Robotic lobectomy: tips, pitfalls and troubleshooting

The robotic approach in thoracic surgery has rapidly gained popularity in recent years. As with the introduction of any new technology, this warrants not only adaptation of the operative technique itself, but also the evolution of appropriate troubleshooting strategies. A selected number of helpful tips and technical procedural manoeuvres have been compiled to prevent intraoperative problems, as well as to overcome challenging situations that can arise during robotic lobectomies. In robotic surgery, as opposed to open surgery or video-assisted thoracic surgery, these tips serve an important purpose for the operating surgeon, as well as the entire surgical team involved in the procedure. All the assembled recommendations have proved their effectiveness and have been successfully used by the authors in many procedures. Furthermore, these manoeuvres have been found to be of great importance in the training and proctoring of thoracic surgeons, fellows and residents (bed-side assistants). This guide of clearly arranged tips and troubleshooting strategies offers surgeons a useful tool to overcome difficult situations in robotic lobectomy and preferably improve the reproducibility and safety of their procedure

Perineal and robot-assisted vesico-urethral reconstruction for anastomotic strictures after RP

Vesico-urethral anastomotic stricture (VUAS) following radical prostatectomy is a rare clinical condition in the robot-assisted procedure era, due to the improved magnification of the surgical field and the perfect knowledge of the anatomic structures deputed to maintaining the mechanisms for urinary continence. Improvements in surgical technique such as muco-mucosal apposition, tension-free anastomosis, water-tight vesico-urethral suture, have been recognized as significant contributors to precise vesico-urethral reconstruction. Conversely, excessive intraoperative blood loss, urinary extravasation and previous history of trans-urethral prostatectomy have been commonly cited as predisposing factors for the development of postoperative scars. Terminology used in the definition of VUAS distinguishes the condition from bladder neck contracture (BNC) and identifies the exact site of the contracture/stenosis/stricture. The majority of cases involves the bladder neck and bulbo-membranous urethra mainly in patients who received radical prostatectomy plus adjuvant radiotherapy. Diagnosis of VUAS is mainly based on symptoms and retrograde urethro-cystogram imaging to identify whether or not the sphincter mechanism is involved and the length of the strictured segment, although delineation of the precise anatomy is often complex. Stricture length is a significant factor for prognosis and correlates with probability of recurrence after reparative surgeries such as urethral dilation, trans-urethral scar incision or resection and perineal urethral buccal mucosa repair. Results obtained via different surgical techniques are amply described, with the hindrance of VUAS and BNC often not being properly distinguished in the reported series of patients treated. Notwithstanding, a 0 to 69% success rate has been reported for patients with bladder neck stricture after urethral dilation and/or cold-knife incision and/or holmium laser incision and/or trans urethral resection, while a 60 to 93% success rate was obtained for patients treated via an abdominal and/or perineal approach. Repair of a long-length urethral stricture often implies the complete loss of urinary continence, whilst it does not appear to have significant impact on sexual potency if previously preserved. The risk of developing VUAS/BNC as a complication after radical prostatectomy falls from 30% of patients treated by Retropubic Radical Prostatectomy (RRP) to less than 5% of patients who received Robotic Assisted Radical Prostatectomy (RARP). Subjects with a histological diagnosis of T3 cancer, positive surgical margins and/or Gleason score >7 and treated by RARP who required early adjuvant radiotherapy, reported an overall 8.4% rate of VUAS. Lavollè et al. treated six patients with anastomotic stricture who had previously undergone radical prostatectomy by extraperitoneal robot-assisted vesico-urethral reconstruction obtaining a 50% success rate. Dinerman et al. presented a case report on a patient with long-length post prostatectomy vesico-urethral stricture by combining robotic-abdominal and open-perineal surgical procedure. The combined abdomino-perineal approach allows to provide “complete” scar removal and a new vesico-urethral anastomosis at a lower risk of developing subsequent recurrences of the stricture also in patients with long-length strictures. An extensive dissection of the bladder neck and bulbo-membranous urethra does imply the complete loss of urinary continence, that can however be recovered through subsequent or concomitant artificial sphincter implant. This novel combined technique was adopted on a series of three patients of whom two previously treated by RARP and one by RRP

Implementing successful systematic Patient Reported Outcome and Experience Measures (PROMs and PREMs) in robotic oncological surgery—The role of physicians

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Treatment of pulmonary nodule: from VATS to RATS

The incidental detection of solitary pulmonary nodule (SPN) is currently increasing due to the widespread use of computed tomography (CT) during the follow up in oncological patients or in screening trials. A quick and definitive histological diagnosis of these nodes is mandatory as, in case of primitive lung cancer, an early detection could improve both surgical results and prognosis. The minimally invasive pulmonary resection (MIPR) is the gold standard procedure for diagnosis and treatment of small lung nodules, but it can be difficult to localize deep nonpalpable nodes that lie in the lung parenchyma. Hence, throughout the years several techniques have been developed to better localize deep or sub solid nodes. We describe our experience with radio-guided technique

Robotic Approach to Ureteral Endometriosis: Surgical Features and Perioperative Outcomes

Introduction: Surgical treatment of ureteral endometriosis is necessary to relieve urinary symptoms of obstruction and to preserve renal function. Which surgical approach to ureteral endometriosis should be considered the most appropriate is debated, due to the lack of scientific evidence. The aim of the present study is to assess the feasibility and to describe the perioperative outcomes of minimally invasive treatment of deep ureteral endometriosis using robotic assistance, highlighting the technical benefits and the limits of this approach. Method: A case-series including 31 consecutive patients affected by high-stage endometriosis including ureteral endometriosis using robotic assistance in our Department between November 2011 and September 2017. Results: All procedures were successfully completed by robotic technique, resulting in full excision of the parametrial nodules involving the ureter. Mean operating time was 184.8 ± 81min. Mean hospital stay was 4.02 ± 3 days. Perioperative complications occurred in five patients and 4 out of 5 involved the urinary tract. Conclusions: Robotic surgery for deep infiltrating endometriosis of the ureter was feasible and allowed complete resection of ureteral nodules in all cases. No intraoperative complications arose, but a non-negligible rate of urinary tract complications was detected. This calls for a careful assessment of the benefits and specific risks associated with the use of robotic surgery for the treatment of deep infiltrating endometriosis of the ureter

Performances on simulator and da Vinci robot on subjects with and without surgical background

Objective: To assess whether previous training in surgery influences performance on da Vinci Skills Simulator and da Vinci robot. Material and methods: In this prospective study, thirty-seven participants (11 medical students, 17 residents, and 9 attending surgeons) without previous experience in laparoscopy and robotic surgery performed 26 exercises at da Vinci Skills Simulator. Thirty-five then executed a suture using a da Vinci robot. Results: The overall scores on the exercises at the da Vinci Skills Simulator show a similar performance among the groups with no statistically significant pair-wise differences (p < .05). The quality of the suturing based on the unedited videos of the test run was similar for the intermediate (7 (4, 10)) and expert group (6.5 (4.5, 10)), and poor for the untrained groups (5 (3.5, 9)), without statistically significant difference (p < .05). Conclusion: This study showed, for subjects new to laparoscopy and robotic surgery, insignificant differences in the scores at the da Vinci Skills Simulator and at the da Vinci robot on inanimate model

Prognostic role of TPL2 in early‑stage non‑small cell lung cancer

Non‑small cell lung cancer (NSCLC) accounts for ~70% of all lung cancer‑associated mortalities worldwide. The serine/threonine protein kinase tumor progression locus 2 [TPL2/MAP3 kinase 8 (MAP3K8)] may impact oncogenic events; however the role of TPL2 in lung carcinogenesis remains unclear. The present study was focused on the potential prognostic role of TPL2 in 101 patients with early‑stage NSCLC. Since TPL2 is a potential target of miR‑21, the association between TPL2 and miR‑21 expression was also examined. TPL2 and miR‑21 mRNA expression was quantified using reverse transcription quantitative polymerase chain reaction (RT‑qPCR). TPL2 protein levels were evaluated by immunohistochemistry (IHC). The present study identified that the mRNA expression of TPL2 was low in 52/101 (51%) cases and high in 49/101 (49%) cases. IHC analysis of TPL2 protein expression often demonstrated identical mRNA results. No statistically significant associations were observed between the mRNA expression of TPL2 and the predominant clinicopathological characteristics of the patients with NSCLC, as well as identifying no association between TPL2 and miR‑21. TPL2 mRNA expression was significantly higher in patients with NSCLC with good prognosis (disease‑free interval P=0.009; overall survival P=0.024), when compared with those of poor prognosis. Focusing on the difference in mRNA expression of TPL2 among the adenocarcinomas in affected patients, TPL2 was more highly expressed in lepidic adenocarcinomas compared with in the other subtypes (P=0.012). The present study is the first examination, to the best of our knowledge, of TPL2 in early‑stage NSCLC in relation to miR‑21, and in different adenocarcinoma subtypes. Future studies must clarify the mechanism by which TPL2 is involved in lung carcinogenesis due to its important translational implications

Malignant pleural mesothelioma and mesothelial hyperplasia: A new molecular tool for the differential diagnosis

Malignant pleural mesothelioma (MPM) is a rare asbestos related cancer, aggressive and unresponsive to therapies. Histological examination of pleural lesions is the gold standard of MPM diagnosis, although it is sometimes hard to discriminate the epithelioid type of MPM from benign mesothelial hyperplasia (MH). This work aims to define a new molecular tool for the differential diagnosis of MPM, using the expression profile of 117 genes deregulated in this tumour. The gene expression analysis was performed by nanoString System on tumour tissues from 36 epithelioid MPM and 17 MH patients, and on 14 mesothelial pleural samples analysed in a blind way. Data analysis included raw nanoString data normalization, unsupervised cluster analysis by Pearson correlation, non-parametric Mann Whitney U-test and molecular classification by the Uncorrelated Shrunken Centroid (USC) Algorithm. The Mann-Whitney U-test found 35 genes upregulated and 31 downregulated in MPM. The unsupervised cluster analysis revealed two clusters, one composed only of MPM and one only of MH samples, thus revealing class-specific gene profiles. The Uncorrelated Shrunken Centroid algorithm identified two classifiers, one including 22 genes and the other 40 genes, able to properly classify all the samples as benign or malignant using gene expression data; both classifiers were also able to correctly determine, in a blind analysis, the diagnostic categories of all the 14 unknown samples. In conclusion we delineated a diagnostic tool combining molecular data (gene expression) and computational analysis (USC algorithm), which can be applied in the clinical practice for the differential diagnosis of MPM

A prospective, single-arm study on the use of the da Vinci® Table Motion with the Trumpf TS7000dV operating table

BACKGROUND: The da Vinci® Table Motion (dVTM) comprises a combination of a unique operating table (Trumpf Medical™ TruSystem® 7000dV) capable of isocenter motion connected wirelessly with the da Vinci Xi® robotic platform, thereby enabling patients to be repositioned without removal of instruments and or undocking the robot. MATERIALS AND METHODS: Between May 2015 to October 2015, the first human use of dVTM was carried out in this prospective, single-arm, post-market study in the EU, for which 40 patients from general surgery (GS), urology (U), or gynecology (G) were enrolled prospectively. Primary endpoints of the study were dVTM feasibility, efficacy, and safety. RESULTS:Surgeons from the three specialties obtained targeting success and the required table positioning in all cases. Table movement/repositioning was necessary to gain exposure of the operating field in 106/116 table moves (91.3%), change target in 2/116 table moves (1.7%), achieve hemodynamic relief in 4/116 table moves (3.5%), and improve external access for tumor removal in 4/116 table moves (3.5%). There was a significantly higher use of tilt and tilt plus Trendelenburg in GS group (GS vs. U p = 0.055 and GS vs. G p = 0.054). There were no dVTM safety-related or adverse events. CONCLUSIONS: The dVTM with TruSystem 7000dV operating table in wireless communication with the da Vinci Xi is a perfectly safe and effective synergistic combination, which allows repositioning of the patient whenever needed without imposing any delay in the execution of the operation. Moreover, it is helpful in avoiding extreme positions and enables the anesthesiologist to provide immediate and effective hemodynamic relief to the patient when needed

EACTS expert consensus statement for surgical management of pleural empyema

Pleural infection is a frequent clinical condition. Prompt treatment has been shown to reduce hospital costs, morbidity and mortality. Recent advances in treatment have been variably implemented in clinical practice. This statement reviews the latest developments and concepts to improve clinical management and stimulate further research. The European Association for Cardio-Thoracic Surgery (EACTS) Thoracic Domain and the EACTS Pleural Diseases Working Group established a team of thoracic surgeons to produce a comprehensive review of available scientific evidence with the aim to cover all aspects of surgical practice related to its treatment, in particular focusing on: surgical treatment of empyema in adults; surgical treatment of empyema in children; and surgical treatment of post-pneumonectomy empyema (PPE). In the management of Stage 1 empyema, prompt pleural space chest tube drainage is required. In patients with Stage 2 or 3 empyema who are fit enough to undergo an operative procedure, there is a demonstrated benefit of surgical debridement or decortication [possibly by video-assisted thoracoscopic surgery (VATS)] over tube thoracostomy alone in terms of treatment success and reduction in hospital stay. In children, a primary operative approach is an effective management strategy, associated with a lower mortality rate and a reduction of tube thoracostomy duration, length of antibiotic therapy, reintervention rate and hospital stay. Intrapleural fibrinolytic therapy is a reasonable alternative to primary operative management. Uncomplicated PPE [without bronchopleural fistula (BPF)] can be effectively managed with minimally invasive techniques, including fenestration, pleural space irrigation and VATS debridement. PPE associated with BPF can be effectively managed with individualized open surgical techniques, including direct repair, myoplastic and thoracoplastic techniques. Intrathoracic vacuum-assisted closure may be considered as an adjunct to the standard treatment. The current literature cements the role of VATS in the management of pleural empyema, even if the choice of surgical approach relies on the individual surgeon's preferenc