Primary abandon of hernia sac for inguinoscrotal hernias: a safe way to cut corners.

INTRODUCTION: Inguinoscrotal hernias (ISH) pose a challenge to surgeons with consistently higher rates of postoperative complications and recurrence rates. The aim of this study is to report our initial experience and early results with a new technique for inguinoscrotal hernia repair. METHODS: A review of a prospectively maintained multi-center database was conducted in patients who underwent minimally invasive repair using the "primary abandon-of-the-sac" (PAS) technique for inguinoscrotal hernias from March 2021 to July 2022. Demographics and outcomes were analyzed. Univariate analysis and multivariate logistic regression were performed. RESULTS: A total of 76 minimally invasive inguinal hernia repairs were performed. In 70 patients (92%) C-PAS was used as the technique to abandon the sac while in the remaining 6 patients, "pirate-eye-patch" technique was used. Median hernia ring was 3 (IQR 2.5-3.5) cm and median hernia sac was 9.5 (8-10.8) cm. Median operative time was 70 min (IQR 56-96). Seroma was present in 22 (28.9%) patients 7 days after surgery. Most had seroma only in the inguinal area (n = 19; 25%). Thirty days after surgery, 12 (15.8%) patients still had seroma in the inguinal area and 6 (7.9%) in the inguinoscrotal area. Ninety days after surgery, four (5.3%) patients had inguinal seroma, 2 (2.6%) scrotal seromas and 3 (3.9%) inguinoscrotal seromas. The size of the hernia sac was not associated with seroma formation 7 days after surgery (OR 1.06; 95% CI 0.89-1.2; P = 0.461) in the multivariate logistic regression. BMI was also not associated with seroma formation (OR 0.8; 95% CI 0.74-1.06; P = 0.2). CONCLUSIONS: Planned abandon of the hernia sac is an interesting alternative and is associated with a low rate of complications and acceptable seroma formation rates.

Robotic Roux-en-Y gastric bypass: surgical technique and short-term experience from 329 cases.

OBJECTIVE: minimally invasive bariatric surgery is clearly superior over open procedures including better early outcomes. Different surgical approaches are used to treat the severely obese, having Roux-en-Y gastric bypass (RYGB) being a highly frequent procedure. Robotic surgery overcomes some laparoscopic limitations adding ergonomics, articulating instruments and a three-dimensional high definition camera. Based on our vast robotic experience, we present our referred group case series and a standardized Robotic Roux-en-Y gastric bypass (rRYGB) technique as well as its outcomes. METHODS: a review of a prospective maintained database was conducted in patients submitted to robotic Roux en Y bariatric surgery between April 2015 and July 2019. Surgical technique is described and illustrated. We also reported patients demographics, outcomes and its follow-up. RESULTS: a Retrospective analysis identified 329 patients submitted to Robotic Roux-en-Y gastric bypass. Both da Vinci Si and Xi platforms were used. Mean age was 34.4 years, with median BMI of 44.2 kg/m2. Mean console time was 102 min and there was no conversion. No surgical hospital readmission rates were seen in the first 30 days. CONCLUSION: this study represents our initial experience of robotic Roux-en-Y gastric bypass (rRYGB), its short outcomes and a standardized surgical technique. Our results encourage that rRYGB is technically feasible and safe, and might offer some advantages showing good outcomes and minimal complications.

Technical essential aspects in robotic colorectal surgery: mastering the Da Vinci Si and Xi platforms.

BACKGROUND: laparoscopy surgery has many proven clinical advantages over conventional surgery and more recently, robotic surgery has been the emerging platform in the minimally invasive era. In the colorectal field, although overcoming limitations of standard laparoscopy, robotic surgery still faces challenging situations even by the most experienced colorectal surgeons. This study reports essentials technical aspects and comparison between Da Vincis Si and Xi platforms aiming to master and maximize efficiency whenever performing robotic colorectal surgery. METHODS: this study overviews the most structured concepts and practical applications in robotic colorectal surgery in both Si and Xi Da Vinci platforms. Possible pitfalls are emphasized and step-wise approach is described from port placement and docking process to surgical technique. We also present data collected from a prospectively maintained database. RESULTS: our early experience includes forty-four patients following a standardized total robotic left-colon and rectal resection. Guided information and practical applications for a safe and efficient robotic colorectal surgery are described. We also present illustrations and describe technical aspects of a standardized procedure. CONCLUSION: performing robotic colorectal surgery is feasible and safe in experienced surgeons hands. Although the Da Vinci Xi platform demonstrates greater versatility in a more user-friendly design with technological advances, the correct mastery of technology by the surgical team is an essential condition for its fully robotic execution in a single docking approach.

Surgical management of esophageal stenosis due to ingestion of corrosive substances.

BACKGROUND: Corrosive ingestion is a significant challenge for healthcare systems. Limited data are available regarding the best treatments, and there remains a lack of consensus about the optimal surgical approach and its outcomes. This study aims to review the current literature and show a single institution's experience regarding the surgical treatment of esophageal stenosis due to corrosive substance ingestion. METHODS: A retrospective review that accounted for demographics, psychiatric profiles, surgical procedures, and outcomes was performed. A systematic review of the literature was performed using PubMed. RESULTS: In total, 27 surgical procedures for esophageal stenosis due to corrosive substance ingestion were performed from 2010 to 2019. Depression and drug abuse were diagnosed in 30% and 22% of the included patients, respectively. Esophagectomies and esophageal bypasses were performed in 13 and 14 patients, respectively. No 30-day mortality was recorded. CONCLUSION: Surgical intervention either by esophagectomy or esophageal bypass results in durable relief from dysphagia. However, successful clinical outcomes depend on a high-quality multidisciplinary network of esophageal and thoracic surgeons, intensivists, psychologists, psychiatrists, and nutritional teams.

INDOCYANINE GREEN FLUORESCENCE IMAGING IN ROBOTIC SURGERY: STATE OF ART, TIPS AND TRICKS IN CURRENT APPLICATIONS.

BACKGROUND: Fluorescent imaging with indocyanine green is an emerging technology whose benefits are put in perspective. OBJECTIVE: This article reports essential principles and approaches of intraoperative fluorescence in general surgery bringing familiarity to its practical usage. Our group describes possible pitfalls and provides tips and tricks for training surgeons making their attempts easier and reproducible during practice. METHODS: This study overviews the most structured concepts, practical applications and its tricks in robotic fluorescence guided imaging surgery with indocyanine green. Possible pitfalls are emphasized and emerging fields of application are put in a perspective. RESULTS: Guided information and practical applications in several surgical fields are described for a safe and reproducible indocyanine green fluorescence imaging use. CONCLUSION: Robotic assisted surgery combined to fluorescence imaging technology represents a logical evolution in image guided surgery and technology familiarity with guided information may represent a wider and safer spectrum of use in surgeons' hands.

Image Inversion during Xi Robotic ventral hernia repair: making it even more effective.

INTRODUCTION: currently, there are several clinical applications for robot-assisted surgery and in the hernia scenario, robot-assisted surgery seems to have the ability to overcome laparoscopic ventral hernias repairs limitations, facilitating dissection, defect closure, and mesh positioning. Exponentially grown in numbers of robotic approaches have been seen and even more complex and initially not suitable cases have recently become eligible for it. An appropriate tension-free reestablishment of the linea alba is still a major concern in hernia surgery and even with the robotic platform, dissecting and suturing in anterior abdominal wall may be challenging. This article reports a technical image artifice during a da vinci Xi-platform robotic ventral hernia repair allowing the surgeon to establish a more familiar and ergonomic manner to perform dissection and suturing in anterior abdominal wall. TECHNICAL REPORT: a step by step guided technique of image inversion artifice is described using detailed commands and figures to assure optimal surgical field and ergonomics whenever acting in robotic ventral hernias repair with the da Vinci Xi-platform. Our group brief experience is also reported, showing an easy and reproducible feature among surgeons with safe outcomes. CONCLUSION: we consider that image inversion artifice is a simple and reproducible feature in robotic ventral hernia repair. Through a step-by-step guide, this report enables the creation of an artifice providing a comfortable operative field and allowing the surgeon to achieve its best proficiency in hernia surgery.

Cirurgia robótica guiada por fluorescência com indocianina verde: aplicações, dicas e truques / Indocyanine green fluorescence imaging in robotic surgery: state of art, tips and tricks in current applications

ABSTRACT BACKGROUND: Fluorescent imaging with indocyanine green is an emerging technology whose benefits are put in perspective. OBJECTIVE: This article reports essential principles and approaches of intraoperative fluorescence in general surgery bringing familiarity to its practical usage. Our group describes possible pitfalls and provides tips and tricks for training surgeons making their attempts easier and reproducible during practice. METHODS: This study overviews the most structured concepts, practical applications and its tricks in robotic fluorescence guided imaging surgery with indocyanine green. Possible pitfalls are emphasized and emerging fields of application are put in a perspective. RESULTS: Guided information and practical applications in several surgical fields are described for a safe and reproducible indocyanine green fluorescence imaging use. CONCLUSION: Robotic assisted surgery combined to fluorescence imaging technology represents a logical evolution in image guided surgery and technology familiarity with guided information may represent a wider and safer spectrum of use in surgeons' hands.

RESUMO CONTEXTO: A imagem fluorescente com verde de indocianina (VI) é uma técnica cirúrgica emergente na cirurgia robótica. OBJETIVO: Este artigo relata princípios e abordagens essenciais da fluorescência intraoperatória para sua prática em cirurgia geral. Nosso grupo descreve possíveis armadilhas e apresenta dicas e truques para treinar cirurgiões, tornando o uso do VI reprodutível. MÉTODOS: Este estudo apresenta uma visão geral dos conceitos e aplicações práticas da imagem guiada por fluorescência com VI na cirurgia robótica. As possíveis armadilhas são enfatizadas e os campos de aplicação emergentes são colocados em perspectiva. RESULTADOS: Aplicações práticas em vários campos cirúrgicos são descritas para um uso seguro e reprodutível de imagens de fluorescência com VI. CONCLUSÃO: A cirurgia assistida por robótica combinada à tecnologia de imagem de fluorescência representa uma evolução lógica na cirurgia guiada por imagem e a familiaridade desta técnica pode representar um ganho da qualidade cirúrgica.

Robotic TAPP inguinal hernia repair: lessons learned from 97 cases.

OBJECTIVES: minimally invasive inguinal hernia repair has proven advantages over open procedures including less pain and earlier return to normal activity. Robotic surgery adds ergonomics, a three-dimensional high definition camera and articulating instruments overcoming some laparoscopic limitations. We aimed to report the outcomes of the early experience of over 97 robotic inguinal hernia repairs performed by a referred surgical group in Brazil. METHODS: a review of a prospective mantined database was conducted in patients submitted to robotic transabdominal preperitoneal (TAPP) inguinal hernia repairs between March 2016 and February 2020. Descriptive statistics were performed. Surgical outcomes data and patient follow-ups are reported. RESULTS: retrospective chart review identified 97 patients submitted to robotic TAPP inguinal hernia repair. Mean age was 36.4 years, with median BMI of 26.9 kg/m2. Mean console time was 58 min (range 40-150) and patients were discharged within 24 hours of their stay in a majority of cases. Mesh was placed in all procedures and there were no conversion rates. Complications were low grade and no recurrence was seen after a mean follow-up of 642 days. CONCLUSION: this study represents to-date the first brazilian case series of robotic TAPP inguinal hernia repair. Our results encourage that robotic assisted TAPP inguinal hernia repair appears to be technically feasible and safe in experienced hands, with good outcomes achieving high health-related quality of life and low recurrence rates in the short and long term.

The history of robotic surgery and its evolution: when illusion becomes reality.

The term "robot" was concepted in the beginning of last century, coming originally from the Czech word "robota", meaning "labor". More recently, computer assistance and robotics based in the telepresence and virtual reality concept have been applied to surgical procedures. The application of robots in surgery dates approximately 35 years, experiencing significant growth in the last two decades fueled by the advent of advanced technologies. Despite its recent and brief status in surgery history, robotic technology has already proven its enhanced visualization, superior dexterity and precision during minimally invasive procedures. Currently, the worldwide diffused and predominant robot system used in surgery is Da Vinci by Intuitive Surgical, however robotic surgery evolution is far from over, with multiple potential competitors on the horizon pushing forward its paradigms. We aim to describe the history and evolution of robotic surgery in the last years as well as present its future perspectives.

Robotic TAPP inguinal hernia repair: lessons learned from 97 cases / Hernioplastia inguinal transabdominal pré-peritoneal (TAPP) robótica: experiência inicial de 97 casos

ABSTRACT Objectives: minimally invasive inguinal hernia repair has proven advantages over open procedures including less pain and earlier return to normal activity. Robotic surgery adds ergonomics, a three-dimensional high definition camera and articulating instruments overcoming some laparoscopic limitations. We aimed to report the outcomes of the early experience of over 97 robotic inguinal hernia repairs performed by a referred surgical group in Brazil. Methods: a review of a prospective mantined database was conducted in patients submitted to robotic transabdominal preperitoneal (TAPP) inguinal hernia repairs between March 2016 and February 2020. Descriptive statistics were performed. Surgical outcomes data and patient follow-ups are reported. Results: retrospective chart review identified 97 patients submitted to robotic TAPP inguinal hernia repair. Mean age was 36.4 years, with median BMI of 26.9 kg/m2. Mean console time was 58 min (range 40-150) and patients were discharged within 24 hours of their stay in a majority of cases. Mesh was placed in all procedures and there were no conversion rates. Complications were low grade and no recurrence was seen after a mean follow-up of 642 days. Conclusion: this study represents to-date the first brazilian case series of robotic TAPP inguinal hernia repair. Our results encourage that robotic assisted TAPP inguinal hernia repair appears to be technically feasible and safe in experienced hands, with good outcomes achieving high health-related quality of life and low recurrence rates in the short and long term.

RESUMO Objetivo: a cirurgia minimamente invasiva das hérnias inguinais apresenta vantagens comprovadas em relação aos procedimentos convencionais, incluindo menos dor e retorno precoce às atividades rotineiras. A cirurgia robótica acrescenta uma melhor ergonomia, ótica estável tridimensional de alta definição e instrumentos articulados, superando algumas limitações laparoscópicas. O objetivo deste estudo é relatar os resultados da experiência inicial de 97 cirurgias de correção de hérnias inguinais robóticas pela técnica transabdominal pré-peritoneal (TAPP) realizadas por um grupo cirúrgico referência no Brasil. Métodos: foi realizada uma revisão de um banco de dados mantido prospectivamente de pacientes submetidos a cirurgias de hérnia inguinal TAPP robótica entre março de 2016 e fevereiro de 2020. Uma análise detalhada dos resultados foi feita e dados dos resultados cirúrgicos e acompanhamento dos pacientes são relatados. Resultados: a revisão retrospectiva do prontuário identificou 97 pacientes submetidos à cirurgia de hérnia inguinal TAPP robótica. A idade média foi de 36,4 anos, com IMC médio de 26,9 kg/m2. O tempo médio de procedimento cirúrgico no console robótico foi de 58 minutos. A colocação de prótese foi realizada em todos os procedimentos e não houve taxas de conversão ou intercorrências. Conclusão: este estudo representa a primeira série de casos de cirurgia robótica de hérnia inguinal pela técnica transabdominal pré-peritoneal no Brasil. Os resultados descritos reforçam que a hernioplastia inguinal robótica apresenta-se como tecnicamente viável e segura em mãos experientes, com bons resultados quanto a qualidade de vida e baixas taxas de recidiva a curto e longo prazo.

Image Inversion during Xi Robotic ventral hernia repair: making it even more effective / Inversão de imagem em cirurgia robótica de hérnia ventral com a plataforma Da vinci Xi: tornando-a ainda mais ergonômica

ABSTRACT Introduction: currently, there are several clinical applications for robot-assisted surgery and in the hernia scenario, robot-assisted surgery seems to have the ability to overcome laparoscopic ventral hernias repairs limitations, facilitating dissection, defect closure, and mesh positioning. Exponentially grown in numbers of robotic approaches have been seen and even more complex and initially not suitable cases have recently become eligible for it. An appropriate tension-free reestablishment of the linea alba is still a major concern in hernia surgery and even with the robotic platform, dissecting and suturing in anterior abdominal wall may be challenging. This article reports a technical image artifice during a da vinci Xi-platform robotic ventral hernia repair allowing the surgeon to establish a more familiar and ergonomic manner to perform dissection and suturing in anterior abdominal wall. Technical Report: a step by step guided technique of image inversion artifice is described using detailed commands and figures to assure optimal surgical field and ergonomics whenever acting in robotic ventral hernias repair with the da Vinci Xi-platform. Our group brief experience is also reported, showing an easy and reproducible feature among surgeons with safe outcomes. Conclusion: we consider that image inversion artifice is a simple and reproducible feature in robotic ventral hernia repair. Through a step-by-step guide, this report enables the creation of an artifice providing a comfortable operative field and allowing the surgeon to achieve its best proficiency in hernia surgery.

RESUMO Introdução: as qualidades da cirurgia robótica em diversos campos da cirurgia minimamente invasiva são notórias e, no cenário de hérnias abdominais, ela tem se mostrado capaz de superar as limitações da laparoscopia facilitando a dissecção, o fechamento do defeito herniário e o posicionamento da tela. O número de abordagens robóticas cresceu exponencialmente e casos ainda mais complexos e inicialmente inadequados tornaram-se recentemente elegíveis para uma cirurgia menos invasiva. A reconstrução adequada da linha alba e livre de tensão ainda é uma grande preocupação na cirurgia de hérnia e, mesmo com a plataforma robótica, dissecar e suturar na parede abdominal anterior pode ser um desafio. Este artigo relata um artifício técnico com inversão de imagem durante a correção de hérnia ventral robótica com a plataforma Da vinci Xi, permitindo ao cirurgião estabelecer uma maneira mais familiar e ergonômica de realizar dissecção e sutura na parede abdominal anterior. Nota Técnica: uma técnica guiada passo a passo com artifício de inversão de imagem é descrita usando comandos e figuras detalhadas para garantir campo cirúrgico ideal e melhor ergonomia ao cirurgião sempre que atuar na correção de hérnias ventrais robóticas com a plataforma Da vinci Xi. Nossa breve experiência de grupo também é relatada, mostrando-se uma técnica fácil e reprodutível entre cirurgiões com resultados seguros. Conclusão: consideramos que o artifício de inversão de imagens é uma característica simples e reprodutível na correção de hérnia ventral robótica. Por meio de um guia passo a passo, este artigo detalha a criação de um artifício técnico que proporciona um campo operatório confortável ao cirurgião atingindo sua melhor proficiência em cirurgia de hérnia.

The history of robotic surgery and its evolution: when illusion becomes reality / Evolução e história da cirurgia robótica: da ilusão à realidade

ABSTRACT The term "robot" was concepted in the beginning of last century, coming originally from the Czech word "robota", meaning "labor". More recently, computer assistance and robotics based in the telepresence and virtual reality concept have been applied to surgical procedures. The application of robots in surgery dates approximately 35 years, experiencing significant growth in the last two decades fueled by the advent of advanced technologies. Despite its recent and brief status in surgery history, robotic technology has already proven its enhanced visualization, superior dexterity and precision during minimally invasive procedures. Currently, the worldwide diffused and predominant robot system used in surgery is Da Vinci by Intuitive Surgical, however robotic surgery evolution is far from over, with multiple potential competitors on the horizon pushing forward its paradigms. We aim to describe the history and evolution of robotic surgery in the last years as well as present its future perspectives.

RESUMO O termo "robô" foi concebido no início do século passado, derivado originalmente da palavra tcheca "robota", que significa "trabalho". Mais recentemente, a tecnologia de computação associada à robótica, baseada no conceito de telepresença e realidade virtual, têm sido aplicadas aos procedimentos cirúrgicos. A aplicação de robôs em cirurgia data de aproximadamente 35 anos, experimentando um crescimento significativo nas últimas duas décadas impulsionado pelo advento de novas tecnologias e seus resultados. Apesar de seu status breve comparado à longevidade da história da cirurgia, a tecnologia robótica já provou seus potenciais benefícios com visualização aprimorada, destreza superior e maior precisão durante procedimentos minimamente invasivos. Atualmente, a plataforma robótica mundialmente difundida e predominantemente usada em cirurgia é o modelo Da Vinci da empresa Intuitive Surgical, e a evolução desse novo conceito de cirurgia está longe de terminar, com inúmeros competidores potenciais no horizonte impulsionando a quebra de paradigmas. Nosso objetivo nesta revisão é descrever a história e evolução da cirurgia robótica nos últimos anos, bem como apresentar suas perspectivas futuras.

Technical essential aspects in robotic colorectal surgery: mastering the Da Vinci Si and Xi platforms / Aspectos técnicos essenciais em cirurgia robótica colorretal: dominando as plataformas Da Vinci Si e Xi

ABSTRACT Background: laparoscopy surgery has many proven clinical advantages over conventional surgery and more recently, robotic surgery has been the emerging platform in the minimally invasive era. In the colorectal field, although overcoming limitations of standard laparoscopy, robotic surgery still faces challenging situations even by the most experienced colorectal surgeons. This study reports essentials technical aspects and comparison between Da Vincis Si and Xi platforms aiming to master and maximize efficiency whenever performing robotic colorectal surgery. Methods: this study overviews the most structured concepts and practical applications in robotic colorectal surgery in both Si and Xi Da Vinci platforms. Possible pitfalls are emphasized and step-wise approach is described from port placement and docking process to surgical technique. We also present data collected from a prospectively maintained database. Results: our early experience includes forty-four patients following a standardized total robotic left-colon and rectal resection. Guided information and practical applications for a safe and efficient robotic colorectal surgery are described. We also present illustrations and describe technical aspects of a standardized procedure. Conclusion: performing robotic colorectal surgery is feasible and safe in experienced surgeons hands. Although the Da Vinci Xi platform demonstrates greater versatility in a more user-friendly design with technological advances, the correct mastery of technology by the surgical team is an essential condition for its fully robotic execution in a single docking approach.

RESUMO Introdução: a cirurgia laparoscópica demonstrou vantagens sobre a cirurgia convencional e, mais recentemente, a cirurgia robótica tem sido a plataforma emergente na era cirúrgica minimamente invasiva. Na prática colorretal, embora supere as limitações da laparoscopia, a cirurgia robótica ainda enfrenta situações desafiadoras, mesmo diante de cirurgiões colorretais experientes. Este estudo relata aspectos técnicos essenciais e comparação entre as plataformas Si e Xi Da Vinci com o objetivo de auxiliar e maximizar a eficiência na realização de cirurgia robótica colorretal regrada. Métodos: este estudo apresenta uma visão geral dos conceitos essenciais e aplicações práticas em cirurgia robótica colorretal nas plataformas Da Vinci Si e Xi. As potenciais dificuldades são enfatizadas e uma abordagem em etapas é descrita desde a colocação dos portais e seu processo de docking até a técnica cirúrgica. Também apresentamos brevemente dados coletados de um banco de dados mantido de forma prospectiva. Resultados: nossa experiência inicial inclui quarenta e quatro pacientes submetidos à cirurgia totalmente robótica padronizada na ressecção colônica e retal. Informações e aplicações práticas para uma cirurgia robótica colorretal segura e eficiente são descritas. Também são apresentadas ilustrações e dados breves da experiência. Conclusão: a cirurgia robótica colorretal é viável e segura nas mãos de cirurgiões experientes, no entanto ainda enfrenta desafios. Apesar da plataforma Da Vinci Xi demonstrar maior versatilidade em um design mais amigável com avanços tecnológicos, o correto domínio da tecnologia pela equipe cirúrgica é condição essencial para sua execução totalmente robótica em etapa única.

Robotic Roux-en-Y gastric bypass: surgical technique and short-term experience from 329 cases / Bypass gástrico em Y de Roux robótico: técnica cirúrgica padronizada e experiência inicial de 329 casos

ABSTRACT Objective: minimally invasive bariatric surgery is clearly superior over open procedures including better early outcomes. Different surgical approaches are used to treat the severely obese, having Roux-en-Y gastric bypass (RYGB) being a highly frequent procedure. Robotic surgery overcomes some laparoscopic limitations adding ergonomics, articulating instruments and a three-dimensional high definition camera. Based on our vast robotic experience, we present our referred group case series and a standardized Robotic Roux-en-Y gastric bypass (rRYGB) technique as well as its outcomes. Methods: a review of a prospective maintained database was conducted in patients submitted to robotic Roux en Y bariatric surgery between April 2015 and July 2019. Surgical technique is described and illustrated. We also reported patients demographics, outcomes and its follow-up. Results: a Retrospective analysis identified 329 patients submitted to Robotic Roux-en-Y gastric bypass. Both da Vinci Si and Xi platforms were used. Mean age was 34.4 years, with median BMI of 44.2 kg/m2. Mean console time was 102 min and there was no conversion. No surgical hospital readmission rates were seen in the first 30 days. Conclusion: this study represents our initial experience of robotic Roux-en-Y gastric bypass (rRYGB), its short outcomes and a standardized surgical technique. Our results encourage that rRYGB is technically feasible and safe, and might offer some advantages showing good outcomes and minimal complications.

RESUMO Objetivo: a cirurgia bariátrica minimamente invasiva é claramente superior aos procedimentos abertos, incluindo melhores resultados iniciais. Diferentes abordagens cirúrgicas são usadas para tratar os gravemente obesos, sendo o bypass gástrico em Y de Roux (RYGB) um procedimento muito frequente. A cirurgia robótica supera algumas limitações laparoscópicas adicionando ergonomia, instrumentos de articulação e uma câmera tridimensional de alta definição. Com base em nossa experiência em cirurgia robótica, apresentamos uma série de casos operados com uma técnica de bypass gástrico em Y de Roux robótico (rRYGB) padronizada, bem como seus resultados. Métodos: foi realizada uma revisão de um banco de dados prospectivamente de pacientes submetidos à cirurgia robotica de bypass gastrico em Roux en Y entre abril de 2015 e julho de 2019. A técnica cirúrgica é descrita e ilustrada. Também relatamos dados demográficos dos pacientes, resultados e seu acompanhamento. Resultados: uma análise retrospectiva identificou 329 pacientes submetidos ao bypass gástrico em Y de Roux robótico. Ambas as plataformas da Vinci, Si e Xi foram usadas. A média de idade foi de 34,4 anos, com mediana de IMC de 44,2 kg/m2. O tempo médio do console foi de 102 min e não houve conversão. Nenhuma taxa de readmissão hospitalar cirurgica foi observada nos primeiros 30 dias. Conclusão: este estudo representa a experiência inicial de bypass gástrico em Y-de-Roux robótico (rRYGB), seus resultados iniciais e uma padronização da técnica cirúrgica. Nossos resultados são encorajadores, com uma técnica viável, segura, e potencial benefício ao paciente mostrando bons resultados e mínimas complicações.

Preoperative botulinum toxin type A: A case report of a proposed new strategy for giant hiatal hernia management.

The use of preoperative ventral botulinum toxin for giant hiatal hernia management.

PRIMARY ABANDON-OF-THE-SAC (PAS) TECHNIQUE: PRELIMINARY RESULTS OF A NOVEL MINIMALLY INVASIVE APPROACH FOR INGUINOSCROTAL HERNIA REPAIR.

BACKGROUND: Laparoscopic best approach of repairing inguinoscrotal hernias are still debatable. Incorrect handling of the distal sac can possibly result in damage to cord structures and negative postoperative outcomes as ischemic orquitis or inguinal neuralgia. AIM: To describe a new technique for a minimally invasive approach to inguinoscrotal hernias and to analyze the preliminary results of patients undergoing the procedure. METHODS: A review of a prospectively maintained database was conducted in patients who underwent minimally invasive repair using the "primary abandon-of-the-sac" (PAS) technique for inguinoscrotal hernias. Patient´s demographics, as well as intraoperative variables and postoperative outcomes were also analyzed. RESULTS: Twenty-six male were submitted to this modified procedure. Mean age of the case series was 53.8 years (range 34-77) and body mass index was 26.8 kg/m2 (range 20.8-34.2). There were no intraoperative complications or conversion. Average length of stay was one day. No surgical site infections, pseudo hydrocele or neuralgia were reported after the procedure and two patients presented seroma. No inguinal hernia recurrence was verified during the mean 21.4 months of follow up. CONCLUSION: The described technique is safe, feasible and reproducible, with good postoperative results.

Standardization and ten essential steps in the lateral robotic extended totally extraperitoneal (eTEP) repair of ventral hernias.

OBJECTIVES: described by Dr. Jorge Daes, principles of the enhanced view totally extraperitoneal (eTEP) has been widely used in the armamentarium of ventral hernia repair recently. Robotic assisted eTEP technique feasibility has been proved, however, a complete understanding of retromuscular abdominal wall planes and its landmarks still uncertain in a majority of general surgeons. The aim of this report is to propose a technical standardization and its anatomic concepts in the robotic-assisted eTEP ventral hernia repair. METHODS: our group describes 10 key steps in a structured step-by-step approach for a safe and reproducible repair based on well defined anatomic landmarks, identification of zones of dissection and correct restoration of the linea alba. RESULTS: the standardization has been developed 2 years ago and applied to all patients. A robotic-assisted surgery with 3 robotic arms is performed in a lateral docking setup. Feasibility is established and reproducibility is high among general surgeons. CONCLUSION: we present a standardized side docking robotic assisted eTEP approach for ventral hernia repairs with 10 key steps. We believe understanding the landmarks and a step-by-step guidance based on the concepts of retromuscular abdominal wall anatomy foment a safe learning of minimally invasive restoration of the abdominal wall integrity regarding non-expert surgeons.

Unusual cause of appendicitis. A case report of acute appendicitis caused by needle ingestion.

INTRODUCTION: Appendicitis is an acute inflammatory process. The purpose of this report is to describe an unusual case of acute appendicitis in adult caused by accidental ingestion of a needle, and treated with appendectomy. PRESENTATION OF CASE: A 64 year-old white woman, seamstress, was admitted with abdominal pain complaints. Plain radiograph and CT scan showed metal density suggesting a foreign body in the lower right abdomen. A diagnostic laparoscopic procedure identified a perforated appendicitis due to a needle perforation. Laparoscopic appendicectomy and foreign body removal were performed. DISCUSSION: Acute appendicitis due foreign body ingestion is extremely rare. Laparoscopy was the chosen access once it was more suitable for inventory of the gastrointestinal tract and help avoiding harm of the medical team during hand maneuvers of open access surgery. CONCLUSION: Foreign body ingestion should be remembered as an unusual differential diagnosis of acute appendicitis.