Robot-sewn Ivor-Lewis anastomosis: preliminary experience and technical details.

INTRODUCTION: Robot-assisted minimally invasive esophagectomy with intra-thoracic anastomosis showed encouraging results but there is a lack of data to demonstrate the safety and feasibility. OBJECTIVE: The aim of this study is to report our experience in RA-ILE (robotic-assisted Ivor-Lewis esophagectomy) with robotic hand-sewn anastomosis. METHODS: This is a retrospective study of patients who underwent robotic-assisted esophagectomy in prone position with intrathoracic anastomosis for malignant neoplasm of the esophagus or esophago-gastric junction. RESULTS: From January 2012 to December 2014 we performed eight completely robot-assisted esophagectomy without intra-operative complication. The mortality rate at 30-day was zero. In two patients we observed a partial leakage of the gastric tube that required revision. The mean operative time was 499 ± 46 min including robotic set up and patient positioning. The median hospital-stay was 10 days. Complete (R0) resection was accomplished in all patients and the mean number of lymph nodes removed was 37.6 ± 14 .7. CONCLUSIONS: This preliminary experience suggests that robotic-assisted RA-ILE for malignant lesions is a real surgical option compared with conventional surgery with satisfactory results. Copyright © 2015 John Wiley & Sons, Ltd.

Laparoscopic appendectomy performed by residents and experienced surgeons.

BACKGROUND: Laparoscopic appendectomy is widely performed by surgical residents, but its changing indications and outcomes have been poorly investigated. The aim of this study was to examine whether a difference exists in indications and outcomes between laparoscopic appendectomies performed by residents and those performed by experienced surgeons. METHODS: Between 1999 and 2007, 218 laparoscopic appendectomies were performed and recorded. Data were analyzed to compare operations performed by residents with those by experienced surgeons in terms of indications for surgery and severity of disease. Moreover, laparoscopic appendectomies were thoroughly compared regarding outcomes and complications. RESULTS: The residents had fewer conversions with laparoscopic appendectomy (8% vs 17%, P=0.04), and similar complication rates (12% vs 13%, P=0.16), compared with experienced surgeons. The median operating time was also comparable (67 minutes vs 60 minutes, P=0.23). However, patients operated on by residents had more emergencies (86% vs 70%, P=0.009), included more foreigners (27% vs 15%, P=0.03), and had intermediate to severe diseases, (81 vs 52%, P<0.001) than patients did operated on by experienced surgeons. CONCLUSIONS: Surgical residents performed more emergency laparoscopic appendectomies on foreign patients suffering from intermediate to severe diseases compared with experienced surgeons, with comparable surgical outcomes and lower conversion rates.

Comparison of laparoscopic and open repair for primary ventral hernias.

We designed a retrospective clinical trial comparing laparoscopic primary ventral hernia repair (LPVHR) and open traditional repair (OPVHR). Demographics, perioperative data, results, and follow-up were examined to determine if there was any difference in the main outcomes. From January 2000 to December 2006, 28 consecutive, unselected patients, who successfully underwent LPVHR, were matched with 36 patients, who received OPVHR (with mesh) during the same period. The operating room records, clinical files, and outpatient sheets were examined. Patient demographics, results, and follow-up were compared in the 2 groups. Demographic characteristics, site of hernia, concomitant surgery, and defect size were comparable between the 2 groups, but the proportion of urgent procedures was higher in OPVHR patients (25% vs. 4%; P=0.03). The overall complication rates were similar, with some specific differences, whereas analgesic requirement and hospital stay were also comparable. The operative times were significantly longer for the LPVHR group (70 min vs. 35 min; P<0.000). Four recurrences were noted in both OPVHR and LPVHR patients, 11% versus 14%, respectively, with no significant difference (P=0.67). LPVHR seemed to be as safe as the OVHR in this study, although LPVHR increased operative time. The complications of each method should be taken into consideration before making the choice of the surgical approach.

Predictors of recurrence after laparoscopic ventral hernia repair.

Laparoscopic ventral hernia repair (LVHR) is widely used to manage ventral hernias, but predictors of hernia recurrence have been poorly investigated. This retrospective study investigated the influence of common risk factors on hernia recurrence. Data from 146 consecutive, unselected patients who underwent LVHR between 2000 and 2006 were collected. Demographic, clinical, and perioperative parameters were analyzed to identify predictable risk factors for hernia recurrence. Both univariate and multivariate Cox's regression analysis were employed. The overall recurrence rate was 8% (12 patients) after an average follow-up of 45 months. On univariate analysis, smoking (P=0.01) and earlier repair (P<0.00) were significantly different in recurred patients. However, only earlier repair was an independent predictor of multivariate Cox's regression analysis (hazard ratio 0.085, 95% confidence interval: 0.020-0.355; P=0.001). LVHR is a safe technique to repair ventral hernias. However, smokers with earlier failed repair attempts have a higher risk of recurrence.

Safety of laparoscopic cholecystectomy performed by surgical residents.

Laparoscopic cholecystectomy is being widely performed by surgical residents, but specific outcomes have been poorly investigated. Data from 171 consecutive, unselected patients who underwent laparoscopic cholecystectomy performed by surgical residents were collected and matched with an equal number of randomly extracted laparoscopic cholecystectomies performed by experienced senior staff surgeons between 2000 and 2006 at our institution. Demographic data, emergency procedures, cholangiographies, complications and length of stay were not significantly different between the two groups. However, surgical residents performed the operations in less complicated patients (ASA group 3-4 2% vs. 8%, respectively, p = 0.04). Moreover, the median duration of surgery was significantly longer in the resident group (67 vs. 50 minutes, p < 0.001), with fewer additional contemporary procedures (3% vs. 7%, respectively, p = 0.009). This study established that although surgical residents operated on less complex patients with longer operative times, the intraoperative difficulties and main outcomes were the same as for the senior surgeons.

Laparoscopic cholecystectomy: retrospective comparative evaluation of titanium versus absorbable clips.

We present a retrospective study of the use of titanium and absorbable clips during laparoscopic cholecystectomy. The aim was to determine any differences in outcome and costs. From January 1999 to February 2002, 690 patients who had successfully undergone a laparoscopic cholecystectomy were reviewed. According to the type of clip, we retrospectively identified two groups of patients: 199 in whom the surgeons had used absorbable clips (absorbable clip group, ACG) and 491 in whom the surgeons had used titanium nonabsorbable clips (titanium clip group, TCG). Data about demographics, operation, results, complications, and follow-up were collected and matched in the two groups. Demographics, concomitant surgery, and the American Society of Anesthesiologists (ASA) status were comparable between the two groups. Although the proportions of cases requiring urgent operation, intraoperative cholangiography, use of a fourth trocar, and use of drainage suction were similar, the difficulty score of the operation was lower (6.3 vs. 7.0, P =.03) and the operative time was shorter (44 vs. 61 minutes, P <.0001) in the ACG than in the TCG. Complications, hospital stay, and long-term results were satisfactory and comparable between the two groups. No correlation was found between clip type and the incidence of biliary tree injuries, bleeding, wound infection, or readmission. The cost of the two types of clips varied slightly (90 euros for each procedure). Despite the fact that absorbable clips are theoretically less likely to cause complications than metallic ones, we were not able to demonstrate any clinical advantage during laparoscopic cholecystectomy in this retrospective study. Furthermore, the results suggest that absorbable clips are preferred when the cholecystectomy presents fewer difficulties.

Laparoscopic treatment of ventral hernias: prospective evaluation.

We describe 50 patients who recently underwent laparoscopic surgery. Early results, complications, and follow-up data were collected prospectively. Of 50 patients, 34 had an incisional hernia, whereas 16 had a primary defect. Three trocars were inserted. EndoShears or Ultracision was used for tissue manipulation. The prosthetic mesh used was an expanded polytetrafluoroethylene (ePTFE) mesh, inserted through the first trocar and fixed with a helicoidal stapler. Patients were followed-up in the outpatient clinic (mean, 14 months). Every operation was successfully completed, and mean operative time was 103 minutes. There were two small bowel injuries (4%) repaired by minilaparotomy. Postoperative pain was limited. Bowel movements, ambulation, and discharge were prompt. We noted 4 cases of urinary retention (8%), 8 seromas (16%), and 1 prolonged ileus, which resolved on day 5 spontaneously. Mean postoperative stay was 4 days. One patient was readmitted after 4 weeks because of incomplete obstruction, resolved conservatively. There has been only 1 recurrence (2%), 8 months after the operation. The technique appears safe and efficacious.