The Brescia Internationally Validated European Guidelines on Minimally Invasive Pancreatic Surgery (EGUMIPS).

OBJECTIVE: To develop and update evidence-based and consensus-based guidelines on laparoscopic and robotic pancreatic surgery. SUMMARY BACKGROUND DATA: Minimally invasive pancreatic surgery (MIPS), including laparoscopic and robotic surgery, is complex and technically demanding. Minimizing the risk for patients requires stringent, evidence-based guidelines. Since the International Miami Guidelines on MIPS in 2019, new developments and key publications have been reported, necessitating an update. METHODS: Evidence-based guidelines on 22 topics in 8 domains were proposed: terminology, indications, patients, procedures, surgical techniques and instrumentation, assessment tools, implementation and training, and artificial intelligence. The Brescia Internationally Validated European Guidelines on Minimally Invasive Pancreatic Surgery (EGUMIPS, September 2022) used the Scottish Intercollegiate Guidelines Network (SIGN) methodology to assess the evidence and develop guideline recommendations, the Delphi method to establish consensus on the recommendations among the Expert Committee, and the AGREE II-GRS tool for guideline quality assessment and external validation by a Validation Committee. RESULTS: Overall, 27 European experts, 6 international experts, 22 international Validation Committee members, 11 Jury Committee members, 18 Research Committee members, and 121 registered attendees of the 2-day meeting were involved in the development and validation of the guidelines. In total, 98 recommendations were developed, including 33 on laparoscopic, 34 on robotic, and 31 on general MIPS, covering 22 topics in 8 domains. Out of 98 recommendations, 97 reached at least 80% consensus among the experts and congress attendees, and all recommendations were externally validated by the Validation Committee. CONCLUSIONS: The EGUMIPS evidence-based guidelines on laparoscopic and robotic MIPS can be applied in current clinical practice to provide guidance to patients, surgeons, policy-makers, and medical societies.

Towards Truly "Bespoke" Robotic Surgery: Vessel-Sparing Sigmoidectomy.

The proposed video-vignette represents a later step towards a truly robotically surgical approach, that combines oncological radicality and preservation of optimal blood flow during a sigmoidectomy for cancer. This totally robotic vessel-sparing approach doesn't result in longer operative times, higher blood loss or extended length of hospitalization.

Coronary Artery Stent for Securing High-risk Pancreatico-jejunal Anastomosis After Pancreatoduodenectomy: A Pilot Series.

OBJECTIVE: To assess the feasibility and clinical utility of coronary artery stent (CAS) in securing pancreatico-jejunal anastomosis (PJ) and avoid stent displacement after pancreatoduodenectomy (PD). SUMMARY OF BACKGROUND DATA: Externalized trans-anastomotic stent (ETS) is a standard mitigation strategy for postoperative pancreatic fistula (POPF) in high-risk patients. However, major morbidity remains extremely elevated, especially in case of ETS malfunction due to displacement. METHODS: A pilot series of 72 patients underwent PD and PJ with CAS positioning between January 2016 and December 2019. All patients were at high-risk for POPF (soft pancreatic texture; main pancreatic duct diameter ≤ 3 mm) and underwent a CT-scan at postoperative day 5 and 10 to assess the correct CAS positioning. Postoperative outcomes were analyzed, and displacement rates were compared with a cohort of 141 patients with the same high-risk characteristics, undergoing PD with PJ and externalized trans-anastomotic stent (ETS). RESULTS: No CAS-related complications were registered in the study group. In particular, no CAS displacement was registered, compared to a 28% ETS malfunction (either displacement or occlusion). The POPF rate, major morbidity, and mortality were 11%, 6%, and 0% respectively. CONCLUSIONS: The CAS positioning appears to be a feasible and safe mitigation strategy to secure PJ anastomosis after PD with high POPF risk avoiding stent displacement. Further validation and comparison with current standard of care is required in a prospective controlled setting.

Robotic oncologic colorectal surgery with a new robotic platform (CMR Versius): hope or hype? A preliminary experience from a full-robotic case-series.

BACKGROUND: The present case-series describes the first full-robotic colorectal resections performed with the new CMR Versius platform (Cambridge Medical Robotics Surgical, 1 Evolution Business Park, Cambridge, United Kingdom) by an experienced robotic surgeon. METHODS: In a period between July 2020 and December 2020, patients aged 18 years or older, who were diagnosed with colorectal cancer and were fit for minimally invasive surgery, underwent robotic colorectal resection with CMR Versius robotic platform at "Casa di Cura Cobellis" in Vallo della Lucania,Salerno, Italy. Three right colectomies, 2 sigmoid colectomies and 1 anterior rectal resection were performed. All the procedures were planned as fully robotic. Surgical data were retrospectively reviewed from a prospectively collected database. RESULTS: Four patients were male and 2 patients were female with a median (range) age of 66 (47-72) years. One covering ileostomy was created. Full robotic splenic flexure mobilization was performed. No additional laparoscopic gestures or procedures were performed in this series except for clipping and stapling which were performed by the assistant surgeon due to the absence of robotic dedicated instruments. Two ileocolic anastomoses, planned as robotic-sewn, were performed extracorporeally. One Clavien-Dindo II complication occurred due to a postoperative blood transfusion. Median total operative time was 160 (145-294) min for right colectomies, 246 (191-300) min for sigmoid colectomies and 250 min for the anterior rectal resection. CONCLUSIONS: The present series confirms the feasibility of full-robotic colorectal resections while highlighting the strengths and the limitations of the CMR Versius platform in colorectal surgery. New devices will need more clinical development to be comparable to the current standard.

Robotic infrahepatic vena cava clamping and Pringle manoeuvre for major hepatectomy: A safe and bloodless procedure - First technical report.

Mini-invasive approaches in hepatic surgery are associated with a significant decrease in the incidence of post-operative morbidity and liver failure. Intraoperative blood loss represents the major intraoperative accident during hepatectomy. Infrahepatic inferior vena cava clamping is an emerging technical trick which guarantees a lower intraoperative blood loss and transfusion rates during liver surgery. Herein, we present the first report of infrahepatic caval clamping during robotic hepatectomy at our centre, highlighting some technical tips and tricks.

Transanal Total Mesorectal Excision: Pneumodissection of Retroperitoneal Structures Eases Laparoscopic Rectal Resection.

INTRODUCTION: Laparoscopic total mesorectal excision is effective and safe but often technically challenging because of inadequate exposure. Transanal total mesorectal excision was introduced to mitigate this limitation and improve the quality of mesorectal dissection in even the most challenging cases. Currently, the technique for transanal total mesorectal excision dissection is not standardized. TECHNIQUE: The sequential approach to transanal total mesorectal excision mirrors the principles of the transanal abdominal transanal procedure. It begins with the transanal step, followed by the laparoscopic step, and then the transanal total mesorectal excision. The perirectal space is entered via a full-thickness dissection of the anterior rectal wall. Carbon dioxide is left flowing, widening the embryonic planes between the mesorectal and pelvic fascias, then moving upward through the retroperitoneal space. The surgeon switches to the abdominal field and begins laparoscopic dissection, consisting of inferior mesenteric artery dissection and division, inferior mesenteric vein dissection and division, and possible splenic flexure dissection. Pneumodissection facilitates this procedure by distancing the inferior mesenteric artery from the hypogastric nerves and opening the embryonic fusion plane between the Toldt and Gerota fascias to allow faster division of the left colon lateral attachments. The operation continues with a switch to the perineal field and mesorectal excision. RESULTS: A total of 102 patients underwent transanal total mesorectal excision as described. Mean operative time was 185.0 + 87.5 minutes (range, 60-480 min), and there was no conversion to open surgery. Postoperative morbidity was 33.3%. Mortality rate at 30 days was 1.96% (2 cases). Quality of mesorectal excision according to Quirke was assessed in all of the specimens and found to be complete in 99 cases (97.1%) and nearly complete in 2.9% of cases. CONCLUSIONS: Transanal total mesorectal excision may benefit from pneumodissection, expedites the laparoscopic step, and the sequential approach facilitates the visualization of the correct dissection planes. The safety and cost-effectiveness of the procedure still warrant consideration. See Video at http://links.lww.com/DCR/A418.

NOSE laparoscopic gastrectomies for early gastric cancer may reduce morbidity and hospital stay: early results from a prospective nonrandomized study.

BACKGROUND: Natural orifice specimen extraction - NOSE laparoscopy is a promising technique that avoids mini-laparotomy, possibly reducing postoperative pain, wound infections and hospital stay. Recent systematic reviews have shown that postoperative morbidity associated with laparoscopically assisted gastrectomies is similar to that after open gastrectomies. More specifically, there is no difference in wound infection rate. The study objective was to evaluate whether postoperative morbidity and hospital stay may be reduced by transoral specimen extraction after laparoscopically assisted gastrectomy for early gastric cancer (EGC). MATERIAL AND METHODS: A prospective, nonrandomized study was carried out starting in August 2012. Data from all patients operated on during the first year, with minimum 18 months follow-up, were collected to assess feasibility, oncologic results, postoperative morbidity, hospital stay and functional results. Overall, 14 patients were included and followed-up. After gastric resection, a 3 cm opening was created on the gastric stump, and the specimen, divided into three segments stitched one to each other, was sutured to the gastric tube and retrieved through the mouth. RESULTS: Postoperative morbidity was 7.14% (1/14): one case of pneumonia. No wound infection occurred. The mean postoperative hospital stay was 4.7 ± 1.0 days. CONCLUSIONS: NOSE laparoscopic subtotal gastrectomy is feasible and safe, with similar oncologic results as LAG, but decreased morbidity and hospital stay.

Techniques and technology evolution of rectal cancer surgery: a history of more than a hundred years.

History of rectal cancer surgery has shown a continuous evolution of techniques and technologies over the years, with the aim of improving both oncological outcomes and patient's quality of life. Progress in rectal cancer surgery depended on a better comprehension of the disease and its behavior, and also, it was strictly linked to advances in technologies and amazing surgical intuitions by some surgeons who pioneered in rectal surgery, and this marked a breakthrough in the surgical treatment of rectal cancer. Rectal surgery with radical intent was first performed by Miles in 1907 and the procedure he developed, abdomino-perineal resection, became a gold standard for many years. In the following years and over the last century other procedures were introduced which became new gold standards: Hartmann's procedure, anterior rectal resection, total mesorectal excision (TME); the last one, developed by Heald in 1982, is the present gold standard treatment of rectal cancer. At the same time, new technologies were developed and introduced into the clinical practice, which enhanced results of surgery and even made possible performing new operations: leg-rests, stapling devices, instruments, appliances and platforms for laparoscopic surgery and transanal rectal surgery. In more recent years the transanal approach to TME has been introduced, which might improve oncologic results of surgery of the rectum. Ongoing randomized studies, future systematic reviews and metanalyses will show whether the transanal approach to TME will become a new gold standard.

Technologies, technical steps, and early postoperative results of transanal TME.

INTRODUCTION: First described in 1982, TME overcomes most of the concerns regarding adequate local control after anterior rectal resection. TME requires close sharp dissection along the so-called Heald's plane down to the levators, with distal dissection often cumbersome. In recent years, Transanal TME was introduced with the aim to improve distal rectal dissection and quality of mesorectal excision. MATERIAL AND METHODS: A prospective, non-randomized study, started in 2013, is currently ongoing in two Italian Centers. Study objectives were assessing the safety of TaTME and TME quality. TaTME technique and technologies as performed in these centers and cumulative results at ≤30 postoperative days of the first 102 patients are reported. RESULTS: Early postoperative morbidity and mortality rates were 33.3% (34 pts, 16 Clavien-Dindo I + II and 18 Clavien-Dindo III + IV + V), and 1.96% (two deaths), respectively. The quality of mesorectal excision according to Quirke was: complete in 97.1% and nearly complete in 2.9% of the cases. CONCLUSIONS: The results confirm the effectiveness of TaTME, especially regarding the quality of the mesorectal dissection. Open questions regarding standardization, anatomical landmarks, indications, morbidity (with special regard to local infection and sepsis), learning curve and oncological outcomes require further answers from larger studies and RCTs before definitive validation of this procedure. .

Laparoscopic Colorectal Cancer Resection in High-Volume Surgical Centers: Long-Term Outcomes from the LAPCOLON Group Trial.

BACKGROUND: Strong evidence has confirmed the benefit of laparoscopy in colorectal cancer resection but remains a challenging procedure. It is not clear that such promising results in selected patients translate into a favorable risk-benefit balance in real practice. We conducted a multicenter national observational registry to assess operative and oncologic long-term outcomes following laparoscopic colorectal cancer resection. METHODS: All patients with laparoscopic colorectal cancer resection between 2001 and 2004 were included. Data were extracted from the prospective Italian national database of 10 high-volume centers (≥40 colorectal cancer laparoscopic resections per year). Surgical technique and follow-up were standardized. Survivals were analyzed by Kaplan-Meier method. RESULTS: We reported 1832 patients with colon (58.5%) and rectal cancer (41.5%). TNM stage was 0-I-II in 1044 patients (57%) and III-IV in 788 patients (43%). Surgery included a totally laparoscopic procedure in 1820 patients (99.3%). Conversion was 10.5%. Postoperative morbidity and 30-day mortality rates were 17 and 1.2%, respectively. Clinical anastomotic leakage rate was 8.3% (n=152). R0 resection was 95%. With a median follow-up of 54.2 months, cancer recurrence rate was 13.3%. At 5 years, cancer-free survival was 86.7%. Upon multivariate analysis, age (P=0.001) and TNM stage (P<0.001) were associated with cancer-free survival. Predictive factors of cancer recurrence were gender (P=0.029) and TNM stage (P<0.001). CONCLUSIONS: In high-volume centers and non-selective patients, laparoscopic colorectal resection for cancer achieves good operative results with satisfactory long-term oncologic results. Even in the laparoscopy era, age, gender, and TNM stage remain the most powerful predictor of oncologic outcomes.

Single-access laparoscopic "lavage" for purulent diverticulitis in a 96-year-old patient: how to reduce surgical trauma and standardize surgical technique.

INTRODUCTION: Recently, laparoscopic lavage emerged as an effective alternative for patients with perforated diverticulitis with purulent peritonitis. CASE REPORT: A 96-year-old woman, diagnosed with Hinchey 3 diverticulitis after a computed tomography scan, was operated on with a single-access "lavage" to reduce surgical trauma and to avoid stoma. METHODS: The procedure was performed under general anesthesia. Tracheal intubation, nasogastric tube, and urethral catheterization were mandatory. The patient was in a modified Lloyd-Davis position, with the table tilted in Trendelenburg position, left side up. Surgeons were on the right side. INSTRUMENTATION: The procedure was performed using a surgical technique similar to standard laparoscopy with traditional laparoscopic instruments. SURGICAL STEPS: The surgical procedure involved single-incision laparoscopic surgery (Covidien, Mansfield, MA) insertion, small bowel dissection, abscess opening, and peritoneal washing. RESULTS: The procedure was completed in 75 minutes with an estimated blood loss of 120 mL. The patient was kept in the intensive care unit for 1 day. She was on postoperative analgesia for 2 days and was discharged from the hospital on postoperative day 5. The patient was able to drink on day 1 and eat on day 3 after flatus.

Minimally invasive pancreatic anastomosis after pancreaticoduodenectomy: multi-institutional step by step video description of the technique.

Minimally invasive pancreaticoduodenectomy (PD) is attracting increased interest in the pancreatic surgical community with more and more teams reporting their experience worldwide. The pancreatic anastomosis (PA) is one of the key steps and challenging manoeuvre of this procedure. Since the introduction of the minimally invasive approach for PD, several PA types have been proposed, ranging from high to low complexity, but none of them have been proven unequivocally superior to the others. Therefore, definitive consensus has not been reached yet. In the present multimedia manuscript, we report the most commonly adopted minimally invasive PA and we propose a "complexity classification" to guide the choice accordingly to different characteristics of the pancreatic stump. We describe five possible different PA that might be tailored to each different case, depending mainly on texture of pancreatic stump (soft/hard, lean/fatty) and the size and visibility of main duct. This manuscript presents a step-by-step portfolio of the most commonly used mini-invasive PA. This technique requires experience in pancreatic surgery and advanced minimally invasive skills. Knowledge of and proficiency in different types of PA could help reducing the incidence of postoperative pancreatic fistula.

Laparoscopic left nephrectomy with "en bloc" distal splenopancreatectomy.

BACKGROUND: Multiorgan resection for cancer is considered a demanding laparoscopic procedure. We report a laparoscopic radical nephrectomy and distal splenopancreatectomy for a locally advanced kidney tumor. METHODS: A 67-year-old woman presented with left flank pain and hematuria. CT scan showed a left kidney upper pole large mass with direct extension to spleen and pancreatic tail, but not metastases. With the patient on the right flank, three 10-mm trocars were placed forming an isosceles triangle in the left subcostal arch. Entering the lesser sac, splenic vessels were separately divided between clips. The pancreatic tail was dissected free and divided with Ultracision. The left renal vein was dissected free, and the aorta was exposed to perform the lymphadenectomy. Superior mesenteric artery and left renal vein and artery were isolated, and renal vessels were separately divided with a vascular stapler. The left kidney was mobilized. The specimen was inserted in a bag and retrieved transvaginally through a posterior colpotomy. RESULTS: Total operation time was 210 minutes. Estimated blood loss was 250 mL. The patient was discharged after 7 days. Final stage of disease was pT4N0M0 G2 R0 renal cell carcinoma. The patient came back 6 years later presenting a ductal adenocarcinoma of pancreatic head. At the second look laparoscopy, very few adhesions were found in right upper quadrant, and the posterior colpotomy scar was very small. The patient died 1 year after Whipple operation. CONCLUSIONS: Oncologic rules of an "en bloc" resection can be respected also with a laparoscopic approach.

Pharyngolaryngo-esophagectomy with laparoscopic gastric pull-up: a reappraisal for the pharyngoesophageal junction cancer.

BACKGROUND: Surgical treatment of advanced hypopharyngeal tumors is still a surgical challenge. We report a case of a hypopharyngeal tumor treated with a pharyngolaryngo-esophagectomy (PLE) and laparoscopic gastric tubulization and interposition. METHODS: A 56-year-old man presented with a relapsing hypopharynx carcinoma, after primary chemoradiation therapy. Preoperative workup showed a stage IV cancer with esophageal invasion and multiple cervical lymph node metastases. Surgical treatment consisted of a cervical phase, with larynx, pharynx, and esophagus dissection, radical lymph node dissection, homolateral hemithyroidectomy and definitive tracheostomy, and an abdominal phase with a 4-trocar laparoscopy. The gastrocolic ligament was opened, and short gastric and left gastric vessels were divided preserving an accessory left hepatic artery. Gastric tailoring was carried out with 45-mm linear staplers. The hiatus was opened and the esophagus dissected free with Ultracision (Ethicon Endo-Surgery, Cincinnati, OH) to the tracheal bifurcation. The upper esophagus was bluntly mobilized by finger and sponge stick dissection. The gastric tube was pulled up, and the anastomosis between the stomach and the tongue base was performed with a 2-layer interrupted hand-sewn technique. RESULTS: Total operative time was 390 min (abdominal time 180 min). Estimated blood loss was 400 cc. The number of dissected cervical lymph nodes was 32. Oral feeding was started after 10 days, and the patient was discharged after 14 days. Stage of disease was pT4N1M0 G3 R0. CONCLUSIONS: Laparoscopic surgery allows a minimally invasive gastric tailoring and tubulization and transhiatal esophageal dissection and represents a valuable alternative for intestinal reconstruction after PLE. CT scan showing a large hypopharynx carcinoma involving cervical lymph nodes and cervical esophagus.

Image-guided robotic radiosurgery (CyberKnife) for pancreatic insulinoma: is laparoscopy becoming old?

Insulinomas constitute about 25% of endocrine pancreatic tumors. Laparoscopic surgery is the treatment of choice. However, pancreas-related complications rate is very high, even in experienced hands, ranging up to 37%. Alternative procedures such as embolization with trisacryl have not been accepted by the surgical community. Image-guided robotic radiosurgery or stereotactic radiosurgery (CyberKnife) is a minimally invasive procedure delivering large doses of ionizing radiation to a well-defined target. CyberKnife radiosurgery is successfully used in brain cancer, lung cancer, prostate cancer, liver metastases, kidney cancer, and pancreatic cancer. The authors present the first case to their knowledge of a benign functioning insulinoma successfully treated by a CyberKnife technique with a 3-year follow-up.