Non-invasive laparoscopic detection of small tumors of the digestive tract using inductive sensors of proximity.

The precise location of gastric and colorectal tumors is of paramount importance for the oncological surgeon as it dictates the limits of resection and the extent of lymphadenectomy. However, this task proves sometimes to be very challenging, especially in the laparoscopic setting when the tumors are small, have a soft texture, and do not invade the serosa. In this view, our research team has developed a new instrument adapted to minimally-invasive surgery, and manipulated solely by the operating surgeon which has the potential to locate precisely tumors of the digestive tract. It consists of an inductive proximity sensor and an electronic block encapsulated into an autoclavable stainless-steel cage that works in tandem with an endoscopic hemostatic clip whose structure was modified to increase detectability. By scanning the serosal side of the colon or stomach, the instrument is capable to accurately pinpoint the location of the clip placed previously during diagnostic endoscopy on the normal bowel mucosa, adjacent to the tumor. In the current in-vivo experiments performed on large animals, the modified clips were transported without difficulties to the point of interest and attached to the mucosa of the bowel. Using a laparoscopic approach, the detection rate of this system reached 65% when the sensor scanned the bowel at a speed of 0.3 cm/s, and applying slight pressure on the serosa. This value increased to 95% when the sensor was guided directly on the point of clip attachment. The detection rate dropped sharply when the scanning speed exceeded 1 cm/s and when the sensor-clip distance exceeded the cut-off value of 3 mm. In conclusion, the proposed detection system demonstrated its potential to offer a swift and convenient solution for the digestive laparoscopic surgeons, however its detection range still needs to be improved to render it useful for the clinical setting.

Nanoprobes-Assisted Multichannel NIR-II Fluorescence Imaging-Guided Resection and Photothermal Ablation of Lymph Nodes.

Lymph node metastasis is a major metastatic route of cancer and significantly influences the prognosis of cancer patients. Radical lymphadenectomy is crucial for a successful surgery. However, iatrogenic normal organ injury during lymphadenectomy is a troublesome complication. Here, this paper reports a kind of organic nanoprobes (IDSe-IC2F nanoparticles (NPs)) with excellent second near-infrared (NIR-II) fluorescence and photothermal properties. IDSe-IC2F NPs can effectively label lymph nodes and helped achieve high-contrast lymphatic imaging. More importantly, by jointly using IDSe-IC2F nanoparticles and other kinds of nanoparticles with different excitation/emission properties, a multichannel NIR-II fluorescence imaging modality and imaging-guided lymphadenectomy is proposed. With the help of this navigation system, the iatrogenic injury can be largely avoided. In addition, NIR-II fluorescence imaging-guided photothermal treatment ("hot" strategy) can ablate those metastatic lymph nodes which are difficult to deal with during resection ("cold" strategy). Nanoprobes-assisted and multichannel NIR-II fluorescence imaging-guided "cold" and "hot" treatment strategy provides a general new basis for the future precision surgery.

Docking for robotic extraperitoneal para-aortic lymphadenectomy with Da Vinci Xi surgical system.

Regarding extraperitoneal para-aortic lymphadenectomy, installation is key when performed with the assistance of the Da Vinci Xi robotic system. We developed a step-by-step guide, from patient installation to placement of the trocars to patient cart docking, to perform in the efficient and safest installation possible this procedure. The operation does not differ from standard laparoscopic extraperitoneal lymphadenectomy. The benefits of robotic surgery in this indication are comparable to those of the standard laparoscopic approach. Those benefits imply a precise knowledge of the management and installation of the da Vinci Xi robotic system.

Transcervical (SP) and Transhiatal DaVinci Robotic Esophagectomy: A Cadaveric Study.

BACKGROUND: This is a preclinical cadaveric study to investigate the feasibility of a fully robotic McKeown esophagectomy in simultaneous rendezvous technique using the DaVinci X for transhiatal dissection and the DaVinci single port (SP) for transcervical dissection. METHODS: Two transcervical esophagectomies with the DaVinci SP surgical system were performed as training procedures. In the third transcervical cadaveric procedure, the DaVinci SP was installed for the transcervical approach and the DaVinci X surgical system for the abdominal transhiatal phase. Primary outcomes were operating time and lymphadenectomy. RESULTS: The mobilization of the esophagus was successfully completed in 118 minutes by using the DaVinci SP for the transcervical phase and the DaVinci X for the transhiatal abdominal phase simultaneously. In total 18 lymph nodes were dissected in the thorax; 3 were located paratracheal right, 3 paratracheal left, 4 subcarinal, 4 para-aortic, 2 paraesophageal upper mediastinal, and 2 paraesophageal middle mediastinal. CONCLUSION: This preclinical study demonstrated that a fully robotic McKeown esophagectomy in simultaneous rendezvous technique using the DaVinci X for transhiatal dissection and the DaVinci SP for transcervical dissection was feasible with adequate lymphadenectomy in a cadaver model. Future research will elucidate the indications for the use of the fully robotic transhiatal and transcervical esophagectomy.

En bloc lymphadenectomy of the right thorax via a uniportal thoracoscopic approach.

The uniportal approach to an en bloc complete lymphadenectomy is significantly more challenging than a multiportal approach or a thoracotomy because of the limited angulation available to the surgeon and the limited number of usable surgical instruments. Because of these limitations, it is very important to completely master the specific surgical steps in order to achieve success. Additionally, it is important to make sure the lymph nodes remain structurally intact, taking care not to cause damage by grasping them during lymphadenectomy, in order to prevent the dissemination of malignant cells into the thorax. In this video tutorial, we demonstrate our surgical technique for lymphadenectomy in the right upper (2R/4R) or lower (7/8/9) mediastinal zone, which is suitable for a uniportal approach, and explain the nuances of performing it.

Low-cost, safe, and effective smoke evacuation device for surgical procedures in the COVID-19 age.

BACKGROUND: Smoke is generated by energy-based surgical instruments. The airborne by-products may have potential health implications. METHODS: We developed a simple way to use de conventional surgical evacuator coupled with de electrosurgical pen attached to a 14G bladder catheter for open surgery. It was used in ten prospective patients with breast cancer. RESULTS: We notice a high reduction in surgical smoke during all breast surgery. A questionnaire was used for all participants of the surgery to answer the impression that they had about the device. The subjective impression was that the surgical smoke in contact whit the surgical team was reduced by more than 95%. CONCLUSIONS: Surgical smoke is the gaseous by-product produced by heat-generating devices in various surgical procedures. Surgical smoke may contain chemicals particles, bacteria, and viruses that are harmful and increase the risk of infection for surgeons and all the team in the operation room due to long term exposure of smoke mainly in coronavirus disease 2019 age. The adapted device described is a very simple and cheaper way to use smoke evacuators attached with the monopolar electrosurgical pen to reduce smoke exposure to the surgical team worldwide.

Reporting and Abstracting Variability in Technical Standards for Breast Cancer Operations.

BACKGROUND: The American College of Surgeons Commission on Cancer has incorporated documentation of critical elements outlined in Operative Standards for Cancer Surgery into revised standards for cancer center accreditation. This study assessed the current documentation of critical elements in partial mastectomy (PM) and sentinel lymph node biopsy (SLNB) operative reports. MATERIALS AND METHODS: Operative reports for PM + SLNB at a single academic institution from 2013 to 2018 were reviewed for compliance and surveyor interobserver reliability with the Oncologic Elements of Operative Record defined in Operative Standards and compared with a nonredundant American Society of Breast Surgeons Mastery of Breast Surgery (MBS) quality measure for specimen orientation. RESULTS: Ten reviewers each evaluated 66 PM + SLNB operative reports for 13 Oncologic Elements and one MBS measure. No operative records reported all critical elements for PM + SLNB or PM alone. Residents completed 36.4% of operative reports: Element documentation was similar for PM but varied significantly for SLNB between resident and attending authorship. Combined reporting performance and interrater reliability varied across all elements and was highest for the use of SLNB tracer (97.1% and κ = 0.95, respectively) and lowest for intraoperative assessment of SLNB (30.6%, κ = 0.43). MBS specimen orientation had both high proportion reported (87.0%) and interrater reliability (κ = 0.84). CONCLUSIONS: Adherence to reporting critical elements for PM and SLNB varied. Whether differential compliance was tied to discrepancies in documentation or reviewer abstraction, clarification of synoptic choices may improve reporting consistency. Evolving techniques or technologies will require continuous appraisal of mandated reporting for breast surgery.

Endobronchial Ultrasound-Guided Radiofrequency Ablation of Lung Tumors and Mediastinal Lymph Nodes: A Preclinical Study in Animal Lung Tumor and Mediastinal Adenopathy Models.

Radiofrequency ablation (RFA) can be a therapeutic option in medically inoperable lung cancer patients. In this study, we evaluated a prototype bipolar RFA device applicator that can be deployed from a standard endobronchial ultrasound (EBUS) bronchoscope to determine feasibility and histopathological analysis in animal models. Rabbit lung cancers were created by transbronchial injection of VX2 rabbit cancer cells. Once the tumors were developed, they were ablated transpleurally, under EBUS guidance using the prototype RFA device. The animals were then sacrificed for specimen resection. Pig inflammatory lung pseudo-tumors and lymphadenopathy were created by transbronchial injection of a talc paste and ablated transbronchially under EBUS guidance. Pigs were evaluated at 5 days, 2 weeks, and 4 weeks following ablation by bronchoscopy and cone beam computed tomography before necropsy. Nicotinamide adenine dinucleotide hydrogen diaphorase staining was employed to measure the ablation area. Twenty-four VX2 rabbit tumors were ablated. The total ablated area ranged from 0.6 to 3.0 cm2 (mean: 1.8 cm2), corresponding to a total energy range of 1 to 6 kJ. Six pig lung pseudo-tumors and 5 mediastinal lymph nodes were ablated. Adjacent airway ulceration was observed in 3 ablations of lymph nodes. These airway complications resolved within 4 weeks of RFA without any treatment. There was no hemoptysis, air embolism, respiratory distress, or other serious complication noted. In these 2 animal models, we provide evidence that EBUS-guided bipolar RFA is feasible and histopathology shows that can ablate lung tumors and mediastinal lymph nodes under real-time ultrasound guidance.

Initial results of a novel technique of clipped node localization in breast cancer patients postneoadjuvant chemotherapy: Skin Mark clipped Axillary nodes Removal Technique (SMART trial).

PURPOSE: Removal of clipped nodes can improve sentinel node biopsy accuracy in breast cancer patients post neoadjuvant chemotherapy (NACT). However, the current methods of clipped node localization have limitations. We evaluated the feasibility of a novel clipped node localization and removal technique by preoperative skin marking of clipped nodes and removal by the Skin Mark clipped Axillary nodes Removal Technique (SMART), with the secondary aim of assessing the ultrasound visibility of the various clips in the axillary nodes after NACT. METHODS: Invasive breast cancer patients with histologically metastatic axillary nodes, going for NACT, and ≤3 sonographically abnormal axillary nodes were recruited. All abnormal nodes had clips inserted. Patients with M1 disease were excluded. Post-NACT, patients underwent SMART and axillary lymph node dissection. Specimen radiography and pathological analyses were performed to confirm the clipped node presence. Success, complication rates of SMART, and ultrasound visibility of the various clips were assessed. RESULTS: Twenty-five clipped nodes in 14 patients underwent SMART without complications. The UltraCor Twirl, hydroMARK, UltraClip Dual Trigger, and UltraClip were removed in 13/13 (100%), 7/9 (77.8%), 1/2 (50.0%), and 0/1 (0%), respectively (P = .0103) with UltraCor Twirl having the best ultrasound visibility and removal rate. Removal of three clipped nodes in the same patient (P = .0010) and deeply seated clipped nodes (P = .0167) were associated with SMART failure. CONCLUSION: Skin Mark clipped Axillary nodes Removal Technique is feasible for removing clipped nodes post-NACT, with 100% observed success rate, using the UltraCor Twirl marker in patients with <3 not deeply seated clipped nodes. Larger studies are needed for validation.

Laparoendoscopic Single-site Radical Hysterectomy: Sufficient Exposure via Effective Suspension.

STUDY OBJECTIVE: To perform a radical hysterectomy for early-stage cervical cancer through laparoendoscopic single-site (LESS) approach and demonstrate if the effective suspension could achieve different exposed purposes and space extension. DESIGN: Presentation of the surgery through this technical video. SETTING: Hospital. INTERVENTIONS: A 52-year-old menopausal woman who presented with postcoital bleeding for 3 months was diagnosed with poorly differentiated (G3) cervical squamous cell carcinoma with International Federation of Gynecology and Obstetrics stage IB1. The patient was carefully consulted about the oncologic risks of the different surgical approaches; thereafter, the LESS approach was decided with informed consent. The LESS procedures for staging surgery were completed. The estimated blood loss was 60 mL, and operation time was 250 minutes. Results of the pathology report showed G3 squamous cell carcinoma and no pelvic lymph nodes metastases. The Foley catheter was removed on the 21st day, and the bladder function recovered completely after removal. She was followed up for a year without any evidence of recurrence or complications. CONCLUSION: Because of technical difficulties with a limited number of hands, complex surgeries, such as radical hysterectomy, have rarely been performed using the LESS approach [1]. The dissection of vesicocervical and parametrial space is critical to radical hysterectomy, and inadequate exposure to these spaces during the procedure presents major difficulties [2]. In the video, surgery for cervical cancer was performed successfully and met the International Federation of Gynecology and Obstetrics' standards for type C radical hysterectomy. Our video demonstrated that the varied and flexible suspension played a significant role in providing clear vision and sufficient exposure; furthermore, it was feasible, effective, and safe in the LESS approach [3,4].

Video-assisted esophagectomy using a port-free organ retractor for the prevention of laryngeal nerve paralysis.

INTRODUCTION: Recurrent laryngeal nerve (RLN) paralysis is a major complication of esophageal cancer surgery. The free jaw clip (FJ clip) was developed as an organ-retracting device, and it can also reduce the number of ports required during surgery. Here, we describe a new technique for lymphadenectomy along the left RLN using the FJ clip. MATERIALS AND SURGICAL TECHNIQUE: After the middle and lower mediastinal lymph nodes were dissected, the upper esophagus and other tissues, including the lymph nodes and left RLN, were retracted by cutting the tracheal arteries between the esophagus and trachea and then pulling the upper esophagus to the dorsal side with the FJ clip. The esophagus was transected at the upper mediastinum, and the proximal esophagus was drawn by the FJ clip. This technique helped provide a good field of view during lymphadenectomy along the left RLN. The data of nine consecutive patients who underwent video-assisted esophagectomy in the left lateral decubitus position by the same surgeon were reviewed. Postoperative left RLN paralysis occurred in only one patient in whom the RLN could not be preserved. DISCUSSION: Given the excellent short-term outcomes with respect to left RLN paralysis, lymphadenectomy along the left RLN using the FJ clip was safe and feasible.

Upgraded bidirectional approach video-assisted neck surgery (BAVANS) using a rigid endoscope with variable viewing direction for advanced endoscopic lymph node dissection in thyroid cancer patients.

In 2011, we developed bidirectional approach video-assisted neck surgery (BAVANS) for endoscopic thyroid cancer surgery. BAVANS combines two different approach pathways at 180 degrees to the cervical lesion for endoscopic thyroidectomy and complete cervical lymphadenectomy. We reported previously that the cranio-caudal approach is extremely useful for endoscopic complete lymph node dissection around the trachea. In 2014, we upgraded the initial BAVANS for better maneuverability and quality of lymph node dissection. A new high-tech rigid endoscope with a variable viewing direction (EndoCAMeleon™), has enabled us to reduce the camera port in the anterior neck while keeping the easy maneuverability and the same quality of central lymph node dissection (LND) as with the initial BAVANS. Endoscopic thyroid cancer surgery is now evolving concurrently with new visual technology.

Targeted axillary dissection after neoadjuvant systemic therapy in patients with node-positive breast cancer.

BACKGROUND: Over the last decade, neoadjuvant systemic therapy (NAST) has gained considerable popularity and its use has been extended to include breast cancer patients with operable node-positive disease. It may no longer be necessary to commit patients who are node-positive at presentation to axillary dissection if they become clinically node-negative after completing NAST. Targeted axillary dissection (TAD) is a technique where the marked pre-NAST positive node is excised along with the sentinel nodes and its response to chemotherapy is assessed and thus helps guide further treatment to the axilla. METHODS: The aim of this study was to determine the feasibility of marking positive axillary nodes with a clip and removing the clipped node after neoadjuvant treatment. We also assessed the concordance of the sentinel node with the clipped node. RESULTS: We prospectively evaluated 37 clinically and/or radiologically node-positive patients who underwent NAST. The overall identification rate of the clipped node was 78%. The identification rate was 100% if the clipped node was localized preoperatively and was much lower at 68% in patients who did not have the clipped node localized. The clipped node was not retrieved as the sentinel node in 14% of patients. CONCLUSION: We present the first Australian series on the feasibility of TAD. TAD is a feasible option in patients having NAST and with every new technique there is a learning curve. With the increasing experience globally and the refinement in marking and localization techniques, the accuracy of performing TAD will likely continue to improve.

Lymphadenectomy using two instrument arms during robotic surgery for gastric cancer: A strategy to facilitate reduced-port robotic gastrectomy.

BACKGROUND: Three instrument arms are used in the current form of reduced-port robotic gastrectomy (RPRG) for gastric cancer. Based on our experience in performing reduced-port laparoscopic gastrectomy (RPLG), we have recently performed RPRG using two instrument arms. METHODS: From February 2018 to January 2019, we performed RPRG using two instrument arms for gastric cancer. One endoscope arm and two instrument arms of da Vinci® Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) were applied in robotic lymphadenectomy. A commercial multi-lumen single-port trocar was used for the endoscopy port. RESULTS: A total of 18 patients underwent the planned robotic surgery using two instrument arms. Median operation time was 288.5 (213.0-446.0) minutes, and median hospital stay was 11.0 (7-18) days. Four patients experienced postoperative complications: one Clavien-Dindo grade IIIa, and the other three grade II. No mortality was reported. The number of retrieved lymph nodes did not differ between patients who underwent RPRG and RPLG (p = 0.412). CONCLUSION: Gastric cancer surgery using two instrument arms of a robotic surgical system can be performed by surgeons with expertise of RPLG. If this technique is successfully introduced in robotic surgery, it is expected to shorten the path to pure single-port robotic gastrectomy.

Laparoscopic Gastrectomy Using Instruments with a Minimal Diameter for Early Gastric Cancer: A Feasible Alternative to Conventional Laparoscopic Gastrectomy for Experienced Surgeons.

Background: The application of laparoscopic surgery using instruments that are 3 mm or less in diameter for patients with early gastric cancer (EGC) has not yet been established. We aimed to evaluate the feasibility and safety of laparoscopic gastrectomy using instruments with minimal diameter. Methods: We retrospectively analyzed 41 patients who underwent laparoscopic subtotal gastrectomy with D1-positive lymph node dissection for EGC. Among them, 17 patients underwent laparoscopic gastrectomy using instruments with a minimal diameter (experimental group), while 24 patients underwent conventional laparoscopic gastrectomy (control group). In the experimental group, we used two 3-mm trocars, one 5-mm trocar, and the GelPOINT® Advanced Access Platform. We compared operative outcomes between the two groups and assessed the learning curve of laparoscopic gastrectomy using instruments with minimal diameter. Results: The operative outcomes were similar between the two groups. The preoperative-to-postoperative day 2 ratio of neutrophil count in the experimental group was significantly lower than in the control group (2.07 versus 2.65; P = .038). Morbidity was not observed in the experimental group and 3 patients experienced complications in the control group, although it was not significantly different (P = .252). The operation time according to the accumulation of cases was stable without any significant change in the experimental group. Conclusions: Laparoscopic gastrectomy using instruments with minimal diameter is technically feasible and safe for EGC and could also be a good alternative to conventional laparoscopic gastrectomy to minimize the impact of surgical invasiveness when performed by experienced surgeons.

Comparison of the harmonic scalpel with scissors in women who experience obturator nerve injury during lymph node dissection for gynaecological malignancies.

OBJECTIVES: Lymphadenectomy is crucial for accurate staging in most gynecological malignancies. Serious complications can occur during the surgery. The present study aimed to present the early and late findings associated with obturator nerve injury, which is rarely observed during lymphadenectomy but can result in serious sequela if not noticed. MATERIAL AND METHODS: The files of the patients who underwent lymphadenectomy at our clinic between 2012 and 2018 were examined. Patients with obturator nerve incisions were identified retrospectively. RESULTS: In total, 287 women patients underwent lymphadenectomy at our clinic between 2012 and 2018. Examination of surgical notes revealed that nine patients underwent obturator nerve incisions using a scissor or a harmonic scalpel (energy- activated ultrasonic scissors). With respect to management of obturator nerve damage, no significant difference was found between the use of a harmonic scalpel and scissors (p < 1.000) and the trendelenburg and lithotomy positions (p < 0.167). In addition, no significant difference was found between laparoscopy and laparotomy in terms of surgical type (p < 0.167). At 6 months post-operatively, sensory-motor examinations and EMG findings of the patients were completely normal. CONCLUSIONS: Surgeries performed for gynaecological malignancies have high mortality and morbidity rates. Moreover, in the event of a complication such as nerve damage during laparoscopy, successful management of the complication before the patient undergoes laparotomy allows the patient to continue benefitting from the advantages of the laparoscopy. The results of our study show that these high-risk surgeries should be performed in advanced and well-equipped medical centres by teams experienced in gynaecological oncology.

Short- and long-term outcomes of totally robotic versus robotic-assisted radical distal gastrectomy for advanced gastric cancer: a mono-institution retrospective study.

PURPOSE: By comparing short- and long-term outcomes following totally robotic radical distal gastrectomy (TRDG) and robotic-assisted radical distal gastrectomy (RADG), we aimed to assess in which modus operandi patients will benefit more. METHODS: From January 2015 to May 2019, we included 332 patients undergone RADG (237) and TRDG (95). Based on the propensity score matching (PSM), inclusion and exclusion criteria, 246 patients were finally included in the propensity score-matched cohort including RADG group (164) and TRDG group (82). We then compared the short- and long-term outcomes following both groups. RESULTS: Propensity score-matched cohort revealed no significant differences in both groups. Intra-abdominal bleeding, time to pass flatus, postoperative activity time, length of incision hospital stays, and stress response were significantly less in TRDG group than in RADG group. We observed 30 complications in RADG group while 13 complications in TRDG group. There were no significant differences in TRDG group and RADG group in terms of operation time, time for anastomosis, proximal resection, distal resection margin, number of lymph node resection, and total hospitalization cost. Both 3-year overall survival and 3-year disease-free survival were comparable in both groups. CONCLUSIONS: TRDG is a safe and feasible modus operandi profiting from short- and long-term outcomes compared with RADG. As surgeons improving their professional skills, TRDG could serve as the standard procedure for distal locally advanced gastric cancer with D2 lymphadenectomy.