Faculty Bibliography

Robotic-assisted abdominal wall repair (RAWR) has seen an exponential adoption over the last 5 years. Skepticism surrounding the safety, efficacy, and cost continues to limit a more widespread adoption of the platform. We describe our initial experience of 312 patients undergoing RAWR at a large academic center. A retrospective review of all patients undergoing any RAWR from July 1, 2016 to March 18, 2020 was completed. Patient specific, operation specific, and 30-day outcomes specific data were collected. Univariate analysis and multivariate logistic regression were used to assess factors associated with 30-day complications. There was a steady adoption of RAWR over the study period. A total of 312 patient were included, 138 (44%) were abdominal wall repairs and 174 (56%) were inguinal repairs. The mean age of the cohort was 54.2 years (SD 16), 69% were males, and the mean BMI was 29 kg/m² (SD 4.8). There were two reported intraoperative events and nine operative conversions. 60 patients had at least one complication at 30-days. These include: 52 seromas, 4 hematomas, 2 surgical-site infections, 1 deep venous thrombus, and 1 recurrence at 30-days. BMI, type of hernia, and sex were not associated with complications at 30-days. The use of absorbable mesh, longer hospital stay, operative conversion, previous repair, and expert hernia surgeon were significant predictors of 30-day complications. Age, operative conversion, and previous repair were the only predictors of 30-day complications on multivariate regression. Our initial experience of 312 patients demonstrates the adoption and comparable short-term outcomes for a wide variety of robotic-assisted hernia repairs.

BACKGROUND:The safety of surgery in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-positive patients remains unclear. On the basis of data from other viral diseases, it has been assumed that coronavirus disease 2019 (COVID-19) has the potential risk of transmission during surgery. The presence of the virus within the peritoneal fluid and the peritoneal tissues is not known. MATERIALS AND METHODS/METHODS:This is a prospective cross-sectional study including adult patients with confirmed COVID-19 who underwent surgery at a single institution. Using specific real-time reverse transcriptase-polymerase chain reaction, the presence of SARS-CoV-2 was determined in abdominal fluid samples. RESULTS:Six patients with COVID-19 underwent abdominal surgery. Five patients were asymptomatic, and 1 had severe disease. SARS-CoV-2 was tested in 20 different samples, all of which resulted negative. CONCLUSIONS:SARS-CoV-2 was not found in the peritoneal cavity of 6 patients undergoing abdominal surgery. The risk of transmissibility of COVID-19 during surgery is still unclear.

BACKGROUND:Lateral incisional hernias arise between the linea alba and the posterior paraspinal muscles. Anatomical boundaries contain various topographic variations, such as multiple nearby bony structures and paucity of aponeurotic tissue that make it particularly challenging to repair. AIM/OBJECTIVE:To describe a robotic assisted surgical technique for incisional lumbar hernia repair. METHODS:Retrospective data was collected from four patients who underwent robotic-assisted repair of their lumbar hernias after open nephrectomies. RESULTS:Age ranged from 41-53 y. Two patients had right sided flank hernias while the other two on the left. One patient had a recurrent hernia on the left side. The patients were placed in lateral decubitus position contralateral to the hernia defect side. A trans-abdominal preperitoneal approach was used in all cases. Each case was accomplished with two 8 mm robotic ports, a 12 mm periumbilical port, and a 5 mm assistance port that allowed docking on the ipsilateral hernia side. The hernias were identified, a preperitoneal plane was created, and the hernia sac completely dissected allowing for complete visualization of the defect. All defects were primarily closed. Polypropylene or ProGripTM mesh was applied with at least 5 cm overlap and secured using either #0 Vicryl® transfacial sutures, Evicel® or a combination of both. The peritoneal space was closed with running suture and the ports were removed and closed. The average surgical length was 4 hr. The post-operative length of stay ranged from 0-2 days. CONCLUSION/CONCLUSIONS:The robotics platform may provide unique advantages in the repair of lateral incisional hernias and represents a safe, feasible and effective minimally invasive approach for the correction of lateral incisional hernias.

INTRODUCTION/BACKGROUND:In recent decades, minimally invasive approaches have found their place in treating a specific subset of patients with inguinal hernias, predominantly those with recurrent or bilateral disease. Classically, prior history of urologic pelvic operations, such as prostatectomy, has been listed as relative contraindication for minimally invasive inguinal hernia repair. As the adoption of the robotics platform continues to grow, we aim to outline a feasible robotic-assisted inguinal hernia repair technique in patients with previous prostatectomies. We report the outcomes of 15 patients who underwent repair at 2 institutions. METHODS:This is a retrospective case series of 15 patients who underwent robotic transabdominal preperitoneal approach repair of their inguinal hernias after prostatectomy. Demographics, intraoperative variables, and outcomes of our cases are described. RESULTS:Fifteen patients were included in our cohort. All patients had a history of prostatectomy (7 open, 2 laparoscopic, and 6 robotic) due to prostate cancer. Median age was 70 years old (range: 60 to 89 y), with a median body mass index of 26.3 kg/m2 (range: 20.5 to 37.4 kg/m2). Hernia defects were bilateral in 6 patients and unilateral in the remaining 9 (right; 6, left; 3). The shortest interval between prostatectomy and subsequent hernia repair was 4 months (range: 4 to 216 mo). The median operative time was 139 min (range: 91 to 281 min). All defects were repaired using a polypropylene mesh except in 1 case, where a coated monofilament polyester mesh was used after having a large peritoneal defect to close, preventing future adhesions to the bowel. Mesh sizes used were large (16×11 cm), extra-large (17×12 cm) for anatomic mesh, and 20×15 cm for the monofilament polyester mesh. The mesh was fixed in 14 of 15 cases. Fixation was accomplished with absorbable suture (n=13), barbed suture (n=1), and fibrin sealant (n=1). Peritoneal closure was always performed using a continuous running v-loc suture. There were no documented major intraoperative complications, no 30-day readmission, or recurrences recorded within the follow-up period. Postoperatively, only 2 seromas and 1 hematoma were documented during the follow-up period. CONCLUSIONS:Robotic inguinal hernia repairs in patients with previous prostatectomy is safe and feasible in most patients. Larger patient series are needed to confirm these findings.

BACKGROUND:Hepatobiliary Scintigraphy (HIDA) aids the diagnosis of acute cholecystitis (AC) but has limitations. We sought to design a model based on the Tokyo Guidelines 2018 (TG18) to predict HIDA results. METHODS:A retrospective review of patients who underwent a HIDA scan during the evaluation of AC was performed. Using logistic regression techniques incorporating the TG18 criterion and additional readily available patient characteristics, a prediction model was created to identify patients likely to test negative for acute cholecystitis by HIDA scan. RESULTS:In 235 patients with suspected AC, a HIDA scan was performed. Variables associated with positive HIDA results were male gender (RR 2.0 (CI 1.33-2.99), age (OR 1.02 (CI 1.01-1.04), right upper quadrant tenderness (RR 1.7 (CI 1.1-2.8)), clinical Murphy's sign (RR 2.2 (CI 1.5-3.4)), ultrasound findings suggestive of AC by any of its components (RR 3.2 (CI 1.6-6.5)), gallbladder wall thickening (RR 2.0 (CI 1.3-3.1)), and gallbladder distention (RR 1.9 (CI 1.3-2.9)). These variables allowed for creation of a model to predict HIDA results. The model predicted HIDA results in 36.9% of patients with an area under the curve of 0.81. CONCLUSIONS:In the era of TG18, HIDA is probably over utilized. We developed an accurate, simple model based on TG18 that identifies a group of patients for whom a HIDA scan is unnecessary to establish the diagnosis of AC.

BACKGROUND:Bariatric surgery is one of the most effective treatments for patients with severe and complex obesity. Lifestyle modifications in diet and exercise habits have long been important adjunct to the long-term success after bariatric surgery. The effect of the COVID-19 pandemic on the postoperative bariatric patient is not well understood. We sought to evaluate the impact the COVID-19 pandemic on postoperative weight loss at 1 year in a bariatric cohort. METHODS:All patients who underwent bariatric surgery from January 1, 2020, to March 12, 2020, were included. Patients who underwent bariatric surgery during the same period of the two preceding years (2018 and 2019) were included as control groups. Primary end point was %EBMIL at 1 year. A telephone survey was administered to all patients from 2020 to assess for their perception on the effects of the COVID-19 pandemic on weight loss. RESULTS:A total of 596 patients were included: 181 from 2020, 199 from 2019, and 216 from 2018. The response rate was 97% and 53.4% of patients reported that the lockdown affected their ability to lose weight. The %EBMIL at 1 year was 64.1%, 63.7%, and 68.1% for 2020, 2019, and 2018, respectively. There was no difference in weight loss at 1 year (p = 0.77) despite a decrease in exercise activity in those who had surgery just before the pandemic. CONCLUSION:There was no difference in target weight loss at 1 year in a cohort who underwent bariatric surgery before the pandemic.