New Robotic Platforms in General Surgery: What's the Current Clinical Scenario?

Background and Objectives: Robotic surgery has been widely adopted in general surgery worldwide but access to this technology is still limited to a few hospitals. With the recent introduction of new robotic platforms, several studies reported the feasibility of different surgical procedures. The aim of this systematic review is to highlight the current clinical practice with the new robotic platforms in general surgery. Materials and Methods: A grey literature search was performed on the Internet to identify the available robotic systems. A PRISMA compliant systematic review was conducted for all English articles up to 10 February 2023 searching the following databases: MEDLINE, EMBASE, and Cochrane Library. Clinical outcomes, training process, operating surgeon background, cost-analysis, and specific registries were evaluated. Results: A total of 103 studies were included for qualitative synthesis after the full-text screening. Of the fifteen robotic platforms identified, only seven were adopted in a clinical environment. Out of 4053 patients, 2819 were operated on with a new robotic device. Hepatopancreatobiliary surgery specialty performed the majority of procedures, and the most performed procedure was cholecystectomy. Globally, 109 emergency surgeries were reported. Concerning the training process, only 45 papers reported the background of the operating surgeon, and only 28 papers described the training process on the surgical platform. Only one cost-analysis compared a new robot to the existing reference. Two manufacturers promoted a specific registry to collect clinical outcomes. Conclusions: This systematic review highlights the feasibility of most surgical procedures in general surgery using the new robotic platforms. Adoption of these new devices in general surgery is constantly growing with the extension of regulatory approvals. Standardization of the training process and the assessment of skills' transferability is still lacking. Further studies are required to better understand the real clinical and economical benefit.

Detection and management of bile duct injury during cholecystectomy.

INTRODUCTION: Cholecystectomy represents one of the most performed surgical procedures. Bile duct injuries (BDIs) are a dangerous complication of this intervention. With the advent of the laparoscopy, the rate of BDIs showed a growing trend that was partially justified by the learning curve of this technique. EVIDENCE ACQUISITION: A literature search was conducted on Embase, Medline, and Cochrane databases to identify studies published up to October 2022 that analyzed the intraoperative detection and management of BDIs diagnosed during cholecystectomy. EVIDENCE SYNTHESIS: According to the literature, approximately 25% of BDIs is diagnosed during the laparoscopic cholecystectomy. In the clinical suspicion of BDI, an intraoperative cholangiography is performed to confirm it. Complimentary technology, such as near-infrared cholangiography, can be also adopted. Intraoperative ultrasound represents a useful tool to furtherly define the biliary and the vascular anatomy. The proper classification of the type of BDI allows to identify the correct treatment. When a good expertise in hepato-pancreato-biliary surgery is available, a direct repair is performed with good outcomes both in case of simple and complex lesions. When the local resources are limited or there is a lack of dedicated surgical experience, patient referral to a reference center shows better outcomes. In particular, complex vasculo-biliary injuries require a highly specialized treatment. The key elements to transfer the patients are a good documentation of the injury, a proper drainage of the abdomen, and an antibiotic therapy. CONCLUSIONS: BDI management requires a proper diagnostic process and prompt treatment to reduce the morbidity and mortality of this feared complication occurring during cholecystectomy.