Robotic Right Posterior Sectionectomy by Intrafascial Approach for Pancreas Neuroendocrine Liver Metastasis.

BACKGROUND: Liver resection is indicated for resectable liver metastases of neuroendocrine tumors.1 Minimally invasive liver resection offers decreased blood loss, reduces pain, reduces postoperative complications, and reduces time to functional recovery.2 However, access to posterior section remains difficult with conventional laparoscopic tools. The robotic approach could overcome these limitations. PATIENTS AND METHODS: A 46-year-old woman had a pancreatic neuroendocrine tumor with synchronous liver metastases (18 mm in segment 6, 29 mm in segment 7, and 31 mm in segment 8). Due to stable disease after 2 years of somatostatin analog treatment, surgical management was decided. The first step was robotic distal pancreatectomy. Two months later, we performed a posterior sectionectomy associated with a wedge resection in segment 8. RESULTS: Da Vinci X robot was used. Surgery was conducted with a second surgeon located between the patient's legs using suction/irrigation device and ultrasonic dissector through laparoscopic ports. The posterior sectorial branches of the hepatic artery and portal vein were controlled via an intra-fascial approach. Robotic parenchymal dissection was performed by a four-hands method,3 with laparoscopic ultrasonic dissector and robotic irrigated bipolar guided by indocyanine green. Transection was led on the right side of right hepatic vein without clamping. Operative duration was 330 min, and estimated blood loss was 50 ml. Postoperative course was complicated by grade B biliary fistula. The patient was discharged on postoperative day 10. CONCLUSIONS: This case illustrates the feasibility and safety of a robotic approach for right posterior liver sectionectomy, which can improve the dexterity of the surgeon and thus the possibility of difficult minimally invasive liver resection.

Ambulatory colectomy for cancer: Results from a prospective bicentric study of 177 patients.

BACKGROUND: The implementation of an Enhanced Recovery After Surgery programme after colectomy reduces postoperative morbidity and shortens the length of hospital stay. OBJECTIVE: To evaluate the short and midterm outcomes of ambulatory colectomy for cancer. METHODS: This was a two-centre, observational study of a database maintained prospectively between 2013 and 2021. Short-term outcome measures were complications, admissions, unplanned consultations and readmission rates. Midterm outcome measures were the delay between surgery and initiation of adjuvant chemotherapy, length of disease-free survival and 2-year disease-free survival rate. RESULTS: A total of 177 patients were included. The overall morbidity rate was 15% and the mortality rate was 0%. The admission rate was 13% and 11% patients left hospital within 24 h of surgery. The readmission rate was 9% and all readmissions occurred before postoperative Day 4. Eight patients underwent repeat surgery because of anastomotic fistula (n = 7) or anastomotic ileocolic bleeding (n = 1). These patients had an uneventful recovery. Sixty-one patients required adjuvant chemotherapy with a median delay between surgery and chemotherapy initiation of 35 days. CONCLUSIONS: Ambulatory colectomy for cancer is feasible and safe. Adjuvant chemotherapy could be initiated before 6 weeks postsurgery. The ambulatory approach may be a step forward to further improve morbidity and oncologic prognosis.

Robotic Left Hepatectomy Extended to Caudate Lobe and Common Biliary Duct for Hilar Cholangiocarcinoma.

BACKGROUND: The safety and efficiency of minimally invasive approaches for liver resection have been confirmed (Wakabayashi in Ann Surg, 2015). However, laparoscopy suffers from several limitations due to technical difficulties, particularly for difficult hepatectomy with lymphadenectomy, biliary, and vascular reconstruction. Robotic assets could improve accessibility for difficult liver resections (Liu in World J Gastroenterol 25: 1432-1444), (Chou in Zhonghua Wai Ke Za Zhi 58: 230-234, 2020). PATIENTS AND METHODS: A 56-year-old woman was treated for a hilar cholangiocarcinoma, Bismuth 3b. RESULTS: A robotic anatomical left hepatectomy extended to caudate lobe and common biliary duct was decided. A Da Vinci X robot was used. The procedure was performed with a second surgeon positioned between the patient's legs. Left hepatectomy was extended to common biliary duct and caudate lobe. A four-hands parenchymal dissection (Camerlo in J Robot Surg, 2020) was performed with laparoscopic ultrasonic dissector and robotic irrigated bipolar, guided by indocyanine green. Axis of deep transection line was maintained using the EndoWrist function and exposure with a fourth arm. No pedicle clamping was necessary. Segment 1 was released with a mediocaudal approach. Lateral portal vein resection was performed after parenchymal transection was completed. Hepaticojejunostomy was done separately to the right anterior and posterior biliary duct. Operation time was 420 min, and estimated blood loss was 100 ml. The postoperative course was uneventful. The patient was discharged on postoperative day 8. Pathological findings revealed a 15-mm hilar cholangiocarcinoma with complete resection and eight lymph nodes, all negative. CONCLUSIONS: Robotic approaches could improve accessibility to minimally invasive liver resection of Klatskin tumor.

Robotic right hepatectomy for giant hepatocellular adenoma - With video.

BACKGROUND: The safety and efficiency of mini-invasive approach for liver resection have been confirmed. However, laparoscopic approach suffers from several limits due to technical difficulties particularly for voluminous tumor. Robotic approach could improve accessibility of these difficult tumors. METHODS: A 29-year-old woman was treated for a giant telangiectasic adenoma [1] of the right liver measuring 20 cm. RESULTS: A robotic anatomical right hepatectomy was decided [2]. Da Vinci X robot was used. The procedure was performed with a second surgeon positioned between the patient's legs using suction/irrigation device and ultrasonic dissector through laparoscopic ports [3]. A first hilar approach allows individualization of right hepatic artery and portal vein. Robotic irrigated bipolar coagulation and laparoscopic ultrasonic dissector was used for parenchymal transection. Operation time was 290 min, and estimated blood loss was 150 ml. Postoperative course was uneventful. The patient was discharged on postoperative day eight. CONCLUSIONS: Robotic approach could improve accessibility to minimally invasive liver resection of voluminous tumor.

Robotic central hepatectomy for hepatocarcinoma by glissonean approach (with video).

BACKGROUND: Central bisegmentectomy of the liver implies excising Couinaud's segments IV, V and VIII (Couinaud and Le Foie, 1957) [1]. In a recent classification of laparoscopic liver resections, it belongs to the highly advanced level procedure group (Kawaguchi and et al., 2018 Jan) [2]. Improvement in laparoscopic devices should lead to a wider accessibility of such indications that are currently expert prerogatives. In order to illustrate the assets of robotic-assistance in the management of highly difficult mini-invasive hepatic resections, we present the case of a robotic central hepatectomy. METHODS: This video illustrates robotic central hepatectomy in a 70-year-old male. A liver tumor involving segments IV, V and VIII was incidentally detected during abdominal ultrasonography. CT scan and MRI suggested the diagnosis of a seventy-millimeter centrally located hepatocellular carcinoma and surgical resection was decided. RESULTS: The patient was placed supine in anti-Trendelenburg position. Four robotic trocars were placed and the da Vinci X robotic system was docked. Two laparoscopic ports were placed for the second surgeon (ultrasonic dissector and suction/irrigation set). Central hepatectomy was performed with a glissonean approach. Robotic irrigated bipolar coagulation and laparoscopic ultrasonic dissector was used for parenchymal transection. Postoperative course was uneventful. The patient was discharged on postoperative day eight. CONCLUSION: The recent publication of an International consensus statement demonstrates the growing involvement of robotics in liver surgery (Liu and et al., 2019 March 28) [3]. Robotic advantages (flexibility, absence of fulcrum effect and visual field stability) could improve accessibility to minimal invasive approach for difficult liver resection.

Robotic hepatic parenchymal transection: a two-surgeon technique using ultrasonic dissection and irrigated bipolar coagulation.

Liver transection is the most challenging part of hepatectomy due to the risk of hemorrhage which is associated with postoperative morbidity and mortality and reduced long-term survival. Parenchymal ultrasonic dissection (UD) with bipolar coagulation (BPC) has been widely recognized as a safe, effective, and standard technique during open and laparoscopic hepatectomy. We here introduce our technique of robotic liver transection using UD with BPC and report on short-term perioperative outcomes. From a single-institution prospective liver surgery database, we identified patients who underwent robotic liver resection. Demographic, anesthetic, perioperative, and oncologic data were analyzed. Fifty patients underwent robotic liver resection using UD and BPC for liver malignancies (n = 42) and benign lesions (n = 8). The median age of the patients was 67 years and 28 were male. According to the difficulty scoring system, 60% (n = 30) of liver resection were considered difficult. Three cases (6%) were converted to open surgery. The median operative time was 240 min, and the median estimated blood loss was 200 ml; 2 patients required operative transfusions. The overall complication rate was 38% (grade I, 29; grade II, 15; grade III, 3; grade IV, 1). Seven patients (14%) experienced biliary leakage. The median length of hospital stay post-surgery was 7 (range 3-20) days. The R0 resection rate was 92%. Robotic parenchymal transection using UD and irrigated BPC appears a simple, safe, and effective technique. However, our results must be confirmed in larger series or in randomized controlled trials.

Robotic Resection of a Central Liver Solitary Fibrous Tumor (with Video).

BACKGROUND: Solitary fibrous tumor is a mesenchymal tumor rare in liver parenchyma 1 but must be considered as a differential diagnosis of a single large hepatic mass. Surgical resection is the treatment because of its potential malignancy, and previous interventions reported were open hepatectomy 2. Robotic assets could improve accessibility for difficult liver resection 3. We present the video of a robotic left hepatectomy extended to caudate lobe and median hepatic vein for central liver tumor. METHODS: A central liver tumor was incidentally detected during abdominal ultrasonography in a 30-year-old man with no medical history. Laboratory tests were normal. CT scan and MRI revealed a solid mass measuring 9 cm involving segments I-IV-VIII and median/left hepatic veins. Percutaneous biopsy confirmed diagnosis of benign liver solitary fibrous tumor. Surgical resection by left hepatectomy extended to segment 1 and median hepatic vein was planned. RESULTS: Da Vinci X system was docked from patient's head. Four robotic ports were placed in right hypochondrium. Two laparoscopic ports were placed for the second surgeon. Extended left hepatectomy was performed with hilar approach. Parenchymal transection was led on the right side of median hepatic vein using laparoscopic ultrasonic dissector and robotic irrigated bipolar. Segment 1 was released with a mediocaudal approach. Procedure was facilitated by good exposure of operative field with arm 4, stable vision, articulated instrumentation and a "4-hand parenchymal dissection". CONCLUSION: Minimal invasive resection of liver solitary fibrous tumor seems safe and feasible. Because of its advantages compared with laparoscopy, robotic approach could improve accessibility to central tumors liver resection.

Laparoscopic right hepatectomy combined with partial diaphragmatic resection for colorectal liver metastases: Is it feasible and reasonable?

BACKGROUND: The impact of diaphragmatic invasion in patients with colorectal liver metastases (CRLMs) remains poorly evaluated. We aimed to evaluate feasibility and safety of laparoscopic right hepatectomy (LRH) with or without diaphragmatic resection for CRLM. METHODS: From 2002 to 2012, 52 patients underwent LRH for CRLM. Of them, 7 patients had combined laparoscopic partial diaphragmatic resection ("diaphragm" group). Data were retrospectively collected and short and long-term outcomes analyzed. RESULTS: Operative time was lower in the control group (272 vs 345 min, P = .06). Six patients required conversion to open surgery. Blood loss and transfusion rate were similar. Portal triad clamping was used more frequently in the "diaphragm" group (42.8% vs 6.6%, P = .02). Maximum tumor size was greater in the "diaphragm" group (74.5 vs 37.1 mm, P = .002). Resection margin was negative in all cases. Mortality was nil and general morbidity similar in the 2 groups. Specific liver-related complications occurred in 2 patients in the "diaphragm" group and 17 in the control group (P = .69). Mean hospital stay was similar (P = 56). Twenty-two (42.3%) patients experienced recurrence. One-, 3-, and 5-year overall survival after surgery in "diaphragm" and control groups were 69%, 34%, 34%, and 97%, 83%, 59%, respectively (P = .103). One- and 3-year disease-free survival after surgery in "diaphragm" and control groups were 57%, 47% and 75%, 54%, respectively (P = .310). CONCLUSION: LRH with en-bloc diaphragmatic resection could be reasonably performed for selected patients in expert centers. Technical difficulties related to diaphragmatic invasion must be circumvented. Further experience must be gained to confirm our results.

Which treatment to choose for portal biliopathy with extensive portal thrombosis?

BACKGROUND: Portal biliopathy refers to abnormalities of the biliary tract developing in relation to portal hypertension. Portosystemic splenorenal or mesenterico-caval shunting is a safe and effective method to relieve biliary obstruction in symptomatic patients but is unfeasible in cases of extensive thrombosis of the splenic and superior mesenteric veins. In such cases, a makeshift portosystemic shunt between a suitable portal varix and the caval system can be an interesting alternative. METHODS: This study describes 3 patients admitted for symptomatic portal biliopathy caused by idiopathic portal cavernoma associated with extensive portal thrombosis. A makeshift portosystemic shunt was carried out after preoperative portal imaging had demonstrated the presence of a suitable splanchnic varix. RESULTS: The makeshift portosystemic shunt was performed by direct anastomosis in 2 patients and by prosthetic interposition in 1 case. Shunting was between a splanchnic varix and the inferior vena cava in 2 cases and the left renal vein in 1 case. Postoperative morbidity was nil and follow-up ranging from 2 to 12 years showed good results with no recurrence of biliary obstruction. CONCLUSION: In patients presenting symptomatic portal biliopathy associated with extensive thrombosis of the portal system, a makeshift portosystemic shunt is preferable to repeated endoscopic procedures or intrahepatic biliodigestive bypass, provided that a suitable varix is available.

Ileal patch duodenoplasty after right colectomy extended to the duodenal wall.

After radical resection of cancer of the right colonic flexure, a parietal defect can be created in case of duodenal invasion. In this paper the authors describe an "easy and safe" duodenoplasty surgical technique using an ileal patch.

[Surgical treatment of penile curvature: primum non nocere]. / Traitement chirurgical des courbures de verge: a propos d'une série de 45 patients.

OBJECTIVE: This study was designed to evaluate the medium-term results of surgical treatment of penile curvature by tunica albuginea plication of tunica albuginea resection-prosthetic graft. MATERIALS AND METHODS: A retrospective study of 45 patients operated for penile curvature was performed: 38 were treated by tunica albuginea plication and 7 were treated by tunica albuginea resection-graft. Each patient returned for early (1 month), medium-term (3 months-1 year) and long-term (total mean follow-up of 34 months) postoperative review. RESULTS: Patients operated by plication were satisfied in 88.6% of cases. Significant shortening of the penis was observed in 52% of cases and one in five patients complained of disabling shortening; other complications were rare. The global satisfaction rate among patients operated by resection-graft was 29%, with 57% of residual curvature and 15% of postoperative erectile dysfunction. CONCLUSION: Tunica albuginea plication is a simple and effective technique with low morbidity for the treatment of penile curvature. Tunica albuginea resection followed by Goretex graft gives unsatisfactory results and is associated with considerable morbidity in the treatment of complex penile curvature.

Endoscopic injection with polydimethylsiloxane for the treatment of pediatric urinary incontinence in the neurogenic bladder: long-term results.

PURPOSE: We report the long-term results of endoscopic injection of PDMS in correcting urinary incontinence in children with neurogenic bladder. MATERIALS AND METHODS: We performed a single center, retrospective study of patients receiving endoscopic injections of PDMS. All procedures were performed as outpatient surgery using endoscopic guidance. Procedure tolerance was assessed at 15 days, and efficacy was evaluated at 3 months, 6 months and annually thereafter. Success was defined as periods of dryness between bladder voiding of more than 4 hours during the daytime without the need to wear pads. Improvement was defined as periods of dryness greater than 2 and less than 4 hours with occasional protection. RESULTS: A total of 49 children (21 boys and 28 girls) have received 1 or more injections of PDMS since 1995. Etiology was spina bifida in 41 patients (84%), with surgery (enterocystoplasty and/or bladder neck reconstruction) performed previously in 27 patients. Mean patient age was 14 years (standard deviation 4.8). Mean volume of PDMS per treatment was 3.6 ml. At the end of the 6-year mean followup 16 patients (33%) were continent and 7 (14%) were improved. Continence was unchanged in the remaining 26 patients (53%). After a significant deterioration of the results the outcome remained almost unchanged from 18 months of followup. Bladder neck surgery, bladder hyperactivity if medically controlled and gender have no influence statistically on the long-term results. CONCLUSIONS: Injection of PDMS for incontinence of neurogenic origin is a reliable technique that achieves long-term continence in almost a third of the patients. This procedure can be used either as first line treatment or in addition to other surgical techniques. The initial success of the procedure seems predictive of success in the long term, and results are stable after 18 months of followup.