STAPLED FASCIAL CLOSURE VS. CONTINUOUS HAND-SEWN SUTURE: EXPERIMENTAL STUDY OF THE ABDOMINAL WALL ON PORCINE MODEL AND HUMAN CADAVER.

BACKGROUND: One of the primary complications associated with large incisions in abdominal surgery is the increased risk of fascial closure rupture and incisional hernia development. The choice of the fascial closure method and closing with minimal tension and trauma is crucial for optimal results, emphasizing the importance of uniform pressure along the suture line to withstand intra-abdominal pressure. AIMS: To evaluate the resistance to pressure and tension of stapled and sutured hand-sewn fascial closure in the abdominal wall. METHODS: Nine abdominal wall flaps from human cadavers and 12 pigs were used for the experimentation. An abdominal defect was induced after the resection of the abdominal wall and the creation of a flap in the cadaveric model and after performing a midline incision in the porcine models. The models were randomized into three groups. Group 1 was treated with a one-layer hand-sewn small bite suture, Group 2 was treated with a two-layer hand-sewn small bite suture, and Group 3 was treated with a two-layer stapled closure. Tension measurements were assessed in cadaveric models, and intra-abdominal pressure was measured in porcine models. RESULTS: In the human cadaveric model, the median threshold for fascial rupture was 300N (300-350) in Group 1, 400N (350-500) in Group 2, and 350N (300-380) in Group 3. Statistical comparisons revealed non-significant differences between Group 1 and Group 2 (p=0.072, p>0.05), Group 1 and Group 3 (p=0.346, p>0.05), and Group 2 and Group 3 (p=0.184, p>0.05). For porcine subjects, Group 1 showed a median pressure of 80 mmHg (85-105), Group 2 had a median of 92.5 mmHg (65-95), and Group 3 had a median of 102.5 mmHg (80-135). Statistical comparisons indicated non-significant differences between Group 1 and Group 2 (p=0.243, p>0.05), Group 1 and Group 3 (p=0.468, p>0.05), and Group 2 and Group 3 (p=0.083, p>0.05). CONCLUSIONS: Stapled and conventional suturing resist similar pressure and tension thresholds.

Bovine Pericardial Graft for Portomesenteric Reconstruction During Robotic Pancreatoduodenectomy.

BACKGROUND: Minimally invasive pancreatoduodenectomy (PD) is one of the most complex procedures in oncologic surgery. We present a video of robotic portomesenteric reconstruction with bovine pericardial graft during PD. METHODS: A 52-year-old woman was referred with a mass in the head of the pancreas. The tumor was in contact with the portomesenteric axis. The multidisciplinary team decided to perform an upfront resection. The surgery was performed as a pylorus-preserving pancreaticoduodenectomy with lymphadenectomy. The superior mesenteric artery first approach was used to expose the head of the pancreas, so that the entire surgical specimen was attached only through the tumor invasion of the portomesenteric axis. After resection of the invaded portomesenteric axis, its large extension precluded primary reconstruction, so a bovine pericardial graft was used for venous reconstruction. After completion of the venous anastomosis, reconstruction of the digestive tract was performed as usual. RESULTS: Surgical time was 430 min; clamp time was 55 min; and portomesenteric reconstruction took 41 min. Estimated blood loss was 320 mL without transfusion. Pathology confirmed T3N1 ductal adenocarcinoma with free margins. No pancreatic or biliary fistula was observed, and she was discharged on postoperative day 8. A postoperative examination confirmed the patency of the graft. The patient is doing well 6 months after surgery and has no signs of the disease. CONCLUSIONS: A bovine pericardial graft is useful for reconstruction and readily available, eliminating the need to harvest an autologous vein or use synthetic grafts. This procedure can be safely performed with the robotic platform.

A new technique of duodenojejunostomy may reduce the rate of delayed gastric emptying after pylorus-preserving pancreatoduodenectomy: The growth factor technique (with video).

BACKGROUND: Despite various technical modifications, delayed gastric emptying (DGE) is one of the most common complications after pancreatoduodenectomy. DGE results in longer hospital stay, higher cost, lower quality of life, and delay of adjuvant therapy. We have developed a modified duodenojejunostomy technique to reduce the incidence of DGE. Here we evaluate our 4-year experience with this technique. METHODS: This study evaluated consecutive patients who underwent pylorus-preserving pancreatoduodenectomy using the growth factor technique. It consists of performing a posterior seromuscular running suture with a zigzag stitch that stretches the jejunum and allows future growth of the anastomosis. This results in a longer jejunal opening. The angles at the edge of the duodenum are cut to accommodate the duodenal opening to the longer jejunum (the growth factor). The anterior seromuscular layer is then performed with interrupted sutures to accommodate the larger anastomosis. These patients were compared with a cohort of patients (n = 103) before the introduction of this new technique using propensity score matching. RESULTS: 134 patients underwent pylorus-preserving pancreatoduodenectomy. Delayed gastric emptying occurred in only three patients (2.2%), one grade B and two grade C. Compared with the 103 patients in the control group with standard technique, the incidence of DGE was significantly higher (11.6%; P = 0.00318). The median hospital stay was also statistically longer in the control group (P = 0.048704). A similar trend was observed in the matched cohort; the proportion of patients who developed DGE was significantly (P = 0.005) lower in the growth factor technique group (2.1% vs. 12.9%). Hospital stay was significantly longer in the standard group (P = 0.008), and patients operated on with the standard technique resumed feeding later than those with the growth factor technique. CONCLUSIONS: This study demonstrated that the new technique of duodenojejunostomy can reduce the incidence and severity of DGE and allow earlier hospital discharge. Comparative studies are still needed to confirm these preliminary results.

Robotic Hepatic Bisegmentectomy (s4b + s5) and Hilar Lymphadenectomy for Incidental Gallbladder Cancer Using Glissonian Approach.

BACKGROUND: Gallbladder carcinoma is a rare cancer with a poor prognosis and the most common biliary tract malignancy. This video shows robotic treatment of a patient with incidental gallbladder cancer diagnosed after laparoscopic cholecystectomy. The operation consisted of a robotic bisegmentectomy (liver segments 4b and 5) using a Glissonian approach and a hilar lymphadenectomy. METHODS: A 73-year-old woman with no relevant history underwent a laparoscopic cholecystectomy at another hospital facility. The pathology revealed a gallbladder carcinoma. The patient was then referred for further treatment. Pathologic revision confirmed T2a carcinoma and staging was negative for distant metastases. The multidisciplinary team decided on a radical resection that will consist of a hilar lymphadenectomy and a frozen section of the cystic stump along the resection of segments 4b and 5. A robotic approach was proposed, and consent was obtained. RESULTS: The operation time was 300 min and was performed 21 days after the cholecystectomy. Estimated blood loss was 120 mL with no transfusions required during or after the procedure. The postoperative recovery was uneventful, and the patient was discharged on the fourth postoperative day. The final pathology showed no residual disease in the liver specimen and no metastases among 16 removed lymph nodes. CONCLUSIONS: The robotic approach is safe and feasible for radical treatment after incidentally discovered gallbladder cancer. The Glissonian approach is useful for anatomic resection of liver segments 4b and 5. This video can help oncologic surgeons to perform this challenging procedure.

ROBOTIC LIVER RESECTION. REPORT OF THE FIRST 50 CASES.

BACKGROUND: Robotic surgery has gained growing acceptance in recent years, expanding to liver resection. OBJECTIVE: The aim of this paper is to report the experience with our first fifty robotic liver resections. METHODS: This was a single-cohort, retrospective study. From May 2018 to December 2020, 50 consecutive patients underwent robotic liver resection in a single center. All patients with indication for minimally invasive liver resection underwent robotic hepatectomy. The indication for the use of minimally invasive technique followed practical guidelines based on the second international laparoscopic liver consensus conference. RESULTS: The proportion of robotic liver resection was 58.8% of all liver resections. Thirty women and 20 men with median age of 61 years underwent robotic liver resection. Forty-two patients were operated on for malignant diseases. Major liver resection was performed in 16 (32%) patients. Intrahepatic Glissonian approach was used in 28 patients for anatomical resection. In sixteen patients, the robotic liver resection was a redo hepatectomy. In 10 patients, previous liver resection was an open resection and in six it was minimally invasive resection. Simultaneous colon resection was done in three patients. One patient was converted to open resection. Two patients received blood transfusion. Four (8%) patients presented postoperative complications. No 90-day mortality was observed. CONCLUSION: The use of the robot for liver surgery allowed to perform increasingly difficult procedures with similar outcomes of less difficult liver resections.

Hepatectomia robótica. Relato dos primeiros 50 casos / Robotic liver resection. report of the first 50 cases

ABSTRACT BACKGROUND: Robotic surgery has gained growing acceptance in recent years, expanding to liver resection. OBJECTIVE: The aim of this paper is to report the experience with our first fifty robotic liver resections. METHODS: This was a single-cohort, retrospective study. From May 2018 to December 2020, 50 consecutive patients underwent robotic liver resection in a single center. All patients with indication for minimally invasive liver resection underwent robotic hepatectomy. The indication for the use of minimally invasive technique followed practical guidelines based on the second international laparoscopic liver consensus conference. RESULTS: The proportion of robotic liver resection was 58.8% of all liver resections. Thirty women and 20 men with median age of 61 years underwent robotic liver resection. Forty-two patients were operated on for malignant diseases. Major liver resection was performed in 16 (32%) patients. Intrahepatic Glissonian approach was used in 28 patients for anatomical resection. In sixteen patients, the robotic liver resection was a redo hepatectomy. In 10 patients, previous liver resection was an open resection and in six it was minimally invasive resection. Simultaneous colon resection was done in three patients. One patient was converted to open resection. Two patients received blood transfusion. Four (8%) patients presented postoperative complications. No 90-day mortality was observed. CONCLUSION: The use of the robot for liver surgery allowed to perform increasingly difficult procedures with similar outcomes of less difficult liver resections.

RESUMO CONTEXTO: A cirurgia robótica tem tido aceitação crescente nos últimos anos, expandindo-se para a ressecção hepática. OBJETIVO: Relatar a experiência com as primeiras cinquenta ressecções hepáticas robóticas. MÉTODOS: Trata-se de análise retrospectiva de dados coletados prospectivamente. De maio de 2018 a dezembro de 2020, 50 pacientes consecutivos foram submetidos à ressecção hepática robótica em um único centro. Todos os pacientes com indicação de ressecção hepática minimamente invasiva foram submetidos à hepatectomia robótica. A indicação de técnica minimamente invasiva seguiu as diretrizes práticas baseadas na segunda conferência internacional de consenso laparoscópico hepático. RESULTADOS: A proporção de ressecções hepáticas robóticas foi de 58,8% de todas as ressecções hepáticas. Trinta mulheres e 20 homens com idade mediana de 61 anos foram submetidos à ressecção hepática robótica. Quarenta e dois pacientes foram operados por doenças malignas. Ressecção hepática maior foi realizada em 16 (32%) pacientes. A abordagem Glissoniana intra-hepática foi usada em 28 pacientes para ressecção anatômica. Em 16 pacientes, a ressecção hepática robótica foi uma re-hepatectomia. Em 10, a hepatectomia prévia foi aberta e em seis foi por via minimamente invasiva. Ressecção simultânea do cólon foi feita em três pacientes. Um paciente foi convertido para ressecção aberta. Dois pacientes receberam transfusão sanguínea. Quatro (8%) pacientes apresentaram complicações pós-operatórias. Mortalidade em 90 dias foi nula. CONCLUSÃO: O uso do robô permitiu realizar procedimentos progressivamente mais complexos com resultados semelhantes às hepatectomias menos complexas.

Mesopancreas Excision and Triangle Operation During Robotic Pancreatoduodenectomy.

BACKGROUND: The retropancreatic space between the superior mesenteric artery, celiac axis, and portal vein is called the mesopancreas. Total mesopancreas excision and skeletonization of both celiac axis and superior mesenteric artery are used to reduce R1 resection in high-risk patients and in those with locally advanced disease. The aim of this study was to present a series of video clips from several patients showing the mesopancreas excision and the triangle operation with a detailed technical description of both techniques with different approaches. METHODS: Video clips were compiled from several robotic pancreatoduodenectomies to demonstrate the total mesopancreas excision and triangle operation technique, as follows: (1) main steps for mesopancreas excision and triangle operation, (2) anterior approach for mesopancreas excision, and (3) triangle operation. RESULTS: A total of 87 patients underwent robotic PD at our center between March 2018 and March 2021. Of these, 22 patients underwent robotic mesopancreas excision. This technique was used for patients at high risk for R1 resection in 18 patients and triangle operation in four patients. Partial portal vein resection was necessary in 6 cases. One patient had R1 resection and was treated with adjuvant therapy. The remaining patients presented free surgical margins. The mean number of harvested lymph nodes was 40 (range: 27-77). The median interval between the operation and chemotherapy was 23 days. CONCLUSIONS: The robotic total mesopancreas excision and the triangle operation are feasible and safe for selected patients. The indication for this radical operation is the presence of a high risk for R1 resection and for those with locally advanced disease. The presented video may help oncological surgeons to perform these techniques.

Robotic Resection and Reconstruction of the Superior Mesenteric Vein Without Graft During Pancreatoduodenectomy (with Video).

BACKGROUND: Pancreatoduodenectomy is the procedure of choice for tumors in the head of the pancreas. Invasion of major vessels is a relative contraindication for minimally invasive approach. We present a video of a robotic resection and reconstruction of the superior mesenteric vein (SMV) without the use of a graft during pancreatoduodenectomy. METHODS: A 56-year-old female with ductal adenocarcinoma is referred for treatment. CT scan and endoscopic ultrasound showed a 3-cm tumor in the pancreatic head with contact with SMV. The multidisciplinary team decided for upfront surgery. Robotic superior mesenteric artery first approach was used to release the head of the pancreas, so the whole surgical specimen is only attached by the tumor invasion of the SM. After the partial resection of the SMV, its extension precluded lateral suture and a transverse anastomosis was necessary to minimize the risk of narrowing of the SMV. After completion of the venous anastomosis, reconstruction of the alimentary tract was done as usual. RESULTS: Operative time was 430 min. Time of clamping was 30 min and the time for the SMV suture is 23 min. Estimated blood loss was 370 mL. Pathology confirmed a T3N1 ductal adenocarcinoma with free margins. The patient was discharged on the 7th postoperative day. CONCLUSIONS: Robotic resection and reconstruction of the SMV is safe and feasible without graft during pancreatoduodenectomy in patients with invasion but not encasing of the portal vein or SMV. The proposed technique should be used in cases where the invasion requires extended resection that precludes simple lateral suture.

Robotic Right Hepatectomy with Portal Vein Thrombectomy for Colorectal Liver Metastasis (with Video).

BACKGROUND: Hepatectomy is the standard treatment for colorectal liver metastases. However, the high recurrence rate is a persistent problem that occurs in up to 65% of patients. Repeat hepatectomy is a feasible treatment and may offer favorable surviva but is technically demanding so minimally invasive repeat hepatectomy has been used in a few patients. Colorectal liver metastases are different from hepatocellular carcinoma and rarely present with macroscopic portal vein tumoral thrombus. To the best of our knowledge, minimally invasive approaches for this rare condition have not yet been reported. METHOD: We present here a video of a robotic right hepatectomy in a patient with single colorectal liver metastasis and macroscopic tumor thrombi in the right portal vein. A 61-year-old woman underwent open resection of a transverse colon cancer (T3N0M0) in December 2015. In March 2019, she underwent nonanatomical resection of a liver metastases located in segment 6 also via an open approach. She then underwent adjuvant chemotherapy. However, in September 2020, she presented with a local recurrence and a tumor thrombus in the right portal vein. She was then referred to us for treatment and a multidisciplinary team decided on upfront liver resection due to the risk of left portal vein progression. Liver volumetry showed future liver remnant of 52.5%. Right hepatectomy with portal vein thrombectomy was indicated. A robotic approach was proposed, and consent was obtained. RESULTS: The Da Vinci system was used. The operation began with the division of adhesions from previous laparotomies. Intraoperative ultrasound was performed to locate the tumor and to confirm the portal vein invasion. Hepatic hilum was carefully dissected. The replaced right hepatic artery from the superior mesenteric artery was ligated and divided. The common bile duct was dissected and encircled with a vessel loop. The portal vein was dissected, and an enlarged right portal vein with a protruding tumoral thrombus was seen. The left portal vein and portal vein trunk were then temporarily clamped. The right portal vein was carefully transected with robotic scissors being careful not to displace the thrombus. A minimum stump was left to safely suture the portal vein. The portal vein was then closed with a running 5-0 prolene suture. The portal vein clamping was then released, and a patent anastomosis with no leakage was observed. Right liver ischemic discoloration was seen and confirmed with fluorescence imaging after indocyanine green injection. A future line of transection was marked along ischemic area. The liver was divided using bipolar forceps under saline irrigation until it was detached from the retrohepatic vena cava. A right hepatic vein was divided with a stapler to complete the right hepatectomy. The surgical specimen was removed through a suprapubic incision, and the abdominal cavity was drained with a closed-suction drain. The total operative time was 270 min with no transfusion. Pathology conformed the diagnosis with free surgical margins. CONCLUSION: Robotic right hepatectomy with tumor thrombectomy is feasible and safe even in the presence of lobar portal vein invasion. This video may help HPB surgeons perform this complex procedure.