伊藤 綾香

PURPOSE: To develop an educational program that enables young surgeons to safely perform laparoscopic transabdominal preperitoneal repair (TAPP). METHODS: This retrospective study comprised 365 patients who underwent elective TAPP performed by surgical residents (SRs; n = 145 patients) and board-certified surgeons (BCSs; n = 220 patients) from January 2018 to December 2023. An educational program for SRs has been underway since April 2021 to facilitate efficient learning and ensure the safe performance of TAPP. This program comprises four steps and highlights the two points mentioned, including understanding technical principles and acquiring fundamental skills. The surgical outcomes of laparoscopic TAPP performed by SRs and BCSs were compared retrospectively. RESULTS: A total of 43 operators (16 SRs and 27 BCSs) performed the laparoscopic TAPP. The SRs demonstrated longer operative times (median 126 vs. 98 min; p < 0.01). No significant differences in the rates of seroma (7.6% vs. 5.5%), grade IIIa or higher Clavien-Dindo complications (early: 0.7 vs. 0.9%; late: 0.7% vs. 0%), and recurrence at 1 year after surgery (1.4% vs. 0.5%) were observed between the SR and BCSs groups. Following the implementation of the educational program in April 2021, laparoscopic TAPP procedures performed by SRs were associated with significantly shorter operation times compared to those conducted before the program was introduced. CONCLUSIONS: SRs who received presurgical education improved the operative time in laparoscopic TAPP, although with intraoperative guidance from Endoscopic Surgical Skill Qualification System-qualified surgeons.

BACKGROUND: Robotic surgery for rectal cancer has grown popular in recent years and has primarily used the da Vinci Surgical System (Intuitive Surgical, CA, USA; da Vinci). In 2020, Japan introduced the hinotori™ Surgical Robot System (Medicaroid, Kobe, Japan; hinotori). We report our initial surgical experiences with robotic surgery using hinotori for rectal cancer and its feasibility and safety comparing with da Vinci. METHODS: A single-institution retrospective study was conducted. Between November 2022 and November 2023, 38 and 96 patients with rectal cancer underwent robotic surgery using hinotori and da Vinci, respectively. The primary endpoint was the incidence of postoperative complications of the Clavien-Dindo classification (CD) grade ≥ II within postoperative 30 days. Secondary endpoints included surgical and console time, blood loss, conversion to other approaches, number of dissected lymph nodes, and postoperative hospital stay. A propensity score matching (PSM) analysis was used to adjust for imbalance in baseline characteristics. RESULTS: After PSM, a total of 76 patients (hinotori: 38, da Vinci: 38) were included. Compared to the da Vinci group, the hinotori group showed a similar postoperative complication rate of CD ≥ II (15.8% vs. 18.4%), comparable operative time (280.5 vs. 258 min), comparable console time (166 vs. 156 min), and less blood loss (9 vs. 17.5 mL, p = 0.025). There was no conversion in either group. The number of dissected nodes and postoperative stay were similar between the two groups. CONCLUSION: Our findings support that robotic surgery for rectal cancer using hinotori is as safe as surgery performed using the da Vinci system.

PURPOSE: Reduced-port surgery has been utilized in gastric cancer surgery but is not predominantly used due to its high technical difficulty. A new single-port surgical robot named da Vinci™ SP System (DVSP) was launched and eventually approved for clinical use in Japan in November 2022. We initiated robotic gastrectomy for gastric cancer using DVSP in March 2023. Here, we report our initial experiences and assessments of the feasibility and safety of robotic gastrectomy for gastric cancer using DVSP. METHODS: This single-center retrospective study included 20 patients with gastric cancer who underwent robotic gastrectomy with DVSP from March 2023 to April 2024. The primary endpoint was the postoperative complication rate within 30 days postoperatively. Secondary endpoints were surgical outcomes, including intraoperative adverse events, operative time, blood loss, and the number of dissected nodes. RESULTS: Of the 20 patients, 6 (30.0%) were male. The median age was 74 years. Tumors in the middle to lower stomach were observed in 20 patients (100.0%), including 18 (90.0%) and 2 (10.0%) with clinical stages I and II diseases, respectively. All patients underwent distal gastrectomy. The postoperative complications of Clavien-Dindo grade ≥ II occurred in 3 (15%) patients. Intraoperative adverse events, including conversion to other approaches, were not observed. All patients underwent R0 resection. The median operative and console times were 289 and 240 min, respectively. The median blood loss was 11 mL with 50 dissected nodes. CONCLUSION: This study revealed the safe performance of robotic distal gastrectomy with standard lymphadenectomy for clinical stage I/II gastric cancer using DVSP.

BACKGROUND: This study aimed to investigate the laparoscopic gastrectomy (LG) performance of non-Endoscopic Surgical Skill Qualification System (ESSQS)-qualified surgeons under the ESSQS-qualified surgeon guidance and compare oncological outcomes of gastric cancer to LG performed by the ESSQS-qualified surgeons. METHODS: This study enrolled 1,030 patients diagnosed with both clinical and pathological stage ≤ III gastric cancer and undergoing LG from January 2009 to June 2019. ESSQS-qualified surgeons served as the operator or the instructive assistant in all LG procedures involving them. A propensity score-matched analysis was used to retrospectively compare the long-term outcomes between the ESSQS-qualified and non-ESSQS-qualified surgeons. RESULTS: Each group included 315 pairs after propensity score matching. The 3-year recurrence-free survival rates were 84.4% and 81.7% in the non-ESSQS and ESSQS groups, respectively. The difference was 2.7% (95% confidence interval: - 3.20%-8.44%, P < 0.001), and the non-ESSQS group statistically demonstrated noninferiority as the lower 95% confidence limit was greater than the prespecified margin of -10%, indicating the achieved primary endpoint. No significant differences in 5-year recurrence-free survival (non-ESSQS: 78.5% vs. ESSQS: 77.4%, P = 0.627) and 5-year overall survival (non-ESSQS: 80.9% vs. ESSQS: 79.3%, P = 0.475) were found between the two groups. The oncological outcomes stratified according to the presence of pathological stage I, II, and III disease did not significantly differ between the two groups. CONCLUSIONS: LG performed by non-ESSQS-qualified surgeons achieved comparable oncological outcomes to the ESSQS-qualified surgeons, as long as ESSQS-qualified surgeons provided intraoperative instructions, in a high-volume center.

Undergoing another surgery after a previous abdominal procedure can sometimes result in significant abdominal adhesions. We present a case of robot-assisted low anterior resection in a patient with rectal cancer who had a urinary reservoir. A 65-year-old male patient underwent robot-assisted total bladder resection and creation of a urinary reservoir for bladder cancer in 2013. He presented with melena. Thus, the findings revealed advanced low rectal cancer. The robot-assisted low anterior resection was performed in 2022. Extensive adhesions were observed in the pelvic space. The indocyanine green function was appropriately used, and the robotic surgery was completed without injury to the urinary reservoir or major complications. The surgical time was 510 min, and the blood loss volume was 15 mL. The patient had been recurrence free for 12 months following the surgery. Robot-assisted surgery can be beneficial for patients with rectal cancer with significant pelvic adhesions.

The patient is a 60-year-old female with a history of multiple times of recurrences of an esophageal diverticulum. She was referred for a diagnosis of persistent dysphagia and vomiting. Balloon dilation did not improve the symptoms; thus, she was referred for surgery. Esophageal fluoroscopy revealed a 5 cm diverticulum. There was no significant change in the size before and after dilation. Gastrointestinal endoscopy revealed a diverticulum in the lower esophagus, with a residue accumulation. The esophagus directly below the diverticulum was narrowed. The patient was diagnosed with recurrent lower esophageal diverticulum and underwent surgery. The operative findings showed poor coloration of the gastric fundus surrounding operated before by Nissen's method, so the patient underwent lower esophagogastric resection and interstitial jejunal reconstruction. The postoperative course was uneventful and discharged on the 19th day. She is 6 years postoperatively and gained six kg compared to her preoperative weight. She has remained in excellent health.

The patient is a 58-year-old woman. She was referred to our hospital following a computed tomography scan that revealed a 2-cm tumor-like lesion in the pancreatic body. Endoscopic ultrasound fine-needle aspiration examination revealed a suspected undifferentiated carcinoma with pleomorphic type. The patient was diagnosed with anaplastic carcinoma of the pancreas (ACP) and underwent distal pancreatectomy with lymph nodes dissection. The resected body and tail of the pancreas had a nodular tumor measuring 30 mm in diameter. Histologically, the main lesion of the tumor showed well-differentiated adenocarcinoma, and diffuse proliferation of atypical short spindle cells and round cells accompanied by multinucleated giant cells aggregation was observed around the tubular structure; hence, it was diagnosed with ACP. The postoperative course was uneventful, and the patient was discharged 14 days after the operation. It has already been about 5 years since the surgery, and although the tumor has recurred, the patient is still alive and undergoing chemotherapy.

Cases of delayed colo-anal anastomosis (DCAA) are currently reported instead of the colo-anal anastomosis with a protective loop ileostomy for rectal cancer. Post-operative colonic ischemia is considered as one of the serious complications of colorectal resection. Although indication of DCAA should be carefully selected, we experienced a case of post-operative stenosis caused by colonic ischemia after low anterior resection for rectal cancer, followed by this procedure.