Search Results (85)

Objectives: To describe the surgical setup, docking strategy, and perioperative outcomes of retroperitoneal renal surgery performed with the Hugo™ RAS system, reporting, to our knowledge, the first dedicated surgical series. Methods: Between February and August 2025, 30 consecutive patients underwent retroperitoneal renal surgery with the Hugo™ RAS system at a single institution. Procedures included robot-assisted partial nephrectomy (RAPN, n = 15) and robot-assisted pyeloplasty (n = 15), performed by a single experienced surgeon. A standardized retroperitoneal access and reproducible trocar configuration were adopted. A three-arm configuration with predefined docking and tilt angles was used. Feasibility was defined as completion of the procedure without conversion to open or transperitoneal surgery. Perioperative data were prospectively collected and reported as median and interquartile range (IQR). Results: All procedures were completed without conversion or additional trocar placement. In the RAPN cohort, median docking time was 5 min (IQR 5–5), operative time was 180 min (IQR 172–200), and estimated blood loss was 200 mL (IQR 150–250). Three patients (20%) experienced Clavien–Dindo grade II complications; no major complications occurred. Positive surgical margins were observed in 1 patient (6%), with no radiological recurrence at 6-month follow-up. In the pyeloplasty cohort, operative time was 150 min (IQR 147–180) and estimated blood loss was 70 mL (IQR 50–100). One patient (7%) developed a grade II complication. Renal function remained stable in both groups. Conclusions: Retroperitoneal renal surgery using the Hugo™ RAS system is feasible, safe, and reproducible when supported by a standardized docking and port configuration. Full article

Remote center-of-motion mechanisms are essential in minimally invasive surgery because they allow surgical instruments or an endoscopic camera to pivot around a trocar entry point while eliminating lateral motion at the incision. This paper presents the design, kinematic modeling, prototype implementation and preliminary evaluation under laboratory conditions of a compact, spherical, remote center-of-motion robot for minimally invasive surgical orientation tasks. The proposed mechanism uses a spherical kinematic architecture actuated by a contra-rotating differential gearbox. This gearbox generates two coaxial output rotations of equal magnitude and opposite direction from a single input, mechanically synchronizing the opposed motion of the two base links and eliminating the need for cable-pulley transmission or dual electronically synchronized motors. A second actuator chain rotates the gearbox assembly around the base axis, thereby decoupling the extension–retraction motion from base-axis rotation. Forward and inverse kinematic formulations were derived for teleoperation of the robot using a 7 degrees of freedom haptic device and for remote center-of-motion orientation control using a 3-axis joystick. A proof-of-concept prototype was developed and integrated with a custom embedded controller, closed-loop motor control, a master-console interface and video feedback loop. The system was evaluated in a phantom-torso setup using a custom endoscopic camera, internal visual markers and an OptiTrack-based measurement of the remote center-of-motion accuracy. The qualitative experiment confirmed functional integration of the mechanical, electronic and software subsystems, while the optical-tracking measurement showed that the pivot constraint was maintained with a mean deviation of 1.69 mm and a root-mean-square deviation of 2.13 mm over the analyzed orientation sweep. The main limitations remain the 1:1 gearbox ratio, limited actuator torque, additively manufactured gearing and the absence of repeated-trial repeatability and full workspace characterization. Full article

Pleural drainage is a fundamental procedure in the management of pneumothorax, pleural effusion, hemothorax, and complex pleural disease. Advances in imaging guidance, small-bore catheter technology, and structured training have improved the safety and effectiveness of pleural interventions. Despite its widespread use, pleural drainage continues to be associated with substantial complication rates, largely driven by operator inexperience, suboptimal insertion technique, and inadequate imaging support. Contemporary guidelines from the American Thoracic Society, European Respiratory Society, and British Thoracic Society emphasize evidence-based indications, routine ultrasound guidance, avoidance of trocar insertion, and the use of appropriately sized small-bore drains in most non-traumatic conditions. This review integrates current evidence and recommendations regarding indications, procedural techniques, imaging modalities, complication prevention, training standards, and malignant pleural effusion management into a practical framework for contemporary pleural drainage while highlighting areas of changing practice, persistent uncertainty, and key challenges in implementation. Full article

Background: Efficient and safe instrument exchange remains an important challenge in robot-assisted laparoscopic surgery (RALS). Current workflows require human assistance, increasing staff workload and contamination risk. The modular design of the AdLap robotic laparoscopic instruments enables automated exchange of instrument shafts. This study presents the development and validation of the Instrument Carousel Exchange System (ICES). Methods: An automatic ICES was developed for the AdLap robotic surgery platform of the Delft University of Technology. The prototype was designed to hold six Shaft-Actuated Tip-Articulating (SATA) modular instrument shafts (SATA instrument line, SATA Medical, Amsterdam, The Netherlands) and focused on compactness, robustness, modularity, and rapid disassembly for cleaning and sterilization. System performance was evaluated using repeated autonomous instrument exchange cycles without user interaction. Reliability, alignment tolerance, safety, and exchange duration were assessed. Results: The ICES prototype was successfully designed, manufactured, and tested. Repeated functional testing demonstrated reliable autonomous instrument shaft exchange without human intervention. The system tolerated minor alignment deviations while maintaining stable and safe operation. The mean time for a complete instrument shaft exchange was 84 s (SD = 10 s). The modular architecture allowed straightforward disassembly and maintenance while preserving structural integrity and compact design. Conclusions: The developed ICES represents a substantial step toward fully automated modular instrument handling in RALS. Automated instrument exchange may reduce staff workload and minimize contamination risk during procedures. Future work will focus on improving automation speed, alignment efficiency, and autonomous reinsertion of the instrument shaft through the trocar to further enhance clinical applicability. Full article

Background: Minimally invasive liver surgery has continuously developed with the advent of robotic systems that could present some advantages regarding dexterity and visualization. Single-port robotic devices have been introduced more recently in order to minimize the invasiveness of surgery. Unfortunately, scientific literature on this topic is still poor. This pilot feasibility study aimed to assess the technical applicability and short-term outcomes of single-port robotic liver resection. Methods: The study was designed as a retrospective analysis of 11 consecutive patients treated with single-port robotic liver resection. All interventions were performed in order to treat lesions localized in the anterolateral segments of the liver. All preoperative, intraoperative, and postoperative data were collected retrospectively and considered for the analysis. Cirrhotic patients were graded according to the Child–Pugh score. Results: The median age was 67 years (IQR 41–78), and 63.6% of the patients were women. There was cirrhosis in 27.3% of the cases, and all cases were categorized as Child–Pugh class A. Neoadjuvant chemotherapy was not administered in any of the patients. All procedures were considered Tampa grade II. The median operation time was 190 min (IQR 70–320), and the median blood loss was 50 mL (IQR 0–300). Pedicle clamping was done in 36.4% of the cases. An additional assistant trocar was needed in 45.4% of the procedures. In total, two anatomical and nine non-anatomical resections were done. There were no postoperative complications, reinterventions, and 90-day readmissions. The median length of hospitalization was 2 days (IQR 1–3). The postoperative pain was minimal, with a median VAS and NRS score of 0 on postoperative days 0 and 1. Analgesic treatment was ceased on postoperative day 1, and the median time to first flatus was 1 day in all patients. Conclusions: Single-port robotic liver resection seems to be technically possible in selected patients with intermediate-difficulty lesions in anterolateral segments. Additional research is necessary to establish its role in minimally invasive liver surgery. Full article

Background and Objectives: Laparoscopic sleeve gastrectomy (LSG) is one of the most commonly performed metabolic bariatric surgery procedures worldwide. However, conventional LSG generally requires liver retraction for adequate visualization of the operative field. This study aimed to evaluate the feasibility, perioperative safety, and metabolic outcomes of a modified three-port LSG technique performed without the use of a liver retractor. Materials and Methods: This retrospective single-center cohort study included 2000 consecutive individuals with obesity who underwent three-port laparoscopic sleeve gastrectomy between January 2020 and December 2023. All procedures were performed without mechanical liver retraction by two experienced bariatric surgeons. Operative outcomes, postoperative complications, weight loss parameters, metabolic variables, and histopathological findings were evaluated during a 12-month follow-up period. All included patients completed the predefined follow-up schedule. Postoperative complications were classified according to the Clavien–Dindo classification system. Results: The mean operative time, defined as skin-to-skin duration, was 30 ± 15 min, and the median hospital stay was 2.3 days. No conversion to open surgery, additional trocar placement, or rescue liver retractor use was required. The overall complication rate was 9.4%, with most complications classified as Clavien–Dindo grade I–II. Reoperation was required in three patients (0.15%), and no mortality was observed. Significant metabolic improvements were detected following surgery. Mean HbA1c levels decreased from 7.23% preoperatively to 5.67% at 12 months (p < 0.001), while BMI decreased from 42.6 kg/m² to 28.7 kg/m² (p < 0.001). Excess weight loss and total weight loss at 12 months reached 82.4% and 34.2%, respectively. Diabetes remission was achieved in 65.4% of patients with baseline type 2 diabetes mellitus. Continuous glucose monitoring findings demonstrated reduced postoperative glycemic variability. Conclusions: Three-port laparoscopic sleeve gastrectomy performed without a liver retractor appears to be a feasible and effective surgical approach when performed by experienced bariatric surgeons. The technique was associated with acceptable perioperative safety and favorable metabolic outcomes. However, because of the retrospective single-center design and absence of a conventional comparison group, definitive conclusions regarding superiority or equivalence to standard techniques cannot be established. Prospective multicenter comparative studies are required to validate these findings. Full article

Background: Robotic-assisted surgery has increasingly been adopted in pediatric surgical practice; however, data from early implementation stages remain limited. Materials and methods: We conducted a prospective audit of the first 71 pediatric robotic-assisted procedures performed over a 24-month period using the da Vinci Xi platform in a tertiary pediatric center. Patient characteristics, surgical indications, perioperative parameters, and postoperative outcomes were analyzed. Results: A total of 71 procedures were performed in 71 patients (39 girls, 32 boys; mean age 4.46 years). The most frequent procedures were cholecystectomy (n = 19), ovarian tumor excision (n = 14), and pyeloplasty (n = 13). Mean operative time was 90 ± 65.30 min. Intraoperative complications occurred in 9.9% of cases, conversion to open surgery in 2.8%, and postoperative complications in 2.8%. Trocar insertion time and docking time improved significantly during the second year (p < 0.05). No mortality or long-term complications were recorded. Conclusions: Robotic-assisted pediatric surgery is feasible and safe, with acceptable complication rates and favorable early outcomes. Progressive improvement in operative setup parameters reflects a measurable learning curve. Full article

Purpose: The aim of this study is to describe a slit-modified 23-gauge infusion trocar designed to enable early postoperative hypotony-free sclerotomy closure by allowing scleral suturing prior to complete trocar removal, and to report initial clinical outcomes in eyes with proliferative diabetic retinopathy with or without vitreous hemorrhage (PDR + H and PDR). Methods: A standard 23-gauge metallic (titanium) trocar was modified by creating a longitudinal slit that permitted passage of a suture needle while the trocar remained partially engaged within the scleral tunnel. At the end of pars plana vitrectomy, a transscleral suture was placed through the slit with the knot prepared prior to trocar removal, followed by simultaneous trocar extraction and suture tightening. Eighteen consecutive patients undergoing vitrectomy for PDR (fourteen with vitreous hemorrhage [PDR + H]; four without) were included. Intraocular pressure (IOP) was recorded preoperatively, immediately after sclerotomy closure (postoperative baseline), and at 8 and 24 h postoperatively. The study was designed as an exploratory pilot feasibility and safety evaluation of a slit-modified infusion trocar in 23-gauge vitrectomy. The primary outcomes were postoperative IOP stability and wound leakage. Secondary outcomes included early hypotony, postoperative hemorrhage, choroidal effusion, and the need for additional suturing. Results: All procedures were completed without intraoperative complications. The mean IOP was 14.83 ± 2.50 mmHg preoperatively, 13.33 ± 1.53 mmHg immediately after closure, 14.17 ± 3.01 mmHg at 8 h, and 15.17 ± 1.79 mmHg at 24 h. No cases of wound leakage or early postoperative hypotony were observed in either subgroup. One eye exhibited a transient IOP increase at 8 h; no choroidal effusion, postoperative hemorrhage, or need for secondary suturing occurred. Endotamponade consisted of balanced salt solution (BSS) in eight eyes, SF6 in seven eyes, silicone oil in two eyes, and air in one eye. Conclusions: The slit-modified infusion trocar enables secure, hypotony-free closure of the infusion sclerotomy by eliminating the open-wound interval during trocar removal. This simple biomedical device modification provides stable early postoperative IOP across different tamponade agents and appears safe and feasible in high-risk eyes with PDR. Full article

Background and Clinical Significance: The management of large benign ovarian cysts in women of reproductive age requires balancing minimally invasive surgery with oncologic safety and preservation of ovarian function. Laparoscopic cystectomy for large cysts is technically challenging and carries an increased risk of intraoperative rupture and spillage; Case Presentation: We describe a novel hybrid laparoscopic–extracorporeal technique in which controlled cyst decompression is performed using a balloon-tipped trocar through a suprapubic port under direct laparoscopic visualization. The ovary is then carefully mobilized and exteriorized through the same incision, allowing extracorporeal cystectomy and ovarian reconstruction before returning the adnexa to the abdominal cavity. This approach was applied in a series of six patients with large benign-appearing ovarian cysts, including one 42-year-old patient with an 18 cm multilocular mature cystic teratoma. There were no intraoperative or postoperative complications, no conversions to laparotomy, and all patients were discharged on postoperative day 1. Follow-up at six weeks and subsequent imaging at nine months demonstrated preserved ovarian architecture, normal menstrual function, and high patient satisfaction; Conclusions: The hybrid laparoscopic–extracorporeal approach appears feasible and may offer a safe surgical option in carefully selected patients, allowing fertility preservation while minimizing the risk of spillage. Further studies are needed to evaluate reproducibility, oncologic safety, and long-term reproductive outcomes. Full article

Background/Objectives: This study aimed to determine the inguinal hernia recurrence rate after transabdominal preperitoneal (TAPP) repair, particularly considering the effect of simultaneous umbilical hernia repair. The secondary aim was to assess whether closing the 10 mm midline supraumbilical port-site fascia affects the incidence of trocar-site hernia (TSH) following inguinal TAPP. Methods: We reviewed medical records of consecutive patients undergoing inguinal TAPP at the Department of Surgery, University Hospital Centre Zagreb, between 1 January 2014 and 30 June 2022, and supplemented the data with telephone follow-up. Demographic, clinical, and operative variables were compared between patients who did and did not report inguinal hernia recurrence. Patients were also grouped by operating surgeon to compare TSH rates. Surgeon A routinely closed the 10 mm supraumbilical fascial defect with a single suture, while Surgeon B mostly did not, deciding on a case-by-case basis. Results: The analysis included 281 patients with a median follow-up of 60 months. The overall recurrence rate was 10.6%. Baseline demographic and clinical characteristics did not differ significantly between patients who reported recurrence and those who did not. A prior hernia repair was more common in the recurrence group (34.1% vs. 17.2%; p = 0.007). Concomitant umbilical hernia repair was performed in 12.5% of cases. Patient-reported recurrence was higher after combined TAPP and umbilical hernioplasty than after TAPP alone (14.3% vs. 12.2%), but this difference was not statistically significant (p = 0.784). Surgeon A had a lower observed TSH rate than Surgeon B (1.0% vs. 3.6%), although this difference did not reach statistical significance (p = 0.242). Conclusions: Concurrent TAPP and umbilical hernioplasty is not associated with a higher recurrence rate, but further research on a larger cohort is necessary. Routine closure of the 10 mm midline supraumbilical fascial defect could reduce the TSH rate, although the difference was not statistically significant. The side of the hernia does not influence recurrence after TAPP. Full article

Background: Surgical site infection (SSI) remains the most frequent postoperative complication after pediatric laparoscopic appendectomy. Evidence is scarce regarding whether the specimen extraction port site represents a modifiable risk factor. This study evaluated the association between 10 mm trocar placement for appendix extraction and postoperative outcomes in children undergoing laparoscopic appendectomy. Methods: A retrospective single-center cohort study was conducted including children aged 0–17 years who underwent laparoscopic appendectomy between January 2012 and January 2026 with ≥30-day follow-up. Patients were grouped by placement site of the 10 mm trocar: supraumbilical versus left lower quadrant (LLQ). The primary outcome was postoperative wound infection. Secondary outcomes included overall complications, intra-abdominal abscess, postoperative ileus, stump dehiscence, operative time, length of stay, readmission, reoperation, and conversion to laparotomy. Subgroup analyses assessed the impact of endoscopic retrieval-bag use within each trocar-position group. Results: Baseline demographic, clinical, laboratory, and histopathological characteristics were comparable between the two 10 mm trocar placement sites. Overall, postoperative complications were higher with supraumbilical placement than with LLQ placement (6.9% vs. 2.9%, p < 0.001). SSI was more frequent with supraumbilical placement (3.7% vs. 0.3%, p < 0.001). Multivariable analysis confirmed trocar position as an independent predictor of SSI, with LLQ placement associated with a lower risk (OR 0.52, 95% CI 0.30–0.88, p = 0.015). Operative time was shorter with LLQ placement (median 32 vs. 36 min, p < 0.001). No significant differences were observed between placement sites in intra-abdominal abscess, postoperative ileus, readmission, reoperation, conversion to laparotomy, or length of hospital stay. Retrieval-bag use was not associated with differences in complication rates within either trocar placement site. Conclusions: LLQ 10 mm trocar placement site was associated with substantially lower SSI rates and shorter operative time compared with supraumbilical extraction, without increasing other postoperative complications. Extraction port selection may represent a simple technical measure to improve outcomes in pediatric laparoscopic appendectomy without requiring additional resources. Full article

Background: Kartagener syndrome (KS) is a rare subset of primary ciliary dyskinesia characterized by the triad of situs viscerum inversus (SVI), chronic sinusitis, and bronchiectasis. Laparoscopic cholecystectomy (LC) in patients with SVI is technically demanding because of mirror-image anatomy, while evidence supporting the use of indocyanine green (ICG) fluorescence in this setting is scarce. Case Presentation: We report the case of a 25-year-old woman with KS and SVI totalis who underwent elective LC for symptomatic cholelithiasis. The procedure was performed using a mirror American approach with four trocars and near-infrared ICG fluorescence cholangiography. ICG enabled real-time visualization of biliary anatomy and facilitated intraoperative orientation. The procedure was completed laparoscopically without intraoperative or postoperative complications, and the postoperative course was uneventful. Methods: A non-systematic narrative review of the literature was conducted to identify reported cases of LC in patients with SVI, including cases associated with KS. Studies published between 1991 and 2025 were retrieved from PubMed, Web of Science, Scopus, and Embase. Data were descriptively summarized, focusing on surgical technique, trocar placement, and reported use of ICG fluorescence. Results: A total of 143 articles were included. Most cases involved isolated SVI, while KS was reported only in a minority of patients. The mirror American technique and four-trocar configuration were the most frequently adopted approaches. Only three cases, including the present report, described the use of ICG fluorescence during LC in patients with SVI or KS. Conclusions: LC in patients with SVI is feasible but technically demanding. ICG fluorescence may assist intraoperative biliary orientation in complex anatomical settings; however, current evidence is extremely limited and should be considered hypothesis-generating only. Full article

Introduction: Understanding superficial epigastric vessel anatomy is crucial for abdominal surgeries like laparoscopy, especially in neonates, to prevent injury. While standard courses are described, variations occur. This case report highlights a unique anatomical variation in the superficial epigastric artery found during the dissection of a stillborn neonatal cadaver. Case Report: In contrast to the usual origin from the femoral artery, this variation features the inferior epigastric artery penetrating the anterior abdominal wall near the umbilicus and branching superiorly to supply the superficial abdominal wall. Conclusions: This distinctive vascular configuration, which to the best of our knowledge has not been previously described in neonatal anatomical literature, diverges from the typical symmetrical arrangement and previously reported variations. The study stresses the clinical importance of this finding, especially for laparoscopic procedures in neonates. During trocar placement, surgeons should be cognizant of such variations to reduce the risk of iatrogenic injuries, including rectus sheath hematoma. The report highlights the need for further investigation to establish the prevalence of this variation and its potential effects on surgical safety and outcomes in a broader neonatal population, which may also reflect the dynamic vascular remodeling that occurs during early developmental stages. Full article

Background: Intraventricular tumors represent a minority in the context of brain tumors, but their surgical treatment is particularly complex due to their vascularization and visualization, especially in deep localization. The characteristics of these tumors make them ideal candidates for minimally invasive surgical strategies such as the tubular retractor technique, above all in the elderly population. Objectives: A 1-year multi-center, retrospective case series was performed: the authors describe their preliminary experience using a neuronavigated tubular retractor in the management of 11 cases of intraventricular meningiomas. Methods: Clinical and radiological findings were examined to define the outcomes. We used an alternative tubular retractor system obtained using a modified preexisting general surgery trocar (ENDOPATH XCEL 15 mm trocar) or the NICO System BrainPath. Results: Gross total resection, defined as the removal of all the tumor visible from the brain scans, was achieved in all cases. Ten out of eleven of the patients did not experience major complications or permanent neurological deficits. Four patients presented transitory post-operative agitation, visual blurring and transient hemiparesis. All patients (mean age 72.6 years) were discharged from the hospital in 5–7 days. Conclusions: Our preliminary experience suggests that the use of navigated tubular retractors, by displacing the fibers and hence minimizing the damage to the surrounding cerebral parenchyma, is feasible and safe, representing a minimally invasive technique for a personalized and patient-tailored approach. The use of the selective ultrasonic aspirator makes it possible to excise the tumor through the narrow corridor of the tubular lumen of around 2 cm, and this technique can also be improved using both endoscope and microscope guidance. Full article

Manual alignment between the trocar, surgical instrument, and robot during minimally invasive surgery (MIS) can be time-consuming and error-prone, and many existing systems do not provide autonomous localization and pose estimation. This paper presents an artificial intelligence (AI)-assisted, vision-guided framework for automated localization and positioning of the ATHENA parallel surgical robot. The proposed approach combines an Intel RealSense RGB–depth (RGB-D) camera with a You Only Look Once version 11 (YOLO11) object detection model to estimate the 3D spatial coordinates of key surgical components in real time. The estimated coordinates are streamed over Transmission Control Protocol/Internet Protocol (TCP/IP) to a programmable logic controller (PLC) using Modbus/TCP, enabling closed-loop robot positioning for automated docking. Experimental validation in a controlled setup designed to replicate key intraoperative constraints demonstrated submillimeter positioning accuracy (≤0.8 mm), an average end-to-end latency of 67 ms, and a 42% reduction in setup time compared with manual alignment, while remaining robust under variable lighting. These results indicate that the proposed perception-to-control pipeline is a practical step toward reliable autonomous robotic docking in MIS workflows. Full article