BACKGROUND: Around 20% of rectal tumors are locally advanced with invasion into adjacent structures at presentation. These may require surgical resections beyond boundaries of total mesorectal excision (bTME) for radicality. Robotic bTME is under investigation. This study reports perioperative and oncological outcomes of robotic bTME for locally advanced rectal cancers.
METHODS: A multicentre, retrospective analysis of prospectively collected robotic bTME resections (July 2015-November 2020). Demographics, clinicopathological features, short-term outcomes, recurrences, and survival were investigated.
RESULTS: One-hundred-sixty-eight patients (eight centres) were included. Median age and BMI were 60.0 (50.0-68.7) years and 24.0 (24.4-27.7) kg/m2. Female sex was prevalent (n = 95, 56.8%). Fifty patients (29.6%) were ASA III-IV. Neoadjuvant chemoradiotherapy was given to 125 (74.4%) patients. Median operative time was 314.0 (260.0-450.0) minutes. Median estimated blood loss was 150.0 (27.5-500.0) ml. Conversion to laparotomy was seen in 4.8%. Postoperative complications occurred in 77 (45.8%) patients; 27.3% and 3.9% were Clavien-Dindo III and IV, respectively. Thirty-day mortality was 1.2% (n = 2). R0 rate was 92.9%. Adjuvant chemotherapy was offered to 72 (42.9%) patients. Median follow-up was 34.0 (10.0-65.7) months. Distant and local recurrences were seen in 35 (20.8%) and 15 patients (8.9%), respectively. Overall survival (OS) at 1, 3, and 5-years was 91.7, 82.1, and 76.8%. Disease-free survival (DFS) at 1, 3, and 5-years was 84.0, 74.5, and 69.2%.
CONCLUSIONS: Robotic bTME is technically safe with relatively low conversion rate, good OS, and acceptable DFS in the hands of experienced surgeons in high volume centres. In selected cases robotic approach allows for high R0 rates during bTME.

BACKGROUND: There are a number of small case series examining new robotic surgical systems, but this is the first large case series assessing the feasibility of the Versius® system from CMR Surgical (1 Evolution Business Park, Cambridge, UK) in a multi-specialty setting.
METHODS: All patients undergoing Versius®-assisted surgery in a previously robot-naïve centre were consented for collection of data on demographics, pre-, intra-, and postoperative outcomes. Data collection was performed prospectively from the start of the robotic surgical programme.
RESULTS: 160 operations were performed over a 19-month period, including 68 colorectal, 60 gynaecology, and 32 general surgery cases. The conversion rate to open surgery was 4.4% for colorectal, and 0% for gynaecology and general surgery. Median length of stay was 6 days for colorectal, 1 day for gynaecology, and 0 days for general surgery. Other outcomes were comparable to existing literature for robotic assisted surgery.
CONCLUSIONS: The Versius® system is safe and feasible for use in a multi-specialty minimally invasive surgery programme, including colorectal, general surgical & gynaecological cases, and operative volume can be safely and easily scaled up in a district general hospital setting without prior robotic surgical experience.

BACKGROUND: Laparoscopic resection is the treatment of choice for colorectal cancer. Rates of conversion to open surgery range between 7% and 30% and controversy exists as to the effect of this on oncologic outcomes. The objective of this study was to analyze what factors are predictive of conversion and what effect they have on oncologic outcomes.
METHODS: From a prospective database of patients undergoing laparoscopic surgery between 2000 and 2018 a univariate and multivariate analyses were made of demographic, pathologic, and surgical variables together with complementary treatments comparing purely laparoscopic resection with conversions to open surgery. Overall and disease-free survival were compared using the Kaplan-Meier method.
RESULTS: Of a total of 829 patients, 43 (5.18%) converted to open surgery. In the univariate analysis, 12 variables were significantly associated with conversion, of which left-sided resection [odds ratio (OR): 2.908; P=0.02], resection of the rectum (OR: 4.749, P=0.014), and local invasion of the tumor (OR: 6.905, P<0.01) were independently predictive factors in the multiple logistic regression. Female sex was associated with fewer conversions (OR: 0.375, P=0.012). The incidence and pattern of relapses were similar in both groups and there were no significant differences between overall and disease-free survival.
CONCLUSIONS: Left-sided resections, resections of the rectum and tumor invasion of neighboring structures are associated with higher rates of conversion. Female sex is associated with fewer conversions. Conversion to open surgery does not compromise oncologic outcomes at 5 and 10 years.

To describe cases of conversion from gynecologic laparoscopy to open surgery and to assess risk factors for conversion and conversion outcomes.
A retrospective case-control study.
Tertiary referral hospital in Melbourne, Australia.
Eighty-five cases of conversion from laparoscopy to laparotomy and 170 controls matched by age, surgical date, and gynecologic unit from 2006 to 2017.
Demographic, clinical, and surgical data were collected and compared between the study groups. Logistic regression was performed to identify preoperative and intraoperative risk factors for conversion.
Rate of conversion during the study period was 0.7%. The most common indication for conversion was unexpected surgical complexity (67% of cases), which included severe adhesive disease, specimen size, severe pathology, and inadequate views. Factors that were significantly associated with risk of conversion in multivariate analysis were previous pelvic inflammatory disease (adjusted odds ratio [aOR] 5.16; 95% confidence interval [CI], 1.35-19.71; p = .02), previous open surgery (aOR 3.62; 95% CI, 1.52-8.58; p <.01), history of endometriosis (aOR 2.96; 95% CI, 1.17-7.50; p = .02), and elevated body mass index (aOR 1.07; 95% CI, 1.01-1.13; p = .02). As compared with current surgery for endometriosis, odds of conversion were higher in surgeries for emergency indications (aOR 5.40; 95% CI, 1.53-18.98; p <.01), uterine pathologies (aOR 3.34; 95% CI, 1.10-10.12; p = .03), and adnexal pathologies (aOR 2.76; 95% CI, 1.19-6.40; p = .02). With the inclusion of intraoperative factors, surgical adhesions were also found to be associated with conversion (aOR 3.19; 95% CI, 1.30-7.85; p = .01). Most skilled laparoscopic surgeon level as defined by the Australasian Gynaecological Endoscopy and Surgery Society was not associated with conversion risk. Conversion to laparotomy was associated with a higher rate of intraoperative and postoperative complications and prolonged length of stay.
Conversion to laparotomy is a rare but very important clinical outcome measure of laparoscopic surgery. Understanding the factors contributing to conversion and perioperative outcomes may help clinicians to identify and counsel patients before surgery and to reduce surgical morbidity.

暂无摘要。

BACKGROUND: Sinistroposition of the gallbladder, or true left-sided gallbladder (LSG) without situs viscerum inversus, is a rare congenital anatomical variant where the gallbladder is located to the left of round/falciform ligament. It can be associated with anomalies of the biliary tree, portal system and hepatic vascularization. The surgical management of a LSG could be challenging even for an experienced operator, being usually an incidental intraoperative finding.
METHODS: A 72 years old woman was admitted to our emergency department because of acute cholecystitis. There were no pre-operative indications of sinistroposition of the gallbladder and its aberrant position was discovered during the explorative laparoscopy; because of the unusual anatomy and chronic flogosis, the laparoscopic approach was converted to open surgery. The patient underwent a successful intervention and was discharged after 4 days without complications. Her family history revealed a daughter with biliary atresia.
CONCLUSIONS: LSG could remain undetected at preoperative imaging, but today, with advances in diagnostic imaging, the report of this condition has increased. Several hypothesis suggest the presence of an underlying embriologic mechanism for LSG and its associated anomalies, but its etiology is still unknown. The association with the daughter\'s biliary atresia makes reasonable a possible genetic correlation with this condition.
CONCLUSIONS: In case of LSG, laparoscopic cholecystectomy could be feasible and safe, but with an increased risk of injury to the major biliary structures, mostly in case of severe and chronic inflammation of the gallbladder. Surgeons have to know this variant because of its associated hepatic anomalies.
UNASSIGNED: Cholecystectomy, Emergency Surgery, Left-Sided-Gallbladder.
La collocazione a sinistra della colecisti consiste nella localizzazione del viscere sul terzo segmento epatico, a sinistra rispetto al legamento rotondo/falciforme del fegato e in assenza di situs viscerum inversus. Questa è una condizione congenita molto rara (la prevalenza riportata in letteratura è compresa tra lo 0,04 e l’1,1%) e può essere associata ad anomalie dell’albero biliare, del sistema portale e della vascolarizzazione epatica. Il management chirurgico non è semplice, anche per operatori esperti, perché spesso la diagnosi avviene intraoperatoriamente. In questo articolo si riporta il caso di una paziente di 72 anni con la colecisti situata a sinistra che è stata sottoposta ad intervento di colecistectomia in regime di urgenza per un quadro di colecistite acuta. L’unico fatto degno di nota nell’anamnesi familiare della paziente era rappresentato da una figlia deceduta a pochi mesi di vita per atresia biliare. L’ecografia dell’addome eseguita in urgenza aveva rilevato distensione della colecisti, con pareti ispessite e presenza di calcolo a livello infundibolare, senza tuttavia evidenziarne anomalie di posizione né ulteriori varianti anatomiche associate. L’intervento è stato iniziato con tecnica laparoscopica, ma l’estesa sindrome aderenziale, nonchè la posizione anomala della colecisti, non rendevano possibile una corretta esposizione del triangolo di Calot, per cui l’intervento è stato convertito con approccio laparotomico mediante incisione sottocostale destra. Questo ha reso possibile un corretto riconoscimento delle strutture dell’ilo epatico, evidenziando il posizionamento a sinistra della colecisti con confluenza del dotto cistico sul lato destro del dotto epatico principale e quindi permettendo una più sicura legatura dell’arteria cistica e del dotto cistico. La paziente è stata dimessa dopo quattro giorni, senza complicanze. La Risonanza Magnetica eseguita due settimane dopo la dimissione ha confermato gli esiti della colecistectomia con il letto della colecisti situato a sinistra rispetto al legamento rotondo/falciforme e non ha evidenziato ulteriori anomalie anatomiche epatiche associate. Questa anomalia nella collocazione della colecisti spesso non viene evidenziata alla diagnostica preoperatoria, anche se il suo riscontro risulta in aumento a causa degli avanzamenti tecnici dell’imaging diagnostico. Sono state formulate alcune ipotesi eziopatogenetiche che potrebbero essere alla base di questa condizione e delle altre anomalie anatomiche ad essa associate. Un aspetto peculiare del caso descritto consiste nel dato anamnestico della figlia deceduta a pochi mesi di vita per atresia biliare, un’altra anomalia molto rara del sistema biliare la cui origine è ancora oggetto di studio. Benchè queste due condizioni siano molto rare e quindi difficili da studiare, la loro possibile associazione potrebbe aprire nuovi scenari eziopatogenetici per entrambe. In conclusione, in caso di colecisti collocata a sinistra, la colecistectomia laparoscopica potrebbe essere una procedura sicura e fattibile, anche se in presenza di un aumentato rischio di complicanze, a causa delle possibili anomalie epatiche associate. La conversione laparotomica va sempre considerata nei casi in cui l’anatomia non sia ben riconoscibile, specialmente in casi di flogosi intensa.

OBJECTIVE: To evaluate the incidence, risk factors and outcomes of conversion from laparoscopic to open surgery in geriatric patients with colorectal cancer (CRC).
METHODS: All patients subjected to laparoscopic procedures for CRC between 2006 and 2018 were included. Patients older than 70 were divided into these necessitating or not necessitating conversion to open surgery (Con>70 and Lap>70 groups, respectively), and those younger than 70 requiring conversion were evaluated in Con<70 group. The results were compared between Con>70 group and the two other groups.
RESULTS: Conversion was significantly more common in Con>70 group than Con<70 group (17.3 vs 9.6%, p=0.011). Although female gender and T4 tumors leading to multivisceral resection were significant risk factors for conversion in univariate analysis, multivariate analysis denied any variable as significant. Perioperative outcomes were significantly worse in Con>70 group than those in Lap>70 group. When conversion groups were compared, the rates of surgical site infection and evisceration were higher in geriatric patients. Pathological results revealed that Con>70 group had more advanced tumors than Lap>70 group regarding pT stage, number of malignant lymph nodes and perineural invasion rate. However, the numbers of harvested lymph nodes were similar in two groups.
CONCLUSIONS: Conversion rate is higher in geriatric patients, particularly in female patients and those who necessitate multivisceral resections. Conversion worsens the perioperative outcomes in geriatric patients. Finally, since the number of harvested lymph nodes does not decrease with conversion, it probably does not threaten the quality of oncological surgery.

Combined laparoscopic resection of liver metastases and colorectal cancer (LLCR) may hold benefits for selected patients but could increase complication rates. Previous studies have compared LLCR with liver resection alone. Propensity score-matched studies comparing LLCR with laparoscopic colorectal cancer resection (LCR) alone have not been performed.
A multicenter, case-matched study was performed comparing LLCR (2009-2016, 4 centers) with LCR alone (2009-2016, 2 centers). Patients were matched based on propensity scores in a 1:1 ratio. Propensity scores were calculated with the following preoperative variables: age, sex, ASA grade, neoadjuvant radiotherapy, type of colorectal resection and T and N stage of the primary tumor. Outcomes were compared using paired tests.
Out of 1020 LCR and 64 LLCR procedures, 122 (2 × 61) patients could be matched. All 61 laparoscopic liver resections were minor hepatectomies, mostly because of a solitary liver metastasis (n = 44, 69%) of small size (≤ 3 cm) (n = 50, 78%). LLCR was associated with a modest increase in operative time [206 (166-308) vs. 197 (148-231) min, p = 0.057] and blood loss [200 (100-700) vs. 75 (5-200) ml, p = 0.011]. The rate of Clavien-Dindo grade 3 or higher complications [9 (15%) vs. 13 (21%), p = 0.418], anastomotic leakage [5 (8%) vs. 4 (7%), p = 1.0], conversion rate [3 (5%) vs. 5 (8%), p = 0.687] and 30-day mortality [0 vs. 1 (2%), p = 1.0] did not differ between LLCR and LCR.
In selected patients requiring minor hepatectomy, LLCR can be safely performed without increasing the risk of postoperative morbidity compared to LCR alone.

OBJECTIVE: To introduce a \'kidney priority\' strategy in treating large renal angiomyolipoma (RAML) with retroperitoneal laparoscopic nephron sparing surgery (RLNSS).
METHODS: From 2010 to 2017, 41 patients with large RAML underwent RLNSS. Distinguished from the standard practice, the kidney was preferentially mobilized and separated from the RAML. Subsequently, it was reconstructed. Finally, the RAML was resected from the perinephric fat. The perioperative variables, surgical technique and complications were reviewed. Patients were followed up with ultrasonography and computed tomography.
RESULTS: RLNSS was successfully performed in 35 patients with four conversions to open surgery and two conversions to nephrectomy, respectively. Eight patients required an intraoperative blood transfusion. Seven patients experienced postoperative complications, including one wound infection, one urinary tract infection, one pneumonia, one urinary fistula and three hemorrhage. The median operation time was 167min (range, 95-285min), the median warm ischemia time was 21 min (range, 0-40 min), and the median estimated blood loss was 200 ml (range, 30-2500 ml). The median postoperative stay was 6.5 days (range, 3-11 days). Angiomyolipoma was confirmed pathologically in all patients. Median serum creatine increased after surgery, from 0.7 mg/dl (range, 0.4-1.1 mg/dl) preoperatively to 0.8 mg/dL (range, 0.5-1.4 mg/dl) postoperatively (P = 0.016). No patient required dialysis, and no recurrence was observed after a median follow-up of 35 months (range, 3-85 months).
CONCLUSIONS: RLNSS is a safe, feasible, effective and minimally invasive procedure to manage large RAML in selected patients.

BACKGROUND: Morgagni Larray hernia (MLH) is a very rare disease, which accounts for less than 5% of all congenital diaphragmatic hernias. Laparoscopic repair has been widely used and accepted as a treatment option for patients with this disease. The purpose of our study is to analyze the outcomes of patients with MLH who underwent laparoscopic repair, and to evaluate their postoperative course for outcome, morbidity, and mortality.
METHODS: A retrospective chart review was performed of patients who were diagnosed with MLH and treated laparoscopically by 10 board-certified pediatric surgeons.
RESULTS: Fourteen patients were included in the study. One patient died 1 month postoperatively due to respiratory complications unrelated to the surgery. Thirteen patients were followed for a median of 1.75 years (interquartile 0.3-6.95). There was a single recurrence, which resulted in a partial resection of the hernia sac and repaired without a mesh. We had a success rate of 92.86%.
CONCLUSIONS: MLH is a rare congenital diaphragmatic hernia that is usually diagnosed incidentally. Laparoscopic repair has high success rates and is a viable option for patients with this pathology.