With the increasing adoption of robotic systems in hepatic surgery, standardized assessment of procedural difficulty has become crucial, particularly for case selection in training and education. The Tampa Difficulty Score (TDS) was developed to classify robotic liver resections into four levels of complexity. This study aimed to externally validate the TDS. Seventy-nine consecutive patients undergoing robotic liver resection between 2018 and 2024 were included in this retrospective single-center study. Group comparisons between TDS categories were performed using descriptive and inferential statistics including analysis of variance via the Kruskal–Wallis test, Chi-square test, Mann–Whitney-U test, or Fisher’s exact test, as appropriate. Effect sizes were calculated accordingly. Post hoc analyses for intergrupal differences were conducted using the Kruskal–Wallis test. Spearman’s rank correlation assessed linear associations between TDS and perioperative variables. Significant intergroup differences between TDS categories were found for major resections (p < 0.001), operative time (p < 0.001), blood loss (p < 0.001), intensive care stay (p = 0.002), hospital stay (p = 0.005), specimen weight (p < 0.001) and tumor size (p = 0.012). Post hoc analyses with Bonferroni–Holm correction confirmed significant differences mainly between TDS groups 2 and 3 for key parameters, but also showed homogenous distribution throughout the other TDS groups. Strong positive correlations were observed between TDS and major resections (|ρ| = 0.651), operative time (|ρ| = 0.715), blood loss (|ρ| = 0.507), and specimen weight (|ρ| = 0.578; all p < 0.001). The Tampa Difficulty Score was validated for RLR, showing consistent results in both intergroup comparisons and correlation analyses. TDS proved to be a reliable instrument for assessing procedural difficulty, demonstrating its value for risk assessment, training standardization, as well as future evaluations despite the limited sample size.

There is a lack of training curricula and educational concepts for robotic-assisted surgery (RAS). It remains unclear how surgical residents can be trained in this new technology and how robotics can be integrated into surgical residency training. The conception of a training curriculum for RAS addressing surgical residents resulted in a three-step training curriculum including multimodal learning contents: basics and simulation training of RAS (step 1), laboratory training on the institutional robotic system (step 2) and structured on-patient training in the operating room (step 3). For all three steps, learning content and video tutorials are provided via cloud-based access to allow self-contained training of the trainees. A prospective multicentric validation study was conducted including seven surgical residents. Transferability of acquired skills to a RAS procedure were analyzed using the GEARS score. All participants successfully completed RoSTraC within 1 year. Transferability of acquired RAS skills could be demonstrated using a RAS gastroenterostomy on a synthetic biological organ model. GEARS scores concerning this procedure improved significantly after completion of RoSTraC (17.1 (±5.8) vs. 23.1 (±4.9), p < 0.001). In step 3 of RoSTraC, all participants performed a median of 12 (range 5–21) RAS procedures on the console in the operation room. RoSTraC provides a highly standardized and comprehensive training curriculum for RAS for surgical residents. We could demonstrate that participating surgical residents acquired fundamental and advanced RAS skills. Finally, we could confirm that all surgical residents were successfully and safely embedded into the local RAS team.

Purpose To define the best possible outcomes for robotic-assisted low anterior rectum resection (RLAR) using total mesorectal excision (TME) in low-morbid patients, performed by expert robotic surgeons in German robotic centers. The benchmark values were derived from these results. Methods The data was retrospectively collected from five German expert centers. After patient exclusion (prior surgery, extended surgery, no prior anastomosis, hand-sewn anastomosis), the benchmark cohort was defined (n = 226). The median with interquartile range was first calculated for the individual centers. The 75th percentile of the median results was defined as the benchmark cutoff and represents the “perfect” achievable outcome. This applied to all benchmark values apart from lymph node yield, where the cutoff was defined as the 25th percentile (more lymph nodes are better). Results The benchmark values for conversion and intraoperative complication rates were ≤ 4.0% and ≤ 1.4%, respectively. For postoperative complications, the benchmark was ≤ 28% for “any” and ≤ 18.0% for major complications. The R0 and complete TME rate benchmarks were both 100%, with a lymph node yield of > 18. The benchmark for rate of anastomotic insufficiency was < 12.5% and 90-day mortality was 0%. Readmission rates should not exceed 4%. Conclusion This outcome analysis of patients with low comorbidity undergoing RLAR may serve as a reference to evaluate surgical performance in robotic rectum resection.

Einleitung Die Vorteile der minimal invasiven Leberchirurgie haben sich in den letzten Jahren deutlich herauskristallisiert. Bei major Leberresektionen könnten die Vorteile des DV Robotik Systems zum Tragen kommen.

Background The number of oncological robotic-assisted rectal cancer resections is rapidly increasing in Germany and worldwide; however, the indications, technique and potential limitations of this surgical technique are still discussed. Material and methods The standardized modular surgical technique, the results in our clinic and the currently published evidence are presented. Results The procedure should be divided into seven modules in terms of standardization and teaching. After the learning curve there are principally no limitations or contraindications. The robotic-assisted approach is superior to open surgery in the following points: blood loss, lymph node harvest, negative circumferential resection margin (CRM), complication rate and length of hospital stay. In comparison to conventional laparoscopy the conversion rate and postoperative sexual and bladder function disorders are decreased. The operating time is longer. Conclusion Robotic-assisted rectal cancer resection is firmly established and standardized. The technique is superior to open surgery and conventional laparoscopy in some important aspects and is developing into the standard for this disease.

BACKGROUND:Complete mesocolic excision is gradually becoming an established oncologic surgical principle for right hemicolectomy. However, the procedure is technically demanding and carries the risk of serious complications, especially when performed laparoscopically. A standardized procedure that minimizes technical hazards and facilitates teaching is, therefore, highly desirable.METHODS:An expert group of surgeons and one anatomist met three times. The initial aim was to achieve consensus about the surgical anatomy before agreeing on a sequence for dissection in laparoscopic CME. This proposal was evaluated and discussed in an anatomy workshop using post-mortem body donors along with videos of process-informed procedures, leading to a definite consensus.RESULTS:In order to provide a clear picture of the surgical anatomy, the "open book" model was developed, consisting of symbolic pages representing the corresponding dissection planes (retroperitoneal, ileocolic, transverse mesocolic, and mesogastric), vascular relations, and radicality criteria. The description of the procedure is based on eight preparative milestones, which all serve as critical views of safety. The chosen sequence of the milestones was designed to maximize control during central vascular dissection. Failure to reach any of the critical views should alert the surgeon to a possible incorrect dissection and to consider converting to an open procedure.CONCLUSION:Combining the open-book anatomical model with a clearly structured dissection sequence, using critical views as safety checkpoints, may provide a safe and efficient platform for teaching laparoscopic right hemicolectomy with CME.

Aim Surgery for rectal cancer is challenging for both technical and anatomical reasons. The European Academy of Robotic Colorectal Surgery (EARCS) provides a competency-based training programme through a standardized approach. However, there is no consensus on technical standards for robotic surgery when used during surgery for rectal cancer. The aim of this consensus study was to establish operative standards for anterior resection incorporating total mesorectal excision (TME) using robotic techniques, based on recommendations of expert European colorectal surgeons. Method A Delphi questionnaire with a 72-item statement was sent through an electronic survey tool to 24 EARCS faculty members from 10 different countries who were selected based on expertise in robotic colorectal surgery. The task was divided into theatre setup, colonic mobilization and rectal dissection, and each task area was further divided into several subtasks. The levels of agreement (A* > 95% agreement, A > 90%, B > 80% and C > 70%) were considered adequate while agreement of < 70% was considered inadequate. Once consensus was reached, a draft document was compiled and sent out for final approval. Results The average length of experience of robotic colorectal surgery for participants in this study was 6 years. Initial agreement was 87%; in nine items, it was < 70%. After suggested modifications, the average level of agreement for all items reached 94% in the second round (range 0.75-1). Conclusion This is the first European consensus on the standardization of robotic TME. It provides a baseline for technical standards and structured training in robotic rectal surgery.

Zusammenfassung Hintergrund Robotik-assistierte kolorektale Resektionen sind gut etablierte und standardisierte Operationen. Die Penetranz dieser Technik steigt weltweit exponentiell an, und diese Entwicklung wird sich durch die Einführung weiterer innovativer Robotik-Assistenz-Systeme noch verstärken. Fragestellung Sinnvolle Indikation, Set-up sowie operative Strategie und Technik werden vorgestellt. Material und Methode Darstellung der eigenen Erfahrungen an fast 400 Robotik-assistierten kolorektalen Resektion mit dem Da Vinci® SI-System. Bewertung der aktuellen Daten- und Studienlage. Ergebnisse Die Möglichkeiten der Robotik-Assistenz sind besonders in technisch schwierigen Situationen und bei komplexen Eingriffen hilfreich und verbessern die Ergebnisse der minimal-invasiven kolorektalen Chirurgie. Für das Da Vinci® SI-System sind onkologische Rektumresektionen, rechtsseitige Hemikolektomien mit totaler mesokolischer Exzision (CME) und die anteriore Rektopexie mit Netzeinlage richtige und sinnvolle Indikationen. Mit dem Da Vinci® X‑ bzw. XI-System und den angekündigten Systemen anderer Firmen sind auch Kolektomien bzw. restaurative Koloproktomukosektomien ideale Eingriffe für die Robotik-Assistenz. Schlussfolgerung Robotik-assistierte kolorektale Resektion sind standardisierte, gut etablierte Eingriffe. Sie verbessern die Ergebnisse nach komplexen Operationen und werden dabei helfen, die Penetranz der minimal-invasiven kolorektalen Chirurgie zu erhöhen. Die bereits vorhandenen (Immunfluoreszenz, intelligente Stapler) und kommenden (Navigation, In-vivo - Mikroskopie, Big-Data - Management, kognitive Systeme) Innovationen werden den Arbeitsplatz Operationssaal weiter revolutionieren. Es gibt nur ein schlechtes Argument, diese wichtige Entwicklung nicht aktiv mitzugestalten – die hohen Kosten.

Robotik-assistierte kolorektale Resektionen sind gut etablierte und standardisierte Operationen. Die Penetranz dieser Technik steigt weltweit exponentiell an, und diese Entwicklung wird sich durch die Einführung weiterer innovativer Robotik-Assistenz-Systeme noch verstärken.

BACKGROUND:The oncological outcome of patients with rectal cancer has improved considerably over the past few decades. This is mainly due to the introduction of the surgical concept of total mesorectal excision (TME) and the implementation of multimodal treatment strategies. Additionally, it has recently been demonstrated that the oncological results of open and laparoscopic TME are comparable. For some time there has been an ongoing debate on the potential relevance of robotic assistance systems in visceral surgery. The aim of this study was to evaluate the operative and perioperative outcomes of patients with rectal or rectosigmoid cancer, who were operated on using the Da Vinci Surgical System.PATIENTS AND RESULTS:We retrospectively analysed the outcomes of 202 consecutive patients, who were operated between September 2010 and November 2015 in three Surgical Centers. The cohort consisted of 136 men and 66 women with a mean BMI of 28. We performed the following procedures: 49 anterior rectal resections, 119 low anterior rectal resections, and 34 abdominoperineal excisions. Conversion to an open procedure was required in 13 patients. Non-surgical complications (n = 27) occurred in 24 patients (12%) and surgical complications (n = 67) in 62 patients (31%). Most complications were due to abdominal or sacral wound infections (n = 25) and anastomotic leaks (n = 18). The mortality rate within 30 days was 2%. The rate of R0 resections was 95%, with circumferential resection margins being negative in 98% of the patients. The quality of the mesorectal resection was scored as good in 91% of the patients.CONCLUSIONS:The Da Vinci Surgical System can be used safely and with a low complication rate for surgical treatment of rectal cancer. While primary evidence suggests that the outcome of robotic-assisted surgery is comparable with open and laparoscopic surgery, its definitive value has to be determined upon publication of the prospective randomized ROLARR trial. The main advantages of the Da Vinci system are its endowristed instruments with multiple degrees of freedom and its optimised visualisation (3D, stable camera platform controlled by the surgeon). Another positive feature is the significant ergonomic advantage for the surgeon.

Hintergrund/Einleitung: Irinotecan (CPT-11) in Kombination mit 5-Fluorouracil wird als „first line“ Chemotherapie des kolorektalen Karzinoms eingesetzt. CPT-11 sowie sein aktiver Metabolit SN-38 sind Topoisomerase I Inhibitoren, die mit DNA Replikation, Transkription, Rekombination und Reparatur interferieren. Die genetischen Determinanten der zellulären Antwort sind nicht bekannt; die SN-38-Wirkung scheint sowohl über p53-abhängige als auch über p53-unabhängige Mechanismen vermittelt zu sein. Da mehr als 50% der kolorektalen Karzinome p53-mutiert sind, ist das Verständnis der Rolle dieses Gens für die Antwort auf Chemotherapie von essentieller Bedeutung.

Einleitung: Konventionell laparoskopische Eingriffe am oberen Gastrointestinaltrakt sind technisch anspruchsvolle Prozeduren. Einzelne Schritte dieser Operationen scheinen mit der Roboterassistenz erleichtert zu werden und auch an Präzision zu gewinnen.

Einleitung: Die robotik-assistierten Operationen setzen sich zunehmend als alternative Methoden zu konventionellen laparoskopischen Operationen in der Viszeralchirurgie durch. Am häufigsten werden die robotik-assistierten Operationen in der kolorektalen Chirurgie eingesetzt. Es gibt aber nur wenige Berichte über den Einsatz der Roboter-Chirurgie in der operativen Therapie der Beckenbodenerkrankungen, wie obstruktives Defäkationssyndrom (ODS) mit Rektumintussuszeption und ventraler Rektozele sowie beim kompletten Rektumprolaps. Als transabdominelles Standardverfahren zur Behandlung der o.g. Pathologien hat sich die laparoskopische ventrale Rektopexie etabliert.

The value of laparoscopic surgery for rectal cancer is still controversially discussed. Robotics offers the opportunity to leave the limitations of conventional laparoscopy behind us. The three-dimensional visualization and the superior dexterity by wristed instruments should be particularly helpful in complex laparoscopic procedures in confined spaces such as the small pelvis. Colorectal resections using the Da Vinci® system are well established and becoming increasingly more standard procedures. Nerve-sparing total mesorectal excision in patients with rectal cancer, total mesocolic excision in patients with right-sided colon cancer and rectopexy in patients with pelvic floor insufficiency are the most promising indications. The prospective randomized ROLARR study has been evaluating the application of the Da Vinci® system in laparoscopic rectal cancer surgery since 2011. Besides the currently available clinical data the perioperative and intraoperative logistics and strategy will be presented in detail.

Einleitung: Das Robotik Assistenz System Da Vinci bietet durch die 3D Sicht, die frei abwinkelbaren Instrumente und eine bis zu 10 fache Vergrößerung optimale Arbeitsbedingungen für die laparoskopische Chirurgie. Diese Vorteile könnten bei Patienten mit Karzinomen im Hinblick auf die onkologischen Ergebnisse und die Lebensqualität postoperativ von Vorteil für die Patienten sein.

Der Stellenwert der laparoskopischen Chirurgie wird insbesondere beim Rektumkarzinom bis heute kontrovers diskutiert. Robotik-Assistenzsysteme können Einschränkungen der konventionellen Laparoskopie aufheben. Insbesondere die dreidimensionale Sicht und die intrakorporal abwinkelbaren und frei beweglichen Instrumente sind bei komplexen Operationen in engen anatomischen Räumen wie dem kleinen Becken hilfreich. Kolorektale Resektionen mit dem Da-Vinci®-System sind mittlerweile gut etablierte und zunehmend standardisierte Verfahren. Der Einsatz des Systems erscheint für die nervenerhaltende totale mesorektale Exzision beim Rektumkarzinom, für die totale mesokolische Exzision beim rechtsseitigen Kolonkarzinom und für die Rektopexie bei Beckenbodeninsuffizienz vielversprechend und sinnvoll. Erfreulicherweise wird der Stellenwert bei der erstgenannten Indikation seit 2011 im Rahmen der prospektiv randomisierten ROLARR-Studie überprüft. Neben den bis heute verfügbaren klinischen Erfahrungen werden die peri- und intraoperative Logistik und Strategie der Robotik-assistierten laparoskopischen kolorektalen Chirurgie detailliert beschrieben.

BACKGROUND: Appendiceal perforation in patients with acute appendicitis may cause a variety of potentially life-threatening complications. Escherichia coli endotoxin has been shown to impact physiological bile flow in vivo. This had led to the theory that hyperbilirubinemia in patients with appendicitis may have a predictive potential for the preoperative diagnosis of appendiceal perforation. The aim of this retrospective study was to investigate the diagnostic value of hyperbilirubinemia as a preoperative laboratory marker for appendiceal perforation in patients with acute appendicitis.METHODS: We identified 538 patients (306 female; 232 male, mean age, 35.6 y) with histologically proved acute appendicitis who underwent laparoscopic or conventional appendectomy between January 2004 and December 2007 in a surgical department of an academic teaching hospital. A retrospective multiple chart review of the medical records including laboratory values and histologic results was conducted.RESULTS: The mean bilirubin level of all patients was .9 mg/dL (+/-.6 SD mg/dL; range, .1-4.3 mg/dL; median, .7 mg/dL). Patients with appendiceal perforation, however, had a mean bilirubin level of 1.5 mg/dL (+/-.9 SD mg/dL; range, .4-4.3 mg/dL; median, 1.4 mg/dL), which was significantly higher than those with a nonperforated appendicitis (P < .05). The specificity of hyperbilirubinemia for appendiceal perforation was .86 compared with .55 for white blood count and .35 for C-reactive protein. Sensitivity was .7 compared with .81 for white blood count and .96 for C-reactive protein.CONCLUSIONS: Patients with hyperbilirubinemia and clinical symptoms of appendicitis should be identified as having a higher probability of appendiceal perforation than those with normal bilirubin levels. (c) 2009 Elsevier Inc. All rights reserved.