34 research outputs found
A Case-Control Comparison of Surgical and Functional Outcomes of Robotic-Assisted Spleen-Preserving Left Side Pancreatectomy versus Pure Laparoscopy
Aim During left-sided spleen-preserving pancreatectomy (SPLP), limitations of laparoscopy may require spleen sacrifice or conversion to maintain patient safety. The objective of our study is to compare surgical and functional outcomes of robot-assisted and pure laparoscopic SPLP in patients with benign or borderline lesions of the body/tail of the pancreas. Patients and methods This was a case-matched study: fifteen patients who had robotic SPLP (R-SPLP) were matched with 15 comparable patients who had pure laparoscopic SPLP (L-SPLP). The peri-operative variables (conversion rate, amount of bleeding, operation time, length of hospital stay, complications, mortality and readmission) as well as the spleen preservation rate were compared between the two groups, The European Organisation for Research and Treatment of Cancer QLQ-C30 (EORTC QLQ-C30) specific questionnaires were used in each arm after at least 1 year of follow up in order to evaluate quality of life (QoL). Results No R-SPLP was converted to conventional laparoscopy, hand-assisted laparoscopy, or open surgery whereas L-SPLP had a conversion rate of 13.3% (p=n.s.); also fistula formation (20% vs. 46%; p=n.s.) was higher in the laparoscopic group although not statistically significant. Mean operative time (220 vs. 279 min; p=0.027) was shorter and the spleen-preserving rate (fail/ success, 0/15 vs. 4/11; p=0.03) of R-SPLP was significantly better compared to L-SPLP. Moreover, length of hospital stay was significantly shorter in the R-SPLP group compared to the L-SPLP group (6.5 vs. 8.8 days; p=0.04). Post-operative high grade surgical complications occurred only in one L-SPLP patient (0% vs. 6.6%; p=n.s.). Quality of life scores were not significantly different between the two groups. Conclusions R-SPLP could provide an increased chance for spleen preservation and faster surgical procedure. Furthermore, fistula formation and conversion rate seem to be lower, reducing the length of the hospital stay. Our case matched study confirmed the potential peri-operative benefits of robotic assistance in this setting, however these benefits did not translate into a better quality of life at least one year post-operatively
Hand-assisted hybrid laparoscopicârobotic total proctocolectomy with ileal pouchâanal anastomosis
PURPOSE:
Few studies have reported minimally invasive total proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). We herein report a novel hand-assisted hybrid laparoscopic-robotic technique for patients with FAP and UC.
METHODS:
Between February 2010 and March 2014, six patients underwent hand-assisted hybrid laparoscopic-robotic total proctocolectomy with IPAA. The abdominal colectomy was performed laparoscopically with hand assistance through a transverse suprapubic incision, also used to fashion the ileal pouch. The proctectomy was carried out with the da Vinci Surgical System. The IPAA was hand-sewn through a trans-anal approach. The procedure was complemented by a temporary diverting loop ileostomy.
RESULTS:
The mean hand-assisted laparoscopic surgery (HALS) time was 154.6 (±12.8) min whereas the mean robotic time was 93.6 (±8.1) min. In all cases, a nerve-sparing proctectomy was performed, and no conversion to traditional laparotomy was required. The mean postoperative hospital stay was 13.2 (±7.4) days. No anastomotic leakage was observed. To date, no autonomic neurological disorders have been observed with a mean of 5.8 (±1.3) bowel movements per day.
CONCLUSIONS:
The hand-assisted hybrid laparoscopic-robotic approach to total proctocolectomy with IPAA has not been previously described. Our report shows the feasibility of this hybrid approach, which surpasses most of the limitations of pure laparoscopic and robotic techniques. Further experience is necessary to refine the technique and fully assess its potential advantages
Short-term clinical outcomes of robot-assisted intersphincteric resection and low rectal resection with double-stapling technique for cancer: a case-matched study
Background: Intersphincteric resection (ISR) with total mesorectal excision (TME) is an accepted technique for the surgical treatment of very low rectal cancer. Historically it is associated with a higher functional complication rate than the Double Stapling (DS) technique when performed with open or laparoscopic approach. The aim of this study was to compare the surgical, short-term oncologic and functional outcomes of robotic ISR TME (R-ISR-TME) with those of robotic low anterior resection TME with a double stapling technique (R-DS-TME).
Methods: Between April 2010 and December 2013, 42 patients underwent robot-assisted rectal resection with TME at our General Surgery Unit, including 10 R-ISR-TME. The outcomes of the R-ISR-TME group were compared with a R-DS-TME group selected using a case-matched methodology. We evaluated the operative, pathological, short-term oncologic results and postoperative sexual, urinary and defecation functions using specific questionnaires.
Results: The analyses of the data showed similar results for R-ISR-TME and R-DS-TME regarding the operative, pathological and oncologic results. Focusing on urinary and sexual function, no score values were significantly different at any time between the two groups. The daily frequency of defecation 1 year after surgery was 1.9±0.9 for RISR-TME and 1.8±0.3 for RDS-TME indicating no difference between the two groups. Moreover, there were no significant differences between the two groups in other defecation functions. The mean Wexner score 1 year after surgery was 3.0±1.1 in R-ISR-TME and 2.2±1.0 in R-DS-TME group (p=0.2) and defecation-related quality of life for R-ISR-TME and R-DS-TME was not significantly different (modified fecal incontinence quality of life score: 30.3±19.1 vs 27.5±14.5, respectively; p=0.2).
Conclusions: These clinical and functional results suggest that R-ISR-TME could be a good sphincter-preserving surgery for patients with very low rectal cancer. Robotic assistance may overcome some intrinsic limitations of the ISR technique flattening the difference with the DS-TME procedure
Sexual and urinary functions after robot-assisted versus pure laparoscopic total mesorectal excision for rectal cancer
Background
Laparoscopic total mesorectal excision (LapTME) is a validated technique for the treatment of rectal cancer. However, the ergonomic limitations of pure laparoscopy could lead to high conversion rates and a high rate of autonomic disorders. For these reasons the robot-assisted TME (RobTME) has been proposed to overcome the limitations of LapTME. The aim of this study is to compare surgical outcomes, medium-term oncologic results, and postoperative autonomic function of LapTME versus RobTME, in a single surgeon experience.
Patients and Methods
The first 26 LapTME were compared with the first 26 RobTME performed by a single surgeon between January 2009 and May 2013. Perioperative outcomes were prospectively collected and compared. The impact of minimally invasive TME on autonomic function and quality of life (QOL) was analyzed with the ICIQ-FLUTS and the ICIQ-MLUTS (International Consultation on IncontinenceâMale/Female Lower Urinary Tract Symptoms) and IIEF (International Index of Erectile Function)/FSFI (Female Sexual Function Index) questionnaires. Pathological aspects and oncological outcomes were also collected.
Results
Of the 26 LapTME, 22 were anterior resections (ARR), 2 intersphincteric resections (ISR), and 2 abdominoperineal resections (APR), while of the 26 RobTME, 17 were ARR, 5 ISR, and 4 APR. Mean operative time was significantly higher (p<0.001) while conversion rate to hand-assisted or open surgery was significantly lower in the robTME group (p<0.05).
There were no significant differences in sexual and urinary scores between the two groups before surgery and at 1 year after surgery. There were no differences in 3 year overall survival, disease free survival, and recurrence rate as well as the other parameters analysed.
Conclusion
RobTME is a safe and effective technique and the results compare favourably to the results obtained with laparoscopic procedures. It seems a promising alternative to preserve autonomic function and results in a low conversion rate even when used for more high risk procedures such as ISR or APR
Pancreatoduodenectomy without vascular resection in patients with primary resectable adenocarcinoma and unilateral venous contact:A matched case study
Purpose. To investigate the oncological outcome and survival of patients following a conservative approach on the portal- mesenteric axis, in an intraoperative ultrasound-selected group of pancreatoduodenectomy (PD), performed on patients with primary resectable with vascular contact (prVC) pancreatic ductal adenocarcinoma (PDAC). Methods. A consecutive series of patients who underwent PD for PDAC at our tertiary care center, between 2008 and 2017, were reviewed. A total of 156 PDs and 88 total pancreatectomies were performed during the study period, including 35 vascular resections. We identified a group of 40 (25.6%) patients with prVC-PDAC in whom after checking the feasibility with intraoperative ultrasound, we were able to perform PD by separation of the tumor from the portomesenteric axis avoiding vascular resection, without residual macroscopic disease (no vascular resection, nvrPD), and compared this group, using case-matched methodology, with the standard PD (sPD) group of primary resectable without vascular contact- (prwVC-) PDAC. Results. The median follow-up was 28.5 ± 23.2 months in the sPD group and 23.8 ± 20.8 months in the nvrPD group (p = 0 35). Isolated local recurrence rate was 2/40 (5%) in both groups. Additionally, there were no statistical differences in the systemic progression of the disease (42.5% sPD vs. 45% nvrPD, p = 0 82) or local plus synchronous systemic disease rates (2.5% sPD vs. 7.5% nvrPD, p = 0 30). The median survival was 22 months for the sPD group and 23 months for the nvrPD group, p = 0 86. The overall survival was similar in the two groups (1 y: 76.3% sPD vs. 70.0% nvrPD; 3 y: 35.6% vs. 31.6%; and 5 y: 28.5% vs. 25.3%; p = 0 80). Conclusions. PD without vascular resection can be considered safe and oncologically acceptable in selected patients with preoperative diagnosis of prVC-PDAC. The poor prognosis of PDAC is related to the aggressive biology and systemic spread of the tumor, rather than the local control of the disease
Structured cost analysis of robotic TME resection for rectal cancer:a comparison between the da Vinci Si and Xi in a single surgeon's experience
Background: Robotic-assisted surgery by the da Vinci Si appears to benefit rectal cancer surgery in selected patients, but still has some limitations, one of which is its high costs. Preliminary studies have indicated that the use of the new da Vinci Xi provides some added advantages, but their impact on cost is unknown. The aim of the present study is to compare surgical outcomes and costs of rectal cancer resection by the two platforms, in a single surgeonâs experience. Methods: From April 2010 to April 2017, 90 robotic rectal resections were performed, with either the da Vinci Si (Si-RobTME) or the da Vinci Xi (Xi-RobTME). Based on CUSUM analysis, two comparable groups of 40 consecutive Si-RobTME and 40 consecutive Xi-RobTME were obtained from the prospectively collected database and used for the present retrospective comparative study. Data costs were analysed based on the level of experience on the proficiencyâgain curve (pâg curve) by the surgeon with each platform. Results: In both groups, two homogeneous phases of the pâg curve were identified: Si1 and Xi1: cases 1â19, Si2 and Xi2: cases 20â40. A significantly higher number of full RAS operations were achieved in the Xi-RobTME group (p < 0.001). A statistically significant reduction in operating time (OT) during Si2 and Xi2 phase was observed (p < 0.001), accompanied by reduced overall variable costs (OVC), personnel costs (PC) and consumable costs (CC) (p < 0.001). All costs were lower in the Xi2 phase compared to Si2 phase: OT 265 versus 290 min (p = 0.052); OVC 7983 versus 10231.9 (p = 0.009); PC 1151.6 versus 1260.2 (p = 0.052), CC 3464.4 versus 3869.7 (p < 0.001). Conclusions: Our experience confirms a significant reduction of costs with increasing surgeonâs experience with both platforms. However, the economic gain was higher with the Xi with shorter OT, reduced PC and CC, in addition to a significantly larger number of cases performed by the fully robotic approach
Chirurgia laparoscopica e robotica della ghiandola surrenale: confronto tra tecniche
Lâobbiettivo di questo studio Ăš quello di valutare, in una serie di pazienti analizzati retrospettivamente, quali sia lâimpatto delle tecniche chirurgiche mini-invasive nella chirurgia del surrene in termini di fattibilitĂ , sicurezza, efficacia ed outcome. MetterĂČ anche a confronto lâuso dellâapproccio laparoscopico con lâutilizzo del sistema robotico Da Vinci, valutando se questo apporti ulteriori benefici clinici, funzionali ed estetici rispetto alla chirurgia laparoscopica pura. I risultati ottenuti verranno confrontati con quelli disponibili nelle letteratura scientifica per cercare di valutare quale sia lâattuale stato dellâarte riguardo alla chirurgia mini-invasiva del surrene
News from the â5th international meeting on inflammatory bowel diseasesâ CAPRI 2010
AbstractAt the â5th International Meeting on Inflammatory Bowel Diseases selected topics of inflammatory bowel disease (IBD), including the environment, genetics, the gut flora, the cell response and immunomodulation were discussed in order to better understand specific clinical and therapeutic aspects. The incidence of IBD continues to rise, both in low and in high-incidence areas. It is believed that factors associated with âWesternizationâ may be conditioning the expression of these disorders. The increased incidence of IBD among migrants from low-incidence to high-incidence areas within the same generation suggests a strong environmental influence.The development of genome-wide association scanning (GWAS) technologies has lead to the discovery of more than 100 IBD loci. Some, as the Th 17 pathway genes, are shared between Crohn's disease (CD) and ulcerative colitis (UC), while other are IBD subtype-specific (autophagy genes, epithelial barrier genes). Disease-specific therapies targeting these pathways should be developed. Epigenetic regulation of the inflammatory response also appears to play an important role in the pathogenesis of IBD.The importance of gut flora in intestinal homeostasis and inflammation was reinforced, the concepts of eubiosis and dysbiosis were introduced, and some strategies for reverting dysbiosis to a homeostatic state of eubiosis were proposed. The current status of studies on the human gut microbiota metagenome, metaprotome, and metabolome was also presented.The cell response in inflammation, including endoplasmic reticulum (ER) stress responses, autophagy and inflammasome-dependent events were related to IBD pathogenesis. It was suggested that inflammation-associated ER stress responses may be a common trait in the pathogenesis of various chronic immune and metabolic diseases.How innate and adaptive immunity signaling events can perpetuate chronic inflammation was discussed extensively. Signal transduction pathways provide intracellular mechanisms by which cells respond and adapt to multiple environmental stresses. The identification of these signals has led to a greater mechanistic understanding of IBD pathogenesis and pointed to potentially new therapeutic targets.A critical analysis of clinical trials and of risk-benefit of biological therapy was presented. The problem of EpsteinâBarr virus (EBV) and lymphoma in IBD was extensively discussed. Lymphomas can develop in intestinal segments affected by IBD and are in most cases associated with EBV. The reasons of treatment failure were also analyzed both from basic and clinical points of view.Two very interesting presentations on the integration of research and clinical care in the near future closed the meeting. These presentations were focused on macrotrends affecting healthcare delivery and research, and the need to innovate traditional infrastructures to deal with these changing trends as well as new opportunities to accelerate scientific knowledge
EARLY EXPERIENCE OF FULL ROBOTIC COLORECTAL RESECTIONS FOR CANCER COMBINED WITH OTHER MAJOR SURGICAL PROCEDURES WITH THE NEW DA VINCI XI
PURPOSE
The new da Vinci XiÂź has been developed and released to overcome some of the limitations of the previous platform, therefore increasing the acceptance of its use in robotic multi-quadrant operations. The new characteristics could have an important role in colon-rectal surgery and particularly in attaining fully robotic colon-rectal resection combined with other major surgical procedures. The aim of this study is to evaluate the pre-operative results of totally robotic colorectal surgery for cancer in association with other major procedures with Da Vinci Xi.
METHODS
We reviewed the charts of all patients undergoing fully robotic combination procedures involving colon-rectal resections using the Da Vinci Xi, from January 2015 to October 2015. Variables that were examined included patient demographic characteristics, pre-operative data such as trocar position, technical aspects, operative time and robot dock/undocking times. Postoperative variables included the length of hospital stay, morbidity and mortality. Ten patients were included in this study, including 12 colorectal procedures: 5 right hemi-colectomy and 5 anterior rectal resections with TME were performed in combination with sigmoidectomy (1), right nephrectomy (2), hysterectomy (1), hepatic resection (3), enucleation of pancreatic tail lesion (2) and ileo-cecal resection (1).
RESULTS
All the operations were completed by a fully robotic approach, without conversion to hand assisted laparoscopy or laparotomy, and without hybrid approaches or need of changing of robotic cart position. Trocar positions respected the Universal Port Placement Guidelines provided by Intuitive Surgical for âleft lower quadrantâ. Simultaneous procedures in the same quadrant or left quadrant and pelvis, or left/right and upper, were performed with a single docking/single targeting approach; in cases of left/right quadrant or right quadrant/pelvis, we performed a dual-docking operation where we re-targeted using the camera to orient the system towards the new work space (an opposite facing quadrant) and re-docked the remaining arms. No external collisions or problems related to trocar positions were noted. Mean overall procedural time was 360 min (±128min). No patient experienced postoperative surgical complications and the mean hospital stay was 6 days (±3days).
DISCUSSION
In our early experience we were able to complete all procedures with a full robotic approach, without the necessity to associated or convert to a laparoscopic approach. Thanks to the targeting function of the Da Vinci Xi, the robot re-targeting could be enough in combined surgical operation of the same hemi-abdomen. This procedure allows us to obtain a new improved alignment of robotic arms. Instead, in the case of left/right quadrant, it was necessary to re-target using the camera to orient the system towards the new work space (an opposite facing quadrant) with 180°-boom rotation and then re-docked the remaining arms. However, this procedure is simple and not time consuming as it was only necessary to rotate the boom without changing cartâ position. These types of combined surgical procedures were not possible with the da Vinci Si. In fact with the previous system, it was mandatory to undock the robotic arms, disconnect and change the cartâ position in the opposite side of the operating table and finally re-docked the Da Vinci System. These maneuvers leads to both a substantial increase in operating time and difficulties in moving the bulky robotic cart. The limitations of Da Vinci Si were overcome by the new realized product Da Vinci Xi.
We tried to suggest an initial proposal for standardized surgical proceduresâ, trying to define the best trocarsâ position for combined surgical operations that would not requires an additional trocar position or problems with instruments collision. In our opinion the trocarsâ position described in the this present experience allows us to perform operations in all abdominal quadrants without major movements thus only changing robotic armsâ position, rotating the boom or exploiting the targeting function. In fact, in all cases we were able to perform all surgical procedures without the need of additional robotic trocar, completing the surgical procedure with a full robotic approach and no robotic arms clashing or an excessive time needed for the re-docking was reported.
CONCLUSIONS
The herein presented high success rate of robotic colorectal resection combined with other surgical interventions for synchronous tumors, without conversion or excessive operating time, suggests the efficacy of the new released product Da Vinci Xi, in minimally invasive multi-quadrant combined surgery. A further possible advantage may be provided by da Vinci Xi Integrated Table Motion feature (available only in the EU), that allows patients to be repositioned without undocking the robot and without removing instruments inside the abdomen
Robotic giant hiatal hernia repair: 3 year prospective evaluation and review of the literature
Background While conventional laparoscopic repair for giant hiatal hernias
is considered difficult, robotic technology is likely to result in an improved
postoperative course.
Methods We prospectively analysed patients with giant hiatal hernias who
underwent robotic repair during a 3 year period. Preoperative data, operative
variables, complications, clinical outcomes and anatomical recurrence after
1 year were evaluated.
Results Six patients with giant hiatal hernias underwent robotic repair using
the Da Vinci surgical system. The mean operative time was 182 min. The mean
hospital stay was 6 days. No patients required reoperation for disease
recurrence, and all claimed the absence of postoperative symptoms.
Conclusions Robotic approaches can minimize surgical trauma in patients
with giant hiatal hernias and result in favourable outcomes in terms of
anatomical recurrence and quality of life. With the availability of the da Vinci
System, all patients with giant hiatal hernias can be offered a minimally
invasive surgical option