Robotic transthoracic esophagectomy.

BACKGROUND: We have initially published our experience with the robotic transthoracic esophagectomy in 32 patients from a single institute. The present paper is the extension of our experience with robotic system and to best of our knowledge this represents the largest series of robotic transthoracic esophagectomy worldwide. The objective of this study was to investigate the feasibility of the robotic transthoracic esophagectomy for esophageal cancer in a series of patients from a single institute. METHODS: A retrospective review of medical records was conducted for 83 esophageal cancer patients who underwent robotic esophagectomy at our institute from December 2009 to December 2012. All patients underwent a thorough clinical examination and pre-operative investigations. All patients underwent robotic esophageal mobilization. En-bloc dissection with lymphadenectomy was performed in all cases with preservation of Azygous vein. Relevant data were gathered from medical records. RESULTS: The study population comprised of 50 men and 33 women with mean age of 59.18 years. The mean operative time was 204.94 mins (range 180 to 300). The mean blood loss was 86.75 ml (range 50 to 200). The mean number of lymph node yield was 18. 36 (range 13 to 24). None of the patient required conversion. The mean ICU stay and hospital stay was 1 day (range 1 to 3) and 10.37 days (range 10 to 13), respectively. A total of 16 (19.28%) complication were reported in these patents. Commonly reported complication included dysphagia, pleural effusion and anastomotic leak. No treatment related mortality was observed. After a median follow-up period of 10 months, 66 patients (79.52%) survived with disease free stage. CONCLUSIONS: We found robot-assisted thoracoscopic esophagectomy feasible in cases of esophageal cancer. The procedure allowed precise en-bloc dissection with lymphadenectomy in mediastinum with reduced operative time, blood loss and complications.

Nerve-sparing radical hysterectomy made easy by laparoscopy.

STUDY OBJECTIVE: To evaluate the technical feasibility of nerve-sparing radical hysterectomy performed laparoscopically. PATIENTS: Thirty-five women with cervical cancer stage Ia1 or Ib1. INTERVENTIONS: All patients underwent laparoscopic nerve-sparing hysterectomy. MEASUREMENTS AND MAIN RESULTS: Oncologic results were comparable to those of conventional laparoscopic radical hysterectomy. There was complete recovery of bladder function after removal of the Foley catheter. Results of urodynamic studies at 3 weeks after surgery were normal. CONCLUSION: Oncologic and functional results are comparable to those of conventional laparoscopic radical hysterectomy. Magnification enabled by laparoscopy is helpful in better dissection and preservation of nerve anatomy.

Single-site laparoscopic radical hysterectomy using conventional ports and instruments.

STUDY OBJECTIVE: To study the technical feasibility of performing a radical hysterectomy via laparoscopic single-site surgery LESS. PATIENT: A 45-year-old woman with cervical cancer stage IA2. INTERVENTION: Biopsy report showed invasive keratinizing squamous cell carcinoma, grade II. We duplicated the steps of our "Pune technique" of laparoscopic radical hysterectomy to perform a radical hysterectomy via laparoscopic single-site surgery using conventional ports and instruments. MEASUREMENTS AND MAIN RESULTS: Oncologic clearance was comparable to that of conventional laparoscopic radical hysterectomy. Operative time was 120 minutes, and blood loss was 50 mL. CONCLUSION: Reduced port laparoscopic radical hysterectomy is technically feasible. Oncologic clearance and functional results are comparable to those of the multiport variant, with good cosmetic results.

Understanding the pelvic anatomy.

The pelvic anatomy is constant, with few variations. It has a distinct appearance when observed using the 2-dimensional laparoscope. Thus it is important to master the laparoscopic anatomy and use this knowledge to perform better surgery. The laparoscope offers better vision in a narrow space and thus helps better understanding of the anatomy than what can be seen during open surgery. The objectives of this video are to enable the observer to become familiar with the surgical anatomy, to apply anatomical knowledge to develop fine surgical skills, and to address the myths of open surgical anatomy. The lucid graphics, images, and commentary will enable easy understanding of the pelvic anatomy.

Laparoscopic Supracolic Pancreaticoduodenectomy: A Novel Technique For Complete Uncinate Process Resection.

BACKGROUND: Laparoscopic pancreaticoduodenectomy represents one of the most advanced surgical approaches for periampullary and pancreatic head tumors. This article aims to describe the novel technique for complete resection of the uncinate process from supracolic compartment only and summarizes the results from our institute. METHODOLOGY: Retrospective review of prospectively maintained database was performed for patients who underwent laparoscopic pancreaticoduodenectomy from April 2008 to March 2012 at our institute. RESULTS: A total of 38 patients with a mean age of 56.5 years (range: 35-70) underwent laparoscopic pancreaticoduodenectomy with this novel approach. Complete resection of uncinate process was achieved in 33 (86.84%) patients. The mean total operative time and resection time was 231.70 mins (range: 210-450) and 116.50 mins (range: 80-250), respectively. The mean blood loss was 183 ml (range 60-340). Major perioperative morbidity included pancreatic anastomotic leak (n = 3), billiary leak (n = 1) and hemorrhage (n = 1). Mean hospital stay was 14 days (range: 12-25 days). CONCLUSION: This novel supracolic approach for laparoscopic pancreaticoduodenectomy is feasible, safe and less time consuming. This technique can help achieving oncological outcomes comparable to those of the other techniques; though with the minimum invasion. This procedure can be performed conveniently by surgeons with substantial knowledge, experience and skills.

Indian experience of robotics in gynecology.

AIMS: To study the role of robotics in various gynaecological cases, benign and malignant. MATERIALS AND METHODS: A total number of 80 cases have been analyzed. Operative time, estimated blood loss, hospital stay, complications, conversion rates have been retrospectively studied in all cases. Nodal yield, vaginal margin and paracervical clearance have been studied in all malignant cases. This investigation was conducted at a single minimal access surgery institute. RESULTS: Of total 80 cases, 29 were benign and 51 were malignant cases. In benign cases, total robotic hysterectomies were 24, 2 cases of tubotuboplasty, 1 case of endometriotic cyst excision, 1 case of metroplasty and 1 case of rectovaginal fistula. In 51 cases, 37 of radical hysterectomy, 9 exenterations and 6 were parametrectomy. In benign cases, mean operative time was 80 min, estimated blood loss was 20 ml, mean hospital stay was for 1 day, no major complications and no conversions. In malignant cases, mean operative time was 122 min, estimated blood loss was 50-100ml, 2 cases of ureteric fistulas and no conversions, nodal yield was 30, vaginal margin was 2.5-3.8 cm and para cervical clearance was 3-3.5 cm. CONCLUSIONS: Ours is the largest series of robotic surgery in gynecological procedures in India. Benign and malignant cases were addressed robotically showing the feasibility.

More with LESS: a novel report of nerve sparing radical hysterectomy performed using LESS.

Laparoendoscopic single-site surgery (LESS) and natural orifice translumenal endoscopic surgery are now being used in gynecologic oncologic procedures. We used our expertise with LESS to perform nerve-sparing laparoscopic radical hysterectomy. A 45-year-old woman with stage IA2 cervical cancer was referred to us. The biopsy specimen showed grade II invasive keratinizing squamous cell carcinoma. We duplicated the steps of our laparoscopic nerve-sparing radical hysterectomy procedure to perform a nerve-sparing radical hysterectomy via LESS using conventional ports and instruments. Oncologic clearance was comparable to that in conventional laparoscopic radical hysterectomy. Bladder function recovered completely after removal of the Foley catheter. Nerve-sparing laparoscopic radical hysterectomy using fewer ports is technically feasible. The oncologic clearance and functional results are comparable to those in the multiport variant.

Laparoscopic transvesical approach for vesicovaginal fistula repair.

STUDY OBJECTIVE: To access the technical feasibility of performing laparoscopic repair of vesicovaginal fistula. MATERIAL AND METHODS: We attempted a laparoscopic repair of vesicovaginal fistula in five women with a history of urinary leakage via the vagina after vaginal hysterectomy. Five pelvic ports were used. The surgical procedure was performed using the same principles as for open surgery, i.e., separation of the vaginal wall from the bladder wall, repair of the fistula, and interposition of the omentum. RESULTS: There was early recovery of the patients in terms of continence, with less chance of recurrence. Results were comparable to those with the vaginal approach. CONCLUSION: The use of minimally invasive surgery for vesicovaginal fistula repair helps to ease the suturing deep in the pelvis, and the magnification facilitates good identification of tissues planes and thus better mobilization of the vaginal and bladder walls and decreases postoperative morbidity.

Nerve-sparing robotic radical hysterectomy: our technique.

Robotic surgery is now becoming accepted for treatment of gynaecological malignancies. Nerve preservation during radical hysterectomy is increasingly being offered due to improved post-operative bladder and sexual function. We aimed to demonstrate the feasibility of performing a nerve-sparing radical hysterectomy robotically and to assess the oncological and functional outcomes associated with this surgery. Between August 2011 and January 2013, a total of 12 non-consecutive patients underwent robotic surgery for early stage cervical cancer at our institution. Patients comprising FIGO stage IA2 to IB1 were treated with nerve-sparing robotic radical hysterectomy using a C1 (Querleu-Morrow classification) type technique. The feasibility, operative time, blood loss, oncological outcome and post-operative bladder function were assessed. All the procedures were completed robotically without conversion to laparoscopy or laparotomy. The mean age of the patients was 56 years (range 44-76) and their mean body mass index was 22.6 kg/m(2) (range 18.1-26.4). The mean operative time was 156 min (range 120-250); the mean blood loss was 120 ml (50-250). The Foley catheter was removed on the third post-operative day, with full recovery of bladder function in all patients except one who required prolonged catheterisation for 3 weeks. Residual urine was 40 ml (range 30-80). Parametrial margins of 2.5-3 cm, distal vaginal margins of 2-2.5 cm and a mean nodal harvest of 24 (range 18-30) were achieved. The mean hospital stay was 3 days (range 2-6). The median follow-up is 12 months. There is no loco-regional recurrence. All the patients are sexually active. Robotic nerve-sparing radical hysterectomy is technically feasible to perform, and is oncologically safe for early stage cervical carcinoma.

Robotic total pelvic exenteration.

INTRODUCTION: Pelvic exenteration is now becoming widely acceptable as a curative procedure rather than a palliative one. Performing these surgeries by minimally invasive techniques helps to improve the quality of life and decrease the morbidity of these extensive procedures. AIMS AND OBJECTIVES: To demonstrate the feasibility of performing a total pelvic exenteration robotically, and to study the morbidity associated with such extensive surgery. MATERIALS AND METHODS: A 35-year-old female with advanced cervical cancer presented with a vesicovaginal fistula and a rectovaginal fistula. In view of these, we performed a total robotic pelvic exenteration with colo-anal anastomosis and uretero-sigmoidostomy. The patient refused an ileal-loop conduit for urinary tract diversion due to social reasons associated with a stoma. RESULTS: The total operative time was 240 min and the console time was 120 min. The estimated blood loss was 300 ml and the intensive care unit stay was 2 days. Post-operatively, the patient had good faecal and urinary continence and good quality of life.

Minimally invasive esophagectomy in the elderly.

OBJECTIVE: A retrospective analysis of a prospectively maintained database to evaluate our experience in elderly patients (>70 years) undergoing Thoracolaparoscopic esophagectomy for cancer oesophagus. To ascertain whether age, is a limiting factor for patients undergoing minimally invasive esophagectomy. METHODS: All Patients above 70 years of age, referred to the Gastro-esophageal clinic were included in the study. Tumours were staged as per AJCC 6th ed. 2002. Patients diagnosed with T1/2/3, N0/1 lesion of the mid/lower oesophagus (Infra Azygous) and type I and II Gastro esophageal junction tumours were included in the study. Patients with ASA grade IV were excluded. All patients who underwent Thoracolaparoscopic esophagectomy from January 2009 till January 2012 were evaluated for their perioperative outcomes. RESULTS: Sixty eight patients underwent Minimal Invasive esophagectomy from January 2009 to January 2012. There were 45 males and 23 females. The average age in elderly group was 75.76 ± 5.96 years (range 70 to 91). Mean operative time was 178.84 ± 65.26 min, mean blood loss 143.84 ml(range 32-450 ml), mean ICU stay 3.84 days(range 2-11 days) and mean hospital stay was 12.76 days(range 8-21 days). Pneumonia and Cardiac related complications occurred in 10.30 % and 1.47 % patients respectively. None of the procedures required conversion to open thoracotomy. CONCLUSIONS: Thoracolaparoscopic esophagectomy is feasible and surgically safe in elderly patients with low morbidity and mortality. Thus age of a patient should not be considered a limiting factor. ULTRAMINI ABSTRACT: This is an original article about our experience of thoracolaparoscopic esophagectomy for cancer esophagus in elderly patients. After analyzing the data we feel that age of the patient cannot be a truly limiting factor for patient diagnosed of esophageal cancer to undergo minimally invasive esophagectomy.