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BACKGROUND The benefits of laparoscopic approach for right colectomy have been well established. However, the technical difficulty to construct the intra-corporeal anastomosis is still cumbersome. AIM To analyze the results of 3D and 2D laparoscopic right colectomy and to compare it to the published series through a systematic review and meta-analysis. METHODS A retrospective study with propensity score matching analysis of patients undergoing laparoscopic right colectomy at Umbria2 Hospitals from January 2014 to March 2020 was performed. A systematic review was accomplished comparing 2D and 3D right colectomy. RESULTS In the personal series 47 patients of the 2D group were matched to 47 patients of the 3D group. The 3D group showed a favorable trend in terms of mean operative time (170.7 ± 32.9 min vs 183.8 ± 35.4 min; P = 0.053) and a significant lower anastomotic time (16.9 ± 2.3 min vs 19.6 ± 2.9 min, P < 0.001). The complete mesocolic excision (CME) subgroups analysis showed a shorter anastomotic time (16.5 ± 1.8 min vs 19.9 ± 3.0 min; P < 0.001) and operative time (175.0 ± 38.5 min vs 193.7 ± 37.1 min; P = 0.063) in the 3D group. Six studies and our series were included in the meta-analysis with 551 patients (2D group: 291; 3D group: 260).The pooled analysis demonstrated a significant difference in favour of the 3D group regarding the operative time (P < 0.001) and the anastomotic time (P < 0.001) while no differences were identified between groups in terms of blood loss (P = 0.827), LNH yield (P = 0.243), time to first flatus (P = 0.333), postoperative complications (P = 0.718) and length of stay (P = 0.835). CONCLUSION The meta-analysis results showed that 3D laparoscopic right colectomy shortens operative and anastomotic time without affecting the standard lymphadenectomy. In our series, the advantage of the 3D system becomes evident when CME and/or more complex associated procedure are requested significantly reducing both the total operative and the anastomotic time.

Although there is no agreement on a definition of elderly, commonly an age cutoff of ≥ 65 or 75 years is used. Even if robot-assisted surgery is a validated option for the elderly population, there are no specific indications for its application in the surgical treatment of gastric cancer. The aim of this study is to evaluate the safety and feasibility of robot-assisted gastrectomy and to compare the short and long-term outcomes of robot-assisted (RG) versus open gastrectomy (OG). Patients aged ≥ 70 years old undergoing surgery for gastric cancer at the Department of Surgery of San Donato Hospital in Arezzo, between September 2012 and March 2017 were enrolled. A 1:1 propensity score matching was performed according to the following variables: age, Sex, BMI, ASA score, comorbidity, T stage and type of resection performed. 43 OG were matched to 43 RG. The mean operative time was significantly longer in the RG group (273.8 vs. 193.5 min, p p = 0.313) and a significantly higher postoperative pain (0.95 vs. 1.24, p = 0.042). Overall survival (p = 0.263) and disease-free survival (p = 0.474) were comparable between groups. Robotic-assisted surgery for oncological gastrectomy in elderly patients is safe and effective showing non-inferiority comparing to the open technique in terms of perioperative outcomes and overall 5-year survival.

Background Giant hiatal hernia (GHH) is a condition where one-third of the stomach migrates into the thorax. Nowadays, laparoscopic treatment gives excellent postoperative outcomes. Strangulated GHH is rare, and its emergent repair is associated with significant morbidity and mortality rates. We report a series of five cases of strangulated GHH treated by a minimally invasive laparoscopic and robot-assisted approach, together with a systematic review of the literature. Methods During 10 years (December 2009–December 2019), 31 patients affected by GHH were treated by robot-assisted or conventional laparoscopic surgical approach. Among them, five cases were treated in an emergency setting. We performed a PubMed MEDLINE search about the minimally invasive emergent treatment of GHH, selecting 18 articles for review. Results The five cases were male patients with a mean age of 70 ± 18 years. All patients referred to the emergency service complaining of severe abdominal and thoracic pain, nausea and vomiting. CT scan and endoscopy were the main diagnostic tools. All patients showed stable hemodynamic conditions so that they could undergo a minimally invasive attempt. The surgical approach was robotic-assisted in three patients (60%) and laparoscopic in two (40%). Patients reported no complications or recurrences. Conclusion Reviewing current literature, no general recommendations are available about the emergent treatment of strangulated hiatal hernia. Acute mechanical outlet obstruction, ischemia of gastric wall or perforation and severe bleeding are the reasons for an emergent surgical indication. In stable conditions, a minimally invasive approach is often feasible. Moreover, the robot-assisted approach, allowing a stable 3D view and using articulated instruments, represents a reasonable option in challenging situations.

Robotic hepatobiliary surgery has significantly developed worldwide with substantial clinical results. Hepatobiliary anatomical anomalies increase the complexity of hepatobiliary resection with a relevant risk of iatrogenic lesions. Among congenital liver anomalies, the ‘bipartite liver’ is an extremely rare condition which might be associated with complex surgical dissection of the hepatic hilum. We herein report a rare case of congenital ‘bipartite liver’ associated with a cholangiocarcinoma of segment VI and calculous cholecystitis. The patient underwent robot-assisted segmentectomy and cholecystectomy with the use of indocyanine-green cholangiography and intraoperative ultrasound. A challenging hilar dissection was performed using this approach. To the best of our knowledge, this is the first case reported that describes a robot-assisted liver resection and cholecystectomy in a patient having a cholangiocarcinoma associated with this rare liver anomaly. The robotic approach was safe and effective and the 3D preoperative imaging, as well as the intraoperative green-indocyanine cholangiography was extremely useful, especially during hilar dissection and cholecystectomy.

Background Several reports demonstrated a strong association between the level of adherence to the protocol and improved clinical outcomes after surgery. However, it is difficult to obtain full adherence to the protocol into clinical practice and has still not been identified the threshold beyond which improved functional results can be reached. Methods The ERCOLE (ERas and COLorectal Endoscopic surgery) study was as a cohort, prospective, multi-centre national study evaluating the association between adherence to ERAS items and clinical outcomes after minimally invasive colorectal surgery. The primary endpoint was to associate the percentage of ERAS adherence to functional recovery after minimally invasive colorectal cancer surgery. The secondary endpoints of the study was to validate safety of the ERAS programme evaluating complications’ occurrence according to Clavien-Dindo classification and to evaluate the compliance of the Italian surgeons to each ERAS item. Results 1138 patients were included. Adherence to the ERAS protocol was full only in 101 patients (8.9%), > 75% of the ERAS items in 736 (64.7%) and > 50% in 1127 (99%). Adherence to > 75% was associated with a better functional recovery with 90.2 ± 98.8 vs 95.9 ± 33.4 h (p = 0.003). At difference, full adherence to the ERAS components 91.7 ± 22.1 vs 92.2 ± 31.6 h (p = 0.8) was not associated with better recovery. Conclusions Our results were encouraging to affirm that adherence to the ERAS program up to 75% could be considered satisfactory to get the goal. Our study could be considered a call to simplify the ERAS protocol facilitating its penetrance into clinical practice.

Background The role of robotic surgery for colorectal cancer liver metastases (CRCLMs) has never been investigated in large series. Methods A systematic literature review was carried out on PubMed and Cochrane libraries. Results We selected 9 studies between 2008 to 2021. 262 patients were included. 131 patients underwent simultaneous resections. The mean blood loss was 309.4 ml (range, 200-450 ml), the mean operative time was 250.5 min (range, 198.5-449.0 min). The mean length of hospital stay was 7.98 days (range, 4.5 to 12 days). The overall postoperative mortality was 0.4%. The overall morbidity rate was 37.0%, Clavien-Dindo grade III-IV complications were 8.4%. The mean 3-year overall survival was 55.25% (range, 44.4-66.1%), the mean 3-year disease free survival was 37% (range, 33.3-41.9%). Conclusion We can conclude that robotic-assisted surgery might be considered as a technical upgrade option for minimally invasive approach to CRCLM resections even for simultaneous operations and challenging cases. This article is protected by copyright. All rights reserved.

We herein report the case of a symptomatic splenic artery aneurysm (SAA) diagnosed in a 65-year-old woman. Endoluminal exclusion was considered as first option, but the potential risk of postoperative splenic infarction, postsplenectomy thrombocytosis and immunodeficiency in an otherwise healthy patient raised the possibility to carry out a surgical procedure of vascular reconstruction using the robotic device Da Vinci® Surgical System (Intuitive Surgical, Sunnyvale, CA, USA). We performed the resection of the aneurysm and the continuity of the splenic artery was restored by end-to-end anastomosis.

Highlights • All symptomatic paraesophageal hiatal hernias should be repaired, particularly those with acute obstructive symptoms or which have undergone volvulus. • Laparoscopic hiatal hernia repair is as effective as open transabdominal repair, with a reduced rate of perioperative morbidity and with shorter hospital stays. It is the preferred approach for the majority of hiatal hernias. • Robotic Assisted Giant-Paraesophageal Hernia repair remain technically challenging predominantly in the dissecation of the hernia sac from the posterior mediastinum. • The robotic platform have the same benefits of the laparoscopic approach in terms of complication rate, total surgical time, and hospital length of stay and in particular case is superior., Introduction Giant hiatus hernia is defined as migration of >30% of the stomach with or without other intra-abdominal organs into the chest. Situs Viscerum Inversus is a rare congenital condition in which the major visceral organs are reversed from their normal arrangement; they are translated (completely or partially) on the opposite side of the body. Diagnosis is often incidental. We report a Robot-assisted Toupet fundoplication for a giant hiatal hernia with gastro oesophageal reflux disease and cholelithiasis, in a 63-years-old woman with situs viscerum inversus. Presentation of case A 63-year-old woman with Situs Viscerum Inversus was diagnosed with giant sliding hiatus hernia. We performed a Robot-assisted procedure of reduction of hiatal hernia in abdomen and Toupet fundoplication with Bio A mesh placement and gastropexy procedure associated to cholecystectomy. The operation time was of 190 min. The patient was discharged on third postoperative day after X-ray check and he tolerated a solid food. Discussion Minimally invasive surgery represents, nowadays, the standard approach for hiatal hernia and cholelithiasis. Conclusion In challenging cases as the giant hernias ad rare anomaly as situs viscerum inversus, the surgical treatment can be facilitated by the use of robotic technology.

BACKGROUND: Emergency situations, as the Covid-19 pandemic that is striking the world nowadays, stress the national health systems which are forced to rapidly reorganizing their sources. Therefore, many elective diagnostic and surgical procedures are being suspended or significantly delayed. Moreover, patients might find it difficult to refer to physicians and delay the diagnostic and even the therapeutic procedures because of emotional or logistic problems. The effect of diagnostic and therapeutic delay on survival in patients affected by gastrointestinal malignancies is still unclear. METHODS: We carried out a review of the available literature, in order to determine whether the delay in performing diagnosis and curative-intent surgical procedures affects the oncological outcomes in patients with oesophageal, gastric, colorectal cancers, and colorectal liver metastasis. RESULTS: The findings indicate that for oesophageal, gastric and colon cancers delaying surgery up to 2 months after the end of the staging process does not worsen the oncological outcomes. Oesophageal cancer should undergo surgery within 7-8 weeks after the end of neoadjuvant chemoradiation. Rectal cancers should undergo surgery within 31 days after the diagnostic process and within 12 weeks after neoadjuvant therapy. Adjuvant therapy should start within 4 weeks after surgery, especially in gastric cancer; a delay up to 42 days may be allowed for oesophageal cancer undergoing adjuvant radiotherapy. CONCLUSIONS: Gastrointestinal malignancies can be safely managed taking into account that reasonable delays of planned treatments appear a generally safe approach, not having a significant impact on long-term oncological outcome.

Background Fluorescence-guided visualization is a recently proposed technology in colorectal surgery. Possible uses include evaluating perfusion, navigating lymph nodes and searching for hepatic metastases and peritoneal spread. Despite the absence of high-level evidence, this technique has gained considerable popularity among colorectal surgeons due to its significant reliability, safety, ease of use and relatively low cost. However, the actual use of this technique in daily clinical practice has not been reported to date. Methods This survey was conducted on April 2020 among 44 centers dealing with colorectal diseases and participating in the Italian ColoRectal Anastomotic Leakage (iCral) study group. Surgeons were approximately equally divided based on geographical criteria from multiple Italian regions, with a large proportion based in public (89.1%) and nonacademic (75.7%) centers. They were invited to answer an online survey to snapshot their current behaviors regarding the use of fluorescence-guided visualization in colorectal surgery. Questions regarding technological availability, indications and techniques, personal approaches and feelings were collected in a 23-item questionnaire. Results Questionnaire replies were received from 37 institutions and partially answered by 8, as this latter group of centers do not implement fluorescence technology (21.6%). Out of the remaining 29 centers (78,4%), fluorescence is utilized in all laparoscopic colorectal resections by 72.4% of surgeons and only for selected cases by the remaining 27.6%, while 62.1% of respondents do not use fluorescence in open surgery (unless the perfusion is macroscopically uncertain with the naked eye, in which case 41.4% of them do). The survey also suggests that there is no agreement on dilution, dosing and timing, as many different practices are adopted based on personal judgment. Only approximately half of the surgeons reported a reduced leak rate with fluorescence perfusion assessment, but 65.5% of them strongly believe that this technique will become a minimum requirement for colorectal surgery in the future. Conclusion The survey confirms that fluorescence is becoming a widely used technique in colorectal surgery. However, both the indications and methods still vary considerably; furthermore, the surgeons' perceptions of the results are insufficient to consider this technology essential. This survey emphasizes the need for further research to reach recommendations based on solid scientific evidence.

Background: The benefits of pure laparoscopic and robot-assisted liver resections (LLR and RALR) are known in comparison to open surgery. The aim of the present retrospective comparative study is to investigate the role of RALR and LLR according to different levels of difficulty. Methods: The institutional databases of six high-volume hepatobiliary centers were retrospectively reviewed. The study population was divided in two groups: LLR and RALR. The procedures were stratified for difficulty levels accordingly to three classifications. A propensity score matching was implemented to mitigate selection bias. Short-term outcomes were the object of comparison. Results: Nine hundred and thirty-six LLR and 403 RALR were collected. RALR exhibited fewer cases of intraoperative blood loss, lower transfusion and conversion rates (especially for oncological radicality) than LLR in the setting of highly difficult operations, whereas LLR had lower postoperative morbidity and fewer low-grade complications. For intermediate and low-difficulty resections, the intraoperative advantages of RALR gradually decreased to nonsignificant results and LLR remained associated with lower postoperative morbidity. Conclusion: Robot-assisted liver resections do not show operative nor clinically significant benefits over LLR for low- and intermediate-difficulty resections. By reducing conversion rates, RALR can favour the operative feasibility of difficult resections possibly extending the indications of minimally invasive approaches for liver resection.

Background: Gastrointestinal stromal tumors (GISTs) are most frequently located in the stomach. In the setting of a multidisciplinary approach, surgery represents the best therapeutic option, consisting mainly in a wedge gastric resection. (1) Materials and methods: Between January 2010 to September 2020, 105 patients with a primary gastrointestinal stromal tumor (GISTs) located in the stomach, underwent surgery at three surgical units. (2) Results: A multi-institutional analysis of minimally invasive series including 81 cases (36 laparoscopic and 45 robotic) from 3 referral centers was performed. Males were 35 (43.2%), the average age was 66.64 years old. ASA score &gt, 3 was 6 (13.3%) in the RS and 4 (11.1%) in the LS and the average tumor size was 4.4 cm. Most of the procedures were wedge resections (N = 76, 93.8%) and the main operative time was 151 min in the RS and 97 min in the LS. Conversion was necessary in five cases (6.2%). (3) Conclusions: Minimal invasive approaches for gastric GISTs performed in selected patients and experienced centers are safe. A robotic approach represents a useful option, especially for GISTs that are more than 5 cm, even located in unfavorable places.

Emergency surgical procedures in elderly patients have been very rarely described in the literature.

Different strategies may be adopted in patients with synchronous colorectal liver metastases (LM). The role of laparoscopy has been investigated to define the benefits of minimally invasive surgery in a single-stage operation. In our study, we report our experience of 28 Minimally Invasive Robotic-Assisted combined Colorectal and Liver Excision Surgery (MIRACLES). From October 2012 to December 2019, 135 Robotic liver resections and 218 Robotic Colorectal resections were performed in our center. Twenty-eight patients underwent MIRACLES resection with 37 nodules removed. Fifty-two lesions in 28 patients were resected in minimally invasive robot-assisted surgery. Eighteen lesions were located in postero-superior liver segments (eight in segment VII, two in segment VIII, eight in segment IVa). Nine right colectomies, seven left colectomies, ten anterior rectal resections, one Hartmann and one MILES procedures were performed. The median surgical time of MIRACLES procedures was 332 min. Two conversions to open approach were necessary. Four major complications (> III) were observed. No postoperative mortality was recorded. The median hospital stay was 8 days. The median overall survival was 27.5 months. The MIRACLES approach is feasible and safe for colorectal resection and hepatic nodules located in all segments, with a low rate of postoperative complications. Surgical technique is demanding and should be reserved, presently, to tertiary centers.

Background The clinical benefit of extending prophylaxis for venous thromboembolism (VTE) beyond hospital discharge after laparoscopic surgery for cancer is undefined. Extended prophylaxis with rivaroxaban is effective in reducing post-operative VTE after major orthopedic surgery without safety concern. Methods PROLAPS II is an investigator-initiated, randomized, double-blind study aimed at assessing the efficacy and safety of extended antithrombotic prophylaxis with rivaroxaban compared with placebo after laparoscopic surgery for colorectal cancer in patients who had received antithrombotic prophylaxis with low molecular-weight heparin for 7 ± 2 days (NCT03055026). Patients are randomized to receive rivaroxaban (10 mg once daily) or placebo for 3 weeks (up to day 28 ± 2 from surgery). The primary study outcome is a composite of symptomatic objectively confirmed VTE, asymptomatic ultrasonography-detected DVT or VTE-related death at 28 ± 2 days from laparoscopic surgery. The primary safety outcome is major bleeding defined according to the International Society of Thrombosis and Haemostasis. Symptomatic objectively confirmed VTE, asymptomatic ultrasonography-detected DVT, major bleeding or death by day 28 ± 2 and by day 90 from surgery are secondary outcomes. Assuming an 8% event rate with placebo and 60% reduction in the primary study outcome with rivaroxaban, 323 patients per group are necessary to show a statistically significant difference between the study groups. Discussion The PROLAPS II is the first study with an oral anti-Xa agent in cancer surgery. The study has the potential to improve clinical practice by answering the question on the clinical benefit of extending prophylaxis after laparoscopic surgery for colorectal cancer.

We describe our preliminary experience in complete mesocolic excision (CME) with central vascular ligation (CVL) and intracorporeal anastomosis for right colon cancer, comparing the robotic and the three-dimensional (3D) laparoscopic approach. We performed a retrospective observational clinical cohort study on patients who underwent radical curative surgical resection of right colon cancer with CME from January 2014 to June 2019. Propensity scores were calculated by bivariate logistic regression, including the following variables: age, BMI, and size of tumor. Fifty-five patients underwent CME with CVL: 26 by means of robot-assisted surgery and 29 by means of 3D laparoscopic procedure. There were not statistically significant differences about all the intra- and postoperative outcomes (operative time, length of the specimen, time to bowel canalization, time to soft oral intake, length of hospital stay, postoperative complication, number of retrieved lymph nodes, number of positive lymph nodes and lymph node ratio) between the robotic and the 3D laparoscopic approach. After the matching procedure, 20 patients of the robotic group and 20 patients of the 3D laparoscopic group were selected for the analysis. There were no differences in any of the analyzed variables between the two groups except for longer operative time in the robotic group (p = 0.002). The 3D vision revealed an important advantage in order to achieve the correct identification of surgical anatomy allowing a safe and effective right colectomy with CME, CVL, and intracorporeal anastomosis, either using laparoscopic or with robotic approach, providing similar short-term outcomes. Taking into account the high costs and the longer operative time of robotic procedure, the 3D laparoscopy could be considered in performing right colectomy with CME, while the robotic approach should be considered as a first choice approach for challenging situations (obese patient, complex associated procedures).

Background: Laparoscopic right hemicolectomy is a commonly performed procedure. Little is known on how to perform the enterotomy closure after stapled side-to-side intracorporeal anastomosis. Method: A multicentric case-controlled study has been designed to compare different ways to fashion enterotomy closure: double layer versus single layer, sewn versus stapled, and robotic versus laparoscopic approach. Furthermore, additional characteristics including sutures’ materials, interrupted versus running suture and the presence of deep corner suture has been investigated. Results: We collected data for 1092 patients who underwent right hemicolectomy at ten centers. We analyzed 176 robotic against 916 laparoscopic anastomosis: no significant differences were found in terms of bleedings (p = 0.455) and anastomotic leak (p = 0.405). We collected data from 126 laparoscopic sewn single-layer versus 641 laparoscopic sewn double-layer anastomosis: a significant reduction was recorded in terms of leaks in double-layer group (p = 0.02). About double-layer characteristics, we found a significant reduction of bleedings (p = 0.008) and leaks (p = 0.017) with a running suture; similarly, a reduction of bleedings (p = 0.001) and leaks (p = 0.005) was observed with the usage of deep corner closure. The presence of a barbed suture thread seemed to significantly reduce both bleedings (p = 0.001) and leaks (p = 0.001). We found no significant differences in terms of bleedings (p = 0.245) and anastomotic leak (p = 0.660) comparing sewn versus stapled anastomosis. Conclusions: Fashioning a stapled ileocolic intracorporeal anastomosis, we can recommend the adoption of a double-layer enterotomy closure using a running barbed suture in the first layer. Totally, stapled closure and robotic assistance have to be considered a non-inferior alternative.

This study aimed to assess the best achievable outcomes in laparoscopic liver resection (LLR) after risk adjustment based on surgical technical difficulty using a national registry.LLRs registered in the Italian Group of Minimally Invasive Liver Surgery registry from November 2014 to March 2018 were considered. Benchmarks were calculated according to the Achievable Benchmark of Care (ABC™). LLRs at each centre were divided into three clusters (groups I, II and III) based on the Kawaguchi classification. ABCs for overall and major morbidity were calculated in each cluster. Multivariable analysis was used to identify independent risk factors for overall and major morbidity. Significant variables were used in further risk adjustment.A total of 1752 of 2263 patients fulfilled the inclusion criteria: 1096 (62·6 per cent) in group I, 435 (24·8 per cent) in group II and 221 (12·6 per cent) in group III. The ABCs for overall morbidity (7·8, 14·2 and 26·4 per cent for grades I, II and II respectively) and major morbidity (1·4, 2·2 and 5·7 per cent) increased with the difficulty of LLR. Multivariable analysis showed an increased risk of overall morbidity associated with multiple LLRs (odds ratio (OR) 1·35), simultaneous intestinal resection (OR 3·76) and cirrhosis (OR 1·83), and an increased risk of major morbidity with intestinal resection (OR 4·61). ABCs for overall and major morbidity were 14·4 and 3·2 per cent respectively for multiple LLRs, 30 and 11·1 per cent for intestinal resection, and 14·9 and 4·8 per cent for cirrhosis.Overall morbidity benchmarks for LLR ranged from 7·8 to 26·4 per cent, and those for major morbidity from 1·4 to 5·7 per cent, depending on complexity. Benchmark values should be adjusted according to multiple LLRs or simultaneous intestinal resection and cirrhosis.Este estudio tuvo como objetivo evaluar los mejores resultados que se pueden conseguir en la resección hepática laparoscópica (laparoscopic liver resection, LLR) después del ajuste por riesgos basado en la dificultad de la técnica quirúrgica utilizando un registro nacional. MÉTODOS: Se consideraron las LLRs incluidas en el Registro del Grupo Italiano de Cirugía Hepática Mínimamente Invasiva desde 11/2014 a 03/2018. Los resultados de referencia (benchmarks) se calcularon de acuerdo con el Achievable Benchmark of Care (ABC™). Las LLRs de cada uno de los centros se dividieron en 3 grupos (Grupo I, II y III) en base a la clasificación de Kawaguchi. Se calculó el ABC de la morbilidad global y de la morbilidad mayor para cada grupo. Se realizó un análisis multivariable para identificar los factores independientes de riesgos para la morbilidad global y morbilidad mayor. Se utilizaron variables significativas para realizar ajustes de riesgo adicionales.Un total de 1.752 pacientes de los 2.263 cumplían los criterios de inclusión, de los cuales 1.096 (62,6%) se incluyeron en el Grupo I, 435 (24,8%) en el Grupo II y 221 (12,6%) en el Grupo III. El ABC de la morbilidad global (7,8%, 14,2%, 26,4%) y de la morbilidad mayor (1,4%, 2,2%, 5,7%) aumentó del Grupo I al Grupo III. El análisis multivariable mostró un incremento del riesgo para la morbilidad global asociada con múltiples LLRs (razón de oportunidades, odds ratio, OR 1,349), resección intestinal simultánea (OR 3,760) y cirrosis (OR 1,825), y para la morbilidad mayor con la resección intestinal (OR 4,606). Los ABC de la morbilidad global y morbilidad mayor fueron 14,4% y 3,2% para las LLR múltiples, 30% y 11% para la resección intestinal, y 14,9% y 4,8% para la cirrosis, respectivamente. CONCLUSIÓN: Los resultados de referencia (benchmark) para la morbilidad global y morbilidad mayor en la LLR variaron entre un 8% y un 26% y entre un 1,4% y un 5,7%, dependiendo de la complejidad. Los valores de referencia deberían ajustarse de acuerdo con la práctica de LLRs múltiples o resección intestinal simultánea y cirrosis.

Minimally invasive liver resection (MILR) has been steadily increasing worldwide. Since its introduction in the early 1990s, initially adopted in cases of wedge and minor anatomical resection for benign hepatic lesions, MILR has been extended to major liver resection and for malignant hepatic lesions (1). Laparoscopic lateral sectionectomy has progressively become a standard operation (2).

Surgical site infection (SSI) is one of the most frequent complications after stoma closure and the optimal skin closure technique is still not clear. The goal of this review was to compare outcomes with purse-string closure technique (PSC) versus conventional closure technique (CCT) for skin closure after stoma reversal.We performed a systematic review and meta-analysis of available randomized controlled trials (RCTs) to compare SSI rate within 30 days, operative time, hospital stay, incisional hernia and intestinal obstruction rates between PSC and CCT.The pooled analysis of 5 studies showed a statically significant lower rate of SSI in favor of PSC compared to CCT (OR -0.24; 95% CI -0.32, - 0.15; p 0.00001). No statistically significant differences were observed in the operative time (OR -0.05; 95% CI -3.95, 3.84; p = 0.98) and in the length of hospital stay (OR -0.20; 95% CI -0.76, 0.36; p = 0.48), between the two techniques. Additionally, two out of the five studies provided data on incisional hernia and intestinal obstruction and the pooled analysis revealed no statistically significant differences between PSC and CCT techniques: incisional hernia (OR 0.81, 95% CI 0.27-2.47; p = 0.71) and intestinal obstruction (OR 1.07, 95% CI 0.41-2.84; p = 0.88).The analysis of 5 RCTs showed that SSI rate is statistically significant lower when PSC is performed, compared to CCT. Whereas, no significant differences were found between the two techniques with regards to operative time, length of hospital stay, incisional hernia and intestinal obstruction rates.

Background Laparoscopic surgery for gastric tumor is considered a demanding procedure because of lymph node dissection and reconstruction. Billroth-I (B-I) reconstruction after laparoscopic distal gastrectomy is commonly performed extracorporeally because of the complexity of an intracorporeal procedure. Robotic surgery overcomes some limitations of laparoscopy, allowing to reproduce the basic maneuvers of open surgery. We describe a new technique to perform robotic B-I anastomosis. Methods Between January 2012 and February 2015, 5 patients underwent distal gastrectomy with intracorporeal B-I-stapled anastomosis. Patient demographics, tumor characteristics, histopathologic features, and perioperative data were analyzed. Results Median operative time was 170 minutes (145 to 180 min). There were no conversions. Contrast swallow was routinely performed on the third postoperative day. Median postoperative hospitalization was 7 days (range: 6 to 8). No major complications or mortality were observed. Conclusions Robotic distal gastrectomy with intracorporeal B-I anastomosis is a safe and promising technique in selected cases of gastric tumors.

Total mesorectal excision (TME) is the gold standard technique for the surgical management of rectal cancer. The transanal approach to the mesorectum was introduced to overcome the technical difficulties related to the distal rectal dissection. Since its inception, interest in transanal mesorectal excision has grown exponentially and it appears that the benefits are maximal in patients with mid-low rectal cancer where anatomical and pathological features represent the greatest challenges. Current evidence demonstrates that this approach is safe and feasible, with oncological and functional outcome comparable to conventional approaches, but with specific complications related to the technique. Robotics might potentially simplify the technical steps of distal rectal dissection, with a shorter learning curve compared to the laparoscopic transanal approach, but with higher costs. The objective of this review is to critically analyze the available literature concerning robotic transanal TME in order to define its role in the management of rectal cancer and to depict future perspectives in this field of research.

Background\ud Following the Food and Drug Administration approval, robot-assisted colorectal surgery has gained more acceptance among surgeons. One of the open issues about robotic surgery is the economic sustainability. The aim of our study is to evaluate the economic sustainability of robotic as compared to laparoscopic right colectomy for the Italian National Health System.\ud \ud Methods\ud We performed a retrospective multicentre case-matched study including 94 patients for each group from four different Italian surgical departments. An economic evaluation gathered from a real-world data was performed to assess the sustainability of the robotic approach for right colectomy in the Italian National Health System. In particular, a differential cost analysis between the two procedures was performed.\ud \ud Results\ud No statistical differences were found between the two groups for postoperative outcomes. After a careful review of the literature on the cost assessment for the operative room, medical devices and hospital stay according with our data, we estimated the followings: (a) the mean operative room cost for robotic group was 2179 ± 476 € vs. 1376 ± 322 € for laparoscopic group; (b) the mean hospital stay cost for robotic group was 3143 ± 1435 € vs. 3292 ± 1123 € for laparoscopic group; and (c) the mean cost for instruments was 6280 € for robotic group vs. 1504 € for laparoscopic group. The total mean cost of robotic right colectomy was 11,576 ± 1915 € vs. 6196 ± 1444 € for laparoscopic right colectomy.\ud \ud Conclusion\ud In conclusion, to date, robotic right colectomy with intracorporeal anastomosis does not provide any significant clinical advantages, which may justify the additional costs, as compared to its laparoscopic counterpart. Further evolution of robotic technology and experience may lead to a reduction of costs, especially if the robotic platform is used in an appropriate healthcare setting.

Background Colorectal cancer (CRC) is one of the most common cancers in patients older than 65 years. Emergency presentation represents about 30% of cases, with increased morbidity and mortality rates. The aim of this study is to compare the perioperative outcome between elderly and non-elderly patients undergoing emergency surgery. Method We retrospectively analysed CRC patients that underwent emergency surgery at the Departments of Surgery of the Sapienza University Sant’Andrea Hospital in Rome, and at San Donato Hospital in Arezzo, between June 2012 and June 2017. Patients were divided into two groups: non-elderly (< 65 years) and elderly (≥ 65 years). Variables analysed were sex, onset symptoms, associated disease, ASA score, tumor site and TNM stage, surgical procedures and approach, and morbidity and mortality. Results Of a total of 123 patients, 29 patients were non-elderly and 94 patients were elderly. No significant differences were observed in sex, onset symptoms and tumor site between the two groups. Comorbidities were significantly higher in elderly patients (73.4% vs 41.4%, p Conclusions Emergency colorectal surgery for cancer still presents significant morbidity and mortality rates, especially in elderly patients. More aggressive tumors and advanced stages were more frequent in the non-elderly group and as a matter it should be taken into account when treating such patients in the emergency setting in order to perform a radical procedure as much as possible.

Background Acute appendicitis is a common acute surgical abdominal condition and despite the majority of cases are observed in children and young adults, its occurrence in the elderly seems to be increasing, with a higher risk of perforation. The aim of this study was to evaluate the surgical outcomes following appendectomy for acute appendicitis in the elderly, making a comparison between perforated and nonperforated groups regarding operative time, hospital stay and postoperative complications. Methods The medical records of 48 patients over the age of 60 years who had a pathologically confirmed diagnosis of acute appendicitis from January 2011 to December 2016 were retrospectively reviewed. Patients were grouped into those with perforated and those with non-perforated appendicitis (NPA) and a comparison was made between both groups regarding demography, operative time, length of hospital stay and postoperative complications. Results From 48 patients over 60 years diagnosed with acute appendicitis, a PA was removed from 10 patients (20.8%). The PA group consisted of 3 males and 7 females, and their mean age was 71.6 years (range 65-84). The NPA group included 22 males and 16 females, and their mean age was 76.5 years (range 63-96). The mean operative time was 58±18.7 minutes and 43.3±9.9 minutes in the perforated and nonperforated groups respectively, with statistically significant difference (P=0.0013). The mean length of hospital stay was similar in the PA group and in the NPA group, being 6.5±1.8 days and 5.4±1.8 days respectively, but these differences were not statistically significant (P=0.093). The frequency of postoperative complications was similar in both groups as they were observed in 3 patients (30%) of the PA group and 10 patients (26%) of the NPA group (P=0.2488). No postoperative intraabdominal abscess was observed in both groups and there was no death after the surgery. Conclusions PA, despite requiring a longer mean operative time, in our series is not producing a longer hospital stay or more postoperative complications compared to NPA. The non-operative management of uncomplicated appendicitis is a reasonable option in frail patients in order to avoid the burden of morbidity related to operation, nevertheless surgery remains the standard of care in all age groups.

Background According to the National Trauma Data Bank, the liver, after the spleen, is the first most injured organ in closed abdominal trauma. Methods From June 2010 to December 2015 we observed in our department of Hepato-biliary Surgery and Liver Transplant Unit of the A.O.R.N. A. Cardarelli of Naples 40 patients affected by hepatic trauma. In our retrospective study, we review our experience and propose portal vein ligation (PVL) as a first – line strategy for damage control surgery (DCS) in liver trauma. Results 26/40 patients (65%) which received gauze-packing represented our study group. In 10 cases out of 26 patients (38,4%) the abdominal packing was enough to control the damage. In 7 cases (18,4%) we performed a liver resection. In 7 cases, after de-packing, we adopted PVL to achieve DCS. Trans Arterial Embolization was chosen in 6 patients. 2 of them were discharged 14 days later without performing any other procedure. In 3 cases we had to perform a right epatectomy in second instance. Two hepatectomies were due to hemoperitoneum, and the other for coleperitoneum. Two patients were treated in first instance by only doing hemostasis on the bleeding site. We observed 6 patients in first instance. Five of them underwent surgery with hepatic resection and surgical hemostasis of the bleeding site. The other one underwent to conservative management. In summary we performed 15 hepatic resections, 8 of them were right hepatectomies, 1 left hepatectomy, 2 trisegmentectomies V-VI-VII. So in second instance we operated on 10 patients out of 34 (30%). Conclusions The improved knowledge of clinical physio-pathology and the improvement of diagnostic and instrumental techniques had a great impact on the prognosis of liver trauma. We think that a rigid diagnostic protocol should be applied as this allows timely pathological finding, and consists of three successive but perfectly integrated steps: 1) patient reception, in close collaboration with the resuscitator; 2) accurate but quick diagnostic framing 3) therapeutic decisional making. Selective portal vein ligation is a well-tolerated and safe manoeuvre, which could be effective, even if not definitive, in treating these subjects. That is why we believe that it can be a choice to keep in mind especially in post-depacking bleeding.

Objective: Laparoscopic liver resection (LLR) for Hepatocellular Carcinoma (HCC) is one of the most important indications for the minimally invasive approach. Our study aims to analyze the experience of the Italian Group of Minimally Invasive Liver Surgery with laparoscopic surgical treatment of HCC, with a focus on tumor location and how it affects morbidity and mortality. Methods: 38 centers participated in this study; 372 cases of LLR for HCC were prospectively enrolled. Patients were divided into two groups according to the HCC nodule location. Group 1 favorable location and group 2 unfavorable location. Perioperative outcomes were compared between the two groups before and after a propensity score match (PS) 1:1. Results: Before PS in group 2 surgical time was longer; conversion rate was higher; postoperative transfusion and comprehensive complication index were also higher. PS was performed with a cohort of 298 patients (from 18 centers), with 66 and 232 patients with HCC in unfavorable and favorable locations, respectively. After PS matching, 62 patients from group 1 and group 2 each were compared. Operative and postoperative course were similar in patients with HCC in favorable and unfavorable LLR locations. Surgical margins were found to be identical before and after PS. Conclusions: These results show that LLR in patients with HCC can be safely performed in all segments because of the extensive experience of all surgeons from multiple centers in performing traditional open liver surgery as well as laparoscopic surgery.

The aim of this study was to evaluate safety, feasibility and short-term outcomes of our first 70 consecutive patients treated by robotic-assisted liver resection after a reversal proctoring between a high HPB volume centre and our well-trained center in minimally invasive General Surgery. Six surgeons were involved in this HubSpoke learning program.From September 2012 to December 2016, 70 patients underwent robotic-assisted liver resections (RALR). We treated 18 patients affected by colorectal and gastric cancer with synchronous liver lesions suspected for metastases in a one-stage robotic-assisted procedure. For the first 20 procedures we had a tutor in the operatory room, who was present also in the next most difficult procedures.The 30- and 90-day mortality rate was zero with an overall morbidity rate of 10.1%. Associated surgical procedures were performed in about 65,7% of patients. The observed conversion rate was 10%. The results of the first 20 cases were similar to the next 50 showing a shortned learning curve.Minimally invasive robot-assisted liver resection is a safe technique; it allows overcoming many limits of conventional laparoscopy. This innovative, time-enduring HubSpoke may allow patients to undergo a proper standard of care also for complex surgical procedures, without the need of reaching referral centres.

Total mesorectal excision (TME) represents the key principle in the surgical treatment of rectal cancer. Transanal mesorectal excision was introduced as a complement to conventional surgery to overcome its technical difficulties. The aim of this study was to evaluate the early surgical results following the introduction of this novel technique at our Unit. Between January and May 2016, 12 patients diagnosed with mid-low rectal adenocarcinoma were enrolled into this study and evaluated with regards demography, histopathology, peri-operative data and postoperative complications. The tumor was located in the middle rectum in 6 patients (50%), in the lower rectum in 6 patients (50%). Mean operative time was 356.5 ± 76.2 min (range 240–494). Eleven out 12 patients (91.6%) had less than 200 mL of intraoperative blood loss. Mean hospital stay was 10.9 ± 4.6 days (range 5–19). No mortality was recorded. Intraoperative complications were recorded in 1, while early post-operative complications (

Background. Colorectal cancer is the fourth most diffuse cause of death in the world and local recurrence is associated with a reduced long-term life expectancy, with a reduced quality of life. Rectal washout at the anastomosis site leads to a statistically significant reduction of local recurrences. Methods. We developed the idea of a new laparoscopic stapler with an integrated washout system that could decontaminate the rectal stump before resection, without the need to enlarge the standard surgical incision or even to distort the incision site, closing the rectal stump just below the inferior part of the cancer, and then proceeding with the resection and stapling of the distal part of the tumor. Combined with these canonical functionalities, the new device, equipped with a patented washout system (patent number EP 3103401A1) will also allow to inject in the closed bowel a physiologic saline liquid. Results. In force of the mechanical action of the liquid injected, carcinogenic exfoliated cells eventually floating in the affected region of the colonic lumen will be expelled through the anal orifice. The intraoperative rectal washout, both in minimally invasive and in traditional open surgery, thus becomes a simple, effective, and reproducible procedure. Conclusions. We describe the technical features and the possible clinical applications of a potentially new surgical laparoscopic stapler coupled with an integrated irrigation system. We have patented the system and we are developing a prototype with the aim to start an experimental pilot study.

BACKGROUND/AIM The role of splenectomy as an essential component of radical surgery for proximal gastric cancer, from an oncological point of view, is still debated, and no consistent recommendations have been proposed. The aim of this systematic review with meta-analysis was to provide a more robust answer regarding the oncological effectiveness and safety of splenectomy in total gastrectomy for proximal gastric carcinoma. MATERIALS AND METHODS A systematic review and meta-analysis of randomized controlled trials was planned and performed in accordance with Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement and Cochrane Handbook for Systematic Reviews of Intervention. Patients with a histological diagnosis of gastric adenocarcinoma located in the upper third of the stomach who underwent D2 total gastrectomy with or without splenectomy were selected. The primary outcome was to analyze the influence of splenectomy on the overall survival of patients. Additionally, the mean difference in procedure time, length of hospital stay, number of retrieved lymph nodes, as well as the odds ratio of postoperative complications comparing splenectomy to spleen preservation were investigated in a secondary analysis Results: Overall, four studies with a total of 978 patients met the inclusion criteria. The pooled analysis showed no difference in overall survival rates between those who underwent spleen preservation compared to the splenectomy-treated group (risk ratio=0.92, 95% confidence interval=0.79 to 1.06, p=0.277). Interestingly, all studies reporting overall morbidity data highlighted statistically significant differences in favor of spleen-preservation group (odds ratio=2.11, 95% confidence interval=1.44 to 3.09, p

Introduction Minimally invasive surgery has gained wide acceptance in many institutions. Complex surgery such as pancreatic resections delayed its diffusion due to high rate postoperative complications and technical aspects, while for pancreaticoduodenctomy the role of a minimally invasive approach is still on debate. Laparoscopic distal pancreatectomy may be considered a safe procedure and a valid alternative in selected cases. The operating time, learning curve and the costs represent major drawbacks for the laparoscopic approach. Elderly patients (>70 years of age) are generally considered to be at higher risk for developing complications after pancreatic surgery due to compromised physiological reserve and presence of multiple comorbidities. Our aim was to make a review about the role of laparoscopic distal pancreatectomy (LDP) in the elderly population. Evidence acquisition A systematic search of the scientific literature was performed using PubMed, EMBASE, online journals, and the Internet for all publications on LDP and open distal pancreatectomy (ODP) in old age patients. All selected articles were reviewed and analyzed. We found 393 abstract that were reviewed. We considered all type of publications. Evidence synthesis Laparoscopic pancreatic resections are considered more difficult due to the retroperitoneal organ location and by the presence of surrounding large vessels and other crucial structures. Therefore, an adequate learning curve is needed. Beyond these remarks, in many institutions, LDP is a standard approach in patients with lesions in the body and tail of the pancreas. The most evident advantage of LDP is the shorter length of stay. Age alone should not be considered as an absolute contraindication for LDP. Obviously, it is still too early to assess oncological outcomes, but the R0 resection rate, the number of harvested lymph nodes, and the overall survival rate are superimposable to ODP. Conclusions LDP is safe and feasible if compared to ODP in selected elderly patients with body and tail pancreatic tumors. Less blood loss and shorter hospital stay are the most evident advantages of minimally invasive approach. Randomized controlled trials and high-volume centers prospective studies with long-term outcomes are necessary to consider laparoscopy a standard of care. Minimally invasive robotic surgery may represent an interesting alternative to laparoscopy especially for spleen-preserving procedures.