Applications of robotic surgery in pediatric patients

Minimally invasive surgery is increasingly becoming the standard approach to treatment for pediatric patients. Infants present a technical challenge due to the small size of structures and the small workspace available. Master-slave robotic surgical telemanipulators help overcome this challenge by facilitating microsurgery in a confined workspace. The Zeus Robotic Surgical System (Computer Motion, Inc., Goleta, CA, U.S.A.) was used to develop the robotic approach and to evaluate the technical feasibility of performing four technically challenging procedures that are typically performed in infants. Robotic enteroenterostomy, hepaticojejunostomy, portoenterostomy, and esophagoesophagostomy were performed in piglets and compared with the same procedures performed by standard minimally invasive techniques. Enteroenterostomy, hepaticojejunostomy, and esophagoesophagostomy procedures were successfully developed and are technically feasible. The portoenterostomy procedure needs further study to validate data from the second set of experiments, showing a lower complication rate in the robotic group. Survivor studies are needed to fully elucidate the advantages that may be provided by the robotic approach.     

Teaching robotic surgery: a stepwise approach

Background After an initial institutional experience with 50 robot-assisted laparoscopic Roux-en-Y gastric bypass procedures, a curriculum was developed for fellowship training in robotic surgery. Methods Thirty consecutive robotic gastric bypasses were performed using the Zeus robotic surgical system to fashion a two-layer gastrojejunostomy. For teaching purposes, performance of the anastomosis was divided into three discrete tasks. Robotic suturing tasks were assigned to the trainee in cumulative order in ten-case increments. Our patient population averaged 44 years of age and 47 kg/m² in BMI. Patients were predominantly female (87%). Results The robotic training experience of the fellow defines the increases in surgical responsibility over the series of cases. Statistical analysis revealed no significant differences in task times or total robotic operative time as participation of the trainee in performing the gastrojejunostomy increased. No adverse robotic events or surgical complications occurred throughout this series. The learning curve of the fellow compared favorably with the initial experience of the institution. Conclusion Robotic surgery training may be safely implemented in a minimally invasive surgery training program. A gradual introduction of robotic technique appears to maximize the learning experience and minimize the potential for adverse outcomes. Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) April 13–16, 2005 in Fort Lauderdale, Florida, USA.     

Transvaginal laparoscopic cholecystectomy: laparoscopically assisted

Natural orifice transluminal endoscopic surgery (NOTES) is considered the new frontier for minimally invasive surgery. NOTES procedures such as peritoneoscopy, splenectomy, and cholecystectomy in animal models have been described. The aim of our experiment was to determine the feasibility and technical aspects of a new endoluminal surgical procedure. After approval from Columbia’s IACUC, a transvaginal laparoscopically assisted endoscopic cholecystectomy was performed on four 30 kg Yorkshire pigs. The first step was to insert a 1.5 cm endoscope into the vagina under direct laparoscopic vision. Then the gallbladder was reached and, with the help of a laparoscopic grasper to hold up the gallbladder, the operation was performed. At the end of the procedure the gallbladder was snared out through the vagina attached to the endoscope. There were no intraoperative complications such as bleeding, common bile duct or endo-abdominal organ damage. Total operative time ranged between 110 and 155 min. Based on our experience in the porcine model, we believe that a transvaginal endoscopic cholecystectomy is feasible in humans. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Robotically assisted biliary pancreatic diversion with a duodenal switch: a new technique

Background Minimally invasive surgical techniques decrease the length of hospitalization and the morbidity for general surgery procedures. Application of minimally invasive techniques to obesity surgery had previously been limited to stapled techniques used primarily for the Roux-en-Y gastric bypass and laparoscopic band placement. The authors present the technique for totally intracorporeal robotically assisted biliary pancreatic diversion with a duodenal switch (BPD/DS) using five ports. Methods After development of the technique in animal and human cadaver models, the da Vinci robot was first used in October 2000 to perform BPD/DS using five ports and a totally intracorporeal technique. Patient selection was based on standard surgery guidelines for the morbidly obese. Results This technique was applied for 47 patients with a mean body mass index (BMI) of 45 kg/m² and a mean age of 38 ± 10 years. The median operating time was 514 min (range, 370–931 min). The median operative time for the last 10 patients was 379 min (range, 370–582 min). Three patients underwent conversion to open surgery, and four patients experienced postoperative leaks with no mortality. Conclusion The safety, feasibility, and reproducibility of a minimally invasive robotic surgical approach to complex abdominal operations such as BPD/DS is demonstrated. The BPD/DS allows for a sutured bowel anastomosis similar to the open technique using a minimal number of small access ports.     

Endo-robotic resection of the submandibular gland in a cadaver model

BACKGROUND: By means of a prospective, nonrandomized investigation, we evaluated the feasibility of performing endo-robotic resection of the submandibular gland in a cadaver model and compared the results of robotically enhanced endoscopic surgery with those from a conventional endoscopic technique. METHODS: Procedural times were recorded in a consecutive series of 11 endoscopic submandibular gland resections using the daVinci Surgical System (Intuitive Surgical, Sunnyvale, CA) and a modified endoscopic surgical approach previously developed in a porcine model. The presence of neurovascular injury was assessed postoperatively, and the specimens were examined histologically. RESULTS: Eleven endo-robotic submandibular gland resections were successfully performed in six cadavers (no conversions to open resection were necessary). The median duration of the procedures was 48 minutes (range, 33-82 minutes). Creation of the operative pocket took an average (+/-SD) of 12.2 +/- 5.3 minutes, assembly of the robot required 9.3 +/- 4.1 minutes, and the mean time for submandibular gland resection was 29.4 +/- 8.9 minutes. The time required for robotic assembly was offset by the reduced operative time necessary compared with conventional endoscopic resection. Histologic examination confirmed the presence of normal glandular architecture, without evidence of excessive mechanical or thermal injury. There were no cases of apparent neurovascular injury. CONCLUSIONS: Robotically enhanced endoscopic surgery in the neck is feasible and offers a number of compelling advantages over conventional endoscopic neck surgery. Clinical trials will be necessary to determine whether these advantages can be achieved in clinical practice.     

Comparison of outcomes between laparotomy and robotic technique for cervical cancer

We evaluated the results of patients who had undergone robotic-assisted radical hysterectomy or open radical hysterectomy for cervical cancer. The study included eight patients who had undergone robotic-assisted radical hysterectomy (group 1) and seven patients who had undergone radical hysterectomy (group 2). Demographic characteristics and operative results of all patients were compared. Body mass index, age, previous abdominal surgery, surgical procedure performed, total anesthesia duration, operation duration, intra- and postoperative complications, duration of hospital stay, and number of resected lymph nodes were recorded. Mean age of patients in the robotic surgery group was 47.8 years (38–56 years) and in the laparotomy group was 45.4 years (32–57 years). Body mass index was 33.2 kg/m2 (24.8–40.2 kg/m2) in group 1 and 27.8 kg/m2 (23.5–33.7 kg/m2) in group 2. Total duration of operation in group 1 and 2 was 233 min (185–321 min) and 210.8 min (134–310 min), respectively. Mean duration of hospital stay was 3.5 days (2–7 days) in group 1 and 9.5 days (6–11 days) in group 2. Mean number of resected lymph nodes was 23.6 (17–36) and 38.8 (22–59) in group 1 and 2, respectively. Robotic surgery was superior to laparotomy in terms of duration of hospital stay, estimated amount of blood loss, and number of complications. Operation duration was longer with robotic surgery compared with laparotomy, and rate of complications was higher with laparotomy. Although the number of patients in the present study is limited, the results are important since they represent the first data relating to robotic surgery in Turkey.     

Robotic radical hysterectomy: applying principles of the laparoscopic Pune technique

Minimal access surgery is an accepted treatment modality in cervical cancer. Despite the advantages of laparoscopy, the surgical technique of laparoscopic radical hysterectomy is not very commonly performed. Robotic surgery is an emerging field with rapid acceptance because of the 3-dimensional image, dexterity of instruments and autonomy of camera control. We report here our technique of performing robotic radical hysterectomy using the Da Vinci surgical system. Twenty patients with cervical cancer stage 1a1–1b2 underwent robotic radical hysterectomy since December 2009. The median duration of surgery was 122 min, and the average blood loss was 100 ml. Postoperative ureteric fistulas occurred in two patients and were managed by ureteric stenting. The median lymph node retrieval was 30 nodes (range 18–38). We compared our robotic results with our published data on laparoscopic radical hysterectomy (Pune technique). We were able to complete all 20 cases robotically with minimal morbidity, and could duplicate our laparoscopic steps in robotic radical hysterectomy.     

Technical assessment of porcine enteroenterostomy performed with ZEUS robotic technology

BACKGROUND/PURPOSE: Limitations of minimally invasive pediatric surgery include the inability to perform precise anastomoses of 2 to 15 mm. Robotic technology facilitates the performance of endoscopic microsurgical procedures. This study examined the technical feasibility of performing an enteroenterostomy in piglets utilizing ZEUS robotic technology. METHODS: Ten piglets (6.5 to 8.5 kg) underwent enteroenterostomy. Standard laparoscopic techniques were used in the control group (n = 5), and ZEUS robotic technology was used in the experimental group (n = 5). AESOP controlled the camera in both groups. Anesthesia time; surgery time; robotic set-up time; and anastomotic time, patency, diameter, and integrity were compared. RESULTS: No statistical difference existed between the means of the control and experimental groups for anesthesia time (176.0 v 154.0 minute; P =.63), surgery time (143.0 v 139.2 minute; P =.92), anastomosis time (109.4 v 93.0 minutes; P =.56), AESOP set-up time (4.2 v 7.0 minutes; P =.51), and anastomotic diameter (7.062 v 7.362 mm; P =.62). All anastomoses were patent without narrowing. The ZEUS cases averaged 14 minutes faster than the standard laparoscopic cases, even with the ZEUS set-up time included. CONCLUSIONS: These data supports the hypothesis that robotic-assisted enteroenterostomy is technically feasible. ZEUS robotic technology will potentially play an important role in expanding the applications of minimally invasive pediatric surgery.     

A comparative study of the surgical outcomes of robotic and conventional open modified radical neck dissection for papillary thyroid carcinoma with lateral neck node metastasis

Background

Several endoscopic modified radical neck dissections (MRND) have been conducted since the introduction of the endoscopic technique to thyroid surgery with the aim of avoiding a long cervical scar. Furthermore, the recent introduction of surgical robotic systems has increased the precision of endoscopic techniques. The aim of this study was to evaluate and compare the early surgical outcomes of robotic and conventional open MRND for papillary thyroid carcinoma (PTC) with lateral neck node metastasis (LNM).

Methods

From January 2009 to May 2010, 165 patients with PTC underwent bilateral total thyroidectomy with central compartment neck dissection and ipsilateral MRND. Of these patients, 56 formed the robotic procedure group (RG) and 109 the conventional open procedure group. These two groups were retrospectively compared with respect to their clinicopathological characteristics, early surgical outcomes, and surgical completeness.

Results

The operative time was longer, mean tumor size was smaller, mean age was lower, and disease stage was earlier in the RG. However, mean numbers of retrieved lymph nodes were similar in the two groups, and mean hospital stay after surgery was shorter in the RG. Furthermore, complication rates were similar in the two groups, and there was no statistical difference in postoperative Tg levels between the groups.

Conclusions

Robotic MRND was found to be similar to conventional open MRND in terms of early surgical outcomes and surgical completeness but leaves no scar on the neck area. Robotic MRND can be viewed as an acceptable alternative method in low-risk PTC with LNM.     

Robot-assisted laparoscopic surgery of the infrarenal aorta

Background Recently introduced robot-assisted laparoscopic surgery (RALS) facilitates endoscopic surgical manipulation and thereby reduces the learning curve for (advanced) laparoscopic surgery. We present our learning curve with RALS for aortobifemoral bypass grafting as a treatment for aortoiliac occlusive disease. Methods Between February 2002 and May 2005, 17 patients were treated in our institution with robot-assisted laparoscopic aorto-bifemoral bypasses. Dissection was performed laparoscopically and the robot was used to make the aortic anastomosis. Operative time, clamping time, and anastomosis time, as well as blood loss and hospital stay, were used as parameters to evaluate the results and to compare the first eight (group 1) and the last nine patients (group2). Results Total median operative, clamping, and anastomosis times were 365 min (range: 225–589 min), 86 min (range: 25–205 min), and 41 min (range: 22–110 min), respectively. Total median blood loss was 1,000 ml (range: 100–5,800 ml). Median hospital stay was 4 days (range: 3–57 days). In this series 16/18 anastomoses were completed with the use of the robotic system. Three patients were converted (two in group 1, one in group 2), and one patient died postoperatively (group 1). Median clamping and anastomosis times were significantly different between groups 1 and 2 (111 min [range: 85–205 min] versus 57.5 min [range: 25–130 min], p < 0.01 and 74 min [range: 40–110 min] versus 36 min [range: 22–69 min], p < 0.01, respectively) Total operative time, blood loss, and hospital stay showed no significant difference between groups 1 and 2. Conclusions Robot-assisted aortic anastomosis was shown to have a steep learning curve with considerable reduction of clamping and anastomosis times. However, due to a longer learning curve for laparoscopic dissection of the abdominal aorta, operation times were not significantly shortened. Even with robotic assistance, laparoscopic aortoiliac surgery remains a complex procedure. Presented at SAGES 2006, April 26–29 2006, Dallas, Texas, USA An erratum to this article can be found at     

��No scar�� small bowel resection in a survival porcine model using transcolonic NOTES? and transabdominal approach

Background  

Fundamental techniques and essential tools for performing “no scar” surgery still need to be developed. Our study was designed to evaluate the feasibility of performing small bowel resection by transcolonic NOTES^? and transabdominal approach using rigid laparoscopic and flexible endoscopic instruments.     

Facelift Approach for Resecting Benign Upper Neck Masses

Background

This study evaluated the feasibility of non-magnified resection of various benign lesions of the upper neck using the facelift incision without endoscopic equipment to establish indications for the procedure.

Methods

This retrospective analysis examined 86 patients who underwent surgery for upper neck masses using the facelift incision or conventional transcervical incision at our institute between January 2012 and December 2015.

Results

We performed 41 operations using facelift incisions (facelift group) and 45 using conventional horizontal incisions (conventional group). All 86 operations were successful. In the facelift group, no patient needed conversion to conventional open resection and no patient required the use of an endoscopic device due to a limited surgical view for safe resection. There were no major surgical complications in either group. Transient sensory changes in the auricle occurred in 26% of the patients in the facelift group, but all patients recovered within 2 months. In all patients in the facelift group, the scars were invisible as they were covered by the auricle and hair, while the surgical scars were noticeable in 91% (41/45) of the patients in the conventional group when they were wearing standard shirts (p < 0.001) at 3–4 weeks after surgery.

Conclusions

The facelift approach provides a short direct route to upper neck masses, and it enables an adequate workspace not only for endoscopic or robotic surgery, but also for open surgery with the naked eye. The surgical indications for the facelift incision include the removal of most benign tumors occurring in the upper neck at levels II and III.

     

Efficiency of manual versus robotical (Zeus) assisted laparoscopic surgery in the performance of standardized tasks

Background: The objective of this study was to compare the efficiency of manual and robotically assisted laparoscopic surgery. Methods: To evaluate the surgical efficiency in a set of basic endoscopic movements, 20 medical students without any surgical experience were selected to perform at random a set of laparoscopic tasks either manually or robotic assisted (Zeus). This task consisted of dropping beads into receptacles, running a 25-cm rope, capping a hypodermic needle, suturing, and performing a laparoscopic cholecystectomy on a cadaver liver of a pig. A quantitative time–action analysis was performed to evaluate the efficacy and skill performance in terms of time and the number of actions. Results: The dropping beads exercise and the laparoscopic cholecystectomy required more time when performed with robotic assistance, as compared with manual performance (respectively, median, 78.5 s; range, 63 – 122 s vs median, 144.5 s; range, 100 – 169 s; p <0.01 and median, 34.0 min; range 11–44 min vs median, 46.5 s; range, 21 – 79 min; p = 0.05). A tendency toward fewer total actions in all the robotically assisted exercises was observed. However, significance was shown only in the rope-passing task (median, 71; range, 59 – 87 vs median, 62; range, 57–80; p = 0.05). Grasping the beads, the rope, and either the needle or the cap were tasks that required fewer actions to complete when performed with robotically assistance (respectively, median, 11; range, 10 – 14 vs median, 12.5; range, 11 – 15; p <0.01; median, 56; range, 55 – 60 vs median, 60.5 min; range, 55 – 65; p = 0.03, and median, 6; range, 4 – 21 vs median, 10.5; range, 6 – 38; p = 0.02). As compared with the robotically assisted rope-passing exercise, more failures were made in the manually performed procedure (p = 0.03), mainly caused by unintentional dropping of the rope (p = 0.02). Conclusions: Robotically assisted laparoscopic surgery by participants without any surgical experience might require more time, but actions can be performed equally or more precisely as compared with manual laparoscopic surgery.     

Laparoscopic gastric bypass performed with the Da Vinci Intuitive Robotic System: preliminary experience

Background This study aimed to analyze retrospectively the authors’ preliminary experience using the Da Vinci Intuitive Robotic System for gastric bypass in managing morbid obesity, and to determine its efficacy and safety in relation to other standardized laparoscopic surgical techniques. Methods From October 2000 to March 2004 the authors performed 146 laparoscopic gastric bypasses, 17 of which were robot assisted using the Da Vinci Intuitive Robotic System. The last patients were 7 men and 10 women with a mean age of 44 years. The mean weight was 139 kg, and the mean body mass index (BMI) was 49.8 kg/m² at first postoperative recovery. The mean excess body weight (EBW) was 131%. Follow-up assessment, performed at months 1, 3, 6, and 12, then yearly thereafter, included evaluation of the variations in BMI and the percentage of excess body weight loss (EBWL%). All the patients were informed of the risks inherent with each surgical procedure as well as the potential benefits. Results The mean operative time was 201 min (range, 90–300 min). No intraoperative complications and no conversion occurred in this series. The mean hospital stay was 9 days (range, 6–18 days). The patients in this series experienced a normal postoperative course without anastomotic complications. The mortality rate was zero. No robot-related complications were noted. The analysis of follow-up assessment at months 1, 3, 6, and 12 showed a progressive decrease in BMI and an increment of EBWL%. Conclusions The authors’ early experience with robotic surgery suggests that it is safe and could be an effective alternative to conventional laparoscopic surgery. The authors believe that robotic surgery, with its ability to restore the hand–eye coordination and three-dimensional view lost in laparoscopic surgery, could allow complex procedures to be performed with greater precision and better results.     

Safety of robotic general surgery in elderly patients

As the life expectancy of people in Western countries continues to rise, so too does the number of elderly patients. In parallel, robotic surgery continues to gain increasing acceptance, allowing for more complex operations to be performed by minimally invasive approach and extending indications for surgery to this population. The aim of this study is to assess the safety of robotic general surgery in patients 70 years and older. From April 2007 to December 2009, patients 70 years and older, who underwent various robotic procedures at our institution, were stratified into three categories of surgical complexity (low, intermediate, and high). There were 73 patients, including 39 women (53.4%) and 34 men (46.6%). The median age was 75 years (range 70–88 years). There were 7, 24, and 42 patients included, respectively, in the low, intermediate, and high surgical complexity categories. Approximately 50% of patients underwent hepatic and pancreatic resections. There was no statistically significant difference between the three groups in terms of morbidity, mortality, readmission or transfusion. Mean overall operative time was 254 ± 133 min (range 15–560 min). Perioperative mortality and morbidity was 1.4% and 15.1%, respectively. Transfusion rate was 9.6%, and median length of stay was 6 days (range 0–30 days). Robotic surgery can be performed safely in the elderly population with low mortality, acceptable morbidity, and short hospital stay. Age should not be considered as a contraindication to robotic surgery even for advanced procedures.     

Reducing errors in the operating room

Technical operative errors cause surgical operative morbidity and adversely affect the clinical outcome of patients. Surgical proficiency thus underpins good and safe practice. In this context, standardization of endoscopic surgical operations and their execution are essential for the procurement and maintenance of quality assurance in endoscopic surgical practice. There is no clash between individual- (surgical proficiency) and system-based defense systems in the prevention of surgical errors — both underpin safe surgical practice. Although more human factors and surgical research are needed, it is possible to formulate and adopt a surgical error reduction system for endoscopic operations based on standardization of operations, surgical operative proficiency, and human reliability assessment and its related clinical counterpart, observational clinical human reliability assessment. These are some patients whom we cannot help, there are none whom we cannot harm. —Arthur L. Bloomfield (1888–1962)     

Robot-assisted total laparoscopic hysterectomy in obese and morbidly obese women

Total laparoscopic hysterectomy (TLH) in obese patients is challenging. We sought to evaluate whether total laparoscopic hysterectomies using the da Vinci robotic system in obese patients, in comparison with non-obese patients, is a reasonable surgical approach. One-hundred consecutive robot-assisted TLHs were performed over a 17-month period. Obesity was not a contraindication to robotic surgery, assuming adequate respiratory function to tolerate Trendelenburg position and, for cancer cases, a small enough uterus to allow vaginal extraction without morcellation. Data were prospectively collected on patient characteristics, total operative time, hysterectomy time, estimated blood loss, length of stay, and complications. Outcomes with non-obese and obese women were compared. The median age, weight, and BMI of the 100 patients who underwent robot-assisted TLH was 57.6 years (30.0–90.6), 82.1 kg (51.9–159.6), and 30.2 kg/m² (19.3–60.2), respectively. Fifty (50%) patients were obese (BMI ≥ 30); 22 patients were morbidly obese (BMI ≥ 40). There was no increase in complications (p = 0.56) or blood loss (p = 0.44) with increasing BMI. While increased BMI was associated with longer operative times (p = 0.05), median time increased by only 36 min when comparing non-obese and morbidly obese patients. Median length of stay was one day for all weight categories (p = 0.42). Robot-assisted TLH is feasible and can be safely performed in obese patients. More data are needed to compare robot-assisted TLH with other hysterectomy techniques in obese patients. Nonetheless, our results are encouraging. Robot-assisted total laparoscopic hysterectomy may be the preferred technique for appropriately selected obese patients.     

The mini-fellowship concept: a six-week focused training program for minimally invasive bariatric surgery

Objective To devise a six-week hands-on training program customized to meet the needs of practicing general surgeons. The aim of this program is to provide the required training experience that will bestow the knowledge and skill necessary to implement a successful practice in laparoscopic bariatric surgery. Methods Ten board-certified/board-eligible practicing general surgeons with no prior hands-on or formal training in laparoscopic bariatric surgery. We report on the participants training experience and the impact that the program had on their subsequent laparoscopic bariatric clinical activity. Results Ten surgeons completed training programs from 9/01 to 3/03. None of the trainees had prior experience in laparoscopic bariatric surgery. Program operative experience averaged 42 cases (range 29–66). Trainees were integrated into all preoperative and postoperative hospital and outpatient care on the service, including workshops and seminars. Seven graduates are in practice performing laparoscopic bariatric surgery and three are implementing new bariatric programs. The active surgeons report performing an average of 101 laparoscopic bariatric procedures (range 18–264) over a mean practice period of 10 months (range 4–16) Conclusion A six-week focused mini-fellowship with hands-on operative and clinical participation enables practicing surgeons to acquire the skill and experience necessary to successfully implement a laparoscopic bariatric surgical practice.     

Single Port Access Laparoscopic Cholecystectomy (with video)

Background  Single port access (SPA) surgery is a rapidly evolving field due to the complexity of NOTES (natural orifice translumenal endoscopic surgery). SPA combines the cosmetic advantage of NOTES and possibility to perform surgical procedure with standard laparoscopic instruments. We report a technique of umbilical SPA cholecystectomy using standard laparoscopic instruments and complying with conventional surgical principle and technique of minimally invasive cholecystectomy. Methods  Preliminary, prospective experience of SPA cholecystectomy in 11 patients (median age, 46 (range, 27–63) years) scheduled for cholecystectomy was evaluated. Diagnoses for cholecystectomy were: symptomatic gallbladder lithiasis (n = 7), previous acute cholecystitis (n = 3), and biliary pancreatitis (n = 1). Results  SPA cholecystectomy was feasible in all patients (median body mass index, 24 (range, 20–34) kg/m²) who were scheduled for preliminary experience using conventional laparoscopic instruments. Median operative time was 52 (range, 40–77) minutes. Intraoperative cholangiography was performed in all patients, except one, and was considered normal. No peroperative or postoperative complications were recorded. Median hospital stay was less than 24 h. Conclusions  SPA cholecystectomy is feasible and seems to be safe when performed by experienced laparoscopic surgeons using standard laparoscopic instrumentation. SPA cholecystectomy may be safer than the NOTES approach at this time. It has to be determined whether this approach would benefit patients, other than cosmesis, compared with standard laparoscopic cholecystectomy. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Treatment of intraductal papillary mucinous neoplasms, neuroendocrine and periampullary pancreatic tumors using robotic surgery: a safe and feasible technique

In the last few years, robotic surgery has started to take its place in pancreatic surgery. Robotic surgery provides advantages such as enhanced visualisation and freedom of dissection within a confined space and also allows economical surgery. The aim of this study was to evaluate the feasibility, safety and short-term outcome of the robotic approach using the da Vinci robotic system in pancreatic/peripancreatic tumors other than pancreatic carcinomas. Fifteen patients with eight intraductal papillary mucinous neoplasms, four pancreatic neuroendocrine and three periampulary tumors were included in this initial series. Seven left pancreatectomies, five pancreatoduodenectomies and two total pancreatectomies were performed at Albert Einstein Hospital, S?o Paulo, Brazil. The mean operating room time for all the procedures was 503 min (315–775 min). Blood transfusion was necessary in one patient (3 units). The mean length of stay for all patients was 16 days (5–52 days). Large series of robotic pancreatic surgery should be described and the decision as to its routine use will come from cumulative experience. This surgical system allows difficult procedures to be performed more easily, effectively and precisely.