Faculty Bibliography

Obesity is known to be epidemiologically associated with malignancy. Although there is an increasing global number of bariatric surgeries, the relationship between bariatric surgery and esophagogastric cancers is not well understood. Diagnosis of esophagogastric cancers following bariatric surgery is challenging because the presentation tends to be nonspecific and may be perceived as usual postoperative symptoms in bariatric patients. Therefore, the early diagnosis requires a high index of suspicion. In addition, endoscopic investigation of the excluded stomach after a Roux-en-Y gastric bypass or a one-anastomosis gastric bypass is technically challenging, which further complicates the diagnosis. The aim of this study is to review the current evidence in the literature on esophagogastric cancers following bariatric surgery.

Intussusception following Roux-en-Y gastric bypass (RYGB) is a rare complication of bariatric surgery with an unclear etiology. The pathogenesis underlying intussusception after gastric bypass is likely different from that in the general population. Post-RYGB intussusception might be related to motility issues in the divided small bowel, thinning of the mesentery following rapid weight loss, or anastomotic sutures/staple line acting as the lead point. This condition can cause obstruction with subsequent strangulation and bowel necrosis if not recognized and treated promptly. Clinical presentation is vague and nonspecific, and computerized tomography scan represents the diagnostic test of choice. Surgical treatment consists of reduction with or without anastomosis resection and reconstruction. This literature review provides an extensive overview of this condition, based on multiple studies involving 120 patients.

Background: Chilaiditi syndrome is a rare clinical entity defined by radiographic evidence of colonic interposition between liver and diaphragm, with associated symptoms and complications including chronic constipation, abdominal pain, cirrhosis, diaphragmatic paralysis, obstructive symptoms, and respiratory distress known as Chiladiti sign.1 It is thought to result from anatomic variations of colonic suspensory ligaments. Radiographically, the incidence of Chilaiditi sign is 0.025-0.28%.1 In asymptomatic patients, treatment is typically conservative involving bowel rest. Surgical intervention depends on both the portion of colon and complication involved.1 There is a growing sentiment to operate on non-obstructive symptomatic Chilaiditi syndrome, however there remains a paucity of adult literature on management.2 Case Presentation: We present a case of a 45-year old female with a one-year history of right upper quadrant (RUQ) abdominal pain. On day of admission, the patient reported persistent similar RUQ pain with a near syncopal event. The patient endorsed two weeks of dyspnea, orthopnea, and right lower extremity swelling. CT-AP was remarkable for colonic interposition anterior to the liver without obstruction or other acute abdominal pathology. Ultimately, her work-up was remarkable for UTI, pericardial effusion, and mild CHF exacerbation. The patient was admitted to medicine for further work-up and management. Surgery was involved in her care, but the patient no longer had abdominal pain, just abdominal fullness with distention. She was ultimately stabilized medically and discharged with a plan for outpatient follow-up. During her outpatient visit, she was with abdominal fullness and concerned that her intermittent pain would continue; therefore, a repeat CT-AP was ordered and surgical options were weighed, pending imaging studies.
Discussion(s): Chilaiditi syndrome is incredibly rare. There is no consensus on the surgical management of non-obstructive symptomatic Chilaiditi. As may be the case for this patient, the intermittent nature of pain may be due to periodic, positional obstruction that self-resolves once the interposed colon reverts back to its original position. Persistently symptomatic Chilaiditi syndrome may warrant surgical colopexy but limited data exists in adults.2 This patient is currently being managed conservatively with close monitoring of symptoms prior to definitive surgical intervention

Introduction: Obesity is a nationwide epidemic and evidence based reliable treatment of this disease is the weight loss surgery once medical management fails. This field has evolved in due time from open to laparoscopic and then to Robotics. There have been several systemic reviews studying at the safety, efficiency as well as cost analysis of the Robots in obesity management. This review examines the published literature on the outcomes and complications of bariatric surgery using a robotic platform. Use of robotics to perform sleeve gastrectomy and roux-en-y gastric bypass (RYGB) is assessed.
Method(s): We critically reviewed the available literature through pub-med on the use of Robots in Bariatric surgery. We selected 18 studies and included them in the review in this article.
Result(s): A total of 18 studies were selected. The results showed the Bariatric surgery when performed with the use of Robots had similar or less complications are compared with traditional laparoscopy. The learning curve appear to be shorter when Robotic gastric bypass is compared with traditional laparoscopy approach. Two studies found a significantly lower leak rate for robotic gastric bypass when compared to laparoscopic method. The learning curve for RYGB seems to be shorter for robotic technique. Three studies revealed a significantly shorter operative time, while four studies found a longer operative time for robotic technique of gastric bypass.
Conclusion(s): The application of Robotics appear to be safe and feasible option. Most investigators stated that Robotic method has superior visualization, better precision, improved dexterity, more degree of freedom and better ergonomics. Use of robotics may provide specific advantages in some situations and overcome limitations of laparoscopic method. Large well designed randomized clinical trials with long follow up are needed to further define the role of digital platforms in management of obesity.

Introduction: Sleeve gastrectomy remains an effective means of addressing obesity and obesityrelated complications. While bariatric procedures have been primarily performed laparoscopically over the past few decades, there has been increasing interest in robotic bariatric surgery (RBS). The emergence of robotic surgery has demonstrated efficacy in non-bariatric procedures. As technology continues to improve, it is important to compare this new modality to conventional approaches.
Method(s): We performed a single center, retrospective review sampling data for year 2019. We compared robotic and laparoscopic sleeve gastrectomies using parameters like average operating times, costs, length of stay, complications along with review current literature.
Result(s): Data was extrapolated from 18 robotic sleeve gastrectomies (RSG) and 17 laparoscopic sleeve gastrectomies (LSG). Average operating time for RSG was 114.6 minutes compared to LSG which was 68.9 minutes. Average intraoperative costs were similar with RSG compared to LSG. Average LOS was 1.44 days for RSG compared to 1.76 days for LSG. There were no 30 day readmissions or serious complications in either group.
Conclusion(s): Both RBS and LBS demonstrated satisfactory weight loss results, resolution of various obesity related comorbidities at follow-up. Our data, and current literature, support that RBS and LBS have comparable outcomes and complications. Operative time and hospital cost may be increased with RBS; however, it is our belief that with improvements in robotic technology and procedural skills, both cost and time should improve.Several literature reviews have compared RBS and laparoscopic bariatric surgery (LBS) and have concluded that clinical outcomes and complications are similar between the two. However, RBS is associated with longer operative times and higher net costs. It has been suggested that the robotic platform may be more beneficial in complex cases, although current literature does not necessarily demonstrate this. Acevedo et al. examined laparoscopic versus robotic-assisted revisional bariatric surgery and concluded that RBS was associated with longer operative times and higher rates of complications. In a similar review examining primary laparoscopic versus robotic-assisted bariatric surgery, Acevedo et al. demonstrated that robot assisted gastric bypass has lower morbidity and mortality. However, this was not demonstrated for the sleeve gastrectomy. Overall they concluded that both robotic sleeve and gastric bypass are very safe.

Introduction: As many as 1 in 13 people will develop appendicitis in his or her lifetime, making it one of the most common gastrointestinal surgical emergencies. The main objective of this retrospective study is to incorporate the glove-finger into our standard approach for laparoscopic appendectomy as a safe and alternative to the EndocatchTM specimen bag during the extraction process. We seek to demonstrate the cost effectiveness, feasibility, implications for operative timing and postoperative complications of using one of the most readily available items in the operating room as a specimen bag, a surgical glove.
Method(s): 128 patients with appendicitis, who underwent laparoscopic appendectomy between 2012- 2015 at our institute were retrospectively reviewed. Out of them, 49 specimens were collected through the glove-finger extraction technique. Outcome parameters noted were duration of the operation, postoperative complications (intra-abdominal abscess, wound infections, post-operative pain), length of hospital stay, and readmission rate.
Result(s): Within the 49 glove-finger extraction (GFX) appendectomies, one patient had a postoperative fever, another had abdominal pain; both were successfully treated with acetaminophen, yielding a complication rate of 4.1% (2/48). In endocatch group (EC), there were 6 complications for a complication rate of 7.6% (6/79). The OR time for GFX and EC group was 51-58 minutes and 57-68 minutes respectively. The mean operating time of the GFX and EC group was 54.4+/-0.6 mins and 62.1+/-0.7 minutes respectively. On average, the GFX was shorter by 7.7 minutes (p = 0.009). There were no significant differences in length of stay (P=0.581).
Conclusion(s): We estimated that a pair of sterile surgical gloves costs $2.06. An EC bag costs $69; there is a total of $66.94 saved using a GFX over the conventional EC bag. Higher hospital costs, mostly due to the specialized equipment and disposable single-use equipment involved with laparoscopic operations is one major disadvantage of the operative modality but can lead to innovative and alternative techniques to provide cost conscious care. The glove-finger extraction is one such technique. In high-volume procedures such as laparoscopic appendectomies, there is a greater need to emphasize cost reduction measures. Using a glove-sleeve in place of an endocatch bag retains the benefits of laparoscopic surgery, while mitigating costs, thus reducing the burden of higher costs in this procedure.

Surgical innovation has been at the forefront of surgery over the last decade, fine tuning many surgical procedures. This innovation occurs with the desire to increase efficiency while decreased morbidity and mortality. Laparoscopic surgery has, with this refinement, become the mainstay for many operations including hernia repairs. This study looks to analyze the upcoming field of robotic surgery to its laparoscopic counterpart. With this analysis, novel contributions to the field can be added in regard to robotic hernia repair and its ability to change the way minimally invasive surgery is done. Analysis was done of eighty-eight patients with hernia surgery who underwent either laparoscopic or robotic hernia repairs between 2016 and 2018. Several outcome parameters were noted, which include the duration of the operation postoperative complications, length of hospital day, and readmission rate. The average OR time for the robotic group was approximately 151 min compared to 139 min for the laparoscopic group. Overall, the robotic surgery time became more efficient showing the possible initial learning curve physician have when transitioning to robotic repair and the gain in effectiveness they achieve with continued practice. The average length of stay for the robotic group was approximately 9 h, 55 min compared to 11 h, 52 min in the laparoscopic group. The difference in postoperative complications between the two groups were noted. In regard to hematomas, one laparoscopic patient complained of this while none experience this in the robotic group. For seroma complications, eight patients from the laparoscopic group were seen with this post-op compared to three patients in the robotic group. Of note, one patient experienced a surgical site infection from the robotic group while no one in the laparoscopic had this complication. For the patient experiencing an SSI, CT confirmed an abscess that was subsequently treated with antibiotics and resolved. Lastly, recurrences of hernia since surgery occurred in one patient, who was in the laparoscopic group. This retrospective study was conducted to assess if the new robotic hernia surgery could be equal if not better than the previously accepted gold standard of laparoscopic repair. Interpreting this data shows that robotic hernia repairs are a suitable alternative to laparoscopic repairs. Robotic repairs were superior went assessing the length of hospital stay and post-operative complications. Thus, if these are major concerns for patients, robotic repair can be considered as a valuable alternative to the laparoscopic methods

Adhesions are fibrotic bands that form between and among abdominal organs. The most common cause of abdominal adhesions is previous surgery in the area as well as radiation, infection and frequently occurring with unknown etiology. These bands occur among abdominal organs, commonly the small bowel, and can lead to obstruction or remain asymptomatic, akin to the patient discussed here. Congenital abdominal adhesions are rare and have received little attention in research and field of study. The patient described in this case is a 25-year-old female with a past medical history of morbid obesity, BMI of 45, hypertension and no past abdominal surgical procedures. The patient presented in August 2017 for bariatric surgical consultation and was ultimately taken for an attempted laparoscopic sleeve gastrectomy. Upon entering the abdomen, significant adhesions were encountered and an additional attending was called to assist in identifying the stomach. The splenic flexure was found to be plastered to the diaphragm and the descending and transverse colon were adhered to the anterior surface of the stomach. Additionally, small bowel adhesions encased the area between the right and left hepatic lobes as well as the caudate lobe. After extensive enterolysis, the pylorus remained the only identifiable portion of the stomach. The patient also demonstrated significant hepatomegaly and a wedge resection was performed. The amount of adhesion and matting of the small and large bowel obscured the view of the stomach and the procedure was deemed too dangerous and terminated. This case represents the uncommon scenario in which an abdomen with no prior surgical history presents with extensive, obscuring adhesions. One such recent study describes the influence of cytokines and proinflammatory states as contributors to obstruction and malrotation in children, but this patient demonstrated no significant history. Further investigation is needed to determine potential etiologies of symptomatic and non-symptomatic congenital adhesions among bariatric patients who fail conservative treatment. Today the patient is doing well and the surgical team will attempt to complete the procedure in the coming months

Background: The foundation of innovation in surgery is driven by the inherent desire to yield an increasingly efficient surgical approached with decreased morbidity and mortality. The advancements of laparoscopy have made a tremendous impact in hernia surgery, and it has largely replaced open surgical repair. In this regard, a novel technical approach is being explored through the robotic platform. This study compares a single physician's experience with inguinal and ventral hernias, being repaired laparoscopically and robotically, with respect to duration of surgery, intraoperative costs, length of stay (LOS), and postoperative complications. Methods: A single center, single surgeon retrospective review was conducted sampling data from January 2017 to August 2017 examining ventral and inguinal hernia repairs. Results: Data was extrapolated from 13 inguinal hernia repairs, 6 were robotic (RIH) and 7 were laparoscopic (LIH). Average OR time for RIH was 127 minutes compared to LIH which was 85 minutes. Average intraoperative cost for RIH was $1,110 compared to LIH which was $890. Of note, one LIH was converted to open, whereas none of the RIH required conversion. Average LOS was 9.16 hours for RIH compared to 11.6 hours for LIH. Postoperative pain at one week follow up was the same between both groups. Two postoperative surgical site occurrences (SSO) occurred in the LIH group (2 groin seromas), whereas no SSOs occurred in the RIH group. Eleven ventral hernia repairs were examined, 7 were robotic (RVH) and 4 were laparoscopic (LVH). Average OR time for RVH was 132 minutes compared to 65 minutes for LVH. Average intraoperative cost for RVH was $1,492 compared to LVH which was $1,264. No procedure from either group required conversion to open. Average LOS was 9.86 hours for RVH, and 13.5 hours for LVH. Again, postoperative pain was the same at one week follow up for both groups. There were no postoperative complications noted in either cohort. Conclusion: Operative time and procedural costs for RVH and RIH repairs were shown to be longer and more expensive when compared to their laparoscopic counterparts. However, with increased operative experience using the robotic platform, surgical time did show a decreasing trend. Length of stay was similar between robotic and laparoscopic cohorts. Postoperative pain and complications were comparable between robotic and laparoscopic groups. In conclusion, we found that the robotic platform offers an acceptable approach to inguinal and ventral hernia repairs

Duplication of the appendix is a rare congenital anomaly that, in adults, is most often found incidentally during surgery for other reasons. Appendicitis in the duplicated appendix is very rare and has been reported less than 10 times in the medical literature. We describe a 33-year-old woman with worsening periumbilical pain, nausea, vomiting, and fever. Physical examination showed localized peritonitis in the right lower quadrant. She had an elevated white blood cell count with neutrophilia. Computed tomography showed acute ruptured appendicitis. Diagnostic laparoscopy showed 2 appendices attached via separate bases to a single cecum with no other concurrent anomalies. Both appendices were removed laparoscopically. Histopathology confirmed normal appendiceal tissue in one and severe acute transmural appendicitis in the other. Awareness of appendiceal duplication and a thorough intraoperative inspection are critical to assess the presence of significant associated anomalies and avoid life-threatening complications.