Robotic Approach Research Articles

Optimizing the technical results of robotic esophagectomy: conduit creation and esophagogastric anastomoses

The esophagectomy, first done over a century ago, has evolved from open procedures to minimally invasive techniques. As minimally invasive surgery has progressed in both safety and efficiency since its inception, it is becoming increasingly favored and continues to demonstrate advantageous outcomes over open techniques. In terms of operative decisions, conduit diameter choice is crucial in esophagectomy. Narrower conduits (≤ 3 cm) seem to be more efficacious, and less prone to stricture than their wider counterparts (> 5 cm). Perfusion assessment, notably with indocyanine green (ICG), is still a topic of debate among surgeons with conflicting opinions on ICG’s impact. There are varying results in leak rates; however, the use of ICG in determining anastomotic site seems to exert some influence on surgical decision-making. Anastomotic techniques, such as circular stapling and linear stapling, have shown to be preferred over more traditional hand-sewn methods. At our institution, a completely robotic approach is used with creation of a 3-4 cm wide conduit and hybrid-type anastomosis. ICG is used to guide conduit transection and gastrotomy for anastomosis. Our experience shows that this approach offers an excellent combination of safety and reproducibility.

Endoscopic Robotic Mitral Operating Room as a Microsystem for Safety and Sustainability.

Safety and sustainability are key elements of a robotic mitral valve (MV) program at any stage of development. Challenges include the positioning of the surgeon at the robotic console, increasing patient complexity, and upstream administrative staffing difficulties. We instituted a systems approach to maximize patient safety and maintain robotic service viability. A single dedicated robotic operating room (OR) was equipped as a microsystem with team training in the operative steps, ergonomics, digital tools, and an explicit culture of safety. Outcomes of all robotic mitral procedures including concomitant procedures in the microsystem OR by a single surgeon were retrospectively reviewed. From January 2014 through December 2023, 1,529 consecutive MV patients were operated with an endoscopic robotic approach. Ten patients (0.65%) were converted to conventional approaches. Overall, 1,300 MV repairs (85%) were performed with residual MV regurgitation of none to trace in 1,205 patients (92.7%), mild in 92 patients (7.1%), and moderate in 3 patients (0.23%). MV replacements were performed in 229 patients (15%) with no paravalvular leaks. Mortality was 0.08% in the repair group and 0.87% in the replacement group. No deaths have occurred in the last 38 months. Stroke occurred in 0.31% of repair patients and 1.3% of replacement patients. One patient developed transient renal failure. Organization of the robotic OR as a microsystem is associated with surgical efficacy and very low morbidity and mortality. A comparable microsystem approach using all or select components may promote safety and sustainability for robotic MV programs at all levels.

Tracheobronchoplasty for severe tracheobronchomalacia: a case-series of patients with acute and chronic critical comorbidities.

There is little data within the literature regarding tracheobronchoplasty (TBP) in the setting of the acute and chronically ill, morbidly obese, or ventilator dependent patients with Tracheobronchomalacia (TBM). Short- and long-term outcomes are studied. The series represents 12 TBM patients with American Society of Anesthesiologists (ASA) physical status scores of 3 to 5. Candidacy was based on bronchoscopic findings during spontaneous respirations with >90% collapse of the trachea and both mainstem bronchi. We used dynamic CT scan as an adjunct in those not mechanically ventilated. Our operative approach was a complete portal robotic approach for those outpatients (wheelchair dependent) and right thoracotomy for those who were already mechanically ventilated with 100% fraction of inspired oxygen (FiO2) with high pressure. Extracorporeal support was used in 2 patients. Patients who underwent robotic repair, were discharged without complications. Two patients who were critically ill and required extracorporeal support for their surgeries, were separated from extracorporeal membrane oxygenation (ECMO) on postoperative day 2. Three patients died at the follow-up. In 1 patient, the prolene mesh migrated into trachea and caused obstruction of the trachea and required removal with endobronchial techniques. The repair of TBM in patients with multiple comorbidities and with severe life-threatening problems in or outside the ICU, may have improvement due to the ability to wean from positive pressure ventilation. Surgical technique and the utilization of mesh support in TBP operations may need to be debated due to duration of the surgery in patients with severe comorbidities.

A comparison between robotic-assisted and open approaches for large ventral hernia repair-a multicenter analysis of 30days outcomes using the ACHQC database.

Over the last few decades, there has been an increase in the use of a minimally invasive (MIS) approach for complex hernias involving component separation. A robotic platform provides better visualization and mobilization of tissues for component separation. We aim to assess the outcomes of open and robotic-assisted approaches for large VHR utilizing the ACHQC national database. A retrospective review of prospectively collected data from the Abdominal Core Health Quality Collaborative (ACHQC) was performed to include all adult patients who had primary and incisional midline ventral hernias larger than 10cm and underwent elective open and robotic hernia repairs with mesh from January 2013 to March 2023. Univariate and multivariate analyses were performed comparing Open and Robotic approaches. The ACHQC database identified 5,516 patients with midline hernias larger than 10cm who underwent VHR. The open group (OG) had 4,978 patients, and the robotic group (RG) had 538. The RG had a higher median BMI (33.3kg/m2 (IQR 29.8-38.1) vs 32.7 (IQR 28.7-36.6) (p < 0.001). Median hernia width was 15cm (IQR 12-18) in the OG and 12cm in the RG (10-14) (p < 0.001). Sublay positioning of the mesh was the most common. The fascial closure was higher in the RG (524; 97% versus 4,708; 95%-p = 0.005). Median Length of Stay (LOS) was 5days (IQR 4-7) in the OG and 2days (IQR 1-3) in the RG (p < 0.001). The readmission rate was higher in the OG (n = 374; 7.5% vs n = 16; 3%; p < 0.001). 30-day SSI were higher in the OG (343; 6.9%% vs 14; 2.6%; p < 0.001). Logistic regression analysis identified diabetes (OR 1.6; CI 1.1-2.1; p = 0.006) and BMI (OR 1.04, CI 1.02-1.06; p < 0.001) as predictors of SSIs, while the robotic approach was protective (OR 0.35, CI 0.17-0.64; p = 0.002). For SSO, logistic regression showed BMI (OR 1.04, CI 1.03-1.06; p < 0.001) and smoking (OR 1.8, CI 1.3-2.4; p < 0.001) as predictors Robotic approach was associated with lower readmission rates (OR .04, CI 0.2-0.6; p < 0.001). A robotic approach improves early 30-day outcomes compared to an open technique for large VHR. There was no difference in SSO at 30days.

Robotic surgery in the aspect of liver transplantation

Introduction. Almost 60 years have passed since the first liver transplant performed by Thomas Starzl. During this time, medical technologies have gradually improved, which has made it possible to use more and more new methods and approaches in this type of medical care. One of the new techniques of recent decades is robotic surgery, which is gradually being introduced into medical practice, including in the field of transplant medicine.Objective. The purpose of writing this review was to summarize knowledge and describe the current status of development of robotic surgery in the aspect of liver transplantation, namely: liver resection in donors, as well as graft implantation in the recipient.Material and methods. The review includes foreign and domestic publications on minimally invasive donor liver surgery. Publications on the topic of robotic liver resection in the aspect of liver transplantation were also processed.Conclusion. Robotic surgery using advanced robotic systems represents the next step in the development of minimally invasive technologies in liver transplantation. Robotic systems provide more precise and dexterous control of instruments, allowing surgeons to perform complex procedures with greater precision and less risk to patients. However, the robotic approach is still very limited in geographical distribution and requires much more experience than laparoscopy. The upcoming introduction of new robotic systems that support haptic feedback or cavitronic ultrasonic surgical aspirators will further promote a widespread adoption of robotic liver resection in liver donors and liver recipients.

Routine conventional leak test is not required for robotic major pulmonary resections.

We retrospectively evaluated whether or not conventional air leak testing is necessary in robotic major pulmonary resections. After excluding patients who received 2 or more days of postoperative drainage for chylothorax or excessive pleural effusion, 578 patients who underwent major pulmonary resection using minimally invasive approaches between February 2019 and November 2023 at our institution were included in this study. All patients were divided into two groups including thoracoscopic (n = 471) and robotic (n = 107) approaches. Conventional air leak testing was performed in all patients in the thoracoscopic approach but not in the robotic approach. After propensity score matching of patient backgrounds between the two groups, perioperative outcomes were compared (n = 100 each). The primary endpoint was the rate of drain removal on postoperative day (POD) 2 or later. In addition, factors associated with drain removal on POD 2 or later in the robotic group were identified. The rate of drain removal at POD 2 or later was not significantly different between the two groups (p = 0.011). Multivariable analysis to identify factors associated with drain removal at POD2 or later in the robotic approach showed that sealant application (p = 0.002) and lobectomy (vs. segmentectomy, p = 0.034) were significantly associated. In conclusion, even in the absence of air leak testing, a robotic approach for major lung resections can result in a drain removal rate on the day of surgery or POD1 that is comparable to a conventional thoracoscopic approach. However, it may be useful in selected patients requiring sealant placement or undergoing lobectomy.

Robotic-assisted versus laparoscopic-assisted extended mesorectal excision: a comprehensive meta-analysis and systematic review of perioperative and long-term outcomes.

Concurrent neoadjuvant chemo-radiation (nCRT) with total mesorectal excision (TME) alone sometimes fails to cure lateral lymph node metastasis (LLNM). Therefore, additional lateral lymph node dissection (LLND) can help in the treatment of these patients. This is what we refer to as extended total mesorectal excision (eTME). Such operations (TME alone or eTME) can be performed using conventional laparoscopic techniques and robotic-assisted techniques as well. Our meta-analysis aims to compare the results of robot-assisted (R-eTME) versus laparoscopic-assisted extended mesorectal excision (L-eTME) in terms of short- and long-term outcomes. Databases searched using title and abstract included Medline (via PubMed), Web of Science, Scopus, and Embase, up to February 20, 2024. All studies that documented robotic versus laparoscopic procedures for extended total mesorectal excision (R-eTME versus L-eTME) and reported more than two relevant outcomes, were included in the study. Our meta-analysis demonstrates four significant outcomes (operative time, urinary complications, overall recurrence, and admission days) between the laparoscopic and robotic groups. The robotic approach shows advantages over the laparoscopic approach in these outcomes except for the operative time (minute), which was longer in the robotic group compared to the laparoscopic group. The laparoscopic group is associated with a higher overall recurrence than the robotic group with an Odds Ratio of 2(95% CI, 1-4, p = 0.05). This meta-analysis study showed that the R-eTME group had a lower recurrence rate compared to the L-eTME group. Additionally, hospital admission days increased significantly in the laparoscopic group. Other long-term outcomes did not differ significantly between the two groups. Short-term outcomes were similar, except for more urinary complications in the laparoscopic group. In conclusion, the study suggests that robotic surgery may offer advantages over laparoscopic surgery for eTME. Further research and analysis could provide further insight into the potential benefits of robotic surgery in this procedure, particularly when surgeon experience, center volume, and learning curve are taken into consideration.

Perineal-First Approach in Robotic Abdominoperineal Resection.

Although abdominoperineal resection (APR) is required for rectal cancer invading the levator ani muscle, its curative outcomes remain poorer than those of other rectal surgeries.1-3 In particular, the anatomic complexity around the anterior wall of the rectum increases the technical difficulty during APR, resulting in a high frequency of margin involvement that causes local recurrence. In this video, we present the technical details of a robotic perineal-first APR approach. For a 46year-old man, locally advanced rectal cancer invading the levator ani muscles was diagnosed. Although total neoadjuvant therapy (8 cycles of induction FOLFOXIRI followed by chemoradiotherapy 50.4 Gy) decreased the tumor size, invasion was suspected still to remain. Therefore, robotic APR was performed. Written informed consent was obtained from the patient. For the perineal-first approach, we created a circular incision around the anus, then divided the fat tissues of the ischiorectal fossa until the levator ani muscle was exposed on both sides. Posterior and anterior dissections were performed along the coccyx and external anal sphincter, respectively. After placement of a lap protector to maintain air-tightness, the robotic approach was initiated. Posterior dissection was performed along the coccyx, then was connected to the already-dissected space created earlier by the perineal approach. Next, the levator ani muscle was divided from the dorsal to the lateral side. Finally, anterior dissection was performed along the prostate, followed by division of the rectourethral muscle, the smooth muscle fibers running vertically. The creation of the already-dissected space on the perineal side offers advantages of robotic manipulation from the abdominal side, especially anterior dissection. We performed robotic APR using the perineal-first approach for 17 consecutive patients (12 men and 5 women) between 2019 and 2023. All 17 patients achieved complete total mesorectal excision with negative margins. The mean time required for the perineal approach was about 25 min. In anterior dissection using the robotic approach, division of the smooth muscle fibers at the perineal body (i.e., rectourethral muscle in males4 or muscular intermingling in females5) was reproducibly performed in both males and females. Robotic APR with a perineal-first approach can be advantageous in ensuring surgical margin safety (especially for the anterior aspect of the rectum).

The impact of powered circular staplers on anastomotic leak in left-sided colorectal cancer surgeries

BackgroundSince the introduction of powered circular staplers in colorectal surgery, there has been growing interest in their impact on reducing complications, particularly anastomotic leakage. This study compared short-term postoperative outcomes between powered and manual circular staplers.MethodsThis retrospective study included colorectal cancer patients at the tertiary referral center from April to October 2023 who underwent anterior or low anterior resection (LAR) using a circular stapler. According to energy source, patients were divided into powered and manual groups, which used two powered and four types of manual staplers, respectively. All open, laparoscopic, and robotic approaches were included. Propensity score matching (PSM) analysis was used to reduce selection bias. Postoperative complications within 30 days, especially for anastomosis-related complications, were compared between the groups.ResultsAmong 511 patients, the powered group was 161 (32%). After PSM, 143 pairs of 286 patients were analyzed. The proportions of LAR were 53.8% and 51.0%, and initial diverting stoma rates were 23.1% and 22.4% for the Powered and Manual groups, respectively. Comprehensive complication rates were similar between the Powered group and the Manual group, without statistical significance (13.3% vs. 21.0%, P = 0.063). Anastomotic leakage was not different between the Powered and Manual groups (4.2% vs. 4.9%, P = 0.782). There was no significant difference in other complications, including anastomotic bleeding, ileus, surgical site infection, and intra-abdominal hematoma.ConclusionsThe study implies that powered circular staplers may not significantly reduce postoperative complications, including anastomotic leakages, compared to manual staplers in colorectal surgery of high-volume centers.Graphical

Robotic assisted laparoscopic total removal of retropubic sling mesh for pelvic pain

Retropubic mid-urethral slings (MUS) have been widely used in the surgical management of female stress urinary incontinence. While generally effective, there are cases when MUS removal becomes necessary due to complications or patient discomfort. Removal may be performed through an open or minimally invasive approach. This video demonstrates a robotic approach for the removal of a retropubic MUS, providing a detailed, step-by-step guide. We present a case of a 60-year-old female with bothersome voiding and storage lower urinary symptoms as well as pelvic pain. She was being managed with narcotic pain medication and gabapentin and undergoing pelvic floor physical therapy. Cystoscopy revealed no mesh erosion and urodynamics were consistent with obstruction. Transvaginal partial mesh excision resolved her voiding complaint, but the pain persisted. She elected for complete removal of the mesh. The video demonstrates a successful robotic removal of the retropubic MUS. The patient had resolution of her pain and post-operatively was off all pain medication and back to regular activity highlighting the effectiveness of the robotic approach. Robotic retropubic MUS removal is a valuable technique for managing complications related to MUS. This video offers a comprehensive guide. MUS complications are amenable to multiple surgical approaches, each should be tailored according to the specific patient.

Minimally invasive subtotal cholecystectomy. What surgeons need to know.

Minimally invasive laparoscopic cholecystectomy is among the most frequently performed abdominal surgeries. Bile duct injury is a significative complication that occurs in about 0.2-0.3% of open procedures and 0.5% of laparoscopic surgeries, with concomitant vasculobiliary injuries in 12-61% of cases. Most of these lesions occurs during challenging severe cholecystitis where the intense inflammation obscures the hepatocystic anatomy. In this case a bailout strategy such as a subtotal cholecystectomy should be considered. Subtotal cholecystectomy is a surgical technique performed to remove a portion of the gallbladder while leaving part of it behind. In such complex cholecystectomies, surgeons should be aware of this technique, and subtotal cholecystectomy should be part of their surgical armamentarium. We aim to familiarize surgeons with bailout techniques like subtotal cholecystectomy and gallbladder emptying for challenging acute cholecystectomy cases to reduce the risk of vasculobiliary injury. This multimedia article provides, a comprehensive step-by-step overview of the different possible minimally invasive subtotal cholecystectomy procedures, we outline five distinct techniques for conducting subtotal cholecystectomy, including some tips and tricks and demonstrates the usefulness of a minimally invasive approach. Finally, we emphasize the importance of carefully choosing between laparoscopic and robotic approaches and suggests using adjunctive tools, such as preoperative indocyanine green, to better identify common bile duct anatomy.

WP5.8 - Robotic versus laparoscopic general surgery in the emergency setting: a systematic review

Abstract Introduction Robot-assisted general surgery, a cutting-edge technology in minimally-invasive procedures, is increasingly utilised in elective general surgery, demonstrating advantages over laparoscopy in select cases. While laparoscopy remains a standard approach for common acute abdominal conditions, the role of robotic surgery in emergency general surgery is unclear. This systematic review aims to compare outcomes in acute general surgery settings for robotic versus laparoscopic surgeries. Method A PRISMA compliant systematic search across MEDLINE, EMBASE, Science Citation Index Expanded, and Cochrane library was performed. The literature review focused on articles comparing perioperative outcomes of emergency general surgery managed laparoscopically versus robot-assisted. A descriptive analysis was performed and outcome measures recorded. Results Six articles, reporting on 1063 patients, compared outcomes of robotic and laparoscopic procedures. Two covered cholecystectomies, while the others addressed ileocaecal resection, subtotal colectomy, hiatal hernia and perforated gastrojejunal ulcer repair. The level of evidence was low. Laparoscopic bowel resection in inflammatory bowel disease (IBD) patients had higher complications; no significant differences were found in complications for other operations. Operative time showed no differences for cholecystectomies, but robotic approaches were longer for other procedures. Robotic cases had shorter hospital length of stay, though the associated costs were significantly higher. Conclusion Perioperative outcomes for emergency robotic surgery in selected general surgery conditions are comparable to laparoscopic surgery. However, recommending robotic surgery in the acute setting requires a well-powered large population study for stronger evidence.

FP1.9 - Evaluating outcomes of multi-visceral resections for locally advanced colorectal cancer

Abstract Introduction Multi-visceral resection for colorectal cancer invading into adjacent organs is often difficult and involves serious complications. The aim of this study is to evaluate the short- and long-term outcomes of patients undergoing multi visceral and beyond TME (total mesorectal excision) resections for locally advanced CRC. Methods Patients undergoing elective surgery for advanced or recurrent CRC between October 2018 and October 2023 were identified. Demographic and clinical data were recorded, and outcomes analysed. Primary outcome was R0 resection rate and post-operative complication rate. Results Thirty-three patients (51.5% male, 48.5% female) were included, with a median age of 66.8 years (IQR 38-82) and median BMI was 26.7 kg/m2 (13.8-50). Majority of patients (n = 29, 87.8%) had surgery for primary, locally advanced CRC and most were referred from external Trusts (n=25, 75.7%). Thirteen patients (39.3 %) had robotic resections, one case was completed laparoscopically, and the remaining were open procedures (n= 19, 57.5%). Seventeen individuals had previous abdominal surgeries with no differences between open (8/20 = 40%) and robotic approach (9/13 = 69.2%) (p=0.207). Median LOS in open and robotic groups were 16 and 10 days respectively (p=0.047). There was no post-operative mortality. Proportion of CD I-II complications was 9/33 (27.3%) and CD III-IV 18/33 (54.5%). R0 resections rate was 63.6 % and eight patients (24.2%) developed recurrence during the follow up period (median = 47.6 months). Conclusions An aggressive surgical approach as part of a multimodal strategy affords the best prospect for long-term survival in selected patients. Robotic multi-visceral resection for locally advanced CRC is a safe and feasible, minimally invasive approach in selected cases.

Robotic colorectal resections are associated with less postoperative pain, decreased opioid use, and earlier return to work as compared to the laparoscopic approach.

While robotic and laparoscopic surgeries are both minimally invasive in nature, they are intrinsically different approaches and it is critical to understand outcome differences between the two. Studies evaluating pain outcomes and opioid requirement differences between the robotic and laparoscopic colorectal resections are conflicting and often underpowered. In this retrospective, cohort study, we compare postoperative opioid requirements, reported as morphine milligram equivalents (MME), postoperative average and highest pain scores across postoperative days (POD) 0-5, and return to work in patients who underwent robotic versus laparoscopic colorectal resections. The sample size was selected based on power calculations. Daily pain scores and MME were used as outcomes in linear mixed effect models with unstructured covariance between time points. Propensity score weighting was used to adjust for imbalances. Patients in the robotic group required significantly less opioids as measured by MME on all postoperative days (p = 0.004), as well as lower average and highest daily pain scores for POD 0-5 (p = 0.02, and p = 0.006, respectively). In a linear mixed-effects model, robotic resections were associated with a decrease in average pain scores by 0.36 over time (p = 0.03) and 35 fewer MME requirements than the laparoscopic group (p = 0.0004). Patients in the robotic arm had earlier return to work (2.1 vs 3.8days, p = 0.036). The robotic approach to colorectal resections is associated with significantly less postoperative pain, decreased opioid requirements, and earlier return to work when compared to laparoscopy, suggesting that the robotic platform provides important clinical advantages overthe laparoscopic approach.

274. ROBOTIC REVISIONAL HIATAL HERNIA REPAIR (R-RHR): DOES IT MAKE SENSE?

Abstract Background The gastroesophageal reflux disease (GERD) is increasing among our population and Nissen Fundoplication still remains as the most widely performed technique. The robotic approach to the hiatal hernia repair has been proven to be safe and feasible. Precision and comfort seem to be some reasons that it makes, at least, comparable to the laparoscopic approach. Revisional hiatal hernia is a challenging situation to the operator due the adhesions and fibrosis of the tissues so our concern is that the best technology available is needed. Methods From June 2019 to November 2023 our division performed 14 cases of Robotic Revisional Hiatal Hernia Repair (R-RHR). Demographic items such as Gender, Age, Body Mass Index (BMI), Previous surgery, Time from first surgery and Postoperative outcomes as Operation Time, Length of stay (LOS), Mesh use, Complications and Readmissions were recorded. Results 10 women and 4 men were recruited. In all cases the DaVinci robotic platform X and Xi (Intuitive) was used. Mean age resulted in 63.5 years old (sd 12.25). Mean BMI was 26.97 (sd 3.52). In 71.4% cases the Previous HH Surgery was Nissen Fundoplication. 49.3 months was the mean time from the first surgery to the revisional procedure. 163.5 (sd 83.7) minutes was the mean operation time. Mean Lenght Of Stay resulted in 3.4 days (sd 1.4). There were no conversions to the laparoscopic approach. In 5 patients (35.8%) a mesh was placed. Pleural effusion was the only postoperative complication reported (1/14) and it was managed non-operatively. No other complications were recorded and mortality rate was 0. Conclusions To the authors knowledge, this is Spain’s largest Robotic - Revisional Hiatal Hernia Repair (R- RHR) series. The results lead us to conclude that the robotic approach, even the complexity of the surgery, is safe and feasible in trained teams with similar outcomes from the primary surgery that are published.

Efficacy and safety of robotic liver surgery for the elderly: A propensity-score matched analysis of short-term outcomes with open liver surgery at a single center in Denmark.

The incidence of liver tumors requiring surgical treatment continues to increase in elderly patients. This study compared the short-term results of robotic liver surgery (RLS) versus open liver surgery (OLS) for liver tumors in elderly patients. A prospective database including all patients undergoing liver surgery at Copenhagen University Hospital between July 2019 and July 2022 was managed retrospectively. Short-term surgical outcomes of the two main cohorts (OLS and RLS) and subgroups were compared using propensity score matching (PSM) in elderly patients (age ≥ 70 years) with liver tumors. A total of 42 matched patients from each group were investigated: the RLS group had significantly larger tumor diameters, less blood loss (821.2 vs. 155.2 mL, p < .001), and shorter hospital stays (6.6 vs. 3.4 days, p < .001). Overall morbidity was comparable, while operative times were longer in the RLS group. The advantages observed with the robotic approach were replicated in the subgroup of minor liver resections. In patients ≥70 years, RLS for liver tumors results in significantly less blood loss and shorter hospital stays than OLS. RLS, especially minor liver resection, is safe and feasible in elderly patients with liver tumors.

277. FLUORESCENCE-GUIDED ANASTOMOSIS DURING SINGLE-PORT VATS IVOR LEWIS ESOPHAGECTOMY

Abstract Background Minimally Invasive Esophagectomy (MIE) is the standard approach for esophageal cancer. The thoracic part is performed using multiple ports during video or robotic approach with CO2 inflation of 8-10 mmHg. There are recent publications of successful lung &amp; thymic surgeries utilizing single port. This video describes our technique for performing ICG-guided intrathoracic anastomosis during single-port Ivor Lewis (IL) esophagectomy. Methods The surgery was performed on a 58-year-old male patient with Siwert type 1 adenocarcinoma (cT3, N0 M0). The patient underwent 4 cycles of neoadjuvant FLOT chemotherapy following a Multidisciplinary tumour board decision. Single-port Ivor Lewis (IL) esophagectomy was planned after three weeks of last cycle. Results Following the laparoscopic abdominal phase with extracorporeal gastric conduit formation and feeding jejunostomy, the patient was placed in a semiprone position. The thoracic phase was performed through single-port (4 cm in the 6th intercostal) VATS without CO2. The intrathoracic anastomosis was performed with a linear stapler in side-to-side manner under 1.5 ml indocyanine green (ICG) guidance. Thoracic phase time was 65 minutes. There were no intraoperative and postoperative complications. The pain score was three without opioid use. The patient was allowed orally on day five and discharged home on the eighth postoperative day. Conclusion Single port VATS IL MIE is a quick and safe surgical technique. Optics, instrumentations and surgical stapler maneuvering through a single port require a learning curve but are not difficult in our experience. A larger cohort and long-term follow-up are necessary for wider utilization of this approach. https://wetransfer.com/downloads/21555d68e61e7f962f2c33ed061b72dc20240319163828/b0b0feeea6f7a7ba47a04bb26ac96c2220240319163854/83de2d

PE021 Salvage radical prostatectomy following local therapy failure: Assessment of open and robotic approach

PE021 Salvage radical prostatectomy following local therapy failure: Assessment of open and robotic approach

Renal autotransplant as a definitive treatment for nutcracker syndrome: A multicenter retrospective study

ObjectiveNutcracker syndrome is a rare condition that involves mechanical compression of the left renal vein, leading to chronic and debilitating left flank pain. The etiology of the pain is misdiagnosed frequently, and patients usually require long-term opioid use to manage their pain. Multiple therapeutic options for nutcracker syndrome have been described in the literature but the reports are limited by small numbers of patients, and the lack of convincing data demonstrating consistently improved outcomes. Here we report the largest series to date of patients undergoing renal autotransplantation for the treatment of nutcracker syndrome. MethodsWe performed a multicenter retrospective cohort review of patients 105 patients with nutcracker syndrome who underwent renal autotransplantation as a primary or salvage therapy. ResultsDuring the overall study period, 93.1% of patients treated with autotransplantation had durable, complete flank pain relief at 12 months with both open and robotic surgical approach. After autotransplantation, a statistically significant decrease in the percentage of patients using opioids from 48.6% to 17.0% was demonstrated at 12 months. In those patients using opioids before autotransplantation, a statistically significant decrease in morphine milligram equivalents was demonstrated from an alarming 68.9 ± 15.0 per day to 25.0 ± 11.02 morphine milligram equivalents per day. ConclusionsOur findings suggest that renal autotransplantation, as a primary treatment or a salvage treatment, in patients with nutcracker syndrome provides durable pain relief and a marked decrease in chronic opioid use regardless of surgical approach.

Autonomous Robotic Ultrasound Approach for Fetoscope Tracking by Fusing Optical and 2D Ultrasound Data

Autonomous Robotic Ultrasound Approach for Fetoscope Tracking by Fusing Optical and 2D Ultrasound Data