Search

Technical and oncological aspects are still debated when dealing with minimally-invasive right colectomy. Main controversial issues still remain about whether the anastomosis should be performed intra- or extracorporeally and if a complete mesocolic excision (CME) should be carried out. We report the feasibility of robotic right colectomy with CME and intracorporeal anastomosis (IA) for right sided colon cancer. Data from patients who underwent robotic right colectomy with IA and CME from January 2015 to April 2020 were prospectively collected and retrospectively analyzed. Intraoperative outcomes and complications (minor I-II and major III-IV according to Clavien-Dindo classification), conversion rate, 30-day postoperative outcomes and pathological outcomes were the variables assessed. A total of 161 patients undergoing robotic right colectomy for cancer met the inclusion criteria. Mean operative time was 185 min, no intraoperative complications were observed, and the conversion rate was 3.7% (6 patients requiring elective conversions). Overall, mean postoperative stay was 4.9 days and the overall 30-day complication rate was 16.1%. 20 patients (12.4%) had minor complications, while major postoperative complications occurred in six patients (3.7%). Anastomotic leak was recorded in one patient (0.6%) and the 30-day re-admission rate was 0.6%. Mean number of harvested lymph nodes was 21.9. Patients requiring conversion experienced two minor complications, with a mean length of stay of 7 days. Robotic right colectomy with CME and IA is feasible and it is associated with good intraoperative and short-term postoperative clinical outcomes.

The minimally invasive treatment of rectal cancer with Total Mesorectal Excision is a complex and challenging procedure due to technical and anatomical issues which could impair postoperative, oncological and functional outcomes, especially in a defined subgroup of patients. The results from recent randomized controlled trials comparing laparoscopic versus open surgery are still conflicting and trans-anal bottom-up approaches have recently been developed. Robotic surgery represents the latest consistent innovation in the field of minimally invasive surgery that may potentially overcome the technical limitations of conventional laparoscopy thanks to an enhanced dexterity, especially in deep narrow operative fields such as the pelvis. Results from population-based multicenter studies have shown the potential advantages of robotic surgery when compared to its laparoscopic counterpart in terms of reduced conversions, complication rates and length of stay. Costs, often advocated as one of the main drawbacks of robotic surgery, should be thoroughly evaluated including both the direct and indirect costs, with the latter having the potential of counterbalancing the excess of expenditure directly related to the purchase and maintenance of robotic equipment. Further prospectively maintained or randomized data are still required to better delineate the advantages of the robotic platform, especially in the subset of most complex and technically challenging patients from both an anatomical and oncological standpoint.

Rectal prolapse is a condition that can cause significant social impairment and negatively affects quality of life. Surgery is the mainstay of treatment, with the aim of restoring the anatomy and correcting the associated functional disorders. During recent decades, laparoscopic abdominal procedures have emerged as effective tools for the treatment of rectal prolapse, with the advantages of faster recovery, lower morbidity, and shorter length of stay. Robotic surgery represents the latest evolution in the field of minimally invasive surgery, with the benefits of enhanced dexterity in deep narrow fields such as the pelvis, and may potentially overcome the technical limitations of conventional laparoscopy. Robotic surgery for the treatment of rectal prolapse is feasible and safe. It could reduce complication rates and length of hospital stay, as well as shorten the learning curve, when compared to conventional laparoscopy. Further prospectively maintained or randomized data are still required on long-term functional outcomes and recurrence rates.

BACKGROUND This study aimed to evaluate the impact of the robotic approach on the minimally invasive elective treatment of diverticular disease. METHODS Data from patients who underwent elective robotic colectomy for diverticular disease from January 2015 to February 2020 were prospectively collected and retrospectively analysed. Intraoperative and 30-day postoperative outcomes were the variables assessed. RESULTS A total of 80 patients (71% with prior complicated diverticulitis) met the inclusion criteria. Mean operative time was 241 min, one intraoperative complication (1.2%) was observed, the conversion rate was 2.5%. Mean hospital stay was 6.4 days and overall 30-day complication rate was 22.5%. Fourteen patients (17.5%) had minor complications, while major postoperative complications occurred in four patients (5%). Anastomotic leak rate was 3.9% and the 30-day readmission rate was 3.7%. CONCLUSIONS Robotic colectomy for diverticular disease has proven to be feasible and safe, with low intraoperative complications, conversion, and anastomotic leak rates.

Background Complete mesocolic excision (CME) for right colectomy increase the technical complexity of a laparoscopic approach especially when an intracorporeal anastomosis (IA) is associated. The robotic platform, with its intrinsic technical advantages, could potentially overcome the limitations of conventional laparoscopy. This study aimed to describe the robotic bottom-up technique and to evaluate short-terms outcomes of robotic right colectomy (RRC) with CME and IA. Methods Data from patients who underwent RRC for cancer with bottom-up suprapubic approach from October 2016 to April 2020 were prospectively collected and retrospectively analyzed. Intraoperative outcomes and complications, conversion rate, 30-day postoperative outcomes, incisional hernia rate and pathological outcomes were the variables assessed. Results A total of 109 patients were submitted to bottom-up suprapubic approach for RRC with CME and IA during the study period. Mean operative time was 179 min, no intraoperative complications were observed, and the conversion rate was 3.6%. Mean postoperative stay was 4.6 days and the overall 30-day complication rate was 15.6%. Thirteen patients (12%) had minor complications, while major postoperative complications occurred in 4 patients (3.6%). Anastomotic leak was recorded in 1 patient (0.9%) and the 30-day re-admission rate was 0.9%. Mean number of harvested lymph nodes was 22.6. Incisional hernia rate at the specimen extraction site was 0.9%. Conclusions Bottom-up approach for RRC with CME and IA carries a low rate of conversions, intraoperative and short-term postoperative complications.

Complete mesocolic excision (CME) was introduced by Hohenberger and it is well standardized for right colonic cancer as well as for cancers of the descending colon and sigma. However, for tumors of distal transverse colon, splenic flexure, and proximal descending colon, the CME remains less homogeneous. This is probably due to the complex anatomy around the splenic flexure, subject to many vascular and lymphatic variations.

Background Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the second most frequently performed bariatric procedure worldwide; however, long-term results are not frequently reported. Objectives To evaluate the outcomes of LRYGB on weight loss and co-morbidities in a single center 15 years after the operation. Setting Tertiary-care referral hospital. Methods From February 2000 to December 2003, 105 patients (86 women; mean age 39.9 ± 17.4; mean body mass index [BMI] 47.2 ± 6.4 kg/m2; 78 with BMI Results The follow-up rate at 15 years was 87.6%. Mean excess weight loss was 58.6 ± 27%, with 74.1% of patients achieving a total weight loss ≥ 20%. According to the Biron et al. criteria, an inadequate outcome was found in 11/21 (52.4%) of patients with an initial BMI ≥ 50 kg/m2 versus 21/64 (32.8%) of patients with a preoperative BMI Conclusion LRYGB provides satisfactory weight loss and resolution of co-morbidities up to 15 years. WR was a common finding. A significant proportion of patients with a preoperative BMI ≥ 50 kg/m2 did not achieve a favorable weight loss outcome. Indications to perform LRYGB in this group of patients should be definitively reconsidered.

Minimally invasive surgery has gained worldwide acceptance in the treatment of colonic cancer in the last decades, thanks to its well-known benefits in terms of 30-day postoperative outcomes and equivalent long-term oncological results. Nevertheless, the penetrance of laparoscopic colectomy still remains low. A main controversial issue remains about whether the anastomosis should be performed intra- or extracorporeally. Furthermore, the introduction of the concept of complete mesocolic excision (CME), together with its potential long-term oncological advantages, has led to another matter of debate when dealing with laparoscopic right colectomy. The principles of CME may potentially increase the technical difficulties of minimally invasive surgery, especially when dealing with right colon cancer.

Background Surgical strategies are being adapted to face the COVID‐19 pandemic. Recommendations on the management of acute appendicitis have been based on expert opinion, but very little evidence is available. This study addressed that dearth with a snapshot of worldwide approaches to appendicitis. Methods The Association of Italian Surgeons in Europe designed an online survey to assess the current attitude of surgeons globally regarding the management of patients with acute appendicitis during the pandemic. Questions were divided into baseline information, hospital organization and screening, personal protective equipment, management and surgical approach, and patient presentation before versus during the pandemic. Results Of 744 answers, 709 (from 66 countries) were complete and were included in the analysis. Most hospitals were treating both patients with and those without COVID. There was variation in screening indications and modality used, with chest X‐ray plus molecular testing (PCR) being the commonest (19·8 per cent). Conservative management of complicated and uncomplicated appendicitis was used by 6·6 and 2·4 per cent respectively before, but 23·7 and 5·3 per cent, during the pandemic (both P, The COVID‐19 pandemic required reorganization of surgical services, affecting patients with common surgical diseases including acute appendicitis. No evidence is available on the topic. This study found global variation in screening policies, use of personal protective equipment and intraoperative directives. There has been increased adoption of non‐operative management and open appendicectomy. Hands off

In this chapter, the different steps of setting up a robotic colorectal surgical program are analysed from both financial and clinical standpoints.

Robotic technology has proven to be safe and effective in many surgical fields with comparable or even better outcomes than conventional minimally invasive surgery for several oncological procedures. However, the widespread diffusion of robotic surgical systems has encouraged, despite their significant cost, an uncontrolled adoption of the robot-assisted approach that is being used by an increasing number of centers with low volume and poor experience. Recent publications have shown a strong inverse relationship between hospital caseload of robotic procedures and the related outcomes especially when performed for oncological indications. On this basis, the surgical community is calling for centralization of patients to high-volume centers. In this chapter the current available evidence on this topic is analyzed for specific fields of application.

Acute appendicitis (AA) is one of the most common causes of abdominal pain requiring surgical intervention. Approximately 20% of AA cases are characterized by complications such as gangrene, abscesses, perforation, or diffuse peritonitis, which increase patients' morbidity and mortality. Diagnosis of AA can be difficult, and evaluation of clinical signs, laboratory index and imaging should be part of the management of patients with suspicion of AA.This consensus statement was written in relation to the most recent evidence for diagnosis and treatment of AA, performing a literature review on the most largely adopted scientific sources. The members of the SPIGC (Italian Polispecialistic Society of Young Surgeons) worked jointly to draft it. The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by the American College of Chest Physicians (CHEST) for the strength of the recommendations.Fever and migratory pain tend to be present in patients with suspicion of AA. Laboratory and radiological examinations are commonly employed in the clinical practice, but today also scoring systems based on clinical signs and laboratory data have slowly been adopted for diagnostic purpose. The clinical presentation of AA in children, pregnant and elderly patients can be unusual, leading to more difficult and delayed diagnosis. Surgery is the best option in case of complicated AA, whereas it is not mandatory in case of uncomplicated AA. Laparoscopic surgical treatment is feasible and recommended. Postoperative antibiotic treatment is recommended only in patients with complicated AA.

Aim Laparoscopic Hartmann's reversal (HR) is a major abdominal operation that is associated with considerable morbidity and mortality. The robotic approach, with its intrinsic advantages, could potentially overcome the technical complexity of laparoscopy. The aim of this study was to evaluate the short-term results of a series of 24 robotic HR cases. Method The data from 24 patients who underwent robotic HR between September 2016 and July 2019 at two different institutions were prospectively collected and retrospectively analysed. A full robotic single-docking reversal procedure with intracorporeal anastomosis was performed in all patients. Results The mean age and body mass index of the patients were 69 years and 26 kg/m2 , respectively. Of the patients, 58% were ≥ 70 years old and 42% had comorbidities (mean Charlson Comorbidity Index 3). The mean operating time was 240 min. There were no cases of conversion to the open or laparoscopic approach. No diverting loop ileostomies were constructed. The mean length of hospital stay was 6 days. Minor complications were recorded in three patients. Neither major complications nor 30-day readmissions were registered. Conclusions Robotic HR is a feasible and safe procedure. The robotic approach has low rates of major complications and conversion and could potentially increase the number of patients undergoing HR.

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.

Dario Ribero's affiliation is corrected as reflected here.

Minimally invasive surgery has gained worldwide acceptance in the treatment of colonic cancer in the last decades, thanks to its well-known advantages in short-term outcomes. Nevertheless, the penetrance of minimally invasive colorectal surgery still remains low. Few studies and metanalysis, to date, have analyzed the results of robotic versus laparoscopic colorectal surgery, often with conflicting conclusions. The robotic platform, thanks to its technological features, may potentially overcome the limitation of standard laparoscopy, especially when performing a complete mesocolic excision resection and an intracorporeal anastomosis. Robotic surgery could also shorten the learning curve of young novice surgeons, provided that strict protocols of structured training are applied. This paper is an update on the current available outcomes of robotic vs laparoscopic surgery in right colectomy.

Background One major issue in general surgery is how to provide novice surgeons with a structured training program (STP). The aim of our study was to assess the efficacy of a STP in robotic colorectal surgery for young surgeons without prior experience in both open and laparoscopic colorectal surgery, who were autonomous in basic minimally-invasive surgical procedures. Right colectomy with intracorporeal anastomosis has been chosen as a model. Methods Between May 2015 and December 2017 two junior attending surgeons were trained through a STP. Right colectomy was divided into three main learning modules (colonic mobilization, vascular control, intracorporeal anastomosis) and each one was carried out by the trainees for at least two times under direct supervision of the senior surgeon. After the initial robotic cases completely performed under formal proctoring, they were privileged to perform robotic right colectomy independently without a mentor (20 procedures). Operative time, conversion rate, intra- and postoperative complications, length of stay and pathological outcomes were the variables analyzed to assess the effectiveness of the STP. Results The mean operative time was 200 minutes and no conversion was required. Neither intraoperative nor major postoperative complications were recorded and the mean length of hospital stay was 6 days. Mean nodal yield was 21. Conclusions A STP in robotic colorectal surgery is feasible and effective. Right colectomy represents a good model as first step of the program in order to develop multiple technical skills. Previous experience in open or laparoscopic colorectal surgery may not be necessary.

Recent reports have suggested that the use of the robot might reduce the rate of pancreatic complications following minimally invasive radical gastrectomy.By meta-analyzing the available literature, we aimed to elucidate possible differences between conventional laparoscopic and robotic radical gastrectomy on pancreatic morbidity.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.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.

During the past decade, the concept of complete mesocolic excision (CME) has emerged as a possible strategy to minimize recurrence for right colon cancers. The purpose of this study was to compare robotic versus laparoscopic CME in performing right colectomy for cancer. Pertinent data of all patients who underwent robotic or laparoscopic right colectomy with CME using a Pfannenstiel incision and intracorporeal anastomosis performed between October 2005 and November 2015 were entered in a prospectively maintained database. A total of 202 patients underwent robotic (n = 101) or laparoscopic (n = 101) right colectomy within the study period. Patient characteristics were equivalent between groups. The robotic group showed a statistically significant reduction in conversion rate (0% vs. 6.9%, p = 0.01) but a longer operative time (279 min vs. 236 min, p

In 1908, Sir Ernest Miles reported his first attempt to develop a radical operation for rectal cancer, publishing his experience with abdominoperineal resection (APR).

Introduction Right-sided colon cancer has a worse prognosis than left-sided colon cancer. Complete mesocolic excision (CME) with central vessels ligation (CVL) reduces local recurrence, but is technically demanding, particularly with a laparoscopic approach. Aim of this study is to describe a new robotic approach to right colectomy with CME and CVL and to report oncologic safety and short term outcomes. Methods Twenty consecutive patients were included. All patients had a right colon adenocarcinoma and underwent right colectomy with a suprapubic approach. Surgery was realized with the Da Vinci Xi ® system and all trocars were placed along a horizontal line 3–6 cm above the pubis. CME with CVL was realized in all the patients. Data analysed were: duration of surgery, conversions to open surgery, intraoperative and postoperative complication by Clavien Dindo classification, margins of resections, length of specimen and number of lymph nodes retrieved. Results Patients median age was 69 years, median body mass index was 27 kg/m 2 . Median operative time was 249 min, blood loss was negligible, no conversions to open or laparoscopic surgery occurred. Median hospital stay was six days; two postoperative grade IIIa Clavien–Dindo complications occurred, no 30-days postoperative death was registered. Resection margins were negative in all patients; median tumour diameter was 3.6 cm, median specimen length was 40 cm, median number of harvested lymph nodes was 40. Conclusions Robotic right colectomy with CME using a suprapubic approach is a feasible and safe technique that allows for an extended lymphadenectomy and provides high quality surgical specimens.

Complete Mesocolic Excision (CME) with central vascular ligation has been reported to potentially improve oncological results in right colectomy [1-4]. However, along with the intracorporeal anastomosis, it represents a challenging step of the laparoscopic procedure [2,3,5]. The video describes a novel bottom-to-up suprapubic approach for robotic right colectomy with CME and intracorporeal anastomosis using the DaVinci Xi Surgical System. This article is protected by copyright. All rights reserved.

Background Robotic Single-Site™ surgery overcomes the technical constraints of single-access laparoscopy. After performing over 130 Single-Site robotic cholecystectomies and stabilizing operative times, we applied this technology to right colon surgery. Methods We successfully completed three Single-Site robotic right colectomies (SSRRCs) using the da Vinci Si Surgical System® with a Single-Site kit (© Intuitive Surgical™) inserted through a suprapubic incision. Results Overall SSRRC operative time was 218.3 ± 75.9 min. A side-to-side anisoperistaltic anastomosis was fashioned intracorporeally (two cases) or extracorporeally (one case). All patients were discharged within 5 days. There were no complications and oncological principles were satisfied. There were no recurrences up to 12 months. Conclusions This is the first report of SSRRC with intracorporeal anastomosis using the da Vinci® Single-Site™ port inserted through a suprapubic incision. This approach is feasible and safe, with oncological outcomes potentially equivalent to those of robotic or laparoscopic multiport surgery. Copyright © 2014 John Wiley & Sons, Ltd.

BACKGROUND: There are few studies of long-term outcomes for either laparoscopic adjustable gastric banding (LAGB) or laparoscopic Roux-en-Y gastric bypass (LRYGB). The objective of this study was to compare outcomes of patients randomly assigned to undergo LAGB or LRYGB at 10 years. METHODS: LAGB, using the pars flaccida technique, and standard LRYGB were performed. From January 2000 to November 2000, 51 patients (mean age 34.0 ± 8.9 years; range 20-49) were randomly allocated to undergo either LAGB (n = 27, 5 men and 22 women; mean age 33.3 years; mean weight 120 kg; mean body mass index [BMI] 43.4 kg/m(2)) or LRYGB (n = 24, 4 men and 20 women; mean age 34.7; mean weight 120 kg; mean BMI 43.8 kg/m(2)). Data on complications, reoperations, weight, BMI, percentage of excess weight loss, and co-morbidities were collected yearly. The data were analyzed using Student's t test and Fisher's exact test, with P

A modified complete mesocolic excision (mCME) technique for the treatment of right-sided colon cancer recently was shown by Hohenberger and colleagues to provide impressive long-term oncologic outcomes. This report aims to describe the authors’ experience with robotic right colectomy using mCME. The safety, feasibility, and efficacy of this procedure are measured by complications, conversion rates, and 4-year oncologic outcomes. A retrospective study analyzed 100 consecutive patients who underwent robotic right colectomy with mCME and intracorporeal anastomosis at the authors’ institution between November 2005 and November 2013. Intra- and postoperative clinical outcomes, pathologic data, and survival were analyzed. Robotic right colectomy with mCME was successfully performed for all the patients. No conversions or intraoperative complications occurred. The major complication rate (Dindo 3 or 4) was 4 %. During a median follow-up period of 48.5 months (range 24–114 months), the survival rates were 94.5 % for disease-specific survival, 91.4 % for disease-free survival, and 90.3 % for overall survival. The authors’ experience confirms the feasibility and safety of mCME for the treatment of right-sided colon cancer. This technique provided satisfying short-term outcomes with promising 4-year oncologic results. However, the real benefits of the CME technique should be evaluated further by well-conducted randomized studies before its adoption in routine practice is recommended.

Laparoscopic adjustable gastric banding (LAGB) is generally safe and well tolerated but complications are not infrequent. As with all other bariatric procedures, there are patients who experience poor weight loss or even weight regain at long term follow up. Some of these complications require prompt management whereas more chronic problems require careful work up involving the multidisciplinary team. All complications require a resolution and revision tailored to the individual. Revision of failed or complicated LAGB should be performed by an experienced bariatric team. A wide range of endoscopic and laparoscopic procedures can be offered to patients with LAGB complications. Management of these issues often requires explanting the device, with or without proceeding to more definitive measures. Invariably, there will be a subgroup of patients with interval weight regain, especially if the gastric band is removed without any immediate salvage or replacement procedure. Redo surgery for LAGB is still a gray area of bariatric surgery. Large experiences with long follow up are lacking and high grade level evidence based experiences are also absent. Overall, outcomes in terms of weight loss and complications are controversial according to different experiences.

The first global survey of bariatric/metabolic surgery based on data from the nations or national groupings of the International Federation for the Surgery of Obesity and Metabolic Diseases (IFSO) was published in 1998, followed by reports in 2003, 2009, 2011, and 2012. In this survey, we report a global overview of worldwide bariatric surgery in 2013. A questionnaire evaluating the number and the type of bariatric procedure performed in 2013 was emailed to all members of bariatric societies belonging to IFSO. Trend analyses from 2003 to 2013 were also performed. There were 49/54 (90.7 %) responders; 37 of the 49 with national registries. The total number of bariatric procedures performed worldwide in 2013 was 468,609, 95.7 % carried out laparoscopically. The highest number (n = 154,276) was from the USA/Canada region. The most commonly performed procedure in the world was Roux-en-Y gastric bypass (RYGB), 45 %; followed by sleeve gastrectomy (SG), 37 %; and adjustable gastric banding (AGB), 10 %. Most significant were the rise in prevalence of SG from 0 to 37 % of the world total from 2003 to 2013, and the fall in AGB of 68 % from its peak in 2008 to 2013. SG is currently the most frequently performed procedure in the USA/Canada and in the Asia/Pacific regions, and second to RYGB in the Europe and Latin/South America regions. The accuracy of the IFSO-based world survey of procedures would be enhanced if each nation or national group would create a national registry.

Minimally invasive surgery is gaining worldwide acceptance in the treatment of colonic cancer and the advantages over the traditional open approach are well known [1, 2, 3]. Unfortunately, during recent decades, the outcomes of patients after colon cancer resection have not improved to the same degree as for rectal cancer, whose treatment with total mesorectal excision (TME) is universally accepted as the standard of care. The complete mesocolic excision (CME), first reported by Hohenberger and colleagues in 2008 [4], seems to produce better long-term outcomes when compared to standard lymphadenectomy by following the same embryological-based principles introduced by Heald for rectal cancer more than 20 years ago [5]. However, well-conducted randomized studies are needed to confirm its efficacy.

Surgery for morbid obesity has been carried out since 1950s, but it was only after the introduction of biliopancreatic diversion by Scopinaro that the surgical approach to obesity gain worldwide consensus and diffusion [1, 2]. During the years, gastric restrictive procedures, malabsorptive or combined procedures were introduced in the bariatric surgical praxis [3, 4]. Several experiences reported risk and benefit of each procedure, and the even increasing number of operated patients run parallel with a similar increase of re-do operations [5, 6]. Re-do bariatric surgical procedures are mainly indicated for two reasons. The first reason is the presence of an acute or chronic complication or a side effect of the primary bariatric procedure or metabolic and nutritional sequel. The second is the absence of postoperative weight loss or the weight regain after a successful period, untreatable with conservative approach [7–11]. Re-do bariatric procedures can be divided into conversions and revisions. Conversion surgery is defined as the exchange of a bariatric procedure to another one. Revision surgery is defined as the modification of the primary bariatric procedure without changes of its anatomical scheme.

The imaging technique based on indocyanine green (ICG) fluorescence has been widely used for more than forty years, especially to study blood flow and microcirculation. This method was first applied in general surgery to perform sentinel lymph node (SLN) biopsies in patients affected by breast and colorectal cancer. In 2010, a near-infrared (NIR) laser light system was integrated with the da Vinci® Si™ HD robotic system (Intuitive Surgical Inc., Sunnyvale, CA, USA). This imaging system is able to provide both white light and near-infrared light images through dedicated endoscopic illuminators and filters by simply pressing a pedal on the surgical console, thus allowing real-time fluorescence-guided surgery.

The severity of complicated diverticulitis includes a broad spectrum of diseases and is classified according to the Hinchey classification system [1]: Stage I: pericolic abscess, confined to the mesentery of the colon, usually responsive to conservative management, with a radiological drainage in the case of an abscess larger than 5 cm; Stage II: distant abscess amenable to percutaneous drainage (Stage IIa) or complex and multiple abscesses with or without a digestive fistula (Stage IIb); Stage III: diffuse purulent peritonitis; Stage IV: diffuse fecal peritonitis

Indocyanine green (ICG) is a vital dye with the distinctive feature of being fluorescent if properly excited and is therefore currently used in near infrared (NIR) fluorescence image-guided oncologic surgery. Recently, a new camera has been developed for the da Vinci® Surgical System which allows real-time switching between a standard three-dimensional vision to a NIR view. The technique of fluorescence imaging, the so-called “Firefly System,” can be applied in several fields of robotic general surgery, some still experimental and continuously evolving.

The robotic approach for the treatment of gastric cancer (GC) has been initially adopted mainly in Asia, where this malignant disease is more common than in Western countries and it is diagnosed at earlier stages thanks to a screening program. Among Asian countries, South Korea started to embrace the robotic technique in 2005 and now it has become one of the leading countries in robotic gastric cancer surgery. In this chapter we present our experience of robotic subtotal gastrectomy (RSTG) with D2 lymph node (LN) dissection for GC where the step-by-step procedure is based mostly on the technique of Dr Woo Jin Hyung [1].

Minimally invasive splenectomy has become an established standard of care in general surgery for nontraumatic splenic lesions. Since laparoscopic splenectomy was first reported in 1991 by Delaitre et al. [1], subsequent literature has clearly shown that this approach dramatically improves short-term perioperative outcomes and provides enhanced cosmesis [2].

Since the first robotic total mesorectal excision (TME) was reported in 2006 [1], two main methods for robotic rectal surgery, hybrid versus totally robotic technique, have been described.

The Single-Site™ platform was primarily designed to work in a narrow operative field and with a specific anatomical target. To date, the most consistent published experiences are regarding the use of this technology to perform cholecystectomy [1, 2, 3, 4, 5, 6, 7, 8, 9] but, recently, it has been applied in other fields of general surgery [10, 11, 12]. This chapter will focus on its current application in performing cholecystectomy and right colectomy.

Background Obesity is an independent risk factor for gastroesophageal reflux disease (GERD), which is often associated with the presence of a hiatal hernia (HH). Despite increasing popularity of laparoscopic sleeve gastrectomy (LSG) in bariatric surgery, its effect on GERD is still unclear. The objective of this study was to evaluate the effect of LSG with or without hiatal hernia repair (HHR) on GERD in obese patients. Methods Seventy-eight patients with HH underwent LSG with concomitant HHR (LSG+HHR group). Their data were compared with that of 102 patients without HH, who underwent only LSG (LSG-group). All patients underwent a standardized questionnaire, a double-contrast barium swallow, and an upper-gastrointestinal endoscopy before the surgical procedure and at least 6 months later. Results At baseline, the prevalence of GERD symptoms and their frequency-intensity scores did not differ between groups. At follow up, there was a significant decrease in the prevalence of typical GERD symptoms only in the LSG-group ( P = .003). LSG+HHR patients showed a significantly higher heartburn frequency-intensity score compared with LSG patients ( P = .009). Conclusion This finding confirms that LSG has a beneficial effect on relieving GERD symptoms, although the underlying mechanisms are still unclear; conversely, the procedure of HHR did not produce any improvement in GERD symptoms.

To the editor:We read with great interest the paper by Moon et al. de-scribing their experience with a novel technique of laparo-scopic banded Roux-en-Y using a bovine pericardial patch(Vascugard, Synovis, St. Paul, MN, USA) to improve theresults and prevent weight regain [1]. Although definitivedata proving the benefit of banding vs unbanded standardRoux-en-Y gastric bypass are not available as yet [2], weshare authors’ view on the mechanism of action of pre-anastomotic ring. We experienced a similar technique on asmaller group of patients from December 2009, 11 primarycase and one revision for weight regain (mean age, 40.5 years; mean preoperative weight, 119.6 kg; mean preop-erative BMI, 44.6 kg/m

Background: Laparoscopic sleeve gastrectomy (LSG) is an approved primary procedure for morbid obesity, but it is associated with serious complications, such as staple line leaks and bleeding. The objective of this study was to assess the effectiveness of staple line reinforcement (SLR) in reducing leaks and bleeding after LSG. Methods: A total of 1162 patients underwent LSG (305 males, 857 females). The mean age was 43.7 years and the mean body mass index was 48 kg/m 2 . The patients were divided into 6 groups based on the type of SLR, including a no-SLR control group, with evaluation of leaking and bleeding risk and correlation of patients’ characteristics with complications. Results: A total of 189 patients underwent LSG without reinforcement. The SLR method was oversewing in 476 patients, bovine pericardium in 312, synthetic polyester in 76, glycolide/trimethylene copolymer in 63, and thrombin matrix in 46. The overall leak frequency was 2.8%; higher with synthetic polyester (7.8%), 4.8% with no reinforcement, and lower with bovine pericardium strips (.3%; P o .01). Postoperative hemorrhage occurred in 35 patients (3%), with a higher frequency being observed without SLR (13.7%; P ¼ .02). Only diabetes was a risk-factor for a leak (P o .01). Conclusion: SLR with bovine pericardium strips significantly reduced the leak risk. Postoperative bleeding was significantly lower with all SLR-methods, although there was no significant difference among the various techniques. Patients with type II diabetes had a higher risk of staple line leak after LSG. Further randomized, controlled studies are needed to improve our understanding of the efficacy of SLR during LSG. (Surg Obes Relat Dis 2013;]:00–00.) r 2013 American Society for Metabolic and Bariatric Surgery. All rights reserved.

Overweight and obesity independently increase cardiovascular risk, while even modest weight loss can result in clinically significant improvements in cardiovascular risk and reduce long-term mortality. Lowering the body mass index (BMI) threshold for bariatric surgery to those with moderate obesity might be one way to lower the burden of this disease. The aim of this study was to evaluate the efficacy and safety of laparoscopic adjustable silicone gastric banding (LAGB) in moderately obese subjects with or without obesity-related co-morbidities.Thirty-four patients with BMI between 30 and 35 kg/m(2) (5 males/29 females, mean age 36 ± 10 years, mean preoperative weight 87.9 ± 7.1 kg, mean BMI 32.6 ± 1.6 kg/m(2) and mean percentage excess weight 48.7 ± 9 %) who underwent LAGB via pars flaccida between June 1, 2002 and August 31, 2010 were included. Good response was defined as BMI30 kg/m(2) or percentage estimated weight loss (%EWL)50. Poor response was defined as BMI30 kg/m(2) or %EWL less than 50 after a minimum of 1 year.Mean weight, BMI and %EWL were recorded at 1, 3, 5 and 7 years and were 77.4 ± 7.6, 69.9 ± 10.8, 70.9 ± 9.3 and 73.3 ± 12.0 kg; 28.8 ± 2.9, 26.4 ± 3.2, 26.5 ± 3.4 and 27.4 ± 5.0 kg/m(2); and 36 ± 23, 46.1 ± 33.8, 58.6 ± 31.5 and 45 ± 57, respectively (p0.01). Co-morbidities were diagnosed in 17/34 (50 %) patients at baseline and underwent remission or improvement in all cases after 1 year.LAGB in a safe and effective procedure in patients with a BMI35 kg/m(2).

AIM: To compare the short- and long-term outcomes of laparoscopic and robotic surgery for middle and low rectal cancer. METHODS: This is a retrospective study on a prospectively collected database containing 111 patients who underwent minimally invasive rectal resection with total mesorectal excision (TME) with curative intent between January 2008 and December 2014 (robot, n = 53; laparoscopy, n = 58). The patients all had a diagnosis of middle and low rectal adenocarcinoma with stage I-III disease. The median follow-up period was 37.4 mo. Perioperative results, morbidity a pathological data were evaluated and compared. The 3-year overall survival and disease-free survival rates were calculated and compared. RESULTS: Patients were comparable in terms of preoperative and demographic parameters. The median surgery time was 192 min for laparoscopic TME (L-TME) and 342 min for robotic TME (R-TME) (P < 0.001). There were no differences found in the rates of conversion to open surgery and morbidity. The patients who underwent laparoscopic surgery stayed in the hospital two days longer than the robotic group patients (8 d for L-TME and 6 d for R-TME, P < 0.001). The pathologic evaluation showed a higher number of harvested lymph nodes in the robotic group (18 for R-TME, 11 for L-TME, P < 0.001) and a shorter distal resection margin for laparoscopic patients (1.5 cm for L-TME, 2.5 cm for R-TME, P < 0.001). The three-year overall survival and disease-free survival rates were similar between groups. CONCLUSION: Both L-TME and R-TME achieved acceptable clinical and oncologic outcomes. The robotic technique showed some advantages in rectal surgery that should be validated by further studies.

Materials and methods All patients who received a gastrectomy for adenocarcinoma in our surgical department from January 1998 to December 2002 were admitted to the study. Inclusion criteria were: a) Curative resection (R0); b)no metastases before surgery; c)no other primitive neoplasms; d)consensus of the patient for a follow-up of 5 years. Recurrence was indicated as haematogenous, peritoneal or locoregional on the basis of the first site of metastases. Patients were divided into two groups by age: cut-off was considered 70 years old.