Robotic Primary and Revisional Hiatal Hernia Repair is Safe and Associated with Favorable Perioperative Outcomes: A Single Institution Experience
Cardiac tamponade after robotic hiatal hernia repair from liver sling stitch: Case report of a rare complication and literature review [Case Report]
INTRODUCTION AND IMPORTANCE/UNASSIGNED:Cardiac tamponade following hiatal hernia repair is a rare and potentially fatal complication most often associated with the use of mechanical fixation devices for hiatal mesh reinforcement. Only three cases have been reported with sutures alone, and none following robotic hiatal surgery. CASE PRESENTATION/METHODS:A 54-year-old patient underwent elective robotic hiatal hernia repair with Toupet fundoplication during which a sling suture was placed to elevate the left lateral segment of liver. No mesh or mechanical fixation devices were used. Eight hours postoperatively, the patient developed hemodynamic instability. Cardiac tamponade was diagnosed on bedside echocardiogram and the patient underwent emergent pericardiocentesis with subsequent stabilization. The remainder of the postoperative course was notable for pericarditis which was treated with aspirin and colchicine. CLINICAL DISCUSSION/UNASSIGNED:While the use of suture-based liver retraction has the advantages of avoiding an additional port and potential collision between retractor holder and robot arms, it constitutes a novel risk factor for cardiac tamponade. Prompt diagnosis via bedside echocardiography is essential and may facilitate percutaneous rather than operative management. CONCLUSION/CONCLUSIONS:Suture-based liver retraction in minimally invasive foregut surgery should be used judiciously until further data is available. Surgeons should maintain a high index of suspicion for tamponade in the setting of postoperative hypotension after its use.
Elective paraesophageal hernia repair in elderly patients: an analysis of ACS-NSQIP database for contemporary morbidity and mortality
BACKGROUND:Elective paraesophageal hernia (PEH) repair in asymptomatic or minimally symptomatic patientsâ€‰â‰¥â€‰65Â years of age remains controversial. The widely cited Markov Monte Carlo decision analytic model recommends watchful waiting in this group, unless the mortality rate for elective repair was to reachâ€‰â‰¤â€‰0.5%; at which point, surgery would become the optimal treatment. We hypothesized that with advances in minimally invasive surgery, perioperative care, and practice specialization, that mortality threshold has been reached in the contemporary era. However, the safety net would decrease as age increases, particularly in octogenarians. METHODS:We identified 12,422 patients from the 2015-2017 ACS-NSQIP database, who underwent elective minimally invasive PEH repair, of whom 5476 (44.1%) were with ageâ€‰â‰¥â€‰65. Primary outcome was 30-day mortality. Secondary outcomes were length of stay (LOS), operative time, pneumonia, pulmonary embolism, unplanned intubation, sepsis, bleeding requiring transfusion, readmission, and return to OR. RESULTS:Patients ageâ€‰â‰¥â€‰65 had a higher 30-day mortality (0.5% vs 0.2%; pâ€‰<â€‰0.001). Subset analysis of patients age 65-80 andâ€‰>â€‰80 showed a 30-day mortality of 0.4% vs. 1.8%, respectively (pâ€‰<â€‰0.001). Independent predictors of mortality in patientsâ€‰â‰¥â€‰65Â years were ageâ€‰>â€‰80 (OR 5.23, pâ€‰<â€‰0.001) and COPD (OR 2.59, pâ€‰=â€‰0.04). Patientsâ€‰â‰¥â€‰65 had a slightly higher incidence of pneumonia (2% vs 1.2%; pâ€‰<â€‰0.001), unplanned intubation (0.8% vs 0.5%; pâ€‰<â€‰0.05), pulmonary embolism (0.7% vs 0.3%; pâ€‰=â€‰0.001), bleeding requiring transfusion (1% vs 0.5%; pâ€‰<â€‰0.05), and LOS (2.38 vs 1.86Â days, pâ€‰<â€‰0.001) with no difference in sepsis, return to OR or readmission. CONCLUSION/CONCLUSIONS:This is the largest series evaluating elective PEH repair in the recent era. While morbidity and mortality do increase with age, the mortality remains below 0.5% until age 80. Our results support consideration for a paradigm shift in the management of patientsâ€‰<â€‰80Â years toward elective repair of PEH.
Plexiform Angiomyxoid Myofibroblastic Tumor (PAMT) of the Stomach: an Extremely Rare Mesenchymal Tumor Masquerading as Gastrointestinal Stromal Tumor or Leiomyoma
Letter to the Editor on "Complications Following Robotic Hiatal Hernia Repair Are Higher Compared to Laparoscopy" [Comment]
Incidence of acute postoperative robotic port-site hernias: results from a high-volume multispecialty center
Fascial closure at 8-mm robotic port sites continues to be controversial. As the use of the robotic platform increases across multiple abdominal specialties, there are more case reports describing reoperation and small bowel resection for acute port-site hernias. A retrospective review of all robotic abdominal surgeries performed from 2012 to 2019 at NYU Langone Medical Center was conducted. Patients who had a reoperation in our facility within 30Â days were identified, and medical records reviewed for indications for reoperation and findings. The study included 11,566 patients, of which 82 patients (0.71%) underwent a reoperation related to the index robotic surgery within 30Â days. Fifteen of 11,566 patients (0.13%) had acute port-site hernias, and 3 of these 15 patients required small bowel resection. Eleven of 15 acute port-site hernias (73%) were at 8-mm robotic port site, 2 of which required a small bowel resection. More than a third of the patients had a hernia at an 8-mm port site where a surgical drain had been placed. Considering that each robotic case, regardless of specialty, has three ports at a minimum, the true incidence of acute postoperative robotic port-site hernia is 0.032% (11/34,698), with the incidence of concomitant small bowel resection being 0.006% (2/34,698). The incidence of acute port-site hernias from 8-mm robotic ports is exceedingly low across specialties. Our results do not support routine fascial closure at 8-mm robotic port sites due to an extremely low incidence. However, drain sites require special consideration.
Comparative Analysis of Patients with Robotic Hiatal Hernia Repairs with and without Collis Gastroplasty
INTRODUCTION/BACKGROUND:After extensive mediastinal dissection fails to achieve adequate intra-abdominal esophageal length, a Collis gastroplasty(CG) is recommended to decrease axial tension and reduce hiatal hernia recurrence. However, concerns exist about staple line leak, and long-term symptoms of heartburn and dysphagia due to the acid-producing neoesophagus which lacks peristaltic activity. This study aimed to assess long-term satisfaction and GERD-related quality of life after robotic fundoplication with CG (wedge fundectomy technique) and to compare outcomes to patients who underwent fundoplication without CG. Outcomes studied included patient satisfaction, resumption of proton pump inhibitors (PPI), length of surgery (LOS), hospital stay, and reintervention. METHODS:This was a single-center retrospective analysis of patients from January 2017 through December 2018 undergoing elective robotic hiatal hernia repair and fundoplication. 61 patients were contacted for follow-up, of which 20 responded. Of those 20 patients, 7 had a CG performed during surgery while 13 did not. There was no significant difference in size and type of hiatal hernias in the 2 groups. These patients agreed to give their feedback via a GERD health-related quality of life (GERD HRQL) questionnaire. Their medical records were reviewed for LOS, length of hospital stay (LOH), and reintervention needed. Statistical analysis was performed using SPSS v 25. Satisfaction and need for PPIs were compared between the treatment and control groups using the chi-square test of independence. RESULTS:> .05) with a median length of stay of 2Â days observed in both groups. There were no leaks in the Collis group and no reoperations, conversions, or blood transfusions needed in either group. CONCLUSION/CONCLUSIONS:Collis gastroplasty is a safe option to utilize for short esophagus noted despite extensive mediastinal mobilization and does not adversely affect the LOH stay, need for reoperation, or patient long-term satisfaction.
Extensive Gastric Necrosis in the Setting of Phytobezoar Causing Gastric Outlet Obstruction
Robotic Foregut Surgery
Robotic-assisted surgery for benign esophageal disease is described for treatment of achalasia, gastroesophageal reflux, paraesophageal hernias, epiphrenic diverticula, and benign esophageal masses. Robotic Heller myotomy has operative times, relief of dysphagia, and conversion rates comparable to laparoscopic approach, with lower incidence of intraoperative esophageal perforation. The use of robotic platform for primary antireflux surgery is under evaluation, due to prolonged operative time and increased operative costs, with no differences in postoperative outcomes or hospital stay. Studies have shown benefits of robotic surgery in complex reoperative foregut surgery with respect to decreased conversion rates, lower readmission rates, and improved functional outcomes.
Safety of Elective Paraesophageal Hernia Repair in Patients over Age 65: Reality Matches Theory [Meeting Abstract]