Microfracture-coagulation for the real robotic liver parenchymal transection.

The use of the robotic approach in liver surgery is exponentially increasing. Although technically the robot introduces several innovative features, the instruments linked with the traditional laparoscopic approach for the liver parenchymal transection are not available, which may result in multiple technical variants that may bias the comparative analysis between the different series worldwide. A real robotic approach, minimally efficient for the liver parenchymal transection, with no requirement of external tool, available for the already existing platforms, and applicable to any type of liver resection, counting on the selective use of the plugged bipolar forceps and the monopolar scissors, or "microfracture-coagulation" (MFC) transection method, is described in detail. The relevant aspects of the technique, its indications and methodological basis are discussed.

Robotic liver surgery: A new reality. Descriptive analysis of 220 cases of minimally invasive liver surgery in 182 patients.

INTRODUCTION: The level of recommendation of the robotic approach in liver surgery is controversial. The objective of the study is to carry out a single-center retrospective descriptive analysis of the short-term results of the robotic and laparoscopic approach in liver surgery during the same period. METHODS: Descriptive analysis of the short-term results of the robotic and laparoscopic approach on 220 resections in 182 patients undergoing minimally invasive liver surgery. RESULTS: Between April 2018 and June 2022, a total of 92 robotic liver resections (RLR) were performed in 83 patients and 128 laparoscopic (LLR) in 99 patients. The LLR group showed a higher proportion of major surgery (P < .001) and multiple resections (P = .002). The two groups were similar in anatomical resections (RLR 64.1% vs. LLR 56.3%). In the LLS group, the average operating time was 212 min (SD 52.1). Blood loss was 276.5 mL (100-1000) and conversion 12.1%. Mean hospital stay was 5.7 (SD 4.9) days. Morbidity was 27.3% and 2% mortality. In the RLS group, the mean operative time was 217 min (SD 53.6), blood loss 169.5 mL (100.900), and conversion 2.5%. Mean hospital stay was 4.1 (SD 2.1) days. Morbidity was 15%, with no mortality. CONCLUSION: Minimally invasive liver surgery is a safe technique, and in particular, RLS allows liver resections to be performed safely and reproducibly; it appears to be a non-inferior technique to LLS, but randomized studies are needed to determine the minimally invasive approach of choice in liver surgery.

Augmented reality in hepatobiliary-pancreatic surgery: a technology at your fingertips.

Augmented reality is a technology that opens new possibilities in surgery. We present our experience in a hepatobiliary-pancreatic surgery unit in terms of preoperative planning, intraoperative support and teaching. For surgical planning, we have used 3D CT and MRI reconstructions to evaluate complex cases, which has made the interpretation of the anatomy more precise and the planning of the technique simpler. At an intraoperative level, it provides for remote holographic connection between specialists, the substitution of physical elements for virtual elements, and the use of virtual consultation models and surgical guides. In teaching, new lessons include sharing live video of surgery with the support of virtual elements for a better student understanding. As the experience has been satisfactory, augmented reality could be applied in the future to improve the results of hepatobiliary-pancreatic surgery.

Laparoscopic and robotic distal pancreatectomy: the choice and the future.

INTRODUCTION: Distal pancreatectomy (DP) is currently well established as a minimally invasive surgery (MIS) procedure, using either a laparoscopic (LDP) or robotic (RDP) approach. METHODS: Out of 83 DP performed between January 2018 and March 2022, 57 cases (68.7%) were performed using MIS: 35 LDP and 22 RDP (da Vinci Xi). We have assessed the experience with the two techniques and analyzed the value of the robotic approach. Cases of conversion have been examined in detail. RESULTS: The mean operative times for LDP and RDP were 201.2 (SD 47.8) and 247.54 (SD 35.8) minutes, respectively (P = NS). No differences were observed in length of hospital stay or conversion rate: 6 (5-34) vs. 5.6 (5-22) days, and 4 (11.4%) vs. 3 (13.6%) cases, respectively (P = NS). The readmission rate was 3/35 patients (11.4%) treated with LDP and 6/22 (27.3%) cases of RDP (P = NS). There were no differences in morbidity (Dindo-Clavien ≥ III) between the two groups. Mortality was one case in the robotic group (a patient with early conversion due to vascular involvement). The rate of R0 resection was greater and statistically significant in the RDP group (77.1% vs. 90.9%) (P = .04). CONCLUSION: Minimally invasive distal pancreatectomy (MIDP) is a safe and feasible procedure in selected patients. Surgical planning and stepwise implementation based on prior experience help surgeons successfully perform technically demanding procedures. RDP could be the approach of choice in distal pancreatectomy, and it is not inferior to LDP.

Indocyanine green (ICG) fluorescent cholangiography in laparoscopic cholecystectomy: Simplifying time and dose.

BACKGROUND: This article aims to analyze and to simplify the optimal dose and time of intravenous indocyanine green (ICG) administration to achieve the identification of the cystic duct and the common bile duct (CBD). METHODS: A consecutive series of 146 patients was prospectively analyzed and divided into three groups according to the time of ICG administration: at induction of anesthesia group (20-30 min); hours before group (between 2 and 6 h); and the day before group (≥6 h); and two groups according to the dose of ICG: 1 cc (2.5 mg) or weight-based dose (0.05 mg/kg). RESULTS: The CBD was better visualized in the at induction of anesthesia group (85.4%), in the hours before group (97.1%) (p = 0.002) and in the 1cc group (p = 0.011). When we analyzed the 1 cc group (n = 126) a greater visualization of the CBD was observed in the at induction of anesthesia group (86.7%) and in the hours before group (97.1%) (p = 0.027). CONCLUSION: Due to its simplicity and reproducibility, we suggest a dose of 2.5 mg administered 2-6 h before the procedure is the optimal. However, ICG administered 30 min prior to the surgery is enough for adequate visualization of biliary structures.

Venous resection in pancreatic oncologic surgery: Different techniques for different situations.

INTRODUCTION: To report the clinical results of patients with malignant pancreatic lesions who underwent oncological surgery with vascular resection. The type of intervention performed, types of vascular reconstruction, the pathological anatomy results, postoperative morbidity and mortality, and survival at 3 and 5 years were analyzed. METHODS: Retrospective, cross-sectional and comparative analysis. We include 41 patients with malignant pancreatic lesions who underwent surgery with vascular resection due to vascular involvement, from 2013 to 2021. RESULTS: The most performed surgery was pancreaticoduodenectomy (Whipple procedure) using median laparotomy, in 35 out of the 41 patients (85%). One of the cases in the series was performed laparoscopically. Type 1 reconstruction (simple suture) was performed in 11 (27%) patients, type 2 in 4 (10%) cases, type 3 (end-to-end) in 23 (56%) cases, and type 4 reconstruction by autologous graft in 3 (7%) cases. The mean length of the resected venous segment was 21 (11-46) mm, and mean surgical time was 290 (220-360) minutes. 90% (37/41) were pancreatic adenocarcinoma. 83% were considered R0, and there was involvement in the resected vascular section in 41% of the cases. Four patients had Clavien Dindo morbidity >3, and there were no cases of postoperative mortality. Survival at 3 years was 48% and at 5 years 20%. CONCLUSIONS: The aggressive surgical treatment with venous resection in pancreatic malignant lesions to ensure R0 and its vascular reconstruction is a feasible technique, with an acceptable morbid-mortality rate and overall survival.

Challenge and future of liver and pancreatic robotic surgery. Analysis of 64 cases in a specialized unit.

INTRODUCTION: Robotic surgery has proven effective in certain surgical procedures. However, in liver and pancreatic surgery (HBP) its use is still rare. The initial experience in HBP robotic surgery of a specialized unit of a tertiary hospital is presented. METHOD: The results of patients undergoing robotic HBP surgery between April 2018 and October 2020 have been prospectively studied. The data analyzed correspond to demographic data, surgical techniques performed, associated morbidity and mortality. RESULTS: 64 patients were operated, corresponding to 35 hepatectomies (major [6.7%], anatomic [52.9%], limited [34.4%], cystectomies [3%] and marsupialization [3%]), 29 pancreatectomies (distal [48.2%], central [6.9%], cephalic [13.8%], enucleations [24.1%], ampullectomies [3.5%] and duodenal resections [3.5%]). In liver surgery the mean operative time was 204.4 min (100-265 min), the median postoperative complications according to the Clavien-Dindo scale was one (1-4), the mean blood losses 166.7 mL (100-300 mL), there was no conversion and the mean postoperative stay was four days (2-14 days). In pancreatic surgery, the mean operative time was 243.8 min (125-460 min), the median of postoperative complications was two (1-4), blood loss of 202.3 mL (100-500 mL) associated to a conversion rate 17.8% and an average stay of seven days (3-23 days). CONCLUSIONS: Robotic HBP surgery is safe and feasible. It is suggested that its use facilitates parenchymal sparing surgery, access to posterior liver segments and anastomosis in pancreatic reconstruction compared to laparoscopic surgery.

Highs and lows in laparoscopic pancreaticoduodenectomy.

INTRODUCTION: Laparoscopic pancreaticoduodenectomy (PD) is not widely accepted, and its use is controversial. Only correct patient selection and appropriate training of groups experienced in pancreatic surgery and laparoscopy will be able to establish its role and its hypothetical advantages. METHODS: Out of 138 pancreatic surgeries performed in a two-year period (2017-2019), 23 were laparoscopic PD. We evaluate its efficacy and safety compared to 31 open PD. RESULTS: There were no cases of B/C pancreatic or biliary fistula, nor any cases of delayed gastric emptying in the laparoscopic group, but hemorrhage required one reoperation. The conversion rate was 21% (five cases): one due to bleeding, and the remainder for non-progression. The converted patients showed no differences compared to those completed by laparoscopy. There were no differences between laparoscopic and open PD in surgical time, postoperative complications, reintervention rate, readmissions or mortality. R0 resection in tumor cases was 85% for laparoscopy and 69% in open surgery without statistical significance. The postoperative hospital stay was shorter in the laparoscopic PD group (eight vs. 15 days). CONCLUSIONS: In a selected group, laparoscopic PD can be safely and effectively performed if carried out by groups who are experts in pancreatic surgery and advanced laparoscopy. The technique has the same postoperative results as open surgery and is oncologically adequate, with less hospital stay. Proper patient selection, a step-by-step program and a lax and early conversion prevents serious operating accidents.

Challenge and future of liver and pancreatic robotic surgery. Analysis of 64 cases in a specialized unit. / Desafío y futuro de la cirugía robótica hepática y pancreática. Análisis de 64 casos en una unidad especializada.

INTRODUCTION: Robotic surgery has proven effective in certain surgical procedures. However, in liver and pancreatic surgery (HBP) its use is still rare. The initial experience in HBP robotic surgery of a specialized unit of a tertiary hospital is presented. METHOD: The results of patients undergoing robotic HBP surgery between April 2018 and October 2020 have been prospectively studied. The data analyzed correspond to demographic data, surgical techniques performed, associated morbidity and mortality. RESULTS: 64 patients were operated, corresponding to 35 hepatectomies (major [6.7%], anatomic [52.9%], limited [34.4%], cystectomies [3%] and marsupialization [3%]), 29 pancreatectomies (distal [48.2%], central [6.9%], cephalic [13.8%], enucleations [24.1%], ampullectomies [3.5%] and duodenal resections [3.5%]). In liver surgery the mean operative time was 204.4 minutes (100-265 min), the median postoperative complications according to the Clavien-Dindo scale was one (1-4), the mean blood losses 166.7 mL (100-300 mL), there was no conversion and the mean postoperative stay was four days (2-14 days). In pancreatic surgery, the mean operative time was 243.8 minutes (125-460 min), the median of postoperative complications was two (1-4), blood loss of 202.3 mL (100-500 mL) associated to a conversion rate 17.8% and an average stay of seven days (3-23 days). CONCLUSIONS: Robotic HBP surgery is safe and feasible. It is suggested that its use facilitates parenchymal sparing surgery, access to posterior liver segments and anastomosis in pancreatic reconstruction compared to laparoscopic surgery.

Pneumoendoscopic single port approach to breast cancer. How we do it?

Endoscopic procedures have not become the gold standard in breast surgery. In order to improve today's outcomes we have developed a pilot study in the Breast Pathology Unit of Hospital Germans Trias i Pujol. A surgical procedure was performed creating a pneumoendoscopic cavity by using a Single Incision Laparoscopic Surgery (Single port) approach with a follow up of four years. Four patients underwent pneumoendoscopic single-port breast surgery receiving skin-sparing quadrantectomy and axillary surgery requiring lymphadenectomy in all of them. All patients had immediate reconstruction with a Latisimus Dorsi flap. No perioperative complications appeared. Mean operative time was 290 min (range 240-315 min) and mean hospital stay was 3,2 days. Surgical margins of all cases were pathologically negative and all patients were disease free after four years of monitoring. All patients were satisfied with the cosmetic outcome in the immediate postoperative and during the follow up. Although all innovative techniques generate hesitation on their beginnings and are liable to improve, we believe that pneumoendoscopic single-port breast surgery can be suitable for breast cancer, offering better cosmetic outcomes with oncological safety.

Highs and lows in laparoscopic pancreaticoduodenectomy. / Luces y sombras de la duodenopancreatectomía cefálica laparoscópica.

INTRODUCTION: Laparoscopic pancreaticoduodenectomy (PD) is not widely accepted, and its use is controversial. Only correct patient selection and appropriate training of groups experienced in pancreatic surgery and laparoscopy will be able to establish its role and its hypothetical advantages METHODS: Out of 138 pancreatic surgeries performed in a two-year period (2017-2019), 23 were laparoscopic PD. We evaluate its efficacy and safety compared to 31 open PD. RESULTS: There were no cases of B/C pancreatic or biliary fistula, nor any cases of delayed gastric emptying in the laparoscopic group, but hemorrhage required one reoperation. The conversion rate was 21% (five cases): one due to bleeding, and the remainder for non-progression. The converted patients showed no differences compared to those completed by laparoscopy. There were no differences between laparoscopic and open PD in surgical time, postoperative complications, reintervention rate, readmissions or mortality. R0 resection in tumor cases was 85% for laparoscopy and 69% in open surgery without statistical significance. The postoperative hospital stay was shorter in the laparoscopic PD group (eight vs. 15 days). CONCLUSIONS: In a selected group, laparoscopic PD can be safely and effectively performed if carried out by groups who are experts in pancreatic surgery and advanced laparoscopy. The technique has the same postoperative results as open surgery and is oncologically adequate, with less hospital stay. Proper patient selection, a step-by-step program and a lax and early conversion prevents serious operating accidents.

Desafío y futuro de la cirugía robótica hepática y pancreática. Análisis de 64 casos en una unidad especializada / Challenge and future of liver and pancreatic robotic surgery. Analysis of 64 cases in a specialized unit

Introducción: La cirugía robótica ha demostrado su eficacia en ciertos procedimientos quirúrgicos. Sin embargo, en cirugía hepática y pancreática (HBP) su uso es todavía poco frecuente. Se presenta la experiencia inicial en cirugía robótica HBP de una unidad especializada en un hospital de tercer nivel. Método: Se han estudiado en forma prospectiva los resultados de los pacientes intervenidos de cirugía HBP robótica entre abril de 2018 y octubre de 2020. Los datos analizados corresponden a datos demográficos, técnicas quirúrgicas realizadas y morbimortalidad asociada. Resultados Se intervinieron 64 pacientes, sometidos a 35 hepatectomías (mayores [6,7%], anatómicas [52,9%], limitadas [34,4%], quistectomías [3%] y marsupializaciones [3%]) y 29 pancreatectomías/resecciones duodenales (distales [48,2%], centrales [6,9%], cefálicas [13,8%], enucleaciones [24,1%], ampulectomías [3,5%] y resecciones duodenales [3,5%]).En cirugía hepática el tiempo operatorio medio fue de 204,4 minutos (100-265 min), la mediana de complicaciones postoperatorias según la escala de Clavien-Dindo fue de uno (1-4), las pérdidas hemáticas medias de 166,7 mL (100-300 mL), no existió conversión y la estancia postoperatoria media de cuatro días (2-14 días).En cirugía pancreática el tiempo operatorio medio fue de 243,8 minutos (125-460 min), la mediana de complicaciones postoperatorias de dos (1-4), las pérdidas hemáticas de 202,3 mL (100-500 mL) asociadas a una tasa de conversión del 17,8% y una estancia media de siete días (3-23 días). Conclusiones: La cirugía robótica HBP es segura y factible. Se sugiere que su uso facilita la cirugía conservadora de parénquima, el acceso a segmentos posteriores hepáticos y la realización de anastomosis en la reconstrucción pancreática respecto a la cirugía laparoscópica (AU)

Introduction: Robotic surgery has proven effective in certain surgical procedures. However, in liver and pancreatic surgery (HBP) its use is still rare. The initial experience in HBP robotic surgery of a specialized unit of a tertiary hospital is presented. results of patients undergoing robotic HBP surgery between April 2018 and October 2020 have been prospectively studied. The data analyzed correspond to demographic data, surgical techniques performed, associated morbidity and mortality.Results64 patients were operated, corresponding to 35 hepatectomies (major [6.7%], anatomic [52.9%], limited [34.4%], cystectomies [3%] and marsupialization [3%]), 29 pancreatectomies (distal [48.2%], central [6.9%], cephalic [13.8%], enucleations [24.1%], ampullectomies [3.5%] and duodenal resections [3.5%]).In liver surgery the mean operative time was 204.4 minutes (100-265 min), the median postoperative complications according to the Clavien-Dindo scale was one (1-4), the mean blood losses 166.7 mL (100-300 mL), there was no conversion and the mean postoperative stay was four days (2-14 days).In pancreatic surgery, the mean operative time was 243.8 minutes (125-460 min), the median of postoperative complications was two (1-4), blood loss of 202.3 mL (100-500 mL) associated to a conversion rate 17.8% and an average stay of seven days (3-23 days).Conclusions: Robotic HBP surgery is safe and feasible. It is suggested that its use facilitates parenchymal sparing surgery, access to posterior liver segments and anastomosis in pancreatic reconstruction compared to laparoscopic surgery (AU)

Luces y sombras de la duodenopancreatectomía cefálica laparoscópica / Highs and lows in laparoscopic pancreaticoduodenectomy

Introducción: La duodenopancreatectomía (DPC) laparoscópica no es ampliamente aceptada y su uso es controvertido. Únicamente una correcta selección de los pacientes y un aprendizaje adecuado por grupos con experiencia en cirugía pancreática y laparoscopia podrán establecer cuál es su papel y sus hipotéticas ventajas. Métodos: De 138 cirugías pancreáticas realizadas en un periodo de dos años (2017-2019) se realizaron 23 DPC laparoscópicas, incluyendo patología benigna y maligna. Se valora la eficacia y seguridad y se compara con 31 DPC abiertas en el mismo periodo. Resultados: No hubo casos de fístula pancreática B/C, biliar, ni retraso en vaciamiento gástrico en el grupo laparoscópico, pero apareció una hemorragia que obligó a una reintervención. El índice de conversión fue del 21% (cinco casos), uno por hemorragia y el resto por no progresión. Los convertidos no mostraron diferencias frente a los que se completó por laparoscopia. No existieron diferencias entre la DPC laparoscópica y abierta en tiempo quirúrgico, complicaciones postoperatorias, índice de reintervenciones, reingresos ni mortalidad. La resección R0 en los casos tumores fue del 85% por laparoscopia y del 69% en cirugía abierta sin significación estadística. La estancia postoperatoria fue inferior en el grupo DPC laparoscópica, ocho vs. 15 días. Conclusiones: En un grupo seleccionado, la DPC laparoscópica puede realizarse de forma segura y eficaz si se realiza por grupos expertos en cirugía pancreática y en laparoscopia avanzada. Obtiene los mismos resultados que la cirugía abierta en el postoperatorio y es oncológicamente adecuada con menor estancia hospitalaria. Una selección adecuada de los pacientes, un programa establecido por pasos con una conversión laxa y precoz evita accidentes operatorios graves. (AU)

Introduction: Laparoscopic pancreaticoduodenectomy (PD) is not widely accepted, and its use is controversial. Only correct patient selection and appropriate training of groups experienced in pancreatic surgery and laparoscopy will be able to establish its role and its hypothetical advantages Methods: Out of 138 pancreatic surgeries performed in a two-year period (2017-2019), 23 were laparoscopic PD. We evaluate its efficacy and safety compared to 31 open PD. Results: There were no cases of B/C pancreatic or biliary fistula, nor any cases of delayed gastric emptying in the laparoscopic group, but hemorrhage required one reoperation. The conversion rate was 21% (five cases): one due to bleeding, and the remainder for non-progression. The converted patients showed no differences compared to those completed by laparoscopy. There were no differences between laparoscopic and open PD in surgical time, postoperative complications, reintervention rate, readmissions or mortality. R0 resection in tumor cases was 85% for laparoscopy and 69% in open surgery without statistical significance. The postoperative hospital stay was shorter in the laparoscopic PD group (eight vs. 15 days). Conclusions: In a selected group, laparoscopic PD can be safely and effectively performed if carried out by groups who are experts in pancreatic surgery and advanced laparoscopy. The technique has the same postoperative results as open surgery and is oncologically adequate, with less hospital stay. Proper patient selection, a step-by-step program and a lax and early conversion prevents serious operating accidents. (AU)

Cirugía robótica hepática: una nueva realidad. Análisis descriptivo de 220 casos de cirugía hepática mínimamente invasiva en 182 pacientes / Robotic liver surgery: A new reality. Descriptive analysis of 220 cases of minimally invasive liver surgery in 182 patients

Introducción El nivel de recomendación del abordaje robótico en la cirugía hepática es controvertido. Se realiza un análisis descriptivo, retrospectivo yunicéntrico de los resultados a corto plazo de la cirugía hepática robótica y laparoscópica en un mismo periodo.MétodosAnálisis descriptivo del abordaje robótico y laparoscópico sobre 220 resecciones en 182 pacientes sometidos a cirugía hepática mínimamente invasiva.ResultadosEntre abril de 2018 y junio de 2022 se realizaron 92 resecciones hepáticas robóticas (RHR) en 83 pacientes y 128 laparoscópicas (RHL) en 99 pacientes. Se observaron más resecciones mayores (p<0,001) y más resecciones múltiples (p=0,002) en el grupo CHL. El porcentaje de resecciones anatómicas fue similar (RHR: 64,1 vs. RHL: 56,3%). En el grupo CHL el tiempo medio operatorio fue de 212min (DE: 52,1), las pérdidas hemáticas de 276,5ml (100-1.000) y la tasa de conversión del 12,1%. La estancia media hospitalaria fue de 5,7 días (DE: 4,9), la morbilidad fue del 27,3%, con un 2% de mortalidad. En el grupo CHR el tiempo medio operatorio fue de 217min (DE: 53,6), las pérdidas hemáticas fueron de 169,5ml (100-900) y la tasa de conversión del 2,5%. La estancia media hospitalaria fue de 4,1 días (DE: 2,1) y la morbilidad fue del 15%, con mortalidad nula.ConclusiónLa cirugía mínimamente invasiva hepática es una técnica segura y reproducible. La CHR permite realizar resecciones hepáticas con seguridad y parece ser una técnica no inferior a la CHL, pero para determinar el abordaje mínimamente invasivo de elección en cirugía hepática se requieren estudios aleatorizados. (AU)

Introduction The level of recommendation of the robotic approach in liver surgery is controversial. The objective of the study is to carry out a single-center retrospective descriptive analysis of the short-term results of the robotic and laparoscopic approach in liver surgery during the same period.MethodsDescriptive analysis of the short-term results of the robotic and laparoscopic approach on 220 resections in 182 patients undergoing minimally invasive liver surgery.ResultsBetween April 2018 and June 2022, a total of 92 robotic liver resections (RLR) were performed in 83 patients and 128 laparoscopic (LLR) in 99 patients. The LLR group showed a higher proportion of major surgery (P<.001) and multiple resections (P=.002). The two groups were similar in anatomical resections (RLR 64.1% vs. LLR 56.3%). In the LLS group, the average operating time was 212min (SD 52.1). Blood loss was 276.5ml (100-1000) and conversion 12.1%. Mean hospital stay was 5.7 (SD 4.9) days. Morbidity was 27.3% and 2% mortality. In the RLS group, the mean operative time was 217min (SD 53.6), blood loss 169.5ml (100.900), and conversion 2.5%. Mean hospital stay was 4.1 (SD 2.1) days. Morbidity was 15%, with no mortality.ConclusionMinimally invasive liver surgery is a safe technique, and in particular, RLS allows liver resections to be performed safely and reproducibly; it appears to be a non-inferior technique to LLS, but randomized studies are needed to determine the minimally invasive approach of choice in liver surgery. (AU)