Evolution of Salvage Radical Prostatectomy from Open to Robotic and Further to Retzius Sparing Surgery

Salvage radical prostatectomy (sRP) has evolved from open to minimally invasive approaches. sRP can be offered to patients with local recurrence to improve biochemical recurrence (BCR)-free and overall survival. We evaluate oncological outcome and continence after retropubic (RRP), conventional (cRARP), and Retzius-sparing robotic (rsRARP) surgery. Materials/methods: A total of 53 patients undergoing sRP between 2010 and 2020 were included. Follow-up included oncological outcome and continence. Results: sRP was done as RRP (n = 25), cRARP (n = 7), or rsRARP (n = 21). Median blood loss was 900 mL, 500 mL, and 300 mL for RRP, cRARP, and rsRARP, respectively. At 12 months, 5 (20%), 0, and 4 (19%) patients were continent, 9 (36%), 3 (43%), and 7 (33%) had grade 1 incontinence, 5 (20%), 2 (29%), and 3 (14%) had grade 2 incontinence, and 3 (12%), 2 (29%), and 4 (19%) had grade 3 incontinence for RRP, cRARP, or rsRARP, respectively. During a mean follow-up of 52.6 months, 16 (64%), 4 (57%), and 3 (14%) developed BCR in the RRP-, cRARP-, and rsRARP-group, respectively. Conclusions: Over the years, sRP has shifted from open to laparoscopic/robotic surgery. RARP shows good oncological and functional outcome. rsRARP ensures direct vision on the rectum during preparation and can therefore increase safety and surgeon’s confidence, especially in the salvage setting.

Application of Indocyanine Green Videoangiography in Cerebellar Hemangioblastoma Surgery as a Valuable Adjunctive Surgical Tool

Introduction : Surgery for cerebellar hemangioblastoma can be challenging because of the tumor’s location in the posterior fossa and its inherent nature of hypervascularity. Methods We reviewed a total of seven consecutive patients who received microsurgery adjunction with indocyanine green (ICG) videoangiography. Results Our study included four female and three male patients. All tumors were located in the cerebellum. We used ICG videoangiography for the purposes of identifying a small tumor inside the cyst in one case, for defining feeding arteries and draining veins in three cases, for confirming residual tumor in the resection cavity in two cases, and for assessment of tumor shunt flow in one case of extremely hypervascular hemangioblastoma. Median blood loss during surgery was 100 mL, and total resection was achieved in all cases with no complications. No adverse effects of ICG videoangiography were observed. Conclusions ICG videoangiography is a very useful adjunctive tool for cerebellar hemangioblastoma surgery.

Laparoscopic cholecystectomy after endoscopic trans-papillary gallbladder stenting for acute cholecystitis: a pilot study of surgical feasibility

Background Percutaneous transhepatic gallbladder drainage (PTGBD) is indicated for patients with acute cholecystitis (AC) who are not indicated for urgent surgery, but external tubes reduce quality of life (QOL) while waiting for elective surgery. The objective of the present study was to investigate the feasibility of laparoscopic cholecystectomy after endoscopic trans-papillary gallbladder stenting (ETGBS) comparing with after PTGBD. Methods Intraoperative and postoperative outcomes of patients with ETGBS and PTGBD were retrospectively compared. Results Eighteen ETGBS and ten PTGBD patients were compared. Differences in the duration of ETGBS and PTGBD [median 209 min (range 107–357) and median 161 min (range 130–273), respectively, P = 0.10], median blood loss [ETGBS 2 (range 2–180 ml) and PTGBD 24 (range 2–100 ml), P = 0.89], switch to laparotomy (ETGBS 11% and PTGBD 20%, P = 0.52), and median postoperative hospital stay [ETGBS 8 (range 4–24 days) and ETGBS 8 (range 4–16 days), P = 0.99]. Thickening of the cystic duct that occurred in 60% of the ETGBS patients and none of the PTGBD patients (P = 0.005) interfered with closure of the duct by clipping. No obstruction occurred in ETGBS patients. Conclusion ETGBS did not make laparoscopic cholecystectomy less feasible than after PTGBD. This is a pilot study, and further investigations are needed to validate the results of the present study.

Manual intracorporeal end-to-end invagination ileotransverse anastomosis, own experience

Aim: to evaluate the results of original manual intracorporeal end-to-end invagination ileotransverse anastomosis after laparoscopic right hemicolectomy.Patients and methods: twenty-two patients with right colon cancer were included in the study: 17 females and 5 males aged 53.1±3.4 years. They underwent laparoscopic right hemicolectomy with the standard D2 lymphadenectomy and intracorporeal ileotransverse anastomosis by the original technique. Follow-up period after surgery was 3 months.Results: no conversions to open surgery occurred. The operation time was 120.0±12.5 minutes, the median blood loss was 87.0±5.0 ml. Twenty (90.9%) patients are still under follow-up. The hospital stay was 11.4±2.6 days. There were no intraoperative complications. There were no cases of anastomotic leakage. No mortality occurred. At the time of the follow-up, all the patients are alive. Two (9.1%) patients have dropped out of control.Conclusion: the experience of the first 22 laparoscopic right hemicolectomies with intracorporeal laparoscopic end-to-end invagination ileotransverse anastomosis makes it possible to recommend this reliably safe method.

Laparoscopic Cholecystectomy After Endoscopic Trans-papillary Gallbladder Stenting for Acute Cholecystitis

Background: Percutaneous transhepatic gallbladder drainage (PTGBD) is indicated for patients with acute cholecystitis (AC) who are not indicated for urgent surgery, but external tubes reduce quality of life (QOL) while waiting for elective surgery. The objective of the present study was to investigate the feasibility of laparoscopic cholecystectomy after endoscopic trans-papillary gallbladder stenting (ETGBS) comparing with after PTGBD.Methods: Intraoperative and postoperative outcomes of patients with ETGBS and PTGBD were retrospectively compared.Results: Eighteen ETGBS and ten PTGBD patients were compared. Differences in the duration of ETGBS and PTGBD [median 209 minutes (range, 107–357) and median 161 minutes (range, 130–273), respectively, P = 0.10], median blood loss [ETGBS 2 (range, 2–180 ml) and PTGBD 24 (range, 2–100 ml), P = 0.89], switch to laparotomy (ETGBS 11% and PTGBD 20%, P = 0.52), and median postoperative hospital stay [ETGBS 8 (range, 4–24 days) and ETGBS 8 (range 4–16 days), P = 0.99]. Thickening of the cystic duct that occurred in 60% of the ETGBS patients and none of the PTGBD patients (P = 0.005) interfered with closure of the duct by clipping. No obstruction occurred in ETGBS patients.Conclusion: ETGBS did not make laparoscopic cholecystectomy less feasible than after PTGBD.

Adoption of Robotic Liver, Pancreatic and Biliary Surgery in Singapore: A Single Institution Experience with Its First 100 Consecutive Cases

Introduction: Presently, robotic hepatopancreatobiliary surgery (RHPBS) is increasingly adopted worldwide. This study reports our experience with the first 100 consecutive cases of RHPBS in Singapore. Methods: Retrospective review of a single-institution prospective database of the first 100 consecutive RHPBS performed over 6 years from February 2013 to February 2019. Eighty-six cases were performed by a single surgeon. Results: The 100 consecutive cases included 24 isolated liver resections, 48 pancreatic surgeries (including 2 bile duct resections) and 28 biliary surgeries (including 8 with concomitant liver resections). They included 10 major hepatectomies, 15 pancreaticoduodenectomies, 6 radical resections for gallbladder carcinoma and 8 hepaticojejunostomies. The median operation time was 383 minutes, with interquartile range (IQR) of 258 minutes and there were 2 open conversions. The median blood loss was 200ml (IQR 350ml) and 15 patients required intra-operative blood transfusion. There were no post-operative 90-day nor in-hospital mortalities but 5 patients experienced major (> grade 3a) morbidities. The median post-operative stay was 6 days (IQR 5 days) and there were 12 post-operative 30-day readmissions. Comparison between the first 50 and the subsequent 50 patients demonstrated a significant reduction in blood loss, significantly lower proportion of malignant indications, and a decreasing frequency in liver resections performed. Conclusion: Our experience with the first 100 consecutive cases of RHPBS confirms its feasibility and safety when performed by experienced laparoscopic hepatopancreatobiliary surgeons. It can be performed for even highly complicated major hepatopancreatobiliary surgery with a low open conversion rate. Keywords: Biliary surgery, hepaticojejunostomy, liver resection, pancreas, pancreaticoduodenectomy

One-year experience of bedside percutaneous VA-ECMO decannulation in a high-ECMO-volume center in Hong Kong

Background: When veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support can be terminated, open repair of arteriotomy wounds in operating theaters is the standard of practice. Comparable outcomes by percutaneous decannulation using different closure devices have been reported. However, transport of the critically- ill, man-power and timeslots of operating theaters could be saved if decannulation was performed at bedside. Method: Bedside percutaneous arteriotomy wound closure became our default method of decannulation since November 2018. We reviewed our 1-year data to evaluate if such practice could be safely adopted in a local high-ECMO-volume center. Results: Between November 2018 and October 2019, 25 patients had their VA-ECMO terminated at the bedside. Twenty-one patients (84%) had successful decannulation. For those who failed, emergency open repair resulted in no additional complications. Two ProGlide devices were used in 15 (71.4%) patients and three were used in 6 (28.6%) patients. The procedure time was 27 (15–45) min. The median blood loss was 300 mL (250–400). Minor complications were found in 4 (19.1%) patients, including two arterial clot formation, one pseudoaneurysm and one wound infection. There were no other major complications. Conclusion: Our 1-year experience showed that percutaneous bedside VA-ECMO decannulation was feasible to commence in a local large-ECMO-volume center.

Splenic Primary Solid Tumors

Background The present study aims to present a case series of patients who underwent splenectomy for splenic primary solid tumors without preoperative histopathologic diagnosis. Methods From 2013 to 2019, 12 patients underwent splenectomy for solid primary splenic tumors at 3 different academic medical centers. All electronic medical records were retrospectively reviewed. Results Seven (58.3%) patients were women, and 5 (41.6%) were male. The median age was 48 years (range: 25-72 years). In 8 (66.6%) patients, a conventional approach was performed. In 2 (16.6%), a hand-assisted laparoscopic surgery procedure was completed, and in other 2 (16.6%) patients, a laparoscopic approach was auspiciously achieved. Median operative time was 135 minutes (range: 60-210 minutes), and median blood loss was 500 mL (range: 200-1500 mL). Procedure-related morbidity was found in 2 (16.6%) patients, and the mortality rate was 0%. The final histopathologic diagnosis was lymphoma in 5 (41.6%) patients, lymphangioma in 3 (25%) patients, hamartoma in 2 (16.6%) patients, angiosarcoma, and sclerosing angiomatoid nodular transformation (SANT) in 1 (8.3%) case each. Conclusion Splenectomy should be the treatment of choice when encountering a primary splenic tumor without the need for preoperative fine-needle aspiration biopsy, avoiding the complications this technique entails.

24 Hours or Less Stay After Laparoscopic Minor Hepatectomy

Background Laparoscopic liver resections can result in decreased length of stay. We looked at our hospital experience with 24 hours or less stay after minor laparoscopic liver resections. Methods Patients who underwent laparoscopic minor hepatectomy (less than 3 hepatic segments resection) and stayed 24 hours or less in the hospital were selected from prospectively kept hepatobiliary surgery database. All were managed according to the established enhanced recovery after surgery protocol. Results 14 cases were identified and included 3 bisegmentectomies and 11 segmental resections. Length of surgery was between 29 and 210 minutes (median 80.5 minutes), and median blood loss was 50 cc (range 20-400 cc). 4 patients were discharged home the same day with 10 staying overnight. Conclusions Selected group of patients undergoing minor laparoscopic hepatectomy can be discharged home the same day or less than 24 hours after surgery.

New way of laparascopic intracorporeal term-terminal invagination ileotransverse anastomosis

Background. Laparoscopic surgery becomes a standard treatment for many surgical diseases. Defects of a stapler laparoscopic mechanical suture during the formation of an anastomosis after hemicolectomy are detected in 18% of observed cases.Objective. Development, substantiate reproducibility and safety of a manual intracorporeal term-terminal invagination ileotransverse anastomosis method after performing the right laparoscopic hemicolectomy.Material and Methods. Authors presented a description of the technique and their own experience of performing laparoscopic hemicolectomy on the right with the formation of a manual original anastomosis in 10 patients with pathology of the right half of the colon. Eight patients (80.0%) had a malignant tumor of the right half of the colon, 1 patient (10.0%) showed multiple polyps of the cecum and the ascending part of the colon, 1 patient (10.0%) developed a cystic-solid submucosa tumor of the ileocecal angle. One patient had metastatic lung disease at the time of establishing diagnosis. The postoperative follow-up period was 7-18 months.Result. There were no conversions to open surgery. All operations (n = 10) were ended completely laparoscopically - right hemicolectomy with standard D2 lymph node dissection. In one patient, we revealed intraoperatively the spread of the tumor to the gallbladder, which required additional cholecystectomy. The duration of the operation was 122.5±10.7 min.; median blood loss was 107±5.2 ml. At the time of follow-up all patients are alive.Conclusion. The technique is universal in the surgical treatment of patients with various pathologies of the right half of the colon.