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Surgery has traditionally been the standard of care for the treatment of neoplastic lesions in the gastrointestinal tract. With advances in endoscopic resection techniques, there has been a paradigm shift in how to approach many of these precancerous and early cancerous lesions. Potential advantages of endoscopic resection include its minimally invasiveness which often translates into quicker patient recovery. In recent years, there have been major strides in safety and efficacy of minimally invasive endoscopic approaches with ongoing advances in therapeutic endoscopy. Advanced Techniques for Endoscopic Resection in the GI Tract by Drs. Peter V. Draganov, Takuji Gotoda, and Dennis J. Yang provides an in-depth analysis of the current state of advanced endoscopic techniques for the evaluation and resection in the gastrointestinal tract. Each chapter in the book addresses specific topics such as: endoscopic evaluation of lesions technical aspects of the procedure management of adverse events post-procedural care and follow-up Advanced Techniques for Endoscopic Resection in the GI Tract provides a comprehensive review of all the different aspects of advanced endoscopic resection in the gastrointestinal tract which makes it ideal for interventional GI endoscopists and general gastroenterologists, as well as surgeons.

Background: Despite the superiority of minimal access surgery (MAS) over open surgery, MAS is difficult to perform and has a demanding learning curve. Robot-assisted surgery is an advanced form of MAS. The Versius® surgical robot system was developed with the aim of overcoming some of the challenges associated with existing surgical robots. The present study was designed to investigate the feasibility, clinical safety, and effectiveness of the Versius system in MAS. Materials and Methods: A comprehensive search was carried out in the Medline, Web of Science Core Collection (Indexes = SCI-EXPANDED, SSCI, A & HCI Timespan), and Scopus databases for articles published until February 2022. The keywords used were Versius robot, visceral, colorectal, gynecology, and urologic surgeries. Articles on the use of the Versius robot in minimal access surgery (MAS) were included in the review. Results: Seventeen articles were reviewed for the study. The investigation comprised a total of 328 patients who had been operated on with this robot system, of which 48.3%, 14.2%, and 37.5% underwent colorectal, visceral, and gynecological procedures, respectively. Postoperative and major complications within 30 days varied from 7.4% to 39%. No major complications and no readmissions or reoperations were reported in visceral and gynecological surgeries. Readmission and reoperation rates in colorectal surgeries were 0–9%. Some procedures required conversion to conventional laparoscopic surgery (CLS) or open surgery, and all procedures were completed successfully. Based on the studies reviewed in the present report, we conclude that the Versius robot can be used safely and effectively in MAS. Conclusions: A review of the published literature revealed that the Versius system is safe and effective in minimal access surgery. However, the data should be viewed with caution until randomized controlled trials (RCTs) have been performed. Studies on the use of this robotic system in oncological surgery must include survival as one of the addressed outcomes.

Purpose While research on inguinal hernias is well-documented, ventral/incisional hernias still require investigation. In India, opinions on laparoscopic ventral hernia repair (LVHR) techniques are contested. The current consensus aims to standardize LVHR practice and identify gaps and unfulfilled demands that compromise patient safety and therapeutic outcomes. Methods Using the modified Delphi technique, panel of 14 experts (general surgeons) came to a consensus. Two rounds of consensus were conducted online. An advisory board meeting was held for the third round, wherein survey results were discussed and the final statements were decided with supporting clinical evidence. Results Experts recommended intraperitoneal onlay mesh (IPOM) plus/trans-abdominal retromuscular/extended totally extraperitoneal/mini- or less-open sublay operation/transabdominal preperitoneal/trans-abdominal partial extra-peritoneal/subcutaneous onlay laparoscopic approach/laparoscopic intracorporeal rectus aponeuroplasty as valid minimal access surgery (MAS) options for ventral hernia (VH). Intraperitoneal repair technique is the preferred MAS procedure for primary umbilical hernia < 4 cm without diastasis; incisional hernia in the presence of a vertical single midline incision; symptomatic hernia, BMI > 40 kg/m 2 , and defect up to 4 cm; and for MAS VH surgery with grade 3/4 American Society of Anaesthesiologists. IPOM plus is the preferred MAS procedure for midline incisional hernia of width < 4 cm in patients with a previous laparotomy. Extraperitoneal repair technique is the preferred MAS procedure for L3 hernia < 4 cm; midline hernias < 4 cm with diastasis; and M5 hernia. Conclusion The consensus statements will help standardize LVHR practices, improve decision-making, and provide guidance on MAS in VHR in the Indian scenario.

Background/Aim: We conducted a randomized controlled trial to investigate whether minimally access spine surgery (MASS) is less morbid than open surgery (OS) in patients with metastatic spinal cord compression (MSCC). Patients and Methods: A total of 49 MSCC patients were included in the trial. The outcome measures were bleeding (L), operation time (min), re-operations and prolonged wound healing. Results: The median age was 67 years (range=42-85 years) and 40% were men. The peri-operative blood loss in the MASS-group was significantly lower than that in the OS-group; 0.175L vs. 0.500L, (p=0.002). The median operation time for MASS was 142 min (range=72-203 min) vs. 103 (range=59-435 min) for OS (p=0.001). There was no significant difference between the two groups concerning revision surgery or delayed wound healing. Conclusion: The MASS technique in MSCC patients is associated with less blood loss, but a longer operation time when compared to the OS technique.

Background: Total hysterectomy with bilateral salpingo-oophorectomy via minimally invasive surgery (MIS) has emerged as the standard of care for early-stage endometrial cancer (EC). Prior systematic reviews and meta-analyses have focused on outcomes reported solely from randomised controlled trials (RCTs), overlooking valuable data from non-randomised studies. This inaugural systematic review and network meta-analysis comprehensively compares clinical and oncological outcomes between MIS and open surgery for early-stage EC, incorporating evidence from randomised and non-randomised studies. Methods: This study was prospectively registered on PROSPERO (CRD42020186959). All original research of any experimental design reporting clinical and oncological outcomes of surgical treatment for endometrial cancer was included. Study selection was restricted to English-language peer-reviewed journal articles published 1 January 1995–31 December 2021. A Bayesian network meta-analysis was conducted. Results: A total of 99 studies were included in the network meta-analysis, comprising 181,716 women and 14 outcomes. Compared with open surgery, laparoscopic and robotic-assisted surgery demonstrated reduced blood loss and length of hospital stay but increased operating time. Compared with laparoscopic surgery, robotic-assisted surgery was associated with a significant reduction in ileus (OR = 0.40, 95% CrI: 0.17–0.87) and total intra-operative complications (OR = 0.38, 95% CrI: 0.17–0.75) as well as a higher disease-free survival (OR = 2.45, 95% CrI: 1.04–6.34). Conclusions: For treating early endometrial cancer, minimal-access surgery via robotic-assisted or laparoscopic techniques appears safer and more efficacious than open surgery. Robotic-assisted surgery is associated with fewer complications and favourable oncological outcomes.

Background: Minimal access surgery (MAS) has been on the rise internationally; however, there seems to be limited information regarding research and training in the general and paediatric surgical (GPS) disciplines in South Africa (SA). We performed a scoping review to identify knowledge gaps that will assist us in developing strategies to improve the delivery and training of MAS within the GPS disciplines in SA. Method: The method of the review--2020 JBI guide and PRISMA for scoping reviews. We searched online databases and websites for publications from 1990 to 2022. Interviews were conducted with senior MAS trainers from training sites. Results: Full texts of 194 articles were reviewed. Most publications were related to trauma, followed by laparoscopic appendicectomy and laparoscopic cholecystectomy. Paediatric MAS comprised 11.9% (21), and training was the focus in 4.5% (7) of all the publications. Published limitations regarding MAS included access to training and equipment. Conclusion: This scoping review has summarised the current MAS research and training within the GPS disciplines in SA. We have highlighted the limitations that exist, which can direct the focus of research and training to improve the delivery of MAS within the GPS disciplines. Keywords: laparoscopy, thoracoscopy, laparoscopic surgery, minimal invasive surgery, minimal access surgery, training, South Africa

PurposeThoracoscopic OA/TOF repair was first described in 1999. Currently, less than 10% of surgeons routinely employ minimally access surgery. Our primary aim was to review our immediate-, early- and long-term outcomes with this technique compared with the open approach.MethodsA retrospective review of all patients undergoing primary OA/TOF (Type C) repair at our institution from 2009 was conducted. Outcome measures included length of surgery, conversion rate from thoracoscopy, early complications such as anastomotic leak and post-operative complications such as anastomotic strictures needing dilatations. Fisher’s exact and Kruskal–Wallis tests were used for statistical analysis.Results95 patients in total underwent OA/TOF repair during the study period of which 61 (64%) were completed via an open approach. 34 were attempted thoracoscopically of which 11 (33%) were converted. There was only one clinically significant anastomotic leak in our series that took place in the thoracoscopic group. We identified a significantly higher stricture rate in our thoracoscopic cohort (72%) versus open surgery (43%, P < 0.05). However, the median number of dilations (3) performed was not significantly different between the groups. There was one recurrent fistula in the thoracoscopic converted to open group. Our median follow-up was 60 months across the groups.ConclusionIn our experience, the clinically significant leak rate for both open and thoracoscopic repair as well as recurrent fistula is much lower than has been reported in the literature. We do not routinely perform contrast studies and are, thus, reporting clinically significant leaks only. The use of post-operative neck flexion, ventilation and paralysis is likely to be protective towards a leak. Thoracoscopic OA/TOF repair is associated with a higher stricture rate compared with open surgery; however, these strictures respond to a similar number of dilatations and are no more refractory. Larger, multicentre studies may be useful to investigate these finding further.

This international study aimed to understand, from the perspective of surgeons, their experience of performing minimal access surgery (MAS), to explore causes of discomfort while operating and the impact of poor ergonomics on surgeon welfare and career longevity across different specialties and techniques. A quantitative online survey was conducted in Germany, the UK and the USA from March to April 2019. The survey comprised 17 questions across four categories: demographics, intraoperative discomfort, effects on performance and anticipated consequences. In total, 462 surgeons completed the survey. Overall, 402 (87.0%) surgeons reported experiencing discomfort while operating at least ‘sometimes’. The peak professional performance age was perceived to be 45–49 years by 30.7% of surgeons, 50–54 by 26.4% and older than 55 by 10.1%. 86 (18.6%) surgeons felt it likely they would consider early retirement, of whom 83 were experiencing discomfort. Our findings highlight the continued unmet needs of surgeons performing MAS, with the overwhelming majority experiencing discomfort, frequently in the back, neck and shoulders, and many likely to consider early retirement consequently. Innovative solutions are needed to alleviate this physical burden and, in turn, prevent economic and societal impacts on healthcare systems resulting from MAS limiting surgeon longevity.

BackgroundMinimal access surgery (MAS) has suggested improvements in clinical outcomes compared to open surgery in several abdominal elective and emergency surgeries. The aims of this study were to compare England with the United States in the utilisation of MAS and mortality from four common abdominal surgical emergencies.MethodsBetween 2006 and 2012, the rate of MAS and in-hospital mortality for appendicitis, incarcerated or strangulated abdominal hernia, small or large bowel and peptic ulcer perforation were compared between England and the United States. Univariate and multivariate analyses were performed to adjust for differences in baseline patient demographics.Results132,364 admissions in England were compared to an estimated 1,811,136 admissions in the United States. Minimal access surgery was used less commonly in England for appendicitis (odds ratio (OR) 0.27, 95% CI 0.267–0.278), abdominal hernia (OR 0.16, 95% CI 0.15–0.17), small or large bowel perforation (OR 0.33, 95% CI 0.32–0.35) and peptic ulcer perforation (OR 0.93, 95% CI 0.87–0.99). In-hospital mortality was increased in England compared to the United States for all four conditions: appendicitis (OR 2.11, 95% CI 1.66–2.68), abdominal hernia (OR 3.25, 95% CI 3.10–3.40), small or large bowel perforation (OR 3.88, 95% CI 3.76–3.99) and peptic ulcer perforation (OR 3.09, 95% CI 2.94–3.25). In England, after adjustment for patient demographics, open surgery was associated with increased in-hospital mortality for abdominal hernia (OR 1.80, 95% CI 1.26–2.71), small or large bowel perforation (OR 1.59, 95% CI 1.37–1.87) and peptic ulcer perforation (OR 2.31, 95% CI 1.91–2.82).ConclusionsMinimal access surgery was performed less commonly and in-hospital mortality was increased in England compared to the United States for common abdominal surgical conditions. Therefore, strategies to enhance adoption of MAS in emergency conditions in England need to be optimised and include appropriate patient selection and improved surgeon MAS training.

Abstract Background: The incidence of seroma formation is high following laparoscopic surgery for an inguinal hernia. Literature has shown many intraoperative techniques to reduce post-operative seroma formation. The hypothesis was made that scrotal support may reduce seroma formation following laparoscopic or robotic hernia surgery. This study aimed to compare the post-operative outcome of uncomplicated inguinal hernia patients with or without scrotal support application. Patients and Methods: A randomised controlled trial was conducted on 266 male patients with inguinal hernias. A block randomisation was done, and accordingly, a scrotal support was applied after mobilisation of study patients following laparoscopic or robotic surgery. After discharge, all patients were followed up for 30 days and their outcomes were compared. Results: Post-operative numbness after hernia surgery was significantly reduced with the application of scrotal support (P = 0.03). However, there were no significant differences in the early post-operative period for seroma formation, scrotal oedema, scrotal haematoma, surgical site infections, epididymo-orchitis or groin pain between the groups. Conclusion: A scrotal support application is not effective at reducing the formation of seroma after laparoscopic or robotic inguinal hernia repairs. Early post-operative groin numbness may be reduced by including scrotal support in post-operative care protocols.