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Aim This study aimed to present our experience with robotic colorectal surgery since its establishment at our institution in 2009. By examining the outcomes of over 500 patients, our experience provides a basis for assessing the introduction of a robotic platform in a colorectal practice. Specific measures investigated include intraoperative data and postoperative outcomes for all operations using the robotic platform. In addition, for our most commonly performed operations we wished to analyse the learning curve to improve operative proficiency. This is the largest single-surgeon robotic database analysed to date. Method A prospectively maintained database of patients who underwent robotic colorectal surgery by a single surgeon at the George Washington University Hospital was retrospectively reviewed. Demographic data and perioperative outcomes were assessed. Additionally, an operating time learning curve analysis was performed. Results Inclusion criteria identified 502 patients who underwent robotic colorectal surgery between October 2009 and December 2018. The most common indications for surgery were diverticulitis (22.9%), colon adenocarcinoma (22.1%) and rectal adenocarcinoma (19.5%). The most common operations were anterior/low anterior resection (33.9%), right hemicolectomy/ileocaecectomy (24.9%) and left hemicolectomy/sigmoidectomy (21.9%). The rate of conversion to open surgery was 4.8%. The most common postoperative complications were wound infection (5.0%), anastomotic leakage (4.0%) and abscess formation (2.8%). The operating time learning curve plateaued at 55-65 cases for anterior and low anterior resection and 35-45 cases for left hemicolectomy and sigmoidectomy. A clear learning curve was not seen in right hemicolectomy. Conclusion Robotic-assisted surgery can be performed in a diverse colorectal practice with low rates of conversion and postoperative complications. Plateau performance was achieved after 65 anterior/low anterior resections and 45 left and sigmoid colectomies.

Traditional trocar systems suffer from several innate flaws due to their silicone seal design. The AirSeal® is a valve-less trocar system that overcomes these flaws by utilizing a system of laminar flow and CO2 recirculation. The purpose of this paper is to examine the effect of the AirSeal® versus a traditional trocar system in operative time, EBL and post-operative complications. To the best of our knowledge, this is the first analysis of this system in robotic colorectal surgery. A single surgeon’s database was reviewed and all LAR and right hemicolectomy robotic cases from 2014–2015 and 2017–2018 were included for analysis. Patient demographic information was evaluated and primary outcomes examined were operative time, EBL, post-operative complications and hospital LOS. Ninety four patients were identified in the LAR cohort and 56 patients were identified in the right hemicolectomy cohort. Mean operative time for LAR was 293 ± 91.6 min in 2014–2015 and 232 ± 74.6 min in 2017–2018 (p = 0.001); however, this significant difference was not seen between right hemicolectomies. Mean EBL for LAR was 209 ± 189 cc in 2014–2015 and 150 ± 173.9 cc in 2017–2018 (p = 0.05); again, this significant difference was not appreciated for right hemicolectomies. There was no statistically significant difference in rates of wound infections, pneumonia, post-operative pneumonia, DVT/PE, intra-abdominal/pelvic abscesses, or unplanned 30-day readmission rate between 2014–2015 and 2017–2018. Length of stay was reduced in both populations between 2014–2015 and 2017–2018; however, it neither reached statistical significance. In patients undergoing low anterior resections, the AirSeal® trocar system demonstrated a statistically significant reduction in mean operative time and EBL compared to the traditional trocar system. There was also a trend towards decreased length of stay and post-operative complications with AirSeal® use in low anterior resections and right hemicolectomies. In patients undergoing distal colorectal procedures, the AirSeal® trocar system should be considered.

The aim of this study was to demonstrate a proof-of-concept approach to rectopexy that would provide the durability of the transabdominal procedure through use of sacral rectopexy with the decreased morbidity of a perineal procedure. This was done by utilizing a transvaginal approach and developing the rectovaginal space to accommodate sacral rectopexy placement using the Flex® Colorectal Drive Robotic System by Medrobotics (Medrobotics Corp., Raynham, MA, USA). A fresh female cadaver was acquired and placed in the high lithotomy position. The rectovaginal space was developed to accommodate the trocar of the Flex robot using blunt and sharp dissection between the posterior vaginal wall and anterior rectum. A piece of mesh was introduced into the space and using an endoscopic tacker, which was secured to the sacral promontory. The mesh was secured to the anterior rectal wall using interrupted vicryl sutures. The purse string suture was removed and the rectovaginal orifice was closed using a running vicryl suture. At the completion of the procedure, a low midline laparotomy was conducted to verify anchoring of the mesh appropriately at the sacral promontory. This proof-of-concept protocol is the first description of the Flex® Colorectal Drive being used successfully to perform a transvaginal rectopexy for rectal prolapse in a cadaver. This is also the first description of the Flex® Colorectal Drive robot being used transvaginally. This proof-of-concept approach demonstrates that transvaginal rectopexy using the Flex® Colorectal Drive is a potential surgical option to address rectal prolapse that could provide patients the durability of a transabdominal approach with the decreased morbidity of a perineal approach. While early results are promising, additional cadaveric studies are required before this procedure can be attempted in vivo.

Surgeon and hospital volume are factors that have been shown to impact outcomes following bariatric surgery. Nevertheless, there is a paucity of literature investigating surgeon training on bariatric surgery outcomes. The purpose of our study was to determine if bariatric specialty training leads to improved short-term outcomes following laparoscopic bariatric surgery using the American College of Surgeons Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (ACS-MBSAQIP) database. All patients undergoing first-time, elective, laparoscopic bariatric surgery from 2015 to 2016 were identified within the ACS-MBSAQIP database. Patients were divided into two groups based on the type of bariatric procedure performed and the surgeon performing the procedure. Thirty-day outcomes were compared between the groups using multivariable logistic regression analysis. A total of 140,340 patients met inclusion criteria. Higher risk patients with more associated comorbidities underwent bariatric surgery by a metabolic and bariatric surgeon. After controlling for these differences, patients who underwent Roux-en-Y gastric bypass (RYGB) had similar 30-day irrespective of the surgeon performing the procedure while patients who underwent sleeve gastrectomy (SG) by a metabolic and bariatric surgeon (MBS) had improved 30-day outcomes. Surgeon type is associated with 30-day morbidity and mortality outcomes for SG but not for RYGB. These differences in 30-day morbidity and mortality outcomes may be facilitated by institutional factors, surgeon experience, and participation in bariatric surgery accredited centers. Standardization of the perioperative process for both surgeons and institutions may improve 30-day morbidity and mortality outcomes for all patients who undergo laparoscopic bariatric surgery.

Dehydration is the most common cause of readmission after laparoscopic sleeve gastrectomy (SG). Bougie size and distance from the pylorus, both of which have been associated with rates of dehydration postoperatively, varies by surgeon and across institutions.To determine if there is an association between bougie size or distance from the pylorus on the rate of dehydration after laparoscopic SG.American College of Surgeons Metabolic and Bariatric Surgery Accreditation Quality Improvement Program database.All patients undergoing first-time, elective laparoscopic SG from 2015-2016 were identified. The association of bougie size and distance from the pylorus on the rate of dehydration within the first 30 days postoperatively was investigated.The inclusion criteria were met by 170,751 patients. The most commonly used bougie size was 36 Fr and the most common distance from the pylorus at which the gastric sleeve was started was 5 cm. Patients were divided into 4 groups based on bougie size and distance from the pylorus (Group 1: bougie size36 Fr, pylorus distance4 cm; Group 2: bougie size ≥36 Fr, pylorus distance4 cm; Group 3: bougie size ≥36 Fr, pylorus distance ≥4 cm; and Group 4: bougie size36 Fr, pylorus distance ≥4 cm). Patients in Group 4 were significantly less likely than any other group to experience dehydration-related complications.Both distance from the pylorus and bougie size are significantly associated with dehydration-related complications after SG. Consideration should be made for standardizing these technical aspects of SG to help reduce the rate of postoperative dehydration and hospital readmission.

The introduction of minimally invasive techniques to the field of colorectal surgery such as laparoscopy has been shown to improve postoperative recovery. The advent of single-incision minimally invasive surgery with both laparoscopic and robotic-assisted approaches aims to reduce abdominal trauma and further improve patient outcomes. The robotic platform allows for angled instruments and a three-dimensional view of the operative field which enhances operative technique. A few small reviews on single-site surgery exist and these demonstrate its safety and efficacy but more robust large-scale studies are lacking at this time. The landscape of minimally invasive colorectal surgery continues to change with novel techniques and technical advancements.

Introduction: Hypertonic saline is often used to treat patients with traumatic brain injury. It carries the undesired side effect of hyperchloremia, which has been linked to acute kidney injury (AKI). We sought to evaluate the relationship of hyperchloremia and AKI in this population and whether the absolute exposure to hyperchloremia, including maximal hyperchloremia and duration of hyperchloremia were associated with AKI. Methods: A retrospective study of severe traumatic brain injury patients who received hypertonic saline at a single academic institution. Demographics, head abbreviated injury scale, development of hyperchloremia (Cl ≥ 115), duration of hyperchloremia, highest chloride level, duration of hypertonic saline use, admission GFR, and administration of nephrotoxic medications were abstracted. The outcome of interest was the association between renal function and hyperchloremia. Results: A total of 123 patients were included in the study. Multivariable logistic regression analysis demonstrated that only duration of hyperchloremia ( p = 0.014) and GFR on admission ( p = 0.004) were independently associated with development of AKI. The number of days of hypertonic saline infusion ( p = 0.79) without the persistence of hyperchloremia and highest serum chloride levels ( p = 0.23) were not predictive of AKI development. Discussion: In patients with traumatic brain injury, admission GFR and prolonged hyperchloremia rather than the highest chloride level or the duration of hypertonic saline infusion were associated with the development of AKI.

Traditional trocar systems suffer from several innate flaws due to their silicone seal design. The AirSealA single surgeon's database was reviewed and all LAR and right hemicolectomy robotic cases from 2014-2015 and 2017-2018 were included for analysis. Patient demographic information was evaluated and primary outcomes examined were operative time, EBL, post-operative complications and hospital LOS.Ninety four patients were identified in the LAR cohort and 56 patients were identified in the right hemicolectomy cohort. Mean operative time for LAR was 293 ± 91.6 min in 2014-2015 and 232 ± 74.6 min in 2017-2018 (p = 0.001); however, this significant difference was not seen between right hemicolectomies. Mean EBL for LAR was 209 ± 189 cc in 2014-2015 and 150 ± 173.9 cc in 2017-2018 (p = 0.05); again, this significant difference was not appreciated for right hemicolectomies. There was no statistically significant difference in rates of wound infections, pneumonia, post-operative pneumonia, DVT/PE, intra-abdominal/pelvic abscesses, or unplanned 30-day readmission rate between 2014-2015 and 2017-2018. Length of stay was reduced in both populations between 2014-2015 and 2017-2018; however, it neither reached statistical significance.In patients undergoing low anterior resections, the AirSeal

Purpose/background Using robotic surgery, we report successful resection of deep invasive pelvic endometriosis with a multidisciplinary team of colorectal and gynecologic surgeons. Methods/interventions Fifteen cases of robotic-assisted endometrial resections for deep invasive endometriosis were performed by a multidisciplinary team between 2013 and 2016. Results/outcomes The average total operative time of robotic endometrial extirpation was 342 minutes, and the average blood loss was 283 cc. There were no intraoperative complications and no conversion to laparotomy. Postoperative complications, including one superficial wound infection, four patients with pelvic abscesses, a bowel leak, and one rectovaginal fistula, occurred in five of 15 patients, three of which required percutaneous drainage and one required reoperation. All patients who followed up after surgery showed 100% dysmenorrhea resolution at one month (13 of 15 patients). Conclusion/discussion Deep infiltrating endometriosis is a complex disease associated with significant morbidity and requires highly trained, multidisciplinary team approach for safe and efficient excision.

Background Patients with wake-up or unknown time of onset stroke are usually excluded from recanalization. However, a few studies indicate that some magnetic resonance sequences can help predict time from symptom onset (SxO). Our goal was to assess the value of fluid-attenuated inversion recovery (FLAIR) signal intensity ratio (SIR) in identifying patients within 6 and 8 hours of stroke onset. Materials and Methods We studied consecutive acute stroke patients with known time of onset who underwent magnetic resonance imaging (MRI) within 48 hours of SxO. SIR was calculated as the value of the FLAIR signal intensity of the identified area of infarction divided by the signal intensity in the homologous contralateral side of the brain. Results Out of 160 patients included in this study, 72 and 80 patients had MRI within 6 and 8 hours of SxO, respectively. We found a positive correlation between SIR and time from SxO (Pearson coefficient, .63). Receiver operating characteristic curves indicated that SIR ≤ 1.18 could accurately identify patients within 6 hours of SxO (86% sensitivity, 79% specificity) and a SIR ≤ 1.20 can be identified within 8 hours (89% sensitivity, 76% specificity). Among patients with no visible FLAIR hyperintensity, 83% (95% CI, 77%-89%) were within the 6-hour window. Conclusion Quantitative assessment of FLAIR sequence can be used to identify patients within 6 and 8 hours of stroke onset.