中村 謙一

BACKGROUND: The da Vinci™ Surgical System, recognized as the leading surgical robotic platform globally, now faces competition from a growing number of new robotic surgical systems. With the expiration of key patents, innovative entrants have emerged, each offering unique features to address limitations and challenges in minimally invasive surgery. The hinotori™ Surgical Robot System (hinotori), developed in Japan and approved for clinical use in November 2022, represents one such entrant. This study demonstrates initial insights into the application of the hinotori in robot-assisted surgeries for patients with rectal neoplasms. METHODS: The present study, conducted at a single institution, retrospectively reviewed 28 patients with rectal neoplasms treated with the hinotori from November 2022 to March 2024. The surgical technique involved placing five ports, including one for an assistant, and performing either total or tumor-specific mesorectal excision using the double bipolar method (DBM). The DBM uses two bipolar instruments depending on the situation, typically Maryland bipolar forceps on the right and Fenestrated bipolar forceps on the left, to allow precise dissection, hemostasis, and lymph node dissection. RESULTS: The study group comprised 28 patients, half of whom were male. The median age was 62 years and the body mass index stood at 22.1 kg/m2. Distribution of clinical stages included eight at stage I, five at stage II, twelve at stage III, and three at stage IV. The majority, 26 patients (92.9%), underwent anterior resection using a double stapling technique. There were no intraoperative complications or conversions to other surgical approaches. The median operative time and cockpit time were 257 and 148 min, respectively. Blood loss was 15 mL. Postoperative complications were infrequent, with only one patient experiencing transient ileus. A median of 18 lymph nodes was retrieved, and no positive surgical margins were identified. CONCLUSIONS: The introduction of the hinotori for rectal neoplasms appears to be safe and feasible, particularly when performed by experienced robotic surgeons. The double bipolar method enabled precise dissection and hemostasis, contributing to minimal blood loss and effective lymph node dissection.

BACKGROUND: Adenosquamous carcinoma of the pancreas (ASCP) accounts for only 1-4% of all pancreatic exocrine cancers and has a particularly poor prognosis. The efficacy of chemotherapy for ASCP remains unknown because of the small number of cases, and few studies have evaluated conversion-intended chemotherapy. CASE PRESENTATION: A 76-year-old woman was referred to our hospital because of epigastric pain and nausea. A preoperative contrast-enhanced multidetector row computed tomography (MDCT) scan revealed a 17 × 17 mm low-density tumor with an ill-defined margin at the arterial phase in the pancreatic head. The tumor involved the common hepatic artery, left hepatic artery bifurcated from the common hepatic artery, and gastroduodenal artery, and was in contact with the portal vein. Fluorodeoxyglucose-positron emission tomography (FDG-PET) showed an uptake in the pancreatic head but no evidence of distant metastasis. The tumor was diagnosed as an adenocarcinoma of the pancreatic head and staged unresectable because the common and left hepatic arteries were involved. Hence, the patient underwent seven courses of conversion-intended chemotherapy using gemcitabine and nab-paclitaxel for pancreatic ductal adenocarcinoma over 7 months. After chemotherapy, the tumor shrank to 10 × 10 mm on contrast-enhanced MDCT. Consequently, the boundary between the tumor and major vessels of the common and left hepatic arteries and the portal vein became clear, and the involvement of the arteries with the tumor was evaluated to be released. The contact of the tumor to the portal vein also reduced to less than half the circumference of the portal vein. FDG-PET showed decreased accumulation in the tumor. Hence, the tumor was judged resectable, and pancreaticoduodenectomy was performed. The tumor and major blood vessels were easily dissected and R0 resection was achieved. The patient experienced no major complications and was discharged on postoperative day 28. The tumor was revealed as ASCP via pathological examination. The patient is alive and recurrence-free seven months after surgery. This is the first report of successful R0 resection for an initially unresectable ASCP following conversion-intended chemotherapy using gemcitabine and nab-paclitaxel regimen. CONCLUSIONS: Conversion-intended chemotherapy using gemcitabine and nab-paclitaxel regimen may be effective for ASCP.

BACKGROUND: This study aimed to investigate the effect of the use of new lithotomy stirrups-2 on the pressure dispersal on lower limbs, which may lead to the prevention of well-leg compartment syndrome (WLCS) and deep venous thrombosis (DVT), which are the most commonly associated adverse events with laparoscopic and robot-assisted rectal surgery. METHODS: A total of 30 healthy participants were included in this study. The pressure (mmHg) applied on various lower limb muscles when using conventional lithotomy stirrups-1 and new type stirrups-2 was recorded in various lithotomy positions; 1) neutral position, 2) Trendelenburg position (15°) with a 0° right inferior tilt, and 3) Trendelenburg position (15°) with a 10° right inferior tilt. Using a special sensor pad named Palm Q®, and the average values were compared between two types of stirrups. RESULTS: The use of new lithotomy stirrups-2 significantly reduced the pressure applied on the lower limb muscles in various lithotomy positions compared with the use of lithotomy stirrups-1. The most pressured lower limb muscle when using both lithotomy stirrups was the central soleus muscle, which is the most common site for the development of WLCS and DVT. In addition, when using the conventional lithotomy stirrups-1, the pressure was predominantly applied to the proximal soleus muscle; however, when using lithotomy stirrups-2, the pressure was shifted to the more distal soleus muscle. CONCLUSION: These results suggest that the new lithotomy stirrups-2 is useful in reducing the pressure load on leg muscles, especially on the proximal to central soleus, and may reduce the incidence of WLCS and DVT after rectal surgery performed in the lithotomy position. Further clinical studies are needed to determine whether the use of lithotomy stirrups-2 prevents these complications in various clinical settings.

BACKGROUND: Hydrocele of the canal of Nuck (HCN) is a rare disease, and its indications for laparoscopic surgery are not well-established. CASE PRESENTATION: A 53-year-old woman was referred to our hospital due to an uncomfortable thumb-sized inguinal mass. Preoperative computed tomography scan and magnetic resonance imaging revealed a hydrocele extending from the abdominal cavity around the left deep inguinal ring via the inguinal canal to the subcutaneous space. The patient was diagnosed with HCN protruding into the abdominal cavity and extending to the subcutaneous space. Laparoscopy can easily access the hydrocele protruding into the abdominal cavity. Furthermore, laparoscopic hernioplasty can be superior to the anterior approach for females. Hence, laparoscopic surgery was performed. After transecting the round ligament of the uterus, a tense 3-cm hydrocele was dissected with it. In order to approach the hydrocele distal to the deep inguinal ring, the transversalis fascia was incised medially to the inferior epigastric vessels. The subcutaneously connected hydrocele was excised from the incision. Then, the enlarged deep inguinal ring was reinforced using a mesh with the laparoscopic transabdominal preperitoneal approach. The patient was discharged 2 days postoperatively. Laparoscopic resection can be more effective for a hydrocele protruding into the abdominal cavity as it facilitates an easy access to the hydrocele. Moreover, laparoscopic resection of a hydrocele extending from the inguinal canal to the subcutaneous space via a transversalis fascia incision can be safer, with low risk of injury to the inferior epigastric vessels. The incised transversalis fascia and the enlarged deep inguinal ring due to the HCN were simultaneously repaired with the laparoscopic transabdominal preperitoneal repair. There are two reports on laparoscopic resection via a transversalis fascia incision for HCNs located between the inguinal canal and the subcutaneous space, which does not require intraperitoneal hydrocelectomy. However, this is the first report on laparoscopic resection of large HCNs protruding into the abdominal cavity and extending beyond the inguinal canal into the subcutaneous space via intraperitoneal hydrocelectomy and a transversalis fascia incision. CONCLUSIONS: Laparoscopic surgery with transversalis fascia incision can be useful for HCNs extending from the abdominal cavity to the subcutaneous space.

BACKGROUND: Although most duodenal carcinomas are pathological adenocarcinomas, a small number of cases have been reported of adenosquamous carcinoma, characterized by variable combinations of two malignant components: adenocarcinoma and squamous cell carcinoma. However, owing to the small number of cases of non-ampullary duodenal adenosquamous carcinoma, there have been no reported cases of emergency pancreaticoduodenectomy for gastrointestinal hemorrhage due to non-ampullary duodenal adenosquamous carcinoma. CASE PRESENTATION: A 66-year-old Japanese male presented to the referring hospital with a chief complaint of abdominal pain, diarrhea, and dark urine that had persisted for 1 month. The patient was referred to our hospital because of liver dysfunction on a blood examination. Laboratory results of the blood on the day of admission showed that total and direct bilirubin levels (12.0 mg/dl and 9.6 mg/dl) were markedly increased. An endoscopic retrograde biliary drainage tube was inserted for the treatment of obstructive jaundice, and imaging studies were continuously performed. Contrast-enhanced computed tomography and endoscopy revealed an ill-defined lesion involving the second portion of the duodenum, predominantly along the medial wall, and measuring 60 mm in diameter. No metastases were observed by positron emission tomography. Pancreaticoduodenectomy was planned based on the pathological findings of poorly differentiated adenocarcinoma. However, 2 days before the scheduled surgery, the patient experienced hemorrhagic shock with melena. Owing to poor hemostasis after endoscopic treatment and poor control of hemodynamic circulation despite blood transfusion, radiological embolization and hemostasis were attempted but were incomplete. An emergency pancreaticoduodenectomy was performed after embolizing the route from the gastroduodenal artery and pseudoaneurysm area to reduce bleeding. The operation was completed using an anterior approach without Kocherization or tunneling due to the huge tumor. The operation time was 4 h and 32 min, and blood loss was 595 mL The pathological diagnosis was adenosquamous carcinoma. The postoperative course was uneventful with 17 day hospital stay and the patient is currently well, with no signs of recurrence 9 months after surgery. CONCLUSIONS: This report presents an extremely rare case of successful emergency pancreaticoduodenectomy for gastrointestinal hemorrhage caused by non-ampullary duodenal adenosquamous carcinoma.

Inflammatory pseudotumor (IPT) is a rare disease that requires a differential diagnosis from malignancies. We describe a case of hepatic IPT with para-aortic lymphadenopathy, treated with a stepwise strategy of laparoscopic surgery. A 61-year-old woman was referred with a liver lesion. Computed tomography revealed a 13 cm well-defined lesion in segments VII-VI. The patient also had bead-like enlarged lymph nodes from the perihilar to the para-aortic regions. Although percutaneous lymph node biopsy showed no evidence of malignancy, 18 F-fluorodeoxyglucose positron emission tomography revealed accumulation in the lesion and lymph nodes. Lymph nodes were harvested laparoscopically for intraoperative pathological examination. With no evidence of malignancy, laparoscopic liver resection was continuously performed as a diagnostic treatment. The patient was given a pathological diagnosis of IPT and was discharged on the 16th day and is well 2 years after surgery. The minimally invasive laparoscopic approach to diagnostic treatment could be useful with secure advantages.

PURPOSE: Robotic gastrectomy (RG) for gastric cancer (GC) was approved for national medical insurance coverage in April, 2018, since when its use has increased dramatically throughout Japan. However, the safety of RG performed by surgeons who are not Endoscopic Surgical Skill Qualification System (ESSQS)-qualified has yet to be established. We conducted this study to verify the short-term outcomes of the initial series of RG procedures performed by non-ESSQS-qualified surgeons. METHODS: Between January, 2020 and December, 2021, 30 patients with clinical Stage I and II GC underwent RG performed by four non-ESSQS-qualified surgeons according to the Japan Society for Endoscopic Surgery guideline. We evaluated, retrospectively, the morbidity rates according to Clavien-Dindo (CD) classification grade II or higher. RESULTS: Each operating surgeon completed all procedures without any serious intraoperative adverse events. The median operative time, console time, and estimated blood loss were 413 (308-547) min, 361 (264-482) min, and 25.5 (4-167) mL, respectively. No patient required conversion to laparoscopic or open surgery. Three (10%) patients suffered CD grade II complications postoperatively. The median postoperative hospitalization was 11 (8-51) days. CONCLUSION: Non-ESSQS-qualified surgeons trained by expert RG surgeons could perform robotic distal gastrectomy safely for initial cases.

BACKGROUND: The current study aimed to investigate the relationship between muscle mass proportion and the incidence of total complications in male gastric cancer (GC) patients after minimally invasive distal gastrectomy (MIDG). METHODS: Between March 2017 and March 2020, 152 male GC patients with clinical stage III or lower GC who underwent MIDG were enrolled in this study. The muscle mass ratio (MMR) was calculated by dividing the total muscle weight obtained from bioelectrical impedance analysis by the whole-body weight. Thereafter, the association between MMR and surgical outcomes was determined. RESULTS: Based on the optimal MMR cutoff value of 0.712 obtained using the receiver operating characteristic (ROC) curve, patients were divided into two groups (69 and 83 patients in the MMR-L and MMR-H groups). The MMR-L group had a significantly higher total complication rate compared to the MMR-H group (MMR-L, 24.6% vs. MMR-H, 7.2%; P = 0.005). Multivariate analysis also identified MMR-L as a significant independent risk factor for total complications and intra-abdominal infectious complications after MIDG. CONCLUSIONS: The MMR calculated using bioelectrical impedance analysis can be a useful predictor for postoperative complications after MIDG in male GC patients.

BACKGROUND: Anastomotic leakage of cervical esophagogastrostomy following radical esophagectomy for esophageal cancer has reduced over time; however, postoperative anastomotic stricture still occurs at a considerably high rate. We developed a novel method of circular-stapled esophagogastrostomy by employing the keyhole procedure, which uses a linear stapler to enlarge the anastomotic opening made with a circular stapler (CS). METHODS: We retrospectively reviewed 70 patients with esophageal cancer who underwent transthoracic esophagectomy and reconstruction via cervical CS-mediated anastomosis with or without the keyhole procedure between 2018 and 2020. The primary outcome was postoperative anastomotic stricture incidence within 180 days after surgery. RESULTS: Among 70 patients, 22 underwent the keyhole procedure (CS + K group) and the remaining did not (CS group). No differences were observed in patients' age, sex, body mass index, performance status, American Society of Anesthesiologists physical status, Charlson's comorbidity index, tumor histological type, tumor location, clinical stage, or preoperative treatment. A smaller stapler was used in the CS + K group (p < 0.001). Incidence of anastomotic stricture was significantly different (CS vs. CS + K, 18.8 vs. 0%, p = 0.049), especially when a 21 or 23 mm CS was used (CS vs. CS + K, 50.0 vs. 0%, p = 0.005). Univariate analysis confirmed that CS ≤ 23 without keyhole was a significant risk factor (p = 0.001). CONCLUSIONS: The keyhole procedure could be a simple and useful alternative technique that reduces the risk of stricture formation in cervical esophagogastric anastomosis, especially when using the smaller-sized CS.

Objective The aim of this study was to determine the safety and clinical efficacy of docetaxel+cisplatin+5-fluorouracil (DCF) as neoadjuvant chemotherapy (NAC). Methods In this single-center study, patient background and treatment outcomes (NAC efficacy assessment, NAC adverse events, short-term postoperative outcomes, and one-year postoperative outcomes) in patients treated with preoperative DCF and preoperative cisplatin+5-FU (CF) were compared retrospectively. Patients Seventeen patients diagnosed with esophageal squamous cell carcinoma (ESCC) and treated with preoperative DCF therapy and 50 patients treated with preoperative CF therapy between January 2013 and July 2019 were included in this study. Results There were significant differences in clinical T factor and clinical stage between the CF and DCF groups (p<0.05). All patients in the DCF therapy group were above clinical T3 and clinical stage III. The clinical response after NAC was partial response (PR) for 23 patients (46.0%) in the CF group and 13 patients (76.5%) in the DCF group (p=0.030). Regarding adverse events in NAC, neutropenia, febrile neutropenia (FN), diarrhea, and stomatitis were observed more frequently in the DCF group than in the CF group (p<0.05). The postoperative results [overall survival (OS), recurrence-free survival (RFS), one-year OS, one-year RFS] of the DCF group were comparable to those of the CF group. Conclusion DCF therapy has been recognized as an effective treatment option for advanced ESCC. However, the indication for DCF therapy should be chosen carefully because of the high incidence of adverse events.

BACKGROUND: A giant inguinoscrotal hernia is a rare inguinal hernia that extends below the midpoint of the inner thigh while standing. Although reports of laparoscopic surgery for giant inguinoscrotal hernias have increased, the risk of delayed hematocele has not yet been clarified. CASE PRESENTATION: A 68-year-old man was evaluated for a left giant inguinoscrotal hernia, and laparoscopic transabdominal preperitoneal repair (TAPP) was performed. In the procedure, the distal hernia sac was not resected. The postoperative course was uneventful for 3 months postsurgery, after which he complained of giant scrotal swelling, which gradually grew to 13 cm. It did not improve with several punctures and caused dysuria because of increased pressure on the urethra. Thus, reoperation was performed 9 months after surgery. The hematocele consisted of a thickened hernia sac, which was tightly adhered to the spermatic cord and testicle. The hernia sac including the hematocele was removed from the scrotum through an anterior approach, preserving the spermatic cord and testicle. On the third postoperative day, an orchiectomy was performed due to poor testicular perfusion caused by spermatic cord injury. There was no hematocele or hernia at the 3-year follow-up. The remnant sac after laparoscopic TAPP for a giant inguinoscrotal hernia possibly caused refractory hematocele. Additionally, the removal of the hernia sac, including hematocele, from the spermatic cord and testicle has a risk of inducing injury, leading to orchiectomy. CONCLUSION: Surgeons should be aware of the possibility of delayed refractory hematoceles after laparoscopic TAPP for giant inguinoscrotal hernias when the hernia sac is not resected.

AIM: The recent development of new surgical robots and network telecommunication technology has opened new avenues for robotic telesurgery. Although a few gastroenterological surgeries have been performed in the telesurgery setting, more technically demanding procedures including gastrectomy with D2 lymphadenectomy and intracorporeal anastomosis have never been reported. We examined the feasibility of telesurgical robotic gastrectomy using the hinotori™ Surgical Robot System in a preclinical setting. METHODS: First, the suturing time in the dry model was measured in the virtual telesurgery setting to determine the latency time threshold. Second, a surgeon cockpit and a patient unit were installed at Okazaki Medical Center and Fujita Health University, respectively (approximately 30 km apart), and connected using a 10-Gbps leased optic-fiber network. After evaluating the feasibility in the dry gastrectomy model, robotic distal gastrectomies with D2 lymphadenectomy and intracorporeal B-I anastomosis were performed in two porcine models. RESULTS: The virtual telesurgery study identified a latency time threshold of 125 ms. In the actual telesurgery setting, the latency time was 27 ms, including a 2-ms telecommunication network delay and a 25-ms local information process delay. After verifying the feasibility of the operative procedures using a gastrectomy model, two telesurgical gastrectomies were successfully completed without any unexpected events. No fluctuation was observed across the actual telesurgeries. CONCLUSION: Short-distance telesurgical robotic surgery for technically more demanding procedure may be safely conducted using the hinotori Surgical Robot System connected by high-speed optic-fiber communication.

A 46-year-old man was referred to further treatment for a 20 mm submucosal tumor at the gastric angle found during a medical check-up. Endoscopic ultrasonography and chest abdominal contrast-enhanced CT revealed the tumor was located at the 4th(proper muscular)layer of the posterior wall of the gastric antrum and slightly enhanced. No metastasis was found. Although a biopsy failed to reveal an accurate diagnosis, GIST was clinically suspected. A robotic distal gastrectomy was planned to manage the residual gastric stricture. The intraoperative findings indicated possible passage of the remnant stomach; therefore, local resection was performed. The patient's postoperative course was uneventful, and he was discharged on postoperative day 9. A histopathological examination confirmed the diagnosis of a PAS-positive, S100-positive granular cell tumor with no nuclear atypia. These findings suggest that use of the robotic approach could help determine the stomach resection extent.

A 79-year-old male presented with epigastric discomfort and appetite loss. A type 1 advanced gastric tumor was detected by upper gastrointestinal endoscopy. Contrast-enhanced CT revealed a 7 cm mass with contrast effect at the greater curvature of the lower body of the stomach. No distant metastases were found. Staging laparoscopy confirmed gastric cancer with single giant lymph node metastasis, which was resectable, although the metastatic node possibly invaded the transverse colon. We performed total gastrectomy and partial colectomy. Pathological examination revealed the tumor was pT3N1; the mass was #4sa lymph node metastasis of gastric cancer. The postoperative course was uneventful. No tumor recurrence has been found for 12 months postoperatively.

A 78-year-old male who had received laparoscopic total gastrectomy for upper gastric cancer 30 months ago(pT3N0, pStage ⅡB)was referred for further treatment for a 30-mm in size mass at the splenic hilum. The mass was suspected of lymph node metastasis was suspected. Two courses of SOX therapy failed to achieve the tumor response. Since there was no other metastasis, surgical treatment was indicated. Robot distal pancreatectomy with splenectomy was performed. There was no finding of peritoneal metastasis during the operation. The operative time was 384 min, the blood loss 22 mL, respectively. The postoperative course was uneventful, and he was discharged on the 12th postoperative day. The histopathological examination found that the resected mass was pancreatic metastasis of gastric cancer. Despite 3 courses of SOX therapy after the operation, the tumor recurred at the liver and paraaortic lymph nodes 2 months later. The second-line ramucirumab plus paclitaxel was started and has continued for 11 months with partial response. Although oncological benefit of surgical resection for isolated metastasis of gastric cancer, including pancreatic metastasis, was unclear, the robotic approach for such an atypical case was safe and feasible, leading to smooth initiation of postoperative systemic therapy.

BACKGROUND: A leiomyosarcoma of the gastrointestinal tract is extremely rare. We report a case of jejunal leiomyosarcoma with intestinal intussusception at the angle of Treitz that was successfully treated with laparoscopic resection followed by intracorporeal reconstruction using a delta-shaped anastomosis. CASE PRESENTATION: A 54-year-old man was referred to our hospital due to fatigue and loss of appetite. Blood tests showed anemia. Enteroscopy and subsequent enterography using meglumine sodium amidotrizoate showed easily hemorrhagic tumor (10 cm in diameter) in the jejunum just beyond the angle of Treitz. Contrast-enhanced computed tomography revealed jejunojejunal intussusception. Histopathological examination of a biopsy specimen revealed a leiomyosarcoma. Laparoscopic resection of the tumor without reduction of the intussusception was performed. The resected line of the proximal intestine was very close to the ligament of Treitz in the present case. Intracorporeal jejunojejunostomy was completed using a delta-shaped anastomosis, wherein anastomosis was performed between the posterior walls of the proximal and distal jejunums after minimal mobilization around the ligament of Treitz. The patient's postoperative course was uneventful, and he was discharged at 10 days postoperatively. No recurrence has been observed within 2 years after surgery. CONCLUSIONS: We present a case in which a totally laparoscopic surgery for leiomyosarcoma located at the angle of Treitz with jejunojejunal intussusception was performed successfully.

In this study, we report a case of incarcerated direct inguinal hernia (DIH) after robot-assisted radical prostatectomy (RARP) in a patient with concomitant DIH. The 71-year-old man underwent RARP. Six days later, he developed a right DIH incarceration. His laparoscopy findings revealed an incarcerated intestine that was adherent to the hernia orifice. After reducing the hernia, the peritoneum was found to be defective in the right DIH orifice. The DIH was then repaired via the Lichtenstein method. The patient was discharged without complications on postoperative day 13. No recurrence was observed at 3-year follow-up. When repair and peritoneum closure for concomitant DIH are not performed in RARP, it should be kept in mind that the nonrepaired concomitant DIH orifice may develop intestinal incarceration and adhesion to the hernia orifice without the peritoneum immediately after RARP.

BACKGROUND: Although recent studies have shown that robotic gastrectomy offers clinical advantages over laparoscopic gastrectomy in decreasing gastric cancer (GC) morbidity, studies focusing on robotic total gastrectomy (RTG) remain limited. The current study aimed to clarify whether the use of a robotic system could clinically improve short-term outcomes. METHODS: Between January 2009 and June 2021, 371 patients diagnosed with both clinical and pathological Stage III or lower GC and underwent RTG or laparoscopic total gastrectomy (LTG) were enrolled in this study. The primary outcome was the incidence of intra-abdominal infectious complications over Clavien-Dindo classification grade IIIa. Demographic characteristics of those who underwent the RTG and LTG were matched using propensity-score matching (PSM), after which short-term outcomes were compared retrospectively. RESULTS: After PSM, 100 patients were included in each group. The RTG group had a significantly shorter duration of hospitalization following surgery [RTG 13 (11-16) days vs. LTG 14 (11-19) days; p = 0.032] and a greater number of dissected LNs [RTG 48 (39-59) vs. LTG 43 (35-54) mL; p = 0.025], despite having a greater total operative time [RTG 511 (450-646) min vs. LTG 448 (387-549) min; p < 0.001]. In addition, the RTG group had significantly fewer total complications (3% vs. 13%, p = 0.019) and intra-abdominal infectious complications (1% vs. 9%; p = 0.023). CONCLUSIONS: The current study showed that robotic surgery might improve short-term outcomes following minimally invasive radical total gastrectomy by reducing intra-abdominal infectious complications.

INTRODUCTION: Intracorporeal esophagojejunostomy is a technically demanding procedure, with many challenges. This study presents the anastomotic and technical complications associated with the mis-insertion of a linear stapler into the esophageal submucosal layer and the recovery procedure for this complication. MATERIALS AND SURGICAL TECHNIQUES: Of 100 intracorporeal esophagojejunostomy cases from 2017 to 2020, this complication occurred in three cases-one during functional end-to-end anastomosis and two during the overlap method. To recover, the residual esophageal mucosa was incised from the entry point to the top of the incomplete staple line, which was then reinforced by suturing in full thickness, including the incised mucosa. After reinforcement, the common stab incision was closed by the linear stapler or handsewn. As a result, none of the patients developed anastomotic leakage or stenosis. DISCUSSION: Mucosal dissection and suturing for recovery for the anastomotic site may be an option to address cases of mis-insertion of a linear stapler into the submucosal layer.

PURPOSE: This study aimed to investigate the clinical efficacy of lower-extremity ultrasonography screening with early intervention for deep venous thrombosis (DVT) on the incidence of venous thromboembolism (VTE) after minimally invasive surgery (MIS) for gastric cancer (GC). METHODS: Between January 2012 and December 2019, 1070 patients were diagnosed with both clinical and pathological stage I-III GC and underwent MIS at our institution. Routine ultrasonographic screening for DVT in lower extremities is performed before MIS. Patients diagnosed with DVT were preoperatively administered anticoagulant therapy. Enoxaparin was routinely administrated after surgery irrespective of the presence of DVT. The incidence of postoperative symptomatic VTE was examined retrospectively. RESULTS: A total of 74 (6.9%) patients were preoperatively diagnosed with DVT. Multivariate analyses revealed that age > 70 years (p = 0.015), female sex (p < 0.001), and positive serum D-dimer test (p < 0.001) were significant and independent risk factors for preoperative DVT. The incidence of symptomatic postoperative VTE was 1 (0.09%); symptomatic VTE developed in one patient among patients without DVT, whereas no patient with DVT developed VTE. CONCLUSIONS: Preoperative DVT screening using lower-extremity ultrasonography followed by preoperative anticoagulant therapy should be considered as a useful strategy to safely perform MIS for GC without increasing the incidence of VTE.

We report a successful case of robot-assisted surgery for Stage Ⅳ gastric cancer with liver metastasis. A 70s man diagnosed with advanced gastric cancer with S3 solitary liver metastasis, and received a chemotherapy with S-1 and cisplatin. After 4 courses of chemotherapy, liver metastatic lesion was disappeared. Thus, robotic distal gastrectomy and partial liver resection were performed. Operating time was 391 minutes, and amount of intraoperative blood loss was 11 mL. The postoperative course was uneventful, and the patient was discharged 11 days after surgery. Histologic examination revealed no viable malignant cells in the resected liver, with a diagnosis of ypT2N1M0, ypStage ⅡA. The patient is alive with no recurrence 12 months after surgery, without adjuvant chemotherapy.

BACKGROUND: Robotic gastrectomy (RG) for gastric cancer (GC) has gradually gained nationwide prominence following 2011 guidelines from the Japan Society for Endoscopic Surgery (JSES), including the surgeons' criteria and the proctor system. In this retrospective study, we examined the short-term outcomes of the initial series of RGs performed by second-generation operating surgeons trained within our institute. METHODS: Between January 2017 and April 2020, five surgeons each performed RG in 20 patients with clinical stage III or lower GC in accordance with the JSES guidelines. We evaluated both the rate of Clavien-Dindo grade II or higher morbidities and the console time required to reach the learning plateau via cumulative summation (CUSUM) analysis. RESULTS: We observed no mortality and 3% of morbidity following RG. Both the operative time (430 vs 387.5 min, P = 0.019) and console time (380 vs . 331.5 min, P = 0.009) were significantly shorter in the second 10 cases than in the initial 10 cases. We observed a remarkable trend in cases of distal gastrectomy (DG), in which the total operative time and console time were significantly shorter in the later cases. Our CUSUM analysis revealed that seven cases were required to achieve a learning plateau in RG when confined to DG. CONCLUSIONS: Non-expert RG surgeons meeting the operating surgeon's criteria from the JSES who had trained under an expert RG surgeon safely performed RG in an initial 20 cases.

A 50-year-old woman diagnosed with clinical Stage Ⅲ esophageal squamous cell carcinoma, received 2 cycles of docetaxel, cisplatin, 5-fluorouracil(DCF)therapy followed by robotic esophagectomy. In the 15th postoperative day, she suddenly had difficulty in breathing and a chest CT finding showed a large amount of right pleural effusion. Thoracocentesis yield a 1 L of chylous fluid confirmed diagnosis with postoperative chylothorax and conservative treatment was initiated. However, chylothorax was not improved. Therefore, a lipiodol lymphangiography from the inguinal lymph node was performed at the 20th postoperative day. Although the site of leakage could not identify, amount of drained pleural effusion was gradually decreased after lymphangiography, and drain was decannulated in the 28th postoperative day. Lipiodol lymphangiography may be a useful modality for both diagnosis and treatment for chylothorax after esophagectomy.

BACKGROUND: We hypothesized that the Endoscopic Surgical Skill Qualification System (ESSQS) can shorten operative time, resulting in a decrease in postoperative morbidity. Here, we aimed to clarify whether ESSQS-qualified surgeons could decrease the incidence of complications. METHODS: Between January 2009 and June 2019, 1042 patients diagnosed with both clinical and pathological Stage ≤ III gastric cancer and undergoing LG were enrolled. In all LG procedures involving ESSQS-qualified surgeons, these served as the operator or the instructive assistant. The short-term outcomes were retrospectively compared between the ESSQS-qualified and the non-ESSQS-qualified surgeons using a propensity-score matched analysis. RESULTS: After propensity-score matching, 321 patients were included in each group. No significant differences were observed in morbidity rate, and length of hospitalization following surgery, although the non-ESSQS-qualified surgeon group had a significantly longer total operative time (Non-ESSQS-qualified group, 368 [170-779] min vs. ESSQS-qualified group, 316 [147-772] min; p < 0.001), and larger estimated blood loss (Non-ESSQS-qualified group, 28 [0-702] mL vs. ESSQS-qualified group 25, [0-1069] mL; p = 0.042). Multivariate analysis revealed that operative time ≥ 360 min (OR 1.818 [1.069-3.094], p = 0.027) was identified as the only significant independent risk factor determining morbidity. CONCLUSIONS: The incidence of postoperative morbidity did not differ between patients operated by the qualified and nonqualified surgeons, as long as ESSQS-qualified surgeons provide intraoperative instructions.

BACKGROUND: Gastric cancer is the third leading cause of cancer-related death worldwide and surgical resection remains the sole curative treatment for gastric cancer. Minimally invasive gastrectomy including laparoscopic and robotic approaches has been increasingly used in a few decades. Thus far, only a few reports have investigated the oncological outcomes following minimally invasive gastrectomy. AIM: To determine the 5-year survival following minimally invasive gastrectomy for gastric cancer and identify prognostic predictors. METHODS: This retrospective cohort study identified 939 patients who underwent gastrectomy for gastric cancer during the study period. After excluding 125 patients with non-curative surgery (n = 77), other synchronous cancer (n = 2), remnant gastric cancer (n = 25), insufficient physical function (n = 13), and open gastrectomy (n = 8), a total of 814 consecutive patients with primary gastric cancer who underwent minimally invasive R0 gastrectomy at our institution between 2009 and 2014 were retrospectively examined. Accordingly, 5-year overall and recurrence-free survival were analyzed using the Kaplan-Meier method with the log-rank test and Cox regression analyses, while factors associated with survival were determined using multivariate analysis. RESULTS: Our analysis showed that age > 65 years, American Society of Anesthesiologists (ASA) physical status 3, total or proximal gastrectomy, and pathological T4 and N positive status were independent predictors of both 5-year overall and recurrence-free survival. Accordingly, the included patients had a 5-year overall and recurrence-free survival of 80.3% and 78.2%, respectively. Among the 814 patients, 157 (19.3%) underwent robotic gastrectomy, while 308 (37.2%) were diagnosed with pathological stage II or III disease. Notably, our findings showed that robotic gastrectomy was an independent positive predictor for recurrence-free survival in patients with pathological stage II/III [hazard ratio: 0.56 (0.33-0.96), P = 0.035]. Comparison of recurrence-free survival between the robotic and laparoscopic approach using propensity score matching analysis verified that the robotic group had less morbidity (P = 0.005). CONCLUSION: Age, ASA status, gastrectomy type, and pathological T and N status were prognostic factors of minimally invasive gastrectomy, with the robot approach possibly improving long-term outcomes of advanced gastric cancer.

Duodenal gastrointestinal stromal tumor(GIST)are relatively rare. Here, we report a case of a duodenal GIST located in the third portion that was successfully treated via laparoscopic local resection using the Kocher maneuver. A 49-year-old woman with a high BMI of 43.4 kg/m2 was diagnosed with a 20 mm duodenal submucosal tumor in the third portion that was suspected to be a GIST; subsequently, she underwent laparoscopic local resection. After mobilization from the first to third portion of the duodenum using the Kocher maneuver, local resection using a linear stapler was completed. The surgery time was 152 minutes, and the estimated blood loss was approximately zero. The postoperative course was uneventful, and she was discharged on the 7th postoperative day. The pathological diagnosis was ultra-low-grade GIST. This procedure can be a useful option for obese patients with good operative field of view.

BACKGROUND: In laparoscopic proximal gastrectomy, the hepatic left lateral segment often obstructs the operative field of view, especially around the esophageal hiatus. Therefore, a safe retraction method is needed. The present study aimed to determine the effectiveness of inverting the hepatic left lateral segment in laparoscopic proximal gastrectomy. METHODS: This was a retrospective review of 81 consecutive patients who underwent laparoscopic proximal gastrectomy. Patients were divided into two groups, i.e., the Nathanson liver retractor group (n = 41) and hepatic left lateral segment inverting group (n = 40). The unedited video recordings of the procedures and the patients' medical records were reviewed and compared. RESULTS: The hepatic left lateral segment inverting method provided a more satisfactory view of the operative fields and a wider working space around the esophageal hiatus than the Nathanson liver retractor. No intraoperative hepatic congestion and significantly improved postoperative liver enzyme elevations were observed with hepatic left lateral segment inverting method compared with the Nathanson liver retractor method. CONCLUSIONS: In laparoscopic proximal gastrectomy, the hepatic left lateral segment inverting method appears to provide improvements in both the operative field of view and liver protection compared with the Nathanson liver retractor method.

BACKGROUND: Minimally invasive surgery for gastric cancer (GC) has gained widespread use as a safe curative procedure especially for early GC. AIM: To determine risk factors for postoperative complications after minimally invasive gastrectomy for GC. METHODS: Between January 2009 and June 2019, 1716 consecutive patients were referred to our division for primary GC. Among them, 1401 patients who were diagnosed with both clinical and pathological Stage III or lower GC and underwent robotic gastrectomy (RG) or laparoscopic gastrectomy (LG) were enrolled. Retrospective chart review and multivariate analysis were performed for identifying risk factors for postoperative morbidity. RESULTS: Morbidity following minimally invasive gastrectomy was observed in 7.5% of the patients. Multivariate analyses demonstrated that non-robotic minimally invasive surgery, male gender, and an operative time of ≥ 360 min were significant independent risk factors for morbidity. Therefore, morbidity was compared between RG and LG. Accordingly, propensity-matched cohort analysis revealed that the RG group had significantly fewer intra-abdominal infectious complications than the LG group (2.5% vs 5.9%, respectively; P = 0.038), while no significant differences were noted for other local or systemic complications. Multivariate analyses of the propensity-matched cohort revealed that non-robotic minimally invasive surgery [odds ratio = 2.463 (1.070-5.682); P = 0.034] was a significant independent risk factor for intra-abdominal infectious complications. CONCLUSION: The findings showed that robotic surgery might improve short-term outcomes following minimally invasive radical gastrectomy by reducing intra-abdominal infectious complications.

A 69-year-old woman, who complained of loss of appetite, was admitted to our hospital and diagnosed with clinical Stage Ⅳgastric cancer and paraaortic lymph node metastases(cT4aN3M1[#16b1LYM], cStage Ⅳ). She underwent 2 cycles of SP therapy(combination of S-1 and CDDP). A partial response of the primary tumor was noted, with no distant metastases, except for the paraaortic lymph nodes. She underwent robotic total gastrectomy with D2 plus paraaortic lymph node dissection. Histopathology showed no residual tumor cells in the stomach or lymph nodes. Postoperatively, the patient underwent 3 cycles of SOX therapy(combination of S-1 and oxaliplatin)and survived for over 6 postoperative months, with no recurrences. For advanced gastric cancers with paraaortic lymph node dissection with no evidences of other distant metastases, gastrectomy with paraaortic lymph node dissection combined with chemotherapy could be a therapeutic option to achieve R0 resection.

OBJECTIVES: Current evidence regarding metabolic surgery suggests that different types of digestive tract reconstruction can result in differences in postoperative glucose tolerance. This study evaluated the impact of Billroth I (B-I), Billroth II (B-II), and Roux-en-Y (R-Y) procedures on peri-operative glucose tolerance in patients with gastric carcinoma who had diabetes mellitus. METHODS: A single-institution, retrospective cohort study was conducted using data from patients who underwent totally laparoscopic distal gastrectomy. These patients were grouped according to the type of reconstruction (B-I, B-II, or R-Y). After the operation, we addressed the changes in glucose tolerance-including changes in HbA1c levels, remission of diabetes, and overall effects of the treatment. RESULTS: We studied 57 patients (B-I, n=32; B-II, n=17; R-Y, n=8). B-II and R-Y reconstruction improved HbA1c levels more than B-I. Notably, R-Y improved tolerance the most (B-I vs. B-II, p<0.001; B-I vs. R-Y, p<0.001; B-II vs. R-Y, p<0.001). The type of reconstruction (B-II and R-Y vs. B-I) and a pre-operative HbA1c ≥7% were the two significant independent contributing factors determining postoperative improvement in HbA1c, with odds ratio (OR) 8.437, 95% confidence interval (CI) 1.635-43.527, p=0.011; OR 16.5, 95% CI 3.361-81.011, p=0.001, respectively. CONCLUSIONS: Either R-Y or B-II should be considered the primary option for patients with gastric carcinoma and diabetes when glycemic control is insufficient.

OBJECTIVES: Anastomotic leak is a common complication after esophagectomy for esophageal cancer. This study evaluated the impact of the Kocher maneuver on the incidence of anastomotic leak following esophagogastrostomy using a 3-cm-wide gastric conduit. METHODS: This single-institution, retrospective, cohort study included 43 patients who underwent thoraco-laparoscopic esophagectomy. The Kocher maneuver was not performed in the first half of the study period between April 2014 and May 2015 (first half group, n=14), but was performed in the second half between May 2015 and January 2017 (second half group, n=29). Primary endpoint was the incidence of anastomotic leak. Metrological values of the gastric conduit were postoperatively assessed on computed tomography. Blood perfusion of the gastric conduit was prospectively examined using the indocyanine green fluorescence method. RESULTS: The incidence of anastomotic leak was 14%; the incidence was significantly lower in the second half group than in the first half group (3.4% vs. 35.7%, p=0.01). The Kocher maneuver was the only significant independent risk factor associated with anastomotic leak (OR 0.064, 95% CI 0.007-0.625, p=0.018). The postoperative length of the entire gastric conduit was significantly shorter in the second half group than in the first half group. A more anal location of the 3-cm-wide gastric conduit was associated with better blood perfusion. CONCLUSIONS: The Kocher maneuver may enable shortening of the gastric conduit, leading to better blood perfusion of the tip of the gastric conduit, and a significant reduction in the occurrence of anastomotic leak.

PURPOSE: This study aimed to evaluate the feasibility and safety of intracorporeal anastomosis with Billroth I, Billroth II, or Roux-en-Y reconstructions in totally laparoscopic distal gastrectomy. MATERIALS AND METHODS: A single-institution, retrospective, cohort study including 553 patients was conducted. Intracorporeal isosceles right triangle-shaped anastomosis without slack and torsion was created using linear staplers. Billroth I was primarily used. Surgical outcomes and perioperative nutritional status were assessed. RESULTS: Morbidity was 11.5%. Postoperative early complications related to anastomosis occurred in 13 patients (2.4%). Operative time and reconstruction type (Billroth I vs. others) were the only significant independent risk factors determining postoperative early and late complications, respectively. No difference was observed in postoperative changes in nutritional status across the groups, although Billroth II increased reflux esophagitis requiring medication. CONCLUSIONS: Intracorporeal isosceles right triangle-shaped anastomosis using linear staplers in totally laparoscopic distal gastrectomy, in combination with our selection algorithm for type of reconstruction, is feasible and safe.

BACKGROUND: Higher morbidity in total gastrectomy than in distal gastrectomy has been reported, but laparoscopic subtotal gastrectomy (LsTG) has been reported to be safe and feasible in early gastric cancer (GC). We determined the surgical, nutritional and oncological outcomes of LsTG for advanced gastric cancer (AGC). METHODS: Of the 816 consecutive patients with GC who underwent radical gastrectomy at our institution between 2008 and 2012, 253 who underwent curative laparoscopic gastrectomy (LG) for AGC were enrolled. LsTG was indicated for patients with upper stomach third tumors, who hoped to avoid total gastrectomy, <4 cm to the esophagogastric junction and a 2-cm proximal margin with cut end negative in frozen section, whereas laparoscopic conventional distal gastrectomy (LcDG) and laparoscopic total gastrectomy (LTG) were performed otherwise. Surgical outcomes and postoperative nutritional status were primarily assessed. RESULTS: Of 253 patients, the morbidity (Clavien-Dindo classification grade ≥ III) was 17.0% (43 patients). The 3-year overall survival and 3-year recurrence-free survival rates were 80.2 and 73.5%, respectively. LcDG, LsTG and LTG were performed in 121, 27 and 105 patients, individually. Morbidity was strongly associated with LTG (P = 0.001). Postoperative loss of body weight was significantly greater after LTG in comparison with LcDG or LsTG (P < 0.001). No difference in morbidity and postoperative loss of body weight were observed between LcDG and LsTG group. CONCLUSIONS: LG for AGC was feasible and safe surgically and oncologically. LsTG for AGC may be safer than LTG from surgical and postoperative nutritional point of view.

INTRODUCTION: Delta-shaped anastomosis has been recognized as a method of intracorporeal Billroth I anastomosis in totally laparoscopic distal gastrectomy. However, the technical aspects and outcomes of the delta-shaped anastomosis in totally robotic distal gastrectomy have never been reported. METHODS: A single-institutional, non-randomized, retrospective study was performed between 2009 and 2013. During the study period, 47 patients underwent robotic distal gastrectomy followed by robotic delta-shaped Billroth I reconstruction, and 165 patients underwent conventional laparoscopic distal gastrectomy followed by laparoscopic delta-shaped Billroth I reconstruction. After 64 were excluded because of insufficient intraoperative video, 43 patients in the robotic group and 105 patients in the laparoscopic group were enrolled in the study. Short-term outcomes were determined from medical records and full-length operative videos. RESULTS: There were no significant differences between the robotic and laparoscopic groups in terms of morbidity (4.7% vs 3.8%), anastomosis-related complications (0% vs 1.0%), non-anastomosis-related complications (2.3% vs 0%), or systemic complications (2.3% vs 0%). Time for reconstruction did not vary between the robotic group (16.6 min [8.8-42.9 min]) and the laparoscopic group (15.8 min [7.2-41.0 min]). There was no mortality in this series. In the conventional group, the morbidity rate was 3.8%. The anastomosis-related complication rate was 1.0% in the conventional group. CONCLUSIONS: Given the excellent short-term outcomes related to anastomosis, delta-shaped anastomosis after robotic distal gastrectomy was at least as feasible and safe as delta-shaped anastomosis after laparoscopic distal gastrectomy.

BACKGROUND: We have established a standard procedure for Roux-en-Y (RY) reconstruction in laparoscopic total gastrectomy (LTG) using esophagojejunostomy by the overlap method (OL). We report on our RY reconstruction technique and special approaches, and evaluate the usefulness of our reconstruction method based on the surgical results of 100 patients we have experienced to date. METHODS: We performed LTG in 100 patients with gastric cancer. After total gastrectomy using five ports, the resected stomach was extracted through a small laparotomy. Through that, we performed sacrifice of the jejunum, Y limb anastomosis, creation of the lifted jejunum. As the OL, a side-to-side anastomosis of the lifted jejunum to the esophageal stump was laparoscopically performed using a linear stapler in an isoperistaltic direction, and the entry hole was closed with full-thickness suturing. The lifted jejunum was fixed with suture to the duodenal stump at a location where the esophagojejunostomy site was made linear, and the duodenal stump was buried. The mesenteric gap was laparoscopically closed with suture. RESULTS: The median operative time in 100 patients undergoing LTG was 385 min, the median blood loss was 65 mL, and the median time required for the OL was 32 min. The mean hospitalization period was 10 days, and postoperative complications included bleeding requiring reoperation in one patient; other complications such as pancreatic fistula in five patients (5 %) were treated conservatively. No complication associated with anastomosis occurred. CONCLUSION: In RY reconstruction using the OL, there were no complications associated with the anastomosis site in 100 consecutive patients, such as anastomotic leak or stenosis, indicating that it is a very useful and safe reconstruction method.

BACKGROUND: Various methods of reconstruction after laparoscopic distal gastrectomy (LDG) have been developed and published, whereas only a limited number of reports are available on the utility of the delta-shaped anastomosis (Delta). This study compared Delta and Roux-en-Y anastomoses (RY), with the aim to clarify the utility of Delta. METHODS: Stage 1 gastric cancer patients who had undergone LDG with Delta (group D, n = 68) and those who had undergone LDG with RY (group RY, n = 60) were compared in terms of operative outcomes, postoperative clinical symptoms, gastrointestinal fiberscopic findings, and changes in body weight. RESULTS: Both the operative and anastomotic times were significantly shorter in group D (230 and 13 min, respectively) than in group RY (258 and 38 min, respectively) (p < 0.001). Among the complications observed at the anastomotic site, obstruction was seen in one group D patient and two group RY patients but was relieved with conservative management. Postoperative clinical symptoms were reported for 26.4% of the group D patients but had decreased to 5.9% 1 year later. Group RY yielded similar results. Upper gastrointestinal fiberscopy performed 1 year postoperatively showed no intergroup differences in the incidence of gastritis or residual retention and a significantly more frequent occurrence of bile reflux in group D. Postoperative weight changes did not differ between the two groups. CONCLUSIONS: Delta reconstruction after LDG is a safe and effective procedure that is totally laparoscopic, less time consuming, and associated with a favorable postoperative course and a better quality of life.