Assuring communication redundancy during the interruption and establishing appropriate teaching environments for local surgeons are essential to making robotic telesurgery mainstream. This study analyzes robotic telesurgery with telementoring using standard domestic telecommunication carriers. Can multiple carriers guarantee redundancy with interruptions? Three commercial optical fiber lines connected Hirosaki University and Mutsu General Hospitals, 150 km apart. Using Riverfield, Inc. equipment, Hirosaki had a cockpit, while both Mutsu used both a cockpit and a surgeon’s console. Experts provided telementoring evaluating 14 trainees, using objective indices for operation time and errors. Subjective questionnaires addressed image quality and surgical operability. Eighteen participants performed telesurgery using combined lines from two/three telecommunication carriers. Manipulation: over 30 min, lines were cut and restored every three minutes per task. Subjects were to press a switch when noticing image quality or operability changes. Mean time to task completion was 1510 (1186–1960) seconds: local surgeons alone and 1600 (1152–2296) seconds for those under remote instructor supervision, including expert intervention time. There was no significant difference (p = 0.86). The mean error count was 0.92 (0–3) for local surgeons and 0.42 (0–2) with remote instructors. Image quality and operability questionnaires found no significant differences. Results communication companies A, B, and C: the A/B combination incurred 0.17 (0–1) presses of the environment change switch, B/C had 0, and C/A received 0.67 (0–3), showing no significant difference among provider combinations. Combining multiple communication lines guarantees communication redundancy and enables robotic telementoring with enhanced communication security.

Background: Conversion surgery, which is defined as chemotherapy or chemoradiotherapy followed by radical surgery, may improve survival of patients with initially unresectable advanced biliary tract cancer, including gallbladder cancer. However, there are few reports on conversion surgery for advanced gallbladder cancer. Case presentation: A 69-year-old woman was referred to our hospital with initially unresectable gallbladder cancer with peritoneal carcinomatosis. She underwent gemcitabine plus cisplatin therapy for 9 months. Extended cholecystectomy, resection of the extrahepatic bile duct with regional lymph node dissection, and total omentectomy were then performed as conversion surgery. The patient has survived without recurrence for 19 months postoperatively (31 months after the initial diagnosis) while continuing chemotherapy. Conclusions: This case suggests that conversion surgery for advanced gallbladder cancer is effective and may be curative for locally advanced disease and distant metastasis such as peritoneal carcinomatosis.

Purpose: Failure and recurrence are concerns in nonoperative management (NOM) for acute appendicitis (AA) and interval appendectomy (IA). The goal of the study was to identify predictors of failure and recurrence in patients with AA who underwent NOM. Methods: A total of 348 adults with appendicitis were treated in our department from April 2016 to October 2021. Among these patients, 337 who did not undergo emergency surgery were divided into those for whom NOM was unsuccessful, leading to unplanned surgery (n=28) and those successful with NOM (n=309). These groups were compared to identify predictive factors for NOM failure. In the NOM-success group, 195 patients were further subdivided into non-recurrence (n=166) and recurrence (n=29) groups to identify predictive factors for recurrence of appendicitis. Results: In multivariate analysis, posttreatment CRP level [odds ratio (OR) = 1.126, 95% confidence interval (CI) 1.076-1.179, P < 0.001] and fecal stones with abscess formation (OR=5.530, 95% CI 2.081-14.691, P=0.001) were independently associated with NOM failure. Receiver operating characteristic curve analysis showed an optimum cutoff CRP level of 10.46 mg/dl for appendicitis treatment failure. The initial CRP level was significantly lower and the percent drop of CRP was significantly higher in the recurrence group than in the nonrecurrence group. Conclusions: These findings suggest that the posttreatment CRP level and fecal stones with abscess formation are predictors for NOM failure, but that recurrence may not be affected by the severity of previous bouts of appendicitis.

When there is an anatomic anomaly in the biliary tract of the donor for living-donor liver transplantation, the risk of postoperative biliary tract complications increases in both the donor and the recipient. We studied a case of living-donor liver transplantation with a left hepatic lobe graft that had anatomic anomalies, in which the medial segmental branch (B4) joined the anterior segmental branch and the posterior segmental branch formed a common trunk with the lateral segmental branch. A 40-year-old man visited our institution as a candidate organ donor for his mother, who had end-stage liver failure. An anomaly of B4 connecting the anterior segmental branch was suspected on magnetic resonance cholangiopancreatography. On intraoperative cholangiography, confluence of B4 with the anterior segmental branch and connection of the posterior and lateral segmental branches forming a common trunk were confirmed. Accordingly, individual anastomoses of the lateral segmental branch and B4 with the recipient jejunum were planned, and a left-lobe graft was excised. The postoperative recovery was smooth, and the donor was discharged with no complications. Even when an anatomic anomaly is present in the donor bile duct, in urgent cases, accurate evaluation through the use of various modalities may enable living-donor liver transplantation with the use of a graft with an anatomic anomaly.

Introduction: In recent years, the practical application of remote robotic surgery has become a reality, and is expected to be applied to difficult surgeries. The purpose of this study is to demonstrate whether the pancreaticojejunostomy in a pancreaticoduodenectomy, a difficult surgery, can be performed through a remote surgery‐assisted robotic operation, as well as to verify the feasibility of remote surgery‐assisted pancreaticojejunostomy. Methods: Hirosaki city and Goshogawara city (about 30 km) were connected via a commercial communication line using the hinotori surgical robot, and five surgeons performed remote surgery on an artificial organ model for pancreaticojejunostomy. Four local surgeons were instructed remotely. Each procedure was repeated 3–5 times in sets of 8 min, and communication latency, Image Quality Score, System Usability Scale (mSUS), and Robot Usability Score were all evaluated. Results: The communication latency was stable at less than 12 msec, and there were no problems in performing the surgery. No significant differences were noted in Image Quality Score, System Usability Scale (mSUS), or Robot Usability Score. Pancreaticojejunostomy was performed using the Blumgart anastomosis technique, and all procedures were completed without any issues. Conclusion: We demonstrated that pancreaticojejunostomy can be performed in a telesurgical environment. This system can be applied to remote surgical guidance and support in the future and it is expected to correct regional disparities in medical care, improve surgical education, and enhance the implementation of remote surgery in society.