Current perspectives in robotic hernia repair.

The surgical treatment of hernias has developed throughout the evolution of surgery. The fascination with hernia surgery is in part driven by its prevalence and by the variety of treatment options. Minimally invasive hernia surgery has a goal of a robust repair with minimal complications, and new robotic techniques are being developed in complex abdominal wall hernias with promising results. This review focuses on inguinal, ventral, and incisional hernias and their outcomes with a discussion on the traditional open, laparoscopic, and robotic techniques. The prevalence of minimally invasive hernia surgery and its advantages are also outlined. We highlight our experience in these procedures, specifically robotic herniorrhaphy, as it pertains to ventral incisional and inguinal hernia repair. We conclude that the robotic platform is proving to be a benefit to hernia repair. Many studies are showing its feasibility and comparable results to standard laparoscopy, and some have shown improved results, including shorter hospital stay without significant increases in cost. The robotic option of hernia repair has resulted in an increase in minimally invasive hernia repair, a number that has remained stagnant for the last decade. With more surgeons gaining training and experience and greater availability of the robotic platform, we expect to see greater numbers of minimally invasive hernia repair.

Feasibility of robotic inguinal hernia repair, a single-institution experience.

BACKGROUND: With the growth of the discipline of laparoscopic surgery, technology has been further developed to facilitate the performance of minimally invasive hernia repair. Most of the published literature regarding robotic inguinal hernia repair has been performed by urologists who have dealt with this entity in a concomitant way during radical prostatectomies. General surgeons, who perform the vast majority of inguinal herniorrhaphies worldwide, have yet to describe the role of robotic inguinal hernia repair. Here, we describe our initial experience and create the foundation for future research questions regarding robotic inguinal hernia repair. METHODS: A retrospective chart review was performed in 78 patients who underwent robotic transabdominal preperitoneal TAPP inguinal hernia repair with a prosthetic mesh using the da Vinci platform (Intuitive Surgical Inc). Data collected included patient demographics, past medical history, previous surgeries, details related to the surgical procedure, perioperative outcomes and complications. RESULTS: A total of 123 hernias were repaired. Forty-five patients had bilateral robotic inguinal herniorrhaphies, and the mean age was 55.1 years (SD 15.1), with a mean BMI of 27.6 (SD 6.1). There were 71 male and 7 female patients. Surgical complications included hematoma in three patients (3.9 %), two seromas (2.6 %) and one superficial surgical site infection at a trocar site (1.3 %), which resolved with oral antibiotics. Chronic postoperative complications (>30 days post-surgery) included the persistence of hematomas in two patients (2.6 %). Same day discharge was achieved in 60 patients (76.9 %) with a mean length of stay of 8 h (SD 2.65). Neither mortality nor conversion to open surgery occurred. CONCLUSION: Our early experience has demonstrated that the robotic transabdominal preperitoneal (TAPP) inguinal hernia repair is a safe and versatile approach that allows the general surgeon to perform this procedure in more complex cases such as those involving incarcerated and/or recurrent hernias.

Robotic inguinal hernia repair.

Inguinal hernias have been described throughout the history of medicine with many efforts to achieve the cure. Currently, with the advantages of minimally invasive surgery, new questions arise: what is going to be the best approach for inguinal hernia repair? Is there a real benefit with the robotic approach? Should minimally invasive hernia surgery be the standard of care? In this report we address these questions by describing our experience with robotic inguinal hernia repair.

A comparative retrospective study of robotic sleeve gastrectomy vs robotic gastric bypass.

BACKGROUND: The introduction of the robotic platform to bariatric surgery has brought forth a novel approach, with modifications to the standard laparoscopic sleeve gastrectomy (LSG) and laparoscopic gastric bypass (LGB). The purpose of this study was to match robotic gastric bypass (RGB) vs robotic sleeve gastrectomy (RSG) and compare them to those observed with the laparoscopic platform. METHODS: A retrospective data collection of RSGs and RGBs from a single institution was performed. Groups were compared. RESULTS: This study included 134 RSG and 165 RGB patients. RGB has a longer surgical time (p < 0.001) and a higher incidence of long-term complications (p = 0.005) but similar lengths of hospital stay (p = 0.093), rate of perioperative complications (p = 0.487) and EWL% at 1 year of follow-up compared to RSG. CONCLUSIONS: RSGs had shorter surgical times and a lower incidence of long-term complications when compared with RGBs. These results appear to be similar to those studies reporting the laparoscopic approach. Copyright © 2014 John Wiley & Sons, Ltd.

Robotic sleeve gastrectomy: experience of 134 cases and comparison with a systematic review of the laparoscopic approach.

BACKGROUND: Robotic technology has recently emerged in different surgical specialties, but the experience with robotic sleeve gastrectomy (RSG) is scarce in the literature. The purpose of this study is to compare our preliminary experience with RSG versus the descriptive results of a systematic review of the laparoscopic approach. METHODS: Data from our RSG experience were retrospectively collected. Two surgeons performed all the cases in one single surgery center. Such information was compared with a systematic review of 22 selected studies that included 3,148 laparoscopic sleeve gastrectomy (LSG) cases. RSG were performed using the daVinci Surgical System. RESULTS: This study included 134 RSG vs. 3,148 LSG. Mean age and mean BMI was 43 ± 12.6 vs. 40.7 ± 11.6 (p = 0.022), and 45 ± 7.1 vs. 43.6 ± 8.1 (p = 0.043), respectively. Leaks were found in 0 RSG vs. 1.97% LSG (p = 0.101); strictures in 0 vs. 0.43% (p = 0.447); bleeding in 0.7 vs. 1.21% (p = 0.594); and mortality in 0 vs. 0.1% (p = 0.714), respectively. Mean surgical time was calculated in 106.6 ± 48.8 vs. 94.5 ± 39.9 min (p = 0.006); and mean hospital length of stay was 2.2 ± 0.6 vs. 3.3 ± 1.7 days (p = <0.005), respectively. Four (2.9%) complications were found in our robotic series. CONCLUSIONS: Our series shows that RSG is a safe alternative when used in bariatric surgery, showing similar results as the laparoscopic approach. Surgical time is longer in the robotic approach, while hospital length of stay is lower. No leaks or strictures were found in the robotic cases. However, further studies with larger sample size and randomization are warranted.

Single-incision cholecystectomy: a comparative study of standard laparoscopic, robotic, and SPIDER platforms.

BACKGROUND: Many series have shown the feasibility and safety of single-incision laparoscopic cholecystectomy (SILC), but this technique still has limitations such as instrument collisions and lack of triangulation. Recently, two single-incision platforms, robotic and SPIDER, have attempted to ameliorate such problems. This study aimed to compare three different techniques of single-incision cholecystectomy: standard laparoscopic, robotic, and SPIDER approaches. METHODS: The authors retrospectively collected data from their first 166 single-incision robotic cholecystectomies (SIRCs) and compared the findings with the data from their first 166 SILCs and the first 166 s-generation SPIDER procedures. All the SILCs were performed with three trocars placed in one umbilical incision and with gallbladder retraction using a Prolene stitch on the right upper quadrant. All the robotic cases were managed using the da Vinci Single-Site Surgical System, and all the SPIDER procedures were performed using the SPIDER Surgical System. RESULTS: The SILC, SIRC, and SPIDER groups consisted respectively of 129 (76.3%), 131 (78.9%), and 136 (81.9%) women with the respective mean ages of 44.5 ± 14.3, 51.6 ± 15.9, and 46.4 ± 15.2 years. The mean body mass indexes (BMIs) were respectively 29.1 ± 5.6, 29.4 ± 6.2, and 27.5 ± 4.8 kg/m(2), and the mean surgical times were 37.1 ± 13.3, 63.0 ± 25.2, and 52.8 ± 18.7 min. The total hospital stays were respectively 1.3 ± 5.3, 1.2 ± 2.2, and 1.5 ± 2.6 days, and complications were seen respectively in three SILC cases (1.8%), three SIRC cases (1.8%), and two SPIDER cases (1.2%). CONCLUSIONS: The results of this study demonstrate similar results among the three platforms for most of the parameters measured. The SILC procedure appears to be superior to SIRC and SPIDER in terms of surgical time, but selection bias could be the cause. The SILS, SIRC, and SPIDER procedures all are similar in terms of complication profile. It can be concluded that SILC, SIRC, and SPIDER all are feasible and safe alternatives when used for single-incision cholecystectomy.

T cell infiltrate and outcome following resection of intermediate-grade primary neuroendocrine tumours and liver metastases.

BACKGROUND: Tumour-infiltrating lymphocytes (TILs) have been shown to predict survival in numerous malignancies. The importance of TILs in primary pancreatic neuroendocrine tumours (NETs) and NET liver metastases (NETLMs) has not been defined. METHODS: We identified 87 patients with NETs and 39 with NETLMs who had undergone resection. Immunohistochemistry was performed to determine TIL counts. Recurrence-free survival (RFS) and overall survival (OS) were determined using the log-rank test. RESULTS: The median follow-up time was 62 months in NET patients and 48 months in NETLM patients. Vascular invasion and histologic grade were the only independent predictors of outcome for NETs and NETLMs, respectively. Analysis of intermediate-grade NETs indicated that a dense T cell (CD3+) infiltrate was associated with a median RFS of 128 months compared with 61 months for those with low levels of intratumoral T cells (P= 0.05, univariate analysis). Examination of NETLMs revealed that a low level of infiltrating regulatory T cells (Treg, FoxP3+) was a predictor of prolonged survival (P < 0.01, univariate analysis). CONCLUSIONS: A robust T cell infiltrate is associated with improved RFS following resection of intermediate-grade NETs, whereas the presence of more Treg correlated with shorter OS after treatment of NETLMs. Further study of the immune response to intermediate-grade NETs and NETLMs is warranted.