Standardization of robotic right liver mobilization.

BACKGROUND: Since its introduction 2 decades ago, robotics has been increasingly used for resection of benign and malignant liver lesions. The robotic platform seems to preserve minimally invasive approach benefits, overcoming laparoscopy limitations. Robotic right liver mobilisation represents a key step for many robotic resections from non-anatomical resections of posterosuperior segments to right hepatectomy. METHODS: We present here a standardized technique of right hepatic lobe mobilisation including technical steps and videos. Robotic resection provide all benefits of minimally invasive approaches in terms of preserving abdominal wall, early alimentation, reduced respiratory stress, associated with more ergonomic conditions for surgeon. RESULTS: We present our standardized and feasible right liver lobe mobilisation needed for posterosuperior resections to the right hepatectomy. CONCLUSIONS: The standardisation of right liver lobe represented our aim to provide a safe and reproducible initial step for many procedures to reduce the conversion rate and to improve the learning curve in young surgeons.

Robotic emergency liver resection of ruptured hepatocellular carcinoma.

BACKGROUND: The spontaneous rupture of hepatocellular carcinoma (HCC) is a rare complication. The management of this complication needs a stepwise, multidisciplinary approach which considers first of all clinical conditions of the patient and also the possibility of the best curative treatment. METHODS: We report our experience of an emergency robotic liver resection for a ruptured HCC in an elderly patient. Minimally invasive liver resection is currently recognised as a safe and feasible approach to the treatment of HCC in elderly patients. RESULTS: Our patient presented haemodynamic stability, which allows us to perform a robotic resection of segment 3. To our knowledge, this is the first report of the application of a robotic platform in an emergency setting for liver resection. CONCLUSIONS: Rupture of HCC is an uncommon complication, burdened by a high rate of mortality. Its management still remains controversial. Treatment should be individualised taking into consideration the clinical status of the patient, tumour features and possibility of centre therapeutic strategy.

Anastomotic Leak Rate and Prolonged Postoperative Paralytic Ileus in Patients Undergoing Laparoscopic Surgery for Colo-Rectal Cancer After Placement of No-Coil Endoanal Tube.

BACKGROUND: Colorectal cancer (CRC) is the second most common gastrointestinal tumor in men and the third in women. Left-hemicolectomy (LC) and low anterior resection (LAR) are considered the gold standard curative treatment. In this retrospective study, we evaluated the presence or absence of post-operative complications, in all patients who underwent Video-laparoscopic (VLS) LAR/LC with No Coil trans-anal tube positioning, and compared the data with the current literature on the topic. METHODS: Thirty-nine patients diagnosed with CRC of the descending colon, splenic flexure, sigma, and rectum were recruited. LC was performed for sigmoid and descending colon cancers, while LAR was applied for tumors of the upper two-thirds of the rectum. The No Coil trans-anal tube (SapiMed Spa, Alessandria, Italy) was placed in all patients of the study at the end of surgical treatment. RESULTS: Eighteen patients received a LAR-VLS (46%) and 21 patients received a LC-VLS (54%). The average length of hospital stay after surgery was 7 days. PPOI occurred in only one in 39 patients (2.6%) who had undergone LAR-VLS. As for complications, in no patient of the study did AL (0%) occur. CONCLUSION: In patients undergoing LAR-VLS and LC-VLS, we performed colorectal anastomosis and in the same surgical operation we introduced the No-Coil device. Although this is a preliminary study and subject to further investigation, we believe that the No Coil tube positioning may reduce the time of presence of first flatus and feces and the risk of AL.

Liver resection versus radiofrequency ablation in octogenarian patients for hepatocellular carcinoma: a propensity score multicenter analysis.

BACKGROUND: Liver resection (LR) and radiofrequency ablation (RFA) are considered curative options for hepatocellular carcinoma (HCC). The aim of this study was to compare outcomes after LR and RFA in octogenarian patients with HCC. MATERIALS AND METHODS: This multicenter retrospective study included 102 elderly patients (> 80 years old) treated between January 2009 and January 2019, who underwent LR or RFA for HCC (65 and 37 with, respectively). RESULTS: After Propensity Score Matching, the postoperative course of LR was burdened by a higher rate of complications than RFA group (64% vs 14%, respectively, p: 0.001). The LR group had also significantly longer operative time (207 ± 85 min vs 33 ± 49 min, p < 0.001) and postoperative hospital stays than the RFA group (7 d vs 2 d, p = 0.019). Overall survival at 1-, 2-, and 3-year were 86%, 86%, and 70% for the LR group and 82%, 64%, and 52% for the RFA group (p = 0.380). Disease-free survival at 1-, 2-, and 3-year were 89%, 74%, and 56% for the LR group, and 51%, 40%, and 40% for the RFA group (p = 0.037). CONCLUSION: Despite a higher rate of Dindo-Clavien I-II post-operative complications, a longer operative time and length of hospital stay, LR in octogenarian patients can provide comparable 90d mortality than RFA and better long-term outcomes.

Awake robotic liver surgery: A case report.

BACKGROUND: In recent years, minimally invasive liver resection has become a standard of care for liver tumors. Considering the need to treat increasingly fragile patients, general anesthesia is sometimes avoided due to respiratory complications. Therefore, surgical treatment with curative intent is abandoned in favor of a less invasive and less radical approach. Epidural anesthesia has been shown to reduce respiratory complications, especially in elderly patients with pre-existing lung disease. CASE SUMMARY: A 77-year-old man with hepatitis-C-virus-related chronic liver disease underwent robotic liver resection for hepatocellular carcinoma. The patient was suffering from hypertension, diabetes and chronic obstructive pulmonary disease. The National Surgical Quality Improvement Program score for developing pneumonia was 9.2%. We planned a combined spinal-epidural anesthesia with conscious sedation to avoid general anesthesia. No modification of the standard surgical technique was necessary. Hemodynamics were stable and bleeding was minimal. The postoperative course was uneventful. CONCLUSION: Robotic surgery in locoregional anesthesia with conscious sedation could be considered a safe and suitable approach in specialized centers and in selected patients.

Hyperthermic intraperitoneal chemotherapy and colorectal cancer: From physiology to surgery.

The pursuit of this paper is to collect principal reviews and systematic reviews about hyperthermic intraperitoneal chemotherapy (HIPEC) and cytoreductive surgery (CRS) used in colorectal cancer (CRC). We focus on principal biological aspects of CRC, hyperthermia effects, and surgical procedures. We searched PubMed/MEDLINE for the principal reviews and systematic reviews published from 2010 to 2021 regarding the bimodal treatment (CRS + HIPEC) against local and advanced CRC. In the literature, from several studies, it seems that the efficacy of bimodal treatment with an accurate CRS can extend overall survival. Despite these studies, there are not still any straight guidelines more detailed and scheduled about the use of combined treatment in patients with CRC. Even if the concept is still not very clear and shared, after a careful evaluation of the published data, and after some technical and pathophysiological descriptions, we concluded that it is possible to improve the overall survival and quality of life and to reduce the tumor relapse in patients affected by locally advanced (pT4) CRC with peritoneal metastases.

No Coil® placement in patients undergoing left hemicolectomy and low anterior resection for colorectal cancer.

BACKGROUND: Colorectal cancer (CRC) is the most common tumor of the gastrointestinal tract. Anastomotic leak (AL) and prolonged postoperative ileus (PPOI) are two important complications of colorectal surgery. In this observational retrospective study, we evaluated the positive effects of transanal tube No Coil® in patients with CRC undergoing low anterior resection (LAR) and left hemicolectomy (LC). METHODS: Thirty-eight cases and forty controls resulted eligible for the final sample. No Coil® placement (SapiMed Spa, Alessandria, Italy) was considered an inclusion criteria for the case group. No Coil® was placed immediately after the end of surgical treatment. RESULTS: PPOI was significantly more frequent in the control group. AL was evident in 1 patient (2.6%) of cases and 3 patients (7.5%) of controls. No statistical difference was found in AL occurrence between groups. POI days and AL resulted associated with hospital stay. POI days were negatively associated with No Coil placement and positively with AL. CONCLUSION: With our preliminary data, we suggest that No Coil® placement can be considered as a valuable procedure assisting colorectal surgery, but further studies are required to confirm and enlarge actual evidence.

The feasibility of extubation in the operating room after bilateral lung transplantation in adult emphysema patients: an observational retrospective study.

OBJECTIVES: We introduced an extubation strategy for emphysema patients after bilateral lung transplantation. Patients who met the extubation criteria were extubated in the operating room (OR) followed by non-invasive ventilation, and the other patients were extubated in the intensive care unit (ICU). The primary objective was to determine the extubation rate. The secondary outcomes were to determine the factors allowing for extubation in the OR and the postoperative course. METHODS: This study is a single-centre retrospective database analysis of 96 patients. Anaesthesia was performed using automated titration of total intravenous anaesthesia combined with thoracic epidural analgesia. Extubation criteria included arterial partial pressure oxygen (PaO2)/fraction of inspired oxygen (FiO2) ratio, chest radiograph, oedema and haemodynamic stability. Data were compared using non-parametric tests and expressed as median (interquartile ranges) or number (%). RESULTS: Fifty-three (55%) patients were extubated in the OR (the OR group) with 1 requiring reintubation and 43 (45%) patients were extubated in the ICU (the ICU group). Preoperative pulmonary hypertension, the requirement for intraoperative extracorporeal membrane oxygenation (ECMO), bleeding and ex vivo lung reconditioning donors were lower in the OR group. At the end of the procedure, the PaO2/FiO2 ratio was better [352 (289-437) vs 206 (144-357), P = 0.004), and the need for postoperative ECMO, mechanical ventilation duration, length of stay in the ICU [5 (4-7) vs 12 (8-20) days, P < 0.0001], Grade 3 primary graft dysfunction at 72 h [1 (2%) vs 10 (24%), P = 0.002] and 1-year mortality [5 (9%) vs 11 (26%) patients, P = 0.014] were lower in the OR group than in the ICU group. CONCLUSIONS: Half of patients were extubated in the OR, and this strategy does not require additional ICU resources.