BACKGROUND:Robotic liver surgery is rapidly evolving, but its standardization is limited by the lack of dedicated instruments for parenchymal transection. The Harmonic ACE Curved Shears are widely used; however, guidance on optimizing their use and a clear assessment of their advantages and limitations are lacking. This study evaluates the strengths and limitations of this transection method in a newly established robotic hepatopancreatobiliary (HPB) centre, based on surgical outcomes. METHODS:Patients undergoing robotic liver resection between February and December 2024 were included. Parenchymal transection was performed using a "one-surgeon, fully robotic technique" with the Harmonic ACE Curved Shears. Intraoperative and postoperative data - including operative time, blood loss, clamping time, complications, and hospital stay - were prospectively collected and retrospectively analyzed. RESULTS:Sixteen robotic hepatectomies were performed (15 minor, 1 major) for benign and malignant conditions. Median blood loss was 25 mL (IQR 0-325), mean operative time 341±120 minutes, and median clamping time was 8 minutes (IQR 0-56). Fifteen patients had an uneventful postoperative course, with a mean hospital stay of 5.2±2.8 days. One patient developed a grade B biliary fistula. No 30-day mortality or readmissions occurred. CONCLUSIONS:The fully robotic technique using Harmonic ACE Curved Shears is safe, effective, and reproducible. It replicates the crush-clamp technique and mimics other transection tools, facilitating precise dissection of biliary and vascular structures while minimizing blood loss and bile leaks. This approach may be particularly valuable in newly established robotic HPB centers, helping to achieve satisfactory surgical outcomes even during the early phase of program implementation. Nevertheless, these promising results require confirmation in larger cohorts and further studies, particularly to validate the safety and effectiveness of this technique in major hepatectomies and in procedures of greater complexity.
BACKGROUND:Patient-reported quality-of-life (QoL) outcomes are increasingly recognized as relevant endpoints in elective colorectal surgery. However, the feasibility and interpretability of systematic QoL assessment after elective laparoscopic sigmoid resection for diverticular disease remain incompletely defined, particularly in single-center settings. METHODS:This retrospective single-center pilot study analyzed consecutive patients undergoing elective laparoscopic sigmoid resection for diverticular disease. The primary objective was to assess the feasibility and completeness of postoperative QoL assessment using EQ-5D, GIQLI, and LARS questionnaires. Secondary objectives included perioperative outcomes and early postoperative morbidity. Clinical and operative data were analyzed descriptively. RESULTS:Thirty-six patients were included. Completion of postoperative QoL questionnaires was achieved in all cases. No floor or ceiling effects were observed across QoL instruments. Median postoperative length of stay was 7 (6-7) days. Minor postoperative complications (Clavien-Dindo <II) occurred in 8.4% of patients, with no major complications, anastomotic leaks, or reoperations. Mean EQ-5D and GIQLI scores indicated satisfactory early postoperative quality of life, while LARS scores suggested minimal bowel dysfunction. CONCLUSIONS:Systematic assessment of patient-reported outcomes after elective laparoscopic sigmoid resection for diverticular disease is feasible and yields interpretable early QoL signals. These pilot data support the integration of standardized QoL metrics in future prospective and comparative studies.
BACKGROUND:Synchronous colorectal liver metastases (CRLM) are diagnosed in approximately 15-25% of patients with colorectal cancer. The optimal surgical approach - simultaneous versus staged resection - remains an ongoing debate. METHODS:We retrospectively analyzed 138 patients with synchronous CRLM who underwent curative-intent resection between 2005 and 2021 at the University Hospital Duesseldorf. Patients were grouped based on the surgical approach: simultaneous (N.=55) versus staged (N.=83) resection. Outcome analysis included postoperative complications, hospital stay, overall survival (OS), and disease-free survival (DFS). Survival was assessed using Kaplan-Meier analysis and log-rank tests. RESULTS:Baseline patient characteristics were comparable between both groups. Major liver resections were significantly more common in the staged group as compared to simultaneous surgery (48 [57.83%] versus 13 [23.64%]; P=0.001). The rates of major postoperative complications (Clavien-Dindo ≥IIIa) were similar (P=0.728). However, hospital stay was significantly longer following simultaneous resection (37.1 versus 25.7 days; P=0.022). Although median DFS was significantly better in the staged group compared to the simultaneous approach (27.3 versus 14.6 months; P=0.019), median OS did not significantly differ between both groups (44 versus 36 months; P=0.369). CONCLUSIONS:Staged and simultaneous resections for CRLM are both safe and feasible with comparable postoperative morbidity and mortality rates. However, the staged approach was associated with reduced hospital stay and improved DFS. The optimal treatment option for synchronous CRLM should be patient tailored and further validated in larger multi-center cohorts.
BACKGROUND:Retroperitoneal tumors are rare and heterogeneous lesions, and their surgical management remains challenging. Although laparoscopic techniques are increasingly adopted in abdominal surgery, a standardized minimally invasive approach for retroperitoneal pathology has not yet been clearly defined. The present study reports our preliminary single-center experience with a standardized laparoscopic management of retroperitoneal tumors. METHODS:We retrospectively reviewed 36 patients treated for retroperitoneal tumors between 2017 and 2022. Patients were selected for a laparoscopic approach when lesion size was ≤10 cm and no vascular invasion was identified on preoperative imaging. Demographic, perioperative, histopathological, and follow-up data were analyzed. Postoperative complications were classified according to the Clavien-Dindo system. RESULTS:Among the 36 patients, 22 underwent laparoscopic surgery, 14 open surgery, and 4 required conversion to an open approach. The mean operative time was 104 minutes for laparoscopic procedures and 168 minutes for open surgery. One patient in the laparoscopic group required postoperative blood transfusion (Clavien-Dindo grade II), with no other postoperative complications observed. Length of hospital stay was shorter after laparoscopy (3.2 vs. 8.8 days). Benign lesions were more frequently treated laparoscopically, whereas sarcomas and metastatic tumors were more commonly managed with an open approach. The laparoscopic technique was standardized by subdividing the retroperitoneum into defined anatomical regions, each associated with specific patient positioning, trocar placement, and surgical steps. R0 resection was achieved in all malignant cases, as confirmed by postoperative pathology. At a mean follow-up of 5 years, no recurrences were observed in either benign or malignant cases. CONCLUSIONS:Our preliminary experience suggests that a standardized laparoscopic approach for retroperitoneal tumors is feasible, safe, and reproducible in carefully selected patients. Nevertheless, the retrospective design, limited sample size, and exclusion of more complex cases represent important limitations. Larger multicenter studies are required to further validate these findings.
BACKGROUND:Remnant gastric cancer (RGC), a malignancy arising in the gastric stump after partial gastrectomy, presents unique diagnostic and surgical challenges. The aim of the study is to recognize the clinicopathologic characteristics of the florescent (FL) and non-FL groups in RGC patients. METHODS:This study retrospectively analyzed the clinicopathologic characteristics and surgical outcomes of 68 patients with RGC from 2014 to 2024 who underwent curative resection, comparing two distinct minimally invasive surgical approaches: the FL group (N.=31) and the non-FL group (N.=37). Baseline demographics, prior gastrectomy history, and tumor characteristics were comparable between the two cohorts. RESULTS:The only statistically significant difference observed was in the operation method, with the FL group showing a significantly higher proportion of robotic-assisted surgery (61.3% vs. 24.3%, P=0.002). Although the FL group had a longer mean operation time (275.0 vs. 251.7 minutes, P=0.163), it demonstrated favorable trends toward lower estimated blood loss (100 vs. 120 mL, P=0.098) and shorter hospital stay (6 vs. 7 days, P=0.089). Postoperative complication rates and mortality were similar and acceptable in both groups. CONCLUSIONS:These findings suggest that while the FL approach, characterized by a higher utilization of robotic technology, is associated with a longer operative duration, it may offer marginal benefits in perioperative metrics for the complex surgery of RGC, underscoring the feasibility and safety of advanced minimally invasive techniques in this challenging patient population.
BACKGROUND:Enhanced recovery after surgery (ERAS) programs improve outcomes after major orthopedic procedures, but the specific contribution of nursing-led implementation has not been well defined. This study evaluated the impact of a nursing-driven ERAS protocol on recovery outcomes in patients undergoing hip surgery. METHODS:A prospective cohort study was conducted in a tertiary academic center. Patients managed under a structured nursing-coordinated ERAS pathway (N.=36) were compared with historical controls receiving conventional perioperative care (N.=34). The cohort included total hip arthroplasty, hemiarthroplasty, and internal fixation procedures. The ERAS protocol emphasized nurse-led preoperative education, multimodal analgesia, early mobilization, nutritional optimization, and standardized postoperative monitoring. Primary outcomes were hospital length of stay (LOS) and postoperative complications. Secondary outcomes included pain scores, opioid consumption, early functional recovery, discharge disposition, and patient satisfaction. RESULTS:Baseline characteristics and distribution of surgical procedures were comparable between groups. The ERAS cohort experienced a significantly shorter LOS (median 7 vs. 9 days; P<0.01) and fewer postoperative complications, with the control group exhibiting approximately triple the complication rate. ERAS patients reported lower pain scores and nearly 50% less opioid use postoperatively. Early mobilization within 24 hours was achieved in 89% of ERAS patients versus 50% of controls (P<0.01). More ERAS patients were discharged directly home, and satisfaction scores were higher (94% vs. 76%; P=0.04). CONCLUSIONS:A nursing-driven ERAS protocol significantly enhanced postoperative recovery across a heterogeneous hip surgery population. Nurse-led coordination and adherence monitoring were central to improved outcomes. These findings support broader adoption of nursing-centered ERAS pathways to optimize surgical recovery.
BACKGROUND:From an anesthesiologic perspective, carotid endarterectomy (CEA) is an operation that is increasingly being performed with locoregional techniques and sedation. The aim of this observational study was to compare dexmedetomidine with midazolam and fentanyl during CEA in terms of perioperative adverse events, patient, anesthetist, and surgeon satisfaction, as well as the possible reduction in clamping time and the number of times additional local anesthesia is needed. METHODS:Sixty patients listed for CEA were enrolled and two types of sedation were used, both protocols widely used in our hospital, resulting in the formation of two groups of patients. Both the intermediate and superficial cervical plexus blocks were administered, and the patients in Group 1 were sedated with midazolam and fentanyl, and Group 2 was sedated with dexmedetomidine. We examined comorbidities, surgical time and clamping, and possible intraoperative use of local anesthetics and intraprocedural complications, and follow-up at 180 days to observe any residual deficits. The data were analyzed with SPSS Statistics 25 (IBM). RESULTS:Patients, anesthetists and surgeons levelled off on a high level of satisfaction (scores 3 and 4). Clamping and operation times were similar between the two groups and within the ranges described in the literature. CONCLUSIONS:There were no significant differences between the two groups regarding perioperative adverse events or decreased clamping or intervention times. Only surgeons and anesthetists were clearly aligned towards a satisfaction score of 4 with dexmedetomidine, although patients did not seem to experience any differences between the two sedations under study.
BACKGROUND:The environmental impact of climate change is unequivocal, and surgical practice, given its substantial carbon footprint, must also move toward sustainability. The primary aim of the study is to assess the environmental impact of surgical practice in breast cancer treatment and to identify interventions that can effectively reduce it. The secondary aim was to explore the feasibility and preliminary clinical performance of indocyanine green (ICG) compared with technetium-99m (99mTc) for sentinel lymph node mapping, within the context of a pilot project on sustainable surgical practices. METHODS:At the Breast Surgery Clinic of Polyclinic San Martino IRCCS Hospital in Genoa, a prospective study was conducted from September 2024 to May 2025 to assess the effectiveness of a series of environmentally sustainable measures within the operating room. Thirty-four women diagnosed with HR-positive/HER2-negative, T1-T2, cN0 invasive breast cancer underwent quadrantectomy and sentinel lymph node biopsy (SLNB). Seventeen patients were treated using a conventional high-impact surgical protocol, while the remaining 17 were treated with a green protocol based on the "5R rule" (Reduce, Reuse, Recycle, Rethink, Research). Key strategies included the use of ICG for SLNB, local anesthesia with intravenous sedation, waste minimization, and the adoption of reusable surgical gowns, drapes, and instruments, along with the segregation of non-infectious plastic waste. RESULTS:Sentinel lymph node identification was achieved in 100% of patients in the 99mTc group and in 94.1% of patients in the ICG group. The green approach was operationally feasible and associated with preliminary indicators of reduced environmental burden, although a full quantitative analysis was beyond the scope of this pilot study. Patients avoided preoperative hospitalization, radiotracer administration, and, importantly, 58.8% were discharged the same day. CONCLUSIONS:Considering the pressing climate crisis, these findings highlight the feasibility and necessity of adopting sustainable practices in surgical oncology to mitigate greenhouse gas emissions while maintaining high-quality patient care.
BACKGROUND:Radiofrequency (RF) hemorrhoidectomy features shorter operating times, less intraoperative bleeding, less postoperative pain, and a quicker return to work compared to conventional hemorrhoidectomy. Numerous RF devices are available at varying costs. The purpose of our study was to compare the 30-day postoperative outcomes of LigaSure hemorrhoidectomy versus Voyant hemorrhoidectomy for grade III and IV hemorrhoids in terms of bleeding, urinary retention, and anal stenosis. METHODS:A prospective observational study was conducted from May 2017 to March 2023. Patients with concomitant anal disorders and patients who had undergone previous anal surgery were excluded from the study. Patient data collected during hospitalization and subsequent 30-day follow-up were entered into an electronic database. Data was analysed using Stata version 18 (StataCorp LLC, TX, USA). RESULTS:In total, 123 patients were enrolled (61 in group A and 62 in group B). Patient demographics and clinical characteristics (age, gender, ASA score, hemorrhoid grade) and the number of resected piles were similar in the two groups. There were three cases of hemorrhage in group A (one requiring blood transfusion and reoperation) and four cases in group B (one requiring blood transfusion). In each group, two cases of anal (sub)stenosis occurred, all resolved with self mechanical anal dilatation. There were two cases of urinary retention in group A and one case in group B. No statistical differences were observed between the two groups in terms of postoperative bleeding, urinary retention, and anal stenosis. CONCLUSIONS:The LigaSure and Voyant devices show comparable results in terms of postoperative complications in the treatment of grade III and IV hemorrhoids. However, the Voyant device is much less expensive.
INTRODUCTION:Despite advancements in colorectal surgery, anastomotic complications such as leakage and stricture remain significant challenges. The influence of circular stapler size on these outcomes is controversial. This meta-analysis evaluates the impact of stapler diameter on anastomotic morbidity following low colorectal anastomosis. EVIDENCE ACQUISITION:A systematic search of PubMed, Google Scholar, and the Cochrane Central Register was conducted in accordance with PRISMA guidelines. Comparative studies that reported outcomes based on circular stapler size were included. Primary endpoints were anastomotic leak, stricture, bleeding, and overall anastomotic morbidity. Secondary outcomes included overall morbidity, major complications, reoperation, readmission, and operative time. Odds ratios (ORs) and standardized mean differences (SMDs) with 95% confidence intervals (CIs) were calculated. The ROBINS-I and GRADE tools were used to assess the risk of bias and quality of evidence. EVIDENCE SYNTHESIS:Seven studies comprising 2214 patients (small stapler size (<30 mm): N.=859, large stapler size (≥30 mm): N.=1355) were included. Use of larger staplers was associated with a significantly lower incidence of anastomotic stricture (OR=2.31, 95% CI: 1.48-3.60, P=0.0002), with low heterogeneity (I2=5%). No significant differences were observed in anastomotic leak, bleeding, or overall anastomotic morbidity. Secondary outcomes, including overall and major morbidity, readmission, reoperation, and operative duration, also showed no significant differences between stapler sizes. CONCLUSIONS:Larger circular staplers are associated with a reduced risk of anastomotic stricture following low colorectal anastomosis, without increasing other postoperative complications. These findings support the consideration of larger stapler diameters when anatomically feasible. Further high-quality prospective studies are warranted to validate these results and guide surgical decision-making.
BACKGROUND:Short-stay and ambulatory pathways for laparoscopic appendectomy (LA) have gained increasing acceptance, yet conventional hospitalization remains common practice for acute appendicitis (AA). This study aimed to evaluate the safety and feasibility of a structured one-day LA protocol (discharge within 24 hours) and to refine patient selection criteria. METHODS:A two-phase observational study was conducted, including a retrospective analysis followed by prospective validation of predefined eligibility criteria for one-day discharge. RESULTS:Among 812 LA patients, early discharge was achieved safely without increased complications or readmissions. In the prospective phase, 132 patients met criteria and 90 were discharged within 24 hours. Logistic regression confirmed operator-dependent factors - especially drainage and longer operative time - as primary barriers to protocol adherence. CONCLUSIONS:A structured one-day LA protocol is safe, feasible, and effective in selected patients. The one-day pathway is now standard of care for uncomplicated AA at our institution.
BACKGROUND:Peristomal skin complications represent one of the main clinical concerns in people with an ostomy. Existing assessment tools do not include preventive approaches and active participation of the patient. S.A.C.S. Evolution was created to fill this gap, introducing the concept of healthy peristomal skin (L0) as a primary clinical reference and developing a dual interface dedicated to the healthcare professional and the patient. METHODS:A prospective multicenter observational study validated the psychometric properties of S.A.C.S. Evolution: Phase one tested face validity, phase two tested content validity and phase three evaluated criterion and predictive validity with the longitudinal application on patients with intestinal or urinary ostomy, followed at 1, 3, and 6 months. RESULTS:Face validity reached unanimous consensus among both healthcare professionals and patients. Content validity showed a Content Validity Index > 0.96 among professionals and 1.00 among patients. Criterion validity showed a 95.5% agreement between S.A.C.S. Evolution and S.A.C.S. 2.0 assessments, and a high overlap between patient and stoma nurse evaluations. Longitudinal analysis showed a significant reduction in lesion severity over time, with an increase in the marginal probability of maintaining a healthy skin state (L0) above 90% at six months. Age was confirmed as a predictive factor of greater severity. CONCLUSIONS:S.A.C.S. Evolution proved valid, reliable, and clinically sensitive in the assessment of peristomal skin condition and consequent prevention of peristomal alterations. Its dual interface, clear terminology, and focus on healthy peristomal skin support early prevention, patient empowerment, and standardization of stoma care pathways. Digital integration could further enhance its impact.
BACKGROUND:Tube ileostomy can prevent anastomotic leakage (AL) on the patients underwent lower anterior resection. However, it has one major disadvantage: the inability to control fecal diversion efficacy (FDE). In this single-center, prospective randomized controlled trial (RCT), we evaluated a novel technique, pressure-controlled tube ileostomy (PCTI), which uses cuff-pressure adjustment to maintain reliable FDE, and assessed its safety and effectiveness. METHODS:This study was conducted as a single-center prospective RCT. Patients were randomly allocated (1:1) to PCTI or LI (Ll) using a computer-generated sequence with allocation concealment via sealed opaque envelopes; blinding of surgeons/patients was not feasible. RESULTS:Baseline characteristics were comparable between groups. The anastomotic leakage rates were 9.2% (23/250) in the PCTI group and 9.7% (24/248) in the LI group received the initial surgery (P=0.85). The rates of stoma-related complications including infections, irritant dermatitis, herniation and so on, were 8.8% in PCTI group and 16.2% in LI group (P=0.0133), respectively. Fifteen patients received LI retained their stoma, compared with 2 in the PCTI group (P=0.0013). In PCTI group, the time of cannula extubation and stoma closure after cannula extubation were 20.5±4.6 and 7.2±4.4 days, respectively. CONCLUSIONS:The PCTI can effectively inhibit the occurrence of grade C anastomotic leakage and reduce the occurrence of serious complications caused by anastomotic leakage through the FDE control by adjusting the cuff pressure and can avoid secondary reversal surgery. We consider that the improved PCTI is a safe and practical-surgical technique in protecting the anastomosis.
Cervical spine fractures are a critical concern in emergency medicine, often resulting in significant morbidity and mortality. Early recognition and management are essential to prevent secondary spinal cord injuries and optimize patient outcomes. This review examines current assessment and treatment strategies for cervical spine fractures in the emergency department. Clinical decision rules such as the Canadian C-Spine Rule and the National Emergency X-Radiography Utilization Study (NEXUS) aid in determining the need for imaging, while computed tomography remains the gold standard for diagnosis. Traditional immobilization techniques, including manual inline spinal immobilization and cervical collars, are widely used, though recent evidence challenges their effectiveness in reducing neurological deterioration. Management approaches vary depending on the severity and stability of the fracture, with stable injuries often treated conservatively and unstable fractures requiring surgical intervention. New evidence suggests that a more individualized approach to immobilization and management may be beneficial, balancing patient comfort and clinical outcomes. Adherence to established trauma protocols remains critical in ensuring timely intervention and reducing complications. Further research is necessary to refine immobilization practices and develop more targeted treatment strategies to improve long-term outcomes for patients with cervical spine fractures.
BACKGROUND:Acute cholecystitis (AC) is a common general surgical emergency. Older age is associated with higher incidence of gallstones and increasing severity of AC. Data on outcomes for older adults with AC remain sparse however. METHODS:All patients with AC presenting to public hospitals in Ireland between January 2017 and July 2023 were identified using the National Quality Assurance and Improvement System (NQAIS). Data were collected on patient demographics, comorbidities, length of stay, clinical management, in-patient mortality, and readmissions. Patients were grouped into cohorts by age range. RESULTS:Overall, 20,886 admission episodes were identified, with a median age of 59 years (IQR 43-73) and 11,747 (56%) female patients; 3745 patients were in the 65-74 year group, 3239 in the 75-84 year, and 1478 in the over 85 year group. Older adults had more co-morbidities (Charlson Co-morbidity Index >3 in 440 (30%) of the over 85s, 689 (21%) of 75-84 years, 429 (11%) 65-74 years, and 421 (3%) under 65s (P<0.0001). In the over 85 years group, patients had the highest in-patient mortality rate (96 [6.5%]; P<0.0001), lowest rate of cholecystectomy (49 [3%]; P<0.0001), highest rate of percutaneous cholecystostomy use (140 [9%]; P<0.0001), and lowest rates of discharge to home (947 [64%]). Patients in the 65-74 year and 75-84 year groups also experienced poorer outcomes than those in the under 65 year group. CONCLUSIONS:Increasing age is associated with worsening outcomes for patients with AC. For the oldest adults, AC is associated with significant risks of morbidity and potential loss of independence.
BACKGROUND:Palliative surgical management of advanced gastric cancer with gastric outlet obstruction remains controversial. While both palliative gastrectomy (PG) and gastrojejunostomy (PGJ) offer symptom relief, their impact on survival and postoperative outcomes is debated. METHODS:We conducted a retrospective cohort study of 70 patients with advanced gastric cancer and symptomatic gastric outlet obstruction, treated at a single tertiary center between 2017 and 2024. Patients underwent either PG or PGJ after being deemed unsuitable for endoscopic intervention. Clinical and surgical parameters, complications, nutritional support, and survival outcomes were analyzed. RESULTS:Of the 70 patients, 46 underwent PG and 24 underwent PGJ. Median survival was significantly longer in the PG group (344 vs. 117 days, P<0.001), and PG was an independent predictor of improved survival (HR 0.083, P<0.001). PG was associated with higher rates of anastomotic leaks and ICU admissions, while PGJ showed higher rates of delayed gastric emptying and need for post-discharge nutritional support (33.3% vs. 6.7%, P=0.009). Return to oral intake was more common after PG (95.7% vs. 79.2%, P=0.042). Postoperative chemotherapy significantly improved survival (HR=0.152, P=0.003). CONCLUSIONS:PG offers a significant survival benefit over PGJ in selected patients with advanced gastric cancer, but at the cost of increased surgical morbidity. Careful patient selection based on disease extent, performance status, and likelihood of postoperative recovery is essential for optimizing outcomes.
