Robotic-assisted laparoendoscopic single-site radical nephrectomy: first experience with the novel Da Vinci single-site platform

Purpose

To report our first cases of robotic laparoendoscopic single-site (R-LESS) radical nephrectomy with the novel Da Vinci R-LESS platform (Intuitive Surgical, Sunnyvale, CA).

Methods

Six radical nephrectomies were performed with R-LESS Da Vinci single-site port and instruments. Data concerning patients characteristics, indication of surgery, operative and postoperative outcomes were collected.

Results

All procedures were completed successfully. Two patients required the placement of an additional port. Median operative, docking and console times were 179 min (range 120–318), 19 min (range 15–24) and 129 min (range 100–264), respectively. Median blood loss was 100 ml (range 50–800). No significant robotic-related problem was noticed during the procedures. There was no operative or major postoperative (Clavien >2) complication. Median length of hospital stay was 3 days.

Conclusion

Our initial experience of R-LESS radical nephrectomies with the novel Da Vinci platform shows that the procedure is feasible. Indications, safety and place of the technique will be confirmed with growing experience.     

Long-term outcomes after totally robotic sacrocolpopexy for treatment of pelvic organ prolapse

Purpose

This study evaluated the feasibility, safety, effectiveness, and long-term results of pelvic organ prolapse surgery using the Da Vinci^® robotic system.

Methods

During a 7-year period, 52 consecutive patients with pelvic organ prolapse underwent robotic-assisted abdominal sacrocolpopexy. Clinical data were retrospectively collected and analyzed.

Results

All but two of the procedures were successfully completed robotically (96 %). Median operative time was 190 (range, 75–340) mins. There was no mortality and no specific morbidity due to the robotic approach. Mean hospital stay was 5 days. The median follow-up was 42 months. Five recurrent prolapses (9.6 %) were diagnosed.

Conclusions

Our experience indicates that using the Da-Vinci^® robotic system is feasible, safe, and effective for the treatment of pelvic organ prolapse with good long-term results.     

Robotic liver resection: technique and results of 30 consecutive procedures

Background

Robotic surgery can enhance a surgeon’s laparoscopic skills through a magnified three-dimensional view and instruments with seven degrees of freedom compared to conventional laparoscopy.

Methods

This study reviewed a single surgeon’s experience of robotic liver resections in 30 consecutive patients, focusing on major hepatectomy. Clinicopathological characteristics and perioperative and short-term outcomes were analyzed.

Results

The mean age of the patients was 52.4?years and 14 were male. There were 21 malignant tumors and 9 benign lesions. There were 6 right hepatectomies, 14 left hepatectomies, 4 left lateral sectionectomies, 2 segmentectomies, and 4 wedge resections. The average operating time for the right and left hepatectomies was 724?min (range 648–812) and 518?min (range 315–763), respectively. The average estimated blood loss in the right and left hepatectomies was 629?ml (range 100–1500) and 328?ml (range 150–900), respectively. Four patients (14.8%) received perioperative transfusion. There were two conversions to open surgery (one right hepatectomy and one left hepatectomy). The overall complication rate was 43.3% (grade I, 5; grade II, 2; grade III, 6; grade IV, 0) and 40% in 20 patients who underwent major hepatectomy. Among the six (20.0%) grade III complications, a liver resection–related complication (bile leakage) occurred in two patients. The mean length of hospital stay was 11.7?days (range 5–46). There was no recurrence in the 13 patients with hepatocellular carcinoma during the median follow-up of 11?months (range 5–29).

Conclusions

From our experience, robotic liver resection seems to be a feasible and safe procedure, even for major hepatectomy. Robotic surgery can be considered a new advanced option for minimally invasive liver surgery.     

Radical resection of gallbladder cancer: could it be robotic?

Background

The only potentially curative option for patients with gallbladder cancer is radical resection. This is the first report that describes the successful application of a minimally invasive, robot-assisted radical resection, including lymphadenectomy, in five gallbladder cancer patients.

Methods

Medical records of patients who underwent radical resection of gallbladder cancer via the da Vinci robotic surgical system in the Hepato-Bilio-Pancreatic Surgical Department of the Shanghai Ruijin Hospital, China, between March 2010 and July 2011 were reviewed and analyzed.

Results

Robot-assisted radical resection was successful in all five patients. The mean number of excised lymph nodes was 9 (range?=?3–11), mean operative time was 200?min (range?=?120–300?min), mean intraoperative blood loss was 210?ml (range?=?50–400?ml), and mean length of hospital stay was 7.4?days (range?=?7–8?days). All patients were discharged with no reported complications. Mean postoperative follow-up was 11?months (range?=?1–17?months). One patient died due to tumor recurrence 10?months postsurgically, but there was no recurrence in the remaining four patients during the follow-up period.

Conclusions

Robot-assisted radical resection for gallbladder cancer is both feasible and safe. Compared to laparoscopic surgery, the robotic surgery system is better suited for subtle dissection in a narrow, deep space. This is advantageous for both the removal of lymph nodes near the pancreas and hepatoduodenal ligament and the skeletonization of the hepatoduodenal ligament, the hepatic artery, and the celiac axis. The long-term outcome and direct comparisons to laparotomy in a larger patient cohort are needed to provide more clinical data supporting the superiority of this approach.     

The Learning Curve for Robotic Thyroidectomy: A Multicenter Study

Purpose

The learning curve for robotic thyroidectomy with central compartment node dissection (CCND) has not been established. We examined the effect of experience of robotic thyroidectomy on a range of perioperative parameters in order to determine the learning curve. The learner surgeon outcomes were compared with those of an experienced surgeon.

Methods

We conducted a prospective, controlled, multicenter study involving four endocrine surgeons at three academic centers. Patients underwent robotic total or subtotal thyroidectomy with CCND between September 2008 and October 2009. One surgeon was experienced in the technique (experienced surgeon, ES), while the other three surgeons had endoscopic thyroid surgery experience but no experience performing the robotic procedure (nonrobotic thyroid surgery experienced surgeon, NS). Outcome measures were demographic data, operative time, blood loss, hospital stay, pathologic results, and postoperative complications.

Results

A total of 644 total or subtotal robotic thyroidectomies with CCND were performed: 377 (58.7%) by NSs and 267 (41.5%) by the ES. Mean operative time was longer and the complication rate was higher for the NS patient group compared with the ES patient group (P < 0.001 for each). The operative times and complications rates for the NS group were similar to those of the ES group once the NSs had performed 50 cases for total thyroidectomies or 40 cases for subtotal thyroidectomies.

Conclusion

The learning curve duration for robotic thyroidectomy with CCND using gasless transaxillary approach for experienced endoscopic thyroidectomy surgeons was 50 cases for total thyroidectomy and 40 cases for subtotal thyroidectomy.     

Initial Experience of Robotic Gastrectomy and Comparison with Open and Laparoscopic Gastrectomy for Gastric Cancer

Background

Robotic gastrectomy has become more popular in the treatment of gastric cancer, especially in Asian countries. Until now, few studies have compared robotic surgery with open or laparoscopic surgery for gastric cancer patients.

Methods

Data were prospectively collected between January 2006 and February 2012. A total of 689 patients underwent curative resection of adenocarcinoma of the stomach. Patients were separated into three groups according to the different surgical approaches used (586 open, 64 laparoscopic, and 39 robotic). The clinicopathological characteristics and surgical outcomes of the three groups were compared.

Results

The open group was associated with a larger tumor size, more D2 dissection, more advanced tumor stage, and more blood loss than the groups treated with laparoscopic and robotic methods. Robotic gastrectomy was associated with female predominance, less blood loss, shorter hospital stay, and longer operative time than open and laparoscopic gastrectomy. The retrieved lymph node numbers were similar between the open and robotic groups. Postoperative morbidity rates were similar among the three groups. In terms of the learning curve of robotic gastrectomy, operative time and docking time were significantly reduced in the recent robotic group (n?=?14) compared to the initial robotic group (n?=?25).

Conclusion

Robotic gastrectomy could achieve extended lymph node dissection similar to open surgery. Our results showed a significant learning curve effect in the initial 25 cases of the robotic group.     

Impact of robotic general surgery course on participants’ surgical practice

Background

Courses, including lectures, live surgery, and hands-on session, are part of the recommended curriculum for robotic surgery. However, for general surgery, this approach is poorly reported. The study purpose was to evaluate the impact of robotic general surgery course on the practice of participants.

Methods

Between 2007 and 2011, 101 participants attended the Geneva International Robotic Surgery Course, held at the University Hospital of Geneva, Switzerland. This 2-day course included theory lectures, dry lab, live surgery, and hands-on session on cadavers. After a mean of 30.1 months (range, 2–48), a retrospective review of the participants’ surgical practice was performed using online research and surveys.

Results

Among the 101 participants, there was a majority of general (58.4 %) and colorectal surgeons (10.9 %). Other specialties included urologists (7.9 %), gynecologists (6.9 %), pediatric surgeons (2 %), surgical oncologists (1 %), engineers (6.9 %), and others (5.9 %). Data were fully recorded in 99 % of cases; 46 % of participants started to perform robotic procedures after the course, whereas only 6.9 % were already familiar with the system before the course. In addition, 53 % of the attendees worked at an institution where a robotic system was already available. All (100 %) of participants who started a robotic program after the course had an available robotic system at their institution.

Conclusions

A course that includes lectures, live surgery, and hands-on session with cadavers is an effective educational method for spreading robotic skills. However, this is especially true for participants whose institution already has a robotic system available.     

Robot-assisted endoscopic surgery for thyroid cancer: experience with the first 100 patients

Background

Various robotic surgical procedures have been performed in recent years, and most reports have proved that the application of robotic technology for surgery is technically feasible and safe. This study aimed to introduce the authors’ technique of robot-assisted endoscopic thyroid surgery and to demonstrate its applicability in the surgical management of thyroid cancer.

Methods

From 4 October 2007 through 14 March 2008, 100 patients with papillary thyroid cancer underwent robot-assisted endoscopic thyroid surgery using a gasless transaxillary approach. This novel robotic surgical approach allowed adequate endoscopic access for thyroid surgeries. All the procedures were completed successfully using the da Vinci S surgical robot system. Four robotic arms were used with this system: a 12-mm telescope and three 8-mm instruments. The three-dimensional magnified visualization obtained by the dual-channel endoscope and the tremor-free instruments controlled by the robotic systems allowed surgeons to perform sharp and precise endoscopic dissections.

Results

Ipsilateral central compartment node dissection was used for 84 less-than-total and 16 total thyroidectomies. The mean operation time was 136.5 min (range, 79–267 min). The actual time for thyroidectomy with lymphadenectomy (console time) was 60 min (range, 25–157 min). The average number of lymph nodes resected was 5.3 (range, 1–28). No serious complications occurred. Most of the patients could return home within 3 days after surgery.

Conclusions

The technique of robot-assisted endoscopic thyroid surgery using a gasless transaxillary approach is a feasible, safe, and effective method for selected patients with thyroid cancer. The authors suggest that application of robotic technology for endoscopic thyroid surgeries could overcome the limitations of conventional endoscopic surgeries in the surgical management of thyroid cancer.     

Laparoendoscopic single-site minor hepatectomy for liver tumors

Background

Laparoscopic liver surgery is gaining increasing acceptance worldwide, but its frontiers are constantly challenged. Laparoendoscopic single-site surgery (LESS) has been performed for various organs, but the feasibility of LESS hepatectomies has yet to be explored fully.

Methods

From May 2010 to March 2011, seven patients underwent LESS minor hepatectomies. Patient demographic, operative, and clinical data were reviewed.

Results

Five left lateral sectionectomies, one segment 3, and one segment 5 resection were performed. The median operative time was 142?min (range, 104–171?min), and the median blood loss was 200?ml (range, 100–450?ml). The median hospital stay was 3?days (range, 1–11?days). For all the patients, the indications for surgery were suspected malignant tumors, and the surgical resection margins were clear for every patient.

Conclusions

Laparoendoscopic single-site minor hepatectomy is a novel modification to traditional laparoscopic surgery. The method is safe and feasible without any compromise to oncologic safety for selected patients with hepatocellular carcinoma (HCC) and colorectal liver metastases that are peripheral and smaller than 5?cm in size.     

Total laparoscopic sigmoid and rectal surgery in combination with transanal endoscopic microsurgery: a preliminary evaluation in China

Background

This study was designed to evaluate the feasibility and safety of total laparoscopic sigmoid and rectal surgery without abdominal incision in combination with transanal endoscopic microsurgery (TEM).

Methods

From May 2010 to October 2011, 34 patients with colon and rectal tumors were treated by total laparoscopic surgery without abdominal incision, and the clinical data of these patients were reviewed.

Results

All operations could be successfully accomplished without conversion to open surgery. No diverting ileostomy was created. The average operative time was 151.60 (range, 125–185) minutes. The average blood loss was 200.20 (range, 55–450) ml. All resection margins were negative. Six patients developed postoperative anastomotic leakage. There were no reports of other complications in all patients.

Conclusions

This preliminary study indicated that total laparoscopic sigmoid and rectal surgery in combination with TEM was a safe, feasible, and minimally invasive technique. This advanced surgical technique was developed by combining laparoscopy with the concept of natural orifice transluminal endoscopic surgery.     

Robot-assisted total mesorectal excision: is there a learning curve?

Background

Laparoscopic total mesorectal excision (TME) is associated with a steep learning curve, but the learning curve for robotic TME is unknown. This study aimed to evaluate the learning curve for robotic TME.

Methods

Between November 2004 and April 2009, 80 patients underwent robotic TME performed by a single surgeon. The operative experience was divided into two groups: group 1 (the first 40 cases) and group 2 (the subsequent 40 cases). Patient demographics, operative characteristics, and morbidities were compared.

Results

The two patient populations selected did not differ statistically in age, body mass index (BMI), preoperative risk assessment, stage, preoperative chemoradiotherapy, or tumor location. The mean operative times in group 1 (310?min) and group 2 (297?min) were similar (p?=?0.55), and the mean robotic TME time did not differ between the two groups (60 vs. 64?min; p?=?0.65). In addition, the operative times did not improve during the course of the study. There were no differences in EBL, margin status, or number of lymph nodes harvested. Furthermore, there were no differences in conversion rate, time to resumption of diet, length of hospital stay, or postoperative complications.

Conclusion

Robot-assisted TME may attenuate the learning curve for laparoscopic rectal cancer resection. Further studies are necessary to establish the role of robotic surgery in minimally invasive rectal operations.     

Laparoscopic versus robotic subtotal splenectomy in hereditary spherocytosis. Potential advantages and limits of an expensive approach

Background

This study was designed to compare the laparoscopic subtotal splenectomy with the robotic approach in patients with hereditary spherocytosis.

Methods

Thirty-two consecutive subtotal splenectomies by minimal approach in patients with hereditary spherocytosis were analyzed (10 robotic vs. 22 laparoscopic subtotal splenectomies).

Results

A significant difference was found for the robotic approach regarding blood loss, vascular dissection duration, and splenic remnant size. Follow-up for 4–103?months was available.

Conclusions

Subtotal splenectomy seems to be a suitable candidate for robotic surgery, requiring a delicate dissection of the splenic vessels and a correct intraoperative evaluation of the splenic remnant. Robotic subtotal splenectomy is comparable to laparoscopy in terms of hospital stay and complication. The main benefits are lower blood loss rate, vascular dissection time, and a better evaluation of the splenic remnant volume.     

Gasless transaxillary robotic versus endoscopic thyroidectomy: exploring the frontiers of scarless thyroidectomy through a preliminary comparison study

Background

Robot-assisted thyroidectomy has been associated with lengthy operative times due to fussy robot preparation and docking maneuvers. The authors propose an endoscopic transaxillary approach using a novel platform, comparing its results with those of the former approach.

Methods

Eight patients (6 females and 2 males; mean age, 38.8?years) with a favorable body habitus (mean body mass index [BMI], 23.4?kg/m²) underwent robot-assisted thyroidectomy through a gasless transaxillary approach using the da Vinci S system. Another four female patients (mean age, 31?years) underwent an endoscopic procedure. The patients’ demographic data, operative time, complications, hospital stay, postoperative visual analog pain score (VAPS), and costs were compared.

Results

Three lobectomies, two near-total thyroidectomies, two total thyroidectomies, and one total thyroidectomy with lateral lymph node dissection were performed in the robotic group. Two lobectomies and two near total thyroidectomies were performed in the endoscopic group. The mean diameter of the largest nodule in the robotic series was 26.5?mm compared with 42.5?mm in the endoscopic group. The mean total operative time was 211?min for the robotic series compared with 160?min for the endoscopic series. There was one temporary recurrent laryngeal nerve paralysis in the robotic group. Two patients in the robotic group exhibited transient symptomatic hypocalcemia compared with one patient in the endoscopic group. Hypoesthesia in the flap dissection area was experienced by three patients in the robotic group and two patients of the endoscopic group. The mean hospital stay was 1.5?days (range 1–3?days) in both groups. The postoperative VAPS also was similar in the two groups (3.1 vs 2.8). The cost was significantly less for the endoscopic approach.

Conclusions

The preliminary comparison in this study shows that both approaches are safe and feasible, with similar results. They also afford an excellent view of the critical neck anatomy that allows precise tissue handling and dissection. However, the endoscopic approach results in a significantly faster and more convenient thyroidectomy.     

Robotic versus laparoscopic liver resection: a comparative study from a single center

Purpose

The significant advantages of robotic surgery have expanded the scope of surgical procedures that can be performed through minimally invasive techniques. The aim of this study was to compare the perioperative outcomes between robotic and laparoscopic liver surgeries at a single center.

Methods

From July 2007 to October 2011, a total of 206 patients underwent laparoscopic or robotic liver surgery at the Asan Medical Center, Seoul, Korea. We compared the surgical outcomes between robotic liver surgery and laparoscopic liver surgery during the same period. Only patients who underwent left hemihepatectomy or left lateral sectionectomy were included in this study.

Results

The robotic group consisted of 13 patients who underwent robotic liver resection including 10 left lateral sectionectomies and three left hemihepatectomies. The laparoscopic group consisted of 17 patients who underwent laparoscopic liver resection during the same period including six left lateral sectionectomies and 11 left hemihepatectomies. The groups were similar with regard to age, gender, tumor type, and tumor size. There were no significant differences in perioperative outcome such as operative time, intraoperative blood loss, postoperative liver function tests, complication rate, and hospital stay between robotic liver resection and laparoscopic liver resection. However, the medical cost was higher in the robotic group.

Conclusions

Robotic liver resection is a safe and feasible option for liver resection in experienced hands. The authors suggest that since the robotic surgical system provides sophisticated advantages, the retrenchment of medical cost for the robotic system in addition to refining its liver transection tool may substantially increase its application in clinical practice in the near future.     

Robotic retroperitoneal partial nephrectomy

Purpose of review

Robotic-assisted renal surgery is being increasingly utilized; however, the majority of these are performed via a transperitoneal approach. Retroperitoneal robotic surgery is a relatively new technique allowing direct access to the posterolateral surface of the kidney, as well as posterior hilar structures. In this review, we summarize the most recent publications and review our experience of robotic retroperitoneal partial nephrectomy.

Recent findings

The retroperitoneal approach has been successfully applied to robotic partial nephrectomy. The current series find this approach ideal for posterior and lateral renal masses, and technically feasible with the advances in robotic technology. The retroperitoneal approach has been shown to decrease operative times, narcotic need, and permit quicker return of bowel function. Furthermore, there does not appear to be any increase in perioperative complications using this approach. Since 2006, we have treated 68 patients using this approach. The mean age was 58.9 years, and mean preoperative tumor size 2.5 cm (range 1–5 cm). Mean operative and warm ischemia time were 125 min and 20.7 min, respectively. The majority of patients had renal cell carcinoma, with a 4.4 % positive margin rate. The most common complication was an arterial pseudoaneurysm in 3 (4.4 %) patients.

Summary

The limited data using this technique offer an encouraging outlook on robotic retroperitoneal partial nephrectomy. The retroperitoneal approach permits direct access to the renal hilum, no need for bowel mobilization, and excellent visualization for posteriorly located renal masses.     

Robotic Left Pancreatectomy for Pancreatic Solid Pseudopapillary Tumor

Background

Solid pseudopapillary pancreatic tumors of pancreas are a rare entity, seen most often in females in their second or third decades. Although previously believed to be benign, this tumor is currently considered a low-grade malignant epithelial neoplasm with low metastatic rate and high overall survival.1,2 Its resection could be performed by robotic technique with respect to oncological principles to avoid tumor cell dissemination.3

Methods

In this multimedia article, we present a 28-year-old female with a history of hyperthyroidism who underwent a computed tomography (CT) scan because of a persistent high C-reactive protein level following caesarean section. This CT scan revealed a 7-cm cystic lesion of the pancreatic tail. The serum tumor marker CA 19-9 was normal. Further investigation with an magnetic resonance imaging (MRI) scan showed that the lesion was macrocystic with internal septas compatible with a solid pseudopapillary neoplasm.4 The patient was treated with robotic distal splenopanceatectomy (video).

Results

The operative time was 5 h with an estimated blood loss of 250 mL. No blood transfusion was necessary. The postoperative period was uneventful, and she was discharged on postoperative day 8. The histological finding revealed a solid pseudopapillary tumor of the pancreas pT2pN0 (0/14 lymph nodes removed). There was no evidence of clinical, biological, and radiological pancreatic fistula, and a control CT scan on postoperative day 8 did not show any abdominal fluid collection. The patient’s 1 month follow-up was normal.

Discussion

The robotic distal splenopancreatectomy is a procedure that offers some technical and oncological advantages over the already described minimally invasive techniques for distal pancreatic tumors.5,6 These advantages are mainly due to the stability of the operative field, to the 3D and magnified vision, and to the articulated robotic arms.7–9 The 3D representation and the stability of the operative field facilitate the performance of operative steps, as the creation of the retropancreatic tunnel and vascular identification. Moreover, the robotic articulated arms permit a superior handling of vascular structures, allowing a fine dissection that is extremely useful during lymphadenectomy. Articulated instruments easily achieve the correct rotation axis, thus minimizing peri-pancreatic tissue retraction and manipulation of the pancreatic gland. This smooth and no-touch technique in theory minimizes the risk of pancreatic capsule rupture as well as tumor cell dissemination, respecting oncological surgical standards. However, robotic surgery needs an adequate learning curve, especially concerning the installation and the lack of force feedback.

Conclusion

The robotic distal pancreatectomy is a possible minimally invasive technique for patients with solid pseudopapillary pancreatic tumors. It presents some advantages over the laparoscopic approach. Nevertheless its oncological indications are yet to be defined.10     

Long-term results of a nationwide general ultrasound screening system for developmental disorders of the hip: the Austrian hip screening program

Background

Diagnosis and early treatment of developmental dysplasia of the hip (DDH) continue to be issues of discussion. In 1992, a nationwide general ultrasound screening program using Graf technique was introduced to detect DDH in Austria. We investigated the effects of this program on the rates of operative and conservative interventions and the influence of the program on the number of hospital admissions for the treatment of DDH.

Methods

All cases of DDH documented in Austrian hospitals from 1992 to 2008 were included in this retrospective study. The database of the Austrian Ministry of Health was used to extract documented diagnoses and treatments.

Results

Since the introduction of the screening program, the number of patients who require pelvic surgery to treat DDH has decreased by 46 % and the number of open reductions is as low as 0.16 per 1,000 live births. Hospital admissions for the treatment of DDH decreased from 9.5 to 3.6 per 1,000 live births. All noted results gained statistical significance.

Conclusion

Compared with routine clinically based screening programs, our results confirm low numbers of open reductions and pelvic surgeries. We, therefore, advocate a standardized nationwide general ultrasound screening program to reduce the rates of operative interventions and hospital admissions associated with the treatment of DDH.

Level of evidence

Level III, diagnostic     

Clinical Application of Image-Enhanced Minimally Invasive Robotic Surgery for Gastric Cancer: A Prospective Observational Study

Background

This study was performed to validate the feasibility and role of image-guided robotic surgery using preoperative computed tomography (CT) images for the treatment of gastric cancer.

Methods

Twelve patients scheduled to undergo robotic gastrectomy for gastric cancer were registered. Vessels encountered during gastrectomy were reconstructed using 3D software and their anatomical variation was evaluated using preoperatively performed CT-angiography. The vascular information was transferred to a robot console using a multi-input display mode. Radiologic findings acquired from preoperative CT by the radiologist were compared with intraoperative findings of the surgeon. This study is registered with www.clinicaltrials.gov as NCT01338948.

Results

All 12 robotic gastrectomies were performed without any problems. All anatomical data acquired using 3D software were transferred successfully during surgery. Intraoperative vascular images depicted vasculatures around the stomach and could identify important vascular variations. During surgery, relevant vascular information led the surgeon to branch sites and facilitated lymphadenectomy around the vessels. Image-guidance during the operation provided a vascular map and enabled the surgeon to avoid accidental bleeding and damage to other organs by preventing vascular injuries.

Conclusion

Image-guided robotic surgery for gastric cancer using preoperative CT-angiography reconstructed during operation by a surgically trained radiologist who could adjust the images by anticipating the operative procedure was feasible and improved the efficiency of surgery by eliminating the possibility of vascular injuries.     

Robotic single-site hysterectomy: feasibility, learning curve and surgical outcome

Background

The field of laparoscopy has undergone several changes to improve the morbidity and cosmesis of laparoscopic surgery. The robotic single-site surgery is the inevitable hybridization of robotic technology with laparoendoscopic single-site surgery.

Methods

Perioperative information of 12 robotic single-site hysterectomies (R-SSH) were collected to evaluate the surgical feasibility and the possible influence of the body mass index (BMI) and the uterine weight on operative times.

Results

The mean operative time was 85 ± 33 min (range, 355 to 149 min), the mean docking time was 9 ± 3 min, and the mean console time was 76 ± 33 min. The mean blood loss was 80 ± 18 mL, and the median weight of resected uteri was 220 ± 45 g. No serious postoperative complications occurred. The CUSUM learning curve was observed to consist of two different phases: phase 1 (the initial 6 cases) and phase 2 (the last 6 cases) with significant reduction in operative and console time observed between the two phases. For BMI, no correlation was found with operative times, console times, and docking times, and no correlation was found between uterine weight and operative time.

Conclusions

This series, identifying two different phases of the learning curve and suggesting that the initial learning phase for the procedure can be achieved after six cases, confirms the feasibility and safety of a robotic approach for single-site hysterectomy. However, the limits of this study mainly rely on the limited casuistic and short follow-up, although the preliminary results appear promising. Larger series and prospective studies comparing R-SSH hysterectomy with standard robotic multiport hysterectomy are necessary to define properly the role of this innovative surgical technique.     

Robotic-Assisted Minimally Invasive Central Pancreatectomy: Technique and Outcomes

Background

Central pancreatectomy is a definitive treatment for low-grade tumors of the pancreatic neck that preserves pancreatic and splenic function at the potential expense of postoperative pancreatic fistula. We analyzed outcomes after robot-assisted central pancreatectomy (RACP) to reexamine the risk–benefit profile in the era of minimally invasive surgery.

Methods

Retrospective analysis of nine RACP performed between August 2009 through June 2010 at a single institution.

Results

The average age of the cohort was 64 (range 18–75 years) with six women (67 %). Indications for surgery included: five benign cystic neoplasm and four pancreatic neuroendocrine tumor. Median operative time was 425 min (range 305–506 min) with 190 ml median blood loss (range 50–350 ml) and one conversion to open due to poor visualization. Median tumor size was 3.0 cm (range 1.9–6.0 cm); all patients achieved R0 status. Pancreaticogastrostomy was performed in seven cases and pancreaticojejunostomy in two. The median length of hospital stay was 10 days (range 7–19). Two clinically significant pancreatic fistulae occurred with one requiring percutaneous drainage. No patients exhibited worsening diabetes or exocrine insufficiency at the 30-day postoperative visit.

Conclusions

RACP can be performed with safety and oncologic outcomes equivalent to published open series. Although the rate of pancreatic fistula was high, only 22 % had clinically significant events, and none developed worsening pancreatic endocrine or exocrine dysfunction.