Controversies in Laparoscopic Surgery

Triumphs and Controversies in Laparoscopy: The Past, the Present, and the Future
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Additionally, this study excluded RCT studies performed for simulation and training purposes. Cochrane Review Manager version 5. In addition to bias assessments on individual RCT evidence, publication biases were visually assessed based on funnel plots. When extracting the numerical information from original articles, some do not report, for example, the standard deviations.

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If the relevant numerical values are missing from the original articles but reported in the meta-analysis, we copied the values from the corresponding meta-analysis. Otherwise, a request was sent to the corresponding author for the missing data. If the requested information was not available or was not received within 30 days after the request date, we imputed the missing standard deviations by taking the median value of the included studies [ 22 ]. If an article did not explicitly describe the method used to measure operative time, we regarded it as Total-OT.

However, if an article distinguishes Total-OT from pure procedural time by, for example, skin-to-skin operative time, we treated it as Net-OT in this study. If an original article explicitly described whether the reported number of complications referred to either intra-operative or post-operative complication rates, we specifically reflected this. However, if the author did not make this distinction, we entered the number into the total complication rate Total-Cx. In addition, Total-Cx was assumed to be the sum of intra-operative complication rate Intra-Cx and post-operative complication rate Post-Cx , unless the original article [ 23 ] reported values for Intra-Cx and Post-Cx that did not add up to the reported Total-Cx.

The operative costs were divided by 1,, since the forest plot of Cochrane Review Manager software does not seem to visually handle values greater than 1, However, the Z-values before and after the division by 1, were found to be the same numerically. If the operative costs were reported in currency other than US dollars, we indicated their currency.

After reviewing the titles, abstracts, and full texts, 27 published studies [ 23 — 49 ] met all inclusion criteria and were included in the meta-analysis. This study attempted to screen leniently and perform a full-text search whenever possible in order to more confidently determine whether to include or exclude studies and extract information necessary for meta-analysis [ 50 ].

Among the 27 RCT studies, with a mean sample size of 65 patients per study With respect to gastrointestinal reconstruction studies, after gastrectomy, Sanchez et al. We had difficulty determining the number of patients allocated to RLS and CLS from one hysterectomy study [ 23 ], therefore the number of patients was taken from its meta-analysis [ 7 ]. Nakadi et al. For this study we chose to enter the latter as Cost, since the authors seemed to suggest that this was a more reasonable representation of the total robotic surgery cost.

Three studies [ 38 — 40 ] reported Cost in Euros. Bias assessments of RCTs in previous reviews [ 1 , 16 — 18 , 51 — 56 ] differed according to the judgements of the authors reviewing the same studies. Bias assessments of RCTs in previous reviews have been typically performed in terms of random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other biases.

This kind of discrepancy could be found frequently among meta-analyses. Thus, our quality assessments Fig 2 were performed rather conservatively with a blank space for denoting unclear risk in consideration of previous assessments [ 1 , 16 — 18 , 51 — 56 ].

The risk of bias in the RCT was high and unclear overall. Bias assessments of RCTs were performed in terms of random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other biases. Comparison of RLS and CLS with respect to A total operative time, B net operative time, C total operative cost, D estimated blood loss, E blood transfusion, F length of hospital stay, G conversion, H total complication, I intra-operative complication, and J post-operative complication.

OR: odds ratio; WMD: weighted mean difference. Publication bias was assessed by funnel plots between the two groups. The funnel plots showed symmetric distributions indicating no evidence of publication bias among the studies S1 Fig. This review provides a comprehensive comparison between RLS and CLS based on RCT studies in order to investigate the general trend of treatment outcomes for the controversial aspects of these approaches. Besides, the forest plots with subgroup analysis provide necessary information not only to investigate the comparison of treatment outcomes from the unique properties of the particular surgical procedure, but also to facilitate a more combined discussion from experts across various surgical procedures.

From the statistical findings, it is concluded that despite its higher cost, RLS does not result in statistically improved treatment outcomes, with the exception of a lower EBL. Xiong et al. Clinical heterogeneity introduced by integrating various surgical procedures may contribute to the deviation from previous meta-analyses findings, presumably reflecting the intrinsic properties of each surgical procedure such as retroperitoneal involvement of prostatectomy [ 58 ].

The subgroup analyses favoring RLS on Conv on colectomy and LOHS on hysterectomy could be reasoned in association with properties of surgical robotics as follows: Lin et al. Ran et al. Chuan et al. Regarding Conv, surgeons might try a new surgical technology on a relatively less complicated surgery, which possibly distorts the outcome and results in inconsistent statistical significance.

Thus, in consideration of the level of difficulties encountered in different surgeries, it may remain to be seen whether Conv would support RLS when more data are accumulated. The present study stems from the motivation to contribute to the advancement in meta-analysis on surgical robotics by listing the limitations, followed by preliminary suggestions, if possible.

The main cause of this confusion lies in the absence of standard ways of comparing operative time between the two groups. Some articles do not explicitly describe specifically how the RLS operative time—which can be broken into several pieces such as skin-to-skin, robot set-up time, etc. These differences in terminology create additional difficulties in identifying the actual operative time. Secondly, the difference of indications across studies could have resulted in the inclusion of patients from each study variable.

For example, in addition to the apparent discrepancy between the patient's conditions and clinical indications, not all the critical criteria of one study [ 58 ] could be possibly matched and compared against those of another study [ 47 ], due to insufficient information. Thus, please be aware of the limitation imposed by heterogeneities, which diminished the significance of the statistical results of weighing advantages and disadvantages. Thirdly, none of the studies evaluated the degree of surgeon proficiency between RLS and CLS in the face of a new technology like robotics with an established technology like laparoscopy.

According to Finkelstein et al. In this regard, it may be worth taking into account surgeon experience, for example, number of surgeries, before comparing other aspects of a surgery.

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Finally, whenever standard deviations were not available, imputations of the standard deviations were conducted. It is proposed that future studies should be encouraged to report standard deviations whenever possible. A total operative time, B net operative time, C total operative cost, D estimated blood loss, E blood transfusion, F length of hospital stay, G conversion, H total complication, I intra-operative complication, and J post-operative complication.

Browse Subject Areas? Click through the PLOS taxonomy to find articles in your field. Abstract Importance This review provides a comprehensive comparison of treatment outcomes between robot-assisted laparoscopic surgery RLS and conventional laparoscopic surgery CLS based on randomly-controlled trials RCTs. Objectives We employed RCTs to provide a systematic review that will enable the relevant community to weigh the effectiveness and efficacy of surgical robotics in controversial fields on surgical procedures both overall and on each individual surgical procedure.

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Conclusions Despite higher operative cost, RLS does not result in statistically better treatment outcomes, with the exception of lower estimated blood loss. Introduction Although conventional laparoscopic surgery CLS allows more rapid postoperative recovery and has superior cosmetic outcomes compared with open laparotomy, CLS has several technical drawbacks [ 1 ] including a limited range of motion of instruments and related loss of dexterity, fixed instrument tips, and an inadequate visual field associated with an unstable camera view and assistant traction [ 2 ].

Materials and methods Identification of studies A systematic review of the literature was conducted by electronic search to find RCT studies with date of publication from to inclusively on PubMed, EMBASE, and Cochrane databases with the following search strategy: mention at least one of robot, robotic, robotics, robotically, robot-assisted, robotic-assisted and, at the same time, at least one of laparoscopic, laparoscopy, laparoscope, since both RLS and CLS should be discussed; RCT evidence with a keyword of at least one of randomized, randomised, random, and RCT.

Eligibility criteria The criteria for eligibility of evidence were as follows: the original article should present a RCT comparison between RLS and CLS in human subjects with basic demographic information, including at least one of the following aspects: total operative time Total-OT , net operative time Net-OT , estimated blood loss EBL , number of transfusions Transf , conversion rate Conv , total complication rate Total-Cx , intra-operative complication rate Intra-Cx , post-operative complication rate Post-Cx , length of hospital stay LOHS , and total operative costs Cost.

Handling operative outcomes When extracting the numerical information from original articles, some do not report, for example, the standard deviations. Gravid patients with antiphospholipid syndrome [] , hereditary spherocytosis [] , and autoimmune thrombocytopenia purpura [, , ] have undergone laparoscopic splenectomy with good outcomes for mother and fetus. Several cases of laparoscopic nephrectomy during pregnancy have been reported without complications [].

Given the paucity of data on laparoscopic solid organ exploration in pregnant patients, each case should be individualized.

Why is laparoscopic surgery done?

If solid organ operation can be delayed until after parturition, it should be. Pathologic surgical conditions of the adrenal gland, kidney, and spleen that are endangering a mother or fetus should be attempted laparoscopically. Guideline Laparoscopy is a safe and effective treatment in gravid patients with symptomatic ovarian cystic masses. Observation is acceptable for all other cystic lesions provided ultrasound is not concerning for malignancy and tumor markers are normal. Most of these adnexal masses discovered during the first trimester are functional cysts that resolve spontaneously by the second trimester [].

Recent literature supports the safety of close observation in these patients when ultrasound findings are not concerning for malignancy, tumor markers CA, LDH are normal, and the patient is asymptomatic [, ].

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In the event that surgery is indicated, various case reports support the use of laparoscopy in the management of adnexal masses in every trimester []. Laparoscopy is the preferred method of both diagnosis and treatment in the gravid patient with adnexal torsion [, , ]. Multiple case reports have confirmed safety and efficacy of laparoscopy for adnexal torsion in pregnant patients [].

If diagnosed before tissue necrosis, adnexal torsion may be managed by simple laparoscopic detorsion []. However, with late diagnosis of torsion adnexal infarction may ensue, which can result in peritonitis, spontaneous abortion, preterm delivery and death [, ].

Current Controversies in Laparoscopic Cholecystectomy: A Roundtable Discussion

The gangrenous adnexa should be completely resected [] and progesterone therapy initiated after removal of the corpus luteum, if less than 12 weeks gestation []. While intraoperative fetal heart rate monitoring was once thought to be the most accurate method to detect fetal distress during laparoscopy, no intraoperative fetal heart rate abnormalities have been reported in the literature [90, ].

Preoperative and postoperative monitoring of the fetal heart rate for a fetus considered viable is the current standard, with no increased fetal morbidity having been reported [91, 93, ]. The current lower limit of viability is between 22 weeks and 24 weeks [, ]. Threatened preterm labor can be successfully managed with tocolytic therapy. The specific agent and indications for the use of tocolytics should be individualized and based on the recommendation of an obstetrician []. No literature supports the use of prophylactic tocolytics [, ].

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Controversies in Laparoscopic Surgery. MICHEL GAGNE, AHMAD ASSALIA, MOSHE SCHEIN EXTENT P/H p, hardback. PRICE/ISBN £ Allow me today to summarize some of the developmental triumphs and political roadblocks of laparoscopic surgery and to share with you my thoughts regarding .

More data have accumulated recently as laparoscopy has become common during pregnancy. Most of the data are found in case series and retrospective reviews that limit the ability to provide definitive recommendations. There are no prospective comparative studies that evaluate common abdominal conditions during pregnancy, such as cholelithiasis and appendicitis. Further controlled clinical studies are needed to clarify these guidelines, and revision may be necessary as new data appear. The current recommendations for laparoscopy during pregnancy are:.

BMJ ; These recommendations will be based on existing data or a consensus of expert opinion when little or no data are available. Guidelines are applicable to all physicians who address the clinical problem s without regard to specialty training or interests, and are intended to indicate the preferable, but not necessarily the only acceptable approaches due to the complexity of the healthcare environment. Guidelines are developed under the auspices of the Society of American Gastrointestinal and Endoscopic Surgeons and its various committees, and approved by the Board of Governors.

Each clinical practice guideline has been systematically researched, reviewed and revised by the guidelines committee, and reviewed by an appropriate multidisciplinary team. Each guideline is scheduled for periodic review to allow incorporation of pertinent new developments in medical research knowledge, and practice. Healthy Sooner: Patient Information. Skip to primary navigation Skip to main content Skip to footer Guidelines for the Use of Laparoscopy during Pregnancy. Disclaimer Guidelines for clinical practice are intended to indicate preferable approaches to medical problems as established by experts in the field.

Literature Review Methodology This is an update of the guideline that was published in April [1] and whose scope included literature through December Keywords Laparoscopy, pregnancy, appendectomy, cholecystectomy, splenectomy, adrenalectomy, MRI, CT scan, ultrasound, radiation, ERCP, MRCP, ultrasound, choledocholithiasis, safety, positioning, monitoring, trimester Study types Randomized trials, meta-analyses, systematic reviews, prospective, retrospective, editorials, case series, existing and past guidelines Dates of review October to March articles that were published during the search period were identified.

Introduction Approximately 1 in women will require non-obstetrical abdominal surgery during pregnancy []. Other conditions that may require operations during pregnancy include ovarian cysts, masses or torsion, symptomatic cholelithiasis, adrenal tumors, splenic disorders, symptomatic hernias, complications of inflammatory bowel diseases, and other rare conditions Over two decades ago, some argued that laparoscopy was contraindicated during pregnancy due to concerns for uterine injury from trocar placement and fetal malperfusion due to pneumoperitoneum.