Alessandra Marano

Application of Fluorescence in Robotic General Surgery: Review of the Literature and State of the Art

The initial use of the indocyanine green fluorescence imaging system was for sentinel lymph node biopsy in patients with breast or colorectal cancer. Since then, application of this method has received wide acceptance in various fields of surgical oncology, and it has become a valid diagnostic tool for guiding cancer treatment. It has also been employed in numerous conventional surgical procedures with much success and benefit to the patient. The advent of minimally invasive surgery brought with it a new use for fluorescence in helping to improve the safety of these procedures, particularly for single-site procedures. In 2010, a near-infrared camera was integrated into the da Vinci Si System, creating a combination of technical and minimally invasive advantages that have been embraced by several experienced surgeons. The use of fluorescence, although useful, is considered challenging. Only a few studies are currently available on the use of fluorescence in robotic general surgery, whereas many articles have focused on its application in open and laparoscopic surgery. Many of these reports describe promising and satisfactory results, although with some shortcomings. The purpose of this article is to review the current status of the use of fluorescence in general surgery and particularly its role in robotic surgery. We also review potential uses in the future.

Robotic gastrectomy: the current state of the art.

Since the first laparoscopic gastrectomy for cancer was reported in 1994, minimally invasive surgery is enjoying its wide acceptance. Numerous procedures of this approach have developed, and many patients have benefited from its effectiveness, which has been recently demonstrated for early gastric cancer. However, since laparoscopic surgery is not exempt from some limitations, the robotic surgery system was introduced as a solution by the late 1990s. Many experienced surgeons have embraced this new emerging method that provides undoubted technical and minimally invasive advantages. To date, several studies have concentrated to this new system, and have compared it with open and laparoscopic approach. Most of them have reported satisfactory results concerning the post-operative short-term outcomes, but almost all believe that the role of robotic gastrectomy is still out of focus, especially because long-term outcomes that can prove robotic oncologic equivalency are lacking, and operative costs and time are higher in comparison to the open and laparoscopic ones. This article is a review about the current status of robotic surgery for the treatment of gastric cancer, especially, focusing on the technical aspects, comparisons to other approaches and future prospects.

Evaluation of technical feasibility and safety of Single-Site™ robotic right colectomy: three case reports

Robotic Single‐Site™ surgery overcomes the technical constraints of single‐access laparoscopy. After performing over 130 Single‐Site robotic cholecystectomies and stabilizing operative times, we applied this technology to right colon surgery.

History of Robotic Surgery

The history of telerobotic surgery involves a revolutionary approach to minimally-invasive surgery. The concept of “telemanipulation” or “telepresence” emerged in the 1940s and was first used to describe the sensation that a person is in one location willIe being in another. It was driven by the need for certain complex tasks to be perfoffiled by machines in hazardous and unhealthy environment for human beings, such as the bottom of the ocean or in outer space. In Robert Heinlein’s 1942 science fiction , entitled “Waldo”, the lead character, Waldo Farthingwaite-Jones, was bom frail and unable to lift his own body weight. Heilnlein describes a glove and hamess device that allowed Waldo to control a powerful mechanical arm by simply moving his hand and fingers.

Right Colectomy with Complete Mesocolic Excision: Four-arm Technique

Minimally invasive surgery is gaining worldwide acceptance in the treatment of colonic cancer and the advantages over the traditional open approach are well known [1, 2, 3]. Unfortunately, during recent decades, the outcomes of patients after colon cancer resection have not improved to the same degree as for rectal cancer, whose treatment with total mesorectal excision (TME) is universally accepted as the standard of care. The complete mesocolic excision (CME), first reported by Hohenberger and colleagues in 2008 [4], seems to produce better long-term outcomes when compared to standard lymphadenectomy by following the same embryological-based principles introduced by Heald for rectal cancer more than 20 years ago [5]. However, well-conducted randomized studies are needed to confirm its efficacy.

Is the routine use of intraoperative cholangiography during laparoscopic cholecystectomy really the key to lowering bile duct injuries

Bile duct injuries (BDI) during laparoscopic cholecystectomy represent a very serious complication [1–5]. Berci et al. [6] have described in a detailed and critical way how the surgeon can understand the causes of this dangerous issue and prevent them by adopting some crucial dissection and intraoperative imaging strategies. Moreover, their article deals with the treatment of common bile duct stones. An aspect particularly emphasized is the low routine use of intraoperative cholangiography (IOC) to prevent BDI. Because some clear demonstrated advantages of this diagnostic method have been reported in the literature [7–10], the authors have suggested the routine performance of IOC during each laparoscopic cholecystectomy for the future. By following this standardized rule, they believe the surgeon could better prevent and detect BDI and thus improve patient care. Is the routine use of IOC during laparoscopic cholecystectomy really the key to lowering the BDI rate? To date, the role and specific value of IOC has been the subject of much debate. Beyond the supporters of its universal application, some authors go so far as to suggest that radiographic cholangiography may itself cause BDI in addition to being time consuming [11, 12]. Surgeons widely agree that IOC is the most practical method for delineating the anatomy of the biliary tree [13, 14] and that it is the best procedure for identifying BDI. The majority of surgeons follow the strategy of a selective IOC rather than its routine use, according to their own opinion. In both cases, as already mentioned in a commentary of a recent article [15], another variable can affect the fulfilment of any BDI, as described in the study by Way et al. [16]. The authors have analyzed more than 250 laparoscopic BDIs. They believe that the ‘‘human misperception’’ has a fundamental role rather than the lack of skill or knowledge because in many cases (75 %), the operator has described the surgery as routine. Moreover, 22 % of the reports did not show anything unusual. The ‘‘misperception’’ itself was the cause for the wrong interpretation of several IOCs performed for selected patients: the cholangiograms were thought to be normal, but they were not. While recognizing the importance of the IOC, the authors emphasize the need for ‘‘an even simpler method of locating the course of the ductal system during the operation, something simpler than cholangiography or ultrasonography.’’ In the wake of this statement, we strongly believe that the use of the fluorescence imaging system could be a valid solution. Our preliminary experience has shown how the preoperative intravenous injection of indocyanine green and the use of a near-infrared light during the surgery allow for a ‘‘real-time’’ fluorescent cholangiography [17]. The interpretation of images is simpler because they appear while they are in view and so can be checked with surgical maneuvers of moving structures, unlike the static information supplied by the radiographic procedure. This challenging method is easy, feasible, and able to facilitate better understanding of the bile duct anatomy. Indeed, the fluorescent dye can be injected intravenously, thereby avoiding the risk of inadvertent damage to the bile duct by direct cannulation of the cystic duct. Moreover, a fluorescent IOC can be performed for any patients without the surgeon needing to make a selection because it is not invasive and does not require additional time. G. Spinoglio (&) A. Marano Department of General and Oncologic Surgery, SS Antonio e Biagio Hospital, Via Venezia 16, 15121 Alessandria, Italy e-mail: gspinoglio@ospedale.al.it; gspinoglio@icloud.com

Robotic Surgery for Complicated Diverticulitis

The severity of complicated diverticulitis includes a broad spectrum of diseases and is classified according to the Hinchey classification system [1]: Stage I: pericolic abscess, confined to the mesentery of the colon, usually responsive to conservative management, with a radiological drainage in the case of an abscess larger than 5 cm; Stage II: distant abscess amenable to percutaneous drainage (Stage IIa) or complex and multiple abscesses with or without a digestive fistula (Stage IIb); Stage III: diffuse purulent peritonitis; Stage IV: diffuse fecal peritonitis;

Robotic Subtotal Gastrectomy: a Modified Korean Technique

The robotic approach for the treatment of gastric cancer (GC) has been initially adopted mainly in Asia, where this malignant disease is more common than in Western countries and it is diagnosed at earlier stages thanks to a screening program. Among Asian countries, South Korea started to embrace the robotic technique in 2005 and now it has become one of the leading countries in robotic gastric cancer surgery. In this chapter we present our experience of robotic subtotal gastrectomy (RSTG) with D2 lymph node (LN) dissection for GC where the step-by-step procedure is based mostly on the technique of Dr Woo Jin Hyung [1].

ICG Fluorescence: Current and Future Applications

The imaging technique based on indocyanine green (ICG) fluorescence has been widely used for more than forty years, especially to study blood flow and microcirculation. This method was first applied in general surgery to perform sentinel lymph node (SLN) biopsies in patients affected by breast and colorectal cancer. In 2010, a near-infrared (NIR) laser light system was integrated with the da Vinci® Si™ HD robotic system (Intuitive Surgical Inc., Sunnyvale, CA, USA). This imaging system is able to provide both white light and near-infrared light images through dedicated endoscopic illuminators and filters by simply pressing a pedal on the surgical console, thus allowing real-time fluorescence-guided surgery.

Single-Site™ Surgery

The Single-Site™ platform was primarily designed to work in a narrow operative field and with a specific anatomical target. To date, the most consistent published experiences are regarding the use of this technology to perform cholecystectomy [1, 2, 3, 4, 5, 6, 7, 8, 9] but, recently, it has been applied in other fields of general surgery [10, 11, 12]. This chapter will focus on its current application in performing cholecystectomy and right colectomy.