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Introduction: Achalasia is an esophageal motility disorder characterized by disordered esophageal peristalsis with failed relaxation of the lower esophageal sphincter resulting in a functional obstruction.Treatment can include medical, endoscopic, or surgical interventions. Although none of these are curative, they each offer methods to create esophageal outflow. Materials and Methods: This article discusses our preferred surgical technique used for laparoscopic Heller myotomy with Dor fundoplication. This technique has been developed over the author's career. Conclusion: The technique discussed provides a safe and effective strategy to manage achalasia. [ABSTRACT FROM AUTHOR]

Background: SARS-CoV-2 has changed global healthcare since the pandemic began in 2020. The safety of minimally invasive surgery (MIS) utilizing insufflation from the standpoint of safety to the operating room personnel is currently being explored. The aims of this guideline are to examine the existing evidence to provide guidance regarding MIS for the patient with, or suspecting of having, the SARS-CoV-2 as well as the healthcare team involved. Methods: Systematic literature reviews were conducted for 2 key questions (KQ) regarding the safety of MIS in the setting of COVID-19 pandemic. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis criteria. Evidence-based recommendations were formulated using a narrative synthesis of the literature by subject experts. Recommendations for future research were also proposed. Results: In KQ1, a total of 1361 articles were reviewed, with 2 articles meeting inclusion. In KQ2, a total of 977 articles were reviewed, with 4 articles met inclusions criteria, of which 2 studies reported on the SARS-CoV2 virus specifically. Despite many publications in the field, very little well-controlled and unbiased data exist to inform the recommendations. Of that which is available, it shows that both laparoscopic and open operations in Covid-positive patients had similar rates of OR staff positivity rates; however, patients who underwent laparoscopic procedures had a lower perioperative mortality than open procedures. Also, SARS-CoV-2 particles have been detected in the surgical plume at laparoscopy. Conclusion: With demonstrated equivalence of operating room staff exposure, and noninferiority of laparoscopic access with respect to mortality, either laparoscopic or open approaches to abdominal operations may be used in patients with SARS-CoV-2. Measures should be employed for all laparoscopic or open cases to prevent exposure of operating room staff to the surgical plume, as virus can be present in this plume. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to examine the perioperative outcomes of robotic inguinal hernia repair as compared to the open and laparoscopic approaches utilizing large-scale population-level data. Methods: This study was funded by the SAGES Robotic Surgery Research Grant (2019). The New York Statewide Planning and Research Cooperative System (SPARCS) administrative database was used to identify all adult patients undergoing initial open (O-IHR), laparoscopic (L-IHR), and robotic (R-IHR) inguinal hernia repair between 2010 and 2016. Perioperative outcome measures [complications, length of stay (LOS), 30-day emergency department (ED) visits, 30-day readmissions] and estimated 1/3/5-year recurrence incidences were compared. Propensity score (PS) analysis was used to estimate marginal differences between R-IHR and L-IHR or O-IHR, using a 1:1 matching algorithm. Results: During the study period, a total of 153,727 patients underwent inguinal hernia repair (117,603 [76.5%] O-IHR, 35,565 [23.1%] L-IHR; 559 [0.36%] R-IHR) in New York state. Initial univariate analysis found R-IHR to have longer LOS (1.74 days vs. 0.66 O-IHR vs 0.19 L-IHR) and higher rates of overall complications (9.3% vs. 3.6% O-IHR vs 1.1% L-IHR), 30-day ED visits (11.6% vs. 6.1% O-IHR vs. 4.9% L-IHR), and 30-day readmissions (5.6% vs. 2.4% O-IHR vs. 1.2% L-IHR) (p < 0.0001). R-IHR was associated with higher recurrence compared to L-IHR. Following PS analysis, there were no differences in perioperative outcomes between R-IHR and L-IHR, and the difference in recurrence was found to be sensitive to possible unobserved confounding factors. R-IHR had significantly lower risk of complications (Risk difference − 0.09, 95% CI [− 0.13, − 0.056]; p < 0.0001) and shorter LOS (Ratio 0.53, 95% CI [0.45, 0.62]; p < 0.0001) compared to O-IHR. Conclusion: In adult patients, R-IHR may be associated with comparable to more favorable 30-day perioperative outcomes as compared with L-IHR and O-IHR, respectively. [ABSTRACT FROM AUTHOR]

Introduction: Even though acute appendicitis is the most common general surgical condition encountered during pregnancy, the preferred approach to appendectomy in pregnant patients remains controversial. Current guidelines support laparoscopic appendectomy as the treatment of choice for pregnant women with appendicitis, regardless of trimester. However, recent published data suggests that the laparoscopic approach contributes to higher rates of fetal demise. Our study aims to compare laparoscopic and open appendectomy in pregnancy at a statewide population level. Methods: ICD-9 codes were used to extract 1006 pregnant patients undergoing appendectomy between 2005 and 2014 from the NY Statewide Planning and Research Cooperative System (SPARCS) database. Surgical outcomes (any complications, 30-day readmission rate, length of stay (LOS)) and obstetrical outcomes (antepartum hemorrhage, preterm delivery, cesarean section, sepsis, chorioamnionitis) were compared between open and laparoscopic appendectomy. Multivariable generalized linear regression models were used to compare different outcomes between two surgical approaches after adjusting for possible confounders. Results: The laparoscopic cohort (n = 547, 54.4%) had significantly shorter LOS than the open group (median ± IQR: 2.00 ± 2.00 days versus 3.00 ± 2.00 days, p value < 0.0001, ratio = 0.789, 95% CI 0.727–0.856). Patients with complicated appendicitis had longer LOS than those with simple appendicitis (p value < 0.0001, ratio = 1.660, 95% CI 1.501–1.835). Obstetrical outcomes (p value = 0.097, OR 1.254, 95% CI 0.961–1.638), 30-day non-delivery readmission (p value = 0.762, OR 1.117, 95% CI 0.538–2.319), and any complications (p value = 0.753, OR 0.924, 95% CI 0.564–1.517) were not statistically significant between the laparoscopic versus open appendectomy groups. Three cases of fetal demise occurred, all within the laparoscopic appendectomy group. Conclusions: The laparoscopic approach resulted in a shorter LOS. Although fetal demise only occurred in the laparoscopic group, these results were not significant (p value = 0.255). Our large population-based study further supports current guidelines that laparoscopic appendectomy may offer benefits over open surgery for pregnant patients in any trimester due to reduced time in the hospital and fetal and maternal outcomes comparable to open appendectomy. [ABSTRACT FROM AUTHOR]

Background: Utilization of robotic surgery has increased over time. Outcomes in bariatric surgery have been variable. This study used the Metabolic and Bariatric Surgery Accreditation Quality and Improvement Program (MBSAQIP) dataset to compare nationwide trends in utilization and outcomes improvement for robotic and laparoscopic bariatric surgery over a four-year period. Methods: We identified all adult patients who underwent robotic or laparoscopic primary sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) from 2015 to 2018. Those with previous bariatric/foregut surgery or open conversion were excluded. Trends in clinical outcomes of different surgery types over years were compared through multivariable regression models. Subgroup analysis was performed for patients in 2018, comparing outcomes among different surgery types. Results: A total of 571,417 patients underwent bariatric surgery, of which 46,764 (8.2%) were performed robotically. Utilization of the robotic platform increased annually, from 6.7% in 2015 to 10.3% in 2018 (p < 0.0001). The majority of patients underwent SG (n = 33,891, 72.5%). Perioperative outcomes improved over time for both robotic and laparoscopic procedures. Improvement was more pronounced in the robotic cohort for extended length of stay (OR 0.76 vs 0.8, p < 0.0001) and operative time (OR 0.98 vs 0.99, p < 0.0001). In the 2018 subgroup, multivariable analysis found laparoscopic RYGB was associated with increased bleeding (OR 2.220, p = 0.0004), overall complications (OR 1.356, p = 0.0013), and extended LOS (OR 1.178, p < 0.0001) compared to robotic surgery. Laparoscopic SG was associated with decreased anastomotic/staple line leak (OR 0.718, p = 0.0321), 30-d readmission (OR 0.826, p = 0.0005), 30-d reintervention (OR 0.723, p = 0.0014), overall event (OR 0.862, p = 0.0009), and extended LOS (OR 0.950, p = 0.0113). Across the board, laparoscopic surgery was associated with decreased operative time (Adjusted Ratio = 0.704, p < 0.0001). Conclusion: Robotic utilization for bariatric surgery is increasing and outcomes continue to improve with time. There is a differential impact of the robotic approach on SG and RYGB, which requires further assessment. [ABSTRACT FROM AUTHOR]

4 Fermont JM, Blazeby JM, Rogers CA, Wordsworth S. The EQ-5D-5L is a valid approach to measure health related quality of life in patients undergoing bariatric surgery. Keywords: Postoperative nausea and vomiting; Quality of life; Sleeve gastrectomy; Bariatric surgery EN Postoperative nausea and vomiting Quality of life Sleeve gastrectomy Bariatric surgery 2107 2109 3 07/31/21 20210801 NES 210801 Introduction Bariatric surgery has been shown to improve patient quality of life (QoL) in a longitudinal manner.[1],[2] However, the impact of postoperative nausea and vomiting (PONV) on QoL in the immediate/short-term postoperative period remains unclear. [Extracted from the article]

Background: The aim of our study is to determine minimally invasive trainee motivation and expectations for their respective fellowship. Minimally Invasive Surgery (MIS) is one of the largest non-ACGME post-residency training pathways though little is known concerning the process of residents choosing MIS as a fellowship focus. As general surgery evolves, it is important to understand resident motivation in order to better prepare them for a surgical career.Methods: A survey invitation was sent to current trainees in the Minimally Invasive and related pathways through the Fellowship Council. The participants were asked to complete a web-based questionnaire detailing demographics, experiences preparing for fellowship, motivation in choosing an MIS fellowship, and expectations for surgical practice after fellowship.Results: Sixty-seven MIS trainees responded to the survey out of 151 invitations (44%). The Fellowship Council website, mentors, and other fellows were cited as the most helpful source of information when applying for fellowship. Trainees were active in surgical societies as residents, with 78% having membership in the ACS and 60% in SAGES. When deciding to pursue MIS as a fellowship, the desire to increase laparoscopic training was the most important factor. The least important reasons cited were lack of laparoendoscopic training in residency and desire to learn robotic surgery. The majority of trainees believed their laparoscopic skill set was above that of their residency cohort (81%). The most desired post-fellowship employment model is hospital employee (46%) followed by private practice (27%). Most fellows plan on marketing themselves as MIS surgeons (90%) or General Surgeons (78%) when in practice.Conclusions: Residents who choose MIS as a fellowship have a strong exposure to laparoscopy and want to become specialists in their field. Mentors and surgical societies including ACS and SAGES play a vital role in preparing residents for fellowship and practice. [ABSTRACT FROM AUTHOR]

Introduction: The current surgical landscape reflects a continual trend towards sub-specialization, evidenced by an increasing number of US surgeons who pursue fellowship training after residency. Despite this growing trend, however, the effect of advanced gastrointestinal (GI)/minimally invasive surgery (MIS) fellowship programs on patient outcomes following foregut/esophageal operations remains unclear. This study looks at two representative foregut surgeries (laparoscopic fundoplication and esophagomyotomy) performed in New York State (NYS), comparing hospitals which do and do not possess a GI/MIS fellowship program, to examine the effect of such a program on perioperative outcomes. We also aimed to identify any patient or hospital factors which might influence perioperative outcomes.Methods: The SPARCS database was examined for all patients who underwent a foregut procedure (specifically, either an esophagomyotomy or a laparoscopic fundoplication) between 2012 and 2014. We compared the following outcomes between institutions with and without a GI/MIS fellowship program: 30-day readmission, hospital length of stay (LOS), and development of any major complication.Results: There were 3175 foregut procedures recorded from 2012 to 2014. Just below one third (n = 1041; 32.8%) were performed in hospitals possessing a GI/MIS fellowship program. Among our entire included study population, 154 patients (4.85%) had a single 30-day readmission, with no observed difference in readmission between hospitals with and without a GI/MIS fellowship program, even after controlling for potential confounding factors (p = 0.6406 and p = 0.2511, respectively). Additionally, when controlling for potential confounders, the presence/absence of a GI/MIS fellowship program was found to have no association with risk of having a major complication (p = 0.1163) or LOS (p = 0.7562). Our study revealed that postoperative outcomes were significantly influenced by patient race and payment method. Asians and Medicare patients had the highest risk of suffering a severe complication (10.00 and 7.44%; p = 0.0311 and p = 0.0036, respectively)-with race retaining significance even after adjusting for potential confounders (p = 0.0276). Asians and uninsured patients demonstrated the highest readmission rates (15.00 and 12.50%; p = 0.0129 and p = 0.0012, respectively)-with both race and payment method retaining significance after adjustment (p = 0.0362 and p = 0.0257, respectively). Lastly, payment method was significantly associated with postoperative LOS (p < 0.0001), with Medicaid patients experiencing the longest LOS (mean 3.99 days) and those with commercial insurance experiencing the shortest (mean 1.66 days), a relationship which retained significance even after adjusting for potential confounders (p < 0.0001).Conclusion: The presence of a GI/MIS fellowship program does not impact short-term patient outcomes following laparoscopic fundoplication or esophagomyotomy (two representative foregut procedures). Presence of such a fellowship should not play a role in choosing a surgeon. Additionally, in these foregut procedures, patient race (particularly Asian race) and payment method were found to be independently associated with postoperative outcomes, including postoperative LOS. [ABSTRACT FROM AUTHOR]

Background: Since the introduction of laparoscopic cholecystectomy (LC), there has been continued evolution in technique, instrumentation and postoperative management. With increased experience, LC has migrated to the outpatient setting. We asked whether increased availability and experience has impacted incidence of and indications for LC.Methods: The New York (NY) State Planning and Research Cooperative System longitudinal administrative database was utilized to identify patients who underwent cholecystectomy between 1995 and 2013. ICD-9 and CPT procedure codes were extracted corresponding to laparoscopic and open cholecystectomy and the associated primary diagnostic codes. Data were analyzed as relative change in incidence (normalized to 1000 LC patients) for respective diagnoses.Results: From 1995 to 2013, 711,406 cholecystectomies were performed in NY State: 637,308 (89.58 %) laparoscopic. The overall frequency of cholecystectomy did not increase (1.23 % increase with a commensurate population increase of 6.32 %). Indications for LC during this time were: 72.81 % for calculous cholecystitis (n = 464,032), 4.88 % for biliary colic (n = 31,124), 8.98 % for acalculous cholecystitis (n = 57,205), 3.01 % for gallstone pancreatitis (n = 19,193), and 1.59 % for biliary dyskinesia (n = 10,110). The incidence of calculous cholecystitis declined (-20.09 %, p < 0.0001) between 1995 and 2013; meanwhile, other diagnoses increased in incidence: biliary colic (+54.96 %, p = 0.0013), acalculous cholecystitis (+94.24 %, p < 0.0001), gallstone pancreatitis (+107.48 %, p < 0.0001), and biliary dyskinesia (+331.74 %, p < 0.0001). Outpatient LC incidence catapulted to 48.59 % in 2013, from 0.15 % in 1995, increasing >320-fold. Analysis of LC through 2014 revealed increasing rates of digestive, infectious, respiratory, and renal complications, with overall cholecystectomy complication rates of 9.29 %.Conclusion: A shifting distribution of operative indications and increasing rates of complications should prompt careful consideration prior to surgery for benign biliary disease. For what is a common procedure, LC carries substantial risk of complications, thus requiring the patient to be an active participant and to share in the decision-making process. [ABSTRACT FROM AUTHOR]

Introduction: There is an increased need for surgical trainees to acquire advanced laparoscopic skills as laparoscopy becomes the standard of care in many areas of general surgery. Since the introduction of minimally invasive surgery (MIS) fellowships, there has been a continuing debate as to whether these fellowships adversely affect general surgery resident exposure to laparoscopic cases. The aim of our study was to examine whether the introduction of an MIS fellowship negatively impacts general surgery residents' experience at a single academic center.Methods: We describe the changes following establishment of MIS fellowship at an academic center. Resident case log system from the Accreditation Council for Graduate Medical Education was queried to obtain all PGY 1-5 resident operative case logs. Two-year time period preceding and following the institution of an MIS fellowship at our institution in 2012 was compared. P values less than 0.05 were considered statistically significant.Results: Following initiation of the MIS fellowship, an MIS service was established. The service comprised of a fellow, midlevel resident, and intern. Operative experience was examined. From 2010-2012 to 2012-2014, residents logged a total of 272 and 585 complex laparoscopic cases, respectively. There were 43 residents from 2010 to 2013 and 44 residents from 2013 to 2014. When the two time periods were compared, a trend of increased numbers for all procedures was noted, except laparoscopic GYN/genito-urinary procedures. Average percent increase in complex general surgery procedures was 249 ± 179.8 %. Following establishment of a MIS fellowship, reported cases by residents were higher or similar to those reported nationally for laparoscopic procedures.Conclusion: Institution of an MIS fellowship had a favorable effect on general surgery resident operative education at a single academic training center. Residents may benefit from the presence of a fellowship at an academic center because they are able to participate in an increased number of complex laparoscopic cases. [ABSTRACT FROM AUTHOR]

Single-port or single-incision cholecystectomy with current rigid laparoscopic devices is limited by in-line visualization, restricting the ability to approach the surgical site with proper angles and instrumentation. A single-port access system with articulating arms and strong instrumentation should minimize these issues. The TransEnterix system may facilitate safe and straightforward single-port surgery. The TransEnterix single-port surgery system was used in both survival and nonsurvival porcine laparoscopic cholecystectomies under animal use committee approval. Nonsurvival procedures compared four standard laparoscopic with four single-port cholecystectomies from a histologic perspective. Five single-port swine laparoscopic cholecystectomy procedures were completed in sterile conditions, and all animals survived for 1 week postoperatively. Standard surgical clips were used for both cystic duct and artery ligation. At sacrifice, both gross and microscopic histology were obtained for assessment of surgical complications. All cholecystectomies were successfully completed with the TransEnterix single-port system. Operative time for the survival procedures averaged 39.4 (range 18–66) min. Histology of the acute specimens showed less inflammation at the single-port site compared with the trocar sites from the standard cholecystectomy. At sacrifice, no complications were identified. The TransEnterix system is safe and straightforward for completing single-port cholecystectomy in this limited porcine series. Port site inflammation is reduced compared with standard laparoscopic trocars. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 49-year-old, African-American female with a several-year history of dysphagia, episodic epigastric discomfort, and symptomatic gastroesophageal reflux. A large pericardial hernia defect containing omentum and portions of liver, and stomach was found on laparoscopic evaluation. The patient was initiated on oral intake before surgery. The article discusses laparoscopic repair of a large pericardial hernia.

Abstract: Over the past few decades, advancements in minimally invasive surgery techniques have made surgical management of gastroesophageal reflux diseases increasingly popular. More recently, the field of minimally invasive surgery has experienced a natural evolution towards a reduction in the invasiveness of surgery and even in the number of abdominal access incisions. In fact, single site/access approaches have been successfully applied to a number of common minimally invasive surgery procedures including cholecystectomy, hysterectomy, colectomy, bariatric and even anti-reflux surgery. However, there is very little published data on the application of this technique in anti-reflux surgery. We present a brief review of available data as well as a summary of our experiences with this innovative approach to minimally invasive foregut surgery. [Copyright &y& Elsevier]

Objective: Use of the VersaStep trocar system (US Surgical, Norwalk, CT) has the perceived advantage of minimal trocar-related hernias in patients undergoing Roux-en-Y gastric bypass surgery (RYGB). We performed a retrospective review of our last 747 consecutive operative procedures using these trocars.Methods and Procedures: The patient population was 747 consecutive patients who underwent laparoscopic RYGB at Duke University Health System Weight Loss Surgery Center from January 2002 through April 2005. A total of 3735 radially expanded trocar sites were used. VersaStep trocars were used in all cases. The port configuration included one supraumbilical Hasson port, two 12-mm ports, and three 5-mm ports. The Hasson port was closed with a figure-of-eight number 1 Polysorb suture. All other trocar sites had no fascial closure. Intestinal anastomoses were created with a linear stapler in all of the laparoscopic cases, with hand suturing of the residual enterotomy. The fascial incisions were therefore not extended to accommodate an EEA stapler. The charts were reviewed for occurrence of subsequent trocar site hernias.Results: There were no hernias at any of the VersaStep trocar sites-an incidence of 0%. There were nine incisional hernias at the Hasson port site which later required surgical repair-an incidence of 1.20%.Conclusions: There were no hernias detected at any of the 1494 12-mm or 2241 5-mm VersaStep trocar sites, despite lack of suture closure. At the Hasson port site, there was a hernia incidence of 1.20%. In the bariatric RYGB population, routine suture closure of the fascia or muscle is not necessary when using radially expanding VersaStep trocars. [ABSTRACT FROM AUTHOR]