Robotic colorectal surgery initial results after 183 cases

IntroductionColorectal cancer is the third most common malignancy (6.1%) worldwide among men and women, and the second reason for death. The current treatment is based on locoregional therapy: surgery, radiotherapy, and systematic treatment like chemotherapy. Now it is well known that laparoscopic/robotic surgery is equal, or even superior, to the open one in colorectal procedures.AimThe aim of this study was to analyze and share our initial results in robotic colorectal surgery and compare them with literature dataMaterials and Methods: A retrospective study was conducted in order to review our first 183 patients with colorectal cancers operated by a robot-assisted and totally robotic techniques. Gender, age, diagnosis and surgical indications, type of surgery, surgical time, conversion, bleeding, post-operative complications, and hospital stay were analyzed and described.Results: The mean age of the patients was 67.87 ± 14.10 years, 101 (58.38%) of them were male and 72 (41.62%) female. The most common localization for the tumor was the rectum—62 (35.83%), followed by the sigmoid—26 (15.02%), left colon—23 (13.29%), cecum—19 (10.98%), rectosigmoid—12 (6.93%), ascending colon—12 (6.93%), right flexure—10 (5.78%), left flexure—4 (2.33%), transverse colon—4 (2.33). The mean blood loss was 165.45 ± 82.85 mL and the mean operative time was 195.20 ± 82.40 min. The average length of hospital stay was 7.22 ± 4.08 days.Conclusion: Our research shows that robotic colorectal surgery can be performed successfully with good short-term outcomes due to the advantages of the DaVinci system and personal laparoscopic experience. One of the disadvantages of robotic surgery is prolonged operative time, which we think could be improved with the accumulation of experience

Robotic Right and Left Colectomies: Extra- or Intracorporeal Anastomosis

IntroductionRobotic right and left hemicolectomies for colon cancer are among the most common surgical procedures. In the past decades they began to be performed laparoscopically and in recent years—by robotic surgical systems. Despite the enhanced recovery protocols and minimal invasiveness of the procedure, there are still complications. Robotic right and left hemicolectomies with an intracorporeal anastomosis (ICA) are less invasive than the same robotic-assisted procedures, and could lead to fast recovery and shortening of the postoperative period.Aim The aim of the study is to evaluate the feasibility and safety of the intracorporeal anastomosis after robotic left and right colectomies.Results and Discussion: Surgical time was found to be insignificantly shorter in the intracorporeal anastomosis group: 125.1 ± 37.1 vs. 128.2 ± 21.1 for right colectomy and 147.3 ± 39.1 vs. 153.8 ± 58.1 for left colectomy.Many studies show similar results, but the advantages of intracorporeal anastomosis evaluated by visual analog scale (VAS) are even more significant. Our results did not indicate significant difference in number of harvested lymph nodes: 24.9 ± 11.3 vs. 25.1.9 ± 10.1 and 26.8 ± 9.3 vs. 25.9 ± 11. Anastomotic leakage in extracorporeal anastomosis (ECA) after left colectomy was significantly higher: 2 (11.7%), < 0.001. Wound infections in our patients again were insignificantly higher in ECA 0.0 vs. 1 (4.2%) in right and 1 (6.2%) vs. 1 (5.9%) in left colon. Overall hospital stay was also significantly shorter in ICA left colectomies and insignificantly in right ones: 7.0 ± 4.9 vs. 7.8 ± 4.1, P = 0.217, and 6.1 ± 2.5 vs. 8.0 ± 4.9, P < 0.001.Conclusion: The results of our study confirmed the literature data that ICA after colon resection is a safe and feasible procedure, accepted by many colorectal surgeon

The Role of Indocyanine Green in Colorectal Surgery

Introduction: Colorectal cancer is one of the most common gastrointestinal tumors. Anastomotic leakage (AL) after low rectal resections remains a serious problem worldwide, varying between 5% and 20%. The main risk factors for AL are the height of the anastomosis, gender, non-adjuvant therapy, difficult mesorectal excision, advanced age, nutritional status of the patient, as well as the chronic use of certain medications. The concept of intraoperative indocyaninegreen (ICG) angiography is based on its ability to absorb near-infrared (NIR) light up to 800 nm and emit fluorescence at a wavelength of 830 nm. Bolus of ICG is injected into the patient intravenously. After a period of time, NIR light is absorbed by the ICG in the tissues and the resulting fluorescence is a reflection of tissue perfusion.Aim: The aim of study is to evaluate the efficancy of ICG in colorectal surgery.Materials and Methods: We conducted a retrospective study, with all robotic colorectal resections for the last year, with and without ICG, for perfusion assessement before and after the construction of the anastomosis, as well as the last 48 colorectal cases without the use of ICG.In our patients, we did not observe significant differences in the operative time (201.6 ± 87.5 min in the ICG and 204.9 ± 76.1 in the group without, 95% CI: −12.42 to 10.87; p = 0.87), the intraoperative blood loss (100 ± 78. mL in ICG group and 98 ± 68 mL in the other; 95% CI: −16.43 to 7.35; p = 0.42), and in the need for blood transfusion in both groups (95% CI: 0.37–2.72; p = 1.10). The incidence of AL in the ICG and non-ICG group was 1/16.6.2% vs. 4/48,8.3%, (95% CI: 0.39–0.56; p < 0.). In the hospital stay, we did not observe a significant difference in the two groups. It was 6.7 ± 5.2 days in the group with ICG and 6.5 ± 5.1 in the group without (95% CI: −0.84 to 0.05; p = 0.08).Conclusion: The results of our study support the thesis of most authors about reducing the AL rate when using ICG. Larger multicenter studies are needed to confirm these data

Robotic-assisted colorectal surgery – initial results

Introduction: The mini invasive procedure in colorectal surgery is gaining ground as an alternative to conventional surgery. Colorectal surgery has significantly evolved since the advent of the automatic stapler devices and subsequently with the minimally invasive approach. The next logical step - the robotic assisted surgery was developed to satisfy surgeons’ needs to the area of colorectal surgery and to offer a new and safer method to patients. The evidence for benefits of its use in this area appears to be promising. Aim: The aim of this study was to analyse and share our initial results in robotic colorectal surgery and compare them with literature data. Materials and methods: A retrospective study was conducted in order to review seven patients with colorectal cancers operated by the robotic-assisted technique over three months in the initial phase of the learning curve. Gender, age, diagnosis, and surgical indication, type of surgery performed, surgical time, conversion, bleeding, post-operative complications, and hospital stay, were analysed and described. A literature review was performed on the role of robotic surgery in colorectal cancer. Results: Seven patients were operated, 5 males and 2 females with a mean age of 68.2 years. The following procedures were performed: left hemicolectomy with primary anastomosis, low anterior resection, left hemicolectomy, sigmoid resection. The mean surgery time for the seven patients was 4 h 06 min, with a time on the console of 2 h and 50 min, and mean bleeding of 192 cc. None of the patients required conversion and the hospital stay was 7 days. Conclusions: Despite the reduced case series, the initial results of our learning curve in colorectal robotic surgery are among the parameters imposed by the medical literature

Comparison of short term results following robotic and laparoscopic total gastrectomy and d2 lymph node dissection

Introduction: In the last decade, there has been a progressive shift from open to mini-invasive operative techniques for surgical resection of gastric cancer. Advanced equipment of surgical robots, with its 3D visualization, steady camera view, flexible instrument tips, attracts more and more practitioners in performing robotic gastrectomy with D2 dissection in gastric cancer patients. Thus, the comparison of some basic oncological as well as some surgical variables related to laparoscopic and robotic gastrectomy and D2 lymphadenectomy is necessary.Aim: The aim of the study was to compare our initial short-term results after robotic and laparoscopic gastrectomy.Materials and methods: A retrospective cohort study was performed. For a period of four years between January 2018 and August 2022, a total number of 110 patients with total gastrectomy and D2 lymphadenectomy due to gastric cancer operated in Department of General Surgery, Kaspela University Hospital, Plovdiv, were included into the study. They were separated in two groups: thirty-eight patients with robotic surgery and 72 with laparoscopic assisted procedure.Results: The oncological variables such as location of tumor, nodal status, number of lymph nodes removed, and pathological tumor showed no statistically significant differences between robotic and laparoscopic group. The demographic variables as age, sex, BMI, as well as ASA score also demonstrated no remarkable difference in both groups (p&amp;gt;0.05). The overall complication rate were similar (p=0.983).Conclusion: We found no significant advantages of robotic over laparoscopic gastric surgery in our patients. However, we think that robotic surgery is effective, safe, and promising approach to the treatment of gastric cancer capable of correcting some of the disadvantages of laparoscopy

Laparoscopic or conventional abdominoperineal extirpation in low rectal cancer

INTRODUCTION: Laparoscopic abdominoperineal resection (LAPR) as a minimally invasive approach for the treatment of large rectal cancer is widely used. It has been proven to be technically feasible and safe with fewer complications and faster postoperative recovery than the open procedure. Our aim was to evaluate LAPR safety and feasibility as compared to the open procedure in large low rectal cancer.PATIENTS AND METHODS: A total of 34 low rectal cancer patients who underwent open APR (OAPR) were matched with 42 patients who underwent LAPR in a one-to-one fashion between 2011 and 2014 in the Divi­sion of General Surgery, Kaspela University Hospital of Plovdiv.RESULTS: Intraoperative parameters of LAPR were better than those of OAPR as followed: mean operation time (121.8±47.8 min versus 152.1±49.2 min), mean operative blood loss (82±30.0 mL versus 120±35.0 mL), mean total number of retrieved lymph nodes (12±1 versus 12±1.4), and percentage of surgical complications (12.3% versus 15.1%). Laparoscopically treated patients showed significantly shorter postoperative analge­sia (2.1±0.7 days versus 3.7±0.6 days), earlier first flatus (36.3±7.9 hours versus 48.5±9.2 hours), shorter uri­nary drainage (3.8±3.4 days versus 5.8±1.3 days), and shorter hospital stay (6.2±1 days versus 8±2.0 days). Local recurrence rate during a three-year period (in 3 versus 4 patients) and metachronous liver metastasis (in 5 versus 6 patients) were less common after LAPR than after OAPR.CONCLUSION: The risks of APR-specific surgical complications such as perineal wound infection and para­stomal hernia were comparable between the laparoscopic and open surgery groups. There were no signifi­cant differences regarding local recurrence and metachronous liver metastasis between these groups. Com­plication and locoregional recurrence rates in low large rectal cancer patients after laparoscopic and open were quite similar. Scr Sci Med 2017; 49(3): 22-2

Estimating reference values of parenchymal stiffness of normal pancreatic parenchyma by means of point shear wave elastography

Introduction: There are numerous imaging modalities available to describe pancreatic parenchyma. None of the broadly accepted diagnostic methods uses elasticity as an indicator of tissue damage. Aim: The aim of the present study was to establish reference values of parenchymal stiffness of normal pancreatic parenchyma through point shear wave elastography. Materials and methods: The design of the study is prospective single-center cohort study. Sixty patients were included in the study. The ultrasound-based point shear wave elastography (pSWE) imaging technique was applied. The mean and median shear wave velocity values of the pancreatic parenchyma in the head, body and tail were calculated. The influence of certain variables on the shear wave velocity (SWV) values was estimated. Results: A reference range for the entire pancreatic parenchyma of 0.66-1.62 m/s and a mean value of 1.17±0.22 m/s were calculated. Apart from age, none of the evaluated factors proved to have statistically significant influence on the obtained results. A measurement success rate of 94.5%, 97.2%, and 95.8% was established for the head, body, and tail of the pancreas, respectively. Transabdominal pSWE could be utilized for assessment of pancreatic parenchyma with high success rate. A mean value of 1.17 m/s was measured which is consistent with the existing literature on the matter. None of the external factors examined in the study, apart from age, was found to have statistically significant influence on the SWV values. Conclusions: The obtained results suggest that pSWE is a highly objective method for evaluating pancreatic parenchyma. Calculated reference range and mean values could be used in future studies to assess the capabilities of the method for differentiating between normal pancreatic parenchyma and diffuse and focal pancreatic disorders

Portal vein reconstruction during pancreaticoduodenal resection using an internal jugular vein as a graft

Portal vein involvement by malignant tumours of the head of the pancreas is observed in almost 50% of the patients. In the past, this finding usually rendered the tumor inoperable. Over the past 30 years, the operative morbidity and mortality rate of pancreatectomy combined with portal vein resection has greatly decreased, and portal vein resection in pancreatic surgery has become a well-tolerated operative procedure in large-volume centres. Options for a venous reconstruction after SMV/PV resection include prosthetic, autologous or cryopreserved cadaveric vein grafts.Vascular resection and reconstruction provides great opportunity for R0 resection and improvement of oncological results in patients with pancreatic tumors and involvement of venous vessels, in the absence of distant metastases. If a longer graft length is required, there is the option of using either synthetic prosthesis or cryopreserved grafts. Their weak sides can be avoided by the use of jugular vein graft. Portal vein resection will be performed more often, safely and aggressively over the next years

Prophylactic central lymph node dissection in differentiated thyroid cancer – benefits and risk

Introduction: Papillary thyroid cancer is the most common thyroid malignancy. Lymph nodes involvement is common in differentiated thyroid cancer, and cervical lymph node micrometastases are observed in up to 85% of patients with papillary thyroid cancer during surgery. While the therapeutic central lymph node dissection has been accepted, the debate on the prophylactic in differentiated thyroid carcinoma (DTC) continues. Aim: To evaluate the benefits and risk of prophylactic central lymph node dissection in differentiated thyroid cancer. Materials and methods: Between January 2014 and December 2018, 223 total thyroidectomies due to papillary thyroid cancer were performed in the Kaspela University Hospital in Plovdiv. The patients were allocated into two groups: group A consisting of 36 patients with total thyroidectomy alone, and group B - 178 patients with total thyroidectomy and prophylactic central lymph node dissection. Results: In 36 (21.6%) patients, we found metastases only in ipsilateral side. In 24 (13.4%) of them we found metastatic spread in both ipsilateral and contralateral lymph nodes. In 7 (3.9%) patients, the metastasis was found only in the contralateral nodes. A pre-laryngeal lymph node was found and removed in 79 patients. Metastases were found in 12 of these 79 nodes. Analysis of complications showed no significant differences in its rate in patients with TT+ PCLND vs. patients with TT alone. Conclusions: The present study suggests that the realization of total thyroidectomy with prophylactic central lymph node dissection in papillary thyroid cancer patients has neither substantial advantages nor significant complications for the short period of observation

Total extra peritoneal inguinal hernia repair: a single-surgeon preliminary findings report

Introduction: Inguinal hernia repair is one of the most frequent operations in general surgery. Various techniques have been used to repair inguinal hernias since the first reconstructive technique described by Bassini in 1887. In 1989 Lichtenstein reported a new technique: tension free inguinal hernia repair. Laparoscopic inguinal hernia repair was introduced in the early 1990s, and soon also became popular. Literature has shown the benefits of laparoscopy (in comparison with open repair) to be mostly related to the more minimally invasive nature of the surgery, having lower wound infection rates, faster recovery, and less postoperative pain.&amp;nbsp;Aim: To evaluate our totally extraperitoneal (TEP) inguinal hernia repair initial results and compare them to literature data.Materials and methods: In a prospective review and analysis, we examined 61 cases of hernia repair via laparoscopy (specifically TEP), performed by a single surgeon, between April 2019 and December 2019 at the Kaspela University Hospital in Plovdiv. The centre&amp;rsquo;s Institutional Review Board approved the study with no specific consents required due to the retrospective, minimal risk nature of the study. The routine informed consent required by the National Insurance Fund has been considered sufficient for the study objectives.The surgical outcome measures included operating time (hours/minutes), conversion, peritoneal injury, surgical emphysema; and the clinical outcome measures included postoperative seroma, post-operative infection, and post-operative chronic groin pain.Results: Inguinal pain on discharge was characterized as mild by 56 (96.55%) patients and moderate by 2 (3.44%), there were no patients describing the pain as severe. The most frequently reported postoperative complications were annoyance and discomfort (10.34%), swelling (6.9%), seroma (3.44), hematoma (1.72%), paresthesia 1.72% (1); however, only those with seromas required special treatment.Conclusions: Limitations of the present study include the relatively small number of patients, all cases were operated on by a single surgeon and short postoperative follow-up period, but we are sharing our initial six months results. These results demonstrate that laparoscopic TEP inguinal hernia repair without mesh &amp;#64257;xation is a reliable technique, which can reduce postoperative morbidity when applied by experienced surgeons