Robot-Assisted Colonic Resections for Cancer

Minimally invasive surgery for colon cancer, if compared with open surgery, has shown similar oncologic outcomes, and it has become the standard management for malignant colonic disease. Its benefits appear yet in early post-operative period such as less postoperative pain, earlier recovery of gastrointestinal functions and shorter hospital stay. Robotic surgery was born in the attempt to overcome the intrinsic limitations of laparoscopic technique. It offers the possibility to have a tridimensional magnified view of surgical field and to use wristed instrument to perform an accurate dissection and lymphadenectomy. It provides the possibility to rotate at 360 degrees the instruments, facilitating considerably the performance of intracorporeal ileo-colic anastomosis in right colectomy. We want to illustrate the feasibility and technique to carry out right and left colectomy in a robotic-assisted way and its advantages with respect to laparoscopic surgery

Nationwide analysis of laparoscopic groin hernia repair in Italy from 2015 to 2020

Since its introduction, the minimally invasive treatment of groin hernias has become widely accepted as a viable alternative to open surgery. Still, the rates and reasons for its adoption vary highly among countries and the regions within a country. After almost thirty years since its introduction, its spread is still limited. The present study, conducted under the auspices of AGENAS (Italian National Agency for Regional Services), aims at giving a snapshot of the spreading of minimally invasive and robotic techniques for the treatment of groin hernia in Italy. This study is retrospective, with data covering the period from 1st January 2015 to 31st December 2020. AGENAS provided data using the operation and diagnosis codes used at discharge and reported in the International Classification of Diseases 9th revision (ICD9 2002 version). Admissions performed on an outpatient basis, i.e., without an overnight stay of at least one night in hospital, were excluded. A total of 33,925 laparoscopic hernia repairs were performed during the considered period. Overall, a slight increase in the number of procedures performed was observed from 2015 to 2019, with a mean annual change of 8.60% (CI: 6.46-10.74; p < 0.0001). The number of laparoscopic procedures dropped in 2020, and when considering the whole period, the mean annual change was - 0.98% (CI: - 7.41-5.45; p < 0.0001). Urgent procedures ranged from 335 in 2015 to 508 in 2020 referring to absolute frequencies, and from 0.87% to 9.8% in relative frequencies of overall procedures in 2017 and 2020, respectively (mean = 4.51%; CI = 3.02%-6%; p < 0.001). The most relevant observation that could be made according to our analysis was that the adoption of the laparoscopic approach knew a slow but steady increase from 2015 onward

Transanal Endoscopic Microsurgery after the attempt of endoscopic removal of rectal polyps

none6The incidence of rectal polyps has steadily increased in recent decades and will continue to rise. [1] The introduction of endoscopic screening programs has probably contributed to the improved detection of rectal polyps and early malignant lesions [2, 3]. With the aim to reduce morbidity and mortality of rectal surgery, in 1983, Gerhard Buess introduced Transanal Endoscopic Microsurgery (TEM) [4]. He conceived a novel endoscopic technology to facilitate the excision of rectal polyps through the anus [5]. This revolutionary technique enabled superfcial or full-thickness excision of large adenomatous lesions. It soon became apparent that indications to TEM could be successfully extended to early malignant polyps [6, 7]. However, in the late nineties, endoscopy was advocated as a diagnostic technique and a therapeutic method. First, large piecemeal snare ablations were reported. Then, the use of endoscopic electrosurgical knives made it possible to achieve en bloc resection, known as Endoscopic Submucosal Dissection (ESD) [8–11]. The sharp increase in endoscopic resection of rectal polyps made the indications for TEM questioned [12]. This unresolved debate confuses the choice of the optimal treatment for complex rectal polyps. Concerns mainly arise where there is uncertainty around early malignancy or where complete resection of an adenomatous polyp is not obtained following endoscopic attempts [13–15]. Accurate prognostic information is not always available after endoscopic removal, mainly when the specimen is fragmented. [16] Additionally, fbrotic tissue growth at the polypectomy site could invalidate the already sub-optimal accuracy of pre-operative imaging techniques. Therefore, endoscopic ultrasound and/or Magnetic Resonance Imaging staging are often misleading [17]. The indication to resect the site of a previous endoscopic resection with a full-thickness technique has been recommended in cases of unexpected malignancy. However, the overall beneft remains unclear [13, 18]. This study aims to evaluate the outcomes of TEM following endoscopic resection of rectal polyps performed at two diferent centres, assess the value of further local excision, and identify features that may contribute to the decisionmaking process.openMonica Ortenzi, Alberto Arezzo, Roberto Ghiselli, Marco Ettore Allaix, Mario Guerrieri, Mario MorinoOrtenzi, Monica; Arezzo, Alberto; Ghiselli, Roberto; Ettore Allaix, Marco; Guerrieri, Mario; Morino, Mari

Nationwide analysis of inpatient laparoscopic ventral hernia repair in Italy from 2015 to 2020

Since 2010, several guidelines and consensus papers have been proposed to support surgeons in the decision-making process (Cuccurullo et al. in Hernia 17(5):557-566, 2013; Silecchia et al. in Surg Endosc 29:2463-2484, 2015; Bittner et al. in Surg Endosc 33(11):3511-3549, 2015) with the conclusion that laparoscopic repair (LR) has gained popularity in the treatment of IH.To date, however, it is not yet clear as to the uptake of LR for IH on national basis. Only dated studies encompassing of all types of incisional hernia repairs are available in literature (Bisgaard et al. in Br J Surg 96:1452-1457, 2009). The aim of our study is to present a snapshot of Italian data for LR of ventral hernias, over a 6 years period, including volume of LR, procedural features and major postoperative outcomes. Data were extracted from the Italian Hospital Information System (HIS) that collects clinical and administrative information regarding each hospital admission of every patient discharged from any hospital in Italy. Using Hospital Discharge records regional Databases (HDD), all laparoscopic ventral hernia procedures carried out in public and private hospitals between 2015 and 2020, in patients over 18 years and resident in Italy, were collected based on diagnosis and procedure codes. The National Agency for Regional Health Services (AgeNaS) oversees the management and analysis of data. All hospital admissions that occurred between 2015 and 2020 were analyzed.A total of 154,546 incisional hernia repairs were performed in Italy from 2015 to 2020. Of these, 20,789 (13.45%) were minimally invasive repairs. The number of procedures performed increased significantly over time, constituting 11.96 and 15.24% of all procedures performed in 2015 and 2020 respectively. However, considering the whole period, the mean annual change was-5.58% (CI - 28.6% to 17.44%; p < 0.0001).Urgent minimally invasive repairs were performed in 1968 cases (1.27%). The absolute rate of laparoscopically treated patients needing an urgent surgical procedure increased overtime (from 7.36% in 2015 to 13.418% in 2020). The mean annual change registered over the whole period was 7.42%. 92% (CI - 0.03 to 14.09%; p < 0.0001). However, when considering the period from 2015 to 2019, the mean annual change was 10.42% (CI 6.35 to 14.49%; p < 0.0001). To our knowledge this is the first nationwide Italian report presenting the national workload of surgical units and the main perioperative features of minimally invasive surgery for ventral hernia repairs

Low-pressure versus standard-pressure pneumoperitoneum in laparoscopic cholecystectomy: a systematic review and meta-analysis of randomized controlled trials

Introduction: It has been previously demonstrated that the rise of intra-abdominal pressures and prolonged exposure to such pressures can produce changes in the cardiovascular and pulmonary dynamic which, though potentially well tolerated in the majority of healthy patients with adequate cardiopulmonary reserve, may be less well tolerated when cardiopulmonary reserve is poor. Nevertheless, theoretically lowering intra-abdominal pressure could reduce the impact of pneumoperitoneum on the blood circulation of intra-abdominal organs as well as cardiopulmonary function. However, the evidence remains weak, and as such, the debate remains unresolved. The aim of this systematic review and meta-analysis was to demonstrate the current knowledge around the effect of pneumoperitoneum at different pressures levels during laparoscopic cholecystectomy. Materials and methods: This systematic review and meta-analysis were reported according to the recommendations of the 2020 updated Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines, and the Cochrane handbook for systematic reviews of interventions. Results: This systematic review and meta-analysis included 44 randomized controlled trials that compared different pressures of pneumoperitoneum in the setting of elective laparoscopic cholecystectomy. Length of hospital, conversion rate, and complications rate were not significantly different, whereas statistically significant differences were observed in post-operative pain and analgesic consumption. According to the GRADE criteria, overall quality of evidence was high for intra-operative bile spillage (critical outcome), overall complications (critical outcome), shoulder pain (critical outcome), and overall post-operative pain (critical outcome). Overall quality of evidence was moderate for conversion to open surgery (critical outcome), post-operative pain at 1 day (critical outcome), post-operative pain at 3 days (important outcome), and bleeding (critical outcome). Overall quality of evidence was low for operative time (important outcome), length of hospital stay (important outcome), post-operative pain at 12 h (critical outcome), and was very low for post-operative pain at 1 h (critical outcome), post-operative pain at 4 h (critical outcome), post-operative pain at 8 h (critical outcome), and post-operative pain at 2 days (critical outcome). Conclusions: This review allowed us to draw conclusive results from the use of low-pressure pneumoperitoneum with an adequate quality of evidence

Laparoscopic treatment of ventral hernias: the Italian national guidelines

Primary and incisional ventral hernias are significant public health issues for their prevalence, variability of professional practices, and high costs associated with the treatment In 2019, the Board of Directors of the Italian Society for Endoscopic Surgery (SICE) promoted the development of new guidelines on the laparoscopic treatment of ventral hernias, according to the new national regulation. In 2022, the guideline was accepted by the government agency, and it was published, in Italian, on the SNLG website. Here, we report the adopted methodology and the guideline's recommendations, as established in its diffusion policy. This guideline is produced according to the methodology indicated by the SNGL and applying the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology. Fifteen recommendations were produced as a result of 4 PICO questions. The level of recommendation was conditional for 12 of them and conditional to moderate for one. This guideline's strengths include relying on an extensive systematic review of the literature and applying a rigorous GRADE method. It also has several limitations. The literature on the topic is continuously and rapidly evolving; our results are based on findings that need constant re-appraisal. It is focused only on minimally invasive techniques and cannot consider broader issues (e.g., diagnostics, indication for surgery, pre-habilitation)

Infected pancreatic necrosis : outcomes and clinical predictors of mortality. A post hoc analysis of the MANCTRA-1 international study

Peer reviewe

Minimally invasive vs. open segmental resection of the splenic flexure for cancer: a nationwide study of the Italian Society of Surgical Oncology-Colorectal Cancer Network (SICO-CNN)

Background Evidence on the efficacy of minimally invasive (MI) segmental resection of splenic flexure cancer (SFC) is not available, mostly due to the rarity of this tumor. This study aimed to determine the survival outcomes of MI and open treatment, and to investigate whether MI is noninferior to open procedure regarding short-term outcomes. Methods This nationwide retrospective cohort study included all consecutive SFC segmental resections performed in 30 referral centers between 2006 and 2016. The primary endpoint assessing efficacy was the overall survival (OS). The secondary endpoints included cancer-specific mortality (CSM), recurrence rate (RR), short-term clinical outcomes (a composite of Clavien-Dindo > 2 complications and 30-day mortality), and pathological outcomes (a composite of lymph nodes removed >= 12, and proximal and distal free resection margins length >= 5 cm). For these composites, a 6% noninferiority margin was chosen based on clinical relevance estimate. Results A total of 606 patients underwent either an open (208, 34.3%) or a MI (398, 65.7%) SFC segmental resection. At univariable analysis, OS and CSM were improved in the MI group (log-rank test p = 0.004 and Gray's tests p = 0.004, respectively), while recurrences were comparable (Gray's tests p = 0.434). Cox multivariable analysis did not support that OS and CSM were better in the MI group (p = 0.109 and p = 0.163, respectively). Successful pathological outcome, observed in 53.2% of open and 58.3% of MI resections, supported noninferiority (difference 5.1%; 1-sided 95%CI - 4.7% to infinity). Successful short-term clinical outcome was documented in 93.3% of Open and 93.0% of MI procedures, and supported noninferiority as well (difference - 0.3%; 1-sided 95%CI - 5.0% to infinity). Conclusions Among patients with SFC, the minimally invasive approach met the criterion for noninferiority for postoperative complications and pathological outcomes, and was found to provide results of OS, CSM, and RR comparable to those of open resection