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Background: Accurate preoperative workup is crucial to identify patients with intrahepatic cholangiocarcinoma (IHC) who would have truly benefit from liver resection, avoiding it in patients with advanced disease or distant metastases. Staging laparoscopy (SL) may prevent unnecessary laparotomies in those patients with otherwise resectable disease, but evidence of its efficacy is scarce and inconclusive. We aimed to aggregate the available evidence dealing with this specific field of research to produce a snapshot of the current knowledge systematically reviewing the inherent literature. Methods: PubMed/Medline, EMBASE, and Web of Sciences electronic databases were queried through December 2022. Inclusion criteria considered all articles reporting data about the role of SL for patients with a diagnosis of IHC. The main outcomes were as follows: overall yield and sensitivity of SL. Results: A total of 5 studies including 119 patients met the inclusion criteria and were included in the analysis. Overall, the yield of SL was 19.6% (11.4%-36%), and the sensitivity was 65.2% (55%-71%). Conclusions: The role of SL for patients with a preoperative diagnosis of IHC remains unclear. The lack of criteria and indications to perform SL for IHC raises the need for international consensus on this specific field of research.

Aim: Although there is growing evidence to support the feasibility of a minimally invasive approach for acute small bowel obstruction, the inability to adequately evaluate compromised bowel segments has been cited as a major limitation. The aim of this work is to report a novel application of extemporaneous indocyanine green (ICG) fluorescence to assess bowel viability where there is a concern for ischaemic damage., Method: After the cause of obstruction has been identified and resolved, and where there are dubious signs of bowel ischaemia present, fluorescent selective angiography is undertaken. The segment of bowel in question is observed under both normal and fluorescent light to assess local microcirculation. The adequacy of both the arterial supply and the venous drainage is thus appraised to define bowel viability., Results: Among 71 patients who have undergone surgery for acute small bowel obstruction with a laparoscopic approach, seven received extemporaneous ICG fluorescence assessment of bowel viability. Different presentations with their relevant management are described., Conclusions: Selective use of intraoperative fluorescent angiography may overcome some of the intrinsic limitations of laparoscopy in assessing bowel viability during surgery for acute small bowel obstruction., (© 2021 The Association of Coloproctology of Great Britain and Ireland.)

The duodenum is traditionally reached and dissected by an anterior approach. Optimal exposure is achieved via complete hepatic flexure mobilization and kocherization of the duodenum and head of the pancreas, which can be technically challenging and time-consuming, especially in the setting of minimally invasive surgery. On the contrary, an inframesocolic approach provides a ready and neat access to the second and third segments of the duodenum with distinct advantages in terms of exposure and operative time. This video presents the details of our laparoscopic technique of approaching the duodenum via the inframesocolic route, as performed to treat a patient with symptomatic duodenal diverticulum.

Although end colostomy closure following Hartmann's procedure is a major surgery that is traditionally performed by conventional celiotomy, over the last decade there has been a growing interest toward the application of different minimally invasive techniques. We aimed at evaluating the relative outcomes of conventional surgery versus minimally invasive surgery by meta-analyzing the available data from the medical literature. The PubMed/MEDLINE, Cochrane Library and EMBASE electronic databases were searched through August 2018. Inclusion criteria considered eligible all comparative studies evaluating open versus minimally invasive procedures. Conventional laparoscopy, robotic and single-port laparoscopy were considered as minimally invasive techniques. Overall morbidity, rate of anastomotic failure, rate of wound complications and mortality were evaluated as primary outcomes. Perioperative details and surgical outcomes were also assessed. The data of a total of 13,740 patients from 26 studies were eventually included in the analysis. There were no significant differences on baseline characteristics such as age, BMI and proportion of high-risk patients between the two groups of patients. As compared to the conventional technique, minimally invasive surgery proved significantly superior in terms of postoperative morbidity, length of hospital stay and rate of incisional hernia. The current literature suggests that minimally invasive surgery should be considered in performing Hartmann's reversal, if technically viable. However, due to the low level of the available evidence it is impossible to draw definitive conclusions.

Background: Recent reports have suggested that the use of the robot might reduce the rate of pancreatic complications following minimally invasive radical gastrectomy., Methods: By meta-analyzing the available literature, we aimed to elucidate possible differences between conventional laparoscopic and robotic radical gastrectomy on pancreatic morbidity., Results: More than 2000 patients from eight studies were eventually included in the analysis. The overall incidence of postoperative pancreatic complications was 2.2%, being 1.7% and 2.5% following robotic and laparoscopic gastrectomy (LG), respectively. In particular, pancreatic fistula occurred in 2.7% of patients receiving robotic gastrectomy (RG) and 3.8% of patients receiving laparoscopy., Conclusions: The use of the robot showed a trend toward better outcomes compared with laparoscopy, despite the presence of more advanced disease and higher body mass index. The meta-analysis resulted in an odd ratio of 0.8 favoring RG over LG on pancreatic morbidity, although without statistical significance.

Objective: The aim of this study was to evaluate the safety and efficacy of elective rectal resection for rectal cancer in adults by robotic surgery compared with conventional laparoscopic surgery., Summary of Background Data: Technological advantages of robotic surgery favor precise dissection in narrow spaces. However, the evidence base driving recommendations for the use of robotic surgery in rectal cancer primarily hinges on observational data., Methods: We searched MEDLINE, Embase, and CENTRAL for randomized controlled trials (until August 2016) comparing robotic surgery versus conventional laparoscopic surgery. Data on the following endpoints were evaluated: circumferential margin status, mesorectal grade, number of lymph nodes harvested, rate of conversion to open surgery, postoperative complications, and operative time. Data were summarized as relative risks (RR) or weighted mean differences (WMDs) with 95% confidence intervals (95% CIs). Risk of bias of studies was assessed with standard methods., Results: Five trials were eligible, including 334 robotic and 337 laparoscopic surgery cases. Meta-analysis showed that RS was associated with lower conversion rate (7.3%; 4 studies, 544 participants, RR 0.58; 95% CI 0.35-0.97, P = 0.04, I = 0%) and longer operating time (MD 38.43 minutes, 95% CI 31.84-45.01: P < 0.00001) compared with laparoscopic surgery. Perioperative mortality, rate of circumferential margin involvement (2 studies, 489 participants, RR 0.82, 95% CI 0.39-1.73), and lymph nodes collected (mean 17.4 Lymph Nodes; 5 trials, 674 patients, MD -0.35, 95% CI -1.83 to 1.12) were similar. The quality of the evidence was moderate for most outcomes., Conclusion: Evidence of moderate quality supports that robotic surgery for rectal cancer produces similar perioperative outcomes of oncologic procedure adequacy to conventional laparoscopic surgery. Robotic surgery portraits lower rate of conversion to open surgery, while operating time is significantly longer than by laparoscopic approach.

To date very few studies with small sample size have compared peroral esophageal myotomy (POEM) with the current surgical standard of care, laparoscopic Heller myotomy (LHM), in terms of efficacy and safety, and no recommendations have been proposed.To investigate the efficacy and safety of POEM compared with LHM, for the treatment of achalasia.The databases of Pubmed, Medline, Cochrane, and Ovid were systematically searched between January 1, 2005 and January 31, 2015, with the medical subject headings (MeSH) and keywords "achalasia," "POEM," "per oral endoscopic myotomy," and "peroral endoscopic myotomy," "laparoscopic Heller myotomy" (LHM), "Heller myotomy."All types of study designs including adult patients with diagnosis of achalasia were selected. Studies that did not report the comparison between endoscopic and surgical treatment, experimental studies in animal models, single case reports, technical reports, reviews, abstracts, and editorials were excluded.The total number of included patients was 486 (196 in POEM group and 290 in LHM group).There were no differences between POEM and LHM in reduction in Eckardt score (MD = -0.659, 95% CI: -1.70 to 0.38, P = 0.217), operative time (MD = -0.354, 95% CI: -1.12 to 0.41, P = 0.36), postoperative pain scores (MD = -1.86, 95% CI: -5.17 to 1.44, P = 0.268), analgesic requirements (MD = -0.74, 95% CI: -2.65 to 1.16, P = 0.445), and complications (OR = 1.11, 95% CI: 0.5-2.44, P = 0.796). Length of hospital stay was significantly lower for POEM (MD = -0.629, 95% CI: -1.256 to -0.002, P = 0.049). There was a trend toward significant reduction in symptomatic gastroesophageal reflux rate in favors of LHM compared to POEM group (OR = 1.81, 95% CI: 1.11-2.95, P = 0.017).All included studied were not randomized. Furthermore all selected studies did not report the results of follow-up longer than 1 year and most of them included patients who were both treatment naive and underwent previous endoscopic or surgical interventions for achalasia.POEM represents a safe and efficacy procedure comparable to the safety profile of LHM for achalasia at a short-term follow-up. Long-term clinical trials are urgently needed., Competing Interests: The authors have no funding and conflicts of interest to disclose.

Background: Open parenchymal-preserving resection is the current standard of care for lesions in the posterosuperior liver segments. Laparoscopy and robot-assisted surgery are emergent surgical approaches for liver resections, even in posteriorly located lesions. The objective of this study was to compare robot-assisted to laparoscopic parenchymal-preserving liver resections for lesions located in segments 7, 8, 4a, and 1., Methods: Demographics, comorbidities, clinicopathologic characteristics, surgical treatments, and outcomes from patients who underwent laparoscopic and robot-assisted liver resection in two centers for lesions in the posterosuperior segments between June 2008 and February 2014 were reviewed. A 1:2 matched propensity score analysis was performed by individually matching patients in the robotic cohort to patients in the laparoscopic cohort based on demographics, comorbidities, performance status, tumor stage, location, and type of resection., Results: Thirty-six patients who underwent robot-assisted liver resection were matched with 72 patients undergoing laparoscopic liver resection. Matched patients displayed no significant differences in postoperative outcomes as measured by blood loss, hospital stay, R0 negative margin rate, and mortality. The overall morbidity according to the comprehensive complication index was also similar (34.6 ± 33 vs. 18.4 ± 11.3, respectively, for robotic and laparoscopic approach, p = 0.11). Patients undergoing robotic liver surgery had significantly longer inflow occlusion time (77 vs. 25 min, p = 0.001) as compared with their laparoscopic counterparts., Conclusions: Although number and severity of complications in the robotic group appears to be higher, robotic and laparoscopic parenchymal-preserving liver resections in the posterosuperior segments display similar safety and feasibility.

Aim: To perform a systematic review and meta-analysis on robotic-assisted vs laparoscopic liver resections., Methods: A systematic literature search was performed using PubMed, Scopus and the Cochrane Library Central. Participants of any age and sex, who underwent robotic or laparoscopic liver resection were considered following these criteria: (1) studies comparing robotic and laparoscopic liver resection; (2) studies reporting at least one perioperative outcome; and (3) if more than one study was reported by the same institute, only the most recent was included. The primary outcome measures were set for estimated blood loss, operative time, conversion rate, R1 resection rate, morbidity and mortality rates, hospital stay and major hepatectomy rates., Results: A total of 7 articles, published between 2010 and 2014, fulfilled the selection criteria. The laparoscopic approach was associated with a significant reduction in blood loss and lower operative time (MD = 83.96, 95%CI: 10.51-157.41, P = 0.03; MD = 68.43, 95%CI: 39.22-97.65, P < 0.00001, respectively). No differences were found with respect to conversion rate, R1 resection rate, morbidity and hospital stay., Conclusion: Laparoscopic liver resection resulted in reduced blood loss and shorter surgical times compared to robotic liver resections. There was no difference in conversion rate, R1 resection rate, morbidity and length of postoperative stay.

Minimally invasive liver surgery (MILS) is going to be a method with a wide diffusion even in general surgery units. Organization, learning curve effect, and the environment are crucial issues to evaluate before starting a program of minimally invasive liver resections. Analysis of a consecutive series of 70 patients has been used to define advantages and limits of starting a program of MILS in a general surgery unit. Seventeen MILS have been calculated with the cumulative sum method as the number of cases to complete the learning curve. Operative times [270 (60-480) vs. 180 (15-550) min; p 0.01] and rate of conversion (6/17 vs. 5/53; p 0.018) decrease after this number of cases. More complex cases can be managed after a proper optimization of all steps of liver resection. When a high confidence of the medical and nurse staff with MILS is reached, economical and strategic issues should be evaluated in order to establish a multidisciplinary hepatobiliary unit independent from the general surgery unit to manage more complex cases.

Background: Robotic surgery was introduced as a means of overcoming the limitations of traditional laparoscopy. This report describes the results of a matched comparative study between traditional (TLLR) and robot-assisted laparoscopic liver resection (RLLR) performed in two European centers., Methods: From January 2008-April 2013, 46 patients underwent RLLR at San Matteo degli Infermi Hospital. Each patient was matched to a patient who had undergone TLLR at Antoine Béclère Hospital. The variables evaluated were operative time, blood loss, conversion rate, morbidity, mortality, and length of hospital stay., Results: Twenty-eight patients were included in each group. Despite matching, more tumors were solitary in the TLLR group (P = 0.02) and more were localized in the superior and posterior segments in the RLLR group (P = 0.003). The median duration of surgery was 210 and 176 min in the RLLR and TLLR groups, respectively (P = 0.12). Conversion rate, blood loss, morbidity, and length of stay were similar in both groups. In multivariate analysis in all cohorts of patients, the sole independent risk factor of postoperative complications was the operative duration [OR = 1.016; P = 0.007]., Conclusions: Robotic LLR is associated with outcomes similar to those obtained with TLLR. However, robotics may facilitate LLR in patients with superior and posterior liver tumors.

Background: Open liver resection is the current standard of care for lesions in the right posterior liver section. The objective of this study was to determine the safety of robot-assisted liver resection for lesions located in segments 6 and 7 in comparison with open surgery., Methods: Demographics, comorbidities, clinicopathologic characteristics, surgical treatments, and outcomes from patients who underwent open and robot-assisted liver resection at 2 centers for lesions in the right posterior section between January 2007 and June 2012 were reviewed. A 1:3 matched analysis was performed by individually matching patients in the robotic cohort to patients in the open cohort on the basis of demographics, comorbidities, performance status, tumor stage, and location., Results: Matched patients undergoing robotic and open liver resections displayed no significant differences in postoperative outcomes as measured by blood loss, transfusion rate, hospital stay, overall complication rate (15.8% vs 13%), R0 negative margin rate, and mortality. Patients undergoing robotic liver surgery had significantly longer operative time (mean, 303 vs 233 minutes) and inflow occlusion time (mean, 75 vs 29 minutes) compared with their open counterparts., Conclusions: Robotic and open liver resections in the right posterior section display similar safety and feasibility.

Background: Laparoscopic liver resection (LAPR) is safe and feasible with a better postoperative course as compared to open resections. Robot-assisted liver surgery (ROBR) is a potential alternative to LAPR. In this study we compare outcomes between ROBR and LAPR., Methods: Forty patients underwent ROBR and 223 LAPR for various indications. The surgical outcomes of two institutions, each with a specific advanced experience in laparoscopic and robotic surgery, were reviewed., Results: The major hepatectomy rate was significantly higher in LAPR (16.6% vs 0%, p = 0.011) while a parenchyma-preserving approach was favoured in ROBR (55% vs 34.1%, p = 0.019). More nodules were resected in the ROBR group (1.97 ± 1.4 vs 1.57 ± 1.1, p = 0.04). Overall conversion rate was 8/40 (20%) in the ROBR and 17/223 (7.6%) in the LAPR group (p = 0.034). Mean blood loss was 330 ± 303 ml and 174 ± 133 ml for the ROBR and LAPR groups, respectively (p = 0.001) CONCLUSIONS: Despite higher conversion rates and blood loss, robot-assisted surgery may allow the resection of more liver lesions, especially those located in the postero-superior segments, facilitating parenchyma-saving surgery with a comparable complication rate with respect to LAPR., (Copyright © 2013 John Wiley & Sons, Ltd.)

While inflow occlusion techniques are accepted methods to reduce bleeding during open liver surgery, their use in laparoscopic liver resections are limited by possible effects of pneumoperitoneum on ischemia-reperfusion liver damage. This retrospective study was designed to investigate the impact of intermittent pedicle clamping (IPC) on patients with normal liver undergoing minor laparoscopic liver resections. Three matched groups of patients were retrospectively selected from our in-house database: 11 patients who underwent robot-assisted liver resection with IPC, and 16 and 11 patients who underwent robot-assisted liver resection without IPC and open liver resection with IPC, respectively. The primary end point was to assess differences in postoperative serum alanine, aspartate aminotransferase (ALT and AST) and bilirubin levels. The curves of serum AST, ALT and bilirubin levels in a span of time of five postoperative days were not significantly different between the three groups. IPC has no relevant effects on ischemia-reperfusion liver damage even in the presence of pneumoperitoneum.

Objective: The aim of the study is to describe techniques of robot-assisted parenchymal-sparing liver surgery., Background: Laparoscopy provides the same oncologic outcomes as open liver resection and better early outcome. Limitations of laparoscopy remain resections in posterior and superior liver segments, frequently approached with laparoscopic right hepatectomy, bleeding from the section line, and prolonged operative times when a combined procedure is needed., Methods: We retrospectively analyzed our series of robot-assisted liver resections between 2008 and September 2010 to evaluate whether robot assistance can overcome the limitations of laparoscopy., Results: A total of 23 patients underwent robot-assisted liver resection for a total of 21 subsegmentectomies, 6 segmentectomies, 2 segmentectomies S6 + subsegmentectomies S7, 1 bisegmentectomy S2-3, and 2 pericystectomies. In ten cases (47.8%) liver nodules were located in the posterior and superior liver segments. In three cases the tumor was in contact with a main portal branch and in two cases with a hepatic vein. In one case the tumor had contact with both hepatic vein and portal branch. In the latter cases a no-margin resection was carried out. In 16 cases (65.5%) liver resection was associated with a concomitant procedure (10 laparoscopic colectomies, 1 robotic rectal resection, 3 laparoscopic radiofrequency ablations, and 2 extensive adhesiolyses). Mean operative time was 280 ± 101 min, blood loss was 245 ± 254 ml, and mean hospital stay was 8.9 ± 9.4 days. Mortality was nil. One case of biliary leakage and two of intraoperative hemorrhage requiring transfusion were the main complications encountered., Conclusions: Robot assistance allows optimal access to all liver segments and facilitates parenchymal-sparing surgery also for lesions located in the posterosuperior segments or in contact with main liver vessels.

Background: A population-based case-control study was conducted in order to investigate the advantages of robot-assisted gastric resection (RGR) for gastric cancer as opposed to traditional open gastrectomy (OG)., Methods: Data were collected in two prospectively maintained databases on patients who underwent a D2 gastrectomy with curative intent for primary gastric adenocarcinoma. All (n = 29) the first consecutive gastric cancer patients submitted to RGR from a referral centre for minimally invasive surgery were matched to control cancers (n = 120) extrapolated from a high volume centre database including patients submitted to OG., Results: Robot-assisted laparoscopic procedures implied increased operative time (290 vs 222 min, p = 0.004), decreased blood loss (197.6 vs 386.1 mL, p = 0.0001) and shorter hospital stay (9.6 vs 13.4 days, p < 0.0009). There was no difference in the mean number of harvested lymph nodes between the two groups (28.0 vs 31.7, p = 0.023). The total morbidity rate, including major complications such as anastomotic and duodenal suture failure, was comparable between groups (41.4% vs 42.5%; in the RGR and OG, respectively, p = 0.764). Preliminary data on overall survival did not show prognostic differences between the two groups (p = 0.615)., Conclusions: Robot-assisted surgery fulfils oncologic criteria for D2 dissection and has an oncologic outcome comparable with that of OG. RGR resulted in shorter hospital stays, the loss of less blood and morbidity comparable with that of OG. Randomized clinical trials and longer follow-up are needed to evaluate whether RGR achieves long-term survival rates equivalent to that of open and laparoscopic surgery., (Copyright © 2011 John Wiley & Sons, Ltd.)

Hemorrhage is a major complication in laparoscopic liver surgery and inflow occlusion methods are difficult to be reproduced in this setting. This study investigated 10 consecutive patients who underwent robot-assisted liver resection. An extracorporeal Pringle maneuver was carried out encircling the hepato-duodenal ligament using an endowristed robotic arm and exteriorizing the tourniquet at the epigastrium allowing the on-table surgeon to independently control intermittent clamping. The extracorporeal Pringle maneuver was effective and without complications for all patients. The assistant was able to apply consecutive clampings whereas the console surgeon proceeded in parenchyma transection. Robot-assisted liver surgery can be made safer by the use of the extracorporeal Pringle maneuver.

Background: Laparoscopic splenectomy is accepted as a safe approach in the surgical treatment of blood disorders worldwide. Compared with the laparotomic technique, it is associated with a lower risk of intraoperative bleeding, less postoperative pain, and faster discharge times. The advent of robotic surgery (RS) has changed the concept of minimally invasive surgery because, in addition to allowing a three-dimensional view, it permits greater freedom of movement and higher levels of accuracy than laparoscopic surgery (LS). The aim of this study was to comparatively evaluate whether RS presents advantages over LS in spleen surgery., Methods: In two Surgical Units with experience in laparoscopic splenectomy, over a 7-year period, two groups of 45 patients underwent LS and RS. The two groups were well matched for demographic characteristics, indications, and spleen size., Results: No statistically significant differences were found regarding intraoperative blood loss, conversion rate to laparotomy, food intake, drain removal, postoperative complications, and median time to discharge. On the contrary, statistically increased differences were observed in median operative time and costs. In both groups, the transfusion and mortality rate was 0%. At the 6-month follow-up no surgical complications were observed., Conclusions: Although RS offers a three-dimensional view, greater freedom of movement, and higher levels of accuracy, it is associated with longer operative times and higher costs. It can consequently be concluded that with the intrinsic limits of the study design used, at the current time, RS does not have any significant advantage over LS in splenectomy.

Background: Resection of cardia and upper gastric carcinoma is considered a demanding procedure in laparoscopic surgery. Robotics could aid laparoscopic dissection of the oesophago-gastric junction and oesophageal anastomosis, enlarging indications for a minimally invasive approach to these tumours., Methods: Data from 17 consecutive patients with histologically proved cardia carcinoma were collected in a prospective database to assess the feasibility and safety of laparoscopic robot-assisted radical surgery, using the four-arm da Vinci surgical system. The type of surgery was chosen according to Siewert recommendations. Outcome measures were conversion rate, intra- and post-operative morbidity and mortality, operative time, blood loss, number of lymph nodes harvested and macroscopic and microscopic evaluation of resection margins., Results: Seventeen laparoscopic operations were completed without conversion (14 extended gastrectomies, two transhiatal distal oesophagectomies and one transthoracic distal oesophagectomy). Extended lymph node dissection and oesophago-jejunal anastomosis were successfully carried out using the da Vinci system. Mean operative time was 327.2 ± 93.4 min and blood loss 279 ± 199 ml. The mean number of nodes retrieved was 28 ± 9 and all resection margins were negative. There was no mortality and overall morbidity was acceptably low (41.1%). During a mean follow-up time of 20 months, four recurrences were recorded (two multivisceral, one to the lung and one nodal), with two recurrence-related deaths., Conclusions: Robot-assisted laparoscopic radical surgery of the oesophago-gastric junction is feasible and safe. Longer follow-up time and randomized studies are needed to evaluate the long-term outcome and advantages for the patient of this new technology., (Copyright © 2011 John Wiley & Sons, Ltd.)

Background: Treatment of splenic flexure (SF) colon cancer is not standardized. A laparoscopic approach is considered a challenging procedure., Methods: This review examines a single-institution experience with laparoscopic colon resection for cancer of the SF. Intraoperative, pathologic, and postoperative data of patients who underwent laparoscopic SF resection were reviewed to assess for oncologic safety as well as early- and medium-term outcomes., Results: Between September 2004 and January 2009, laparoscopic SF resection was performed for 15 patients with SF. Two cases of conversion were reported, and for three patients, colonic resection was robot assisted. In all cases, the anastomosis was completed intracorporeally. The distal margin was 3.8 +/- 2.5 cm, and the proximal margin was 7.8 +/- 3.7 cm from the tumor site. The mean number of harvested nodes was 9.2 +/- 5.3. The mean operative time was 183.6 +/- 45 min, and the blood loss was 98 +/- 33 ml. No major morbidity was recorded., Conclusions: Laparoscopic partial resection seems to be feasible and safe for the treatment of early-stage and locally advanced SF cancer.

Background: Robotics has been proposed as a tool to improve laparoscopic Nissen fundoplication. However, a clear benefit of this technology for minimally invasive antireflux surgery has not been demonstrated., Materials and Methods: A retrospective review of a prospective database was used to compare the intraoperative and postoperative outcome of 137 patients who underwent conventional laparoscopic fundoplication (CLF) and 45 patients who underwent laparoscopic robot-assisted fundoplication (LRF). Intraoperative outcome measures were: operative time, blood loss and complications. Length of hospital stay, functional results and patient satisfaction were used to compare postoperative outcome., Results: Operative time was significantly shorter in the LRF group (65 min) compared to the CLF group (85 min) (p < 0.0001). The overall complication rate was comparable between the two techniques, even though a higher incidence of liver tears was encountered in the CLF group (p < 0.05). Hospital stay, symptom relief and patient satisfaction did not differ between the groups., Conclusion: Robotics improves surgeon dexterity and maneuverability during laparoscopic Nissen fundoplication, but this does not correspond to a better postoperative outcome. LRF should be used only for complex cases and training., (Copyright 2009 S. Karger AG, Basel.)

Background/purpose: One-stage resection of primary colon cancer and synchronous liver metastases is considered an effective strategy of cure. A laparoscopic approach may represent a safe and advantageous choice for selected patients with the aim of improving the early outcome., Methods: Between January 2008 and October 2008, 7 patients underwent one-stage laparoscopic resection for primary colorectal cancer combined with laparoscopic or robot-assisted liver resection., Results: A total of five laparoscopic left-colon, one right-colon, and one rectal resections were performed. Three patients underwent preoperative left-colon stenting and two received neoadjuvant chemotherapy. The patient with rectal cancer underwent neoadjuvant radiotherapy. Liver procedures included one bisegmentectomy (segments 2, 3), 3 segmentectomies, 6 metastasectomies, and four laparoscopic ultrasound-guided radiofrequency ablations (LUG-RFAs). One patient with multiple liver metastases was managed by a two-stage hepatectomy partially conducted by a totally laparoscopic approach. The overall postoperative morbidity was null. The median hospital stay was 10 days (range 7-10 days)., Conclusions: This pilot study suggests that laparoscopic one-stage colon and liver resection is feasible and safe. Robot assistance may facilitate liver resection, increasing the number of patients who may benefit from a minimally invasive operation.

Background: Lymph node dissection and esophageal anastomosis, considered the more demanding steps of laparoscopic gastrectomy for gastric adenocarcinoma, can be performed with the use of a remote-controlled robot., Methods: Thirteen patients with a histologically proved gastric cancer (six stage I, six stage II, and one stage III) were enrolled in a prospective study to assess feasibility and safety of the Da Vinci surgical system in total and partial gastrectomy with extended lymph node dissection. Outcome measures were conversion rate, intra- and postoperative morbidity and mortality, operative time, blood loss, number of lymph nodes harvested, and macroscopic and microscopic evaluation of resection margins., Results: Eight distal, four total, and one proximal laparoscopic gastrectomies were completed without conversion. Extended lymph node dissection, and esophagojejunal and esophagogastric anastomoses were successfully carried out using the da Vinci System. Mean operative time was 286 +/- 32.6 min and blood loss was 103 +/- 87.5 ml. Mean number of nodes retrieved was 28.1 +/- 8.3 and all resection margins were negative. There was no mortality. Trocar bleeding requiring laparoscopy was the only major complication encountered. No recurrence occurred during a mean follow-up time of 12.2 +/- 4.5 months., Conclusions: Robot-assisted laparoscopic lymph node dissection and esophageal anastomosis are feasible and safe. Longer follow-up time and randomized studies are needed to evaluate long-term outcome and clinical advantages of this new technology.

A variety of options have been proposed to treat malignant ascites but most of them have failed to reach a significant impact in terms of palliation. Laparoscopic hyperthermic intraperitoneal chemotherapy (LHIPEC) could represent a good therapeutic tool for patients in whom medical therapies have failed and peritoneovenous shunting is contraindicated. Here we present a case of a 49-year-old woman with malignant ascites secondary to peritoneal spreading of a right pleural mesothelioma. After failure of medical therapy, the patient underwent LHIPEC with Cisplatin 25 mg/m/L and Doxorubicin 7 mg/m/L. A dramatic reduction of ascites was documented in the postoperative period and the patient experienced complete abdominal symptom relief. Ascites did not recur during a follow-up period of 6 months. LHIPEC could be a good therapeutic option to palliate malignant ascites from mesothelioma in cases not eligible for a radical treatment. Further studies are needed to standardize dosage and perfusion parameters.

Background: Incisional hernia is a main complication of abdominal surgery. Laparoscopic hernia mesh repair has been demonstrated to be as effective as open repair. However, the mesh fixation method is, to date, a matter of debate, and there are few clinical studies evaluating a single technique. This was a case-control study to assess the "double-crown" fixation method., Methods: From March 2000 to November 2005, we prospectively collected operative and outcome data on 94 laparoscopic mesh repairs of large incisional hernias performed by using the double-crown technique. The data were compared with those from a retrospective review of 87 matched open incisional hernia repairs done from January 1995 to January 2000., Results: The open and laparoscopic repair groups were comparable in patient age, sex, and hernia size. Operative time was significantly longer in the laparoscopic group; the duration of hospitalization and number of early postoperative complications (e.g., wound infection and prolonged ileus) were significantly greater in the open group. Recurrence rate after a mean follow-up of 38 months (range, 12-72) was 2.1% in the laparoscopic group and 6.9% in the open repair group (mean follow-up, 8 years; range, 5-10) (P > 0.05)., Conclusions: Medium-term results indicate that laparoscopic incisional hernia repair with the double-crown technique has a low complication rate and a comparable recurrence rate to open repair.

Background: One advantage of laparoscopic surgery over open surgery is the absence of laparotomic incisions. This advantage is reduced when an auxiliary incision is performed to remove surgical specimens larger than the trocar., Methods: A special incision was performed at umbilical trocar level that enabled removal of a large surgical specimen as in right hemicolectomy (colic), gastric resection, and splenic surgery., Results: The authors have used this method routinely for 10 years for all cases requiring removal of a surgical specimen too large for the normal incision of a 10-mm trocar., Conclusion: The authors maintain that this method avoids the use of auxiliary incisions, which undo the many benefits of laparoscopic surgery.

Background: Laparoscopic hernia repair is not as popular as cholecystectomy. We have performed more than 3,000 laparoscopic herniorrhaphies using the trans-abdominal (TAPP) technique. To prevent recurrences we fix the polypropylene mesh with staples. The use of fibrin glue for graft fixation is a possible alternative., Methods: We have performed 3,130 laparoscopic hernia repairs over 14 years. For mesh fixation we used titanium clips and observed a small number of complications. In July 2003 we started using fibrin glue (Tissucol(R)). The purpose of this retrospective longitudinal study was to evaluate if the use of fibrin sealant was as safe and effective as conventional stapling and if there were differences in post-operative pain, complications and recurrences., Results: From July 2003 to June 2006 we performed 823 laparoscopic herniorrhaphies. Fibrin glue (Tissucol(R)) was used in 88 cases. Two homogeneous groups of 68 patients (83 cases) treated with fibrin glue and 68 patients (87 cases) where the mesh was fixed with staples, were compared. Patients with relevant associated diseases or large inguino-scrotal hernias were excluded. Operative times were longer in the group treated with fibrin glue with a mean of 35 minutes (range 22-65 mins) compared to the group treated with staples (25 minutes, range 14-50 mins). The time of hospital stay was the same (24 hours). Post-operative complications, that were more frequent in the stapled group, included trocar site pain, hematomas, intra-operative bleedings and incisional hernias. No significant difference was observed concerning seromas, chronic pain and recurrence rate., Conclusions: Less post-operative pain, and a faster return to usual activities are the main advantages of laparoscopic repair compared to the traditional approach. The use of fibrin sealant reduces in our experience the risk of post- and intra-operative complications such as bleeding and incisional hernia; recurrence rates are similar, but the operative time is longer.

A 24-year-old man was admitted at the emergency department with a lower quadrant abdominal pain and a slight hypoglycaemia. Abdominal ultrasonography showed the presence of a fluid peritoneal collection and a 3.2 x 2.5 cm hypoisoechogenic mass closed to the left iliac vessels with an echo-color-Doppler pattern similar to that of a hamartoma. CT examination confirmed the hypothesis of a vascular tumour. Although an abdominal angiography added no new information to establish a preoperative diagnosis, it showed a well vascularized mass. The patient underwent laparoscopy that revealed a bleeding mass of the great omentum. Laparoscopic stapled resection of the greater omentum was carried out. The solid lesion consisted of spindle-shaped cells, but no atypical cells were observed. The histological findings were diagnostic of a benign solitary fibrous tumor, an extremely rare neoplasm for a long time considered to be an exclusively thoracic lesion. This is the first case of a solitary fibrous tumor presenting as haemoperitoneum and the first time it was removed laparoscopically. The patient is disease-free at the 2-year follow-up.

Cavernous hemangioma is the most common benign liver tumor. When it becomes symptomatic, enucleation is considered the treatment of choice because of its lower morbidity compared with liver resection. Therefore, although there have been many series of laparoscopic liver resection, only a few cases of laparoscopic enucleation of liver hemangiomas have been reported. We report the case of a 36-year-old woman with a symptomatic 4-cm liver hemangioma of the left lobe who underwent laparoscopic enucleation, with complete relief of the symptoms at the 3-month follow-up. The operating time was 90 minutes. Neither liver mobilization nor ligament division was necessary. The dissection was carried out with minimal blood loss. The postoperative period was uneventful, and the patient was discharged on postoperative day 4. Laparoscopic enucleation is easy to perform in suitable lesions, and its advantage with respect to liver resection is the preservation of healthy parenchyma and liver ligaments. No outflow occlusion is needed, and the intraoperative bleeding is easily controlled. Technical aspects of laparoscopic enucleation are described and a review of the literature is also provided.

Background: Laparoscopic adrenalectomy is now used worlwide and is a great advance in laparoscopic technology. The reported benefits of this approach include decreased blood loss, better intraoperative haemodynamic control and shorter hospital stay, however some doubts on its indication for adrenal secreting tumors are still present. The aim of this retrospective study is to compare the physiologic alterations on blood pressure during laparoscopic and laparotomic adrenalectomy in patients with adrenal secreting adenoma, the intraoperative blood loss and mean hospital stay in the 2 groups of patients. A review of the literature is included., Methods: Laparoscopic adrenalectomy was performed in 13 patients (Conn's syndrome with adrenal adenoma in 10, pheochromocytoma in 3). Laparotomy was used for adrenalectomy in 9 patients: 4 with pheochromocytoma and 5 with Conn's adenoma. All the selected patients in the 2 groups had benign adenoma with tumor size less than 6 cm. During surgery the following data were determined: blood pressure before inducing anaesthesia, pressure peaks, episodes of hypertension and of hypotension, blood loss and operating times. The mean hospital stay was also recorded., Results: No differences were found in the blood-pressure values of the 2 groups of patients. The blood loss was minimal in all but 2 patients. The mean hospital stay was significantly longer in those patients who underwent laparotomy. No significant differences were recorded in the mean operating time., Conclusions: The 2 techniques seem to have the same physiological consequences in the cardiovascular system, and the operating times for laparoscopic and laparotomic adrenalectomy are not so different. Laparoscopic adrenalectomy is a safe technique to treat small benign adrenal secreting adenomas.

Background: The authors reviewed the experience on the use of laparoscopy performed since January 1997 in malignant neoplasms at their institution. The aim of the study was to evaluate the real effectiveness of this procedure in the staging of abdominal neoplasms which were considered resectable at preoperative examinations and in particular in the detection of peritoneal metastases not evidenced with traditional imaging techniques., Methods: Twenty-eight patients with malignant neoplasms: colo-rectum (15), stomach (5), pancreas (4), gallbladder (2), cardias (1), liver (1), were studied. All the patients were preoperatively examined with abdominal computed tomography (CT). In the 2 patients with gallbladder neoplasm a MR cholangiography was also performed. An explorative laparoscopy with peritoneal washing was then performed in all the patients. The diagnostic and therapeutic choices were subsequently done on the basis of laparoscopy results., Results: Therapeutic approach was modified in 21% of cases, as a result of the detection of peritoneal metastases which were not evidenced with imaging examinations. On the contrary, peritoneal washing was not responsible of any preoperative evaluation., Conclusions: Laparoscopy performed in patients with abdominal neoplasms allows the detection of peritoneal micrometastases not previously evidenced through preoperative CT, thus modifying the therapeutic approach.

Background: The more wide spread laparoscopic technique to operate on the adrenal gland is transabdominal approach with a lateral flank adrenalectomy. However, the transabdominal anterior approach can be a sure and safe alternative in selected patients., Methods: From 1997 to 1999, 18 selected patients underwent laparoscopic anterior adrenalectomy. Mean age was 43 years (range 25-63) with a male/female ratio of 1:1. Indications were Conn's adenoma in 10 patients, pheochromocytoma in 3 cases, Cushing syndrome in 1 and incidentaloma in 4. All the procedures were carried out laparoscopically and only one patient required conversion to an open adrenalectomy for clear signs of malignancy. The mean time for adrenalectomy was 140 minutes and the shorter times were recorded in the right-sided procedures (mean time 84 minute). Estimated blood loss was minimal and no transfusion was done. There were no postoperative complications related to the surgical technique and the hospital stay was 4 days in average., Results: Our data confirm, according with other authors, that this method is feasible in selected patients. Longer times recorded for the left-sided lesions were due to the more difficult dissection required to gain the left adrenal gland., Conclusions: Transabdominal adrenalectomy with patient in the supine position is feasible, but its use is restricted to the cases with suspect bilateral or multifocal pheochromocytoma, to patients with concomitant abdominal pathologies that can be operated on laparoscopically, to surgeons who prefer to have a frontal view of the operative field.

Background: In laparoscopic surgery, pneumoperitoneum may be obtained either by a blind or an open access technique. These two techniques and the advantages of Hasson technique are compared., Methods: Through January 1998 and May 1999, 262 unselected patients underwent laparoscopic surgery; pneumoperitoneum was obtained with a random technique, while in the patients previously operated on the open technique was always performed. In 161 cases (61.5%) pneumoperitoneum was obtained with Hasson technique and in 101 (38.5%) with Veress technique. All the patients were clinically evaluated after surgery and then after 30-40 days. The complications encountered were always associated with the Veress needle blind access: peritoneal space insufflation in 3 cases, greater omentum insufflation in 3 cases, 4 cases of difficult management and only one case of incisional hernia on the umbilical wound., Results: Our data confirm that Hasson open technique is safer than Veress blind technique as the risk of severe early and late complications is lower., Conclusions: The open laparoscopic technique with the Hasson trocar is recommended as it showed to be a quicker, safer and superior technique for obtaining pneumoperitoneum.

Abstract 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.

Abstract Background COVID-19 pandemic has rapidly spread in Italy in late February 2020. Almost all surgical services have been reorganized, with the aim of maintaining an adequate therapeutic path, especially for surgical emergencies. The knowledge of how surgeons dealing with emergency surgery have reacted to the epidemic in the real life can be useful while drafting clinical recommendations. Methods Surgeons from multiple Italian regions were invited answering to an online survey in order to make a snapshot of their current behaviors towards COVID-19-positive patients bearing urgent surgical diseases. Questions about institutional rules and personal approach for patient treatment and to limit epidemic spread were included in a 37-item questionnaire. Results Seventy-one questionnaires from institutions dealing with emergency surgery were accepted. Participating surgeons were equally subdivided from a geographical point of view, with a large proportion of public (97.2%) and non-academical (91.5%) centers. In 80.3% of cases, the hospitals treated COVID-19 patients; in 69.1% of centers, a change in work plan was necessary, and 33.8% of teams had almost a surgeon infected or in preventive quarantine. The vast majority of surgeons operated only on urgent cases (73.9%), but the number of interventions significantly dropped. Up to 40% of non-traumatic abdominal emergency cases had an unusual delayed treatment. The laparoscopic approach was used in 69.6% of interventions on COVID-19 patients. Strategies to protect health care workers against COVID-19 infection and to identify asymptomatic infected surgeons were suboptimal with respect to the WHO recommendations in 70.4% and 90.2% of centers, respectively. Advanced personal protective equipment for operating room workers was adopted for all surgeries in only 12.7% of centers. Discussion This survey confirms that the COVID-19 outbreak is dramatically changing the practice of emergency surgery centers in Italy. Despite the reduction in number, urgent cases were on average more challenging owing to diagnostic delay. Recommendations from the International Scientific Societies are frequently not complied concerning the use of laparoscopic approach, the availability of personal protective equipment in the operating rooms, and the testing of both asymptomatic physicians and patients scheduled for surgery. A further evaluation of the short-term results of these attitudes is warranted to modulate international recommendations.