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We describe a case of an uncommon early pancreatic cancer presentation in a patient in his 60s who had haemorrhagic shock from extensive haematochezia and required blood transfusions as well as surveillance in an intensive care unit. A splenic artery pseudoaneurysm that had been effectively embolized by angiography was seen to be actively bleeding into the colon lumen on a computerized tomography (CT) scan along with a necrotic mass of the pancreatic tail. A pancreatic mucinous adenocarcinoma was diagnosed by a transgastric biopsy. A pancreatico-colic fistula was discovered by CT scan after a colic contrast enema. A transabdominal drainage of the necrotic collection and targeted antibiotic treatment had been performed with a satisfying patient outcome. In order to assess a potential secondary surgical resection, systemic chemotherapy was planned. In conclusion, haematochezia with hemodynamic instability originated from a splenic artery pseudoaneurysm fistulising into the colon (arterio-colic fistula) and sepsis originating from a tumoral pancreatic abscess fistulising into the colon (tumoral pancreatico-colic fistula).

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In adults, cerebral oxy-([O2Hb]) and deoxyhemoglobin concentrations ([HHb]) change characteristically at transitions of sleep stages. The aims were to assess these changes in adolescents and additionally to measure tissue oxygen saturation (StO2) by near infrared spectroscopy (NIRS). Previously it was reported that in adults [O2Hb] increased and [HHb] decreased at the transition from non-rapid eye movement sleep (NREMS) to REMS and wakefulness. Transitions to NREMS from REMS/wakefulness led to a decrease in [O2Hb] and an increase in [HHb]. We measured [O2Hb], [HHb] and tissue oxygenation (StO2) with NIRS approximately above the left prefrontal cortex in 12 healthy adolescent males (aged 10-16 years). We found comparable signs and magnitudes of changes in [O2Hb] and [HHb] as observed in adults. StO2 increased at the transitions from NREMS to REMS and decreased from REMS to NREMS and at sleep onset (all p < 0.01, linear mixed effects model). Changes in oxygen metabolism during sleep transitions are similar in adolescents and adults. In addition, we show for the first time temporal changes of StO2 at sleep transitions.

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Robotic surgery has been gaining increasing acceptance for several years now, establishing itself with success in all the surgical fields. Besides, since the introduction of single site surgery, the interest for the robotic technology is more than obvious, offering technical possibilities to overcome the natural limitations of laparoscopy. This article reviews the different devices available and the indications of robotic single site surgery. Moreover, the future developments of this new technology are discussed as well.

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BACKGROUND: Conventional laparoscopy with three or more ports remains the 'gold standard' for cholecystectomy, but a laparoendoscopic single-site (LESS) approach is emerging, designed to decrease parietal trauma and improve cosmesis. This study compared conventional laparoscopic (CL) with LESS cholecystectomy, with short-term clinical results as the main outcomes. METHODS: A randomized trial of CL and LESS cholecystectomies involving 150 patients was undertaken. Follow-up was for 1 month after surgery. The primary endpoint was body image results evaluated by means of validated scales. Secondary endpoints were: postoperative pain measured on a visual analogue scale, analgesia requirement, morbidity, quality of life (QoL) measured with Short Form 12, duration of operation, hospital stay, time to return to work and cost analysis. RESULTS: Operating times and complications were similar in the two groups. Two LESS procedures (3 per cent) were converted to two-port laparoscopy owing to difficulties with exposure, and one CL operation was achieved through a single port because extensive fibrous peritoneal adhesions prevented placement of other ports. There were three and four port-site seroma/haematomas in the LESS and CL groups respectively. Better pain profiles and lower analgesia requirements were recorded in the LESS group (P < 0·001). QoL, body image and scar scale results were also better (P < 0·001). Operative costs were higher for LESS procedures (P < 0·001), although median time to return to work was shorter (P = 0·003). CONCLUSION: LESS is an alternative to CL cholecystectomy associated with better cosmesis, body image, QoL and an improved postoperative pain profile.

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Minimally invasive approach for gastric cancer has gained increasing acceptance. Introduction of the da Vinci robotic system has allowed overcoming the technical limitations of standard laparoscopy. To date, several studies have been published reporting the feasibility of robot-assisted gastrectomy (RAG). The aim of this study is to extensively review all the published literature concerning RAG and to assess its value. Since 2003, this systematic review of the literature shows that 10 original studies reporting 199 RAG for cancer have been published worldwide. The authors analyzed operative time, blood loss, conversion rate, lymph nodes retrieval, complications, mortality, length of hospital stay and follow-up through a systematic review. Mean age was 63 years (range: 25-96). Mean operative times were 265 minutes and 334 minutes for total and subtotal gastrectomy respectively. Mean blood loss reported was 113 mL (range: 12-1400). Conversion rate was 2.5%. Average lymph nodes retrieval was 32 (range: 11-83). Twenty-nine complications were reported (14.6%). Mortality rate was 1.5%. Mean length of stay was 10 days (range: 3-175).This review demonstrates that RAG for cancer is not only feasible but also seems to be safe, with low mortality and acceptable morbidity. However, due to the lack of long-term follow-up and the limited number of published studies, it is relatively too early to draw definitive conclusions and/or to recommend the use of RAG for oncologic gastrectomy. Randomized controlled trials with long-term follow up are needed before this promising approach can eventually be generalized.

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Minimally invasive pancreatic resection remains one of the most challenging abdominal procedures. A wide diffusion of the laparoscopic approach for pancreatic resection is still waited. However, interest is growing since the introduction of robotics in this field and many reports have been published so far. Distal pancreatectomy with or without spleen-preservation, pancreaticoduodenectomy, total and middle pancreatectomy and even extended resections or reconstructions have been reported with good outcomes. This review reports and evaluates the robotic approach for such advanced pancreatic resections. While complex pancreatic resections are feasible and safe by a robotic approach, it is still very early to draw definitive conclusions. Further randomized and controlled studies are required to support a routine use of the robotic technology for pancreatic resection.

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Surgical innovations (associating LESS, NOTES, robotics, images software and Fast-track surgery) will allow a less and less invasive surgery. While these advances could be view as surgical or industrial marketing, or compared to the laparoscopic revolution, they simply answer patients' demand in a society changing its standard regarding: medical care, body image, recovery and rehabilitation. We will in this paper, according to results of a Google Survey analyzing population expectations of surgery, evaluate the interest of these surgical innovations. While, these innovations at least in part answers patients expectation, their therapeutic validity will have to be proved. It is our job, to foresee the future of surgery in accordance with health care system needs and patients expectation for adequate implementation of these innovations.

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BACKGROUND: Transumbilical single incision laparoscopic surgery (SILS) has made its initial forays into clinical minimally invasive surgery. SILS combines in part the cosmetic advantage and decrease parietal trauma of natural orifice surgery, but allow operative realization with standard and validated laparoscopic instruments. We report here the first clinical transumbilical SILS sigmoidectomy for benign disease. METHOD: Preliminary experience with transumbilical single incision laparoscopic surgery (or embryonic natural orifice transluminal endoscopic surgery) sigmoidectomy in a female patient (34 years, BMI 22 kg/m(2)) with sigmoid stenosis caused by nodular endometriosis was reported. Transumbilical SILS treatment of pelvic endometriosis was performed during the same operation through cauterization. RESULTS: Transumbilical single incision laparoscopic sigmoidectomy was feasible with conventional laparoscopic instruments. The combined uses of straight and articulated laparoscopic instruments allow the avoidance of transparietal sling suture for exposition. Operative time for sigmoidectomy and endometriosis therapy was 125 min. No intra-operative or postoperative complications were recorded. SILS achieved excellent cosmetic results and may be associated with accelerated recovery. CONCLUSION: Transumbilical single incision laparoscopic sigmoidectomy is feasible by experienced laparoscopic surgeons using conventional laparoscopic instruments and staplers. The combined uses of strait and articulated instruments allow transumbilical SILS sigmoidectomy without the need for additional incision or transparietal sling suture. SILS sigmoidectomy may have the clinical advantage over NOTES of offering the safety of laparoscopic colectomy and the avoidance of vaginal access. It has to be determined if SILS offers benefit to the patient, except in cosmesis, compared with standard laparoscopic sigmoidectomy.

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Laparoendoscopic Single-Site Surgery (LESS) has made its fore ways into clinical practice, and allows foreseeing a less traumatic surgery without visible scar. Its development reminds the revolution associated with apparition of laparoscopy. Actual clinical experience gained showed that LESS is valid, seems as safe as conventional laparoscopy, while offering patients a surgery without trace. LESS development, which requires advanced laparoscopy training, has made surgeons and industry rethink surgical ergonomic thus allowing rapid technical innovations. These innovations will change minimally invasive surgery in a near future, if they did not already. We, now, have to control its evolution to build a safe and reasonable future for minimally invasive surgery combining patients' desire and safety, populations needs.

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BACKGROUND AND STUDY AIMS: The advantages of a hybrid natural orifice transluminal endoscopic surgery approach to Roux-en-Y gastric bypass (hNOTES-RYGBP) might include: easier access to the peritoneal cavity, reduced number of ports and related complications, improved cosmesis, and others. However, currently available conventional endoscopic and laparoscopic instruments might be unsuitable for complex surgical procedures using transluminal access. The aim of this study was to investigate the feasibility and limitations of a NOTES RYGBP. METHODS: hNOTES-RYGBP was performed in human cadavers. Pouch creation was achieved by needle-knife dissection using a transvaginal, flexible scope. Articulating linear staplers were placed transumbilically to transect the stomach. Measurements of the small bowel were accomplished intraluminally or with flexible and rigid graspers. New methods were tested to create the gastro-jejunal anastomosis. A linear laparoscopic stapler was used to form the jejuno-jejunal anastomosis. RESULTS: Stapler manipulation and anvil docking, bowel manipulation and measurement, and tissue dissection presented the main obstacles for hNOTES-RYGBP. Conventional instruments were too short for some transvaginal manipulations. The time to complete the procedure was 6 - 9 hours. It was feasible to perform a complete hNOTES-RYGBP in four out of seven cadavers. Two cadavers were unsuitable due to anatomical abnormalities or advanced decay. One procedure was terminated before completion because of time constraints. Combinations of flexible and rigid visualization and manipulation were helpful, especially for dissection and gastric pouch creation. CONCLUSIONS: Several factors made hNOTES-RYGBP very challenging and time-consuming. A lack of proper instrumentation resulting in insufficient tissue traction, countertraction, and instrument manipulation complicated several steps during the procedure. A combination of flexible with rigid endoscopic techniques offers specific advantages for components of this type of surgery. Changes in instrument design are required to improve more complex endosurgical procedures.

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Natural orifice translumenal endoscopic surgery (NOTES) is an exciting concept bringing scarless surgery a reality consisting in body cavity and organs approach through natural orifices (digestive, female genital, urinary tracts). While new instrumentation necessitated by NOTES is still developing, multiple surgical procedures have been performed with success in human. Whenever this approach combining surgical and endoscopic expertise needs technical improvement and clinical validation, it will have a large impact on the future of surgery related to population demand for scarless surgery. The next decade, will show us if surgery will be performed through NOTES or if minimally invasive surgery will be positively influenced by the technical progress of NOTES to be the most minimally traumatic.

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OBJECTIVE: Long-term results after surgery for thoracic outlet syndrome (TOS) are reviewed in terms of personal histories and surgical techniques. METHODS: Forty-eight operations were performed in 37 patients. In 21 instances, the picture was one of ordinary TOS, in eight TOS was traumatic and in nine the picture was sub-acute. Cervical ribs were excised through a supraclavicular approach (in seven cases), and first ribs through transthoracic, transaxillary or supraclavicular approaches (in 25, 15 or one, respectively). Long-term follow-up was obtained in 41 cases and averaged 11.7 years. RESULTS: Surgical decompression was successful in 28 cases (68%), including all patients with traumatic TOS (8/8) and seven with sub-acute symptoms (7/9). Outcome was good in five of seven supraclavicular cervical rib resections, and in 23 of 34 first rib excisions. First rib resections performed transaxillary had shorter post-operative stays, fewer complications. CONCLUSION: Surgical decompression is more successful when TOS is traumatic or sub-acute. When involved, a cervical rib can be resected through a supraclavicular approach, since the procedure is easy and has little morbidity. The transaxillary approach should be preferred for first rib resections because of shorter post-operative stays and fewer complications than after the transthoracic approach.

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