Robotic complete mesocolic excision for right-sided colon cancer.

Complete mesocolic excision (CME) with central vascular ligation for right-sided colon cancer has been proven to provide superior oncologic outcomes and survival advantage when compared to standard lymphadenectomy [1]. A number of studies comparing conventional laparoscopic versus open CME have shown feasibility and safety of the laparoscopic approach with acceptable oncological profile and postoperative outcomes [2, 3]. The introduction of robotic systems with its technical advantages, including improved vision, better ergonomics and precise dissection, has further revolutionized minimally invasive approach in colorectal surgery. However, there seems to be a relatively slow adoption of robotic approach in the CME technique for right-sided colon cancer. This video demonstrates our detailed operative technique and feasibility for performing right-sided CME robotically. The surgical procedure is performed with a medial-to-lateral approach through four 8-mm robotic and one assistant ports. First, the ileocolic vessels are isolated, clipped and transected near their origins. Cephalad dissection continues along the ventral aspect of the superior mesenteric vein. Staying in the embryological planes between the mesocolon and retroperitoneal structures, mesenteric dissection is extended up to the root of the right colic vessels, if present, and the middle colic vessels, which are clipped and divided individually near their origins. After the terminal ileum is transected using an endolinear staple, the colon is mobilized fully from gastrocolic tissue and then from its lateral attachments. The transverse colon is transected under the guidance of near-infrared fluorescence imaging. Creation of an intracorporeal side-to-side ileotransversostomy anastomosis and extraction of the specimen complete the operation. We consider robotic CME to be feasible, safe and oncologically adequate for the treatment of right-sided colon cancer. Its technical advantages may lead to further dissemination of the robotic approach and better standardization of this surgical technique.

Comparison of two minimal invasive techniques of splenectomy: Standard laparoscopy versus transumbilical multiport single-site laparoscopy with conventional instruments.

BACKGROUND: Laparoendoscopic single-site (LESS) splenectomy which is performed on small number of patients, has been introduced with better cosmetic outcome, less postoperative pain, greater patient satisfaction and faster recovery compared to standard laparoscopy. MATERIALS AND METHODS: Thirty six patients were included in the study comparing standard laparoscopic splenectomy (LS, 17 patients) transumbilical multiport splenectomy performed with conventional laparoscopic instruments (TUMP-LS, 19 patients). Two groups of patients were compared retrospectively by means of operation time, intra- and postoperative blood loss, perioperative complications, packed red cell and platelet requirements, lenght of hospitalization, pain scores and patient satisfaction. RESULTS: There was no mortality in any of the groups, and no significant differences determined in operative time (P = 0,069), intraoperative blood loss (P = 0,641), patient satisfaction (P = 0,506), pain scores (P = 0,173) and the average length of hospital stay (P = 0,257). Umbilical incisions healed uneventfully and no hernia formation or wound infection was observed during follow-up period (2-34 months). There were no conversions to open surgery. CONCLUSIONS: Transumbilical multiport splenectomy performed with the conventional laparoscopic instruments is feasible and could be a logical alternative to classical laparoscopic splenectomy by combining the advantages of single access techniques and standard laparoscopy.

Comparison of classical surgery and sutureless repair with DuraSeal or fibrin glue for duodenal perforation in rats.

BACKGROUND: The purpose of the study was to compare classical primary suture repair and sutureless repair with fibrin glue or DuraSeal adhesion barrier for the closure of duodenal perforation in rats. METHODS: Forty adult female Wistar Albino rats weighing between 250-300 g were randomly divided into four equal groups. Primary repair, primary repair and omentoplasty, or application of fibrin glue or DuraSeal adhesion barrier was performed in each of the four groups, respectively. The bursting pressure, tissue hydroxyproline levels and histopathology were evaluated. RESULTS: Bursting pressure values of the primary repair and primary repair and omentoplasty groups were significantly higher than in the fibrin glue and DuraSeal groups (p < 0.001). There were no significant differences between the experimental groups regarding hydroxyproline levels and histological parameters. CONCLUSION: The sutureless methods (Fibrin glue, DuraSeal) have no superior effects when compared with the conventional repair techniques. We observed similar results between the sutureless repair groups; thus, DuraSeal can be considered an alternative to fibrin glue for this purpose. This suggestion must be supported with new studies, however, which would be planned with other wound healing markers and different designs.

The Feasibility of Conventional Forward-viewing Endoscope for Endoscopic Retrograde Cholangiopancreatography in Patients With Altered Gastrointestinal Anatomy.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) has been commonly used for biliopancreatic diseases of patients with normal gastrointestinal (GI) anatomy with a success rate of >90%. However, this procedure may also be necessary in patients with altered GI anatomy such as Billroth II or Roux-en-Y reconstructions. Performing ERCP in these patients may pose extreme technical challenges, and increase the risk of complications. The aim of this study was to analyze the feasibility of ERCP using forward-viewing endoscopy in patients with altered GI anatomy. MATERIALS AND METHODS: Twenty-three patients with previous gastric resections and GI anastomosis, who underwent ERCP between 2012 and 2017, were included in this retrospective study. The major indication for ERCP was choledocholithiasis in 19 patients, and the others were acute cholangitis, sphincter Oddi dysfunction, and biliary pancreatitis. The sedation was induced using a combination of midazolam and propofol, and all procedures were performed using a forward-viewing endoscope. RESULTS: Among the 23 patients, 14 were male individuals and 9 were female individuals, with an average age of 62 (range: 58 to 73) years. The median procedure time was 24 (range: 19 to 43) minutes. The success rate of bile duct cannulation was 91.3% (21/23 patients) and that of stone extirpation was 89.4% (17/19 patients with choledocholithiasis). Plastic stents were placed in the 2 patients in whom stone extirpation was not successfully performed. ERCP was repeated in these patients 8 weeks after the initial approach, and stone extraction procedures were successfully completed. The only procedure-related complication was edematous pancreatitis, which was observed in 1 patient (4.7%). The mean length of hospitalization was 2 (range: 1 to 5) days. CONCLUSIONS: Forward-viewing endoscopes can be effectively used in patients with altered GI anatomy by facilitating the access to the papilla and bile duct cannulation without increasing the incidence of complications.

Efficacy and safety of endoscopic retrograde cholangiopancreatography in pregnancy: A high-volume study with long-term follow-up.

BACKGROUND/AIMS: Pancreaticobiliary diseases are observed more frequently in pregnancy due to increased biliary stone formation. There are some concerns about the use of endoscopic retrograde cholangiopancreatography (ERCP) because of potential fetal exposure to radiation and serious adverse events, such as post-ERCP pancreatitis, which increases fetal or maternal morbidity and mortality. The aim of this study was to evaluate the efficacy and safety of ERCP during pregnancy and to present our experience. MATERIALS AND METHODS: This study included 25 pregnant patients who underwent ERCP due to biliopancreatic pathologies between 2010 and 2017. Indications for ERCP were choledocholithiasis (n=12), biliary pancreatitis (n=9), and acute cholangitis (n=4). ERCP procedures were performed using fluoroscopy (n=18) and the non-radiation technique (n=7). The duration of fluoroscopy was recorded in all cases. Fetal and maternal complications were both assessed. RESULTS: The mean age of patients was 29.4 (range, 21-40) years, and the mean duration of pregnancy was 19.9 weeks. All the 25 ERCP procedures were performed successfully. Biliary sphincterotomy was performed in all patients, and 18 patients with choledocholithiasis underwent stone extraction. The average procedure duration was 11 min, and the average duration of fluoroscopy was 6 s. There were no major complications in any patient. After the deliveries, the newborns were apparently healthy during the follow-up period of 1-7 years. CONCLUSION: Either conventional or non-radiation ERCP procedures can be performed successfully in pregnancy, with no increase in the number of feto-maternal complications when performed by experienced endoscopists.

Totally robotic complete mesocolic excision for right-sided colon cancer.

Complexity and operative risks of complete mesocolic excision (CME) seem to be important drawbacks to generalize this procedure in the surgical treatment of right colon cancer. Robotic systems have been developed to improve quality and outcomes of minimal invasive surgery. The aim of this study was to evaluate the feasibility of robotic right-sided CME and present our initial experience. A retrospective review of 37 patients undergoing totally robotic right-sided CME between February 2015 and November 2017 was performed. All the operations were carried out using the key principles of both CME with intracorporeal anastomosis and no-touch technique. Data on perioperative clinical findings and short-term outcomes were analyzed. There were 20 men and 17 women with a mean age of 64.4 ± 13.5 years and a body mass index of 26.8 ± 5.7 kg/m2. The mean operative time and estimated blood loss were 289.8 ± 85.3 min and 77.4 ± 70.5 ml, respectively. Conversion to laparoscopy occurred in one patient (2.7%). All the surgical margins were clear and the mesocolic plane surgery was achieved in 27 (72.9%) of the cases. The mean number of harvested lymph nodes was 41.8 ± 11.9 (median, 40; range 22-65). The mean length of hospital stay was 6.6 ± 3.7 days. The intraoperative and postoperative complication rates were 5.4 and 21.6%, respectively. We believe that use of robot for right-sided CME is feasible and appears to provide remarkably a high number of harvested lymph nodes with good specimen quality.

Prognostic factors for recurrence and survival in primary vulvar squamous cell cancer.

OBJECTIVE: To evaluate survival estimates and clinico-pathological variables in women with primary vulvar squamous cancer. DESIGN: Retrospective observational study. Setting. University hospital in Turkey. POPULATION OR SAMPLE: Patients treated for primary vulvar squamous cancer. METHODS: Retrospective evaluation of demographic, pathologic and follow-up data of 91 patients obtained from hospital records and private gynecologic oncology files. MAIN OUTCOME MEASURES: Recurrence rate and survival estimates. RESULTS: The mean age at the time of diagnosis was 62 years. Of the women, 62% had early stage disease (stages I-II), while 39% had advanced stages (stages III-IV) at diagnosis. The overall recurrence rate was 13%. Recurrence rates were significantly higher in the presence of local wide-deep excision as an initial treatment, larger initial tumor size, positive lymph node involvement, advanced stage, presence of ulcerative lesions and adjuvant radiotherapy. The overall and 5-year survival estimates were 92 and 83%, respectively. CONCLUSION: Lymph node invasion, stage, having ulcerative lesion, receiving adjuvant therapy, tumor diameter larger than 10 mm and having local excision as primary surgery may increase the risk of recurrent disease.

Effects of prior abdominal surgery on laparoscopic cholecystectomy.

OBJECTIVES: With increased experience and technological advancement, laparoscopic cholecystectomy is reported to be safe and feasible even in the presence of most of the previously recognized contraindications. The purpose of this study was to explore the effects of prior upper and lower abdominal surgery on laparoscopic cholecystectomy. MATERIAL AND METHODS: A retrospective evaluation of all sequential patients who underwent laparoscopic cholecystectomy from January 2014 to June 2016 was conducted. Patients were divided into three groups (Group A: patients without any prior abdominal surgical procedures; Group B: patients with prior upper abdominal surgical procedures; and Group C: patients with prior lower abdominal surgical procedures). RESULTS: A total of 329 patients were assessed. Group A consisted of 223, Group B of 18, and Group C of 88 patients. A statistically significantly higher operative time, postoperative pain, and complication rate after laparoscopic cholecystectomy were noted in patients with prior upper abdominal surgery. The groups were comparable regarding patients' demographics and surgery indications. The length of hospital stay was not statistically different between the groups (p=0.065). CONCLUSION: According to the results of the current study, prior upper abdominal surgery leads to a significantly longer procedure time, higher postoperative pain, and complication rates after laparoscopic cholecystectomy. However, the length of hospital stay was not affected by the parameters investigated.

Robotic Versus Laparoscopic Stapler Use for Rectal Transection in Robotic Surgery for Cancer.

BACKGROUND: This study was designed to compare the operative and short-term postoperative outcomes of the robotic and laparoscopic staplers in patients undergoing rectal surgery for cancer. MATERIALS AND METHODS: Between December 2014 and April 2017, patients consecutively undergoing robotic rectal surgery for cancer were included in this study. Patients were grouped into two according to the type of staplers for rectal transection [Robotic (45-mm) versus Laparoscopic (60-mm) linear staplers]. Patient demographics, pathologic data, perioperative outcomes, and short-term results were compared. RESULTS: One hundred seven patients met our inclusion criteria. The number of male patients were higher in robotic stapler group than in the laparoscopic stapler group (55% versus 76%, P = .03). Age (59 versus 63 years, P = .40), body mass index (27 versus 27 kg/m2, P = .60), American Society of Anesthesiologists score (2 versus 2, P = .20), number of prior abdominal operations (31% versus 20%, P = .22) and number of patients having neoadjuvant chemoradiotherapy (34% versus 36%, P = .86) were comparable between the groups. The numbers of cartridges used were similar regardless of the type of staplers (2 versus 2, P = .58). The overall complication was similar between the groups (24% versus 31%, P = .32). Leak rates were 5% (n = 2) and 3% (n = 2) in the robotic and laparoscopic stapler groups, respectively (p = 1). There was no mortality. CONCLUSIONS: This is the first study evaluating the role of robotic stapler specifically for rectal transection in comparative manner. The use of robotic stapler for rectal transection was safe and feasible in rectal surgery for cancer.

Does Robot Overcome Obesity-related Limitations of Minimally Invasive Rectal Surgery for Cancer?

BACKGROUND: Adoption of laparoscopic surgery for cancers requiring partial or total proctectomy has been slow due to difficulty of achieving oncologically adequate resection. Obesity is a factor complicating use and outcomes of laparoscopic technique for rectal surgery. Impact of obesity on the outcomes of robotic rectal surgery for cancer is not well defined. This study is designed to assess whether if the robotic technique has potential to overcome the limitations of obesity and to improve outcomes of minimally invasive rectal surgery for cancer. PATIENTS AND METHODS: Patients undergoing robotic sphincter-saving radical resection with da Vinci Xi System between December 2014 and December 2016 were included. Patients were divided into 2 groups as obese and nonobese. Patient demographics, perioperative outcomes and short-term results were compared between the groups. RESULTS: The study included 101 patients (30 were obese). Sex (female: 35 vs. 37%, P=0.89), American Society of Anesthesiologists score (2 vs. 2, P=0.41), number of patients undergoing neoadjuvant chemoradiation (39% vs. 23%, P=0.12) and history of prior abdominal surgery (28% vs. 23%, P=0.62) were comparable between the groups. Operative time was longer in the obese group (311 vs. 332 min. P=0.01). Overall complication rates (27% vs. 23%, P=0.72), length of hospital stay (6 vs. 7, P=0.10) and pathologic outcomes were similar between the groups. Conversion to laparoscopy was not required in any operation. Two nonobese patients required conversion to open surgery. CONCLUSION: Robotic rectal surgery for cancer in obese patients is equally safe and effective as in nonobese patients. The new robotic platform can facilitate to overcome obesity-related limitations of rectal surgery.

Vascular High Ligation and Embryological Dissection in Laparoscopic Restorative Proctocolectomy for Ulcerative Colitis.

INTRODUCTION: After its description in 1980, restorative proctocolectomy has become the procedure of choice for ulcerative colitis (UC). The supposed advantages of the laparoscopy have proven beneficial for colorectal operations but a standard technique in laparoscopic restorative proctocolectomy (LRP) is still lacking. In this study, we present our technique of LRP with vascular high ligation (VHL) and embryological dissection (ED). MATERIALS AND METHODS: This retrospective study reviewed patients who underwent LRP with VHL for UC from January 2009 to June 2015. Of these, only two-stage LRP patients were included to the study. The LRP technique was performed by five ports through a medial-to-lateral approach. The dissection was carried out between the embryological planes and all the vessel roots were highly divided. A diverting ileostomy was performed in all of the patients. RESULTS: Forty-six patients were operated for UC with the laparoscopic approach. Among these patients, there were 19 (8 females) patients who were performed LRP with VHL. The median age was 42 (range 25-62) years. No intraoperative complications occurred. There was no conversion to open procedure. Early postoperative complications were observed in 3 (15.8%) patients, including postoperative mechanical bowel obstruction (n = 1), wound infection (n = 1), and ileal pouch bleeding (n = 1). DISCUSSION: High ligation of the vessels is not routinely performed except in the presence of malignancy. In our study, we focus on the importance of high ligation and ED for better observation and preservation of the important anatomical structures. According to our opinion, this approach aids in the preservation of the ureters, nerves, and the duodenum providing better observation of dissection planes.

Is da Vinci Xi Better than da Vinci Si in Robotic Rectal Cancer Surgery? Comparison of the 2 Generations of da Vinci Systems.

BACKGROUND: We aimed to compare perioperative outcomes for procedures using the latest generation of da Vinci robot versus its previous version in rectal cancer surgery. PATIENTS AND METHODS: Fifty-three patients undergoing robotic rectal cancer surgery between January 2010 and March 2015 were included. Patients were classified into 2 groups (Xi, n=28 vs. Si, n=25) and perioperative outcomes were analyzed. RESULTS: The groups had significant differences including operative procedure, hybrid technique and redocking (P>0.05). In univariate analysis, the Xi group had shorter console times (265.7 vs. 317.1 min, P=0.006) and total operative times (321.6 vs. 360.4 min, P=0.04) and higher number of lymph nodes harvested (27.5 vs. 17.0, P=0.008). In multivariate analysis, Xi robot was associated with a shorter console time (odds ratio: 0.09, P=0.004) with no significant differences regarding other outcomes. CONCLUSIONS: Both generations of da Vinci robot led to similar short-term outcomes in rectal cancer surgery, but the Xi robot allowed shorter console times.

Single-site multiport combined splenectomy and cholecystectomy with conventional laparoscopic instruments: Case series and review of literature.

INTRODUCTION: Conventional laparoscopic procedures have been used for splenic diseases and concomitant gallbladder stones, frequently in patients with hereditary spherocytosis since 1990's. The aim of this study is to evaluate the feasibility of single-site surgery with conventional instruments in combined procedures. PRESENTATION OF CASE SERIES: Six consecutive patients who scheduled for combined cholecystectomy and splenectomy because of hereditary spherocytosis or autoimmune hemolytic anemia were included this study. Both procedures were performed via trans-umbilical single-site multiport approach using conventional instruments. All procedures completed successfully without conversion to open surgery or conventional laparoscopic surgery. An additional trocar was required for only one patient. The mean operation time was 190min (150-275min). The mean blood loss was 185ml (70-300ml). Median postoperative hospital stay was two days. No perioperative mortality or major complications occurred in our series. Recurrent anemia, hernia formation or wound infection was not observed during the follow-up period. DISCUSSION: Nowadays, publications are arising about laparoscopic or single site surgery for combined diseases. Surgery for combined diseases has some difficulties owing to the placement of organs and position of the patient during laparoscopic surgery. Single site laparoscopic surgery has been proposed to have better cosmetic outcome, less postoperative pain, greater patient satisfaction and faster recovery compared to standard laparoscopy. CONCLUSION: We consider that single-site multiport laparoscopic approach for combined splenectomy and cholecystectomy is a safe and feasible technique, after gaining enough experience on single site surgery.

Colorectal stenting for palliation and as a bridge to surgery: A 5-year follow-up study.

AIM: To evaluate the long-term effectiveness of colonic stents in colorectal tumors causing large bowel obstruction. METHODS: We retrospectively analyzed data from 49 patients with colorectal cancer who had undergone colorectal stent placement between January 2008 and January 2013. Patients' symptoms, characteristics and clinicopathological data were obtained by reviewing medical records. The obstruction was diagnosed clinically and radiologically. Histopathological diagnosis was achieved endoscopically. Technical success rate (TSR) was defined as the ratio of patients with correctly placed SEMS upon stent deployment across the entire stricture length to total number of patients. Clinical success rate (CSR) was defined as the ratio of patients with technical success and successful maintenance of stent function before elective surgery (regardless of number of SEMS deployed) to total number of patients. The surgical success rate (SSR) of colorectal stent as a bridge to surgery was defined as the ratio of patients with successful surgical procedures. Unsuccessful surgical outcomes were defined as being due to insufficient colonic decompression. The technical, clinical, surgical success rates and complications after stenting were assessed. RESULTS: The median age of patients was 64 (36 to 89). 44.9% of patients were male and 55.1% were female. Eighteen patients had the obstruction located in the rectum, 15 patients in the rectosigmoid region, 10 patients in the sigmoid region, and 6 patients had a tumor causing obstruction in the proximal colon. Each patient was categorized pathologically as stage 2 (32.7%, 16 patients) or stage 3 (42.9%, 21 patients) and 12 patients (24.4%) had metastatic disease. None of the patients received chemotherapy before stenting. Stenting was undertaken in 37 patients as a bridge to surgery, and in 12 patients stents were used for palliation. Median time to surgery after stenting was 30 ± 91.9 d. All surgery was completed in one single operation and thus no colostomy with stoma was needed. The median overall survival rate of patients with stage 2-3 colorectal cancer was 53.1 mo and stage 4 was 37.1 mo (P = 0.04). Metastatic colorectal patients who were treated palliatively with stents had backbone chemotherapy with oxaliplatin and/or irinotecan-based regimens plus antiangiogenic therapies, especially bevacizumab. Resolution of the obstruction and clinical improvement was achieved in all patients. The technical, clinical and surgical success rates were 95.9%, 100% and 94.6%, respectively. CONCLUSION: The efficacy and safety of colonic stents was demonstrated both as a bridge to surgery and for palliative decompression. In addition, results emphasize the importance of the skills of the endoscopist in colonic stenting.

Covered self-expandable metallic stents could be used successfully in the palliation of malignant cervical esophageal strictures: preliminary report.

PURPOSE: To present the authors' preliminary experience with covered self-expandable metallic stents in the palliation of malignant cervical esophageal strictures. METHODS: Covered self-expandable metallic stents were placed into the cervical esophagus of 6 patients with malignant cervical esophageal strictures under fluoroscopic guidance. RESULTS: Stent placement was technically successful in all patients, and the mean dysphagia score decreased from 3.3 to 0.5 according to the Ogilvie Dysphagia Scoring. Two patients complained of chest pain, which lasted for 24 to 48 hours. Foreign body sensation disappeared spontaneously within a week in all patients, but one. Migration, dysphagia, or obstruction was not observed in any of the patients during the follow-up period (47 d to 8 mo). CONCLUSIONS: According to our limited number of cases, placement of covered self-expandable metallic stents into the cervical esophagus can be performed safely, and significant improvement of dysphagia scores and life quality of patients can be obtained instantly after the procedure.