Preserving vascular integrity during totally robotic sigmoidectomy: unleashing the power of vessel-sparing precision.

BACKGROUND: This study assesses the feasibility, safety, and clinical utility of vessel-sparing approach in totally robotic sigmoidectomy for adenocarcinoma. MATERIAL AND METHODS: A comprehensive protocol for completely vessel-sparing robotic sigmoidectomy (VsRS) was established at the authors' institution from January 2019 through December 2020. Surgical and pathological outcomes were indagated and compared with results of current literature. RESULTS: The study population consisted of 34 patients. The median number of examined lymph nodes (ELN) was 21 (range 15-28); the median number of positive lymph nodes (PLN) was 0 (range 0-8). Mean operative time was 240 min (sd 43.56, range 180-360 min), and conversion to open rate was 0%. Anastomotic leak rate was 0%. The median follow-up period was 28 months CONCLUSION: This pilot series represents a significant step forward in the development of completely vessel-sparing sigmoidectomy for adenocarcinoma. The study demonstrates the safety and feasibility of this innovative approach, which aims to achieve oncological radicality while preserving vital vascular structures. Notably, the postoperative outcomes observed in this study were comparable to those reported in the existing literature for the current standard of care at high-volume centers. Nevertheless, further validation through prospective and controlled investigations is essential before this technique can be fully incorporated into clinical practice.

Intrathoracic Robotic-Sewn Anastomosis During Ivor Lewis Esophagectomy for Cancer: Back to Basics?

BACKGROUND: To assess the feasibility, clinical utility, and safety of intrathoracic robotic-sewn esophageal anastomosis (IrEA) during Ivor Lewis esophagectomy for adenocarcinoma of the lower third of the esophagus, or cancer at the gastro-esophageal junction type I (Siewert classification). METHODS: A protocol for completely robotic Ivor Lewis esophagectomy (CrIE) and intrathoracic robotic-sewn anastomosis (IrEA) was established at the authors' institutions from January 2015 through December 2019. Overall surgery-related postoperative complications were analyzed. Overall survival and disease-free survival analysis were performed using standard methods. RESULTS: The study population consisted of 40 patients. Median operative time was 320 min (sd 62, range 235-500 min), and conversion to open rate was 0%. Anastomotic leak rate was 10%. The mean number of examined lymph nodes (ELN) was 19 (IQR 11-29), and the mean number of positive lymph nodes (PLN) was 3 (IQR 0-5). Short- and long-term surgical and oncological outcomes were comparable at a medium follow-up of 37 months. The median overall survival was 48 months while the mean disease-free survival was 29 months. CONCLUSION: This pilot series, in which an intrathoracic robotic-sewn anastomosis (IrEA) was performed during CrIE, demonstrated the safety and feasibility of this approach. Compared to the current standard of care at a high-volume center, IrEA was associated with better postoperative surgical outcomes and similar oncological outcomes to those reported worldwide today. These results call for further validation in a prospective and controlled setting to be fully incorporated into clinical practice.

Robotic right colectomy with robotic-sewn anastomosis: a pilot case series.

The background of this study is to assess the feasibility, clinical utility and safety of intra-corporeal robotic-sewn anastomosis (ICrA) in completely robotic right hemicolectomy (CRH) for adenocarcinoma. A protocol for completely robotic right hemicolectomy (CRH) and intra-corporeal robotic-sewn anastomosis (ICrA), was established at the authors' institution from January 2012 through December 2017. Univariate and multivariable models were constructed to explore the prognostic significance of clinical and surgical findings. Survival and recurrence analysis were performed using standard univariable and multivariable methods. The study population consisted of 123 patients. The median number of examined lymph nodes (ELN) was 25 (range 1-59), the median number of positive lymph nodes (PLN) was 1 (range 0-21). Mean operative time was 240 min (SD 43.56, range 180-360 min), and conversion to open rate was 0%. Anastomotic leaks rate was 1.6%. The median overall survival was 69 months. This pilot series, in which an intra-corporeal robotic-sewn anastomosis (ICrA) was performed during CRH, demonstrated the safety and feasibility of this approach. Compared to the current standard of care at a high-volume center, ICrA was associated with post-operative surgical outcomes similar to those reported in the literature. These results call for further validation in a prospective and controlled setting to be fully incorporated into clinical practice.

Coronary artery stent for securing pancreatico-jejunal anastomosis after PD: The "Huscher technique".

The "Medici effect" is known as the effect that arises when the intersection of interrelated disciplines manifests an enriching link for the involved disciplines in their own identity. To a certain extent, we think that the "Medici Effect" can be applied in any field; more specifically we applied this concept in pancreatic surgery. So, may we borrow coronary stents from cardiology to settle pancreatic-jejunostomy (PJ) issues after pancreaticoduodenectomy (PD)?

Laparoscopic treatment of blunt splenic injuries: initial experience with 11 patients.

BACKGROUND: Nonoperative treatment of splenic injuries is the current standard of care for hemodynamically stable patients. However, uncertainty exists about its efficacy for patients with major polytrauma, a high Injury Severity Score (ISS), a high grade of splenic injury, a low Glasgow Coma Score (GCS), and important hemoperitoneum. In these cases, the videolaparoscopic approach could allow full abdominal cavity investigation, hemoperitoneum evacuation with autotransfusion, and spleen removal or repair. METHODS: This study investigated 11 hemodynamically stable patients with severe polytrauma who underwent emergency laparoscopy. The mean ISS was 29.0 +/- 3.9, and the mean GCS was 12.1 +/- 1.6. A laparoscopic splenectomy was performed for six patients, whereas splenic hemostasis was achieved for five patients, involving one electrocoagulation, one polar resection, and three polyglycolic mesh wrappings. RESULTS: The average length of the operation was 121.4 +/- 41.6 min. There were two complications (18.2%), with one conversion to open surgery (9.1%), and no mortality. CONCLUSIONS: Laparoscopy is a safe, feasible, and effective procedure for evaluation and treatment of hemodynamically stable patients with splenic injuries for whom nonoperative treatment is controversial.

Combining ultrasonic dissection and the Storz operation rectoscope.

BACKGROUND: Transanal endoscopic microsurgery (TEM) allows a precise, full-thickness resection of rectal tumors anywhere within the rectum. Unfortunately, the standard TEM technique needs complex and rather expensive equipment, demands high skill, and is attended by bleeding and oozing that may be challenging. A modified TEM procedure combining the new Storz operation rectoscope and ultrasonic dissection has been developed to overcome the limitations of the original technique. METHODS: The Storz operation rectoscope features a 5-mm telescope combined with a single-monitor display. Standard laparoscopic instruments and the LCSC5 Ultracision Maniple are used for dissection and coagulation. Full-thickness resection is performed most often. Closure of the defect is accomplished by interrupted 3-0 polydoxanone sutures secured by extracorporeal slipknots. RESULTS: Altogether, 18 TEMs have been performed according to the modified technique: 9 for malignant and 9 for benign lesions. The median operating time was 92.5 min for resection of malignant lesions and 40 min for resection of benign lesions. Two postoperative complications occurred: a bleeding and a partial dehiscence. The median follow-up periods were 35 months for malignant disease and 19.5 months for benign disease. No recurrence was observed. CONCLUSION: For tumors located up to 15 cm from the anal verge, TEM with the Storz rectoscope and ultrasonic dissection is indicated. Despite the complication described, coagulation is optimal and ultrasonic scissors allow working in a fairly bloodless field. The overall costs of the equipment are significantly lower.

Laparoscopic cholecystectomy by ultrasonic dissection without cystic duct and artery ligature.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the gold standard treatment of gallstones. Nevertheless, there are some pitfalls due to the limits of current technology and the use of inappropriate ligature material, with a relevant risk of injuries and postoperative, mainly biliary, complications. Ultrasonically activated scissors may divide both vessels and cystic duct, with no need of further ligature, and possibly reduce the risk of thermal injuries. METHODS: A prospective nonrandomized clinical trial was started in 1999 to test harmonic shears (Ultracision, Ethicon Endo-Surgery, Cincinnati, OH, USA) in 461 consecutive patients undergoing LC in order to evaluate the theoretical benefits of ultrasonic dissection and the possible reduction in intraoperative bile duct injuries (BDIs) and postoperative complications. Patients were divided in two groups: in group 1 (HS; 331 patients) the operation was performed by Ultracision (including coagulation-division of cystic duct and artery); in group 2 (LOOP; 130 patients) the cystic duct, after coagulation-division by harmonic scissors, was further secured with an endo-loop. Both groups were further divided into two subgroups: expert and surgeon-in-training. The following categories of data were collected and analyzed: individual patient data, indication for laparoscopic cholecystectomy, surgical procedure data (associated procedures, intraoperative cholangiography, intraoperative complications, length of surgery, and conversion to open), and postoperative course data (postoperative morbidity, postoperative mortality, reinterventions, and postoperative hospital stay). Furthermore, biliary complications were analyzed as a single parameter comparing the incidence within groups and subgroups. Cumulative complications (intraoperative and postoperative) were also analyzed as a single parameter comparing their incidence in the series of each surgeon within the surgeon-in-training subgroup to the average results of the expert subgroup. Finally, length of surgery, postoperative complication rate, and length of postoperative hospital stay within subgroups were analyzed to evaluate the learning curve. RESULTS: Overall conversion rate was 0.87%. The mean operating time was 76.8 min (median, 70 min) in group 1 and 97.5 min (median 90 min) in group 2. BDI occurred in 1 case (0.32%) in the surgeon-in-training subgroup. Overall BDI rate was 0.22% (1/461). The overall incidence of postoperative bile leak was 2.7% (9 patients of subgroup 1 and 1 patient of subgroup 2). Clinical observation with spontaneous resolution occurred in 4 patients, and in 1 case the management consisted in an endoscopic biliary drainage; surgery was requested in the remaining cases. A laparoscopic approach was successfully attempted in all cases. Overall morbidity rate was 8.76% in group 1 and 13.84% in group 2. Rates of major complications, overall biliary complication, and postoperative bile leaks within the expert and surgeon-in-training subgroup differ significantly (p = 0.026, p = 0.03, and p = 0.049, respectively). There was 1 death (0.22%) due to sepsis that resulted from a small bowel injury by trocar insertion. Mean postoperative stay was 4.28 days for group 1 and 5.05 days for group 2. CONCLUSION: No significant difference was found in both patient groups regarding postoperative mortality and complications, biliary complications, and especially cystic duct leaks. A retrospective comparison of literature data showed that use of ultrasonic dissection during LC seems to reduce the risk of BDI. Nevertheless, a learning curve in the use of ultrasonic-activated devices is required: a significant differences in postoperative major complications and biliary complications between the expert and the surgeon-in-training subgroups was shown. Furthermore, ultrasonic scissors misuse may cause bowel injuries in patients with severe adhesions, and this could represent a possible limitation for surgical safety.