Innovative microsurgical treatment of male external genitals lymphedema

Secondary lymphedema of male external genital organs,characterized by increase in genital organs volume,tissue fibrosis,erysipelas,and objective difficulties in the normal use of lower limbs and the penis,is a very common and impairing consequence of invasive surgery,radical lymphadenectomy and radiotherapy of the pelvic-inguinal area.Standard surgical approach to lymphedema are either very invasive and/or at high risk of lymphedema recurrence and do not guarantee an efficient long-term treatment.Alternatively,we developed a microsurgical technique to perform direct anastomoses between the lymphatic collectors of the spermatic funiculum afferent to the external iliac chains and the vessels tributary to the spermatic vein.This innovative approach,although surgically demanding,provided a long term successful treatment of external genitals with no clinical complications,low invasivity,rapid post-surgical recovery,minor tissue demolition and satisfactory post-surgical functional and esthetic results.In addition,lympho-venous microsurgery seems to trigger the local development of new lymphatic vessels that notonly canalize along new collecting channels,but also form complex meshes in proximity to the anastomosis area,thus improving lymphedema also in adjacent tissues like lower limbs,supplied by lymphatics emptying into common developed lymphatic shunt.

Evaluation of the economic impact of the robotic approach in major and postero-superior segment liver resections: a multicenter retrospective analysis

Background:Economic impact of robotic liver surgery(RLS)is still a debated issue due to the heterogeneity of liver resections considered and the lack of a rigorous methodology.Therefore,the aim of this study is to perform a time-driven activity-based costing(TD-ABC)comparing the costs of RLS,laparoscopic liver surgery(LLS)and open liver surgery(OLS)in the context of complex liver resections and to compare short term perioperative outcomes.Methods:The institutional databases of two Italian high volume hepatobiliary centres were retrospectively reviewed from February 2021 to April 2022.Patients submitted to major hepatectomies or postero-superior liver resections were selected and divided into three groups according to the approach scheduled(RLS,LLS and OLS)and compared.Major contributors of perioperative expenses were calculated using the TD-ABC model and accurately quantifying each unit resource consumed per patient and the time spent performing each activity.A primary intention-to-treat analysis(ITT-A)including conversions in the RLS and LLS groups was performed.Results:Forty-seven RLS,101 LLS and 124 OLS were collected.LLS and RLS showed reduced blood loss,morbidity,mortality and hospital stay compared with open.A trend towards reduced conversion rate in RLS compared to LLS was registered.Total costs associated with RLS were estimated at€10,637 vs.€9,543 for LLS and vs.€13,960 for OLS.The higher intraoperative costs associated with RLS(+153.3%vs.OLS and+148.2%vs.LLS,P<0.001),primarily related to surgical equipment expenses,were slightly offset by the postoperative savings(−56.0%vs.OLS and−29.4%vs.LLS,P<0.001)resulting from significantly reduced hospital stays.Conclusions:RLS offers economic advantages over OLS,as initial higher costs are offset by better perioperative outcomes.The evolving robotic marketplace is expected to drive down RLS costs,promoting widespread adoption in minimally invasive procedures.Despite its higher costs than LLS,RLS’s ability to enhance minimally invasive feasibility makes it a preferred choice for complex cases,reducing the need for conversions.

Have we really understood when the efforts of laparoscopic liver resection are justified?-a complexity-based appraisal of the differential benefit

Background:The implementation of minimally invasive liver resection surgery(MILS)programs starts from procedures with a low degree of technical difficulty.Data regarding the real short-term advantage of laparoscopy according to technical difficulty are still lacking.The aim of the present study is to evaluate the differential benefit of laparoscopic over open technique according to the technical difficulty of the procedures and to investigate if efforts associated with laparoscopic approach are always justified.Methods:Nine hundred and thirty-six MILS resections performed between 2005 and 2018 were stratified according to technical complexity(low,intermediate and high difficulty)and to approach(MILS or open)and matched in a 1:1 ratio using propensity scores to obtain three pairs of groups(Pair 1:Low-MILS and Low-Open,including 274 cases respectively;Pair 2:Int-MILS and Int-Open,including 237 patients respectively;Pair 3:High-MILS and High-Open,including 226 patients respectively).Results:MILS approach resulted in a statistically significant lower blood loss,reduced morbidity,reduced and shorter time for functional recover and length of stay within all pairs.The evaluation of the differential benefit showed a greater advantage of laparoscopic approach in high degree procedures compared with intermediate and low degree,both in terms of blood loss(-250 and-200 mL respectively)and morbidity rate(-5.7%and-4.1%respectively).Conclusions:The favorable biological scenario associated with laparoscopic approach allows to obtain significant benefits in the setting of technically complex procedures.The commitment towards MILS approach should be therefore stronger in this setting,where the advantage of laparoscopy seems to be enhanced.

Liver resection for hepatocellular carcinoma within a fast-track management: a propensity-score matched analysis between open and laparoscopic approach

Aim:The study was designed to assess the implications of enhanced recovery after surgery(ERAS)approach in patients submitted to open liver resection for hepatocellular carcinoma(HCC)comparing their short term outcome with patients treated by laparoscopic approach,in a case-matched design.Methods:The open-group(n=60)was matched in a ratio of 1:1 with patients undergoing laparoscopic liver resection for HCC(Lap-group,n=60),with a matching achieved on a basis of propensity scores including 6 covariates representing patients characteristics and severity of the disease.Primary outcome analysis was performed in terms of ERAS-specific items and postoperative morbidity and mortality.Results:Overall morbidity and mortality were comparable between groups.Incidence of ascites was slightly higher in the open-compared with the Lap-group(respectively 11.7%and 13.3%),without statistical significance.The need for introduction or increase of chronic diuretic therapy was significantly higher in the open-compared with the Lap-group(16.7%vs.11.7%,P=0.046).Furthermore,ascites more frequently required percutaneous drainage in the open-compared with the Lap-group(5%vs.1.7%respectively,P=0.041).Conclusion:In patients who can’t benefit from minimally-invasive approach because of disease characteristics,ERAS management seems to be associated with an improved postoperative functional recovery and postoperative outcomes,comparable to those of the minimally invasive approach.