Soft Tissue Robotic Assisted Orbital Surgery Using da Vinci SP: A Cadaveric Experience.

PURPOSE: Robotic surgical techniques have transformed many surgical specialties however robotic techniques and applications have been much more limited in ophthalmology. This study aims to evaluate the feasibility of robotic assisted orbital surgery using a single-port novel robotic platform, the da Vinci SP. METHODS: A series of orbital procedures were performed in cadaveric specimens utilizing the da Vinci SP robotic system. The procedures performed included lacrimal gland dissection and biopsy, medial and lateral orbital wall dissections, enucleation, and lid-sparing orbital exenteration. Successful completion of each procedure was defined by the operating surgeon and was considered the primary outcome and marker of feasibility. RESULTS: Seven cadaveric procedures were performed in 3 cadaveric specimens. All 7 procedures were completed successfully without complication. Setup optimization occurred throughout the study and setup and operative times were acceptable. Three instrument arms and 1 endoscope were utilized throughout the study allowing 3 arm operating and dynamic retraction. Instrument size was found to limit surgical access and precision particular at the orbital apex. CONCLUSIONS: This preclinical study demonstrates that the da Vinci SP can be utilized within the orbit and is feasible for several applications. Robotic surgical systems offer significant advantages over conventional techniques and should be embraced. However, current commercially available robotic platforms are not optimized for the orbit and have their limitations although they may be suitable for some clinical applications.

New Approaches for Robot-Assisted Neck Surgery: Clavicular and Submental Approaches Using the da Vinci SP System.

BACKGROUND: Minimally invasive robot-assisted thyroid surgery or neck dissection can improve cosmetic results and reduce surgical trauma. Several approaches have been described but each has both advantages and limitations. We aimed to determine the feasibility of performing robot-assisted neck surgery using the da Vinci SP system. METHODS: The clavicular approach using the da Vinci SP system was done in 1 cadaveric model. Lateral neck dissection was carried out with parapharyngeal space dissection, lateral thyroid gland exposure, and anatomical references. The submental approach was performed in the same cadaveric model. Total thyroidectomy plus lateral neck dissection was performed. RESULTS: The required 2.5-cm skin incision, minimal flap development to insert the SP Access Port plus docking was done in 5 minutes for each procedure. The neck dissection by clavicular access took 77 minutes, the parapharyngeal dissection 60 minutes, and hemi-thyroidectomy 30 minutes. The neck dissection by submental access took 60 minutes and the total thyroidectomy took 45 minutes. CONCLUSION: We have demonstrated the feasibility of single-incision clavicular and submental approaches in neck surgery using the da Vinci SP system. The amount of skin flap dissection was minimal, the system docking was rapid, and no additional ports or retractors were required. Further studies on patients are warranted.

Hybrid Laparoscopic Versus Open Pancreatoduodenectomy. A Meta-Analysis.

INTRODUCTION: Hybrid laparoscopic techniques have been proposed as a good transition from open to complete minimally invasive approach especially in complex surgical procedures. This meta-analysis aimed to compare the outcomes of hybrid laparoscopic pancreatoduodenectomy versus open pancreatoduodenectomy. METHODS: A systematic literature research was performed according to PRISMA guidelines. A broad search strategy with terms "laparoscopy" and "pancreatoduodenectomy" was used. Included studies were analyzed by quantitative meta-analysis using the metafor package for R software. RESULTS: Of 655 identified articles, 627 were excluded and 28 articles fully assessed, including 14 comparative studies, 8 case series and 6 case reports. Extracted data included intraoperative variables and postoperative outcome parameters. The predefined inclusion criteria were met by 14 comparative studies, and 371 patients were pooled in the meta-analysis. Hybrid laparoscopic pacreatoduodenectomy was associated with significantly longer operative time (I2 0%, p = 0,01, Mean HPD 494,6 min, Mean OPD 421,6 min, WMD 67 min, 95% CI 14-120 min). For all other postoperative outcome parameters, no statistically significant differences were found. A nonsignificant reduction in intraoperative transfusion rate (I2 20%, p = 0,2, proportion HPD 2%, proportion OPD 1,6%, OR 0,44, 95% CI 0,16-1,27) and blood loss (I2 95%, p = 0,1, Mean HPD 397,2 ml, Mean OPD 1017,8 ml, MD - 601 ml, 95% CI - 1311-108) was observed for hybrid pancreatoduodenectomy in comparison to open surgery. CONCLUSIONS: This meta-analysis demonstrates significantly increased operation time for hybrid laparoscopic compared to open pancreatoduodenectomy. Intraoperative variables as well as postoperative parameters and major morbidity were comparable for both techniques. Overall results of this meta-analysis demonstrated the hybrid technique as a safe procedure in high-volume centers offering aspects of a safe transition to fully laparoscopic pancreatoduodenectomy.

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.

Feasibility of bilateral internal thoracic artery harvesting using the da Vinci SP system.

PURPOSE: We conducted this study to investigate the feasibility of mobilizing the bilateral internal thoracic arteries (ITAs) using the da Vinci SP through a single intercostal incision and to compare the amount of rib spreading with that required for mini-thoracotomy procedures. We also evaluated the construction of an intrathoracic T-graft anastomosis using existing instrumentation of the SP system. METHODS: We harvested bilateral ITAs from two male cadavers via a single incision made in the fifth intercostal space using the da Vinci SP. A T-graft end-to-side anastomosis was created in one cadaver. RESULTS: The bilateral ITAs were harvested in less than 60 min and a T-graft was completed. No additional rib spreading was required. Intraoperative adjustments of the da Vinci SP were necessary to maintain alignment with the surgical targets. CONCLUSIONS: Bilateral ITA harvest using the da Vinci SP through a single intercostal incision was feasible, with less rib spreading than in mini-thoracotomy procedures. Thus, creating an intrathoracic T-graft with the existing da Vinci SP instruments is possible.

Da Vinci Single-Port robot-assisted transanal mesorectal excision: a promising preclinical experience.

INTRODUCTION: Robotic single-port platforms represent a viable option for advanced surgical procedures. This preclinical study investigated the dual-field, single-port, robot-assisted transanal total mesorectal excision (taTME). TECHNIQUE: In a male human cadaver, we employed the novel da Vinci® SP™ Surgical System, sequentially, to realize the transanal and abdominal parts of the taTME procedure. We evaluated the feasibility of the one-team approach. RESULTS: We showed that single-port access for the taTME was technically feasible with the current da Vinci® SP™ Surgical System in both surgical fields. The total console times were 189 min for the juxta-anal purse-string suture placement, partial intersphincteric resection, and bottom-up mesorectal dissection to where it meets the peritoneal reflection and 43 min for the abdominal procedure. A good quality specimen was achieved. The surgeon comfort was high during simulated surgery. The task load was highly acceptable (NASA-TLX global score: 35), even though it was the surgeon's first use of this platform. CONCLUSION: This preclinical study demonstrated that the robotic, single-port taTME was feasible and could be performed with the da Vinci® SP™ Surgical System, beginning at the level of the dentate line. Further simulations are necessary to confirm this promising approach.

Robot-assisted cervical esophagectomy: first clinical experiences and review of the literature.

Pulmonary complications, and especially pneumonia, remain one of the most common complications after esophagectomy for esophageal cancer. These complications are reduced by minimally invasive techniques or by avoiding thoracic access through a transhiatal approach. However, a transhiatal approach does not allow for a full mediastinal lymphadenectomy. A transcervical mediastinal esophagectomy avoids thoracic access, which may contribute to a decrease in pulmonary complications after esophagectomy. In addition, this technique allows for a full mediastinal lymphadenectomy. A number of pioneering studies have been published on this topic. Here, the initial experience is presented as well as a review of the current literature concerning transcervical esophagectomy, with a focus on the robot-assisted cervical esophagectomy procedure.

Transhepatic forceps biopsy after PTCD for histological assessment of bile duct stenoses or occlusions.

PURPOSE: The goal of this study was to evaluate the experience of 11 years of wire-guided forceps biopsy via PTCD in patients with obstructive jaundice. MATERIALS AND METHODS: In a retrospective approach, 56 biopsies in 51 patients were analyzed (22 female, 29 male). Data was collected from 2006 to 2016. Mean age was 71 years (range: 34 - 86 years). Data was extracted from dig. Patients' records (KIS, PACS, RIS) to be analyzed in Microsoft Excel. RESULTS: All 56 procedures were technically successful. Stenosis in anastomoses were benign due to scarring in 7 patients and in 9 due to papillitis or others. In 4 patients, results in anastomosis were malignant. In 19 patients without anastomosis, CCC was the diagnosis, thereof 10 klatskin, 9 stenosis in other locations, followed by gastric, pancreatic, and colon carcinoma in 5, 3, and 2 patients. Three patients had a CUP (multimetering in case of more than 1 related category). Overall results were 35 mal. and 16 benign, 76.8 % of all proc. had a correct histopathologic result, and 23.2 % were false negative. Sensitivity was 65.8 %, which results in negative predictive value of 58.1 %. There was no false positive and so specificity was 100 %, as was the positive predictive value. False negative results (no malignancy but clinically and imaging suspect) were corrected by rerunning the procedure, by CT-guided biopsy or by 1 PET-CT. In 1 case the surg. sample brought the result. Minor complications occurred in 8 patients: shivering in 1 case, distinct but hemodynamically not relevant hemobilia in 5 cases, 2 portovenal bleedings. All bleedings were short-term and self-limiting. CONCLUSION: Despite good feasibility, low peri- and post-interv. risk and high validity the forceps biopsy via PTCD is not widely used. For experienced interventionalists, it is an effective method for obtaining histology.

Predictors of Outcome in Modern Surgery for Lung Abscess.

Background Surgery for lung abscess is a challenging task. Timing and indications for surgery are not well established. Identification of predictors of outcome could help to clarify the role of surgery. Methods Patients who underwent major thoracic surgery for infectious lung abscess were identified at six centers for general thoracic surgery in Germany, Spain, the United Kingdom, and the United States. Study period was 2000 to 2016. Results There were 91 patients. Pulmonary sepsis (48), pleural empyema (43), persistent air leakage (25), acute renal failure (12), and respiratory failure with mechanical ventilation (25) were already preoperatively present. The mean Charlson index of comorbidity was 3.0 (median: 2.0; interquartile range: 3). Procedures were segmentectomy (18), lobectomy (58), and pneumonectomy (15). The 30-day mortality following surgery was 13/91.Preoperative sepsis (odds ratio [OR]: 13.69; 95% confidence interval [CI]: 1.86-610.53; p < 0.01), preoperative persistent air leak (OR: 13.46, 95% CI: 3.00-85.37, p < 0.01), respiratory failure (OR: 5.60; 95% CI: 1.41-24.84; p < 0.01), acute renal failure (OR: 6.15 ; 95% CI: 1.24-29.56 ; p = 0.01), and Charlson index of comorbidity ≥ 3 (OR: 7.19 ; 95% CI: 1.43-71.21 ; p < 0.01) are associated with higher mortality, whereas age > 70 years (p = 0.46) and the extent of pulmonary resection (segmentectomy, lobectomy, pneumonectomy) have no significant influence on mortality. Patients with fatal outcome have significantly higher Charlson index of comorbidity (p < 0.01). Conclusions Delayed referral for surgery is common. Significant predictors for fatal outcome are pulmonary sepsis, septic complications (air leak, pleural empyema), septic organ failure (respiratory, acute renal failure), and preexisting comorbidity (Charlson index of comorbidity ≥ 3). The extent of surgical resection shows no significant influence.

Surgery for parapneumonic pleural empyema--What influence does the rising prevalence of multimorbidity and advanced age has on the current outcome?

OBJECTIVE: Pleural empyema is a critical condition. In the western world the share of sufferers with multiple comorbidities and advanced age is rapidly increasing. METHODS: This retrospective study comprises all patients who underwent surgery for parapneumonic pleural empyema at a major center for thoracic surgery in Germany between January 2006 and April 2013. RESULTS: A total of 335 patients (mean age 60.4 years) were included. The average ASA grade was 2.8. Empyema stage 1, 2 and 3 (classification of the American Thoracic Society) was encountered in 30, 230 and 75 cases, respectively. The most common comorbidities were cardiac disorders (124), diabetes mellitus (76), COPD (66) and alcoholism (54). The mean Charlson index of comorbidity score was 2. Minimally invasive surgery was feasible in 290 cases. A total of 88 patients sustained pulmonary sepsis. The overall mortality was 29/335 (8.7%). The occurrence of pulmonary sepsis (OR: 17.95; 95% CI: 6.38-62.69; p < 0.001), respiratory failure (OR: 23.08; 95% CI: 8.52-73.35; p < 0.001) and acute renal failure (OR: 8.20; 95% CI: 3.18-20.80; p < 0.001) and Charlson score ≥ 3 (OR: 6.65; 95% CI: 2.76-17.33; p < 0.001) were associated with higher mortality. On the other hand, very elderly sufferers (≥80 years) showed neither higher odds for pulmonary sepsis (OR: 0.78) nor for fatal outcome (OR: 0.92; 95% CI: 0.22-2.86; p = 1). CONCLUSIONS: Parapneumonic pleural empyema is still associated with considerable morbidity and mortality. Pre-existing comorbidity, the occurrence of pulmonary sepsis and sepsis related complications have a determining influence on the results whereas advanced age itself shows no higher risk for adverse outcome. Further improvement seems achievable by earlier surgical intervention before the onset of pulmonary sepsis.

Prevalence and topography of lymph node metastases in early esophageal and gastric cancer.

OBJECTIVE: To determine the prevalence and localization of lymph node metastases in patients with pT1 carcinoma of the esophagus, esophagogastric junction, and stomach. BACKGROUND: Retrospective analysis and topographic description. METHODS: We included 793 consecutive patients with pT1 carcinomas who underwent primary surgery for squamous cell carcinoma (SCC) of the esophagus, adenocarcinomas of the esophagogastric junction (AEG), or gastric cancer (GC). Clinical records and pathology reports were reviewed, and the prevalence and topography of lymph node metastases were identified. RESULTS: The prevalence of lymph node metastases in SCC, AEG, and GC was 7%, 0%, and 5% for pT1a tumors and 24%, 18%, and 14% for pT1b tumors, respectively. Positive lymph node status was associated with worse overall survival (P<0.001). Not only infiltration of the submucosa (P=0.002) but also lymphatic vessel invasion (P<0.001), multifocal tumor growth (P=0.001), lower patient age (P=0.001), and poor tumor differentiation (P=0.05) were associated with nodal disease. These 5 parameters allowed the compilation of a nomogram to estimate the individual risk of lymph node metastases. In SCC, lymph node metastases were found from the neck to the celiac axis. In AEG, nodal disease was limited to the lower mediastinum and the D1 compartment. In GC, lymphatic spread exceeded the D1 compartment in 7% of node positive patients. CONCLUSIONS: Risk estimation for lymph node metastases should not be based on depth of tumor infiltration alone but additional clinicopathological parameters should also be considered. The extent of lymphadenectomy in surgical procedures should respect the presented topography of lymph node metastases.

Subcostal bilateral internal thoracic artery harvesting with the da Vinci Single Port system: an experimental feasibility study.

We evaluated the feasibility of harvesting bilateral internal thoracic arteries with the da Vinci Single Port system (SP) through a single left-sided subcostal incision. Complete bilateral mobilization with sufficiently long conduits for multivessel grafting was possible in 2 human cadavers and 2 live porcine. Creating the subcostal access and docking the SP system took between 14 and 21 min and the total harvest time ranged from 65 to 125 min in all models. No major bleeding was observed in the live porcine and hemostasis was managed with the available instrumentation. One porcine deceased during surgery due to ventricular fibrillation followed by cardiac arrest. The robotic harvesting was technically easily reproduced by the surgeons and required no additional rib-spreading. Further studies will be required to assess if this subcostal approach with the da Vinci SP system yields true clinical benefits in patients.

Surgical therapy for necrotizing pneumonia and lung gangrene.

OBJECTIVE: Necrotizing pneumonia, pulmonary abscess, and lung gangrene are rare complications of severe pulmonary infection with devitalization and sloughing of lung tissue. Pulmonary necrosis is often associated with alcoholism and other chronic disorders with known immunodeficiency. Mortality is significant and both treatment strategies as well as the role of surgery are controversially debated. METHODS: In a retrospective review at a German tertiary referral hospital, 20 patients with pulmonary resection for necrotizing lung disorders were identified since 2008. At hospital admission, all patients suffered from pulmonary sepsis and despite adequate medical treatment progressing parenchymal destruction and devitalization took place. The majority of the patients sustained pleural empyema (13/20) and five patients a persisting air leak. On account of failing medical therapy, eight patients (40%) developed severe sepsis with septic shock and four patients (20%) were already preoperatively ventilated. Chronic alcoholism was present in 10 patients (50%). RESULTS: Gangrene of a complete lung was seen in four cases. Lobar gangrene or necrotizing pneumonia complicated by fulminate abscess was seen in the right lower lobe (8/20), middle lobe (4/20), right upper lobe (2/20), and left lower lobe (2/20). Procedures included pneumectomy (4/20), lobectomy (13/20), and limited resection (3/20). The bronchial stump was reinforced with a pedicle muscle flap in seven cases. There were three postoperative deaths due to septic shock with multiorgan failure. The remaining 17 patients (85%) recovered well and were transferred to rehabilitation clinics specialized on pulmonary disorders. CONCLUSION: Necrotizing pulmonary infections are infrequent but are life-threatening disease entities. Patients often present with severe comorbidity and chronic disorders causing immunodeficiency. If initial medical therapy fails surgery offers a reasonable therapeutic approach. Aim of surgical therapy is resection of all gangrenous lung parenchyma and effective drainage of pleural empyema. Then recovery is feasible in up to 80%.

Pancreaticopleural fistula-induced empyema thoracis: principles and results of surgical management.

OBJECTIVE: Pancreaticopleural fistula is a very uncommon complication of pancreatitis resulting from pancreatic duct disruption with leakage of pancreatic secretions into the pleural cavity. Fistulization occurs either through the esophageal hiatus or straight through the diaphragm. Pleural effusion with dyspnea is the main presenting symptom, and delayed diagnosis is frequent. Initial conservative treatment fails in a significant number of cases. Ascending infection via the fistulous tract results in empyema and life-threatening sepsis. METHODS: All patients who underwent surgery for pancreaticopleural fistula-induced empyema thoracis at a tertiary referral hospital from 2008 to 2011 were included in a retrospective case study. RESULTS: Altogether six patients with pancreaticopleural fistula and associated pleural empyema were identified. All patients suffered from pancreatitis and received initial medical and endoscopic treatment. Despite all nonsurgical treatment efforts, superinfection led to left-sided pleural empyema in four and bilateral empyema in two cases. The contagious spread took place through the fistulous tract connecting the pancreatic duct with the pleural cavity. The patients were referred for surgery with considerable delay and already advanced pleural empyema. Minimally invasive thoracic surgery with pleural debridement was performed in all cases. Furthermore, left pancreatic resection was mandatory in five cases and cystostomy in one case. All patients recovered well and upon follow-up there were no further complications. CONCLUSION: Surgical management combining minimally invasive thoracic surgery and removal of the fistulous tract is highly effective. If initial medical treatment fails, surgery should be considered early to prevent severe sepsis. Further improvement seems achievable by reducing the time between fruitless conservative efforts and surgical intervention.

Remote-access thyroidectomy with the da Vinci SP system: feasibility in a cadaveric model.

Background: This study aims to study the feasibility of a remote-access thyroidectomy through presternal and submental approaches with the da Vinci SP system. Methods: Bilateral thyroidectomies were performed in five cadaveric models. A single incision in the presternal area was used in two cadavers, and a submental facelift incision approach was used in three cadavers. Results: Performing remote-access thyroidectomy was completed with a presternal approach in one cadaver and with the submental approach in three cadavers. The required skin flap development was minimal, and the docking time for the SP system was quick for all procedures. Time to full exposure of the thyroid gland after skin incision was less than 30 min for the presternal approach and less than 27 min for the submental procedure. Completing total thyroidectomies took 83 min in the presternal approach and between 67 and 127 min in the submental access. No additional ports were required to expose the gland and complete the bilateral resection. Conclusions: Total thyroidectomy was feasible with the da Vinci SP system in single incision presternal and submental approaches comparing promisingly with other currently applied robotic methods. Further studies will be required to assess whether a presternal or submental thyroidectomy with the da Vinci SP system provides clinical benefits in real patients.

Retroperitoneal robot-assisted laparoscopic nephroureterectomy using the da Vinci Xi and SP systems: Initial experiences in cadaveric models.

PURPOSE: To investigate the feasibility and optimal port placements of robot-assisted laparoscopic nephroureterectomy (RANU) via the retroperitoneal approach in the lateral decubitus and supine positions using the da Vinci Xi (DVXi) and da Vinci SP (DVSP) systems. MATERIALS AND METHODS: We performed lateral decubitus extraperitoneal RANU on the right side and supine extraperitoneal RANU on the left side using the DVXi and DVSP systems without repositioning in two fresh cadavers. In addition, paracaval and pelvic lymphadenectomies were performed simultaneously during both surgical procedures. The operative time of each procedure was calculated, and the technical details associated with these procedures were evaluated. RESULTS: Lateral decubitus and supine extraperitoneal RANU using the DVXi and DVSP systems were achieved without repositioning. The surgeon console time ranged from 89 to 178 minutes, and no major technical complications were observed. However, carbon dioxide insufflation into the abdominal cavity was observed owing to a peritoneal breach during the creation of the surgical workspace, particularly in the supine position. Compared with the DVXi system, the DVSP system was more suitable for RANU using the retroperitoneal approach, except for renal handling. CONCLUSIONS: The DVXi and DVSP systems are feasible for performing lateral decubitus and supine extraperitoneal RANU without patient repositioning. The lateral decubitus position may be better than the supine position, and the DVSP system is more suitable for retroperitoneal RANU than the DVXi system. Nevertheless, further studies should be performed in clinical settings to validate our results.

A Preclinical Feasibility Study of Single-Port Robotic Subcostal Anatomical Lung Resection and Subxiphoid Thymectomy Using the da Vinci® SP System.

Despite the recent introduction of technologically advanced single-port (SP) robotic systems, their use in the field of thoracic surgery has been rarely explored. Here, we report our preclinical experience concerning SP robotic thoracic surgery using the da Vinci® SP system. The da Vinci® SP system was used to perform subcostal anatomical lung resection and subxiphoid thymectomy in three cadavers. The operative settings that best met the surgeon's requirements for each resection were also determined. Four subcostal anatomical lung resections and two subxiphoid thymectomies were completed. While both procedures did not require additional incisions, the use of an observation port in the intercostal spaces was strongly recommended to safely create subcostal access. Dissection of hilar structures and mediastinal lymph nodes was feasible. However, due to the current unavailability of a robotic stapler, a handheld stapling instrument was required to perform a transection of vital structures. When the stapling process proved to be difficult, the table surgeon temporarily removed a robotic arm to acquire the necessary space to complete the procedure. Our data represent a promising preclinical step in understanding the feasibility of using the da Vinci® SP system to perform an SP subcostal anatomical lung resection and a subxiphoid thymectomy.

Video-assisted thoracoscopic surgery for posttraumatic hemothorax in the very elderly.

OBJECTIVE: Thoracic injury is a life-threatening condition with advanced age being an independent risk factor for both higher morbidity and mortality. Furthermore, elderly patients often have severe comorbidity and in case of chest trauma with rib fractures and hemothorax, their clinical condition is likely to deteriorate fast. Aim of this study is to investigate the feasibility and results of video-assisted thoracoscopy for the treatment of posttraumatic hemothorax in very elderly patients of 80 years or more. METHODS: The outcomes of 60 consecutive patients who received video-assisted thoracoscopic surgery for posttraumatic hemothorax in a German tertiary referral hospital between 2006 and 2010 were reviewed in a retrospective case study. Patients older than 80 years were identified. RESULTS: There were 39 male and 21 female patients. The median age was 63.2 years. The in-hospital-mortality was 1.7% (1/60). Fifteen of the 60 patients were 80 years or older (80-91). Main reason for hemothorax was blunt chest trauma. Altogether 23 patients had fractures of three or more ribs including six octogenarians. Elderly patients suffered from preexisting cardiopulmonary disease and were often referred to the thoracic surgeon with considerable delay. Video-assisted thoracoscopic surgery was feasible and all octogenarian patients finally recovered well without in-hospital-mortality. CONCLUSIONS: Video-assisted thoracoscopic surgery for treatment of posttraumatic hemothorax shows excellent results in very elderly patients of 80 years or more. Despite severe comorbidity and often delayed surgery all patients recovered. We therefore conclude that advanced age is no contraindication for surgical management of posttraumatic hemothorax by means of video-assisted thoracoscopy.

Management of ERCP-related small bowel perforations: the pivotal role of physical investigation.

BACKGROUND: Management of endoscopic retrograde cholangiopancreatography (ERCP)-associated duodenal perforation remains controversial. Some recommend surgery, while others recommend conservative treatment. METHODS: A retrospective chart review was conducted to identify patients treated at our institution for ERCP-related duodenal perforations. Study variables included indication for ERCP, clinical presentation, diagnostic procedures, time to diagnosis and treatment, location of injury, management, length of stay in hospital and survival. RESULTS: Between January 2000 and October 2009, 12 232 ERCP procedures were performed at our centre, and perforation occured in 11 patients (0.08%; 5 men, 6 women, mean age 71 yr). Six of the perforations were discovered during ERCP; 5 required radiologic imaging for diagnosis. Three perforations were diagnosed incidentally by follow-up ERCP. In 1 patient, perforation occurred 3 years after the procedure owing to a dislocated stent. Four of 11 perforations were stent-related; in 2 patients ERCP was performed in a nonanatomic situation (Billroth II gastroenterostomy). Free peritoneal perforation occurred in 4 patients; 1 was successfully managed conservatively. Four patients (36%) were treated surgically and none died. Five patients were managed conservatively with a successful outcome, and 2 patients died after conservative treatment (18%). Operative treatment included hepaticojejunostomy and duodenostomy (1 patient), suture of the perforation with T-drain (1 patient) and suture only (2 patients). The mean length of stay in hospital for all patients was 20 days. CONCLUSION: Post-ERCP duodenal perforations are associated with significant morbidity and mortality. Immediate surgical evaluation and close monitoring is needed. Management should be individually tailored based on clinical findings only.

Intraoperative conversion and complications in robotic assisted primary and redo gastric bypass surgery.

The rise of robotic assisted surgery in the treatment of morbidly obese patients has enlarged the armamentarium for surgeons involved in bariatric surgery. This in particular is of great advantage not only in primary cases, but also in patients undergoing revisional procedures following preceding upper GI surgery. In the following, our experience with intraoperative conversions and complications in revisional robotic surgery using the Da Vinci robotic system will be reported and compared to primary robotic bypass surgery and the literature. In a 36-month period, a total of 157 minimally invasive bariatric procedures (48 robotic assisted, 109 laparoscopic) were performed. Out of 43 patients receiving a gastric bypass 32 (74%) were performed robotically. Out of these 20 (62.5%) had previous operations (RRBP): one hiatal mesh repair, one open Mason operation, eight gastric band, nine gastric sleeve, one sleeve with fundoplication. The Da Vinci Xi was used for all surgeries. 3/20 (15%) RRBP were converted to open laparotomy because of a huge left liver lobe (1), extreme adhesions (1) and short mesentery (1) (p = 0.631 vs 1/12 RBP). One out of these had to be reoperated for an insufficiency of the gastroenterostomy. 3/17 (23%) patients (RRBP) without conversion had complications: hemorrhage (1), insufficiency of biliodigestive anastomosis (1), insufficiency of gastroenterostomy (1). There was no mortality and length of hospital stay was 3.5 days in uncomplicated cases and 12.3 days in complicated cases (p < 0.05). This preliminary experience suggests, that robotic revisional surgery can be performed safely even in complicated cases. Conversion to laparoscopic or open surgery may be required when adverse anatomical conditions are present. However, the incidence of complications was not increased when conversion was performed. In this series, the incidence of complications was not greater in case of revisional surgery.