Minimally Invasive Adrenalectomy: Technical Aspects of the Laparoscopic and the Robotic Approach.

Adrenalectomy is nowadays a procedure routinely performed by minimally invasive surgery. In this article we aim to describe in depth our technique for laparoscopic and robotic left and right adrenalectomies, by using four cases and discussing the advantages and disadvantages of each technique.

Totally laparoscopic 95% gastrectomy for cancer: technical considerations.

INTRODUCTION: Total gastrectomy is the standard treatment for tumours arising in the proximal stomach and for diffuse cancer according to the Lauren classification. Laparoscopic approach is progressively accepted and provides encouraging results. In order to reduce complications associated to the esophago-jejunal anastomosis, the concept of the 95 % open gastrectomy was developed in Japan, in the early 1980s. This procedure provides the spearing of a small remnant gastric stump of 2 cm and allows performing a gastro-jejunal anastomosis. Unlike the 7/8 gastrectomy, the 95 % gastrectomy allows the complete resection of the gastric fundus and an optimized pericardial lymph node dissection (group 1 and 2). We herein describe, step-by-step, our technique of full laparoscopic 95 % gastrectomy (G95 %), with D2 lymphadenectomy, including complete lymphadenectomy of the cardial nodes. DISCUSSION: When it is possible to respect the oncologic criteria regarding proximal resection margin, 95 % gastrectomy would offer best short-term results, such as lower anastomotic leak rate and a better quality of life, limiting the effect of disruption of the eso-gastric junction. CONCLUSION: In selected patients, laparoscopic G95 % is feasible and safe; it could be performed without any additional technical difficulties. Controlled clinical trials are necessary to confirm the encouraging results of the cases series, recently reported in literature.

Laparoscopic gastrointestinal anastomoses using knotless barbed sutures are safe and reproducible: a single-center experience with 201 patients.

BACKGROUND: Intestinal anastomosis is a complex procedure during laparoscopy, mainly due to the difficulties knotting the sutures. Unidirectional barbed sutures have been proposed to simplify wall and mesentery closure, but the results for intestinal anastomosis are not clear. This study aimed to establish the feasibility and the safety of laparoscopic intestinal anastomosis using barbed suture. METHODS: Between June 2011 and May 2012, 15-cm-long unidirectional absorbable barbed sutures (V-Loc; Covidien, Mansfield, MA, USA) were used for all laparoscopic intestinal anastomoses: one suture for closure of intestinal openings after mechanical anastomoses and two sutures for hand-sewn anastomoses. RESULTS: Over a 1-year period, 201 consecutive patients required 220 laparoscopic anastomoses for gastrojejunostomy (n = 177; 172 during Roux-en-Y gastric bypass and 5 after gastrectomy), ileocolostomy (n = 15), colocolostomy (n = 1), esophagojejunostomy (n = 5), and jejunojejunostomy (n = 22; 4 after small bowel resection and 18 during gastric bypass or gastrectomy). Senior and training surgeons performed 209 closures of intestinal openings and 11 hand-sewn anastomoses. There was no conversion to usual sutures. One fistula occurred in an esophagojejunostomy and was managed conservatively. One self-limited anastomotic bleeding occurred, and no anastomotic stenosis occurred during 6 months of follow-up evaluation. CONCLUSIONS: The use of knotless barbed suture for laparoscopic intestinal anastomosis is safe and reproducible.

Laparoscopic sigmoidectomy in moderate and severe diverticulitis: analysis of short-term outcomes in a continuous series of 121 patients.

BACKGROUND: The role of laparoscopic surgery has been shown to be safe, feasible, and equivalent to open surgery for moderate diverticulitis, but its role in severe disease is still being elucidated. The aim of this study was to compare short-term outcomes in patients who underwent laparoscopic sigmoidectomy for moderate and severe diverticulitis. METHODS: All patients who had elective laparoscopic sigmoidectomy for diverticulitis between April 2003 and September 2011 at the University Hospital of Luxembourg were selected from a retrospective database. The patients were divided in two groups: moderate acute diverticulitis (MAD) included patients with an episode of left-lower-quadrant pain, elevated inflammatory markers, and radiologic evidence of diverticulitis, and severe acute diverticulitis (SAD) included patients with diverticula associated with abscess, phlegmon, perforation, fistula, obstruction, bleeding, or stricture. RESULTS: A total of 121 patients (81 MAD and 40 SAD) underwent elective laparoscopic sigmoidectomy with primary anastomosis. There were no significant differences between the two groups with respect to demographic characteristics, except for sex ratio. In this series the overall morbidity rate at 30 postoperative days (POD) was 12.4 %, with no significant differences between MAD and SAD (16.0 vs. 5 %, respectively; P = 0.083). No significant differences were found with respect to mean length of hospital stay (6.7 vs. 7.7 days; P = 0.399) as well. The overall conversion rate to open surgery was 2.5 % (3 patients), with no difference between the two groups. Conversion to laparotomy was associated with an increased morbidity rate (11.0 % for full laparoscopy vs. 66.6 % for conversion; P = 0.040) and a longer length of stay (6.8 vs. 16.7 days; P = 0.008). There were no deaths within 30 POD. CONCLUSIONS: Elective laparoscopic sigmoidectomy is safe and feasible for patients with moderate and severe acute diverticulitis and the outcomes are equivalent.

Two staged minimally invasive treatment for acute cholecystitis in high risk patients.

BACKGROUND/AIMS: The most optimal treatment for acute cholecystitis in high risk patients and severe acute cholecystitis remains still controversial. We review the outcomes of a two step treatment with percutaneous cholecystostomy and delayed laparoscopic cholecystectomy (DLC). METHODOLOGY: We collected data prospectively from January 2004 to April 2010 from 26 patients that underwent percutaneous transhepatic CT-guided cholecystostomy and DLC. RESULTS: Percutaneous transhepatic CT-guided cholecystostomy was achieved in all cases with no complications. There was just one catheter dislodgement. Most of patients, 92%, improved after drainage. There was one case of mortality. Laparoscopic cholecystectomy was achieved in 88% of patients with no mortality, and a low rate of morbidity (7.6%) and of conversion to open surgery. Pre-operative percutaneous cholangiogram showed additional and useful information in 55.5% of patients. CONCLUSIONS: Two-step minimally invasive treatment combining percutaneous transhepatic CT-guided cholecystostomy and DLC is safe and feasible and report low morbi-mortality rates.

[Three-port laparoscopic sleeve gastrectomy: feasibility and short outcomes in 25 consecutives super-obese patients]. / Gastrectomía vertical laparoscópica a través de 3 puertos: viabilidad y resultados a corto plazo en en una serie de 25 pacientes con hiperobesidad.

INTRODUCTION: The aim of this paper is to propose our technique, namely three-port laparoscopic sleeve gastrectomy (TPLSG), to define the feasibility and expose the short-outcomes, as an alternative between the standard laparoscopic approach and the single incision (SILSG) for such patients. MATERIAL AND METHODS: We conducted a prospective study of 25 patients: 12 male and 13 female, reporting a mean BMI of 53 kg/m² (range: 50-72) and a mean age of 38 years (range: 29-55). To evaluate the feasibility of our technique we have always respecting 3 pre-operatives conditions: BMI ≥ 50 kg/m². Preoperative abdominal US or CT to measure the liver and determine the hepato-splenic characteristics. "Intent to treat by 3 ports" (2 of 5 mm and one 12 mm in diameter). The short outcomes follow-up include: operative time, conversion, transfusions, fistula, reinterventions and parietal herniation at one and three months after surgery. RESULTS: Hepatomegaly was present in 19 (76%) patients, and it's greater on the left hepatic lobe in 9 (36%) patients. The mean operation time was 72 min (range: 50-110). No per-operative complications were observed. Conversion to four ports procedure was necessary in one patient. The mean hospital stay was 3 days (range: 2-5). No mortality and 30th POD morbidity rate was reported. No patient developed an incisional hernia to date. CONCLUSION: The TPLSG reduces the ports in number and in size and subsequently the parietal trauma, it also an instrumental triangulation, making surgery safe and reproducible.

Minimally invasive surgery for gastric cancer: A comparison between robotic, laparoscopic and open surgery.

AIM: To investigate the role of minimally invasive surgery for gastric cancer and determine surgical, clinical, and oncological outcomes. METHODS: This is a propensity score-matched case-control study, comparing three treatment arms: robotic gastrectomy (RG), laparoscopic gastrectomy (LG), open gastrectomy (OG). Data collection started after sharing a specific study protocol. Data were recorded through a tailored and protected web-based system. Primary outcomes: harvested lymph nodes, estimated blood loss, hospital stay, complications rate. Among the secondary outcomes, there are: operative time, R0 resections, POD of mobilization, POD of starting liquid diet and soft solid diet. The analysis includes the evaluation of type and grade of postoperative complications. Detailed information of anastomotic leakages is also provided. RESULTS: The present analysis was carried out of 1026 gastrectomies. To guarantee homogenous distribution of cases, patients in the RG, LG and OG groups were 1:1:2 matched using a propensity score analysis with a caliper = 0.2. The successful matching resulted in a total sample of 604 patients (RG = 151; LG = 151; OG = 302). The three groups showed no differences in all baseline patients characteristics, type of surgery (P = 0.42) and stage of the disease (P = 0.16). Intraoperative blood loss was significantly lower in the LG (95.93 ± 119.22) and RG (117.91 ± 68.11) groups compared to the OG (127.26 ± 79.50, P = 0.002). The mean number of retrieved lymph nodes was similar between the RG (27.78 ± 11.45), LG (24.58 ± 13.56) and OG (25.82 ± 12.07) approach. A benefit in favor of the minimally invasive approaches was found in the length of hospital stay (P < 0.0001). A similar complications rate was found (P = 0.13). The leakage rate was not different (P = 0.78) between groups. CONCLUSION: Laparoscopic and robotic surgery can be safely performed and proposed as possible alternative to open surgery. The main highlighted benefit is a faster postoperative functional recovery.

Fast-Track in Bariatric and Metabolic Surgery: Feasibility and Cost Analysis Through a Matched-Cohort Study in a Single Centre.

BACKGROUND: Due to the rise in severe obesity in Western countries and the increase in bariatric surgery, enhanced recovery (ER) pathways should be developed and promoted. METHODS: A monocentric prospective series of 103 bariatric surgery patients managed with the ER pathway (group ER) was compared with a retrospective and immediately previous series of 103 patients managed with standard care (group CS). The aim of the present study was to assess and compare the differences in terms of mean postoperative length of stay (LOS), costs for surgery and recovery, and the differences in terms of complications, readmission, and reoperation rate in the short term between the ER and CS groups. RESULTS: The mean LOS was 4.18 days in group CS and 1.79 days in group ER (p < 0.0001). The mean operative time (OT) per patient was 190.20 min in the group CS and 133.54 min in the group ER, resulting in an average cost of 7272.57€ per patient in group CS and 5424.09€ per patient in group ER. The average recovery cost was 1809.94€ for the group CS series and 775.07 for the group ER one. Overall complications (Clavien-Dindo up to II) occurred in 6 patients (5.8 %) in group CS and in 2 patients (1.9 %) in group ER (p = 0.149) and specific complications (Clavien-Dindo IIIb) occurred for 9 patients (8.7 %) in Group CS and for 14 patients (13.5 %) in group ER (p = 0.268) after hospital discharge within 1-month of follow-up. Twelve patients (11.5 %) in group CS and 13 (12.5 %) in group ER were readmitted after discharge (p = 0.831) within 1-month of follow-up; 8 patients (7.7 %) in group CS versus 9 patients (8.8 %) in group ER needed to be reoperated (p = 0.800) within 1-month follow-up. CONCLUSIONS: Enhanced recovery pathway reduces significantly LOS in bariatric surgical patients and shortens the mean OT of the procedure, with no significant differences in terms of surgical outcomes. Furthermore, recovery charges were lower and operative time was shorter allowing for procedural cost reduction.

Pure laparoscopic pancreatoduodenectomy with initial approach to the superior mesenteric artery.

INTRODUCTION: The "artery-first approach" (AFA) to the superior mesenteric artery allows an early assessment of resectability of pancreatic tumours and could improve the benefits of laparoscopy, reducing invasiveness, especially for unresectable tumours. AIM: To describe our technique of pure laparoscopic pancreatoduodenectomy (PLPD) with the AFA, and to report the surgical outcomes of this procedure in a small series of 12 patients through a retrospective analysis of a prospectively collected database. MATERIAL AND METHODS: Twelve selected patients underwent elective full laparoscopic pancreatoduodenectomy with the AFA. The technical aspects of the procedure are described in detail and the included images facilitate the understanding of the procedure. RESULTS: The mean operative time was 300 min (range: 250-540 min). No intraoperative complications were observed. No conversion to laparotomy was necessary. The mean postoperative hospital stay was 18 days (range: 8-42). Mortality was null. There were 3 major complications at the 3rd post-operative month follow-up: 2 patients reporting a grade A pancreatic fistula and one biliary fistula. CONCLUSIONS: Our work shows that pure laparoscopic pancreatoduodenectomy (PLPD) with the AFA is feasible, in selected patients. The AFA could improve on the advantages of laparoscopy in the identification of unresectable patients, and it also allows early control of vascular structures.

Robotic, laparoscopic and open surgery for gastric cancer compared on surgical, clinical and oncological outcomes: a multi-institutional chart review. A study protocol of the International study group on Minimally Invasive surgery for GASTRIc Cancer-IMIGASTRIC.

INTRODUCTION: Gastric cancer represents a great challenge for healthcare providers and requires a multidisciplinary treatment approach in which surgery plays a major role. Minimally invasive surgery has been progressively developed, first with the advent of laparoscopy and recently with the spread of robotic surgery, but a number of issues are currently being debated, including the limitations in performing an effective extended lymph node dissection, the real advantages of robotic systems, the role of laparoscopy for Advanced Gastric Cancer, the reproducibility of a total intracorporeal technique and the oncological results achievable during long-term follow-up. METHODS AND ANALYSIS: A multi-institutional international database will be established to evaluate the role of robotic, laparoscopic and open approaches in gastric cancer, comprising of information regarding surgical, clinical and oncological features. A chart review will be conducted to enter data of participants with gastric cancer, previously treated at the participating institutions. The database is the first of its kind, through an international electronic submission system and a HIPPA protected real time data repository from high volume gastric cancer centres. ETHICS AND DISSEMINATION: This study is conducted in compliance with ethical principles originating from the Helsinki Declaration, within the guidelines of Good Clinical Practice and relevant laws/regulations. A multicentre study with a large number of patients will permit further investigation of the safety and efficacy as well as the long-term outcomes of robotic, laparoscopic and open approaches for the management of gastric cancer. TRIAL REGISTRATION NUMBER: NCT02325453; Pre-results.

Current status of minimally invasive surgery for gastric cancer: A literature review to highlight studies limits.

BACKGROUND: Gastric cancer represents a great challenge for health care providers and requires a multidisciplinary approach in which surgery plays the main role. Minimally invasive surgery has been progressively developed, first with the advent of laparoscopy and more recently with the spread of robotic surgery, but a number of issues are currently being investigate, including the limitations in performing effective extended lymph node dissections and, in this context, the real advantages of using robotic systems, the possible role for advanced Gastric Cancer, the reproducibility of completely intracorporeal techniques and the oncological results achievable during follow-up. METHOD: Searches of MEDLINE, Embase and Cochrane Central Register of Controlled Trials were performed to identify articles published until April 2014 which reported outcomes of surgical treatment for gastric cancer and that used minimally invasive surgical technology. Articles that deal with endoscopic technology were excluded. RESULTS: A total of 362 articles were evaluated. After the review process, data in 115 articles were analyzed. CONCLUSION: A multicenter study with a large number of patients is now needed to further investigate the safety and efficacy as well as long-term outcomes of robotic surgery, traditional laparoscopy and the open approach.

Minimally invasive management of postoperative esophagojejunal anastomotic leak.

PURPOSE: Postoperative esophagojejunal fistula induces morbidity and mortality after total gastrectomy and affects the long-term survival rate. METHODS: Between 2003 and 2011, 38 patients underwent laparoscopic total gastrectomy and 2 developed an esophagojejunal fistula. RESULTS: The diagnosis was established by a computed tomography scan with contrast ingestion. The absence of complete dehiscence and the vitality of the alimentary loop were checked during laparoscopic exploration, associated with effective drainage. During the endoscopy, dehiscence was assessed and a covered stent and nasojejunal tube were inserted for enteral feeding. The leaks healed progressively, oral feeding was resumed and the drains removed within 3 weeks. The stent was removed 6 weeks. Three months later, the patients were able to eat without dysphagia. CONCLUSIONS: Early diagnosis allows successful conservative management. The objectives are effective drainage, covering by an endoscopic stent and renutrition. Management by a multidisciplinary team is essential.

Barbed versus usual suture for closure of the gastrojejunal anastomosis in laparoscopic gastric bypass: a comparative trial.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass is one of the main bariatric procedures that require safe and reproducible anastomosis. The objective of this study is to compare the risk of leaks and stenosis of a mechanical gastric pouch jejunal anastomosis between the usual interrupted sutures and a continuous barbed suture for gastrojejunotomy, in order to reduce procedure time and costs. METHODS: A comparative trial of 100 consecutive patients undergoing laparoscopic Roux-en-Y gastric bypass was performed between October 2010 and July 2011. The population was divided into two groups of 50 consecutive patients. In the first group, gastrojejunotomy was sutured with resorbable interrupted sutures and the second with continuous barbed suture. Diabetes, body mass index and the American Society of Anaesthesiology score were compared. The time required for suturing and the incidence of anastomotic leaks and stricture were also compared after 6 months. RESULTS: No fistulas or anastomotic stenoses had occurred at post-operative month 6 in either group. Gastrojejunotomy suture time was significantly shorter in the barbed suture group (11 versus 8.22 min; p < 0.01). Total costs of material to complete the reconstruction were significantly lower in the barbed suture group (€26.69 versus €18.33; p < 0.001). CONCLUSIONS: The use of barbed suture is as safe as usual sutures and allows easier and faster suture in the closure of gastrojejunotomy. This suture could be incorporated in the standard laparoscopic Roux-en-Y gastric bypass technique.

Laparoscopic liver resection for malignant liver tumors: preliminary results of a multicenter European study.

OBJECTIVE: To assess the feasibility, safety, and outcome of laparoscopic liver resection for malignant liver tumors. SUMMARY BACKGROUND DATA: The precise role of laparoscopy in resection of liver malignancies (hepatocellular carcinoma [HCC] and liver metastases) remains controversial despite an increasing number of publications reporting laparoscopic resection of benign liver tumors. METHODS: A retrospective study was performed in 11 surgical centers in Europe regarding their experience with laparoscopic resection of liver malignancies. Detailed questionnaires were sent to each surgeon focusing on patient characteristics, clinical data, type and characteristics of the tumor, technical details of the operation, and early and late clinical outcome. All patients had radiologic investigations at follow-up to exclude disease recurrence. RESULTS: From February 1994 to December 2000, 37 patients with malignant liver tumors were included in this study. Ten patients had HCC, including 9 with cirrhotic liver, and 27 patients had liver metastases. The mean tumor size was 3.3 cm, and 89% of the tumors were located in the left lobe or in the anterior segments of the right liver. Liver procedures included 12 wedge resections, 9 segmentectomies, 14 bisegmentectomies (including 13 left lateral segmentectomies), and 2 major hepatectomies. The transfusion rate, the use of pedicular clamping, the conversion rate (13.5% in the whole series), and the complication rate were significantly greater in patients with HCC. There were no deaths. Postoperative complications occurred in eight patients (22%). The surgical margin was less than 1 cm in 30% of the patients. During a mean follow-up of 14 months, the 2-year disease-free survival was 44% for patients with HCC and 53% for patients having hepatic metastases from colorectal cancer. No port-site metastases were observed during follow-up. CONCLUSIONS: In patients with small malignant tumors, located in the left lateral segments or in the anterior segments of the right liver, laparoscopic resection is feasible and safe. The complication rate is low, except in patients with HCC on cirrhotic liver. By using laparoscopic ultrasound, a 1-cm free surgical margin should be routinely obtained. The late outcome needs to be evaluated in expert centers.