Comparative study of 2-D and bichanneled 3-D laparoscopic images: Is there a difference?

INTRODUCTION: Lack of depth perception and spatial orientation are drawbacks of laparoscopic surgery. The advent of the 3-D camera system enables surgeons to regain binocular vision. The aim of this study was to gain subjective and objective data to determine whether 3-D systems are superior to 2-D systems. MATERIALS AND METHODS: Our study consisted of two parts: a laparoscopic training model and an actual operation assessment. In the first part, we compared two groups of surgeon (specialists and trainees) performing a laparoscopic task using a 2-D and a 3-D camera system. In the second part, surgeons were assessed on their performance of standard laparoscopic cholecystectomies using the two different camera systems. At the end of each assessment, participants were required to complete a questionnaire on their impressions of the comparative ease of operation tasks under 2-D and 3-D vision. RESULT: In the laboratory training model, trainees' performance time was shorter with the 3-D camera system than with the 2-D camera, but no difference was observed in the specialists group. In the surgical (cholecystectomy) assessment, no significant difference was observed between the 2-D and 3-D camera systems in terms of operative time and precision. The questionnaire indicated that all participants did not significantly favor the 3-D system. CONCLUSION: We believe that the 3-D camera system can allow young surgeons to perform standard laparoscopic tasks safely and quickly, so as to accelerate the learning curve. However, new-generation 3-D systems will be essential to overcome surgeons' discomfort.

Robot-assisted laparoscopic liver resection for hepatocellular carcinoma: short-term outcome.

BACKGROUND: This study aimed at analyzing the perioperative and early survival outcomes of robotic liver resection of hepatocellular carcinoma (HCC). METHODS: The study population included a consecutive series of patients with HCC who underwent robotic liver resection at a single center. RESULTS: During the study period, 41 consecutive patients with HCC underwent 42 robotic liver resections. Five resections (11.9%) were carried out for recurrent HCC, and 23.8% (n = 10) were hemihepatectomy procedures. The mean operating time and blood loss was 229.4 minutes and 412.6 mL, respectively. The R0 resection rate was 93%. The hospital mortality and morbidity rates were 0% and 7.1%, respectively. The mean hospital stay was 6.2 days. The 2-year overall and disease-free survival rates were 94% and 74%, respectively. In the subgroup analysis of minor liver resection, when compared with the conventional laparoscopic approach, the robotic group had similar blood loss (mean, 373.4 mL vs 347.7 mL), morbidity rate (3% vs 9%), mortality rate (0% vs 0%), and R0 resection rate (90.9% vs 90.9%). However, the robotic group had a significantly longer operative time (202.7 mins vs 133.4 mins). CONCLUSIONS: This study demonstrated the feasibility and safety of robotic surgery for HCC, with favorable short-term outcome. However, the long-term oncologic results remain uncertain.

Robot-assisted laparoscopic approach of management for Mirizzi syndrome.

Mirizzi syndrome is an uncommon cause of common hepatic duct obstruction resulting from gallstone impaction in the cystic duct or gallbladder neck. Mirizzi syndrome is traditionally considered as a contraindication to laparoscopic surgery mainly due to risk of bile duct injury during dissection. We present the surgical experience of 5 patients with Mirizzi syndrome who were diagnosed preoperatively and managed using minimally access surgical technique, either total laparoscopic or robotic-assisted laparoscopic approach. All patients had successful operations and recovered without complications. We concluded that with a correct preoperative diagnosis, careful operative strategy, increasing expertise with laparoscopic technique, and introduction of robotic surgical system, minimally invasive approach of management of Mirizzi syndrome becomes safe and feasible.

Robot-assisted whipple's operation for solid pseudopapillary tumour of pancreas.

Solid pseudopapillary tumor is a rare tumor of the pancreas. They are slow growing with low malignant potential. The prognosis is excellent after surgical resection. Here we report a case of solid pseudopapillary tumor of the pancreas at the uncinate process. There are increasing interests about minimal access surgery for pancreatic lesion. However conventional laparoscopic Whipple's operation is technically difficult. With the benign characteristic of this tumor, as well as the advance in robotic surgery, robot assisted approach is an ideal alternative for this case. The operation was performed with a five-port approach with the use of da Vinci S Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA). The operative time was 420 min and operative blood loss was 100 ml. The post operative course was uneventful and the patient was discharged on post operative day 10. This case demonstrates the feasibility of robot assisted Whipple's operation, which has not been extensively reported in the literature.

Robot-assisted laparoscopic pancreaticoduodenectomy versus open pancreaticoduodenectomy--a comparative study.

BACKGROUND: Traditionally, pancreatic surgery is considered as one of the most complex surgeries. The recently developed robotic technology allows surgeons to perform pancreaticoduodenectomy. A comparative study was undertaken to study outcomes between robotic approach and open approach. METHODS: A consecutive patients underwent pancreaticoduodenectomy (robotic approach, n=20; open approach=67) between January 2000 and February 2012 at a single institution were analyzed. RESULTS: The robotic group had a significantly longer operative time (mean, 491.5 vs. 264.9 min), reduced blood loss (mean, 247 vs. 774.8 ml), and shorter hospital stay (mean, 13.7 vs. 25.8 days) compared to the open group. Open conversion rate was 5%. There was no significant difference between the two groups in terms of overall complication rates, mortality rates, R0 resection rate and harvested lymph node numbers. CONCLUSIONS: This study showed that robot-assisted laparoscopic pancreaticoduodenectomy was safe and feasible in appropriately selected patients. However, it is too early to draw definitive conclusions about the value of robot-assisted laparoscopic pancreaticoduodenectomy. In light of remaining uncertainties regarding short-term and long-term outcome, caution should be exercised in the assessment of the appropriateness of this operation for individual patient.

Approach to manage the complications of choledochoduodenostomy: robot-assisted laparoscopic Roux-en-Y hepaticojejunostomy.

PURPOSE: To evaluate the technical feasibility and safety of robot-assisted laparoscopic Roux-en-Y hepaticojejunostomy, using the robotic surgical system. METHODS: This is a report of the use of robot-assisted laparoscopic Roux-en-Y hepaticojejunostomy on 2 patients with recurrent pyogenic cholangitis. Both had past history of side-to-side choledochoduodenostomy with complications of Sump syndrome and benign biliary stricture, respectively. RESULTS: Robot-assisted laparoscopic Roux-en-Y hepaticojejunostomy was completed successfully in these 2 patients. Both patients recovered from the operation, except for 1 patient who had minor bile leakage over the anastomosis 4 days after operation, which subsided after conservative treatment. The mean operating time was 300 minutes and 400 minutes, respectively. The blood loss was 20 mL and 10 mL, respectively. They were able to tolerate liquids on the second postoperative day. They were discharged 6 and 11 days after the operation, respectively. CONCLUSIONS: Robot-assisted laparoscopic Roux-en-Y hepaticojejunostomy is a feasible and safe procedure. However, more large-scale studies with long-term follow-up results are needed.

Prospective randomized comparative study of single incision laparoscopic cholecystectomy versus conventional four-port laparoscopic cholecystectomy.

BACKGROUND: This study aimed to compare the outcomes of single-incision laparoscopic cholecystectomy (SILC) versus conventional 4-port laparoscopic cholecystectomy (LC). METHODS: From November 2009 to August 2010, 51 patients with symptomatic gallstone or gallbladder polyps were randomized to SILC (n = 24) or 4-port LC (n = 27). RESULTS: Mean surgical time (43.5 vs 46.5 min), median blood loss (1 vs 1 mL) and mean hospital stay (1.5 vs 1.8 d) were similar for both the SILC and 4-port LC group. There were no open conversions and no major complications. The mean total wound length of the SILC group was significantly shorter (1.76 vs 2.25 cm). The median visual analogue pain score at 6 hours after surgery was similar (4.5 vs 4.0) but the SILC group had a significantly worse pain score on day 7 (1 vs 0). There was no difference in time to resume usual activity (mean, 5.6 vs 5.0 d). The median cosmetic score of SILC was significantly higher than at 3 months after surgery (7 vs 6). CONCLUSIONS: SILC was feasible and safe for properly selected patients in experienced hands.

Internal pancreatic ductal stenting to reduce leakage rate of pancreaticojejunostomy after pancreaticoduodenectomy: a comparative study.

BACKGROUND/AIMS: This is a non-randomized comparative trial designed to compare the results of pancreaticoduodenectomy with internal pancreatic stenting versus no stenting for pancreaticojejunal (PJ) anastomosis after pancreaticoduodenectomy. METHODOLOGY: Between January 1999 and March 2008, a total of 49 consecutive patients undergoing pancreaticoduodenectomy with duct-to-mucosa PJ anastomosis with, or without an internal stent were evaluated. RESULTS: The 2 groups were comparable in demographic data, underlying pathologies, and pancreatic stump condition. Four patients (16.7%) in the stented group, and four patients (16%) in the non-stented anastomosis group had pancreatic fistula. There was no significant difference in pancreatic fistula rate between two groups. No surgical reintervention was necessary in all the patients with pancreatic fistulas. There were also no significant differences in operating time (mean, 270.5 minutes vs. 263.6 minutes), intra-operative blood loss (mean, 772.9 ml vs. 665.3 ml), overall morbidity (45.8% vs. 40%) and hospital mortality (4.2% vs. 4.0%). The mean hospital stay after surgery was 34 days in stented group and 21.5 days in non-stented group. CONCLUSIONS: Internal stenting of pancreatic duct could not reduce pancreatic fistula rate after pancreaticoduodenectomy.

Robotic hepatobiliary and pancreatic surgery: a cohort study.

BACKGROUND: Robotic surgery has emerged as one of the most promising surgical advances since its launch at the turn of the millennium. Despite its worldwide acceptance in many different surgical specialties, the use of robotic assistance in the field of hepatobiliary and pancreatic (HBP) surgery remains relatively unexplored. This article aims to evaluate the efficacy and outcomes of robotic HBP surgery in a single surgical center. METHODS: Between May 2009 and December 2010, all patients admitted to our unit for robotic HBP surgery were evaluated. A retrospective analysis of a prospectively maintained database on clinical outcomes was performed. RESULTS: There were 55 robotic HBP operations performed during the study period. There were 27 robotic liver resections (left lateral sectionectomies n = 17, left hepatectomy n = 1, other segmentectomies n = 2 and wedge resections n = 7), 12 robotic pancreatic procedures (Whipple's operations n = 8, spleen-preserving distal pancreatectomies n = 2, double bypass n = 1 and cystojejunostomy n = 1) and 16 biliary procedures (biliary enteric bypass n = 9, bile duct exploration and related procedures n = 7). The median postoperative hospital stays for robotic liver resections, biliary procedures and pancreatic operations were 5.5 days (range 3-11 days), 6 days (range 4-11 days) and 12 days (range 6-21 days), respectively. Morbidities for liver resection, biliary procedures and pancreatic operations were 7.4, 18 and 33%, respectively. There was no mortality in our series. CONCLUSIONS: Robotic surgery is feasible and can be safely performed in patients with complicated HBP pathologies. Further evaluation with clinical trials is required to validate its real benefits.

Multimodality laparoscopic liver resection for hepatic malignancy--from conventional total laparoscopic approach to robot-assisted laparoscopic approach.

INTRODUCTION: Laparoscopic liver resection can either be total laparoscopic or hand-assisted laparoscopic approach. The recent introduction of robotic surgical systems has revolutionized the field of minimally invasive surgery. It was developed to overcome the disadvantages of conventional laparoscopic surgery. The role of robotic system in laparoscopic surgery was not well evaluated yet. The aim of this cohort study was to evaluate the outcome of multimodality approach of laparoscopic liver resection for hepatic malignancy METHODS: From January 1998 to August 2010, all patients with hepatic malignancy underwent laparoscopic liver resection were included. A prospectively collected data was analyzed retrospectively. RESULTS: During the study period, a total of 56 patients with hepatic malignancies (hepatocellular carcinoma, HCC, n = 42; colorectal liver metastases, CLM, n = 14) underwent laparoscopic liver resection in our surgical unit. The majority of cases were performed by hand-assisted laparoscopic approach, n = 31 (55.3%) and the remainder were with total laparoscopic approach, n = 10 (17.9%) and robot-assisted laparoscopic approach, n = 15 (26.8%). The median operation time was 150 min (range, 75-307 min). The median blood loss during surgery was 175 ml (range, 5-2000 ml). Two patients (3.6%) needed open conversion and one patient (1.8%) needed to be converted to hand-assisted laparoscopic approach. The morbidity rate was 14.3%. There was no procedure-related death. 89.3% of patients had R0 resection and 10.7% of patients had R1 resection. The median hospital stay was 6.5 days (range, 2-13 days). The 1-year, 3-year, and 5-year disease-free survival rates for HCC were 85%, 47%, and 38%, respectively. The 1-year, 3-year, and 5-year overall survival rates for HCC were 96%, 67%, and 52%, respectively. The 1-year, and 3-year disease-free survival rates for CLM were 92% and 72%. The 1-year, and 3-year overall survival rates for CLM were 100% and 88%, respectively. CONCLUSIONS: Multimodality approach of laparoscopic liver resection of hepatic malignancy was feasible, and safe in selected patients. It was associated with a low complications rate. The mid-term and long-term survival outcome was favorable also.

Combined percutaneous and endoscopic approach in management of dropped gallstones following laparoscopic cholecystectomy.

Dropped gallstones due to accidental perforation of gallbladder wall during laparoscopic cholecystectomy are often encountered. However, dropped gallstones as nidus of infection with subsequent abscess formation is a rare complication of laparoscopic cholecystectomy (0.3%). Most of the reported cases of complicated dropped stones required open surgical drainage. Minimally invasive measures were less frequently employed. We report a case of dropped gallstones that were removed endoscopically through a percutaneous drainage tract.

Laparoscopic approach of surgical treatment for primary hepatolithiasis: a cohort study.

BACKGROUND: The aim of the current study was to evaluate the perioperative and long-term outcome of a laparoscopic approach for management of primary hepatolithiasis. METHODS: From January 1995 to June 2008, 55 consecutive patients with primary hepatolithiasis who underwent laparoscopic partial hepatectomy and laparoscopic bile duct exploration were analyzed. Immediate outcomes included stone clearance rate, operative morbidity, and mortality. Long-term outcomes included stone recurrence rate and hepatolithiasis-related mortality. RESULTS: Nineteen patients underwent laparoscopic left lateral sectionectomy and 36 patients underwent laparoscopic bile duct exploration. Twenty-five patients also underwent concomitant laparoscopic choledochoduodenostomy bypass. The operative morbidity and mortality rates were 25.5% and 1.8%, respectively. Four procedures needed open conversion. The immediate stone clearance rate was 90.9%, and the final stone clearance rate was 94.5% after subsequent choledochoscopic treatment. With a mean follow-up of 59 +/- 30 months, recurrent stones developed in 3 patients. One patient died of advanced cholangiocarcinoma. CONCLUSIONS: In selected patients with primary hepatolithiasis, a laparoscopic approach of definitive treatment is safe and effective with good immediate and long-term outcomes.

Minimally invasive surgical treatment of hepatocellular carcinoma: long-term outcome.

BACKGROUND: Laparoscopic liver resection for hepatocellular carcinoma (HCC) is still a matter of debate because of the uncertainty of the long-term results and the fear of compromising the oncological resection. Published findings on survival and outcome after laparoscopic liver resection for HCC are scarce still. The aim of the present study was to report the perioperative and long-term outcome of minimally invasive surgical treatment of HCC. METHODS: From January 1998 to November 2008, all patients with HCC who underwent laparoscopic liver resection in our unit were included. A prospectively collected database was analyzed retrospectively. Perioperative outcome included procedure-related morbidity and mortality. Long-term outcome included 5-year overall survival and disease-free survival. RESULTS: During the study period, 30 consecutive patients with HCC underwent laparoscopic liver resection (hand-assisted laparoscopic liver resection, n = 22; total laparoscopic liver resection, n = 7; converted to open approach, n = 1). The mean tumor size was 2.8 cm. The mean operating time was 139.4 min, and 90% of patients had R0 resection and 10% of patients had R1 resection. The hospital mortality and morbidity rates were 0 and 20%, respectively. The mean hospital stay was 7.4 days. For those patients (n = 22) with a minimal follow-up of 24 months, the 5-year overall and disease-free survival rates were 50 and 36%, respectively. No port site recurrence occurred. CONCLUSIONS: This study showed that laparoscopic liver resection for HCC was feasible and safe in selected patients. The long-term survival was also favorable.

A laparoscopic approach for incarcerated Spigelian hernia.

Incarcerated Spigelian hernia (SH) is an uncommon surgical emergency that demands immediate operative treatment. In the era of minimal access surgery, elective laparoscopic repair of uncomplicated SH is safe and feasible. Herein, we report a case of incarcerated Spigelian hernia that was successfully managed by laparoscopic hernioplasty on an emergent basis.