E-ISSN 2587-0610
Laparoscopic Endoscopic Surgical Science (LESS) - Laparosc Endosc Surg Sci : 28 (1)
Volume: 28  Issue: 1 - 2021
1.Systematic review of 241 laparoscopic isolated liver segment VII resections
Kutay Sağlam, Örgün Guneş, Yusuf Murat Bağ, Mehmet Can Aydin, Fatih Sümer, Cüneyt Kayaalp
doi: 10.14744/less.2021.05826  Pages 1 - 11
Laparoscopic liver resections are performed with increasing frequency; however, they are less preferred for the deep parts of liver because of difficulty in reaching a posterior superior segment and working in a narrow area. The aim of this study is to analyze the outcomes of laparoscopic segment 7 resections with two new patients and previously published 239 patients. PubMed, Scopus, and Google Scholar databases were scanned for the topic with several keywords. Eligible studies were selected for the analysis and reference cross-check was added to the search. Surgical technique details (application of Pringle maneuver, using Cavitron ultrasonic surgical aspirator (CUSA), patient position, Glissonean approach, and intercostal trocar (ICT) placement) were examined for the outcomes (operating time, blood loss, conversion to open surgery, and post-operative complications). Total data of 239 cases were collected from 27 studies and we added two more cases from our clinic. Lateral decubitus patient position was with less post-operative complications when compared to the supine position (8.4% vs. 50.0%, p=0.01). ICT placement seemed to have less conversion rate (1.3% vs. 7.3%, p=0.07) and less post-operative complications (4.5% vs. 19.1%, p=0.05). Glissonean approach increased the operating time but had no effect on blood loss. Using CUSA for parenchymal transection lowered the rates of post-operative complications (4.4% vs. 19.5%, p<0.05) but it was not useful for blood loss or operating time. Application of Pringle maneuver had no effect on these outcomes. Laparoscopic isolated segment 7 liver resection is a feasible surgical procedure for selected patients in centers with experienced surgeons on advanced laparoscopy. Lateral decubitus patient position, ICT placement, and using CUSA for parenchymal transection seem beneficial to decrease conversion to open surgery and complication rates. Pringle maneuver or Glissonean approach were not found as useful for the outcomes.

2.Early results of colorectal cancer treated with robotic surgery: A single-center experience
Yılmaz Özdemir, Ayetullah Temiz
doi: 10.14744/less.2021.79037  Pages 12 - 17
INTRODUCTION: Colorectal cancer is the third most common cancer among adults and one of the most common malignancies seen in developed countries. The use of robotic surgical systems in minimally invasive procedures has many potential advantages. Unlike the two dimensional (D) visual images provided by modern laparoscopic systems, robotic systems provide a continuous 3D image and a sense of depth, especially for surgeons familiar to traditional open surgery. In this study, it was aimed to present the early results of patients who underwent robotic surgical resection for colorectal cancer
METHODS: The patient files of 33 colorectal cancer patients, who had been treated with robotic surgery, between September 2015 and June 2019, were retrospectively reviewed. Age, gender, tumor location, surgery performed, duration of surgery, intraoperative blood loss, post operative histopathological findings, length of hospital stay, morbidity, and mortality were recorded.
RESULTS: The mean age of the patients was 66.78±12.11 years. Of the patients, 17 (51.5%) were male. The rectum was the most common localization (66.5%). The most common procedure performed was low anterior resection (n=12). The mean blood loss was 195.45±62.95 mL and the mean operative time was 315.24±92.40 min. No complications developed intraoperatively in any of the patients. A total of four patients were converted to open surgery. Post-operative complications occurred in three patients. The average length of stay was 6.22±1.08 days. In the histopathological evaluation, the mean total number of lymph nodes removed was 15.8±3.4, and the mean number of pathological lymph nodes was 1.54±0.6. The most common tumor stage was, Stage 3 (48.4%). There was no positive surgical margin in any of the patients.
DISCUSSION AND CONCLUSION: Due to the articulating instruments and advanced imaging technology used in robotic surgery, dissection of the tissues for total mesorectal excision can be performed more easily and effectively in colorectal cancers. In this way, better quality resection and lymph node dissection can be performed and more accurate staging and appropriate oncological results can be obtained.

3.Comparison of complications associated with the use of three different uterine manipulators (Clermont-Ferrand, VCare, and RUMI II) in total laparoscopic hysterectomy
Melike Aslan, Şeyda Yavuzkır
doi: 10.14744/less.2021.85698  Pages 18 - 23
INTRODUCTION: In total laparoscopic hysterectomy (TLH), uterine manipulators (UM) are utilized to facilitate dissection by moving the uterus. However, some complications may occur during the utilization of a manipulator. The aim of this study is to compare the complications that occur during the utilization of three different manipulators.
METHODS: In this retrospectively designed study, 103 patients who underwent TLH due to benign indications were included in the study. All patients were operated by the same two surgeons using the same technique. The patients were divided into three groups according to the manipulators utilized. Group 1 (G1) included patients operated with Clermont-Ferrand UM, Group 2 (G2) included patients operated with RUMI II, and Group 3 (G3) included patients operated with VCare. UM-related complications, duration of operation, estimated amount of bleeding, duration of hospital stay, uterine weight, uterine length, number of myomas, and diameter of the largest myoma were recorded.
RESULTS: Uterine weight and mean blood loss were higher in G1 than in G3. There was no significant difference between the groups in terms of uterine perforation. Penetration of the manipulator into the mesorectum occurred in one patient in G1 with Douglas perforation. There were two cervical cup melts in G2 and 1 in G3. Cuff dehiscence occurred in one patient each in G2 and G3.
DISCUSSION AND CONCLUSION: Manipulation of the UM, which is an indispensable instrument of the TLH procedure today, by people with skill and experience and the surgeon’s knowledge on the features and limits of the manipulator used will reduce the risk of UM-related complications.

4.Laparoscopic pyeloplasty in ureteropelvic junction obstruction: A single-center experience
Mehmet Kutlu Demirkol, Osman Barut, Tayfun Şahinkanat, Sefa Resim, Ömer Faruk Boran
doi: 10.14744/less.2021.58219  Pages 24 - 28
INTRODUCTION: The aim of the study is to retrospectively evaluate the perioperative and post-operative outcomes of the initial laparoscopic pyeloplasties (LPs); we performed in our clinic in the treatment of ureteropelvic junction obstruction (UPJO).
METHODS: The data of 23 patients who underwent LP with the diagnosis of UPJO between February 2016 and March 2020 in our clinic were retrospectively analyzed. The charts of patients such as demographic data, presenting complaint, pre-operative imaging, operation time, presence of crossing aberrant vessel, post-operative complications, hemoglobin drop, length of drain and hospital stay, and success rates were evaluated.
RESULTS: The mean age of patients was 25.5±17.1 (4–63) years with a male predominance of 56.5%. Of the 23 patients, 22 had primary and one patient had secondary UPJO previously treated with retrograde endopyelotomy. The mean operative time, drain stay time, and hospital stay time were 214.8±43.1 (160–310) min, 2.8±1.0 (2–7) days, and 3.5±1.8 (2–9) days, respectively. Although no major operative or post-operative complications were seen in our series, 2 (8.7%) patients had minor operative complications and 4 (17.3%) patients had minor postoperative complications. The mean follow-up period of all patients followed for at least 3 months was 13.9±7.8 (3–34) and the surgical success rate was 95.7%.
DISCUSSION AND CONCLUSION: Due to increased worldwide experience in laparoscopic surgery, the challenge on intracorporeal suturing of LP in initial cases is overcome in a short time. With a high success rate, low post-operative complication rate, and low hospital stay, our initial series results are consistent with high-volume studies in the literature.

5.An easy nomogram to predict 30-day mortality in warfarin overdose patients undergoing endoscopy for gastrointestinal bleeding
Hatice Tolunay, Aziz Ahmet Surel
doi: 10.14744/less.2021.67878  Pages 29 - 35
INTRODUCTION: Gastrointestinal bleeding (GIB) is a crucial medical issue in patients receiving oral anticoagulant therapy. Thus, the management of these patients is important in daily clinical practice. In this study, first, we sought to show the predictors of mortality and, second, provide a nomogram for clinicians to evaluate the risk of mortality in patients undergoing endoscopic therapy with warfarin overdose.
METHODS: Patients who underwent endoscopic treatment with warfarin overdose and GIB between February 15, 2019, and March 20, 2021, were retrospectively evaluated. Clinical, demographic, and laboratory parameters of patients were recorded. The primary outcome was 30-day all-cause mortality after the procedure.
RESULTS: A total of 359 patients admitted with warfarin overdose and GIB who underwent endoscopic treatment were included in the study. All cause death was observed in 50 (14%) patients in the 30-day period after the procedure. According to univariate and multivariate logistic regression analysis, age (OR=1.019; 95% CI=1.000–1.039; p=0.008), hypertension (OR=1.909; 95% CI=1.051–3.468; p=0.004), alcohol history (OR=1.618; 95% Cl=1.196–2.954; p=0.018), and albumin value (OR=0.318; 95% Cl=0.214–0.471; p=0.001) were determined as independent predictors for 30-day all-cause mortality. The areas under the curves of the nomogram were 0.73 (95% CI: 0.70–0.76) may have clinical usefulness.
DISCUSSION AND CONCLUSION: This study provides a nomogram containing age, hypertension, alcohol, and albumin that can be conveniently used to predict individual mortality in warfarin overdose patients undergoing endoscopy for GIB.

6.Repeated colonoscopy results after an unsuccessful procedure due to inadequate bowel cleansing
Murat Yıldırım, Uğur Özsoy, Celil Uğurlu, Bülent Koca, Abdullah Özgür Yeniova, Ismail Okan
doi: 10.14744/less.2021.60320  Pages 36 - 43
INTRODUCTION: The aim of this study is to evaluate repeated colonoscopy results after a failed procedure due to inadequate bowel cleansing.
METHODS: Patients who underwent colonoscopy between the dates of January 2014 and December 2019 were included in the study. Patients’ distance from the hospital, appointment times, repeated colonoscopy times, demographic data, and predictive factors were evaluated.
RESULTS: There were 522 (5.1%) patients who had failed procedure due to insufficient bowel cleansing among the 10,420 colonoscopy procedures. Failure rates were increased in each repeated colonoscopies (21.8%, 25%, and 33.3%). In repeated second colonoscopy, if the procedure was on the same day and the next day, it was associated with a high success rate (odds ratio [OR]=3.31, 95% confidence interval [CI]=0.91–12.36; p=0.048, OR=3.22, 95% CI=1.26–8.24; p=0.011, respectively). Elder age (OR=1.04, 95% CI=1.02–1.06; p<0.001), diabetes mellitus (OR=5.23, 95% CI=2.92–9.38; p<0.001), neurologic disorders (OR=7.02, 95% CI=3.12–15.8; p<0.001), and constipation (p<0.001) were defined as risk factors for inadequate bowel cleansing. Patients who did not attend the second recurrent colonoscopy appointment had a significantly higher distance from the hospital compared to the patients who attended the appointment (p<0.001).
DISCUSSION AND CONCLUSION: The failure rates in repeated colonoscopies after inadequate bowel preparation continues exponentially. In this difficult patient group, failure rates can be reduced by repeating colonoscopy on the same day or the next day. It is extremely important to know the risk factors before the procedure and to determine patient management accordingly.

7.Safety of the concomitant cholecystectomy during laparoscopic sleeve gastrectomy in patients with symptomatic gallstone: A single-center experience
Azmi Lale, Mesut Yur, Oğuz Doğan, Cüneyt Kırkıl, Erhan Aygen
doi: 10.14744/less.2020.25428  Pages 44 - 49
INTRODUCTION: There are still controversies in the management of gallstones in patients who are candidate for bariatric surgery. The aim of this study was to evaluate the effect of the concomitant cholecystectomy (CC) during laparoscopic sleeve gastrectomy (LSG) on post-operative short-term complications in patients with symptomatic gallstone.
METHODS: After exclusion and inclusion criteria, a total of 251 patients were included in the study. Patients were divided into two study groups as Group A (only LSG, n=214) and Group B (LSG + CC, n=37).
RESULTS: Female-to-male ratio was 2/1 in Group A and 8/1 in Group B (p=0.01). The mean age, comorbid disease distributions, length of stay, and initial body mass index were similar in both groups. The differences in the rates of postoperative 30-day minor and major complications in Group A (7.5% and 2.8%, respectively) and Group B (18.9% and 2.7%, respectively) were not significant (p=0.64). CC prolonged the operation time at an average of 15 min (p<0.001).
DISCUSSION AND CONCLUSION: CC during LSG is a safe procedure in patients with symptomatic gallstone, which has an acceptable increase in operation time and does not cause an increase in minor or major complications and prolongation on length of stay.

8.Comparative study of groin hernia repair
Ilker Özgür, Irem Karataş, Halil Alper Bozkurt, Metin Keskin, Ali Akyüz
doi: 10.14744/less.2021.62534  Pages 50 - 54
INTRODUCTION: The aim of the study is to compare results of Lichtenstein repair, laparoscopic totally extraperitoneal (TEP), and transabdominal preperitoneal (TAPP) repair of groin hernias.
METHODS: We retrospectively extracted medical records of 127 consecutive male patients operated on for inguinal hernia between June 2014 and June 2019. Patients were grouped according to preferred surgery; Lichtenstein (Group 1), TAPP (Group 2), and TEP (Group 3) repair groups. Demographic data, body mass index (BMI), American society of anesthesiologists score, surgery time, post-operative hospital stay, pain score, complications, and recurrence rates were compared.
RESULTS: Mean age was 53.6 (17–86) years. Mean BMI was 24.8 kg/m2. Mean surgery time was 62.0±24.2 (30–150), 71.1±26.9 (40–135), and 76.5±20.9 (35–1 40) min in groups, respectively. Mean hospital stay was 1.3 (1–3), 1.2 (1–4), and 1.3 (1–2) days. Post-operative pain was less in laparoscopic group, especially in TEP repair group (1.0±0.9 [0–4], 0.4±0.8 [0–3], 0.2±0.6 [0–3]; 1 vs. 2 p: 0.005/2 vs. 3 p: 0.000/1 vs. 3 p: 0.001). No major complication was observed and two recurrent hernias were detected after mean 953-day follow-up period.
DISCUSSION AND CONCLUSION: Both open and laparoscopic hernia repair can be performed safely, with a low rate of complications. Post-operative pain is reduced in the laparoscopic group.

9.Steps to be considered in the unsuccessful endoscopic retrograde cholangiopancreatography pre-criteria: Early pre-cut intervention. A retrospective cohort study
Mehlika Bilgi Kırmacı, Tamer Akay, Sezgin Yılmaz
doi: 10.14744/less.2021.56833  Pages 55 - 62
INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) is a widely used procedure for the treatment of several hepatobiliary and pancreatic diseases and also for diagnostic purposes of rare conditions. Despite advances in endoscopic accessories, selective biliary cannulation fails in 5–15% of cases, even in expert high-volume centers. However, there is still no consensus regarding the clinical outcomes of failed ERCP patients who underwent precut sphincterotomy. In the current work, we present the therapeutic approach and the outcomes of our patients with failed ERCP due to several reasons.
METHODS: There were 1986 patients who were referred from another center due to primary ERCP requirement (n=1862) or unsuccessful attempts to study at the primary center (n=124). If the papilla has prerequisite criteria for failed ERCP, then the procedure was begun directly with precut incision.
RESULTS: The ERCP procedure was successfully performed in all 1794 patients using a classic cannulation procedure. Pre-cut sphincterotomy method was successfully performed in 160 patients. There were 123 patients diagnosed by ERCP in our center and 103 of them were cannulated successfully with pre-cut sphincterotomy method. Pancreatitis developed in 12 of the 1794 patients (0.66%) whose primary cannulation was successful. However, only two of the 160 patients (1.25%) who underwent precut sphincterotomy developed pancreatitis postoperatively. One of these two patients had undergone unsuccessful precut trials.
DISCUSSION AND CONCLUSION: The cannulation rate depends on the experience, the referral center where the procedure is carried out, the anatomical structure of the papilla, the indication necessitating the ERCP, and also the use of precut incision. In cannulation failure, patients should be directed to experienced, high-volume, and tertiary centers. In patients with failed ERCP pre-criteria, intervention should be initiated with the liberal use of the precut method. In unsuccessful cannulation, a 3-day waiting period reduces complications.

10.Prognostic value of neutrophil to lymphocyte ratio in patients with colon cancer undergoing open and laparoscopic curative resection
Ümit Mercan, Bahri Çakabay, Abdullah Durhan, Ogün Erşen, Afig Gojayev, Ali Ekrem Ünal
doi: 10.14744/less.2021.24382  Pages 63 - 70
INTRODUCTION: It is known that many patient-related factors such as pre-operative nutritional status, comorbid diseases and especially the systemic inflammatory response affect post-operative outcomes and survival as much as the success of curative resection and the pathological stage. In the present study, it has been aimed to determine the effect of neutrophil to lymphocyte ratio (NLR) on post-operative and long term results in patients with colon cancer who underwent laparoscopic curative resection.
METHODS: Eligible 281 patient with colon adenocarcinoma underwent open and laparoscopic curative resection included in study. The patients were grouped as low and high NLR according to a cutoff NLR of 2.27 determined with receiver operating characteristic curve analysis and clinicopathological features, post-operative complications, and survival outcomes were compared.
RESULTS: It was found that patients with high NLR had more advanced disease and there was a significant relationship between post-operative morbidity and high NLR. No significant relationship was found between overall and disease-free survival and NLR.
DISCUSSION AND CONCLUSION: NLR, which can be measured by preoperative routine laboratory results, may be a simple, easily accessible prognostic biomarker in predicting the stage of the disease before surgery and identifying patients with high post-operative morbidity in patients with colon cancer. Considering that many factors affect long-term results, these data suggest that NLR, which is a marker that reflects the severity of the inflammatory response, is mostly associated with perioperative and short-term outcomes.

11.How much more can minimally invasive surgery be minimized? Mini-laparoscopic Nissen fundoplication in adults
Fatih Sumer, Gökalp Okut, Kuntay Kaplan, Necip Tolga Baran, Cuneyt Kayaalp
doi: 10.14744/less.2021.80664  Pages 71 - 73
INTRODUCTION: Mini-laparoscopy has become a current issue as a minimally invasive technique in gastroesophageal reflux surgery, which does not require specimen extraction. There are a limited number of cases of Nissen fundoplication performed in the adult age group using the mini-laparoscopic method. In this article, our aim is to draw attention to the fact that mini-laparoscopy is a preferable technique in Nissen fundoplication surgery.
METHODS: Seven patients underwent mini-laparoscopic Nissen fundoplication between January 2010 and December 2019. Demographic data and perioperative parameters were analyzed retrospectively.
RESULTS: Three of our patients (43%) were female and the average age of our patients was 45.4±11.1. All patients presented with complaints of heartburn and regurgitation. There was Barrett metaplasia in the pathology results and no dysplasia was observed in any patient. Mean operation time was 117±49.9 min, bleeding amount was <10 ml in all surgeries. The median time to oral intake was 8th post operative h, and no complications developed in any of our patients. In the post-operative period, there was no need for narcotic analgesic, after a single dose of nonsteroidal anti-inflammatory drugs, the treatment was continued with two doses of oral analgesic. Median length of stay hospital was 3 (2–4) days, the median follow-up period was 67 (29–120) months.
DISCUSSION AND CONCLUSION: Anti-reflux surgery can be easily performed, mini-laparoscopically since it is not a resective surgical procedure. It can provide advantages such as better cosmesis, less port site complications, and less analgesic use.

12.Our experiences of Sanliurfa Mehmet Akif İnan Training and Research Hospital endoscopic retrograde cholangiopancreatography
Esat Taylan Uğurlu, Mehlika Bilgi Kırmacı, Hüseyin Avni Demir, Sezgin Yılmaz
doi: 10.14744/less.2020.81557  Pages 74 - 77
Endoscopic retrograde cholangiopancreatography (ERCP) is very important in the diagnosis and treatment of hepatopancreatic biliary diseases. This study shares 5.5 months of general surgical endoscopy unit experience. This study retrospectively evaluated clinical, medical, and radiological data of 213 patients with cholangitis who underwent ERCP between May 15, 2019, and January 1, 2020. Patients were 22 90 (average 53.2) years old, and there were 148 women (69%) and 65 men (31%). The most common indication was biliary obstruction and pancreatitis with fistula due to hydatid cyst surgery. The procedure time ranged from 20 min to 90 min (average, 37 min). Cannulation was done successfully in 203 patients (95%). Four of 10 patients who could not be cannulated were then cannulated with a precut technique, two of them underwent PTK, and three patients underwent open choledochal exploration. ES was performed in 203 patients, choledochal stone excision was performed in 164 patients, and stents were placed in 18 patients. After ERCP, 72 patients had hyperamylasemia that did not require treatment. Eighteen patients had acute pancreatitis, and they recovered within 3 days of medical treatment. Two patients had bleeding, which was stopped with adrenaline balloon. No mortality was recorded.

13.Duodenal perforation due to an ERCP stent migration after liver transplantation
Burak Mahmut Kılcı, Sertaç Usta, Burak Işık, Sezai Yılmaz
doi: 10.14744/less.2021.04372  Pages 78 - 81
Biliary tract complications are one of the most common complications, after liver transplantation. Endoscopic retrograde cholangiopancreatography (ERCP) is a frequently performed diagnostic and therapeutic procedure for those complications. Stent dislocation after ERCP procedure is a very rare complication. There are only case reports, about the perforation complications due to stent migration in the literature. Therefore, there is not enough data about the incidence of this complication. Here, we present a case who had ERCP procedure due to biliary tract stricture after liver transplantation. The patient admitted with an abdominal pain and intra-abdominal free liquid was detected on computed tomography scan. The patient was urgently operated and primary repair of the duodenal perforation was performed.

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