Fabio Sbrana

Robotic liver surgery: results for 70 resections.

BACKGROUND Robotic surgery is gaining popularity for digestive surgery; however, its use for liver surgery is reported scarcely. This article reviews a surgeons experience with the use of robotic surgery for liver resections. METHODS From March 2002 to March 2009, 70 robotic liver resections were performed at 2 different centers by a single surgeon. The surgical procedure and postoperative outcome data were reviewed retrospectively. RESULTS Malignant tumors were indications for resections in 42 (60%) patients, whereas benign tumors were indications in 28 (40%) patients. The median age was 60 years (range, 21-84) and 57% of patients were female. Major liver resections (≥ 3 liver segments) were performed in 27 (38.5%) patients. There were 4 conversions to open surgery (5.7%). The median operative time for a major resection was 313 min (range, 220-480) and 198 min (range, 90-459) for minor resection. The median blood loss was 150 mL (range, 20-1,800) for minor resection and 300 mL (range, 100-2,000) for major resection. The mortality rate was 0%, and the overall rate of complications was 21%. Major morbidity occurred in 4 patients in the major hepatectomies group (14.8%) and in 4 patients in the minor hepatectomies group (9.3%). All complications were managed conservatively and none required reoperation. CONCLUSION This preliminary experience shows that robotic surgery can be used safely for liver resections with a limited conversion rate, blood loss, and postoperative morbidity. Robotics offers a new technical option for minimally invasive liver surgery.

Long-term survival in pancreatic cancer: Pylorus-preserving versus Whipple pancreatoduodenectomy

BACKGROUND This study compared long-term survival in pancreatic or periampullary cancer treated with Whipple pancreatoduodenectomy (PD) and pylorus-preserving pancreatoduodenectomy (PPPD). METHODS Two hundred twenty-one patients with pancreatic head or periampullary cancer were treated. Prognostic variables included age, gender, type and period of operation, and tumor stage. In the ductal adenocarcinomas variables also included tumor and node status, type of lymphadenectomy, pathologic grade, and presence of microscopic residual tumor. The end point was death as a result of neoplastic recurrence. Survival curves were estimated by using the Kaplan-Meier method, and multifactorial analysis was also performed on the data from the ductal adenocarcinoma group. RESULTS The mortality rate was 8.2% in the PD group versus 7.0% in the PPPD group. Morbidity rates were 34.4% for PD and 45.8% for PPPD. Five-year survival was 9.6% in the ductal adenocarcinoma and 63.8% in the periampullary carcinoma groups. Univariate analysis failed to show statistically significant differences in survival curves between the two treatments in either patient group. Correcting for multiple variables in the ductal adenocarcinoma group did not reveal any significant differences in survival rates between the two treatments. CONCLUSIONS PPPD was as successful as classic PD in the treatment of ductal adenocarcinoma and periampullary cancer of the pancreas. Long-term survival was not influenced by the type of resection.

Robot-assisted laparoscopic extended right hepatectomy with biliary reconstruction.

Robotic surgery represents one of the most advanced developments in the field of minimally invasive surgery. In this article, we describe the case of an extended right hepatectomy with a left hepaticojejunostomy performed for radical resection of a hilar cholangiocarcinoma. This operation was performed by using the da Vinci Robotic Surgical System (Intuitive Surgical, Sunnyvale, CA). In this case, the operative time was 540 minutes, with an intraoperative blood loss of 800 mL. The postoperative course was uneventful, and the patient was discharged at postoperative day 11. This report confirms the technical feasibility and safety of robot-assisted extended hepatic resections with biliary reconstruction. Further experience and a long follow-up are required to validate this initial report.

Robotic transabdominal kidney transplantation in a morbidly obese patient.

Kidney transplantation in morbidly obese patients can be technically demanding. Furthermore, morbidly obese patients experience a high rate of wound infections and related complications, which mostly result from the longer length and extent of the incision. These complications can be avoided through minimally invasive surgery; however, conventional laparoscopic instruments are unsuitable for the safe performance of a kidney transplant in morbidly obese patients. Herein, we report the first minimally invasive, total robotic kidney transplant in a morbidly obese patient. A left, deceased donor kidney was transplanted into a 29‐year‐old woman with a body mass index (BMI) of 41 kg/m2 who had been on hemodialysis for 5 years. The operation was performed intraabdominally using the DaVinci Robotic Surgical System with 4 trocars and a 7 cm midline incision. The operative time was 223 min, and the blood loss was less than 50 cc. The kidney had immediate graft function. No perioperative complications were observed, and the patient was discharged on postoperative day 5 with normal kidney function. Minimally invasive access and robotic technology facilitated the safe performance of a successful kidney transplant in a morbidly obese patient.

Robot-assisted laparoscopic middle pancreatectomy

BACKGROUND Middle pancreatectomy has been accepted as a valid surgical alternative to more extensive standard resections for the treatment of benign central pancreatic tumors. In this article, we describe a new minimally invasive approach to this procedure, using a robot-assisted laparoscopic technique. MATERIALS AND METHODS From May 2004 to October 2005, 3 patients (2 female and 1 male), with a mean age of 52 years (range, 44-68), underwent robot-assisted laparoscopic middle pancreatectomies at the Department of General Surgery of Misericordia Hospital in Grosseto, Italy. Two of the patients had symptomatic serous cystadenomas, and 1 patient had a mucinous cystadenoma, which was discovered incidentally. The da Vinci((R)) Surgical System (Intuitive Surgical, Sunnyvale, CA) was used to perform the main steps of the intervention. All patients underwent a pancreaticogastrostomy for pancreaticoenteric reconstruction to the distal stump. RESULTS The mean operative time was 320 minutes (range, 270-380). Mean blood loss was 233 mL (range, 100-400). There were no mortalities. One patient developed a postoperative pancreatic fistula, which was managed conservatively. The postoperative hospital stay was 9 days for 2 patients and 27 days for the third patient. No endocrine or exocrine deficiencies were observed in the patients during a mean follow-up of 44 months (range, 38-48). CONCLUSIONS Robot-assisted laparoscopic middle pancreatectomy presents an interesting, less-invasive option for resection of benign tumors of the neck and proximal body of the pancreas. In benign disease, it allows for the preservation of functional pancreatic parenchyma and, subsequently, reduced operative trauma.

Robot-assisted laparoscopic repair of renal artery aneurysms

OBJECTIVE The aim of this article is to report our experience in the repair of renal artery aneurysms using robot-assisted surgery. METHODS Between December 2002 and March 2009, five women with a mean age of 63.8 years (range, 57-78 years) underwent robot-assisted laparoscopic repair of renal artery aneurysms by the same surgeon at two different institutions, the Department of General Surgery, Misericordia Hospital, Grosseto, Italy (three patients) and the Division of Minimally Invasive and Robotic Surgery at the University of Illinois, Chicago (two patients). The mean size of the lesions was 19.4 mm (range, 9-28 mm). Four of the lesions were complex aneurysms involving the renal artery bifurcation. Two patients were symptomatic and three had hypertension. In situ repair by aneurysmectomy was performed in all cases, followed by revascularization. In complex aneurysms, an autologous saphenous vein graft was used for the reconstruction. RESULTS The mean operative time was 288 minutes (range, 170-360 min) and the estimated surgical blood loss was 100 ml (range, 50-300 ml). Warm ischemia time was 10 minutes in the patient treated by aneurysmectomy, followed by direct reconstruction. The average warm ischemia time was 38.5 minutes (range, 20-60 min) for patients treated with saphenous vein graft interposition. The mean time to resume a regular diet was 1.6 days (range, 1-2 days). The mean postoperative length of hospital stay was 5.6 days (range, 3-7 days). No postoperative morbidity was noted. The mean follow-up time for the entire series was 28 months (range, 6-48 months). Color Doppler ultrasonography examination showed patency in all reconstructed vessels. One patient had stenosis of one of the reconstructed branches, which was treated with percutaneous angioplasty. CONCLUSIONS Robot-assisted laparoscopic repair of renal artery aneurysms is feasible, safe and effective. The technical advantages of the robotic system allows for microvascular reconstruction to be performed using a minimally invasive approach, even in complex cases. This approach may also allow for improved postoperative recovery and reduce the morbidity correlated with open repair of renal artery aneurysms. Although more experience and technical refinements are necessary, robot-assisted laparoscopic repair of renal artery aneurysms represents a valid alternative to open surgery.

Robot-Assisted Hybrid Laparoscopic Roux-en-Y Gastric Bypass: Surgical Technique and Early Outcomes

BACKGROUND Roux-en-Y gastric bypass performed laparoscopically remains the gold standard in bariatric surgery. The role of robot-assisted laparoscopic Roux-en-Y gastric bypass has not been clearly defined. METHODS We present 80 consecutive cases of robot-assisted laparoscopic Roux-en-Y gastric bypass performed at a single institution. Mechanics, early outcomes, and learning curve are evaluated. Eighty robot-assisted laparoscopic Roux-en-Y gastric bypasses were performed on 71 women and 9 men with a mean age of 39 years, mean preoperative weight of 134 kg, and mean BMI of 48. RESULTS Total mean operative time was 209 minutes. There was no mortality, leak, stricture, or obstruction. CONCLUSION Robot-assisted laparoscopic Roux-en-Y gastric bypass is a safe and feasible option for bariatric surgery. Its role in improving surgical outcomes needs to be defined further.

Robotic-assisted Minimally Invasive Pancreatic Resections: The Modern Way of Avoiding Blood Transfusions

console connected to a surgical arm cart, a manipulator unit with 3 arms for 2 instruments and a camera. The movements of the surgeon’s hands are transferred to the tip of the instruments via highly sensitive motion sensors. The ‘EndoWrist technology’ allows for 7 degrees of movement, thus exceeding the capacity of a surgeon’s hand in open surgery. The 10 standardized steps of the conventional thoracoscopic Thx are modified with the da Vinci robotic system. Analyses of 100 thymectomies with broad clinical and anatomic variety resulted in the development of a 3-trocar unilateral standardized technique for rThx with the da Vinci robotic system. Results: Preferably, the patient is placed in a right 30-degree antidecubitus position. The special da Vinci trocars are placed between the 2 and 5 intercostal spaces in the submammary fold. The placement of the first (camera) trocar allows for so-called thoraco-lift which together with the CO2-insufflation provides an enlargement of the entire operation field. The pericardial fatty tissue along the phrenic nerve is mobilized. The cervical compartment is opened at the cranial mediastinal pleural fold. The innominate vein is localized. Dissection of the aorto-caval groove mobilizes the right thymic portion with the surrounding tissue. For cervical dissection of the upper thymic poles the endo-wrist instruments are most important. Conclusions: The dexteritiy of tissue dissection is improved with the da Vinci system. The experience with other operation techniques for Thx helped to avoid a typical learning curve. Due to the inherent technical advantages the approach of rThx most effectively combines the requirements of minimal invasion and radical dissection for Thx.