Robotic single port anti-reflux surgery: Initial worldwide experience of two cases with a novel surgical approach to treat gastroesophageal reflux disease

Robotic single-port multiquadrant surgery to treat renal tumors and benign abdominal conditions

BACKGROUND

Multiquadrant procedures are technically more demanding than sequential operations. The new single port (SP) system allows to work in every abdominal quadrant maintaining an adequate triangulation without the need for changes in the port positioning.

METHODS

In February 2020, two patients underwent a robotic SP partial nephrectomy for malignancy combined with a cholecystectomy and a left inguinal hernia repair respectively.

RESULTS

Both procedures were successfully completed with one robotic docking and without the need for conversion. The operative time was 213 minutes for the right partial nephrectomy (126 min) with cholecystectomy (18 min), and 257 minutes for the left partial nephrectomy (161 min) with inguinal hernia repair (35 min). Estimated blood loss was 200 (150-250) mL, while the total warm ischemia time was 15 minutes for the right partial nephrectomy and 53 minutes for the left partial nephrectomy. There were no intraoperative complications or perioperative transfusions. The postoperative course was uneventful, and the postoperative hospital stay was 1 and 2 days. Both resections had free margins and the median tumor size was 2.5 (1.5-3.5) cm. Histopathology analysis revealed chronic cholecystitis and renal cell carcinomas with free margins and a median tumor size of 2.5 (1.5-3.5) cm. After a mean follow-up of 24 months, no surgical-related complications or recurrence were detected.

CONCLUSIONS

The robotic SP approach facilitates the completion of combined surgical procedures in multiple abdominal quadrants through a single 25mm incision.

New Robotic Platforms in General Surgery: What's the Current Clinical Scenario?

Background and Objectives: Robotic surgery has been widely adopted in general surgery worldwide but access to this technology is still limited to a few hospitals. With the recent introduction of new robotic platforms, several studies reported the feasibility of different surgical procedures. The aim of this systematic review is to highlight the current clinical practice with the new robotic platforms in general surgery. Materials and Methods: A grey literature search was performed on the Internet to identify the available robotic systems. A PRISMA compliant systematic review was conducted for all English articles up to 10 February 2023 searching the following databases: MEDLINE, EMBASE, and Cochrane Library. Clinical outcomes, training process, operating surgeon background, cost-analysis, and specific registries were evaluated. Results: A total of 103 studies were included for qualitative synthesis after the full-text screening. Of the fifteen robotic platforms identified, only seven were adopted in a clinical environment. Out of 4053 patients, 2819 were operated on with a new robotic device. Hepatopancreatobiliary surgery specialty performed the majority of procedures, and the most performed procedure was cholecystectomy. Globally, 109 emergency surgeries were reported. Concerning the training process, only 45 papers reported the background of the operating surgeon, and only 28 papers described the training process on the surgical platform. Only one cost-analysis compared a new robot to the existing reference. Two manufacturers promoted a specific registry to collect clinical outcomes. Conclusions: This systematic review highlights the feasibility of most surgical procedures in general surgery using the new robotic platforms. Adoption of these new devices in general surgery is constantly growing with the extension of regulatory approvals. Standardization of the training process and the assessment of skills' transferability is still lacking. Further studies are required to better understand the real clinical and economical benefit.

What Is the Current Role and What Are the Prospects of the Robotic Approach in Liver Surgery?

Simple Summary

Robotic liver surgery is being applied with increasing frequency. Comparable, and in specific settings superior, perioperative outcomes compared to laparoscopic liver surgery have been reported. In its current form, the most commonly mentioned advantage of robotic surgery is improved dexterity. Important obstacles to its wider implementation in daily clinical practice are the associated costs, technical difficulties, and a scarce amount of evidence. Robotic liver surgery will likely continue to evolve in parallel with technological developments that enhance the robots’ abilities.

Abstract

In parallel with the historical development of minimally invasive surgery, the laparoscopic and robotic approaches are now frequently utilized to perform major abdominal surgical procedures. Nevertheless, the role of the robotic approach in liver surgery is still controversial, and a standardized, safe technique has not been defined yet. This review aims to summarize the currently available evidence and prospects of robotic liver surgery. Minimally invasive liver surgery has been extensively associated with benefits, in terms of less blood loss, and lower complication rates, including liver-specific complications such as clinically relevant bile leakage and post hepatectomy liver failure, when compared to open liver surgery. Furthermore, comparable R0 resection rates to open liver surgery have been reported, thus, demonstrating the safety and oncological efficiency of the minimally invasive approach. However, whether robotic liver surgery has merits over laparoscopic liver surgery is still a matter of debate. In the current literature, robotic liver surgery has mainly been associated with non-inferior outcomes compared to laparoscopy, although it is suggested that the robotic approach has a shorter learning curve, lower conversion rates, and less intraoperative blood loss. Robotic surgical systems offer a more realistic image with integrated 3D systems. In addition, the improved dexterity offered by robotic surgical systems can lead to improved intra and postoperative outcomes. In the future, integrated and improved haptic feedback mechanisms, artificial intelligence, and the introduction of more liver-specific dissectors will likely be implemented, further enhancing the robots’ abilities.