Robotic single-port surgery: Preliminary experience in general surgery.

BACKGROUND: We aim to analyse the safety and feasibility of the DaVinci Single Port (SP) platform in general surgery. METHODS: A prospective series of robotic SP transabdominal pre-peritoneal inguinal hernia repairs (SP-TAPP) and cholecystectomies (SP-C) (off-label) were analysed. Primary endpoints were safety and feasibility defined by the need for conversion and incidence of perioperative complications. RESULTS: A total of 225 SP procedures were performed; 84 (37.3%) SP-TAPP (70 unilateral, 7 bilateral), and 141 (62.7%) SP-C. There were no conversions or additional ports placed. Mean console time was 17.6, 31.9, and 54 min for SP-C, unilateral, and bilateral SP-TAPP, respectively. There was no mortality, intraoperative or major postoperative complications. Mean LOS was 2.7 h for elective SP-TAPP and 2.3 h for SP-C. CONCLUSION: Robotic SP surgery is safe and feasible for two of the most performed general surgery operations. Further experience might allow expanding the applications of robotic single-incision surgery for other procedures.

Acute Hiatal Hernia with Incarcerated Proximal Half of Recent Sleeve Gastrectomy: Super Rare Complication.

BACKGROUND: Vertical sleeve gastrectomy (VSG) has become the most commonly performed operation for the treatment of morbid obesity (JAMA. 312(9):959-61, 2014). Nevertheless, VSG is still associated with some early postoperative complications (JAMA. 312(9):959-61, 2014; Surg Obes Relat Dis. 9(5):816-29, 2013; Obes Surg. 27(8):1944-1951, 2017). Hiatal hernia is a complication that has been widely described in the literature, but not in the immediate postoperative course (Obes Surg. 17(7):962-9, 2007). We, herein, report a case of an acute postoperative hiatal hernia after sleeve gastrectomy. METHODS: A 29-year-old female (BMI 38.54 kg/m2) presented to our center and her options for metabolic surgery were discussed. Laparoscopic sleeve gastrectomy (LSG) was the chosen procedure. Preoperative assessment includes a chest x-ray, and standard lab-work up was within a normal limit. Barium swallow did not show any evidence of hiatal hernia. She underwent a LSG. On POD 1, she was able to pass the bariatric clears trial and was discharged home. Three days after discharge, the patient was complaining of constant nausea and vomiting, and chest pain, and was diagnosed with acute hiatal hernia with the incarceration of the proximal sleeve. The patient was taken to the operating room. RESULTS: Postoperatively, the patient started on the usual bariatric clinical pathway which she tolerated well and was discharged on the POD 4. The operative time was 156 min. The estimated blood loss was 50 ml. CONCLUSIONS: Our report highlights the need for more broad differential diagnosis in early post sleeve gastrectomy patients. Those who are presented with nausea and vomiting in the early postoperative period should be evaluated for possible post sleeve hiatal hernia with a potential risk of strangulation.

Robot-assisted enucleation of gigantic liver hemangiomas: Case series of 3 patients.

INTRODUCTION: Liver hemangiomas are benign liver lesions that require surgical excision when large and symptomatic. Often, these tumors are removed through large anatomical resections which sacrifice more liver parenchyma than needed. Tumor enucleation, which takes advantage of a digitoclasia-like technique along the plane between the tumor pseudo-capsule and liver parenchyma, poses challenges when performed laparoscopically. We propose a parenchymal sparing, minimally invasive, robotic-assisted technique to remove liver hemangiomas. PRESENTATION OF CASES: Three male patients with symptomatic hemangiomas were treated in our center between 2015 and 2018. The lesions were located in segment II, III and segment IV-V respectively. Robotic-assisted hemangioma enucleation was accomplished successfully in all three patients. The procedures were performed with a parenchyma-sparing intent and a formal segmentectomy was not required. There were no conversions to open surgery. DISCUSSION: The robotic platform provides a powerful tool in the enucleation of liver hemangiomas. The enhanced vision and the superior suturing ability allow to develop safely the plane between the tumor pseudo-capsule and the liver parenchyma, with outstanding selective control of all the vascular supply and drainage encountered during the dissection. Furthermore, precision of the hilar dissection allows selective lobar or sectorial arterial control which helps minimize intraoperative bleeding. CONCLUSION: In our experience, robot-assisted enucleation of liver hemangiomas offers low morbidity, fast recovery, excellent cosmetic results, and it could become a therapeutic option when the location of the hemangioma allows this approach.