Alberto Bartoli

Robot-assisted laparoscopic total and partial gastric resection with D2 lymph node dissection for adenocarcinoma

BackgroundLymph node dissection and esophageal anastomosis, considered the more demanding steps of laparoscopic gastrectomy for gastric adenocarcinoma, can be performed with the use of a remote-controlled robot.MethodsThirteen patients with a histologically proved gastric cancer (six stage I, six stage II, and one stage III) were enrolled in a prospective study to assess feasibility and safety of the Da Vinci surgical system in total and partial gastrectomy with extended lymph node dissection. Outcome measures were conversion rate, intra- and postoperative morbidity and mortality, operative time, blood loss, number of lymph nodes harvested, and macroscopic and microscopic evaluation of resection margins.ResultsEight distal, four total, and one proximal laparoscopic gastrectomies were completed without conversion. Extended lymph node dissection, and esophagojejunal and esophagogastric anastomoses were successfully carried out using the da Vinci System. Mean operative time was 286xa0±xa032.6xa0min and blood loss was 103xa0±xa087.5xa0ml. Mean number of nodes retrieved was 28.1xa0±xa08.3 and all resection margins were negative. There was no mortality. Trocar bleeding requiring laparoscopy was the only major complication encountered. No recurrence occurred during a mean follow-up time of 12.2xa0±xa04.5xa0months.ConclusionsRobot-assisted laparoscopic lymph node dissection and esophageal anastomosis are feasible and safe. Longer follow-up time and randomized studies are needed to evaluate long-term outcome and clinical advantages of this new technology.

Robot-assisted parenchymal-sparing liver surgery including lesions located in the posterosuperior segments

ObjectiveThe aim of the study is to describe techniques of robot-assisted parenchymal-sparing liver surgery.BackgroundLaparoscopy provides the same oncologic outcomes as open liver resection and better early outcome. Limitations of laparoscopy remain resections in posterior and superior liver segments, frequently approached with laparoscopic right hepatectomy, bleeding from the section line, and prolonged operative times when a combined procedure is needed.MethodsWe retrospectively analyzed our series of robot-assisted liver resections between 2008 and September 2010 to evaluate whether robot assistance can overcome the limitations of laparoscopy.ResultsA total of 23 patients underwent robot-assisted liver resection for a total of 21 subsegmentectomies, 6 segmentectomies, 2 segmentectomies S6xa0+xa0subsegmentectomies S7, 1 bisegmentectomy S2–3, and 2 pericystectomies. In ten cases (47.8%) liver nodules were located in the posterior and superior liver segments. In three cases the tumor was in contact with a main portal branch and in two cases with a hepatic vein. In one case the tumor had contact with both hepatic vein and portal branch. In the latter cases a no-margin resection was carried out. In 16 cases (65.5%) liver resection was associated with a concomitant procedure (10 laparoscopic colectomies, 1 robotic rectal resection, 3 laparoscopic radiofrequency ablations, and 2 extensive adhesiolyses). Mean operative time was 280xa0±xa0101xa0min, blood loss was 245xa0±xa0254xa0ml, and mean hospital stay was 8.9xa0±xa09.4xa0days. Mortality was nil. One case of biliary leakage and two of intraoperative hemorrhage requiring transfusion were the main complications encountered.ConclusionsRobot assistance allows optimal access to all liver segments and facilitates parenchymal-sparing surgery also for lesions located in the posterosuperior segments or in contact with main liver vessels.

Laparoscopic and robot-assisted one-stage resection of colorectal cancer with synchronous liver metastases: a pilot study

BACKGROUND/PURPOSEnOne-stage resection of primary colon cancer and synchronous liver metastases is considered an effective strategy of cure. A laparoscopic approach may represent a safe and advantageous choice for selected patients with the aim of improving the early outcome.nnnMETHODSnBetween January 2008 and October 2008, 7 patients underwent one-stage laparoscopic resection for primary colorectal cancer combined with laparoscopic or robot-assisted liver resection.nnnRESULTSnA total of five laparoscopic left-colon, one right-colon, and one rectal resections were performed. Three patients underwent preoperative left-colon stenting and two received neoadjuvant chemotherapy. The patient with rectal cancer underwent neoadjuvant radiotherapy. Liver procedures included one bisegmentectomy (segments 2, 3), 3 segmentectomies, 6 metastasectomies, and four laparoscopic ultrasound-guided radiofrequency ablations (LUG-RFAs). One patient with multiple liver metastases was managed by a two-stage hepatectomy partially conducted by a totally laparoscopic approach. The overall postoperative morbidity was null. The median hospital stay was 10 days (range 7-10 days).nnnCONCLUSIONSnThis pilot study suggests that laparoscopic one-stage colon and liver resection is feasible and safe. Robot assistance may facilitate liver resection, increasing the number of patients who may benefit from a minimally invasive operation.

Comparing fibrin sealant with staples for mesh fixation in laparoscopic transabdominal hernia repair: a case control-study

BackgroundLaparoscopic hernia repair is not as popular as cholecystectomy. We have performed more than 3,000 laparoscopic herniorrhaphies using the trans-abdominal (TAPP) technique. To prevent recurrences we fix the polypropylene mesh with staples. The use of fibrin glue for graft fixation is a possible alternative.MethodsWe have performed 3,130 laparoscopic hernia repairs over 14 years. For mesh fixation we used titanium clips and observed a small number of complications. In July 2003 we started using fibrin glue (Tissucol®). The purpose of this retrospective longitudinal study was to evaluate if the use of fibrin sealant was as safe and effective as conventional stapling and if there were differences in post-operative pain, complications and recurrences.ResultsFrom July 2003 to June 2006 we performed 823 laparoscopic herniorrhaphies. Fibrin glue (Tissucol®) was used in 88 cases. Two homogeneous groups of 68 patients (83 cases) treated with fibrin glue and 68 patients (87 cases) where the mesh was fixed with staples, were compared. Patients with relevant associated diseases or large inguino-scrotal hernias were excluded. Operative times were longer in the group treated with fibrin glue with a mean of 35 minutes (range 22–65 mins) compared to the group treated with staples (25 minutes, range 14–50 mins). The time of hospital stay was the same (24 hours). Post-operative complications, that were more frequent in the stapled group, included trocar site pain, hematomas, intra-operative bleedings and incisional hernias. No significant difference was observed concerning seromas, chronic pain and recurrence rate.ConclusionsLess post-operative pain, and a faster return to usual activities are the main advantages of laparoscopic repair compared to the traditional approach. The use of fibrin sealant reduces in our experience the risk of post- and intra-operative complications such as bleeding and incisional hernia; recurrence rates are similar, but the operative time is longer.

A Modified Umbilical Incision for Specimen Extraction After Laparoscopic Abdominal Surgery

BackgroundOne advantage of laparoscopic surgery over open surgery is the absence of laparotomic incisions. This advantage is reduced when an auxiliary incision is performed to remove surgical specimens larger than the trocar.MethodsA special incision was performed at umbilical trocar level that enabled removal of a large surgical specimen as in right hemicolectomy (colic), gastric resection, and splenic surgery.ResultsThe authors have used this method routinely for 10 years for all cases requiring removal of a surgical specimen too large for the normal incision of a 10-mm trocar.ConclusionThe authors maintain that this method avoids the use of auxiliary incisions, which undo the many benefits of laparoscopic surgery.

Robot-assisted laparoscopic management of cardia carcinoma according to Siewert recommendations.

Resection of cardia and upper gastric carcinoma is considered a demanding procedure in laparoscopic surgery. Robotics could aid laparoscopic dissection of the oesophago–gastric junction and oesophageal anastomosis, enlarging indications for a minimally invasive approach to these tumours.

Extracorporeal Pringle maneuver in robot-assisted liver surgery.

Hemorrhage is a major complication in laparoscopic liver surgery and inflow occlusion methods are difficult to be reproduced in this setting. This study investigated 10 consecutive patients who underwent robot-assisted liver resection. An extracorporeal Pringle maneuver was carried out encircling the hepato-duodenal ligament using an endowristed robotic arm and exteriorizing the tourniquet at the epigastrium allowing the on-table surgeon to independently control intermittent clamping. The extracorporeal Pringle maneuver was effective and without complications for all patients. The assistant was able to apply consecutive clampings whereas the console surgeon proceeded in parenchyma transection. Robot-assisted liver surgery can be made safer by the use of the extracorporeal Pringle maneuver.

Robot-Assisted Versus Open Liver Resection in the Right Posterior Section

Background: Open liver resection is the current standard of care for lesions in the right posterior liver section. The objective of this study was to determine the safety of robot-assisted liver resection for lesions located in segments 6 and 7 in comparison with open surgery. Methods: Demographics, comorbidities, clinicopathologic characteristics, surgical treatments, and outcomes from patients who underwent open and robot-assisted liver resection at 2 centers for lesions in the right posterior section between January 2007 and June 2012 were reviewed. A 1:3 matched analysis was performed by individually matching patients in the robotic cohort to patients in the open cohort on the basis of demographics, comorbidities, performance status, tumor stage, and location. Results: Matched patients undergoing robotic and open liver resections displayed no significant differences in postoperative outcomes as measured by blood loss, transfusion rate, hospital stay, overall complication rate (15.8% vs 13%), R0 negative margin rate, and mortality. Patients undergoing robotic liver surgery had significantly longer operative time (mean, 303 vs 233 minutes) and inflow occlusion time (mean, 75 vs 29 minutes) compared with their open counterparts. Conclusions: Robotic and open liver resections in the right posterior section display similar safety and feasibility.

Laparoscopic resection with intracorporeal anastomosis for colon carcinoma located in the splenic flexure

BackgroundTreatment of splenic flexure (SF) colon cancer is not standardized. A laparoscopic approach is considered a challenging procedure.MethodsThis review examines a single-institution experience with laparoscopic colon resection for cancer of the SF. Intraoperative, pathologic, and postoperative data of patients who underwent laparoscopic SF resection were reviewed to assess for oncologic safety as well as early- and medium-term outcomes.ResultsBetween September 2004 and January 2009, laparoscopic SF resection was performed for 15 patients with SF. Two cases of conversion were reported, and for three patients, colonic resection was robot assisted. In all cases, the anastomosis was completed intracorporeally. The distal margin was 3.8xa0±xa02.5xa0cm, and the proximal margin was 7.8xa0±xa03.7xa0cm from the tumor site. The mean number of harvested nodes was 9.2xa0±xa05.3. The mean operative time was 183.6xa0±xa045xa0min, and the blood loss was 98xa0±xa033xa0ml. No major morbidity was recorded.ConclusionsLaparoscopic partial resection seems to be feasible and safe for the treatment of early-stage and locally advanced SF cancer.

Non-cirrhotic liver tolerance to intermittent inflow occlusion during laparoscopic liver resection

While inflow occlusion techniques are accepted methods to reduce bleeding during open liver surgery, their use in laparoscopic liver resections are limited by possible effects of pneumoperitoneum on ischemia–reperfusion liver damage. This retrospective study was designed to investigate the impact of intermittent pedicle clamping (IPC) on patients with normal liver undergoing minor laparoscopic liver resections. Three matched groups of patients were retrospectively selected from our in-house database: 11 patients who underwent robot-assisted liver resection with IPC, and 16 and 11 patients who underwent robot-assisted liver resection without IPC and open liver resection with IPC, respectively. The primary end point was to assess differences in postoperative serum alanine, aspartate aminotransferase (ALT and AST) and bilirubin levels. The curves of serum AST, ALT and bilirubin levels in a span of time of five postoperative days were not significantly different between the three groups. IPC has no relevant effects on ischemia–reperfusion liver damage even in the presence of pneumoperitoneum.