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surgical intervention video

Colectomie droite robotisée avec excision mésocolique complète et lymphadénectomie D3 pour cancer du côlon ascendant

Since Hohenberger introduced the concept of complete mesocolic excision (CME), surgery for right colon cancer has evolved significantly, leading to an oncologically optimized approach, which prioritizes the preservation of embryological anatomical planes, as well as a more extensive lymphadenectomy (1). Right colectomy with CME and D3 lymphadenectomy is a complex procedure, which ensures optimal oncological outcomes through meticulous dissection of embryological planes, precise exposure of the superior mesenteric vein axis, and ligation of feeding vessels at their true origin. This technique guarantees adequate longitudinal and circumferential resection margins, as well as an optimal lymphadenectomy in accordance with current oncological standards. For this procedure, the authors adapted the critical view concept, integrating their standardized steps (2). To maintain anatomical consistency, they followed the descriptions previously proposed by Benz *et al.* (3).

Although the oncological superiority of CME with D3 lymphadenectomy has yet to be validated by randomized controlled trials, several cohort studies have demonstrated excellent outcomes in specimen quality, completeness of tumor resection, and lymph node dissection. These factors contribute to optimal staging and a potential oncological advantage in locally advanced colon cancer. Additionally, the standardization of the technique ensures that postoperative complication rates remain comparable to those of standard right colectomy (4).

Bibliography:

1\. Hohenberger W, Weber K, Matzel K, Papadopoulos T, Merkel S. Standardized surgery for colonic cancer: complete mesocolic excision and central ligation--technical notes and outcome. Colorectal Dis 2009 May;11(4):354-64; discussion 364-5. doi: 10.1111/j.1463-1318.2008.01735.x. Epub 2009 Nov 5. PMID: 19016817.

2\. Strey CW, Wullstein C, Adamina M, Agha A, Aselmann H, Becker T, Grützmann R, Kneist W, Maak M, Mann B, Moesta KT, Runkel N, Schafmayer C, Türler A, Wedel T, Benz S. Laparoscopic right hemicolectomy with CME: standardization using the "critical view" concept. Surg Endosc 2018 Dec;32(12):5021-5030. doi: 10.1007/s00464-018-6267-0. Epub 2018 Oct 15. PMID: 30324463; PMCID: PMC6208708.

3\. Wedel T, Heimke M, Fletcher J, Miskovic D, Benz S, Stelzner S, Heinze T. The retrocolic fascial system revisited for right hemicolectomy with complete mesocolic excision based on anatomical terminology: do we need the eponyms Toldt, Gerota, Fredet and Treitz? Colorectal Dis 2023 Apr;25(4):764-774. doi: 10.1111/codi.16436. Epub 2022 Dec 11. PMID: 36457274.

4\. Conti C, Pedrazzani C, Turri G, Fernandes E, Lazzarini E, De Luca R, Valdegamberi A, Ruzzenente A, Guglielmi A. Comparison of Short-term Results after Laparoscopic Complete Mesocolic Excision and Standard Colectomy for Right-Sided Colon Cancer: Analysis of a Western Center Cohort. Ann Coloproctol. 2021 Jun;37(3):166-173. doi: 10.3393/ac.2020.05.18. Epub 2021 Apr 22. PMID: 33887816; PMCID: PMC8273717.

Robotic right colectomy with complete mesocolic excision and D3 lymphadenectomy for ascending colon cancer

video lecture

Localisation du ganglions sentinelle, cancer de l'endomètre

This lecture describes the role of sentinel lymph node (SLN) injection and mapping in the staging of apparent uterine confined endometrial cancer. Dr. Abu-Rustum described the technique of injection. The most common location of sentinel nodes following a cervical injection with dye and the less common location were presented. The author also discussed potential pitfalls of sentinel node mapping with ICG. The data on lymph node metastasis was reviewed, and the results of sentinel node mapping were compared to the traditional historical pelvic lymphadenectomy for staging. The issue of isolated paraaortic lymph node metastasis was mentioned. At the end of this lecture, surgeons should have a better understanding of SLN mapping for endometrial cancer and the rationale for this staging approach.

Sentinel lymph node mapping, endometrial cancer

Excision totale du mésorectum robotisée pour cancer du rectum : guidage via reconstruction 3D

The complex anatomy of the pelvis and the challenge of predicting clear resection margins pose significant obstacles in rectal cancer surgery. Effective surgical planning for locally advanced rectal cancer requires a detailed understanding of pelvic spatial relationships to perform total mesorectal excision (TME). Magnetic resonance imaging (MRI) plays a critical role in local staging and in determining patient management (1, 2), providing a foundational surgical roadmap (3). However, the role of MRI in directly guiding surgery is limited by interpretive difficulties (3, 4). Three-dimensional (3D) modeling may offer a valuable enhancement, providing detailed visualization of critical anatomical and tumor characteristics both preoperatively and intraoperatively, potentially improving safety and outcomes in rectal cancer surgery (4, 5, 6, 7).

 

Clinical case presentation:

A 60-year-old man was diagnosed with locally advanced rectal cancer (cT3c, EMVI+, MRF threatened). He underwent neoadjuvant chemoradiotherapy and consolidation chemotherapy followed by robotic TME. To aid in surgical planning, a 3D model generated via image processing and reconstruction (CELLA©), based on pelvic MRI and CT-scan was developed preoperatively. This model provided the surgical team with a clearer understanding of mesorectal fascia involvement, facilitating both planning and operative decision-making.

 

Summary:

This case highlights the clinical benefits of using high-resolution preoperative 3D reconstruction models for guiding surgical planning in rectal cancer. Such models offer precise lesion localization, detailed spatial relationships with surrounding structures, and the ability to rotate the model to mimic intraoperative perspectives. The integration of 3D modeling into rectal cancer surgery holds promise for improving both surgical and oncological outcomes.

 

Bibliography:

1\. MERCURY Study Group. Diagnostic accuracy of preoperative magnetic resonance imaging in predicting curative resection of rectal cancer: prospective observational study. BMJ 2006 Oct 14;333(7572):779. doi: 10.1136/bmj.38937.646400.55. Epub 2006 Sep 19. PMID: 16984925 PMCID: PMC1602032 DOI: 10.1136/bmj.38937.646400.55

2\. Regina G H Beets-Tan, Doenja M J Lambregts, Monique Maas, Shandra Bipat, Brunella Barbaro, Luís Curvo-Semedo, Helen M Fenlon, Marc J Gollub, Sofia Gourtsoyianni, Steve Halligan, Christine Hoeffel, Seung Ho Kim, Andrea Laghi, Andrea Maier, Søren R Rafaelsen, Jaap Stoker, Stuart A Taylor, Michael R Torkzad, Lennart Blomqvist. Magnetic resonance imaging for clinical management of rectal cancer: Updated recommendations from the 2016 European Society of Gastrointestinal and Abdominal Radiology (ESGAR) consensus meeting. Eur Radiol 2018 Apr;28(4):1465-1475. doi: 10.1007/s00330-017-5026-2. Epub 2017 Oct 17. PMID: 29043428 PMCID: PMC5834554 DOI: 10.1007/s00330-017-5026-2

3\. A Corr, J Fletcher, J T Jenkins, D Miskovic. Image-guided pelvic exenteration-preoperative and intraoperative strategies. Eur J Surg Oncol 2022 Nov;48(11):2263-2276. doi: 10.1016/j.ejso.2022.08.002. Epub 2022 Sep 20. PMID: 36243647 DOI: 10.1016/j.ejso.2022.08.002.

4\. Anna Przedlacka, Gianluca Pellino, Jordan Fletcher, Fernando Bello, Paris P Tekkis, Christos Kontovounisios. Current and future role of three-dimensional modelling technology in rectal cancer surgery: A systematic review. World J Gastrointest Surg 2021 Dec 27;13(12):1754-1769. doi: 10.4240/wjgs.v13.i12.1754. PMID: 35070078 PMCID: PMC8727188 DOI: 10.4240/wjgs.v13.i12.1754.

5\. C Kontovounisios, P Tekkis, F Bello. 3D imaging and printing in pelvic colorectal cancer: 'The New Kid on the Block'. Tech Coloproctol 2019 Feb;23(2):171-173. doi: 10.1007/s10151-018-1922-y. Epub 2019 Jan 17. PMID: 30656576 PMCID: PMC6440928 DOI: 10.1007/s10151-018-1922-y.

6\. A Przedlacka, S Cox, P Tekkis, F Bello, C Kontovounisios. Rectal 3D MRI modelling for benign and malignant disease. Br J Surg 2020 Oct;107(11):e561-e562. doi: 10.1002/bjs.11858. Epub 2020 Aug 25. PMID: 32841363 DOI: 10.1002/bjs.11858.

7\. A Garcia-Granero, G Pellino, F Giner, M Frasson, D Fletcher-Sanfeliu, V P Romaguera, B Flor-Lorente, M Gamundi, L Brogi, D Garcia-Calderón, F X Gonzalez-Argente, E Garcia-Granero. A mathematical 3D-method applied to MRI to evaluate prostatic infiltration in advanced rectal cancer. Tech Coloproctol 2020 Jun;24(6):605-607. doi: 10.1007/s10151-020-02170-4. Epub 2020 Feb 28. PMID: 32107687 DOI: 10.1007/s10151-020-02170-4.

Robotic total mesorectal excision (TME) for rectal cancer guided by 3D reconstruction

Introduction

Biliary drainage is necessary for unresectable malignant hilar biliary obstruction (MHBO) caused by obstructive jaundice or cholangitis. In addition, endoscopic transpapillary biliary drainage (ETBD) is the first-choice drainage method for malignant hilar biliary obstruction (MHBO). However, complex intrahepatic bile duct (IHBD) stenosis in unresectable MHBO renders the appropriate drainage method selection difficult, since factors such as bile duct anatomy, presence of hepatic atrophy, prognosis, and Bismuth classification must be considered (1).

Although various drainage methods for MHBO have been reported, the time to recurrent biliary obstruction (TRBO) varies among reports, and the optimal stenting method has not yet been established. Recent reports suggest that self-expandable metallic stents (SEMSs) demonstrate superiority over plastic stents (PSs) in terms of stent patency duration despite the controversy regarding stent type selection in MHBO. Additionally, the feasibility of side-by-side (SBS), partial stent-in-stent (PSIS), and hybrid (SBS and PSIS combined) methods for transpapillary SEMSs placement in MHBO, particularly in Bismuth type II and above complex cases, has been reported (2). A prospective randomized study revealed that the median TRBO was similar for SBS and PSIS (262 and 253 days, respectively) (2). In addition, a meta-analysis comparing SBS and PSIS showed that overall median TRBO in three analyzed publications was 155 to 262 and 104 to 253 days for SBS and PSIS, respectively (3). Although these values were comparable, forest plot results of a fixed-effects model indicated a significantly longer median TRBO for PSIS than for SBS. Additionally, a study about the hybrid method reported a median TRBO of 189 days (4).

Endoscopic ultrasound-guided biliary drainage (EUS-BD) is widely used for cases in which ETBD is difficult for various reasons. The primary target of EUS-BD, particularly EUS-guided hepaticogastrostomy (EUS-HGS), conventionally focuses on addressing distal biliary obstruction. However, the EUS-HGS with bridging (EUS-HGSB) method, in which stenting is performed between the left and right hepatic ducts via the EUS-HGS route, has recently been developed for MHBO, allowing for bilateral drainage without ETBD or percutaneous transhepatic biliary drainage. Currently, only three reports about the EUS-HGSB method, excluding case reports, are available, indicating technical and clinical success rates of 50 to 100%. However, the previous reports primarily focused on technical and clinical success rates of EUS-HGSB as an alternative to ETBD, and no reports have addressed long-term outcomes after stent placement (e.g., rate and causes of RBO and TRBO).

Procedure:&#x20;

This video demonstrates the case of a 64-year-old female patient with a surgical history of a Whipple procedure for pancreatic neuroendocrine tumor (pNET) at the level of the pancreatic head. She was scheduled for an EUS-guided biliary drainage with bridging technique due to the presence of a hepatic hilar metastasis originating from a pNET.

During the procedure, the common bile duct (CBD) was punctured, and the opacification of the entire bile duct was performed. A guidewire was inserted. A 6 French cystostome was then introduced. A 6 cm vascular self-expanding stent (Zilver®) with a 10 mm diameter was inserted to connect the right hepatic duct to the left hepatic duct. A 10 cm biliary stent (GIOBOR™) was inserted to create a hepaticogastrostomy between the left hepatic duct and the stomach.

Postoperative outcomes: After drainage, jaundice disappeared, and chemotherapy restarted 3 weeks afterwards.

After 3 months, the patient remained stable without recurrence of jaundice. However, by six months, the disease had progressed, and she passed away seven months after undergoing EUS drainage.

Bibliography:

([1). Bashar J Qumseya, Laith H Jamil, Badih Joseph Elmunzer, Ahsun Riaz, Eugene P Ceppa, Nirav C Thosani, James L Buxbaum, Andrew C Storm, Mandeep S Sawhney, Swati Pawa, Mariam Naveed, Jeffrey K Lee, Joanna K Law, Richard S Kwon, Terry L Jue, Larissa L Fujii-Lau, Douglas S Fishman, Audrey H Calderwood, Stuart K Amateau, Mohammed Al-Haddad, Sachin Wani. ASGE guideline on the role of endoscopy in the management of malignant hilar obstruction. Gastrointest Endosc 2021 Aug;94(2):222-234.e22. doi: 10.1016/j.gie.2020.12.035. Epub 2021 May 20. PMID: 34023067 DOI: 10.1016/j.gie.2020.12.035]()

(2). Lee TH, Moon JH, Choi JH et al. Prospective comparison of endoscopic bilateral stent-in-stent versus stent-by-stent deployment for inoperable advanced malignant hilar biliary stricture. Gastrointest Endosc. 2019;90:222–230.

(3). Gabriel Mayo Vieira de Souza, Igor Braga Ribeiro, Mateus Pereira Funari, Diogo Turiani Hourneaux de Moura, Maria Vitória Cury Vieira Scatimburgo, João Remí de Freitas Júnior, Sergio A Sánchez-Luna, Renato Baracat, Eduardo Turiani Hourneaux de Moura, Wanderley Marques Bernardo, Eduardo Guimarães Hourneaux de Moura. Endoscopic retrograde cholangiopancreatography drainage for palliation of malignant hilar biliary obstruction - stent-in-stent or side-by-side? A systematic review and meta-analysis. World J Hepatol 2021 May 27;13(5):595-610. doi: 10.4254/wjh.v13.i5.595. PMID: 34131473 PMCID: PMC8173339 DOI: 10.4254/wjh.v13.i5.595

(4). Yuta Maruki, Susumu Hijioka, Shih Yea Sylvia Wu, Akihiro Ohba, Yoshikuni Nagashio, Shunsuke Kondo, Chigusa Morizane, Hideki Ueno, Takuji Okusaka, Yutaka Saito. Novel endoscopic technique for trisegment drainage in patients with unresectable hilar malignant biliary strictures (with video). Gastrointest Endosc 2020 Sep;92(3):763-769. doi: 10.1016/j.gie.2020.03.003. Epub 2020 Mar 10. PMID: 32169434 DOI: 10.1016/j.gie.2020.03.003

Endoscopic ultrasound-guided biliary drainage using the bridging technique for hepatic hilar metastasis from a pancreatic neuroendocrine tumor (pNET) causing jaundice

Drainage biliaire guidé par écho-endoscopie utilisant la technique de pontage pour métastase hilaire hépatique provenant d'une tumeur neuroendocrine pancréatique provoquant un ictère

This video presents the case of an asymptomatic 57-year-old male patient, with no history of previous surgeries. He had undergone a routine colonoscopy, which revealed the presence of an adenocarcinoma in the transverse colon, with a 15mm laterally spreading lesion and an adjacent whitish scar. A robotic resection of the transverse colon was performed. The postoperative period was uneventful, with no reports of pain, and the patient was discharged on postoperative day 3. Pathological examination confirmed the presence of a pT2pN0 adenocarcinoma.

Robotic surgery, particularly in colectomies for the treatment of transverse colon neoplasms, stands out for its high technical precision and clinical benefits to the patient, resulting in favorable oncological outcomes.

As a result, robotic resection of the transverse colon proves to be a promising and effective approach in the surgical management of colon cancer, offering safety and oncological efficacy, especially in more complex cases.

Bibliography:

1\. V Maertens, S Stefan, M Rutgers, N Siddiqi, J S Khan. Oncological outcomes of open, laparoscopic and robotic colectomy in patients with transverse colon cancer. Tech Coloproctol 2022 Oct;26(10):821-830. doi: 10.1007/s10151-022-02650-9. Epub 2022 Jul 8.[https://pubmed.ncbi.nlm.nih.gov/35804251/](https://pubmed.ncbi.nlm.nih.gov/35804251/)

2\. Kyung Uk Jung, Yoonah Park, Kang Young Lee, Seung-Kook Sohn. Robotic transverse colectomy for mid-transverse colon cancer: surgical techniques and oncologic outcomes. J Robot Surg 2015 Jun;9(2):131-6. doi: 10.1007/s11701-015-0502-7. Epub 2015 Feb 17.[https://pubmed.ncbi.nlm.nih.gov/26531113/](https://pubmed.ncbi.nlm.nih.gov/26531113/)

Pure robotic transversectomy/transverse colectomy for a moderately differentiated transverse colon adenocarcinoma

Transversectomie/colectomie transverse robotisée pure pour adénocarcinome du côlon transverse modérément différencié

This is the case of a 76-year-old woman diagnosed with antral adenocarcinoma identified through gastroscopy. Based on her clinical staging (cT2-3 N0 M0), and following a multidisciplinary meeting, she was considered suitable for upfront curative surgery. In accordance with current clinical guidelines, a subtotal gastrectomy with D2 lymphadenectomy was planned (1). The da Vinci Xi™ surgical robotic platform was used to capitalize on its benefits over conventional laparoscopy, including 3D and stable view, enhanced dexterity, and the ability to perform complex tasks with precision in confined spaces (2). Roux-en-Y reconstruction was chosen to minimize the risk of bile reflux (3). The procedure was completed without perioperative or postoperative complications, with an estimated blood loss of 40mL. The patient began drinking on postoperative day (POD) 1 and transitioned to a soft diet on POD 2. She was discharged on POD 5. The histopathological report confirmed a pT2 N0 M0 intestinal-type adenocarcinoma, with 42 lymph nodes analyzed, indicating the adequacy of lymphadenectomy. Based on the pathological staging, the patient was referred for follow-up.

Bibliography:

1\. Jaffer A Ajani, Thomas A D'Amico, David J Bentrem, Carlos U Corvera, Prajnan Das, Peter C Enzinger, Thomas Enzler, Hans Gerdes, Michael K Gibson, Patrick Grierson, Garima Gupta, Wayne L Hofstetter, David H Ilson, Shadia Jalal, Sunnie Kim, Lawrence R Kleinberg, Samuel Klempner, Jill Lacy, Byrne Lee, Frank Licciardi, Shane Lloyd, Quan P Ly, Karen Matsukuma, Michael McNamara, Ryan P Merkow, Aaron M Miller, Sarbajit Mukherjee, Mary F Mulcahy, Kyle A Perry, Jose M Pimiento, Deepti M Reddi, Scott Reznik, Robert E Roses, Vivian E Strong, Stacey Su, Nataliya Uboha, Zev A Wainberg, Christopher G Willett, Yanghee Woo, Harry H Yoon, Nicole R McMillian, MaryElizabeth Stein. Gastric Cancer, Version 2.2025, NCCN Clinical Practice Guidelines In Oncology. J Natl Compr Canc Netw 2025 May;23(5):169-191. PMID: 40341199 DOI: 10.6004/jnccn.2025.0022

2\. Seth I Felder, Rajesh Ramanathan, Ashley E Russo, Rosa Maria Jimenez-Rodriguez, Melissa E Hogg, Amer H Zureikat, Vivian E Strong, Herbert J Zeh, Martin R Weiser. Robotic gastrointestinal surgery. Curr Probl Surg 2018 Jun;55(6):198-246. doi: 10.1067/j.cpsurg.2018.07.001. Epub 2018 Aug 8. PMID: 30470267 PMCID: PMC6377083 DOI: 10.1067/j.cpsurg.2018.07.001

3\. Motohiro Hirao, Shuji Takiguchi, Hiroshi Imamura, Kazuyoshi Yamamoto, Yukinori Kurokawa, Junya Fujita, Kenji Kobayashi, Yutaka Kimura, Masaki Mori, Yuichiro Doki; Osaka University Clinical Research Group for Gastroenterological Study. Comparison of Billroth I and Roux-en-Y reconstruction after distal gastrectomy for gastric cancer: one-year postoperative effects assessed by a multi-institutional RCT. Ann Surg Oncol 2013 May;20(5):1591-7. doi: 10.1245/s10434-012-2704-9. Epub 2012 Oct 28. PMID: 23104705 DOI: 10.1245/s10434-012-2704-9

Robotic subtotal gastrectomy with D2 lymphadenectomy and Roux-en-Y reconstruction for antral adenocarcinoma

Gastrectomie subtotale robotisée avec curage ganglionnaire D2 et reconstruction selon Roux pour adénocarcinome antral

Computer-assisted surgery. Everything changed again?

Traitement robotisé d'une lésion du canal biliaire E4 (avec le robot Hugo™ RAS)

In this educational video, the author presents the case of a 67-year-old woman who suffered from a bile duct injury during a laparoscopic cholecystectomy. She had an endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic drainage during the following days and she was then transferred to the author’s hospital 6 days after the index event.

Bile duct injury was repaired with the HUGO RAS robotic surgical platform.

In this procedure, the author aimed to highlight how the stability or steadiness of the surgical camera improves dissection, precise debridement, and suturing, particularly during the complex bilioenteric anastomosis construction. He also aimed to stress that external liver retraction was unnecessary, and that Roux-en-Y reconstruction was easily performed without changing the operating table’s position, without any robotic redocking. Finally, the author demonstrated that advanced surgical energy devices were unnecessary in that specific case.

The entire procedure was performed with the patient placed in a reverse Trendelenburg position with a 5-degree tilt to the left side. Patient repositioning or robotic redocking was unnecessary. Four robotic arms were used for the camera, bipolar grasper, monopolar scissors, and Cadiere grasper. Bowel transection and anastomosis were performed with standard laparoscopic staplers placed through the assistant port. Surgery lasted 210 minutes. The postoperative period was uneventful. Twenty-one months after the repair, the patient remained asymptomatic.

Bibliography:

Allyson Lim-Dy, Sharona Ross, Iswanto Sucandy. Delayed Repair of E2 Bile Duct Injury With Robotic Roux-en-Y Hepaticojejunostomy. Am Surg 2024 Jun;90(6):1727-1728. doi: 10.1177/00031348241227194. Epub 2024 Jan 9. PMID: 38194949 DOI: 10.1177/00031348241227194

Marco Vito Marino, Antonello Mirabella, Domenico Guarrasi, Massimo Lupo, Andrzej Lech Komorowski. Robotic-assisted repair of iatrogenic common bile duct injury after laparoscopic cholecystectomy: Surgical technique and outcomes. Int J Med Robot 2019 Jun;15(3):e1992. doi: 10.1002/rcs.1992. Epub 2019 Mar 10. PMID: 30773791 DOI: 10.1002/rcs.1992

Antonio Cubisino, Nicolas H Dreifuss, Gianluca Cassese, Francesco M Bianco, Fabrizio Panaro. Minimally invasive biliary anastomosis after iatrogenic bile duct injury: a systematic review. Updates Surg 2023 Jan;75(1):31-39. doi: 10.1007/s13304-022-01392-5. Epub 2022 Oct 7. PMID: 36205829 DOI: 10.1007/s13304-022-01392-5

Robot-assisted E4 bile duct injury repair (with Hugo™ RAS system)

Percutaneous ablation of liver tumors. Navigation guide. Robotics. Role of HBP surgery.

In this key lecture, Dr. Costa, MD, PhD outlines the use of 3D planning, its modalities and specifications.

Three-dimensional (3D) imaging has emerged as a valuable tool in preoperative planning for liver surgery, particularly in the context of complex resections and parenchyma-sparing procedures. Starting from high-resolution CT or MRI, dedicated software enables the extraction of hepatic parenchyma, vascular structures, and tumors, generating a volumetric reconstruction, which supports surgical decision-making. Tridimensional planning allows for the precise assessment of future liver remnant and the simulation of alternative resection strategies, offering a more accurate risk-benefit analysis as compared to conventional two-dimensional imaging.

The author presents the workflow and applications of 3D planning, including organ and vascular segmentation, tumor extraction, volumetric assessment, and virtual hepatectomy. In two illustrative cases of colorectal liver metastases (CLM), volumetric prediction closely matched intraoperative measurements (error ratio \<1%), confirming the accuracy and reproducibility of this approach. Beyond volumetry, 3D analysis improves the identification of anatomical variants, guides resection margins, and helps to address disappearing liver metastases (dCLM), a clinical challenge in patients receiving neoadjuvant chemotherapy. By integrating prechemotherapy imaging with 3D modeling and intraoperative navigation, surgeons can target dCLM sites and reduce the recurrence risk.

When combined with navigation techniques, 3D reconstructions enhance intraoperative ultrasound interpretation and provide significant educational benefits, allowing trainees to explore surgical strategies in complex scenarios.

In conclusion, 3D planning is a simple, fast, and reproducible tool, which improves surgical safety, supports parenchyma-sparing resections, and fosters education. It should be considered mandatory in cases with disappearing metastases, volumetric assessment for major hepatectomies, and technically demanding parenchyma-sparing procedures. Ultimately, the autho recommends that surgeons themselves lead and interpret the planning process.

3D planning - How to do it, is its use mandatory?

In this keynote lecture, Dr. Bizzarri outlines techniques for sentinel lymph node (SLN) detection. The use of sentinel lymph node (SLN) mapping in gynecological cancers aims to reduce morbidity associated with full lymphadenectomy while maintaining accurate staging. Technically, SLN detection involves the injection of a tracer substance into specific anatomical sites to identify the first draining lymph node. Common tracers include indocyanine green (ICG) visualized using near-infrared fluorescence (NIRF) imaging, technetium-99m radiocolloid detected with a gamma probe, and blue dyes such as patent blue. Injection techniques differ by cancer type: cervical injection at the 3 and 9 o’clock positions is standard for endometrial and cervical cancer, while peritumoral injection is preferred for vulvar cancer. Laparoscopic or robotic platforms enhance visualization, especially with ICG, improving bilateral detection rates. After identification, the SLN is excised and subjected to ultrastaging with serial sectioning and immunohistochemistry to detect micrometastases or isolated tumor cells. Key technical challenges include failed bilateral mapping, learning curve variability, and false negatives due to aberrant lymphatic drainage. Algorithms, such as side-specific lymphadenectomy when mapping fails, have been integrated to standardize practice. &#x20;

This video focuses on the technical aspects with tips and tricks on how to detect and retrieve SLN in gynecologic cancers. Overall, SLN mapping incorporates advanced imaging, tracer pharmacokinetics, and precise surgical technique to optimize staging accuracy with reduced surgical trauma.&#x20;

Techniques for sentinel lymph node detection 

Robot-assisted radical prostatectomy (RALP) has become the standard technique for the surgical treatment of localized prostate cancer. Several approaches are possible, namely transperitoneal, which is the most common and offers a large surgical field; extraperitoneal, which is useful in patients who have undergone previous abdominal surgery; and, more rarely, transvesical. The standard placement of six trocars allows for optimal exposure based on the anatomical landmarks of the umbilicus, iliac crests, and pubis.

The surgical sequence begins with the opening of Retzius' space and the release of the bladder, followed by antegrade dissection with bladder neck preparation. Isolation of the vas deferens and seminal vesicles precedes lateral dissection, an essential step in nerve preservation. This can be extrafascial (no preservation), interfascial, or intrafascial (maximum preservation), depending on the patient's oncological and functional profile. 

Energy use is limited in order to prevent thermal damage: bipolar coagulation is restricted to the prostate base, while the apex is dissected without electrical current, even if this means tolerating minimal bleeding. The excision continues with the division of the dorsal venous complex and the urethra, before the vesicourethral anastomosis is performed using running or separate stitches.

Anatomical reconstruction aims to restore continence mechanisms. Anteriorly, a puboprostatic suspension suture is performed; posteriorly, Denonvilliers' fascia and the rhabdosphincter are reconstructed using the Rocco technique; laterally, the endopelvic fascia and pelvic floor muscle fibers are preserved. Innovative approaches such as the Hood technique allow the anterior musculofascial complex to be preserved, promoting a faster recovery of continence.

The results show continence rates greater than 95% at one year. However, early recovery remains variable, influenced by the quality of the reconstruction and pelvic muscle tone. Bilateral preservation of the neurovascular bundles is essential for the recovery of erectile function.

In conclusion, RALP is based on a standardized, yet adaptable technical sequence, incorporating a reasoned choice of approach, atraumatic dissection, and careful anatomical reconstruction. The surgeon's expertise remains crucial in optimizing oncological and functional outcomes.

Robotic radical prostatectomy: general principles, step-by-step procedure, ways of access

In this authoritative lecture, Professor Antonello Forgione, MD, PhD, MBA, FACS, FCBC (Hon), FRAES (Hon) addresses the evolution of robotic surgery. Surgical robotics aims to enhance precision, safety, and minimally invasive procedures. Early robotic systems evolved into advanced platforms such as the da Vinci surgical robots, revolutionizing soft-tissue surgery. Milestones such as Operation Lindbergh demonstrated the potential of remote and tele-operated surgery. Recent innovations include single-port, miniaturized, and flexible robots, addressing new surgical challenges. Future trends focus on AI integration, in vivo systems, and greater automation in the operating room.

Evolution of robotic surgery

In this authoritative lecture, Professor Jacques Marescaux, Founder and President of the IRCAD Institute (Strasbourg, France) and Editor-in-Chief of WebSurg explores how artificial intelligence (AI) is transforming minimally invasive surgery (MIS) by enhancing precision, decision-making, training, and patient outcomes. It highlights innovations such as AI-assisted imaging, robotics, real-time analytics, and predictive modeling, showing how these technologies are redefining the surgical landscape and shaping the future of healthcare.

Focus on innovative technologies and surgical techniques