Luis Gustavo Capochin Romagnolo

Robotic—assisted surgery (RAS) has established itself as an advanced technique in colorectal surgery, providing better postoperative outcomes due to its greater precision and less invasiveness. However, RAS requires dedicated and supervised training to avoid complications in the initial learning curve. This study evaluated the safety and efficacy of a supervised RAS training program focusing on postoperative complications, and its classification according to the Clavien-Dindo (CD) grade. This is a retrospective, single-center cohort study that included only patients undergoing RAS performed by specialized colorectal surgeons in supervised training. Postoperative complications were evaluated according to the CD classification. A total of 226 patients undergoing different colorectal surgical procedures performed between December 2021 and November 2023 were included. Demographic, clinical, and operative data were collected and compared with the results of previously published studies in order to evaluate the efficacy of supervised training. The median age of patients was 58 years and 58.8% of them were male. The most common surgeries were sigmoidectomy (50%) and rectosigmoidectomy with total mesorectal excision (19%). The overall complication rate was 7.5%, and the most frequent were anastomotic fistulas (2.6%) and intraperitoneal abscesses (1.7%). The mean surgical time was 175 min, and the median hospital stay was three days. According to CD classification 10 patients (4, 4%) developed surgical complications classified as CD III, CD V (0, 4%), CD IV (0.8%), CD I (0.8%), CD II (0, 8%). Patients with complications grade III and IV had significantly longer hospital stay. One patient died (0.4%). The complication rates found were comparable to those reported in the international literature, demonstrating that the risk of complications did not increase during well-structured and supervised training. The risk of perioperative complications during supervised and well-structured training in RAS is similar to those reported in the literature.

RESUMO Introdução: Todas as formas de acesso a cavidade peritoneal na laparoscopia possuem riscos de lesionar as estruturas intra-abdominais. Atualmente, a ultrassonografia (USG) está sendo utilizada em diversos procedimentos para direcionar algum tipo de punção: biópsia de mama, acesso venoso central, bloqueios anestésicos de nervos etc. Diante disso, esta pesquisa busca verificar a factibilidade e viabilidade da realização do pneumoperitônio por punção guiada por USG, em um estudo piloto em modelo porcino. Métodos: O estudo experimental foi feito com uma amostra de 10 porcas anestesiadas, no laboratório do IRCAD-América Latina Unidade de Barretos. O experimento consistiu na punção abdominal guiado por USG com transdutor linear para confecção do pneumoperitônio. Após a punção, foi realizado o teste da gota e insuflado CO2 na cavidade, posteriormente, um trocarte de 10mm foi introduzido para inserção da óptica. Os parâmetros a partir do USG foram: as espessuras das camadas da parede abdominal; medida da agulha intraperitoneal; teste da gota; e presença de complicações. Resultados: A mensuração da média das camadas foi de 0,45 centímetros (cm) de subcutâneo, 0,67cm de muscular e 0,15cm de peritônio. A média da medida da agulha intraperitoneal foi de 1,17cm. Ademais, o teste da gota foi positivo em 100% dos casos e não houve sangramento ou lesões em nenhuma tentativa. Conclusão: É factível e seguro a realização de pneumoperitônio guiado por ultrassonografia no modelo porcino. As camadas subcutâneas, muscular e peritônio são identificáveis e mensuráveis no modelo. Estudos subsequentes são necessários para verificar a importância deste novo procedimento.

Introduction: All forms of access to the peritoneal cavity in laparoscopy could damage intra-abdominal structures. Currently, ultrasound (USG) is being used in several procedures to guide needles: breast biopsy, central venous access puncture, anesthetic nerve blocks, etc. Therefore, this research seeks to verify the feasibility and viability of performing pneumoperitoneum using USG-guided puncture in a pilot study using a porcine model. Methods: The cross-sectional study was carried out with a sample of 10 anesthetized sows in the IRCAD-América Latina Barretos Unit laboratory. The experiment consisted of an abdominal puncture guided by USG with a linear transducer to create the pneumoperitoneum. After the puncture, the drop test was performed, and CO2 was insufflated into the cavity. Subsequently, a 10mm trocar was introduced to insert the optic. The parameters from the USG were the thickness of the abdominal wall layers, intraperitoneal needle measurement, drop test, and the presence of complications. Results: The average measurement of the layers was 0.45 centimeters of subcutaneous tissue, 0.67 centimeters of muscle, and 0.15 centimeters of peritoneum. The mean measurement of the intraperitoneal needle was 1.17cm. Furthermore, the drop test was positive in 100% of cases, and there was no bleeding or lesions on any attempt. Conclusion: Ultrasound-guided pneumoperitoneum is feasible and safe in the porcine model. The subcutaneous, muscular, and peritoneum layers are identifiable and measurable in this model. Subsequent studies are necessary to verify the importance of this new procedure.

Background and Objectives: Robotic surgical systems have rapidly become integrated into colorectal surgery practice in recent years, particularly for rectal resections, where the advantages of robotic platforms over conventional laparoscopy are more pronounced. However, as with any technological advancement, the initial high costs can be a limiting factor, leading to unequal health service access, especially in middle- and lower-income countries. Materials and Method: A narrative review was conducted with the objective of providing an overview of the escalating adoption, current training programmes, and certification process of robotic colorectal surgery in Brazil. Results: Brazil has witnessed a rapid increase in robotic platforms in recent years. Currently, there are 106 robotic systems installed nationwide. However, approximately 60% of the medical facilities which adopted robotic platforms are in the Southeast region, which is both the most populous and economically prosperous in the country. The Brazilian Society of Coloproctology recently established clear rules for the training programme and certification of colorectal surgeons in robotic surgery. The key components of the training encompass theoretical content, virtual robotic simulation, observation, assistance, and supervised procedures in colorectal surgery. Although the training parameters are well established, no colorectal surgery residency programme in Brazil has yet integrated the teaching and training of robotic surgery into its curriculum. Thus far, the training process has been led by private institutions and the industry. Conclusion: Despite the fast spread of robotic platforms across Brazil, several challenges still need to be addressed to democratise training and promote the widespread use of these platforms. It is crucial to tackle these obstacles to achieve greater integration of robotic technology in colorectal surgery throughout the country.

Anais do congresso internacional de cases de open innovation () - Harena: Centro De Inovação Aberta Em Um Hospital Oncológico Filantrópico

Background and Objective: Rectal cancer is often surgically treated, but it is still associated with morbidity rates. Minimally invasive techniques are increasingly being used to reduce complications, and the use of such techniques can be found in the literature. This study aims to report our experience in a reference oncology center.Methods: A retrospective cohort study was performed on a prospective database of patients who underwent robotic surgery for rectal cancer using the single‐docking technique from September 2014 to April 2018. Clinical and surgical variables, as well as morbidity and mortality rates, were analyzed.Results: One hundred and two patients underwent robotic surgery. Intraoperative complications occurred in six patients (4.9%), and postoperative complications in 24 patients (23.5%), of which anastomotic fistula represented 3.9%. The conversion rate was 1.96%. Two cases (1.9%) faced death within 30 days. The median length of hospitalization was 3 days. The median number of lymph nodes dissected was 15. Clinical and surgical data were correlated with postoperative complications, and no statistically significant differences were found.Conclusion: Robotic surgery is a safe and feasible approach to manage rectal cancer. The method presents satisfactory results with regard to the rate of operative complications, conversion rate, oncologic outcomes, and length of hospitalization.

The benefits of laparoscopic approaches to treat colorectal cancer (CRC) and colorectal liver metastases (CRLM) separately are well established. However, there is no consensus about the optimal timing to approach the primary tumor and CRLM, whether simultaneously or staged. The objective of this review with practical reports is to discuss technical aspects required for patient selection to perform simultaneous laparoscopic approaches for CRC and CRLM. Literature review of oncological factors associated with patient selection for surgical treatment of CRLM and the use of laparoscopy in those cases, and report of technical aspects for simultaneous CRC and CRLM approaches. Simultaneous laparoscopic resection has been successful in many series of selected patients, although it seems to be safer to perform minor and major liver resection with non-extended colorectal resections, and to avoid two high-risk procedures at the same time. Simultaneous CRC and CRLM resections seem to be safe when patients are carefully selected, also considering the risk of recurrence concerning oncologic outcomes. The pre-planning of simultaneous resection is mandatory to plan trocar positioning, procedure sequencing, and patient position.

Real-time stereotactic navigation for transanal total mesorectal excision has been demonstrated to be feasible in small pilot series using laparoscopic techniques. The possibility of real-time stereotactic navigation coupled with robotics has not been previously explored in a clinical setting.

INTRODUCTION: Technical difficulty and unfamiliar surgical anatomy are the main challenges in transanal total mesorectal excision. Precise 3-dimensional real-time image guidance may facilitate the safety, accuracy, and efficiency of transanal total mesorectal excision. TECHNIQUE: A preoperative CT was obtained with 10 skin fiducials and further processed to emphasize the border of the anatomical structure by 3-dimensional modeling and pelvic organ segmentation. A forced sacral tilt by placing a 10-degree wedge under the patient’s sacrum was induced to minimize pelvic organ movement caused by lithotomy position. An optical navigation system with cranial software was used. Preoperative CT images were loaded into the navigation system, and patient tracker was mounted onto the iliac bone. Once the patient-to-image paired point registration using skin fiducials was completed, the laparoscopic instrument mounted with instrument tracker was calibrated for instrument tracking. After validating the experimental setup and process of registration by navigating laparoscopic anterior resection, stereotactic navigation for transanal total mesorectal excision was performed in the low rectal neuroendocrine tumor. RESULTS: The fiducial registration error was 1.7 mm. The accuracy of target positioning was sufficient at less than 3 mm (1.8 ± 0.9 mm). Qualitative assessment using a Likert scale was well matched between the 2 observers. Of the 20 scores, 19 were judged as 4 (very good) or 5 (excellent). There was no statistical difference between mean Likert scales of the abdominal or transanal landmarks (4.4 ± 0.5 vs 4.3 ± 1.0, p = 0.965). CONCLUSIONS: Application of an existing navigation system to transanal total mesorectal excision for a low rectal tumor is feasible. The acceptable accuracy of target positioning justifies its clinical use. Further research is needed to prove the clinical need for the procedure and its impact on clinical outcomes.