Center for Minimally Invasive Surgery Dept. General Surgery
August 28, 2008
Center for Minimally Invasive Surgery
University of Torino
corso Dogliotti 14
10126 Torino, Italy
Prof. Mario Morino, Full Professor of Surgery
tel. +39 011 6335670
fax +39 011 6312548
mario.morino@unito.it
Prof. Mauro Toppino, Associate Professor of Surgery
tel. +390116335598
mauro.toppino@unito.it
Prof. Fabrizio Rebecchi, Assistant Professor of Surgery
tel. +390116335578
fabrizio.rebecchi@unito.it
Prof. Alberto Arezzo, Assistant Professor of Surgery
tel. & fax +390116336641
alberto.arezzo@unito.it
The Center for Minimally Invasive Surgery was founded in 1992 by Prof. Mario Morino.
The Center is linked to the II Department of Surgery also directed by Prof. Morino.
At the Center for Minimally Invasive Surgery we treat every year around 1200 patients, of whom around 800 patients with minimally invasive techniques. Patients referred to the center are affected by digestive diseases including gastro-esophageal junction (reflux disease, achalasia), small bowel, colon and rectum, anus, liver, biliary tract, pancreas, adrenal gland.
The Center is also equipped with a Flexible Endoscopy Unit that treats about 4000 patients every year, of whom about 1200 operatively, under gastroscopy, colonoscopy and ERCP.
The Center is at the moment involved in the following Research Project:
1. Robotic Surgery
2. Energy sources
3. NOTES - Natural Orifices Transulmenal Endoscopic Surgery
4. Obesity surgery & Diabetes
5. Endoscopic Stenting for Colorectal Obstruction (ESCO trial)
6. Virtual Training
ROBOTIC SURGERY
The exact role of Robot application in general surgery is still under debate.
For this reason we have started two separate projects comparing laparoscopic surgery to robotic surgery to achieve data about the real advantage of the use of robotics, if any.
In the first study we are comparing patients affected by rectal neoplasm, candidates for TME (Total Mesorectal Excision). In this trial the robot is used only in the dissection of the mesorectum, while in both groups the anastomosis is performed mechanically. As the aim is to understand the efficacy and safety of the dissection performed robotically we are analizing time requirement, intraoperative and postoperative complications, late complications with particular respect to anal sphincter and genito-urinary function.
In the second study we are are comparing patients affected by severe obesity, candidates for gastric by-pass. In this trial the robot is used only in the gastro-jejunal anastomosis. As the aim is to understand the efficacy and safety of suturing performed robotically we are analizing time requirement, intraoperative and postoperative complications with particular respect to anastomosi leakage and bleeding.
ENERGY SOURCES
The exact role of sophisticated energy sources in general surgery is still under debate.
Many different options are available at the moment, including ultrasonic dissection devices and bipolar HF devices. For this reason we have started a project comparing the use of an ultrasonic device and a bipolar HF device in colorectal surgery. Patients enrolled in the study are affected either by colo-rectal neoplasms or acute diverticulitis. As the aim is to understand the efficacy and safety of the dissection performed with each of the two different energy sources, we are analizing time requirement, intraoperative and postoperative complications, late complications with particular respect to anal sphincter and genito-urinary function.
NOTES - Natural Orifices Transulmenal Endoscopic Surgery
The exact role of Natural Orifices Transulmenal Endoscopic Surgery in general surgery is still under debate.
Many different options are available at the moment, including transgastric, transvaginal, transcolonic and transvescical approach. One of the major concern at the moment is the reliability of hallow organ closure with existing endoscopic tools. As we believe the technique should have a universal prospective of cure, without excluding the male gender, although today the transvaginal approach seems more realistic, we decided to investigate the possibility of closure of the transgastric approach. We have programmed a series of bench tests ex-vivo in order to unserstand the efficacy of different systems available, including different endoscopic clips, suturing devices, stapling devices and OTSC clip (Over The Scope Clip, Ovesco Gmbh, Tuebingen, Germany) a novel tool for flexible endoscopy that allows larger amount of tissue compression. In ex vivo experiments we tried to seal a gastric wall defect created simulating a transgastric approach with these different devices and then we measured the different burst pressures to which the wall defects were able to resist.
Once ex-vivo tests will be completed we will enter the in vivo tests on animal model reproducing a transgastric cholecystectomy followed by wall defect closure with the different tools and letting the animal survive 3 to 4 weeks to record possible complication events.
A second topic of interest regarding NOTES is represented by the creation of a novel endoscopic platform that would allow stabile surgical conditions to operate by flexible endoscopy intruments. For this reason a new project has been designed in order to develop this platform, in cooperation with Scuola Superiore Sant’Anna (Pisa, Italy), Novineon GmbH (Tuebingen, Germany), Università di Tor Vergata (Roma, Italy) and Politecnico di Torino (Torino, Italy). The aim is to create dedicated instrumentation with sufficient rigidity and degrees of freedom that could turn out to be useful both in endoluminal and transluminal surgery.
OBESITY SURGERY AND DIABETES
The retrospective analysis of results of bariatric surgery has demonstrated that surgery for severe obesity is also treating diabetes, when associated. Therefore a prospective study is about to start with the aim to demonstrate if in moderate obese patients with associated diabete, surgery can be offered as a valid treatment for both obesity and diabetes. If preliminary data will be confirmed this will probably help in understanding the real mechanism of diabetic disease, in order, in future to replace surgery with medical therapy.
ENDOSCOPIC STENTING FOR COLORECTAL OBSTRUCTION (ESCO trial)
The management of acute colorectal obstruction for malignant disease is challenging. In emergency surgery, although surgical and resuscitation techniques were improved, the postoperative complications and mortality rates are still high and however higher than for those patients that underwent to elective surgery. Using a Metallic prosthesis stent in an obstructed colon allows to transform an emergency surgical case into an elective surgery case. This allows to restore the bowel transit and to operate in elective condition reducing morbidity, mortality and the need of an enterostomy. Although there are recent outcomes on literature about use of a decompressive stent before surgery in obstruced patients from malignant colic tumours, there are any prospective and randomised studies were stent positioning followed by elective surgery is compared with emergency surgery. Prospective, randomized multicentric clinical trial where samples are patients with emergency room diagnosis of obstructing colonic neoplasm.Once informed and obtained consent, patiens will be included in the study and randomized in one of the two branches of the study: A.- enteral stent positioning followed by second time resection in the same hospital stay. B.- emergency surgical treatment consisting in Hartmann operation or resection with same time anastomosis. Results from transit reconstruction in patients underwent Hartmann operation will be considered in the study. Short term clinical evolution control in order to determine postoperative morbi-mortality, hospital stay. Follow-up will be performed to evaluate survival rate and disease free survival. To evaluate and compare the results obtained using enteral stent followed by elective surgery versus common emergency surgical techniques. Primary endpoint will be 60 days postoperative morbidity. Others endpoints will be: postoperative mortality, lenght of hospital stay, need for analgesia. Long term follow up with specific instrumental controls (CT scan, US, colonscopy or RX clysma) to identify disease recurrences or metastases as cost analisys and patient’s quality of life will also be evaluated.
VIRTUAL TRAINING
As an Academic Institution we have the task to instruct many university students attending the Course of Medicine as well as post-doc students of the School of General Surgery. We developed a precise learning path adapting different tasks to different level of knowledge of the students and attending coleagues. In cooperation with SIMENDO Ltd (Amsterdam, The Netherlands) we acquired a PC based Virtual Reality system that allows to train on different tasks that prepare the surgeon for minimally invasive surgical practice. The course is divided in Basic SKills and Advanced Tasks on virtual inanimated model, which is considered a basic training before starting with more complex animated models. It is at the moment under development an animated model to simulate a laparoscopic cholecystectomy for training purposes on the same platform.
Videos
LINKS:
http://www.unito.it
http://www.eaes-eur.org
http://www.esge.com
http://www.euro-notes.org
http://www.sied.it
http://www.siccr.it
