Vinci Xi Surgical System Research Articles

Robotic infraclavicular approach for minimally invasive neck dissection in head-neck cancers.

In the recent years, there has been a rapid increase in the use of robot assisted neck dissection (RAND) as an alternative method for conventional neck dissection. Several recent reports have emphasized upon the feasibility and effectiveness of this technique. However, substantial technical and technological innovation is still essential in spite of the availability of multiple approaches for RAND. The present study describes a novel technique, i.e., Robotic Infraclavicular Approach for Minimally Invasive Neck Dissection (RIA MIND) used in head and neck cancers with the help of Intuitive da Vinci Xi Surgical System. After RIA MIND procedure, the patient was discharged on the third post operative day. Also, the total wound size was less than 3.5 cm which enhanced the patient recovery time and required minimal post operative care. The patient was further reviewed 10 days after the procedure for the removal of sutures. RIA MIND technique was effective and safe for performing neck dissection for oral, head and neck cancers. However, additional detailed studies will be required for establishing this technique.

Three-Arm Robotic Lung Resection via the Open-Thoracotomy-View Approach Using Vertical Port Placement and Confronting Monitor Setting: Focusing on Segmentectomy.

To perform robotic lung resections with views similar to those in thoracotomy, we devised a vertical port placement and confronting upside-down monitor setting: the three-arm, robotic “open-thoracotomy-view approach (OTVA)”. We described the robotic OTVA experiences focusing on segmentectomy and its technical aspects. We retrospectively reviewed 114 consecutive patients who underwent robotic lung resections (76 lobectomies and 38 segmentectomies) with OTVA using the da Vinci Xi Surgical System between February 2019 and June 2022. To identify segmental boundaries, we administered indocyanine green intravenously and used the robotic fluorescence imaging system (Firefly). In all procedures, cranial-side intrathoracic structures, which are often hidden in the conventional look-up-view method, were well visualized. The mean durations of surgery and console operation were 195 and 140 min, respectively, and 225 and 173 min, for segmentectomy and lobectomy, respectively. In segmentectomy, console operation was significantly shorter (approximately 30 min, p < 0.001) and two more staplers (8.2 ± 2.3) were used compared with lobectomy (6.6 ± 2.6, p = 0.003). In both groups, median postoperative durations of chest tube placement and hospitalization were 0 and 3 days, respectively. This three-arm robotic OTVA setting offers natural thoracotomy views and can be an alternative for segmentectomy and lobectomy.

Short-term outcomes of da Vinci Xi versus Si robotic systems for minor hepatectomies.

In the recent years, robotic technology has been drastically improved and the last generation of robotic platforms is hardly comparable with the earlier ones. The present study aims to investigate the short-term outcomes of minor hepatectomies performed with da Vinci Xi surgical system vs. Si surgical systems. Consecutive patients operated on between 2013 and 2020 in two referral centers were selected if underwent elective robotic minor hepatectomy (<3 consecutive segments) for primarily resectable benign or malignant lesions. Operative, postoperative, and cost outcomes were compared between the two groups by univariate and multivariate analyses. Eighty-nine patients were selected (64 in the Si system vs. 25 in the Xi system group). Wedge resection was the most commonly performed procedure (49.4%). The Si system group showed a significantly greater total incisional length (+8.99 mm; p<0.0001) related to the use of a higher number of robotic/laparoscopic ports. Pedicle clamping was more frequent in patients operated on by the Xi system (80% vs. 21.9%; p<0.0001) but without group differences in ischemia duration when clamping. A significantly shorter time to flatus (-0.75 days; p=0.015) was observed for patients operated on by the Xi system, whereas no group differences were found for operative time, conversion rate, estimated blood loss, postoperative complications, mortality, use of analgesics, and costs. The da Vinci Xi system represents a technological advancement with a potential clinical relevance, although further studies are needed to clearly detect the clinical impact of the use of this robotic platform in liver surgery.

Using Real-time Feedback To Improve Surgical Performance on a Robotic Tissue Dissection Task

BackgroundThere is no standard for the feedback that an attending surgeon provides to a training surgeon, which may lead to variable outcomes in teaching cases. ObjectiveTo create and administer standardized feedback to medical students in an attempt to improve performance and learning. Design, setting, and participantsA cohort of 45 medical students was recruited from a single medical school. Participants were randomly assigned to two groups. Both completed two rounds of a robotic surgical dissection task on a da Vinci Xi surgical system. The first round was the baseline assessment. In the second round, one group received feedback and the other served as the control (no feedback). Outcome measurements and statistical analysisVideo from each round was retrospectively reviewed by four blinded raters and given a total error tally (primary outcome) and a technical skills score (Global Evaluative Assessment of Robotic Surgery [GEARS]). Generalized linear models were used for statistical modeling. According to their initial performance, each participant was categorized as either an innate performer or an underperformer, depending on whether their error tally was above or below the median. Results and limitationsIn round 2, the intervention group had a larger decrease in error rate than the control group, with a risk ratio (RR) of 1.51 (95% confidence interval [CI] 1.07–2.14; p = 0.02). The intervention group also had a greater increase in GEARS score in comparison to the control group, with a mean group difference of 2.15 (95% CI 0.81–3.49; p < 0.01). The interaction effect between innate performers versus underperformers and the intervention was statistically significant for the error rates, at F(1,38) = 5.16 (p = 0.03). Specifically, the intervention had a statistically significant effect on the error rate for underperformers (RR 2.23, 95% CI 1.37–3.62; p < 0.01) but not for innate performers (RR 1.03, 95% CI 0.63–1.68; p = 0.91). ConclusionsReal-time feedback improved performance globally compared to the control. The benefit of real-time feedback was stronger for underperformers than for trainees with innate skill. Patient summaryWe found that real-time feedback during a training task using a surgical robot improved the performance of trainees when the task was repeated. This feedback approach could help in training doctors in robotic surgery.

Preoperative indocyanine green fluorescence injection to accurately determine a proximal margin during robotic distal gastrectomy.

Adequate surgical margins following gastrectomy for gastric cancer are required. In addition, a method for accurately detecting tumor location without palpation is needed during robotic surgery. Although several methods have been reported, most of these either lack accuracy or require increased time and effort during intraoperative detection. Herein, we introduce a new method for detecting tumor location using preoperative indocyanine green (ICG) marking and the built-in ICG detection system of the da Vinci Xi Surgical System in robotic gastrectomy to determine appropriate surgical margins. We used this method to determine the resection line in six patients who underwent robotic distal gastrectomy for clinical T1 gastric cancer. One to three days before surgery, ICG was diluted to 1.0mg/mL, and 0.1mL of this diluted ICG solution was endoscopically injected at one site into the submucosal layer of the stomach, 1cm proximal to the tumor edge. Gastrectomy was performed using the da Vinci Xi surgical platform, equipped with a near-infrared fluorescence imaging system (Firefly®). The diameter of the fluorescent signal during gastrectomy was estimated to be approximately 2cm. The resection line was determined on the outer edge of the fluorescent signal, which ensured a tumor-free margin of ≥2cm. Fluorescent signals were successfully observed in all cases. Moreover, the required 2-cm surgical margin was achieved in all cases. We could successfully determine proximal margins using preoperative ICG injection marking during robotic distal gastrectomy for gastric cancer.

Robot-Assisted Resection of Intestinal Duplication in Children.

Background: Intestinal duplication is the most common type of alimentary tract duplications in childhood. Laparoscopic-assisted surgery has become the main surgical procedure, but robot-assisted resection has rarely been reported; the aim of this study was to retrospectively present our experience with robot-assisted intestinal duplication excision using the Da Vinci Xi surgical system and discuss the technical points. Methods: In total, 49 patients who were diagnosed with intestinal duplication and underwent surgery from April 2020 to February 2022 in the Children's Hospital, Zhejiang University School of Medicine, were retrospectively analyzed. The data were collected including the clinical information of the patients, operative details, and postoperative outcomes. Results: Among these 49 patients, a total of 15 underwent robot-assisted surgery and 34 underwent laparoscopic-assisted surgery. For the robot-assisted surgery group, all the cysts were peeled off by complete endoscope, the integrity of the intestine was preserved and intestinal resection and anastomosis were not required. The operation time of 80 minutes for the robot-assisted group was not significantly longer than the 90 minutes for the laparoscopic-assisted surgery group(P > .05), but the mean time to take the liquid diet after surgery and the average length of postoperative hospital stay were significantly shorter (P < .05). Conclusion: Robot-assisted resection of intestinal duplication is safe and feasible and the refinement of the Da Vinci Xi surgical system was much better than that of the conventional laparoscopic equipment, resulting in significantly improved intraoperative and postoperative outcomes.

Cumulative Summation Analysis of Learning Curve for Robotic-assisted Hysterectomy in Patients With Gynecologic Tumors

This study aimed to evaluate the learning curve and perioperative outcomes of robot-assisted hysterectomy (RAH). We retrospectively analyzed data from 45 patients who underwent RAH using the da Vinci Xi surgical system. The learning curve was evaluated using the cumulative summation method. Demographic data and various perioperative parameters, including total operative time, docking time, and console time, were obtained from the medical records. Cumulative summation analysis indicated that proficiency regarding hysterectomy time was reached after 33 cases. There were two unique phases of the learning curve for console time: the introduction phase identified by the bottom point in the curve, and the proficient phase, identified by an upward line after the bottom point in the curve. There were no significant differences between the two phases in terms of patient age and body mass index. Total operative time, docking time, and console time were significantly decreased in the proficient phase compared with those in the introduction phase. There was a significant reduction in blood loss during operation in the proficient phase. The perioperative complication rates were 12.1% in the introduction phase and 0% in the proficient phase (p=0.5606). No blood transfusion or conversion to laparotomy was required in either phase. The introduction and proficient phases identified by cumulative summation analysis demonstrated progressive improvement of surgical performance in surgeons carrying out RAH.

Robot-assisted scaffold implantation and two-stage flap raising of the greater omentum for reconstruction of the facial skeleton: Description of a novel technique.

Bone regeneration in the greater omentum is a promising strategy in facial skeleton reconstruction. This feasibility-study aims to perform robot-assisted scaffold implantation and second-stage flap raising. Firstly, scaffolds were implanted into the greater omentum using the da Vinci Xi surgical system or conventional technique in five miniature pigs, respectively. After 3months a free flap including the gastrocolic vascular pedicle was harvested and procedures were evaluated. The average operation time was 59.2min for open surgery and 73.8min for robot-assisted surgery. The average incision length of open surgery was 11.6cm. Both techniques led to successful scaffold implantation without any complication. In all cases the scaffolds were integrated as intended and resulted in bone formation. Current study demonstrated that the implantation of scaffolds into the greater omentum and flap harvesting using da Vinci Xi surgical system is a promising minimally-invasive approach in regenerative surgery.

Clinical Statistics From 2017 to 2019 in the Department of Urology, Hospital of the University of the Occupational and Environmental Health, Japan

We introduced the da Vinci Xi surgical system (Intuitive Surgical G.K. CA) in January 2018, and here we report clinical statistics on outpatients, inpatients, and surgical procedures for the 3-year period from January 2017 to December 2019. The number of new outpatients since 2017 has remained almost unchanged at 1,406, 1,530, and 1,494 per year. There was an increasing trend in the number of inpatients, from 862 to 1,021 to 1,239. The main diseases of the inpatients over the 3-year period were bladder cancer in 676 (21.7%), renal cancer in 374 (12.0%), prostate cancer in 268 (8.6%), and urolithiasis in 263 (8.4%). The total number of surgeries in the three years was 1,931. The numbers of transurethral surgeries and laparoscopic surgeries, including robotic surgeries, were 1,063 (55.0%) and 396 (20.5%), respectively. The numbers of inpatients and surgery have been increasing year by year. Medical resources are limited and need to be distributed more efficiently.

Robot-assisted pericystectomy using Da Vinci Xi surgical system with indocyanine green fluorescence imaging for hepatic cystic echinococcosis

The clinical efficacy of robot-assisted laparoscopic pericystectomy using the Da Vinci Xi surgical system plus indocyanine green（ICG） fluorescence imaging and the conventional laparotomy for en bloc pericystectomy was compared. The clinical data of 7 patients treated by robot-assisted laparoscopic pericystectomy using the Da Vinci Xi surgical system plus ICG fluorescence imaging at our hospital between October 2019 and July 2021 and 15 patients treated by conventional laparotomy for en bloc pericystectomy were retrospectively analyzed. Compared with the conventional laparotomy group, the intraoperative blood loss was reduced using the Da Vinci surgical system [(225.43±44.75)ml: (521.33±246.34) ml, P=0.015]. The indwelling time of the urinary catheter was also shorter [2.86±0.75)d: (3.87±0.81)d, P=0.012]. However, the total expense was increased significantly [(49.9±3.7) thousand RMB: (28.7±5.0) thousand RMB, P<0.001]. The two groups of patients were not significantly different in operation time, time to flatulence after surgery, time to eat a liquid diet after surgery, length of hospital stay after surgery, time to drainage tube removal, and the incidence of postoperative complications (P=0.899). Both two groups were followed up for 3-12 months after surgery. The patients were generally good without recurrence or intra-abdominal implantation. The Da Vinci Xi surgical system could be feasibly and safely applied to the robot-assisted laparoscopic pericystectomy plus ICG fluorescence imaging for Hepatic cystic echinococcosis(HCE). This procedure could effectively remove the hepatic hydatid cysts under the ICG fluorescence imaging with a higher resection rate, causing less trauma and fewer complications.

Robotic vs. laparoscopic liver surgery: a single-center analysis of 600 consecutive patients in 6 years

BackgroundWhile laparoscopic liver surgery has become a standard procedure, experience with robotic liver surgery is still limited. The aim of this prospective study was to evaluate safety and feasibility of robotic liver surgery and compare outcomes with conventional laparoscopy.MethodsWe here report the results of a single-center, prospective, post-marketing observational study (DRKS00017229) investigating the safety and feasibility of robotic liver surgery. Baseline characteristics, surgical complexity (using the IWATE score), and postoperative outcomes were then compared to laparoscopic liver resections performed at our center between January 2015 and December 2020. A propensity score-based matching (PSM) was applied to control for selection bias.ResultsOne hundred twenty nine robotic liver resections were performed using the da Vinci Xi surgical system (Intuitive) in this prospective study and were compared to 471 consecutive laparoscopic liver resections. After PSM, both groups comprised 129 cases with similar baseline characteristics and surgical complexity. There were no significant differences in intraoperative variables, such as need for red blood cell transfusion, duration of surgery, or conversion to open surgery. Postoperative complications were comparable after robotic and laparoscopic surgery (Clavien–Dindo ≥ 3a: 23% vs. 19%, p = 0.625); however, there were more bile leakages grade B–C in the robotic group (17% vs. 7%, p = 0.006). Length of stay and oncological short-term outcomes were comparable.ConclusionsWe propose robotic liver resection as a safe and feasible alternative to established laparoscopic techniques. The object of future studies must be to define interventions where robotic techniques are superior to conventional laparoscopy.

Robot-Assisted Orbital Fat Decompression Surgery: First in Human.

PurposeTo explore the safety and feasibility of robot-assisted orbital fat decompression surgery.MethodsTen prospectively enrolled patients (18 eyes) with Graves’ ophthalmopathy underwent robot-assisted orbital fat decompression surgery with the da Vinci Xi surgical system. Intraoperative blood loss, operative time, and complications were recorded. For every patient, the exophthalmos of the operated eyes and Graves’ orbitopathy quality of life (GO-QoL) were measured both preoperatively and 3 months postoperatively to assess the surgical effect.ResultsAll surgical procedures were successfully performed. The mean duration to complete the whole procedure was 124.3 ± 33.2 minutes (range, 60–188). The mean intraoperative blood loss was 17.8 ± 6.2 mL (range, 7.5–28). There were neither complications nor unexpected events in terms of either orbital decompression surgery or robot-assisted procedures. The mean exophthalmos was 20.2 ± 1.8 mm before surgery and 17.9 ± 1.4 mm postoperatively (P < 0.0001). The preoperative and postoperative GO-QoL on the visual function arm was 84.38 ± 20.04 and 93.75 ± 9.32, respectively. The preoperative and postoperative GO-QoL on the appearance arm was 42.50 ± 14.97 and 64.38 ± 21.46, respectively (P = 0.027).ConclusionsThe da Vinci Xi surgical system provided the stability, dexterity, and good visualization necessary for orbital fat decompression surgery, indicating the safety and feasibility of robot-assisted orbital fat decompression surgery.Translational RelevanceBased on a literature search using EMBASE and MEDLINE databases, we believe that this study reports the first in-human results of the safety and effectiveness of da Vinci robot-assisted orbital fat decompression surgery.

AB049. SOH22ABS227. An update of robotic-assisted laparoscopic urological surgeries: our experience with a dual-console da Vinci Xi surgical system

Background: Minimally invasive surgery (MIS) has increasing becoming new standard of care in various surgical fields. Robotic-assisted laparoscopic surgery (RALS) benefits both patient and surgeon alike. We report our up to date experience with a variety of urological procedures performed utilizing a da Vinci Xi robotic surgical system at our tertiary care university teaching hospital.

PD60-08 OUTCOMES OF SALVAGE ROBOTIC-ASSISTED RADICAL PROSTATECTOMY COMPARING PATIENTS WITH PRIMARY FOCAL THERAPY VERSUS WHOLE GLAND ABLATION: A MULTICENTRIC COLLABORATIVE DATA

You have accessJournal of UrologyCME1 May 2022PD60-08 OUTCOMES OF SALVAGE ROBOTIC-ASSISTED RADICAL PROSTATECTOMY COMPARING PATIENTS WITH PRIMARY FOCAL THERAPY VERSUS WHOLE GLAND ABLATION: A MULTICENTRIC COLLABORATIVE DATA Seetharam Bhat Kulthe Ramesh, Arjun Nathan, Marcio Moschovas, Senthil Nathan, and Vipul Patel Seetharam Bhat Kulthe RameshSeetharam Bhat Kulthe Ramesh More articles by this author , Arjun NathanArjun Nathan More articles by this author , Marcio MoschovasMarcio Moschovas More articles by this author , Senthil NathanSenthil Nathan More articles by this author , and Vipul PatelVipul Patel More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002645.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Introduction With increasing experience, surgeons worldwide have increasingly used Salvage Robotic-assisted Radical Prostatectomy as a tool to treat patients who failed previous non-surgical treatment for prostate cancer. Our study compared the outcomes of salvage radical prostatectomy from two high-volume centers from the US and UK in patients who failed prior treatment with whole gland ablation (SRARP) and focal therapy (fSRARP). METHODS: The study assessed 339 patients compared in two groups: 145 patients who had primary focal therapy and 194 patients who had primary whole gland treatment. SRARP was performed in all cases using a standardized technique developed at respective institutes with the da Vinci Xi Surgical System. Our primary endpoint was the comparison of the functional and oncological outcomes between the groups. RESULTS: The median total operative time for fSRARP was 18 mins higher than SRARP (P <0.001). Significantly higher rates of nerve-sparing was performed in fSRARP (focal vs whole gland; bilateral – 15.2% vs 9.3%; unilateral 49% vs 28.4%; p <0.001). SRARP group had higher rates of ISUP GGp 5 (26.3% vs 19.3%; p <0.001) and deferred ISUP score due to altered pathology (14.8% vs 0.7; p <0.001) while fSRSRP had higher rates of ISUP GGp 4 (11.7% vs 10.7%; p <0.001) and ≥pT3a (64.8% vs 51.6%; p <0.001). Also, fSRARP had higher rates of positive surgical margins (26.2% vs 10.3%; p <0.001). Fig 1 shows a cox regression proportional hazard model for BCR excluding PSA persistence showsa trend towards higher postoperative BCR probability in patients who had SRARP (p= 0.534). Fig 2 shows a cox regression proportional hazard model reporting the probability of postoperative continence shows higher and faster recovery in patients who had fSPARP compared to SRARP (p=0.013). There was no difference in trends of postoperative potency probability in both groups (p=0.997) (Fig 3). CONCLUSIONS: Salvage robotic-assisted radical prostatectomy is challenging wherein patients have adverse pathological features irrespective of primary treatment. Focal therapy group had higher rates of nerve-sparing with increased positive surgical margins. However, both groups had poor functional outcomes regardless of nerve-sparing degree, indicating significant collateral and contralateral damage to tissues surrounding the prostate. We believe that this analysis is crucial for counseling patients regarding expected outcomes before performing a salvage treatment following non surgical local therapy failure. Source of Funding: Nil © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e1028 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Seetharam Bhat Kulthe Ramesh More articles by this author Arjun Nathan More articles by this author Marcio Moschovas More articles by this author Senthil Nathan More articles by this author Vipul Patel More articles by this author Expand All Advertisement PDF DownloadLoading ...

Robotic retroperitoneal lymph node dissection for testicular cancer at a national referral centre.

ObjectivesWe aim to determine if robot‐assisted retroperitoneal lymph node dissection (R‐RPLND) can be performed as a safe option to open RPLND in selected patients with metastatic germ cell cancer.Patients and methodsThis population‐based prospective study was performed at a one of two national referral centres for RPLND in Sweden. All patients referred during January 2017–March 2021 were screened for possible inclusion. R‐RPLND was performed using the Da Vinci Xi surgical system. Perioperative parameters, postoperative complications (Clavien–Dindo), final pathology, preservation of antegrade ejaculation and relapse rates were evaluated. Classifiers for selecting patients to open versus robotic RPLND were analysed by logistic regression modelling. The median follow‐up was 23 months.ResultsOf 87 patients referred, 29 were selected for R‐RPLND, 19 in a post‐chemotherapy setting. In median, retroperitoneal tumour diameter was 18 mm, BMI 24 kg/m2, operative time 433 min, estimated blood loss 50 ml and length of stay 3 days. One patient underwent open conversion due to failure to progress. Four patients had Clavien–Dindo grade 3 complications, of which three were chylous‐related. No in‐field recurrences occurred during follow‐up.ConclusionThis population‐based study suggests that R‐RPLND can be safely performed in at least one third of patients referred for an RPLND. A relatively high rate of lymph‐leakage may represent a potential drawback. Tumour size may be the most important discriminator when deciding on robotic versus open RPLND. Further studies with longer follow‐up are needed to validate the results.

Robotic biliary surgery for benign and malignant bile duct obstruction: a case series.

The majority of patients with benign or malignant biliary obstruction require surgical treatment with a bilio-enteric anastomosis. This requires fine dissection and advanced suturing. Robotic surgery may overcome some major limitations of conventional laparoscopic surgery. The precise role of robotic biliary surgery is, however, still to be defined. In our institution, patients requiring complex bile duct surgery were consecutively selected for minimally invasive robotic surgery from September 2020. All surgeries were undertaken using the da Vinci Xi Surgical System® (Intuitive Surgical, Sunnyvale, CA, USA). Intra-operative technique and postoperative outcome were analyzed. A total number of 14 patients underwent robotic biliary surgery for a variety of benign and malignant indications between September 2020 and May 2021. Six of fourteen patients (43%) had previous open abdominal surgery. Median blood loss was 25mL (range 10-120mL). There were no intra-operative complications and no conversions. Length of stay was between 3 and 11days without major postoperative morbidity. Robotic surgery for benign and malignant bile duct obstruction is efficient and safe in experienced hands. Referral to a high-volume expert center is, however, advised.

Robotic total gastrectomy with thrombectomy and portal vein reconstruction for gastric cancer and portal vein tumor thrombus

BackgroundGastric cancer with portal vein tumor thrombus (PVTT) is poor prognosis, and the treatment remains challenging. Regarding surgery, there are only reports of highly invasive laparotomy. We report some techniques of the completely robotic total gastrectomy with thrombectomy and portal vein reconstruction for the patient with gastric cancer and PVTT for the first time.Case presentationA 79-year-old man was diagnosed with a 5-cm gastric cancer on the side of the lesser curvature from the middle of the gastric body to the cardia. Computed tomography revealed a massive PVTT extending from the left gastric vein to the portal trunk (28 x 16 mm). There were no other distant metastases. After 3 cycles of the chemotherapy, the PVTT shrank to 19 x 12 mm. After obtaining informed consent from the patient, robotic total gastrectomy with regional lymphadenectomy and thrombectomy were performed. We used the da Vinci Xi Surgical System. A 3-cm incision was made at the umbilicus, and a wound retractor was placed. Five additional ports were placed. The right side suprapancreatic lymph nodes were performed at the time of the thrombectomy. It was important to identify the precise extent of the PVTT with intraoperative ultrasonography before the thrombectomy. After PVTT identification, the portal trunk was clamped above and below the tumor thrombus with vascular clips. The membrane on the anterior wall of the portal trunk around the PVTT was carefully incised with da Vinci Scissors. The tumor thrombus was completely enucleated without separation. The incised part of the portal trunk was reconstructed with continuous 5-0 synthetic monofilament nonabsorbable polypropylene sutures. After removing the vascular clamps, we made sure there was no leakage from the portal vein and no tumor thrombus remnants with intraoperative ultrasonography. Robotic total gastrectomy with lymphadenectomy and Roux-en-Y reconstruction were performed. The patient was discharged without complications. The patient has remained alive for 30 months after surgery.ConclusionsRobotic total gastrectomy with thrombectomy and portal vein reconstruction is a safe, minimally invasive, and precise surgery. It may contribute to improved prognosis of gastric cancer with PVTT when combined with chemotherapy.

Simultaneous robotic partial nephrectomy for bilateral renal masses.

There is currently no consensus regarding the optimal treatment strategy for patients presenting with synchronous bilateral renal masses. The decision to perform bilateral procedures on the same intervention or in staged procedures is debated. The aim of this manuscript is to analyse the outcomes of simultaneous robot-assisted partial nephrectomy (RAPN) in a series of patients with bilateral renal masses treated at five Italian robotic institutions. Data from a prospectively maintained multi-institutional database on patients subjected to simultaneous RAPN between November 2011 and July 2019 were reviewed. RAPNs were performed with da Vinci Si or Xi surgical system by expert robotic surgeons. Baseline demographics and clinical features, peri- and post-operative data were collected. Overall, 27 patients underwent simultaneous bilateral RAPN, and 54 RAPNs were performed without need of conversion; median operative time was 250 minutes, median estimated blood loss was 200 mL. Renal artery clamping was needed for 27 (50%) RAPNs with a median warm ischemia time of 15 minutes and no case of acute kidney injury. Complications were reported in 7 (25.9%) patients, mainly represented by Clavien 2 events (6 blood transfusions). Positive surgical margins were assessed in 2 (3.7%) of the renal cell carcinoma. At the median follow-up of 30 months, recurrence-free survival was 100%. Our data showed that, in selected patients and expert hands, simultaneous bilateral RAPNs could be a safe and feasible procedure with promising results for the treatment of bilateral synchronous renal masses.

Extreme Lateral Lumbar Interbody Fusion Surgery with a Robot-Assisted System in a Swine Model.

To evaluate the technical aspects of the Da Vinci Xi Surgical System in minimally invasive extreme lateral lumbar interbody fusion (XLIF) surgery in a swine model. Endoscopic discectomy and XLIF cage insertion were performed using a robot-assisted system. The time taken and the pros and cons of each steps were recorded. A total of 4 ports were used for the surgical access; one for the camera, two for bipolar forcepses, and one auxiliary port for modified discectomy. Punch and curette were used for discectomy. The cage was inserted through the auxiliary port. Cage position was manipulated and checked by using the C-arm fluoroscopy. The operative time was 80 minutes. No complications or cage malposition was noted throughout the procedure. This study shows that the robot-assisted XLIF approach is safe and feasible, and helps to protect the neurovascular structures. Moreover, a high image quality was also obtained during the procedure.

Initial Experience of Robot-Assisted Laparoscopic Nephroureterectomy in Japan: A Useful Technique Using a Vessel Sealing Device for Securing a Good Surgical Field and Efficient Sealing.

Although robot-assisted nephroureterectomy (RANU) has been increasingly used worldwide, the history of RANU remains short, and the optimal surgical method for performing RANU has yet to be established. Here we introduce the ideal approach for RANU using the Vessel Sealer Extend (VSE). RANU was performed by using a da Vinci Xi surgical system with fenestrated bipolar forceps (by the left arm), and monopolar scissors or needle drivers (by the right arm), and the VSE (by the third arm). First, nephrectomy and lymphadenectomy were performed at the kidney direction stage, followed by the removal of the distal ureter and suturing of the bladder at the bladder direction stage. The key point of our technique is that the console surgeon can continue to obtain the optimal surgical field by traction using the third arm, and thus cut the tissue by smoothly switching between the right hand and the third arm without the need to exchange instruments, especially in the kidney direction stage. In this study we performed RANU in nine patients and lymphadenectomy in seven patients. The median console time was 195 (range: 165-265) min, the median blood loss was 55 (range: 5-179) ml. In eight cases of RANU using the VSE, no lymphatic leakage was observed and all procedures could be performed safely. The use of VSE provides sufficient coagulation and optimal surgical field development, thus allowing console surgeons to perform RANU more safely.