Creation Of Anastomosis Research Articles

Taenia saginata: unexpected finding during laparoscopic Roux-en-Y gastric bypass.

Laparoscopic finding showing a tapeworm in the intestinal lumen during the creation of the jejuno-jejunal anastomosis.

Feasibility of Conversion of a New Bariatric Fully Endoscopic Bypass Procedure to Bariatric Surgery: a Porcine Pilot Study.

Bariatric endoscopic procedures are emerging as alternatives to bariatric surgical procedures. This study aimed to assess if a natural orifice transluminal endoscopic surgery (NOTES) bariatric procedure could be converted to a surgical duodenal-jejunal bypass (DJB) or sleeve gastrectomy (SG). This 12-week prospective study compared 4 test pigs to 3 control (no procedures) pigs aged 3months at baseline. The test pigs received a fully endoscopic NOTES-based bypass including measurement of the bypassed limb and creation of a gastrojejunal anastomosis (GJA) using gastrojejunal lumen-apposing metal stents (GJ-LAMS) at Week 0, placement of a duodenal exclusion device (DED) at Week 2, and randomization to DJB or SG surgery at Week 8 with subsequent 4-week follow-up. At Week 12, the pigs were sacrificed and necropsy was performed. Endoscopic procedures were technically successful. One pig did not receive a DED due to early GJ-LAMS migration leading to premature closure of the GJA. At Week 8, all 4 pigs were doing well, and the remaining 3 GJ-LAMS and 3 DEDs were uneventfully endoscopically removed. Two one-anastomosis DJB were performed, and 2 SG were performed, closing in one case the site of the previous GJA. The surgical procedures were technically feasible and uneventful during follow-up. Necropsy assessments showed no local or peritoneal inflammation or abscess and no leakage or fistula. An endoscopic bariatric bypass can be transitioned to a one-anastomosis duodenal-jejunal bypass or sleeve gastrectomy, without complications.

55: COMPETENCY ASSESSMENT TOOL FOR MINIMALLY INVASIVE ESOPHAGECTOMY: DEVELOPMENT AND PRELIMINARY CONSTRUCT VALIDITY AND RELIABILITY RESULTS

Abstract Background and aim Performance of the surgical team is essential for patient outcome. Minimally invasive esophagectomy (MIE) is a complex and technically demanding procedure and implementation is associated with a substantial learning curve. A validated, procedure specific and scientifically robust competency assessment tool (CAT) could provide structured feedback and can be a tool to improve patient outcome. The aim is to develop a MIE-CAT and assess construct validity, intra-observer reliability and inter-observer reliability. Methods Based on defined key steps from a Delphi study and refinement with a core group of MIE experts to establish content validity and obtain user agreement, the MIE-CAT was developed. Eighteen independent and blinded international MIE experts (> 120 MIEs performed) followed an online workshop to train in using the MIE-CAT and assessed Ivor Lewis MIE videos that were performed from 2010–2020 by four MIE surgeons from the Esophageal Center East Netherlands. To analyze construct validity, 32 videos were divided into four groups (novice, intermediate, advanced and expert) based on the surgical team’s experience. For intra-rater and inter-rater reliability, the same video was scored twice by the same and different experts. Results The MIE-CAT consists of eight procedural phases, starting with the mobilization of the greater curvature and ending with creation of the intrathoracic anastomosis. Each phase contains four domains (exposure, execution, adverse events and end-product quality) and are scored with a 1–4 Likert scale. A total of 72 video assessments were used for analysis. Substantial performance variation between the MIE-CAT scores was seen (median 98 [IQR, 84–113.4]; range = 47–126). Median MIE-CAT scores were 79.5 [IQR 74–96.3], 91 [87.5–107], 101 [84.8–108] and 101 [95.5–108.3] for respectively the novice, intermediate, advanced and expert group (Figure 1). Significant differences between the average MIE-CAT scores of the experience groups were found with a Kruskal Wallis (P = 0.002). Good intra-rater reliability was observed (ICC, 0.71, 95% CI [0.35, 0.89) and moderate inter-rater reliability was observed (ICC, 0.54, 95% CI [0.10, 0.87). Conclusion A specific competency assessment tool to score the MIE performance, the MIE-CAT, was developed. It has the potential to be used for surgical training, safe implementation, performance improvement and research purposes.

Therapeutic endoscopic ultrasound.

Endoscopic ultrasound (EUS) has been continuously evolving for the past three decades and has become widely used for both diagnostic and therapeutic purposes. The efficacy of therapeutic EUS (TEUS) has proven to be superior and better tolerated than conventional percutaneous or surgical techniques. TEUS has allowed the performance of multiple procedures including gallbladder, pancreatic duct and biliary drainage as well as gastrointestinal anastomoses. TEUS procedures generally require the following critical steps: needle access, guidewire placement, fistula creation and stent deployment. The indications and contraindication for TEUS procedures vary with different procedures but common contraindications include hemodynamic instability, severe coagulopathy unable to be reversed, large volume ascites or the inability to obtain access to the target site. Proficiency and high volume in endoscopic retrograde cholangiopancreatography (ERCP) and diagnostic EUS procedures are required for training in TEUS. The complexity of the cases performed can be seen as a pyramid with drainage of pancreatic fluid collections at the base, pancreaticobiliary decompression in the middle, and creation of digestive anastomosis at the top. The mastery of each level is crucial prior to reaching the next level of complexity. TEUS has been incorporated in our arsenal and is impacting on a daily basis the way we offer minimally invasive therapy.

Remote ischemic postconditioning has a detrimental effect and remote ischemic preconditioning seems to have no effect on small intestinal anastomotic strength

Background The effect of remote pre- and postconditioning on anastomotic healing has been sparsely studied. The aim of our study was to investigate whether remote ischemic conditioning (RIC) applied before and after the creation of a small bowel anastomosis had an effect on anastomotic healing on postoperative day five evaluated by a tensile strength test and histological analysis. Materials and methods Twenty-two female piglets were randomized into two groups. The intervention group (n = 12) received RIC on the forelimbs consisting of 15 min of ischemia followed by 30 min of reperfusion before the first end-to-end ileal anastomosis was created. The RIC procedure was repeated and the second and more distal anastomosis was performed. The control group (n = 10) had two similar anastomoses with similar time intervals but without RIC. On postoperative day five, the anastomoses were subjected to macroscopic evaluation, tensile strength test and histological examination. Results Mean tensile strength when the first transmural rupture appeared (MATS-2) was significantly lower in the first anastomosis in the intervention group compared to the control group (11.4 N vs 14.7 N, p < .05). Similar result was found by the maximal strength (MATS-3) as defined by a drop in the load curve (12.3 N vs 15.9 N, p < .05). Histologically, a significantly higher necrosis score was found in the anastomosis in the intervention group (1.4 vs 0.8, p < .05). No other significant differences were found. Conclusions In conclusion, post-anastomotic remote ischemic conditioning had a detrimental effect and pre-anastomotic conditioning seems to have no effect on small intestinal anastomotic strength.

Evaluation of sutureless anastomosis after ileostomy takedown using the self-forming magnet anastomosis system in a porcine model.

Current standard of care for creation of small bowel anastomoses after a loop ileostomy reversal includes the use of stapler devices and sutures. Compression anastomosis devices have been used for decades, aimed toward improved outcomes with a "staple free" &amp; "suture free" anastomosis. The self-forming magnet (SFM) device is a type of compression anastomosis device used to safely and effectively create an end-to-end small bowel anastomosis without the localized inflammatory response seen with sutures or staples, as no foreign bodies are left behind. A Good Laboratory Practice preclinical study using a porcine model to evaluate creating an in vivo anastomosis via magnetic compression between two segments of small bowel (jejunum or ileum) was performed. Magnetic anastomoses were compared to stapled and handsewn anastomoses. Six animals were used for the magnetic anastomosis and eight for the two control groups for a total of 14 subjects. Mean creation times were 17.1min (SD 6.06) for the SFM group, 10.3min (SD 6.55, CI 95%) for the stapled anastomosis group, and 28.3min (SD 2.63, CI 95%) for the suture anastomosis group, with a statistically significant difference among groups (p &lt; 0.0021). All evaluated SFM anastomosis, stapled anastomosis, and handsewn anastomosis underwent a burst test with a pressure of 1.3 PSI. All six magnets used for anastomoses were naturally expelled. The range of days to expel magnets was 10-17days. Intestinal anastomoses using magnets had considerably less residual scarring and intestinal distortion than anastomoses done with either suture or staples. This preclinical study documents the safety and efficacy of creating end-to-end small bowel anastomoses after ileostomy takedown using a magnetic compression device. The result is an anastomosis free of foreign objects with less inflammation, scarring, distortion, and mural thickening than seen in sutured or stapled anastomoses.

Evaluating proximal clamp site and intraoperative ischemia time among open repair of juxtarenal aneurysms

BackgroundThe proportion of open aneurysm repairs requiring at least a suprarenal clamp has increased in the past few decades, partly owing to preferred endovascular approaches for most patients with infrarenal aneurysms, suggesting that the management of aortic clamp placement has become even more relevant. This study evaluated the association between the proximal clamp site and intraoperative ischemia times with postoperative renal dysfunction and mortality. MethodsWe used the Vascular Quality Initiative to identify all patients undergoing open repairs of elective or symptomatic juxtarenal AAAs from 2004 to 2018 and compared outcomes by clamp site: above one renal artery, above both renal arteries (suprarenal), or above the celiac trunk (supraceliac). Outcomes evaluated included acute kidney injury (AKI), new-onset renal failure requiring renal replacement therapy (RRT), 30-day mortality, and 1-year mortality. We used multilevel logistic regressions and Cox proportional hazards models, clustered at the hospital level, to adjust for confounding. ResultsWe identified 3976 patients (median age, 71 years; 70% male; 8.2% non-Caucasian), with a median aneurysm diameter of 5.9cm (interquartile range [IQR], 5.4-6.8 cm). Proximal clamp sites were above one renal artery (31%), suprarenal (52%), or supraceliac (17%). The rates of unadjusted outcomes were 20.5% for AKI, 4.1% for new-onset RRT, 4.9% for 30-day mortality, and 8.3% for 1-year mortality. On adjusted analyses, independent of ischemia time, suprarenal clamping relative to clamping above a single renal artery had higher odds of postoperative AKI (adjusted odds ratio [aOR], 1.50; 95% confidence interval; 95% CI, CI, 1.28-1.75), but similar odds for new-onset RRT (aOR, 1.27; 95% CI, 0.79-2.06) and 30-day mortality (aOR, 1.12; 95% CI, 0.79-1.58) and hazards for 1-year mortality (adjusted hazard ratio, 1.12; 95% CI, 0.86-1.45). However, every 10 minutes of prolonged intraoperative ischemia time was associated with an increase in odds or hazards ratio of postoperative AKI by 7% (IQR, 3%-11%), new-onset RRT by 11% (IQR, 4%-17%), 30-day mortality by 11% (IQR, 6%-17%), and 1-year mortality by 7% (IQR, 2%-13%). Patients with more than 40 minutes of ischemia time had notably higher rates of all four outcomes. ConclusionsSuprarenal clamping relative to clamping above a single renal artery was associated with AKI, but not new-onset RRT or 30-day mortality. However, the intraoperative renal ischemia time was independently associated with all four postoperative outcomes. Although further studies are warranted, our findings suggest that an expeditious proximal anastomosis creation is more important than trying to maintain clamp position below one renal artery, suggesting that suprarenal clamping may be the best strategy for open AAA repair when needed to efficiently perform the proximal anastomosis.

Endoscopic ultrasound-guided biliary drainage and gastrointestinal anastomoses: the journey from promising innovations to standard of care.

Biliary obstruction (BO) and gastric outlet obstruction (GOO) are frequent complications of pancreatobiliary and gastroduodenal neoplasia, which can severely impact oncological outcomes, patient survival and quality of life. Although endoscopic retrograde cholangiopancreatography (ERCP) remains the gold standard for biliary drainage, this may fail or be unfeasible because of duodenal/papillary infiltration or surgically-altered anatomy. Percutaneous transhepatic biliary drainage (PTBD) has been the standard rescue therapy in this setting, but is burdened by high morbidity and reduced quality of life. As for GOO, surgical gastroenterostomy and enteral stenting are limited by invasiveness and suboptimal long-term outcomes, respectively. Endoscopic ultrasound (EUS) has evolved from a diagnostic to a therapeutic modality, providing a safe and effective alternative for draining the pancreatobiliary tract into the stomach or duodenum. EUS-guided biliary drainage (EUS-BD) has already demonstrated similar efficacy, greater safety and fewer reinterventions compared to PTBD, and can be performed in the same session after ERCP failure. Further development of lumen apposing metal stents has paved the way towards the creation of EUS-guided anastomoses. EUS-guided gastroenterostomy (EUS-GE) is nowadays increasingly used to treat GOO, combining the minimal invasiveness of endoscopy with surgical-range efficacy. This review summarizes the technical details, current evidence and society recommendations contributing to EUS-BD and EUS-GE gaining ground in everyday practice or tertiary referral centers and becoming crucial in improving the multidisciplinary management of cancer-related symptoms.

Safety of anastomoses in colorectal cancer surgery in octogenarians: a prospective cohort study with propensity score matching.

BackgroundUp to 20 per cent of all operations for patients with colorectal cancer (CRC) are performed in octogenarians. Anastomotic leakage is a leading cause of morbidity and death after resection for CRC. The aim of this study was to assess the rate of anastomosis creation, the risk of anastomotic leakage and death in surgery for left-sided CRC in elderly patients.MethodsThis prospective cohort study compared patients less than 80 and 80 or more years with left-sided CRC resection performed between 2013 and 2019. Data were provided from a risk-adjusted surgical quality-assessment system with 219 participating centres in Germany. Outcome measures were the rate of anastomoses, anastomotic leakages, death at 30 days and 2-year overall survival (OS). Propensity score matching was used to control for selection bias and compare subgroups of patients of less than 80 and 80 or more years.ResultsOut of 18 959 patients, some 3169 (16.7 per cent) were octogenarians. Octogenarians were less likely to receive anastomoses (82.0 versus 92.9 per cent, P < 0.001; odds ratio 0.50 (95 per cent c.i. 0.44 to 0.58), P < 0.001). The rate of anastomotic leakages did not differ between age groups (8.6 versus 9.7 per cent, P = 0.084), but 30-day mortality rate after leakage was significantly higher in octogenarians (15.8 versus 3.5 per cent, P < 0.001). Overall, anastomotic leakage was the strongest predictor for death (odds ratio 4.95 (95 per cent c.i. 3.66 to 6.66), P < 0.001). In the subgroup with no leakage, octogenarians had a lower 2-year OS rate than younger patients (71 versus 87 per cent, P < 0.001), and in the population with anastomotic leakage, the 2-year OS was 80 per cent in younger and 43 per cent in elderly patients (P < 0.001). After propensity score matching, older age remained predictive for not receiving an anastomosis (odds ratio 0.54 (95 per cent c.i. 0.46 to 0.63), P < 0.001) and for death (odds ratio 2.60 (95 per cent c.i. 1.78 to 3.84), P < 0.001), but not for the occurrence of leakages (odds ratio 0.94 (95 per cent c.i. 0.76 to 1.15), P = 0.524).ConclusionAnastomotic leakage is not more common in octogenarians, but an age of 80 years or older is an independent factor for not receiving an anastomosis in surgery for left-sided CRC. The mortality rate in the case of leakage in octogenarians was reported to exceed 15 per cent.

Vascular Graft Implantation Using a Bilateral End-to-Side Aortoiliac Preclinical Model.

Arterial bypass grafts are a standard preclinical model for evaluating physiology and pathophysiology at graft-material interfaces. Implantations of vascular grafts are commonly done as end-to-end grafts in small animal models. Here we detail bilateral end-to-side aortoiliac graft implantation, which requires open surgery and the creation of vascular anastomoses between the graft material and the infrarenal aorta and iliac artery in a nonhuman primate model. In this model, the aortoiliac graft configuration is created using two 4mm inner diameter vascular grafts (e.g., ePTFE). After exposure and control of the infrarenal aorta and bilateral common iliac arteries and heparinization, the proximal aortic-graft anastomosis is sewn on the lateral wall of the aorta, and subsequently the distal graft-common iliac anastomosis is sewn on the anterior wall of the common iliac artery with one tube graft. Another tube graft is sewn on the contralateral side in the same manner.

Resizing a large pouch after laparoscopic Roux-en-Y gastric bypass: comparing the effect of two techniques on weight loss.

Insufficient weight loss or weight regain has many causes including a large gastric pouch. A large gastric pouch may be due to the surgical technique or can be patient related (dilation). Resizing the gastric pouch may lead to additional weight loss. Currently, there is no gold standard for the revisional surgical technique. Therefore this study was performed to determine which surgical technique for revisional bariatric surgery (BS) has superior outcomes in terms of weight loss: sleeve resection of the gastrojejunostomy and gastric pouch (SGP), or resection of the gastrojejunostomy with resizing of the pouch and creation of a new anastomosis (RGJ). All patients who underwent revisional BS for insufficient weight loss or weight regain as a result of an enlarged pouch after LRYGB from April 2014 to June 2018 in our hospitals were included in this observational cohort study. Outcomes were measured in percentage total weight loss (%TWL). A total of 37 patients who underwent SGP and 21 patients who underwent RGJ as revisional BS were included in this study. The median body mass index before revisional BS was 37.6kg/m2 versus 35.7kg/m2 (SGP vs RGJ, respectively, P = 0.115). There was no significant difference in %TWL between the two cohorts 1 and 2years after revisional BS, respectively; SGP 14.5% vs RGJ 11.0%, P = 0.885 and SGP 12.3% vs RGJ 10.8%, P = 0.604. Comparing %TWL based on weight at LRYGB, there was also no significant difference two years after revisional BS (SGP 22.0% vs RGJ 22.2%, P = 0.885). The average use of surgical disposables for the SGP technique were lower compared to the RGJ technique. Resizing a large pouch leads to additional weight loss. Both techniques have comparable outcomes in terms of weight loss. However, based on average surgical costs, the SGP technique may be preferable.

The Utility of Peers and Trained Raters in Technical Skill-based Assessments a Generalizability Theory Study

The gold standard for evaluation of resident procedural competence is that of validated assessments from faculty surgeons. A provision of adequate trainee assessments is challenged by a shortage of faculty due to increased clinical and administrative responsibilities. We hypothesized that with a well constructed assessment instrument and training, there would be minimal differences in procedural assessments made by near-peer resident raters (RR), faculty raters (FR), and trained raters (TR). Deidentified videos of residents performing hand-sewn (HA) and stapled (SA) anastomoses were distributed to blinded reviewers of 3 types. Intra-class correlation (ICC) of RR, FR and TR assessments was determined for each procedure. A fully-crossed design was used to examine the internal structure validity in a generalizability study. A Decision study was performed to make projections on the number of raters needed for a g-coefficient > 0.70. This study was conducted within a private academic institution, using the creation of intestinal anastomoses as the procedural model. Raters consisted of residents who were untrained to the assessment (UTA) tool, UTA faculty surgeons, and individuals with training. Twenty nine videos were reviewed (15 HA and 14 SA) by a total of 9 video reviewers (4 RR, 2 FR, and 3 TR). HA ICC values were 0.84 (Confidence Interval [CI]:0.81-0.87) for RR, 0.89 (CI:0.86-0.92) for FR, and 0.88 (CI:0.86-0.90) for TR. SA ICC values were 0.77 (CI:0.72-0.80) for RR, 0.79 (CI:0.75-0.83) for FR, and 0.86 (CI:0.83-0.88) for TR. The g-coefficient was RR = 0.72, FR = 0.85, and TR = 0.77 for HA; and RR = 0.33, FR = 0.38, and TR = 0.4 for SA. The D-study indicated that at least 2 raters of any type were needed for HA and > 11 FR for SA. Faculty without training have high assessment agreement. Peers for surgical skills assessment is an option for formative evaluation without training. Training to assessment tools should be performed for any assessment, formative or summative, for the optimal evaluation of procedural competence.

COMPARATIVE STUDY OF SINGLE LAYER CONTINUOUS VERSUS SINGLE LAYER INTERRUPTED EXTRA MUCOSAL TECHNIQUES IN SMALL INTESTINE ANASTOMOSIS

Background: Intestinal anastomosis is most commonly performed surgical procedure both in emergency and elective settings therefore its leak and disruption is a common cause of post-operative morbidity and mortility. Gut anastomosis heals by the same mechanism as that of wound healing. The submucosa, is the strongest layer of gut wall therefore ideal anastomotic technique is the one which includes apposition and approximation of this layer. Aim:The outcome of comparative study of single layer continuous extra mucosal technique and single layer interrupted extra mucosal technique for the anastomosis of small bowel. Methods:This was a prospective study based on randomization and was carried out in surgery department of ANMMC&amp;H, Gaya from 1 st March 2019 to 29th February 2020. Total Fifty patients were included in study requiring small intestine anastomosis and were divided in two groups based on randomization. Group Aincluded those patients in which the anastomosis performed by single layer continuous extra mucosal technique and Group B patients underwent single layer interrupted extramucosal technique for creation of anastomosis, Group Aincluded 24 patients (n=24) and Group B 26 patients (n=26) . The demographic features, time taken to create anastomosis , postoperative complications , number of deaths if any and hospital stay in days were recorded on a printed proforma and data analysis was done through computer soft ware SPSS 16. Results: Group Aand B were similar as for as the demographic features, postoperative complications and duration of hospital stay are concerned. 4.2% patients of Group A and 7.7% of Group B developed anastomotic dehiscence with non signicant p value. Mean time taken for creation of anastomosis was 10.04 minutes in continuous extra mucosal anastomosis group (Group A ) and 19.2 minutes in interrupted extra mucosal anastomosis [Group B ] (p=0.0001) Overall hospital mortality was 2%. Conclusion: Single layer continuous extra mucosal technique is as safe as interrupted extra mucosal anastomosis technique but can be performed in shorter time and can be a cost effective alternative for construction of bowel anastomosis.

PARCELAR GASTRIC RESECTION IN ASSOCIATION WITH BOWEL RESECTIONS AS PART OF DEBULKING SURGERY FOR ADVANCED STAGE OVARIAN CANCER – A CASE REPORT

Ovarian cancer represents one of the most aggressive gynecological malignancies affecting women worldwide, associated with significant rates of cancer related death within the first years after the initial diagnostic. The poor survival rates are usually explained by the presence of disseminated lesions even from the beginning. In such situations, the digestive tube is one of the most commonly involved territory, therefore necessitating extended resections in order to achieve complete cytoreduction. The aim of this paper is to report the case of a 53 year old patient who was diagnosed with peritoneal carcinomatosis from ovarian cancer, presenting multiple levels of digestive tract involvement due to the presence of disseminated tumoral masses. Therefore the patients was submitted to multiple digestive resections represented by parcelar gastrectomy, segmental ileal resection and subtotal colectomy. In order to minimize the risks of developing severe postoperative complications – due to the relatively high number of anastomoses – the continuity of the digestive tract was established by a terminal ileostomy, considering that creation of a ileorectal anastomosis would be too dangerous in the context of multiple digestive resections. The postoperative evolution was simple, the patient being further submitted to adjuvant treatment.

A Comprehensive Review of Intestinal Atresias

A Comprehensive Review of Intestinal Atresias

A Near-Zero Anastomotic Leak Rate in Cytoreductive Surgery with Heated Intraperitoneal Chemotherapy is Achievable.

Gastrointestinal complications are the main source of severe morbidity after cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC), mainly in the form of anastomotic leak. Reducing the rate of anastomotic leaks is of paramount importance and should be approached both through risk factor understanding and reduction, as well as optimization of surgical team performance. We performed a study that describes the details of a technical protocol for the creation of anastomoses after colorectal resections in CRS and HIPEC and the anastomotic outcomes associated with its systematic application in a high-volume peritoneal surface malignancy center. An extremely low, near-zero anastomotic leak rate (0.85% in colorectal anastomoses, 1% in ileo-colic anastomoses, and 0% in ileo-rectal anastomoses) was observed among 1172 patients. Extremely low, near-zero rates of anastomotic leak after colorectal resections in CRS and HIPEC could be achievable in high-volume peritoneal malignancy centers. The described techniques could be adopted and validated in other high-volume peritoneal malignancy centers.

METHODS OF ILEO-TRANSVERSE AND COLON INVAGINATIONAL ANASTOMOSES CREATING

Summary. The aim of the study. To improve the results of patients with tumors and non-neoplastic diseases of the colon treatment, to introduce into clinical practice the original surgical technique and methods of creating of colon anastomoses, which were tested in experiment.&#x0D; Materials and methods. Original methods of invaginational ileo-transverse and colon anastomoses creating were developed in the experiment on rabbits. Taking into account the obtained positive results, the methods of anastomoses formation were transferred to the surgical clinic and patents of Ukraine were obtained.&#x0D; In 2020, ileo-transverse and colonic anastomoses were formed in 134 patients on the basis of Transcarpathian Antitumor Center: one-row invaginational anastomosis according to the developed method in 22 patients (16.4 %), two-row manual — in 58 (43.3 %), circular stapler — in 36 (26.9 %), linear stapler anastomosis — in 4 (3 %), laparoscopic (linear stapler) — in 14 (10.4 %).&#x0D; Results and discussion. The most of complications occurred in the group with manual two-row anastomosis (16), in two cases the anastomotic leakage was recorded. When using a circular stapler suture, anastomotic leakage was observed in 1 patient, and anastomositis — in 4. When using linear stapler anastomoses, postoperative wound suppuration was observed in 1 patient.&#x0D; Conclusions. The most of early postoperative complications was observed after using a two-row manual colonic anastomosis (27.5 %). When using a circular stapler suture, the number of early postoperative complications was less than with a two-row manual anastomosis (22.2 % vs. 27.5 %, respectively). The least number of complications was recorded after the creation of a one-row invaginational anastomosis in the proposed original technique.

Robotic Resection of a Type IIIB Klatskin Tumor

Perihilar cholangiocarcinoma (Klatskin tumor) is one of the most challenging hepatobiliary cancers to treat due to its critical location and tendency to involve nearby vascular structures in the portal hepatic. A combined biliary and major liver resection is often required to achieve a complete oncological resection. Traditionally, Klatskin tumor resection is performed using an “open” approach until recently when the minimally invasive technique becomes popular due to its proven advantages. The laparoscopic technique had been reported; however, the majority of resections were types I and II without the need for ipsilateral hepatectomy. Inherent limitations of straight laparoscopic instruments result in significant technical difficulties in performing precise tissue dissection and vessel repair and creating a fine bilioenteric anastomosis. In this didactical video, we described our technique of type IIIB Klatskin tumor (B3-L perihilar cholangiocarcinoma) resection utilizing a robotic technology. The use of a robotic platform facilitates precise porta hepatic dissection, bleeding control, and creation of a fine bilioenteric anastomosis at the level of the hilar plate. We believe that the robotic platform provides an alternative method for resection of perihilar cholangiocarcinoma with excellent short-term outcomes.

Minimally Invasive Management of Diverticular Disease.

Traditionally, management of complicated diverticular disease has involved open damage control operations with large definitive resections and colostomies. Studies are now showing that in a subset of patients who would typically have undergone an open Hartmann's procedure for Hinchey III/IV diverticulitis, a laparoscopic approach is equally safe, and has better outcomes. Similar patients may be good candidates for primary anastomosis to avoid the morbidity and subsequent reversal of a colostomy. While most operations for diverticulitis across the country are still performed open, there has been an incremental shift in practice toward minimally invasive approaches in the elective setting. The most recent data from large trials, most notably the SIGMA trial, found laparoscopic sigmoid colectomy is associated with fewer short-term and long-term complications, decreased pain, improvement in length of stay, and maintains better cost-effectiveness than open resections. Some studies even demonstrate that robotic sigmoid resections can maintain a similar if not more reduction in morbidity as the laparoscopic approach while still remaining cost-effective. Intraoperative approaches also factor into improving outcomes. One of the most feared complications in colorectal surgery is anastomotic leak, and many studies have sought to find ways to minimize this risk. Factors to consider to minimize incidence of leak are the creation of tension-free anastomoses, amount of contamination, adequacy of blood supply, and a patient's use of steroids. Techniques supported by data that decrease anastomotic leaks include preoperative oral antibiotic and mechanical bowel prep, intraoperative splenic flexure mobilization, low-tie ligation of the inferior mesenteric artery, and use of indocyanine green immunofluorescence to assess perfusion. In summary, the management of benign diverticular disease is shifting from open, morbid operations for a very common disease to a minimally invasive approach. In this article, we review those approaches shown to have better outcomes, greater patient satisfaction, and fewer complications.

Implementation of Robotic Assistance in Pancreatic Surgery: Experiences from the First 101 Consecutive Cases.

Robotic assisted minimally invasive surgery has been implemented to overcome typical limitations of conventional laparoscopy such as lack of angulation, especially during creation of biliary and pancreatic anastomoses. With this retrospective analysis, we provide our experience with the first 101 consecutive robotic pancreatic resection performed at our center. Distal pancreatectomies (RDP, N = 44), total pancreatectomies (RTP, N = 3) and pancreaticoduodenectomies (RPD, N = 54) were included. Malignancy was found in 45.5% (RDP), 66.7% (RTP) and 61% (RPD). Procedure times decreased from the first to the second half of the cohort for RDP (218 min vs. 128 min, p = 0.02) and RPD (378 min vs. 271 min, p < 0.001). Overall complication rate was 63%, 33% and 66% for RPD, RPT and RDP, respectively. Reintervention and reoperation rates were 41% and 17% (RPD), 33% and 0% (RTP) and 50% and 11.4% (RPD), respectively. The thirty-day mortality rate was 5.6% for RPD and nil for RTP and RDP. Overall complication rate remained stable throughout the study period. In this series, implementation of robotic pancreas surgery was safe and feasible. Final evaluation of the anastomoses through the median retrieval incision compensated for the lack of haptic feedback during reconstruction and allowed for secure minimally invasive resection and reconstruction.