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Background: Minimally invasive approaches to liver resection (MILR) are associated with favorable outcomes. The aim of this study was to determine the implications of conversion to an open procedure on perioperative outcomes., Methods: Patients who underwent MILR at 10 North American institutions were identified from the Americas Minimally Invasive Liver Resection (AMILES) database. Outcomes of patients who required conversion were compared to those who did not. Additionally, outcomes after conversion due to unfavorable findings (poor visualization/access, lack of progress, disease extent) versus intraoperative events (bleeding, injury, cardiopulmonary instability) were compared., Results: Of 1675 patients who underwent MILR, 102 (6.1%) required conversion. Conversion rate ranged from 4.4% for left lateral sectionectomy to 10% for right hepatectomy. The primary reason for conversion was unfavorable findings in 67 patients (66%) and intraoperative adverse events in 35 patients (34%). By multivariable analysis, major resection, cirrhosis, prior liver surgery, and tumor proximity to major vessels were identified as risk factors for conversion (p < 0.05). Patients who required conversion had higher blood loss, transfusion requirements, operative time, and length of stay, (p < 0.05). They also had higher major complication rates (23% vs. 5.2%, p < 0.001) and 30-day mortality (8.8% vs. 1.3%, p < 0.001). When compared to those who required conversion due to unfavorable findings, patients who required conversion due to intraoperative adverse events had significantly higher major complication rates (43% vs. 14%, p = 0.012) and 30-day mortality (20% vs. 3.0%, p = 0.007)., Conclusions: Conversion from MILR to open surgery is associated with increased perioperative morbidity and mortality. Conversion due to intraoperative adverse events is rare but associated with significantly higher complication and mortality rates, while conversion due to unfavorable findings is associated with similar outcomes as planned open resection. High-risk patients may benefit from early conversion in a controlled fashion if difficulties are encountered or anticipated., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Incisional hernia repair is one of the most common general surgery operations being performed today. With the advancement of laparoscopy since the 1990s, we have seen vast improvements in faster return to normal activity, shorter hospital stays and less post-operative narcotic use, to name a few., Objective: The key aims of this review were to measure the impact of minimally invasive surgery versus open surgery on health care utilization, cost, and work place absenteeism in the patients undergoing inpatient incisional/ventral hernia (IVH) repair., Methods: We analyzed data from the Truven Health Analytics MarketScan ® Commercial Claims and Encounters Database. Total of 2557 patients were included in the analysis., Results: Of the patient that underwent IVH surgery, 24.5% (n = 626) were done utilizing minimally invasive surgical (MIS) techniques and 75.5% (n = 1931) were done open. Ninety-day post-surgery outcomes were significantly lower in the MIS group compared to the open group for total payment ($19,288.97 vs. $21,708.12), inpatient length of stay (3.12 vs. 4.24 days), number of outpatient visit (5.48 vs. 7.35), and estimated days off (11.3 vs. 14.64), respectively. At 365 days post-surgery, the total payment ($27,497.96 vs. $30,157.29), inpatient length of stay (3.70 vs. 5.04 days), outpatient visits (19.75 vs. 23.42), and estimated days off (35.71 vs. 41.58) were significantly lower for MIS group versus the open group, respectively., Conclusion: When surgical repair of IVH is performed, there is a clear advantage in the MIS approach versus the open approach in regard to cost, length of stay, number of outpatient visits, and estimated days off.

Background: Centers for Medicare and Medicaid Services define laparoscopic ventral hernia repair (LVHR) as outpatient procedure. We identified our institutional length of stay (LOS) to be above the National Surgical Quality Improvement Program (NSQIP) benchmark of 1 day [interquartile range (IQR) 2 days]. This study was undertaken to investigate risk factors associated with prolonged hospital stay and design an intervention to decrease median LOS., Methods: This study analyzed institutional NSQIP data on patients who underwent elective LVHR from 2006 to 2011 to define factors associated with prolonged LOS, defined as LOS > 2 days. Modifiable factors identified in the initial analysis were included in a clinical care pathway to impact LOS. We repeated the NSQIP data analysis after implementation (4/2011-9/2012) to assess the effect of our intervention. Analysis was by univariate, ANOVA and logistic regression models., Results: During the pre-implementation period, 80 patients with a median age of 54 years (31-84) stayed a median of 2 days (IQR 3). On univariate analysis, factors associated with prolonged LOS included operative time, mesh size, amount of narcotics used and female gender. In multivariate analysis, operative time and narcotics used were associated with a prolonged LOS, C statistic = 0.88. Introduction of a clinical pathway focusing on non-narcotic pain relief resulted in a decrease in mean narcotic usage from 223 to 63 mg morphine equivalents/patient (p < 0.0001), decrease in median LOS to 1 day (IQR 2) (p = 0.027), in line with NSQIP benchmarks, a slight decrease in complications and a 10% decrease in hospital cost., Conclusion: High narcotic use and long operative times are independent predictors of prolonged LOS in our patient population. Introduction of a standardized clinical care pathway designed to reduce perioperative narcotic use resulted in shorter LOS, improved quality and cost savings for patients undergoing LVHR.

Background: Bariatric surgery has been established as the most effective long-term treatment for morbid obesity and obesity-related comorbidities. Despite its success, there is a paucity of data on the outcomes of bariatric surgery on Hispanic patients., Study Design: We performed a retrospective review of obese patients treated at our institute between 2008 and 2014. We identified self-reported Hispanic patients who underwent a laparoscopic gastric bypass (LGBP), sleeve gastrectomy (LSG), or gastric band (LGB) procedure. The primary end point was excess weight loss (EWL) at 6, 12, 24, and 36 months. Secondary end points included improvement of obesity-related metabolic parameters at 1 year. We performed a repeated measures analysis of variance to calculate statistical significance throughout our study time period., Results: We identified 2002 Hispanic patients who underwent bariatric surgery (1,235 LGBP, 600 LSG, 167 LGB) at our institute from 2008 to 2014. Follow-ups at 6, 12, 24, and 36 months were 62.2%, 54.5%, 36.2%, and 19.8%, respectively. Mean preoperative BMIs were 47.0 ± 7.2 kg/m2, 46.1 ± 7.8 kg/m2, and 44.9 ± 6.0 kg/m2 for the LGBP, LSG, and LGB cohorts, respectively. Excess weight loss was significantly more pronounced in the LGBP and the LSG groups than in the LGB group; this difference was accentuated over time (p < 0.0001). Obesity-related metabolic parameters and the need for comorbidity medical therapy decreased in all 3 surgical groups., Conclusions: Bariatric surgery is highly successful in Hispanic obese patients. In the largest series to date, LGBP and LSG seem to yield more effective EWL and reduction of cardiometabolic parameters than LGB among Hispanics; however, outcomes are still markedly reduced when compared with those in non-Hispanic populations., (Copyright © 2016. Published by Elsevier Inc.)

Bloody otorrhagia in the perioperative period is an uncommon event. We present a case of bilateral bloody otorrhagia after uncomplicated robotic-assisted laparoscopic prostatectomy in a 66-year-old man. Anesthetic management was unremarkable. No symptoms were noted by the patient. Postoperative otolaryngology evaluation revealed bilateral ear canal hematomas with intact tympanic membranes. The patient was discharged with Ciprodex ear drops on postoperative day 1. One-month otolaryngology follow-up revealed no long-term sequelae. Although the etiology is unclear, there seems to be a trend in the literature toward occurrence with laparoscopy in the Trendelenburg position.

Background: Laparoscopic Heller myotomy (LHM) has become the standard treatment for achalasia in the USA. Robot-assisted Heller myotomy (RHM) has emerged as an alternative approach due to improved visualization and fine motor control, but long-term follow-up studies have not been reported. We sought to report the long-term outcomes of RHM and compare them to those of LHM., Methods: A retrospective cohort study was performed for patients who underwent laparoscopic or RHM between 1995 and 2006. Long-term follow-up was performed via mail or telephone questionnaire. The primary outcome measure was durable relief of dysphagia without need for further intervention. Secondary outcomes included gastroesophageal reflux symptoms, disease-specific quality of life, and patient satisfaction with their operation., Results: Seventy-five patients underwent laparoscopic (n = 19) or robotic (n = 56) myotomy during the study period. Long-term follow-up was obtained in 53 (71 %) patients with a median interval of 9 years. RHM was associated with a decreased mucosal injury rate (0 vs. 16 %, p = 0.01) and median hospital stay (1 vs. 2 days, p < 0.01) compared to conventional laparoscopy. All patients reported initial dysphagia relief, and 80 % required no further intervention. This did not differ between groups. Sixty-two percent required medications to control reflux symptoms at long-term follow-up, including 56 % following robotic myotomy and 80 % after laparoscopic myotomy (p = 0.27). Overall, 95 % of patients were satisfied with their operation, and 91 % would choose surgery again given the benefit of hindsight., Conclusion: There is a dearth of long-term follow-up data to support the effectiveness of RHM. This study demonstrates durable dysphagia relief in the vast majority of patients with a high degree of patient satisfaction and a low rate of esophageal mucosal injury. While a significant proportion of patients report reflux symptoms, these symptoms are well controlled with medical acid suppression.

Background: The ideal surgical approach for treatment of symptomatic paraesophageal hernias (PEH) in obese patients remains elusive. The objective of this study was to assess the safety, feasibility, and effectiveness of combined laparoscopic PEH repair and Roux-en-Y gastric bypass (RYGB) for the management of symptomatic PEH in morbidly obese patients., Methods: Fourteen patients with symptomatic PEH and morbid obesity (body mass index [BMI]>35 kg/m(2)) underwent laparoscopic PEH repair with RYGB between 2008 and 2011. Demographic characteristics and preoperative and perioperative details were analyzed. Patients were contacted in October 2013 for follow-up. BMI, reflux symptoms, and disease-specific quality of life (QoL) data were obtained., Results: There were 11 females (79%). Median age and preoperative BMI were 48 years and 42 kg/m(2), respectively. Mean operative time was 180 minutes, with median length-of-stay of 4 days. There were no perioperative deaths, and 5 patients experienced postoperative complications including 1 gastrojejunostomy leak. Complete follow-up with a median follow-up interval of 35 months was available in 9 (64%) patients. The median % excess weight loss was 67.9%. Thirty-three percent required antisecretory medications for reflux control, compared to 89% preoperatively. Seventy-eight percent of patients reported good to excellent QoL outcomes assessed by the Gastroesophageal Reflux Disease Health-Related Quality of Life questionnaire. Overall, 89% of patients were satisfied with their operation and would undergo the procedure again., Conclusion: Combined laparoscopic PEH repair and RYGB is a safe, feasible, and effective treatment option for morbidly obese patients with symptomatic PEH, and offers good to excellent disease-specific quality-of-life outcomes at medium-term follow-up. To date, this is the largest series with the longest follow-up in this unique patient population., (Copyright © 2014 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The health-care burden related to ventral hernia management is substantial, with more than 3 billion dollars in expenditures annually in the US. Previous studies have suggested that the utilization of laparoscopic repair remains relatively low although national volume estimates have not been reported. We sought to estimate the inpatient national volume of elective ventral hernia surgery and characterize the proportion of laparoscopic versus open operations., Methods: We analyzed data from the Nationwide Inpatient Sample to identify adults with a diagnosis of an umbilical, incisional, or ventral hernia who underwent an elective inpatient repair between 2009 and 2010. Cases that involved other major abdominal or pelvic operations were excluded. Covariates included patient demographics, surgical approach, and use of mesh. National surgical volume estimates were generated and length of stay and total hospital charges were compared for laparoscopic versus open repairs., Results: A total of 112,070 ventral hernia repairs were included in the analysis: 72.1 % (n = 80,793) were incisional hernia repairs, while umbilical hernia repairs comprised only 6.9 % (n = 7,788). Laparoscopy was utilized in 26.6 % (n = 29,870) of cases. Mesh was placed in 85.8 % (n = 96,265) of cases, including 49.3 % (n = 3,841) of umbilical hernia repairs and 90.1 % (n = 72,973) of incisional hernia repairs. Length of stay and total hospital charges were significantly lower for laparoscopic umbilical, incisional, and "other" ventral hernia repairs (p values all <0.001). Total hospital charges during this 2-year period approached 4 billion dollars ($746 million for laparoscopic repair; $3 billion for open repair)., Conclusions: Utilization of laparoscopy for elective abdominal wall hernia repair remains relatively low in the US despite its excellent outcomes. Given the substantial financial burden associated with these hernias, future research focused on preventing the development and optimizing the surgical treatment of ventral abdominal wall hernias is warranted.

Background: We examined the safety and effectiveness of antegrade laparoscopic inversion esophagectomy (LIE) for patients with multifocal high-grade dysplasia and distal esophageal cancer., Methods: We reviewed our experience with antegrade LIE, using an institutional research board-approved prospective database., Results: Thirty-six patients with an average age of 64 years underwent LIE. Indications included multifocal high-grade dysplasia (n = 4), adenocarcinoma (n = 30), and squamous cell carcinoma (n = 2); 11 patients had undergone neoadjuvant chemoradiation. LIE was completed successfully in 34 (94%) patients, whereas 2 required a conversion to open transhiatal esophagectomy. LIE required 221 minutes to perform, with a median blood loss of 100 mL. R0 resection was achieved in 97% of cases with a median lymph node harvest 15. Median hospital stay was 8 days, and 61% of patients were discharged to their home. Postoperative complications included anastomotic leak (n = 11) and stricture (n = 18), atrial arrhythmia (n = 5), pneumonia (n = 4), and tracheoesophageal fistula (n = 2). Operative outcomes after neoadjuvant therapy did not differ from those for primary operative resection., Conclusion: Antegrade LIE is a safe treatment approach for patients with high-grade dysplasia and distal esophageal cancer. Complete resection with an adequate lymph node harvest can be achieved consistently for primary operative resection or after neoadjuvant chemoradiation., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Introduction: Transoral incisionless fundoplication (TIF) has been used for endoscopic treatment of gastroesophageal reflux disease (GERD). Full-thickness polypropylene H-fasteners create a serosa-to-serosa gastroesophageal plication. A certain subset of TIF patients will require subsequent antireflux surgery to achieve adequate reflux control, and it is unknown whether this procedure increases the technical difficulty of laparoscopic Nissen fundoplication for recurrent GERD., Patients and Methods: Between 2008 and 2010, patients demonstrating objective evidence of recurrent gastroesophageal reflux following TIF using the Esophyx device (Endogastric Solutions, Redmond, WA) underwent laparoscopic Nissen fundoplication. The study end points included operative time, operative blood loss, gastric or esophageal perforation, and length of hospital stay., Results: In total, 7 patients underwent laparoscopic Nissen fundoplication for recurrent GERD at a median interval of 7 (range, 3-28) months after TIF. Revisional fundoplication required 97 (range, 48-122) minutes and was performed in all cases with minimal blood loss. There were no cases of esophageal or gastric perforation during the dissection of the previous fundoplication. A significant hiatal hernia was noted during 1 case, and all others revealed partially disrupted gastroesophageal fundoplications with visible dislodged polypropylene H-fasteners visible. All patients were discharged from the hospital on the first postoperative day., Conclusions: Severe recurrent gastroesophageal reflux necessitating laparoscopic Nissen fundoplication occurs in a subset of patients following TIF. In this series, previous TIF did not result in prolonged operative times, significant operative hemorrhage, or iatrogenic hollow viscus injury. These data suggest that laparoscopic Nissen fundoplication can be safely performed in this patient population without increased operative morbidity.

Esophageal cancer remains one of the most deadly cancers with a low overall 5-year survival rate of 17%. Surgical options for esophageal cancer are varied, and debate exists on the best option. The literature was searched for articles discussing minimally invasive esophagectomy (MIE) compared with open esophagectomy (OE), and articles were chosen at the discretion of the authors. Several studies have shown that MIE has a statistically significant rate of decreased blood loss, increased length of operative time, shorter hospital stay, and overall decreased morbidity. Anastomotic leak, stricture rate, and survival benefit have also been demonstrated to be similar between OE and MIE. As is made apparent by the small amount of literature on MIE, further research must be done to determine outcomes. Although it is likely that MIE does offer benefits when compared with open surgery, it has not been shown in any large-scale comparative studies.

Ventral hernias, whether naturally occurring or the result of previous surgery, comprise one of the most common problems confronting general surgeons. As many as 25% of laparotomy incisions develop a hernia over long-term follow-up, which is a difficult problem with many treatment algorithms. Laparoscopic ventral hernia repair has improved over the last decade and has proven to be an effective treatment option. With fewer wound complications and low recurrence rates, it is a useful tool in the surgeon's armamentarium. Care should be taken regarding patient selection, operative technique, and mesh size to ensure adequate repair of the hernia, thereby preventing recurrence at a later date. The first attempt at a hernia repair has the highest chance of long-term success, so it is important that the surgeon take all the factors into mind before proceeding with operative repair.

Background: Inguinal hernia recurrence after surgical repair is a major concern. The authors report their experience with open and laparoscopic repair of recurrent inguinal hernias., Methods: After institutional review board approval, a retrospective review was performed with the charts of 197 patients who had undergone surgical repair of recurrent inguinal hernias from January 2000 through August 2009, and the data for 172 patients who met the inclusion criteria were analyzed. Surgical variables and clinical outcomes were compared using Student's t test, the Mann-Whitney U test, chi-square, and Fisher's exact test as appropriate., Results: The review showed that 172 patients had undergone either open mesh repair (n=61) or laparoscopic mesh repair (n=111) for recurrent inguinal hernias. Postoperative complications were experienced by 8 patients in the open group and 17 patients in laparoscopic group (p=0.70). Five patients (8.2%) in the open group and four patients (3.6%) in the laparoscopic group had re-recurrent inguinal hernias (p=0.28). Four patients in the open group (9.5%) and no patients in the laparoscopic group had recurrence during long-term follow-up evaluation (p=0.046). In the laparoscopic group, 76 patients (68.5%) underwent total extraperitoneal (TEP) repair, and 35 patients (31.5%) had transabdominal preperitoneal (TAPP) repair. Postoperative complications were experienced by 13 patients in the TEP group and 4 patients in the TAPP group (p=0.44). Two patients (2.6%) in the TEP group and two patients (5.7%) in the TAPP group had re-recurrent inguinal hernias (p=0.59)., Conclusions: This retrospective review showed no statistical difference in the re-recurrence rate between the two techniques during short-term follow-up evaluation. However, the laparoscopic technique had a significantly lower re-recurrence rate than the open technique during long-term follow-up evaluation. Both procedures were comparable in terms of intra- and postoperative complications. Among laparoscopic techniques, TEP and TAPP repair are acceptable methods for the repair of recurrent inguinal hernia. A multicenter prospective randomized control trial is needed to confirm the findings of this study.

Background: The methodology of Natural Orifice Translumenal Endoscopic Surgery (NOTES) has been validated in both human and animal models. Herein is a discussion of our experience gained from the initial 130 patients enrolled in transgastric pre-NOTES and NOTES protocols at our institution., Methods: A retrospective review of our research database was performed for all patients enrolled in NOTES protocols. The infectious risk of a gastrotomy with and without a NOTES procedure was assessed in 100 patients. Eighty patients completed a true NOTES protocol looking at staging, access, and insufflation with select patients evaluating the potential for bacterial contamination of the abdominal compartment., Results: A total of 130 patients have completed pre-NOTES and NOTES protocols at our institution. We observed no clinically significant contamination of the abdomen secondary to transgastric procedures in 100 patients. Diagnostic transgastric endoscopic peritoneoscopy (DTEP) was completed in 20 patients with pancreatic head masses and found to have a 95% concordance with laparoscopic exploration for assessment of peritoneal metastases. Blind endoscopic gastrotomy and DTEP were evaluated in 40 patients who underwent laparoscopic Roux-en-Y gastric bypass procedures (LSRYGB) and were found to be safe, reliable, and without a clinically significant risk of contamination. Endoscopic peritoneal insufflation was successfully established and correlated with standard laparoscopic insufflation in 20 patients., Conclusions: Transgastric NOTES is a safe alternative approach to accessing the peritoneal cavity in humans. The risk of bacterial contamination secondary to peroral and transgastric access is clinically insignificant. A device for the facile closure of the gastric defect is the sole factor limiting institution of this methodology as a standalone technique.

Background: Diagnostic transgastric endoscopic peritoneoscopy has been used to evaluate the abdomen. We present our experience with transgastric endoscopic peritoneoscopy (TEP) to access the peritoneum, direct trocar placement, and perform adhesiolysis without laparoscopic visualization in patients undergoing laparoscopic Roux-en-Y gastric bypass., Methods: Forty patients participated. There are 2 arms to the study. The initial 20 patients underwent pre-insufflation of the abdomen prior to TEP. The second 20 had no pre-insufflation. Ten patients in each arm had no surgical history. The other 10 had previous intra-abdominal procedures. TEP was performed through a gastrotomy created without laparoscopic visualization. Adhesions were visualized and taken down endoscopically prior to trocar placement. Diagnostic findings, operative times, and clinical course were recorded., Results: Average TEP time was 19 min. Three patients had limited visualization due to intra-abdominal adhesions (2) and omental fat (1). Three of the 20 without and 17 of 20 with a history of intra-abdominal surgery had adhesions visualized endoscopically. Endoscopic adhesiolysis was performed in 1 and 4 patients in these groups respectively. Six occult umbilical hernias, 1 inguinal hernia, and 1 hiatal hernia were noted on endoscopic exploration. There were no complications related to intubation of the stomach, accessing the peritoneum, or endoscopic exploration., Conclusion: TEP is a safe and accurate means to access the peritoneum, visualize the abdominal wall, perform adhesiolysis, and direct trocar placement without laparoscopic guidance. Safe and reliable gastric closure remains the sole limitation to its clinical use outside of a protocol necessitating a gastrotomy., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Background: Laparoscopic adrenalectomy (LA) has become the standard approach to an adrenal mass. This technique provides for decreased convalescence, less postoperative pain, and improved cosmesis. The use of LA for pheochromocytoma (PHE) has been questioned due to concerns of increased morbidity and negative hemodynamic sequelae. This study aimed to compare the outcomes of LA for PHE with the results of LA for other adrenal pathologies., Methods: A retrospective chart review was performed for an 11-year period from July 1997 to December 2008. Patient demographics, perioperative data, and outcomes were recorded. Statistical analysis was performed using SPSS 16.0. Statistical significance was defined as a p value less than 0.05., Results: A total of 102 LA procedures were completed for 95 patients. The data for 33 PHE cases were compared with the data for 69 non-PHE cases (26 adenomas, 14 aldosteronomas, 5 cortisol-secreting tumors, 5 multinodular hyperplasias, and 19 other disorders). Five LA procedures were converted to open surgery. Four of these conversions involved patients with PHE (p = 0.03). There was no difference in the mean estimated blood loss (p = 0.2) or operative time (p = 0.1) between the two groups. The frequency of intraoperative hypertension and hypotension did not differ between the PHE and non-PHE cohorts. The complication rate was 7.5% for the PHE group and 6.9% for the non-PHE group (p = 0.7). The patients with PHE had a longer postoperative hospital stay (3.6 vs 2.3 days; p < 0.001) and overall hospital stay (4.9 vs 2.6 days; p < 0.001). Time in the intensive care unit (1.1 vs 0.1 days; p < 0.001) and time until oral intake (1.5 vs 1.0 days; p = 0.02) also were increased in the PHE population. There was one death in the PHE group secondary to congestive heart failure., Conclusions: Concerns of increased morbidity related to a laparoscopic approach for patients with a diagnosis of PHE are unfounded. In this series, the only disparity in outcomes between the two groups was an increased conversion rate with PHE.

Introduction: Several studies have confirmed that gastroesophageal reflux disease (GERD) in lung transplant patients is a risk factor for the development and progression of bronchiolitis obliterans syndrome (BOS), a form of rejection after lung transplantation. Moreover, numerous reports indicate that surgical correction of GERD may control the decline in lung function characteristic of BOS. Although laparoscopic fundoplication is an accepted treatment option for these patients with GERD, the surgical technique, which often includes a laparoscopic pyloroplasty, has not been standardized., Methods: The purpose of this article is to describe a step-by-step approach to the laparoscopic treatment of GERD in lung transplant patients. We also address specific technical concerns encountered in the surgical management of this high-risk patient population; we provide data on the safety of this operation; and we illustrate the evidence-based rationale for each technical step of the procedure.

Background: The validity of natural orifice transluminal endoscopic surgery (NOTES) was confirmed in a human trial of 10 patients undergoing diagnostic transgastric endoscopic peritoneoscopy (DTEP) for staging of pancreatic head masses. This report is an update with 10 additional patients in the series and includes bacterial contamination data., Methods: The patients in this human trial were scheduled to undergo diagnostic laparoscopy for abdominal staging of a pancreatic head mass. A second surgeon, blinded to the laparoscopic findings, performed a transgastric endoscopic peritoneoscopy (TEP). The findings of laparoscopic exploration were compared with that those of the TEP. Diagnostic findings, operative times, and clinical course were recorded. Bacterial contamination data were collected for the second cohort of 10 patients. Bacterial samples were collected from the scope before use and the abdominal cavity before and after creation of the gastrotomy. Samples were assessed for bacterial counts and species identification. Definitive care was rendered based on the findings from laparoscopy., Results: In this study, 20 patients underwent diagnostic laparoscopy followed by DTEP. The average time for completion of diagnostic laparoscopy was 10 min compared with 21 min for TEP. The experience acquired during the initial 10 procedures translated to a 7-min decrease in TEP time for the second 10 cases. For 19 of the 20 patients, DTEP corroborated laparoscopic findings for surgical decision making. One endoscopic and five laparoscopic biopsies were performed. Pancreaticoduodenectomy was performed for 14 patients and palliative gastrojejunostomy for 6 patients. No cross-contamination of the peritoneum or infectious complications were noted. No significant complications related to either the endoscopic or laparoscopic approach occurred., Conclusions: This study supports the authors' previous conclusions that the transgastric approach to diagnostic peritoneoscopy is feasible, safe, and accurate. The lack of documented bacterial contamination further supports the use of this technique. Technical issues, including intraabdominal manipulation and gastric closure, require further investigation.

Background: The optimal method for closing gastrotomies after transgastric instrumentation has yet to be determined., Objective: To compare gastrotomy closure with endoscopically delivered bioabsorbable plugs with no closure., Design: Prospective, controlled study., Setting: Animal laboratory., Subjects: Twenty-three dogs undergoing endoscopic transgastric peritoneoscopy between July and August 2007., Interventions: Endoscopic anterior wall gastrotomies were performed with balloon dilation to allow passage of the endoscope into the peritoneal cavity. The plug group (n = 12) underwent endoscopic placement of a 4 x 6-cm bioabsorbable mesh plug in the perforation, whereas the no-treatment group (n = 11) did not. Animals underwent necropsy 2 weeks after the procedure., Main Outcome Measurements: Complications related to gastrotomy closure, gastric burst pressures, relationship of burst perforation to gastrotomy, and the degree of adhesions and inflammation at the gastrotomy site., Results: After the gastrotomy, all dogs survived without any complications. At necropsy, burst pressures were 77 +/- 11 mm Hg and 76 +/- 15 mm Hg (P = .9) in the plug group and no-treatment group, respectively. Perforations occurred at the site of the gastrotomy in 2 of 12 animals in the plug group and in none of the 11 dogs in the no-treatment group (P = .5). Finally, there were minimal adhesions in all dogs (11/11) in the no-treatment group and minimal adhesions in 3 and moderate adhesions or inflammatory masses in 9 of the 12 animals in the plug group (P = .004)., Limitations: Small number of subjects, animal model, no randomization. Gastrotomy trauma during short peritoneoscopy may not be applicable to longer procedures., Conclusions: After endoscopic gastrotomy, animals that were left untreated did not show any clinical ill effects and demonstrated adequate healing, with fewer adhesions and less inflammation compared with those treated with a bioabsorbable plug., (2010 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Objectives: Minimally invasive surgery is beneficial for complex operations; robotics may improve performance in these procedures; however, robotic pancreaticoduodenectomy (PD) has been plagued by long operative times. We describe a small series (n = 5) of patients who underwent a hybrid PD for treatment of obstructive jaundice and pancreatic mass., Methods: After diagnostic laparoscopy, the gallbladder was retracted cephalad and the porta hepatis was dissected. The lesser sac was opened to expose the superior mesenteric vein below the pancreas. Once the vein was cleared, the bile duct, stomach, pancreas, and jejunum were transected. After the uncinate process was cleared, the specimen was removed. The da Vinci S Surgical Robotic System was docked to perform a mucosa-to-mucosa pancreaticojejunostomy and an end-to-side choledochojejunostomy. A stapled gastrojejunostomy and drain placement completed the operation., Results: Five patients underwent hybrid PD between May 2006 and June 2007. All patients had a history of pancreatitis and presented with obstructive jaundice and a pancreatic mass. The operations were completed with 5 ports. The mean operative time was 7 hours. The mean hospital stay was 9.6 days. At 6 months after the operation, all patients were disease-free., Conclusions: Complex procedures such as PD can be accomplished with minimally invasive surgical techniques using robotic instrumentation.

Background: Diagnostic transgastric endoscopic peritoneoscopy is a safe model for exploration of the peritoneum. Endoscopic insufflation of the peritoneal cavity has not been validated in humans. We report here our experience with pneumoperitoneum established endoscopically with a laparoscopic insufflator., Design: Pneumoperitoneum was established with a laparoscopic insufflator through the biopsy channel of the gastroscope. Intra-abdominal pressure was measured with a transfascial Veress needle and compared with endoscopic values. The gastrotomy was used in the creation of the gastric pouch., Patients: Twenty patients undergoing laparoscopic Roux-en-Y gastric bypass participated in the study. Ten had undergone no previous surgery, whereas the other 10 patients had a history of abdominal procedures., Interventions: Diagnostic transgastric endoscopic peritoneoscopy was performed through a gastrotomy created endoscopically without laparoscopic visualization., Main Outcome Measurements: Diagnostic findings, operating times, and clinical course were recorded., Results: The average time for transgastric access was 9.6 minutes. This did not vary in patients with previous surgery (P = .3). Endoscopic insufflation was successful in all patients. The mean endoscopic and laparoscopic pressures were 9.80 and 9.75 mm Hg, respectively (P = .9). In no patients were there limitations to visualization of the abdomen. Adhesions were noted in 80% and 10% of patients with and without a history of surgery, respectively (P = .005). There were no complications related to transgastric passage of the endoscope or exploration of the peritoneal cavity., Conclusions: Although limited by the small sample size in this study, we believe that transgastric access may be considered as an alternative approach to peritoneal insufflation and provides a safe alternative for exploration of the abdomen. Endoscopic insufflation through the biopsy channel by using a laparoscopic insufflator seems to be an effective and safe method for establishing pneumoperitoneum., (2010 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Introduction: Natural orifice translumenal endoscopic surgery (NOTES) is a rapidly evolving field that provides endoscopic access to the peritoneum via a natural orifice. One important requirement of this technique is the need to minimize the risk of clinically significant peritoneal contamination. We report the bacterial load and contamination of the peritoneal cavity in ten patients who underwent diagnostic transgastric endoscopic peritoneoscopy., Methods: Patients participating in this trial were scheduled to undergo diagnostic laparoscopy for evaluation of presumed pancreatic cancer. Findings at diagnostic laparoscopy were compared with those of diagnostic transgastric endoscopic peritoneoscopy, using an orally placed gastroscope, blinding the endoscopist to the laparoscopic findings. We performed no gastric decontamination. Diagnostic findings, operative times, and clinical course were recorded. Gastroscope and peritoneal fluid aspirates were obtained prior to and after the gastrotomy. Each sample was sent for bacterial colony counts, culture, and identification of species., Results: Ten patients, with an average age of 63.7 years, have completed the protocol. All patients underwent diagnostic laparoscopy followed by successful transgastric access and diagnostic peritoneoscopy. The average time for laparoscopy was 7.2 min, compared with 18 min for transgastric instrumentation. Bacterial sampling was obtained in all ten patients. The average number of colony-forming units (CFU) in the gastroscope aspirate was 132.1 CFU/ml, peritoneal aspirates prior to creation of a gastrotomy showed 160.4 CFU/ml, and peritoneal sampling after gastrotomy had an average of 642.1 CFU/ml. There was no contamination of the peritoneal cavity with species isolated from the gastroscope aspirate. No infectious complications or leaks were noted at 30-day follow-up., Conclusions: There was no clinically significant contamination of the peritoneal cavity from the gastroscope after transgastric endoscopic instrumentation in humans. Transgastric instrumentation does contaminate the abdominal cavity but, the pathogens do not mount a clinically significant response in terms of either the species or the bacterial load.

The treatment of hydatidosis traditionally consisted of surgery with a perioperative course of anthelmintic medications. However, percutaneous aspiration, injection, and reaspiration (PAIR) combined with oral albendazole has been recently shown to be as effective as surgery in the treatment of liver hydatidosis. We report a 20-year-old female immigrant from Western Europe who presented with discomfort in her upper abdomen. Computed tomography revealed a 5.7 x 7 x 5.9-cm cyst in segment 7 of the liver and a 17 x 15-cm cyst in the spleen in contiguity with the hilar vessels. Indirect hemaglutination test confirmed hydatidosis. A strategy with two different surgical approaches was designed to treat her condition: laparoscopic splenectomy and ultrasound-guided PAIR of the liver cyst. The patient was discharged on postoperative day 5, and at 18 months follow-up, she is free of symptoms.

Purpose: This study was designed to compare self-reported sexual function, body image, and quality of life outcomes among ulcerative colitis patients undergoing laparoscopic or open ileal pouch-anal anastomosis., Methods: Between 1978 and 2004, 100 laparoscopic and 189 open operations were performed in patients who were identified from a previously published cohort. Patients were surveyed one year after operation to evaluate sexual function, body image, and quality of life., Results: A total of 125 of 289 patients (43 percent) returned completed surveys. There were no significant differences in terms of demographics, complications, or long-term functional outcomes between those who completed the surveys and those who did not. There were no clinical differences in results between laparoscopic and open patients using the three survey instruments. Orgasmic function scores were lower in men who underwent laparoscopic ileal pouch-anal anastomosis (P < 0.05) compared with open ileal pouch-anal anastomosis. Overall, sexual function scores were equal to or better than normal values for men but were lower in women. Finally, overall body image and quality of life scores were above the means published for the United States., Conclusions: After ileal pouch-anal anastomosis, men and women reported excellent body image and high cosmetic and quality of life scores regardless of operative approach. Female sexual function was more adversely affected after ileal pouch-anal anastomosis than was male sexual function.

Background: Natural-orifice translumenal endoscopic surgery (NOTES) is a possible advancement for surgical interventions. We initiated a pilot study in humans to investigate feasibility and develop the techniques and technology necessary for NOTES. Reported herein is the first human clinical trial of NOTES, performing transoral transgastric diagnostic peritoneoscopy., Methods: Patients were scheduled to undergo diagnostic laparoscopic evaluation of a pancreatic mass. The findings of traditional laparoscopy were recorded by anatomical abdominal quadrant. A second surgeon, blinded to the laparoscopic findings, performed transgastric peritoneoscopy. Diagnostic findings between the two methods were compared and operative times and clinical course were recorded. Definitive care was based on findings at diagnostic laparoscopy., Results: Ten patients completed the protocol with an average age of 67.6 years. All patients underwent diagnostic laparoscopy followed by successful transgastric access and diagnostic endoscopic peritoneoscopy. The average time of diagnostic laparoscopy was 12.3 minutes compared to 24.8 minutes for the transgastric route. Transgastric abdominal exploration corroborated the decision to proceed to open exploration made during traditional laparoscopic exploration in 9 of 10 patients. Peritoneal or liver biopsies were obtained in four patients by traditional laparoscopy and in one patient by the transgastric access route. Findings were confirmed by laparotomy in nine patients. Eight patients underwent pancreaticoduodenectomy and two underwent palliative gastrojejunostomy and/or hepaticojejunostomy., Conclusions: Transgastric diagnostic peritoneoscopy is safe and feasible. This study demonstrates the initial steps of NOTES in humans, providing a potential platform for incisionless surgery. Technical issues, including instrumentation, visualization, intra-abdominal manipulation, and gastric closure need further development.

Introduction: Robotic technology has been postulated to improve performance in advanced surgical skills. We utilized a novel computerized assessment system to objectively describe the technical enhancement in task performance comparing robotic and laparoscopic instrumentation., Methods and Procedures: Advanced laparoscopic surgeons (2-10 yrs experience) performed three unique task modules using laparoscopic and Telerobotic surgical instrumentation (Intuitive Surgical, Sunnyvale, CA). Performance was evaluated using a computerized assessment system (ProMIS, Dublin, Ireland) and results were recorded as time (s), path (mm) and precision. Each surgeon had an initial training session followed by two testing sessions for each module. A paired Student's t-test was used to analyze the data., Results: Ten surgeons completed the study. 8/10 surgeons had significant technical enhancement utilizing robotic technology., Conclusions: The ProMIS computerized assessment system can be modified to objectively obtain task performance data with robotic instrumentation. All the tasks were performed faster and with more precision using the robotic technology than standard laparoscopy.

Objectives: To compare the clinicopathologic data of 286 laparoscopic radical prostatectomies (LRPs) and 714 open radical prostatectomies (RRPs) performed at the Massachusetts General Hospital from 2001 to 2005., Methods: A total of 1000 radical prostatectomy procedures were analyzed for prostate weight, pathologic stage, Gleason score, surgical margin status, and positive margin location., Results: The mean patient age was 58.6 and 59.1 years for the LRP and RRP groups, respectively. The mean preoperative prostate-specific antigen level was 5.96 and 6.00 ng/mL, respectively. Clinical Stage T1c cancer was seen in 86.4% of the LRP and 90.5% of the RRP patients. Gleason score 7 or less disease was seen on biopsy in 97.5% of the LRP and 96.9% of the RRP patients. The average prostate weight was 46.8 g for LRP and 46.0 g for RRP. In the radical prostatectomy specimens, 94.4% of LRP and 93.3% of RRP patients had Gleason score 7 or less disease and 86.0% of LRP and 81.7% of RRP patients had pathologic Stage pT2 cancer. The rate of positive surgical margins was 15.0% and 17.4% for the LRP and RRP groups, respectively. The positive margins occurred mainly at the peripheral and apical regions in both groups. No significant difference was found in the preoperative variables or final pathologic findings between the two surgical groups., Conclusions: With similar case selection, LRP and RRP achieve similar pathologic outcomes.

Background: Laparoscopic skills vary with experience and training; however, objective measures to ascertain the level of training have not yet been established. New technology allows noninterfering measurement of eye motion parameters that correlate with attention and distraction during visually oriented tasks. Our objective was to apply this new technology in the setting of video-assisted surgery to evaluate eye motion parameters among surgeons of varying experience., Materials and Methods: Subjects with various levels of laparoscopic experience (novice, intermediate, and expert) were fitted with a noninvasive, Food and Drug Administration approved, eye motion monitoring device. The device was used to measure and record parameters of eye motion, including saccadic rate (SR), standardized peak velocity (PV), standardized saccadic amplitude (SA), and the duration of gaze fixation (FD), during the performance of 3 basic laparoscopic tasks on a laparoscopic training station., Results: A total of 24 subjects (3 groups of 8 each) participated in this study. Experience level was found to have a main significant effect on SR (P = 0.047) and PV (P = 0.028). Two-way ANOVA demonstrated that experience level approached significance for SA (P = 0.058) and FD (P = 0.055)., Conclusion: The advancement of laparoscopic techniques and instrumentation relies, in part, on expanding the current understanding of operator/instrument interactions. This places an increasing demand on objective methods of monitoring such interactions during laparoscopy. Our study demonstrates a significant difference in eye motion parameters in surgeons with differing levels of experience. Further testing is needed in actual clinical settings to determine the importance of eye motion during surgery.

Background: Laparoscopic Heller myotomy has emerged as the treatment of choice for achalasia. However, intraoperative esophageal perforation remains a significant complication. Computer-enhanced operative techniques have the potential to improve outcomes for certain operative procedures. Robotic, computer-enhanced laparoscopic telemanipulators using 3-dimensional magnified imaging and motion scaling are designed uniquely to facilitate certain operations requiring fine-tissue manipulation. We hypothesized that computer-enhanced robotic Heller myotomy would reduce intraoperative complications compared with laparoscopic techniques., Methods: All patients undergoing an operation for achalasia at 3 institutions with a robotic surgery system (DaVinci; Intuitive Surgical Corporation, Sunnyvale, Calif) were followed-up prospectively. Demographics, perioperative course, complications, and hospital stay were recorded. Follow-up evaluation was obtained via a standardized symptom survey, office visits, and medical records. Data were compared with preoperative symptoms using a Mann-Whitney U test, and operating times were compared using the ANOVA test., Results: Between August 2000 and August 2004 there were 104 patients who underwent a robotic Heller myotomy with partial fundoplicaton. There were 53 women and 51 men. All patients were symptomatic. The operative time was 140.55 minutes overall, but improved from 162.63 minutes to 113.50 minutes from 2000-2002 to 2003-2004 (P = .0001). There were no esophageal perforations. There were 8 minor complications and 1 patient required conversion to an open operation. Sixty-six (62.3%) patients were discharged on the first postoperative day and the average hospital stay was 1.5 days. A symptom survey was completed in 79 of 104 patients (76%) at follow-up evaluation. Symptoms improved in all patients with an average follow-up symptom score of 0.48 compared with 5.0 before the operation (P = .0001). Forty-three of the 79 patients from whom follow-up data were collected had a minimum follow-up period of 1 year. The follow-up period averaged 16 months. No patients required reoperation., Conclusions: Computer-enhanced robotic laparoscopic techniques provide a clear advantage over standard laparoscopy for the operative treatment of achalasia. We have shown in this large series that Heller myotomy can be completed using this technology without esophageal perforation. The application of computer-enhanced operative techniques appears to provide superior outcomes in selected procedures.

Obesity is recognized as a health problem of epidemic proportions. Surgical intervention for the treatment of obesity is a well-studied and effective method. Various procedures have been utilized over the past decades. Roux-en-Y gastric bypass has emerged over the last 20 years and is currently the most commonly offered surgical treatment. Within the last decade, advances in laparoscopic technology and surgical experience have allowed the application of laparoscopic techniques to the surgical treatment of obesity. Many centers and individuals have developed excellent techniques through experience over time as well as improvements in instrumentation. Hand-assisted laparoscopy was reported as a technique, but has mostly fallen out of favor. Currently, laparoscopic application of adjustable gastric band and laparoscopic Roux-en-Y gastric bypass are widely used throughout the United States. Data have been generated to demonstrate the improvement in surgical outcomes associated with minimally invasive surgical techniques for the surgical treatment of obesity. Further advances will allow continued improvement in patient outcomes utilizing a variety of minimally invasive surgical approaches to the treatment of this difficult disease.

Computer-assisted telesurgical devices have recently been approved in the United States for general surgery. To determine the safety and efficacy of these procedures, we performed a prospective trial of computer-enhanced "robotic" fundoplication compared to standard laparoscopic control procedures. Consecutive patients undergoing surgical treatment for gastroesophageal reflux were included. The operating surgeon worked at a console using a three-dimensional image and manipulated hand controls. Operative times, complications, and length of hospital stay were recorded. A standardized questionnaire was administered to evaluate symptoms. Twenty patients were entered into each group. There were no differences in age, preoperative weight, or sex. Operative times were significantly longer in the robot group (97 vs. 141 minutes). There were no complications and most patients went home the first postoperative day. At follow-up, symptoms were similar in both groups; however, there was a significant difference in the number of patients taking antisecretory medication--none in the robotic group but six in the laparoscopic group reported regular use. Computer-assisted laparoscopic antireflux surgery is safe. However, operative times are longer, with little difference in outcomes. At the current level of technology and experience, robotic antireflux surgery appears to offer little advantage over standard laparoscopic approaches.