SAGES/AHPBA guidelines for the use of microwave and radiofrequency liver ablation for the surgical treatment of hepatocellular carcinoma or colorectal liver metastases less than 5 cm.

BACKGROUND: Primary hepatocellular carcinoma (HCC) and colorectal liver metastases (CRLM) represent the liver's two most common malignant neoplasms. Liver-directed therapies such as ablation have become part of multidisciplinary therapies despite a paucity of data. Therefore, an expert panel was convened to develop evidence-based recommendations regarding the use of microwave ablation (MWA) and radiofrequency ablation (RFA) for HCC or CRLM less than 5 cm in diameter in patients ineligible for other therapies. METHODS: A systematic review was conducted for six key questions (KQ) regarding MWA or RFA for solitary liver tumors in patients deemed poor candidates for first-line therapy. Subject experts used the GRADE methodology to formulate evidence-based recommendations and future research recommendations. RESULTS: The panel addressed six KQs pertaining to MWA vs. RFA outcomes and laparoscopic vs. percutaneous MWA. The available evidence was poor quality and individual studies included both HCC and CRLM. Therefore, the six KQs were condensed into two, recognizing that these were two disparate tumor groups and this grouping was somewhat arbitrary. With this significant limitation, the panel suggested that in appropriately selected patients, either MWA or RFA can be safe and feasible. However, this recommendation must be implemented cautiously when simultaneously considering patients with two disparate tumor biologies. The limited data suggested that laparoscopic MWA of anatomically more difficult tumors has a compensatory higher morbidity profile compared to percutaneous MWA, while achieving similar overall 1-year survival. Thus, either approach can be appropriate depending on patient-specific factors (very low certainty of evidence). CONCLUSION: Given the weak evidence, these guidelines provide modest guidance regarding liver ablative therapies for HCC and CRLM. Liver ablation is just one component of a multimodal approach and its use is currently limited to a highly selected population. The quality of the existing data is very low and therefore limits the strength of the guidelines.

Castleman's disease: a rare presentation in a retroperitoneal accessory spleen, treated with a minimally invasive robotic approach.

Unicentric Castleman's disease (UCD) is a rare disorder of unknown etiology characterized by localized lymphoid tissue proliferation and interfollicular hypervascularity. A 33-year-old Caucasian female presented with vague abdominal discomfort and pain with pressure. Ultrasound and computed tomography detected a large peripancreatic mass. Robotic-assisted resection of the mass along with en bloc dissection of the encased left adrenal gland was done. Frozen section examination confirmed UCD hyaline vascular variant in a retroperitoneal accessory spleen. Preoperative diagnosis of UCD is difficult due to its lack of specific symptoms and its cytologic similarity to reactive lymphadenopathy and other lymphoproliferative disorders. Surgical resection is standard treatment and provides the pathological specimen required for diagnostic confirmation. Here, robotic-assisted laparoscopy allowed visualization, mobilization, precise resection and extraction of the mass from a difficult to access retroperitoneal region.

Left ovarian to left external iliac vein transposition for the treatment of nutcracker syndrome.

Nutcracker syndrome represents the constellation of symptoms caused by extrinsic compression of the left renal vein between the aorta and superior mesenteric artery, producing left renal venous outflow obstruction and, frequently, pelvic venous congestion. When severe, the syndrome is most commonly treated by surgical transposition of the left renal vein onto the inferior vena cava or by renal venous stent placement. Each of these treatment modalities is associated with significant immediate and long-term risks. This report provides the details of a simpler technique for the treatment of nutcracker syndrome by transposing the distal left ovarian to the left external iliac vein.

Overcoming the challenges of single-incision cholecystectomy with robotic single-site technology.

OBJECTIVE: To analyze the preliminary experience with the new da Vinci single-site technology for cholecystectomy. HYPOTHESIS: Single-incision laparoscopic cholecystectomy is technically challenging and a related learning curve clearly exists. A novel approved robotic single-port platform has recently been introduced. This technology may help overcome some of the limitations of manual single-incision surgery relating to triangulation of instruments, ergonomics, and surgical exposure. DESIGN: A prospective longitudinal observational study was conducted on 100 consecutive da Vinci single-site cholecystectomies. SETTING: Five Italian centers of robotic general surgery. MAIN OUTCOME MEASURES: Primary end points were feasibility without conversion and the absence of major complications. Operative times were analyzed to define the learning curve using a mixed regression model.A questionnaire collected the opinions of the surgeons involved in using the new technique. RESULTS: Two patients underwent conversion. No major intraoperative complications occurred, but there were 12 minor incidents (7 ruptures of the gallbladder and 5 cases of minor bleeding from the gallbladder bed). Mean (SD) total operative time was 71 (19) minutes, with a mean (SD) console time of 32 (13) minutes. No significant reduction in the operative times was observed with the increasing of each surgeon's experience. The technique was judged more complex than standard 4-port laparoscopy but easier than single-incision laparoscopy. CONCLUSIONS: Da Vinci single-site cholecystectomy is an easy and safe procedure for expert robotic surgeons. It allows the quick overcoming of the learning curve typical of single-incision laparoscopic surgery and may potentially increase the safety of this approach.

Totally robotic right hepatectomy: surgical technique and outcomes.

HYPOTHESIS: Robotic surgery for performance of right hepatectomy is safe and effective. DESIGN: Case series from 2 medical institutions. SETTING: University of Illinois at Chicago and Misericordia Hospital, Grosseto, Italy. PATIENTS: Twenty-four patients underwent right hepatectomy between March 1, 2005, and January 31, 2010, using a robotic surgical system. MAIN OUTCOME MEASURES: Intraoperative blood loss, operative time, morbidity, mortality, and long-term oncologic follow-up. RESULTS: The procedure was converted to open surgery in 1 patient (4.2%). The overall mean (SD) operative time was 337 (65) minutes (range, 240-480 minutes), and the mean (SD) intraoperative blood loss was 457 (401) mL (range, 100-2000 mL). Three patients (12.5%) underwent blood transfusion. There were no perioperative deaths and no reoperations. Six patients (25.0%) experienced postoperative morbidity, including transitory liver failure in 2 patients and pleural effusion, bile leak, fluid collection, and deep venous thrombosis in 1 patient each. The patients' diagnoses included colorectal liver metastases (n = 11), noncolorectal liver metastases (n = 4), hemangioma (n = 4), adenoma (n = 2), hepatocellular carcinoma (n = 1), hepatoblastoma (n = 1), and biliary amartoma (n = 1). At a mean follow-up duration of 34 months, no port site metastases were observed in patients with malignant pathologic findings. CONCLUSIONS: The zero mortality and acceptable morbidity of our series indicate that in experienced hands, robotic right hepatectomy is feasible and safe. Robotic surgery offers a new technical option for minimally invasive major hepatic resections. Long-term results seem to confirm oncologic effectiveness of the procedure.

Robot-assisted treatment of splenic artery aneurysms.

BACKGROUND: Although splenic artery aneurysms (SAAs) are relatively uncommon, they are clinically relevant because of the risk of rupture. Optimal management is a matter of debate and involves the use of percutaneous endovascular stenting, which has limitations, versus the open surgical approach which can lead to significant morbidity. The present study reports the outcomes of robot-assisted surgery for SAA and its role in overcoming many of the limitations of laparoscopy. METHODS: A total of nine patients with incidentally detected SAAs underwent a surgery between September 2001 and November 2007. Six of these nine patients underwent a robot-assisted splenic aneurysm resection with vascular reconstruction. The remaining three cases included one robotic arterial ligation, one robotic partial splenectomy, and one laparoscopic splenectomy. RESULTS: The mean operating time was 212 ± 61 minutes (range: 90-300), mean intraoperative blood loss was 186.6 ± 202.4 mL (range: 0-500), and mean hospital stay was 7.1 ± 3.7 days (range: 3-14). The morbidity rate was 11.1% and no mortality was reported. Doppler-ultrasonography surveillance showed regular organ perfusion in all patients with vascular reconstruction. CONCLUSION: Robot-assisted surgery for SAA represents one of the most advanced developments among minimally invasive procedures and can become an important option for the treatment of this disease.

Robotic liver surgery: results for 70 resections.

BACKGROUND: Robotic surgery is gaining popularity for digestive surgery; however, its use for liver surgery is reported scarcely. This article reviews a surgeon's experience with the use of robotic surgery for liver resections. METHODS: From March 2002 to March 2009, 70 robotic liver resections were performed at 2 different centers by a single surgeon. The surgical procedure and postoperative outcome data were reviewed retrospectively. RESULTS: Malignant tumors were indications for resections in 42 (60%) patients, whereas benign tumors were indications in 28 (40%) patients. The median age was 60 years (range, 21-84) and 57% of patients were female. Major liver resections (≥ 3 liver segments) were performed in 27 (38.5%) patients. There were 4 conversions to open surgery (5.7%). The median operative time for a major resection was 313 min (range, 220-480) and 198 min (range, 90-459) for minor resection. The median blood loss was 150 mL (range, 20-1,800) for minor resection and 300 mL (range, 100-2,000) for major resection. The mortality rate was 0%, and the overall rate of complications was 21%. Major morbidity occurred in 4 patients in the major hepatectomies group (14.8%) and in 4 patients in the minor hepatectomies group (9.3%). All complications were managed conservatively and none required reoperation. CONCLUSION: This preliminary experience shows that robotic surgery can be used safely for liver resections with a limited conversion rate, blood loss, and postoperative morbidity. Robotics offers a new technical option for minimally invasive liver surgery.

Robot-assisted hybrid laparoscopic Roux-en-Y gastric bypass: surgical technique and early outcomes.

BACKGROUND: Roux-en-Y gastric bypass performed laparoscopically remains the gold standard in bariatric surgery. The role of robot-assisted laparoscopic Roux-en-Y gastric bypass has not been clearly defined. METHODS: We present 80 consecutive cases of robot-assisted laparoscopic Roux-en-Y gastric bypass performed at a single institution. Mechanics, early outcomes, and learning curve are evaluated. Eighty robot-assisted laparoscopic Roux-en-Y gastric bypasses were performed on 71 women and 9 men with a mean age of 39 years, mean preoperative weight of 134 kg, and mean BMI of 48. RESULTS: Total mean operative time was 209 minutes. There was no mortality, leak, stricture, or obstruction. CONCLUSION: Robot-assisted laparoscopic Roux-en-Y gastric bypass is a safe and feasible option for bariatric surgery. Its role in improving surgical outcomes needs to be defined further.

Robot-assisted laparoscopic middle pancreatectomy.

BACKGROUND: Middle pancreatectomy has been accepted as a valid surgical alternative to more extensive standard resections for the treatment of benign central pancreatic tumors. In this article, we describe a new minimally invasive approach to this procedure, using a robot-assisted laparoscopic technique. MATERIALS AND METHODS: From May 2004 to October 2005, 3 patients (2 female and 1 male), with a mean age of 52 years (range, 44-68), underwent robot-assisted laparoscopic middle pancreatectomies at the Department of General Surgery of Misericordia Hospital in Grosseto, Italy. Two of the patients had symptomatic serous cystadenomas, and 1 patient had a mucinous cystadenoma, which was discovered incidentally. The da Vinci((R)) Surgical System (Intuitive Surgical, Sunnyvale, CA) was used to perform the main steps of the intervention. All patients underwent a pancreaticogastrostomy for pancreaticoenteric reconstruction to the distal stump. RESULTS: The mean operative time was 320 minutes (range, 270-380). Mean blood loss was 233 mL (range, 100-400). There were no mortalities. One patient developed a postoperative pancreatic fistula, which was managed conservatively. The postoperative hospital stay was 9 days for 2 patients and 27 days for the third patient. No endocrine or exocrine deficiencies were observed in the patients during a mean follow-up of 44 months (range, 38-48). CONCLUSIONS: Robot-assisted laparoscopic middle pancreatectomy presents an interesting, less-invasive option for resection of benign tumors of the neck and proximal body of the pancreas. In benign disease, it allows for the preservation of functional pancreatic parenchyma and, subsequently, reduced operative trauma.

Robot-assisted laparoscopic extended right hepatectomy with biliary reconstruction.

Robotic surgery represents one of the most advanced developments in the field of minimally invasive surgery. In this article, we describe the case of an extended right hepatectomy with a left hepaticojejunostomy performed for radical resection of a hilar cholangiocarcinoma. This operation was performed by using the da Vinci Robotic Surgical System (Intuitive Surgical, Sunnyvale, CA). In this case, the operative time was 540 minutes, with an intraoperative blood loss of 800 mL. The postoperative course was uneventful, and the patient was discharged at postoperative day 11. This report confirms the technical feasibility and safety of robot-assisted extended hepatic resections with biliary reconstruction. Further experience and a long follow-up are required to validate this initial report.

Robot-assisted laparoscopic repair of renal artery aneurysms.

OBJECTIVE: The aim of this article is to report our experience in the repair of renal artery aneurysms using robot-assisted surgery. METHODS: Between December 2002 and March 2009, five women with a mean age of 63.8 years (range, 57-78 years) underwent robot-assisted laparoscopic repair of renal artery aneurysms by the same surgeon at two different institutions, the Department of General Surgery, Misericordia Hospital, Grosseto, Italy (three patients) and the Division of Minimally Invasive and Robotic Surgery at the University of Illinois, Chicago (two patients). The mean size of the lesions was 19.4 mm (range, 9-28 mm). Four of the lesions were complex aneurysms involving the renal artery bifurcation. Two patients were symptomatic and three had hypertension. In situ repair by aneurysmectomy was performed in all cases, followed by revascularization. In complex aneurysms, an autologous saphenous vein graft was used for the reconstruction. RESULTS: The mean operative time was 288 minutes (range, 170-360 min) and the estimated surgical blood loss was 100 ml (range, 50-300 ml). Warm ischemia time was 10 minutes in the patient treated by aneurysmectomy, followed by direct reconstruction. The average warm ischemia time was 38.5 minutes (range, 20-60 min) for patients treated with saphenous vein graft interposition. The mean time to resume a regular diet was 1.6 days (range, 1-2 days). The mean postoperative length of hospital stay was 5.6 days (range, 3-7 days). No postoperative morbidity was noted. The mean follow-up time for the entire series was 28 months (range, 6-48 months). Color Doppler ultrasonography examination showed patency in all reconstructed vessels. One patient had stenosis of one of the reconstructed branches, which was treated with percutaneous angioplasty. CONCLUSIONS: Robot-assisted laparoscopic repair of renal artery aneurysms is feasible, safe and effective. The technical advantages of the robotic system allows for microvascular reconstruction to be performed using a minimally invasive approach, even in complex cases. This approach may also allow for improved postoperative recovery and reduce the morbidity correlated with open repair of renal artery aneurysms. Although more experience and technical refinements are necessary, robot-assisted laparoscopic repair of renal artery aneurysms represents a valid alternative to open surgery.

Robot-assisted laparoscopic pancreatic surgery: single-surgeon experience.

BACKGROUND: Use of robotic surgery has gained increasing acceptance over the last few years. There are few reports, however, on advanced pancreatic robotic surgery. In fact, the indication for robotic surgery in pancreatic disease has been controversial. This paper retrospectively reviews one surgeon's experience with robotic surgery to treat pancreatic disease, and analyzes its indications and outcomes, as well as the controversy that exists. METHODS: A retrospective review of the charts of all patients who underwent robotic surgery for pancreatic disease by a single surgeon at two different institutions was carried out. RESULTS: From October 2000 to January 2009, 134 patients underwent robotic-assisted surgery for different pancreatic pathologies. All procedures were performed using the da Vinci robotic system. Of the 134 patients, 83 were female. The average age of all patients was 57 years (range 24-86 years). Mean operating room (OR) time was 331 min (75-660 min). There were 14 conversions to open surgery. Mean length of stay was 9.3 days (3-85 days). Length of stay for patients with no complications was 7.9 days (3-15 days). The postoperative morbidity rate was 26% and the mortality rate was 2.23% (three patients). Among the procedures performed were 60 pancreaticoduodenectomies, 23 spleen-preserving distal pancreatectomies, 23 splenopancreatectomies, 3 middle pancreatectomies, 1 total pancreatectomy, and 3 enucleations. Another 21 patients underwent different surgical procedures for treatment of acute and chronic pancreatitis. Two cases of pancreaticoduodenectomy were performed in outside institutions and are not included in this series. CONCLUSIONS: This is the largest series of robotic pancreatic surgery presented to date. Robotic surgery enables difficult technical maneuvers to be performed that facilitate the success of pancreatic minimally invasive surgery. The results in this series demonstrate that it is feasible and safe. Complication and mortality rates are comparable to those of open surgery but with the advantages of minimally invasive surgery.

Robotics in general surgery: personal experience in a large community hospital.

HYPOTHESIS: Robotic technology is the most advanced development of minimally invasive surgery, but there are still some unresolved issues concerning its use in a clinical setting. DESIGN: The study describes the clinical experience of the Department of General Surgery, Misericordia Hospital, Grosseto, Italy, in robot-assisted surgery using the da Vinci Surgical System. RESULTS: Between October 2000 and November 2002, 193 patients underwent a minimally invasive robotic procedure (74 men and 119 women; mean age, 55.9 years [range, 16-91 years]). A total of 207 robotic surgical operations, including abdominal, thoracic and vascular procedures, were performed; 179 were single procedures, and 14 were double (2 operations on the same patient). There were 4 conversions to open surgery and 3 to conventional laparoscopy (conversion rate, 3.6%; 7 of 193 patients). The perioperative morbidity rate was 9.3% (18 of 193 patients), and 6 patients (3.1%) required a reoperation. The postoperative mortality rate was 1.5% (3 of 193 patients). CONCLUSIONS: Our preliminary experience at a large community hospital suggests that robotic surgery is feasible in a clinical setting. Its daily use is safe and easily managed, and it expands the applications of minimally invasive surgery. However, the best indications still have to be defined, and the cost-benefit ratio must be evaluated. This report could serve as a basis for a future prospective, randomized trial.