Luca Moraldi

The torsion of a wandering pelvic spleen: A case report

A 15 years old patient was taken to the operative room for an explorative laparotomy due to abdominal pain and a pelvic spleen at preoperative computed tomography: was pointed out the absence of all splenic ligamentous attachments and short gastric vessels with a consequently dislocation of a bigger and congested spleen in the pelvis. This organ, wrapped in the omentum, was in a serious ischemic suffering due to a 720 degrees clock torsion around its exceptionally long pedicle (about 20 cm); besides was confirmed pancreatic body and tail ectopy. Following the derotation, the volume of the organ has decreased but became fixed in above norm dimensions. A total splenectomy was executed.

Esophageal surgery in minimally invasive era.

The widespread popularity of new surgical technologies such as laparoscopy, thoracoscopy and robotics has led many surgeons to treat esophageal diseases with these methods. The expected benefits of minimally invasive surgery (MIS) mainly include reductions of postoperative complications, length of hospital stay, and pain and better cosmetic results. All of these benefits could potentially be of great interest when dealing with the esophagus due to the potentially severe complications that can occur after conventional surgery. Moreover, robotic platforms are expected to reduce many of the difficulties encountered during advanced laparoscopic and thoracoscopic procedures such as anastomotic reconstructions, accurate lymphadenectomies, and vascular sutures. Almost all esophageal diseases are approachable in a minimally invasive way, including diverticula, gastro-esophageal reflux disease, achalasia, perforations and cancer. Nevertheless, while the limits of MIS for benign esophageal diseases are mainly technical issues and costs, oncologic outcomes remain the cornerstone of any procedure to cure malignancies, for which the long-term results are critical. Furthermore, many of the minimally invasive esophageal operations should be compared to pharmacologic interventions and advanced pure endoscopic procedures; such a comparison requires a difficult literature analysis and leads to some confounding results of clinical trials. This review aims to examine the evidence for the use of MIS in both malignancies and more common benign disease of the esophagus, with a particular emphasis on future developments and ongoing areas of research.

Gastrointestinal robotic surgery: challenges and developments

License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. Permissions beyond the scope of the License are administered by Dove Medical Press Limited. Information on how to request permission may be found at: http://www.dovepress.com/permissions.php Robotic Surgery: Research and Reviews 2015:2 11–27 Robotic Surgery: Research and Reviews Dovepress

Ultrasound-Guided Robotic Enucleation of Pancreatic Neuroendocrine Tumors.

Background. Pancreatic neuroendocrine tumors (PanNETs) are relatively rare neoplasms with a low to mild malignant potential. They can be further divided into functioning and nonfunctioning, according to their secretive activity. Surgery is an optimal approach, but the classic open approach is challenging, with some patients having long hospitalization and potentially life-threatening complications. The robotic approach for PanNETs may represent an option to optimize their management. Methods. We retrospectively reviewed our prospectively maintained databases from 2 high-volume Italian centers for pancreatic surgery. Demographics, pathological characteristics, perioperative outcome, and medium-term follow-up of patients who underwent robotic pancreatic enucleations were collected. Results. Twelve patients with final diagnosis of PanNET were included. The mean age of the patients was 53.8 years (25-77). The median body mass index was 26 (24-29). Three lesions were functioning insulinomas, while the others were nonfunctioning tumors. No deaths occurred. Mild postoperative complications occurred, except for 1 grade B pancreatic fistula. The mean postoperative stay was 3.9 days (2-5). Conclusions. Our results confirm that robotic enucleation is a feasible and safe approach for the treatment of PanNETs, with short hospital stay and low incidence of morbidity.

Current Management of Pancreatic Neuroendocrine Tumors: From Demolitive Surgery to Observation

Incidental diagnosis of pancreatic neuroendocrine tumors (PanNETs) greatly increased in the last years. In particular, more frequent diagnosis of small PanNETs leads to many challenging clinical decisions. These tumors are mostly indolent, although a percentage (up to 39%) may reveal an aggressive behaviour despite the small size. Therefore, there is still no unanimity about the best management of tumor smaller than 2 cm. The risks of under/overtreatment should be carefully evaluated with the patient and balanced with the potential morbidities related to surgery. The importance of the Ki-67 index as a prognostic factor is still debated as well. Whenever technically feasible, parenchyma-sparing surgeries lead to the best chance of organ preservation. Lymphadenectomy seems to be another important prognostic issue and, according to recent findings, should be performed in noninsulinoma patients. In the case of enucleation of the lesion, a lymph nodal sampling should always be considered. The relatively recent introduction of minimally invasive techniques (robotic) is a valuable option to deal with these tumors. The current management of PanNETs is analysed throughout the many available published guidelines and evidences with the aim of helping clinicians in the difficult decision-making process.

Specific Risks Related to Robotic Surgery: Are They Real?

Robotic surgery, in recent years, has had an exponential increase, both as a number of procedures and as new indications to a robotic surgical approach. With the massive use of the robotic approach in surgery, the safety of this device and monitoring of any malfunctions play an increasingly important role. The goal of this literature review is to analyze different causes of unexpected complications or potential errors in the Da Vinci system, to increase patient and operator safety in the future. The complication rate directly related to robotic malfunction is very low, approximately from 0,02% to 4,97%. Splitting the data across studies MAUDE based and single or multi center experience will notice immediately that the rate is lowest among the MAUDE based (from 0,02% to 0,61% vs from 2,39% to 4,97%). Malfunctions are uncommon and the need to abort or convert to another modality is rare. Most importantly, while mechanical and electronic errors can happen, they do not appear to impact surgical outcomes or patient safety.