Faculty Bibliography

Background and Objective: The use of robot technology has greatly expanded the field of general surgery. While robot technology has become almost standard for many general surgeons, there is an increasing interest in how this same technology may be utilized within more specialized fields. We sought to explore the advances and current uses of robot technology within the field of vascular surgery. We evaluated this topic broadly in the context of both the open and endovascular approach. Methods: A comprehensive literature search was employed using the following search strategy on PubMed: ("Robotic Surgical Procedures"[Mesh]) AND ("Vascular Surgical Procedures"[Mesh]). A total of 381 articles were identified. No filters were applied. All articles were then screened manually for applicability. Articles relating to cardiothoracic and neurosurgery were excluded (n=366), as the authors were most interested in performing this literature review from the focus of the vascular surgeon, and procedures involving the heart and brain are outside his or her scope of practice. The remaining (n=15) articles were then utilized to provide a synopsis of the advances made in robotic-assisted procedures within the field of vascular surgery. Key Content and Findings: Robot technology is currently being utilized by vascular surgeons to assist in both open and endovascular procedures. Some typical open procedures wherein the robot has shown to be most effective are in complex aortic reconstruction, first rib resection, venous thrombectomy and venous reconstruction following oncologic resection. In addition to open procedures, there is also evidence that robot technology may offer some benefits in purely endovascular ones, such as in inferior vena cava (IVC) filter retrieval and in standard angiograms. Conclusions: This work highlights that robot technology is greatly expanding the field of vascular surgery. In addition to offering a less invasive approach for both major and minor procedures, robot technology has also led to significant increases in team members"™ safety by decreasing radiation exposure. This review will hopefully act as a catalyst to further expand the use of robot technology in vascular procedures, and by effect increase the value that the vascular surgeon brings to the health care system.

BACKGROUND:New York University Langone Health has three accredited bariatric centers, with 10 different bariatric surgeons. This retrospective analysis compares surgeon techniques in laparoscopic or robotic sleeve gastrectomy (SG) to identify associations with perioperative morbidity and mortality. METHODS:All adults who underwent SG between 2017 and 2021 at NYU Langone Health were evaluated via EMR and MBSAQIP 30-day data. We also surveyed all 10 bariatric surgeons and compared their techniques and total adverse outcomes. Bleeding, SSI, mortality, readmission, and reoperation were specifically sub-analyzed via logistic regression. RESULTS:86 (2.77%) out of 3,104 patients who underwent SG encountered an adverse event. Lower adverse outcomes were observed with a laparoscopic approach, 40-Fr bougie, buttressing, not oversewing the staple line, using hemostatic agents, stapling 3-cm from pylorus, and no routine UGI series. Lower bleeding rates were observed in a laparoscopic approach, 40-Fr bougie, buttressing, not oversewing the staple line, using hemostatic agents, stapling 3-cm from pylorus, no routine UGI series, and not proceeding with SG if hiatal hernia is present. Lower SSI rates were observed with ViSiGi™ bougie, no hemostatic agents, and routine EGD. Lower readmission rates were observed with 40-Fr bougie, buttressing, not oversewing, and stapling 3-cm from pylorus. Hemostatic agents had higher reoperation rates. It was not feasible to test for mortality given the low incidence. CONCLUSION:Certain surgical techniques in SG among our bariatric surgeons had a significant effect on the rates of adverse outcomes, bleeding, readmission, reoperation, and SSI. Our findings warrant further investigation into these techniques via multivariate regression or prospective design. LIMITATIONS:This study was limited by its retrospective and univariate design. We did not account for interaction. The sample size was small, and follow-up of 30 days was relatively short. We did not include patient characteristics in the model or control for surgeon skill.

BACKGROUND:New York University Langone Health has three accredited bariatric centers, with altogether ten different bariatric surgeons. This retrospective analysis compares individual surgeon techniques in laparoscopic or robotic Roux-en-Y gastric bypass (RYGB) to identify potential associations with perioperative morbidity and mortality. METHODS:All adult patients who underwent RYGB between 2017 and 2021 at NYU Langone Health campuses were evaluated via electronic medical records and MBSAQIP 30-day follow-up data. We surveyed all ten practicing bariatric surgeons to analyze the relationship between their techniques and total adverse outcomes. Bleeding, SSI, mortality, readmission, and reoperation were specifically sub-analyzed via logistic regression. RESULTS:54 (7.59%) out of 711 patients who underwent laparoscopic or robotic RYGB encountered an adverse outcome. Lower adverse outcomes were observed with laparoscopic approach, creating the JJ anastomosis first, flat positioning, division of the mesentery, Covidien™ laparoscopic staplers, gold staples, unidirectional JJ anastomosis, hand-sewn common enterotomy, 100-cm Roux limb, 50-cm biliopancreatic limb, and routine EGD. Lower bleeding rates were observed with flat positioning, gold staples, hand-sewn common enterotomy, 50-cm biliopancreatic limb, and routine EGD. Lower readmission rates were observed in laparoscopic, flat positioning, Covidien™ staplers, unidirectional JJ anastomosis, and hand-sewn common enterotomy. Gold staples had lower reoperation rates. Otherwise, there was no statistically significant difference in SSI. CONCLUSION/CONCLUSIONS:Certain surgical techniques in RYGB within our bariatric surgery group had significant effects on the rates of total adverse outcomes, bleeding, readmission, and reoperation. Our findings warrant further investigation into the aforementioned techniques via multivariate regression models or prospective study design. LIMITATIONS/CONCLUSIONS:This study was limited by the inherent nature of its retrospective and univariate statistical design. We did not account for the interaction between techniques. The sample size of surgeons was small, and follow-up of 30 days was relatively short. We did not include patient characteristics in the model or control for surgeon skill.

BACKGROUND:Many insurance companies mandate medically supervised weight loss programs (MSWLPs) prior to bariatric surgery. This retrospective study aims to elucidate whether the average 6-month preoperative medical-management period decreases preoperative BMI for those with BMI ≥ 50. METHODS:All adult patients with bariatric consultation at any time at the New York University Langone Health campuses during the period 2015 to 2021 were evaluated via electronic medical records. Only patients with ≥ BMI 50, without previous bariatric surgeries, and those with 6-month insurance-mandated medical visits were included. A paired t-test was performed on the difference in BMI and percent-weight loss among the subjects at least 6 months before surgery and on the day of surgery. RESULTS:Of the 130 patients with BMI ≥ 50, undergoing preoperative 6-month office weigh-ins, the mean difference in BMI was - 1.51 (P < 0.01). The mean total body weight loss was 4.8% (P < 0.01). There were no intraoperative complications nor 30-day complications or mortality in the group. CONCLUSIONS:We found that there was weight loss during the 6-month insurance-mandated medical management prior to surgery, but the amount (4.8%) did not reach the goal target of 10% of body weight. We found that there were no complications and question the need for prolonged delay to surgery.

Introduction: Many insurance companies mandate a minimum of a 6-month preoperative medical intervention prior to bariatric surgery. It has been conventional experience that this does not make a difference in BMI prior to surgery. This cross-sectional study is an effort towards elucidating whether or not a 6-month preoperative medical intervention makes any difference in preoperative BMI.
Method(s): All adult patients with bariatric consultation at any time at the New York University Langone Health campuses during the period 2015 to 2021 were evaluated via electronic medical records. Only patients with>BMI 50 on initial visit and those without previous bariatric surgeries at other institutions were included. Along with BMI and weight, baseline characteristics were obtained during this perioperative period. A paired t-test was performed on the difference in BMI and percent-weight loss among the subjects at least 6 months before surgery and the same subjects right before surgery. Additionally, sub-group analysis was performed on those that had>5% weight loss.
Result(s): Of the 130 super-morbidly obese patients undergoing preoperative medical intervention, by the time of surgery there was a statistically significant mean difference in BMI of-1.51, standard deviation 3.26 with a p-value of<0.01. There was also a statistically significant mean difference in percent-weight loss of 0.048, standard deviation 0.11 with a p-value of<0.01. Furthermore, there were no observed intraoperative complications nor 30-day mortality.
Conclusion(s): We found that BMI and percent-weight loss is present and is statistically significant, but these small differences have little clinical significance given that the goal target of medical preoperative weight-loss is typically 5-10% body weight. This study provides additional data to suggest that mandatory preoperative medical interventions in the super morbidly obese may make no difference in BMI nor operative outcomes, and warrants further study in the form of cohort design

Techniques for laparoscopic Roux-en-Y gastric bypass vary in the creation of the jejuno-jejunostomy and the gastro-jejunostomy. Here we share the principles of the key steps in our long experience with this procedure and the evolution to its present-day form. First, patient positioning involves supine position without the need for steep reverse Trendelenburg. In conjunction, subcostal port placements play a critical role for exposure, including one for liver retraction using a grasper holding the diaphragm from the subxiphoid port to give adequate exposure. In case of poor visualization due to size of the liver, mobilization of the left lateral segment of the liver allows work to be done anterior to it. Second, starting with the creation of the jejuno-jejunostomy allows for freedom of movements and fluid creation of the anastomosis. Critical to this step is no division of the mesentery, to reduce risk of internal hernia. No stay sutures are needed. Common enterotomy is closed in a single layer hand-sewn anastomosis. Mesentery is closed with interrupted sutures with the inclusion of the "Brolin stitch" to prevent intussusception. Third, the G-J anastomosis has evolved in the past 20 years, starting with the laparoscopic retrocolic retrogastric anastomosis with the EEA 21 mm with a short biliary limb in 1997. Between 2000-2001, the technique shifted to retrocolic retrogastric side-to-side anastomosis with the GIA and handsewn entero-enterostomy (with a longer biliary limb of 100 cm). Since 2004, the technique now involves antecolic antegastric single-layer handsewn anastomosis without any division of mesentery. Vagus nerve is left intact during dissection and pouch creation. With 857 cases using this current technique, there has been 1 anastomotic leak, 1 leak from pouch due to infected hematoma, 1 internal hernia, 16 marginal ulcers (1.87%), 1 mortality, and 1 aborted case

BACKGROUND:Laparoscopic cholecystectomy is still fraught with bile duct injuries (BDI). A number of methods such as intra-operative cholangiography, use of indocyanine green (ICG) with infrared imaging, and the critical view of safety (CVS) have been suggested to ensure safer Laparoscopic cholecystectomy (LC).To these, we add posterior infundibular dissection as the initial operative maneuver during LC. Here, we report specific technical details of this approach developed over 30 years with no bile duct injuries and update our experience in 1402 LC. METHODS:In this manuscript, we present a detailed and illustrated description of a posterior infundibular dissection as the initial approach to laparoscopic cholecystectomy (LC). This technique developed after thirty years of experience with LC and have used it routinely over the past ten years with no bile duct injury. RESULTS:Between January of 2010 and December 2019, 1402 Laparoscopic cholecystectomies were performed using the posterior infundibular approach. Operations performed on elective basis constituted 80.3% (1122/1402) and 19.97% were emergent (280/1402). One intra-operative cholangiogram was performed after a posterior sectoral duct was identified. There was one conversion to open cholecystectomy due to bleeding. There were 4 bile leaks that were managed with endoscopic retrograde cholangio-pancreatography (ERCP). There were no bile duct injuries. CONCLUSION/CONCLUSIONS:Adopting an initial posterior mobilization of the gallbladder infundibulum lessens the need for medial and cephalad dissection to the node of Lund, allowing for a safer laparoscopic cholecystectomy. In fact the safety of the technique comes from the initial dissection of the lateral border of the infundibulum. The risk of BDI can be reduced to null as was our experience. This approach does not preclude the use of other intra-operative maneuvers or methods.

BACKGROUND:Laparoscopic repair of large paraesophageal hiatal hernia with defects too large to close primarily or greater than 8 cm is technically challenging. The ideal repair remains unclear and is often debated. Utilizing the gastric fundus as an autologous patch to obliterate and tamponade large hiatal defects may offer a new solution. The aim of this study was to evaluate the short-term outcomes following partial posterior fundoplication with gastric fundus tamponade. METHODS:Retrospective chart review and prospective patient follow up was conducted on patients who underwent laparoscopic hiatal hernia repair between 2015 and 2019 by a single surgeon. Basic demographics, pre-operative diagnoses, operative technique, and clinical outcomes were recorded. RESULTS:Fifteen patients underwent the described technique for repair of large paraesophageal hiatal hernia. All procedures were completed laparoscopically with a short post-operative length of stay (mean of 3 days) and no 30-day readmissions. The majority of patients reported resolution of their pre-operative symptoms. Only one patient required surgery for emergent indications and the same patient was the only mortality in the study, which was secondary to respiratory failure, necrotizing pneumonia, and sepsis as a result of gastric volvulus and obstruction. CONCLUSION/CONCLUSIONS:Utilizing the gastric fundus as an autologous patch to repair large hiatal hernia may be a safe and efficacious solution with good short-term outcomes. However, further studies should be conducted to elucidate long-term results.

In 2014 the International Endohernia Society (IEHS) published the first international "Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias". Guidelines reflect the currently best available evidence in diagnostics and therapy and give recommendations to help surgeons to standardize their techniques and to improve their results. However, science is a dynamic field which is continuously developing. Therefore, guidelines require regular updates to keep pace with the evolving literature.

Background: We present a case of a 33-year-old female that underwent a laparoscopic Roux-En-Y gastric bypass 5 months prior that subsequently developed a gastrojejunostomy stricture treated with endoscopic balloon dilation. Following her third balloon dilation she developed severe abdominal pain and was found to have free air on an upright abdominal x-ray. The patient was immediately brought to the operating room for a diagnostic laparoscopy which demonstrated an anterior perforation of the gastrojejunostomy anastomosis. The decision was made to revise the anastomosis by performing a stricturoplasty where the perforation was extended longitudinally and closed transversely with interrupted silk sutures to both repair the perforation and resolve the anastomotic stricture. The patient had an uncomplicated postoperative course. Gastrojejunostomy strictures are a common complication after laparoscopic Roux-En-Y gastric bypass. There are multiple factors that may lead to the formation of a stricture including marginal ulcers or technical error. Anastomotic strictures are often managed endoscopically with serial balloon dilations. However, if endoscopy fails to relieve the stricture, the patient may need to undergo a laparoscopic gastrojejunostomy revision, which can be morbid. Additionally, anastomotic perforation represents a surgical emergency that warrants immediate exploration. This case presents a unique situation where both situations are present and more conservative measures such as endoscopic stenting are not feasible. By performing a revision stricturoplasty, we attempted to repair the perforation as well as lengthen the anastomosis to relieve the stenotic area. [Figure presented]
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