Long-term Results of Robotic Modified Belsey (Gastroesophageal Valvuloplasty) Fundoplication.

PURPOSE: Nissen fundoplication is associated with poor long-term durability, as well as dysphasia and gas bloat. We report here the long-term results of modified Belsey fundoplication (Gastroesophageal Valvuloplasty; GEV) performed laparoscopically using a surgical robot. METHODS: Patients who underwent robotic GEV were reviewed retrospectively. Operations were performed by laparoscopy and included robotic dissection of the esophageal hiatus, primary closure of the hiatus, followed by intussusception of a 4 cm segment of the esophagus into the stomach for 270°, and suspension of the fundoplication on the hiatal closure. The results were assessed by postoperative endoscopy, contrast esophagography, a Subjective Symptom Questionnaire (SSQ), and objective Visick grading. RESULTS: There were 291 patients (156 male, 135 female, mean age 51±14 years). Indications were intractability (73%) and pulmonary symptoms (27%). Mean operative time was 130 minutes ± 52 minutes. Minor complications were seen in 21%. There was no mortality. Mean hospitalization was 2.8 days ± 1.7 days. Mean follow-up was 85 months ± 7 months. During this period, the mean SSQ score decreased from 8.3 ± 0.6 to 0.7± 0.2 (P < 0.05). There was no long-term dysphasia or gas bloat. Ninety-five percent of patients were Visick I and 5% were Visick II. Hiatal hernia recurred in 7 patients (2%). CONCLUSIONS: Robotic laparoscopic modified Belsey fundoplication (GEV) is associated with excellent long-term durability, reflux control, and low rates of dysphasia and gas bloat. This procedure may represent an alternative to medical antireflux therapy and other surgical antireflux procedures such as Nissen fundoplication.

Surgical Transcatheter Aortic Valve Replacement Explantation Technique.

As transcatheter aortic valve replacement (TAVR) indications expand, cardiac surgeons need to be prepared to manage heretofore rare TAVR complications requiring explantation, such as acute type A dissection, in these typically high-risk patients. This report describes the successful use of an explantation technique that is ready to hand, efficient, and effective at avoiding further injury to the aortic root and coronary ostia.

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.

Robotic liver surgery: literature review and future perspectives.

INTRODUCTION: Minimally invasive liver resections (MILR) have been gaining popularity over the last decades. MILR provides superior peri-operative outcome. Despite these advantages, the penetrance of MILR in the clinical setting has been limited, and it was slowed down, among other factors, also by the laparoscopic technological limitations. EVIDENCE ACQUISITION: A literature review has been carried out (Pubmed, Embase and Scopus platforms) focusing on the role of robotic surgery in MILR. EVIDENCE SYNTHESIS: The literature review results are presented and our additional remarks on the topic are discussed. CONCLUSIONS: Robotic MILR has been helping to expand the penetrance of MIS in liver surgery by making possible increasingly more challenging procedures. Minor resections still represent most of the robotic liver surgery data currently available. Robotic liver surgery is safe and effective, and it shows perioperative outcomes comparable with laparoscopic and open surgery. The oncological efficacy, within the limitations of the current level of evidence (mostly retrospective studies and literature heterogeneity), seems to show promising result. High quality prospective randomized studies, the use of prospective registry data, and multi-institutional efforts are needed.

Robotic resection of a large ovarian leiomyoma.

Uterine leiomyomata are the most frequent leiomyomata. However, this benign tumor can also arise in unusual locations (e.g. ovaries, urethra, bladder and vulva). The diagnostic process of ovarian leiomyomata can be difficult, and it is mostly incidental: the lesions are usually small and the clinical presentation is mainly asymptomatic. Since the first case described in 1862, less than 100 cases have been described. Some of these lesions have been treated laparoscopically. To our knowledge, this is the first worldwide case of an ovarian leiomyoma treated with a robotic approach (surgeon: Prof. P.C. Giulianotti, M.D., F.A.C.S.). Moreover, we provide an overview of the recent literature, and an intraoperative video of the intervention.

Robotic transthoracic first-rib resection for Paget-Schroetter syndrome.

OBJECTIVES: First-rib resection is a key component in the treatment of Paget-Schroetter syndrome. We report our experience with robotic first-rib resection. METHODS: Patients diagnosed with Paget-schroetter syndrome underwent thrombolysis followed by robotic first-rib resection. The diagnosis was made by preoperative venography (VA) and magnetic resonance venography. The robot was used to dissect the first rib, disarticulate the costosternal joint and divide the scalene muscles. Success of the first-rib resection was assessed by physical examination, venogram and magnetic resonance venography. RESULTS: Eighty-three robotic first-rib resections were performed (49 men and 34 women). The mean age of the patients was 24 years ± 8.5 years. The operative time was 127.6 min ± 20.8 min. The median hospitalization was 4 days. There were no surgical complications, neurovascular injuries or mortality. Patients with a patent subclavian vein on the postoperative venogram (57 of 83 patients, 69%) were anticoagulated with warfarin for 3 months. In the remaining 27 patients with a persistent postoperative occlusion of the subclavian vein, 21 (21 of 83 patients, 24%) underwent angioplasty and were anticoagulated with warfarin for 3 months, and 6 (6 of 83, 7%) required stent placement to achieve complete vein patency. Patients who underwent stent placement received antiplatelet therapy in addition to warfarin anticoagulation for 3 months. At a median follow-up of 24 months, all patients had an open subclavian vein with a patency rate of 100%. CONCLUSIONS: The robotic transthoracic first-rib resection is feasible and allows for a minimally invasive resection of the first rib, while minimizing neurovascular complications.

Reasons for open conversion in robotic liver surgery: A systematic review with pooled analysis of more than 1000 patients.

BACKGROUND: Conversion to open during minimally invasive liver resection has a high rate. To identify the reasons to convert could help in defining a strategy to decrease the event "conversion." METHODS: A systematic review has been performed. Our large series of robotic hepatic resections were analyzed and included in the review. RESULTS: Fifty papers were selected and carefully evaluated in full text. Twenty-nine were ultimately used for analysis, including all published robotic liver resections. Our series included 11 conversions out of 139 patients (7.9%). Adhesions were not a declared reason to convert. The robotic approach still had a high percentage of open conversions because of difficulties in assessing the tumor margin. CONCLUSIONS: Causes for conversion were carefully analyzed and compared with what previously described for the pure laparoscopic approach. This could be crucial in defining how to improve the performance and minimize the conversion rate.

Development of diabetes mellitus in living pancreas donors and recipients.

Previously, recurrence of insulin-dependent diabetes mellitus after pancreas transplants was only sporadically reported. Newer data, however, indicate recurrence rates as high as 5%. After identical-twin pancreas transplants, diabetes recurs in the absence of immunosuppressive therapy - strong evidence that it is an autoimmune disease. After deceased donor pancreas transplants, immunologic markers (autoantibodies, autoreactive T cells) herald recurrence. Selective destruction of ß cells, still relatively uncommon, is not restricted to MHC compatibility. The development of diabetes in living pancreas donors is rare; it can be largely avoided by meticulous metabolic evaluation before donation and prevention of obesity after donation.