Standard Laparoscopic Approach Research Articles

Safety of cholecystectomy performed by surgeons who prefer fundus first versus surgeons who prefer a standard laparoscopic approach

BackgroundAn alternative method to standard laparoscopic cholecystectomy (SLC) is the “fundus first” method (FFLC). Concerns have been raised that FFLC can lead to misinterpretation of important anatomical structures, thus causing complications of a more serious kind than SLC. Comparisons between the methods are complicated by the fact that FFLC is often used as a rescue procedure in complicated cases. To avoid confounding related to this we conducted a population-based study with comparisons on the surgeon level. MethodIn GallRiks, the Swedish registry for Gallbladder surgery, we stratified all cholecystectomies performed 2006–2020 in three groups: surgeries carried out by surgeons that uses FFLC in <20 % of the cases (N = 150,119), in 20–79 % of the cases (N = 10,212) and in 80 % or more of the cases (N = 3176). We compared the groups with logistic regression, adjusting for sex, age, surgical experience, year of surgery and history of acute cholecystitis. All surgical complications (bleeding, gallbladder perforation, visceral perforation, infection, and bile duct injury) were included as outcome. A separate analysis was done with regards to operation time. ResultsNo difference in incidence of all surgical complications or bile duct injury were seen between groups. The rates of bleeding (OR 0.34 [0.14–0.86]) and gallbladder perforation (OR 0.61 [0.45–0.82]) were significantly lower in the “fundus first > 80% group” and the operative time was shorter (OR 0.76 [0.69–0.83]). ConclusionIn this study including >160,000 cholecystectomies, both methods was found to be equally safe. Key messageDuring laparoscopic cholecystectomy, the standard method of dissection and fundus first dissection are equally safe surgical techniques. Surgeons need to learn both methods to be able to use the one most appropriate for each individual case.

Retrospective analysis of operative time and time to discharge for laparoscopic vs robotic approaches to appendectomy and cholecystectomy.

Robotic-assisted appendectomies and cholecystectomies are believed to increase cost compared to the gold standard laparoscopic approach. Two equally qualified surgeons performed both approaches over 2 years to evaluate intraoperative duration, time to discharge, conversion to open procedure, and readmission within 30days. 110 laparoscopic, 81 robotic-assisted appendectomies; and 105 laparoscopic and 165 robotic-assisted cholecystectomies were performed. Intraoperative time; laparoscopic appendectomy was 1.402 vs 1.3615h for robotic-assisted (P value = 0.304); laparoscopic cholecystectomy was 1.692 vs 1.634h for robotic-assisted (P value = 0.196). Time to discharge, was 38.26 forlaparoscopic vs 28.349h for robotic-assisted appendectomy (P value = 0.010), and 35.95 for laparoscopic vs 28.46h for robotic-assisted cholecystectomy (P value = 0.002). Intraoperative conversion to open; only laparoscopic procedures were converted,one appendectomy and nine cholecystectomies. None in therobotic-assisted procedures. Readmissions, none in the appendectomy group and three in the cholecystectomy group. One laparoscopic and two robotic-assisted cholecystectomy patients were readmitted. Intraoperative times for robotic appendectomy and cholecystectomy were notlonger thanlaparoscopic approach. Robotic approach shortened the time to discharge and the likelihood for conversion to open procedure.

Outcomes of Robotic-Assisted Bariatric Surgery Compared to Standard Laparoscopic Approach Using a Standardized Definition: First Look at the 2020 Metabolic and Bariatric Surgery Accreditation Quality Improvement Project (MBSAQIP) Data.

The primary objective of this study is to evaluate the outcomes of robotic-assisted (RA-) approach compared to the standard laparoscopic (L-) approach usingthe 2020 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)registry Public Use File (PUF). Our secondary objective is to establish standards for the reporting of outcomes using PUF. Using the PUF database (n = 168,568), patients were divided into sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), revisions, and conversions and then analyzed separately. We created balanced covariate through propensity score matching and inverse probability treatment weighting (IPTW). We also conducted multivariable relative risk regression to confirm our results. For RYGB, the incidence of "transfusion" was significantly lower in the RA-RYGB compared to the L-RYGB. There was no significant difference in the rate of Serious Event Occurrences (SEOs) or rate of intervention at 30days. For SG, there was a higher rate of "transfusion" in the RA group. Incidence ofSEOs was also significantly higher in the RA-group. There was no significant difference in SEOs for conversions; however, revisions had a trend toward a lower rate of SEOs favoring the robotic approach. Operative times were significantly higher for all RA-groups. RA- approach in metabolic and bariatric surgery (MBS) remains controversial because of differences in outcomes. The use of SEOs as reported by MBSAQIP in its semi-annual report can be used as a composite score to assess outcomes while using PUF. Further studies are needed to compare RA- to L- MBS.

OC-079 LAPAROSCOPIC TAPP APPROACH FOR A RECURRENT INGUINAL HERNIA

Abstract Aim To analyze the safety, feasibility, and effectiveness of a systematized laparoscopic transabdominal preperitoneal approach for a recurrent inguinal hernia. Material &amp; Methods A retrospective observational analysis of a database between July 2012 and July 2022. Inclusion: all patients with a standard laparoscopic tapp approach to treat a recurrent inguinal hernia. The variables were compared with our results in primary inguinal hernias: laparoscopic finding (cause and type using the EHS classification) conversion rate, cause of conversion, complications, and quality of life outcomes. Demographic analysis of the population Age, BMI, and a number of recurrences. Results In this period, 5452 patients underwent a tapp laparoscopic approach to treat an inguinal hernia. 372 (6.82%) were registered as recurrent hernias. Men (98.4%). BMI: (26). When comparing the patients with a previous anterior approach: 316 patients (90%), there were no differences with the results of the primary hernia. Patients with the antecedents of the posterior approach were 39 patients (10,4%). Reviewed case by case, the effectiveness in diagnosis was (100%), and the conversion rate of 8 patients (20,5%). The cause of conversion was severe mesh adhesions to the vascular triangle and vesical preperitoneal space. There were no significant differences when comparing the results between patients who underwent tapp repair in primary and recurrent hernias. There was also no significant difference according to the number of recurrences. Conclusions The laparoscopic systematized approach in recurrent hernias shows effective rates in providing safe diagnosis and treatment while maintaining the quality of life standards.

Robotic-assisted foregut surgery is associated with lower rates of complication and shorter post-operative length of stay.

Two of the most common foregut operations are laparoscopic Heller myotomy and laparoscopic Nissen fundoplication. Robotic assistance, compared to standard laparoscopic approach, may potentially grant surgeons advantages such as enhanced visualization and dexterity. This study compares patient outcomes for Heller myotomy (HM) and Nissen fundoplication (NF) when performed laparoscopically versus robotically. A retrospective review of patients at a single institution who underwent laparoscopic or robotic-assisted HM or NF from January 2019 to July 2022 was conducted. 123 HM (72 laparoscopic, 51 robotic-assisted) and 92 NF (62 laparoscopic, 30 robotic-assisted) were performed by three surgeons. Outcomes investigated were operative time, hospital length of stay, pre- and post-operative imaging, resolution of symptoms at 30days, resolution of symptoms at 90days, and complications. In the HM cohorts, the average operative time was longer in the robotic cohort (127min robotic versus 108min laparoscopic, p < 0.01). However, overall complication rates (p < 0.05) were lower, and hospital length of stay was shorter in the robotic group (1.5days compared to 2.7days, p < 0.001). In the NF cohorts, there was no significant difference in operative time. However, hospital length of stay was shorter in the robotic group (1.54days compared to 2.7days, p < 0.001) with otherwise similar outcomes. There was no difference in the rate of post-operative resolution of symptoms or need for additional interventions in either HM or NF. Robotic-assisted HM and NF are associated with shorter hospital stays compared to their respective laparoscopic approaches. Robotic-assisted HM also has a lower rate of complications. Our findings suggest that robotic assistance may be beneficial for shortening hospital length of stay and decreasing complications for certain surgeries specific to Foregut surgery.

177: A 5-YEAR SINGLE CENTER EXPERIENCE IN ROBOTIC SURGERY FOR ESOPHAGEAL ACHALASIA IN A TERTIARY CENTER, WITH PERI-OPERATIVE TAILORED PROTOCOLS

Abstract Background and aim Esophageal achalasia is a rare benign disease with heavy impact on daily life. Laparoscopic Heller-myotomy as the gold standard surgical treatment. In recent years the robot-assisted (DaVinci, Intuitive Surgical Inc., CA) technique became widely used for its reported advantages in terms of vision, precision and motion. The aim of the study was to evaluate the supposed advantages of robot-assisted Heller myotomy compared to the standard laparoscopic approach in a single center experience. Methods We included the patients who underwent standard laparoscopic and robot-assisted Heller-myotomy with Dor fundoplicatio in the last 5 years in the Upper-GI division of the University Hospital of Verona. We assessed if the robot-assisted Heller-Dor myotomy was simplified in terms of the ease of the myotomy, especially on the gastric side and the following fundoplicatio, on the sharpness of the endoscope and on the precision of the movements. We also compared the operative times with the two techniques, and the overall morbidity and mortality rates, also with the introduction of new peri-operative protocols for standardized and enhanced recovery. Results We included 40 patients who underwent Heller-Dor, robot-assisted Heller-Dor approach was performed in 17 patients and standard laparoscopic approach in 23 patients. Based on the surgeons experience and judgment, robot-assisted Heller-myotomy seems to be easier than the laparoscopic procedure in terms of sharpness of vision, freedom of motion and consequently precision in the single-fibers dissection of the muscularis. The operative times were comparable between the robot-assisted procedures and the laparoscopic approach, as were morbidity and mortality rates; in-hospital stay was also similar in the two groups, with a slight decrease in the last 6 months, after the introduction of new post-operative protocols for enhanced recovery with mandatory contrast swallow on POD1. Conclusion Our study suggests that robot-assisted Heller-myotomy for achalasia is a valid alternative to the traditional laparoscopic approach, for the improvement of surgical precision and myotomy outcome, with apparently no deterioration of safety and surgical complications, in particular with dedicate personnel and standardized recovery protocols. It also suggests that the learning curve is negligible if supported by an adequate number of patients per-year, as in a tertiary center.

Direct medical costs of robotic sleeve gastrectomy compared to laparoscopic approach in a single academic center.

The use of the robotic platform in bariatric surgery remains controversial because of lack of level I evidence to support its superiority compared to the laparoscopic approach and because of cost concerns. Recently, an extended use program (EUP) for robotic instruments was also introduced at our institution to help reduce the associated direct medical costs of robotic surgery. To evaluate the direct medical costs of a robotic sleeve gastrectomy (R-SG) and compare it to a standard laparoscopic approach (L-SG). Academic, tertiary care center. The analysis included the last 50 R-SG performed at our institution between June 1st 2019 and October 31st 2020. Those cases were compared to the L-SG cases (29 cases) performed in the same time period. All revisions or conversions were then excluded which resulted in a total of 74 primary SG (R-SG = 45 and L-SG = 29). Direct medical costs included operating room cost, instrument cost, miscellaneous cost, and cost of hospital stay. Direct cost data was generated using the StrataJazz reporting module, which is fed daily from EPIC, our electronic health record system. Patients who underwent a primary SG or a primary SG with a concomitant Paraesophageal Hernia Repair (PEH) were analyzed separately using Mann-Whitney rank sum tests and Student's t tests. An additional analysis and subanalysis of the groups was also performed after applying the potential savings of the Extended Use Program (EUP). Overall, the direct medical cost of R-SG was comparable to L-SG ($6330.77 vs $6804.12 respectively, p = 0.07). The direct medical cost of patients undergoing SG alone without PEH was significantly lower in the R-group compared to the L-group ($5927.08 vs $6508.01, respectively, p = 0.04). When applying the EUP savings to our data, the predicted direct medical cost of R-SG becomes significantly lower than L-SG ($6145.77 vs $6804.12 respectively, p = 0.01). At our academic medical center, we found no difference in direct medical costs between R-SG and L-SG. With the application of the EUP, direct medical costs of R-SG can be significantly lowered compared to L-SG. It is important to consider that cost data are largely dependent upon the academic medical center of interest, and surgeons need to collect their own cost data to evaluate whether robotic surgery is feasible at their institution.

Robotic-Assisted vs. Standard Laparoscopic Surgery for Rectal Cancer Resection: A Systematic Review and Meta-Analysis of 19,731 Patients.

Simple SummarySurgery remains a mainstay of combined modality treatment at patients with rectal cancer; however, there is a growing interest in using laparoscopic techniques (LG); including robotic-assisted techniques (RG). Therefore, we have prepared a meta-analysis of the literature regarding the safety and efficacy of robotic versus laparoscopic approaches in patients undergoing curative surgery for rectal cancer. The results indicate a number of advantages of RG in terms of both safety and efficacy. Operative time in the RG group was shorter and associated with a statistically significantly lower conversion of the procedure to open surgery. RG technique provided a shorter duration of hospital stay and lowered urinary risk retention. No differences were found between these techniques regarding TNM stage; N stage or lymph nodes harvested. Survival to hospital discharge or 30-day overall survival rate was 99.6% in RG vs. 98.8% for LG.Robotic-assisted surgery is expected to have advantages over standard laparoscopic approach in patients undergoing curative surgery for rectal cancer. PubMed, Cochrane Library, Web of Science, Scopus and Google Scholar were searched from database inception to 10 November 2021, for both RCTs and observational studies comparing robotic-assisted versus standard laparoscopic surgery for rectal cancer resection. Where possible, data were pooled using random effects meta-analysis. Forty-Two were considered eligible for the meta-analysis. Survival to hospital discharge or 30-day overall survival rate was 99.6% for RG and 98.8% for LG (OR = 2.10; 95% CI: 1.00 to 4.43; p = 0.05). Time to first flatus in the RG group was 2.5 ± 1.4 days and was statistically significantly shorter than in LG group (2.9 ± 2.0 days; MD = −0.34; 95%CI: −0.65 to 0.03; p = 0.03). In the case of time to a liquid diet, solid diet and bowel movement, the analysis showed no statistically significant differences (p > 0.05). Length of hospital stay in the RG vs. LG group varied and amounted to 8.0 ± 5.3 vs. 9.5 ± 10.0 days (MD = −2.01; 95%CI: −2.90 to −1.11; p < 0.001). Overall, 30-days complications in the RG and LG groups were 27.2% and 19.0% (OR = 1.11; 95%CI: 0.80 to 1.55; p = 0.53), respectively. In summary, robotic-assisted techniques provide several advantages over laparoscopic techniques in reducing operative time, significantly lowering conversion of the procedure to open surgery, shortening the duration of hospital stay, lowering the risk of urinary retention, improving survival to hospital discharge or 30-day overall survival rate.

Standardized Technique of Selective Left Liver Vascular Exclusion During Laparoscopic Liver Resection for Benign and Malignant Tumors

BackgroundTumors located close to major hepatic veins pose a technical challenge to standard laparoscopic liver resection. Hepatic outflow occlusion may reduce the risks of bleeding from hepatic vein and gas embolism. The aim of this study was to detail our standardized laparoscopic approach for a safe extrahepatic control of the common trunk of middle and left hepatic veins during laparoscopic liver resection and to assess its feasibility in patients with tumors located in both right and left lobes of the liver. MethodsData of 25 consecutive patients who underwent laparoscopic liver resection with extrahepatic control of the common trunk of middle and left hepatic veins were reviewed. ResultsAll patients underwent primary hepatectomy. The vast majority (84%) of patients had malignant tumors. The control of the common trunk of middle and left hepatic veins was achieved in 96% of patients. There were 14 (56%) major hepatectomies and 11 (44%) minor hepatectomies. Some form of vascular clamping was performed in 23 (62%) patients: Pringle maneuver in 17 (median time = 45 min; range, 10–109) and selective vascular exclusion of the liver in 6 patients (median time = 30 min; range, 15–94). The median duration of operation was 254 min (range, 70–441). There was one case (4%) of gas embolism but without any complications during the postoperative course. Conversion to open surgery was performed in 2 (7.7%) patients: 1 for oncologic reason and 1 for non-progression during the transection plane. Perioperative blood transfusion rate was nil. The overall morbidity rate was 24%. ConclusionsThe laparoscopic approach for an extrahepatic control of the common trunk of middle and left hepatic veins is reproducible, safe, and effective, and can be applied during laparoscopic liver resection for tumors close to major hepatic veins.

Docking for robotic extraperitoneal para-aortic lymphadenectomy with Da Vinci Xi surgical system

Regarding extraperitoneal para-aortic lymphadenectomy, installation is key when performed with the assistance of the Da Vinci Xi robotic system. We developed a step-by-step guide, from patient installation to placement of the trocars to patient cart docking, to perform in the efficient and safest installation possible this procedure. The operation does not differ from standard laparoscopic extraperitoneal lymphadenectomy. The benefits of robotic surgery in this indication are comparable to those of the standard laparoscopic approach. Those benefits imply a precise knowledge of the management and installation of the da Vinci Xi robotic system.

Risk factors for complications after robotic adrenalectomy: a review

The application of adrenal surgery has been spreading steadily in recent years. With the increased use of robotics in surgery, robotic adrenalectomy (RA), especially for the posterior retroperitoneoscopic approach, has been taken on by many high-volume institutions as a good option over the standard laparoscopic approach (LA). This paper reviews the recent literature from May 2010 up to November 2019 with the aim of analyzing RA complications in order to identify risk factors for complications after RA. We analyzed 7 principal risk factors for complication: body mass index (BMI), age, tumor size, tumor side, pathology, previous surgery, and surgeon experience. In the review, some studies identified tumor size, malignancy type, completion of learning curve and, and less clearly, previous ipsilateral upper mesocolic or retroperitoneal surgery, as risk factors for postoperative complications and failure of robotic surgery. Whether RA is meaningfully superior to the standard minimally invasive approach is still a subject of discussion. RA appears safer by virtue of its reduction in hospital stay, lower blood loss, and equivalent complication rates, and surgeons should prefer adrenalectomy over the LA. Despite these advantages, the operative time and the overall cost of the robotic procedure are higher than the LA. Further high-quality trials, especially those analyzing the specific risk factors for complications in robotic surgery, should be conducted in order to optimize the stratification of patients eligible for robotic surgery.

Outcomes of minimally invasive partial nephrectomy among very elderly patients: report from the RESURGE collaborative international database.

The aim of the study was to perform a comprehensive investigation of clinical outcomes of robot-assisted partial nephrectomy (RAPN) or laparoscopic partial nephrectomy (LPN) in elderly patients presenting with a renal mass.The REnal SURGery in Elderly (RESURGE) collaborative database was queried to identify patients aged 75 or older diagnosed with cT1-2 renal mass and treated with RAPN or LPN. Study outcomes were: overall complications (OC); warm ischemia time (WIT) and 6-month estimated glomerular filtration rate (eGFR); positive surgical margins (PSM), disease recurrence (REC), cancer-specific mortality (CSM) and other-cause mortality (OCM). Descriptive statistics, Kaplan-Meier, smoothed Poisson plots and logistic and linear regression models (MVA) were used.Overall, 216 patients were included in this analysis. OC rate was 34%, most of them being of low Clavien grade. Median WIT was 17 minutes and median 6-month eGFR was 54 ml/min/1.73 m2. PSM rate was 5%. After a median follow-up of 20 months, the 5-year rates of REC, CSM and OCM were 4, 4 and 5%, respectively. At MVA predicting perioperative morbidity, RAPN relative to LPN (odds ratio [OR] 0.33; p <0.0001) was associated with lower OC rate. At MVA predicting functional outcomes, RAPN relative to LPN was associated with shorter WIT (estimate [EST] -4.09; p <0.0001), and with higher 6-month eGFR (EST 6.03; p = 0.01).In appropriately selected patients with small renal masses, minimally-invasive PN is associated with acceptable perioperative outcomes. The use of a robotic approach over a standard laparoscopic approach can be advantageous with respect to clinically relevant outcomes, and it should be preferred when available.

Feasibility of laparoscopic isolated caudate lobe resection for rare hepatic mesenchymal neoplasms.

BACKGROUNDMesenchymal tumors such as perivascular epithelioid cell neoplasm (PEComa) and inflammatory pseudotumor-like follicular dendritic cell sarcoma (IPT-like FDC sarcoma) are relatively uncommon in the liver and are particularly rare in the caudate lobe. The clinical manifestations and available imaging tests lack specificity for hepatic mesenchymal tumors. To the best of our knowledge, no caudate PEComa or IPT-like FDC sarcoma has been completely resected by laparoscopy. The standard laparoscopic technique, surgical approaches, and tumor margins for potentially malignant or malignant caudate mesenchymal tumors are still being explored.AIMTo assess both the safety and feasibility of laparoscopic resection for rare caudate mesenchymal neoplasms.METHODSEleven patients who underwent isolated caudate lobe resection from 2003 to 2017 were identified from a prospective database. Three consecutive patients with rare caudate mesenchymal tumors underwent laparoscopic resection. Patient demographic data, intraoperative parameters, and postoperative outcomes were assessed and compared with the open surgery group.RESULTSAll procedures for the three resection patients with caudate mesenchymal tumors were completed using a total laparoscopic technique by two different approaches. The average operative time was 226 min, and the estimated blood loss was 133 mL. The average length of postoperative hospital stay was 6.3 ± 0.3 d for the laparoscopy group and 15.5 ± 2.3 d for the open surgery group (P < 0.05). There were no perioperative complications or patient deaths in this series.CONCLUSIONLaparoscopic isolated caudate lobe resection for rare mesenchymal neoplasms is a feasible and curative surgical option in selected patients.

2870 Tips and Tricks in Laparoscopic Removal of the Remaining Cervical Stump

Study Objective the objective is to propose specific recommendations regarding the laparoscopic approach for removal of the retained cervix after subtotal hysterectomy. This is a rare operation and it will require systematic preoperative assessment and intraoperative approach. Design Retrospective study of 10 cases done over three years with follow up. Setting All cases were done in one centre and all had a laparoscopic approach with variable difficulty intraoperatively. Patients or Participants The cases had retained the cervix for different reasons; including a default approach to leave the cervix, surgical difficulty due to endometriosis. the reason for removing the remaining cervix included cervical abnormality, symptoms of pain, bleeding and Interventions the cases had standard laparoscopic approach. Measurements and Main Results all cases were successful in achieving the target of the removal of the cervical stump. One case needed conversion to laparotomy due to severe adhesions and bowel injury. one cases resulted in some worsening prolapse and two cases still have residual pain. Conclusion These cases need a careful preoperative assessment including a thorough analysis of the reason of leaving the cervix. The assessment should include transvaginal ultrasound to assess the length of the cervix and the Pouch of Douglas and supported by Pelvic MRI. Colposcopy and hysteroscopy can be useful aids to assess high grade lesions and evaluate endocervical canal to exclude precancer or cancer. It is a useful recommendation to avoid instrumentation of the cervix. McCartney tube can be considered instrument of choice for manipulation and colpotomy. Bilateral ureterolysis is strong recommendation and prior ureteric stenting can be useful in anticipation of residual severe endometriosis. Ample dedicated surgical time is important as the degree of adhesions over the remaining stump is unpredictable. These cases should attempted at advanced laparoscopic settings.

Laparoscopic Glissonian approach is safe and efficient when compared to standard laparoscopic liver resection

Background: Standard laparoscopic anatomical liver resection requires the dissection the hilar plate. In contrast, the Glissonian approach identifies the intrahepatic pedicles by tentative clamping. This study examines experience in a single center with regards to safety and efficacy. Methods: All consecutive patients undergoing laparoscopic liver resections from April 2007 to April 2014 were included. A comparison between Glissonian and standard laparoscopic liver resections was performed. Primary endpoint was safety of the procedures as assessed by the comprehensive complication index. Secondary endpoints were surgical parameters such as operating time, blood loss, blood transfusion, conversion rate, length of hospitalization, and pathological margin of the specimen. Results: 234 laparoscopic resections were performed at our institution, 120 using the conventional approach and 114 using the Glissonian approach. There was no difference in age, gender, tumor types, comorbidities, between the groups. The number of major liver resections was higher in the Glissonian group. There were fewer complications in the Glissonian group as compared to the standard group (p<0.05). Operative time was longer and more transfusions were given in the standard group and more patients had positive margins (p<0.01). Overall hospital stay was shorter in Glissonian group. Conclusion: In the 7 year experience of a single center, the Glissonian approach is not less safe and may have advantages when compared to the standard laparoscopic approach.

Su1449 EUS-GUIDED GASTROJEJUNOSTOMY USING A LUMEN APPOSING METAL STENT IN PATIENTS WITH SYMPTOMATIC GASTRIC OUTLET OBSTRUCTION

EUS gastrojejunostomy (GJ) is emerging as an alternative novel technique in patients with symptomatic gastric outlet obstructions (GOO) who have advanced malignancy. Recent studies have shown that the EUS-guided approach has less adverse events and is more cost-effective compared to laparoscopic GJ. We share our experience of 5 patients who underwent EUS Guided GJ with favourable outcomes. Five patients with symptomatic gastric outlet obstruction underwent EUS-guided GJ interventions from May 2017 to November 2017. Patients were informed of the potential risks of this novel procedure and informed consent was taken. Technical success was defined as successful deployment of lumen apposing metal stents (LAMS); while clinical success was the ability to tolerate diet. Median age was 61.5 (Range 53-83) years. GOO was secondary to advanced pancreatic malignancy (4) and duodenal malignancy (1). Two patients had altered anatomy from previous post bilroth gastrectomy and Roux-en-Y hepaticojejunostomy. For all five patients with GOO, LAMS 15mm diameter with electrocautery-enhanced delivery system was used to create the GJ anastomosis. Identification of the distal jejunal limb was done with an inflated balloon catheter and this was use as a target for direct puncture with a 19G needle. All five interventions had technical success with median procedure time of 80min (38-163 range). All stents were dilated up to their corresponding diameters. Duration of stay after procedure was 3-7 days and there were no adverse events post procedure such as bleeding or perforation. There were no stent migrations and stents were left in place for the rest of their life expectancy. One patient developed intermittent vomiting four weeks after stent deployment. This was possibly secondary to proximal stomach deployment, as repeated endoscopy showed a patent stent. The rest of the patients had clinical success and could tolerate diet on discharge. Range of follow up time was 1-6 months and at time of analysis GOO did not recur in all 5 patients. Three patients died due to disease progression with no symptoms of GOO prior to terminal event. EUS guided GJ is a novel procedure with favourable outcomes in patients with symptomatic GOO. Further prospective studies with larger number of patients are required to compare this new technique against the gold standard laparoscopic approach.

Iatrogenic spleen injury risk during robotic left colonic and rectal resections by routine left flexure mobilization technique: a retrospective study.

The routine mobilization of the left colonic flexure as a standard procedure during left colonic/rectal resection is a controversial topic in open and minimally invasive surgery. According to some authors, this maneuver may increase the risk of iatrogenic spleen damage; for others this does not change the odds. Ligaments over-traction is the most frequent injury mechanism. Some documented risk factors are reported: laparotomic approach, male gender, vascular disease, cancer, diverticulitis, surgery performed in emergency-setting. The type of procedure influences the associated risk: transverse colectomy is the riskiest, followed by left colonic resection and pancolectomy. Retrospective original paper. Sample size - a total of 125 patients have been considered. 75 robotic left colonic resections (60%), 40 robotic rectal resections (32%) and 10 robotic pancolectomy (8%). Primary outcomes - 1) percentage of iatrogenic splenic injuries; 2) conversion rate. Secondary outcomes - 1) intra-/postoperative complications; 2) anastomotic leakage rate; 3) mortality. In order to avoid potential confounding factors and technical/expertise heterogeneity, all the procedures included have been performed using the same standardized operative technique and by the same experienced surgeon (P.C.G.). We retrospectively analyzed 125 procedures. Primary outcomes - 1) iatrogenic splenic injuries: 0%; 2) conversion rate: 1.6%. Secondary outcomes - 1) intraoperative complications: 0%; 2) anastomotic leakage rate: 1 case of leakage out of 125 cases (1.3% of the left colectomy sub-sample); in this case the leakage was probably due to an infectious process rather than a vascular deficit; 3) mortality: 0%; 4) miscellanea postoperatory complications (small bowel obstructions, wound infection, pelvic collections, pneumonia and acute kidney injury) are detailed in the manuscript. In our experience, and according to some of the literature data as well, during robotic left colonic/rectal resections the routine mobilization of the left flexure as a standard procedure is not a risk factor in terms of iatrogenic spleen injury rate. Conversely, this technique may be beneficial as it does not excessively extend the operative time, increases the surgical skills acquirement, and reduces the tension-related anastomotic ischemia. It also allows a better oncological dissection. Standard laparoscopic approach reduces the rate of spleen by almost 3.5 times in comparison to open surgery. The improved technical accuracy provided by the robotic platform may decrease the rate of splenic injury. More studies are needed on the topic to confirm our findings.

Does Robotic Roux-en-Y Gastric Bypass Provide Outcome Advantages over Standard Laparoscopic Approaches?

ObjectiveThe aim was to compare clinical outcomes of patients treated with totally robotic Roux-en-Y gastric bypass (TRRYGB) with those treated with the different laparoscopic Roux-en-Y gastric bypass (LRYGB) techniques.Summary Background DataThe clinical benefit of the robotic approach to bariatric surgery compared to the standard laparoscopic approach is unclear. There are no studies directly comparing outcomes of TRRYGB with different LRYGB techniques.MethodsOutcomes of 578 obese patients who underwent RYGB between 2011 and 2014 at an academic center were assessed. Multivariable analysis and propensity matching were used for comparing TRRYGB to different LRYGB techniques, including 21-mm EEA circular-stapled gastrojejunal anastomosis (GJA, LRYGB-21CS), linear-stapled GJA (LRYGB-LS), and hand-sewn GJA (LRYGB-HS).ResultsThe TRRYGB technique required a longer mean operative time compared to the other groups, respectively 204 ± 46 vs. 139 ± 30 min (LRYGB-21CS), 206 ± 37 vs. 158 ± 30 min (LRYGB-LS), and 210 ± 36 vs. 167 ± 30 min (LRYGB-HS). TRRYGB experienced a lower stricture rate (2 vs. 17%, P = 0.003), shorter hospital stay (2.6 ± 1.2 vs. 4.3 ± 5.5 days, P = 0.008), and lower readmission rate (12 vs. 28%, P = 0.009). No significant differences in outcomes were observed when comparing RRYGB to LRYGB-LS or LRYGB-HS.ConclusionsTRRYGB increases operative time compared to all LRYGB techniques. TRRYGB was superior to LRYGB-21CS in terms of significantly shorter hospital stay, lower readmission rate, and less frequent GJA stricture formation. TRRYGB provides no clinical advantages over the LRYGB-LS and LRYGB-HS techniques.

Robot-Assisted Extraperitoneal Radical Prostatectomy, Single Site Plus Two Model.

To demonstrate a feasible procedure of robot-assisted extraperitoneal radical prostatectomy single site plus two model to overcome the limitation of traditional single-port laparoscopic surgery. All consecutive cases of robot-assisted extraperitoneal radical prostatectomy single site plus two model between November 2015 and April 2016 in our institution were included. We analyze the surgical and continence outcome. Twenty cases were included in the analysis. All cases successfully completed without any necessity for conversion to a standard laparoscopic approach or open surgery. The average age is 64.3 ± 8.2 years and average body mass index is 24.3 ± 2.9 kg/m2. Eight focal positive margins (40%) (5 in T2 and 3 in T3a disease) were encountered and all occurred at the apex. For continence outcomes, 9 (45%) patients need average 0-1 pads/day and 2 (10%) patients need average 3 pads/day after surgery, but most recover after several months. No intraoperative complications or major postoperative complications were recorded, excluding blood transfusion in one case. Robot-assisted extraperitoneal radical prostatectomy single site plus two model is technically feasible and safe in our experience. It can also be performed in patients that have previously received intraperitoneal abdominal surgery using the extraperitoneal approach. We can take this procedure into account for minimal invasive surgical option.

Robotic-assisted single-port donor nephrectomy using the da Vinci single-site platform

BackgroundAlthough single-port donor nephrectomy offers improved cosmetic outcomes, technical challenges have limited its application to selected centers. Our center has performed over 400 single-port donor nephrectomies. The da Vinci single-site robotic platform was utilized in an effort to overcome the steric, visualization, ergonomic, and other technical limitations associated with the single-port approach. Materials and methodsFood and Drug Administration device exemption was obtained. Selection criteria for kidney donation included body mass index <35, left kidney donors, and ≤2 renal arteries. After colonic mobilization using standard single-port techniques, the robotic approach was utilized for ureteral complex and hilar dissection. ResultsThree cases were performed using the robotic single-site platform. Average total operative time was 262 ± 42 min including 82 ± 16 min of robotic use. Docking time took 20 ± 10 min. Blood loss averaged 77 ± 64 mL. No intraoperative complications occurred, and all procedures were completed with our standard laparoscopic single-port approach. ConclusionsThis is the first clinical experience of robotic-assisted donor nephrectomy utilizing the da Vinci single-site platform. Our experience supported the safety of this approach but found that the technology added cost and complexity without tangible benefit. Development of articulating instruments, energy, and stapling devices will be necessary for increased application of robotic single-site surgery for donor nephrectomy.