Robotic Resection Research Articles

OGC SO44 - Robotic gastric resection is feasible and safe - the first 25 cases at a tertiary UK Oesophago-gastric unit

Abstract Background Robotic approaches to upper GI surgery are being increasingly used due to purported benefits including improved vision and dexterity over conventional laparoscopy, and reduction in surgical trauma and wound-related morbidity over open surgery. Introduction of new technology and its implementation into practice comes with an inevitable learning curve and it is paramount that this does not occur at the expense of patient outcomes. This study looked at the surgical and oncological outcomes from the implementation of a robotic gastric resectional service at a tertiary centre in the UK. Method A prospectively maintained database was used to identify all patients undergoing robotic subtotal and total gastrectomy irrespective of indication. Patients having sleeve gastrectomy or gastric wedge resection were not included. Demographic, operative, pathological and complications data were included. Complications were graded using the Clavien-Dindo classification. Textbook outcomes for gastric cancer surgery were defined as complete resection, pathological R0, >15 lymph nodes resected, no intraoperative complications, no reintervention, no ICU readmission, no prolonged hospital stay (defined as > 21 days), no mortality or readmission at 30 days, and no severe complications (Clavien Dindo ≥ II). Results Twenty-five patients were identified, 13 (52%) were women and the median age was 73 (range: 40 – 88). Twenty-two (92%) had a subtotal gastrectomy and adenocarcinoma was the diagnosis in 15 (62.5%). Median blood loss was 50ml (50 – 310 ml) and operative time 320 minutes (225 – 480 minutes). There were no conversions to open. Complications occurred in 6 (24%) with one leak, 2 theatre returns, one death and no readmissions. Median stay was 6 days (4-14 days). Of the 16 having cancer surgery, median nodal yield was 29.5 (16 – 66), R0 rate 100% and a textbook outcome achieved in 14 (87.5%). Conclusion Robotically-assisted gastric resection can be implemented with a low rate of complication. In those patients having surgery for cancer, pathological outcomes were good and 14/16 patients achieved a textbook outcome which is significantly higher than most published studies.

Gradual expansion of the indications for minimally invasive liver resection to include highly complex procedures may improve postoperative outcomes

Aim: Liver resection is performed in patients with benign and malignant liver tumors. Advancements in surgical instruments and improved perioperative management have enabled safe laparoscopic and robotic liver resections. Herein, we aimed to evaluate the patients who underwent minimally invasive liver resection (MISLR) and compare their short-term outcomes with those of patients who underwent open liver resection (OLR), according to surgical complexity. Methods: Data of patients who underwent liver resection at our institution from January 2011 to August 2023 were obtained from a prospectively maintained database. We gradually expanded the indications for MISLR from technically less demanding procedures to intermediate- and high-complexity MISLRs. The procedures were categorized into three grades (low, intermediate, and high) according to the liver resection complexity classification. Results: Of the 1,866 patients who underwent liver resection, 953 were included in the analysis. Of the 953 patients, 781 underwent OLR and 172 underwent MISLR. The operative time and estimated blood loss increased with the increase in surgical complexity in the MISLR group, which was similar to finding in the OLR group. The complication rate also increased with the increase in surgical complexity in the OLR group (low complexity vs. high complexity, 34.8% vs. 50.1%). However, the complication rate was steadily low and approximately 10% across all complexity grades in the MISLR group. Conclusion: Careful selection and gradual expansion of the indications of MISLR may facilitate improved postoperative outcomes in patients undergoing highly complex MISLRs.

A Contemporary Review of Robotic Resection for Hepatocellular Carcinoma

Background: Robotic hepatectomy represents an appealing treatment modality for resectable hepatocellular carcinoma (HCC). A contemporary review of robotic hepatectomy compared to laparoscopic/open hepatectomy is necessary. Methods: We performed a literature review to identify studies between 2018–2024 comparing robotic to laparoscopic/open hepatectomy for HCC with measurable outcomes. Results: A total of 10 studies were identified, including 943 patients undergoing robotic hepatectomy compared to 1678 patients undergoing laparoscopic/open hepatectomy. Generally, while similar short/long-term survival was noted across all resection modalities, robotic hepatectomy was associated with longer operative time, shorter length of stay, and less post-operative complications. An additional 4 studies were evaluated in the context of HCC, reviewing the prognostic value of robotic hepatectomy margins, robotic hepatectomy in the context of metabolic syndrome, “huge” (>10 cm) HCCs, and robotic hepatectomy vs. microwave ablation. Conclusions: Robotic hepatectomy is a safe alternative to laparoscopic/open hepatectomy for HCC that provides similar oncological/long-term outcomes, while potentially decreasing post-operative complications and length of stay.

Evolution from laparoscopic to robotic radical resection for gallbladder cancer: a propensity score-matched comparative study.

The use of robotic or laparoscopic surgery for gallbladder cancer (GBC) is increasing, with reported advantages over conventional open surgery. The purpose of this study was to compare the perioperative outcomes and postoperative overall survival (OS) associated with robotic radical resection (RRR) and laparoscopic radical resection (LRR) for GBC. A total of 109 patients with GBC who underwent radical resection with the same surgical team between January 2015 and December 2023 were enrolled, with 21 patients in the RRR group and 88 cases in the LRR group. A 1:1 propensity score matching (PSM) algorithm was used to compare the surgical outcomes and postoperative prognosis between the RRR and LRR groups. Logistic regression analysis was used to identify the risk factors of postoperative overall survival (OS) and complications of Clavien-Dindo (C-D) Grades III-IV. The median follow-up time was 46 (inter-quartile range, IQR 29-70) months for the LRR group and 16 (IQR 12-34) months for the RRR group. After PSM, the baseline characteristics of the RRR and LRR groups were generally well balanced, with 21 patients in each group. RRR was associated with significantly decreased intraoperative bleeding [100.00 (50.00, 200.00) mL vs 200.00 (100.00, 300.00) mL] and higher number of lymph nodes (LNs) yield [12.00 (9.00, 15.50) vs 8.00 (6.00, 12.00)]. The two groups showed comparable outcomes in terms of the incidence of biliary reconstruction, the range of liver resection, the length of operation, the incidence of postoperative morbidity, the incidence of C-D Grades III-IV complications, number of the days of drainage tubes indwelling and postoperative hospital stay, and mortality by postoperative days 30 and 90. After PSM, the 1-, 2-, and 3-year overall survival rates were 78, 70, and 37%, respectively, in the RRR group, and 71, 59, and 48%, respectively, in the LRR group (P = 0.593). Multivariate analysis showed that the preoperative TB level ≥ 72µmol/L and biliary reconstruction were found to be the independent risk factors of C-D Grades III-IV complications. T3 stage was identified to be the risk factor for postoperative OS. Compared with LRR, RRR showed comparable perioperative outcomes in terms of length of operation, and postoperative complications, recovery, and OS. In our case series, RRR of GBC can be accomplished safely and tends to show less intraoperative bleeding and higher LNs yield.

Robotic endoscopic resection: the next revolution in therapeutic endoscopy is already here!

Robotic endoscopic resection: the next revolution in therapeutic endoscopy is already here!

Case report: Radical robotic nephroureterectomy after chemotherapy followed by avelumab in a patient with node-positive UTUC

IntroductionPlatinum-based chemotherapy followed by the immune checkpoint inhibitor avelumab represents an intensified upfront therapy regimen that may result in significant downstaging and, subsequently, potentially radical robotic nephroureterectomy with a lymph node dissection, an uncommon approach with an unexpectedly favorable outcome.Case presentationWe report a case of a 70-year-old female presented with a sizeable cN2+ tumor of the left renal pelvis and achieved deep partial radiologic response after systemic therapy with four cycles of gemcitabine-cisplatin chemotherapy followed by avelumab maintenance therapy and subsequent robotic resection of the tumor. The patient continued with adjuvant nivolumab therapy once recovered after surgery and remained tumor-free on the subsequent follow-up. The systemic treatment was without any severe adverse reaction.ConclusionWe highlight the feasibility of the upfront systemic therapy with four cycles of gemcitabine-cisplatin chemotherapy followed by avelumab maintenance, robotic-assisted removal of the tumor, and adjuvant immunotherapy with nivolumab. This intensification of the upfront systemic therapy, and the actual treatment sequence significantly increase the chances of prolonged survival or even a cure. This type of personalized therapeutic approach can accelerate future advanced immunotherapeutic strategies.

A novel low-cost high-fidelity porcine model of liver metastases for simulation training in robotic parenchyma-preserving liver resection.

In the era of minimally invasive surgery (MIS), parenchyma-preserving liver resections are gaining prominence with the potential to offer improved perioperative outcomes without compromising oncological safety. The surgeon learning curve remains challenging, and simulation plays a key role in surgical training. Existing simulation models can be limited by suboptimal fidelity and high cost. We describe a novel, reproducible, high-fidelity, low-cost liver metastases model using porcine livers from adult Landrace pigs, with porcine perinephric fat used to simulate subcapsular metastases. This model was then utilised in a training session for surgical trainees performing robotic parenchyma-preserving surgery (PPS) under the guidance of expert robotic surgeons, with feedback being recorded. Trainees rated the model highly on its fidelity to human liver simulation (median score 9), tissue handling (median score 8), and overall usefulness (median score 9). Tissue handling was felt to simulate in vivo liver resection closely, while suggestions for improvement included adding simulated blood flow. This is a novel, low-cost, high-fidelity simulation model of liver metastases with high acceptability to surgical trainees, which could be readily adopted by other training centres.

Comparative Systematic Review and Meta-Analysis Between Robotic and Laparoscopic Abdominoperineal Resection for Rectal Cancer: Oncological and Short-Term Outcomes

Comparative Systematic Review and Meta-Analysis Between Robotic and Laparoscopic Abdominoperineal Resection for Rectal Cancer: Oncological and Short-Term Outcomes

Initial Experience With Robotic Liver Resection in the United States.

This study's aim was to show the feasibility and safety of robotic liver resection (RLR) even without extensive experience in major laparoscopic liver resection (LLR). A single center, retrospective analysis was performed for consecutive liver resections for solid liver tumors from 2014 to 2022. The analysis included 226 liver resections, comprising 127 (56.2%) open surgeries, 28 (12.4%) LLR, and 71 (31.4%) RLR. The rate of RLR increased and that of LLR decreased over time. In a comparison between propensity score matching-selected open liver resection and RLR (41:41), RLR had significantly less blood loss (384 ± 413 vs 649 ± 646mL, P = .030) and shorter hospital stay (4.4 ± 3.0 vs 6.4 ± 3.7 days, P = .010), as well as comparable operative time (289 ± 123 vs 290 ± 132 mins, P = .954). A comparison between LLR and RLR showed comparable perioperative outcomes, even with more surgeries with higher difficulty score included in RLR (5.2 ± 2.7 vs 4.3 ± 2.5, P = .147). The analysis of the learning curve in RLR demonstrated that blood loss, conversion rate, and complication rate consistently improved over time, with the case number required to achieve the learning curve appearing to be 60 cases. The findings suggest that RLR is a feasible, safe, and acceptable platform for liver resection, and that the safe implementation and dissemination of RLR can be achieved without solid experience of LLR.

12035 Robotic Resection of Deep Infiltrative Endometriosis of the Rectum and Vagina

12035 Robotic Resection of Deep Infiltrative Endometriosis of the Rectum and Vagina

Simple Trocar Placement for Robotic Liver and Pancreatic Surgery: Multiple Access Devices at 5-cm Single Umbilicus Incision with 2 Robotic Ports.

Robotic trocars are recommended to be placed 6-8 cm apart, and assistant trocars are placed 7 cm away from the horizontal line of the robotic trocar placement. However, adhering to these rules may be difficult, particularly in lean patients. This study aims to demonstrate our standardized simple trocar placement, 5-cm single umbilicus incision + 2 ports for robotic liver resection (RLR) and robotic pancreaticoduodenectomy (RPD). During 2022-2024, patients undergoing RLR and RPD at The University of Tokyo were identified from a prospectively maintained database. Our standardized trocar placement consisted of multiple access devices at the 5-cm umbilicus incision, including two robotic trocars and one assistant trocar, and two other robotic trocars inserted to shape a hemi-circle around the surgical object. A total of 29 and 31 consecutive patients underwent RLR and RPD, respectively. The 5-cm single umbilicus incision + 2 ports method was used in 82.8% of patients undergoing RLR and 100% of patients undergoing RPD. No patients undergoing RLR developed hepatic insufficiency and bile leakage with the median postoperative hospital stay of 5 days. No patients undergoing RPD developed clinically relevant pancreatic fistula, delayed gastric emptying, and bile leakage with the median postoperative hospital stay of 8 days. Our standardized trocar placement technique is simple and widely feasible for lean-to-obese patients, allowing for RLR and RPD while minimizing incisions for patients.

Total Mesorectal Excision with New Robotic Platforms: A Scoping Review.

Colorectal surgery is one of the specialties that have significantly benefited from the adoption of robotic technology. Over 20 years since the first robotic rectal resection, the Intuitive Surgical Da Vinci system remains the predominant platform. The introduction of new robotic systems into the market has enabled the first documented total mesorectal excision (TME) using alternative platforms. This scoping review aimed to assess the role and adoption of these emerging robotic systems in performing TME for rectal cancer surgery. Methods: A comprehensive search of the Medline, Embase, and Cochrane databases was conducted up to August 2024, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. Results: Thirty-six studies were included in the review. The majority of rectal surgical procedures were performed using eight different robotic platforms. Intraoperative, short-term, and functional outcomes were generally favorable. However, pathological results were frequently incomplete. Several studies identified the lack of advanced robotic instruments as a significant limitation. Conclusions: The quality of the resected specimen is critical in rectal cancer surgery. Although TME performed with new robotic platforms appears to be feasible and safe, the current body of literature is limited, particularly in the assessment of pathological and long-term survival outcomes.

Six-Port Robotic Liver Resection Using Double Bipolar Clamp-Crush Method With Saline Drops: Advancing Safety, Efficiency, and Versatility in Liver Parenchymal Dissection

Six-Port Robotic Liver Resection Using Double Bipolar Clamp-Crush Method With Saline Drops: Advancing Safety, Efficiency, and Versatility in Liver Parenchymal Dissection

Experience-based transition to robotic surgery in an experienced program in minimally invasive hepatobiliary surgery.

The adoption of robotic techniques in liver surgery introduces significant challenges for their safe integration within hepatobiliary surgery units. This study is designed to investigate the complexities associated with establishing a robotic surgery program. Data on robotic hepatobiliary surgeries were prospectively collected from October 2021 to October 2023. Historical cohorts from the institutional experiences for comparison were hand-assisted (HALS) and purely laparoscopic procedures (PLS). Inverse probability of treatment weighting and propensity score matching were employed to compare outcomes between PLS and robotic resections. The learning curve for robotic surgeries was evaluated by the cumulative sum method. In this study, 454 patients were enrolled (113 robotic surgeries, 157 HALS, and 184 PLS). The posterosuperior segments resections were significantly higher in the robotic group (47.8%) compared to PLS (31.5%) and HALS (35.7%). There were no conversions in the robotic group, in PLS 2.7% and HALS 3.8%. The degree of difficulty according to the median of the IWATE score and IMM score was significantly higher in the robot group (p < 0.001 and p = 0.008, respectively). No significant differences in short-term outcomes were observed between robotic procedures and PLS in a matched subset of patients. Operative efficiency and blood loss improved significantly after the 75th robotic surgery patient, with high-difficulty cases (IWATE ≥ 10) incorporated from the beginning. This study suggests that robotic liver surgery in units with prior experience in minimally invasive liver surgery offers benefits, such as a lower conversion rate and a higher rate of successful difficult resections.

Immunohistochemical Glutamine Synthetase As a Surrogate Marker for Beta Catenin (Exon 3 Deletion) in a Rare Case of Hepatic Adenomatosis with Early Malignant Transformation to Well Differentiated Hepatocellular Carcinoma

Abstract Introduction/Objective Hepatic adenomatosis (HA) is a rare entity defined by ≥ 10 hepatocellular adenomas (HCAs). About half of HA cases are asymptomatic and incidentally found. Compared to individual HCAs, HA carries a higher risk of complications including: tumor rupture, bleeding, and an approximate 4.2% overall frequency of malignant transformation. Methods/Case Report A 29-year-old woman presented to the emergency department (ED) requesting a CT scan. She was seen by a gastroenterologist days prior to her ED visit for ongoing sharp rectal pain for 2-3 months. After a recent rectal exam, she was recommended to have a CT abdomen/pelvis to rule out a potential abscess. CT did not show a perianal or perirectal abscess but instead identified a 9.1 cm right hepatic lobe mass. A liver MRI showed a 6.4 x 8.5 cm mass with arterial enhancement. The patient had a prior history of OCP use. She underwent robotic wedge resection of liver segment 6 with cholecystectomy. Gross examination showed a 6 cm tumor with many smaller nodules ranging in size from 0.5-2.2 cm. Our case was submitted entirely for histologic examination. Microscopy demonstrated well differentiated hepatocellular carcinoma (WDHCC) confirmed with positive immunohistochemical (IHC) staining for HepPar1 and Arginase. Tumor cells showed mild patchy cytological atypia, occasional pseudoglands, and architectural atypia with “nodule in nodule growth.” There was reticulin loss in multiple areas and CD34 showed strong diffuse sinusoidal staining. Glypican 3, CRP, and HAA were negative. Low Ki-67, LFABP retention, and absent nuclear staining of beta catenin (BC) were noted. Glutamine synthetase (GS) was diffuse and homogeneous. The gallbladder was unremarkable. Results (if a Case Study enter NA) NA Conclusion This case emphasizes that, despite negative nuclear BC staining, diffuse homogenous staining of GS is a quality surrogate marker for BC mutations (ex. exon 3 deletions). Thorough gross, microscopic, and molecular examination in HA cases is essential for identifying transformation to WDHCC.

Robotic Rectosigmoid Resection with Totally Intracorporeal Colorectal Anastomosis (TICA) for Recurrent Ovarian Cancer: A Case Series and Description of the Technique.

Most patients with ovarian cancer relapse within 2 years. Prospective randomized trials, such as DESKTOP III and SOC-I, have shown the role of secondary cytoreduction in improving oncological outcomes in selected patients, when complete tumor resection is achieved. Recent retrospective series suggest that minimally invasive surgery is a feasible option in oligometastatic recurrences, such as rectal ones. Five patients with an isolated rectal recurrence infiltrating the bowel wall underwent a robotic rectosigmoid resection with totally intracorporeal colorectal anastomosis. The procedure began with retroperitoneal access to manage the vascular structures, followed by visceral resection with a minimally invasive approach. The standard steps of an en-bloc pelvic resection, including intracorporeal end-to-end anastomosis, were performed. The treatment data were evaluated. The mean age of the patients was 54 years, and their mean body mass index was 30. All patients had at least one previous abdominal surgery and 60% had high-grade serous ovarian cancer at their initial diagnosis. Their mean platinum-free interval was 17.4 months. Complete secondary cytoreduction was achieved in all cases, with histopathology confirming bowel infiltration. The mean procedure duration was 294 min, with an estimated blood loss of 180 mL. No intraoperative complications occurred. The mean hospital stay was 8 days. One patient had a grade 2 postoperative complication. The mean follow-up period was 14 months, with only one patient experiencing a recurrence at the level of the abdominal wall. Robotic rectosigmoid resection is a viable option for complete cytoreduction in isolated recurrent ovarian cancer.

Comparing Open, Laparoscopic and Robotic Liver Resection for Metastatic Colorectal Cancer-A Systematic Review and Network Meta-Analysis.

Colorectal liver metastases (CRLM) can be surgically managed through open resections (OLR), laparoscopic resections (LLR), or robotic liver resections (RLR). However, there is ongoing uncertainty regarding the safety and effectiveness of minimally invasive approaches like LLR and RLR. This study aims to clarify these issues by conducting a network meta-analysis (NMA) to compare outcomes across OLR, LLR and RLR for patients with CRLM. Following the PRISMA-NMA guidelines, the meta-analysis included 13 studies with a combined total of 6582 patients. Of these, 50.6% underwent LLR, 45.3% underwent OLR, and 4.1% underwent RLR. The analysis found no significant differences in R0 resection rates between LLR (odds ratio [OR] 1.03, 95% confidence interval [CI]: 0.84-1.26) and RLR (OR 1.57, 95% CI: 0.98-2.51) when compared to OLR. Additionally, there were no significant differences in disease-free survival (DFS) and overall survival (OS) at 1, 3, and 5 years. Despite these findings, both LLR and RLR were associated with reduced postoperative complication rates (RLR: OR 0.52, 95% CI: 0.32-0.86; LLR: OR 0.50, 95% CI: 0.37-0.68). However, patients undergoing LLR were more likely to require conversion to open surgery compared to those undergoing RLR (OR: 12.46, 95% CI: 2.64-58.67). Furthermore, RLR was associated with a reduced need for blood transfusions (OR: 0.13, 95% CI: 0.05-0.32), and LLR resulted in shorter hospital stays (mean difference: -6.66 days, 95% CI: -11.6 to -1.88 days). This study demonstrates the oncological safety of LLR and RLR approaches for CRLM relative to OLR, with enhanced perioperative outcomes anticipated following minimally invasive resections of CRLM.

Body image and quality of life undergoing totally robotic versus robotic-assisted distal gastrectomy: a retrospective propensity score matched cohort study

BackgroundWith the improvement of anastomotic techniques and the iteration of anastomotic instruments, robotic intracorporeal suturing has become increasingly proficient. The era of fully intracorporeal anastomosis in robotic gastric cancer resection is emerging. This study aims to explore the impact of totally robotic distal gastrectomy (TRDG) and robotic-assisted distal gastrectomy (RADG) on patients’ quality of life.Patients and methodsThis study is a comparative retrospective study of propensity score matching. This study included 306 patients who underwent robotic distal gastrectomy for gastric cancer between June 2016 and December 2023 at our center. Covariates used in the propensity score included sex, age, BMI, ASA score, maximum tumour diameter, degree of histological differentiation, Pathological TNM stage, Pathological T stage, Pathological N stage, and Lauren classification. Outcome measures included operative time, intraoperative bleeding, time to first venting, time to first fluid intake, postoperative hospital stay, total hospitalization cost, total length of abdominal incision, postoperative complications, inflammatory response, body image, and quality of life.ResultsAccording to the results of the study, compared with the RADG group, the TRDG group had a faster recovery time for gastrointestinal function (P = 0.025), shorter length of abdominal incision (P < 0.001), fewer days in the hospital (P = 0.006) less pain (P < 0.001), less need for additional analgesia (P = 0.013), and a postoperative white blood cell count (P < 0.001) and C-reactive protein content indexes were lower (P<0.001). In addition, the TRDG group had significantly better body imagery and cosmetic scores (P = 0.015), physical function (P = 0.039), role function (P = 0.046), and global function (P = 0.021) than the RARS group. Meanwhile, the TRDG group had milder symptoms of fatigue (P = 0.037) and pain (P < 0.001). The PASQ Total Subscale Score (P < 0.001) and Global Subscale Score (P < 0.001) were significantly lower in the TRDG group than in the RADG group at postoperative 3 months.ConclusionTotally robotic distal gastrectomy has a smaller incision, faster gastrointestinal recovery time, fewer days of postoperative hospitalization, and lower inflammatory markers than robotic-assisted distal gastrectomy. At the same time, postoperative cosmetic and quality of life outcomes were satisfactory. Clinically, these benefits translate to enhanced patient recovery, reduced surgical trauma, and better postoperative outcomes. These findings could guide surgeons in selecting more effective surgical approaches for patients undergoing gastrectomy, leading to better overall patient satisfaction and outcomes.

7698 A case of Pheochromocytoma in a patient with severe aortic stenosis

Abstract Disclosure: C. Lane: None. L.E. Aguirre: None. J. Azocar-Villalobos: None. R.I. Dorin: None. Background: Pheochromocytomas are rare neuroendocrine tumors derived from chromaffin tissue of the adrenal medulla and can secrete catecholamines. Pre-operative management of pheochromocytoma involves initiation of a- followed by b-adrenergic receptor blockade. In critical aortic stenosis (AS), adrenergic blockade may be complicated by decreased cardiac output and hypotension owing to dependence of venous return on maintenance of high afterload (1). We report a case of critical AS and incidentally discovered pheochromocytoma and describe our management strategy, which involved prioritization of aortic valve repair prior to adrenal surgery and multidisciplinary approach to initiation and titration of a- and b-adrenergic blockade prior to cardiac catheterization and transcutaneous aortic valve replacement (TAVR) procedures. Clinical Case: A 75-year-old Caucasian male with past medical history of obstructive sleep apnea, tobacco use, and cocaine use disorder was admitted with progressive dyspnea, decreased exercise tolerance, and involuntary weight loss of 18 kg over 3 months, and community acquired pneumonia. On admission, he was found to have critical aortic stenosis (valve area of 0.59 cm2, mean gradient 83 mmHg) and new HFrEF (EF 40-45%). CT chest demonstrated incidental right adrenal mass (5.6 x 5.0 x 4.7 cm) with central necrosis, HU units &amp;gt;10, and evidence of internal hemorrhage. Subsequent laboratory and functional imaging studies confirmed diagnosis of pheochromocytoma. Pre-procedural a-adrenergic blockade with doxazosin followed by beta-blockade was managed by a multidisciplinary team with ICU admission for monitoring and uncomplicated completion of cardiac catheterization and TAVR. Conclusions: Pre-procedural diagnosis of pheochromocytoma, multidisciplinary management, and intensive care setting for monitoring hemodynamic response to initiation and titration of a and b-adrenergic blockade appeared to be key factors in achieving uncomplicated completion of cardiac interventions prior to surgical resection of pheochromocytoma and critical AS. Successful TAVR was associated with marked improvement in hemodynamic status. Maintenance of b-adrenergic blockade to reduce myocardial contractility was critical to preservation of the prosthetic aortic valve and in preparation for planned robotic resection of the pheochromocytoma.

Risk factors and outcomes of conversions in robotic and laparoscopic liver resections: A nationwide analysis

BackgroundUnfavorable intraoperative findings or incidents during minimally invasive liver surgery may necessitate conversion to open surgery. This study aimed to identify predictors for conversion in minimally invasive liver surgery and gain insight into outcomes following conversions. MethodsThis nationwide, retrospective cohort study compared converted and non-converted minimally invasive liver surgery procedures using data from 20 centers in the Dutch Hepatobiliary Audit (2014–2022). Propensity score matching was applied. Subgroup analyses of converted robotic liver resection versus laparoscopic liver resection and emergency versus non-emergency conversions were performed. Predictors for conversions were identified using backward stepwise multivariable logistic regression. ResultsOf 3,530 patients undergoing minimally invasive liver surgery (792 robotic liver resection, 2,738 laparoscopic liver resection), 408 (11.6%) were converted (4.9% robotic liver resection, 13.5% laparoscopic liver resection). Conversion was associated with increased blood loss (580 mL [interquartile range 250–1,200] vs 200 mL [interquartile range 50–500], P < .001), major blood loss (≥500 mL, 58.8% vs 26.7%, P < .001), intensive care admission (19.0% vs 8.4%, P = .005), overall morbidity (38.9% vs 21.0%, P < .001), severe morbidity (17.9% vs 9.6%, P = .002), and a longer hospital stay (6 days [interquartile range 5–8] vs 4 days [interquartile range 2–5], P < .001) but not mortality (2.2% vs 1.2%, P = .387). Emergency conversions had increased intraoperative blood loss (1,500 mL [interquartile range 700–2,800] vs 525 mL [interquartile range 208–1,000], P < .001), major blood loss (87.5% vs 59.3%, P = .005), and intensive care admission (27.9% vs 10.6%, P = .029), compared with non-emergency conversions. Robotic liver resection was linked to lower conversion risk, whereas American Society of Anesthesiologists grade ≥3, larger lesion size, concurrent ablation, technically major, and anatomically major resections were risk factors. ConclusionBoth emergency and non-emergency conversions negatively impact perioperative outcomes in minimally invasive liver surgery. Robotic liver resection reduces conversion risk compared to laparoscopic liver resection.