Faculty Bibliography

BACKGROUND:Small bowel obstruction is typically managed nonoperatively; however, refractory small bowel obstructions or closed loop obstructions necessitate operative intervention. Traditionally, laparotomy has long been the standard operative intervention for lysis of adhesions of small bowel obstructions. But as surgeons become more comfortable with minimally invasive techniques, laparoscopy has become a widely accepted intervention for small bowel obstructions. The objective of this study was to compare the outcomes of laparoscopy to open surgery in the operative management of small bowel obstruction. METHODS:This is a retrospective analysis of operative small bowel obstruction cases at a single academic medical center from June 2016 to December 2019. Data were obtained from billing data and electronic medical record for patients with primary diagnosis of small bowel obstruction. Postoperative outcomes between the laparoscopic and open intervention groups were compared. The primary outcome was time to return of bowel function. Secondary outcomes included length of stay, 30-day mortality, 30-day readmission, VTE, and reoperation rate. RESULTS:The cohort consisted of a total of 279 patients with 170 (61%) and 109 (39%) patients in the open and laparoscopic groups, respectively. Patients undergoing laparoscopic intervention had overall shorter median return of bowel function (4 vs 6 days, p = 0.001) and median length of stay (8 vs 13 days, p = 0.001). When stratifying for bowel resection, patients in the laparoscopic group had shorter return of bowel function (5.5 vs 7 days, p = 0.06) and shorter overall length of stay (10 vs 16 days, p < 0.002). Patients in the laparoscopic group who did not undergo bowel resection had an overall shorter median return of bowel function (3 vs 5 days, p < 0.0009) and length of stay (7 vs 10 days, p < 0.006). When comparing surgeons who performed greater than 40% cases laparoscopically to those with fewer than 40%, there was no difference in patient characteristics. There was no significant difference in return of bowel function, length of stay, post-operative mortality, or re-admission laparoscopic preferred or open preferred surgeons. CONCLUSION/CONCLUSIONS:Laparoscopic intervention for the operative management of small bowel obstruction may provide superior clinical outcomes, shorter return of bowel function and length of stay compared to open operation, but patient selection for laparoscopic intervention is based on surgeon preference rather than patient characteristics.

INTRODUCTION:We report a case of a patient who presented with incarceration of the epiploic appendix in a spigelian hernia, subsequently treated by a robotic-assisted surgical approach. CASE DESCRIPTION:This is a case of a 52 year-old male patient who presented with nausea and two-week history of worsening left lower quadrant pain. On examination, the patient had an irreducible left lower quadrant mass. Computed tomography scan showed an epiploic appendagitis in a left Spigelian hernia. The patient underwent a robotic transabdominal preperitoneal hernia repair successfully and was discharged home the same day. CONCLUSION:The robotic platform was a safe and effective approach to treating the patient with no postoperative complications.

INTRODUCTION:We report the case of a transplanted ureter obstructed by an inguinal herniation treated by a robotic-assisted approach. CASE REPORT:This is a case of a 63-year-old male who had a kidney transplant with a graft on the left pelvis in September 2014, and presented to the clinic for evaluation of bilateral inguinal hernia. On physical examination he had bilateral palpable inguinal hernias, with the right one larger and only partially reducible. Computed tomography scan showed portion of urinary bladder and transplant ureter in the left inguinal hernia and mild hydroureteronephrosis in the transplanted kidney. Patient underwent catheterization of the transplant ureter where indocyanine green was injected for proper transplant ureter identification with the Firefly filter and robotic assisted hernia repair. Surgery was uneventful and patient was discharged home the same day with no further complications. CONCLUSION:The robotic approach using the Firefly filter was shown to be safe during the dissection to avoid injury to the transplant ureter.

BACKGROUND:) obese patients after robotic VHR (RVHR). METHODS:) systems. RESULTS:were included in the study. PSM analysis stratified these into 69 patients for each of the class-II and class-III groups. When comparing matched groups, there were no differences in any of the variables across all timeframes, except for a higher rate of Polytetrafluoroethylene (PTFE)-based mesh use in the class-III group (39.1% vs 17.4%, p = 0.008). The estimated recurrence-free time was 76.4 months (95% CI = 72.5-80.4) for the class-II group and 80.4 months (95% CI = 78-82.8) for the class-III group. CONCLUSION/CONCLUSIONS:This multicenter study showed no difference in outcomes after RVHR between matched class-II and class-III obese patients.

BACKGROUND:Incisional hernia is a frequent complication of abdominal wall incision. Surgical technique is an important risk factor for the development of incisional hernia. The aim of these updated guidelines was to provide recommendations to decrease the incidence of incisional hernia. METHODS:A systematic literature search of MEDLINE, Embase, and Cochrane CENTRAL was performed on 22 January 2022. The Scottish Intercollegiate Guidelines Network instrument was used to evaluate systematic reviews and meta-analyses, RCTs, and cohort studies. The GRADE approach (Grading of Recommendations, Assessment, Development and Evaluation) was used to appraise the certainty of the evidence. The guidelines group consisted of surgical specialists, a biomedical information specialist, certified guideline methodologist, and patient representative. RESULTS:Thirty-nine papers were included covering seven key questions, and weak recommendations were made for all of these. Laparoscopic surgery and non-midline incisions are suggested to be preferred when safe and feasible. In laparoscopic surgery, suturing the fascial defect of trocar sites of 10 mm and larger is advised, especially after single-incision laparoscopic surgery and at the umbilicus. For closure of an elective midline laparotomy, a continuous small-bites suturing technique with a slowly absorbable suture is suggested. Prophylactic mesh augmentation after elective midline laparotomy can be considered to reduce the risk of incisional hernia; a permanent synthetic mesh in either the onlay or retromuscular position is advised. CONCLUSION/CONCLUSIONS:These updated guidelines may help surgeons in selecting the optimal approach and location of abdominal wall incisions.

INTRODUCTION AND IMPORTANCE/UNASSIGNED:Lateral abdominal wall defects are a rare event and commonly result from iatrogenic causes and trauma. We report the first known case of flank hernia after endoscopic submucosal resection of a colonic polyp complicated by colonic perforation. CASE PRESENTATION/METHODS:This is a case of a 50-year-old male who underwent endoscopic colonic resection complicated by perforation of the colon. Eight months later, he presented with an enlarging, asymptomatic left flank bulge. CT showed a large flank hernia which was successfully repaired using a robotic transabdominal preperitoneal (TAP) approach. CLINICAL DISCUSSION/UNASSIGNED:The hypothesis is that the endoscopic resection with colonic perforation caused an iatrogenic injury to the abdominal wall creating a lateral abdominal hernia. Injury to abdominal wall musculature may take months to develop into a clinically apparent hernia. Flank hernias can be successfully repaired using a robotic minimally invasive approach. CONCLUSION/CONCLUSIONS:Flank bulge and hernias must be included or at least be considered as consequence of a potential complication from endoscopic colonic perforation. Surgeons and endoscopists must be aware of this potential complication and its latent presentation. This case stresses the importance of long-term outcomes monitoring, particularly with innovative procedures.