Minimally-invasive liver resection (MILR) is a promising approach and has become a standard therapy option for a variety of indications, including liver tumors, in adults. Although minimally-invasive techniques are common practices in children, the usage and literature regarding MILR in children is scarce. In this article, we give an update on the current literature, share some of our own experience and give a future outlook of the potential benefits and shortcomings regarding MILR in children.
Several reconstruction techniques are possible after totally laparoscopic distal radical gastrectomy. An optimal technique of digestive tract reconstruction after distal gastrectomy has not yet been established. The ideal reconstruction should be not only for doctors but also for patients. Alimentary intake, satisfactory nutritional status and easy performing should be all considered. The aim of the study was to describe the different Billroth-I reconstruction techniques that can be proposed after totally laparoscopic distal radical gastrectomy.
Transanal total mesorectal excision (TaTME) is the latest in a long list of developments in the surgical treatment of low rectal cancer. This article describes the evolution of the technique, a brief summation of the technical procedure, the current literature into its results, and the possible future direction that it might take. It is the authors’ opinion that TaTME will form another technique within the modern colorectal surgeon’s armament.
Aim: The purpose of this study was to evaluate the clinical feasibility and efficacy of the intracorporeal hemi-hand-sewn (IC-HHS) technique for Billroth-I gastroduodenostomy in comparison with extracorporeal total hand-sewn (EC-THS) anastomosis. We also examined the size of resected specimens in each procedure.
Methods: The number of enrolled cases of EC-THS and IC-HHS anastomosis groups were 85 and 110 cases, respectively. Perioperative data and the measured sizes of resected specimens were analyzed.
Results: Operation time in the IC-HHS group was significantly longer than the EC-THS group (234.8 min vs. 275.0 min, P < 0.01), whereas intraoperative blood loss was less in the IC-HHS group (48.4 mL vs. 25.4 mL, P = 0.03). There were no procedure-related complications in the IC-HHS group. The greater curvature of the EC-THS group was significantly shorter than the IC-HHS group (214.6 mm vs. 228.7 mm, P < 0.01). There was no correlation between body mass index (BMI) and the length of the greater curvature in the IC-HHS group (r = 0.07, P = 0.47), but in the EC-THS group, the length of the greater curvature tends to shorten as BMI increases (r = -0.45, P < 0.01).
Conclusion: IC-HHS technique for Billroth-I gastroduodenostomy revealed feasible with acceptable operation time and postoperative outcome. Another advantage of total laparoscopic distal gastrectomy that intracorporeal transection can facilitate is to ensure an adequate proximal margin, especially in obese middle gastric cancer patients.
Ablative techniques (AT) offer a combination of nephron-sparing and minimally invasive approaches. AT include different options and cryoablation (CA) and radiofrequency ablation (RFA) have been relatively safe and traditionally can be either performed laparoscopically or percutaneously. CA and RFA have emerged as a leading option for renal ablation, and compared with surgical techniques they offer benefits in preserving renal function with fewer complications, shorter hospitalization times, and allow for quicker convalescence. A mature dataset exists at this time, with intermediate and long-term follow up data available. Generally, laparoscopic access was the first technique used in the past, and typically for anterior and lateral mass. Afterwards, with the improvements in imaging and percutaneous techniques, laparoscopic approaches are progressively decreased and currently limited in few lesions and in relation with the surgeon’s and center’s experience. Nevertheless, laparoscopic CA and RFA could be useful techniques and currently, recommendations as a first-line therapy are made at this time in limited populations, including elderly patients, patients with multiple comorbidities, and those with imperative indications of a nephron sparing surgery. As more data emerge on oncologic efficacy, and technical experience continue to improve, the application of AT will likely be extended in future treatment guidelines and laparoscopic approaches will be a valid option in the era of tailored therapy.
Aim: It is unclear whether elderly patients with advanced gastric cancer can benefit from laparoscopic gastrectomy. This study aimed to compare the surgical and early postoperative outcomes of laparoscopic distal gastrectomy with those of open distal gastrectomy for advanced gastric cancer in elderly patients aged 75 years or older.
Methods: We retrospectively examined all elderly patients who underwent laparoscopic distal gastrectomy or open distal gastrectomy from October 2010 to October 2017 using prospectively collected data. Operative results, hospital courses, and survival rates were compared between the two groups.
Results: Distal gastrectomy was performed in 60 patients, laparoscopically in 20 and through open surgery in 40. The laparoscopic group had significantly lesser intraoperative blood loss (100 mL vs. 300 mL; P < 0.001) and shorter mean postoperative hospital stays (12 days vs. 23 days; P < 0.001). The overall 3-year survival rate was 50.1% in the laparoscopic group and 41.7% in the open group (P = 0.531).
Conclusion: Laparoscopic distal gastrectomy led to a faster return to a full diet and a shorter postoperative hospital stay in our study, and it was well tolerated by elderly patients with advanced gastric cancer.
The laparoscopic gastrectomy (LG) with D2 lymph node dissection (LND) for advanced gastric cancer (AGC) have been widely done. However, the applicability to more advanced disease is still under debate. Actually, there are a lot of technical demands against D2 LND for AGC, e.g., total omentectomy, splenic hilar node dissection, and the management for bulky lymph nodes, etc. Recently, extensive research has been gradually performed in the field of LG for AGC and demonstrated that LG for AGC is a safe and feasible procedure with better short-term outcomes compared with open gastrectomy. Also, large-scaled phase III trials are ongoing, and their long-term outcomes are awaited the publication in the near future. LG with D2 LND by expert surgeons under the cautious indications could be acceptable treatment for locally AGC. On the other hand, we should keep searching for solutions to the technical or oncological issues, and long-term outcome of phase III study should be warranted for standard treatment. Robotic surgery, LG following neoadjuvant chemotherapy, or conversion therapy using LG for several stage IV patients may help us clear the technical hurdles, and may show survival advantages in the future.
Laparoscopic liver resection is technically challenging compared to open liver surgery and has a steep learning curve. Tumors located in the posterior sector, centrally, in proximity of major vascular pedicles or in a background of liver cirrhosis are surgically more complex with a higher risk of blood loss. There is emerging consensus about indications for laparoscopic liver resection. While laparoscopic approach is considered standard for left lateral sectionectomy and minor laparoscopic liver resections in antero-lateral segments, with increasing experience, major resections, parenchyma sparing resections and even donor hepatectomies are being performed laparoscopically with good outcomes. Laparoscopic liver surgery is feasible and safe for well selected patients by well-trained surgeons with short-term advantages and non-inferior long-term oncologic outcomes.
Cross-sectional imaging shows a limited diagnostic accuracy for the histological discrimination of small renal masses (SRM). In this scenario, a renal tumor biopsy is a safe, feasible and effective diagnostic tool that can guide treatment strategy by providing the histological characterization of a SRM. Although nephron-sparing surgery is still considered the gold standard treatment for patients with SRM, more and more evidence suggests that active surveillance (AS) is a reasonable alternative option, especially in old and comorbid patients. Indeed, owing to the relatively slow growth and favorable biology of SRM, AS followed up by, if necessary, a delayed intervention provides an optimal oncological outcome with low rates of systemic progression or death.
The number of robotic gastrectomy (RG) cases is increasing, especially in East Asia. The da Vinci Surgical System for RG allows surgeons to perform meticulous procedures using articulated devices and provides potential advantages over laparoscopic gastrectomy (LG). Meta-analyses including a large number of retrospective studies comparing RG and LG revealed only a limited advantage for RG over LG, such as lower blood loss, and the obvious disadvantage of longer operation times and higher medical cost. Specifically, a multicenter, prospective, single-arm study performed in Japan showed favorable short-term outcomes of RG over LG, while a non-randomized controlled trial in Korea showed similar postoperative complication rates for RG and LG, although the medical costs were significantly higher in RG. A well-designed randomized controlled trial is thus necessary to establish robust evidence comparing the two surgeries. In addition, further development of surgical robotics is expected for RG to be accepted more widely.
Aim: To report the initial monocentric experience of totally laparoscopic total gastrectomy, assessing its feasibility and safety, especially relating to the challenging step of esophago-jejunal (E-J) reconstruction.
Methods: All consecutive patients, underwent laparoscopic total gastrectomy for gastric cancer with curative intent, between January 2017 and June 2018 at our institution, were considered. Data of the selected patients was retrieved from a prospectively collected database. Short and long term outcomes were analyzed.
Results: Ten patients underwent totally laparoscopic total gastrectomy with D2 lymphadenectomy and 4 of these had received preoperative chemotherapy; Two patients also received the lymphadenectomy of the station 10. E-J reconstruction consisted of hemi-double stapling technique with transorally inserted anvil in 1 case, side-to-side overlap anastomosis in 5 cases and end-to-side anastomosis in 4 cases. One patient experienced intraoperative complications needing conversion to laparotomy. Seven patients experienced postoperative complications, three of these were severe according to Dindo-Clavien classification. All the specimens had free proximal resection margins with R0 resection in all the cases. Average postoperative length of hospital stay was 10 days and no patients died during hospitalization. Median overall survival and disease-free survival were 15.5 and 12.5 months respectively.
Conclusion: Totally laparoscopic total gastrectomy is a feasible and safe option in the treatment of gastric cancer. The choice about the type of E-J reconstruction should be based on the single patient’s features and on the dexterity of the surgeon who should be able to perform more than one option for a tailored approach.
Oesophageal and gastroesophageal junction (GEJ) malignancy is the fastest growing cancer in the Western population. This together with the deadly nature of the disease has attracted increased attention from doctors and researchers alike. The increasing incidence has been primarily attributed to the increase in rates of obesity that in turn causes increased gastroesophageal reflux disease leading to Barrett’s oesophagus and eventually adenocarcinoma of the oesophagus especially at the GEJ. We discuss the epidemiology, risk factors and the management of GEJ tumours.
The incidence of adenocarcinoma of esophagogastric junction (AEG) has been increased continuously in the past decades, especially in western countries. Siewert type II is regard as the true AEG because of its location, however, the treatment for Siewert type II AEG has not reached a consensus in the academic. According to published studies nowadays, this commentary will introduce the surgical strategies and put forward suggestions for Siewert type II AEG in several aspects as follows: (1) optimal surgical approach; (2) optimal extent of lymph node dissection; (3) reconstruction methods. With the development of minimally invasive surgery, many experienced surgeons perform esophagogastrostomy via transhiatal approach. Moreover, many details during the surgery still need further research by cooperation between different departments and even countries.
The incidence of esophagogastric junction (EGJ) cancer is increasing in the world. EGJ cancer is traditionally classified by the Siewert classification, despite its limitations. The definition and classification of EGJ cancer is a controversial topic. Thus, the best available strategy for the surgical treatment of EGJ cancer remains controversial. This chapter reviews a minimally invasive approaches for EGJ cancer. Most operations for EGJ cancer that are performed by open surgery can be performed minimally invasively. A minimally invasive transthoracic approach (Ivor-Lewis or McKeown esophagectomy) is the optimal surgical approach for Siewert type I cancer. Mediastinoscope-assisted transhiatal esophagectomy, which was recently reported, may be a suitable surgical option, especially for frail patients with Siewert type I cancer. Generally, laparoscopic total or proximal gastrectomy is regarded as the standard for surgerical method for Siewert type III cancer, while both laparoscopic gastrectomy (with lower esophagectomy) or a minimally invasive Ivor-Lewis approach are recommended for Siewert type II cancer. Minimally invasive surgery (MIS) has the potential to shorten the length of hospitalization, reduce the risk of postoperative pulmonary complications, and improve quality of life with a similar margin status, nodal harvest, and survival rate to open techniques. However, as the existing literature is still limited, the choice of surgical method should be judged by the experienced surgeons, especially in MIS. This review reveals that further large clinical stuidies are need to deepen our understanding of MIS for EGJ cancer.
The presence of hydronephrosis usually signifies the presence of significant urinary tract obstruction, more commonly at the level of the ureter, and occasionally at the bladder outlet in cases of bilateral hydronephrosis. Unilateral hydronephrosis is most commonly caused by a ureteric stone or stricture, and rarely caused by neoplasm. Metastatic disease to the urinary bladder is rare and usually presents with hematuria, and we report the first case of hydronephrosis resulting from a metastatic esophageal cancer to the bladder.
Aim: Minimally invasive techniques for esophagectomy decrease cardiopulmonary complications and guarantee better quality of life (QoL) compared to open techniques, without compromising oncological radicality. This retrospective study compares the short-term and QoL outcomes of hybrid Ivor Lewis (HIL) and totally minimally invasive Ivor Lewis (TMIIL).
Methods: Patients with cancer of the distal esophagus and esophagogastric junction were included into (HIL) and (TMIIL) groups in the period January 2017-July 2018. General features, intraoperative and postoperative results were analyzed. The surgical radicality and number of resected nodes were also evaluated. QoL was determined preoperatively and at 7 and 90 days postoperatively with EORTC QLQ-C30 questionnaire.
Results: General features were similar in the TMIIL and HIL groups, which contained 13 and 14 patients, respectively. Median intervention duration was 360 min (range: 240-420) for TMIIL and 330 min (range: 240-400) for HIL (P = 0.0647). Median blood losses were similar for TMIIL and HIL at 100 mL (range: 50-400) and 175 mL (range: 50-350), respectively (P = 0.0831); pulmonary complications were 15% and 14% (P = 1) and leaks were 7% and 14% (P = 1) for TMIIL and HIL, respectively.
Conclusion: Our experience suggests that TMIIL esophagectomy appears to give results similar to HIL and positively influences the QoL within 90 days after surgery. Duration of surgery and anastomotic leaks are the key elements influencing the learning curve. Randomized controlled trials are necessary to confirm the good results obtained and to give recommendations to avoid a high rate of complications during the learning curve for this difficult technique.
Aim: The overall incidence of adenocarcinoma is on the rise, mainly in the western population. Minimally invasive thoracolaparoscopic esophagectomy for adenocarcinoma of gastroesophageal junction tumors is being adopted worldwide, albeit with a slower pace. This study is to share our experience and technical modifications over two decades.
Methods: This a retrospective data from 2009-2018 at a single center, including all the 143 cases of thora-colaparoscopic Ivor Lewis esophagectomies performed. There were no exclusions. The study objectives were to evaluate postoperative recovery, complications, and pathological completeness.
Results: In 11 years, we have performed 532 cases of minimally invasive esophagectomies for both malignant and benign etiologies. Out of which 143 cases were of Ivor Lewis esophagectomy. The mean age of patients was 64.4 ± 10.86 years, and male to female ratio is 3:1. Out of these cases, 139 (97.20%) were performed for malignancy and 4 (2.79%) for benign cases, which include peptic stricture, sigmoid esophagus. The mean operative time is 457.97 ± 79.35 min. The mean blood loss was 138.08 ± 29.3mL. Out of these cases, the hand-sewn anastomosis was performed in 72 (50.34%), circular stapler anastomosis in 46 (32.16%) and, linear stapled anastomosis in 25 (17.48%). The mean lymph node retrieval rate was 22.68 ± 9.49 nodes. The average ICU stay in the postoperative period was 4.68 ± 3.95 days, and overall hospital stay was 13.48 ± 7.43 days. Among malignant cases (139), adenocarcinoma in 121 (87.05%), squamous cell carcinoma in 18 (12.94%). Among these cases T2, lesions in 56 (40.28%), T3 lesions in 77 (55.39%), T4 lesions in 6 (4.31%) The overall complication rate was 12.58% (pneumonia- 8.39%, RLN injury in 1.39%, anastomotic leak in 2.09%, chyle leak in 0.69%, anastomotic stricture in 12.58%). 3 (2.09%) cases had re-intervention in the form of combined endoscopic procedures (stenting) and re-thoracoscopic lavage in 3. Overall 30-day mortality in 1 case (0.69%).
Conclusion: Thoracolaparoscopic esophagectomy with intrathoracic Ivor Lewis anastomosis is an excellent option for selected patients, in experienced hands.
A 67-year-old man complained of the sudden onset of disabling pain in his right leg. He had already undergone full-endoscopic lumbar discectomy, interlaminar (FELD-IL) approach twice for lumbar disc herniation (LDH) at the L4/5 level. MRI showed recurrence of LDH at L4/5 level. Intradural masses were also suspected at the L4 vertebral level. Discography at the L4/5 disc showed contrast medium leakage from the disc to the subarachnoid space. Operation was performed and fragments of the herniated disc were carefully removed under a surgical microscope. The ventral dura mater could be seen adhering to the L4/5 disc. This report is the first documentation of intradural LDH after FELD-IL. Although FELD is less invasive than previous procedures, adhesion between dura mater and surrounding tissues may occur. It is most important to apply discography to confirm the presence of a hole between the intradural space and the disc.
We present an alternative didactic approach to the esophagogastric junction through an active liver retraction with a laparoscopic palpator. We believe this didactic approach is not necessarily carried by a well-trained team. However, it is a minor modification of the standard operation that has advantages on surgical training in academic centers.
Gastric cancer remains one of the most frequent cancers worldwide. Currently the only potentially curative treatment is surgery, often in combination with perioperative chemotherapy. Gastric cancer surgery is associated with significant morbidity. However, over the last few decades several potential advances have been introduced to improve the treatment for gastric cancer patients. Introduction of laparoscopic gastric cancer surgery has shown promising results and therefore gained popularity worldwide. This review describes an overview of laparoscopic gastrectomy for gastric cancer patients. In general, the introduction of laparoscopic surgery has shown improvement in the short-term outcomes of gastric cancer treatment. Laparoscopic approach for gastric cancer is feasible, safe and should be performed in experienced high volume centres. However, results from randomised trials in advanced gastric cancer are awaited to further determine the effect of a laparoscopic gastrectomy on oncological and long-term outcomes.
Surgical treatment for non-achalasia primary esophageal motility disorders is reserved for few situations. Proper selection of patients brings good outcomes with low morbidity, which makes surgical therapy an adequate therapeutic option. High resolution manometry reclassifies esophageal motility disorders. Interestingly, literature is scarce on surgical therapy for this new classification with per oral endoscopic myotomy as the leading treatment.
The incidence of renal cell carcinoma is rising and its represents the 2%, 3% of all cancers. The increased use of ultrasonography, contrast enhanced ultrasonography, computed tomography and magnetic resonance imaging have resulted in incidentally detected small renal masses (SRMs). SRMs represent a heterogeneous group of tumors that included metastatic lesions, benign, malignant, and cystic lesions. With the increase number of renal incidentalomas, we have seen an increase in therapeutic choices (surgery, ablation therapies and active surveillance). The role of imaging has progressively grown over the decades and became currently a cornerstone that is needed to perform diagnosis, treatment and follow-up of SRMs after ablation treatment. Hence, in this review, we critically assess recent literature on the role of imaging in the context of ablation management of SRMs with a focus on the diagnosis and follow-up protocol.
One anastomosis gastric bypass (OAGB) is a popular bariatric procedure, but controversies remain regarding biliary reflux and the potential risk of cancer. Esophagojejunostomy (EJ) in rats is a validated and reproducible model for the development of metaplasia [Barett’s esophagus (BE)] and esophageal adenocarcinoma (EA) with a minimal exposure of 12 to 20 weeks. We are analyzing the risks of BE and EA in an OAGB rat model and comparing these with the EJ rat model. The purpose of this study is to describe our OAGB and EJ techniques in rats that we used to evaluate biliary reflux and share our experience with scientists and the bariatric community. These operations are short and simple procedures with acceptable morbidity.
Aim: Transforaminal percutaneous endoscopic lumbar discectomy (TF-PELD) is usually performed under local anesthesia because the patient should be conscious to prevent nerve root injury. However, some patients cannot tolerate intraoperative pain and require intravenous analgesia, or must be converted to surgery under general anesthesia (GA). If PELD under GA can be performed safely, it is more convenient and comfortable for both the patient and surgeon.
Methods: A total of 49 cases (mean age, 53 years) were examined. PELD was performed under GA with free-run electromyography (f-EMG) monitoring. Clinical outcomes were assessed according to the visual analogue scale score (VAS) and the Oswestry disability index (ODI). All patients were monitored with f-EMG.
Results: VAS decreased from 7.7 to 1.1 and ODI from 62.3% to 20.5%. A true-positive was observed in one of 27 TF-PELD cases. Care during the procedure is necessary to avoid the risk of severe neurological injury. A false-negative was observed in one of 22 interlaminar (IL)-PELD cases. This patient complained of aggravated numbness for 6 months after surgery. False-positives were recorded in 2 cases of IL-PELD with a train wave just after removal of the herniated discs.
Conclusion: F-EMG monitoring during PELD under GA was useful to identify nerve root damage. TF-PELD under GA requires f-EMG to ensure safety. On the contrary, IL-PELD does not necessitate f-EMG.
Minimally-invasive conventional up-to-down laparoscopic approach is a widespread alternative for rectal cancer resection. Its potential benefits towards open surgery have been shown to rely, however, at secondary clinical outcomes, and its oncological non-inferiority compared with the traditional open approach has not been demonstrated yet. In this scenario, robotic-assisted minimally-invasive rectal resection has gained increasing popularity and promising expectancies. This narrative review aims to assemble the most updated evidence available and to discuss the future perspectives and challenges for this emergent surgical tool. The main benefit over conventional laparoscopy appears to be a reduction of conversion rates to open surgery, whereas the oncologic and functional outcomes seem similar than the other alternatives. Increased costs are the main limitation of the widespread of robotic technology. Low quality of the current evidence is remarkable.
Aim: To analyze the series in literature of pure robotic surgery.
Methods: A complete review of the literature was performed to identify papers with data concerning robotic synchronous treatment of colorectal liver metastases.
Results: Three papers demonstrate the feasibility of this kind of synchronous treatment.
Conclusion: Robotic synchronous treatment of primary tumor and colorectal liver metastasis is feasible and safe.
Aim: The incidence of adenocarcinoma among lung cancer patients has increased in recent years. We identified the factors affecting lymph node status in patients with primary lung adenocarcinoma who underwent minimally-invasive anatomic resection.
Methods: We retrospectively analyzed the medical records of primary lung adenocarcinoma patients who underwent minimally-invasive anatomic lung resections and mediastinal lymph node dissection between January 2012 and December 2017. We evaluated lymph node positivity and nodal status in each T and histologic subgroup, tumoral prognostic characteristics, minimally-invasive surgical methods and resection type.
Results: Of 473 patients who underwent anatomic resection for lung cancer between January 2012 and December 2017, 274 underwent minimally-invasive anatomic lung resections for primary lung cancer, 158 adenocarcinoma patients were analyzed in this study. Nodal status and number of positive lymph nodes were similar in the stages T1, T2, T3. Lymphovascular invasion (n : 78) and micropapillary predominance tended to be significant predisposing factors for lymph node metastasis. Mean dissected lymph node number was significantly higher in patients who underwent Robot-assisted thoracoscopic surgery compared to Video-assisted thoracoscopic surgery (P < 0.05), and in those who underwent lobectomy compared to segmentectomy (P < 0.05).
Conclusion: We were unable to demonstrate a relationship between T stage and N status. Factors contributing to unexpected N positivity were tumor characteristics that could not be identified in the preoperative period. We recommend performing systematic mediastinal lymph node dissection regardless of the size and histopathologic type of adenocarcinoma. In our study, robotic surgery and lobectomy operation showed superiority in dissecting more lymph nodes.
Transanal total mesorectal excision (TaTME) is widely performed for the resection of rectal cancer around the world. However, due to lower body mass index and a lack of necessity, TaTMEs have not been accepted in East Asia as generally as in Western countries. In East Asia, conventional laparoscopic surgeries have been performed with lower rates of open conversions and robotic surgery has been considered as an acceptable option for patients with narrow pelvis. This review article discusses TaTMEs from an East Asian perspective.
Aim: We report our four-arm robotic bronchial sleeve anatomical lung resection technique and its early results.
Methods: We retrospectively collected all the four-arm robotic sleeve anatomical lung resections we performed in our institution from February 2014 to August 2019. We reported the results as a series of cases.
Results: During that period, 582 robotic procedures were performed by a single surgeon, of which 486 were major anatomical lung resections. From this group, 10 patients (2%) underwent bronchial sleeve resections. All patients were treated on the right lung. Neither conversion nor major events occurred during surgery. The first bronchial sleeve was performed for Patient 219. The mean length of procedure was 164 (± 43) min. One patient died during hospitalization due to a non-related complication (gastric massive bleeding). Three patients had no complications. Six had minor complications (Clavien Dindo Grade 2) resulting in prolonged length of stay. The mean length of stay was 10 (± 5.7) days. No bronchial fistula occurred. All resection margins were R0.
Conclusion: Four-arm robotic bronchial sleeve is a feasible and safe procedure. Telemanipulation surgery offers excellent technical conditions to ensure a hand-sewed anastomosis and R0 resection. The technical principle and dissection are the same as those of open surgery. Patient selection and mastering of the telemanipulation device are mandatory to perform these complex and rare procedures.
Robotic-assisted abdominal surgery was introduced with the aim of overcoming the drawbacks of the conventional laparoscopic approach. The present narrative review focuses on the comparison between laparoscopic and robotic-assisted approaches for right colectomy (RC) regarding short- and long-term outcomes, costs, and learning curve. The main technical aspects related to the use of robotic assistance for this specific procedure are further discussed. Minimally invasive RC is considered technically challenging due to the particularities of the right and middle colic vascular anatomy. Robotic RC is not yet widespread due to its high cost and longer operating time. However, its use may result in advantages regarding short-term clinical outcomes, and it facilitates the acquisition of basic surgical skills by speeding up the learning curve of minimally invasive colorectal surgery.
Aim: Rates of clinically relevant postoperative morbidity after transanal endoscopic microsurgery (TEM) are low. For this reason, there are few descriptions in the literature on the management of these complications. Because of this lack of information, their importance may be either underestimated or overestimated (in the latter case, leading to overtreatment). The present article reports the frequency of the occurrence of postoperative surgical complications after TEM and describes various approaches to their management.
Methods: An observational study was carried out with prospective data collection and retrospective analysis from June 2004 to June 2019, including all patients undergoing TEM for rectal tumors. All postoperative complications were recorded using the Clavien-Dindo classification (Cl-D), as well as preoperative, surgical, postoperative, and pathological variables.
Results: During the study period, 778 patients underwent TEM, of whom 716 met the inclusion criteria. Postoperative morbidity was 22.1% (158/716). Clinically relevant morbidity (Cl-D > II) was 5% (36/716). The most frequent complication was rectal bleeding, occurring in 115/716 (16.1%) patients; 85 of these 115 (73.9%) patients were grade I Cl-D. Urinary complications were rare (30/716, 4.2%). Similarly, infectious complications of perianal and pelvic abscesses appeared in 7/716 (1%) patients, two of whom required colostomy.
Conclusion: Clinically relevant complications after TEM are rare. For this reason, experience of these complications is limited. Here, we propose a management protocol to ensure that these complications are neither underestimated nor subjected to excessively aggressive or unnecessary treatment.
Aim: The use of robotic-assisted laparoscopy seems fully adapted to pelvic surgery. However, few studies focus on robotic-assisted abdominoperineal resection (RAAPR). The aim of this study was to assess the feasibility, short-term postoperative outcomes, and pathological results of RAAPR. In addition, we provide a detailed description of the operative procedure and a brief review of the current literature.
Methods: Between January 2013 and April 2018, we performed a total of 428 robotic surgeries, including 294 colorectal resections (68.7%). Data were prospectively collected and included demographics, intraoperative findings, postoperative outcomes, and pathological data. For this study, we included the first 20 consecutive RAAPRs performed with the four-arm da Vinci Si surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA).
Results: Twenty patients (nine men) with a mean age of 68 years and a mean BMI of 24.5 ± 5.0 kg/m2 underwent RAAPR for low rectal adenocarcinoma (80%) or squamous cell carcinoma of the anal canal. Sixteen (80%) patients underwent preoperative pelvic radiotherapy and eight (40%) had a history of previous abdominal surgery. Mean operative duration was 218 ± 52 min. There was no conversion to open surgery. Mortality, reoperation, and morbidity rate were 5%, 25%, and 60%, respectively. Three (15%) patients presented perineal complications. Mean length of hospital stay was 20 days. Three (15%) patients had pT4 tumor. Mesorectal excision was considered complete in 90%. On average, 16.5 ± 7.2 lymph nodes were retrieved.
Conclusion: RAAPR is feasible, with acceptable pathologic and short-term outcomes. The current literature does not demonstrate significant differences between robotic and laparoscopic APR. Indeed, we cannot justify its use in routine on the basis on the available evidence.
Gynaecomastia is a benign clinical condition that can occur in men of all ages, attributed by the proliferation of glandular tissue. Most patients are asymptomatic while symptoms ranging from mild discomfort to severe pain can present in patients with gynaecomastia. In addition to these, this condition may affect the psychological well-being of patients leading to a need for further treatment. Medical treatment of primary gynaecomastia in the form of anti-oestrogen therapy has not been proven to be effective and there is no consensus regarding the drug of choice or optimal duration of treatment. Surgical treatment is usually the standard treatment in primary gynaecomastia. There have been various techniques described in the literature with the aim of restoring a pleasant chest shape with limited scar on incision. Most of the techniques however involve the use of a peri-areolar or a Wise pattern incision, which can be obvious, especially in patients with a tendency to scar badly. The authors describe a novel approach, whereby a single-port endoscopic subcutaneous mastectomy using the three-dimensional endoscopic system with incision placed along the anterior axillary line was performed for a patient with gynaecomastia and thereby conferring excellent aesthetic outcomes.