Partial nephrectomy (PN) has become the standard of treatment for most T1 renal masses and is suitable for selected T2 renal cortical masses. In this setting, the management of complex renal masses (CRM) requires a thorough understanding of the potential risks and benefits of both PN and radical nephrectomy (RN). Indeed, thanks to the advent of robotic surgery, indications of PN have expanded to include larger tumors and CRM, despite the associated surgical complexity and oncologic risks. The decision-making process for CRM treatment with PN or RN is complex. Thus, the current review aims to explore the decision-making essentials for patients with CRM, identify research gaps, and address the clinical challenge of determining the most suitable surgical approach. Current evidence suggests that while PN offers a clear advantage in renal tissue preservation, it may carry higher perioperative risks compared to RN. However, these risks should be balanced with the long-term benefits of renal function preservation. In conclusion, further high-quality, prospective studies are needed to better define the comparative effectiveness of PN vs. RN to guide clinical decision-making for CRM.

Aim: This study aims to clarify the effectiveness of laparoscopic anatomical liver resections (ALRs) in surgical site infections (SSIs).

Methods: We included 95 cases (44.0%) of laparoscopic ALRs (LALRs) and 121 (56.0%) of open ALRs (OALRs). Retrospective comparisons were performed between the two groups.

Results: In preoperative factors, tumor size was significantly smaller in LALRs than in OALRs (34.4 ± 23.0 mm vs. 45.9 ± 35.7 mm, P = 0.007). The operative duration was longer in LALRs than in OALRs (523.0 ± 186.5 min vs. 356.3 ± 100.5 min, P < 0.001). However, the blood loss and the blood transfusion were fewer in LALRs than in OALRs (592.1 ± 911.7 mL vs. 1,240.6 ± 1,131.8 mL, P < 0.001, 26.3% vs. 48.8%, P = 0.001, respectively). Postoperative complications above the Clavien-Dindo grade IIIb were one case (1.1%) in LALRs and two in OALRs (P = 1.000). The postoperative hospital stay was shorter in LALRs than in OALRs (14.8 ± 16.5 days vs. 20.7 ± 18.9 days, P = 0.017). There was one (0.8%) postoperative death within 90 days in OALRs and none (0.0%) in LALRs (P = 1.000). Incisional SSIs (ISSIs) were significantly reduced in LALRs than in OALRs (1.1% vs. 7.4%, P = 0.045). Organ/space SSIs (OSSIs) were observed in five cases (5.3%) in LALRs and seven cases (5.8%) in OALRs (P = 1.000). A strong correlation between bile leakage and OSSIs was found. Although OSSIs (Odds ratio 31.200, P = 0.009) were the significant predictive factors for developing ISSIs in OALRs, no risk factors predicting ISSIs were found in LALRs using Multivariate logistic regression analyses.

Conclusion: Although this is a limited study at a single institution, minimally invasive anatomical hepatectomy can reduce ISSIs.

Foregut disorders including gastroesophageal reflux disease (GERD), hiatal hernia (HH), and achalasia are often treated operatively including anti-reflux surgery (ARS), fundoplication, and Heller myotomy (HM). Minimally invasive surgery has become the preferred technique to treat these disorders. These operations have an inherent risk of failure requiring reoperation. These redo operations are more difficult because adhesions and destruction of tissue planes impair visualization during dissection of the hiatus and the gastroesophageal junction (GEJ). Conventional laparoscopic techniques have been described for redo foregut surgery with good results. Surgical robotic systems provide an alternative minimally invasive approach that improves visualization, dexterity, and surgeon ergonomics in many operations. The robot can be used safely and effectively for redo foregut surgery. In this review, we discuss the robotic surgical technique for reoperative foregut surgery and discuss the approach to individual foregut diseases.

The concept of a single anesthetic event (SAE) for lung cancer diagnosis and treatment has recently developed with the aim to streamline care and reduce delays in treatment. SAE integrates advanced diagnostic bronchoscopy, histopathologic diagnosis, and immediate surgical resection in one single anesthetic procedure. This review explores the historical surgical treatment of lung cancer, development of SAE, and the theoretical framework and practical implementation of SAE. While offering potential advantages such as shorter treatment times and reduced hospital stays, SAE encounters logistical difficulties and limitations in use. Despite these challenges, SAE demonstrates feasibility and suggests a pathway towards improved cancer management.

Aim: Lateral hernias are quite uncommon as compared to other ventral abdominal hernias. This study aims to show the feasibility and technical details of laparoscopic preperitoneal repair of lateral hernia.

Methods: This was a retrospective study performed from April 2016 to March 2024 involving patients with lateral hernia who underwent laparoscopic preperitoneal repair. The data regarding patient demographics, operative details, outcomes and follow-up were analyzed.

Results: A total of 57 patients who underwent laparoscopic preperitoneal repair for lateral hernia were identified. The mean age was 57.4 years (range 35-74), with a male preponderance in the ratio of 1.28:1 (males-32:females-25) and body mass index of 28.7 kg/m² (range 22.3-34.8). Most of the hernias were of postsurgical etiology (53, 92.9%), while the remaining were post-traumatic (4, 7.0%). No recurrent hernias were observed. The mean hernia defect width was 6.8 cm (range 3-12). The mean operative time was 178 min (range 145-242). There was no conversion to open. There have been no major complications noted. The mean hospital stay was 2.64 days (range 1-4). No recurrences have been reported in 24 months.

Conclusion: Lateral hernia is a rare entity. Based on our experience, the laparoscopic preperitoneal approach is a safe, feasible and effective choice for lateral hernia repair.

Artificial intelligence (AI) is becoming increasingly utilized as a tool for physicians to optimize medical care and patient outcomes. The multifaceted approach to managing esophageal cancer provides a perfect opportunity for machine learning to support clinicians in all stages of management. Preoperatively, AI may aid gastroenterologists and surgeons in diagnosing and prognosticating premalignant or early-stage lesions. Intraoperatively, AI may also aid surgeons in identifying anatomic structures or minimize the learning curve for new learners. Postoperatively, machine learning algorithms can help predict complications and guide high-risk patients through recovery. While still evolving, AI holds promise in enhancing the efficiency and efficacy of multidisciplinary esophageal cancer care.

Conventional minimally invasive esophagectomy (MIE) and robotic-assisted MIE (RAMIE) have increased in prevalence across the world for the management of esophageal cancer. Both minimally invasive modalities have demonstrated decreased morbidity, with preservation of oncologic outcomes, when compared to open esophagectomy. A limitation of conventional MIE is the use of rigid instruments with 2D visualization leading to a prolonged learning curve and extended operative times. RAMIE offers both improved visualization with 3D video capable of magnification and full dexterity with wristed instruments. To date, retrospective and randomized controlled trials demonstrate overall higher harvest during lymphadenectomy by RAMIE compared to MIE, though more studies are needed to determine definitive impact on oncologic outcomes and long-term survival. RAMIE showed superiority for lymphadenectomy after neoadjuvant therapy and for bilateral recurrent laryngeal nerve (RLN) lymphadenectomy with decreased rates of RLN paralysis. Current data suggests no overall cost difference between the two modalities. Ongoing studies will further clarify the role for RAMIE in esophageal adenocarcinoma (EA) and the outcomes of robotic/MIE hybrid techniques.

During the past decade, technological advancements have transformed liver surgery. New tools are available to assist the surgeon during complex operations, such as a hepatectomy for liver cancer. Augmented reality (AR) is an innovative technology that utilizes computed tomography (CT) or magnetic resonance imaging (MRI) scans to create three-dimensional (3D) images of the area or the organ of interest. This is especially useful for minimally invasive liver resection (MILR), where the field of view and maneuverability during the operation is limited. A 3D image of vascular structures, hilar segments, and the tumor location is projected into the operating field, thus contributing to a more precise resection. Combining AR with the groundbreaking capabilities of artificial intelligence (AI) could further improve the surgical outcomes of MILR. Specialized AI programs are designed to analyze the surgical field, provide information and facilitate the operation plan, simplify intraoperative decision making and reduce human error. 3D printing of hepatocellular cancer liver models is another useful technology that allows for procedure simulation, proper preoperative planning, and effective intraoperative navigation. Even though the benefits could be outstanding, the large cost of those technologies is a major limiting factor. Future research should focus on making AI and 3D imaging tools more widely affordable to the healthcare industry as data show that they could improve diagnostic efficiency, increase surgical precision, minimize human error and optimize patient care.

Locally advanced pancreatic ductal adenocarcinoma (LA-PDAC) involving the body and neck of the pancreas often necessitates complex resections in selected cases, such as the Appleby procedure, also known as distal pancreatectomy with en bloc celiac axis resection (DP-CAR). A 75-year-old female with LA-PDAC, confirmed by endoscopic ultrasound-guided biopsy and treated with neoadjuvant chemotherapy, was initially planned for a robotic DP-CAR. During surgery, transit-time flow measurement (TTFM) showed an inverted and threefold increase in the gastroduodenal artery flow after clamping of the common hepatic artery (CHA), ensuring adequate liver perfusion and avoiding unnecessary preoperative CHA embolization to enhance collateral arterial circulation to the liver. Intraoperative findings revealed only fibrosis without evidence of tumor infiltration around the celiac axis, as confirmed by intraoperative frozen sections. This led to a shift from the planned DP-CAR procedure to an anterior radical antegrade modular pancreatosplenectomy (RAMPS). Final histopathological examinations revealed chronic pancreatitis and complete tumor regression (tumor regression grade 0, ypT0N0). This case underscores the role of robotic platforms and intraoperative tools like TTFM in real-time decision making, enabling tailored surgical strategies for complex pancreatic resections, ensuring oncological adequacy, and optimizing patient outcomes.

Aim: Weight recidivism following bariatric surgery has major physical and psychological consequences. Revisional surgery is a common management option but is associated with increased complications compared to primary surgery. The objective of this study was to assess the efficacy and safety of revisional bariatric surgery for weight regain at our institution.

Methods: A retrospective database review identified patients who underwent revisional bariatric surgery for weight regain at our institution from 2014 to 2023. Emergent operations were excluded. The primary outcomes were percentage total (%TWL) and excess weight loss (%EWL) using revisional surgery weight as the baseline. Secondary outcomes were 30-day morbidity, mortality, readmission, and reoperation rates.

Results: Seventy patients were identified. Five types of revisional procedures were performed: 39 (55.7%) Roux-en-Y gastric bypass (RYGB) revisions (21 endoscopic, 11 laparoscopic, 6 robotic, 1 open), 15 (21.4%) sleeve gastrectomy (SG) to one-anastomosis gastric bypass (OAGB) conversions (8 robotic, 7 laparoscopic), 8 (11.4%) SG revisions (7 laparoscopic, 1 robotic), 7 (10.0%) laparoscopic gastric band to SG conversions, and 1 (1.4%) laparoscopic gastric band to OAGB conversion. SG to OAGB conversion had the largest mean 12-month %EWL at 67.9 ± 25.1, which was significantly greater than SG revision at 47.4 ± 6.7 (P = 0.04) and gastric band to SG conversion at 44.1 ± 21.1 (P = 0.04). SG to OAGB conversion also had the largest mean 12-month %TWL at 19.1 ± 9.4, significantly greater than RYGB revision at 9.0 ± 6.0 (P < 0.001). The 30-day morbidity rate for all patients was 7.1% (N = 5), including 1 anastomotic leak following an SG revision requiring 1 reoperation (1.4%). The 30-day readmission rate was 5.7% (N = 4) and there were no 30-day mortalities.

Conclusion: Revisional bariatric surgery is an effective tool for addressing weight regain and achieving sustained weight loss. Among the revisional options, converting SG to OAGB was most effective at promoting significant weight loss at 12 months. These findings highlight the important role of tailored revisional procedures in the broader context of bariatric care.

Aim: Incidentally diagnosed renal cancers have increased with the increase in imaging modalities. Incidentally diagnosed masses are smaller in size and there are conflicts in the management of these 3,259 masses. Active surveillance (AS) and surgery are the treatment options. In our study, we aimed to compare the data of patients who underwent these two methods.

Methods: The data of 34 patients who underwent AS and 89 patients who underwent surgery were retrospectively analyzed. AS patients were defined as Group 1 and surgical patients as Group 2. Treatment options were determined according to tumor characteristics, patient age, comorbidities, and surgical risks. The Eastern Cooperative Oncology Group (ECOG) performance score and the Charlson Comorbidity Index (CCI) were used to assess comorbidity in each patient. AS patients were offered surgical treatment when their tumors reached > 4 cm in maximal diameter or had rapid tumor growth rates.

Results: The mean patient age was 74.06 ± 6.78 in Group 1 and 58.82 ± 7.60 in Group 2 (P < 0.001). The ECOG performance score was > 1 in all patients in Group 1, while the rate of ECOG > 1 was 59.6% in Group 2 (P < 0.001). CCI was 8.09 ± 0.75 in Group 1 and 3.94 ± 1.14 in Group 2 (P < 0.001). Mortality rates developed in 10 (29.4%) patients in Group 1 and 3 (3.4%) patients in Group 2. Regarding 5- and 10-year cancer-specific survival (CSS), the 5-year survival rate was 81.1% in Group 1 and 97.7% in Group 2, and the 10-year CSS was 63.2% in Group 1 and 89.5% in Group 2, which was statistically higher in Group 2 (P: 0.0022).

Conclusion: Although AS has worse outcomes than surgery in terms of CSS, it is a recommended option for patients with older age and poor performance scores.

Post-bariatric hypoglycemia (PBH) is an underdiagnosed complication of metabolic surgery, resulting in reduced quality of life and weight gain. There is currently no gold standard for the diagnosis of PBH. Although various guidelines and consensuses do not consider continuous glucose monitoring (CGM) a valid diagnostic tool, currently available CGM devices have adequate accuracy for euglycemia and hyperglycemia and have improved accuracy for hypoglycemia over time. This has expanded the use of CGM in the non-diabetic population and may be a useful tool in PBH, but evidence in this population is limited. CGM provides a real-time assessment of glucose fluctuations and variability, providing insights that standard diagnostic tools such as the oral glucose tolerance test (OGTT) and the mixed meal test (MMT) cannot capture in real-world settings. CGM can provide detailed information on the immediate dynamic changes in glucose levels and glycemic profile that reflect the patient’s “real life” situation, assess risk factors for PBH such as postoperative glycemic variability, and enable objective assessment of clinical response to nutritional and pharmacological therapy. Currently, there are limitations to its use in patients with PBH, but evidence of its usefulness in the management of these patients has increased in recent years. The aim of this narrative review is to highlight the benefits of evaluating different CGM metrics in patients with PBH.

Biomechanical damage to the respiratory epithelium by acidic refluxate and endopeptidases (such as activated pepsin) are thought to be key mechanisms by which gastroesophageal reflux disease (GERD) contributes to the development and worsening of chronic respiratory disorders. These chronic disorders include chronic cough, asthma, suppurative lung diseases, chronic obstructive pulmonary disease, and idiopathic pulmonary fibrosis (IPF). In such patients, acid suppression therapy to treat GERD and associated respiratory symptoms has produced controversial results, as these treatments decrease the acidity of the refluxate but do not prevent gastroesophageal reflux and aspiration itself. Consequently, mechanical control of GERD through laparoscopic and endoscopic procedures is a plausible option to halt the progression of such chronic respiratory disorders. This article provides an overview of GERD diagnosis and therapeutic alternatives (i.e., pharmacological therapy, antireflux surgery, and other minimally invasive procedures) in the context of advanced pulmonary disease, particularly IPF.

Aim: Biliopancreatic diversion with duodenal switch (BPD-DS) was simplified by the single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S). It reduces the surgical duration and postoperative complications while maintaining effectiveness in weight loss and mitigating comorbidities.

Methods: This study aims to report personal experiences regarding short- and medium-term outcomes 8 years after the introduction of SADI-S in clinical practice and compare these with the current literature evidence.

Results: At our center, 4,854 bariatric procedures were executed from July 2016 to October 2024, with 157 (3.2%) patients undergoing SADI-S/SADI. This included 104 (66.2%) primary SADI-Ss, 8 (5.1%) conversions to SADI-S, and 45 (28.7%) SADI procedures. Conversion to SADI-S was planned in eight out of 157 after adjustable gastric banding (6 cases) and Roux-en-Y gastric bypass (2 cases). Median age and preoperative body mass index (BMI) were 46 (40-53) years and 51.6 (46.7-56.7) kg/m², respectively. The median surgical duration was 120 min, with an interquartile range of 100 to 160 min. Reoperation was required for two of the four patients (2.5%) who experienced early postoperative complications. Furthermore, 5 (3.1%) patients developed late complications. At a median follow-up of 23 (12-31) months, the median %TWL, %EWL, and BMI were 42 (29.3-52.4), 82 (59.1-99.4), and 27.3 (21.2-33) kg/m², respectively. Seven years of follow-up were eligible in 13 out of 157 patients: median %TWL, %EWL and BMI were 43 (40.1-52.7), 69 (66.4-85.6), and 31.1 (26.2-32.2) kg/m², respectively.

Conclusion: SADI-S is regarded as an effective primary and conversion operation, balancing bariatric and metabolic outcomes with early and late complications.

Since its inception and eventual use by Mason and Ito to treat obesity in 1966, the Roux-en-Y gastric bypass has proven to be an effective procedure for achieving durable weight loss and improving obesity-related comorbidities. Over time, the technique and its complication profile have evolved, including modifications such as lengthening the Roux and biliopancreatic limbs and altering the preferred path of the Roux limb. Due to its longstanding use, a substantial body of research has accumulated regarding the gastric bypass and its outcomes. Long-term follow-up demonstrates durable weight loss in most patients, extending up to twenty years postoperatively. Comorbidity resolution has been extensively studied, showing significant improvements in diabetes mellitus, hypertension, dyslipidemia, and other obesity-related conditions. Although the incidence of complications has decreased since the procedure’s inception, they have not been entirely eliminated.

Aim: The single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) is the most recent procedure to be endorsed by the American Society for Metabolic and Bariatric Surgery. It is gaining popularity due to its combined restrictive and malabsorptive properties, and a single anastomosis may theoretically decrease operative time and risk of enteric leak compared to alternative options such as the biliopancreatic diversion duodenal switch or Roux-en-Y gastric bypass (RNY). However, because SADI-S has only recently been adopted, outcomes data remain limited. Here, we present our single-center adverse outcome data after incorporating the SADI-S into our bariatric practice to compare its safety profile with that of other common bariatric procedures.

Methods: We retrospectively analyzed the data of patients who underwent robotic-assisted laparoscopic SADI-S, vertical sleeve gastrectomy (VSG), or RNY at Saint Joseph Hospital in Denver, Colorado. Postoperative adverse events after SADI-S were compared to those following VSG and RNY, respectively. We evaluated complications occurring within a 30-day follow-up period, including superficial surgical site infection (SSI), organ space infection, deep vein thrombosis (DVT), gastrointestinal bleeding, and anastomotic staple line leak. Additionally, we assessed rates of readmission, reoperation, or any procedural intervention within 30 days postoperatively. Length of hospital stay and operative time were also compared as indirect indicators of cost and procedural efficiency.

Results: In this retrospective data review from January 2023 to August 2024, 35 patients underwent SADI-S, 592 patients underwent VSG, and 200 patients underwent RNY. Compared to VSG, SADI-S demonstrated no significant difference in adverse outcomes with respect to SSI, DVT, gastrointestinal bleeding, readmission, reoperation, and interventions within 30 days. Length of stay was also similar. Compared to RNY, SADI-S also demonstrated no significant differences in adverse outcomes or length of hospital stay. Additionally, there was no significant difference in operative time. (P < 0.05).

Conclusion: When compared individually to VSG and RNY, SADI-S was not associated with a higher incidence of early postoperative complications, including SSI, DVT, gastrointestinal bleeding, readmission, reoperation, or need for additional interventions within 30 days, nor with prolonged hospital stay. These findings support the safe implementation of SADI-S in a high-volume bariatric practice without an increased risk of early adverse outcomes.

Robotic-assisted minimally invasive esophagectomy (RAMIE) is increasingly used in the treatment of resectable esophageal cancer. This is a report on the current technique of RAMIE at University of Pittsburgh Medical Center (UPMC), including a summary of early data on 65 patient outcomes reported in an ongoing esophageal cancer database. To date, we have performed over 200 cases of RAMIE at UPMC from September 2013 to July 2024, and the analysis of the data will be presented soon. The practice has evolved into a near-total RAMIE experience for several surgeons, while others remain in a learning curve. It is our experience that the initial performance of RAMIE requires strong mentoring by an experienced robotic surgeon. However, at this time, we are unable to provide guidelines for specific case numbers to achieve proficiency. As more patients with esophageal cancer are treated with robotic-assisted minimally invasive esophagectomy (MIE) at UPMC, data have shown that patient outcomes are not compromised compared with that of traditional MIE. In fact, RAMIE may demonstrate superiority in the median number of lymph nodes harvested, which could contribute to increased accuracy in pathologic staging. This approach has developed a strong surgeon preference for both new graduates and experienced MIE surgeons alike.

The global prevalence of obesity [body mass index (BMI) ≥ 30 kg/m²] was estimated to affect nearly 890 million adults in 2022, with increasing rates in both adults and children. While comprehensive lifestyle management (diet, exercise, behavioral modification) and pharmacotherapy are central to obesity treatment, metabolic bariatric surgery (MBS), such as sleeve gastrectomy and Roux-en-Y gastric bypass (RYGB), remains the most effective and durable approach for obesity and obesity-related comorbidities, including hypertension, type 2 diabetes, and cardiovascular disease. Despite its effectiveness, MBS is significantly underutilized due to multiple barriers such as the risk of surgery, access limitations, prohibitive social factors, the perceived need for surgery, and fear and beliefs about surgery. Endoscopic bariatric and metabolic therapies (EBMTs) have emerged as an alternative approach to address this gap. While EBMTs are less invasive and have fewer complications than MBS, they are also less effective, though more effective than lifestyle modifications and pharmacotherapy alone. EBMTs, including procedures that involve gastric volume reduction through gastric remodeling or space-occupying devices, malabsorption, or caloric intake reduction, are recommended by the American Society for Gastrointestinal Endoscopy (ASGE) and American Society of Metabolic and Bariatric Surgery (ASMBS) for patients who have not succeeded with lifestyle changes or medications, and as bridge therapies for patients who require weight loss for additional medical treatments. Although EBMTs do not replace bariatric surgery, they complement the existing treatment options, offering patients a less invasive pathway to weight loss and improved metabolic health. Reimbursement models for physicians and the associated financial cost of EBMTs may present inherent complexities. Nevertheless, the prospect of enhanced patient outcomes, substantial reductions in long-term healthcare costs, and expansion of insurance coverage to include these procedures collectively foster optimism for the wider integration of these innovative therapies into clinical practice.

Robot-assisted rectal resection has increasingly gained acceptance as a minimally invasive surgical approach for rectal cancer, primarily due to its enhanced precision, dexterity, and superior visualization compared to traditional laparoscopic surgery. Accumulating evidence from randomized controlled trials, systematic reviews, and large-scale national registry analyses underscores its feasibility and safety, particularly in technically demanding scenarios such as male patients, obese individuals, and those with low rectal tumors. Robotic surgery demonstrates favorable short-term outcomes, including significantly lower conversion rates, reduced intraoperative blood loss, and accelerated postoperative recovery. Nonetheless, results regarding operative duration, postoperative complications, and cost-effectiveness remain heterogeneous. Additionally, robotic techniques may facilitate improved functional preservation, especially concerning urinary and sexual functions, attributed to superior visualization and precise nerve-sparing capabilities; however, these benefits require further rigorous validation. Continued advancements in robotic technology and growing surgical proficiency necessitate future large-scale, multicenter trials to definitively establish the long-term oncological and functional advantages. Emerging robotic platforms and technological innovations hold promise for reducing costs and enhancing accessibility. This narrative review critically examines current evidence, outlining the clinical benefits, inherent limitations, and prospective advancements in robotic-assisted surgery for rectal cancer.

Minimally invasive esophagectomy (MIE) has become a preferred surgical approach for treating esophageal cancer, offering significant advantages over traditional open surgery, such as reduced recovery times, fewer complications, and shorter hospital stays. This review highlights advancements in MIE techniques, with a focus on the growing role of robotic-assisted MIE (RAMIE) in enhancing surgical precision and patient outcomes. Recent trials, such as REVATE and ROBOT-2, highlight RAMIE’s advantages in lymph node resection and reduction in nerve injury rates, suggesting its potential to improve both short- and long-term outcomes. Further innovations, including artificial intelligence (AI) and telementoring, are enhancing surgical navigation and procedural safety, making MIE more accessible globally. Despite these advances, challenges remain, particularly regarding the steep learning curve. This review examines the evolution of MIE techniques, their clinical outcomes, and the future role of emerging technologies in optimizing esophageal cancer surgery.

Urinary incontinence immediately following robotic-assisted laparoscopic radical prostatectomy can significantly impact quality of life. Pelvic fascia-sparing robotic-assisted radical prostatectomy (PFS-RARP) was first described in 2010 to improve urinary functional outcomes via further preservation of anterior pelvic fascial structures. In this article, we summarize the anatomic basis, origin, and outcomes of PFS-RARP compared to standard RARP (S-RARP), highlighting potential advantages in urinary continence and ongoing debate over oncologic efficacy.

Aim: To systematically identify and evaluate key risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis in the Chinese population, providing evidence-based guidance to inform clinical practice, particularly strategies for prevention.

Methods: A comprehensive literature search was conducted across PubMed, China National Knowledge Infrastructure, and other databases from October 2003 to October 2023. Data from 38 rigorously appraised investigations - comprising randomized controlled trials, case-control analyses, and cohort studies - were synthesized in RevMan 5.3 using both fixed- and random-effects models as appropriate. Risk factors were evaluated using odds ratios (ORs) with 95% confidence intervals (CIs), adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results: The meta-analysis identified 22 significant risk factors. The strongest predictors included prior post-ERCP pancreatitis (OR = 6.56, 95%CI: 2.40-17.92), duodenal papillary abnormalities (OR = 3.38, 95%CI: 1.41-8.08), and difficult cannulation (OR = 3.39, 95%CI: 2.07-5.54). Other notable factors were endoscopic papillary balloon dilation (OR = 2.75, 95%CI: 1.61-4.72), elevated superoxide dismutase (SOD) levels (OR = 2.81, 95%CI: 1.24-6.34), female gender (OR = 2.77, 95%CI: 2.00-3.82), and prolonged cannulation time (OR = 2.05, 95%CI: 1.18-3.57). In contrast, hypertension (OR = 1.93, 95%CI: 0.78-4.78) and biliary stenting (OR = 1.65, 95%CI: 0.41-6.58) were not significantly associated with ERCP.

Conclusion: Procedural, anatomical, and biochemical factors were significantly associated with increased post-ERCP pancreatitis risk in Chinese patients. Early identification of high-risk individuals, especially those with prior pancreatitis or papillary abnormalities, and tailored interventions are critical for reducing incidence. These findings provide an evidence-based framework to enhance clinical outcomes in ERCP procedures.

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Aim: Previous literature has evaluated the feasibility and safety of robot-assisted partial nephrectomy (RAPN) performed entirely sutureless and off-clamp. The aim of the present study was to report a series of consecutive, unselected patients with renal masses of intermediate complexity who underwent sutureless off-clamp robot-assisted partial nephrectomy (sl-oc RAPN) by a single surgeon, focusing on surgical strategies, technique, and safety.

Methods: A retrospective analysis was conducted on 29 patients between January 2022 and September 2024. Preoperative clinical characteristics, intraoperative data, and postoperative outcomes were examined, with particular attention to adverse events classified according to the Clavien-Dindo system. Additionally, hemoglobin, serum creatinine, and estimated glomerular filtration rate (eGFR) were analyzed at discharge and at three months postoperatively.

Results: The median patient age was 60 years. All tumors were classified as T1a or T1b according to the tumor, node, metastasis (TNM) system. The median tumor diameter was 30 mm (range: 28-45), and the median PADUA score was 8 (range: 7-8). The median operative time (OT) was 135 min (range: 110/160), and the median estimated blood loss (EBL) was 100 mL (range: 50-100). Serum creatinine and eGFR at discharge and three months postoperatively showed no statistically significant changes (P > 0.05). Three patients (10%) experienced Clavien-Dindo ≥ 3 complications: two developed urine leakage requiring ureteral stent placement, and one experienced postoperative bleeding requiring blood transfusions.

Conclusion: Although limited by a small sample size and the absence of a control group, and with urinary fistula as a potential limitation of the technique, sl-oc RAPN appears effective for treating intermediate-complexity renal tumors. It maintains oncological outcomes, minimizes complications, and preserves renal function.

Obesity remains a global public health burden. The most common surgical approach for this condition worldwide is laparoscopic sleeve gastrectomy (LSG). Although it is highly effective at achieving both short- and long-term weight loss, comparable to outcomes demonstrated by Roux-en-Y gastric bypass, there are growing concerns about the development or worsening of another prevalent and morbid condition, gastroesophageal reflux disease (GERD), following sleeve gastrectomy (SG). In this narrative review, we summarize current concerns related to GERD in the context of SG. We review the pathophysiologic mechanisms that predispose the SG anatomy to GERD, focus on the prevalence of de novo and worsening GERD and its associated complications, Barrett’s esophagus, review expert recommendations for GERD evaluation pre- and post-surgery, and discuss therapeutic options for those with severe GERD following SG.

The objectives of this article are to review the essential anatomy of the paranasal sinuses, describe computed tomography (CT) and magnetic resonance (MR) imaging approaches to the evaluation of paranasal sinus neoplasms, discuss imaging features of common sinonasal tract tumors, and examine systemic staging and surveillance of sinonasal neoplasms using FDG PET/CT and DOTATATE PET/CT.

Aim: Management of clinically localized renal masses ≤ 7 cm (cT1RM) is typically guided by imaging rather than renal mass biopsy (RMB), unlike most other malignancies, where tissue diagnosis precedes treatment decisions. Despite advancements, fewer than 25% of cT1RM patients undergo RMB before surgery or active surveillance (AS). While imaging modalities such as CT, magnetic resonance imaging (MRI), and ultrasound can often identify benign lesions (e.g., Bosniak I-IIF cysts, angiomyolipoma), decisions regarding solid, enhancing masses and Bosniak III-IV cysts frequently proceed without histological confirmation of renal cell carcinoma. This practice may lead to potentially unnecessary or “needless” interventions. AS has emerged as a viable alternative to surgery for renal masses < 3-4 cm, showing low metastatic progression rates comparable to those seen with intervention.

Methods: We systematically reviewed observational studies (retrospective and prospective) due to the absence of randomized controlled trials on RMB for cT1RM.

Results: Reported sensitivity, specificity, positive predictive value, and negative predictive value of RMB range from 93%-99%, 71%-100%, 97%-100%, and 38%-63%, respectively. Safety data affirm RMB as a low-risk procedure, with minor complications (e.g., bleeding, hematoma) occurring in < 5% of cases and hospital admissions/readmissions in < 3%.

Conclusion: While RMB is accurate, its role in treatment planning remains underexplored. Emerging evidence suggests increased adoption of non-interventional approaches (e.g., AS), with RMB influencing treatment decisions (e.g., avoidance of nephrectomy) in 10%-30% of cases. Future studies should investigate when RMB is warranted, its influence on treatment selection, and its effects on patient-centered outcomes such as decisional conflict and regret.

Chronic pancreatitis (CP) is a progressive inflammatory disease characterized by debilitating pain and exocrine insufficiency. When medical and endoscopic treatments fail, surgical decompression may be required. The Partington-Rochelle procedure, a well-established option for ductal decompression via pancreaticojejunostomy, is traditionally performed through open surgery. While the laparoscopic approach is technically challenging, robotic-assisted surgery offers enhanced precision, reduced trauma, and faster recovery. We present the case of a 45-year-old male with CP, recurrent pseudocyst formation, and persistent symptoms despite medical and endoscopic treatment. The patient underwent a robotic Partington-Rochelle procedure using the Da Vinci Xi system. The procedure was successfully completed in 240 min with and an estimated blood loss of 150 mL. Postoperative recovery was uneventful, and the patient was discharged on postoperative day 7 with no complications. At the 3-month follow-up, symptoms had completely resolved, and cyst size had decreased. At 30 months, the patient remained asymptomatic and no longer required analgesics. MRI showed stable pancreatic parenchyma with reduced cystic lesions, and fecal elastase levels indicated mild pancreatic insufficiency. This case highlights the feasibility and effectiveness of the robotic Partington-Rochelle procedure for CP management. The robotic approach provides superior visualization and precision, enabling optimal ductal decompression while overcoming the limitations of laparoscopic and open techniques. Compared to traditional open surgery, it offers faster recovery, reduced morbidity, and excellent long-term symptom control, making it a promising alternative for selected patients.

Achalasia, a primary esophageal motility disorder characterized by impaired peristalsis and the inability of the lower esophageal sphincter to relax, affects approximately 0.5-1.2 individuals per 100,000 annually. Traditional treatments have included endoscopic interventions and Heller myotomy with partial fundoplication, long regarded as the gold-standard surgical option. The advent of minimally invasive techniques, particularly robotic Heller myotomy performed since 2001, has introduced significant advancements in the treatment of achalasia. This review examines the evolution of Heller myotomy, focusing on the robotic approach, which offers distinct advantages such as enhanced surgical precision, a lower risk of mucosal perforation, and shorter hospital stays. By comparing robotic-assisted Heller myotomy (RAHM) with laparoscopic and open approaches, this review underscores the effectiveness of the robotic method in improving operative outcomes and offering a safer, more efficient treatment for patients with achalasia. Through an overview of diagnostic strategies, surgical techniques, and postoperative management, this review underscores the growing role of RAHM as a pivotal shift toward optimizing care for patients with this complex esophageal disorder.

Aim: Laparoscopic hiatus hernia (HH) repair with cruroplasty is an effective treatment for symptomatic patients with type III-IV HH. Various techniques have been described for posterior cruroplasty, ranging from simple suture (SS) repair to suture reinforced with mesh. Mesh-buttressed (MB) cruroplasty aims to reduce HH recurrence, but there is no consensus on indications for mesh placement, mesh type, fixation method, or materials. This study aimed to assess the medium-term effectiveness of MB cruroplasty guided by the Patient-Tailored Algorithm (PTA) in laparoscopic repair of type III-IV HH.

Methods: We conducted a single-center, retrospective observational study from November 2019 to April 2023, including patients with type III-IV HH. The institutional PTA, based on intraoperative measurable parameters (HH type, hiatus diastasis, pillars trophism, and redo surgery), was utilized to guide the decision-making process. If the PTA score exceeded 5, MB cruroplasty using a 10 × 7 cm keyhole-shaped Phasix-ST mesh was performed. The primary outcome was HH recurrence, defined as a combination of symptoms and anatomical gastric migration > 2 cm above the diaphragm. Univariate and bivariate analyses were performed. Statistical significance was set at P-value < 0.05.

Results: Seventy-four patients with a minimum follow-up of 12 months were included. The median age was 66 years and 69% were female. The median follow-up was 38 months (range 12-98). MB cruroplasty was performed in 37 patients (50%). HH recurrence occurred in 7 patients (9.5%), with a clinical trend toward higher recurrence after SS compared with MB (10.8% vs. 8.1%). Postoperative quality of life, measured with the disease-specific GERD-HRQL, improved significantly compared to baseline (20 vs. 3, P = 0.004). In the MB group, both GERD-HRQL and Reflux Symptom Index (RSI) scores improved significantly compared to SS (GERD-HRQL: 2 vs. 7, P = 0.048; RSI: 3 vs. 10, P = 0.003). Trends toward improved SF-36 scores and reduced postoperative proton pump inhibitor (PPI) use were also observed.

Conclusion: MB cruroplasty is associated with favorable medium-term outcomes, including reduced HH recurrence, improved quality of life, and decreased daily postoperative PPI use in patients with type III-IV HH. The PTA provides a simple, reproducible intraoperative strategy for guiding cruroplasty and standardizing surgical decision making in type III-IV HH repair.

Ventral hernia repair in contaminated fields remains challenging, with evolving mesh technologies reshaping surgical approaches. While biologic mesh was traditionally preferred, recent evidence supports the use of permanent synthetic mesh in Centers for Disease Control (CDC) Class I-III wounds, showing lower recurrence rates and similar infection risks. Biosynthetic meshes, such as Phasix^TM, provide reliable long-term durability and offer a cost-effective alternative to biologics, with promising infection resistance. A novel mesh suture (Duramesh^TM) improves fascial closure by distributing tension and integrating with tissue, showing early success in contaminated settings. This review outlines an approach to complex and contaminated hernias that incorporates these new technologies and discusses considerations for staged reconstruction. Permanent synthetic mesh remains the most reliable way to reduce hernia recurrence, while biosynthetic and mesh-suture technologies serve as valuable adjuncts for non-definitive repairs. Further research on the long-term safety and efficacy of biosynthetic meshes and mesh sutures is required to establish consensus in contaminated hernia repair.

Aim: The Competency-Based Assessment of Robotic Surgery Skills (CARS) scale was developed as a novel approach to assess robotic surgery (RS) skills through 10 relevant RS competencies. CARS 2.0 aimed to expand on the findings of CARS by conducting a global survey study in which participants graded a blinded, edited surgical video with the CARS scale for 7 competencies measurable via video.

Methods: CARS 2.0 is being conducted globally, including participants across medical specialties and training stages, from medical students to attending/consultant surgeons. Participants evaluated a blinded, edited surgical video using the CARS scale via an anonymous Google form, focusing on 7 video-measurable competencies.

Results: A total of 320 responses were collected over 3 months, including 125 (39.06%) attending/consultant surgeons, 98 (30.6%) surgical specialty postgraduate trainees, 96 (30%) medical students, and 1 pre-medical student. ANOVA (analysis of variance) analysis showed that the operator scores increased with the evaluators’ level of experience, reaching statistical significance across all 7 competency categories. Spearman’s correlation indicated moderate associations between participants’ surgical experience and proficiency (ρ = 0.314, P < 0.001), as well as between their comfort with the CARS scale and proficiency (ρ = 0.337, P < 0.001). Regression analysis demonstrated that robotic stapler use and camera handling were predictors of higher CARS scores based on participants’ experience.

Conclusion: CARS represents a first step toward establishing competency-based assessment of RS performance independent of specific surgical procedures. Its integration into surgical training programs can facilitate trainees’ attainment of RS competency. Longitudinal studies could further validate its effectiveness at improving surgical training with its implementation into training curricula.

Aim: Laparoscopic liver resection (LLR) is increasingly used in the management of hepatocellular carcinoma (HCC), even among patients traditionally considered high risk due to advanced age or poor nutritional status. Malnutrition, assessed by the prognostic nutritional index (PNI), is known to negatively affect surgical outcomes; however, its impact in the context of LLR remains unclear. We aimed to clarify the effect of malnutrition, defined by the PNI, on short- and long-term outcomes following laparoscopic liver resection for HCC.

Methods: We retrospectively analyzed 121 patients with HCC who underwent primary LLR between 2011 and 2019. Nutritional status was evaluated using the PNI, with a cutoff of < 40 indicating malnutrition. Short-term outcomes were assessed using the textbook outcome (TO), defined as meeting five criteria: no 30-day mortality, R0 resection, no major complications (Clavien–Dindo ≥ III), no unplanned readmission, and no prolonged hospitalization. Long-term outcomes included overall survival (OS) and recurrence-free survival (RFS).

Results: Seventeen patients (14%) were classified as malnourished. TO achievement rates were similar between the malnutrition and normal-nutrition groups (70.6% vs. 74.0%, P = 0.771). No significant differences were observed in individual TO criteria. However, OS was significantly worse in the malnutrition group (median 40 vs. 107 months, P < 0.001), while RFS showed a non-significant trend (P = 0.085). In multivariate analysis, PNI-defined malnutrition was the only independent predictor of poorer OS.

Conclusion: LLR yields acceptable short-term outcomes even in malnourished patients with HCC, as defined by the PNI. However, malnutrition remains a strong independent risk factor for decreased long-term survival. These findings underscore the importance of preoperative nutritional assessment and optimization in surgical candidates with HCC.

This review aims to evaluate the current literature on sutureless clampless partial nephrectomy (sl-oc PN) and assess its potential advantages in terms of renal function preservation, oncological safety, and perioperative outcomes. We conducted a literature search across multiple databases, including MEDLINE, PubMed, and Embase, selecting studies published in the last 10 years that reported on clampless and sutureless partial nephrectomy in cohorts of 10 or more patients. Ten studies from 2015 to 2025 were included, mostly involving tumors with low RENAL (Radius, Exophytic/endophytic properties, Nearness of tumor to collecting system or sinus, Anterior/posterior descriptor, and Location relative to polar lines) scores (< 5). Key outcomes analyzed were estimated blood loss, positive surgical margin rates, major complications (Clavien-Dindo grade ≥ 3), and postoperative renal function changes. Overall, the sutureless clampless technique demonstrated comparable oncological safety, low complication rates, and favorable preservation of renal function. These findings support the feasibility and safety of sl-oc PN, with careful case selection being essential.

Minimally invasive cardiac surgery (MICS) represents a significant advancement in cardiac surgical care, offering benefits such as reduced trauma, shorter hospital stays, and faster recovery. However, the complexity of perioperative management in MICS demands highly accurate risk stratification and decision-making. Artificial intelligence (AI) technologies are increasingly being integrated into perioperative workflows, providing clinicians with data-driven tools to enhance patient selection, predict complications, and optimize outcomes. This review explores current applications of AI in the perioperative assessment of patients undergoing minimally invasive cardiac procedures, with a focus on preoperative risk prediction, intraoperative monitoring, and postoperative management. It discusses the potential of AI to support precision medicine in MICS, highlights the technical and ethical challenges associated with its implementation, and outlines future directions for research and clinical integration. By bridging surgical innovation and computational intelligence, AI is poised to reshape the landscape of perioperative cardiac care.

Robotic surgery has become ubiquitous across a variety of surgical specialties including bariatric surgery. Application of this new technology to bariatric surgery requires some modifications to the traditional laparoscopic technique to accomplish the procedures effectively and efficiently. In this technical report, we describe our approach to robotic Roux-en-Y gastric bypass, outline potential benefits over laparoscopy, and highlight technical variations in the conduct of this operation that may be helpful to practicing bariatric surgeons, especially those who plan to adopt robotic surgery to their practice. We present handsewn vs. stapled gastrojejunostomy creation, omega loop technique vs. traditional construction of the jejunojejunostomy, and other technical variations. Each method has its own advantages and disadvantages which we have highlighted throughout this article. We also discuss pre- and postoperative management. When compared to traditional laparoscopic gastric bypass, robotic approaches remain less often used in current practice but are expected to surpass laparoscopy in just a few years. A robotic approach offers unique benefits for gastric bypass while still proving to be a safe and effective procedure for surgical weight loss.

Aim: To perform a systematic review on the current evidence about the squamous cell carcinoma (SCC) of the upper urinary tract in patients with urolithiasis.

Methods: A comprehensive bibliographic search on the MEDLINE, Scopus, Web of Science, and Cochrane Library databases was performed in December 2024. The SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research type) framework was used to define inclusion criteria: male and female patients with urolithiasis (S); presence of SCC of the upper urinary tract (PI); prospective and retrospective studies (D); diagnosis based on imaging or pathological examination (E); qualitative, quantitative or mixed-methods (R). Quality of studies was assessed with Murad scale. Extracted data were synthesized in a narrative fashion. PROSPERO ID: “CRD42024625816”.

Results: A total of 35 articles were included. Eight case series (22.9%) and 27 case reports (77.1%) were analyzed. The overall quality of papers was low. Sixty-three cases of SCC in patients with urolithiasis (range: 1-11) were identified. The male-to-female ratio was 1.55, with a median age of 60 years (range: 25-87). Most common symptoms included pain (70%), hematuria (60%), and infection (40%). Staghorn stones (48%) and multiple stones (42%) were the most frequently encountered types of calculi. Almost all SCCs (97%) developed in the calico-pyelic system. A radiological suspicion of SCC was raised using imaging in 64% of patients, while in 52% of cases it was an incidental finding during pathological examination after nephrectomy for a non-functional kidney. Locally advanced disease was observed in 44% of patients, while metastasis was reported in 16%. The overall prognosis was poor, with a survival of approximately 6 months and 1-2 years for metastatic and locally advanced cases, respectively.

Conclusion: The available evidence is poor because the disease is extremely rare and the literature is limited to isolated case reports and small series. Therefore, robust conclusions cannot be drawn. Only a limited number of cases are reported in the literature and the current data prevent the estimation of prevalence or reliable pathophysiologic hypotheses. However, this tumor appears to be associated with a severe prognosis. Further investigations are needed to explore the topic and provide sufficient evidence to formulate clear recommendations.

In recent years, minimally invasive pancreatic surgery (MIPS) has become increasingly popular and is now considered an important part of pancreatic surgery practice. Nevertheless, MIPS is feasible and safe only in high-volume centres, with good training of surgeons and good patient selection. This commentary aims to focus on the role of MIPS, in particular robotic pancreaticoduodenectomy, highlighting the advantages of the robotic approach in terms of early postoperative recovery, reduced postoperative complications, and comparable oncological outcomes.

Robotic-assisted surgery represents a significant advancement in minimally invasive colorectal cancer (CRC) surgery, providing enhanced precision, superior visualization, and potentially improved oncological outcomes compared to laparoscopy. These benefits are particularly significant in low rectal cancer, characterized by narrow pelvic anatomy and critical autonomic nerve preservation. Nonetheless, challenges such as increased operative times, high costs, and extensive training requirements hinder broader adoption. This commentary reviews clinical advantages, current limitations, and future perspectives of robotic colorectal surgery, aiming to inform colorectal surgeons and healthcare stakeholders on the evolving role of robotics in CRC treatment.

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