Minimally Invasive Surgery
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The “Dark Side” of Pneumoperitoneum and Laparoscopy

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Research Article

Surgery for Perforated Peptic Ulcer: Is Laparoscopy a New Paradigm?

Introduction. Laparoscopic repair of perforated peptic ulcer (PPU) remains controversial mainly due to its safety and applicability in critically ill patients. The aim of this study is to compare the outcomes of laparoscopy versus laparotomy in the treatment of PPU. Methods. Single-institutional, retrospective study of all patients submitted to surgical repair of PPU between 2012 and 2019. Results. During the study period, 169 patients underwent emergent surgery for PPU. A laparoscopic approach was tried in 60 patients and completely performed in 49 of them (conversion rate 18.3%). The open group was composed of 120 patients (included 11 conversions). Comparing the laparoscopic with the open group, there were significant differences in gender (male/female ratio 7.2/1 versus 2.2/1, respectively; ) and in the presence of sepsis criteria (12.2% versus 38.3%, respectively; ), while the Boey score showed no differences between the two groups. The operative time was longer in the laparoscopic group (median 100’ versus 80’, ). Laparoscopy was associated with few early postoperative complications (18.4% versus 41.7%, ), mortality (2.0% versus 14.2%; ), shorter hospital stay (median 6 versus 7 days, ), and earlier oral intake (median 3 versus 4 days, ). Conclusion. Laparoscopic repair of PPU may be considered the procedure of choice in patients without sepsis criteria if expertise and resources are available. This kind of approach is associated with a shorter length of hospital stay and earlier oral intake. In patients with sepsis criteria, more data are required to access the safety of laparoscopy in the treatment of PPU.

Research Article

Longitudinal Gastrectomy for Nonbariatric Indications

Background. Sleeve gastrectomy is the most commonly performed bariatric procedure. Laparoscopic longitudinal gastrectomy (LLG) may be indicated for other indications. Patients and Methods. Two men and two women aged 67, 72, 77, and 80 years underwent LLG for nonbariatric indications with two having normal weight, one being cachectic, and one severely obese. Results. LLG was discussed with patients prior to surgery, but decision for LLG was made during surgery after contemplating other surgical options. A wide sleeve over a 42 French bougie was created with the staple line being oversewn with running 3–0 silk. Indications included a bleeding Dieulafoy lesion that failed endoscopic clipping, fundus gland polyposis found during paraesophageal hernia repair, fundus nodules suspected to be leiomyosarcoma metastases revealing splenosis on final pathology, and significant gastric dilatation associated with organoaxial gastric volvulus. Three patients had an uneventful recovery; the severely obese patient temporarily lost weight but died after two years from a stroke. The last patient developed dysphagia due to an alpha-loop in the sleeve, which was managed by endoscopic stenting. The device subsequently migrated and was laparoscopically removed, with a side-side gastrogastrostomy performed to straighten the alpha-loop. The patient tolerated food better and with overnight PEG tube feeds gained weight but continued heavy smoking. He died after one year from COPD exacerbation. Conclusion. LLG seems to be an appropriate intervention for various gastric pathologies. Training of residents and fellows in the minimally invasive surgical steps of LLG is encouraged.

Research Article

Totally Extraperitoneal Herniorrhaphy (TEP): Lessons Learned from Anatomical Observations

Background. Totally extraperitoneal herniorrhaphy (TEP) is a therapeutic challenge because of its complex anatomical location in inguinal region. The aim of this study was to describe the related surgical anatomy through laparoscopic observation and share the lessons learned from a review of 250 primary inguinal hernia repair procedures performed at our hospital from January 2013 to November 2019. Patients and Methods. There were 245 men and 5 women (median age: 63.2 years). Right hernia (60.2%) was the most common site. Indirect hernia (60.5%) was the most common abnormality. The classification of type II (65.0%) was the most common form. Surgical techniques comprised retromuscular approach using cauterized dissection, management of variations of arcuate line, Retzius space and Bogros space dissection, hernia sac reduction, and mesh positioning. Results. The incidence of peritoneum injury was in 27 (10.1%). No epigastric vessels were injured. There were 8 (3%) hematoma and 18 (6.8%) seroma. No mesh infection, chronic pain, and recurrence were found after follow-up of an average of 35 months. Conclusion. A good understanding of the anatomically complex nature in the inguinal region can make it easier and safer to learn the TEP approach. Early and midterm outcomes after TEP are satisfactory.

Review Article

Is There a Place for Spinal Cord Stimulation in the Management of Patients with Multiple Sclerosis? A Systematic Review of the Literature

Objective. Spinal cord stimulation (SCS) is a minimally invasive technique mainly used to treat neuropathic pain associated with failed back surgery syndrome. However, this therapy has been utilized to treat other chronic painful conditions, such as pain associated with multiple sclerosis (MS). Nonetheless, the efficacy of SCS in MS patients has not been fully established. In fact, in most of SCS series, MS patients represent only a subset of a bigger cohort which comprises different causes of pain, motor disorder, and other functional limitations. The aim of our study was to systematically review the literature to evaluate the effectiveness of SCS in MS patients. Methods. A literature search was performed through different databases (PubMed, Scopus, and Embase) using the following terms: “multiple sclerosis,” “spinal cord stimulation,” and “dorsal column stimulation,” according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Results. A total of 452 articles were reviewed, and 7 studies were included in the present analysis. 373 MS patients were submitted to a stimulation trial, and 82 MS patients underwent a de novo implantation. 285/373 (76.4%) of cases submitted to the SCS trial were enrolled for permanent stimulation. We found a long-lasting improvement in 193/346 (55.8%) MS patients with motor disorders, in 90/134 (67.13%) MS patients with urinary dysfunction, and in 28/34 (82.35%) MS patients with neuropathic pain. The efficacy of SCS was higher for urinary dysfunction ( = 0.0144) and neuropathic pain ( = 0.0030) compared with motor disorders. Conclusions. Our systematic review evidences that SCS is effective in MS patients. Urinary dysfunction and pain symptoms seem to be most responsive to SCS. Further studies are needed to improve the patient selection and clarify the best timing to perform SCS in these patients.

Research Article

Weight Loss Outcomes following Roux-en-Y Gastric Bypass and Sleeve Gastrectomy in an Ethnically Diverse Bariatric Population: Which Is More Effective?

Background. Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) have comparable weight loss outcomes in a general bariatric population. Objectives. This study aimed to investigate whether similar outcomes can be observed in Hispanic and African American population. Settings. Community Hospital in New York, New York, United States. Methods. The 5-year prospective data of patients who underwent LRYGB and LSG at a single center were retrospectively reviewed. The long-term weight loss outcomes between patients who had LRYGB and LSG were compared after adjusting for age, sex, race, diabetes mellitus, and hypertension with the linear mixed-effects or logistic regression model. Results. Most patients were Hispanic (59.2%) and African American (22.7%). The mean% total weight loss (%TWL) values of patients with BMI <45 kg/m2 who underwent LRYGB and LSG were 73% and 62% after 1 year, 69% and 56% after 2 years, and 71% and 54% after 5 years, respectively. In patients with a BMI of 45–50 kg/m2 who underwent LRYGB and LSG, the mean %TWL values were 69% and 56% after 1 year, 75% and 58% after 2 years, and 57% and 45% after 5 years, respectively. Meanwhile, the %TWL values of patients with BMI >50 kg/m2 who had LRYGB and LSG were 53% and 42% after 1 year, 53% and 45% after 2 years, and 49% and 36% after 5 years, respectively. All results were statistically significant and remained valid after adjusting for cofactors. Conclusion. Thus, LRYGB had consistent and sustained long-term weight loss outcomes compared with LSG in a predominantly ethnically diverse patient population with different BMI. Our study had several limitations in that it is retrospective in nature and some patients were lost to follow-up during the study period.

Research Article

Comparison of Survival between Single-Access and Conventional Laparoscopic Surgery in Rectal Cancer

Introduction. Innovative laparoscopic surgery for rectal cancer can be classified into 2 types: firstly, new instruments such as robotic surgery and secondly, new technique such as single-access laparoscopic surgery (SALS) and transanal total mesorectal excision (TaTME). Most reports of SALS for rectal cancer have shown pathologic outcomes comparable to those of conventional laparoscopic surgery (CLS); however, SALS is considered to be superior to CLS in terms of lower levels of discomfort and faster recovery rates. This study aimed to compare the survival outcomes of the two approaches. Methods. From 2011 to 2014, 84 cases of adenocarcinoma of the rectum and anal canal were enrolled. The operations were anterior, low anterior, intersphincteric, and abdominoperineal resections. Data collected included postoperative outcomes. The oncological outcomes recorded included 3-year and 5-year survival, local recurrence, and metastasis. Results. SALS was performed on 41 patients, and CLS was utilized in 43 cases. The demographic data of the two groups were similar. Intraoperative volumes of blood loss and conversion rates were similar, but operative time was longer in the SALS group. There were no significant differences in postoperative complications or pathological outcomes. The oncologic results were similar in terms of 3-year survival (100% and 97.7%;  = 1.00), 5-year survival (78.0% and 86.0%;  = 0.401), local recurrence rates (19.5% vs 11.6%,  = 0.376), and metastasis rates (19.5% vs 11.6%;  = 0.376) for SALS and CLS, respectively. Conclusion. SALS and CLS for rectal and anal cancer had comparable pathological and survival results, but SALS showed some superior benefits in the early postoperative period.

Minimally Invasive Surgery
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Article of the Year Award: Outstanding research contributions of 2020, as selected by our Chief Editors. Read the winning articles.