Search

Importance: Laparoscopic and robotic techniques have both been well adopted as safe options in selected patients undergoing hepatectomy. However, it is unknown whether either approach is superior, especially for major hepatectomy such as right hepatectomy or extended right hepatectomy (RH/ERH)., Objective: To compare the outcomes of robotic vs laparoscopic RH/ERH., Design, Setting, and Participants: In this case-control study, propensity score matching analysis was performed to minimize selection bias. Patients undergoing robotic or laparoscopic RH/EHR at 29 international centers from 2008 to 2020 were included., Interventions: Robotic vs laparoscopic RH/ERH., Main Outcomes and Measures: Data on patient demographics, tumor characteristics, and short-term perioperative outcomes were collected and analyzed., Results: Of 989 individuals who met study criteria, 220 underwent robotic and 769 underwent laparoscopic surgery. The median (IQR) age in the robotic RH/ERH group was 61.00 (51.86-69.00) years and in the laparoscopic RH/ERH group was 62.00 (52.03-70.00) years. Propensity score matching resulted in 220 matched pairs for further analysis. Patients' demographics and tumor characteristics were comparable in the matched cohorts. Robotic RH/ERH was associated with a lower open conversion rate (19 of 220 [8.6%] vs 39 of 220 [17.1%]; P = .01) and a shorter postoperative hospital stay (median [IQR], 7.0 [5.0-10.0] days; mean [SD], 9.11 [7.52] days vs median [IQR], 7.0 [5.75-10.0] days; mean [SD], 9.94 [8.99] days; P = .048). On subset analysis of cases performed between 2015 and 2020 after a center's learning curve (50 cases), robotic RH/ERH was associated with a shorter postoperative hospital stay (median [IQR], 6.0 [5.0-9.0] days vs 7.0 [6.0-9.75] days; P = .04) with a similar conversion rate (12 of 220 [7.6%] vs 17 of 220 [10.8%]; P = .46)., Conclusion and Relevance: Robotic RH/ERH was associated with a lower open conversion rate and shorter postoperative hospital stay compared with laparoscopic RH/ERH. The difference in open conversion rate was associated with a significant decrease for laparoscopic but not robotic RH/ERH after a center had mounted the learning curve. Use of robotic platform may help to overcome the initial challenges of minimally invasive RH/ERH.

Background: Robotic surgery is a burgeoning minimally invasive approach to pancreaticoduodenectomy. This study was undertaken to compare survival after robotic vs "open" pancreaticoduodenectomy for ductal adenocarcinoma using propensity score-matched patients., Study Design: With institutional review board approval, we prospectively followed 521 patients who underwent robotic (n = 311) or open (n = 210) pancreaticoduodenectomy. Patients who underwent robotic (n = 75) or open (n = 75) pancreaticoduodenectomy were propensity score-matched by age, sex, and American Joint Committee on Cancer stage. Neoadjuvant therapy was rarely administered, and adjuvant therapy was stressed (FOLFIRINOX for patients <70 years of age and gemcitabine + nab-paclitaxel for patients >70 years of age). Data are presented as median (mean ± SD)., Results: Operative duration was longer and estimated blood loss and length of stay were less with robotic pancreaticoduodenectomy (421 [409 ± 94.0] vs 267 [254 ± 81.2] minutes; 307 [(150 ± 605.3] vs 444 [255 ± 353.1] mL; 7 [5 ± 5.1] vs 11 [8 ± 9.5] days; p < 0.00001 for all). There were no differences in complications (Clavien-Dindo class ≥III, p = 0.30), in-hospital mortality (p = 0.61), or 30-day readmission rates (p = 0.19). Median survival after robotic vs open pancreaticoduodenectomy was 37 vs 24 months (p = 0.08). For propensity score-matched patients, operative duration for robotic pancreaticoduodenectomy was longer (442 [438 ± 117.7] vs 261 [249 ± 67.1] minutes) and estimated blood loss was less (269 [200 ± 296.1] vs 468 [300 ± 394.9] mL), as was length of stay (7 [5 ± 5.1] vs 10 [7 ± 8.6] days; p < 0.00001 for all). There were no differences in complication rates (Clavien-Dindo class ≥ III, p = 0.31) or in-hospital mortality (p = 0.40); 30-day readmissions were fewer after robotic pancreaticoduodenectomy (7% vs 20%, p = 0.03). Median survival for the robotic vs the open approach was 41 vs 17 months (p = 0.02)., Conclusion: Patients that underwent robotic pancreaticoduodenectomy had longer operations, less estimated blood loss, shorter length of stay, and fewer 30-day readmissions; they lived much longer than patients who underwent open pancreaticoduodenectomy. We believe that robotic pancreaticoduodenectomy provides salutary and survival benefits for reasons yet unknown., (Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: This study was undertaken to analyze and compare the cost of robotic transhiatal esophagectomy (THE) to "non-robotic" THE (ie, "open" and laparoscopic)., Methods: With IRB approval, we prospectively followed 82 patients who underwent THE. We analyzed clinical outcomes and perioperative charges and costs associated with THE. To compare profitability, the robotic approach was analyzed against "non-robotic" approaches of THE using F-test, Mann-Whitney U test/Student's t-test, and Fisher's exact test. Statistical significance was reported as P ≤0.05. Data are presented as median (mean ± SD)., Results: 67 patients underwent the robotic approach, and 15 patients underwent "non-robotic" approach; 4 were "open" and 11 were laparoscopic. 79 patients had adenocarcinoma. Operative duration for robotic THE was 327 (331 ± 82.8) vs 213 (225 ± 62.0) minutes ( P = 0.0001) and estimated blood loss was 150 (184 ± 136.1) vs 300 (476 ± 708.7) mL ( P = 0.0001). Length of stay was 7 (11 ± 11.8) vs 8 (12 ± 10.6) days ( P = 0.76). 16 patients had post-operative complications with a Clavien-Dindo score of three or more. Hospital charges for robotic THE were $197,405 ($259,936 ± 203,630.8) vs "non-robotic" THE $159,588 ($201,565 ± $185,763.5) ( P = 0.31). Cost of care for robotic THE was $34,822 ($48,844 ± $45,832.8) vs "non-robotic" THE was $23,939 ($39,386 ± $44,827.2) ( P = 0.47). Payment received for robotic THE was $14,365 ($30,003 ± $40,874.7) vs "non-robotic" THE was $28,080 ($41,087 ± $44,509.1) ( P = 0.41). 15% of robotic operations were profitable vs 13% of "non-robotic" operations., Conclusions: Patients were predominantly older overweight men who had adenocarcinoma of the esophagus. The robotic approach had increased operative time and minimal blood loss. More than a fourth of operations included concomitant procedures. Patients were discharged approximately one week after THE. Overall, the robotic approach has no apparent significant differences in charges, cost, or profitability.

Gallbladder cancer (GBC) is an uncommon but very aggressive malignancy with poor prognosis. Concerns for oncological inferiority related to the technical difficulties in performing laparoscopic portal lymphadenectomy discourage many surgeons to undertake this operation minimally invasively. With wide application of robotic technology to solve limitations of conventional laparoscopy, we describe our initial outcomes of robotic central hepatectomy and portal lymphadenectomy for gallbladder carcinoma in 15 consecutive patients. Data were presented as median (mean ± SD). Patients were 70 (73 ± 10.9) years old with BMI of 26 (26 ± 3.6) kg/m 2 . Tumor size was 3(4 ± 1.9) cm. Operative duration was 222 (237 ± 85.7) minutes and estimated blood loss was 200 (222 ± 135.4) mL. There were no intraoperative complications and complete resection (R0) was obtained in nearly all patients. Postoperative complications were seen in two patients (bile leak (n = 1) and respiratory failure (n = 1)). Length of stay was 3 (4 ± 4.0) days without 30-day mortality. Robotic approach is safe and effective for the treatment of GBC.

Introduction: We undertook this study to describe the number and variety of robotic operations undertaken for hepatopancreatic and esophageal disorders., Methods: Data from 2015 through March of 2018 were analyzed for da Vinci™ robot application for hepatopancreatic disorders, gastroesophageal reflux disease (GERD), and achalasia., Results: From 2015 through 2017, robotic hepatopancreatic operations increased 49%, robotic hepatic operations increased 107%, and robotic pancreatic operations increased 26%. Quarter after quarter, robotic application increased for hepatopancreatic operations, hepatic operations, and pancreatic operations ( P < .001 for each) with acceleration over the most recent months. The application of the Xi robot platform increased from 12% of robotic hepatopancreatic operations in 2015-71% in 2018 (1075% increase in numbers). From 2015 through 2017, robotic fundoplications and myotomies increased by 55%, robotic fundoplications increased by 59%, and robotic Heller myotomies increased by 211%. Quarter after quarter, robotic application increased for fundoplications and Heller myotomies ( P < .001 for each) with acceleration over the most recent months. The application of the Xi robot platform increased from 13% of these robotic operations in 2015-64% in 2018 (935% increase in numbers). Less than 10% of hepatopancreatic operations, fundoplications, and myotomies are undertaken robotically., Conclusions: There has been an accelerating increase in the number of robotic operations for hepatopancreatic disorders, GERD, and achalasia over the past 3 ¼ years. Application of the Xi robot has dramatically increased, both absolutely and relatively. Still only a small proportion of operations for hepatopancreatic disorders, GERD, and achalasia use the robotic platform; this is changing fast.

Background and Objectives: The purpose of this study is to report our early experience and outcomes, the first in North America, of Extrahepatic Cholangiocarcinoma (EHC) resection with Roux-en Y Hepaticojejunostomy reconstruction via the robotic approach., Methods: With Institutional Review Board approval, 15 patients who underwent robotic resection of EHC were studied., Results: Patients were 74 (73 ± 8.9) years of age. There were 9 men and 6 women. Average body mass index was 24 (27 ± 6.3) kg·m -2 . Mean & Median ASA class was 3. Median Tumor size was 2 (2 ± 1.3) cm. There were no intraoperative complications. Operative duration was 453 (443 ± 85.0) minutes and the estimated blood loss was 150 (182 ± 138.4) ml. No patient required admission to the intensive care unit. Hospital length of stay was 4 (6 ± 3.2) days. There was one patient with Clavien-Dindo Class 3 or greater complication. No mortality was seen in this series., Discussion: Robotic resection of EHC is safe, feasible, and reproducible with excellent clinical outcomes. Consequently, the robotic technique should be considered in some patients requiring EHC resection., (© 2021 Wiley Periodicals LLC.)

Background: The dissemination of robotic liver surgery is slow-paced and must face the obstacle of demonstrating advantages over open and laparoscopic (LLS) approaches. Our objective was to show the current position of robotic liver surgery (RLS) worldwide and to identify if improved short-term outcomes are observed, including secondary meta-analyses for type of resection, etiology, and cost analysis., Methods: A PRISMA-based systematic review was performed to identify manuscripts comparing RLS vs open or LLS approaches. Quality analysis was performed using the Newcatle-Ottawa score. Statistical analysis was performed after heterogeneity test and fixed- or random-effect models were chosen accordingly., Results: After removing duplications, 2728 RLS cases were identified from the final set of 150 manuscripts. More than 75% of the cases have been performed on malignancies. Meta-analysis from the 38 comparative reports showed that RLS may offer improved short-term outcomes compared to open procedures in most of the variables screened. Compared to LLS, some advantages may be observed in favour of RLS for major resections in terms of operative time, hospital stay and rate of complications. Cost analyses showed an increased cost per procedure of around US$5000., Conclusions: The advantages of RLS still need to be demonstrated although early results are promising. Advantages vs open approach are demonstrated. Compared to laparoscopic surgery, minor perioperative advantages may be observed for major resections although cost analyses are still unfavorable to the robotic approach., (© 2020 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Studies regarding the influence of diabetes on perioperative outcomes after major hepatectomy are conflicting. The objective of this study is to analyze the effects of diabetes on patients undergoing robotic major hepatectomy. With Institutional Review Board (IRB) approval, 94 patients undergoing major hepatectomy were prospectively followed. Demographic data and postoperative outcomes were analyzed and compared between diabetic and non-diabetic patients. Data were presented as median (mean ± SD). Patients were of age 62 (61 ± 13.0) years, BMI of 29 (29 ± 5.9) kg/m 2 , and ASA class of 3 (3 ± 0.55). The mass size was 5 (5 ± 3.0) cm. Operative duration was 252 (277 ± 106.6) min with estimated blood loss (EBL) was 175 (249 ± 275.9) mL. One operation was converted to 'open' due to bleeding, accounting for one intraoperative complication. Postoperatively, nine patients required ICU admission, with a duration of 1 (4 ± 5.9) day. Seven patients had postoperative complications. Length of stay (LOS) was 4 (4 ± 2.6) days. Fourteen patients were readmitted within 30 days. There were no deaths in-hospital or within 30 days. Of the 94 patients, 22 were diabetic and 72 were nondiabetic. Diabetic patients were older (70 (69 ± 11.3) years versus 58 (58 ± 12.4) years (p = 0.004)). Intraoperatively, operative duration, EBL, and complications were not significantly different. Postoperatively, LOS, ICU admission, ICU duration, complications, in-hospital mortality, readmission in 30 days, and death after 30 days showed no significant difference between diabetics and nondiabetics. In our experience, diabetes has no significant effect on perioperative outcomes after a robotic major hepatectomy., (© 2021. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Background: Despite the widespread of laparoscopic technique in hepatobiliary tumor resection, nearly all Klatskin tumor resection is undertaken using an open approach (Marino et al. in Updates Surg 72(3):911-912. https://doi.org/10.1007/s13304-020-00777-8 ; Sucandy et al. in Am Surg, 2020. https://doi.org/10.1177/0003134820956336 , Am Surg, 2020;86(3):200-207; Luberice et al. in HPB (Oxford), 2020. https://doi.org/10.1016/j.hpb.2020.10.008 ; Ciria et al. in J Hepatobiliary Pancreat Sci, 2020. https://doi.org/10.1002/jhbp.869 ; Chong and Choi in J Gastrointest Surg 23(9):1947-19488, 2019. https://doi.org/10.1007/s11605-019-04242-9 ). A minimally invasive approach for malignant extrahepatic biliary resection is rarely used due to technical complexity and concerns of oncological inferiority. In the United States, robotic technique for Klatskin tumor resection has not been adequately described. This video described our technique of robotic extrahepatic biliary resection with Roux-en-Y hepaticojejunostomy (HJ) for type 2 Klatskin tumor., Methods: A 77-year-old man presented with obstructive jaundice. Endobiliary brushing confirmed adenocarcinoma. MRI/MRCP showed a focal lesion at the cystic duct entrance into the common hepatic duct, extending cephalad toward the biliary bifurcation. No obvious vascular invasion was identified on the CT scan., Results: The operation was undertaken using a six-port technique. Systematic portal dissection was undertaken to identify the bile duct at the level of the pancreas up toward the hepatic hilum. A partial Kocher maneuver was performed to expose the area dorsal to the distal common bile duct, which allows for a more thorough lymphadenectomy and facilitates creation of a later tension-free hepaticojejunostomy. The distal common bile duct was transected, and the distal margin was sent for frozen section. The right hepatic artery coursing posterior to the common hepatic duct was skeletonized and preserved. Biliary duct bifurcation was transected at the level of the right and left duct, removing the cancer completely. Portal lymphadenectomy was completed as part of oncological staging and treatment. A total of eight lymph nodes were removed and all confirmed to be nonneoplastic on the final pathology report. For the purpose of the biliary reconstruction, a standard side-to-side stapled jejunojejunostomy was created. A jejunal mesenteric defect was closed to prevent a future internal herniation. A 60-cm Roux limb was transposed antecolically for the Roux-en-Y hepaticojejunostomy. A running technique was used to create a watertight end-to-side bilioenteric anastomosis, using 3-0 barbed sutures, 6 inches in length. A closed suction drain was placed before closing. Pathology report confirmed intraductal papillary adenocarcinoma with R-0 resection margins (proximal, distal, and radial margin). Perineural invasion was present; however, lymphovascular invasion was not identified. Total operative time was 240 minutes with 75 ml of estimated blood loss. The postoperative recovery was uneventful. One-year follow-up showed no evidence of disease recurrence or HJ anastomotic stricture., Conclusions: This video demonstrates a safe and feasible application of the robotic platform in extrahepatic bile duct cancer resection requiring fine biliary reconstruction., (© 2021. Society of Surgical Oncology.)

Background: Minimally invasive right posterior sectionectomy (RPS) is a technically challenging procedure. This study was designed to determine outcomes following robotic RPS (R-RPS) and laparoscopic RPS (L-RPS)., Methods: An international multicentre retrospective analysis of patients undergoing R-RPS versus those who had purely L-RPS at 21 centres from 2010 to 2019 was performed. Patient demographics, perioperative parameters, and postoperative outcomes were analysed retrospectively from a central database. Propensity score matching (PSM) was performed, with analysis of 1 : 2 and 1 : 1 matched cohorts., Results: Three-hundred and forty patients, including 96 who underwent R-RPS and 244 who had L-RPS, met the study criteria and were included. The median operating time was 295 minutes and there were 25 (7.4 per cent) open conversions. Ninety-seven (28.5 per cent) patients had cirrhosis and 56 (16.5 per cent) patients required blood transfusion. Overall postoperative morbidity rate was 22.1 per cent and major morbidity rate was 6.8 per cent. The median postoperative stay was 6 days. After 1 : 1 matching of 88 R-RPS and L-RPS patients, median (i.q.r.) blood loss (200 (100-400) versus 450 (200-900) ml, respectively; P < 0.001), major blood loss (> 500 ml; P = 0.001), need for intraoperative blood transfusion (10.2 versus 23.9 per cent, respectively; P = 0.014), and open conversion rate (2.3 versus 11.4 per cent, respectively; P = 0.016) were lower in the R-RPS group. Similar results were found in the 1 : 2 matched groups (66 R-RPS versus 132 L-RPS patients)., Conclusion: R-RPS and L-RPS can be performed in expert centres with good outcomes in well selected patients. R-RPS was associated with reduced blood loss and lower open conversion rates than L-RPS., (© The Author(s) 2021. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: The application and feasibility of minimally invasive liver resection (MILR) for huge liver tumours (≥10 cm) has not been well documented., Methods: Retrospective analysis of data on 6,617 patients who had MILR for liver tumours were gathered from 21 international centers between 2009-2019. Huge tumors and large tumors were defined as tumors with a size ≥10.0 cm and 3.0-9.9 cm based on histology, respectively. 1:1 coarsened exact-matching (CEM) and 1:2 Mahalanobis distance-matching (MDM) was performed according to clinically-selected variables. Regression discontinuity analyses were performed as an additional line of sensitivity analysis to estimate local treatment effects at the 10-cm tumor size cutoff., Results: Of 2,890 patients with tumours ≥3 cm, there were 205 huge tumors. After 1:1 CEM, 174 huge tumors were matched to 174 large tumors; and after 1:2 MDM, 190 huge tumours were matched to 380 large tumours. There was significantly and consistently increased intraoperative blood loss, frequency in the application of Pringle maneuver, major morbidity and postoperative stay in the huge tumour group compared to the large tumour group after both 1:1 CEM and 1:2 MDM. These findings were reinforced in RD analyses. Intraoperative blood transfusion rate and open conversion rate were significantly higher in the huge tumor group after only 1:2 MDM but not 1:1 CEM., Conclusions: MILR for huge tumours can be safely performed in expert centers It is an operation with substantial complexity and high technical requirement, with worse perioperative outcomes compared to MILR for large tumors, therefore judicious patient selection is pivotal., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://dx.doi.org/10.21037/hbsn-21-327). Dr. MMV is a consultant for CAVA robotics LLC. Dr. PJ reports a research grant from Intuitive Surgical Deutschland GmbH and personal fees or non-financial support from Johnson & Johnson, Medtronic, AFS Medical, Astellas, CHG Meridian, Chiesi, Falk Foundation, La Fource Group, Merck, Neovii, NOGGO, pharma-consult Peterson, and Promedicis. MS reports personal fees or other support outside of the submitted work from Merck, Bayer, ERBE, Amgen, Johnson & Johnson, Takeda, Olympus, Medtronic, Intuitive. Dr. BKPG has received travel grants and honorarium from Johnson and Johnson and Transmedic the local distributor for the Da Vinci Robot. Dr. JP and Dr. HSH serve as the unpaid editorial board members of Hepatobiliary Surgery and Nutrition. The other authors have no conflicts of interest to declare., (2021 Hepatobiliary Surgery and Nutrition. All rights reserved.)

Perihilar cholangiocarcinoma (Klatskin tumor) is one of the most challenging hepatobiliary cancers to treat due to its critical location and tendency to involve nearby vascular structures in the portal hepatic. A combined biliary and major liver resection is often required to achieve a complete oncological resection. Traditionally, Klatskin tumor resection is performed using an "open" approach until recently when the minimally invasive technique becomes popular due to its proven advantages. The laparoscopic technique had been reported; however, the majority of resections were types I and II without the need for ipsilateral hepatectomy. Inherent limitations of straight laparoscopic instruments result in significant technical difficulties in performing precise tissue dissection and vessel repair and creating a fine bilioenteric anastomosis. In this didactical video, we described our technique of type IIIB Klatskin tumor (B3-L perihilar cholangiocarcinoma) resection utilizing a robotic technology. The use of a robotic platform facilitates precise porta hepatic dissection, bleeding control, and creation of a fine bilioenteric anastomosis at the level of the hilar plate. We believe that the robotic platform provides an alternative method for resection of perihilar cholangiocarcinoma with excellent short-term outcomes., (© 2021. The Society for Surgery of the Alimentary Tract.)

Background: The objective of this study is to apply this criteria to determine its applicability to robotic hepatectomy., Methods: We prospectively followed 105 patients undergoing robotic hepatectomy. Operations were categorized into Low (0-3), Intermediate (4-6), Advanced (7-9), and Expert (10-12)., Results: Patients had a median age of 62 (61 ± 13.1) years, with a BMI of 28 (29 ± 6.1) kg/m 2 ; 38% were women. ASA class was 3 (3 ± 0.6). Of the 105 operations, 2 were categorized as Low, 31 as Intermediate, 49 as Advanced, and 23 as Expert. EBL and operative duration were found to be significantly greater as the operative difficulty level increased (p < 0.03 and p < 0.01, respectively). Intraoperatively, when comparing Expert and Intermediate, EBL and operative duration were significantly greater (p = 0.0001 and p = 0.0031, respectively). In the comparison of Expert with Advanced, operative duration was significantly longer (p = 0.0001). Postoperatively, comparisons between Expert and Intermediate, Expert and Advanced, and Advanced and Intermediate showed no differences., Conclusion: EBL and operative duration increased with IWATE scores reflecting more difficult robotic hepatectomies. However, with the robotic approach, our postoperative outcomes were similar irrespective of IWATE difficulty scores. Perhaps, the robotic approach potentially has a mitigating effect on postoperative outcomes regardless of difficulty level., (Copyright © 2020 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: This study was undertaken to analyze our outcomes after robotic fundoplication for GERD in patients with failed antireflux procedures, with type IV (i.e., giant) hiatal hernias, or after extensive intra-abdominal surgery with mesh, and to compare our results to outcomes predicted by the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Surgical Risk Calculator and to national outcomes reported by NSQIP., Methods: 100 patients undergoing robotic fundoplication for the aforementioned factors were prospectively followed., Results: 100 patients, aged 67 (67 ± 10.3) years with body mass index (BMI) of 26 (25 ± 2.9) kg/m 2 underwent robotic fundoplication for failed antireflux fundoplications (43%), type IV hiatal hernias (31%), or after extensive intra-abdominal surgery with mesh (26%). Operative duration was 184 (196 ± 74.3) min with an estimated blood loss of 24 (51 ± 82.9) mL. Length of stay was 1 (2 ± 3.6) day. Two patients developed postoperative ileus. Two patients were readmitted within 30 days for nausea.Nationally reported outcomes and those predicted by NSQIP were similar. When comparing our actual outcomes to predicted and national NSQIP outcomes, actual outcomes were superior for serious complications, any complications, pneumonia, surgical site infection, deep vein thrombosis, readmission, return to OR, and sepsis ( P  < 0.05); our actual outcomes were not worse for renal failure, deaths, cardiac complications, and discharge to a nursing facility., Conclusions: Our patients were not a selective group; rather they were more complex than reported in NSQIP. Most of our results after robotic fundoplication were superior to predicted and national outcomes. The utilization of the robotic platform for complex operations and fundoplications to treat patients with GERD is safe and efficacious., Competing Interests: Conflicts of Interest: Alexander Rosemurgy and Sharona Ross have educational and research relationships with Intuitive Surgical Inc. (Intuitive Corporation, Sunnyvale, CA). Kenneth Luberice, Kaitlyn Crespo, Christina De La Cruz, John-Kevin Dolce, and Iswanto Sucandy have no disclosures/conflicts of interest., (© 2021 by SLS, Society of Laparoscopic & Robotic Surgeons.)

Background: The robotic approach to pancreaticoduodenectomy is thought by many to be associated with increased financial burden for hospitals. We undertook this study to analyze and compare the cost of "open" pancreaticoduodenectomy with that associated with the application of the robotic surgical system to pancreaticoduodenectomy in our hepatobiliary program., Study Design: With IRB approval, all patients undergoing pancreaticoduodenectomy at our institution, from August 2012 to November 2019, were prospectively followed. Cost, including total, variable, fixed-direct, fixed-indirect, and profitability for robotic and "open" pancreaticoduodenectomy were analyzed and compared. Data are presented as median (mean ± SD)., Results: There were 386 patients who underwent pancreaticoduodenectomy; 205 patients underwent robotic pancreaticoduodenectomy and 181 underwent "open" pancreaticoduodenectomy. Costs are presented as mean ± SD. Overall, the cost of care for robotic pancreaticoduodenectomy was $31,389 ($36,611 ± $20,545.40) vs $23,132 ($31,323 ± $28,885.50) for "open" pancreaticoduodenectomy (p = 0.04); total variable cost was $20,355 ($22,747 ± $11,127.60) vs $11,680 ($16,032 ± $14,817.20) (p = 0.01), total fixed direct cost was $1,999 ($2,330 ± $1,363.10) vs $2,073 ($2,983 ± $3,209.00) (p = 0.01), and total indirect cost was $7,217 ($9,354 ± $6,802.40) vs $6,802 ($9,505 ± $9,307.20) (p = 0.86), for robotic vs "open" pancreaticoduodenectomy, respectively. Since 2016, profitability was achieved in 29% of patients undergoing robotic pancreaticoduodenectomy., Conclusions: Robotic pancreaticoduodenectomy had lower estimated blood loss and shorter length of stay. Cost of care for robotic pancreaticoduodenectomy was greater across all categories, except for total indirect cost, than "open" pancreaticoduodenectomy. For our institution, profitability was accomplished in less than one-third of patients undergoing robotic pancreaticoduodenectomy. The role of the robotic platform for pancreaticoduodenectomy needs to be discussed among all stakeholders., (Copyright © 2021. Published by Elsevier Inc.)

Background: Relative to conventional laparoscopy, Laparo-Endoscopic Single Site (LESS) surgery has been associated with improved cosmesis. This study investigated preoperative and postoperative patient perceptions of LESS surgery and what factors may affect those perceptions., Methods: Patients undergoing LESS Surgery were queried before and after their operations. Body image and other factors were assessed preoperatively and postoperatively in 881unselected patients undergoing LESS surgery utilizing Likert scale questionnaires. Responses were collated and analyzed. Data are reported as median (mean ± SD), where appropriate., Results: 881 patients studied had a median age of 59 (57 ± 15.3) years and had a median Body Mass Index of 27 (28 ± 6.2) kg/m 2 . 65% were women. 343 (39%) had undergone a previous abdominal operation(s). Prior to LESS surgery, patients reported neutral body image scores and rated their overall appearance satisfaction as 40% (37% ± 30.7) on a Visual Analog Scale (VAS). 68% were unwilling to undergo LESS surgery if it involved more risk relative to traditional laparoscopy as safety was their number one concern. Postoperatively, patients reported a significant improvement in body image perception and safety was no longer their foremost concern., Conclusion: Preoperatively, patients are most concerned with safety (e.g. risk) with secondary concerns of cost and pain but they were less concerned with their appearance. Postoperatively, safety is much, much less of an issue (because it has been achieved) and appearance is more paramount with significant improvements in their self-assessed appearance. With LESS surgery patients indicate a high level of satisfaction with cosmesis., Competing Interests: Declaration of competing interest Authors Alexander Rosemurgy and Sharona Ross have educational and research relationships with Medtronic (Medtronic plc, Minneapolis, Minnesota) and Intuitive Surgical Inc. (Intuitive Corporation, Sunnyvale, CA). Kenneth Luberice, Kaitlyn Crespo, Timothy Bourdeau BS, Vladamir Fausin, and Iswanto Sucandy have no disclosures/conflicts of interest., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: This study was undertaken to determine if age influences postoperative outcomes for patients undergoing robotic major hepatectomy., Methods: Ninety-four patients undergoing robotic major hepatectomy were prospectively followed. With regression analysis, demographic data and postoperative outcomes were compared to age. Data are presented as median (mean ± SD)., Results: Overall, the patients were of age 62 (61 ± 13) years, body mass index (BMI) of 29 (29 ± 5.9) kg/m 2 , and American Society of Anesthesiologists (ASA) class of 3 (3 ± 0.5). The mass size was 5 (5 ± 3.0) cm. The operative duration was 252 (276 ± 106) minutes with an estimated blood loss (EBL) of 175 (249 ± 275.9) mL. One operation was converted to "open" due to bleeding, accounting for the only intraoperative complication. Nine patients required intensive care unit (ICU) admission. Postoperatively, 7 patients had complications with no in-hospital mortalities, and a length of stay (LOS) of 4 (5 ± 2.6) days. Thirteen patients were readmitted within 30 days with 0 deaths within 30 days.A significant relationship was found between age and ASA class ( P = .001) and LOS ( P = .03). No correlation was found when comparing age to operative duration, EBL, ICU admission, ICU duration, complications, and readmission within 30 days., Conclusion: For patients undergoing robotic major hepatectomy, there was no significant correlation between age and perioperative outcomes, with the exception of LOS. Increasing age is not associated with increased morbidity or perioperative mortality. With the application of innovative technology, that is, the robotic approach, surgeons should be encouraged to undertake major hepatectomy in elderly patients deemed candidates for surgery.

Introduction: Most of the literature has only reported outcomes on robotic minor non-anatomical hepatectomy. This study was undertaken to analyze and examine the safety, feasibly, and perioperative outcomes of robotic major hepatectomy at our institution., Methods: All patients undergoing robotic major hepatectomy were prospectively followed. Major hepatectomy was defined as a resection of 3 or more segments. Data are expressed as median (mean ± SD)., Results: A total of 170 consecutive patients underwent robotic hepatectomies, of which 100 were major resections involving at least 3 segments. The 100 patients were of median 62 (61 ± 13.0) years, and 46% were women. Median BMI was 29 (29 ± 5.9) kg/m 2 and median ASA class was 3 (3 ± 0.5). Thirty percent of robotic major hepatectomies were for hepatocellular carcinoma, 28% were for metastatic adenocarcinoma, 9% were for cholangiocarcinoma, and 5% were for metastatic neuroendocrine tumor. Prep time (in the room until incision) was a median 58 min (62 ± 18.4), extraction time (incision until specimen extraction) was 124 min (146 ± 99.5), console time was 198 min (210 ± 123.9), closure time (extraction until dressing placement) was 109 min (131 ± 93.8), operative duration was 246 min (269 ± 123.2), and time under anesthesia was 330 min (353 ± 109.6). Estimated blood loss was 175 ml (249 ± 275.9) and length of stay was 4 days (5 ± 4.3). Seven patients experienced postoperative complications. Thirteen patients were readmitted within 30 days, and one patient died within 30 days., Conclusion: Application of the robotic platform to major hepatectomy is safe and feasible. Our early experience shows that this minimally invasive approach results in excellent short-term outcomes.

Background: Surgery has long been a man-dominated discipline with gender roles traditionally defined along societal norms. Presumably, as society has evolved, so have men surgeons' perceptions of women surgeons, though data are lacking. This study was undertaken to determine if men surgeons' perceptions of women surgeons represent a bias against women in Surgery., Methods: 190 men surgeons were queried about attitudes toward women surgeons utilizing a validated questionnaire. The survey included binary, multiple choice, and Likert scale questions (1 = definitely disagree to 5 = definitely agree)., Results: 84% of the men surgeons have been attending surgeons for more than 5 years; 80% deem women surgeons as capable as their man colleagues. 80% of respondents consider it possible for a woman to be a good surgeon, mother, and spouse; however, 76% believe women surgeons experience more pressure to balance work and family. 75% of the men surgeons think women surgeons have the same advancement opportunities as men, though 30% believe gender discrimination exists in Surgery. 45% of the respondents consider the "surgical discipline" accountable for fewer women finishing training, yet 57% think the rate of women entering Surgery is not a problem to address., Conclusion: While most men surgeons have favorable opinions of the personal and professional abilities of women surgeons, favorable opinions are not universal; a bias against women persists in Surgery. Considering most medical students today are women, the discipline of Surgery dismisses this talent pool only to its detriment. Surgery, and men in Surgery specifically, must evolve to eliminate bias against women in Surgery, promoting an equitable and inclusive work environment for the betterment of Surgery and all its stakeholders, including patients.

Background: Achalasia is a rare esophageal motility disorder that affects 1 in 100,000 individuals. Currently, laparoscopic Heller myotomy with anterior fundoplication is the 'gold standard' therapy for achalasia, alleviating symptoms by de-functionalizing the lower esophageal sphincter mechanism. The advent of the Laparo-Endoscopic Single Site (LESS) technique provides a more minimally invasive approach to Heller myotomy., Methods: With IRB approval, 179 patients who underwent LESS Heller myotomy with anterior fundoplication since 2007 have been prospectively followed. Patients self-assessed symptom frequency and severity preoperatively and postoperatively using a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). Patients scored their scar satisfaction (1 = revolting to 10 = beautiful). Data are presented as median (mean ± SD). Significance was accepted with 95% probability., Results: Fifty-one percent of patients were men, of age 55 (53 ± 17) years and BMI of 25 (25 ± 6.1) kg/m 2 . Patients had an operative time of 134 (135 ± 34.3) minutes with an estimated blood loss (EBL) of 50 mL. Postoperative complications occurred in 18% of patients (e.g., urinary retention, capnothorax). Length of stay was 1 (2 ± 2.1) day. Preoperatively, symptoms (e.g., dysphagia, regurgitation) were frequent and severe; following myotomy, all symptoms queried were significantly less frequent and severe with follow-up of 28 (34 ± 18.4) months (p < 0.0001 for all, paired Student's t test). Eighty-seven percent of patients reported they were 'very satisfied' or 'satisfied' with their experience and 95% of patients would undergo the operation again knowing what they know now. Patients scored their satisfaction with their scar as 10 (9 ± 1.6)., Conclusion: Heller myotomy with anterior fundoplication undertaken via the LESS approach provides efficacious, satisfactory, and durable amelioration of symptoms. Patients reported significant symptom resolution as well as satisfaction with their overall experience. Our decade of experience documenting the salutary benefits of LESS Heller myotomy should be more than enough to encourage surgeons to incorporate the approach into their armamentarium.

The model for end-stage liver disease (MELD) score is objective, reproducible, and it has shown to predict mortality related to cirrhosis. This study was undertaken to investigate safety of robotic hepatectomy in patients with elevated preoperative MELD score and to examine correlation between preoperative MELD scores and postoperative outcomes after robotic hepatectomy for liver tumors. Demographic data, MELD score, and clinical outcomes were prospectively collected. Regression analysis was used. Data are presented as median (mean ± SD). 75 patients underwent robotic hepatectomy. Age was 64 (62.5 ± 14.2) years and BMI 28 (29 ± 7.0) kg/m 2 ; 56% women. 60 (81%) of the hepatectomies were undertaken for malignancy (25% hepatocellular carcinoma, 20% colorectal metastasis, 15% cholangiocarcinoma). On regression analysis, MELD score did not correlate with operative time (p = 0.518) or blood loss (p = 0.583). MELD score, however, correlated with length of stay (p = 0.002). 8 (11%) patients experienced postoperative complications; their MELD score was 7 (8 ± 2.5). 68 (91%) patients did not experience postoperative complications; their MELD score was 7 (8 ± 2.8) (p = 0.803). One patient died in this series. In patients undergoing robotic hepatectomy to treat liver tumors, preoperative MELD score only correlates with length of stay. Preoperative MELD score does not correlate with operative time and amount of blood loss. An elevated MELD score should not deter surgeons from offering robotic hepatectomy.

Introduction: This study was undertaken to examine 100 consecutive robotic distal pancreatectomies with splenectomies, and to compare our outcomes to predicted outcomes as calculated using the American college of surgeons national surgical quality improvement program (ACS NSQIP) Surgical Risk Calculator and to the outcomes contained within NSQIP., Methods: Outcomes were compared with predicted outcomes, calculated using the ACS NSQIP Surgical Risk Calculator, and with outcomes documented in NSQIP for distal pancreatectomy. For illustrative purposes, data are presented as median (mean ± SD)., Results: Patients who underwent robotic distal pancreatectomy were of age 67 (63 ± 13.4) years with a BMI of 29 (29 ± 6.3) kg/m 2 , with 49% being women. Operative duration was 242 (265 ± 112.2) minutes and estimated blood loss was 110 (211 ± 233.9) mL. Predicted outcomes were similar to those reported in NSQIP. Our actual outcomes were significantly superior to the predicted outcomes for serious complication, any complication, surgical site infection, sepsis, and length of stay. Compared to NSQIP outcomes, our actual outcomes for serious complication, any complication, surgical site infection, sepsis, and delayed gastric emptying were significantly superior. Twelve percent of operations were converted to "open." There were 3 deaths within 30 days, similar to predicted outcomes. Deaths were due to sepsis (2) and respiratory failure (1)., Conclusion: Our patients' predicted outcomes were the same as national outcomes; our patients were not a select group. However, their actual outcomes were like or significantly superior than those predicted by NSQIP or reported in NSQIP. We believe that the robot has the future of distal pancreatectomy with or without splenectomy.

Robotic surgery is flourishing worldwide. Pancreatic cancer is the fourth leading cause of cancer death in the United States. Most pancreatic operations are undertaken for the management of pancreatic adenocarcinoma. Therefore, it is essential for all physicians caring for patients with cancer to understand the role and importance of molecular tumor markers. This article details our technique and application of the robotic platform to robotic pancreatectomy. The use of the robot does not change the nature of pancreatic operations, but it is our belief that it will improve patient outcomes and, possibly, survival by reducing perioperative complications., Competing Interests: Disclosures/Conflicts of Interest The authors A.S. Rosemurgy and S. Ross are consultants and proctors for Medtronicplc, (Minneapolis, MN) and Intuitive Surgical Inc (Sunnyvale, CA). K. Luberice, H. Browning, and I. Sucandy have no disclosures/conflicts of interest., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The nascent robotic approach for hepatic resections is gaining momentum in the United States because it offers solutions to the known limitations of laparoscopic approach. Herein, we report our initial experience and short-term outcomes of the first 100 robotic hepatectomies. With Institutional Review Board approval, all patients undergoing robotic hepatectomy were prospectively followed up. Patient demographics, operative outcomes, complications, and 30-day readmissions were collected and analyzed. Data are presented as median (mean ± SD). One hundred consecutive patients underwent robotic hepatectomy. Patients were aged 62 (63 ± 13.6) years, 66 per cent were women, and BMI was 29 (29 ± 6.4) kg/m². In all, 76 per cent of the hepatectomies were undertaken for malignancy [metastatic colorectal cancer (28%), hepatocellular carcinoma (21%), and intrahepatic cholangiocarcinoma (15%)], and 20 per cent for benign lesions; 66 per cent of patients underwent nonanatomical partial hepatectomies, 17 per cent right hepatectomies, 16 per cent left hepatectomies, and 1 per cent trisegmentectomy. Operative time was 233 (268 ± 109.3) minutes, and the estimated blood loss was 123 (269 ± 322.1) mL. Conversion to "open" approach was necessary in one patient. The length of stay was 3 (5 ± 4.6) days. There were no intraoperative complications. Twelve patients experienced postoperative complications. Six patients required readmission to the hospital within 30 days of discharge. Robotic hepatectomy is safe and feasible with favorable short-term outcomes. The robotic system enhances application of minimally invasive surgery for complex hepatobiliary operations.

High body mass index (BMI) is associated with other multiple comorbidities such as non-alcoholic fatty liver disease, steatohepatitis, liver cirrhosis, and cardiopulmonary diseases, which can impact the perioperative outcomes following liver resection. We aimed to study the impact of BMI on perioperative outcomes after robotic liver resection. All the patients undergoing robotic liver resection between 2013 and 2017 were prospectively followed. The patients were divided into three groups (BMI < 25, BMI 25-35, BMI > 35 kg/m 2 ) for illustrative purposes. Demographic and perioperative outcome data were compared. Data are presented as median (mean ± SD). Thirty-eight patients underwent robotic hepatectomy, 73% were women, age was 58 (57 ± 17.6) years, and ASA class was 3 (3 ± 0.5). Indications for surgery were neoplastic lesions in 34 patients (89%), hemangioma in two patients (6%), fibrous mass in one patient (2.5%), and focal nodular hyperplasia in one patient (2.5%). 32% of the patients underwent right or left hemihepatectomy, 21% underwent sectionectomy, 5% underwent central hepatectomy and the reminder underwent non-anatomical liver resection. Operative time was 261 (254.6 ± 94.3) min. Estimated blood loss was 175 (276 ± 294.8) ml. Length of hospital stay was 3 (5 ± 4.9) days. By regression analysis of the three BMI groups, estimated blood loss, rate of postoperative complication, rate of conversion, need for transfusion, length of ICU stay, and length of hospital stay did not have a significant relationship with BMI. A total of five patients (13%) experience complications. Four patients had complications that were nonspecific to liver resection, including acute renal injury, respiratory failure, and enterocutaneous fistula. One patient had bile leak, treated with ERCP stenting. No mortality was seen in this study. Obesity should not dissuade surgeons from utilizing minimally invasive robotic approach for liver resection. Robotic technique is a safe and feasible in patients with high BMI. The impact of BMI on outcomes is insignificant.

Minimally invasive hepatectomy for benign and malignant liver lesions has gained popularity in the past decade due to improved perioperative outcomes when compared to conventional 'open' technique. We aim to investigate our initial experience of robotic hepatectomy undertaken in our hepatobiliary program. All patients undergoing robotic hepatectomy between 2013 and 2018 were prospectively followed. Data are presented as median (mean ± SD). A total of 80 patients underwent robotic hepatectomy within the study period. 60% of the patients were women, age of 63 (62.4 ± 14.1), body mass index of 28 (29.6 ± 9.4), ASA class of 2.5 (2.5 ± 0.6), and MELD score of 7 (8.2 ± 2.8). Size of resected lesion was 3.9 (4.6 ± 3) cm. Indications for resection were metastatic lesions (30%), hepatocellular carcinoma (28%), cholangiocarcinoma (7%), gallbladder cancer (5%), neuroendocrine tumors (4%), and benign lesions (26%). Formal hepatectomy (right or left) was performed in 30% of the patients. Operative time was 233 (267.2 ± 109.6) minutes, and estimated blood loss was 150 (265.7 ± 319.9) ml. Length of hospital stay was 3 (5.0 ± 4.6) days. One patient was converted to 'open' approach. 10 patients experienced postoperative complications. Readmissions within 30 days of hospital discharge were seen in eight patients. Our data support that robotic hepatectomy is safe and feasible, with favorable short-term outcomes and low conversion rate. Robotic technology extends the application of minimally invasive techniques in the field of hepatobiliary surgery.

Introduction: Hepatectomy is the gold standard curative treatment for hepatic neoplasms in patients with preserved liver function. Many large tumors require extended hepatectomy (EH). Possibility of developing major postoperative complications including liver failure is feared by many surgeons. We aim to describe our outcomes of EH for large hepatobiliary tumors., Material and Methods: All patients undergoing hepatectomy between 2012 and 2017 were prospectively followed., Results: 91 patients underwent hepatectomy with ten patients underwent EH. The majority of patients were women, age of 63, BMI of 24, and MELD score of 11. Six patients underwent an extended right hepatectomy, while four patients underwent extended left hepatectomy. Operative time was 224 min with estimated blood loss of 500 ml. No intraoperative complications were seen. Two patients experienced postoperative complications (pleural effusion in one patient and respiratory failure in another). Length of ICU stay was 2 days, and hospital stay was 5 days. 80% of the patients are currently alive with median follow-up of 41.2 months., Conclusion: EH can be undertaken safely with acceptable morbidity and mortality in our center., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Benign bile duct stricture poses a significant challenge for gastroenterologists and general surgeons due to the inherent nature of the disease, difficulty in sustaining long-term solutions and fear of pitfalls in performing biliary tract operations. Operative management with an open biliary bypass is mainly reserved for patients who have failed multiple attempts of endoscopic and percutaneous treatments. However, recent advances in minimally invasive technology, notably in the form of the robotics, have provided a new approach to tackling biliary disease. In this technical report, we describe our standardized method of robotic choledochoduodenostomy in a 59-year-old woman with history of Roux-en-Y gastric bypass who presents with benign distal common bile duct stricture following failure of non-operative management. Key steps in this approach involved adequate duodenal Kocherization, robotic portal dissection and creation of a side-to-side choledochoduodenal anastomosis. The operative time was 200 min with no intraoperative complications and estimated blood loss was less than 50 mL. No abdominal drains were placed. The patient was discharged home on postoperative day 1 tolerating regular diet and able to resume her usual activities within 1 week of her operation. A video is attached to this report.

Only a small percentage of patients fail laparoscopic fundoplications undertaken for gastroesophageal reflux disease. But because many laparoscopic fundoplications have been undertaken, surgeons frequently encounter patients in need of "redo" operations. This study was undertaken to evaluate the robotic approach versus laparoendoscopic single-site (LESS) approach for redo fundoplications. With an Institutional Review Board approval, 64 patients undergoing LESS (n = 32) or robotic (n = 32) redo antireflux operations were prospectively followed up. Data are presented as median (mean + SD). For LESS versus robotic redo operations, the operative duration was 145 (143 ± 33.5) versus 196 (208 ± 76.7) minutes ( P < 0.01), estimated blood loss was 50 (80 ± 92.1) versus 20 (43 ± 57.1) mL ( P = 0.07), and length of stay was 1 (3 ± 5.4) versus 1 (2 ± 1.9) day ( P = 0.57); 1 LESS operation was converted to "open." Operative duration was longer for men ( P = 0.01). Postoperative complications were not more frequent after Nissen (n = 36) or Toupet (n = 28) fundoplication, regardless of the approach. When matched by BMI, operative duration was prolonged by a large Type I to IV hiatal hernia ( P = 0.01). Symptoms improved dramatically and were similar with both approaches, and patient satisfaction was high. Robotic redo antireflux operations take longer than LESS operations. LESS and robotic redo antireflux operations are both safe and offer significant and similar amelioration of symptoms after failed fundoplications.

As minimally invasive operations evolve, it is imperative to evaluate the advantages and risks involved. The aim of our study was to evaluate our institution's experience in incorporating a robotic platform for transhiatal esophagectomy (THE). Patients undergoing robotic THE were prospectively followed. Data are presented as median (mean ± SD). Forty-five patients were of 67 (67 ± 6.9) years and BMI 26 (27 ± 5.5) kg/m². Nine per cent of operations were converted to "open," but none in the last 25 operations. Operative duration of robotic THE was 334 (364 ± 108.8) minutes and estimated blood loss was 200 (217 ± 144.0) mL, which decreased with time ( P = 0.017). Length of stay was 8 (12 ± 11.1) days. Twenty per cent had respiratory failure requiring intubation that resolved, 4 per cent developed pneumonia, 11 per cent developed a surgical site infection, 2 per cent developed renal insufficiency, and 2 per cent developed a UTI. Two per cent (one patient) died within 30 days postoperatively, because of cardiac arrest. Our experience with robotic THE promotes robotic application because we endeavor to achieve high-level proficiency. With experience, we improved estimated blood loss and converted fewer transhiatal esophagectomies to "open." Our length of hospital stay seems long but reflects the ill-health of patients, as does the variety of complications. Our data support the evolving future of THE, which will integrally include a robotic approach.

The incidence of esophageal cancer in the United States seems to have significantly increased since the 1970s. In undertaking this study, we sought to describe changes in the incidence, histologic type, and presenting stage of esophageal cancer over the past four decades. With Institutional Review Board approval, the Surveillance, Epidemiology, and End Results database of the National Cancer Institute was queried. Regression analysis was used to analyze data, and significance was accepted with 95 per cent probability. Forty-two thousand seven hundred thirty-nine patients had squamous cell carcinoma or adenocarcinoma located in their upper, middle, and/or lower esophagus from 1973 through 2010, reflecting a 7.5-fold annual increase from 1973 through 2010. Squamous cell carcinoma increased annually 2.5-fold ( P < 0.001) and esophageal adenocarcinoma increased annually 57-fold from 1973 through 2010 ( P < 0.001), whereas the overall population in the United States increased only 43 per cent (215,092,900 to 308,745,538) in the same period. From 1973 through 2010, there was a significant increase in the incidence of esophageal cancer in the United States. This increase was much greater than the increase in the population in the United States. The incidence of adenocarcinoma increased much more than that of squamous cell carcinoma of the esophagus from 1973 through 2010.

Despite advantages of minimally invasive surgery, many hepatobiliary surgeons are hesitant to offer this approach for major hepatic resection due to concerns of difficulty in liver manipulation, bleeding control, and suboptimal oncologic outcomes. The robotic surgical system has revolutionized the way traditional laparoscopic liver resection is undertaken. Limitations of traditional laparoscopy are being resolved by robotic technology. We aimed to describe aspects of minimally invasive liver surgery and our standardized technical approach. We discussed technical aspects of performing robotic total right hepatic lobectomy and described our standardized institutional method. A 79-year-old man with an 11-cm biopsy-proven hepatocellular carcinoma was taken to the operating room for a robotic total right hepatic lobectomy. Past medical and surgical history was consistent with hypertension and diabetes mellitus. Robotic extrahepatic Glissonean pedicle approach was used to gain inflow vascular control. Right hepatic artery and portal vein were individually dissected and isolated prior to division. An intraoperative robotic ultrasound was utilized to guide liver parenchymal transection, securing negative margins. Robotic vessel sealing device was used as the main energy device during the parenchymal transection. Right hepatic vein was transected intrahepatically using a linear stapler. Operative time was 200 min without intraoperative complications. Estimated blood loss was 100 ml. Postsurgical recovery was uneventful and he was discharged home on postoperative day 4. Minimally invasive robotic total right hepatic lobectomy is feasible with excellent perioperative outcomes.

Background: This study was undertaken to examine our outcomes after robotic pancreaticoduodenectomy and to compare our outcomes with predicted outcomes using the American College of Surgeons (ACS) NSQIP Surgical Risk Calculator and with outcomes reported through ACS NSQIP., Methods: We prospectively followed 155 patients undergoing robotic pancreaticoduodenectomy. Outcomes were compared with predicted outcomes calculated using the ACS NSQIP Surgical Risk Calculator and with outcomes documented in ACS NSQIP for pancreaticoduodenectomy from 2012 to 2017. Median data are presented., Results: Eighty-eight percent of our robotic pancreaticoduodenectomies were performed in 2015 to 2018. Predicted outcomes were like those reported in ACS NSQIP. Actual outcomes were superior to predicted outcomes and outcomes reported in ACS NSQIP for overall complications, serious complications, returned to operating room, surgical site infections, deep vein thrombosis, and length of stay. Seventeen percent had conversions to open operations, generally due to failure to progress or need for major vascular reconstruction; only 3 (3.5%) of the last 80 operations were converted to open. Robotic operations took 423 minutes; estimated blood loss was 200 mL. Biliary fistulas occurred in 5% and pancreatic fistulas occurred in 5%. Six percent of patients died perioperatively; 5 patients died due to cardiac deterioration and 4 (3.1%) patients died after pancreaticoduodenectomy completed robotically., Conclusions: Our patients were not a select group, they were like those reported in ACS NSQIP. Their outcomes after robotic pancreaticoduodenectomy were like or better than predicted outcomes or national data. Our mortality was high because of preoperative ill health (eg renal failure) and cardiac risk. Although we believe our results will continue to improve, our current data document the salutary benefits of minimally invasive robotic pancreaticoduodenectomy., (Copyright © 2019. Published by Elsevier Inc.)

Minimally invasive technique has been adopted as the standard of care in many surgical fields within general surgery. Hepatobiliary surgery, however, is lacking behind due to the complex nature of the operation and concerns of major bleeding. Several centers suggested that inherent limitations of conventional laparoscopy precludes its wide adoption. Robotic technique provides solutions to these limitations. In this study, we report our standardized technique of robotic left hepatectomy. We discuss aspects of robotic hepatectomy and describe our standardized approach for robotic left hepatectomy. A video is attached to this article. A 76-year-old man with a 4.5 cm biopsy-proven hepatocellular carcinoma was taken to the operating room for a robotic left hepatectomy. His past medical and surgical history was only consistent with hypertension and diabetes. Robotic extrahepatic glissonian pedicle approach was applied to gain inflow control. Left hepatic artery and portal vein were individually dissected and isolated prior to division. An intraoperative robotic ultrasound was utilized to ensure negative resection margins. Left hepatic vein was transected intrahepatically using a laparoscopic Endo GIA stapler. Segment 2,3, and part of 4 were removed. Operative time was 180 min without intraoperative complications. Estimated blood loss was less than 50 cc. The patient was discharged home on postoperative day 3. The use of robotic technology during complex hepatic resections such as left hepatectomy is safe and feasible. This approach provides an alternative technique in minimally invasive liver surgery.

Robotic liver resection is being introduced with its potential to overcome limitations of conventional laparoscopy. This study was undertaken to document early experience and learning curve of robotic liver resection in our institution. All patients undergoing liver resection between 2013 and 2017 were prospectively followed. Patients were divided into three consecutive tertiles (cohort I-III). Thirty-three patients underwent robotic liver resection within the study period. Twenty-four per cent of patients underwent formal right or left hemihepatectomy, 21 per cent underwent sectionectomy, 6 per cent underwent central hepatectomy, and the remainder underwent nonanatomical liver resection. Formal hemihepatectomy and right posterosuperior segment resection were undertaken in two patients in cohort I, four patients in cohort II, and four patients in cohort III. Two cases were converted to "open" operation. Operative time was 172 (194.5 ± 65.1) minutes in cohort I, 222 (247.8 ± 109.8) minutes in cohort II, and 280 (302.5 ± 84.9) minutes in cohort III, reflecting increasing degree of technical complexity. Estimated blood loss decreased significantly throughout the cohorts, being 400 mL, 200 mL, and 100 mL in cohorts I to III, respectively. Major intraoperative complications were not seen. Three patients experienced postoperative complications, resulting in a single mortality. Length of hospital stay was three days, with two patients being readmitted within 30 days. Robotic technique for liver resection is feasible and safe. It offers good short-term clinical outcomes, including for patients who require major liver resection. As the proficiency developed, a notable improvement in technically ability to undertake more complex resections with decreasing blood loss and minimal morbidity was seen.

Background: As minimally invasive technique becomes more popular, an increasing number of elderly patients were considered for minimally invasive liver resection (MILR). Limited physiologic reserve remains a major concern, which frequently leads surgeons to recommend nonresectional alternatives. We sought to evaluate complications and outcomes of elderly patients undergoing MILR., Methods: Eight hundred and thirty-one patients who underwent MILR were classified into groups A, B, and C based on age [(< 70, n = 629), (70-79, n = 148), (≥ 80, n = 54) years old, respectively]., Results: Gender distribution, BMI, and cirrhotic status were comparable among all groups. Groups B and C had higher MELD (p = 0.047) and ASA (p = 0.001) scores. Operative time (170, 157, 152 min; p = 0.64) and estimated blood loss (145, 130, 145 ml; p = 0.95) were statistically equal. Overall postoperative complications were greater in groups B and C (12.9 and 9.3 vs. 6.5%, respectively). Complications in group C were all minor. Clavien-Dindo grade III-IV complications were higher in group B when compared to group A (6.8 vs. 2.7%, p = 0.43). There was no significant difference in cardiopulmonary complications, thromboembolic events, ICU admissions, and transfusion rates seen in groups B and C when compared to group A. Duration of hospital stay was statistically longer in groups B and C (3.6, 3.5 vs. 2.5 days, p = 0.0012). 30- and 90-day mortality rates were comparable among the groups, irrespective of age., Conclusions: In spite of greater preoperative comorbidities and ASA score, there was no significant increase in postoperative morbidity after minimally invasive liver resection in patients ≥ 70 years of age.

Laparoscopic liver resection has been adopted slowly due to concerns for bleeding and oncologic outcomes. Currently, over 9,500 laparoscopic liver resections have been performed and reported worldwide. Numerous studies have shown the safety and oncologic equivalence of laparoscopic liver resection when compared to open resection. Pure laparoscopic and hand-assisted laparoscopic liver resection are the two most commonly used techniques for minimally invasive liver resection surgery. Advantages of the hand-port include tactile feedback, facilitation of liver mobilization, and ease of ability to control bleeding. We present a case report with video of a hand-assisted laparoscopic left liver resection for a hepatocellular carcinoma in a non-cirrhotic patient., (© 2016 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)