Robotic Roux-en-Y Hepaticojejunostomy for Right Hepatic Duct Transection. Application of Minimally Invasive Technique for High Bile Duct Injury.

Minimally Invasive bile duct repair is an emerging modern technique in hepatobiliary surgery. Conventional laparoscopic technique had been sporadically reported by high volume surgeons as an alternative to open operation, however, the majority of those repairs were undertaken for biliary injury below the biliary bifurcation. Roux-en-Y Hepaticojejunostomy below the biliary bifurcation is technically much simpler to complete when compared to that above the hilar plate (high bile duct injury). The risk of long-term anastomotic stricture is also higher as bile duct caliber decreases. This is anatomically inherent as we travel further cranial beyond the hilar plate. In this multimedia article, we describe our minimally invasive technique for high bile duct injury repair using robotic technology.

Institutional First 100 Case Experience and Outcomes of Robotic Hepatectomy for Liver Tumors.

The nascent robotic approach for hepatic resections is gaining momentum in the United States because it offers solutions to the known limitations of laparoscopic approach. Herein, we report our initial experience and short-term outcomes of the first 100 robotic hepatectomies. With Institutional Review Board approval, all patients undergoing robotic hepatectomy were prospectively followed up. Patient demographics, operative outcomes, complications, and 30-day readmissions were collected and analyzed. Data are presented as median (mean ± SD). One hundred consecutive patients underwent robotic hepatectomy. Patients were aged 62 (63 ± 13.6) years, 66 per cent were women, and BMI was 29 (29 ± 6.4) kg/m². In all, 76 per cent of the hepatectomies were undertaken for malignancy [metastatic colorectal cancer (28%), hepatocellular carcinoma (21%), and intrahepatic cholangiocarcinoma (15%)], and 20 per cent for benign lesions; 66 per cent of patients underwent nonanatomical partial hepatectomies, 17 per cent right hepatectomies, 16 per cent left hepatectomies, and 1 per cent trisegmentectomy. Operative time was 233 (268 ± 109.3) minutes, and the estimated blood loss was 123 (269 ± 322.1) mL. Conversion to "open" approach was necessary in one patient. The length of stay was 3 (5 ± 4.6) days. There were no intraoperative complications. Twelve patients experienced postoperative complications. Six patients required readmission to the hospital within 30 days of discharge. Robotic hepatectomy is safe and feasible with favorable short-term outcomes. The robotic system enhances application of minimally invasive surgery for complex hepatobiliary operations.

Does preoperative MELD score affect outcomes following robotic hepatectomy for liver tumors?

The model for end-stage liver disease (MELD) score is objective, reproducible, and it has shown to predict mortality related to cirrhosis. This study was undertaken to investigate safety of robotic hepatectomy in patients with elevated preoperative MELD score and to examine correlation between preoperative MELD scores and postoperative outcomes after robotic hepatectomy for liver tumors. Demographic data, MELD score, and clinical outcomes were prospectively collected. Regression analysis was used. Data are presented as median (mean ± SD). 75 patients underwent robotic hepatectomy. Age was 64 (62.5 ± 14.2) years and BMI 28 (29 ± 7.0) kg/m2; 56% women. 60 (81%) of the hepatectomies were undertaken for malignancy (25% hepatocellular carcinoma, 20% colorectal metastasis, 15% cholangiocarcinoma). On regression analysis, MELD score did not correlate with operative time (p = 0.518) or blood loss (p = 0.583). MELD score, however, correlated with length of stay (p = 0.002). 8 (11%) patients experienced postoperative complications; their MELD score was 7 (8 ± 2.5). 68 (91%) patients did not experience postoperative complications; their MELD score was 7 (8 ± 2.8) (p = 0.803). One patient died in this series. In patients undergoing robotic hepatectomy to treat liver tumors, preoperative MELD score only correlates with length of stay. Preoperative MELD score does not correlate with operative time and amount of blood loss. An elevated MELD score should not deter surgeons from offering robotic hepatectomy.

Laparoendoscopic Single-Site (LESS) versus Robotic "Redo" Hiatal Hernia Repair with Fundoplication: Which Approach Is Better?

Only a small percentage of patients fail laparoscopic fundoplications undertaken for gastroesophageal reflux disease. But because many laparoscopic fundoplications have been undertaken, surgeons frequently encounter patients in need of "redo" operations. This study was undertaken to evaluate the robotic approach versus laparoendoscopic single-site (LESS) approach for redo fundoplications. With an Institutional Review Board approval, 64 patients undergoing LESS (n = 32) or robotic (n = 32) redo antireflux operations were prospectively followed up. Data are presented as median (mean + SD). For LESS versus robotic redo operations, the operative duration was 145 (143 ± 33.5) versus 196 (208 ± 76.7) minutes (P < 0.01), estimated blood loss was 50 (80 ± 92.1) versus 20 (43 ± 57.1) mL (P = 0.07), and length of stay was 1 (3 ± 5.4) versus 1 (2 ± 1.9) day (P = 0.57); 1 LESS operation was converted to "open." Operative duration was longer for men (P = 0.01). Postoperative complications were not more frequent after Nissen (n = 36) or Toupet (n = 28) fundoplication, regardless of the approach. When matched by BMI, operative duration was prolonged by a large Type I to IV hiatal hernia (P = 0.01). Symptoms improved dramatically and were similar with both approaches, and patient satisfaction was high. Robotic redo antireflux operations take longer than LESS operations. LESS and robotic redo antireflux operations are both safe and offer significant and similar amelioration of symptoms after failed fundoplications.

Nefrectomía totalmente laparoscópica en donante vivo / Nefrectomía totalmente laparoscópica en donante vivo

El abordaje laparoscópico para la nefrectomía del donante vivo, ha representado en los últimos años un paradigma con resultados comparables e incluso superiores al abordaje abierto. Objetivo: Evaluar el abordaje laparoscópico en la nefrectomía de donante vivo como procedimiento de elección en el trasplante renal. Métodos: Entre los meses de enero y octubre de 2010, se evaluaron de manera prospectiva 13 pacientes donantes vivos de riñón, sometidos a nefrectomía laparoscópica para trasplante renal en el Hospital Dr. Miguel Pérez Carreño. Resultados: La sobrevida de los pacientes y del órgano fue de 100 %, sin necesidad de conversión en ningún caso. La edad promedio de los donantes fue de 33,8 años, el tiempo quirúrgico promedio fue 187 min, el tiempo de isquemia caliente promedio fue 4,31 min. En el 15,4 % de los pacientes se encontraron variantes anatómicas y en el 23,1 % se presentaron complicaciones intraoperatorias resueltas sin inconvenientes. La estancia hospitalaria fue 3,6±1,4 días. El promedio del dolor postoperatorio (EVA) fue de 5,9 durante el primer día con descenso a 2,1 en el tercero. Conclusiones: La nefrectomía laparoscópica en donantes vivos es una técnica reproducible que requiere de instrumental adecuado y personal entrenado, demuestra sus ventajas en cuanto a disminución de sangrado, dolor postoperatorio, complicaciones y estancia hospitalaria(AU)

The laparoscopic approach for living donor nephrectomy has represented in recent years a paradigm with comparable and even better results to the open approach. Objective: To evaluate the laparoscopic approach in living donor nephrectomy as the procedure of choice in kidney transplantation. Methods: Between January and October 2010, 13 living kidney donor patients undergoing laparoscopic nephrectomy for kidney transplantation at the Dr. Miguel Pérez Carreño Hospital were prospectively evaluated. Results: The survival of the patients and the organ was 100 %, there was no need for conversion in any case. The mean age was 33.8 years, the mean surgical time was 187 minutes, the mean warm ischemia time was 4.31 minutes. Anatomical variants were found in 15.4% of the patients and in 23.1 % intraoperative complications were resolved without problems. The hospital stay was 3.6 ± 1.4 days. The average postoperative pain (VAS) was 5.9 on the first day, decreasing to 2.1 on the third day. Conclusions: Laparoscopic nephrectomy in living donors is a reproducible technique that requires adequate instruments and trained personnel and demonstrates its advantages in terms of decreased bleeding, postoperative pain, complications and hospital stay(AU)