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A biloma is an encapsulated collection of bile located in the abdomen. It occurs spontaneously or secondary to traumatic or iatrogenic injury to the biliary system. The patient's medical history, symptoms and diagnostic imaging findings suggest the diagnosis, but a definitive diagnosis is provided by drainage and biochemical analysis of the fluid. We report a case of a patient admitted with acute abdominal pain in the right hypochondrium caused by a spontaneous biloma. This is a rare condition, and the reason for the onset was not identified. We discuss the role of the various diagnostic imaging techniques, particularly that of ultrasound.Keywords Spontaneous biloma Á Imaging Á Ultrasound Á Contrast-enhanced CT Riassunto Il biloma è una raccolta circoscritta di bile in addome, spontanea o secondaria ad una lesione traumatica o iatrogena del sistema biliare. L'anamnesi, i sintomi ed i reperti radiologici suggeriscono la diagnosi, anche se spesso la diagnosi finale è legata al drenaggio del liquido. Riportiamo il caso di un paziente ricoverato per dolore addominale acuto in ipocondrio destro determinato da un biloma spontaneo, condizione rara in cui non si identifica la causa del danno al sistema biliare e discutiamo il ruolo delle varie metodiche di diagnostica per immagine, in particolare dell'ecografia.

Background and Objective: Robotic distal pancreatectomy (DP) is an emerging attractive approach, but its role compared with laparoscopic or open surgery remains unclear. Benchmark values are novel and objective tools for such comparisons. The aim of this study was to identify benchmark cutoffs for many outcome parameters for DP with or without splenectomy beyond the learning curve. Methods: This study analyzed outcomes from international expert centers from patients undergoing robotic DP for malignant or benign lesions. After excluding the first 10 cases in each center to reduce the effect of the learning curve, consecutive patients were included from the start of robotic DP up to June 2020. Benchmark patients had no significant comorbidities. Benchmark cutoff values were derived from the 75th or the 25th percentile of the median values of all benchmark centers. Benchmark values were compared with a laparoscopic control group from 4 high-volume centers and published open DP landmark series. Results: Sixteen centers contributed 755 cases, whereof 345 benchmark patients (46%) were included the analysis. Benchmark cutoffs included: operation time ≤300 minutes, conversion rate ≤3%, clinically relevant postoperative pancreatic fistula ≤32%, 3 months major complication rate ≤26.7%, and lymph node retrieval ≥9. The comprehensive complication index at 3 months was ≤8.7 without deterioration thereafter. Compared with robotic DP, laparoscopy had significantly higher conversion rates (5×) and overall complications, while open DP was associated with more blood loss and longer hospital stay. Conclusion: This first benchmark study demonstrates that robotic DP provides superior postoperative outcomes compared with laparoscopic and open DP. Robotic DP may be expected to become the approach of choice in minimally invasive DP.

Background RPD (Robotic pancreatoduodenectomy) was first performed by P. C. Giulianotti in 2001 (Arch Surg 138 (7): [777][778][779][780][781][782][783][784] 2003). Since then, the complexity and lack of technique standardization has slowed down its widespread utilization. RPD has been increasingly adopted worldwide and in few centres is the preferred apporached approach by certain surgeons. Some large retrospective series are available and data seem to indicate that RPD is safe/feasible, and a valid alternative to the classic open Whipple. Our group has recently described a standardized 17 steps approach to RPD (Giulianotti et al. Surg Endosc 32(10): 4329-4336, 2018). Herin, we present an educational step-by-step surgical video with short technical/operative description to visually exemplify the RPD 17 steps technique. Methods The current project has been approved by our local Institutional Review Board (IRB). We edited a step-by-step video guidance of our RPD standardized technique. The data/video images were collected from a retrospective analysis of a prospectively collected database (IRB approved). The narration and the images describe hands-on operative "tips and tricks" to facilitate the learning/teaching/evaluation process. Results Each of the 17 surgical steps is visually represented and explained to help the in-depth understanding of the relevant surgical anatomy and the specific operative technique. Conclusions Educational videos descriptions like the one herein presented are a valid learning/teaching tool to implement standardized surgical approaches. Standardization is a crucial component of the learning curve. This approach can create more objective and reproducible data which might be more reliably assessed/compared across institutions and by different surgeons. Promising results are arising from several centers about RPD. However, RPD as gold standard-approach is still a matter of debate. Randomized-controlled studies (RCT) are required to better validate the precise role of RPD.Keywords Robotic pancreatoduodenectomy · Whipple procedure · Evidence based surgery · Pancreatic surgery · Pancreatic cancer · Minimally invasive surgery The current short description with video visually illustrates and it is complementary to the technique previously described in the paper published by our group in 2018 [1]. Herein, we epitomize the 17 surgical steps as a complementary adjunct to the associated surgical educational video. and Other Interventional TechniquesElectronic supplementary material The online version of this article (https ://doi.org/10.1007/s0046 4-020-07383 -0) contains supplementary material, which is available to authorized users.

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BACKGROUND: There is currently ample consensus about the safety and feasibility of robotic pancreaticoduodenectomy (RPD). However, few studies are available on the long-term oncological outcomes of this procedure. We present a long-term survival analysis (up to 10 years) of our series of RPD carried out for ductal and ampullary adenocarcinoma. METHODS: A retrospective analysis of a prospectively collected approved database was carried out including 39 patients who underwent RPD for pancreatic ductal and ampullary adenocarcinomas. RESULTS: The 5-year overall survival for ductal and ampullary carcinoma was 41% with an estimated median and mean survival of 27 and 52 months. The ampullary group had significantly longer 5-year survival (68%) than the ductal group (30%). CONCLUSION: Our data show, within the limitations of their retrospective nature, that robotic pancreaticoduodenectomy provides similar short-and long-term survival outcomes compared to open technique in the treatment of pancreatic ductal and ampullary adenocarcinoma.

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