Faculty Bibliography

BACKGROUND:Open Hartmann's procedure has traditionally been the procedure of choice to treat complicated diverticulitis. We analyzed the ACS-NSQIP database to compare outcomes in patients who underwent emergent laparoscopic Hartmann's procedure (LHP) to those who had an open Hartmann's procedure (OHP). STUDY DESIGN/METHODS:Data analyzed from 2015 to 2019 using ICD-10 codes. Patients were matched on several important covariates using a propensity score matching method (PSM). Patients were matched in a 4:1 ratio of controls to cases based on the propensity score. RESULTS:We identified 5026, of which 456 had LHP and 4570 had OHP. PSM analysis yielded 369 LHP and 1476 OHP patients. LHP had lower rates of superficial surgical site infection (SSSI) compared to OHP (2.44% vs. 5.89%, p = 0.007). LHP had similar post-operative outcomes compared to OHP, including 30-day mortality (5.15% vs. 2.98%, p = 0.060), organ space surgical site infection (OSSSI) (14.36% vs. 12.60%, p = 0.161), wound disruption (1.36% vs. 2.44%, p = 0.349), median LOS (8 vs. 9 days, p = 0.252), readmission within 30 days (11.92% vs. 8.67%, p = 0.176), rate of reoperation (6.0 vs. 6.5%, p = 0.897), and discharge to home (76% vs. 77%, p = 0.992). LHP had longer operative times compared to OHP (median 129 vs. 118 min, p < 0.0001). CONCLUSION/CONCLUSIONS:The LHP is associated with lower rates of SSSI. However, it is not associated with lower rates of mortality, OSSSI, readmissions and reoperations within 30 days. Surgical times are longer in LHP. More studies are needed to determine whether LHP offers advantages in the long-term, particularly in rates of incisional hernia and colostomy closure.

BACKGROUND:The evolution of midline ventral hernia repair has progressed from the open Rives-Stoppa technique to minimally invasive robotic approaches, notably the trans-abdominal retromuscular (TARM) and enhanced-view Totally Extraperitoneal (eTEP) methods. This study compares these two robotic techniques in repairing medium-sized midline ventral hernias. METHODS:A retrospective comparative study of electronic medical records from 2015 to 2021 was conducted on patients undergoing robotic TARM or eTEP at NYU Langone Hospital-Long Island. Data on demographics, comorbid conditions, surgical history, intraoperative details, hernia characteristics, and postoperative outcomes were analyzed. RESULTS:Both eTEP and TARM groups exhibited comparable outcomes regarding operative duration, hernia defect size, and overall complications. However, notable differences were observed in patients' BMI, implanted mesh area, mesh composition, and fixation techniques across the groups. The TARM group required a longer hospital stay (median: 1 day) in contrast to the eTEP group (median: 0 days). Additionally, eTEP patients indicated reduced postoperative pain scores (median: 2) compared to TARM (median: 3), with both differences being statistically significant (p < 0.001). CONCLUSION:The robotic eTEP approach is associated with lower post-operative pain scores, decreased hospital length of stay, and larger areas of mesh implantation as compared to the TARM approach. Other variables are largely comparable between the two techniques. LEVEL OF EVIDENCE:Level III.

PURPOSE/OBJECTIVE:International guidelines exist for surgical treatment of either ventral or inguinal hernias repair (VHR; IHR). However, approach for managing both of them remains unestablished and is further complicated by newly developed surgical techniques and modalities (namely, robotic). This highlights the need for a tailored, algorithmic strategy to streamline surgical management. METHODS:An algorithm was developed by the directors of the NYU Langone Abdominal Core Health program of which four treatment groups were described: Group 1: open VHR and either laparoscopic or robotic IHR; Group 2: robotic transabdominal pre-peritoneal (TAPP) approach for both VHR and IHR; Group 3: robotic retro-muscular VHR and IHR; and Group 4: open repair for both. Demographics, comorbidities, operative characteristics, and surgical outcomes from November 2021 to July 2023 were retrospectively compared. RESULTS:, and 73% (n = 67) were ASA class II. Distribution of groups was: 48% (n = 44) in 1A, 8% (n = 7) in 1B, 8% (n = 7) in 2A, 3% (n = 3) in 2B, 23% (n = 21) in 3A, 8% (n = 7) in 3B, and 3% (n = 3) in 4. Ventral hernia size, OR time, and postoperative length of stay varied across groups. Postoperative outcomes at 30 days including emergency consults, readmissions, and complications, showed no differences across groups. CONCLUSION/CONCLUSIONS:Access without guidance to new minimally invasive surgical approaches can be a challenge for the general surgeon. We propose an algorithm for decision-making based on our experience of incorporating robotic surgery, when available, for repair of concomitant VHR and IHR with consistent favorable outcomes within a small sample of patients.

INTRODUCTION/BACKGROUND:Robotic abdominal wall reconstruction (RAWR) is one of the most significant advances in the management of complex abdominal wall hernias. The objective of this study was to evaluate long term outcomes in a cohort of patients that underwent complex RAWR in a single center. METHODS:This was a longitudinal retrospective review of a cohort of 56 patients who underwent complex RAWR at least 24 months prior by a single surgeon at a tertiary care institution. All patients underwent bilateral retro-rectus release (rRRR) with or without robotic transversus abdominis release (rTAR). Data collected include demographics, hernia details, operative and technical details. The prospective analysis included a post-procedure visit of at least 24 months from the index procedure with a physical examination and quality of life survey using the Carolinas Comfort Scale (CCS). Patients with reported symptoms concerning for hernia recurrence underwent radiographic imaging. Descriptive statistics (mean ± standard deviation or median) were calculated for continuous variables. Chi-square or Fisher's exact test as deemed appropriate for categorical variables, and analysis of variance or the Kruskal-Wallis test for continuous data, were performed among the separate operative groups. A total score for the CCS was calculated and analyzed in accordance with the user guidelines. RESULTS:for rRRR. The mean length of follow-up was 28.1 months. Fifty-seven percent of patients underwent post-op imaging at an average follow-up of 23.5 months. Recurrence rate was 3.6% for all groups. There were no recurrences in patients that underwent solely bilateral rRRR. Two patients (7.7%) that underwent rTAR procedures were found with recurrence. Average time to recurrence was 23 months. Quality of life survey demonstrated an overall CCS score of 6.63 ± 13.95 at 24 months with 12 (21.4%) patients reporting mesh sensation, 20 (35.7%) reporting pain, and 13 (23.2%) reporting movement limitation. CONCLUSION/CONCLUSIONS:Our study contributes to the paucity of literature describing long term outcomes of RAWR. Robotic techniques offer durable repairs with acceptable quality of life metrics.

Post-cholecystectomy syndrome (PCS) is a well-documented complication of incomplete cholecystectomy. The etiology is often post-surgical chronic inflammation from unresolved cholelithiasis, which is secondary to anatomical abnormalities, including a retained gallbladder or a large cystic duct remnant (CDR). An exceedingly rare consequence is retained gallstone fistulization into the gastrointestinal tract. We present a case of a 70-year-old female with multiple comorbidities 4 years status-post incomplete cholecystectomy, who developed PCS with cholecystoduodenal fistula secondary to retained gallstone in the remnant gallbladder, with CDR involvement, treated via robotic-assisted surgery. Reoperation in PCS has been traditionally performed via laparoscopic approach with recent advances made in robotic-assisted surgery. However, we report the first documented case of PCS complicated by bilioenteric fistula repaired with robotic-assisted surgery. This highlights the value of robotic-assisted surgery in complicated cases, where one must contend with post-surgical anatomic abnormalities and visualization difficulties. Subsequent investigation is necessary to objectively quantify the safety and reproducibility of our approach.

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.

Introduction: Acute colonic diverticulitis is a common surgical condition, and as many as 25% of patients will present with complicated disease. The procedure of choice for emergent management of complicated diverticulitis has been the open Hartmann's procedure. We analyzed the NSQIP database to compare outcomes in patients who underwent emergent laparoscopic Hartmann's procedure for complicated diverticulitis to those who had an Open Hartmann's procedure.
Method(s): Data analyzed was from the ACS-NSQIP database. We identified patients with complicated colonic diverticulitis using ICD-10 codes, and who required either a laparoscopic or open Hartmann's procedure from 2010-2019. Propensity score method (PSM) was utilized to match patients in each of the two surgical groups on a number of important covariates.
Result(s): Prior to PSM analysis, 4,570 patients had an open Hartmann's procedure, while 456 had laparoscopic Hartmann's procedure. PSM analysis yielded 374 open Hartmann's and 347 laparoscopic Hartmann's patients. Laparoscopic Hartmann's patients had similar post-operative outcomes when compared to open, including; Mortality (5.08% vs. 4.55%, p<0.8642), wound disruption (1.34% vs. 1.6%, p<1.000), SSSI (2.41% vs. 5.35%, p<0.0614), median LOS (10.5 d vs. 10.6 d, p<0.9630), any readmission within 30 days (11.76% vs. 9.63%, p<0.4282). Laparoscopic Hartmann's procedures were longer compared to open, (Median procedure time; 129 m vs. 116.5 m, p<0.0001).
Conclusion(s): Laparoscopic Hartmann's procedure is a safe and effective alternative to open Hartmann's procedure for emergent surgical management of complicated diverticulitis. More studies are needed to determine differences in long-term outcomes between these two procedures