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High-volume hospitals are purported to provide “best” outcomes. We undertook this study to evaluate the outcomes after pancreaticoduodenectomy when high-volume surgeons relocate to a low-volume hospital (ie, no pancreaticoduodenectomies in >5 years). Outcomes after the last 50 pancreaticoduodenectomies undertaken at a high-volume hospital in 2012 (ie, before relocation) were compared with the outcomes after the first 50 pancreaticoduodenectomies undertaken at a low-volume hospital (ie, after relocation) in 2012 to 2013. Patients undergoing pancreaticoduodenectomies at a high-volume vs a low-volume hospital were not different by age or sex. Patients who underwent pancreaticoduodenectomy at the low-volume hospital had shorter operations with less blood loss, spent less time in the intensive care unit, and had shorter length of stay (P < .05 for each); 30-day mortality and 30-day readmission rates were not different. The salutary benefits of undertaking pancreaticoduodenectomy at a high-volume hospital are transferred to a low-volume hospital when high-volume surgeons relocate. The “best” results follow high-volume surgeons.

Background Robotic technology is increasingly utilized in perihilar cholangiocarcinoma treatments, requiring expertise in minimally invasive liver surgeries and biliary reconstructions. These resections often involve vascular and multiple sectoral bile duct reconstructions. Minimally invasive vascular repairs are now emerging with promising outcomes, potentially altering criteria for selecting minimally invasive hepatobiliary tumor resections. In this multimedia article, we describe our technique of robotic portal venous tangential primary reconstruction with right sectoral bile duct unification ductoplasty for the treatment of perihilar cholangiocarcinoma using the robotic approach. Methods The robotic technique was chosen in this operation with preoperative anticipation of needing vascular resection and reconstruction due to left portal vein tumor involvement. Additionally, a Roux-en-Y hepaticojejunostomy to the right anterior and posterior sectoral duct was planned for biliary reconstruction. Proximal and distal vascular control of the portal vein bifurcation was obtained by placing vascular bulldog clamps across the main and right portal veins. Once an R0 vascular margin was obtained on the left portal vein, portal bifurcation was tangentially repaired. Perfusion to the liver was then restored, and left hemihepatectomy with en bloc extrahepatic biliary resection was carried out, followed by Roux-en-Y hepaticojejunostomy reconstruction to the right anterior and posterior sectoral bile ducts, as a single anastomosis. Results The operation was uneventful without vascular or biliary complications. Robotic unification ductoplasty circumvented the need for multiple anastomoses. Conclusion The robotic approach for left-sided perihilar cholangiocarcinoma resections, requiring precise biliovascular management, is safe, feasible, and efficient. This method demonstrates the potential of robotic techniques as an alternative to traditional open surgery.

Introduction Perihilar cholangiocarcinoma is a difficult cancer to treat with frequent vascular invasion, local recurrence, and poor survival. Due to the need for biliary anastomosis and potential vascular resection, the standard approach is an open operation. Suboptimal outcomes after laparoscopic resection had been sporadically reported by high-volume centers. In this first, Trans-Atlantic, multicenter study, we report our outcomes of robotic resection for perihilar cholangiocarcinoma. This is the largest study of its kind in the Western hemisphere. Methods Between 2016 and 2023, we prospectively followed patients undergoing robotic resection for perihilar cholangiocarcinoma at three, high-volume, robotic, liver-surgery centers. Results Thirty-eight patients underwent perihilar cholangiocarcinoma utilizing the robotic technique; Klatskin type-3 was the most common. The median age was 72 years, and 82% of the patients underwent preoperative biliary drainage. Median operative time was 481 minutes with a median estimated blood loss of 200 mL. The number of harvested lymph nodes was seven, and 11 (28%) patients yielded positive lymph nodes. Three patients required vascular reconstruction; 18% of patients had >1 biliary anastomosis. R0 resection margins were achieved in 82% of patients. Clavien-Dindo Grade ≥3 complications were seen in 16% of patients. The length of stay was 6 days. Five patients had an unplanned readmission within 30 days. One patient died within 30 days. With a median follow-up of 15 months, 68% of patients are alive without disease, 13% recurred, and 19% died. Conclusions Application of the robotic platform for perihilar cholangiocarcinoma is safe and feasible with acceptable short-term clinical and oncological outcomes.

IntroductionAs the robotic approach in hepatectomy gains prominence, the need to establish a robotic-specific difficulty scoring system (DSS) is evident. The Tampa Difficulty Score was conceived to bridge this gap, offering a novel and dedicated robotic DSS aimed at improving preoperative surgical planning and predicting potential clinical challenges in robotic hepatectomies. In this study, we internally validated the recently published Tampa DSS by applying the scoring system to our most recent cohort of patients.MethodsThe Tampa Difficulty Score was applied to 170 recent patients who underwent robotic hepatectomy in our center. Patients were classified into: Group 1 (score 1–8, n = 23), Group 2 (score 9–24, n = 120), Group 3 (score 25–32, n = 20), and Group 4 (score 33–49, n = 7). Key variables for each of the groups were analyzed and compared. Statistical significance was accepted at p ≤ 0.05.ResultsNotable correlations were found between the Tampa Difficulty Score and key clinical parameters such as operative duration (p < 0.0001), estimated blood loss (p < 0.0001), and percentage of major resection (p = 0.00007), affirming the score’s predictive capacity for operative technical complexity. The Tampa Difficulty Score also correlated with major complications (Clavien–Dindo ≥ III) (p < 0.0001), length of stay (p = 0.011), and 30-day readmission (p = 0.046) after robotic hepatectomy.ConclusionsThe Tampa Difficulty Score, through the internal validation process, has confirmed its effectiveness in predicting intra- and postoperative outcomes in patients undergoing robotic hepatectomy. The predictive capacity of this system is useful in preoperative surgical planning and risk categorization. External validation is necessary to further explore the accuracy of this robotic DSS.

BackgroundOutcome data on robotic major hepatectomy are lacking. This study was undertaken to compare robotic vs. ‘open’ major hepatectomy utilizing patient propensity score matching (PSM).MethodsWith institutional review board approval, we prospectively followed 183 consecutive patients who underwent robotic or ‘open’ major hepatectomy, defined as removal of three or more Couinaud segments. 42 patients who underwent ‘open’ approach were matched with 42 patients who underwent robotic approach. The criteria for PSM were age, resection type, tumor size, tumor type, and BMI. Survival was individually stratified for hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (IHCC), and colorectal liver metastases (CLM). The data are presented as: median (mean ± SD).ResultsOperative duration for the robotic approach was 293 (302 ± 131.5) vs. 280 (300 ± 115.6) minutes for the ‘open’ approach (p = NS). Estimated Blood Loss (EBL) was 200 (239 ± 183.6) vs. 300 (491 ± 577.1) ml (p = 0.01). There were zero postoperative complications with a Clavien–Dindo classification ≥ III for the robotic approach and three for the ‘open’ approach (p = NS). ICU length of stay (LOS) was 1 (1 ± 0) vs. 2 (3 ± 2.0) days (p = 0.0001) and overall LOS was 4 (4 ± 3.3) vs. 6 (6 ± 2.7) days (p = 0.003). In terms of long-term oncological outcomes, overall survival was similar for patients with IHCC and CLM regardless of the approach. However, patients with HCC who underwent robotic resection lived significantly longer (p = 0.05).ConclusionUtilizing propensity score matched analysis, the robotic approach was associated with a lower EBL, shorter ICU LOS, and shorter overall LOS while maintaining similar operative duration and promoting survival in patients with HCC. We believe that the robotic approach is safe and efficacious and should be considered a preferred alternative approach for major hepatectomy.

Despite increased adoption of the robotic platform for complex hepatobiliary resections for malignant disease, little is known about long-term survival outcomes. This is the first study to evaluate the postoperative outcomes, and short- and long-term survival rates after a robotic hepatectomy for five major malignant disease processes. A prospectively collected database of patients who underwent a robotic hepatectomy for malignant disease was reviewed. Pathologies included colorectal liver metastases (CLM), hepatocellular carcinoma (HCC), Klatskin tumor, intrahepatic cholangiocarcinoma (IHCC), and gallbladder cancer (GC). Data are presented as median (mean ​± ​standard deviation) for illustrative purposes. Of the 210 consecutive patients who underwent robotic hepatectomy for malignant disease, 75 (35 ​%) had CLM, 69 (33 ​%) had HCC, 27 (13 ​%) had Klatskin tumor, 20 (10 ​%) had IHCC, and 19 (9 ​%) had GC. Patients were 66 (65 ​± ​12.4) years old with a BMI of 29 (29 ​± ​6.5) kg/m2. R0 resection was achieved in 91 ​%, and 65 ​% underwent a major hepatectomy. Postoperative major complication rate was 6 ​%, length of stay was four (5 ​± ​4.3) days, and 30-day readmission rate was 17 ​%. Survival at 1, 3, and 5-years were 93 ​%/75 ​%/72 ​% for CLM, 84 ​%/71 ​%/64 ​% for HCC, 73 ​%/55 ​%/55 ​% for Klatskin tumor, 80 ​%/69 ​%/69 ​% for IHCC, 79 ​%/65 ​%/65 ​% for GC. This study suggests a favorable 5-year overall survival benefit with use of the robotic platform in hepatic resection for colorectal metastases, hepatocellular carcinoma, intrahepatic cholangiocarcinoma, Klatskin tumor, and gallbladder cancer. The robotic platform facilitates fine dissection in complex hepatobiliary operations, with a high rate of R0 resections and excellent perioperative clinical outcomes. •First comprehensive US study on outcomes of robotic hepatectomies.•Robotic surgery boosts 5-year survival rates for colorectal liver metastases.•Robotic hepatectomies yield positive results in hepatocellular carcinoma patients.•High survival with robotic resection in patients with cholangiocarcinoma.•Robotic hepatectomy outcomes: lower complications, shorter hospital stays.

Late outcomes after laparoscopic Nissen fundoplication are only now becoming available. This study was undertaken to document late outcomes after laparoscopic Nissen fundoplication. Five hundred ten patients underwent laparoscopic Nissen fundoplication >10 years ago and were prospectively followed. Preoperatively and postoperatively, patients scored the frequency and severity of symptoms (from 0 = never/not bothersome to 10 = always/very bothersome). Symptom scores before and after fundoplication were compared. Median symptom scores are presented. Early after fundoplication, significant improvements were noted in the frequency and severity of symptoms (e.g., for heartburn, from 8 to 0 and from 8 to 0, respectively, P < .001 for each). Late after fundoplication, significant improvements were maintained in the palliation of symptoms (e.g., frequency and severity for heartburn, 2, 1; respectively). At latest follow-up, 89% of patients were pleased with their symptom resolution. With long-term follow-up, laparoscopic Nissen fundoplication durably and significantly palliates symptoms of gastroesophageal reflux disease. This trial promotes the application of laparoscopic Nissen fundoplication.

BackgroundThe increasing use of robotic systems for anti-reflux operations prompted this study to evaluate and compare the efficacy of robotic and Laparo-Endoscopic Single-Site (LESS) approaches.MethodsFrom 2012, 228 robotic fundoplication and 518 LESS fundoplication patients were prospectively followed, analyzing perioperative metrics. Data are presented as median (mean ± SD); significance at p ≤ 0.05.ResultsPatients undergoing a robotic vs. LESS fundoplication were 67 (64 ± 13.7) vs. 61 (59 ± 15.1) years-old with BMIs of 25 (25 ± 3.2) vs. 26 (25 ± 3.9) kg/m2 (p = 0.001 and 1.00, respectively). 72% of patients who underwent the robotic approach had a previous abdominal operation(s) vs 44% who underwent the LESS approach (p = 0.0001). 38% vs. 8% had a re-operative fundoplication (p = 0.0001), 59% vs. 45% had a type IV hiatal hernia (p = 0.0004). Operative duration was 160 (176 ± 76.7) vs. 130 (135 ± 50.5) min (p = 0.0001). There were 0 (robotic) vs. 5 (LESS) conversions to a different approach (p = 0.33). 5 Patients vs. 3 patients experienced postoperative complications (p = 0.06), and length of stay (LOS) was 1 (2 ± 2.6) vs. 1 (1 ± 3.2) days (p = 0.0001). Patient symptomatic dysphagia preoperatively for the robotic vs. LESS approach was scored as 2 (2.4 ± 1.9) vs. 1 (1.9 ± 1.6). Postoperatively, symptomatic dysphagia was scored as 1 (1.5 ± 1.6) vs. 1 (1.7 ± 1.7). The change in these scores was − 1 (− 1 ± 2.2) vs. 0 (− 0.5 ± 2.2) (p = 0.004).ConclusionDespite longer operative times and LOS in older patients, the robotic approach is efficient in undertaking very difficult operations, including patients with type IV or recurrent hiatal hernias. Furthermore, preoperative anti-reflux operations were more likely to be undertaken with the robotic approach than the LESS approach. The patient’s postoperative symptomatic dysphagia improved relatively more than after the LESS approach. The vast majority of patients who underwent the LESS approach enjoyed improved cosmesis, thus, making LESS a stronger candidate for more routine operations. Despite patient selection bias, the robotic and LESS approaches to anti-reflux operations are safe, efficacious, and should be situationally utilized.

Laparoendoscopic single-site (LESS) surgery can be performed without apparent scarring, while maintaining the salutary benefits of conventional laparoscopic surgery. The purpose of this study was to compare patients' preoperative and postoperative perceptions of LESS surgery. Before and after undergoing LESS surgery, 120 patients were given questionnaires; their responses were assimilated and analyzed. Of 120 patients, 62% were female (age, 52 ± 16.6 y), and 54% had prior abdominal surgery. Preoperatively, women and older patients reported heightened appearance dissatisfaction. Preoperatively, most patients would not accept more risk, pain, surgery/recovery times, and/or costs than associated with standard laparoscopy. Postoperatively, patients reported increased satisfaction in their overall and abdominal region appearance. Satisfaction was noted by 92%; satisfaction was related significantly to scar appearance and cosmesis. Preoperatively, patients were most concerned with safety; postoperatively, patients' concerns shifted to cosmetic outcome. LESS surgery provides an opportunity for improved patient satisfaction.