E-ISSN 2587-0610
Laparoscopic Endoscopic Surgical Science (LESS) - Laparosc Endosc Surg Sci : 31 (4)
Volume: 31  Issue: 4 - 2024
1. Front Matter

Pages I - V

RESEARCH ARTICLE
2. Learning total extraperitoneal (TEP) herniorrhaphy without supervision: A study on proficiency, efficiency, and safety
Yahya Ozel, Yalçın Burak Kara, Sevde Nur Emir
doi: 10.14744/less.2024.99705  Pages 145 - 153
INTRODUCTION: This study investigated the learning curve (LC) of TEP herniorrhaphy performed without super-vision and with telescopic dissection.
METHODS: This study was a retrospective data analysis. Patients who underwent inguinal hernia repair via the TEP method between April 2009 and December 2012 were included. Data from patient records, such as demographic information, hernia type, surgical details, intraoperative and postoperative complications, conversion to other surgical techniques, and early hernia recurrence, were collected and analyzed.
RESULTS: A total of 141 patients were included in the study. The mean age was 48.5±14.7 years, and 131 (92.9%) patients were male. The mean surgery duration was 66.7±15.3 minutes. After performing 75 TEP herniorrhaphy surgeries, a significant reduction in operative time was observed (p<0.001). The study also reported that 9.2% of surgeries required conversion to other techniques, such as transabdominal preperitoneal (TAPP) or open hernia repair, with the conversion rate decreasing after the 75th surgery. Of the 12 conversions, 9 occurred during the first 75 cases, whereas only 3 were recorded afterward.
Postoperative complication rates remained consistently low throughout the study. Hematoma was observed in only 1.4% of patients, seroma in 4.3%, and mesh infection in 0.7%. There was no significant difference in complication rates before and after the 75-case threshold, suggesting that the safety of the procedure was maintained throughout the learning process. Early recurrence of hernia occurred in one patient (0.79%) within the first month.
DISCUSSION AND CONCLUSION: This study demonstrated that surgeons with sufficient laparoscopic experience can effectively and safely learn TEP herniorrhaphy without the need for supervision or the use of a balloon dissector, a tool that typically increases procedural costs. However, more complex cases should be approached cautiously until the LC is fully established.

3. The role of bronchoscopic lavage culture monitoring in affecting the length of stay in intensive care unit in lung transplant patients
Ertan Sarıbaş
doi: 10.14744/less.2024.33341  Pages 154 - 160
INTRODUCTION: The aim of this study was to investigate whether bacterial growth detected in bronchial lavage is related to the length of stay in the intensive care unit (ICU).
METHODS: A single-center retrospective cohort study was conducted, including patients who underwent lung transplantation for end-stage lung disease at a tertiary hospital between January 2017 and December 2022. Data were collected from the hospital database, comprising 86 patients admitted to the ICU for at least 24 hours postoperatively. The study focused on the first 30 days in the ICU after transplantation. Seventeen patients were excluded due to early transfer to the ward, infection developed in the ward, intra-operative mortality, or missing data.
RESULTS: The final cohort consisted of 69 patients, with 81.2% male and a median age of 47 years (range: 32–56 years). The average waiting list duration was 3 months (range: 1–5 months). Among the patients, 44% had interstitial lung disease (ILD), followed by other conditions. Comorbidity indices showed that 30.4% had a score of 1, 46.4% had a score of 2, and 23.2% had a score of 3. No significant differences were detected in bronchoscopic lavage samples taken on days 0–3, 7, 14, and 30 post-transplantation. Additionally, bacterial culture positivity did not affect the length of stay in the ICU.
DISCUSSION AND CONCLUSION: Postoperative mortality is highest in the months following transplantation, primarily due to complications and infections. This study found no significant relationship between bacterial culture growth and ICU stay length, likely due to effective prophylactic antibiotic strategies and diligent patient monitoring. Further multicenter studies are needed to explore potential relationships between bacterial positivity and ICU stay duration.

4. Challenges in total minimally invasive esophagectomy procedures; Our single center initial experiences
Rıdvan Yavuz, Orhan Aras, Hüseyin Çiyiltepe, Onur Dinçer, Ömer Kürklü, Tebessüm Çakır
doi: 10.14744/less.2024.08379  Pages 161 - 167
INTRODUCTION: We aimed to retrospectively evaluate the first period patient portfolio and surgical outcomes, difficulties in operations, morbidity, and early mortality rates in minimally invasive esophagectomy procedures in a clinic with high experience in gastrointestinal minimally invasive surgery.
METHODS: The records of fifteen esophageal cancer patients who underwent minimally invasive laparoscopic/robotic-thoracoscopic esophagectomy between November 2019 and July 2024 in our Gastroenterology Surgery Clinic were retrospectively reviewed.
RESULTS: The mean age of the patients was 61.2 (42-74) years. Ten patients (66.6%) were male, and five patients (33.3%) were female. The tumor locations were 1 (6%) in the upper esophagus, 5(36%) in the middle esophagus, and 9 (60%) in the lower esophagus. Eleven (73.4%) patients were operated on laparoscopically-thoracoscopically, and four (16.6%) patients were operated on robotic-thoracoscopically. Total esophagectomy - cervical anastomosis (McKeown) was performed in 13 (86.6%) patients. Subtotal esophagectomy - intrathoracic anastomosis (Ivor Lewis) was performed in 2 (13.4%) patients. Two patients with intrathoracic anastomosis were in the laparoscopy group.
The mean operation time was 280.53(180-464) minutes. The mean intraoperative bleeding was 200.33 (50-550) ml. The mean intensive care unit (ICU) stay was 3.26(1-27) days, and the mean ward stay was 7.26 (0-11) days. One (6%) of our patients followed up in the ICU in the early postoperative period resulted in mortality.
DISCUSSION AND CONCLUSION: We believe that in clinics experienced in gastrointestinal system (GIS) and minimally invasive surgery, sufficient experience can be achieved with smaller patient series in the transition to minimally invasive esophagectomy.

5. Outcomes of laparoscopic cholecystectomy in the elderly: A single-center study
Tugrul Demirel, Zeliha Turkyilmaz
doi: 10.14744/less.2024.60437  Pages 168 - 179
INTRODUCTION: The elderly population is at high risk for perioperative morbidity and mortality due to their disease profiles. This study aimed to evaluate the results of laparoscopic cholecystectomy (LC) performed in a single center in terms of young and elderly patients.
METHODS: Patients who underwent LC between January 2022 and March 2023 were evaluated retrospectively. Two hundred and eighty-three patients were included in the study. Patients were divided into two groups: ≥65 years and <65 years, and perioperative findings were compared.
RESULTS: Patients aged ≥65 had higher rates of heart disease, lung disease, kidney disease, and neurological disease; American Society of Anesthesiologists Score II–III; longer length of hospital stay (LOS); and longer length of intensive care unit (ICU) stay than patients aged <65. In addition, patients aged ≥65 had lower levels of hematocrit, hemoglobin, platelets, and albumin than patients aged <65, and patients aged ≥65 had higher levels of urea, creatinine, and total bilirubin than patients aged <65. High white blood cell count, C-reactive protein, aspartate transferase, and bilirubin values, as well as low hematocrit, hemoglobin, and albumin values, were associated with longer LOS and ICU stay. In addition, high aspartate transferase, alanine aminotransferase, alkaline phosphatase, direct bilirubin, and total bilirubin values were associated with increased development of complications. No mortality was observed during the study period.
DISCUSSION AND CONCLUSION: LC is a safe method and has acceptable mortality and morbidity rates, even in patients with high comorbidities in elective conditions.

6. The role of video-assisted thoracoscopic lung biopsy in the diagnosis of interstitial lung disease
Mesut Buz, Mehmet Ilhan Sesigüzel, Yunus Emre Özsaray, Rıza Berk Çimenoğlu, Mahmut Talha Doğruyol, Attila Özdemir, Recep Demirhan
doi: 10.14744/less.2024.82956  Pages 180 - 184
INTRODUCTION: Interstitial lung diseases (ILDs) are a heterogeneous group of disorders characterized by fibrosis and inflammation of the lung parenchyma. Early and accurate diagnosis is crucial for effective management and prognosis. Video-assisted thoracoscopic surgery (VATS) has emerged as a minimally invasive technique that provides sufficient tissue for histopathological diagnosis, particularly in cases where non-invasive methods, like high-resolution computed tomography (HRCT), are inconclusive.
METHODS: This retrospective observational study was conducted on patients with suspected ILD who underwent VATS lung biopsy between January 1, 2014, and January 1, 2024. Demographic data, clinical symptoms, imaging results, biopsy sites, and histopathological findings were collected and analyzed. The study aimed to evaluate the diagnostic role of VATS and the relationship between biopsy locations and diagnostic success.
RESULTS: A total of 39 patients were included, with a median age of 51 years (range: 21–69). Of the patients, 59% were male, and 41% were female. Biopsies were performed on 85% of the right lung and 15% of the left lung. Specific diagnoses were achieved in 87% of cases, with idiopathic pulmonary fibrosis (30%), non-specific interstitial pneumonia (20%), and cryptogenic organizing pneumonia (15%) being the most common. Surgical complications were observed in 3.4% of patients, including prolonged air leakage in two cases.
DISCUSSION AND CONCLUSION: VATS is a reliable and minimally invasive method for diagnosing ILD, providing high diagnostic accuracy and a low rate of complications. This study demonstrates the clinical utility of VATS in obtaining accurate histopathological diagnoses in patients with interstitial lung diseases.

7. Impact of coronary artery disease on outcomes of video-assisted thoracoscopic surgery for non-small cell lung cancer: A retrospective analysis
Sevinc Citak, Ertan Sarıbaş, Gonca Geçmen, Fatma Feyza Alkilic, Murat Ersin Çardak, Busra Yaprak Bayrak
doi: 10.14744/less.2024.62144  Pages 185 - 190
INTRODUCTION: Coronary artery disease (CAD) is a prevalent comorbidity among patients undergoing lung cancer surgery, posing significant perioperative challenges. Video-assisted thoracoscopic surgery (VATS) has gained prominence for its minimally invasive approach and reduced morbidity compared to open thoracotomy. This study investigates the outcomes of VATS in patients with non-small cell lung cancer (NSCLC) and concomitant CAD.
METHODS: This retrospective study analyzed 42 patients with NSCLC who underwent VATS anatomical resections at Kartal Kosuyolu High Specialization Education & Research Hospital from April 2020 to August 2024. Patients were divided into two groups: the study group included those with a history of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), while the control group comprised patients without such histories. All patients underwent preoperative cardiac evaluations and tailored antithrombotic management. Outcomes were assessed in terms of perioperative complications, postoperative recovery, and pathological findings.
RESULTS: The study group (n=20) and control group (n=22) were comparable in terms of demographics and tumor characteristics. The mean operative time was 312 minutes for the study group and 330 minutes for the control group. Drain removal time and hospital stay were slightly longer in the study group. Post-operative cardiovascular complications were minimal, with no significant differences between groups. Pathological evaluation revealed similar tumor histology and staging, predominantly adenocarcinoma in both groups. VATS demonstrated low conversion rates and acceptable outcomes, even in high-risk patients with CAD.
DISCUSSION AND CONCLUSION: VATS is a feasible and safe surgical option for NSCLC patients with concomitant CAD. With appropriate preoperative evaluations and individualized management, perioperative risks can be minimized, enabling effective surgical treatment for this complex patient population.

8. Predictive factors of mortality and hospitalization in elderly patients undergoing laparoscopic cholecystectomy for acute cholecystitis
Emre Teke, Sibel Yaman, Burcu Gümüştekin, Murat Mert, Zekeriya Sayın, Bilal Turan
doi: 10.14744/less.2024.88614  Pages 191 - 195
INTRODUCTION: Gallstone disease is a prevalent condition, affecting over 10% of the population, and acute cholecystitis (AC) remains a frequent cause of emergency gastrointestinal admissions. The Tokyo Guidelines (TG18/TG13) provide criteria for assessing the severity of AC and guide treatment decisions. This study aims to identify factors associated with mortality and prolonged hospitalization in elderly patients undergoing laparoscopic cholecystectomy (LC) for AC.
METHODS: This retrospective study included patients aged 70 and older who underwent LC for TG18/TG13 grade 1–2 AC between 2016 and 2023. Patients with recurrent AC, organ dysfunction, or a history of ERCP were excluded. Data on demographics, comorbidities (Charlson Comorbidity Index (CCI)), ASA (American Society of Anesthesiologists) scores, CRP/Albumin ratio (CAR), POSSUM (Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity) scores, postoperative outcomes, and length of hospital stay were collected. Statistical analyses were performed to evaluate the correlation between clinical factors and outcomes, including mortality and hospitalization duration.
RESULTS: A total of 52 patients, with a mean age of 74 years, were included. Mortality occurred in 4 patients (7.6%). Higher ASA, CCI, and POSSUM scores were significant predictors of mortality. CAR and serum albumin levels showed borderline significance. The timing of surgery and Tokyo severity scores were not associated with mortality. A positive correlation was found between the timing of surgery and length of hospital stay. The POSSUM score had higher specificity and sensitivity compared to CCI in predicting mortality.
DISCUSSION AND CONCLUSION: The POSSUM score was superior to CCI and ASA in predicting mortality in elderly patients undergoing LC for AC. The CAR ratio also showed potential as a predictive factor. These scores may help in optimizing treatment decisions and outcomes in this high-risk population.

9. Colorectal foreign body due to aspiration in children: The experience of a tertiary-level hospital
Uğur Deveci, Yaşar Doğan, Abdullah Murat Kayaokay, Şükran Akgeyik, Ferhat Karakoç
doi: 10.14744/less.2024.02418  Pages 196 - 199
INTRODUCTION: Foreign bodies resulting from aspiration are seen in children, especially those aged <5 years. Colorectal foreign bodies must be removed by colonoscopy because they may cause complaints or complications in children. This study aims to evaluate the clinical characteristics of children treated in a tertiary-level hospital for a diagnosis of colorectal foreign body.
METHODS: The study included 12 children (50% male, 50% female), aged median 5 years (range, 0.6–17.0 years), who were diagnosed with a colorectal foreign body due to aspiration. The demographic data, clinical findings, and operation notes of the cases were examined retrospectively from the hospital records.
RESULTS: The time from aspiration to presentation was a median of 15 days (range, 5 days–3 years). Colonoscopy was performed in 7 cases. The localization of the foreign body was the base of the cecum in 4 cases, the hepatic flexure in 2, and the descending colon in 1. The foreign body was removed with colonoscopy in 7 cases, with surgical intervention in 3, and with forceps in 2 where the localization was the distal rectum. In one case, an open-ended safety pin embedded in the appendix was surgically removed. In another case, a sewing needle had passed the right hepatic flexure, leading to subcapsular bleeding in the liver. The needle was removed with a surgical procedure. No complications were observed in any of the cases during or after colonoscopy or surgical procedures.
DISCUSSION AND CONCLUSION: Pediatric cases with colorectal foreign bodies can be treated successfully and without serious complications with colonoscopy.

10. Effect of sleeve gastrectomy on histopathological changes in the gastric mucosa
Mehmet Sait Berhuni, Hasan Elkan
doi: 10.14744/less.2024.35651  Pages 200 - 204
INTRODUCTION: This study aimed to evaluate the impact of weight loss on the histopathological findings of gastric mucosa in patients who underwent laparoscopic sleeve gastrectomy (LSG).
METHODS: Patients who underwent LSG for morbid obesity in our clinic between January 2019 and December 2023 were included in the study. The LSG specimen data were recorded as the surgical group (SG), and the postoperative 6-month endoscopic gastric biopsy data from the same patients were recorded as the biopsy group (BG). The two groups were compared in terms of body mass index (BMI) and histopathological observations of Helicobacter pylori (HP), chronic active gastritis (CAG), chronic inactive gastritis (CIG), and intestinal metaplasia (IM).
RESULTS: A total of 86 patients were included in the study. The median BMI was 44.00 (6.05) in the SG and 34.80 (6.00) in the BG, indicating a statistically significant difference between the groups in terms of BMI (p<0.001). Histopathological examination revealed no significant differences between the groups in terms of CAG, CIG, and IM (p>0.05). However, a significant difference was observed between the groups regarding HP (p<0.001).
DISCUSSION AND CONCLUSION: It was observed that weight loss did not lead to significant changes in histopathological findings such as CAG, CIG, and IM in the gastric mucosa, but it did result in significant differences in terms of HP.

11. Evaluation of changes in posterior segment parameters and cardiovascular risk score following laparoscopic sleeve gastrectomy in obese patients
Ulviye Kıvrak, Mehmet Karahan, Ismail Ertuğrul, Ömer Faruk Boğazlıyan, Müjgan Kaya Tuna, Yiğit Şenol, Nazlı Hacıağaoğlu
doi: 10.14744/less.2024.19794  Pages 205 - 215
INTRODUCTION: To investigate the effects of laparoscopic sleeve gastrectomy (LSG) on body mass index (BMI), visceral adipose index (VAI), waist circumference (WC), cardiovascular risk score, and retinal microvascular and neurogenic changes in obese patients.
METHODS: This retrospective study included 30 obese patients and 40 age- and sex-matched control subjects. Comprehensive systemic and ophthalmic examinations, including posterior segment parameters preoperatively and at six months postoperatively, were obtained for all participants. Data on BMI, VAI, and WC were collected from patient records. The Framingham Risk Score (FRS) was calculated both preoperatively and six months postoperatively.
RESULTS: The study indicated a significant reduction in BMI, VAI, WC, and FRS post-surgery (p=0.015, p=0.001, p=0.035, p<0.001, respectively). Retinal assessments revealed thinner temporal quadrant central macular thickness (CMT) and nasal quadrant peripapillary retinal nerve fiber layer (RNFL), as well as reduced vascular densities in all quadrants of the superficial capillary plexus (SCP), except for the fovea, and in the superior, temporal, and nasal quadrants of the deep capillary plexus (DCP) compared to the control group preoperatively, with improvements noted in temporal quadrant RNFL and nasal quadrant SCP post-surgery. Significant negative correlations were observed between VAI and subfoveal choroidal thickness (SCT), between WC and both superior quadrant MT and SCT, and between FRS and both temporal quadrant RNFL and nasal choriocapillaris vascular density.
DISCUSSION AND CONCLUSION: These findings suggest that LSG not only facilitates weight loss but also positively impacts retinal neurogenic and microvascular health, highlighting potential predictive markers for future cardiometabolic risks in obese patients.

12. A comparison of extracorporeal and intracorporeal anastomosis in patients undergoing laparoscopic right hemicolectomy for right colon tumors
Cem Batuhan Ofluoğlu, Fırat Mülküt
doi: 10.14744/less.2025.96992  Pages 216 - 221
INTRODUCTION: Colorectal cancer is a global health concern, and laparoscopic right hemicolectomy is widely performed for right-sided colon tumors. The choice between intracorporeal and extracorporeal anastomosis in laparoscopic right hemicolectomy remains controversial. This study compares early outcomes of these techniques.
METHODS: A retrospective analysis of 61 patients who underwent laparoscopic right hemicolectomy between 2019 and 2024 was conducted. The patients were divided into two groups: intracorporeal anastomosis (n=20) and extracorporeal anastomosis (n=41). The patients were evaluated in terms of their demographic characteristics, perioperative findings, and histopathological results. Statistical significance was defined as p<0.05.
RESULTS: The operative time was significantly shorter in the extracorporeal anastomosis group (181.95±26.88 vs. 200.0±24.17 minutes, p=0.015). Hospital stay duration was similar between groups (6.10±1.14 vs. 6.50±0.89 days, p=0.165). The median number of dissected lymph nodes was comparable (24 vs. 25.5, p=0.742). Surgical site infection rates (12.2% vs. 5.0%, p=0.376), ileus (26.8% vs. 20.0%, p=0.561), and anastomotic leakage (7.3% vs. 5.0%, p=0.731) showed no significant differences. No mortality was observed.
DISCUSSION AND CONCLUSION: Both intracorporeal and extracorporeal anastomosis are safe and effective techniques for laparoscopic right hemicolectomy, with no clear advantage regarding complications or oncological outcomes. The shorter operative time in the extracorporeal anastomosis group may favor its use in certain cases. Further randomized trials are needed to clarify long-term outcomes and support surgical decision-making.

LETTER TO THE EDITOR
13. Simultaneous laparoscopic management of acute appendicitis and an incidental gallbladder cystic lesion: A case report
Mehmet Torun, Umur Anil Pehlivan
doi: 10.14744/less.2024.83604  Pages 222 - 225
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