Dissertations / Theses on the topic 'Chirurgia laparoscopica'

La Surrenectomia Laparoscopica rappresenta un'importante opzione per il trattamento della patologia tumorale surrenalica ed è associata ad una riduzione della morbilità, del dolore post-operatorio e della durata della degenza ospedaliera. La letteratura ha dimostrato come la la sua efficacia sia superiore a quella della chirurgia open nel trattamento delle lesioni benigne mentre è sovrapponibile nel caso di lesioni maligne primitive o secondarie.

L’elaborato propone soluzioni progettuali originali per realizzare una serie di meccanismi presenti all’interno di uno strumento chirurgico per laparoscopia. Prendendo in disamina un prototipo realizzato precedentemente, vengono proposte alcune migliorie e soluzioni alternative dei sistemi di attuazione che lo compongono. L’obiettivo è progettare e realizzare un nuovo prototipo di strumento laparoscopico altamente performante contenendo i costi di fabbricazione. Seguendo una logica di progettazione il lavoro parte dal confronto di diverse soluzioni raccolte in una matrice morfologica, quindi analizza ogni movimentazione valutando quella già esistente e possibili alternative. Procede quindi con la progettazione della soluzione scelta e la verifica della sua funzionalità. Infine, ogni componente viene realizzato con le tecnologie a disposizione e montato seguendo un manuale di montaggio riportato nell’elaborato.

L'emergere di nuovi concetti in ambito anestesiologico e chirurgico ha evidenziato negli ultimi anni la possibilita' di un ampio spazio di miglioramento nella ripresa post-operatoria dopo chirurgia resettiva colorettale. Due sono state le principali innovazioni introdotte. La chirurgia laparoscopica, che prevede accessi addominali minimi, determina risultati a breve termine superiori rispetto alla chirurgia convenzionale. L'altra importante innovazione riguarda lo sviluppo della cosiddetta Fast-Track Surgery (FT) o Enhanced Recovery After Surgery (ERAS), che consiste nell'applicazione integrata e multimodale di nozioni sulla gestione perioperatoria dei pazienti basate sull'evidenza scientifica, riducendo i fattori che limitano una rapida ripresa post-operatoria (dolore, ileo paralitico e compromissione della funzione di altri organi) con notevole riduzione dei tempi di recupero e di degenza. Scopo del nostro studio e' la valutazione prospettica dell'efficacia e della fattibilita' dei protocolli Fast-track nella chirurgia resettiva colorettale laparoscopica. Dal marzo 2009 al settembre 2010 sono stati sottoposti a resezione colorettale laparoscopica con gestione perioperatoria secondo protocollo Fast Track 36 pazienti, con ASA mediano di 2. L'eta' mediana e' di 63,6 anni (range 30-83 anni). I pazienti di sesso maschile sono stati 13, quelli di sesso femminile 23. Il BMI mediano e' risultato 26 (range 19-33). In 31 pazienti la patologia di base era un adenocarcinoma colico, mentre in 5 casi si trattava di patologia benigna. Sono state effettuate, in laparoscopia, 3 colectomie sinistre, 11 resezioni di sigma, 12 resezioni anteriori di retto, 1 resezione di retto secondo Hartmann, 6 emicolectomie destre, 2 resezioni della flessura splenica e 1 ricanalizzazione dopo Hartmann. La durata media dell'intervento e' stata 5h (range 2h50à à ¢ -9h33à à ¢ ). La conversione laparotomica (incisione ombelico-pubica) si e' resa necessaria in 1 caso per difficolta' tecniche (2,8%). Nei restanti 35 casi (97%) e' stata eseguita una minilaparotomia, di lunghezza mediana di 7 cm (sovrapubica in 28, pararettale in 5, in fossa iliaca in 2). Sono state osservate 2 fistole anastomotiche precoci (5,5%), che hanno richiesto un re-intervento con confezionamento di ileostomia. Si sono inoltre registrate 9 complicanze minori (25%). Per quanto attiene il controllo del dolore, 29 (81%) pazienti sono stati sottoposti pre-operatoriamente al posizionamento di catetere epidurale. La canalizzazione alle feci si e' verificata dopo una mediana di 25,5 ore dalla fine dell'intervento. Il 74% dei pazienti ha assunto una dieta liquida/semiliquida gia' a partire da 2h dopo l'intervento e il 94% una dieta leggera entro 24h. In prima giornata post-operatoria l'84% dei pazienti si e' attenuto ad una mobilizzazione precoce associata a deambulazione, con una media di tempo trascorso fuori dal letto di 8 ore. Nel complesso, la compliance agli items del protocollo e' stata superiore al 90%. La degenza mediana e' stata di 3 giorni (range 2-24 giorni). In 3 casi si e' assistito ad una infezione del sito chirurgico (grado 1 sec. Dindo) che ha richiesto semplici medicazioni ambulatoriali. I risultati preliminari del nostro studio confermano che l'applicazione rigorosa di un protocollo Fast-track in chirurgia colorettale videolaparoscopica consente di ottenere un rapido recupero post-operatorio riducendo i tempi di degenza. Tale risultato e' stato ottenuto con completa soddisfazione dei pazienti. Sono necessari studi controllati randomizzati piu' ampi per una validazione definitiva di questi protocolli.
New concepts in analgesia and surgery recently showed a large potential for improving postoperative recovery after colorectal surgery. Two main innovations were the introduction of laparoscopic surgery (minimally invasive, with better short-term outcome) and the introduction of the so-called enhanced recovery protocols, consisting in multimodal integration of modern and evidence-based concepts in anesthesiological and surgical perioperative management, resulting in shortened hospital stays. Aim of our study is to prospectively evaluate feasibility and efficacy of such protocols, combined with a routine laparoscopic approach in colorectal surgery, in the setting of a University-tertiary care center. From March 2009 to september 2010, 36 patients were submitted to laparoscopic colorectal resection with enhanced recovery protocols. Mean age was 63.6 years (range 30-83 years). Female were 23; mean BMI was 26 (range 19-33). In 31 cases surgery was performed for a malignant indication. 3 left colectomies sinistre, 11 sigmoidectomies, 12 rectal anterior resections, 1 Hartmann procedure, 6 right colectomies, 2 splenic flexure resections and 1 reversion of a Hartmann procedure. Mean operative time was 300 min (range 170-577à à à ¢ ). Conversione rate was (2,8%). Anastomotic leak rate was 5,5%. 9 minor complication occurred (25%). 29 (81%) patients had epidural anesthesia. First flatus occurred after a mean of 25.5 hours after the end of the operation. 74% of the patients had a semiliquid fluid intake after 2 h from the operations and 94% a solid food intake after 24h. 84% of the patients were mobilized spending more than 8 h out of bed. Median length of the stay was 3 days (range 2-24 days). Our preliminary results confirm that a strict application of enhanced recovery protocols in laparoscopic colorectal surgery allow to improve postoperative outcomes, reducing hospital stay. Larger and randomized trials are needed to definitively evaluate these protocols.

Nonostante l applicazione di una corretta tromboprofilassi, il tasso residuo di tromboembolismo venoso (TEV) nei pazienti chirurgici si aggira in Letteratura intorno al 10 15 % [1]. Negli ultimi anni, con il sopravvento della chirurgia laparoscopica, gli Autori in Letteratura hanno iniziato a discutere le differenze emergenti in termini di aspetti medici e clinici tra la chirurgia tradizionale e la chirurgia laparoscopia, come le alterazioni emocoagulative ed immunologiche. La chirurgia laparoscopica è stata considerata una procedura a basso rischio di sviluppare trombosi venosa profonda ed embolia polmonare, in quanto comporta un limitato trauma chirurgico ed una precoce deambulazione post-operatoria. In realtà, l'incidenza di trombosi venosa profonda e di embolia polmonare dopo chirurgia laparoscopica è poco chiara, in quanto studi sulle alterazioni dell'emostasi dopo laparoscopia mostrano risultati contraddittori. Gli interventi chirurgici possono inoltre indurre profonde alterazioni nelle capacità immunitarie dell organismo che sono proporzionali alla grandezza del trauma chirurgico, e che contribuiscono allo stato di ipercoagulabilità ematica. Tale immuno-modulazione può inoltre predisporre i pazienti ad episodi settici post- operatori e anche alla progressione di un eventuale tumore residuo, come dimostrato da sempre crescenti evidenze sperimentali. Piuttosto che provare a contrapporre specifici elementi dell intricata risposta immunitaria all insulto chirurgico, vari Autori in Letteratura sostengono che, riducendo il danno tissutale, come avviene in chirurgia mininvasiva, la reazione immunitaria del paziente venga alterata in minore misura rispetto che alla chirurgia tradizionale. Obiettivo di questo studio è studiare e comparare i cambiamenti immunitari, emocoagulativi e dei parametri fibrinolitici in 2 gruppi omogenei di pazienti sottoposti rispettivamente a chirurgia laparoscopica e chirurgia tradizionale (open), allo scopo di individuare i meccanismi molecolari delle alterazioni emocoagulative, per perfezionare la profilassi antitrombotica e per lo sviluppo di nuove terapie volte a curare i disordini trombo-embolici. La presente ricerca inoltre migliorerà le conoscenze circa le alterazioni indotte dall insulto chirurgico sull assetto emocoagulativo ed immunitario, permetterà di stabilire e di comparare i benefici e i rischi della metodica laparoscopica e tradizionale, e di programmare strategie mediche e chirurgiche secondo le necessità specifiche del singolo paziente.

Obiettivi: sempre maggiore negli ultimi anni è il consenso che ha ottenuto tra i vari chirurghi la chirurgia laparoscopica del colon-retto per il trattamento di tutte le patologie, sia benigne che maligne; sebbene sia stata già da tempo dimostrata sia la fattibilità che la sicurezza di tutte le principali procedure laparoscopiche restano ancora controverse alcune indicazioni in particolare riguardo alla emicolectomia destra laparoscopica, meno studiata in letteratura. Scopo di questo studio è di analizzare i risultati perioperatori e oncologici anche a distanza delle emicolectomie destre laparoscopiche eseguite nella nostra esperienza con l’EBVS Ligasure per valutare possibili vantaggi rispetto a quelle riportate in letteratura. Metodi: presentiamo un’analisi retrospettiva di 241 interventi di emicolectomia dx laparoscopica di cui 182 per patologia eteroproliferativa effettuata mediante l’utilizzo dell’EBVS tra il Gennaio 2004 e il Dicembre 2008 presso la clinica di Chirurgia Generale e Metodologia chirurgica. Sono stati considerati parametri perioperatori quali il sanguinamento, il tempo operatorio, il tasso di conversione, il numero di linfonodi asportati, la degenza e le complicanze nonché un follow-up medio di 48,1 mesi. Risultati: non si sono osservate complicanze intraoperatorie; unica complicanza postoperatoria è stata una fistola anastomotica che ha portato ad exitus del paziente per shock settico. Clinicamente irrilevante è risultato il sanguinamento perioperatorio; il tempo operatorio medio è stato di 109,6 min con una percentuale di conversione del 6,5 %; degenza media di 5,6 gg. Oncologicamente adeguato è sempre stato il numero di linfonodi asportati e la clearance dei margini. Al follow-up non si sono osservate recidive endoaddominali e dei siti dei trocars e 23 sono stati i decessi per progressione di malattia. Conclusioni: l’emicolectomia dx laparoscopica è una procedura sicura affidabile ed oncologicamente corretta pari a quella laparotomica rispetto alla quale però offre vantaggi in termini di minore ospedalizzazione e di migliore cosmesi.
Background: the laparoscopic approach for colorectal resections is increasingly becoming fully accepted in the surgical treatments of the most benign, malignant and functional diseases. While laparoscopic surgery of the left colon and rectum has been evaluated in many studies, laparoscopic resection of the right colon has not been as widely examined. Aim of this study was examine the short and long-term outcomes after laparoscopic right colectomy with EBVS Ligasure and to determinate possible advantages with those described in other studies. Methods: a total of 241 consecutive unselected cases of laparoscopic right colectomy performed with EBVS Ligasure in our Surgical Institute between January 2004 and December 2008. Short-term outcomes as intra/postoperative blood loss, operating time, number of lymph nodes found in the resected specimen, complications and hospital stay and long-term outcomes as recurrence and survival rate for a mean follow-up of 48,1 mounths have been investigated. Results: no intraoperative complications occured. We had only one case of 30-day mortality (0,41%) for anastomotic failure. No significant morbidity occurred. Mean perioperative blood loss was 105 ml; mean operative time was 109, 6 min with rate conversion of 6,5%. Mean p.o. hospital stay was 5,6 day. The distance of the resection margin from the tumor was always oncological safe with a mean number of lymph nodes removed of 13,2. No significant differences were found at the follow-up in terms of overall survival and disease recurrence with other studies. Conclusion: laparoscopic right colectomy is as feasible and safe and with equivalent oncological clearance as the open technique. There are also the advantage of a shorter p.o. hospital stay and thus better cosmesis.

Il presente lavoro si prefigge lo scopo di eseguire l’analisi di fattibilità a cui farà seguito la realizzazione di un prototipo per strumento di chirurgia laparoscopica a sette gradi di libertà. La prima parte del lavoro si concentra sullo studio di un particolare meccanismo spaziale, il meccanismo RCRCR, che verrà utilizzato per trasmettere una componente di moto alla parte terminale dello strumento. Per l’analisi del meccanismo si sono inizialmente svolte diverse indagini teoriche, alle quali sono seguite la ricerca delle singolarità, l’analisi cinematica e l’analisi cinetostatica dello stesso. Le suddette analisi sono state svolte numericamente, tramite il software Ptc Creo Parametric, sulla base di un modello CAD tridimensionale creato e studiato appositamente. La seconda parte del lavoro, dopo aver studiato le condizioni operative a cui uno strumento di questa tipologia è soggetto, si concentra sulla completa progettazione dello stesso. Nel dettaglio viene progettata la parte adibita alla flessione dello strumento e il sistema di taglio/presa. Vengono poi eseguite diverse analisi statiche, tramite simulazioni strutturali agli elementi finiti, su ogni componente progettato, in diverse condizioni di lavoro e di configurazione, in modo da verificarne la corretta progettazione e comprendere meglio la distribuzione degli sforzi sullo strumento. Infine viene proposta una possibile soluzione progettuale per l’impugnatura dello strumento.

Scopo: La chirurgia robotica ha lo scopo di migliorare i risultati chirurgici superando i limiti intrinseci della laparoscopia convenzionale, semplificando le procedure più complesse come il confezionamento intracorporeo dell’anastomosi. Diversi studi suggeriscono che la realizzazione dell’anastomosi intracorporea dopo una colectomia destra possa offrire diversi vantaggi. Gli autori riportano uno studio retrospettivo nel quale vengono confrontati i risultati della colectomia destra robotica con anastomosi intracorporea (RRC-IA) rispetto a quella laparoscopica con anastomosi extracorporea (LRC-EA). Metodi: Una revisione retrospettiva del database prospetticamente mantenuto nella nostra istituzione è stata eseguita estrapolando i dati relativi ai pazienti sottoposti a RRC-IA e LRC-EA per malattia di Crohn, adenoma o neoplasia nel periodo compreso tra Settembre 2013 ed Agosto 2017. Centosessantotto pazienti (RRC-IA = 70, LRC-EA = 98) hanno soddisfatto i criteri di inclusione per l'ammissibilità nello studio. Sono stati valutati i risultati perioperatori e postoperatori a breve termine riportati nei due gruppi di studio. Risultati: Il gruppo RRC-IA, a fronte di un tempo operatorio superiore, ha mostrato una più breve ripresa della funzione alvica e dell’alimentazione. Non sono state riscontrate differenze significative nella durata della degenza ospedaliera, morbilità a 30 giorni, mortalità e numero di linfonodi asportati. Conclusione: La RRC-IA sembra offrire lievi vantaggi rispetto alla LRC-EA in termini di risultati postoperatori, anche se necessita di maggiori tempi operatori e costi. Una maggiore esperienza con la tecnica robotica potrebbe consentire a questi vantaggi clinici di bilanciare alcune delle preoccupazioni legate agli elevati costi che hanno scoraggiato la diffusione della tecnologia robotica per l’esecuzione della colectomia.
Aim: Robotic surgery is intended to improve surgical outcomes overcoming the inherent limitations of conventional laparoscopy by simplifying the most complex procedures such as the intracorporeal fashioning of an anastomosis. Several studies suggest that the intracorporeal confectioning of an anastomosis after a laparoscopic right colectomy may offer several advantages. The authors report a retrospective study comparing robotic right colectomy with intracorporeal anastomosis (RRC-IA) versus laparoscopic right colectomy with extracorporeal anastomosis (LRC-EA) Methods: A retrospective review of a prospectively maintained database of our institution was performed on the data on patients undergoing RRC-IA or LRC-EA for Crohn’s disease, adenomas or cancer between September 2013 and August 2017. One hundred and sixty-eight patients (RRC-IA=70, LRC-EA=98) met the inclusion criteria for eligibility in the study. Perioperative and short-term outcomes have been assessed. Results: A statistically significant difference was found between the two groups in terms of mean operative time and postoperative outcomes. Compared with the LRC-EA, the RRC-IA required a longer operative time but had better postoperative outcomes, such as a shorter time to first flatus and oral feeding recovery. No significant differences were found in the length of hospital stay, 30-day morbidity, mortality and number of lymph nodes harvested. Conclusion: The RRC-IA seems to offer slight advantages over LRC-EA in term of postoperative outcomes even if it still requests increased operative time and costs. Greater experience with the robotic technique may allow these advantages to counter some of the cost-related concerns that have deterred the more widespread utilization of robotic technology for colectomy.

Il presente studio si propone di eseguire un’analisi comparativa fra diverse tecniche chirurgiche per l’esecuzione dell’intervento di colectomia totale addominale e di confrontare i risultati di diversi standard di cura postoperatoria, in pazienti affetti da malattie infiammatorie croniche intestinali. A tal fine è stato disegnato uno studio prospettico randomizzato della durata di tre anni, di cui i primi due per l’arruolamento e trattamento dei pazienti e l’ultimo per garantire un follow-up minimo postoperatorio ed eseguire l’analisi statistica dei risultati. Il presente studio monocentrico verrà eseguito in un centro di riferimento riconosciuto a livello nazionale per il trattamento medico e chirurgico delle patologie in oggetto. L’obiettivo primario del presente studio è di valutare differenze in termini di outcomes chirurgici a breve e lungo termine dell’intervento di colectomia totale addominale eseguito con tecnica tradizionale open e laparoscopica. Si propone inoltre di evidenziare, come obiettivo secondario, eventuali differenze nella degenza postoperatoria e negli outcomes clinici nei pazienti sottoposti ad intervento di colectomia in relazione al tipo di gestione postoperatoria, confrontando la gestione postoperatoria tradizionale con i nuovi protocolli di trattamento fast-track.
This study aims to perform a comparative analysis between different surgical techniques for total abdominal colectomy surgery and to compare the results of different standards of postoperative care, in patients suffering from chronic inflammatory bowel diseases. A prospective randomized three-year study was designed, the first two for the enrollment and treatment of patients and the last to ensure a minimum postoperative follow-up and perform statistical analysis of the results. This single-center study was performed in a nationally recognized reference center for the medical and surgical treatment of the diseases in question. The primary objective of this study is to evaluate differences in terms of short and long-term surgical outcomes of total abdominal colectomy performed with traditional open and laparoscopic technique. It is also proposed to highlight, as a secondary objective, any differences in postoperative hospitalization and clinical outcomes in patients undergoing colectomy in relation to the type of postoperative management, comparing traditional postoperative management with new fast-track treatment protocols.

La tesi propone una sintesi dello stato dell’arte della tecnologia degli strumenti chirurgici per eseguire laparoscopie, operazioni chirurgiche minimamente invasive (MIS). Si analizzeranno i principali strumenti manuali meccanici, manuali robotici e robotici attualmente in uso per evidenziare l’evoluzione di tale tecnologia, i vantaggi e gli svantaggi.

La présente thèse traite de l'utilisation de retours haptiques pour fournir des informations aux chirurgiens durant des opérations de chirurgie minimalement invasive dans le but de les aider à améliorer leurs gestes.De meilleurs résultats pour les patients on amené la chirurgie minimalement invasive à devenir le standard pour bon nombre d'interventions. Cependant, la perte de perception de profondeur, la coordination main-oeil compliquée ainsi que les distorsions de sensations haptiques compliquent largement la tâche pour le chirurgien. Nous explorons le potentiel de retours haptiques pour intuitivement assister les chirurgiens durant des gestes de chirurgie minimalement invasive. Les formes de retour évaluées sont principalement haptiques (tactiles et kinesthésiques), avec des comparaisons à des retours visuels et multi-modaux (combinaisons de retours visuels et haptiques).Nos expériences dans le domaine de la navigation d'outils de chirurgie montrent des résultats encourageants quand aux bénéfices obtenus par des retours haptiques en termes d'amélioration de la qualité du geste chirurgical. Les guides par "virtual fixtures" montrent une nette supériorité par rapport aux autres formes de retour étudiées, cependant les retours vibrotactiles permettent aussi des améliorations notables. Des travaux parallèles sur le retour d'informations au sujet des efforts d'intéraction en bout d'outils a mis en évidence des différences importantes en termes des exigences de conception pour le retour tactile. Ceci nous a permis d'effectuer une conception et validation préliminaire de retours tactiles spécifiques à des applications de maitrise d'efforts, en utilisant l'exemple de la suture
The present thesis focuses on the use of haptic feedback technologies to provide information to surgeons during laparoscopic or minimal access surgery (MAS) with the aim of assisting them in improving their gestures.Better overall outcomes for patients have led MAS to become standard for many surgical interventions. However, loss of visual depth perception, difficult hand-eye coordination and distorted haptic sensation seriously complicate this task for the surgeon. We explore the potential of haptic cues for intuitively assisting surgeons during MAS gestures. Evaluated forms of feedback mainly focus on haptic (tactile and kinaesthetic) cues, but include comparisons to visual and multi-modal combined haptic and visual cues.Experiments on surgical tool navigation show encouraging results for the benefit of haptic cues in improving surgical gestures, with clear superiority of soft guidance virtual fixtures over other forms of feedback. However, promising results for the use of vibrotactile feedback are also obtained. These results are confirmed in preliminary experiments on tool navigation in preliminary experiments on tool navigation during a laparoscopic cutting training task.Parallel work on feeding back interaction forces highlighted significant differences in the usability and design requirements for tactile cues when compared to instrument navigation applications. This led us to design and perform preliminary testing on tactile cues appropriate force information in the case of intra-corporeal suture knot tying

Diversi studi dimostrano i vantaggi delle resezioni del colon minimamente invasive per il miglioramento dei risultati post-operatori a breve termine. Tuttavia, attualmente, la strategia di trattamento per i pazienti più anziani dipende dalle politiche di ciascuna istituzione. Lo scopo di questo studio è stato quello di indagare la sicurezza e la fattibilità dell’emicolectomia destra minimamente invasiva per i pazienti con il cancro al colon di età superiore ai 75 anni. MATERIALI E METODI Questo è stato uno studio retrospettivo multicentrico su più pazienti sottoposti a emicolectomia destra elettiva. L’endpoint primario dello studio è stato analizzare i risultati post-operatori a breve termine dell’emicolectomia destra minimamente invasiva nei pazienti anziani. I pazienti sono stati suddivisi in tre gruppi di età: Gruppo I (gruppo di controllo, < 60 anni), Gruppo II (>60-75), Gruppo III (≧75), e secondo l’approccio operativo utilizzato: Laparoscopia (LrH) o Robotico (RrH) e Resezione aperta (OrH). RISULTATI Sono stati considerati 618 pazienti: 267 (43.2%) nel Gruppo II, 268 (43.4 %) nel Gruppo III, 337 (54.5) LrH, 144 (23.3%) RrH e 137 (22.2%) OrH. I gruppi II e III non differivano per il tasso di complicanze chirurgiche a breve termine (p=0,392), né per la durata della degenza ospedaliera e il tasso di riammissione (p=0,944 e p=0,308 rispettivamente). Nessuno dei parametri post-operatori differiva tra LrH e RrH. OrH e LrH/RrH differivano statisticamente per complicanze intraoperatorie (6 vs 1; p=0,011), perdita ematica stimata (p=0,001) e complicanze postoperatorie (40 vs 82; p=0,22). La mortalità a 90 giorni è stata osservata in 5 pazienti (3,8%) nel gruppo OrH. OrH è stato associato a un tempo operatorio >180 min. La conversione alla chirurgia a cielo aperto è stata un fattore di rischio per complicanze e complicanze di classe III. CONCLUSIONI L’indicazione per la chirurgia laparoscopica non dovrebbe essere abbandonata per i pazienti anziani esclusivamente sulla base dell’età avanzata. La decisione della procedura chirurgica ottimale deve essere presa in base alle condizioni del singolo paziente, all’aspettativa di vita, e alla volontà del paziente e non basata esclusivamente sull’età del paziente.
Several studies demonstrate the advantages of minimally invasive colonic resections in improving short-term postoperative outcomes. However, currently, the treatment strategy for elderly patients depends on the policies of each institution. The aim of this study was to investigate the safety and feasibility of minimally invasive right hemicolectomy for patients with colon cancer aged over 75 years. MATERIALS AND METHODS This was a multicenter retrospective study on consecutive patients undergoing elective right hemicolectomy. The primary endpoint of the study was to analyse the short-term postoperative results of minimally invasive right hemicolectomy in elderly patients. Patients were divided into three age groups: Group I (control group, < 60 years), Group II (>60-75), Group III (≧75), and according to the operative approach used: Laparoscopic (LrH) or Robotic (RrH) and Open resection (OrH). RESULTS 618 patients were included: 267 (43.2%) in Group II, 268 (43.4 %) in Group III, 337 (54.5) LrH, 144 (23.3%) RrH and 137 (22.2%) OrH. Group II and III did not differ for short term major surgical complications rate (p=0.392), nor in the length of hospital stay and readmission rate (p=0.944 and p= 0.308 respectively). None of the postoperative parameters differed between LrH and RrH. OrH and LrH/RrH statistically differed in intraoperative complications (6 vs 1; p=0.011), estimated blood loss (p=0.001) and post-operative complications (40 vs 82; p=0.22). Mortality at 90 days was observed in 5 patients (3.8%) in the OrH group. OrH was associated with operative time >180 min. Conversion to open surgery was a risk factor for complication and class III complications. CONCLUSIONS Indication for laparoscopic surgery should not be abandoned for elderly patients solely based on older age. The decision of optimal surgical procedure should be taken based on the individual patient condition, life expectancy, and patient’s wishes and not specifically based on patient age

Habilitacijos procedūrai teikiamoje mokslo darbų apžvalgoje apibendrinama minimaliai invazinės endokrininių liaukų chirurgijos patirtis Vilniaus universiteto Pilvo chirurgijos centre. Apžvelgtos minimaliai invazinės skydliaukės operacijos, išanalizuoti ir apibendrinti dviejų klinikinių studijų rezultatai. 2004-2006 m. atliktoje perspektyvioje atsitiktinių imčių studijoje ,,Endoskopinės adrenalektomijos dviejų metodų įvertinimas“ pateikti ir išanalizuoti 70 pacientų, operuotų dėl įvairios antinksčių patologijos dviem minimaliai invaziniais būdais (laparoskopiniu bei endoskopiniu retroperitoniniu), rezultatai. Išanalizuota operacijos trukmės priklausomybė nuo antinksčio naviko dydžio, paciento kūno masės, palyginta kraujo netektis operacijos metu, operacinių komplikacijų skaičius. Įvertinus visus duomenis, prieita išvados, kad abu operacijos būdai geri, tačiau laparoskopinės adrenalektomijos išmokstama greičiau. 2005-2007 m. atliktame darbe ,,Minimaliai invazinė fokusuota ir tradicinė paratiroidektomija, gydant pirminį hiperparatiroidizmą: perspektyvioji, atsitiktinių imčių studija“ pateikiami pirminiu hiperparatiroidizmu sergančių pacientų, operuotų dviem būdais, gydymo rezultatai. Atsitiktinių imčių būdu 47 pacientai suskirstyti į dvi grupes: operuotų minimaliai invaziniu būdu (24 pacientai) ir operuotų tradiciniu Kocherio būdu (23 pacientai). Išanalizuota prieskydinės liaukos adenomos instrumentinių tyrimų diagnostinė vertė, palyginta operacijos trukmė, komplikacijų... [toliau žr. visą tekstą]
The experience of minimally invasive endocrine surgery accumulated at Vilnius University Centre of Abdominal Surgery is presented in this review of scientific publications submitted for habilitation procedure. The material concerning minimally invasive thyroid gland operations is summarized and the results of two clinical trials are evaluated. The results of prospective randomized study “Evaluation of two methods endoscopic adrenalectomy” were presented and analyzed; this study included 70 patients who underwent surgery for various pathology of adrenal glands; one group of the patients underwent laparoscopic minimally invasive operation and another one – endoscopic retroperitoneal minimally invasive surgery. The relationship between the size of adrenal gland tumour, patients’ body weight and duration of operation was analyzed; blood loss and rate of operative complications were compared. The evaluation of all data showed that both methods of surgery were acceptable; however, laparoscopic adrenalectomy was more was easier to learn. Clinical study “Minimally invasive focused and traditional parathyroidectomy for treatment of primary hyperparathyroidism: a prospective randomized study” was performed during the period since 2005 till 2007; the results of treatment of patients by means of two methods of surgery were presented. The patients (n = 47) were randomized into two groups; one group included 24 patients who were operated on using minimally invasive technique and another... [to full text]

Nous avons développé un système de réalité augmentée (RA) permettant de guider le chirurgien dans son geste opératoire coelioscopique grâce aux données d’imagerie acquises en préopératoire. Ce système permet de voir au travers d’un organe comme si celui ci était semi-transparent. Le chirurgien peut ainsi parfaitement localiser une tumeur dans le parenchyme d’un organe. Il peut ou pourra voir également toutes les données anatomiques et structurelles disponibles en préopératoire sur l’imagerie. Le fonctionnement de notre système se déroule en trois phases. En préopératoire, une acquisition des données d’imagerie (IRM) et la création des modèles 3D associés (surface externe de l’organe, tumeur(s), repères anatomique(s)) sont réalisées. En peropératoire un modèle 3D de l’organe d’intérêt est réalisé, une phase de recalage initial est réalisée, puis le suivi de l’organe est effectué en temps réel. Notre système permet de suivre un organe mobile ce qui n’avait jamais été réalisé auparavant. Pour débuter le développement de notre système, nous avons étudié deux modèles de tumeurs : les myomes utérins et les tumeurs rénales. Pour chaque type de tumeur et d’organe les phases initiales de développement sont identiques: test sur modèle (phase 1), test ex-vivo et faisabilité clinique (phase 2), tests cliniques (phase 3). Nous sommes en phase 3 pour la myomectomie et en phase 2 pour la néphrectomie partielle. Nous avons démontré sur un modèle utérin (utérus imprimé en 3D, myomes virtuels) les avantages de la RA par rapport à une technique standard pour laquelle l’opérateur n’utilise que la lecture de l’IRM. En effet, dans ce modèle, l’utilisation de la RA améliore la localisation des myomes en permettant à l’opérateur de voir littéralement au travers de l’utérus. Après optimisation ex-vivo, nous avons testé notre système en clinique. Nous avons démontré la faisabilité de son utilisation avec une localisation en temps réel des myomes et de la cavité utérine. L’objectif est maintenant la validation de son utilisation en pratique courante. Pour la néphrectomie partielle nous avons développé un modèle de tumeur du rein (reins porcins, tumeurs créées par injection d’alginate). Dans ce modèle l’utilisation de la RA améliore la localisation tumorale en améliorant de façon significative le taux de marges saines péri-tumorales. La phase 2 est en cours de mise en place. Parallèlement l’étude du système pour les tumeurs hépatiques a débuté. Le développement de notre système a été réalisé grâce à une équipe mixte associant scientifiques, ingénieurs, chirurgiens et médecins. Le champ des possibilités offert par la RA est très prometteur car il permettra d’intégrer l’ensemble des données préopératoires à notre vue laparoscopique. Le système devrait pouvoir rapidement être utilisé pour d’autres pathologies en gynécologie mais aussi en urologie et en chirurgie digestive. D’autres technologies comme le deep learning permettront également des évolutions majeures dans l’automatisation du système
We developed an Augmented reality (AR) system that can guide the surgeon during laparoscopy. Augmented Reality (AR) is a technology that can allow a surgeon to see subsurface structures. This works by overlaying information from another modality, such as MRI and fusing it in real time with the endoscopic images. The surgeon can easily localize tumor in the parenchyma of an organ. He could also easily localize all anatomical and structural landmarks available on the preoperative imaging. Three phases are necessary. Firstly, Preoperative MRI data are used (segmentation) to construct 3D mesh models (external surface of the organ, tumor(s), anatomical landmarks). During the surgery a 3D mesh model of the organ is constructed and an initial registration phase (using a deformable model of the organ) is performed. Then the third phase is a real-time tracking phase. AR has never been developed for a very mobile organ like the uterus and has never been performed for gynecology. Our system works for soft and mobile organs. We used two tumor models: myomas in gynecology and kidney’s tumor for partial nephrectomy. For each type of tumor we used the same step to develop our system. First step: experimental tumor model, second step: ex vivo improvement and first clinical evaluation, third step: clinical evaluation. We are in the third phase for myomectomy and in the second phase for partial nephrectomy. In our uterine model (3D printed uterus), AR improves localization accuracy of the myomas compared to the classical localization method (MRI only). This was the first user study to quantitatively evaluate an AR system for improving a surgical task. After optimizing our system using ex-vivo data, we tested it during laparoscopic myomectomy and demonstrated the feasibility of the real-time tracking and localization of the myomas and of the uterine cavity. For partial nephrectomy we created a kidney’s tumor model (porcine model). Our study shows that AR allows accurate localization of very small tumors and improved the mean accuracy of tumor resection, with higher rate of free margins around the tumor. We are currently developing phase 2. For liver resection the development is in phase 1. Our team is a mix of engineers, scientists, doctors and surgeons. AR is a very promising technique with large applications. It allows displaying all preoperative imaging data on our laparoscopic screen. AR should be used soon for other gynecological, urological and digestive pathologies. Other technologies (including deep learning) should allow major improvement of our system

Lo sviluppo tecnologico degli ultimi decenni ha reso gli ospedali strutture altamente specializzate in cui l’introduzione di nuove e sofisticate metodiche medico chirurgiche, ha considerevolmente innalzato il livello di attività diagnostiche e curative moltiplicando, tuttavia, le fonti di rischio. Assicurare la sicurezza ai pazienti e al personale che opera all’interno dell’ospedale è divenuto quindi un compito estremamente articolato e complesso. il 18% dei chirurghi e il 33.3% dei ginecologi riferisce di aver avuto esperienze di ustioni in pazienti sottoposti ad interventi in laparoscopia. (18) Nello studio condotto da Meijer e pubblicato su Mitat 2003 sulla sicurezza elettrica condotto in 33 ospedali olandesi sono stati analizzati 1438 strumenti laparoscopici e sono stati rilevati difetti di isolamento in 267 pari al 18,6% e più della metà dei difetti non erano visibili ad occhio nudo, nel suo studio Maijer ha utilizzato un particolare strumento che alla tensione di 3000V ha prodotto in corrispondenza delle lesioni delle guaine una corona di luce. L’approccio utilizzato nella ricerca condotta nel Dipartimento di Chirurgia dell’Università di Tor Vergata è stato quello di evidenziare le lesioni sulla superficie delle guaine che ricoprono i ferri chirurgici e studiare possibili alternative per risolvere il problema in condizioni di normale utilizzo clinico, cioè a tensioni molto più basse. La parte iniziale della tesi ha riguardato l'analisi delle lesioni presenti sulle guaine chirurgiche, sono stati sviluppati algoritmi matematici basti su operatori morfologici in grado di rilevare eventuali lesioni presenti sulla superficie delle guaine che ricoprono i ferri chirurgici utilizzati in laparoscopia. La verifica di questo metodo è stata effettuata tramite la termocamera per la misura dell'infrarosso, Il ricorso all'infrarosso come metodo di analisi è stato scelto sulla base delle seguenti considerazioni, in quanto ogni oggetto emette radiazione infrarossa la cui intensità e il cui spettro dipende dalle caratteristiche interne e superficiali dell'oggetto stesso nonché dalla sua temperatura, ed inoltre è possibile calcolare la temperatura del corpo emittente dalla misura dell'intensità della radiazione emessa. E' stata pertanto eseguita una misura, seppur qualitativa, della distribuzione superficiale di temperatura lungo tutta la guaina a seguito di una sollecitazione di origine termica indotta collegando lo strumento in esame, che in questo caso era una forbice, all'elettrobisturi. L'analisi termografica ha prodotto risultati contrastanti, inoltre anche in presenza di lesioni microscopiche non si è osservata alcuna variazione di colore associata a dispersione elettrica; è stata rilevata conduzione elettrica tra la punta elettrificata dello strumento e guaina intatta in presenza di sangue o più in generale di liquidi biologici contenenti ioni. Il problema è stato risolto utilizzando un filtro che fosse contemporaneamente adsorbente cioè in grado di effettuare una separazione ionica a livello superficiale all’interfase solido-liquido e avesse una certa difficoltà ad immagazzinare carica elettrica e a trasferirla da un conduttore ad un altro. I materiali inizialmente analizzati i materiali ceramici ma poi esclusi per l’eccessiva rigidità, tra i polimeri una possibile soluzione è stata identificata nel polimetilmetacrilato ma la temperatura di fusione intorno a 130°C molto vicine a quelle utilizzate nelle autoclavi per la seterilizzazione lo rende inutilizzabile su ferri poliuso. E’ stato pertanto scelto il polifluoroetilene in quanto oltre ad essere un isolante migliore rispetto al polimetilmetacrilato mantiene le sue caratteristiche inalterate fino a temperature di 200°C.
The aim of the plan is reduce the risk of burns that are taken place accidentally in laparoscopic surgery due of an unexpected transmission of electric current. The incidence of laparoscopic burns is between 2.3 and 4 cases on 1000 major operation. Almost 18% of surgery and 33.33% of gynaecology has a direct or indirect experience about burn injuries, The first step is understand what is the causes about this injuries. In Add to the conventional theory, we have discovered that the burns are also due of the contact between the intact sheath wet of blood or biological liquids and the anatomic parts. In Laparoscopic surgery the tip of instruments is under power and often get in touch with blood contains some ions available for electric conduction. Material and methods: Preliminary, we performed any electric test on the surface of sheath, then we investigated the microscopic frame with different way. We implemented different math algorithms based on morphological operation to identify anomaly shapes as contour, colour, area. We implemented also math algorithm based on zoom able to detect a small rupture of sheath similar to grain dust We checked our results with thermograph analysis and we didn’t observed change of colour near points suspect. Results: The thermograph analysis didn't confirm our hypothesis and we focus our research on composition of blood, biological liquids and the materials of sheath. We have detected the presence of ions as iron, calcium, sodium, potassium, and even if few concentrate, they carry electric current in according with electrolytic conduction theory. We developed a special filter in adsorption material able to attract to its surface molecules and ions with which it is in contact and reduce the electric conduction. Conclusions: The carried out measures effectively show an increment of the electric resistance when the blood enters in contact with the adsorbing material therefore turns out more difficult the transfer than current to the near tissue ones.

En chirurgie laparoscopique, les chirurgiens doivent prendre des décisions appropriées en se basant sur une image qui leur offre un point de vue unique du site opératoire. Cette tâche est difficile à réaliser compte tenu du champ de vue limité de l'endoscope et du fait que l'endoscope rigide doit passer par un point d'insertion unique. Ces contraintes obligent les chirurgiens à réaliser des mouvements d'aller-retour avec l'endoscope, alternant entre des vues détaillées et des vues globales de la scène, qui leur permettent de se repérer plus facilement. Dans le but d'observer les parties cachées d'un organe, les chirurgiens aimeraient bien pouvoir changer le point de vue, sans avoir à insérer l'endoscope dans un nouveau point d'insertion. Pour répondre à cette problématique, nous proposons au chirurgien de visualiser une image virtuelle de la cavité abdominale, synthétisée selon un point de vue quelconque. Notre approche est basée sur l'insertion d'un commando de caméras miniatures au sein de la cavité abdominale. Ces caméras sont fixées à la paroi abdominale, aux trocarts ou aux outils chirurgicaux, de sorte qu'au moins l'une d'entre elles soit en mesure de percevoir une information pertinente pour le chirurgien. Les caméras sont regroupées en paires stéréoscopiques pour reconstruire des modèles 3D du site opératoire. Ces modèles fournissent un cadre de référence qui permet la fusion de toutes les images perçues par les caméras, restituée sous forme d'une image stable synthétisée selon tout point de vue. L'image virtuelle est rendue selon le point de vue désiré par le chirurgien, ce qui lui permet d'explorer la cavité abdominale sans intervenir sur les caméras réelles.

La chirurgie laparoscopique reproduit fidèlement les principes de la chirurgie conventionnelle avec une agressioncorporelle minimale. Si cette chirurgie apparaît comme étant très avantageuse pour le patient, il s’agit d’une interventionchirurgicale difficile où la complexité du geste chirurgical est accrue, en comparaison avec la chirurgie conventionnelle.Cette complexité réside en partie dans la manipulation des instruments chirurgicaux et la visualisation dela scène chirurgicale (notamment le champ de visualisation restreint d’un endoscope classique). La prise de décisionsdu chirurgien pourrait être améliorée en identifiant des zones critiques ou d’intérêts non visibles dans la scènechirurgicale.Mes travaux de recherche visent à combiner la robotique, la vision par ordinateur et la fluorescence pour apporterune réponse à ces difficultés : l’imagerie de fluorescence fournira une information visuelle supplémentaire pour aiderle chirurgien dans la détermination des zones à opérer ou à éviter (par exemple, visualisation du canal cystique lorsd’une cholécystectomie). La robotique assurera la précision et l’efficience du geste du chirurgien ainsi qu’une visualisationet un suivi "plus intuitif" de la scène chirurgicale. L’association de ces deux technologies permettra de guideret sécuriser le geste chirurgical.Une première partie de ce travail a consisté en l’extraction d’informations visuelles dans les deux modalités d’imagerie(laparoscopie/fluorescence). Des méthodes de localisation 2D/3D en temps réel d’instruments chirurgicaux dansl’image laparoscopique et de cibles anatomiques dans l’image de fluorescence ont été conçues et développées.Une seconde partie a consisté en l’exploitation de l’information visuelle bimodale pour l’élaboration de lois de commandepour des robots porte-endoscope et porte-instrument. Des commandes par asservissement visuel d’un robotporte-endoscope pour suivre un ou plusieurs instruments dans l’image laparoscopique ou une cible d’intérêt dansl’image de fluorescence ont été mises en oeuvre.Dans l’objectif de pouvoir commander un robot porte-instrument, enfonction des informations visuelles fournies par le système d’imagerie, une méthode de calibrage basée sur l’exploitationde l’information 3D de la localisation d’instruments chirurgicaux a également été élaborée. Cet environnementmultimodal a été évalué quantitativement sur banc d’essai puis sur spécimens anatomiques.À terme ce travail pourra s’intégrer au sein d’architectures robotisées légères, non-rigidement liées, utilisant des robotsde comanipulation avec des commandes plus élaborées tel que le retour d’effort. Une telle "augmentation" descapacités de visualisation et d’action du chirurgien pourraient l’aider à optimiser la prise en charge de son patient
Laparoscopic surgery faithfully reproduce the principles of conventional surgery with minimal physical aggression.If this surgery appears to be very beneficial for the patient, it is a difficult surgery where the complexity of surgicalact is increased, compared with conventional surgery. This complexity is partly due to the manipulation of surgicalinstruments and viewing the surgical scene (including the restricted field of view of a conventional endoscope). Thedecisions of the surgeon could be improved by identifying critical or not visible areas of interest in the surgical scene.My research aimed to combine robotics, computer vision and fluorescence to provide an answer to these problems :fluorescence imaging provides additional visual information to assist the surgeon in determining areas to operate or tobe avoided (for example, visualization of the cystic duct during cholecystectomy). Robotics will provide the accuracyand efficiency of the surgeon’s gesture as well as a visualization and a "more intuitive" tracking of the surgical scene.The combination of these two technologies will help guide and secure the surgical gesture.A first part of this work consisted in extracting visual information in both imagingmodalities (laparoscopy/fluorescence).Localization methods for 2D/3D real-time of laparoscopic surgical instruments in the laparoscopic image and anatomicaltargets in the fluorescence image have been designed and developed. A second part consisted in the exploitationof the bimodal visual information for developing control laws for robotics endoscope holder and the instrument holder.Visual servoing controls of a robotic endoscope holder to track one or more instruments in laparoscopic image ora target of interest in the fluorescence image were implemented. In order to control a robotic instrument holder withthe visual information provided by the imaging system, a calibration method based on the use of 3D information of thelocalization of surgical instruments was also developed. This multimodal environment was evaluated quantitativelyon the test bench and on anatomical specimens.Ultimately this work will be integrated within lightweight robotic architectures, not rigidly linked, using comanipulationrobots with more sophisticated controls such as force feedback. Such an "increase" viewing capabilities andsurgeon’s action could help to optimize the management of the patient

Premessa: Lo studio ha verificato i risultati e l’efficacia del trattamento della litiasi colecisto‐coledocica per via laparoscopica mediante esplorazione transcistica (LTC‐CBDE) e coledocotomica (LCBDEC). Metodi: L’analisi si basa su dati raccolti in un database che include 78 pazienti affetti da litiasi coledocica trattati con LTC‐CBDE e LCBDEC, in un periodo compreso dal Novembre 2002 al Dicembre 2012. In 47 pazienti (60,2%) asintomatici, la presenza di litiasi coledocica è stata riscontrata intraoperatoriamente mediante l’impiego sistematico della colangiografia, mentre nei restanti 31 pazienti (41%), precedentemente sottoposti ad ERCP e sfinterotomia (SE), si evidenziava la presenza di calcolosi residua della via biliare principale. Risultati: Dei 78 pazienti, 43 femmine e 35 maschi (età media 60.96 anni, range 28‐90). Si è osservato un solo caso di mortalità in una paziente di 87 anni. Il tasso di morbilità è pari a 6,4%: tre pazienti hanno sviluppato una raccolta addominale trattata mediante posizionamento di drenaggio per via radiologica, un paziente ha sviluppato un’infezione polmonare e in un paziente trattato con approccio transcistico è stato riscontrato ittero da calcolosi residua coledocica per cui si è proceduto a bonifica mediante ERCP‐SE. Tre pazienti (3,8%), già sottoposti a ERCP‐SE, hanno subito la conversione dell’intervento a celo aperto. Il tempo operatorio medio è stato di 126 min, (range 50‐275 min). L’approccio transcistico (LTC‐CBDE) è stato effettuato in 41 di 47 pazienti asintomatici per litiasi coledocica e in 15 (48%) di 31 pazienti già sottoposti a ERCP‐SE. Nei restanti 6 e 16 pazienti, dopo fallimento dell’approccio transcistico (LTC‐CBDE), sono stati sottoposti a trattamento coledocotomico (LCBDEC). In un solo paziente (1,8%) su 56 pazienti è stato posizionato un drenaggio biliare transcistico dopo LTC‐CBDE. In 22 casi è stata eseguita l’esplorazione diretta della via biliare principale per via transcoledocotomica: in 3 casi (13,6%) un drenaggio addominale sottoepatico ed in 19 (86,4%) pazienti è stato posizionato un drenaggio biliare: in 16 casi un tubo a T di Kehr, in un caso un drenaggio transcistico, in 2 casi un sondino naso biliare prima dell’ intervento. Il followup a lungo termine è stato eseguito per un periodo medio di 53 mesi (range 12‐98) in 57 pazienti (73%), cinque pazienti (6,4%) sono deceduti per cause non inerenti la terapia chirurgica, 16 pazienti (20,5%) sono risultati non rintracciabili, 2 pazienti (3,5%) sono stati nuovamente sottoposti a ERCP‐SE e 4 pazienti asintomatici non sottoposti a ERCP hanno riscontrato parametri ematochimici alterati. Conclusioni: LTC‐CBDE e LCBDEC sono efficaci nel trattamento della litiasi coledocica e possono rappresentare un’alternativa al trattamento con ERCP‐SE.
Aims: To evaluate the effectiveness and results of laparoscopic transcystic common bile duct exploration (LTC‐CBDE) and of laparoscopic common bile duct exploration by choledochotomy (LCBDEC). Methods: Analysis was based on a prospectively collected database and included 78 patients with common bile duct stones treated with LTC‐CBDE and LCBDEC between November 2002 and December 2012. In forty seven patients (60,2%) asymptomatic, common bile duct stones were discovered at perioperative through the systematic use of cholangiography and the remaining 31 (41%) patients had residual common bile duct stones after ERCP with endoscopic sphincterotomy (ES). Results: Of 78 patients, 43 were females and 35 males (median age 60.9 years, range 28‐90). Mortality occurred in an 87 years old female patient. Morbidity rate was 6.4%: three patients developed a subhepatic fluid collection treated through radiological drainage positioning, one patient developed a pneumopathy and one patient treated with approach transcystic (LTC‐CBDE) was discovered jaundice residual bile duct stones, for which proceeded to reclamation by ERCP‐ES. Three patients (3,8%) with residual choledocholithiasis, already treated by ERCP‐SE, were converted to open surgery. Mean operative time was 126 min (range 50 ‐ 275). LTC‐CBDE was the method of choice and it was possible in 41 of 47 patients with unsuspected CBD stones (87%) and in 15 (48%) of 31 patient with residual choledocholithiasis already treated by ERCP‐SE. In the remaining 6 and 16 patients LCBDEC was performed after failed LTCCBDE. Trans‐cystic biliary drainage was positioned in only one (1.8%) of 56 patients after LTC‐CBDE. In the 22 cases where choledochotomy was require: a drainage sub‐hepatic in 3 patients (15,6%) and a biliary drainage was placed in 19 patients (86,4%): a T‐tube in 16 patients, drainage transcystic in one patient, before operation a drainage nose‐biliary in 2 patients. Long‐term follow‐up (53 months, range 12‐98) is available in 57 patients (73%), 5 patients (6,4%) unrelated deaths for nonsurgical causes and 16 patients (20.5%) lost to follow up and it showed the occurrence of recurrent ductal stones in 2 cases (3.5%) and mild biochemical signs of bile stasis in 4 asymptomatic patients who did not require ERCP. Conclusions: LTC‐CBDE and LCBDEC are effective in the management of CBDS and may be an alternative treatment option to ERCP‐ES.

La chirurgie laparoscopique conventionnelle apporte des avantages aux patients mais pose des défis aux chirurgiens. Utiliser le robot permet de surmonter certaines des difficultés. Nous utilisons ici le concept de comanipulation, où un bras robotique sert de comanipulateur et génère des champs de force pour aider les chirurgiens. Pour implémenter des fonctions telles que la compensation de la gravité de l’instrument, il est utile de connaître la position du trocart en temps réel par rapport à la base du robot. Nous proposons un algorithme de détection et localisation de trocarts, basé sur la méthode du moins carré. Des expériences in vitro et in vivo valident son efficacité. Considérant des caractéristiques de la chirurgie laparoscopique, i.e., de l’espace de travail grand et de la difficulté de planifier le geste, des champs visqueux sont utilisés. Afin de s’adapter aux mouvements différents, nous utilisons une loi de commande de viscosité variable. Cependant, elle rencontre un problème d’instabilité, qui est analysé théoriquement et expérimentalement. Une solution d’ajout d’un filtre passe-bas de premier ordre est proposée, dont l’efficacité est mise en évidence par une expérience de ciblage point à point. Avec la position du trocart connue, nous pouvons établir «le modèle de levier», une formule décrivant la relation entre les vitesses et les forces appliquées à différents points de l’instrument. Ceci permet de mettre en œuvre une loi de commande de viscosité sans utiliser de signaux bruités, au point de centre de la poignée ou la pointe de l’instrument. Une expérience est menée pour comparer l’influence de la loi de commande sur les comportements de mouvement humain
Traditional laparoscopic surgery brings advantages to patients but poses challenges to surgeons. The introduction of robots into surgical procedures overcomes some of the difficulties. In this work, we use the concept of comanipulation, where a 7-joint serial robotic arm serves as a comanipulator and generates force fields to assist surgeons.In order to implement functions like instrument gravity compensation, identifying real-time trocar position with respect to robot base is a prerequisite. Instead of obtaining trocar information from the registration step, we propose a robust trocar detection and localization algorithm based on least square method. Both in-vitro and in-vivo experiments validate its efficiency.Considering the characteristics of laparoscopic surgery, i.e., relatively large workspace and flexible operating objects, viscous fields are employed. To better adapt to different motion, we use a variable viscosity controller. However, this controller encounters an instability problem, which is analyzed both theoretically and experimentally. A solution of adding a first order low pass filter is proposed to slow down the variation of the viscosity coefficient, whose efficiency is evidenced by a point-to-point targeting experiment.With real-time trocar position known, the “lever model”, a formula describing therelationship of the velocities and forces of different instrument points, can be established. This allows implementing viscosity controller without using noisy signals at the center points of instrument handle and tip. Another point-to-point movement experiment is conducted to compare the features of the controller influence on human motion behaviors

L’obésité est un problème de santé publique majeur croissant, nécessitant une prévention et un traitement le plus souvent multidisciplinaire. Le seul traitement de l’obésité ayant prouvé un gain en termes d’augmentation de l’espérance de vie est la chirurgie. Le but de cette étude est d’évaluer la faisabilité de la sleeve gastrectomie laparoscopique en ambulatoire dans un centre hospitalo-universitaire. Méthode : Cette étude monocentrique prospective a été réalisée au CHU d’Amiens de mai 2011 à avril 2012. L’étude entrait dans le cadre d’un protocole de recherche local. L’indication chirurgicale était validée lors d’une réunion de concertation pluridisciplinaire. L’étude a porté sur 30 patients répondant à la fois aux critères de prise en charge chirurgicale de l’obésité morbide et aux critères de prise en charge anesthésique en ambulatoire. Les protocoles d’anesthésie, de chirurgie et de prise en charge de la douleur et des vomissements étaient standardisés. Résultats : La population étudiée est à prédominance féminine(93 %). L’âge moyen du groupe était de 34 ans (22-55). L’IMC moyen était de 42,7 et le poids moyen de 117,3 kg. La moitié de la population présentait des comorbidités associées à l’obésité : HTA (5), dyslipidémie (3), tabagisme actif (6), prédiabète (1). La durée opératoire moyenne a été de 60 minutes. En peropératoire, nous n’avons noté aucune hémorragie, ni laparo-conversion. Il n’y a eu aucune complication postopératoire nécessitant la reprise chirurgicale. Nous avons comparé la douleur à l’entrée et à la sortie de SSPI. 27 patients présentent une douleur faible ou nulle en sortie de bloc. La totalité des patients présentent une douleur nulle ou faible en sortie de SSPI. 27 patients ne présentent pas de nausées ni vomissements postopératoires à la sortie du bloc. La durée moyenne en salle de réveil était de 86,5 minutes. L’appel du lendemain a trouvé seulement quatre patients présentant des symptômes ne nécessitant pas l’hospitalisation. Le critère de satisfaction globale est de 90 %. Conclusion : L’obésité ne constitue pas à elle seule une contre-indication à l’anesthésie ambulatoire. La chirurgie bariatrique du fait du terrain du patient nécessite une coopération entre anesthésistes et chirurgiens. La décision d’une prise en charge ambulatoire en chirurgie bariatrique ne doit se faire qu’au cas par cas après analyse du bénéfice/risque. L’évidence suggère que la sleeve gastrectomie est possible chez des patients sélectionnés par des équipes expertes en chirurgie bariatrique. Cependant, des études supplémentaires sont nécessaires pour évaluer l’innocuité et l’acceptabilité.

L'incontinenza anale (IA), è definita come l'incapacità a controllare volontariamente l'emissione di gas e/o feci. L' IA si definisce totale se comporta la perdita di feci solide, parziale se solo di gas e feci liquide; potrà essere passiva (fecal soiling), oppure manifestarsi durante urgenza defecatoria. La gravità dell' IA si valuta con degli score. I più affidabili sono CCF score (Jorge & Wexner) da 0-20, il quale valuta anche l'impatto della IA sulla qualità di vita, il Pescatori score (1-6), AMS, Vaizey ( St. Mark's Hospital), Williams. I pazienti con IA che presentano sintomi da lievi a moderati, rispondono bene al trattamento conservativo, il trattamento chirurgico invece è riservato a quelli pazienti con IA grave. L'associazione tra prolasso rettale e IA rappresenta un entità clinica di non semplice risoluzione. Matteriali e Metodi. L'esame obiettivo ano perineale, intergrato dall'esame anoscopico sarà mirato a cercare di identificare quale struttura anatomico-funzionale è principalmente coinvolta nella patogenesi del disturbo. L'ispezione potrà evidenziare: ano beante, cicatrici, ectropion mucoso, fistole, ascessi, emorroidi, patologie uro-ginecologiche (es. cistocele, prolasso utero-genitale), l'entità del prolasso del retto, perineo discendente. L'esplorazione rettale valuterà il tono sfinteriale (in condizioni basali, durante contrazione volontaria e sotto i colpi di tosse). L'esame endoscopico valuta la presenza di malattie infiammatorie,tumori, ulcera solitaria e prolasso mucoso del retto. Le indagini morfologiche quali la manometria anale, la colpocisto-defecografia, l'eletromiografia dei muscoli del pavimento pelvico,l'endosonografia anale,vaginale e perineale dinamica, potranno rivelarsi utili nello studio di lesioni organiche colo-rettali e dell'integrità anatomica della componente sfinteriale. Trattamento chirurgico: sfinterolpastica, levatorplastica anteriore, plicatura posteriore del pavimento pelvico sec. Park's, total pelvic floor repair, iniezioni di biomateriali, procedure di "encirclement". Nelle unità di coloproctologia della Società Italiana di Chirurgia Colo-Rettale (1983-2000), sono stati osservati 738 pazienti. Quarantasette (30 donne) pazienti, (6.4%), presentavano IA associata a prolasso rettale, di questo gruppo, venticinque pazienti (53%), sono stati sottoposti a trattamento chirurgico Prolasso rettale (PR), il prolasso rettale è caratterizzato dalla fuoriuscita di vari strati della parete attraverso il canale anale. Può essere a tutto spessore (completo) o esterno, oppure occulto (interno). I sintomi più frequenti sono dolore anale, perdite ematiche, perdite mucose, urgenza defecatoria. L' incontinenza anale associata è stata dimostrata nel 50-70% dei casi, il 25-50% dei paziente invece potrebbe presentare stipsi, valutata secondo il CCF score (0-30), per la stipsi. Anamnesi accurata, esame obiettivo,valutazione di patologie genito-urinarie associate, abitudini intestinali. I pazienti vengono sottoposti ad anoscopia, colonscopia, cine-defecografia, misurazione dei tempi di latenza del nervo pudendo e tempi di transito intestinale. La manometria ano-rettale spesso risulta essere alterata. La terapia chirurgica del prolasso del retto è la cosiddetta terapia su misura (tailored surgery), tenendo in considerazione i disordini funzionali associati, in particolare se vi sia o no IA associata. Gli approcci perineali comprendono più frequentemente l'intervento secondo Delorme e Altemeier. Risultati. Nella nostra casistica Ospedale S. Eugenio (1987-2003), sedici pazienti (10 donne ) sono stati sottoposti ad intervento sec. Delorme. Il tasso di recidiva era 9% a 5 anni (range del follow-up 6-60 mesi). L'indice di soddisfazione nel postoperatorio era 73%, il 46-75% dei pazienti hanno avuto miglioramento della loro continenza. Dodici pazienti (8 donne) sono stati sottoposti ad intervento chirurgico sec. Altemeier, il tasso di recidiva era 1% (range del follow-up 6-60 mesi), sono stati raggiunti con questo tipo di tecnica ottimi risultati funzionali per incontinenza e stipsi. Nelle procedure addominali, la rettopessi secondo Orr-Loyge è stata effettuata in 25 pazienti (9 donne), il tasso di recidiva era 2,5%, (range del follow-up 8-80 mesi). La continenza è stata migliorata nel 58% dei casi, la stipsi invece nel 61% dei pazienti. Trentasei pazienti (16 donne), sono stati sottoposti a rettopessi secondo Wells, 12 pazienti hanno avuto recidiva di malattia (range del follow-up 8-80 mesi). La continenza è migliorata nel 35% dei casi, la stipsi invece è peggiorata nel 20% dei pazienti. L'approccio addominale ha dimostrato minor rischio di recidiva e migliori risultati funzionali, in termini di incontinenza anale e stipsi in confronto alle tecniche perineali. La chirurgia laparoscopica anche, dimostra essere una scelta affidabile, con ottimi risultati in termini di recidiva ed outcomes funzionali. Conclusioni La chirurgia del prolasso rettale è la tipica chirurgia su misura. Lo specialista deve considerare varie tecniche in base al tipo di paziente,( se maschio o femmina, se giovane o anziano, se sano o fragile), del rischio operatorio, delle caratteristiche del prolasso (se interno o esterno, se mucoso o totale, se piccolo oppure di grandi dimensioni), i sintomi associati, in particolare la stipsi cronica o incontinenza anale. Questa risulta essere complessa e di eziologia multifattoriale, e potrebbe essere dovuta sia a difetti anatomici, sia funzionali. In alcuni casi il trattamento chirurgico esclusivo del prolasso rettale, potrebbe non essere sufficiente, a risolvere tutti i sintomi, per qui potrebbe essere indicato associare alla prolassectomia o rettopessi una sfinteroplastica, tenendo presente che dopo rettopessi, o Altemeier, o Delorme, ci si può attendere un miglioramento della continenza. Parole chiave Incontinenza anale, stipsi, prolasso rettale, recidiva, rettopessi, laparoscopia, risultati funzionali
Background. Anal Incontinence (AI) is the ability to defer the call to stool to a socially acceptable time and place. Loss of control of solid feces is complete anal incontinence, whereas loss of control over flatus or liquid is partial anal incontinence, incomplete and more associated with diarrheal syndromes and fecal impaction. The most frequently used score are the CCF (0-20) score (Jorge and Wexner), which takes in account also the quality of life, and the Pescatori score (0-6), which is simple an easily understandable by the patients, AMS, Vaizey (St.Mark’s Hospital), Williams. Severe incontinence is likely to require surgery, whereas mild and moderate AI are better managed conservatively. The association between rectal prolapse and AI represent a clinical entity difficult to manage. Methods History, the most important factor is determination of the etiology, by physical examination, inspection of perineus for soiling, scars, mucosal ectropion , size of the rectal prolapse muscular deficit, fistulae, prolapsing hemorrhoids. digital exploration will allow to assess anal sphincter’s function: such as resting tone and squeeze contraction endoscopic evaluation to esclude the existence of inflammatory bowel disease, tumors, solitary rectal ulcer syndrome, mucosal prolapse. Special Investigations: anal manometry, cine defecography, electromyography of the pelvic floor, rectal compliance, anal, vaginal and dynamic parineal endosonography. Surgical treatment: Park’s post anal repair, overlapping sphincteroplasty, total pelvic floor repair, encirclement procedures, injection of bulking agents. At the coloproctology units of the Italian society of Colorectal surgery, from 1983 to 2000, 738 patients were observed . Fortyseven (30 women) pts (6.4%), presented AI associated with rectal prolapse, twentyfive of those patients (53%), underwent surgical treatment. Rectal prolapse ( RP) may be full thickness, i.e. procidentia of the rectum through the sphincters, causes a variety of symptoms including pain, bleeding, mucous discharge, and urge to defecate. Associated AI, is experienced by 50% to 70% of the patients, and 25% to 50% of them have significant constipation according to CCF scoring system (0-30) for constipation. The specific causation has yet to be fully elucidated. The patients generally undergo baseline functional tests, following a detailed history and physical examination, as well as an evaluation of a comorbid history of genitourinary dysfunction and bowel habits. In addition anoscopy and full colonoscopy should be performed to exclude other sources of rectal bleeding or the presence of masses that may initiate an intussusception. Cinedefecography, pudendal nerve terminal motor latency assessment and colonic transit studies are generally performed to better evaluate the concomitant presence of enterocele, paradoxical puborectalis contraction, pudendal nerve injury and denervation of the pelvic floor muscles and sphincter. Anorectal manometry is usually abnormal in the incontinent rectal prolapse patients. Surgical therapy of rectal prolapse is often non standard, but rather, tailored after careful consideration of the patient’s operative risk, life expectancy, associated functional disorders, and previous operative history.The goals of the surgical treatment are to eradicate the external prolapse of the rectum and to reduce the risk of recurrence, without causing an adverse impact on bowel function and continence. Perineal approaches, including Delorme’s procedure and perineal rectosigmoidectomy according to Altemeier, with or without levatorplasty (in case of incontinence) are usually carried out and may be tailored according to the presence and the degree of AI. Results Sixteen patients (10 women), at St. Eugenio Hospital (Rome) from 1987 to 2003, underwent Delorme’s procedure. Recurrence rate was 9% at 5 years (range of follow-up 6-60 months). Postoperative overall satisfaction was 73%, 46-75% of the patients experienced an improvement in continence. Twelve patients (8 women) underwent Altemeier procedure, recurrence rate was 1% with excellent results in terms of functional outcome regarding constipation and incontinence rates. Twenty five patients (9 women), underwent abdominal rectopexy according Orr-Loygue, recurrence rate at 5 years, was 2.5%, (range of follow-up 8-80 months).Continence was improved in 58% and constipation was improved in 61% of the patients. Satisfaction rate was 72%. Thirty six patients (16 women),underwent rectopexy according to Wells technique, 12 patients developed recurrence (range of follow-up 8-80 months). Continence was improved in 35%, constipation was worsened in 20% of the cases. Transabdominal open repair, has gained acceptance by most clinicians as the standard surgical procedure for patients with acceptable surgical risks, and is considered to have lower recurrence rates and better functional results than perineal approaches. In addition low recurrence rates, better functional outcome can be safely achieved using laparoscopic surgical techniques to repair full thickness rectal prolapse. Conclusion Selecting an operative approach based on clinical criteria provides satisfactory functional outcomes with regard to symptoms of constipation and incontinence. Anal incontinence is a complex dysfunction with multiple causes, and in rectal prolapse, it may be difficult to understand if it is due anatomical defect (full rectal eversion, internal and external anal sphincter and anal canal integrity in their anatomy and nerve supply) or to a functional lesion (abnormal anal and rectal sensitivity, loss of rectal reservoir function and rectal compliance). This may explain why in some cases treating just the prolapse may not be sufficient to cure all symptoms. A combination of both rectal excision or rectopexy and sphincteroplasty may be required to cure some patients with rectal prolapse and severe anal incontinence due to sphincters weakness, taking in account that rectopexy and other rectal prolapse procedure may improve anal continence. Keywords Anal incontinence, constipation, rectal prolapse, recurrence, rectopexy, laparoscopy, treatment outcomes.

Introduzione: Nei tumori del retto non avanzato è possibile, in casi selezionati e dopo trattamento neoadiuvante, effettuare una terapia chirurgica alternativa alla Total Mesorectal Excision (TME) come l’escissione loco-regionale mediante TEM. Metodi: Il presente studio analizza i risultati a lungo termine di un trial prospettico randomizzato che confronta due diverse metodiche: l’escissione loco-regionale transanale mediante TEM (Transanal Endoscopic Microsurgery) e la TME (Total Mesorectal Excision) laparoscopica in pazienti con cancro del retto non avanzato. Sono stati selezionati solo pazienti con stadio cT2 N0 M0, G1-2, con un diametro massimo del tumore di 3 cm e a una distanza massima di 6 cm dalla linea pettinata. Tutti i pazienti inclusi sono stati sottoposti a radiochemioterapia neoadiuvante. Risultati: Il 51% dei pazienti ha avuto un downstaging del tumore dopo terapia neoadiuvante e il 26 % una riduzione significativa della massa. Tutti i pazienti hanno avuto un intervento R0 con margini di resezione liberi da malattia. Al follow-up si sono verificate 4 (8 %) recidive locali nel gruppo della TEM e 3 (6 %) in quello della TME (P = 0.972). In entrambi i gruppi 2 (4 %) pazienti hanno sviluppato metastasi a distanza. Nei due gruppi i pazienti liberi da malattia non hanno portato a differenze statisticamente significative. 4 4 Conclusioni: I due gruppi di pazienti trattati mediante TEM e TME laparoscopica dopo terapia neoadiuvante hanno ottenuto risultati oncologici simili.
Background: In selected patients with early low rectal cancer, loco-regional excision combined with neoadjuvant therapy may be an alternative treatment option to total mesorectal excision (TME). Methods: This prospective randomized trial compares the results of endoluminal loco-regional resection (ELRR) by Transanal Endoscopic Microsurgery (TEM) versus laparoscopic TME in the treatment of patients with small, non-advanced low rectal cancer. Patients with rectal cancer staged as cT2 N0 M0, G1-2, tumour diameter < 3 cm, located ≤ 6 cm from the anal verge were randomized to ELRR and TME. All patients underwent long course neoadjuvant chemoradiotherapy (NT). Results: Tumour downstaging and downsizing rates after NT were 51.0 % and 26.0 %, respectively, and were similar in both groups. All patients had R0 resection with tumour-free resection margins. At long-term follow-up, 4 local recurrences (8.0 %) occurred after ELRR and 3 (6.0 %) after TME (P = 0.972). Distant metastases were observed in 2 (4.0 %) cases in both groups. There was no statistically significant difference in disease-free survival (P = 0.686). Conclusions: In selected patients, ELRR had similar oncological results to TME. (Study ID Numbers: URBINO-LEZ-1995; ClinicalTrials.gov)

Une chirurgie minimalement invasive (CMI), qui implique généralement une caméra endoscopique et des instruments de laparoscopie, peut sembler être la procédure chirurgicale idéale pour ses avantages apparents. Toutefois, en comparaison à la chirurgie ouverte, les limites spatiales et outils mécaniques posés sur les chirurgiens sont si élevés que, souvent, la CMI est abandonné pour des cas complexes et même quand elle est possible, la procédure nécessite une grande dextérité, calibre et expérience du chirurgien. Cette recherche a été motivée par la nécessité d'habiles instruments chirurgicaux qui offrent un contrôle intuitif et une interface ergonomique, avec l'objectif final de développer un instrument robotisé adapté aux interventions par laparoscopie. La recherche a été basée sur l'évaluation comparative des différentes interfaces, modes de contrôle et cinématiques, en utilisant un simulateur de réalité virtuelle, développée spécialement à cet effet. Les résultats montrent que: 1. l'interface optimale a un mode de contrôle WYSIWYD (ce que vous voyez est ce que vous faites) et est exploité par les doigt. 2. les mobilités distales motorisées de l'effecteur doivent produire deux degrés de liberté (DDL) indépendants pour la flexion et la rotation de l'effecteur. Ce qui est suffisant pour des gestes SIG complexes. 3. ajouter une libre articulation à la poignée de l'instrument permet au chirurgien d'avoir une posture ergonomique. 4. un trocart actif permettrait la rotation de l'arbre de l'instrument avec un joint libre. Cette recherche a également permis le développement d'un prototype de validation de concept. Le prototype a été testé avec succès, in vitro et in vivo sur un modèle porcin.

The doctoral dissertation analyses and compares general endotracheal and combined endotracheal epidural anesthesia’s impact on organ systems and describes the systems parameters in laparoscopic colorectal surgery. Comparing two perioperative analgesia techniques used in laparoscopic colorectal surgery the hemodynamic and respiratory parameters trends; the impact of anesthesia and postoperative analgesia methods on patients’ tracheal extubation time, intestinal motility recovery rate, duration of hospitalization and inflammatory response have been determined. Laparoscopic colorectal resection, even being a minimally invasive technique for laparoscopic surgery, stimulates the body's response to stress and pro-inflammatory mediator’s secretion. Perioperative pain management may also influence the immune response. The doctoral dissertation analyses the impact of epidural analgesia method on the body stress response, investigating variations of cortisol and interleukin-6 levels. The results showed that analgesia and patient satisfaction using epidural analgesia method for perioperative pain management were better. Tracheal extubation time was significantly shorter. Recovery of intestinal motility using epidural analgesia was significant and much prior than using intravenous analgesia. The use of epidural analgesia in laparoscopic colorectal surgery caused less stress response – less cortisol levels increase. It has not showed the increase in number of complications.
Disertacijoje analizuojama ir lyginama bendrosios endotrachėjinės ir kombinuotos endotrachėjinės epiduralinės anestezijos įtaka atskiroms organų sistemoms ir tas sistemas apibūdinantiems rodikliams laparoskopinių kolorektalinių operacijų metu. Darbe nagrinėjama dviejų perioperacinių skausmo malšinimo būdų įtaka hemodinamikos ir kvėpavimo sistemos parametrų kitimo tendencijoms, pacientų trachėjos ekstubacijos laikui, žarnyno motorikos atsinaujinimo greičiui, hospitalizacijos trukmei bei organizmo uždegiminiam atsakui. Laparoskopinės storosios žarnos rezekcinės operacijos, net ir būdamos minimaliai invazinės dėl laparoskopinės operacijos technikos, sužadina stresinį organizmo atsaką bei uždegimo mediatorių išskyrimą. Perioperacinis skausmo valdymas taip pat gali daryti įtaką imuniniam atsakui. Disertacijoje nagrinėjama epiduralinės analgezijos metodo įtaka organizmo stresiniam atsakui tiriant kortizolio kiekio kitimus ir interleukino-6, kaip vieno pagrindinių uždegimą skatinančių citokinų, koncentracijos kitimą taikant epiduralinę analgezijos metodiką. Gauti rezultatai parodė, kad analgezijai pasitelkiant epiduralinį skausmo malšinimo metodą, perioperacinis pacientų skausmo valdymas ir pasitenkinimas yra geresnis, trachėjos ekstubacijos laikas patikimai trumpesnis, žarnyno peristaltikos atsitaisymas ankstyvesnis, sukeliamas stresinis organizmo atsakas mažesnis (mažesnis kortizolio koncentracijos padidėjimas) ir nenustatyta komplikacijų padaugėjimo.

Le développement de la chirurgie laparoscopique entraîne de nouveaux défis pour le chirurgien, sa perception visuelle et tactile du site opératoire étant modifiée par rapport à son expérience antérieure. De nombreux dispositifs ont été développés autour de la procédure chirurgicale afin d'aider le chirurgien à réaliser le geste avec la meilleure qualité possible. Ces dispositifs visent à permettre au chirurgien de mieux percevoir le contexte dans lequel il intervient, à planifier de façon optimale la stratégie opératoire et à l'assister lors de la réalisation de son geste. La conception d'un système d'analyse de la procédure chirurgicale, permettant d'identifier des situations à risque et d'améliorer la qualité du geste, est un enjeu majeur du domaine des Gestes Médico-Chirurgicaux Assistés par Ordinateur. L'évaluation de la qualité du geste explore plusieurs composantes de sa réalisation : les habiletés techniques du chirurgien, ainsi que ses connaissances théoriques et sa capacité de jugement. L'objectif de cette thèse était de développer une méthode d'évaluation de la qualité technique des gestes du chirurgien à partir de connaissances a priori, qui soit adaptée aux contraintes spécifiques du bloc opératoire sans modifier l'environnement du chirurgien. Cette évaluation s'appuie sur la définition de métriques prédictives de la qualité du geste chirurgical, dérivées des trajectoires des instruments au cours de la procédure. La première étape de ce travail a donc consisté en la mise au point d'une méthode de suivi de la position des instruments laparoscopiques dans la cavité abdominale au cours de la chirurgie, à partir des images endoscopiques et sans ajout de marqueurs. Ce suivi combine des modèles géométriques de la caméra, de l'instrument et de son orientation, ainsi que des modèles statistiques décrivant les évolutions de cette dernière. Cette méthode permet le suivi de plusieurs instruments de laparoscopie dans des conditions de banc d'entraînement, en temps différé pour le moment. La seconde étape a consisté à extraire des trajectoires des paramètres prédictifs de la qualité du geste chirurgical, à partir de régressions aux moindres carrés partiels et de classifieurs k-means. Plusieurs nouvelles métriques ont été identifiées, se rapportant à la coordination des mains du chirurgien ainsi qu'à l'optimisation de son espace de travail. Ce dispositif est destiné à s'intégrer dans un système plus large, permettant d'apporter au chirurgien, en temps réel, des informations contextualisées concernant son geste, en fusionnant par exemple les données issues de la trajectoire à des données multi-modales d'imagerie per-opératoire
The development of laparoscopic surgery has led to new challenges for surgeons, their visual and tactile perception of the operating field having been modified compared to their prior experience. Numerous devices have been designed around the surgical process in order to help the surgeon to perform the best possible intervention. These devices aim at enhancing the surgeon's perception of the operating context, optimally planning the surgical strategy, and assisting him/her during the intervention. The design of a system dedicated to the analysis of the surgical process, enabling the identification of risky situations and improving the quality of the surgery, is a major issue in the field of Computer Assisted Medical Interventions. The assessment of quality in surgery covers different aspects: the technical skills of the surgeon, as well as his/her theoretical knowledge and decision-making abilities. The objective of this thesis was to develop a technical skills assessment device for laparoscopic surgery, using a priori knowledge, suitable for the operating room's specific constraints without modifying the surgeon's environment. This assessment is based on the definition of predictive metrics for the quality of the surgery, derived from the instruments' trajectories during the procedure. The first step of this work consisted in the implementation of an instrument tracking method, based on endoscopic images without addition of any markers, in order to retrieve the 3D position of the instrument's tip inside the abdominal cavity during the surgical procedure. This tracking combines geometric models of the camera, the instrument and its orientation, with statistical models describing the evolutions of the latter. This method allows for simultaneous off-line tracking of multiple instruments within a training bench environment. The second step consisted in the extraction, from these trajectories, of predictive metrics for the assessment of the technical skills of the surgeon, using partial least squares regression and k-means classifiers. Several new metrics were identified, relating to the coordination of the surgeon's hands and the optimization of his/her workspace. This device is intended to be integrated in a more general system, in order to provide the surgeon with context-aware information regarding the surgical process, for example by merging data obtained from the trajectory with per-operative multi-modal image data

La chirurgie laparoscopique minimalement invasive guidée par l'image permet la réduction de la durée des séjours à l'hôpital pour le patient, réduisant ainsi les traumatismes postopératoires et accélérant le temps de guérison. Avec les progrès récents des techniques d'imagerie, les chirurgiens peuvent planifier une chirurgie de manière efficace et en toute confiance en utilisant différentes modalités d'image telles que la tomodensitométrie / IRM, les images échographiques, etc. Les techniques de fusion d'images en temps réel permettent la superposition de différents types d'images pour fournir une vue complète au chirurgien. Un aspect important de la fusion en temps réel est que l'instrument laparoscopique est suivi en temps réel à l'aide de capteurs. Dans cette thèse, nous présentons une analyse détaillée de ces technologies de suivi tout en fournissant une nouvelle configuration de capteurs pour le suivi d'images par laparoscope à ultrasons. Nous présentons une chaîne cinématique pour la configuration des capteurs et nous fournissons une solution pour la réduction du bruit présent dans les données des capteurs en utilisant la technique de moyennage des rotations. Le Hand-Eye calibration (étalonnage main-œil) est également un élément fondamental des systèmes de suivi hybrides. Nous présentons une révision détaillée de cette technique. Nous présentons également une méthode déterministe, robuste et précise pour résoudre le problème d'étalonnage main-œil, même pour de grandes quantités de valeurs aberrantes et des niveaux élevés de bruit de mesure. La méthode proposée est basée sur une reformulation d'un problème de programmation semi-définie à contraintes de rang où la robustesse est renforcée via une approche d'optimisation pondérée de façon itérative
Minimally invasive image-guided laparoscopic surgery allows shorter hospital stays for the patient reducing post-operative trauma and faster healing time. With the recent advances in imaging techniques, surgeons can efficiently and confidently plan a surgery by using different image modalities such as CT/MRI scans, ultrasound images etc. Real-time image fusion techniques can overlay the images from different modalities together to provide a comprehensive view to the surgeon. An important aspect of real-time fusion is that the laparoscopic instrument is tracked in real-time using sensors. In this thesis, we present a detailed analysis of such tracking technologies while providing a novel sensor setup for ultrasound laparoscope image tracking. We present a kinematic chain for the sensor setup and provide a solution for noise reduction in the sensor data using rotation averaging technique. Hand-Eye calibration is also a fundamental part of hybrid tracking systems. We present a detailed review of this technique. We also present a deterministic, robust and accurate method for solving Hand-Eye calibration problem even for large amounts of outliers and high levels of measurement noise. The proposed method is based on a reformulation of a rank-constrained semi-definite programming problem allowing for robustness to be enforced via an iteratively re-weighted optimization approach

La chirurgie par laparoscopie est synonyme de faible invasivité et par conséquent d’une réduction du temps d’hospitalisation et des coûts associés. En effet l’utilisation d’un endoscope, de trocarts et d’instruments longs et rigides permet d’opérer dans un milieu clos, réduisant ainsi la taille des incisions et le temps de cicatrisation. Cependant ces conditions imposent au chirurgien une réorganisation des habilités motrices et cognitives. Ainsi, il est confronté à une inversion du sens du travail, des contraintes ergonomiques plus fortes, des rétroactions visuelles et proprioceptives réduites, ce qui complexifie considérablement la pratique. Au-delà, la formation des chirurgiens nécessite d’être mise à jour pour mieux répondre à ces nouvelles exigences. Les résultats expérimentaux montrent qu’il est nécessaire de mieux identifier les invariants de l’activité (ex : capacités spatiales, coordination visuo-motrice) pour permettre d’accélérer la courbe d’apprentissage. De plus, l’entraînement des capacités spatiales doit être integré dans les simulateurs et ceux-ci doivent mieux prendre en compte les principes pédagogiques (charge cognitive, rétroactions). La simulation cognitive doit être introduite au plus tôt et de manière espacée dans la formation, pour être mieux maitrisée et pour mieux exploiter tout son potentiel. La coordination visuo-motrice doit faire l’objet d’un entraînement explicite en dehors des salles d’opérations. Enfin, pour favoriser l’apprentissage, les différentes techniques de simulation doivent être implémentées de manière complémentaire dans le cursus
Minimally invasive surgery reduces postoperative pain, hospitalisation and associated costs. The use of long and rigid instruments in a closed haptic space limits incisions. The latter working conditions also challenge cognitive and motor skills of the surgeons. The surgeons need to mentally rotate the work scene, execute accurate movements with decreased sensitive and visual feedback. Moreover, the current learning paradigm needs to be updated to better match laparoscopic requirements. Our results show that cognitive features underpinning laparoscopy e.g., spatial abilities, hand eye coordination need to be contemplated to improve the learning curve. Simulators should provide the training of spatial abilities and better consider learning features (cognitive load, feedback). To be mastered and express the full potential of mental simulation, this technique should be implemented on a distributed way and earlier in the curricula. Hand-eye coordination needs explicit training outside the operation room. Finally, to favour skill learning, simulation techniques should be implemented on a complementary way in the curricula

Le pronostic de la carcinose péritonéale (CP) s’est nettement amélioré et son traitement permet aujourd’hui chez certains patients sélectionnés d’atteindre des survies prolongées. L’un des facteurs pronostics majeurs est l’étendue de la CP, évaluée par l’Indice de carcinose péritonéale (PCI). La prise en charge de la CP doit évoluer vers un double objectif : une évaluation précise du caractère chirurgicalement totalement extirpable des lésions (possibilité d’une CCR complète) et une détection la plus précoce possible de la maladie. Or sur ces deux objectifs, nos examens d’imagerie sont régulièrement mis en défaut, et ce n’est souvent qu’on moment de la laparotomie qu’une évaluation précise de la CP est possible.Dans ce projet nous nous sommes intéressés à l’apport potentiel de deux nouvelles technologies dans l’exploration de la CP : l’endoscopie péritonéale souple et la chromoendoscopie virtuelle.Dans la première partie de cette thèse, nous présentons notre technique d’exploration péritonéale par monotrocart (SILPE) au cours de laquelle nous réalisons en plus de l’endoscopie rigide, une endoscopie souple. Nous avons montré que cette technique est sûre et faisable. Dans une série de 183 SILPE, cette procédure a pu être réalisée dans 90,2% des cas. Cinq complications post-opératoires ont été observées (3%). La valeur prédictive positive de la SILPE pour prédire une CCR complète était de 79,5%. Le PCI était de 9,7±7,5 lors de la SILPE et de 13,5±9,6 lors de la laparotomie (p<0,0001). Le nombre de régions explorées était 13,0±0,3 en laparotomie et 12,2±1,6 en SILPE (p<0,0001). Le nombre de régions envahies était 6,9±4,5 en laparotomie et 5,4±3,8 en SILPE (p<0,0001). La sensibilité globale de la SILPE dans la détection de la CP dans les différentes régions était de 75%, avec une spécificité de 97%, soit une précision de 85%. Dans la deuxième partie de cette thèse, nous avons étudié l’apport de la chromoendoscopie virtuelle dans l’exploration de la cavité péritonéale et la détection de la CP.Nous sommes partis de l’hypothèse que le péritoine, comme tout autre organe soumis à un processus métastatique, subit des modifications selon le principe de la niche métastatique, pouvant être détectées par cette technologie. Le FICE est un système de chromoendoscopie virtuelle, qui contient 10 réglages différents permettant d’obtenir 10 images virtuelles, construites à partir d’images ayant des longueurs d’ondes réduites différentes. Nous avons d’abord mené une étude de faisabilité clinique au cours de laquelle des endoscopies péritonéales avec le système FICE étaient réalisées. Grâce à un système d’évaluation par deux questionnaires, nous avons déterminés les trois canaux du FICE adaptés à l’exploration du péritoine (canaux 2, 6 et 9). Pour la luminosité, la LB a été jugée meilleure (p<0,0001). En ce qui concerne la qualité du contraste, l’architecture vasculaire, la différentiation des organes, et la détection des nodules de CP, le canal 2 du FICE était jugé supérieur (p<0,0001). Dans un 2ème travail, nous avons créé un modèle murin de CP naissante. Les souris ont été opérées puis sacrifiées à des dates différentes. L’intervention consistait en une endoscopie péritonéale souple, au cours de laquelle les nodules de CP étaient pris en photo en LB et en FICE. 935 images correspondant à 85 nodules ont été analysées. Nous avons ensuite décomposé chaque image endoscopique en ces trois composantes élémentaires R-G-B. Nous avons par la suite comparé les contrastes obtenues avec ces différentes longueurs d’ondes. Nous avons pu ainsi déterminer la longueur d’onde du spectre de la LB qui donnait le meilleur contraste entre nodule de CP et péritoine avoisinant. Il s’agit de la lumière monochromatique à 460 nm (p<0,0001), avec un contraste moyen à 0,240±0,151. Ces résultats ont fait l’objet d’un dépôt de brevet via InsermTransfert
The prognosis of peritoneal carcinomatosis (PC) has improved and today, its treatment could lead to long-term survivals in some selected patients. One of the major prognosis factors of this condition is the extent of the disease measured in terms of Peritoneal cancer index (PCI). The management of PC has to evolve towards two main goals: first an accurate evaluation of the disease burden in order to recognize the patients amenable to complete cytoreduction (CCR), and second an early detection of the disease. Unfortunately, current imaging methods strongly lack sensitivity in determining small tumor nodules, and it is often only at the time of laparotomy that an accurate evaluation of the PCI is possible.In this work, we have studied the potential role of two new techniques in the evaluation of PC: peritoneal flexible endoscopy and virtual chromoendoscopy.In the first part of the thesis, we present our technique of single incision laparoscopic peritoneal exploration (SILPE), in which we perform a peritoneoscopy with both a rigid endoscope and a flexible endoscope. Through a series a 183 SILPE, we showed that this technique is safe and feasible. The SILPE procedure was successful in 90.2% of the cases. Five postoperative complications were observed (3%). The positive predictive value of SILPE to predict CCR was 79.5%. The PCI was 9.7±7.5 at the time of SILPE, and 13.5±9.6 at the time of laparotomy (p<0.0001). The number of the regions explored by SILPE was 12.2±1.6, and by laparotomy 13.0±0.3 (p<0.0001). The number of affected regions was 5.4±3.8 at the time of SILPE and 6.9±4.5 at the time of laparotomy (p<0.0001). The overall sensitivity of SILPE in the detection of PC in the different regions was 75%, with a specificity of 97%, thus an accuracy rate of 85%. In the second part of this thesis, we have studied the role of virtual chromoendoscopy in the peritoneal exploration and PC detection. We started from the hypothesis that, as any organ subject to a metastatic process, the peritoneum would change according to the theory of the metastatic niche, changes that could be detected by this technology. FICE is a virtual chromoendoscopy system that is merchandised with 10 factory-determined presets, built from different reduced single-wavelength images. We have first carried out a feasibility study in human in which peritoneal endoscopies using the FICE system were performed. Thanks to an evaluation plan based on two questionnaires, we have determined the three FICE channels suitable for peritoneal exploration (channels 2, 6, and 9). For brightness, white light endoscopy was judged superior to all FICE channels (p<0.0001). FICE Channel 2 was superior to white light endoscopy and other FICE channels, in terms of contrast, visualization of vascular architecture, differentiation between organs, and detection of PC (p<0.0001). In a second study, we created a murine model of an incipient PC. Mice had peritoneal explorations with FICE at different times. For each PC nodule detected, one white light endoscopy and 10 FICE images were recorded. 935 images corresponding to 85 nodules were analyzed. Each image was then divided into its elementary red, green and blue band images. Therefore, we compared the contrasts obtained with each wavelength. Thus, we’ve determined the wavelength of the white light specter that provides the highest contrast between PC nodule and background peritoneum. It was the monochromatic light with a wavelength at 460 nm (p<0.0001), with a mean contrast value of 0.240±0.151. A patent via InsermTransfert has been filed

La chirurgie laparoscopique est une chirurgie mini-invasive qui est devenue un standard pour certaines procédures tant elle présente de nombreux avantages pour le patient d'un point de vue esthétique et rémission post-opératoire. Malheureusement, la chirurgie laparoscopique s'accompagne aussi de difficultés d'ordre mécanique, visuel et ergonomique. L'apprentissage de cette chirurgie est alors long et difficile pour les internes en école de médecine. Traditionnellement, l'apprentissage se déroule au bloc opératoire, les internes assistant le chirurgien en naviguant la caméra par exemple. L'apprentissage sur patient réel est cependant stressant et ne laisse pas la possibilité de répéter les gestes. Selon la procédure, la courbe d'apprentissage peut-être très lente avec des conséquences sanitaires et financières significatives. Dans ces conditions, l'apprentissage en dehors du bloc opératoire devient nécessaire et des simulateurs de laparoscopie ont été développés. Malheureusement, les restrictions budgétaires et réglementaires ne permettent pas d'avoir des séances d'entrainement efficaces en dehors de la salle d'opération. Ainsi, la thèse présentée porte sur l'amélioration de la formation à la chirurgie laparoscopique lors de ces séances sur simulateur en dehors du bloc opératoire. Tout d'abord, il est apparu dans nos recherches que, durant les séances d'entrainement, les élèves étaient peu guidés dans leurs gestes et qu'ils n'avaient pas de retour quantitatif sur leur performance. Nous avons donc implémenté dans un premier temps un guidage kinesthésique qui se comporte comme un guide virtuel pour l'élève. Puis nous avons implémenté deux retours sensoriels (visuel et tactile) pour avoir cette fois-ci des élèves actifs dans la correction du geste laparoscopique. Ensuite, nous avons remarqué que l'élève lui-même est très peu considéré lors des séances d'entrainement où les exercices pratiqués sont standardisés. Nous avons alors proposé deux pistes pouvant mener à un apprentissage personnalisé : - Considérer les capacités psychomotrices des internes dans le processus d'apprentissage afin d'homogénéiser les groupes d'internes et faciliter l'enseignement ; - Décomposer les difficultés de la laparoscopie afin de palier le problème d'absence de gradualité des séances d'entrainement classiques
Laparoscopic surgery is a minimally invasive surgery that becomes a standard for some procedures as its many benefits for the patient (esthetic and postoperative remission). Unfortunately, laparoscopic surgery also comes with mechanical, visual and ergonomic difficulties. Consequently, the learning of this surgery is long and difficult for the students in medical school. Traditionally, learning takes place in the operating room (ex: students assist the surgeon by navigating the camera). Operating a real patient is, however, very stressful and does not allow the possibility of repeating gestures. Depending on the procedure, the learning curve may be very slow with significant health and financial consequences. Under these conditions, learning outside of the operating room becomes necessary and laparoscopic simulators have been developed. Unfortunately, budget and time restrictions do not allow for effective training sessions outside of the operating room. Thus, the thesis presented concerns the improvement of laparoscopic surgery training during these simulator sessions outside of the operating room. First of all, it appeared in our research that during the training sessions, the students were not very guided in their actions and that they had no quantitative feedback on their performance. We first implemented a kinesthetic guidance as a virtual teacher for the student. Then we implemented two sensory feedbacks (visual and tactile) to have more active students in the correction of the laparoscopic gesture. Then we noticed that the student himself is not considered during the training sessions where the exercises are complex. Thus, we proposed two ideas to personalized the learning : - Consider the psychomotor skills of the students in the learning process in order to homogenize the groups of students and facilitate the teaching ; - Decompose the difficulties of laparoscopy to overcome the problem of lack of gradual training sessions

Background: The best technique of radical prostatectomy – open retropubic versus robot-assisted surgery – is a subject of controversy. Patients and Methods: Between January 1st, 2007 and December 31st, 2011, 2,177 men underwent radical prostatectomy at our department. 252 (12%) cases were laparoscopic robot-assisted, the remainder open retropubic procedures. In Germany, certified prostate cancer centers are required to collect urinary tract-related outcome data after radical prostatectomy using the International Consultation of Incontinence Questionnaire Male Lower Urinary Tract Symptoms. The questionnaire data were used to compare both surgical approaches concerning the urinary tractrelated outcome 1, 2 and 3 years postoperatively. Results: Neither the voiding score nor the incontinence score or the bother scale sum differed between the two cohorts at any of the measurement times. Conclusions: Concerning continence recovery, in this series, there were no detectable differences between robot-assisted and open radical prostatectomy.

Au cours des dernières décennies, la chirurgie mini invasive a progressivement gagné en popularité face à la chirurgie ouverte, grâce à de meilleurs bénéfices cliniques. Cependant, ce type d'intervention introduit une perte de vision directe sur la scène pour le chirurgien. L'introduction de la réalité augmentée en chirurgie mini invasive semble être une solution viable afin de remédier à ce problème et a donc été activement considérée par la recherche. Néanmoins, augmenter correctement une scène laparoscopique reste difficile à cause de la non-rigidité des tissus et organes abdominaux. En conséquence, la littérature ne fournit pas d'approche satisfaisante à la réalité augmentée en laparoscopie, car de telles méthodes manquent de précision ou requièrent un équipement supplémentaire, contraignant et onéreux. Dans ce contexte, nous présentons un nouveau paradigme à la réalité augmentée en chirurgie laparoscopique. Se reposant uniquement sur l'équipement standard d'une salle opératoire hybride, notre approche peut fournir la relation statique entre l'endoscope et un scan intraopératoire 3D. De nombreuses expériences sur un motif radio-opaque montrent quantitativement que nos augmentations sont exactes à moins d'un millimètre près. Des tests sur des données in vivo consolident la démonstration du potentiel clinique de notre approche dans plusieurs cas chirurgicaux réalistes
Over the past decades, minimally invasive surgery has progressively become more popular than open surgery thanks to greater clinical benefits. However, this kind of intervention introduced a loss of direct vision upon the scene for the surgeon. Introducing augmented reality to minimally invasive surgery appears to be a viable solution to alleviate this drawback and has thus been an attractive topic for the research community. Yet, correctly augmenting a laparoscopic scene remains challenging, due to the non-rigidity of abdominal tissues and organs. Therefore, the literature does not report a satisfactory approach to laparoscopic augmented reality, as such methods lack accuracy or require expensive and impractical additional equipment. In light of this, we present a novel paradigm to augmented reality in abdominal minimally invasive surgery. Based only on standard hybrid operating room equipment, our approach can provide the static relationship between the endoscope and an intraoperative 3D scan. Extensive experiments on a radio-opaque pattern quantitatively show that the accuracy of our augmentations is less than one millimeter. Tests on in vivo data further demonstrates the clinical potential of our approach in several realistic surgical cases

Rationnel: La simulation en chirurgie colorectale laparoscopique (CCL) est peu évaluée & n'a jamais été analysée en parcours de soin. Objectifs: Etudier & développer 1 formation en parcours de soin simulé (FPSS) en CCL: patients virtuels en périopératoire & programme d'entrainement virtuel (PEV) peropératoire. Déterminer si cette FPSS améliore la prise en charge des malades. Méthodes: 1) Développement d'1 FPPS pour l'appendicite. Test de sa faisabilité auprès des internes d'un service de chirurgie & évaluation de son impact sur 38 patients admis pour appendicite avant (n=21) & après (n=17) FPSS. 2) Développement d'1 FPPS en CCL respectant les objectifs de réhabilitation précoce (ORP) & validation d'un PEV en CCL. Impact de sa mise en place auprès des internes d'un service, sur 20 patients inclus prospectivement avant (n=10) & après (n=10) FPSS.Résultats: 1) Tous les internes ont suivi la FPSS. Les données pré/peropératoires étaient comparables entre les 2 groupes patients. Les délais de réalimentation liquide & solide étaient réduits après FPSS (7h (2-20) vs. 4 (4-6); P = 0.004 & 17h (4-48) vs. 6 (4-24); P = 0.005) sans modifier la morbidité ni la durée d'hospitalisation (DH). 2) La participation des internes comme opérateur a augmenté après FPSS (0% (0-100) vs. 82.5% (10-100); P = 0.006). Les données pré/peropératoires étaient comparables entre les 2 groupes patients. Le respect des objectifs de RP était meilleur à J2 après FPSS (3 (30%) vs. 8 (80%); P = 0.035). La morbidité & la DH étaient inchangées. Conclusion: Une FPSS en CCL a montré sa faisabilité. Elle a amélioré le respect des ORP & augmenté la participation des internes sans altérer les suites opératoires
Background: Few studies have assessed simulation in laparoscopic colorectal surgery (LCS) & simulation has never been designed in a care pathway approach (CPA) manner. Objectives: To design a CPA to training in LCS, involving virtual patients perioperative training & a virtual competency-based curriculum for intraoperative training. To implement such CPA & to look whether such training may improve patients' management. Methods:1) A CPA to training in appendicitis was designed and implemented. All residents of our department were trained & 38 patients undergoing appendectomy were prospectively included before (n=21) and after (n=17) CPA. 2) A CPA to training in LCS was designed in accordance with enhanced recovery (ER) recommendations, and a curriculum in LCS was validated. All residents of our department were trained & 20 patients were prospectively included before (n = 10) and after (n = 10) CPA. Results: 1) All residents were trained. Pre/intraoperative data were comparable between groups of patients. Times to liquid and solid diet were reduced after CPA (7 h (2-20) vs. 4 (4-6); P=0.004 & 17 h (4-48) vs. 6 (4-24); P=0.005) without changing postoperative morbidity & length of stay (LS). 2) Residents' participation in LCS improved afterCPA (0% (0-100) vs. 82.5% (10-100); P = 0.006). Pre/intraoperative data were comparable between groups of patients. Compliance for ER improved at day 2 in post-training patients (3 (30%) vs. 8 (80%); P = 0.035). Postoperative morbidity and LS were comparable. Conclusion: A CPA to training in LCS has been designed and implemented. It improved compliance for ER & residents participation without adversely altering patients' outcomes

L'intégration de systèmes robotiques au sein du bloc opératoire a modifié le déroulement de certaines interventions, laissant ainsi place à des pratiques favorisant le bénéfice médical rendu au patient en dépit des aspects conventionnels. Dans ce cadre, de récentes études de la Haute Autorité de Santé ont mis en avant les effets indésirables graves intervenant au cours des procédures chirurgicales robotisées. Ces erreurs, majoritairement dues aux compétences techniques du praticien, remettent ainsi en cause la formation et les techniques d'apprentissage pour la chirurgie robotisée. Bien que l'utilisation abondante de simulateurs facilite cet apprentissage au travers différents types d'entraînement, le retour fourni à l'opérateur reste succinct et ne lui permet pas de progresser dans de bonnes conditions. De ce fait, nous souhaitons améliorer les conditions d'entraînement en chirurgie laparoscopique robotisée. Les objectifs de cette thèse sont doubles. En premier lieu, ils visent le développement d'une méthode pour la segmentation et la reconnaissance des gestes chirurgicaux durant l'entraînement en se basant sur une approche non-supervisée. Utilisant les données cinématiques des instruments chirurgicaux, nous sommes capables de reconnaître les gestes réalisés par l'opérateur à hauteur de 82%. Cette méthode est alors une première étape pour l'évaluation de compétences basée sur la gestuelle et non sur l'ensemble de la tâche d'entraînement. D'autre part, nous souhaitons rendre l'entraînement en chirurgie robotisée plus accessible et moins coûteux. De ce fait, nous avons également étudié l'utilisation d'une nouvelle interface homme-machine sans contact pour la commande des robots chirurgicaux. Dans ces travaux, cette interface a été couplée au Raven-II, un robot de téléopération dédié à la recherche en robotique chirurgicale. Nous avons alors évalué les performances du système au travers différentes études, concluant ainsi à la possibilité de téléopérer un robot chirurgical avec ce type de dispositif. Il est donc envisageable d'utiliser ce type d'interface pour l'entraînement sur simulateur afin de réduire le coût de la formation, mais également d'améliorer l'accès et l'acquisition des compétences techniques spécifiques à la chirurgie robotisée
Integration of robotic systems in the operating room changed the way that surgeries are performed. It modifies practices to improve medical benefits for the patient but also brought non-traditional aspects that can lead to serious undesirable effects. Recent studies from the French authorities for hygiene and medical care highlight that these undesirable effects mainly come from the surgeon's technical skills, which question surgical robotic training and teaching. To overcome this issue, surgical simulators help to train practitioner through different training tasks and provide feedback to the operator. However the feedback is partial and do not help the surgeon to understand gestural mistakes. Thus, we want to improve the surgical robotic training conditions. The objective of this work is twofold. First, we developed a new method for segmentation and recognition of surgical gestures during training sessions based on an unsupervised approach. From surgical tools kinematic data, we are able to achieve gesture recognition at 82%. This method is a first step to evaluate technical skills based on gestures and not on the global execution of the task as it is done nowadays. The second objective is to provide easier access to surgical training and make it cheaper. To do so, we studied a new contactless human-machine interface to control surgical robots. In this work, the interface is plugged to a Raven-II robot dedicated to surgical robotics research. Then, we evaluated performance of such system through multiple studies, concluding that this interface can be used to control surgical robots. In the end, one can consider to use this contactless interface for surgical training with a simulator. It can reduce the training cost and also improve the access for novice surgeons to technical skills training dedicated to surgical robotics

Le syndrome dilatation-torsion de l'estomac est chez le chien une affection suraiguë aux conséquences gravissimes qui engagent le pronostic vital. L'étiologie obscure et la multitude de facteurs de risque isolés rendent difficile la mise en place d'une stratégie de prévention non invasive et ne permettent pas d'en garantir l'efficacité. La gastropexie antropylorique prophylactique semble être un moyen efficace. La technique chirurgicale par laparoscopie présentée ici a été étudiée sur un lot de 7 chiennes pendant plus de 2 mois. Elle permet de manière peu invasive l'obtention d'adhérences mécaniquement compétentes tout en n'entraînant aucune conséquence délétère sur la physiologie du tractus gastro-intestinal (inflammation et douleur induites, vidange gastrique, absorption gastro-intestinale de sucres). L'absence d'effets secondaires et de morbidité post-opératoire de cette technique permet d'en envisager l'application en routine clinique
Gastric dilatation-volvulus is an acute life-threatening disease in dog. Its obscur etiology and the many isolated risk factors make non invasive prevention strategy hard to be introduced and don't guarantee its efficacy. Prophylactic antropyloric gastropexy seems to be an efficient tool. The laparoscopic surgical procedure described here was studied on 7 female dogs for more than two month. This not very invasive procedure gives strong adhesions without any morbid consequences on the gastro-intestinal tract physiology (induced inflammation and pain, gastric emptying, gastro-intestinal sugar absorption). The absence of secondary effects and the lack of post operative morbidity of the technique lead to plan its use in routine clinics

La réalité augmentée permet d'aider les chirurgiens à localiser pendant l'opération la position des structures d'intérêt, comme les vaisseaux sanguins. Dans le cadre de la chirurgie laparoscopique, les modèles 3D affichés durant l'intervention ne correspondent pas à la réalité à cause des déformations dues au pneumopéritoine. Cette thèse a pour objectif de corriger ces déformations afin de fournir un modèle du foie réaliste. Nous proposons de déformer le modèle préopératoire du foie à partir d'une acquisition intraopératoire de la surface antérieure du foie. Un champ de déformations entre les modèles préopératoire et intraopératoire est calculé à partir de la distance géodésique à des repères anatomiques. De plus, une simulation biomécanique du pneumopéritoine est réalisée pour prédire la position de la cavité abdomino-thoracique qui est utilisée comme condition limite. L'évaluation de cette méthode montre que l'erreur de position du foie et de ses structures internes est réduite à 1cm
Augmented reality can provide to surgeons during intervention the positions of critical structures like vessels. The 3D models displayed during a laparoscopic surgery intervention do not fit to reality due to pneumperitoneum deformations. This thesis aim is to correct these deformations to provide a realistic liver model during intervention. We propose to deform the preoperative liver model according to an intraoperative acquisition of the liver anterior surface. A deformation field between the preoperative and intraoperative models is computed according to the geodesic distance to anatomical landmarks. Moreover, a biomechanical simulation is realised to predict the position of the abdomino-thoracic cavity which is used as boundary conditions. This method evaluation shows that the position error of the liver and its vessels is reduced to 1cm

Teleoperation systems have been used in the operating rooms for more than a decade. However, the lack of force feedback in commercially available systems still raises safety issues and forbids surgical gestures like palpation. Although force feedback has already been implemented in experimental setups, a systematic methodology is still lacking to design the control laws.

The approach developed in this thesis is a contribution towards such a systematic

methodology: it combines the use of disturbance observers with the use of a structured fixed-order controller. This approach is validated by experiments performed on a one degree of freedom teleoperation system. A physical model of this system is proposed and validated experimentally.

Disturbance observers allow to compensate friction, which is responsible for performance degradation in teleoperation. Contrary to alternative approaches,they are based on a model of the frictionless mechanical system. This allows to compensate friction with a time varying behavior, which occurs in laparoscopy.

Parametric uncertainties in this model may lead to an unstable closed-loop. A kind of "separation principle" is provided to decouple the design of the closed-loop system from the design of the observer. It relies on a modified problem statement and on the use of available robust design and analysis tools.

A new metric is proposed to evaluate the performance of friction compensation systems experimentally. This metric evaluates the ability of a compensation system to linearize a motion system, irrespective of the task and as a function of frequency. The observer-based friction compensation is evaluated with respect to this new metric and to a task-based metric. It correctly attenuates the friction in the bandwidth of interest and significantly improves position and force tracking during a palpation task.

Structured fixed-order controllers are optimized numerically to achieve robust closed-loop performance despite modeling uncertainty. The structure is chosen among classical teleoperation structures. An efficient algorithm is selected and implemented to design such a controller, which is evaluated for a palpation task. It is compared to a full-order unstructured controller, representative of the design approach that has been used in the teleoperation literature up to now. The comparison highlights the advantages of our new approach: order-reduction steps and counter-intuitive behaviors are avoided.

A structured fixed-order controller combined with a disturbance observer is implemented during a needle insertion experiment and allowed to obtain excellent performance.
Doctorat en Sciences de l'ingénieur
info:eu-repo/semantics/nonPublished

Les robots à tubes concentriques deviennent de plus en plus populaires dans la communauté de la robotique médicale. Dans cette thèse, un état de l’art général des travaux existants et qui couvre les thématiques de recherche en robots à tubes concentriques (RTC) est présenté dans un premier temps. Les modélisations géométrique (directe et inverse) et cinématique des RTC sont détaillées car elles servent de base pour les contributions de cette thèse. La première contribution consiste en une étude de concept d’utilisation des RTCs pour la résection des tumeurs profondes situées au niveau du lobe frontal du cérveau. ‘Grid searching’a été utilisée comme méthode d’optimisation pour la conception des tubes des RTCs. Cette méthode permet d’éviter le problème crucial de présélection des coefficients de pondération, cette pondération étant nécessaire dans toutes les méthodes de scalarisation existantes dans la litérature. La méthode de ‘grid searching’ utilisée dans ce travail permet la sélection des paramères optimaux avec l’aide d’une illustration graphique de la distribution des résultats de calcul concernant les critères de séléction. La stabilité élastique due aux interactions destubes en flexion et en torsion est incluse dans les critères de séléction et est évaluée avec une nouvelle approche introduite dans ce travail. La deuxième contribution de cette thèse repose sur la synthèse d’une loi de commande qui permet de faire face aux incertitudes cinématiques dans le contrôle de mouvement des RTCs. L’étude réalisée a montré qu’un contrôle au niveau des couples moteurs avec un retour dans l’espace opérationnel et une matrice Jacobienne approchée, ce contrôle assure une robustesse en présence des incertitudes cinématiques au niveau de la matrice Jacobienne et permet d’obtenir des bonnes performances de contrôle en terme d’erreur de poursuite
Concentric Tube Robots (CTR) are becoming more and more popular in medical robotics community. In this thesis, a general literature survey on existing works covering the research topics of CTR is first presented. The kinematics of CTR is more specifically detailed since it is the basics of the main contributions of this thesis. The first contribution is a concept study of exploiting CTR for resection of deep brain tumors located at the frontal lobe. Grid searching has been used as the optimization method for the CTR tubes design. This method allows to avoid the crucial problem of weights preselection which is required in all scalarizationmethods existing in literature. Instead, the grid searching method used in this work allows to choose the optimal parameters with the help of graphical illustration of calculation results distribution with respect to the selection criteria. The elastic stability dues to the bending and torsion interaction between tubes is considered and evaluated with a new approach introduced in this work. The second contribution then is to deal with the kinematic uncertainties in motion control of CTR. The proposed control method designed at the actuator level shows that the control design of actuator input with task-space feedback and approximate Jacobian matrix provides robustness in handling inaccuracy in kinematic model and maintains good control performance at the same time

Le développement de la chirurgie laparoscopique entraîne de nouveaux défis pour le chirurgien, sa perception visuelle et tactile du site opératoire étant modifiée par rapport à son expérience antérieure. De nombreux dispositifs ont été développés autour de la procédure chirurgicale afin d'aider le chirurgien à réaliser le geste avec la meilleure qualité possible. Ces dispositifs visent à permettre au chirurgien de mieux percevoir le contexte dans lequel il intervient, à planifier de façon optimale la stratégie opératoire et à l'assister lors de la réalisation de son geste. La conception d'un système d'analyse de la procédure chirurgicale, permettant d'identifier des situations à risque et d'améliorer la qualité du geste, est un enjeu majeur du domaine des Gestes Médico-Chirurgicaux Assistés par Ordinateur. L'évaluation de la qualité du geste explore plusieurs composantes de sa réalisation : les habiletés techniques du chirurgien, ainsi que ses connaissances théoriques et sa capacité de jugement. L'objectif de cette thèse était de développer une méthode d'évaluation de la qualité technique des gestes du chirurgien à partir de connaissances à priori, qui soit adaptée aux contraintes spécifiques du bloc opératoire sans modifier l'environnement du chirurgien. Cette évaluation s'appuie sur la définition de métriques prédictives de la qualité du geste chirurgical, dérivées des trajectoires des instruments au cours de la procédure. La première étape de ce travail a donc consisté en la mise au point d'une méthode de suivi de la position des instruments laparoscopiques dans la cavité abdominale au cours de la chirurgie, à partir des images endoscopiques et sans ajout de marqueurs. Ce suivi combine des modèles géométriques de la caméra, de l'instrument et de son orientation, ainsi que des modèles statistiques décrivant les évolutions de cette dernière. Cette méthode permet le suivi de plusieurs instruments de laparoscopie dans des conditions de banc d'entraînement, en temps différé pour le moment. La seconde étape a consisté à extraire des trajectoires des paramètres prédictifs de la qualité du geste chirurgical, à partir de régressions aux moindres carrés partiels et de classifieurs k-means. Plusieurs nouvelles métriques ont été identifiées, se rapportant à la coordination des mains du chirurgien ainsi qu'à l'optimisation de son espace de travail. Ce dispositif est destiné à s'intégrer dans un système plus large, permettant d'apporter au chirurgien, en temps réel, des informations contextualisées concernant son geste, en fusionnant par exemple les données issues de la trajectoire à des données multi-modales d'imagerie per-opératoire.

La chimiothérapie systémique par voie intraveineuse, essentiellement réservée aux cancers avancés, n'est pas ciblée sur la tumeur, il est très difficile d’atteindre des niveaux thérapeutiques en intra tumoral, et ses effets secondaires et sa toxicité sont doses-limitantes.La chimiothérapie localisée pourrait permettre :1) la stabilisation des molécules médicamenteuses incorporées une seule administration médicamenteuse,2) une libération prolongée et contrôlée du médicament pour assurer une diffusion adéquate et l'absorption par les cellules cancéreuses sur plusieurs cycles de division cellulaire 3) le chargement de molécules de chimiothérapie insolubles dans l’eau, 4) l’apport direct au site de la maladie, 6) des effets secondaires diminués en évitant la circulation systémique,7) des résections chirurgicales moindres en traitant les marges de la tumeur. Nous nous sommes plus particulièrement intéressés aux cancers gynécologiques. Nous avons étudié les effets pharmacologiques et cliniques de microsphères chargées en doxorubicine (Doxo) sur un modèle de carcinose péritonéale et de tumeur de glande mammaire, et étudié le profil de diffusion ganglionnaire de divers implants non chargés. 12 jours après injection laparoscopique de tumeurs VX2 sur les ligaments larges droits et gauches de lapines WNZ 12 une injection laparoscopique de 0,5 ml de microsphères chargées ou non de Doxo (respectivement DM, groupe 1 et BM, groupe 2) a été réalisée de façon aléatoire d’un côté ou de l’autre, en sous péritonéal, au site tumoral. 7 jours après les ligaments larges, l’utérus, les ovaires, les orifices de trocarts, les intestins, la vessie, le foie et les poumons ont été examinés en macroscopie et microscopie. Le volume tumoral était plus faible dans le groupe 1 (3,6 ± 3,2 cm) par rapport au groupe 2 (8,9 ± 5,4 cm) (MW, p = 0,0179). La nécrose a été observée autour de toutes les DM, sans nécrose autour des BM. La concentration de Doxo était de 2,1 ± 2,7 uM aux limites tumorales, au-dessus du niveau thérapeutique de 1,0 uM. Sur un autre modèle, 19 jours après injection locale de suspensions tumorales de VX2 sur la deuxième glande mammaire de lapines WNZ chaque glande a été aléatoirement traitée par injection locale de 0,5 ml de microsphères chargées ou non de Doxo (HSDOXO, Groupe1, et HS, groupe 2).Pour les tumeurs de moins de 5 cm3 ou 2 cm de diamètre avant traitement, le volume final était plus faible dans le groupe 1 par rapport à groupe2 (respectivement p<0.008 et p<0.3, MW)et la croissance tumorale a été diminuée après injection de HSDOXO par rapport à HS. En microscopie une nécrose tissulaire a été observée autour des HSDOXO en extratumoral, sans nécrose autour des HS.Nous avons enfin étudié la diffusion de particules de diverses tailles, non chargées, au ganglion sentinelle d’une tumeur de glande mammaire . Les animaux ont été répartis en trois groupes de trois, chacun d'eux recevant des particules de 100 nM, 1 uM ou 10 uM. Cinq jours après traitement, l'intensité de fluorescence a été évaluée par lampe UV. Le ganglion sentinelle a été disséqué selon la technique du bleu, avant curage complet. Les premiers résultats montrent la capture de particules de 1 et 100µm par les ganglions tumoraux mais aussi dans les ganglions sains, ce qui permettrait d’envisager un traitement ganglionnaire préventif et curatif.De plus en plus de tumeurs seront décelées au stade local. Par ailleurs l'identification des phénotypes génomiques permettra un traitement personnalisé « à la carte ». On pourrait envisager un dispositif de délivrance programmable traitant tous les aspects de la maladie, de l'inhibition de la croissance tumorale et de l'angiogenèse à la promotion de la cicatrisation des tissus normaux
Systemic chemotherapy is mainly reserved for advanced cancers, is not targeted to the tumor, it is very difficult to achieve intratumoral therapeutic levels and its side effects and toxicity are dose-limiting.Local chemotherapy may have several advantages:1) stabilization of embedded drug molecules and preservation of anticancer activity,2) controlled and prolonged drug release to ensure adequate diffusion and uptake into cancer cells over many cycles of tumor cell division, 3) loading and release of water-insoluble chemotherapeutics, 4) direct delivery to the site of disease, 5) one-time administration of the drug, 6) diminished side effects due to the avoidance of systemic circulation of chemotherapeutic drugs.We were particularly interested in gynecological cancers. We studied the pharmacological and clinical effects of doxorubicin-loaded microspheres (Doxo) in a model of peritoneal carcinomatosis,a model of mammary gland tumor, and studied the diffusion profile of various micro and nanoparticles in tumoral and non tumoral lymph nodes.12 days after laparoscopic injection of VX2 tumors on the right and left broad ligament of WNZ rabbits laparoscopic injection of 0.5 ml of microspheres loaded or not with Doxo (DM or Group 1, BM Group 2 respectively) was conducted randomly to one side or another, at the sub peritoneal tumor site. 7 days after the broad ligaments, uterus, ovaries, trocars, bowels, bladder, liver and lungs were examined macroscopically and microscopically. The tumor volume was lower in group 1 (3.6 ± 3.2 cm) compared with group 2 (8.9 ± 5.4 cm) (MW, p = 0.0179). Necrosis was observed around all DM without necrosis around the BM. Doxo concentration was 2.1 ± 2.7 µM at the tumor margins, above the therapeutic level of 1.0 uM.On another model, 19 days after local injection of VX2 tumor suspensions in the second mammary gland of WNZ rabbits each gland was randomly treated by local injection of 0.5 ml of microspheres loaded or not with Doxo (HSDOXO, Group1, and HS Group 2).For tumors less than 5 cm3 or 2 cm in diameter before treatment, the final volume was lower in group 1 compared to Group 2 (p <0.008 and p <0.3, MW) and tumor growth was reduced after HSDOXO injection compared to HS. Microscopic tissue necrosis was observed around extratumoral HSDOXO without necrosis around the HS.We finally studied the diffusion of unloaded particles of various sizes on the lymph nodes of a mammary gland tumor. The animals were divided into three groups of three, each receiving particles of 100 nm, 1 µm or 10 µm. Five days after treatment, the fluorescence intensity was measured by UV lamp. The sentinel lymph node was dissected according to the technique of blue dye.The first results show the capture of 1 μm and 100μm particles by the tumoral and non tumoral lymph nodes, which would consider a preventive and curative treatment of the nodes.Since more and more tumors are detected at the local stage and with the identification of genomic phenotypes, a personalized local chemotherapy could be the next step of cancer therapy. One could imagine a programmable controlled drug delivery device dealing with all aspects of the disease, inhibition of tumor growth and angiogenesis, while promoting the healing of normal tissues

Das Krankheitsbild der Adipositas hat sich weltweit zu einem relevanten Gesundheitsproblem entwickelt. Die bariatrische Chirurgie wird zunehmend als wirkungsvolle Behandlung bei schwer ausgeprägter Adipositas eingesetzt. Jedoch ist über die Rolle psychologischer Variablen im bariatrischen Behandlungsverlauf noch wenig bekannt. Die vorliegende Dissertation untersucht Einfluss und Veränderung patientenberichteter Gesundheitsmerkmale in der chirurgischen Adipositastherapie. Dazu werden in einer naturalistischen Beobachtungsstudie Patienten mit schwerer Adipositas vor und im Durchschnitt zwei Jahre nach einer bariatrischen Operation (OP) befragt. Ziele der Arbeit sind 1) die Charakterisierung adipöser Patienten vor OP hinsichtlich bio-psycho-sozialer Variablen; 2) die Identifikation möglicher Einflussvariablen auf den gewichtsbezogenen Behandlungserfolg nach OP; 3) die Untersuchung von Auswirkungen der OP auf das Essverhalten; und 4) die Analyse von Veränderungen in der essstörungsbezogenen Psychopathologie und in der gesundheitsbezogenen Lebensqualität nach OP. Die Ergebnisse der bariatrischen Patienten werden im Vergleich zu denen konservativ behandelter Patienten betrachtet. Die Ergebnisse zeigen, dass Patienten mit bariatrischem Behandlungswunsch eine somatisch und psychisch belastete Patientengruppe darstellen. Die bariatrische OP führt im zweiten postoperativen Jahr zu einer nachhaltigen und klinisch bedeutsamen Gewichtsreduktion. Der präoperative Body-Maß-Index, das Bildungsniveau und aktives Problembewältigungsverhalten sind mit dem Gewichtsverlust nach OP assoziiert. Im Vergleich zur konservativen Behandlung berichten die Patienten, die sich der OP unterziehen, über stärker ausgeprägte Verbesserungen in ihrem Essverhalten und eine Steigerung ihrer Lebensqualität. Auf Basis der Befunde wird ein routinemäßiges Monitoring der somatischen und psychischen Situation der Patienten nach bariatrischer OP empfohlen, um die gezeigten Behandlungserfolge optimal zu sichern.
Obesity has become a relevant global health problem. Bariatric surgery is an effective treatment for severe obesity. However, while the number of operations performed continues to increase, the role of psychological variables throughout the bariatric surgery pathway remains uncertain. The present dissertation investigates the patient-reported health status as it impacts and results from bariatric surgery. In a naturalistic observational study, patients with severe obesity are assessed before and, on average, two years after the surgical treatment. Main aims are 1) to characterize obese patients prior to bariatric surgery in terms of biological, psychological and socio-demographic variables; 2) to identify possible predictors for the postoperative weight-related treatment success after bariatric surgery; 3) to examine changes in eating behaviors; and 4) to analyze changes in eating-related psychopathology and in health-related quality of life (HRQoL). The outcomes of surgical patients are compared with those of conservatively treated patients for the same follow-up period. The findings show that bariatric surgery candidates represent a vulnerable patient group with high physical and psychological burden. In the second postoperative year after bariatric surgery, a sustainable and clinically meaningful weight reduction is achieved. The preoperative body mass index, education level and active coping behavior are associated with weight loss after surgery. Compared with conservative treatment, patients who undergo bariatric surgery report not only greater improvements in their eating behavior and eating-related psychopathology but also an increase in their HRQoL. Based on the results, the provision of a routine monitoring of the somatic and psychological situation of patients following bariatric surgery is recommended to secure longer-term treatment success.

Il nostro studio nasce, dall’esigenza di valutare l’effettiva possibilità di utilizzare il dissettore ad ultrasuoni per eseguire la colecistectomia laparoscopica in day surgery sia come strumento di dissezione e coagulo che per sigillare il dotto cistico e l’arteria cistica. La colecistectomia laparoscopica clipless con dissettore ad ultrasuoni si è dimostrata una procedura efficace e sicura anche in regime di day surgery. L’utilizzo routinario del bisturi armonico non incide sui costi generali della procedura ed anzi consente un ipotetico risparmio rispetto alla colecistectomia laparoscopica tradizionale

Sono stati arruolati dal 1° Ottobre 2014 in modo prospettico 25 pazienti adulti e 20 adolescenti obesi con indicazione alla chirurgia bariatrica o a trattamento multimodale (dieta ed esercizio fisico). Al fine di ottenere uno studio caso-controllo età -correlato, sono stati arruolati, nello stesso periodo,12 adolescenti e 12 adulti sani volontari normopeso (NP) presso l’Unità di Metagenomica del Microbioma umano dell’Ospedale Pediatrico Bambin Gesù (OPBG) e presso il dipartimento di Medicina Clinica del Policlinico Umberto I rispettivamente. Applicando il test di Kruskal-Wallis per le abbondanze relative di phylum per i 4 Gruppi/Gruppo CTRL, abbiamo osservato differenze statisticamente significative nella distribuzione di Actinobacteria, Bacteroidetes and Firmicutes (p < 0.05). Nel confronto di distribuzione Actinobacteria e Bacteroidetes erano statisticamente significativi per le coppie ob_ado/ob_adulti, con livelli di Actinobacteria più elevati per il gruppo ob_ado, mentre i livelli di Bacteroidetes erano predominanti nel gruppo ob_adulti Dei 20 pazienti adulti obesi (ob_adulti) arruolati, 10 sono stati sottoposti a sleeve gastrectomy . Applicando il test di Kruskal-Wallis per le abbondanze relative di specie pre e post sleeve gastrectomy abbiamo osservato differenze statisticamente significative nella distribuzione di Bacteroides fragilis, Coriobacteriaceae, Veillonella parvula. (p < 0.05) Venticinque pazienti obesi adolescenti (ob-ado)sono stati arruolati e 21 sottoposti a sleeve gastrectomy. Tredici hanno raggiunto il follow-up di 6 mesi ed hanno eseguito campionatura di feci, pasto misto e prelievi ematici.Applicando il test di Kruskal-Wallis per le abbondanze relative di phylum per i pazienti ob_ado pre e post sleeve gastrectomy abbiamo osservato differenze statisticamente significative nella distribuzione di Actinobacteria (p < 0.05) Applicando il test di Kruskal-Wallis per le abbondanze relative di genere/ specie pre e post sleeve gastrectomy abbiamo osservato differenze statisticamente significative nella distribuzione di Clostridiales, Erysipelotrichaceae, Abiotrophia, Haemophilus parainfluenzae,Propionibacterium acnes, (p < 0.05) E’ in corso l’analisi delle correlazioni tra le caratteristiche cliniche e antropometriche e le abbondanze di batteri. . Il modello basato sulle OTUs, ci ha consentito di assegnare come markers F. prausnitzii e Actinomyces al gruppo Obesi adolescenti( Ob_ado), mentre Parabacteroides, Rikenellaceae, B. caccae, Barnesiellaceae, e Oscillospira al gruppo di controllo (CTRL_ado). In conclusione questo studio ha dimostrato caratteristiche uniche nella diversità ecologica, nella composizione e nel modello correlato alle OTU del microbiota intestinale in obesi adolescenti e adulti, e tra questi e gli individui normopeso. I “markers” identificati in questo studio potrebbero essere considerati per lo sviluppo di nuovi probiotici, età-correlati, che possono portare a definire nuove strategie, basate sulla modulazione del microbiota, per la prevenzione e il trattamento dell’obesità.