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Luigi MARANO

San Matteo degli Infermi Hospital, AUSL Umbria 2
Spoleto, Italy
MD, PhD
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Robotic Nissen fundoplication with the da Vinci Xi robotic surgical system
For a long time, laparoscopic Nissen fundoplication has been used to treat gastroesophageal reflux disease (GERD). The main challenges of laparoscopic Nissen fundoplication involve the 2-dimensional visualization, exposure of complex gastroesophageal anatomy, and suturing of the wrap fundoplication. In 1999, robotic Nissen fundoplication, a completely new technique, was introduced, demonstrating advantages over conventional laparoscopic surgery due to improved manual dexterity, ergonomics, and 3-dimensional visualization. However, time spent on robotic platform docking and arm clashing during the procedure are factors that surgeons often find cumbersome and time-consuming. The newest surgical platform, the da Vinci Xi surgical robotic system, can help to overcome such problems. This video shows a stepwise approach of the da Vinci Xi docking process and surgical technique demonstrating fundoplication according to the Nissen technique.
L Marano, A Spaziani, G Castagnoli
Surgical intervention
1 month ago
555 views
1 like
2 comments
07:00
Robotic Nissen fundoplication with the da Vinci Xi robotic surgical system
For a long time, laparoscopic Nissen fundoplication has been used to treat gastroesophageal reflux disease (GERD). The main challenges of laparoscopic Nissen fundoplication involve the 2-dimensional visualization, exposure of complex gastroesophageal anatomy, and suturing of the wrap fundoplication. In 1999, robotic Nissen fundoplication, a completely new technique, was introduced, demonstrating advantages over conventional laparoscopic surgery due to improved manual dexterity, ergonomics, and 3-dimensional visualization. However, time spent on robotic platform docking and arm clashing during the procedure are factors that surgeons often find cumbersome and time-consuming. The newest surgical platform, the da Vinci Xi surgical robotic system, can help to overcome such problems. This video shows a stepwise approach of the da Vinci Xi docking process and surgical technique demonstrating fundoplication according to the Nissen technique.
Robotic Heller myotomy with Dor fundoplication for esophageal achalasia
Achalasia is an esophageal motility disorder characterized by an incomplete or absent esophagogastric junction (EGJ) relaxation associated with loss of peristalsis or uncoordinated contractions of the esophageal body in response to swallowing. All available treatments for achalasia are palliative, directed towards the elimination of the outflow resistance caused by abnormal lower esophageal sphincter (LES) function and aiming to improve the symptoms related to esophageal stasis, such as dysphagia and regurgitation. Laparoscopic Heller myotomy with partial fundoplication is the current standard of care for the treatment of achalasia. It is associated with symptom improvement or relief in about 90% of patients. However, it is a challenging procedure with the potential risk of esophageal perforation reported in up to 10% of cases. Interestingly, laparoscopic myotomy has some limitations which depend on the laparoscopic technique (bidimensional vision, poor range of movement) and on the surgeon’s experience. Recently, the use of the robotic technology has been proposed claiming that it might reduce intraoperative esophageal perforation rates and improve postoperative quality of life after Heller myotomy, mainly due to the 3D view and enhanced dexterity of the surgeon. Despite significant improvements in surgical treatment, the length of myotomy is still a matter of debate to date. Substantially, although some authors proposed a limited myotomy on the lower esophagus preserving a small portion of the LES to prevent postoperative reflux, most authors recommended a myotomy extending 4 to 6cm on the esophagus and 1 to 2cm on the gastric side. In this video, we performed a 6cm long esophagogastric myotomy, with a 2.5cm proximal extension above the Z-line (endoscopically recognized) and a 3.5cm distal extension below the same landmark. In a previous experimental study with intraoperative computerized manometry, we observed that myotomy of the esophageal portion of the LES (without dissection of the gastric fibers) did not lead to any significant variation in sphincteric pressure. Instead, the dissection of the gastric fibers for at least 2 to 2.5cm on the anterior gastric wall created a significant modification of the LES pressure profile. This may be due to the interruption of the anterior portion of gastric semicircular clasp and sling fibers, with consequent loss of their hook properties on the LES pressure profile.
L Marano, A Spaziani, G Castagnoli
Surgical intervention
7 months ago
869 views
4 likes
0 comments
08:13
Robotic Heller myotomy with Dor fundoplication for esophageal achalasia
Achalasia is an esophageal motility disorder characterized by an incomplete or absent esophagogastric junction (EGJ) relaxation associated with loss of peristalsis or uncoordinated contractions of the esophageal body in response to swallowing. All available treatments for achalasia are palliative, directed towards the elimination of the outflow resistance caused by abnormal lower esophageal sphincter (LES) function and aiming to improve the symptoms related to esophageal stasis, such as dysphagia and regurgitation. Laparoscopic Heller myotomy with partial fundoplication is the current standard of care for the treatment of achalasia. It is associated with symptom improvement or relief in about 90% of patients. However, it is a challenging procedure with the potential risk of esophageal perforation reported in up to 10% of cases. Interestingly, laparoscopic myotomy has some limitations which depend on the laparoscopic technique (bidimensional vision, poor range of movement) and on the surgeon’s experience. Recently, the use of the robotic technology has been proposed claiming that it might reduce intraoperative esophageal perforation rates and improve postoperative quality of life after Heller myotomy, mainly due to the 3D view and enhanced dexterity of the surgeon. Despite significant improvements in surgical treatment, the length of myotomy is still a matter of debate to date. Substantially, although some authors proposed a limited myotomy on the lower esophagus preserving a small portion of the LES to prevent postoperative reflux, most authors recommended a myotomy extending 4 to 6cm on the esophagus and 1 to 2cm on the gastric side. In this video, we performed a 6cm long esophagogastric myotomy, with a 2.5cm proximal extension above the Z-line (endoscopically recognized) and a 3.5cm distal extension below the same landmark. In a previous experimental study with intraoperative computerized manometry, we observed that myotomy of the esophageal portion of the LES (without dissection of the gastric fibers) did not lead to any significant variation in sphincteric pressure. Instead, the dissection of the gastric fibers for at least 2 to 2.5cm on the anterior gastric wall created a significant modification of the LES pressure profile. This may be due to the interruption of the anterior portion of gastric semicircular clasp and sling fibers, with consequent loss of their hook properties on the LES pressure profile.