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Purpose: In this study, we aim to analyze the learning curve of each step of robotic transabdominal pre-peritoneal inguinal hernia repair (rTAPP) in two surgeons with varying degrees of expertise with the robotic platform but no experience with laparoscopic hernia repair., Methods: Data on 124 rTAPP cases performed by two surgeons were retrospectively reviewed. Cumulative sum (CUSUM) analysis was applied to visualize the learning curve of rTAPP on operation time of each step of the procedure [the peritoneal flap creation (T1), the completion of the critical view of the myopectineal orifice (T2), the mesh application (T3) and the peritoneal flap closure (T4)]. Each intraoperative and postoperative outcome was compared according to surgeon's experience with the robotic platform and learning phase. The robotic surgeon mentored the surgeon-in-training and was present during all surgeries in his learning period., Results: The surgeon in training with the robotic platform showed a learning phase till the 20th procedure followed by a gradual improvement in performances. The expert surgeon showed a learning phase till the 35th procedure after which a constant decrease of operative time was recorded till the last procedure included. The operative times of each step of the procedures of both surgeons were significantly improved after the learning phase. In the late phase, the surgeon in training could achieve operative times in T2 and T3, which are similar to those of an experienced robotic surgeon with no experience with TAPP before the completion of the learning phase., Conclusions: In conclusion, the learning phase of rTAPP surgery may vary between 20 and 35 cases, depending on the surgeon's experience in robotic surgery., (© 2023. The Author(s).)

The advantages of using the robotic platform may not be clearly evident in left colectomies, where the surgeon operates in an "open field" and does not routinely require intraoperative suturing. Current evidences are based on limited cohorts reporting conflicting outcomes regarding robotic left colectomies (RLC). The aim of this study is to report a bi-centric experience with robotic left colectomy in order to help in defining the role of the robotic approach for these procedures. This is a bi-centric propensity score matched study including patients who underwent RLC or laparoscopic left colectomy (LLC) between January 1, 2012 and May 1, 2022. RLC patients were matched to LLC patients in a 1:1 ratio. Main outcomes were conversion to open surgery and 30-day morbidity. In total, 300 patients were included. Of 143 (47.7%) RLC patients, 119 could be matched. After matching, conversion rate (4.2 vs. 7.6%, p = 0.265), 30-day morbidity (16.1 vs. 13.7%, p = 0.736), Clavien-Dindo grade ≥ 3 complications (2.4 vs 3.2%, p = 0.572), transfusions (0.8 vs. 4.0%, p = 0.219), and 30-day mortality (0.8 vs 0.8%, p = 1.000) were comparable for RLC and LLC, respectively. Median operative time was longer for RLC (296 min 260-340 vs. 245, 195-296, p < 0.0001). Early oral feeding, time to first flatus, and hospital stay were similar between groups. RLC has safety parameters as well as conversion to open surgery comparable with standard laparoscopy. Operative time is longer with the robotic approach., (© 2023. The Author(s).)

Background: Evidence on the efficacy of minimally invasive (MI) segmental resection of splenic flexure cancer (SFC) is not available, mostly due to the rarity of this tumor. This study aimed to determine the survival outcomes of MI and open treatment, and to investigate whether MI is noninferior to open procedure regarding short-term outcomes., Methods: This nationwide retrospective cohort study included all consecutive SFC segmental resections performed in 30 referral centers between 2006 and 2016. The primary endpoint assessing efficacy was the overall survival (OS). The secondary endpoints included cancer-specific mortality (CSM), recurrence rate (RR), short-term clinical outcomes (a composite of Clavien-Dindo > 2 complications and 30-day mortality), and pathological outcomes (a composite of lymph nodes removed ≧12, and proximal and distal free resection margins length ≧ 5 cm). For these composites, a 6% noninferiority margin was chosen based on clinical relevance estimate., Results: A total of 606 patients underwent either an open (208, 34.3%) or a MI (398, 65.7%) SFC segmental resection. At univariable analysis, OS and CSM were improved in the MI group (log-rank test p = 0.004 and Gray's tests p = 0.004, respectively), while recurrences were comparable (Gray's tests p = 0.434). Cox multivariable analysis did not support that OS and CSM were better in the MI group (p = 0.109 and p = 0.163, respectively). Successful pathological outcome, observed in 53.2% of open and 58.3% of MI resections, supported noninferiority (difference 5.1%; 1-sided 95%CI - 4.7% to ∞). Successful short-term clinical outcome was documented in 93.3% of Open and 93.0% of MI procedures, and supported noninferiority as well (difference - 0.3%; 1-sided 95%CI - 5.0% to ∞)., Conclusions: Among patients with SFC, the minimally invasive approach met the criterion for noninferiority for postoperative complications and pathological outcomes, and was found to provide results of OS, CSM, and RR comparable to those of open resection., (© 2022. The Author(s).)

The aim of this study was to review the latest evidence on the robotic approach (RHR) for inguinal hernia repair comparing the pooled outcome of this technique with those of the standard laparoscopic procedure (LHR). A systematic literature search was performed in PubMed, Web of Science and Scopus for studies published between 2010 and 2021 concerning the comparison between RHR versus LHR. After screening 582 articles, 9 articles with a total of 64,426 patients (7589 RHRs) were eligible for inclusion. Among preoperative variables, a pooled higher ratio of ASA > 2 patients was found in the robotic group (12.4 vs 8.6%, p < 0.001). Unilateral hernia repair was more common in the laparoscopic group (79.9 vs 68.1, p < 0.001). Overall, operative time was longer in the robotic group (160 vs 90 min, p < 0.001); this was confirmed also in the sub-analysis on unilateral procedures (88 vs 68 min, p = 0.040). The operative time for robotic bilateral repair was similar to the laparoscopic one (111 vs 100, p = 0.797). Conversion to open surgery was 0% in the robotic group. The pooled rate of chronic pain and postoperative complications was similar between the groups. The standardized mean difference MD of the costs between LHR versus RHR was - 3270$ (95% CI - 4757 to - 1782, p < 0.001). In conclusion, laparoscopic and robotic inguinal hernia repair have similar safety parameters and postoperative outcomes. Robotic approach may require longer operative time if the unilateral repair is performed. Costs are higher in the robotic group., (© 2021. The Author(s).)

Background: In literature, most of the comparative studies of robotic (RRC) versus laparoscopic (LRC) right colectomy are biased by the type of the anastomotic technique adopted. With this study, we aim to understand whether there is a role for robotics in performing right colectomies, comparing RRC versus LRC, both performed with intracorporeal anastomosis., Methods: In this retrospective cohort study, all consecutive patients who underwent minimally invasive right colectomy (robotic or laparoscopic) with intracorporeal anastomosis in three Italian high-volume centers between February 1, 2007 and December 31, 2017 were included. Patients were grouped according to the method of surgery: RRC or LRC., Results: A total of 389 patients were included in the study (305 RRC vs. 84 LRC). Patients' baseline characteristics were comparable between the groups. Operative time was significantly longer in RRC (250 min, IQR 209-305) group than LRC group (160 min, IQR 130-200) (p < 0.001). The median number of lymph nodes harvested was 22 (IQR 18-29) in RRC group while it was 19 (IQR 15-27) in LRC one (p = 0.028). No significant differences between the groups were seen in terms of time-to-first flatus, postoperative complications and length of hospital stay. Re-admission rate was significantly higher in LRC (n = 3, 3.6%) group than in RRC group (n = 1, 0.3%) (p = 0.033)., Conclusions: In conclusion, RRC and LRC are comparable in terms of functional postoperative outcomes and length of hospital stay. RRC requires longer operative time, but the number of lymph nodes harvested may be higher.

Background: Outside the US, FLS certification is not required and its teaching methods are not well standardized. Even if the FLS was designed as "stand alone" training system, most of Academic Institution offer support to residents during training. We present the first systematic application of FLS in Italy. Our aim was to evaluate the role of mentoring/coaching on FLS training in terms of the passing rate and global performance in the search for resource optimization., Methods: Sixty residents in general surgery, obstetrics & gynecology, and urology were selected to be enrolled in a randomized controlled trial, practicing FLS with the goal of passing a simulated final exam. The control group practiced exclusively with video material from SAGES, whereas the interventional group was supported by a mentor., Results: Forty-six subjects met the requirements and completed the trial. For the other 14 subjects no results are available for comparison. One subject for each group failed the exam, resulting in a passing rate of 95.7%, with no obvious differences between groups. Subgroup analysis did not reveal any difference between the groups for FLS tasks., Conclusion: We confirm that methods other than video instruction and deliberate FLS practice are not essential to pass the final exam. Based on these results, we suggest the introduction of the FLS system even where a trained tutor is not available. This trial is the first single institution application of the FLS in Italy and one of the few experiences outside the US. Trial Number: NCT02486575 ( https://www.clinicaltrials.gov ).

Background: In the right colon surgery, there is a growing literature comparing the safety of robotic right colectomy (RRC) to that of laparoscopic right colectomy (LRC). With this paper we aim to systematically revise and meta-analyze the latest comparative studies on these two minimally invasive procedures., Methods: A systematic review of studies published from 2000 to 2017 in the PubMed, Scopus, and Embase databases was performed. Primary endpoints were postoperative morbidity and mortality. Secondary endpoints were blood loss, conversion to open surgery, harvested lymph node anastomotic leak, postoperative hemorrhage, abdominal abscess, postoperative ileus, time to first flatus, non-surgical complications, wound infections, hospital stay, and incisional hernia and costs. A subgroup analysis was performed on those series presenting only extracorporeal anastomosis in both arms., Results: After screening 355 articles, 11 articles with a total of 8257 patients were eligible for inclusion. Operative time was found to be significantly shorter for the laparoscopic procedures in the pooled analysis (SMD - 0.99 95% CI - 1.4 to - 0.6, p < 0.001). Conversion to open surgery was more common during laparoscopic procedures than during the robotic ones (RR 1.7; 95% CI 1.1-2.6, p = 0.02). No significant differences in mortality (RR 0.47; 95% CI 0.18-1.23, p = 0.124) and postoperative complications (RR 1.05; 95% CI 0.9-1.2, p = 0.5) were found between LRC versus RRC. The pooled mean time to first flatus was higher in the laparoscopic group (SMD 0.85 days; 95% CI 0.16-1.54, p = 0.016). Hospital costs were significantly higher in RRCs (SMD - 0.52; 95% CI - 0.52 to - 0.04, p = 0.035)., Conclusions: RRC can be regarded as a feasible and safe technique. Its superiority in terms of postoperative recovery must be confirmed by further large prospective series comparing RRC and LRC performed with the same anastomotic technique. RRC seemed to be associated with higher costs than LRC.

Introduction: The ideal surgical treatment for pulmonary metastasectomy remains controversial. Minimally invasive surgery may offer advantages for quality of life outcomes, with equivalent oncologic long-term results. The purpose of our study was to confirm the validity of the thoracoscopic approach for pulmonary metastasectomy., Methods: We retrospectively reviewed 164 patients who underwent 212 lung metastasectomies from January 2000 to December 2010. Complete curative pulmonary resections were performed in 159 (96.95 %) cases; 126 patients developed lung metastases from epithelial tumors: 28 from sarcoma, 7 from melanoma, and 3 from germ cell tumors. The mean disease-free interval (DFI) was 38.75 months. Fifty-four patients underwent a major VATS resection (53 thoracoscopic lobectomies and 1 pneumonectomy), and 110 patients underwent a wedge resection/segmentectomy. Lymph node sampling was performed in 117 cases., Results: After a mean follow-up of 38 months, 87 patients (53 %) had died. All resection margins were tumor-free at final pathological examination. Multivariate analysis not confirmed in our series a better prognosis for patients with a particular histologic type and also DFI, age, number of metastases, and type of surgery did not statistically influence long-term survival., Conclusions: Thoracoscopic surgery is an acceptable procedure, safe and efficacious, with a 5-year overall survival that is equivalent to open surgery.

Purpose: A very simple technique to repair a superior lumbar hernia is described. The location of this type of hernia, also known as the Grynfeltt-Lesshaft hernia, is defined by a triangle placed in the lumbar region., Method: An unusual case of a 67-year-old woman with a superior lumbar hernia is reported. The diagnosis was made by physical examination., Results: The defect of the posterior abdominal wall was repaired with a polypropylene dart mesh. The patient had no evidence of recurrence at 11 months follow up., Conclusions: The surgical approach described in this paper is simple and easy to perform, and its result is comparable with other techniques that are much more sophisticated. No cases on the use of dart mesh to repair Grynfeltt-Lesshaft hernia have been reported by surgical journals indexed in PubMed.

Background: Video-assisted thoracic surgery (VATS) in the diagnosis and treatment of pulmonary diseases has been used since the early 1990s, yet its impact on intraoperative and postoperative morbidity has not yet been fully evaluated. This report aims to provide a retrospective analysis of the literature and the authors' clinical experience with VATS in pulmonary surgery, with the goal of ascertaining rational criteria that explain operative complications and thus improve outcomes., Methods: Over a period of 15 years 1,615 VATS procedures were performed in our department, 743 of which involved only the lung. The accesses employed were based on the use of three ports through which a thoracoscope, endoscopic instruments, and an endostapler were inserted; for major pulmonary resections, a utility thoracotomy without rib spreader was added. Resections less than segmentectomy were performed using the endostapler directly on the parenchyma, whereas in the anatomic resections all the hilar structures were isolated and separately sectioned., Results: The procedures performed were as follows: surgical biopsy, 98; wedge resection, 412; segmentectomy, 15; lobectomy, 217; pneumonectomy, 1. Besides the cases in which there were intraoperative complications that could be resolved thoracoscopically, it was necessary to convert to open surgery in 80 patients (10.8%): in 24 (3.3%), for general reasons linked to the technique of VATS itself; in 56 (7.5%), for specific causes correlated to the type of exeresis. The overall postoperative morbidity rate was 8.3% with no deaths., Conclusions: The analysis of the literature and our experience show that VATS is a reliable approach to the diagnosis and treatment of pulmonary diseases with low complication rate. To further reduce intraoperative and postoperative morbidity, however, it is necessary to select the patients carefully, to adhere strictly to oncological surgical principles, and to adopt a meticulous technique. Although conversion to open surgery represents failure of VATS, it is mandatory when the procedure is not completely safe.

Background: The use of video-assisted thoracic surgery (VATS) in the treatment of pleural empyema has been proposed since the early 1990s, but among surgeons, its use varies considerably, and the results are discordant. This report aims to provide a retrospective assessment of the authors' experience and the literature on VATS in an effort to ascertain rational criteria for the use of this technique., Methods: Over a period of 12 years, a total of 120 cases of pleural empyema were recorded. The patients were assessed with chest x-ray, computed tomography, ultrasound, and thoracentesis. On the basis of clearly defined clinical and radiographic parameters, 38 patients underwent VATS immediately, whereas the remaining 82 were treated initially by means of tube thoracostomy. The latter was found to be sufficient for only 10 patients. Consequently, for the remaining 72 patients, it was decided to proceed also with VATS., Results: The procedure was performed completely by VATS in 101 patients (91.8%), whereas in 9 patients (8.2%) it was necessary to convert to thoracotomy. The postoperative course was uneventful for 98 of the 110 patients (89%), whereas the remaining 12 patients experienced complications, including one case of persistent empyema (0.9%) treated by thoracotomy. The mean chest tube duration was 6 days (range, 3-25 days). The mean postoperative hospital stay was 7.1 days (range, 5-17 days). Of the 80 patients completing a 6-month follow-up evaluation, the results were considered good for 72, moderately good for 8, and less than satisfactory for 2 patients., Conclusions: In conclusion, the authors consider VATS to be the technique of first choice for the treatment of pleural empyema when the disease is advanced or tube thoracostomy fails. It provides excellent results with a low level of invasiveness and considerably reduces the need for thoracotomy. These results can be achieved with good videothoracoscopic experience and the use of a very precise technique.

Background: Indications for the use of video-assisted thoracic surgery (VATS) lobectomy are a controversial matter. This study aims to provide a retrospective evaluation of VATS lobectomy in typical bronchopulmonary carcinoids., Methods: Patient selection criteria for VATS lobectomy were as follows: (a) typical carcinoids with clear diagnosis; (b) centrally located lung tumors not amenable to bronchial resection with bronchoplastic procedures, or tumors located in peripheral lung tissues; (c) no hilar or mediastinal lymph node enlargement; and (d) normal respiratory function. Between January 1995 and December 1999, 12 patients (eight men and four women with a mean age of 57 years) were treated, seven with a peripheral and five with a centrally located tumor. Preoperative examination included chest roentgenograms, computed tomography (CT) of the chest, bronchoscopy, and spirometry; diagnosis was established by direct bronchoscopy in five cases, transbronchial biopsy in two cases, transthoracic biopsy in two cases, and video thoracoscopic wedge resection in three cases. Eleven VATS lobectomies and one VATS bilobectomy were performed. All patients underwent hilar lymphadenectomy and mediastinal sampling., Results: There were no intraoperative complications. The only postoperative complication, hematothorax (8.3%), required VATS reoperation. Mean postoperative hospital stay was 5.33 days. Pathological examination of the resected specimens confirmed that the procedure was radical in all 12 patients and revealed eight T1N0 and four T2N0. At a mean follow-up of 30 months, no signs of recurrence were recorded., Conclusion: VATS lobectomy in the treatment of selected typical carcinoids, both central and peripheral, seems to yield favorable results and is therefore preferable to thoracotomy since it is less invasive.