The article describes our initial experience using CMR Versius platform for several procedures in general surgery. Between September 2022 and April 2023, seventy patients underwent robotic surgery in a multi-robotic referral center (San Paolo University Hospital, Milan, Italy). Three surgeons with only laparoscopic experience performed 24 cholecystectomies, 13 inguinal hernia repairs, 9 ventral hernia repairs, 7 right hemicolectomies, 11 left hemicolectomies, 1 sigmoidectomy, 1 ileocecal resection, 1 ventral rectopexy, 1 Nissen fundoplication, 1 total splenectomy, and 1 exploration with multiple biopsies. All surgeries were full-robotic, with only one conversion to laparoscopy. The short length of stay and low rate of severe morbidity are promising findings. Although operative time was lengthened, clinical outcomes were not affected. Our experience demonstrates that the adoption of Versius system is safe and feasible in general surgery. The standardization of port placement and BSU set-up can certainly reduce the operative time.

The wounds failing to heal through a timely and orderly standard of care (SOC) treatment are considered as chronic wounds, which add significant burden to healthcare systems around the world. SOC treatment has been commonly applied for management of chronic wounds, but SOC alone may not be adequate to heal all ulcers effectively. Fish skin graft (FSG) is a xenogenic skin substitute which could be used for accelerating skin healing. The current study was performed with the view of evaluating the effectiveness of FSG as an adjuvant treatment of SOC for chronic ulcer treatment. Two authors independently searched the following electronic databases: PubMed, Embase, and CENTRAL, using keywords including "diabetic foot ulcer," "fish skin graft," and "wound healing." Clinical studies that evaluated the clinical outcomes of FSG in treatment of chronic ulcers were included in this meta-analysis. Random- or fixed-effect modeled meta-analyses were performed according to the heterogeneity test result (i.e., I2), to analyze the clinical outcome of FSG. A total of 8 studies were included in qualitative synthesis and meta-analysis, with 145 patients treated by SOC and 245 patients treated by SOC plus FSG. There was no significant difference between two groups for time to healing (MD = 1.99, 95% CI: -3.70~7.67, p = 0.493). The complete healing rate was significantly higher in FSG group compared with SOC alone (OR = 3.44, 95% CI: 2.03~5.82, p < 0.001***). Mean percentage area reduction (PAR) was reported in six studies, with a range of 71.6~97.3%. However, many of these studies did not report the value of standard deviation (SD), so we could not pool the data. No significantly different ulcer recurrence rate (RR = 0.60, 95% CI: 0.07~5.27, p = 0.645) and severe adverse events (SAEs) risk (RR = 1.67, 95% CI: 0.42~6.61, p = 0.467) were found between two groups. The application of FSG treatment for patients with chronic ulcers that do not respond well to SOC management could significantly increase the complete healing rate compared with SOC alone, without increased recurrence rate and SAEs risk.

Gallstone formation is increased after gastric (GR) or esophageal resection (ER); however, the exact pathophysiology is not fully understood yet. Symptomatic cholecystolithiasis and the need for subsequent cholecystectomy after upper gastrointestinal resection can alter the outcome in oncological patients. There is an ongoing discussion if these patients benefit from a simultaneous prophylactic cholecystectomy.This study aims to analyze the risk of gallstone formation after GR or ER and the perioperative course of a subsequent cholecystectomy. In this study, all patients were included, who underwent an oncological gastric or esophageal resection at the Medical University of Innsbruck, Department of Visceral, Transplant and Thoracic Surgery in the years 2003-2021. A simultaneous cholecystectomy was performed in 29.8% with GR and in 2.1% with ER (p < 0.001). There was no significant difference in complications or length-of-stay between patients with simultaneous vs. no simultaneous cholecystectomy. Newly developed gallstones tended to be more common after GR (16% vs. 10% ER), after reconstruction without preservation of the duodenal passage (17% vs. 11% with) and after GR with lymph node dissection (19% vs. 5% without). After ER, subsequent cholecystectomy was significant less frequently (11.4% vs. 2.9% OR) (p = 0.005). The subsequent cholecystectomy was performed openly in 57.1% with major complications classified as Clavien-Dindo ≥ 3a in 14.3%. Based on the findings of our study, we do not recommend simultaneous cholecystectomy routinely in oncological gastric or esophageal resections. An individualized approach depending on risk factors like extensive lymphadenectomy or duodenal passage can be discussed.

Portal vein embolization (PVE) is often performed prior to right hemihepatectomy (RH) to increase the future liver remnants. However, intraoperative removal of portal vein thrombus (PVT) is occasionally required. An algorithm for treating the right branch of the PV using laparoscopic RH (LRH) after PVE is lacking and requires further investigation. In our department, after the confirmation of a lack of extension of PVT to the main portal trunk or left branch on preoperative examination (ultrasound and contrast-enhanced computed tomography), a final evaluation was performed using intraoperative ultrasonography (IOUS). Here we present the cases of eight patients who underwent LRH after PVE and examine the safety of our treatment strategies. IOUS revealed PVT extension into the main portal trunk in two cases. For the other six patients without PVT extension, we continued the laparoscopic procedure. In contrast, in the two cases with PVT extension, we converted to laparotomy after hepatic transection and removed the PVT. The median operation time for hepatectomy was 562min (421-659min), the median blood loss was 293mL (85-1010mL), no liver-related postoperative complications were observed, and the median length of stay was 10days (6-34days). PVT evaluation and removal are important in cases of LRH after PVE. Our strategy is safe and IOUS is particularly useful for laparoscopically evaluating PVT extension.

It remains unclear whether ultrasound-detected hernias (UDH) are the sole cause of pain in patients with groin pain, and clinical examination plays a complementary role. The aim of our study is to describe the evolution of patients with ultrasound detected hernias in terms of development of groin hernia detected by physical examination, pain resolution, and alternative diagnosis. An observational, descriptive, longitudinal study of a prospective case series including patients with UDH with groin pain. Follow-up evaluation included the following: follow-up time, side of pain, its evolution, time to resolution, clinical hernia (CH) development, need for surgical resolution, and the presence of postoperative pain and alternative diagnosis. A total of 98 patients with complete follow-up for groin pain and UDH were included. Seven patients (7.1%) developed CH, with a median time to conversion of 8months. Four of them (4.1% of the total and 57.1% of the ones who developed CH) ended up having surgery. Fifty-three patients (54.1%) resolved their pain in a median time to resolution of 2months, and 75.5% of them did so spontaneously. The majority of patients with persistent pain (73.3%) were able to lead a normal life and only reported pain with movement. More than half of the patients (53.3%) reached a specific diagnosis. Among those patients who did not develop CH, 39.6% reached an alternative diagnosis, the majority being musculoskeletal pathologies. Watchful waiting and a thorough search for other alternative causes of groin pain in UDH and clinically occult hernia would be a reasonable option.

A notable advantage of laparoscopic colorectal surgery is that only a small incision at the extraction site is necessary, which is considered to be cosmetically beneficial. Meanwhile, the optimal extraction site for the resected specimen in laparoscopic colectomy is controversial in terms of cosmetic benefit. This randomized controlled trial compares midline and off-midline extraction sites in laparoscopic colectomy in patients with colon cancer, with consideration of cosmetic benefits as the primary endpoint. Included were patients that underwent elective laparoscopic colectomy at WMUH between October 2014 and February 2017. Patients were randomly assigned to either midline incision group or off-midline incision group. Prospectively collected data included cosmetic results (patients and observer assessment scale) and complications including incidence of incisional hernia, SSI, and pain. This trial was registered with UMIN Clinical Trials (UMIN000028943). Finally, 98 patients with colorectal cancer were analyzed. No significant differences were found between the two groups in patient and observer assessment scales of cosmetic results (midline 8 ± 1.1 vs off-midline 11 ± 5.9 p = 0.16, midline 13.5 ± 6.6 vs off-midline 15 ± 11 p = 0.58, respectively) or in postoperative pain. However, incisional hernia occurred in four cases in the midline group (8%), which was significantly higher than that in the off-midline group (no cases, 0%). There was no significant difference in terms of cosmetic benefit, the primary endpoint, between the two groups. In this study, only the extraction site location was compared; future studies will examine differences depending on the incisional direction, including the incidence of incisional hernia.

The reported threshold of a near-infrared fluorescence detection probe (FDP) for judging parathyroid glands (PGs) is based on the autofluorescence intensity relative to other non-PG tissues, making it unreliable when not enough reference tissues are measured. We aim to convert FDP into a more convenient tool for identifying accidentally resected PGs by quantitative measurements of autofluorescence in resected tissues. It was a prospective study approved by the Institutional Review Board. The research was divided into two stages: (1) In order to calibrate the novel FDP system, autofluorescence intensity of different in / ex vivo tissues was measured and the optimal threshold was obtained using receiver operating characteristic (ROC) curve. (2) To further validate the effectiveness of the new system, detection rates of incidental resected PGs by pathology in the control group and by FDP in the experimental group were compared. Autofluorescence of PGs was significantly higher than that of non-PG tissue (43 patients, Mann-Whitney U test, p < 0.0001). An optimal threshold of sensitivity / specificity (78.8% and 85.1%) for discriminating PGs was obtained. The detection rates of experimental group (20 patients) and control group (33 patients) are 5.0% and 6.1% respectively (one-tailed Fisher's exact test, p = 0.6837), indicating the novel FDP system can achieve a similar proportion of PG detection compared with pathological examinations. The novel FDP system can be used as an easy-to-use adjunct for detecting PG accidentally resected intraoperatively before the tissues are sent for frozen sections during thyroidectomy surgeries. Registration number: ChiCTR2200057957.

A robotic platform has enabled extremely low-pressure pneumoperitoneum (ELPP, 4 mmHg) to reduce surgical insults to human physiology during a minimally invasive surgery. The objective of this study was to investigate the effect of ELPP in single-site robotic cholecystectomy (SSRC) on postoperative pain, shoulder pain, and physiological changes during surgery compared to a standard pressure pneumoperitoneum (SPP, 12-14 mmHg). A total of 182 patients who underwent an elective cholecystectomy were randomized into an ELPP SSRC group (n = 91) and an SPP SSRC group (n = 91). Postoperative pain was assessed at 6, 12, 24, and 48 h after surgery. The number of patients complaining of shoulder pain was observed. Intraoperative changes of ventilatory parameters were also measured. Postoperative pain scores (p = 0.038, p < 0.001, p < 0.001, and p = 0.015 at 6, 12, 24, and 48 h after surgery, respectively) and the number of patients with shoulder pain (p <0.001) were significantly lower in the ELPP SSRC group than in the SPP SSRC group. Intraoperative changes in peak inspiratory pressure (p < 0.001), plateau pressure (p < 0.001), EtCO2 (p < 0.001), and lung compliance (p < 0.001) were also less in the ELPP SSRC group. The ELPP during robotic cholecystectomy could significantly relieve postoperative pain and shoulder pain. In addition, the ELPP can reduce changes in lung compliance during surgery and the demand for postoperative analgesics, thereby improving the quality of life of patients during early stages of postoperative rehabilitation.

PurposeBile duct injury (BDI) remains the most serious complication following cholecystectomy. However, the actual incidence of BDI in the Czech Republic remains unknown. Hence, we aimed to identify the incidence of major BDI requiring operative reconstruction after elective cholecystectomy in our region despite the prevailing modern 4 K Ultra HD laparoscopy and Critical View of Safety (CVS) standards implemented in daily surgical practice among the Czech population.MethodsIn the absence of a specific registry for BDI, we analysed data from The Czech National Patient Register of Reimbursed Healthcare Services, where all procedures are mandatorily recorded. We investigated 76,345 patients who were enrolled for at least a year and underwent elective cholecystectomy during the period from 2018–2021. In this cohort, we examined the incidence of major BDI following the reconstruction of the biliary tract and other complications.ResultsA total of 76,345 elective cholecystectomies were performed during the study period, and 186 major BDIs were registered (0.24%). Most elective cholecystectomies were performed laparoscopically (84.7%), with the remaining open (15.3%). The incidence of BDI was higher in the open surgery group (150 BDI/11700 cases/1.28%) than in laparoscopic cholecystectomy (36 BDI/64645 cases/0.06%). Furthermore, the total hospital stays with BDI after reconstruction was 13.6 days. However, the majority of laparoscopic elective cholecystectomies (57,914, 89.6%) were safe and standard procedures with no complications.ConclusionOur study corroborates the findings of previous nationwide studies. Therefore, though laparoscopic cholecystectomy is reliable, the risks of BDI cannot be eliminated.