Metabolic and bariatric surgery remains one of the most effective interventions in the management of obesity and its associated medical conditions. The field has continuously grown to now encompass newer procedures that include one-anastomosis gastric bypass, single anastomosis duodeno-ileal bypass with sleeve gastrectomy, sleeve gastrectomy with transit bipartition, and single anastomosis sleeve ileal bypass. These procedures were developed with an aim to tackle current weight loss challenges and safety concerns that tend to present with the more common procedures. Taken together, they have been shown to induce excess weight loss ranging from 64% to 93% over 5 to 10 years, contribute to near-complete resolution of obesity-associated medical conditions, and simultaneously achieve lower rates of complications. However, as most of the current literature reports short-term outcomes, this review aims to identify and discuss their long-term efficacy and safety profiles, emphasizing the need for standardized guidelines that would encourage wider adoption and optimize patient outcomes.
Aim: Robotic-assisted surgery has been successfully introduced in hiatal hernia repair; however, clear advantages over laparoscopy remain limited, with small series and contradictory results. This study aims to evaluate the outcomes of robotic hiatal hernia repair in non-selected patients.
Methods: All patients presenting with symptomatic hiatal hernia were included. The DaVinci® robotic platform was used, and a strict standardized operative technique was performed. Preoperative and postoperative data were prospectively collected and retrospectively analyzed.
Results: A total of 103 consecutive, unselected patients underwent surgery. Median total operating time was 72 min [range 46-168 min]. The 30-day complication rate was 12% (12/103). After a median follow-up of 29 months [range 1-64 months], the late complication rate was 5% and the recurrence rate was 5%.
Conclusion: Robotic surgery is a valuable option for hiatal hernia repair, especially in difficult cases or emergency operations. Whether this translates to better long-term outcomes needs to be further investigated in series with longer follow-up.
The endoluminal functional lumen imaging probe (EndoFLIP) has emerged as a transformative tool in the operative and perioperative management of foregut disorders, including achalasia, gastroesophageal reflux disease (GERD), and esophagogastric junction outflow obstruction. Unlike traditional modalities such as high-resolution manometry and barium swallow studies, EndoFLIP provides real-time, intraoperative assessment of distensibility, compliance, and luminal geometry at the esophagogastric junction. As such, EndoFLIP may augment surgical precision in procedures such as Heller myotomy, fundoplication, and peroral endoscopic myotomy (POEM) by enabling physiologic calibration rather than reliance on static anatomical correction. We further discuss its evolving role in risk stratification, postoperative surveillance, and personalized foregut surgical planning. As the field moves toward functional and minimally invasive solutions, EndoFLIP may offer a data-driven framework to optimize patient outcomes through physiology-informed decision-making in real time.
Aim: Combined ablation and resection (CARe) is a recognized approach for managing multiple colorectal liver metastases (CRLM). Perioperative and long-term results of laparoscopic versus open CARe were evaluated in this study.
Methods: This retrospective multicenter cohort study included CRLM patients who underwent CARe at three hospitals between January 2018 and December 2023. Laparoscopic and open approaches were compared for perioperative and oncological results, with propensity score matching (PSM) applied to reduce baseline imbalance-related bias.
Results: Of the 107 CARe procedures, 65 (60.7%) were performed laparoscopically and 42 (39.3%) via open approach. After PSM, patients who underwent laparoscopic CARe had significantly lower intraoperative blood loss (55 vs. 100 mL, P = 0.028) and shorter postoperative hospital stays (6 vs. 8 days, P = 0.005) compared to those who underwent open surgery. However, the complication rates were comparable (P = 0.415). No differences in median recurrence-free survival (14.9 vs. 13.5 months, P = 0.781) or overall survival (70.9 vs. 48.7 months, P = 0.183) were observed. Notably, laparoscopic CARe group had a higher repeat resection rate following intrahepatic recurrence (52.94% vs. 20.00%, P = 0.036).
Conclusion: Laparoscopic CARe is a safe and effective approach for multiple CRLM, offering reduced perioperative morbidity and enhanced feasibility of repeat hepatic resection compared with the open approach.
Aim: Indocyanine green (ICG) fluorescence is not routinely used in acute small bowel obstruction (SBO), and standardized methods for its use in assessing intestinal perfusion, particularly via laparoscopy, remain lacking. Therefore, we aimed to explore its role in acute SBO in elderly and frail patients undergoing operative management.
Methods: In this single-center, prospective, non-randomized study, we included a case series of patients who underwent emergency laparoscopic surgery for SBO from January 2024 to January 2025 at an Italian community hospital. Patients included were those with acute SBO confirmed by computed tomography scan, who provided signed informed consent, had no allergy to ICG, and were ≥ 18 years old. In borderline cases of intestinal ischemia, we standardized the application of ICG fluorescence to help determine the need for intestinal resection: ICG dosage, timing of injection, timing of fluorescence imaging capture and assessment of the intestinal segment. The postoperative course and the need for re-intervention were evaluated.
Results: ICG fluorescence was applied in 16 patients. Half of the cases were male, the median age was 72 years old, 63% presented an American Society of Anesthesiologists (ASA) Physical Status score of 3-4, and the median Charlson Comorbidity Index was 3. Conversion rate was 37%. Main causes of SBO were strangulated hernia, adhesive bands, adhesions and vascular ischemia. In 6 patients, ICG fluorescence showed a non-fluorescent or perivascular pattern, prompting an intestinal resection. Two patients needed re-intervention. Postoperative complications occurred in 43% of the patients.
Conclusion: SBO often affects elderly and frail patients. ICG fluorescence serves as a useful and feasible tool in emergency laparoscopic surgery. It facilitates the surgical assessment in borderline cases of intestinal ischemia, thereby preventing unnecessary bowel resections.
Aim: We propose a novel pre-operative planning approach based on Deep-Learning techniques in the context of minimally invasive mitral valve surgery (MIMVS), for the identification of the mitral valve and optimal thoracic working port positioning in a patient-specific fashion.
Methods: We used supervised Deep-Learning for the processing of contrast-enhanced computed tomography (CT) scans. Our algorithm consisted of four steps: segmentation on CT scans, localization of the mitral valve, creation of maps under three criteria (distance/angle between the mitral valve plane and candidate working port spots, absence/presence of ribs), and selection of optimal working port.
Results: We compared the performance of the Deep-Learning-based approach vs. the previously described semiautomatic method and conventional user’s planning (Dice mean value: 93.59). The Deep-Learning method outperformed the semiautomatic method [intraclass correlation coefficient (ICC) = 0.206]. We defined two interfaces to navigate among candidate working ports.
Conclusion: We suggest that the Deep-Learning-based approach may help the surgeon in identifying the most appropriate working port (thoracic access) for MIMVS, and to comparatively predict the features of different candidate thoracic accesses in individual patients, and help address individual anatomic issues. It may also help standardize the pre-operative planning and obtain a faster learning curve for trainee surgeons.
Aim: To establish and describe a standardized single-position workflow for robot-assisted radical nephroureterectomy with bladder cuff excision (RANU + BCE) using the da Vinci Xi platform. This approach features a dual-rotation reconfiguration, allowing a seamless transition from the renal to the pelvic field without repositioning the patient.
Methods: A retrospective, single-center series of 37 patients with upper tract urothelial carcinoma (UTUC) undergoing transperitoneal Xi RANU + BCE. The rotational reconfiguration commenced with a 90° axial rotation of the multichannel single-site platform - clockwise for left-sided and counterclockwise for right-sided UTUC (as observed externally on the platform). This was followed by coordinated patient-cart axis rotation and overhead-boom adjustment to achieve a pelvic suturing view (12 → 3 for left-sided; 12 → 9 for right-sided), without altering port sites or patient position.
Results: All procedures were completed without repositioning; there were no conversions or reoperations. The median docking time was 15.00 min [interquartile range (IQR) 13.0-19.5], and the median console time was 150.0 min (IQR 121.50-175.50). Estimated blood loss was 50 mL (IQR 20.00-50.00). Hemoglobin reduction was 11.48% on postoperative day (POD) 1 and 10.20% on POD 3. Serum creatinine increased by 8.09% on POD 1 and 18.80% on POD 3. Postoperative complications occurred in 2/37 patients (5.41%), with no complications graded Clavien–Dindo ≥ III.
Conclusion: This integrated Xi workflow may enable a reproducible renal-to-pelvic transition and may help maintain continuous exposure for bladder cuff management without patient repositioning. The straightforward disengage–rotate–re-engage arm choreography allows flexible traction under surgeon discretion and facilitates team adoption and process standardization.
Transcatheter mitral valve replacement (TMVR) has emerged as a transformative intervention for patients with severe mitral valve disease who are at high or prohibitive surgical risk. Among the various access routes, the transseptal approach has gained prominence due to its minimally invasive nature and favorable hemodynamic profile. The transseptal route offers direct access to the mitral valve while avoiding thoracotomy and cardiopulmonary bypass, making it particularly suitable for frail and comorbid patients. However, it poses unique technical challenges, including precise transseptal puncture, complex valve anchoring in the dynamic mitral annulus, and management of left ventricular outflow tract obstruction risk. Multimodal imaging, especially real-time 3D transesophageal echocardiography and cardiac computed tomography, plays a pivotal role in procedural planning and execution. This review underscores the transseptal TMVR approach as a rapidly advancing frontier in structural heart disease treatment, emphasizing the need for further randomized trials and long-term data to fully define its role in the therapeutic landscape of mitral valve disease.
Aim: Temporary diverting ileostomy protects low colorectal/rectal anastomoses but adds stoma morbidity and a planned reversal. We evaluated an Interrupted Ileostomy Tube as a stoma-sparing diversion strategy.
Methods: We retrospectively analyzed 122 patients undergoing radical resection for low rectal cancer with prophylactic diversion (April 2020 - November 2022): traditional diverting ileostomy (n = 90) vs. Interrupted Ileostomy Tube (n = 32). Outcomes were compared before and after 1:1 propensity-score matching.
Results: The Tube group had shorter diversion-creation time (21.38 ± 4.53 vs. 32.03 ±
Conclusion: In this retrospective analysis, the Interrupted Ileostomy Tube was associated with faster recovery and lower index costs and avoided planned stoma reversal and late stoma morbidity without an apparent increase in early complications.
Aim: To assess whether the surgical approach - open pancreatoduodenectomy (OPD) vs. minimally invasive pancreatoduodenectomy (MIPD) - affects short-term postoperative complications in elderly patients, and to determine whether body mass index (BMI) and age-adjusted Charlson Comorbidity Index (aCCI) modify this effect.
Methods: This retrospective cohort study included 156 elderly patients (≥ 65 years) undergoing pancreatoduodenectomy (PD) between 2020 and 2025. Multivariable logistic regression with interaction terms evaluated effect modification by BMI and aCCI on 30-day postoperative complications. Predicted probability-based scenario analyses were used for risk stratification. Exploratory computed tomography (CT) analyses were performed in a representative subgroup (n = 80).
Results: Overall complication rates were comparable between OPD and MIPD, and surgical approach alone was not an independent predictor of complications. Significant interactions were identified between surgical approach and BMI [odds ratio (OR) = 1.28, P = 0.032] and aCCI (OR = 4.18, P < 0.001). Scenario analyses showed that MIPD was associated with lower predicted complication risk in patients with aCCI ≤ 6 and BMI < 23.43 kg/m2, whereas OPD was safer in patients with aCCI > 6. CT analysis demonstrated fewer complications after MIPD in patients with low subcutaneous adipose tissue.
Conclusion: A combined BMI–aCCI–based risk stratification framework supports individualized surgical approach selection in elderly patients undergoing PD.
Since the first laparoscopic liver resection (LLR) was reported in 1991, both surgical techniques and conceptual frameworks have developed rapidly worldwide. Progress in hepatic anatomy - from the classical Couinaud segmentation to refined subsegmental and dynamic portal territory systems - has provided a stronger foundation for precision liver surgery. The “gate theory” and its application in LLR have further enhanced the safety and reproducibility of anatomic dissections. Technically, indications for LLR continue to expand, preoperative evaluation has become more precise, and there has been rapid development in multimodal intraoperative navigation, vascular reconstruction techniques, and robot-assisted surgery. Conceptually, emerging strategies such as anatomic resection based on portal territory and limited anatomic resection are becoming key directions for precision liver surgery. Overall, LLR is advancing toward standardization, precision, and individualization, and is increasingly recognized as a mainstream approach for hepatic resection.