Pietro Addeo

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.

Pancreatic fistula after a pancreaticoduodenectomy for ductal adenocarcinoma and its association with morbidity: a multicentre study of the French Surgical Association

BACKGROUNDS A pancreatic fistula (PF) is the most relevant complication after a pancreaticoduodenectomy (PD). This retrospective multicentric study attempts to elucidate the risk factors and complications of a PF in a large cohort of patients undergoing a PD for ductal adenocarcinoma. METHODS Using a survey tool, clinical data of 1325 patients undergoing a PD for ductal adenocarcinoma at 37 institutions, between January 2004 and December 2009, were collected. Peri-operative risk factors associated with PF and its association with morbidity and mortality were assessed. Morbidity and PF were graded according to the ISGPF (International Study group for pancreatic fistula) definition and the Dindo-Clavien classification. RESULTS Overall PF, mortality, morbidity and relaparotomy rates were 14.3%, 3.8%, 54.4% and 11.7%, respectively. PF occurred more frequently after a pancreaticojejunostomy (PJ) compared with a pancreaticogastrostomy (PG) (16.8% vs. 10.4%; P = 0.0012). Independent risk factors for PF by multivariate analysis were absence of pre-operative diabetes (P = 0.0014), PJ reconstruction (P = 0.0035), soft pancreatic parenchyma (P < 0.0001) and low-volume centre (P = 0.0286). Clinically relevant PF (grade B and C) and severe complications (Dindo-Clavien grade IIIB, IV, V) were significantly more frequent after PJ than PG (71.6% vs. 28.3%; P = 0.030 and 24.8% vs. 19.1%; P = 0.015, respectively). Overall mortality and relaparotomy rates were similar after PG and PJ. CONCLUSIONS A soft pancreatic parenchyma, the absence of pre-operative diabetes, PJ and low-volume centre are independent risk factors for PF after PD for ductal adenocarcinoma. A significantly higher incidence and clinical severity of PF are associated with PJ.

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 extended pancreatectomy with vascular resection for locally advanced pancreatic tumors

Objectives: Limited involvement of the major peripancreatic vessels is no longer considered a contraindication for resection in cases of locally advanced pancreatic cancer. Extended open pancreatectomies associated with vascular resection are performed in experienced centers with mortality and morbidity rates comparable to standard pancreatic resection. We evaluate the safety, feasibility, and outcomes of robotic extended pancreatectomy with vascular resection. Methods: We reviewed data of 5 patients with a median age of 60 years (range, 52-74 years) who underwent robotic surgery for pancreatic tumors with vascular involvement between May 2007 and March 2010 at our institution. The types of resection included 2 left-sided splenopancreatectomy with celiac axis resection, 1 left-sided splenopancreatectomy with portal vein resection, and 2 pancreaticoduodenectomy with portal vein resection. Results: No conversions occurred. The overall mean operating time was 392 ± 66 minutes (range, 310-460 min). The overall mean blood loss was 200 ± 61 mL (range, 150-300 mL) with no transfusions. No mortalities occurred. At a median follow-up of 6 months (range, 3-20 months), 4 patients were alive and disease free. Conclusions: This early series by a single surgeon supports the feasibility and safety of robotic pancreatectomy with vascular resection for selected patients with locally advanced pancreatic tumor.

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 sleeve gastrectomy for super-morbidly obese patients.

BACKGROUND Sleeve gastrectomy represents a valid option for morbidly obese patients, either as a primary or as a staged bariatric procedure. Several variations of the technique have been reported. Herein, we report our initial experience with robot-assisted sleeve gastrectomy (RASG). MATERIALS AND METHODS A prospectively held database for patients who underwent RASG was reviewed. Data included patient demographics, operative parameters, morbidity, and follow-up outcomes. The outcomes after RASG were compared to the laparoscopic approach. RESULTS From September 2007 to February 2010, 69 morbidly obese patients underwent sleeve gastrectomy. Of these, 30 (43.5%) were robot-assisted and 39 (56.5%) were laparoscopic. There was no statistically significant difference in demographics between the two groups. The RASG group underwent an oversewing of the staple line, and mean operative time was 135 minutes. In the laparoscopic group, where the staple line was not oversewn, mean operative time was 114 minutes (P = .003). Morbidity after RASG was 3.3%, and there were no gastrointestinal leaks or staple line bleeding. Mean postoperative hospital stay after RASG was 2.6 days (range: 1.6-8.3 days). Mean body mass index decrease at 1 year was 16  kg/m(2). There were no differences between the two groups in terms of morbidity, mortality, length of stay, and weight loss. CONCLUSIONS RASG can be performed safely, with good outcomes. However, the exact role and the advantages of RASG require further study in larger series.

Robot-assisted adrenalectomy: a technical option for the surgeon?

The robotic approach is an interesting option for overcoming the limitations of laparoscopic adrenalectomy. We aimed to report our technique and outcomes of robot‐assisted adrenalectomy (RAA).

Multivariate Analysis of Risk Factors for Pulmonary Complications After Hepatic Resection

Objective:To generate the first evaluation of risk factors for postoperative pulmonary complications (PPCs) after hepatectomy. Background:Postoperative pulmonary complications (PPCs) after surgery are associated with significant morbidity and have been shown to increase the length of hospital stays. Several studies have been conducted to identify the risk factors for PPCs after abdominal surgery. Methods:Between January 2006 and December 2009, 555 patients underwent elective hepatectomy. We prospectively collected and retrospectively analyzed demographic data, pathological variables, associated pathological conditions, and preoperative, intraoperative, and postoperative variables. The dependent variables studied were the occurrence of PPCs, pleural effusion, pneumonia, and pulmonary embolism. Results:Multivariate analysis identified 5 independent risk factors for global PPCs: prolonged surgery [odds ratio (OR) = 1], presence of a nasogastric tube (OR = 1.6), intraoperative blood transfusion (OR = 1.7), diabetes mellitus (OR = 2.7), and a transverse subcostal bilateral muscle cutting incision (OR = 3.4). There were 4 independent risk factors for pleural effusion: prolonged surgery (OR = 1), surgery on the right lobe of the liver (OR = 1.6), neoadjuvant chemotherapy (OR = 2), and a transverse subcostal bilateral muscle cutting incision (OR = 2.5). There were 3 independent risk factors for pneumonia: intraoperative blood transfusion (OR = 1.9), diabetes mellitus (OR = 2.2), and atrial fibrillation (OR = 3). For pulmonary embolism, history of previous thromboembolic events was identified as the only risk factor (OR = 8.8). Conclusions:The correction of modifiable risk factors among the identified factors could reduce the incidence of PPCs and, as a consequence, improve patient outcomes and reduce the length of hospital stays.

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.

Value of contrast-enhanced 18F-fluorodeoxyglucose positron emission tomography/computed tomography in detection and presurgical assessment of pancreatic cancer: A prospective study

Background and Aim:  Positron Emission Tomography (PET) using 18F‐fluorodeoxyglucose (FDG) associated with computed tomography (CT) is increasingly used for the detection and the staging of pancreatic cancer, but data regarding its clinical added value in pre‐surgical planning is still lacking. The aim of this study is to investigate the performance of FDG PET associated with contrast‐enhanced CT in detection of pancreatic cancer.