Minerva chirurgica
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Advances in reconstructive breast surgery with new materials and techniques now allow us to offer patients the best possible cosmetic results without the risks associated with oncological control of the disease. These advances, in both oncological and plastic surgery, have led to a new field, oncoplastic breast surgery, which enables us to undertake large resections and, with advance planning, and prevent subsequent deformities. This is particularly important when more than 30% of the breast volume is removed, as it allows us to obtain precise information for conservative surgery according to the site of the lesion and to set the boundary between conservative surgery and mastectomy.
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Axillary surgery in breast cancer patients has shifted from more extensive to minimalist approaches with re-evaluation of the risks versus benefits of available treatment options which are increasingly tailored to individual patient characteristics. A radical axillary node dissection is rarely indicated nowadays due to several factors including screening with detection of small node negative cancers, introduction of targeted node sampling, less reliance on information from nodal staging for adjuvant therapy decision making and evidence that non-surgical treatments such as systemic therapies (chemotherapy, hormonal therapy, biological therapy) together with radiotherapy can safely treat low burden axillary disease. Sentinel lymph node biopsy (SLNB) alone with omission of further axillary surgery for nodal macrometastases (>2 mm) might be sufficiently extirpative to achieve local control when combined with adjuvant treatments. ⋯ Emerging evidence suggests that a complete radiological response with removal of at least 3 nodes (including clipped nodes at time of biopsy) can yield false negative rates of <10% and be a safe option. New technologies involving percutaneous biopsy of sentinel nodes under radiological guidance are under investigation and could potentially replace surgical staging of the axilla in the future. Moreover, omission of any type of node biopsy might be a potential option in more favorable tumors and could herald the beginning of the end for histological axillary sampling in selected cases.
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Anastomotic leakage (AL) is a serious complication in colorectal surgery leading to significant morbidity and mortality. Progressively lower anastomoses are associated with a greater leak rate. Adequate bowel perfusion has been stressed as one of the key elements for suture healing. ⋯ Real time intraoperative ICG fluorescent angiography (FA) is a safe and feasible technique to guide the surgeon in intraoperative decision-making process. ICG FA seems to reduce AL rates following rectal surgery for cancer. However large well-designed RCTs are needed to provide evidence for its routine use.
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Minimally invasive surgery has gained wide acceptance in many institutions. Complex surgery such as pancreatic resections delayed its diffusion due to high rate postoperative complications and technical aspects, while for pancreaticoduodenctomy the role of a minimally invasive approach is still on debate. Laparoscopic distal pancreatectomy may be considered a safe procedure and a valid alternative in selected cases. The operating time, learning curve and the costs represent major drawbacks for the laparoscopic approach. Elderly patients (>70 years of age) are generally considered to be at higher risk for developing complications after pancreatic surgery due to compromised physiological reserve and presence of multiple comorbidities. Our aim was to make a review about the role of laparoscopic distal pancreatectomy (LDP) in the elderly population. ⋯ LDP is safe and feasible if compared to ODP in selected elderly patients with body and tail pancreatic tumors. Less blood loss and shorter hospital stay are the most evident advantages of minimally invasive approach. Randomized controlled trials and high-volume centers prospective studies with long-term outcomes are necessary to consider laparoscopy a standard of care. Minimally invasive robotic surgery may represent an interesting alternative to laparoscopy especially for spleen-preserving procedures.