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Background: Robotic camera holders for endoscopic surgery have been available for 20 years but market penetration is low. The current camera holders are controlled by voice, joystick, eyeball tracking, or head movements, and this type of steering has proven to be successful but excessive disturbance of surgical workflow has blocked widespread introduction. The Autolap™ system (MST, Israel) uses a radically different steering concept based on image analysis. This may improve acceptance by smooth, interactive, and fast steering. These two studies were conducted to prove safe and efficient performance of the core technology., Methods: A total of 66 various laparoscopic procedures were performed with the AutoLap™ by nine experienced surgeons, in two multi-center studies; 41 cholecystectomies, 13 fundoplications including hiatal hernia repair, 4 endometriosis surgeries, 2 inguinal hernia repairs, and 6 (bilateral) salpingo-oophorectomies. The use of the AutoLap™ system was evaluated in terms of safety, image stability, setup and procedural time, accuracy of imaged-based movements, and user satisfaction., Results: Surgical procedures were completed with the AutoLap™ system in 64 cases (97%). The mean overall setup time of the AutoLap™ system was 4 min (04:08 ± 0.10). Procedure times were not prolonged due to the use of the system when compared to literature average. The reported user satisfaction was 3.85 and 3.96 on a scale of 1 to 5 in two studies. More than 90% of the image-based movements were accurate. No system-related adverse events were recorded while using the system., Conclusion: Safe and efficient use of the core technology of the AutoLap™ system was demonstrated with high image stability and good surgeon satisfaction. The results support further clinical studies that will focus on usability, improved ergonomics and additional image-based features.

Background: Hiatal hernia (HH) after esophagectomy is becoming more relevant due to improvements in survival. This study evaluated and compared the occurrence and clinical course of HH after open and minimally invasive esophagectomy (MIE)., Methods: The prospectively recorded characteristics of patients treated with esophagectomy for cancer at 2 tertiary referral centers in the United Kingdom and the Netherlands between 2000 and 2014 were reviewed. Computed tomography reports were reviewed to identify HH., Results: Of 657 patients, MIE was performed in 432 patients (66%) and open esophagectomy in 225 (34%). A computed tomography scan was performed in 488 patients (74%). HH was diagnosed in 45 patients after a median of 20 months (range, 0 to 101 months). The development of HH after MIE was comparable to the open approach (8% vs 5%, p = 0.267). At the time of diagnosis, 14 patients presented as a surgical emergency. Of the remaining 31 patients, 17 were symptomatic and 14 were asymptomatic. An elective operation was performed in 10 symptomatic patients, and all others were treated conservatively. During conservative treatment, 2 patients presented as a surgical emergency. An emergency operation resulted in a prolonged intensive care unit stay compared with an elective procedure (3 vs 0 days, p < 0.001). In-hospital deaths were solely seen after emergency operations (19%)., Conclusions: HH is a significant long-term complication after esophagectomy, occurring in a substantial proportion of the patients. The occurrence of HH after MIE and open esophagectomy is comparable. Emergency operation is associated with dismal outcomes and should be avoided., (Copyright © 2017. Published by Elsevier Inc.)

Esophagolymphadenectomy is the cornerstone of multimodality treatment for resectable esophageal cancer. The preferred surgical approach is transthoracic, with a two-field lymph node dissection and gastric conduit reconstruction. A minimally invasive approach has been shown to reduce postoperative complications and increase quality of life. Robot-assisted minimally invasive esophagectomy (RAMIE) was developed to facilitate this complex thoracoscopic procedure. RAMIE has been shown to be safe with good oncologic results and reduced morbidity. The use of RAMIE opens new indications for curative surgery in patients with T4b tumors, high mediastinal tumors, and lymph node metastases after neoadjuvant treatment.

Laparoscopic gastrectomy (LG) is a safe alternative compared to open gastrectomy for cancer. To increase the uptake of minimally invasive approaches and facilitate their analysis and improvement a stepwise approach is warranted. This study describes our technique and experiences total laparoscopic gastrectomy (TLG) with jejunal pouch reconstruction for gastric cancer. Technical modifications throughout the years were described. In patients with anastomotic leakage, the CT-scan and reoperation report were reviewed to identify the location and cause of the leak. A total of 47 patients who underwent laparoscopic total gastrectomy with extracorporeal jejunal pouch reconstruction and stapled circular esophagojejunostomy from May 2007 to August 2015 were prospectively analyzed. A stepwise approach of 10 steps was designed based on video and case analysis. Median operation time was 301 (148-454) minutes and median blood loss was 300 (30-900) milliliters. Anastomotic leakage occurred in six (12.8 %) patients; additionally, one (2.12 %) jejunal-pouch staple line leak was identified. An important modification in our technique was a purse-string suture around the anvil of the circular stapler to prevent esophageal mucosa to slip away. After this modification, the leakage rate was reduced to 7 % in the last 15 procedures. In conclusion, TLG with jejunal pouch reconstruction is a feasible procedure in a selected group of patients. Our stepwise approach and technique may help surgeons to introduce jejunal pouch reconstruction during laparoscopic gastrectomy in their center., Competing Interests: Compliance with Ethical Standards Disclosures JR and RvH received an unrestricted educational grant from Johnson and Johnson for proctoring of MIG. The MIG course at the UMC Utrecht is supported by Medtronic, Olympus, Takeda and Intuitive Surgical. HJFB and JCC have no conflicts of interest or financial ties to disclose.

Background: For cholecystectomy, multiport laparoscopy is the recommended surgical approach. Single-port laparoscopy (SPL) was introduced to reduce postoperative pain and provide better cosmetic results, but has technical disadvantages. Robotic SPL (RSPL) was developed to overcome these disadvantages. In this prospective study, we aim to describe intraoperative results and postoperative outcomes of RSPL cholecystectomies and evaluate technical aspects of the technique., Methods: A prospective database of all patients who underwent a RSPL cholecystectomy between January 2012 and December 2014 was analyzed. Intraoperative results and postoperative complications were evaluated., Results: A total of 27 patients underwent RSPL cholecystectomy. Median age was 59 (20-78) years and median body mass index was 25 (19-35) kg/m 2 . The majority of patients had American Society of Anesthesiologists (ASA) II classification (67%) and 89% underwent surgery for cholecystolithiasis or cholecystitis. The median operating time was 81 (41-115) minutes. Conversion to a multiport procedure occurred in 2; one due to insufficient length of the robotic instruments. In the second and third patients, conversion to an open procedure was necessary due to inadequate exposure caused by liver cirrhosis and purulent ascites, respectively. In seven procedures, spill occurred due to rupture of the gallbladder. Postoperative complications occurred in 4 patients, including 1 bleeding (no reintervention), 1 peritonitis, and 2 wound infections. After a median follow-up of 33 (10-44) months, 5 (19%) trocar-site hernias were seen., Conclusion: RSPL cholecystectomy is feasible, however, encountered by technical challenges due to inadequate length of the nonwristed robotic instruments. A high incidence of gallbladder rupture and trocar-site hernias may limit its application.

Esophagolymphadenectomy is the cornerstone of multimodality treatment for resectable esophageal cancer. The preferred surgical approach is transthoracic, with a two-field lymph node dissection and gastric conduit reconstruction. A minimally invasive approach has been shown to reduce postoperative complications and increase quality of life. Robot-assisted minimally invasive esophagectomy (RAMIE) was developed to facilitate this complex thoracoscopic procedure. RAMIE has been shown to be safe with good oncologic results and reduced morbidity. The use of RAMIE opens new indications for curative surgery in patients with T4b tumors, high mediastinal tumors, and lymph node metastases after neoadjuvant treatment.

Background: There is no consensus on the optimal technique for hiatal hernia (HH) repair, and considerable recurrence rates are reported. The aim of this study was to evaluate the perioperative outcomes, quality of life (QoL), and recurrence rate in patients undergoing robot-assisted laparoscopic HH repair., Materials and Methods: All patients who underwent robot-assisted laparoscopic HH repair between July 2011 and March 2015 were evaluated. The procedure consisted of hernia sac reduction, crural repair without mesh, and Toupet fundoplication. Postoperative radiological imaging or endoscopy was performed in all symptomatic patients to exclude recurrence. Perioperative results were collected retrospectively from the patient records. QoL was evaluated with Short Form-36 (SF-36), Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQOL), and Gastrointestinal Quality of Life Index (GIQLI) questionnaires., Results: A total of 40 patients were identified. The majority (75%) had a type III HH. Median operation time was 118 (62-173) minutes; median blood loss was 20 (10-934) mL, and one procedure was converted to an open procedure. In 6 (15%) patients, postoperative complications occurred, including 2 grade II and 1 grades I, III, IV, and V, according to the Clavien-Dindo classification. Median hospital stay was 3 (1-15) days. At a median follow-up of 11 months, radiological imaging was performed on indication in 12 (30%) patients, and 1 recurrence was found. Overall QoL scores were satisfactory, and there was no difference related to the time elapsed since surgery., Conclusion: Robot-assisted laparoscopic HH repair followed by Toupet fundoplication demonstrated a very low short-term recurrence rate. Postoperative morbidity was minimal, and a satisfactory QoL was achieved.

Aim: The aim of this study was to determine the oncologic value of omentectomy in patients undergoing gastrectomy for gastric cancer., Methods: All consecutive patients with gastric cancer that underwent gastrectomy with curative intent between April 2012 and August 2015 were prospectively analyzed. The greater omentum was separately marked during operation and pathologically evaluated for the presence of omental lymph nodes and tumor deposits., Results: In total, 50 patients were included. The greater omentum harbored lymph nodes in nine (18 %) patients. The omental lymph nodes contained metastases in one (2 %) patient, still free of disease after 20 months. Omental tumor deposits were found in four (8 %) patients; one died <30 days postoperative and three developed peritoneal carcinomatosa after 4, 4, and 8 months. Patients with omental tumor deposits had a significantly reduced 1-year disease-free survival compared to patients without tumor deposits (0 vs. 58.7 %, p = 0.003). No predictive factors for omental tumor involvement could be identified., Conclusion: Omental lymph node metastases or tumor deposits are present in 10 % of Western European patients undergoing gastrectomy for gastric cancer. Omentectomy has a prognostic and oncologic value in the curative treatment of patients with gastric cancer. As no predictive factors for omental tumor involvement could be identified, omentectomy should be the standard in gastrectomy for gastric cancer patients.

Aim: To evaluate the current status of gastric cancer surgery worldwide., Methods: An international cross-sectional survey on gastric cancer surgery was performed amongst international upper gastro-intestinal surgeons. All surgical members of the International Gastric Cancer Association were invited by e-mail to participate. An English web-based survey had to be filled in with regard to their surgical preferences. Questions asked included hospital volume, the use of neoadjuvant treatment, preferred surgical approach, extent of the lymphadenectomy and preferred anastomotic technique. The invitations were sent in September 2013 and the survey was closed in January 2014., Results: The corresponding specific response rate was 227/615 (37%). The majority of respondents: originated from Asia (54%), performed > 21 gastrectomies per year (79%) and used neoadjuvant chemotherapy (73%). An open surgical procedure was performed by the majority of surgeons for distal gastrectomy for advanced cancer (91%) and total gastrectomy for both early and advanced cancer (52% and 94%). A minimally invasive procedure was preferred for distal gastrectomy for early cancer (65%). In Asia surgeons preferred a minimally invasive procedure for total gastrectomy for early cancer also (63%). A D1+ lymphadenectomy was preferred in early gastric cancer (52% for distal, 54% for total gastrectomy) and a D2 lymphadenectomy was preferred in advanced gastric cancer (93% for distal, 92% for total gastrectomy), Conclusion: Surgical preferences for gastric cancer surgery vary between surgeons worldwide. Although the majority of surgeons use neoadjuvant chemotherapy, minimally invasive techniques are still not widely adapted.

Background: For gastric cancer patients, surgical resection with en-bloc lymphadenectomy is the cornerstone of curative treatment. Open gastrectomy has long been the preferred surgical approach worldwide. However, this procedure is associated with considerable morbidity. Several meta-analyses have shown an advantage in short-term outcomes of laparoscopic gastrectomy compared to open procedures, with similar oncologic outcomes. However, it remains unclear whether the results of these Asian studies can be extrapolated to the Western population. In this trial from the Netherlands, patients with resectable gastric cancer will be randomized to laparoscopic or open gastrectomy., Methods: The study is a non-blinded, multicenter, prospectively randomized controlled superiority trial. Patients (≥18 years) with histologically proven, surgically resectable (cT1-4a, N0-3b, M0) gastric adenocarcinoma and European Clinical Oncology Group performance status 0, 1 or 2 are eligible to participate in the study after obtaining informed consent. Patients (n = 210) will be included in one of the ten participating Dutch centers and are randomized to either laparoscopic or open gastrectomy. The primary outcome is postoperative hospital stay (days). Secondary outcome parameters include postoperative morbidity and mortality, oncologic outcomes, readmissions, quality of life and cost-effectiveness., Discussion: In this randomized controlled trial laparoscopic and open gastrectomy are compared in patients with resectable gastric cancer. It is expected that laparoscopic gastrectomy will result in a faster recovery of the patient and a shorter hospital stay. Secondly, it is expected that laparoscopic gastrectomy will be associated with a lower postoperative morbidity, less readmissions, higher cost-effectiveness, better postoperative quality of life, but with similar mortality and oncologic outcomes, compared to open gastrectomy. The study started on 1 December 2014. Inclusion and follow-up will take 3 and 5 years respectively. Short-term results will be analyzed and published after discharge of the last randomized patient., Trial Registration: NCT02248519.