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Background: The increased digitization in robotic surgical procedures today enables surgeons to quantify their movements through data captured directly from the robotic system. These calculations, called objective performance indicators (OPIs), offer unprecedented detail into surgical performance. In this study, we link case- and surgical step-specific OPIs to case complexity, surgical experience and console utilization, and post-operative clinical complications across 87 robotic cholecystectomy (RC) cases., Methods: Videos of RCs performed by a principal surgeon with and without fellows were segmented into eight surgical steps and linked to patients' clinical data. Data for OPI calculations were extracted from an Intuitive Data Recorder and the da Vinci ® robotic system. RC cases were each assigned a Nassar and Parkland Grading score and categorized as standard or complex. OPIs were compared across complexity groups, console attributions, and post-surgical complication severities to determine objective relationships across variables., Results: Across cases, differences in camera control and head positioning metrics of the principal surgeon were observed when comparing standard and complex cases. Further, OPI differences across the principal surgeon and the fellow(s) were observed in standard cases and include differences in arm swapping, camera control, and clutching behaviors. Monopolar coagulation energy usage differences were also observed. Select surgical step duration differences were observed across complexities and console attributions, and additional surgical task analyses determine the adhesion removal and liver bed hemostasis steps to be the most impactful steps for case complexity and post-surgical complications, respectively., Conclusion: This is the first study to establish the association between OPIs, case complexities, and clinical complications in RC. We identified OPI differences in intra-operative behaviors and post-surgical complications dependent on surgeon expertise and case complexity, opening the door for more standardized assessments of teaching cases, surgical behaviors and case complexities., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Robot-assisted transabdominal preperitoneal inguinal hernia repair (rTAPP-IHR) is a safe and feasible approach for hernias of varying etiology. We aim to present a single surgeon's learning curve (LC) of this technique based on operative times, while accounting for bilaterality and complexity., Methods: This is a retrospective cohort analysis of patients who underwent rTAPP-IHR over a period of 5 years. Patients who underwent primary, recurrent, and complex (previous posterior repair, previous prostatectomy, scrotal, incarcerated) repairs were included. Cumulative and risk-adjusted cumulative sum analyses (CUSUM and RA-CUSUM) were used to depict the evolution of skin-to-skin times and complications/surgical site events (SSEs) with time, respectively., Results: A total of 371 patients were included in the study. Mean skin-to-skin times were stratified according to four subgroups: unilateral non-complex (46.8 min), unilateral complex (63.2 min), bilateral non-complex (70.9 min), and bilateral complex (102 min). A CUSUM-LC was then plotted using each procedures difference in operative time from its subgroup mean. The peak of the plot occurred at case number 138, which was used as a transition between 'early' and 'late' phases. The average operative time for the late phase was 15.9 min shorter than the early phase (p < 0.001). The RA-CUSUM, plotted using the weight of case complexity and unilateral/bilateral status, also showed decreasing SSE rates after the completion of 138 cases (early phase: 8.8% vs. late phase: 2.2%, p = 0.008). Overall complication rates did not differ significantly between the two phases., Conclusions: Our study shows that regardless of bilateral or complex status, rTAPP operative times and SSE rates gradually decreased after completing 138 procedures. Previous laparoscopic experience, robotic team efficiency, and surgical knowledge are important considerations for a surgeon's LC., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Although the advantages of laparoscopic inguinal hernia repair (LIHR) have been described, guidelines regarding robotic inguinal hernia repair (RIHR) have yet to be established, despite its increased adoption as a minimally invasive alternative. This study compares the largest single-center cohorts of LIHR and RIHR and aims to shed light on the differences in outcomes between these two techniques. Methods: Patients who underwent LIHR or RIHR over an 8-year period were included as part of a retrospective analysis. Variables were stratified by preoperative, intraoperative, and postoperative timeframes. Complications were listed according to the Clavien–Dindo classification system and comprehensive complication index (CCI®). Study groups were compared using univariate analyses and Kaplan–Meier's time-to-event analysis. Results: A total of 1153 patients were included: 606 patients underwent LIHR, while 547 underwent RIHR. Although demographics and comorbidities were mostly similar between the groups, the RIHR group included a higher proportion of complex hernias. Operative times were in favor of LIHR (42 vs. 53 min, p < 0.001), while RIHR had a smaller number of peritoneal breaches (0.4 vs. 3.8%, p < 0.001) as well as conversions (0.2 vs. 2.8%, p < 0.001). The number of patients lost-to-follow-up and the average follow-up times were similar (p = 0.821 and p = 0.304, respectively). Postoperatively, CCI® scores did not differ between the two groups (median = 0, p = 0.380), but Grade IIIB complications (1.2 vs. 3.3%, p = 0.025) and recurrences (0.8% vs. 2.9%, p = 0.013) were in favor of RIHR. Furthermore, estimated recurrence-free time was higher in the RIHR group [p = 0.032; 99.7 months (95% CI 98.8–100.5) vs. 97.6 months (95% CI 95.9–99.3). Conclusion: This study demonstrated that RIHR may confer advantages over LIHR in terms of addressing more complex repairs while simultaneously reducing conversion and recurrence rates, at the expense of prolonged operation times. Further large-scale prospective studies and trials are needed to validate these findings and better understand whether RIHR offers substantial clinical benefit compared with LIHR. [ABSTRACT FROM AUTHOR]

Purpose: This is the first study to investigate clinical outcomes after robotic emergent inguinal hernia repair (rEIHR). Methods: Data were retrospectively analyzed from patients who underwent rEIHR from 2013 to 2020. Any patients who underwent concomitant nonabdominal wall procedures were excluded. Complications were assessed with the Clavien-Dindo (CD) and Comprehensive Complication Index (CCI®) scoring systems. Results: Out of 616 patients who underwent inguinal herniorrhaphy throughout the study period, 23 rEIHRs were identified among 19 patients. The median Acute Physiology and Chronic Health Evaluation-II score was 6, and the average skin-to-skin time was 75.9 minutes. The average length of stay (LOS) was 1.4 days. During the mean follow-up period of 31.7 months, a total of three complications (CD-grades I, II, and IVa) in two patients were observed. The median CCI score was 0 (max = 43.3). Conclusion: rEIHR is a feasible option for surgeons to utilize, with a short LOS and low complication rate, given the sufficient experience and support as well as the appropriate patient selection. [ABSTRACT FROM AUTHOR]

Aim: A sigmoidectomy is the most definitive surgical treatment for recurrent diverticulitis. While it is usually accomplished via transabdominal specimen extraction and stapled anastomosis, the robotic platform can facilitate novel approaches and techniques. This is the first report of the initial experience using robotic sigmoidectomy with natural orifice specimen extraction and hand‐sewn anastomosis (NOSHA). Method: A prospectively maintained database of NOSHA procedures performed between 2018 and 2020 was retrospectively examined. The technique was described and variables across preoperative, intra‐operative and postoperative timeframes were presented. The Clavien‐Dindo classification system was used to describe postoperative complications. Results: Sixteen patients with recurrent diverticulitis treated with NOSHA were included in this study. Transanal specimen extraction and an intracorporeal hand‐sewn anastomosis were achieved in all patients. However, two (12.8%) patients required specimen debulking prior to extraction. The mean operating time was 171.7 min, and patients had a return of bowel function within an average period of 35.2 h. The mean hospital length of stay was 2.9 days. In total, two (12.8%) complications were seen: one postoperative ileus managed conservatively and one readmission for abdominal pain which resolved without intervention. No anastomotic leaks or reoperations were observed. Conclusion: Robotic NOSHA appears to be a viable technique for the surgical management of diverticulitis. Further studies are needed to establish its utility for various diseases and its reproducibility across clinical practices. [ABSTRACT FROM AUTHOR]

Background: Robotic Rives-Stoppa ventral hernia repair (rRS-VHR) is a minimally invasive technique that incorporates extraperitoneal mesh placement, using either transabdominal or totally extraperitoneal access. An understanding of its learning curve and technical challenges may guide and encourage its adoption. We aim at evaluating the rRS-VHR learning curve based on operative times while accounting for adverse outcomes. Materials and Methods: We conducted a retrospective analysis of patients undergoing rRS repair for centrally located ventral and incisional hernias. A single surgeon operative time-based cumulative sum (CUSUM) analysis learning curve was created, and a composite outcome was used for risk-adjusted CUSUM (RA-CUSUM). Results: Eighty-one patients undergoing rRS-VHR were included. A learning curve was created by using skin-to-skin times. Accordingly, patients were grouped into three phases. The mean skin-to-skin time was 72.2 minutes, and there was a significant decrease in skin-to-skin times throughout the learning curve (Phase-I: 86.4 minutes versus Phase-III: 63.8 minutes; P = .001), with a gradual decrease after 29 cases. Eleven patients experienced adverse composite outcomes, which were used to create a RA-CUSUM graph. Results showed the highest adverse outcome rates in Phase-II, with a gradual decrease in risk-adjusted operative times after 51 cases. Conclusions: Consistently decreasing operative times and adverse outcome rates in rRS-VHR was observed after the completion of 29 and 51 cases, respectively. Future studies that provide group learning curves for this procedure can deliver more generalizable results in terms of its performance rates. [ABSTRACT FROM AUTHOR]

Purpose: Retromuscular mesh placement positioning utilizing the robotic platform can be performed using either a transabdominal or an extraperitoneal approach. The aim of this study is to compare short-term outcomes of robotic transabdominal access retromuscular (rTA-RM) repair and robotic totally extraperitoneal access retromuscular (rTEP-RM) repair for ventral hernias Methods: Patients who underwent robotic retromuscular repair between February 2013–October 2019 were included in the study. A one-to-one propensity score matching (PSM) analysis was conducted to obtain two balanced groups. A comparative analysis was performed in terms of perioperative and early post-operative outcomes. Results: A total of 214 patients were included for PSM analysis. 82 patients were allocated into each study group. Operative times were longer in rTA-RM group. Adhesiolysis was more frequently required in the rTA-RM group. Intra-operative complications occurred more frequently in patients who underwent rTA-RM repair (p = 0.120; 4.9% in rTA-RM vs. 0% in rTEP-RM). The rate of major complications during the first 90 days did not differ between groups (p = 0.277; 7.3% vs. 2.4%, respectively). The proportion of patients with minor perioperative complications was statistically higher in the rTA-RM group than the rTEP-RM group (p = 0.003; 30.5% vs. 11%, respectively). Overall rate of surgical site events was higher in the rTA-RM group than the rTEP-RM group (p = 0.049; 17.1% vs. 6.1%, respectively). Seroma frequency was higher after rTA-RM repair (p = 0.047; 13.4% vs. 3.7%). Conclusion: Our data suggest that rTEP-RM repair was associated with shorter surgery duration and improved early post-operative outcomes in comparison with rTA-RM repair. [ABSTRACT FROM AUTHOR]

Perforated diverticulitis remains a challenging emergency, with its management widely debated. Although a laparoscopic approach reduces the risk of both procedures, studies showed that sigmoidectomy with primary anastomosis in perforated diverticulitis is preferable to a Hartmann's [3,4]. Robotic natural orifice intracorporeal anastomosis and extraction sigmoidectomy for Hinchey Class IV diverticulitis - A video vignette. [Extracted from the article]