Robotic or laparoscopic pelvic exenteration for gynecological malignancies: feasible options to open surgery.

OBJECTIVE: To acknowledge that minimally invasive pelvic exenteration is a feasible alternative to open surgery and potentially identify prediction factors for patient outcome. METHODS: The study was designed as a retrospective single team analysis of 12 consecutive cases, set between January 2008 and January 2022. RESULTS: Six anterior and 6 total pelvic exenterations were performed. A 75% of cases were treated using a robotic approach. In 4 cases, an ileal conduit was used for urinary reconstruction. Mean operative time was 360±30.7 minutes. for anterior pelvic exenterations and 440±40.7 minutes. for total pelvic exenterations and mean blood loss was 350±35 mL. An R0 resection was performed in 9 cases (75%) and peri-operative morbidity was 16.6%, with no deaths recorded. Median disease-free survival was 12 months (10-14) and overall survival (OS) was 20 months (1-127). In terms of OS, 50% of patients were still alive 24 months after surgery. Taking into consideration the follow up period,16.6% of females under 50 or above 70 years old did not reach the cut off and 4 out of 6 patients that failed to reach it were diagnosed with distant metastases or local recurrence (p=0.169). CONCLUSION: Our experience is very much consistent with literature in regard to primary site of cancer, post-operative complications, R0 resection and survival rates. On the other hand, minimally invasive approach and urinary reconstruction type were in contrast with cited publications. Minimally invasive pelvic exenteration is indeed a safe and feasible procedure, providing patients selection is appropriately performed.

Propensity Score-Matched Analysis of Minimal Invasive Surgery versus Open Surgery for Colorectal Cancer in Older Patients.

Introduction: Currently, surgeons deal with an older patient cohort, confronting new challenges brought by the raised life expectancy. This population is unrepresented in surgical trials; therefore, the optimal therapy is still a matter of debate. The efficacy of open versus minimal invasive management of colorectal cancer (CRC) in an elderly cohort is not clearly established. The current study assesses the minimal invasive approach in elderly patients undergoing colorectal surgery. Material and Methods: The General Surgery Department database was inquired between 2012 and 2015 using the following filters: age â?¥ 65 and rectal or colon adenocarcinoma. After applying the exclusion criteria, 975 cases were obtained: 842 underwent open surgery (OS) and 133 underwent minimal invasive surgery (MIS). A propensity score matching was performed to reduce patient selection bias. Results: After the propensity score matching, the MIS group had a shorter postoperative hospital stay than the OS group (p = 0.025). From the preoperative variables, the presence of chronic lung disease was significantly higher in the OS group (p = 0.039). The presence of chronic lung disease positively associates with the Clavien-Dindo classification (p 0.001) and with the number of days from surgery to discharge (p = 0.028). Conclusion: The chronological age alone should not be a limit to MIS granting that it showed no inferiority to the OS in terms of postoperative morbidity, correlating with lower postoperative stay in the elderly. Further prospective studies are needed to assess the outcome of MIS in elderly population.

Short-term Outcome of Robotic and Laparoscopic Surgery for Gynecological Malignancies: A Single-center Experience.

Objectives: Minimally invasive surgery (MIS) has become the preferred option for many gynecologic pathologies since complication rate and postoperative recovery time have decreased considerably. Postoperative complications remain an important aspect when using the MIS approach, if they are not timely or accurately diagnosed and treated. The main aim of the study is to first assess their incidence, followed by identifying possible risk factors. Furthermore, the secondary aim is to identify if the type of MIS approach used, robotic or laparoscopic, may render some additional benefits. Materials and Methods: The database of the General Surgery Department was queried between 2008 and 2019 for patients with gynecologic pathology: 2907 cases were identified. An additional selection was performed using the following filters: MIS and neoplasia. All emergency surgeries were excluded. One hundred and ninety-eight cases were obtained. Results: The majority of complications were urological (11.6%) with only 7.07% requiring a specific urological procedure. The second most common was lymphorrhea 4.5%. Dindo-Clavien classification correlates positively with the postoperative hospital stay (PHS) (P = 0.000), the type of surgery (P = 0.046), the primary tumor location (P = 0.011), conversion rate (P = 0.049), the expertise of the lead surgeon (P = 0.012), and the operative time (P = 0.002). The urological complications correlate positively with the type of surgery (P = 0.002), the tumor location (P = 0.001), early reintervention (P = 0.000), operative time (P = 0.006), postoperative hemorrhage (P = 0.000), pelvic abscess (P = 0.000), venous thrombosis (P = 0.011), and postoperative cardiac complications (P = 0.002). Laparoscopic and robotic approaches were comparatively assessed. The PHS (P = 0.025), the type of surgery performed (P = 0.000), and primary tumor location (P = 0.011) were statistically significantly different. Conclusion: Postoperative complications reported after MIS for gynecological malignancies show similar incidence as in the current literature, also taking into consideration those for the open approach. The robotic approach seems to be able to perform more complex surgeries with no difference in the postoperative complication rates. The expertise of the lead surgeon in gynecology correlates with lower postoperative complications. Further prospective studies are needed to confirm these results.

Safety and Efficacy of Simultaneous Resection of Gastric Carcinoma and Synchronous Liver Metastasis-A Western Center Experience.

Background and objectives: Gastric cancer (GC) is often diagnosed in the metastatic stage. Palliative systemic therapy is still considered the gold standard, even for patients with resectable oligometastatic disease. The aim of the current study is to assess the potential benefit of up-front gastric and liver resection in patients with synchronous resectable liver-only metastases from GC (LMGC) in a Western population. Materials and Methods: All patients with GC and synchronous LMGC who underwent gastric resection with or without simultaneous resection of LMs between January 1997 and December 2016 were selected from the institutional records. Those with T4b primary tumors or with unresectable or more than three LMs were excluded from the analysis. All patients who underwent emergency surgery for hemorrhagic shock or gastric perforation were also excluded. Results: Out of 28 patients fulfilling the inclusion criteria, 16 underwent simultaneous gastric and liver resection (SR group), while 12 underwent palliative gastric resection (GR group). The median overall survival (OS) of the entire cohort was of 18.81 months, with 1-, 3- and 5-year OS rates of 71.4%, 17.9% and 14.3%, respectively. The 1-, 3- and 5-year OS rates in SR group (75%, 31.3% and 25%, respectively) were significantly higher than those achieved in GR group (66.7%, 0% and 0%, respectively; p = 0.004). Multivariate analysis of the entire cohort revealed that the only independent prognostic factor associated with better OS was liver resection (HR = 3.954, 95% CI: 1.542-10.139; p = 0.004). Conclusions: In a Western cohort, simultaneous resection of GC and LMGC significantly improved OS compared to patients who underwent palliative gastric resection.

The seen and the unseen: Molecular classification and image based-analysis of gastrointestinal cancers.

Gastrointestinal cancers account for 22.5% of cancer related deaths worldwide and represent circa 20% of all cancers. In the last decades, we have witnessed a shift from histology-based to molecular-based classifications using genomic, epigenomic, and transcriptomic data. The molecular based classification revealed new prognostic markers and may aid the therapy selection. Because of the high-costs to perform a molecular classification, in recent years immunohistochemistry-based surrogate classification were developed which permit the stratification of patients, and in parallel multiple groups developed hematoxylin and eosin whole slide image analysis for sub-classifying these entities. Hence, we are witnessing a return to an image-based classification with the purpose to infer hidden information from routine histology images that would permit to detect the patients that respond to specific therapies and would be able to predict their outcome. In this review paper, we will discuss the current histological, molecular, and immunohistochemical classifications of the most common gastrointestinal cancers, gastric adenocarcinoma, and colorectal adenocarcinoma, and will present key aspects for developing a new artificial intelligence aided image-based classification of these malignancies.

Is There a Role for Minimally Invasive Surgery in Cervical Cancer Treatment: Carry on, Discard, or Modify? A Literature Review and Case Series Presentation.

Oncological surgery is constantly evolving. Recommendations and guidelines are updated periodically in light of new research. Since surgery is a key step in the treatment of cervical cancer in Romania and considering the new findings, this study aims to assess the new guideline recommendations and the surgical treatment options available. The paradigm shift that took place in 2018 left the question: does minimally invasive surgery still play a role in the treatment of cervical cancer? K ouml;hler surgical technique seems to address some of the issues raised by the minimally invasive surgery with good results. H ouml;ckel proposes total mesometrial excision to decrease the risk of recurrence. This study presents 3 cases of cervical cancer patients with stages ranging from IB1 to IIIB that had undergone total mesometrial excision and vaginal cuff closure using the laparoscopic approach to minimize the risk of local recurrence. The case series presented showed that it is feasible and safe to merge these techniques. Further prospective studies are needed in order to assess the risk and benefits of these techniques.

Progress and challenges for the machine learning-based design of fit-for-purpose monoclonal antibodies.

Although the therapeutic efficacy and commercial success of monoclonal antibodies (mAbs) are tremendous, the design and discovery of new candidates remain a time and cost-intensive endeavor. In this regard, progress in the generation of data describing antigen binding and developability, computational methodology, and artificial intelligence may pave the way for a new era of in silico on-demand immunotherapeutics design and discovery. Here, we argue that the main necessary machine learning (ML) components for an in silico mAb sequence generator are: understanding of the rules of mAb-antigen binding, capacity to modularly combine mAb design parameters, and algorithms for unconstrained parameter-driven in silico mAb sequence synthesis. We review the current progress toward the realization of these necessary components and discuss the challenges that must be overcome to allow the on-demand ML-based discovery and design of fit-for-purpose mAb therapeutic candidates.

TNF-alpha releasing capacity of the whole blood drops after open total splenectomy, but increases after partial/subtotal or minimally invasive splenectomy.

BACKGROUND: The mechanisms that induce immunodeficiency after splenectomy remain unknown. The aim of this study was to measure the cytokine releasing capacity of the whole blood as an expression of the innate immunity after total (TS) and subtotal/partial splenectomy (S/PS) in order to assess the impact of splenectomy on the individual cytokine reactivity. METHODS: We prospectively collected blood before (D0) and at multiple time points after splenectomy (7 days - D7, 30 days - D30, 90 days - D90, 180 days - D180, and 360 days - D360) and measured the cytokines releasing capacity of IL-6, TNF-alpha and IL-10 from whole blood under LPS stimulation which we normalized to the monocytes number. RESULTS: When analyzing all splenectomies at D0, D7 and D30, normalized ΔTNF-alpha significantly dropped after splenectomy (p = .0038) and normalized ΔIL-6 and ΔIL-10 did not significantly change. More specifically, normalized ΔTNF-alpha dropped after TS (p = .0568) and significantly increased after S/PS (p = .0388). Open surgery induced a decrease in normalized ΔTNF-alpha (p = .0970), whereas minimally invasive (MI) surgery significantly increased the normalized ΔTNF-alpha releasing capacity (p = .0178). The cytokine levels were heterogenous between pathologies at D0, and ΔIL-6 dropped mainly in cirrhotic patients after splenectomy (all underwent TS), ΔTNF-alpha dropped in immune thrombocytopenic purpura patients (all underwent TS), but increased in spherocytosis (91% underwent S/PS) after splenectomy. CONCLUSIONS: Splenectomy induces a decrease of the pro-inflammatory cytokine TNF-alpha and if splenic parenchyma is spared and the surgery is performed MI, this change is hindered.

Abdominoperineal Resection for Rectal Cancer: Open, Laparoscopic or Robotic Approach.

OBJECTIVES: The present study compares abdominoperineal resection (APR) performed by minimally invasive and open approach, regarding preoperative selection criteria, intraoperative and early postoperative aspects, in choosing the suitable technique performed by surgical teams with experience in both open and minimally invasive surgery (MIS). Methods: This is a retrospective study, conducted between 2008-2020. Two hundred thirty-three patients with APR performed for low rectal or anal cancer were included. The cohort was divided into two groups, depending on the surgical approach used: Minimally Invasive Surgery (laparoscopic and robotic procedures) and Open Surgery (OS). The perioperative characteristics were analyzed in order to identify the optimal approach and a possible selection criteria. Results: We identified a high percentage of patients with a history of abdominal surgery in the open group (p = .0002). Intraoperative blood loss was significantly higher in the open group (p= .02), with an increased number of simultaneous resections (p = .041). The early postoperative outcome was marked by significantly lower morbidity in the MIS group (p = .005), with mortality recorded only in the open group (3 cases), in patients that associated severe comorbidities. The hystopathological results identified a significant number of patients with stage T2 in the MIS group (p= .037). Conclusions: Minimally invasive surgery provides a major advantage to APR, by avoiding an additional incision, the specimen being extracted through the perineal wound. The success of MIS APR seems to be assured by a good preoperative selection of the patients, alongside with experienced surgical teams in both open and minimally invasive rectal resections. The lack of conversion identified in robotic APR confirm the technical superiority over laparoscopic approach.

Pancreatic Fistula after D1+/D2 Radical Gastrectomy according to the Updated International Study Group of Pancreatic Surgery Criteria: Risk Factors and Clinical Consequences. Experience of Surgeons with High Caseloads in a Single Surgical Center in Eastern Europe.

PURPOSE: Incidence, risk factors, and clinical consequences of pancreatic fistula (POPF) after D1+/D2 radical gastrectomy have not been well investigated in Western patients, particularly those from Eastern Europe. MATERIALS AND METHODS: A total of 358 D1+/D2 radical gastrectomies were performed by surgeons with high caseloads in a single surgical center from 2002 to 2017. A retrospective analysis of data that were prospectively gathered in an electronic database was performed. POPF was defined and graded according to the International Study Group for Pancreatic Surgery (ISGPS) criteria. Uni- and multivariate analyses were performed to identify potential predictors of POPF. Additionally, the impact of POPF on early complications and long-term outcomes were investigated. RESULTS: POPF was observed in 20 patients (5.6%), according to the updated ISGPS grading system. Cardiovascular comorbidities emerged as the single independent predictor of POPF formation (risk ratio, 3.051; 95% confidence interval, 1.161-8.019; P=0.024). POPF occurrence was associated with statistically significant increased rates of postoperative hemorrhage requiring re-laparotomy (P=0.029), anastomotic leak (P=0.002), 90-day mortality (P=0.036), and prolonged hospital stay (P<0.001). The long-term survival of patients with gastric adenocarcinoma was not affected by POPF (P=0.661). CONCLUSIONS: In this large series of Eastern European patients, the clinically relevant rate of POPF after D1+/D2 radical gastrectomy was low. The presence of co-existing cardiovascular disease favored the occurrence of POPF and was associated with an increased risk of postoperative bleeding, anastomotic leak, 90-day mortality, and prolonged hospital stay. POPF was not found to affect the long-term survival of patients with gastric adenocarcinoma.

Long-Term Evaluation of the Outcomes of Subtotal Laparoscopic and Robotic Splenectomy in Hereditary Spherocytosis.

BACKGROUND: Hereditary spherocytosis (HS) is a common inherited disease affecting the erythrocyte membrane. Total splenectomy (TS) is effective in reducing hemolysis and decreasing the need of transfusions, but total removal of the spleen represents a potential risk factor for infectious and non-infectious complications. On the other hand, subtotal splenectomy (STS) could be an alternative therapy for HS. The aim of this study is to establish which surgical approach has the best outcome in HS. METHODS: All patients (n = 63) receiving splenectomy for HS between 2002 and 2016 from one institution were retrospectively reviewed. Hemoglobin and reticulocytes levels during preoperative and postoperative follow-up periods were compared. Additionally, a meta-analysis was performed analyzing data regarding hemoglobin and reticulocytes levels from several available studies. RESULT: At 1-year follow-up, our clinical data showed that mean hemoglobin levels increased after TS from (mean ± SD) 9.77 ± 1.82 to 11.88 ± 2.08 g/dl, while after STS from 8.98 ± 1.66 to 11.87 ± 1.38 g/dl. At 3-year and 5-year follow-up after TS, we observed an increase from 9.77 ± 1.82 to 13.59 ± 2.03 and 13.46 ± 1.64 g/dl, respectively. At 3-year and 5-year follow-up after STS in our cohort, we observed an increase from 8.98 ± 1.66 to 13.21 ± 1.95 and 13.68 ± 1.65 g/dl, respectively. The meta-analysis (for a follow-up period of 1 year) showed that the hemoglobin levels increased with 2.61 g/dl (95% CI 2.15-3.08 g/dl; p < 0.001) after TS, and with 1.67 g/dl (95% CI 1.25-2.10 g/dl; p < 0.001) after STS. CONCLUSION: We conclude that subtotal and minimally invasive splenectomy could be considered as the first line of treatment in severe HS cases, especially in children.

The non-coding RNome after splenectomy.

Splenectomy is a common surgical procedure performed in millions of people worldwide. Epidemiologic data show that splenectomy is followed by infectious (sepsis) and non-infectious complications, with unknown mechanisms. In order to explore the role of the non-coding transcripts involved in these complications, we analysed a panel of circulating microRNAs (miRNAs), which were previously reported to be deregulated in sepsis, in the plasma of splenectomized patients. MiR-223 was overexpressed immediately and late after splenectomy, while miR-146a was overexpressed immediately after splenectomy, returning latter to basal levels; and miR-16, miR-93, miR-26a and miR-26b were overexpressed only late after splenectomy, suggesting similarities with sepsis. We also explored the non-coding (nc)RNome of circulating peripheral blood leucocytes by performing a ncRNA full genome profiling. We observed a reorganization of the ncRNoma after splenectomy, characterized by up-regulation of miRNAs and down-regulation of transcribed pyknons (T-PYKs). Pathway analysis revealed that deregulated miRNAs control pathways involved in immunity, cancer and endothelial growth. We checked the expression of the ncRNAs in 15 immune cell types from healthy donors and observed that plasma miRNAs, cellular miRNAs and T-PYKs have a cell-specific expression pattern and are abundant in different types of immune cells. These findings suggest that the ncRNAs potentially regulate the immune changes observed after splenectomy.

Laparoscopic Hartmann s Reversal: A Single Center Experience.

Minimally invasive colorectal surgery showed multiple advantages in terms of morbidity, surgeons applied this approach to Hartmann reversal considering improving the reversal rate and postoperative outcome. The database from Fundeni Clinical Institute, General Surgery Department, was analyzed, selecting the laparoscopic Hartmann reversals. Nine cases were reported with a median age of 63 years, mean BMI 29 and three of them with prior open Hartmann surgery. The average operative time was 223 minutes, without any case necessitating ileostomy diversion. No anastomotic leakage was reported. The laparoscopic approach seems to be an attainable alternative in the reversal of Hartmann procedure, considering the experience of the surgical team and the patient's characteristics. Further studies are needed in order to confirm its superiority on larger case series.

Splenic Cysts: A Strong Indication for a Minimally Invasive Partial Splenectomy. Could the Splenic Hilar Vasculature Type Hold a Defining Role?

BACKGROUND: The aim of the study is to assess the impact of the splenic hilar vasculature configuration on the amount of remnant splenic parenchyma volume after partial splenectomy for splenic cysts. METHODS: The data of all patients receiving a splenectomy for a splenic cyst from 2002 to 2016 at the Center of General Surgery and Liver Transplantation of Fundeni Clinical Institute were retrospectively reviewed. The size and location in the splenic parenchyma of the cyst and the splenic hilar vasculature type were assessed for each patient with a splenectomy. RESULTS: Thirty-one patients with non-parasitic and 32 patients with hydatid cysts were recorded. In cases of centrally located cysts, a total splenectomy was performed for the majority of cases, while in peripheral cysts a spleen-preserving surgery was feasible for most of the patients (p = 0.001). The size of the cyst was significantly higher in the group of patients with a total splenectomy, compared with the group with a partial splenectomy (p = 0.003). In the subgroup with a distributed arterial pattern, preservation of more than 50% of the initial parenchyma was achieved in a significantly higher proportion of patients, compared with the subgroup of patients with a magistral pattern (p = 0.012). CONCLUSION: Besides cyst size or peripheral location in the splenic parenchyma, the vascular pattern is also considered another decisive factor that associates with successful conservative or minimally invasive approach.

D2 Lymphadenectomy for Gastric Adenocarcinoma: Long-term Results and the Impact of Surgeon Experience on the Survival Rates.

Background: Surgery is the main component of the multimodality treatment of gastric cancer (GC). The present study aims to comparatively assess the early and long-term outcomes after D1 and D2 lymph node dissection. Furthermore, the impact of surgeon case-load on the long-term survival after D2 gastrectomies is also explored. Methods: A number of 773 patients with curative-intent surgery for GC adenocarcinoma (1997 - 2010: 325 patients with D1 lymphadenectomy, 448 patients with D2 lymphadenectomy) were included. Results: No statistically significant differences of overall morbidity rates were observed between the D1 and D2 groups of patients (16.3%for D1 group vs. 18.8% for D2 group, p = 0.39). However, statistically significant higher rates of post operative pancreatic fistulae rates were observed in the D2 group of patients (3.2% for D1 group vs. 7.9% for D2 group, p 0.001). Interestingly, statistically significant higher rates of mortality were observed for the D1 group of patients (8.9% for D1 group vs. 2.9% for D2 group, p 0.001). The 5-year survival rate was statistically significant higher in the D2 group of patients (median overall survival time of 18 months for D1 group vs. 60 months for D2 group, p 0.001). A statistically significant correlation (p=0.005, r=0.571) was observed between the overall survival time and the number of D2 lymphadenectomies performed by each surgeon. Conclusions: D2 lymph node dissection is associated with statistically significant improved longterm survivals at the expense of higher postoperative pancreatic fistulae rates, compared to D1 surgery. However, no increased mortality rates were observed in the D2 group of patients. D2 radical gastrectomies should be performed in high-volume centers by high case-load surgeons.

Plasma Viral miRNAs Indicate a High Prevalence of Occult Viral Infections.

Prevalence of Kaposi sarcoma-associated herpesvirus (KSHV/HHV-8) varies greatly in different populations. We hypothesized that the actual prevalence of KSHV/HHV8 infection in humans is underestimated by the currently available serological tests. We analyzed four independent patient cohorts with post-surgical or post-chemotherapy sepsis, chronic lymphocytic leukemia and post-surgical patients with abdominal surgical interventions. Levels of specific KSHV-encoded miRNAs were measured by reverse transcription-quantitative polymerase chain reaction (RT-qPCR), and KSHV/HHV-8 IgG were measured by immunoassay. We also measured specific miRNAs from Epstein Barr Virus (EBV), a virus closely related to KSHV/HHV-8, and determined the EBV serological status by ELISA for Epstein-Barr nuclear antigen 1 (EBNA-1) IgG. Finally, we identified the viral miRNAs by in situ hybridization (ISH) in bone marrow cells. In training/validation settings using independent multi-institutional cohorts of 300 plasma samples, we identified in 78.50% of the samples detectable expression of at least one of the three tested KSHV-miRNAs by RT-qPCR, while only 27.57% of samples were found to be seropositive for KSHV/HHV-8 IgG (P<0.001). The prevalence of KSHV infection based on miRNAs qPCR is significantly higher than the prevalence determined by seropositivity, and this is more obvious for immuno-depressed patients. Plasma viral miRNAs quantification proved that EBV infection is ubiquitous. Measurement of viral miRNAs by qPCR has the potential to become the "gold" standard method to detect certain viral infections in clinical practice.

Cellular and viral microRNAs in sepsis: mechanisms of action and clinical applications.

Regardless of its etiology, once septic shock is established, survival rates drop by 7.6% for every hour antibiotic therapy is delayed. The early identification of the cause of infection and prognostic stratification of patients with sepsis are therefore important clinical priorities. Biomarkers are potentially valuable clinical tools in this context, but to date, no single biomarker has been shown to perform adequately. Hence, in an effort to discover novel diagnostic and prognostic markers in sepsis, new genomic approaches have been employed. As a result, a number of small regulatory molecules called microRNAs (miRNAs) have been identified as key regulators of the inflammatory response. Although deregulated miRNA expression is increasingly well described, the pathophysiological roles of these molecules in sepsis have yet to be fully defined. Moreover, non-human miRNAs, including two Kaposi Sarcoma herpesvirus-encoded miRNAs, are implicated in sepsis and may drive enhanced secretion of pro-inflammatory and anti-inflammatory cytokines exacerbating sepsis. A better understanding of the mechanism of action of both cellular and viral miRNAs, and their interactions with immune and inflammatory cascades, may therefore identify novel therapeutic targets in sepsis and make biomarker-guided therapy a realistic prospect.

Robot-assisted surgery for gastric cancer.

Minimally invasive surgery for gastric cancer is a relatively new research field, with convincing results mostly stemming from Asian countries. The use of the robotic surgery platform, thus far assessed as a safe procedure, which is also easier to learn, sets the background for a wider spread of minimally invasive technique in the treatment of gastric cancer. This review will cover the literature published so far, analyzing the pros and cons of robotic surgery and highlighting the remaining study questions.

Robotic splenectomy: what is the real benefit?

BACKGROUND: The laparoscopic approach to a difficult splenectomy requires a longer total operative time and is frequently associated with an increased risk of bleeding and a high conversion rate. METHODS: A total of 418 elective splenectomies were registered in the Department of General Surgery and Liver Transplantation of Fundeni Clinical Institute between January 1995 and June 2012, of which 299 splenectomies (212 laparoscopic and 77 robotic) were performed by a single surgical team and retrospectively documented. The effect of the learning curve and the relative complexity of each type of procedure were analyzed using the Minimally Invasive Splenectomy Score, which further allowed categorizing the splenectomies as simple or difficult. Statistical analyses using the CUSUM algorithm of the intra- and postoperative parameters of the laparoscopic and robotic approaches, for both the simple and the difficult splenectomies, were performed. RESULTS: The results of the statistical analyses clearly indicated that there was a learning curve effect for laparoscopic splenectomy but not for robotic splenectomy. When compared with the laparoscopic approach in difficult splenectomies, the robotic approach had a shorter total operative time (84.13 vs. 97.2 min), less blood loss (30.88 vs. 156.9 ml), and decreased risk of hemorrhagic complications during surgery. CONCLUSIONS: Laparoscopic splenectomy remains the approach of choice for simple splenectomies in the surgical treatment for common indications. The robotic system is particularly beneficial in difficult splenectomies (i.e., partial splenectomy, splenectomy in liver cirrhosis, splenic tumors, or malignant hemopathies).