomized to have a colonic j-pouch or a side-to-end anastomosis after low anterior resection. Demographics, characteristics of disease and treatment, perioperative results, and functional outcomes and life quality were compared between the groups., Results: Seventy four patients were randomized. Reservoir creation was withdrawn in 17 (23%) patients, mostly related to reach problem (n = 11, 64.7%). Anastomotic leakage rate was significantly higher in j-pouch group (8 [27.6%] vs. 0, p = 0.004). Stoma closure could not be achieved in 16 (28.1%) patients. Life quality and functional outcomes, measured 4, 8 and 12 months after the stoma reversal, were similar., Conclusions: Colonic j-pouch and side-to-end anastomosis are similar regarding perioperative measures including operation time, rates of postoperative complications, reoperation and 30-day mortality, and hospitalization period except anastomotic leak rate, which is higher in j-pouch group. Postoperative aspects are not different in patients receiving either technique including functional outcomes and life quality for the first year after stoma closure. In our opinion, both techniques may be preferred during the daily practice while performing laparoscopic surgery; but surgeons may be aware of a possibly higher anastomotic leak rate in case of a j-pouch., (Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Patients with hepatocellular adenomas are, in selected cases, candidates for liver resection, which can be approached via laparoscopy or laparotomy. The present study aimed to investigate the effects of the surgical approach on the postoperative morbidities of both minor and major liver resections., Methods: In this multi-institutional study, all patients who underwent open or laparoscopic hepatectomies for hepatocellular adenomas between 1989 and 2013 in 27 European centers were retrospectively reviewed. A multiple imputation model was constructed to manage missing variables. Comparisons of both the overall rate and the types of complications between open and laparoscopic hepatectomy were performed after propensity score adjustment (via the standardized mortality ratio weighting method) on the factors that influenced the choice of the surgical approach., Results: The laparoscopic approach was selected in 208 (38%) of the 533 included patients. There were 194 (93%) women. The median age was 38.9 years. After the application of multiple imputation, 208 patients who underwent laparoscopic operations were compared with 216 patients who underwent laparotomic operations. After adjustment, there were 20 (9.6%) major liver resections in the laparoscopy group and 17 (7.9%) in the open group. The conversion rate was 6.3%. The two surgical approaches exhibited similar postoperative morbidity rates and severities. Laparoscopic resection was associated with significantly less blood loss (93 vs. 196 ml, p < 0.001), a less frequent need for pedicle clamping (21 vs. 40%, p = 0.002), a reduced need for transfusion (8 vs. 24 red blood cells units, p < 0.001), and a shorter hospital stay (5 vs. 7 days, p < 0.001). The mortality was nil., Conclusions: Laparoscopy can achieve short-term outcomes similar to those of open surgery for hepatocellular adenomas and has the additional benefits of a reduced blood loss, need for transfusion, and a shorter hospital stay.