Search Results (39)

Background: Bile leakage remains a significant challenge following major liver resection, with potential for improvement depending on the transection technique used. In this study, we aimed to evaluate the effectiveness of our hybrid resection technique—utilizing both LigaSure and stapler devices—in reducing bile leakage after major liver resection compared to our conventional stapler-only technique. As a secondary aim, we compared overall morbidity, costs, and reimbursements. Method: Patients who underwent major hepatectomy without biliary reconstruction using either the hybrid or stapler technique between August 2014 and December 2021 were included in the study. Propensity score matching was performed using a one-to-two algorithm. Perioperative data, bile leakage rates, and cost and reimbursement information based on the diagnosis-related group (DRG) system were analyzed. Results: In total, data from 492 patients were evaluated (hybrid = 152; stapler = 340). After one-to-two propensity score matching, the operation time was significantly longer in the hybrid group (p = 0.005). A cost analysis showed no significant difference in total operative costs between the two techniques (p = 0.092). However, the hybrid group had a significantly lower rate of bile leakage (p = 0.002), as well as shorter intensive care unit (ICU) and overall hospital stays (p = 0.034 and p = 0.007, respectively). Consequently, ICU and ward costs were significantly lower in the hybrid group (p = 0.024 and p = 0.014, respectively) compared to the stapler group. The financial difference calculated as DRG reimbursement minus costs was two-fold higher in the hybrid group (p = 0.02). Conclusions: Although the hybrid technique resulted in a longer operating time, it proved superior to the stapler technique in reducing postoperative bile leakage and shortening ICU and hospital stays. Furthermore, the use of the hybrid technique was more cost efficient and resulted in a greater positive financial margin. Full article

Background and Objectives: In contrast to the standardization of laparoscopic gastrectomy techniques, the complexity of intracorporeal anastomosis techniques in totally laparoscopic total gastrectomy, the lack of standardization, the positional challenges posed by working in a confined space, and varying complication rates have prevented a consensus on the optimal intracorporeal digestive tract reconstruction method. Selecting an appropriate reconstruction method for esophagojejunostomy is crucial for a successful surgical outcome. This study aims to define a modified anastomotic technique for TLTG and share our experience with this technique. Materials and Methods: A total of 21 patients who underwent TLTG with D2 LND between July 2024 and December 2024 using the sutureless L-shape esophagojejunostomy (SLEJ) technique at the Surgical Oncology Clinic of Gulhane Training and Research Hospital due to gastric cancer were included in the study. In our technique, gastrectomy, lymph node dissection, anastomosis preparation, esophagojejunostomy anastomosis, and enteroenterostomy anastomosis were all performed laparoscopically and intracorporeally. Results: The mean operative time was 180.48 min, with a mean EJ anastomosis duration of 40.24 min. In the standard technique, two Endo GIA™ staplers were used for pyloric and small bowel transection, two for EJ anastomosis, and one for intracorporeal jejunojejunostomy. In only one patient, three staplers were used for anastomosis. Therefore, the average number of staplers was 5.05, with a mean of 2.05 staplers used for anastomosis. The mean hospital stay was 8.19 days, and there were no mortalities. The number of patients with an anastomotic leakage was 1. Since the patient’s general condition remained stable, percutaneous drainage or laparotomy was not planned. The patients’ esophagojejunostomy anastomotic leak was classified as Class 1 and Grade 3a according to the Clavien–Dindo classification. The average size of our widest incision was 3.28 cm, and surgical site infections were developed in two patients. Conclusions: Sutureless L-Shape With Endoscopic Assistance (SLEJ) is an easily applicable, technically simpler, shorter-in-duration, easier-to-learn, and safer intracorporeal EJ anastomosis technique with a low rate of postoperative complications. Full article

Background: Emphysema is a chronic lung disease characterized by alveolar wall destruction, leading to impaired gas exchange. Giant bullous emphysema (GBE) is a severe form of emphysema, often requiring surgical intervention. Video-assisted thoracoscopic surgery (VATS) is a minimally invasive approach for various thoracic pathologies, including lung volume reduction surgery (LVRS) and bullectomy for emphysematous bullae. Uniportal VATS (U–VATS), a further refinement, offers benefits such as reduced postoperative pain and faster recovery. Methods: This retrospective study analyzed data from two high-volume European Thoracic Surgery centers between August 2016 to January 2024. A total of 29 patients underwent U–VATS bullectomy for GBE. Results: Nineteen patients were males (65.5%) with a mean age of 44.7 ± 8.8 years. Ten (34.5%) were active smokers. Eighteen patients (62.1%) presented with a single giant bulla, while the remaining cases were in the context of pulmonary emphysema. Four patients (13.8%) presented with pneumothorax, with one requiring preoperative chest drainage. Twenty-eight patients (96.6%) underwent only U–VATS bullectomy, with additional chemical pleurodesis in eleven cases (37.9%). One patient (3.4%) underwent a left upper lobectomy for a giant bulla and NSCLC. In cases of severe lung emphysema and fragile pulmonary tissue, the stapler line was buttressed with Gore^® Seamguard^®. No conversions to thoracotomy, postoperative air-leaks, or major complications were recorded. At a mean follow-up time of 22.0 ± 14.0 months, no pneumothorax recurrence was documented. At about six months after surgery, pulmonary function significantly improved. Conclusions: U–VATS bullectomy appears to be a safe and feasible technique for the treatment of bullae in GBE, offering promising postoperative outcomes. Full article

Introduction: Following the rapid advances in minimally invasive surgery, there are a multitude of surgical modalities available for resecting rectal cancers. Robotic resections represent the current pinnacle of surgical approaches. Currently, decisions on the surgical modality depend on local resources and the expertise of the surgical team. Given limited access to robotic surgery, developing tools based on pre-operative data that can predict the difficulty of surgery would streamline the efficient utilisation of resources. This systematic review aims to appraise the existing literature on artificial intelligence (AI)-driven preoperative MRI analysis for surgical difficulty prediction to identify knowledge gaps and promising models warranting further clinical evaluation. Methods: A systematic review and narrative synthesis were undertaken in accordance with PRISMA and SWiM guidelines. Systematic searches were performed on Medline, Embase, and the CENTRAL Trials register. Studies published between 2012 and 2024 were included where AI was applied to preoperative MRI imaging of adult rectal cancer patients undergoing surgeries, of any approach, for the purpose of stratifying surgical difficulty. Data were extracted according to a pre-specified protocol to capture study characteristics and AI design; the objectives and performance outcome metrics were summarised. Results: Systematic database searches returned 568 articles, 40 ultimately included in this review. AI to support preoperative difficulty assessments were identified across eight domains (direct surgical difficulty grading, extramural vascular invasion (EMVI), lymph node metastasis (LNM), lymphovascular invasion (LVI), perineural invasion (PNI), T staging, and the requirement for multiple linear stapler firings. For each, at least one model was identified with very good performance (AUC scores of >0.80), with several showing excellent performance considerably above this threshold. Conclusions: AI tools applied to preoperative rectal MRI to support preoperative difficulty assessment for rectal cancer surgeries are emerging, with the progressing development and strong performance of many promising models. These warrant further clinical evaluation, which can aid personalised surgical approaches and ensure the adequate utilisation of limited resources. Full article

Background: Compared with the da Vinci platform, there is limited experience with the Hugo RAS^® platform for colorectal surgery in Europe. This difference is especially notable when considering complex procedures such as total colectomy. Aim: To demonstrate the feasibility and safety of using the Hugo RAS^® (Medtronic, Minneapolis, MN, USA) platform for total colectomy. Clinical case: An 18-year-old female patient with Familial Adenomatous Polyposis (FAP) and a BMI of 19 underwent a total colectomy with ileorectal anastomosis using the Hugo RAS^® platform. The procedure lasted 253 min without complications. The postoperative period was uneventful, and she was discharged from the hospital on the third postoperative day. Conclusion: The Hugo RAS^® platform is an emerging minimally invasive robotic that can be used even for total colectomy with proper patient selection. The placement and choice of arms and trocars were crucial to obtaining a similar operative time to the standard laparoscopic approach. The certification of Hugo’s new instruments, such as energy devices and staplers, will make this platform even more competitive. Full article

Background: In the landscape of thoracic surgery, innovation continually drives progress, offering novel approaches to address complex pathologies while prioritizing patient well-being. Dual-port robotic-assisted thoracic surgery (DRATS) represents a new frontier in this evolution. In this report, we describe our experience with the fully dual-port robotic-assisted thoracic surgery (F-DRATS) approach for segmentectomy with the indocyanine green intersegmental plane identification. Methods: We define as F-DRATS the robotic thoracic surgery performed by two intercostal incisions without rib spreading, using the robotic camera, robotic dissecting instruments, and exclusively robotic staplers. We herein describe our F-DRATS approach in lingulectomy and lymphadenectomy of stations 5, 6, 7, and 10 using the da Vinci Surgical System. Results: The patient’s postoperative course was uneventful with the chest tube removed on the second postoperative day. The final pathological analysis confirmed a low-grade malignant potential adenocarcinoma, with a main diameter of 1.1 cm, at 3 cm from the lung margins. Conclusions: This is the first description in the literature of a F-DRATS lingulectomy with ICG intersegmental plane identification. Full article

We report a case in which a 74-year-old man suffering from esophageal achalasia complicated with epiphrenic esophageal diverticulum was successfully treated with a simultaneous laparoscopic surgery. The gentleman was referred with symptoms suggestive of a passage disorder in the lower esophagus for the past 5 years. Esophagogastroduodenoscopy demonstrated an epiphrenic diverticulum at the left wall of the lower esophagus, and esophagography led to the suspicion of a combined esophageal achalasia. A simultaneous laparoscopic surgery with an abdominal approach was performed in which, following the opening of the esophageal hiatus, the diverticular wall was separated from the mediastinal organs and diverticulectomy was performed with linear staplers. After Heller’s myotomy, Dor’s fundoplication was subsequently performed in which both the incisional line of muscle layer and the suturing line of diverticulectomy were wrapped by the fornix of the stomach to make up for the wall strength and avoid the suture leakage. It was theoretically considered logical and effective to reinforce this vulnerable site with Dor’s fundoplication. He had an uneventful recovery and a rapid relief from symptoms following surgery. Full article

Background: Robotic-assisted nephrectomy for living kidney-donation (RANLD) has the potential of becoming the leading technique of harvesting kidney, if expertise is available. The aim of this work is to present our initial experience with robotic technique with additional hand-assistance. Materials and Methods: We initiated RANLD at our clinic using the DaVinci System in September 2022, since then harvesting six kidneys, four left and two right; in two cases, multiple arteries existed. The renal vessels were ligated using vascular staplers. All the operations included a hand-assist with the use of Gelport. The mean operation time was 119.2 min (SD 12 min). Results: There were no conversions or donors’ post-operative complications. Time of discharge from the hospital was 4.5 days post-operatively. Total hospital length of stay was 7.8 days. All the harvested kidneys were transplanted, five of them with adequate function, three with initially delayed function, and one needed to be removed due to thrombotic complications. Post-operative was pain assessed on the VAS scale and overall pain was assessed according to the NRS scale. At the discharge day, donors’ performance status was about 87.5% according to the Karnofsky scale. The donors resumed their normal life activity within 15.7 days and returned to work within 45.2 days. The serum mean creatinine level before the donation was 0.85 mg/dL (SD 0.1 mg/dL), and mean eGFR (MDRD) = 91.8 mL/min/1.73 m² (SD 16.1 mL/min/1.73 m²). Conclusions: Further development of RANLD could lead to an increase in the number of living kidney donors, particularly in Poland where the number is currently lower than that of deceased donors. Prolonged operation time, longer warm ischemic time, and high equipment costs are significant drawbacks of RANLD. Full article

Pulmonary metastasectomy has become a well-established procedure for patients with certain types of solid tumors. Patients are usually scheduled for staged lung metastasectomy in case of primary tumor control, the absence of distant non-lung metastases, and when complete resection is achievable. Nodules are removed with precision resection in order to ensure radical resection with minimal margins; this technique permits good oncological results, preserving the surrounding pulmonary parenchyma and causing minimal distortion compared to staplers. When possible, anatomical resections should be avoided since they are not justified by real oncological advantages and, in the majority of cases, sacrifice too much healthy tissue, possibly leading to inoperability in the case of metachronous relapses. Thus, preserving the maximum amount of pulmonary parenchyma is crucial because repeated metastasectomies are possible and frequent, with no theoretical limits to the number of reinterventions. In our multidisciplinary board team, we support the role of pulmonary metastasectomy as a useful curative therapy, with acceptable morbidity and mortality, with indications to be discussed case-by-case. Full article

Background: DaVinci^® single-port (SP) robotic surgery offers several benefits compared to traditional multiport laparoscopic or robotic surgeries. One of the main advantages is that it allows for a minimally invasive approach, resulting in a single, smaller incision and reduced trauma to the patient’s body, leading to less postoperative pain, faster recovery, and reduced risk of complications. The cosmesis of a single port with minimal visible scarring is also an attractive aspect to the patients; however, many surgeons use an additional port for energy device, stapler use, and drain insertion. Pure single-port surgery with one incision is still rare. Here, we share our experience of our first 10 cases using the SP robotic platform in colorectal surgery. Methods: From May 2023 to December 2023, colorectal patients who underwent SP robotic surgery were analyzed. Placement of the incision was the umbilicus for eight patients, and right lower quadrant for two patients, through which ileostomy maturation was performed. Data on perioperative parameters and postoperative outcomes were analyzed, with a median follow-up of 4.6 months (range 0.6–7.4 months). Results: A total of 10 colorectal patients underwent DaVinci^® single-port robotic colorectal surgery at our institution during this period. The patient demographic was four males (40%) and six females (60%) with a median age of 63.5 years (range 50–75 years). Median body mass index (BMI) was 22.89 kg/m² (range 19.92–26.84 kg/m²). Nine patients were diagnosed with colorectal cancer, and one patient was diagnosed with a rectal gastrointestinal tumor. One patient underwent anterior resection and cholecystectomy simultaneously. Mean operation time was 222 min (range 142–316 min), and mean wound size was 3.25 cm (range 2.5–4.5 cm). Nine patients underwent surgery with single incision through which a single-port trocar was inserted, and one patient had one additional port for drain insertion. Mean hospital stay was 6 days (range 4–8 days) with one postoperative complication of bleeding requiring transfusion, but there was no readmission within 30 days. Conclusions: Overall, our experience with single-port robotic colorectal surgery has been promising. With only one patient with additional port for drain insertion, all nine patients underwent SP-robotic surgery with single incision for colon as well as rectal surgeries. Compared to an average postoperative length of stay of 6.5-8 days in laparoscopic colorectal surgeries reported in literature, SP-robotic surgery 33showed faster recovery of 6 days highlighting its benefits in patient recovery and satisfaction. Full article

Rectal oncological pathology represents an increased degree of difficulty in terms of surgical approach. Along with the development of minimally invasive surgery, technology has also increased the options for performing digestive anastomoses. A significant increase has been observed among mechanical anastomoses. The evolution of mechanical sutures through the use of the stapler has become a true symbol of technological advancement, as they have led to improvements and effective gains in quality and productivity in suture making. The aim of this paper is to highlight the advantages of the use of staplers in rectal surgery, with their help achieving a lower percentage of postoperative complications, a lower incidence of suppuration, fistula and evisceration, a much faster patient recovery, a lower mortality, an increase in the possibility of performing low anastomosis and a decrease in the performance of colostomies that are difficult to be accepted by patients, most of them requiring a shorter period of hospitalization after major oncological surgery. Full article

The hemidouble stapler technique (HDST) in laparoscopic intracorporeal esophagojejunostomy has aspects that pose risks to the safety of the anastomosis. We developed a new esophagojejunostomy technique that converts a double-stapled anastomosis to a single-stapled anastomosis in laparoscopic total gastrectomy (LTG). The aim of this study is to compare the results of two techniques. Patients who underwent LTG for gastric cancer in our hospital between October 2016 and May 2022 were included in the study. Patients were retrospectively reviewed in two groups: those who underwent HDST and the ghosting double stapling technique (GDST). Both groups were analysed in terms of demographics, perioperative findings, and postoperative outcomes. The GDST was used in 14 patients. The HDST was used on 16 patients. Two patients in the HDST group whose esophagojejunal anastomosis was not assessed on endoscopic imaging were excluded. The mean total operative times were 292.6 ± 43.7 and 224.3 ± 36.1 min (p < 0.001). The mean times for esophagojejunostomy were 38.6 ± 4.3 and 26.8 ± 6.4 min (p < 0.001). One case of anastomotic stenosis was observed in the HDST group. Anastomotic leakage was not observed in both groups. However, there was no significant difference in overall morbidity between the groups (p > 0.05). Both HDST and GDST can be safely performed in the esophagojejunostomy for LTG. Full article

Stapling devices have emerged as a widespread and effective option for soft tissue surgery, offering promising outcomes for patients by reducing complication rates and surgery time. This review aims to provide an exhaustive analysis of commercially available alternatives in the market, incorporating insights from market analysis, patent landscape, and the existing literature. The main focus lies in identifying and evaluating the most widely adopted and innovative stapling devices, including linear, linear cutting, circular, and powered staplers. In addition, this review delves into the realm of bioabsorbable staples, exploring the materials utilized and the surgical fields where these advanced staples find applications. To facilitate easy comprehension, the gathered information is presented in tables, highlighting the essential parameters for each stapling device. This comprehensive research about stapling devices is intended to aid healthcare practitioners and researchers in making informed decisions when choosing the most appropriate instrument for specific surgical procedures. Full article

This article describes the development of a flexible surgical stapler mechanism, which serves as a fundamental tool for laparoscopic rectal cancer surgery, addressing the challenges posed by difficult types of accessibility using conventional instruments. The design of this mechanism involves the incorporation of a stacked tensegrity structure, in which a flexible beam serves as the central spine. To assess the stapler’s range of operation, an analysis of the workspace was conducted by examining collaborative Computed Tomography (CT) scan data obtained from different perspectives (Axial, Coronal, and Sagittal planes) at various intervals. By synthesizing kinematic equations, Hooke’s law was employed, taking into account rotational springs and bending moments. This allowed for precise control of the mechanism’s movements during surgical procedures in the rectal region. Additionally, the study examined the singularities and simulations of the tensegrity mechanism, considering the influential eyelet friction parameter. Notably, the research revealed that this friction parameter can alter the mechanism’s curvature, underscoring the importance of accurate analysis. To establish a correlation between the virtual and physical models, a preliminary design was presented, facilitating the identification of the friction parameter. Full article

Objective—The objective of this study was to systematically assess meta-analyses to determine the lacunae in the literature for PCF following laryngectomy. Methods—Bibliometric analysis were carried out on meta-analyses on PCF after total laryngectomy for laryngeal cancer in the PubMed database. Results—Twenty-four meta-analyses were considered eligible and chosen for analysis. Six meta-analyses (25%) focused on the risk factors for PCF in TL. Four meta-analyses (16.6%) focused on the role of the onlay flap. Four meta-analyses (16.6%) focused on the timing of feed initiation. Three meta-analyses (12.5%) focused on using a stapler for pharyngeal closure. Two meta-analyses focused on types of pharyngeal reconstruction. Other meta-analyses analyzed the use of salivary bypass tubes, the method of pharyngeal closure, organ preservation protocols on PCF, primary and secondary TEP, and the effect of non-surgical treatment on PCF. Conclusion—Despite plenty of published meta-analyses, there is a lack of scrutiny on certain critical aspects of PCF. Full article