Laparoscopic and robot-assisted laparoscopic digestive surgery: Present and future directions

Laparoscopic surgery is applied today worldwide to most digestive procedures. In some of them, such as cholecystectomy, Nissen’s fundoplication or obesity surgery, laparoscopy has become the standard in practice. In others, such as colon or gastric resection, the laparoscopic approach is frequently used and its usefulness is unquestionable. More complex procedures, such as esophageal, liver or pancreatic resections are, however, more infrequently performed, due to the high grade of skill necessary. As a result, there is less clinical evidence to support its implementation. In the recent years, robot-assisted laparoscopic surgery has been increasingly applied, again with little evidence for comparison with the conventional laparoscopic approach. This review will focus on the complex digestive procedures as well as those whose use in standard practice could be more controversial. Also novel robot-assisted procedures will be updated

Novel Insights into the Treatment of Complicated Diverticulitis

In this thesis, novel insights into the treatment of the different entities of complicated diverticulitis are described. Moreover, results of research into the treatment and incidence of stoma-related complications are presented

New Approaches to the Surgical Treatment of Intra-abdominal Infection

Buikpijn is een veel voorkomende reden van presentatie op de spoedeisende hulp. In ongeveer de helft van de gevallen betreft het buikpijn ten gevolge van een infectie. Een dergelijke infectie kan aanleiding geven tot peritonitis; inflammatoire reactie van het lichaam binnen het abdomen. Dit proefschrift richt zich op de behandeling van intra-abdominale infecties en complicaties volgend op intra-abdominale infecties. Een van de meest voorkomende oorzaken van abdominale infecties is diverticulitis. Divertikel ziekte leidt in Nederland tot 18.000 ziekenhuisopnames per jaar. De ziekte komt voor in verschillende verschijningen: van asymptomische diverticulose tot geperforeerde diverticulitis met systemische sepsis. Om een goede inschatting van de ernst van de ziekte te kunnen maken wordt in de meeste patiënten verdacht voor diverticulitis aanvullend onderzoek verricht. De eerste keus is hierbij echografisch onderzoek. Indien deze niet conclusief is of verdacht voor gecompliceerde diverticulitis wordt een CT-scan geadviseerd. Classificatie van de ernst van de ziekte op basis van de Hinchey classificatie blijkt een diagnostische accuraatheid tussen de 71 en 92% te hebben. Daarom adviseren wij een nieuw gradatie systeem om richting te geven aan de behandeling van diverticulitis. De chirurgische behandeling van diverticulitis bestaat van oudsher uit een sigmoidresectie met eindstandig colostoma of met directe anastomose. Een minder invasieve behandeling middels laparoscopische lavage (spoelen van de buikholte) is onderzocht in de gerandomiseerde Ladies trial. In de LOLA arm werd de laparoscopische lavage vergeleken met een sigmoidresectie. Deze studie toonde dat er geen voordeel is van lavage op het primaire eindpunt van ernstige morbiditeit en mortaliteit. In geval van geperforeerde diverticulitis is er een verhoogde kans op ontwikkelen van hernia cicatricalis. In enkele dierexperimenten werden synthetische en biologische meshes onderzocht op infectieuze complicaties, adhesie vorming en ingroei na implantatie in schone en gecontamineerde omgeving. Er werden significant meer mesh infecties gevonden na implantatie van gecrosslinkte biomeshes en de synthetische meshes C-Qur en Dualmesh. Ingroei van biologische meshes in de buikwand varieerde tussen de 0 en 39%. Opvallend was de complete verdwijning van Surgisis meshes. De slechte ingroei, hoge percentage meshinfecties en complete verdwijning maakt lange termijn biomechanische kracht van hernia herstel met behulp van biologische meshes twijfelachtig

Individualized laparoscopic and related technique in rectal cancer surgery

[Extract from Preface] The main studies listed in each chapter were carefully selected as to reflect the critical knowledge essential in each of the important steps to overcome the main challenges toward the success in achieving the best possible outcomes in rectal cancer patient care. However, the main original contribution of the thesis was demonstrated clearly in "Chapter 3: Laparoscopic surgery for rectal cancer" where the proposed laparoscopic pull-through with coloanal anastomosis was highlighted. The chapter showed a prospective comparative study comparing all aspects of the two techniques; laparoscopic ultralow anterior resection versus laparoscopic pull-through with coloanal anastomosis for rectal cancers. All the published studies involved in each chapter of the thesis were carefully illustrated in their original format with my great respect to the international peer-review. Nevertheless, each chapter contained the overview aiming to state the connectivity of the ideas for each specific detail contained in each chapter. Despite the fact that the majority of the studies were conducted in high-volume, specialized centers, it was a real challenge to organize prospective studies for highly specific research questions over the limited time of my doctorate degree study. Chapter Overview. Chapter 1: Introduction. This chapter described the context of this research; why rectal cancer treatment is challenging; impact of multidisciplinary treatment on the outcomes. Chapter 2: Overview in colorectal cancer treatment. To review of role of various treatment modalities and variations to optimise both short-term and long-term outcomes; Hiranyakas A, Yik Hong H. Surgical Treatment of Colorectal Cancer – a Review. Int Surg. 2011; 96(2):120-6. Chapter 3: Laparoscopic surgery for rectal cancer. To discuss and propose appropriate laparoscopic techniques / approaches in the challenging surgical conditions to achieve the best possible outcomes; Hiranyakas A, Yik Hong H. Laparoscopic Ultralow Anterior Resection Versus Laparoscopic Pull-through with Coloanal Anastomosis for Rectal Cancers – a Comparative Study. Am J Surg. 2011; 202(3):291-7. Chapter 4: Factors influencing rectal cancer treatment outcomes. To discuss and propose the factors influencing the optimal outcomes for rectal cancer treatment; Hiranyakas A, Yik-Hong H, da Silva, GM, Wexner SD, Allende D, Berho M. Factors Influencing Circumferential Resection Margin in Rectal Cancer. Colorectal Dis. 2013 ;15(3):298-303. Chapter 5: Technique to avoid postsurgical complication. To discuss and propose surgical techniques essential in avoiding serious postsurgical consequences; Hiranyakas A, da Silva GM, Denoya P, Shawki S, Wexner SD. Colorectal Anastomotic Stricture: Is it associated with inadequate Colonic Mobilization? Tech Coloproctol. 2013 ;17(4):371-5. Chapter 6: Protocols for rapid recovery. To discuss in depth for the appropriate immediate postsurgical-care protocols to achieve the smooth and rapid recovery (among the most common diseased population); Hiranyakas A, Bashankaev B, Seo CJ, Khaikin M, Wexner SD. Epidemiology, Pathophysiology and Medical Management of Postoperative Ileus in the Elderly. Drugs Aging. 2011; 28(2):107- 18. Chapter 7: Closure of the ileostomy. To discuss and propose the necessity of certain surgical procedures to enhance optimal immediate postsurgical outcomes in low rectal cancer patients; Hiranyakas A, Rather A, da Sliva GM, Wexner SD, Weiss EG. Loop ileostomy Closure after Laparoscopic vs. Open Surgery: Is There a Difference? Surg Endosc. 2013 ;27(1):90-4. Chapter 8: Treatment of common stomal complication. To discuss and propose minimally invasive surgical approaches in the treatment of the common stomal consequence; Hiranyakas A, Yik Hong H. Laparoscopic Parastoma Hernia Repair, Multi-media Article. Dis Colon Rectum 2010; 53(9):1334-6. Chapter 9: Conclusion, outcomes and future research directions. This chapter gives the conclusions from the studies and proposes future research directions

Mixed Reality Annotation of Robotic-Assisted Surgery videos with real- time tracking and stereo matching

Robotic-Assisted Surgery (RAS) is beginning to unlock its potential. However, despite the latest advances in RAS, the steep learning curve of RAS devices remains a problem. A common teaching resource in surgery is the use of videos of previous procedures, which in RAS are almost always stereoscopic. It is important to be able to add virtual annotations onto these videos so that certain elements of the surgical process are tracked and highlighted during the teaching session. Including virtual annotations in stereoscopic videos turns them into Mixed Reality (MR) experiences, in which tissues, tools and procedures are better observed. However, an MR-based annotation of objects requires tracking and some kind of depth estimation. For this reason, this paper proposes a real-time hybrid tracking–matching method for performing virtual annotations on RAS videos. The proposed method is hybrid because it combines tracking and stereo matching, avoiding the need to calculate the real depth of the pixels. The method was tested with six different state-of-the-art trackers and assessed with videos of a sigmoidectomy of a sigma neoplasia, performed with a Da Vinci® X surgical system. Objective assessment metrics are proposed, presented and calculated for the different solutions. The results show that the method can successfully annotate RAS videos in real-time. Of all the trackers tested for the presented method, the CSRT (Channel and Spatial Reliability Tracking) tracker seems to be the most reliable and robust in terms of tracking capabilities. In addition, in the absence of an absolute ground truth, an assessment with a domain expert using a novel continuous-rating method with an Oculus Quest 2 Virtual Reality device was performed, showing that the depth perception of the virtual annotations is good, despite the fact that no absolute depth values are calculated

Overcoming Barriers to Natural Orifice Translumenal Endoscopic Surgery (Notes)

Natural Orifice Translumenal Endoscopic Surgery (NOTES) avoids skin incisions by accessing the abdominal cavity through natural orifices. Benefits include less pain, fewer complications and no scars. The aims of this study were to evaluate safety and efficacy of access techniques for natural orifice surgery, to investigate safety and efficacy of closure methodologies and to compare the inflammatory response induced by NOTES with that following conventional surgery. Access techniques were evaluated for safety and efficacy by measuring resultant injury and time required to access the peritoneal cavity in an acute porcine model. Four different gastrotomy closure modalities were evaluated for safety and efficacy by measuring clinical data, evidence of infection and closure integrity in a chronic porcine study. Markers of inflammation were measured in a chronic study comparing NOTES to conventional surgery. 70 anterior transgastric access procedures were performed without any serious injury to adjacent organs. NOTES access required significantly longer than laparoscopic access. Of the seven methods evaluated none was significantly superior to others. In distinguishing between safe and unsafe alternate access sites, endoscopic ultrasound (EUS) provided a statistically significant difference for antral and posterior stomach access points but not for rectal access. Gastrotomy closure time varied widely for the four techniques evaluated. No leak was detected with any method and the strength of closure for each technique was equivalent to control. Three of the four methods resulted in injury and evidence of infection was found in all groups. Postoperative elevation of inflammatory markers was not significantly different between NOTES and laparoscopy except in the case of cortisol, which was greater in the laparoscopic group. This study supports the safety of anterior transgastric access while demonstrating the potential use of EUS in minimizing risks of injury at alternate sites. Likewise, evidence for the reliability o