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Background Laparoscopic liver resection is considered a safe and feasible alternative to open surgery for malignant liver lesions. However, laparoscopic surgery in cirrhotic patients remains challenging. The aim of this retrospective case–control study was to compare morbidity, mortality, and long-term patient survival between laparoscopic liver resections (LLR) and open liver resections (OLR) for hepatocellular carcinoma (HCC) in patients with histologically proven cirrhosis. Methods A total of 45 patients treated with LLR were matched by cause of cirrhosis, Child-Pugh score, type of surgical resection (subsegmentectomy, segmentectomy, and bisegmentectomy), tumor number, tumor size, and alpha-fetoprotein value with 45 patients treated with OLR. Pre-, intra-, and post-operative variables were compared between groups. Results Compared with OLR, the LLR group displayed a significantly shorter operative time (140 vs. 180 min; p  = 0.02), shorter hospital stay (7 vs. 12 days; p  < 0.0001), and lower morbidity rate (20 vs. 45 % of patients; p  = 0.01). A higher rate of R0 resection was observed in the LLR group than in the OLR group (95 vs. 85 %; p  = 0.03). Postoperative ascites was more frequently observed in the OLR group (18 vs. 2 %; p  = 0.01). Mortality, patient, and disease-free survival rates were similar between groups. The 1-, 5-, and 10-year survival rates were 88, 59, and 12 %, respectively, in the LLR group and 63, 44, and 22 % in the OLR group ( p  = 0.27). Conclusions Significantly shorter operative times, better resection margins, lower postoperative complications, and shorter hospital stay were observed in the LLR group compared with the OLR group. LLR and OLR have similar overall and disease-free survival rates in cirrhotic HCC patients.

BackgroundProlonged surgical operative time is associated with postoperative adverse outcomes following total knee arthroplasty (TKA). Increasing operating room efficiency necessitates the accurate prediction of surgical operative time for each patient. One potential way to increase the accuracy of predictions is to use advanced predictive analytics, such as machine learning. The aim of this study is to use machine learning to develop an accurate predictive model for surgical operative time for patients undergoing primary total knee arthroplasty.MethodsA retrospective chart review of electronic medical records was conducted to identify patients who underwent primary total knee arthroplasty at a tertiary referral center. Three machine learning algorithms were developed to predict surgical operative time and were assessed by discrimination, calibration and decision curve analysis. Specifically, we used: (1) Artificial Neural Networks (ANNs), (2) Random Forest (RF), and (3) K-Nearest Neighbor (KNN).ResultsWe analyzed the surgical operative time for 10,021 consecutive patients who underwent primary total knee arthroplasty. The neural network model achieved the best performance across discrimination (AUC = 0.82), calibration and decision curve analysis for predicting surgical operative time. Based on this algorithm, younger age (< 45 years), tranexamic acid non-usage, and a high BMI (> 40 kg/m2) were the strongest predictors associated with surgical operative time.ConclusionsThis study shows excellent performance of machine learning models for predicting surgical operative time in primary total knee arthroplasty. The accurate estimation of surgical duration is important in enhancing OR efficiency and identifying patients at risk for prolonged surgical operative time.Level of evidenceLevel III, case control retrospective analysis.

Objective This study aims to evaluate the impact of gynecologic oncologists' laparoscopic proficiency on survival outcomes in cervical cancer patients. Methods A cohort of 1,965 cervical cancer cases from four clinical centers in China was analyzed, including abdominal radical hysterectomy (ARH), laparoscopic radical hysterectomy (LRH), and robotic radical hysterectomy (RRH). The median operative time (MOT) for LRH was used as a measure of surgical proficiency. Survival outcomes of ARH vs. LRH were compared in early-stage cervical cancer patients without adjuvant therapy to identify a critical MOT threshold. Below this threshold, no significant differences in prognosis were observed between ARH and LRH. Propensity score matching and mixed-effects Cox regression were used to adjust for baseline risk factors and random effects, validating the finding across all LRH cases. Results The Kaplan–Meier analysis showed that improved prognosis was associated with reduced MOT. When gynecologic oncologists had an MOT within 210 min, LRH vs ARH was no longer a significant risk factor (HR 1.1998; 95% CI: 0.9785–1.4713; p  = 0.07998). Propensity score matching and mixed-effects Cox regression were used to further clarify the significant prognostic differences in LRH performed by different level surgeons. Conclusion MOT reflects surgical efficiency and serves as a key indicator of the operative proficiency of gynecologic oncologists, which is pivotal in determining the survival prognosis of cervical cancer patients undergoing LRH. For surgeons with rigorous laparoscopic training, the survival outcomes of LRH are expected to be comparable to those of ARH.

Introduction Breast hypertrophy, a common pathological condition, often requires surgical intervention to alleviate musculoskeletal pain and improve patients’ quality of life. Various techniques have been developed for breast reduction, each with its own advantages and complications. The primary aim of this study is to evaluate the efficacy, safety, and patient-reported outcomes of the authors technique: the Superomedial-Posterior Pedicle-Based Reduction Mammaplasty. Material and Methods A prospective study was conducted on 912 patients who underwent breast reduction surgery between November 2012 and July 2020. The surgical technique involved preserving all glandular tissue from the areola to the pectoralis major muscle using the superomedial-posterior pedicle. The patients’ demographic data, operative details, complications, breast-related quality of life (measured using the Breast-Q questionnaire), and nipple–areola complex sensitivity were analyzed. Results The average operative time was 62.12 ± 10.3 minutes. Complications included minor wound dehiscence (4.05%) and hematoma (1.2%), with no cases of nipple–areola complex necrosis. Nipple–areola sensitivity was fully restored in all patients at the 2-year follow-up. Patient satisfaction with the procedure was high with a statistically significant difference observed between pre- and postoperative scores ( p < 0.001) of the Breast-Q questionnaire. Conclusion Authors technique offers reliable vascularization and innervation of the nipple–areola complex and achieves satisfactory aesthetic outcomes. It is associated with shorter operative times compared to other techniques reported in the literature. The Superomedial-Posterior Pedicle-Based Reduction Mammaplasty represents a safe and effective method for breast reduction surgery, providing significant benefits to patients with breast hypertrophy. Level of Evidence I This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Background A defunctioning loop ileostomy mitigates the consequences of anastomotic leak from low rectal anastomosis but it is associated with significant morbidity. In this study, the outcome of early reversal of defunctioning ileostomy during the same admission with the primary operation was assessed. Methods This randomized study was carried out at York Teaching Hospital during the period 2003–2007. All patients with defunctioning ileostomy were considered for an early second operation if they had an uneventful recovery and were in good general condition. Patients on steroids, at high cardiorespiratory risk and those experiencing any postoperative complication were excluded. Eligible patients with satisfactory gastrografin enema on postoperative day 6 were randomized to early versus late reversal at 6–8 weeks. Outcome measures were ease of closure as assessed by a visual analog scale by the operating surgeon, all postoperative complications, duration of the operation, total length of hospital stay and associated costs. Results Thirty-nine consecutive patients were assessed for eligibility and finally 26 were included in the study. Sixteen patients underwent early reversal. The median(interquartile range (IQR)) age was 62(22) years. Early reversal was significantly superior in terms of ease of abdominal wall closure, ease of reversal ( p  < 0.01 each), duration of the operation (median(IQR) 20(13) vs. 40(9) min, p  < 0.01) and costs of stoma care (median(IQR) 27(9) vs. 311(108) £, p  < 0.01). There were no major (grade III/IV) complications in either group. Total length of hospital stay was similar between groups. Conclusion In carefully selected patients, early reversal of defunctioning ileostomy is feasible, technically easier and has shorter operative time which can also lead to significant cost savings.

Background The aim of this study was to compare the outcomes of single-site robotic cholecystectomy with multi-port laparoscopic cholecystectomy within a high-volume tertiary health care center. Methods A retrospective analysis of prospectively maintained data was conducted on patients undergoing single-site robotic cholecystectomy or multi-port laparoscopic cholecystectomy between October 2011 and July 2014. A single surgeon performed all the surgeries included in the study. Results A total of 678 cholecystectomies were performed. Of these, 415 (61%) were single-site robotic cholecystectomies and 263 (39%) were multi-port laparoscopic cholecystectomies. Laparoscopic patients had a greater mean BMI (30.5 vs. 29.0 kg/m 2 ; p  = 0.008), were more likely to have undergone prior abdominal surgery (83.3 vs. 41.4%; p  < 0.001) and had a higher incidence of preexisting comorbidities (76.1 vs. 67.2%; p  = 0.014) as compared to the robotic group. There was no statistical difference in the total operative time, rate of conversion to open procedure and mean length of follow-up between the two groups. The mean length of hospital stay was shorter for patients within the robotic group (1.9 vs. 2.4 days; p  = 0.012). Single-site robotic cholecystectomy was associated with a higher rate of wound infection (3.9 vs. 1.1%; p  = 0.037) and incisional hernia (6.5 vs. 1.9%; p  = 0.006). Conclusion Multi-port laparoscopic cholecystectomy should remain the gold standard therapy for gallbladder disease. Single-site robotic cholecystectomy is an effective alternative procedure for uncomplicated benign gallbladder disease in properly selected patients. This must be carefully balanced against a high rate of surgical site infection and incisional hernia, and patients should be informed of these risks.

Background Human factors research has suggested benefits of consistent teams yet no surgical team consistency measures have been established for teamwork improvement initiatives. Methods Retrospective analysis was conducted of teams performing consecutive elective procedures of unilateral primary total knee and hip replacement between June 2008 and May 2010 at a large tertiary medical center. Surgeons who performed fewer than 50 cases of the procedures during the study period were excluded. A team was defined as consistent when its nurse and surgical technologist members were both among the three most frequent working with the surgeon during the study period. Odds ratios for prolonged operative time (in the longest quartile), prolonged hospital stay (longer than median), and 30-day all-cause readmissions were adjusted for patient characteristics (sex, age, comorbidity, American Society of Anesthesiology status), surgery characteristics (procedures, time of day), and surgeons. Results Inconsistent teams performed 61 % of the 1,923 cases with eight surgeons, each of which worked with a median of 43.5 (range, 28–58) nurses and 29 (range, 13–47) technologists. Inconsistent teams were associated with higher likelihood of prolonged operative time [odds ratio 1.52, 95 % confidence interval (CI) 1.20–1.91], higher likelihood of prolonged hospital stay (odds ratio 1.51, 95 % CI 1.23–1.86), and more readmissions (adjusted odds ratio 1.42, 95 % CI 1.07–1.89). Conclusions Team consistency was an independent predictor of prolonged operative time, prolonged hospital stay, and 30-day hospital readmission in elective, primary, unilateral total knee, and hip replacement procedures, after adjusting for patient and surgery characteristics and surgeons.

BackgroundRecently, robot-assisted surgical systems have become more and more popular, but have not been reported in functional minimally invasive radical resection of esophageal cancer,which preserves the mediastinal pleura, the azygos arch, bronchial artery, and pulmonary branch of the vagus nerve.MethodsRetrospective analysis of all patients in our hospital who underwent surgery for esophageal cancer from September 2022 to February 2024. Robot-assisted functional minimally invasive esophagectomy (RAFMIE)was performed for 44 patients who were compared with 66 functional minimally invasive esophagectomy (FMIE) cases.ResultSignificantly, shorter operation time was taken in RAFMIE (222.98 ± 28.02 vs 250.45 ± 30.25 min P < 0.001), thoracic operation time (75.50 ± 14.23 vs 89.59 ± 16.34 min P < 0.001), abdominal operation time (51.93 ± 14.18 vs 71.75 ± 14.85 min P < 0.001). Both groups were equal regarding intraoperative blood loss (82.73 ± 57.23 vs 94.55 ± 60.19 ml, P = 0.286), radical resection (R0) rate (97.73% vs 96.97%, P = 0.813) and total lymph node yield (25.45 ± 7.40 vs 21.03 ± 7.00, P = 0.013). Postoperative hospital stay (9.75 ± 2.23 vs 10.47 ± 2.72, P = 0.402); incidence of postoperative complications (25.76% vs 20.45%, P = 0.519).ConclusionEarly results suggest that RAFMIE is safe and feasible for the treatment of esophageal cancer. The operation time of RAFMIE is shorter than FMIE, and the lymph node dissection results are better. Long-term results need to be further investigated.

We evaluated the association between operating room time and developing a deep vein thrombosis (DVT) or pulmonary embolus (PE) after emergency general surgery (EGS). We reviewed six common EGS procedures in the 2013–2015 NSQIP dataset. After tabulating their incidence of postoperative VTE events, we calculated predictors of developing a VTE using adjusted multivariate logistic regressions. Of 108,954 EGS patients, 1,366 patients (1.3%) developed a VTE postoperatively. The median time to diagnosis was 9 days [5–16] for DVTs and 8 days [5–16] for PEs. Operating room time of 100 min or more was associated with increased risk of developing a DVT (OR 1.30 [1.12–2.21]) and PE (OR:1.25 [1.11–2.43]) with a 7% and 5% respective increase for every 10 min increase after the 100 min. Other independent predictors of VTE complications were older age, and history of cancer, and emergent colectomies on procedure-level analysis. Prolonged operating room time is independently associated with increased risk of developing VTE complications after an EGS procedure. Most of the VTE complications were delayed in presentation. •Operating time of ≥100 min is associated with increased risk of developing a VTE.•Every 10 min thereafter increases the risk of developing a DVT by 7% and PE by 5%.•Other independent predictors of VTE complications were older age and history of cancer.•Emergent colectomies were associated with the highest odds for both DVT and PE.

Objective: To compare the use of Titanium clips and Monopolar diathermy for laparoscopic appendectomy mesoappendix closure in terms of operative time and cost. Study Design: Quasi-experiment study. Place and Duration of Study: Department of Surgery, Combined Military Hospital, Nowshera Pakistan, from Jul 2021 to Jun 2022. Methodology: A total of 70 patients who were diagnosed with acute appendicitis and were admitted for laparoscopic appendectomy were randomly divided into two groups via the lottery method. In Group-A, the closure of the mesoappendix was done using Titanium clips, and in Group-B, the ligation of the mesoappendix was done using Monopolar diathermy. Patient outcomes in terms of operative time and procedure cost were assessed. Results: Out of 70 patients, 49(70.0%) were males and 21(30.0%) were females, aged 18 to 60 years, with a mean age of 37.57±7.71 years. The overall mean weight of the patients was 65.29±12.14 kg; height was 1.71±0.12 metres; and BMI was 24.96±5.23 kg/m2, respectively. Prolonged operative time was observed in 16(45.71%) patients in Group-A, compared to 7(20.0%) in Group-B (p-value 0.022). In Group-A, the total cost of the operation was Rs. 32,000, whereas in Group-B, it was Rs. 30,000 (p-value=0.001). Conclusion: This study concluded that Monopolar diathermy for the closure of the mesoappendix is better in terms of operating time and cost as compared to the use of Titanium clips.