Graziano Pernazza - Academia.edu (original) (raw)

Papers by Graziano Pernazza

Laparoscopic surgery has become widely accepted and used as a minimally invasive approach for a n... more Laparoscopic surgery has become widely accepted and used as a minimally invasive approach for a number of procedures because it offers a number of patient benefits compared to open surgery such as milder morbidity, earlier time to walking, flatus, and oral intake, and quicker recovery with a shorter hospital stay. The current standard of care for resectable locally advanced gastric cancer, in Japan and Europe, is R0- gastrectomy with extensive D2 lymph node dissection. Although laparoscopic D2-lymphadenectomy has been described and found to be feasible by several authors, widespread use of this technique was limited by the pitfalls of this complex procedure. The anatomic complexity of the vascular structures, the technical limits of the conventional laparoscopic instrumentation, and the lack of a steady image, can consequently add to surgeons’ stress, making this procedure quite complex even for minimally-invasive well-trained surgeons. In an effort to minimize the difficulty of lap...

Surgical Treatment of Pancreatic Diseases, 2009

ABSTRACT The role of minimally invasive surgery in the diagnosis and treatment of pancreatic path... more ABSTRACT The role of minimally invasive surgery in the diagnosis and treatment of pancreatic pathologies, although fully evolved, remains controversial and the subject of lively scientific discussions. Despite a growing number of documented studies clearly showing the safety and feasibility of minimally invasive procedures, their advantages and tremendous value to patients, with respect to staging, palliation and therapy of pancreatic pathologies, are still far from obvious. Traditional open surgery is considered the standard procedure both for treatment and palliation, while the laparoscopic approach is reserved for a small number of patients and performed only by a selected group of highly skilled surgeons. Robotic surgery, a genuine improvement to current conventional laparoscopic interventions, may broaden the applications of minimally invasive surgery and thereby extend its indications.

Colorectal Cancer - From Prevention to Patient Care, 2012

Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 2011

Cystic lesions of the spleen represent a rare entity with an overall incidence of 0.5% among sple... more Cystic lesions of the spleen represent a rare entity with an overall incidence of 0.5% among splenectomies. They can remain asymptomatic in 30% to 60% of patients or may cause symptoms for secondary compression of adjacent structures. Peripheral cysts may be suitable for conservative treatment whereas splenectomy is the accepted procedure for bulky and/or central lesions. Laparoscopy is the standard approach for elective splenic surgery, but in the last decade, introduction of the da Vinci robotic system has represented a further improvement in minimally invasive surgery, thanks to 3-dimensional vision and more accurate motion control. Herein, we report a case of a mesothelial splenic cysts successfully treated by robotic splenectomy; some anatomical considerations and technical aspects of robotic procedures have been discussed: it is a feasible and safe approach, particularly indicated in the presence of anatomic features such as an enlarged pancreatic tail and a type II vascular pattern of splenic pedicle. In such patients, the choice of a robotic approach may decrease the risk of intraoperative bleeding, thereby representing a further improvement in laparoscopic techniques.

Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 2006

ABSTRACT An abstract is unavailable. This article is available as HTML full text and PDF.

Surgical Endoscopy, 2012

In January 2010, the SICE (Italian Society of Endoscopic Surgery), under the auspices of the EAES... more In January 2010, the SICE (Italian Society of Endoscopic Surgery), under the auspices of the EAES, decided to revisit the clinical recommendations for the role of laparoscopy in abdominal emergencies in adults, with the primary intent being to update the 2006 EAES indications and supplement the existing guidelines on specific diseases. Methods Other Italian surgical societies were invited into the Consensus to form a panel of 12 expert surgeons. In order to get a multidisciplinary panel, other stakeholders involved in abdominal emergencies were invited along with a patient's association. In November 2010, the panel met in Rome to discuss each chapter according to the Delphi method, producing key statements with a grade of recommendations followed by commentary to explain the rationale and the level of evidence behind the statements. Thereafter, the statements were presented to the Annual Congress of the EAES in June 2011. Results A thorough literature review was necessary to assess whether the recommendations issued in 2006 are still current. In many cases new studies allowed us to better clarify some issues (such as for diverticulitis, small bowel obstruction, pancreatitis, hernias, trauma), to confirm the key role of laparoscopy (such as for cholecystitis, gynecological disorders, nonspecific abdominal pain, appendicitis), but occasionally previous strong recommendations have to be challenged after review of recent research (such as for perforated peptic ulcer).

Surgical Endoscopy, 2013

Background Long-term data from the CLASICC study demonstrated the oncologic equivalence of laparo... more Background Long-term data from the CLASICC study demonstrated the oncologic equivalence of laparoscopic and open rectal cancer surgery despite an increased circumferential resection margin involvement in the laparoscopic group in the initial report. Moreover, laparoscopic total mesorectal excision (TME) may be associated with increased rates of male sexual dysfunction compared to conventional open TME. Robotic surgery could potentially obtain better results than laparoscopy. The aim of this study was to compare the clinical and functional outcomes of robotic and laparoscopic surgery in a single-center experience. Methods This study was based on 100 patients who underwent minimally invasive anterior rectal resection with TME. Fifty consecutive robotic rectal anterior resections with TME (R-TME) were compared to the first 50 consecutive laparoscopic rectal resections with TME (L-TME). Results Median operative time was 270 min in R-TME and 275 min in L-TME. No conversions occurred in the R-TME group whereas six conversions occurred in the L-TME group. The mean number of harvested lymph nodes was 16.5 ± 7.1 for R-TME and 13.8 ± 6.7 for L-TME. The circumferential margin (CRM) was\2 mm in six L-TME patients, whereas no one in R-TME group had a CRM \2 mm. The International Prostate Symptom Score (IPSS) scores were significantly increased 1 month after surgery in both the L-TME and R-TME groups, but they normalized 1 year after surgery. Erectile function worsened significantly 1 month after surgery in both the groups but it was restored completely 1 year after surgery in the R-TME group and partially in the L-TME group. Conclusions Robotic TME is oncologically safe and adequate for rectal cancer treatment, showing better results than laparoscopic TME in terms of CRM, conversions, and hospital length of stay. Better recovery in voiding and sexual function is achieved with the robotic technique.

Surgery Today, 2011

A carcinoma in a groin hernia is uncommon. We herein report a case of an intrasaccular carcinoma ... more A carcinoma in a groin hernia is uncommon. We herein report a case of an intrasaccular carcinoma of the cecum in a right inguinoscrotal hernia with a simultaneous left inguinal hernia treated by a laparoscopic approach. A 70-year-old man presented with a painful, not completely reducible bilateral hernia. Blood examinations showed severe anemia. A computed tomography scan of the abdomen confirmed the presence of the cecum in the hernia sac, showing a round wall thickening of the herniated portion of the colon. A standard laparoscopic right colectomy with radical oncological purpose was performed. An incarcerated inguinal hernia is a relatively common surgical problem. In the case of anemia or other signs suggestive of malignancy, a specific preoperative work-up should be assessed. This case demonstrates that it is possible to perform an oncologically correct laparoscopic resection when the presence of malignancy is confirmed while performing an open traditional hernioplasty to avoid any possible contamination of the mesh.

Journal of Surgical Research, 2011

Widespread diffusion of minimally-invasive surgery for gastric cancer treatment is limited by the... more Widespread diffusion of minimally-invasive surgery for gastric cancer treatment is limited by the complexity of performing an extended D2-lymphadenectomy. This surgical step can be facilitated by using robot-assisted surgery. The aim of this study is to describe our technique and short-term results of a consecutive series of full robotic gastrectomies with D2-lymphadenectomy for gastric cancer, using the da Vinci Surgical System. Between May 2004 and December 2009, we performed 24 consecutive full robot-assisted total and subtotal gastrectomies with extended D2-lymphadenectomy for histologically-proven gastric adenocarcinoma. Data referring to 11 robot-assisted total gastrectomies and 13 subtotal gastrectomies were collected in a database and analyzed. Median operative time was 267.50 min (255-305). Median intraoperative blood loss was 30 mL. Median number of harvested lymph nodes was 28 (23-34). Resection margins were negative in all cases. No conversions occurred. Surgery-related morbidity was 8%. Thirty-day mortality was 0%. Liquid diet started on postoperative d 5 (2-5). Median length of stay was 6 d (5-8). Robot-assisted gastrectomy with D2-lymphadenectomy is a safe technique and allows achieving an adequate lymph node harvest and optimal R0-resection rates with low postoperative morbidity and the learning curve appears to be shorter than in laparoscopic surgery. Longer follow-up and randomized clinical trials are needed to define the role of robot-assistance in gastric cancer surgery.

International Journal of Surgery, 2012

Traditionally, pancreatic surgery is considered as one of the most complex surgeries. The recentl... more Traditionally, pancreatic surgery is considered as one of the most complex surgeries. The recently developed robotic technology allows surgeons to perform pancreaticoduodenectomy. A comparative study was undertaken to study outcomes between robotic approach and open approach. A consecutive patients underwent pancreaticoduodenectomy (robotic approach, n=20; open approach=67) between January 2000 and February 2012 at a single institution were analyzed. The robotic group had a significantly longer operative time (mean, 491.5 vs. 264.9 min), reduced blood loss (mean, 247 vs. 774.8 ml), and shorter hospital stay (mean, 13.7 vs. 25.8 days) compared to the open group. Open conversion rate was 5%. There was no significant difference between the two groups in terms of overall complication rates, mortality rates, R0 resection rate and harvested lymph node numbers. This study showed that robot-assisted laparoscopic pancreaticoduodenectomy was safe and feasible in appropriately selected patients. However, it is too early to draw definitive conclusions about the value of robot-assisted laparoscopic pancreaticoduodenectomy. In light of remaining uncertainties regarding short-term and long-term outcome, caution should be exercised in the assessment of the appropriateness of this operation for individual patient.

The International Journal of Medical Robotics and Computer Assisted Surgery, 2012

Background Adrenal surgery is undergoing continuous evolution, and robotic technology may extend ... more Background Adrenal surgery is undergoing continuous evolution, and robotic technology may extend indications for a minimally invasive approach to adrenalectomy.

European Journal of Surgical Oncology (EJSO), 2011

each period between two controls. To reach this purpose, we tried to individualize the frequency ... more each period between two controls. To reach this purpose, we tried to individualize the frequency of follow-up visits based on the individual patient's risk of tumor recurrence over time. This follow-up scheme allows an optimal timing for control visits. Also, this follow-up scheme allows to reduce the frequency of instrumental examinations when the probability of recurrence is lower.

Colorectal Disease, 2011

Laparoscopic appendectomy (LA) is not yet unanimously considered the gold standard treatment for ... more Laparoscopic appendectomy (LA) is not yet unanimously considered the gold standard treatment for appendicitis, despite the increasing use of advanced laparoscopic operations and the high incidence of the disease. Due to the results of an audit which classified LA as widespread in Italy, a Consensus Conference was organized, in order to give evidence-based answers to the most debated problems regarding the operation. After researching the literature, a panel of 20 experts were selected and interviewed on hot topics; a subsequent discussion using the Delphi methodology was utilized in the course of the consensus conference and submitted to the evaluation of an audience of surgeons. Checkpoint statements were formulated whenever an agreement was reached. A level of evidence was then assigned to single statements and the process revised by two external reviewers. Consensus development guidelines are herein reported and regard diagnostic pathway, diagnostic laparoscopy, indications, behaviour in case of innocent appendix, technical aspects, learning curve; however, some questions remain unsolved due to the lack of evidence.

Annals of Surgical Oncology, 2010

Background. Colorectal cancer is the fourth leading cause of death in the world. Minimally invasi... more Background. Colorectal cancer is the fourth leading cause of death in the world. Minimally invasive surgery has been demonstrated to have the same oncological results as open surgery, with better clinical outcomes. Robotic assistance is an evolution of minimally invasive technique. This study aims to evaluate surgical and oncological short-term outcomes of robotic-assisted right colon resection in malignant disease. Methods. Fifty consecutive patients affected by rightsided colon cancer were operated from May 2001 to May 2009 using the da Vinci Ò surgical system. Data regarding surgical and early oncological outcomes were systematically collected in a specific database for statistical analysis. Results. Twenty-four male and 26 female patients underwent robotic right colectomy. Median age was 73.34 ± 11 years. Median operative time was 223.50 (180-270) min. No conversion occurred. Specimen length was 26.7 ± 8 cm (range 21-50 cm), number of harvested lymph nodes was 18.76 ± 7.2 (range 12-44), and mean number of positive lymph nodes was 1.65 ± 3 (range 0-17). Surgeryrelated morbidity was 1/50 (2%): one twisting of the mesentery in one case with extracorporeal anastomosis. All patients were included in a follow-up regimen. Diseasefree survival was 90% (45/50), and overall survival was 92% (46/50). Cancer-related mortality was 8% (4/50). Conclusions. Robotic assistance allows performance of oncologically adequate dissection of the right colon with radical lymphadenectomy and to fashion a handsewn intracorporeal anastomosis as in open surgery, confirming the safety and oncological adequacy of this technique, with acceptable results and short-term outcomes.

Minimally Invasive Therapy & Allied Technologies, 2012

Epiphrenic diverticula are rare protrusions of the distal esophagus attributed to esophageal moti... more Epiphrenic diverticula are rare protrusions of the distal esophagus attributed to esophageal motility disorders or obstructive diseases. In presence of a relevant symptomatology, surgery is mandatory. Although many reports confirm the feasibility of the laparoscopic transhiatal approach, the mobilization of the esophagus and the myotomy appear challenging. The intrinsic characteristics of the da Vinci Robotic System could facilitate the approach to the esophagogastric junction and an extended mobilization of the esophagus. We describe a robotic transhiatal surgical treatment of an epiphrenic diverticulum with a Dor antireflux procedure. Robotic-assisted diverticulectomy appears feasible and safe with a low risk of esophageal perforation and pleura damage.