Faculty Bibliography

Background. The SARS-CoV-2 novel coronavirus disease 2019 (COVID-19) pandemic has posed significant challenges to urban health centers across the United States. Many hospitals are reallocating resources to best handle the influx of critical patients. Methods. At our New York City hospital, we developed the ancillary central catheter emergency support service (ACCESS), a team for dedicated central access staffed by surgical residents to assist in the care of critical COVID-19 patients. We conducted a retrospective review of all patients for whom the team was activated. Furthermore, we distributed a survey to the critical care department to assess their perceived time saved per patient. Results. The ACCESS team placed 104 invasive catheters over 10 days with a low complication rate of .96%. All critical care providers surveyed found the service useful and felt it saved at least 30 minutes of procedural time per patient, as patient to critical care provider ratios were increased from 12 patients to one provider to 44 patients to one provider. Conclusions. The ACCESS team has helped to effectively redistribute surgical staff, provide a learning experience for residents, and improve efficiency for the critical care team during this pandemic.

INTRODUCTION/BACKGROUND:Diagnostic laparoscopy (DL) is an increasingly used modality when approaching penetrating abdominal trauma (PAT). Trauma surgeons can utilize this minimally invasive technique to quickly assess for injury in hemodynamically stable patients. DL with a confirmed injury can be repaired through therapeutic laparoscopy (TL) or conversion to exploratory laparotomy (EL). This study analyzes the use of laparoscopy as a first-line therapy for hemodynamically stable patients with PAT. METHODS:Data were reviewed of patients presenting with PAT between December 2006 and September 2016. A retrospective analysis was conducted to analyze demographics, baseline presentations, treatment protocols and outcomes. RESULTS:A total of 56 patients with PAT were initially treated with laparoscopy. Injuries included stab wounds (n = 48) and gunshot wounds (n = 8). Patients were divided into three groups: DL, DL to TL, and DL to EL. Ten patients (17.9%) required conversion to laparotomy (DL to EL). Of the 46 patients who did not require conversion, 33 patients (71.7%) underwent DL, while 13 patients (28.3%) required TL (DL to TL). There were no differences in postoperative complication rates between the groups (p = 0.565). The mean lengths of hospital stay for DL, DL to TL, and DL to EL were 3.1, 2.7, and 8.1 days, respectively (p = 0.038). No missed injuries or mortalities occurred in any of the groups. CONCLUSION/CONCLUSIONS:Laparoscopy can be utilized for hemodynamically stable patients with PAT. DL can be converted to TL in the hands of a skilled laparoscopist. In this study, we analyze the use of DL over a 10-year period in patients who presented to our level 1 trauma center with PAT. We also provide a comprehensive review of literature to create clear definitions, and to clarify a systematic stepwise approach of how to effectively perform DL and TL. This study adds to the body of literature supporting the role of laparoscopy in PAT, and advances the discussion regarding management.

Case Description: A 30-year-old female with no past medical or surgical history presents with a symptomatic right inguinal hernia for 1 month prior to evaluation. She underwent a laparoscopic totally extraperitoneal (TEP) inguinal hernia repair. Three infraumbilical ports were used and the pre-peritoneal space was insufflated to 12 mmHg. Appropriate structures were visualized and the hernia was repaired with mesh in the standard fashion after extensive dissection. She was discharged the same day with no complaints. She returned to the emergency room that night complaining of sharp pleuritic chest pain which radiated to the back and neck. She denied any fevers, dysphagia, cough or shortness of breath. Physical exam was negative for chest wall or neck crepitus. CT chest demonstrated evidence of pneumomediastinum and pneumoperitoneum. She was admitted and observed overnight with improvement of symptoms the following morning. She was discharged after tolerating a diet and without requiring any further interventions.
Discussion(s): Laparoscopic totally extraperitoneal (TEP) inguinal hernia repair is a growing technique amongst minimally invasive surgeons. This approach allows for the repair of all three inguinal spaces (direct, indirect and femoral) as well as bilateral inguinal hernias with only three incisions. Pneumomediastinum is a rare complication after a TEP procedure, with a reported incidence of only 0.1-0.3%. Insufflated carbon dioxide can enter into the thoracic cavity through three fascial planes; subcutaneous fascia, retroperitoneum (myopectineal dissection) or transdiaphragmatic (congenital diaphragmatic hernia or aortic/esophageal hiatus). Each route may present differently ranging from chest wall crepitus to a pneumothorax. Risk factors include high working CO2 insufflation pressures (>10 mmHg), extensive dissection, and prolonged duration of surgery. CO2 diffuses through tissue very rapidly and often patients can be observed for 24 h and managed conservatively. There is no role for repeat imaging as long as the patient remains asymptomatic and stable. Although uncommon, early recognition of pneumomediastinum is important to prevent further complications such as respiratory distress or cardiac compromise. Anesthesiology must be cognizant intraoperatively as a pneumothorax secondary to progressive pneumomediastinum may complicate airway management

Introduction: Diagnostic laparoscopy (DL) is an increasingly used modality when approaching penetrating anterior abdominal injury (PAAI). Historically, exploratory laparotomy (EL) for PAAI can result in a 20% negative laparotomy, 5% mortality and 20% morbidity rate. Laparoscopically trained trauma surgeons can utilize a minimally invasive technique to quickly assess for intra-abdominal organ injury in hemodynamically stable patients. In the hands of a skilled surgeon, PAAI with a confirmed injury can be repaired through therapeutic laparoscopy (TL) or EL without delay in treatment. This study analyzes the safety and efficacy of using DL as a first line therapy for hemodynamically stable patients with PAAI. Methods: Between December 2006 and September 2016, 56 patients underwent DL after presenting to NYU Langone Hospital-Brooklyn Emergency Room with PAAI. A retrospective analysis was conducted to analyze protocol and treatment outcomes. Variables reviewed included Glasgow Coma Scale (GCS), Injury Severity Scale (ISS), FAST exam and/or CT scan results, length of stay (LOS), and postoperative complications. Based on outcomes, patients were cate-gorized into three groups: DL, DL with progression to TL, and DL with conversion to EL. Results: In the study period, a total of 94 patients presented with PAAI that went to the OR, 56 of which were initially treated laparoscopically. Causes of injury included stab wounds, gunshot wounds, traffic accidents, and self-inflicted injuries. The mean age was 40 +/- 12 years. The mean GCS was 14 +/- 2, and the mean ISS was 4 +/- 4. Of the 56 patients who underwent DL, 25 patients (44.6%) required no further intervention (group 1), 21 patients (37.5%) underwent TL (group 2), and 10 patients (17.8%) required EL (group 3). Mean LOS for groups 1, 2 and 3 were 4 +/- 3.3 days, 3 +/- 1.9 days and 6 +/- 4.5 days, respectively. There were no missed injuries or postoperative complications requiring the OR in all groups. TL included diaphragm laceration repairs, control of hepatic laceration and primary bowel repair. Conclusion: Diagnostic Laparoscopy should be considered first line for hemodynamically stable patients with PAAI with equivocal FAST and/or CT scan findings. Eighty-two percent of our patients did not require conversion to EL. This allowed for decreased postoperative pain, quicker recovery time, and shorter hospital stays. When in the hands of laparoscopically trained trauma surgeons, these patients can be quickly and safely treated while avoiding any delays in diagnosis

The current rate of bile duct injury (BDI) after laparoscopic cholecystectomy is 0.4%, which is an unacceptable outcome. Several surgical approaches have been suggested to mitigate the occurrence of this dreaded complication. We propose a standardized approach, using Calot's node as a critical anatomical landmark to guide gallbladder dissection and avoid BDI. We retrospectively analyzed a prospectively gathered database of 907 laparoscopic cholecystectomies using this standardized approach in our practice over a 5-year period. To date we have had no BDI and no cystic duct leak. Therefore, we suggest identification of Calot's node as an additional method to avoid BDI during laparoscopic cholecystectomy.