Background: Robotic-assisted hysterectomy (RAH) is a widely accepted minimally invasive approach for uterus removal. However, as RAH is typically performed in the umbilical region, it usually results in scars in cosmetically suboptimal locations. This is the first case of RAH with cervicosacropexy performed below the bikini line, using the new Dexter robotic system™. Objectives: The aim of this article is to show the surgical steps of the first RAH with cervicosacropexy performed below the bikini line with the new Dexter robotic system™ (Distalmotion), and furthermore assess the feasibility of this approach using this robotic platform. Materials and methods: A 43-year-old woman with uterine adenomyosis and recurrent uterine prolapse underwent a robotic-assisted subtotal hysterectomy with cervicosacropexy, performed below the bikini line, using the Dexter robotic system™, at the Clinic of Gynecology and Obstetrics at Universitätsklinikum Schleswig-Holstein (UKHS) in Kiel, Germany. Main outcome measures: Perioperative data, surgical approach specifics, objective, and subjective outcomes of this new approach. Results: The procedure was performed without intra-operative complications; estimated blood loss was 10 ml. Operative time was 150 minutes, console time 120 minutes, total docking time 6 minutes. Dexter performed as expected; no device-related issues or robotic arm collisions occurred. The patient did not require pain medication and was released on the second postoperative day. Conclusion: RAH performed below the bikini line using the Dexter robotic system™ is a feasible, safe, and adequate procedure. These initial results should be confirmed and further extensively refurbished with larger patient cohorts, and functional and psychological outcomes need further investigation.

IntroductionObesity is frequently associated with its hepatic manifestation, the nonalcoholic fatty liver disease (NAFLD). The most effective treatment for morbid obesity is bariatric surgery (BS) also improving NAFLD and liver function. In patients where NAFLD has already progressed to liver cirrhosis, BS can be considered a high-risk procedure. Hence, consideration of the procedure and the most appropriate timing is crucial.Material and MethodsObese patients suffering from NAFLD who underwent BS from two German University Medical Centers were retrospectively analyzed.ResultsTwenty-seven patients underwent BS. Most common procedures were laparoscopic Roux-en-Y-gastric (RYGB) and laparoscopic sleeve gastrectomy (SG). All patients suffered from liver cirrhosis Child A. A preoperative transjugular portosystemic shunt (TIPS) was established in three patients and failed in another patient. Postoperative complications consisted of wound healing disorders (n = 2), anastomotic bleeding (n = 1), and leak from the staple line (n = 1). This patient suffered from intraoperatively detected macroscopic liver cirrhosis. Excess weight loss was 73% and 85% after 1 and 2 years, respectively. Two patients suffered from postoperative aggravation of their liver function, resulting in a higher Child–Pugh score, while three could be removed from the waiting list for a liver transplantation.ConclusionBS leads to weight loss, both after SG and RYGB, and potential improvement of liver function in liver cirrhosis. These patients need to be considered with care when evaluated for BS. Preoperative TIPS implantation may reduce the perioperative risk in selected patients.

Based on the principles of biomedical ethics, the authors conducted a survey focusing on the ethical aspects of, didactic benefits of and possible alternatives to live surgery events. This work provides an investigation of the ethics of live surgery events in an interdisciplinary and multicentre setting. Critical ethical concerns regarding the justification of such events are highlighted through evaluation of attendees and surgeons.

Aims Anastomotic insufficiencies(AI) and perforations of the upper gastrointestinal tract(uGIT) result in high morbidity and mortality. Besides surgical revision and endoscopic stent placement the endoluminal vacuum therapy(EVT) has been established as an additional strategy. So far, the Eso-Sponge is the only licensed EVT system with limitations in very small defects. Therefore, a fistula sponge(FS) was established in our center for the treatment of small defects of the uGIT as a new therapeutic approach. To evaluate success rates, indications and complications of both EVT options in a retrospective, single-center trial.

Einleitung Indocyaningrün (ICG) ist ein nahe infrarot fluoreszierender Farbstoff, der in degenerierten Leberzellen akkumuliert und helfen kann, entartetes von gesundem Gewebe zu differenzieren. Ziel war die Machbarkeitstestung präoperativer intravenöser (iv) ICG-Gaben bei primären und metastasierten hepatischen Tumoren und die Evaluation der intraoperativen real-time Visualisierung bei Roboter-assistierten Leberresektionen.

Hintergrund Ösophagusresektionen haben einen beträchtlichen Einfluss auf körperliche Funktion, Lebensqualität und Selbstwahrnehmung. Die onkologischen Ergebnisse und das Langzeitüberleben nach Ösophagusresektion werden in den letzten Jahren besser. Outcome kann daher nicht länger nur nach Morbidität und Mortalität beurteilt werden. Vielmehr muss die peri- und postoperative Lebensqualität, besonders im Langzeitverlauf, mit in Betracht gezogen werden.

Hinsichtlich einer individuellen Risikostratifizierung und Therapieentscheidung können liquid biopsies hilfreich sein und etablierte Stagingsysteme ergänzen. Neben anderen Biomarkern gehört der Nachweis von zirkulierende Tumorzellen (CTC) zu einem wichtigen Segment der liquid biopsies. Mittels einer semiquantitativen RT-PCR gegen Zytokeratin 20 konnte unsere Arbeitsgruppe zeigen, dass der Nachweis von CTC bei Kolorektalkarzinompatienten auch in den frühen Tumorstadien (UICC I +II) ein negativ prognostischer Marker ist.

Anastomoseninsuffizienzen (AI) oder Perforationen am oberen Gastrointestinaltrakt (oGIT) sind schwerwiegende Erkrankungen mit einer hohen Mortalität. In den letzten Jahren hat sich vor allem die minimal invasive endoluminale Vakuumtherapie (EVT) als eine vielversprechende Behandlungsmöglichkeit bei septischen Geschehen etabliert. Diverse unizentrische Studien mit kleinen Patientenkollektiven indizieren, dass die EVT der aktuell noch häufig verwendeten Stent-Therapie überlegen ist. Eine prospektive multizentrische Studie zur Evaluation der Effektivität und Sicherheit der EVT ist bisher allerdings nicht durchgeführt worden. Daher ist dies die erste groß angelegte prospektive, multizentrische Studie zur Evaluation der EVT.

Zonation of liver metabolism and its regulation has been intensely studied in the past but was focused on the healthy organ and animal models. Major break throughs were accomplished especially using so called omics-techniques. Although liver cirrhosis has become one of the major problems in the western world, it was not yet achieved to use those methods at this stage of disease progression.

Die metabolische Zonierung der Leber und deren Regulation wurde in den letzten Jahrzehnten intensiv erforscht. Das Hauptaugenmerk der meist an Tiermodellen durchgeführten Versuche lag dabei vor allem auf dem gesunden Organ. Insbesondere die sogenannten omics-Methoden führten hierbei zu bahnbrechenden Ergebnissen. Trotzdem die Leberzirrhose eine der wichtigsten Erkrankungen westlicher Länder darstellt, ist es bisher nicht gelungen eine Zonierung in diesem fortgeschrittenen Stadium unter Nutzung dieser Techniken zu analysieren.

Background: Pylorus preserving pancreaticoduodenectomy is one oft he most complex procedures in general surgery. Laparoscopic pancreaticoduodenectomy was initially described in 1994. However, its worldwide distribution is limited to only a few specialist centers. Robotic surgery using the DaVinci®-system can overcome many limitations of laparoscopic surgery. Methods: Video presentation. Results: The video presents a robotic pylorus preserving pancreaticoduodenectomy for periampullary carcinoma in a female patient. Alternate types of reconstruction are demonstrated and discussed. The clinical course was uneventful, the patient was discharged on day 10. Conclusion: Robotic pancreaticoduodenectomy is feasible and safe. The Robotic system is a promising tool for a more widespread introduction of minimally invasive surgery for pancreatic disease.

AIM:Robotic techniques are being increasingly used in colorectal surgery. There is, however, a lack of training opportunities and structured training programmes. Robotic surgery has specific problems and challenges for trainers and trainees. Ergonomics, specific skills and user-machine interfaces are different from those in traditional laparoscopic surgery. The aim of this study was to establish expert consensus on the requirements for a robotic train-the-trainer curriculum amongst robotic surgeons and trainers. METHOD:This is a modified Delphi-type study involving 14 experts in robotic surgery teaching. A reiterating 19-item questionnaire was sent out to the same group and agreement levels analysed. A consensus of 0.8 or higher was considered to be high-level agreement. RESULTS:Response rates were 93-100% and most items reached high levels of agreement within three rounds. Specific requirements for a robotic faculty development curriculum included maximizing dual-console teaching, theatre team training, nontechnical skills training, patient safety, user-machine interface training and telementoring. CONCLUSION:A clear need for the development of a train-the-trainer curriculum has been identified. Further research is needed to assess feasibility, effectiveness and clinical impact of a robotic train-the-trainer curriculum.

A considerable number of reports have been published on the feasibility, techniques, and early postoperative results of robotic-assisted oesophageal surgery. However, these are mostly smaller case series, suggesting that the robot-assisted Ivor Lewis procedure is still in the implementation phase and far from being standardised. Oesophageal surgeons from seven robotic university centres in Germany, experienced in both minimally invasive and robot-assisted minimally invasive surgery, took part in a workshop on robot-assisted surgery. An intensive exchange of opinions and experiences, followed by a step-by-step re-enactment of the operation in a cadaver lab, enabled us to develop a standardised robot-assisted Ivor Lewis surgical workflow, which is presented here. Systematic and objective comparison of experiences and results using a robot-assisted Ivor Lewis procedure has made it possible to develop a standardised surgical workflow that is now clinically applied in our centres. It is hoped that standardisation of this procedure will help to maintain patient safety, prevent medical errors, and facilitate the learning curve, while introducing robotic surgery into a centre.

Bariatrische Operationen werden standardmäßig konventionell laparoskopisch durchgeführt. Während international zunehmend auch roboterassistiert operiert wird, gibt es aus Deutschland nur wenig Erfahrungsberichte über die Verwendung des Systems in der Adipositaschirurgie. Seit Januar 2017 führen wir roboterassistierte Magenbypassoperationen durch. Unklar bleibt, ob die roboterassistierte bariatrische Chirurgie in Bezug auf den proximalen Magenbypass Vorteile gegenüber der sehr gut etablierten laparoskopischen Technik aufweist. Insgesamt 53 minimal-invasive Magenbypassoperationen inklusive Omega-loop-Bypass sowie distalem und proximalem Redo-Roux-Y-Magenbypass erfolgten innerhalb eines Zeitraumes von Januar bis Anfang August 2017. Davon wurden 16 primäre proximale Roux-Y-Magenbypassoperationen mittels des DaVinci-Si-Systems durchgeführt und 29 laparoskopisch. Es erfolgte eine retrospektive Analyse des operativen, stationären und frühpostoperativen Verlaufs. Gewicht, BMI, EOSS und ASA-Klassifikation unterschieden sich nicht signifikant. Bezüglich des geschätzten Blutverlustes, intraoperativer Komplikationen, Operationsdauer, postoperativer Entzündungsparameter und des Gewichtsverlustes fanden sich ebenfalls keine signifikanten Unterschiede. In beiden Gruppen gab es keine Mortalität und keine notwendigen Reoperationen. Nach laparoskopischem proximalem Magenbypass trat eine Spätinsuffizienz der Gastrojejunostomie auf, die eine Wiederaufnahme und endoskopische Behandlung mittels VAC-Therapie notwendig machte. Die Ergebnisse zeigen, dass der proximale Roux-Y-Magenbypass sicher und effizient mittels des DaVinci-Si-Systems durchgeführt werden kann. Signifikante Unterschiede zum konventionellen laparoskopischen Vorgehen finden sich in der relativ kleinen Kohorte nicht. Größere randomisiert kontrollierte Studien sind erforderlich, um die Rolle des Operationsroboters in der Adipositaschirurgie näher zu definieren.

Conventional laparoscopy is the gold standard in bariatric surgery. Internationally, robot-assisted surgery is gaining in importance. Up to now there are only few reports from Germany on the use of the system in bariatric surgery. Since January 2017 we have been performing robot-assisted gastric bypass surgery. It remains unclear whether the use of the robotic system has advantages over the well-established laparoscopic technique. Within a period from January to early August 2017 a total of 53 gastric bypass operations were performed. Of these 16 proximal redo Roux-en-Y gastric bypass operations were performed with the DaVinci Si system versus 29 laparoscopic procedures. A retrospective analysis of the perioperative course was carried out. Body weight, body mass index (BMI), Edmonton obesity staging system (EOSS) and American Society of Anesthesiologists (ASA) classification did not show significant differences. There were also no significant differences in terms of estimated blood loss, intraoperative complications, duration of surgery, postoperative inflammatory parameters and weight loss. There was no mortality and no need for revisional surgery in either group. After laparoscopic surgery there was a delayed occurrence of a leak of the gastrojejunostomy followed by readmission and endoscopic negative pressure wound therapy. The results show that the proximal Roux-en-Y gastric bypass can be performed safely and efficiently using the DaVinci surgical system. Significant differences to the conventional laparoscopic procedure were not found. Larger randomized controlled trials are needed to define the role of the DaVinci system in bariatric surgery.