1,721,033 research outputs found
Minimally invasive surgery for deep-infiltrating endometriosis and its impact on fertility: can robotic surgery play a role?
No full textAlternative uses of virtual simulators for laparoscopy and robot-assisted surgery for medical students
No full textLetter to the edito
The use of da Vinci Xi and the increased surgeon's experience could change the perspective over the cost-benefit ratio of robot-assisted surgery
No full textTo the Editor:
We read with great interest the article by Khorgami et al. entitled “The cost of robotics: an analysis of the added costs of robotic-assisted versus laparoscopic surgery using the National Inpatient Sample” [1] recently published on Surgical Endoscopy.
The introduction of robotic systems in surgery was intended to overcome the known limitations of conventional laparoscopic surgery, while preserving the advantages of the minimally invasive surgery [2], justifying the growing interest in robotic technology for abdominal surgery worldwide. However, the costs of robot-assisted surgery (RAS) still represent a critical issue for its widespread adoption.
The study of Khorgami et al. is a very well structured retrospective analysis of the 2012–2014 Healthcare Cost and Utilization Project-National Inpatient Sample which is the largest inpatient health care database in the United States, collecting data from more than 7 million hospital admissions annually. A total of 91,630 abdominal major and minor surgeries (87,965 laparoscopic, 3,665 robotic) were analyzed, including cholecystectomy, ventral hernia repair, right and left hemicolectomy, sigmoidectomy, abdominoperineal resection, and total abdominal hysterectomy. The average cost for the laparoscopic group was 4986 versus 5880 for the robotic cases (p < 0.001), suggesting that RAS is more costly when compared to conventional laparoscopic surgery. However, robotic total abdominal hysterectomy showed the lowest increased cost and was the only procedure to be performed more often robotically. This suggests that although RAS costs are higher, the difference may be offset with more routine performance of procedures using the robot.
Some recent published studies of our group on rectal surgery [3,4] support this theory, showing a significant decrease of RAS overall variable costs with surgeon’s experience. This means that a possible major bias of the current economic evaluations such as those of this article, unfavorable to RAS when compared to standard laparoscopy, is that they are referred mainly to results obtained by comparing expert laparoscopists with novice robotic surgeons.
A second possible bias, is that the study of Khorgami et al. refers to the years 2012-2014, when the new da Vinci Xi robotic platform was not available yet. Indeed, recent works have reported that the use of the new da Vinci Xi represents an improvement on its Si predecessor in robot-assisted colorectal resections, being associated with shorter operative time, reduced docking time and higher full robotic resection rates and significantly reducing RAS-associated costs [3-5].
In conclusion, the article by Khorgami et al. deals with a very interesting topic analyzing a huge sample size. However, the use of the new da Vinci Xi platform, as well as of new robots, by robotic surgeons with an adequate experience could nowadays change the perspective over the cost-benefit ratio of RAS
Considerations on "Impact of ABO-incompatibility on hepatocellular carcinoma recurrence after living donor liver transplantation"
No full textTotal abdominal proctocolectomy: what is new with the da Vinci Xi?
No full textTo the Editor:
We read with great interest the recently published article by Rodriguez et al. entitled “Use of the Xi robotic platform for total abdominal colectomy: a step forward in minimally invasive colorectal surgery” [1].
Although possible benefits regard the use of robotic assistance in performing a total colectomy have been already reported with the da Vinci Si, until now the main limits to the widespread of this technique in this field, were the low versatility, the long operative times and the high costs.
In order to overcome some of these limitations, we previously reported a possible application of robotic technology in total procto-colectomy for Familiar Adenomatous Polyposis or severe Ulcerative Colitis, describing a hybrid laparoscopic/robotic technique with da Vinci Si, capable to save time respect to the multiple docking techniques and simultaneously to maintain the advantages of the robot in the pelvic phase [2]. In line with other published results with the da Vinci Si on rectal surgery [3-5], we reported very good functional outcomes with this technique also in proctocolectomies with ileal pouch anal-anastomosis. However, we acknowledge that the simultaneous use of both laparoscopic and robotic devices is still costly (paradoxically more than robotic alone), and has the disadvantage of loosing benefits coming from the full use of the robotic technology.
As the advent of da Vinci Xi® into clinical practice has overpassed several limits of the previous version, thanks to the functionality of a boom-mounted system combined with the greater flexibility of the robotic arms, we completely agree with the authors that its use in total abdominal proctocolectomy could represent a good application, and could find more spread. The very good results reported by the authors are in line with those of our previously published articles on rectal surgery, and on multiquadrant robotic surgery [6,7]. Indeed, although not specifically applied to total proctocolectomy, we reported significantly shorter docking and operative time during rectal resection for cancer if performed with the Xi versus the Si, as well as a significantly higher rates of fully-robotic approach, also avoiding the need of hybrid phases and higher percentage of complete mobilization of splenic flexure [6-8]. Furthermore, we used the da Vinci Xi in several multiple-organs resections, with very satisfactory results.
Thus, we completely agree with the authors about the capability of the da Vinci Xi to enhance the surgical workflow, and the possibility to obtain similar operative times and even better clinical results respect standard laparoscopy. We think that a further improvement of these promising results can be obtained by adding to the described technique the use of the da Vinci Table Motion (dVTM). Indeed, in our experience the dVTM allows to further increase the flexibility of the robotic system, providing access to different parts of the anatomy even faster and more efficiently respect to the da Vinci Xi alone [9]. The da Vinci Xi plus the new operating table enables the surgeon to optimize gravity exposure and provides the quick access to different surgical targets, bringing advantages in term of operative time and indirectly of personnel costs.
In conclusion, because we also observed a significant reduction of costs with increasing robotic experience and changing from the Si to the Xi version [10], we think that the da Vinci Xi plus dVTM in perfoming total proctcolectomies could represent a combination capable of increase versatility, further reduce operative time and costs, and promote the dissemination of this application. Comparative studies are strongly suggested to draw definitive conclusions
Perfore apandisitte pulmoner sekestrasyonun neden olduğu hemoptizi: Seyrek görülen bir olgunun raporu
No full textPulmonary sequestration is a rare and usually asymptomatic congenital anomaly. Optimal management of this condition is still a subject of debate, including superiority of surgical resection or angiographic embolization of the aberrant arterial vessel. Presently described is rare case of a 51-year-old male who presented with hemoptysis related to pulmonary sequestration associated with acute right lower quadrant abdominal pain caused by perforated appendicitis
Resezioni coliche in urgenza. Un fattore critico per il rispetto dei criteri oncologici?
No full textE' possibile rispettare anche in urgenza, mediante una appropriata tecnica chirurgica, il rispetto dei criteri resettivi oncologici (T,N) della chirurgia colorettale
Comment on “Lessons learnt from living donor liver transplantation with ABO-incompatibility: A single-center experience from southern India”
No full textTo the Editor:
We read with great interest the article by Shajahan et al. entitled “Lessons learnt from living donor liver transplantation with ABO-incompatibility: A single-centre experience from southern India” [1] recently published on Indian Journal of Gastroenterology.
ABO-incompatible living donors liver transplantation (ABO-I LDLT) represents a precious opportunity to shorten the waiting time for surgery, avoiding the disease progression that might occur waiting for an ABO-compatible living or deceased donor. However, ABO-I LDLT is still associated with a high risk of antibody-mediated rejection (AMR), lower patient and graft survival and a high risk of vascular thrombosis and ischemic bile duct complications if compared to ABO-compatible LT.
The study of Shajahan et al. represents the largest report of ABO-I LDLT from India, even if the sample size is still small. The authors retrospectively analyzed data of 12 patients undergone ABO-I LDLT using Rituximab and preoperative plasmapheresis for desensitisation, adjusting doses after facing a very high mortality rate in the first 7 patients (5 deaths), mostly due to septic complications.
Rituximab, a murine/human monoclonal chimeric antibody against CD20 depleting B-lymphocytes, has traditionally been used to treat haematological malignancies and autoimmune diseases. More recently, it has been gained interest as an immunomodulatory agent in solid organ transplantations. [2] Although if current literature is more and more supporting the effectiveness of Rituximab in antibody-mediated rejection (AMR) as a desensitizing regimen, several reports have shown that concerns still remain in the high incidence of complication rates, such as biliary strictures, ischemic-type biliary lesions and postoperative infections. [3,4,5]
Particularly this latter complication afflicted the study of Shajahan et al. who faced a dramatically high rate of postoperative infections involving 9 out of 12 patients, of whom 5 died due to overwhelming sepsis from multidrug-resistant pathogens. Several works such as a Japanese multicenter study have demonstrated that multiple or large Rituximab doses significantly increase the incidence of infection [3], advocating for a “minimization” of the desensitizing protocols. Even if authors have reduced the Rituximab doses after the first 7 cases, the overall septic complications and morality rates still remain very high (75% and 50% respectively), raising the issue of the desensitizing regimen’s adequacy.
Actually, different modalities of Rituximab free immunosuppressive regimens to prevent AMR have been successfully reported in literature, such as the use of high-dose polyclonal intravenous immunoglobulin associated with plasmapheresis without the use of steroid pulses or monoclonal antibodies, or even of everolimus-based immunosuppressive regimen under a strict monitoring of anti-A/B antibodies titres [6,7].
In conclusion, we strongly believe that more and more efforts should be make to minimize the desensitization regimen in ABO-I LDLT in order to reduce the rates of septic complications and improve patients’ and grafts’ survival.
Moreover, prospective studies with bigger sample sizes are required to validate the Indian ABO-I LDLT experience
Is there a role of robotic surgery in abdominal organs transplantations?
No full textAbdominal organs transplantations represent the only poten-tially curative treatment in several end stage-diseases, but despite the improvement of the surgical techniques and the overall good outcomes, the invasiveness of these procedures is still very high. Therefore, the possible application of mini-mally invasive surgery in this field would be of great interest.Until a few years ago this application was not even con-sidered because of the kinematic limitations of laparoscopy which makes very challenging to carry out the reconstruc-tive phases of the transplant. Instead, more recently, since the successful introduction of the da Vinci Surgical System, the possible application of robot-assisted Surgery (RAS) in organ transplantation has become a reality [1].Indeed, with RAS, several limitations of laparoscopic technique for minimally invasive surgical procedures have been overcome, particularly with its latest version, the da Vinci Xi, capable to ensure an easy docking, a wide range of motion with its small, thin arms, the ability to attach the endoscope to any arm, and a highly flexible access to differ-ent anatomical regions [2]. Thus, thanks to these features, the execution of vascular anastomoses has become feasible, offering a new impetus in proposing a minimally invasive approach to patients suitable for an abdominal solid organ transplantation.However, although the technical feasibility of RAS to certain abdominal transplantations procedures has been recently demonstrated by several groups [1], we think that its use in this field is still affected by some main limita-tions that prevent its wide diffusion. In fact, the first critical issue is related to the donor organ’s insertion and manipula-tion through a narrow incision, with the associated risk of organ damage and/or difficult positioning. Furthermore, this limitation together with the longer execution time of vascu-lar anastomoses, could negatively impact on the ischemia time, the reduction of which is instead crucial, especially nowadays that organs procurement from deceased marginal donors is becoming more and more frequent to shorten the continuously growing waiting lists [3, 4].For all these reasons, although dedicated clinical postop-erative follow-up strategies [5, 6] and optimized immuno-suppressant therapies [7, 8] have contributed today to very good outcomes in abdominal solid organs transplantations even with marginal donors, the reduction of operative time for the reconstructive phase is still a major critical factor, and can represent a major limitation for a wide application of RAS.Finally, the use of RAS for organ transplantations on a wider scale could clash with two other non-clinical funda-mental matters, such as the necessity of a continuous avail-ability of the robotic system for a non-elective surgery and the economical sustainability of this approach [9].In conclusion, we think that RAS in transplant surgery is an appealing and promising technique, and without any doubt it represents an open window out to the future, but today it is still far to become the new standard approach, particularly for deceased donor organs transplantation
The role of hand-assisted laparoscopic splenectomy for mega spleens in the da Vinci era
No full textDear Editor,
we read with great interest the article by Cavaliere et al., entitled “Robotic vs laparoscopic splenectomy for splenomegaly: A retrospective comparative cohort study” published on International Journal of Surgery [1].
Laparoscopic splenectomy is nowadays considered the gold standard for normal to moderately enlarged spleens. However, in case of more challenging conditions such as mega-spleens or cirrhotic patients, the laparoscopic approach is still associated with high risk of intra-and post-operative bleeding, high conversion rate, and high morbidity.
In this setting, the authors compared the robot-assisted laparoscopic surgery (RAS) with the direct manual laparoscopy (DML), reporting possible advantages with the use of the da Vinci System for splenectomy in case of splenomegaly. In particular, they reported improved outcomes with RAS in terms of reduced intraoperative bleeding and less conversions to open surgery, although if they also admitted the limitations of the study, such as its retrospective nature and the small sample size, which prevent to draw definitive conclusions. Furthermore, they reported the longer operative time and the higher costs as two limitations of RAS, respect to DML.
We think that, while it is true that the increased dexterity offered by RAS should reasonably help younger or less skilled laparoscopic surgeons to obtain better results in splenectomies for moderate splenomegaly, in case of mega spleens, due to the reduced operative field and to the lack of a tactile feedback, these advantages could not be translated in the same good results, also in expert hands.
Indeed, facing with mega spleens, the robot-assisted intra-corporeal manipulation and the exposure of the hilum, as well of the ligaments dissection can still be very difficult, and this difficulty can be accented by the absence of tactile feedback together with the fragility of the parenchyma, which can easily break and bleed. For these reasons, although if we strongly support RAS for several indications in general surgery [2-9], we think that so far, the better option to face a splenectomy in case of mega spleens should be still the Hand Assisted Laparoscopic Surgery (HALS) technique.
Indeed, HALS has the advantage of maintaining a minimally invasive surgical approach like DML, without losing the tactile feedback, thanks to the non-dominant hand inserted in the abdomen, with a powerful ability to gently manipulate the spleen and to bluntly dissect. As a consequence, with HALS, the use of the non-dominant hand strongly increases local control, exposure and manipulation. In particular, HALS allows to improve the accuracy of manipulation by direct tactile sense, and by maintaining tactile feedback and hand-eye coordination, the surgeon can bluntly dissect adhesion around the spleen and encircle the splenic pedicle and the space beneath the tail of the pancreas with the hand in the abdominal cavity [10]. Moreover, in case of marked splenomegaly, it is difficult and sometimes impossible to dissociate the spleen using both DML or RAS, due to the limited visualization of this area owing to the large spleen size, while for HALS, these attachments can usually be severed by blunt finger dissection even in areas that are hidden from the endoscopic view because of the retained tactile feedback [11].
For all these reasons we think that, in challenging cases, the HALS approach can increase safety and reduce conversion rates without significantly increasing costs, at the same time maintaining the good post-operative outcomes of DML or RAS in terms of hospitalization and complications, thus maintaining all the advantages of minimally invasive management [10–12].
Finally, the access for the left hand for the HALS technique can be used in malignant diseases, for the extraction of the entire spleen through the subcostal incision used for the hand port.
In conclusion, thanks to the possibility to choose between DML, RAS and HALS, the minimally invasive surgery should be always considered as the best approach for splenectomy in case of splenomegaly of any size. The limits of the traditional laparoscopic technique can be increasingly overcome by the technical advantages of the robotic system or by the use of an HALS technique, depending on surgeon’s experience and on spleen size or disease
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