Robotic liver resections based on Laennec’s capsule pedicular driven dissection is a challenging surgical procedure, because of the intrinsic relationship between the liver parenchyma and the main intrahepatic vessels. The absence of anatomical landmarks and the frailty of the fine vascular structures requires broad experience, anatomical knowledge and refined technical skills to successfully perform such a procedure. As robotic platforms do no offer the standard laparoscopic advanced tools for liver resection, real robotic approach has been proposed as a default technique for the liver parenchymal transection, precise robotic anatomical and parenchymal-sparing liver resection, and pedicle driven dissection, like the microfracture-coagulation method. A more specific refinement of the real robotic approach, similar to the pencil cleaning process, useful in very careful deep dissections, is defined towards the standardization of the real robotic approach in advanced liver surgery. The rationale of the method, its indications and tips and tricks are described in detail.

This article provides a detailed description of the robotic approach used to perform an extended left hepatectomy with venous resection in a 65-year-old female patient with a Bismuth-Corlette tumour type 3b infiltrating the portal confluence. A Glissonean pedicle approach was used to achieve total prehepatic vascular control and resection of the left portal confluence, followed by transverse reconstruction according to the Heineke-Mikulicz technique. The parenchymal transection, including the entire caudate lobe, was performed robotically, with left hanging manoeuvre after complete piggybacking of the vena cava. The final pathological result was G3 pT2bN1M0 (2/11) signet ring cell adenocarcinoma. The robotic approach enabled adjuvant treatment to be initiated immediately. No major complications were recorded within 90 days, and the patient was discharged on the 5th day.

BACKGROUND:Exocrine pancreatic insufficiency (EPI) and malnutrition are prevalent but systematically underestimated in patients with periampullary tumors. SUMMARY:Prospective observational single-center study. Thirty-two patients with potentially resectable periampullary tumors underwent nutritional assessment including fecal elastase-1 (FE-1), psoas muscle index (PMI) on CT, bioelectrical impedance analysis (BIA) with phase angle, and handgrip strength. Postoperative complications, Textbook Outcome (TO), and nutritional follow-up at 1, 3, and 6 months were assessed in 23 resected patients. EPI (FE-1 <200 mcg/g) was present in 76.9% (20/26). Prealbumin was <20 mg/dL in 62.1% and vitamin D deficient in 82.8%, despite normal albumin in most patients. Sarcopenia by PMI was detected in 53.1% (17/32) of the full preoperative cohort, substantially higher than handgrip strength alone (15-17%). After resection, universal EPI (100%) was confirmed. TO was achieved in 73.9% (17/23). Median weight declined from 64.0 kg preoperatively to 61.2 kg at 6 months; cumulative weight loss from pre-illness habitual weight reached 18.5% at 6 months, of which 9.2% had already occurred before surgery. Vitamin D deficit persisted throughout follow-up; sarcopenia was numerically higher at 1 month (68.8%), with values returning toward baseline by 6 months (65.2%). KEY MESSAGES:Patients with periampullary tumors present a severe, multidimensional preoperative nutritional burden more prevalent than recognized. Systematic assessment should be incorporated into standard protocols within a structured multidisciplinary perioperative pathway.

Se describe detalladamente la técnica quirúrgica de hepatectomía izquierda ampliada al caudado con resección venosa, con abordaje robótico real asistido con modelo 3D, en una paciente de 65 años por un tumor Bismuth 3b con infiltración del confluente portal. Mediante abordaje hiliar intraglissoniano, se procedió al control vascular prehepático total y la resección del confluente izquierdo portal, siendo reconstruido transversalmente según técnica de Heineke-Mikulicz. La transección parenquimatosa fue robótica real incluyendo la totalidad del lóbulo caudado, con hanging izquierdo tras piggy-back completo de la vena cava. El resultado patológico final fue de adenocarcinoma de células en anillo de sello G3 pT2bN1M0 (2/11). El abordaje robótico permitió un inicio inmediato del tratamiento adyuvante. No se registraron complicaciones mayores a 90 días, y la paciente fue dada de alta al 5° día.

OBJECTIVE:To compare postoperative pancreatic fistula (POPF) rates between Blumgart anastomosis (BA) and invaginating pancreatogastrostomy (PG) after pancreatoduodenectomy (PD). BACKGROUND:POPF rates after PD are still high. The only modifiable factor available to improve POPF is the anastomotic technique. BA and PG anastomoses have been previously shown to be feasible and safe, but they have never been compared in a randomized trial. METHODS:A multicenter, randomized, controlled trial was conducted in 13 University Hospitals. Eligible patients were those presenting a pancreatic or periampullary neoplasm undergoing PD. Assignment to each group (BA or PG) was randomized by blocks and stratified by centers. The primary endpoint was the rate of POPF with special assessment of clinically relevant (grade B-C) POPF; secondary endpoints were postoperative (p.o.) complications, factors related to POPF and quality of life (QoL). RESULTS:Two hundred sixteen patients were randomized. POPF and B-C POPF were 44% to 28% in BA group and 34% to 23% in PG group ( P = 0.39 and P = 0.74, respectively). Overall complications, severe complications and mortality rates were 76%, 24%, and 3.7% respectively, in the BA group, and 73%, 32%, and 5.9%, in the PG group, with no significant differences. Soft pancreatic consistency, small preoperative Computed Tomography Wirsung diameter, patient age, and first p.o. drain amylase concentration were independently associated with B-C POPF. QoL functional scales favoured the PG anastomosis at 9 months. CONCLUSIONS:BA and PG showed no differences in POPF and p.o. outcomes; B-C POPF can be predicted based on several pre-intra and early p.o. parameters; QoL favoured PG anastomosis at 9 months.

This article provides a detailed description of the robotic approach used to perform an extended left hepatectomy with venous resection in a 65-year-old female patient with a Bismuth-Corlette tumour type 3b infiltrating the portal confluence. A Glissonean pedicle approach was used to achieve total prehepatic vascular control and resection of the left portal confluence, followed by transverse reconstruction according to the Heineke-Mikulicz technique. The parenchymal transection, including the entire caudate lobe, was performed robotically, with left hanging manoeuvre after complete piggybacking of the vena cava. The final pathological result was G3 pT2bN1M0 (2/11) signet ring cell adenocarcinoma. The robotic approach enabled adjuvant treatment to be initiated immediately. No major complications were recorded within 90 days, and the patient was discharged on the 5th day.

Abstract Introduction Surgical site infection (SSI) is the most common healthcare-associated infection. Patients undergoing pancreaticoduodenectomy (PD) may require preoperative biliary stent placement, which is a risk factor for postoperative SSI. Scientific Justification: Historically, antibiotic prophylaxis in our hospital was the same for all patients undergoing PD (cephalosporin). Our historical rate of organ-space SSI was twice higher in patients with biliary stents compared to those without (28% versus 14%). We modified the prophylaxis specifically with piperacillin-tazobactam in patients with preoperative biliary stents, intending to reduce postoperative SSI. Objectives Main objective: To confirm if, in our hospital, biliary microbiology differs between patients undergoing PD based on whether they have preoperative biliary stents or not. Secondary objectives: 1-To evaluate if perioperative antibiotic treatment targeted according to the expected flora, based on the presence or absence of biliary stents, reduces SSI. 2-To evaluate if controlling SSI in patients undergoing resection for pancreatic ductal adenocarcinoma and periampullary tumors allows timely initiation of adjuvant treatment. Study Design Observational, single-center, retrospective, analytical study of two cohorts of patients who underwent PD in which bacterobilia is analyzed between two groups: NP (no biliary prosthesis) and P (with biliary prosthesis), and infectious complications after applying directed perioperative antibiotic treatment. The antibiotic regimens used were cefotaxime and metronidazole for group NP, and piperacillin-tazobactam for group P. Analysis of the patients in the subgroup (pancreatic adenocarcinoma and periampullary tumors) includes the percentage of adjuvant therapy and survival rates. Overall sample size: N = 90, 45 per group. The double number of patients from the NP group (90) is included as the control group. Results Between January 2014 and December 2021, 127 patients underwent PD (84 NP and 43 P). The intraoperative culture was positive in 16.7% (NP) versus 76.7% (P, P < 0.01), with 72.7% of polymicrobial cultures in the P group. The microorganisms isolated in the NP group were Enterobacterales (10.7%) and Enterococcus (7.1%), without Candida. In the P group, there was an increase in Enterococcus (48.8%), Enterobacterales (51.2%), and Candida (16.3%) (P < 0.01). There were no differences in morbidity or mortality between the two groups. The organ-space SSI rate was 15.5% in the NP group and 13.9% in the P group (not significant). The multivariate analysis revealed that significant risk factors for developing SSI were intraoperative bile culture positive for Enterobacterales (OR 3.7; P = 0.02), presence of pancreatic fistula (OR 5.5; P = 0.04), and surgical reintervention (OR 27.2; P < 0.01). The agreement between intraoperative and postoperative bile cultures was 80% in the P group versus 13.3% in the NP group (P = 0.002). Among the analyzed cancer patients, 76% initiated adjuvant treatment, with 95% of them starting within the optimal time, with no differences between groups, as well as survival. Conclusions The biliary flora differs in patients with biliary stents, with a higher presence of Enterobacterales, Enterococcus, and Candida. After applying perioperative antibiotic treatment targeted at the expected biliary microbiology, there were no observed differences in SSI or delays in the initiation of adjuvant therapy. The need to change antibiotic prophylaxis in patients undergoing DPC is suggested.

BACKGROUND:Different techniques have been proposed to reduce the incidence of the intraoperative bile duct injury during laparoscopic cholecystectomy (LC). Among these, Near-Infrared Fluorescence Cholangiography (NIFC) with Indocyanine Green (ICG) represents a relatively recent addition. At present, there is considerable variation in the protocols for the administration of ICG. METHODS:The aim of this randomized multicenter clinical trial (RCT) is to ascertain whether there are differences between the dosage and administration intervals of ICG, with a view to optimizing a good-quality NIFC during LC. Furthermore, an analysis was conducted to determine the potential impact of different factors on the outcomes of this technique. The trial was approved by the local institutional Ethics Committee. RESULTS:From June 2022 to June 2023, 200 patients were randomized in four arms (G1: 2.5 mg ICG > 3 h prior to surgery, G2: 2.5 mg ICG 15-30 min prior to surgery, G3: 0.05 mg/kg ICG > 3 h prior to surgery and G4: 0.05 mg/kg ICG 15-30 min prior to surgery). We found differences in the DISTURBED score between the groups (p < 0.001), suggesting that ICG administration 15-30 min before surgery was worse than administration > 3 h after LC (p = 0.02). Additionally, it was observed that body mass index (BMI), gender, ASA Classification System, previous liver and biliary disease and the type of surgery had influence on NIFC. Finally, the NIFC had an impact in intraoperative and postoperative complications, operative time and hospital length of stay. CONCLUSIONS:The administration of ICG > 3 h improve liver background fluorescence in the NIFC during LC. There are different factors may affect NIFC results (BMI, ASA grade, previous liver disease, presence of gallbladder inflammation and type of surgery). Finally, high-quality NIFC was associated with fewer surgical complications, shorter surgical time and shorter length of hospital stay.

Background:Major liver resection is often required for complete clearance of colorectal liver metastases (CRLM). Patients with insufficient future liver remnant (FLR) volume/function are at high risk of post-hepatectomy liver failure (PHLF) and require FLR hypertrophy-inducing procedures to enable safe resection. The most recent variant of these procedures is combined portal and hepatic vein embolization (PVE/HVE). The DRAGON 1 trial evaluates the safety and efficacy of PVE/HVE, while assessing recruitment potential for the DRAGON 2 randomized trial. Methods:DRAGON 1 is a prospective, single-arm, international, multicenter trial. Patients with upfront unresectable CRLM due to a small FLR were included. The primary outcome was the ability of centers to recruit three patients and perform PVE/HVE and liver resection without 90-day mortality. Secondary outcomes included recruitment capacity, PVE/HVE technical details, FLR volume changes, complications, and resection rates. The study is registered at ClinicalTrials.gov, identifier: NCT04272931. Findings:In total, 102 patients were included from 43 centers. Twenty-four centers (24/43 = 56%) recruited three or more patients, and 20 centers (20/43 = 47%) achieved this without 90-day mortality. Of 96 patients undergoing PVE/HVE, no post-embolization mortality occurred, though major complications were reported in two patients. Resection was completed in 86 patients (86/96 = 90%), with seven patients (7/86 = 8%) dying within 90 days. PHLF grade B/C (International Study Group of Liver Surgery criteria) occurred in 19 patients (19/86 = 22%). Interpretation:DRAGON 1 demonstrates that PVE/HVE is safe, with no embolization-related mortality, low morbidity, and high resection rates in upfront unresectable CRLM. Funding:The Dutch Cancer Society, National Institute for Health and Care Research UK, Maastricht UMC+, Abbott Laboratories and Guerbet.

The use of the robotic approach in liver surgery is exponentially increasing. Although technically the robot introduces several innovative features, the instruments linked with the traditional laparoscopic approach for the liver parenchymal transection are not available, which may result in multiple technical variants that may bias the comparative analysis between the different series worldwide. A real robotic approach, minimally efficient for the liver parenchymal transection, with no requirement of external tool, available for the already existing platforms, and applicable to any type of liver resection, counting on the selective use of the plugged bipolar forceps and the monopolar scissors, or "microfracture-coagulation" (MFC) transection method, is described in detail. The relevant aspects of the technique, its indications and methodological basis are discussed.

Background This study aims to compare the visualization of the cystic duct-common bile duct junction with indocyanine green (ICG) among 3 groups of patients divided according to the difficulty of elective laparoscopic cholecystectomy. Methods Conducted at a single center, this non-randomized, prospective, observational study encompassed 168 patients who underwent elective laparoscopic cholecystectomy and were assessed with a preoperative risk score to predict difficult cholecystectomies, including clinical factors and radiological findings. Three groups were identified: low, moderate, and high risk. A dose of 0.25 mg of IV ICG was administered during anesthesia induction and the different objectives were evaluated. Results The visualization of the cystic duct-common bile duct junction was achieved in 28 (100%), 113 (91.1%), and 10 (63%) patients in the low, moderate, and high-risk groups, respectively. The high-risk group had longer total operative time, higher conversion, more complications and longer hospital stay. In the surgeon’s subjective assessment, ICG was considered useful in 36% of the low-risk group, 58% in the moderate-risk group, and 69% in the high-risk group. Additionally, there were no cases where ICG modified the surgeon’s surgical approach in the low-risk group, compared to 11% in the moderate-risk group and 25% in the high-risk group (p < 0.01). Conclusions The results of this study confirm that in the case of difficult cholecystectomies, the visualization of the cystic duct-common bile duct junction is achieved in 63% of cases and prompts a modification of the surgical procedure in one out of four patients.