Takuya Saito

Introduction: We have developed a stapler repair technique as an endoscopic retromuscular strategy for ventral hernia repair. Because transversus abdominis release before stapled fascial closure is technically difficult in this technique, preoperative reduction of fascial tension may be valuable even in moderate‐sized hernias. Botulinum toxin A may address this limitation, but its necessity and appropriate dosing in Asian patients remain unclear. Methods: This prospective, single‐center study included 10 patients with midline ventral hernias ≥ 5 cm in width. Ultrasound‐guided botulinum toxin A was injected into the bilateral lateral abdominal wall muscles using a weight‐adjusted dose of 200 units of Botox Vista for patients weighing ≥ 50 kg and 100 units for those weighing < 50 kg. Surgery was scheduled 4 weeks later, and endoscopic retromuscular repair using the stapler repair technique was the preferred approach. CT‐based changes in defect width and muscle length, surgical outcomes, and treatment‐related adverse events were evaluated. Results: Eight patients underwent endoscopic repair, one open repair, and one intraperitoneal onlay mesh plus repair. Median defect width decreased from 5.7 to 4.5 cm ( p = 0.004), and lateral abdominal wall muscles significantly elongated bilaterally. No treatment‐related adverse events occurred. Primary fascial closure was achieved in all patients, with no recurrence during a median follow‐up of 12 months. Conclusion: Weight‐adjusted preoperative botulinum toxin A was safe and produced favorable CT‐based morphological changes. These changes may reduce fascial tension before stapled closure and help expand the applicability of the stapler repair technique to selected patients with moderate‐sized ventral hernias.

Purpose Video-based learning, a form of nonsynchronous imitation, is widely used in robotic surgical training. However, the effectiveness of synchronous imitation, in which trainees replicate expert movements in real time, remains unclear. This study aimed to evaluate the effect of synchronous imitation on robotic surgical skill acquisition. Methods A randomized-controlled trial was conducted with 20 novices in robotic surgery, between April 2023 and March 2024. Participants were stratified by suturing experience and randomly assigned to either the synchronous or nonsynchronous group. The training task was “Thread the Rings” on the da Vinci Skills Simulator. Before each of the 10 trials, participants in the synchronous group watched a recorded expert demonstration and attempted to mimic instrument movements in real time. In contrast, the nonsynchronous group viewed the same video passively without simultaneous imitation. Proficiency scores (0–100) were calculated automatically for each trial. Results Both groups demonstrated improvement over time; however, mixed-effects regression models showed no significant difference in the rate of score improvement between the two groups (P = 0.88). Conclusions Synchronous imitation did not lead to superior skill acquisition compared with video-based observations alone. Further research with a larger sample size is warranted to validate these findings.

Esophageal bypass surgery is a palliative option for patients with unresectable esophageal cancer who present with severe obstruction or esophago-respiratory fistula. Although it is highly invasive and associated with frequent postoperative complications, in selected cases, it may support completion of curative-intent therapies. We present a rare case of long-term survival after esophageal bypass performed prior to definitive chemoradiotherapy (CRT). A 55-year-old woman presented with progressive dysphagia. Endoscopy revealed a circumferential type 2 mass in the mid-esophagus, which could not be traversed. Biopsy confirmed squamous cell carcinoma. Computed tomography (CT) demonstrated a 4 cm mass just below the tracheal bifurcation with suspected bilateral bronchial invasion and multiple mediastinal nodal metastases, staged as cT4bN2M0 (stage IVA). Gastrostomy was initially performed due to poor oral intake, followed by two cycles of docetaxel, cisplatin, and 5-fluorouracil (DCF) as neoadjuvant chemotherapy. Although tumor shrinkage was achieved, residual bronchial invasion rendered the lesion unresectable. To secure oral intake and maintain performance status, laparoscope-assisted esophageal bypass with a cervical gastric tube and Roux-en-Y reconstruction (modified Kirschner procedure) was performed. The postoperative course was uneventful. One month later, the patient underwent definitive CRT (50 Gy with concurrent cisplatin and 5-fluorouracil), followed by four additional cycles of chemotherapy. A complete clinical response was confirmed, and the patient remains disease-free at five years after treatment. Esophageal bypass surgery, when carefully indicated in patients with good performance status, can enable continuation of CRT by stabilizing oral intake and preserving quality of life. Although bypass does not directly improve oncologic outcomes, in selected cases, it may indirectly contribute to long-term survival by supporting completion of curative treatment.

Purpose During laparoscopic inguinal hernia repair, the inferior epigastric vessels (IEVs), vas deferens, and spermatic vessels are often used as landmarks for horizon adjustment during camera navigation. The present study investigated the visual angle of landmarks around the internal inguinal ring using recorded video clips. Methods The angle of the IEVs, vas deferens, spermatic vessels, and the degree of lateral tilt of the scope were measured using a video clip. The angle of the median line of the vas deferens and spermatic vessels (MVS) was also calculated. Results Between 2018 and 2022, 70 inguinal hernia lesions underwent robot-assisted inguinal hernia repair. Under adjustment according to lateral tilt of the scope, the mean angles of the IEVs and MVS were 14.1° laterally (SD = 15.9°) and −1.5° medially (SD = 15.8°), respectively. Conclusion The IEVs and MVS do not always adopt an absolutely vertical course, and some structures run obliquely. The angles of the IEVs and MVS should, therefore, be confirmed at the beginning of the operation to guide horizon adjustment.

Aim: We successfully established the stapler repair technique (SRT), a straightforward laparoscopic Rives‐Stoppa approach utilizing a linear stapler. This study retrospectively evaluated its short‐term outcomes to determine its safety and efficacy.Methods: The surgical outcomes of 87 patients who underwent laparoscopic median incisional hernia repair at our hospital were reviewed between August 2017 and May 2024. Patients were treated with intraperitoneal onlay mesh (IPOM), laparoscopic trans‐abdominal retromuscular (TARM), or SRT.Results: Among these patients, 37 were treated with IPOM, 16 with TARM, and 34 with SRT, with no significant differences in patient characteristics. The median surgical time (range) was 96 min (50–211) for IPOM, 256 min (196–300) for TARM, and 112 min (60–289) for SRT, respectively. The median mesh areas (ranges) were 210 cm² (80–500) for IPOM, 500 cm² (270–780) for TARM, and 379 cm² (176–864) for SRT, respectively. The SRT group had significantly shorter operative times (p < 0.001) and smaller mesh areas (p = 0.005) than the TARM group. Compared to the IPOM group, there was no significant difference in operative time in the SRT group (p = 0.444), but the mesh area was significantly larger (p < 0.001). The SRT group had no significant intraoperative complications or conversions to open surgery.Conclusion: SRT offers a comparable operative time to IPOM and a significantly shorter time than TARM. Additionally, SRT can be performed extraperitoneally with no significant intraoperative complications or conversion to open surgery. These findings suggest that SRT is a safe and effective minimally invasive approach in median laparoscopic incisional hernia repair.

Background: Circulating tumor cells (CTCs) have recently been developed as biomarkers. Several studies have reported on the clinical use of CTCs to assess drug resistance in various cancers. However, sequential and multiple CTC measurements during chemotherapy are relatively rare. We recently reported a transient increase in CTCs early after chemotherapy by sequentially detecting CTCs in a human pancreatic cancer xenograft model in nude mice. Method: In the present study, using a newly developed immunocytology and glass slide-based convenient CTC detection platform, we examined CTC numbers sequentially before, during, and after chemotherapy in the peripheral blood of 14 pancreatic cancer patients, pathological stage (pStage) I-IV, who underwent surgery with preoperative chemotherapy and GS (Gem/S-1) and GnP (Gem/nab-PTX). Results: Among patients with strongly or weakly elevated CTC counts (3–44/5 mL of blood) following GS treatment, four out of six pancreatic cancer patients were judged to have a partial response (PR), and two out of six were deemed to have stable disease (SD) as a clinical response based on the CT image. In contrast, in patients with GnP therapy, three out of four patients showed no CTC response, and these three patients were judged to have progressive disease (PD), while the remaining one patient was judged to have SD in terms of their clinical response. Conclusion: These results suggest that sequential CTC monitoring during preoperative chemotherapy in pancreatic cancer patients can be a helpful liquid biopsy diagnostic tool as a therapeutic marker to predict tumor chemosensitivity and chemoresistance in clinical settings. Further large-scale clinical studies are required to confirm and clarify this hypothesis.

The use of robotic surgery has increased worldwide and has the potential to amplify the surgeon’s skill owing to its versatile functions. However, robotic surgery requires specific skills that differ from laparoscopic surgery, and the field of robotic surgery training systems is underdeveloped. Therefore, to ensure patient safety, a task protocol should be prepared before the introduction of novel robotic surgeries. This article provides the pioneering description of performing robotic sleeve gastrectomy (RSG) through the medial-to-lateral approach, utilising our newly revised protocol. The preliminary clinical results of 10 patients who underwent RSG using the stapling-first technique between June 2021 and March 2023 showed that RSG is safe and feasible and that the implementation of a task protocol is an effective strategy for the safe introduction of a novel robotic surgical technique.

Background: Liposarcomas represent ~9.8–16% of soft tissue sarcomas, with the extremities and retroperitoneum being the primary sites of occurrence. While liposarcoma in the inguinal region is uncommon, few reported cases originate from the retroperitoneum and protrude into the scrotum through the inguinal canal. Here, we present a case of a retroperitoneal liposarcoma with prolapse from the left inguinal canal into the scrotum following hernia repair with a mesh plug. Case presentation: A 55-year-old male patient underwent a CT scan for a suspected recurrent inguinal hernia, which revealed a sizeable adipose-dense tumor by the left kidney extruded through the left inguinal canal surrounding the scrotum. The patient had undergone mesh plug repair for a left inguinal hernia at another hospital one year ago and noticed ipsilateral inguinal swelling after the hernia repair. The patient was referred to our hospital. The tumor resection was completed with combined resection of potentially involved organs: left side colon, left kidney, and left adrenal gland. Also, complete excision of the tumor was accomplished through surgical resection of the posterior wall of the inguinal canal, the mesh plug, and the tumor extending into the scrotum. Given the nearly complete absence of the inguinal canal's posterior wall and the anterior wall’s torn state, sutures were employed to close the external obturator tenosynovitis. Additionally, the inguinal ligament was closed using a tension-free incision technique. Only a mesh was subsequently placed. The resected tumor measured 47 × 30 × 15 cm and 7.5 kg in weight. After surgical resection, a retroperitoneal liposarcoma diagnosis was established. After 2 years and 6 months following the surgical resection, no recurrence has been observed for either liposarcoma or inguinal hernia. Conclusion: The previous inguinal hernia in this case must be a prolapse of retroperitoneal liposarcoma. Thus, it is recommended to conduct a preoperative examination, which should include a CT scan, since the presence of a fatty mass within the hernia may indicate the presence of a retroperitoneal liposarcoma. Even if a preoperative diagnosis cannot be made, a long-term prognosis can be expected if the retroperitoneal liposarcoma can be completely resected at reoperation.