Despite advances in technology and technique of minimally invasive liver surgery, resection of lesions in the posterosuperior segments such as segment 8 (S8) remains challenging. Compared to open surgery, there are specific differences that make minimally invasive access to S8 challenging. These include the caudal view along the axis of the hepatoduodenal ligament, increased distance between trocars and the operative field, and the liver fulcrum created by the anterolateral segments limiting the view. However, several advancements have helped to overcome these challenges, such as the use of intercostal trocars (combined lateral-abdominal approach) and a flexible tip camera. Consequently, a total thoracoscopic (transthoracic) approach was developed to resect subdiaphragmatic tumors, which may particularly benefit patients with a hostile abdomen. This article summarizes the anatomic, technical, and technological considerations for safe resection of lesions in S8.
The Japanese healthcare system is characterized by universal coverage and free access. It is an excellent social system that allows everyone to receive advanced medical care at a low cost. Minimally invasive hepato-pancreato-biliary (HPB) surgery in Japan is now covered by insurance. However, after experiencing a series of serious medical accidents, Japan’s government requested a more advanced system to safely promote highly advanced surgery including laparoscopic HBP surgery. As a practical measure, the academic societies of HPB surgery established a new prospective registration system for all cases of minimally invasive HPB for highly advanced hepatobiliary and pancreatic surgery while utilizing the existing technical certification system. Under these systems, hepatobiliary and pancreatic surgeries in Japan are now being undertaken gradually but safely.
Laparoscopic liver resection (LLR) is safer and more advantageous than open surgery regarding morbidity, blood loss, and length of hospital stay. Several radiological studies and liver surgical strategies confirmed that the anatomy of the liver is more complex than what Couinad described. Intraoperative ultrasound (IOUS) has become an indispensable tool to identify the “real anatomy” and to plan a tailored LLR because of wide sub-segmentary variability and lack of external indicators for small functional liver cores. We schematized our standard ultrasound guidance technique during anatomical and non-anatomical LLR as a four-step method called the Ultrasound Liver Map Technique: (1) Compose the three-dimensional mind map to study the relationships between lesions and surrounding vascular elements; (2) create a sketch on the Glissonian using cautery to help the surgeon recall the mind liver anatomy map; (3) check the section plane while proceeding with the transection; and (4) correct the direction of resection plan to ensure a healthy margin concerning the lesion and to point out the pedicle section correctly and not affected structures. Finally, IOUS-Doppler can be used to study the segmental portal flow to assess venous drainage of the remnant parenchyma, avoiding ischemia and increasing the possibility of performing parenchyma-sparing surgery.
Aim: The magnetic ring (LINX®) system was approved by the FDA in 2012 as a device to augment the lower esophageal sphincter pressure to manage reflux in the general population. It was introduced into the bariatric population in 2014 as an alternative to Roux-en-Y gastric bypass (RYGB) in managing reflux after sleeve gastrectomy (SG).
Materials: Between January 2015 and December 2021, Seventeen patients had the Magnetic Ring (MR) device placement to manage their reflux after SG.
Methods: The mean age was 54 ± 12 years. Their mean body mass index (BMI) was 31 ± 6 kg/m2. The mean time between the SG and MR device placement was 41 ± 19 months. The mean DeMeester score was 48 ± 26
Results: All seventeen patients underwent a successful laparoscopic placement of the MR device. Two patients had early post-operative dysphagia requiring removal of the device and one patient was lost to follow-up. The mean follow up of the remaining fourteen patients was 65 ± 31 months. Recurrent reflux occurred in 11 (79%). In three of these eleven (27%) patients the recurrent reflux was due to a broken device. None of these patients were interested in conversion to RYGB.
Conclusion: The MR device is a valuable tool in treating reflux after SG in spite of its potential risk of recurrence. Our results can be interpreted as being dissatisfying if complete resolution is the goal. Larger studies, with more than 3 year follow up, are needed before a final decision is made on its value in the bariatric population.
Since its introduction in 1985, anatomical liver resection (AR) has been performed to treat early-stage hepatocellular carcinoma. The minimally-invasive AR (MIALR) approach can be safely performed at high-volume tertiary referral centers. The resection techniques can vary among surgeons, depending on the center’s experience, patient characteristics, hepatic segment involvement, and tumor characteristics. Profound knowledge of the liver’s surgical anatomy and a standardized inflow control approach is fundamental to performing MIALR safely. This article aims to summarize the applications of the MIALR and its outcomes, focusing on the techniques for vascular inflow control and the essential tips and tricks to standardize these techniques for laparoscopic and robotic approaches.
Anastomotic leaks (ALs) after esophageal resection remain a dreaded complication and are associated with high morbidity and mortality, along with an increased cost of care and prolonged hospitalization. Management strategies include confirming conduit viability, controlling sepsis with drainage/antibiotics, and maintaining nutrition. Traditional treatment of ALs has given way to nonoperative management including endoscopic and radiological techniques, which are associated with decreased morbidity. This article aims to review novel technologies and techniques for the management of esophageal ALs, including self-expandable metal stents, endoluminal vacuum therapy, leak content drainage, and radiology-guided drain placement.
Aim: Minimally invasive distal pancreatectomy has become the standard of care for benign and low malignant lesions. Spleen preservation in this setting has been proposed to reduce surgical trauma and long-term sequelae. The aim of the current study is to present real-world data on indications, techniques, and outcomes of spleen-preserving distal pancreatectomy (SPDP).
Methods: Patients who underwent SPDP and distal pancreatectomy with splenectomy (DPWS) were extracted from the 2019-2022 Italian National Registry for Minimally Invasive Pancreatic Surgery (IGoMIPS). Perioperative and pathological data were collected.
Results: One hundred and ten patients underwent SPDP and five hundred and seventy-eight underwent DPWS. Patients undergoing SPDP were significantly younger (56 vs. 63.5 years; P < 0.001). Seventy-six percent of SPDP cases were performed in six out of thirty-four IGoMIPS centers. SPDP was performed predominantly for Neuroendocrine Tumors (43.6% vs.23.5%; P < 0.001) and for smaller lesions (T1 57.6% vs. 29.8%; P < 0.001). The conversion rate was higher in the case of DPWS (7.6% vs. 0.9%; P = 0.006), even when pancreatic cancer was ruled out (5.0% vs. 0.9%; P = 0.045). The robotic approach was most commonly used for SPDP (50.9% vs. 29.7%; P < 0.001). No difference in postoperative outcomes and length of stay was observed between the two groups, as well as between robotic and laparoscopic approaches in the SPDP group. A trend toward a lower rate of postoperative sepsis was observed after SPDP (0.9% vs. 5.2%; P = 0.056). In 84.7% of SPDP, splenic vessels were preserved (Kimura procedure) without an impact on short-term postoperative outcomes.
Conclusion: In this registry analysis, SPDP was feasible and safe. The Kimura procedure was prevalent over the Warshaw procedure. The typical patient undergoing SPDP was young with a neuroendocrine tumor at an early stage. Robotic assistance was used more frequently for SPDP than for DPWS.
Small bowel capsule endoscopy (SBCE) is a tool used for Crohn’s disease (CD) diagnosis and monitorization, which aids in appropriate clinical decision-making, especially in the switch of treatment or withdrawal and influencing reclassification of unclassified inflammatory bowel disease. Compared to cross-sectional imaging, namely intestinal ultrasound and magnetic resonance enterography, SBCE has a superior diagnostic yield in proximal small bowel inflammatory activity, which has been associated with greater morbidity. The risk of capsule retention is higher in patients with established CD with suspected stenosis and those with suspected CD with obstructive symptoms, known stenosis or previous small bowel resection. In these situations, SBCE should be administered only after small bowel patency has been evaluated. There is evidence that the pan-enteric capsule (PEC) has a higher diagnostic yield than ileocolonoscopy in detecting terminal ileum mucosal defects. Future research should evaluate the PEC place in CD algorithms as it offers a non-invasive approach, which is especially important in a long-term follow-up, likely diminishing the disease burden.
Renal cell carcinoma is identified most often in the sixth or seventh decade of life, coinciding with the rise in incidental diagnosis of small renal masses as imaging technology has advanced. However, not all patients in this older age group are surgical candidates owing to their comorbidities. Cryoablation is a well-established minimally invasive technique for the treatment of small renal masses. The advent of less invasive ablative treatment has alleviated the surgical dilemma for certain patients who are contraindicated for extirpative procedures. With the appropriate patient selection, cryoablation is safe and effective, resulting in comparable local tumor control, fewer complications, better preservation of renal function, a faster recovery, and a shorter hospital stay. The percutaneous procedure has increased in popularity due to the advantages of reduced pain, shorter hospitalization, the ability to be performed without general anesthesia, and decreased cost relative to surgery.
Fluorescence-guided surgery (FGS) has seen increased interest in recent decades. Technological advances have made it more widely accessible for a variety of applications, including thyroid and parathyroid surgery. Parathyroid autofluorescence can be utilized to help identify parathyroid glands during thyroid or parathyroid surgery and reduce rates of postoperative hypocalcemia after thyroidectomy. Fluorescent dyes such as indocyanine green (ICG) may be used to evaluate perfusion of parathyroid glands during thyroid or parathyroid surgery and help guide decision-making about auto-transplantation or which gland to leave as a remnant. As an emerging technology, additional research is needed to determine the optimal use of FGS in thyroid and parathyroid surgery, including the developing field of molecularly targeted fluorophores. FGS is an exciting and promising field that may help make endocrine surgery safer, faster, and more effective.
Aim: To standardize surgical techniques for and define the safety, feasibility and oncologic validity of minimally invasive anatomic liver segmentectomy for hepatocellular carcinoma (HCC).
Methods: We retrospectively studied perioperative and long-term outcomes of isolated anatomic segmentectomy (IA-Seg) using the extrahepatic Glissonian approach in 157 HCC cases, including 77 open and 80 minimally invasive (59 laparoscopic and 21 robotic) cases. Surgical outcomes were compared between the approaches using propensity score matching (PSM).
Results: After matching (46:46), compared with open IA-Seg, minimally invasive IA-Seg was significantly associated with less blood loss (274 vs. 955 g), a lower transfusion rate (21.7% vs. 45.7%), the lower postoperative serum total bilirubin (TB) level (1.5 vs. 2.2 mg/dL) and shorter length of hospital stay (LOS) (17 vs. 27 days), while the latter had a significantly higher rate of Pringle maneuver application (15.2% vs. 2.2%) and a higher aspartate aminotransferase (AST) level (669 vs. 402 IU/L). Additionally, laparoscopic and robotic IA-Seg before and after matching (16:16) had comparable perioperative outcomes. Long-term outcomes after IA-Seg for newly developed HCC in matched cohorts were comparable, either between open and minimally invasive IA-Seg (36:36) or between laparoscopic and robotic IA-Seg (12:12).
Conclusion: Although minimally invasive IA-Seg is technically demanding, it could be standardized using the extrahepatic Glissonian approach. This procedure for HCC was safe, feasible and oncologically acceptable, with several perioperative outcomes superior to those in open IA-Seg and with comparable long-term outcomes. By expert hands, the laparoscopic or robotic approach could be a reliable option for IA-Seg in selected HCC patients.
Robotic approaches have facilitated the minimally invasive completion of increasingly complex surgical procedures. In the management of the difficult gallbladder, we have found that the wristed instruments, three-dimensional camera, the ability to use indocyanine green (ICG) with integrated fluorescent imaging, and ease of intracorporeal suturing to be useful in tackling the challenges associated with complex benign gallbladder disease. We describe the rationale and technical lessons learned during four cases of complex cholecystectomies that highlight the management principles and technical advantages afforded by the use of the robotic-assisted laparoscopic (RAL) approach. The cases include a subtotal fundus-first reconstituting cholecystectomy, subtotal fenestrating cholecystectomy, a cholecystocolonic fistula managed by a RAL subtotal fenestrating cholecystectomy, and an iatrogenic cholecystoduodenal fistula managed by RAL cholecystectomy. In each case, the operation was performed safely without intraoperative injury or conversion to open, and three of the four patients were discharged from the recovery room. In our view, these favorable outcomes were greatly facilitated by the robotic platform. It is our intent to share adaptations and innovations that we found helpful to encourage other surgeons with sufficient robotic experience to tackle complex gallbladder cases minimally invasively.
Minimally invasive liver surgery (MILS) has become increasingly popular over the last two decades, with hepatocellular carcinoma (HCC) representing a common indication. While data has shown the benefits of a laparoscopic vs. an open approach, robotic liver surgery is rapidly emerging. In this context, among the two minimal access approaches [robotic (RLR) vs. laparoscopic liver resection (LLR)], a differential benefit is still under investigation. While the advantages of RLR include increased dexterity, reduction of physiological tremors, and wrist articulation, it currently has no haptic feedback or specialized liver parenchymal transection devices and is associated with increased operative time and cost. However, RLR has proved to be a safe and effective approach for select patients with HCC. Some benefits of RLR include similar oncological outcomes to open or laparoscopic surgery, possibly reduced conversion rates, and an easier transition from open surgery to a minimally invasive approach. Moreover, while already today RLR can facilitate resection for HCC in hard-to-reach anatomic locations (e.g., transthoracic approach to posterior-superior liver), the future of robotics with the development of advanced image processing technologies, haptic feedback, liver-specific devices, lower cost, and more robot choices seems even more promising.
Surgeon technical improvements made in the 1980s significantly decreased the morbidity and mortality associated with pancreaticoduodenectomy (PD). While minimally invasive surgery (MIS) is now the standard surgical approach for many benign and malignant pathologies, the technical complexity associated with PD presents many challenges to MIS adoption. However, advancements in robotic technology have done much to ameliorate mechanical impediments. Compared to laparoscopic surgery, the robotic platform provides surgeons with enhanced visualization, greater degrees of freedom and range of motion, tremor elimination, and superior ergonomic positioning. Although cost and availability concerns persist, training programs have increasingly incorporated robotic curricula, boosting the prevalence of robotic procedures, including robotic PD (RPD). While prospective data are limited, studies evaluating RPD demonstrate safety, equivalent short-term oncological outcomes, and longer operating times compared to open PD. Furthermore, exciting avenues exist for the future of RPD, ranging from continued instrument innovations to AI-enhanced adjuncts. Robotics has the potential to improve PD for patients and surgeons alike; however, further evaluation of oncologic and surgical outcomes requires well-powered, randomized, prospective trials to confirm the results of earlier retrospective studies, given the significant biases present. In this article, we review the progression of minimally invasive PD, present outcomes from studies evaluating RPD, and discuss areas of innovation for RPD.
Gallbladder cancer is a lethal disease when diagnosed at later stages, and gallbladder polyps may have malignant potential or harbor cancer, especially as the polyp increases in size. Therefore, cholecystectomy has been recommended by guidelines for gallbladder polyps ≥ 10 mm, or smaller polyps with risk factors. In this article, we review minimally invasive approaches to the management of gallbladder polyps. The predominant method of cholecystectomy has been laparoscopic, which has advantages in faster recovery compared to open cholecystectomy. More recently, many surgeons have converted their minimally invasive techniques to robotic approaches. In addition, combined laparoscopic-endoscopic or purely endoscopic approaches have been reported. The ultimate goal of gallbladder polyp management using minimally invasive approaches is to minimize morbidity, given the low incidence of cancer within polyps, while preventing polyps with malignant potential from converting to cancer, or curing cancerous polyps.
Background: While well-described for hepatic and pancreatic resection, the minimally invasive (MIS) approach in the treatment of choledochal cysts (CC) has been under-reported. Due to the technical complexity and steeper learning curve of minimally invasive biliary reconstruction, the MIS approach has not been as widely adopted in biliary surgery. We herein review the use of laparoscopic and robotic-assisted surgery in the treatment of CC.
Methods: A comprehensive review of the literature was performed on the use of laparoscopic and robotic-assisted surgery in the treatment of CC.
Results: Similar morbidity and mortality rates were noted among patients undergoing laparoscopic choledochal cyst resection (LCCR) compared with previous data from patients in the literature who had undergone an open approach (OCCR, open choledochal cyst resection); however, LCCR was associated with longer operative times and high conversion rates, largely attributable to the learning curve given the technically challenging nature of the procedure. The robotic platform (RCCR, robotic choledochal cyst resection) has been shown to offer an advantage in the hepaticojejunostomy anastomosis portion of CC resection vs. laparoscopy while providing comparable short-term outcomes compared with the LCCR approach.
Conclusion: A minimally invasive approach to CC likely has improved perioperative outcomes with shorter LOS, return to baseline function, as well as improved cosmesis vs. OCCR. Longer operative times with minimally invasive approaches to CC have been attributed to steep learning curves, which have improved over time as surgeons become more facile with this technique. Both LCCR and RCCR have demonstrated similar rates of long-term postoperative complications and overall survival when compared to OCCR.
Aim: The transorally inserted anvil (OrVilTM) is often selected for esophagojejunostomy after total laparoscopic gastrectomy due to its versatility. During anastomosis with OrVilTM, it is possible to select a double stapling technique (DST) or a hemi-double technique (HDST) by overlapping the linear stapler and the circular stapler, although there has been no report on the anastomotic strength. Thus, an animal experiment was conducted and verified this study.
Methods: This experiment used 10 fresh porcine esophageal and jejunal specimens. Two models were created: a model in which the rod is placed at the center of the esophageal transection line (DST model) and a model in which the rod is placed at the lateral end of the esophageal transection line (HDST model). A pressure gage was inserted into the anastomosed intestine while continuously measuring pressure to determine the leakage site and leakage pressure.
Results: The leakage site in both the DST (n = 5) and HDST models (n = 5) were at the staple overlapping with a leakage pressure of 151.2 ± 14.2 mmHg in the DST model and 148.2 ± 6.3 mmHg in the HDST model (P = 0.678). When the leakage site was repaired with hand-sewn sutures and conducted remeasuring pressure, leakage was observed from the contralateral crossing in the DST model and the leakage pressure was 155.8 ± 12.2 mmHg. In the HDST model, all models were capable of withstanding 300-mmHg pressures.
Conclusion: HDST with a single staple intersection is beneficial for esophagojejunostomy, in terms of pressure resistance, and the repairing suture at the staple intersection can increase pressure resistance.
While the incidence of intrahepatic cholangiocarcinoma (ICC) is increasing, few patients are surgical candidates, and recurrence rates remain high. Surgical resection remains the only potential curative therapy for ICC, and many retrospective cohorts have demonstrated comparable short-term and long-term outcomes between open, laparoscopic, and robotic liver resection (RLR) for ICC. However, rates of lymphadenectomy remain low amongst all groups, especially in laparoscopic approaches, despite its role in prognostication and therapeutic management. RLR may offer many of the short-term benefits of laparoscopic liver resection (LLR) and facilitate adequate lymphadenectomy while also increasing the ability to access posterosuperior segments and perform major hepatectomies.
As a treatment option for early middle gastric cancer, pylorus-preserving gastrectomy (PPG) has been shown to exhibit good clinical efficacy in Japan and Korea and has attracted widespread attention in China. PPG has a similar surgical safety to conventional distal gastrectomy (DG). The incidence of postoperative complications (such as dumping syndrome, bile reflux gastritis, gallstones, weight loss, and malnutrition) has been shown to be lower, while that of delayed gastric emptying (DGE) was higher after PPG than after DG. However, preserving the vagus nerve, blood supply to the pylorus, and adequate antral cuff length can effectively reduce DGE after PPG. Whether or not incomplete lymphadenectomy affects tumor safety is a primary focus for concern. According to the analysis of lymph node metastasis rates in early middle gastric cancer, the metastasis rates of lymph nodes No. 5 and No. 6 were low, providing a theoretical basis for performing limited lymph node dissection.
Aim: Incisional hernias frequently occur after open abdominal surgery. Up to 30% of elective midline laparotomy closures result in an incisional hernia. The properties of a safe abdominal wall reconstruction must be assessed under lifelike conditions to obtain a realistic estimate of the durability. The interplay of the biomechanical qualities determines the long-term stability of a repair. Various suture materials and techniques for optimal closure of the abdominal wall are still under discussion. The results of this experimental study might significantly affect the active discussion about optimal suturing techniques for median abdominal wall closure.
Methods: For this purpose, a bench test was developed that delivers repetitive cyclic pressure impacts to the abdominal wall, simulating coughs. This allows the assessment of the reconstructed abdominal wall as a compound. We used stiff porcine abdominal walls and elastic bovine flanks as model tissues. We chose two different types of defects. Type one consisted of a 15 cm long medial incision, whereas for type two, a 5 cm circular defect was added in the center of the incision. The incisions were solely sutured in large-bite (0.8-1.2 mm bites) or small-bite (0.5-0.8 mm bites) technique with Monomax® or PDS® sutures USP 2-0 or USP 1. The suture to wound length (SWL) ratio had to exceed 4:1. After suturing, the tissues were subjected to repetitive cyclic loading on a validated bench test.
Results: We found that regardless of technique and material thickness, secure closure of median abdominal wall incisions is feasible by suturing. In larger defects, the small bites technique using Monomax® sutures achieves a safer closure compared to PDS® sutures.
Conclusion: Based on the results of this experimental study, a tailored standardized closure technique after midline incision of the abdominal wall, including an optional mesh augmentation, is recommended.
The article reviews the biomechanical principles of durable abdominal wall reconstructions. The aim is to provide insights and conclusions for future research in this area. Incisional hernia repair implies the creation of a compound made of tissue, textile, and fixation elements. A pulse load bench test for incisional hernia repair has been available since 2014, and its influences are evaluated in three different versions of the test stand. Based on these evaluations, a biomechanical concept for long-term durable reconstructions was determined. To apply the concept to individual patients, computed tomography of the abdomen at rest and during the Valsalva maneuver was used. A load limit can be given for every patient based on the hernia defect area (CRIP- critical resistance to impacts related to pressure). By considering the mesh to defect area ratio, the retention strength of a planned reconstruction can be calculated (GRIP-gained resistance to impacts related to pressure). The gripping coefficients for tissues vary significantly, up to 18 fold. About half of the patients have overall tissue distensions up to 350% or more, with potential high regional variations. The surface retention forces for hernia meshes and for different sutures, tacks, and adhesives span a wide range of 14fold. Suturing a defect strengthens the reconstruction up to 3fold. Furthermore, recalculating data taken from multicentric randomized studies on primary sutures reveals that improved GRIP values are associated with reduced rates of incisional hernia. Repairing consecutive incisional hernias according to the GRIP concept results in no recurrence and low pain levels after one year. A future policy for market access of repair materials should include cyclic load bench testing. Moreover, a tailored approach to incisional hernia repair should take into account the biomechanical aspects involved.
Birt-Hogg-Dubé Syndrome (BHDS) is a rare genetic condition that affects the connective tissue of kidneys, lungs, and skin, causing an aberration in the proteic folliculin (FLCN) pathway. In the lungs, the altered FLCN is found in the outer part of the alveoli, particularly in the lower lobes, causing parenchymal weakness and subsequent cystic degeneration. Because of its rarity, a comprehensive management protocol is not available yet. We present a case of a man with left recurrent pneumothorax due to bilateral multiple bullae, as revealed by a preoperative chest Computed Tomography (CT) scan. Given the characteristic radiological features of BHDS, the CT scan should always be considered for the differential diagnosis to exclude other more common cystic diseases, such as lymphoid interstitial pneumonia, Langerhans cell histiocytosis, or lymphangioleiomyomatosis. Considering the different options suitable for bullous diseases, we decided to treat the patient with a pleural abrasion through a biportal Video-Assisted Thoracic Surgery approach and sterile talc pleurodesis. No more spontaneous episodes were reported one year later. Bullectomy was not carried out because the diffuse cystic intraoperative pattern would never be solved by marginal parenchymal resections. Relapsing spontaneous pneumothorax could be a spy of a hidden genetic disease (such as BHSD), and a CT scan should be considered case-by-case because it may provide crucial information regarding the overall lung pattern. In such cases, pleural abrasion with talc pleurodesis is a considerably effective treatment.
Parastomal hernia is a frequent complication after ostomy formation, causing a significant reduction of the quality of life of patients. In contrast to surgical dogmas dealing with the surgical technique of ostomy formation, mesh-based prophylaxis of parastomal hernia seemed to be effective, leading to the strong recommendation in the European Hernia Society(EHS) guidelines. More recent studies do not favor prophylaxis of parastomal hernia anymore, mainly due to the lack of clearly differentiating the techniques. The mostly used keyhole technique (flat mesh) cannot be equated with the “chimney technique” (3-dimensional mesh) that can be easily performed laparoscopically. Very recent results of the Finnish Randomized Study showed a dramatic reduction of parastomal hernia using the chimney technique. Concerning therapy of parastomal hernia, the chimney technique was also revealed to be effective. The laparoscopic “sandwich technique” should also be used therapeutically with very promising mid- and long-term results and seems to be superior to any other approaches. In a conclusion, investigating the prevention of parastomal hernia should clearly differentiate between the keyhole and chimney techniques and adopt strict technical standardization. Therapy of parastomal hernia should be based on the most effective sandwich or the chimney technique in specialized centers, according to recent registry results. Both techniques are based on the intraperitoneal placement of meshes requiring 3-dimensionality or the possibility of overlapping two meshes. Up to now, these requirements are only fulfilled by meshes made by polyvinylidene fluoride.
Aim: Durable reconstruction of the abdominal wall needs to be assessed in a lifelike experimental setting and consider the reconstructed abdominal wall as a coherent compound. Our aim was to evaluate broader possibilities in preclinical testing and to deepen the understanding of the biomechanical influences.
Methods: We developed a test bench that allows studying a compound under cyclic, repetitive loads. Pulse loads transmit energy to the abdominal wall repeatedly. The amount of energy is related to the load characteristics. We used porcine bellies with a round central (5 cm) defect. They were bridged in a sublay position with Cicat Dynamesh®. Further defects, located in an additional incision, were sutured in a standardized small-bite technique. We varied the number of loads, the maximum peak pressure, the pressure plateau length, and the impact area size.
Results: Increasing the peak pressure by 30 mmHg lowers the durability by about 20 %. Prolonging the plateau phase led to a significant durability decrease. During the first 100 dynamic intermittent strain (DIS) impacts, the major tissue deformation and the majority of failures occur. Beyond the 425th DIS impact, about 10 % more failures occur. Increasing elongation and deformation of the tissue raise the likelihood of failure.
Conclusion: If the compound does not establish a strain-stable condition during the period of plastic deformation, failure occurs. The outcome does not only depend on the reconstruction technique but also on the external influences acting on the abdominal wall compound. Considering the biomechanical reality is important for open and minimally invasive abdominal wall reconstruction.
Aim: The HerniaSurge Group established inguinal hernia repair guidelines to reduce recurrence and chronic pain. We evaluated whether the surgeons of the Abdominal Core Health Quality Collaborative (ACHQC) follow these guidelines and identify areas for improvement.
Methods: A retrospective evaluation of data from the ACHQC database between 2013-2021 using 18,641 eligible subjects undergoing elective and emergent hernia repair with 30-day follow-up. Compliance with a given guideline was defined as following the recommendation in 70% of cases.
Results: Twelve of 19 questions with available data met recommendations based on our above criteria. Eight recommendations with strong evidence and four recommendations with weak evidence were met. The recommendations not met were using the Shouldice technique for any non-mesh open inguinal herniorrhaphy, using local anesthesia for open repair of reducible inguinal hernias, using lightweight mesh, and avoiding the use of prophylactic antibiotics in laparoscopic herniorrhaphy.
Conclusion: Despite varied techniques for inguinal hernia repair, surgeons of the ACHQC follow the majority of the recently published guidelines on the subject. While further research is needed to strengthen the existing guidelines, a standardized approach will facilitate this effort while aiming to reduce negative patient outcomes.
After metabolic surgery, patients with type 2 diabetes (T2DM) typically experience a rapid improvement in glycemic control before any significant weight loss occurs. Furthermore, a significant proportion of patients are able to achieve long-term T2DM remission and improvement in
Aim: To determine if introducing a standardized minimally invasive esophagectomy (MIE) to robot-assisted MIE (RAMIE) improves the short-term patient outcomes.
Methods: A total of 292 patients with esophageal cancer underwent thoracic esophagectomy [MIE (n = 208); RAMIE (n = 84)] at Aichi Cancer Center Hospital between January 2019 and August 2022. The cumulative sum (CUSUM) method was used to analyze the learning curve for RAMIE. The MIE and RAMIE surgical and postoperative outcomes were also analyzed retrospectively. Propensity score matching was used to compensate for the selection bias.
Results: The CUSUM plot of the console time reached a plateau in the 29th case and began to decrease in the 43rd case. Therefore, we defined phase I (introductory phase) up to the 28th case, phase II from the 29th - 42nd case, and phase III from the 43rd case onward. The median thoracic operative time was significantly longer in the RAMIE group than the MIE group in phase I (P < 0.001); however, the median RAMIE console time was 227.5, 212, and
Conclusion: Standardization of RAMIE may decrease the incidence of RLN palsy in patients compared to MIE.
Aim: The modified Blumgart mattress (BM) and conventional interrupted suture (IS) methods are currently the most widely adopted pancreaticojejunostomy (PJ) techniques utilized during minimally invasive pancreaticoduodenectomy (MIPD). This study aimed to evaluate the postoperative outcomes between the two PJ techniques using robotic and laparoscopic approaches.
Methods: This was a retrospective study involving patients who underwent robotic or laparoscopic pancreaticoduodenectomy (PD) performed by two surgeons from two institutions. Surgical outcomes of the patients were compared according to the PJ techniques of robotic BM (Rob-BM), robotic IS (Rob-IS), and laparoscopic IS (Lap-IS), which were further analyzed among patients who had a soft pancreas and small pancreatic duct, while those with pancreatic ductal adenocarcinoma were excluded from the study.
Results: A total of 230 patients underwent MIPD with 63 Rob-BM, 48 Rob-IS, and 119 Lap-IS for PJ. Within the study population, clinically relevant-postoperative pancreatic fistula (CR-POPF) rates were comparable between Rob-BM and Rob-IS (6.3% vs. 10.4%, P = 0.283) and between Rob-IS and Lap-IS (10.4% vs. 7.6%, P = 0.661). Comparing patients with soft pancreas and small pancreatic duct, CR-POPF rates were not statistically different among the groups [16.0% (Rob-BM) vs. 10.5% (Rob-IS), P = 0.055, and 10.5% (Rob-IS) vs. 10.1% (Lap-IS),
Conclusion: POPF rates after MIPD were not different according to the PJ methods of BM and IS when performed by skilled surgeons.
Background: The popularity of minimally invasive surgery for gastric cancer has been on the rise due to its advantages in faster recovery and improved outcomes. However, the lack of tactile sensation poses challenges for tumor identification and anatomical recognition. Indocyanine green (ICG) with near-infrared (NIR) fluorescence imaging has emerged as a potential solution to address these challenges. This review summarizes the current status, limitations, and future prospects of ICG and NIR fluorescence imaging in minimally invasive surgery for gastric cancer. Search strategy: This narrative review searched the PubMed database for relevant articles related to ICG and NIR fluorescence imaging in minimally invasive gastric cancer surgery, published through 2023. The search criteria comprised “indocyanine green”, “ICG”, “near-infrared fluorescence imaging”, “gastric cancer”, “gastrectomy”, and “minimally invasive surgery”. Findings: ICG with NIR fluorescence imaging offers three main applications in gastric cancer surgery. Firstly, it aids in real-time intraoperative tumor identification when injected locally around the tumor, surpassing traditional tattooing techniques. Secondly, ICG facilitates lymph node mapping, particularly in identifying sentinel lymph nodes, which could reduce unnecessary lymphadenectomy. Thirdly, ICG angiography enables the assessment of blood perfusion during reconstructive surgery, evaluating anastomosis sites and potentially reducing anastomotic leakage risk. Conclusions: ICG and NIR fluorescence imaging have shown promising advancements in enhancing the precision and safety of minimally invasive gastric cancer surgery. However, standardized analysis methods and further prospective studies are needed to fully establish their clinical significance. Overall, ICG and NIR fluorescence imaging hold potential as valuable tools to improve patient outcomes in minimally invasive gastric cancer surgery.
Radical esophagectomy is the cornerstone in the treatment of esophageal cancer combined with perioperative therapies, whereas patients diagnosed at an early stage may be candidates for endoscopic resection. Minimally invasive procedures aim to improve the postoperative complications and reduce overall morbidity. The short and long-term results of the incorporation of robot-assisted esophagectomy in specialised centres worldwide have been encouraging. The Ivor Lewis technique has become the preferable approach, reaching up to 61% of the minimally invasive reconstructions in the Western World; however, the percentage of anastomotic leaks remains problematic. Throughout the last decade, a few modifications of the anastomotic technique have been proposed in an effort to improve the surgical results of the robot-assisted approach. This review presents the evolving robotic techniques of performing the esophagogastric anastomosis. An overview of the available approaches will be discussed with a focus on the intrathoracic anastomosis.
Pancreatic resections are complex operations that carry the potential for long-term and life-threatening complications. Over the past several decades, improved surgical techniques and perioperative care have decreased the morbidity and mortality associated with these operations. As laparoscopic and robotic-assisted surgery has been increasingly used in other specialties, the role of minimally invasive techniques in pancreatic surgery remains unclear. We aimed to review the evolution of pancreatic surgery and summarize current data comparing outcomes between open and minimally invasive pancreatic techniques. A comprehensive review was performed using MEDLINE/PubMed with the search dates of January 1, 2018 to February 28, 2023. In PubMed, the terms “pancreas”, “minimally invasive surgery”, and “robotic surgery” were searched. Minimally invasive distal pancreatectomy (DP) is associated with decreased length of hospital stay and intraoperative blood loss with similar morbidity and mortality when compared to open DP. While randomized data supports decreased length of stay for minimally invasive pancreaticoduodenectomy (PD), the LEOPARD 2 trial was terminated early due to increased mortality among patients undergoing laparoscopic PD. Minimally invasive DP appears safe and efficacious compared to open surgery, whereas additional ongoing randomized studies from experienced centers are needed to determine the role of minimally invasive surgery for PD.
Esophageal cancer continues to rise as a public health issue, and esophagectomy remains a mainstay therapy for the disease. Surgical approaches to esophagectomy have evolved over the past few decades with the advent of laparoscopic, thoracoscopic, and robotic technologies. The aim of this review is to identify original articles and perform a comprehensive literature search to provide updates on surgical approaches and technical considerations for esophagectomy. Articles describing the surgical technique specific to robotic-assisted minimally invasive esophagectomy (RAMIE) were reviewed and included. Technical considerations reviewed were comprised of patient positioning, optimal trocar placement, dissection, indocyanine green use, kocherization, pyloric interventions, anastomotic techniques, jejunostomy tube placement, and gastric ischemic conditioning, discussing relevant outcomes for each consideration and approach. Clinical outcomes were also evaluated by comparing RAMIE to open esophagectomy and minimally invasive esophagectomy. Outcomes reviewed included lymph node harvest, intra-operative blood loss, operative times, 30-day readmission, mortality, length of stay, pulmonary complications, recurrent laryngeal nerve injury, anastomotic leak, long-term survival, and disease-free survival.
Aim: Robotic liver surgery (RLS) is a feasible and safe procedure. However, limitations of the robotic instruments used for liver parenchyma dissection compared to laparoscopic and open approaches are major drawbacks of RLS. There is no established technique for liver parenchymal dissection in RLS. The aim of this study is to discuss the surgical outcomes of Totally RLS using Robotic Harmonic curve shears at the University Hospital of Copenhagen, Denmark.
Methods: Between June 2019 and June 2022, RLS was performed with 100 patients. Patient variables and short-term outcomes were retrospectively analysed.
Results: The mean patient age was 63.1 years; the median operating time was 246 min; and the median estimated blood loss was 100 mL. Thirty-two patients underwent subsegmentectomy, 18 mono-segmentectomies,
Conclusion: Based on our study of minor and major hepatectomies in Totally RLS, we conclude that the use of the Robotic Harmonic curve shear for liver parenchyma dissection is feasible and safe.
The aim of this study is to review the current literature on the learning curve for robotic-assisted minimally invasive esophagectomy (RAMIE) and explore strategies for introducing and implementing RAMIE. A literature search of electronic databases (Pubmed and Science Direct) was conducted using multiple combinations and synonyms of the keywords “esophageal cancer”, “robotic esophagectomy”, “RAMIE”, and “learning curve” up to March 31, 2023. In total, eighteen studies were included. Fourteen studies reported on surgeons with experience in minimally invasive surgery. Seven studies reported on surgeons with prior robotic experience for benign diseases or experience as observant or assistant in robotic surgery or experience on cadaveric robotic training. Four studies reported on a specific training pathway. The learning curve was mostly analyzed using the cumulative sum control chart (CUSUM). The most commonly used measured variables were the total operation time, the thoracic and abdominal console time, the lymph node yield, and vocal cord palsy rates. Τhe learning curve plateaus for the total operative time, the vocal cord palsy rates, and the lymph node yield varied between 20-80, 15-80, and 18-73 cases, respectively. At present, several centers are increasingly adopting RAMIE for esophageal cancer. Education about the learning curve of RAMIE is crucial for the training pathway in order to safely introduce RAMIE in centers without pre-existing robotic esophagectomy experience.
Nephron-sparing surgery is the standard treatment for cT1 renal masses, and robot-assisted partial nephrectomy (RAPN) has gained popularity due to its minimally invasive nature and potential advantages in terms of earlier discharge and lower post-operative pain. The Da Vinci Single Port® (SP) system offers the advantages of a smaller incision and the ability to work in smaller spaces. This narrative review aims to address the technical aspects and collect existing evidence on surgical, oncological, and functional outcomes of SP RAPN. Initial experiences with SP RAPN have demonstrated safety and feasibility, both through transperitoneal and retroperitoneal approaches. Several studies have reported similar peri- and post-operative outcomes between SP and multi-port RAPN. Overall, SP RAPN appears to be a promising technique that expands the role of retroperitoneal approaches. This holds the potential to expedite post-operative recovery and minimize hospital stays.
Due to greater accessibility, robotic technology is becoming increasingly common in a wide range of general surgical procedures. In relation to traditional laparoscopic techniques, robotic surgery has four significant advantages: greater accessibility, visibility, accuracy, and comfortability. For example, robotic surgery is particularly beneficial for procedures in hard-to-reach areas (e.g., pelvis, rectum, and endoluminal areas) because it offers a greater range of motion and precision. In addition, surgical visibility and accuracy can be improved by providing 3D and magnified visualization of the surgical field. Robotic systems are also designed for surgeons’ comfort, allowing the operator to sit while working. For these reasons, robotic surgery is preferable for colorectal and other abdominal surgical procedures. As interest in minimally invasive surgery increases, so does the need to develop new approaches and procedures in colorectal surgery. While robotic surgery has great potential for improving outcomes, there may be disadvantages over traditional laparoscopic and open surgical procedures. For example, possible disadvantages include increased maintenance, training, and cost. This review discusses the evolution of robot-assisted surgery with respect to short-term and long-term outcomes. The development of robotic surgical devices, the new devices entering the market, and the possible future directions of robotic surgery will also be discussed.
Robot-assisted partial nephrectomy (PN) is a complex and index procedure with a difficult learning curve that urologists need to learn how to perform safely. We systematically evaluated the development and validation evidence underpinning PN training models (TMs) by extracting and reviewing data from PubMed, Cochrane Library Central, EMBASE, MEDLINE, and Scopus databases from inception to April 2023. The level of evidence was assessed using the Oxford Center for Evidence-Based Medicine. Of the 331 screened articles, 14 cohort studies were included in the analysis. No randomized controlled trials were found, and the heterogeneous nature of the models, study groups, task definitions, and subjectivity of the metrics used were transversal to all studies. All the models were rated good for realism and usefulness as training tools. Methodological discrepancies preclude definitive conclusions regarding the construct validation. No discriminative or predictive validation evidence was reported, nor were there comparisons between an experimental group trained with a TM and a control group. The previous findings stand for the low level of evidence supporting the efficacy of the described TMs in the acquisition of skills required to safely perform PN.
Metabolic and bariatric surgery has been proven to be effective in the glycemic and metabolic control of type 2 diabetes (T2D) and obesity. While most patients experience remission of T2D after surgery, some individuals remain with suboptimal glycemic control. In addition, a significant subset of patients experience relapse of diabetes in the long term after attaining diabetes remission. As a heterogenous disease, the underlying etiology of T2D and response to treatment can be variable in different individuals. The mechanism of diabetes relapse is not completely understood as is the optimal medical management of T2D after metabolic and bariatric surgery. Nonetheless, person-centred collaborative and supportive care beyond the monitoring of parameters forms the cornerstone in formulating care for people with diabetes. This paper reviews the clinical management of T2D after bariatric surgery, including persistent T2D or diabetes relapse after initial remission.