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Background: The article describes our initial experience using CMR Versius platform for several procedures in general surgery., Methods: Between September 2022 and April 2023, seventy patients underwent robotic surgery in a multi-robotic referral center (San Paolo University Hospital, Milan, Italy). Three surgeons with only laparoscopic experience performed 24 cholecystectomies, 13 inguinal hernia repairs, 9 ventral hernia repairs, 7 right hemicolectomies, 11 left hemicolectomies, 1 sigmoidectomy, 1 ileocecal resection, 1 ventral rectopexy, 1 Nissen fundoplication, 1 total splenectomy, and 1 exploration with multiple biopsies., Results: All surgeries were full-robotic, with only one conversion to laparoscopy. The short length of stay and low rate of severe morbidity are promising findings. Although operative time was lengthened, clinical outcomes were not affected., Conclusions: Our experience demonstrates that the adoption of Versius system is safe and feasible in general surgery. The standardization of port placement and BSU set-up can certainly reduce the operative time., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Robotic surgery offers new possibilities in repairing complex hernias with a minimally invasive approach. This study aimed to analyze our preliminary results., Methods: Between November 2015 and February 2020, 150 patients underwent robotic reconstruction for abdominal wall defects (77 primary and 73 incisional). A retrospective analysis of a prospectively maintained database was conducted to evaluate the short-term outcomes., Results: The mean operative time was 176.9 ± 72.1 min. No conversion to open or laparoscopic approach occurred. The mean hospital length of stay was 2.6 ± 1.6. According to Clavien-Dindo classification, two (grade III) complications following retromuscular mesh placement (1.3%) occurred. One patient (0.7%) required surgical revision due to small bowel occlusion following an intraparietal hernia. The 30-day readmission rate was 0.6%, and the mortality was nihil., Conclusions: Robotic surgery is valuable for safely completing challenging surgical procedures like complex abdominal wall reconstruction, with low conversion and complication rates. A stepwise approach to the different surgical techniques is essential to optimize the outcomes and maximize the benefits of the robotic approach., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Indocyanine green fluorescence (ICG) is one of the first fluorophore that found a clinical application in medicine. In the liver, ICG fluorescence is due to the preserved uptake but impaired washout of the dye from hepatocellular cells into the bile ducts. Therefore, some hepatobiliary surgeons proposed the technique of intravenous ICG injection before surgery for the detection of superficial hepatocarcinomas (HCCs) and colorectal liver metastases (CRLMs). Little evidence exists regarding the use of ICG to identify other hepatic tumors, such as intrahepatic cholangiocarcinoma (ICC). We report two patients affected by ICC who underwent laparoscopic liver resection with lymphadenectomy, the ICG staining was routinely performed not only to evaluate the site of the hepatic lesions but also to guide the extension of liver resection., Methods: It was injected intravenously a single dose of ICG dye (0.5 mg/kg) during liver function tests 5 days before scheduled surgery. All patients underwent laparoscopic staging with both laparoscopic ultrasound and ICG fluorescence imaging., Results: It was identified two different patter of ICG imaging: rim and segmental fluorescence for mass forming and mixed ICC subtype respectively., Conclusions: Identification of the ICC subtype before definitive histological examination may have an impact on the surgical plan.

The diffusion of robotic surgery is rapidly and constantly growing in different surgical specialties. Recently, novel robotic platforms have entered into the market. To date, however, most of the reports on their clinical use have specifically focused on gynecological and urological surgery. In this study, we present the first three robotic-assisted colectomies performed with the new Hugo RAS system (Medtronic, Minneapolis, MN, USA). The surgical team had previous robotic experience and completed simulation training and an official 2-day cadaver laboratory session. Operating room setting and trocar layout were planned and two full cadaver procedures were carried out (right and left colectomy). Onsite dry-run sessions were performed before tackling clinical cases. Three patients underwent robotic-assisted colectomies: one left colectomy, two right colectomies with complete mesocolic excision (CME) and high vascular ligation (HVL) at our Institution. Preoperative diagnosis was colonic adenocarcinoma in all cases. A description of the operative room setup, robotic arm configuration and docking angles is provided. Mean docking time and console time were 8 and 259 min, respectively. All the surgical steps were completed without critical surgical errors or high-priority alarms. Neither intraoperative complications nor conversions to open surgery were recorded. Postoperative courses were uneventful with a mean length of stay of 5 days. Further clinical data and experience are required for procedural standardization and potential integration of the system into robotic general surgery and colorectal programs., (© 2023. Italian Society of Surgery (SIC).)

Background: Since the introduction of minimally invasive surgery, new techniques like transabdominal preperitoneal (TAPP) repair have progressively gained acceptance for the treatment of groin hernia. Laparoscopic TAPP (LTAPP) is recommended for bilateral repairs. Likewise, the introduction of robotic platforms has promised additional surgical benefits for robotic TAPP (RTAPP), which are yet to be confirmed. This study compared multicenter data obtained from patients undergoing bilateral inguinal hernia repair with RTAPP, performed during the preliminary learning curve period, versus conventional LTAPP., Materials and Methods: All consecutive bilateral inguinal hernia patients from four Italian centers between June 2015 and July 2020 were selected. A propensity score model was used to compare patients treated with LTAPP versus RTAPP, considering sex, age, body mass index, current smoking status, overall comorbidity, hernia classification (primary or recurrent), and associated procedures as covariates. After matching, intraoperative details and postoperative outcomes were evaluated., Results: In total, 275 LTAPP and 40 RTAPP were performed. After matching, 80 and 40 patients were allocated to the LTAPP and RTAPP cohorts, respectively. No intraoperative complications or conversion to open surgery occurred. However, a longer operative time was recorded in the RTAPP group (79 ± 21 versus 98 ± 29 min; p < 0.001). Postoperative visual analog scale (VAS) pain scores (p = 0.13) did not differ and complication rates were similar. There were no clinical recurrences in either group, with mean follow-up periods of 52 ± 14 (LTAPP) and 35 ± 8 (RTAPP) months. A statistical difference in length of hospital stay was found between the groups (1.05 ± 0.22 vs 1.50 ± 0.74 days; p < 0.001)., Conclusion: In this patient population, outcomes for bilateral inguinal hernia repair appear comparable for RTAPP and LTAPP, except for a shorter recovery after laparoscopic surgery. A longer operative time for robotic surgery could be attributable to the learning curve period of each center., (© 2022. 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).)

Background: Minimally invasive surgery (MIS), including laparoscopic and robotic approaches, is widely adopted in elective digestive surgery, but selectively used for surgical emergencies. The present position paper summarizes the available evidence concerning the learning curve to achieve proficiency in emergency MIS and provides five expert opinion statements, which may form the basis for developing standardized curricula and training programs in emergency MIS., Methods: This position paper was conducted according to the World Society of Emergency Surgery methodology. A steering committee and an international expert panel were involved in the critical appraisal of the literature and the development of the consensus statements., Results: Thirteen studies regarding the learning curve in emergency MIS were selected. All but one study considered laparoscopic appendectomy. Only one study reported on emergency robotic surgery. In most of the studies, proficiency was achieved after an average of 30 procedures (range: 20-107) depending on the initial surgeon's experience. High heterogeneity was noted in the way the learning curve was assessed. The experts claim that further studies investigating learning curve processes in emergency MIS are needed. The emergency surgeon curriculum should include a progressive and adequate training based on simulation, supervised clinical practice (proctoring), and surgical fellowships. The results should be evaluated by adopting a credentialing system to ensure quality standards. Surgical proficiency should be maintained with a minimum caseload and constantly evaluated. Moreover, the training process should involve the entire surgical team to facilitate the surgeon's proficiency., Conclusions: Limited evidence exists concerning the learning process in laparoscopic and robotic emergency surgery. The proposed statements should be seen as a preliminary guide for the surgical community while stressing the need for further research., (© 2023. The Author(s).)

Introduction: Inguinal hernia repair is one of the most commonly performed surgical procedures in general surgery. Despite surgical advances, recurrence and chronic pain are still major issues after this intervention. Aim of our study was to retrospectively assess and compare outcomes of robotic versus laparoscopic repair of recurrent inguinal hernia. Methods: All patients who underwent recurrent inguinal hernia repair between 2014 and 2021 in five different institutions were included in our study. Baseline data on age, gender, body mass index, comorbidities, smoking habit, and anticoagulant therapy were retrospectively collected from prospectively maintained databases. Operative time, length of stay, and early and late complications were compared between the robotic and the laparoscopic approach. Results: Forty-eight patients underwent recurrent inguinal hernia repair between January 2014 and December 2021. Twenty-three patients underwent a robotic procedure, whereas 25 were submitted to the laparoscopic intervention. Overall mean follow-up was 26.2 months. There was no significant difference in the baseline characteristics of the two groups. Acceptable and comparable rates of peri- and postoperative outcomes were recorded. However, postoperative visual analog scale score and incidence of chronic pain were lower after the robotic rather than after the laparoscopic approach. (2.9 versus 3.8 P  = .002; 20% versus 0%; P  = .02, respectively). Conclusions: Minimally invasive repair of recurrent inguinal hernia is safe and feasible; robotic surgery is associated with low rate of postoperative and chronic pain without a significant increase in operative time.

Despite the well-known benefits of the minimally invasive approach for the right colon cancer treatment, less is known about its feasibility and advantages in morbid obese patients. The aim of this study is to compare the postoperative outcomes after totally minimally invasive right colectomy between the obese and non-obese population. Data derived from a prospectively maintained multicenter colorectal database were analysed, dividing the enrolled patients into two groups: obese (BMI > 29.99) patient group and non-obese patient group. Data about gender, age, American Society of Anesthesiologists (ASA) Score, tumor characteristics, operative time, anastomosis time, extraction site, incision length, intraoperative complications, postoperative complications, postoperative recovery, specimen length and retrieved nodes were taken to assess the achievement of the oncologic standards. After a propensity score matching, a total of 184 patients was included, 92 in each group. No differences were found in terms of demographic data and tumor characteristics. Intraoperative data showed a significant difference in terms of anastomosis time in favour of non-obese group (p < 0.0001). No intraoperative complications were recorded and no conversion was needed in both groups. No differences were found in terms of postoperative complications. There were no differences in terms of first mobilization (p = 0.745), time to first flatus (p = 0.241) time to tolerance to liquid and solid diet (p = 0.241 and p = 0.06) and length of hospital stay (p = 0.817). The analysis of oncologic outcomes demonstrated adequate results in both groups. The results obtained by our study confirmed the feasibility and safety of the totally minimally invasive approach even in obese population., (© 2022. The Author(s).)

Background: Robotic surgery may facilitate complex procedures such as right colectomy with complete mesocolic excision (CME) and shorten the learning curve. This study aimed to compare senior and junior surgeons' results in performing robotic right colectomy (RRC) with CME and intracorporeal anastomosis for right colon cancer., Materials and Methods: Between January 2015 and April 2020, a total of 161 patients underwent RRC with CME. After propensity score matching, two groups of 31 patients for each surgeon were formed. Intraoperative, postoperative and pathological outcomes were the variables assessed., Results: No statistically significant difference was recorded between the two groups. The senior surgeon experienced 16.1% minor complications (Clavien-Dindo I-II) and 3.2% major complications (Clavien-Dindo III-IV), while the novice surgeon reported 19.3% and 3.2% rates of minor and major adverse events, respectively., Conclusions: After a structured training protocol, a novice may obtain comparable results to an expert in performing RRC with CME., (© 2022 John Wiley & Sons Ltd.)

Technical and oncological aspects are still debated when dealing with minimally-invasive right colectomy. Main controversial issues still remain about whether the anastomosis should be performed intra- or extracorporeally and if a complete mesocolic excision (CME) should be carried out. We report the feasibility of robotic right colectomy with CME and intracorporeal anastomosis (IA) for right sided colon cancer. Data from patients who underwent robotic right colectomy with IA and CME from January 2015 to April 2020 were prospectively collected and retrospectively analyzed. Intraoperative outcomes and complications (minor I-II and major III-IV according to Clavien-Dindo classification), conversion rate, 30-day postoperative outcomes and pathological outcomes were the variables assessed. A total of 161 patients undergoing robotic right colectomy for cancer met the inclusion criteria. Mean operative time was 185 min, no intraoperative complications were observed, and the conversion rate was 3.7% (6 patients requiring elective conversions). Overall, mean postoperative stay was 4.9 days and the overall 30-day complication rate was 16.1%. 20 patients (12.4%) had minor complications, while major postoperative complications occurred in six patients (3.7%). Anastomotic leak was recorded in one patient (0.6%) and the 30-day re-admission rate was 0.6%. Mean number of harvested lymph nodes was 21.9. Patients requiring conversion experienced two minor complications, with a mean length of stay of 7 days. Robotic right colectomy with CME and IA is feasible and it is associated with good intraoperative and short-term postoperative clinical outcomes.

Background: This study aimed to evaluate the impact of the robotic approach on the minimally invasive elective treatment of diverticular disease., Methods: Data from patients who underwent elective robotic colectomy for diverticular disease from January 2015 to February 2020 were prospectively collected and retrospectively analysed. Intraoperative and 30-day postoperative outcomes were the variables assessed., Results: A total of 80 patients (71% with prior complicated diverticulitis) met the inclusion criteria. Mean operative time was 241 min, one intraoperative complication (1.2%) was observed, the conversion rate was 2.5%. Mean hospital stay was 6.4 days and overall 30-day complication rate was 22.5%. Fourteen patients (17.5%) had minor complications, while major postoperative complications occurred in four patients (5%). Anastomotic leak rate was 3.9% and the 30-day readmission rate was 3.7%., Conclusions: Robotic colectomy for diverticular disease has proven to be feasible and safe, with low intraoperative complications, conversion, and anastomotic leak rates., (© 2020 John Wiley & Sons Ltd.)

Background: Right colectomy is the standard surgical treatment for tumors in the right colon and surgical complications are reduced with minimally-invasive laparoscopy compared with open surgery, with potential further benefits achieved with robotic assistance. The anastomotic technique used can also have an impact on patient outcomes. However, there are no large, prospective studies that have compared all techniques., Methods/design: MIRCAST is the Minimally-Invasive Right Colectomy Anastomosis Study that will compare laparoscopy with robot-assisted surgery, using either intracorporeal or extracorporeal anastomosis, in a large prospective, observational, multicenter, parallel, four-cohort study in patients with a benign or malignant, non-metastatic tumor of the right colon. Over 2 years of follow-up, the study will prospectively evaluate peri- and postoperative complications, postoperative recovery, hospital stay, and mid-term results including survival, local recurrence, metastases rate, and conversion rate. The primary composite endpoint will be the efficacy of the surgical method regarding surgical wound infections and postoperative complications (Clavien-Dindo grade III-IV complications at 30 days post-surgery). Secondary endpoints include long-term oncologic results, conversion rate, operative time, length of stay, and quality of life., Discussion: This will be the first large, international study to prospectively evaluate the use of minimally-invasive laparoscopy or robot-assisted surgery during right hemicolectomy and to control for the impact of the anastomotic technique. The research will contribute to current knowledge regarding the medical care of patients with malignant or benign tumors of the right colon, and enable physicians to determine which technique may be the most appropriate for their patients., Trial Registration: This study was registered on Clinicaltrials.gov (clinicaltrials.gov identifier: NCT03650517 ) on August 28th 2018 (study protocol version CI18/02 revision A, 21 February 2018).

Background: During the past decade, the concept of complete mesocolic excision (CME) has emerged as a possible strategy to minimize recurrence for right colon cancers. The purpose of this study was to compare robotic versus laparoscopic CME in performing right colectomy for cancer., Methods: Pertinent data of all patients who underwent robotic or laparoscopic right colectomy with CME using a Pfannenstiel incision and intracorporeal anastomosis performed between October 2005 and November 2015 were entered in a prospectively maintained database., Results: A total of 202 patients underwent robotic (n = 101) or laparoscopic (n = 101) right colectomy within the study period. Patient characteristics were equivalent between groups. The robotic group showed a statistically significant reduction in conversion rate (0% vs. 6.9%, p = 0.01) but a longer operative time (279 min vs. 236 min, p < 0.001) compared with the laparoscopic group. There were no other differences in perioperative clinical or pathological outcomes. Five-years overall survival was 77 versus 73 months for the robotic versus laparoscopic groups (p = 0.64). The disease-free survival (DFS) rates were 85% and 83% for the robotic versus laparoscopic groups (p = 0.58). Among UICC stage III patients, there was a slight but not significant difference in 5-year DFS for the robotic group (81 vs. 68 months; p = 0.122)., Conclusions: Both approaches for right colectomy with CME were safe and feasible and resulted in excellent survival. Robotic assistance was beneficial for performing intracorporeal anastomosis and dissection as evidenced by the lower conversion rates. Further robotic experience may shorten the operative time.

Background: Recent reports have suggested that the use of the robot might reduce the rate of pancreatic complications following minimally invasive radical gastrectomy., Methods: By meta-analyzing the available literature, we aimed to elucidate possible differences between conventional laparoscopic and robotic radical gastrectomy on pancreatic morbidity., Results: More than 2000 patients from eight studies were eventually included in the analysis. The overall incidence of postoperative pancreatic complications was 2.2%, being 1.7% and 2.5% following robotic and laparoscopic gastrectomy (LG), respectively. In particular, pancreatic fistula occurred in 2.7% of patients receiving robotic gastrectomy (RG) and 3.8% of patients receiving laparoscopy., Conclusions: The use of the robot showed a trend toward better outcomes compared with laparoscopy, despite the presence of more advanced disease and higher body mass index. The meta-analysis resulted in an odd ratio of 0.8 favoring RG over LG on pancreatic morbidity, although without statistical significance.

Parenchymal sparing procedures are gaining interest in pancreatic surgery and recent studies have reported that minimally invasive pancreatic enucleation may be associated with enhanced outcomes when compared with traditional surgery. By meta-analyzing the available data from the literature, minimally invasive surgery is not at higher risk of pancreatic fistula and offers a number of advantages over conventional surgery for pancreatic enucleation., (© 2018 Wiley Periodicals, Inc.)

Aim: To investigate the rate of laparoscopic colectomies for colon cancer using registries and population-based studies. To provide a position paper on mini-invasive (MIS) colon cancer surgery based on the opinion of experts leader in this field., Methods: A systematic review of the literature was conducted using PRISMA guidelines for the rate of laparoscopy in colon cancer. Moreover, Delphi methodology was used to reach consensus among 35 international experts in four study rounds. Consensus was defined as an agreement ≥75.0%. Domains of interest included nosology, essential technical/oncological requirements, outcomes and MIS training., Results: Forty-four studies from 42 articles were reviewed. Although it is still sub-optimal, the rate of MIS for colon cancer increased over the years and it is currently >50% in Korea, Netherlands, UK and Australia. The remaining European countries are un-investigated and presented lower rates with highest variations, ranging 7-35%. Using Delphi methodology, a laparoscopic colectomy was defined as a "colon resection performed using key-hole surgery independently from the type of anastomosis". The panel defined also the oncological requirements recognized essential for the procedure and agreed that when performed by experienced surgeons, it should be marked as best practice in guidelines, given the principles of oncologic surgery be respected (R0 procedure, vessel ligation and mesocolon integrity)., Conclusion: The rate of MIS colectomies for cancer in Europe should be further investigated. A panel of leaders in this field defined laparoscopic colectomy as a best practice procedure when performed by an experienced surgeon respecting the standards of surgical oncology., (Copyright © 2018 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Background: Postoperative pancreas-related complications are quite uncommon but potentially life-threatening occurrences that may occasionally complicate the postoperative course of gastrectomy. A number of reports have described such conditions after both standard open and minimally invasive surgery. Our study has the purpose to systematically determine the pooled incidence of pancreatic events following radical gastrectomy. We also aimed to elucidate whether any difference in incidence exists between patients operated via conventional open or minimally invasive surgery., Methods: PubMed, EMBASE, and the Cochrane Library were systematically searched for randomized or well-matched studies comparing conventional with minimally invasive oncological gastrectomy and reporting pancreas-related postoperative complications. We evaluated possible differences in outcomes between open and minimally invasive surgery. A meta-analysis of relevant comparisons was performed using RevMan 5.3., Results: A total of 20 studies, whereby 6 randomized and 14 non-randomized comparative studies including a total of 7336 patients, were considered eligible for data extraction. Globally, more than 1% of patients experienced some pancreatic occurrences during the postoperative course. The use of minimally invasive surgery showed a trend toward increased overall pancreatic morbidity (OR 1.39), pancreatitis (OR 2.69), and pancreatic fistula (OR 1.13)., Conclusions: Although minimally invasive radical gastrectomy is currently established as a valid alternative to open surgery for the treatment of gastric cancer, a higher risk of pancreas-related morbidity should be taken into account.

Importance: Robotic rectal cancer surgery is gaining popularity, but limited data are available regarding safety and efficacy., Objective: To compare robotic-assisted vs conventional laparoscopic surgery for risk of conversion to open laparotomy among patients undergoing resection for rectal cancer., Design, Setting, and Participants: Randomized clinical trial comparing robotic-assisted vs conventional laparoscopic surgery among 471 patients with rectal adenocarcinoma suitable for curative resection conducted at 29 sites across 10 countries, including 40 surgeons. Recruitment of patients was from January 7, 2011, to September 30, 2014, follow-up was conducted at 30 days and 6 months, and final follow-up was on June 16, 2015., Interventions: Patients were randomized to robotic-assisted (n = 237) or conventional (n = 234) laparoscopic rectal cancer resection, performed by either high (upper rectum) or low (total rectum) anterior resection or abdominoperineal resection (rectum and perineum)., Main Outcomes and Measures: The primary outcome was conversion to open laparotomy. Secondary end points included intraoperative and postoperative complications, circumferential resection margin positivity (CRM+) and other pathological outcomes, quality of life (36-Item Short Form Survey and 20-item Multidimensional Fatigue Inventory), bladder and sexual dysfunction (International Prostate Symptom Score, International Index of Erectile Function, and Female Sexual Function Index), and oncological outcomes., Results: Among 471 randomized patients (mean [SD] age, 64.9 [11.0] years; 320 [67.9%] men), 466 (98.9%) completed the study. The overall rate of conversion to open laparotomy was 10.1%: 19 of 236 patients (8.1%) in the robotic-assisted laparoscopic group and 28 of 230 patients (12.2%) in the conventional laparoscopic group (unadjusted risk difference = 4.1% [95% CI, -1.4% to 9.6%]; adjusted odds ratio = 0.61 [95% CI, 0.31 to 1.21]; P = .16). The overall CRM+ rate was 5.7%; CRM+ occurred in 14 (6.3%) of 224 patients in the conventional laparoscopic group and 12 (5.1%) of 235 patients in the robotic-assisted laparoscopic group (unadjusted risk difference = 1.1% [95% CI, -3.1% to 5.4%]; adjusted odds ratio = 0.78 [95% CI, 0.35 to 1.76]; P = .56). Of the other 8 reported prespecified secondary end points, including intraoperative complications, postoperative complications, plane of surgery, 30-day mortality, bladder dysfunction, and sexual dysfunction, none showed a statistically significant difference between groups., Conclusions and Relevance: Among patients with rectal adenocarcinoma suitable for curative resection, robotic-assisted laparoscopic surgery, as compared with conventional laparoscopic surgery, did not significantly reduce the risk of conversion to open laparotomy. These findings suggest that robotic-assisted laparoscopic surgery, when performed by surgeons with varying experience with robotic surgery, does not confer an advantage in rectal cancer resection., Trial Registration: isrctn.org Identifier: ISRCTN80500123.

Aim: To compare the short- and long-term outcomes of laparoscopic and robotic surgery for middle and low rectal cancer., Methods: This is a retrospective study on a prospectively collected database containing 111 patients who underwent minimally invasive rectal resection with total mesorectal excision (TME) with curative intent between January 2008 and December 2014 (robot, n = 53; laparoscopy, n = 58). The patients all had a diagnosis of middle and low rectal adenocarcinoma with stage I-III disease. The median follow-up period was 37.4 mo. Perioperative results, morbidity a pathological data were evaluated and compared. The 3-year overall survival and disease-free survival rates were calculated and compared., Results: Patients were comparable in terms of preoperative and demographic parameters. The median surgery time was 192 min for laparoscopic TME (L-TME) and 342 min for robotic TME (R-TME) (P < 0.001). There were no differences found in the rates of conversion to open surgery and morbidity. The patients who underwent laparoscopic surgery stayed in the hospital two days longer than the robotic group patients (8 d for L-TME and 6 d for R-TME, P < 0.001). The pathologic evaluation showed a higher number of harvested lymph nodes in the robotic group (18 for R-TME, 11 for L-TME, P < 0.001) and a shorter distal resection margin for laparoscopic patients (1.5 cm for L-TME, 2.5 cm for R-TME, P < 0.001). The three-year overall survival and disease-free survival rates were similar between groups., Conclusion: Both L-TME and R-TME achieved acceptable clinical and oncologic outcomes. The robotic technique showed some advantages in rectal surgery that should be validated by further studies.

Minimally invasive surgery has gained worldwide acceptance in the treatment of colonic cancer in the last decades, thanks to its well-known advantages in short-term outcomes. Nevertheless, the penetrance of minimally invasive colorectal surgery still remains low. Few studies and metanalysis, to date, have analyzed the results of robotic versus laparoscopic colorectal surgery, often with conflicting conclusions. The robotic platform, thanks to its technological features, may potentially overcome the limitation of standard laparoscopy, especially when performing a complete mesocolic excision resection and an intracorporeal anastomosis. Robotic surgery could also shorten the learning curve of young novice surgeons, provided that strict protocols of structured training are applied. This paper is an update on the current available outcomes of robotic vs laparoscopic surgery in right colectomy.

Background: The treatment of colon cancer located in splenic flexure is not standardized. Laparoscopic approach is still considered a challenging procedure. This study reviews two Institutions experience in laparoscopic treatment of left colonic flexure cancer. Intraoperative, pathologic and postoperative data from patients undergoing laparoscopic splenic flexure resection were analyzed to assess oncological safety as well as early and medium-term outcomes., Methods: From October 2005 to May 2014 laparoscopic splenic flexure resection was performed in 23 patients., Results: Conversion rate was nihil. In 7 cases the anastomosis was performed intracorporeally. Specimen mean length was 21.2 cm, while the distance of distal and proximal resection margin from tumor site was 6.5 and 11.5 respectively. The mean number of harvested lymph nodes was 20.8. Mean operative time was 190 min and mean estimated blood loss was equal to 55 ml. As regard major postoperative complications, one case of postoperative acute pancreatitis and one case of postoperative bleeding from the anastomotic suture line were reported., Conclusions: Although our experience is limited and appropriate indications must be set by future randomized studies, we believe that laparoscopic resection with intracorporeal anastomosis appears feasible and safe for patients affected by splenic flexure cancer.

Background/aims: Recently, pelvic anatomy has been taken into consideration and related to surgical outcome indicators after low anterior resection (LAR). Several pelvimetric parameters have been matched with conversion rate, postoperative complications and duration of surgery in laparoscopic series, and with the quality of specimen and pathologic outcomes in further open surgical series., Methodology: In 97 consecutive patients submitted to sphincter-saving LAR with total mesorectal excision (TME) five pelvic dimensions were measured by abdominal computed tomography scan: anteroposterior and transverse diameters in the pelvic inlet (IAP and ITRA), anteroposterior and transverse diameters in the pelvic outlet (OAP and OTRA), and the pelvic depth. The endpoint evaluated was anastomotic leakage (AL) rate., Results: There were 51 open, 12 laparoscopic and 34 robotic LARs. The sum of IAP OAP and OTRA (Pelvic Index) significantly predicted AL showing that starting from the cut-point of 290 mm down to a PI of 278 mm the odds-ratio of having an AL increased from 2.63 (95% CI: 1.10,5.47) to 5.07 (95% CI: 1.35,8.02)., Conclusions: The sum of the 3 pelvic dimensions which we termed “Pelvic Index” was associated to AL following sphinctersaving LAR. This may be considered in planning the surgical strategy for rectal cancer patients.

Introduction: Diagnostic laparoscopy in pancreatic tumors remains controversial. The main argument in favor of this procedure is that it helps prevent a delay of chemotherapy in cases of unresectable tumors or peritoneal/lymph node metastasis. We report a technique of performing this exploration through single-incision laparoscopy. VIDEO: The umbilicus is incised, and a purse-string suture is applied. An 11-mm nondisposable trocar is inserted for a 10-mm, 30° angled scope. Curved and reusable instruments (Karl Storz-Endoskope, Tuttlingen, Germany) are inserted transumbilically. Laparoscopic exploration of the cavity allows the visualization of suspected peritoneal or lymph node metastasis. Peritoneal lavage for cytology is performed. Biopsy is accomplished through the curved shape of the instruments, which establishes the working triangulation inside the abdomen as well as externally. Laparoscopic ultrasonography of the liver and of the pancreas (after opening the lesser sac) is performed after replacement of the 11-mm trocar with a 13-mm trocar and the use of a 5-mm scope. The procedure can be continued either by laparoscopy or by open surgery. At completion, the umbilicus is meticulously closed to avoid complications., Results: Operative time is 45-60 minutes, blood loss is minimal, and the size of the umbilical incision is less than 15 mm., Conclusions: In case of unresectable tumors or peritoneal metastasis, single-access diagnostic laparoscopy for pancreatic tumors permits the start of chemotherapy after less than 7 days. Curved and reusable instruments allow the achievement of ergonomic conditions as classic laparoscopy, without increasing of conventional laparoscopic cost.

Background: Angiogenesis is crucial for tissue repair and cancer progression. We investigated a panel of angiogenic cells, macroparticles and RNA transcripts before, during and after laparoscopic colectomy or open colectomy for colorectal cancer., Results: Viable and apoptotic circulating endothelial cells were significantly increased after open but not after laparoscopic colectomy (p < 0.01). A significant decrease of circulating mRNA coding for VEGFR-C and D and PDGFR-β was found after laparoscopic but not after open colectomy., Methods: A total of 24 patients were enrolled. Viable and apoptotic circulating endothelial cells, progenitors and macroparticles were evaluated by flow cytometry. The number of copies of angiogenesis-related RNA transcripts we reevaluated by quantitative PCR., Conclusion: Open, but not laparoscopic colectomy, was associated with a significant post-operative increase in circulating endothelial cells, either apoptotic (likely due to surgery-related vascular damage) and viable (likely representing vascular remodeling). Circulating RNA copies coding for some angiogenic genes were significantly decreased after laparoscopic colectomy likely because of the removal of the tumor lesion. This decrease was not observed after open colectomy,were a more pronounced wave of angiogenesis related to wound healing was expected. These results indicate a relevant wave of angiogenesis-related cells and transcripts after open but not after laparoscopic colectomy.

Background: Gastrointestinal stromal tumors are rare neoplasms involving the entire digestive system, in particular the stomach. Generally, laparoscopic wedge resection is the preferred means of treating anterior lesions, while the preferred means of treating tumors in the posterior wall and near the esophagogastric junction remains controversial., Case Report: We report the case of a patient with a gastric stromal tumor in the posterior wall of the greater curvature approximately 3 cm from the esophagogastric junction. Under intraoperative ultrasonic guidance, a large wedge resection was done using an ultrasonic scalpel; the gastric wall was reconstructed through a long intracorporeal suture. At 6-month follow-up, the patient was free from tumor recurrence., Conclusions: If a meticulous surgical technique is followed, laparoscopic wedge resection is a safe and feasible means of treating gastric stromal tumors in the posterior wall near the esophagogastric junction.

Purpose: The role of laparoscopic resection in the management of rectal cancer is still controversial. We prospectively evaluated patient survival and outcomes in patients undergoing laparoscopic rectal resection for rectal cancer at a single institution., Methods: From November 1999 to November 2005, 107 patients with rectal cancer were treated by laparoscopy. Exclusion criteria were: metastatic disease, advanced disease with invasion of adjacent structures, clinical or radiologic involvement of the external anal sphincter, previous colonic resection, synchronous colonic adenocarcinoma, and contraindications to laparoscopy. All patients were followed prospectively for survival and complications. Survival was calculated by the Kaplan-Meier method., Results: A laparoscopic sphincter-saving procedure was performed in 104 patients, 2 patients had a laparoscopic Miles operation, and 1 underwent a laparoscopic Hartmann's procedure. Mean operating time was 278 (range, 135-430) minutes. Conversion to open surgery was required in 20 of 107 patients (18.7 percent). Overall morbidity was 27 percent, anastomotic leakage occurred in 14 of 104 patients (13.5 percent). There was no postoperative mortality. A mean of 18 (range, 1-49) lymph nodes was removed. Mean distance of distal margin from tumor was 2.6 (range, 0.5-10) cm; in two patients there was microscopic invasion of the distal margin. Mean hospital stay was nine (range, 4-43) days. Mean follow-up was 35.8 months. There was local recurrence in 1 of 107 patients (0.95 percent); there were no port site metastases. Actuarial five-year and disease-free survival rates are 81.4 and 79.8 percent, respectively., Conclusions: Laparoscopic rectal surgery is feasible and oncologically radical but also technically demanding (conversion rate, 18.7 percent), time-consuming (mean operating time, 278 minutes), and associated with specific intraoperative complications. At present, the technique should only be performed in specialist centers by teams experienced in laparoscopic surgery.

Background: The utility of lymph node mapping to improve staging in colon cancer is under evaluation. Laparoscopic colectomy for colon cancer has been validated in multicentric trials. This study assessed the feasibility of lymph node mapping in laparoscopic colectomy for colon cancer., Methods: From March 2004 to December 2005, 22 patients were studied. Before resection, 2 to 3 ml of Patent Blue V dye was injected subserosally around the tumor. Colored lymph nodes were marked as sentinel nodes (SNs) with metal clips, and laparoscopic colectomy with lymphadenectomy was completed as normal. In SNs, multiple 4-microm slices at 50-microm intervals were stained with hematoxylin and eosin and examined. Anticytokeratin antibody immunostaining was applied in doubtful cases. Other lymph nodes were examined with multiple slices at 100- to 500-microm intervals by standard methods., Results: The SN detection rate was 100%, although ex vivo lymph node mapping was necessary for an obese patient. Five patients (22.7%) were SN positive. There was one false-negative SN (16.7%). In two cases (9.1%) with aberrant lymphatic drainage, lymphadenectomy was extended. The SN reflected the status of the regional lymph nodes in 21 patients (95.4%). Accuracy was 95.4%, and negative predictive value was 94.1%., Conclusions: Laparoscopic lymphatic mapping and SN removal is feasible in laparoscopic colectomy for colon cancer. Although the false-negative rate was high (16.7%), the overall results are promising and justify prospective studies to determine the real accuracy and false-negative rate for the technique.

Over the past decade advances in laparoscopic surgery have revolutionized the surgical approach to many diseases. Although the first case series on laparoscopic segmental colectomy in patient with sigmoid cancer was described in 1991, this technique has not been readily accepted. Despite reduced morbidity and improved convalescence after laparoscopic surgery for benign disorders, surgeons have been sceptical about similar advantages of laparoscopic colectomy for cancer. The safety of the procedure has been questioned because of early reports of port-site metastases and there has been uncertainty about whether minimally invasive surgery for colonic malignancies would achieve adequate oncologic resection. Open surgical resection of the primary tumor, until just recently, has been widely considered the most effective treatment of colon cancer. The adherence to the principles of complete abdominal exploration, high ligation of mesenteric vessels, lymphnodal clearance and adequate bowel resection margins is essential. Several randomized trials were initiated in the early 1990s to compare the short- and long-term outcomes of patients undergoing minimally invasive and conventional open surgery for colon cancer. Today the results of this large multiinstitutional randomized trials have been reported. This review examines recent data from randomized, controlled trials and meta-analysis, that report the short- and long-term outcomes after laparoscopic colectomy for cancer.

The need for an accurate intrahepatic staging is crucial for patients with hepatocellular carcinoma candidates to an aggressive surgical or ablative treatment. Currently available data indicate that laparoscopy with laparoscopic ultrasound provides information similar to that obtained by intraoperative ultrasound and it is able to identify small intrahepatic lesions not diagnosed by preoperative imaging techniques. Furthermore, laparoscopy with laparoscopic ultrasound also allows performance of ultrasound-guided biopsies or interstitial therapies as ethanol injection, cryoablation or radiofrequency thermal ablation in the same session. A laparoscopic segmentectomy or subsegmentectomy is technically feasible and safe in selected patients with small peripheral tumors. Combinations of resection and ablation may be required in certain cases, extending the indications for the laparoscopic approach to hepatocellular carcinoma in liver cirrhosis. The AA review the technical issues and the preliminary results of their experience in the field of minimally invasive approach to hepatocellular carcinoma. On the basis of these preliminary findings, laparoscopy with laparoscopic ultrasound seems to be useful to identify unsuspected new nodules and to help in choosing the most suitable treatment. In case of hepatocellular carcinoma not amenable to surgical resection, laparoscopic radiofrequency represents a safe and effective treatment above all when the percutaneous approach is difficult or impossible. Furthermore, laparoscopy with laparoscopic ultrasound could represent a sound preliminary examination in patients who are candidates to liver transplantation in order both to improve the staging and to guide an interstitial therapy as a bridge to the transplantation itself.

Background: CME is a radical resection for colon cancer, but the procedure is technically demanding with significant variation in its practice. A standardised approach to the optimal technique and training is, therefore, desirable to minimise technical hazards and facilitate safe dissemination. The aim is to develop an expert consensus on the optimal technique for Complete Mesocolic Excision (CME) for right-sided and transverse colon cancer to guide safe implementation and training pathways.Methods: Guidance was developed following a modified Delphi process to draw consensus from 55 international experts in CME and surgical education representing 18 countries. Domain topics were formulated and subdivided into questions pertinent to different aspects of CME practice. A three-round Delphi voting on 25 statements based on the specific questions and 70% agreement was considered as consensus.Results: Twenty-three recommendations for CME procedure were agreed on, describing the technique and optimal training pathway. CME is recommended as the standard of care resection for locally advanced colon cancer. The essential components are central vascular ligation, exposure of the superior mesenteric vein and excision of an intact mesocolon. Key anatomical landmarks to perform a safe CME dissection include identification of the ileocolic pedicle, superior mesenteric vein and root of the mesocolon. A proficiency-based multimodal training curriculum for CME was proposed including a formal proctorship programme.Conclusions: Consensus on standardisation of technique and training framework for complete mesocolic excision was agreed upon by a panel of experts to guide current practice and provide a quality control framework for future studies. [ABSTRACT FROM AUTHOR]

The colorectal session was one of the most successful and well attended sessions at the Fifth Worldwide Clinical Robotic Surgery Association Congress because of the increasing interest and diffusion of robotic techniques in this specific field. This session was structured as follows: two technical focuses, one on rectal resection and the other on right colectomies; a journal club with two hot topic papers presented by the authors; a face-to-face on single-port laparoscopic versus robotic surgery; an update on the transanal approach; and three lectures, on the oncologic safety of robotic total mesorectal excision, on the use of fluorescence in colorectal surgery, and finally an update on the ongoing ROLARR trial (laparoscopic versus robotic rectal resection). [ABSTRACT FROM AUTHOR]

Purpose: In recent years, colorectal cancer surgery has benefitted from new techniques such as laparoscopy and robotic surgery. However, many treatment disparities exist among different centers for patients affected by the same kind of tumors. Methods: Forty-five (41%) open (OCO) vs. 30 (28%) laparoscopic (LCO) vs. 34 (31%) robotic-assisted (RCO) colectomies and 34 (40%) open (ORR) vs. 52 (60%) robotic (ROR) rectal resections performed during a 15-month period, in elective setting, were compared. Patients presenting contraindications for minimally invasive procedures were excluded from the study, so that all the enrolled patients were suitable for either of the surgical procedures. Results: Overall morbidity rates were similar among groups. Perioperative mortality was nil. No significant differences were noted as for total number of lymph nodes harvested between arms. Mean time (days) to first bowel movement to gas was 3.3 vs. 2.3 vs. 2.6 for OCO, LCO, and RCO, respectively ( p < 0.001), and 3.3 vs. 2.0 for ORR and ROR, respectively ( p = 0.003). Among several European Organization in Research and Treatment of Cancer QLQ-C30 functional scales considered only physical functioning was significantly better at 30 days for RCO vs. OCO (96.3 ± 10 RCO vs. 85.5 ± 12.6 OCO; p = 0.015). Robotic surgery was much more expensive in comparison to open as well as laparoscopic procedures. Conclusions: Laparoscopic and robotic surgeries for colorectal cancer present both the same advantages in comparison to open procedures in terms of faster recovery. However, our data do not seem to support the routine use of RCO as a cost-effective procedure. [ABSTRACT FROM AUTHOR]

Hepatic resection is still considered the treatment of choice for hepatocellular carcinoma in patients with liver cirrhosis. Radiofrequency ablation is a new emerging modality. The aim of this study was to compare two homogeneous groups of patients who underwent either surgical resection or laparoscopic radiofrequency, analyzing the factors predicting survival and intrahepatic recurrences with use of a multivariate analysis. From February 1997 to April 2003, 98 patients were enrolled in this prospective study. Inclusion criteria were a single nodule of less than 5 cm, Child A-B class of liver function, and no previous treatment: 40 patients were in the surgical group and 58 patients were in the radiofrequency group. The two groups were homogeneous as far as preoperative characteristics were concerned. Operative mortality was zero, and the rates of operative morbidity were similar. Actuarial survival at 4 years was not significantly different (61% after resection and 45% after radiofrequency). There was a significant higher incidence of intrahepatic recurrences after radiofrequency than after resection (53% versus 30%; P=0.018). This was mainly due to local recurrences, whereas those appearing in other liver segments were similar in both groups. A multivariate analysis showed that the significant factors predictive of an intrahepatic recurrence were the level of α-fetoprotein, the etiology of cirrhosis, and the type of the treatment. On the other hand, multivariate analysis of the survival showed that only the level of α-fetoprotein was an independent predictor of survival. The results of our study showed a significant lower incidence of intrahepatic recurrences after resection compared with after radiofrequency. This seems not to significantly influence the overall survival, probably because of a prompt and effective treatment of the recurrences themselves. [Copyright &y& Elsevier]