Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy remains a challenging field in therapeutic endoscopy due to the complex anatomical reconstructions that limit access to the biliary tree. Over the past two decades, device-assisted enteroscopy (DAE), including single-balloon, double-balloon, and motorized spiral enteroscopy, has expanded the feasibility of ERCP in this population, with overall technical success rates generally reported between 70% and 90%. Nevertheless, these techniques are technically demanding, time-consuming, and frequently affected by limited reach and unstable positioning. More recently, interventional endoscopic ultrasound (EUS)-guided procedures have emerged as highly effective alternatives, significantly improving clinical outcomes in selected patients, particularly in those with long-limb Roux-en-Y reconstructions where conventional methods are less effective. Percutaneous transhepatic biliary drainage continues to represent a valuable salvage option when endoscopic approaches fail, though it is associated with a greater burden of reinterventions and adverse events. This minireview provides a comprehensive overview of the main endoscopic strategies for biliary drainage in altered anatomy, focusing on technical considerations, efficacy, and safety profiles of DAE-assisted ERCP, EUS-guided interventions, and motorized systems. The evolving landscape of biliary drainage in this setting highlights the need for tailored treatment strategies, multidisciplinary collaboration, referral to high-volume centers, and further prospective studies to refine patient selection and optimize clinical outcomes.

Background: The Rives–Stoppa retromuscular repair remains the reference standard for open ventral hernia repair. Advances in robotic surgery have expanded the minimally invasive options for extraperitoneal mesh placement, enabling both retromuscular and preperitoneal approaches. The robotic ventral transabdominal preperitoneal repair (Rv-TAPP), has seen increasing adoption, but comparative evidence with the robotic retromuscular techniques remains limited. Methods: A systematic review and meta-analysis were reported in accordance with PRISMA and AMSTAR II guidelines (PROSPERO 2025: CRD420251173188). Searches of PubMed, Embase, Scopus, and Cochrane Library were searched to identify comparative studies evaluating robotic preperitoneal and retromuscular ventral hernia repair. Random-effects models (DerSimonian–Laird) were used to pool weighted mean differences (WMD) and risk ratios (RR) with 95

Robotic-assisted transabdominal preperitoneal repair (r-TAPP) is increasingly adopted for inguinal hernia repair, but the number of procedures required to achieve stable operative performance remains unclear. This scoping review synthesised CUSUM-based learning curve evidence to characterise reported operative-time stabilisation thresholds and their methodological determinants. PubMed, Embase, Scopus, Cochrane Library, and Google Scholar were searched for studies published between January 2000 and December 2025 reporting CUSUM-based learning curve analyses of r-TAPP or SP-TAPP using Da Vinci systems. The review followed PRISMA-ScR guidance and was registered with the Open Science Framework. The primary outcome was the CUSUM inflection point, summarised descriptively using median, sample-size-weighted mean, range, and non-parametric bootstrap 95

Background: A preliminary analysis from the COVID-Advanced Gastrointestinal Cancer Surgical Treatment (AGICT) study showed that the rate of minimally invasive surgery (MIS) for elective and urgent procedures did not decrease during the pandemic year. In this article, we aimed to perform a subgroup analysis using data from the COVID-AGICT study to evaluate the trend of MIS during the COVID-19 pandemic period in Italy. Methods: This study was conducted collecting data of MIS patients from the COVID-AGICT database. The primary endpoint was to demonstrate whether the SARS-CoV-2 pandemic scenario reduced MIS for elective treatment of gastrointestinal cancer (GIC) in Italy in 2020. The secondary endpoint was to evaluate the impact of the pandemic period on perioperative outcomes in the MIS group. Results: In the pandemic year, 62% of patients underwent surgery with a minimally invasive approach, compared to 63% in 2019 (P = .23). In 2020, the proportion of patients undergoing elective MIS decreased compared to the previous year (80% versus 82%, P = .04), and the rate of urgent MIS did not differ between the 2 years (31% and 33% in 2019 and 2020 - P = .66). Colorectal cancer was less likely to be treated with MIS approach during 2020 (78% versus 75%, P < .001). Conversely, the rate of MIS pancreatic resection was higher in 2020 (28% versus 22%, P < .002). Conversion to an open approach was lower in 2020 (7.2% versus 9.2% - P = .01). Major postoperative complications were similar in both years (11% versus 11%, P = .9). Conclusion: In conclusion, although MIS for elective treatment of GIC in Italy was reduced during the COVID-19 pandemic period, our study revealed that the overall proportion of MIS (elective and urgent) and postoperative outcomes were comparable to the prepandemic period. ClinicalTrial.gov (NCT04686747).

In the light of the current dissemination of robotic surgery, there will likely be fundamental robotic skills requirements to complete general surgery residency, and the need for a structured robotic training curriculum has been supported by several associations and program directors. Training a robotic colorectal surgeon has two different aspects to consider: learning how to use the platform, and learning procedural skills strictly related to colorectal surgery. Broad consensus exists on the fact that a structured robotic colorectal training program should have a modular approach including theoretical knowledge, case observation, simulation, and proctored training. Additionally, the ideal robotic colorectal training program should provide an objective assessment of acquired skills with well-established requirements to proceed from one step to the next, and non-operative robotic skills should also be implemented and evaluated. Another relevant feature of robotic colorectal training is the component-based approach, which consists in deconstructing the procedure in defined and measurable components that can be evaluated more objectively. Finally, we are not only training console surgeons, but also bedside assistants since correct trocar positioning and reliable feedback from the operating table are essential to the effective and safe completion of a robotic colorectal procedure.

Background: This Italian multicentric retrospective study aimed to investigate the possible changes in outcomes of patients undergoing surgery for gastrointestinal cancers during the COVID-19 pandemic. Method: Our primary endpoint was to determine whether the pandemic scenario increased the rate of patients with colorectal, gastroesophageal, and pancreatic cancers resected at an advanced stage in 2020 compared to 2019. Considering different cancer staging systems, we divided tumors into early stages and advanced stages, using pathological outcomes. Furthermore, to assess the impact of the COVID-19 pandemic on surgical outcomes, perioperative data of both 2020 and 2019 were also examined. Results: Overall, a total of 8250 patients, 4370 (53%) and 3880 (47%) were surgically treated during 2019 and 2020 respectively, in 62 Italian surgical Units. In 2020, the rate of patients treated with an advanced pathological stage was not different compared to 2019 (P = 0.25). Nevertheless, the analysis of quarters revealed that in the second half of 2020 the rate of advanced cancer resected, tented to be higher compared with the same months of 2019 (P = 0.05). During the pandemic year 'Charlson Comorbidity Index score of cancer patients (5.38 +/- 2.08 vs 5.28 +/- 2.22, P = 0.036), neoadjuvant treatments (23.9% vs. 19.5%, P < 0.001), rate of urgent diagnosis (24.2% vs 20.3%, P < 0.001), colorectal cancer urgent resection (9.4% vs. 7.37, P < 0.001), and the rate of positive nodes on the total nodes resected per surgery increased significantly (7 vs 9% -2.02 +/- 4.21 vs 2.39 +/- 5.23, P < 0.001). Conclusions: Although the SARS-CoV-2 pandemic did not influence the pathological stage of colorectal, gastro-esophageal, and pancreatic cancers at the time of surgery, our study revealed that the pandemic scenario negatively impacted on several perioperative and post-operative outcomes.

The robotic platform is becoming a multidisciplinary tool, versatile, and suitable for multiple procedures. Combined multivisceral resections may represent an alternative to sequential procedures with a potential favorable impact on postoperative morbidity, and on the timing of administration of adjuvant chemotherapy. We herein present our initial experience with full robotic multivisceral resections, and a review of the literature available. Between January 2018 and April 2020, 11 patients underwent multivisceral full robotic abdominal surgery: 4 patients presented with two synchronous tumors, 4 with primary cancer associated with a benign condition and 3 cases involved deep infiltrating endometriosis. Surgical teams enrolled were: General Surgery, Urology and Gynecology. A systematic bibliographic research up to April 2020 was conducted in PubMed. 4 colorectal resections combined with partial or radical nephrectomy were performed, as well as 2 right colectomies in combination with right adrenalectomy and gastric banding removal, 2 radical prostatectomies with Nissen Fundoplication and abdominal wall hernia repair, and 3 resections of deep pelvic endometriosis with colorectal involvement. Mean total operative time was 367 min. No intraoperative complication or conversion to open was registered. Overall postoperative complication rate was 18.2%. 26 papers were included in the review (10 case series and 16 case reports) with a total of 156 combined multivisceral robotic procedures recorded. Robotic combined multivisceral resections proved to be safe and feasible when performed in high volume centers by expert surgeons. The heterogeneity of reports does not allow for a standardization of the procedure. Further studies and accumulation of experience are needed.

INTRODUCTION: A true left sided gallbladder (T-LSG) is a rare finding mostly discovered incidentally during laparoscopy and often associated with several anatomic anomalies; surgical approach may be challenging with an increased risk of intra-operative injuries and conversion to open. PRESENTATION OF THE CASE: A 76 years old woman presented with acute cholecystitis. The left sided gallbladder was unexpectedly discovered as an intra-operative finding. Laparoscopic cholecystectomy was carried out using our usual trocar set-up without the need of intra-operative cholangiography or conversion to open. DISCUSSION: LSG is reported to be associated with a higher risk of intraoperative bile duct injuries (up to 7.3%) due to anomalies of the bile duct, portal vein, and other structures. Achieving the Critical View of Safety by opening Calot's triangle is essential to avoid bile duct injuries. CONCLUSION: Experienced surgeons could safely approach LSG laparoscopically, also in emergency setting, without major changing in their surgical technique with limitation of diathermy use and prudent dissection of anatomical structures to avoid biliary injuries. Intra-operative cholangiography is not mandatory. (C) 2020 Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd.

INTRODUCTION:Most Human taeniasis are asymptomatic or associated with vague clinical manifestations, but cases of unusual migration of these parasites have been described. PRESENTATION OF A CASE:A case of challenging diagnosis of human Taenia Saginata infection is here presented: during COVID-19 pandemic we performed a mininvasive robotic subtotal gastrectomy for gastric angulus adenocarcinoma. 10 h after the end of the operation the patient presented an episode of vomiting with expulsion of a 5-meter-long adult form of Taenia Saginata. DISCUSSION:Parasitic infections are more frequent in the developing countries; in our case the transposition of small intestinal loop surely promoted the migration of Taenia Saginata through the gastro-jejunal anastomosis into the gastric stump.Preoperative evaluation (history, physical examination and imaging features) led to gastric cancer diagnosis and hindered the recognition of the taeniasis because of similar clinical presentations and the need to start quickly a therapeutic oncological strategy. CONCLUSION:Even if these cases are exceptional especially in Western Europe, it is important to obtain a detail clinical history and exclude parasitic infection as a cause of loss of weight and gastrointesinal abnormalities.

Pecchini, Francesca MD; Esposito, Sofia MD; Mullineris, Barbara MD; Francescato, Alice MD; Gozzo, Davide MD; Colli, Giovanni MD; Piccoli, Micaela MD Author Information

Robotic-assisted transaxillary surgery of the thyroid and parathyroid may overcome some of the limitations of the endoscopic approach. Although the robotic system proved to have several advantages, its widespread use is still controversial due to technical and economic issues. Nevertheless, robotic thyroidectomy and parathyroidectomy proved to be safe and feasible, but should be performed in high-volume centers and in selected patients. High-volume centers have an advantage over low-volume ones, in terms of surgical outcomes and costs containment, since the learning curve is reported to be around 35–40 procedures, which is nonetheless shorter than that of the endoscopic approach. Robotic surgery is reported to offer several advantages over standard laparoscopy also with reference to minimally invasive adrenalectomy. Robotic adrenalectomy is associated with a shorter learning curve, less intraoperative blood loss, shorter length of hospital stay, and an easier approach to large tumors; the main criticism remains cost-effectiveness. Number of cases per year is reported to have a positive influence on both costs and postoperative morbidity, so that robotic adrenalectomy should be implemented in high-volume centers, with experience in both robotic and endocrine surgery. The threshold defining high-volume surgeons is believed to be six procedures per year.

Background Nowadays the robotic platform is widespread in general surgery, urology, and gynecology. Combined surgery may represent an alternative to sequential procedures and it allows the treatment, at the same time, of coexisting lesions; in this perspective, full-robotic multiorgan surgery is starting to gain interest from surgeons worldwide. Methods Between April and June 2019, two patients presenting with synchronous colorectal and kidney cancers underwent, respectively, full-robotic right colectomy with right partial nephrectomy and anterior rectal resection with left partial nephrectomy. Surgeries were performed by both the general surgery and urology team. Results No intraoperative complications were registered and the postoperative course was uneventful in both cases. Conclusions Combined multiple organ surgery with full robotic technique is safe and offers oncological adequate results. A multi-team surgical pre-planning is mandatory to reduce invasiveness and operative time. To the best of our knowledge, these are the first reports of full robotic partial nephrectomy combined with colorectal procedures.

BACKGROUND: One major issue in general surgery is how to provide novice surgeons with a structured training program (STP). The aim of our study was to assess the efficacy of a STP in robotic colorectal surgery for young surgeons without prior experience in both open and laparoscopic colorectal surgery, who were autonomous in basic minimally-invasive surgical procedures. Right colectomy with intracorporeal anastomosis has been chosen as a model. METHODS: Between May 2015 and December 2017 two junior attending surgeons were trained through a STP. Right colectomy was divided into three main learning modules (colonic mobilization, vascular control, intracorporeal anastomosis) and each one was carried out by the trainees for at least two times under direct supervision of the senior surgeon. After the initial robotic cases completely performed under formal proctoring, they were privileged to perform robotic right colectomy independently without a mentor (20 procedures). Operative time, conversion rate, intra-and postoperative complications, length of stay and pathological outcomes were the variables analyzed to assess the effectiveness of the STP. RESULTS: The mean operative time was 200 minutes and no conversion was required. Neither intraoperative nor major postoperative complications were recorded and the mean length of hospital stay was 6 days. Mean nodal yield was 21. CONCLUSIONS: A STP in robotic colorectal surgery is feasible and effective. Right colectomy represents a good model as first step of the program in order to develop multiple technical skills. Previous experience in open or laparoscopic colorectal surgery may not be necessary.

BACKGROUND:Conversion to open during minimally invasive liver resection has a high rate. To identify the reasons to convert could help in defining a strategy to decrease the event "conversion."METHODS:A systematic review has been performed. Our large series of robotic hepatic resections were analyzed and included in the review.RESULTS:Fifty papers were selected and carefully evaluated in full text. Twenty-nine were ultimately used for analysis, including all published robotic liver resections. Our series included 11 conversions out of 139 patients (7.9%). Adhesions were not a declared reason to convert. The robotic approach still had a high percentage of open conversions because of difficulties in assessing the tumor margin.CONCLUSIONS:Causes for conversion were carefully analyzed and compared with what previously described for the pure laparoscopic approach. This could be crucial in defining how to improve the performance and minimize the conversion rate.

from the University of Pittsburgh where they report nine patients.The robotic 3D camera allows for immersive visualization of the anatomy, allowing the surgeon to see the individual submucosal muscle fibers to ensure complete resection of the mass without going too deep.The instruments' seven degrees of freedom also aided in the careful dissection and made it easier to accurately reapproximate the mucosa and reimplant the bile duct compared to laparoscopic surgery.Conclusion: Robotic transduodenal resection of a periampullary mass is feasible, providing optimal visualization, the ability to meticulously dissect the lesion off of the submucosa, and effectively reimplant the bile duct.Further studies need to be done to determine the safety of the robotic approach.

Introduction: Laparoscopic adrenalectomy (LA) is accepted as the gold standard treatment for most adrenal pathologies. Open surgery is still considered the standard of care for large tumors and malignancies. In the past decade, robotic adrenalectomy (RA) has become an alternative to the laparoscopic and open approaches. The aim of this study was to analyze perioperative and postoperative outcomes in a series of consecutive nonselected patients undergoing a RA, to determine whether factors that negatively affect outcomes in LA (body mass index [BMI], size, and side of the tumor) have the same impact in RA. Materials and Methods: This is a single-center single-surgeon retrospective study with 43 patients who underwent a RA. Patients were divided into different groups according to tumor size (cutoff values of 5 or 8cm), tumor side (left/right), and BMI (cutoff value of kg/m(2)). Perioperative and postoperative outcomes included operative time, length of hospital stay, blood loss, readmissions, complications, and conversions to open. Results: There were no significant differences between the groups with tumors <5cm versus 5cm regarding gender, age, race, BMI, American Society of Anesthesiologists (ASA) score, history of previous abdominal surgery, tumor side, and histopathological diagnosis (all P values .06). There were no significant differences in any of the outcomes analyzed with respect to the tumor size (all P values .14) except for a higher occurrence of complications in patients with tumors 8cm versus <8cm (P=.03). There were no significant differences in any outcomes related to side (left versus right) of the tumor nor BMI (<30 versus 30kg/m(2)). The overall readmission and conversion rates were both 2.3% and no mortalities were registered. Conclusion: Patient's BMI, tumor side, and size did not demonstrate a negative impact on perioperative and postoperative outcomes of RA. This approach could potentially expand the indications of minimally invasive surgery.

A number of technical improvements regarding the pancreatic anastomosis have decreased the morbidity and mortality after pancreaticoduodenectomy. However, postoperative pancreatic fistula (POPF) remains is the most feared complication, and the ideal technique for pancreatic reconstruction is undetermined.

Laparoscopic total mesorectal excision (TME) is technically demanding and has a steep learning curve. Moreover, two recent randomized controlled trials have questioned the oncological safety of laparoscopic treatment for rectal cancer. Robotic surgery, thanks to its technical advantages, could potentially overcome the intrinsic limitations of standard laparoscopy. In this paper we will describe the surgical technique of robotic TME and review the recent literature on robotic rectal surgery. Short term, functional and oncological outcomes will be taken into consideration, as well as learning curve and costs. Robotic rectal resection is reported to have lower conversion rates (CRs), better functional outcomes and shorter learning curve, with comparable oncological results. Robotic surgery remains more time consuming and affected by higher costs. The technological advantages provided by the robotic system could probably facilitate the widespread adoption of minimally-invasive TME, that still has a low penetration worldwide. The educational capabilities of the platform, together with structured training programs, could allow novice surgeons to safely approach colorectal surgery.

Background: Gold standard treatment for Primary hyperparathyroidism (PHPT) is surgical resection of the adenoma, which in nearly 22-25% of the cases is ectopic. The evolution of preoperative imaging techniques, in association with the intraoperative PTH measurement (IOPTH) have led to the development of minimally invasive targeted approaches for the management of PHPT. We hereby report a case of a mediastinal parathyroid adenoma removed using the robotic-assisted transaxillary approach Case presentation: A 46-year-old female presented with PHPT caused by a parathyroid ectopic adenoma located in the upper mediastinum, adjacent to the left sternal notch. We performed a robotic transaxillary parathyroidectomy, with IOPTH measurement. Total operative time was 97 minutes, with no complications. The patient was discharged the next day. At one month follow up total serum calcium was between normal ranges Discussion: The Robotic transaxillary approach for parathyroid adenoma has been recently described in literature providing promising results. This procedure completely avoids a scar in a visible area such as the neck and can be performed without the need for gas insufflation. This procedure is particularly recommended in selected patients with history of keloid or hypertrophic scar formation or deeply concerned about the cosmetic outcomes. Robotic-assisted surgery allows fine dissection with better control of the instruments even in narrow spaces Conclusion: The role of the transaxillary approach in ectopic mediastinal parathyroid adenoma is still under evaluation, but in our opinion, it represents a valid option in case of a well localized single adenoma in the upper mediastinum.