Gregorio Di Franco

Use of the new da Vinci Xi® during robotic rectal resection for cancer: a pilot matched-case comparison with the da Vinci Si®

The aim of this study was to compare the short‐term outcomes of robotic rectal resection with total mesorectal excision (TME) for rectal cancer, with the use of the new da Vinci Xi® (Xi‐RobTME group) and the da Vinci Si® (Si‐RobTME group).

Use of the new Da Vinci Xi® during robotic rectal resection for cancer: technical considerations and early experience

Dear Editor: Robotic rectal resection with the Da Vinci Si System (Intuitive Surgical, Sunnyvale, CA, USA) is a well-defined approach to rectal cancer. The tremor filter, three-dimensional vision, and wrist-like movements facilitate the preparation of autonomic nerves in a narrow space such as the pelvis. These technical advantages translate into clinical and surgical benefits as suggested by a reduced conversion rate, a shorter learning curve, and good functional outcomes compared with the same parameters applied to standard laparoscopy. Nevertheless, there are still several limitations in robotic rectal surgery, such as the reduced skill to perform a multi-quadrant operation, which could result in difficulty performing a complete splenic flexure mobilization. Additionally, a fixed position of the patient after docking limits the possibility to change it during the procedure. These characteristics may require multiple undocking and re-docking, repositioning the entire platform, or use of conventional laparoscopy. Recently, Intuitive Surgical marketed a new product called Da Vinci Xi®, which is expected to overcome some of the limitations of the previous platform, thereby increasing the acceptance of its use for minimally invasive techniques in all surgical fields. Whereas increasingly more studies are being published about the use of the Da Vinci Si® System for robot-assisted proctectomy to treat rectal cancer, the Da Vinci Xi® is still in its infancy. Hence, correct standardization is required for all surgical procedures but explicitly for rectal resection. Rectal cancer surgery could be a valid benchmark for testing the new robotic platform because of its multi-quadrant approach for splenic and left colon mobilization and the need to deal with the risks of external collision and problems related to rectal transection down the pelvis. Additionally, the technique for full robotic rectal resection with total mesorectal excision (TME) using the new Da Vinci Xi® is not yet well defined. Particularly, patient and port positions have not yet been standardized. We describe our successful experience with robot, patient, and trocar positioning that allowed us to perform ten consecutive full robotic rectal resections for a low-lying cancer using Da Vinci Xi® between January and May 2015. For the first phase of the procedure (left colon mobilization, ligation of the inferior mesenteric vessels, and complete mobilization of the splenic flexure), the patients were placed in a modified lithotomy position, with 30° Trendelenberg, and tilted to the right side. After establishing the pneumoperitoneum at 12 mmHg, the first 8-mm robotic trocar was placed in the umbilical region along the right pararectal line. More trocars were then placed following the Universal Port Placement Guidelines provided by Intuitive Surgical for Bleft lower^ abdominal procedures. Four trocars were then inserted under visualization: an 8-mm port in the right iliac fossa, a 12-mm assistant trocar in the right flank, and two 8-mm robotic ports in the periumbilical region and the left hypochondriac space, respectively. A modified version of the Universal Port Placement Guidelines for Bleft lower^ abdominal procedures^ was the same as just described but translating all the trocars of 2–5 cm to the right side. BPatient-left^ was the selected approach, and the surgical cart was driven to position the * Gregorio Di Franco gregoriodifranco@yahoo.it

Da Vinci single site© surgical platform in clinical practice: a systematic review.

The Da Vinci single‐site© surgical platform (DVSSP) is a set of single‐site instruments and accessories specifically dedicated to robot‐assisted single‐site surgery.

Sexual and urinary functions after robot-assisted versus pure laparoscopic total mesorectal excision for rectal cancer

Dear Editor: Laparoscopic total mesorectal excision (LapTME) is a validated surgical technique for the treatment of rectal cancer, but the surgery is still challenging and therefore functional outcomes are uncertain. Thanks to a 3-D view, better view of the pelvic structures, and articulated instruments, robotic rectal surgery allows for finer dissection and nerve-sparing during total mesorectal excision; thus it is supposed to better preserve urinary and sexual functions versus open and laparoscopic surgery as described in some literature. The aim of this study is to compare pre-operative and post-operative autonomic function after LapTME versus robotic TME (RobTME) for mid to low rectal cancer, in a single surgeon experience. For this purpose we compared the outcomes of the first 30 RobTME, with those of the first 30 Lap TME performed by a single surgeon between January 2009 and July 2013 at our institution. The impact of surgery on autonomic function was assessed with validated questionnaires. For sexual dysfunction, the International Index of Erectile Function (IIEF) questionnaire for males and the Female Sexual Function Index (FSFI) for females were used. For evaluation of urinary dysfunction, the International Consultation on IncontinenceMale/Female Lower Urinary Tract Symptoms (ICIQ-MLUTS, ICIQ-FLUTS) questionnaires were used. The questionnaires submitted to patients pre-operatively and at months 1, 6, and 12 postoperatively. Data were analyzed with Statistical Production and Service Solution (SPSS for Windows, SPSS Inc., Chicago, IL, USA). Of the 30 LapTME, 26 were anterior rectal resections (ARR), 2 intersphincteric resection (ISR), and 2 abdominoperineal resection (APR), while of the 30 RobTME, 20 were ARR, 6 ISR, and 4 APR. A temporary diverting ileostomy was fashioned in 26 cases of LapTME group and in 25 of the RobTME group. With regard to the urinary function, males presented with a significant worsening of voiding symptoms 1 month after surgery in both groups (p<0.05). Urinary retention after catheter removal was observed in two patients in each group. Incontinence worsened 1 month after surgery in both groups (p<0.05). Nevertheless, a gradual improvement in incontinence was observed at 6 months, and at 1 year after surgery, the grade of incontinence was not statistically different when compared with the pre-operative status (p=ns). The analyses of urinary function in female patients showed no difference between the pre-operative and post-operative scores concerning voiding and filling symptoms, in both groups (p=ns). Conversely, there was a significant increase of incontinence in females in the LapTME group 1 and 6 months after surgery (p<0.05 for each pair-wise comparison). Incontinence worsened also in the RobTME group after surgery, but there was a difference not statistically significant with the pre-operative score at 6 months (p=ns). A gradual improvement in incontinence was observed in both groups with no difference at 1 year when compared with the pre-operative status (p=ns). With regard to the impact of urinary symptoms on quality of life (QoL), patients experienced a worsening of QoL in the first month after surgery in both groups (p<0.05). However, with improvement of urinary symptoms 1 year after * Gregorio Di Franco gregoriodifranco@yahoo.it

Use of a new integrated table motion for the da Vinci Xi in colorectal surgery

Dear Editor: Integrated Table Motion (ITM) for the da Vinci Xi surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA) is a new feature comprising a unique operating table by Trumpf Medical Systems that communicates wirelessly with the da Vinci Xi. The ITM feature allows surgical staff to reposition the patient without undocking the robot and without removing instruments from inside the abdomen. The da Vinci Xi surgical system and the TruSystem 7000dV operating table (TS7000dV, TRUMPF Medizin Systeme GmbH & Co. KG, Saalfeld, Germany) have been specifically developed to address some technical limitations of the da Vinci Si surgical system, and to improve multiquadrant robotic surgery. An important drawback during robotic procedures with the previous da Vinci Si system is the inability to move the table position with the robotic arms docked. This problem may be particularly amplified in multiquadrant operations, such as colorectal surgery, in which the patient and the robot itself need to be rearranged several times to optimally achieve different surgical targets or provide patient relief. Herein, we present the first study on human use of this device in colorectal surgery. The purpose of this study was to evaluate the efficacy, feasibility, and safety of ITM for the da Vinci Xi system in performing robotic colorectal resections. Between May and October 2015, the first human use of ITMwas carried out in a post-market study in the EU in which 40 cases from different specialties (general surgery, urology, or gynecology) were prospectively enrolled. The Ethics Committee of our institution approved this study. Patients who planned to undergo minimally invasive surgery within the specialties of general surgery, urology, or gynecology with the commercially available da Vinci Xi surgical system and who were eligible based on the inclusion and exclusion criteria of this study were offered enrolment. Study-specific informed consent was obtained in writing from each patient before any procedure specific to the clinical investigation was performed. Inclusion criteria were as follows: bodymass index ≤45 kg/ m; age 18 years or older; suitable for minimally invasive surgery; undergoing a surgical procedure in urology, gynecology, or general surgery; ability to tolerate the Trendelenburg position; willingness to participate as demonstrated by giving written informed consent. Exclusion criteria were as follows: American Society of Anesthesiologists (ASA) IV patients; pregnancy; lack of cooperation due to psychological or severe systemic illness; comorbid medical conditions contraindicating general anesthesia or standard surgical approaches; vulnerable population (such as prisoners, mentally disabled); anatomy unsuitable for endoscopic visualization or minimally invasive surgery; extensive previous abdominal surgery; patient not Study supported by the ARPA foundation, www.fondazionearpa.it

Full Robotic Colorectal Resections for Cancer Combined With Other Major Surgical Procedures: Early Experience With the da Vinci Xi

Background. The da Vinci Xi has been developed to overcome some of the limitations of the previous platform, thereby increasing the acceptance of its use in robotic multiorgan surgery. Methods. Between January 2015 and October 2015, 10 patients with synchronous tumors of the colorectum and others abdominal organs underwent robotic combined resections with the da Vinci Xi. Trocar positions respected the Universal Port Placement Guidelines provided by Intuitive Surgical for “left lower quadrant,” with trocars centered on the umbilical area, or shifted 2 to 3 cm to the right or to the left, depending on the type of combined surgical procedure. Results. All procedures were completed with the full robotic technique. Simultaneous procedures in same quadrant or left quadrant and pelvis, or left/right and upper, were performed with a single docking/single targeting approach; in cases of left/right quadrant or right quadrant/pelvis, we performed a dual-targeting operation. No external collisions or problems related to trocar positions were noted. No patient experienced postoperative surgical complications and the mean hospital stay was 6 days. Conclusions. The high success rate of full robotic colorectal resection combined with other surgical interventions for synchronous tumors, suggest the efficacy of the da Vinci Xi in this setting.

Short-term clinical outcomes of robot-assisted intersphincteric resection and low rectal resection with double-stapling technique for cancer: a case-matched study

Dear Editor: Survival for patients with rectal cancer has been improving with the development of surgical techniques and combined neo-adjuvant therapies. Traditionally, low rectal cancer located less than 5 cm from the anal verge required abdominoperineal resection (APR) with permanent colostomy. The advent of mechanical low-stapling, double-stapling techniques have made low anterior resection (AR) the procedure of choice for the majority of patients with low rectal cancer increasing the frequency of sphincter salvage. However, in some patients, a narrow pelvis and very low tumor site pose limitations to the use of stapled colorectal anastomosis. For such patients, intersphincteric resection (ISR) with coloanal anastomosis as employed by Schiessel in 1994may be an acceptable alternative. ISRmay also be done laparoscopically; however, it was historically associated with a higher functional complication rate than the Knight Griffen technique. The Da Vinci Si HD Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) can render an operation more like an open surgery with all the benefits of laparoscopy, expanding the range of feasibility of minimally invasive surgery. However, the use of robotic-assisted surgery for ISR has been reported in few centers and some surgeons question the value of robotic assistance to treat patients with low rectal cancer and allows to manage this type of procedures with good functional results. Herein, we present our experience with robotic-assisted ISR with total mesorectal excision (R-ISR-TME) and provide a case control comparison with robotic TME, using the double-stapling technique (R-DS-TME) for low rectal cancer with specific attention to functional and short-term oncologic outcomes. Between April 2010 and December 2014, 52 patients with histologically proven rectal cancer underwent robot-assisted rectal resection with TME at our General Surgery Unit, including 15 R-ISR-TME (eight males and seven females, mean age 70.1 years, mean body mass index 24.9 kg/m). A control group of 15 patients (eight males and seven females, mean age 69.6 years, mean bodymass index 23.1 kg/m) with low rectal tumors (<5 cm from the dentate line) undergoing R-DS-TME was selected by one-to-one case-matched methodology, where each patient undergoing R-ISR-TME was matched with a patient undergoing R-DS-TME according to the following criteria: age, gender, body mass index, American society of Anesthesiologists score, and neo-adiuvant chemo-radiotherapy. Patients with cT3 or node-positive disease (five in each groups) received preoperative chemoradiotherapy (capecitabine 825 mg bid plus 50.4 Gy in 28 fractions). The operation was performed 6–8 weeks after the end of the radiation. Exclusion criteria for robotic surgery were preoperative diagnosis of locally advanced malignancy, history of major lower abdominal surgery, and contraindications to anesthesia. Analyzed variables included overall operative time (from creation of pneumoperitoneum to application of dressing), blood loss, length of hospital stay, postoperative complications, number of harvested lymph nodes, margin status, and functional results. Patients received a physical exam and blood tests 1 and 2 weeks and 1 month after discharge. Just before ileostomy The study was supported by ARPA foundation, www.fondazionearpa.it/.

Robotic Colorectal Resection With and Without the Use of the New Da Vinci Table Motion: A Case-Matched Study

Background. The da Vinci Table Motion (dVTM) is a new device that enables patients to be repositioned with instruments in place within the abdomen, and without undocking the robot. The present study was designed to compare operative and short-term outcomes of patients undergoing colorectal cancer surgery with the da Vinci Xi system, with or without use of the dVTM. Methods. Ten patients underwent robotic colorectal resection for cancer with the use of dVTM (Xi-dVTM group) between May 2015 and October 2015 at our center. The intraoperative and short-term clinical outcome were compared, using a case-control methodology (propensity scores approach to create 1:2 matched pairs), with a similar group of patients who underwent robotic colorectal surgery for cancer without the use of the dVTM device (Xi-only group). Results. Overall robotic operative time was shorter in the Xi-dVTM group (P = .04). Operations were executed fully robotic in all Xi-dVTM cases, while 2 cases of the Xi-only group required conversion to open surgery because of bulky tumors and difficult exposure. Postoperative medical complications were higher in the Xi-only group (P = .024). Conclusions. In this preliminary experience, the use of the new dVTM with the da Vinci Xi in colorectal surgery, by overcoming the limitations of the fixed positions of the patient, enhanced the workflow and resulted in improved exposure of the operative field. Further studies with a greater number of patients are needed to confirm these benefits of the dVTM-da Vinci Xi robotically assisted colorectal surgery.

Primary retroperitoneal müllerian adenocarcinoma: a case report and literature review.

Primary retroperitoneal müllerian adenocarcinoma (PRMA) is an extremely rare clinical entity. We report the case of a 54-year-old woman who presented with a mass in the right lower retroperitoneum, identified during an ultrasound exam. Computed tomography confirmed a retroperitoneal mass measuring 11 cm. The patient underwent laparotomy and the mass was completely excised. The histopathological exam revealed PRMA.

The future today: new options for surgical care

It is a great pleasure for us to introduce this special section of Updates in Surgery focused on “New technologies in surgery”. Technology has always been used in applied sciences to solve practical problems, to optimize procedures and to define operative strategies to achieve a goal. This process has always happened, but until the late 80s it moved very slowly. More recently, with the exponential growth of electronics and information technology, as well as the intuition of some great medical pioneers, technology in the biomedical field has generated very accurate and sophisticated diagnostic tools and many minimally invasive treatment options available, in addition to different and more effective ways to train people. Thus, all the aspects of surgical practice, such as planning, surgical procedures and training, have been considerably affected by technologic evolution over the years. Innovations have stimulated radical changes in the way surgical procedures are performed, from the traditional open approach to minimally invasive surgery (MIS), which has become more and more widespread thanks to the undisputed advantages such as diminished postoperative pain, decreased length of hospital stay and accelerated recovery with early return to activities of daily living. The desire to continue to improve and increase the spread of MIS, with a view to further reduce surgical trauma, has led to the development of smaller and more effective laparoscopic instruments, the evolution of single incision or natural orifice endoscopic surgeries (SILS/NOTES), and of course to the implementation of robotic-assisted surgery (RAS) as well. Today robotic surgery is widely used in general surgery, urologic surgery, and gynecologic surgery and to a lesser extent in vascular surgery, cardiac surgery, and otolaryngology. However, high costs, bulkiness and time needed to set up the equipment, joint to absence of overwhelming data that demonstrate the superiority of robotic-assisted procedures over procedures done by well-trained laparoscopic surgeons, have frequently claimed criticisms [1]. As MIS has changed the way to operate, it has introduced the need for surgeons to acquire new and different skills. Technology has then been helpful to simulation which allows for the acquisition of skills through practice in a safe environment. Trainees can acquire the fundamental motor skills such as depth perception, hand–eye coordination, and bimanual dexterity in a simulation center, allowing them to focus on operative strategy, anatomy, and judgment in the operating room. Today many models of virtual simulators for laparoscopic and robotic surgery, for endovascular and urologic procedures, and for endoscopy are available on the market and curricula for training in laparoscopic (FLS— Fundamentals of Laparoscopic Skills) and robotic (FRS— Fundamentals of Robotic Skills) surgery have been validated [2]. The importance of simulation as part of training has been recognized by the American College of Surgeons with its Accredited Education Institutes (ACS-AEI) program and the accreditation of institutes for surgical education and training. In this respect, the Italian Center, Endocas (Center for Computer-Assisted Surgery, www.endoc as.org), of the University of Pisa has been appointed this special and high honor privilege. Technology has changed diagnostic tools and the way to plan surgical procedures as well. With technology, the concept of telemedicine has emerged making it possible to obtain, in real time, an expert second opinion [3]. Technology has made it possible to use CT and MRI images to generate a virtual 3D image of the target anatomy starting from a standard medical image dataset which is useful for the planning of surgical procedures [4]. Moreover, thanks to 3D printing technology, which emerged in the mid-1980s and rapidly spread around the world, it is possible to reproduce * Luca Morelli luca.morelli@unipi.it