GENERAL SURGERY SCIENTIFIC PAPERS & VIDEOS
Silvio Alen A. Canton, Claudio Pasquali
Scientific Paper. “Slim-Mesh”: Obese/Superobese Populations (64 Cases, Including Ones with Large-Giant/Massive Ventral Hernia)
Objective: In 2009, we designed the sutureless “Slim-Mesh” laparoscopic procedure to facilitate and promote the repair of ventral hernias in the obese/superobese populations, including cases with large-giant/massive ventral hernias. We also aimed to reduce operation time and intra- and postoperative complications.
Methods and Procedures: We divided our obese cases into Class I (BMI 30.0–34.9 kg/m2), II (35.0–39.9 kg/m2), III (40.0–49.9 kg/m2), and Superobese (50.0–59.9 kg/m2). A ventral hernia was small-medium, or large-giant/massive when its diameter measured 2–9.9 cm, 10–14.9 cm, 15–19.9 cm, and ≥ 20 cm, respectively. Between September 2009 and May 2023, 64 obese/superobese ventral hernia patients were enrolled prospectively (81%)-retrospectively and treated with the “Slim-Mesh” technique.
Results: We operated on 35 males and 29 females. Mean age and BMI were 60 years old and 33 kg/m2, respectively. Class I cases numbered 48, II 13, III 2, with 1 superobese case. Small-medium, large-giant/massive ventral hernia were found intraoperatively in 40, 21, and 3 cases respectively. Mean operation time for all cases was 104 minutes. Mean length of hospital stay was 2 days and follow-up time was 5 years. We had one case of chronic abdominal-wall pain and 6 late postoperative-complications: 4 (6%) hernia recurrences and 2 trocar-site hernias.
Conclusion: The sutureless “Slim-Mesh” technique implements the laparoscopic approach to repair ventral hernias in the obese/superobese populations rather than open surgery or traditional transfixation suture-based laparoscopy, including cases with large/giant/massive hernias. In our experience, “Slim-Mesh” proved to be safe, straightforward, quick, easy-to-reproduce, and economical.
Video. Robotic-Assisted Surgery for Bariatric Emergency: Robotic Repair of Perforated Marginal Ulcer with Modified Graham's Patch Omentopexy
Objective: Management of bariatric surgery emergency; perforated marginal ulcer by robotic-assisted surgery.
Methods and Procedures: Robotic-assisted repair of perforated marginal ulcer.
Results: Bariatric and gastric surgical emergency remain challenging due to the need of intracorporeal suturing, this can be challenging due to the body habitus and suboptimal exposure as a result of the location and complexity of the disease in certain cases. We present a case of a 39-year-old female who underwent a robotic modified Graham’s patch repair of a perforated marginal ulcer.
Conclusion: Robotic surgery for bariatric emergency is feasible and can result in superior outcome and may decrease the conversion rate to open surgery.
Video. Robotic Partial Central Hepatectomy for Incidental Gallbladder Cholangiocarcinoma
Ahmed Younos, Iswanto Sucandy, Sharona Ross, Alona Bilik
Objective: In this video, we demonstrate our technique of robotic portal lymphadenectomy and central hepatectomy in a 59-year-old man presenting with a T2 incidental gallbladder adenocarcinoma.
Methods and Procedures: A new preoperative CT scan showed no evidence of extrahepatic disease as part of the oncological workup. The operation began with systematic portal lymphadenectomy with goal of achieving more than 6 lymphnodes for adequate tumor staging according to American Joint Committee on Cancer (AJCC), followed by a partial resection of liver segment 4B/5. The operative duration was 150 minutes with estimated blood loss of <50 cc.
Results: The postoperative recovery was uneventful, and the patient was discharged on postoperative day 3 without complications. The final pathology report showed no evidence of residual disease in the liver bed. Ten portal lymph nodes were removed without evidence of carcinoma. The cystic duct margin was negative for dysplasia. The patient is doing well without evidence of disease at 9-month follow-up.
Conclusion: Minimally invasive liver resection has become the preferred approach for surgical treatment of primary and metastatic liver tumors in the past 5 years. The use of laparoscopic method in biliary tract cancer resection is however limited by the need to complete a technically challenging radical portal lymphadenectomy with/without biliary resection.
Video. Robotic Resection of Ruptured Large Hepatic Adenoma. Application of Robotic Technology in Semiacute Setting
Ahmed Younos, Iswanto Sucandy, Sharona Ross, Alona Bilik
Introduction and Objective: Application of robotic technology in hepatobiliary surgery is mostly practiced in elective setting. Despite of the traditional belief on open resection, in the last 5 years, there is increasing reports on safety and feasibility of minimally invasive techniques in acute and semiacute setting. As clinical experience grows in robotic hepatectomy, surgeons are more comfortable in performing robotic resection for bleeding liver tumors in patients with stable hemodinamics. In this study, we demonstrated the use of robotic approach for a ruptured 10-cm hepatic adenoma with excellent outcomes.
Methods: A 50-year-old woman presents with a left upper quadrant pain and an MRI showing a 9.7-cm hematoma expanding within the segment-3 of the liver with extracapsular rupture into the peritoneal cavity. The past medical history was consistent with the use of oral contraceptive pills for 20 years. After a period of observation and hemodynamic stability, we proceeded with robotic resection of the bleeding liver tumor.
Results: Robotic resection of the hemorrhagic liver tumor was completed with minimal blood loss without any intraoperative complications. The patient had an uneventful recovery, and she was seen in our office for postoperative follow-up in excellent condition. The final pathology specimen was consistent with a 6-cm hepatic adenoma, surrounded by extensive necrosis (approximately 50%) and hematoma into and through the round ligament. No evidence of malignancy seen. The background liver is noncirrhotic with patchy zone 3 macrovesicular steatosis (25%).
Conclusions: Robotic resection of ruptured large hepatic adenoma is safe and feasible in select patients with stable hemodynamic parameters.
Video. Robotic Resection of Extrahepatic Hepatocellular Carcinoma Recurrence after Tumor Rupture
Ahmed Younos, Iswanto Sucandy, Sharona Ross, Alona Bilik
Introduction and Objectives: Tumor rupture with extratumoral bleeding is rare but known complications in hepatocellular carcinoma (HCC), especially those located in peripheral/subcapsular locations. Major hemorrhage requiring emergency arterial embolization and surgical exploration had been reported, however the rate/incidence of tumor seeding into the peritoneal cavity is unknown. In this video, we described our robotic approach for resection of an extrahepatic HCC recurrence following treatment of a ruptured HCC.
Methods: A 73-year-old woman presented to our hepatobiliary clinic for perigastric mesenteric tumor excision. CT scan of the abdomen pelvis showed a 5.5-cm soft tissue nodular mass adjacent to the distal stomach which may represent hepatocellular carcinoma implant, associated with peritumoral bleeding. Metastatic workup shows an isolated single mass mentioned above, without evidence of extra-abdominal disease. Past medical history includes alcohol abuse, hepatitis C (treated 2003), and ruptured HCC 3 years prior requiring partial liver resection of segment 6. Past surgical history includes cholecystectomy, colonoscopy, femur fracture open reduction internal fixation, knee replacement, and spinal fusion.
Results: Robotic resection of the HCC recurrence was uneventful with uncomplicated postoperative course. The final pathology was consistent with a 5.5-cm completely resected perigastric mass, a moderately differentiated hepatocellular carcinoma with focal necrosis.
Conclusions: Robotic resection of extrahepatic hepatocellular carcinoma recurrence after tumor rupture is feasible, technically safe, and oncologically adequate with excellent short-term outcomes.
Video. Robotic Right Posterior Sectionectomy for Biliary Cystadenoma—Description of Standardized Technique of Anatomical Liver Resection
Parisa Yazdankhah Kenary, Sharona Ross, Iswanto Sucandy, Melissa Touadi
Objective: With recent advances in surgical technology, minimally invasive technique for surgical management of the upper gastrointestinal diseases has become the standard practice in the United States. Biliary cystadenoma is a rare benign tumor with potential for malignancy. Hence, surgical resection is the preferred treatment. In this video, we describe our technique for robotic right posterior sectionectomy for biliary cystadenoma.
Methods and Procedures: Patient is a 65-year-old woman presenting with a complex multiloculated liver cyst involving segment 6/7. The CT scan and MRI revealed multiseptated 5.3 cm with enhancing nodules and thickened septum concerning for neoplasm along with multiple solid mural nodules. After an adequate liver mobilization and dissection of hepatocaval confluence, the line of the parenchymal dissection was drawn toward the root of the right hepatic vein under intraoperative liver ultrasound guidance. Posterior short hepatic veins were divided as necessary. Transection of the liver parenchyma was then undertaken along with intermittent Pringle maneuver. The operation was completed with transection of the right hepatic vein using a robotic stapler.
Results: The operative time of 5 hours and an estimated blood loss of 50 cc. Patient was discharged on POD 3. The final pathology report was consistent with 6 cm multiloculated biliary cystadenoma, which was completely resected without evidence of carcinoma.
Conclusion: Robotic right posterior sectionectomy for biliary cystadenoma is technically feasible, safe, and reproducible. Despite the learning curve, we believe that this approach will be the preferred method for posterior-segment liver resection.
Scientific Paper. Individualized Technical Approach to Laparoscopic Appendectomy: a Strategy towards Microinvasive Surgery
Objective: Most surgeons use 1 10- to 12-mm and 2 5-mm trocars for laparoscopic appendectomy (LA). It would be desirable to further miniaturize LA.
Methods and Procedures: Sixty-five consecutive appendectomies were divided into 5 subgroups: group 1 (n = 12) and 2 (n = 15) were done with 2 5-mm ports and a needle grasper or suture passer, group 3 (n = 11) using 3 5-mm ports, group 4 (n = 19) and using 1 10- to 12- and 2 5-mm ports; group 5 (n = 8) included miscellaneous cases. Left upper quadrant and umbilical 5-mm ports were placed and after exploration it was decided, which technique was most appropriate. The appendix was secured with an endoloop in groups 1, 2, 3 and a stapler in group 4.
Results: Patients in groups 1 and 2 were younger (median 26.1/16.9 years vs 33.4/28.2 years for groups 3 and 4), had a lower BMI (median 25.5/25.9 vs 26.9/30.9 kg/m2 for groups 3 and 4) and had the shortest OR times (median 30.5/36 minutes vs 42/35 minutes for groups 3 and 4); 79% of children were in groups 1 and 2. In group 4 significantly more patients had gangrenous or perforated appendicitis. There were no stump leaks and no differences in complication rates between the groups were found. Group 5 included combined procedures including hernia repair (1), cholecystectomy (2), Meckel diverticulum resection (2), abdominal exploration with biopsies (2), and small bowel resection (1).
Conclusion: With our approach, 64% of patients did not require a large (12 mm) port and in one third only 2 5-mm ports were used and excellent outcome and high patient satisfaction was achieved.
★ Best General Surgery Scientific Paper
Scientific Paper. Assessment and Validation of Training Performance and Learning Curves Using Simulation-Based 3D-Printed Models for Laparoscopic Roux-en-Y Gastric Bypass Surgery
Zhifei Wang, Jianfu Xia, Minjun Xia, Menghui Zhou
Background and Aims: Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) is technically complex with a challenging learning curve. Our aim was to create a low-cost, realistic, reproducible LRYGB model and validate its authenticity, effectiveness, and the learning curve for surgeons.
Methods: 3D-printed intra-abdominal models were developed, and their physical properties were evaluated. A total of 16 surgeons (5 experts, 6 intermediates, 5 residents) assessed face validity, content validity, technical authenticity using questionnaires. Modified Bariatric Objective Structured Assessment of Technical Skills (MBOSATS) evaluated construct validity, and operation time was recorded to assess the learning curve.
Results: The 3D models simulated human physical properties well. Compared to porcine models, they scored higher for aesthetics, size, and stomach shape (P < .05), but content validity was not statistically different (P > .05). The 3 groups had significantly different MBOSATS scores and operation times (P < .01, P < .001), indicating construct validity. With repeated training, the learning curve shortened significantly.
Conclusions: These low-cost 3D-printed LRYGB models demonstrate realistic physical performance, serving as a substitute for porcine models. Simulated training enhances surgical skills and shortens the learning curve, potentially useful for future LRYGB training and assessment.
Scientific Paper. The Comparison of Robot-Assisted Laparoscopic Fundoplication (RALF) and Conventional Laparoscopic Fundoplication (CLF) in Hiatal Hernia Surgery
Zhifei Wang, Minjun Xia, Zhou Menghui
Background: This study aims to compare the perioperative outcomes of robot-assisted laparoscopic fundoplication (RALF) and conventional laparoscopic fundoplication (CLF), with a particular focus on operative time and costs.
Methods: A randomized controlled trial (RCT) comparing RALF and CLF was conducted to evaluate perioperative outcomes, with a particular focus on operative time and costs. Patients meeting inclusion and exclusion criteria were randomized to either RALF or CLF groups. RALF was performed by a surgeon with at least 30 procedures of learning experience, while CLF was performed by 3 different experienced surgeons. Perioperative variables, including patient demographics, operative details, postoperative complications, hospital stay, and costs, were analyzed using appropriate statistical tests.
Results: The study compared total operative time, perioperative complication rates, postoperative complication rates, hospital stay, costs, postoperative symptoms, and quality of life between the RALF and CLF groups. Analysis revealed comparable outcomes between the 2 groups in terms of complications, mortality, and hospital stay. However, RALF showed significantly longer operative times and increased costs compared to CLF.
Conclusion: RALF demonstrates feasibility and safety comparable to CLF, with similar complication rates and hospital stays. However, RALF is associated with longer operative times and increased costs. Further advancements in robotic technology may improve the cost-effectiveness and overall utility of robot-assisted antireflux surgery.
Scientific Paper. Single Center Experience with 2 Stage Conversion from Gastric Banding to Sleeve Gastrectomy
Hugo J.R. Bonatti, Cheryl Frushour, Mohammad Jamal
Objectives: Adjustable gastric banding (AGB) may cause esophageal dysmotility. Conversion to sleeve gastrectomy (SLG) is a good option; most bariatric surgeons prefer a staged approach.
Methods and Procedures: A total of 38 patients underwent SLG (laparoscopically 20, robotic 18) after AGB removal between October 2018 and December 2024 at our center. Demographic and clinical data of this study group were prospectively recorded and outcome was retrospectively analyzed.
Results: AGBs had been inserted between 2007 and 2013. Pre-AGB weight was median 269 (range 223–429) pounds. AGB removal was done for dysphagia in most cases (2 slipped one migrated band, one technical failure). Thirty-four bands were removed at our hospital. Median weight at AGB removal was 242 (range 152–396) pounds with 83% experiencing significant weight gain after device removal. Median age of the 30 females and 8 males at time of SLG was 52 (range 39–67) years. A total of 24 patients underwent SLG within 1 year after AGB removal, in the remaining 14 patients SLG was done between 1.5 and 10 years after AGB removal. Median weight at SLG was 264 (range 172–436) pounds. After a median follow-up of 2.2 (range 0.2–4.5) years after SLG, median weight was 223 (range 147–390) pounds (minus 12%). Two patients underwent SLG to RYGBP conversion for severe GERD and both lost significant weight, thereafter. There were 2 leaks (both successfully treated with stenting) and no strictures in this series.
Conclusions: SLG after AGB for dysphagia remains a challenge and a 2-stage approach seems advisable to give the esophagus time to recover.
Scientific Paper. Robotic versus Open Repair of Iatrogenic Bile Duct Injury during Cholecystectomy - A Prospective Follow-up Study beyond Short-Term Outcomes
Moran Slavin, Iswanto Sucandy, Sharona Ross, Andrew Kim, Maria Christodoulou, Tara M. Pattilachan, Alexander Rosemurgy, Hasan Al Harakeh
Objective: Iatrogenic bile duct injury (BDI) is a dreaded complication of laparoscopic cholecystectomy, resulting in significant short and long-term morbidity. Recent reports suggest superior clinical outcomes with laparoscopic and robotic BDI repairs; however, results beyond short-term have not been addressed. This study compares follow-up outcomes of robotic and open iatrogenic BDI repair.
Methods and Procedures: A prospectively maintained database of patients who underwent BDI repair between 2016–2023 was analyzed. Patients converted to open operation at the index laparoscopic cholecystectomy underwent open BDI repair; otherwise, robotic approach was used. Hepaticojejunostomy was the default technique, except in patients with prior gastric bypass.
Results: A total of 21 patients (14 female/7 male) were included; 6 had open repair and 15 robotic. Median age and BMI were similar in both groups; 62% had repair within 10 days of BDI. Strasberg-Bismuth classification varied from C-E4. Operative time was longer (331 vs 254 minutes) and EBL was higher (150 vs 50 ml) in the open group. There were no conversions in the robotic group. Median length of stay was shorter in the robotic group (4 vs 5 days). Clavien-Dindo Classification≥III complications occurred in one patient per group. No postoperative mortality was observed. Median follow-up time was longer in the open group (1029 vs 300 days). Delayed anastomotic stricture after 6 months was identified in 2 patients in each group, treated with percutaneous dilation.
Conclusion: Robotic BDI repair is feasible and effective, offering a minimally invasive approach with excellent short-term results. Long-term outcomes are predicted to be superior to open repair.
★ Medical Educator Consortium Award for Best Scientific Paper
General Surgery. Is Pancreatic Cancer Sporadic or Part of the Syndrome?
Sharona B. Ross, Iswanto Sucandy, Lucas Larocca, Maria Christodoulou, Tara M. Pattilachan, Alexander Rosemurgy, Hasan Al Harakeh
Objective: The origins of pancreatic cancer remain elusive. Pancreatic cancer can emerge sporadically or through hereditary patterns, with a pancreaticoduodenectomy routinely employed as a treatment approach. Individuals who encounter sporadic pancreatic cancer typically lack a family history of the disease. Within the hereditary domain, there are 2 main subsets: those who have family history of cancer (cancer-family syndrome) and those who have family history of pancreatic cancer (site-specific syndrome). In this study, by analyzing frequencies of these patterns, we aim to better understand the origin of pancreatic cancer and improve our treatment approach.
Methods and Procedures: With IRB approval, 418 patients who underwent robotic pancreaticoduodenectomy for pancreatic tumors from 2012 to 2023 were prospectively reviewed. Family history of cancer and cancer type were determined for each patient and further used to separate them into cancer-family and site-specific syndromic subgroups. Those who did not have known family history of cancer did not belong to any syndromic subgroups.
Results: Of 418 patients (229 male/189 female), 256 (61%) presented sporadic pancreatic cancer, aged 69.5 (68 ± 10.4) years. Conversely, 162 (39%), aged 70.0(67 ± 11.6) years, presented nonsporadic tendencies (P < .001). Among nonsporadic cases, 34 (21%) had family history specific to pancreatic cancer, classifying them under site-specific syndrome. Meanwhile, 128 (79%) had varied family cancer histories, placing them within cancer-family syndrome (P < .001).
Conclusion: Majority of pancreatic cancer cases are sporadic, lacking familial cancer history. Nonetheless, nonsporadic instances often correlate with cancer-family or site-specific syndromes. Notably, the prevalence is higher for cancer-family syndrome, while site-specific syndrome is less frequent.
Scientific Paper. Endoscopic Stent Application: Addressing Long-Term Complications of Bariatric Surgery
James E. Terrell, Pradeep Atla, Hawwa Alao, Sofiya Reicher, Viktor Eysselein, Christian Perez, Amy K. Yetasook
Objective: Vertical banded gastroplasty (VBG) is a historic form of bariatric surgery. A possible long-term complication is a stricture/obstruction related to the fixed gastric band. Endoscopic techniques can be successful in removal without surgery.
Methods: A 70-year-old woman with history of VBG initially presented with refractory gastroesophageal reflux disease (GERD). Esophagogastroduodenoscopy (EGD) revealed severe reflux esophagitis and stricture in the proximal stomach caused by extrinsic compression. A 18 × 59 mm fully covered metal stent was deployed across the stricture under fluoroscopic guidance. Follow-up evaluation in 4 weeks noted gastric wall ulceration with eroding band into the luminal side. The stent was removed followed by removal of the gastric band that eroded completely using endoscopy.
Results: Following band removal, stricture showed gastric wall ulceration without any perforation confirmed under fluoroscopy. Patient was discharged the same day tolerating diet and reported improved GERD. She was placed on high dose proton pump inhibitors. Follow-up EGD showed stricture at the site of gastric band removal and currently being managed with luminal stenting.
Conclusion: Use of stents to induce erosion of the band into the lumen of the stomach is a safe way to prepare it for endoscopic removal. Stents aid in rapidly eroding the band by slow transmural necrosis, preventing free perforation. Removal is performed in a minimally invasive fashion, reducing complications and avoiding higher risk surgery. This remains possibly safer than surgical intervention when indicated. Recurrent stricture at the site of band removal could be a potential complication needing further endoscopic interventions.
Video. Robotic Central Hepatectomy with Portal Lymphadenectomy: The Preferred Technique in Gallbladder Cancer Resection
Lucas Larocca, Maria Christodoulou, Sharona B. Ross, Iswanto Sucandy, Kristana Milivojev Covillo
Objective: The need for portal lymphadenectomy for the treatment of biliary tract cancer creates technical challenges for most laparoscopic liver surgeons. Robotic technology helps overcome many of these difficulties, without having to convert to the traditional open method. This video depicts the application of a robotic central hepatectomy with portal lymphadenectomy undertaken for the treatment of gallbladder cancer.
Methods and Procedures: A 72-year-old woman presented with incidental gallbladder cancer and possible tumor extension into liver segments 4b/5 after a laparoscopic cholecystectomy. The preoperative work-up included a CT scan that was consistent with postcholecystectomy findings without radiological evidence of metastasis. A PET scan indicated no evidence of extrahepatic disease.
Results: The procedure involved adhesiolysis and omentectomy, followed by a radical portal lymphadenectomy. The cystic duct remnant was re-excised for pathological examination. A partial nonanatomical central segmentectomy 4/5/6 was undertaken to remove potential hepatic metastatic disease. The patient tolerated the operation well, had an uneventful postoperative course, and was discharged on POD 3. The final pathology report showed no evidence of residual disease and absence of nodal metastasis.
Conclusion: The robotic approach for gallbladder cancer resection is not only feasible, but also safe and oncologically effective with ease of radical lymphadenectomy. We believe this approach will be the preferred method for the treatment of incidental gallbladder cancer.
Video. Robotic Release of Median Arcuate Ligament Syndrome (MALS) with Variant Vascular Anatomy
Tara Ranjbar, Dillon Rogando, Katerina Jou, Kiara Singer, Taylor Loui, Caitlin Russell, Kuldeep Singh, Indraneil Mukherjee
Objective: Median Arcuate Ligament Syndrome (MALS) is a rare phenomenon occurring in 2/100,000 individuals in which the celiac trunk is compressed by the musculo-fibrous structure that unites the diaphragmatic crura of the aortic hiatus, called the median arcuate ligament. Patients present with vague symptoms including chronic postprandial abdominal pain, nausea, and weight loss. Our purpose is to convey a variation in the vascular anatomy in a MALS case.
Methods: A 49-year-old female with a PMH of coronary artery disease and a 50 packs a year smoking history presents with chronic recurrent postprandial abdominal pain and nausea with PO intake. After imaging confirmed MALS, the patient underwent robotic resection of the median arcuate ligament and TAP block.
Results: During the dissection, the variant vascular anatomy was confirmed. The left hepatic artery arose off of the stenosed left gastric artery which came off the aorta. Further dissection identified a replaced right hepatic artery arising from the superior mesenteric artery.
Conclusion: Postoperatively, the patient was discharged the following day and was seen in the clinic 2 weeks and 2 months postoperative. She is now able to tolerate 3 meals a day with no return of her initial symptoms. According to the Hiatt Classification for vascular variant anatomy, the patient had a type IV variation (accessory left hepatic artery originating from the left gastric artery and the replaced right hepatic artery originating from the SMA).
Video. Robotic Resection of Type-2 Klatskin Tumor with Portal Venorrhaphy and Dual Hepaticojejunostomy
Allyson Lim-Dy, Iswanto Sucandy, Sharona Ross, Alexander Rosemurgy
Objective: Perihilar cholangiocarcinoma resection with vascular involvement/abutment is a technically demanding procedure. This operation is therefore generally undertaken not by minimally invasive technique. With an increasingly wider use of robotics in hepatobiliary surgery, experienced centers are exploring the application of this platform in complex perihilar cholangiocarcinoma resections. We describe a technical approach for perihilar cholangiocarcinoma resection requiring concomitant tangential vascular repair and dual Roux-en-Y hepaticojejunostomies.
Methods and Procedures: A 78-year-old man presented with jaundice, indicating a Klatskin tumor type-2. MRI/MRCP confirmed an intrahepatic biliary dilation and filling defect within the common hepatic and common bile duct junction. An ERCP showed a malignant appearing stricture at the level of midbile duct. No obvious vascular invasion was detected. Portal lymphadenectomy was carried out in a standard fashion. Due to tumor involvement on the lateral wall of the main portal vein, vascular bulldog clamps were placed. A small defect in the portal vein from tumor involvement was repaired with lateral venorrhaphy technique, similar to that in open surgery. The duration of portal vein crossclamping was 15 minutes. Once resection was completed, dual Roux-en-Y hepaticojejunostomies were performed to begin the reconstructive phase. The first anastomosis occurred at the right anterior and right posterior hepatic duct. Second anastomosis was fashioned separately to the left hepatic duct.
Results: Operative time was 5 hours with an estimated blood loss of <50 cc. The postoperative recovery was uneventful.
Conclusion: Robotic resection of type-2 Klatskin Tumor with tangential portal venorrhaphy and dual hepaticojejunostomy is safe, feasible, and effective with excellent short-term outcomes.
Video. Robotic Extrahepatic Bile Duct Resection with Arterial Reconstructions for Cholangiocarcinoma
Allyson Lim-Dy, Iswanto Sucandy, Sharona Ross, Alexander Rosemurgy
Introduction: Resection of perihilar cholangiocarcinoma requiring hepatic arterial anastomoses and Roux-en-Y hepaticojejunostomy is associated with high technical challenges, therefore it is typically not performed by conventional laparoscopy even at high-volume liver expert centers. Technical description of robotic hepatic arterial reconstruction is nonexistent in the literature. In this video, we describe the robotic technique of an arterial end-to-end anastomosis during a Bismuth-Corlette type 2 Klatskin tumor resection.
Methods and Procedures: A 90-year-old man presented with jaundice and an obstruction within the midbile duct. CT scan showed intrahepatic biliary dilatation and a filling defect (mass) in the common hepatic duct. An endoscopic retrograde cholangiopancreatography was also conducted and confirmed the presence of obstructing mass. The operation began with diagnostic laparoscopy and radical portal lymphadenectomy. Radical excision of the extrahepatic duct was performed to gain negative proximal and distal margins. A segment of invaded right hepatic artery was transected sharply. After confirming negative margins, we proceeded with the reconstruction of the right hepatic artery using a parachute technique with 5-0 polypropylene sutures. Roux-en-Y hepaticojejunostomy was also performed in a running fashion to complete the reconstruction.
Results: The overall operative time was 6 hours with an estimated blood loss of 50 mL. A distal triphasic arterial flow was confirmed on doppler echogram. The postoperative recovery was uneventful. Klatskin tumor type 2 measured to be 4.5 cm with negative margins. Four out of 6 examined lymph nodes from the portal lymphadenectomy were positive for carcinoma.
Conclusion: Robotic technique for arterial and biliary reconstruction is safe and feasible with excellent results.
Scientific Paper. Optimal Dose and Timing of Icg for Fluorescent Cholangiogram – A Survey among Practitioners
Tsanko Ivelinov Yotsov, Martin Karamanliev, Svilen Maslyankov, Dobromir Dimitrov
Introduction: Bile duct injuries (BDI) are a serious complication during laparoscopic cholecystectomy with uncertain outcome even when detected and repaired early. The most common cause for BDI is poor visualization of the structures in the triangle of Calot. Fluorescent cholangiogram is a novel technique aimed at reducing the rates of BDI.
Materials and Methods: Three different doses of ICG (0.05 mg/kg, 1 and 2 mg) were injected at 3 different time periods (1, 3, 6 hours) prior surgery. Images of the anatomy of the bile ducts anatomy were obtained under white light and near infrared (NIR) light for all cases. Questionnaire containing side-by-side pictures of the anatomy under wight light and NIR light was prepared and uploaded on Google Forms. The survey was sent to different practitioners and the result were collected anonymously.
Results: The survey had 122 responders. According to them the most optimal image of the fluorescent cholangiogram was obtained with 1 mg ICG injected 3 hours preoperatively. The worst case was presented when 0.05 mg/kg ICG was injected 1 hour preoperatively. Only 16.4% report routine use of the method. However more than 80% find the method useful. Nearly 70% of the surveyed report that they would use the method, if they had access to it.
Conclusion: Even though, there are few surgeons that routinely use the method, most the responders affirm that the method is useful and more than half are willing to use the method routinely, if they have access to it.
Video. Distal Gastrectomy for New Onset Gastric Outlet Obstruction in the Setting of Stage IV Mesothelioma
Katerina Jou, Jeffrey Robles, Tara Ranjbar, Audrey Heldreth, Caitlin Russell, Indraneil Mukherjee
Objective: We present an 83-year-old male nonsmoker with progressive weakness, rectal bleeding, and 50-lb weight loss. History included iron deficiency anemia, DVT/PE, and stage IV metastatic mesothelioma of the lung, for which he was on apixaban and immunotherapy. EGD revealed erosive gastritis and a friable prepyloric mass positive for signet ring cell carcinoma causing gastric outlet obstruction. Initially a covered stent was placed; however, after initial reluctance to surgery, the stent migrated. It was removed and replaced. The objectives were to remove the mass and resolve the obstruction and bleeding.
Methods: He underwent a laparoscopic distal gastrectomy, Billroth II gastrojejunostomy, and stent removal. After adhesiolysis and lymph node harvesting, the stomach and duodenum were transected using a linear stapler. A gastro-jejunostomy were created with a linear stapler and sutures. Transversus abdominis plane blocks were performed before closure.
Results: The pathology was positive for poorly differentiated signet ring cell carcinoma and metastatic carcinoma in one of 17 lymph nodes. Postoperatively, he had successful diet advancement, return of bowel movement and flatus, and good gastric emptying. He has resumed his normal routine and continues immunotherapy for mesothelioma and gastric cancer surveillance.
Conclusions: New gastric signet ring cell carcinoma with metastatic malignant mesothelioma is uncommon. With such presentations, surgery can be high risk but necessary for palliation, with possible curative intent. The extent of intervention should be agreed upon between surgeon and patient and aim to improve quality of life.
Video. Robotic Remnant Cholecystectomy in A Patient with Recurrent Gallstone Pancreatitis
Objectives: Partial cholecystectomy is utilized by surgeons challenged by difficult anatomy in patients with diseases of the gallbladder. Incomplete gallbladder and gallstone removal puts the patient at risk of recurrence of the initial presentation. Remnant cholecystectomy may be required, which entails operating at the porta hepatis in a reoperative field. The challenges of such a case may be facilitated with the use of robotic technology, intraoperative ultrasonography and indocyanine green fluorescence.
Methods and Procedures: A 69-year-old male presents with recurrent gallstone pancreatitis. Imaging confirmed the presence of common bile duct gallstones and a remnant gallbladder filled with debris and gallstones. The patient was offered and greed to undergo robotic remnant cholecystectomy with intraoperative ultrasound.
Results: Operation lasted 60 minutes. Estimated blood loss was 10 ml. The patient left the hospital the following day, and has had no recurrence of symptoms since the procedure.
Conclusion: The robotic platform’s wristed instrumentation and 3-dimensional optics permitted a safe, effective, and efficient resolution. Indocyanine green fluorescence and intraoperative ultrasonography served as critical adjuncts guiding precise dissection in the reoperative field of the porta hepatis.
Video. Robotic Redo Hiatal Hernia Repair with Nissen Fundoplication
Denis Gratsianskiy, Sharona B. Ross, Trevor Jones, Iswanto Sucandy, Alexander Rosemurgy, Hasan Al Harakeh
Objective: Robotic operations have significantly influenced fundoplication, especially for reoperation for patients with recurrent symptoms. This study aimed to assess the efficacy and safety of robotic redo hiatal hernia repair with Nissen fundoplication in patients with a failure of the previous fundoplication and recurrent hiatal hernias for gastroesophageal reflux disease.
Methods and Procedures: A 69-year-old male presented with recurrent symptoms of heartburn and dysphagia. EDG/Bravo showed remanent Nissen fundoplication with recurrent hiatal hernia; subsequent Bravo pH on day 1 was 45 and on day 2, 43. UGI confirmed recurrent hiatal hernia, and manometry was normal.
Results: The robotic procedure was completed successfully with minimal blood. The patient tolerated the operation well and was discharged home on POD0 on a full-liquid diet. Beginning with division of the gastrohepatic ligament and isolation of the right crus, careful tissue dissection using robotic instruments facilitates reducing the stomach into the abdomen. Mobilization of the phrenoesophageal membrane and division of short gastric vessels provide exposure for hernia sac resection and closure of the diaphragmatic crura with absorbable mesh placement. Fundoplication creation, guided by bougie dilator insertion, aims for Nissen fundoplication to minimize postoperative complications, with intraoperative endoscopy confirming the integrity of the repair.
Conclusion: Robotic redo hiatal hernia repair with Nissen fundoplication is an effective and safe treatment option for patients with recurrent hiatal hernias. The procedure provides durable symptom relief and low perioperative complication rates. This study underscores the importance of robotic surgery in managing complex hiatal hernias and highlights the need for further research to optimize patient outcomes.
Scientific Paper. Robotic Transabdominal Repair of a Cough-Induced Right Sided Diaphragmatic Hernia
Chelsea L. Spector, Christopher Seaver, Shebin George, Eshak Abdalla, Ashley Tongkam-Godfrey
Objective: Discuss a rare case of a cough-induced right-sided diaphragmatic hernia repaired using a robotic-assisted laparoscopic approach.
Methods and Procedures: A 64-year-old male smoker presenting with right abdominal wall bulging and dyspnea after a coughing fit 5 months prior. CT scan revealed a 10.5 × 13 × 3.7 cm hernia in the lateral right abdominal wall, extending between the eighth and ninth ribs and traversing below the diaphragm and lateral to the liver.
Results: Using a robotic-assisted laparoscopic approach, a 12 × 10 cm defect was identified at the posterior lateral aspect of the diaphragm and repaired with a 25 × 20 cm monofilament polyester mesh with absorbable collagen. The patient was discharged the day of surgery with cyclobenzaprine, ibuprofen, and diazepam.
Conclusion: Cough-induced diaphragmatic hernias are extremely uncommon, even more so on the right side. Robotic-assisted diaphragmatic hernia repair (RA-DHR) is an emerging technique that has addressed many of the technical challenges encountered with the traditional laparoscopic approach. RA-DHR provides improved visibility, exposure, and maneuverability and should be considered.
Video. Robotic Small Bowel Resection with Intracorporeal Anastomosis: an Updated Method
Jennifer Hernandez, Luis A. Quintero, Juliana L. Colvin, Michael Dolberg
Objectives: Stapled small bowel resection can be performed open, laparoscopically, or robotic assisted. With each modality, bowel resection and anastomosis are performed in a similar fashion. The afferent and efferent limbs are transected, aligned, and stapled in a side to side, functional end to end anastomosis. The common channel is closed with another staple load. Performing the anastomosis this way uses 4–6 staple loads. The purpose of this video is to demonstrate the classic way of performing a small bowel resection and anastomosis, followed by presentation of an updated method in which fewer staple loads are used.
Methods and Procedures: In the first case, we present a robotic loop ileostomy reversal as described above and use 5 staple loads. In the second case, we present a robotic small bowel resection. The updated technique used in this case involves bowel transection using the robotic vessel sealer, rather than use of at least 2 staple loads. The bowel is aligned and the antimesenteric portion of the sealed bowel is opened using traction. A robotic stapler is then used to create a common channel, followed by closure of the common enterotomy. Performing the anastomosis in this fashion allows the use of at least 2 fewer staple loads. In the third case, we present the novel bowel resection technique in the setting of loop ileostomy reversal.
Results and Conclusion: Performing bowel resections with this updated technique allows the use of fewer staple loads, reduced operative time, and decreased operative costs.
Scientific Paper. The Impact of Laparoscopic Cholecystectomy on Pregnancy Outcomes throughout the US
Chelsea Spector, Joshua Parreco, Robert Hunter, Gary Curcio, Jennifer Hernandez, Lisa Ngo
Objective: Compare outcomes of cholecystectomy during pregnancy after the widespread use of laparoscopy throughout the United States.
Methods: The 2016–2020 Nationwide Readmissions Database was queried for all patients aged 18–45 years undergoing cholecystectomy during pregnancy. The primary outcome was stillbirth and the secondary outcome was prolonged length of stay (pLOS) >5 days. Univariable comparison with χ2 was performed for each outcome using covariables of laparoscopic versus open surgery, trimester of surgery, patient age, comorbidities, hospital characteristics, and socioeconomic status. Multivariable logistic regression was performed for each outcome using significant covariables from the univariable analysis.
Results: There were 5,742 patients undergoing cholecystectomy during pregnancy. Laparoscopic surgery was performed in 5,477 (95.4%) patients. Stillbirth occurred in 92 (1.6%) patients overall and there was no significant difference in patients undergoing laparoscopic versus open surgery. Risk factors for stillbirth included: surgery during the second trimester (OR 5.4 [1.6–18.3]) P = .01), 2 or more comorbidities (OR 3.1 [1.9–5.1] P < .001), and investor-owned hospitals (OR 1.9 [1.2–3.3] P = .01). pLOS was experienced by 1,240 (21.6%) patients. Risk of pLOS was increased with open surgery (OR 3.6 [2.7–4.6] P < .001) and 2 or more comorbidities (OR 3.1 [2.6–3.7] P < .001).
Conclusions: This study provides reassuring evidence regarding the safety of laparoscopic cholecystectomy during pregnancy, affirming its viability as a preferred surgical approach. Stillbirth was rare and prolonged length of stay was associated with open surgery. Clinicians should recognize the risk factors such as the timing of surgery and the presence of comorbidities, which may influence the likelihood of adverse outcomes.
Scientific Paper. Laparoscopic versus Robotic Elective Sigmoid Resection for Complicated Diverticulitis: a Single Institution Experience
Peyton M. Murdock, Robert E. Heidel, Andrew J. Russ
Objective: Minimally invasive surgical techniques for diverticulitis have grown in prevalence. Due to the increased degrees of freedom, robotic colectomy may provide benefits over the traditional laparoscopic approach, especially in complicated diverticulitis. This study examines the outcomes of laparoscopic versus robotic elective sigmoid resection for complicated diverticulitis at an academic tertiary care center.
Methods and Procedures: A retrospective review of patients at an academic tertiary care center from 2018 to 2023 who underwent elective minimally invasive sigmoid resection for complicated diverticulitis—defined as a history of abscess, perforation, drain, stricture, or fistula. Multiple regression analysis was used with primary outcomes being reoperation within 30 days and overall complications. Secondary outcomes were conversion to open, estimated blood loss, operative time, days until bowel function, and length of stay.
Results: In this patient cohort of 134, 39 patients underwent laparoscopic and 95 patients underwent robotic sigmoid resections. There was no significant difference between rate of reoperation (7.7% vs 2.1%, P = .42), complications (5.1% vs 8.4%, P = .52), conversion to open (5.1% vs 2.1%, P = .25), days until return of bowel function (1.87 vs 2.01, P = .41), or length of stay (5.2 vs 5.2, P = .92). There was a significant difference in operative time and estimated blood loss. Robotic approach was 128.11 min longer (β = 128.11, SE = 12, P < .001) with 33.4 cc less estimated blood loss (β = –33.4, SE = 16.6, P = .046).
Conclusion: Robotic sigmoid resection for complicated diverticulitis had mostly equivalent outcomes at this institution. There was some decrease in estimated blood loss, however, operative time was increased in the robotic group.
Scientific Paper. Is Previous Prostatectomy a Risk Factor for Postoperative Complications following Minimally Invasive Inguinal Hernia Repair? A Systematic Review and Meta-Analysis
Diego L. Lima, Joao P. G. Kasakewitch, Carlos A. B. Silveira, Ana Caroline Rasador, Julia Kasmirski, Marina Eguchi, Valberto Sanha, Flavio Malcher
Objective: The aim of this study was to conduct a systematic review and meta-analysis to evaluate the influence of previous prostatectomy in men undergoing minimally invasive surgery (MIS) inguinal hernia repair (IHR).
Methods and Procedures: We searched Cochrane Central, Scopus, SciELO, Lilacs, and PubMed/MEDLINE for studies comparing men undergoing MIS IHR after prostatectomy with men without previous pelvic surgery. Outcomes evaluated included recurrence, overall postoperative complications, seroma, hematoma, surgical site infection (SSI), conversion rates, and operative time (OT).
Results: 9 studies met the inclusion criteria. Three analyzed totally extraperitoneal (TEP) technique, while 4 analyzed transabdominal preperitoneal (TAPP) and 2 presented both techniques together. The analysis comprised 189,183 patients, of which 4,551 (2.4%) had a history of prostatectomy. Postprostatectomy patients presented higher postoperative complications (3.7% vs 1.9%; RR 1.9; 95% CI [1.23; 2.94]; P = .004) and seroma (1.6% vs 0.9%; RR 1.58; 95% CI [1.23; 2.04]; P < .001) following MIS IHR. Patients with a previous prostatectomy presented an increased OT (MD 21.25 minutes; 95% CI [19.1; 23.4]; P < .001). No differences were observed in recurrence (0.98% vs 0.92%; RR 1.1; 95% CI [0.8; 1.53]; P = .54), SSI (0.07% vs 0.07%; RR 0.99; 95% CI [0.34; 2.9]; P = .98), hematoma (3.6% vs 1.2%; RR 3.18; 95% CI [0.84; 12.1]; P = .09), and conversion rates (1.1% vs 0.9%; RR 1.26; 95% CI [0.91; 1.72]; P = .16).
Conclusion: This study indicates that patients with a history of prostatectomy undergoing MIS IHR may present higher postoperative complications and an increased operative time.
Scientific Paper. Enhancing Patient Safety and Outcomes in Bariatric Surgery: The Role of Resident Participation—A Systematic Review and Meta-Analysis
Raquel N. Cordeiro, Diana Q. Nguyen, Joao P. G. Kasakewitch, Diego L. Lima, Carlos A. B. Silveira, Rachel C. Santana, Aisulu Desup, Saad Ahmed, Diego Camacho
Objective: Amidst concerns about surgical training’s impact on patient care, this study aims to evaluate the outcomes and safety of bariatric surgeries, including robotic and laparoscopic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), with resident participation.
Methods and Procedures: Cochrane, PubMed/MEDLINE, and Embase databases were searched on studies that compared outcomes of bariatric surgeries performed with resident involvement against those conducted by attending surgeons alone. The selection process was carried out by 3 independent reviewers, with any disagreements being adjudicated by a fourth reviewer.
Results: From 750 records, 25 studies were included, encompassing 1,818,940 patients, of whom 382,661 (21.0%) underwent bariatric surgery with resident participation. Our findings indicate that surgeries involving residents were associated with a reduced risk of postoperative bleeding (RR 0.68; 95% CI 0.49–0.96) compared to those performed by attending surgeons alone. Conversely, surgeries without resident involvement showed a higher risk of small bowel obstruction (SBO) and large bowel obstruction (LBO) (RR 1.56; 95%CI 1.31–1.85). No significant differences were observed in ICU admissions, anastomotic leakage, mortality, readmission rates, reoperations, or SSI.
Conclusions: Resident participation in bariatric surgeries does not compromise patient safety and may enhance certain postoperative outcomes. This supports the integration of residents in bariatric surgical teams, emphasizing the importance of hands-on training in surgical education without adversely affecting patient care.
Scientific Paper. The Role of Tranexamic Acid (TXA) on Postoperative Bleeding in Bariatric Surgery: a Systematic Review and Meta-Analysis
Carlos A. Balthazar da Silveira, Gabriele E. Lech, Laura M. Vidotto, Carolina M. Sturmer, João P. G. Kasakewitch, Diego L. Lima, Erin Moran-Atkin, Diego Camacho
Introduction: Recent research highlights TXA’s potential in managing postoperative bleeding in bariatric surgery, prompting us to evaluate its effectiveness for treatment and prophylaxis.
Methods: PubMed, Scopus, Cochrane Central, SciElo, and LILACS were searched for TXA studies in bariatric surgery, excluding those without control groups or with overlapping populations. Outcome analysis focused on postoperative bleeding, length of hospital stay (LOS), TXA side effects, mortality, transfusion needs, and thromboembolic complications.
Results: From 93 results, 6 studies involving 1,121 patients were included. TXA use significantly decreased the LOS (MD = –0.12; 95% CI: –0.18, –0.06; P < .01), operative time (MD = –5.77; 95% CI: –9.98, –1.56; P < .01), and postoperative bleeding (OR = 0.57; 95% CI: 0.34, 0.98; P = .043). However, TXA did not affect the number of surgical clips used (MD = 0.04; 95% CI –0.83, 0.92; P = .92), rate of hematoma formation (OR = .39; 95% CI: 0.07, 2.29; P = .299), rate of reoperation (OR = 0.46; 95% CI: 0.08, 2.82; P = .403), or need for transfusion (OR = 0.25; 95% CI: 0.06, 1.07; P = .062). There was no register of thromboembolic events or mortality.
Conclusion: TXA significantly reduces LOS, operative time, and postoperative bleeding in bariatric surgery without affecting the need for surgical clips, hematoma formation rate, reoperation rates, or transfusion needs, while also not increasing thromboembolic risk.
Scientific Paper. Comparative Outcomes of Robotic versus Laparoscopic Nonelective Colectomy: a Systematic Review and Meta-Analysis
Carlos A. Balthazar da Silveira, Ana C. D. Rasador, João P. G. Kasakewitch, Diego L. Lima, Abier A. Abdelnaby
Aim: Minimally invasive surgery has emerged as a viable and safe alternative for urgent colorectal procedures. However, in the urgent care context, there is no consensus on the superiority of robotic versus laparoscopic techniques. Addressing this gap, our study performs a systematic review and meta-analysis comparing the outcomes of robotic and laparoscopic nonelective colectomies.
Materials and Methods: Cochrane, Embase, PubMed, and Web of Science were searched for studies that directly compared laparoscopic and robotic nonelective colectomies. The outcomes of interest included readmission, reoperation rates, anastomotic leak, surgical site infections (SSI), incidence of prolonged postoperative ileus, length of hospital stay (LOS), and rates of conversion to open surgery.
Results: Our search yielded 597 records, from which 3 studies were included, totaling 7,471 patients. Of these, 429 (5.7%) underwent robotic colectomies. Our analysis highlighted a significantly lower rate of conversion to open surgery in the robotic group compared to the laparoscopic group (10.3% vs 28.3%; RR 0.37; 95% CI [0.27, 0.51]; P < .001). Conversely, laparoscopic colectomies were associated with a lower incidence of postoperative ileus (10.6% vs 16.5%; RR 1.55; 95% CI [1.19, 2.02]; P = .001). No statistically significant differences were observed in mortality, readmission, reoperation, SSI, or LOS.
Conclusions: This systematic review and meta-analysis suggest that robotic nonelective colectomy is associated with a lower rate of conversion to open surgery compared to laparoscopic approaches, with no significant differences in major postoperative complications or mortality rates.
Scientific Paper. The Role of the Ast to Platelet Ratio Index (APRI Score) on Outcomes following Robotic Major Hepatectomy for Liver Tumors
Cameron Syblis, Maria Christodoulou, Sharona B. Ross, Tara M. Pattilachan, Iswanto Sucandy
Objective: The predictive capability of the Aspartate Transaminase to Platelet Ratio Index (APRI) in assessing fibrosis and cirrhosis, both linked to adverse patient prognosis, has been established. APRI score had also been recently studied in patients undergoing minor hepatectomy. This study aims to evaluate the correlation between APRI scores and perioperative outcomes in patients undergoing major hepatic resection utilizing the robotic platform.
Methods and Procedures: With IRB approval, a prospective database encompassing 166 consecutive patients undergoing robotic major hepatectomy was analyzed. Patients were stratified based on an APRI score threshold of 0.7. Major resection was defined as removal of ≥3 Couinaud segments. Data are presented as median (mean ± standard deviation).
Results: Among the 166 patients, 118 (71%) exhibited an APRI <0.7, while 48 (29%) had an APRI >0.7. Patients demonstrated comparable demographics in terms of age (P = .25), sex (P = .60), and BMI (P = .09). Those with APRI > 0.7 were associated with fewer previous abdominal resections (36% vs 58%, P = .01), higher Child-Pugh scores (5 [6 ± 0.9] vs 5 [5 ± 0.4], P < .0001), cirrhosis (31% vs 10%, P = .0008), and neoplastic pathology (85% vs 60%, P = .001). There were no significant differences, however, in operative time (P = .59) or estimated blood loss (P = .38). Ninety-day postoperative complications (P = .29), length of stay (P = 1.00), and 90-day mortality (P = .76) were similar, irrespective of APRI score.
Conclusion: Elevated APRI levels were indicative of cirrhosis, reinforcing its utility as a preoperative fibrosis/cirrhosis diagnostic tool. However, outcomes following robotic major hepatectomy for liver tumors are not readily affected by elevated APRI scores.
Scientific Paper. Early Detection of Esophageal Cancer: a Novel Approach with Applications in Primary Care
Mohammed Elniel, Ishaan Maitra, Ihtesham Ur Rehman, Ravindra S. Daté
Objective: Esophageal cancer typically presents at an advanced stage with resultant poor survival rates. The yield of oesophago-gastro-duodenoscopy (OGD) undertaken on the 2-week wait pathway in diagnosing esophageal cancer is thought to be 5%. The 2022 esophago-gastric (OG) audit suggests only 35.9% of patients diagnosed with OG cancer were treated with curative intent. Raman spectroscopy of plasma and serum is a noninvasive and rapid diagnostic technique which has proved promising in cancer diagnostics. We aim to demonstrate whether this technique can accurately diagnose esophageal cancer (OAC).
Methods and Procedures: Chemometric analysis of the spectral data from a proof of concept study undertaken by our team revealed Raman spectroscopy of plasma and serum to be 95% sensitive and specific in diagnosing OAC. Our research group has conducted a further study to validate these findings by reanalysing 60 of the samples from the proof of concept study in a separate lab.
Results: Spectral peaks representing methylene deformation and C-O stretch of ribose were identified as discriminant spectral peaks in identifying OAC in both analyses, inferring that these results are reproducible. Specificity and sensitivity of 72% and 71% respectively was calculated from chemometric spectral analysis.
Conclusion: We conclude that Raman spectroscopy has potential applications as a noninvasive screening tool for patients with suspected OAC in primary care.
Video. Laparoscopic Surgery Training: Gaining Competence with Confidence
Mohammed Elniel, Ilayaraja Rajendran, Ravindra S. Daté
Objective: Our goal is to present a novel educational framework for laparoscopic surgery training, designed to overcome the limitations in the transfer of skills from open to laparoscopic surgery.
Methods and Procedures: Our teaching approach is rooted in sequentially mastering fundamental surgical skills before advancing to complex tasks. Our concept, “known to unknown” advances trainees through 5 steps:
Step 1—Basic surgical skills
Step 2—Laparoscopic control of bleeding
Step 3—Laparoscopic suturing
Step 4— Familiarization
Step 5—Improvement of skills by watching their own videos
This progression is designed to prepare trainees for real-life surgeries through a structured, step-by-step approach.
Results: The framework allows trainees to advance from basic surgical skills to completing common laparoscopic procedures such as cholecystectomy and appendicectomy.
Conclusion: This structured training model diverges from the conventional “see one, do one, teach one" paradigm, offering a comprehensive, graduated exposure to laparoscopic surgery that ensures a thorough grasp of essential skills before undertaking complex operations. By emphasizing systematic skill acquisition and mentor-guided practice, the approach aims to significantly reduce the learning curve and enhance operative safety in laparoscopic surgery.
Scientific Paper. The Impact of Surgeon’s Experience in Abdominal Wall Hernia Repair: a Systematic Review
Ana Caroline D. Rasador, Carlos B. da Silveira, Diego L. Lima, Raquel Nogueira, Prashanth Sreeramoju, Flávio Malcher
Objective: Evidence on the impact of the surgeon’s experience in hernia repair is limited. We aimed to perform a systematic review assessing surgeon’s experience and abdominal wall hernia repair.
Methods and Procedures: PubMed, Cochrane, EMBASE, Lilacs, and SciELO databases were searched for studies on adults undergoing ventral hernia repairs (VHR) and inguinal hernia repairs (IHR), reporting surgeon’s experience numerically with annual volume or total volume, focusing on the outcomes: reoperation, recurrence, intraoperative and postoperative complications.
Results: A total of 15,879 studies were screened, and 8 observational studies were selected, comprising 205,127 patients. 96.1% were IHR and 3.9% were VHR patients; 81.7% of surgeries were open and 18.5% laparoscopic (TAPP or TEP techniques). Recurrence rates for laparoscopic approaches ranged between 1 to 4.3% for annual volume <25 and reduced to 0.7–1.2% for >25. Among surgeons with total volume of >500 procedures, recurrence ranged between 0.6 and 3%, compared with 2 and 2.2% for <500. As for reoperation, rates for IHR ranged between 2 to 2.6% for annual surgeon volume <25 and between 1.2 and 2.6% for >25. Reoperation rates were 2.9% for VHR among surgeons with annual volume <9 and reduced to 2% for >30. Surgeons with annual volume <25 presented higher incidence of intraoperative complications (1.3–5.6%), compared to >25 (0.9–1.2%). Postoperative complications had higher incidence among annual surgeon volume <25 (2.2–35.9%) compared to >25 (4.9–13.3%).
Conclusion: Higher surgeon’s experience might be related to lower recurrence, reoperation, and intraoperative and postoperative complications rates.
Scientific Paper. Comparative Effectiveness of Laparoscopic versus Open Colectomy in Emergency Diverticulitis Treatment: a Systematic Review and Meta-Analysis
Sophia Zigouras, Joao P. G. Kasakewitch, Carlos B. Silveira, Ana Caroline Rasador, Diego L. Lima, Abier Abdelnaby
Objective: Our systematic review and meta-analysis sought to identify the optimal surgical technique for emergency diverticulitis cases featuring perforation and peritonitis by comparing laparoscopic versus open colectomy, addressing the debate on the best surgical approach.
Methods and Procedures: Cochrane Central, Embase, PubMed, MEDLINE, and Web of Science were searched for studies comparing laparoscopic and open colectomy for emergency diverticulitis. We focused on key outcomes such as mortality, postoperative complications, dehiscence, leakage, surgical site infections, readmissions, reoperations, prolonged ileus, ICU admission rates, and hospital stay duration.
Results: From 1692 records, 8 studies were included, with 4 focusing on acute perforated diverticulitis and the remaining 4 on all emergency diverticulitis causes, involving 10,547 patients, of whom 1922 (18.2%) underwent laparoscopic colectomy. Laparoscopic surgery was associated with decreased mortality (2.6% vs 6.2%; RR 0.56; 95% CI: 0.42, 0.76; P < .001), postoperative complications (35.1% vs 45.7%; RR 0.84; 95% CI: 0.78, 0.90; P < .001), SSI (5.9% vs 7.6%; RR 0.67; 95% CI: 0.54, 0.82; P < .001), and postoperative prolonged ileus (28.2% vs 34.5%; RR 0.83; 95% CI: 0.73, 0.93; P = .002) compared to open colectomy. Laparoscopy was also associated with a reduced LOS (MD −1.75 days; 95% CI: −2.6, −0.88; P < .001). No significant differences were observed in leakage, dehiscence, readmission, reoperation, and ICU admission rates.
Conclusions: Our findings suggest that using a laparoscopic approach for emergency diverticulitis is associated with lower mortality, morbidity, and shorter hospital stays, presenting it as a favorable treatment option.
Scientific Paper. Consequences of Conversion to Open during Minimally Invasive Colectomy: a Systematic Review and Meta-Analysis
Ana Caroline D. Rasador, Carlos B. da Silveira, Diego L. Lima, Raquel Nogueira, João G. Kasakewitch, Gabriele E. Lech, Abier A. Abdelnaby
Objective: Minimally invasive surgery (MIS) has underscored the consequences of conversion to open colectomies. We performed a systematic review and meta-analysis assessing the impact of conversion during MIS colectomy.
Methods and Procedures: PubMED, Cochrane, Scopus, and SciELO were searched for studies analyzing conversion during MIS colorectal resections. Outcomes were readmission, surgical site infections (SSI), blood loss, postoperative complications, transfusion, cancer recurrence, 30-day mortality, 5-year cancer-free survival rate, 5-year overall survival rate, operative time, ileus, bleeding, and leak.
Results: A total of 5,407 studies were screened, and 45 were included, comprising 499,519 patients, from which 68,638 (13.74%) underwent conversion. Converting increases postoperative complications (RR 2.2; 95% CI 1.76, 2.75; P < .001), readmission (RR 1.54; 95% CI 1.44, 1.66; P < .001), transfusion (RR 2.73; 95% CI 2.41, 3.08; P < .001), leak (RR 1.75; 95% CI 1.53, 2.01; P < .001), ileus (RR 2.26; 95% CI 1.64, 3.12; P < .001), SSI (RR 2.58; 95% CI 2.1, 3; P < .001), and recurrence (RR 1.57; 95% CI 1.24, 1.98; P < .001). Conversion had greater blood loss (MD 196.7 mL; 95% CI 117.4, 275.2; P < .001), longer operative time (MD 27 min; 95% CI 17.7, 36.3; P < .001), higher 30-day mortality (RR 3.26; 95% CI 1.5, 7; P = .003), longer time to flatus (MD 0.8 day; 95% CI 0.52, 1; P < .001), and lower 5-year overall survival (RR 0.85; 95% CI 0.76, 0.94; P = .002) and 5-year disease-free survival (RR 0.78; 95% CI 0.65, 0.95; P = .012). Subgroup analyses showed similar results for malignant and benign diseases.
Conclusion: Converting is associated with increased perioperative complications during MIS colectomy for both malignant and benign colorectal diseases.
Video. Robotic Parenchymal Sparing Segment 7 Tumor Resection
Melissa Touadi, Iswanto Sucandy, Sharona B. Ross
Objective: Focal nodular hyperplasia is a benign liver tumor which often presents diagnosis challenge due to its resemblance with hepatocellular carcinoma and hepatic adenoma. Despite of its benign nature, presence of symptoms is an indication for tumor resection. In this case, we demonstrate a robotic parenchymal sparing resection technique for a large hepatic adenoma in posterosuperior segments requiring liver mobilization.
Methods: A 37-year-old woman with past medical history of avid reflux and focal nodular hyperplasia presented with severe right upper abdominal pain. CT scan showed an arterially enhancing 8-cm mass consistent with hepatic nodular hyperplasia in segments 7 and 8. The operation begun with complete right hepatic lobe mobilization to gain anatomical access to the lesion. An intraoperative liver ultrasound was used to map the intrahepatic major vascular structures and to guide the intended liver parenchymal transection. Under intermittent Pringle maneuver, parenchymal sparing liver resection was undertaken using crush-clamp synchroseal technique. Crossing biliovascular structures to the tumor were divided between clips as appropriate. Finally, the specimen was resected from the future liver remnant with minimal blood loss.
Results: The operative time was 150 minutes with <100 cc of blood loss. The patient had an uneventful recovery and she was discharged home on postoperative day 3. The patient was asymptomatic during the follow-up appointment with complete resolution of her right upper quadrant pain.
Conclusion: Robotic parenchymal sparing liver resection using crush-clamp synchroseal technique is simple, reproducible, and effective. This technique allows clear identification of intrahepatic structures without proper handling of intrahepatic biliovascular structures.
Scientific Paper. Comparing the Outcomes between Robotic and Laparoscopic Cholecystectomy for Acute Cholecystitis
Zamaan Hooda, Toghrul Talishinskiy, Sydney Abaijan, Scott Wessner
Objective: Laparoscopic cholecystectomy is the “gold standard” surgical approach for acute cholecystitis. Recently, there has been increased interest in robotic-assisted cholecystectomy for acute cholecystitis and its outcomes compared to the laparoscopic approach. Currently, there is a paucity of literature pertaining to this topic. This study compares length of operative time and clinical outcomes between these 2 techniques.
Methods and Procedures: A 1-year retrospective analysis at a single institution was performed of patients that underwent laparoscopic or robotic-assisted cholecystectomy. Patients excluded included those undergoing elective cholecystectomy, cases involving intraoperative cholangiogram and final pathology inconsistent with acute cholecystitis. The variables compared were length of operative time, postoperative complications and conversion to open cholecystectomy. Unpaired t-test was utilized to compare the collected information.
Results: A total of 103 total patients (55 in the laparoscopic cholecystectomy group, 48 in the robotic-assisted cholecystectomy group) were included in the study. Average operative time for laparoscopic cholecystectomy was 108.6 minutes (SD of 25.7 minutes) and 104.1 minutes (SD of 18.6 minutes) for robotic-assisted cholecystectomy (P = .32). Three patients had postoperative complications with the laparoscopic cholecystectomy approach. Zero cases of postoperative complications occurred with the robotic-assisted approach (P = .10). Conversion to open cholecystectomy occurred once with laparoscopic cholecystectomy, which was not required during any of the robotic-approach cases (P = .35).
Conclusion: Our data indicate that robotic-assisted cholecystectomy is a feasible option for the treatment of acute cholecystitis. Our data suggests that the robotic approach is associated with decreased operative time, less risk of postoperative complications and open conversion.
★ Michael S. Kavic Award for Best Scientific Paper by a Resident
Video. Diagnostic Challenges of A Bleeding Meckel's Diverticulum in A Young Adult
Ahmed E. Eissa, Gabrielle Dabrowski, Carlos Ruiz, Indraneil Mukherjee
Objective: This study aims to illustrate the diverse presentations of Meckel’s diverticulum (MD) in adults and the diagnostic challenges associated with it. Additionally, it seeks to demonstrate the approach to the laparoscopic management of a bleeding MD.
Methods and Procedures: We present the case of a 19-year-old male with intermittent abdominal pain and hematochezia. Diagnostic workup included esophagogastroduodenoscopy, CT angiography, and colonoscopy, which were inconclusive. Technetium-99mm scan showed aberrant uptake, suggesting ectopic gastric mucosa, prompting exploratory laparoscopy, and terminal ileectomy with primary side-to-side anastomosis.
Results: Despite negative imaging and atypical symptoms, a MD was identified intraoperatively, underscoring the diagnostic challenge in adults. Surgical intervention resulted in resolution of symptoms.
Conclusion: Adult MD poses diagnostic dilemmas due to varied presentations and negative imaging. Clinicians should maintain a high index of suspicion, especially in cases of nonspecific symptoms, to prevent delays in diagnosis and reduce associated morbidity.
Video. Sliding Inguinal Bladder Hernia: a Minimally Invasive Robotic-Assisted Repair
Dillon Rogando, Tara Ranjbar, Jeffrey Robles, Katerina Jou, Sourodip Mukharjee, Audrey Heldreth, Indraneil Mukherjee
Objective: Inguinal hernias are a common occurrence with a lifetime risk of 27% and 3% among men and women, respectively. Passage of retroperitoneal organs through the abdominal wall defect is known as sliding inguinal hernias.
Methods and Procedures: A 60-year-old male with a known history of hypertension and previous open appendectomy presented with a 10-year history of unilateral scrotal swelling associated with suprapubic discomfort. Physical examination revealed bilateral inguinal hernias, with a larger nonreducible hernia sac on the left. Preoperative noncontrast CT confirmed the presence of the urinary bladder wall within the left hemi-scrotum.
Results: The patient underwent robotic-assisted repair of bilateral inguinal hernias. Intraoperatively, multiple dense intra-abdominal adhesions beneath the umbilicus and the site of previous open appendectomy were seen. Extensive lysis of adhesions was performed and peritoneal flaps were created. A large right-sided direct, indirect and femoral hernia was discovered and subsequently reduced. On the left, a 15-cm hernia sac consisting mainly of fat was reduced through a 4 × 6 cm defect in the abdominal wall - likely containing the urinary bladder. Primary closure of the defects was achieved and bilaterally, polypropylene mesh was inserted into the peritoneal flaps to reduce the risk of recurrence.
Conclusion: Robotic-assisted repair represents a safe approach for managing complex inguinal hernias, including sliding bladder hernias. This approach allows for direct visualization of the hernia sac, intraoperatively, which may reduce iatrogenic injury to the bowel during repair. This case underscores the feasibility of robotic surgery in achieving favorable outcomes and importance of individualized treatment strategies in inguinal hernia management.
Video. A Surgical Spigelian Surprise
Jeffrey Robles, Dillon Rogando, Tara Ranjbar, Indraneil Mukherjee, Sourodip Mukharjee
Introduction: A spigelian hernia occurs when bowel or peritoneum protrudes through the spigelian fascia, which is made up of the internal oblique aponeuroses and the rectus abdominis muscle. It is relatively rare and seen in 1–2% of all abdominal wall hernias. It can be caused by an increase in intra-abdominal pressure, abdominal wall trauma, or degeneration. Risk factors include previous abdominal surgeries, chronic coughing, collagen disorders, and multiple pregnancies. Our purpose is to present the incidental finding of a spigelian hernia discovered during a robotic assisted hysterectomy for endometrial cancer.
Methods: A 58-year-old female with a PMH pelvic floor weakness, postmenopausal bleeding, endometrial adenocarcinoma, prior c-section, and cholecystectomy admitted for hysterectomy with bilateral salpingo-oophorectomy for definitive endometrial adenocarcinoma treatment.
Results: The patient underwent hysterectomy with bilateral salpingo-oophorectomy. During initial ligation of uterine tissue, a large 2 × 5 cm spigelian hernia at least 5 cm deep was identified between the rectus abdominis muscle and anterior rectus sheath. After repair of the spigelian hernia using a 2-0 barbed suture, all instruments were removed from the abdomen and vagina, and the abdominal fascia was closed using 0 vicryl.
Conclusion: Postoperatively, the patient was discharged that evening and was seen in the clinic 2 weeks later. Patient endorsed no new complaints except for some occasional incontinence and dyspareunia, consistent with her postmenopausal status and past medical history of pelvic floor weakness. Patient reported complete surgical recovery during her follow-up appointment 3 months later, and subsequently scheduled for a follow-up in another 3 months.
Video. Retromuscular Local Anesthesia Technique (RLAT) in Laparoscopic Retro-Muscular Inguinal Hernia Repair (LRMIR)
Background: Laparoscopic retromuscular inguinal repair (LRMIR) is an ideal site to place the mesh on the inner bone surface of the abdominal muscle. Mobilization of fascia transversalis maybe causes bleeding. Retro-muscular local anesthesia technique (RLAT) was used successfully in laparoscopic sleeve gastrectomy and in place laparoscopic placement peritoneal dialysis catheter encouraging to modify the technique in LRMIR aiming, local anesthesia and aid in creating retro muscular plane assessing the outcome of pain and recurrence.
Methods/Technique: Seventy patients were involved in this study from January 2016 to January 2023. RLAT was used in LRMIR for all patients. A 2 mg/kg bupivacaine with 0.1 ml norepinephrine was diluted in 250 ml saline and injected retro rectal spaced distal to umbilical up to pubic bone and second site from the anterior superior iliac spine to the edge of posterior rectal sheath infraumbilically. The peritoneum including fascia transversalis cut with secured haemostasis up to the pubic rami identifying rectus abdominis, transverse abdominis, psous major, and pubic rami 15 × 15 cm mesh was applied to cover the hernial defect. All were discharged same day.
Results: No wound infection occurred. One patient has pain and needs to be treated in a pain clinic. No recurrence was encountered during the follow-up. Five patients were treated by local anesthesia only. The procedure was done as day surgery. One patient has had pain for 3 months.
Conclusion: RLAT is a valuable, practical, and easy technique in LRMIR, helping to create an ideal retro muscular plane in placing 15 × 15 cm mesh in managing inguinal and femoral hernia.
Video. Laparoscopic Retromuscular Inguinal Hernia (LRMIHR) Repair Using Phasix and Polypropylene Mesh: 5 Years Outcome
Background and Objective: Inguinal hernia routinely repaired with synthetic nonabsorbable mesh. However, chronic pain may affect the success of flow recurrence. This work assesses the results and cost of TAPP repair using lightweight polypropylene mesh.
Methods: Laparoscopic retromuscular inguinal hernia repair (LRMIHR) was performed from January 2015 to January 2023 with Institutional review board approval for 98 patients, 9 female and 90 male. The average age is 55.8, with a 27.5 mean BMI. The study was done in the hospital by one surgeon. Studying postoperative pain, reaction, mesh sensation discomfort, recurrence, and cost.
Results: In 5 years follow-up, the outcome is good. No recurrence or chronic pain was encountered.
Conclusion: Lightweight mesh repair in RLRIHR is suitable economy with low postoperative risk.
Video. Laparoscopic Anatomical Landmark in Inguinal Hernia (LALIH)
Background: The laparoscopic inguinal repair was described in 1992. However, the standard of dissection and size of the mesh and hernias identification and managing fat in the inguinal canal are not described. Adoption of laparoscopic 5-mm incision and managing bilateral inguinal femoral and description of the inguinal area anatomy.
Methods: One surgeon managed all patients from May 2015 to May 2023, and one technique of laparoscopic retromuscular inguinal repair was reviewed and classified as an important point.
Results: The important landmarks are the inferomedial angle of the deep inguinal ring, which guides you to the vas deferens or round ligament uterus, gonadal vessels, and hernia sac, compass rose. The line of the flap includes the peritoneum and retroperitoneum rate 3–4 cm away from the hernial defects, which usually varies 14–17 cm, identifying pubic ramus, Rectus abdominis, and transverse abdominis psous major inguinal canal. The rectangular of pain is psous major, where you can see nerves over the muscle. Additionally, rectangular of bleeding (RB) runs parallel to psous major and inferomedial containing extrailiac vessels. Following RB will be distal and medial femoral canal and hernia are identified. Furthermore, fat clearance from the inguinal canal and preserving the neurovascular structure of the inguinal canal. On the other hand, the mesh should reach the median umbilical ligament 4 cm lateral to the deep inguinal ring and 3 cm inferior to the pubic rami. Tacking should avoid RB and PVR.
Conclusion: For safe, pain-free, low recurrence, and less complication, identifying the compass rose, RB, and, VR is the safest method.
Video. Female Inguinal Hernia
Background: Inguinal hernia in male is common hernia. On the other hand, proper surgical treatment of female inguinal hernia and its outcome is insufficient. As a result, the experience of managing inguinal hernia outcomes in females is reported.
Materials and Methods: The female patient diagnosed with inguinal hernia from May 2016 to May 2023 were involved in this study.
Results: Eleven female patients complain of groin pain mainly and swelling; the pain is severe. All patients were operated with laparoscopic retromuscular mesh repair. One patient has a femoral hernia only, 2 patients had a femoral hernia, an inguinal hernia, and 1 patient has a bilateral inguinal hernia. Female patients have more inguinal fat in the inguinal canal. All cases were discharged within one day postoperatively. No recurrence or chronic pain was encountered.
Conclusion: Laparoscopic retromuscular mesh repair for inguinal hernia and canal is a better approach to discovering misdiagnosed femoral hernia, combined femoral and inguinal hernia. Moreover, a bilateral inguinal hernia is managed by the same incisions, additional laparoscopy spares nerves, and cosmetics for females.
Scientific Paper. Effect of Fascial Closure versus Nonfascial Closure on Developing Trocar-Site Hernias (TsH) in the Bariatric Population: a Systematic Review
Nagham Toba, Bassem Abou Hussein, Omar Al Marzouqi, Sameera Hajijama, Mohammed Amaan Khokar, Hessa Alqasimi, Ali Khammas, Amar Hassan
Background: Trocar site hernia (TsH) is a less common complication of laparoscopic bariatric procedures. The aim of this study is to investigate whether fascial closure (FC) or nonfascial closure (NFC) of the trocar site, in patients undergoing bariatric surgery, will affect the incidence of TsH.
Methods: A systematic review was conducted from July to September of 2023 and registered on Prospero 2023 CRD42023403504. The study included articles of patients that had bariatric surgery describing the closure technique and TsH incidence, and excluded procedures using a single port, natural orifice, open or robotic technique. Search engines included PubMed, Medline, Scopus, and ClinicalTrials. The risk of bias was assessed using standard tools.
Results: Of the 1,433 screened studies, 14 articles consisting of 5,232 participants met the eligibility criteria, which consisted of only cohort studies. Of the 14 studies, only 3 compared the development of TsH between the FC and NFC groups. Two of the 3 reported a significantly increased incidence of TsH in the NFC group (P = .02, P < .05), whereas the remaining study reported no significant difference in incidence between both groups. Eleven of the 14 studies did not compare the incidence of TsH between FC and NFC. Six studies only included patients that underwent FC, while 5 studies only included NFC. The study’s limitations were data heterogeneity and lack of adequate comparative literature.
Conclusions: This systematic review revealed equivocal results Further studies must be conducted with more statistical evidence to formally declare an association.
Video. Video Presentation of Laparoscopic Epigastric Hernia Repair
Sourodip Mukharjee, Indraneil Mukherjee, Dillon Rogando
Objectives: Epigastric hernias, though less common than inguinal hernias, pose significant challenges due to their small size and incarceration of preperitoneal fat. The laparoscopic approach to epigastric hernia repair offers several advantages, including reduced postoperative pain, faster recovery, and improved visualization of the hernia defect. This video submission aims to demonstrate a standardized laparoscopic technique for the repair of epigastric hernias, highlighting key steps and technical nuances to optimize surgical outcomes.
Methods: A 39-year-old male with no known comorbidities, past tobacco smoker and past surgical history of ORIF for distal radius fracture and treated H. pylori chronic gastritis presented with chief concern of 3-month history of pain and swelling over the epigastric region. Examination revealed 2 × 2 cm tender, reducible swelling over the epigastric region. CT scan showed fat containing ventral wall hernia situated 5 cm inferior to xiphoid bone and 8 cm superior to umbilicus. A small fat containing umbilical hernia was also noted.
Results: The patient underwent laparoscopic epigastric hernia repair with mesh. Intraoperatively, 1-cm epigastric defect was noted with preperitoneal fat as the content. Reduction of contents was achieved followed by primary repair and preperitoneal polypropylene mesh placement.
Conclusion: This video submission underscores the efficacy and safety of the laparoscopic approach, advocating its adoption as a preferred technique for epigastric hernia repair in suitable candidates.
Scientific Paper. Incisional Hernia Incidence following Laparoscopic versus Open Abdominal Surgery: an Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials
Victor Perim, João P. G. Kasakewitch, Diego L. Lima, Carlos A. Balthazar da Silveira, Diana Q. Nguyen
Objective: Incisional hernias (IH) are a frequent complication following open surgery. While minimally invasive surgery (MIS) is designed to enhance patient recovery through smaller incisions, contemporary quantitative evidence supporting its efficacy in reducing IH rates is sparse. This study aims to provide an overview of IH rates comparing open and MIS abdominal.
Methods and Procedures: Cochrane Central, Embase, and PubMed were searched for randomized controlled trials (RCTs) that compared open surgical approaches to MIS and reported incisional hernia incidence as a postoperative complication. RStudio Software was used for statistical analysis.
Results: From the initial 9,425 results, 27 studies involving 6,052 patients were included, of which 3,309 (54.7%) underwent MIS. Analysis revealed a significantly lower incidence of IH among patients who received MIS (RR 0.56; 95%CI 0.38–0.82). Subgroup analysis by surgery type indicated that bariatric (RR 0.23; 95%CI 0.075–0.707) and fundoplication surgeries (RR 0.1; 95%CI 0.018–0.545) were associated with a substantial reduction in IH rates. Conversely, surgeries such as nephrectomy, cholecystectomy, colorectal, cystectomy, and gastrectomy did not show a significant difference.
Conclusion: MIS is associated with a reduced incidence of IH in abdominal surgeries, particularly evident in bariatric and fundoplication procedures. These findings confirm the benefits of MIS in specific surgical contexts, highlighting its potential to decrease postoperative complications like IH. Further research focusing on comparing IH rates on open versus MIS approaches is warranted.
Scientific Paper. A Simple Reproducible Method of Measuring the Esophageal Hiatus and Its Potential Use in Hiatal Hernia Repairs
Hiley D. Cammock, Sarah E. Couch, Danial A. Malik, William Ralston, Jeremy Gaskins, Farid Kehdy
Objective: Esophageal hiatus closure during hiatal hernia repair is essential. Improper closure can lead to recurrence and high patient morbidity. Our aim is to introduce an easy and reproducible method of calculating the surface area (HSA) of the esophageal hiatus. Standardization of this value will enable surgeons to have an evidence-based approach for hiatal hernia closure during laparoscopic repair.
Methods and Procedures: We developed a measurement of the HSA of the esophageal hiatus corresponding to a right-angle triangle: Area = (1/2) Base*Height. The height was defined as the left crus of the diaphragm. The base was defined as perpendicular to the crus and tangential to the medial edge of the esophagus. The mean esophageal hiatus surface area was calculated from deceased patients without a hiatal hernia undergoing full autopsies and compared to patients undergoing laparoscopic repair.
Results: A total of 237 (37 cadaveric) hiatuses were measured. The median HSA defect in the cadaveric group was 1.97 cm2 with an interquartile range (IQR) of 1.87 cm2 (1.13–3.0 cm2) was significantly different compared to 5.0 cm2 with an IQR of 4 cm2 (3.5–7.5 cm2) in the operative group (P < .001). Multivariate linear regression demonstrated an overall significant positive correlation between esophageal hiatus surface area defect and the variables of age and weight but not with gender.
Conclusion: This study demonstrated a new reproducible method of measurement for esophageal hiatus. The significant difference between the 2 groups suggests that our formula can be utilized to develop a standardized value for the surface area of the esophageal hiatus.
Video. Robotic Type IV Large Hiatal Hernia Repair with Mesh
Objective: The indications for mesh reinforcement in paraoesophageal hernias are controversial. Our experience has shown satisfactory results in the routine use of mesh reinforcement without overt complications such as mesh erosion. Our research seeks to show our robotic surgical technique of pledgeted absorbable mesh paraoesophageal hernia repairs.
Methods and Procedures: We present a case of a 72-year-old female, with a history of symptomatic paraoesophageal hernia. Preoperative upper GI study and CT chest and abdomen showed a large paraoesophageal hernia with most of the stomach and pancreatic body in the hernia sac, with a partial gastric volvulus. Preoperative esophagogastroduodenoscopy demonstrated congestion of the fundus and erosions. The patient was taken to the OR electively for a robotic-assisted laparoscopic paraoesophageal hiatal hernia repair. The hernia sac was dissected, and the stomach and retroperitoneal contents were reduced to the abdominal cavity. The crura was approximated with barbed prolene sutures pledgeted with poly-4-hydroxybutyrate mesh. The angle of His was recreated by performing a gastropexy approximating the fundus of the stomach to the diaphragm and the esophagus. The procedure was uneventful. Postoperative upper GI study showed a patent esophagus and no signs of recurrence. The patient was discharged on postoperative day 3, tolerating a clear liquid diet.
Results: The video is about 8 minutes long and describes the preoperative, intraoperative, and postoperative course.
Conclusion: Our video provides a resource for those interested in learning a technique of paraoesophageal hiatal hernia repair with mesh.
Video. Robotic Combined Liver and Colorectal Resection with Microwave Ablation for Colorectal Liver Metastases
Parisa Yazdankhah Kenary, Ahmed Allawi, Sharona Ross, Alexander Rosemurgy, Iswanto Sucandy, Melissa Touadi
Objective: Robotic platform has become a standard method of practice for surgical management for colorectal and liver diseases in the United States. In cases such as combined liver and colorectal metastases at multiple loci, surgical resection is preferred. In this video, we describe our method of a feasible and safe technique for robotic combined liver and colorectal resection with microwave ablation for colorectal liver metastases.
Methods and Procedures: Patient is a 36-year-old man presenting with stage IV upper rectal cancer and FDG avid metastasis including 3 hypermetabolic lesions in liver. The CT scan revealed a decrease in size of rectal mass, and liver oligometastases. Rectum biopsy revealed T3 N1 rectal cancer. We dissected the upper rectum after a low anterior resection procedure. We then mobilized the right hemi liver, took down short hepatic vein branches, and performed partial resection of segment 4B, segments 7 and 8 ventral liver, and lateral segment 7 liver. We then performed microwave liver ablation of segment 7 and 8 under the guide of intraoperative ultrasound.
Results: The operative time was 9 hours with an estimated blood loss of 50 cc. Patient was discharged on POD 4, and 2-week and 3-month follow-up showed no evidence of disease. The pathology report was consistent with metastatic adenocarcinoma in liver segments 7 ventral and 7 dorsal, as well as adenocarcinoma of sigmoid colon 3.2 cm, with negative margins.
Conclusion: In conclusion, robotic combined liver and colorectal resection with microwave ablation for colorectal liver metastases is feasible and useful with excellent postoperative outcomes.
Video. Robotic Surgery in Trauma and Acute Care Surgery: Case in Point—the Ruptured Diaphragm
Leo I. Amodu, Owen Pyke, Venkata Kella, Jun Levine, Collin Em Brathwaite
Objective: Although robotic surgery has its origins in telepresence surgery and potential treatment of battlefield injury, the penetration into trauma and acute care surgery has been limited. Our objective was to highlight the utility of robotic surgery in a treating a patient with acute diaphragmatic rupture.
Methods and Procedures: The patient presented to the hospital with abdominal pain, nausea, bloating and eructation. Computed tomographic (CT) scan demonstrated an incarcerated paraesophageal hernia. Emergent operative repair using the robotic approach was undertaken. Herniation of an infarcted terminal ileum, appendix, and cecum through a left-sided diaphragmatic rupture was found. Using the robot, we lysed intraabdominal adhesions, reduced the hernia and repaired the defect in 2 layers. An ileocecal resection with end-ileostomy was performed. Upon further questioning postoperatively, the patient reported that she had experienced sudden left abdominal pain while practicing yoga on the day of the injury. She was discharged home on postoperative day 10. A planned robotic ileostomy closure was performed approximately 5 weeks after discharge from the index admission. A robotically sutured isoperistaltic anastomosis was created between the neo-terminal ileum and ascending colon. The ascending colon was anchored to the abdominal wall to prevent malrotation.
Results: The patient had an uneventful recovery. Recent CT scan this year (4.5 years later) showed an intact diaphragmatic repair.
Conclusion: Patients with acute traumatic diaphragmatic injury may be treated using robotic surgery if they are hemodynamically stable. The robotic platform should be considered more frequently as a viable option in acute care surgery.
★ Best General Surgery Video
Scientific Paper. Robotic Surgery in Carcinoma of the Rectum—the Experience of University Hospital “St. Marina”—Varna
Turgay Turgay Kalinov, Alexander Kamenov Zlatarov, Nikola Yordanov Kolev, Krasimir Dimitrov Ivanov
Introduction: Minimally invasive surgery is characterized by a number of advantages over conventional. The narrow space in the small pelvis is a technical challenge in low resections of the rectum. In these cases, robotic surgery has potential due to the articulation of instruments and excellent visualization.
Objective: To study the experience in robotic surgery for rectal cancer.
Materials and Methods: In the First Clinic of Surgery at the University Hospital “St. Marina”—Varna for the period December 2019 to April 2023, 68 robot-assisted resections of the rectum were performed with the surgical robotic system platform. The protocol for preoperative diagnosis includes FCS, histological verification, CT with contrast material, PET-CT.
Results: The mean age of the patients was 65 years, predominantly male (62.0% male, 37.9% female). The average BMI is 26 kg/m2. A total of 41 anterior resections of the rectum, 26 extirpations of the rectum, and 1 intrasphincter resection of the rectum were performed. The average operating time was 225 minutes. The average number of dissected lymph nodes was 11.6. Early postoperative results are similar to those of conventional and laparoscopic access. The docking time averaged 32.3 minutes (26–35 minutes) and the console time averaged 153 minutes. Three conversion was performed. The incidence of complications is 8.3%, Dindo-Clavien 3b: n = 3, Dindo-Clavien 3: n = 1.
Conclusion: The presented initial results demonstrate the possibilities of robotic surgery for rectal cancer, and the method is comparable to the results of a series of conventional and laparoscopic operations. The long-term oncological results are yet to be studied.
Scientific Paper. Comparative Analysis of Laparoscopic and Robotic Cholecystectomy: a Multi-Hospital Retrospective Cohort Study
Marvin Rhodes, Javier Otero, Summer Rochester, Andrew Schneider
Objective: Laparoscopic cholecystectomy has remained the gold standard approach of gallbladder surgery for nearly 2 decades. However, adoption of robotics for treatment of gallbladder disease continues to grow. Despite this growth, clinical outcomes regarding laparoscopic versus robotic cholecystectomy remain unclear.
Methods: We conducted a multihospital retrospective cohort study of patients who underwent cholecystectomy between August 1, 2021 and November 30, 2023. We compared demographic and clinical characteristics, surgical details, and postoperative outcomes between laparoscopic and robotic groups. The postoperative outcomes analyzed included conversion to open, bile leak, major duct injury, return to operating room, surgical site infection, blood transfusion, readmission, and death. Statistical analysis included χ2 tests, t-tests, Wilcoxon rank sum tests, and multivariable logistic regression.
Results: A total of 4,316 patients were included (3,736 laparoscopic, 580 robotic). Robotic surgery was associated with lower rates of conversion to open (P = .019) and bleeding requiring transfusion (P = .017). We also saw trends towards statistical significance for bile leaks, major duct injuries, surgical site infections, and 30-day return to operating room. Robotic approach was associated with a 5 minute longer average surgery time (P = .002). Using multivariable logistic regression analysis to account for preoperative differences between the 2 groups, robotic surgery was associated with a 62% decreased risk of any complication (OR = 0.38, 95% CI [0.20, 0.74]).
Conclusion: Robotic cholecystectomy demonstrates favorable clinical outcomes compared to laparoscopic cholecystectomy. These findings support the advantages of robotic assistance during cholecystectomy. To our knowledge, this represents one of the largest retrospective studies showing a clinical benefit from the robotic approach.
Video. Robotic Assisted Single-Incision Laparoscopic (SILS) Colostomy Reversal
Jonathan Velez Padilla, Jetsen Rodriguez Silva, Robert Bennett
Objective: Stoma reversal surgery can result in significant morbidity and mortality. Traditionally, it required a midline laparotomy. Minimally invasive techniques, including laparoscopic and single incision laparoscopic (SILS) methods, have shown improved outcomes such as reduced postoperative pain, shorter hospital stays, faster recovery, and better cosmetic results. This publication presents the adaptation of SILS technique using a robotic surgical platform for colostomy reversal, which may overcome the challenges of traditional laparoscopic and SILS Hartmann’s reversal, such as adhesions and instrument proximity issues.
Methods and Procedures: A robotic single-incision end colostomy reversal was performed on a 59-year-old male with a history of colonic perforation following a motor vehicle collision, requiring colon resection. He also had a previous Hartmann’s reversal and parastomal hernia repair after perforated diverticulitis. The surgery was conducted through the existing colostomy site, using a purple hand-access laparoscopic system for 3 robotic trocars. A combination of blunt and sharp dissection as well as minimal monopolar cautery was used.
Results: The procedure was successfully completed in 194 minutes. The patient's recovery was uneventful, and he was discharged on postoperative day 2 with no complaints at follow-up.
Conclusion: Robotic SILS Hartmann’s reversal via the colostomy site is safe and feasible, offering an effective alternative to traditional open, laparoscopic, and SILS reversal methods. This approach avoids additional incisions and dense midline adhesions from previous procedures. The use of flexible-tip instruments in robotic SILS can overcome difficulties associated with straight-tip laparoscopic instruments, enhancing the overall benefits of minimally invasive surgery.
Video. Robotic Common Bile Duct Exploration and Cholecystectomy
Emanuel A. Shapera, Melissa Touadi
Objective: Concomitant common bile duct exploration with cholecystectomy offers patients presenting with calculous obstructive jaundice a single efficient procedure that can minimize hospital stay and cost. However, the rise of endoscopic technology and challenges in performing laparoscopic common bile duct exploration has sidelined this useful strategy. The waxing use of robotic technology promises to increase the uptake of concomitant bile duct exploration and cholecystectomy once more.
Methods and Procedures: This video presents the use of a ureteroscope with a simple working channel during a robotic cholecystectomy in a patient with a history of an open gastric bypass to decompress an obstructed common bile duct, overcoming the difficult anatomy and scar tissue that straight stick laparosocpy would have struggled against.
Results: A 73-year-old woman presented with acute cholecystitis and obstructive jaundice. MRPC demonstrated a distal common bile duct obstruction. She was taken to the operating room and underwent a robotic cholecystectomy and common bile duct exploration, decompressing her biliary system. The operation took 1 hour and 10 ml of blood loss. She was discharged home the next day with improvement in her bilirubin levels.
Conclusion: The robotic platform’s wristed instruments and superior optics increases technical success in a reoperative field with altered anatomy; the gallbladder and biliary tree were safely exposed, permitting bile duct exploration. A simple ureteroscope with a guidewire successfully decompressed the patient. We hope other surgeons can utilize this simple and reproducible strategy to expedite patient care with calculous common bile duct obstruction.
Scientific Paper. Artificial Intelligence Trends in General Surgery Publications: Fad or Future?
Objective: Recent advances in artificial intelligence (AI) have significantly impacted the medical field. This study evaluates the trends in AI reporting in the general surgery literature with a focus on the most recent years (2021 to June 2024).
Methods and Procedures: PubMed was queried with combinations of keywords including “artificial intelligence,” “AI,” and “general surgery” to retrieve relevant citations. Citations were categorized into 3 date ranges: 1950 to June 2024, 2000 to June 2024, and 2021 to June 2024. The number of relevant citations published annually was reviewed and modeled to analyze trends.
Results: A total of 14,699 citations were retrieved since 1950 based on the search criteria. Of these, 14,224 citations (96.77%) were published since 2000. From 2021 through June 2024, 5,590 citations were published, accounting for 38.03% of the total. The number of publications totaled 1,449 (2021), 1,439 (2022), and 1,602 (2023). In the first half of 2024 (January to June), there have been 1,100 published citations. The complete annual data from 1950 to 2023 was modeled exponentially, yielding an R2 value of 0.9886, indicating a strong fit. From 2000 to 2023, the number of published citations increased from 75 to 1602 (2036.00%).
Conclusion: The integration of AI into general surgery is evidenced by a notable rise in publications. As technological advancements progress at a dramatic pace, AI is expected to play an increasingly significant role in surgical workflows. This rapid growth suggests that the adoption of AI is still in its infancy, with a promising future for further development and widespread application.
Video. Laparoscopic Median Arcuate Ligament Release and Celiac Ganglion Neurectomy: a Video Demonstration of the Case Report
Avian Pham, Nikhilesh Chitibomma, Courtney Horton, Francis Essien, Xiu-Jie Wang
Introduction: Median arcuate ligament syndrome (MALS) causes chronic abdominal pain due to the median arcuate ligament compressing the celiac artery and celiac plexus. This rare condition affects about 2 in 100,000 people. Treatment generally involves decompression of the celiac trunk. This presentation showcases a laparoscopic technique for median arcuate ligament release and highlights key intraoperative events.
Methods and Procedures: A case of a 70-year-old woman with PMH of hypertension, hyperlipidemia, diverticulitis, GERD, depression, anxiety, anemia, CKD, COPD, and CHF was admitted with generalized epigastric pain. She has experienced intermittent postprandial pain since her 30s, leading to frequent hospitalizations and no relief from a prior cholecystectomy. CTA revealed focal narrowing and irregularity at the celiac artery’s origin, suggesting celiac artery compression syndrome due to the median arcuate ligament. A summarized video illustrates the laparoscopic approach and intraabdominal findings.
Results: During the procedure, the left gastric artery was initially used to locate the celiac artery. The approach was later adjusted to follow the left and right crura, dissecting caudally along the aorta’s anterior wall to reach the origin of the celiac artery. The patient’s recovery was uneventful, with immediate pain relief and no issues with oral intake. POD-1 angiogram confirmed a patent celiac artery with no significant stenosis or compression during the inspiration and expiration phases.
Conclusion: While MALS is a diagnosis of exclusion, surgical intervention can offer significant relief for patients with chronic symptoms that severely affect their quality of life. A minimally invasive approach, executed by an experienced surgeon, ensures quicker recovery and considerable symptomatic relief.
Video. Laparoscopic Hysterectomy for Large Fibroid Uterus
Pengfei Wang, Denize Gallapher, Liasian Uzianbaeva, Alireza Mehdizadeh, Noemi Hughes
Objective: To demonstrate the outcome and surgical techniques in laparoscopic hysterectomy for large fibroid uterus.
Methods and Procedures: The data of 73 cases of laparoscopic and robotic hysterectomy, performed by Dr. Wang in one year, were collected. All cases were divided into 2 groups by the cut-off number of 500 g in specimen weight. In this video, we also presented a laparoscopic hysterectomy on a patient with about 40-week size uterus. The final specimen weight was 3,064 g.
Results: The specimen of 26 cases were more than 500 g, with OR time 228.85 ± 53.04 minutes, EBL 127.88 ± 69.76 mL and average of one day hospitalization. There was no incidence of blood transfusion or conversion to laparotomy. For the case that was presented in the video, the OR time was 5 hours, EBL was 50 cc and the hospital stay was 1 day.
Conclusion: Minimally invasive hysterectomy on large uterus is feasible, safe, and beneficial.
Scientific Paper. The Feasibility and Benefits of Hysterectomy for Large Uterus by Minimally Invasive Surgery
Pengfei Wang, Liasian Uzianbaeva, Noemi Hughes, Alireza Mehdizadeh
Objective: To demonstrate the feasibility and benefits of hysterectomy for large uterus by a minimally invasive surgical approach. We demonstrate and explain specific techniques applied during surgery.
Methods and Procedures: Data from of 73 cases of laparoscopic and robotic hysterectomy were collected from one institute over a 1-year study period. All cases were performed at BronxCare Health System by one surgeon (Dr P.W.) between September 2022 to September 2023. A uterine weight of 500 g was used as a threshold to divide the cases into 2 groups. The estimated blood loss (EBL in ml), operative time (in minutes), length of hospital stays (in days) and perioperative complications were compared between the 2 groups. χ2 test and Student’s t-test were used for the statistical analysis.
Results: There was no statistically significant difference in length of hospital stay between the 2 groups (<500 vs >500 g). Only 3 of 73 patients were hospitalized for more than one day. There was a statistically significant difference in the EBL between the 2 groups (78.19 ± 43.8 vs 127.88 ± 69.76 ml, P < .01). There was also a statistically significant difference in operative time between the 2 groups (180.68 ± 48.36 vs 228.85 ± 53.04 minutes, P < .01). There were no instances of conversion to laparotomy, intraoperative or postoperative blood transfusion. There were 2 cases of bladder laceration, both in the group with uterine weight exceeding 500 g.
Conclusion: With advanced surgical skills and adoption of several specific techniques, hysterectomy for large uterus can be performed safely and efficiently by minimally invasive surgery.
Scientific Paper. Successful Implementation of Same Day Discharge after Minimally Invasive Hysterectomy and Myomectomy in A Low Resource Safety Net Hospital
Nuha Khalfay, Hasmik Adetyan, Michelle Han
Objective: The study purpose was to evaluate the success and safety of same day discharge (SDD) following minimally invasive hysterectomy and myomectomy at a safety net hospital. While there is ample evidence for the safety of SDD, there is less literature on its success in underserved populations. A quality improvement project was conducted at an academic safety net hospital in which the population is 50% Spanish-speaking, 66% Latinx, 70% have public insurance, and 25% are uninsured.
Methods and Procedures: Patients undergoing hysterectomy or myomectomy from June 2020 to February 2022 were included. Preoperatively, patients were counseled about discharge, safe housing/transportation were ensured, and comorbidities were addressed. Intraoperatively, medications were given to minimize nausea and pain. Postoperatively, the surgeon performed a telephone visit the day after.
Results: A total of 185 patients underwent surgery. Previous to June 2020, 100% of these patients were admitted for overnight stay. SDD success in June 2020 was 63% (5/8) with gradual increases over time. SDD success maintained an average of >95% from August 2021 to February 2022. Postoperative day 1 phone calls per month ranged from 67% to 100%. During the 22-month duration of the project, the overall SDD success rate was 77% (143/185); 92% (132/143) had postoperative telephone visits, and only one patient (0.54%) was readmitted.
Conclusion: There is limited data on the details of SDD protocols at safety-net hospitals. This QI project demonstrates that SDD is possible and safe in this environment. Future practices will need to assess social determinants of health that affect recovery and SDD success.
★ Best Gynecology Scientific Paper
Scientific Paper. Racial and Social Determinants of Health Disparities in Post-Operative Pain following Minimally Invasive Gynecologic Surgery
Objective: To determine whether postoperative pain management following gynecologic laparoscopy differed based on patient race or socioeconomic status at a single institution.
Methods and Procedures: We performed a retrospective cohort study of all patients who underwent laparoscopy for benign gynecologic indications from January 1, 2016 to January 1, 2023 at a single academic institution. The average morphine milligram equivalent (MME) prescribed following each surgery was calculated and classified by age, race, ethnicity, BMI, type of insurance, and surgery class. Associations were estimated by univariable analysis and multivariable logistic regression.
Results: We identified 3,376 patients who met inclusion. Case characteristics were similar between all groups. We found no difference in MME prescriptions based on patient age, BMI, or type of insurance. Women undergoing major surgery were given higher doses of opiates upon discharge than those undergoing minor surgery. White and black patients were discharged with significantly higher doses of opioids when compared with Hispanic patients (P = .01).
Conclusion: Studies published in the obstetric and pediatric populations have found disparities in postoperative pain management in nonwhite patients and patients of lower socio-economic status. To the best of our knowledge, no study of this kind has been performed in patients who have undergone laparoscopic surgery for gynecologic indications. Our results indicate that disparities exist in postoperative pain prescription practices at our institution. These findings could influence prescribing habits in providers to help improve these disparities in our population, and highlights the importance of establishing more uniform, evidence-based guidelines for postoperative pain management.
Scientific Paper. Discordance between Clinical Endometriosis and Pathological Correlation—the Gap Widens!
Objective: To identify the area of research which may simplify the hisopathological correlates and biomarkers which may signify endometriosis rather than continue looking for “typical endometriosis” in histopathological specimens obtained during surgery.
Methods and Procedures: A retrospective study of cases of endometriosis diagnosed at laparoscopy during the past 5 years, from the author's data will be presented. OR findings of endometriotic lesions or indirect evidence thereof (like de novo adhesions) will be discussed along with Pathological Correlation- at a tertiary care hospital in New York. The common biomarkers which indicate endometrial stroma and epithelial markers where “atypical endometriosis” or occult microscopic endometriosis (OME) is suspected and their results as compared to clinical/visual presentation will be reviewed.
Results: In the author's data there is approximately 40% correlation and 60% discordance between clinical and pathological findings.
Conclusion: A need for a deeper investigative histological methods is required in this enigmatic disease known as endometriosis. The clinical-histological grading currently in use is getting outdated rapidly as tissue biomarkers become available and a demand for definitive diagnosis of “atypical endometriosis” and OME are on the uprise. Research in this field is imperative and a concomitant education of pathologists and clinicians is necessary to treat patients effectively.
Video. Fertility Sparing Management of Cesarean Scar Ectopic Pregnancy (CSEP)
Esra Cetin, Panagiotis Cherouveim, Manuel Merida, Celine Sooknarine, Macy Hudson, Khaleel Ahmad, Pooja Patel, Saqib Ahmad
Study Objective: To demonstrate the importance of a combined surgical approach for the treatment of cesarean scar ectopic pregnancy (CSEP) by combining laparoscopic resection with suction and curettage.
Methods and Procedures: This is a case report and review of the literature on the treatment of CSEP. Robotic-assisted CSEP evacuation, isthmocele repair, and dilatation and curettage (D&C) under the guidance of laparoscopic visualization.
Measurements and Main Results: In this study, we implemented a combined surgical approach combining Robotic-assisted CSEP evacuation, isthmocele repair, and D&C facilitated by laparoscopic visualization. Intraoperative complications were minimal, with no incidences of major vascular injury or uterine rupture observed.
Conclusion: Our study demonstrates the feasibility and favorable outcomes of combined robotic-assisted CSEP evacuation, isthmocele repair, and D&C guided by laparoscopic visualization, supplemented by vasopressin administration. This combined surgical approach facilitates effective CSEP management and addresses concurrent pathologies such as isthmocele. Additional advantages of the combined approach include minimizing EBL, hysterectomy risk, hospital stay, and recurrence risk, all within a comparable OR time which in our case was 44 minutes. The minimal intraoperative complications and favorable postoperative results underscore the safety and efficacy of this comprehensive strategy. Further research with larger cohorts and long-term follow-up is warranted to validate these findings and establish the efficacy of a combined surgical approach as a standard of care for patients with CSEP to optimize their operative and future fertility outcomes.
Video. Robotic Myomectomy in a Unicornuate Uterus with Broad Ligament Myoma
Pooja Uppalapati, Michael L. Nimaroff
Objective: To provide an overview of fibroid location. To discuss pertinent anatomical landmarks and a clinical case of robot-assisted laparoscopic myomectomy. To demonstrate surgical technique of myomectomy with broad ligament extension in a unicornuate uterus.
Methods and Procedures: Case report from academic institution of a robotic myomectomy.
Results: Patient is a 37-year-old G1P0010 desiring myomectomy for history of uterine fibroids and infertility. She has MRI confirmed left unicornuate uterus and was referred by her infertility specialist. She had undergone IVF with a tested embryo and a prior cycle failed. She underwent robotic assisted laparoscopic myomectomy. During her procedure, there was a concern for a broad ligament myoma on the left side however dissection proved a false broad ligament myoma. All fibroids were removed and excellent hemostasis was noted at the end of the procedure.
Conclusion: Preoperative MRI is useful in identifying uterine contours and relation of fibroids to normal myometrium. This modality is especially useful in identifying Mullerian anomalies that need to be considered during surgical planning and have fertility implications. For true or false broad ligament myomas, a variety of surgical techniques and dissection should be employed. Careful dissection of the vesicouterine peritoneum, retroperitoneal entry, and identification of the ureter is key in preventing injury. Identifying ovarian and uterine vessels will decrease blood loss. Traction and countertraction should be employed to successfully enucleate a fibroid from a potentially vascular area in the case of broad ligament myomas. Both true and false broad ligament myomas can be safely removed using these laparoscopic surgical techniques.
Scientific Paper. Transvaginal Mesh Compared to Native Tissue Repair in the Surgical Treatment of Pelvic Organ Prolapse: a Review of the Literature
Objective: To review and assess the current literature within the past 10 years on the use of native tissue repairs (NTR) versus mesh for anterior compartment defects and provide evidence-based recommendations on safety and durability derived from recent data analysis.
Methods: A PubMed keyword search was conducted using [native tissue repair] and [mesh] and [pelvic organ prolapse] from 2003 to 2024 including non-English language publications.
Results: The keyword search yielded 248 publications of which the most recent, ie, studies conducted within the last 10 years were included in the literature review. Of the 218 most recent studies, based on investigator (I.M.V.) discretion as to clinical relevance and significance, 15 were included in the final analysis for presentation.
Conclusion: Since the 2019 FDA ban on the sale and distribution of surgical mesh for the treatment of anterior compartment prolapse, there has been a resurgence in interest in NTR as an alternative approach. Although many of the surgical techniques such as SSLF-Richter have been previously described, their long-term anatomical and functional outcomes are still somewhat unknown and therefore, further studies are required to assess their suitability and efficacy in the treatment of pelvic organ prolapse (POP).
Video. Contained Excision Technique in A Robot-Assisted Cytoreduction for Recurrent Ovarian Cancer
Hadi Erfani, Esra Demirel, Farr Nezhat
Objective: The study aims to evaluate the effectiveness and safety of a contained excision technique utilizing a robot-assisted approach for the cytoreductive surgery of a recurrent ovarian carcinosarcoma in a 74-year-old patient.
Methods and Procedures: A minimally invasive secondary cytoreductive surgery was planned for a patient with a history of stage IIIa ovarian carcinosarcoma, who presented with local recurrence. The procedure began with a global survey of the intraperitoneal cavity with no visible tumors were found in the abdominal area. Extensive lysis of adhesion was performed to optimize visualization in the pelvis, where the recurrent tumor was identified on the left pelvic sidewall. Two key principles were followed: extensive dissection of the surrounding tissue to access the tumor base and avoidance of direct tumor handling.
Results: The recurrent tumor was successfully removed without direct contact using the contained excision technique. The procedure resulted in minimal estimated blood loss (50 cc), no complications, and the patient was discharged on the same day. Histologic and molecular evaluation of the excised mass confirmed poorly differentiated carcinoma. Pelvis remained disease free following surgery. Patient is receiving adjuvant systemic treatment following surgery and for suspected liver tumor implants.
Conclusion: The contained excision technique, as part of a robot-assisted surgery for recurrent ovarian cancer, is feasible and should be considered to reduce the risk of tumor spillage. The successful execution of this technique with minimal blood loss and no complications supports its adoption in suitable cases.
Video. Step-by-Step Approach to an Intact Cystectomy of a Large Dermoid Ovarian Cyst
Nina Nguyen, Youssef Youssef, Lindsey Michel
Objective: To demonstrate the surgical technique of an intact cystectomy of a large dermoid ovarian cyst.
Methods and Procedures: This is a case of a 32-year-old G2P1011 with intermittent right sided pelvic pain who was found to have an 11-cm right ovarian dermoid cyst on MRI. Laparoscopic right ovarian cystectomy was performed with the following video footage illustrating the surgical steps with narrated description.
Results: A pathologically confirmed ovarian dermoid cyst was enucleated intact and subsequently decompressed in an endocatch bag. Given the characteristic viscous, sticky material within dermoid tumors, cyst rupture can make a successful cystectomy increasingly challenging. We identified key steps to facilitate an intact cystectomy by avoiding unintentional cyst rupture:
Create a longitudinal incision along the antimesenteric axis of the mass
Identify the plane between the cyst wall and ovarian cortex
Extend initial longitudinal incision along the full length of the cyst
Minimal use of direct traction on the thinned ovarian cortex
Alternating blunt and sharp dissection with use of a laparoscopic rolling technique
Judicious use of thermal energy to minimize damage to ovarian follicles and preserve reproductive potential
Use of bipolar energy near vascular ovarian hilum to minimize blood loss and release cyst intact
Conclusion: Laparoscopic cystectomy of large dermoid cysts is safe and feasible. While this may become more challenging in the setting of cyst rupture, following a systematic approach with these key steps can facilitate intact enucleation in a reproducible fashion.
Scientific Paper. Peritoneal Washings to Detect Myometrial Cell Spillage during Minimally Invasive Hysterectomy with Manual Morcellation in A Contained Extraction System: a Pilot Study
Mostafa Eyada, Cecilia Clement, Gokhan Kilic, Karren Lewis, Jerome Yaklic, Russell Snyder, Lucy Villarreal, Truong Nguyen
Objective: To determine if there is any endometrial or myometrial cell spillage during minimally invasive hysterectomy with manual morcellation in a contained extraction system.
Methods:
Design: Prospective cohort study.
Setting: University of Texas Medical Branch, an academic center.
Patients: Patients undergoing laparoscopic or robotic hysterectomy for large fibroid uterus between August 2023 and April 2024.
Intervention: Three peritoneal washings were collected at designated points in the surgery: First washing (W1) was collected once the peritoneal cavity was accessed laparoscopically second washing (W2) was collected after completion of hysterectomy, and third washing (W3) was collected “after” contained manual morcellation of the uterus. Three cytospin slides were prepared from each washing and stained with Romanowsky and Papanicolaou stains. Caldesmon IHC stain was used to confirm presence of smooth muscle cells if any was detected. If any washing was positive for myometrial cells, the number of cells was counted and reported per high power field (HPF).
Results: Twenty-five patients were included in the analysis. The median age was 43.5 years (range, 28–52), the median weight of the uterus was 388 g (range, 191–831). Contained manual morcellation was done transvaginally in 22 subjects (88%), and transabdominally through a mini laparotomy incision in 3 subjects (12%). Two subjects (8%) had myometrial cell spillage detected in the peritoneal washings. The first case; spillage was detected only in W2, spilled cells count was 10–20 cells/HPF, morcellation was done transvaginally and uterus weighed 464 g. The second case; spillage was detected only in W3, spilled cells count was 10–20 cells/HPF, morcellation was done transvaginally and uterus weighed 242 g.
Conclusion: Contained manual morcellation of large fibroid uterus appears to be effective technique to minimize tissue dissemination during minimally invasive hysterectomy; however, spillage still can occur before morcellation from manipulation of the large uterus.
Video. Minimally Invasive Hemihysterectomy with Hemivaginectomy for the Treatment of Recurrent Vaginal Septum in OHVIRA Syndrome
Objective: Obstructed hemivagina and ipsilateral renal agenesis (OHVIRA) syndrome is a rare congenital anomaly affecting 0.1–3.8% of the female population. First line management is with vaginal septum excision however when recurrence occurs management options vary. The objective of this video is to demonstrate in patients with OHVIRA syndrome and recurrence of vaginal septum, hemihysterectomy with hemivaginectomy is a reasonable definitive option and can be completed minimally invasively.
Methods and Procedures: A 16-year-old female with OHVIRA syndrome and recurrence of vaginal septum after resection is presented. Recurrence occurred 6 months after the initial surgery. She underwent subsequent diagnostic laparoscopy and attempted re-excision of the vaginal septum which was unsuccessful and ultimately opted for definitive management with minimally invasive robot-assisted hemihysterectomy and hemivaginectomy.
Results: The patient underwent uncomplicated robot-assisted hemihysterectomy and hemivaginectomy and recovered well without complications.
Conclusion: Although vaginal septum excision is the mainstay of treatment in most cases and recurrence is rare, minimally invasive hemihysterectomy with hemi-vaginectomy is a reasonable and definitive option after recurrence or when septum excision cannot be performed safely.
★ Carl J. Levinson Award for Best Video
Video. Case Series: Single-Port Hysterectomies of Large Uteri
Objective: Laparoscopic hysterectomy is a common gynecologic surgical procedure, and the single-port approach has become increasingly adopted. However, there is a lack of data regarding performing this procedure on large uteri, especially in the United States. This study aims to demonstrate the single-port approach for laparoscopic hysterectomies of large uteri.
Methods and Procedures: This case series demonstrates 3 benign single-port hysterectomies performed on large uteri by a single surgeon from April 2017 to December 2023.
Results: All 3 cases involving uteri weighing 1,500–3,050 g were successfully performed using a single umbilical port and the extracorporeal C-incision tissue extraction technique. There were no complications.
Conclusion: Single-port hysterectomies on large uteri can be done safely and can be considered.
Video. Laparoscopic Drainage of a Tubo-Ovarian Abscess
Samantha Kegel, Gregory Lewis, Chanda Reese
Objective: To highlight the minimally invasive management of a tubo-ovarian abscess.
Methods and Procedures: This is a video case presentation of a 27-year-old G2P1011 patient who presented with abdominal pains, nausea, vomiting, and vaginal discharge. Her vital signs were stable, and she had an elevated white blood cell count. A CT scan and pelvic ultrasound both demonstrated complex enlargement of the right adnexa measuring 8.3 × 7.2 × 6.8 cm, suspicious for a right tubo-ovarian abscess. An IUD was noted to be displaced in the lower uterine segment. The patient was started on IV antibiotics, and deemed a poor candidate for IR drainage. She was subsequently taken to the operating room for laparoscopic exploration.
Results: Intraoperatively, dense adhesions were noted involving the omentum, right adnexa, and right pelvic sidewall. There was attenuation of the normal pelvic anatomy. The omentum was dissected off the right adnexa using blunt dissection and hydro-dissection. After adhesiolysis, attenuation of the right round ligament was noted. The abscess cavity was explored and purulent material suctioned. Copious irrigation was performed. Hemostasis was achieved by compression sutures between the defect in the broad ligament and the round ligament using barbed suture. A Jackson-Pratt drain was then placed. The IUD was removed hysteroscopically. The patient was discharged on postoperative day 2. At her postoperative visit the patient was doing well and remained asymptomatic.
Conclusion: Laparoscopic drainage of a tubo-ovarian abscess is an effective minimally invasive option for patients with large abscesses or those who have failed medical therapy.
Video. N-Methyl-D-Aspartic Acid Receptor Antibody Encephalitis Due to Ovarian Teratoma
Objective: Anti-NMDA receptor encephalitis is an autoimmune encephalitis with antibodies to NR1 or NR2 subunits of the NMDA receptor. It is commonly associated with ovarian teratomas which are present in 44% of female cases. The objective of this video is to demonstrate the critical role of the gynecologic surgeon in the treatment of anti-NMDA receptor encephalitis.
Methods and Procedures: A 29-year-old female with anti-NMDA receptor encephalitis is presented. She was transferred to a tertiary care center after presenting with psychosis, altered mental status, and seizures. Pelvic imaging revealed the presence of an adnexal cystic lesion and so ovarian teratoma-related anti-NMDAR encephalitis was suspected.
Results: The patient underwent laparoscopic unilateral sapling-oophorectomy. Following surgery, neuropsychiatric symptoms improved although postoperative course was initially complicated by factors related to the critical progression of the disease prior to surgery. She went on to make a full recovery to cognitive baseline and was discharged to inpatient rehab on hospital day 46.
Conclusion: Surgical removal of ovarian teratoma if present in patients with anti-NMDA receptor encephalitis is crucial to treatment. Studies suggest that early surgical intervention significantly improves neuropsychiatric symptoms, decreases recurrence, and is associated with more frequent complete recovery.
Video. The Use of the Uterine Artery for Bladder Flap Dissection
Sonia M. Koshy, Taralyn C. Sowby, Emery M. Salom
Bladder Flap dissection remains one of the most difficult portions of a hysterectomy and a common site of surgical injury. Incidental cystotomy rates for hysterectomy is as high as 2.4%, with predisposing risk factors including cesarean section, pelvic adhesions, and vaginal hysterectomy. Rates of vesicovaginal vaginal fistulas were up to 5.9% following cystotomies. For this reason, standardized method for identifying the bladder is crucial in order to avoid injury. We will demonstrate bladder flap dissection in both uncomplicated hysterectomy and in Stage IV endometriosis with extensive adhesions.
Video. Laparoscopic Resection Deep Infiltrating Endometriosis Anterior Vagina
Alexander Matthaeus, Elizabeth Ball, Grace Janik
Objective: Vaginal endometriosis is an underreported form of deeply infiltrating endometriosis which is rarely located anteriorly. This video demonstrates a laparoscopic approach to extensive, severely symptomatic deep infiltrating anterior vaginal endometriosis.
Methods and Procedures: Case report of rare case of anterior deep infiltrating vaginal endometriosis.
Results: Laparoscopic excision of deep infiltrating anterior vaginal endometriosis by laparoscopic approach with amelioration of symptoms and successful pregnancy.
Conclusion: Anterior deep infiltrating endometriosis is rare with symptoms that can include severe dyspareunia, dyschezia, and dysmenorrhea. Massive vaginal bleeding can occur. Laparoscopic resection aided by vaginal palpation is able to remove the disease and resolve symptoms. Preservation of the uterus and pregnancy is possible. There is limited data on option of vaginal delivery.
Video. Role of Indocyanine Green (ICG) in Delineating Ureter in Difficult Pelvic Procedures
Nutan Jain, Vandana Jain, Sakshi Srivastava
Objective: To evaluate the effectiveness of indocyanine green (ICG) in delineating ureters during complex pelvic surgeries, especially in cases with extensive adhesions due to conditions such as endometriosis, repeat surgeries, and adhesions due to previous septicaemia.
Methods and Procedures: In patients suspected of severe pelvic adhesions based on history, pelvic examination, and transvaginal ultrasound, we employed ICG to highlight the ureters. One vial of ICG was reconstituted with 10 ml of distilled water. During cystoscopy, ureteral catheters were inserted, and 2 ml of ICG was injected. The surgical procedure commenced, and the ureters were visualized due to their fluorescent appearance in overlay mode. Near-infrared (NIR) imaging was also utilized, which effectively highlighted the hydro-ureter. The fluorescence of the ureters appeared immediately post-ICG injection without any waiting time.
Results: ICG was found to be safe, with no idiosyncratic reactions and no renal, or hepatic toxicity. Over 7 years and approximately 400 cases, the laparoscopic delineation of ureters using a 2 ml dosage of ICG was consistently effective. In the most recent 50 cases, we reduced the dosage to 1 ml without any loss of fluorescence. The overall fistula rate was minimal, with only one case reported of post hysterectomy fistula and in that case there was a malfunction in the camera system fluorescence mode.
Conclusion: The use of ICG in complex adhesiolysis significantly enhances the safety and ease of the procedure for surgeons by clearly delineating the ureters, thereby mitigating the risk of inadvertent injury. The ureters show up themselves the surgeons do not have look for them.
★ Harrith M. Hasson Award for Best Presentation Promoting Education or Training
Video. Placental Site Nodule in Cesarean Scar Isthmocele: a Robot-Assisted Laparoscopic Repair
Objective: Placental site nodule (PSN) is a rare benign remnant of intermediate trophoblastic cells in uterine or extrauterine sites, such as a cesarean scar defect, or isthmocele. There are several surgical approaches described for isthmocele repair, however, no surgical approach has been identified as superior. For desired surgical management and uterine conservation, laparoscopic repair can be considered. The objective of this video is to demonstrate a minimally-invasive robot-assisted laparoscopic resection of a PSN within an isthmocele.
Methods: A 39-year-old female with pelvic pain and a history of one prior cesarean section was found to have a cesarean scar defect. She preferred uterine-conserving treatment and opted for robot-assisted laparoscopic repair. Postoperative ultrasound revealed resolution of isthmocele and symptoms resolved after 6 weeks.
Results: The patient underwent uncomplicated robot-assisted isthmocele repair. Surgical pathology of the resected scar revealed a PSN. PSN is rarely seen clinically, however, can masquerade on ultrasound as other etiology including polyps or scar defects.
Conclusion: Although there is no superior surgical technique currently described for isthmocele repair, a minimally-invasive laparoscopic approach is safe and effective and led to resolution of symptoms. Further research is needed to better understand the development of PSNs, how suture technique at the time of C-section impacts the development of an isthmocele, and if one surgical approach leads to superior outcomes over another.
★ Best Gynecology Video
Video. Robot-Assisted Laparoscopic Hysterectomy in Large Element Myomatosis at 23 Weeks
Miguel A. Caceres, Carlos E. Vargas, Alberto De Abate
Objective: Large elements uterine myomatosis is considered to be a uterus larger than 250 g. Robotic hysterectomy is presented as an advanced surgical option for the treatment of this condition. Through video, analyze the approach to a 24-week large element myomatosis with a robotic surgical system, highlight its safety and effectiveness, reduction in blood loss and faster recovery.
Methods and Procedures: This is a descriptive video of the surgical strategy for a complicated hysterectomy of a 24-week size uterus with a robotic surgical platform. We summarize the 24-week robotic hysterectomy for myomatosis in 7 steps:
Palmer’s incision point is the technique to introduce optical lens and plan surgery under these conditions.
Abdominal incisions to introduce trocars are adapted to the patient in this particular scenario.
Liberation of adhesions that obstruct visibility of the optical lens.
Docking of the robotic arms.
Dissection, sealing, cutting of round ligaments, opening of broad ligaments, uterine arteries, colpectomy, and infundibulopelvics ligaments.
The vaginal cuff is closed with barbed sutures.
Minilaparotomy of 6 cm was use for a surgical piece extraction.
Results: This is the largest myomatosis recorded with this robotic system so far. Piece: 1,391 g, blood loss: 125 cc.
Conclusion: Robot-assisted laparoscopic hysterectomy is a safest and effective option for the treatment of large uterine fibroids, minimizing blood loss and improving precision in surgical dissections. The patient benefits of a fast recovery.
Video. Fertility Sparing Resection of Severe Vaginal Deep Endometriosis
Zoran J. Pavlovic, Valerie C. Nemov, Emad Mikhail
Objective: To describe a reproducible, step-by-step technique for excising vaginal deep endometriosis in patients who desire future fertility.
Methods and Procedures: Our patient is a 34-year-old female G1P1001 who presented with chronic pelvic pain, dyspareunia, and dysmenorrhea with a history of an uncomplicated cesarean section. Transvaginal ultrasound and MRI both revealed extensive deep endometriosis, with a large nodule invading the posterior fornix and rectum. Vaginoscopy was first performed to visualize the lesion and assess its invasiveness into the posterior fornix. Then, via a minimally invasive technique, the medial pararectal spaces were dissected and opened bilaterally followed by dissection of the rectovaginal space to isolate the rectum. The large endometriotic nodule was bisected, with half invading the anterior rectum and half invading the vagina. Next, colorectal surgery resected the affected portion of the rectum. The endometriotic lesion invading the posterior vagina was then resected, followed by resection of any residual lesions at the margins to prevent disease recurrence. Finally, the colpotomy was closed and reanastomosis of the rectum was performed.
Results: In a patient desiring fertility sparing surgery, deep endometriosis invading the vaginal canal and rectum was successfully resected while also preserving the patient’s normal anatomy.
Conclusion: Vaginal endometriosis is an underappreciated and underrepresented form of endometriosis and can be challenging to diagnose and treat, yet it is often a marker of more advanced disease. The surgical technique we present offers a treatment option for women with deep vaginal endometriosis that could provide both symptomatic relief and help achieve future fertility goals.
MULTISPECIALTY SCIENTIFIC PAPERS & VIDEOS
Scientific Paper. Natural Orifice Surgery—an Emerging Discipline
Objective: In 2026, the New European Surgical Academy established Europe’s first “Natural Orifice Surgery” working group. Comprising leading surgeons across diverse disciplines, the group’s primary aim was to advance the development of scarless surgical procedures and to follow the various stages of progress, alongside the challenges.
Methods and Procedures: Anatomical and preclinical studies evaluating the feasibility of Trans Douglas and Trans Oral operations were conducted at the University Hospital of Rotterdam. The findings indicated that the Douglas Pouch in women allows for the utilization of instruments up to 25 mm in diameter without causing any damage. The sublingual approach to the Thyroid was successfully demonstrated with minimal complications. Initial clinical studies were undertaken, with Trans-Douglas surgeries performed as hybrid operations due to the unavailability of designed instruments, while transoral thyroidectomy is already widely employed through endoscopy or robotics.
Results: Over 400 hybrid Trans-Douglas cholecystectomies have already been conducted, with a conversion rate to endoscopy of less than 1%. The method proves as successful as conventional endoscopic cholecystectomy, potentially becoming a routine for women. Over 350 publications from various countries exist on transoral thyroidectomy, highlighting complications such as CO2 embolism, transient perioral numbness, hypoparathyroidism, and vocal cord palsy. While designed instruments are still necessary, this approach is feasible and comparable to conventional procedures in highly selected patients.
Conclusion: The realm of scarless operations, or natural orifice surgeries, holds great promise. However, the realization of safe and efficient procedures for patients necessitates the development of surgical simulators and designed instruments.
Scientific Paper. A Prospective Randomized Study Comparing 3 Training Approaches for Laparoscopy Surgery Skills Acquisition Using Virtual Reality Simulation, 3D-Printed Organ Models, and a Combination of Both
Sidney Moses Amadi, Zhifei Wang, Rakshit Vadher
Objective: Evaluate the effectiveness of a hybrid training approach combining virtual reality (VR) simulation for basic laparoscopic skills and 3D-printed models for advanced skills in facilitating comprehensive skill acquisition among novice trainees.
Methods and Procedures: Undergraduate medical students and interns without prior laparoscopic surgery experience were enrolled. After randomization into 3 cohorts (VR simulator, 3D-printed models, hybrid), standardized training was provided over 6 weeks (3 hours/day 3 times a week). The hybrid cohort underwent a 2-phase curriculum: phase 1 (weeks 1–3) basic skills on VR simulator; phase 2 (weeks 4–6) advanced skills on 3D models, all participants were ensured to have completed not more than or less than 40 hours cumulatively, all performances were video recorded. All cohorts then performed a laparoscopic ileo-jejunum anastomosis on a wet laboratory model, video-recorded for blinded OSATS assessment by experts. Primary outcomes were OSATS scores and procedure times, compared using ANOVA. Pre/post questionnaires assessed perceptions, analyzed by paired t-tests.
Conclusion: For laparoscopic skill acquisition, a hybrid curriculum significantly enhanced training outcomes compared to either modality alone. This approach optimized resource utilization across training stages, facilitating efficient skill transfer and a shortened overall learning curve. Broader implementation of hybrid simulation-based curricula may expand access to effective laparoscopic surgical training.
Video. Ureteral Reimplantation in Stage IV Endometriosis
Caroline R. Shadowen, Marissa Holden, Robert H. Moore, Lance J. Hampton, Katherine Czyszczon
Objective: The purpose of our video is to demonstrate minimally invasive robotic-assisted endometriosis excision and ureter transection and reimplantation in the case of stage IV endometriosis wherein a patient’s ureter was obstructed by endometriosis implant.
Methods and Procedures: Two surgical teams—gynecology and urology—collaborated to perform this case and edit this video submission.
Results: Our patient’s case was successful and she had excellent improvement in her presenting symptoms.
Conclusion: For patients with stage IV endometriosis involving other organ systems like the urologic tract, surgical procedures may be performed using minimally invasive methods to relieve their symptoms. Collaboration between surgical teams is imperative to good outcomes.
Scientific Paper. Assessing the Robot-Assisted Surgical Systems between Developed and Developing Economies
Robot-assisted surgery (RAS) is a revolutionary technology for the surgeons, doctors, and physicians. Although RAS deployment is rapid since 2019, despite decades of successful robotic assisted surgeries in the developed economies that have positively impacted millions of patients, RAS was barely explored by the developing countries compared to the developed countries whereby capabilities to enhance and improve the levels of expertise is limited besides acquisition and operating costs. This paper aims to investigate what is the future of RAS in selected developing countries given its multitude of needs and challenges? Is RAS still in early days too expensive to be put to general use in these developing economies today? We applied indicators to test the adoption of RAS using economic consideration of robotic surgery in health economics. We examine the likelihood of acquiring and using RAS with different market characteristics from 2000 to 2022. We used data on traditional and robot-assisted surgical interventions and transform it into an improved version on Quality-Adjusted Life Year and Willingness-to-Pay for Robot-Assisted Surgery. Asia growth was spectacular. China’s participation resulted in closing the gap much faster in advanced medical technology and RAS treatment between developing and developed economies beside knowledge diffusion. South Koreans had catch up with the Europeans, ie, Italy, Germany, France, and United Kingdom. Since 2015, Singapore had a huge improvement rapidly towards competing with United States, while China has tremendous progress leap over Malaysia and Thailand. China’s total patents had explosive growth and the robot density was among the highest among the selected economies compared in this study.
Scientific Paper. Artificial Intelligence in Medicine: a Comprehensive Review of Emerging AI Trends
Jesse L. Popover, Christoph Stephenson-Moe, Chris Kalathia, Trevor Jones, Jeremie Feldman, Natalie King, Ryan Tougaw, Alexandra Mackey, Adnan Imam, Majd Almasri, Paul Toomey
Objective: Artificial intelligence (AI) is a turning-point in medical advancement. Despite the burgeoning research in this field, there exists a general lack of overview of where AI is being most utilized. This study reviews and describes trends of AI in the major medical specialties.
Methods: A literature search was conducted through PubMed in 2024 using 2 different search methods. Twenty-nine medical specialties were included, including all 24 major medical board specialties and 5 additional subspecialties.
Results: There were 154,296 publications identified. Most these (87%) were published in the last 10 years (121,042) and 37% (52,405) the last 2 years. Radiology and Pathology publications were the largest cohorts, 18% (28,443) and 16% (25,074), respectively. Plastic Surgery (1,053), Hepatobiliary (662), Allergy/Immunology (449), Medical Genomics (0), and Otolaryngology (0) were the least published. There has been a 10,859% growth rate in annual publications across all medical specialties, with Ophthalmology and Preventative Medicine being the fastest growing areas of research despite Radiology and Pathology being the most researched to date.
Conclusion: This comprehensive review underscores the profound impact of AI on medical research, highlighting significant growth and utilization across various specialties. AI's influence is most pronounced in Radiology and Pathology, but the substantial increase in publications in Ophthalmology and Preventative Medicine suggest emerging areas of focus. The ongoing expansion of AI in medicine presents a promising horizon for addressing complex healthcare challenges, fostering a deeper and more comprehensive integration across all specialties.
★ Paul Alan Wetter Award for Best Multispecialty Scientific Paper
Video. Development of Low-Cost Laparoscopic Box Trainers with FLS Simulation Models
Margot Barker, Rebecca Schneyer, Mireille Truong
Objective: In pelvic surgery, a minimally invasive approach provides a multitude of benefits compared to open surgery. The surgical skills required for laparoscopic surgery are unique, requiring enhanced hand-eye coordination to safely operate using 2-dimension visual images. Surgical training thus must balance patient safety while ensuring that surgeons reach appropriate proficiency levels. To achieve this aim, simulation has been widely utilized to provide laparoscopic skills training. Box trainers have been shown to be effective in acquiring basic laparoscopic skills and have additionally shown benefit in reducing operative time and risk of perioperative complication. However, surgical trainers can be cost-prohibitive in resource-limited areas and are not consistently available across all training centers.
The objectives of this video are to demonstrate construction of 2 low-cost laparoscopic box trainers and show application of the trainer to practice the fundamentals of laparoscopic surgery (FLS) practical examination tasks.
Methods and Procedures: Both laparoscopic box trainer designs were created by author MT and their construction and application have been documented to improve access to low-cost laparoscopic training devices.
Results: No data collection was involved in the creation of this surgical education video.
Conclusion: This technique may be used and modified by surgical trainees for home use or in low-resource settings to improve access to laparoscopic skills simulation, thus improving trainee comfort with laparoscopy.
Video. Large Mesenteric Cyst Casting Wide Differential across Specialties
Jessica N. Harper, Katherine A. Kleinberg, J. Salvador Saldivar
Objective: To investigate a differential for a large abdominal cyst and to discuss multidisciplinary collaboration in minimally invasive surgery.
Methods and Procedures: In a health professional shortage area of West Texas, a 59-year-old G7P5025 presented with acute on chronic epigastric pain accompanied by nausea, anorexia, and constipation. A well demarcated, 14.5–14.9 cm simple cyst arising from the left adnexa or flank was evident, although its distinct origin was unclear despite the robust employment of imaging studies—CT scan of the abdomen and pelvis with and without contrast, transabdominal ultrasound, transvaginal ultrasound, and MRI. The gynecological-oncology team, in accordance with the patient’s goals, proceeded with surgical management.
Results: Pathology revealed a serous cyst with no evidence of malignancy, arising from the mesentery.
Conclusion: When consulted for a pelvic mass, surgeons operating in the abdomen and pelvis are prudent to consider mesenteric cyst on their differential. Alongside the primary medical team, the consulting teams of general surgery, gynecology, urology, and gynecology-oncology all contributed to the collaborative care of the patient. Robotic-assisted laparoscopic surgery ultimately provided significant relief to the patient.
Video. Posterior Approach to Retrogastric Cystogastrostomy
Mallory M. Loe, Blake L. Milson, Adarsh Vijay
Objective: Pancreatic pseudocyst is a known complication of recurrent pancreatitis and requires intervention if symptomatic or complicated. Anterior cystogastrostomy has been well-described in surgical literature but data on a posterior laparoscopic/robotic approach are limited. Here we report a case of robotic cystogastrostomy and drainage of a pancreatic pseudocyst in a patient with a history of recurrent pancreatitis and compressive biliary obstruction.
Methods and Procedures: In this video we demonstrate a posterior robotic approach to cystogastrostomy in a patient with a symptomatic pancreatic pseudocyst.
Results: This is the case of a 43-year-old female with recurrent pancreatitis and resulting pancreatic pseudocyst. She presented with symptomatic biliary tract obstruction due to compression from the cyst. Gastroenterology evaluated the patient and determined her not to be a candidate for endoscopic ultrasound and stenting as they were concerned of proximity of the splenic artery. In this video, we visualize the posterior gastric wall and the retrogastric pseudocyst via the robotic approach, then proceed to open and drain the cyst. We utilize a stapler to create a cystogastrostomy and running sutures for closure.
Conclusion: This video demonstrates the safety and efficacy of a posterior robotic approach to cytogastrostomy in patients with a retrogastric pancreatic pseudocyst. The posterior approach avoids the large anterior gastrostomy, provides more precise cyst visualization, and enables creation of a larger cystgastrostomy anastomosis as warranted.
Scientific Paper. Minimizing Risk of Retroperitoneal Vascular Injury at Laparoscopic Abdominal Entry
Objective: The objective of this observational study is to demonstrate the safe use of abdominal wall elevation device with closed technique using Veress needle or direct entry with 3-mm port.
Methods and Procedures: Female patients undergoing laparoscopic gynecologic procedure between July 2023 to May 2024 underwent preoperative screening ultrasounds to predict presence of obliterating adhesions. Abdominal wall elevation device was used during abdominal entry. Once entry confirmed major vascular, or visceral injury was assessed. Other events such as number of entry attempts, failed entry, and presence of adverse events during entry were noted. Descriptive statistics were used to characterize the patient population and incidence of abdominal entry injury or events.
Results: Elevation device was used in 15 patients with Veress needle and 25 patients with 3 mm direct trocar. Abdominal entry was achieved via the umbilicus in 36 patients and left upper quadrant in 4 patients. There was no major vascular, visceral injury or failed entry events. Entry was achieved on first attempt in 35 patients. Of second attempt entries, one was with 3 mm trocar and 4 with Veress needle.
Conclusion: Use of a device to elevate the abdominal wall in a standardized fashion is both safe and effective for laparoscopic abdominal entry. It can be used with its designed entry method of Veress needle and direct entry using 3 mm port.
Video. Radical versus Conservative Surgical Management of Bilateral Hydroureter: Long-Term Outcome
Objective: Report a comparison of conservative and radical laparoscopic management of bilateral hydroureter due to ureteral endometriosis in a woman with severe deep infiltrative endometriosis.
Methods and Procedures: A 30-year-old nulliparous woman with previous diagnosis and treatment of umbilical endometriosis presented with pelvic pain and bilateral hydroureter. The patient had continued hydroureter with distal ureteral stricture after initial extensive ureterolysis on right ureter. She underwent right ureterolysis and ureteroneocystostomy with psoas hitch. Post operatively she did well, and left ureter was managed conservatively with ureteral stent as needed. Two years later worsening symptoms required surgical management of the left ureter with extensive ureterolysis, partial wall resection and repair secondary to absence of intrinsic disease. Currently, she has been followed for 10 years from the right ureteroneocystostomy and 8 years from left ureterolysis, ureteral wall resection and repair. Nuclear medicine renal function scans throughout the follow-up years reveal right side function of 37% and left sided function of 63%.
Results: Treatment of bilateral hydroureter.
Conclusion: This case demonstrates the long-term renal function with conservative surgical management of one ureter and radical surgical management of the contralateral ureter in the same patient. Current recommendation of routine ureter resection and reimplantation for extrinsic distal ureteral endometriosis may be inferior to conservative ureterolysis and excision of endometriosis.
Scientific Paper. From Burnout to Balance: Integration of Artificial Intelligence in Minimally Invasive Surgery
Objective: Artificial intelligence (AI) innovations are leaving a notable imprint in the medical field. In 2024, surgical subspecialties continue to experience the highest burnout rates, necessitating solutions to improve working conditions for surgeons. This paper aims to explore the potential applications of AI in reducing burnout, specifically within minimally invasive surgery (MIS). By examining the integration of AI tools and systems, we seek to identify how various technologies may streamline surgical workflows, enhance decision-making, and alleviate administrative burdens.
Methods and Procedures: A comprehensive literature review was conducted, focusing on studies that have implemented AI in MIS. A list of relevant AI tools and systems was complied.
Results: Current technologies include AI-driven intraoperative guidance to enhance precision during robotic surgery, 3D modeling systems for operative planning and navigation, and data analytics programs that offer predictive insights and procedural trends. Additionally, natural language processing and administrative tools streamline documentation, and intelligent monitoring systems assess patients’ vital signs.
Conclusion: Various AI tools are designed to streamline surgery. Integrating AI in MIS not only strives to improve patient outcomes, but may also offer the additional benefit of combating surgeon burnout. Enabling surgeons to better assess risks, visualize anatomy and areas of concern, and implement measures that improve patient outcomes, minimizes physical exhaustion and ultimately surgeon stress. Continued research and development of AI, tailored to the needs of surgeons, are essential to fully realize their benefits and ensure successful implementation in the clinical setting. While preliminary findings are promising, further advancements are warranted to alleviate the inherent stress within MIS.
Scientific Paper. Comparison of Endoscopic Combined Intrarenal Surgery with Standard Percutaneous Nephrolithotomy in Treatment of Stones Having Medium to High Seoul National University Renal Stone Complexity Score
Objective: To compare the efficacy and safety of endoscopic combined intrarenal surgery with standard percutaneous nephrolithotomyin renal stones having medium to high S-ReSC score.
Methods and Procedures: This study, which is nonrandomized, includes 62 patients who were admitted to the SZH Lahore urology department.Group B consisted of 31 patients who underwent sPCNL surgery while Group A consisted of 31 patients who underwent ECIRS surgery. χ2, t-test, and poststratification analysis were performed using SPSS version 25.
Results: In the ECIRS group, 29.1% of patients had trouble making a puncture during surgery, compared to 51.6% in the sPCNLgroup.16.1% of ECIRS users had trouble establishing access, compared to 25.8% of sPCNL users. In the ECIRS group (9.7% vs 90.3%) and SPCNL group (6.5% vs 93.5%), the ReSCscores were medium and high, respectively. The incidence of pleural injuries was 6.5% in the ECIRS group and 25.8% in the sPCNL group. Operative time was greater in the sPCNL group (58.1% vs 16.1%) compared to the ECIRS group. Nephrostomy usage was 35.5% in the ECIRS group compared to 29.1% in the sPCNL group. DJ stent need in sPCNL compared to ECIRS (74.2% vs 51.6%). On one POD X Ray KUB and one month CT KUB, the residual stone free rate was 90.3% vs 83.9%) and 61.3% versus 48.4% in the sPCNL group, respectively, in the ECIRS group; 51.6% of group A had mild hematuria, while group B had 3.2% of severe hematuria; 93.5% of the sPCNLgroup had bleeding segmental vessels, compared to 0% in the ECIRS.
Conclusions: When compared to standard percutaneous nephrolitholotomy for stones with a medium to high S-ReSC score, the study found that endoscopic combined intrarenal surgery yielded better results in terms of the number of tracts, iatrogenic damage, operational time, and stone-free rate.
Video. Artificial Intelligence-Generated Virtual 3D Anatomical Models Can Facilitate Robotic Renal Surgery in the Setting of Highly Complex Vasculature: Robotic-Assisted Heminephrectomy of a Large Renal Cell Carcinoma Confined to the Isthmus of a Horseshoe Kidney
Objective: Surgery on horseshoe kidneys is challenging due to complex anatomy, with over 75% having anomalous vasculature. Fewer than 300 cases of renal cell carcinoma (RCC) in horseshoe kidneys have been reported, with very few isolated to the isthmus. Using artificial intelligence (AI) software, a virtual segmented 3D kidney model was generated from triphasic CT imaging for preoperative planning and intraoperative navigation. We present a 65-year-old male with a 6-cm RCC at the isthmus of a horseshoe kidney and our approach to performing robotic-assisted heminephrectomy.
Methods and Procedures: Robotic trocars were placed to left of the midline for transperitoneal access to the renal isthmus. The 3D model assisted in delineating the tumor and complex vasculature. Three renal arteries and 2 renal veins were identified and transected. Near-infrared fluorescence and intraoperative ultrasonography were used to define a margin between the mass and the left renal moiety. Right heminephrectomy and renorrhaphy was then performed.
Results: Operative time was 5 hours 43 minutes. Estimated blood loss was 200 mL. Pathology revealed pT3aN0M0 clear cell RCC with negative margins. The patient had an uncomplicated postoperative course, and there was no evidence of disease at 6 months.
Conclusion: Heminephrectomy of a horseshoe kidney with a renal mass located at the isthmus is technically challenging. Few reports of robotic-assisted partial nephrectomy for small isthmus-located RCCs have been published. To our knowledge, this is the first report describing the technique of robotic-assisted heminephrectomy for a large RCC located at the isthmus of a horseshoe kidney with the assistance of 3D anatomical modeling.
Video. Advances in Technology Facilitate Robotic Reconstructive Surgery: Robotic-Assisted Bladder Neck Reconstruction for Recurrent Bladder Neck Contracture following Multiple Failed Endoscopic Procedures
Ravi Munver, Ernest Tong, Yu Zhang
Objective: Bladder neck contracture (BNC) is typically managed with transurethral endoscopic techniques. If these approaches fail, bladder neck reconstruction may be considered. We present a 56-year-old male with recurrent BNC after robotic-assisted radical prostatectomy. Postoperatively, he developed reactive thrombocytosis and urinary clots, leading to BNC after traumatic Foley catheterization. Despite 8 unsuccessful endoscopic procedures, he underwent robotic-assisted Y-V plasty bladder neck reconstruction. We demonstrate our surgical approach.
Methods and Procedures: A multiport transperitoneal approach was used. Guided by cystoscopic transillumination, the anterior bladder neck was incised in a Y shape to avoid the external sphincter and expose healthy urethra. Fibrotic tissue was excised to create a V-shaped bladder flap. A running anastomosis was performed, and the bladder was filled to ensure a watertight closure. A bioregenerative amniotic membrane allograft was placed over the anastomosis for healing and as an adhesion barrier. The peritoneal defect was closed. A Foley catheter and drain were placed.
Results: Operative time was 2 hours and 58 minutes. EBL was less than 5 mL. The patient had an uncomplicated postoperative course and was discharged on postoperative day 1. Cystogram and Foley catheter removal was performed on postoperative day 10. At 3-month follow-up, cystoscopy confirmed bladder neck patency, and the patient continues to void without urinary incontinence at 1 year.
Conclusion: Robotic Y-V plasty bladder neck reconstruction may be offered for the treatment of recurrent BNC in patients with prior endoscopic treatment failure. This complex reconstructive procedure introduces healthy tissue to the fibrotic bladder neck, promotes healing, and can improve quality of life.
★ Best Urology Video
PEDIATRIC SURGERY SCIENTIFIC PAPERS & VIDEOS
Nagham Toba, Maahroo Makhdoom, Reem Hatem, Fatima Alhashmi, Bassem Abou Hussein, Ali Khammas, Omar Marzouqi
Scientific Paper. Quality of Life of Bariatric Surgery in Adolescent Patients: a Cross-Sectional Study
Objective: Childhood and adolescent obesity is a significant public health concern in the United Arab Emirates (UAE). Although bariatric surgery is a well-established treatment for severe obesity in adults, its effect on quality of life (QoL) in the younger population is still underexplored. We aim to investigate the QoL of adolescent patients who undergo bariatric surgery in the UAE.
Methods: A retrospective cross-sectional study was conducted on 44 adolescent patients with severe obesity who underwent bariatric surgery between 2013 and 2020. The Bariatric Analysis and Reporting Outcome System (BAROS) QoL questionnaire was administered via phone calls after a minimum 2 years follow-up.
Results: A total of 44 patients ≤18 years old were included, 64% of patients were female. Their initial BMI was 47 ± 6 kg/m2 and an average percent of 95th percentile of 157 ± 20%. Most patients underwent laparoscopic sleeve gastrectomy (91%) and the remaining underwent one anastomosis gastric bypass. They experienced a total weight loss of 38 ± 11% and an excess weight loss of 76 ± 22%. The BAROS questionnaire revealed that 14% of patients had excellent and 38% had very good outcomes (31% good, 12% fair, and 5% failure). Patients reported high levels of satisfaction in self-esteem, social, labor, and physical appearance-related domains on a 5-point scale (4.6 ± 0.8, 4.9 ± 0.5, 4.7 ± 0.7, and 3.8 ± 1.0).
Conclusion: Adolescent bariatric surgery is a promising solution for severe obesity experienced in this age group. Our data indicate a high rate of positive outcomes and QoL across all domains.
★ Gustavo Stringel Award for Best Pediatric Surgery Presentation
Poster. Strategies for Ureteral Avoidance during Complex Robotic-Assisted Hemicolectomy in a Patient with Retrocaval Ureter: a Case Report
Marie S. Nunez Duarte, Fadi Dahdaleh, Mark Biebel
Objective: Latrogenic ureteral injury is a surgical complication causing severe morbidity for patients. Surgeons performing minimally invasive operations in the abdominopelvic cavity must recognize anatomical variations to avoid injury. We report our experience using pre- and intraoperative strategies to avoid ureteral injury during a robotic hemicolectomy for a patient with variations in abdominopelvic anatomy.
Methods and Procedures: A 56-year-old male was found to have a 10-mm sessile polyp consistent with well-differentiated neuroendocrine tumor and dilated collecting system on imaging. During ureteral catheter placement, torturous, obstructed ureter was found. Extensive lysis of adhesions was required due to previously undetected intestinal malrotation.
Results: Manipulation of the duplicated ureter around structures such as the inferior vena cava and ascending colon prolonged the expected operative time. The specimen obtained was a primary malignant neuroendocrine tumor of the small intestine. Injection of indocyanine green and dissection of the ureters allowed the urologist to avoid injury to the retrocaval ureter. The use of landmarks and robotic approach enabled the surgical oncologist to resect the specimen without complications in a patient with multiple anatomic variations.
Conclusion: Previous studies have found decreased odds of IUI with the minimally invasive approach vs open cases and particularly robotic surgery vs open cases. Our report lends support to the practice of identifying which patients are at high-risk for IUI and using a robotic approach in abdominopelvic surgery. Clearer guidelines are needed to select which patients are at need for these interventions.
Poster. Robotic Cholecystectomy with Cholecysto-Duodenal Fistula Division
Introduction: Cholecysto-duodenal fistula is a rare complication of chronic calculous cholecystitis. Due to advancement in minimally invasive techniques, a paradigm shift has occurred from the traditional open surgery to laparoscopic repair but only one case report highlights robotic repair. In this article, we report a case of cholecystoduodenal fistula management by robotic approach.
Case Report: A 50-year-old female with history of laparoscopic Roux-en-Y gastric bypass surgery and total abdominal hysterectomy presented with intermittent, postparandial right upper quadrant abdominal pain, associated with diarrhea. Abdominal ultrasound showed cholelithiasis with dilated common bile duct, that did not contain gallstones based on magnetic resonance cholangiopancreatography. She was taken to the operating room for robotic assisted laparoscopic cholecystectomy, where she was found to have cholecystoduodenal fistula which was divided robotically. The patient had an uneventful recovery.
Discussion: Patients with cholecysto-duodenal fistula often present with nonspecific signs and symptoms and preoperative diagnosis of cholecysto-enteric fistulas remains a challenge. Once diagnosed intraoperatively management has ranged from laparoscopic repair to open surgery. This case report discusses the advantage of enhanced visualization of dense adhesions in 3 dimensions by the robot, eliminating the need for conversion to open surgery.
Poster. Gauging National Public Interest in Bariatric Surgery for Weight Loss Management: a Google Trends Analysis
Objective: The escalating prevalence of obesity has emerged as a pressing public health concern. The ever-expanding array of bariatric surgical options available in modern medicine emphasizes the need for comprehending the evolving interests of patients. Subsequently, this study seeks to analyze and compare the temporal trends of online searches pertaining to bariatric surgery queries.
Methods and Procedures: Search terms related to bariatric surgery included, “Weight loss surgery,” “Bariatric surgery,” “Sleeve Gastrectomy,” “Gastric Sleeve,” “Lap Band,” “Adjustable Gastric Band,” “Roux-en-Y,” and “Gastric Bypass.” Google Trends was employed to acquire the relative search volume (RSV) at the United States state and national level. This analysis spanned from 2004 to 2021.
Results: United States national analysis revealed a 1.6-fold increase in RSV for weight loss surgery and bariatric surgery, and a remarkable 48.7-fold surge in interest for sleeve gastrectomy and gastric sleeve (both P < .00001). Conversely, there was a 2.1-fold decrease in RSV for lap band and adjustable gastric band, as well as a 1.8-fold decrease for Roux-en-Y and gastric bypass (both P < .001). State analysis consistently showed highest RSV stemming from the geographic southern United States.
Conclusion: This study demonstrates a consistent rise in search queries for bariatric surgery since 2004. The data suggests patient's growing inclination towards self-education on surgical weight loss options especially in the southern United States. These findings serve as a valuable guide to multidisciplinary approaches for weight loss and highlights the importance of fostering open discussions of obesity management strategies with patients.
Poster. Innovating Care: Laparoscopic Bilateral Prophylactic Mastectomy with Simultaneous Breast Reconstruction in BRCA2 Mutations
Sonia Dziugieł, Zuzanna Niedbał, Denise Nemeth, Marina Trimmer-Torres, Daphne Sanchez, Karimeh Ortiz, Tomasz Sachańbiński
Introduction: Breast cancer stands as the most prevailing form of malignancy affecting women globally.1–3 It is estimated that with continued globalization and economic growth, the incidence of breast cancer in developed countries will increase to 56% and in developing countries to 95% by the year 2040.4 Breast cancer genes BRCA1 and BRCA2 are tumor suppressor genes whose mutations increase the lifetime risk of developing certain malignancies, particularly breast and ovarian cancer.5–7 Data show that prophylactic mastectomies reduce the risk of breast cancer in BRCA2 mutation carriers by over 90%.7 With the progression of laparoscopy being used in surgical oncology, this approach to mastectomies is gaining momentum and has been shown to improve postoperative recovery and decrease upper limb postoperative deficits.8 The aim of this case report is to highlight the role of laparoscopic and endoscopic techniques in the setting of breast surgery.
Methods and Procedures: This is a case report of a 42-year-old female with a family history of gynecologic cancers, diagnosed with BRCA2 gene mutation via genetic testing. A laparoscopic bilateral prophylactic mastectomy with simultaneous reconstruction using an endoprosthesis was performed with the goal of increasing patient comfort, and reducing scar size and overall invasiveness.
Results: Histopathological examination revealed no malignancy. Patient discharged without further complications secondary to the procedure.
Conclusions: Laparoscopic breast surgeries are technically challenging due a small working area, limited range of motion of instruments, and poor visibility. However, considering its benefits, it is an attractive alternative to traditional open mastectomies.9
★ Gustavo Stringel Award for Best Poster by a Student
Poster. Nationwide Analysis of the Colorectal Cancer Minimally Invasive Surgical Treatment in Bulgaria
Martin Karamanliev, Meri Shoshkova, Yoan Ivanov, Tsanko Yotsov, Dobromir Dimitrov
Objective: The timely diagnosis and treatment management of colorectal cancer is of great importance for the oncologic results. A screening program and a national database for colorectal cancer in Bulgaria are not available. In the current study, a platform with access for scientific purposes to all national medical data was used to perform a nationwide analysis of colorectal cancer minimally invasive surgical treatment.
Methods and Procedures: We analyzed data from January 2019 to May 2024 on a nationwide basis using an artificial intelligence (AI) powered software solution that has access to anonymized medical information through science-oriented hospital contracts. Information about colorectal cancer diagnosis, radical and palliative surgery procedures (open and minimally invasive) is analyzed and interpreted. An advanced SAP HANA in-memory database algorithms were used.
Results: During the study period, the diagnosed patients with colorectal cancer (C18, C19, and C20—ICD) were 24,729. Surgical procedures were performed in 12,854 patients. Laparoscopic resections were done in 3,779 patients and robotic resections in 453 patients (a total of 4,232 minimally invasive resections—32.92%). Radical procedure was performed in 8184 patients (63.67%). Out of the 12,854 patients that underwent surgery, 2,877 were in IV stage (22.38%), 3,716 patients in III stage (28.91%), 3,929 patients in II stage (30.57%) and 2,332 patients in I stage (18.14%).
Conclusion: In Bulgaria, the rate of minimally invasive radical surgery for colorectal cancer is still low and high rates of late-stage at the time of the diagnosis are observed. Colorectal screening program implementation is essential and needed.
Poster. Diagnostic Challenges of a Bleeding Meckel’s Diverticulum in a Young Adult
Ahmed E. Eissa, Gabrielle K. Dabrowski, Carlos Ruiz, Indraneil Mukherjee
Objective: This study aims to illustrate the diverse presentations of Meckel’s diverticulum (MD) in adults and the diagnostic challenges associated with it. Additionally, it seeks to demonstrate the approach to the laparoscopic management of a bleeding MD.
Methods and Procedures: We present the case of a 19-year-old male with intermittent abdominal pain and hematochezia. Diagnostic workup included esophagogastroduodenoscopy, CT angiography, and colonoscopy, which were inconclusive. Technetium-99mm scan showed aberrant uptake, suggesting ectopic gastric mucosa, prompting exploratory laparoscopy, and terminal ileectomy with primary side-to-side anastomosis.
Results: Despite negative imaging and atypical symptoms, a MD was identified intraoperatively, underscoring the diagnostic challenge in adults. Surgical intervention resulted in resolution of symptoms.
Conclusion: Adult MD poses diagnostic dilemmas due to varied presentations and negative imaging. Clinicians should maintain a high index of suspicion, especially in cases of nonspecific symptoms, to prevent delays in diagnosis and reduce associated morbidity.
Poster. Single Center Analysis of Primary Roux-en-Y Gastric Bypass with Concurrent Paraesophageal Hernia Repair in Patients with BMI >30 kg/m2
Daniel K. Knewitz, Jorge A. Cornejo, Shalyn M. Fullerton, Lorna A. Evans, Steven P. Bowers, Enrique F. Elli
Objective: Additional support regarding the safety and feasibility of combined paraesophageal hernia (PEH) repair and Roux-en-Y gastric bypass (RYGB) is needed. We sought to analyze both the short- and long-term outcomes of patients who underwent this combined operation. Additionally, we aim to supplement the limited literature reporting outcomes following robotic surgery.
Methods and Procedures: We performed a single institution retrospective analysis of overall morbidity and mortality of patients who underwent primary RYGB with PEH repair from January 2014 to July 2023.
Results: Fifty-two patients were included. Mean preoperative BMI was 40 kg/m2. The mean follow-up period was 14 months. Most operations were performed robotically (59.6%). A robotic approach was associated with a significantly decreased operative time along (P = .05) with decreased symptomatic recurrence (P = .163). Six and 3 patients were noted to have minor and major post operative complications, respectively. Significant improvement in GERD, OSA, HTN, and HLD was noted by last follow-up. We report an average excess weight loss (%EWL) at 1, 3, 6, 12, and 24 months of 18%, 35.3%, 47.1%, 56.6%, and 62.2%, respectively.
Conclusions: To the best of our knowledge, our report represents the largest single institution analysis of patients who underwent combined PEH repair with RYGB, and one of the few reporting outcomes following its completion via a robotic approach. Although this combined operation is feasible, the addition of PEH repair may be associated with increased risk of postoperative complications.
Poster. A Rural Community Hospital Case Series: Robotic NICE Procedure—Alternative to Traditional Diverticulitis Surgery
Afia M. Wilson, Jonathan Stahl
Objective: At most centers, patients with sigmoid diverticulitis, who are candidates for elective surgery undergo conventional laparoscopic/robotic extracorporeal-assisted surgery. The NICE procedure is a completely intracorporeal anastomosis with extraction of the specimen through the rectum. Here we present 3 successful cases of robotic NICE procedures for complicated diverticulitis, completed at our rural community hospital, which has implications for improved outcomes.
Methods and Procedures: Consecutive patients presenting with complicated diverticulitis, ie, fistula, abscess, stricture—undergoing the NICE procedure in April 2024 were evaluated. Intraoperative and postoperative data were collected and reviewed. The data extracted included demographic, clinical data, disease features, and outcomes data. The main outcomes assessed were operative time, time to return of bowel function, pain scales, and length of stay.
Results: Three patients underwent the NICE procedure electively for complicated recurrent diverticulitis. All cases required intricate dissection due to the complexity of their diseases and had successful intracorporeal anastomosis and extraction of specimen through the rectum. None experienced postoperative leaks or infections. The mean operative time was 365 minutes. Average time to bowel movement was 4.7 days. Average pain scales were less than 4 by postoperative day 4. Finally, the mean total length of stay was 5.6 days.
Conclusion: We hypothesize the robotic NICE procedure is a successful alternative to traditional diverticulitis surgery, without a negative effect on complication rates and better patient outcomes at our rural community hospital. Our greatest limitation is sample size; however, after these successful cases we anticipate many more to come.
Poster. Outcomes of Minimally Invasive Necrosectomy for Pancreatic Necrosis: a Single Institution’s Experience
Yukiko Suzuki, Kedar Sukharamwala, Enrilen Alta, Kenneth Luberice, Subhasis Misra, Prashant Sukharamwala
Pancreatic necrosis is a severe complication of acute pancreatitis, often requiring surgical intervention. Traditional open necrosectomy has significant morbidity and mortality, prompting the development of minimally invasive techniques. This study analyzes the outcomes of minimally invasive necrosectomy at a single institution. Demographic data and perioperative outcomes of laparoscopic necrosectomy cases from August 2015 to October 2023 were analyzed using χ2 analysis and the Mann-Whitney U-test. Data are presented as median (mean ± standard deviation). Twenty-one patients (17 men, 4 women) underwent laparoscopic necrosectomy, with an average age of 58 years (±14.8) and a mean body mass index of 26.2 kg/m2 (±6.3). The causes of pancreatitis included pseudocysts (n = 4), gallstone pancreatitis (n = 7), alcohol-related pancreatitis (n = 5), recurrent pancreatitis of unspecified etiology (n = 4), and pancreatic cancer (n = 1). Lesion size averaged 14.1 cm (±5.4). Intraoperative findings highlighted an average estimated blood loss of 132.8 mL (±243.0) and an operative time of 126.8 minutes (±50.4). Postoperative outcomes indicated a median hospital stay of 8.3 days (±6.5), with drain placement in 90% of cases for an average of 53.7 days (±43.7). There was no in-hospital mortality. Seventy-five percent of patients were discharged home, and 25% were transferred to assisted living facilities. The readmission rate was 37%, with one reoperation for intra-abdominal fluid collection. These findings underscore that minimally invasive necrosectomy for pancreatic necrosis can reduce mortality and improve recovery. Despite the high readmission rate, the significant percentage of patients discharged home suggests favorable short-term outcomes. Further research is needed to optimize patient selection and reduce readmission rates.
Poster. Pain Management Techniques Utilized for In-Office Water Vapor Uterine Ablation
Mindy Sydnor, Firas Shalabi, Neil Simmerman
Introduction: Heavy menstrual bleeding affects ∼40% of reproductive aged women and is often treated utilizing uterine ablation (UA). Pain management protocols vary for in-office UA and there is no published pain management protocol specific water vapor UA. The study purpose was to evaluate pain management methods utilized by physicians following the conduction of in-office water vapor UA.
Methods: An IRB-approved Qualtrics survey was completed by 32 physicians following an in-office water vapor ablation procedure.
Results: The endometrium was pretreated in 59% of patients using progesterone and 68% received 10 mg progesterone and the most common length of treatment was 10 days. Misoprostol was given to 41% of patients. Acetaminophen was given to 41% of patients, the most common dose was 650 mg. NSAIDs were taken by 97% of patients, with 61% receiving ibuprofen 800 mg and 45% receiving ketorolac 60 mg IM. Narcotics were given to 81% of patients, with 35% receiving oxycodone/acetaminophen 5/325 mg. Anxiolytics were given to 63% of patients, with the most common being diazepam 10 mg 1–2 hours (55%) prior to UA. All patients received a paracervical block, and of those patients 56% received lidocaine 1%, and 9% percent received lidocaine 1% with epinephrine. Postablation, ibuprofen was given as needed in 75% of patients. Physicians perceived the procedure to be tolerated by patients in 94%of cases.
Conclusion/Implications: Pain management strategies varied by physician but demonstrated patient tolerance of in-office water vapor UA. Further evaluation with a larger sample size is recommended.
Poster. Ovarian Preservation after Robotic Hysterectomy and Radical Resection for Advanced Stage Endometriosis—A Retrospective Clinical Series on Pain Improvement
Objective: Bilateral oophorectomy during hysterectomy is often performed at time of hysterectomy for endometriosis-associated pain. The purpose of our study is to evaluate pain outcomes in women undergoing hysterectomy and radical resection of endometriosis with ovarian conservation.
Methods and Procedures: Retrospective clinical case series of patients undergoing hysterectomy and radical resection of endometriosis with ovarian conservation in advanced staged endometriosis between 2014 and 2022 from a single surgeon. Inclusion criteria included premenopausal patients age >18 undergoing hysterectomy and radical resection of endometriosis with ovarian conservation for endometriosis-associated pain. Exclusion criteria included patients who had prior hysterectomy, BSO at time of hysterectomy, malignancy or precancer, or were loss to follow-up. Patients were contacted via telephone for follow-up. Descriptive analysis was utilized.
Results: A total of 53 patients were evaluated; 38 patients excluded and 15 met inclusion criteria. The mean reported improvement of pain since surgery was 95% (SD 13). The mean preoperative pain score was 8.69. Postoperative pain score means were 1.56, 1.2, 0.57, 0.58, and 1.13 and 0.78 at 1, 2, 3, 4, 5 years and current pain score respectively. The median and mean follow-up were 56 and 69.5 months respectively. The mean operative time was 111 minutes (SD 43.6). N = 1 (6.25%) had an intraoperative complication and n = 3 (20%) had a post op complication. N = 2 (13.33%) required reoperation.
Conclusion: Patients undergoing definitive surgery with hysterectomy and routine excision of all endometriosis with ovarian conservation have long-term pain relief which avoids the detrimental effects of early onset menopause.
★ Gustavo Stringel Award for Best Poster
Poster. Bipolar Radiofrequency Endometrial Ablation Complicated by Uterine Perforation and Extensive Bowel Injury—a Case Report
Katerina Litvinova, Ann Barral, Taryn Dee, Richard Trester, Burnetta Herron
Objective: Bipolar radiofrequency ablation is a second-generation endometrial ablation procedure for treatment of abnormal uterine bleeding. It is associated with a high success rate and major complications are rare. Thermal bowel injury is an uncommon but serious complication of bipolar radiofrequency ablation. This case illustrates the most extensive thermal bowel injury described in literature from bipolar radiofrequency ablation. The objective of this case report is to highlight a catastrophic procedure complication and emphasize the importance of device-specific patient safety initiatives.
Methods and Procedures: A 41-year-old G3P2012 with history of abnormal uterine bleeding and 2 cesarean sections postoperative day 6 after bipolar radiofrequency ablation and hysteroscopy presented to the emergency department with abdominal pain, nausea/vomiting, obstipation, and anorexia since the procedure. General surgery, interventional radiology, and infectious disease were consulted. Serial computed tomography abdomen/pelvis studies revealed worsening pneumoperitoneum and intraperitoneal free fluid concerning for bowel perforation. Emergent exploratory laparotomy was performed. Seven bowel perforations and a uterine perforation were identified. Right hemicolectomy, enterectomy with primary anastomosis, and rectosigmoid resection with end-colostomy were performed. Postoperative course was complicated by ileus. Patient was discharged on postoperative day 24.
Results: Seven thermal proximal ileum, terminal ileum, right colon, and rectal sigmoid perforations with severe serositis and cautery artifact were confirmed by pathology.
Conclusion: Bowel injury secondary to bipolar radiofrequency endometrial ablation is a rare but grim complication. Ongoing improvement of device deficiencies, standardized ablation device training, and perioperative briefing protocols are advised strategies to minimize procedure complication rates.
Poster. The Prevalence of Endometriosis of the Appendix
Linda S. Martinez, Abid Qureshi, Lauren Stanley, Luca Milone, Radha Syed
Objective: Endometriosis is a chronic inflammatory syndrome that is the most common cause of chronic pelvic pain in women. Endometriosis of the appendix is less common but it can present as acute appendicitis, appendiceal invagination, atypical abdominal symptoms or be asymptomatic. Here we present a small case series dedicated to encounters of endometriosis with appendiceal involvement during laparoscopy, and analysis of prevalence and management.
Methods and Procedures: This was a retrospective case series between the years 2018 and 2024. The patient cohort comprised 28 patients, age range 19–66 (mean age of 37), with a history of chronic pelvic pain that underwent diagnostic laparoscopic surgery with appendectomy for endometriosis. Inclusion criteria was chronic pelvic pain and exclusion criteria was pregnancy, suspected infectious etiology as cause of pelvic pain and prior history of hysterectomy.
Results: Out of the 28 patients, 8 patients specifically complained of right lower quadrant abdominal pain (28%); 11 patients had pathology-confirmed endometriosis, with 2 having appendiceal pathology-confirmed endometriosis. Of the subgroup with complaints of right lower quadrant pain, 3 had endometriosis, 1 had acute appendicitis, and none had appendiceal endometriosis. The prevalence of endometriosis in patients with chronic pelvic pain, RLQ pain, and appendiceal endometriosis in this study were: 39%, 38%, and 18%, respectively.
Conclusion: Although this study consists of a small sample size, it highlights associations of location of pain with appendiceal endometriosis. It also supports inspecting the appendix for gynecological disease during surgical management of chronic pelvic pain in women of reproductive age.
★ Gustavo Stringel Award for Best Poster by a Resident
Poster. Modified Technique for Safer Primary Trocar Entry in Laparoscopy
Pandurang Ramchandra Rotithor, Varnika Rajvardhan
Objective: A modified technique was developed for primary trocar entry to reduce risk of serious injury to vessels and internal organs like bladder and bowel. This technique enhanced patient safety by addressing the potential complications associated with traditional trocar entry methods.
Methods and Procedures: There are 2 layers in abdomen that need sharp instrument to penetrate—skin and rectus sheath. The skin was cut as usual. The subcutaneous fat was separated by blunt end of blade. Towel clip was anchored to skin below incision and pulled up by the surgeon’s nondominant hand in such a way that a “blunt conical” trocar enters at 90° to the incision and at 30° to horizontal. A small incision was made by blade on rectus sheath in the intended direction of trocar insertion and a stopper was employed over the trocar sheath to prevent overshooting. The clip pull gave firm grip even in cases of toned abdomen. The countertraction from towel clip made trocar entry independent of an assistant.
Results: This modified technique has been successfully applied in numerous cases, demonstrating its efficacy in minimizing the risk of trauma to internal organs. This method was faster and safer than traditional techniques such as the Veress needle entry or Hassan’s technique, showcasing its potential for widespread adoption. Surgeons new to laparoscopy found the technique easier to adopt.
Conclusion: By addressing the limitations of existing methods, this technique offers a faster, safer, and more consistent approach to trocar entry.
Poster. Increases in Serum Creatinine as a Predictor of Perioperative Outcomes after Robotic-Assisted Pulmonary Lobectomy
Alexis Behne Sharma, Shreya Chapyala, Joseph Mikhail, Carla C. Moodie, Joseph R. Garrett, Katherine M. Dillen, Jenna R. Tew, Jobelle J. Baldonado, Jacques P. Fontaine, Eric M. Toloza
Objective: Acute kidney injury (AKI) is associated with increased postoperative mortality after cardiac surgery, but this relationship is not well-studied for pulmonary surgery. We aimed to determine effects of increases in serum creatinine on postoperative outcomes after pulmonary lobectomy.
Methods and Procedures: We retrospectively analyzed patients who underwent robotic-assisted pulmonary lobectomy by one surgeon over 13-years. A modified Kidney Disease Improving Global Outcomes (KDIGO) definition of AKI grouped patients based on 0.3 mg/dL increase in serum creatinine within 48 hours after surgery or 1.5-fold increase from baseline within 1 week after surgery. Those with end stage renal disease or who have undergone renal replacement therapy were excluded. Perioperative outcomes were compared using Student’s t, Mann-Whitney U, and χ2 (or Fisher’s exact) tests, with significance at P ≤ .05.
Results: Of 797 study patients, 71 (8.9%) met KDIGO criteria for AKI. Overall postoperative complications were higher in AKI vs non-AKI patients (P < .001). Postoperative pneumonia rates differed (P < .001), but postoperative atrial fibrillation rates were not significantly different (P = .063) between study groups. Hospital length of stay (LOS) was higher in AKI versus non-AKI patents (P < .001). Median LOS in AKI patients was 7 days vs 4 days in non-AKI patients. In-hospital and 30-day mortality rates were 12.7% (n = 9) and 15.5% (n = 11), respectively, for AKI patients versus 0.41% (n = 3) and 0.55% (n = 4), respectively, for non-AKI patients.
Conclusions: Patients with KDIGO-defined AKI have more postoperative complications, especially postoperative pneumonia, and higher in-hospital and 30-day mortality. Creatinine should be monitored closely, and even minor AKIs should be treated promptly to prevent adverse outcomes.
Poster. Preoperative Resting Heart Rate as a Predictor of Postoperative Atrial Fibrillation after Robotic-Assisted Pulmonary Lobectomy
Joseph Mansour, Carla C. Moodie, Joseph R. Garrett, Jenna R. Tew, Jobelle Joyce-Ann R. Baldonado, Jacques P. Fontaine, Eric M. Toloza
Objective: Postoperative atrial fibrillation (POAF) is a common complication following pulmonary lobectomy, with potential adverse effects on patient outcomes. Identifying predictors of POAF could aid in risk stratification and preventive strategies. Resting heart rate (RHR) has been suggested, as a potential predictor of POAF in pulmonary lobectomy patients. This study aimed to investigate the association between RHR and development of POAF in patients undergoing robotic-assisted pulmonary lobectomy (RAPL).
Methods and Procedures: Analysis was conducted on 719 lobectomy patients, with 188 excluded for prior history of arrythmias, leaving 531 in the final cohort. RHR was measured during preoperative evaluation prior to RAPL. Patients were monitored postoperatively for occurrence of POAF.
Results: Among the study cohort, 95 patients (17.9%) developed POAF following RAPL. The non-POAF mean was calculated as 73.8 ± 0.6 (SEM) bpm, and the POAF sample mean as 75.9 ± 1.3 (SEM) bpm. A single sample z-score of 1.71 was calculated for the POAF population, with a P value of .046 (P < .05), which is statistically significant. The sensitivity of a RHR greater than 89.5 bpm was found to be 15.8%, and the specificity was 89.2%. For Patients with RHR above 89.5 bpm (n = 62), the risk of POAF increased by greater than 50% (odds ratio = 1.55), with 24.2% developing POAF.
Conclusion: These findings suggest that RHR along with other factors may serve as a valuable tool for early identification of individuals at higher risk of developing POAF. However, further research is needed to explore potential interventions for reduction of POAF in this population.
Poster. Attracted to Trouble: a Case of Pediatric Chronic Foreign Body Ingestion Leading to Magnamosis
Dillon Rogando, Jeffrey Robles, Tara Ranjbar, Dhruv Patel, Joseph Doran, Kevin Butler, Indraneil Mukherjee, Mitchell Price
Objective: Pediatric foreign body ingestion (FBI) is a healthcare concern that affects more than 100,000 children in the United States annually. The risk of ingestion is high among children with neurodevelopmental and intellectual disability (ND-ID). Ingestion of large, sharp or caustic substances may lead to significant morbidity and mortality through gastrointestinal fistula formation or perforation.
Methods and Procedures: A 15-year-old male with severe autism spectrum disorder (ASD), significant ND-ID and a history of previous FBI of metal objects, such as outlet plugs, presented to the ED with a 1-day history of right sided abdominal pain, nausea, and bilious vomiting. Initial examination revealed RLQ tenderness without guarding or rebound. CT Abdomen and Pelvis demonstrated aggregated metallic objects without evidence of perforation. Due to low likelihood of spontaneous foreign bodies passage, and risk of perforation, the patient was brought urgently to the OR for exploratory laparotomy and removal of the foreign bodies.
Results: Intraoperatively, multiple fistulas were discovered. One gastrojejunal fistula and 2 jejuno-jejunal fistulas of varying chronicity were identified, suggesting chronic FBI. Involved-sections of small bowel were resected and a side-to-side stapled anastomosis was performed. The patient’s postoperative course was uncomplicated. His diet was advanced and was subsequently discharged on POD7. Patient is tolerating a normal diet well without abdominal pain or change in bowel movements 2 weeks postoperatively.
Conclusion: Clinical suspicion of FBI should be high among children with ND-ID presenting with abdominal pain, followed by prompt surgical evaluation and intervention to prevent adverse outcomes such as bowel necrosis, perforation, and mortality.
Poster. Utilization of Minimally Invasive Gynecologic Surgery Subspecialists within an Urban Tertiary Care Network
Ashelee McManaman, Michael Shu, Ashley Ewert, Elena Moses, Victoria Arruga Novoa y Novoa
Background: Minimally invasive gynecologic surgery (MIGS) is a quickly developing subspecialty of obstetrics and gynecology. Consistent surgical consultations and referrals remain critical for multiple stakeholders including patients and their outcomes, physicians, and hospitals. The objective of this study is to provide a description of common MIGS subspecialist practices in that of a large, midwest urban tertiary care network.
Methods: This is a retrospective chart review from August 2022 to June 2023. All patients under the care of a MIGS subspecialist within an urban tertiary care network were included in this study.
Results: A total of 426 patients were seen in the MIGS department. Of those, 25% of these patients (n = 107) were referred specifically for consultation and eventually underwent surgery for benign gynecologic pathology; 2% of patients (n = 9) were seen within the MIGS division for obstetrical care, either as a new patient or for ongoing antenatal care; 4% of patients (n = 18) were seen in the office for a well woman’s examination. 68% of patients (n = 292) presented to the office for a problem-focused visit that was gynecologic in origin but did not require surgical consultation.
Conclusion: Within a large urban referral network, surgical consultations made up a total of 25% of patients seen in a daily office day amongst MIGS subspecialists. In order to better utilize MIGS subspecialists for optimum surgical care, ease of routine physician schedules, as well as maximized hospital utilization of surgical subspecialists, a referral pattern would be reasonable to help patients seeking the appropriate level of care for their gynecological surgical needs.
Poster. MRI Artifacts from Metallic Clips: PSA Screening Implications and Informed Consent Considerations in BPH Patients
Juan Varela, Chengbo Liang, Victoria Bird
Objective: Minimally invasive procedures for benign prostatic hyperplasia (BPH) have emerged to preserve sexual function, including those with metallic devices. However, aging patients requiring MRIs for prostate cancer screening may experience significant image distortions due to these clips, especially at higher magnetic field strengths. This study evaluates the impact of BPH procedure metallic artifacts on image quality and interpretation in 3 Tesla (3T) and 1.5 Tesla (1.5T) MRIs.
Methods and Procedures: Data were gathered from patients with hip prostheses, BPH procedure clips, or both, who underwent 3T or 1.5T MRIs. Evaluation criteria included spatial misregistration, signal void, geometric distortions, and thermal mapping distortion. MRI interpretations were conducted by a radiologist and urologist, assigning a Prostate Imaging Quality Score (PI-QUAL) on a 1–5 scale.
Results: The 1.5T MRI demonstrated reduced signal voids, geometric distortions, thermal map distortion, and spatial misregistration compared to the 3T MRI, which showed significant signal voids in the anterior prostate. However, PI-QUAL scores between 3T and 1.5T were not statistically different (P > .1). Despite improvements at 1.5T, clip-induced signal voids in the anterior prostate remain problematic for detecting clinically significant prostate cancer.
Conclusion: MRI distortion was significant at 3T compared to 1.5T, with BPH procedure clips causing substantial signal voids in the anterior prostate, complicating cancer detection. Patients with BPH procedure implants should consider a transperineal approach and be informed about these metallic artifacts’ effects on MRIs of the prostate, particularly when continuing PSA screening through MRI-guided biopsies.
Poster. Combined Laparoscopic Right and Left Colectomy Followed by Combined Robotic Colostomy Reversal and Fundoplication in A Patient with Synchronous Colon Cancer and Paraesophageal Hernia
Janani B. Karunaratne, Hugo J.R. Bonatti
Objective: Combined minimally invasive colon resection together with other major procedures has been shown feasible and safe. Rarely this is done for independent pathologies.
Methods and Procedures: A 35-year-old female with learning disability presented with 30 pounds weight loss during the past year, fatigue, and stool irregularities. On workup she was found to have iron deficiency anemia. Her BMI was 28 kg/m2. Colonoscopy showed a cecal and descending colon mass and biopsy revealed adenocarcinoma. CT-scan also showed a small hiatal hernia.
Results: She underwent uneventful laparoscopic right and left colectomy with ileocolic anastomosis and end colostomy; the sigmoid colon was preserved for future reconstruction. Pathology revealed T3N1aM0 and T3N0M0 adenocarcinomas and she underwent adjuvant chemotherapy. Workup showed no evidence of recurrent cancer, however, she had gained significant weight (BMI now 35 kg/m2) and developed ostomy prolapse and a parastomal hernia and CT-scan showed the PEH had significantly increased in size and she developed GERD and dysphagia. After supervised weight loss, she underwent combined laparoscopic/robotic colostomy closure and paraoesophageal hernia repair. She had a slow recovery with ileus and gastric distention and a PEG was placed for drainage. She was discharged but returned to the ER with a small bowel obstruction and underwent exploratory laparotomy revealing a mesenteric mass and a Meckel diverticulum which were resected. Pathology showed benign desmoid fibromatosis. She is well after 2 years.
Conclusions: The case confirms that patients will benefit from a minimally invasive approach in complex abdominal surgeries. The robot was found beneficial in this case.
Author Index
Abaijan Sydney, 11
Abdalla Eshak, 7
Abdelnaby Abier, 10
Abdelnaby Abier A., 9, 11
Adetyan Hasmik, 17
Ahmad Khaleel, 18
Ahmad Saqib, 18
Ahmed Saad, 8
Al Harakeh Hasan, 3-4, 6
Alhashmi Fatima, 26
Al Marzouqi Omar, 13
Alao Hawwa, 4
Aldohayan Abdullah, 12-13
Aldohayan Abdullah Dohayan, 12
Allawi Ahmed, 15
Almasri Majd, 23
Alqasimi Hessa, 13
Alta Enrilen, 29
Amadi Sidney Moses, 23
Amodu Leo I., 15
Anoosh Farhad, 1
Atla Pradeep, 4
Baldonado Jobelle Joyce-Ann R., 31
Baldonado Jobelle J., 31
Ball Elizabeth, 21
Balthazar da Silveira Carlos A., 14
Barker Margot, 24
Barral Ann, 30
Beman Scott, 14
Bennett Robert, 16
Bhattacharyya Eesha, 20
Biebel Mark, 27
Bilik Alona, 1-2
Bird Victoria, 32
Bonatti Hugo J.R., 3, 32
Bonatti Hugo J.R., 2
Bowers Steven P., 28
Brathwaite Collin Em, 15
Burns Megan, 21
Burns Megan K., 20-21
Butler Kevin, 31
Caceres Miguel A., 22
Camacho Diego, 8
Cammock Hiley D., 14
Canton Silvio Alen A., 1
Cetin Esra, 18
Chapyala Shreya, 31
Cheng Connie, 24-25
Cherouveim Panagiotis, 18
Chitibomma Nikhilesh, 17
Christodoulou Maria, 3-4, 9
Clement Cecilia, 20
Colvin Juliana L., 7
Cordeiro Raquel N., 8
Cornejo Jorge A., 28
Couch Sarah E., 14
Covillo Kristana Milivojev, 4
Curcio Gary, 7
Czyszczon Katherine, 23
da Silveira Carlos A. Balthazar, 8-9
da Silveira Carlos B., 10-11
Dabrowski Gabrielle, 11
Dabrowski Gabrielle K., 28
Dahdaleh Fadi, 27
Daté Ravindra S., 9-10
De Abate Alberto, 22
Dee Taryn, 30
Demirel Esra, 19
Desup Aisulu, 8
Dillen Katherine M., 31
Dimitrov Dobromir, 6, 28
Dolberg Michael, 7
Doran Joseph, 31
Duke Darcy, 27
Dziugieł Sonia, 27
Eguchi Marina, 8
Eissa Ahmed E., 11, 28
Elli Enrique F., 28
Elniel Mohammed, 9-10
Erfani Hadi, 19
Essien Francis, 17
Evans Lorna A., 28
Ewert Ashley, 31
Eyada Mostafa, 20
Eysselein Viktor, 4
Feldman Jeremie, 23
Fontaine Jacques P., 31
Frushour Cheryl, 3
Fullerton Shalyn M., 28
Gallapher Denize, 17
Garrett Joseph R., 31
Gaskins Jeremy, 14
George Shebin, 7
Gratsianskiy Denis, 6
Hajijama Sameera, 13
Hampton Lance J., 23
Han Michelle, 17
Harper Jessica N., 24
Hassan Amar, 13
Hatem Reem, 26
Heidel Robert E., 7
Heldreth Audrey, 6, 12
Hernandez Jennifer, 7
Herron Burnetta, 30
Hoeferkamp Joelle J., 27
Holand Arthur, 14
Holden Marissa, 23
Hooda Zamaan, 11
Horton Courtney, 17
Hudson Macy, 18
Hughes Noemi, 17
Hunter Robert, 7
Hussein Bassem Abou, 13, 26
Imam Adnan, 23
Ivanov Krasimir Dimitrov, 15
Ivanov Yoan, 28
Jain Nutan, 21
Jain Vandana, 21
Jamal Mohammad, 3
Janik Grace, 21
Jones Trevor, 6, 23
Jou Katerina, 5-6, 12
Kalathia Chris, 23
Kalinov Turgay Turgay, 15
Karamanliev Martin, 6, 28
Karunaratne Janani B., 32
Kasakewitch João G., 11
Kasakewitch João P. G., 8-9, 14
Kasakewitch Joao P. G., 8, 10
Kasmirski Julia, 8
Kegel Samantha, 20
Kehdy Farid, 14
Kella Venkata, 15
Kenary Parisa Yazdankhah, 2, 15
Khalfay Nuha, 17
Khammas Ali, 13, 26
Khokar Mohammed Amaan, 13
Kilic Gokhan, 20
Kim Andrew, 3
King Emily H., 20-21
King Natalie, 23
Kleinberg Katherine A., 24
Knewitz Daniel K., 28
Kolev Nikola Yordanov, 15
Koshy Sonia M., 21
Larocca Lucas, 4
Lech Gabriele E., 8, 11
Lee Bruce, 29
Levine Jun, 15
Lewis Gregory, 20
Lewis Karren, 20
Liang Chengbo, 32
Lim-Dy Allyson, 5
Lima Diego L., 10
Lima Diego L., 8-11, 14
Litvinova Katerina, 30
Loe Mallory M., 24
Loui Taylor, 5
Luberice Kenneth, 29
Ma Shani, 20
Mackey Alexandra, 23
Maitra Ishaan, 9
Makhdoom Maahroo, 26
Malcher Flávio, 10
Malcher Flavio, 8
Malik Danial A., 14
Mansour Joseph, 31
Martinez Linda S., 30
Marzouqi Omar, 26
Maslyankov Svilen, 6
Matthaeus Alexander, 21
McManaman Ashelee, 31
Mehdizadeh Alireza, 17
Menghui Zhou, 3
Merida Manuel, 18
Michel Lindsey, 19
Mikhail Emad, 22
Mikhail Joseph, 31
Milone Luca, 30
Milson Blake L., 24
Misra Subhasis, 29
Moodie Carla C., 31
Moore Robert H., 23
Moran-Atkin Erin, 8
Moses Elena, 31
Mukharjee Sourodip, 12-13
Mukherjee Indraneil, 5-6, 11-13, 28, 31
Munver Ravi, 26
Munver Sujan R., 16, 25
Murdock Peyton M., 7
Murphy Colleen, 18
Nemeth Denise, 27
Nemov Valerie C., 22
Nezhat Ceana, 24-25
Nezhat Farr, 19
Ngo Lisa, 7
Nguyen Diana Q., 8, 14
Nguyen Nina, 19
Nguyen Truong, 20
Niedbał Zuzanna, 27
Nimaroff Michael L., 18
Nogueira Raquel, 10
Nogueira Raquel, 11
Novoa y Novoa Victoria Arruga, 31
Nunez Duarte Marie S., 27
Ortiz Karimeh, 27
Otero Javier, 15
Parreco Joshua, 7
Pasquali Claudio, 1
Patel Dhruv, 31
Patel Pooja, 18
Pattilachan Tara M., 3-4, 9
Pavlovic Zoran J., 22
Perez Christian, 4
Perim Victor, 14
Pham Avian, 17
Popover Jesse L., 23
Price Mitchell, 31
Pyke Owen, 15
Q
Quintero Luis A., 7
Qureshi Abid, 30
R
Rajendran Ilayaraja, 10
Rajvardhan Varnika, 30
Ralston William, 14
Ranjbar Tara, 5-6, 12, 31
Rasador Ana C. D., 9
Rasador Ana Caroline, 8, 10
Rasador Ana Caroline D., 10-11
Rauf Abdul, 25
Reese Chanda, 20
Reicher Sofiya, 4
Rhodes Marvin, 15
Robles Jeffrey, 6, 12, 31
Rochester Summer, 15
Rodriguez Silva Jetsen, 16
Rogando Dillon, 5, 12-13, 31
Rosemurgy Alexander, 3-6, 15
Ross Sharona, 15
Ross Howard, 16, 25
Ross Sharona, 1-3, 5
Ross Sharona B., 4, 6, 9, 11
Rotithor Pandurang Ramchandra, 30
Ruiz Carlos, 11, 28
Russ Andrew J., 7
Russell Caitlin, 5-6
S
Sachańbiński Tomasz, 27
Saldivar J. Salvador, 24
Salom Emery M., 21
Sanchez Daphne, 27
Sanha Valberto, 8
Santana Rachel C., 8
Sbeih Mohammed, 1
Schneider Andrew, 15
Schneyer Rebecca, 24
Seaver Christopher, 7
Seifi Farinaz, 18
Shadowen Caroline R., 23
Shalabi Firas, 29
Shapera Emanuel A., 6, 16
Sharma Alexis Behne, 31
Shoshkova Meri, 28
Shu Michael, 31
Siddiqi Shirin, 27
Silveira` Carlos A. B., 8
Silveira Carlos B., 10
Simmerman Neil, 29
Singer Kiara, 5
Singh Kuldeep, 5
Slavin Moran, 3
Snyder Russell, 20
Sooknarine Celine, 18
Sowby Taralyn C., 21
Spector Chelsea, 7
Spector Chelsea L., 7
Sreeramoju Prashanth, 10
Srivastava Sakshi, 21
Stahl Jonathan, 28
Stanley Lauren, 30
Stark Michael, 22
Stephenson-Moe Christoph, 23
Stoklosa Anne, 21
Sturmer Carolina M., 8
Sucandy Iswanto, 1-6, 9, 11, 15
Sukharamwala Kedar, 29
Sukharamwala Prashant, 29
Suzuki Yukiko, 29
Syblis Cameron, 9
Sydnor Mindy, 29
Syed Radha, 18, 30
T
Talishinskiy Toghrul, 11
Terrell James E., 4
Tew Jenna R., 31
Than Lee Lee, 23
Toba Nagham, 13, 26
Toloza Eric M., 31
Tong Ernest, 26
Tongkam-Godfrey Ashley, 7
Toomey Paul, 23
Touadi Melissa, 2, 11, 15-16
Tougaw Ryan, 23
Trester Richard, 30
Trimmer-Torres Marina, 27
Truong Mireille, 24
U
Uppalapati Pooja, 18
Ur Rehman Ihtesham, 9
Uzianbaeva Liasian, 17
V
Vadher Rakshit, 23
Varela Juan, 32
Vargas Carlos E., 22
Vasicka Ian M., 19
Velez Padilla Jonathan, 16
Vidotto Laura M., 8
Vijay Adarsh, 24
Villarreal Lucy, 20
W
Wang Pengfei, 17
Wang Xiu-Jie, 17
Wang Zhifei, 3, 23
Wessner Scott, 11
Wilson Afia M., 28
X
Xia Jianfu, 3
Xia Minjun, 3
Xia Zhiye, 23
Yaklic Jerome, 20
Y
Yetasook Amy K., 4
Yotsov Tsanko, 28
Yotsov Tsanko Ivelinov, 6
Younos Ahmed, 1-2
Youssef Youssef, 19
Z
Zhang Yu, 26
Zhou Menghui, 3
Zigouras Sophia, 10
Zlatarov Alexander Kamenov, 15