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Resumen Introduccion La cirugia robotica ha demostrado su eficacia en ciertos procedimientos quirurgicos. Sin embargo, en cirugia hepatica y pancreatica (HBP) su uso es todavia poco frecuente. Se presenta la experiencia inicial en cirugia robotica HBP de una unidad especializada en un hospital de tercer nivel. Metodo Se han estudiado en forma prospectiva los resultados de los pacientes intervenidos de cirugia HBP robotica entre abril de 2018 y octubre de 2020. Los datos analizados corresponden a datos demograficos, tecnicas quirurgicas realizadas y morbimortalidad asociada. Resultados Se intervinieron 64 pacientes, sometidos a 35 hepatectomias (mayores [6,7%], anatomicas [52,9%], limitadas [34,4%], quistectomias [3%] y marsupializaciones [3%]) y 29 pancreatectomias/resecciones duodenales (distales [48,2%], centrales [6,9%], cefalicas [13,8%], enucleaciones [24,1%], ampulectomias [3,5%] y resecciones duodenales [3,5%]). En cirugia hepatica el tiempo operatorio medio fue de 204,4 minutos (100-265 min), la mediana de complicaciones postoperatorias segun la escala de Clavien-Dindo fue de uno (1-4), las perdidas hematicas medias de 166,7 mL (100-300 mL), no existio conversion y la estancia postoperatoria media de cuatro dias (2-14 dias). En cirugia pancreatica el tiempo operatorio medio fue de 243,8 minutos (125-460 min), la mediana de complicaciones postoperatorias de dos (1-4), las perdidas hematicas de 202,3 mL (100-500 mL) asociadas a una tasa de conversion del 17,8% y una estancia media de siete dias (3-23 dias). Conclusiones La cirugia robotica HBP es segura y factible. Se sugiere que su uso facilita la cirugia conservadora de parenquima, el acceso a segmentos posteriores hepaticos y la realizacion de anastomosis en la reconstruccion pancreatica respecto a la cirugia laparoscopica.

The "liver-first" approach (LFA) is a strategy indicated for advanced synchronous liver metastases (ASLM) from colorectal cancer (CRC). Includes neoadjuvant chemotherapy, resection of the ASLM followed by CRC resection.Retrospective descriptive analysis from a prospective database of hepatectomies from liver metastases (LM) from CRC in two centers. Between 2007-2019, 88 patients with CRC-ASLM were included in a LFA scheme. Bilobar (LM) was present in 65.9%, the mean number of lesions was 5.5 and mean size 42.7 mm. Response to treatment was assessed by RECIST criteria. Progression-free survival (PFS) and overall survival (OS) were estimated using Kaplan-Meier survival curves.Seventy-five of 88 patients (85.2%) completed the LFA. RECIST evaluation showed partial response in 75.7% and stable disease in 22.8%. Severe morbidity rate (Clavien-Dindo ≥ IIIA) after liver and colorectal surgery was present in 29.4% and 9.3%, respectively. There was no 90-day postoperative mortality in both liver and colorectal surgeries. Recurrence rate was 76%, being the liver the most frequent site, followed by the pulmonary. From the total number of recurrences (106) in 56 patients, surgical with chemotherapy rescue treatment was accomplished in 34 of them (32.1%). The mean PFS was 8.5 and 5-year OS was 53%.In patients with CRC-ASLM the LFA allows control of the liver disease beforehand and an assessment of the tumor response to neoadjuvant chemotherapy, optimising the chance of potentially curative liver resection, which influences long-term survival.

Robotic surgery has proven effective in certain surgical procedures. However, in liver and pancreatic surgery (HBP) its use is still rare. The initial experience in HBP robotic surgery of a specialized unit of a tertiary hospital is presented.The results of patients undergoing robotic HBP surgery between April 2018 and October 2020 have been prospectively studied. The data analyzed correspond to demographic data, surgical techniques performed, associated morbidity and mortality.64 patients were operated, corresponding to 35 hepatectomies (major [6.7%], anatomic [52.9%], limited [34.4%], cystectomies [3%] and marsupialization [3%]), 29 pancreatectomies (distal [48.2%], central [6.9%], cephalic [13.8%], enucleations [24.1%], ampullectomies [3.5%] and duodenal resections [3.5%]). In liver surgery the mean operative time was 204.4 minutes (100-265 min), the median postoperative complications according to the Clavien-Dindo scale was one (1-4), the mean blood losses 166.7 mL (100-300 mL), there was no conversion and the mean postoperative stay was four days (2-14 days). In pancreatic surgery, the mean operative time was 243.8 minutes (125-460 min), the median of postoperative complications was two (1-4), blood loss of 202.3 mL (100-500 mL) associated to a conversion rate 17.8% and an average stay of seven days (3-23 days).Robotic HBP surgery is safe and feasible. It is suggested that its use facilitates parenchymal sparing surgery, access to posterior liver segments and anastomosis in pancreatic reconstruction compared to laparoscopic surgery.

Loop ileostomy reduces the rates of morbidity due to colorectal anastomotic dehiscence. For its part, ileostomy closure is associated with low mortality (0–4%) but substantial morbidity (11–37%). Incisional surgical site infection (SSI) is one of the most frequent complications (2–40%). A single-center, prospective, randomized controlled clinical trial of two study groups: control (conventional primary skin closure) and experimental (primary skin closure with a contralateral Penrose® drain). Seventy patients undergoing loop ileostomy closure between April 2013 and June 2017 were included (35 per branch). Four were later removed from the study. Six of the remaining 66 patients (per protocol analysis) were diagnosed with incisional SSI (9.1%); there were no statistically significant differences between the two groups (control group: 9.7%; experimental group: 8.6%) or between the risk factors associated with incisional SSI. Rates of overall and relevant morbidity (Clavien ≥ III) were considerable (28.1% and 9.1%, respectively), and there were no statistically significant differences between the two groups. No patients died. Contralateral drainage does not significantly affect the results of primary ileostomy closure. The rate of incisional SSI was similar in the drainage and non-drainage groups, and the overall rate of 9.1% was in the low range of those reported in the literature. The absence of mortality (0%) and the non-negligible rates of overall and relevant morbidity (28.1% and 9.1%, respectively) in our series suggest that loop ileostomy is a safe procedure. However, the bowel reconstruction involves risks that must be borne in mind. The study was registered and approved by the clinical research ethics committee of the study center (reference number 2012076). Clinical trial was registered in ClinicalTrial.gov (identification number NCT02574702 and reference: ILEOS-ISS_2013).

An important drawback of local surgery for lesions in the anal canal is the difficulty of achieving en bloc full-thickness resections. The aim of this study is to evaluate TEM/TEO in lesions of this type from the point of view of morbidity, mortality and the quality of the pathology specimen. This is an observational study with prospective data collection from June 2004 to July 2018. Two groups are defined: group A (rectal tumors with proximal margin between 0 and ≤4 cm from anal verge) and group B (distal margin > 4 cm from anal verge). A technical description is provided; resections and postoperative complications in both groups are compared. During the study period, 757 patients underwent TEM/TEO. Finally, 692 patients were included, 192 patients in group A and 500 patients in group B. An en bloc surgical specimen was obtained in 176/192 patients (91.7%), although the defect was completely sutured in 132 (68.8%). In the comparative analysis, group A did not present significantly greater fragmentation of the resected piece [16/192 (8.3%) vs. 36/500 (7.2%), p = 0.630], although group A was associated with greater involvement of the surgical margin [28/192 (14.6%), 32/500 (6.4%), p = 0.001] and clinically relevant morbidity [16/192 (8.3%), 20/500 (4%), p = 0.034]. There was no mortality. The use of TEM/TEO to remove lesions originating in the anal canal is feasible. But we have to take into account that there is an increase in complications, technical difficulties and affected margins resection.