Onur Bayraktar

Is da Vinci Xi Better than da Vinci Si in Robotic Rectal Cancer Surgery? Comparison of the 2 Generations of da Vinci Systems.

Background: We aimed to compare perioperative outcomes for procedures using the latest generation of da Vinci robot versus its previous version in rectal cancer surgery. Patients and Methods: Fifty-three patients undergoing robotic rectal cancer surgery between January 2010 and March 2015 were included. Patients were classified into 2 groups (Xi, n=28 vs. Si, n=25) and perioperative outcomes were analyzed. Results: The groups had significant differences including operative procedure, hybrid technique and redocking (P>0.05). In univariate analysis, the Xi group had shorter console times (265.7 vs. 317.1 min, P=0.006) and total operative times (321.6 vs. 360.4 min, P=0.04) and higher number of lymph nodes harvested (27.5 vs. 17.0, P=0.008). In multivariate analysis, Xi robot was associated with a shorter console time (odds ratio: 0.09, P=0.004) with no significant differences regarding other outcomes. Conclusions: Both generations of da Vinci robot led to similar short-term outcomes in rectal cancer surgery, but the Xi robot allowed shorter console times.

Robotic complete mesocolic excision for right-sided colon cancer.

Complete mesocolic excision (CME) with central vascular ligation for right-sided colon cancer has been proven to provide superior oncologic outcomes and survival advantage when compared to standard lymphadenectomy [1]. A number of studies comparing conventional laparoscopic versus open CME have shown feasibility and safety of the laparoscopic approach with acceptable oncological profile and postoperative outcomes [2, 3]. The introduction of robotic systems with its technical advantages, including improved vision, better ergonomics and precise dissection, has further revolutionized minimally invasive approach in colorectal surgery. However, there seems to be a relatively slow adoption of robotic approach in the CME technique for right-sided colon cancer. This video demonstrates our detailed operative technique and feasibility for performing right-sided CME robotically. The surgical procedure is performed with a medial-to-lateral approach through four 8-mm robotic and one assistant ports. First, the ileocolic vessels are isolated, clipped and transected near their origins. Cephalad dissection continues along the ventral aspect of the superior mesenteric vein. Staying in the embryological planes between the mesocolon and retroperitoneal structures, mesenteric dissection is extended up to the root of the right colic vessels, if present, and the middle colic vessels, which are clipped and divided individually near their origins. After the terminal ileum is transected using an endolinear staple, the colon is mobilized fully from gastrocolic tissue and then from its lateral attachments. The transverse colon is transected under the guidance of near-infrared fluorescence imaging. Creation of an intracorporeal side-to-side ileotransversostomy anastomosis and extraction of the specimen complete the operation. We consider robotic CME to be feasible, safe and oncologically adequate for the treatment of right-sided colon cancer. Its technical advantages may lead to further dissemination of the robotic approach and better standardization of this surgical technique.

Comparison of two minimal invasive techniques of splenectomy: Standard laparoscopy versus transumbilical multiport single-site laparoscopy with conventional instruments

Background: Laparoendoscopic single-site (LESS) splenectomy which is performed on small number of patients, has been introduced with better cosmetic outcome, less postoperative pain, greater patient satisfaction and faster recovery compared to standard laparoscopy. Materials and Methods : Thirty six patients were included in the study comparing standard laparoscopic splenectomy (LS, 17 patients) transumbilical multiport splenectomy performed with conventional laparoscopic instruments (TUMP-LS, 19 patients). Two groups of patients were compared retrospectively by means of operation time, intra- and postoperative blood loss, perioperative complications, packed red cell and platelet requirements, lenght of hospitalization, pain scores and patient satisfaction. Results: There was no mortality in any of the groups, and no significant differences determined in operative time (P = 0,069), intraoperative blood loss (P = 0,641), patient satisfaction (P = 0,506), pain scores (P = 0,173) and the average length of hospital stay (P = 0,257). Umbilical incisions healed uneventfully and no hernia formation or wound infection was observed during follow-up period (2-34 months). There were no conversions to open surgery. Conclusions: Transumbilical multiport splenectomy performed with the conventional laparoscopic instruments is feasible and could be a logical alternative to classical laparoscopic splenectomy by combining the advantages of single access techniques and standard laparoscopy.

Covered self-expandable metallic stents could be used successfully in the palliation of malignant cervical esophageal strictures: preliminary report.

Purpose: To present the authors’ preliminary experience with covered self-expandable metallic stents in the palliation of malignant cervical esophageal strictures. Methods: Covered self-expandable metallic stents were placed into the cervical esophagus of 6 patients with malignant cervical esophageal strictures under fluoroscopic guidance. Results: Stent placement was technically successful in all patients, and the mean dysphagia score decreased from 3.3 to 0.5 according to the Ogilvie Dysphagia Scoring. Two patients complained of chest pain, which lasted for 24 to 48 hours. Foreign body sensation disappeared spontaneously within a week in all patients, but one. Migration, dysphagia, or obstruction was not observed in any of the patients during the follow-up period (47 d to 8 mo). Conclusions: According to our limited number of cases, placement of covered self-expandable metallic stents into the cervical esophagus can be performed safely, and significant improvement of dysphagia scores and life quality of patients can be obtained instantly after the procedure.

Robotic Complete Mesocolic Excision for Splenic Flexure of Colon Cancer

Robotic surgery, with its enhanced dexterity and increased range of motion, is being increasingly used in colorectal surgery. In addition to the rectal approaches, where laparoscopic limitations are overcome by the dexterity and superior vision of robotics, colon cancer procedures could also be perf

Identification of mesenteric lymph nodes in robotic complete mesocolic excision by near-infrared fluorescence imaging

One of the most important prognostic factors in colorectal cancer is nodal status at the time of surgical treatment. Complete mesocolic excision (CME) with central vascular ligation, which follows similar oncologic principles to total mesorectal excision, has revolutionized the surgical treatment of colon cancer, showing a higher degree of lymphadenectomy and better oncologic outcomes compared to standard colectomy [1]. The rationale behind this technique is to remove the entire mesocolon and all potential routes of lymphatic spread by dissecting along embryologic tissue planes and transecting the supplying vessels at their origin [1, 2]. Since 2001, surgical treatment for colorectal cancer has seen another substantial development due to the introduction of robotic technology [3]. Thanks to its potential for overcoming the limitations of standard laparoscopy, the robotic approach is increasingly being employed in colorectal surgery. Recently, the technical feasibility and safety of robotic surgery in the CME technique for right colon cancer also has been reported [4]. Although CME is now the technique for optimal clearance of lymph nodes, a more sophisticated capability to visualize the actual lymphatic drainage from the tumor site into the colonic mesentery may further maximize nodal harvest in CME. This may also be of use in the determination of a suitable mesentery division line, especially in obese patients with excessive mesenteric adipose tissue. The near-infrared fluorescence imaging (NIFI) system has been developed for this type of navigation surgery, and now, this system is also available in robotic technology. The utility of NIFI has been previously reported in various colorectal procedures [5–7], but its role in the identification of both the lymphatic flow distribution and lymphatic basin in robotic CME has not been described. Here, we present a video to demonstrate intraoperative lymph node identification in an obese patient undergoing robotic CME for cecal adenocarcinoma. The patient was a 76-year-old female with a body mass index of 39.6 kg/m. One day before surgery, indocyanine green (ICG) solution was injected via colonoscopy into the submucosa in four quadrants around the lesion; 0.5 ml of ICG (2.5 mg/ml) was delivered with each injection. Intraoperatively, the da Vinci Xi Firefly NIFI system (Intuitive Surgical Inc., Sunnyvale, CA, USA) was used to assess lymphatic flow distribution from the colonic wall into its mesentery. The lymphatic ducts and lymph nodes were clearly visualized in real time, and this proved useful in choosing the extent of mesenteric dissection. No complications occurred during surgery. Total operative time was 395 min, and blood loss was 100 ml. The patient did not show any adverse reaction to the ICG injection and was discharged home on postoperative day 5 following an uneventful recovery; histopathologic examination revealed a T3 tumor. The total number of harvested lymph nodes was 25, none of which were metastatic (pT3N0M0). Electronic supplementary material The online version of this article (doi:10.1007/s10151-015-1413-3) contains supplementary material, which is available to authorized users.

Single-site multiport combined splenectomy and cholecystectomy with conventional laparoscopic instruments: Case series and review of literature

Highlights • Single site surgery has benefits for combined diseases.• Outcomes are not worse than conventional laparoscopic approaches.• After gaining experience for SILS procedures, combined procedures can be performed safely.

Vascular high ligation and embryological plane dissection in laparoscopic restorative proctocolectomy for ulcerative colitis - a video vignette.

abscesses and autonomic nerve damage. This can be done by an intersphincteric transperineal approach, avoiding an abdominal procedure [3]. If a uniquely perineal approach is not possible (e.g. in the case of a preexisting ileorectal anastomosis), an abdominal single port can be added. In 2012 a 40-year-old woman with an American Society of Anesthesiologists score of 2 and body mass index of 20 kg/m underwent a laparoscopic subtotal colectomy with ileorectal anastomosis and loop ileostomy for complicated Crohn’s colitis with perianal disease. Later, despite maximal therapy and diversion, rectal fistulating disease worsened and a completion proctectomy and definitive ileostomy was agreed upon. A combined abdominal and transanal procedure was planned. The perineal phase consisted of dissection in the intersphincteric plane to the pelvic floor with detachment of an anovaginal fistula, induction of a pneumorectum through a single-port device (GelPOINT Path, Applied Medical, Rancho Santa Margarita, California, USA) and close-rectal dissection carried distally to the peritoneal reflection. Synchronously, the loop ileostomy was closed and a single-port (GelPOINT) pneumoperitoneum was established. After dividing the adhesions, resection of the ileorectal anastomosis was performed and a terminal ileostomy was created. The patient was discharged 5 days after the procedure following an uneventful recovery.

Comparison of classical surgery and sutureless repair with DuraSeal or fibrin glue for duodenal perforation in rats.

BACKGROUND The purpose of the study was to compare classical primary suture repair and sutureless repair with fibrin glue or DuraSeal adhesion barrier for the closure of duodenal perforation in rats. METHODS Forty adult female Wistar Albino rats weighing between 250-300 g were randomly divided into four equal groups. Primary repair, primary repair and omentoplasty, or application of fibrin glue or DuraSeal adhesion barrier was performed in each of the four groups, respectively. The bursting pressure, tissue hydroxyproline levels and histopathology were evaluated. RESULTS Bursting pressure values of the primary repair and primary repair and omentoplasty groups were significantly higher than in the fibrin glue and DuraSeal groups (p < 0.001). There were no significant differences between the experimental groups regarding hydroxyproline levels and histological parameters. CONCLUSION The sutureless methods (Fibrin glue, DuraSeal) have no superior effects when compared with the conventional repair techniques. We observed similar results between the sutureless repair groups; thus, DuraSeal can be considered an alternative to fibrin glue for this purpose. This suggestion must be supported with new studies, however, which would be planned with other wound healing markers and different designs.

V-Y advancement flap reconstruction for anal stricture - a video vignette

meant to be analogous to the TME but the concepts are not directly transferable. Whilst some evidence suggests that CME is associated with improved survival outcomes, it is debatable whether this is related to an increased number of nodes [5]. As such, considering the increased morbidity with increased nodal yield, there is insufficient evidence to recommend its widespread adoption. Perhaps the right answer is to perform a more accurate dissection, not just procure more nodes. Techniques to improve nodal assessment and supplement pathological staging, such as radioimmunoguided surgery and sentinel lymph node mapping, have been described although their role remains poorly defined. The most meaningful tool for guiding the optimal resection margins may be intra-operative fluorescence imaging (FI) with a fluorophore such as indocyanine green. FI allows direct visualization of the tumour with its draining nodal basin, the sentinel node(s) and any aberrant nodes outside the planned resection field, thus permitting a more precise mesenteric lymphadenectomy, obviating a reliance on lymph node numbers alone. FI can also show the watershed areas in the mesentery and define the lateral extents of lymphatic spread, allowing a CME-style dissection to be completed. This type of lymphatic mapping may permit improved intra-operative cancer-targeting techniques. The clinical implications for this precision-guided surgery could impact staging and patient prognosis and guide adjuvant therapy recommendations the way simply harvesting more nodes could not. Studies are under way to validate these clinical assumptions with FI, and technical details are being standardized. In the meantime, ensuring pathological scrutiny of our surgery, we must continue to strive for optimal resections based on oncological principles to obtain a minimum of 12 nodes for our patients and the best outcomesn.