Robotic assisted versus laparoscopic surgery for deep endometriosis: a meta-analysis of current evidence.

Endometriosis is a benign inflammatory onco-mimetic disease affecting 10-15% of women in the world. When it is refractory to medical treatments, surgery may be required. Usually, laparoscopy is the preferred approach, but robotic surgery has gained popularity in the last 15 years. This study aims to evaluate the safety and efficacy of robotic-assisted laparoscopic surgery (RAS) versus conventional laparoscopic surgery (LPS) in the treatment of endometriosis. This study adheres to PRISMA guidelines and is registered with PROSPERO. Studies reporting perioperative data comparing RAS and LPS surgery in patients with endometriosis querying PubMed, Google Scholar and ClinicalTrials.gov were included in the analysis. The Quality Assessment of Diagnostic Accuracy Studies 2 tool (QUADAS-2) was used for the quality assessment of the selected articles. Fourteen studies were identified, including 2709 patients with endometriosis stage I-IV for the meta-analysis. There were no significant differences between RAS and LPS in terms of intraoperative and postoperative complications, conversion rate and estimated blood loss. However, patients in the RAS group have a longer operative time (p < 0.0001) and longer hospital stay (p = 0.020) than those in the laparoscopic group. Robotic surgery is not inferior to laparoscopy in patients with endometriosis in terms of surgical outcomes; however, RAS requires longer operative times and longer hospital stay. The benefits of robotic surgery should be sought in the easiest potential integration of robotic platforms with new technologies. Prospective studies comparing laparoscopy to the new robotic systems are desirable for greater robustness of scientific evidence.

Artificial Intelligence and ChatGPT in Abdominopelvic Surgery: A Systematic Review of Applications and Impact.

BACKGROUND/AIM: The integration of AI and natural language processing technologies, such as ChatGPT, into surgical practice has shown promising potential in enhancing various aspects of abdominopelvic surgical procedures. This systematic review aims to comprehensively evaluate the current state of research on the applications and impact of artificial intelligence (AI) and ChatGPT in abdominopelvic surgery summarizing existing literature towards providing a comprehensive overview of the diverse applications, effectiveness, challenges, and future directions of these innovative technologies. MATERIALS AND METHODS: A systematic search of major electronic databases, including PubMed, Google Scholar, Cochrane Library, Web of Science, was conducted from October to November 2023, to identify relevant studies. Inclusion criteria encompassed studies that investigated the utilization of AI and ChatGPT in abdominopelvic surgical settings, including, but not limited to preoperative planning, intraoperative decision-making, postoperative care, and patient communication. RESULTS: Fourteen studies met the inclusion criteria and were included in this review. The majority of the studies were analysing ChatGPT's data output and decision making while two studies reported patient and general surgery resident perception of the tool applied to clinical practice. Most studies reported a high accuracy of ChatGPT in data output and decision-making process, however with an unforgettable number of errors. CONCLUSION: This systematic review contributes to the current understanding of the role of AI and ChatGPT in abdominopelvic surgery, providing insight into their applications and impact on clinical practice. The synthesis of available evidence will inform future research directions, clinical guidelines, and development of these technologies to optimize their potential benefits in enhancing surgical care within the abdominopelvic domain.

Exploring 6 years of colorectal cancer surgery in rural Italy: insights from 648 consecutive patients unveiling successes and challenges.

The multidisciplinary management of patients suffering from colorectal cancer (CRC) has significantly increased survival over the decades and surgery remains the only potentially curative option for it. However, despite the implementation of minimally invasive surgery and ERAS pathway, the overall morbidity and mortality remain quite high, especially in rural populations because of urban - rural disparities. The aim of the study is to analyze the characteristics and the surgical outcomes of a series of unselected CRC patients residing in two similar rural areas in Italy. A total of 648 consecutive patients of a median age of 73 years (IQR 64-81) was enrolled between 2017 and 2022 in a prospective database. Emergency admission (EA) was recorded in 221 patients (34.1%), and emergency surgery (ES) was required in 11.4% of the patients. Tumor resection and laparoscopic resection rates were 95.0% and 63.2%, respectively. The median length of stay was 8 days. The overall morbidity and mortality rates were 23.5% and 3.2%, respectively. EA was associated with increased median age (77.5 vs. 71 ys, p < 0.001), increased mean ASA Score (2.84 vs. 2.59; p = 0.002) and increased IV stage disease rate (25.3% vs. 11.5%, p < 0.001). EA was also associated with lower tumor resection rate (87.3% vs. 99.1%, p < 0.001), restorative resection rate (71.5 vs. 89.7%, p < 0.001), and laparoscopic resection rate (36.2 vs. 72.6%, p < 0.001). Increased mortality rates were associated with EA (7.2% vs. 1.2%, p < 0.001), ES (11.1% vs. 2.0%, p < 0.001) and age more than 80 years (5.8% vs. 1.9%, p < 0.001). In rural areas, high quality oncologic care can be delivered in CRC patients. However, the surgical outcomes are adversely affected by a still too high proportion of emergency presentation of elderly and frail patients that need additional intensive care supports beyond the surgical skill and alternative strategies for earlier detection of the disease.

Obesity paradox: is a high body mass index positively influencing survival outcomes in gynecological cancers? A systematic review and meta-analysis.

OBJECTIVE: Obesity represents an exponentially growing preventable disease leading to different health complications, particularly when associated with cancer. In recent years, however, an 'obesity paradox' has been hypothesized where obese individuals affected by cancer counterintuitively show better survival rates. The aim of this systematic review and meta-analysis is to assess whether the prognosis in gynecological malignancies is positively influenced by obesity. METHODS: This study adheres to PRISMA guidelines and is registered with PROSPERO. Studies reporting the impact of a body mass index (BMI) of >30 kg/m2 compared with <30 kg/m2 in patients with gynecological cancers listed in PubMed, Google Scholar and ClinicalTrials.gov were included in the analysis. The Quality Assessment of Diagnostic Accuracy Studies 2 tool (QUADAS-2) was used for quality assessment of the selected articles. RESULTS: Twenty-one studies were identified for the meta-analysis, including 14 108 patients with cervical, ovarian, or endometrial cancer. There was no benefit in 5-year overall survival for obese patients compared with non-obese patients (OR 1.2, 95% CI 1.00 to 1.44, p=0.05; I2=71%). When pooling for cancer sub-groups, there were no statistically significant differences in 5-year overall survival in patients with cervical cancer and 5-year overall survival and progression-free survival in patients with ovarian cancer. For obese women diagnosed with endometrial cancer, a significant decrease of 44% in 5-year overall survival (p=0.01) was found, with no significant difference in 5-year disease-free survival (p=0.78). CONCLUSION: According to the results of the present meta-analysis, a BMI of ≥30 kg/m2 does not have a positive prognostic effect on survival compared with a BMI of <30 kg/m2 in women diagnosed with gynecological cancers. The existence of the 'obesity paradox' in other fields, however, suggests the importance of further investigations with prospective studies.

Sclerotherapy with 3% polidocanol foam for the treatment of mucocutaneous bridges and/or residual piles after open excisional hemorrhoidectomy.

Injection sclerotherapy is an effective and safe treatment in selected cases. It might be used as the first treatment for I-III degree hemorrhoidal disease (HD), but also as a bridge therapy for more severe cases not amenable to invasive treatments. However, concerning the long-term recurrence rate, open excisional hemorrhoidectomy remains the gold standard in cases of III- and IV-degree HD. In this context, it is recommended to perform the excision of no more than three piles and to preserve the muco-cutaneous bridges to avoid post-operative anal stenosis. The aim of this study is to evaluate surgical outcomes and efficacy of the combined treatment of open excisional hemorrhoidectomy and the use of ST on the remnant muco-cutaneous bridges/residual piles. This was a single-center retrospective study and a total of 18 patients with IV-degree HD, aged between 18 and 75 years with symptomatic HD according to the Goligher classification, were enrolled between January 2023 and June 2023 and their follow-up continued until October 2023 after reaching 3 months of follow-up. The Hemorrhoidal Disease Symptom Score (HDSS), the Short Health Scale for HD (SHS-HD) score and the Vaizey Incontinence Score were used to assess symptoms and their impact on quality of life and continence. A total of 77.8% (14/18) of the patients were symptom-free (hemorrhoidal disease symptom score (HDSS) score = 0) after 3 months. Moreover, a statistically significant decrease in the median HDSS and short health scale for HD (SHS-HD) score was registered from 16 preoperatively (T0) to 2 at 3-month follow-up (T3). Neither post-operative bleeding nor any type of complications occurred. The use of sclerotherapy in combination with the traditional open excisional hemorrhoidectomy has shown promising results. Further structured studies are needed and greater dissemination and education of the general surgeon on the subject is necessary.

Ultrasound-guided robotic surgical procedures: a systematic review.

INTRODUCTION: Ultrasound has been nicknamed "the surgeon's stethoscope". The advantages of laparoscopic ultrasound beyond a substitute for the sense of touch are considerable, especially for robotic surgery. Being able to see through parenchyma and into vascular structures enables to avoid unnecessary dissection by providing a thorough assessment at every stage without the need for contrast media or ionising radiation. The limitations of restricted angulation and access within the abdominal cavity during laparoscopy can be overcome by robotic handling of miniaturised ultrasound probes and the use of various and specific frequencies will meet tissue- and organ-specific characteristics. The aim of this systematic review was to assess the reported applications of intraoperative ultrasound-guided robotic surgery and to outline future perspectives. METHODS: The study adhered to the PRISMA guidelines. PubMed, Google Scholar, ScienceDirect and ClinicalTrials.gov were searched up to October 2023. Manuscripts reporting data on ultrasound-guided robotic procedures were included in the qualitative analysis. RESULTS: 20 studies met the inclusion criteria. The majority (53%) were related to the field of general surgery during liver, pancreas, spleen, gallbladder/bile duct, vascular and rectal surgery. This was followed by other fields of oncological surgery (42%) including urology, lung surgery, and retroperitoneal lymphadenectomy for metastases. Among the studies, ten (53%) focused on locating tumoral lesions and defining resection margins, four (15%) were designed to test the feasibility of robotic ultrasound-guided surgery, while two (10.5%) aimed to compare robotic and laparoscopic ultrasound probes. Additionally two studies (10.5%) evaluated the robotic drop-in probe one (5%) assessed the hepatic tissue consistency and another one (5%) aimed to visualize the blood flow in the splenic artery. CONCLUSION: The advantages of robotic instrumentation, including ergonomics, dexterity, and precision of movements, are of relevance for robotic intraoperative ultrasound (RIOUS). The present systematic review demonstrates the virtue of RIOUS to support surgeons and potentially reduce minimally invasive procedure times.

Laparoscopic-Assisted Vaginal Trachelectomy with Prophylactic Cerclage: A Safe Fertility-Sparing Treatment for Early Stage Cervical Cancer.

BACKGROUND: In recent years fertility-sparing treatments are increasingly developing in patients with early stage cervical cancer.1,2 Among these, trachelectomy represents a milestone with a wide range of surgical approaches,3 evidence of oncological safety, and positive obstetric outcomes.4 PATIENTS AND METHODS: A 26-year-old patient underwent conization for CIN3 with a subsequent diagnosis of squamous cervical cancer stage FIGO IB1. After a negative laparoscopic bilateral pelvic nodes sampling and the radiologic evidence [positron emission tomography-computed tomography (PET-CT) and magnetic resonance imaging (MRI)] of a disease limited to the cervix, the patient was a candidate for trachelectomy according to her fertility-sparing desire. RESULTS: The first laparoscopic time is dedicated to the safe opening of the vesicouterine and rectovaginal spaces until the medial pararectal fossa. Ureters are found and bilateral ureterolysis performed under vision. Colpotomy is then vaginally achieved, and the cervix is closed in a vaginal cuff to avoid tumor spread. Careful dissection of the anterior and posterior septa is carried out until reunification with laparoscopic dissection. Bilateral parametrectomy is performed. Vaginal trachelectomy is finalized with a negative deep margin at the frozen section. In the second laparoscopic time a monofilament polypropylene sling cerclage is bilaterally positioned from posterior to anterior through the broad ligaments and fixed anteriorly on the uterine isthmus to prevent an eventual preterm delivery. CONCLUSION: Laparoscopic-assisted vaginal trachelectomy is a feasible procedure combining the conservative advantages of the vaginal approach and the oncological safety of laparoscopic spaces dissection with possible good obstetric outcomes.

Initial experience of robotically assisted endometriosis surgery with a novel robotic system: first case series in a tertiary care center.

Endometriosis is a benign disease requiring surgery if medical treatment can not achieve symptom control. Laparoscopy remains the gold standard and robotic assistance can be beneficial in complex cases. Robot-assisted radical endometriosis excision using the Hugo™ RAS system is a novel approach. The aim of this study is to describe its setting and outcomes in a series of patients in a robotic surgery center. Endometriosis patients who consecutively underwent robot-assisted surgery with the Hugo™ RAS system (Medtronic, USA) were retrospectively enrolled. Disease-specific symptoms before and after surgery, endometriosis stage, as well as perioperative and intraoperative variables including system setup were collected. Early post-operative complications (< 30 days) and follow-up (up to 3 months) were reported. All procedures were completed robotically. Port placement followed the "bridge" configuration with a "compact" docking. The median operative time was 186.5 min (IQR 174-220), the median estimated blood loss 50 ml (IQR 0-100). An intraoperative complication occurred in one patient (6.6%), a bladder laceration with postoperative antibiotic treatment. The median lenght of hospital stay (LOS) was 3 days (IQR 3-4). Surgery achieved a statistically significant decrease in symptoms: mean dysmenorrhea (9.50 ± 0.83 versus 1.7 ± 2.26; p = 0.001), dyschezia (4.27 ± 3.61 versus 2.40 ± 2.92; p = 0.026), dysuria (2.73 ± 3.39 versus 1.87 ± 2.41; p = 0.358), dyspareunia (6.53 ± 3.15 versus 2.93 ± 2.89; p = 0.002) and chronic pelvic pain (8.8 ± 1.20 versus 3.20 ± 2.39; p = 0.001). The integration of this platform in the described configuration was safe with regular perioperative outcomes and significant improvement in symptoms. Prospective comparative studies with a larger cohort and longer follow-up are needed to assess potential advantages over the current gold standard.

An international survey exploring the management of pilonidal disease.

AIM: Pilonidal disease (PD) is a common debilitating condition frequently seen in surgical practice. Several available treatments carry different benefit/risk balances. The aim of this study was to snapshot the current management of PD across European countries. METHOD: Members affiliated to the European Society of Coloproctology were invited to join the survey. An invitation was extended to others via social media. The predictive power of respondents' and hospitals' demographics on the change of therapeutic approach was explored. RESULTS: Respondents (n = 452) were mostly men (77%), aged 26-60 years, practising in both academic and public hospitals and with fair distribution between colorectal (51%) and general (48%) surgeons. A total of 331 (73%) respondents recommended surgery at first presentation of the disease. Up to 80% of them recommended antibiotic therapy and 95% did not use any classification of PD. A primary closure technique was the preferred procedure (29%), followed by open technique (22%), flap creation (7%), sinusectomy (7%) and marsupialization (7%). Approximately 27% of subjects would choose the same surgical technique even after a failure. Almost half (46%) perform surgery as office based. A conservative approach was negatively associated with acutely presenting PD (p < 0.001). Respondents who were not considering tailored surgery based on patient presentation tended to change their approach in the case of a failed procedure. CONCLUSION: With the caveat of a heterogeneous number of respondents across countries, the results of our snapshot survey may inform the development of future guidelines.