634 ROBOTIC-ASSISTED HIATAL HERNIA AND GASTROESOPHAGEAL DISEASE SURGERY: INITIAL RESULTS AND EXPERIENCE IN A SINGLE INSTITUTION

Gastroesophageal reflux disease, associated with sliding or large paraesophageal hiatal hernia, represents a common disease that frequently needs a surgical solution. The repair of large paraesophageal hiatal hernias is still a challenge in minimally invasive surgery but the robotic approach seems to gain widespread acceptance because offers enhanced visualization, dexterity and reach, which may facilitate the hiatal reconstruction and mediastinal dissection. Methods Between June 2019 and February 2021, 23 patients (5 male, 18 female) underwent robotic approach fundoplication (19 sliding hernia, 3 paraesophageal and 2 gastroesophagic reflux) after being pre operative diagnosed. All surgeries were elective. Biosynthetic tissue absorbable mesh was applied in one patient with double time recurrence hernia. Sixteen patients underwent total fundoplication (Nissen), 6 patients had Toupet fundoplication, and one patient had hiatus repair without fundoplication. Results The mean age of the patients was 61 years. Biosynthetic mesh was used in one patient. The mean operative time was 127 minutes (80-240) and no intraoperative complications were described. There were no conversions to open or laparoscopic procedures. Nine of the twenty-three patients underwent redo hiatal hernia repairs and the mean hospital stay was 2 days. Only one patient had a major complication (Clavien Dindo 3b) requiring urgent surgery. The early and 30 day mortality rate was 0%. Conclusion In our experience, robotic approach to paraesophageal repair seems safe and effective with low complication rates even in high-risk patients and those with redo surgery. Subjectively, the robotic approach provides the surgeon better vision and maneuverability during the intervention. We hope to progressively increase the number of robotic cases to analyse long-term clinical outcomes such as hiatal hernia recurrences, need of medical therapy and quality of life.

66 SHORT-TERM RESULTS OF RADICAL SURGERY FOR ESOPHAGEAL CANCER WITHOUT THORACOTOMY

In recent years, surgery without thoracotomy for esophageal cancer has been reported by performing mediastinoscope and laparoscope-assisted esophagectomy. It is reported that this procedure reduces pulmonary complications. Methods Since June 2018, we introduced this surgical operation for esophageal cancer patients using mediastinoscope without thoracotomy. The patient was placed in a supine position and tilts head slightly to the right with bilateral lung ventilation. The upper mediastinal dissection, using a left cervical approach, was performed with a single-port mediastinoscopic technique using LigaSure™ Maryland. But the lymph nodes along the right recurrent laryngeal nerve (RLN) were dissected under direct vision using a right cervical approach. And then, the operation and the course after the operation were examined. Results We experienced 14 cases of surgery by February 2020 and have experienced only one pulmonary complication in the course of the surgery. This case had a left recurrent nerve palsy as a complication after surgery. For this reason, aspiration was combined, but it improved immediately. There were 2 patients that lung cancer and COLD (Chronic Obstructive Pulmonary Disease), but pneumonia did not occur. Suture failure was very high frequent. However, this complication decreased over time. Conclusion We reported that pneumonia after esophageal cancer surgery deteriorates the prognosis. Suppression of pneumonia by this operation formula can be expected to improve the prognosis.

Video mediastinoscopy-assisted superior mediastinal dissection in the treatment of thyroid carcinoma with mediastinal lymphadenopathy: preliminary results

Background Mediastinal lymph node metastases (MLNM) are not rare in thyroid cancer, but their treatment has not been extensively studied. This study aimed to explore the preliminary application of video mediastinoscopy-assisted superior mediastinal dissection in the diagnosis and treatment of thyroid carcinoma with mediastinal lymphadenopathy. Materials and methods We retrospectively reviewed the clinical pathologic data and short-term outcomes of thyroid cancer patients with suspicious MLNM treated with video mediastinoscopy-assisted mediastinal dissection at our institution from 2017 to 2020. Results Nineteen patients were included: 14 with medullary thyroid carcinoma and five with papillary thyroid carcinoma. Superior mediastinal nodes were positive in nine (64.3%) patients with medullary thyroid carcinoma and in four (80.0%) patients with papillary carcinoma. No fatal bleeding occurred. There were three cases of temporary recurrent laryngeal nerve (RLN) palsy postoperatively, one of which was bilateral. Four patients had temporary hypocalcemia requiring supplementation, one had a chyle fistula, and one developed wound infection after the procedure. Postoperative serum molecular markers decreased in all patients. One patient died of cancer while the other 18 patients remained disease-free, with a median follow-up of 33 months. Conclusion Video mediastinoscopy-assisted superior mediastinal dissection can be performed relatively safely in patients with suspicious MLNM. This diagnostic and therapeutic approach may help control locoregional recurrences.

Case Report: Modified Thoracoscopic-Assisted Cervical Resection for Retrosternal Goiter

Introduction: The treatment of choice for retrosternal goiters (RSG) is surgical resection to relieve symptoms and rule out malignancy. Although the majority of RSG can be removed by a cervical approach only, an extracervical approach (e.g., sternotomy, thoracotomy or thoracoscopy) may be required. Herein, we describe a refined thoracoscopic-assisted cervical two-team RSG resection without thoracoscopic mediastinal dissection.Technique: A 57-year-old man presented with a large RSG with posterior mediastinal extension (PME) and extensive peritumoral vascularization. Due to its extension below the aortic arch and its small connection with the right thyroid lobe, a combined cervical and thoracoscopic approach was intended. The endocrine surgery unit performed the cervical mobilization of the right thyroid lobe, while the thoracic surgery unit gently pushed the mediastinal tumor through the thoracic inlet without performing mediastinal dissection. This allowed a safe visualization of the inserting vessels by the endocrine surgery team at the neck, followed by a stepwise division of the vessels and resection of the retrosternal nodule through the cervical access.Comment: The described approach is indicated for RSG with posterior mediastinal extension, anteroposterior dimension smaller than the thoracic inlet and inaccessibility from a cervical approach only. This minimally invasive approach is associated with a faster recovery, decreased morbidity and postoperative pain, shorter hospital stay and better cosmetic results.

New Technique for Intrathoracic Implantation of Extraluminal Spiral Prostheses in the Trachea

Background: Extraluminal surgical procedures for intrathoracic tracheal collapse in dogs are not routinely performed. The patients are normally treated with different drugs or by intraluminal stents. However, in more severe cases, drug treatment does not always have good outcomes, and intraluminal prostheses can be correlated to several postoperative problems. In order to obtain better results, we aimed to develop a surgical technique for implantation of a new extraluminal helical prosthesis in the thoracic segment of the trachea through cervical access, associated with pneumatic mediastinoscopy for certification of the technique and minimization of possible complications.Materials, Methods & Results: Seven canine corpses (CCs) from non-traumatic death, weighing between 2 and 7 kg, were used. A ventral cervical approach to the trachea was associated with blunt mediastinal dissection. Trans cervical pneumatic mediastinoscopy was used for evaluation of the dissection and location of the implant. These were compared with the necropsy findings by the exact Wilcoxon two-sample test, with P < 0.05. The results of necropsy and mediastinoscopy did not present significant differences at P < 0.05. During the examinations, the presence of some mediastinal visceral lesions caused by the prosthesis, the integrity of the mediastinum and possible lesions to RLN and blood vessels (BV) were analyzed. We also investigated the location of the distal part of the prosthesis in the thoracic segment of the trachea and its dissection. To evaluate the technique, statistical comparison was made between mediastinoscopy and necropsy findings. The data were compared by the Wilcoxon test at 5% probability. The tracheas of all CCs were efficiently dissected, but in some cases problems that can happen during the procedure were noticed. This was checked by mediastinoscopy and confirmed by necropsy. The median of the scores was 1 (good dissection and visualization), with variance of zero for mediastinoscopy and 0.14 for necropsy. In the mediastinoscopy of one CC, the prosthesis crossed the tracheal bifurcation, involving the posterior vessels of this region, which was confirmed by necropsy. However, the dissection showed no vascular lesions. The integrity of the mediastinum was assessed only by mediastinoscopy. There was no impairment caused by any of the procedures performed. This resulted in a median score of 1 (integrity) with zero variance. When the positioning of the prosthesis was evaluated in relation to the tracheal bifurcation, identical values were obtained by both methods. The median score was 1, with variance of 0.62. No statistical differences were found between the two evaluation methods for the analyzed variables. This demonstrates the strong potential of the proposed evaluation techniques.Discussion: Our results show that the execution of the technique is possible, but some complications may occur. Mediastinoscopy as an evaluation procedure can pose some complications, these considerations are important, but by using technique proposed in this study, these factors are minimized due to the ease of technical implantation of the extraluminal tracheal stent, without the need for several instruments competing in the inflated mediastinal space. We concluded that the technique is viable and a safe method with minimal invasion for investigation and treatment of mediastinal diseases, presenting low impairment of the paratracheal structures, and that mediastinoscopy can be used as a transoperative evaluation method to minimize complications.