Abstract


Laparoscopic One-Anastomosis Gastric Bypass (OAGB) is a bariatric procedure that combines the principles of restriction and malabsorption, which are achieved by creating a long and narrow gastric pouch and bypassing part of the small bowel (duodenum and part of the jejunum). It is currently the third most common bariatric procedure worldwide; more than19,000 operations (4.8%) are performed per year. OAGB is synonymous with “Mini Gastric Bypass” and “Omega Loop Gastric Bypass”.
There are numerous technical variants for performing OAGB and organizing pre- and postoperative care. This article is based on the approach to bariatric surgery at the Department of General Surgery at Vienna Medical University.
We focus on patient preparation before a bariatric/metabolic procedure with mandatory and optional examinations to decrease the patient’s risk and find the procedure best suited for each individual patient. Next, the surgical technique itself is described, including positioning of the patient, positioning of the trocars and related tips, tricks, and technical highlights, as well as the specifics of the postoperative course.
OAGB is an effective procedure for weight loss and remission of comorbidities with a low risk of malnutrition for patients with good compliance. For OAGB to be successful, important technical steps such as a long and narrow pouch, exact length of the biliopancreatic limb and hiatoplasty, if necessary, should be taken. In terms of post-operative care, regular check-ups are vital to ensure a positive outcome in long-term follow-up and the early detection of adverse developments.

Abstract


Introduction: While the well-known DaVinci ® robotic system (Intuitive Surgical, Inc., Sunnyvale, CA) uses 8 mm articulated instruments, the Senhance ® robotic system (TransEnterix, Morrisville, NC), available since 2016, uses 5 mm instruments, which is the standard size in laparoscopy. We report here the first 43 procedures using 5 mm articulating instruments with the Senhance ® system (TransEnterix).
Methods: From September 9, 2019, to January 15, 2020, we performed 43 various robotic-assisted abdominal procedures. Before the first clinical intervention, the surgeons and surgical nurses were trained in the handling and operation of the articulating instruments. The main procedure was Inguinal Hernia Repair with the TAPP technique. We performed the operations with a 5 mm articulating bipolar forceps and a 5 mm articulating needle holder. In all cases, the Senhance ® (TransEnterix) articulating instruments were inserted through a 5 or 10 mm trocar, connected to the robotic arm and used for tissue dissection (inguinal hernia repair, cholecystectomy, and sigmoid resection) on the left hand of the robot arm and for suturing (inguinal hernia repair) on the right hand of the robot arm.
Results and Discussion: We observed technical issues in three patients: two resulted from user error and one occurred due to a software update. No technical issues were observed in the remaining 40 cases. There were two unscheduled conversions to laparoscopic surgery and no conversions to open surgery. No case of damage to surrounding tissue was observed. In one case, the branches of the grasper were jammed due to severe clot buildup after extensive coagulation following a strong bleed. After unproblematic laparoscopic bleeding control, robotic surgery was continued. There were no further intraoperative or early postoperative complications. The first impression of the participating surgeons and surgical nurses was that the smaller instruments were easy to handle after special training and offered a wider range of movement within the surgical field. All of the surgeons involved saw advantages with the use of 5 mm articulating instruments.
Conclusion: Senhance ® (TransEnterix) 5 mm articulating instruments are technically stable and can be safely used in various abdominal procedures. The initial results suggest that these 5 mm articulating instruments can be a supportive tool in further robotic surgery, providing advantages in suturing and dissection with less risk of injury to surrounding tissue.

Abstract


Positive identification of the biliary anatomy is a crucial step during laparoscopic cholecystectomy to prevent iatrogenic biliary injuries. While it is usually quite straightforward in elective cholecystectomies, it may be very challenging in an emergency setting, when inflammation and adhesions at the gallbladder pedicle make identification of the common bile duct a difficult and risky manoeuvre. Indocyanine green (ICG) is a dye that, when injected intravenously at 0.2-0.5 mg/kg, concentrates in the bile and becomes fluorescent under near-infrared light. When administered well in advance, ideally 24 hours before the procedure, ICG is completely cleared by the liver and reaches a good concentration in the bile, thus allowing a good fluorescence-cholangiogram. Unfortunately, in emergency cholecystectomy―when it would be most needed―the injection of ICG cannot be planned with such long notice. However, even when injected less than 1 hour before the operation, ICG may be able to reach a sufficient concentration in the bile.
This report shows that ICG-fluorescence can be helpful in identifying the extrahepatic biliary anatomy during the dissection of Calot’s triangle in both elective and emergency cases.

Abstract


Hepatocellular carcinoma (HCC) and secondary hepatic malignancies, most often arising from colorectal cancer, are a leading cause of morbidity and cancer-related deaths worldwide. In lieu of first-line surgical resection, which is precluded in more than 75% of cases due to underlying comorbid conditions or locally advanced disease, several minimally-invasive transarterial and thermal ablation procedures have emerged as safe and effective alternative therapies in select patients. Among the thermal ablative techniques, microwave ablation (MWA) has become the preferred treatment modality because of its operational convenience and superior heating profile, allowing for larger ablation zones and reduced treatment times while maintaining high technical success rates. To date, MWA has been demonstrated to provide equivalent, and in some cases improved, clinical outcomes compared to radiofrequency ablation (RFA) in patients with inoperable HCC or oligometastatic disease. Active areas of investigation include the comparison of MWA and transarterial therapies, such as transarterial chemoembolization (TACE), as well as combined multimodality therapies. Here we review the emerging topic of MWA for the treatment of hepatic malignancies by examining staging and treatment strategies, available technologies, procedural protocol and technique, and clinical outcomes.

Abstract


Background: The prognostic factors for long-term survival after curative resection of pancreatic adenocarcinoma are still poorly understood. The purpose of this study was to identify the prognostic factors of long-term survival after resection of pancreatic adenocarcinoma based on actual 5-year survival including different lymph node status classifications.
Method: A total of 106 patients who underwent pancreatectomy were enrolled at our institution and retrospectively analyzed according to actual survival (> vs < 5 years), as well as several currently available node classifications: N0/N1, N0/N1/N2, and lymph-node ratio (LNR) including multivariate logistic regression.
Results: The actual 5-year overall survival rate of the series was 12.26%. In a univariate analysis, operative blood loss and blood transfusion, completion of adjuvant treatment, histological differentiation, perineural invasion, N0/N1, N0/N1/N2 and LNR were significant predictive factors for actual long-term survival. A multivariate analysis showed that only N0/N1 was an independent predictive factor for actual 5-year survival (OR: 1.593; 0.730-1.325; p= 0.264).
Conclusion: The nodal involved status is the strongest independent unfavorable factor for actual long-term survival after pancreatic resection for adenocarcinoma.