Project description:Introduction and importance Pancreatic body and tail adenocarcinoma is a tumor of silent evolution, showing up as advanced disease at diagnosis in the majority cases. Case presentation A 60-year-old man, presenting a solid expansive lesion (3.1 × 2.8 cm) in the body of the pancreas, by imaging exams. There was 50% involvement of the celiac trunk at the level of the it's bifurcation and suspected peripancreatic lymph nodes. Clinical staging was cT4N1M0. After neoadjuvant chemotherapy (NQT), there was a small reduction of the tumor to 3.0 × 2.6 cm, an important decreasing of the celiac trunk involvement (25%), and also a reduction in the levels of C19–9 from 650 U/mL to 358 U/mL. Further on, the patient underwent a Robotic Modified Appleby procedure, without intra and postoperative complications. Clinical discussion Locally advanced pancreatic tumors should be referred to NQT, and those with good response might benefit to radical surgery. The modified Appleby technique - distal pancreatectomy with splenectomy and celiac trunk resection – is the procedure of choice when there is involvement of celiac trunk, but concern must be given to the liver vascularization. The use of robotic system on pancreatic surgery is emerging, but still, there is lower data regarding its safety in major pancreatic procedures. Conclusion The use of neoadjuvant therapy is recommended to assess the in vivo response, improve oncological results and increase negative margins. Pre-operative imaging is mandatory for surgical planning. The robotic modified Appleby procedure is feasible and safe, with reduced of intraoperative blood loss and transfusion rate, corroborating the literature. Highlights • 30% of pancreatic cancer presents as locally advanced disease at diagnosis with invasion to vascular structures.• Arterial involvement is the biggest challenge for oncological resection, and involvement of the celiac axis or its branches can make curative resection impossible• Robotic systems have been used in pancreatic surgery, but there is fewer data regarding feasibility and safety in major procedures.• Preoperative radiology is crucial to assess the response to neoadjuvant therapy and allows for the analysis of vascular anatomy.

Project description:ObjectiveTo describe the technical aspects and outcomes of robotic-assisted radical prostatectomy (RARP) following abandoned open radical prostatectomy (ORP).Patients and methodsA retrospective review was performed of patients who underwent RARP following abandonment of ORP between 2016 and 2020. RARP was undertaken by two highly experienced robotic surgeons. Analysis of patient and operative characteristics, outcomes, and reasons for abandonment of ORP were described.ResultsSix patients were included for analysis with a median age of 63.5 years [50.3-67.5]. The median body mass index (BMI) was 34.7 [27.8-36.2]. All patients had intermediate-risk prostate cancer. Small prostate and deep pelvis were given as reasons for abandoning ORP in five cases (83.3%), with four of these also attributing increased BMI as a factor. Extensive mesh from previous bilateral inguinal hernia repair was cited as the reason for abandonment in the remaining patient. One patient had commenced androgen deprivation therapy following abandoned ORP. Extensive retropubic adhesions were noted at the time of RARP in five of six patients, with intraoperative complication of small bladder lacerations encountered in the patient with prior mesh hernia repair. The median time from abandoned ORP to RARP was 128 days [40-216]. Median operating time was 160 minutes [139-190] and estimated blood loss was 225 mL [138-375]. Negative margins were obtained in four of six cases, with further salvage treatment being required in one case at a median follow-up duration of 10.5 months [6.5-25.3].ConclusionAbandonment of ORP is an uncommonly reported event, however, in this small case series, we demonstrate that, in the hands of experienced surgeons, RARP is a safe and technically feasible alternative in such cases. Increased BMI, small prostate size and pelvic anatomical constraints appear to be common catalysts for abandonment of open surgery in this cohort. Identifying these high-risk patients early and considering referral to robotic centers may be preferred.

Project description:Introduction: Robotic and thoracoscopic surgery are being increasingly adopted as minimally invasive alternatives to open sternotomy for complete thymectomy. The superior maneuverability range and three-dimensional magnified vision are potential ergonomical advantages of robotic surgery. To compare the ergonomic characteristics of robotic versus thoracoscopic thymectomy, a previously developed scoring system based on impartial findings was employed. The relationship between ergonomic scores and perioperative endpoints was also analyzed. Methods: Perioperative data of patients undergoing robotic or thoracoscopic complete thymectomy between January 2014 and December 2022 at three institutions were retrospectively retrieved. Surgical procedures were divided into four standardized surgical steps: lower-horns, upper-horns, thymic veins and peri-thymic fat dissection. Three ergonomic domains including maneuverability, exposure and instrumentation were scored as excellent(score-3), satisfactory(score-2) and unsatisfactory(score-1) by three independent reviewers. Propensity score matching (2:1) was performed, including anterior mediastinal tumors only. The primary endpoint was the total maneuverability score. Secondary endpoints included the other ergonomic domain scores, intraoperative adverse events, conversion to sternotomy, operative time, post-operative complications and residual disease. Results: A total of 68 robotic and 34 thoracoscopic thymectomies were included after propensity score matching. The robotic group had a higher total maneuverability score (p = 0.039), particularly in the peri-thymic fat dissection (p = 0.003) and peri-thymic fat exposure score (p = 0.027). Moreover, the robotic group had lower intraoperative adverse events (p = 0.02). No differences were found in residual disease. Conclusions: Robotic thymectomy has shown better ergonomic maneuverability compared to thoracoscopy, leading to fewer intraoperative adverse events and comparable early oncological results.

Project description:BACKGROUND:The first reported case of cardiac herniation was in 1948 and occurred following pericardiectomy during a lung cancer resection. Although rare, this potentially fatal surgical complication may occur following any operation in which a pericardial incision or resection is performed. The majority of literature on cardiac herniation involves case reports after intrapericardial pneumonectomy. Currently, there are no reports of cardiac herniation after thymectomy with pericardial resection. CASE PRESENTATION:A 44-year-old Asian female with symptomatic myasthenia gravis was referred for thymectomy. Originally thought to have Bell's Palsy, her symptoms began with right eyelid drooping and facial weakness. Over time, she developed difficulty holding her head up, upper extremity weakness, difficulty chewing and dysarthria. These symptoms worsened with activity. She was found to have positive acetylcholine receptor binding antibody on her myasthenia gravis panel. A preoperative CT scan demonstrated a 3.5?cm?×?2?cm anterior mediastinal mass along the right heart border and phrenic nerve. A complete thymectomy, via right-sided robotic-assisted approach was performed en bloc with a portion of the right phrenic nerve and a 4?cm?×?4?cm portion of pericardium overlying the right atrium and superior right ventricle. Upon undocking of the robot and closure of the port sites, the patient became acutely hypotensive (lowest recorded blood pressure 43/31?mmHg). The camera was reinserted and demonstrated partial cardiac herniation through the anterior pericardial defect toward the right chest. An emergent midline sternotomy was performed and the heart was manually reduced. The patient's hemodynamics stabilized. A vented Gore-Tex 6?cm?×?6?cm patch was sewn along the pericardial edges with interrupted 4-0 prolene to close the pericardial defect. CONCLUSION:This potentially fatal complication, although rare, should always be considered whenever there is hemodynamic instability entry or resection of the pericardium during surgery. We now routinely sew in a pericardial patch using our robotic surgical system for any defect over 3?cm?×?3?cm that extends from the mid- to inferior portions of the heart.

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The technical aspects of a midline robotic thymectomy.

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The technical aspects of a midline robotic thymectomy.

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