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Purpose: Our aim was to develop practical training for laparoscopic surgery using Thielembalmed cadavers. Furthermore, in order to verbalize experts' motion characteristics and provide objective feedback to trainees, we initiated motion capture analyses of multiple surgical instruments simultaneously during the cadaveric trainings. In the present study, we report our preliminary results. Methods: Participants voluntarily joined the present cadaveric simulation trainings, and performed laparoscopic radical nephrectomy. After the trainings, scores for tissue similarity (face validity) and impression of educational merit (content validity) were collected from participants based on a 5-point Likert scale (tissue similarity: 5: very similar, 3: average, 1: very different; educational merit: 5: very high, 3: average, 1: very low). In addition, after the additional IRB approval, we started motion capture (Mocap) analyses of 6 surgical instruments (scissors, vessel sealing system, grasping forceps, clip applier, right-angled forceps, and suction), using an infrared trinocular camera (120-Hz location record). Mocap-metrics were compared according to the previous surgical experiences (experts: ≧50 laparoscopic surgeries, intermediates: 10-49, novices: 0-9), using the Kruskal-Wallis test. Results: A total of 9 experts, 19 intermediates, and 15 novices participated in the present study. In terms of face validity, the mean scores were higher than 3, other than for the Vena cava(mean score of 2.89). Participants agreed with the training value (usefulness for future skill improvement: mean score of 4.57). In terms of Mocap analysis, faster speed-related metrics (e.g., velocity, the distribution of tip velocity, acceleration, and jerk) in the scissors and vessel sealing system, a shorter path length of grasping forceps, and fewer dimensionless squared jerks, which indicated more purposeful motion of 4 surgical instruments (vessel sealing system, grasping forceps, clip applier and suction), were observed in the more experienced group. Conclusions: The Thiel-embalmed cadaver provides an excellent training opportunity for complex laparoscopic procedures with participants' high level of satisfaction, and may become a promising tool for a better objective understanding of surgical dexterity. In order to enrich formative feedback to trainees, we are now proceeding with Mocap analysis. [ABSTRACT FROM AUTHOR]

• It is unclear how Epstein–Barr virus causes cancer. • EBVaGC should be considered when multiple gastric cancer is recognized. • Robotic surgery has high-resolution three-dimensional images. • Using forceps with multi-joint functions was effective for this case. Epstein–Barr virus-associated gastric cancer (EBVaGC) sometimes appears as multiple gastric cancer lesions. Here, we report a case of robot-assisted laparoscopic total gastrectomy (RTG) for a relatively rare disease with four synchronized lesions in EBVaGC and discuss the usefulness of robotic gastrectomy. A 60-year-old woman was diagnosed with multiple gastric cancer because she had five lesions in the stomach and biopsy showed the presence of adenocarcinoma in four of the five lesions. We performed robot-assisted laparoscopic total gastrectomy on the patient. The histopathological diagnosis was multiple gastric cancer T1bN0M0 pStage IA. The four lesions were positive for the Epstein–Barr virus encoding region in in-situ hybridization and were considered to be EBVaGC. The patient had no sign of recurrence without postoperative therapy for 24 months. EBVaGC was found in about 10% of all gastric cancer cases worldwide. EBVaGC sometimes appears as multiple gastric cancer, suggesting that EBV infection is closely related to the early stages of tumor formation. Total gastrectomy may be necessary for multiple gastric cancer such as EBVaGC, and robotic surgery is useful in total gastrectomy in terms of high-resolution three-dimensional images and using forceps with multi-joint functions. We performed RTG on a patient with four synchronous lesions of EBVaGC, which is relatively rare. Robot-assisted laparoscopic total gastrectomy is known to be a safe procedure, and we effectively performed total gastrectomy for multiple EBVaGC. [ABSTRACT FROM AUTHOR]

Highlights • Large abdominal intercostal hernia in the thoracoabdominal region must be treated. • Repair of abdominal intercostal hernia using mesh and surgical approach is controversial. • With exposed mesh, partial mesh removal may be an option if conditions are met. Abstract Introduction Abdominal intercostal hernia repair for huge incisional hernia after thoracoabdominal surgery involves a complex anatomical structure. Hence, it is difficult to apply the laparoscopic approach to large hernias in the lateral upper abdomen. Further the optimal approach to mesh exposure without infection after incisional hernia repair is still controversial. Herein, we describe our experience of repairing a huge abdominal intercostal hernia by mesh trimming and suture reconstruction for wound dehiscence. Presentation of case A 73-year-old man presented with an incisional hernia in the left flank from just below the eight intercostal space to the transverse umbilical region 6 months after thoracoabdominal aortic aneurysm surgery. Computed tomography revealed an incisional hernia orifice of 17 × 13 cm located on the left flank around the ninth rib. We chose the open approach as treatment because the hernia orifice was large, and we created a mesh placement space in the extraperitoneal cavity and placed expanded polytetrafluoroethylene mesh there with 1–0 nonabsorbable monofilament suture. At postoperative day 26, we observed mesh exposure due to wound dehiscence. Mesh trimming and suture reconstruction for wound dehiscence was performed because there were no signs of wound infection. The postoperative course was uneventful including infection and dehiscence. The patient has been well without recurrence for 14 months since last operation. Conclusions Optimal treatment for repair of a large abdominal intercostal hernia with thoracoabdominal location is necessary. Moreover, partial mesh removal may be one of the treatment options for mesh exposure if conditions are met. [ABSTRACT FROM AUTHOR]

It is essential to identify variations of celiac artery (CA) and common hepatic artery (CHA), using preoperative computed tomography (CT) imaging, for safe gastrectomy and lymph node dissection in gastric cancer (GC) surgery. We report a relatively rare case with the CHA passing behind the portal vein (PV), in which we performed robot-assisted total gastrectomy (RTG) after chemotherapy as conversion surgery. A 78-year-old man with GC was referred for conversion surgery. Three-dimensional CT angiography revealed an anomalous CHA passing behind the PV. The anomaly corresponded to type I according to Adachi's classification, and the patient underwent robot-assisted laparoscopic total gastrectomy D2 lymphadenectomy (RTG D2) with Roux-en-Y reconstruction. The operation time was 543 min, blood loss was 115 ml, and no intraoperative complications occurred. The postoperative course was uneventful. A word of caution during the surgical procedure entails the manipulation of the suprapancreatic lymph node dissection. Initially, it is crucial to identify the anterior surface of the portal vein (PV) and the nerve plexus surrounding the common hepatic artery (CHA). After completely dissecting the entire circumference, the PV is secured using vascular tape. By gently pulling the vascular tape towards the ventral aspect, a safe execution of lymph node dissection no.8 and 12 on the dorsal side of the PV can be accomplished. Meticulous handling of the anatomical abnormalities observed in the preoperative images may prevent unintended hemorrhage. We report a case with vascular anomalies in which RTG D2 was performed successfully as a conversion surgery. • Robotic surgery for gastric cancer is on the rise. • Robot-assisted gastrectomy is feasible for performing lymphadenectomy safely in conversion surgery with vascular anomalies. • Preoperative enhanced computed tomography imaging is necessary to identify the vascular abnormality. [ABSTRACT FROM AUTHOR]

Background The aim of this study was to determine the impact of the site of portal vein invasion on survival after hepatectomy for perihilar cholangiocarcinoma. Methods This study classified 168 patients undergoing resection for perihilar cholangiocarcinoma histologically as without portal vein resection or tumor invasion to the portal vein (PV0), with tumor invasion to unilateral branches of the portal vein (PVt3), or with tumor invasion to the main portal vein or its bilateral branches, or to unilateral second-order biliary radicals with contralateral portal vein involvement (PVt4). Patients in PVt4 were subclassified into the A-M group (cancer invasion limited to the tunica adventitia or media) or the I group (cancer invasion reaching the tunica intima). Results Of the patients, 121 were in PV0, 21 were in PVt3, and 26 were in PVt4. There was no difference in survival between the PV0 and PVt3 groups ( P = .267). The PVt4 group had a worse prognosis than the PVt3 group ( P = .046). In addition, the A-M ( n = 19) and I subgroups ( n = 7) of PVt4 had worse prognoses than the PV0 or PVt3 groups ( P = .005 and < .001, respectively). All patients in the I subgroup of PVt4 died within 9 months after resection. On multivariate analysis, PVt4 ( P = .029) was identified as an independent prognostic factor. Conclusions In perihilar cholangiocarcinoma, postoperative survival was no different between patients with and without ipsilateral portal vein invasion, although patients with tumor invasion to the main or contralateral branches of the portal vein, especially with tunica intima invasion, had extremely poor prognoses. [ABSTRACT FROM AUTHOR]

A gastrointestinal stromal tumor (GIST) often arises in the stomach and small intestine, while esophageal GIST is rare. The first-choice treatment is surgical resection, but there is no standard technique. Herein, we describe our experience in the treatment of esophageal GIST and discuss the usefulness of robotic esophagectomy. The patient was a 60-year-old woman, who was diagnosed with a 30 mm GIST in the middle thoracic esophagus. We underwent robot-assisted thoracoscopic esophagectomy in the prone position. The duration of the thoracoscopic part was 69 min and the total operation time was 319 min. Total blood loss was 135 ml. The patient's postoperative course was uneventful after surgery and the patient was discharged home in good condition on the 18th postoperative day. The prognosis of esophageal GIST was less favorable compared with gastric GIST, and due to the anatomical peculiarities of the esophagus, which surgical procedure should be performed is still under debate. Robotic surgery has several technological advantages as it provides a three-dimensional view, ten times magnification, tremor control, and ambidexterity. Therefore, Robotic-assisted minimally invasive esophagectomy (RAMIE) allows achieving for safe R0 resection of esophageal GIST. RAMIE may be useful for esophageal GIST because it facilitates safe and minimally invasive surgery in a limited space of the thoracic cavity. • There is no standard technique due to the anatomical peculiarities of the esophagus. • We think McKeown's procedure in the prone position has some advantages from others. • Robot surgery has a three-dimensional view, tremor control, and ambidexterity. • RAMIE would be useful techniques in a limited space of the thoracic cavity. [ABSTRACT FROM AUTHOR]

• Peritoneal dissemination of pancreatic cancer may not be obvious on standard scans and workup. • PPIX is absorbed by pancreatic cancer metastasis and fluoresces. • We present a novel laparoscopic device for photodiagnosis of peritoneal metastasis. Diagnosing peritoneal dissemination is essential for selecting the appropriate therapeutic strategy for patients with pancreatic cancer. Intraoperative laparoscopic diagnosis enables the selection of less invasive surgical strategies. Photodynamic diagnosis using 5-aminolevulinic acid may improve gastrointestinal cancer diagnostic accuracy, although weak fluorescence is not easily detected. Here we aimed to improve this sensitivity using laparoscopic spectrophotometry. Photodynamic diagnosis was performed using serial dilutions of protoporphyrin IX, and its detectability using laparoscopic spectrophotometry was compared with that using naked-eye observation. Five-aminolevulinic acid-photodynamic diagnosis was performed for pancreatic cancer cell lines, and a murine peritoneal disseminated nodule model was established. We compared laparoscopic spectrophotometry and naked-eye observation results using white and fluorescent lights and compared them to routine histopathological examination results. Photodynamic diagnoses were made in 2017 and 2018 in eight patients with pancreatic cancer. Weaker fluorescence of the diluted protoporphyrin IX samples was better detected with spectrophotometry than with naked-eye observation. Moreover, a spectrograph of protoporphyrin IX in multiple cell lines was detected by spectrophotometry. In the murine model, the detection rates were 62 %, 78 %, and 90 % for naked-eye observation with white light, fluorescent light, and spectrophotometry, respectively. Comparisons of fluorescent light–negative peritonea with and without pathological metastases showed significantly higher spectrophotometric intensities in the former (P < 0.010). In clinical studies, three fluorescent light–negative spectrophotometry-positive pathologically metastatic lesions were observed. Laparoscopic spectrophotometry in the murine model and extraperitoneally photodynamic diagnoses using spectrophotometry in clinical practice are sensitive photodynamic diagnostic techniques. [ABSTRACT FROM AUTHOR]