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The frequency of robotic-assisted bariatric surgery has been on the rise. An increasing number of fellowship programs have adopted robotic surgery as part of the curriculum. Our aim was to compare technical efficiency of a surgeon during the first year of practice after completing an advanced minimally invasive fellowship with a mentor surgeon. A systematic review of a prospectively maintained database was performed of consecutive patients undergoing robotic-assisted sleeve gastrectomy between 2015 and 2019 at a tertiary-care bariatric center (mentor group) and between 2018 and 2019 at a semi-academic community-based bariatric program (mentee 1 group) and 2019–2020 at a tertiary-care academic center (mentee 2 group). 257 patients in the mentor group, 45 patients in the mentee 1 group, and 11 patients in the mentee 2 group were included. The mentee operative times during the first year in practice were significantly faster than the mentor’s times in the first three (mentee 1 group) and two (mentee 2 group) years (P

Sleeve gastrectomy (SG) is the most common bariatric operation in the United States but increases the incidence of gastroesophageal reflux disease (GERD). The aim of our study was to describe our experience with robotic-assisted management of intractable GERD after SG. A systematic review of a prospectively maintained database was performed of consecutive patients undergoing robotic-assisted magnetic sphincter augmentation placement after sleeve gastrectomy (MSA-S group) or conversion to Roux-en-Y gastric bypass (RYGB group) for GERD from 2015 to 2019 at our tertiary- care bariatric center. These were compared to a consecutive group of patients undergoing robotic-assisted magnetic sphincter augmentation placement (MSA group) for GERD without a history of bariatric surgery from 2016 to 2019. The primary outcome was perioperative morbidity. Secondary outcomes were operative time (OT), 90-day re-intervention rate, length of stay, symptom resolution and weight change. There were 51 patients included in this study; 18 patients in the MSA group, 13 patients in the MSA-S group, and 20 patients in the RYGB group. There was no significant difference in age, gender, ASA score, preoperative endoscopic findings, or DeMeester scores (P > 0.05). BMI was significantly higher in patients undergoing RYGB compared to MSA or MSA-S (P

Poly-4-hydroxybutyric acid (P4HB, Phasix™) is a biosynthetic polymer that degrades by hydrolysis that can be woven into a mesh for use in soft tissue reinforcement. Herein, we describe our initial experience performing complex abdominal wall repair (CAWR) utilizing component separation and P4HB mesh as onlay reinforcement. All patients undergoing CAWR between June 2014 and May 2017 were followed prospectively for postoperative outcomes. Only those patients who underwent components separation with primary repair of the fascial edges followed by onlay of P4HB mesh were included in this study. 105 patients (52 male, 53 female; mean age 59.2 years, range 22–84) met inclusion criteria. Mean BMI was 29.1 (range 16–48); 52% patients had prior attempted hernia repair, most with multiple medical comorbidities (71% of patients with ASA 3 or greater). 30% of cases were not clean at the time of repair (CDC class 2 or greater). Median follow-up was 36 months (range 9–63). Eighteen patients (17%) developed a hernia recurrence ranging from 2 to 36 months postoperatively. Five (5%) patients developed a localized superficial infection treated with antibiotics, three (2.8%) required re-operation for non-healing wounds, and six (6%) patients developed seroma. These data demonstrate a relatively low rate of hernia recurrence, seroma, and other common complications of CAWR in a highly morbid patient population. Importantly, the rate of mesh infection was low and no patients required complete mesh removal, even when placed into a contaminated or infected surgical field.

Pre-operative esophagogastroduodenoscopy (EGD) is becoming routine practice in patients undergoing bariatric surgery. Many patients with morbid obesity have obstructive sleep apnea (OSA), which can worsen hypoxia during an EGD. In this study, we report our outcomes using the SuperNO2VA™ device, a sealed nasal positive airway pressure mask designed to deliver high-fraction inhaled oxygen and titratable positive pressure compared to conventional nasal cannula. Between June 2016 and August 2017, we conducted a prospective observational study that included 56 consecutive patients who presented for EGD prior to bariatric surgery. Airway management was done using either the SuperNO2VA™ (N = 26) device or conventional nasal cannula (N = 30). Patient demographics, procedure details, and outcomes were compared between the two groups. The SuperNO2VA™ group had a lower median age compared to the control group (38.5 vs. 48.5 years, p = 0.04). These patients had a higher body mass index (BMI) (47.4 vs. 40.5, IQR, p

Poly-4-hydroxybutyric acid (P4HB, Phasix™) is a biosynthetic polymer that degrades by hydrolysis that can be woven into a mesh for use in soft tissue reinforcement. Herein, we describe our initial experience performing complex abdominal wall repair (CAWR) utilizing component separation and P4HB mesh as onlay reinforcement.All patients undergoing CAWR between June 2014 and May 2017 were followed prospectively for postoperative outcomes. Only those patients who underwent components separation with primary repair of the fascial edges followed by onlay of P4HB mesh were included in this study.105 patients (52 male, 53 female; mean age 59.2 years, range 22-84) met inclusion criteria. Mean BMI was 29.1 (range 16-48); 52% patients had prior attempted hernia repair, most with multiple medical comorbidities (71% of patients with ASA 3 or greater). 30% of cases were not clean at the time of repair (CDC class 2 or greater). Median follow-up was 36 months (range 9-63). Eighteen patients (17%) developed a hernia recurrence ranging from 2 to 36 months postoperatively. Five (5%) patients developed a localized superficial infection treated with antibiotics, three (2.8%) required re-operation for non-healing wounds, and six (6%) patients developed seroma.These data demonstrate a relatively low rate of hernia recurrence, seroma, and other common complications of CAWR in a highly morbid patient population. Importantly, the rate of mesh infection was low and no patients required complete mesh removal, even when placed into a contaminated or infected surgical field.

Pre-operative esophagogastroduodenoscopy (EGD) is becoming routine practice in patients undergoing bariatric surgery. Many patients with morbid obesity have obstructive sleep apnea (OSA), which can worsen hypoxia during an EGD. In this study, we report our outcomes using the SuperNOBetween June 2016 and August 2017, we conducted a prospective observational study that included 56 consecutive patients who presented for EGD prior to bariatric surgery. Airway management was done using either the SuperNOThe SuperNOThis is the first study to report on the use of the SuperNO

The use of the robotic platform has not been well established in patients with super obesity (SO; body mass index, BMI ≥ 50) and super-super obesity (SSO, BMI ≥ 60). We aimed to determine safety and feasibility of robotic bariatric surgery in this cohort. Review of a prospectively maintained database was performed of consecutive patients undergoing robotic bariatric surgery between 2015 and 2017. Propensity score analysis with 1:2 nearest neighbor matching was performed to control for baseline characteristics and procedure type. A propensity-matched cohort of 47 SO patients (median BMI 55.3, range 50.1–92.5) and 94 morbidly obese (MO; median BMI 41.8, range 35.1–48.8) patients were analyzed. After matching, there were no difference in baseline characteristics including age, American Society of Anesthesiologists (ASA) score, or preoperative comorbidities. Most patients in each group underwent sleeve gastrectomy (81% of SO patients versus 76% of MO patients) or Roux-en-Y gastric bypass (13% vs. 18%, respectively), p = 0.66. There were no differences in operative time, intraoperative complications, postoperative complications, or re-admissions between groups. Length of stay was slightly longer in the MO group (2.2 days, IQR 1.8–3.2 vs. 1.8 days, IQR 1.2–2.7; p = 0.01). A subset of SSO patients (n = 11, median BMI 67, range 60–92) was analyzed; there was no increase in operation time, and zero intraoperative complications, conversions to open, or postoperative complications in this subset. Robotic bariatric surgery can safely be performed on patients with SO or SSO with low perioperative morbidity and no increase in operating time.

Patients undergoing sleeve gastrectomy experience a significant amount of postoperative gastrointestinal (GI) symptoms. The purpose of our study was to assess the efficacy of omentopexy during laparoscopic sleeve gastrectomy (LSG) in reducing postoperative food intolerance and GI symptoms. Morbidly obese patients undergoing LSG were randomly assigned to have LSG with or without omentopexy from May 2012 to June 2013. A total of 60 patients were recruited with 30 patients in each group. Patients and the symptom scorer were blinded as to the assigned surgery. All procedures were performed by one of two surgeons utilizing the same surgical technique. Patients were administered standardized surveys, including the Rhodes Index survey, gastroesophageal reflux disease (GERD) impact survey, and Eating Assessment Tool (EAT) survey at various time points postoperatively to assess nausea, vomiting, retching, frequency of GI symptoms, and level of distress. There was no significant difference in patient age, percent decrease in BMI at any time point, or length of hospitalization between the two groups (P > 0.05). Furthermore, there was no significant difference in Rhodes Index scores, GERD impact scores, or EAT scores at any time point (P > 0.05). Patients in the LSG with omentopexy group required significantly more ondansetron perioperatively (16.1 ± 12.9 mg vs. 10.3 ± 10.2 mg, respectively; P = 0.04); however, there was no difference in metoclopramide requirement (P = 0.22). Surgical morbidity was not significantly different between the two groups (P > 0.05). Finally, there was no significant difference in number of postoperative clinic visits, office telephone encounters, total postoperative readmissions, or postoperative readmissions associated with GI symptoms (P > 0.05). Omentopexy did not significantly decrease postoperative food intolerance or GI symptoms in morbidly obese patients undergoing LSG. Other methods of mitigating postoperative intolerance to oral intake and GI symptoms should be investigated.

The aim of this study was to describe the occurrence and clinical characteristics of symptomatic internal hernias (IH) after laparoscopic bariatric procedures. We conducted a retrospective review of cases of IH after 1,064 laparoscopic gastric bypasses (LGB) and biliopancreatic diversions with duodenal switch (LBPD-DS) performed from September 1998 to August 2002. We documented 35 cases of IH (overall incidence of 3.3%). The IH occurred in 6.0% of patients with retrocolic procedures and 3.3% of patients with antecolic procedures. Most were in the Petersen defect (55.9%) and at the enteroenterostomy site (35.3%). A bimodal presentation was observed, with 22.9% of patients with IH diagnosed in the early postoperative period (2–58 days) and 77.1% in a delayed fashion (187–1,109 days). A laparoscopic approach to the repair of IH was possible in 60.0% of patients. Complications occurred in 18.8% of patients, including one death (2.9%). Complete closure of all mesenteric defects is strongly recommended during laparoscopic bariatric procedures to avoid IH and their associated complications.

While laparoscopy is now the standard for cholecystectomy, recent papers have focused on single-incision approaches. Intraoperative cholangiography remains an integral part of laparoscopic cholecystectomy but has not yet been well described within the single-access literature. We discuss our method of single-incision laparoscopic cholecystectomy with routine intraoperative cholangiograms. A retrospective review of our surgical database was completed. One hundred twenty-three patients undergoing laparoscopic cholecystectomy were identified (83 standard laparoscopy, 40 single-incision laparoscopy). Patient demographics including age and body mass index (BMI), and indications for surgery, operative time, intra- and postoperative complications, and ability to complete cholangiography were analyzed. All patients with standard laparoscopy had successful cholangiograms. Two patients did not undergo cholangiography based on a preoperative decision (pregnancy). In the 40 patients who underwent single-incision cholecystectomy, 38 cholangiograms were completed (95%). One patient with acute cholecystitis had a small cystic duct which could not be cannulated. The second had a cystic duct through which the cholangiocatheter could not be advanced. Comparative analysis of patient demographics showed a significant difference in patient age between the two groups, as well as a significantly greater number of patients undergoing single-incision cholecystectomy for symptomatic cholelithiasis as opposed to acute cholecystitis. Completion of intraoperative cholangiography is an important aspect of cholecystectomy in order to identify choledocholithiasis and verify anatomy. With the advent of single-access laparoscopy, standard operative principles should not be compromised. Cholangiography may provide a safer approach to cholecystectomy when adopting a new technique. We present our technique of single-incision cholecystectomy and routine cholangiography with a 95% success rate. The ability to perform single-incision intraoperative cholangiograms will allow a safe, more minimally invasive approach to cholecystectomy with suspected choledocholithiasis and obviate the need to convert to standard multiport laparoscopy for the sole reason of completing cholangiograms.

Peptic ulcers are a frequent cause of upper G.I. bleeding. Since endoscopic methods may be unsuccessful, we have studied the feasibility of a new laparoscopic approach on a porcine model to control the bleeding of these ulcers with transgastric suturing.After approval of the Animal Ethics Committee, 20 pigs (20 kg) were anticoagulated with intravenous sodium heparin (400 U/kg), and anesthetized. A nasogastric tube was inserted and a 15 mmHg pneumoperitoneum was created. Two 10-mm trocars and one 5-mm trocar were inserted through the abdominal cavity for laparoscopic guidance of three 7-mm endoluminal trocars inside the stomach through the anterior wall. Two posterior gastric ulcers were mechanically made on each pig by a "lift and cut technique." Ulcers were observed for at least 1 min for evidence of continued bleeding. First, bleeding ulcers were treated with sclerosing agents (epinephrine and ethanolmine oleate 5%); following sclerotherapy, ulcers were sutured intraluminaly with 2-0 silk, with intracorporeal knots.Ulcers created extended into the vascular submucosa and averaged 7 mm in diameter. Bleeding rate was variable, but significant (2 cm3/min) in 40%. It was technically possible to suture these ulcers in 80%. Bleeding was controlled in 95% of cases with sclerotherapy and intraluminal sutures. One perforation of the posterior gastric wall occurred and four endoluminal trocars had to be reinserted after dislodgement.It is possible to technically control bleeding ulcers in most cases with a laparoscopic transgastric technique using sclerosing agent and intraluminal sutures. This approach is promising for future human application; also, the intragastric suturing skills developed may be useful for other surgical interventions.

Increasing the length of the Roux limb in open Roux-en-Y gastric bypass (RYGB) effectively increases excess weight loss in superobese patients with a body mass index (BMI)50 kg/m2. Extending the RYGB limb length for obese patients with a BMI50 could produce similar results. The purpose of this study was to compare the outcomes of superobese patients undergoing laparoscopic RYGB with standard (or =100-cm) with those undergoing the procedure with an extended (150-cm) Roux limb length over 1-year period of follow-up.Retrospective data over 2.5 years were reviewed to identify patients with a BMI50 who underwent primary laparoscopic RYGB with 1-year follow-up ( n = 58). Forty-five patients (sRYGB group) received limb lengthsor = 100 cm, including 45 cm ( n = 1), 50 cm ( n = 2), 60 cm ( n = 6), 65 cm ( n = 1), 70 cm ( n = 1), 75 cm ( n = 3), and 100 cm ( n = 31). Thirteen patients (eRYGB group) received 150-cm limbs. Postoperative weight loss was compared at 3 weeks, 3 months, 6 months, and 1 year.Comparing the sRYGB vs the eRYGB group (average +/- SD), respectively: There were no significant differences in age (41.5 +/- 11.0 vs 38.0 +/- 11.9 years), preoperative weight (119.2 +/- 11.9 vs 127.8 +/- 12.5 kg), BMI (43.7 +/- 3.0 vs 45.2 +/- 3.5 kg/m2), operative time (167.1 +/- 72.7 vs 156.5 +/- 62.4 min), estimated blood loss (129.9 +/- 101.1 vs 166.8 +/- 127.3 cc), or length of stay (median, 3 vs 3 days; range, 2-18 vs 3-19). Body weight decreased over time in both groups, except in the sRYGB group between 3 and 6 months and 6 and 12 months after surgery and in the eRYGB group between 6 and 12 months. BMI also decreased over time, except in the eRYGB group between 6 and 12 months. Absolute weight loss leveled out between 6 and 12 months in both groups, with no increase after 6 months. Percent of excess weight loss did not increase in the eRYGB group after 6 months. An extended Roux limb did not significantly affect body weight, BMI, absolute weight loss, or precent of excess weight loss at any time point when the two groups were compared. A trend toward an increased proportion of patients with50% excess weight loss ( p = 0.07) was observed in the extended Roux limb group.In this series, no difference in weight loss outcome variables were observed up to 1 year after laparoscopic RYGB. Thus, extending Roux limb length fromor =100 cm to 150 cm did not significantly improve weight loss outcome in patients with a BMI50 kg/m2.

Laparoscopic surgeons are a curious lot. When we were accused of surgical adventurism in the early 1990s and were ostracized from presenting our early findings at the American College of Surgeons, we decided to invest our academic achievements in the Society of American Gastrointestinal Endoscopic Surgeons (SAGES). All of the early laparoscopic pioneers suffered the indignity of being the object of derogatory comments by the surgical establishment about ‘‘Nintendo’’ surgery (as if they knew what a video game was) and the ridiculousness of statements such as, ‘‘what’s wrong with a four-inch incision to remove the gallbladder that gets the patient back to work in 3 to 4 weeks?’’. We kept our council (silence), in spite of some misgivings, as the next technological revolution, robotics, swept the minimal invasive world. After the first year or so there were about 12–14 publications in our literature, all proclaiming this robotic surgery as being as ‘‘safe and effective’’ as laparoscopic surgery, but none actually proving it to be better. When the publications were looked at closely, all of the operations cost more and took longer (how is that effective?). While no one has actually said so, no one is taking robotics very seriously other than for its obvious use as a marketing tool. If there is anyone who thinks this million-dollar instrument has any utility in urology, I invite him or her to watch Dr. George Ferzli do a laparoscopic prostatectomy. Then, in 2006, we all heard about or saw a remarkable edited video of the removal of an appendix, albeit very normal appearing, through a gastroscope. By early 2007, there was one publication in a human subject about surgery done through a natural orifice transluminal endoscopic surgery (NOTES) technique, and that was about the rescue of a dislocated Percutaneous Endoscopic Gastrostomy (PEG), hardly something we see every day [1]. At the SAGES meeting in 2007 we were treated to edited videos that showed scopes introduced through the rectum, with stool affixed, used to guide surgery on gallbladders that were poorly grasped and dissected with no discernable anatomic landmarks, all often culminating in an explosion of bile. To those that state that these videos resemble the early era of laparoscopy, I paraphrase the Lloyd Bentsen/ Dan Quayle 1988 Vice Presidential debate: I knew the great surgical innovators of the early era of laparoscopy like Barry McKernan (gallbladder and hernia), Joe Petelin and Maurice Arregui (common bile duct), Dennis Fowler (colon), Lee Swanstrom (esophagus), Michel Gagner (adrenal and pancreas), and we never operated like that. If we did we certainly never filmed it. All of these pioneers did not work in traditional academic powerhouses but were rather busy general surgeons in smaller hospitals; such was the nature of early laparoscopy that in able hands it translated well from the open approach. At the SAGES 2007 meeting we were also treated to videos of endoscopic gastric plications (what exactly was plicated to what is difficult to determine), in the guise of performing an endoluminal vertical banded gastroplasty (VBG). In 2000 Michael Sarr’s group published excellent follow-up data on the VBG, showing that this operation worked to sustain weight loss less than 25% of the time and required reoperation about 20% of the time [2]. American surgeons have essentially abandoned this operation. It was Karl Marx who said that history repeats itself first as a tragedy and then as a farce. Why on Earth would we A. Pomp (&) Section of Laparoscopic and Bariatric Surgery, Frank Glenn Faculty Scholar in Surgery, Joan and Sanford I. Weill Medical College of Cornell University, New York, NY, USA e-mail: alp2014@med.cornell.edu

A standard technique for laparoscopic ventral hernioplasty (peritoneal onlay using an expanded polytetrafluoroethylene [ePTFE] patch for hernias/=4 cm2) is being used in a prospective, multicenter, long-term study.Demographic, operative, and postoperative data were collected and analyzed. Follow-up clinical evaluations were conducted 7-10 days, 4 weeks, 6 months, 1 year, and then annually after surgery in all patients.In the first 2 years of the study, 144 patients were enrolled; nine were lost to follow-up. The mean operating time was 120 min. The mean follow-up was 222 days (range 5-731). Postoperative complications were five infections, three cases of prolonged ileus, one bowel obstruction, 23 seromas (15 resolved without intervention), and six hernia recurrences. Hospital discharge occurred a mean of 2.3 days after surgery and return to normal activity a mean of 15 days postoperatively.Laparoscopic prosthetic ventral hernioplasty avoids the large wound required in open repairs, with attendant complications and recurrences, and appears safe, especially if an ePTFE mesh is used. Compared with conventional open ventral hernioplasty, the laparoscopic technique may also allow shorter hospitalization and a quicker return to normal activities after surgery.

A case of chronic pancreatitis localized in the head of the pancreas with pancreas divisum was treated by laparoscopic pylorus-preserving pancreatoduodenectomy. The laparoscopic technique of resection and reconstruction with a gastrojejunostomy, hepaticojejunostomy, and pancreaticojejunostomy is described. The postoperative period was complicated by a jejunal ulcer and delayed gastric emptying necessitating a prolonged hospitalization and intravenous hyperalimentation. No fistulas occurred, a follow-up CT scan revealed no pancreatic abnormalities, and the patient was discharged in good condition on the 30th postoperative day. Although technically feasible, the laparoscopic Whipple procedure may not improve the postoperative outcome or shorten the postoperative recovery period.

Adrenalectomy is usually performed via transabdominal or posterior approaches. Unfortunately, both approaches are associated with painful postoperative syndromes. Recently, laparoscopic surgery was applied to organ removal. During a period of 12 months, we performed a series of successful laparoscopic adrenalectomies (10 of the right and 11 of the left gland). The pathologies were medullary cyst (1), angiomyolipoma (1), DHEAS hyperplasia (1), primary aldosteronism (2), Cushing's adenoma (3), pheochromocytoma (4), Cushing's syndrome (4), and nonfunctional adenoma (5). A flank approach was taken with four 11-mm trocars. Electrocautery and blunt forceps were used for dissection. The vessels were secured with medium-large titanium clips, and the adrenal was removed in a sterile plastic bag. The average operating time was 2.3 h, and median postoperative stay was 4 days. Two patients required blood transfusion of 2 units postoperatively. We believe this technique is adequate for the surgical removal of adrenal tissue, resulting in less postoperative pain and in rapid recovery. It may also change the surgical management of asymptomatic adrenal lesions.