The treatment of rectal cancer is evolving at a rapid pace in parallel with advancements in surgical technique. One such advancement is the application of the laparoscopic platform to the transanal approach, coined transanal minimally invasive surgery (TAMIS). TAMIS overcomes many of the shortcomings of the traditional transanal approach to the local resection of rectal neoplasia, offering greater visualization and access to the middle and upper rectum with improved oncologic outcomes. Following the introduction of conventional TAMIS, the robotic platform was introduced and applied in analogous fashion. Over the past decade, data have accumulated enabling the comparison of the two approaches most notably with regard to patient morbidity, mortality, and oncologic outcomes. This review discusses the most recently available outcomes regarding conventional and robotic TAMIS and provides a comparison of the two platforms in the treatment of rectal neoplasia. While randomized controlled trials comparing the two platforms are lacking, important differences have been identified. Conventional TAMIS is the more cost-effective approach while advancements in the robotic platform allow the surgeon to be seated and ergonomically optimized, allowing greater visualization and ease of suturing. Differences in oncologic outcomes between the two platforms have not been identified. Head-to-head randomized controlled trials are required to determine if any differences in functional or oncologic outcomes exist.
Paraesophageal Hernia (PEH) is the protrusion of the stomach and/or other abdominal viscera into the mediastinum due to an enlargement of the diaphragmatic hiatus. The treatment of PEH is challenging: On the one hand, watchful waiting carries the risk of developing acute life-threatening complications requiring an emergency operation. On the other hand, elective repair of PEH has non-negligible morbidity and mortality rates, also due to the characteristics of PEH affected patients, who are generally elder and frail. A review of the literature is presented to highlight strategies that can be adopted to minimize early and long-term complications after PEH surgical repair. The laparoscopic approach has been shown to provide reduced hospital stay, postoperative morbidity and mortality, and overall costs compared to traditional open surgery, and it is currently considered the standard approach both to elective and emergency operations. The evidence suggests that strict adherence to surgical principles, such as hernia sac excision, extended mediastinal dissection of the esophagus, and tension-free crural repair with or without mesh are mandatory to achieve optimal surgical outcomes and reduce PEH recurrence rate. Different shapes, materials, and techniques of prosthetic repair and the use of relaxing incisions have been proposed, but long-term data are lacking, and no conclusions can be drawn regarding the ideal method of crural closure. When a short esophagus is recognized despite extensive mediastinal dissection, esophageal lengthening procedures are indicated. Systematic addition of a fundoplication is strongly encouraged, for either treating gastroesophageal reflux or reducing recurrence rate.
Surgical resection by lobectomy is the gold standard of therapy for early stage non-small cell lung cancer. However, not all patients are medically fit to undergo surgery. In patients considered high-risk for lobectomy, alternative strategies have been developed including radiofrequency ablation, cryoablation, microwave ablation, stereotactic radiation therapy, wedge resection, and segmentectomy. This work reviews the definition of high-risk, and the outcomes that have been associated with each treatment technique. Some technical points regarding wedge resection versus segmentectomy are noted. Future directions are discussed in the context of treatment for patients considered at high-risk for lobectomy.
With the recent increase in small-sized lung cancers, sublobar resection and minimally invasive surgeries are becoming preferred. In particular, the detection of ground-glass nodules (GGNs) on high-resolution computed tomography has increased. Although lobectomy has been considered a standard procedure for treating lung cancer, sublobar resections have been indicated for treating GGN-dominant small-sized lung cancers. Wedge resection and segmentectomy have generally been performed as sublobar resection; however, each procedure has some technical advantages and disadvantages. Although anatomical resection as a segmentectomy is a complicated procedure, it has recently been increasingly performed with the accurate anatomical grasp using three-dimensional computed tomography and the identification of the intersegmental plane. Other procedures involving the use of newer technologies can also be performed. Individualized sublobar resection might be a suitable procedure for small-sized lung cancer with the appropriate selection of procedures based on each tumor’s characteristics and improving the methods to overcome some technical difficulties.
Aim: Partial nephrectomy is the standard treatment for small renal tumors; however, it remains unclear which surgical approach from among robot-assisted partial nephrectomy (RAPN) and open partial nephrectomy (OPN) is superior. This study aimed to compare perioperative outcomes of RAPN and OPN performed at a single institution after adjusting for preoperative patient and tumor characteristics using propensity score matching (PSM).
Methods: In this retrospective cohort study, patients who underwent RAPN or OPN for a renal mass of cT1-2 N0 M0 between 2005 and 2020 at our institution were recruited. The study outcomes were perioperative outcomes, complications, and pathological and functional outcomes. PSM was used to account for baseline covariates.
Results: Overall, 131 RAPN and 71 OPN cases were extracted; in addition, 58 cases of RAPN and OPN were selected via PSM. RAPN was superior to OPN in terms of estimated blood loss (10 g vs. 160 g, P < 0.001), ischemia time (23 min vs. 34 min, P < 0.001), and hospital duration (7 days vs. 12 days, P < 0.001). There were no significant differences in the incidence of perioperative complications or in the rate of positive surgical margins (both P > 0.05). With respect to functional outcomes, the rates of preservation of renal function at both 1 day and 3 months postoperatively were higher with RAPN than with OPN (85.3% vs. 69.1% and 93.3% vs. 85.6% respectively, both P < 0.001).
Conclusion: In selected cases, RAPN with warm ischemia appears to preserve renal function equally well or better compared to OPN with cold ischemia.
Meningiomas are the most common neoplasm of the central nervous system. Usually benign and generally discovered incidentally at imaging, meningiomas can also be responsible for severe neurological symptoms and deficits, with potentially high morbidity and non-negligible mortality. Therefore, neuroimaging plays a crucial role in meningiomas diagnosis, therapeutic planning, and long-term surveillance, for early detection of both recurrence in treated patients and disease progression in untreated ones. Here, we review conventional findings in meningiomas’ imaging, review the role for advanced diagnostic techniques, and offer an overview on possible future neuroimaging applications.
We describe a method for eliciting an episcleral venous fluid wave (EVFW) in eyes presenting with reticular patterned episcleral venous plexus, after a hemi-gonioscopy assisted transluminal trabeculotomy (hemi-GATT). To reduce the risk of post-operative hyphema and reduce intraoperative tissue manipulation, a hemi-GATT (targeting 180-degrees of Schlemm’s canal) was performed. Post-hemi-GATT, the ability to inject balanced salt solution and obtain an EVFW in both the treated (inferior) and untreated (superior) sectors of the eye supports the surgical success of the technique, and demonstrates an enhanced fluid outflow and subsequent vessel blanching. The pre-operative intraocular pressure of 20/21 mmHg in a single subject decreased to 18-, 12- and 15-mmHg after one day, one month and 3 months post-op, respectively, and the subject was rendered medication-free. This method of performing a hemi-GATT to effectively obtain an EVFW provides evidence for novel treatment algorithms in patients with a reticular episcleral venous plexus where identification of major outflow vessels is less apparent.
Protective ileostomy may be a risk factor for the development of Clostridium difficile (CD) infection (CDI). In the postoperative period signs of CDI may be particularly difficult to differentiate from intra-abdominal sepsis. Presented here are 2 cases that developed CDI after ileostomy reversal. Two patients who underwent low anterior resections after neoadjuvant chemoradiation with protective ileostomy developed fever, leukocytosis and elevated serum C-reactive protein (CRP) levels. The first patient also had negative CD stool toxins and his signs were so severe that he underwent a negative diagnostic laparoscopy and re-creation of ileostomy. The second patient who presented in a similar fashion was more fortunate in that her CD stool toxin was positive and she was treated successfully with oral vancomycin. CDI after ileostomy reversal after low anterior resection can be difficult to diagnose. In the first patient, the situation was so misleading that diagnostic laparoscopy was required. Outcome was eventually favorable in both cases. CDI must be high on the list of differential diagnoses for febrile patients with a leukocytosis and elevated CRP level even in the setting of negative CD stool toxins. Prophylactic intravenous metronidazole and/or vancomycin enemas should be considered prior to colorectal surgery when a protective ileostomy is likely.
Laparoscopic minimally invasive surgery is increasing, and in the last decade some modifications of the technique have been introduced, especially concerning mesh type, fixation, and peritoneal closure, which are herein individually discussed. Currently, a standard unique technique is still missing, and modifications of the technique might be useful in challenging cases, such as the use of fibrine glue to both fix the mesh and close the peritoneum. The aim of this technical note essay is to discuss and update some tips and tricks as well as recent modifications of the trans-abdominal preperitoneal (TAPP) repair of groin hernia.
Aim: The aims of this study were to better understand the outcomes of Roux-en-Y gastric bypass (RYGB) surgery in patients across multiple hospitals in China along with patients with type 2 diabetes mellitus (T2DM) and to explore the potential preoperative predictors of diabetes outcomes after RYGB.
Methods: This was a retrospective cohort study in Chinese patients who underwent laparoscopic RYGB at five Chinese hospitals from April 2009 to December 2014 and returned for follow-up approximately one-year post-surgery. The STROCSS guideline checklist was applied.
Results: In total, 130 patients underwent RYGB: 85 males and 45 females; age, 43.4 ± 11.3 years; and preoperative body mass index (BMI), 33.1 ± 9.0 kg/m2. Of those, 103 (79.2%) had T2DM duration of 6.6 ± 4.7 years and pre-RYGB HbA1c of 8.1 ± 1.9%. Among the patients with T2DM, glycemic control (HbA1c < 7.0%) increased from 28.7% before surgery to 79.3% at 12 months post-procedure, with a concurrent reduction in the use of anti-hyperglycemic agents, including a reduction in insulin requirement from 55.4% to 27.0%. The percentage of excess weight loss was -42.8 ± 44.2%. Among 71 patients with T2DM and data about remission status, 14 (19.7%) achieved T2DM remission at 12 months post-surgery. Age and duration of T2DM were lower in the remission group, while baseline BMI and weight were higher compared with the non-remission group.
Conclusion: RYGB may be effective for weight loss and T2DM control in Chinese patients, and outcomes are consistent with the literature in Western populations. Younger patients with T2DM and with a higher BMI pre-surgery and shorter duration of T2DM were more likely to achieve T2DM remission.
Minimally invasive glaucoma surgery (MIGS) has become increasingly popular as a step in the management pathway of open angle glaucoma. Due to the relative novelty of these devices, there remains some paucity of evidence relating to their long-term efficacy and safety, and this can make comparison between these techniques somewhat complex. This review article aims to guide clinical decision making by providing the latest evidence on the comparative efficacy of current iterations of minimally invasive glaucoma surgery. A literature review was conducted to identify the most significant recent evidence to support the safety and efficacy of the various forms of minimally invasive glaucoma surgery. Included studies provided efficacy and safety data on a variety of minimally invasive glaucoma surgery methods. The PubMed database was searched and a total of 484 studies, published between 2015 and 2020 were identified, of which 27 were included. The studies indicate that most available forms of minimally invasive glaucoma surgery show statistically significant efficacy in terms of intra-ocular pressure reduction and improvement in medication burden, while maintaining an acceptable safety profile.
The addition of robotic-assistance is the latest evolution of minimally invasive esophageal resection and reconstruction. Despite the improved visualization, the addition of wristed instrumentation, and improved ergonomics, there remains a significant learning curve for complex procedures like esophagectomy. In experienced, high-volume centers, robotic-assisted minimally invasive esophagectomy (RAMIE) has demonstrated outcomes equivalent to traditional laparoscopic and thoracoscopic minimally invasive esophagectomy. Herein, the RAMIE procedure is described in detail in key steps. This approach has been established as safe and effective for esophagectomy.
Situs Viscerum Inversus (SVI) is a rare autosomal recessive disease. Because of this particular anatomy, it could be challenging for the surgeon to perform any abdominal procedure, including laparoscopic cholecystectomy. In these situations, indocyanine green fluorescence cholangiography can be essential. A 29-year-old female with documented situs viscerum inversus totalis underwent laparoscopic cholecystectomy with a four-trocar technique. Switching the vision to the near-infrared camera, which elicited the indocyanine green molecules, the surgeon could easily identify the common bile duct and the cystic duct. Switching back to the normal vision, the operator completed the dissection. The described procedure is still challenging due to the “mirror effect” and the uncommon position of the surgical instruments, especially for right-handed surgeons. Indocyanine green fluorescence angiography can help the surgeon identify the structures in cases of non-regular anatomy such as this.
One of the most serious complications after inguinal hernia repair is still the occurrence of chronic pain. The literature describes rates of severe chronic pain of 3%-6%. Laparo-endoscopic inguinal hernia repair is favored to prevent postoperative pain through a minimally invasive approach and sparing of the layers of tissue covering nerves and vessels in terms of reduced risk of damage to these structures. However, the method of fixation of the mesh is still controversial discussed. The use of these penetrating devices such as staples and staplers has been shown to often be complicated by injury to nerves and vessels and occurrence of postoperative pain. The shift to completely atraumatic fixation using adhesives (fibrin glue, cyanoacrylate) began in the early part of this century. Several studies confirmed less postoperative pain after mesh fixation by glue compared to stapler or tacker. Historically, the TEP technique has always been performed without any fixation. Several studies comparing fixation versus non-fixation have been performed in TEP repair and found results with no increase in recurrence rate. Notwithstanding that very few studies comparing fixation versus no fixation with exclusion of large medial inguinal hernias have been published on this topic in TAPP repair, identical results to those with TEP repair were obtained. On the basis of current evidence, no mesh fixation is recommended for laparo-endoscopic inguinal hernia repair except for large medial and combined inguinal hernias. If mesh fixation is required, atraumatic techniques should be used.
Meningiomas of the tuberculum sellae, planum sphenoidale and olfactory groove region are relatively common. Traditionally these meningiomas have been approached through several transcranial approaches. More recently, keyhole approaches have been utilized with success even for large tumors. Endoscopic approaches are an extension of this philosophy, which, in carefully selected patients, may be an excellent alternative, offering a direct line of site from an endonasal approach without brain retraction. Furthermore, bilateral optic canal decompression can be safely and effectively accomplished. We propose that a majority of tuberculum sellae and posterior planum meningiomas may be removed via an endonasal approach, particularly those that are 3 cm or smaller in maximal diameter with minimal lateral extension beyond the supraclinoid carotid arteries and with medial optic canal invasion. A deepened sella is also a favorable factor for endonasal removal. In contrast, we propose that a minority of olfactory groove meningiomas are ideal candidates for endoscopic trans-cribriform removal given the higher risk of anosmia and cerebrospinal fluid leak via the nasal corridor. Instead, a majority of these tumors can be safely and effectively removed via a transcranial keyhole approach, such as the supraorbital “eyebrow” craniotomy or traditional pterional craniotomy with a higher rate of olfaction preservation.
Inguinal hernias are a very common problem and the most common reason for primary care physicians to refer patients for surgery. The diagnosis is usually made from history and physical examination and men are significantly more likely to be affected than women. Most patients will present with a painful bulge in the groin, though up to a third of patients will be asymptomatic at the time of diagnosis. Previously, it had been recommended that all hernias be repaired surgically at the time of diagnosis to prevent the development of a hernia accident (bowel obstruction or strangulation) that would require emergent surgery, which is associated with much higher morbidity and mortality than an elective repair. However, several clinical trials have reported that risks of a hernia accident are sufficiently low so that a “watchful waiting” (WW) approach for male patients who are asymptomatic or minimally symptomatic is a safe management strategy. WW spares patients any risk of operative complications related to their herniorrhaphy, perhaps the most significant of which is post-herniorrhaphy groin pain that has only recently been appreciated as a significant issue. Although WW has now been proven to be safe in asymptomatic males with an inguinal hernia, long-term results of randomized controlled trials have shown that most patients initially managed with WW will eventually elect to have the hernia surgically repaired primarily due to increased pain. The purpose of this article is to review the current evidence on watchful waiting for the management of inguinal hernias.
Aim: We investigated the impact of the anastomotic method in the frame of open abdominothoracic esophageal resection (hand-sewn vs. stapler anastomosis) in patients with carcinoma submitted to surgery in the University Clinic of Saarland over a 14-year period.
Methods: In total, 176 patients underwent an abdominothoracic resection with intrathoracic anastomosis and conventional gastric conduit formation; two groups of patients were analyzed: end-to-end, hand-sewn anastomosis (Group 1) and end-to-side, circular stapler anastomosis (Group 2). Both groups were compared regarding anastomotic leaks and strictures, postoperative morbidity, 90-day mortality and survival.
Results: The rates of anastomotic leak and stricture in the stapler group were reduced in comparison to hand-sewn group, however without reaching statistical significance (8% vs. 13.5%, P = 0.22, and 6% vs. 13.5%, P = 0.1, respectively). In contrast, the rates of redo surgery (34.1% vs. 8%, P = 0.001) and 90-day mortality (11.9% vs. 2%, P = 0.02) were significantly higher in the hand-sewn anastomosis group.
Conclusion: The management of anastomotic leak (stent insertion vs. reoperation) combined with the use of stapler to perform intrathoracic esophagogastric anastomosis improved the postoperative outcome after abdominothoracic esophageal resection.
Currently, the standard treatment for pancreatic neoplasms is surgical resection. However, pancreatic surgical resection is associated with high morbidity and mortality. Patients unfit for surgery are undergoing regular cross-sectional imaging surveillance. Controversy surrounds the optimal surveillance of patients with pancreatic neoplasms, underlying the need for minimally invasive treatment modalities as an alternative to surgical treatment. To date, endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) is an emerging minimally invasive therapeutic alternative to surgical resection for various pancreatic neoplasms. We review evaluations of EUS-RFA for various pancreatic neoplasms to better understand its effectiveness and safety.
Aim: The aim of the study was to retrospectively analyze long-term results of surgical treatment of patients diagnosed with primary inguinal hernia up to 15 years after a Desarda pure tissue repair.
Methods: The study was conducted on a group of adult patients with primary inguinal hernia who underwent elective surgery at our center during 2005-2006. Patients’ data and hernia and surgery characteristics were recorded. Incidence of postoperative complications was assessed seven days after surgery. An attempt was made to contact all patients 15 years after the procedure regarding recurrence, possible surgical re-treatment, pain, and satisfaction.
Results: Desarda procedure was performed in 341 patients. Fifteen years after the surgical procedure, a follow-up was successful in 215 (63%) patients, of whom 198 (58.1%) answered all of the questions. In the early perioperative period, minor postoperative complications were found in 5.6% of patients. After 15 years of follow-up, three recurrences were found (1.5%). Recurrences occurred 2, 3, and 5 years after the surgery. All patients expressed their satisfaction with the treatment. Twenty-eight patients (14.4%) reported a rare occurrence of mild pain while performing certain activities. Three patients reported persistent chronic pain (1.5%).
Conclusion: Surgical repair of primary inguinal hernia using the Desarda technique is a simple, feasible, repeatable procedure, using the patient’s own tissues, and with a low learning curve. It seems that the Desarda repair can still be a safe alternative to other non-mesh surgical techniques, especially when the patient refuses the use a synthetic mesh.
Specific injuries due to poor positioning seen in robotic pelvic surgery include slips, compartment syndrome, facial oedema, injuries on pressure points, and accidental injuries caused by the robotic arms. The use of the vacuum bean-bag positioner, L-bar against the patient’s face, and inflated gloves for hand support are simple and effective techniques and should be included in the standard operating policies for robotic surgery. We recommend use of the “L” shaped safety bar against the patient’s face to ensure protection against accidental injuries caused by the robotic arms. The anti-slip bean-bag mattress is efficient to prevent slipping; it conforms to the shape of the body for stable positioning and allows extremities to lie in a natural position. Protection of pressure points of hands and elbows can be done with inflated medical gloves placed in the patient’s hands. Surgeons, anaesthetists and theatre teams are together responsible for ensuring that safety measures are in place to reduce the risk of these complications.
Robot-assisted radical cystectomy is an alternative to the standard open surgical approach and has been increasingly used to surgically treat bladder cancer. Data on oncologic outcomes for the robotic approach have matured, and now intermediate and long-term oncologic outcomes are available. This review focuses on oncologic outcomes of the robotic approach with a focus on recent data and high-quality studies. Based on the current literature available, there are no consistent differences between the robotic and open approaches with respect to positive margin rates, lymph node yields, recurrence patterns, or recurrence free, cancer-specific, and overall survival. If oncologic surgical principles are adhered to, excellent oncologic outcomes are achievable with the robotic approach.
Biliary access is a prerequisite to all endoscopic interventions in the biliary tract. Successful cannulation of the papilla of Vater is the predominant challenge for the majority of endoscopists training in endoscopic retrograde cholangiopancreaticography (ERCP), and the skills required for success differ substantially from those of regular luminal endoscopy. This paper reviews some of the key elements to successful biliary cannulation, a range of options for problem-solving when cannulation is difficult, and some tips and tricks in select special situations as well. The techniques are described, and available evidence is reviewed.
Inguinal hernia repair is one of the most commonly performed general surgery operations. Throughout the years there have been many variations and advancements, including open and laparoscopic techniques, to accomplish the same task of reducing herniated contents and preventing groin hernia recurrence. An array of factors contributes to deciding which operative technique is the best approach to managing a patient presenting with an inguinal hernia. Published data vary due to the heterogeneity of techniques compared, patient presentations, and surgeon expertise. In experienced hands, laparoscopic repair results in a quicker return to work and reduced postoperative pain. Patients with bilateral groin hernias, female patients with groin hernias, and patients with recurrent hernias after prior anterior mesh repair should be offered a laparoscopic preperitoneal mesh approach, when surgeons have the appropriate skill set and experience. We find that open and laparoscopic techniques of inguinal hernias can both achieve exceptional outcomes when applied to the right patient population. To know one’s own capabilities, it is beneficial for surgeons to have baseline familiarity of the multitude of methods of repair, become proficient in both mesh and mesh-free techniques as well as open and laparoscopic techniques to best tailor the surgery to the patient and the clinical circumstances, and follow personal outcomes to evaluate individual results.
The development of a postoperative seroma after endoscopic transabdominal (TAPP) or extraperitoneal (TEP) groin repair is a frequent problem. Although seromas are usually only mildly symptomatic, the swelling that develops postoperatively often causes patients to feel insecure and worried. In the literature some technical approaches to reduce the incidence of postoperative seroma are described. This technical note deals with the authors’ approach in the management of large medial and lateral hernial orifices during robotic r-TAPP procedures using DaVinci Xi technology with the aim of seroma prophylaxis.
Radical cystectomy involves a urinary diversion, the most used being the ileal conduit and the orthotopic neobladder. This review focuses on the complications associated with these procedures, dividing them into general and diversion related complications, as well as their management. We conducted a search on PubMed and Scopus to identify eligible articles on complications of urinary diversions. Randomized controlled trials and systematic reviews with meta-analysis were preferred when available. Early complications occur in the first 90 days after surgery. The most common is post-operative ileus, followed by urinary tract infections and urinary leakage. Most complications occur in the late post-operative setting, being related to the type of urinary diversion. Some of these complications are renal failure, metabolic abnormalities, infections, urolithiasis, and ureteroenteric strictures, each with particular management options. Specific ileal conduit complications are conduit deformities and parastomal hernias. Neobladder patients can have continence problems, like incontinence or urinary retention, but also fistulas and dehiscence. Standardization of complications’ definitions and time-dependent reporting are crucial to better understand and manage these complications. Complication rates are similar between open and robot-assisted procedures and between intracorporeal and extracorporeal diversion. Radical cystectomy with urinary diversion is the most difficult surgical procedure in urology with high early and late complication rates. There is an urgent need of standardizing complication reporting to better compare different procedures.
Endoscopic retrograde cholangiopancreatography (ERCP) and its related procedures are established as necessary and indispensable techniques in the diagnosis and treatment of bilio-pancreatic diseases. However, these procedures are associated with a high risk of complications, and caution is needed as the complications may occasionally follow a fatal course. The primary complications are pancreatitis, bleeding, perforation, and issues associated with biliary stents and lithiasis treatment. Endoscopists must perform ERCP with a strong understanding of the mechanisms of each of these complications and should be familiar with the prevention and countermeasures.
Kidney transplant recipients are at a higher risk of developing cancers as compared to the general population. This is of concern when it comes to gynaecological pathologies because the transplanted kidney lies in the pelvic region, in close proximity to the diseased organ. The successful use of laparo-endoscopic single site surgery with conventional laparoscopic instruments for total hysterectomy and bilateral salpingo-oophorectomy in three patients with prior renal transplantation is reported.
Laparoscopic inguinal hernia repair was introduced in the early nineties as a minimally invasive alternative to the classic Lichtenstein repair. Over the decades, minimally invasive approaches have demonstrated both postoperative benefits and easy replicability. Robotic inguinal hernia repair has been shown as a safe alternative to laparoscopic repair. Furthermore, due to technical difficulties, complex inguinal hernia repairs (scrotal hernias, incarcerated hernias, recurrent hernias, mesh removal, and previous pelvic surgery) are a relative contraindication for laparoscopic repairs. In this article, we highlight the advantages of the robotic approach for complex cases of inguinal hernia.
Minimally invasive surgery (MIS) has changed not only the performance of specific operations but also the more effective strategic approach to all surgeries. Expansion of MIS to more complex surgeries demands further development of new technologies, including robotic surgical systems, navigation, guidance, visualizations, dexterity enhancement, and 3D printing technology. In the cardiovascular domain, 3D printed modeling can play a crucial role in providing improved visualization of the anatomical details and guide precision operations as well as functional evaluation of various congenital and congestive heart conditions. In this work, we propose a novel deep learning-driven tracking method for providing quantitative 3D tracking of mock cardiac interventions on custom-designed 3D printed heart phantoms. In this study, the position of the tip of a catheter is tracked from bi-plane fluoroscopic images. The continuous positioning of the catheter relative to the 3D printed model was co-registered in a single coordinate system using external fiducial markers embedded into the model. Our proposed method has the potential to provide quantitative analysis for training exercises of percutaneous procedures guided by bi-plane fluoroscopy.
Biliary tract malignancies include cancers of the intra-hepatic and extra-hepatic bile ducts. Cholangiocarcinoma is the predominant biliary tract malignancy with nearly 60% of them occurring in the peri-hilar region. They can present with biliary strictures causing jaundice but can be insidious and present late in their clinical course. Recent advances in imaging and other diagnostic modalities help in the earlier identification of these tumors. Diagnosis should be suspected in anyone presenting with jaundice with evidence of biliary ductal dilatation or in patients with primary sclerosing cholangitis with worsening clinical status. The diagnostic approach consists of obtaining tumor markers, mainly CA 19-9, imaging modalities which include computed tomography and/or magnetic resonance imaging to establish the level of biliary obstruction and presence or absence of mass. Tissue sampling is performed with endoscopic retrograde cholangiopancreatography (ERCP) guided cytology and biopsies and with endoscopic ultrasound (EUS) if a mass is visible on imaging. Indeterminate strictures after initial biopsies could be further evaluated by cholangioscopy directed biopsies. Treatment for resectable and distal bile duct cancers involves surgical referral, but palliative biliary drainage is the key for unresectable cancers. Metal stents are generally preferred for distal cancers and plastic stents for proximal cancers. EUS guided biliary drainage can be an alternative approach in patients with failed ERCP.
No robust data support laparoscopic mesh repair in strangulated groin hernias. This is a retrospective review over 6 years of a single surgeon’s experience treating strangulated groin hernias using the laparoscopic trans-abdominal preperitoneal mesh repair with concomitant bowel resection through a periumbilical incision. Nine patients presented with incarceration of 2 inguinal and 7 femoral hernias. The median age was 83 years (IQR 68, 85). One patient was male, all were Caucasian, and 5 were ASA 3-4. The median hospital length of stay was 6 days (IQR 4, 7). There were no known hernia recurrences or mesh infections at 30 days. Laparoscopic repair necessitates mesh placement, and doing so in a clean-contaminated setting is acceptably low risk. Laparoscopy permits better assessment of bowel viability compared to open repair and enables mesh coverage of both the inguinal and femoral spaces.
Aim: The purpose of this study was to assess the learning curve and the accuracy of robot-assisted pedicle screw placement in the first 41 cases.
Methods: This retrospective study investigated the first 41 patients undergoing spinal fusion, whereby 250 pedicle screws were inserted with robotic assistance in a private hospital by a single surgeon. The pedicle screw accuracy was evaluated by computed tomography scan by an orthopedic surgeon according to the Gertzbein and Robbins classification. Planning time and screw placement time were noted. In addition, data about any screw malposition, a return to the operating theatre, and intraoperative repositioning were collected. The data were analyzed with Microsoft Excel.
Results: The results show a high degree of accuracy (98%) of pedicle screw placement with a minimally invasive robot-assisted spinal fusion with no screw malposition requiring a return to the operating theatre. The learning curve improved with time, reaching a plateau at around 25 cases.
Conclusion: This study shows a high degree of accuracy of pedicle screw placement with the robot and it shows a surgeon’s improved experience with the robot with time. Further comparative studies are needed to better assess the robot’s accuracy and its future in spine surgery.
This review considers the preferred preoperative examinations, indications for endoscopic submucosal dissection (ESD), and curative ability of ESD in patients with esophageal squamous cell carcinoma (SCC). Endoscopic evaluation by non-magnifying endoscopy followed by magnifying endoscopy is a common procedure for diagnosing invasion depth of superficial esophageal SCCs in Japan. However, endoscopic ultrasonography may increase overdiagnosis of the depth of cancer invasion, and therefore should not be performed routinely. Image-enhanced magnifying endoscopy or iodine staining is recommended for diagnosing the lateral extent of esophageal SCC. The indications for ESD include clinical T1a-epithelial/lamina propria (EP/LPM) N0M0 non-circumferential lesions, clinical T1a EP/LPM N0M0 circumferential lesions ≤ 50 mm, and clinical T1a-muscularis mucosae/T1b-submucosa 1 cancer (invading submucosa by ≤ 200 µm) N0M0 non-circumferential lesions. Pathological T1a EP/LPM without vascular invasion is defined as curative resection, while pathological T1a MM without vascular invasion is considered as non-curative resection, with undetermined recommendations for additional treatment. Pathological T1b cancer invading the submucosa or pathological vascular invasion-positivity is considered as non-curative resection, and additional treatment is recommended. An accurate preoperative diagnosis, appropriate indication, and adequate curability assessment based on the pathological diagnosis of resected specimens are important for effective ESD.
In the last decades, minimally invasive partial nephrectomy (PN) has gained traction and, as of today, robot-assisted laparoscopic PN (RAPN) is increasingly being performed; this procedure might be performed with a transperitoneal or retroperitoneal (rRAPN) approach. However, rRAPN is less standardized in the literature. Therefore, we describe our rRAPN technique using a da Vinci Xi Surgical System and four robotic arms. First, with the patient placed in full flank position, the camera port is placed at the level of the Petit’s triangle apex. Retroperitoneal space is created by turning the index finger in a 180° movement through this port. After, the two first 8 mm robotic ports are blindly placed with the surgeon’s index finger guide, 8 cm far from the first port, respectively along the anterior and posterior axillary line; 3-5 cm caudally to the last one, a 12 mm AirSeal® assistant port is placed in the same manner. To create space for the last 8 mm robotic port, the peritoneum is reflected medially and downward off of the transversus abdominis muscle laparoscopically. Only then, the last port is placed under direct vision 8 cm ventral and about 2 cm cephalad from the port on the anterior axillary line. The robotic ports placement will result in a caudally convex arc. This technique, due to the extensive use of the surgeon index, implies fast access to the retroperitoneum, protects the underlying anatomical structures from damage, and, due to the trocar positioning along an arc, lowers the arm conflict risk.
Conventionally, resection of the first rib has been performed by the transaxillary and supraclavicular approaches. These approaches are hampered by poor visualization and exposure of the operative field, neurovascular complications, and less than optimal surgical outcomes. The Robotic Surgical System allows for high-definition, magnified, three-dimensional visualization of the operative field and is associated with accurate instrument maneuverability in a confined space. Importantly, the robotic transthoracic technique facilitates the disarticulation of the costo-sternal joint, which appears to be the most critical determinant of surgical success. Robotic first rib resection has been associated with the best-reported outcomes in patients with both Neurogenic and Venous (Paget Schroetter Syndrome) Thoracic Outlet Syndrome (TOS). This paper outlines the technique of robotic first rib resection with disarticulation of the costo-sternal joint for patients with TOS.
Aim: Hair loss is a common complication after bariatric surgery that is related to nutritional deficiencies. The aim of this study was to evaluate the prevalence of micronutrient deficiencies preoperative and postoperative and their relationship with hair loss 12 months after bariatric surgery (BS) in those younger and older than 45 years of age, with or without a prescription for supplements.
Methods: In this prospective study, performed between 2018 and 2020 on patients undergoing laparoscopic sleeve gastrectomy (LSG) (not generally BS) in our hospital, the patients were categorized into two main groups of with or without a prescription for supplements. In addition, each main group was divided into age subgroups. Then, complete clinical and biological nutritional assessments were performed in these four subgroups, before and after surgery. Hair loss related to nutritional deficiencies were systematically recorded at 12 months after LSG.
Results: In total, 1224 patients undergoing LSG were enrolled into the study. Nutritional deficits in some variables were even tripled after LSG in both the younger and older groups without a prescription for supplements. In the group with a prescription for supplements, nutritional deficiencies declined postoperatively. The postoperative deficits in the group without a prescription for supplements were frequently in iron (41.83% for younger group; 44.44% for older group) and zinc (42.15% for younger group; 43.79% for older group). In the group with a prescription for supplements, hair loss was less common than in the group without a prescription for supplements postoperatively.
Conclusion: Preoperative monitoring of the combination of several nutritional deficits could be used to identify patients at risk and prevent the onset of deficiencies and their consequences after BS. Identification and correction of micronutrient deficiencies were essential for treating hair loss.
Robot-assisted radical cystectomy has become widely accepted as a safe and minimally invasive procedure for the treatment of bladder cancer. The urinary diversion continues to be performed completely intracorporeally or extracorporeally. Over the past decade, there has been an increasing number of continent diversions being performed intracorporeally. We evaluated the most recent literature regarding intraoperative metrics and outcomes that compare the intracorporeal and extracorporeal approaches.
Aim: We aimed to review and summarize recent data on surgical and functional outcomes in women undergoing robot-assisted radical cystectomy (RARC) and urinary diversion (UD) for bladder cancer, compared with male and open counterparts.
Methods: A systematic review of English-language articles published in the last 15 years was performed on PubMed/Medline database according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Outcomes of interest included peri- and post-operative surgical outcomes [operative time (OT), estimated blood loss (EBL), hospital stay (LOS), complications, and readmission], pathological outcomes [pT stage, lymph node (LN) yield, positive surgical margins (PSMs), and positive LN (pN+)], and functional outcomes [daytime and nighttime continence, sexual activity, need for clean intermittent catheterization (CIC), and quality of life (QoL) evaluation].
Results: Overall, eight studies were selected collecting data from 229 female patients undergoing RARC. The median OT was 418 min (range 311-562 min) and the median EBL was 380 mL (range 100-1160 mL). OT and EBL were not significantly different comparing males and females, whereas the robotic approach was found to be significantly related with longer OT and lower EBL compared to the open procedure. The median LOS was 9.8 days (range 6.5-21 days); no significant differences in LOS were found between open RC (ORC) and RARC in female patients, as well as between RARC in women and men. The mean incidence of 30-day complications after RARC in women was 32.9%, with 12% of high-grade complications, while the 30- and 90-day readmission rates were 20.8%, and 28%, respectively. Complications and readmission comparing RARC and ORC in female patients appear to be overlapping. The mean rate of PSMs was 2.5% and the mean rate of pN+ was 12.7%; both these outcomes were similar in RARC compared with ORC. The mean number of retrieved LN was 20.6 (range 11.3-35.5). The LN yield resulted significantly influenced by the robotic approach [median 27 (range 19-41)] compared to the open one [20.5 (range 13-28)]. After 12 months, the rate of women with daytime and nighttime continence was 66.7%-90.9% and 66.7%-86.4%, respectively, while that of sexually active women ranged 66.7%-72.7%. The need for CIC ranged 12.5%-27.2%. Administering the EORTC-QLQ-C30 questionnaire after RARC and intracorporeal neobladder, the global health status/QoL and physical and emotional functioning items improved significantly over time.
Conclusion: RARC and UD in female patients is a feasible procedure with surgical outcomes overlapping with those in the male patient population. Postoperative functional outcomes on continence, sexual function, and QoL are still poorly investigated, although results inherent in the nerve-sparing approach appear promising.
Aim: The purpose of this study was to review a single surgeon’s preliminary experiences with minimally invasive single lateral position anterior-to-psoas lumbar interbody fusion with multiple techniques of percutaneous pedicle screws and present perioperative results and complication rates.
Methods: After obtaining Institutional Review Board approval, thirty-five consecutive patients undergoing, in 2018-2020, single position lateral interbody fusion with posterior fixation after obtaining written informed consent. Pedicle screw accuracy, screw-related complications, overall and segmental lumbar lordosis, intraoperative data, perioperative complications, and Visual Analog Pain Scale (VAS) at 6 months follow-up were collected.
Results: One hundred sixty-nine pedicle screws were placed in 35 patients with a 95.3% accuracy rate. 6/7 breaches measured < 2 mm. No complications or reoperations were performed in relation to screw malposition. Mean preoperative overall lumbar lordosis was 45.6° ± 12.5° (range, 19°-71°), and 50.3° ± 9.6° (range, 25°-67°) at 6 months follow up. Mean preoperative VAS scores were 7.3 ± 1.2 (range, 5-10) and 7.3 ± 1.3 (range, 5-10) for the back and leg, respectively and at 6 months follow up, 2.6 ± 2.3 (range, 0-7) and 2.6 ± 2.2 (range, 0-7) for the back and leg, respectively. The mean total operative time was 152.2 ± 54.8 min (range, 80-320 min).
Conclusion: Single lateral position antepsoas lumbar interbody fusion with bilateral percutaneous pedicle screws and rod fixation report comparable screw accuracy rates, operative times, and lordosis correction with the published literature. This modified technique eliminates the resources and time related to intraoperative prone repositioning and may lead to significant cost savings.
Robotic intracorporeal neobladder (RIN) is increasingly the modality of choice for intracorporeal urinary diversion in high-volume Robotic Urology centers. This article details the modern technique of RIN, explains specific tips and tricks to facilitate timely operative progression as well as weighs the outcomes from recently published series. An OVID/EMBASE database search was done using keywords: robotic, cystectomy, intracorporeal neobladder, orthotopic, and intracorporeal urinary diversion. The inclusion criteria were original studies on Robot-Assisted Radical Cystectomy (RARC) with RIN series, available in full text in English, published over the last ten years with a specific analysis of oncological and functional outcomes. Pooled data analysis of the 10 studies included shows 80% of patients had organ-confined disease (≤pT2), 1.86% of patients had positive surgical margin, median lymph node yield of 23 nodes (IQR = 7.5), and cancer-specific survival rate of 78% (range 72%-100%) over a mean follow up of 27.43 months (range 13-37 months). Functionally, the median day continence rate is 81.5%, night continence rate is 61%, and rate of return to spontaneous sexual activity is 33.5%. This compares favorably with outcomes of The International Robotic Cystectomy Consortium - Extracorporeal Urinary Diversion data and data from open radical cystectomy (ORC) neobladder series with long term follow up. High-volume robotic centers have successfully introduced programs for RARC, with RIN demonstrating its safety and feasibility. Their results suggest potential to improve perioperative and functional outcomes over ORC. Moreover, under mentorship, surgeons can learn the technique of RARC and RIN without these outcomes being significantly affected.
Aim: Greenlight photoselective vaporization of the prostate (PVP) is considered a safe alternative to transurethral resection of the prostate (TURP) in men with lower urinary tract symptoms (LUTS) and a prostate volume of 30-80 mL for the comparable short- and mid-term results. Long-term re-treatment rate is still being debated.
Methods: We retrospectively reviewed greenlight PVP procedures in a multi-institutional database from September 2011 to December 2019 collecting data on patients requiring re-intervention with a follow-up period of at least 12 months.
Results: Among 867 patients with a median follow-up period of 32.5 months (interquartile range: 20.0-49.0 months), 35 patients (4%) required re-intervention. Patients requiring re-intervention had a prostate volume ≥
Conclusion: Greenlight PVP has good functional long/mid-term results. The presence of preoperative urethral stricture and the occurrence of early complications correlate with the risk of late re-treatment. In patients with prostate ≥ 100 mL, the enucleation technique may be superior to vaporization in terms of lower long-term risk of re-intervention for LUTS relapse.
Aim: In keeping with the ethos of surgical oncology, male nerve sparing (NS) robotic assisted radical cystectomy (RARC) aims to maximise functional outcomes without sacrificing oncological outcomes. This review details the surgical technique of male NS RARC as well as discussing strategies that may be employed in tandem with surgery to improve post-operative recovery and longer-term quality of life.
Methods: An OVID/EMBASE database search was done with key words of robotic, cystectomy, male and nerve sparing. Publications with no description of post-operative functional outcome were excluded. A total number of 25 relevant publications were selected investigating male NS RARC, assessing functional outcomes along with other surgical standard indicators.
Results: Most series contained small numbers of patients with largely retrospective data and the associated bias of selection. Mean follow up of 27.06 months (range 2.8-58 months) was noted overall. Study design, technique, definitions and measurements of continence and erectile function are heterogeneous across series. With a mean follow up of 27.06 months (range 2.8-58 months), a post-operative satisfactory erectile function of 54.32% (range 9%-100%) and satisfactory day time continence of 90% (range 54.5%-100%) and night time continence of 80.55% (range 46.7%-88%) was found with a mean positive surgical margin rate of only 1.8% (range 0%-6.4%).
Conclusion: Male NS RARC for appropriately selected patients will offer good functional outcomes. Results from the series reviewed suggest the technique is both feasible and safe, without compromising longer term oncological results.
Salvage radical cystectomy (SRC) is currently performed after failure of a trimodal treatment (TMT) for muscle invasive bladder cancer (MIBC) and also as a palliative surgery to manage bladder cancer-related symptoms. We reviewed the available literature to assess the current outcomes of SRC. A comprehensive research of the Medline and Embase databases was carried out by following the Preferred Items for Systematic Reviews and Meta-Analysis. Bladder cancer, radiotherapy, salvage, and cystectomy were the main keywords used in the research. Due to the lack of studies, no time restriction was applied, however only English language and only studies using Clavien-Dindo Grade (CCS) to report complications were considered. Overall, 285 studies were identified, of which 41 studies were considered eligible for the purpose of this review. No comparative studies were found between TMT plus SRC and immediate radical cystectomy. Thirteen studies reported oncological outcomes after TMT. The five-year mean disease free survival rate of patients who underwent SRC after TMT was reported to be about 50% and the 5-year OS rate was between 33% and 48%. Three studies including fewer than 20 patients performed SRC with palliative purpose. Although no perioperative death occurred, patients were highly selected. Overall, 4 studies graded surgery-related complications by CCS. The rate of major complications, defined as CCS ≥ 3, was reported to be between 16% and 32%, most of them being gastrointestinal complications. SRC still preserves a role in the management of MIBC, being part of TMT and palliative care in highly selected patients. However, this surgery is at higher risk of complications and is associated with incontinent urinary diversion, thus an accurate discussion during patient counseling is advisable.
Minimally invasive surgery over the last three decades has provided a credible alternative for the treatment of inguinal hernias. One of the main techniques involved utilises the creation of an extraperitoneal space, thereby avoiding the need to enter the abdominal cavity. The totally extraperitoneal (TEP) inguinal hernia repair is described as well as the common and more serious complications that are possible. TEP has a proven track record of expertise for the surgical treatment of inguinal hernias, but has a steeper learning curve, with more serious complications such as vascular and bladder injuries, which are explored in more detail. The key to managing any such serious complications is early recognition. Rectus sheath hematomas secondary to inferior epigastric artery injury usually require only conservative measures such as close observation with the requirement for any embolization of any arterial bleed a rare event. Bladder injuries if recognized at the time of surgery require immediate repair, with late presentation inevitably needing more invasive intervention for a potentially septic patient. TEP remains an excellent repair with caveats of serious complications which are rare at < 0.5% however, they must be discussed and be part of the consent process prior to any repair taking place.
The aim of the paper is to demonstrate the practicability of retroperitoneoscopic single-site 3D left adrenalectomy after previous homolateral laparotomic renal surgery. We present a case report of a 70-year-old male who underwent radical nephrectomy in 1999. Twenty years after radical nephrectomy, the patient underwent a computed tomography scan for B-cell lymphoma follow-up, which revealed a 30 mm left adrenal mass suspicious for a delayed renal-cell carcinoma metastasis. After multidisciplinary discussion, surgery was chosen as first option. To minimize surgical morbidity as much as possible, a 3D laparoscopic single-site retroperitoneal approach was chosen. The patient had no peri- or intra-operative complications and was discharged on Postoperative Day 3. The final histological report revealed an adrenal clear cell renal-cell carcinoma metastasis. This experience shows that single-site retroperitoneal laparoscopic adrenalectomy is possible in patients who underwent previous abdominal cancer surgery and is an option to consider when determining optimal approaches for adrenal surgery.
This article reviews the Emory University Experience with hybrid coronary revascularization and identifies key factors essential for the success of this relatively new and evolving strategy for the treatment of coronary artery disease. Key decisional and technical factors were identified. In addition, careful patient selection, stepwise progression in learning the different aspects of the procedure, and close collaboration between cardiac surgery-interventional cardiology are key factors for success.
Robot-assisted hepatectomy (RAH) is rarely indicated in Japan because of the lack of reimbursement from the national health insurance system. Instead, laparoscopic hepatectomy has been approved for all hepatectomy procedures except resections requiring biliary reconstruction. An obvious advantage of RAH over laparoscopic hepatectomy is the fact that surgeons can use multi-articulated surgical devices, which may facilitate resection of superior/posterior hepatic regions, hilar dissection, biliary reconstruction, and hepatic segmentation by fluorescence imaging. With the accumulation of evidence supporting the use of robotic surgical devices in particular situations of hepatectomy, RAH will become more commonly indicated in Japan under the existing nationwide reporting system and board certification systems to assure surgical safety.
Atrial fibrillation is the most common cardiac arrhythmia and is associated with morbidity and mortality due to cerebral or systemic embolization, with cardiac thrombi mainly forming in the left atrial appendage (LAA). Anticoagulation is the treatment of choice; however, in patients who do not tolerate anticoagulation, LAA occlusion (LAAO) is a valid alternative. Over the last decade, many different LAAO devices have been developed and tested in trials, providing good clinical results. The purpose of this paper is to make an overview of the current state of the art of LAAO procedure, with a focus on available devices and future perspectives.
The introduction of the da Vinci single port (SP) surgical system (Intuitive Surgical, Sunnyvale, CA, USA) has meant a necessary evolution in the surgical techniques used to perform various Urologic surgeries, such as robotic-assisted radical cystectomy (RARC). In this paper, we describe a step-by-step technique for RARC with intracorporeal ileal conduit urinary diversion using the SP system at our institution and summarize early outcomes in the literature. The surgery was performed utilizing the standard institutional approach for radical cystectomy for the multiport robot, modified for the SP where appropriate. A total of 3 articles were found that included early patient outcomes after SP RARC. Including our institution, a total of 21 patients were included in the final analysis. The average patient age was 68 years old, 16 of the 21 patients were male, 13 of the patients had intracorporeal urinary diversions, the average operative time was 366 min with an average estimated blood loss of 185. The average length of stay was 5.4 days. Among these patients, there were three 30-day complications noted and five 90-day complications, all of which were Clavian II or lower. We conclude that RARC utilizing the SP approach is both feasible and offers several theoretical advantages over the open and multiport approaches, but further study is necessary before advocating for widespread adoption of this modality.
Uterine leiomyomas are common benign solid tumors of the uterus. While the presence of fibroids is rarely life threatening, they are associated with symptoms affecting quality of life and fertility. Myomectomy is a standard fertility-sparing surgery which should be considered for women suffering from fibroid-related symptoms who do not desire hysterectomy or any alternative treatment option. While open surgery is thought to be reserved for large and numerous myomas, mini-invasive methods as laparoscopy and robot-assisted surgery have evolved in the hands of experienced surgeons to also deal with these more complex cases. Robotic myomectomy has its advantages in lower blood loss, fewer complications, and shorter hospital stay over open surgery, whereas the comparison outcomes with laparoscopic myomectomy are still uncertain. Advantages of the wristed instruments, three-dimensional vision along with the incorporation of correct surgical techniques could emphasize the benefits of the robotic assisted approach in large and numerous myoma cases. Careful and detailed assessment should precede the surgery to recognize risks and steps to reduce operation time, which tends to be the most presented drawback of robotic myomectomy. As the tendency of robot-assisted surgeries is growing, many authors share their experience or publish comparison studies with other surgical methods. Our article describes the current status concerning robotic myomectomy, reviewing publications from the past five years (2016-2021).
Robotic-assisted laparoscopic prostatectomy (RALP) has revolutionised the surgical management of localised prostate cancer in the modern era. The surgeon is provided with greater precision, more versatile dexterity and an immersive three-dimensional visual field. The impressive hardware facilitates, for example, the dissection of the peri-prostatic fascia, whilst preserving the neurovascular bundle, or the suturing of the vesico-urethral anastomosis. Prior to RALP, laparoscopic radical prostatectomy (LRP) represented the first venture into the minimally invasive world. Associated with more cumbersome ergonomics, LRP has a significant learning curve compared with the robotic approach. There has been a paucity, until recently, of high-quality literature comparing outcomes between the two operations, including the attainment of the Pentafecta of survivorship: biochemical recurrence-free, continence, potency, no postoperative complications and negative surgical margins.
In this article, we reviewed the techniques and outcomes of minimally invasive surgery for gallbladder cancer performed at an expert center. The techniques of laparoscopic extended cholecystectomy with the short- and long-term outcomes at our center were described. The short- and long-term survival outcomes of laparoscopic extended cholecystectomy are comparable to open surgery. Laparoscopic surgery is a safe, effective alternative for open surgery in the treatment of gallbladder cancer. The benefits of robotic surgery should be proven with further research.