Even though robotic-assisted surgery is increasingly used for resection of non-small cell lung cancer (NSCLC), data on long-term oncologic outcomes of robotic surgery are still not well defined. The primary endpoint of this review is to analyse the long-term results of robotic lobectomy in NSCLC patients. A systematic research was performed using the PubMed database. Articles published from January 2008 to January 2019 were included. We excluded studies that did not provide results for the long-term outcomes of robotic lobectomy, studies that had fewer than 50 cases and ones that focused on results of sub-lobar resections. Therefore, ten eligible studies were included in this analysis. In total, 2873 patients, with a mean age ranging between 66 and 68 years, who underwent robotic lobectomy for NSCLC, were analysed. Most patients (81%) had early-stage disease. The five-year overall survival for stage I disease fluctuated between 77% and 100%. The five-year disease-free survival was reported to be near 73%. We can conclude that robotic assisted lobectomy is an effective minimally-invasive procedure for lung resection. The current literature shows that robotic lobectomy is associated with long-term survival and lasting disease-free survival, equivalent to those reached by video-assisted thoracic surgery and open approach.

The present article is a historical review intended to trace the most important phases in the development of robotic surgical technology, with a special focus on colorectal surgery. The initial section considers the origin and some etymological aspects of the word “robot”. Then, a historical overview traces the development of robotic technology in industry and its implementation within the operating theatres. Finally, the first publications concerning robot-assisted colon and rectal surgery are reported together with a brief state of the art about this issue.

Aim: Bariatric surgery is an effective treatment for morbid obesity that has inevitable complications including postoperative bleeding and staple-line leakage. Erythrocyte sedimentation rate (ESR) can be a clinical indicator for prediction of leakage.

Methods: This retrospective cohort study was done on 1999 patients who underwent sleeve gastrectomy in Erfan Niyayesh Hospital, Tehran, Iran. ESR levels of patients were evaluated in cases which had postoperative leak. Statistical analyses were performed using SPSS software.

Results: Among the 2350 patients, 50 subjects experienced gastric leak (2.12%). ESR mean was 73.1 mm/h for cases, statistically significantly higher in patients with leakage compared to the control group. In addition, ESR serum level mean was 31.34 mm/h for control groups. Other variables including C-reactive protein and platelet count were not statistically significant.

Conclusion: Higher ESR serum level can be seen in various conditions, and, in obese patients who undergo bariatric surgery, it can be a reliable predictor for postoperative gastric leak complication.

Total mesorectal excision (TME) is accepted as the standard technique in rectal surgery. In recent years, significant attention has been focused on transanal TME (taTME) as a promising approach for rectal cancer. However, this approach can involve an inherent risk of male urethral injury, because there is no clear anatomical border between the rectal muscularis propria and rectourethral muscle. We used a lighted urethral stent to identify the urethra during taTME for 6 patients with distal rectal cancer. In five of six cases, an infrared-detecting camera could detect a red fluorescent signal from the lighted urethral stent during the anterior dissection of the rectum, which helped us to determine the correct dissection line. A lighted urethral stent is a useful tool that helps visualize the urethra during taTME and improves taTME applicability in clinical practice.

For robotic thoracic surgical patients, minimizing pulmonary complications is the key to decreasing morbidity. Once the pain is controlled, the morbidity associated with thoracic surgery is decreased. Consequently, control of pain is the core requirement in robotic thoracic surgical patients. Appropriate pain control depends on a multifaceted program that is based on an understanding of the pathophysiology of pain. A multifaceted pain control program after robotic surgery needs to address local and systemic pain pathways. This review outlines such a multifaceted program with the use of subpleural catheters for prolonged ambulatory infusion of local anesthetic for 10 days, nonsteroidal anti-inflammatory agents, and measured use of narcotic analgesics.

Aim: We report our experience in minimally invasive thoracic robot-assisted surgery in children, and a current analysis is carried out on this topic.

Methods: Observational, prospective, and longitudinal studies were performed for children with thoracic pathology treated with robotic surgery, from March 2015 to April 2019. We used the “da Vinci surgical system” (Intuitive Surgical, Inc., Sunnyvale, CA. USA). Registered variables included demographic data, diagnosis, surgery, total time, time of console surgery, bleeding, hemotransfusions, conversions, complications, postoperative (PO) stay, and follow-up. Measures of central tendency were used. Research Ethics Committee of Hospital approved the study. We conducted a detailed non-systematic review of previous publications of children undergoing thoracic robotic surgery.

Results: We treated 11 children, with average age of 5.7 years and weight of 21.3 kg. Diagnosis were: congenital cystic adenomatoid malformation, intralobar sequestration, diaphragmatic paralysis, diaphragmatic eventration, mediastinal teratoma, Ewing’s tumor of the fourth left rib, and pulmonary tuberculosis. Surgeries performed were: four lobectomies, four diaphragmatic plications, two tumor resections, and a case of pleural and lung biopsies. The average of console surgery time was 166.45 min, PO stay was 3.6 days, and follow-up was 24.7 months. Conversions and PO complications were 9.1%, and there were no intraoperative complications and mortality. Currently, the number of children treated with thoracic robot-assisted surgery has barely reached 100 cases.

Conclusion: Our results are encouraging, although our experience is limited to a few cases. Robotic surgery for the treatment of thoracic pathology is feasible and safe, and has advantages. To date, very few patients have been treated, and few pediatric surgeons worldwide have applied thoracic robotic surgery in children.

Thoracoscopic surgeries have witnessed tremendous and prompt recent development, especially in the field of uniportal video assisted thoracoscopic surgery (VATS) surgery. It is now possible to perform the most complex surgeries through this technique, which is of great benefit to the patient by significantly reducing the level of postoperative pain and complications of surgery. As surgeons gain experience in this field, their confidence and ability to push the limits and develop technologies are increasing. Performing uniportal VATS surgeries in children is a significant challenge for the surgeon due to the limited size of the thoracic cavity and the difficulty of the instrumentation. Here, we report the first case in the literature (as far as we know) of a uniportal Subxiphoid VATS lobectomy in a 2.5-year-old child. In conclusion, Subxiphoid uniportal VATS lobectomy is feasible in pediatric patients and may have some benefits over the intercostal approach.

The surgical approach for lobectomy has changed over time with recent data demonstrating that the majority are performed using a minimally invasive approach. While the use of the robotic platform for pulmonary resection has been shown to have acceptable clinical outcomes, cost and quality of life need to be considered when starting a robotic lobectomy program. In this review, we evaluate the literature on cost of robotic lobectomy and quality of life. The results suggest that early experience in a robotic lobectomy program may be associated with relatively higher index hospital costs when compared to video-assisted thoracoscopic surgery; however, with increased experience and volume, the difference may no longer be of significance. When compared with thoracotomy, the cost is comparable if not less costly and may even be profitable for the hospital. Quality of life appears to be acceptable in the early experience of robotic lobectomy.

Aim: Currently, there is a paucity of data comparing robotic to traditional video-assisted thoracic surgery stapling devices and the effects on perioperative outcomes during robotic anatomic lung resection. We sought to investigate our institutional experience with patients undergoing robotic anatomic lung resection stratified by the type of stapler used over a contemporary period.

Methods: We performed a retrospective review of a prospectively maintained thoracic surgery database and evaluated all patients who underwent robotic anatomic lung resection between January 2015 and December 2018. Patients were grouped based on the type of stapler used during surgery and preoperative characteristics and intraoperative and postoperative outcomes were compared.

Results: In total, 634 lung resections occurred during the study period. Of those, 236 met inclusion criteria, and 49 cases (20.8%) fully utilized the robotic stapler. We found no clinically significant difference in preoperative or intraoperative characteristics between groups, except operative time was longer in the robot stapler group. This was likely related to surgeon learning curve. There were no differences between groups in postoperative outcomes or complications.

Conclusion: We found equivalent rates of complications, prolonged air leak, and chest tube duration between the two groups. Based on our data, we recommend that surgeons use the stapling device with which they are most confident.

Nodal upstaging takes place when unsuspected lymph node metastases are detected by pathological evaluation, after surgical treatment for non-small cell lung cancer. In early stages non-small cell lung cancer, nodal upstaging amounts to 4.8%-24.6%, depending on several factors, such as accuracy of preoperative staging, localisation and size of tumour and number of lymph nodes removed. Nodal upstaging is considered a surrogate of the completeness of thoracic oncologic surgery; for this reason, various studies focus on the evaluation of its rate in the different surgical approaches used to treat lung cancer. In this analysis, a high percentage of upstaging is observed in robotic surgery, having similar values to open surgery results, usually considered the gold standard in terms of oncologic radicality. In fact, thanks to its features, robotic surgery allows carrying out a thorough lymphadenectomy in the most comfortable manner, ensuring an excellent vision and manoeuvrability of the instruments even in the most remote areas of the thorax. According to these results, robotic surgery constitutes a safe and radical surgical option, showing encouraging results on the efficacy of lymphadenectomy and, consequently, on its the long-term outcomes.

Aim: Thoracic sympathectomy is indicated in patients with upper extremity hyperhidrosis. The success of dorsal thoracic sympathectomy is judged by the rates of relief of hyperhidrosis, recurrence, and compensatory hyperhidrosis. We studied robotic selective sympathectomy (RSS) directed at the division of the preganglionic and postganglionic rami without interruption of the sympathetic chain.

Methods: During RSS, the preganglionic and postganglionic sympathetic fibers and communicating rami to intercostal nerves 2, 3, and 4 are divided. The sympathetic chain is left intact.

Results: Forty-seven patients underwent RSS. RSS was performed in a staged fashion with the more symptomatic side first, followed by the contralateral side after at least four weeks. Mean operative time was 67 ± 13 min for unilateral RSS. There was no conversion to thoracotomy. The mean increase in ipsilateral palmar temperature was 1.2 ± 0.3 °C. Median hospital stay was three days (range 1-4 days). Complications included transient heart block after sympathectomy on the second side in 1/47 (2%) and transient partial Horner’s syndrome which resolved in two weeks in 1/47 (2%). There was no permanent Horner’s syndrome. Relief of hyperhidrosis was seen in 98% of patients. At a mean follow up of 28 ± 6 months, 46/47 (98%) patients were free of sustained compensatory hyperhidrosis.

Conclusion: RSS is associated with excellent relief of hyperhidrosis and the lowest reported rate of compensatory hyperhidrosis.

Bariatric surgeries have proven to be an effective treatment for morbid obesity to reduce the excess body weight of the individuals. Besides weight loss and improvement in metabolic parameters, bariatric surgery procedures can also cause some complications. One of the most common complications observed after bariatric surgery is vitamin deficiencies. Vitamin deficiencies occur due to malabsorptive surgery in patients with absorption disorder and restrictive surgery in patients with inadequate intake. These deficiencies may be accompanied by systematic and neurological findings. Therefore, regular follow-up of patients after bariatric surgery is crucial. If any vitamin deficiency is detected in the patient clinically or biochemically, it is recommended to eliminate this deficiency through supplementation.

The incidence of bariatric surgery is increasing exponentially. The number of bariatric surgeries performed in the United States has significantly increased in the past decades. Complications of bariatric surgery can present days to years postoperatively. Advances in endoscopic procedures and technology has made it possible to address many complications endoscopically. We describe the most common complications after bariatric surgery and the endoscopic treatment options available to date.

More and more data are available on the benefits of minimally invasive thoracic surgery compared to open thoracic surgery in the curative treatment of early-stage non-small cell lung cancer. However, results are conflicting, especially when video-assisted thoracoscopic surgery (VATS) is compared to robotic-assisted thoracoscopic surgery (RATS) for lobectomy. Our goal is to report the main results of recent systematic reviews and meta-analyses comparing RATS, VATS, and open surgery for lobectomy. Using PubMed database, we selected systematic reviews and meta-analyses, which compared the short-term outcomes of patients treated by RATS, VATS, or open surgery for lobectomy. In all but one of the systematic reviews, robotic lobectomy allowed similar short-term outcomes as VATS lobectomy and better short-term outcomes than open surgery. One meta-analysis by O’Sullivan et al. found that robotic lobectomy was associated with fewer adverse events (P < 0.00001) and lower 30-day mortality (P = 0.001), compared to VATS lobectomy. Robotic lobectomy could be a valid alternative to VATS and open lobectomy. Short-term outcomes do not appear to be different between VATS and RATS cohorts, except in one recent meta-analysis, which reported the superiority of RATS compared to VATS. Without cost analysis and randomized controlled trials with long-term outcomes, no strong conclusions can be drawn.

Aim: After bariatric surgery, a variety of complaints may arise. Identification of the causes of such symptoms is often challenging due to the postoperatively modified anatomy. While standard examinations with upper endoscopy and upper gastrointestinal series might miss the three-dimensional anatomic nature of the problem, quantitative three-dimensional computed tomography volumetry (3D-CT) of the upper gastrointestinal tract offers a novel, adjunctive examination, revealing the detailed anatomy. The aim of this study was to analyse the clinical value of 3D-CT in post-bariatric patients.

Methods: Prospective data of 279 patients, who underwent 3D-CT due to complications after different bariatric procedures, were retrospectively analysed. Directly before examination, the surgical-modified stomach was distended with an effervescent-powder. CT images were 3D-reconstructed and, further, gastric volume was calculated.

Results: In total, 279 patients were examined. Time between surgery and examination was significantly different between Roux-en-Y gastric bypass (n = 168) (54.3 ± 38.6 months) and sleeve gastrectomy (n = 78) (27.8 ± 21.7 months) (P = 0.0001). Others, less numerous, but included procedures were one-anastomosis/mini gastric bypass (n = 11), and dated procedures, such as the vertical banded gastrostomy. The examination allowed calculation of the gastric volume, and the 3D-reconstructions depicted accurately the pivotable anatomic details of the modified upper gastrointestinal tract with 360° view. As a robust result, patients with a higher gastric volume showed more weight regain after sleeve gastrectomy.

Conclusion: 3D-CT is easy-to-perform and facilitates identification of the post-surgical three-dimensional gastric anatomy. It represents a valuable additional diagnostic tool in post-bariatric patients with post-procedural complications. 3D-CT might be an important preoperative tool prior to revisional surgery. In addition, this is the only exact and reproducible calculation of the gastric volume.

Transanal surgery has evolved significantly in the past few decades. With the technological advancements of endoscopic systems, minimally invasive approaches in transanal surgeries are quickly increasing in popularity. Transanal endoscopic microsurgery was developed initially with subsequent transanal minimally invasive surgery (TAMIS) being introduced as an alternative in 2009. Over the past decade, more and more papers have been published on TAMIS, regarding the management of benign/malignant rectal lesions as well as repair of anastomotic leaks, anastomotic strictures, rectovaginal/rectourethral fistula, etc. This review details the progress of transanal surgery and the use of TAMIS in different scenarios.

Transanal minimally invasive surgery (TAMIS) is a surgical technique which allows the local excision of rectal benign tumors and early stage cancers measuring up to 4 cm and lying within 6-8 cm from the anal verge. It is performed by means of a disposable transanal platform and conventional laparoscopic instruments, proving to be effective and easily available. Hence, TAMIS soon became a valid alternative to other transanal resective procedures, especially transanal endoscopic microsurgery, and rapidly spread. Moreover, soon after its introduction, TAMIS started to be performed also using robotic technologies, but no clear advantages were found to date. This review is intended to provide a general overview on TAMIS, with a special focus on its association with robotic systems and the perspectives of this approach.

Obesity is a growing epidemic affecting more than one third of the United States’ population. It has detrimental effects on an individual’s health and is associated with myriad negative outcomes including increased mortality. It also poses a substantial financial burden on the healthcare system. Weight loss surgery is an effective way of treating obesity with tremendous positive outcomes. Most patients who undergo bariatric surgery lose a significant amount of weight, reverse most of their comorbidities, and enjoy an improved quality of life. However, fewer than one percent of patients eligible for bariatric surgery actually undergo treatment. Furthermore, there exists a considerable gender disparity, with women comprising 80% of those patients who undergo bariatric surgery, despite equal obesity rates across genders. Many barriers exist between obese patients and weight loss surgery including misconceptions among patients and primary care providers regarding the perceived risk of surgery. This is in addition to numerous other psychosocial and cultural factors that may have contributed to and precipitated the existing gender imbalance. This review aims to highlight barriers to patients undergoing bariatric surgery and examine factors leading to the gender disparity that exists.

Aim: Laparoscopic anterior esophageal myotomy with a Dor anterior fundoplication is the most commonly performed surgical myotomy procedure. A lateral esophageal myotomy without an antireflux procedure performed through a left thoracotomy has been associated with the lowest rate of postoperative gastroesophageal reflux and the highest rate for relief of dysphagia. The surgical robot allows for the lateral myotomy procedure to be performed by laparoscopy rather than thoracotomy. We studied our experience with Robotic Lateral Heller Myotomy Without Fundoplication (RLHM) for achalasia.

Methods: A retrospective review was conducted of the patients with achalasia who underwent RLHM. All patients completed a subjective dysphagia score questionnaire, received an Eckardt Score, and underwent manometry and pH testing preoperatively, as well as at 6 and 12 months following the myotomy procedure.

Results: Forty-eight patients underwent RLHM. The median operating room time was 85 min (range 60-132 min). There was no conversion to a laparotomy. Median hospitalization was 2 days (range 2-3 days). There were no mucosal perforations, complications, or deaths. Following RLHM, the Lower Esophageal pressure decreased from 35 mmHg (range 18-120 mmHg) to 13.2 mmHg (range 9.8-16.6 mmHg) (P < 0.0001). The length of the Lower Esophageal high-pressure xone decreased from 5.5 cm (range 4-9 cm) to 2.2 cm (range 1.5-2.8 cm) (P < 0.0001). Two patients (2/48) (4.2%) had pathologic gastroesophageal reflux. The median acid exposure in all patients was 0.4% (range 0%-17.8%), and the median Demeester score was 7.5 (range 2-125). The Eckardt score decreased from 6.3 ± 1.8 to 0.8 ± 1.8 at 1 month (P < 0.0001), and 0.8 ± 1.1 at 12 months (P < 0.0001).

Conclusion: RLHM is associated with excellent relief of dysphagia and a low incidence of new gastroesophageal reflux.

Obesity is an expanding threat globally. Several surgical procedures have been developed to achieve the best outcomes in obesity. One of them is laparoscopic sleeve gastrectomy that was first applied in 1999 to initiate weight loss in overweight patients. Laparoscopic sleeve gastrectomy is a restrictive bariatric technique consisting of subtotal partial vertical gastrectomy with the preservation of the pylorus, and a gastric tube is created as a continuation of the esophagus along the lesser curvature with the resection of the fundus, corpus, and antrum. Although this technique is routinely-applied all over the world, the technical details are still controversial. This review aims to define the tips and tricks for the sleeve gastrectomy technique and discuss the controversial subjects in this technique.

Aim: We aimed to evaluate the feasibility of single-port laparoscopic myomectomy in the virgin womb.

Methods: A retrospective chart review of 31 consecutive cases between November 2017 and October 2019 performed by a single surgeon was performed.

Results: The mean age of patient was 50.10 ± 7.79 years old. The mean BMI was 23.55 ± 4.36 kg/m². The mean number of myoma in single patient was 3.84 ± 2.45 pieces. The mean maximum diameter of myoma in single patient was 11.24 ± 3.27 cm. The mean operation time was 182.32 ± 52.39 min. The mean blood loss was 231.77 ± 238.90 mL. The Visual Analogue Score (VAS) of pain when immediately arriving at the ward after operation was 2.32 ± 1.60. The VAS after 24 h dropped to 1.23 ± 1.43. In total, 119 myomas were removed in our study. There were 15 (48.4%) women with more than four myomas. Fifteen (48.4%) women had more than two myomas that were > 5 cm. There were 58 (48.74%) intramural myomas, with mean diameter of 6.72 ± 4.41 cm. Fifty-two (43.70%) subserous type myoma were removed with mean diameter 2.58 ± 3.35 cm. Posterior myoma accounted for five (4.20%) pieces with mean diameter of 9.30 ± 4.49 cm. The broad ligament type myoma accounted for four pieces (3.36%), and the mean diameter was 3.74 ± 1.87 cm. There were 51 (42.9%) myomas > 5 cm in diameter. Among the different types of myoma, there were 36 (62.1%) intramural type and 6 (11.5%) subserous type, and all posterior and broad ligament type were > 5 cm in diameter. The blood loss and operation time showed no relationship to myoma number. There were differences in blood loss (P = 0.0359) and operation time (P = 0.0537) based on the maximum diameter of myoma. No learning curve was noted in the cumulative sum control chart analysis of the 31 consecutive cases.

Conclusion: In our 31 consecutive cases, the operation time, blood loss, and postoperative VAS score were all comparable to the previously published literature for single-port laparoscopic myomectomy. It is feasible for virgin women with symptomatic myoma to receive single-port laparoscopic myomectomy.

Endo-bronchial tumors are sporadic in the pediatric population. Pneumonectomy is rarely indicated and best to be avoided if possible due to the morbidity it may cause. In children, preserving as much of the lung parenchymal tissue as possible is crucial and maintaining the integrity of the "still maturing" chest wall may reduce the risk of developing scoliosis and chest deformities in the future. The integration of minimally invasive surgical techniques and parenchymal sparing procedures rep-resents the best possible outcome for these patients. Of course, oncological principles should be re-spected when such a procedure is performed. We present the first report in the literature of a "left" upper lobe sleeve resection in an 8 year old patient via a single port video-assisted thoracoscopic surgery technique.

Sentinel lymph node biopsy is currently the standard of care for axillary staging in early breast cancer patients with no clinical or radiological evidence of axillary lymph node involvement. Novel techniques studied in recent years include the use indocyanine green (ICG) fluorescence imaging, which was reported in a recent network meta-analysis to be comparable to standard dual modality in terms of false negative as well as detection rate. However, there have been no standardized operative methods leading to the underutilization of this modality in clinical practice. In addition, technical limitations such as the difficulty in tracing ICG flow in obese patients further restrict the use of ICG fluorescence in sentinel lymph node biopsy. In this article, we describe in detail the use of the endoscopic-assisted ICG technique in performing sentinel lymph node biopsy, which addresses limitations associated with conventional use of ICG fluorescence imaging. The technical novelty of this technique lies in the fact that it has not been previously described in the literature and it allows for the identification of sentinel lymph nodes with minimal incision and tissue disruption as well.

The surgical management of rectal cancers located in the distal rectum presents a unique challenge for surgeons as it is anatomically unfavorable and technically difficult to access. Over the course of the 20th century, novel techniques contributed to the improvement of rectal cancer management and led to improved quality of life for patients following surgical resection. In this article, we explore the background of rectal surgery techniques, which have progressed from abdominal perineal resection to transanal abdominal transanal proctosigmoidectomy, transanal total mesorectal excision (taTME), and ultimately minimally invasive transanal sphincter preserving techniques utilizing single port robotic technology (SPr taTME). In the first clinical experience with the DaVinci SP robot in the United States, we are finding many advantages of this new platform in transanal surgery. The SP offers superior image quality with 3D view, wristed instruments facilitating ergonomics, and superior surgical precision.

This chapter is devoted towards analyzing the progress and barriers to the development of artificial intelligence (AI) and medical robotics in minimally-invasive surgery. The less invasive the surgical intervention and the further the surgeon is from the operating table, the greater the roles of decision support systems (AI) and performance of specific tasks (by medical robots).

The current obesity pandemic has a clear impact on quality of life and health resource utilization; hence it has become a significant global health concern. Multiple obesity-related comorbidities such as gastroesophageal reflux disease (GERD) are frequently observed among this patient population. GERD is a complex disease with multiple elements contributing to the failure of the anti-reflux barrier. If left untreated, the excessive reflux of gastric contents into the esophagus can give rise to multiple complications such as esophagitis, strictures, metaplasia, and cancer. When surgical treatment of GERD is indicated in an obese patient, adequate preoperative evaluation and treatment are critical to achieve durable resolution of symptoms attributed to GERD as well as other obesity related comorbidities. To maximize the potential for a positive outcome, when suitable, gastric bypass surgery rather than sleeve gastrectomy or fundoplication should be strongly considered in the obese patient with GERD.

Aim: Recurrent laryngeal nerve paralysis (RLNP) after esophageal cancer surgery, especially on the left, is a major clinical challenge. We believe that the use of intra-operative neural monitoring can help us to learn and identify surgical maneuvers that can cause RLNP, so as to improve the postoperative course for patients. Thus, the aim of this study was to determine the causes of RLNP and to devise a preventive surgical technique.

Methods: Radical esophageal cancer surgery was performed with intra-operative neural monitoring at our institution from July 2015 to January 2019. The cause(s) of RLNP was investigated by video analysis, which enabled a preventive technique to be developed and introduced. Short-term surgical outcomes of the modified and conventional surgical methods were compared.

Results: RLNP occurred in 10/57 (17.5%) of cases. The causes of paralysis were traction (n = 5), compression (n = 3), thermal injury (n = 1), and compression in cervical procedure (n = 1). Subsequently, 20 surgeries were performed between February and December 2019 using the modified technique and there was only one case (5%) of RLNP.

Conclusion: The main causes of RLNP are compression and traction. Our modified technique for esophageal cancer surgery substantially decreases the incidence of RLNP post-operatively.

Heart transplant is the primary treatment for end-stage heart failure; however, morbid obesity limits candidacy. Bariatric surgery performed in patients with advanced heart failure improves eligibility for heart transplantation. This is the first report of an intra-aortic balloon pump used during laparoscopic sleeve gastrectomy. A patient with morbid obesity and non-ischemic cardiomyopathy was referred for weight loss surgery prior to evaluation for heart transplantation. An intra-aortic balloon pump was placed for aggressive diuresis and cardiovascular support during laparoscopic sleeve gastrectomy. The patient did not suffer any complications or require readmission. The use of an intra-aortic balloon pump as a mechanical circulatory system provided a safe laparoscopic sleeve gastrectomy in a patient with advanced heart failure.

We developed a method for mediastinoscopic esophagectomy via a bilateral transcervical and transhiatal approach under pneumomediastinum as a less-invasive radical operation. The right recurrent nerve is first identified using an open approach, and the right cervical paraesophageal lymph nodes and part of the right recurrent nerve lymph nodes are dissected, after which pneumomediastinum is initiated. The upper thoracic paraesophageal lymph nodes and right recurrent nerve lymph nodes are dissected along the right vagus nerve. The dorsal side of the esophagus is dissected along the visceral sheath taking care to avoid thoracic duct injury and is then dissected along the vascular sheath in front of the descending aorta. The esophagus is dissected from the trachea at the caudal side of the aortic arch, and then dissected along the ventral side of the left main bronchus, reaching the pulmonary artery. Finally, the right recurrent nerve lymph nodes around the right subclavian artery are completely retrieved. The left cervical approach is almost the same as that via the right side. The dorsal side of the esophagus is almost dissected along the visceral sheath with a right transcervical approach. The subaortic arch to the left tracheobronchial lymph nodes are dissected using the crossover technique. These lymph nodes are easily dissected by cutting the left and ventral side of the lymph nodes because the caudal side is already dissected in the right transcervical approach. A bilateral (especially right trans-cervico-pneumomediastinal) approach is useful for bilateral upper mediastinal lymph node dissection and esophagectomy.

Aim: We have recently standardized upper mediastinal lymph node dissection (UMLND) based on microanatomical concepts in minimally invasive esophagectomy using a 4K ultra-high-definition (HD) system. In this study, the aim was to investigate the outcomes of microanatomy-based standardization using 4K ultra-HD for UMLND with the main focus on thoracoscopic operative time.

Methods: We have performed more than 500 cases of thoracoscopic esophagectomy in the prone position as minimally invasive esophagectomy. After about 400 cases of thoracoscopic esophagectomy in the prone position, we established the microanatomy-based standardization of UMLND using a 4K ultra-HD system. Two groups were analyzed: a pre-standardization group (n = 100) and a post-standardization group (n = 100). Furthermore, the change in our thoracoscopic operative time for all cases was analyzed using the moving average method.

Results: In the post-standardization group, the rate of surgeries performed by operators with less than 20 years’ experience was significantly higher (P < 0.001). There were no significant differences in the number of mediastinal lymph nodes dissected, intraoperative blood loss and total postoperative morbidity rates between the two groups. The rate of recurrent laryngeal nerve palsy decreased to less than half (19.8% to 9.6%) (P = 0.061) and the thoracoscopic operative time decreased [232.0 (202.8-264.0) min to 209.0 (176.0-235.0) min] significantly (P < 0.001) after standardization. The moving average showed a marked decrease of thoracoscopic operative time during the standardization phase.

Conclusion: Microanatomy-based standardization enabled quicker and more precise UMLD despite an increase in the number of surgeries performed by less experienced operators.

Total mesorectal excision remains the gold standard for surgical treatment for rectal cancer to achieve excellent oncological outcomes. The transanal approach to the mesorectum was introduced to complement conventional surgery so that technical difficulties related to the distal rectal dissection could be overcome. Since its introduction, interest in transanal mesorectal excision has been growing and it appears that the benefits are maximal in patients with mid-low rectal cancer where anatomical and pathological factors present the greatest challenges. Current evidence demonstrates this approach is safe and feasible, with an acceptable morbidity profile, but with specific complications related to the technique. Oncological and functional data seem comparable to the conventional approaches, but most of the results come from small studies with short-term endpoints. Robotics, when available, might potentially overcome the difficulty of distal rectal dissection with a shorter learning curve compared to the transanal approach, but with higher costs. The aim of this review is to critically evaluate the available literature concerning transanal total mesorectal excision so that we can better define its role in the management of rectal cancer.

The recent improvement in surgical techniques for non-small cell lung cancer enables evident better results in term of postoperative recovery with lower adverse events. Even though the interest in minimally invasive procedures has increased, more subjective advantages are not always so apparent in the literature. There is indeed a growing interest in the daily life of patients including their management of physical and emotional pain, the perception of quality of life, and pulmonary function recovery. This review aims to highlight the advantages of minimal invasive surgery on pain, quality of life, and functional pulmonary recovery after lobectomy alone for early stage non-small cell lung cancer. Minimal invasive techniques or limited sparing open techniques offer better results in term of postoperative pain than open non-sparing techniques, allowing a lighter analgesia protocol. However, these clear benefits seem to disappear in the mid-term postoperative period. Studies suggest that minimal invasive surgery is non-inferior to thoracotomy in terms of quality of life, and seems to give patients at least a better vision of their health, but larger-scale studies are needed to demonstrate its superiority. Data show clear advantages in the postoperative pulmonary function recovery for minimal invasive surgery compared to that of open procedures, although sparing and anterior incisions can show equivalence. That benefit does not seem to persist in the mid and long term. Nevertheless, the posterolateral thoracotomy appears to have the worse effect on the loss of pulmonary function.

Transcatheter mitral valve implantation provides an off-pump treatment option for mitral valve regurgitation, especially for secondary mitral regurgitation. It offers an opportunity for the treatment of a large cohort of patients not referred for conventional surgery. One of the biggest challenges is the development of a valved stent that suits the complex anatomy of the native mitral valve. Furthermore, secure anchorage of the device is difficult in the mitral area without clearly defined structures. In the last few years, various new self-expanding nitinol valved stents for transapical implantation in the beating heart have been developed. Different design iterations were conducted to improve fixation and overall stent performance. The risk of paravalvular leakage was decreased and reproducibility enhanced. This article reviews the major achievements in the development process of our apically fixed mitral valved stent over the last few years, with prototypes that provide secure stent deployment, high reproducibility and low paravalvular leakage rates.

Thymectomy is an effective treatment option for the management of myasthenia gravis, as demonstrated by a recent multicenter randomized clinical trial. Complete removal of all thymic tissue, including ectopic foci, increases the chance of achieving a remission or a substantial improvement of the disease; therefore, extended transsternal thymectomy was long considered the procedure of choice. Over the years, several minimally invasive approaches have been proposed, with the aim to reduce perioperative morbidity and to improve aesthetics; however, concerns exist that through such approaches, it may not be possible to achieve a complete resection. Robotic thymectomy seems to overcome many of the limitations associated with other minimally invasive approaches. The available evidence suggests that robotic thymectomy for myasthenia gravis is a safe procedure, and that long-term neurological outcomes are satisfactory.

The evolution of video technology and instrumentation have revolutionised the way lung resections are performed without compromising outcomes. In a new thoracic surgery setup, we have adopted the uniportal video assisted thoracoscopic surgery (U-VATS) technique for lung resections in most of our cases. A retrospective review of operative records from July 2017 till June 2019 in Hospital Kuala Lumpur (HKL) for all thoracic surgeries was done. Patients were divided into two groups: those that underwent U-VATS surgery in the first and second year as part of the learning curve. The operative time, blood loss, lymph node yield, duration of drain placement, and length of hospital stay were compared between the groups. The most common indication for U-VATS surgery was malignant lung tumors (21%) followed by ruptured bullae (20%) and empyema thoracis (15%). The average time taken for lobectomies performed for non-small cell lung cancer was 201 min. U-VATS decortication caused the most amount of blood loss with an average of 350 mL, followed by aspergilloma at 315 mL and bronchoplasty at 250 mL. The rest of the procedures had < 150 mL of blood loss. There was no significant difference in the parameters compared between procedures in the two groups.No mortality was seen.The learning curve of U-VATS was used as a guide to gradually increase the complexity of cases performed in a pyramidal manner. U-VATS is an alternative and promising minimal access approach in thoracic surgery that can be safely performed in Malaysia.

Aim: The purpose of this study is to investigate the efficacy of surgical management in ovarian endometrioma for early disease control and long-term fertility preservation in adolescents and women of very young age. A history of cyclic pains in adolescents is highly associated with endometriosis. Sonography enables the diagnosis of small endometriomas 1-2 cm in diameter. Although it is obvious that the risk of damage to normal ovarian tissue is diminished when operating and removing a 2 cm endometrioma, it is not approved since there are currently no tools available to identify at-risk patients. Additionally, performing laparoscopic surgery with 5 mm instruments in patients with small endometriomas will likely cause more harm than benefit.

Methods: A literature review was performed using key words for endometrioma surgery, in vitro fertilization (IVF), implantation rate, pregnancy rate and adolescents. The pros and cons of surgical removal prior to assisted reproductive therapy (ART), outcomes of endometrioma surgical treatment before IVF, and current recommendations for endometrioma removal were investigated.

Results: The total patient population from articles supporting removal of endometrioma before assisted reproductive therapy and evidence against were 30,741 and 9983 respectively. However, the only study reporting a statistically significant result found an 8.2% implantation rate for the surgical removal group vs. 12% in the direct-to-IVF group, and 14.9% pregnancy rate in the surgical removal group vs. 24.9% in the direct-to-IVF group. Damage to ovarian reserve and function due to surgery is exacerbated by large cyst size, stripping of the pseudocapsule and older age. Larger endometrioma, ablation of the endometrioma base and younger age are associated with higher recurrence rate.

Conclusion: The patient’s age, in addition to the size and type of endometrioma, can direct and indicate the timing of surgical management. Bilateral endometriomas and those larger than 7 cm are associated with more damage to ovarian reserve due to disease and surgery, as compared with unilateral lesions and those smaller than 7 cm. High-risk adolescents and very young women seeking fertility treatment can thus benefit from an early diagnosis of endometrioma. Treatment by trans vaginal hydro-laparoscopy of selected cases can probably be suggested for the treatment of small endometriomas, since 5fr instruments are used following microsurgery principles. Therefore, an early diagnosis of endometrioma, especially in young patients, must be encouraged, improved and standardized, through stepwise clinical reasoning and diagnostic testing.

Locally advanced non-small cell lung cancer (NSCLC) has historically been defined as Stage III by the IASCLC staging. While the workup for these patients has been standardized, the treatment algorithms remain unclear. The use of neoadjuvant chemotherapy, radiotherapy, and now immunotherapy still awaits results in terms of optimal regimen. Surgery for local disease control is routinely used and this group of patients have historically been treated with open thoracotomy for resection. Only in the last 10-20 years have minimally invasive surgical methods been applied for treatment. Video-assisted and robotic-assisted thoracoscopic surgery have retrospectively been shown to be safe and effective with equivalent or better perioperative outcomes, long-term overall and disease-free survival, mediastinal lymph node staging to open thoracotomy, and the ability to operate on patients who are too sick for thoracotomy. This review shows that minimally invasive surgery for treatment of locally advanced NSCLC disease should now be routinely offered to patients as the initial surgical method of resection.

Aim: Esophagectomy is associated with several post-operative complications (50%-70%) due to surgical trauma. Minimally invasive techniques have therefore been applied to decrease mortality and morbidity. Robot-assisted minimally-invasive esophagectomy (RAMIE) was developed to overcome the drawbacks of the thoraco-laparoscopic approach. The objective of this systematic review is to report some recent experiences and to compare RAMIE with other approaches to esophagectomy, focusing on technical and oncological aspects.

Methods: Pubmed, Embase and Scopus databases were searched for “robot-assisted esophagectomy”, “minimally invasive esophagectomy” and “robotic esophagectomy” in January 2020. The study was focused on original papers on totally endoscopic RAMIE in the English language. No statistical procedures (meta-analysis) were performed.

Results: Three hundred and twenty studies were identified across the database and after screening and reviewing, 14 were included for final analysis. The overall 90-day post-operative mortality after trans-thoracic esophagectomy ranged from 0% to 9% and did not differ between approaches. Post-operative complications ranged between 24% and 60.9%: respiratory (6.25% to 65%), cardiac (0.8% to 32%), anastomotic leak (3.1% and 37.5%) and vocal cord palsy (9.1%-35%) were the most frequent. The evidence for long-term outcomes is weak, with no significant differences in overall survival, disease-free survival and recurrence identified in comparison with other approaches. The selected papers showed that RAMIE had comparable outcomes between the open and thoraco-laparoscopic approaches within a multimodal treatment pathway.

Conclusion: RAMIE also seems to be associated with better lymph node dissection, nerve sparing and quality of life, but larger studies are needed to obtain more evidence.

As the obesity epidemic continues to grow, the need for effective management strategies is more important than ever. There are several medical, endoscopic, and surgical management options available. The last decade has seen a rise in endoscopic bariatric interventions. These minimally invasive therapies can be used for patients who do not qualify or are unwilling to undergo bariatric surgery. Currently, there is limited formal training in bariatric endoscopy. In this commentary, we discuss our experience in establishing a center for bariatric endoscopy at a large academic medical center.

Surgical resection is treatment of choice for early stage non-small cell lung cancer, even though 20%-30% of patients do not undergo surgery. Compared to conventional fractionated radiotherapy, stereotactic body radiotherapy (SBRT) has demonstrated excellent local control (LC) and overall survival (OS). Central and ultra-central lesions present higher toxicity rates after SBRT because of their proximity to mediastinal structures. Dose escalation studies have documented that 10-12 Gy per fraction is the maximal tolerable dose with acceptable rates of treatment adverse events and survival. Peripheral lesions can be safely treated with high radiotherapy dose (biologically equivalent dose of ≥ 150 Gy) and a different SBRT dose schedule has showed comparable results with LC rates > 90% and OS comparable to surgical resection. Elderly patients, defined as 75 years or older, are a subgroup of patients who may benefit the most from SBRT, as they have higher morbidity and mortality risks because of comorbidities and decreased lung function. At present, there are no randomized studies comparing SBRT with surgery for patients who are potential candidates for surgical removal. Retrospective studies and systematic reviews have showed encouraging results in terms of cancer-specific survival and LC.

Much effort has been made to improve outcomes and/or minimize the invasiveness of esophagectomy for thoracic esophageal cancer. This has led to the evolution from open esophagectomy to thoracoscopic minimally invasive esophagectomy (MIE), and from MIE to robot-assisted minimally invasive esophagectomy (RAMIE). RAMIE is being applied clinically to overcome the limitations of MIE. In this article, we review the trends in the evolution from thoracoscopic MIE to RAMIE. It has now been demonstrated that RAMIE is both safe and feasible, and may decrease morbidity and mortality rates associated with esophagectomy and improve oncological outcomes. On the other hand, there are still many problems that need to be solved.

Aim: The advantages and feasibility of video-assisted thoracoscopic surgery (VATS) in the surgical management of early resectable thymoma and thymic hyperplasia have largely been described and adopted in many thoracic surgery units. In order to allow for resection of all immunogenic thymic cells in patients with myasthenia gravis, surgical removal of the whole thymus gland including perithymic and pericardiophrenic fatty tissue becomes imperative. It is also important to achieve radical resection and excision in cases of thymoma.

Methods: Numerous technical variations of VATS thymectomy have been reported in literature. In this study, the surgical technique of a minimally invasive, extended thymectomy through a bilateral approach is illustrated with key features highlighted.

Results: In our experience, no conversion to the open transternal approach, surgical mortality or major complications were observed; the median length of hospital stay was 3 days.

Conclusion: Bilateral video-assisted extended thymectomy is an effective, safe and well-tolerated approach, with surgical benefits and clinical outcomes similar to other thoracoscopic techniques.

Esophageal cancer persists as one of the most common causes of cancer-related death and 5-year survival remains poor at 20%. Surgical resection is the gold standard for treatment and cure, and the development of minimally invasive surgery has increased the popularity of robotic-assisted minimally-invasive esophagectomy. The benefits described include less morbidity and greater patient satisfaction compared to open techniques. Nevertheless, institution capabilities and surgeon experience are strong determinants of whether a robotic program will be adopted for oncologic esophageal care. Thus, we review the available literature regarding the history of esophagectomy, evolution to minimally invasive approaches, the introduction of robotic-assisted esophagectomy including its respective outcomes in comparison to open and minimally invasive approaches, and future directions.

The steady increase in bariatric surgery has led to room for innovation. Endoscopy has become an important tool for evaluation, diagnosis, management of complications, and even for primary bariatric interventions. Leaks are the most feared complication and new endoscopic therapies have been developed such as septotomy, double-pigtail stents, and endoscopic vacuum therapy. Additionally, primary bariatric endoscopic procedures are gaining popularity and the new procedures include intragastric balloons, stoma reduction, aspiration therapy, among others. The altered anatomy and reoperation increase the risk of complications after bariatric surgery, especially when managing conditions like achalasia, gastroparesis, and cholelithiasis. Per-oral endoscopic myotomy, per-oral pyloromyotomy, and endoscopic ultrasound-guided transgastric endoscopic retrograde cholangiopancreatography provide a less invasive approach to address these conditions. This narrative review article intends to expose current endoscopic therapies for the management of primary bariatric procedures, complications and related conditions.

Thoracic sympathectomy is used for the palliation of hyperhidrosis. However, significant controversies surround the optimal surgical approach and the extent of sympathectomy. The determinants of success in the surgical palliation of hyperhidrosis are the postoperative rate of anhidrosis, recurrence of symptoms, and rate of compensatory hyperhidrosis. This paper attempts to shed light on the controversies by examining the historic background, clearly defining the anatomic considerations, and outlining the various surgical approaches culminating with robotic selective dorsal thoracic sympathectomy.

Advanced heart failure (HF) prevalence is increasing and ranges between 1% and 10% of the overall HF population, due to the growing number of patients with HF and their better treatment and survival in the last 20 years. The best treatment for these patients is represented by heart transplantation, which, unfortunately, is only available for a minority of them. A significant portion of patients with advanced HF has concomitant severe mitral regurgitation, which acts as a driving force in inducing and maintaining this end-stage condition in a vicious cycle. Percutaneous mitral valve repair with MitraClip is a treatment option to stop this vicious cycle, providing safer outcomes and clinical benefits in some of these patients. Preliminary clinical observations show a possible selective role for percutaneous mitral valve treatment with MitraClip as a bridge to transplantation, candidacy or recovery. Further evidence will be necessary to confirm these preliminary data and support this new treatment framework of patients with advanced HF.

We began performing mediastinal lymph node dissection using the laparoscopic transhiatal approach in 2009. Following the initiation of the single-port mediastinoscopic cervical approach in 2014, we developed a technique for transmediastinal radical esophagectomy without a thoracic approach. We herein describe our surgical procedures for en bloc mediastinal lymph node dissection by the laparoscopic transhiatal approach with a focus on pitfalls. We opened the esophageal hiatus and the working space was secured using long retractors. During division of the right crus of the diaphragm, we made efforts to avoid damaging the left hepatic vein and inferior vena cava. Dissection of the posterior plane of the pericardium was extended to the cranial side, and the bilateral inferior pulmonary veins were identified. To avoid misorientation, the posterior plane was initially extended along the long axis of the esophagus. The anterior and posterior sides of the posterior mediastinal lymph nodes were then both dissected. These lymph nodes were lifted in a sheet-like form and then cut along the borderline of the left mediastinal pleura. The right side of the mediastinal lymph nodes was then dissected. To avoid damaging the arch of the azygos vein, it was identified at the dorsal side of the right main bronchus prior to lymph node dissection. This procedure decreased the total operative time, total operative bleeding, and postoperative respiratory complications without reducing the quality of lymphadenectomy. In conclusion, the procedure described herein resulted in a good surgical view and safe en bloc mediastinal lymph node dissection. A detailed understanding of mediastinal 3D anatomy and specific pitfalls is crucial for the successful use of this approach.

Compared to the open approach, minimally invasive esophagectomy (MIE) offers several advantages including smaller incisions with decreased pain, improved cosmesis, and earlier return of the patient to baseline function. Robotic-assisted minimally invasive esophagectomy (RAMIE) builds on standard MIE by offering three-dimensional visualization, better instrument articulation, tremor filtration, and superior ergonomics, all of which facilitate technical precision and surgeon comfort. An evolving literature demonstrates that when performed by experienced surgeons, RAMIE leads to improved perioperative outcomes with long-term oncologic equivalency to open approaches, and may offer advantages compared to traditional MIE. This review focuses on the key steps of performing 3-field McKeown, 2-field Ivor Lewis, and transhiatal robotic esophagectomies, data regarding the short- and long-term outcomes, and a brief overview of upcoming trials comparing RAMIE with MIE.

Echocardiography is the primary imaging modality for the evaluation of mitral valve regurgitation. A comprehensive assessment of mitral regurgitation using different echocardiographic techniques provides important information regarding the etiology and severity of mitral regurgitation and its consequences on cardiac function. In addition, echocardiography plays an important role in the management of patients with mitral regurgitation.

Acute mitral regurgitation is a heterogeneous and life-threatening pathology, with severe hemodynamic consequences and extremely adverse outcomes. Traditionally, the definitive treatment is prompt surgical intervention after hemodynamic stabilization. Nowadays, however, percutaneous repair of mitral valve with MitraClip device has emerged as a safe and effective therapeutic option. Evidences in this field are still scarce. Hereby, we report the case of an 82-year-old woman with lateral ST-elevation myocardial infarction determining severe acute mitral regurgitation (MR) with an asymmetric leaflet tethering mechanism. Due to prohibitive operative risk and unstable hemodynamic status, the patient underwent a successful urgent MitraClip procedure with optimal reduction of MR and immediate hemodynamic improvement. Moreover, we provide a review of the available literature regarding the echocardiographic assessment of acute MR, results of published cases and possible management of this complex pathology.

Aim: To define the outcome of robot-assisted spleen preserving distal pancreatectomy (RA-SPDP) in a high-volume center.

Methods: A retrospective analysis of a prospectively maintained database was performed to identify RA-SPDP performed at our Center between April 2008 to October 2017.

Results: During the study period, RA-SPDP was attempted in 54 patients. The spleen was preserved, always along with the splenic vessels (Kimura procedure), in 52 patients (96.3%). There were no conversions to open or laparoscopic surgery. Mean operative time was 260 min (231.3-360.0). Grade B post-operative pancreatic fistula (POPF) occurred in 19 patients (35.2%). There were no grade C POPF. Two patients required repeat surgery because of postoperative bleeding and splenic infarction, respectively. There were no post-operative deaths at 90 days. Excluding one patient with known diagnosis of metastasis from renal cell carcinoma, malignancy was eventually identified in 7 of 53 patients (13.2%).

Conclusion: In the hands of dedicated pancreatic surgeons, robotic assistance results in a high rate of spleen preservation with good clinical outcomes. Despite careful preoperative selection, several patients can be found to have a malignant tumor. Taken altogether these results suggest that patients requiring these procedures should be preferentially referred to specialized centers.

Robotic Lobectomy has been evolving over the past decade and is an oncologically efficacious procedure. Although robotic lobectomy is performed more frequently around the world, it accounts for a small percentage of all lobectomies. The major determinants for the lower level of adoption of the robotic lobectomy procedure are 1. The lack of concise step by step procedure outlines for the surgeons who are transitioning from either open or video-assisted thoracic surgical procedures to robotics, or 2. A strategy for control of catastrophic bleeding during the robotic lobectomy procedure. The Technique of Robotic Lobectomy Part I outlines a stepwise approach to robotic lobectomy for the right upper, middle, and lower lobes. Part II outlines a stepwise approach to robotic lobectomy for left upper, and lower lobes. Part III outlines a methodical technical approach for the control of catastrophic bleeding complications.

Robotic lobectomy has been evolving over the past decade and has been shown to be an oncologically efficacious procedure. The Technique of Robotic Lobectomy I outlined the stepwise approach to robotic lobectomy of the right upper, right middle and right lower lobes. This paper outlines the stepwise technical approach to robotic lobectomy of the left upper and lower lobes. The accompanying paper, Technique of Robotic Lobectomy III: Control of Bleeding Complications, outlines a methodical technical approach for the control of catastrophic bleeding complications.

Robotic Lobectomy has been evolving over the past decade and has been shown to be an oncologically efficacious procedure. Although robotic lobectomy is performed more frequently in centers around the world, it accounts for a small percentage of all lobectomies. One of the major causes of reluctance to adopt robotic lobectomy and segmentectomy procedures by surgeons is the fear of bleeding complications, as well as the lack of a standardized reproducible approach to these potentially catastrophic events. This paper outlines a proven strategy for control of bleeding complications during robotic lobectomy and segmentectomy procedures: the 5 “P”’s of Prevention, Preparedness, Poise, Pressure, and Proximal Control.

After 30 years since its introduction, the edge-to-edge technique has become one of the most popular and adopted worldwide for surgical repair of mitral regurgitation. The success of this procedure could possibly be explained by its unique simplicity and high level of reproducibility. Indeed, it possesses the ability of being very versatile and it has been used in a wide spectrum of mitral valve pathologies and lesions: from degenerative to functional disease, from posterior to anterior leaflet lesions, including commissural defects. The rapidity of this easy surgical gesture has also enhanced its application in minimally invasive approaches. Finally, it has become a true milestone for the era of transcatheter correction of mitral regurgitation. Here, we describe the history and evolution of this breakthrough in the world of cardiac surgery.

Patulous eustachian tube (PET) dysfunction is a rare complication of weight loss, which can be easily misdiagnosed. We present a case of PET dysfunction after laparoscopic sleeve gastrectomy. A 36-year-old Caucasian female with Class III morbid obesity (131 kg, BMI 46.6 kg/m²) successfully underwent laparoscopic sleeve gastrectomy. At her postoperative follow-up appointment six months later, her weight dropped to 96 kg and she complained of severe autophony (hearing of self-generated sounds), leading to anxiety and insomnia. She was initially misdiagnosed with a sinus infection by her primary care provider and was started on antibiotics. She was subsequently seen by an otolaryngologist who diagnosed her with PET. Weight loss can be a predisposing factor for PET. Our patient did not notice onset of symptoms of PET until significant weight loss (35 kg, 59.5% EWL).

Cavernous sinus (CS) meningiomas represent a formidable neurosurgical pathology. The desired treatment depends on tumor size and extensions apart from the presenting clinical symptoms of the patient. The last few decades have shown a paradigm shift in the management towards a multimodal treatment. For patients with tumors presenting with a medial extension or when the meningioma occupies the antero-inferior portion of the CS, an endoscopic biopsy can be safely performed through the endonasal route. The boundaries of endoscopic endonasal approaches have been pushed during the last decade, and a direct access to the CS may now be performed. At the same time, an extensive bony decompression to decompress the optic canal and the pituitary gland may be performed. Autologous fat may be interposed between the residual tumor and radiosensitive structures to safely perform adjuvant radiation therapy. The aim of this manuscript is to describe the role of endoscopic surgery in the management of cavernous sinus meningiomas along with the complementary role of radiotherapy. We describe the endoscopic anatomy and the surgical technique to safely perform the procedure and we review the surgical series reported in the literature dealing with the endoscopic approach for CS meningiomas with or without complementary radiation therapy. Endoscopic endonasal approaches have shown promising results in terms of improvement or stabilization of cranial neuropathy and hypopituitarism. Furthermore, the endoscopic approach may enhance the efficacy and safety of stereotactic radiosurgery through the performance of an hypophysopexy and/or chiasmopexy.

Much effort has been spent evaluating the difference between robotic and laparoscopic surgery platforms for rectal cancer. There is a plethora of literature comparing outcomes for intraoperative events, postoperative complications, long term outcomes, cost, and learning curve. The data are conclusive regarding the higher cost of robotic surgery compared to laparoscopic surgery. This article is a comprehensive review of the available literature regarding intraoperative and postoperative outcomes. For practically all parameters evaluated, there are no significant differences between the two platforms. The ultimate decision on whether to perform robotic vs. laparoscopic surgery should be based on surgeon preference and familiarity with equipment, as well as local resources.

Myocardial infarction (MI) has become a major health concern these days. Elevated levels of cholesterol due to improper diet cause severe damage to human health, resulting in the narrowing of blood vessels leading to MI. Different approaches have been used based on surgical and non-surgical treatments for these blockages to cure MI. In this regard, injectable and non-injectable hydrogel-based percutaneous coronary intervention has shown promising applicability for the treatment of cardiac damage and its repair. In this report, we summarize a few hydrogels based on natural polymers such as chitosan, alginate, polyethylene glycol and extracellular matrices to be used for percutaneous coronary intervention in the treatment of MI. Their structure, biological properties and biocompatibilities are discussed, and their existing challenges are also detailed. In addition, the probable solutions to overcome certain set backs are also highlighted.

Radical thymectomy is the gold standard treatment for thymoma; in particular, completeness of surgical resection of a well-encapsulated thymoma and adequate margins are considered the most important prognostic factors. According to the International Thymic Malignancy Interest Group instructions, in fact, the thymus should be resected en bloc with its upper cervical poles and the surrounding mediastinal fat and through a no-touch surgical technique. For years, the open approaches have been considered the gold standard treatment for thymic masses, because of technical advantages and proved good oncological results. When applied to properly chosen patients on the basis of the tumor stage, dimension, and histology, minimally invasive approaches could be as effective as open ones in terms of long-term outcomes. To accomplish a minimally invasive thymoma resection, several minimally invasive techniques (transcervical, subxiphoid, thoracoscopic, and robotic) have been described, each presenting advantages and drawbacks. Moreover, when dealing with early stage neoplasms, many authors have proposed to perform the thymomectomy alone, not involving the rest of the thymic gland, but evidence is still imprecise and vague, and some studies have described a higher rate of local recurrence when using this technique. Finally, many studies suggest that surgeons with expertise in minimally invasive lymphadenectomy for lung cancer may easily endorse the idea of nodal dissection, to be performed at least in advanced thymomas involving neighboring structures, large masses, and thymic carcinomas.

Aim: Growing experience with minimally invasive pancreaticoduodenectomy (PD) has led surgeons to expand the indications for this approach. We systematically reviewed the literature on minimally invasive PD with venous resection.

Methods: The EMBASE, MEDLINE, and Cochrane central databases were systematically searched for articles from January 2010 to January 2020 describing cases of PD with venous resection. The search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The primary outcomes were feasibility and conversion rate. Secondary outcomes were morbidity, mortality, blood loss and 1-year survival.

Results: The literature search found 9 studies reporting 140 patients undergoing PD with venous resection. Sixty-six PDs were performed robotically (47.1%). The conversion rate ranged from 0% to 55%, blood loss ranged from 200 to 842 mL, and operative time ranged from 397 to 518 min. There were 82 lateral (58.5%) and 18 segmental (12.8%) PDs with venous resection. One patient had an associated arterial resection (0.7%). A graft was used for venous reconstruction in 28 patients (20%). Eight deaths (5.7%) were reported postoperatively.

Conclusion: Minimally invasive pancreatectomies with synchronous lateral venous resections are increasingly reported by highly experienced surgeons in high-volume institutions. Further experience is needed to validate this approach and prove its advantages over open surgery.

Tracheal bronchus is a rare, congenital abnormality of the tracheobronchial tree. Majority of patients with tracheal bronchus are asymptomatic. Lung malignancy associated with tracheal bronchus is rare. An asymptomatic 40-year-old female was diagnosed with right upper lobe lung carcinoma. CT thorax revealed a right upper lobe tracheal bronchus. The patient underwent right uniportal video-assisted thoracoscopic (VATS) lobectomy and recovered well. To our knowledge, this is the first reported case of primary lung carcinoma with tracheal bronchus treated with right uniportal VATS upper lobectomy in Malaysia, and the second reported case internationally.

Anatomic pulmonary segmentectomy and mediastinal nodal dissection have been advocated in patients with smaller tumors or patients with limited pulmonary reserve. The overall five-year survival and lung cancer-specific five-year survival following anatomic segmentectomy have been shown to be equivalent to lobectomy. Robotic surgical systems have the advantage of magnified high-definition three-dimensional visualization and greater instrument maneuverability in a minimally invasive platform. Robotics can facilitate the dissection of the broncho-vascular structures and replicate the technique of segmentectomy by thoracotomy. Greater experience with the robotic platform has resulted in a reproducible technique. The Technique of Robotic Anatomic Segmentectomy Part I outlines a stepwise approach to robotic segmentectomy of S1, S2, S3, S4, S5, S6, and S7-S10 of the right lung. The Technique of Robotic Anatomic Segmentectomy Part II outlines a stepwise approach to robotic segmentectomy to the left lung.

Aim: Percutaneous mitral valve repair (PMVR) with MitraClip® has proven to be an effective therapy to reduce mitral regurgitation in patients at high risk for conventional surgery. This population is currently characterized by advance age and high prevalence of comorbidities. Our aim was to evaluate the prevalence of frailty in a cohort of patients undergoing PMVR and its impact on clinical outcomes during follow-up.

Methods: A prospective registry was performed including all consecutive patients who underwent elective PMVR between June 2014 and March 2018 in our institution. Frailty was evaluated at admission with the functional FRAIL scale. In-hospital and 30-day procedural outcomes were collected. Clinical follow up was carried out including New York Heart Association (NYHA) functional class, heart failure hospitalization and death.

Results: Overall, 70 patients were included (mean age 75.3 ± 9.9 years, 65.7% male). Among them, 27 patients (38.6%) had a pre-procedural FRAIL score greater than 2, meeting frailty criteria. No differences between frail and non-frail patients were found in technical success (P = 1.0) or 30-day device success (P = 0.739). At six months follow up, both groups showed a significant improvement in NYHA functional class compared to baseline (frail: P = 0.002; non-frail: P < 0.001). During a median follow up of 675 (range 416-976) days, frailty patients had a higher incidence of HF admission and all-cause mortality (P = 0.013). In multivariate COX regression analysis, FRAIL score greater than 2 was significantly related to the primary composite endpoint (HR = 2.45; 95%CI: 1.02-5.88; P = 0.044).

Conclusion: Frailty was common in patients undergoing PMVR in our institution. Despite post-procedural clinical improvement, frailty was related to adverse outcomes in our series.

Anatomic pulmonary segmentectomy and mediastinal nodal dissection has been advocated in patients with smaller tumors or patients with limited pulmonary reserve. The overall 5-year survival and the lung cancer-specific 5-year survival following anatomic segmentectomy have been shown to be equivalent to that of lobectomy. Robotic surgical systems have the advantage of magnified, high-definition three-dimensional visualization and greater instrument maneuverability in a minimally invasive platform. These robotic systems can facilitate the dissection of the bronchovascular structures and replicate the technique of segmentectomy by thoracotomy. Greater experience with the robotic platform has resulted in a reproducible anatomic segmentectomy technique. This is a companion paper to The Technique of Robotic Anatomic Segmentectomy I: Right Sided Segments. This paper outlines the technique of anatomic pulmonary segmentectomy for the left lung: Left Upper Lobe (LUL) Anterior Segment (S3), LUL Apicoposterior Segment (S1 + S2), LUL Lingulectomy (S4, S5), Left Lower Lobe (LLL) Superior Segmentectomy (S6), and LLL Basal Segmentectomy (S7-S10).

The introduction of laparoscopic technology and surgical robots in hepatobiliary surgery in the 1990s and 2000s, respectively, has dramatically revolutionized the field. Even though laparoscopic and robotic major hepatectomy was slower to adopt compared to minimally-invasive minor hepatectomy, the number of major hepatectomies performed with both approaches worldwide has significantly increased and is still rising. Despite the few comparative studies between laparoscopic and robotic major hepatectomy, most studies are focused on describing the procedures or reporting the outcomes of each method, either separately, or mixed with minor hepatectomies. Based on the available data, the direct comparison between the two techniques has shown that when robotic major hepatectomy is performed by experienced hepatobiliary surgeons in high-volume centers, it can lead to similar operating times, estimated blood loss, hospital length of stay, complication and mortality rates compared to its laparoscopic counterpart. The likelihood of achieving a margin-negative resection in cancer patients, as well as long-term disease-free and overall-survival are comparable between the groups. However, broader adoption of the robotic approach might be a hurdle in low-volume centers due to the high fixed capital and annual maintenance cost of the surgical robot.

Mitral regurgitation (MR) is the most common left-sided heart valve disease in developed countries with a constantly rising number of patients requiring hospitalization or intervention. Organic MR is defined as a primary structural abnormality of the mitral valve (MV) apparatus which may be caused by a broad set of pathological processes, among which myxomatous degeneration of the leaflets causing MV prolapse is the most common. If left untreated, chronic severe MR leads to serious adverse outcomes, from heart failure to death, but medical therapy is unable to change the natural history of the disease. Surgical correction, by means of valve repair or replacement, is the gold standard for the treatment of symptomatic patients with severe primary MR. However, surgery is not feasible for a large percentage of patients because of old age, reduced left ventricular ejection fraction and the presence of severe comorbidities. Therefore, in recent years, several percutaneous therapeutic alternatives suitable for high or prohibitive surgical risk patients were developed. In this review we discuss the transcatheter treatment of primary MR, from available evidence to technical practice, with a focus on the percutaneous “edge-to-edge” leaflet repair performed with the MitraClip System and the PASCAL Repair System.

Functional or secondary mitral regurgitation (MR) is a heterogeneous entity afflicting patients with heart failure both with reduced or preserved left ventricular ejection fraction. It results from an imbalance between closing forces and tethering or pushing strengths acting on the valve in the absence of structural alterations of mitral valve (MV) apparatus. According to previous studies, more than 20% of patients with heart failure and reduced left ventricular ejection fraction have severe MR, even though the definition of the severity of the MV disease in this setting remains a debated issue due to the poor reproducibility of quantitative measurements and its dynamic nature, highly dependent on left ventricular loading conditions and performance in relation to optimization of medical treatment. Furthermore, it is still unclear whether MR is a direct contributor to a worse prognosis or merely a marker of severity of the disease affecting the left ventricle. Isolated MV surgery in these patients is burdened by significant operative mortality, high rates of recurrent MR and absence of proven survival benefit. In recent years, percutaneous treatment of functional MR arose as a viable and safe alternative to conventional surgery, proving capable of reducing symptoms and recurrent hospitalization rates for heart failure, and even improving prognosis in selected patients. In this review we will discuss the percutaneous treatment of functional MR through transcatheter “edge-to-edge” leaflet repair performed with the two systems currently available: the MitraClip System and the PASCAL Repair System, from available evidence to technical practice.

Robotic pancreatic surgery provides several advantages. Since the first report of a robotic-assisted distal pancreatectomy in 2001, total pancreatectomies, pancreatic tumor enucleations, pancreaticoduodenectomy, central pancreatectomy and Appleby procedures have been performed, indicating a promising future. The aim of this article is to describe our experience of robotic pancreatic surgery including technical aspects for pancreaticoduodenectomy and distal pancreatectomy. The current literature on feasibility, safety and early postoperative outcomes will be discussed.

Since its introduction in 1982, percutaneous mitral balloon valvuloplasty (PMV) has been used successfully as an alternative to open or closed surgical mitral commissurotomy in the treatment of patients with symptomatic rheumatic mitral stenosis. PMV is safe and effective and provides sustained clinical and hemodynamic improvement in patients with mitral stenosis. The immediate and long-term results appear to be similar to those of surgical mitral commissurotomy. Proper patient selection is an essential step for being able to predict the immediate results of PMV. Candidates for PMV require precise assessment of the mitral valve morphology. The Wilkin’s echocardiographic score (Echo-Sc) is currently the most widely used method for predicting PMV outcome. Leaflet mobility, leaflet thickening, valvular calcification, and sub valvular disease are each scored from 1 to 4. An inverse relationship exists between the Echo-Sc and PMV success. Both immediate and intermediate follow-up studies have shown that patients with Echo-Sc ≤ 8 have superior results, significantly greater survival, and event free survival compared to patients with Echo-Sc > 8. We identified other clinical and morphologic predictors of PMV success that include age, pre-PMV mitral valve area, history of previous surgical commissurotomy, and mitral regurgitation (MR), and post-PMV variables (e.g., post-PMV MR ≥ 3 + and pulmonary artery pressure), that may be used in conjunction with the Echo-Sc to optimally identify candidates for PMV. This concept demonstrates a multifactorial nature of the prediction of immediate and long-term results. Other echocardiographic scores have been developed for the screening of potential candidates for PMV. They include a unique score that take into account the length of the chordae. A novel quantitative score that included the ratio of the commissural areas over the maximal excursion of the leaflets from the annulus in diastole. The components of this score include mitral valve area ≤ 1 cm², maximum leaflet displacement ≤ 12 mm, commissural area ratio ≥ 1.25, and sub valvular involvement. Finally, a score that is able to identify patients who are more likely to develop significant mitral regurgitation post-PMV. This score takes into account the distribution (even or uneven) of leaflet thickening and calcification, the degree and symmetry of commissural disease, and the severity of subvalvular disease. The transvenous transseptal approach is the most widely used PMV technique. The two major techniques of PMV are the double-balloon technique and the Inoue technique which are equally effective techniques of PMV. Encouraging results of PMV have been reported in special mitral stenosis population cohorts including pregnant women, patients with previous surgical commissurotomy, patients with atrial fibrillation, patients with pulmonary hypertension, elderly patients, patients with calcific mitral stenosis, and patients with associated aortic regurgitation. To summarize, PMV is the preferred form of therapy for relief of mitral stenosis for a selected group of patients with symptomatic mitral stenosis and suitable valve anatomy for valvuloplasty. Patients with Echo-Sc ≤ 8 have the best results, particularly if they are young, are in normal sinus rhythm, have no pulmonary hypertension, and have no evidence of calcification of the mitral valve under fluoroscopy. The immediate and long-term results of PMV in this group of patients are similar to those reported after surgical mitral commissurotomy. Patients with Echo-Sc > 8 have only a 50% chance to obtain a successful hemodynamic result with PMV, and the long-term follow-up results are worse than those from patients with Echo-Sc ≤ 8. In patients with Echo-Sc ≥ 12, it is unlikely that PMV could produce good immediate or long-term results and they preferably should undergo mitral valve replacement. However, PMV could be considered in these patients if they are high-risk or unqualified surgical candidates.

Aim: There is no standard technique for transection of the hepatic parenchyma during robotic liver resection. The aim of this study was to describe the outcomes of robotic liver resections using the Vessel Sealer for parenchymal transection.

Methods: This is a post hoc analysis of a prospective database. All consecutive patients who underwent robotic liver resection in the Regional Academic Cancer Centre, Utrecht, Netherlands, between August 2015 and January 2019 were included.

Results: A total of 70 robotic liver resections were performed, including 60 minor resections (86%) and ten hemihepatectomies (14%). Five procedures (7%) were converted. Mean parenchymal transection time was 43 ± 26 min. Median blood loss was 150 mL (interquartile range 40-300). Ten patients (14%) suffered from a major complication, and three patients (4%) had bile leakage postoperatively. One patient died from post-hepatectomy liver failure.

Conclusion: Based on the results of this series, consisting of 60 minor liver resections and 10 hemihepatectomies, we conclude that the use of the Vessel Sealer during the parenchymal transection in liver resection is feasible and safe.

The favorable outcome generally associated with spinal meningioma surgery is the result of the continuing refinement of the surgical technique, the use of intraoperative neuromonitoring, and a better understanding of the tumor biological behavior. Among all the technological advancements, visualization tools are the keys to any successful surgical procedure. The operating microscope is the gold standard in all neurosurgical procedures. In recent years, high-definition exoscope systems have entered the field of neurosurgery, as another tool in the armamentarium of the contemporary neurosurgeon. After initial experiences and technical improvements, the exoscope has proven to be best suited for spinal procedures. This study aims to briefly review the exoscope journey in neurosurgery, with a special focus on spinal meningioma surgery. Benefits and limitations are analyzed and an illustrative case is reported. Spinal meningiomas removal under exoscope visualization has proven to be feasible, efficient, and safe. Indication for the use of the exoscope greatly depends on meningioma size, consistency, relationship to surrounding neurovascular structures, and the surgeon’s experience. Switching to the operating microscope, if deemed safer, should always be considered.

A growing body of evidence shows that transcatheter mitral valve edge-to-edge repair (TMVr) for mitral regurgitation (MR) improves symptoms and prognosis of patients with heart failure. Still, as recently shown by two large randomized controlled trials (COAPT and MITRA-FR), there is differing information on which patients have the largest benefit. We aimed to summarize the current knowledge of clinical and anatomic predictors for acute procedural failure and long-term all-cause mortality after TMVr. TMVr is an effective treatment option for patients with symptomatic MR fulfilling certain echocardiographic and clinical criteria or being ineligible for surgery despite optimal medical therapy. Acute procedural failure is influenced by anatomic features of the mitral valve, among those are increased tenting and mitral valve leaflet configuration, leaflet-to-annulus index, as well as the mitral valve opening area. In contrast, anatomy of the mitral valve plays a minor role in predicting all-cause mortality after TMVr. This endpoint is associated with patient comorbidities (e.g., renal failure and chronic lung disease), severe heart failure as expressed by New York Hear Association functional class (NYHA) IV, left and right heart dysfunction, laboratory parameters (NT-proBNP), clinical scoring systems (STS and EuroScore), and procedural MR reduction. In patients undergoing TMVr for severe MR, careful preprocedural evaluation of relevant comorbidities, mitral valve anatomy, as well as left and right heart function can provide detailed prognostic value regarding acute procedural success and long-term survival.

Aim: The aim of this study was to describe our technique for the surgical treatment of clinically suspected or incidentally diagnosed gallbladder cancer (GBC) and to report the outcomes of our experience.

Methods: This is a retrospective observational study including consecutive patients operated by a robotic approach for the surgical treatment of clinically suspected or incidentally diagnosed GBC (with the intent of radical re-resection after index cholecystectomy) performed between January 2017 and December 2019. Clinical outcomes and technical details related to the robotic approach were analyzed.

Results: During the study period, 8 patients underwent robotic radical cholecystectomy with lymphadenectomy and atypical resection of segments IVb-V. No conversion or major complications occurred intraoperatively. All patients underwent a radical resection. There were one Clavien-Dindo grade II and one grade IIIb complication. Median hospital stay was 6 days (range 5-11). At a median follow-up of 17.5 months (range 29.3-7.3), all patients are alive and free from disease except one who had peritoneal recurrence and underwent chemotherapy. No trocar site recurrence was observed.

Conclusion: The present study describes a standardized step-by-step robotic technique for the surgical treatment of GBC and demonstrates the feasibility and safety of the robotic approach. More data and multicentre series are needed to confirm our results and to assess the oncologic outcomes of the robotic approach.

The past several decades have seen remarkable advancements in percutaneous interventions for treatment of congenital heart disease (CHD). These advancements have been significantly aided by improvements in noninvasive diagnostic imaging. The use of three-dimensional (3D) printed models for planning and simulation of catheter-based procedures has been demonstrated for numerous cardiac defects and has been shown to reduce complications, procedure times, and limit radiation exposure. This paper reviews the process by which patient-specific 3D cardiac models are produced, as well as numerous applications of these models for use in percutaneous interventions in CHD.

Percutaneous mitral valve intervention is emerging as a valid alternative for patients affected by mitral regurgitation. By addressing the pathophysiology, therapeutic options mainly target the leaflets, annulus or left ventricle. The present review will cover the intraprocedural guidance of the most used approaches, such as edge to edge repair, adjustable transapical beating-heart chordal implantation and percutaneous direct or indirect annuloplasty. Intraprocedural monitoring relies on integration of fluoroscopy and echocardiography, and is based on the continuous communication between the interventional imager and the interventional cardiologist.

Achalasia is a neurodegenerative disorder of the esophagus of unknown etiology, which affects motility, causing symptoms such as progressive dysphagia with liquids then solids, heartburn, regurgitation, odynophagia, weight loss, nocturnal cough, and chest pain. Evaluation will show a characteristic “bird’s beak” appearance on barium esophagram and diagnosis is confirmed with esophageal manometry. Durable relief from the symptoms of achalasia can be achieved with pneumatic dilation, per-oral endoscopic myotomy, or surgical myotomy. Laparoscopic Heller myotomy with Dor (or Toupet) fundoplication for many years had been considered the gold standard for therapy. Since its development in 2001, the robotic Heller myotomy (RHM) has gained increasing popularity. Studies have shown equivalent efficacy of relieving achalasia symptoms but decreased incidence of esophageal perforation with RHM. The higher cost of RHM remains the largest barrier. Our objective was to provide a brief review of the current literature related to RHM and provide a detailed description of how to perform the procedure.

New transcatheter mitral valve (MV) therapies are now available as alternatives to surgical and medical treatments in patients at high or prohibitive operative risk. Multimodality imaging including echocardiography, cardiac magnetic resonance, and cardiac computed tomography provide complementary information to guide patient and device selection. Morphology and functional anatomy of the MV should be carefully evaluated to determine the feasibility of percutaneous treatment; to identify the best therapeutic approach, either leaflet or annulus or combined; and to predict the probability of procedural success that is crucial for subsequent outcome and should be integrated by comprehensive preprocedural assessment of chamber size, biventricular systolic and diastolic function, valvopathy hemodynamic impact and aortic or peripheral vascular disease. The spectrum of transcatheter options is now wide and encompasses leaflet repair, direct or indirect annuloplasty, and cordal implantation. The aim of this review is to provide an overview on the role of multimodality imaging in the patient selection and preprocedural planning of percutaneous mitral valve repair.

Epiphrenic diverticula occur within the distal 10 cm of the esophagus. Because they are secondary to an underlying esophageal motility disorder, the surgical treatment of these diverticula must include a myotomy in addition to the resection of the diverticulum. In selected cases, the diverticulum can be left in place, performing only the myotomy and the partial fundoplication. Most patients will eventually become asymptomatic and the diverticulum can be left in place. Overall, it is a challenging operation that may be associated to significant morbidity. In this review, we illustrate the key technical elements and how to troubleshoot eventual problems.

The contemporary management of meningiomas is the result of the continuous evolution of neurosurgical techniques, along with the refinement of dedicated instrumentations. Above all, it is the magnification of the surgical view, thanks to the microscope and the endoscope, and their advancements, which allowed the improvement of surgical outcomes, in terms of both extent of resection and morbidity rates. Because of the benign nature of the vast majority of meningiomas, complete tumor resection is curative, and it is the gold-standard treatment. However, in the case of high risk of surgical morbidity, a less aggressive surgical treatment may be justified, also upon tailored analysis of the meningiomas’ biological behavior and the improvements in postoperative strategies. The endoscopic technique plays a role, as a unique visualization tool or in combination with the microscope, in granting so-called maximum allowed resection. Considering the above, the most challenging task confronting modern meningioma surgery remains the selection of the most appropriate surgical approach, the latter greatly depending on location, anatomic tumor features, and relationships with critical neurovascular structures. Herein, we present a cogent analysis of the modern multifaceted indications for the endoscopic treatment of meningiomas, with a glimpse into the adjacent fields.

Treatment of rectal cancer is ever evolving with the introduction of newer surgical technologies and multimodal treatment approach. The literature evaluating the various surgical treatment options with regards to operative and nonoperative outcomes is abundant. This is a comprehensive review focused on oncological outcomes of rectal cancer resection performed robotically or laparoscopically. Based on the current literature available, there is no significant difference in total mesorectal excision completeness, lymph node harvest, positive circumferential resection margin, or proximal resection margin between robotic and laparoscopic approaches for rectal resection. Selection of surgical approach should not be based on pathological outcomes as they are equivalent.

Surgery still offers the best option for patients with early stage non-small cell lung cancer that can tolerate surgery. With the increase in screening programs, more patients are diagnosed at early stages of cancer. Sadly, not all of them are fit for surgery, but with minimally invasive approaches, large number of those patients can be offered surgery and get a better overall survival. Awake non-intubated video assisted thoracic surgery resection is one of the most recent technique that we believe to be a game changer in this spectrum of patients who were previously classified as medically inoperable.

Although lobectomy has been traditionally considered the standard treatment for early stage non-small cell lung cancer (NSCLC), lung-sparing resections usually called “sublobar resections” have exponentially increased in their use in the age of minimally-invasive surgery. Sublobar resection, especially anatomical segmentectomy, has shown comparable oncological outcomes in tumors less than 2 cm in diameter without nodal involvement and distant metastasis. On the other hand, more advanced radiation techniques such as stereotactic ablative radiotherapy, have shown excellent local control rates in stage I NSCLC, with low rates of post-treatment complications, so not only is its role growing in inoperable patients, but also in standard-risk stage I patients. There is a need for multicenter randomized trials addressing specifically this issue. This review aims to collect comparative data about the outcomes of both treatment strategies in early stage NSCLC.

Aim: This systemic review aims to determine if intracorporeal anastomosis (IA) adds value to patient outcomes without compromising operative and oncological safety when compared to extracorporeal anastomosis (EA) in laparoscopic colectomies. This is the first systematic review with meta-analysis to evaluate the outcomes in a combined fashion including both laparoscopic right and left colectomies.

Methods: A systematic review of Medline, EMBASE, Cochrane Library, and PubMed was performed on studies analysing direct comparison between IA and EA. The primary outcome was anastomotic leakage. Quality assessment was carried out using a modified Institute of Health Economics appraisal tool. Meta-analysis was performed using a random-effects model.

Results: A total of 24 papers with 2,674 patients were included in the analysis. No significant difference was found in anastomotic leakage (OR = 0.84; 95%CI: 0.54-1.31; P = 0.44) and short-term mortality (OR = 0.56; 95%CI: 0.20-1.58; P = 0.27) between the IA and EA cohorts. The IA cohort was associated with faster return of bowel function [MD = -0.53 days; 95%CI: -0.67-(-0.39); P < 0.00001] and lower incidence of surgical site infection (OR = 0.52; 95%CI: 0.31-0.85; P = 0.009). The number of lymph nodes harvested was higher in IA (MD = 1.05; 95%CI: 0.19-1.91; P = 0.02; I² = 83%) with considerable heterogeneity.

Conclusion: Intracorporeal anastomosis can be considered a safe alternative technique in laparoscopic colectomies, with potential benefits in patient outcomes. A lack of randomised studies and heterogeneity need to be addressed by additional high-quality trials.

Anterior skull base meningiomas are benign, dural-based tumors that originate from the tuberculum sellae, planum sphenoidale or olfactory groove. A multitude of traditional transcranial approaches have been effectively used for resection of these tumors. However, in the era of minimally invasive neurosurgery, the endoscopic endonasal and the endoscope-assisted or endoscope-controlled supraorbital keyhole eyebrow approaches stand out as the two main options utilized to resect these tumors. The supraorbital keyhole approach minimizes brain retraction, tissue dissection and length of the skin incision. Consequently, this approach is associated with a lower complication profile and much better cosmetic results in comparison to classic approaches. With endoscopic assistance or control, the approach provides an excellent view of anterior skull base meningiomas and enables optic nerve decompression when angled scopes are used. In our opinion, endoscopes will ultimately replace the surgical microscopes as the viewing tools in this type of surgery. A limited number of studies have directly compared the endoscopic endonasal approach versus the supraorbital keyhole one for resection of anterior cranial base meningiomas. In these studies, scores and algorithms have been suggested to help select the suitable approach. The practical value of these algorithms still needs to be validated by further research. Although the endoscope-assisted or -controlled supraorbital keyhole approach offers a minimally invasive and highly effective approach for excision of anterior cranial base meningiomas, the ideal approach should be tailored to the individual patient according to the tumor size, lateral extension, optic canal involvement, extent of vascular encasement and surgeon’s experience.

The advent of neuroendoscopy catalyzed the ongoing development of minimally invasive neurosurgery in the 1990s. This millennium has seen rapid developments in the design of scopes, improved high-definition visualization systems, and a plethora of dedicated instruments. Many minimally invasive and endoscopic procedures have become the new “standard of care” today. Endoscopic third ventriculostomy and endonasal pituitary surgeries have replaced alternative techniques in most major institutes in the world and the indications are rapidly increasing to tackle many midline skullbase, intraventricular, and some parenchymal lesions as well. The scope of minimally invasive neurosurgery has extended to spine surgery, peripheral nerve surgery, and unique indications, viz. craniosynostosis repair. This review describes many of these developments over the years, evaluates current scenario, and tries to give a glimpse of the “not so distant” future.

In the field of minimally invasive surgery, robotic surgery (RS) was introduced to overcome drawbacks in laparoscopic surgery. However, its clinical application in hepatobiliary surgery is not yet standardized. This review analyzed the results of RS to clarify the benefits of robotic liver surgery in comparison with standard laparoscopy. Among 112 publications found in the literature, the 72 most relevant were selected and the following data were extracted: patients characteristics, operative procedures, histopathology, short-term and long-term outcomes, and costs. Twenty-nine articles on robotic liver resections, published in the last five years (2015-2020) and including 1831 patients, were analyzed. Twenty-five comparative studies between robotic and laparoscopic surgery were evaluated to underline the differences in operative outcomes. Eventually, 4 sub-group analyses were conducted on hepatocellular carcinoma, gallbladder cancer, hilar cholangiocarcinoma, and colorectal liver metastases. Almost all the authors reported data on safety, feasibility and oncologic effectiveness of RS reaching comparable results with laparoscopy. However, even if robotic surgery showed longer operative time and higher costs, in selected cases it allowed to increase the rate of minimally invasive approach when compared with laparoscopy. Thus, both open and minimally invasive surgery should be provided in a modern hepatobiliary center, including the robotic approach particularly to complex cases, otherwise very demanding by laparoscopy. In conclusion, different techniques should be tailored to each patient, choosing the minimally invasive approach when possible, enhancing patients’ recovery after surgery, especially in cirrhotic livers and in the context of liver transplantation. Although many centers experienced robotic liver surgery, more and larger studies are necessary to define its real benefits relative to laparoscopy, in order to standardize patient selection criteria and techniques.