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Background: Umbilical hernias are highly prevalent in patients with liver dysfunction, ascites, and cirrhosis. This patient population carries significant perioperative risk and poses significant challenges because of their comorbidities. Literature suggests that elective repair of umbilical hernias can lead to better outcomes by reducing the risk of ascitic leak and compromised bowel. Medical optimization followed by open repair has been the standard approach; however, little is known about whether a laparoscopic approach may be equivalent or superior., Methods: We retrospectively analyzed the American College of Surgeons National Surgical Quality Improvement Program database from 2015 to 2021 for umbilical hernia repairs in patients with liver dysfunction, as defined per the aspartate aminotransferase to platelet ratio index ≥1. We compare operative outcomes for open and laparoscopic repair, adjusting for confounders using propensity score matching and stratifying by case acuity., Results: We identified 1,983 patients with liver dysfunction who underwent umbilical hernia repair. Most patients (86%) were operated via an open approach rather than laparoscopy. Operative outcomes between the laparoscopy and open group were comparable regarding mortality and serious complications. Notably, length of stay and need for blood transfusion intraoperatively or postoperatively were reduced in the laparoscopy group (P < .001). These findings remained significant after subgroup analysis with propensity matching stratified by elective and emergency case types., Conclusion: Minimally invasive umbilical hernia repair in liver dysfunction is as safe and, in some metrics, superior to open technique. We found no difference in mortality although hospital stays and the need for blood transfusions were lower in the laparoscopy groups. Prospective randomized trials are needed to validate these findings further., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Minimally invasive distal pancreatectomy (MIDP) has established advantages over the open approach. The costs associated with robotic DP (RDP) versus laparoscopic DP (LDP) make the robotic approach controversial. We sought to compare outcomes and cost of LDP and RDP using propensity matching analysis at our institution., Methods: Patients undergoing LDP or RDP between 2000 and 2021 were retrospectively identified. Patients were optimally matched using age, gender, American Society of Anesthesiologists status, body mass index, and tumor size. Between-group differences were analyzed using the Wilcoxon signed-rank test for continuous data, and the McNemar's test for categorical data. Outcomes included operative duration, conversion to open surgery, postoperative length of stay, pancreatic fistula rate, pseudocyst requiring intervention, and costs., Results: 298 patients underwent MIDP, 180 (60%) were laparoscopic and 118 (40%) were robotic. All RDPs were matched 1:1 to a laparoscopic case with absolute standardized mean differences for all matching covariates below 0.10, except for tumor type (0.16). RDP had longer operative times (268 vs 178 min, p < 0.01), shorter length of stay (2 vs 4 days, p < 0.01), fewer biochemical pancreatic leaks (11.9% vs 34.7%, p < 0.01), and fewer interventional radiological drainage (0% vs 5.9%, p = 0.01). The number of pancreatic fistulas (11.9% vs 5.1%, p = 0.12), collections requiring antibiotics or intervention (11.9% vs 5.1%, p = 0.12), and conversion rates (3.4% vs 5.1%, p = 0.72) were comparable between the two groups. The total direct index admission costs for RDP were 1.01 times higher than for LDP for FY16-19 (p = 0.372), and 1.33 times higher for FY20-22 (p = 0.031)., Conclusions: Although RDP required longer operative times than LDP, postoperative stays were shorter. The procedure cost of RDP was modestly more expensive than LDP, though this was partially offset by reduced hospital stay and reintervention rate., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Spleen-preservation during minimally invasive distal pancreatectomy (MIDP) can be technically challenging and remains controversial. Our primary aim was to compare MIDP and splenectomy with spleen-preserving MIDP. Secondarily, we compared two spleen-preserving techniques., Methods: Adults undergoing MIDP (2007-2021) were retrospectively included in this single-center study. Intraoperative and postoperative outcomes between spleen-preservation and splenectomy and between the two spleen-preserving techniques were compared using the Mann-Whitney U test for continuous data, and Fisher's exact test for categorical data., Results: Of the 293 patients who underwent MIDP, preservation of the spleen was intended in 208 (71%) patients. Spleen-preservation was achieved in 174 patients (84%) via the Warshaw technique (130; 75%) or vessel-preservation (44; 25%). The spleen-preserving group had shorter length of stay (3 vs 4 days, p < 0.01), fewer conversions to open (1 vs 12, p < 0.01) and less blood loss (p < 0.01) compared to the splenectomy group. Operative (OR) times were comparable (229 vs 214 min, p = 0.67). Except for the operative time, which was longer for the Warshaw technique (245 vs 183 min, p = 0.01), no other differences between the two spleen-preserving techniques were found. At a median follow-up of 43 (IQR 18-79) months after spleen-preservation, only 2 (1.1%) patients had required splenectomy (1 partial splenectomy for infarct/abscess after Warshaw, 1 for variceal bleeding after vessel-preserving)., Conclusions: Spleen-preservation is not associated with increased risk of blood loss, longer hospital stay, conversion, nor lengthy OR times. Late splenectomy is very rarely required. Given the immune consequences of splenectomy, spleen-preservation should be strongly considered in MIDP., (© 2023. The Society for Surgery of the Alimentary Tract.)

Background: Surgical resection is the standard of care for unilateral adrenal adenomas and hyperplasia resulting in primary aldosteronism (PA). Resolution of PA following surgery is variable and some patients continue to require some or all of their antihypertensives. Prior studies have investigated factors contributing to "cure" of PA (defined as no hypertension [HTN] medications required postoperatively). These models are a tool in patient selection, yet fail to consider the benefit of some reduction in medications, resolution of hypokalemia, or reduction in blood pressure which may improve long-term cardiovascular and renal outcomes. We sought to investigate factors contributing to postoperative improvement or complete resolution following surgery., Methods: This is a retrospective review of prospectively collected data on 58 adrenalectomies performed for PA from December 1999 to April 2013 at a single center. Patient demographics, PA characteristics, labs, and imaging studies were evaluated, as well as operative characteristics. Mean systolic and diastolic blood pressures were calculated over several visits after discharge, and postoperative antihypertensive regimen was recorded. Patients were stratified by cured vs not cured and then again by improved vs not improved based on differences in pre- and postoperative values. Aldosteronoma Resolution Score was also calculated for each patient., Results: Median age was 52.6 years, with 44.8% women and an average duration of HTN of 13.5 years. Average body mass index (BMI) was 31.5 kg/m(2); 74% of the lesions were adenomas. Patients with complications had higher BMIs than those without (36.9 vs 28.7 kg/m(2), P = .02). In comparing improved (n = 42, 72%) vs not improved (n = 16, 28%) patients, preoperative systolic blood pressure (147.5 vs 159.7 mm Hg, P = .047) and serum creatinine (.94 vs 1.32 mg/dL, P = .016) were higher in the not improved group. Cured (n = 13) vs not cured (n = 45) patients differed in terms of BMI (27.4 vs 32.7, P = .009), duration of HTN (9.1 vs 14.9 years, P = .020), and number of preoperative antihypertensives (2.1 vs 3.7, P = .002). Aldosteronoma Resolution Score was significantly higher in cured patients (3.2 vs 1.0, P < .01)., Conclusions: A significant number of patients who are not cured by adrenalectomy for PA will still benefit from surgery. Obesity, duration of HTN, and number of medications may predict cure, yet fail to detect a population of patients with overall improvement. Attention to serum creatinine may help in distinguishing this population of patients., (Copyright © 2015 Elsevier Inc. All rights reserved.)