Mini-invasive Surgery

Aim : The HerniaSurge Group established inguinal hernia repair guidelines to reduce recurrence and chronic pain. We evaluated whether the surgeons of the Abdominal Core Health Quality Collaborative (ACHQC) follow these guidelines and identify areas for improvement. Methods : A retrospective evaluation of data from the ACHQC database between 2013-2021 using 18,641 eligible subjects undergoing elective and emergent hernia repair with 30-day follow-up. Compliance with a given guideline was defined as following the recommendation in 70% of cases. Results : Twelve of 19 questions with available data met recommendations based on our above criteria. Eight recommendations with strong evidence and four recommendations with weak evidence were met. The recommendations not met were using the Shouldice technique for any non-mesh open inguinal herniorrhaphy, using local anesthesia for open repair of reducible inguinal hernias, using lightweight mesh, and avoiding the use of prophylactic antibiotics in laparoscopic herniorrhaphy. Conclusion : Despite varied techniques for inguinal hernia repair, surgeons of the ACHQC follow the majority of the recently published guidelines on the subject. While further research is needed to strengthen the existing guidelines, a standardized approach will facilitate this effort while aiming to reduce negative patient outcomes.

The article reviews the biomechanical principles of durable abdominal wall reconstructions. The aim is to provide insights and conclusions for future research in this area. Incisional hernia repair implies the creation of a compound made of tissue, textile, and fixation elements. A pulse load bench test for incisional hernia repair has been available since 2014, and its influences are evaluated in three different versions of the test stand. Based on these evaluations, a biomechanical concept for long-term durable reconstructions was determined. To apply the concept to individual patients, computed tomography of the abdomen at rest and during the Valsalva maneuver was used. A load limit can be given for every patient based on the hernia defect area (CRIP- critical resistance to impacts related to pressure). By considering the mesh to defect area ratio, the retention strength of a planned reconstruction can be calculated (GRIP-gained resistance to impacts related to pressure). The gripping coefficients for tissues vary significantly, up to 18 fold. About half of the patients have overall tissue distensions up to 350% or more, with potential high regional variations. The surface retention forces for hernia meshes and for different sutures, tacks, and adhesives span a wide range of 14fold. Suturing a defect strengthens the reconstruction up to 3fold. Furthermore, recalculating data taken from multicentric randomized studies on primary sutures reveals that improved GRIP values are associated with reduced rates of incisional hernia. Repairing consecutive incisional hernias according to the GRIP concept results in no recurrence and low pain levels after one year. A future policy for market access of repair materials should include cyclic load bench testing. Moreover, a tailored approach to incisional hernia repair should take into account the biomechanical aspects involved.

Summary of Recent Classification of Salivary Gland Lesions: A Review

Fluorescence-guided surgery (FGS) has seen increased interest in recent decades. Technological advances have made it more widely accessible for a variety of applications, including thyroid and parathyroid surgery. Parathyroid autofluorescence can be utilized to help identify parathyroid glands during thyroid or parathyroid surgery and reduce rates of postoperative hypocalcemia after thyroidectomy. Fluorescent dyes such as indocyanine green (ICG) may be used to evaluate perfusion of parathyroid glands during thyroid or parathyroid surgery and help guide decision-making about auto-transplantation or which gland to leave as a remnant. As an emerging technology, additional research is needed to determine the optimal use of FGS in thyroid and parathyroid surgery, including the developing field of molecularly targeted fluorophores. FGS is an exciting and promising field that may help make endocrine surgery safer, faster, and more effective.

Since its introduction in 1985, anatomical liver resection (AR) has been performed to treat early-stage hepatocellular carcinoma. The minimally-invasive AR (MIALR) approach can be safely performed at high-volume tertiary referral centers. The resection techniques can vary among surgeons, depending on the center’s experience, patient characteristics, hepatic segment involvement, and tumor characteristics. Profound knowledge of the liver’s surgical anatomy and a standardized inflow control approach is fundamental to performing MIALR safely. This article aims to summarize the applications of the MIALR and its outcomes, focusing on the techniques for vascular inflow control and the essential tips and tricks to standardize these techniques for laparoscopic and robotic approaches.

Laparoscopic liver resection (LLR) is safer and more advantageous than open surgery regarding morbidity, blood loss, and length of hospital stay. Several radiological studies and liver surgical strategies confirmed that the anatomy of the liver is more complex than what Couinad described. Intraoperative ultrasound (IOUS) has become an indispensable tool to identify the “real anatomy” and to plan a tailored LLR because of wide sub-segmentary variability and lack of external indicators for small functional liver cores. We schematized our standard ultrasound guidance technique during anatomical and non-anatomical LLR as a four-step method called the Ultrasound Liver Map Technique: (1) Compose the three-dimensional mind map to study the relationships between lesions and surrounding vascular elements; (2) create a sketch on the Glissonian using cautery to help the surgeon recall the mind liver anatomy map; (3) check the section plane while proceeding with the transection; and (4) correct the direction of resection plan to ensure a healthy margin concerning the lesion and to point out the pedicle section correctly and not affected structures. Finally, IOUS-Doppler can be used to study the segmental portal flow to assess venous drainage of the remnant parenchyma, avoiding ischemia and increasing the possibility of performing parenchyma-sparing surgery.

The Japanese healthcare system is characterized by universal coverage and free access. It is an excellent social system that allows everyone to receive advanced medical care at a low cost. Minimally invasive hepato-pancreato-biliary (HPB) surgery in Japan is now covered by insurance. However, after experiencing a series of serious medical accidents, Japan’s government requested a more advanced system to safely promote highly advanced surgery including laparoscopic HBP surgery. As a practical measure, the academic societies of HPB surgery established a new prospective registration system for all cases of minimally invasive HPB for highly advanced hepatobiliary and pancreatic surgery while utilizing the existing technical certification system. Under these systems, hepatobiliary and pancreatic surgeries in Japan are now being undertaken gradually but safely.

Significant technical changes and a shift toward a transoral approach have occurred in the management of Zenker’s diverticulum over the past three decades. Transoral stapling is already an established and commonly performed procedure. Zenker peroral endoscopic myotomy (Z-POEM) and Zenker peroral endoscopy septotomy (Z-POES) are innovative techniques that are rapidly spreading and replacing more traditional therapeutic options. This review provides an overview of the current status of minimally invasive transoral management to assess whether a tailored approach is feasible and safe and may improve quality of life and reduce recurrence rates.

The incorporation of magnetic fields into surgery to reduce the invasiveness of minimally invasive surgery led to the creation of magnetic-assisted surgery. External magnets coupled with their internal counterparts assist during surgical procedures, avoiding the need for additional trocars. Multiple advances have been made in this field in the past 15 years, with new promising technologies being developed. This review centers on the history of magnetic-assisted surgery and the available evidence of its safety, benefits and discusses the very promising combination of this new paradigm-shift technology with robotics.

Aim: We retrospectively compared and evaluated the safety, efficacy, and 1-year outcomes of 200-W Thulium laser vaporization of the prostate (ThuVAP) and the GreenLight high-performance system (HPS) 120-W system for benign prostatic hyperplasia (BPH). Methods: Between February 2019 and December 2021, 137 patients with lower urinary tract symptoms secondary to BPH underwent ThuVAP. Between October 2014 and April 2019, 233 patients underwent GreenLight HPS 120-W vaporization of the prostate (HPS-PVP). Prostate-specific antigen (PSA) levels, International Prostate Symptom Scores (IPSS), quality of life (QOL) scores, overactive bladder symptom scores (OABSS), post-void residual (PVR), and maximum flow rates (Qmax) were evaluated before and 1, 3, 6, and 12 months after surgery. Results: Mean ages in the ThuVAP and HPS-PVP groups were 73.7 and 73.4 years, respectively. Prostate volumes (PV) were 77.0 and 61.4 mL (P < 0.001), respectively. Significant improvements were observed in IPSS, QOL scores, OABSS, Qmax, and PVR in both groups 1 to 12 months after surgery. Laser and hospitalization times were significantly shorter and approximate tissue removal (ΔPV) was significantly larger in the ThuVAP group than in the HPS-PVP group (means, 49.4 min vs. 62.5 min, P < 0.001, means, 4.9 days vs. 5.4 days, P = 0.007, means, 50.4 mLvs. 27.8 mL, P < 0.001, respectively). Vaporization efficiency (ΔPV/laser time) was > 2-fold higher in the ThuVAP group than in the HPS-PVP group (1.1 mL/min vs. 0.5 mL/min). There were significantly fewer postoperative complications in the ThuVAP group than in the HPS-PVP group (13.9% vs. 23.6%, P = 0.030). Conclusion: Both procedures are safe and useful for BPH obstruction. Based on shorter operating and hospitalization times, fewer complications, and more efficient tissue removal, ThuVAP is a more favorable and effective treatment than HPS-PVP.

The future of minimally invasive treatment of gastroesophageal reflux disease (GERD) will be realized through collaborative precision medicine more than any foreseeable new technology. Multidisciplinary foregut societies are fostering the collaboration and expertise needed to provide a personalized treatment of GERD. Patient-centric therapy will consider combination therapies’ clinical successes. Taking a patient uncontrolled on medication to controlled via a combination of medicine and a procedure will replace the historical mutual exclusivity of acid-suppressive medication or surgery as a treatment for GERD. Research directed at precision medicine will focus on subgroup analysis rather than randomized controlled trials. Recognition of the crural diaphragm as a reflux barrier which fails in GERD patients regardless of the presence of an axial hernia has resulted from modalities such as 3-D high-resolution impedance manometry, endoscopic ultrasound, functional luminal impedance planimetry. More precise patient selection for purely endoscopic therapies will be possible.The concept of hernia reduction will be replaced by calibration of the crural repair to restore its sphincteric function. Partnering a surgically calibrated hernia repair partnered with interventional gastrointestinal endoscopic reinforcement of the lower esophageal sphincter will foster physician alliances and offer patient-centric alternatives to traditional fundoplication. As such, laparoscopic Nissen Fundoplication will lose its historical primacy and be relegated to the most severe GERD. Magnetic sphincter augmentation (LINX®), varing degrees of partial fundoplication, and endoluminal therapies with or without hiatal hernia repair will become the mainstay of GERD AntiReflux Procedures. Radio Frequency modulation (Stretta®) may be an alternative to neuromodulators in treating the acid-sensitive esophagus. The nascent era of endoscopic robotics will improve precision, reproducibility and revive natural orifice transluminal endoscopic surgery.

Bariatric surgery continues to grow as a treatment modality for obesity and weight-related comorbidities. The anatomic rearrangement can produce unique anatomic complications, as well as functional problems that are correctible with revisional operations. Understanding the unique subset of complications and the options available for correction can allow surgical solutions to be tailored to both the patient’s anatomy, and the symptoms or pathologies they are targeting. Revisional operations are becoming increasingly common, as the proportion of the general population who have previously undergone bariatric surgery continues to increase. Revisional bariatric operations are associated with an increased risk of complications and longer hospital stays, but in experienced centers can be performed safely, and often using minimally invasive approaches.

The development of a tailored, patient-specific medical and surgical approach is becoming the object of intense research. In robotic urologic surgery, where a clear understanding of case-specific surgical anatomy is considered a key point to optimizing the perioperative outcomes, such philosophy has gained increasing importance. Recently, significant advances in three-dimensional (3D) virtual modeling technologies have fueled the interest in their application in the field of robotic minimally invasive surgery for kidney and prostate tumors. The aim of the review is to provide a synthesis of current applications of 3D virtual models for robot-assisted radical prostatectomy and partial nephrectomy. Medline, PubMed, the Cochrane Database, and Embase were screened for literature regarding the use of 3D augmented reality (AR) during robot-assisted radical prostatectomy and partial nephrectomy. The use of 3D AR models for intraoperative surgical navigation has been tested in prostate and kidney surgery. Its application during robot-assisted radical prostatectomy has been reported by different groups as influencing the positive surgical margins rate and guiding selective bundle biopsy. In robot-assisted partial nephrectomy, AR guidance improves surgical strategy, leading to higher selective clamping, less healthy parenchyma loss, and better postoperative kidney function. In conclusion, the available literature suggests a potentially crucial role of 3D AR technology in improving perioperative results of robot-assisted urological procedures. In the future, artificial intelligence may represent the key to further improving this promising technology.

Achalasia is a primary motility disorder of unknown origin. Palliative treatment is often adopted to resolve its symptoms by eliminating the resistance due to a non-relaxing and hypertensive lower esophageal sphincter. There are three available effective treatment modalities: pneumatic dilation, laparoscopic Heller myotomy with fundoplication, and peroral endoscopic myotomy. In choosing the proper treatment, it is important to remember that the esophagus lacks peristalsis in patients with achalasia. So once the lower esophageal sphincter is eliminated, reflux may occur with the potential of causing reflux symptoms, esophagitis, peptic strictures, Barrett’s esophagus, and cancer. For this reason, we believe that laparoscopic myotomy offers the best chance in most patients of improving esophageal emptying while protecting them from abnormal reflux.

Bariatric surgery is the most effective treatment for morbidly obese patients. Studies investigating the relationship between bariatric surgery and gastroesophageal reflux disease (GERD) are discordant. Depending on the type of intervention, pre-existing GERD can improve, worsen, or develop “de novo” in previously unaffected patients. Therefore, a review of the literature is performed to evaluate the effects of different bariatric surgical procedures on GERD. Currently, the bariatric surgical procedures more frequently performed are laparoscopic sleeve gastrectomy (LSG) and gastric bypass. The majority of studies examining the relationship between GERD and bariatric surgery are low quality, small, and non-randomized. Furthermore, GERD has been investigated through clinical symptoms scales or questionnaires, which often do not correlate with objective endoscopic or functional findings. Therefore, the interpretation of the results of these studies is challenging. Roux-en-Y gastric bypass is considered the preferred surgical operation for bariatric patients with GERD. Despite contradictory results reported among the studies, GERD seems to be a major issue after LSG. Preliminary results on mini-gastric bypass/one anastomosis gastric bypass seem to indicate that biliary reflux might be overrated, but more long-term results are mandatory before drawing conclusions. Further studies are needed to clarify the role of extensive preoperative examinations prior to bariatric surgery, even in asymptomatic patients, and provide clear guidance regarding the indications for the bariatric surgery technique of choice according to the patient’s characteristics.

Internal hernia formation is a feared complication following bariatric surgery. Protrusion of the small bowel through mesenteric defects can result in volvulus presenting with symptoms of bowel obstruction. If left untreated, patients may go on to develop bowel ischemia with possible perforation or necrosis necessitating emergent surgical exploration with resection. In severe cases, extensive bowel resection is required, leading to short-gut syndrome, which can have devastating consequences for the already nutritionally vulnerable bariatric patient. This review presents a comprehensive summary of various surgical techniques and technical factors implicated in the formation of internal hernias. The clinical presentation of patients with internal hernias, appropriate diagnostic work-up, and effective management and treatment strategies are discussed based on the established literature.

Although the diagnostic and therapeutic opportunities for superficial nonampullary duodenal epithelial tumors (SNADETs) have been increasing, the natural history and treatment outcomes remain unclear. Due to the anatomical characteristics of the duodenum, clinicians should be more sensitive to the occurrence of complications for tumors in the duodenum compared to other gastrointestinal tumors. Recently, with the expectation of minimally invasive treatment, cold snare polypectomy (CSP) and underwater endoscopic mucosal resection (UEMR) have been accepted as simple and safe endoscopic treatments for SNADETs. In our institution, CSP achieved good treatment outcomes: a median procedure time of 3 (range, 1-23) min, an en bloc resection rate of 96.9%, an R0 resection rate of 50.0%, and a low incidence of adverse events (no delayed bleeding and no intra- and postoperative perforation). Moreover, UEMR also achieved good treatment outcomes: a median procedure time of 5 (range, 1-104) min, an en bloc resection rate of 82.9%, an R0 resection rate of 52.0%, and a low incidence of adverse events (delayed bleeding occurred in 2.6% of cases, and there were no incidences of no intra- and postoperative perforation). Residual recurrences occurred in two lesions (4.1%) that were treated with CSP and three lesions (4.8%) that were treated with UEMR, but these recurrences could be treated by re-endoscopic resection. Although there are limited data on these treatments for SNADETs, some previous reports and our data suggest that CSP could be indicated for adenomas sized 10 mm or less and that UEMR could be indicated for adenomas sized 10-20 mm and for intramucosal carcinomas. However, at present, the number of cases evaluated is still insufficient, and further studies are needed to evaluate long-term outcomes with enough cases.

The prevalence of obesity in both the United States and worldwide has grown significantly over the last several decades. With this growing pandemic, more patients are seeking surgical alternatives to achieve weight loss goals. Bariatric surgery has multiple proven health benefits, including weight loss and resolution of several co-morbidities, including diabetes. Advances in surgical techniques, including laparoscopy, have allowed bariatric surgery to increase in popularity among obese patients. However, bariatric surgery is not without complications. Key to successful weight loss surgery includes appropriate pre-operative laboratory workup, a multidisciplinary approach with other health care providers, proper peri-operative techniques as well as close post-operative follow up. This article will highlight several important criteria bariatric surgeons should bear in mind when evaluating patients in pre-operative, peri-operative and post-operative states to help prevent common complications seen in weight loss surgery.

Widespread adoption of colorectal endoscopic submucosal dissection (ESD) in clinical practice is lagging despite the peer evidence that it permits en bloc resection of large lesions that can be curative and facilitate pathological staging, thereby improving management. Limited adoption of colorectal ESD is likely due to technical challenges and a steep learning curve. Most conventional ESD devices are used without fixing the target, making them difficult to maneuver and thus creating a potential risk of perforation. Comparatively, a scissor-type knife, such as the SB Knife Jr, enables grasping of the target tissue, facilitating controlled dissection of tissue being held between the blades. This potentially prevents unexpected muscular layer injury. Colorectal ESD with the SB Knife Jr does not require complex endoscopic maneuvering or advanced skills for safe ESD. Since the incision and dissection procedure using the SB Knife Jr is different from that of conventional ESD knives, familiarization with its features is vital. In this review, we focus on the use of the SB Knife Jr for colorectal ESD. The basic colorectal ESD procedure using the SB Knife Jr consists of grasping, pulling, and cutting. By repeating these steps, circumferential incision, submucosal dissection, and hemostasis can be performed with a single device. For incision and dissection, a circumferential mucosal incision is performed similar to “cutting paper”. Submucosal dissection is performed with the image of “connecting the dots at the appropriate dissection depth”. The SB Knife Jr is useful as a secondary device in challenging ESD procedures, and surgeons should master its use.

With the rising prevalence of obesity, there has been a steady rise in the number of bariatric surgeries performed worldwide. As expected, there has also been an increase in the number of revisional surgeries performed to manage acute and chronic postoperative complications. This review will discuss the major complications that can arise from the most common bariatric surgeries, their diagnosis, medical management, and potential revisional surgical options.

Superficial non-ampullary duodenal epithelial tumors (SNADETs) are rare, but their incidence is increasing recently. Considering the invasiveness of pancreatoduodenectomy, endoscopic treatment is widely accepted as an option for maintaining patients’ quality of life. SNADETs larger than 20 mm are an indication for duodenal ESD, and intramucosal cancer can be cured by ESD. Duodenal ESD is extremely difficult with a high risk of adverse events. However, some modified treatment techniques such as the water pressure method or the pocket creation method have been proposed to improve outcomes. Furthermore, evidence is accumulating that protection of the mucosal defect reduces delayed adverse events after duodenal endoscopic treatments. Moreover, endoscopic drainage of the bile and pancreatic juice is effective as conservative management even in cases with delayed perforation.

Bariatric surgery is the cornerstone of treatment for severe obesity. In evaluating patients for such procedures, surgeons must be aware of the potential complications, including post-operative gastroesophageal reflux disorder (GERD). This review article outlines the current literature regarding GERD prior to and after bariatric surgery. It aims to establish a framework for evaluating and managing GERD in both the pre- and post-operative setting for common bariatric procedures such as the sleeve gastrectomy, Roux-en-Y gastric bypass, adjustable gastric band, duodenal switch type procedures as well as one-anastomosis gastric bypass. This review also outlines the latest recommendations from major international bariatric societies for screening prior to surgery, the incidence of GERD after each respective procedure and a summary of current trends in the management of post-operative GERD after bariatric surgery.

Aim: We aimed to evaluate trifecta outcomes after Retzius-sparing robot-assisted radical prostatectomy (rs-RARP). Methods: We evaluated 1488 patients who had undergone rs-RARP at our institution from 2011 to 2019. All patients filled out questionaries for functional outcomes before surgery, and only patients with baseline continence and IIEF-5 scores of > 16 were included. Biochemical recurrence (BCR) was defined as two consecutive prostatic specific antigen levels of > 0.2 ng/mL after rs-RARP. Postoperative continence was defined as the use of no pads. Potency was defined as the ability to achieve erections for sexual intercourse, with or without phosphodiesterase-5 (PDE-5) inhibitors. A multivariable logistic regression model was performed to identify predictors of trifecta outcome. Results: In total, 1240 patients were included in the analysis. During the 24-month follow-up time, 149 patients (11.9%) harbored BCR. Urinary continence was observed in 981 patients (79.5%), while 171 (13.8%) still used a safety pad daily after 24 months. Sexual potency was reported in 643 patients (51.9%), of whom 379 (30.6%) had spontaneous erections and 264 (21.3%) used a PDE-5 inhibitor. Overall, the trifecta outcome was reached by 42.1% of the study’s population. The trifecta outcome was easily reached by younger patients and patients who underwent a full nerve-sparing (NS) prostatectomy. In the multivariable model, age [odds ratio (OR) = 0.89; 95% confidence interval (CI): 0.84-0.90; P < 0.01] and type of NS surgery [partial NS (OR = 3.34; 95%CI: 1.01-11; P = 0.04) full NS (OR = 4.57; 95%CI: 1.86-12; P < 0.01)] resulted as independent predictors. Conclusion: rs-RARP is associated with optimal trifecta outcome rate. Age and NS technique are independent predictors of trifecta outcomes.

The impact of sex on baseline characteristics and morphological and clinical presentation of degenerative aortic stenosis has been widely demonstrated but poorly understood. Moreover, differently from valve surgery, where patients were predominantly male, both sexes have been well represented in percutaneous treatment of aortic stenosis (AS), and women appeared to derive greater benefit with transfemoral aortic valve implantation (TAVI) compared to surgical treatment. This review focuses on sex-specific differences in epidemiology, pathophysiology, diagnostic issues, treatment options, and clinical outcomes of degenerative AS. Moreover, we evaluate how sex-based TAVI management, from device selection to procedural tricks, may affect outcomes.

Robotic Assisted Laparoscopic Prostatectomy (RALP) has revolutionised the surgical management of localised Prostate Cancer in the modern era. The surgeon is provided with greater precision, more versatile dexterity and an immersive three-dimensional visual field. The impressive hardware facilitates, for example, the dissection of the peri-prostatic fascia, whilst preserving the neurovascular bundle, or the suturing of the vesico-urethral anastomosis. Prior to RALP, Laparoscopic Radical Prostatectomy (LRP) represented the first venture into the minimally invasive world. Associated with more cumbersome ergonomics, LRP has a significant learning curve when compared with the robotic approach. There has been a paucity, until recently, of high-quality literature comparing outcomes between the two operations, including the attainment of the Pentafecta of survivorship: biochemical recurrence-free, continence, potency, no postoperative complications and negative surgical margins.

Robotic intracorporeal neobladder (RIN) is increasingly the modality of choice for intracorporeal urinary diversion in high-volume Robotic Urology centers. This article details the modern technique of RIN, explains specific tips and tricks to facilitate timely operative progression as well as weighs the outcomes from recently published series. An OVID/EMBASE database search was done using keywords: robotic, cystectomy, intracorporeal neobladder, orthotopic, and intracorporeal urinary diversion. The inclusion criteria were original studies on Robot-Assisted Radical Cystectomy (RARC) with RIN series, available in full text in English, published over the last ten years with a specific analysis of oncological and functional outcomes. Pooled data analysis of the 10 studies included shows 80% of patients had organ-confined disease (≤pT2), 1.86% of patients had positive surgical margin, median lymph node yield of 23 nodes (IQR = 7.5), and cancer-specific survival rate of 78% (range 72%-100%) over a mean follow up of 27.43 months (range 13-37 months). Functionally, the median day continence rate is 81.5%, night continence rate is 61%, and rate of return to spontaneous sexual activity is 33.5%. This compares favorably with outcomes of The International Robotic Cystectomy Consortium - Extracorporeal Urinary Diversion data and data from open radical cystectomy (ORC) neobladder series with long term follow up. High-volume robotic centers have successfully introduced programs for RARC, with RIN demonstrating its safety and feasibility. Their results suggest potential to improve perioperative and functional outcomes over ORC. Moreover, under mentorship, surgeons can learn the technique of RARC and RIN without these outcomes being significantly affected.

This review considers the preferred preoperative examinations, indications for endoscopic submucosal dissection (ESD), and curative ability of ESD in patients with esophageal squamous cell carcinoma (SCC). Endoscopic evaluation by non-magnifying endoscopy followed by magnifying endoscopy is a common procedure for diagnosing invasion depth of superficial esophageal SCCs in Japan. However, endoscopic ultrasonography may increase overdiagnosis of the depth of cancer invasion, and therefore should not be performed routinely. Image-enhanced magnifying endoscopy or iodine staining is recommended for diagnosing the lateral extent of esophageal SCC. The indications for ESD include clinical T1a-epithelial/lamina propria (EP/LPM) N0M0 non-circumferential lesions, clinical T1a EP/LPM N0M0 circumferential lesions ≤ 50 mm, and clinical T1a-muscularis mucosae/T1b-submucosa 1 cancer (invading submucosa by ≤ 200 µm) N0M0 non-circumferential lesions. Pathological T1a EP/LPM without vascular invasion is defined as curative resection, while pathological T1a MM without vascular invasion is considered as non-curative resection, with undetermined recommendations for additional treatment. Pathological T1b cancer invading the submucosa or pathological vascular invasion-positivity is considered as non-curative resection, and additional treatment is recommended. An accurate preoperative diagnosis, appropriate indication, and adequate curability assessment based on the pathological diagnosis of resected specimens are important for effective ESD.

Aim: We aimed to review and summarize recent data on surgical and functional outcomes in women undergoing robot-assisted radical cystectomy (RARC) and urinary diversion (UD) for bladder cancer, compared with male and open counterparts. Methods: A systematic review of English-language articles published in the last 15 years was performed on PubMed/Medline database according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Outcomes of interest included peri- and post-operative surgical outcomes [operative time (OT), estimated blood loss (EBL), hospital stay (LOS), complications, and readmission], pathological outcomes [pT stage, lymph node (LN) yield, positive surgical margins (PSMs), and positive LN (pN+)], and functional outcomes [daytime and nighttime continence, sexual activity, need for clean intermittent catheterization (CIC), and quality of life (QoL) evaluation]. Results: Overall, eight studies were selected collecting data from 229 female patients undergoing RARC. The median OT was 418 min (range 311-562 min) and the median EBL was 380 mL (range 100-1160 mL). OT and EBL were not significantly different comparing males and females, whereas the robotic approach was found to be significantly related with longer OT and lower EBL compared to the open procedure. The median LOS was 9.8 days (range 6.5-21 days); no significant differences in LOS were found between open RC (ORC) and RARC in female patients, as well as between RARC in women and men. The mean incidence of 30-day complications after RARC in women was 32.9%, with 12% of high-grade complications, while the 30- and 90-day readmission rates were 20.8%, and 28%, respectively. Complications and readmission comparing RARC and ORC in female patients appear to be overlapping. The mean rate of PSMs was 2.5% and the mean rate of pN+ was 12.7%; both these outcomes were similar in RARC compared with ORC. The mean number of retrieved LN was 20.6 (range 11.3-35.5). The LN yield resulted significantly influenced by the robotic approach [median 27 (range 19-41)] compared to the open one [20.5 (range 13-28)]. After 12 months, the rate of women with daytime and nighttime continence was 66.7%-90.9% and 66.7%-86.4%, respectively, while that of sexually active women ranged 66.7%-72.7%. The need for CIC ranged 12.5%-27.2%. Administering the EORTC-QLQ-C30 questionnaire after RARC and intracorporeal neobladder, the global health status/QoL and physical and emotional functioning items improved significantly over time. Conclusion: RARC and UD in female patients is a feasible procedure with surgical outcomes overlapping with those in the male patient population. Postoperative functional outcomes on continence, sexual function, and QoL are still poorly investigated, although results inherent in the nerve-sparing approach appear promising.

Biliary tract malignancies include cancers of the intra-hepatic and extra-hepatic bile ducts. Cholangiocarcinoma is the predominant biliary tract malignancy with nearly 60% of them occurring in the peri-hilar region. They can present with biliary strictures causing jaundice but can be insidious and present late in their clinical course. Recent advances in imaging and other diagnostic modalities help in the earlier identification of these tumors. Diagnosis should be suspected in anyone presenting with jaundice with evidence of biliary ductal dilatation or in patients with primary sclerosing cholangitis with worsening clinical status. The diagnostic approach consists of obtaining tumor markers, mainly CA 19-9, imaging modalities which include computed tomography and/or magnetic resonance imaging to establish the level of biliary obstruction and presence or absence of mass. Tissue sampling is performed with endoscopic retrograde cholangiopancreatography (ERCP) guided cytology and biopsies and with endoscopic ultrasound (EUS) if a mass is visible on imaging. Indeterminate strictures after initial biopsies could be further evaluated by cholangioscopy directed biopsies. Treatment for resectable and distal bile duct cancers involves surgical referral, but palliative biliary drainage is the key for unresectable cancers. Metal stents are generally preferred for distal cancers and plastic stents for proximal cancers. EUS guided biliary drainage can be an alternative approach in patients with failed ERCP.

Minimally invasive surgery (MIS) has changed not only the performance of specific operations but also the more effective strategic approach to all surgeries. Expansion of MIS to more complex surgeries demands further development of new technologies, including robotic surgical systems, navigation, guidance, visualizations, dexterity enhancement, and 3D printing technology. In the cardiovascular domain, 3D printed modeling can play a crucial role in providing improved visualization of the anatomical details and guide precision operations as well as functional evaluation of various congenital and congestive heart conditions. In this work, we propose a novel deep learning-driven tracking method for providing quantitative 3D tracking of mock cardiac interventions on custom-designed 3D printed heart phantoms. In this study, the position of the tip of a catheter is tracked from bi-plane fluoroscopic images. The continuous positioning of the catheter relative to the 3D printed model was co-registered in a single coordinate system using external fiducial markers embedded into the model. Our proposed method has the potential to provide quantitative analysis for training exercises of percutaneous procedures guided by bi-plane fluoroscopy.

Inguinal hernia repair is one of the most commonly performed general surgery operations. Throughout the years there have been many variations and advancements, including open and laparoscopic techniques, to accomplish the same task of reducing herniated contents and preventing groin hernia recurrence. An array of factors contributes to deciding which operative technique is the best approach to managing a patient presenting with an inguinal hernia. Published data vary due to the heterogeneity of techniques compared, patient presentations, and surgeon expertise. In experienced hands, laparoscopic repair results in a quicker return to work and reduced postoperative pain. Patients with bilateral groin hernias, female patients with groin hernias, and patients with recurrent hernias after prior anterior mesh repair should be offered a laparoscopic preperitoneal mesh approach, when surgeons have the appropriate skill set and experience. We find that open and laparoscopic techniques of inguinal hernias can both achieve exceptional outcomes when applied to the right patient population. To know one’s own capabilities, it is beneficial for surgeons to have baseline familiarity of the multitude of methods of repair, become proficient in both mesh and mesh-free techniques as well as open and laparoscopic techniques to best tailor the surgery to the patient and the clinical circumstances, and follow personal outcomes to evaluate individual results.

The development of a postoperative seroma after endoscopic transabdominal (TAPP) or extraperitoneal (TEP) groin repair is a frequent problem. Although seromas are usually only mildly symptomatic, the swelling that develops postoperatively often causes patients to feel insecure and worried. In the literature some technical approaches to reduce the incidence of postoperative seroma are described. This technical note deals with the authors’ approach in the management of large medial and lateral hernial orifices during robotic r-TAPP procedures using DaVinci Xi technology with the aim of seroma prophylaxis. Keywords Inguinal hernia, robotic surgery, hernial orifices, seroma, barbed suture, TISSEEL, fibrin sealant

Specific injuries due to poor positioning seen in robotic pelvic surgery include slips, compartment syndrome, facial oedema, injuries on pressure points, and accidental injuries caused by the robotic arms. The use of the vacuum bean-bag positioner, L-bar against the patient’s face, and inflated gloves for hand support are simple and effective techniques and should be included in the standard operating policies for robotic surgery. We recommend use of the “L” shaped safety bar against the patient’s face to ensure protection against accidental injuries caused by the robotic arms. The anti-slip bean-bag mattress is efficient to prevent slipping; it conforms to the shape of the body for stable positioning and allows extremities to lie in a natural position. Protection of pressure points of hands and elbows can be done with inflated medical gloves placed in the patient’s hands. Surgeons, anaesthetists and theatre teams are together responsible for ensuring that safety measures are in place to reduce the risk of these complications.

Inguinal hernias are a very common problem and the most common reason for primary care physicians to refer patients for surgery. The diagnosis is usually made from history and physical examination and men are significantly more likely to be affected than women. Most patients will present with a painful bulge in the groin, though up to a third of patients will be asymptomatic at the time of diagnosis. Previously, it had been recommended that all hernias be repaired surgically at the time of diagnosis to prevent the development of a hernia accident (bowel obstruction or strangulation) that would require emergent surgery, which is associated with much higher morbidity and mortality than an elective repair. However, several clinical trials have reported that risks of a hernia accident are sufficiently low so that a “watchful waiting” (WW) approach for male patients who are asymptomatic or minimally symptomatic is a safe management strategy. WW spares patients any risk of operative complications related to their herniorrhaphy, perhaps the most significant of which is post-herniorrhaphy groin pain that has only recently been appreciated as a significant issue. Although WW has now been proven to be safe in asymptomatic males with an inguinal hernia, long-term results of randomized controlled trials have shown that most patients initially managed with WW will eventually elect to have the hernia surgically repaired primarily due to increased pain. The purpose of this article is to review the current evidence on watchful waiting for the management of inguinal hernias.

One of the most serious complications after inguinal hernia repair is still the occurrence of chronic pain. The literature describes rates of severe chronic pain of 3%-6%. Laparo-endoscopic inguinal hernia repair is favored to prevent postoperative pain through a minimally invasive approach and sparing of the layers of tissue covering nerves and vessels in terms of reduced risk of damage to these structures. However, the method of fixation of the mesh is still controversial discussed. The use of these penetrating devices such as staples and staplers has been shown to often be complicated by injury to nerves and vessels and occurrence of postoperative pain. The shift to completely atraumatic fixation using adhesives (fibrin glue, cyanoacrylate) began in the early part of this century. Several studies confirmed less postoperative pain after mesh fixation by glue compared to stapler or tacker. Historically, the TEP technique has always been performed without any fixation. Several studies comparing fixation versus non-fixation have been performed in TEP repair and found results with no increase in recurrence rate. Notwithstanding that very few studies comparing fixation versus no fixation with exclusion of large medial inguinal hernias have been published on this topic in TAPP repair, identical results to those with TEP repair were obtained. On the basis of current evidence, no mesh fixation is recommended for laparo-endoscopic inguinal hernia repair except for large medial and combined inguinal hernias. If mesh fixation is required, atraumatic techniques should be used.

Meningiomas are the most common neoplasm of the central nervous system. Usually benign and generally discovered incidentally at imaging, meningiomas can also be responsible for severe neurological symptoms and deficits, with potentially high morbidity and non-negligible mortality. Therefore, neuroimaging plays a crucial role in meningiomas diagnosis, therapeutic planning, and long-term surveillance, for early detection of both recurrence in treated patients and disease progression in untreated ones. Here, we review conventional findings in meningiomas’ imaging, review the role for advanced diagnostic techniques, and offer an overview on possible future neuroimaging applications.

With the recent increase in small-sized lung cancers, sublobar resection and minimally invasive surgeries are becoming preferred. In particular, the detection of ground-glass nodules (GGNs) on high-resolution computed tomography has increased. Although lobectomy has been considered a standard procedure for treating lung cancer, sublobar resections have been indicated for treating GGN-dominant small-sized lung cancers. Wedge resection and segmentectomy have generally been performed as sublobar resection; however, each procedure has some technical advantages and disadvantages. Although anatomical resection as a segmentectomy is a complicated procedure, it has recently been increasingly performed with the accurate anatomical grasp using three-dimensional computed tomography and the identification of the intersegmental plane. Other procedures involving the use of newer technologies can also be performed. Individualized sublobar resection might be a suitable procedure for small-sized lung cancer with the appropriate selection of procedures based on each tumor’s characteristics and improving the methods to overcome some technical difficulties.

The advent of neuroendoscopy catalyzed the ongoing development of minimally invasive neurosurgery in the 1990s. This millennium has seen rapid developments in the design of scopes, improved high-definition visualization systems, and a plethora of dedicated instruments. Many minimally invasive and endoscopic procedures have become the new "standard of care" today. Endoscopic third ventriculostomy and endonasal pituitary surgeries have replaced alternative techniques in most major institutes in the world and the indications are rapidly increasing to tackle many midline skullbase, intraventricular, and some parenchymal lesions as well. The scope of minimally invasive neurosurgery has extended to spine surgery, peripheral nerve surgery, and unique indications, viz. craniosynostosis repair. This review describes many of these developments over the years, evaluates current scenario, and tries to give a glimpse of the "not so distant" future.

The past several decades have seen remarkable advancements in percutaneous interventions for treatment of congenital heart disease (CHD). These advancements have been significantly aided by improvements in noninvasive diagnostic imaging. The use of three-dimensional (3D) printed models for planning and simulation of catheter-based procedures has been demonstrated for numerous cardiac defects and has been shown to reduce complications, procedure times, and limit radiation exposure. This paper reviews the process by which patient-specific 3D cardiac models are produced, as well as numerous applications of these models for use in percutaneous interventions in CHD.

The favorable outcome generally associated with spinal meningioma surgery is the result of the continuing refinement of the surgical technique, the use of intraoperative neuromonitoring, and a better understanding of the tumor biological behavior. Among all the technological advancements, visualization tools are the keys to any successful surgical procedure. The operating microscope is the gold standard in all neurosurgical procedures. In recent years, high-definition exoscope systems have entered the field of neurosurgery, as another tool in the armamentarium of the contemporary neurosurgeon. After initial experiences and technical improvements, the exoscope has proven to be best suited for spinal procedures. This study aims to briefly review the exoscope journey in neurosurgery, with a special focus on spinal meningioma surgery. Benefits and limitations are analyzed and an illustrative case is reported. Spinal meningiomas removal under exoscope visualization has proven to be feasible, efficient, and safe. Indication for the use of the exoscope greatly depends on meningioma size, consistency, relationship to surrounding neurovascular structures, and the surgeon’s experience. Switching to the operating microscope, if deemed safer, should always be considered.

Percutaneous mitral valve intervention is emerging as a valid alternative for patients affected by mitral regurgitation. By addressing the pathophysiology, therapeutic options mainly target the leaflets, annulus or left ventricle. The present review will cover the intraprocedural guidance of the most used approaches, such as edge to edge repair, adjustable transapical beating-heart chordal implantation and percutaneous direct or indirect annuloplasty. Intraprocedural monitoring relies on integration of fluoroscopy and echocardiography, and is based on the continuous communication between the interventional imager and the interventional cardiologist.

Abstract A growing body of evidence shows that transcatheter mitral valve edge-to-edge repair (TMVr) for mitral regurgitation (MR) improves symptoms and prognosis of patients with heart failure. Still, as recently shown by two large randomized controlled trials (COAPT and MITRA-FR), there is differing information on which patients have the largest benefit. We aimed to summarize the current knowledge of clinical and anatomic predictors for acute procedural failure and long-term all-cause mortality after TMVr. TMVr is an effective treatment option for patients with symptomatic MR fulfilling certain echocardiographic and clinical criteria or being ineligible for surgery despite optimal medical therapy. Acute procedural failure is influenced by anatomic features of the mitral valve, among those are increased tenting and mitral valve leaflet configuration, leaflet-to-annulus index, as well as the mitral valve opening area. In contrast, anatomy of the mitral valve plays a minor role in predicting all-cause mortality after TMVr. This endpoint is associated with patient comorbidities (e.g., renal failure and chronic lung disease), severe heart failure as expressed by New York Hear Association functional class (NYHA) IV, left and right heart dysfunction, laboratory parameters (NT-proBNP), clinical scoring systems (STS and EuroScore), and procedural MR reduction. In patients undergoing TMVr for severe MR, careful preprocedural evaluation of relevant comorbidities, mitral valve anatomy, as well as left and right heart function can provide detailed prognostic value regarding acute procedural success and long-term survival.

Since its introduction in 1982, percutaneous mitral balloon valvuloplasty (PMV) has been used successfully as an alternative to open or closed surgical mitral commissurotomy in the treatment of patients with symptomatic rheumatic mitral stenosis. PMV is safe and effective and provides sustained clinical and hemodynamic improvement in patients with mitral stenosis. The immediate and long-term results appear to be similar to those of surgical mitral commissurotomy. Proper patient selection is an essential step for being able to predict the immediate results of PMV. Candidates for PMV require precise assessment of the mitral valve morphology. The Wilkin’s echocardiographic score (Echo-Sc) is currently the most widely used method for predicting PMV outcome. Leaflet mobility, leaflet thickening, valvular calcification, and sub valvular disease are each scored from 1 to 4. An inverse relationship exists between the Echo-Sc and PMV success. Both immediate and intermediate follow-up studies have shown that patients with Echo-Sc ≤ 8 have superior results, significantly greater survival, and event free survival compared to patients with Echo-Sc > 8. We identified other clinical and morphologic predictors of PMV success that include age, pre-PMV mitral valve area, history of previous surgical commissurotomy, and mitral regurgitation (MR), and post-PMV variables (e.g., post-PMV MR ≥ 3 + and pulmonary artery pressure), that may be used in conjunction with the Echo-Sc to optimally identify candidates for PMV. This concept demonstrates a multifactorial nature of the prediction of immediate and long-term results. Other echocardiographic scores have been developed for the screening of potential candidates for PMV. They include a unique score that take into account the length of the chordae. A novel quantitative score that included the ratio of the commissural areas over the maximal excursion of the leaflets from the annulus in diastole. The components of this score include mitral valve area ≤ 1 cm², maximum leaflet displacement ≤ 12 mm, commissural area ratio ≥ 1.25, and sub valvular involvement. Finally, a score that is able to identify patients who are more likely to develop significant mitral regurgitation post-PMV. This score takes into account the distribution (even or uneven) of leaflet thickening and calcification, the degree and symmetry of commissural disease, and the severity of subvalvular disease. The transvenous transseptal approach is the most widely used PMV technique. The two major techniques of PMV are the double-balloon technique and the Inoue technique which are equally effective techniques of PMV. Encouraging results of PMV have been reported in special mitral stenosis population cohorts including pregnant women, patients with previous surgical commissurotomy, patients with atrial fibrillation, patients with pulmonary hypertension, elderly patients, patients with calcific mitral stenosis, and patients with associated aortic regurgitation. To summarize, PMV is the preferred form of therapy for relief of mitral stenosis for a selected group of patients with symptomatic mitral stenosis and suitable valve anatomy for valvuloplasty. Patients with Echo-Sc ≤ 8 have the best results, particularly if they are young, are in normal sinus rhythm, have no pulmonary hypertension, and have no evidence of calcification of the mitral valve under fluoroscopy. The immediate and long-term results of PMV in this group of patients are similar to those reported after surgical mitral commissurotomy. Patients with Echo-Sc > 8 have only a 50% chance to obtain a successful hemodynamic result with PMV, and the long-term follow-up results are worse than those from patients with Echo-Sc ≤ 8. In patients with Echo-Sc ≥ 12, it is unlikely that PMV could produce good immediate or long-term results and they preferably should undergo mitral valve replacement. However, PMV could be considered in these patients if they are high-risk or unqualified surgical candidates.

Mitral regurgitation (MR) is the most common left-sided heart valve disease in developed countries with a constantly rising number of patients requiring hospitalization or intervention. Organic MR is defined as a primary structural abnormality of the mitral valve (MV) apparatus which may be caused by a broad set of pathological processes, among which myxomatous degeneration of the leaflets causing MV prolapse is the most common. If left untreated, chronic severe MR leads to serious adverse outcomes, from heart failure to death, but medical therapy is unable to change the natural history of the disease. Surgical correction, by means of valve repair or replacement, is the gold standard for the treatment of symptomatic patients with severe primary MR. However, surgery is not feasible for a large percentage of patients because of old age, reduced left ventricular ejection fraction and the presence of severe comorbidities. Therefore, in recent years, several percutaneous therapeutic alternatives suitable for high or prohibitive surgical risk patients were developed. In this review we discuss the transcatheter treatment of primary MR, from available evidence to technical practice, with a focus on the percutaneous “edge-to-edge” leaflet repair performed with the MitraClip System and the PASCAL Repair System.

The introduction of laparoscopic technology and surgical robots in hepatobiliary surgery in the 1990s and 2000s, respectively, has dramatically revolutionized the field. Even though laparoscopic and robotic major hepatectomy was slower to adopt compared to minimally-invasive minor hepatectomy, the number of major hepatectomies performed with both approaches worldwide has significantly increased and is still rising. Despite the few comparative studies between laparoscopic and robotic major hepatectomy, most studies are focused on describing the procedures or reporting the outcomes of each method, either separately, or mixed with minor hepatectomies. Based on the available data, the direct comparison between the two techniques has shown that when robotic major hepatectomy is performed by experienced hepatobiliary surgeons in high-volume centers, it can lead to similar operating times, estimated blood loss, hospital length of stay, complication and mortality rates compared to its laparoscopic counterpart. The likelihood of achieving a margin-negative resection in cancer patients, as well as long-term disease-free and overall-survival are comparable between the groups. However, broader adoption of the robotic approach might be a hurdle in low-volume centers due to the high fixed capital and annual maintenance cost of the surgical robot.

Anatomic pulmonary segmentectomy and mediastinal nodal dissection have been advocated in patients with smaller tumors or patients with limited pulmonary reserve. The overall five-year survival and lung cancer-specific five-year survival following anatomic segmentectomy have been shown to be equivalent to lobectomy. Robotic surgical systems have the advantage of magnified high-definition three-dimensional visualization and greater instrument maneuverability in a minimally invasive platform. Robotics can facilitate the dissection of the broncho-vascular structures and replicate the technique of segmentectomy by thoracotomy. Greater experience with the robotic platform has resulted in a reproducible technique. The Technique of Robotic Anatomic Segmentectomy Part I outlines a stepwise approach to robotic segmentectomy of S1, S2, S3, S4, S5, S6, and S7-S10 of the right lung. The Technique of Robotic Anatomic Segmentectomy Part II outlines a stepwise approach to robotic segmentectomy to the left lung.