Faculty Bibliography

Background: Inguinal hernia repair is one of the most common general surgery procedures with over 600,000 performed annually in the United States. When compared to traditional open inguinal hernia repair (OIHR), laparoscopic inguinal hernia repair (LIHR) has been associated with faster postoperative recovery rates and lower postoperative pain. With advances in the robotic platform, robotic inguinal hernia repair (RIHR) is an available technique that is currently being explored. This study examines LIHR and RIHR as described in literature to see if one is superior to the other. Study Design: Search terms: "Inguinal Hernia Repair" "Robotic Inguinal Hernia Repair," "Laparoscopic Inguinal Hernia Repair." A systematic search was performed in August 2017 of Medline, PubMed, and relevant journals using the above-listed search terms. Out of 80 articles found, only 8 were suitable for this content review. Results: Operative time in RIHR averaged 99 minutes as compared to 68 minutes in LIHR. Patients undergoing RIHR had an average complication rate of 5% with a recurrence rate of 0.06%. For obese patients, a lower percentage experienced postoperative complications when undergoing RIHR as compared to OIHR (unadjusted: 2.7% vs. 11.5%, p=0.005; and matched: 3.2 % vs. 10.8%, p=0.047), with bilateral robotic repairs more easily conducted in obese patients (unadjusted 29.7% vs. 16.8%, p=0.019; and unadjusted 35.1% vs. 11.5%, p\0.0001-respectively). More complicated procedures were performed using R-TAPP (n=11 vs. n=1, p=0.0001) with nearly identical (69.12 +/-35.13 min, R-TAPP; 69.05+/-26.31, L-TEP) intraoperative and postoperative complication rates. Similarly, average pain scores in recovery (2.5 vs 3.8, p=0.02) were significantly less after R-TAPP. However, mean operative time (77.5 vs 60.7 min, p=0.001) and room time (109.3 vs 93.0 min, p=0.001) were longer but with less recovery time and reported pain. Surgical complications including hematomas (3.9%), seromas (2.6%), and trocar site infection (1.3%) resolved with antibiotics, with a 2.6% postoperative complication rate. Conclusion: RIHR repair is a safe alternative to LIHR, with fewer postoperative complications and a faster recovery time. However, operative time as well as OR room time is significantly longer, which may increase overall cost. Further high quality randomized controlled trials are needed to assess efficacy and outcomes of RIHR

Introduction: Acute cholecystitis is a common surgical disease with roughly 500,000 cholecystectomies performed in the US annually. The current dogma revolves around the "72 hour rule" advocating early cholecystectomy if within the window, and if beyond 72 hours, conservative treatment and interval operation. In patients beyond the 72 hour window, as well as with multiple comorbidities, advanced age, and other complicating factors, cholecystostomy has become an acceptable treatment as a bridge to interval cholecystec-tomy. While this has become an appropriate treatment modality, it does not come without its own set of complications. We aim to evaluate the rate of complications in our institution. Methods: This is a retrospective review of all patients at our institution who underwent cholecystostomy placement between 2013 and 2016. We evaluate the comorbidities, readmission rate, overall rate of complication associated with cholecystostomy tubes, and eventual definitive cholecystectomy. Results: Our cohort includes 100 patients, 52% of whom were male, with a mean age of 71. We had an overall complication rate of 49.5%, including tube dislodgements, leaking tubes, and misplaced tubes. All cause readmission rate was 56% and only 32% of patients who had cholecystostomy drains underwent interval cholecystectomy. Conclusion: There has been much interest in treatment of acute cholecystitis in patients with multiple comorbidities. In review of our data, a surprisingly large number of patients had mechanical complications involving the cholecystostomy drain. In an era focused on decreasing readmission rates and their associated costs, drains carry a high risk of mal-function which will in turn, lead to increases in these two metrics. While there is more work to be done in the evaluation of early cholecystectomy versus cholecystostomy in this subgroup of patients, we suspect that early cholecystectomy in the medically optimized patient will lead to reduced length of stay and hospital costs as well as increased patient satisfaction

Background: Morbid obesity, a common medical concern with significant health risks, has a prevalence of 10.4% among U.S. adults. Bariatric surgery provides effective weight loss for morbidly obese patients with improvement in their comorbid conditions. Traditionally, routine intraoperative drain placement (IDP) and postoperative esophagram (UGIS) were thought to identify early postoperative complications. Recently, these interventions have been scrutinized for their effectiveness. We hypothesized that IDP and postoperative UGIS do not alter outcomes in bariatric surgery and only increase hospital length of stay (LOS). Methods: Two cohorts, each consisting of 100 patients from either 2015 or 2017 were analyzed from our institution. In the 2015 cohort, all patients had IDP and an UGIS on postoperative day 1, prior to starting a clear liquid diet. In the 2017 cohort, no patients had IDP or UGIS, but instead were started on a clear liquid diet on postoperative day 1, in the absence of vomiting. All patients in each cohort underwent either a laparoscopic sleeve gastrectomy or a Roux-en-Y gastric bypass. A retrospective study was performed to analyze whether there was a significant difference in post-operative complications, length of stay, and operating room time between these two cohorts. Results: The average bariatric procedure duration was 85.04 minutes in 2015 as compared to 124.68 minutes in 2017, with a p-value of\0.001. This discrepancy can be attributed to the greater number of surgeons operating in 2017, 8 in 2017 compared to 3 in 2015. The length of stay in 2015 averaged 2.42 days, compared to 1.44 days in 2017, with a p-value of\0.001. For patients with complications, all were Clavien-Dindo Grade 1-2 and did not require any invasive interventions. The complication rate was 0.07 in 2015 and 0.02 in 2017 with a p-value of 0.089 with all complications being early minor ones. The readmission rate within 30 days was the same in both groups, 0.03. Conclusion: Our retrospective study results support the initial hypothesis that IDP and postoperative UGIS do not alter outcomes in bariatric surgery. Moreover, we found that stopping routine use of IDP and UGIS significantly reduced LOS while complication rates remained low. Therefore, we do not recommend routine use of IDP and UGIS in the uncomplicated bariatric patient

OBJECTIVE:To analyze existing tinnitus treatment trials with regard to eligibility criteria, outcome measures, study quality, and external validity and to recognize the effect of patient demographics, symptom duration, severity, and otologic comorbidity on research findings to help practitioners apply them to patient encounters. DATA SOURCES/METHODS:Systematic literature search conducted by an information specialist for development of the American Academy of Otolaryngology-Head and Neck Surgery Foundation's tinnitus clinical practice guideline. REVIEW METHODS/METHODS:Articles were assessed for eligibility with the PRISMA protocol (Preferred Reporting Items for Systematic Reviews and Meta-analyses) and data extracted by 2 independent investigators. Studies were assessed for methodological quality, inclusion and exclusion criteria, patient demographics, and outcome measures. RESULTS:A total of 147 randomized trials met inclusion criteria. Nearly all studies took place in a specialist setting. More than 50% did not explicitly define tinnitus, and 44% used a subjective severity threshold, such as "severely disturbing." Fifty-four percent required symptom duration of at least 6 months for study eligibility, and up to 33% excluded patients with "organic" hearing loss or otologic conditions. Mean age was 52.2 years, and median follow-up was 3 months. Only 20% had a low risk of bias. CONCLUSION/CONCLUSIONS:Randomized trials of tinnitus interventions are most applicable to older adults with tinnitus lasting ≥ 6 months who are evaluated in specialty settings. High risk of bias, short follow-up, and outcome reporting raise concerns about the validity of findings and may influence how clinicians apply trial results to individual patients and establish treatment expectations, thus demonstrating the need for further quality research in this field.

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.