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Background Minimally invasive pancreaticoduodenectomy (MIPD) has recently been safely performed by experts, and various methods for resection have been reported. This review summarizes the literature describing surgical approaches for MIPD. Methods A systematic literature search of PubMed (MEDLINE) was conducted for studies reporting robotic and laparoscopic pancreaticoduodenectomy; the reference lists of review articles were searched. Of 444 articles yielded, 23 manuscripts describing the surgical approach to dissect around the superior mesenteric artery (SMA), including hand-searched articles, were assessed. Results Various approaches to dissect around the SMA have been reported. These approaches were categorized according to the direction toward the SMA when initiating dissection around the SMA: anterior approach (two articles), posterior approach (four articles), right approach (16 articles), and left approach (three articles). Thus, many reports used the right approach. Most articles provided a technical description. Some articles showed the advantage of their method in a comparison study. However, these were single-center retrospective studies with a small sample size. Conclusions Various approaches for MIPD have been reported; however, few authors have reported the advantage of their methods compared to other methods. Further discussion is needed to clarify the appropriate surgical approach to the SMA during MIPD.

Background Surgical views with high resolution and magnification have enabled us to recognize the precise anatomical structures that can be used as landmarks during minimally invasive distal pancreatectomy (MIDP). This study aimed to validate the usefulness of anatomy-based approaches for MIDP before and during the Expert Consensus Meeting: Precision Anatomy for Minimally Invasive HBP Surgery (February 24, 2021). Methods Twenty-five international MIDP experts developed clinical questions regarding surgical anatomy and approaches for MIDP. Studies identified via a comprehensive literature search were classified using Scottish Intercollegiate Guidelines Network (SIGN) methodology. Online Delphi voting was conducted after experts had drafted the recommendations, with the goal of obtaining >75% consensus. Experts discussed the revised recommendations in front of the validation committee and an international audience of 384 attendees. Finalized recommendations were made after a second round of online Delphi voting. Results Four clinical questions were addressed, resulting in 10 recommendations. All recommendations reached at least a 75% consensus among experts. Conclusions The expert consensus on precision anatomy for MIDP has been presented as a set of recommendations based on available evidence and expert opinions. These recommendations should guide experts and trainees in performing safe MIDP and foster its appropriate dissemination worldwide.

Background This pioneering study is aimed to design training models for robotic pancreaticojejunostomy (PJ) and to assess their usefulness using quality improvement exercise in the dry lab. Methods Three dry lab models were developed including the anastomosis model of a transected silicon pancreatic stent (model 1), a rough model (model 2) simulating PJ, and an advanced three-dimensional printed model (model 3) more vividly simulating PJ. Three surgeons (A, B, C) with same specialty and levels of expertise in surgery were enrolled in the training which was divided into three rounds of tasks. In the first round, all three surgeons (A, B, C) participated in the training on basic technical tasks before moved on to the next rounds. While surgeons A, B participated in the second round on model 1, only surgeon A worked on model 2 in the third round. Their proficiency of performance was evaluated on model 3. Results The results of the first and second rounds between surgeons are similar. Surgeon A practiced with model 2 for 6 h, completing 10 cases. In model 3, the times of attempts before achieving a consecutively three times of satisfactory anastomosis procedures were compared, for surgeon A, six cases, 20 for B and 25 for C. Conclusions The specifically designed series of dry lab training models may be a potential training tool for advancing the robotic PJ through quality improvement exercise in dry lab. Further larger and well-designed studies are warranted to validate this issue.

BACKGROUND Minimally invasive distal pancreatectomy (MIDP) was initially performed for benign tumors, but recently its indications have steadily broadened to encompass other conditions including pancreatic malignancies. Thorough anatomical knowledge is mandatory for precise surgery in the era of minimally invasive surgery. However, expert consensus regarding anatomical landmarks to facilitate the safe performance of MIDP is still lacking. METHODS A systematic literature search was performed using keywords to identify articles regarding the vascular anatomy and surgical approaches/techniques for MIDP. RESULTS All of the systematic reviews revealed that MIDP was not associated with an increase in postoperative complications. Moreover, most showed that MIDP resulted in less blood loss than open surgery. Regarding surgical approaches for MIDP, a standardized stepwise procedure improved surgical outcomes, including blood loss, operative time, and major complications. There are two approaches to the splenic vessels, superior and inferior; however, no study has ever directly compared them with respect to clinical outcomes. The morphology of the splenic artery affects the difficulty of approaching the artery's root. To select an appropriate dissecting layer when performing posterior resection, thorough knowledge of the anatomy of the fascia, left renal vein/artery, and left adrenal gland is needed. CONCLUSIONS In MIDP, a standardized approach and precise knowledge of anatomy facilitates safe surgery and has the advantage of a shorter learning curve. Anatomical features and landmarks are particularly important in cases of radical MIDP and splenic vessel preserving MIDP.

Background The anatomical structure around the pancreatic head is very complex, and it is important to understand its precise anatomy and corresponding anatomical approach to safely perform minimally invasive pancreatoduodenectomy (MIPD). This consensus statement aimed to develop recommendations for elucidating the anatomy and surgical approaches to MIPD. Methods Studies identified via a comprehensive literature search were classified using the Scottish Intercollegiate Guidelines Network method. Delphi voting was conducted after experts had drafted recommendations, with a goal of obtaining >75% consensus. Experts discussed the revised recommendations with the validation committee and an international audience of 384 attendees. Finalized recommendations were made after a second round of online Delphi voting. Results Three clinical questions were addressed, providing six recommendations. All recommendations reached at least a consensus of 75%. Preoperatively evaluating the presence of anatomical variations and superior mesenteric artery (SMA) and superior mesenteric vein (SMV) branching patterns was recommended. Moreover, it was recommended to fully understand the anatomical approach to SMA and intraoperatively confirm the SMA course based on each anatomical landmark before initiating dissection. Conclusions MIPD experts suggest to surgical trainees to perform resection based on precise anatomical landmarks for safe and reliable MIPD.

Robotic total pancreatectomy (RTP) is a novel surgical approach currently performed by a select group of skilled surgeons. As robotic approaches to pancreatic surgery increase worldwide, rates of RTP are expected to increase. However, the standard technique is still evolving and several technical problems still require evaluation. Here, we describe our approach in a stepwise fashion and discuss solutions to overcome technical difficulties.

Total pancreatectomy (TP) is a complex pancreatic procedure that has regained acceptance in the recent years due to progress in diabetic management and better understanding of pancreatic pathophysiology and tumor biology. Although advance in critical care medicine and innovation in surgical techniques have contributed to improved outcomes in TP patients, surgical morbidities remain significant with the traditional laparotomy approach. The idea of applying minimally invasive surgery to TP began taking shape following laparoscopic cholecystectomy success. However, with inherent limitations of non-wristed laparoscopic instruments, two-dimensional view, and unnatural hand-eye coordination, laparoscopic TP has been limited to only few highly skilled laparoscopic-pancreatic surgeons. The advent of the dVSS provided a better MIS alternative that has allowed more pancreatic surgeons to perform complex MI pancreatic surgeries including TP.

Background A robotic approach to general surgery procedures may provide improved postoperative outcomes compared to either open or laparoscopic approaches. The role of robotics for gastroesophageal surgery, however, is still being evaluated. Study Design A review of the prospective database for robotic surgery at Valley Hospital between January 2002 and March 2014 identified 105 patients who underwent robotic gastric and esophageal resection. Patient demographics and perioperative factors were studied. Results Over a 12 years period, 105 patients underwent robotic gastroesophageal resection. The median operative time for distal gastrectomy (230 min [112–327]) was significantly less compared to either total gastrectomy (302 min [214–364]) or esophagogastrectomy (309 min [190–682]). The length of stay for patients undergoing distal gastrectomy (6 days [4–32]) was also significantly less than patients undergoing total gastrectomy (11 days [7–43]), as well as esophagogastrectomy (9 days [5–64]). In regard to the learning curve to perform robotic gastroesophageal surgery, there was a significant correlation between operative time and overall experience. Conclusions This study demonstrated that robotic gastroesophageal surgery is feasible and can be safely performed. Assuming familiarity with the open procedures and acquisition of basic robotic skills, the learning curve for robotic gastroesophageal surgery requires approximately 20 cases. J. Surg. Oncol. 2015;112:888–893. © 2015 Wiley Periodicals, Inc.

The authors found that robotic distal pancreatectomy, with or without splenic preservation, can be performed safely for patients with lesions of the distal pancreas., Background: A robotic-assisted minimal invasive approach has the potential to overcome the limitations of conventional laparoscopic pancreatectomies. We analyzed the outcomes of robotic-assisted distal pancreatectomies (RDPs) to demonstrate the safety and feasibility of robotic distal pancreas resection, including spleen preservation. Methods: We performed a descriptive retrospective analysis of 40 RDPs. Statistical comparisons were performed between two groups of patients undergoing robotic-assisted spleen-preserving distal pancreatectomy (SPDP) and distal pancreatectomy with splenectomy (SDP). Survival analysis was performed using the Kaplan-Meier method. Results: Of 49 attempted RDPs, 40 were completed with robotic assistance, with a conversion rate of 18.4%. Compared with the published reports of laparoscopic distal pancreatotomy (DP) and robotic DP, the spleen preservation rate (30%), operating time (203 minutes), major complications rate (5%), fistula rate (20%), and length of hospital stay (5 days) were similar in our RDP patients. Also, the perioperative outcomes of the SPDP and SDP groups did not differ significantly. The median survival was 12.5 months for the patients undergoing RDP for pancreatic ductal adenocarcinoma. Conclusions: Robotic-assisted distal pancreatectomy, with or without splenic preservation, can be safely performed for lesions of the distal pancreas, with appropriate indications.

Blood loss is associated with postoperative morbidity and mortality. Outflow control could be used concomitantly with inflow control for maximum reduction in blood loss during parenchymal transection. However, in left hepatectomy (LH) and left lateral sectionectomy (LLS), extrahepatic control of the left hepatic vein (LHV) is still less commonly used. Some authors reported extrahepatic LHV control technique using ligamentum venosum (LV) in open or laparoscopic surgery, but no reports of this technique in robotic surgery have been found.The dissection of LV from the liver was performed, followed by clipping and transecting LV. The cephalad LV stump was retracted to the left inferior direction and then the dissection of the posterior part of LHV was performed until the opening space was connected to the anterior part of LHV. The LHV was encircled with the tape and vascular stapler was inserted to manage LHV stump. From 2013 to 2015, LHV was successfully encircled by using this technique in 7 out of 11 cases. The mean operative time was 244 minutes, the mean estimated blood loss was 300 mL, and the mean length of hospital stay was 4.8 days. Neither injury to LHV, nor complications related to the liver were found.From our experiences, LHV was routinely controlled in robotic LH or LLS and the success rate was 60%. However, this technique is not recommended for the tumor that compresses or abuts LHV/LV, and in cirrhotic liver with associated hypertrophic left lateral segment.

Our objective is to demonstrate the feasibility of robotic adrenalectomy by a traditional open surgeon using the da Vinci Robotic Surgical System and to analyze our outcomes. All patients who underwent robotic adrenalectomy by a single surgeon from July 2001 to April 2011 were included in the study. Vascular inflow control was obtained early on to facilitate dissection and handling of the adrenal gland. Forty adrenalectomies were performed during the study period in 39 patients (15 males; 25 left sided; 1 bilateral). Four patients underwent conversion to complete the procedure. The mean tumor size was 6.97 ± 2.4 cm. The mean operating room (OR) time was 117 ± 50.4 min. Comparing the OR time between da Vinci and da Vinci S robotic systems showed that the OR time was significantly less (169 ± 46 vs. 94.25 ± 32 min; P = 0.002) while blood loss, length of stay, size and weight were not different. The mean length of stay was 3 days. There were no mortalities in our study. Benign neoplasms formed a majority of the tumors removed. Robotic adrenalectomy is an option for surgeons without extensive training in advanced laparoscopic techniques provided they have adequate open experience.

Minimally invasive surgery for pancreas has advanced at a steady pace in recent years. Although proximal pancreatic resection is still a formidable task, distal resection has become routine with a laparoscopic approach. The recent introduction of the Da Vinci Robotic Surgical System has helped to make this complex procedure much more feasible, efficient, and safe. In this paper, we describe our technique for robot-assisted distal pancreatectomy with splenic preservation, which can be broken down into five steps in a medial-to-lateral progression. Preservation of splenic vessels is routine, although in certain instances a Warshaw's technique is employed. The advantages of the robotic approach are described.

The duodenum is the second most common site for diverticulae, after the colon. They are common after the fifth decade and usually asymptomatic. Ten percent of patients present with symptoms, which include abdominal pain, hemorrhage, duodenal obstruction, diverticulitis, perforation, pancreatitis, and obstructive jaundice. After a thorough search of medline we present, for the first time, a case of obstructive jaundice secondary to duodenal diverticulum compressing the common bile duct. It was managed by laparobotic duodenal diverticulectomy with choledocho-duodenostomy. The operative technique is discussed.A 78-year-old female was found to have an abnormal cholestatic liver function profile and dilated common bile duct during workup for upper abdominal pain. CT scan showed dilated common bile duct measuring 2.7 cm with suspected ampullary mass. Endoscopic ultrasound showed a large diverticulum next to the ampulla. Upper GI endoscopy confirmed duodenal diverticulum, arising from the second part of the duodenum. Laparobotic duodenal diverticulectomy and choledochoduodenostomy were performed. Her post-operative course was complicated by Clostridium difficile diarrhea, treated with metronidazole and she was discharged home on the 6th postoperative day. Follow-up at 18 months demonstrated that she was well.Obstructive jaundice due to compression by a duodenal diverticulum is rare. It poses a diagnostic challenge and requires technically demanding surgical and endoscopic intervention. Robotic surgery has revolutionized the field of minimally invasive surgery by improving vision and motion control. Robotic duodenal diverticulectomy and choledocho-duodenostomy are safe and feasible.

A robotic approach to general surgery procedures may provide improved postoperative outcomes compared to either open or laparoscopic approaches. The role of robotics for gastroesophageal surgery, however, is still being evaluated.A review of the prospective database for robotic surgery at Valley Hospital between January 2002 and March 2014 identified 105 patients who underwent robotic gastric and esophageal resection. Patient demographics and perioperative factors were studied.Over a 12 years period, 105 patients underwent robotic gastroesophageal resection. The median operative time for distal gastrectomy (230 min [112-327]) was significantly less compared to either total gastrectomy (302 min [214-364]) or esophagogastrectomy (309 min [190-682]). The length of stay for patients undergoing distal gastrectomy (6 days [4-32]) was also significantly less than patients undergoing total gastrectomy (11 days [7-43]), as well as esophagogastrectomy (9 days [5-64]). In regard to the learning curve to perform robotic gastroesophageal surgery, there was a significant correlation between operative time and overall experience.This study demonstrated that robotic gastroesophageal surgery is feasible and can be safely performed. Assuming familiarity with the open procedures and acquisition of basic robotic skills, the learning curve for robotic gastroesophageal surgery requires approximately 20 cases.

The occurrence of a pancreatic tumor in a young patient is rare. However, when one identifies a pancreatic mass during pregnancy and particularly when the lesion is located in the tail of the pancreas, “unusual tumors” of the pancreas should be considered. The management of these tumors during pregnancy presents unusual challenges because of rapid tumor growth probably related to elevated levels of sex hormones. An immunohistochemical study was done to evaluate for hormone receptors of the tissue removed from the tumor. We present a case of a 37-year-old female patient in her 4th week of pregnancy who was found to have a pancreatic mass; she was followed with ultrasonography. At the 23rd week of gestation, the tumor increased in size to more than 12 cm and required resection. Immunohistochemical studies were done to evaluate receptors for progesterone, estrogen, PS2-estrogen-related protein, pancreatic polypeptide antigen, flow cytometry, DNA ploidy, and proliferative activity in tumor cells. Pathology showed a low-grade multiloculated mucinous cystic neoplasm of the pancreas. There was a positivity for progesterone receptor and PS2-estrogen-related protein but not for estrogen receptor in the tumor. We conclude that a pancreatic mass detected during pregnancy requires a different consideration for its management. Early tissue diagnosis with CT or ultrasound-guided biopsy is essential. Even those lesions diagnosed as benign would require early intervention because of their rapid growth, probably influenced by female sex hormones.

Annular pancreas in an adult is an uncommon and infrequently reported anomaly which is characterized by the presence of ectopic pancreatic tissue surrounding the descending part of the duodenum. It is one of the few congenital anomalies of the gastrointestinal tract, which can manifest with symptoms late in life (Ravitch and Woods in Ann Surg 132:1116-1127, 1950). In adults, the factors initiating symptoms are recurrent pancreatitis, duodenal stenosis at the site of the annulus, or duodenal or gastric ulceration (Morrell and Keynes in Br J Surg 57:814-816, 1970). Operative management of these cases involves bypassing the obstructed duodenum. Duodenoduodenostomy is routinely performed in neonates and children. We report a case of annular pancreas in a 55-year-old male that was successfully treated with robotic duodenoduodenostomy.

AIM: To develop a panel of blood-based diagnostic biomarkers consisting of circulating microRNAs for the detection of pancreatic cancer at an early stage. METHODS: Blood-based circulating microRNAs were profiled by high throughput screening using microarray analysis, comparing differential expression between early stage pancreatic cancer patients (n = 8) and healthy controls (n = 11). A panel of candidate microRNAs was generated based on the microarray signature profiling, including unsupervised clustering and statistical analysis of differential expression levels, and findings from the published literature. The selected candidate microRNAs were then confirmed using TaqMan real-time quantitative reverse transcription polymerase chain reaction (RT-qPCR) to further narrow down to a three-microRNA diagnostic panel. The three-microRNA diagnostic panel was validated with independent experimental procedures and instrumentation of RT-qPCR at an independent venue with a new cohort of cancer patients (n = 11), healthy controls (n = 11), and a group of high risk controls (n = 11). Receiver operating characteristic curve analysis was performed to assess the diagnostic capability of the three-microRNA panel. RESULTS: In the initial high throughput screening, 1220 known human microRNAs were screened for differential expression in pancreatic cancer patients versus controls. A subset of 42 microRNAs was then generated based on this data analysis and current published literature. Eight microRNAs were selected from the list of 42 targets for confirmation study, and three-microRNAs, miR-642b, miR-885-5p, and miR-22, were confirmed to show consistent expression between microarray and RT-qPCR. These three microRNAs were then validated and evaluated as a diagnostic panel with a new cohort of patients and controls and found to yield high sensitivity (91%) and specificity (91%) with an area under the curve of 0.97 (P < 0.001). Compared to the CA19-9 marker at 73%, the three-microRNA panel has higher sensitivity although CA19-9 has higher specificity of 100%. CONCLUSION: The identified panel of three microRNA biomarkers can potentially be used as a diagnostic tool for early stage pancreatic cancer.

A 59-year-old man with metastatic an esophageal tumor from hepatocellular carcinoma (HCC) presented with progressive dysphagia. He had undergone liver transplantation for HCC three and a half years prevously. At presentation, his radiological and endoscopic examinations suggested a submucosal tumor in the lower esophagus, causing a luminal stricture. We performed complete resection of the esophageal metastases and esophagogastrostomy reconstruction using the da Vinci robotic system. Recovery was uneventful and he was been doing well 2 mo after surgery. α-fetoprotein level decreased from 510 ng/mL to 30 ng/mL postoperatively. During the follow-up period, he developed a recurrent esophageal stricture at the anastomosis site and this was successfully treated by endoscopic esophageal dilatation.

Actinomyces is a normal commensal of the upper aerodigestive tract, colon and female reproductive tract. It can give rise to invasive disease in case of any breach in mucosal integrity, as well as, in patients with immunosuppression. Rarely, actinomycosis can involve the pancreas especially after episodes of pancreatitis or in post operative patients. We observed a case of actinomycosis affecting recurrent intraductal papillary mucinous neoplasm (IPMN) of pancreatic remnant, 5 years after a Whipple's procedure. Our patient, a 66 years old male with a history of Whipple's procedure for IPMN of pancreatic uncinate process, presented with repeated episodes of acute pancreatitis. Repeated radiological investigations (CT, MRI and EUS) revealed resolving pancreatitis with recurrent IPMN of the pancreatic tail. The patient underwent laparobotic assisted resection of the remnant pancreas and spleen 3 months later. Intraoperatively, in addition to the recurrent IPMN of pancreatic tail, we found a dense peripancreatic desmoplastic reaction with areas of thick yellow pus pockets in the remnant pancreatic body. Bacteriology and histopathology revealed it as a recurrent IPMN associated with actinomycosis of pancreas with chronic xanthogranulomatous changes. We conclude that actinomycosis of the pancreas is a rare entity with only 5 cases reported in English literature to the best of our knowledge. If diagnosed preoperatively, early institution of antibiotics can improve the surgical outcome. Fortunately, after diagnosis, we were able to start antibiotics in early postoperative period with successful outcome.

Gastric mucus and air bubbles are frequent sources of artifacts during endoscopic ultrasonography (EUS). To reduce these artifacts, we prepared a mucolytic-antifoam solution consisting of simethicone, acetylcysteine, and sodium bicarbonate and performed a prospective randomized and controlled trial comparing this solution (21 patients) to a placebo (22 patients) during EUS. Eight patients in the drug group received a perfect score for both mucolytic and antifoam effect compared with none in the placebo group (p less than 0.001). For overall rating, the drug group received a total of 10 excellents and 9 goods compared with 9 goods, 10 satisfactories, and 1 unacceptable in the placebo group (p less than 0.001). There were no complications associated with the solution. In conclusion, a mucolytic-antifoam solution improved endoscopic visualization and reduced artifacts during EUS study. Its routine use during EUS procedures is therefore recommended.

• Seventy patients with Merkel cell carcinoma were treated at Memorial Sloan-Kettering Cancer Center between 1969 and 1989. The overall estimated 5-year survival rate was 64%. Factors predictive of improved survival included head and neck site and negative lymph nodes at presentation. Local recurrence was seen in 18 patients (26%) and did not correlate with patient-, tumor-, or treatment-related variables. Nine patients with local recurrence (50%) were free of disease following aggressive reoperation. Regional nodes were involved at some point during the course of the disease in forty-six patients (66%). Regional lymph node involvement was apparent within 2 years of diagnosis in 40 (87%) of 46 patients in whom it occurred. Systemic disease was nearly uniformly preceded by the appearance of nodal metastases and was uniformly fatal regardless of subsequent therapy. This suggests an orderly "cascade" pattern of spread for this tumor, in which elective regional lymph node dissection may be justified. Our recommendations for treatment include a wide excision of the primary tumor and either elective or early therapeutic regional node dissection. The role of adjuvant radiotherapy or chemotherapy remains unproven. ( Arch Surg . 1991;126:1514-1519)

The application of ultrasonography by surgeons in hospitalized patients and the potential benefits thereof were evaluated in 52 patients. Ultrasonography was used to diagnose emergent conditions in 30 patients, nonemergent conditions in 16 patients, and as a guide for interventional procedures in 6 patients. The procedure was carried out by a specially trained member of the surgical team, thus providing use of the technique as required. In assessing the degree of reliability of ultrasonography for surgical decision-making, it was found to be helpful in arriving at a decision in 47 patients, not helpful in 3 patients, and misleading in 2 patients in whom results were misinterpreted. The use of ultrasonography by the surgical team may help to provide early diagnosis, and thus may shorten the delay in necessary surgical intervention. It can also serve as a guide during interventional procedures and thereby can increase their safety and accuracy. We believe that the ability to carry out and interpret ultrasonographic tests is a helpful addition to the surgeon's armamentarium.

From May 1985 to February 1986, high-frequency B-mode real-time ultrasound examinations proved helpful in localizing bullets that were not palpable externally in the extremities and body wall of six patients. Of these, four patients had bullets removed successfully with the ultrasonically guided needle puncture technique. The entire procedure was carried out independently at the bedside by the surgical team. We further concluded that surgeons would benefit by learning and using ultrasound, a technique that is relatively easy to acquire and that has broad potential for surgical application, especially in the operating room.