Robotics in general surgery: personal experience in a large community hospital

HYPOTHESIS

Robotic technology is the most advanced development of minimally invasive surgery, but there are still some unresolved issues concerning its use in a clinical setting.

DESIGN

The study describes the clinical experience of the Department of General Surgery, Misericordia Hospital, Grosseto, Italy, in robot-assisted surgery using the da Vinci Surgical System.

RESULTS

Between October 2000 and November 2002, 193 patients underwent a minimally invasive robotic procedure (74 men and 119 women; mean age, 55.9 years [range, 16-91 years]). A total of 207 robotic surgical operations, including abdominal, thoracic and vascular procedures, were performed; 179 were single procedures, and 14 were double (2 operations on the same patient). There were 4 conversions to open surgery and 3 to conventional laparoscopy (conversion rate, 3.6%; 7 of 193 patients). The perioperative morbidity rate was 9.3% (18 of 193 patients), and 6 patients (3.1%) required a reoperation. The postoperative mortality rate was 1.5% (3 of 193 patients).

CONCLUSIONS

Our preliminary experience at a large community hospital suggests that robotic surgery is feasible in a clinical setting. Its daily use is safe and easily managed, and it expands the applications of minimally invasive surgery. However, the best indications still have to be defined, and the cost-benefit ratio must be evaluated. This report could serve as a basis for a future prospective, randomized trial.

Robot-assisted laparoscopic pancreatic surgery: single-surgeon experience

BACKGROUND

Use of robotic surgery has gained increasing acceptance over the last few years. There are few reports, however, on advanced pancreatic robotic surgery. In fact, the indication for robotic surgery in pancreatic disease has been controversial. This paper retrospectively reviews one surgeon's experience with robotic surgery to treat pancreatic disease, and analyzes its indications and outcomes, as well as the controversy that exists.

METHODS

A retrospective review of the charts of all patients who underwent robotic surgery for pancreatic disease by a single surgeon at two different institutions was carried out.

RESULTS

From October 2000 to January 2009, 134 patients underwent robotic-assisted surgery for different pancreatic pathologies. All procedures were performed using the da Vinci robotic system. Of the 134 patients, 83 were female. The average age of all patients was 57 years (range 24-86 years). Mean operating room (OR) time was 331 min (75-660 min). There were 14 conversions to open surgery. Mean length of stay was 9.3 days (3-85 days). Length of stay for patients with no complications was 7.9 days (3-15 days). The postoperative morbidity rate was 26% and the mortality rate was 2.23% (three patients). Among the procedures performed were 60 pancreaticoduodenectomies, 23 spleen-preserving distal pancreatectomies, 23 splenopancreatectomies, 3 middle pancreatectomies, 1 total pancreatectomy, and 3 enucleations. Another 21 patients underwent different surgical procedures for treatment of acute and chronic pancreatitis. Two cases of pancreaticoduodenectomy were performed in outside institutions and are not included in this series.

CONCLUSIONS

This is the largest series of robotic pancreatic surgery presented to date. Robotic surgery enables difficult technical maneuvers to be performed that facilitate the success of pancreatic minimally invasive surgery. The results in this series demonstrate that it is feasible and safe. Complication and mortality rates are comparable to those of open surgery but with the advantages of minimally invasive surgery.

Robotic liver surgery: results for 70 resections

BACKGROUND

Robotic surgery is gaining popularity for digestive surgery; however, its use for liver surgery is reported scarcely. This article reviews a surgeon's experience with the use of robotic surgery for liver resections.

METHODS

From March 2002 to March 2009, 70 robotic liver resections were performed at 2 different centers by a single surgeon. The surgical procedure and postoperative outcome data were reviewed retrospectively.

RESULTS

Malignant tumors were indications for resections in 42 (60%) patients, whereas benign tumors were indications in 28 (40%) patients. The median age was 60 years (range, 21-84) and 57% of patients were female. Major liver resections (≥ 3 liver segments) were performed in 27 (38.5%) patients. There were 4 conversions to open surgery (5.7%). The median operative time for a major resection was 313 min (range, 220-480) and 198 min (range, 90-459) for minor resection. The median blood loss was 150 mL (range, 20-1,800) for minor resection and 300 mL (range, 100-2,000) for major resection. The mortality rate was 0%, and the overall rate of complications was 21%. Major morbidity occurred in 4 patients in the major hepatectomies group (14.8%) and in 4 patients in the minor hepatectomies group (9.3%). All complications were managed conservatively and none required reoperation.

CONCLUSION

This preliminary experience shows that robotic surgery can be used safely for liver resections with a limited conversion rate, blood loss, and postoperative morbidity. Robotics offers a new technical option for minimally invasive liver surgery.

Indocyanine green (ICG) fluorescent cholangiography during robotic cholecystectomy: results of 184 consecutive cases in a single institution

BACKGROUND/AIM

Laparoscopic cholecystectomy is currently the gold standard treatment for gallstone disease. Bile duct injury is a rare and severe complication of this procedure, with a reported incidence of 0.4% to 0.8% and is mostly a result of misperception and misinterpretation of the biliary anatomy. Robotic cholecystectomy has proven to be a safe and feasible approach. One of the latest innovations in minimally invasive technology is fluorescent imaging using indocyanine green (ICG). The aim of this study is to evaluate the efficacy of ICG and the Da Vinci Fluorescence Imaging Vision System in real-time visualization of the biliary anatomy.

METHODS

A total of 184 robotic cholecystectomies with ICG fluorescence cholangiography were performed between July 2011 and February 2013. All patients received a dose of 2.5 mg of ICG 45 minutes prior to the beginning of the surgical procedure. The procedures were multiport or single port depending on the case.

RESULTS

No conversions to open or laparoscopic surgery occurred in this series. The overall postoperative complication rate was 3.2%. No biliary injuries occurred. ICG fluorescence allowed visualization of at least 1 biliary structure in 99% of cases. The cystic duct, the common bile duct, and the common hepatic duct were successfully visualized with ICG in 97.8%, 96.1%, and 94% of cases, respectively.

CONCLUSIONS

ICG fluorescent cholangiography during robotic cholecystectomy is a safe and effective procedure that helps real-time visualization of the biliary tree anatomy.

Long-term survival in pancreatic cancer: pylorus-preserving versus Whipple pancreatoduodenectomy

BACKGROUND

This study compared long-term survival in pancreatic or periampullary cancer treated with Whipple pancreatoduodenectomy (PD) and pylorus-preserving pancreatoduodenectomy (PPPD).

METHODS

Two hundred twenty-one patients with pancreatic head or periampullary cancer were treated. Prognostic variables included age, gender, type and period of operation, and tumor stage. In the ductal adenocarcinomas variables also included tumor and node status, type of lymphadenectomy, pathologic grade, and presence of microscopic residual tumor. The end point was death as a result of neoplastic recurrence. Survival curves were estimated by using the Kaplan-Meier method, and multifactorial analysis was also performed on the data from the ductal adenocarcinoma group.

RESULTS

The mortality rate was 8.2% in the PD group versus 7.0% in the PPPD group. Morbidity rates were 34.4% for PD and 45.8% for PPPD. Five-year survival was 9.6% in the ductal adenocarcinoma and 63.8% in the periampullary carcinoma groups. Univariate analysis failed to show statistically significant differences in survival curves between the two treatments in either patient group. Correcting for multiple variables in the ductal adenocarcinoma group did not reveal any significant differences in survival rates between the two treatments.

CONCLUSIONS

PPPD was as successful as classic PD in the treatment of ductal adenocarcinoma and periampullary cancer of the pancreas. Long-term survival was not influenced by the type of resection.

Robot-assisted right lobe donor hepatectomy

Recent advances in robotic surgical technology have enabled application to complex surgical procedures. Following extensive institutional experience with major robotic liver resections, we determined that it was safe to apply this technology to right lobe donor hepatectomy (RLDH). The procedure was performed using the Da Vinci Robotic Surgical System, in an entirely minimally invasive fashion, during which the liver graft was safely extracted through a limited lower abdominal incision. Both donor and recipient recovered well, without acute complications. To our knowledge, this is the first case reported in the literature. The technical feasibility of this minimally invasive approach is demonstrated, exemplifying the novel exciting opportunities offered by robotic technology.

Totally robotic right hepatectomy: surgical technique and outcomes

HYPOTHESIS

Robotic surgery for performance of right hepatectomy is safe and effective.

DESIGN

Case series from 2 medical institutions.

SETTING

University of Illinois at Chicago and Misericordia Hospital, Grosseto, Italy.

PATIENTS

Twenty-four patients underwent right hepatectomy between March 1, 2005, and January 31, 2010, using a robotic surgical system.

MAIN OUTCOME MEASURES

Intraoperative blood loss, operative time, morbidity, mortality, and long-term oncologic follow-up.

RESULTS

The procedure was converted to open surgery in 1 patient (4.2%). The overall mean (SD) operative time was 337 (65) minutes (range, 240-480 minutes), and the mean (SD) intraoperative blood loss was 457 (401) mL (range, 100-2000 mL). Three patients (12.5%) underwent blood transfusion. There were no perioperative deaths and no reoperations. Six patients (25.0%) experienced postoperative morbidity, including transitory liver failure in 2 patients and pleural effusion, bile leak, fluid collection, and deep venous thrombosis in 1 patient each. The patients' diagnoses included colorectal liver metastases (n = 11), noncolorectal liver metastases (n = 4), hemangioma (n = 4), adenoma (n = 2), hepatocellular carcinoma (n = 1), hepatoblastoma (n = 1), and biliary amartoma (n = 1). At a mean follow-up duration of 34 months, no port site metastases were observed in patients with malignant pathologic findings.

CONCLUSIONS

The zero mortality and acceptable morbidity of our series indicate that in experienced hands, robotic right hepatectomy is feasible and safe. Robotic surgery offers a new technical option for minimally invasive major hepatic resections. Long-term results seem to confirm oncologic effectiveness of the procedure.

Robotic liver surgery: technical aspects and review of the literature

Minimally invasive surgery for liver resections has a defined role and represents an accepted alternative to open techniques for selected cases. Robotic technology can overcome some of the disadvantages of the laparoscopic technique, mainly in the most complex cases. Precise dissection and microsuturing is possible, even in narrow operative fields, allowing for a better dissection of the hepatic hilum, fine lymphadenectomy, and biliary reconstruction even with small bile ducts and easier bleeding control. This technique has the potential to allow for a greater number of major resections and difficult segmentectomies to be performed in a minimally invasive fashion. The implementation of near-infrared fluorescence with indocyanine green (ICG) also allows for a more accurate recognition of vascular and biliary anatomy. The perspectives of this kind of virtually implemented imaging are very promising and may be reflected in better outcomes. The overall data present in current literature suggests that robotic liver resections are at least comparable to both open and laparoscopic surgery in terms of perioperative and postoperative outcomes. This article provides technical details of robotic liver resections and a review of the current literature.

Robotic kidney transplantation in the obese patient: 10-year experience from a single center

Despite increasing obesity rates in the dialysis population, obese kidney transplant candidates are still denied transplantation by many centers. We performed a single-center retrospective analysis of a robotic-assisted kidney transplant (RAKT) cohort from January 2009 to December 2018. A total of 239 patients were included in this analysis. The median BMI was 41.4 kg/m² , with the majority (53.1%) of patients being African American and 69.4% of organs sourced from living donors. The median surgery duration and warm ischemia times were 4.8 hours and 45 minutes respectively. Wound complications (mostly seromas and hematomas) occurred in 3.8% of patients, with 1 patient developing a surgical site infection (SSI). Seventeen (7.1%) graft failures, mostly due to acute rejection, were reported during follow-up. Patient survival was 98% and 95%, whereas graft survival was 98% and 93%, at 1 and 3 years respectively. Similar survival statistics were obtained from patients undergoing open transplant over the same time period from the UNOS database. In conclusion, RAKT can be safely performed in obese patients with minimal SSI risk, excellent graft function, and patient outcomes comparable to national data. RAKT could improve access to kidney transplantation in obese patients due to the low surgical complication rate.

Robot-assisted surgery for gastric carcinoma: Five years follow-up and beyond: A single western center experience and long-term oncological outcomes

INTRODUCTION

Robot-assisted surgery for the treatment of gastric cancer is considered to be safe and feasible with early post-operative outcomes comparable to open and laparoscopic series. However, data regarding long-term oncological outcomes are lacking. Aim of this study is to evaluate long-term oncological outcomes of a cohort of gastric cancer patients treated surgically with the robot-assisted approach.

MATERIALS AND METHODS

A prospectively collected database of robot-assisted gastrectomies performed for gastric cancer at the 'Misericordia Hospital' between September 2001 and October 2011 was retrospectively analysed. Data regarding surgical procedures, early postoperative course, and long-term follow-up were analysed.

RESULTS

The study included 98 consecutive robot-assisted gastrectomies. Fifty-nine distal gastrectomies, 38 total gastrectomies, and 1 proximal gastrectomy. Open conversion occurred in seven patients (7.1%) due to locally advanced disease. Postoperative morbidity and mortality were 12.2% and 4.1% respectively. Post-operative staging showed 46 patients (46.9%) with stage I disease, 25 patients (25.5%) with stage II, 26 (26.5%) with stage III and 1 (1.02%) with stage IV. The mean follow-up was 46.9 months. Cumulative 5-year overall survival (OS) was 73.3% (95% CI: 62.2-84.4). Five-year survival by stage subgroups was 100% for patients with stage IA, 84.6% for stage IB, 76.9% for stage II, and 21.5% for stage III. The only patient in stage IV of this series died eight months after surgery.

CONCLUSIONS

Robot-assisted gastrectomy for the treatment of gastric cancer is safe and feasible. It provides long-term outcomes comparable to most open and laparoscopic series. Further studies are necessary to better define its indication.

Robot-assisted gastrectomy for gastric cancer: current status and technical considerations

BACKGROUND

Robot-assisted gastrectomy has been reported as a safe alternative to the conventional laparoscopy or open approach for treating early gastric carcinoma. To date, however, there are a limited number of published reports available in the literature.

METHODS

We assess the current status of robotic surgery in the treatment of gastric cancer, focusing on the technical details and oncological considerations.

RESULTS

In gastric surgery, the biggest advantage of robotic surgery is the ease and reproducibility of D2-lymphadenectomy. Reports show that even the intracorporeal digestive restoration is facilitated by use of the robotic approach, particularly following total gastrectomy. Additionally, the accuracy of robotic dissection is confirmed by decreased blood loss, as reported in series comparing robot-assisted with laparoscopic gastrectomy. The learning curve and technical reproducibility also appear to be shorter with robotic surgery and, consequently, robotics can help to standardize and diffuse minimally invasive surgery in the treatment of gastric cancer, even in the later stages. This is important because the application of minimally invasive surgery is limited by the complexity of performing a D2-lymphadenectomy. The potential to reproduce D2-lymphadenectomy, enlarged resections, and complex reconstructions provides robotic surgery with an important role in the therapeutic strategy of advanced gastric cancer.

CONCLUSIONS

While published reports have shown no significant differences in surgical morbidity, mortality, or oncological adequacy between robot-assisted and conventional laparoscopic gastrectomy, more studies are needed to assess the indications and oncological effectiveness of robotic use in the treatment of gastric carcinoma. Herein, the authors assess the current status of robotic surgery in the treatment of gastric cancer, focusing on the technical details and oncological considerations.

Fluorescence in robotic surgery

Currently, there are several clinical applications for intraoperative ICG, such as identification of vascular and biliary anatomy, assessment of organ and tissue perfusion, lymph node mapping, and real-time identification of lesions. In this paper we present a review of the available literature related to the use of ICG fluorescence in robotic surgery in order to provide a better understanding of the current applications, show the rapid growth of this technique, and demonstrate the potential future applications.

Conjugation of benzoic acid with glycine in human liver and kidney: a study on the interindividual variability

1. The rate of conjugation of benzoic acid with glycine was measured in the homogenates of 110 specimens of human liver and in 67 specimens of human renal cortex. 2. The assay for the formation of benzoyl glycine consisted of measuring the formation of benzoyl glycine from (14C) benzoic acid and glycine in the presence of coenzyme A and ATP. 3. In human liver, the mean (+/- SD) and coefficient of variation for the formation rate of benzoyl glycine were 254 +/- 90.5 nmol min-1 per g liver and 36%, respectively. There was a weak, but significant, negative correlation (r = -0.339, p < 0.001) between the rate of formation of benzoyl glycine and the liver donor's age. 4. In the human kidney, the rate of benzoyl glycine formation was normally distributed. The mean (+/- SD) and coefficient of variation were 321 +/- 99.3 nmol min-1 per g kidney and 31%, respectively. 5. These in vitro results are consistent with the view that the in vivo rate of conjugation of carboxylic acid with glycine varies among subjects and is normally distributed.

Operative technique in robotic pancreaticoduodenectomy (RPD) at University of Illinois at Chicago (UIC): 17 steps standardized technique : Lessons learned since the first worldwide RPD performed in the year 2001

Background

Minimally invasive pancreaticoduodenectomy (MIPD) was introduced in the attempt to improve the outcomes of the open approach. Laparoscopic pancreaticoduodenectomy (LPD) was first reported by Gagner and Pomp (Surg Endosc 8:408–410, 1994). Unfortunately, due to its complexity and technical demand, LPD never reached widespread popularity. Since it was first performed by P. C. Giulianotti in 2001, Robotic PD (RPD) has been gaining ground among surgeons. MIPD is included as a surgical option in the latest NCCN Guidelines. However, lack of surgical standardization, however, has limited the reproducibility of MIPD and made the acquisition of the technique by other surgeons difficult. We provide an accurate description of our standardized step-by-step RDP technique.

Methods

We took advantage of our 15-year long experience and > 150 cases performed to provide a step-by-step guidance of our RPD standardized technique. The description includes practical “tips and tricks” to facilitate the learning curve and assist with the teaching/evaluation process.

Results

17 surgical steps were identified as key components of the RPD procedure. The steps reflect the subdivision of the RPD into several parts which help to understand a strategy that takes into accounts specific anatomical landmarks and the demands of the robotic platform.

Conclusions

Standardization is a key element of the learning curve of RPD. It can potentially provide consistent, reproducible results that can be more easily evaluated. Despite promising results, full acceptance of RPD as the ‘gold standard’ is still work in progress. Randomized-controlled trials with the application of a standardized technique are necessary to better define the role of RPD.

Could ICG-aided robotic cholecystectomy reduce the rate of open conversion reported with laparoscopic approach? A head to head comparison of the largest single institution studies

Comparative studies between robotic and laparoscopic cholecystectomy (LC) focus heavily on economic considerations under the assumption of comparable clinical outcomes. Advancement of the robotic technique and the further widespread use of this approach suggest a need for newer comparison studies. 676 ICG-aided robotic cholecystectomies (ICG-aided RC) performed at the University of Illinois at Chicago (UIC) Division of General, Minimally Invasive and Robotic Surgery were compiled retrospectively. Additionally, 289 LC were similarly obtained. Data were compared to the largest single institution LC data sets from within the US and abroad. Statistically significant variations were found between UIC-RC and UIC-LC in minor biliary injuries (p = 0.049), overall open conversion (p ≤ 0.001), open conversion in the acute setting (p = 0.002), and mean blood loss (p < 0.001). UIC-RC open conversions were also significantly lower than Greenville Health System LC (p ≤ 0.001). Additionally, UIC ICG-RC resulted in the lowest percentages of major biliary injuries (0 %) and highest percentage of biliary anomalies identified (2.07 %). ICG-aided cholangiography and the technical advantages associated with the robotic platform may significantly decrease the rate of open conversion in both the acute and non-acute setting. The sample size discrepancy and the non-randomized nature of our study do not allow for drawing definitive conclusions.

Catechol-O-methyltransferase: variation in enzyme activity and inhibition by entacapone and tolcapone

OBJECTIVE

The aim of this investigation was to study the variation of catechol-O-methyltransferase (COMT) activity in the human liver, duodenal mucosa and renal cortex, and to investigate the inhibition of COMT by entacapone and tolcapone. This study included 87 samples of human liver, 94 samples of the duodenum and 72 samples of the renal cortex.

RESULTS

The activity of COMT was measured with 3,4-dihydroxybenzoic acid (242 micromol x l(-1)), the methyl acceptor substrate, and adenosyl-L-methionine (44 micromol x l(-1)), the methyl donor substrate. The hepatic activity of COMT activity was significantly higher in men than in women, whereas it was not sex-dependent in the duodenum or renal cortex. The activity of COMT varied 4.4-fold in the liver of men, 2.6-fold in the duodenum and 5.3-fold in the renal cortex. The median estimates of COMT activity were 577, 499, 103 and 159 pmol x min(-1) x mg(-1) in the liver of men and women, in the duodenum and in the renal cortex, respectively.

CONCLUSION

Entacapone and tolcapone were powerful inhibitors of COMT and their IC50 estimates were 151 and 773 nM (P = 0.008), respectively, in the liver; consistent results were obtained with the other tissues.

Application of Improved Robot-assisted Laparoscopic Telesurgery with 5G Technology in Urology

The demand for telesurgery is rising rapidly, but robust evidence regarding the feasibility of its application in urology is still rare. From March to October 2021, a surgeon-controlled surgical robot in a tertiary hospital in Qingdao was used to remotely conduct robot-assisted laparoscopic radical nephrectomy (RN) in 29 patients located in eight primary hospitals. The median round-trip delay was 26 ms (interquartile range [IQR] 5) and the median distance between the primary hospital and the surgeon was 187 km (IQR 57). Both the master unit and the slave unit were guaranteed by network and mechanical engineers, and surgical assistants were well prepared on the patient side to prevent complications. The primary evaluation metric was the success rate, defined as the percentage of patients who underwent successful remote RN without conversion to other surgical procedures and no major intraoperative or postoperative complications. The results demonstrate that the combination of 5G technology and surgical robots is a novel potential telemedicine-based therapy choice for renal tumors. PATIENT SUMMARY: Our study shows that telesurgery using 5G technology is a safe and feasible treatment option for patients with kidney tumors. The total delay between the remote location and the operating rooms where surgery was being performed was just 200 ms. This approach could reduce health care costs and improve the quality of medical services accessed by patients.

[Robotic approach to hepatobiliary surgery. German version]

Robot-assisted hepatobiliary surgery has been steadily growing in recent years. It represents an alternative to the open and laparoscopic approaches in selected patients. Endowristed instruments and enhanced visualization provide important advantages in terms of selective bleeding control, microsuturing, and dissection. Cholecystectomies and minor hepatectomies are being performed with comparable results to open and laparoscopic surgery. Even complex procedures, such as major and extended hepatectomies, can have excellent outcomes, in expert hands. The addition of indocyanine green fluorescence provides an additional advantage for recognition of the vascular and biliary anatomy. Future innovations will allow for expanding its use and indications. Robotic surgery has become a very important component of modern minimally invasive surgery and the development of new robotic technology will facilitate a broader adoption of this technique.

Robotic-assisted pancreatic surgery

BACKGROUND

Pancreatic surgery is a challenging application of minimally invasive surgery. Due to the complexity of the surgical technique, requiring dissection along major abdominal vessels as well as delicate reconstruction involving biliary, pancreatic and enteric anastomoses, reports on laparoscopic pancreatic surgery have been scanty. With the advent of robotic-assisted surgery, however, the increased dexterity granted by endo-wristed instruments, the improved three-dimensional vision and the computer filtration of the surgeon's movements have brought minimally invasive pancreatic surgery into a new era.

METHODS

As the surgical group which has performed the highest number of robotic-assisted pancreatic procedures worldwide, we review the state of the art of minimally invasive robotic-assisted pancreatic surgery. Clinical results from all major robotic-assisted pancreatic surgery series are considered.

RESULTS

Preliminary reports from the published major pancreatic surgery series show encouraging results, with morbidity and mortality comparable to open surgery. Preliminary data on cancer survival rates also appear to be similar to open series.

CONCLUSION

Robotic-assisted pancreatic surgery is safe and feasible for all pancreatic diseases. The complexity of pancreatic procedures warrant them to be carried out in specialised centres, where short- and long-term outcomes seem to be similar to the ones achieved in open surgery.

Comparative evaluation of contact ultrasonography and transcystic cholangiography during laparoscopic cholecystectomy: a prospective study

BACKGROUND

The role of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) is controversial. While many advocate its routine use, others argue for a selective approach. Recent reports showed laparoscopic contact ultrasonography (LCU) as a viable alternative to IOC. However, no prospective data were available to compare the accuracy, efficacy, and safety of the two diagnostic procedures.

OBJECTIVE

To evaluate the benefits and disadvantages of LCU and IOC during LC.

METHODS

Seventy-eight patients who underwent LC at Pisa (Italy) and Dundee (Scotland) university hospitals were entered in a prospective data registry. Details of operative technique and results of LCU and IOC were analyzed by reviewing videotape recordings of each procedure.

RESULTS

Laparoscopic cholecystectomy was achieved in 73 patients, with five requiring conversion to the open procedure. The success rate of IOC was 90% (64/71). Performance of IOC demanded more than twice the time needed for LCU. Eleven percent (8/71) of cholangiograms were abnormal, with a false-positive rate of 1% (1/71). Laparoscopic contact ultrasonography detected all four instances of unsuspected ductal stones but none of the three cases of anomalous biliary anatomy. Clinically relevant incidental findings were picked up by LCU in six patients.

CONCLUSIONS

Laparoscopic contact ultrasonography proved to be extremely accurate in the detection of ductal stones but less reliable in the disclosure of anomalous biliary anatomy. The essential role of IOC in providing a clear spatial display of the biliary tract was confirmed. Since the two procedures are complementary, their combined use is advisable in difficult LC to avoid retained common bile duct stones and prevent iatrogenic complications.

Robot-assisted hybrid laparoscopic Roux-en-Y gastric bypass: surgical technique and early outcomes

BACKGROUND

Roux-en-Y gastric bypass performed laparoscopically remains the gold standard in bariatric surgery. The role of robot-assisted laparoscopic Roux-en-Y gastric bypass has not been clearly defined.

METHODS

We present 80 consecutive cases of robot-assisted laparoscopic Roux-en-Y gastric bypass performed at a single institution. Mechanics, early outcomes, and learning curve are evaluated. Eighty robot-assisted laparoscopic Roux-en-Y gastric bypasses were performed on 71 women and 9 men with a mean age of 39 years, mean preoperative weight of 134 kg, and mean BMI of 48.

RESULTS

Total mean operative time was 209 minutes. There was no mortality, leak, stricture, or obstruction.

CONCLUSION

Robot-assisted laparoscopic Roux-en-Y gastric bypass is a safe and feasible option for bariatric surgery. Its role in improving surgical outcomes needs to be defined further.

Prognostic value of histological grading in ductal adenocarcinoma of the pancreas. Klöppel vs TNM grading

A new histological grading system with prognostic correlation for pancreatic cancer was proposed by Klöppel et al. in 1985. Histological sections from 60 ductal adenocarcinomas operated on between January 1980 and December 1990 were retrospectively reviewed in order to compare Klöppel's grading with standard TNM's grading and assess their prognostic value. Klöppel grading was determined through the following histologic and cytologic factors: number duct-like structures, mucus production, neoplastic epithelium, arrangement and pleomorphism of nuclei, and mitotic activity. A score from 0 (well differentiated) to 2 (poorly differentiated) was given to each factor. The mean value obtained dividing the sum of the different values by the number of parameters was used to construct a malignancy scale and therefore allocate each patient to his Klöppel grading. The concordance index K between the two grading systems was relevant (K = 0.85 p < 0.001). There was no relation either between gradings (Klöppel or TNM) and preoperative duration of symptoms or between gradings and UICC stages. TNM's G2 grades of malignancy, N status, and tumor stage were significantly related to survival time (p < 0.05). Klöppel's grading does not show any advantage over the classical and simpler TNM's grading, even though it can be considered more objective and therefore more easily reproducible. This characteristic further should be enhanced by the introduction of a malignancy scale such as the "mean value."

State of the art of robotic pancreatic surgery

More than a decade has passed since robotic technology was adopted for abdominal surgery, and virtually every gastrointestinal operation has since been shown to be feasible, safe, and reproducible using the robotic approach. Robotic pancreatic surgery had been left behind at the beginning, because they were technically challenging, requiring not only being very familiar with the robotic technology but also having a perfect knowledge of the anatomical variations, very frequent in this area. Nonetheless in the last few years many authors have approached the robot for pancreatic surgery with very promising results in terms of surgical and oncological outcomes. The aim of this article is to review the literature on robotic pancreatic surgery and to define the state of the art use of the robotic approach for pancreatic disease.