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BackgroundNew platforms for robotic surgery have recently become available for clinical use; however, information on the introduction of new surgical robotic platforms compared with the da Vinci™ surgical system is lacking. In this study, we retrospectively determined the safe introduction of the new “hinotori™” surgical robot in an institution with established da Vinci surgery using four representative digestive organ operations.MethodsSixty-one patients underwent robotic esophageal, gastric, rectal, and pancreatic operations using the hinotori system in our department in 2023. Among these, 22 patients with McKeown esophagectomy, 12 with distal gastrectomy, 11 with high- and low-anterior resection of the rectum, and eight with distal pancreatectomy procedures performed by hinotori were compared with historical controls treated using da Vinci surgery.ResultsThe console (cockpit) operation time for distal gastrectomy and rectal surgery was shorter in the hinotori group compared with the da Vinci procedure, and there were no significant differences in the console times for the other two operations. Other surgical results were almost similar between the two robot surgical groups. Notably, the console times for hinotori surgeries showed no significant learning curves, determined by the cumulative sum method, for any of the operations, with similar values to the late phase of da Vinci surgery.ConclusionsThis study suggests that no additional learning curve might be required to achieve proficient surgical outcomes using the new hinotori surgical robotic platform, compared with the established da Vinci surgery.

Background Endoscopic management of leaks/fistulas after laparoscopic sleeve gastrectomy (LSG) is gaining popularity in the bariatric surgery. Objectives This study aimed to review the efficacy and safety of over-the-scope-clip (OTSC) system in endoscopic closure of post-LSG leak/fistula. Methods PubMed/Medline and major journals of the field were systematically reviewed for studies on endoscopic closure of post-LSG leaks/fistula by means of the OTSC system. Results A total of ten eligible studies including 195 patients with post-LSG leaks/fistula were identified. The time between LSG and leak/fistula ranged from 1 day to 803 days. Most of the leaks/fistula were located at the proximal staple line, and they sized from 3 to 20 mm. Time between leak diagnosis and OTSC clipping ranged from 0 to 271 days. Thirty-three out of 53 patients (63.5%) required one clip for closure of the lesion. Regarding the OTSC-related complications, a leak occurred in five patients (9.3%) and OTSC migration, stenosis, and tear each in one patient (1.8%). Of the 73 patients with post-LSG leak treated with OTSC, 63 patients had an overall successful closure (86.3%). Conclusion OTSC system is a promising endoscopic approach for management of post-LSG leaks in appropriately selected patients. Unfortunately, most studies are series with a small sample size, short-term follow-up, and mixed data of concomitant procedures with OTSC. Further studies should distinguish the net efficacy of the OTSC system from other concomitant procedures in treatment of post-LSG leak.

Background The transanal minilaparoscopy-assisted natural orifice transluminal endoscopic surgery (NOTES) approach holds significant promise as a safe and less morbid alternative to conventional low anterior rectal resection. Previous reports have shown satisfactory short-term oncologic results. We evaluated the safety and short-term outcomes in rectal cancer subjects who underwent transanal minilaparoscopy-assisted natural orifice surgery total mesorectal excision (TME) rectal resection. Methods Twenty selected patients with rectal cancer were enrolled onto a prospective study of minilaparoscopy-assisted natural orifice surgery TME rectal resection. The study endpoints were safety of access (intra- or postoperative morbidity) and adequacy of oncological resection criteria; intact TME; distal and circumferential margins; and number of lymph nodes retrieved. Results All procedures were successfully completed with the transanal NOTES and minilaparoscopy technique. The mean age was 65 ± 10 years; 55 % of patients were male; the mean body mass index was 25.3 ± 3.8 kg/m 2 . Thirty-five percent of tumors were in the distal rectum, 50 % in midrectum, and 15 % in proximal rectum. Coloanal anastomoses were hand sewn in 65 % and stapled in 35 %. Mean operative time was 235 ± 56 min. There were no procedure-related complications. Pathologic analysis demonstrated negative distal and circumferential margins in all patients. An average of 15.9 ± 4.3 lymph nodes were retrieved. The mesorectal fascia was intact in all the specimens. Conclusions This study demonstrates that transanal NOTES with minilaparoscopic assistance in the hands of a specialized team is safe; meets the oncologic requirements for high-quality rectal cancer surgery; and may offer advantages over pure laparoscopic approaches for visualizing and dissecting out the distal mesorectum. Minilaparoscopic assistance allows one to compensate for the limitations of current NOTES instrumentation to ensure the safety and adequacy of oncologic resection in these difficult cases. Careful patient selection, a specialized team, and long-term outcome evaluation are critical before this procedure can be considered for routine clinical use.

Anastomosis formation constitutes a critical aspect of many gastrointestinal procedures. Barbed suture materials have been adopted by some surgeons to assist in this task. This systematic review and meta-analysis compares the safety and efficacy of barbed suture material for anastomosis formation compared with standard suture materials. An electronic search of Embase, Medline, Web of Science and Cochrane databases was performed. Weighted mean differences were calculated for effect size of barbed suture material compared with standard material on continuous variables and pooled odds ratios were calculated for discrete variables. There were nine studies included. Barbed suture material was associated with a significant reduction in overall operative time (WMD: -12.87 (95% CI = -20.16 to -5.58) ( = 0.0005)) and anastomosis time (WMD: -4.28 (95% CI = -6.80 to -1.75) ( = 0.0009)). There was no difference in rates of anastomotic leak (POR: 1.24 (95% CI = 0.89 to 1.71) ( = 0.19)), anastomotic bleeding (POR: 0.80 (95% CI = 0.29 to 2.16) ( = 0.41)), or anastomotic stricture (POR: 0.72 (95% CI = 0.21 to 2.41) ( = 0.59)). Use of barbed sutures for gastrointestinal anastomosis appears to be associated with shorter overall operative times. There was no difference in rates of complications (including anastomotic leak, bleeding or stricture) compared with standard suture materials.

Background: Different surgical techniques have been indicated for the management of Zenker's diverticulum (ZD), including diverticulectomy, diverticulopexy, and diverticular inversion, with or without myotomy, and myotomy alone. More recently, minimally invasive techniques (such as the transoral endoscopic approach) have become increasingly reliable for this disorder. We therefore conducted this systematic review in order to gain a profound understanding of the current trend and evidence in surgical management of ZD. Methods: Medline and PubMed were searched to identify studies on surgical intervention of ZD published in English between January 1990 and March 2011. Results: We identified 6,915 patients from 93 studies evaluating the effect of the surgical intervention for ZD. No randomized controlled trials comparing one technique with another were identified. Conclusion: Diverticulectomy with myotomy has become the mainstream treatment option for ZD. In certain selected patients, endoscopic diverticulotomy may offer some advantages over open surgery, such as less trauma and a lower complication rate. It is important to individualize optimal therapy for each patient. More randomized controlled trials with long-term follow-up results are required to draw a valid conclusion on the best surgical intervention modality for ZD.

BackgroundLaparoscopic and endoscopic surgery has undergone vast progress during the last 2 decades, translating into improved patient outcomes. A prime example of this development is the use of magnetic devices in gastrointestinal surgery. Magnetic devices have been developed and implemented for both laparoscopic and endoscopic surgery, providing alternatives for retraction, anchoring, and compression among other critical surgical steps. The purpose of this review is to explore the use of magnetic devices in gastrointestinal surgery, and describe different magnetic technologies, current applications, and future directions.MethodsIRB approval and written consent were not required. In this review of the existing literature, we offer a critical examination at the use of magnets for gastrointestinal surgery currently described. We show the experiences done to date, the benefits in laparoscopic and endoscopic surgery, and additional future implications.ResultsMagnetic devices have been tested in the field of gastrointestinal surgery, both in the contexts of animal and human experimentation. Magnets have been mainly used for retraction, anchoring, mobilization, and anastomosis.ConclusionResearch into the use of magnets in gastrointestinal surgery offers promising results. The integration of these technologies in minimally invasive surgery provides benefits in various procedures. However, more research is needed to continually evaluate their impact and implementation into surgical practice.

Background The growing use of staplers, manual and powered, especially in minimally invasive surgeries, necessitates evaluating their efficacy in gastrointestinal and thoracic surgeries. Parameters analysed include anastomotic and air leakage rates, bleeding, infection, cost, and operative duration. Methods We searched Cochrane Library, CINAHL, EMBASE, PubMed, and Web of Science using terms like “surgical staplers,” “manual staplers,” “automatic staplers,” and “powered staplers.” We assessed study quality using the Joanna Briggs Institute (JBI) Critical Appraisal tools and conducted meta-analysis using Review Manager software. Results A total of 43,104 patients with a mean age of 60.8 were involved in the studies. The meta-analysis revealed a significant reduction in anastomotic leaks in GI surgery patients (OR 0.31, p  = 0.0001) and a significant decrease in postoperative air leakage in thoracic surgery patients (OR 0.65, p  = 0.05) when powered staplers were employed. Additionally, we observed a significant decline in hemostasis-related complications for both thoracic and GI surgeries (OR 0.48, p  = 0.002) with the use of powered staplers. Although individually costlier than manual staplers, powered staplers significantly decreased total hospitalisation costs (MD -1725.82, p  < 0.00001) amoungst the thoracic surgeries, due to the cost saved on remedying the lower rate of complications compared to manual staplers. It also decreased the average operative times in thoracic and GI surgeries, although not significant ( p  = 0.06, p  = 0.07 respectively). Conclusion Powered staplers surpass manual staplers by reducing operative duration, total hospital costs, and complications like anastomotic leaks and bleeding. Hence, they are poised to become the preferred alternative in future surgeries.

Laparoscopic rectal cancer surgery involving rectal division with intracorporeal stapling devices is technically difficult. This study aimed to identify risk factors for anastomotic leakage associated with laparoscopic anterior resection for rectal cancer. We studied 363 patients who underwent laparoscopic anterior resection with intracorporeal rectal transection and double-stapling technique (DST) anastomosis for rectal cancer between July 2005 and February 2010. Twenty-two independent clinical variables were examined by univariate and multivariate analyses. The outcome of interest was clinical anastomotic leakage. Anastomotic leakage was identified in 13 (3.6%) patients. Multivariate analysis identified middle/lower rectal cancer (odds ratio, 9.446) and lack of pelvic drain (odds ratio, 3.814) as independent predictive factors for anastomotic leakage. The number of cartridges used for rectal division had no significant impact on anastomotic leakage. Laparoscopic anterior resection involving intracorporeal rectal transection and DST anastomosis is safe if performed using an appropriate technique.

Background The da Vinci ® Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) is a computer-assisted (robotic) surgical system designed to enable and enhance minimally invasive surgery. The Food and Drug Administration (FDA) has cleared computer-assisted surgical systems for use by trained physicians in an operating room environment for laparoscopic surgical procedures in general, cardiac, colorectal, gynecologic, head and neck, thoracic and urologic surgical procedures. There are substantial numbers of peer-reviewed papers regarding the da Vinci ® Surgical System, and a thoughtful assessment of evidence framed by clinical opinion is warranted. Methods The SAGES da Vinci ® TAVAC sub-committee performed a literature review of the da Vinci ® Surgical System regarding gastrointestinal surgery. Conclusions by the sub-committee were vetted by the SAGES TAVAC Committee and SAGES Executive Board. Following revisions, the document was evaluated by the TAVAC Committee and Executive Board again for final approval. Results Several conclusions were drawn based on expert opinion organized by safety, efficacy, and cost for robotic foregut, bariatric, hepatobiliary/pancreatic, colorectal surgery, and single-incision cholecystectomy. Conclusions Gastrointestinal surgery with the da Vinci ® Surgical System is safe and comparable, but not superior to standard laparoscopic approaches. Although clinically acceptable, its use may be costly for select gastrointestinal procedures. Current data are limited to the da Vinci ® Surgical System; further analyses are needed.

Background Natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopy are emerging, minimally invasive techniques. Total mesorectal excision (TME), the gold standard treatment for patients with resectable distal rectal tumors, is usually performed in an “up-to-down” approach, either laparoscopically or via open techniques. A transanal, “down-to-up” TME has already been reported. Our NOTES variant of TME ( NOTES TME) is based on a transperineal approach without any form of abdominal assistance. The aim was to reduce further the invasiveness of the procedure while optimizing the anatomical definition of the distal mesorectum. This approach may lead to reduced postoperative pain, decreased hernia formation and improved cosmesis when compared to standard laparoscopy. Methods NOTES TME was attempted in 16 patients with distal rectal neoplasia (i.e., distal edge of the tumor lower than the pouch of Douglas, between 0 and 12 cm from the dentate line). Additional inclusion criteria consisted of an ASA status ≤III and the absence of previous abdominal surgery. Results NOTES TME was completed in all patients. Additional abdominal, single-incision laparoscopic assistance was required in 6 (38 %) patients. Mean operative time was 265 min (range 155–440 min). The morbidity rate was 18.8 % (two small bowel obstructions and one pelvic abscess), requiring re-operation in each case. No leaks occurred, and the mortality rate at 30 and 90 days was 0 %. Resection margins were negative in all patients. A median of 17 nodes (range 12–81) was retrieved per specimen. Mean length of hospital stay was 10 days (range 4–29 days). Patients were followed for an average of 7 months (range 3–23 months). Conclusion NOTES TME was feasible and safe in this series of patients with mid- or low rectal tumors. The short-term mortality and morbidity rates are acceptable, with no apparent compromise in the oncological quality of the resection. Larger, randomized controlled trials with long-term follow-up are warranted.