Transanal endoscopic microsurgery (TEM) has revolutionized the technique and outcomes of transana... more Transanal endoscopic microsurgery (TEM) has revolutionized the technique and outcomes of transanal surgery, becoming the standard of treatment for large sessile rectal adenomas, and may represent a possible treatment modality for early rectal cancer. Methods A full-thickness excision is made on the rectal wall down to the perirectal fatty tissue. The specimen is retrieved transanally. After the parietal defect is disinfected, the wound is closed with one or more running sutures secured with silver clips. Results Peritoneal perforation during TEM is not associated with adverse short-term or oncologic outcomes. The postoperative morbidity rate ranges between 2 % and 15 %, and in most cases, complications can be conservatively managed. The local recurrence rate of large adenomas is about 6 %, and most recurrences can be safely re-resected by TEM. TEM represents an effective treatment for pT1 sm1 rectal malignancies, while pT1 sm2-3 and pT2 should be considered at high risk of recurrence if treated by TEM alone. Finally, TEM does not influence anorectal function or quality of life. Conclusion TEM is a safe procedure and provides excellent functional and oncologic outcomes in the treatment of large sessile benign rectal lesions and selected early rectal cancers.
Background and aimIn presence of malignant dysphagia, in patients unfit for surgery, the placemen... more Background and aimIn presence of malignant dysphagia, in patients unfit for surgery, the placement of a self‐expandable metal stent (SEMS) represents a safe and effective palliative treatment. Esophageal stents (ES) present an over‐the‐wire mechanism where the stent is deployed under X‐ray control. Recently a through‐the‐scope (TTS) ES was launched. The aim of our retrospective study is to assess the technical and clinical success of the new TTS‐ES.Materials and methodsPatients with malignant dysphagia caused by esophageal cancer or ab‐extrinsic compression, who underwent TTS esophageal stent in six Italian endoscopic referral centers, were retrospectively reviewed.ResultsA total of 40 patients were enrolled. TTS stent placement was successful in 39/40 patients (97.5%). 31 patients had an Ogilvie score of 4, nine an Ogilvie 3. After 2 weeks from stent placement 29 reported Ogilvie score of 0, eight a score of 1. None of the patients developed retrosternal pain requiring drugs. No pa...
Endoscopic Follow-up of Digestive Anastomosis, 2014
After esophagectomy, the surgical defect is reconstructed to form an esophageal conduit to mainta... more After esophagectomy, the surgical defect is reconstructed to form an esophageal conduit to maintain the continuity of digestive tract. The reconstruction requires the transposition of stomach (gastric pull-up), intestinal graft, or musculocutaneous graft to replace the esophagus. Despite continuous refinements over decades, this technique is still associated with high risk of graft-related complications such as necrosis, leakage, fistula, strictures, or impaction. Local recurrence of primary esophageal cancer and development of metachronous cancers in the remnant esophagus are constant risks for neoplastic patients undergoing esophagectomy. Failure to detect these complications during follow-up may lead to severe or even fatal outcomes. Therefore, a rigorous postoperative surveillance is always justified. Being a safe tool with versatile diagnostic and therapeutic utilities, endoscopy deserves a central role in the physician’s armamentarium in the postoperative management of esophageal reconstruction.
International Journal of Advanced Robotic Systems, 2015
In this paper a simple but effective measuring system for endoluminal procedures is presented. Th... more In this paper a simple but effective measuring system for endoluminal procedures is presented. The device allows measuring forces during the endoluminal manipulation of tissues with a standard surgical instrument for laparoscopic procedures. The force measurement is performed by recording both the forces applied directly by the surgeon at the instrument handle and the reaction forces on the access port. The measuring system was used to measure the forces necessary for appropriate surgical manipulation of tissues during transanal endoscopic microsurgery (TEM). Ex-vivo and in-vivo measurements were performed, reported and discussed. The obtained data can be used for developing and appropriately dimensioning novel dedicated instrumentation for TEM procedures.
Laparoscopy for rectal cancer reduces short-term mortality and morbidity: results of a systematic... more Laparoscopy for rectal cancer reduces short-term mortality and morbidity: results of a systematic review and meta-analysis
Background Transanal endoscopic microsurgery (TEM) has revolutionized the technique and outcome o... more Background Transanal endoscopic microsurgery (TEM) has revolutionized the technique and outcome of transanal surgery, becoming the standard of treatment for large sessile rectal adenomas. Nevertheless, only a few studies have evaluated the risk factors for local recurrence in order to recommend a "tailored" approach. The aim of this study was to identify predictor variables for recurrence after TEM to treat rectal adenoma. Methods This study is a retrospective analysis of a prospective database of patients treated for large sessile rectal adenomas by TEM at our institution, with a minimum follow-up of 12 months. Age, gender, tumor diameter, distance from the anal verge, degree of dysplasia, histology, and margin involvement were investigated. Results Between January 1993 and July 2010, 293 patients with a rectal adenoma ≥3 cm underwent TEM. Postoperative morbidity rate was 7.2 % (21/293) and there was no 30-day mortality. Over a median follow-up period of 110 (range = 12-216) months, 13 patients (5.6 %) were diagnosed with local recurrence. The median time to recurrence was 10 (range = 4-33) months, with 76.9 % of recurrences detected within 12 months after TEM. At univariate analysis, tumor diameter (p = 0.007), and positive margins (p < 0.001) were shown to be significant risk factors, while multivariate analysis indicated the presence of positive margins as the only independent predictor of recurrence (p = 0.003). Conclusions TEM provides excellent oncological outcomes in the treatment of large sessile benign rectal lesions, assuring a minimal risk of resection margin infiltration at pathology examination, which represents the only risk factor for recurrence. Keywords Transanal endoscopic microsurgery Rectal adenoma Recurrence Risk factors Rectal cancer is a common disease in Western countries, with increased incidence in the elderly, males, and obese people [1, 2]. Dysplasia precedes the occurrence of invasive rectal cancer [3, 4]. Endoscopic detection and removal of rectal adenomas prevents the development of rectal cancer, significantly contributing to the "cure" of the disease [5, 6]. Complete resection of the precancerous lesion is mandatory to prevent recurrence. However, for large sessile lesions, endoscopic mucosal resection (EMR) techniques may be inadequate to achieve a documented en bloc resection, and piecemeal resection has been reported to have a recurrence rate as high as 11.2 % [7]. On the other hand, endoscopic submucosal dissection (ESD) still remains a technical challenge without clear advantages compared to EMR in terms of achieving R0 resections [8-11]. Therefore, transanal surgery is mostly indicated.
Background Sponsored by the European Commission, the FP7 STIFF-FLOP project aimed at developing a... more Background Sponsored by the European Commission, the FP7 STIFF-FLOP project aimed at developing a STIFFness controllable Flexible and Learn-able manipulator for surgical operations, in order to overcome the current limitations of rigid-link robotic technology. Herein, we describe the first cadaveric series of Total Mesorectal Excision (TME) using a soft and flexible robotic arm for optic vision in a cadaver model. Methods TME assisted by the STIFF-FLOP robotic optics was successfully performed in 2 embalmed male human cadavers. The soft and flexible optic prototype consisted of 2 modules, each measuring 60 mm in length and 14.3 mm in maximum outer diameter. The robot was attached to a rigid shaft connected to an anthropomorphic manipulator robot arm with six Degrees of Freedom (DoFs). The controller device was equipped with two joysticks. The cadavers (BMI 25 and 28 kg/m 2) were prepared according to the Thiel embalming method. The procedure was performed using three standard laparoscopic instruments for traction and dissection, with the aid of a 30° rigid optics in the rear for documentation. Results Following mobilization of the left colonic flexure and division of the inferior mesenteric vessels, TME was completed down to the pelvic floor. The STIFF-FLOP robotic optic arm seemed to acquire superior angles of vision of the surgical field in the pelvis, resulting in an intact mesorectum in both cases. Completion times of the procedures were 165 and 145 minutes respectively. No intraoperative complications occurred. No technical failures were registered. Conclusions The STIFF-FLOP soft and flexible robotic optic arm proved effective in assisting a laparoscopic TME in human cadavers, with a superior field of vision compared to the standard laparoscopic vision, especially low in the pelvis. The introduction of soft and flexible robotic devices may aid in overcoming the technical challenges of difficult laparoscopic procedures based on standard, rigid instruments.
Background Despite being considered the most effective method for colorectal cancer diagnosis, co... more Background Despite being considered the most effective method for colorectal cancer diagnosis, colonoscopy take-up as a mass-screening procedure is limited mainly due to invasiveness, patient discomfort, fear of pain, and the need for sedation. In an effort to mitigate some of the disadvantages associated with colonoscopy, this work provides a preliminary assessment of a novel endoscopic device consisting in a softly tethered capsule for painless colonoscopy under robotic magnetic steering. Methods The proposed platform consists of the endoscopic device, a robotic unit, and a control box. In contrast to the traditional insertion method (i.e., pushing from behind), a "front-wheel" propulsion approach is proposed. A compliant tether connecting the device to an external box is used to provide insufflation, passing a flexible operative tool, enabling lens cleaning, and operating the vision module. To assess the diagnostic and treatment ability of the platform, 12 users were asked to find and remove artificially implanted beads as polyp surrogates in an ex vivo model. In vivo testing consisted of a qualitative study of the platform in pigs, focusing on active locomotion, diagnostic and therapeutic capabilities, safety, and usability. Results The mean percentage of beads identified by each user during ex vivo trials was 85 ± 11%. All the identified beads were removed successfully using the polypectomy loop. The mean completion time for accomplishing the entire procedure was 678 ± 179 s. No immediate mucosal damage, acute complications such as perforation, or delayed adverse consequences were observed following application of the proposed method in vivo. Conclusions Use of the proposed platform in ex vivo and preliminary animal studies indicates that it is safe and operates effectively in a manner similar to a standard colonoscope. These studies served to demonstrate the platform's added advantages of reduced size, front-wheel drive strategy, and robotic control over locomotion and orientation. Keywords Colonoscopy Colorectal cancer Robotic endoscopy Wireless capsule endoscopy Advanced colonoscopy Self-propelling colonoscopy Presented at the 19th EAES Congress, June 15-18, 2011, Torino, Italy. Colorectal cancer (CRC) is third in terms of incidence rate among all cancers in high-income countries, accounting for 610,000 deaths worldwide in 2008 [1]. The survival rate of CRC patients can reach 90% in cases with early diagnosis [2]. For this reason, regular screening is highly
Most patients with hemorrhoidal disease may be treated conservatively Along the years several sur... more Most patients with hemorrhoidal disease may be treated conservatively Along the years several surgical options have been proposed. including closed open and semiclosed hemorrhoidectomy (HC), radiofrequency HC (LigaSure), piles' suture or Farag operation, manual and stapled haemorrhoidopexy (PPH) with or without excision of anal tags, doppler hemorrhoidal artery ligation with or without recto-anal mucopexy ano-mucosal flap circumferential HC or Whitehead-Rand procedure. Randomized prospective trials and metanalyses have been carried out with the aim of finding the gold standard operation. When carried out for advanced disease, HC appears to be more effective than PPH, which achieves good results in third degree, but carries high reintervention rate in fourth degree piles. Almost all trials comparing open and closed HC show similar outcomes. None of the costly innovations appears to be superior when compared with conventional procedures in terms of cure of the disease in the long ...
Video Journal and Encyclopedia of GI Endoscopy, 2013
Post-surgical colorectal leaks and fistulas are severe complications that dramatically increase m... more Post-surgical colorectal leaks and fistulas are severe complications that dramatically increase morbidity and mortality. Overthe-scope clip (OTSC) application, introduced in clinical practice in 2007, represents an innovative technique to seal the visceral wall for acute and chronic colorectal post-surgical leaks and fistula management. Endoscopic closure of colorectal post-surgical leaks and fistulas with OTSC is a safe technique that accomplishes a high success rate in both acute and chronic cases, including rectovaginal, rectovesical, and colocutaneous fistulas. Overall success rate is higher than 80%, as reported in the literature, in both acute and chronic situations. No OTSC-related complications have been described in the lower gastrointestinal tract so far. This article is part of an expert video encyclopedia.
The advent of endoscopic techniques changed surgery in many regards. This paper intends to descri... more The advent of endoscopic techniques changed surgery in many regards. This paper intends to describe an overview about technologies to facilitate endoscopic surgery. The systems described have been developed for the use in general surgery, but an easy application also in other fields of endoscopic surgery seems realistic. The introduction of system technology and robotic technology enables today to design a highly ergonomic solo-surgery platform. This consists of a system of devices for endoscopic surgery (HF, light source, etc...) with which the surgeon interacts directly, positioning systems for optic and instruments that the surgeon drives as the likes without assistance, and a chair to increase the comfort of the surgeon during surgery. The system of endoscopic devices named OREST (Dornier, München) designed already in 1992 opened the way to a number of systems available today that allow to the surgeon a direct control of the instrumentation. A considerable step ahead in endoscop...
Endoscopic surgery has acquired undisputed importance in the field of both general and specialise... more Endoscopic surgery has acquired undisputed importance in the field of both general and specialised surgery. The introduction of robotic technology in surgery has recently led to the development of new positioning systems for endoscopic surgery. These allow direct control of the endoscopic procedures by the surgeon, whose vision currently depends on the assistant in charge of positioning the optic camera in compliance with his wishes. We experimented different positioning systems for optics and rigid endoscopic instruments for laparoscopy, some of which were our own design. Over 400 cholecystectomies were carried out by six different surgeons on phantoms containing animal organs. The experimental systems were AESOP (Computer Motion, USA), with both foot-pedal and voice control, ENDOASSIST (Armstrong Healthcare Co. UK), controlled by a device worn by the surgeon, FIPS Endoarm (Karlsruhe Research Centre, Germany), controlled by a joystick and voice, and the passive TISKA Endoarm system...
Reducing the number of ports used to perform laparoscopic cholecystectomy (LC) is indicated as me... more Reducing the number of ports used to perform laparoscopic cholecystectomy (LC) is indicated as means of further minimising postoperative pain, allowing a rapid return to activity and work, and obtaining patient satisfaction and better cosmetic results. It is still debatable whether the three-port technique is comparably safe. Since 2001, 374 consecutive patients underwent laparoscopic cholecystectomy in elective and emergency surgery. Three ports were routinely positioned and the need for a fourth cannula was evaluated during the surgical procedure. Of the 374 consecutive cholecystectomies performed, 204 were completed with three ports and 161 needed a fourth port to be completed, while 9 required conversion to laparotomy. Patients who were operated on with just three ports were significantly younger and mostly female. Complications of procedures completed with three ports were negligible and those of procedures completed with four ports were in line with the recent literature. Our ...
Transanal endoscopic microsurgery (TEM) has revolutionized the technique and outcomes of transana... more Transanal endoscopic microsurgery (TEM) has revolutionized the technique and outcomes of transanal surgery, becoming the standard of treatment for large sessile rectal adenomas, and may represent a possible treatment modality for early rectal cancer. Methods A full-thickness excision is made on the rectal wall down to the perirectal fatty tissue. The specimen is retrieved transanally. After the parietal defect is disinfected, the wound is closed with one or more running sutures secured with silver clips. Results Peritoneal perforation during TEM is not associated with adverse short-term or oncologic outcomes. The postoperative morbidity rate ranges between 2 % and 15 %, and in most cases, complications can be conservatively managed. The local recurrence rate of large adenomas is about 6 %, and most recurrences can be safely re-resected by TEM. TEM represents an effective treatment for pT1 sm1 rectal malignancies, while pT1 sm2-3 and pT2 should be considered at high risk of recurrence if treated by TEM alone. Finally, TEM does not influence anorectal function or quality of life. Conclusion TEM is a safe procedure and provides excellent functional and oncologic outcomes in the treatment of large sessile benign rectal lesions and selected early rectal cancers.
Background and aimIn presence of malignant dysphagia, in patients unfit for surgery, the placemen... more Background and aimIn presence of malignant dysphagia, in patients unfit for surgery, the placement of a self‐expandable metal stent (SEMS) represents a safe and effective palliative treatment. Esophageal stents (ES) present an over‐the‐wire mechanism where the stent is deployed under X‐ray control. Recently a through‐the‐scope (TTS) ES was launched. The aim of our retrospective study is to assess the technical and clinical success of the new TTS‐ES.Materials and methodsPatients with malignant dysphagia caused by esophageal cancer or ab‐extrinsic compression, who underwent TTS esophageal stent in six Italian endoscopic referral centers, were retrospectively reviewed.ResultsA total of 40 patients were enrolled. TTS stent placement was successful in 39/40 patients (97.5%). 31 patients had an Ogilvie score of 4, nine an Ogilvie 3. After 2 weeks from stent placement 29 reported Ogilvie score of 0, eight a score of 1. None of the patients developed retrosternal pain requiring drugs. No pa...
Endoscopic Follow-up of Digestive Anastomosis, 2014
After esophagectomy, the surgical defect is reconstructed to form an esophageal conduit to mainta... more After esophagectomy, the surgical defect is reconstructed to form an esophageal conduit to maintain the continuity of digestive tract. The reconstruction requires the transposition of stomach (gastric pull-up), intestinal graft, or musculocutaneous graft to replace the esophagus. Despite continuous refinements over decades, this technique is still associated with high risk of graft-related complications such as necrosis, leakage, fistula, strictures, or impaction. Local recurrence of primary esophageal cancer and development of metachronous cancers in the remnant esophagus are constant risks for neoplastic patients undergoing esophagectomy. Failure to detect these complications during follow-up may lead to severe or even fatal outcomes. Therefore, a rigorous postoperative surveillance is always justified. Being a safe tool with versatile diagnostic and therapeutic utilities, endoscopy deserves a central role in the physician’s armamentarium in the postoperative management of esophageal reconstruction.
International Journal of Advanced Robotic Systems, 2015
In this paper a simple but effective measuring system for endoluminal procedures is presented. Th... more In this paper a simple but effective measuring system for endoluminal procedures is presented. The device allows measuring forces during the endoluminal manipulation of tissues with a standard surgical instrument for laparoscopic procedures. The force measurement is performed by recording both the forces applied directly by the surgeon at the instrument handle and the reaction forces on the access port. The measuring system was used to measure the forces necessary for appropriate surgical manipulation of tissues during transanal endoscopic microsurgery (TEM). Ex-vivo and in-vivo measurements were performed, reported and discussed. The obtained data can be used for developing and appropriately dimensioning novel dedicated instrumentation for TEM procedures.
Laparoscopy for rectal cancer reduces short-term mortality and morbidity: results of a systematic... more Laparoscopy for rectal cancer reduces short-term mortality and morbidity: results of a systematic review and meta-analysis
Background Transanal endoscopic microsurgery (TEM) has revolutionized the technique and outcome o... more Background Transanal endoscopic microsurgery (TEM) has revolutionized the technique and outcome of transanal surgery, becoming the standard of treatment for large sessile rectal adenomas. Nevertheless, only a few studies have evaluated the risk factors for local recurrence in order to recommend a "tailored" approach. The aim of this study was to identify predictor variables for recurrence after TEM to treat rectal adenoma. Methods This study is a retrospective analysis of a prospective database of patients treated for large sessile rectal adenomas by TEM at our institution, with a minimum follow-up of 12 months. Age, gender, tumor diameter, distance from the anal verge, degree of dysplasia, histology, and margin involvement were investigated. Results Between January 1993 and July 2010, 293 patients with a rectal adenoma ≥3 cm underwent TEM. Postoperative morbidity rate was 7.2 % (21/293) and there was no 30-day mortality. Over a median follow-up period of 110 (range = 12-216) months, 13 patients (5.6 %) were diagnosed with local recurrence. The median time to recurrence was 10 (range = 4-33) months, with 76.9 % of recurrences detected within 12 months after TEM. At univariate analysis, tumor diameter (p = 0.007), and positive margins (p < 0.001) were shown to be significant risk factors, while multivariate analysis indicated the presence of positive margins as the only independent predictor of recurrence (p = 0.003). Conclusions TEM provides excellent oncological outcomes in the treatment of large sessile benign rectal lesions, assuring a minimal risk of resection margin infiltration at pathology examination, which represents the only risk factor for recurrence. Keywords Transanal endoscopic microsurgery Rectal adenoma Recurrence Risk factors Rectal cancer is a common disease in Western countries, with increased incidence in the elderly, males, and obese people [1, 2]. Dysplasia precedes the occurrence of invasive rectal cancer [3, 4]. Endoscopic detection and removal of rectal adenomas prevents the development of rectal cancer, significantly contributing to the "cure" of the disease [5, 6]. Complete resection of the precancerous lesion is mandatory to prevent recurrence. However, for large sessile lesions, endoscopic mucosal resection (EMR) techniques may be inadequate to achieve a documented en bloc resection, and piecemeal resection has been reported to have a recurrence rate as high as 11.2 % [7]. On the other hand, endoscopic submucosal dissection (ESD) still remains a technical challenge without clear advantages compared to EMR in terms of achieving R0 resections [8-11]. Therefore, transanal surgery is mostly indicated.
Background Sponsored by the European Commission, the FP7 STIFF-FLOP project aimed at developing a... more Background Sponsored by the European Commission, the FP7 STIFF-FLOP project aimed at developing a STIFFness controllable Flexible and Learn-able manipulator for surgical operations, in order to overcome the current limitations of rigid-link robotic technology. Herein, we describe the first cadaveric series of Total Mesorectal Excision (TME) using a soft and flexible robotic arm for optic vision in a cadaver model. Methods TME assisted by the STIFF-FLOP robotic optics was successfully performed in 2 embalmed male human cadavers. The soft and flexible optic prototype consisted of 2 modules, each measuring 60 mm in length and 14.3 mm in maximum outer diameter. The robot was attached to a rigid shaft connected to an anthropomorphic manipulator robot arm with six Degrees of Freedom (DoFs). The controller device was equipped with two joysticks. The cadavers (BMI 25 and 28 kg/m 2) were prepared according to the Thiel embalming method. The procedure was performed using three standard laparoscopic instruments for traction and dissection, with the aid of a 30° rigid optics in the rear for documentation. Results Following mobilization of the left colonic flexure and division of the inferior mesenteric vessels, TME was completed down to the pelvic floor. The STIFF-FLOP robotic optic arm seemed to acquire superior angles of vision of the surgical field in the pelvis, resulting in an intact mesorectum in both cases. Completion times of the procedures were 165 and 145 minutes respectively. No intraoperative complications occurred. No technical failures were registered. Conclusions The STIFF-FLOP soft and flexible robotic optic arm proved effective in assisting a laparoscopic TME in human cadavers, with a superior field of vision compared to the standard laparoscopic vision, especially low in the pelvis. The introduction of soft and flexible robotic devices may aid in overcoming the technical challenges of difficult laparoscopic procedures based on standard, rigid instruments.
Background Despite being considered the most effective method for colorectal cancer diagnosis, co... more Background Despite being considered the most effective method for colorectal cancer diagnosis, colonoscopy take-up as a mass-screening procedure is limited mainly due to invasiveness, patient discomfort, fear of pain, and the need for sedation. In an effort to mitigate some of the disadvantages associated with colonoscopy, this work provides a preliminary assessment of a novel endoscopic device consisting in a softly tethered capsule for painless colonoscopy under robotic magnetic steering. Methods The proposed platform consists of the endoscopic device, a robotic unit, and a control box. In contrast to the traditional insertion method (i.e., pushing from behind), a "front-wheel" propulsion approach is proposed. A compliant tether connecting the device to an external box is used to provide insufflation, passing a flexible operative tool, enabling lens cleaning, and operating the vision module. To assess the diagnostic and treatment ability of the platform, 12 users were asked to find and remove artificially implanted beads as polyp surrogates in an ex vivo model. In vivo testing consisted of a qualitative study of the platform in pigs, focusing on active locomotion, diagnostic and therapeutic capabilities, safety, and usability. Results The mean percentage of beads identified by each user during ex vivo trials was 85 ± 11%. All the identified beads were removed successfully using the polypectomy loop. The mean completion time for accomplishing the entire procedure was 678 ± 179 s. No immediate mucosal damage, acute complications such as perforation, or delayed adverse consequences were observed following application of the proposed method in vivo. Conclusions Use of the proposed platform in ex vivo and preliminary animal studies indicates that it is safe and operates effectively in a manner similar to a standard colonoscope. These studies served to demonstrate the platform's added advantages of reduced size, front-wheel drive strategy, and robotic control over locomotion and orientation. Keywords Colonoscopy Colorectal cancer Robotic endoscopy Wireless capsule endoscopy Advanced colonoscopy Self-propelling colonoscopy Presented at the 19th EAES Congress, June 15-18, 2011, Torino, Italy. Colorectal cancer (CRC) is third in terms of incidence rate among all cancers in high-income countries, accounting for 610,000 deaths worldwide in 2008 [1]. The survival rate of CRC patients can reach 90% in cases with early diagnosis [2]. For this reason, regular screening is highly
Most patients with hemorrhoidal disease may be treated conservatively Along the years several sur... more Most patients with hemorrhoidal disease may be treated conservatively Along the years several surgical options have been proposed. including closed open and semiclosed hemorrhoidectomy (HC), radiofrequency HC (LigaSure), piles' suture or Farag operation, manual and stapled haemorrhoidopexy (PPH) with or without excision of anal tags, doppler hemorrhoidal artery ligation with or without recto-anal mucopexy ano-mucosal flap circumferential HC or Whitehead-Rand procedure. Randomized prospective trials and metanalyses have been carried out with the aim of finding the gold standard operation. When carried out for advanced disease, HC appears to be more effective than PPH, which achieves good results in third degree, but carries high reintervention rate in fourth degree piles. Almost all trials comparing open and closed HC show similar outcomes. None of the costly innovations appears to be superior when compared with conventional procedures in terms of cure of the disease in the long ...
Video Journal and Encyclopedia of GI Endoscopy, 2013
Post-surgical colorectal leaks and fistulas are severe complications that dramatically increase m... more Post-surgical colorectal leaks and fistulas are severe complications that dramatically increase morbidity and mortality. Overthe-scope clip (OTSC) application, introduced in clinical practice in 2007, represents an innovative technique to seal the visceral wall for acute and chronic colorectal post-surgical leaks and fistula management. Endoscopic closure of colorectal post-surgical leaks and fistulas with OTSC is a safe technique that accomplishes a high success rate in both acute and chronic cases, including rectovaginal, rectovesical, and colocutaneous fistulas. Overall success rate is higher than 80%, as reported in the literature, in both acute and chronic situations. No OTSC-related complications have been described in the lower gastrointestinal tract so far. This article is part of an expert video encyclopedia.
The advent of endoscopic techniques changed surgery in many regards. This paper intends to descri... more The advent of endoscopic techniques changed surgery in many regards. This paper intends to describe an overview about technologies to facilitate endoscopic surgery. The systems described have been developed for the use in general surgery, but an easy application also in other fields of endoscopic surgery seems realistic. The introduction of system technology and robotic technology enables today to design a highly ergonomic solo-surgery platform. This consists of a system of devices for endoscopic surgery (HF, light source, etc...) with which the surgeon interacts directly, positioning systems for optic and instruments that the surgeon drives as the likes without assistance, and a chair to increase the comfort of the surgeon during surgery. The system of endoscopic devices named OREST (Dornier, München) designed already in 1992 opened the way to a number of systems available today that allow to the surgeon a direct control of the instrumentation. A considerable step ahead in endoscop...
Endoscopic surgery has acquired undisputed importance in the field of both general and specialise... more Endoscopic surgery has acquired undisputed importance in the field of both general and specialised surgery. The introduction of robotic technology in surgery has recently led to the development of new positioning systems for endoscopic surgery. These allow direct control of the endoscopic procedures by the surgeon, whose vision currently depends on the assistant in charge of positioning the optic camera in compliance with his wishes. We experimented different positioning systems for optics and rigid endoscopic instruments for laparoscopy, some of which were our own design. Over 400 cholecystectomies were carried out by six different surgeons on phantoms containing animal organs. The experimental systems were AESOP (Computer Motion, USA), with both foot-pedal and voice control, ENDOASSIST (Armstrong Healthcare Co. UK), controlled by a device worn by the surgeon, FIPS Endoarm (Karlsruhe Research Centre, Germany), controlled by a joystick and voice, and the passive TISKA Endoarm system...
Reducing the number of ports used to perform laparoscopic cholecystectomy (LC) is indicated as me... more Reducing the number of ports used to perform laparoscopic cholecystectomy (LC) is indicated as means of further minimising postoperative pain, allowing a rapid return to activity and work, and obtaining patient satisfaction and better cosmetic results. It is still debatable whether the three-port technique is comparably safe. Since 2001, 374 consecutive patients underwent laparoscopic cholecystectomy in elective and emergency surgery. Three ports were routinely positioned and the need for a fourth cannula was evaluated during the surgical procedure. Of the 374 consecutive cholecystectomies performed, 204 were completed with three ports and 161 needed a fourth port to be completed, while 9 required conversion to laparotomy. Patients who were operated on with just three ports were significantly younger and mostly female. Complications of procedures completed with three ports were negligible and those of procedures completed with four ports were in line with the recent literature. Our ...
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