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Background: Advanced gastric cancer with gastric outlet obstruction (GOO) causes malnutrition and medication adherence issues, leading to a poor prognosis. We developed a novel multimodal, less invasive treatment approach for gastric cancer patients with symptomatic GOO: laparoscopic stomach-partitioning gastrojejunostomy (LSPGJ) combined with neoadjuvant chemotherapy (NAC), followed by minimally invasive gastrectomy with reuse of gastrojejunostomy. This study is a retrospective analysis of the safety and feasibility of our treatment strategy., Methods: In this single-institution retrospective study, we enrolled 54 patients (NAC group, n = 26; upfront gastrectomy group, n = 28) who achieved R0 resection through a minimally invasive approach between 2007 and 2020 and evaluated their short- and long-term outcomes., Results: After LSPGJ, the Gastric Outlet Obstruction Scoring System score significantly improved (p < 0.001). The median relative dose intensity of NAC was 88.2%. Regarding short-term outcomes, there were no differences in postoperative complications, length of postsurgical hospital stay, and adjuvant chemotherapy administration. Although overall survival and relapse-free survival showed trends toward improvement in the NAC group, these differences were not statistically significant. The cumulative incidence curve for recurrence in the NAC group was significantly lower than that of the upfront gastrectomy group (p = 0.041). Recurrence and hematogenous metastasis were significantly lower in the NAC group (p = 0.031 and 0.041, respectively) than in the upfront gastrectomy group. A forest plot revealed that NAC yielded favorable outcomes, particularly for patients with a body mass index (BMI) < 18.5 kg/m 2 , cT4, or cN1., Conclusions: LSPGJ combined with NAC followed by minimally invasive gastrectomy was a safe and feasible treatment strategy for patients with advanced gastric cancer with symptomatic GOO. This procedure may contribute to the early recovery of oral intake and help maintain NAC dose intensity, potentially improving prognosis, particularly for patients with low BMI and advanced-stage disease., Competing Interests: Declarations. Disclosures: Tsuyoshi Tanaka, Koichi Suda, Masaya Nakauchi, Masahiro Fujita, Kazumitsu Suzuki, Yusuke Umeki, Akiko Serizawa, Shingo Akimoto, Yusuke Watanabe, Susumu Shibasaki, Hiroshi Matsuoka, Kazuki Inaba, and Ichiro Uyama do not have conflicts of interest or financial relationships to disclose regarding the present study. Ichiro Uyama received funding from Medicaroid, Inc. related to the Collaborative Laboratory for Research and Development in Advanced Surgical Technology, Fujita Health University. Ichiro Uyama also received advisory fees from Intuitive Surgical, Inc. and Asahi Intecc Co., Ltd., as well as lecture fees from Intuitive Surgical, Inc., Medicaroid Inc., and Medtronic Japan Co., Ltd., all of which were unrelated to the submitted work. Koichi Suda received funding from Sysmex, Co. related to the Collaborative Laboratory for Research and Development in Advanced Surgical Intelligence, Fujita Health University. Koichi Suda also received funding for research expenses from Sysmex, Co. and Medtronic, Inc., which were unrelated to the present study., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

The transition from open hepatectomy to minimally invasive techniques has reduced morbidity and mortality. However, laparoscopic liver resection (LLR) requires substantial expertise. Robotic liver resection (RLR) combines minimal invasiveness with open surgical precision. It may facilitate complex procedures without the learning required for LLR. We evaluated RLR outcomes in a limited resource setting and assessed its efficacy and practicality. This retrospective study analyzed 67 robotic hepatectomies conducted from 2020 to 2023. Demographic, perioperative factors, and surgical outcomes were analyzed. Major hepatectomies were required in 46/67 (68.7%) patients who underwent RLR. No open conversions, 30-day mortalities, or readmissions occurred. Complications occurred in 7.4% of patients; major complications occurred in 5.9%. Learning curve analysis showed a negative correlation between operation sequence and operative time. Effective use of robotic technology combined with the expertise of well-trained surgeons facilitates successful execution of RLR with feasible surgical outcomes, even at smaller centers., (© 2024. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Background: Over the past 20 years, surgeons involved in soft tissue minimally invasive surgery have experienced the pros and cons of both conventional and tele-robotic laparoscopic approaches. The Maestro System, developed by Moon Surgical (Paris, France) aims to overcome the challenges inherent to both approaches thanks to a new concept that augments the surgeon's performance at the bedside during a laparoscopic procedure., Methods: The current study aims to present the first human experience with laparoscopic cholecystectomy with the Maestro system on 10 patients., Results: All ten procedures were completed successfully. No significant complications related to the use of the Maestro system werenoted., Conclusion: Our preliminary observations appear to support the benefits of the Maestro system in non-emergent laparoscopic cholecystectomies. It goes without saying that further research is necessary to demonstrate the safety of this approach in other procedures., (© 2023. The Author(s).)

Background: Valvuloplastic esophagogastrostomy (VEG) using the double flap technique (DFT) after proximal gastrectomy (PG) represents a promising procedure for the prevention of reflux oesophagitis. We aimed to retrospectively investigate the efficacy of minimally invasive PG followed by VEG-DFT in preventing reflux oesophagitis among patients who require intra-mediastinal anastomosis., Methods: A total of 80 patients who underwent reconstruction with DFT after LPG from November 2013 to January 2021 were enrolled in the present study. Data were obtained through a review of our prospectively maintained database. At 1 year after surgery, multivariate analyses were performed to identify risk factors for gastroesophageal reflux disease of Los Angeles (LA) classification grade B or higher., Results: The incidence of LA grade B or higher reflux oesophagitis 1 year after surgery was 10%. Multivariate analyses revealed that the longitudinal length of the resected oesophagus of > 20 mm was the only significant risk factor for reflux oesophagitis. Patients with a longitudinal length of the resected oesophagus > 20 mm (group-L, n = 35) had a significantly longer total operative time and a higher rate of complications within 30 days of surgery than those with a length of ≤ 20 mm (group-S, n = 45). LA grade B or higher reflux oesophagitis was significantly higher in group-L than in group-S (20% vs. 2.2%; P = 0.011)., Conclusions: There is a need for surgical procedures with improved efficacy for the prevention of reflux oesophagitis in patients requiring oesophageal resection of > 20-mm., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Laparoscopic techniques have been used for hiatal hernia repair. Robotic-assisted repairs have been increasingly used with unproven benefits. The aim of this study was to compare outcomes between laparoscopic and robotic-assisted hiatal hernia repair., Methods: The Nationwide Readmissions Database (NRD) was used to identify hospitalizations for laparoscopic or robotic hiatal hernia repair from 2010 to 2019. Primary outcomes included post-operative complications and 30- and 90-day readmission rates. Secondary outcomes included in-hospital death, length of stay, and inflation-adjusted hospital cost. Multivariable models were estimated for overall complication and readmission rates., Results: Approximately 517,864 hospitalizations met inclusion criteria with 11.3% including robotic repairs. Robotic repair was associated with a higher overall complication rate (9.2% vs. 6.8%, odds ratio [OR]: 1.4, 95% CI: 1.3-1.5, p < .001); however, the trend showed more similar complication rates across years. The higher overall complication rate remained after adjusting for patient and facility characteristics (adjusted OR [aOR]: 1.3, 95% CI: 1.2-1.4, p < .001). Robotic repairs were associated with higher 30-day (6.1% vs. 7.4%, aOR: 1.2, 95% CI: 1.2-1.3, p < .001) and 90-day readmission rates (9.4% vs. 11.2%, aOR: 1.2, 95% CI: 1.2-1.3, p < .001). In-hospital mortality and length of stay were similar, although, higher hospital costs were associated with robotic repairs. Both complications and readmission rates were lower as annual procedural volume increased., Conclusion: Robotic repairs had higher unadjusted and adjusted complication and readmission rates. The overall complication rate has shown a trend towards improvement which may be a result of increasing experience with robotic surgery., (© 2022. The Society for Surgery of the Alimentary Tract.)

Objective: The aim of this study was to provide an interim safety analysis of the first 30 surgical procedures performed using the Versius Surgical System., Background: Robot-assisted laparoscopy has been developed to overcome some of the important limitations of conventional laparoscopy. The new system is currently undergoing a first-in-human prospective clinical trial to confirm the safety and effectiveness of the device when performing minimal access surgery (MAS)., Methods: Procedures were performed using Versius by a lead surgeon supported by an operating room (OR) team. Male or female patients aged between 18 and 65 years old and requiring elective minor or intermediate gynaecological or general surgical procedures were enrolled. The primary endpoint was the rate of unplanned conversion of procedures to other MAS or open surgery., Results: The procedures included nine cholecystectomies, six robot-assisted total laparoscopic hysterectomies, four appendectomies, five diagnostic laparoscopy cases, two oophorectomies, two fallopian tube recanalisation procedures, an ovarian cystectomy and a salpingo-oophorectomy procedure. All procedures were completed successfully without the need for conversion to MAS or open surgery. No patient returned to the OR within 24 h of surgery and readmittance rate at 30 and 90 days post-surgery was 1/30 (3.3%) and 2/30 (6.7%), respectively., Conclusions: This first-in-human interim safety analysis demonstrates that the Versius Surgical System is safe and can be used to successfully perform minor or intermediate gynaecological and general surgery procedures. The cases presented here provide evidence that the Versius clinical trial can continue to extend recruitment and begin to include major procedures, in alignment with the IDEAL-D Framework Stage 2b: Exploration., (© 2020. The Author(s).)

Background: The transoral endoscopic thyroidectomy vestibular approach (TOETVA) has been the subject of increasing interest from several institutions around the world over the last 2 years. Recently, we successfully performed TOETVA in live human patients without CO 2 gas using our newly designed retractable blade., Methods: We reviewed the medical records of 15 consecutive patients who underwent gasless TOETVA using a self-retaining retractor., Results: We successfully performed 13 thyroid lobectomies and 2 total thyroidectomies in 15 patients. No patient exhibited serious postoperative complications such as recurrent laryngeal nerve palsy and permanent hypocalcemia. One patient developed transient hypocalcemia but recovered within 2 months. No patient developed a wound infection; furthermore, no visible scar or dimpling was evident on the neck of any patient., Conclusion: Gasless TOETVA provides enough working space and good visibility to perform thyroid surgery without any risk of CO 2 gas-related complications.

Background: Transoral endoscopic thyroidectomy vestibular approach is expected to be a safe alternative to open surgery for certain patients and has been used increasingly by several surgeons around the world for the past 2 years. The purpose of this paper is to review our 2-year experience and describe in detail our preoperative considerations, patient selection, operating room settings, anesthetic considerations, surgical technique, postoperative management, and outcomes., Methods: We reviewed the medical records of 65 consecutive patients who underwent transoral endoscopic thyroidectomy between July 2016 and May 2018 in our hospital., Results: We have performed 65 thyroid surgeries (54 thyroid lobectomies, 1 completion thyroidectomy, and 10 total thyroidectomies) in 64 patients. Postoperative pathology revealed papillary carcinoma in 55 patients (84.6%), follicular carcinoma in two (3.1%), hyalinizing trabecular tumor in one (1.5%), and other benign tumor in seven (10.8%). All surgical margins were negative. Two (3.1%) patients developed transient vocal cord palsy but recovered within 2 months. One (1.5%) patient with vocal cord palsy had not recovered by 3 months after surgery. Five (7.7%) patients who underwent total thyroidectomy developed transient hypocalcemia but recovered within 2 months., Conclusion: Although transoral thyroid surgery is a relatively recent technique requiring further validation, it affords several advantages. Transoral thyroid surgery has not yet been universally accepted, but may be the best choice for thyroid surgery in the future.

Although robot-assisted surgeries offer various advantages, the discontinuous surgical operation flow resulting from switching the control between the patient-side manipulators and the endoscopic robot arm can be improved to enhance the efficiency further. Therefore, in this study, a head-mounted master interface (HMI) that can be implemented to an existing surgical robot system and allows continuous surgical operation flow using the head motion is proposed. The proposed system includes an HMI, a four degrees of freedom endoscope control system, a simple three-dimensional endoscope, and a da Vinci Research Kit. Eight volunteers performed seven head movements and their data from HMI was collected to perform support vector machine (SVM) classification. Further, ten-fold cross-validation was performed to optimize its parameters. Using the ten-fold cross-validation result, the SVM classifier with the Gaussian kernel (σ = 0.85) was chosen, which had an accuracy of 92.28%. An endoscopic control algorithm was developed using the SVM classification result. A peg transfer task was conducted to check the time-related effect of HMI's usability on the system, and the paired t test result showed that the task completion time was reduced. Further, the time delay of the system was measured to be 0.72 s. Graphical abstract A head-mounted master interface (HMI), which can be implemented to an existing surgical robot system, was developed to allow simultaneous surgical operation flow. The surgeon's head motion is detected through the proposed HMI and classified using a support vector machine to manipulate the endoscopic robotic arm. A classification accuracy of 92.28% was achieved.