Giovanni Ferrari

Objective: To assess the feasibility of and clinical outcomes after a pan-European training program for robotic pancreatoduodenectomy (RPD). Summary Background Data: The implementation of RPD into clinical practice comes with considerable challenges, leading to concerns about patient safety, oncological outcomes, and costs. To address this, a structured training program was implemented in which 2 surgeons at each of the 20 sites were trained and maintained as a consistent operative team. Study Design: A structured training program for RPD was implemented, and outcomes were prospectively collected in 20 European high-volume centers, all without previous RPD experience, from 12 countries. The program included a video library, biotissue simulation (pancreaticojejunostomy and hepaticojejunostomy), off-site RPD case observations, and on-site proctoring. Surgeons’ simulation anastomoses were assessed using Objective Structured Assessment of Technical Skills (OSATS) and technical errors. The primary endpoint was intra- and postoperative patient outcome. A key secondary analysis assessed safety using OSATS scores and error counts during the biotissue training.. Results: Overall, 486 RPD procedures were performed. Median intraoperative blood loss was 200 mL (IQR: 100–400), operative time was 475 minutes (IQR: 414–553.3), and the conversion rate was 18.3% (n=89). The rate of Clavien-Dindo grade ≥III complications was 31.4% (n=153), POPF was 21.2% (n=103), delayed gastric emptying was 15% (n=73), postpancreatectomy hemorrhage was 8.6% (n=42), and in-hospital/30-day mortality was 2.7% (n=13). Median length of stay was 12 days (IQR: 8–20). During simulation training, OSATS scores significantly improved (0.350 points/attempt ( ρ ), P P P =0.006]). Conclusions: We report on the first successfully completed international training program for RPD. Simulation established a standardized technical competency, although a learning-curve effect (POPF) remained detectable per center. These data highlight that safe adoption of complex procedures requires structured, team-based, proctored training beyond simulation alone.

Background: Although robot-assisted pancreatoduodenectomy (RPD) enhances patient recovery, it could be associated with higher costs than open pancreatoduodenectomy (OPD), potentially limiting its widespread adoption. High-level evidence comparing costs of RPD and OPD is lacking. This analysis in a randomized trial compared costs and cost-effectiveness between RPD and OPD. Methods: Predefined cost-effectiveness analysis in the international randomized DIPLOMA-2 trial (ISRCTN27483786) comparing RPD and OPD in patients with primary resectable neoplasm in 14 centers in 6 European countries (2022–2023). Primary outcomes were mean total hospital costs (euro) at 6 months postoperatively and cost-effectiveness based on costs per quality-adjusted life year (QALY; incremental cost-utility ratio). Three analyses were performed: (1) costs, (2) QALYs including Health-Related Quality of Life (HR-QoL), and (3) cost-effectiveness with probabilities at various willingness-to-pay (WTP) thresholds. Results: Overall, 268 patients were included (170 RPD, 98 OPD). No significant difference in total hospital costs was found between RPD and OPD (€30,956 vs. €28,271, P =0.538). The intraoperative costs were €5,491 higher with RPD (€11,906 vs. €6,451, P P =0.518). The HR-QoL index scores were comparable at 1 and 3 months, but worse at 6 months with RPD (Δ−0.08 [−0.15 to −0.001]). Consequently, over 6 months a QALY loss was observed with RPD (Δ−0.02 [−0.07 to 0.01]) with a <30% probability of RPD being cost-effective across various WTP thresholds. Conclusion: This analysis in a randomized trial found no significant differences in costs between RPD and OPD up to 6 months. Nonsignificantly lower QALYs at 6 months with RPD resulted in a <30% probability that RPD is cost-effective compared with OPD within 6 months after surgery in selected patients in high-volume centers.

Background: Minimally invasive approaches have transformed ventral hernia management, with robotic platforms enhancing challenging techniques like the robotic Transabdominal Retromuscular Umbilical Prosthesis (r-TARUP). While traditionally performed using the da Vinci system, the introduction of the Medtronic Hugo RAS system offers a valuable alternative. We present our first case series with standardized surgical technique for r-TARUP using the Hugo RAS system, detailing operative setup, technical considerations, and initial outcomes. Methods: Between September 2024 and February 2025, we performed 30 r-TARUP procedures using the Hugo RAS system. Preoperative evaluation included imaging and risk factor optimization. The technique involved a lateral retromuscular approach, ipsilateral posterior rectus sheath (PRS) closure, and mesh placement. Patients were discharged the following day, with follow-ups assessing complications and recurrences. Results: The mean hernia dimensions were 3.1±1.0 cm in width and 2.6±0.8 cm in length. Rectus diastasis repair was performed in 57% of cases. Mean operating and docking times were 190.6±61.6 and 15±5.3 minutes, respectively. Two cases required conversion to laparoscopic surgery during peritoneal closure. No complications or recurrences were observed after a mean follow-up of 3.6 (1.7 to 5.3) months. Conclusions: Despite the short follow-up, our experience demonstrates the feasibility and safety of r-TARUP with the Hugo RAS system. Comparable outcomes to other robotic platforms suggest that the Hugo RAS system is a viable alternative for ventral hernia repair, offering technical flexibility and promising short-term results.

Background: Despite benefits during open pancreatoduodenectomy (PD), the artery-first approach (AFA) during minimally invasive PD (MIPD) has been poorly investigated. Methods: Data of consecutive patients undergoing MIPD (both laparoscopic (LPD) and robotic (RPD)) from 2020 to 2024 for pancreatic cancer (PC) were prospectively collected and retrospectively analyzed, comparing the surgical and oncological outcomes of LPD with right AFA and RPD with posterior AFA. The rate of ineffective AFA (IAFA), defined in the case of excessive resection time, estimated blood loss, or conversion to laparotomy, was also investigated. Results: 71 patients undergoing MIPD were selected (32 LPD and 39 RPD). Baseline patients’ characteristics only differed for a higher rate of neoadjuvant treatment in LPD and RPD groups, respectively (23.1% vs. 0%, p = 0.0036). No patients underwent conversion. R0 resection was obtained in 74.6% of patients. No difference between the groups was found regarding intraoperative, postoperative, and oncological outcomes except for a greater number of lymph nodes harvested in RPD (24 vs. 17, p = 0.023). IAFA was observed in 12.7% of patients, without difference between the groups (9.4 vs. 15.4%, p = 0.499, in LPD and RPD, respectively). Conclusions: MIPD with AFA was feasible and safe in patients affected by PC. RPD using posterior AFA had a higher number of lymph nodes retrieved when compared to LPD using right AFA. RPD has provided subjective advantages for the surgeon in terms of handling, safety, and reproducibility, although these have not translated into better outcomes.

Background Complete mesocolic excision (CME) has not gained wide diffusion, mainly due to its technical complexity and unclear oncological benefits. We investigated the long-term outcomes of patients with right-sided colon cancer who underwent CME surgery compared to those treated with conventional surgery (NCME). Methods Prospectively collected data of patients who underwent surgery between 2010 and 2018 were retrospectively analysed. Propensity score matching (PSM) was used to balance baseline characteristics of CME and NCME patients. The primary endpoints of the study were overall and disease-free survival (OS and DFS), distant and local recurrence-free survival (DRFS and LRFS). Results Out of the 444 patients included in the study, 254 were correctly matched after PSM, 127 in each group. The median follow-up was 70 months (IQR 54–81). Conversion rate, complications, and 90-day mortality were comparable in both groups. Five-year LRFS rates for CME patients was 100% and 95% for NCME (log-rank p = 0.044). At 5 years, there were no differences between the two groups in terms of overall survival and disease-free survival. Conclusions Laparoscopic CME for RCC is associated with a significant decrease in terms of LRFS. No benefit on long-term disease-free survival and overall survival was obtained.

Objective: To validate the International Study Group for Pancreatic Surgery (ISGPS) complexity grading system for minimally invasive pancreaticoduodenectomy (MIPD). Background: Although concerns about patient safety persist, MIPD is gaining popularity. The ISGPS recently introduced a difficulty grading system to improve patient selection by aligning procedural complexity with surgeon and center expertise. Methods: Data from MIPD cases reported in the IGOMIPS registry (October 2019–February 2024) were analyzed, with severe postoperative complications as the primary outcome. Logistic regression was used to identify risk factors for complications. Results: Of the 771 MIPD cases, 426 (55.3%) were analyzed. A pancreatic duct size ≤3 mm was the only significant risk factor for severe complications (odds ratio = 2.22, P = 0.0001). Most cases (n = 255; 59.9%) were classified as grade C complexity, whereas 22 (5.1%) were classified as grade A. Severe postoperative complications increased with complexity (grade A, 31.8%; grade B, 36.3%; grade C, 48.6%; P = 0.0091). For grade A complexity, the outcomes were consistent across surgeons and centers. Grade B outcomes were similar between grade B and C centers but superior to grade A centers. In grade C cases, outcomes were comparable between grade A and B centers, with improvements at grade C centers. Grade A ISGPS experience correlated strongly with mismatches between planned and performed procedures (grade A, 15.0%; grade B, 3.0%; grade C, 3.1%; P < 0.0001), including total pancreatectomy (grade A, 11.5%; grade B, 1.2%; grade C, 3.1%; P = 0.0005). Conclusions: The ISGPS complexity grading system effectively predicted MIPD outcomes, supporting better patient selection and alignment of complexity with surgical expertise.

Background: Minimally invasive pancreatic resections (MIPRs) have been shown to be safe and feasible, but there is still a lack of high-level evidence on oncological outcomes for cephalic pancreatic ductal adenocarcinoma (PDAC). The aim of this study was to compare the oncological outcomes of patients undergoing MIPR and open pancreatic resection (OPR) for pancreatic head cancer in a single high-volume center. Methods: Data from a prospectively collected database of patients who underwent radical-intent surgery for resectable and borderline resectable PDAC of the head at our institution between January 2013 and May 2023 were retrieved and analyzed, comparing the surgical and oncological outcomes of MIPR and OPR, using a propensity score matching analysis. Results: In the study period, 220 patients were selected. After matching, a total of 81 MIPRs and 81 OPRs were compared. No difference was found regarding R0 rate (OPR 83.9% vs. MIPR 74.1%, p = 0.122). Median overall survival (24 and 31 months for the OPR and MIPR groups, respectively; log rank p = 0.665) and disease-free survival (12 and 21 months for the OPR and MIPR groups, respectively; log rank p = 0.118) did not differ between the groups. The MIPR group was associated with a greater number of harvested lymph nodes (22 vs. 16, p = 0.0008), longer operative time (565 vs. 420 min, p < 0.0001), and shorter length of stay (12 vs. 18 days; p = 0.0001). No differences between the groups were found regarding all other postoperative and pathological outcomes. Conclusions: Regarding oncological outcomes, MIPR appeared to be comparable to OPR for treating patients with PDAC of the head. Despite an increased operative time, MIPR was associated with a greater number of LNs harvested and a shorter length of stay.

Objective/Background: Various anastomotic and reconstruction techniques are used for minimally invasive total (miTG) and distal gastrectomy (miDG). Their effects on postoperative morbidity have not been extensively studied. Methods: MiTG and miDG patients were selected from 9356 oncological gastrectomies performed in 2017–2021 in 43 centers. Endpoints included anastomotic leakage (AL) rate and postoperative morbidity tested by multivariable analysis. Results: Three major anastomotic techniques [circular stapled (CS); linear stapled (LS); and hand sewn (HS)], and 3 major bowel reconstruction types [Roux (RX); Billroth I (BI); Billroth II (BII)] were identified in miTG (n=878) and miDG (n=3334). Postoperative complications, including AL (5.2% vs 1.1%), overall (28.7% vs 16.3%), and major morbidity (15.7% vs 8.2%), as well as 90-day mortality (1.6% vs 0.5%) were higher after miTG compared with miDG. After miTG, the AL rate was higher after CS (4.3%) and HS (7.9%) compared with LS (3.4%). Similarly, major complications (LS: 9.7%, CS: 16.2%, and HS: 12.7%) were lowest after LS. Multivariate analysis confirmed anastomotic technique as a predictive factor for AL, overall, and major complications. In miDG, AL rate (BI: 1.4%, BII 0.8%, and RX 1.2%), overall (BI: 14.5%, BII: 15.0%, and RX: 18.7%), and major morbidity (BI: 7.9%, BII: 9.1%, and RX: 7.2%), and mortality (BI: 0%, BII: 0.1%, and RY: 1.1%%) were not affected by bowel reconstruction. Conclusions: In oncologically suitable situations, miDG should be preferred to miTG, as postoperative morbidity is significantly lower. LS should be a preferred anastomotic technique for miTG in Western Centers. Conversely, bowel reconstruction in DG may be chosen according to the surgeon’s preference.

Background: International guidelines recommend monitoring the use and outcome of minimally invasive pancreatic surgery (MIPS). However, data from prospective international audits on minimally invasive distal pancreatectomy (MIDP) are lacking. This study examined the use and outcome of robot-assisted (RDP) and laparoscopic (LDP) distal pancreatectomy in the E-MIPS registry. Patients and methods: Post-hoc analysis in a prospective audit on MIPS, including consecutive patients undergoing MIDP in 83 centers from 19 European countries (01-01-2019/31-12-2021). Primary outcomes included intraoperative events (grade 1: excessive blood loss, grade 2: conversion/change in operation, grade 3: intraoperative death), major morbidity, and in-hospital/30-day mortality. Multivariable logistic regression analyses identified high-risk groups for intraoperative events. RDP and LDP were compared in the total cohort and high-risk groups. Results: Overall, 1672 patients undergoing MIDP were included; 606 (36.2%) RDP and 1066 (63.8%) LDP. The annual use of RDP increased from 30.5% to 42.6% (PPPP=0.264) and in-hospital/30-day mortality (0.3% vs. 0.8%, P=0.344). Three high-risk groups were identified; BMI greater than 25 kg/m², previous abdominal surgery, and vascular involvement. In each group, RDP was associated with fewer conversions and longer operative times. Conclusion: This European registry-based study demonstrated favorable outcomes for MIDP, with mortality rates below 1%. LDP remains the predominant approach, whereas the use of RDP is increasing. RDP was associated with fewer conversions and longer operative time, including in high-risk subgroups. Future randomized trials should confirm these findings and assess cost differences.

Aim: Locally advanced rectal cancer (LARC) is commonly treated with neoadjuvant chemoradiotherapy (nCRT) and total mesorectal excision (TME) to reduce local recurrence (LR) and improve survival. However, LR, particularly associated with lateral lymph node (LLN) involvement, remains a concern. The aim of this study was to investigate preoperative factors associated with LLN involvement and their impact on LR rates in LARC patients undergoing nCRT and curative surgery. Method: This multicentre retrospective study, including four academic high‐volume institutions, involved 301 consecutive adult LARC patients treated with nCRT and curative surgery between January 2014 and December 2019 who did not undergo lateral lymph node dissection (LLND). Baseline and restaging pelvic MRIs were evaluated for suspicious LLNs based on institutional criteria. Patients were divided into two groups: cLLN+ (positive nodes) and cLLN– (no suspicious nodes). Primary outcome measures were LR and lateral local recurrence (LLR) rates at 3 years. Results: Among the cohort, 15.9% had suspicious LLNs on baseline MRI, and 9.3% had abnormal LLNs on restaging MRI. At 3 years, LR and LLR rates were 4.0% and 1.0%, respectively. Ten out of 12 (83.3%) patients with LR showed no suspicious LLNs at the baseline MRI. Abnormal LLNs on MRI were not independent risk factors for LR, distant recurrence or disease‐free survival. Conclusion: Abnormal LLNs on baseline and restaging MRI assessment did not impact LR and LLR rates in this cohort of patients with LARC submitted to nCRT and curative TME surgery.