Correction to: Standard (8 weeks) vs long (12 weeks) timing to minimally-invasive surgery after NeoAdjuvant Chemoradiotherapy for rectal cancer: a multicenter randomized controlled parallel group trial (TiMiSNAR).

Following publication of the original article [1], the authors reported that the family name of the author, Ludovica Baldari, was misspelled.

Correction to: Robotic Versus Laparoscopic Right Colectomy with Complete Mesocolic Excision for the Treatment of Colon Cancer: Perioperative Outcomes and 5-Year Survival in a Consecutive Series of 202 Patients.

Dario Ribero's affiliation is corrected as reflected here.

Standard (8 weeks) vs long (12 weeks) timing to minimally-invasive surgery after NeoAdjuvant Chemoradiotherapy for rectal cancer: a multicenter randomized controlled parallel group trial (TiMiSNAR).

BACKGROUND: The optimal timing of surgery in relation to chemoradiation is still controversial. Retrospective analysis has demonstrated in the recent decades that the regression of adenocarcinoma can be slow and not complete until after several months. More recently, increasing pathologic Complete Response rates have been demonstrated to be correlated with longer time interval. The purpose of the trial is to demonstrate if delayed timing of surgery after neoadjuvant chemoradiotherapy actually affects pathologic Complete Response and reflects on disease-free survival and overall survival rather than standard timing. METHODS: The trial is a multicenter, prospective, randomized controlled, unblinded, parallel-group trial comparing standard and delayed surgery after neoadjuvant chemoradiotherapy for the curative treatment of rectal cancer. Three-hundred and forty patients will be randomized on an equal basis to either robotic-assisted/standard laparoscopic rectal cancer surgery after 8 weeks or robotic-assisted/standard laparoscopic rectal cancer surgery after 12 weeks. DISCUSSION: To date, it is well-know that pathologic Complete Response is associated with excellent prognosis and an overall survival of 90%. In the Lyon trial the rate of pCR or near pathologic Complete Response increased from 10.3 to 26% and in retrospective studies the increase rate was about 23-30%. These results may be explained on the relationship between radiation therapy and tumor regression: DNA damage occurs during irradiation, but cellular lysis occurs within the next weeks. Study results, whether confirmed that performing surgery after 12 weeks from neoadjuvant treatment is advantageous from a technical and oncological point of view, may change the current pathway of the treatment in those patient suffering from rectal cancer. TRIAL REGISTRATION: ClinicalTrials.gov NCT3465982.

Robotic Versus Laparoscopic Right Colectomy with Complete Mesocolic Excision for the Treatment of Colon Cancer: Perioperative Outcomes and 5-Year Survival in a Consecutive Series of 202 Patients.

BACKGROUND: During the past decade, the concept of complete mesocolic excision (CME) has emerged as a possible strategy to minimize recurrence for right colon cancers. The purpose of this study was to compare robotic versus laparoscopic CME in performing right colectomy for cancer. METHODS: Pertinent data of all patients who underwent robotic or laparoscopic right colectomy with CME using a Pfannenstiel incision and intracorporeal anastomosis performed between October 2005 and November 2015 were entered in a prospectively maintained database. RESULTS: A total of 202 patients underwent robotic (n = 101) or laparoscopic (n = 101) right colectomy within the study period. Patient characteristics were equivalent between groups. The robotic group showed a statistically significant reduction in conversion rate (0% vs. 6.9%, p = 0.01) but a longer operative time (279 min vs. 236 min, p < 0.001) compared with the laparoscopic group. There were no other differences in perioperative clinical or pathological outcomes. Five-years overall survival was 77 versus 73 months for the robotic versus laparoscopic groups (p = 0.64). The disease-free survival (DFS) rates were 85% and 83% for the robotic versus laparoscopic groups (p = 0.58). Among UICC stage III patients, there was a slight but not significant difference in 5-year DFS for the robotic group (81 vs. 68 months; p = 0.122). CONCLUSIONS: Both approaches for right colectomy with CME were safe and feasible and resulted in excellent survival. Robotic assistance was beneficial for performing intracorporeal anastomosis and dissection as evidenced by the lower conversion rates. Further robotic experience may shorten the operative time.

Robotic Right Colectomy with Modified Complete Mesocolic Excision: Long-Term Oncologic Outcomes.

BACKGROUND: A modified complete mesocolic excision (mCME) technique for the treatment of right-sided colon cancer recently was shown by Hohenberger and colleagues to provide impressive long-term oncologic outcomes. This report aims to describe the authors' experience with robotic right colectomy using mCME. The safety, feasibility, and efficacy of this procedure are measured by complications, conversion rates, and 4-year oncologic outcomes. METHODS: A retrospective study analyzed 100 consecutive patients who underwent robotic right colectomy with mCME and intracorporeal anastomosis at the authors' institution between November 2005 and November 2013. Intra- and postoperative clinical outcomes, pathologic data, and survival were analyzed. RESULTS: Robotic right colectomy with mCME was successfully performed for all the patients. No conversions or intraoperative complications occurred. The major complication rate (Dindo 3 or 4) was 4 %. During a median follow-up period of 48.5 months (range 24-114 months), the survival rates were 94.5 % for disease-specific survival, 91.4 % for disease-free survival, and 90.3 % for overall survival. CONCLUSIONS: The authors' experience confirms the feasibility and safety of mCME for the treatment of right-sided colon cancer. This technique provided satisfying short-term outcomes with promising 4-year oncologic results. However, the real benefits of the CME technique should be evaluated further by well-conducted randomized studies before its adoption in routine practice is recommended.

Real-time near-infrared (NIR) fluorescent cholangiography in single-site robotic cholecystectomy (SSRC): a single-institutional prospective study.

BACKGROUND: Bile duct injury is a rare but serious complication of laparoscopic cholecystectomy and the primary cause is misinterpretation of biliary anatomy. This may occur more frequently with a single-incision approach due to difficulties in exposing and visualizing the triangle of Calot. Intraoperative cholangiography was proposed to overcome this problem, but due to multiple issues, it is not used routinely. Indocyanine green (ICG) near-infrared (NIR) fluorescent cholangiography is non invasive and provides real-time biliary images during surgery, which may improve the safety of single-incision cholecystectomy. This study aims to evaluate the efficacy and safety of this technique during single-site robotic cholecystectomy (SSRC). METHODS: Patients presenting with symptomatic biliary gallstones without suspicion of common bile duct stones underwent SSRC with ICG-NIR fluorescent cholangiography using the da Vinci Fluorescence Imaging Vision System. During patient preparation, 2.5 mg of ICG was injected intravenously. During surgery, the biliary anatomy was imaged in real time, which guided dissection of Calot's triangle. Perioperative outcomes included biliary tree visualizations, operative time, conversion and complications rates, and length of hospital stay. RESULTS: There were 45 cases between July 2011 and January 2012. All procedures were completed successfully; there were no conversions and at least one structure was visualized in each patient. The rates of visualization were 93 % for the cystic duct, 88 % for the common hepatic duct, and 91 % for the common bile duct prior to Calot's dissection; after Calot's dissection, the rates were 97 % for all three ducts. Mean hospital stay was 1.1 days and there were no bile duct injuries or any other major complications. CONCLUSION: Real-time high-resolution fluorescent imaging to identify the biliary tree anatomy during SSRC using the da Vinci Fluorescence Imaging Vision System was safe and effective.

Application of fluorescence in robotic general surgery: review of the literature and state of the art.

The initial use of the indocyanine green fluorescence imaging system was for sentinel lymph node biopsy in patients with breast or colorectal cancer. Since then, application of this method has received wide acceptance in various fields of surgical oncology, and it has become a valid diagnostic tool for guiding cancer treatment. It has also been employed in numerous conventional surgical procedures with much success and benefit to the patient. The advent of minimally invasive surgery brought with it a new use for fluorescence in helping to improve the safety of these procedures, particularly for single-site procedures. In 2010, a near-infrared camera was integrated into the da Vinci Si System, creating a combination of technical and minimally invasive advantages that have been embraced by several experienced surgeons. The use of fluorescence, although useful, is considered challenging. Only a few studies are currently available on the use of fluorescence in robotic general surgery, whereas many articles have focused on its application in open and laparoscopic surgery. Many of these reports describe promising and satisfactory results, although with some shortcomings. The purpose of this article is to review the current status of the use of fluorescence in general surgery and particularly its role in robotic surgery. We also review potential uses in the future.

Single-site robotic cholecystectomy (SSRC) versus single-incision laparoscopic cholecystectomy (SILC): comparison of learning curves. First European experience.

BACKGROUND: Single-incision laparoscopic surgery is an emerging procedure developed to decrease parietal trauma and improve cosmetic results. However, many technical constraints, such as lack of triangulation, instrument collisions, and cross-handing, hamper this approach. Using a robotic platform may overcome these problems and enable more precise surgical actions by increasing freedom of movement and by restoring intuitive instrument control. METHODS: We retrospectively collected, under institutional review board approval, data on the first 25 patients who underwent single-site robotic cholecystectomies (SSRC) at our center. Patients enrolled in this study underwent SSRC for symptomatic biliary gallstones or polyposis. Exclusion criteria were: BMI > 33; acute cholecystitis; previous upper abdominal surgery; ASA > II; and age >80 and <18 years. All procedures were performed with the da Vinci Si Surgical System and a dedicated SSRC kit (Intuitive). After discharge, patients were followed for 2 months. These SSRC cases were compared to our first 25 single-incision laparoscopic cholecystectomies (SILC) and with the literature. RESULTS: There were no differences in patient characteristics between groups (gender, P = 0.4404; age, P = 0.7423; BMI, P = 0.5699), and there were no conversions or major complications in either cohort. Operative time was significantly longer for the SILC group compared with SSRC (83.2 vs. 62.7 min, P = 0.0006), and SSRC operative times did not change significantly along the series. The majority of patients in each group were discharged within 24 h, with an average length of hospital stay of 1.2 days for the SILC group and 1.1 days for the SSRC group (P = 0.2854). No wound complications (infection, incisional hernia) were observed in the SSRC group and in the SILC. CONCLUSIONS: Our preliminary experience shows that SSRC is safe, can easily be learned, and performed in a reproducible manner and is faster than SILC.

Robotic laparoscopic surgery with the da Vinci® system: an early experience.

Theoretically, robotic surgery is likely to overcome the intrinsic limitations of laparoscopic surgery, such as a view not under the direct surgeon's control, two-dimensional imaging, and limited motion of instruments. In this chapter, the preliminary experience with a robotic laparoscopic surgery system in the Surgical Department of the Alessandria Hospital, Italy, is reported. From November 2005 to August 2007, a total of 162 laparoscopic robotic operations were performed, in which robotic surgery was found to be feasible and safe. It takes a longer time than standard laparoscopy but seems able to reduce the need of a steep learning curve.

Robotic right colectomy in a patient with ventriculoperitoneal shunt. Report of a case.

INTRODUCTION: Ventriculoperitoneal shunt procedure has become the most common neurosurgical method for hydrocephalus because it considerably improves patients prognosis. Pneumoperitoneum has been considered a contraindication to laparoscopic surgery because of risk for increased intracranial pressure during pneumoperitoneum and/or malfunction/infection of the VP shunt itself. Laparoscopic resection of the cecum and of the rectum for cancer has been reported. PRESENTATION OF CASE: A 74-year old man with ventriculoperitoneal shunt for normal pressure hydrocephalus referred to the emergency medicine ward for COPD, lower limb oedema and severe anemia. CT Scan showed a substenotic tumor of the right colon and non-specific enlarged regional lymph nodes, with no distant metastases. Colonoscopy confirmed the presence of an ulcerated tumor of the right colon involving half of the colic lumen. A right colectomy with CME was carried out, with a stapled intracorporeal ileocolic side-to-side isoperistaltic anastomosis and without manipulating the VPS catheter. DISCUSSION: Laparoscopic surgery in patients with VPS tubes was previously contraindicated because of the possibility of shunt-associated complications, that may include shunt malfunction due to increased intra-abdominal pressure, damage or infection of the catheter. Some authors reported that intracranial pressure increased up to 25 mmHg at a pneumoperitoneum pressure of 12 mmHgHerein we report, to our knowledge, the first case report of robotic assisted right colectomy for cancer in a patient with a VP shunt. CONCLUSION: Robotic assistance may allow to perform colorectal resection safely and with low risk also in patients with ventriculoperitoneal shunt.

Robotic transanal total mesorectal excision: A new perspective for low rectal cancer treatment. A case series.

BACKGROUND: Rectal cancer treatment is still a challenging frontier in general surgery, as there is no general agreement on which surgical approach is best for its management. Total mesorectal excision (TME), influenced the practical approach to rectal cancer, and brought a significant improvement on tumor recurrence and patients survival. Robotic transanal surgery is a newer approach to rectal dissection whose purpose is to overcome the limits of the traditional transabdominal approach, improving accuracy of distal dissection and preservation of hypogastric innervation. An increasing interest on this new technique has raised, thanks to the excellent pathological and acceptable short-term clinical outcomes reported. MATERIALS AND METHODS: Three consecutive cases of robotic transanal TME were prospectically performed between May 2017 and October 2017. RESULTS: TME quality was Quirke 3 grade in all cases. Mean operative time was 530 min. None of the patients had intra-operatively or post-operatively complications. CONCLUSIONS: Robotic transanal TME is a very recent procedure. Acclaimed greatest advantage of robotic transanal TME is the facilitation of dissection with an in-line view, which translates in an improved surgical field exposure and visualization. Further investigations are needed to assure the actual value of robotic transanal approach.

Robotic colorectal surgery: first 50 cases experience.

PURPOSE: Laparoscopic colorectal surgery is believed to be technically and oncologically feasible. However, some limitation of traditional laparoscopic surgery may cause difficulties. Robotic-assisted surgery may overcome these pitfalls. METHODS: From December 2005 to July 2007, 50 patients were selected for robotic-assisted colorectal resection mainly for cancer. RESULTS: Of the 50 patients enrolled, 32 (64 percent) were men and 18 (36 percent) were women. Their mean age was 66.7 (range, 37-92) years. The American Society of Anesthesiologists' (ASA) class distribution was 13 (26 percent) ASA I, 24 (48 percent) ASA II, 12 (24 percent) ASA III, and 1 (2 percent) ASA IV. Forty-four patients suffered from cancer and six patients from benign disease. Amongst the cancer patients, 3 percent were at UICC (International Union Against Cancer) Stage 0, 36 percent at UICC Stage I, 24 percent at Stage II, 28 percent at Stage III, and 9 percent at Stage IV. The global conversion rate was 4 percent. The mean operative time was 338.8 minutes. It decreased as the experience increased (419 minutes in the first 20 cases vs. 346 minutes in the last 30 cases; P = 0.036). As a gross comparison, the results of a coeval standard laparoscopy group of patients were shown. CONCLUSIONS: Robotic laparoscopic colon surgery is feasible and safe. A longer operating time is needed.

[Treatment of inguinal hernia: a prospective study comparing Bassini's procedure, the inguinal pre-peritoneal prosthesis and the Lichtenstein technique]. / Trattamento dell'ernia inguinale. Studio prospettico: Bassini vs protesi peritoneale per via inguinale vs Lichtenstein.

Inguinal hernia surgery has aroused considerable interest in recent years, with numerous advances being proposed to treat these disorders. Bassini's procedure, based on the importance of the transversalis fascia as a fundamental containment mechanism, was for many years the treatment of choice for inguinal hernia. In our study, covering eight years of activity, we focused our attention on this principle, comparing repair procedures such as Bassini's and those with a preperitoneal mesh, in which the repair involves the transversalis fascia, with procedures based on Lichtenstein's technique in which the fascia is left intact. The investigation protocol was thus based on the performance of the three techniques in parallel by the same surgical team. The parameters of immediate complications, lasting pain and recurrence were used to evaluate the results. The first two occurred infrequently in all groups (a greater incidence was seen with mesh procedures). Recurrence rates after preperitoneal mesh techniques were extremely low, confirming the paramount functional importance of the transversalis fascia. The results of our analysis substantiate the advantage of employing the preperitoneal mesh technique, which opens up new horizons for the treatment of recurrent hernia.

A Single Centre Retrospective Evaluation of Laparoscopic Rectal Resection with TME for Rectal Cancer: 5-Year Cancer-Specific Survival.

Laparoscopic colon resection has established its role as a minimally invasive approach to colorectal diseases. Better long-term survival rate is suggested to be achievable with this approach in colon cancer patients, whereas some doubts were raised about its safety in rectal cancer. Here we report on our single centre experience of rectal laparoscopic resections for cancer focusing on short- and long-term oncological outcomes. In the last 13 years, 248 patients underwent minimally invasive approach for rectal cancer at our centre. We focused on 99 stage I, II, and III patients with a minimum follow-up period of 5 years. Of them 43 had a middle and 56 lower rectal tumor. Laparoscopic anterior rectal resection was performed in 71 patients whereas laparoscopic abdomino-perineal resection in 28. The overall mortality rate was 1%; the overall morbidity rate was 29%. The 5-year disease-free survival rate was 69.7%, The 5-year overall survival rate was 78.8%.

Thoracoscopic and Laparoscopic Esophagectomy in a Case of Spontaneous Rupture of the Esophagus (Boerhaave's Syndrome).

Spontaneous barogenic rupture of the esophagus is a rare disease with high morbidity and mortality. Many therapeutic options are available. Esophagectomy is indicated when a large rupture is found with huge mediastinal contamination. Here, we describe a minimal invasive esophagectomy procedure for an esophageal barogenic rupture. A thoracoscopic esophagectomy was performed with the patient in a prone position. After a laparoscopic gastric tubulization, a cervical esopagho-gastro anastomosis was performed with a retro-sternal passage of the stomach in order to avoid the heavily contaminated posterior mediastinum. The postoperative outcome was almost uneventful. This minimal-invasive approach allowed direct optimal visualization of the esophageal laceration and a thorough mediastinal cleansing, thereby avoiding any septic complications, which are the major concern in this particular clinical procedure. In our case, the esophagectomywas mandatory because of the large laceration and massive mediastinal contamination. The minimal invasive thoracoscopic and laparoscopic esophagectomy approach is feasible even in an emergency setting. This is the first report of this procedure being used in a high-risk patient with Boerhaave's syndrome.