Background
In 2017, the utilization of robotic-assisted surgery had grown 10–40-fold relative to laparoscopic surgery in common general surgery procedures. The rapid rise in the utilization of ...robotic-assisted surgery has necessitated a standardized training curriculum. Many curricula are currently being developed and validated. Additionally, advancements in virtual reality simulators have facilitated their integration into robotic-assisted surgery training. This review aims to highlight and discuss the features of existing curricula and robotic-assisted surgery training simulators and to provide updates on their respective validation process.
Materials and methods
A literature review was conducted using PubMed from 2000–2019 and commercial websites. Information regarding availability, content, and status of validation was collected for each current robotic-assisted surgery curriculum. This review did not qualify as human subjects research, so institutional review board approval was not required.
Results
The daVinci Technology Training Pathway and Fundamentals of Robotic Surgery are purely web-based and self-paced robotic-assisted surgery training. The Society of American Gastrointestinal and Endoscopic Surgeon Robotic Masters Series, Fundamental Skills of Robot-Assisted Surgery training program, and the Robotics Training Network curriculum require trainees to be on site in order to provide expert feedback on surgical techniques and robot maintenance. Currently, there are few virtual reality simulators for robotic-assisted surgical training available on the market.
Conclusions
Didactic courses are available in all of these training programs, but their contents are inconsistent. Furthermore, the availability and nature of hands-on training offered by these curriculums are widely variable.
Background
We aimed to examine the outcomes and utilization of different hiatal hernia repair (HHR) approaches in elective and emergent/urgent settings. Methods: Vizient 2015–2017 database was ...queried for adult patients who underwent HHR. Patients were grouped into open (OHHR), laparoscopic (LHHR), or robotic-assisted (RHHR), and further stratified by elective or urgent status and severity of illness at admission. Surgical outcomes and costs were compared across all groups. Statistical analysis were done using SPSS v.25.0.
Results
9171 adults were included (OHHR
N
= 1534;LHHR
N
= 6796;RHHR
N
= 841). LHHR was the most utilized approach (74.1%), followed by OHRR (16.7%) and RHHR (9.2%). OHHR was employed three times as frequently in U settings, compared to elective. Overall, OHHR had longer mean length of stay (LOS; 9.41 vs. < 4 days) and higher postoperative complication rates (8.8% vs < 3.8%), mortality (2.7% vs < 0.5%) and mean direct cost ($27,842 vs < $10,407), when compared to both LHHR and RHHR, all
p
< 0.05. Analysis of mild to severely ill elective cases demonstrated LHHR and RHHR to be better than OHHR regarding complications (
p
< 0.05), cost (
p
< 0.001) and LOS (
p
< 0.013); there were insufficient extremely ill elective patients for meaningful analysis. In the urgent setting, minimally invasive approaches predominate, overtaken by OHHR only for the extremely ill. Despite the urgent setting, for mild-moderately ill patients, OHHR was statistically inferior to both LHHR and RHHR for LOS (
p
= 0.002,
p
< 0.0001) and cost (
p
= 0.0133,
p
< 0.001). In severe-extremely ill patients, despite being more utilized, OHHR was not superior to LHHR; in fact, complication, cost, and mortality trends (all
p
> 0.05) favored LHHR.
Conclusion
Our analysis demonstrated LHHR to currently be the most employed approach overall. LHHR and RHHR were associated with lower cost, decreased LOS, complications, and mortality compared to OHHR, in all but the sickest of patients. Patients should be offered minimally invasive HHR, even in urgent/emergent settings, if technically feasible.
Obesity and gastroesophageal reflux disease (GERD) are prevalent in Western populations. In obese patients, high-resolution manometry often shows altered gastroesophageal pressure gradients, ...promoting retrograde gastric content flow into the esophagus and esophagogastric junction disruption, leading to a hiatal hernia. Hernia recurrence is higher in the obese, and recurrence is seen regardless of the operative approach used. Bariatric surgery is the gold-standard treatment for GERD in obese patients, and symptom improvement varies depending on the specific bariatric procedure performed, Roux-en-Y (RYGB), laparoscopic adjustable gastric banding (LAGB), or sleeve gastrectomy (SG). Studies have shown these surgeries significantly improve GERD, but RYGB had the greatest effect. Limited data is available examining the progression or regression of Barrett’s following bariatric surgery. We currently recommend RYGB for morbidly obese patients with Barrett’s esophagus.
Background
Women surgeons may experience more ergonomic challenges while performing surgery. We aimed to assess ergonomics between men and women surgeons.
Methods
Laparoscopic surgeons from a single ...institution were enrolled. Demographics and intraoperative data were collected. Muscle groups were evaluated objectively using surface electromyography (EMG; TrignoTM, Delsys, Inc., Natick, MA), and comprised upper trapezius (UT), anterior deltoid, flexor carpi radialis (FCR), and extensor digitorum (ED). Comparisons were made between women (W) and men (M) for each muscle group, assessing maximal voluntary contraction (MVC) and median frequency (MDF). The Piper Fatigue Scale-12 (PFS-12) was used to assess self-perceived fatigue. Statistical analyses were performed using SPSS v26.0,
α
= 0.05.
Results
18 surgeries were recorded (W:8, M:10). Women had higher activation of UT (32% vs 23%,
p
< 0.001), FCR (33% vs 16%,
p
< 0.001), and ED (13% vs 10%,
p
< 0.001), and increased effort of ED (90.4 ± 18.13 Hz vs 99.1 ± 17.82 Hz). Comparisons were made between W and M for each muscle group, assessing MVC and MDF.
Conclusions
After controlling for surgeon’s height and duration of surgery, an increase in muscle activation was seen for women laparoscopic surgeons. Since poor ergonomics could be a major cause of work-related injuries, we must understand differences in ergonomics between men and women and evaluate which factors impact these variations.
This study sought to evaluate surgical outcomes, cost, and opiate utilization of patients who underwent laparoscopic (LC) or robotic cholecystectomy (RC).
The Vizient database was queried for ...patients admitted with mild to moderate severity of illness (SOI) scores who underwent LC or RC from January 2015 through December 2017. Rates of overall complications, postoperative infection, mortality, LOS, cost, and opiate utilization were compared between groups using IBM SPSS v.25.0, α = 0.05.
91,849 patients (LC:N = 89,878; RC:N = 1,971) met the inclusion criteria. Robotic approach was associated with more complications (LC:0.9%, RC:1.7%; p < 0.001), postoperative infections (LC:0.2%, RC:0.4%; p = 0.033) and a higher direct cost (LC:$6782 ± 3421, RC:$9354 ± 5497; p < 0.001). Opiates were prescribed more frequently in the laparoscopic group (LC:98.3%, RC:97.2%; p = 0.002).
The direct cost of RC is significantly higher than LC with no added benefit. Routine use of the robotic platform for cholecystectomy should be discouraged until costs are reduced.
•Cost of robotic cholecystectomy remains significantly higher than laparoscopy.•Robotic approach is associated with increased rate of complications and infection.•Use of the robotic platform does not improve outcomes for patients with obesity.
The Vizient database was queried for patients admitted with mild to moderate severity of illness scores who subsequently underwent laparoscopic or robotic cholecystectomy for biliary disease. Robotic approach was associated with a significantly higher direct cost and slightly increased rates of overall complications and postoperative infection.
Paraesophageal hernia Oleynikov, Dmitry; Jolley, Jennifer M
The Surgical clinics of North America,
06/2015, Letnik:
95, Številka:
3
Journal Article
Recenzirano
The treatment of PEHs is challenging. They tend to occur in patients in their 60s and 70s with multiple medical problems and a variety of associated symptoms. Detailed preoperative evaluation is ...crucial to determining a safe and effective strategy for repair in the operating room. Laparoscopic PEH repair has shown to be advantageous compared with conventional open repair with regard to hospital stay, recovery time, and decreased complications. Although some results indicate there are higher recurrence rates in laparoscopic PEH repair, the clinical significance of these recurrences has not yet been determined. In order to maximize the efficacy of this procedure, modifications have emerged, such as performing a fundoplication and using an absorbable mesh onlay to reinforce the cruroplasty. Althoughmoreprospective, randomized studies are needed to support the superior results of these surgical adjuncts, laparoscopic PEH repair with an antireflux procedure and absorbable mesh should be the current standard of care.
Abstract Background Morbidity and mortality are very high for critically ill patients who develop acute acalculous cholecystitis (AAC). The aim of this study was to compare outcomes in extremely ill ...patients with AAC treated with percutaneous cholecystostomy (PC), laparoscopic cholecystectomy (LC), or open cholecystectomy (OC), which were also analyzed together in the LC-plus-OC (LO) group. Methods Discharge data from the University HealthSystem Consortium database were accessed using International Classification of Diseases codes. The University HealthSystem Consortium's Clinical Data Base/Resource Manager allows member hospitals to compare patient-level, risk-adjusted outcomes. Multivariate regression models for extremely ill patients undergoing PC or LO for the diagnosis of AAC were created and analyzed. Results A total of 1,725 extremely ill patients were diagnosed with AAC between October 2007 and June 2011. Patients undergoing PC (n = 704) compared with the LO group (n = 1,021) showed decreased morbidity (5.0% with PC vs 8.0% with LO, P < .05), fewer intensive care unit admissions (28.1% with PC vs 34.6% with LO, P < .05), decreased length of stay (7 days with PC vs 8 days with LO, P < .05), and lower costs ($40,516 with PC vs $53,011 with LO, P < .05). Although perioperative outcomes of PC compared with LC were statistically similar, PC had lower costs compared with LC ($40,516 vs 51,596, P < .005). Multivariate regression analysis showed that LC (n = 822), compared with OC (n = 199), had lower mortality (odds ratio OR, .3; 95% confidence interval CI, .1 to .6), lower morbidity (OR, .4; 95% CI, .2 to .7), reduced intensive care unit admission (OR, .3; 95% CI, .2 to .5), and similar 30-day readmission rates (OR, 1.0; 95% CI, .6 to 1.5). Also, decreased length of stay (7 days with LC vs 8 days with OC) and costs ($51,596 with LC vs $61,407 with OC) were observed, with a 26% conversion rate to an open procedure. Conclusions On the basis of this experience, extremely ill patients with AAC have superior outcomes with PC. LC should be performed in patients in whom the risk for conversion is low and in whom medical conditions allow. These results show PC to be a safe and cost-effective bridge treatment strategy with perioperative outcomes superior to those of OC.
Background
This study compares the impact of open (OIHR) versus laparoscopic (LIHR) inguinal hernia repair on healthcare spending and postoperative outcomes.
Methods
The TRUVEN database was queried ...using ICD9 procedure codes for open, laparoscopic, and robotic-assisted IHR, from 2012 to 2013. Patients > 18 years of age and continuously enrolled for 12 months postoperatively were included. Demographics, patient comorbidities, postoperative complications, pain medication use, length of hospital stay, missed work hours, postoperative visits, and overall expenditure were collected, and assessed at time of surgery and at 30-, 60-, 90-, 180-, and 365-days postoperatively. Statistical analysis was conducted using SAS, with
α
= 0.05.
Results
66,116 patients were included (LIHR:
N
= 23,010; OIHR:
N
= 43,106). Robotic-assisted procedures were excluded due to small sample size (
N
= 61). The largest demographic was males between 55 and 64 years. LIHR had fewer surgical wound complications than OIHR (LIHR: 0.3%; OIHR: 0.5%,
p
= 0.007), less utilization of pain medication (LIHR: 23.3%; OIHR: 28.5%;
p
< 0.001), and fewer outpatient visits. In the 90-day postoperative period, LIHR had significantly fewer missed work hours (LIHR: 12.1 ± 23.2 h; OIHR: 12.9 ± 26.7 h,
p
= 0.023). LIHR had higher postoperative urinary complications (LIHR: 0.2%; OIHR: 0.1%;
p
< 0.001), consistent with the current literature. LIHR expenditures ($15,030 ± $25,906) were higher than OIHR ($13,303 ± 32,014),
p
< 0.001.
Conclusions
The results highlight the benefits of laparoscopic repair with regard to surgical wound complications, postoperative pain, outpatient visits, and missed work hours. These improved outcomes with respect to overall healthcare spending and employee absenteeism support the paradigm shift toward laparoscopic inguinal hernia repairs, in spite of higher overall expenditures.
Background
Approximately 10% of patients receiving anti-reflux procedures present with shortened esophagus. Collis gastroplasty (CG) is the current gold standard for esophageal lengthening, but ...mediastinal esophageal mobilization without gastroplasty may be an alternative approach. This study assesses preoperative and intraoperative hernia characteristics and mediastinal dissection impact in patients with large hiatal hernia repair (HHR).
Methods
A single-institution, prospectively collected database was reviewed for adults who underwent laparoscopic HHR with mesh and anti-reflux surgery between 2005 and 2016, hernia ≥ 5 cm. Preoperative hernia and follow-up were assessed using upper endoscopy and barium swallow. Intraoperative hernia characteristics were collected from the operative note. Esophageal symptom scores were collected pre- and postoperatively. Analyses were conducted using SPSS v26.0.
Results
Among 662 patients who had anti-reflux surgery in this period, a total of 205 patients who underwent HHR with mesh met the inclusion criteria and were included in study. Mean age was 61.7 ± 13.6 years, and majority of patients were female and Caucasian. Mean BMI was 29.9 ± 6.0 kg/m
2
. Median hernia size was 6.5 cm 5.0–12.0 cm, and intra-thoracic stomach had a prevalence of 21.9%. Analysis of preoperative barium swallow revealed an average of elevated gastroesophageal junction above the diaphragm of 4.10 ± 1.67 cm. Radiographically, average hernia size was 6.34 ± 1.93 cm and 6.38 ± 1.92 cm in the anterior–posterior and obliquus view, respectively. Median follow-up time was 2.7 years 1–9 years. Esophageal symptoms improved in all patients (
p
< 0.05). 45% of patients had radiographic recurrence, but only four presented symptomatic or were on PPI.
Conclusions
CG has been the standard for ensuring adequate esophageal length prior to anti-reflux surgery. Our results support that CG is unnecessary in the majority of cases, and extensive mediastinal dissection was successfully used instead of CG with durable, long-term outcomes. Extended mediastinal dissection may mitigate CG risks in patients requiring additional intra-abdominal esophagus.
